Extranodal natural killer/T-cell lymphoma, nasal type, involving the skin, misdiagnosed as nasosinusitis and a fungal infection: A case report and literature review

Abstract

The present study reports a case of extranodal natural killer (NK)/T-cell lymphoma, nasal type, involving the skin. The clinical manifestations, pathological characteristics, treatment and prognosis of the case were analyzed to improve the clinical diagnosis and treatment for this disease. The patient was a 56-year-old male, presenting with dark red nodules and plaques that had been visible on the nose for half a year. Based on the skin lesions and histopathological and immunohistochemical examination results, the patient was diagnosed with extranodal NK/T-cell lymphoma, nasal type. This disease has unique histopathological and immunohistochemical features and a high malignancy. The condition tends to be misdiagnosed and has a poor prognosis, but seldom involves the skin. In the present case, only radiotherapy was performed, with no relapse occurring within 6 months.

Keywords: lymphoma; nasal type; natural killer/T cell; skin perforation.

Figure 1

Image of the nodule upon initial presentation.

Figure 2

(A) Image of the nodule captured one week after the biopsy procedure. (B) One week after the biopsy procedure, following the removal of the stitches.

Figure 3

Fungal culture with negative results.

Figure 4

Two weeks after the biopsy procedure. The damaged skin around the lesion site demonstrated improvement, but the size of the ulcer had increased.

Figure 5

Biopsy samples from the left wing of the nose. (A) Dermis exhibiting epidermal necrosis and erosion, hyperkeratosis of the skin, side dyskeratosis, crusting and epidermal angle extension. Dermal shallow central vascular dilatation and extravasation of erythrocytes is also present. In addition, infiltration of the lymphocytes, plasma cells and neutrophils into the dermis, with profuse necrosis, may be observed (bar = 4 mm). The extent of image 5(B) is indicated by a small black boxand the extent of image 5(D) is indicated by a larger black box. (B) The specific lymphocytes in the lower dermis and subcutaneous sections of the biopsy sample (bar = 200 μm). The majority of large cells, which positively stained for CD56 were NK cells and the majority of small cells were T-cells. There are more medium and large cells with thick nuclear membranes. The chromatin within the cells is fine and the plasmosomes are not evident. Mitotic phases are more common and are attached to vessels. The extent of image 5(C) is indicated by a large black box. (C) Image (bar = 100 μm) (B) at a higher magnification. (D) Large areas of necrosis and infiltration of neutrophils (bar = 1 mm). Hematoxylin and eosin staining.

Figure 6

(A) Biopsy sample positive for cytoplasmic cluster of differentiation (CD)3ɛ expression. The extent of image (B) is indicated by a black box. (B) Magnification of the black box in image (A). CD3ɛ-cytoplasmic-positive results. (A) Bar = 4 mm. (B) Bar = 2 mm.

Figure 7

(A) Biopsy sample positive for Epstein-Barr virus-encoded small RNA (EBER) expression (bar = 4 mm). The extent of image (B) is indicated by a black box. (B) Magnification of the black box in image (A) (bar = 500 μm). EBER-positive results.

Figure 8

(A) Biopsy sample positive for cluster of differentiation (CD)56 expression (bar = 4 mm). The extent of image (B) is indicated by a black box. (B) Magnification of the black box in image (A) (bar = 2 mm). CD56-positive results.

Figure 9

(A) Biopsy sample positive for granzyme B expression (bar = 4 mm). The extent of image (B) is indicated by a black box. (B) Magnification of the black box in image (A) (bar = 2 mm). Granzyme B-positive results.

Figure 10

Biopsy sample positive for TIA1 expression. Bar = 200 μm.

Figure 11

(A) Biopsy sample with a Ki67 proliferation index of 60–70% (bar = 4 mm). The extent of image B is indicated by a black box. (B) Magnification of the black box in image (A) (bar = 2 mm). Ki67 index of 60–70%.

Figure 12

Biopsy samples negative for (A) cluster of differentiation (CD)5 (bar = 2 mm), (B) CD20 (bar = 4 mm) and (C) CD2 expression (bar = 1 mm).

Figure 13

(A) Lesion site one month after treatment. (B) Magnified version of image (A) showing the oval defect and healed scar.