Recurrent Verruciform Xanthoma of the Vulva

Verruciform xanthoma is a rare, benign, mucocutaneous, nondestructive lesion characterized by proliferation of non-Langerhans lipid-rich histiocytes. We describe the clinical and pathologic findings in a 30-year-old female with recurrent verruciform xanthoma of the vulva 8 years after initial therapy. The differential diagnosis includes seborrheic keratosis, verruca simplex, condyloma acuminatum, granular cell myoblastoma, vulvar intraepithelial neoplasia, bowenoid papulosis, erythroplasia of Queyrat, and verrucous carcinoma.

Aromatase expression in low-grade endometrial stromal sarcomas: an immunohistochemical study

Aromatase expression has been described in stromal cells of endometriosis, adenomyosis and endometrial cancer. We analyzed aromatase expression in a series of 23 low-grade endometrial stromal sarcomas. Archival formalin-fixed and paraffin-embedded material was analyzed with immunohistochemistry. Aromatase expression was evaluated with a monoclonal and a polyclonal antibody using the peroxidase-antiperoxidase method. A score was calculated based on the percentage of positive tumor cells and the staining intensity. Aromatase was seen in 19 (83%) of 23 tumors with monoclonal antibody and 20 (87%) of 23 tumors with polyclonal antibody. Aromatase expression using the monoclonal antibody was scored as high in five (22%), moderate in nine (39%) and low in five (22%) tumors. Four (17%) low-grade endometrial stromal sarcomas did not stain for aromatase. Aromatase expression with the polyclonal antibody was scored as high in seven (31%), moderate in four (17%) and low in nine (39%) tumors. Three (13%) low-grade endometrial stromal sarcomas did not stain for aromatase. Little or no aromatase expression tended to correlate with stage I disease, while higher scores were more frequently associated with advanced disease. Our results demonstrate that most low-grade endometrial stromal sarcomas express aromatase. The staining pattern, however, is heterogeneous. The high percentage of aromatase positivity in low-grade endometrial stromal sarcomas may have implications in the management of these tumors and offer new treatment modalities such as hormonal therapy with aromatase inhibitors.

Colliding / concomitant tumors of the intestine: report of 3 cases

Collision/concomitant tumors of the intestine involving lymphomas are very rare. For these cases molecular genetic analyses are valuable diagnostic adjuncts. We report one collision tumor of the rectum (adenocarcinoma and peripheral T-cell lymphoma, unspecified), and two cases of concomitant tumors (carcinoma in the cecum and lymphoma in the ileum; carcinoma in the sigmoid and lymphoma in the ileum). The collision tumor (poorly differentiated adenocarcinoma and a peripheral T-cell lymphoma, unspecified) showed a variable proportion of the anaplastic tumor cells expressing lymphatic markers as well as cytokeratin. Only polymerase chain reaction (PCR) analysis revealing T-cell monoclonality of the anaplastic part of the colliding tumor allowed the correct diagnosis. In the second case, a moderately differentiated adenocarcinoma in the cecum with a concomitant B-cell Non-Hodgkin lymphoma in the ileum, PCR analysis was non contributory. In the third case (adenocarcinoma in the sigmoid colon and a follicular center lymphoma in the ileum) PCR analysis revealed gene rearrangement of the immunoglobulin heavy chain gene. We would like to emphasize that collision and concomitant tumors of the gut are rare and that molecular genetic analysis may be mandatory for correct diagnosis. It is our impression, that these tumors may be diagnosed more often in the intestinal tract if molecular genetic analysis and immunohistochemistry are used routinely, at least for all anaplastic tumors.

The flow cytometric DNA index can predict the presence of lymph node metastases in invasive ductal breast carcinoma

Axillary lymph node (LN) dissection is an important staging procedure for invasive ductal breast carcinoma (IDC), but causes elevated morbidity. Reliable preoperative prediction of metastases is at present not possible. We investigated whether flow cytometric analysis of primary IDC can correctly predict the presence of LN metastases at the time of primary diagnosis. In 341 primary IDC, DNA index (DI) in absolute values, S-phase fraction (SPF), size of the primary tumor, tumor grade (G), estrogen/progesterone receptors (ER/PR) expression and age were analysed and correlated with the axillary LN status with the aim of correctly predicting the LN status. No predictive value was identified for S-phase fraction (SPF), tumor grade, or ER/PR expression. The DI correlated statistically with LN status in all patients. A practically useful association was, however, only observed in 37 women aged 45-58 years with an IDC >2 cm diameter: a DI >1.44 predicted the presence of LN metastases at the time of operation with a specificity of 100% and a sensitivity of 89%, a negative predictive value of 91% and a positive predictive value of 100%. Determination of the absolute values of the DI may be a useful adjunct to sentinel LN preparation when predicting the axillary LN status and may spare some women the morbidity associated with axillary LN dissection.

