Reflectance Confocal Microscopy of Pigmented Bowen's Disease: A Case Series of Difficult to Diagnose Lesions

Pigmented Bowen's disease is a rare variant of in situ squamous skin cell carcinoma. It mainly affects patients between 60 and 70 years of age. Its clinical features include well-demarcated, pigmented plaque arising in photo-exposed areas of the body. The best-characterized feature of the disease by histological examination is the presence of atypical keratinocytes, hyperpigmentation of the epidermis with trans-epidermal elimination of melanin and dermal melanophages. Precise diagnosis is often difficult, both clinically and dermoscopically, as Bowen's disease is often mistaken with keratinocyte tumors such as solar lentigines, seborrheic keratosis, Bowenoid papulosis, pigmented basal cell carcinoma, pigmented actinic keratosis; or even melanocytic lesions such as melanocytic nevus, pigmented epithelioid melanocytoma, and melanoma. Precise diagnosis often requires biopsy and histopathological examination of the tissue. Reflectance confocal microscopy is a noninvasive technique to diagnose pigmented skin lesions. To date, not much data are available regarding its use in the diagnosis of pigmented Bowen's disease. Herein, we report a well-represented case series of pigmented Bowen's disease imaged using dermoscopy and reflectance confocal microscopy.

Aging dependent effect of nuclear tau

Tau protein is characterized by a complex pattern of phosphorylation and is localized in the cytoplasm and nucleus in both neuronal and non-neuronal cells. Human AT100 nuclear tau, endowed by phosphorylation in Thr212/Ser214, was recently shown to decline in cornus ammonis 1 (CA1) and dentate gyrus (DG) in Alzheimer's disease (AD), but a defined function for this nuclear tau remains unclear. Here we show that AT100 progressively increases in the nuclei of neuronal and non-neuronal cells during aging, and decreases in the more severe AD stages, as recently shown, and in cancer cells (colorectal adenocarcinoma and breast cancer). AT100, in addition to a co-localization with the DAPI-positive heterochromatin, was detected in the nucleolus of pyramidal cells from the CA1 region, shown to be at its highest level in the more senescent cells and in the first stage of AD (ADI), and disappearing in the more severe AD cases (ADIV). Taking into account the nuclear distribution of AT100 during cell aging and its relation to the chromatin changes observed in degenerated neurons, as well as in cancerous cells, which are both cellular pathologies associated with age, we can consider the Thr212/Ser214 phosphorylated nuclear tau as a molecular marker of cell aging.

Pleomorphic dermal sarcoma: a more aggressive neoplasm than previously estimated

BACKGROUND

Pleomorphic dermal sarcoma (PDS) is a rare neoplasm sharing pathological features with atypical fibroxanthoma, but adding tumor necrosis, invasion beyond superficial subcutis or vascular or perineural infiltration. Although its metastatic risk has been estimated to be less than 5%, its real outcome is presently uncertain because of its rarity and to the lack of homogeneous criteria used in reported cases.

METHODS

Retrospective clinicopathological study of 18 cases of PDS.

RESULTS

The lesions presented as tumors or plaques (size: 7-70 mm) on the head of elderly patients (median: 81 years), without a gender predominance. Histopathologically, they consisted of spindle cells arranged in a fascicular pattern, containing pleomorphic epithelioid and giant multinucleated cells in varying proportions, and usually exhibiting numerous mitotic figures and infiltrative tumor margins. No immunoexpression for cytokeratins, S100 protein, desmin or CD34 was observed. Necrosis and venous invasion were found in three tumors each (17%). Follow-up was available in 15 cases (median: 33 months). Three patients (20%) had local recurrences, all with incomplete primary surgical resections. Three patients (20%) developed distant metastases in the skin, regional lymph nodes and/or lungs and died from the disease.

CONCLUSION

Our data suggest that PDS may be a more aggressive neoplasm than previously estimated.

