A phase III, randomized, double-blind, placebo-controlled study of peldesine (BCX-34) cream as topical therapy for cutaneous T-cell lymphoma

BACKGROUND

The purine nucleoside phosphorylase inhibitor peldesine is a new agent being evaluated as a T-cell inhibitor.

OBJECTIVE

We attempted to determine the efficacy of peldesine (BCX-34) in a 1% dermal cream formulation as a treatment for cutaneous T-cell lymphoma (CTCL).

METHODS

Ninety patients with patch and plaque phase CTCL, histologically confirmed by a referee dermatopathologist, were enrolled in a randomized, double-blind, placebo-controlled study. BCX-34 dermal cream 1% or the vehicle cream (as a placebo control) was applied twice daily to the entire skin surface for up to 24 weeks. Efficacy of the topical therapy was assessed in terms of complete or partial (> or = 50%) clearing of patches and plaques.

RESULTS

Of the 89 patients able to be examined, 43 received BCX-34 and 46 received the placebo vehicle cream. One patient withdrew early and was not analyzed. The two groups were well balanced for potential prognostic factors. A total of 28% (12/43) of the patients treated with BCX-34 showed a response, but 24% (11/46) of patients who received vehicle also responded (P =.677).

CONCLUSION

Although BCX-34 dermal cream 1% was not significantly better than the control as therapy for patch and plaque-phase CTCL, this appears to be the first published placebo-controlled trial evaluating treatment for CTCL. Whether the vehicle cream has more than a placebo therapeutic effect is unclear. The relatively high (24%) placebo response rate should be kept in mind in assessing other treatments for early-stage CTCL.

Interphase cytogenetic analysis of 1q12 satellite III DNA in melanocytic lesions: increased aneuploidy with malignant histology

To examine the relationship of chromosome 1 copy number to melanocytic tumorigenesis, interphase cytogenetic analysis of 1q12 satellite III DNA was performed on the spectrum of melanocytic lesions comprising Clark's tumor progression model. Results showed increased copy number in a "step off" pattern between melanoma in-situ and the intraepidermal component of invasive melanoma rather than a progression between each lesional group. These findings support Clark's concept of independent clonal expansion of a cell population giving rise to the vertical growth phase and further demonstrates increased chromosome 1 copy number as a late event in melanoma tumor progression.

Iontophoresis treatment of basal cell carcinoma with cisplatin: a case report

Iontophoresis is a process that uses electrical current to increase the flux of ionized substances through tissue. Iontophoresis has been used in rehabilitation to decrease inflammation and pain using dexamethasone and lidocaine. In 1993, Chang et al. reported visual improvements in the lesions of nine patients diagnosed with basal cell carcinoma (BCC) following iontophoresis of cisplatin. The present case report describes the successful treatment of a 67-year-old male with a histologically confirmed BCC on his upper anterolateral left leg. The treatment consisted of four cycles of five successive days of cisplatin iontophoresis, with a 2-week rest period between cycles. The cisplatin solution (5 mL at 1 mg/mL) was used in combination with epinephrine hydrochloride. The effectiveness of the treatment was confirmed by post-treatment biopsies, which revealed granulation tissue scarring without evidence of BCC. Measurements of cellular proliferation were monitored immunohistochemically with Ki-67 and cell cycle distribution analyzed by flow cytometry.

The specialty of the treating physician affects the likelihood of tumor-free resection margins for basal cell carcinoma: results from a multi-institutional retrospective study

BACKGROUND

Basal cell carcinoma (BCC) is the most common cutaneous malignancy. Surgical experience and physician specialty may affect the outcome quality of surgical excision of BCC.

METHODS

We performed a multicenter retrospective study of BCC excisions submitted to the respective Departments of Pathology at 4 major university medical centers. Our outcome measure was presence of histologic evidence of tumor present in surgical margins of excision specimens (incomplete excision). Clinician experience was defined as the number of excisions that a clinician performed during the study interval. The analytic sample pool included 1459 tumors that met all inclusion and exclusion criteria. Analyses included univariate and multivariate techniques involving the entire sample and separate subsample analyses that excluded 2 outlying dermatologists.

RESULTS

Tumor was present at the surgical margins in 243 (16.6%) of 1459 specimens. A patient's sex, age, and tumor size were not significantly related to the presence of tumor in the surgical margin. Physician experience did not demonstrate a significant difference either in the entire sample (P <.09) or in the subsample analysis (P >.30). Tumors of the head and neck were more likely to be incompletely excised than truncal tumors in all the analyses (P <.03). Compared with dermatologists, otolaryngologists (P <.02) and plastic surgeons (P <.008) were more likely to incompletely excise tumors; however, subsample analysis for plastic surgeons found only a trend toward significance (P <.10). Dermatologists and general surgeons did not differ in the likelihood of performing an incomplete excision (P >.4).

CONCLUSION

The physician specialty may affect the quality of care in the surgical management of BCC.

Melanoma thickness and histology predict sentinel lymph node status

BACKGROUND

It remains unclear which patients with melanoma will benefit most from lymphatic mapping and sentinel lymphadenectomy. The purpose of this study is to determine whether primary melanoma histopathologic features could be applied to predict sentinel node status.

METHODS

One hundred twelve patients underwent sentinel node biopsy between May 1995 and August 1999. Reported histologic features were assessed for predictive value by univariate and multivariate logistic regression.

