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Niu N, Roy SF, Ko CJ. A pilot study of p53 immunohistochemistry in atypical squamous lesions, using a vulvar scoring system. J Cutan Pathol 2024; 51:379-386. [PMID: 38317537 DOI: 10.1111/cup.14591] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/15/2024] [Accepted: 01/21/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Histopathologic overlap between cutaneous squamous cell carcinoma (cSCC) and its indolent mimics likely leads to the overdiagnosis of cSCC. OBJECTIVE To perform a pilot study of the p53 immunohistochemical scoring system developed on vulvar squamous lesions in cSCC. METHODS The consistency and reliability of p53 immunostaining using a scoring system developed on vulvar cases, as compared with TP53 genomic sequencing, was studied in an initial cohort of 28 cutaneous cases. p53 labeling was further assessed in an additional 63 cases of atypical squamous lesions, including 20 atypical squamous lesions classified by the authors as benign, 22 cases diagnosed as cSCC without high-risk features, and 21 cases of high-risk cSCC (cSCC-HR). RESULTS The concordance of p53 labeling and TP53 sequencing was 82.1%. Four positive patterns of p53 mutation were identified: basal, parabasal/diffuse, null, and cytoplasmic. p53 positivity in atypical, benign squamous lesions (10%) was significantly lower than that of low-risk cSCC (63.6%, p = 0.0004) or cSCC-HR (90.5%, p < 0.0001). p53 positivity in low-risk cSCC versus cSCC-HR was not statistically significant (p = 0.07). CONCLUSION p53 Labeling may be a helpful biomarker to support the diagnosis of cSCC and distinguish cSCC from atypical but benign mimics.
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Affiliation(s)
- Na Niu
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Simon F Roy
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christine J Ko
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
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2
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Ko CJ, Gehlhausen JR, Cohen JM, Croskerry P. Cognitive Bias in the Patient Encounter: Part I. Background and significance. J Am Acad Dermatol 2024:S0190-9622(24)00557-7. [PMID: 38588821 DOI: 10.1016/j.jaad.2024.01.091] [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: 09/28/2023] [Revised: 01/16/2024] [Accepted: 01/21/2024] [Indexed: 04/10/2024]
Abstract
Cognitive bias may lead to diagnostic error in the patient encounter. There are hundreds of different cognitive biases, but certain biases are more likely to affect patient diagnosis and management. As during morbidity and mortality rounds, retrospective evaluation of a given case, with comparison to an optimal diagnosis, can pinpoint errors in judgment and decision-making. The study of cognitive bias also illuminates how we might improve the diagnostic process. In Part 1 of this series, cognitive bias is defined and placed within the background of dual process theory, emotion, heuristics, and the more neutral term judgment and decision-making bias.
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3
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Ko CJ, Gehlhausen JR, Cohen JM, Jiang Y, Myung P, Croskerry P. Cognitive Bias in the Patient Encounter: Part II. Debiasing using an adaptive toolbox. J Am Acad Dermatol 2024:S0190-9622(24)00558-9. [PMID: 38588820 DOI: 10.1016/j.jaad.2024.02.061] [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: 09/28/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 04/10/2024]
Abstract
Cognitive bias may lead to medical error, and awareness of cognitive pitfalls is a potential first step to addressing the negative consequences of cognitive bias (see Part 1). For decision-making processes that occur under uncertainty, which encompass most physician decisions, a so-called "adaptive toolbox" is beneficial for good decisions. The adaptive toolbox is inclusive of broad strategies like cultural humility, emotional intelligence, and self-care that help combat implicit bias, negative consequences of affective bias, and optimize cognition. Additionally, the adaptive toolbox includes situational-specific tools such as heuristics, narratives, cognitive forcing functions, and fast and frugal trees. Such tools may mitigate against errors due to cultural, affective, and cognitive bias. Part 2 of this two-part series covers metacognition and cognitive bias in relation to broad and specific strategies aimed at better decision-making.
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Hanly A, Turner N, Ko CJ, Panse G. Spiny Keratoderma: Clinical and Histopathological Findings in a Series of 3 Cases. Am J Dermatopathol 2024:00000372-990000000-00327. [PMID: 38574081 DOI: 10.1097/dad.0000000000002705] [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: 04/06/2024]
Abstract
ABSTRACT Spiny keratoderma is a rare entity presenting with minute keratotic spines on the palms and soles. Spiny keratoderma can be inherited or acquired, and the acquired form may be associated with underlying malignancy or systemic disease. Clinically, the differential diagnosis includes other digitate keratoses on acral sites, most notably arsenical keratosis, filiform verruca, and punctate porokeratosis. Biopsy findings typically include a column of parakeratosis overlying a diminished granular cell layer. In this article, we present 3 cases of acquired spiny keratoderma in patients with various systemic diseases, but no underlying malignancy.
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Affiliation(s)
- Ailish Hanly
- Department of Dermatology, Yale School of Medicine, New Haven, CT
| | - Noel Turner
- Integrated Dermatology of Clinton, Madison, CT; and
- Departments of Pathology, Yale School of Medicine, New Haven, CT
| | - Christine J Ko
- Department of Dermatology, Yale School of Medicine, New Haven, CT
- Departments of Pathology, Yale School of Medicine, New Haven, CT
| | - Gauri Panse
- Department of Dermatology, Yale School of Medicine, New Haven, CT
- Departments of Pathology, Yale School of Medicine, New Haven, CT
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Turner N, Ko CJ, McNiff JM, Galan A. Pitfalls of PRAME Immunohistochemistry in a Large Series of Melanocytic and Nonmelanocytic Lesions With Literature Review. Am J Dermatopathol 2024; 46:21-30. [PMID: 37982498 DOI: 10.1097/dad.0000000000002584] [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] [Indexed: 11/21/2023]
Abstract
ABSTRACT Preferentially expressed antigen in melanoma (PRAME) immunohistochemistry is currently used to facilitate distinction of benign and malignant melanocytic proliferations. We hypothesized that evaluation of 1 institution's experience with PRAME labeling in a large number of consecutive cases might elucidate additional strengths and potential pitfalls and reveal base rates of positivity versus negativity in 1 academic practice. Pathology reports for all specimens on which PRAME labeling was performed at our institution between January 2021 and May 2022 were retrieved from our database. Eighty percent of conventional malignant melanomas were labeled diffusely positive with PRAME; there were no significant differences in mean age, sex, site, Breslow depth, ulceration status, or American Joint Committee on Cancer pathological tumor stage when comparing diffusely PRAME-positive malignant melanomas with those that lack diffuse labeling. Although no banal melanocytic nevi were labeled with PRAME, 13% of dysplastic nevi were diffusely PRAME positive, with junctional proliferations, severe atypia, male gender, and older age being associated with PRAME positivity. As some but not all ambiguous melanocytic lesions in which malignancy could not be excluded based on morphology alone were diffusely PRAME positive, PRAME's accuracy in predicting malignancy remains unclear to the authors; further study is needed to assess the precision to which PRAME immunohistochemistry can separate benign borderline lesions from their malignant counterparts. Among nonmelanocytic lesions, some poorly differentiated tumors, including atypical fibroxanthomas, can be PRAME positive. This series underscores the importance of clinicopathologic correlation and shows that diffuse PRAME positivity is highest in conventional malignant melanomas (∼80%, or 8 of 10 lesions), is seen in about half of challenging borderline lesions at our institution, and can be observed in lesions diagnosed as dysplastic nevi by our group (∼10% or 1 in 10 lesions), as well as in rare poorly differentiated malignancies.
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Affiliation(s)
- Noel Turner
- Department of Dermatology, Yale University, New Haven, CT; and
| | - Christine J Ko
- Department of Dermatology, Yale University, New Haven, CT; and
- Department of Pathology, Yale University, New Haven, CT
| | - Jennifer M McNiff
- Department of Dermatology, Yale University, New Haven, CT; and
- Department of Pathology, Yale University, New Haven, CT
| | - Anjela Galan
- Department of Dermatology, Yale University, New Haven, CT; and
- Department of Pathology, Yale University, New Haven, CT
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6
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Ko CJ, Glusac EJ. Cognitive bias in pathology, as exemplified in dermatopathology. Hum Pathol 2023; 140:267-275. [PMID: 36906184 DOI: 10.1016/j.humpath.2023.03.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023]
Abstract
Cognitive bias refers to human thinking patterns, as well as pitfalls, that are reproducible. Importantly, cognitive bias is not intentionally discriminatory and is necessary to properly interpret the world around us, including microscopic slides. Thus, it is a useful exercise to examine cognitive bias in pathology, as exemplified in dermatopathology.
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Affiliation(s)
- Christine J Ko
- Yale University School of Medicine, New Haven, CT, 06510, USA.
| | - Earl J Glusac
- Yale University School of Medicine, New Haven, CT, 06510, USA
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Tang H, Seykora JT, Ko CJ. Squamous carcinogenesis: potential truncal mutations. Hum Pathol 2023; 140:32-38. [PMID: 37001739 DOI: 10.1016/j.humpath.2023.03.016] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
Squamous carcinogenesis is incompletely understood, but more recent genetic studies support that the order of acquired mutations is important. This paper will review more recent genetic studies with an emphasis on the potential truncal mutations, mutations critical to the trunk of the cancer evolutionary tree, in actinic keratosis, squamous cell carcinoma in situ, cutaneous squamous cell carcinoma, keratoacanthoma, and keratoacanthoma-like squamous proliferation.