Monoclonal gamma-T-cell receptor rearrangement in vulvar lichen sclerosus and squamous cell carcinomas

Risk factors for vulvar squamous cell carcinoma (SCC) are human papilloma virus (HPV) infections and lichen sclerosus (LS). The significance of monoclonal gamma-T-cell receptor (gamma-TCR) rearrangement in the lymphoid infiltrate of LS and the consequence for vulvar carcinogenesis is unknown. One hundred sixty-one biopsies of vulvar LS and SCC, with and without LS, were examined for monoclonal gamma-TCR rearrangement and HPV16 expression, and for the expression of B- and T-cell markers and fascin. Monoclonal gamma-TCR rearrangement was identified in 8 of 17 patients with LS and 11 of 21 patients with SCC arising in LS with only occasional HPV16 DNA detection. None of the 19 SCC without LS showed monoclonal gamma-TCR rearrangement, but 14 of 19 patients had strong HPV16 detection. The lichenoid infiltrate of LS with germline configuration consisted predominantly of T cells (CD8 > CD4), along with numerous B cells. However, in biopsies with monoclonally rearranged gamma-TCR, CD4-positive T cells dominated along with B cells and fascin-positive cells in the lichenoid infiltrate and in deeply located lymphocyte aggregates (LAs). These LAs additionally contained fascin-positive dendritic cells with only individual CD8, CD57, and granzyme-positive cells. LAs in biopsies with germline configuration demonstrated numerous T cells (CD8 >CD4), but only single peripheral B cells, CD57, and fascin-positive lymphocytes. Our data suggest that monoclonal gamma-TCR rearrangement is characteristic for and limited to LS and SCC arising in LS, raising the question for a LS-associated antigen. We interpret B cells, CD4-positive T cells, and fascin-expressing dendritic cells within LS as a cellular immune response to antigen or proliferating T-cell clones. The resulting local immune dysregulation in LS may provide a permissive environment for the development of a SCC.

[Primary sinu-nasal melanomas. Clinical aspects, therapy and follow-up]

BACKGROUND AND OBJECTIVE

Primary malignant melanoma of the nasal cavity and paranasal sinuses is a rare entity felt to have a poor prognosis. We examined the frequency and characteristics of this type of melanoma in a defined geographic region over a period of 16 years.

PATIENTS/METHODS

Nine patients (eight men, one woman, mean age 62 years) with primary nasal and sinusoidal malignant melanoma were treated between 1985 and 2000 in the Department of Dermatology in cooperation with the Department of Otorhinolaryngology. All patients underwent surgery, eight with clinical complete tumor removal and one with only partial removal. All patients had radiotherapy after surgery. History, potential risk factors, clinical presentation, histological and immunohistochemical data and clinical course were documented.

RESULTS

All patients died because of their tumor within the observation period (median survival: 30 months, range 7 to 75 months). There were three different courses of the disease: (1) uncontrollable primary tumor (one patient, survival 11 months); (2) local recurrence with metastasis (five patients, median survival 40.2 months); (3) metastasis after a disease-free interval (three patients, median survival 19.3 months).

CONCLUSIONS

Malignant melanoma of the nasal cavity and paranasal sinuses is a rare entity which is usually rapidly fatal. Effective treatment approaches are not available.

Evidence of fetal microchimerism in Hashimoto's thyroiditis

Fetal microchimerism, the engraftment of fetal progenitor cells into maternal tissues, has been implicated in the etiology of autoimmune diseases. We used PCR analysis to determine whether microchimerism occurred in the thyroid glands of female patients suffering from Hashimoto's disease and thus may be involved in its etiology. PCR amplification was performed from thyroid gland specimens using primers unique to a Y-chromosomal sequence (SRY gene) and primers for a sequence that is Y/X-chromosomal homologous except for a 6-bp deletion in the X-chromosomal sequence (amelogenin). Microchimerism was detected in 8 of 17 Hashimoto patients, but in only 1 of 25 controls (nodular goiters). Both groups were of similar age and had comparable numbers of pregnancies and numbers of sons. All individuals with microchimerism had given birth to at least 1 son. Our results show that microchimerism is significantly more common in Hashimoto patients than in patients suffering from nodular goiter. We therefore suggest that microchimerism might play a role in the development of Hashimoto's disease, although we cannot completely eliminate the hypothesis that microchimerism is just an "innocent bystander" in a process triggered by other mechanisms.

