1
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Cai ZR, Chen ML, Kim J, Novoa RA, Barnes LA, Beam A, Linos E. Assessment of Correctness, Content Omission, and Risk of Harm in Large Language Model Responses to Dermatology Continuing Medical Education Questions. J Invest Dermatol 2024:S0022-202X(24)00088-5. [PMID: 38310972 DOI: 10.1016/j.jid.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 02/06/2024]
Affiliation(s)
- Zhuo Ran Cai
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA; Department of Dermatology, Medical School, Université de Montréal, Montreal, Canada
| | - Michael L Chen
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA; Center for Digital Health, Stanford University School of Medicine, Stanford, California, USA
| | - Jiyeong Kim
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA; Center for Digital Health, Stanford University School of Medicine, Stanford, California, USA
| | - Roberto A Novoa
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA; Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Leandra A Barnes
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Andrew Beam
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Eleni Linos
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA; Center for Digital Health, Stanford University School of Medicine, Stanford, California, USA.
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2
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Johanis M, Cheema KS, Young PA, Narala S, Saleem A, Novoa RA, Bae GH. Cutaneous larva migrans in the northeastern US. Dermatol Online J 2023; 29. [PMID: 37921817 DOI: 10.5070/d329461906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 11/04/2023] Open
Abstract
Cutaneous larva migrans (CLM) is a dermo-epidermal parasitic infection with a disproportionate incidence in developing countries, particularly in, and near tropical areas. It is characterized by erythematous, twisting, and linear plaques that can migrate to adjacent skin. Herein, we present an otherwise healthy 45-year-old woman who acquired a pruritic, erythematous, and serpiginous rash localized to her right medial ankle during a trip to New England. Oral ivermectin, the preferred first-line treatment for cutaneous larva migrans, was administered in combination with triamcinolone. This was followed by removal of the papular area via punch biopsy; treatment was successful with a one-week recovery. Although cutaneous larva migrans has traditionally been considered a tropical disease, clinicians should be cognizant of its expanding geographic spread.
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Affiliation(s)
| | | | | | | | | | | | - Gordon H Bae
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California, USA.
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3
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Chen ML, Rotemberg V, Lester JC, Novoa RA, Chiou AS, Daneshjou R. Evaluation of diagnosis diversity in artificial intelligence datasets: a scoping review. Br J Dermatol 2023; 188:292-294. [PMID: 36763858 DOI: 10.1093/bjd/ljac047] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 01/22/2023]
Affiliation(s)
| | - Veronica Rotemberg
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jenna C Lester
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
| | - Roberto A Novoa
- Department of Dermatology and.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
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4
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Cai ZR, Chen ML, Weinstock MA, Kim YH, Novoa RA, Linos E. Incidence Trends of Primary Cutaneous T-Cell Lymphoma in the US From 2000 to 2018: A SEER Population Data Analysis. JAMA Oncol 2022; 8:1690-1692. [PMID: 36048455 PMCID: PMC9437821 DOI: 10.1001/jamaoncol.2022.3236] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Using SEER database data, this cohort study analyzed cutaneous T-cell lymphoma incidence by tumor subtype, sex, age, race and ethnicity, socioeconomic status, and geography.
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Affiliation(s)
- Zhuo Ran Cai
- Program for Clinical Research and Technology, Stanford University, Stanford, California
| | - Michael L. Chen
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Martin A. Weinstock
- Center for Dermatoepidemiology, Providence Veterans Affairs Medical Center, Providence, Rhode Island,Department of Dermatology, Brown University, Providence, Rhode Island,Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Youn H. Kim
- Department of Dermatology, Stanford University School of Medicine, Stanford, California,Department of Medicine (Oncology), Stanford University School of Medicine, Stanford, California
| | - Roberto A. Novoa
- Department of Dermatology, Stanford University School of Medicine, Stanford, California,Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Eleni Linos
- Department of Dermatology, Stanford University School of Medicine, Stanford, California,Stanford Cancer Institute, School of Medicine, Stanford, California
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5
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Daneshjou R, Vodrahalli K, Novoa RA, Jenkins M, Liang W, Rotemberg V, Ko J, Swetter SM, Bailey EE, Gevaert O, Mukherjee P, Phung M, Yekrang K, Fong B, Sahasrabudhe R, Allerup JAC, Okata-Karigane U, Zou J, Chiou AS. Disparities in dermatology AI performance on a diverse, curated clinical image set. Sci Adv 2022; 8:eabq6147. [PMID: 35960806 PMCID: PMC9374341 DOI: 10.1126/sciadv.abq6147] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/30/2022] [Indexed: 06/10/2023]
Abstract
An estimated 3 billion people lack access to dermatological care globally. Artificial intelligence (AI) may aid in triaging skin diseases and identifying malignancies. However, most AI models have not been assessed on images of diverse skin tones or uncommon diseases. Thus, we created the Diverse Dermatology Images (DDI) dataset-the first publicly available, expertly curated, and pathologically confirmed image dataset with diverse skin tones. We show that state-of-the-art dermatology AI models exhibit substantial limitations on the DDI dataset, particularly on dark skin tones and uncommon diseases. We find that dermatologists, who often label AI datasets, also perform worse on images of dark skin tones and uncommon diseases. Fine-tuning AI models on the DDI images closes the performance gap between light and dark skin tones. These findings identify important weaknesses and biases in dermatology AI that should be addressed for reliable application to diverse patients and diseases.
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Affiliation(s)
- Roxana Daneshjou
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
- Department of Biomedical Data Science, Stanford School of Medicine, Stanford, CA, USA
| | - Kailas Vodrahalli
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA
| | - Roberto A. Novoa
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
- Department of Pathology, Stanford School of Medicine, Stanford, CA, USA
| | - Melissa Jenkins
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
| | - Weixin Liang
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Veronica Rotemberg
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Justin Ko
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
| | - Susan M. Swetter
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
| | - Elizabeth E. Bailey
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
| | - Olivier Gevaert
- Department of Biomedical Data Science, Stanford School of Medicine, Stanford, CA, USA
| | - Pritam Mukherjee
- Department of Biomedical Data Science, Stanford School of Medicine, Stanford, CA, USA
| | - Michelle Phung
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
| | - Kiana Yekrang
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
| | - Bradley Fong
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
| | - Rachna Sahasrabudhe
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
| | - Johan A. C. Allerup
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
| | | | - James Zou
- Department of Biomedical Data Science, Stanford School of Medicine, Stanford, CA, USA
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA
- Department of Computer Science, Stanford University, Stanford, CA, USA
- Chan-Zuckerberg Biohub, San Francisco, CA, USA
| | - Albert S. Chiou
- Department of Dermatology, Stanford School of Medicine, Redwood City, CA, USA
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6
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Saknite I, Gill M, Alessi-Fox C, Zwerner JP, Lehman JS, Shinohara MM, Novoa RA, Chen H, Byrne M, Gonzalez S, Ardigo M, Tkaczyk ER. In Vivo Reflectance Confocal Microscopy of Cutaneous Acute Graft-Versus-Host Disease: Concordance with Histopathology and Interobserver Reproducibility of a Glossary with Representative Images. J Eur Acad Dermatol Venereol 2022; 36:1034-1044. [PMID: 35175678 DOI: 10.1111/jdv.18004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The reliability to noninvasively identify features of inflammatory dermatoses by reflectance confocal microscopy (RCM) remains unknown. Lack of formal training among RCM readers can result in inconsistent assessments, limiting clinical utility. Specific consensus terminology with representative images is necessary to ensure consistent feature-level interpretation among RCM readers. OBJECTIVES (1) Develop a glossary with representative images of RCM features of cutaneous acute graft-versus-host disease (aGVHD) for consistent interpretation among observers, (2) assess the interobserver reproducibility among RCM readers using the glossary, and (3) determine the concordance between RCM and histopathology for aGVHD features. METHODS Through an iterative process of refinement and discussion among five international RCM experts, we developed a glossary with representative images of RCM features of aGVHD. From April to November 2018, patients suspected of aGVHD were imaged with RCM and subsequently biopsied. 17 lesions from 12 patients had clinically and pathologically confirmed cutaneous aGVHD. For each of these lesions, four dermatopathologists and four RCM readers independently evaluated the presence of aGVHD features in scanned histopathology slides and 1.5x1.5 mm RCM submosaics at 4 depths (blockstacks), respectively. RCM cases were adjudicated by a fifth RCM expert. Interobserver reproducibility was calculated by U statistic. Concordance between modalities was determined by fraction agreement. RESULTS We present a glossary with representative images of 18 aGVHD features by RCM. The average interobserver reproducibility among RCM readers (75%, confidence interval, CI: 71%-79%) did not differ significantly from dermatopathologists (80%, 76%-85%). The concordance between RCM and histopathology was 59%. CONCLUSIONS By using the glossary, the interobserver reproducibility among RCM readers was similar to the interobserver reproducibility among dermatopathologists. There was good concordance between RCM and histopathology to visualize aGVHD features. The implementation of RCM can now be advanced in a variety of inflammatory conditions with a validated glossary and representative image set.