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Affiliation(s)
- Haiming Tang
- Department of Pathology, School of Medicine, Yale University, New Haven, CT, 06510, USA.
| | - John T Seykora
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Christine J Ko
- Department of Pathology, School of Medicine, Yale University, New Haven, CT, 06510, USA; Department of Dermatology, School of Medicine, Yale University, New Haven, CT, 06510, USA
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Chen JS, Murphy MJ, Singh K, Wang A, Chow RD, Kim SR, Cohen JM, Ko CJ, Damsky W. IL17A mRNA Staining Distinguishes Palmoplantar Psoriasis from Hyperkeratotic Palmoplantar Eczema in Diagnostic Skin Biopsies. JID Innov 2023; 3:100189. [PMID: 37205304 PMCID: PMC10186614 DOI: 10.1016/j.xjidi.2023.100189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/04/2023] [Accepted: 01/22/2023] [Indexed: 02/11/2023] Open
Abstract
Acral dermatoses, including hyperkeratotic palmoplantar eczema (HPE), palmoplantar psoriasis (PP), and mycosis fungoides palmaris et plantaris (MFPP), can be challenging to diagnose clinically and histopathologically. In this setting, cytokine biomarkers may be able to help provide diagnostic clarity. Therefore, we evaluated IL-17A, IFN-γ, and IL-13 expression in PP, HPE, and MFPP and compared their expression profiles with nonacral sites. We used biopsy specimens from the Yale Dermatopathology database, selecting cases of HPE (n = 12), PP (n = 8), MFPP (n = 8), normal acral skin (n = 9), nonacral eczema (n = 10), and nonacral psoriasis (n = 10) with classic clinical and histopathologic features. IL17A mRNA expression by RNA in situ hybridization differentiated PP (median score 63.1 [interquartile range 9.4-104.1]) from HPE (0.8 [0-6.0]; P = 0.003), MFPP (0.6 [0-2.6]; P = 0.003), and normal acral skin (0 [0-0]; P < 0.001). Unexpectedly, both PP and HPE showed co-expression of IFNG and IL13 mRNA. In contrast, nonacral psoriasis and eczema showed divergent patterns of IFNG and IL13 mRNA expression. Taken together, we show that IL17A mRNA expression may be a useful biomarker of PP, and we further show that acral dermatoses exhibit distinct immunology compared to nonacral sites, with implications for clinical management.
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Affiliation(s)
- Jennifer S. Chen
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael J. Murphy
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katelyn Singh
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alice Wang
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
- Medical Scientist Training Program, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Ryan D. Chow
- Department of Genetics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sa Rang Kim
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey M. Cohen
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christine J. Ko
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
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9
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Ugwu N, Cheraghlou S, Ko CJ, Cohen JM. Incidence, survival, and prognostic factors associated with malignant nodular hidradenoma in the United States. J Am Acad Dermatol 2023; 88:875-877. [PMID: 36228937 DOI: 10.1016/j.jaad.2022.09.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/09/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Nelson Ugwu
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Shayan Cheraghlou
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Christine J Ko
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut; Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Jeffrey M Cohen
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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10
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Xu S, Patrignelli RJ, Ramachandran S, Koumpouras F, Desir D, Ko CJ, Gehlhausen JR. Vascular-Targeted Therapy for Systemic Lupus Erythematosus-Associated Vasculitis. JAMA Dermatol 2023; 159:460-462. [PMID: 36884229 DOI: 10.1001/jamadermatol.2023.0077] [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: 03/09/2023]
Abstract
This case report describes a woman in her 40s with a medical history of systemic lupus erythematosus with 1 year of tender papules, plaques, and progressive ulcers on her hands and feet.
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Affiliation(s)
- Suzanne Xu
- Department of Dermatology, Yale University, New Haven, Connecticut
| | | | | | | | - Deborah Desir
- Department of Rheumatology, Yale University, New Haven, Connecticut
| | - Christine J Ko
- Department of Dermatology, Yale University, New Haven, Connecticut.,Department of Pathology, Yale University, New Haven, Connecticut
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11
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Kim SR, Ko CJ, Nelson CA, Ramachandran S, Gehlhausen JR. Random skin biopsies for diagnosis of intravascular large B-cell lymphoma: Retrospective analysis of 31 biopsies from a US dermatology inpatient consultative service with literature review. J Am Acad Dermatol 2023; 88:714-716. [PMID: 36152693 DOI: 10.1016/j.jaad.2022.09.016] [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: 05/09/2022] [Revised: 08/29/2022] [Accepted: 09/13/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Sa Rang Kim
- Department of Dermatology, Yale University, New Haven, Connecticut
| | - Christine J Ko
- Department of Dermatology, Yale University, New Haven, Connecticut; Department of Pathology, Yale University, New Haven, Connecticut
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12
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Atzmony L, Ugwu N, Bercovitch L, Robinson-Bostom L, Ko CJ, Myung P, Choate KA. Segmental basaloid follicular hamartomas derive from a post-zygotic SMO p.L412F pathogenic variant and express hair follicle development-related proteins in a pattern that distinguish them from basal cell carcinomas. Am J Med Genet A 2022; 188:3525-3530. [PMID: 35972041 PMCID: PMC9669121 DOI: 10.1002/ajmg.a.62951] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/14/2022] [Accepted: 08/01/2022] [Indexed: 01/31/2023]
Abstract
Basaloid follicular hamartomas (BFH) are benign small basaloid skin tumors that can present as solitary or multiple lesions. Congenital BFH lesions arranged in a segmental distribution have been described, suggesting they derive from a somatic post-zygotic mutational event. Previously, BFH were described in Happle-Tinschert syndrome, which results from a post-zygotic SMO variant and is characterized by segmental BFH with variable involvement of the teeth, skeleton, and central nervous system. Here, we describe two patients with isolated segmental BFH and no systemic involvement. Paired whole exome sequencing of BFH and normal tissue revealed a pathogenic SMO c.1234 C>T, p.L412F variant restricted to BFH tissue. We characterized the proliferation index and expression of Hedgehog and Wnt/beta-catenin pathway related proteins in segmental BFH compared to sporadic basal cell carcinomas (BCCs) and found that segmental BFH had a lower proliferation index. Although segmental BFH expressed a similar level of Gli-1 compared to BCCs, levels of LEF-1 and SOX-9 expression in BFH were weaker for both and patchier for LEF-1. Our results show that a somatic SMO activating variant causes segmental BFH. Since these patients are prone to developing BCCs, differences in SOX9, LEF1, and Ki-67 expression can help distinguish between these two basaloid lesions.
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Affiliation(s)
- Lihi Atzmony
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA
- Division of Dermatology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nelson Ugwu
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lionel Bercovitch
- Department of Dermatology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Leslie Robinson-Bostom
- Department of Dermatology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Christine J. Ko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peggy Myung
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Keith A. Choate
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Genetics, Yale University School of Medicine, New Haven, Connecticut, USA
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13
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Talty R, Micevic G, Wang A, Ko CJ, Damsky W. Leukoderma Induced by Rotigotine Patch, a Transdermal Dopamine Agonist. Case Rep Dermatol 2022; 14:214-218. [PMID: 36158852 PMCID: PMC9459519 DOI: 10.1159/000525894] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/30/2022] [Indexed: 11/19/2022] Open
Abstract
Leukoderma, or hypomelanosis of the skin, can occur in response to various chemical and pharmacologic substances ranging from topical medications to optic preparations and systemic medications. In this case report, we present a 78-year-old man with a history of restless leg syndrome (RLS) who had been using rotigotine transdermal patches once daily for 1 year and developed leukoderma on the bilateral anterior shoulders in the area of patch application. Histopathologic examination showed an absence of melanocytes at the dermal-epidermal junction confirmed by Melan A stain. While the patient was not bothered by the depigmentation and elected to continue the rotigotine patch for his RLS, this case highlights leukoderma as a potential side effect of dopamine transdermal patches and offers insight into the potential mechanism of hypopigmentation in response to dopamine agonism.