Association of C4d deposition with clinical outcomes in IgA nephropathy

BACKGROUND AND OBJECTIVES

Several studies have suggested that activation of the complement system is a contributing pathogenic mechanism in IgA nephropathy (IgAN). C4d staining is an inexpensive and easy-to-perform method for the analysis of renal biopsies. This study aimed to assess the clinical and prognostic implications of C4d staining in IgAN.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective cohort study included 283 patients with IgAN in 11 hospitals in Spain who underwent a renal biopsy between 1979 and 2010. The primary predictor was mesangial C4d staining. Secondary predictors included demographic, clinical, and laboratory characteristics, and Oxford pathologic classification criteria. The primary end point was the cumulative percentage of patients who developed ESRD, defined as onset of chronic dialysis or renal transplantation. C4d was analyzed by immunohistochemical staining using a polyclonal antibody. Kaplan-Meier and Cox proportional hazards analyses were performed to evaluate the effect of C4d staining on renal survival.

RESULTS

There were 109 patients (38.5%) and 174 patients (61.5%) who were classified as C4d positive and C4d negative, respectively. Renal survival at 20 years was 28% in C4d-positive patients versus 85% in C4d-negative patients (P<0.001). Independent risk factors associated with ESRD were as follows: proteinuria (hazard ratio [HR] per every 1 g/d increase. 1.16; 95% confidence interval [95% CI], 1.03 to 1.31; P=0.01), eGFR (HR per every 1 ml/min per 1.73 m(2) increase, 0.96; 95% CI, 0.94 to 0.97; P<0.001), T2 Oxford classification (tubular atrophy/interstitial fibrosis, >50%; HR, 4.42; 95% CI, 1.40 to 13.88; P=0.01), and C4d-positive staining (HR, 2.45; 95% CI, 1.30 to 4.64; P=0.01).

CONCLUSIONS

C4d-positive staining is an independent risk factor for the development of ESRD in IgAN. This finding is consistent with the possibility that complement activation is involved in the pathogenesis of this disease.

NADPH oxidase NOX4 mediates stellate cell activation and hepatocyte cell death during liver fibrosis development

A role for the NADPH oxidases NOX1 and NOX2 in liver fibrosis has been proposed, but the implication of NOX4 is poorly understood yet. The aim of this work was to study the functional role of NOX4 in different cell populations implicated in liver fibrosis: hepatic stellate cells (HSC), myofibroblats (MFBs) and hepatocytes. Two different mice models that develop spontaneous fibrosis (Mdr2(-/-)/p19(ARF-/-), Stat3(Δhc)/Mdr2(-/-)) and a model of experimental induced fibrosis (CCl(4)) were used. In addition, gene expression in biopsies from chronic hepatitis C virus (HCV) patients or non-fibrotic liver samples was analyzed. Results have indicated that NOX4 expression was increased in the livers of all animal models, concomitantly with fibrosis development and TGF-β pathway activation. In vitro TGF-β-treated HSC increased NOX4 expression correlating with transdifferentiation to MFBs. Knockdown experiments revealed that NOX4 downstream TGF-β is necessary for HSC activation as well as for the maintenance of the MFB phenotype. NOX4 was not necessary for TGF-β-induced epithelial-mesenchymal transition (EMT), but was required for TGF-β-induced apoptosis in hepatocytes. Finally, NOX4 expression was elevated in patients with hepatitis C virus (HCV)-derived fibrosis, increasing along the fibrosis degree. In summary, fibrosis progression both in vitro and in vivo (animal models and patients) is accompanied by increased NOX4 expression, which mediates acquisition and maintenance of the MFB phenotype, as well as TGF-β-induced death of hepatocytes.

Esophageal verruciform xanthoma following radiotherapy

Verruciform xanthoma (VX) is an uncommon benign lesion of unclear etiology which has only been reported twice before in the esophagus. We describe a 70-year-old male who presented an exophytic esophageal lesion incidentally found upon endoscopy 2.7 years following radiation therapy for unresectable squamous cell carcinoma of the tracheal carina. Histologically, the lesion showed a papillary surface change with numerous foamy histiocytes within the lamina propia papillae. Xanthoma cells were strongly positive for vimentin and CD68 (KP1). Polymerase chain reaction did not demonstrate human papillomavirus (HPV) infection. Our results indicate that esophageal VX is not an HPV-induced lesion and suggest a causal relationship between VX and radiotherapy, as previously noted. Histological differential diagnosis is discussed and emphasis is placed on obtaining adequate biopsy material for accurate diagnosis.

