Recent developments in the therapy of localized and systemic sclerosis

Scleroderma: An insight into causes, pathogenesis and treatment strategies

Scleroderma is an autoimmune disorder, characterized by morphological changes in skin followed by visceral organs. The pathogenesis of scleroderma involves immune imbalance and generation of auto antibodies. The major causes of scleroderma include multitude of factors such as immune imbalance, oxidative stress, genetics and environment factors. A constant effort has been made to treat scleroderma through different approaches and necessitates life time administration of drugs for maintenance of a good quality life. It has been reported more in women compared to men. Traditional treatment strategies are restricted by limited therapeutic capability due to associated side effects. Advancement in development of novel drug delivery approaches has opened a newer avenue for efficient therapy. Current review is an effort to reflect scleroderma in provisions of its pathogenesis, causative factors, and therapeutic approaches, with concern to mode of action, pharmacokinetics, marketed products, and side effects of drugs.

Immunophenotypic correlation between skin biopsy and peripheral blood findings in mycosis fungoides

In mycosis fungoides (MF) with blood involvement, T-cell immunophenotypes in skin and blood have not been compared. Our aim was to evaluate T-cell immunophenotypes in skin by immunohistochemical analysis and compare results with flow cytometric (FC) findings in blood. Of 20 patients with MF with blood involvement, the immunophenotype was discrepant in 11 (55%). Compared with FC findings in blood, immunohistochemical analysis of skin samples failed to detect partial deletion of CD2 (5/11 [45%]), CD3 (3/11 [27%]), and CD5 (3/11 [27%]) and overrepresented deletion of CD7 in 2 (18%) of 11 patients. In addition, CD8+ MF was missed by immunohistochemical analysis in 2 (18%) of 11 patients. Identical T-cell populations were demonstrated by T-cell gene polymerase chain reaction in skin and blood in 8 of the 11 patients who had a discrepant immunophenotype. Awareness of the limitations of immunohistochemical analysis of skin samples is of practical value for pathologists interpreting skin biopsies in MF patients. In addition, our findings suggest CD8+ MF to be more common than previously reported.

WHO/EORTC classification of cutaneous lymphomas 2005: histological and molecular aspects

The new WHO/EORTC classification for cutaneous lymphomas comprises mature T-cell and natural killer (NK)-cell neoplasms, mature B-cell neoplasms, and immature hematopoietic malignancies. It reflects the unique features of lymphoproliferative diseases of the skin, and at the same time it is as compatible as possible with the concepts underlying the WHO classification for nodal lymphomas and the EORTC classification of cutaneous lymphomas. This article reviews the histological, phenotypical, and molecular genetic features of the various nosological entities included in this new classification. These findings always have to be interpreted in the context of the clinical features and biologic behavior.

AIM

To review the histological, phenotypical and molecular genetic features of the various nosological entities of the new WHO/EORTC classification for cutaneous lymphomas.

METHODS

Extensive review of the literature cited in Medline and own data of the authors.

RESULTS

The WHO/EORTC classification of cutaneous lymphomas comprises mature T-cell and NK-cell neoplasms, mature B-cell neoplasms and immature hematopoietic malignancies. It reflects the unique features of primary cutaneous lymphoproliferative diseases.

CONCLUSION

This classification is as much as possible compatible with the concept of the WHO classification for nodal lymphomas and the EORTC classification of cutaneous lymphomas. The histological, phenotypical and molecular genetic features always have to be interpreted in the context of the clinical features and biologic behavior.

A simple clinical scoring system to improve the sensitivity and standardization of the diagnosis of mycosis fungoides type cutaneous T-cell lymphoma: logistic regression of clinical and laboratory data

BACKGROUND

The diagnosis of mycosis fungoides (MF) is notoriously difficult to establish because in the early stages, histological features may be nonspecific or merely suggestive.

OBJECTIVES

To standardize the diagnosis of MF.

