Adnexal carcinomas of the skin. I. Eccrine carcinomas

The diagnostic identification of sweat gland carcinomas is hampered by their rarity and their histologic resemblance to various visceral tumors, leading to confusion with metastatic lesions. In this series, 14 cases of eccrine carcinoma in five male and nine female patients, ranging in age from 13 to 84 years, are described. Ten tumors strongly resembled infiltrating ductal adenocarcinomas of the breast, and were thus classified as ductal. Three had a prominent mucinous matrix, similarly explaining their categorization as mucinous carcinomas. Finally, one neoplasm was a classic eccrine porocarcinoma. Four patients with ductal eccrine carcinomas suffered metastasis, and a 50% mortality rate was observed among this group of ten cases. In contrast, only one of three mucinous carcinomas metastasized, although all of these lesions recurred locally, as did the single porocarcinoma. None of the latter four neoplasms proved fatal. The results of conventional special stains in these 14 cases are discussed, and histologic features that they shared, and which may be utilized in distinguishing eccrine carcinomas from benign sweat gland tumors, are presented.

Balloon cell malignant melanoma

A patient was seen with a pigmented plaque of malignant melanoma and multiple surrounding skin-colored dermal and subcutaneous nodules. Histologic examination showed that the pigmented lesion represented the balloon cell variant of malignant melanoma and that the adjacent nodules were local metastatic lesions. This case, along with a review of the literature, illustrates that many balloon cell melanomas show only mild cellular atypia and minimal mitotic figures, although the tumor has a malignant course, with local or distant metastasis. A careful examination of all the sections of the balloon cell tumor is important.

Pyoderma gangrenosum: a review of 86 patients

The clinical, histologic, and immunofluorescent findings in 86 cases of pyoderma gangrenosum seen at the Mayo Clinic between 1970 and 1983 were reviewed. Males and females were affected in equal numbers. The most frequent site of lesions was the leg. Sixty-seven patients (78 per cent) had associated systemic disease, with arthritis and inflammatory bowel disease being commonest. Cutaneous histopathologic changes varied with the site of biopsy. Lymphocytic vasculitis was predominant in the zone of erythema peripheral to the area of ulceration, while neutrophilic infiltrate and abscess formation were more prominent centrally. In most cases studied, direct immunofluorescence showed immunoglobulins and complement deposited in and around superficial and deep dermal vessels.

Leukemia cutis. A histopathologic study of 42 cases

Biopsy specimens of skin from 42 patients with leukemia cutis were studied. Typing of leukemia was based on histopathologic and histochemical findings in peripheral blood and bone marrow. There were three patients with acute lymphocytic leukemia, 16 with chronic lymphocytic leukemia, 12 with acute granulocytic leukemia, three with chronic granulocytic leukemia, five with acute monocytic leukemia, and three with acute myelomonocytic leukemia. In general, leukemia cutis shows a diffuse infiltration of leukemic cells in the dermis and subcutaneous tissue, often infiltrating between collagen bundles. Extensive involvement and disruption of blood vessels and skin adnexa are characteristic findings in granulocytic, monocytic, and myelomonocytic leukemia cutis, but biopsy specimens of skin in patients with different types of leukemia show a wide range of histopathologic changes that are variable among the various types of leukemia and sometimes even among different patients with the same type of leukemia. A final typing of leukemia should not rely only on regular histopathologic findings of a skin biopsy, but should depend more on morphologic and histochemical studies of smears of peripheral blood or of bone marrow or both.

Multicenter clinical evaluation of a hydrocolloid dressing for leg ulcers

The need for a moist environment for the normal healing process led to the development of occlusive dressings. Results from this study support the contention that a moist wound environment is favorable to the healing process in humans as well as in animal models. Hydrocolloid dressings are effective in the practical daily management of chronic and even refractive ulcerations of the lower extremities and offer a time-saving treatment alternative with a high degree of patient acceptability.

