Non-Vitamin K Oral Anticoagulants Assessment in High Risk of Bleeding Patients with Non-Valvular Atrial Fibrillation

Atrial fibrillation (AF) is commonly associated with advanced age and the presence of multiple, concomitant acute and chronic health conditions, placing this population at high risk for serious therapeutic side effects. Nonvitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in patients with atrial fibrillation. The purpose of this study was to investigate the effectiveness and safety of NOAC in a group at high risk of bleeding complications, in a real-world setting. We conducted a retrospective analysis of a high-risk cohort of 418 patients (pts) followed-up in our anticoagulation unit; data on patient characteristics, anticoagulation treatment, and bleeding and thrombotic complications were evaluated. The population had a median age of 77.8 ± 10.3 years and the mean CHA₂DS₂-VASc score was 3.85 (SD ± 1.4). Overall, 289 (69.1%) were ≥75 years old. During a mean follow-up time of 51.2 ± 35.7 months, we observed a rate of any bleeding of 7, a clinically relevant non-major bleeding rate of 4.8, a major bleeding rate of 2.2, a stroke rate of 1.6, and a rate of thrombotic events of 0.28 per 100 patient-years. There were 59 hospitalizations due to any cause (14.1%) and 36 (8.6%) deaths (one due to ischemic stroke). A structured follow-up, with judicious prescribing and drug compliance, may contribute to preventing potential complications.

Epicardial fat volume improves prediction of adverse clinical events

Funding Acknowledgements

Type of funding sources: None.

Introduction

Recent studies have demonstrated the potential of epicardial fat volume (EFV) to predict obstructive coronary artery disease (CAD), however its impact in clinical outcomes remains elusive.

Objectives

To assess the association between EFV and demo­graphic and morphometric data, coronary atherosclerotic burden and adverse events in a population of patients (pts) referred for coronary computed tomography angiography (CTA).

­Methods: Retrospective analysis of pts without known CAD referred for coronary CTA in a single tertiary care centre. A standardized protocol for quantification of EFV, thoracic fat volume (TFV), coronary artery calcification (CAC) and coronary angiography was performed. Endpoint was composite of cardiovascular death, nonfatal myocardial infarction and urgent hospitalization leading to revascularization at 12 months.

Results

72 pts were included, 58% male, mean age 67 ± 9 years. The prevalence of hypertension, dyslipidemia and diabetes was 75%, 82% and 24%, respectively. Median EFV was 101 (68) ml and total TFV 1504 (694) ml. EFV was directly related with age (rs= 0.42, p <0.001), male sex (135 ± 50 vs 78 ± 30, p <0.001), body mass index (rs= 0.32, p= 0.008) and TFV (rs= 0.27, p= 0.025). A positive correlation with CAC (rs= 0.47, p <0.001) and a significant association with CAD (116 ± 50 vs 90 ± 37, p= 0.029) and obstructive CAD (141 ± 60 vs 97 ± 39, p= 0.031) were demonstrated. Composite endpoint was observed in 13 pts (18%). After adjusting for all considered confounders, EFV remained an independent predictor of adverse events (OR: 1.015, 95%CI: 1.003-1.027, p= 0.041). ROC analysis of EFV (AUC 0.751, p = 0.005) allowed to estimate that EFV >124 ml had a sensibility and specificity to predict clinical outcomes of 69% and 71%, respectively.

Conclusion

EFV positively relates to coronary atherosclerotic burden. This study also advocates that EFV may improve risk stratification for clinical outcomes. Larger studies are required to evaluate these results. Abstract Figure 1

Pulmonary hypertension in mitral stenosis patients submitted to percutaneous balloon mitral valvuloplasty: an innocent bystander?

Funding Acknowledgements

Type of funding sources: None.

Background

Percutaneous balloon mitral valvuloplasty (PBMV) is the cornerstone of the treatment of rheumatic mitral stenosis (MS) in suitable patients. Pulmonary hypertension (PH) is a common coexisting finding and an indication for intervention. We sought to assess the influence of PH in PBMV immediate results and in very longterm outcome.

