Single chest drain is not inferior to double chest drain after robotic esophagectomy: a propensity score-matched analysis

Background

Chest drain management has a significant influence on postoperative recovery after robot-assisted minimally invasive esophagectomy (RAMIE). The use of chest drains increases postoperative pain by irritating intercostal nerves and hinders patients from early postoperative mobilization and recovery. To our knowledge, no study has investigated the use of two vs. one intercostal chest drains after RAMIE.

Methods

This retrospective cohort study evaluated patients undergoing elective RAMIE with gastric conduit pull-up and intrathoracic anastomosis. Patients were divided into two groups according to placement of one (11/2020-08/2022) or two (08/2018-11/2020) chest drains. Propensity score matching was performed in a 1:1 ratio, and the incidences of overall and pulmonary complications, drainage-associated re-interventions, radiological diagnostics, analgesic use, and length of hospital stay were compared between single drain and double drain groups.

Results

During the study period, 194 patients underwent RAMIE. Twenty-two patients were included after propensity score matching in the single and double chest drain group, respectively. Time until removal of the last chest drain [postoperative day (POD) 6.7 ± 4.4 vs. POD 9.4 ± 2.7, p = 0.004] and intensive care unit stay (4.2 ± 5.1 days vs. 5.3 ± 3.5 days, p = 0.01) were significantly shorter in the single drain group. Overall and pulmonary complications, drainage-associated events, re-interventions, number of diagnostic imaging, analgesic use, and length of hospital stay were comparable between both groups.

Conclusion

This study is the first to demonstrate the safety of single intercostal chest drain use and, at least, non-inferiority to double chest drains in terms of perioperative complications after RAMIE.

P03.07.A MRI signature in preoperative imaging predicts mesenchymal stem cell features and radioresistance in primary glioblastoma stem cell cultures

Background

Recently, a molecular signature describing the mesenchymal / proneural features of primary stem-cell-enriched glioblastoma cultures was identified correlating with invasiveness, radiation sensitivity and patient-outcome. However, generating and characterizing primary cultures is time-consuming and this might hamper translation into clinical concepts. The aim of this study was to evaluate the use of standard preoperative MR imaging (T1ce and T2FLAIR sequences) to predict the molecular signature and thus enable the development of clinical treatment concepts based on the molecular properties of the individual tumors.

Material and Methods

For 16 patients, for whom primary stem cell enriched cultures had been characterized for their mesenchymal / proneural signature and radiation sensitivity, tumor volume (hyperintense volume in T1ce), necrosis (hypointense volume inside the tumor volume) and edema (hyperintense volume in T2FLAIR) were contoured for volumetric analysis. Volume parameters were used to calculate ratios (edema/tumor and necrosis/tumor) and a MRI signature, which was then correlated with molecular parameters and patient outcome stratified by MGMT promoter methylation.

Results

As expected, the prognosis of patients with MGMT-promoter-methylated tumors was better (n.s.) compared to those with unmethylated MGMT promoters. Neither molecular nor imaging data were significantly different between these subgroups. In the subgroup of patients with unmethylated MGMT promoter, volumetric imaging parameters correlated with the molecular signature and cellular radiation sensitivity of the stem cell enriched cultures. This association was much weaker in the subgroup with methylated MGMT promoter.

Conclusion

In the subgroup of patients with unmethylated MGMT promoter, volumetric parameters on preoperative standard MR imaging might hint at the molecular properties of the respective tumor and its radiation sensitivity. This might be a clinically applicable method to stratify treatment according to molecular stem cell subtype without tissue culture and molecular analysis.

