Sneddon-Wilkinson disease treated with etanercept: report of two cases

Sneddon-Wilkinson disease (SWD), also known as subcorneal pustular dermatosis, is a rare, chronic eruption that is often difficult to treat, particularly in patients who do not respond to or cannot tolerate dapsone. Few case reports exist of patients with SWD treated with antitumour necrosis factor-alpha therapy. We report two patients with SWD refractory to numerous treatments, who responded to etanercept (in combination with low-dose acitretin in one case).

Pleomorphic T-cell infiltrate associated with molluscum contagiosum

The authors observed a pleomorphic lymphocytic infiltrate composed of CD8 cytotoxic/suppressor T-cells in two pediatric cases associated with molluscum contagiosum. T-cell clonality was not detected. In both cases, the lesions resolved after the biopsy was performed. The patients were otherwise healthy, and no evidence of lymphoproliferative process was detected on follow-up. The authors believe the pleomorphic lymphoid infiltrate is inflammatory and reactive in nature. The close apposition of lymphocytes to molluscum bodies and cytoid bodies with high expression of CD30 and the proliferating marker Ki67 is suggestive of a cytotoxic cell-mediate blastic reaction against poxvirus antigens.

Tubulopapillary hidradenoma-like tumor of the mandible: clinicopathologic and immunohistochemical features

Tubulopapillary hidradenoma is a benign sweat gland tumor that appears as a well-defined, superficially located dermal nodule. It combines ductal as well as apocrine and eccrine glandular differentiation. Microscopically, the tumor is composed of tubular structures that characteristically show intraluminal non-villous papillary projections and a peripheral myoepithelial cell layer. A tumor that is histologically and immunohistochemically identical to tubulopapillary hidradenoma occurred in the mandible of a 73-year-old man and resulted in considerable diagnostic difficulty. The neoplasm developed in a mandibular cyst and recurred 5 years after initial enucleation. This is the first report of a central (intraosseous) sweat gland adenoma of the mandible. The differential diagnosis and possible histogenesis are discussed.

Cutaneous granular cell angiosarcoma

The majority of cutaneous angiosarcomas display typical architectural features of irregular anastomosing vascular channels in the dermis and subcutis. Nuclei are usually hyperchromatic and pleomorphic but the volume of cytoplasm of the neoplastic cells is often small. Diagnosis can be made readily on an adequate biopsy. We recently experienced difficulty diagnosing an angiosarcoma composed predominantly of cells with abundant granular cytoplasm. We were able to compare the present case with sections obtained from the only other reported example. The architectural expression of an anastomosing vascular pattern in areas of tumor, combined with the positive staining for Factor VIII-related antigen (FVIIIRAg) and Ulex europaeus agglutinin-1 (UEA1) enabled us to make a diagnosis of angiosarcoma. The tumor failed to stain for the other endothelial markers (CD31 and CD34) which were positive in the original case. A marker for lysosomes (CD68) stained the granules in both cases. The granular cell variant of cutaneous angiosarcoma is very rare. Diagnosis is possible by recognizing the typical anastomosing neoplastic vascular channels at the periphery of the lesion, and by use of a combination of lectin (UEA1) and immunohistochemical (FVIIIRAg, CD34 and CD31) endothelial markers.

Large-cell acanthoma of the skin. A study by image analysis cytometry and immunohistochemistry