Healing process after alveolar ridge distraction in sheep

OBJECTIVE

Mandibular augmentation by distraction of the alveolar ridge has been in use for several years. Since 1996, a distraction device that remains in the alveolar ridge after distraction has been used by the Department of Oral and Maxillofacial Surgery of Graz University. The distraction device is transformed into a dental implant after the end of the distraction process and can later be used for prosthetic purposes. We aimed to show the application of the device in this animal experiment and to follow the osseous healing process.

STUDY DESIGN

Two distraction implants were inserted into the mandibles of 8 sheep. Distraction of 0.5 mm per day was carried out for 8 days. Two sheep were killed 1, 2, 3, and 6 months after distraction, and the dissected mandibles were examined clinically, radiologically, and histologically.

RESULTS

After the first month of distraction, only slight radiopacity of the distraction gap was found. This increased steadily up to the third month after distraction. The boundary between the distraction fragments and the gap disappeared gradually. Six months after distraction, a homogeneous fine-meshed spongiosa structure was found in the area of distraction. Histologic examination showed desmoid ossification in the distraction gap and a continued increase in osteoid. After 6 months, mature bone was found. Only in the center was the rebuilding process not complete. Six months after distraction, osseointegration of the implants was shown in the region of the screw thread and distraction cylinder.

CONCLUSIONS

The healing process corresponded to that found in long bones, but showed only desmal ossification. Osseous integration of the distraction implants was found 6 months after distraction, although the implants were stable 3 months after distraction.

CK7 expression in carcinomas of the Waldeyer's ring area

Primary carcinomas of the Waldeyer's ring area are typically nonkeratinizing squamous cell carcinomas (SCC). Their cervical lymph node metastases are not uncommonly cystic and filled with necrotic tumor cells. Some cysts, however, contain clear fluid. During the investigation of SCC producing "fluid-filled" cystic metastases, we evaluated hematoxylin and eosin (H&E) sections of 90 primary SCC for their site of origin. We analyzed the cytokeratin (CK) profile of primary and metastatic carcinoma with special focus on the expression of CK7, a putative marker for ductal differentiation. CK7 was expressed in submucosal minor salivary gland acini and ducts, but not in the squamous surface epithelium of the Waldeyer's ring. CK7 was expressed in 11 primary SCC (8 base of tongue/3 palatine tonsil). The CK7-positive SCC were deep-seated, arose from large excretory ducts of submucosal minor salivary glands, and showed only insignificant surface involvement. They were characterized by a solid infiltrative growth pattern of basaloid cells with focal ductal differentiation. Salivary ducts adjacent to the carcinoma showed extensive intraductal hyperplasia and metaplasia. All CK7-positive carcinomas produced CK7-positive cystic nodal metastases, most of which contained paucicellular fluid. No solid CK7-positive nodal metastases were identified. In summary, a subset of carcinomas occurring in the Waldeyer's ring area appear to arise from large excretory ducts of submucosal minor salivary glands with only limited surface involvement, express CK7, and produce CK7-positive cystic "fluid-filled" nodal metastases. The histomorphology and immunophenotype suggest that these carcinomas represent basaloid SCC arising from excretory ducts of the submucosal minor salivary glands.

Trichoblastic carcinoma ("malignant trichoblastoma") with lymphatic and hematogenous metastases

We report an aggressively behaving malignant trichogenic tumor arising in a trichoblastoma (TB) with widespread lymphatic and hematogenous metastases in a 55-year-old man with a concomitant B-cell chronic lymphocytic leukemia. The primary tumor had been present and unchanged for as long as 40 years before excision. Typical trichogenic TB with dystrophic calcification and even ossification was still present peripheral to the malignant transformation. The malignant neoplasm consisted of basaloid cells, spindle cells arranged in fascicles and densely packed rounded nests or "cell balls." The metastases consisted of immature basaloid cells and cell balls, and the recurrences became successively more undifferentiated. The residual TB reacted with antibodies to cytokeratin (CK) 6, 8, 14, and 17 and focally to S-100; the malignant primary tumor reacted uniformly with antibodies to vimentin and only focally with antibodies to CK and S-100. The metastatic tumor had lost epidermal CK expression but maintained expression of S-100 in paraffin-embedded tissues. Trichoblastic differentiation was confirmed in frozen tissues with antibodies to hair keratins. No expression of p53 or bcl-2 was identified, but p-glycoprotein (MDR-1 gene related) was expressed by primary and metastatic tumor cells. We believe that this neoplasm is best classified as a trichoblastic carcinoma arising in a TB in association with a B-cell chronic lymphocytic leukemia. This case illustrates that TBs have the potential for malignant transformation and aggressive behavior.

