Cutaneous Cephalic Neurocristic Hamartoma on the Head With Melanocytic, Cartilage, Blood Vessel, Neural, and Bony Tissue

ABSTRACT

We report on a congenital tumor of the face and scalp in a male newborn, histologically proven to contain melanocytes, cartilage, and bone, vascular, and neural tissue as part of a pigmented congenital tumor. Thus, this tumor was classified as a cutaneous cephalic neurocristic hamartoma.

Cicatricial alopecia

In the classification of the North American Hair Research Society, primary cicatricial alopecias (PCA) are divided into four groups according to their prominent inflammatory infiltrate: PCAs with lymphocytic, neutrophilic, mixed or nonspecific cell inflammation pattern. The hair loss can begin subclinically and progress slowly so that the exact onset of the disease is often difficult to determine. The diagnosis is often delayed. While most forms of cicatricial alopecia can be clearly diagnosed based on clinical presentation in the acute disease stage, diagnosis can be challenging in the subacute, early or late disease stages. At first presentation, a detailed patient history and dermatological examination of the body, including trichoscopy, should be performed. In clinically unclear cases, a biopsy should be performed. Due to the scarcity of primary cicatricial alopecia, there is little evidence on the efficacy of the various therapies. The aims of treatment are to stop or at least delay hair loss and progression of the scarring process, reduce clinical inflammation signs as well as to alleviate subjective symptoms. Hair re-growth in already scarred areas should not be expected. Anti-inflammatory treatment with topical corticosteroids class III to IV and / or with intracutaneous intralesional triamcinolone acetonide injections can be considered in most of the primary cicatricial alopecias. The choice of systemic therapy depends on the type of predominant inflammatory infiltrate and includes antimicrobial, antibiotic or immunomodulating/immunosuppressive agents. Psychological support and camouflage techniques should be offered to the patients.

Abstract 5333: Methylation profiling identifies two subclasses of cutaneous squamous cell carcinoma related to distinct cell types of origin

Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer type and arises from keratinocytes. Most cSCC progress from a UV-induced precancerous lesion termed actinic keratosis (AK). Despite various efforts to characterize these lesions molecularly, the etiology of AK and its progression to cSCC remain only partially understood. Here we have used Infinium MethylationEPIC BeadChips to interrogate the DNA methylation status of about 850.000 CpGs in epidermis samples from healthy skin, AK and cSCC. Importantly, we found that the premalignant AK samples displayed classical features of cancer methylomes and were highly similar to cSCC methylomes. Further analysis identified typical features of stem cell methylomes, such as a reduced DNA methylation age, non-CpG methylation and stem cell-related keratin and enhancer methylation patterns. Interestingly, this signature was detected only in one half of the AK and cSCC samples, while the other half showed keratin and enhancer methylation patterns that were more closely related to the control epidermis. These findings suggest the existence of two distinct subclasses of AK and cSCC that originate from distinct keratinocyte differentiation stages.

Citation Format: Manuel Rodríguez Paredes, Felix Bormann, Günter Raddatz, Julian Gutekunst, Carlota Lucena-Porcel, Florian Köhler, Elisabeth Wurzer, Katrin Schmidt, Joachim Röwert-Huber, Evgeniya Denisova, Lars Feuerbach, Esther Herpel, Ingo Nindl, Thomas G. Hofmann, Marc Winnefeld, Frank Lyko. Methylation profiling identifies two subclasses of cutaneous squamous cell carcinoma related to distinct cell types of origin [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5333.