Although large-cell acanthoma is a well-known clinicopathological entity, its biologic spectrum and nature are still subject to debate. We studied seven cases of large-cell acanthoma by image analysis cytometry for DNA content and by immunohistochemistry, using antibodies to proliferating cell nuclear antigen (PCNA)/cyclin. The data were compared with individual cases of seborrheic keratosis (SK), actinic keratosis (AK), and Bowen's disease (BD). The DNA distribution of large-cell acanthoma was variable. There were varying peaks at the DNA index values of 1 and 2 (diploid and tetraploid values), but all cases contained a significant aneuploid population between DNA index of 1 and 2. The mean DNA index was 1.44 (1.27-1.77); 1-20% of the cells exceeded 2, and 0-2% exceeded 3. The DNA index for lesions in the other differential diagnostic groups studied was as follows: SK, 1.0; AK, 1.4; BD, 1.8. The percentage of cells with positive nuclear staining for PCNA/cyclin was < 20% in all cases of large-cell acanthoma. The discrepancy between the high number of aneuploid and tetraploid cells observed on the DNA distribution curve and the lack of evidence for significant proliferation based on immunohistochemical stains suggest that these cells are resting cells with abnormal DNA clone. Although these results provide additional information about the biologic nature of large-cell acanthoma, they do not resolve the controversial nosologic status of lesions in this histologic group.

Adenolipoma of the skin: a report of nine cases

BACKGROUND

We have identified nine cases of a variant of superficial lipoma that are characterized by the presence of eccrine sweat glands.

OBJECTIVE

The purpose of this study was to elucidate the clinical and histopathologic features of this distinctive lesion.

METHODS

Nine cases of lipoma that contain eccrine glands were retrieved from our pathology files from 1989 through 1992. Their clinical and histopathologic features were studied and compared with those of conventional lipoma.

RESULTS

The clinical features of these lesions did not deviate appreciably from those of the usual lipomas. However, their microscopic appearances differed by the presence of displaced and distorted eccrine glands. One lesion had the added features of a myxolipoma.

CONCLUSION

Adenolipoma of the skin is a distinct lesion that can occur in the dermis or subcutaneous tissue.

Fine-needle aspiration biopsy: dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans (DFSP) represents a spectrum of mesenchymal spindle cell tumors that typically involve both dermis and subcutis. Presented herein are six cases of DFSP, four of which were initially diagnosed by FNAB. The cytologic features useful in the identification of this lesion on Papanicolaou- and Diff-Quik-stained smears are discussed. Chief among these are the storiform stromal fragments, presence of entrapped adipose tissue and the recognition of fibrohistiocytic spindle cells. The potential pitfalls and the differential diagnostic possibilities of spindle-cell lesions, particularly those of fibrohistiocytic origin are discussed.

Fibroepithelioma-like changes associated with anogenital epidermotropic mucinous carcinoma. Fibroepitheliomatous Paget phenomenon

We describe two patients with crusted perineal plaques that were biopsied and diagnosed as Paget's disease. Resection specimens of each contained a dermal mucinous carcinoma with extensive epidermotropism and coexistent epidermal basaloid proliferations closely resembling fibroepithelioma (Pinkus). The presence of the Paget phenomenon was supported by histochemical, immunohistochemical, and ultrastructural evidence. No other primary neoplasms were found in either patient. Followup at 2 1/2 and 3 1/2 years, respectively, has been negative. We conclude that either the fibroepitheliomatous changes may be induced by or may represent a collison (unlikely) with the epidermotropic mucinous carcinoma. It is proposed that the concept fibroepitheliomatous Paget phenomenon be used to stand for the histologic changes common to our cases as well as those previously reported.

Syringomatous squamous tumors of the breast

Four cases are reported of syringomatous squamous tumors of the breast occurring in women aged 37 to 70 years. The lesions were characterized histologically by relatively well-circumscribed tumor-like nodules composed of a proliferation of teardrop or comma-shaped islands of squamous epithelium. The squamous epithelial islands contained central lumens lined by eosinophilic cuticles and were surrounded by a densely cellular fibrous matrix, thus closely resembling the growth pattern of dermal eccrine syringomas. The lesions appeared to arise de novo from breast parenchyma without evidence of transitions with the surrounding normal or hyperplastic mammary epithelium and were not associated with the overlying skin or nipple epidermis. In all cases, the surrounding breast tissue showed fibrocystic and benign proliferative changes, and in one case, the lesion was found in the vicinity of a large cyst surrounded by microcalcifications. All patients were treated by local surgical excision and have shown no evidence of recurrence over a follow-up period of 1 to 6 years. The histologic differential diagnosis and the possible pathogenesis of these lesions are discussed.