Expression of oestrogen and progesterone receptors in low-grade endometrial stromal sarcomas

We analysed oestrogen receptor (ER) and progesterone receptor (PR) expression in a retrospective series of 21 low-grade endometrial stromal sarcomas (LGSSs). Archival formalin-fixed and paraffin-embedded material was analysed by immunohistochemistry. ER and PR were measured with monoclonal antibodies and the peroxidase-antiperoxidase method and a score was calculated as for breast carcinoma based on both the percentage of positive tumour cell nuclei and the staining intensity. ER were seen in 15 (71%) and PR in 20 (95%) of tumours respectively. ER expression was scored as high in three (14%), moderate in four (19%), and low in eight (38%) tumours. Six (29%) tumours did not stain for ER and all of these were positive for PR. PR expression was scored as high in eight (38%), moderate in ten (47%) and weak in two (10%) LGSSs. Only one (5%) LGSS did not stain for PR (this tumour was positive for ER). ER and PR expression in LGSS is heterogeneous. This may have implications for hormone therapy in the management of these tumours. These results suggest that ER and PR should be routinely quantified in LGSSs by immunohistochemical methods.

Nasopharyngeal angiofibroma: true neoplasm or vascular malformation?

Nasopharyngeal angiofibromas (NA) are rare tumor-like lesions characterized by architecturally irregular vessels set in a fibrous stroma. The unique morphology, the strong predilection for male adolescents, and the uncertainty about its etiology contributes to significant confusion regarding the classification of NA, which still has not been solved today. Based on immunohistochemical and electron microscopic examinations, we demonstrate in detail the various unusual vascular architectural features of NA. They represent discontinuous vascular basal laminae, focal lack of pericytes, and pronounced irregularity of the smooth muscle layers. In thick smooth muscle layers and pads, the orientation of muscle cells is frequently disturbed, and the individual cells differ in size and shape. Occasionally, the muscle layers disperse peripherally into individual cells, creating the impression of vessel-independent smooth muscle cells within the stroma. The summation of all morphological irregularities demonstrated in this paper allows the conclusion that NA represent vascular malformations.

Giant liposarcoma of the esophagus: radiological findings

This case of an esophageal liposarcoma illustrates a polypoid lesion within the esophagus that extended from the left pyriform sinus to the distal esophagus above the gastric cardia. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) showed an inhomogenously-enhancing intraluminal mass, while video-fluoroscopy revealed that the mass was adherent to the esophageal wall and was associated with esophageal dilatation and diminished peristalsis. This ninth reported case of esophageal liposarcoma is the first described where preoperative radiologic studies and endoscopy showed broad fixation of the tumor to the esophageal wall.

Cystic lymph node metastases of squamous cell carcinoma of Waldeyer's ring origin

We analysed in a retrospective study the frequency of cystic lymph node (LN) metastases in neck dissection specimens of 123 patients with primary squamous cell carcinoma (SCC) arising in the palatine tonsils (62 M/14 F), the base of the tongue (38 M/5 F) and the nasopharynx (2 M/2 F). Eighty-two per cent of patients had metastases (64 tonsillar SCC, 33 base of tongue SCC and all four nasopharynx SCC) in 368 LN of a total 2298 sampled LN. Thirty-nine per cent of patients had exclusively solid metastases and 37% of patients had exclusively cystic metastases. A total of 62 patients had some signs of cyst formation in one or more metastatically affected LN (27 with only histological evidence of cyst formation with luminal diameters < 5 mm, 35 with clinically detectable cyst with luminal diameter > 5 mm). Cystic metastases were more common in patients with SCC of the base of the tongue (P = 0.005), while solitary clinically evident cystic metastasis with lumina > 5 mm were found exclusively in tonsillar carcinoma (P = 0.024). In comparison with solid metastases, cyst formation was associated with N-categories (N2b and N3, P = 0.005) in SCC of the base of the tongue origin. No such association was observed for tonsillar SCC (P = 0.65). The primary mechanism of cyst formation was cystic degeneration.

