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Paper text:
cutaneous lymphomas form the second most common group of extranodal non - hodgkin 's lymphoma .
t - cell lymphomas comprise 65% of the cases , whereas b - cell lymphomas form 25% of the cutaneous lymphomas .
primary cutaneous anaplastic large cell lymphoma ( pcalcl ) forms 9% of the cutaneous t - cell lymphomas .
there are three types of anaplastic large cell lymphoma : pcalcl , primary systemic anaplastic lymphoma kinase ( alk)-positive alcl , and primary systemic alk - negative alcl . the diagnosis of primary cutaneous alcl is made only if the lesions are limited to the skin for at least 6 months after the initial identification .
therefore , regular follow up of these patients is important to rule out any systemic disease .
a 35-year - old man presented with a complaint of asymptomatic red raised nodule over chin for last 15 days .
after a few days , the lesion increased in size and progressed to form an erythematous nodule , which used to bleed easily .
on cutaneous examination there was a single well - defined exophytic erythematous nodule of size 4  3 cm approximately , with a glistening surface [ figure 1 ] .
lesion used to bleed easily on touch and was nontender . in view of these clinical findings
complete hemogram , routine biochemistry , hiv test , and chest x - ray were within normal limit .
fine - needle aspiration cytology ( fnac ) from the lesion revealed cellular smears comprising of large atypical lymphoid cells in isolation .
the dermis showed diffuse infiltrate of large atypical lymphoid cells with pleomorphic round to irregular horse shoe - shaped nuclei , finely granular chromatin , multiple nucleoli , and moderate cytoplasm .
in addition there were increased apoptotic cells , neutrophils , and erythrophagocytosis [ figure 2 ] .
keeping in view the histopathology , and cd45 and cd30 positivity , the diagnosis of alcl was made .
ultrasonography of neck revealed regional cervical lymphadenopathy involving levels i  iii ; largest lymph node measuring 0.4  0.3 cm .
the patient was started on chop regimen , which consisted of cyclophosphamide , doxorubicin , vincristine , and prednisolone .
after first cycle of chemotherapy there was a significant reduction in the size of the lesion [ figure 5 ] .
exophytic erythematous nodule mimicking a large pyogenic granuloma in the submandibular region photomicrograph showing diffuse infiltrate of large atypical lymphoid cells with pleomorphic round to irregular nuclei ( h and e , 40 ) tumor cells showing 1 + positivity for cd45 tumor cells showing strong ( 4 + ) cd30 membranous positivity improvement in lesion after first cycle of chemotherapy
lymphoproliferative disorders of the primary cutaneous cd30 + type , of t - cell origin , consist of lymphomatoid papulosis , and cd30 + anaplastic large cell lymphoma .
it commonly affects the trunk , extremities , and presents as solitary or multiple localized nodules with ulceration .
but , sometimes it resembles other dermatological diseases like eczema , pyoderma gangrenosum , pyogenic granuloma , morphea , and squamous cell carcinoma .
pyogenic granuloma is a common benign vascular tumor , which appears as a smooth , lobulated , exophytic mass , exhibiting pink to reddish - purple color , which can bleed on slight manipulation .
cutaneous cd30 + anaplastic large cell lymphoma ( alcl ) is characterized by presence of cd30 expression in more than 75% of neoplastic cells .
presence of cytogenetic abnormality , that is , nonrandom t(2 ; 5 ) ( p23 ; q35 ) chromosomal translocation which involves fusion of anaplastic lymphoma kinase ( alk ) with the nucleophosmin ( npm ) gene is usually seen in systemic alcl but only rarely in pcalcl .
pcalcl usually presents as a solitary papulonodular lesion , which sometimes shows ulceration . our case presented with a large pyogenic granuloma - like lesion .
reported a case of systemic alcl with local cutaneous involvement in the form of nonhealing pyogenic granuloma - like lesion in the right axillary area .
reported a case of 57-year - old man who presented with asymptomatic lobulated erythematous nodule on the gingiva mimicking pyogenic granuloma .
there was no regional lymphadenopathy and systemic involvement ; however , he was hiv positive .
our patient had a similar morphology of lesion but he was younger in age , immunocompetent , and had regional lymphadenopathy . generalized or multifocal lesions are seen in about 20% of the patients .
secondary regional lymphadenopathy is seen in approximately 25% of patients and it does not correlate with the prognosis of the disease . in our patient ,
systemic alcl was ruled out as all the related investigations were within normal limit and there was no systemic lymphadenopathy .
a five - year survival rate of pcalcl is more than 90% but cutaneous disease arising from systemic
alk expression in cutaneous lesions usually indicates systemic disease but rarely , it can be positive in pcalcl .
also negative expression of alk does not rule out systemic disease as 20%60% of systemic alcl can be alk negative .
twenty - five percent of the cases of primary cutaneous anaplastic cd30 + large t - cell lymphoma can also remit spontaneously .
alcl can have varied cutaneous presentations . being uncommon , it may be missed . as the cutaneous lesions can be the only manifestation in a case of systemic alcl
, clinicians should keep a high suspicion so that the disease can be detected at an early stage .
primary cutaneous anaplastic large cell lymphoma ( pcalcl ) forms 9% of the cutaneous t - cell lymphomas . 
 it usually presents as solitary reddish brown ulcerating nodule or indurated plaque . 
 sometimes , it mimics other dermatological diseases such as eczema , pyoderma gangrenosum , pyogenic granuloma , morphea , and squamous cell carcinoma . our case presented with large pyogenic granuloma like lesion with regional lymphadenopathy . 
 since pcalcl is rare , one can misdiagnose such cases and therefore high index of suspicion is necessary .