10.5826/dpc.1303a176
text/xml
2160-9381
2865
en
María Mercedes  Nusshold
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermoscopy
Rosettes: An Additional Clue for the Identification of the Primary Cutaneous Marginal Zone Lymphoma
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Letter to the Editor
2023-07-31
2022-09-30
2023-07-31
2023-08-24
e2023176
Dermatol Pract Concept
María Mercedes  Nusshold
2023/07/31
10.5826/dpc.1303a176
e2023176
School of Medicine, University of Buenos Aires, Argentina
2160-9381
dermoscopy
en
e2023176
Piccolo V, Russo T, Agozzino M, et al. Dermoscopy of Cutaneous Lymphoproliferative Disorders: Where Are We Now? Dermatology. 2018;234(3-4):131-136. DOI: 10.1159/000490412. PMID: 30032152.
Rosettes: An Additional Clue for the Identification of the Primary Cutaneous Marginal Zone Lymphoma
https://dpcj.org/index.php/dpc/article/download/2865/2251
 Rosettes: An Additional Clue for the Identification
of the Primary Cutaneous Marginal Zone Lymphoma
          Maria Eugenia Gil1, Rosario Peralta2, Maria Cecilia Laporta1, Jimena Lorenzo1,
                                   María Mercedes Nusshold1


1 School of Medicine, University of Buenos Aires, Argentina
2 Dermatology Department, Instituto de Investigaciones Médicas “A. Lanari”, University of Buenos Aires, Argentina



Key words: rosettes, lymphoma, primary cutaneous marginal zone lymphoma, dermoscopy
Citation: Gil ME, Peralta R, Laporta MC, Lorenzo J, Nusshold MM. Rosettes: An Additional Clue for the Identification of the Primary
Cutaneous Marginal Zone Lymphoma. Dermatol Pract Concept. 2023;13(3):e2023176. DOI: https://doi.org/10.5826/dpc.1303a176
Accepted: March 1, 2023; Published: July 2023
Copyright: ©2023 Gil et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Maria Eugenia Gil, MD, Paraguay 2155, Ciudad Autónoma de Buenos Aires, Argentina.
Tel: (+54) 011-61562798, E-mail: meugenia@fmed.uba.ar




Introduction                                                             salmon-colored area/background, serpiginous vessels, and
                                                                         multiple rosettes (Figure 1).
Primary cutaneous marginal zone lymphoma (PCMZL) is a                         Neither adenopathies nor other lesions were palpated in
B-cell lymphoma arising in the skin and accounts for a low               the rest of the tegument. The histopathological examination
incidence of all primary cutaneous lymphomas (2-7%) [1].                 presented preserved epidermis and a dense dermal lymphoid
Dermoscopic features that have been described are                        infiltration, which was arranged in a nodular pattern. The im-
­salmon-colored area/background, serpentine vessels, scales              munohistochemistry was characterized by the expansion of
and white circles [2]. Rosettes are a specific form of a white           the marginal zone cellular population BCL 2 + and CD 20 +.
shiny structure seen with polarized dermoscopy [3]. We re-               Nodal lymphocytes were CD3 - and peripheral lymphoid
port a case showing multiple rosettes on PCMZL.                          population was CD3+ (Figure 2).
                                                                              The diagnosis was PCMZL. A blood test was performed,
Case Presentation                                                        with normal values: hemogram, hepatogram, urine and cre-
                                                                         atinine, beta two microglobulin assay, lactate dehydrogenase
A 36-year-old male patient presented an 8-month history                  (LDH) and serological test for Epstein Barr Virus (EBV) and
of an enlarging asymptomatic lesion on his lower back.                   Cytomegalovirus (CMV). The computed tomography (CT)
Physical examination showed a well-defined, indurated,                   evaluation displayed no other lesions and the surgical exci-
reddish plaque measuring 1 x 2 cm. Dermoscopy revealed                   sion with 2 cm of diameter was performed.




Research Letter | Dermatol Pract Concept. 2023;13(3):e2023176                                                                         1
       Figure 1. (A-B) Clinical presentation of a well-defined, indurated, reddish plaque measuring 1 x 2 cm on lower back (white
       circle). (C) Polarized dermoscopy shows a salmon-colored background with serpiginous vessels (black circle) and multiple
       rosettes (arrows) of different sizes.




Figure 2. Histopathological analysis. (A) Dense dermal lymphoid infiltrate which was arranged in a nodular pattern (H&E, ×10).
(B) Preserved epidermis (H&E, ×40). (C) CD3 – nodal lymphocytes/CD3 + peripheral lymphoid population. (D) BCL2 +. (E) CD 20+.