Methods

Between 1991 and June 2021, 202 consecutive patients underwent PBMV in a single tertiary centre. Clinical data, echocardiographic parameters, and MACE (cardiovascular mortality, need for percutaneous or surgical mitral reintervention) were analysed.

Results

Mean age was 47.3 ± 13.6 years and 89.6% were women. A previous commissurotomy or PBMV was found in 10.4% and mean Wilkins score was 7.6 ± 1.4. PH, defined as pulmonary artery systolic pressure (PASP) ≥45mmHg, was present in 32.7% of patients. A successful procedure was achieved in 89.1% of total population. Mean mitral valve (MV) gradient decreased from 13.1 to 5.0 mmHg (p < 0.001) and MV area increased from 1.1 to 1.8 cm2 (p < 0.001). A significant reduction also occurred in left atrium diameter (48.8 to 46.8 mm, p < 0.001) and PASP (50.5 to 38.5 mmHg, p < 0.001). During a mean follow-up of 12.0 ± 8.8 years, 7 cardiovascular deaths occurred (3.5%) and 33.2% of patients needed MV reintervention. Baseline PH did not impact immediate success and was not related with MACE in the follow-up. However, PH persistence after PBMV was correlated with unsuccessful procedure (p = 0.023) and with the occurrence of MACE during FU (HR 3.3, CI 95% 1.1-9.6, p = 0.028 and Kaplan-Meier analysis, log-rank 0.020).

Conclusions

PBMV in patients with MS and PH is a safe and effective intervention, achieving a significant decrease in PASP after procedure. Baseline PH was not associated with success or MACE. However, PH persistence after PBMV, correlated with worse prognosis in longterm follow up. Special attention and further investigation for this subgroup is needed. Abstract Figure.

Myocardial work brings a new insight into left ventricule remodelling in cardiooncology patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Serial echocardiographic assessment of 2D left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) is the gold standard screening method for cancer therapeutics-related cardiac dysfunction (CTRCD). Non-invasive left ventricular (LV) pressure-strain loop (PSL) provides a novel method of quantifying myocardial work (MW) with potential advantages, as it incorporates measurements of myocardial deformation and LV pressure.

Purpose

To evaluate the impact of cardiotoxic treatments in MW indices.

Methods

Prospective study of female breast cancer patients (P) submitted to therapy (TH) who underwent serial monitoring by 2D, 3D transthoracic echocardiography (TTE) and concomitant blood pressure assessment. P were evaluated at T0, T1 and T2 (before, ≥6 and ≥12 months after starting TH). PSL analysis allowed the calculation of the following indices: Global Work Index (GWI), Global Constructive Work (GCW), Global Work Waste (GWW) and Global Work Efficiency (GWE). CTRCD was defined as an absolute decrease in 2D LVEF > 10% to a value < 54% or a relative decrease in 2D GLS > 15%, according to literature. 

Results

122 patients (mean age 54.7 ± 12.0 years), mostly treated with anthracyclines (77.0%, cumulative dose 268.6 ± 71.8mg/m2), anti-HER (75.4%) and radiotherapy (77.0%) were included. 2D and 3D LVEF were significantly reduced during TH, however remaining within the limits of normality (2D LVEF T0-T1 64.2 ±7.6 vs 61.1 ± 8.2%, p = 0.006 and 3D LVEF T0-T1 60.2 ± 6.7 vs 56.9 ±6.3%, p = 0.022). 2D GLS was also more impaired at T1 (-19.8 ± 2.7% vs -18.5 ± 3.0%, p = 0.003).

All MW indices were significantly reduced at T1 compared to baseline (GWI 1756.9 ± 319.2 vs 1614.3 ± 338.5mmHg%, p = 0.005; GCW 2105.6 ± 352.0 vs 1970.5 ± 376.2 mmHg%, p = 0.015; GWW 121.1 ± 66.6 vs 161.1 ± 84.1 mmHg%, p = 0.001; GWE 93.5 ± 3.1 vs 91.1 ± 4.5%, p = 0.001). Between T1 and T2 no statistical difference was found but a partial recovery of parameters was observed when comparing T2 to T0 (GWI (T2) 1650.6 ± 357.5 mmHg%, p = 0.035; GCW (T2) 2013.3 ± 379.3 mmHg%, p = 0.086; GWW (T2) 148.0 ± 85.0 mmHg%, p = 0.02 and GWE (T2) 92.0 ± 4.7%, p = 0.012). 

