Reducing surgical margins in dermatofibrosarcoma protuberans using the pathological analysis technique 'vertical modified technique': a 5-year experience

BACKGROUND

For the treatment of dermatofibrosarcoma protuberans (DFSP), wide surgical excision has been recommended, with 3-5-cm margins, including the first underlying clear fascia. Since 2006, a technical improvement in pathological analysis called the vertical modified technique (VMT) has allowed us to reduce the surgical margin without increased oncological risk.

METHODS

Between 2006 and 2011, 66 cases of DFSP were analysed in our hospital, using VMT. We reviewed patient records, considering the initial margin, total margin, number of surgeries and outcomes. Functional and aesthetic consequences were assessed by the surgeon and by the patients.

RESULTS

Mean initial margin for the first resection was 18 mm (10-30 mm). First resection allowed complete resection of the tumour in 52 cases (78.8%). Mean total surgical margin was 21.3 mm (10-60 mm). There were no cases of local tumour recurrence at a median follow-up of 30 months. Reconstruction was performed using direct sutures in 53 cases (80.3%), split-thickness skin grafts in six cases (9.1%), full-thickness skin grafts in five cases (7.6%) and flaps in two patients (3%). For 90.9% of the patients, the aesthetic result was acceptable, whereas 84.8% patients were satisfied with the functional result.

CONCLUSION

VMT reduces surgical margins and allows for extensive analysis of margins. This technique represents a safe and reliable strategy in DFSP, without increasing the risk of recurrence. The outcomes of our study have confirmed the data from the literature regarding oncological safety.

[Myeloproliferative hypereosinophilic syndrome revealed by bipolar mucosal ulcerations]

BACKGROUND

Hypereosinophilic syndrome (HES) is defined as an eosinophil count equal to or greater than 1.5 G/L for more than 6 months with organ damage (heart, nervous system, lung, etc) after the exclusion of other common causes of eosinophilia. A myeloproliferative variant of HES with FIP1L1-PDGFRα fusion gene inducing constitutive activation of a tyrosine kinase receptor has been characterized. We report a case in which the diagnosis was revealed by mucosal erosions and ulcerations.

PATIENTS AND METHODS

A 50-year-old man reported bipolar erosions. He presented with an erosion on the glans, an ulceration on the lower lip and mild dermographism. He had an eosinophil count of 7.5 G/L (n<0.7) and raised LDH at 520 IU/L (n<480). Screening for the usual causes of eosinophilia was negative. Histology of the labial ulceration showed a polymorphous inflammatory infiltrate containing eosinophils. A chest scan demonstrated a ground glass-like pulmonary infiltrate and broncho-alveolar lavage revealed eosinophilic alveolitis. The myelogram showed rich bone marrow with eosinophils. FIP1L1-PDGFRα fusion transcript was detected in the blood. Imatinib (Glivec(®)) was initiated and a favourable outcome was achieved within a few months and maintained after one year of treatment.

DISCUSSION

Cutaneous signs are frequent features of HES. They are polymorphous and include pruritis, erythematous rash and urticaria. Mucosal ulcerations are uncommon and appear more frequently with the myeloproliferative FIP1L1-PDGFRα-associated variant of HES. Early diagnosis allows the onset of a targeted treatment with imatinib that may prevent the apparition of organ damage.

[Disseminated perinaevic Meyerson phenomenon revealing melanoma]

BACKGROUND

Meyerson phenomenon (MP) consists of an eczematous reaction occurring around a pre-existing dermatologic lesion that is usually melanocytic and generally benign, and which is known as a Meyerson naevus. We report a case of multiple Meyerson naevi revealing melanoma, which itself was surrounded by a halo of eczema.

PATIENTS AND METHODS

A 55-year-old man of phototype III with atopic eczema presented for pruritic eczema present for a fortnight, found solely on and around the naevi on his trunk and at roots of his limbs. One of the melanocytic lesions affected by these Meyerson phenomena was clinically atypical and had been active for several years. Excision confirmed the diagnosis of level II extensive superficial melanoma measuring 0.75 mm in thickness and associated with lesional and perilesional eczematous remodelling. After surgery involving a 1-cm excision margin and local corticosteroid therapy of the eczema, the Meyerson phenomenon subsided with complete remission of the melanoma at 1 year.