Clinical and histologic findings in Degos' syndrome (malignant atrophic papulosis)

Records of nine patients (aged ten to sixty-four years) seen at the Mayo Clinic with the typical cutaneous lesions of Degos' syndrome were reviewed. The three patients who died all had central nervous system involvement. The six patients now alive have been evaluated for two to fourteen years and have had their disease for four to fourteen years. Histopathologic examination was performed in all nine cases (total of 27 skin biopsy specimens). Wedge-shaped infarction in the dermis and subcutaneous tissue was observed only in one biopsy specimen from each of three patients, and the infarction occurred in older, well-formed skin lesions. Thrombosis of the arterioles was found in two patients. Hyperkeratosis and dermal acid mucopolysaccharide deposits were common. The most consistent histopathologic finding was lymphocytic infiltrate around and in the walls of venules and arterioles. Various degrees of lymphocyte-mediated necrotizing vasculitis were present in all patients.

Clinical and histopathologic spectrum of necrotizing vasculitis. Report of findings in 101 cases

Clinical and histopathologic features of 101 cases of necrotizing vasculitis were selected on the basis of the following histopathologic criteria: fibrinoid necrosis of blood vessel walls, endothelial cell hyperplasia, and an infiltrate within and around the blood vessel walls predominantly of polymorphonuclear leukocytes. There were three clinical patterns of vasculitis: (1) associated with other coexistent disease, (2) associated with known precipitating events, and (3) idiopathic. Two histologic features were particularly notable in view of the clinical findings. First, vasculitis extending deep into the reticular dermis or subcutaneous tissue seemed to be associated more often with systemic disease such as malignancy or connective tissue disease. Second, in biopsy specimens from patients with hypocomplementemia, the inflammatory infiltrate was composed almost exclusively of neutrophils, as compared with the mixed infiltrate seen in normocomplementemic vasculitis.

Vulvar sweat gland carcinomas

Sweat gland carcinomas constitute less than 10% of all malignant tumors of the vulva, including those associated with extramammary Paget's disease (EPD). The histopathologic diagnosis of vulvar sweat gland carcinomas is difficult because of their rarity; their resemblance to metastatic carcinomas of the internal female genitalia, kidneys, and other sites; and their diversity of microscopic appearances. We report five examples of vulvar sweat gland carcinomas, two of which were associated with EPD. The other tumors included one example each of ductal eccrine adenocarcinoma, eccrine porocarcinoma, and clear cell hidradenocarcinoma. The clinical behavior of these neoplasms is correlated with their histologic types; we also discuss differential diagnosis and treatment recommendations.

Epidermolytic palmo-plantar keratoderma

An 11-year-old girl who at 9 1/2 months was diagnosed as having keratoderma of the palms and soles, present since birth, developed typical granuloma annulare at the age of 11 years. To the authors' knowledge, this is the first report of epidermolytic palmo-plantar keratoderma associated with granuloma annulare. There was no known family history of keratoderma. A review of the literature revealed three other patients without family history, although most of the patients have had multiple family members with the same problem. Many skin conditions can be associated with epidermolytic hyperkeratosis. The authors believe that epidermolytic palmo-planter keratoderma is a distinct form of palmo-plantar keratoderma rather than a type of ichthyosis.

Ecthyma gangrenosum: report of clinical, histopathologic, and bacteriologic aspects of eight cases

The records of eight patients with ecthyma gangrenosum who were treated at the Mayo Clinic between 1970 and 1982 were reviewed. All patients had hematologic disease and had received immunosuppressive drugs. Patients with neutropenia that did not resolve by the end of a course of appropriate antibiotic treatment usually died. Solitary lesions of ecthyma gangrenosum were associated with a better prognosis than were multiple lesions. The typical skin findings of ecthyma gangrenosum usually occurred early and were often incorrectly diagnosed, resulting in time lost during which antibiotic therapy could have been instituted. For patients with ecthyma gangrenosum, a systematic procedure is important to establish the diagnosis early, so that appropriate systemic antibiotic therapy can be initiated.