During a mean follow-up of 14.9 ± 9.3 months, 36 patients (29.5%) developed CTRCD.  P presenting CTRCD revealed a significant decrease in GWI and GWE at T1 comparing with women without CTRCD (GWI 1.8 ± 21.6 vs -14.2 ± 18.5%, p = 0.004 and GWE -1.0 ±3.0 vs -3.6 ±3.9%, p = 0.005). GWW had a substantially increase at T1 in P with cardiotoxicity (27.6 ± 76.3% vs 64.1 ± 68.0%, p = 0.051).

Conclusion

Left ventricular systolic function study with MW showed a reduction in cardiac performance with a peak at 6 months from the start of chemotherapy and partial recovery after term. Assessment of myocardial deformation parameters, namely MW, proved to be a useful tool for a better characterisation of cardiac remodelling, and could enhance patient selection for cardioprotective therapeutics.

Abstract Figure. TTE parameters

P3628Contemporary coronary artery disease prevalence in a valvular heart disease population undergoing surgery

Background

Patients undergoing heart valve surgery are routinely evaluated for the presence of Coronary Artery Disease (CAD), with the standard practice of combining valve intervention with a revascularization procedure, notably Coronary Artery Bypass Graft (CABG). Older studies suggest rates as high as 50% prevalence of CAD in this population. However, CAD prevalence, its treatment and prognostic implication has been questioned recently.

Objectives

The goal of this study is to evaluate the baseline characteristics, prevalence of CAD and treatment strategies in a contemporary population with valvular heart disease (VHD) referred for valve surgery.

Methods

In a national multicentre registry, consecutive patients, from Jan 2015 to Dec 2016, with a formal indication for heart valve surgery referred for a pre-op routine coronary angiogram were systematically analysed. Baseline characteristics, valve pathology and CAD prevalence and patterns were determined. Obstructive CAD was defined as luminal angiographic stenosis ≥70% (≥50% for left main artery). The prognostic impact of the different valve disease and CAD treatment strategies were assessed.

Results

1175 patients (mean age 72.5±10.1; male 49.2%) fulfilled the clinical or echocardiographic indication for valve surgery by European guidelines. Valvular disease prevalence was: aortic stenosis (66.7%), aortic regurgitation (6.6%), mitral stenosis (6%), mitral regurgitation (19.2%), tricuspid regurgitation (7.5%). Mean follow-up time was 29.06±18.46 months. Prevalence of comorbidities was: Diabetes Mellitus (DM) 26%, chronic obstructive pulmonary disease (COPD) 5.7% and chronic kidney disease (CKD) 23.4%. Mean Euroscore II was 2.6%. Obstructive CAD was present in 27.3% patients. Mean Syntax score was 10.2 (<22 in 88%, 23–32 in 10.2% and >33 in 1.8%). Left main artery and 3-vessel disease were found in 13.1% and 11.8% of patients with CAD, respectively. Valvular surgery was ultimately performed in 80.3%. In patients with CAD, 57.3% were revascularized. All-cause mortality rate during follow-up was 12.9%, with 7.8% from cardiovascular causes. In univariate analysis DM, COPD, CKD, NYHA class, obstructive CAD and no surgery (p<0.05) were associate with mortality on follow up. In multivariate analysis obstructive CAD (OR 2.36, 95% CI 1.53–3.65, p<0.01) and no surgery (OR 6.05, 95% CI 3.95–9.30, p<0.01) persisted as independent all-cause mortality predictors.

Conclusion

In a contemporary cohort of patients with VHD and surgical indication, CAD prevalence is lower (27.3%) than described in literature. Mortality rates were higher in patients with obstructive CAD, worse NYHA functional class and in those who never underwent surgery.

