Severe Esophageal Lichen Planus Treated With Tofacitinib

Lichen planus is a chronic inflammatory immune disorder that most commonly affects the skin and mucous membranes. Esophageal lichen planus (ELP) is a frequently misdiagnosed and poorly understood form of lichen planus that can be asymptomatic or present with dysphagia and odynophagia caused by the formation of erosions and strictures in the esophagus. These strictures often reduce a patient's quality of life and may lead to emaciation in more severe cases. We present the case of an 89-year-old woman with a history of cutaneous lichen planus (CLP) and mucosal lichen planus that were successfully managed with topical corticosteroids and oral cyclosporine rinses who presented with an esophageal stricture and erosions that were treated unsuccessfully with surgery. Our patient's condition continued to worsen until she presented in an emaciated state and was treated with tofacitinib, which resulted in complete resolution of oral lichen planus (OLP), ELP, and genital lichen planus.

Human Polyomavirus 9-An Emerging Cutaneous and Pulmonary Pathogen in Solid Organ Transplant Recipients

IMPORTANCE

We describe the first report to our knowledge of cutaneous and systemic pathogenicity of human polyomavirus 9 in solid organ transplant recipients.

OBJECTIVE

Three solid organ transplant recipients developed a widespread, progressive, violaceous, and hyperkeratotic skin eruption. All died from pulmonary and multiorgan failure around 1 year from onset of the rash. Routine clinical diagnostic testing could not identify any causative agent; therefore, samples and autopsies were investigated for novel pathogens using high-throughput sequencing.

DESIGN, SETTING, AND PARTICIPANTS

This case series, including 3 solid organ transplant recipients who developed characteristic pink, violaceous, or brown hyperkeratotic papules and plaques throughout the body, was conducted at the Columbia University Medical Center. Lesional skin biopsies were collected from all 3 patients and subjected to high-throughput illumina sequencing for identification of microbial pathogens. Human polyomavirus 9 was identified in lesional skin biopsies. We subsequently collected ocular swabs, oral swabs, urine samples, and blood samples from patients, and organ tissues at autopsy in 1 patient. We investigated these samples for the presence of human polyomavirus 9 using in situ hybridization and quantitative polymerase chain reaction (PCR) assays.

MAIN OUTCOMES AND MEASURES

A description of the clinical and pathologic findings of 3 patients.

RESULTS

This case series study found that human polyomavirus 9 was detected in the skin biopsies of all 3 patients by a capture-based high-throughput sequencing method platform (VirCapSeq-VERT). Human polyomavirus 9 was also detected in blood, oral, ocular swabs, and urine by real-time polymerase chain reaction (PCR) assay. In situ hybridization and quantitative PCR assays were performed on the skin biopsies from 3 patients and lung autopsy of 1 patient, which showed the presence of human polyomavirus 9 messenger RNA transcripts, indicating active viral replication and pathogenesis in the skin and lungs.

CONCLUSIONS AND RELEVANCE

Human polyomavirus 9 was associated with the widespread cutaneous eruption. All 3 patients had progression of cutaneous disease, accompanied by clinical deterioration, pulmonary failure, and death. One patient underwent autopsy and human polyomavirus 9 was identified in the lungs and paratracheal soft tissue. These findings suggest that human polyomavirus 9 may be associated with cutaneous and possibly pulmonary infection and death in solid organ transplant recipients.

