Immunofluorescent localization of cytokeratin intermediate filaments as a means of defining the presence of recurrent basal cell carcinoma

Intermediate filament subunits are reliable markers of cytogenetic origin for both normal and neoplastic cells. Immunohistochemical localization of cytokeratin filaments offers a sensitive and specific means of identifying basal or reserve cells when studying histologic sections of skin biopsy specimens. We have applied this technique on eighteen cases in which unequivocal diagnosis or recurrent basal cell carcinoma could not be rendered by conventional histologic techniques. In three of the cases studied, microscopic islands of basal cell carcinoma could be demonstrated by positive staining with cytokeratin antibodies. In the remaining fifteen cases, the possibility of recurrent basal cell carcinoma could be conclusively eliminated on the basis of negative staining with this antibody. Immunolabeling with tissue specific cytokeratin antibodies by indirect immunofluorescent examination may thus constitute a reliable and relatively simple technique that may serve to establish a definitive diagnosis in equivocal cases of suspected recurrent basal cell carcinoma.

Histiocytic lymphophagocytic panniculitis. An unusual extranodal presentation of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease)

A 72-year-old woman presented with the sudden onset of multiple, large, firm, subcutaneous nodules in her right arm and left thigh. Biopsy of the lesions revealed a septal and lobular panniculitis of unknown cause. The lesions regressed spontaneously without therapy over a period of a few weeks. A follow-up review of the microscopic slides from the biopsy disclosed a lymphohistiocytic and plasma cell proliferation with lymphophagocytosis by histiocytes, the characteristic morphological features of sinus histiocytosis with massive lymphadenopathy. This diagnosis was further supported by the immunocytochemical demonstration of S100 protein reactivity within the histiocytic cells. A seven-year follow-up has failed to reveal any evidence of recurrence or progression of the disease. Sinus histiocytosis with massive lymphadenopathy should be entertained in the differential diagnosis of cutaneous lesions presenting with septal and lobular panniculitis.

Paget's disease of the breast with underlying carcinoma arising in systemic scleroderma

A case is presented of Paget's disease of the breast with underlying infiltrating carcinoma arising in a 35-year-old woman with systemic scleroderma. The tumor arose in an area of the skin affected by the systemic scleroderma 4 years after the onset of her systemic disease. The possibility of a causal relationship between these two processes is discussed and a brief review of the literature is presented.

Reactive histiocytic hyperplasia with hemophagocytosis in hematopoietic organs: a reevaluation of the benign hemophagocytic proliferations

Histiocytic hyperplasia with hemophagocytosis (HHH) is a relatively rare condition that has often been mistaken for a neoplastic disorder, but which most frequently represents a secondary reactive phenomenon whose associated risk factors have not yet been clearly defined. Histologic sections of hematopoietic organs (bone marrow, lymph nodes, and spleen) from 230 consecutive adults autopsies were reviewed to identify cases of HHH and to correlate them with clinical and autopsy findings. Moderate to severe HHH was present in the bone marrow in 102 and 230 cases, in the lymph nodes in 79 of 191 cases, and in the spleens of 16 of 209 cases. Recent blood transfusions, bacterial sepsis, major surgery, underlying disseminated malignancy, Candida sepsis, and viral infection were studied as potential risk factors. Both crude and adjusted analyses indicated a strong association between recent blood transfusions and the development of HHH in the bone marrow (P less than .0001). There was a marked dose-response relationship between number of units and the risk of HHH, with an adjusted risk ratio of 59.9 for five or more units compared with no transfusions. Bacterial sepsis was also associated with a significantly increased risk of HHH in the bone marrow in both the crude and adjusted analyses (adjusted risk ratio, 4.10; P = .0002). Major surgery and viral infection were only marginally associated with an increased risk for HHH (P = .03 and P = 0.06, respectively), and underlying disseminated malignancy and Candida sepsis did not appear to contribute any risk. Analyses for HHH in lymph nodes and spleen were similar to analysis for the bone marrow, but were somewhat less marked. The results of this study suggest that reactive HHH in hematopoietic organs may be far more common than has previously been acknowledged, and is most often multifactorial rather than related to a single underlying condition, with transfusions and bacterial sepsis constituting the most significant risk factors. Therefore, reactive HHH may represent a frequent secondary phenomenon in critically ill patients undergoing transfusions and should not be mistaken for an ominous sign or for the development of a superimposed malignancy.

Granular cell leiomyosarcoma of the skin

A case is presented of a multifocal malignant neoplasm involving the skin of the upper back in a 10-year-old boy following radiation therapy to the head and neck for a cerebellar medulloblastoma. Histologically, the neoplastic cells were remarkable for the presence of abundant periodic acid-Schiff (PAS)-positive diastase-resistant intracytoplasmic eosinophilic granules. Immunoperoxidase procedures revealed strong positive staining of the tumor cells with desmin, vimentin, and smooth muscle myosin antibodies, and negative staining for myoglobin, S-100 protein and keratin, thus supporting a smooth muscle line of differentiation for this neoplasm. Electronmicroscopy demonstrated numerous intracytoplasmic autophagic vacuoles that corresponded to the granules observed under the light microscope. Leiomyosarcoma should be entertained in the differential diagnosis of poorly differentiated cutaneous neoplasms histologically characterized by a proliferation of cells containing abundant granular eosinophilic cytoplasm.

