Hemopneumothorax secondary to multiple cavitary metastasis in angiosarcoma of the scalp

We report a case of hemopneumothorax secondary to multiple cavitary metastasis in the angiosarcoma of the scalp in an 86-year-old woman, who died of respiratory failure. At autopsy, multiple cavities were found in both lungs. Histologic specimen of the cavitary metastasis of the lung showed that tumor cells proliferated forming several tubular spaces and these tubular spaces seemed to communicate with the central cyst. These findings suggested that imperfect vessel-like structures of the cavitary metastasis are likely to break down and finally grow up to large thin-walled cavities.

Sebaceous epithelioma

An 83-year-old woman had developed an asymptomatic, yellowish, dome-shaped skin tumor on her scalp which had enlarged for a period of 60 years to 10 x 10 x 10 mm in size. Histopathologically, the tumor consisted of undifferentiated basaloid cells, differentiated sebaceous cells and transitional cells. Although the basaloid cells resembled those of basal cell epithelioma (BCE), the tumor was distinct from BCE in the following points; existence of cystic spaces, no peripheral palisading, no proliferation of connective tissue stroma, and no tendency toward local invasion. Immunohistochemical studies using antikeratin monoclonal antibodies revealed that the tumor contained both the keratin types of BCE and of sebaceous glands. Electron microscopically, the tumor cells contained lipid droplets and keratohyaline granules in their cytoplasm. It is suggested that "sebaceous epithelioma" is a benign skin tumor which may be distinguished cytologically from BCE.

Synchronous dural and cutaneous metastases along the distribution of the external carotid artery

Dural metastases in the posterior fossa are relatively rare. We report a combination of cutaneous metastases in the scalp of the occiput with ipsilateral dural metastasis in the posterior fossa, on the inferior surface of the tentorium. It is suggested that all the metastases spread via the external carotid artery.

Malignant aneuploid spindle-cell transformation in a proliferating trichilemmal tumour

A case of spindle-cell carcinoma developed on a proliferating trichilemmal tumour (PTT) is presented. The tumour on the scalp of an 84-year-old white woman was excised and histological examination showed typical features of PTT, but with a coexistent malignant spindle-cell tumour with a sarcomatoid appearance. There were some areas of transition between squamous trichilemmal epithelium and the neoplastic mass composed of atypical spindle-shaped cells. Two years later, the patient was well, and neither recurrence nor metastases were observed. We report the second case of PTT with a malignant spindle-cell transformation with a sarcomatoid appearance (spindle-cell carcinoma), and a proven aneuploidy, demonstrated with DNA-flow cytometric analysis.

Differences in testosterone metabolism by beard and scalp hair follicle dermal papilla cells

OBJECTIVE

Androgens have paradoxically different effects on hair follicles depending on body site, stimulating beard growth while inducing regression in some areas of the scalp. The mesenchyme derived dermal papilla at the base of the hair follicle regulates many aspects of the growth of follicular epithelium, and is probably the site of androgen action. Since 5 alpha-dihydrotestosterone is considered to be the active intracellular androgen in many target tissues and is required for some androgen-mediated hair growth, such androgen-sensitive cells should contain 5 alpha-reductase. This study was designed to investigate whether cultured human dermal papilla cells contain 5 alpha-reductase and whether the metabolic capacity varies with the body site of the follicle in line with the clinical picture.

DESIGN

Testosterone metabolism in cultured dermal papilla cells from androgen sensitive beard follicles was compared with less androgen dependent non-balding scalp follicles. Primary cell cultures were established from follicles of 11 patients with normal hair growth. The cells were grown to confluence in 10-cm Petri dishes and incubated with 5 nM 3H-testosterone in serum-free medium for 2 hours. The cells and the culture medium were collected separately for individual analysis.

MEASUREMENTS

Unlabelled carrier and 14C-marker steroids were added to both the cell and medium extracts before separation by thin-layer chromatography. The individual steroid identities were confirmed by recrystallizing up to five times to a constant 3H/14C ratio.

RESULTS

Testosterone was taken up by both cell types; significant amounts of 5 alpha-dihydrotestosterone were recovered inside beard cells, but not in scalp cells, whereas androstenedione was identified in both. An unidentified compound was present intracellularly in both cell types, but was not present in the culture medium. 5 alpha-Dihydrotestosterone was present only in the culture medium of beard cells but androstenedione was present in a similar amount in the medium from both cell types. The presence of other steroids could not be confirmed in either the cell extracts or the culture medium.

CONCLUSIONS

The production of 5 alpha-dihydrotestosterone by beard cells concurs with the poor beard growth in men with 5 alpha-reductase deficiency, supporting our hypothesis that androgens mediate their effects on the hair follicle via the mesenchyme-derived dermal papilla.