Unique histopathologic features of the eyelid dermatofibroma

Purpose: Dermatofibromas are common cutaneous lesions, but rarely occur in the eyelid skin. The reason for the low incidence in the palpebral skin has not been elucidated. In this study, we analyze the histopathologic features of an illustrative case of dermatofibroma and review previously published cases to determine whether eyelid dermatofibroma develops differently from the prototypical dermatofibroma. Methods: Histopathologic analysis of a new illustrative case of eyelid dermatofibroma and retrospective review of published cases. Results: The distinguishing features of the illustrative lesion included a rounder gross appearance, nonacanthotic epithelium, basophilic staining, cellular character, and a paucity of "collagen trapping." These features deviated from the typical features associated with classic dermatofibroma. Review of the 11 previously published cases of eyelid dermatofibroma revealed that they were more similar in appearance to the illustrative lesion than to classic dermatofibroma. Discussion: The rarity and histological deviations of the eyelid dermatofibroma suggest that the dermal substrate from which the lesion develops differs from that of the classic dermatofibroma. This difference may be explained microanatomically based on the fact that the dermis of the eyelid is predominantly papillary, whereas the dermis of extrapalpebral skin where dermatofibromas are more common is predominantly reticular. Conclusions: Although related, eyelid dermatofibromas appear to be histologically distinct from classic dermatofibromas, owing to the unique dermal composition of the site of origin.

Genomic Characterization of Dysplastic Nevi Unveils Implications for Diagnosis of Melanoma

A well-defined risk factor and precursor for cutaneous melanoma is the dysplastic nevus. These benign tumors represent clonal hyperproliferation of melanocytes that are in a senescent-like state, but with occasional malignant transformation events. To portray the mutational repertoire of dysplastic nevi in patients with the dysplastic nevus syndrome and to determine the discriminatory profiles of melanocytic nevi (including dysplastic nevi) from melanoma, we sequenced exomes of melanocytic nevi including dysplastic nevi (n = 19), followed by a targeted gene panel (785 genes) characterization of melanocytic nevi (n = 46) and primary melanomas (n = 42). Exome sequencing revealed that dysplastic nevi harbored a substantially lower mutational load than melanomas (21 protein-changing mutations versus >100). Known "driver" mutations in genes for melanoma, including CDKN2A, TP53, NF1, RAC1, and PTEN, were not found among any melanocytic nevi sequenced. Additionally, melanocytic nevi including dysplastic nevi showed a significantly lower frequency and a different UV-associated mutational signature. These results show that although melanocytic nevi and dysplastic nevi harbor stable genomes with relatively few alterations, progression into melanomas requires additional mutational processes affecting key tumor suppressors. This study identifies molecular parameters that could be useful for diagnostic platforms.

Clinical efficacy of short contact topical 5-Fluorouracil in the treatment of keratoacanthomas: a retrospective analysis

OBJECTIVE

To determine the efficacy of treating patients with a recent onset, biopsy-proven keratoacanthoma with short-contact topical 5% 5-fluorouracil cream twice daily until resolution.

DESIGN

Chart review of 10 patients who applied 5% 5-fluorouracil for the treatment of biopsy-proven keratoacanthoma.

SETTING

Outpatient clinic of a board-certified dermatologist.

PARTICIPANTS

The study population was 90-percent women (9/10), 10-percent men (1/10) and ranged in ages from 52 to 92 years old with a mean age of 74.4.

MEASUREMENTS

Patients were followed for weekly visits for the duration of their treatment and at varying, less-frequent intervals after resolution of the lesion clinically. Photographs were taken at each visit.

RESULTS

The authors performed a retrospective analysis of 10 patients with biopsy-confirmed keratoacanthomas treated with topical 5-fluorouracil. One patient elected to have Mohs surgery after one week of topical 5-fluorouracil due to personal concern and cosmetic appearance and did not complain of any side effects due to the drug. Of the nine patients that remained on topical 5-fluorouracil, all patients had complete resolution of the lesion within six weeks. The range in the number of weeks to resolution was four to six weeks. Two patients required a one- to two-week drug holiday secondary to erythema, which resolved without any further complication or patient discomfort. All nine patients who continued therapy reported satisfaction with the results and showed excellent compliance with treatment.

CONCLUSION

Short-contact topical 5% 5-fluorouracil appears to provide excellent cosmetic results and is well-tolerated by patients. This should be an initial consideration for the treatment of keratoacanthomas and does not preclude future surgical intervention if deemed necessary.