RESULTS

The sentinel node was located successfully in 105 of the 112 patients (94%). Twenty-one of these 105 patients (20%) had sentinel nodes that were positive for metastatic disease. Multivariate analyses revealed that tumor thickness greater than 1.5 mm (P = 0.01), ulceration (P <0.01), and lymphovascular invasion (P = 0.05) predicted the presence of micrometastases.

CONCLUSIONS

The presence of unfavorable histopathology such as ulceration and lymphovascular invasion may identify a group of patients with thin melanomas who would benefit from sentinel lymphadenectomy.

Genital cutaneous Crohn disease: two cases with unusual clinical and histopathologic features in young men

Cutaneous Crohn disease, sometimes called metastatic Crohn disease or Crohn disease with cutaneous involvement, is a rare complication of Crohn disease in which granulomatous lesions involve skin separated from gastrointestinal lesions by normal tissue. We report two cases of cutaneous Crohn disease presenting in young males with erythematous, nontender swelling of the scrotum. One of the young males presented erythematous, nontender swelling of the penis as well. In one case, cutaneous Crohn disease represented the primary presentation. The original biopsy in this case showed unusual areas of degeneration of dermal connective tissue forming cystic cavities. The diagnostic biopsies in both cases showed sarcoidal granulomas with an associated superficial and deep perivascular mixed infiltrate including eosinophils. On endoscopy, both patients showed lesions of active Crohn disease in the colon. Because changes that would suggest cutaneous Crohn disease may not be present on the initial biopsy, unusual presentations and negative cultures may warrant a second biopsy. A high index of suspicion and open communication with the clinician are essential to diagnose this disease.

The effect of tamoxifen and cisplatin on the disease-free and overall survival of patients with high risk malignant melanoma

The adjuvant treatment of high-risk malignant melanoma remains problematic. Previously we reported moderate success in the treatment of metastatic disease using tamoxifen, cisplatin, dacarbazine and carmustine. Based upon data that suggested tamoxifen and cisplatin were the active agents in this regimen, we initiated a phase II trial of this combination in the adjuvant setting. We treated 153 patients with 4 cycles of tamoxifen (160 mg day(-1), days 1-7) and cisplatin (100 mg m(-2), day 2) for 28-day intervals. Patients received an anti-nausea regimen of dexamethasone with ondansetron or granisetron. During the first 2 years of follow-up, patients were evaluated every 2 months with a history, physical exam, laboratory work and computed tomography scans of the chest, abdomen and pelvis every 4 months. Thereafter, patients were evaluated every 3 months and radiographic studies were performed if necessary. Currently, with a median follow-up of 36 months, the disease-free survival (DFS) is 68.4% and overall survival (OS) is 84.5%. Kaplan-Meier analysis predicts a 5-year DFS of 62% with an OS of 79%. Relapses after 20 months have been rare. No effect of gender or number of positive lymph nodes was noted, however, stage of disease prior treatment was a factor. The major toxicity proved to be gastrointestinal in nature with nausea the most prevalent symptom. Minimal renal, haematologic and neurologic toxicity occurred. These preliminary results suggest that there is a positive impact of tamoxifen and cisplatin on both the DFS and OS of high-risk malignant melanoma patients. The 5-year projected DFS and OS compare favourably with those reported for the ECOG 1684 trial and warrant confirmation in a prospective randomized trial.

Atypical Spitz nevi/tumors: lack of consensus for diagnosis, discrimination from melanoma, and prediction of outcome

The biological nature of Spitz nevi/tumors and their diagnostic distinction from, or relationship to, melanoma remain unresolved issues. In this report, a series of 30 melanocytic lesions removed from 28 patients, including atypical Spitz nevi/tumors and metastasizing Spitzoid tumors/melanomas, were evaluated by a panel of dermatopathologists to evaluate interobserver diagnostic concordance and to assess the prognostic power of histological criteria. For inclusion in the study, each lesion had to display some criteria for the Spitz nevus, and in addition one of the following was required: (1) definitive clinical outcome such as metastasis or death of disease, or (2) long-term follow-up if the patient remained disease free. Each lesion was reviewed independently and blinded as to the clinical data by 10 pathologists, who categorized them as (1) typical Spitz nevus/tumor, (2) atypical Spitz nevus/tumor, (3) melanoma, (4) tumor with unknown biological potential, or (5) other melanocytic lesion. There was limited discussion of criteria before the review. Evaluation of 17 Spitzoid lesions yielded no clear consensus as to diagnosis; in only one case did six or more pathologists agree on a single category, regardless of clinical outcome. Notably, however, some lesions that proved fatal were categorized by most observers as either Spitz nevi or atypical Spitz tumors. Conversely, seven or more pathologists scored 13 lesions as melanoma. These results illustrate (1) substantial diagnostic difficulties posed by many Spitz tumors, especially those with atypical features, even among experts, and (2) the lack of objective criteria for their distinction from melanoma and for gauging their malignant potential. Nevertheless, our observations do suggest that a biological relationship exists between the Spitz nevus/tumor and melanoma.