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Affiliation(s)
- Ronan Talty
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Goran Micevic
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alice Wang
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
- Medical Scientist Training Program, Renaissance School of Medicine at Stony Brook University, New York, New York, USA
| | - Christine J Ko
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
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Vesely M, Martinez-Morales S, Gehlhausen JR, McNiff JM, Whang PG, Rimm D, Ko CJ. Not all well-differentiated cutaneous squamous cell carcinomas are equal: Tumors with disparate biologic behavior have differences in protein expression via digital spatial profiling. J Am Acad Dermatol 2022; 87:695-698. [DOI: 10.1016/j.jaad.2022.03.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/11/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
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15
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Weiss EH, Ko CJ, Leung TH, Micheletti RG, Mostaghimi A, Ramachandran SM, Rosenbach M, Nelson CA. Neutrophilic Dermatoses: a Clinical Update. Curr Derm Rep 2022; 11:89-102. [PMID: 35310367 PMCID: PMC8924564 DOI: 10.1007/s13671-022-00355-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/13/2022]
Abstract
Purpose of Review Neutrophilic dermatoses are defined by the presence of a sterile neutrophilic infiltrate on histopathology. This review focuses on the pathogenesis, epidemiology, clinicopathological features, diagnosis, and management of four disorders: Sweet syndrome, pyoderma gangrenosum, Behçet syndrome, and neutrophilic eccrine hidradenitis. Recent Findings Recent studies have provided insight into the complex pathogenesis of neutrophilic dermatoses. Evidence supports an intricate interplay of abnormal neutrophil function and inflammasome activation, malignant transformation into dermal infiltrating neutrophils, and genetic predisposition. Summary Neutrophilic dermatoses have diverse cutaneous and extracutaneous manifestations and may be associated with significant morbidity and mortality. Common underlying associations include infectious, inflammatory, and neoplastic disorders, as well as drug reactions. Emerging diagnostic and therapeutic frameworks identify an expanding role for biologic and targeted anti-inflammatory therapies.
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16
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Choi R, Ko CJ, Eisenstein A. Skin-limited Langerhans cell histiocytosis presenting as crusted papules in an acneiform distribution in an adolescent man. JAAD Case Rep 2022; 20:37-39. [PMID: 35036502 PMCID: PMC8753055 DOI: 10.1016/j.jdcr.2021.11.024] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Rachel Choi
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Christine J Ko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Anna Eisenstein
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
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Ugwu N, Atzmony L, Ellis KT, Panse G, Jain D, Ko CJ, Nassiri N, Choate KA. Erratum: Cutaneous and hepatic vascular lesions due to a recurrent somatic GJA4 mutation reveal a pathway for vascular malformation. HGG Adv 2022; 3:100061. [PMID: 35047851 DOI: 10.1016/j.xhgg.2021.100061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
[This corrects the article DOI: 10.1016/j.xhgg.2021.100028.].
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18
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Kim SR, McNiff JM, Ko CJ. Clustered intraepidermal lymphocytes and Langerhans cell microgranulomas are consistently observed in hyperkeratotic palmoplantar eczema compared with palmoplantar psoriasis and mycosis fungoides palmaris et plantaris. J Am Acad Dermatol 2021; 87:884-886. [PMID: 34883152 DOI: 10.1016/j.jaad.2021.11.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Sa Rang Kim
- Department of Dermatology, Yale University, New Haven, Connecticut.
| | - Jennifer M McNiff
- Department of Dermatology, Yale University, New Haven, Connecticut; Department of Pathology, Yale University, New Haven, Connecticut
| | - Christine J Ko
- Department of Dermatology, Yale University, New Haven, Connecticut; Department of Pathology, Yale University, New Haven, Connecticut
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19
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Siegel JD, Bhatia A, Ko CJ, Christensen SR. Concurrent development of high-stage cutaneous squamous cell carcinoma during complete response of metastatic cutaneous squamous cell carcinoma to programmed cell death protein 1 blockade with cemiplimab. JAAD Case Rep 2021; 18:23-25. [PMID: 34778502 PMCID: PMC8577130 DOI: 10.1016/j.jdcr.2021.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Jacob D Siegel
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Aarti Bhatia
- Department of Medicine, Section of Medical Oncology, Yale University School of Medicine, New Haven, Connecticut
| | - Christine J Ko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Sean R Christensen
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
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20
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Grossman ME, Appel G, Little AJ, Ko CJ. Post-COVID-19 vaccination IgA vasculitis in an adult. J Cutan Pathol 2021; 49:385-387. [PMID: 34779011 PMCID: PMC8652641 DOI: 10.1111/cup.14168] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 06/01/2021] [Revised: 10/31/2021] [Accepted: 11/09/2021] [Indexed: 12/15/2022]
Abstract
Leukocytoclastic vasculitis has been reported in the setting of COVID‐19 infection and post‐COVID‐19 vaccination. We report a case of IgA vasculitis (IgAV) post‐COVID‐19 vaccination, with immunoglobulin A (IgA) immune deposits in the skin and renal involvement. SARS‐CoV spike protein immunohistochemical staining was negative. IgAV with skin and renal involvement is a potential reaction to COVID‐19 vaccination.
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Affiliation(s)
- Marc E Grossman
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gerald Appel
- Department of Internal Medicine, Columbia University Medical Center, New York, New York, USA
| | - Alicia J Little
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Christine J Ko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
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21
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Ko CJ, Kim R, Fortin AH, Spak JM, Hafler JP. Relationship-Centered Care in the Physician-Patient Interaction: Improving Your Understanding of Metacognitive Interventions. Cutis 2021; 107:320-324. [PMID: 34314316 DOI: 10.12788/cutis.0266] [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: 11/20/2022]
Abstract
The concept of relationship-centered care was first introduced approximately 20 years ago, but this important concept has not yet been widely disseminated in clinical practice. Relationship-centered care in the health profession focuses on all relevant relationships in health care, not only between health care professionals and patients but also among colleagues, staff members, students, community, and self. This review summarizes the key literature to date on relationship-centered care as it pertains to the physician-patient relationship. Becoming more aware of the physician (self) and patient is a form of metacognition, thinking about what is happening in the moment as physicians and patients come together. Considering the complexity of the physician-patient relationship, we can implement simple metacognitive techniques toward the daily habitual practice of relationship-centered care.
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Affiliation(s)
- Christine J Ko
- Drs. Ko, Fortin, and Hafler as well as Ms. Spak are from Yale University, New Haven, Connecticut. Drs. Ko, Fortin, and Hafler are from the School of Medicine. Dr. Kim is from Cooper Medical School of Rowan University, Camden, New Jersey
| | - Rose Kim
- Drs. Ko, Fortin, and Hafler as well as Ms. Spak are from Yale University, New Haven, Connecticut. Drs. Ko, Fortin, and Hafler are from the School of Medicine. Dr. Kim is from Cooper Medical School of Rowan University, Camden, New Jersey
| | - Auguste H Fortin
- Drs. Ko, Fortin, and Hafler as well as Ms. Spak are from Yale University, New Haven, Connecticut. Drs. Ko, Fortin, and Hafler are from the School of Medicine. Dr. Kim is from Cooper Medical School of Rowan University, Camden, New Jersey
| | - Judy M Spak
- Drs. Ko, Fortin, and Hafler as well as Ms. Spak are from Yale University, New Haven, Connecticut. Drs. Ko, Fortin, and Hafler are from the School of Medicine. Dr. Kim is from Cooper Medical School of Rowan University, Camden, New Jersey
| | - Janet P Hafler
- Drs. Ko, Fortin, and Hafler as well as Ms. Spak are from Yale University, New Haven, Connecticut. Drs. Ko, Fortin, and Hafler are from the School of Medicine. Dr. Kim is from Cooper Medical School of Rowan University, Camden, New Jersey
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22
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Wang A, Fogel AL, Murphy MJ, Panse G, McGeary MK, McNiff JM, Bosenberg M, Vesely MD, Cohen JM, Ko CJ, King BA, Damsky W. Cytokine RNA In Situ Hybridization Permits Individualized Molecular Phenotyping in Biopsies of Psoriasis and Atopic Dermatitis. JID Innovations 2021; 1:100021. [PMID: 34909719 PMCID: PMC8659380 DOI: 10.1016/j.xjidi.2021.100021] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/23/2021] [Accepted: 03/30/2021] [Indexed: 12/13/2022] Open
Abstract
Detection of individual cytokines in routine biopsies from patients with inflammatory skin diseases has the potential to personalize diagnosis and treatment selection, but this approach has been limited by technical feasibility. We evaluate whether a chromogen-based RNA in situ hybridization approach can be used to detect druggable cytokines in psoriasis and atopic dermatitis. A series of psoriasis (n = 20) and atopic dermatitis (n = 26) biopsies were stained using RNA in situ hybridization for IL4, IL12B (IL-12/23 p40), IL13, IL17A, IL17F, IL22, IL23A (IL-23 p19), IL31, and TNF (TNF-α). NOS2 and IFNG, canonical psoriasis biomarkers, were also included. All 20 of the psoriasis cases were positive for IL17A, which tended to be the predominant cytokine, although some cases had relatively higher levels of IL12B, IL17F, or IL23A. The majority of cytokine expression in psoriasis was epidermal. A total of 22 of 26 atopic dermatitis cases were positive for IL13, also at varying levels; a subset of cases had significant IL4, IL22, or IL31 expression. Patterns were validated in independent bulk RNA-sequencing and single-cell RNA-sequencing datasets. Overall, RNA in situ hybridization for cytokines appears highly specific with virtually no background staining and may allow for individualized evaluation of treatment-relevant cytokine targets in biopsies from patients with inflammatory skin disorders.