A tumor suppressor function for the lipid phosphatase INPP4B in melanocytic neoplasms

The phosphoinositide-3 kinase (PI3K) pathway is deregulated in a significant proportion of melanomas, and PI3K pathway activation in combination with constitutively active mitogen-activated protein kinase signaling shows synergistic effects in the process of melanoma tumorigenesis. Recently, a tumor suppressor function for the lipid phosphatase inositol polyphosphate 4-phosphatase type II (INPP4B) has been described in breast and prostate cancers, with impact on PI3K signaling output. Given the importance of PI3K pathway activity for melanoma formation and growth, we aimed to assess the role of INPP4B in melanocytic tumors. Our studies in native tumors suggest that decreased INPP4B expression is an event correlating with tumor progression in melanocytic neoplasms. We further demonstrate that INPP4B regulates PI3K/Akt signaling and exerts a tumor suppressor effect, impacting the proliferative, invasive, and tumorigenic capacity of melanoma cells. INPP4B expression in melanocytic neoplasms may therefore have potential as a biomarker for disease progression and as a modulator for the prediction of treatment outcome.

9p21 gene locus in Spitz nevi of older individuals: absence of cytogenetic and immunohistochemical findings associated with malignancy

The diagnosis of Spitz nevus in an elderly individual is often met with skepticism because the lesion can be difficult to distinguish from melanoma and because the probability of a malignant melanoma is higher in older patients. Recently, increased sensitivity for detection of malignant spitzoid neoplasms using 9p21 fluorescence in situ hybridization (FISH) has been described. In this study, we address the question of whether histopathologically typical Spitz nevi occurring in patients 50 years and older show any abnormalities regarding the 9p21 CDKN2A tumor suppressor gene locus. p16 immunohistochemistry (IHC), as well as dual-color FISH for assessment of diploid or hypodiploid status at 9p21, was performed in 25 classic Spitz nevi from patients 50 years and older and was compared with findings in a younger control population. All cases of typical Spitz nevi occurring in older patients retained p16 expression by immunohistochemistry and showed normal, diploid 9p21 FISH signals. Heterozygous loss of 9p21 by FISH was noted in a control case of a 9-year-old girl and is of unknown significance. These findings indicate that p16 expression by immunohistochemistry in classic Spitz nevi correlates well with absence of malignancy-associated cytogenetic abnormalities at 9p21 by FISH independent of the patient's age. Assessment of p16 expression by standard immunohistochemistry may therefore be reassuring in routine clinical practice when the patient is of advanced age, and can be helpful as a screening tool to select IHC-negative cases for extended FISH analysis targeting the 9p21 gene locus.

GAB2 induces tumor angiogenesis in NRAS-driven melanoma

GAB2 is a scaffold protein with diverse upstream and downstream effectors. MAPK and PI3K signaling pathways are known effectors of GAB2. It is amplified and overexpressed in a variety of human tumors including melanoma. Here we show a previously undescribed role for GAB2 in NRAS-driven melanoma. Specifically, we found that GAB2 is co-expressed with mutant NRAS in melanoma cell lines and tumor samples and its expression correlated with metastatic potential. Co-expression of GAB2(WT) and NRAS(G12D) in melanocytes and in melanoma cells increased anchorage-independent growth by providing GAB2-expressing cells a survival advantage through upregulation of BCL-2 family of anti-apoptotic factors. Of note, collaboration of GAB2 with mutant NRAS enhanced tumorigenesis in vivo and led to an increased vessel density with strong CD34 and VEGFR2 activity. We found that GAB2 facilitiated an angiogenic switch by upregulating HIF-1α and VEGF levels. This angiogenic response was significantly suppressed with the MEK inhibitor PD325901. These data suggest that GAB2-mediated signaling cascades collaborate with NRAS-driven downstream activation for conferring an aggressive phenotype in melanoma. Second, we show that GAB2/NRAS signaling axis is non-linear and non-redundant in melanocytes and melanoma, and thus are acting independent of each other. Finally, we establish a link between GAB2 and angiogenesis in melanoma for the first time. In conclusion, our findings provide evidence that GAB2 is a novel regulator of tumor angiogenesis in NRAS-driven melanoma through regulation of HIF-1α and VEGF expressions mediated by RAS-RAF-MEK-ERK signaling.