Cutaneous findings in hairy cell leukemia

Hairy cell leukemia is a distinctive clinicopathologic entity that is histologically characterized by infiltration of the spleen, bone marrow, and blood by uniform mononuclear cells--"hairy cells." We reviewed the prevalent cutaneous findings, specific and nonspecific, in 113 cases of hairy cell leukemia. Only one patient had specific lesions (skin infiltration by leukemic cells). Nonspecific cutaneous findings included recurrent infections, ecchymoses, petechiae, pallor, drug reactions and reactions to transfusions, and nonherpetic ulcerations. Although leukemic infiltration of the skin in hairy cell leukemia is rare, cutaneous histopathologic features may be diagnostic, particularly when cytomorphologic examination is coupled with staining of a fresh specimen with tartrate-resistant acid phosphatase. Cutaneous and extracutaneous infections, often extensive and with opportunistic organisms, were the most common nonspecific findings and demonstrated severely deficient immunologic responsiveness. Associated malignant diseases, cutaneous and extracutaneous, were few in number and are of uncertain significance.

Management of leg ulcers with hydrocolloid occlusive dressing

Twenty-two patients with 31 leg ulcers of various causes received local wound management consisting of the application of an adhesive hydrocolloid (HC) occlusive dressing (DuoDerm). Group 1 comprised 15 patients (11 outpatients) with 19 ulcers. Approximately two thirds (12/19) of the ulcers healed when treated solely with the HC dressing; mean treatment time was 57 days. Group 2 comprised seven hospitalized patients with at least two leg ulcers of similar size and distribution. The 20 ulcers in the seven patients were treated with either mild topical antimicrobial wet dressings (Sweitzer's 1:32 solution) or HC dressings, with each patient serving as his own "control." All 20 ulcers healed; the average time to healing was 44 days with HC dressing and 42 days with wet dressing management. Most of the patients reported convenience in management and substantial relief of pain with the use of HC dressings.

Cutis marmorata telangiectatica congenita: report of nine cases and review of the literature

The major clinical features of nine patients (seven women and two men) with cutis marmorata telangiectatica congenita (CMTC) were persistent cutis marmorata, spider nevus-like telangiectasia, and phlebectasia. Three of the patients had persistent ulcers and atrophy. In two patients, atrophie blanche-like lesions developed on the legs with ulcers. No patient had a family history of a similar disorder. Skin lesions were present at birth in seven cases, at the age of eight months in one case, and at eighteen months in one case. Three patients had clinical improvement of the skin lesions with age. Eight of the nine patients had associated physical anomalies. Biopsy specimens showed an increase in the number and size of the blood vessels in the upper dermis. Alkaline phosphatase staining gave negative results in the dilated blood vessels of the single case in which this histochemical study was done.

Scleredema: a review of thirty-three cases

A review of thirty-three cases of scleredema, with particular reference to clinical and histologic findings, revealed that the disease was often of insidious onset and the course was usually prolonged. A preceding respiratory tract infection was uncommon and usually did not indicate a short course. The patients were divided into two groups according to the presence or absence of diabetes. Diabetes, when present, was typically the late-onset, insulin-dependent type and difficult to control. In many of these patients, the onset of scleredema was so subtle that it went unnoticed by the patient until pointed out by an examining physician.

Clinicopathologic correlations in leukemia cutis

This clinicopathologic study involved 42 cases of leukemia cutis: 3 of acute lymphocytic leukemia (ALL), 16 of chronic lymphocytic leukemia (CLL), 12 of acute granulocytic leukemia (AGL), 3 of chronic granulocytic leukemia (CGL), 5 of acute monocytic leukemia (AML), and 3 of acute myelomonocytic leukemia (AMML). The clinical appearance of leukemia cutis included papules, macules, plaques, nodules, ecchymoses, palpable purpura, and ulcerative lesions, and these were seen in all types of leukemias. Gingival hypertrophy was seen only in AML or AMML, and erythroderma and bullous lesions of leukemic infiltration were observed only in CLL. Cutaneous leukemic lesions may be concomitant with or preceding the diagnosis of systemic leukemia. Therefore, skin biopsy may be helpful in detecting the leukemia and may facilitate the work-up. Leukemia cutis probably is a dissemination of systemic leukemia to the skin, and the demonstration of leukemia in skin is associated with a very poor prognosis.