Integration of radiation oncology teaching in medical studies by German medical faculties due to the new licensing regulations : An overview and recommendations of the consortium academic radiation oncology of the German Society for Radiation Oncology (DEGRO)

The new Medical Licensing Regulations 2025 (Ärztliche Approbationsordnung, ÄApprO) will soon be passed by the Federal Council (Bundesrat) and will be implemented step by step by the individual faculties in the coming months. The further development of medical studies essentially involves an orientation from fact-based to competence-based learning and focuses on practical, longitudinal and interdisciplinary training. Radiation oncology and radiation therapy are important components of therapeutic oncology and are of great importance for public health, both clinically and epidemiologically, and therefore should be given appropriate attention in medical education. This report is based on a recent survey on the current state of radiation therapy teaching at university hospitals in Germany as well as the contents of the National Competence Based Learning Objectives Catalogue for Medicine 2.0 (Nationaler Kompetenzbasierter Lernzielkatalog Medizin 2.0, NKLM) and the closely related Subject Catalogue (Gegenstandskatalog, GK) of the Institute for Medical and Pharmaceutical Examination Questions (Institut für Medizinische und Pharmazeutische Prüfungsfragen, IMPP). The current recommendations of the German Society for Radiation Oncology (Deutsche Gesellschaft für Radioonkologie, DEGRO) regarding topics, scope and rationale for the establishment of radiation oncology teaching at the respective faculties are also included.

Prognostic parameters and outcome after re-irradiation for progressive glioblastoma

OBJECTIVES

In progressive glioblastoma, salvage treatment remains unstandardized, response is highly variable, and detailed analysis of individual approaches is mandatory. Re-irradiation is an established option in the therapy of progressive glioblastoma. Thus, we analysed outcome and prognostic parameters of patients with re-irradiated glioblastoma treated at our institution since 1998.

MATERIALS AND METHODS

In a total of 51 patients, clinical and treatment parameters were collected and analysed retrospectively. Re-irradiation protocols included radiosurgery, hypofractionated radiotherapy or normofractionated radiotherapy. Outcome was analysed regarding prognostic factors in this highly selected cohort.

RESULTS

Median overall survival after primary diagnosis was 28.8 months. Patients re-irradiated with single-dose stereotactic radiosurgery or hypofractionated regimes showed a superior overall survival after primary diagnosis compared to normofractionated treatment. Positive prognostic factors included a smaller gross tumour volume and younger age. A methylated MGMT promoter approached statistical significance as a positive factor regarding overall survival after re-irradiation. Further well-known prognostic factors as extension of the initial resection and the concomitance of temozolomide with the initial radiation treatment only appeared relevant in a subgroup of four long-term survivors.

CONCLUSIONS

The favourable results regarding overall survival are probably due to patient selection for re-irradiation. If technically feasible, stereotactic radiosurgery or hypofractionated regimes should be preferred. In this highly selected re-irradiation cohort, only some of the well-known prognostic factors of the primary tumour setting were found to influence overall survival significantly. In contrast, also some patients presenting with unfavourable predictive parameters showed an encouraging course of disease and thus should not be excluded from re-irradiation.

Beyond checkpoint inhibition - Immunotherapeutical strategies in combination with radiation

The revival of cancer immunotherapy has taken place with the clinical success of immune checkpoint inhibition. However, the spectrum of immunotherapeutic approaches is much broader encompassing T cell engaging strategies, tumour-specific vaccination, antibodies or immunocytokines. This review focuses on the immunological effects of irradiation and the evidence available on combination strategies with immunotherapy. The available data suggest great potential of combined treatments, yet also poses questions about dose, fractionation, timing and most promising multimodal strategies.

[Apocrine poroma. A relatively little known skin tumor with multilineage differentiation]

Poromas were originally classified as eccrine tumors which predominantly consist of poroid ductal cells and differentiate in the direction of sweat gland ducts. However, there have now been many reports on poromas with additional differential characteristics differentiating in the direction of sebaceous and/or apocrine glands and/or hair follicles. These tumors have been termed apocrine poromas. Multilineage differentiation within a poroma can be explained by the embryological association of the sweat duct with the so-called folliculo-sebaceous-apocrine unit. The clinical and histopathological features of apocrine poromas are reviewed in comparison to classical eccrine poromas by taking into account seven own cases of apocrine poroma and a review of the literature. It is important for histopathologists not to confuse apocrine poroma with other tumors with multilineage differentiation. Apocrine poroma needs to be distinguished from sebaceoma and from basal cell carcinoma with sebaceous differentiation, in particular, because these tumors have therapeutic consequences for the patient. The main histopathological differences between apocrine poroma, sebaceoma and basal cell carcinoma with sebaceous differentiation are explained.