Clark's nevus

"Clark's nevi" is the name we apply to lesions that have been referred to in the past as dysplastic nevi or nevi with architectural and/or cytologic atypia. Our criteria for this histopathologic diagnosis include such architectural features as: (1) uneven distribution of melanocytes along the dermoepidermal junction; (2) irregularly spaced junctional nests that sometimes bridge between rete; and (3) ill-defined margins often characterized by a lentiginous growth pattern. If dermal nests are present, the junctional component usually extends laterally for some distance beyond the dermal nests. When there is cytologic atypia, it involves scattered melanocytes. Clark's nevi are of doubtful significance if few in number and occurring in a young patient in whom there is no family history of melanoma. When many are found in a patient with a family history of melanoma, their presence serves as a marker for dysplastic nevus syndrome (familial atypical mole-melanoma syndrome). When Clark's nevi develop in patients older than 40 or 50 years of age who have no family history of melanoma, their significance is less clear. However, they might signify a defect in those mechanisms that normally control formation and growth of melanocytic neoplasms.

Morphometric discrimination of melanoma in situ of sun-damaged skin from chronically sun-damaged skin

BACKGROUND

The histologic discrimination of melanoma in situ of sun-damaged skin (MIS) from chronically sun-damaged skin (SDS) can sometimes be difficult using accepted criteria.

OBJECTIVE

We evaluated these entities by means of morphometry and multifactorial analysis.

METHODS

We measured the number and area of melanocyte nuclei, melanocyte nucleoli, stratum spinosum keratinocyte nuclei, and papillary dermal lymphocyte nuclei from hematoxylin-eosin-stained slides representing 38 cases of MIS and 18 cases of SDS matched for age, sex, and site with a high-resolution digital imaging and analysis system.

RESULTS

Multiple logistic regression analysis correctly classified 100% of the cases using the number of melanocytes per 0.5 mm and the maximum melanocyte nuclear area divided by the maximum keratinocyte nuclear area. The strongest results were achieved measuring approximately 1 mm of epidermis.

CONCLUSION

Morphometry and multifactorial analysis can distinguish MIS from SDS. Morphometric analysis of melanocytic proliferations may be useful at the margins of surgical resections.

Reduced TSC2 RNA and protein in sporadic astrocytomas and ependymomas

Individuals affected with tuberous sclerosis complex (TSC) develop several benign and malignant tumors at increased frequency, including astrocytomas. Tuberin, the protein product of the tuberous sclerosis complex-2 (TSC2) tumor suppressor gene, has been shown to directly inhibit cell growth and is expressed at high levels in normal central nervous system neurons and astrocytes. To determine whether TSC2 RNA and protein are reduced in astrocytomas from individuals without tuberous sclerosis, reverse transcriptase-polymerase chain reaction and immunoblotting analyses were performed on 49 adult astrocytomas, 10 pediatric astrocytomas, and 13 ependymomas. Eighteen of 40 (45%) high-grade (World Health Organization [WHO] grade III/IV) astrocytomas and 4 of 8 (50%) adult low-grade (WHO grade II) astrocytomas demonstrated reduced or absent TSC2 expression, including 1 giant cell astrocytoma, whereas none of the 10 pediatric low-grade astrocytomas analyzed showed a reduction in TSC2 expression. Reduced or absent tuberin was observed in 2 of 6 (33%) ependymomas analyzed. These data demonstrate, for the first time, that reduced or absent TSC2 expression may represent one of the critical genetic events associated with the development of sporadic adult, but not pediatric, astrocytomas.

Expression of the TSC2 product tuberin and its target Rap1 in normal human tissues

The tuberous sclerosis-2 (TSC2) gene is linked to tuberous sclerosis (TSC), a dominantly inherited genetic syndrome in which inactivation of the normal TSC2 allele is associated with the development of mostly benign tumors and focal dysplasias. TSC2 encodes the protein tuberin, which is a widely expressed 180-kd polypeptide that exhibits specific GTPase activating activity toward Rap1 in vitro and co-localizes with Rap1 in cultured cells. In this study, we have performed immunohistochemical analyses, using affinity-purified anti-tuberin antibodies, to study the distribution of tuberin in a panel of normal human organs that are commonly affected by TSC. Cryosections indicated that tuberin is widely expressed at low levels. More intense staining of tuberin, in the cryosections and in paraffin sections, was observed in the small blood vessels of many organs, including the kidney, skin, and adrenal gland. High levels of tuberin were also detected in cortical neurons and cerebellar Purkinje cells. These findings imply that loss-of-function mutations in TSC2 might lead to the development of highly vascularized tumors, subcortical tubers, and focal atrophy of the cerebellar cortex, which are features commonly associated with TSC. Moreover, Rap1 was also found to be highly expressed in many of the same cells that contained high levels of tuberin, suggesting a functional interaction between tuberin and Rap1 in these tissues.