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Affiliation(s)
- I Saknite
- Department of Dermatology, Vanderbilt University Medical Center, 719 Thompson Lane, One Hundred Oaks Suite 26300, Nashville, TN, 37204, USA.,Biophotonics Laboratory, Institute of Atomic Physics and Spectroscopy, University of Latvia, Jelgava Str 3 - #605, Riga, LV1004, Latvia
| | - M Gill
- SkinMedical Research and Diagnostics, PLLC, 64 Southlawn Ave, Dobbs Ferry, NY, 10522, USA.,Department of Pathology, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA.,Medicine and Medical Specialties Department, Alcalá University, 28871, Alcalá de Henares, Madrid, Spain
| | - C Alessi-Fox
- Clinical Development, Caliber Imaging and Diagnostics Inc, 50 Methodist Hill Drive, Suite 1000, Rochester, NY, 14623, USA
| | - J P Zwerner
- Department of Dermatology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - J S Lehman
- Division of Dermatology, Department of Medicine, Department of Laboratory Medicine and Pathology, University of Washington, Box 356524, Seattle, WA, 98195, USA
| | - M M Shinohara
- Department of Dermatology, Department of Pathology, Stanford University, 300 Pasteur Dr Rm H1507, MC 5627, Stanford, CA, 94305, USA
| | - R A Novoa
- Department of Biostatistics, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3903, Nashville, TN, 37232, USA
| | - H Chen
- Department of Biostatistics, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3903, Nashville, TN, 37232, USA.,Vanderbilt-Ingram Cancer Center, 1301 Medical Center Dr #1710, Nashville, TN, 37232, USA
| | - M Byrne
- Vanderbilt-Ingram Cancer Center, 1301 Medical Center Dr #1710, Nashville, TN, 37232, USA
| | - S Gonzalez
- Medicine and Medical Specialties Department, Alcalá University, 28871, Alcalá de Henares, Madrid, Spain
| | - M Ardigo
- San Gallicano Dermatological Institute - IRCCS, Via Elio Chianesi 53, 00144, Rome, Italy
| | - E R Tkaczyk
- Department of Dermatology, Vanderbilt University Medical Center, 719 Thompson Lane, One Hundred Oaks Suite 26300, Nashville, TN, 37204, USA.,Vanderbilt-Ingram Cancer Center, 1301 Medical Center Dr #1710, Nashville, TN, 37232, USA.,Dermatology Service and Research Service, Tennessee Valley Healthcare System, Department of Veterans Affairs, 1310 24th Avenue South, Nashville, TN, 37212, USA
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7
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Bahrani E, Kunder CA, Teng JM, Brown RA, Rieger KE, Novoa RA, Cloutier JM. Spitz nevus with EHBP1-ALK fusion and distinctive membranous localization of ALK. J Cutan Pathol 2022; 49:584-588. [PMID: 35113459 DOI: 10.1111/cup.14209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/26/2022] [Accepted: 01/30/2022] [Indexed: 11/30/2022]
Abstract
ALK rearrangements define a histopathologically distinctive but diverse subset of Spitz tumors characterized by fusiform to epithelioid melanocytes with frequent fascicular growth and ALK overexpression. Molecularly, these tumors are characterized by fusions between ALK and a variety of other genes, most commonly TPM3 and DCTN1. We describe an unusual case of a Spitz nevus occurring in a 13-year-old female that manifested ALK immunopositivity with cell membrane localization. The proliferation was polypoid and composed of elongated nests of epithelioid melanocytes with enlarged nuclei, prominent nucleoli, and abundant cytoplasm without significant atypia and lacking mitotic figures. The nevus exhibited strong and diffuse expression of p16. Targeted next-generation RNA sequencing revealed an in-frame EHBP1-ALK fusion, which has been reported only once in the literature. EHBP1 encodes an adaptor protein with plasma membrane targeting potential. Together, these findings suggest that the 5' ALK fusion partner in Spitz tumors may dictate the subcellular localization of the ALK chimeric oncoprotein. In summary, this case highlights a rare ALK fusion associated with a distinct immunohistochemical staining pattern and further expands the spectrum of ALK-rearranged melanocytic tumors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Eman Bahrani
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Christian A Kunder
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Joyce M Teng
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.,Department of Dermatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ryanne A Brown
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Dermatology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Pathology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Kerri E Rieger
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Dermatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Roberto A Novoa
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Dermatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jeffrey M Cloutier
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
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8
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Chen SB, Novoa RA. Artificial intelligence for dermatopathology: Current trends and the road ahead. Semin Diagn Pathol 2022; 39:298-304. [DOI: 10.1053/j.semdp.2022.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/06/2022] [Accepted: 01/12/2022] [Indexed: 02/07/2023]
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9
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Hirotsu KE, Scott MKD, Marquez C, Tran AT, Rieger KE, Novoa RA, Robinson WH, Kwong BY, Zaba LC. Histologic subtype of cutaneous immune-related adverse events predicts overall survival in patients receiving immune checkpoint inhibitors. J Am Acad Dermatol 2021; 87:651-653. [PMID: 34875301 DOI: 10.1016/j.jaad.2021.11.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/27/2021] [Accepted: 11/12/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Kelsey E Hirotsu
- Stanford University School of Medicine, Department of Dermatology, 780 Welch Road. Palo Alto, CA 94304
| | | | - Cesar Marquez
- Stanford University School of Medicine, 275 Campus Drive, Stanford, CA
| | - Anhthy T Tran
- Stanford University School of Medicine, Department of Dermatology, 780 Welch Road. Palo Alto, CA 94304
| | - Kerri E Rieger
- Stanford University School of Medicine, Department of Dermatology, 780 Welch Road. Palo Alto, CA 94304; Stanford University School of Medicine, Department of Pathology, 300 Pasteur Drive, H2110, Stanford, CA, 94305
| | - Roberto A Novoa
- Stanford University School of Medicine, Department of Dermatology, 780 Welch Road. Palo Alto, CA 94304; Stanford University School of Medicine, Department of Pathology, 300 Pasteur Drive, H2110, Stanford, CA, 94305
| | - William H Robinson
- Stanford University School of Medicine, Department of Medicine, Division of Immunology & Rheumatology and the VA Palo Alto Health Care System, Palo Alto, CA
| | - Bernice Y Kwong
- Stanford University School of Medicine, Department of Dermatology, 780 Welch Road. Palo Alto, CA 94304
| | - Lisa C Zaba
- Stanford University School of Medicine, Department of Dermatology, 780 Welch Road. Palo Alto, CA 94304.
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10
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Brown RA, Cloutier JM, Bahrani E, Liman A, Tasso D, Palmer A, Manning MA, Galperin I, Rieger KE, Novoa RA, Lau H, Louie CY. Immunohistochemical ALK Expression in Granular Cell Atypical Fibroxanthoma: A Diagnostic Pitfall for ALK-Rearranged Non-neural Granular Cell Tumor. Am J Dermatopathol 2021; 43:831-834. [PMID: 33767072 DOI: 10.1097/dad.0000000000001931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Atypical fibroxanthoma (AFX) is a neoplasm that most commonly occurs on sun-damaged skin of the head and neck in elderly patients and that usually exhibits indolent clinical behavior with complete excision. The granular cell variant of AFX demonstrates overlapping histopathologic features with dermal non-neural granular cell tumor (NNGCT), which typically arises on the extremities of young to middle aged adults with rare reports of regional metastasis. A subset of NNGCT harbors ALK rearrangements and expresses ALK by immunohistochemistry. Here, we present 2 cases of granular cell AFX occurring on the scalp of males aged 73 and 87 with ALK expression by immunohistochemistry and no evidence of an ALK rearrangement on fluorescence in situ hybridization, representing a diagnostic pitfall for NNGCT.
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Affiliation(s)
- Ryanne A Brown
- Department of Pathology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA
| | - Jeffrey M Cloutier
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Eman Bahrani
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Agnes Liman
- Department of Pathology, Veterans Affairs Central California Health Care System, Fresno, CA; and
| | - David Tasso
- Department of Pathology, Veterans Affairs Central California Health Care System, Fresno, CA; and
| | - Adrian Palmer
- Department of Pathology, Veterans Affairs Central California Health Care System, Fresno, CA; and
| | - Melanie A Manning
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Ilana Galperin
- Cytogenetics Laboratory, Department of Pathology, Stanford Health Care, Palo Alto, CA
| | - Kerri E Rieger
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA
| | - Roberto A Novoa
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA
| | - Hubert Lau
- Department of Pathology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Christine Y Louie
- Department of Pathology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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11
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Raghavan SS, Wang JY, Gru AA, Marqueling AL, Teng JMC, Brown RA, Novoa RA, Kim Y, Zehnder J, Zhang BM, Rieger KE. Next-generation sequencing confirms T-cell clonality in a subset of pediatric pityriasis lichenoides. J Cutan Pathol 2021; 49:252-260. [PMID: 34614220 DOI: 10.1111/cup.14143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/10/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pityriasis lichenoides (PL) is a papulosquamous disease that affects both adults and children. Previous studies have shown a subset of this entity to have clonal T-cell populations via PCR-based assays. In this study, we sought to implement next-generation sequencing (NGS) as a more sensitive and specific test to examine for T-cell clonality within the pediatric population. METHODS We identified 18 biopsy specimens from 12 pediatric patients with clinical and histopathologic findings compatible with PL. Patient demographics, clinical features, management, and histopathologic findings were reviewed. All specimens were analyzed for clonality with NGS of T-cell receptor beta (TRB) and gamma (TRG) genes. RESULTS Of the 12 patients, 9 (75%) had complete resolution of lesions at the time of data collection (mean follow-up 31 months). The remaining three patients significantly improved with methotrexate (with or without acitretin). Interestingly, 7 of 12 patients (58%) and 9 of 17 biopsy specimens (53%) showed evidence of T-cell clonality. Two patients showed matching TRB clones from different anatomic sites. CONCLUSIONS T-cell clonality is a common finding in PL, probably representing a "reactive clonality" rather than a true lymphoproliferative disorder. Clonality alone cannot be used as a means to distinguish PL from lymphomatoid papulosis or cutaneous lymphoma.
