Fucoidan from New Zealand Undaria pinnatifida: monthly variations and determination of antioxidant activities

The content and composition of fucoidans extracted from Undaria pinnatifida from mussel farms at the Marlborough Sounds, New Zealand were investigated using CaCl2 extraction. Crude fucoidan (F0) was subsequently extracted on a monthly basis from U. pinnatifida harvested from July to October 2011 from mussel farms in the Marlborough Sounds, New Zealand. Fucoidan yield varied between the frond and sporophyll parts of the algae, with the sporophyll consistently the highest content. The yield from the sporophyll increased significantly from July (25.4-26.3%) to September (57.3-69.9%). Sulphate content in the extracted fucoidan increased more than twice within the same period, while fucose content remained constant. F0 was further purified by ion-exchange chromatography to yield three fractions, F1, F2 and F3. All three fucoidan fractions contained fucose as the primary sugar component followed by galactose, with xylose, glucose and mannose as minor constituents. All fractions exhibited strong antioxidant activities using the DPPH scavenging and CUPRAC assays. This study showed that sporophyll maturation of U. pinnatifida in New Zealand influenced fucoidan content and composition. Sporophyll fucoidan could potentially be a good resource for natural antioxidants.

Medulloblastoma presenting with tentorial "dural-tail" sign: is the "dural-tail" sign specific for meningioma?

To the best of our knowledge, the association of a medulloblastoma with a "dural-tail" sign has not been previously reported. A 24-year-old male developed severe headaches and right-sided dysmetria that worsened over 1 month. Magnetic resonance (MR) imaging of the brain demonstrated a heterogeneously enhancing lesion in the posterior fossa. The lesion appeared to be tentortally-based and exhibited a characteristic "dural-tail" sign, which is considered pathognothonic for meningioma. Cerebellar tonsil ectopia and hydrocephalus were also present. The presumptive diagnosis of tentorial meningioma was made. The lesion was resected by a posterior fossa approach. At surgery, the appearance of the tumor was inconsistent with the diagnosis of meningioma, and histopathologic evaluation yielded the diagnosis of medulloblastonia. This case and the literature demonstrate that malignant tumors can present with the characteristic MR imaging appearance of a meningioma. This possibility must be considered when treatment is planned, especially if a nonoperative course is favored.

Phase II study of rituximab and cladribine (2-CDA) in newly diagnosed mantle cell lymphoma (MCL) (N0189)

17505

Background: A previous trial of 2-CDA as a single agent for therapy of mantle cell lymphoma demonstrated this agent to be efficacious with an overall response rate of 81% (31% complete responses) (Blood 1999 Nov 15; 94:660a). A phase II study of the addition of rituximab to 2-CDA was conducted by the North Central Cancer Treatment Group based on improved outcomes achieved by the addition of rituximab to other regimens active in MCL. Methods: This one-stage phase II study was designed to determine the complete response (CR) or complete response/unconfirmed (CRu) rate. Central pathology confirmation of cyclin D1 positive mantle cell lymphoma was required. No previous therapy for lymphoma was allowed, with the exception of splenectomy. The shedule was rituximab 375 mg/m2 IV day 1; 2-CDA 5 mg/m2/d IV days 1–5 of a 4-week cycle. After 2 of the first 6 patients developed grade 4 neutropenia, subsequent patients received either pegfilgrastim or filgrastim support. Patients received 2–6 cycles of therapy, depending on response. Patients were required to achieve at least a PR after 2 cycles of therapy to continue on protocol therapy. Results: Patient characteristics of all 29 eligible pts: median age: 70 (range: 41–86); 21 male, 8 female; PS 0 (55.2%), PS 1 (41.4%), PS 2 (3.5%); stage II (6.9%), stage III (3.5%), stage IV (89.7%); prior splenectomy (20.7%). The only grade 4 adverse event occurring more than once was neutropenia (20.7%). One patient died of cerebral ischemia in the setting of pneumonia without neutropenia. Response has been determined in 26 pts with 50.0% (95% CI: 30.0–70.0%) achieving a CR, none of whom have relapsed to date. Three patients progressed early at 17, 45, and 46 days, two of whom have died, and a fourth relapsed day 222. 10 pts (34.0%) went on to receive further therapy off study, 5 in less than a PR after 2 cycles, 2 in PR after study therapy, and 1 who went off study for a rash. At last contact, 26 (89.7%) were alive (median follow-up 10.7 months; range: 1–28). Conclusions: Rituximab and cladribine were well tolerated for the treatment of MCL in a group including elderly patients. The response rate may have been underestimated due to the study design, which required at least a PR after 2 cycles to continue therapy. Despite this, 50% achieved a complete remission.