Vernarbende Alopezien

Primär vernarbende Alopezien (PVA) werden nach der Klassifikation der North American Hair Research Society nach ihrem prominenten entzündlichen Infiltrat in vier Gruppen eingeteilt: PVA mit lymphozytärem, neutrophilem, gemischtzelligem oder unspezifischem Entzündungsmuster. Der Haarausfall kann subklinisch beginnen und langsam fortschreiten, so dass der genaue Erkrankungsbeginn oft schwer nachzuvollziehen ist. Die Diagnose wird häufig verzögert gestellt. Während die meisten vernarbenden Alopezien bei vollständiger Ausprägung anhand des klinischen Bildes klar zugeordnet werden können, ist die Diagnosestellung in der Frühphase oder im Endstadium häufig schwierig. Bei Erstvorstellung sollte eine ausführliche Anamnese und dermatologische Ganzkörperuntersuchung, inklusive Trichoskopie durchgeführt werden. In klinisch unklaren Fällen sollte eine Biopsie erfolgen. Aufgrund der Seltenheit der PVA gibt es bisher nur eine niedrige Evidenz über die Wirksamkeiten der Vielzahl der verschiedenen angewandten Therapien. Ziele der Therapie einer PVA sind, den Haarausfall zu stoppen oder zumindest zu verzögern, die klinischen Entzündungszeichen zu reduzieren, weitere Vernarbung zu verhindern sowie die subjektiven Symptome zu lindern. Ein Nachwachsen in bereits vernarbten Arealen sollte nicht erwartet werden. Eine antientzündliche Therapie mit topischen Kortikosteroiden der Klasse III-IV und/oder mit intrakutanen intraläsionalen Triamcinolonacetonid-Injektionen kommt bei den meisten PVA in Betracht. Die Wahl der systemischen Therapie hängt von der Art des prädominierenden entzündlichen Infiltrates ab und umfasst antimikrobielle/antibiotische oder immunmodulatorische/immunsuppressive Ansätze. Psychologische Unterstützung und Camouflage-Techniken sollten den Patienten angeboten werden.

Methylation profiling identifies two subclasses of squamous cell carcinoma related to distinct cells of origin

Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer and usually progresses from a UV-induced precancerous lesion termed actinic keratosis (AK). Despite various efforts to characterize these lesions molecularly, the etiology of AK and its progression to cSCC remain partially understood. Here, we use Infinium MethylationEPIC BeadChips to interrogate the DNA methylation status in healthy, AK and cSCC epidermis samples. Importantly, we show that AK methylation patterns already display classical features of cancer methylomes and are highly similar to cSCC profiles. Further analysis identifies typical features of stem cell methylomes, such as reduced DNA methylation age, non-CpG methylation, and stem cell-related keratin and enhancer methylation patterns. Interestingly, this signature is detected only in half of the samples, while the other half shows patterns more closely related to healthy epidermis. These findings suggest the existence of two subclasses of AK and cSCC emerging from distinct keratinocyte differentiation stages.

Tumor vascularization and clinicopathologic parameters as prognostic factors in merkel cell carcinoma

PURPOSE

Merkel cell carcinoma (MCC) is a rare but aggressive neuroendocrine tumor of the skin with an increasing incidence. The clinical course is variable and reliable prognostic factors are scarce. Tumor angiogenesis has been shown to have prognostic impact in different types of cancer. The aim of our study was to determine potential prognostic factors, including tumor vascularization, for clinical outcome of MCC.

METHODS

The medical records of 46 patients with MCC diagnosed between 1997 and 2010 were analyzed retrospectively. Tissue samples were immune-stained for the lymphatic endothelial vessel marker podoplanin/D2-40 and the panvascular marker CD31. These immunostained sections were analyzed using computer-assisted morphometric image analyses. Aside from the parameters of tumor vascularization, clinicopathologic features were investigated, and progression-free survival (PFS) and tumor-specific survival (TSS) were assessed. Univariate and multivariate analyses were performed to determine prognostic factors.

RESULTS

Male sex of the MCC patients and a high cross-sectional whole vessel area (WVA) in relation to the entire tumor area as determined on CD31-stained tumor sections were found to be negative prognostic factors for PFS in a univariate and multivariate regression analysis. Ulceration of the primary tumor was significantly associated with both impaired PFS and TSS.

CONCLUSIONS

Our results indicate a high prognostic impact of tumor vascularization on the clinical outcome of MCC patients. Male sex and ulceration of the primary MCC were identified as independent unfavorable prognostic markers for the clinical outcome. As an outlook, MCC patients with increased angiogenesis might be identified and subjected to a targeted anti-angiogenic treatment.