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Abstract
Although clinicians often put vasculitis and microvascular occlusion in the same differential diagnosis, biopsy findings often are either vasculitis or occlusion. However, both vasculitis and occlusion are present in some cases of levamisole-associated vasculopathy and certain infections. Depth of dermal involvement and vessel size should be reported, because superficial and deep small vessel leukocytoclastic vasculitis and/or involvement of medium-sized vessels may be associated with systemic disease. Microvascular occlusion of vessels in the fat should prompt consideration of calciphylaxis. Clues to ultimate clinical diagnosis can be garnered from depth of involvement, size of vessels affected, and presence of both vasculitis and occlusion.
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Affiliation(s)
- Christine J Ko
- Department of Dermatology, Yale University, 333 Cedar Street, PO Box 208059, New Haven, CT 06520, USA; Department of Pathology, Yale University, 310 Cedar St, New Haven, CT 06511, USA.
| | - Jeff R Gehlhausen
- Department of Dermatology, Yale University, 333 Cedar Street, PO Box 208059, New Haven, CT 06520, USA
| | - Jennifer M McNiff
- Department of Dermatology, Yale University, 333 Cedar Street, PO Box 208059, New Haven, CT 06520, USA; Department of Pathology, Yale University, 310 Cedar St, New Haven, CT 06511, USA
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24
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Ko CJ, Wang A, Panse G, Lee EE, Wang RC, Whang PG, Bosenberg M, Damsky W. HPyV6- and HPyV7-negative parakeratosis and dyskeratosis in squamous cell carcinoma in situ. J Cutan Pathol 2021; 48:998-1000. [PMID: 33813761 DOI: 10.1111/cup.14022] [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: 12/30/2020] [Revised: 03/16/2021] [Accepted: 03/31/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Christine J Ko
- Department of Dermatology, Yale University Medical School, New Haven, Connecticut, USA.,Department of Pathology, Yale University Medical School, New Haven, Connecticut, USA
| | - Alice Wang
- Department of Dermatology, Yale University Medical School, New Haven, Connecticut, USA
| | - Gauri Panse
- Department of Dermatology, Yale University Medical School, New Haven, Connecticut, USA.,Department of Pathology, Yale University Medical School, New Haven, Connecticut, USA
| | | | - Richard C Wang
- Department of Dermatology, University of Texas Southwestern, Dallas, Texas, USA
| | - Peter G Whang
- Department of Orthopaedic Surgery, Yale University Medical School, New Haven, Connecticut, USA
| | - Marcus Bosenberg
- Department of Dermatology, Yale University Medical School, New Haven, Connecticut, USA.,Department of Pathology, Yale University Medical School, New Haven, Connecticut, USA
| | - William Damsky
- Department of Dermatology, Yale University Medical School, New Haven, Connecticut, USA.,Department of Pathology, Yale University Medical School, New Haven, Connecticut, USA
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25
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Ugwu N, Atzmony L, Ellis KT, Panse G, Jain D, Ko CJ, Nassiri N, Choate KA. Cutaneous and hepatic vascular lesions due to a recurrent somatic GJA4 mutation reveal a pathway for vascular malformation. HGG Adv 2021; 2. [PMID: 33912852 PMCID: PMC8078848 DOI: 10.1016/j.xhgg.2021.100028] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The term “cavernous hemangioma” has been used to describe vascular anomalies with histology featuring dilated vascular spaces, vessel walls consisting mainly of fibrous stromal bands lined by a layer of flattened endothelial cells, and an irregular outer rim of interrupted smooth muscle cells. Hepatic hemangiomas (HHs) and cutaneous venous malformations (VMs) share this histologic pattern, and we examined lesions in both tissues to identify genetic drivers. Paired whole-exome sequencing (WES) of lesional tissue and normal liver in HH subjects revealed a recurrent GJA4 c.121G>T (p.Gly41Cys) somatic mutation in four of five unrelated individuals, and targeted sequencing in paired tissue from 9 additional HH individuals identified the same mutation in 8. In cutaneous lesions, paired targeted sequencing in 5 VMs and normal epidermis found the same GJA4 c.121G>T (p.Gly41Cys) somatic mutation in three. GJA4 encodes gap junction protein alpha 4, also called connexin 37 (Cx37), and the p.Gly41Cys mutation falls within the first transmembrane domain at a residue highly conserved among vertebrates. We interrogated the impact of the Cx37 mutant via lentiviral transduction of primary human endothelial cells. We found that the mutant induced changes in cell morphology and activated serum/glucocorticoid-regulated kinase 1 (SGK1), a serine/threonine kinase known to regulate cell proliferation and apoptosis, via non-canonical activation. Treatment with spironolactone, an inhibitor of angiogenesis, suppressed mutant SGK1 activation and reversed changes in cell morphology. These findings identify a recurrent somatic GJA4 c.121G>T mutation as a driver of hepatic and cutaneous VMs, revealing a new pathway for vascular anomalies, with spironolactone a potential pathogenesis-based therapy.
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Affiliation(s)
- Nelson Ugwu
- Department of Dermatology, School of Medicine, Yale University, New Haven, CT 06510, USA.,Vascular Malformations Program (VaMP), Yale New Haven Hospital, New Haven, CT, USA
| | - Lihi Atzmony
- Department of Dermatology, School of Medicine, Yale University, New Haven, CT 06510, USA.,Department of Genetics, Yale University School of Medicine, New Haven, CT, USA.,Department of Pathology, Yale University School of Medicine, New Haven, CT, USA.,Vascular Malformations Program (VaMP), Yale New Haven Hospital, New Haven, CT, USA
| | - Katharine T Ellis
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
| | - Gauri Panse
- Department of Dermatology, School of Medicine, Yale University, New Haven, CT 06510, USA.,Department of Pathology, Yale University School of Medicine, New Haven, CT, USA.,Vascular Malformations Program (VaMP), Yale New Haven Hospital, New Haven, CT, USA
| | - Dhanpat Jain
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA.,Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Christine J Ko
- Department of Dermatology, School of Medicine, Yale University, New Haven, CT 06510, USA.,Department of Pathology, Yale University School of Medicine, New Haven, CT, USA.,Vascular Malformations Program (VaMP), Yale New Haven Hospital, New Haven, CT, USA
| | - Naiem Nassiri
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT 06510, USA.,Vascular Malformations Program (VaMP), Yale New Haven Hospital, New Haven, CT, USA.,Senior author
| | - Keith A Choate
- Department of Dermatology, School of Medicine, Yale University, New Haven, CT 06510, USA.,Department of Genetics, Yale University School of Medicine, New Haven, CT, USA.,Department of Pathology, Yale University School of Medicine, New Haven, CT, USA.,Vascular Malformations Program (VaMP), Yale New Haven Hospital, New Haven, CT, USA.,Senior author
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Abstract
OBJECTIVES Plasma cell myeloma (PCM) involving skin is rare and occurs in 1% to 4% of patients with PCM. We evaluated the clinicopathologic features, cytogenetic findings and clinical follow-up in a series of PCM cases with cutaneous involvement. METHODS Cases of PCM with cutaneous involvement were retrospectively reviewed with clinical data. RESULTS Skin involvement in PCM occurred in older individuals (mean, 75 years) and was more frequent in men (7/10 patients). All cases showed bone marrow involvement preceding the cutaneous lesions. Histopathologically, the infiltrate was plasmacytic (n = 5) or primitive or plasmablastic (n = 4), and 1 case showed predominantly lymphoplasmacytic features with cyclin D1 immunoreactivity and CCND1 gene rearrangement. Concurrent amyloid deposition was seen in one biopsy, and another case demonstrated coexisting squamous cell carcinoma. The most common immunophenotype was CD138+, CD20-, and CD56+ with light chain restriction. Cytogenetic analysis (available for 7 cases) showed multiple hyperdiploid abnormalities. Follow-up was available for 8 cases (mean, 42 months; range, 11-156 months) and showed short-term disease-related death in 7 of 8 patients. CONCLUSIONS Cutaneous involvement in PCM demonstrates a diverse cytomorphologic spectrum with plasmacytic, plasmablastic, or lymphoplasmacytic features and may show concurrent amyloid deposition or neoplasms such as squamous cell carcinoma. Cutaneous involvement typically occurs late in the course of the disease and likely portends poor outcome.
