Diffuse neurofibroma with hypertrichosis in a toddler

Diffuse neurofibroma is a rare type of neurofibroma uncommonly reported in infancy. It is a slow growing tumor originating in the peripheral nerve sheath. We present the case of a 17-month-old boy with diffuse neurofibroma of the scalp associated with hypertrichosis. His genetic and clinical workup for neurofibromatosis was negative.

Impact of trainee experience on shave biopsy specimen size

BACKGROUND

Skin biopsies are crucial for the diagnosis of many cutaneous pathologies, yet specimen adequacy is essential for definitive diagnosis. Recent literature has noted a trend in decreasing biopsy size over time, which has created concern over implications regarding adequacy for diagnosis.

METHODS

This study sought to evaluate if clinician training length or type of residency training impacted the average biopsy size and sample adequacy. Dermatopathology reports for shave biopsies between January 1, 2021, and June 30, 2021, at Penn State Health were queried through PathNet, the software application for pathology reports in this health system's electronic medical record system. Biopsy dimensions, volume, diagnosis, location, clinician training level, and descriptions of evaluation of deeper sections (recuts) and superficial sampling were recorded for each biopsy. Basic statistical calculations were performed to assess the mean and standard deviation for biopsy sizes per clinician group.

RESULTS

Differences in biopsy size between training levels were statistically significant despite qualitatively similar biopsy locations and final diagnosis categories for each clinician training group. After evaluating measures for sample adequacy, our data showed significantly smaller biopsies; however, overall frequencies were minimal. Additionally, more inadequate specimens were noted for clinician groups with the least amount of dermatology experience.

CONCLUSIONS

The results of this study identify a correlation with decreasing biopsy size amidst increased experience in dermatology training but find no evidence to support that this trend currently threatens sample adequacy.

Schweinfurthin natural products induce regression of murine melanoma and pair with anti-PD-1 therapy to facilitate durable tumor immunity

Metastatic melanoma is a significant clinical problem with a 5-year survival rate of only 15-20%. Recent approval of new immunotherapies and targeted inhibitors have provided much needed options for these patients, in some cases promoting dramatic disease regressions. In particular, antibody-based therapies that block the PD-1/PD-L1 checkpoint inhibitory pathway have achieved an increased overall response rate in metastatic melanoma, yet durable response rates are reported only around 15%. To improve the overall and durable response rates for advanced-stage melanoma, combined targeted and immune-based therapies are under investigation. Here, we investigated how the natural products called schweinfurthins, which have selective anti-proliferative activity against many cancer types, impact anti-(α)PD-1-mediated immunotherapy of murine melanomas. Two different compounds efficiently reduced the growth of human and murine melanoma cells in vitro and induced plasma membrane surface localization of the ER-resident protein calreticulin in B16.F10 melanoma cells, an indicator of immunogenic cell death. In addition, both compounds improved αPD-1-mediated immunotherapy of established tumors in immunocompetent C57BL/6 mice either by delaying tumor progression or resulting in complete tumor regression. Improved immunotherapy was accomplished following only a 5-day course of schweinfurthin, which was associated with initial tumor regression even in the absence of αPD-1. Schweinfurthin-induced tumor regression required an intact immune system as tumors were unaffected in NOD scid gamma (NSG) mice. These results indicate that schweinfurthins improve αPD-1 therapy, leading to enhanced and durable anti-tumor immunity and support the translation of this novel approach to further improve response rates for metastatic melanoma.

Alopecia Mucinosa: Report of a Case and Review

Background:

Alopecia mucinosa has been shown to be associated with many benign and malignant conditions. It can be seen in childhood but is seen more commonly in adulthood. Alopecia mucinosa is generally felt to occur in three settings: a primary idiopathic form, a form associated with malignancy, and a form secondary to inflammatory conditions. The histologic hallmark is the accumulation of mucin in the follicular epithelium, called follicular mucinosis. Therapy for alopecia mucinosa remains problematic.

Objective:

We present a representative case of alopecia mucinosa and discuss the etiology, histology, epidemiology, treatment, and prognosis.

Conclusion:

We report a case of idiopathic alopecia mucinosa that responded to minocycline with a complete remission and we review the literature on alopecia mucinosa.

The Utility of Digital Clinical Photographs in Dermatopathology

Background and Objective:

Technological improvements have helped digital cameras become widely available and inexpensive. Dermatopathologic diagnosis is often aided by clinical information. The purpose of this study was to determine whether submitting a digital image along with a skin biopsy provides additional helpful information to the dermatopathologist.

Methods:

Digital pictures were taken of the lesion being biopsied and were submitted along with routine paper work to the dermatopathologists. The dermatopathologists interpreted the skin biopsy as usual without viewing the digital image, and then later viewed the submitted picture. The dermatopathologists evaluated the help provided by the image.