Impact of refractive index mismatches on coherent anti-Stokes Raman scattering and multiphoton autofluorescence tomography of human skin in vivo

Optical non-linear multimodal tomography is a powerful diagnostic imaging tool to analyse human skin based on its autofluorescence and second-harmonic generation signals. Recently, the field of clinical non-linear imaging has been extended by adding coherent anti-Stokes Raman scattering (CARS)-a further optical sectioning method for the detection of non-fluorescent molecules. However, the heterogeneity of refractive indices of different substances in complex tissues like human skin can have a strong influence on CARS image formation and requires careful clinical interpretation of the detected signals. Interestingly, very regular patterns are present in the CARS images, which have no correspondence to the morphology revealed by autofluorescence at the same depth. The purpose of this paper is to clarify this phenomenon and to sensitize users for possible artefacts. A further part of this paper is the detailed comparison of CARS and autofluorescence images of healthy human skin in vivo covering the complete epidermis and part of the upper dermis by employing the flexible medical non-linear tomograph MPTflex CARS.

In vivo study for the discrimination of cancerous and normal skin using fibre probe-based Raman spectroscopy

Raman spectroscopy has proved its capability as an objective, non-invasive tool for the detection of various melanoma and non-melanoma skin cancers (NMSC) in a number of studies. Most publications are based on a Raman microspectroscopic ex vivo approach. In this in vivo clinical evaluation, we apply Raman spectroscopy using a fibre-coupled probe that allows access to a multitude of affected body sites. The probe design is optimized for epithelial sensitivity, whereby a large part of the detected signal originates from within the epidermal layer's depth down to the basal membrane where early stages of skin cancer develop. Data analysis was performed on measurements of 104 subjects scheduled for excision of lesions suspected of being malignant melanoma (MM) (n = 36), basal cell carcinoma (BCC) (n = 39) and squamous cell carcinoma (SCC) (n = 29). NMSC were discriminated from normal skin with a balanced accuracy of 73% (BCC) and 85% (SCC) using partial least squares discriminant analysis (PLS-DA). Discriminating MM and pigmented nevi (PN) resulted in a balanced accuracy of 91%. These results lie within the range of comparable in vivo studies and the accuracies achieved by trained dermatologists using dermoscopy. Discrimination proved to be unsuccessful between cancerous lesions and suspicious lesions that had been histopathologically verified as benign by dermoscopy.

Correlation of optical coherence tomography and histology in microcystic adnexal carcinoma: a case report

BACKGROUND/AIMS

Herein, we report a case of microcystic adnexal carcinoma (MAC), which we correlated and evaluated by optical coherence tomography (OCT) and conventional H&E histology.

METHODS

A commercially available OCT scanner was used for imaging. Several multi-slice images were obtained from the central portion of the lesion. Correlation of OCT findings with histology was performed retrospectively.

RESULTS

Microcystic adnexal carcinoma showed characteristic criteria, which were divided into superficial and sub-epidermal findings.

CONCLUSION

The use of OCT can visualize characteristic criteria of MAC, thus enabling prompt diagnosis before surgery.

Modes of action of diclofenac 3%/hyaluronic acid 2.5% in the treatment of actinic keratosis

BACKGROUND

The efficacy of topically applied diclofenac 3 % in combination with hyaluronic acid 2.5 % in the treatment of actinic keratoses (AKs) has been demonstrated in several clinical studies, but the exact mode of action is still unclear. This study evaluates the potential molecular and cellular main modes of action of topically applied diclofenac in the treatment of AKs.

PATIENTS AND METHODS

In this prospective study 20 male patients with AKs were treated for 90 days with topically applied diclofenac 3 %/hyaluronic acid 2.5 %. Before and after treatment, skin biopsies were taken from the treatment area and were investigated histologically and immunohistochemically as well as compared to healthy skin. For this purpose, markers for inflammation (COX-2, CD3, CD8), apoptosis (p53), cell cycle arrest (p53, p21), proliferation (Ki67), and angiogenesis (CD31) were examined.