Parathyroid hormone is associated with incident diabetes in white, but not black adults: The Atherosclerosis Risk in Communities (ARIC) Study

OBJECTIVE

Accumulating evidence has linked elevated parathyroid hormone (PTH) with insulin resistance, beta cell dysfunction and dysglycaemia, however, its role in the development of diabetes is largely unclear, particularly among non-whites. We sought to examine the association of PTH with the incidence of diabetes.

METHODS

We studied 8066 white and 2034 black adults aged 46-70 years at baseline (1990-92) from the ARIC Study with follow-up for incident diabetes ascertained during study visits conducted in 1993-95 and 1996-98. Hazard ratios (HR) and their 95% CIs for diabetes adjusted for demographics, lifestyle, and 25-hydroxyvitamin D were estimated according to PTH measured at baseline.

RESULTS

PTH was higher among blacks than whites (median [IQR], 43.8 [35.0-55.8] vs. 37.9 [30.4-47.3] pg/mL; P<0.001). During a median follow-up of 6 years, 498 white and 167 black participants developed diabetes. The association of PTH with diabetes varied significantly by race (P-interaction 0.02). PTH was not associated with risk for diabetes among black adults. Among whites, HRs according to quintiles of PTH were 1 (referent), 0.95 (0.71, 1.29), 0.95 (0.70, 1.28), 1.12 (0.84, 1.51), and 1.31 (0.98, 1.76) (P-trend 0.03). When a clinical cut-point for PTH was applied (≥65pg/mL; 5.7% of whites), the HR for diabetes among whites was 1.38 (1.01, 1.88). Results were similar when restricted to participants with normal baseline kidney function.

CONCLUSION

In this large, population-based study, elevated PTH was independently associated with risk for diabetes among white, but not black adults. Further studies are needed to elucidate the mechanisms that may underlie this differential association of PTH with diabetes across race groups.

Cognitive function in a middle aged cohort is related to higher quality dietary pattern 5 and 25 years earlier: the CARDIA study

BACKGROUND

Preserving cognitive function is an important public health issue. We investigated whether dietary pattern associates with cognitive function in middle-age.

METHODS

We studied 2435 participants in the community-based Coronary Artery Risk Development in Young Adults (CARDIA) study of black and white men and women aged 18-30 in 1985-86 (year 0, Y0). We hypothesized that a higher A Priori Diet Quality Score, measured at Y0 and Y20, is associated with better cognitive function measured at Y25. The diet score incorporated 46 food groups (each in servings/day) as the sum of quintile ranks of food groups rated beneficial, 0 for food groups rated neutral, and reversed quintile ranks for food groups rated adverse; higher score indicated better diet quality. Y25 cognitive testing included verbal memory (Rey Auditory-Verbal Learning Test (RAVLT)), psychomotor speed (Digit Symbol Substitution Test (DSST)) and executive function (Stroop).

RESULTS

Per 10-unit higher diet score at Y20, the RAVLT was 0.32 words recalled higher, the DSST was 1.76 digits higher, and the Stroop was 1.00 seconds+errors lower (better performance) after adjusting for race, sex, age, clinic, and energy intake. Further adjustment for physical activity, smoking, education, and body mass index attenuated the association slightly. Diet score at Y0 and increase in diet score over 20 years were also positively associated with each cognitive test.

CONCLUSIONS

A higher quality dietary pattern was associated with better cognitive function 5 years and even 25 years later in apparently healthy middle-aged adults.

Plate-like osteoma cutis: nothing but skin and bone?

Osteoma cutis encompasses a group of cutaneous ossifying disorders, more commonly secondary to trauma, inflammation or neoplasms. Fourteen per cent, however, are primary, and these may be syndromatic (associated to Albright's hereditary osteodystrophy) or occur in isolation. We report a case of a 10-year-old girl who presented with a stone-hard plate on the scalp, with no relevant personal or family history, nor changes in calcium-phosphate metabolism, parathyroid hormone or thyroid function. Skin biopsy confirmed osteoma cutis. Plate-like osteoma cutis is rare, and believed to be a non-progressive form of heterotopic ossification, included in the spectrum of progressive osseus heteroplasia and Albright hereditary osteodystrophy, due to GNAS gene mutations. This recently clarified association should remind us of the possible unfavourable evolution of a seemingly innocent clinical picture, emphasising the need for appropriate evaluation, management and follow-up.