Results:

A clinical digital image was helpful in confirming the initial diagnosis and narrowing down the differential diagnosis ( p < 0.001). Including pictures did not change the diagnosis, result in an increase in the differential diagnosis, or result in fewer or additional step sections being performed. Digital imaging of inflammatory disorders was felt to be good help in 43 % of the biopsies and narrowed down the differential diagnosis in 31%.

Conclusion:

In certain cases the inclusion of a digital image may help a dermatopathologist. Digital imaging was found to be most helpful in evaluation of inflammatory disorders.

Cutaneous involvement in multiple myeloma (MM): A case series with clinicopathologic correlation

BACKGROUND

Disease-specific skin lesions are rare in patients with multiple myeloma (MM).

OBJECTIVE

We sought to further characterize the clinical and pathologic features of patients with cutaneous involvement with MM.

METHODS

We identified 13 patients with cutaneous lesions of MM.

RESULTS

Cutaneous lesions consisted of pink, red, and violaceous papules, nodules, and/or plaques that varied in size. Histopathology revealed atypical plasma cells with occasional plasmablastic features. MM had aggressive biologic features and was at an advanced stage in the majority of patients. Despite aggressive management, including chemotherapy and stem-cell transplantation, most patients died of progressive disease within a few months after the development of cutaneous lesions.

LIMITATIONS

The study group was relatively small.

CONCLUSIONS

Cutaneous involvement with MM is associated with aggressive biologic behavior and short survival.

Gamma-delta T-cell lymphoma arising in a long-standing cutaneous plaque

The precise classification and characterization of primary cutaneous gamma-delta T-cell lymphoma (PCGD-TCL) has been hindered by clinical and morphologic features that overlap with other lymphomas, especially subcutaneous panniculitis-like T cell lymphoma (SPTCL). The recent World Health Organization/European Organization for Research and Treatment of Cancer (WHO/EORTC) classification distinguishes the more aggressive PCGD-TCL from the usually indolent SPTCL, however. We report a 30-year-old woman with an indurated violaceous plaque on the left cheek that had been present for several years. Biopsies showed a dense lymphocytic infiltrate involving the subcutis and dermis that consisted mostly of small and medium-sized lymphocytes, some with irregular nuclear contours and dense chromatin. These cells were positive for TIA-1, TCR-gamma and CD8, but negative for beta-F1 and granzyme-B. Staging with positron emission tomography-computed tomography (PET/CT), CBC and bone marrow with flow cytometry identified lymphadenopathy as well as blood and marrow involvement by an abnormal TCRgd-positive T-cell proliferation (Ann Arbor Stage IV). The patient's history of a long-standing lesion in this case is unusual, in that gamma-delta T-cell lymphomas are typically rapidly progressive neoplasms. As such, it raises the possibility of 'transformation' of a long-standing inflammatory process into an overt lymphoma.

Macrophage-tumor cell fusions from peripheral blood of melanoma patients

Background

While the morbidity and mortality from cancer are largely attributable to its metastatic dissemination, the integral features of the cascade are not well understood. The widely accepted hypothesis is that the primary tumor microenvironment induces the epithelial-to-mesenchymal transition in cancer cells, facilitating their escape into the bloodstream, possibly accompanied by cancer stem cells. An alternative theory for metastasis involves fusion of macrophages with tumor cells (MTFs). Here we culture and characterize apparent MTFs from blood of melanoma patients.

Methods

We isolated enriched CTC populations from peripheral blood samples from melanoma patients, and cultured them. We interrogated these cultured cells for characteristic BRAF mutations, and used confocal microscopy for immunophenotyping, motility, DNA content and chromatin texture analyses, and then conducted xenograft studies using nude mice.

Findings

Morphologically, the cultured MTFs were generally large with many pseudopod extensions and lamellipodia. Ultrastructurally, the cultured MTFs appeared to be macrophages. They were rich in mitochondria and lysosomes, as well as apparent melanosomes. The cultured MTF populations were all heterogeneous with regard to DNA content, containing aneuploid and/or high-ploidy cells, and they typically showed large sheets (and/or clumps) of cytoplasmic chromatin. This cytoplasmic DNA was found within heterogeneously-sized autophagic vacuoles, which prominently contained chromatin and micronuclei. Cultured MTFs uniformly expressed pan-macrophage markers (CD14, CD68) and macrophage markers indicative of M2 polarization (CD163, CD204, CD206). They also expressed melanocyte-specific markers (ALCAM, MLANA), epithelial biomarkers (KRT, EpCAM), as well as the pro-carcinogenic cytokine MIF along with functionally related stem cell markers (CXCR4, CD44). MTF cultures from individual patients (5 of 8) contained melanoma-specific BRAF activating mutations. Chromatin texture analysis of deconvoluted images showed condensed DNA (DAPI-intense) regions similar to focal regions described in stem cell fusions. MTFs were readily apparent in vivo in all human melanomas examined, often exhibiting even higher DNA content than the cultured MTFs. When cultured MTFs were transplanted subcutaneously in nude mice, they disseminated and produced metastatic lesions at distant sites.

