A study evaluating the safety and efficacy of the Velasmooth™ system in the treatment of cellulite

BACKGROUND

Most cellulite treatments are limited in their effectiveness. A combination of radiofrequency energy, infrared light and mechanical manipulation of the skin and fat merits further examination.

OBJECTIVE

Subjects were treated with a device combining these energies to evaluate its safety and efficacy.

METHODS

Sixteen subjects with cellulite were treated twice weekly for 6 weeks with the VelaSmooth system. One thigh was treated while the other served as a control. Treatment efficacy was measured through circumferential measurements of both thighs and by having the investigator and an independent evaluator grade visual improvement during follow-up visits. Five patients provided blood specimens for assessment of lipid and hormone levels and liver function. Two subjects provided three biopsies each in order to monitor the level of estrogen and progesterone receptors.

RESULTS

The overall thigh circumference decreased in 71.87% of the treated legs. The mean decrease was 0.44 cm of the lower thigh and 0.53 cm of the upper thigh. There was significant visual improvement in cellulite and skin texture. At the final follow-up visit, 50% of subjects had greater than 25% improvement (good be very good).

CONCLUSION

This study showed positive results. Future studies employing higher energy levels and additional treatments will likely augment the results of the present study.

Laser peel: facial rejuvenation with a superficial erbium:YAG laser treatment

BACKGROUND

Facial rejuvenation is a popular procedure to temporarily mask the effects of aging. Most patients desiring this treatment are younger and want improvement without any down time. This study was conducted to evaluate the use of Er:YAG laser as a facial rejuvenation tool.

METHODS

The full faces of 18 volunteers were treated with an Er:YAG laser using a fluence of either 5 or 10 J/cm2. All volunteers applied EMLA cream (lidocaine 2.5% and prilocaine 2.5%) two hours before the procedure and were treated with a single pass using a pulse duration of about 300 microseconds. Follow-up visits were made in order to evaluate the degree of discomfort, erythema, swelling and improvement in skin aging. Skin biopsy was performed in one volunteer before and two hours after EMLA application, although preceding laser treatment.

RESULTS

Most volunteers experienced moderate discomfort during the treatment. There was mild to moderate erythema and mild swelling. The improvement in general skin appearance, actinic bronzing and photo-damage was mild to moderate. The microscopic evaluation of pre-laser treated skin two hours after EMLA application was suggestive of increased water content in the dermis.

CONCLUSION

The Er:YAG laser is an effective and safe tool for facial rejuvenation. With a superficial treatment, resolution of intense erythema is fairly rapid, averaging two to three days. The improvement, however, is mild compared to full laser skin resurfacing (LSR).

Prospective clinical and histological study to evaluate the efficacy and safety of a targeted high‐intensity narrow band UVB/UVA1 therapy for striae alba

OBJECTIVE

The purpose of this study was to determine the efficacy and safety of a targeted narrow band UVB/UVA1 therapy for the treatment of striae alba.

METHODS

Fourteen individuals with skin types II-VI were enrolled in this 22-week trial that consisted of up to 10 treatments with a combination of UVB/UVA1 (MultiClear, Curelight Ltd, Israel). Participants were treated with a maximum of 10 treatments unless 100% repigmentation of stretch was achieved prior to the tenth treatment. Biopsies were taken from willing participants at baseline, immediately after the final treatment and 12 weeks after the last treatment.

RESULTS

Nine participants completed all treatment visits. After the final treatment, all the participants had >51% repigmentation of the treated striae. At the 4-week follow-up visit, 67% of participants had greater than 51% improvement, and 56% had greater than 51% improvement at the 8-week and 12-week follow-ups. Hyperpigmentation of striae was seen in >50% of the participants treated. The pretreatment biopsies were confirmatory of striae. There were no diagnostic light microscopic differences in the 4-week post-treatment biopsy set available in one patient.

CONCLUSION

This high intensity UVB\UVA1 device is an effective and safe modality for the short-term repigmentation of hypopigmented stretch marks. Additional morphologic studies over time are needed to confirm these clinical findings.

Revision of the 1996 working formulation for the standardization of nomenclature in the diagnosis of lung rejection

In 1990, an international grading scheme for the grading of pulmonary allograft rejection was adopted by the International Society for Heart and Lung Transplantation (ISHLT) and was modified in 1995 by an expanded group of pathologists. The original and revised classifications have served the lung transplant community well, facilitating communication between transplant centers with regard to both patient management and research. In 2006, under the direction of the ISHLT, a multi-disciplinary review of the biopsy grading system was undertaken to update the scheme, address inconsistencies of use, and consider the current knowledge of antibody-mediated rejection in the lung. This article summarizes the revised consensus classification of lung allograft rejection. In brief, acute rejection is based on perivascular and interstitial mononuclear infiltrates, Grade A0 (none), Grade A1 (minimal), Grade A2 (mild), Grade A3 (moderate) and Grade A4 (severe), as previously. The revised (R) categories of small airways inflammation, lymphocytic bronchiolitis, are as follows: Grade B0 (none), Grade B1R (low grade, 1996, B1 and B2), Grade B2R (high grade, 1996, B3 and B4) and BX (ungradeable). Chronic rejection, obliterative bronchiolitis (Grade C), is described as present (C1) or absent (C0), without reference to presence of inflammatory activity. Chronic vascular rejection is unchanged as Grade D. Recommendations are made for the evaluation of antibody-mediated rejection, recognizing that this is a controversial entity in the lung, less well developed and understood than in other solid-organ grafts, and with no consensus reached on diagnostic features. Differential diagnoses of acute rejection, airway inflammation and chronic rejection are described and technical considerations revisited. This consensus revision of the working formulation was approved by the ISHLT board of directors in April 2007.