Extraskeletal Ewing's sarcoma of the scalp

A 15-year-old boy had an extraskeletal Ewing's sarcoma arising in the soft tissues of the scalp. The tumor was rapidly growing, subcutaneous mass unattached to the underlying bony structures. Histologic examination revealed a proliferation of primitive-appearing, round to oval cells adopting a lobular configuration. Immunohistochemical studies confirmed the undifferentiated mesenchymal nature of the neoplasm.

Fibrous papules. A light microscopic and immunohistochemical study

Thirty-six cases of fibrous papules of the face and nose were studied by light microscopy and by immunohistochemistry. Positive staining with antibodies to vimentin and negative staining with antibodies to S-100 protein, alpha 1-antichymotrypsin, and factor VIII-RAG of the spindle, stellate, and multinucleated cells observed in the dermis support a fibroblastic line of differentiation. Fibrous papules of the nose and face are a distinctive clinicopathologic entity that most probably represents an inflammatory rather than a neoplastic process, sharing some histologic features of angiofibromas (angiofibrosis) and perifollicular fibromas (perifollicular fibrosis).

Verrucous pseudonevoid melanoma

A case of an unusual variant of malignant melanoma resembling a papillomatous dermal nevus is presented here. The lesion was initially diagnosed as a Spitz nevus, and recurred locally five months after excision. The features which distinguish this lesion from the more common types of benign dermal nevi include the architectural atypia of the melanocytes, with a tendency for continuous proliferation of single cells along the dermoepidermal junction, as well as the presence of cytologic atypia with large hyperchromatic nuclei and mitoses. Despite its seemingly innocent appearance, distinction of this low-grade variant of melanoma from its benign counterparts is of importance in order to avert the possibility of recurrence and potential metastases.

Angioimmunoblastic lymphadenopathy following Kaposi's sarcoma

The close relationship of Kaposi's sarcoma (KS) with other lymphoproliferative disorders is a poorly understood, but well documented, phenomenon. A case is presented of a 68-year-old woman with the classical form of cutaneous KS in whom disappearance of the lesions after treatment was shortly followed by the development of angioimmunoblastic lymphadenopathy, pursuing a fulminant course to death. Postmortem examination revealed diffuse involvement of the marrow, spleen, liver, and lymph nodes by the immunoblastic proliferation. The close association of these two conditions may represent more than a chance occurrence. The appearance of a constellation of nonspecific symptoms suggestive of a lymphoproliferative disorder in debilitated patients with KS should alert the physician to the possibility of the development of this rare complication.

Fibrosarcoma of the urinary bladder. Study of a case showing extensive chondroid differentiation

A case of primary fibrosarcoma of the urinary bladder showing extensive chondroid differentiation was studied by light microscopy and immunofluorescent microscopy using tissue-specific antibodies against intermediate filaments. The tumor cells were uniformly and positively labeled with vimentin antibodies and were negative for desmin and keratin, thus confirming the nonmuscle mesenchymal origin of the neoplasm. The value of intermediate filament typing in the differential diagnosis of spindle cell tumors of the urinary bladder is discussed, and a review of the literature on the subject is presented. It is postulated that the retained capacity for continued differentiation displayed by this tumor may account for the relatively better prognosis observed for this patient.

Spindle cell squamous carcinoma of the lung. Immunocytochemical and ultrastructural study of a case

A case of squamous cell carcinoma of the lung showing extensive spindle transformation is presented. On light microscopy, the tumour showed sheets and fascicles of elongated fusiform cells resulting in a growth pattern which closely resembled a sarcoma. Immunocytochemistry using tissue-specific antibodies against intermediate filaments demonstrated exclusive labelling of the tumour cells with prekeratin antibodies. Electron microscopy showed well-formed intercellular junctions and thick bundles of tonofilaments within the cytoplasm of the cells further confirming the squamous epithelial nature of the neoplasm. The findings in the present case point to the existence of a non-metaplastic spindle cell variant of squamous carcinoma of the lung. The possible mechanisms which may account for the spindle shape of the cells are reviewed.

Nodal angiolymphoid hyperplasia with eosinophilia

Angiolymphoid hyperplasia with eosinophilia (AHE) is a benign process of unknown origin that tends to mainly affect the skin and subcutaneous tissue. A case is presented of AHE arising in a lymph node in the absence of dermal or subcutaneous involvement. The unusual location and histologic characteristics of the lesion prompted an initial diagnosis of Hodgkin's disease. Follow-up and review of the biopsy at a later date disclosed the characteristic features of AHE. The present case illustrates the ubiquitous nature of this process. AHE should be included in the differential diagnosis in lymph nodes showing effacement of their architecture by a diffuse, predominantly eosinophilic cellular infiltrate.

