Cutaneous presentation of Diffuse large B cell lymphoma: BMJ
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An 85-year-old patient was brought to the emergency department due to progressive weight loss and bed confinement over a period of 6 months. After recollecting a fully detailed medical history, the patient describes the growth of a gruelling mass on her right breast over the course of 1 year, with no mention of other concurrent symptoms such as fever or diaphoresis.

On her physical examination, there was an extremely emaciated patient with a performance status Eastern Cooperative Oncology Group (ECOG) 4, presenting with multiple subcutaneous nodules distributed mainly through her upper body, the largest in size being the one on her right breast already with evidence of tissue necrosis and coexisting right axillary lymphadenopathies.

A full body CT Scan revealed uncountable lymph nodes mainly on the mediastinum, abdomen and pelvic regions, also with extensive subcutaneous and soft-tissue involvement of the right breast.

For diagnostic purposes, the patient underwent a fine-needle biopsy of the right breast nodule, which histopathology revealed to be a large cell diffuse lymphoma non-germinal centre B cell CD20+, CD5+, MUM1+, bcl-2+, with a proliferation index of 70% compatible.

Learning points
• The differential diagnosis of primary nodular skin lesions opens a wide number of hypothesis making it a challenge for the clinician to investigate other signs and symptoms that allow for a better diagnostic approach.

• The first clinical sign of diffuse large B-cell lymphoma (DLBCL) is a quickly growing, non-painful mass, typically a lymph node in the neck, groin or abdomen, which may be accompanied with type B symptoms making this case an atypical presentation as for the initial absence of B symptoms but also the location of skin lesion.

• Subcutaneous nodule as the presenting sign of DLBCL is a rare form of primary presentation. The uncommon incidence of such manifestations in this subtype of neoplasia justifies reporting this case and highlights the importance of multidisciplinary teams in the management of patients with cancer.

• Onset presentation on an older female patient versus most current reports that focus on younger patients of the male sex with better outcomes at the point of diagnosis, makes this case explanatory of how diagnostic approach and prognostic indicators are relevant.

• The majority of cases reported of primary or secondary skin lesions of lymphoma focus on patients with singular, patchy or smaller dimension nodules making this presentation less frequent.

• This case is explanatory of how an adequate evaluation of patient’s performance status and burden of disease should be used as markers for treatment feasibility and outcome.

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