Intracellular and extracellular expression of the major inducible 70kDa heat shock protein in experimental ischemia-reperfusion injury of the spinal cord

Inflammatory responses exacerbate ischemia-reperfusion (IR) injury of spinal cord, although understanding of mediators is incomplete. The major inducible 70kDa heat shock protein (hsp70) is induced by ischemia and extracellular hsp70 (e-hsp70) can modulate inflammatory responses, but there is no published information regarding e-hsp70 levels in the cerebrospinal fluid (CSF) or serum as part of any neurological disease state save trauma. The present work addresses this deficiency by examining e-hsp70 in serum and CSF of dogs in an experimental model of spinal cord IR injury. IR injury of spinal cord caused hind limb paraplegia within 2-3 h that was correlated to lumbosacral poliomalacia with T cell infiltrates at 3 d post-ischemia. In this context, we showed a 5.2-fold elevation of e-hsp70 in CSF that was induced by ischemia and was sustained for the following 3 d observation interval. Plasma e-hsp70 levels were unaffected by IR injury, indicating e-hsp70 release from within the central nervous system. A putative source of this e-hsp70 was ependymal cells in the ischemic penumbra, based upon elevated i-hsp70 levels detected within these cells. Results warrant further investigation of e-hsp70's potential to modulate spinal cord IR injury.

The molecular basis of melanomagenesis and the metastatic phenotype

The last two decades have seen spectacular advances in our understanding of the biology of melanoma and, in particular, have elucidated the mechanisms operative in disease initiation and progression. With respect to the former, the genetics of melanoma and in particular the impact of genetic defects on dysregulation of the cell cycle are key issues in malignant transformation and are a major focus of this review. With respect to the latter, consideration also is given to the acquisition of growth factor autonomy and the capacity for invasion and metastasis from the standpoint of cell adhesion, motility, and matrix digestion. These events have specific morphologic correlates that will be briefly addressed. Where relevant, we will address certain of the modern pharmacogenetic strategies that flow from these novel observations concerning melanoma biology.

Head and neck melanoma in the sentinel lymph node era

OBJECTIVE

To determine whether, in the era of sentinel lymph node (SLN) biopsy, head and neck melanoma (HNM) has a poorer outcome than melanomas at other sites (OMS).

DESIGN

Prospective database, 1994 to 2004. Characteristics and outcomes of patients with HNM vs those with OMS were analyzed by Fisher test, paired t test, and chi(2) test.

SETTING

Tertiary referral center.

PATIENTS

A total of 755 patients with melanoma who had undergone SLN biopsy.

MAIN OUTCOME MEASURES

Differences between patients with HNM and those with OMS.

RESULTS

A total of 17.4% of patients had HNM vs 82.6% with OMS. There was a male HNM preponderance: 68.7% vs 50.3% for females (P < .01). Patients with HNM were older (mean [SD] age, 57.1 [16.6] years vs 53.3 [16.2] years; P < .01). There were fewer cases of superficial spreading melanoma in patients with HNM (29.0% vs 53.7%; P < .01). There were more diagnoses of lentigo maligna in patients with HNM (26.0% vs 1.9%; P < .01). The mean thickness of the primary lesion was 2.32 (1.9) mm vs 2.31 (2.9) mm; P = .49. Fewer patients with HNM had Clark level involvement lower than level IV (13.3% vs 24.0%; P < .01). More SLNs were harvested from patients with HNM (3.72 [3.2] vs 2.89 [2.6]; P < .01), but a lower percentage of positive SLNs was found (9.2% vs 16.0%; P < .05). There was no difference in local, regional, or distant recurrence (5.3%, 6.9%, and 5.3%, respectively, in patients with HNM and 3.4%, 5.5%, and 6.7%, respectively, in patients with OMS). The 2- and 5-year survival rates for patients with HNM were 96.2% and 72.6%, respectively, vs 93.6% and 79.0%, respectively, in patients with OMS (P = .40).

CONCLUSIONS

Most patients with HNM are older males with more SLNs harvested. They do not seem to have poorer outcome than patients with OMS.

Unusual histologic and clinical variants of melanoma: Implications for therapy

Unusual histologic variants of melanoma may be problematic to the histopathologist. Several of these variants are sufficiently rare that their biologic behavior remains obscure. As identification of some of these melanoma subtypes has specific implications for the therapeutic approach, and as some may mimic other forms of epithelial or mesenchymal neoplasia, their recognition is key to patient management.

Cutaneous T-Cell Lymphoid Dyscrasia

It often takes several years before the diagnosis of mycosis fungoides is clearly established. During this period preceding the diagnosis of cutaneous T-cell lymphoma (CTCL), some patients experience a variety of distinct skin conditions of ambiguous origin. With refinement in the methods of T-cell clonal detection in skin biopsy specimens, we can now establish that many of these preceding entities are characterized by a T-cell clone. Therefore, we studied the association of these clonal conditions with CTCL. We identified 8 distinct clinicopathological conditions characterized by the frequent detection of T-cell clonality, a chronic course often recalcitrant to topical therapy, lack of a known triggering event, and lack of morphologic evidence of a T-cell lymphoma with potential for progression to CTCL. We propose the term cutaneous T-cell lymphoid dyscrasias to unify these entities. Defining the preceding stages of CTCL is important to properly categorize these conditions and to help us understand and redefine the evolution of idiopathic clonal dermatoses and their potential for lymphoma progression.

The expression of CD23 and CD40 in primary cutaneous B-cell lymphomas

BACKGROUND

CD23 expression in normal B lymphocytes is limited to autoreactive B cells, naïve B cells and mature B cells manifesting an activated phenotype. As a marker of hematologic dyscrasia/malignancy, expression of CD23 is associated with small lymphocytic lymphoma/chronic lymphocytic leukemia. An absence of CD23 expression within small lymphocytes is typically seen in marginal zone lymphoma and mantle cell lymphoma. Positive CD23 expression amidst neoplastic cells in primary cutaneous B-cell lymphoma is not a reported phenomenon.