Extraskeletal cutaneous chondroblastic osteosarcoma: a case report

Extraskeletal osteosarcoma is an uncommon neoplasm that usually arises in the deep soft tissues, especially in the lower extremities, with rare cases involving the subcutis or dermis. We report a 60-year-old man with an enlarging cutaneous mass in the right lower thigh. An incisional skin biopsy showed a well-defined, but non-encapsulated neoplasm, characterized by extensive cartilage with marked cellularity, atypia and high mitotic activity, involving the dermis and subcutis. Although osteoid or bone was not observed, a diagnosis of cutaneous chondroblastic osteosarcoma was suggested after excluding an origin in bone or other primary tumor sites by imaging techniques. Histopathologic features of the surgical specimen were characteristic, with a predominant high-grade chondroid component together with focal fibrosarcomatous zones, areas of multinucleated giant cells and foci of bone and osteoid formation. The patient underwent postoperative chemotherapy and is currently alive with pulmonary metastases 15 months after surgery. In summary, we report a unique case of cutaneous osteosarcoma of the chondroblastic subtype, diagnosed on incisional skin biopsy despite the absence of osteoid or bone during tumor sampling. As a rule, when an obviously malignant 'chondrosarcoma' is identified, one should always consider this entity.

Cytologic features of hepatoid carcinoma of the ovary: a case report with immunocytologic evaluation of HepPar1

BACKGROUND

Hepatoid carcinoma is a rare, primary neoplasm of the ovary characterized by histologic, immunobistochemical and analytical evidence of hepatic differentiation. Reflecting the rarity of this entity, few cytologic descriptions are available.

CASE

A 65-year-old woman presented with an abdominopelvic mass, peritoneal implants and elevated levels of CA-125 and a-fetoprotein (AFP). Cytologic examination of the ascitic fluid revealed cellular samples of polygonal cells in trabecular and papillary groups. Neoplastic cells were predominantly monomorphous, but some groups exhibited marked cellular atypia. A few trabecular groups showed peripheral endothelial rimming. Histologically, the neoplasm had evident hepatocellular differentiation, with a solid, trabecular growth of polygonal, eosinophilic cells with well-defined boundaries. The cells were immunoreactive with keratins, AFP and HepPar1. Retrospectively, HepPar1 was tested in cytologic samples, with a positive result.

CONCLUSION

As occurs with other hepatocellular neoplasms, the hepatic differentiation that characterizes this unusual neoplasm may not be easily recognizable in effusion samples. However, there are some features that, in addition to an elevated AFP value, may help to suggest the diagnosis. A predominant trabecular arrangement with occasional endothelial rimming and HepPar1 immunoreactivity, consistent with hepatic differentiation, are unusual in common surface epithelial ovarian tumors.

[Cutaneous follicular center B-cell lymphoma treated with intralesional rituximab]

Cutaneous follicular center B-cell lymphomas are indolent tumors characterized by the presence of neoplastic follicular center cells. They contain a mixture of centrocytes with a variable number of centroblasts. The tumor is usually treated by surgery or radiotherapy, although other treatments may be used such as interferon-alpha, chemotherapy, and biological agents (rituximab). Rituximab is a chimeric monoclonal anti-CD20 antibody that can be administered intravenously or intralesionally. We report the case of a 41-year-old man who consulted for violaceous nodular lesions in the left scapular region and who was diagnosed with cutaneous follicular center B-cell lymphoma after biopsy, laboratory tests, thoracic-abdominal-pelvic computed tomography, abdominal ultrasound, and bone marrow biopsy. It was decided to treat him with 30 mg of intralesional rituximab administered for 1 week (3 times) every month for 4 months. Complete response was obtained. We also review the published cases of cutaneous B-cell lymphoma treated with intralesional rituximab.

Nummular headache with trophic changes inside the painful area

Nummular headache (NH) is a primary disorder characterized by chronic pain that is exclusively felt in a small area of the head surface. We describe five patients with circumscribed head pain and sensory dysfunction consistent with NH, who in addition developed colocalized trophic changes. All of them had a round or oval patch of skin depression (1-2 cm in diameter) inside of the painful area (2-4.5 cm in diameter). Three of them also showed hair loss, reddish colour, and local increased temperature. Skin biopsies were performed in three patients, and were not specific for any particular dermatological disease. Local trophic changes may be a clinical feature of NH. Together with pain and sensory disturbances, they could represent a restricted form of complex regional pain syndrome. This should be taken as a possible evolution of the underlying morbid process of NH.