Effect of concurrent chemotherapy and hyperthermia on outcome of preoperative radiotherapy of high-risk soft tissue sarcomas

BACKGROUND AND PURPOSE

As treatment results for high-risk soft tissue sarcoma are still disappointing, treatment intensification is warranted. We performed a retrospective analysis of multimodal preoperative treatment to evaluate the additional effect of concurrent chemotherapy and/or locoregional hyperthermia in comparison to radiotherapy alone.

PATIENTS AND METHODS

Between 1999 and 2011, 28 patients were treated with neoadjuvant radiotherapy to a median 45 Gy for high-risk soft tissue sarcoma. All tumors were deep-seated and grade 2 or 3, 86% (n = 24) larger than 5 cm. Multimodal treatment (n = 12) consisted of ifosfamide (n = 7), locoregional hyperthermia (n = 3), or both modalities (n = 2) concurrent to radiotherapy.

RESULTS

Prognostic factors (grade, size, histology, location) were balanced in the groups with and without concurrent multimodal treatment. There was a significant improvement of disease-specific survival (100% vs. 70% at 3 years, p = 0.03) with multimodal treatment. Distant metastases-free survival was influenced, but was not statistically significant. Local control and disease-free survival did not differ in the two groups.

CONCLUSION

Our data suggest that multimodal treatment with ifosfamide and/or locoregional hyperthermia in combination with neoadjuvant radiotherapy might improve outcome in high-risk soft tissue sarcomas.

Are there biologic differences between male and female breast cancer explaining inferior outcome of men despite equal stage and treatment?!

BACKGROUND

Reasons for inferior outcome of male compared to female breast cancer are still under debate. Therefore, we retrospectively analyzed male breast cancer cases to figure out possible treatment- and gender-related differences.

PATIENTS AND METHODS

A total of 40 men (median age 62 years) were curatively treated with mastectomy and postoperative radiotherapy from 1982-2007. They presented predominantly in stages II and IIIb. Postoperative radiotherapy was applied with doses of 1.8-2.5 Gy to a median of 50 Gy including regional lymphatics in 22 patients. Adjuvant systemic treatment consisted of chemotherapy (22.5%) and antihormonal treatment (55%). For reasons of comparison, we estimated outcome of a virtual female matched cohort for no/equal to men/optimal adjuvant treatment with the Adjuvant!Online(®) 8.0 algorithm.

RESULTS

After a median follow-up of 47 months, the estimated 5-year local control rate was 97%, disease-free and distant metastasis-free survival rates reached 79% and 82%, respectively. With update of survival data by tumor registry, mean overall survival reached 120 months with 5- and 10-year overall survival rates of 66% and 43%, respectively. Predominant prognostic factor was T-stage for overall survival (T1/2 vs. T4: > 80% vs. 30%). The generated virtual matched cohorts of women with equal characteristics reached superior 10-year-overall survival for no/equal to men/optimal adjuvant treatment with 55/59/68%.

CONCLUSION

Compared to historical and virtual matched cohorts of women, male breast cancer patients had inferior outcome despite of equal stage and treatment which indicates that biological differences (of tumor or population) may contribute to worse prognosis.

Limited disease of extra-pulmonary small cell carcinoma. Impact of local treatment and nodal status, role of cranial irradiation

PURPOSE

As extra-pulmonary small cell carcinoma (EPSCC) is a rare entity of tumors, the available treatment recommendations are mainly based on retrospective analyses and deduction from treatment of small cell lung cancer. The aim of this study was to provide a detailed analysis concerning prognostic factors and treatment modalities.

PATIENTS AND METHODS

A total of 20 patients with limited disease (LD) of EPSCC treated at our institution from 1999–2009 were retrospectively analyzed. Data were gathered from chart review. Localization, lymph node involvement, as well as local and systemic treatment were documented and their impact on pattern of failure and survival times statistically evaluated.