METHODS

This paper reports nine patients with cutaneous B-cell lymphoma manifesting CD23 expression.

RESULTS

In seven of the nine cases CD23 expression was observed in the setting of recurrent disease, being present in both large and small lymphocytes. CD23 expression paralleled staining for CD40 in all but one case.

CONCLUSIONS

A potential mechanism of CD23 upregulation may involve the anti-apoptotic nuclear kappa beta CD40-CD40 ligand pathway. Neoplastic B cells manifesting CD23 expression could have a survival advantage, predisposing to recurrent disease and or oncogenic events permissive to disease progression.

Verruca Vulgaris of the Vulva in Children and Adults: A Nonvenereal Type of Vulvar Wart

Condyloma acuminata are common lesions of the vulva in adults, and associated with infection by human papillomavirus (HPV) types 6 and 11, which are acquired via sexual contact. The detection of an HPV 6/11 condyloma in the genital tract of a child, therefore, raises the question of sexual abuse. In this study, 29 genital warts in girls less than 5 years of age were examined for nongenital and genital tract HPVs by in situ hybridization. These results were compared with 275 vulvar lesions clinically suspicious for condyloma from adults. Of the 27 HPV-related lesions in young girls, 11 (41%) were due to HPV 2 whereas the other 16 (59%) were associated with HPV 6/11 infection. Of the 214/275 (78%) HPV positive vulvar lesions in adults, 6 (3%) were due to HPV 2 whereas 202/214 (94%) contained HPVs 6/11; 1 lesion contained HPV 16 and the 5 other lesions contained HPV 42, 43, or 44. Histologic correlation documented that the vulvar lesions positive for HPV 2 commonly showed the marked hyperkeratosis typical of verruca vulgaris. However, the verrucous pattern was present in lesions HPV 6/11 positive. It is concluded that verruca vulgaris of the vulva, which is likely not transmitted sexually, can occur, albeit rarely, in the genital tract of women and is common in the genital tracts of young girls. This highlights the value of HPV testing in such cases, especially if the histologic changes are consistent with verruca vulgaris.

Promising pharmacologic innovations in treating pulmonary fibrosis

Idiopathic pulmonary fibrosis is the most common form of the interstitial lung diseases and is characterized by chronic progressive pulmonary parenchymal fibrosis. Although the diagnosis and pathophysiology of this disease have been better characterized over the past few years, there remains no effective therapy for this disease. Therapies initially aimed at inflammation have proven ineffective, and newer strategies targeting aspects of aberrant wound repair involving alveolar epithelial cells or septal endothelial cells are now being investigated. Therapeutic strategies include the anti-fibrotic agents pirfenidone and interferon-gamma. Agents targeting specific cytokines, including connective tissue growth factor, transforming growth factor-beta and chemokines, are being evaluated. The restoration of oxidant balance and inhibition of leukotrienes represent other strategies. Additionally, the role of the coagulation/fibrinolytic systems and angiogenesis has also been examined.

Unusual histologic and clinical variants of melanoma: Implications for therapy

Unusual histologic variants of melanoma may prove problematic to the histopathologist. Several of these variants are sufficiently rare that their biological behavior remains obscure. Because identification of some of these melanoma subtypes has specific implications for the therapeutic approach and some may mimic other forms of epithelial or mesenchymal neoplasia, their recognition is key to patient management.

Natural killer cells produce T cell-recruiting chemokines in response to antibody-coated tumor cells

In the current report, we have examined the ability of natural killer (NK) cells to produce T cell-recruiting chemokines following dual stimulation with interleukin (IL)-2 or IL-12 and human breast cancer cells coated with an antitumor antibody (trastuzumab). NK cells stimulated in this manner secreted an array of T cell-recruiting chemotactic factors, including IL-8, macrophage-derived chemokine, macrophage inflammatory protein 1alpha (MIP-1alpha), monocyte chemoattractant protein 1, and regulated on activation, normal T-cell expressed and secreted (RANTES), whereas stimulation of NK cells with either agent alone had minimal effect. Furthermore, these factors were functional for T-cell chemotaxis as culture supernatants derived from costimulated NK cells induced migration of both naïve and activated T cells in an in vitro chemotaxis assay. T-cell migration was significantly reduced when neutralizing antibodies to IL-8, MIP-1alpha, or RANTES were added to culture supernatants before their use in the chemotaxis assay. In addition, coadministration of trastuzumab-coated tumor cells and IL-12 to mice led to enhanced serum MIP-1alpha. As a clinical correlate, we examined the chemokine content of serum samples from breast cancer patients enrolled on a phase I trial of trastuzumab and IL-12, and found elevated levels of IL-8, RANTES, IFN-gamma inducible protein 10, monokine induced by IFN-gamma, and MIP-1alpha, specifically in those patients that experienced a clinical benefit. Sera from these patients exhibited the ability to direct T-cell migration in a chemotaxis assay, and neutralization of chemokines abrogated this effect. These data are the first to show chemokine production by NK cells, specifically in response to stimulation with antibody-coated tumor cells, and suggest a potential role for NK cell-derived chemokines in patients receiving therapeutic monoclonal antibodies.

Incorporation of photodynamic therapy as an induction modality in non-small cell lung cancer

BACKGROUND AND OBJECTIVES

Incorporation of photodynamic therapy (PDT) into the induction therapy regimen utilized for treatment of locally advanced primary non-small cell bronchogenic carcinoma (NSCLC) is explored.

STUDY DESIGN/MATERIALS AND METHODS

We present a retrospective review of 41 patients diagnosed with non-metastatic NSCLC who underwent induction PDT with chemotherapy and/or radiation.