METHODS

We studied 138 patients with suspected MF referred over a 7-year period to a university department of a dermatology-based cutaneous lymphoma clinic. Six diagnostic criteria were evaluated: clinical morphology, clinical distribution, skin biopsy T-cell receptor gene rearrangement (TCR-GR), skin biopsy pan T-cell marker loss > or = 2, skin biopsy CD4/CD8 ratio > or = 6, and skin biopsy diffuse epidermal HLA-DR expression. These six clinical and laboratory criteria were compared by logistic regression analysis in patients with histologically diagnosed MF and those with benign disease.

RESULTS

Of the 138 patients, 74 had histology of MF, 47 of benign dermatoses and 17 were indeterminate. Close associations were found between a histological diagnosis of MF and TCR-GR (odds ratio 14.4), classical morphology (7.5), classical distribution (2.5) and diffuse epidermal HLA-DR expression (2.8). Logistic regression models were developed depending on the availability of data (either TCR-GR or HLA-DR). Probabilities for correctly diagnosing MF compared with histology as the 'gold standard' were derived from these logistic regression models. A scoring system assigning point values based on these probabilities was then created in order to assist the clinician in making the diagnosis. If using TCR-GR data, a positive TCR-GR = 2.5 points, the presence of classical morphology = 2.0 points, and the presence of classical distribution = 1.5 points. A total score of > or = 3.5 points assigns a high probability (> 85%) of having MF. If using HLA-DR expression, then the presence of classical morphology = 2.5 points, a positive diffuse epidermal HLA-DR expression = 2.0 points, and the presence of classical distribution = 1.5 points. In this case, a total score of > or = 4.0 points assigns a high probability (> 85%) of MF.

CONCLUSIONS

The logistic regression models and scoring systems integrate clinical and laboratory assessments, allow rapid probability estimation, and provide a threshold for the diagnosis of MF in an objective, standardized manner.

Criterion by criterion, mycosis fungoides

A wide variety of histologic features have been associated with mycosis fungoides. Virtually all these features can be seen at least episodically in some inflammatory conditions, and little is known regarding which histologic features are most useful in establishing a diagnosis of this challenging condition. Three recent blind histologic studies have addressed this topic, however, and their results and those of other studies are reviewed and compared herein.

Experts and gold standards in dermatopathology: qualitative and quantitative analysis of the self-assessment slide seminar at the 17th colloquium of the International Society of Dermatopathology

The diagnosis of lymphoproliferative and melanocytic skin lesions is one of the most vexing problems in dermatopathology, a problem that is compounded by the far-reaching therapeutic and psychosocial consequences of the diagnosis for both patient and physician. On the occasion of a self-assessment slide seminar held during a dermatopathology meeting, 30 unusual lymphoproliferative and melanocytic lesions, each provided with four differential diagnoses, were evaluated by "expert pathologists" and other participants ("nonexperts") of the slide seminar. The final diagnosis was pinpointed by the majority of the experts in 16 of 30 cases (56%). The group of experts returned an unanimous decision on the diagnosis in only 2 of the 30 cases (7%). In contrast to the expert group, the preferred diagnoses given by the nonexperts showed a wider range. In 20 of 30 cases (66%), the final diagnosis could only be established after consideration of clinical, histologic, immunophenotypic, and molecular features. Our findings agree with the results of recent studies indicating quite a high degree of discordance among expert pathologists. The discordance between experts and, to a higher extent, nonexperts may have some crucial consequences for dermatopathology. Full agreement on diagnosis, particularly in unusual skin lesions, cannot be achieved only by an accumulation of expertises. Instead of relying on one single finding or diagnostic procedure ("gold standard") as the main criterion upon which to base a diagnosis, the diagnoses become more reliable if based on the integration of several factors including an evaluation of clinical and histomorphologic features and immunophenotypic and molecular findings ("diagnostic elements"), particularly in the field of lymphoproliferative and melanocytic lesions. In addition, a continuous retrospective work-up of difficult or unusual cases is recommended to ensure a long-term improvement in diagnostic reliability.