RESULTS

With a median follow-up of 21 months, the estimated median overall- and disease-free survival were 59 and 25 months, respectively. Local control was excellent with 100% at 2 years. Nodal involvement was observed in 74% (n = 14/19) of evaluable patients. However, outcome was not altered by this parameter. Local treatment consisted of surgery in 10 cases, radiotherapy in 7 cases, and a combination of both in 3 cases. Only 3 patients (15%) developed hematogenous central nervous system metastases, while none of the patients received prophylactic cranial irradiation.

CONCLUSION

Nodal involvement did not worsen prognosis. Local control was excellent irrespective of local treatment modality and the leading cause of failure was distant metastasis. Therefore, systemic treatment should not be omitted. Prophylactic cranial irradiation might be dispensable but discussed for head and neck malignancies.

COSMO-RS: a novel view to physiological solvation and partition questions

Both, dielectric continuum solvation models as well as surface or group based methods using polarity and lipophilicity parameters have been proven to be useful tools for the analysis of solvation and partition questions. For the first time, COSMO-RS provides an integrated theory, which combines the aspects of continuum solvation and surface interactions, and which ends up with chemical potentials of molecules in almost arbitrary solvents and mixtures. Due to its sound theoretical basis, COSMO-RS does not only provide a new quantitative access to solvation and partition properties in well defined solvents, but it also opens a novel view and gives a better understanding of the general problem of solvation. Finally, this allows for a generalisation of COSMO-RS to sophisticated physiological partition problems involving as complex phases as blood, brain, or cell membranes. The use of COSMO-RS for drug discovery and design is demonstrated by applications to blood-brain partition coefficients, and water solubility.

Palpable migratory arciform erythema. Clinical morphology, histopathology, immunohistochemistry, and response to treatment

BACKGROUND

Palpable migratory arciform erythema is clinically characterized by sharply circumscribed, infiltrated erythematous patches that tend to spread irregularly, resulting in arciform morphologic features. The histopathologic features are characterized by a patchy inflammatory perivascular and periadnexal T-lymphocytic infiltrate throughout the dermis. The disease runs a chronic course and is rarely described in the literature.

OBSERVATION

Three middle-aged patients of both sexes had palpable migratory arciform erythema with 1, several, or multiple lesions on the trunk. There was a dense perivascular and periadnexal, predominantly lymphocytic infiltrate of the reticular dermis without any interstitial distribution of inflammatory cells. Absence of mucin deposits and plasma cells was a striking feature. The immunohistochemical profile showed an infiltrate dominated by T cells of polyclonal origin. In addition, polyclonal B cells and histiocytes were present in small numbers. In all 3 cases, oral antibacterial treatment resulted in a complete (2 patients) or temporary (1 patient) resolution of skin lesions.

CONCLUSIONS

Palpable migratory arciform erythema shows distinctive differences in clinical and pathological features and treatment in contrast to other diseases with cutaneous lymphocytic infiltrates, including lymphocytic infiltration of Jessner and Kanof. Therefore, it is likely a distinct disease entity.

Apocrine cystadenoma, apocrine hidrocystoma, and eccrine hidrocystoma: three distinct tumors defined by expression of keratins and human milk fat globulin 1

Eccrine hidrocystomas and apocrine cystadenomas are morphologically related cystic sweat gland tumors. To elucidate their cellular differentiation we examined by immunohistochemistry the expression of keratins and of human milk fat globulin 1 in 12 of each of these tumors, diagnosed using established conventional histological criteria. All tumors diagnosed as apocrine cystadenomas by these criteria were characterized by a keratin pattern of secretory type. In addition, they expressed human milk fat globulin 1. Tumors diagnosed as eccrine hidrocystomas expressed a keratin pattern of excretory type. A part of the tumors with an excretory keratin pattern expressed human milk fat globulin, while others did not. Some presumed eccrine hidrocystomas expressed the very same antigens as apocrine cystadenomas. Thus, our study reveals three distinct types of tumors, in contrast to the conventional distinction of only eccrine hidrocystomas and apocrine cystadenomas. Apocrine cystadenomas differentiate towards the secretory coil of apocrine sweat glands. Presumed eccrine hidrocystomas may represent cystic tumors of the eccrine sweat duct, or they may represent cystic tumors of the apocrine duct. Thus, the name hidrocystoma should be used without further specification of an eccrine or apocrine nature, unless certainty is reached by immunohistochemical characterization. Also, hidrocystomas often prove to be histologically misdiagnosed apocrine cystadenomas because of a flattened cyst wall secondary to increased intraluminal pressure.