Epidermotropic neuroendocrine carcinoma. Immunohistochemical differentiation from simulators, including malignant melanoma

Epidermotropic neuroendocrine carcinoma (NEC) is rare. Based on such a case in an 88-year-old woman with a facial NEC showing epidermotropism with a pagetoid growth pattern, we asked whether several similar tumors involving the epidermis could be easily differentiated by immunohistochemical methods. We constructed a panel of control cases (2 each) for NEC, clear cell Bowen's disease (CCBD), Paget's disease (PD), superficial basal cell carcinoma (SBCC), cutaneous T-cell lymphoma (CTTL), and superficial spreading malignant melanoma (SSMM) to compare with our patient. A panel of antibodies including epithelial membrane antigen (EMA), neuron specific enolase (NSE), AE1/3 cytokeratin (CK), carcinoembryonic antigen (CEA), leukocyte common antigen (LCA), S-100, and HMB-45 were applied. Cutaneous NEC controls and our patient's tumor were strongly positive for EMA and NSE and had paranuclear dot-like cytoplasmic positivity for CK. CCBD was moderate to strong for CK. PD was strong for CEA. SBCC was essentially negative for all. CTLL was strong for LCA. SSMM was strong for S-100 and HMB-45. Controls were either negative or weak for the antibodies not mentioned. We conclude that this antibody panel can reliably differentiate these epidermotropic or juxtaepidermal tumors in diagnostic dermatopathology and should be applied to lesions requiring separation beyond H & E capabilities, especially with superficial shave biopsies showing small cell "Pagetoid" growth patterns.

Human papillomavirus--associated vulvar verrucous carcinoma in a 20-year-old with an intact hymen. A case report

A 20-year-old woman with vulvar verrucous carcinoma, the youngest such patient reported to date, had human papillomavirus DNA 6/11 identified with an in situ hybridization technique. In addition to her youth, the patient was unusual in that she had an intact hymen. Although she denied having engaged in sexual activity, venereal transmission of the virus may have occurred without vaginal penetration.

The rule of halves. A method of controlling the uniform "cutting-in" of skin biopsies

This article describes a method of uniform gross-room sectioning of skin biopsy specimens, especially excisional biopsy specimens, to insure even thickness and maximum control of the tissue before paraffinization. This is accomplished by sequentially halving portions of the specimen after each cut as opposed to serially cutting the skin from one end to the other.

Cutaneous inflammatory pseudotumor. Lesions resembling "inflammatory pseudotumors" or "plasma cell granulomas" of extracutaneous sites

This report describes four cases of a previously undocumented circumscribed idiopathic inflammatory fibrosclerotic lesion of the skin. The lesions occurred in two black women and two white men; they had been apparent from months to a year. The nodules were solitary; two were located on the arm, one on the calf, and one on the posterior neck. The clinical diagnoses included nodules, keratinous cyst, pilar tumor, pilomatricoma, vascular leiomyoma, dermatofibroma, and metastatic carcinoma. The lesions were grossly white, homogeneous, and circumscribed; one was located in the superficial subcutis and three in the reticular dermis. Histologically, they were sharply circumscribed and surrounded by a dense peripheral rim of lymphocytes and plasma cells. Peripheral germinal centers were noted in two cases. All cases had variable amounts of fibrosis centrally, giving them the low-power appearance of lymph nodes; however, no subcapsular or medullary sinuses were found. In the center of the lesions, the mononuclear infiltrate was accompanied by eosinophils and neutrophils. Virtually imperceptible vasculature was noted in portions of three lesions; in the fourth lesion, high endothelial venules were seen in the lymphoid portions, and "targetoid" perivascular sclerosis was seen in the central portions. There appears to be a transition from the early, mostly inflammatory, lesions to the sclerotic ones. The process seems to be reactive in nature. No obvious local or systemic etiology was found in our series, and follow-up of 2 to 5 years has been noncontributory. These mixed-cell proliferations resemble the extracutaneous masses that have been described in numerous viscera--particularly the lung--as "inflammatory pseudotumors" or "plasma cell granulomas." In our opinion, these lesions also bore a superficial resemblance to cutaneous lymphoid hyperplasia secondary to insect bites. Other differential diagnostic considerations include dermatofibroma, nodular fasciitis, Kimura's disease, epithelioid (histiocytoid) hemangioma, and reactive lymph nodes.