Localization of tuberous sclerosis 2 mRNA and its protein product tuberin in normal human brain and in cerebral lesions of patients with tuberous sclerosis

Tuberous sclerosis (TSC), an autosomal dominant disorder, is characterized by malformations, hamartomas and tumors in various organs including the brain. TSC is genetically linked to two loci: TSC1 on chromosome 9q34 and TSC2 on 16p13.3. TSC2 has been cloned, sequenced and encodes a protein (tuberin) which functions as a tumor suppressor. We have analyzed the distribution of TSC2 mRNA and tuberin in the brains of TSC patients and non-affected individuals using both autopsy and biopsy material. High levels of transcript and protein expression were observed in choroid plexus epithelium, ependymal cells, most brainstem and spinal cord motor neurons, Purkinje cells and the external granule cell layer of the cerebellum in both TSC and control cases. Individual balloon cells from TSC patients showed very faint expression while other glia showed no expression of either transcript or tuberin. Neocortical and hippocampal neurons expressed high levels of TSC2 transcript, but only modest levels of tuberin. The internal granule cell layer of the cerebellum expressed abundant transcript but low levels of tuberin. These observations suggest either that tuberin expression is controlled at the level of both transcription and translation or the antibody and in-situ hybridization recognize different splice variants of the TSC2 gene. In TSC patients, dysmorphic cytomegalic neurons expressed high levels of tuberin and transcript, particularly when in an 'ectopic' location. Individual cells within subependymal giant cell astrocytomas (SEGAs) and hamartomas from TSC patients expressed moderate to high levels of TSC2 transcript and tuberin. While the TSC2 transcript is widely expressed primarily within neurons, tuberin is demonstrable primarily within dysplastic/cytomegalic cells of the cortex and subependymal hamartomas/SEGAs. CNS expression of tuberin is unique in that primarily non-dividing cells express it in this location, whereas extra-CNS expression of tuberin is mainly found in actively proliferating cell types such as epithelium.

Co-localization of the TSC2 product tuberin with its target Rap1 in the Golgi apparatus

Tuberin is the protein product of the tuberous sclerosis-2 (TSC2) gene, which is associated with tuberous sclerosis (TSC), a human genetic syndrome characterized by the development of tumors in a variety of tissues. We have previously shown that tuberin is a widely expressed 180 kDa protein which exhibits specific GTPase activating activity in vitro towards the Ras-related Rap1 protein. In this study we have used affinity-purified antibodies against tuberin to analyse its expression in human and rat tissues and to examine its subcellular localization. Tuberin expression was detected in all adult human tissues tested, with the highest levels found in brain, heart and kidney, organs that are commonly affected in TSC patients. By contrast, in adult rats the highest levels of tuberin were found in brain, liver and testis. Indirect immunofluorescence of tuberin in various cultured cell lines revealed a punctate, mostly perinuclear staining pattern. Double-indirect immunofluorescence analysis with anti-tuberin sera and antisera against known Golgi markers (mannosidase-II and furin) revealed that the staining of tuberin was consistent with its localization in the stacks of the Golgi apparatus. In support of this, treatment of cells with brefeldin A, a drug known to cause disassembly of the Golgi apparatus, abolished the perinuclear staining of tuberin. Moreover, conventional and confocal immunofluorescence demonstrated co-localization of tuberin with Rap1, which has previously been localized to the Golgi apparatus. The co-localization of tuberin and Rap1 in vivo strengthens the likelihood that the in vitro catalytic activity of tuberin toward Rap1 plays a physiologically relevant role in the tumor suppressor function of tuberin.

Suppression of tumorigenicity by the wild-type tuberous sclerosis 2 (Tsc2) gene and its C-terminal region

The Tsc2 gene, which is mutationally inactivated in the germ line of some families with tuberous sclerosis, encodes a large, membrane-associated GTPase activating protein (GAP) designated tuberin. Studies of the Eker rat model of hereditary cancer strongly support the role of Tsc2 as a tumor suppressor gene. In this study, the biological activity of tuberin was assessed by expressing the wild-type Tsc2 gene in tumor cell lines lacking functional tuberin and also in rat fibroblasts with normal levels of endogenous tuberin. The colony forming efficiency of Eker rat-derived renal carcinoma cells was significantly reduced following reintroduction of wild-type Tsc2. Tumor cells expressing the transfected Tsc2 gene became more anchorage-dependent and lost their ability to form tumors in severe combined immunodeficient mice. At the cellular level, restoration of tuberin expression caused morphological changes characterized by enlargement of the cells and increased contact inhibition. As with the full-length Tsc2 gene, a clone encoding only the C terminus of tuberin (amino acids 1049-1809, including the GAP domain) was capable of reducing both colony formation and in vivo tumorigenicity when transfected into the Eker rat tumor cells. In normal Rat1 fibroblasts, conditional overexpression of tuberin also suppressed colony formation and cell growth in vitro. These results provide direct experimental evidence for the tumor suppressor function of Tsc2 and suggest that the tuberin C terminus plays an important role in this activity.

Silicone deposition in reconstruction scars of women with silicone breast implants

BACKGROUND

The possible association of silicone breast implants and disease is a subject of continuous debate and concern.

OBJECTIVE

Our purpose was to examine microscopically and ultrastructurally the periprosthetic fibrous capsules and reconstruction scars of women with silicone breast implants.

METHODS

Representative samples from the periprosthetic capsules and reconstruction scars from six women with silicone breast implants were examined by a variety of light microscopy techniques, transmission electron microscopy, and electron probe microanalysis.

RESULTS

Silicone globules of various sizes were identified in every periprosthetic capsule and reconstruction scar.

CONCLUSION

Extrusion and seeding of the incision tract during surgery most likely accounts for the presence of silicone in the reconstruction scar specimens. This observation suggests that the identification of silicone in the reconstruction scars of women with silicone breast implants does not necessarily implicate rupture of the silicone breast implant with systemic dissemination of silicone gel.