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Affiliation(s)
- Gauri Panse
- Department of Dermatology, Yale School of Medicine, New Haven, CT
- Department of Pathology, Yale School of Medicine, New Haven, CT
| | - Antonio Subtil
- Department of Dermatology, Yale School of Medicine, New Haven, CT
- Department of Pathology, Yale School of Medicine, New Haven, CT
| | - Jennifer M McNiff
- Department of Dermatology, Yale School of Medicine, New Haven, CT
- Department of Pathology, Yale School of Medicine, New Haven, CT
| | - Earl J Glusac
- Department of Dermatology, Yale School of Medicine, New Haven, CT
- Department of Pathology, Yale School of Medicine, New Haven, CT
| | - Christine J Ko
- Department of Dermatology, Yale School of Medicine, New Haven, CT
- Department of Pathology, Yale School of Medicine, New Haven, CT
| | - Anjela Galan
- Department of Dermatology, Yale School of Medicine, New Haven, CT
- Department of Pathology, Yale School of Medicine, New Haven, CT
| | - Peggy Myung
- Department of Dermatology, Yale School of Medicine, New Haven, CT
- Department of Pathology, Yale School of Medicine, New Haven, CT
| | - Mina L Xu
- Department of Pathology, Yale School of Medicine, New Haven, CT
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27
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Gehlhausen JR, Ko CJ, Damsky W. Response to Tembhre et al.: 'Enhanced expression of angiotensin-converting enzyme 2 in psoriatic skin and its upregulation in keratinocytes by interferon-γ: implication of inflammatory milieu in skin tropism of SARS-CoV-2'. Br J Dermatol 2020; 184:984. [PMID: 33300150 PMCID: PMC9619457 DOI: 10.1111/bjd.19714] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/01/2020] [Accepted: 12/07/2020] [Indexed: 01/11/2023]
Abstract
Linked Article: Tembhre et al. Br J Dermatol 2021; 184:577–579.
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Affiliation(s)
- J R Gehlhausen
- Departments of Dermatology and Dermatopathology, Yale School of Medicine, New Haven, CT, USA
| | - C J Ko
- Departments of Dermatology and Dermatopathology, Yale School of Medicine, New Haven, CT, USA
| | - W Damsky
- Departments of Dermatology and Dermatopathology, Yale School of Medicine, New Haven, CT, USA
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28
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Ko CJ, Harigopal M, Gehlhausen JR, Bosenberg M, McNiff JM, Damsky W. Discordant anti-SARS-CoV-2 spike protein and RNA staining in cutaneous perniotic lesions suggests endothelial deposition of cleaved spike protein. J Cutan Pathol 2020; 48:47-52. [PMID: 32895985 DOI: 10.1111/cup.13866] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [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: 07/15/2020] [Revised: 08/10/2020] [Accepted: 09/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Prior studies have shown the presence of immunohistochemical staining for the SARS-CoV-2 spike protein (SP) in endothelial cells and eccrine epithelium of acral perniosis classified as "COVID toes." Yet, other studies have been unable to detect SARS-CoV-2 RNA in skin biopsies of "COVID toes" by reverse-transcriptase polymerase chain reaction testing. OBJECTIVE In order to address these apparently conflicting findings, we compared detection of SARS-CoV-2 SP, through RNA in situ hybridization (ISH) vs immunohistochemistry (IHC), in skin biopsies of acral perniotic lesions presenting during the COVID-19 pandemic. RESULTS Three of six cases showed positive immunohistochemical labeling of endothelial cells, with one of three cases with sufficient depth also having labeling of eccrine glands, using an anti-SP SARS-CoV-2 antibody. These three cases positive with IHC were negative for SP by RNA ISH. CONCLUSION While the gold standard for detection of SARS-CoV-2 in tissue sections has yet to be determined, the detection of SARS-CoV-2 SP alone without spike RNA suggests that cleaved SP may be present in cutaneous endothelial cells and eccrine epithelium, providing a potential pathogenetic mechanism of COVID-19 endotheliitis.
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Affiliation(s)
- Christine J Ko
- Department of Dermatology, Yale Medical School, New Haven, Connecticut, USA.,Department of Pathology, Yale Medical School, New Haven, Connecticut, USA
| | - Malini Harigopal
- Department of Pathology, Yale Medical School, New Haven, Connecticut, USA
| | - Jeff R Gehlhausen
- Department of Dermatology, Yale Medical School, New Haven, Connecticut, USA
| | - Marcus Bosenberg
- Department of Dermatology, Yale Medical School, New Haven, Connecticut, USA.,Department of Pathology, Yale Medical School, New Haven, Connecticut, USA
| | - Jennifer M McNiff
- Department of Dermatology, Yale Medical School, New Haven, Connecticut, USA.,Department of Pathology, Yale Medical School, New Haven, Connecticut, USA
| | - William Damsky
- Department of Dermatology, Yale Medical School, New Haven, Connecticut, USA.,Department of Pathology, Yale Medical School, New Haven, Connecticut, USA
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29
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Ko CJ, Harigopal M, Damsky W, Gehlhausen JR, Bosenberg M, Patrignelli R, McNiff JM. Perniosis during the COVID-19 pandemic: Negative anti-SARS-CoV-2 immunohistochemistry in six patients and comparison to perniosis before the emergence of SARS-CoV-2. J Cutan Pathol 2020; 47:997-1002. [PMID: 32745281 PMCID: PMC7436569 DOI: 10.1111/cup.13830] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 06/16/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Acral inflammatory lesions that have some resemblance to idiopathic or autoimmune-associated perniosis (chilblains) have been described in multiple countries during the COVID-19 pandemic. METHODS We examined histopathologic findings in six consecutive such cases from five patients received in mid-May to mid-June of 2020, evaluating immunohistochemical staining for the SARS-CoV-2 nucleocapsid protein. We compared these six cases to eight cases diagnosed as perniosis between January and June of 2019. RESULTS Five of six lesions with perniosis-like histopathology during the COVID-19 pandemic had distinctive tight cuffing of lymphocytes; intravascular material was present in one case. SARS-CoV-2 immunohistochemical staining using an antibody directed at the nucleocapsid protein was negative in all six cases. Only one of eight specimens with microscopic findings of perniosis received prior to the COVID-19 pandemic had tightly cuffed perivascular lymphocytes, and none had obvious intravascular occlusion. CONCLUSIONS A tightly cuffed pattern of perivascular lymphocytes is a feature of perniosis during the COVID-19 pandemic. The absence of SARS-CoV-2 nucleocapsid protein in these cases suggests against the virus being directly present in these lesions.
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Affiliation(s)
- Christine J Ko
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA.,Department of Pathology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - Malini Harigopal
- Department of Pathology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - William Damsky
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA.,Department of Pathology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - Jeff R Gehlhausen
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - Marcus Bosenberg
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA.,Department of Pathology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - Robert Patrignelli
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
| | - Jennifer M McNiff
- Department of Dermatology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA.,Department of Pathology, Yale Department of Dermatology, Yale University, New Haven, Connecticut, USA
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30
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Gehlhausen J, Sibindi C, Ko CJ, Grant M, Zubek A. A rare case of lupoid leishmaniasis defying diagnosis for a decade. J Cutan Pathol 2020; 47:1054-1057. [DOI: 10.1111/cup.13793] [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: 03/27/2020] [Revised: 05/31/2020] [Accepted: 07/01/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Jeff Gehlhausen
- Department of Dermatology Yale University, School of Medicine New Haven Connecticut USA
| | - Cosmas Sibindi
- Section of Infectious Disease Yale University, School of Medicine New Haven Connecticut USA
| | - Christine J. Ko
- Department of Dermatology Yale University, School of Medicine New Haven Connecticut USA
| | - Matthew Grant
- Section of Infectious Disease Yale University, School of Medicine New Haven Connecticut USA
| | - Amanda Zubek
- Department of Dermatology Yale University, School of Medicine New Haven Connecticut USA
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31
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Yumeen S, Mirza FN, Mirza HN, Ko CJ, Cohen JM. Primary cutaneous adenoid cystic carcinoma: Characterizing US demographics, clinical course, and prognostic factors. J Am Acad Dermatol 2020; 85:245-247. [PMID: 32798575 DOI: 10.1016/j.jaad.2020.08.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/02/2020] [Accepted: 08/07/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Sara Yumeen
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Fatima N Mirza
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Humza N Mirza
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Christine J Ko
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut; Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Jeffrey M Cohen
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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32
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Gehlhausen JR, Wetter DA, Nelson C, Ramachandran S, McNiff JM, Ko CJ. A detailed analysis of the distribution, morphology, and histopathology of complex purpura in hospitalized patients: A case series of 68 patients. J Am Acad Dermatol 2020; 84:1188-1196. [PMID: 32376433 DOI: 10.1016/j.jaad.2020.04.149] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Purpura in inpatients commonly leads to dermatologic consultation. The differential diagnosis is broad and algorithms are intricate. OBJECTIVE We evaluated inpatient consultations for complex purpura to document the most common diagnoses and to validate the true diagnostic utility of histopathology, clinical morphology, and distribution. METHODS We reviewed a case series of 68 inpatients during a 4-year period with a dermatologic consultation for purpura and biopsy findings of vasculitis or microvascular occlusion. RESULTS Key features of complex purpura are nonbranching (round) versus branching (retiform) morphology, dependent versus acral or generalized distribution, and leukocytoclastic vasculitis versus microvascular occlusion (with emphasis on depth of involvement). Dependent nonbranching purpura with only superficial vessels involved by leukocytoclastic vasculitis was most often due to IgA vasculitis or cutaneous single-organ small-vessel vasculitis. In contrast, deeper involvement by leukocytoclastic vasculitis was suggestive of systemic disease (eg, antineutrophil cytoplasmic antibody-associated vasculitis). Branching purpura was concerning, with greater than 90% sensitivity and specificity for microvascular occlusion and associated high mortality (≈50%). The majority of patients who died had acral branching lesions. LIMITATIONS Small sample size, inpatients at a tertiary care center, and retrospective nature are some limitations. CONCLUSION Nonbranching dependent purpura corresponded to leukocytoclastic vasculitis, with the most common diagnoses being IgA vasculitis or skin-limited small-vessel vasculitis; patients with deep involvement often had systemic diseases. In this series, branching purpura was due to microvascular occlusion rather than medium-vessel vasculitis, and had associated high mortality.