Fibroblastic rheumatism - case report

Fibroblastic rheumatism is a rare fibro-proliferative disease, of unknown etiology. It is characterized by sudden onset of symmetric inflammatory polyarthritis simultaneously or preceded by multiple cutaneous nodules, ranging from 5 to 20mm in diameter, with predilection for the upper and lower extremities. With only a few dozens of cases described, it has a worldwide distribution, affecting primarily caucasians of all ages (cases described ranging 8 to 68 years), without gender predilection. The authors describe the case of a patient presenting multiple cutaneous nodules located on the back of the hands, without any articular or sistemyc complaints. Correlation between clinical and histopathological aspects led to the diagnosis and treatment, with a favorable outcome.

Nasal septum perforation as the presenting sign of lupus erythematosus

Nasal septum perforation is an uncommon and not well known feature of lupus erythematosus (LE). In general, it occurs during exacerbations and in a context of systemic vasculitis. Very rarely it can be a presenting sign, accompanying more usual manifestations of LE. We report the case of a 30-year-old woman who presented with a 2-year history of painful, slowly progressive nasal septum perforation. Laboratory study disclosed positive antinuclear antibodies, circulating immune complexes, hypocomplementemia, nuclear epidermal deposition of IgG in normal skin and transitory positive antiphospholipid antibodies. Symmetric peripheral joint arthritis, photosensitivity and diffuse alopecia subsequently developed. This case seems unique in that the nasal septum perforation occurred as an isolated presenting sign; it emphasizes the value of this feature in the diagnosis of LE.

How many days of pedometer monitoring predict weekly physical activity in adults?

BACKGROUND

The study purpose was to establish the number (and type) of days needed to estimate mean pedometer-determined steps/day in a field setting.

METHODS

Seven days of data were collected from 90 participants (33 males, age = 49.1 +/- 16.2 years, BMI = 27.2 +/- 4.1 kg/m(2); 57 females, age = 44.8 +/- 16.9 years, BMI = 27.0 +/- 5.9 kg/m(2)). Mean steps/day were computed for all 7 days (the criterion), each single day, and combinations of days. Analyses included repeated measures ANOVA, intra-class correlations (ICC), and regression.

RESULTS

There was a significant difference (P < 0.001) between days. The difference was limited to Sunday and accounted for 5% of the variance. ICC analyses indicated a minimum of 3 days is necessary to achieve a reliability of 0.80. The adjusted R(2) was 0.79 for a single day (specifically Wednesday), 0.89 for 2 days (Wednesday, Thursday), and 0.94 for 3 days (Wednesday, Thursday, Friday). Sunday was the last day to enter the model.

CONCLUSIONS

Although there is a statistical difference between days, there is little practical difference, and the primary distinction appears limited to Sunday. Although a single day of collection is not acceptable, any 3 days can provide a sufficient estimate.

Pemphigus vulgaris with nail involvement presenting with vegetating and verrucous lesions

We report the case of a 68-year-old female with longstanding insulin-treated diabetes mellitus, observed for the first time in our department in August 1999 with multiple painful erosive lesions of the oral cavity and many bullous or erosive lesions on the abdominal wall, back, and thigh. She also had vegetating and verrucous lesions, similar to common warts, involving the hands and feet, mainly on the palms, palmar surface of the fingers, and nail folds. Her lesions were present for 1 year. Skin and mucous biopsies showed the characteristic histopathologic findings of pemphigus vulgaris, with an epidermal intercellular IgG deposition on direct immunofluorescence. Histology of a warty lesion of the finger also showed suprabasal acantholysis. After partial improvement with low doses of oral steroids and azathioprine, her disease progressed to involve the oral cavity, trunk, hands, feet, and scalp. Control of her disease required successive treatments of mycophenolate mofetil and cyclophosphamide, as well as corticosteroids. A partial response was obtained with all these treatments. After being controlled by cyclophosphamide that was slowly tapered, she is now well controlled with azathioprine and oral steroids, showing only discrete lesions of the oral mucosa after 1 year of followup. We report this case of pemphigus vulgaris with unusual clinical aspects, namely vegetating and verrucous lesions as well as nail involvement, rarely described in this disease.