Sister Mary Joseph's nodule: a clinical and histologic study

The clinical and histologic findings in eighty-five cases of tumors metastatic to the umbilicus were studied. Clinically, the lesions were seen as firm, indurated nodules, sometimes with fissuring or ulceration. In twelve cases, the initial presentation of the internal primary malignancy was an umbilical nodule. Histologic material from the metastatic umbilical tumor was studied in all cases but was diagnostic of the primary carcinoma in only twenty-one. In seventeen cases, the primary site was never reliably determined, while stomach, large bowel, ovary, and pancreas were the most frequent primary sites in the other cases. Most patients died within months after the appearance of the umbilical tumors, thus emphasizing the ominous significance of this sign of metastatic, usually intra-abdominal, malignant disease.

Lymphocytic vasculitis: is it a specific clinicopathologic entity?

Seventy-one biopsy specimens taken at the Mayo Clinic from June 1977 through May 1981 demonstrated lymphocytic vasculitis. All specimens met the criteria for lymphocytic vasculitis, defined as (1) a predominantly lymphocytic infiltrate that involves and surrounds blood vessel walls, (2) fibrinoid necrosis of blood vessel walls, and (3) endothelial cell hyperplasia. Other histologic findings such as thrombosis, extravasation of erythrocytes, ulceration, epidermal infarction, and evidence of nuclear dust were seen only occasionally. Hypocomplementemia and other serologic abnormalities were very rare, even when lymphocytic vasculitis was extensive. The clinical diagnoses varied, with drug reaction (12 patients) and chronic urticaria (10 patients) being most frequent. In 32 cases, no specific diagnosis could be made at the time of dermatologic dismissal. In the remaining 39 cases, the diagnoses were varied and no definite clinical categories can be applied to them. We also observed typical lymphocytic vasculitis in some cases of other clinical entities, such as nodular scabies, erythema multiforme, and urticarial vasculitis, and so forth. We conclude that lymphocytic vasculitis is probably not a specific clinicopathologic entity but is more likely a reactive process, secondary to severe lymphocytic inflammation in the skin.

Ophthalmic changes of Degos' disease (malignant atrophic papulosis)

A 49-year-old woman with typical skin lesions of Degos' disease was found to have an afferent pupillary defect, and altitudinal field loss. This loss was probably secondary to vascular occlusion in the optic nerve of a patient with a congenital anomalous retinal vascular pattern. The patient has had no other systemic involvement after a follow-up of 4 years. Three other patients seen in the past had eye involvement and involvement of the central nervous system and died between 1 and 16 years of the diagnosis. Multiple ocular manifestations of Degos' disease have been reported affecting the eyelids, bulbar conjunctivae, retina, and choroid in varying degrees. Diplopia, visual field defects, ophthalmoplegia, ptosis, papilledema, and optic atrophy are ocular changes secondary to involvement of the central nervous system.

Pseudomonas aeruginosa infections of the skin

Otitis externa, green nail syndrome, toe web infections, hot tub folliculitis, superinfections in chronic antibiotic-treated acne and infectious eczematoid dermatitis are examples of mild cutaneous infections due to Pseudomonas aeruginosa. These may occur in otherwise healthy persons. In persons with lowered resistance, more severe infections such as malignant otitis externa, blastomycosis-like pyoderma and necrotizing fasciitis are observed. Ecthyma gangrenosum, the pathognomonic skin sign of Pseudomonas septicemia, occurs in debilitated or terminally ill patients and must be treated immediately.

Discoid lupus erythematosus and monoclonal gammopathy

Of twelve patients with discoid lupus erythematosus and dysgammaglobulinaemia, eight had a monoclonal gammopathy with a benign course to date, two had 'smouldering' myeloma, and two developed overt multiple myeloma. Six patients had generalized discoid lupus erythematosus, and six had skin lesions localized to the head and neck. Further screening of patients with discoid lupus erythematosus by serum protein electrophoresis is indicated to determine the significance of these findings.