GAB2 amplifications refine molecular classification of melanoma

PURPOSE

Gain-of-function mutations in BRAF, NRAS, or KIT are associated with distinct melanoma subtypes with KIT mutations and/or copy number changes frequently observed among melanomas arising from sun-protected sites, such as acral skin (palms, soles, and nail bed) and mucous membranes. GAB2 has recently been implicated in melanoma pathogenesis, and increased copy numbers are found in a subset of melanomas. We sought to determine the association of increased copy numbers of GAB2 among melanoma subtypes in the context of genetic alterations in BRAF, NRAS, and KIT.

EXPERIMENTAL DESIGN

A total of 85 melanomas arising from sun-protected (n = 23) and sun-exposed sites (n = 62) were analyzed for copy number changes using array-based comparative genomic hybridization and for gain-of-function mutations in BRAF, NRAS, and KIT.

RESULTS

GAB2 amplifications were found in 9% of the cases and were associated with melanomas arising from acral and mucosal sites (P = 0.005). Increased copy numbers of the KIT locus were observed in 6% of the cases. The overall mutation frequencies for BRAF and NRAS were 43.5% and 14%, respectively, and were mutually exclusive. Among the acral and mucosal melanomas studied, the genetic alteration frequency was 26% for GAB2, 13% for KIT, 30% for BRAF, and 4% for NRAS. Importantly, the majority of GAB2 amplifications occurred independent from genetic events in BRAF, NRAS, and KIT.

CONCLUSIONS

GAB2 amplification is critical for melanomas arising from sun-protected sites. Genetic alterations in GAB2 will help refine the molecular classification of melanomas.

Acquired ichthyosis with systemic lupus erythematosus: both dermatoses in a single skin biopsy specimen

Acquired ichthyosis (AI) in association with systemic lupus erythematosus (SLE) is a rare dermatologic finding, with only 7 previously published cases worldwide. We report a 25-year-old black woman with AI associated with SLE. A skin biopsy specimen from the lower extremity showed histologic changes consistent with both ichthyosis vulgaris and SLE, a unique finding that has not been previously reported. We also review the world literature on AI and SLE.

Influence of age on survival in childhood spitzoid melanomas

BACKGROUND

Melanoma occurring during childhood and adolescence is rare. Although a few limited studies suggest that the prognosis of childhood melanomas is similar to those in adults, and is dependent on the initial stage of the tumor, there is controversy with respect to the biologic behavior of childhood melanomas. Spitzoid melanoma is a subtype of melanoma with distinct clinical and histopathologic features. The prognosis of spitzoid melanoma in children, despite metastasis, has been suggested to be better than that observed in adults; however, this assertion remains controversial. Whereas a number of spitzoid melanomas with regional lymph node metastasis with no further progression have been reported, cases leading to widespread metastasis and fatal outcomes are also well documented.

METHODS

A retrospective review of the literature was conducted between 1949 and 2006. A total of 82 cases of spitzoid melanoma with regional and/or widespread metastasis that occurred in children, 17 years of age and under, were selected for the analysis.

RESULTS

The 5-year survival rate in children diagnosed with metastatic spitzoid melanomas between 0 and 10 years of age was 88% compared with 49% in those between 11 and 17 years of age.

CONCLUSIONS

The findings support the notion that younger age (< or =10) may be associated with longer survival in children with metastatic spitzoid melanomas.

Melanotic macule of nail unit and its clinicopathologic spectrum

The clinical and histologic spectrum of melanotic macule of the nail unit is examined and the differences in the clinical appearance of longitudinal melanochychia caused by melanotic macule and by other kinds of proliferations of melanocytes are assessed. We observed that the clinical appearance of the pigmented band was of little help in establishing the underlying basic pathologic process. This underscores the importance of obtaining a biopsy of the nail matrix in patients who present with solitary longitudinal melanonychia.