Conclusions and Hypothesis

Apparent MTFs are present in peripheral blood of patients with cutaneous melanomas, and they possess the ability to form metastatic lesions when transplanted into mice. We hypothesize that these MTFs arise at the periphery of primary tumors in vivo, that they readily enter the bloodstream and invade distant tissues, secreting cytokines (such as MIF) to prepare “niches” for colonization by metastasis initiating cells.

Multifocal lymphangioendotheliomatosis with devastating intracranial hemorrhage

An in utero female was found to have a small hemorrhage at the foramen of Monro, hydrocephalus, and what was originally interpreted as a Dandy-Walker variant. At birth she had macrocephaly and numerous cutaneous, multifocal, red-pink blanchable macules. Postnatal MRI demonstrated a hemorrhagic soft-tissue mass involving the upper brainstem, thalamus, and basal ganglia most consistent with in utero complex multifocal intracranial hemorrhage. The skin lesions were thought to be consistent with multifocal lymphangioendotheliomatosis with thrombocytopenia (MLT). The size and location of the hemorrhage precluded operative intervention, although the hydrocephalus was treated with a ventricular shunt. The child continues to have severe developmental delays. Multifocal lymphangioendotheliomatosis with thrombocytopenia is a multifocal vascular disorder most commonly involving the skin and gastrointestinal tract. Intracranial hemorrhages are rare in this context. This case is the third reported instance of MLT with associated intracranial hemorrhage and the only case described in the neurosurgical literature. The authors review the presenting features and pathophysiology of this condition.

Expression of CK7, Cam 5.2 and Ber-Ep4 in cutaneous squamous cell carcinoma

BACKGROUND

Cytokeratin 7 (CK7) and Cam 5.2 are often used to differentiate extramammary Paget's disease (EPD) from squamous cell carcinoma (SCC) in situ because they are generally considered to be expressed in the former but not in the latter. However, we have encountered CK7+ and Cam 5.2+ SCCs.

METHODS

We evaluated CK7, Cam 5.2 and Ber-Ep4 expression in SCC and EPD.

RESULTS

We found significant CK7 and Cam 5.2 positivity in SCCs, particularly in those with a pagetoid pattern. Only one case expressed Ber-Ep4.

CONCLUSIONS

We conclude that CK7 and Cam 5.2 expression may occur in SCC. A panel including Ber-Ep4 is advisable for immunohistochemical differentiation of EPD from SCC.

A congenital case of circumscribed acral hypokeratosis

Circumscribed acral hypokeratosis is a disorder characterized by areas of erythematous depressed skin with distinct histopathological findings typically found on the palmar and plantar surfaces. Most patients are middle-aged women who report a multiyear history. We present an 10-year-old African American boy who had an asymptomatic, irregularly shaped erythematous lesion on his left medial foot that had been present since birth. A biopsy showed an abrupt, well-demarcated decrease in the thickness of the stratum corneum layer, with no parakeratosis, that was consistent with a diagnosis of circumscribed hypokeratosis. This represents the first pediatric and congenital case of circumscribed hypokeratosis reported. We review the literature and discuss the ramifications of a congenital case on understanding the etiology of circumscribed hypokeratosis.

Dermal dendritic cells in psoriasis, nummular dermatitis, and normal-appearing skin

BACKGROUND

The reason psoriasis (PSO) favors extensor skin is unknown. We hypothesized that PSO may involve extensor skin preferentially because of differences in the number or type of dermal dendritic cells (dDCs) between flexural and extensor skin.

OBJECTIVE

We sought to compare dDC type and distribution in normal-appearing flexural and extensor skin, PSO, and nummular dermatitis (ND).

METHODS

Using immunohistochemical markers, the number, distribution, and type of Langerhans cells, myeloid dendritic cells (DCs), and plasmacytoid DCs was compared in normal-appearing skin, PSO, and ND.

RESULTS

Significant differences in dDC density were not identified between flexural and extensor skin, although extensor skin contained fewer CD11a(+) and CD11c(+) cells. Compared with normal-appearing skin, cells expressing CD11a, CD11c, CD123, CD303, and CD207 were increased in PSO. ND lesions showed similar increases. No significant difference between PSO and ND was evident with the exception of decreased S100A6(+) cells in PSO.

LIMITATIONS

We did not study seasonal variation in DC density or assess nonlesional skin from patients with PSO.