Detection of proopiomelanocortin-derived antigens in normal and pathologic human skin

We investigated the presence of proopiomelanocortin (POMC) products in sections of skin from normal subjects and patients with neoplastic and non-neoplastic cutaneous disorders. Antibodies specific against adrenocorticotropin, beta-melanotropin, and beta-endorphin were used for detection and characterization of cell types bearing POMC peptides. POMC products were not observed in sections of normal skin from the corporal (non-scalp) areas (six cases), whereas the hair follicles of scalp skin exhibited positive immunostains that were readily apparent (four cases). POMC products were frequently detected in corporal skin affected by diseases (13 of 26 cases), for example, psoriatic keratinocytes, the inflammatory infiltrate in scarring alopecia, nevocytes, the epithelial cell nests of basal cell carcinoma, and melanoma cells. Further tests were performed in keloids, a primary reactive skin disorder, to evaluate whether POMC accumulation represented a disease-related phenomenon or an expression of normal cutaneous reactivity. POMC products were consistently detected (10 of 11 cases) in the keratinocytes and mononuclear cells at keloid lesions. Thus these observations indicate that POMC products may accumulate locally in lesional skin representing, presumably, a novel cutaneous response to injury. The broad spectrum of POMC products detected suggests that these arise from production in situ (expression of the POMC gene itself) by human skin.

Seizure localization in temporal lobe epilepsy: a comparison of scalp-sphenoidal EEG and volumetric MRI

We determined the accuracy of volumetric MRI (based on identification of unilateral hippocampal atrophy) and scalp-sphenoidal EEG (based on concordant interpretations of scalp-sphenoidal ictal EEG by three independent interpreters) for seizure focus localization in 20 patients with temporal lobe epilepsy. All patients became seizure-free or had rare seizures following temporal lobectomy. Among the 20 patients, nine (45%) met both MRI and EEG localization criteria, six (30%) met MRI localization criteria alone, three (15%) met EEG localization criteria alone, and two patients (10%) did not meet either localization criteria. In the 18 patients meeting MRI or EEG localization criteria, the predicted localization agreed with the side of temporal lobectomy. These results suggest that a noninvasive approach combining MRI and EEG will correctly localize the side of seizure onset in most patients with temporal lobe epilepsy.

Intracranial extension of basal cell carcinoma of the scalp

A case of recurrent basal cell carcinoma of the right occipital scalp is reported. Plain film, CT, and MRI examinations of the head demonstrated direct neoplastic invasion through the occipital bone and meninges into the right cerebellar hemisphere.

Microcystic adnexal carcinoma

Microcystic adnexal carcinoma is a rare cutaneous neoplasm characterized by invasive, relentless, and destructive local growth. The incidence of perineural invasion and tumor recurrence is high. We report two cases of microcystic adnexal carcinoma with typical clinical features. The use of formalin-fixed, paraffin-embedded horizontal Mohs sections is described in one case. We also review the current concepts and management of microcystic adnexal carcinoma.

Somatosensory potentials in dogs with naturally acquired thoracolumbar spinal cord disease

Somatosensory evoked potentials (SEP) were recorded at the scalp and at various levels along the lumbar and caudal thoracic parts of the spine in response to tibial nerve stimulations. The SEP were observed in 24 diseased dogs, 2 with a vertebral fracture, 1 with a spinal cord tumor, 1 with a vertebral tumor, and 20 with disk herniation. Cord compression location was confirmed by myelography, laminectomy, or both. The clinical state had significant (P < 0.0001) influence on SEP characteristics. The scalp-recorded SEP latency changed only in association with the most severe lesions; spine-recorded SEP conduction velocity was lower in association with mild lesions; scalp-recorded SEP amplitude changed with lesions of intermediary severity. Because these 3 electrophysiologic variables were influenced differently by cord damage, it was possible to discriminate the various clinical grades by use of these techniques. However, dogs with signs of pain only could not be differentiated from clinically normal dogs. The evoked injury potential was observed in all but 4 diseased dogs, and its maximal amplitude corresponded, in all cases, with cord damage location. Increased duration (P < 0.05) of the spine-recorded SEP was associated with long-standing problems, but not necessarily with clinically detectable malfunction. Use of SEP and evoked injury potential for identifying lateralized cord damage may be of value.

Detection of largyneal sensory-evoked potentials (LSEPs) in the cat

We previously reported on evoked potentials elicited by electrical stimulation of the superior laryngeal nerve at an appropriate site on the dural surface as a reflection of activities in the brain stem and cortex in anesthetized cats. This evoked potential was called the laryngeal sensory evoked potential (LSEP). In this study we attempted to establish a less invasive procedure for measuring LSEP. The procedures were recording on the scalp using chloride-coated silver disk electrodes and stimulation by insertion of a bipolar platinum hooked wire electrode into the laryngeal mucosa. Evoked potentials could be detected using these less invasive procedures. The response morphologies and relative timing of LSEP components were quite similar for each method in a given cat. However, the amplitudes were slightly lower and the latencies were slightly prolonged with the less invasive techniques. These results suggest that this LSEP method might be applicable to human beings as a noninvasive method for evaluating the function of the laryngeal sensory pathway.