Late Syphilis in a Cardiac Transplant Patient

Patients undergoing cardiac transplantation are routinely screened for prior exposure to Treponema pallidum, the bacterium implicated in syphilis. Although acute syphilis typically presents with a painless genital chancre, chronic syphilis can manifest in protean forms and linger undiagnosed. Left untreated, syphilis can cause multi-system disease, particularly irreversible neurologic damage. We describe a case of cutaneous secondary syphilis, neurosyphilis and luetic hepatitis in a cardiac transplant patient.

Are all melanomas the same?

BACKGROUND

Although the majority of melanomas demonstrate high rates of mutations in B-RAF or N-RAS that result in constitutive activation of the mitogen-activated protein kinase-signaling pathway, emerging data suggest molecular differences among melanoma subtypes. In this study, the authors evaluated the contribution of B-RAF and N-RAS mutations to the pathogenesis of Spitzoid melanomas.

METHODS

In total, 33 Spitzoid melanomas were analyzed for clinical and pathologic characteristics as well as for hot-spot mutations in the B-RAF and N-RAS genes. In the majority of patients (28 of 33 melanomas), the tumors were confined to the skin with no evidence of metastasis (average follow-up, 32.5 mos). There were five metastasizing melanomas (5 of 33 tumors) with regional or systemic spread.

RESULTS

Of 33 Spitzoid melanomas, only 1 showed the V600E mutation in the B-RAF gene (1 of 33 tumors; 3%). It was noteworthy that none of the metastatic Spitzoid melanomas (0 of 5 tumors; 0%), of which 2 resulted in fatal outcomes, demonstrated mutations in B-RAF or N-RAS.

CONCLUSIONS

In contrast to the majority of cutaneous melanomas, activating hot-spot mutations in B-RAF or N-RAS were not involved in the pathogenesis of Spitzoid melanoma. These data suggested that Spitzoid melanoma is a distinct form of melanoma with unknown genes and/or signaling pathways involved in its development.

Genetic similarities between Spitz nevus and Spitzoid melanoma in children

BACKGROUND

Melanoma in children is rare. Diagnosis of the subtype of melanoma known as Spitzoid melanoma can be extremely challenging in this age group. Spitzoid melanoma clinically and histopathologically resembles a benign melanocytic proliferation referred to as Spitz nevus. In some cases, distinction between the two is impossible. Initial misdiagnoses of Spitzoid melanomas as Spitz nevi, thus leading to fatal outcomes, have occurred. The genetic basis and biologic behavior of Spitzoid melanoma is unknown. Although melanoma specimens exhibit high rates of mutation in the B-RAF and N-RAS genes, the Spitzoid melanoma subtype has not been evaluated. Spitz nevi have been found to be associated with a low percentage of mutations in the H-RAS gene; however, the mutational profile of H-RAS in Spitzoid melanoma is unknown.

METHODS

The authors evaluated a unique series of melanomas occurring in prepubescent children that showed Spitz nevus-like histopathology (Spitzoid melanoma). All of the melanomas in the current series have metastasized to lymph nodes, confirming the diagnosis of melanoma. The authors examined these tumors, as well as age-matched Spitz nevi, for mutations in the B-RAF, N-RAS, and H-RAS genes.

RESULTS

Activating hotspot mutations in the B-RAF, N-RAS, and H-RAS genes were not identified in Spitzoid melanoma or Spitz nevus specimens.

CONCLUSIONS

There are genetic similarities with respect to the B-RAF, N-RAS, and H-RAS genes between Spitzoid melanoma and Spitz nevi. Such similarities further differentiate these two tumor types from other melanoma subtypes and from melanocytic nevi, respectively. However, mutation analysis of B-RAF, N-RAS, and H-RAS was not useful in differentiating between Spitzoid melanoma and Spitz nevus in children.