Eosinophilic histiocytosis. Histopathology and immunohistochemistry

We review the clinical features, histopathology, and immunohistochemistry in three cases of eosinophilic histiocytosis, comparing lymphomatoid papulosis and eosinophilic histiocytosis. Each of the patients presented with self-healing recurrent papules and ulcerative nodules that were associated with pruritus. Disease duration was 5 months to 9 years. Histologically, the lesions demonstrated spongiosis and lymphocytic exocytosis, epidermal hyperplasia, papillary dermal edema, and a superficial and deep mixed perivascular inflammatory infiltrate. The infiltrate showed numerous eosinophils, histiocytoid cells, lymphocytes, and large mononuclear cells with atypical hyperchromatic nuclei. Most of the lymphocytes and large mononuclear cells with atypical nuclei marked with UCHL-1 (T-cell marker). The histiocytoid cells marked with S-100 and were dendritic both in the epidermis and the dermis. Eosinophilic histiocytosis appears to differ from classic lymphomatoid papulosis. It presents with recurrent papules and nodules associated with marked pruritus. Eosinophilic histiocytosis uniformly has more eosinophils and does not have the Reed-Sternberg cells often observed in lymphomatoid papulosis type A. Eosinophilic histiocytosis does not have cells that mark with Ki-1 and shows numerous S-100-positive histiocytoid cells that are most likely Langerhans cells, unlike lymphomatoid papulosis. However, eosinophilic histiocytosis may be an unusual Ki-1-negative variant of lymphomatoid papulosis with histopathologic changes not typical of type A or type B. In addition, eosinophilic histiocytosis lacks multinucleated histiocytes and the atypical histiocyte with a reniform nucleus, findings that are characteristic of histiocytosis X. Further studies are needed to define the pathophysiology and prognosis of this apparently distinct entity more accurately.

Caterpillar bodies of porphyria cutanea tarda ultrastructurally represent a unique arrangement of colloid and basement membrane bodies

Caterpillar bodies are eosinophilic, periodic acid-Schiff (PAS)-positive globules arranged in a linear fashion in the epidermis overlying subepidermal blisters of porphyria cutanea tarda (Am J Dermatopathol 1993;15:199-202). We retrospectively studied by transmission electron microscopy nine cases of porphyria cutanea tarda (PCT) that demonstrated caterpillar bodies. We identified three components of the eosinophilic bodies: degenerating keratinocytes, colloid bodies, and basement membrane bodies. The colloid bodies consisted of whorled masses of filaments containing degenerating melanosomes, vacuoles, mitochondria, and desmosomes. Basement membrane bodies were composed of convoluted basement membrane material and associated collagen. Both colloid and basement membrane bodies were often associated with degenerating keratinocytes, were located both intra-and extracellularly, and were occasionally fused to one another. We believe that caterpillar bodies are a combination of degenerating keratinocytes, colloid bodies, and basement membrane bodies formed by repeated blistering and reepithelialization with transepidermal migration. Furthermore, we believe that caterpillar bodies are a diagnostic clue for the diagnosis of PCT.

Nonmelanoma skin cancers in association with seborrheic keratoses. Clinicopathologic correlations

BACKGROUND

Seborrheic keratoses (SKs) can be seen in association with cancers.

OBJECTIVE

Our study was designed to demonstrate the occurrence of concomitant SKs and nonmelanoma skin cancers, as well as to correlate their histological types and clinical locations. The study was not intended to be an epidemiologic survey.

METHODS

We prospectively collected 108 completely excised SKs, examined them microscopically, categorized them, and correlated the clinical site, histological type, and determined the incidence of concomitant malignancy.

RESULTS

Of the 108 SKs studied, 71 were acanthotic, 27 hyperkeratotic, and 10 reticulated. The incidence of associated nonmelanoma cancers was 4.6%. All malignancies were squamous cell carcinomas and were on sun-exposed skin. Three of the five malignancies arose in conjunction with reticulated SKs.

CONCLUSIONS

The incidence of nonmelanoma skin cancer in association with SKs may be greater than previously reported, particularly in SKs situated on photo damaged skin and of the reticulated type. SKs that have undergone recent growth or other clinical change should be biopsied and all SKs that are removed should be examined histologically.

A multiobserver, population-based analysis of histologic dysplasia in melanocytic nevi

BACKGROUND

Nevi that are clinically atypical and histologically dysplastic have been associated with increased melanoma risk. There are few reproducibility studies or population-based studies of nevus histology.

OBJECTIVE

Our purpose was to quantify concordance in histologic diagnosis of melanocytic lesions among a diverse group of pathologists, to assess intraobserver concordance by comparing readings of the same slide as well as of adjacent recuts from the same block, to correlate histology with nevus appearance and melanoma risk, and to estimate the range of prevalence of histologic dysplasia.

METHODS

Histologic slides were prepared from 149 tissue blocks of pigmented lesions from melanoma cases, relatives, and controls. Six dermatopathologists independently evaluated the lesions for histologic dysplasia, without prior agreement on criteria.

RESULTS

According to kappa statistics, intraobserver reproducibility was substantial, and interobserver concordance was fair, despite differences in criteria. The estimated prevalences of histologic dysplasia for the six pathologists ranged from 7% to 32%. Histologic dysplasia was correlated with nevus size for most observers, confounding the observed correlation between nevus appearance and histology.