Conclusions                                                           significance are not known. There are different types that
                                                                      would be caused by the interaction of keratin-filled adnexal
Rosettes are defined as 4 bright white circles arranged as            openings with the polarized light: smaller ones (0.1-0.2
a square resembling a 4-leaf clover, mainly localized in              mm), usually oriented at the same angle, and larger ones that
the follicular openings. Despite being well-described der-            would be the result of concentric fibrosis around the follicles
moscopically, the precise histology correlation and optical           (0.2-0.5 mm) [3].



2                                                                         Research Letter | Dermatol Pract Concept. 2023;13(3):e2023176
     Table 1. Dermoscopy findings of primary                           Diagnosis of PCMZL may be challenging and histopatho-
           cutaneous B-cell lymphoma.                              logical examination is mandatory for a definite diagnosis.

       Dermoscopy findings of primary cutaneous                    Dermoscopy could play an adjuvant role in the achievement
                  B-cell lymphoma                                  of the diagnosis. This case provides an additional clue for its
 Salmon-colored background area                                    identification.
 Arborizing /Serpentine vessels
 Scales
 White circles                                                     References
 Rosettes
                                                                    1. Vitiello P, Sica A, Ronchi A, Caccavale S, Franco R, Argenziano G.
                                                                       Primary Cutaneous B-Cell Lymphomas: An Update. Front Oncol.
   They have been characteristically described in actinic              2020;10:651. DOI: 10.3389/fonc.2020.00651. PMID: 32528871.
keratosis and squamous cell carcinoma. However, they were              PMCID: PMC7266949.
commonly seen in non-lesional actinic damaged skin, scars,          2. Geller S, Marghoob AA, Scope A, Braun RP, Myskowski PL.
many tumoral and inflammatory skin lesions and hence are               Dermoscopy and the diagnosis of primary cutaneous B-cell lym-
                                                                       phoma. J Eur Acad Dermatol Venereol. 2018;32(1):53-56. DOI:
not lesion specific.
                                                                       10.1111/jdv.14549. PMID: 28846171. PMCID: PMC5773353.
   Related to cutaneous lymphoproliferative disorders there
                                                                    3. Peralta R, Salerni G, Sabban EC, Marin MB, Cabo H. Dermoscopy
are isolated reports of their presence in T-cell pseudolym-            of a Squamous Cell Carcinoma of the Lower Lip Showing Mul-
phoma and classic Mycosis Fungoides in patients with skin              tiple Rosettes. Dermatol Pract Concept. 2019;10(1):e2020022.
of color [4-5].                                                        DOI: 10.5826/dpc.1001a22. PMID: 31921509. PMCID:
   The dermoscopic findings of primary cutaneous B-cell                PMC6936628.
                                                                    4. Alves RG, Ogawa PM, Enokihara MMSES, Hirata SH. Rosettes
lymphomas are not specific, characterized by s­ almon-colored
                                                                       in T-cell pseudolymphoma: a new dermoscopic finding. An Bras
background/area, serpentine vessels, scales and white
                                                                       Dermatol. 2021;96(1):68-71. DOI: 10.1016/j.abd.2020.05.010.
circles [6]. Considering that the size of the rosettes can vary,       PMID: 33288369. PMCID: PMC7838094.
we noticed in our case multiple small rosettes like targeted        5. Nakamura M, Huerta T, Williams K, Hristov AC, Tejasvi T.
follicles instead of white circles. Both signs could be a pro-         Dermoscopic Features of Mycosis Fungoides and Its Vari-
gression of the same feature [3].                                      ants in Patients with Skin of Color: A Retrospective Analysis.
                                                                       ­Dermatol Pract Concept. 2021;11(3):e2021048. DOI: 10.5826
   Differential diagnosis of PCMZL is wide, including be-
                                                                        /dpc.1103a48. PMID: 34123556. PMCID: PMC8172036.
nign and malignant diseases. They are frequently misdiag-
                                                                    6. Piccolo V, Russo T, Agozzino M, et al. Dermoscopy of Cuta-
nosed as inflammatory and infectious lesions or as other                neous Lymphoproliferative Disorders: Where Are We Now?
cutaneous neoplasms such as basal cell carcinoma or amel-               Dermatology. 2018;234(3-4):131-136. DOI: 10.1159/000490412.
anotic melanoma.                                                        PMID: 30032152.




Research Letter | Dermatol Pract Concept. 2023;13(3):e2023176                                                                          3
