Epstein-Barr virus-positive, primary cutaneous marginal zone lymphoma, with transformation: Case report and review of the literature

Am J Clin Pathol. 2025 Feb 12;163(2):298-312. doi: 10.1093/ajcp/aqae124.

Abstract

Introduction: Epstein-Barr Virus (EBV) positive primary cutaneous marginal zone lymphoma (PCMZL) is uncommon and subsequent transformation is rare.

Methods: We report a patient with EBV positive PCMZL with subsequent transformation to plasmablastic lymphoma and review the literature for transformed PCMZL to assess clinical and pathologic characteristics. In the case we describe, the patient presented with multifocal PCMZL, developed large B cell transformation with plasmacytic differentiation, followed by plasmablastic transformation (PBL), and ultimately died of disease progression despite multiple lines of therapy. Past history was significant for psoriatic arthritis (multiple prior lines of immunomodulatory therapy). The lymphomas and non-involved bone marrow share the same somatic DNMT3A and TET2 mutations, suggesting clonal relatedness and an association with clonal hematopoiesis (CH).

Results: Eighteen cases comprised the cohort (seventeen cases from the literature and the case reported herein). Nearly half of the eighteen cases of PCMZL with transformation died of progressive disease (44%). Transformed cases were more commonly seen in patients with >2 sites at initial diagnosis. EBV was assessed in 5 patients, 3 were positive (all died of disease). Two patients with NGS studies demonstrated TET2 and DNMT3A mutations.

Conclusions: Transformation of EBV positive PCMZL appears to be a poor prognostic indicator, with our reported case being the first well defined case transformed to PBL, suspected to arise from myeloid-CH.

Keywords: EBV; PCMZL; clonal hematopoiesis; plasmablastic; primary cutaneous marginal zone lymphoma; transformation.

Publication types

  • Case Reports
  • Review

MeSH terms

  • Aged
  • Cell Transformation, Neoplastic / genetics
  • Cell Transformation, Neoplastic / pathology
  • DNA Methyltransferase 3A
  • DNA-Binding Proteins
  • Dioxygenases
  • Epstein-Barr Virus Infections* / complications
  • Epstein-Barr Virus Infections* / pathology
  • Fatal Outcome
  • Female
  • Herpesvirus 4, Human / genetics
  • Herpesvirus 4, Human / isolation & purification
  • Humans
  • Lymphoma, B-Cell, Marginal Zone* / genetics
  • Lymphoma, B-Cell, Marginal Zone* / pathology
  • Lymphoma, B-Cell, Marginal Zone* / virology
  • Male
  • Middle Aged
  • Mutation
  • Plasmablastic Lymphoma / diagnosis
  • Plasmablastic Lymphoma / genetics
  • Plasmablastic Lymphoma / pathology
  • Plasmablastic Lymphoma / virology
  • Skin Neoplasms* / genetics
  • Skin Neoplasms* / pathology
  • Skin Neoplasms* / virology

Substances

  • TET2 protein, human
  • DNA Methyltransferase 3A
  • DNA-Binding Proteins
  • Dioxygenases