[A skin lymphoepithelial tumor (skin lymphadenoma)]

The study of a case of cutaneous lymphadenoma and a literature review allowed us to verify that, in contrast to immunohistochemical findings, clinical and histological dates are basically reproducible. Accordingly the eccrine or hair follicle natures of the pleonasm cannot be either excluded or confirmed. The initial terms "cutaneous lympho-epithelial tumor" or "epithelial lymphohistiocytic tumor" seem more suitable than that of "cutaneous lymphadenoma" to describe this peculiar skin neoplasm.

Visual erotic stimulation test for initial screening of psychogenic erectile dysfunction: a reliable noninvasive alternative?

PURPOSE

We determined the role and validity of visual erotic stimulation using RigiScan monitoring as a more physiological and cost-effective diagnostic modality for primary noninvasive screening of psychogenic versus organic impotence. We also clarified the correlation between erotic and pharmacological erections, and their diagnostic usefulness in the clinical routine.

MATERIALS AND METHODS

A total of 76 impotent patients and 20 potent controls were entered into the study. A detailed medical and sexual history was obtained, and psychological evaluation and minimally invasive diagnostic studies were done, including a 15-minute visual erotic stimulation test, intracavernous pharmacological stimulation with 10 micrograms. prostaglandin E1 and penile duplex ultrasound. Responses to each test were interpreted blindly and independently of each other, and of the results of the psychological evaluation. Visual erotic stimulation results were then correlated with the results of intracavernous pharmacological stimulation and penile duplex ultrasound, and validity assessments were also obtained.

RESULTS

Results of the visual erotic stimulation test confirmed the clinical diagnosis in 10 of the 14 patients (71%) with psychogenic impotence (71% sensitivity and 96% specificity). There was a 97% correlation with the clinical diagnosis of predominantly organic dysfunction (97% sensitivity and 71% specificity). However, characterization of the etiological inferences based on visual erotic stimulation findings was poor.

CONCLUSIONS

A positive response to visual erotic stimulation is strongly indicative of a predominantly psychogenic cause of erectile dysfunction. In combination with patient sexual history and pharmacological erection testing, visual erotic stimulation can be performed as an initial, minimally invasive test for cost-effective screening of psychogenic impotence.

Tubular apocrine adenoma with eccrine and apocrine immunophenotypes or papillary tubular adenoma?

A case of papillary tubular adenoma is reported. On microscopic examination the lesion, located on the scalp, showed a tubular-branching pattern, opening on the skin surface, and features of decapitation secretion. Immunohistochemical evidence of both eccrine and apocrine differentiation was found. This case, which on a clinicopathological basis alone could be classified as tubular apocrine adenoma, illustrates the difficulties in contrasting the latter to its eccrine counterpart (papillary eccrine adenoma) and suggests that the terms papillary tubular adenoma or tubulopapillary hidradenoma more accurately describe these lesions.

Dermal cylindroma. An immunohistochemical study of thirteen cases

Thirteen dermal cylindromas (DC) have been studied immunohistochemically using a panel of antibodies that stain different portions of normal eccrine and apocrine glands. Distinct staining patterns were found in the different cell populations of the tumor. Although the expression of cytokeratins (CK) 19 and 1/10/11 in occasional duct structures could indicate excretory (ductal) differentiation, a link between DC and apocrine secretory coil is suggested by the expression of alpha-1-antichymotrypsin, lysozyme, human milk factor globulin 1, alpha smooth muscle actin (1A4), and CK 8 and 18. The presence of intermingled S-100 protein-, HLA DR-, and CD1a-positive cells argues for the existence of Langerhans cells within the neoplasm. DC shares epithelial membrane antigen, carcinoembryonic antigen, mucin-like carcinoma-associated antigen (B12), laminin, collagen IV, fibronectin, and CD34(QBEND/10) expression with both eccrine and apocrine glands.