Epithelioid leiomyosarcoma of the stomach. A case study of the intermediate filaments

The intermediate filament typing of skeletal and smooth muscle tumors has shown that these neoplasms are characterized by the combined expression of desmin and vimentin intermediate filaments. A case of epithelioid leiomyosarcoma of the stomach was studied by conventional light microscopy and by indirect immunofluorescence using tissue-specific antibodies against intermediate filaments. The tumor cells labeled strongly with vimentin antibodies and were negative for desmin and prekeratin. This peculiar staining pattern may be the result of poor differentiation of the tumor cells with resultant loss of expression of desmin, or may be due to origin from a distinctive smooth muscle cell characterized by the exclusive expression of vimentin intermediate filaments.

A reappraisal of Richter's syndrome. Development of two phenotypically distinctive cell lines in a case of chronic lymphocytic leukemia

Richter's syndrome, the development of a malignant lymphoma in a patient with preexisting chronic lymphocytic leukemia (CLL) is an infrequent but well-documented phenomenon generally thought to represent a monoclonal proliferation of B-lymphocytes arising from the CLL. A heterogeneous population of cells consisting of sheets of transformed lymphocytes in combination with clusters of bizarre, atypical histiocytes developed in a patient with a history of longstanding CLL. Immunocytochemistry using a panel of monoclonal and polyclonal antibodies by immunoperoxidase techniques identified the presence of both B-lymphocytic and monocytic-histiocytic cell lines of differentiation. A mechanism of multiple differentiation is proposed to account for the dual cell population observed in this patient. Review of the literature appears to indicate that this phenomenon often may be involved in cases diagnosed as Richter's syndrome. The demonstration of cellular heterogeneity in the current case underscores the need for establishing a more precise definition for the histologic characterization of the terminal malignancy in Richter's syndrome.

Adenosquamous carcinoma of the gallbladder with spindle cell features. A light microscopic and immunocytochemical study of a case

A case of adenosquamous carcinoma of the gallbladder showing extensive spindle transformation is presented. By light microscopy, areas showing interwoven fascicles of fusiform, poorly differentiated cells closely resembling a sarcoma were seen to merge imperceptibly with areas showing more obvious glandular and squamous cell features. Immunocytochemistry utilizing tissue-specific antibodies against intermediate filaments demonstrated the exclusive presence of prekeratin antibodies in both components of the tumour, thus establishing the epithelial nature of this neoplasm. The importance of immunological phenotyping in the differential diagnosis of epithelial tumours of the gallbladder showing pseudosarcomatous features is underscored.

Sclerosing hemangioma of the lung. Immunohistochemical demonstration of mesenchymal origin using antibodies to tissue-specific intermediate filaments

A case of pulmonary sclerosing hemangioma of the lung was studied by light microscopy and indirect immunofluorescence using tissue-specific antibodies against intermediate filament subunits. All the tumor cells stained positively and exclusively with antivimentin antibodies thus indicating their mesenchymal origin. In addition, positive staining with cytokeratin antibodies was observed in cells lining cystic spaces and elongated slit-like spaces were occasionally encountered throughout the tumor, disclosing residual epithelial elements. Using brightfield microscopy, the keratin-positive areas were identified as distorted alveolar spaces lined by hyperplastic respiratory epithelium entrapped within the tumor. It is proposed that these entrapped epithelial elements may account for the conflicting results obtained by different investigators in previous attempts to determine the histogenesis of this tumor.

Effects of Solcoderm

The effects of treatment and depths of penetration of a 5-fluorouracil and salicylic acid preparation (Solcoderm) were studied in 24 patients treated for basal cell carcinoma with this compound. Two thirds of the patients in our study showed islands of residual tumor in the dermis following treatment, whereas total disappearance of the tumor was observed in one third. The depth of the fibrotic changes induced by the drug varied from 0.34 to 0.40 cm for the morphea type of basal cell carcinoma and from 0.52 to 0.88 cm for the conventional types. It is recommended that treatment with this compound be reserved only for superficial basal cell carcinomas and that it be avoided altogether in basal cell carcinomas of the morphea type.

Familial atrophie blanche-like lesions with subcutaneous fibrinoid vasculitis. The Georgian ulcers

Atrophie blanche is an uncommon condition characterized by the development of white atrophic patches of skin on the lower extremities, which form as a result of fibrinoid vasculitis of superficial and mid-dermal vessels followed by necrosis and ulceration of the epidermis. We report four cases in which similar lesions developed on the legs and ankles of young Jewish Russian immigrants to Israel. Although the lesions share many features with atrophie blanche, they differ in their early age of onset, the male predilection, and the extension of the fibrinoid vasculitic process into the subcutaneous tissue. Additionally, the peculiar population clustering (Georgia, U.S.S.R.), common ethnic background, and a family history of similar lesions in close relatives seem to point to a familial or genetic predisposition underlying the development of the disease.