RESULTS

The immunohistochemical analysis demonstrated a significant decrease in expression of COX-2, CD3 and CD8. Furthermore, there was a clear reduction of CD31 expression as a marker for angiogenetic processes. Additionally, there was a tendency toward a reduction in markers for proliferation and apoptosis.

CONCLUSIONS

The efficacy of diclofenac 3 %/hyaluronic acid 2.5 % in the treatment of AKs is probably due to anti-inflammatory and anti-angiogenic effects, potentially associated with anti-proliferative and apoptosis-inducing underlying mechanisms.

Preliminary evaluation of benign vascular lesions using in vivo reflectance confocal microscopy

BACKGROUND

Reflectance confocal microscopy (RCM) is a novel noninvasive imaging technique for in vivo evaluation of cutaneous lesions at near-histologic resolution. The applicability of RCM for various neoplastic and inflammatory skin diseases has been shown, but a descriptive evaluation of different vascular lesions has not yet been performed.

OBJECTIVES

To define specific RCM criteria for congenital and acquired vascular lesions and to determine whether these criteria may assist in their differential diagnosis.

MATERIALS AND METHODS

Seven patients with a clinical diagnosis of vascular lesion, including spider angioma, venous lake, cherry angioma, pyogenic granuloma, port wine stain, angiokeratoma, and lymphangioma, participated in this study. Skin sites were systematically analyzed using RCM, and biopsy was obtained for clinically indeterminate lesions.

RESULTS

For each entity, characteristic RCM criteria could be identified and selected parameters correlated well to established histopathologic findings. The most relevant criteria included the diameter of the vessels and degree of vascular tortuosity or dilation. Additional findings such as flow velocity, inflammation, and disruption of the epidermal architecture could be documented.

CONCLUSION

The findings of this preliminary evaluation indicate that RCM may aid in the noninvasive characterization of inflammatory, proliferative, and ectatic vascular malformations in vivo.

Genomic characterization of a novel human papillomavirus (HPV-117) with a high viral load in a persisting wart

Warts from immunosuppressed organ transplant recipients (OTR) persist over years and may progress into non-melanoma skin cancer. Human papillomaviruses (HPV) are considered the causal agents for the development of such warts. We isolated the novel type HPV-117 from a persisting wart by rolling circle amplification. One hundred eighteen warts from immunocompetent patients (IC) and 49 warts from OTR were analyzed by HPV-117 E6 type-specific PCR. As inferred from a phylogenetic analysis, the new type HPV-117 belonged to alpha-PV species 2, including the most similar types HPV-10 and HPV-94. The general prevalence of HPV-117 in warts was 2% in IC (2/118), and 12% in OTR (6/49). The high viral load in dysplastic cells of a Verruca vulgaris was shown by in situ hybridization. Our results suggest an active role of the novel type in the development of cutaneous warts of OTR.

Impact of Molecular Staging Methods in Primary Melanoma: Reverse-Transcriptase Polymerase Chain Reaction (RT-PCR) of Ultrasound-Guided Aspirate of the Sentinel Node Does Not Improve Diagnostic Accuracy, But RT-PCR of Peripheral Blood Does Predict Survival

Purpose

This study analyzes (1) the value of tyrosinase reverse-transcriptase polymerase chain reaction (RT-PCR) of aspirates obtained by ultrasound-guided fine-needle aspiration cytology (US-FNAC) of sentinel nodes (SNs) in patients with melanoma before sentinel lymph node biopsy (SLNB) and (2) the value of RT-PCR of blood samples of all SLNB patients.

Patients and Methods

Between 2001 and 2003, 127 patients with melanoma (median Breslow depth, 2.1 mm) underwent SLNB. FNAC was performed in all SNs of all patients pre- and post-SLNB. The aspirates were partly shock-frozen for RT-PCR and were partly used for standard cytology. Peripheral blood was collected at the time of SLNB and at every outpatient visit thereafter.

Results

Thirty-four (23%) of 120 SNs were positive for melanoma. SN involvement was predicted by US-FNAC with a sensitivity of 82% and a specificity of 72%. Additional tyrosinase RT-PCR revealed the same sensitivity of 82% and a specificity of 72%. At a median follow-up time of 40 months from first blood sample, peripheral-blood RT-PCR was a significant independent predictor of disease-free survival (DFS) and overall survival (OS; P < .001).