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Affiliation(s)
- Jeff R Gehlhausen
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut
| | - David A Wetter
- Mayo Clinic Department of Dermatology, Rochester, Minnesota
| | - Caroline Nelson
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut
| | | | - Jennifer M McNiff
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut; Department of Pathology, New Haven, Connecticut
| | - Christine J Ko
- Yale School of Medicine Department of Dermatology, New Haven, Connecticut; Department of Pathology, New Haven, Connecticut.
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Siegel JD, Ko CJ. Diltiazem-associated Photodistributed Hyperpigmentation. Yale J Biol Med 2020; 93:45-47. [PMID: 32226335 PMCID: PMC7087047] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Diltiazem is a calcium-channel blocker commonly used for the treatment of hypertension. Common adverse effects include dizziness, headache, and edema. Fewer than 20 cases of diltiazem-associated photodistributed hyperpigmentation have been reported in the literature. Here, we present the case of a 71-year-old woman with new-onset facial hyperpigmentation 6 months after initiating treatment with diltiazem.
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Affiliation(s)
- Jacob D. Siegel
- To whom all correspondence should be addressed: Jacob D. Siegel, LMP 5031 Department of Dermatology, New Haven, CT, 06520; ORCID iD: 0000-0002-0086-6272, Tel: 516-476-4071, Fax: 203-785-7637,
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Charifa A, Paulson N, Levy L, Perincheri S, Lee A, McNiff JM, Ko CJ. Intravascular Large B-Cell Lymphoma: Clinical and Histopathologic Findings. Yale J Biol Med 2020; 93:35-40. [PMID: 32226333 PMCID: PMC7087051] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Intravascular large B-cell lymphoma (IVLBCL) is a rare subset of extranodal non-Hodgkin lymphoma characterized by neoplastic lymphocytes within the lumina of small to medium-sized blood vessels. IVLBCLs are B-cell tumors that can present in essentially any organ system, including the skin. Cutaneous manifestations vary greatly and can mimic other skin disease which may delay diagnosis; in the absence of skin lesions, blind skin biopsies can be utilized for diagnosis. Early studies suggested that IVLBCL is a very aggressive lymphoma with high overall mortality rate and short survival times. However, earlier diagnosis and use of new treatment modalities have shown promise in recent studies. This case series illustrates the heterogeneity of clinical and pathologic presentations of this uncommon lymphoma.
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Affiliation(s)
- Ahmad Charifa
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Nathan Paulson
- Department of Pathology, Yale University School of Medicine, New Haven, CT,To whom all correspondence should be addressed: Nathan Paulson, MD, 200 S Frontage Rd EP2-612A, New Haven, CT, 06510; Tel: 203-747-4378,
| | - Lauren Levy
- Department of Dermatology, Yale University School of Medicine, New Haven, CT
| | - Sudhir Perincheri
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Alfred Lee
- Department of Hematology, Yale University School of Medicine, New Haven, CT
| | - Jennifer M. McNiff
- Department of Pathology, Yale University School of Medicine, New Haven, CT,Department of Dermatology, Yale University School of Medicine, New Haven, CT
| | - Christine J. Ko
- Department of Pathology, Yale University School of Medicine, New Haven, CT,Department of Dermatology, Yale University School of Medicine, New Haven, CT
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Atzmony L, Khan HM, Lim YH, Paller AS, Levinsohn JL, Holland KE, Mirza FN, Yin E, Ko CJ, Leventhal JS, Choate KA. Second-Hit, Postzygotic PMVK and MVD Mutations in Linear Porokeratosis. JAMA Dermatol 2020; 155:548-555. [PMID: 30942823 DOI: 10.1001/jamadermatol.2019.0016] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Linear porokeratosis features linear and whorled configurations of keratotic papules and plaques, with coronoid lamellae present on histologic examination. Because linear porokeratosis manifests in the lines of Blaschko representing the dorsoventral migration patterns of keratinocyte precursors, it has been suggested that postzygotic somatic mutation underlies the disease. However, no genetic evidence has supported this hypothesis to date. Objective To identify genetic mutations associated with linear porokeratosis. Design, Setting, and Participants Paired whole-exome sequencing of affected skin and blood/saliva samples from 3 participants from 3 academic medical centers with clinical and histologic diagnoses of linear porokeratosis. Interventions or Exposures Whole-exome sequencing of paired blood/saliva and affected tissue samples isolated from linear porokeratosis lesions. Main Outcomes and Measures Germline and somatic genomic characteristics of participants with linear porokeratosis. Results Of the 3 participants, 2 were male. Participant ages ranged from 5 to 20 years old. We found a combination of a novel germline mutation and a novel somatic mutation within affected tissue in all cases. One participant had a germline heterozygous PMVK c.329G>A mutation and a somatic copy-neutral loss of heterozygosity confined to the lesional skin, while a second had a germline heterozygous PMVK c.79G>T mutation and an additional PMVK c.379C>T mutation in the lesional skin. In a third participant, there was a germline splice-site mutation in MVD (c.70 + 5G>A) and a somatic deletion in MVD causing frameshift and premature codon termination within the lesional skin (c.811_815del, p.F271Afs*33 frameshift). Conclusions and Relevance Our findings suggest that linear porokeratosis is associated with the presence of second-hit postzygotic mutations in the genes that encode enzymes within the mevalonate biosynthesis pathway, and provide further evidence that the mevalonate pathway may be a potential target for therapeutic intervention in porokeratosis.
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Affiliation(s)
- Lihi Atzmony
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Habib M Khan
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Young H Lim
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut.,Department of Genetics, Yale University School of Medicine, New Haven, Connecticut
| | - Amy S Paller
- Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonathan L Levinsohn
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut.,Department of Genetics, Yale University School of Medicine, New Haven, Connecticut
| | | | - Fatima Nadeem Mirza
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Emily Yin
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Christine J Ko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan S Leventhal
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Keith A Choate
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut.,Department of Genetics, Yale University School of Medicine, New Haven, Connecticut
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Ring NG, Craiglow BG, Panse G, Antaya RJ, Ashack K, Ashack R, Faith EF, Paller AS, McNiff JM, Choate KA, Ko CJ. Histopathologic findings characteristic of CARD14-associated papulosquamous eruption. J Cutan Pathol 2019; 47:425-430. [PMID: 31849081 DOI: 10.1111/cup.13633] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 12/25/2018] [Revised: 10/24/2019] [Accepted: 12/05/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Pathogenic mutations in caspase recruitment domain-containing protein 14 (CARD14) lead to CARD14-associated papulosquamous eruption, which shares clinicopathologic findings with psoriasis and pityriasis rubra pilaris. We aimed to describe distinguishing histopathologic features of CARD14-associated papulosquamous eruption. METHODS This retrospective study examined the histopathologic features of specimens from patients with confirmed CARD14-associated papulosquamous eruption and adult patients with plaque psoriasis and pityriasis rubra pilaris. RESULTS Lesional skin biopsies from patients with CARD14-associated papulosquamous eruption consistently showed alternating checkerboard parakeratosis and orthokeratosis, acanthosis without acantholysis, and dilated vessels in the dermal papillae, with some cases also showing follicular plugging. CONCLUSION CARD14-associated papulosquamous eruption has a range of findings, with a predominance of features typically associated with pityriasis rubra pilaris.
