A 70-year-old woman developed red-to-violaceous papules, plaques, and nodule- like skin lesions several months prior to her presentation. The skin lesions mostly involved her lower neck and abdominal area (Figure 1). Initial topical and/or systemic treatments with antibiotic, antifungal, and allergy medications failed to provide a definitive clinical improvement, so a skin biopsy was performed. Hematoxylin and eosin staining of the skin biopsy revealed a dense lymphoid infiltrate involving the dermis, with small- to intermediate-sized lymphoid cells (Figure 2). Immunophenotyping confirmed the presence of B cells with positive CD20 and BCL2, as well as partially positive MUM1. Tests for CD3, CD10, BCL6, cyclin D1, CD5, CD23, CD30, terminal deoxynucleotidyl transferase, kappa, lamda, and CD34 were negative (Figure 3). The Ki-67 proliferative index was 20%, and the clonality of B lymphocytes was analyzed on paraffin-embedded, unstained slides from the skin biopsy. DNA amplification by polymerase chain reaction using consensus primers to the heavy locus (IGH) gene variable and joining regions was performed. A strong clonal gene rearrangement was detected to the framework II (FR2) region at 282 base pairs, and to the framework III (FR3) region at 142 base pairs (Figure 4).
Based on the clinical presentation and pathology of the skin biopsy, what is the most likely diagnosis?
A. Primary cutaneous follicle center lymphoma
B. Primary cutaneous marginal zone lymphoma
C. Primary cutaneous large B-cell lymphoma
D. Secondary involvement of skin by noncutaneous marginal zone lymphoma
E. Both B and D
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