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Affiliation(s)
- Shyam S Raghavan
- Department of Pathology, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Jennifer Y Wang
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA
| | - Alejandro A Gru
- Department of Pathology, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Ann L Marqueling
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA
| | - Joyce M C Teng
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA
| | - Ryanne A Brown
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA.,Department of Pathology, Stanford University Medical Center, Stanford, California, USA
| | - Roberto A Novoa
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA.,Department of Pathology, Stanford University Medical Center, Stanford, California, USA
| | - Youn Kim
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA
| | - James Zehnder
- Department of Pathology, Stanford University Medical Center, Stanford, California, USA
| | - Bing Melody Zhang
- Department of Pathology, Stanford University Medical Center, Stanford, California, USA
| | - Kerri E Rieger
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA.,Department of Pathology, Stanford University Medical Center, Stanford, California, USA
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12
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Fung MA, Vidal CI, Armbrecht EA, Andea AA, Cassarino DS, Comfere NI, Emanuel PO, Ferringer T, Hristov AC, Kim J, Lauer SR, Linos K, Missall TA, Motaparthi K, Novoa RA, Patel R, Shalin SC, Sundram U, Calame A, Bennett DD, Duncan LM, Elston DM, Hosler GA, Hurley YM, Lazar AJ, Lowe L, Messina J, Myles J, Plaza JA, Prieto VG, Reddy V, Schaffer A, Subtil A. Appropriate use criteria for ancillary diagnostic testing in dermatopathology: New recommendations for 11 tests and 220 clinical scenarios from the American Society of Dermatopathology Appropriate Use Criteria Committee. J Cutan Pathol 2021; 49:231-245. [PMID: 34536035 DOI: 10.1111/cup.14135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Appropriate use criteria (AUC) provide patient-centered physician guidance in test selection. An initial set of AUC was reported by the American Society of Dermatopathology (ASDP) in 2018. AUC reflect evidence collected at single timepoints and may be affected by evolving evidence and experience. The objective of this study was to update and expand AUC for selected tests. METHODS RAND/UCLA (RAND Corporation [Santa Monica, CA]/University of California Los Angeles) methodology used includes the following: (a) literature review; (b) review of previously rated tests and previously employed clinical scenarios; (c) selection of previously rated tests for new ratings; (d) development of new clinical scenarios; (e) selection of additional tests; (f) three rating rounds with feedback and group discussion after rounds 1 and 2. RESULTS For 220 clinical scenarios comprising lymphoproliferative (light chain clonality), melanocytic (comparative genomic hybridization, fluorescence in situ hybridization, reverse transcription polymerase chain reaction, telomerase reverse transcriptase promoter), vascular disorders (MYC), and inflammatory dermatoses (periodic acid-Schiff, Gömöri methenamine silver), consensus by panel raters was reached in 172 of 220 (78%) scenarios, with 103 of 148 (70%) rated "usually appropriate" or "rarely appropriate" and 45 of 148 (30%), "appropriateness uncertain." LIMITATIONS The study design only measures appropriateness. Cost, availability, test comparison, and additional clinical considerations are not measured. The possibility that the findings of this study may be influenced by the inherent biases of the dermatopathologists involved in the study cannot be excluded. CONCLUSIONS AUC are reported for selected diagnostic tests in clinical scenarios that occur in dermatopathology practice. Adhering to AUC may reduce inappropriate test utilization and improve healthcare delivery.
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Affiliation(s)
| | - Maxwell A Fung
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California, USA.,Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Claudia I Vidal
- Dermatology Center of Southern Indiana, Bloomington, Indiana, USA
| | - Eric A Armbrecht
- Center for Health Outcomes Research, Saint Louis University, Saint Louis, Missouri, USA
| | - Aleodor A Andea
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - David S Cassarino
- Department of Pathology, Kaiser Permanente Southern California, Los Angeles, California, USA
| | - Nneka I Comfere
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Tammie Ferringer
- Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania, USA.,Department of Laboratory Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Alexandra C Hristov
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jinah Kim
- Palo Alto Medical Foundation, Palo Alto, California, USA
| | - Scott R Lauer
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Konstantinos Linos
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Tricia A Missall
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Roberto A Novoa
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA.,Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Rajiv Patel
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sara C Shalin
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Uma Sundram
- Department of Anatomic Pathology, Oakland University William Beaumont School of Medicine and Beaumont Health Systems, Royal Oak, Michigan, USA
| | | | | | - Daniel D Bennett
- Department of Dermatology, University of Wisconsin, Madison, Wisconsin, USA
| | - Lyn M Duncan
- Pathology Service and Dermatopathology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dirk M Elston
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory A Hosler
- ProPath, Department of Dermatology, Dallas, Texas, USA.,Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yadira M Hurley
- Department of Dermatology, Saint Louis University School of Medicine, Saint Louis, Missouri, USA.,Department of Pathology, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Alexander J Lazar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lori Lowe
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jane Messina
- Department of Dermatology and Cutaneous Surgery, University of South Florida, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jonathan Myles
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jose A Plaza
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Victor G Prieto
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vijaya Reddy
- Department of Pathology, Rush Medical College, Chicago, Illinois, USA.,Department of Dermatology, Rush Medical College, Chicago, Illinois, USA
| | - András Schaffer
- Division of Dermatology, Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Antonio Subtil
- Royal Jubilee Hospital, Victoria, British Columbia, Canada.,Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada
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13
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Winge MCG, Rieger KE, Kim J, Weng WK, Johnston LJ, Miklos DB, Win TS, Strelo J, Zaba LC, Pugliese SB, Novoa RA, Kwong BY. Nutritional deficiency contributing to refractory erythroderma in hematopoietic cell transplant patients: Distinctive clinical and histopathologic findings. J Am Acad Dermatol 2021; 87:847-848. [PMID: 34450206 DOI: 10.1016/j.jaad.2021.07.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/25/2021] [Accepted: 07/23/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Marten C G Winge
- Program in Epithelial Biology, Stanford University School of Medicine, Stanford, California; Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Kerri E Rieger
- Department of Dermatology, Stanford University School of Medicine, Stanford, California; Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Jinah Kim
- Department of Dermatology, Stanford University School of Medicine, Stanford, California; Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Wen-Kai Weng
- Department of Medicine, Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, California
| | - Laura J Johnston
- Department of Medicine, Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, California
| | - David B Miklos
- Department of Medicine, Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, California
| | - Thet Su Win
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jenna Strelo
- Stanford Cancer Center, Stanford University School of Medicine, Stanford, California
| | - Lisa C Zaba
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Silvina B Pugliese
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Roberto A Novoa
- Department of Dermatology, Stanford University School of Medicine, Stanford, California; Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Stanford, California.
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14
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Pepper MA, Theparee T, Messenger EA, Brown RA, Novoa RA. Cutaneous acral myofibroma with PDGFRB mutation in a patient with linear morphea en coup de sabre. J Cutan Pathol 2021; 48:1097-1100. [PMID: 33495995 DOI: 10.1111/cup.13971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/24/2020] [Accepted: 01/08/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Michael A Pepper
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Talent Theparee
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Elizabeth A Messenger
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Ryanne A Brown
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Roberto A Novoa
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA.,Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
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15
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Winge MCG, Iberri DJ, Novoa RA, Kwong BY, Zaba LC. Telescope punch biopsy of normal-appearing skin to diagnose intravascular lymphoma. Br J Dermatol 2021; 184:e194. [PMID: 33523506 DOI: 10.1111/bjd.19711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/24/2020] [Indexed: 11/28/2022]
Affiliation(s)
- M C G Winge
- Stanford University School of Medicine, Department of Dermatology, 780 Welch Road, Palo Alto, CA, 94304, USA
| | - D J Iberri
- Stanford University School of Medicine, Department of Medicine, Division of Hematology, 875 Blake Wilbur Drive, Palo Alto, CA, 94304, USA
| | - R A Novoa
- Stanford University School of Medicine, Department of Dermatology, 780 Welch Road, Palo Alto, CA, 94304, USA.,Stanford University School of Medicine, Department of Pathology, 300 Pasteur Drive, Stanford, CA, 94304, USA
| | - B Y Kwong
- Stanford University School of Medicine, Department of Dermatology, 780 Welch Road, Palo Alto, CA, 94304, USA
| | - L C Zaba
- Stanford University School of Medicine, Department of Dermatology, 780 Welch Road, Palo Alto, CA, 94304, USA
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16
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Vodrahalli K, Daneshjou R, Novoa RA, Chiou A, Ko JM, Zou J. TrueImage: A Machine Learning Algorithm to Improve the Quality of Telehealth Photos. Pac Symp Biocomput 2021; 26:220-231. [PMID: 33691019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Telehealth is an increasingly critical component of the health care ecosystem, especially due to the COVID-19 pandemic. Rapid adoption of telehealth has exposed limitations in the existing infrastructure. In this paper, we study and highlight photo quality as a major challenge in the telehealth workflow. We focus on teledermatology, where photo quality is particularly important; the framework proposed here can be generalized to other health domains. For telemedicine, dermatologists request that patients submit images of their lesions for assessment. However, these images are often of insufficient quality to make a clinical diagnosis since patients do not have experience taking clinical photos. A clinician has to manually triage poor quality images and request new images to be submitted, leading to wasted time for both the clinician and the patient. We propose an automated image assessment machine learning pipeline, TrueImage, to detect poor quality dermatology photos and to guide patients in taking better photos. Our experiments indicate that TrueImage can reject ~50% of the sub-par quality images, while retaining ~80% of good quality images patients send in, despite heterogeneity and limitations in the training data. These promising results suggest that our solution is feasible and can improve the quality of teledermatology care.
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Affiliation(s)
- Kailas Vodrahalli
- Department of Electrical Engineering, Stanford University, Stanford, CA 94305, USA† Correspondence authors*These authors contributed equally,
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17
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Hirotsu KE, Rana J, Wang JY, Raghavan SS, Rieger KE, Srinivas S, Fan AC, Kwong BY, Novoa RA, Zaba LC. Clinicopathologic characterization of enfortumab vedotin-associated cutaneous toxicity in patients with urothelial carcinoma. J Am Acad Dermatol 2020; 85:1610-1611. [PMID: 33301805 DOI: 10.1016/j.jaad.2020.11.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/22/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Kelsey E Hirotsu
- Department of Dermatology, Stanford University School of Medicine, Stanford, California.
| | - Jasmine Rana
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Jennifer Y Wang
- Department of Dermatology, Stanford University School of Medicine, Stanford, California; Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Shyam S Raghavan
- Department of Dermatology, Stanford University School of Medicine, Stanford, California; Department of Pathology, Stanford University School of Medicine, Stanford, California; Department of Pathology, University of Virginia School of Medicine, UVA Health System, Charlottesville, Virginia
| | - Kerri E Rieger
- Department of Dermatology, Stanford University School of Medicine, Stanford, California; Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Sandhya Srinivas
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Alice C Fan
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Roberto A Novoa
- Department of Dermatology, Stanford University School of Medicine, Stanford, California; Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Lisa C Zaba
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
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18
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Raghavan SS, Wang JY, Toland A, Bangs CD, Rieger KE, Novoa RA, Charville GW, Brown RA. Diffuse PRAME expression is highly specific for malignant melanoma in the distinction from clear cell sarcoma. J Cutan Pathol 2020; 47:1226-1228. [PMID: 32681554 DOI: 10.1111/cup.13812] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Shyam S Raghavan
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Jennifer Y Wang
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Angus Toland
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Charles D Bangs
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Kerri E Rieger
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Roberto A Novoa
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Gregory W Charville
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Ryanne A Brown
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
- Department of Pathology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
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19
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Raghavan SS, Wang JY, Kwok S, Rieger KE, Novoa RA, Brown RA. PRAME expression in melanocytic proliferations with intermediate histopathologic or spitzoid features. J Cutan Pathol 2020; 47:1123-1131. [PMID: 32700786 DOI: 10.1111/cup.13818] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND PRAME (PReferentially expressed Antigen in MElanoma) has shown utility in distinguishing melanoma from benign melanocytic lesions, but knowledge of its expression pattern in intermediate melanocytic and spitzoid proliferations is limited. METHODS Immunohistochemical expression of PRAME was examined in 112 melanocytic proliferations with intermediate histopathologic or spitzoid features. RESULTS Any intensity of nuclear PRAME staining in at least 60% of lesional melanocytes was determined as the best threshold for diffuse staining in this cohort. Nearly all non-spitzoid melanomas (23/24; 95.8%) demonstrated diffuse PRAME expression. PRAME was completely negative in 95.6% (43/45) of mitotically-active nevi, traumatized nevi, nevi with persistent/recurrent features, and dysplastic nevi. Most Spitz nevi (15/20) and atypical Spitz tumors (10/13) entirely lacked PRAME expression. One Spitz nevus, one atypical Spitz tumor, and one spitzoid melanoma (1/2) demonstrated diffuse PRAME expression. CONCLUSIONS Although diffuse PRAME expression is generally limited to malignant melanoma, benign Spitz nevi and atypical Spitz tumors can infrequently express diffuse PRAME. PRAME immunohistochemistry can be useful in the evaluation of atypical melanocytic proliferations with intermediate histopathologic features but should be interpreted with caution in the setting of spitzoid neoplasms.
