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Journal of Clinical Oncology, Vol 23, No 28 (October 1), 2005: pp. 7246-7248 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.03.0395
Cutaneous Lymphomas Reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results Program: Applying the New WHO–European Organisation for Research and Treatment of Cancer Classification SystemNational Cancer Institute, National Institutes of Health, Bethesda, MD To the Editor: As noted in the recent study by Smith et al,1 there is a paucity of data describing primary cutaneous B-cell lymphoma in the United States, and discordant results have been reported in other countries. Interestingly, the study by Smith et al1 was published nearly synchronously with the new WHO–European Organisation for Research and Treatment of Cancer (EORTC) classification system for primary cutaneous lymphoma, which utilized data from the Dutch and Austrian Cutaneous Lymphoma Group (DACLG) to describe the relative frequency and survival of the entities within the new classification.2 Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program, we sought to apply the WHO-EORTC classification system to compare results with results from the DACLG. The SEER program classifies information on histology and topography according to the International Classification of Diseases for Oncology–Third Edition (ICD-O-3).3 Using ICD-O codes specified in the WHO Classification of Tumors of Hematopoietic and Lymphoid Tissues and histologic descriptions of the WHO-EORTC classification, we attempted to categorize primary cutaneous lymphomas (histology codes 9670-9729 and topography codes C440-C449) in SEER into categories specified in the WHO-EORTC system (see Appendix).2,4 In those instances where entities in the WHO-EORTC system were not specified in the ICD-O-3 coding scheme, we included the entities under broader disease categories. Incidence rates (IR) and disease-specific 5-year actuarial survival were derived from SEER*Stat 6.1.4.5 We identified 4,310 cases of primary cutaneous lymphoma diagnosed from 1992 to 2002 among patients in 13 population-based cancer registries. Primary cutaneous T-cell lymphoma and primary cutaneous B-cell lymphoma accounted for 76.9% and 22.7% of cases in SEER, respectively (Table 1), similar to the DACLG.2 Mycosis fungoides was the most common entity in SEER (45%; IR = 0.51 per 100,000 person-years) and in the DACLG (44%). Sézary syndrome was relatively rare in SEER (1.3%; IR = 0.02) and in the DACLG (3%). Taken together, entities comprising the broader category of peripheral T-cell lymphoma made up more than 25% (IR = 0.29) of cutaneous lymphomas in SEER compared with less than 6% in the DACLG. Collectively, diffuse large B-cell lymphoma comprised 12% (IR = 0.14) of the cutaneous lymphomas in SEER, and was associated with a disease-specific 5-year survival of 81.7%. In comparison, diffuse large B-cell lymphoma accounted for less than 6% of all cutaneous lymphomas in the DACLG, and had a disease-specific 5-year survival of 50% to 65%.
In sum, when categorizing primary cutaneous lymphoma according to the new WHO-EORTC classification system, similarities and differences were noted between SEER and the DACLG. We did not undertake a centralized clinical and pathologic review of cases, but rather relied on ICD-O codes that reflect the diagnostic practices of clinicians across the 13 registry catchment areas in the United States. As the WHO-EORTC classification for cutaneous lymphoma is incorporated into the community, diagnostic practices will evolve to reflect the new classification system. By necessity, the ICD-O coding scheme will similarly need to incorporate the new entities defined in the WHO-EORTC classification. Our discordant results suggest that we were currently unable to completely translate SEER data into WHO-EORTC categories. The extent to which geographic variation between United States and European populations, diagnostic misclassification, treatment, or other factors contribute to our findings is uncertain. Large-scale population-based data can be used to complement information from smaller clinical studies to advance our understanding of lymphomas. However, to maximize the potential of population-based data for primary cutaneous lymphoma, classification schemes will need to evolve in parallel. Appendix
ICD-O-3 codes corresponding to cutaneous lymphoma subtypes included in Table 1: Mycosis fungoides [9700]. ICD-O codes for WHO–European Organisation for Research and Treatment of Cancer (EORTC) –defined mycosis fungoides subtypes and variants (folliculotropic mycosis fungoides, pagetoid reticulosis, granulomatous slack skin) were not available. CD30+ lymphoproliferative disorders [9714, 9718] included anaplastic large cell lymphoma (T-cell and null-cell type) and primary cutaneous CD30+ T-cell lymphoproliferative disorder, including lymphomatoid papulosis. WHO-EORTC entities included herein are primary cutaneous anaplastic large cell lymphoma and lymphomatoid papulosis. Subcutaneous panniculitis-like T-cell lymphoma [9708]. Sézary syndrome [9701]. NK/T-cell lymphoma, nasal type [9719]. Peripheral T-cell lymphoma [9702, 9705, 9709] included mature T-cell lymphoma, not otherwise specified; angioimmunoblastic T-cell lymphoma; and cutaneous T-cell lymphoma, not otherwise specified. WHO-EORTC entities included herein include CD4+ small/medium pleomorphic T-cell lymphoma (indolent clinical behavior) and aggressive CD8+ T-cell lymphoma, Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES
1. Smith BD, Smith GL, Cooper DL, et al: The cutaneous B-cell lymphoma prognostic index: A novel prognostic index derived from a population-based registry. J Clin Oncol 23:3390-3395, 2005
2. Willemze R, Jaffe ES, Burg G, et al: WHO-EORTC classification for cutaneous lymphomas. Blood 105:3768-3785, 2005 3. Fritz A, Percy C, Jack A, et al: (eds): International Classification of Diseases for Oncology (ed 3). Geneva, Switzerland, World Health Organization, 2000 4. Jaffe ES, Harris NL, Stein H, et al: (eds): World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues. Lyon, France, IARC Press, 2001 5. Surveillance, Epidemiology, and End Results (SEER) Program: SEER*Stat SEER 13 Public-Use Database, Nov 2004 (1992-2002). Bethesda, MD, National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch. Released April 2005, based on the November 2004 submission
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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T-cell lymphoma, and peripheral T-cell lymphoma (all with aggressive clinical behavior). Marginal zone B-cell lymphoma [9670, 9671, 9699] included malignant lymphoma, small B lymphocytic, not otherwise specified; malignant lymphoma, lymphoplasmacytic; and marginal zone B-cell lymphoma, not otherwise specified. Follicle center lymphoma [9690, 9691, 9695, 9698] included follicular lymphoma, not otherwise specified; follicular lymphoma, grade 2; follicular lymphoma, grade 1; and follicular lymphoma, grade 3. Diffuse large B-cell lymphoma [9675, 9680, 9684] included malignant lymphoma, mixed small and large cell, diffuse; malignant lymphoma, large B-cell, diffuse, not otherwise specified; and malignant lymphoma, large B-cell, diffuse, immunoblastic, not otherwise specified. ICD-O-3 topography codes: leg [C447], specified site other than leg [C440-446], overlapping lesions or unspecified site [448-449]. 