Conclusion

US-FNAC is highly accurate and eliminates the need for SLNB in 16% of all SLNB patients. RT-PCR of the aspirate or excised SN does not improve sensitivity or specificity. RT-PCR of blood samples predicts DFS and OS.

Actinic keratosis is an early in situ squamous cell carcinoma: a proposal for reclassification

The term actinic keratosis (AK) describes a sun-induced, clinical erythematous lesion covered with scale, but does not provide an understanding of the biology or histopathology of the lesion. Consequently, several classification systems for AK have been suggested, but as yet no consensus has been reached. These systems strive to correlate the pathological and clinical features to better provide physicians with the most accurate information to enable correct decisions to be made regarding treatments, Prognosis and metastatic potential. AK is a clinical description that has a histological diagnosis consistent with squamous cell carcinoma (SCC) in situ. We recommend an AK classification system that describes these lesions as squamous cell carcinomas (SCCs), using the terminology 'early in situ SCC Type AK I', 'early in situ SCC type AK II' and 'in situ SCC Type AK III', there by giving clinicians better guidance for diagnosis and specific treatment recommendations.

Actinic keratoses: non-invasive diagnosis for field cancerisation

BACKGROUND

Actinic keratoses (AKs) are among the most common cutaneous malignancies and have previously been classified as in situ squamous cell carcinoma (SCC) with reported progression rates of up to 20% over 10 years. Since current scientific evidence suggests the presence of multilocular preneoplastic changes in the areas surrounding the affected skin sites, the detection of subclinical AKs remain an ongoing and challenging effort in the clinical and diagnostic management of these lesions. In vivo reflectance confocal microscopy (RCM) has been used for evaluation of the morphological features of non-melanoma skin cancer (NMSC) and RCM evaluation parameters for the diagnosis of AKs have been reported.

OBJECTIVES

The objective of this study was to evaluate the RCM-morphology of clinically diagnosed AKs in our study population and to correlate the findings with routine histopathology.

PATIENTS/METHODS

Forty four Caucasians (SPT I-III) with a minimum of one actinic keratosis (AK) lesion were included in this study. Evaluation consisted of clinical examination, RCM and routine histology. Reflectance confocal microscopy evaluation parameters included parakeratosis, architectural disarray and keratinocyte pleomorphism.

RESULTS

A total of 44 AKs were included in the final analysis. Following blinded evaluation by two independent investigators, 97.7% of all skin samples were identified as AK using RCM. 2.3% were incorrectly identified as normal skin by RCM, while routine histology showed features consistent with AK.

CONCLUSIONS

Reflectance confocal microscopy may be a feasible alternative in the diagnosis of AK and may aid in the differentiation against normal skin, as well as in the detection of subclinical disease.

Low prevalence of p53, p16(INK4a) and Ha-ras tumour-specific mutations in low-graded actinic keratosis

BACKGROUND

Ultraviolet radiation induces DNA damage and is the major risk factor for the development of non-melanoma skin cancer (NMSC). Different mutation rates of p53, p16(INK4a) and Ha-ras in cutaneous squamous cell carcinoma (SCC) and the earlier stage actinic keratosis (AK) have been reported.

OBJECTIVES

To assess the presence of missense mutations in hotspot exons of p53, p16(INK4a) and Ha-ras in low-graded AK.

PATIENTS/METHODS

Cryo-biopsies of 75 sun-exposed AK lesions and 75 sun-shielded areas of normal skin from 75 AK patients were analysed to identify mutations in p53 (exons 7 and 8), p16(INK4a) (exon 2) and Ha-ras (exon 1) using polymerase chain reaction (PCR) followed by direct sequencing. As a representative subset of the specimens, ten mutation-negative AK were also micro-dissected in order to exclude the possibility that additional mutations were undetected.