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Affiliation(s)
- Shyam S Raghavan
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Jennifer Y Wang
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Shirley Kwok
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Kerri E Rieger
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Roberto A Novoa
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Ryanne A Brown
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
- Department of Pathology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
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20
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Chang MS, Bae GH, Almazan T, Raghavan SS, Wang JY, Czech MM, Wang H, Banaei N, Blackburn BG, Novoa RA, Rieger KE. Concurrent Trypanosoma cruzi and Cytomegalovirus Reactivation in an Immunosuppressed Patient With Limited Cutaneous Systemic Sclerosis. Am J Dermatopathol 2020; Publish Ahead of Print. [PMID: 33201010 DOI: 10.1097/dad.0000000000001842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chagas disease, a multisystem infection caused by the protozoan Trypanosoma cruzi, is primarily found in Latin America. In recent years, prevalence has increased in the United States, where reactivation is the most common clinical scenario. Here, we describe cutaneous reactivation of T. cruzi in a patient with limited cutaneous systemic sclerosis on immunosuppression therapy who simultaneously presented with cytomegalovirus reactivation. Histopathology showed parasitized histiocytes in the superficial and deep dermis. Occasional epidermal keratinocytes were also parasitized, and rare organisms were also seen in the walls of blood vessels. Also noted were viral cytopathic changes within the vascular endothelium, and immunostaining confirmed cytomegalovirus. In this report, we describe the difference in cutaneous findings between reactivated and acute Chagas disease, and we also review the histopathologic features that help distinguish T.cruzi from other intracellular organisms.
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Affiliation(s)
| | - Gordon H Bae
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA
| | - Timothy Almazan
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA
| | - Shyam S Raghavan
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, VA
| | - Jennifer Y Wang
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA
| | - Mary M Czech
- Department of Infectious Disease, Stanford University School of Medicine, Stanford, CA
| | - Hannah Wang
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Niaz Banaei
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Brian G Blackburn
- Department of Infectious Disease, Stanford University School of Medicine, Stanford, CA
| | - Roberto A Novoa
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Kerri E Rieger
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
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21
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Brown RA, Wang JY, Raghavan SS, Zhang J, Wan DC, Born D, Koo M, Hazard FK, Novoa RA, Rieger KE. ALK-positive compound Spitz nevus with extensive perineural and intraneural neurotropism. J Cutan Pathol 2020; 48:154-159. [PMID: 33034114 DOI: 10.1111/cup.13890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/01/2020] [Accepted: 10/04/2020] [Indexed: 01/18/2023]
Abstract
Historically recognized by their characteristic histopathologic features, Spitz neoplasms are now known to be molecularly defined by mutually exclusive recurrent abnormalities that cause activation of the MAPK pathway. Spitz neoplasms with ALK rearrangements frequently demonstrate polypoid growth with a plexiform arrangement of nested, fusiform melanocytes in intersecting fascicles. Although neurotropism has been described in indolent Spitz neoplasms, this feature is not frequently mentioned in publications on histopathologic assessment of this group of melanocytic tumors. Here, we present an unusual case of a 3-year-old female with an ALK-positive compound Spitz nevus with extensive perineural and intraneural neurotropism occurring on the vermilion border of the lower lip.
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Affiliation(s)
- Ryanne A Brown
- Department of Pathology, Stanford Medicine, Stanford, California, USA.,Department of Dermatology, Stanford Medicine, Stanford, California, USA.,Department of Pathology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Jennifer Y Wang
- Department of Pathology, Stanford Medicine, Stanford, California, USA.,Department of Dermatology, Stanford Medicine, Stanford, California, USA
| | - Shyam S Raghavan
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Jingjing Zhang
- Department of Pathology, Stanford Medicine, Stanford, California, USA
| | - Derrick C Wan
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford Medicine, Stanford, California, USA
| | - Donald Born
- Department of Pathology, Stanford Medicine, Stanford, California, USA
| | - Matthew Koo
- Department of Pathology, Stanford Medicine, Stanford, California, USA
| | - Florette K Hazard
- Department of Pathology, Stanford Medicine, Stanford, California, USA
| | - Roberto A Novoa
- Department of Pathology, Stanford Medicine, Stanford, California, USA.,Department of Dermatology, Stanford Medicine, Stanford, California, USA
| | - Kerri E Rieger
- Department of Pathology, Stanford Medicine, Stanford, California, USA.,Department of Dermatology, Stanford Medicine, Stanford, California, USA
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22
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Rojansky R, Fernandez-Pol S, Wang E, Rieger KE, Novoa RA, Zehnder JL, Kunder CA, Kim YH, Khodadoust MS, Brown RA. Cutaneous T-cell lymphomas with pathogenic somatic mutations and absence of detectable clonal T-cell receptor gene rearrangement: two case reports. Diagn Pathol 2020; 15:122. [PMID: 32988392 PMCID: PMC7523289 DOI: 10.1186/s13000-020-01022-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/02/2020] [Indexed: 12/20/2022] Open
Abstract
Background Cutaneous T-cell lymphomas (CTCL) are a heterogeneous group of extranodal non-Hodgkin lymphomas for which diagnosis can be challenging given the potential for overlap with inflammatory dermatoses. Current diagnostic criteria for CTCL incorporate clinical and histopathologic findings as well as results of T-cell receptor (TCR) gene sequencing. Molecular interrogation of TCR genes, TRG and TRB, has proven to be a critical tool for confirming diagnoses of CTCL and for disease tracking after initiation of therapy or after stem cell transplant. Methods for confirming a diagnosis of lymphoma in the absence of TCR gene clonality are lacking. We present two patients with CTCL with pathogenic somatic mutations in the absence of TRG and TRB clonality. Case presentations Case 1: A 38-year-old male had a 19-year history of a diffuse skin rash with papulosquamous, granulomatous, and verrucous features and progressive ulcerated plaques and tumors demonstrating an atypical CD4+ T-cell infiltrate with expression of cytotoxic markers CD56, TIA-1, granzyme, and perforin on histopathology. No definitive evidence for T-cell clonality was detected by conventional PCR of 6 biopsies or by next-generation sequencing (NGS) of 14 biopsies. Somatic mutational profiling of a skin biopsy revealed pathogenic mutations in PIKC3D and TERT promoter hotspots, confirming the presence of a clonal process. Case 2: A 69-year-old male with a 13-year history of progressive, diffuse hypertrophic and eroded plaques showed an atypical CD4+ T-cell infiltrate with subset expression of TIA-1 and granzyme on histopathology. No TCR clonality was detected by TCR-NGS of 6 biopsies. Somatic mutational profiling of a skin biopsy detected a pathogenic mutation in TP53, confirming the presence of a clonal process. Conclusions These cases highlight how detection of pathogenic somatic mutations can confirm a diagnosis of lymphoma in a clinically and histopathologically suspicious cutaneous lymphoid proliferation without detectable TCR clonality.
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Affiliation(s)
- Rebecca Rojansky
- Department of Pathology, Stanford Medicine, Stanford, CA, 94305, USA
| | | | - Erica Wang
- Department of Dermatology, Stanford Medicine, Stanford, CA, 94305, USA
| | - Kerri E Rieger
- Department of Pathology, Stanford Medicine, Stanford, CA, 94305, USA.,Department of Dermatology, Stanford Medicine, Stanford, CA, 94305, USA
| | - Roberto A Novoa
- Department of Pathology, Stanford Medicine, Stanford, CA, 94305, USA.,Department of Dermatology, Stanford Medicine, Stanford, CA, 94305, USA
| | - James L Zehnder
- Department of Pathology, Stanford Medicine, Stanford, CA, 94305, USA.,Division of Hematology, Department of Medicine, Stanford Medicine, Stanford, CA, 94305, USA
| | | | - Youn H Kim
- Department of Dermatology, Stanford Medicine, Stanford, CA, 94305, USA.,Division of Oncology, Department of Medicine, Stanford Medicine, Stanford, CA, 94305, USA
| | - Michael S Khodadoust
- Department of Dermatology, Stanford Medicine, Stanford, CA, 94305, USA.,Division of Oncology, Department of Medicine, Stanford Medicine, Stanford, CA, 94305, USA
| | - Ryanne A Brown
- Department of Pathology, Stanford Medicine, Stanford, CA, 94305, USA. .,Department of Dermatology, Stanford Medicine, Stanford, CA, 94305, USA. .,Department of Pathology, Veterans Affairs Palo Alto Health Care System, 3375 Hillview Ave, Room 1821, Palo Alto, CA, 94304-1204, USA.