RESULTS

Fifty percent of patients initially deemed unresectable, were able to undergo definitive surgical resection after trimodality induction therapy. Twenty-seven percent of patients considered to require pneumonectomy were able to have a lobectomy. The pathological stage was less than the preinduction clinical stage in 14 of 22 cases; of which four patients had no residual tumor. There was no 30/90-day postoperative mortality. Mean survival was 35.9 months (lobectomy), 25.5 months (pneumonectomy) and 14.7 months (no surgery). Median survival was 78% (12 months) and 46% (36 months). The main postoperative complication following pneumonectomy was bronchopleural fistula formation. All patients who developed this complication had undergone trimodality induction therapy. Incorporation of PDT into the induction arsenal for patients with loco-regionally advanced NSCLC may be safely performed.

CONCLUSIONS

PDT may define an alternative induction strategy for patients requiring pneumonectomy; further studies exploring the true efficacy of PDT as an induction modality are encouraged.

Expression of STAT1 and STAT2 in malignant melanoma does not correlate with response to interferon-alpha adjuvant therapy

Interferon-alpha (IFN-alpha) is used as an adjuvant therapy in patients with malignant melanoma and who have undergone surgical resection of high-risk lesions. Defective expression or activation of STAT1 or STAT2 has been shown to correlate with IFN-alpha or resistance in vitro; however, recent data from our laboratory suggest that the anti-tumor effects of IFN-alpha are dependent on STAT1 signaling within host immune cells. We measured STAT1 and STAT2 expression in 28 melanoma biopsies (8 cutaneous lesions; 1 lung metastasis; 19 nodal metastases) obtained from patients prior to the initiation of adjuvant IFN-alpha therapy. Disease recurrence following IFN-alpha treatment did not correlate with the staining intensity of either STAT1 (P = 0.61) or STAT2 (P = 0.52). Tumors with minimal STAT1 or STAT2 expression (< 20% positive) were present in four patients with tumor-positive lymph nodes, who exhibited prolonged relapse-free survival (> 44 months) following adjuvant therapy. Conversely, high levels of STAT1 were present in a patient who recurred during the course of IFN-alpha therapy. A case study of one patient who experienced recurrent disease during IFN-alpha treatment revealed that STAT1 levels were greater in the recurrent tumor when compared to the original lesion. These studies provide direct evidence to suggest that levels of STAT1 and STAT2 within the tumor do not influence a patient's response to adjuvant IFN-alpha.

Cytomegalovirus-Associated Pulmonary Septal Capillary Injury Sine Inclusion Body Change

The authors describe four patients with symptomatic lung disease morphologically representing a septal capillary injury syndrome temporally associated with serologic and culture evidence of active cytomegalovirus (CMV) infection but without classic cytopathic changes. The authors conducted a thorough review of clinical data, microscopic examination, and in situ hybridization to detect CMV mRNA encoding immediate early protein. The assay detects transcripts that encode early and immediate early proteins. In two cases additional tissue was available for direct immunofluorescent studies. The disease process in each of the patients was morphologically indistinguishable from the pattern of organ injury associated with autoimmune diseases including a small vessel microvascular injury syndrome involving skin and lung and immune complex- mediated glomerulonephritis. Cytopenias were seen in all cases, most commonly thrombocytopenia. All treated patients demonstrated improvement on combined ganciclovir and low-dose steroid therapy. CMV infection may be of pathogenetic importance in some cases of alveolar hemorrhage, especially when accompanied by peripheral blood cytopenia in otherwise healthy patients and if clinical worsening occurs in the setting of a traditional immunosuppressive regimen typically used to treat vasculitis.

Assessment of T-cell Clonality via T-cell Receptor-γ Rearrangements in Cutaneous T-cell–Dominant Infiltrates Using Polymerase Chain Reaction and Single-stranded DNA Conformational Polymorphism Assay

Discerning the pathologic significance of cutaneous T-cell infiltrates can pose a diagnostic challenge for dermatopathologists. Reactive conditions such as drug-associated lymphomatoid hypersensitivity and lymphomatoid lupus erythematosus can demonstrate lymphoid atypia and a phenotype resembling cutaneous T-cell lymphoma (CTCL). Further, lymphoid dyscrasias such as pityriasis lichenoides chronica, large plaque parapsoriasis, and atypical pigmentary purpura confuse the picture because they not only mimic CTCL but also represent prelymphomatous states with inherent malignant potential. Although the emergence of a dominant clone has been considered a clue indicative of a T-cell dyscrasia, there are reports concerning the identification of monoclonality in biopsies of reactive lymphoid infiltrates. We have conducted a modified single-stranded DNA conformational polymorphism (SSCP) assay using paraffin-embedded, formalin-fixed tissue on 92 T-cell-rich biopsies to determine the relative specificity and sensitivity of this methodology. In addition, laser capture microdissection (LCM) was performed on 22 of the 92 samples to isolate the area of interest and to compare its specificity and sensitivity with those SSCP assays performed without LCM. We found that monoclonality or oligoclonality is 86% specific for preneoplastic and neoplastic states, whereas the finding of polyclonality appears to be relatively specific for a reactive process. Some cases of reversible T-cell dyscrasia produced a molecular profile mimicking lymphoma or prelymphomatous states by virtue of monoclonality or oligoclonality. Although LCM appears to improve the sensitivity for detecting preneoplastic conditions, the relative specificity appears to be the same as that encountered with routine SSCP.

The antitumor effects of interferon-alpha are maintained in mice challenged with a STAT1-deficient murine melanoma cell line

INTRODUCTION

Interferon-alpha (IFN-alpha) is currently administered to patients with metastatic malignant melanoma and those who are at risk for recurrence following surgery for high-risk lesions. Signal transducer and activator of transcription 1 (STAT1) is a transcription factor that is activated by IFN-alpha and is thought to mediate the majority of its antitumor effects. Loss of STAT1 has been found in IFN-resistant melanoma cells. We developed a murine melanoma cell line in a STAT1-deficient mouse. We also transfected B16 melanoma cells with a wild-type form of STAT1 to induce its overexpression. Using the resulting cell lines and STAT1-deficient mice, we tested whether IFN-alpha could exert an antitumor effect on melanoma cells in the absence of STAT1-mediated signal transduction.