Correlation between the EGFR intron 1 CA dinucleotide repeat and skin toxicity in lung cancer patients treated with erlotinib

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Background: Acneiform rash is the main toxicity of erlotinib, an epidermal growth factor receptor (EGFR) inhibitor. The length of the CA dinucleotide repeat in EGFR intron 1 has been suggested to predict the biological effects of tyrosin kinase inhibitors. Thus, we compared this polymorphism with the rash severity in non-small cell lung cancer (NSCLC) patients treated with erlotinib. Methods: Toxicity was evaluated in 18 metastatic or locally advanced unresectable NSCLC patients treated orally with 150 mg/d of erlotinib: 7 retrospectively and 11 prospectively. Rash was graded according to a modified scale based on the Common Toxicity Criteria v.3.0, which subclassified grade II rash into IIA (topic intervention indicated) and IIB (oral intervention indicated). Genomic DNA was isolated from each patient; the length of the EGFR intron 1 CA dinucleotide repeat was measured by PCR amplification and analyzed on a capillary sequencer. Results: The most common EGFR genotypes were: 16, 20, 17 and 18 CA repeats (with 50, 25, 8 and 8% frequency, respectively). 33% of the subjects with a total amount of CA repeats <34 had grade IIB-III rash vs 11% of the subjects with =34 CA repeats. In addition, all patients with 0 grade toxicity belonged to the =34 CA group. When the only patient with a previous dermatological disease (psoriasis) was excluded from the analysis, the difference between both groups increased, reaching statistical significance (p=0.047). Conclusions: This data suggests that NSCLC patients with long EGFR intron 1 CA alleles present lower grades of skin toxicity when treated with erlotinib than patients with short CA alleles. Further studies are required to confirm this data.

[Table: see text]

No significant financial relationships to disclose.

[Cutaneous adverse reaction to Bio-Alcamid implant]

In the last years new and numerous materials for the correction of defects and wrinkles have been developed. One of these materials is Bio-Alcamid, a non reabsorbable gel polymer constituted by meshes of poly-alkyl-imide, without known adverse effects. We report a 34-year-old woman that had Bio-Alcamid implants for acne scars and several months after presented nodular lesions together with a painful inflammatory nodule. The nodule was drained and culture of the purulent material yielded Streptococcus viridans. A cytology and a cellular block of that material showed a granulomatous inflammatory reaction together with a foreign body. The different types of reactions to implants and their pathogenic mechanism are discussed. It is important to know these possible reactions to filler materials given their increasing use and the potential medico-legal consequences.

Sinonasal fibrosarcoma: a case report

Sinonasal fibrosarcoma (SFS) is an infrequent malignant neoplasm. It usually presents as other sarcomas in this region, with nasal obstruction and epistaxis. The final diagnosis is based on the histopathology and immunohistochemistry. We report the case of a 58-year-old man with an 8-month history of left proptosis, recurrent epistaxis and nasal obstruction. Nasal endoscopy confirmed a left nasal neoplasia. CT and MRI showed the extension of the neoplasia, occupying the left nasal fossa and ethmoid sinuses, and eroding the medial wall of the orbit. Complete removal was achieved through endoscopic sinus surgery, preserving the orbit. SFS was found on histopathologic examination. After 4 years of follow-up, nasal endoscopy, CT and MRI imaging show no sign of recurrence.

Fibroxantoma atípico. Estudio clinicopatológico de 10 casos

INTRODUCTION

Atypical fibroxanthoma (AFX) is a rare tumor of unknown histogenesis, considered by most authorities as a superficial form of malignant fibrous histiocytoma (MFH). The aim of this work is to report the clinicopathological features of 10 cases of AFX.

MATERIAL AND METHODS

Data were retrospectively collected of the computerized medical history. Clinical (age, onset-diagnosis time, location, accompanying pathology, outcome), histological (architectural pattern, cell type, ulceration, vascular or perineural invasion, subcutis involvement, pleomorphism, mitosis, inflammatory infiltrate) and immunohistochemical variable were analyzed.

CASES REPORT

Clinical and epidemiological features coincide with those previously reported: onset late in life, short time onset-diagnosis, involvement of skin with notable sun damage and a good outcome. Pathologically all the cases showed a spindle-cell prevalence arranged in a vaguely storiform pattern, along with both, multinucleated and eosinophilic cells.