CONCLUSIONS

The data did not support the hypothesis that PSO favors extensor skin because of differences in DC localization. However, dDCs were significantly increased in PSO by comparison with normal-appearing skin, supporting existing evidence that they are involved in the overall pathogenesis of PSO.

Scleromyxedema presenting with neurologic symptoms: a case report and review of the literature

Scleromyxedema is a rare variant of lichen myxedematosus. In addition to cutaneous manifestations, scleromyxedema often presents with systemic manifestations, including dysphagia, proximal muscle weakness, central nervous system disturbances, encephalopathy, and restrictive lung disease. It is almost always associated with paraproteinemia, usually IgG with gamma light chains. We review the literature on scleromyxedema associated with neurologic symptoms and present a case of a 49-year-old woman with encephalopathy attributable to scleromyxedema.

CD10-positive myxofibrosarcomas: a pitfall in the differential diagnosis of atypical fibroxanthoma

CD10 is now commonly used to differentiate atypical fibroxanthoma (AFX) from melanoma, spindle cell and dedifferentiated variants of squamous cell carcinoma and leiomyosarcoma. However, we have encountered CD10-positive tumors that mimicked AFX but proved to be myxofibrosarcomas. The purpose of this study was to evaluate CD10 expression in a wide range of mesenchymal neoplasms that may involve the skin using tissue microarrays. Our results indicate that in addition to AFX, CD10 expression is common in myxofibrosarcomas, undifferentiated pleomorphic sarcomas, dermatofibromas and dermatofibrosarcoma protuberans. Myxofibrosarcomas commonly present in the skin and may be difficult to distinguish from AFX on small biopsies and CD10 positivity may confound the diagnostic difficulty.

Histiocytic erythema multiforme

Erythema multiforme is histologically characterized by liquefactive degeneration along the dermal-epidermal junction, necrotic keratinocytes and a lymphocytic infiltrate. We report a 10-year-old boy with recurrent erythema multiforme major of undetermined etiology with unusual histologic findings. A skin biopsy taken at day 2 of his eruption revealed histologic features otherwise characteristic of erythema multiforme, but mediated instead by a CD68-positive infiltrate, resembling cutaneous Kikuchi's disease. To the best of our knowledge this is the first reported case of 'histiocytic' erythema multiforme.

Actinic keratosis: precancer, squamous cell carcinoma, or marker of field cancerization?

The early detection, recognition, and progression of the actinic keratosis (AK) and its relationship with squamous cell carcinoma have long been an area of debate. Recent advancements in medicine have examined the role of field cancerization in a variety of tumors. The role of AK as a marker for field cancerization will be here discussed.

Interstitial granulomatous drug reaction to anakinra

Interstitial granulomatous drug reactions are an uncommon entity presenting as asymptomatic, annular, erythematous to violaceous plaques. The incidence of such reactions has been increasing with the use of biologic agents. We report, to the best of our knowledge, the first such reaction to the interleukin (IL)-1 inhibitor anakinra. Our patient presented with pink dermal plaques and nodules in the periaxillary region which resolved with discontinuation of anakinra and recurred upon restarting anakinra. Biopsy revealed a diffuse dermal infiltrate of lymphocytes and histiocytes with interspersed neutrophils and eosinophils. Fragmentation and degeneration of collagen and elastic fibers was also present. Withdrawal of anakinra led to complete resolution of the lesions. Interstitial granulomatous drug reactions are increasing in frequency and we add anakinra to the list of causative agents.

Plaque-like myofibroblastic tumor of infancy

Fibrohistiocytic neoplasms are relatively uncommon in infancy and childhood. We report an unusual spindle cell tumor occurring in two infants within the first 3 months of life. These tumors histologically resembled dermatofibromas, but the young age of onset, large size, and plaque-like morphology were distinctly different from those of dermatofibromas. The features of these neoplasms are discussed and the differential of other spindle cell tumors of infancy is reviewed.

Eruptive latent metastatic melanomas after initiation of antitumor necrosis factor therapies

We report two cases of late recurrence of eruptive locoregional metastatic melanoma occurring 6 and 9 years after definitive surgical treatment. Each case (stage IB and IA) occurred after initiation of the subcutaneous anti-tumor necrosis factor medications etanercept and adalimumab, respectively. We discuss the association of immune suppression and melanoma. These cases illustrate a previously unrecognized and potentially causal relationship between tumor necrosis factor-alpha inhibition and reactivation of latent melanoma.

Localized chronic fibrosing vasculitis causing a rhinophymatous eruption

We describe a patient with localized chronic fibrosing vasculitis who presented with a rhinophymalike eruption of the nose. To our knowledge, the manifestation of this condition on the nose has not been previously reported. The differential diagnosis also is examined.