MATERIALS AND METHODS

A melanoma tumor was induced in STAT1-deficient mice via the application of DMBA (tumor initiator) followed by croton oil (tumor promoter). Immunohistochemical analysis confirmed that the resulting tumor was a malignant melanoma. Immunoblot analysis, intracellular flow cytometry, and gel-shift analysis were used to confirm the lack of STAT1 in the derivative cell line (AGS-1). In addition, the STAT1 protein was overexpressed in B16 melanoma cells by stable transfection with a plasmid construct encoding wild-type STAT1. The effects of IFN-alpha on these cell lines were studied in vitro and in vivo.

RESULTS

STAT1 was not expressed in the AGS-1 murine melanoma cell line. Treatment with IFN-alpha did not lead to activation of STAT1. Cell proliferation assays revealed that while IFN-alpha did not exert an antiproliferative effect on this cell line, it was capable of prolonging the survival of STAT1-competent C57BL/6 mice bearing 1 x 10(6) AGS-1 tumor cells in the intraperitoneal position (n = 20, P < 0.05), as compared to PBS-treated controls. Also, the survival of IFN-alpha-treated mice (as compared to PBS-treated controls) was not affected by the overexpression of STAT1 in B16 tumor cells.

CONCLUSIONS

This data suggests that IFN-alpha can enhance survival in an animal model where STAT1-mediated signal transduction and gene regulation is absent within the tumor but is present within the host. This data also indicates that the overexpression of STAT1 within the tumor does not significantly enhance the effects of exogenously administered IFN-alpha in this model. These findings indicate that the bulk of the antitumor actions of IFN-alpha may be derived from its effects on host tissues.

Cutaneous manifestations of Crohn's disease, its spectrum, and its pathogenesis: intracellular consensus bacterial 16S rRNA is associated with the gastrointestinal but not the cutaneous manifestations of Crohn's disease

The classic pathology of skin disease discontinuous from the inflamed gastrointestinal (GI) tract in patients with Crohn's disease (CD) includes pyoderma gangrenosum (PG), erythema nodosum (EN), and so-called metastatic Crohn's disease. The purpose of this study was two-fold: First, we explored the full spectrum of cutaneous lesions associated with Crohn's disease, and second, we sought to explore a potential molecular basis of the skin lesions in patients with CD. In this regard, we analyzed skin and GI tract biopsies from affected patients for the consensus bacterial SrRNA to determine whether direct bacterial infection was associated with either condition. Formalin-fixed, paraffin-embedded sections were studied and correlated to clinical presentation and histories from 33 patients with CD. Consensus bacterial RNA sequences were analyzed using an RT in situ PCR assay on both skin biopsy and GI biopsy material. The GI tract material included biopsies from 3 patients who had skin lesions and from 7 patients in whom there were no known skin manifestations. There were 8 cases of neutrophilic dominant dermal infiltrates, including pyoderma gangrenosum, 6 cases of granuloma annulare/necrobiosis lipoidica-like lesions, 5 cases of sterile neutrophilic folliculitis, 5 cases of panniculitis, 4 cases of vasculitis, 2 cases of psoriasis, 2 cases of lichenoid and granulomatous inflammation, and 1 case of classic metastatic CD. Intracellular bacterial 16S rRNA was detected in 8 of 10 tissues of active CD in the GI tract, of which 3 of the cases tested were from patients who also developed skin lesions at some point in their clinical course; in contrast, none of the skin biopsies had detectable bacterial RNA. The dermatopathological manifestations of CD discontiguous from the involved GI tract mucosa have in common a vascular injury syndrome, typically with a prominent extravascular neutrophilic and/or histiocytic dermal infiltrate. In addition, this study, the first to document in situ intracellular consensus bacterial SrRNA in the GI tract in CD, suggests that hematogenous dissemination of viable microbes is not associated with the cutaneous manifestations of this disease. Bacteria do, however, appear to play a role in bowel lesions of patients with CD.

Recent developments in the biology and therapy of T-cell and natural killer-cell lymphomas

PURPOSE OF REVIEW

T-cell/natural killer (T/NK)-cell lymphomas represent a group of poor-risk lymphoproliferative disorders that have only recently been recognized as distinct clinicopathologic entities. The average outcome with currently available therapy is substantially inferior to that of aggressive B-cell lymphomas. Significant gaps remain in our knowledge of their origin, diagnosis, and clinical spectrum. This review outlines recent developments in the biology and molecular genetics of these disorders, current diagnostic challenges, and future avenues for therapy.

RECENT FINDINGS

Several cancer-prone transgenic mouse models that develop predominantly T/NK-cell lymphomas have been produced in the past 2 to 3 years. These models point to an important role for chronic cytokine stimulation and for disruption of genes involved in the control of chromatin remodeling and maintenance of genome integrity in the pathogenesis of T-cell lymphomas. The recognition of T/NK-cell lymphomas has been greatly facilitated by the broad acceptance of standard diagnostic criteria and by the increasing availability of assays for the analysis of T-cell receptor rearrangement and a more precise definition of functional T/NK-cell subsets. New drugs with potential for use in T/NK-cell lymphomas, including monoclonal antibodies, tyrosine kinase inhibitors, synthetic retinoids, immunoconjugates, and immunosuppressive molecules with novel mechanisms of action are in the early phase of clinical investigation.

SUMMARY

Much remains to be learned in the pathogenesis, clinical spectrum, and optimal therapy of T/NK-cell lymphomas. The availability of animal models of disease, new diagnostic tools, and targeted drugs with novel mechanisms of action should lead to rapid progress in this group of malignancies in the near future.