[Epithelioid cell histiocytoma]

We report on seven examples of this rare, only recently described benign tumor, which presented clinically as solitary elevated nodules on the lower (n = 5) and upper (n = 2) extremity, measuring between 0.6 and 1.1 cm in diameter. Histologically, all tumors were well-defined with a characteristic epidermal collarette. There were abundant (60-80%) epithelioid cells with prominent cytoplasm, a vesicular nucleus and inconspicuous nucleolus, as well as a number of dilated blood vessels. Immunohistologically, tumor cells did not react with monocyte/macrophage antibodies (KP1, MAC387). In addition, there was no evidence of myofibroblastic differentiation (alpha-smooth muscle actin and desmin negative). Thus, while immunohistological markers are helpful to exclude the diagnosis of other tumors, they do not shed light on the differentiation of epithelioid cell histiocytomas. The present cases are identical to those described originally. Recently similar lesions have been described in deeper parts of the corium as well as more cellular forms. Epithelioid cell histiocytoma represents a characteristic, poorly known variant within the spectrum of benign fibrous histiocytomas; it needs to be distinguished clinically and histopathologically especially from Spitz nevus.

Cutaneous follicular lymphoid hyperplasia with monotypic plasma cells. A clinicopathologic study of 18 patients

Twenty cases of cutaneous follicular lymphoid hyperplasia with monotypic plasma cells are presented in a clinicopathologic study on 18 patients. The plaque-like or nodular lesions were solitary in 10 and multiple in eight patients. Immunohistochemistry showed well-defined B- and T-cell areas. Sheets of monotypic plasma cells occurred either interfollicularly or adjacent to the sclerotic stroma, with expression of IgG/kappa in 14 and IgG/lambda in six cases. In one patient with multiple lesions, one sample contained polyclonal plasma cells, whereas the other specimen showed light chain restriction. In another patient, disease recurred with a polytypic cutaneous plasma cell infiltrate. Polymerase chain reaction (PCR) revealed clonal immunoglobulin heavy chain gene rearrangements in eight of 13 cases, which was confirmed by Southern blot analysis in three samples. Clonal T-cell receptor chain gene rearrangements were not detected. Disease progression to overt malignant lymphoma did not occur within the follow-up period of up to 12 years, but recurrent disease was seen in three patients. Our data indicate that cutaneous lymphoid hyperplasia with monotypic plasma cells is a biologically distinct clinicopathological entity.

[Value of nucleolus organizer regions (AgNORs) in dermatologic oncology]

Nucleolus-organizing regions (Ag-NORs) are silver-stained loops of DNA transcribing to ribosomal RNA. Quantitative analysis helps to differentiate normal tissue from malignant tissue and can be used for diagnosis in several kinds of tumours. The analysis of AgNORs can also be used in dermatopathology for diagnostic and prognostic purposes. Apart from skin tumours such as basal, cell carcinomas and squamous cell carcinomas, this technique is of interest principally for melanocytic lesions. Benign naevi can be distinguished from malignant melanomas by simple counting of the AgNOR dots. For the differentiation of dysplastic naevi, Spitz naevi and malignant melanomas, this parameter alone is not sufficient. By combination of several AgNOR parameters (number, size, pattern of dispersal) only, significant differentiation could be achieved. The prognostic value of AgNORs remains to be examined.