DISCUSSION

The diagnosis of AXF is always of exclusion. Other spindle-cell tumors such as squamous cell carcinoma, malignant melanoma, leyomiosarcoma or dermatofibrosarcoma protuberans must be ruled out by immunohistochemical techniques. In spite of its rarity, the recognition of AFX is important in order to avoid inappropriately aggressive treatment.

Pustular idiopathic recurrent palmoplantar hidradenitis: an unusual clinical feature

A 12-year-old boy had painful lesions on both soles. He had had a similar episode several months before that resolved spontaneously. Physical examination showed erythematous, extremely tender nodules on both plantar surfaces and the toes. The second and third left toes had small pustules on top of the nodules. There was no palmar involvement. The clinical features, pathologic findings, and self-limited course suggested recurrent palmoplantar hidradenitis. This distinctive entity of unknown origin appears during childhood and is characterized histologically by a neutrophilic infiltrate affecting the eccrine glands. We report the case of a patient with unusual clinical features.

Subcutaneous nodular amyloidosis in Sjögren's syndrome

We describe a female patient with primary Sjögren's syndrome (SS) associated with a subcutaneous tumor formed by amyloid surrounded by mature IgG-kappa plasma cells, in the absence of lymphoproliferation or amyloid deposit in other organs. This case represents an unusual presentation of localized amyloidosis, without systemic involvement. Together with other reported cases this suggests that only immunocytic and not reactive systemic amyloidosis develops in chronic SS patients.

[Nodular regenerative hepatic hyperplasia associated with primary biliary cirrhosis]

An Hepatic Regenerative Nodular Hyperplasia (RNH) linked to a stage I Primary Biliary Cirrhosis (PBC) is presented. The scientific literature backing such association in reviewed. The pathogenic relationship between the two lesions and the role of RNH in the onset of portal hypertension in the initial stages of PBC is discussed.

Nodular regenerative hyperplasia of the liver in early histological stages of primary biliary cirrhosis

Nodular regenerative hyperplasia (NRH) is a condition characterized by hepatocytic nodules distributed throughout the liver without perinodular fibrosis. The etiology is unknown, but it has been reported in patients with a variety of diseases, including autoimmune diseases and primary biliary cirrhosis (PBC). In this study, the liver biopsies of 64 patients with PBC were reviewed. Thirty-five biopsies in histological stages I or II belonging to 30 patients were suitable for study. NRH was found in 43% of biopsies (47% of patients). In 80% of these biopsies, nodular transformation was focal, while it was diffuse in the remaining 20%. Splenomegaly was more common in patients with NRH. Laparoscopy displayed evidence of portal hypertension in two of these patients and endoscopy showed esophageal varices in one patient. Serum levels of gamma-glutamyl transpeptidase were also higher in these patients. Lesions in small intrahepatic vessels, florid bile duct lesions, and portal granulomas were found more frequently in biopsies with NRH. We conclude that nodular hyperplastic changes are very common in early histological stages of PBC, and consequently, this disease should be considered in the etiology of NRH. These changes may contribute to early development of portal hypertension in these patients.

Epithelial atypia in gynecomastia induced by chemotherapeutic drugs. A possible pitfall in fine needle aspiration biopsy

The clinical, cytopathologic and histopathologic features of a case of gynecomastia induced by chemotherapeutic drugs are described. Fine needle aspiration (FNA) smears showed epithelial atypia, and an erroneous cytologic diagnosis of carcinoma was made. Histopathologic study showed gynecomastia with epitheliosis, papillomatosis and atypical ductal hyperplasia. Review of the FNA smears showed the findings to be more typical of a reparative or regenerative process; these findings had been cytologically overinterpreted, partly due to the lack of adequate clinical information submitted with the aspirate. The possible causes of gynecomastia, the induction of epithelial atypia by cytotoxic chemotherapy and the cytologic features whose recognition may prevent false-positive diagnoses in such cases are discussed.

Primary malignant melanoma of the uterine cervix: case report and review of the literature

A case of primary malignant melanoma of the uterine cervix is presented. So far only 26 cases have been reported. Vaginal bleeding was the most common complaint. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and adjuvant radiotherapy is the elective treatment. Prognosis for this entity is poor. The tumor seems to arise from melanocytes that are usually present in the cervix.