RESULTS

Eight missense and one nonsense point mutations were found in the 75 AK lesions examined (12%), of which seven (9%) were tumour-specific (i.e. present in AK lesions only) and two (3%) were p16(INK4a) mutations (i.e. also detected in normal skin). Three of the tumour-specific mutations (42%) were cytosine (C) to thymine (T) transitions at pyrimidine-rich sequences. Tumour-specific mutations were identified in 1% of p16(INK4a) (exon 2), 1% of Ha-ras (exon 1) and at a higher rate of 7% in p53 (exons 7 and 8), including one nonsense mutation.

CONCLUSIONS

The evaluation of a large number of AK specimens in this study have found a low gene mutation rate in low-graded AK lesions. p53 mutations rather than p16(INK4a) and/or Ha-ras mutations may be an early event in the development of AK to cutaneous SCC.

Apoptosis pathways as promising targets for skin cancer therapy

Apoptosis pathways provide efficient safeguard mechanisms against cancer that are mediated via cell-intrinsic responses and immune-mediated extrinsic signals. Intrinsic pro-apoptotic pathways are largely controlled by p53 and Bcl-2 proteins, whereas the extrinsic induction of apoptosis is initiated by death ligands, such as tumour necrosis factor-alpha (TNF-alpha), CD95L/FasL and TNF-related apoptosis-inducing ligand (TRAIL), or by granzyme B. Initiation of these pathways results in the induction of a caspase cascade leading to cell death. The inactivation of pro-apoptotic pathways is elementary for tumourigenesis and may be responsible for therapy resistance. Thus, apoptosis-based strategies represent important tools for the development of effective tumour therapies. The aim of these therapies is to restore p53 activity, downregulate anti-apoptotic Bcl-2 proteins or NF-kappaB activity, and to upregulate extrinsic, death receptor-mediated pathways. The initial results of apoptosis-based strategies are proving promising. Also, topical treatments for actinic keratosis (AK), such as cyclo-oxygenase-2 inhibitors (e.g. diclofenac 3% gel), have been shown to trigger pro-apoptotic pathways. There is hope that pro-apoptotic strategies will lead to pronounced therapeutic success against skin cancer. Importantly, the involvement of the different pro-apoptotic pathways in specific tumour types needs to be unravelled and understood in order to evaluate drug effectiveness, as well as to modify and optimise therapeutic approaches.

Differentiation between actinic keratoses and disseminated superficial actinic porokeratoses with reflectance confocal microscopy

BACKGROUND

Clinical differentiation between actinic keratosis (AK) and disseminated superficial actinic porokeratosis (DSAP) may pose a significant challenge, and histological evaluation is often also required for diagnosis. Distinct morphological features can be distinguished upon histopathological examination, but the use of non-invasive tools, such as reflectance confocal microscopy (RCM), may be an eligible alternative for confirmation of diagnosis.

OBJECTIVES

The aim of this study was to determine the relevant RCM criteria for the identification of disseminated superficial actinic porokeratoses (DSAPs) and to define distinguishing criteria for DSAPs compared with actinic keratosis (AKs).

PATIENTS/METHODS

A total of 20 patients with a clinical diagnosis of AK or DSAP were included in this study. All lesions were evaluated by clinical examination, and RCM and one clinically identified lesion was biopsied for histological confirmation.

RESULTS

Cellular and nuclear atypia, inflammation, spongiosis, parakeratosis and changes in epidermal architecture were present in both lesion types (i.e. AKs and DSAPs). However, these features were more pronounced in AKs. Whereas AKs exhibited more disseminated parakeratotic changes, parakeratosis was found focally present on the border of DSAP lesions. Most characteristically, a distinct border corresponding to cornoid lamella in RCM can be identified in DSAPs.

CONCLUSIONS

Distinguishing features of DSAPs, such as cornoid lamella, sharp demarcation of the lesion and focal keratinocyte atypia are easily identifiable using RCM, and correlate well with histopathology. Whilst RCM has previously been used in the evaluation of AKs, it has not yet been used to investigate DSAPs. The findings in this study suggest the feasibility of non-invasive tools, such as RCM for the differentiation of AKs and DSAPs. However, further studies are warranted to assess the sensitivity and specificity of RCM in the diagnosis of DSAP.