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23
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Tabata MM, Chase M, Kwong BY, Novoa RA, Fernandez-Pol S. Differentiation syndrome during ivosidenib treatment with immunohistochemistry showing isocitrate dehydrogenase R132H mutation. J Cutan Pathol 2020; 47:1042-1045. [PMID: 32588467 DOI: 10.1111/cup.13780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 05/30/2020] [Accepted: 06/17/2020] [Indexed: 11/29/2022]
Abstract
We report a case of differentiation syndrome in a patient receiving the IDH1 inhibitor ivosidenib, with skin biopsy showing isocitrate dehydrogenase (IDH) R132H-mutated leukemia cutis. A 72-year-old man with IDH1-mutated acute myeloid leukemia (AML), status-post allogeneic cell transplantation, on ivosidenib for 6 months, was admitted for culture-negative neutropenic fever, pink and purpuric plaques and patches on the legs, abdomen and back, edema, hypotension, and shortness of breath. Skin biopsy revealed an infiltrate of atypical, immature, myeloperoxidase-positive mononuclear cells compatible with leukemia cutis or Sweet syndrome. Although dermal edema and interstitial neutrophilic infiltrate with karyorrhexis characteristic of Sweet syndrome were not seen, the atypical cells lacked expression of CD117 and CD34, which were expressed in the original leukemia. Additional immunohistochemical staining of suspected blasts was strongly positive for IDH1 R132H, suggesting a diagnosis of leukemia cutis. As the immunophenotype of blasts in skin infiltrates can significantly differ from the immunophenotype seen in blood and bone marrow, this case shows that mutation-specific antibodies such as anti-IDH1 R132H may be useful to help distinguish malignant from non-malignant infiltrates in the skin. Furthermore, differentiation syndrome may show histopathologic features of leukemia cutis on skin biopsy.
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Affiliation(s)
- Mika M Tabata
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Melissa Chase
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Roberto A Novoa
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA.,Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
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24
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Motaparthi K, Kim J, Andea AA, Missall TA, Novoa RA, Vidal CI, Fung MA, Emanuel PO. TERT and TERT promoter in melanocytic neoplasms: Current concepts in pathogenesis, diagnosis, and prognosis. J Cutan Pathol 2020; 47:710-719. [PMID: 32202662 DOI: 10.1111/cup.13691] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 02/26/2020] [Accepted: 03/13/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Located on chromosome locus 5p15.33, telomerase reverse transcriptase (TERT or hTERT) encodes the catalytic subunit of telomerase which permits lengthening and preservation of telomeres following mitosis. Mutations in TERT promoter (TERT-p) upregulate expression of TERT, allowing survival of malignant cells and tumor progression in wide variety of malignancies including melanoma. The objective of this review is to examine the roles of TERT and TERT-p in the pathogenesis, diagnosis, and prognostication of cutaneous melanoma. METHODS All studies of TERT or TERT-p in cutaneous melanocytic neoplasms with the following inclusion criteria were reviewed: publication date between 2010 and 2019, English language, and series of ≥3 cases were reviewed for evidence supporting the role of TERT in pathogenesis, diagnosis, and prognosis. Studies with <3 cases or focused primarily on mucosal or uveal melanocytic tumors were excluded. RESULTS AND CONCLUSION TERT-p mutations are frequent in chronic and non-chronic sun damage melanoma and correlate with adverse prognosis, inform pathogenesis, and may provide diagnostic support. While TERT-p mutations are uncommon in acral melanoma, TERT copy number gains and gene amplification predict reduced survival. Among atypical spitzoid neoplasms, TERT-p mutations identify biologically aggressive tumors and support the diagnosis of spitzoid melanoma. TERT-p methylation may have prognostic value in pediatric conventional melanoma and drive tumorigenesis in melanoma arising within congenital nevi. Finally, TERT-p mutations may aid in the differentiation of recurrent nevi from recurrent melanoma.
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Affiliation(s)
- Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | - Jinah Kim
- Palo Alto Medical Foundation, Palo Alto, California
| | - Aleodor A Andea
- Department of Dermatology, University of Michigan Medical Center, Ann Arbor, Michigan
- Department of Pathology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Tricia A Missall
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | - Roberto A Novoa
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Claudia I Vidal
- Dermatology Center of Southern Indiana, Bloomington, Indiana
| | - Maxwell A Fung
- Department of Dermatology, University of California, Davis, California
| | - Patrick O Emanuel
- Laboratorio Recavarren Emanuel, Clínica Ricardo Palma, Lima, Peru
- IGENZ Molecular Laboratory, Auckland, New Zealand
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25
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Bahrani E, Fernandez-Pol S, Wang JY, Aasi SZ, Brown RA, Novoa RA. Reticulohistiocytoma (solitary epithelioid histiocytoma) with mutations in RAF1 and TSC2. J Cutan Pathol 2020; 47:985-987. [PMID: 32342514 DOI: 10.1111/cup.13727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/18/2020] [Accepted: 04/21/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Eman Bahrani
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | | | - Jennifer Y Wang
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA
| | - Sumaira Z Aasi
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA
| | - Ryanne A Brown
- Department of Pathology, Stanford University Medical Center, Stanford, California, USA.,Department of Dermatology, Stanford University Medical Center, Stanford, California, USA
| | - Roberto A Novoa
- Department of Pathology, Stanford University Medical Center, Stanford, California, USA.,Department of Dermatology, Stanford University Medical Center, Stanford, California, USA
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26
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Puing AG, Couture-Cossette A, Wang AX, Zygourakis CC, Cheng X, Stevens BA, Banaei N, Novoa RA, Ho DY, Subramanian AK. Simultaneous coccidioidomycosis and phaeohyphomycosis in a kidney transplant recipient: A case report and literature review. Transpl Infect Dis 2020; 22:e13365. [PMID: 32533741 DOI: 10.1111/tid.13365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 11/30/2022]
Abstract
Advances in solid organ transplantation have improved the survival of end-stage organ disease at the expense of an increased risk for opportunistic infections. Unusual clinical presentations and the possibility of concurrent infections make diagnosing invasive fungal infection (IFI) more difficult. Here, we present a case of simultaneous vertebral infection caused by Coccidioides immitis-posadasii and subcutaneous phaeohyphomycosis due to Nigrograna mackinnonii in a kidney transplant recipient. The diagnosis of both infections required invasive procedures to obtain tissue and a high index of suspicion that more than one IFI could be present. A multidisciplinary team approach for the management of immunocompromised patients with suspected or diagnosed IFI is warranted.
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Affiliation(s)
- Alfredo G Puing
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Antoine Couture-Cossette
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Aileen X Wang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Corinna C Zygourakis
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Xingxing Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Bryan A Stevens
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Niaz Banaei
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Roberto A Novoa
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Dora Y Ho
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Aruna K Subramanian
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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27
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Wang JY, Brown RA, Pugliese S, Kwong BY, Novoa RA. Disseminated tuberculosis presenting as medium-vessel vasculitis in an immunocompromised host. J Cutan Pathol 2020; 47:725-728. [PMID: 32133689 DOI: 10.1111/cup.13678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/22/2020] [Accepted: 02/26/2020] [Indexed: 11/26/2022]
Abstract
Cutaneous tuberculosis is an uncommon entity with several clinical forms recognized. Histopathologically, most cases are characterized by granulomatous inflammation and caseating necrosis, although less common findings, including vasculitis, have also been described. We report a 55-year-old male with a history of recently diagnosed dermatomyositis receiving immunosuppression with mycophenolate mofetil and prednisone, who developed multifocal soft tissue abscesses and an indurated erythematous plaque on the back. Skin biopsy of the back revealed a necrotizing medium-vessel vasculitis. Mycobacterium tuberculosis was detected in the skin via acid-fast bacilli stain and confirmed by tissue culture and polymerase chain reaction. Cutaneous findings improved rapidly with antituberculosis therapy. This case illustrates an uncommon clinical and histopathologic presentation of disseminated tuberculosis.
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Affiliation(s)
- Jennifer Y Wang
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA.,Department of Pathology, Stanford University Medical Center, Stanford, California, USA
| | - Ryanne A Brown
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA.,Department of Pathology, Stanford University Medical Center, Stanford, California, USA
| | - Silvina Pugliese
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA
| | - Roberto A Novoa
- Department of Dermatology, Stanford University Medical Center, Stanford, California, USA.,Department of Pathology, Stanford University Medical Center, Stanford, California, USA
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28
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Affiliation(s)
- Roberto A. Novoa
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Olivier Gevaert
- Department of Biomedical Data Science, Stanford University, Stanford, California
| | - Justin M. Ko
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
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29
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Sargen MR, Cloutier JM, Sarin KY, Rieger KE, Chu P, Swetter SM, Novoa RA. Biomarker discovery analysis: Alterations in p14, p16, p53, and BAP1 expression in nevi, cutaneous melanoma, and metastatic melanoma. Pigment Cell Melanoma Res 2019; 32:474-478. [PMID: 30672662 DOI: 10.1111/pcmr.12768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/04/2019] [Accepted: 01/19/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Michael R Sargen
- Department of Pathology, Stanford University Medical Center, Stanford, California
| | - Jeffrey M Cloutier
- Department of Pathology, Stanford University Medical Center, Stanford, California
| | - Kavita Y Sarin
- Department of Dermatology, Stanford University Medical Center, Stanford, California
| | - Kerri E Rieger
- Department of Pathology, Stanford University Medical Center, Stanford, California
- Department of Dermatology, Stanford University Medical Center, Stanford, California
| | - Pauline Chu
- Department of Pathology, Stanford University Medical Center, Stanford, California
| | - Susan M Swetter
- Department of Dermatology, Stanford University Medical Center, Stanford, California
- Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Roberto A Novoa
- Department of Pathology, Stanford University Medical Center, Stanford, California
- Department of Dermatology, Stanford University Medical Center, Stanford, California
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30
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Schlessinger DI, Chhor G, Gevaert O, Swetter SM, Ko J, Novoa RA. Artificial intelligence and dermatology: opportunities, challenges, and future directions. Semin Cutan Med Surg 2019. [PMID: 31051021 DOI: 10.12788/j.sder.2019.] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The application of artificial intelligence (AI) to medicine has considerable potential within dermatology, where the majority of diagnoses are based on visual pattern recognition. Opportunities for AI in dermatology include the potential to automate repetitive tasks; optimize time-consuming tasks; extend limited medical resources; improve interobserver reliability issues; and expand the diagnostic toolbox of dermatologists. To achieve the full potential of AI, however, developers must aim to create algorithms representing diverse patient populations; ensure algorithm output is ultimately interpretable; validate algorithm performance prospectively; preserve human-patient interaction when necessary; and demonstrate validity in the eyes of regulatory bodies.
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Affiliation(s)
| | - Guillaume Chhor
- Institute for Computational and Mathematical Engineering, Stanford University, Stanford, California.,Department of Biomedical Data Science, Stanford University, Stanford, California
| | - Olivier Gevaert
- Department of Biomedical Data Science, Stanford University, Stanford, California.,Department of Medicine, Stanford University, Stanford, California
| | - Susan M Swetter
- Department of Dermatology, Stanford University, Stanford, California.,Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Justin Ko
- Department of Dermatology, Stanford University, Stanford, California
| | - Roberto A Novoa
- Department of Dermatology, Stanford University, Stanford, California.