UV-A-provoked localized bullous pemphigoid

A 71-year-old woman had noticed the development of blisters on her forehead 4 months before she was referred to our department. Treatment with oral corticosteroids resulted in complete healing, but new blisters subsequently developed on the face, neck and backs of the hands. After the possibility of phototoxic and photoallergic reactions, as well as an abnormal porphyrin profile, had been excluded, the diagnosis of bullous pemphigoid was made by histological and direct immunofluorescent examination. UV-A provocation on the upper arm produced lesions histologically and immunohistochemically typical of bullous pemphigoid. Of particular importance was the fact that the blisters were limited strictly to light-exposed skin areas.

[Adenoid cystic sweat gland carcinoma. A clinicopathologic and immunohistochemical study]

Adenoid cystic carcinoma of the skin is one of the rarest sweat gland tumours. We have studied two cases of adenoid cystic sweat gland carcinoma clinically, histologically and immunohistochemically. One tumour was located on the occiput of an 18-year-old male patient, while the other developed on the back of a 49-year-old woman. Histologically, both carcinomas were characterized by basaloid tumour cells showing the typical adenoid-cystic growth pattern. The cells were arranged in solid, cribriform, tubular and cystic aggregates, which were surrounded by mucoid, Alcian blue material. Immunohistochemically, the tumour cells showed coexpression of cytokeratins typical of stratified epithelia (CK1/5/10/14) and cytokeratins of the simple epithelial type, namely CK7, CK8, CK18, and CK19. Coexpression of these cytokeratins is usually observed in normal fetal sweat glands, but not in adult sweat glands.

Coexpression of cytokeratin and vimentin intermediate filaments in benign and malignant sweat gland tumors

The coexpression of cytokeratin and vimentin intermediate filaments has been immunohistochemically evaluated in 124 benign and malignant sweat gland tumors of various types in comparison to normal sweat glands. In addition, all neoplasms have been stained by an antibody to alpha-smooth muscle actin. Epithelial cells reacted with the pan-cytokeratin antibody lu-5. In normal sweat glands, vimentin immunoreactivity was restricted to myoepithelial cells and to some cells of the coiled duct. In benign sweat gland tumors (n = 88), coexpression of vimentin and alpha-smooth muscle actin was frequently found in basal cells of neoplasms considered to differentiate towards the secretory coil of the eccrine or apocrine gland. These included eccrine spiradenoma, apocrine cystadenoma, hidradenoma papilliferum, syringocystadenoma papilliferum, and cylindroma. Thus, in these tumors, vimentin-reactive cells corresponded to myoepithelial cells. Vimentin-positive cells were also found in 14 of 36 sweat gland carcinomas, including 1 case of sclerosing sweat duct carcinoma, 1 case of porocarcinoma, 4 cases of eccrine adenocarcinoma, 1 case of mucinous eccrine carcinoma, and 5 cases of apocrine adenocarcinoma. Co-expression of vimentin and alpha-smooth muscle actin was observed in some cells of eccrine and apocrine adenocarcinomas. Therefore, in these neoplasms, some vimentin-positive cells appear to represent myoepithelial cells. In contrast, vimentin-positive cells in all other malignant tumors did not express alpha-smooth muscle actin. Our results indicate that coexpression of cytokeratin and vimentin may be frequently found in a variety of benign and malignant sweat gland tumors. In the majority of these neoplasms, vimentin-positive cells correspond to myoepithelial cells. Because vimentin is not specific for myoepithelial cells, additional stains for alpha-smooth muscle actin should be performed to prove the myoepithelial nature of vimentin-positive cells.

p53 protein in benign and malignant sweat gland tumors

Mutation of the p53 gene and increased levels of p53 protein are among the most frequent alterations in human cancers. To date, very little is known about the mechanisms underlying the development of sweat gland carcinomas. In this study, we analyzed 43 benign and 39 malignant sweat gland tumors for p53 protein level using the antibody PAB1801. Nine (23%) of 39 sweat gland carcinomas were positive for p53 protein. Among these carcinomas, six of 12 cases of extramammary Paget's disease were positive using immunohistochemistry. No other correlation between tumor subtype and p53 reactivity was detected. Among 43 benign sweat gland tumors, only one case displayed staining for p53. We conclude that p53 protein plays a role in a subset of sweat gland tumors, especially in extramammary Paget's disease.