CD44 expression in sinonasal melanomas: is loss of isoform expression associated with advanced tumour stage?

The expression of the adhesion molecule CD44 was examined in 14 primary sinonasal melanomas (SMs), aggressive neoplasms with short survival times, as CD44 overexpression has been linked to poor survival in human cancers. Immunohistochemistry was performed on formalin-fixed, paraffin-embedded sections with CD44 isoform-specific monoclonal antibodies to the CD44 standard (s) and variant isoforms (v) v5 and v6. CD44s, v5, and v6 were strongly expressed in a membranous pattern in SM in situ, early invasive SM, and in uninvolved respiratory/squamous epithelium. In invasive SM, membranous CD44s expression was identified in a large proportion of melanoma cells. Membranous staining of CD44v5 and v6 was lost in invasive SM, independently of the histological subtype. Diffuse cytoplasmic staining was observed focally in invasive SM and loss of cytoplasmic expression of CD44v6 and v5 was associated with advanced tumour stage in the linear-by-linear association test (p = 0.042 and 0.066, respectively). CD44s may not be important for malignant transformation, as it is expressed in both benign and malignant melanocytes. Loss of membranous CD44 isoform expression in widely invasive SM suggests that loss of cellular adhesion facilitates matrix and vascular infiltration and dissemination of sinonasal melanoma cells.

Cultured human sole-derived keratinocyte grafts re-express site-specific differentiation after transplantation

Cultured epithelial autografts (CEA) derived from sole skin were transplanted to full-thickness wounds excised to muscle fascia over a variety of diverse body sites in 12 pediatric patients treated for acute burns or giant congenital nevi. The skin regenerated from the grafts was biopsied from 7 days to 6 years after grafting. The resultant epidermal phenotype was analyzed histologically and by immunohistochemical localization of keratin 9 (K9) as objective evidence of sole-type site-specific differentiation. Expression of K9 was also verified by one-dimensional gel electrophoresis of epidermal cytoskeletal extracts and K9 immunoblot analysis. Grafts prepared from epidermis of axilla; groin or foreskin and transplanted to wounds of comparable depth in an identical manner in the same patients served as controls of postgrafting differentiation. Biopsies of sole skin from amputation specimens from patients of comparable age served as normal positive controls, and biopsies of nonsole skin from patients of comparable age served as normal negative controls. As early as 2 weeks postgrafting, the histologic appearance of sole-derived CEA differed substantively from that of axilla- or groin-derived CEA controls and displayed a phenotype characteristic of sole skin with a thick compact stratum corneum, a thick stratum granulosum, and a distinct stratum lucidum. In sole-derived grafts rete ridges regenerated within 2 months postgrafting, whereas nonsole-derived grafts required 4-6 months for rete ridge regeneration. Once acquired, the sole skin phenotype was maintained long-term by all sole-derived CEA. In vitro, sole-derived keratinocytes synthesized little, if any, K9. However, within 7 days after grafting, K9 synthesis by multiple suprabasal keratinocytes was seen within the epidermis regenerated from sole-derived CEA. Protein of K9 appeared progressively more diffuse throughout the suprabasal layers, attaining a confluent pattern of expression comparable to normal controls of sole skin by 6 to 12 months postgrafting, and the confluent pattern of suprabasal K9 synthesis was maintained long-term. The results demonstrate that site-specific differentiation is an intrinsic property of postnatal human keratinocytes and can be expressed and maintained in a permissive environment in the absence of dermal tissue.

Keratoacanthoma: a clinically distinct variant of well differentiated squamous cell carcinoma

Keratoacanthomas are distinct skin lesions that occur most often as solitary tumors in sun-exposed areas in elderly, fair-skinned patients. Clinically, these tumors are characterized by a rapid onset and regression within months. Keratoacanthomas display distinct histological features including a keratin-filled crater lined by a proliferating squamous epithelium. Cytologically, there may be overlap with classical well differentiated squamous cell carcinoma. Rarely, otherwise typical keratoacanthomas show intravascular and perineural invasion and lymph node metastases. Keratoacanthomas should, therefore, be considered to be a clinically distinct variant of well differentiated squamous cell carcinoma capable of spontaneous regression. This view is supported by their common etiology, occasional concurrent occurrence, and a multitude of studies revealing no substantial differences between these two lesions. Regression is immunologically mediated and activated by a variety of molecular mechanisms. Considering the common nature of keratoacanthomas and well differentiated squamous cell carcinomas, and the lack of any features predicting prognosis, surgical excision of keratoacanthoma is advisable.