Hospital Consult

Clinical Characterization of Leukemia Cutis Presentation

IN PARTNERSHIP WITH THE SOCIETY FOR DERMATOLOGY HOSPITALISTS

Cutis. 2019 December;104(06):326-330, E3

Leukemia cutis (LC) is a rare condition that results from infiltration of neoplastic cells into the skin in patients with leukemia, mainly described in case reports or small case series. This study aimed to characterize the clinical presentation of LC and its association with leukemia evolution and prognosis. A single-institution retrospective review of medical records of patients with LC was performed. Biopsy-proven LC cases diagnosed in patients with leukemia were analyzed for a variety of clinical characteristics and prognosis; 46 patients met inclusion criteria. Leukemia cutis most commonly presented in patients with acute myeloid leukemia (AML), though lesions were seen in several other leukemia types. Most LC lesions were identified at initial presentation of underlying leukemia but also occurred with leukemia relapse and at other stages of treatment. Most patients died within 1 year of LC diagnosis. The clinical presentation of LC is highly variable. Lesions occur in different anatomic regions; can present as papules, nodules, or plaques; and have different associated colors and symptoms. Duration between diagnosis of leukemia and death in patients who develop LC, and between LC diagnosis and death, are highly variable. Early detection of lesions might help provide a diagnosis in patients with leukemia and potentially improve prognosis if doing so results in earlier initiation of chemotherapy.

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Practice Points

Complete and comprehensive skin examination is important in leukemia patients, as leukemia cutis (LC) lesions can present in all body sites including ocular and oral mucosa as well as the groin.
Given the wide variability in appearance, symptoms, distribution, and stage of leukemia at presentation, dermatologists and oncologists need to keep LC in the differential diagnosis for any new skin lesion and to have a low threshold for performing skin biopsy.
Performing thorough skin examination on leukemia patients throughout the course of their disease may help identify LC early so that treatment can be implemented in a timely fashion at initial diagnosis, first sign of relapse, or change in disease state.

References

Wagner G, Fenchel K, Back W, et al. Leukemia cutis—epidemiology, clinical presentation, and differential diagnoses. J Dtsch Dermatol Ges. 2012;10:27-36.
Grunwald MR, McDonnell MH, Induru R, et al. Cutaneous manifestations in leukemia patients. Semin Oncol. 2016;43:359-365.
Martínez-Leboráns L, Victoria-Martínez A, Torregrosa-Calatayu JL, et al. Leukemia cutis: a report of 17 cases and a review of literature. Actas Dermosifiliogr. 2016;107:e65-e69.
Li L, Wang Y, Lian CG, et al. Clinical and pathological features of myeloid leukemia cutis. An Bras Dermatol. 2018;93:216-221.
Paydas¸ S, Zorludemir S. Leukaemia cutis and leukaemic vasculitis. Br J Dermatol. 2000;143:773-779.
Lee JI, Park HJ, Oh ST, et al. A case of leukemia cutis at the site of a prior catheter insertion. Ann Dermatol. 2009;21:193-196.
Kang YS, Kim HS, Park HJ, et al. Clinical characteristics of 75 patients with leukemia cutis. J Korean Med Sci. 2013;28:614-619.
Stern M, Halter J, Buser A, et al. Leukemia cutis preceding systemic relapse of acute myeloid leukemia. Int J Hematol. 2008;87:108-109.
Patel LM, Maghari A, Schwartz RA, et al. Myeloid leukemia cutis in the setting of myelodysplastic syndrome: a crucial dermatological diagnosis. Int J Dermatol. 2012;51:383-388.
American Cancer Society. Cancer Facts & Figures 2019. Atlanta, GA: American Cancer Society; 2019. http://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf. Accessed November 21, 2019.
Cho-Vega JH, Medeiros LJ, Prieto VG, et al. Leukemia cutis. Am J Clin Pathol. 2008;129:130-142.
Su WP. Clinical, histopathologic, and immunohistochemical correlations in leukemia cutis. Semin Dermatol. 1994;13:223-230.
Barzilai A, Lyakhovitsky A, Goldberg I, et al. Aleukemic monocytic leukemia cutis. Cutis. 2002;69:301-304
Howlader N, Noone AM, Krapcho M, et al, eds. SEER cancer statistics review (CSR) 1975-2014. Bethesda, MD: National Cancer Institute; April 2017. https://seer.cancer.gov/archive/csr/1975_2014/. Accessed November 21, 2019.
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Colburn DE, Welch MA, Giles FJ. Skin infiltration with chronic lymphocytic leukemia is consistent with a good prognosis. Hematology. 2002;7:187-188.
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Leukemia is a malignant, life-threatening neoplasm affecting the hematopoietic system. Extramedullary manifestations can occur in various organs, including skin.¹ Skin findings in leukemia patients are common and varied, including pallor secondary to anemia, petechiae or ecchymoses due to thrombocytopenia, and skin manifestations of neutropenia and chemotherapy.² When patients with leukemia develop skin lesions without leukemic infiltration, the resulting nonspecific cutaneous manifestations are known as leukemids.³ Specific cutaneous manifestations of leukemia resulting from direct invasion of leukemic cells into the epidermis, dermis, or subcutis are referred to as leukemia cutis (LC).^2,3

Acute myeloid leukemia (AML) is the most common type of leukemia associated with LC, but LC also is seen in other leukemias with various frequencies.¹ The lesions of LC can present anywhere on skin, though it has been reported that LC has a tendency to occur at sites of prior ongoing inflammation,^2,4 most commonly the extremities, trunk, and face.^2,5,6 LC lesions have a range of morphological findings and most commonly present as nodules, papules, and plaques.^1,7

Most reports of LC in the literature are case reports or case series with small numbers of subjects.^3,6,8 A study of LC patients (N=75) in Korea by Kang et al⁷ has been the only one to analyze clinical characteristics of LC since 2000.

The aim of this study was to further contribute to the knowledge of clinical characteristics of LC. Clinical patterns of 46 patients were analyzed to further characterize the presentation of LC and to compare our results with those in the literature.

Methods

We conducted a single-institution retrospective review of medical records of patients with LC diagnosed in the Department of Dermatology at Wake Forest School of Medicine (Winston-Salem, North Carolina) over a 17-year period (2001-2017). The study protocol was approved by the institutional review board of Wake Forest University School of Medicine (IRB No. 00054474). Patients had a leukemia diagnosis established by bone marrow biopsy. Patients were included in this analysis if they had ongoing active leukemia and a skin biopsy consistent with LC. Patients of all sexes and ages were included in the cohort. Patients were excluded if they presented only with nonspecific cutaneous lesions associated with leukemia (leukemids). After removing duplicate records from a total of 60 patients initially identified, 46 unique patients were included in this study.

Clinical Characterization of Leukemia Cutis Presentation

IN PARTNERSHIP WITH THE SOCIETY FOR DERMATOLOGY HOSPITALISTS

References

Methods

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