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31
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Schlessinger DI, Chhor G, Gevaert O, Swetter SM, Ko J, Novoa RA. Artificial intelligence and dermatology: opportunities, challenges, and future directions. Semin Cutan Med Surg 2019; 38:E31-37. [PMID: 31051021 DOI: 10.12788/j.sder.2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The application of artificial intelligence (AI) to medicine has considerable potential within dermatology, where the majority of diagnoses are based on visual pattern recognition. Opportunities for AI in dermatology include the potential to automate repetitive tasks; optimize time-consuming tasks; extend limited medical resources; improve interobserver reliability issues; and expand the diagnostic toolbox of dermatologists. To achieve the full potential of AI, however, developers must aim to create algorithms representing diverse patient populations; ensure algorithm output is ultimately interpretable; validate algorithm performance prospectively; preserve human-patient interaction when necessary; and demonstrate validity in the eyes of regulatory bodies.
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Affiliation(s)
| | - Guillaume Chhor
- Institute for Computational and Mathematical Engineering, Stanford University, Stanford, California
- Department of Biomedical Data Science, Stanford University, Stanford, California
| | - Olivier Gevaert
- Department of Biomedical Data Science, Stanford University, Stanford, California
- Department of Medicine, Stanford University, Stanford, California
| | - Susan M Swetter
- Department of Dermatology, Stanford University, Stanford, California
- Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Justin Ko
- Department of Dermatology, Stanford University, Stanford, California
| | - Roberto A Novoa
- Department of Dermatology, Stanford University, Stanford, California.
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32
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Schlessinger DI, Chhor G, Gevaert O, Swetter SM, Ko J, Novoa RA. Artificial intelligence and dermatology: opportunities, challenges, and future directions. ACTA ACUST UNITED AC 2019. [DOI: 10.12788/j.sder.2019.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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33
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Emanuel PO, Andea AA, Vidal CI, Missall TA, Novoa RA, Bohlke AK, Hughes SR, Hurley MY, Kim J. Evidence behind the use of molecular tests in melanocytic lesions and practice patterns of these tests by dermatopathologists. J Cutan Pathol 2018; 45:839-846. [DOI: 10.1111/cup.13327] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 06/24/2018] [Accepted: 07/05/2018] [Indexed: 12/21/2022]
Affiliation(s)
| | - Aleodor A. Andea
- Departments of Dermatology and Pathology; University of Michigan Medical Center; Ann Arbor Michigan
| | - Claudia I. Vidal
- Departments of Dermatology and Pathology; Saint Louis University School of Medicine; St. Louis Missouri
| | - Tricia A. Missall
- Departments of Dermatology and Pathology; Saint Louis University School of Medicine; St. Louis Missouri
| | - Roberto A. Novoa
- Departments of Dermatology and Pathology; Stanford University School of Medicine; Stanford California
| | | | - Sarah R. Hughes
- Department of Pathology; Gundersen Health System; La Crosse Wisconsin
| | - Maria Y. Hurley
- Departments of Dermatology and Pathology; Saint Louis University School of Medicine; St. Louis Missouri
| | - Jinah Kim
- Departments of Dermatology and Pathology; Stanford University School of Medicine; Stanford California
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34
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Tabata MM, Novoa RA, Martires KJ. Paraneoplastic granulomatous dermatitis in a patient with Hodgkin's disease: a diagnostic pitfall. BMJ Case Rep 2018; 2018:bcr-2018-224961. [PMID: 30100570 DOI: 10.1136/bcr-2018-224961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The association of malignant lymphomas with non-necrotic epithelioid granulomas has been reported rarely since 1977. Hodgkin's disease-associated widespread cutaneous granuloma annulare (GA) has been reported in only eight patients. We report the second case of subcutaneous GA associated with Hodgkin's disease. A 73-year-old man with Epstein-Barr virus-associated Hodgkin's lymphoma and paraneoplastic subcutaneous GA, presented 3 months after the diagnosis of malignancy. Examination revealed a large, broad erythematous, indurated, subcutaneous plaque spanning the majority of the left lower back and flank with no associated symptoms. Initial biopsy was suggestive of morphea. Prompted by positron emission tomography (PET) findings of increased fluorodeoxyglucose (FDG) uptake, a second, deeper biopsy was performed, revealing subcutaneous palisaded granulomatous dermatitis. After complete workup, the diagnosis most strongly suggested subcutaneous GA. This case highlights the importance of deep incisional biopsies, the fluorodeoxyglucose - positron emission tomography (FDG-PET) findings in GA and the rare association of GA with Hodgkin's disease which may signal the presence of malignancy.
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Affiliation(s)
- Mika M Tabata
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Roberto A Novoa
- Department of Dermatology, Stanford University, Stanford, California, USA
| | - Kathryn J Martires
- Department of Dermatology, Stanford University, Stanford, California, USA
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35
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Vidal CI, Armbrect EA, Andea AA, Bohlke AK, Comfere NI, Hughes SR, Kim J, Kozel JA, Lee JB, Linos K, Litzner BR, Missall TA, Novoa RA, Sundram U, Swick BL, Hurley MY, Alam M, Argenyi Z, Duncan LM, Elston DM, Emanuel PO, Ferringer T, Fung MA, Hosler GA, Lazar AJ, Lowe L, Plaza JA, Prieto VG, Robinson JK, Schaffer A, Subtil A, Wang WL. Appropriate use criteria in dermatopathology: Initial recommendations from the American Society of Dermatopathology. J Cutan Pathol 2018; 45:563-580. [DOI: 10.1111/cup.13142] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 02/21/2018] [Accepted: 03/13/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Claudia I. Vidal
- Departments of Dermatology and Pathology; Saint Louis University School of Medicine; St. Louis Missouri
| | - Eric A. Armbrect
- Center for Health Outcomes Research; Saint Louis University; St. Louis Missouri
| | - Aleodor A. Andea
- Departments of Dermatology and Pathology; University of Michigan Medical Center; Ann Arbor Michigan
| | | | - Nneka I. Comfere
- Department of Dermatology and Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota
| | - Sarah R. Hughes
- Department of Pathology; Gundersen Health System; La Crosse Wisconsin
| | - Jinah Kim
- Departments of Dermatology and Pathology; Stanford University School of Medicine; Stanford California
| | | | - Jason B. Lee
- Departments of Dermatology and Cutaneous Biology; Sidney Kimmel Medical College at Thomas Jefferson University; Philadelphia Pennsylvania
| | - Konstantinos Linos
- Department of Pathology and Laboratory Medicine; Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth Lebanon; Hanover New Hampshire
| | - Brandon R. Litzner
- Departments of Dermatology and Pathology, Via Christi Clinic; Ascension Medical Group; Wichita Kansas
- Department of Family Medicine; University of Kansas Medical Center-Wichita; Wichita Kansas
| | - Tricia A. Missall
- Departments of Dermatology and Pathology; Saint Louis University School of Medicine; St. Louis Missouri
| | - Roberto A. Novoa
- Departments of Dermatology and Pathology; Stanford University School of Medicine; Stanford California
| | - Uma Sundram
- Department of Anatomic Pathology; Oakland University William Beaumont School of Medicine and Beaumont Health Systems; Royal Oak Michigan
| | - Brian L. Swick
- Departments of Dermatology and Pathology; University of Iowa; Iowa City Iowa
| | - Maria Yadira Hurley
- Departments of Dermatology and Pathology; Saint Louis University School of Medicine; St. Louis Missouri
| | - Murad Alam
- Departments of Dermatology Otolaryngology, and Surgery; Feinberg School of Medicine, Northwestern University; Chicago Illinois
| | - Zsolt Argenyi
- Department of Pathology; University of Washington; Seattle Washington
| | - Lyn M. Duncan
- Pathology Service and Dermatopathology Unit; Massachusetts General Hospital and Harvard Medical School; Boston Massachusetts
| | - Dirk M. Elston
- Department of Dermatology; Dermatologic Surgery, Medical University of SC; Charleston South Carolina
| | - Patrick O. Emanuel
- Department of Pathology and Molecular Medicine; University of Auckland; Auckland New Zealand
| | - Tammie Ferringer
- Departments of Dermatology and Laboratory Medicine; Geisinger Medical Center; Danville Pennsylvania
| | - Maxwell A. Fung
- Departments of Dermatology and Pathology and Laboratory Medicine; University of California, Davis School of Medicine; Sacramento California
| | - Gregory A. Hosler
- ProPath; Departments of Dermatology and Pathology; University of Texas Southwestern Medical Center; Dallas Texas
| | - Alexander J. Lazar
- Departments of Pathology, Dermatology, & Genomic Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Lori Lowe
- Departments of Dermatology and Pathology; University of Michigan Medical Center; Ann Arbor Michigan
| | | | - Victor G. Prieto
- Departments of Pathology, Dermatology, & Genomic Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - June K. Robinson
- Department of Dermatology; Northwestern University; Chicago Illinois
| | | | - Antonio Subtil
- Department of Dermatology; Yale School of Medicine; New Haven Connecticut
| | - Wei-Lien Wang
- Departments of Pathology and Translational Molecular Pathology, Division of Pathology and Laboratory Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
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36
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Vidal CI, Armbrect EA, Andea AA, Bohlke AK, Comfere NI, Hughes SR, Kim J, Kozel JA, Lee JB, Linos K, Litzner BR, Missall TA, Novoa RA, Sundram U, Swick BL, Hurley MY, Alam M, Argenyi Z, Duncan LM, Elston DM, Emanuel PO, Ferringer T, Fung MA, Hosler GA, Lazar AJ, Lowe L, Plaza JA, Prieto VG, Robinson JK, Schaffer A, Subtil A, Wang WL. Appropriate use criteria in dermatopathology: Initial recommendations from the American Society of Dermatopathology. J Am Acad Dermatol 2018; 80:189-207.e11. [PMID: 29689323 DOI: 10.1016/j.jaad.2018.04.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 04/05/2018] [Accepted: 04/15/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Appropriate use criteria (AUC) provide physicians guidance in test selection, and can affect health care delivery, reimbursement policy, and physician decision-making. OBJECTIVES The American Society of Dermatopathology, with input from the American Academy of Dermatology and the College of American Pathologists, sought to develop AUC in dermatopathology. METHODS The RAND/UCLA appropriateness methodology, which combines evidence-based medicine, clinical experience, and expert judgment, was used to develop AUC in dermatopathology. RESULTS With the number of ratings predetermined at 3, AUC were developed for 211 clinical scenarios involving 12 ancillary studies. Consensus was reached for 188 (89%) clinical scenarios, with 93 (44%) considered "usually appropriate" and 52 (25%) "rarely appropriate" and 43 (20%) having "uncertain appropriateness." LIMITATIONS The methodology requires a focus on appropriateness without comparison between tests and irrespective of cost. CONCLUSIONS The ultimate decision to order specific tests rests with the physician and is one where the expected benefit exceeds the negative consequences. This publication outlines the recommendations of appropriateness-the AUC for 12 tests used in dermatopathology. Importantly, these recommendations may change considering new evidence. Results deemed "uncertain appropriateness" and where consensus was not reached may benefit from further research.