[Table: see text]

The autogenous dermis-fat orbital implant in children

PURPOSE

The autogenous dermis-fat graft orbital implant is one alternative for volume augmentation in the adult anophthalmic socket. We have reviewed our experience with dermis-fat grafts after primary enucleation in the pediatric population.

METHODS

We reviewed the clinic charts of all patients under 8 years of age who underwent primary enucleation combined with dermis-fat graft implantation. We assessed subsequent orbital growth by measuring lid and fissure symmetry, superficial soft tissue socket volume, prosthetic fit, and periorbital symmetry. All measurements were obtained by 2 of the authors.

RESULTS

Eight children had primary enucleations combined with a dermis-fat implant (Table 1). Age at the time of surgery ranged from 1 week to 8 years. Indications for enucleation were retinoblastoma (4), malignant teratoid medulloepithelioma (1), blind, painful eye secondary to trauma (2), or phthisis secondary to end-stage retinopathy of prematurity (1). Two patients were lost to follow up at 3 months and 6 months post enucleation. The remaining 6 patients had between 1 year and 6 years of follow up. All implants maintained appropriate volume allowing proper prosthetic fit and facial symmetry. Two children experienced excessive growth of their implants, managed by surgical debulking. Two children developed a central graft ulcer, managed by superficial revision and reclosure.

CONCLUSIONS

We have observed that dermis-fat grafts in pediatric primary enucleations demonstrate good maintenance of orbital soft tissue volume and periorbital symmetry. The complications of excessive dermis-fat growth or central ulceration were easily corrected. We feel this is a promising implant for the pediatric anophthalmic socket.

Delayed orbital hemorrhage after cataract surgery in a patient with an acquired factor VIII inhibitor

PURPOSE

To report the occurrence of delayed orbital hemorrhage after cataract surgery with retrobulbar anesthesia in a patient with previously unknown acquired factor VIII antibodies.

METHODS

Interventional case report. A 79-year-old woman underwent uneventful cataract surgery with retrobulbar anesthesia and subsequently incurred a severe orbital hemorrhage 12 hours postoperatively.

RESULTS

Despite aggressive surgical and medical intervention, the patient lost all vision in the involved eye.

CONCLUSION

Delayed postoperative retrobulbar hemorrhage may cause total loss of vision in patients with acquired factor VIII antibodies.

Primary signet ring cell carcinoma of the eyelid: report of a case demonstrating further analogy to lobular carcinoma of the breast with a literature review

Primary signet ring cell carcinoma of the eyelid is a rare neoplasm with less than ten cases described. This report details another case, which shows further parallels to lobular carcinoma of the breast, and reviews the literature on this subject. A 73-year-old white female presented with diffuse induration of her left eyelids. Histopathology revealed a delicate infiltrate of epithelial cells scattered throughout the lid stroma in a non-destructive pattern. The cells were relatively monomorphous and showed only mild atypia and rare mitotic figures. Many had slightly granular amphophilic cytoplasms, others showed distinct signet ring cell morphology, and all were strongly positive for epithelial mucin. Immunomicroscopy showed strong reactivity for estrogen receptor (ER), progesterone receptor (PR) and gross cystic disease fluid protein-15 (GCDFP-15), and was negative for Her-2/neu (erb-2) and cytokeratin 20. An extensive workup for other primary sites was negative. Orbital exenteration showed extensive involvement of both lids and soft tissue, including diffuse muscle and lacrimal gland infiltration. In the breast, signet ring cell carcinoma is considered a variant of lobular carcinoma. The delicate infiltrating pattern in our case and the ER+, PR+, GCDFP-15+, Her-2/neu-phenotype further strengthen this analogy. Together, these data also support apocrine differentiation of primary eyelid signet ring cell carcinoma.