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Affiliation(s)
- Nan G Ring
- Department of Dermatology, Yale University, New Haven, Connecticut
| | | | - Gauri Panse
- Department of Dermatology, Yale University, New Haven, Connecticut.,Department of Pathology, Yale University, New Haven, Connecticut
| | - Richard J Antaya
- Department of Dermatology, Yale University, New Haven, Connecticut
| | - Kurt Ashack
- Department of Dermatology, University of Illinois at Chicago, Chicago, Illinois
| | - Richard Ashack
- Dermatology Associates of West Michigan, Grand Rapids, Michigan
| | - Esteban F Faith
- Department of Pediatrics and Dermatology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Amy S Paller
- Department of Dermatology, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jennifer M McNiff
- Department of Dermatology, Yale University, New Haven, Connecticut.,Department of Pathology, Yale University, New Haven, Connecticut
| | - Keith A Choate
- Department of Dermatology, Yale University, New Haven, Connecticut
| | - Christine J Ko
- Department of Dermatology, Yale University, New Haven, Connecticut.,Department of Pathology, Yale University, New Haven, Connecticut
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Roy SF, Ko CJ, McNiff JM. Human papillomavirus-related verrucous cysts and hypergranulotic dyscornification within a cyst are likely distinct entities. J Cutan Pathol 2019; 47:314-315. [PMID: 31808963 DOI: 10.1111/cup.13625] [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: 11/06/2019] [Revised: 11/16/2019] [Accepted: 11/19/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Simon F Roy
- Department of Pathology, University of Montréal, Montréal, Canada
| | - Christine J Ko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer M McNiff
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
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38
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Lowenstein EJ, Sidlow R, Ko CJ. Visual perception, cognition, and error in dermatologic diagnosis: Diagnosis and error. J Am Acad Dermatol 2019; 81:1237-1245. [DOI: 10.1016/j.jaad.2018.12.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/18/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
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Ko CJ, Atzmony L, Lim Y, McNiff JM, Craiglow BG, Antaya RJ, Choate KA. Review of genodermatoses with characteristic histopathology and potential diagnostic delay. J Cutan Pathol 2019; 46:756-765. [DOI: 10.1111/cup.13520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/16/2019] [Accepted: 05/28/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Christine J. Ko
- Department of DermatologyYale University Medical School New Haven Connecticut
| | - Lihi Atzmony
- Department of DermatologyYale University Medical School New Haven Connecticut
| | - Young Lim
- Department of DermatologyYale University Medical School New Haven Connecticut
| | - Jennifer M. McNiff
- Department of DermatologyYale University Medical School New Haven Connecticut
| | | | - Richard J. Antaya
- Department of DermatologyYale University Medical School New Haven Connecticut
| | - Keith A. Choate
- Department of DermatologyYale University Medical School New Haven Connecticut
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40
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Roy SF, Ko CJ, Moeckel GW, Mcniff JM. Hypergranulotic dyscornification: 30 cases of a striking epithelial reaction pattern. J Cutan Pathol 2019; 46:742-747. [PMID: 31157457 DOI: 10.1111/cup.13522] [Citation(s) in RCA: 2] [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: 04/13/2019] [Revised: 05/13/2019] [Accepted: 05/28/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hypergranulotic dyscornification (HD) is a rarely reported histological reaction pattern that may be observed in solitary benign keratoses. OBJECTIVE AND METHODS We retrospectively reviewed all cases described as displaying "hypergranulotic dyscornification" at our institution between January 1st 1990 to September 1st 2018. We excluded cases that on retrospective review displayed changes of epidermolytic hyperkeratosis. We conducted electron microscopy (EM) of two lesions. RESULTS Thirty cases were identified in our search. Eleven patients were men and 19 were women. Their mean age was 56.9 ± 21.2 years. In contrast to previous reports, we found that HD does not spare the head and neck area. Frequent clinical impressions were inflamed seborrheic keratosis, Bowen disease or inflamed verruca. The most distinctive histopathologic finding was the presence of a prominent granular layer with clumped perinuclear keratohyaline granules. Some cases had mounds of rounded, anucleate glassy eosinophilic corneocytes in the stratum corneum. We observed one case of incidental HD occurring in an epidermoid cyst. EM of HD showed dense perinuclear bands which appeared to match areas of positive staining by keratin immunohistochemistry, without evidence of pale cytoplasmic areas devoid of keratin filaments, characteristic of epidermolytic hyperkeratosis. CONCLUSION HD is a reproducible finding in some benign keratoses, probably because of abnormal keratinization. Awareness of this unique reaction pattern will help prevent misdiagnosis.
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Affiliation(s)
- Simon F Roy
- Department of Pathology, University of Montréal, Montréal, Canada
| | - Christine J Ko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Gilbert W Moeckel
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer M Mcniff
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
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41
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Cheng JY, Li FY, Ko CJ, Colegio OR. Cutaneous Squamous Cell Carcinomas in Solid Organ Transplant Recipients Compared With Immunocompetent Patients. JAMA Dermatol 2019; 154:60-66. [PMID: 29167858 DOI: 10.1001/jamadermatol.2017.4506] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Solid organ transplant recipients (SOTRs) have a 100-fold increased risk of squamous cell carcinoma (SCC), and they may develop more aggressive SCCs compared with immunocompetent individuals. Objective To compare outcomes associated with aggressive behavior of SCC in SOTRs and high-risk immunocompetent patients. Design, Setting, and Participants A retrospective cohort study of 58 SOTRs and 40 immunocompetent patients evaluated at the Yale Transplant Dermatology Clinic in New Haven, Connecticut, who had at least 1 SCC confirmed histopathologically between January 1, 2008, and December 31, 2015. Cumulative follow-up time for this study was 369 patient-years. Exposure Immunosuppressive medication regimen for SOTRs. Main Outcomes and Measures The primary outcome measure was tumor depth of SCC. Secondary outcome measures that reflected tumor aggressiveness included perineural invasion, regional metastases, nodal metastases, disease-specific death, and overall death. Results Of the 58 SOTR study participants, 14 were women and 44 were men; the mean (SD) age was 61.3 (8.4) years. Of the 40 immunocompetent study participants, 16 were women and 24 were men; the mean (SD) age was 69.8 (10.9) years, resulting in a statistically significant difference from the SOTR group. The mean (SD) number of years that SOTRs were immunosuppressed was 14.6 (9.2) years (range, 2-37 years). The SOTR and immunocompetent groups were statistically comparable regarding race and sex, patient care, follow-up time, numbers of skin lesions, and field cancerization and chemopreventive therapies. The SOTR group had a significantly higher annual frequency of visits (mean [SD], 4 [2] vs 3 [2] office visits per patient per year, P = .02) and annual biopsy rates (mean [SD], 6 [4] vs 5 [3] biopsies per patient per year, P = .04). The SOTRs developed SCCs that did not appear to be significantly more aggressive than those found in the immunocompetent control group. These SOTRs also did not develop significantly thicker tumors than the immunocompetent control group (median [IQR] tumor depth, 1.30 [0.90-1.60] mm in 35 SOTRs vs 1.22 [1.10-1.60] mm in 20 immunocompetent patients). Conclusions and Relevance The increased risk and the potential for aggressive behavior of SCCs in SOTRs may be successfully managed at a level comparable to that in high-risk immunocompetent individuals through close adherence to current dermatologic surveillance recommendations and a marginally lower threshold for biopsy of suspicious lesions for SOTRs.
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Affiliation(s)
- Joyce Y Cheng
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Fang-Yong Li
- Yale Center for Analytical Sciences, New Haven, Connecticut
| | - Christine J Ko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Oscar R Colegio
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale University School of Medicine, New Haven, Connecticut.,Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.,Yale Cancer Center, Yale-New Haven Hospital, New Haven, Connecticut.,Yale Transplant Dermatology Clinic, Yale-New Haven Transplantation Center, New Haven, Connecticut
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Abstract
Skin tags are fairly common lesions usually seen in adults on the neck and in body folds. The sacrococcygeal region is an unusual location for skin tags in children and may represent a congenital malformation of the spine or an isolated skin lesion. In this review, we summarize the clinical presentation, histopathologic changes, and differential diagnosis of coccygeal polypoid eccrine nevus as a rare cause of sacrococcygeal papules in children.
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Affiliation(s)
- Ahmad Charifa
- From the Department of Pathology (Dr Charifa) and the Department of Dermatology (Dr Ko), Yale School of Medicine, New Haven, Connecticut
| | - Christine J Ko
- From the Department of Pathology (Dr Charifa) and the Department of Dermatology (Dr Ko), Yale School of Medicine, New Haven, Connecticut
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43
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Totonchy MB, Leventhal JS, Ko CJ, Leffell DJ. Hypertrophic Lichen Planus and Well-Differentiated Squamous Cell Carcinoma: A Diagnostic Conundrum. Dermatol Surg 2018; 44:1466-1470. [PMID: 29360655 DOI: 10.1097/dss.0000000000001465] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Mariam B Totonchy
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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44
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Ko CJ, Myung P, Leffell DJ, Bourdon JC. Cutaneous immunohistochemical staining pattern of p53β isoforms. J Clin Pathol 2018; 71:1120-1122. [PMID: 30305316 DOI: 10.1136/jclinpath-2018-205098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 02/14/2018] [Revised: 09/03/2018] [Accepted: 09/17/2018] [Indexed: 01/29/2023]
Abstract
p53 is considered the guardian of the genome and as such has numerous functions. The TP53 gene is the most commonly mutated gene in cancer, and yet the exact biological significance of such mutations remains unclear. There are at least 12 different isoforms of p53, and the complexity of the p53 pathway may be in part related to these isoforms. Prior research has often not teased out what isoforms of p53 are being studied, and there is evidence in the literature that p53 isoforms are expressed differently. In this paper, we document the staining pattern of p53β isoforms in the skin and correlate it with mutational status in a subgroup of squamous proliferations of the skin. p53β isoforms are present in the cytoplasm of the differentiated layer of the epidermis and hair follicles (granular layer, infundibular and isthmus-catagen). p53β isoforms are diffusely expressed within the cytoplasm of well-differentiated squamous tumours with tetramerisation (C-terminal) domain mutations in TP53 Our results lend support to p53β isoforms being a marker of differentiation in keratinocytes.