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Affiliation(s)
| | - Claudia I Vidal
- Departments of Dermatology and Pathology, Saint Louis University School of Medicine, Saint Louis, Missouri.
| | - Eric A Armbrect
- Center for Health Outcomes Research, Saint Louis University, Saint Louis, Missouri
| | - Aleodor A Andea
- Departments of Dermatology and Pathology, University of Michigan Medical Center, Ann Arbor, Michigan
| | | | - Nneka I Comfere
- Department of Dermatology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Sarah R Hughes
- Department of Pathology, Gundersen Health System, La Crosse, Wisconsin
| | - Jinah Kim
- Departments of Dermatology and Pathology, Stanford University School of Medicine, Stanford, California
| | | | - Jason B Lee
- Departments of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Konstantinos Linos
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Brandon R Litzner
- Departments of Dermatology and Pathology, Via Christi Clinic, Ascension Medical Group, Wichita, Kansas; Department of Family Medicine, University of Kansas Medical Center, Wichita, Kansas
| | - Tricia A Missall
- Departments of Dermatology and Pathology, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Roberto A Novoa
- Departments of Dermatology and Pathology, Stanford University School of Medicine, Stanford, California
| | - Uma Sundram
- Department of Anatomic Pathology, Oakland University William Beaumont School of Medicine and Beaumont Health Systems, Royal Oak, Michigan
| | - Brian L Swick
- Departments of Dermatology and Pathology, University of Iowa, Iowa City, Iowa
| | - M Yadira Hurley
- Departments of Dermatology and Pathology, Saint Louis University School of Medicine, Saint Louis, Missouri
| | | | - Murad Alam
- Departments of Dermatology Otolaryngology, and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Zsolt Argenyi
- Department of Pathology, University of Washington, Seattle, Washington
| | - Lyn M Duncan
- Pathology Service and Dermatopathology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Dirk M Elston
- Department of Dermatology, Dermatologic Surgery Medical University of South Carolina, Charleston, South Carolina
| | - Patrick O Emanuel
- Department of Pathology and Molecular Medicine, University of Auckland, Auckland, New Zealand
| | - Tammie Ferringer
- Departments of Dermatology and Laboratory Medicine, Geisinger Medical Center, Danville, Pennsylvania
| | - Maxwell A Fung
- Departments of Dermatology and Pathology and Laboratory Medicine, University of California, Davis School of Medicine, Sacramento, California
| | - Gregory A Hosler
- ProPath and Departments of Dermatology and Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alexander J Lazar
- Departments of Pathology, Dermatology, and Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lori Lowe
- Departments of Dermatology and Pathology, University of Michigan Medical Center, Ann Arbor, Michigan
| | | | - Victor G Prieto
- Departments of Pathology, Dermatology, and Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - June K Robinson
- Department of Dermatology, Northwestern University, Chicago, Illinois
| | | | - Antonio Subtil
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Wei-Lien Wang
- Departments of Pathology and Translational Molecular Pathology, Division of Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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37
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Dai J, Kunder CA, Chu EY, Chan EF, Egan CL, Novoa RA. Development of RET mutant cutaneous angiosarcoma during BRAF inhibitor therapy. J Cutan Pathol 2017; 44:1053-1056. [PMID: 28796396 DOI: 10.1111/cup.13024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 07/28/2017] [Accepted: 08/06/2017] [Indexed: 12/12/2022]
Abstract
Treatment with BRAF inhibitors may lead to paradoxical mitogen-activated protein kinase (MAPK) pathway activation and accelerated tumorigenesis in cells with preexisting oncogenic hits. This phenomenon manifests clinically in the development of squamous cell carcinomas (SCCs) and keratoacanthomas (KAs) in patients treated with BRAF inhibitors. Cases of extracutaneous malignancies associated with BRAF inhibitors have also been reported. We present a case of a patient who developed a cutaneous angiosarcoma 6 months after initiation of vemurafenib therapy. Next-generation sequencing (NGS) revealed a mutation in RET, which lies upstream of the MAPK pathway. This case highlights that treatment with BRAF inhibitors may promote the accelerated growth of secondary malignancies. Physician awareness of the spectrum of secondary malignancies associated with BRAF inhibitor treatment will support their early detection and treatment.
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Affiliation(s)
- Julia Dai
- Department of Dermatology, Stanford University Medical Center, Stanford, California
| | - Christian A Kunder
- Department of Pathology, Stanford University Medical Center, Stanford, California
| | - Emily Y Chu
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Edward F Chan
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Christine L Egan
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Roberto A Novoa
- Department of Dermatology, Stanford University Medical Center, Stanford, California.,Department of Pathology, Stanford University Medical Center, Stanford, California
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38
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Esteva A, Kuprel B, Novoa RA, Ko J, Swetter SM, Blau HM, Thrun S. Corrigendum: Dermatologist-level classification of skin cancer with deep neural networks. Nature 2017; 546:686. [PMID: 28658222 DOI: 10.1038/nature22985] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This corrects the article DOI: 10.1038/nature21056.
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39
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Esteva A, Kuprel B, Novoa RA, Ko J, Swetter SM, Blau HM, Thrun S. Dermatologist-level classification of skin cancer with deep neural networks. Nature 2017; 542:115-118. [PMID: 28117445 DOI: 10.1038/nature21056] [Citation(s) in RCA: 4670] [Impact Index Per Article: 667.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 12/14/2016] [Indexed: 11/09/2022]
Abstract
Skin cancer, the most common human malignancy, is primarily diagnosed visually, beginning with an initial clinical screening and followed potentially by dermoscopic analysis, a biopsy and histopathological examination. Automated classification of skin lesions using images is a challenging task owing to the fine-grained variability in the appearance of skin lesions. Deep convolutional neural networks (CNNs) show potential for general and highly variable tasks across many fine-grained object categories. Here we demonstrate classification of skin lesions using a single CNN, trained end-to-end from images directly, using only pixels and disease labels as inputs. We train a CNN using a dataset of 129,450 clinical images-two orders of magnitude larger than previous datasets-consisting of 2,032 different diseases. We test its performance against 21 board-certified dermatologists on biopsy-proven clinical images with two critical binary classification use cases: keratinocyte carcinomas versus benign seborrheic keratoses; and malignant melanomas versus benign nevi. The first case represents the identification of the most common cancers, the second represents the identification of the deadliest skin cancer. The CNN achieves performance on par with all tested experts across both tasks, demonstrating an artificial intelligence capable of classifying skin cancer with a level of competence comparable to dermatologists. Outfitted with deep neural networks, mobile devices can potentially extend the reach of dermatologists outside of the clinic. It is projected that 6.3 billion smartphone subscriptions will exist by the year 2021 (ref. 13) and can therefore potentially provide low-cost universal access to vital diagnostic care.
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Affiliation(s)
- Andre Esteva
- Department of Electrical Engineering, Stanford University, Stanford, California, USA
| | - Brett Kuprel
- Department of Electrical Engineering, Stanford University, Stanford, California, USA
| | - Roberto A Novoa
- Department of Dermatology, Stanford University, Stanford, California, USA.,Department of Pathology, Stanford University, Stanford, California, USA
| | - Justin Ko
- Department of Dermatology, Stanford University, Stanford, California, USA
| | - Susan M Swetter
- Department of Dermatology, Stanford University, Stanford, California, USA.,Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Helen M Blau
- Baxter Laboratory for Stem Cell Biology, Department of Microbiology and Immunology, Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, California, USA
| | - Sebastian Thrun
- Department of Computer Science, Stanford University, Stanford, California, USA
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40
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Cedeno-Laurent F, Wysocka M, Obstfeld AE, Novoa RA, Vittorio CC, Kim EJ, Weng WK, Rook AH. Gain of CD26 expression on the malignant T-cells in relapsed erythrodermic leukemic mycosis fungoides. J Cutan Pathol 2017; 44:462-466. [PMID: 28083948 DOI: 10.1111/cup.12899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/17/2016] [Accepted: 01/11/2017] [Indexed: 11/29/2022]
Abstract
Loss of CD26 surface expression on the circulating malignant T-cell is the most widely accepted diagnostic marker in patients with leukemic cutaneous T-cell lymphoma (CTCL). CTCL cases with reemergence of CD7 and/or CD26 surface expression are unusual and of uncertain prognosis. We report the case of an erythrodermic leukemic mycosis fungoides patient who had achieved temporary remission after several months on multimodality immunotherapy and extracorporeal photopheresis, but who relapsed with aggressive disease phenotypically characterized by CD4+ T-cells with high CD26 expression. Polymerase chain reaction studies and high-throughput sequencing analyses from peripheral blood mononuclear cells at presentation and relapse consistently showed an identical clonal T-cell receptor suggesting evolution of her original malignant clone which lacked CD26 expression. Interestingly, quantitative expression of the sialomucin, CD164, mirrored her clinical picture, thus favoring its reliability as a novel biomarker in CTCL.
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Affiliation(s)
- Filiberto Cedeno-Laurent
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria Wysocka
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amrom E Obstfeld
- Department of Molecular Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roberto A Novoa
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carmela C Vittorio
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ellen J Kim
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wen-Kai Weng
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Alain H Rook
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
We describe the case of a 26-year-old woman with a history of congenital ichthyosiform erythroderma (CIE) who initially presented with a stage IIA amelanotic melanoma on her forearm that was surgically excised. We also review the literature on CIE-associated skin cancers and discuss the possible contribution of ichthyosis to the risk of cutaneous malignancies. Our findings emphasize the importance of close lifelong skin cancer screening in individuals with CIE and highlight the unique malignancy risk of these individuals.