Automated kappa and lambda light chain mRNA expression for the assessment of B-cell clonality in cutaneous B-cell infiltrates: its utility and diagnostic application

INTRODUCTION

Primary cutaneous B-cell lymphoma (1 degrees CBCL) accounts for 25% of all lymphomas. The difficulty in distinction of reactive from neoplastic B-cell infiltrates prompts the use of molecular diagnostic adjuncts. While T-cell clonality can be seen in various reactive states, clonal B-cell infiltrates are often neoplastic; standard assays employed include polymerase chain reaction (PCR) or Southern blot analysis to assess heavy chain rearrangement. We sought to assess the utility of kappa (kappa) and lambda (lambda) mRNA expression using the Ventana automated assay (Ventana Medical Systems, Tucson, AZ, USA) in the analysis of atypical cutaneous B-cell lymphoid infiltrates.

MATERIALS AND METHODS

Multiple 4 micro m sections of paraffin-embedded, formalin-fixed skin biopsies from 31 patients with CBCL were placed on silane-coated slides, deparaffinized, then digested in pepsin (5 mg/ml) for 30 min at 37 degrees C. Fluorescein-tagged oligoprobes and tissue mRNA were denatured at 80 degrees C for 5 min, hybridized for 2 h at 37 degrees C, and incubated with antifluorescein alkaline phosphatase conjugates. Detection of the probe target complex employed nitroblue tetrazolium and bromochloroindolyl phosphate conjugates with a nuclear fast red counterstain. A kappa : lambda ratio > 3 : 1 was held to represent kappa light chain restriction and a kappa : lambda ratio </= 1 : 1 to indicate lambda light chain restriction.

RESULTS

The diagnosis in each case was determined by careful integration of clinical, histologic, and phenotypic data. The diagnoses included: pseudolymphoma (PL), marginal zone lymphoma (MZL), 1 degrees CBCL of the trunk, scalp or leg, 2 degrees lymphoma, and plasma cell dyscrasia. All but one case of lymphoma were light chain restricted. All cases of PL were proven to be polyclonal by this methodology. In non-plasmacytic small cell lymphomas, only 5-10% of the infiltrate expressed kappa or lambda, with clonality established through the abnormal kappa : lambda ratio. Interpretations were most difficult in the 2 degrees small cell-dominant follicular center cell lymphomas and easiest in cases with significant plasmacytic differentiation (i.e. MZL, immunocytomas, or plasma cell dyscrasias).

CONCLUSION

The Ventana kappa/lambda assay is a reliable, quick, and inexpensive way to determine B-cell clonality in cutaneous lymphoid infiltrates in paraffin-embedded formalin-fixed tissue.

The antitumor effects of IFN-alpha are abrogated in a STAT1-deficient mouse

IFN-alpha activates the signal transducer and activator of transcription (STAT) family of proteins; however, it is unknown whether IFN-alpha exerts its antitumor actions primarily through a direct effect on malignant cells or by stimulating the immune system. To investigate the contribution of STAT1 signaling within the tumor, we generated a STAT1-deficient melanoma cell line, AGS-1. We reconstituted STAT1 into AGS-1 cells by retroviral gene transfer. The resulting cell line (AGS-1STAT1) showed normal regulation of IFN-alpha-stimulated genes (e.g., H2k, ISG-54) as compared with AGS-1 cells infected with the empty vector (AGS-1MSCV). However, mice challenged with the AGS-1, AGS-1STAT1, and AGS-1MSCV cell lines exhibited nearly identical survival in response to IFN-alpha treatment, indicating that restored STAT1 signaling within the tumor did not augment the antitumor activity of IFN-alpha. In contrast, STAT1-/- mice could not utilize exogenous IFN-alpha to inhibit the growth of STAT1+/+ melanoma cells in either an intraperitoneal tumor model or in the adjuvant setting. The survival of tumor-bearing STAT1-/- mice was identical regardless of treatment (IFN-alpha or PBS). Additional cell depletion studies demonstrated that NK cells mediated the antitumor effects of IFN-alpha. Thus, STAT1-mediated gene regulation within immune effectors was necessary for mediating the antitumor effects of IFN-alpha in this experimental system.

Rapid diagnosis of smallpox infection and differentiation from its mimics

The potential for a bioterrorism-induced smallpox outbreak has been much discussed of late. The literature of the late 1960s stressed that the distinction between smallpox and the other viral-induced vesicle-forming diseases, namely varicella zoster and disseminated herpes simplex, was difficult to make. Given that the cutaneous manifestations of smallpox would be among the initial symptoms, we reviewed 2 cases of smallpox diagnosed in South America in the 1970s in conjunction with 9 cases of multiple skin vesicles diagnosed as either disseminated herpes simplex or varicella-zoster. These were examined by routine hematoxylin and eosin stain (H&E) as well as by in situ hybridization. A blind review of the cases demonstrated that each showed striking intraepithelial vesicles containing multinucleated squamous cells exhibiting a ground glass appearance of the nuclear chromatin. Thus, as expected, routine H&E examination could not differentiate the 2 smallpox cases from the other 9 samples. In situ hybridization easily distinguished the 2 cases of smallpox from the other 9 samples, 5 of which contained varicella-zoster (two had been misdiagnosed as herpes) and the other 4 were disseminated herpes simplex. The in situ test, readily accomplished in any histology-based molecular laboratory in 4 hours, allows for the rapid and specific identification of smallpox infection and, importantly, its distinction from its mimics. Formalin fixation, which is optimal for in situ hybridization, guarantees the inactivation of the smallpox virus.

