The impact of the World Health Organization classification and clonality assessment of posttransplant lymphoproliferative disorders on disease management.

CONTEXT: The World Health Organization classification of posttransplant lymphoproliferative disorders divides them into 4 main categories. OBJECTIVE: To classify cases of posttransplant lymphoproliferative disorders diagnosed in our institution according to the World Health Organization scheme and correlate the classification and clonality with clinical data. DESIGN: Cases of posttransplant lymphoproliferative disorders were reviewed. They were classified according to the World Health Organization scheme. Clonality was determined by flow cytometry and/or polymerase chain reaction. Patients' charts were reviewed. RESULTS: Thirty-one cases were identified. Median age was 33 years. There were 19 cases of kidney, 8 cases of liver, and 4 cases of bone marrow transplant. Immunosuppression consisted of cyclosporin A and prednisone (N = 24) or FK506 and prednisone (N = 7). Twenty cases (63%) were World Health Organization type 3, 7 cases (23%) type 2, 3 cases (6.4%) type 1, and 1 case type 4 posttransplant lymphoproliferative disorder. Ten patients received chemotherapy, 20 patients had reduction of immunosuppression, and 1 had no treatment. Follow-up was available on 25 patients. Seven (43.75%) of 16 with type 3 lesions with available follow-up died of their disease. Five of these patients received reduction of immunosuppression alone. Only 2 of 9 patients with type 3 disease who received chemotherapy died of disease. Two patients with type 2 disease died of unrelated causes. One patient is alive with disease; the remaining patients with types 1 and 2 disease are alive with no disease. CONCLUSIONS: The World Health Organization classification of posttransplant lymphoproliferative disorders is valuable in the identification of subtypes. It helps identify early lesions (1 and 2) requiring reduction of immunosuppression and type 3 disease, which requires chemotherapy from the outset.

Increased breast cancer risk after radiotherapy for acne among women with skin cancer.

BACKGROUND: Radiotherapy was commonly used to treat benign conditions, especially skin diseases, during the first half of the twentieth century. Previous studies have shown that radiotherapy for some of these conditions increases the risk of developing breast cancer. Although breast cancer associated with previous radiotherapy for acne has been reported, no statistically significant correlation has been established. OBJECTIVE: The aim of this study was to determine whether radiotherapy for acne is a risk factor for subsequent development of breast cancer. METHODS: A retrospective nested case-control study was conducted using the cohort of all patients referred for Mohs micrographic surgery to the senior author (R. G. B.) from 1978 to 2003. The case group consisted of 244 women who were skin cancer patients and who had received radiotherapy for acne. The control group consisted of 244 age-matched women skin cancer patients from the same records randomly selected within the initial Mohs micrographic surgery treatment year. Clinical data from both groups regarding cancer history and radiotherapy were extracted and statistically analyzed. RESULTS: Women skin cancer patients who had received radiotherapy for acne have a prevalence of breast cancer of 15% compared with 6.6% in control women skin cancer patients, for an odds ratio (OR) of 2.5 (P = .0033; 95% confidence interval, 1.3-4.6). Increased prevalence is correlated with age at treatment younger than 20 years (age-adjusted OR, 2.9; age-adjusted P = .002), treatment sessions numbering 5 or more (age-adjusted OR, 3.5; age-adjusted P = .005), and treatment year occurring before 1950 (age-adjusted OR, 2.9; age-adjusted P = .00013). LIMITATIONS: The data used are based primarily on patient history and physical examinations and are therefore limited by the accuracy of the patient and the caregiver. CONCLUSION: Women with skin cancer exposed to previous radiotherapy for acne are significantly more likely to develop breast cancer than their age-matched controls with skin cancer. Therefore all women previously treated for acne with radiotherapy should be identified and closely monitored for subsequent breast cancer development.

Unilateral rash on a baby girl.

An 11-month-old baby girl came to the clinic with a pruritic rash. The rash initially appeared in her popliteal fossa 2 weeks before the visit. The eruption extended to the right leg, arm, and flank the week before the visit, subsequently spreading to the contralateral flank. Three weeks before to the eruption's appearance, the patient had an upper respiratory infection with a dry nonproductive cough, which resolved spontaneously without antibiotics. The physical examination revealed a healthy-appearing infant girl with excoriated erythematous papules coalescing into plaques on her right flexural arm that continued to the axilla and down the right flank to the flexural aspect of her leg (Figure 1). Her left side was essentially free of any rash (Figure 2). No cervical or axillary lymphadenopathy was noted, and the remainder of her exam was normal. What is your diagnosis? How would you manage this condition?