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Affiliation(s)
- Prajakta Jaju
- Department of Dermatology, Stanford University Medical Center, Stanford, California
| | - Roberto A Novoa
- Department of Dermatology, Stanford University Medical Center, Stanford, California
| | - Susan M Swetter
- Department of Dermatology, Stanford University Medical Center, Stanford, California.,Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Kavita Y Sarin
- Department of Dermatology, Stanford University Medical Center, Stanford, California
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42
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Berg SA, Novoa RA, Stewart C, Sobanko JF, Miller CJ, Rosenbach M. Sarcoidosis and squamous cell carcinoma: a connection documented in a case series of 3 patients. Cutis 2016; 98:377-380. [PMID: 28099531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Sarcoidosis is a chronic multisystem disease characterized by the formation of noncaseating granulomas in multiple organs, including the skin. An association between multisystem sarcoidosis and an increased risk for malignancy has been established. Dermatologists should be aware of the increased risk for nonmelanoma skin cancers in patients with sarcoidosis. We report a series of 3 patients with primarily cutaneous sarcoidosis who presented with new-onset cutaneous squamous cell carcinoma (SCC). Two patients were black women and 1 patient presented with lesions of cutaneous sarcoidosis arising concurrently with SCCs in the same location, distinguishable only by biopsy. These cases highlight the association between sarcoidosis and an increased risk for SCC. Because dermatologists may be the primary clinicians caring for these patients, it is important that they remain aware of the increased risk for cutaneous malignancies and that they have a low threshold for biopsy of new and unusual skin lesions. Furthermore, 2 patients were black women, a population not commonly affected by skin cancer, which further exemplifies the need for comprehensive skin examinations in black patients. Although the precise mechanism for an increased risk for malignancy in these patients requires further investigation, chronic inflammation and immune dysregulation may play a role.
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Affiliation(s)
- Sara A Berg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Roberto A Novoa
- Department of Dermatology, University of Pennsylvania, Philadelphia, USA
| | - Campbell Stewart
- Department of Dermatology, University of Pennsylvania, Philadelphia, USA
| | - Joseph F Sobanko
- Department of Dermatology, University of Pennsylvania, Philadelphia, USA
| | | | - Misha Rosenbach
- Department of Dermatology, University of Pennsylvania, Philadelphia, USA
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43
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Cornejo CM, Novoa RA, Krisch RE, Kim EJ. Low-dose radiotherapy for primary cutaneous anaplastic large-cell lymphoma while on low-dose methotrexate. Cutis 2016; 98:253-256. [PMID: 27874877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Primary cutaneous anaplastic large-cell lymphoma (pcALCL) is part of a spectrum of CD30+ primary cutaneous lymphoproliferative disorders (pcLPDs) that also includes lymphomatoid papulosis (LyP). Localized radiotherapy at doses of 34 to 44 Gy is first-line treatment of pcALCL, but the use of low-dose radiotherapy for pcALCL has not been reported. We present the case of a patient with a history of pcALCL/LyP who was treated with low-dose radiotherapy while on oral low-dose methotrexate (MTX) once weekly. This report suggests that low-dose radiotherapy can be an effective palliative treatment of pcALCL. Low-dose radiotherapy may offer certain advantages over traditional radiotherapy, such as a more economical and efficient treatment for patients, potentially fewer short-term and long-term side effects, and the potential for concomitant use with low-dose MTX.
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Affiliation(s)
- Christine M Cornejo
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Roberto A Novoa
- Department of Dermatology, Stanford University School of Medicine, California, USA
| | - Robert E Krisch
- Department of Radiation Oncology, Chester County Hospital, West Chester, Pennsylvania, USA
| | - Ellen J Kim
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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44
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Scott GD, Kwong BY, Novoa RA. Epidermotropic metastasis of primary lung adenocarcinoma. J Cutan Pathol 2016; 43:798-801. [PMID: 27234927 DOI: 10.1111/cup.12741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/09/2016] [Accepted: 05/25/2016] [Indexed: 11/26/2022]
Abstract
Cutaneous metastasis of lung cancer is a rare event and usually portends a grim prognosis. Several cases of lung cancer with cutaneous metastasis have been reported, but these have been largely limited to the dermis. Here we describe a unique case of cutaneous metastatic lung adenocarcinoma largely limited to the epidermis, mimicking Paget's disease or a cutaneous adnexal tumor.
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Affiliation(s)
- Gregory D Scott
- Department of Pathology, Stanford University Medical Center, Stanford, CA, USA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University Medical Center, Stanford, CA, USA
| | - Roberto A Novoa
- Department of Pathology, Stanford University Medical Center, Stanford, CA, USA.,Department of Dermatology, Stanford University Medical Center, Stanford, CA, USA
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45
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Khosla D, Novoa RA, Merati M, Honda K, Gerstenblith MR. Multiple eccrine axillary hidrocystomas. JAAD Case Rep 2016; 2:257-8. [PMID: 27437442 PMCID: PMC4939421 DOI: 10.1016/j.jdcr.2016.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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46
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Schaberg KB, Novoa RA, Wakelee HA, Kim J, Cheung C, Srinivas S, Kwong BY. Immunohistochemical analysis of lichenoid reactions in patients treated with anti-PD-L1 and anti-PD-1 therapy. J Cutan Pathol 2016; 43:339-46. [PMID: 26762844 DOI: 10.1111/cup.12666] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 12/08/2015] [Accepted: 11/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recent advances in the immunotherapeutic treatment of cancer have led to the development of multiple new directed therapies including monoclonal antibodies that block the immune checkpoint T-cell receptor programmed death 1 (PD-1) and the PD-1 ligand, programmed death ligand 1 (PD-L1). Various immune-related toxicities have been associated with these drugs including, most commonly, skin rashes. METHODS Five cases of lichenoid dermatitis, including one case of lichenoid mucositis and one case of lichen sclerosus, associated with anti-PD-L1 and anti-PD1 therapy were compared with three biopsies of non-drug-related lichen planus (LP) and three lichen planus-like keratoses (LPLK) used as controls. RESULTS Histopathologic and immunophenotypic analysis of these lichenoid lesions demonstrated significantly greater histiocytic infiltrates than observed in control lichenoid reactions (p = 0.0134). We also observed increased spongiosis and epidermal necrosis. No significant differences were seen in expression of CD3, CD4:CD8, CD20, PD-1, CD25, Foxp3, CXCL13 and PD-L1 expression. CONCLUSIONS These findings expand the literature of immune-related toxicities of PD-L1 and PD-1 blockade to include lichenoid dermatitis and lichenoid mucositis. Of note, these cutaneous side effects were amenable to topical treatment, without the need for medication dose reduction or discontinuation.
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Affiliation(s)
- Kurt B Schaberg
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Roberto A Novoa
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Dermatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Heather A Wakelee
- Department of Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jinah Kim
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Dermatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Christine Cheung
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sandhya Srinivas
- Department of Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, USA
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47
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Langenhan J, Novoa RA, Pappas-Taffer L. Acquired port-wine stain with superimposed eczema following penetrating abdominal trauma. Cutis 2015; 96:391-394. [PMID: 26761933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Port-wine stains (PWSs), or capillary malformations, are common congenital lesions, but acquired lesions rarely present in the setting of trauma. We present the case of an 18-year-old man who developed a PWS and associated localized eczema following penetrating trauma to the left abdomen. The diagnoses were confirmed on biopsy. The patient's eczema improved with topical steroids. Magnetic resonance imaging of PWSs is recommended in order to rule out deeper arteriovenous malformations. More research is needed to elucidate the connection between PWS pathophysiology and the development of eczema.
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Affiliation(s)
- Jamie Langenhan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Roberto A Novoa
- Departments of Pathology and Dermatology, Stanford Medical Center, California, USA
| | - Lisa Pappas-Taffer
- Department of Dermatology, Perelman Center for Advanced Medicine, University of Pennsylvania, USA
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48
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MacArthur KM, Richardson V, Novoa RA, Stewart CL, Rosenbach M. Carpet beetle dermatitis: a possibly under-recognized entity. Int J Dermatol 2015; 55:577-9. [PMID: 26475226 DOI: 10.1111/ijd.12952] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 09/15/2014] [Accepted: 10/25/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Kelly M MacArthur
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Veronica Richardson
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Roberto A Novoa
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Campbell L Stewart
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Misha Rosenbach
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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49
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Boos MD, Wine Lee L, Freedman JL, Novoa RA, Chu EY, Perman MJ. Presentation of Acute Megakaryoblastic Leukemia Associated with a GATA-1 Mutation Mimicking the Eruption of Transient Myeloproliferative Disorder. Pediatr Dermatol 2015. [PMID: 26205501 DOI: 10.1111/pde.12643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Children with trisomy 21 are prone to developing hematologic disorders, including transient myeloproliferative disorder (TMD) and acute megakaryoblastic leukemia (AMKL). The papulovesicular eruption of TMD provides an important clue to the diagnosis. In contrast, AMKL rarely has associated cutaneous findings. We report the case of a 22-month-old child with trisomy 21 who presented with the acute onset of diffusely scattered and crusted papules, plaques, and vesicles. A thorough infectious evaluation was negative and the patient was unresponsive to empiric antibiotic and antiinflammatory therapies. Complete blood count (CBC) was notable for mild pancytopenia, with a normal peripheral smear. Two weeks later he was reassessed and found to have a population of blasts on repeat CBC. Subsequent evaluation ultimately led to a diagnosis of AMKL. This is the first reported case of a cutaneous eruption in a young child with Down syndrome and transformed AMKL. When children with trisomy 21 present with the acute onset of crusted papules and vesicles that cannot be accounted for by an infectious etiology, a diagnosis of AMKL should be considered even in the absence of a history of TMD.
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Affiliation(s)
- Markus D Boos
- Section of Dermatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lara Wine Lee
- Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina.,Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Jason L Freedman
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Roberto A Novoa
- Department of Pathology, Stanford Medical Center, Palo Alto, California.,Department of Dermatology, Stanford Medical Center, Palo Alto, California
| | - Emily Y Chu
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marissa J Perman
- Section of Dermatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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50
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Affiliation(s)
- Roberto A Novoa
- Department of Dermatology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Kord S Honda
- Department of Dermatology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Erica Campagnaro
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Meg R Gerstenblith
- Department of Dermatology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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