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Affiliation(s)
- Christine J Ko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peggy Myung
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - David J Leffell
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA
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Kibbi N, Totonchy M, Suozzi KC, Ko CJ, Odell ID. A case of subungual tumors of incontinentia pigmenti: A rare manifestation and association with bipolar disease. JAAD Case Rep 2018; 4:737-741. [PMID: 30167449 PMCID: PMC6113656 DOI: 10.1016/j.jdcr.2018.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Nour Kibbi
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Mariam Totonchy
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Kathleen C Suozzi
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Christine J Ko
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Ian D Odell
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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46
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Panse G, Cowper SE, Leffell DJ, Pulitzer M, Ko CJ. Well-differentiated neuroendocrine tumors in skin: Terminology and diagnostic utility of cytokeratin 5/6 and p63. J Cutan Pathol 2018; 44:557-562. [PMID: 28417484 DOI: 10.1111/cup.12952] [Citation(s) in RCA: 5] [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: 02/09/2017] [Revised: 04/05/2017] [Accepted: 04/06/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Well-differentiated neuroendocrine tumors (WDNETs) in skin include metastases from visceral primary sites and very uncommonly, primary cutaneous carcinoid tumors. Cutaneous WDNET may present a diagnostic challenge and in particular can be mistaken for a benign skin adnexal tumor. In contrast to cutaneous adnexal tumors, metastatic adenocarcinomas to the skin are cytokeratin 5/6 (CK5/6) and p63 negative in the majority of cases. It is unclear if failure to stain with CK5/6 and p63 would be helpful in differentiating WDNETs from cutaneous adnexal neoplasms. METHODS We reviewed 10 cases of cutaneous WDNETs (8 cases of metastatic disease and 2 presumed primary carcinoid tumors of the skin) and performed immunohistochemical stains for CK5/6 and p63 on all cases. RESULTS All 10 cases were negative with both CK5/6 and p63. CONCLUSION Negative staining for CK5/6 and p63 can be helpful to distinguish WDNETs from cutaneous adnexal neoplasms. It is important to consider WDNETs in the differential diagnosis of cutaneous adnexal neoplasms as low-grade tumors may be the first sign of aggressive metastatic disease.
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Affiliation(s)
- Gauri Panse
- Department of Dermatology, Division of Dermatopathology, Yale School of Medicine, New Haven, Connecticut
| | - Shawn E Cowper
- Department of Dermatology, Division of Dermatopathology, Yale School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - David J Leffell
- Department of Dermatology, Division of Dermatopathology, Yale School of Medicine, New Haven, Connecticut
| | - Melissa Pulitzer
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christine J Ko
- Department of Dermatology, Division of Dermatopathology, Yale School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale School of Medicine, New Haven, Connecticut
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47
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Roffman D, Hart G, Girardi M, Ko CJ, Deng J. Predicting non-melanoma skin cancer via a multi-parameterized artificial neural network. Sci Rep 2018; 8:1701. [PMID: 29374196 PMCID: PMC5786038 DOI: 10.1038/s41598-018-19907-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/10/2018] [Indexed: 12/20/2022] Open
Abstract
Ultraviolet radiation (UVR) exposure and family history are major associated risk factors for the development of non-melanoma skin cancer (NMSC). The objective of this study was to develop and validate a multi-parameterized artificial neural network based on available personal health information for early detection of NMSC with high sensitivity and specificity, even in the absence of known UVR exposure and family history. The 1997-2015 NHIS adult survey data used to train and validate our neural network (NN) comprised of 2,056 NMSC and 460,574 non-cancer cases. We extracted 13 parameters for our NN: gender, age, BMI, diabetic status, smoking status, emphysema, asthma, race, Hispanic ethnicity, hypertension, heart diseases, vigorous exercise habits, and history of stroke. This study yielded an area under the ROC curve of 0.81 and 0.81 for training and validation, respectively. Our results (training sensitivity 88.5% and specificity 62.2%, validation sensitivity 86.2% and specificity 62.7%) were comparable to a previous study of basal and squamous cell carcinoma prediction that also included UVR exposure and family history information. These results indicate that our NN is robust enough to make predictions, suggesting that we have identified novel associations and potential predictive parameters of NMSC.
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Affiliation(s)
- David Roffman
- Department of Therapeutic Radiology, School of Medicine, Yale University, New Haven, USA
| | - Gregory Hart
- Department of Therapeutic Radiology, School of Medicine, Yale University, New Haven, USA
| | - Michael Girardi
- Department of Dermatology, School of Medicine, Yale University, New Haven, USA
| | - Christine J Ko
- Department of Dermatology, School of Medicine, Yale University, New Haven, USA
| | - Jun Deng
- Department of Therapeutic Radiology, School of Medicine, Yale University, New Haven, USA.
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48
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Levy L, Layher H, McNiff JM, Ko CJ. Dermatomyositis: Histopathologic findings of parakeratosis and dermal edema revisited. J Cutan Pathol 2018; 45:282-285. [PMID: 29330862 DOI: 10.1111/cup.13104] [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: 11/18/2017] [Revised: 01/03/2018] [Accepted: 01/09/2018] [Indexed: 12/01/2022]
Abstract
The cutaneous manifestations of dermatomyositis range from classical in the case of heliotrope rash and Gottron papules to less common papulosquamous and edematous/vesiculobullous lesions; histopathologic descriptions are dominated by interface dermatitis. We present a case of dermatomyositis with a combination of common and rare skin findings, both clinically and histologically. Increased awareness of papulosquamous and edematous lesions of dermatomyositis can help direct patient care. Although uncommon, confluent parakeratosis and dermal edema can be manifestations of dermatomyositis.
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Affiliation(s)
- Lauren Levy
- Department of Dermatology, Yale University Medical School, New Haven, Connecticut
| | - Heather Layher
- Department of Dermatology, Keller Army Community Hospital, West Point, New York
| | - Jennifer M McNiff
- Department of Dermatology, Yale University Medical School, New Haven, Connecticut
| | - Christine J Ko
- Department of Dermatology, Yale University Medical School, New Haven, Connecticut
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Panse G, Bossuyt V, Ko CJ. Metastatic serous carcinoma presenting as inflammatory carcinoma over the breast-Report of two cases and literature review. J Cutan Pathol 2017; 45:234-239. [PMID: 29194708 DOI: 10.1111/cup.13091] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 09/12/2017] [Revised: 11/20/2017] [Accepted: 11/27/2017] [Indexed: 11/29/2022]
Abstract
Non-mammary metastases involving breast are rare and most commonly involve the breast parenchyma. Infrequently, metastasis from an extramammary primary site presents as inflammatory carcinoma over the breast. Diagnosis of such lesions can be challenging, especially in patients with coexisting primary breast carcinoma. Few such cases have been described in literature; however, none of the previously reported cases had a prior history of primary breast carcinoma. We present 2 patients with history of breast carcinoma and serous carcinoma of ovarian/peritoneal origin that presented with inflammatory carcinoma over the breast. Biopsies from breast tissue showed atypical cells in the dermis forming cords and papillary structures. Histopathologic differential diagnosis included infiltrating ductal carcinoma of breast origin and metastatic serous carcinoma. Immunohistochemical studies showed that the tumor cells were positive for markers of ovarian origin such as PAX-8 and CA-125 and negative for breast markers such as GATA-3, thus supporting the diagnosis. In summary, we describe the unusual presentation of metastatic serous carcinoma as inflammatory carcinoma over breast and discuss the diagnostic challenges in patients with coexisting primary breast and ovarian malignancies. We also review the morphologic features of tumors of breast and ovarian origin and the immunohistochemical stains to differentiate these 2 entities.
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Affiliation(s)
- Gauri Panse
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Veerle Bossuyt
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Christine J Ko
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale School of Medicine, New Haven, Connecticut
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Lin KH, Hsu HT, Teng TH, Lin PY, Ko CJ, Hsieh CE, Chen YL. Rapidly increasing liver progenitor cell numbers in human regenerating liver after portal vein ligation and liver partition. Malays J Pathol 2017; 39:289-291. [PMID: 29279592] [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: 06/07/2023]
Abstract
BACKGROUND Liver regeneration is dependent on the proliferation of hepatocytes. Hepatic progenitor cells are intra-hepatic precursor cells capable of differentiating into hepatocytes or biliary cells. Although liver progenitor cell proliferation during the regenerative process has been observed in animal models of severe liver injury, it has never been observed in vivo in humans because it is unethical to take multiple biopsy specimens for the purpose of studying the proliferation of liver progenitor cells and the roles they play in liver regeneration. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a staged procedure for inducing remnant liver hypertrophy so that major hepatectomy can be performed safely. This staged procedure allows for liver biopsy specimens to be taken before and after the liver begins to regenerate. CASE PRESENTATION The liver progenitor cell proliferation is observed in a patient undergoing ALPPS for a metastatic hepatic tumour. Liver biopsy is acquired before and after ALPPS for the calculation of average number of liver progenitor cell under high magnification examination by stain of immunomarkers. This is the first in vivo evidence of growing liver progenitor cells demonstrated in a regenerating human liver.
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Affiliation(s)
- K H Lin
- Changhua Christian Hospital, Department of General Surgery, No. 135 Nan-Hsiao Street, Changhua, Taiwan 500.
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