Eccrine syringofibroadenoma (Mascaró). An acrosyringeal hamartoma

Two patients with eccrine syringofibroadenomas were studied. The first patient had a 3-year history of asymptomatic, unilateral, linear, moist mosaic plaques of the lower part of the left leg and foot; the second patient had a solitary papule on the back. Histologically, both tumors exhibited superficial elongated strands of eccrine ductal epithelium containing occasional lumina lined by an eosinophilic cuticle. The stroma was loose, myxoid, and fibrovascular. The secretory portions of the eccrine glands were ectatic in the first patient but were not seen in the second patient. We believe these lesions represent acrosyringeal hamartomas (nevi), although some authors interpret them as adenomas. The literature seems to indicate that lesions with similar histologic features may be solitary, multiple, or combined with other neoplasms; in other cases, the lesions may possibly represent an unusual morphologic expression of hidrotic ectodermal dysplasia.

Eccrine squamous syringometaplasia. A cutaneous sweat gland reaction in the histologic spectrum of 'chemotherapy-associated eccrine hidradenitis' and 'neutrophilic eccrine hidradenitis'

A 31-year-old Hispanic man presented in the pancytopenic phase of acute myelocytic leukemia and was treated with the chemotherapeutic agents mitoxantrone and cytarabine. After 5 days, an erythematous, blanching, papular, crusted eruption developed on his forehead, chest, and legs. Some lesions showed confluence and all were at the same developmental stage. Clinical diagnoses included necrotizing vasculitis and sepsis. A biopsy specimen revealed widespread noninflammatory syringometaplasia of eccrine ducts. Well-developed intercellular bridges and eosinophilic cytoplasm were seen within the metaplastic cells; apoptoses and occasional mitoses were present. This process is distinct and probably occurred secondary to direct toxic injury from the chemotherapeutic drugs. Because similar changes have occurred in patients with neutrophilic eccrine hidradenitis, we believe our patient represents an example of the noninflammatory end of the spectrum of chemotherapeutic eccrine gland reactions.

Nodular-cystic fat necrosis. A reevaluation of the so-called mobile encapsulated lipoma

We describe five patients with distinct posttraumatic subcutaneous nodules that usually evolved for several months before diagnosis. The nodules occurred in the subcutis of the elbow or hip of women, 33 to 74 years old, and in the hip of a 16-year-old boy. Histologically the fully developed lesions were totally or nearly totally encapsulated by thin, fibrous tissue. All contained well-preserved outlines of nonnucleated adipocytes; there was no inflammation or saponification. In one patient's lestion the viable subcutaneous tissue merged into several partially encapsulated necrotic nodules. In another case a smaller nodule was found within a larger, mostly calcified nodule. Names such as nodular-cystic fat necrosis, mobile encapsulated lipoma, and encapsulated necrosis have been offered to designate the lesion. Its pathogenesis seems to be related to trauma, rapid vascular insufficiency, and subsequent fibrous capsule formation. Many previously reported patients, however, had no history of trauma. The lesion must be distinguished histologically from lipoma, angiolipoma, alpha 1-antitrypsin deficiency-associated panniculitis, membranous fat necrosis, and pancreatic fat necrosis. Simple excision is the treatment of choice.