Increased detection of rickettsialpox in a New York City hospital following the anthrax outbreak of 2001: use of immunohistochemistry for the rapid confirmation of cases in an era of bioterrorism

BACKGROUND

Rickettsialpox is a self-limited febrile illness with skin lesions that may be mistaken for signs of potentially more serious diseases, such as cutaneous anthrax or chickenpox. The cluster of cutaneous anthrax cases from bioterrorism in October 2001 likely heightened awareness of and concern for cutaneous eschars.

OBJECTIVES

To apply an immunohistochemical technique on paraffin-embedded skin biopsy specimens for diagnosing rickettsialpox, and to compare the reported incidence of rickettsialpox before, during, and after the cluster of cutaneous anthrax cases.

DESIGN

Case series.

SETTING

Dermatology department in a large tertiary care hospital in New York City.

PATIENTS

Eighteen consecutive patients with the clinical diagnosis of rickettsialpox from February 23, 2001, through October 31, 2002.

MAIN OUTCOME MEASURES

Results of immunohistochemical testing of skin biopsy specimens and of serological testing.

RESULTS

Immunohistochemical testing revealed spotted fever group rickettsiae in all 16 eschars and in 5 of the 9 papulovesicles tested. A 4-fold or greater increase in IgG antibody titers reactive with Rickettsia akari was observed in all 9 patients for whom acute and convalescent phase samples were available; 6 patients had single titers indicative of rickettsialpox infection (> or =1:64). Of the 18 patients, 9 (50%) presented in the 5 months following the bioterrorism attacks.

CONCLUSIONS

Rickettsialpox remains endemic in New York City, and the bioterrorism attacks of October 2001 may have led to increased awareness and detection of this disease. Because rickettsialpox may be confused with more serious diseases, such as cutaneous anthrax or chickenpox, clinicians should be familiar with its clinical presentation and diagnostic features. Immunohistochemical staining of skin biopsy specimens, particularly from eschars, is a sensitive technique for confirming the clinical diagnosis.

Periungual myxoid neurofibroma

A 34-year-old woman presented with a slow growing nontender nodule on her left index finger that had been present for 2 years. The tumor was excised and was histologically determined to be a myxoid neurofibroma. We report this case because of the rarity of both the tumor and its periungual location and to provide a review of the literature.

PTCH mutations in squamous cell carcinoma of the skin

Ultraviolet light exposure is the major risk factor for the development of squamous cell carcinoma in Caucasians. Mutations in the tumor suppressor gene p53 have been identified in both squamous cell carcinomas and basal cell carcinomas. The human homolog of the Drosophila patched gene, has been shown to be mutated in sporadic basal cell carcinomas; however, mutations in the patched gene have not been found in squamous cell carcinoma. In this study, we screened a total of 20 squamous cell carcinoma samples for mutations in the patched gene. Using polymerase chain reaction-single strand conformation polymorphism as an initial screening method, we identified one non-sense mutation, two mis-sense mutations and three silent mutations in five squamous cell carcinoma samples. In one squamous cell carcinoma sample, we identified a tandem GG-->AA transitional change at nucleotide 3152 in exon 18 of the patched gene that resulted in a premature stop codon at codon 1051. The three squamous cell carcinoma samples containing non-sense and mis-sense mutations were isolated from individuals with histories of multiple basal cell carcinoma. Sequence analysis of the p53 gene in these five squamous cell carcinoma samples identified one CC-->TT and three C-->T ultraviolet-specific nucleotide changes. Our study provides evidence that the patched gene is mutated in squamous cell carcinoma from individuals with a history of multiple basal cell carcinoma. The identification of ultraviolet-specific nucleotide changes in both tumor suppressor genes supports the notion that ultraviolet exposure plays an important part in the development of squamous cell carcinoma.