Granulomatous eccrinotropic lymphomatoid papulosis

We describe 9 patients with a novel variant of lymphomatoid papulosis characterized by prominent localization of the infiltrate around the eccrine coil, resulting in nodular expansion of the coil accompanied by variable granulomatous inflammation. Light microscopy, immunohistochemical analysis using antibodies to CD2, CD3, CD4, CD5, CD7, CD8, and CD30 in 6 cases, and polymerase chain reaction--single-stranded conformational polymorphism analysis for T-cell receptor gamma chain gene rearrangement in 5 cases revealed 2 cytomorphologic patterns (large cell dominant with polymorphous inflammation, small cell lymphocyte--rich with an inconspicuous large cell component [phenotypes, CD30+/CD3+/CD4+/CD7-for large atypical cells; reactive for small lymphocytes]) and clonal restriction in 4 and polyclonality in 1 of the lymphocyte-dominant cases. During an average 6-year follow-up, no lymphomas developed. Recognition of this variant is important--accentuation of the infiltrate around the eccrine coil and cutaneous nerves, presence of granulomatous inflammation, dominance of small lymphocytes in the dermis, and variable extension into the panniculus may lead to diagnostic confusion with entities such as discoid lupus erythematosus, Jessner lymphocytic infiltrate of skin, subcutaneous T-cell lymphoma, and persistent arthropod bite reaction. Our findings suggest that pruritus, a younger age at diagnosis, and a more indolent course are defining clinical features.

Mammographic findings in pseudoxanthoma elasticum

BACKGROUND

There have been isolated case reports of arterial and skin calcification in mammograms of patients with pseudoxanthoma elasticum (PXE), and unpublished anecdotes of many women with PXE undergoing breast biopsy for evaluation of microcalcifications.

OBJECTIVE

Our aim was to systematically evaluate mammography and breast pathology in PXE.

METHODS

The mammograms of 51 women with confirmed PXE were compared with those of a control sample of 109 women without PXE, noting each of the following characteristics on each mammogram: breast density, skin thickening, skin microcalcifications, vascular calcification, breast microcalcifications and macrocalcifications, and masses. The characteristics of the 2 samples were compared using the 2-tailed t test with a pooled estimate of variance. The indications for mammography and data for each of the mammographic findings were analyzed using the chi(2) test. Available breast biopsy material was reviewed.

RESULTS

The PXE and control groups were similar in age and indications for mammography. There was a statistically significant increase in skin thickening, vascular calcification, and breast microcalcifications in the PXE group (P <.001 each). Breast density, masses, macrocalcifications, and skin calcification did not differ statistically in the 2 groups, but no control patient had axillary calcification, or both vascular calcification and microcalcifications (P <.001). Nearly 1 in 7 of the patients with PXE demonstrated at least 3 of the following: microcalcifications, skin calcifications, vascular calcification, and skin thickening; whereas none of the control group did. Histopathologic findings of breast tissue showed calcification of dermal elastic fibers, subcutaneous arteries, and elastic fibers of the deep fascia and interlobular septae of the fat adjacent to breast parenchyma.

CONCLUSION

Breast microcalcification and arterial calcification are not rare in the normal population and are not of diagnostic value. The presence of both of these findings, especially with skin thickening or axillary skin calcification, should suggest a diagnosis of PXE. The majority of breast calcifications in PXE are benign.

Pyoderma gangrenosum: a review

Since its first description in 1930, the pathogenesis of pyoderma gangrenosum (PG) has remained obscure even as an ever-widening array of systemic diseases has been described in association with it. The histopathologic distinction of PG from other ulcerative processes with dermal neutrophilia is challenging and at times impossible. In consequence, when confronted with a biopsy from such a lesion, the pathologist has an obligation to obtain a full and detailed clinical history. In short, as a diagnosis of PG does not hinge exclusively upon the biopsy findings in isolation from other studies, a solid knowledge of the clinical features, the systemic disease associations and the differential diagnosis will help the pathologist to avoid diagnostic pitfalls or the generation of a report which is non-contributory to patient care. In this review, we describe in detail the different clinicopathologic forms of PG, summarize the diseases associated with this process in the literature and in our experience, and briefly review the treatment options.

The histologic spectrum of epidermodysplasia verruciformis in transplant and AIDS patients

BACKGROUND

The purpose of this study was to correlate the histologic findings of skin lesions clinically suspicious for epidermodysplasia verruciformis with the viral findings in patients with organ transplants or AIDS.

METHODS

Thirty-seven skin biopsies from 17 patients (six with AIDS and 11 with transplants) were studied as a non-randomized, controlled, unblinded case series by in situ hybridization for HPV DNA.

RESULTS

Nineteen (51%) of these biopsies were HPV-positive by in situ hybridization either for HPV type 5 (five cases), type 8 (10 cases), type 16 (four cases) or HPV 31 (one case, with one case of dual infection). Only eight of the 19 HPV-positive tissues (42%) showed the classic histologic features of verruca planae. The more common histologic feature significantly associated with HPV detection was a focally thickened and disrupted granular layer (13/19 [68%] vs. 8/18 [44%], p < 0.04). Dysplasia was evident in 12/19 HPV-positive tissues (63%), which was significantly greater than in patients with congenital epidermodysplasia verruciformis (20%).

CONCLUSIONS

Oncogenic HPV types are detected in about one-half of skin biopsies from immunocompromised patients with a clinical presentation suspicious for epidermodysplasia verruciformis. Many of these lesions lack the histologic features of verruca planae, a focally thickened granular layer is a marker for viral detection, and the risk for dysplasia in such lesions is much higher than in epidermodysplasia verruciformis not associated with acquired immunosuppression.