Immunohistochemical demonstration of myoepithelial cells in sweat gland carcinomas

Although myoepithelial cells are detectable in many benign sweat gland tumours, little is known about their role in sweat gland carcinomas. To specifically demonstrate myoepithelial cells, paraffin sections from 46 sweat gland carcinomas were stained, using a standard avidin-biotin-peroxidase complex method, with the monoclonal alpha-smooth muscle actin antibody 1A4. Myoepithelial cells were not found in adenoid cystic eccrine carcinoma (n = 2), malignant nodular hidradenoma (n = 2), porocarcinoma (n = 4), extramammary Paget's disease (n = 12), sclerosing sweat duct carcinoma (n = 4) or in adenosquamous-mucoepidermoid carcinoma (n = 1). In contrast, myoepithelial cells were demonstrated in two of eight apocrine adenocarcinomas, one of six mucinous eccrine carcinomas and two of seven eccrine adenocarcinomas. In all these tumours myoepithelial differentiation was found in peripheral cells of solid tumour islands, or in basal cells of tubular structures. However, in most areas of the tumours, myoepithelial layers were discontinuous. Cells in the centre of solid tumour nodules, and luminal cells of tubular structures, were negative for alpha-smooth muscle actin. In analogy to breast tumours, in which malignancy and invasiveness correlate with scattered or absent myoepithelial cells, we suggest that disrupted myoepithelial layers in sweat gland carcinomas may be interpreted as a loss of the invasion barrier.

Deposits of paraprotein in small vessels as a cause of skin ulcers in Waldenström's macroglobulinemia

A 71-year-old man presented with epistaxis and large ulcers on arms and legs. A monoclonal IgM-kappa gammopathy and high levels of cryoglobulins were found. Histology of the affected skin showed deposits of paraprotein in the small vessels, causing luminal obstruction. This in turn caused ischemic skin lesions, which were successfully treated with cortisone (fluocortolone 100 mg/day every second day) and cyclophosphamide (100 mg/day).

[Multiple disseminated glomus tumors (glomangioma). Immunohistochemical analysis and differentiation from viscerocutaneous hemangiomatosis]

A 25-year-old patient presented with multiple disseminated asymptomatic bluish nodules, which had been present since childhood. Histological examination revealed vascular cavities surrounded by round to oval eosinophilic cells. Positive immunohistochemical staining with alpha-smooth-muscle antigen (alpha-SMA) and vimentin confirmed the diagnosis of multiple disseminated glomus tumours of the vascular type. Tumour cells were surrounded by a network of type IV collagen. In contrast antibodies against the intermediate filament protein desmin and the endothelial markers BMA 120 and anti-von Willebrand factor revealed no staining of the glomus cells. This was the first immunohistochemical investigation of a glomus tumour of vascular type. Immunohistochemical staining of these glomus cells revealed no difference from other histological types of glomus tumours.

Gastric carcinoma metastatic to the site of a congenital melanocytic nevus

Cutaneous metastasis from gastric carcinoma is uncommon. We describe a patient with a metastasis from gastric carcinoma to a congenital melanocytic nevus. The diagnosis was confirmed by positive immunohistochemical staining for cytokeratin 20 and lack of cytokeratin 7.

Spiradenomas in Brooke-Spiegler syndrome

Brooke-Spiegler syndrome is an autosomal dominantly inherited disease characterized by the development of multiple trichoepitheliomas and cylindromas. Among other neoplasms that may also occur in Brooke-Spiegler syndrome are basal cell carcinomas and spiradenomas. Spiradenomas and cylindromas have so many features in common that they have been regarded as variants of the same neoplasm. This assumption was supported by the occurrence of both types of lesions in Brooke-Spiegler syndrome. We report a case of Brooke-Spiegler syndrome in which spiradenomas were found in the immediate vicinity of trichoepitheliomas and in continuity with follicles. Because of the embryonic relationship between follicles and apocrine glands, these features indicate that spiradenomas are apocrine neoplasms. We conclude that Brooke-Spiegler syndrome is an inherited disease that affects the folliculosebaceous apocrine unit.