Monoclonal antibody Ber EP4 distinguishes basal-cell carcinoma from squamous-cell carcinoma of the skin

Twenty-two cases of basal-cell carcinoma (BCC) and 21 cases of squamous-cell carcinoma of the skin (SCC) were stained for Ber EP4 using indirect immunofluorescence and avidin-biotin-peroxidase techniques. The results showed that all BCCs were diffusely and intensely labeled, whereas none of the SCCs expressed Ber EP4, irrespective of their histological type or grade of differentiation. This difference may prove useful in (a) histologically differentiating between these two neoplasms; and (b) in clarifying the histogenesis of neoplasms considered to be intermediate between BCC and SCC, or derived from BCC. In addition, because significant differences between the staining of hair follicles and BCC were noted, evaluation for Ber EP4 expression could assist in distinguishing between BCC and hair follicles in Mohs micrographic sections.

Trichilemmal carcinoma: review of 8 cases

Clinical and histological data from 8 trichilemmal carcinomas are reviewed. The tumors occurred mainly on sun-exposed skin of the face of elderly people as small solitary, frequently ulcerated nodules. Histologically, they consisted of multilobulate, infiltrative growths, connected to the epidermis and pilosebaceous structures and showing features reminiscent of the outer root sheath of the hair follicle. The presence of lobules of clear, glycogen-rich cells with peripheral palisading, hyaline basement membranes, trichilemmal keratinization, and abortive follicular sheaths and the absence of ductal or acinar differentiation allow distinction from other clear cell tumors of the skin. Although the histological picture suggests a high-grade malignant neoplasm, trichilemmal carcinoma has an indolent course. No recurrence or metastases have been observed.

Desmoplastic trichilemmoma

Seven cases of desmoplastic trichilemmoma (DT), a recently described pseudomalignant variant of trichilemmoma, are reviewed. The tumor generally occurs in men after the fifth decade of life and presents as a small solitary nodule on the face. It is frequently misdiagnosed clinically as a basal cell carcinoma or a papilloma. Histologically DT displays a superficial lobular growth arranged about a central prominent desmoplastic stroma. At the periphery, the tumor lobules show the typical features of trichilemmoma. In contrast, at the center the cells assume a more random pattern of cords and strands traversed by the hyaline stroma, mimicking invasive carcinoma. The tumor's architectural pattern, in particular the perilobular hyaline mantle, enables DT to be differentiated from basal cell carcinoma and malignant trichilemmoma. Immunohistochemical analysis failed to demonstrate human papilloma virus (HPV), epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA), and alpha-lactalbumin in tumor epithelium. Keratin was expressed by the central pseudoinvasive epithelial cords. Neither factor XIIIa nor keratin expression was found in the stromal cells, which stained only for vimentin. These findings suggest that DT is not an HPV-induced epithelial proliferation and that the stroma is not the result of degenerative changes in tumor epithelium. Instead, there appears to be a fibroblast-mediated, dendrocyte-independent, stromal reaction producing this appearance.

[Dermal nerve sheath myxoma. (Neurothekeoma)]

A 59-year-old male presented with a painful nodule on the interscapular area of 20 year duration. The microscopic examination showed a myxomatous lobulated tumor composed of dendritic fusiform cells with some epithelioid and multinucleated cells typical of a nerve sheath myxoma. Immunohistochemical analysis demonstrated reactivity for S100 protein. Neither factor XIIIa nor epithelial membrane antigen (EMA) expression was found in the tumor cells. These findings suggest a schwannian origin for this tumor.

Nucleolar organizer regions argyrophilic associated proteins in cutaneous melanocytic lesions

We applied a simple silver staining technique to visualize nucleolar organizer regions associated proteins (AgNORs) for the study of 47 melanocytic lesions (20 malignant melanomas, 5 dysplastic nevi, 4 Spitz nevi, 2 Reed and Gartman's fusiform nevi and 16 melanocytic nevi). A statistically significant difference existed between the numbers of AgNORs per cell in benign and malignant lesions as a group. However, some overlapping counts were found, limiting the usefulness of the technique in differentiating benign from malignant lesions in individual cases.