DISCUSSION

Meyerson phenomenon can affect one or more naevi at the same time; it is generally transient, may recur on occasion, and has a favourable outcome either spontaneously or with corticosteroid treatment. When not removed for histological verification, the melanocytic lesion regains its initial appearance following resolution of the phenomenon. MP differs from Sutton phenomenon (SP), which is a perinaevic vitiligo reaction leading to complete or partial regression of the melanocytic lesion, which may be either benign or malignant.

CONCLUSION

This case of Meyerson phenomenon revealing melanoma shows that the melanocytic lesions targeted by MP are not necessarily benign.

Calcinosis cutis: a rare reaction to subcutaneous injections of calcium-containing heparin in patients with renal failure

Calcinosis of the cutis and the subcutis is a rare complication of calcium-containing heparin cutaneous injections, mostly occurring in a context of severe renal failure. We report 2 cases. The first patient developed firm erythematous nodules on his thighs and right arm, in a context of disseminated tuberculosis and acute severe renal failure related to human immunodeficiency virus nephropathy. Cutaneous location of tuberculosis was suspected. Histological features allowed to establish the diagnosis of calcinosis of the cutis and the subcutis, showing violaceous and crackled von Kossa-positive calcium deposits in the whole reticular dermis and in thin collagenous septa of subcutaneous tissue. A retrospective inquiry confirmed that subcutaneous injections of calcium-containing heparin had been performed on the sites where lesions occurred. The second patient developed similar lesions at injection sites of calcium-containing heparin, in a context of non-Hodgkin lymphoma and end-stage renal failure. Similar histological features were observed. Calcinosis of the cutis and the subcutis after subcutaneous injections of calcium-containing heparin is rare. It always occurs in a context of elevated calcium-phosphate product, a situation mostly encountered in severe renal failure. Early cutaneous lesions do not bear specific clinical features.

Neonatal and early infantile cutaneous langerhans cell histiocytosis: comparison of self-regressive and non-self-regressive forms

OBJECTIVES

To describe clinical and immunohistochemical findings in patients with cutaneous Langerhans cell histiocytosis (LCH) beginning in the first 3 months of life and to define predictors of disease evolution.

DESIGN

Observational retrospective survey from July 15, 1989, to April 30, 2007.

SETTING

Referral center in pediatric dermatology.

PATIENTS

Thirty-one patients with a diagnosis of cutaneous LCH in the first 3 months of life and no previous visceral LCH.

MAIN OUTCOME MEASURES

Cutaneous lesion characteristics, regulatory T-lymphocyte density, and E-cadherin expression were assessed. Data were compared between the patient groups with self-regressive vs non-self-regressive forms of cutaneous LCH. Pathologic analysis was performed blinded to patient group.

RESULTS

Self-regressive cutaneous LCH was found in 21 patients and non-self-regressive cutaneous LCH in 10 patients. Monolesional forms, necrotic lesions, hypopigmented macules at presentation, and distal topography of limb lesions were seen only in patients with self-regressive cutaneous LCH. Regulatory T-lymphocyte density correlated with interleukin 10 expression in lesions (r = 0.77, P = .003) but was not predictive of disease evolution. E-cadherin expression by Langerhans cells was found in 7 patients with disease limited to the skin whether self-regressive or not. One patient with secondary disseminated disease showed loss of E-cadherin expression in Langerhans cells.

CONCLUSIONS

Some morphologic traits of skin lesions can orient the diagnosis to a self-regressive form of cutaneous LCH. Regulatory T-lymphocyte density does not seem to be predictive of disease evolution. E-cadherin expression seems to be an indicator of limited skin disease but not of disease regression. Additional immunohistochemical study is required to confirm these data.

Sunitinib efficacy in the treatment of metastatic skin adnexal carcinomas: report of two patients with hidradenocarcinoma and trichoblastic carcinoma

BACKGROUND

Adnexal carcinomas are rare and diverse cutaneous tumours. They are locally aggressive and have the potential for distant metastasis. Metastatic adnexal carcinomas are very resistant to conventional chemotherapies. Sunitinib, an oral tyrosine kinase inhibitor, is reportedly effective for the treatment of various solid cancers. Its use in adnexal carcinomas has never been reported.