Leiomyoma of the breast

Leiomyoma of the breast parenchyma proper is a rare neoplasm. This tumor occurs predominantly in late middle-aged women and can be clinically difficult to discern from carcinoma. Mammographically, the tumor lacks typical features of carcinoma, but this possibility cannot be absolutely excluded. Immunohistochemical, ultrastructural, and DNA characteristics are reported in a new case. Mammographic findings are reported for the first time. Immunoperoxidase findings with antibodies to muscle-specific actin, desmin, vimentin, S-100 protein, and cytokeratins, as well as the ultrastructural features, suggest a pure smooth muscle cell origin and not a myoepithelial cell origin.

Immature trichoepithelioma: report of six cases

We report 6 cases of an immature variant of trichoepithelioma which histologically appears to show differentiation toward the primitive hair germ. The lesions presented in mature adults (mean age 44 years). Four occurred in men and 2 in women. Four lesions occurred on extremities, an unusual location for trichoepitheliomas. Histologically, the lesions were characterized by well-circumscribed, but unencapsulated, dermal collections of small tumor lobules composed of basaloid cells with invaginations resembling primitive dermal hair papillae. There was no adenoidal growth pattern or horn cyst formation. The separation of the immature lesions from those of classical trichoepithelioma and basal cell carcinoma can be made if multiple morphological features are considered; no one particular finding is diagnostic. The major differential features between the immature trichoepithelioma and basal cell carcinoma are circumscription, tumor lobule uniformity, occasional immature hair germs, and lack of retraction artifact of the tumor lobules from the stroma. The differential features between the immature and classical trichoepithelioma are less conspicuous. The immature form typically exhibits no horn cysts, displays fewer primitive hair structures, and lacks the adenoidal growth patterns of the tumor lobules which are usually present in the classical trichoepitheliomas.

Posttraumatic lobular squamous metaplasia of breast. An unusual pseudocarcinomatous metaplasia resembling squamous (necrotizing) sialometaplasia of the salivary gland

Squamous metaplasia arising in nonneoplastic breast parenchyma is reportedly rare. We present a unique case which occurred following severe blunt trauma to the right breast of a 59-yr-old woman. The lesion contained sheets of squamous cells with a lobular growth pattern, bland cytology with few mitoses, and keratin and keratohyalin granules. It bore a striking resemblance to squamous (necrotizing) sialometaplasia of the salivary gland in that it exhibited lobular, pseudocarcinomatous growth. The patient has remained free of disease 49 mo after segmental resection of the lesion. Four previous cases of squamous metaplasia of the female breast have been reported, though none presented with a history of trauma or previous surgical manipulation. It is important to differentiate this entity from pure squamous cell carcinoma, and metaplastic change in ductal breast carcinoma, fibroadenoma, and other lesions. Breast aspiration biopsies revealing squamous cells cannot exclude carcinoma; thus, caution must be exercised.

Metastatic transitional-cell carcinoma to the mandible: a case report

Transitional-cell carcinoma to the mandible is an uncommon occurrence. Only three cases have been reported in the literature. This is a case report of such a metastasis, the first diagnosed by fine-needle aspiration. Emphasis is placed on the cytologic features of the tumor cells.

Increased levels of dihydrofolate reductase in rifampin-resistant mutants of Bacillus subtilis

Several independent, spontaneous rifampin-resistant mutants of Bacillus subtilis were isolated and found to have an increased resistance to trimethoprim, an inhibitor of dihydrofolate reductase. This increased resistance in the rif mutants was the result of a specific threefold increase in the activity of dihydrofolate reductase, since six other enzymes examined remained unchanged. This increased level of dihydrofolate reductase and the trimethoprim resistance were cotransformed (100%) with the rif marker. These results suggest that the RNA polymerase is altered in its recognition of the gene that specifies dihydrofolate reductase.