Role of PTCH and p53 genes in early-onset basal cell carcinoma

Basal cell carcinoma (BCC) is the most common skin cancer in the Western world. Ultraviolet (UV) exposure, race, age, gender, and decreased DNA repair capacity are known risk factors for the development of BCC. Of these, UVB irradiation from sunlight is the most significant risk factor. The incidence of sporadic BCC increases in individuals older than age 55, with the greatest incidence reported in individuals who are older than 70, and is rare in individuals who are younger than 30. In this study, we analyzed 24 BCC samples from individuals who had BCC diagnosed by the age of 30. Fifteen single-stranded conformation polymorphism variants in the PTCH gene were identified in 13 BCC samples. Sequence analysis of these single-stranded conformation polymorphism variants revealed 13 single nucleotide changes, one AT insertion, and one 15-bp deletion. Most of these nucleotide changes (nine of 15) were predicted to result in truncated PTCH proteins. Fifteen p53 mutations were also found in 11 of the 24 BCC samples. Thirty-three percent (five of 15) and 60% (nine of 15) of the nucleotide changes in the PTCH and p53 genes, respectively, were UV-specific C-->T and CC-->TT nucleotide changes. Our data demonstrate that the p53 and PTCH genes are both implicated in the development of early-onset BCC. The identification of UV-specific nucleotide changes in both tumor suppressor genes suggests that UV exposure is an important risk factor in early onset of BCC.

Identification of PTEN mutations in metastatic melanoma specimens

CONTEXT

PTEN, a tumour suppressor gene located on chromosome 10q23, develops somatic mutations in various tumours and tumour cell lines including brain, endometrium, prostate, breast, kidney, thyroid, liver, and melanoma.

OBJECTIVES

To investigate the mutational profile of this gene further, as well as its role in tumour progression in melanoma. DESIGN, SETTINGS: We examined 21 metastatic melanoma samples for 10q23 allelic losses and PTEN sequence alterations. Additionally, we screened these samples for mutations in CDKN2A, a gene in which alterations are well documented in primary melanoma as well as in the germline of familial melanoma.

RESULTS

Loss of heterozygosity (LOH) at 10q23 was observed in 33% (7/21) of the samples tested. We identified four sequence alterations in PTEN (19%) and two in CDKN2A (9.5%). Of interest, only one case showed mutations in both genes.

CONCLUSIONS

These data support the notion that PTEN alterations occur in some metastatic melanomas, and that mutation of this gene plays a role in the progression of some forms of melanoma.

Varicella-zoster virus proteins in skin lesions: implications for a novel role of ORF29p in chickenpox

Skin biopsy samples from varicella-zoster virus (VZV)-infected patients examined by immunohistochemistry demonstrated VZV replication in nonepithelial cell types. ORF29p, a nonstructural nuclear protein, was found in nerves of two of six patients with chickenpox. In tissue culture, ORF29p was secreted by VZV-infected fibroblasts. Extracellular ORF29p can be taken up through endocytosis by human neurons, implying a novel role for this protein in pathogenesis.

Invasive squamous cell carcinoma with sporotrichoid metastasis in a patient with cutaneous T cell lymphoma treated with chronic extracorporeal photopheresis

An 83-year-old Caucasian man with cutaneous T-cell lymphoma developed an aggressive squamous cell carcinoma of the left forearm, which recurred and metastasized after Mohs micrographic surgery and systemic chemotherapy with cis-platin and 5-fluorouracil. He was treated with extracorporeal photopheresis, radiation therapy, PUVA photochemotherapy, and interferon therapy for cutaneous T-cell lymphoma. Aggressive squamous cell carcinoma can occur in the setting of extracorporeal photopheresis.

A comparison of frozen and paraffin sections in dermatofibrosarcoma protuberans

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a tumor with a high local reoccurrence rate. Mohs micrographic surgery offers the highest cure rate. However, differentiating minimal residual tumor from normal skin can be difficult during Mohs surgery.

OBJECTIVE

To clarify the problem of determining when a tumor-free plane had been achieved during Mohs surgery for a DFSP.