OBSERVATIONS

The first patient had metastatic clear cell hidradenocarcinoma and was stabilized over 8 months with sunitinib, before she relapsed. The second patient had a metastatic malignant hair follicle tumour (trichoblastic carcinoma) and achieved a partial remission with sunitinib, and disease stabilized after 10 months. Dynamic contrast-enhanced ultrasound (DCE-US) performed to evaluate tumour vascularization during treatment depicted a dramatic and early decrease in the tumour blood volume.

CONCLUSIONS

Sunitinib was effective in controlling the disease in our two patients. DCE-US using linear raw data may have an early predictive value for tumour response to sunitinib. Further studies involving larger cohorts of patients are warranted in order to confirm the efficacy of sunitinib in these rare tumours.

[Cutaneous heterotopic meningeal nodules]

Cutaneous heterotopic meningeal nodules are rare lesions whose pathogenesis remain discussed. They are typically located on the scalp or the rachidian axis. They often are congenital and diagnosed during childhood or young adulthood. There are two admitted theories for pathogenesis of heterotopic meningeal nodules: (1) tumoral proliferation of ectopic arachnoïdal cells (true cutaneous meningioma), (2) meningocele-type developmental defect (rudimentary meningocele). Histological and immunohistochemical aspects are characteristic, showing arachnoidal cells, EMA+ and vimentine+, that infiltrate collagene and whorl around collagene or psammomatous bodies. We report the expression of progesterone receptor (PR) in a cutaneous heterotopic meningeal nodule on the scalp of a 23-year-old man, and propose this PR expression as a new diagnosis tool for such lesions.

Prediction of clinical outcome in multiple lung cancer cohorts by integrative genomics: implications for chemotherapy selection

The role of adjuvant chemotherapy in patients with stage IB non-small-cell lung cancer (NSCLC) is controversial. Identifying patient subgroups with the greatest risk of relapse and, consequently, most likely to benefit from adjuvant treatment thus remains an important clinical challenge. Here, we hypothesized that recurrent patterns of genomic amplifications and deletions in lung tumors could be integrated with gene expression information to establish a robust predictor of clinical outcome in stage IB NSCLC. Using high-resolution microarrays, we generated tandem DNA copy number and gene expression profiles for 85 stage IB lung adenocarcinomas/large cell carcinomas. We identified specific copy number alterations linked to relapse-free survival and selected genes within these regions exhibiting copy number-driven expression to construct a novel integrated signature (IS) capable of predicting clinical outcome in this series (P = 0.02). Importantly, the IS also significantly predicted clinical outcome in two other independent stage I NSCLC cohorts (P = 0.003 and P = 0.025), showing its robustness. In contrast, a more conventional molecular predictor based solely on gene expression, while capable of predicting outcome in the initial series, failed to significantly predict outcome in the two independent data sets. Our results suggest that recurrent copy number alterations, when combined with gene expression information, can be successfully used to create robust predictors of clinical outcome in early-stage NSCLC. The utility of the IS in identifying early-stage NSCLC patients as candidates for adjuvant treatment should be further evaluated in a clinical trial.

Information sources for medical waste management

Although many hospital professionals now have personal access to online databases, popular communications services may not have the full range of electronic services needed for technical problem solving. Librarians are practiced at cross-disciplinary technical research and so health professionals may be best served by consulting an experienced database search analyst so that important information is not accidentally missed. Additionally, many commercially produced databases have repackaged and redistributed data developed by NIOSH and other federal agencies, data that are readily available in the public sector. The cost of accessing or purchasing commercial databases is usually higher than for federal databases, though commercial products use the federal databases to develop their products. Public agencies should always be consulted to obtain the most current information issued by those bodies and also because a variety of free and low-cost support materials may be available. Because of the expense of routinely consulting electronic databases when comparable printed materials may be available at a lower cost, a small reference collection of books, journals, and audiovisuals may be desirable. A selective print reference collection is found in Appendix A.