Cameo Large B-cell lymphoma of the leg Elsa Vasquez-del-Mercado, MD, Sonia Toussaint, MD, Fernando de la Barreda, MD, and Carlos Ortiz-Hidalgo, MD A 74-year-old Mexican man presented with an 18-month history of multiple, violaceous, coalescing, ®rm, tender nodules with an ulcer in the anterior aspect of the right leg (Fig. 1) and slightly in®ltrated, ill-de®ned erythematous plaques affecting the left leg and both forearms. He had not received any treatment for his condition. Past medical history was relevant for noninsulin-dependent diabetes mellitus and hypertension without formal treatment and a history of heavy alcohol intake in his youth. A biopsy specimen of both plaque-type lesions of the forearm and tumorous lesions of the leg showed a diffuse, nonepidermotropic mononuclear in®ltrate throughout the dermis and extending to the subcutis. The in®ltrate was composed of pleomorphic, atypical, large mononuclear cells (Fig. 2). Immunostaining with CD20 was positive for the atypical cells while CD3 was positive for normal appearing lymphocytes, characterized as reactive T cells. Additional laboratory and image studies ruled out extracutaneous involvement. The diagnosis of primary cutaneous large B cell lymphoma of the leg (LBCLL) was made. The patient was initiated on radiotherapy localized to the right leg with a very good initial response, nevertheless resolution was not achieved and the plaques in the rest of the limbs remained unchanged. Thus, the patient started chemotherapy with CHOP (Cyclophosphamide, Vincristine, Doxorubicin, Prednisone). He has currently ®nished his fourth cycle with this chemotherapy regimen. The tumorous lesions involuted leaving only residual hyperpigmentation (Fig. 3) and the plaques in the rest of the limbs disappeared, the area of the ulcer diminished considerably. There is still no evidence of extracutaneous involvement. Discussion Large B cell lymphoma of the leg (LBCLL) has recently been described as a distinct entity among the primary cutaneous B-cell lymphomas (CBCL), nevertheless con- troversy still exist and consensus was not reached at a recent meeting of the European Organization for Research and Treatment of Cancer (EORTC). 1 Described as a follicular center cell lymphoma or as B-cell immuno- blastic lymphoma, the LBCLL differs from other CBCL affecting the head and trunk. CBCL affects younger individuals, it has a much better prognosis and response to radiotherapy and relapse is less frequent. 2,3 Large B cell lymphoma of the leg has been described mainly in elderly women, most of the cases con®ned to one leg in its distal portion with a relapse rate as high as 50%. Survival rates reported for LBCLL are 77% and 58% at 2 and 5 years, respectively, compared with 95% at 5 years for CBCL. 3 It has been reported that LBCLL expresses ICAM-1 and bcl-2 protein and seems to have a follicular center origin. 1,4 Large numbers of reactive T cells have also been noted among the in®ltrate in some of de CBCL which have been denominated T-cell rich B-cell lymphomas. 5 The EORTC classi®cation excludes chromosomal changes, that is one of the reasons why some authors From the Department of Dermatology, Hospital General Dr Manuel Gea Gonza  lez, Mexico City, Mexico, the Department of Dermatology, Instituto Nacional de Cancerologõ Âa, Mexico City, Mexico and the Department of Pathology, American British Cowdray Hospital, Mexico City, Mexico Correspondence Elsa Vasquez-del-Mercado, MD Hospital General Dr Manuel Gea Gonza Âlez Calzada de Tlalpan 4800 Col. Toriello Guerra, CP 14000 Mexico, DF E-mail: elsavmk@yahoo.com Figure 1 Nodules and ulcer in the anterior aspect of the right leg 646 International Journal of Dermatology 2001, 40, 646±647 ã 2001 Blackwell Science Ltd