Histologic distribution of fatal rotaviral pneumonitis: an immunohistochemical and RT in situ PCR analysis

Rotaviral infection is a common cause of gastroenteritis and pharyngitis; to our knowledge, infection has not been associated with severe pneumonia. We report on two cases of fatal pneumonitis in 49-and 54-year-old men; the latter was on long-term steroid treatment of multiple sclerosis. In the latter case, the histologic examination after a several week history of symptoms showed severe organizing interstitital pneumonitis and necrotizing bronchiolitis with extensive squamous metaplasia. The other case, which was fatal several days after the onset of symptoms, showed marked septal capillaritis with denudement of the alveolar pneumocytes, extravascated red blood cells, and intravascular thrombi formation. In each case, rotaviral RNA was localized by reverse transcription (RT) in situ PCR to the endothelial cells of the alveolar capillaries, macrophages, and pneumocytes as well as, in the second case, to the squamous metaplastic cells. Immunohistochemical analysis for the virus demonstrated an equivalent histologic distribution. It is concluded that rotaviral infection can lead to fatal pneumonitis and that the mechanism of this complication is centered on a diffuse septal endothelialitis with concomitant tissue damage.

Natural killer cells contribute to the lethality of a murine model of Escherichia coli infection

BACKGROUND

Cooperative interactions between natural killer (NK) cells and macrophages occur normally during the course of the early immune response to bacterial, protozoal, and viral pathogens, with each cellular compartment providing the other with critical stimulatory factors. We conducted the present study to determine whether NK cells contribute to the dysregulated immune response that accompanies septic shock.

METHODS

An analysis of the lethality of Escherichia coli CP9 was conducted in mice that had been depleted of NK cells via the injection of an anti-asialo GM1 antibody and in CD epsilon transgenic mice that are deficient in both NK cells and T cells. The 2 groups of mice were analyzed for serum levels of interferon-gamma, tumor necrosis factor-alpha, and interleukin-1beta as well as activation of NFkappaB and STAT1, 2 proinflammatory transcription factors.

RESULTS

NK cell-depleted and NK cell-deficient mice exhibited 80% survival in the face of an intraperitoneal bacterial challenge, whereas control mice all died within 12 hours. Serum levels of proinflammatory cytokines were markedly reduced in NK-depleted mice. NF kappaB and STAT1 activation were also reduced. NK-depleted mice exhibited less inflammation within multiple organs on histologic analysis.

CONCLUSIONS

These results show that NK cells may contribute to the lethality of bacterial infections via effects on cytokine production.

Pityriasis lichenoides: a clonal T-cell lymphoproliferative disorder

Pityriasis lichenoides (PL) is a papulosquamous disorder often considered a form of reactive dermatosis and classified with small plaque parapsoriasis (digitate dermatosis). However, some patients with PL have developed large plaque parapsoriasis (LPP) and mycosis fungoides (MF), and lymphoid atypia and T-cell clonality have been reported in lesions of PL. We set out to explore the possibility that PL is a form of T-cell dyscrasia. Cases were selected by natural language search from an outpatient dermatopathology database; 35 cases were reviewed and clinicians and patients were contacted. Hematoxylin and eosin-stained sections were examined and immunophenotyping was carried out on paraffin-embedded, formalin-fixed tissue using antibodies to CD2, CD3, CD4, CD5, CD7, CD8, CD20, CD30, and CD56. In paraffin-embedded tissue, T-cell receptor (TCR)-gamma chain rearrangement was sought through polymerase chain reaction single stranded conformational polymorphism analysis. There were 14 males and 21 females with a mean age of 40 years held clinically to have PL chronica (PLC) (28 cases) and/or PL et varioliformis acuta (PLEVA) (7 cases). Five patients developed large atrophic poikilodermatous and/or annular plaques compatible with MF and/or LPP in a background of typical PLC. All biopsies showed tropism of lymphocytes to an epidermis manifesting psoriasiform hyperplasia, dyskeratosis, parakeratosis, and intraepithelial collections of Langerhans' cells and lymphocytes mimicking Pautrier's microabascesses. Epidermal atrophy, dermal fibroplasia, poikilodermatous alterations, and a dominance of intraepidermal cerebriform cells were seen only in patients with chronic persistent disease (i.e., PLC) and in some cases corresponded with clinical progression to MF. All cases had a T cell-dominant infiltrate, with a CD7 deletion in 21 of 32 biopsies examined; the CD7-negative cells were typically the largest and most atypical forms, often in a cohesive array within the upper layers of the epidermis. In 17 biopsies in which a CD4 stain was satisfactory for evaluation, 50% or more of the intraepidermal population was CD4 positive in 8 biopsies, whereas in 11 biopsies 50% or more of the dermal infiltrate was CD4 positive. The CD4-positive cells frequently had a cerebriform nuclear morphology and were CD7 negative. Most cases had an admixture of CD8-positive lymphocytes in excess of 40% or more of the intraepidermal and/or dermal infiltrate; it was the dominant intraepidermal infiltrate in 10 cases. The CD8-positive cells, typically small, round, and CD7 positive, showed a directed pattern of migration into acrosyringia and suprapapillary plates, with satellitosis around CD4-positive/CD8-negative/CD7-negative atypical lymphocytes. CD56 positivity was seen among the intraepidermal lymphoid cells and roughly paralleled the CD8 profile. In general, CD8-positive lymphocytes dominated in cases of PLEVA, whereas CD4-positive lymphocytes were very conspicuous and composed the dominant intraepidermal populace only in those biopsies of progressive PL/PLC. Clonality was shown in 25 of 27 biopsies in which amplifiable DNA was obtained. Intraepithelial atypical lymphocytes, phenotypic abnormalities, and TCR-gamma rearrangements suggest that PLC and PLEVA are a form of T-cell dyscrasia. Lesions may follow a recalcitrant course characteristic of MF and premycotic disorders such as LPP. The aberrant phenotype cell is similar to that defining MF: a CD4-positive T lymphocyte with a CD5 and CD7 deletion. Directed epidermal migration seen in biopsies procured from incipient lesions along with occasional temporal association to viral or drug exposure suggests that an abnormal immune response to an antigenic trigger may be the inciting event.