CONCLUSION

Although experienced dermatopathologists use different diagnostic criteria for histologic dysplasia, their usage is consistent. Histologic changes ascribed to melanocytic dysplasia are prevalent in the white population for all pathologists. The term nevus with histologic dysplasia should be used in preference to dysplastic nevus.

Demonstration of silicon in sites of connective-tissue disease in patients with silicone-gel breast implants

BACKGROUND AND DESIGN

Silica, Silastic, and silicone (any organic compound in which silicon replaces carbon) have been associated with a number of connective-tissue diseases, most commonly systemic sclerosis (scleroderma). Silicone is known to leak from breast implants and spread to surrounding tissues, including lymph nodes, but silicone's role in the origin and pathogenesis of the inflammation and fibrosis related to such conditions remains controversial. Synovial tissue, alveolar macrophages, and skin, each from three different patients with silicone-gel implants, plus the breast implant capsules from each of the three patients, were examined by light microscopy, transmission electron microscopy, and electron probe microanalysis for the presence of silicon-containing material.

RESULTS

Silicon was identified within the fibrous breast capsule of each case, associated with a chronic inflammatory cell infiltrate. Silicon was also identified within tissues involved by chronic inflammation and fibrosis, namely, synovium, skin, and alveolar macrophages, in association with clinical, serologic, and histologic evidence of connective tissue disease. All three patients improved after removal of the silicone-gel breast implants.

CONCLUSIONS

The presence of silicon-containing material within sites of connective-tissue disease supports a role for silicon in the origin or pathogenesis of such conditions in patients with silicone-gel breast implants. All patients with connective-tissue disease should be questioned about exposure to various forms of silicon. In those patients with known exposure, tissue specimens should be examined carefully for silicon-containing material and, if found, the source should be removed.

A histopathologic comparison of Shulman's syndrome (diffuse fasciitis with eosinophilia) and the fasciitis associated with the eosinophilia-myalgia syndrome

A comparison of the histopathologic features of Shulman's syndrome (diffuse fasciitis with eosinophilia) and the fasciitis associated with the eosinophilia-myalgia syndrome is presented. The study population consisted of eight biopsy specimens of seven patients with Shulman's syndrome and 11 specimens from 10 patients with eosinophilia-myalgia syndrome. Both groups exhibited inflammatory changes in the subcutaneous fat, septa, and fascia; cutaneous changes were more prominent in cases of eosinophilia-myalgia syndrome. Eosinophils and plasma cells were not consistently present in either condition; mast cells and factor XIIIa-positive cells were consistently present in the inflammatory infiltrates. Although there was overlap in the histopathologic findings, Shulman's syndrome tends to involve the subcutis alone and the eosinophilia-myalgia syndrome tends to be a pancutaneous-subcutaneous process.

Morsicatio buccarum et labiorum (excessive cheek and lip biting)

In some individuals habitual cheek and lip biting becomes a fixed neurosis. Pieces of oral mucosa are actually torn free from the surface, producing a distinctive clinical appearance termed morsicatio buccarum et labiorum. Sometimes it may be confused with other dermatological disorders involving the oral mucosa, and can lead to misdiagnosis. Most patients with this condition are unaware of their habit and will not aid in the diagnosis. We suggest that the histopathological features of this condition are distinctive, if not pathognomonic, and that an accurate diagnosis should be rendered if a biopsy sample is taken. Two cases are reported herein that were originally misdiagnosed as pemphigus, one of which resulted in complications of improper oral corticosteroid use.

Circumscribed storiform collagenoma (sclerosing fibroma)

In the past several years we have examined eight dermal nodules that have morphologic features identical to the nodules described in patients with Cowden's disease. The patients in this series had no other clinical manifestations of Cowden's disease. In an attempt to better define this distinctive entity, we subjected tissue sections to a battery of histochemical and immunohistochemical stains and examined tissue from one of the nodules ultrastructurally. Although we found similarities between these nodules and other common dermal fibrotic lesions, we believe that they are distinctive architecturally (they are sharply circumscribed and have a strikingly uniform storiform pattern) and immunohistochemically (with uniformly scattered factor 13a-positive cells). Because of the unique histologic features, we propose that the term "circumscribed storiform collagenoma" be applied to these nodules.

Multiple rhabdomyomatous mesenchymal hamartomas of skin

A case of multiple rhabdomyomatous mesenchymal hamartomas is presented. The patient is a black male infant, the product of an uncomplicated term gestation and delivery. At birth, there were numerous polyps distributed over the periorbital and periauricular areas bilaterally. Some appeared fingerlike with constrictions below their tips. Others were branched or globular in shape. These projections showed spontaneous and independent movement, particularly during feedings. On histopathologic examination, the polyps were covered by squamous epithelium and contained normal follicular units. Bundles of skeletal muscle were present in the reticular dermis, extending into the subcutis. Regular cross-striations were seen in these muscle fibers. In some specimens, the muscle bundles formed a solid, central core. Skeletal muscle histochemical stains confirmed the presence of both types 1 and 2 muscle fibers. Electron microscopy revealed a normal skeletal muscle banding pattern. This case is the first report of multiple rhabdomyomatous mesenchymal hamartomas of skin. Functional skeletal muscle with spontaneous movement is part of the clinical picture.