Anterior fontanelle scalp cysts in infancy

Seven infant patients with anterior fontanelle scalp cysts who were managed at the Paediatric Surgical Department of Muhimbili Medical Centre, Dar-es-Salaam between January 1986 and December, 1992 were studied. They were all Africans. There were 2 boys and 5 girls. Their ages ranged from 4 months to 24 months. The onset was at birth in 6 infants while in one case it was at 3 months of age. Their mental as well as motor development was normal. They were all easily and completely excised and in none was there intracranial communication. The histology was that of dermoid cyst in 6 patients and sebaceous cyst in one. There were no preoperative or postoperative complications noted.

Dosimetric evaluation of total scalp irradiation using a lateral electron-photon technique

PURPOSE

To evaluate the radiation dosimetry of a new technique for total scalp irradiation.

METHODS AND MATERIALS

A treatment technique described by Akazawa (1989) has been studied. During each fraction, two electron and two photon fields are treated. While most of the lateral scalp is treated with the electron fields, a rind of scalp close to the midsagittal plane is irradiated by parallel-opposed lateral photon fields. A wax bolus is used to build up skin dose and to protect the brain from electron dose. The dose distribution and dose-volume histograms were evaluated for different field arrangements using a 3-dimensional treatment planning system. After modifying the technique, in-vivo thermoluminescent dosimetry were used to evaluate the dose distributions for the first two patients.

RESULTS

To compensate for the lack of dose from the opposed photon field at the junction, the technique was modified using overlapped fields instead of abutting fields. A field overlap of 3 to 4 mm between the electron and photon fields was found optimal. When used with the field junction shift of 1 cm midway through the treatment, this scheme resulted in a dose uniformity of -5% to +15% of the prescribed dose in the region of abutment. Results of the 3-dimensional dose calculation were supported by in-vivo thermoluminescent dosimetry on two patients.

CONCLUSION

On the basis of computer dose calculations and in-vivo dosimetry. Akazawa's technique for scalp irradiation can be improved by using a 3 to 4 mm overlap of electron and photon fields. This modified technique is practical and produces clinically acceptable dosimetry.

Subcutaneous granuloma annulare: recognition and treatment

Subcutaneous granuloma annulare (SGA) is a benign inflammatory disorder that occurs in children. The profiles of 12 children with SGA who were diagnosed and treated at our institution were reviewed. The patients presented with a rapidly growing, painless soft-tissue mass of the extremities or scalp. Parental concerns of malignancy and lack of recognition of this condition by the physician led to excessive diagnostic testing and, on occasion, inappropriate therapy. The mean age at presentation was 3.9 years, and the mean follow-up after biopsy study was 3.4 years. The lesions were most commonly located about the elbow, knee, and scalp. While complete blood count, erythrocyte sedimentation rate, and plain radiographs were helpful in ruling out other conditions, no ancillary test was specific for this disorder. In all cases, definitive diagnosis required a biopsy sample. Excisional biopsy was diagnostic but not therapeutic, because 75% of the children had one or more recurrences of this condition at either local or distant sites. Two of the subsequent lesions resolved spontaneously, and no child within the study group has progressed to any recognized systemic illness or connective-tissue disorder.

Solid basal cell epithelioma (BCE) possibly originates from the outer root sheath of the hair follicle

The presence and distribution of several cytokeratins (CKs) in 20 solid basal cell epitheliomas (BCEs) were investigated and compared with the pattern of CKs in normal epidermis, perilesional skin and in the outer root sheath (ORS) of the human hair follicle. Tissue samples were stained with monoclonal antibodies (MoAbs) against human CKs, using the APAAP technique. Additionally, CK profiles were assessed by gel electrophoresis and immunoblot technique. Cells of BCE and ORS were positively stained with the MoAb KL1, whereas the basal layer of normal epidermis remained negative. Six out of 20 BCEs were partially stained with the MoAb RPN1165, which also stained the lower ORS, but not the epidermal basal layer. Using SDS-PAGE and immunoblot, the CK profiles of BCE and ORS were almost identical, showing the presence of CKs 5, 6, 14, 16 and 17; the CK pattern of normal epidermis, however, showed the presence of CKs 1, 5, 10 and 14. Perilesional skin (< 5 mm) showed keratin changes similar to the BCE pattern; the basal layer was stained with the MoAb KL1 and the suprabasal layer was negative to MoAb CK1, in contrast to normal epidermis. Keratin analysis revealed a CK pattern of perilesional skin different from that of normal epidermis (CKs 1, 5, 6, 10, 14, 16 and 17). Our immunohistochemical and biochemical investigations underline the possible role of the lower ORS as a cellular pool for the generation of BCE.