METHODS

In two patients with DFSPs, we compared frozen and paraffin-embedded sections extending from tumor to normal skin, using both H&E and CD34 stains.

RESULTS

On frozen, but not paraffin-embedded, sections scattered dermal spindle cells were seen in normal skin.

CONCLUSIONS

Scattered dermal spindle cells in the dermis of normal skin make it difficult to differentiate minimal residual tumor from normal dermis during Mohs surgery. A biopsy of normal skin can be useful as a control in this setting.

Detection of clonal T-cell receptor gamma chain gene rearrangements by polymerase chain reaction and denaturing gradient gel electrophoresis (PCR/DGGE) in archival specimens from patients with early cutaneous T-cell lymphoma: correlation of histologic findings with PCR/DGGE

BACKGROUND

Early stages of cutaneous T-cell lymphoma (CTCL) may be difficult to distinguish from benign inflammatory dermatoses by routine histologic examination.

OBJECTIVE

Our purpose was to determine whether clonal rearrangements of the T-cell receptor (TCR) gamma gene by polymerase chain reaction and denaturing gradient gel electrophoresis (PCR/DGGE) could be detected in the early stages of CTCL and to correlate these findings with conventional histopathology.

METHODS

A total of 39 specimens from 12 patients with CTCL were obtained. The slides were evaluated independently by three dermatopathologists, and categorized into three groups: nondiagnostic, suggestive of CTCL, and diagnostic of CTCL. Of the 39 specimens, 33 were tested by PCR/DGGE by means of GC-clamped primers for clonal rearrangement of the TCR gamma gene.

RESULTS

The histologic evaluation of the 12 cases showed a significant variation among the three dermatopathologists. The correlation of PCR/DGGE with routine histology was as follows: Clonal TCR gamma gene rearrangements were demonstrated in 73% of the specimens nondiagnostic for CTCL, 71% of those suggestive of CTCL, and 74% of those diagnostic of CTCL.

CONCLUSION

Clonal TCR gamma gene rearrangements may be detected in patients with early CTCL, even when the histologic findings are not unequivocally diagnostic. In patients with multiple biopsy specimens, identical clones were demonstrated in all rearranged samples, indicating the same neoplastic clone was present in the earliest stages of disease.

In situ hybridization detection of varicella zoster virus in paraffin-embedded skin biopsy samples

BACKGROUND

When virologic and molecular diagnostic techniques are unavailable, the diagnosis of varicella zoster virus (VZV) infection depends on clinical criteria and histologic evaluation of skin biopsy specimens or Tzank preparations. These methods can misdiagnose chickenpox and zoster, particularly when the clinical manifestations are atypical.

OBJECTIVE

To improve diagnosis in these settings, we developed an in situ hybridization technique for the detection of VZV utilizing a fluorescein-labeled oligonucleotide probe visualized with anti-fluorescein alkaline phosphatase-conjugated antibody.

STUDY DESIGN

We retrospectively examined 26 paraffin-embedded skin biopsy specimens with histologic features consistent with VZV or herpes simplex virus (HSV) infection and 11 control cases by in situ hybridization. In situ hybridization for VZV and HSV-1 was compared with polymerase chain reaction (PCR) for VZV and HSV-1 and clinical and histologic examination.

RESULTS

Thirteen of the 26 study cases and two of the 11 control cases were positive for VZV by in situ hybridization. When compared with PCR, in situ hybridization was 92% sensitive and 88% specific. When compared with clinical diagnosis, in situ hybridization was 86% sensitive and 87% specific. All cases of chickenpox had VZV-positive inflammatory cells in the dermis but this finding was less frequent among the cases of zoster.

CONCLUSIONS

This in situ hybridization technique is a sensitive and specific method for the diagnosis of VZV in skin lesions that is applicable to most histopathology laboratory settings. In addition, in situ hybridization reveals individual infected cells and may provide insight into the pathogenesis of VZV skin infection.