Scleroderma following augmentation mammoplasty. Report of a case and review of the literature

A 46-year-old woman developed localized scleroderma after surgical manipulation of her silicone gel-filled breast prostheses. She developed firm, shiny plaques on her legs that progressed to involve the thighs. Histopathologic examination of a deep-skin biopsy specimen confirmed the diagnosis of scleroderma. On surgical removal of the silicone implants, and their replacement with saline-filled implants, the scleroderma gradually resolved. Histopathologic examination of the removed implant capsules revealed evidence of silicone leakage. All new female patients with scleroderma should be questioned and examined regarding augmentation mammoplasty. Until prospective studies are completed on the possible association between scleroderma and silicone breast implants, it would seem prudent to use the saline-filled, elastomeric envelope-type breast implant for augmentation mammoplasty rather than the silicone gel-filled implant.

Squamous syringometaplasia in lobular panniculitis and pyoderma gangrenosum

Squamous metaplasia of eccrine sweat glands has been most frequently described in chronic cutaneous ulcerations with associated epidermal hyperplasia. We found examples of the process in skin biopsy specimens from five patients: three had associated lobular panniculitis and two had lesions of pyoderma gangrenosum. The metaplasia was located in the mid-to-deep reticular dermis in all five patients and extended into the superficial subcutis in one. Immunohistochemical stains for CEA and S-100 protein were used to accentuate the relationship of the metaplastic islands with eccrine ducts. It is postulated that necrosis of a portion of the eccrine duct is the stimulus for this process.

Scleroderma, fasciitis, and eosinophilia associated with the ingestion of tryptophan

An association between the ingestion tryptophan and a syndrome characterized by scleroderma-like skin abnormalities, fasciitis, and eosinophilia has recently been recognized in the United States. We report the clinical and histopathological findings in nine patients and the results of biochemical analyses of tryptophan metabolism in seven patients with this syndrome. Edema of the extremities, frequently accompanied by pruritus, paresthesia, and myalgia, developed in the nine patients (six women and three men; age range, 30 to 66 years) 1 to 18 months after the start of therapy with tryptophan (1.5 to 3.0 g daily) for insomnia, depression, or obesity. Five patients were taking drugs (benzodiazepines) known to inhibit hypothalamic-pituitary-adrenal function, and one had adrenal insufficiency. All had blood eosinophilia in the acute phase of their illness (mean eosinophil count [+/- SD], 3.62 +/- 2.87 X 10(9) cells per liter). All had histopathological changes in the dermis and subcutaneous tissue typical of scleroderma, and seven patients had eosinophils. The fascia was inflamed and fibrotic, and adjacent skeletal muscle often showed perifascicular inflammation. Tryptophan was discontinued in all patients, and eight received prednisone. The cutaneous symptoms improved, but only two patients had complete resolution of their illness. The patients had plasma levels of tryptophan before and after an oral dose of tryptophan that were similar to those in normal subjects. Plasma levels of L-kynurenine and quinolinic acid, which are metabolites of tryptophan, were significantly higher in four patients with active disease than in three patients studied after eosinophilia had resolved or in five normal subjects (P less than 0.001)--findings consistent with the activation of the enzyme indoleamine-2,3-dioxygenase. This illness resembles eosinophilic fasciitis and probably represents one aspect of the recently reported eosinophilia-myalgia syndrome. The development of the syndrome may result from a confluence of several factors, including the ingestion of tryptophan, exposure to agents that activate indoleamine-2,3-dioxygenase, and possibly, impaired function of the hypothalamic-pituitary-adrenal axis.

D-penicillamine-induced elastosis perforans serpiginosa in a child with juvenile rheumatoid arthritis. Report of a case and review of the literature

Elastosis perforans serpiginosa is a rare complication of D-penicillamine therapy. It has been reported to occur in Wilson's disease and cystinuria, usually after many years of high-dose therapy. We report a case of D-penicillamine-induced elastosis perforans serpiginosa with unique clinical features occurring in a 10-year-old child with juvenile rheumatoid arthritis who received only 71 gm of the drug over 9 months. The case is also unusual because of the short course and low cumulative dose of drug received and because of the calcification of elastic fibers. The calcification of elastic fibers suggests that this case may represent an unusual variant of elastosis perforans serpiginosa or an overlap with pseudoxanthoma elasticum. All reported cases of D-penicillamine-induced elastosis perforans serpiginosa are reviewed, and histopathologic and electron microscopic findings are presented. The theoretic mechanisms of action of D-penicillamine on elastic tissue synthesis and morphology are discussed.

A new method for the comprehensive automatic morphologic image analysis of Langerhans cells

Standard techniques used to study Langerhans cell (LC) populations are tedious and time-consuming. We developed a rapid and comprehensive method to evaluate LC using automatic digital image analysis. Human epidermal sheets were stained with OKT6 monoclonal antibody and evaluated on an IBAS 2000 computerized automatic digital image analysis system. The fields were imaged on a Photomicroscope I using a high-resolution monochrome video camera. Each field was digitized, normalized, and filtered. The LC were discriminated by density; each field was interactively edited to separate overlapping cells and to bridge small gaps in the dendrites. The discriminated binary image of the LC was measured for number of cells per field, total area of individual cells per field, and percent of the field occupied by LC. The cell bodies were then separately discriminated and subtracted from the thinned cell image to allow a separate measurement of number and length of dendrites per cell. Finally, the binary cell image in a reference section was dilated to occupy approximately the total field area. This degree of dilation was then applied to all subjects to give the "area of influence." This methodology provides a rapid and comprehensive tool for the evaluation of LC.