[Malignant blue nevus]

A 35-year-old male patient suffering from a malignant blue naevus is presented. An uncommon melanocytic naevus and malignant melanoma were considered in the differential diagnosis. The final diagnosis was established by histological examination. Immunohistochemical studies showed a strongly positive reaction of the tumour cells for vimentin and S-100 protein. In addition, tumour cells reacted with the antibody HMB-45.

Cytokeratin expression in mucinous sweat gland carcinomas: an immunohistochemical analysis of four cases

Four mucinous sweat gland carcinomas were examined for the distribution of cytokeratin (CK) polypeptides using immunohistochemical techniques on paraffin-embedded sections. All the tumour specimens reacted with monoclonal antibodies to CK 7, CK 8, CK 18 and CK 19. Antibodies to CK 1, CK 1/2/10/14, CK 1/5/10/11, CK 13, CK 14 and CK 20 did not stain any of the carcinomas. The results add additional support to the notion that mucinous sweat gland carcinoma represents a tumour histogenetically related to the eccrine secretory coil. Furthermore, the absence of CK 20 might significantly contribute to the differentiation of this tumour from cutaneous metastases from gastrointestinal carcinomas.

Myoepithelial differentiation in benign sweat gland tumors. Demonstrated by a monoclonal antibody to alpha-smooth muscle actin

One hundred and two cases of benign sweat gland tumors of the skin were studied for the presence of myoepithelial cells specifically identified by a monoclonal antibody to alpha-smooth muscle actin on paraffin-embedded tissues. The monoclonal antibody gave a positive result in 12 of 12 cases of cylindroma, 14 of 16 cases of spiradenoma, 2 of 2 cases of apocrine tubular adenoma (papillary eccrine adenoma), 5 of 5 cases of apocrine hidrocystoma, 5 of 5 cases of hidradenoma papilliferum, and in 10 of 10 cases of syringocystadenoma papilliferum. Rare myoepithelial cells were detected in only 1 of 10 cases of mixed tumor, apocrine type. There was no immunoreactivity for alpha-smooth muscle actin in eccrine hidrocystoma (2 cases), mixed tumor of eccrine type (2 cases), syringoma (7 cases), hidroacanthoma simplex (1 case), eccrine poroma (14 cases), clear cell hidradenoma (15 cases), and in 1 case of eccrine syringofibroadenoma. Our data support the concept that myoepithelial cells are seen in most sweat gland tumors considered to differentiate toward the secretory coil of the normal sweat gland. In contrast, myoepithelial cells are absent in tumors showing differentiation toward the excretory (ductal) component of the gland.

Atypical presentation of co-existent Haemophilus ducreyi and Treponema pallidum infection in an HIV-positive male

A 25-year-old homosexual black male presented with asymmetrical perianal ulceration of uncertain clinical origin. Indepth microbiological examination revealed the combined presence of Haemophilus ducreyi and Treponema pallidum. The atypical clinical appearance may have been due to the changed immunological status of the host's being infected with Human Immunodeficiency Virus.

Metastatic signet-ring cell melanoma in a patient with an unknown primary tumor. Histologic, immunohistochemical, and ultrastructural findings

Signet-ring cell melanoma is a rare morphologic variant of malignant melanoma. We describe a 27-year-old man with widespread cutaneous and internal metastases of an unknown primary tumor. One skin biopsy specimen and a fine-needle aspirate showed polygonal tumor cells consistent with the diagnosis of metastatic melanoma, but a second skin biopsy specimen revealed neoplastic cells with a signet-ring cell appearance. Both specimens, however, yielded identical immunohistochemical findings. Tumor cells were positive for vimentin and S-100 protein and reacted with the melanoma markers HMB-45 and NKI-C3. Ultrastructural studies revealed abundant intermediate filaments in the cytoplasm of the signet-ring cells. Based on these findings, a diagnosis of metastatic melanoma was made. In this report we describe the fourth case of metastatic signet-ring cell melanoma, and discuss how malignant melanoma may lead to metastases that have divergent morphologic appearances in the same patient.