Papillary eccrine adenoma. A light microscopic and immunohistochemical study

The papillary eccrine adenoma is a rare benign sweat gland neoplasm characterized by a potentially locally aggressive clinical course. The light microscopic findings in two cases of this unusual neoplasm are discussed, with emphasis on the differential diagnosis of this tumor from other benign and malignant sweat gland neoplasms. Immunohistochemistry studies directed against various epithelial antigens were also performed. Immunoperoxidase stains positive for carcinoembryonic antigen, S-100 protein, and epithelial membrane antigen strongly support the hypothesis that this unusual neoplasm differentiates toward the eccrine secretory coil.

Mucosal melanosis

The labial melanotic macule has an increased number of dendritic melanocytes along the basal layer. Numerous counterparts of the labial melanotic macule occur on the other mucosal and cutaneous surfaces. Most melanoacanthomas of the lip show a similar number of melanocytes along the junctional zone. Melanoacanthoma of the lip differs histologically from the labial melanotic macule by the presence of intraepithelial dendritic melanocytes. It also has histologic counterparts that occur on other oral mucosal surfaces. Primary acquired melanosis of the conjunctiva is biologically different from the other mucosal melanoses because it frequently progresses to malignant melanoma. All mucosal melanoses must be taken seriously by the physician, because it is usually not possible to exclude malignant melanoma on clinical inspection alone. A biopsy is always indicated. The labial melanotic macule and melanoacanthoma demonstrate histologic features strikingly different from those of melanoma. Although intraepithelial dendritic melanocytes are seen in melanoacanthoma, they are mostly present in the lower portions of the epithelium, and there is no full-thickness haphazard dispersion of atypical single and nested melanocytes. Along the basal layer in melanotic macules and melanoacanthomas of the lip, melanocytes are arranged as solitary units without a tendency to form abnormal nests or become confluent, in contrast to the picture in melanoma. Melanocytes in this zone show no pleomorphism, in contradistinction to the often bizarre, atypical melanocytes seen in melanoma.

Melanotic macules and melanoacanthomas of the lip. A comparative study with census of the basal melanocyte population

Fifteen labial melanotic macules and three melanoacanthomas of the lip were studied with particular regard to their distinguishing histopathological features including a quantitative study of the basal melanocyte population. Both of these entities show an increased population of melanocytes arranged as single units along the junctional zone. These conditions differ from each other primarily by the presence of intraepithelial melanocytes in melanoacanthoma. In our opinion, the melanotic macule of the lip has numerous histological counterparts that occur on other mucosal and cutaneous surfaces. Oral mucosal analogies to the labial melanoacanthoma also exist.

Subcutaneous phaeohyphomycosis caused by Exserohilum rostratum in an immunocompetent host

A healthy, 55-year-old woman developed a subcutaneous abscess and systemic symptoms of nausea, dizziness, and chills following minor trauma to her leg. Histopathologic examination of a skin biopsy specimen revealed golden-brown colored mycelial elements, and culture resulted in growth of a dematiaceous fungus identified as Exserohilum rostratum. Surgical excision of the abscess and concomitant oral therapy with ketoconazole resulted in resolution of symptoms. In previously reported cases of human phaeohyphomycosis caused by Exserohilum and related Bipolaris species in both immunocompromised and immunocompetent hosts, treatment has varied from topical antimicrobial therapy to combined surgery and intravenous antifungal chemotherapy. Our experience leads us to believe that surgical débridement of an accessible focus of infection along with orally administered ketoconazole may provide adequate therapy in an immunocompetent host.

Bronchial mucoepidermoid carcinoma metastatic to skin. Report of a case and review of the literature

A case of bronchial mucoepidermoid carcinoma is reported, the presentation of which was as cutaneous metastases. Histologic, histochemical, and ultrastructural features of the neoplasm are described, and the literature pertaining to bronchial mucoepidermoid carcinoma is reviewed. This case illustrates the potential for aggressive behavior in a mucoepidermoid neoplasm, the histologic features of which are considered low grade by some authors. Because such metastatic lesions may be morphologically identical to tumors that have been described as primary cutaneous mucoepidermoid carcinomas, this differential must be considered by the histopathologist confronted by such a neoplasm.

Follicular lymphomatoid papulosis

A patient with follicular lymphomatoid papulosis is reported. Only two cases of this rare variant have been previously reported in the literature. Lesions typical of lymphomatoid papulosis in this case were centered around disrupted hair follicles. They corresponded to the type A "histiocytic" variant of lymphomatoid papulosis. The histologic features and theories regarding histogenesis of this unusual disorder are discussed.

Recurrent adenoid cystic carcinoma of the skin managed by microscopically controlled surgery (Mohs surgery)

A patient with recurrent adenoid cystic carcinoma of the skin managed by Mohs surgery is reported. The histopathologic features and differential diagnosis of this tumor are reviewed. Mohs surgery appears to be an ideal way to manage this neoplasm since recurrences after routine excision are common and metastases are uncommon.