Iatrogenic complications related to the use of Herrick Lacrimal Plugs

PURPOSE

To report a series of lacrimal complications associated with a specific type of lacrimal plug (Herrick Lacrimal Plug; Lacrimedics Incorporated, Rialto, CA.)

DESIGN

Retrospective, noncomparative case series and survey.

METHODS

Members of the American Society of Ophthalmic Plastic and Reconstructive Surgery were asked to submit personally treated cases of patients referred for treatment of complications after placement of a Herrick Lacrimal Plug.

MAIN OUTCOME MEASURES

Failure of the device to be removed by simple lacrimal irrigation.

RESULTS

The clinical courses of 41 patients were analyzed. Patients ranged in age from 19 to 81 years, and all had symptomatic epiphora related to the presence of the lacrimal plug. Several interventions were used to treat lacrimal obstruction. Nasolacrimal duct probing with irrigation was used in 15 lacrimal systems, whereas six systems were probed and subsequently stented with silicone tubing. Eyelid margin cutdown was used in eight cases. Balloon dacryoplasty was performed in three systems, dacryocystorhinostomy in 18 instances, and conjunctivodacryocystorhinostomy in two patients.

CONCLUSIONS

The Herrick lacrimal occlusion device sometimes cannot be removed by simple irrigation and is capable of inducing permanent, irreversible, symptomatic lacrimal drainage system obstruction.

Use of heat-malleable thermoplastic splints in eyelid skin grafting

PURPOSE

To report on the usage of a thermoplastic material in eyelid reconstruction.

METHODS

Retrospective single-surgeon case review.

RESULTS

Thirty-eight full-thickness skin grafts in 37 patients are reported. No major complications were encountered. All outcomes with the use of this technique yielded satisfactory results.

CONCLUSIONS

The use of thermoplastic materials in eyelid reconstruction appears to achieve results equal to those seen with traditional materials. This technique in eyelid surgery may save operative time and be less expensive than traditional methods.

Expression of microtubule-associated protein 2 in benign and malignant melanocytes: implications for differentiation and progression of cutaneous melanoma

Cutaneous melanocytic neoplasms are known to acquire variable characteristics of neural crest differentiation. Melanocytic nevus cells in the dermis and desmoplastic melanomas often display characteristics of nerve sheath differentiation. The extent and nature of neuronal differentiation characteristics displayed by primary and metastatic melanoma cells are not well understood. Here, we describe induction of a juvenile isoform of microtubule-associated protein 2 (MAP-2c) in cultured metastatic melanoma cells by the differentiation inducer hexamethylene bisacetamide. Up-regulation of this MAP-2 isoform, a marker for immature neurons, is accompanied by extended dendritic morphology and down-regulation of tyrosinase-related protein 1 (TYRP1/gp75), a melanocyte differentiation marker. In a panel of cell lines that represent melanoma tumor progression, MAP-2c mRNA and the corresponding approximately 70-kd protein could be detected predominantly in primary melanomas. Immunohistochemical analysis of 61 benign and malignant melanocytic lesions showed abundant expression of MAP-2 protein in melanocytic nevi and in the in situ and invasive components of primary melanoma, but only focal heterogeneous expression in a few metastatic melanomas. In contrast, MAP-2-positive dermal nevus cells and the invasive cells of primary melanomas were TYRP1-negative. This reciprocal staining pattern in vivo is similar to the in vitro observation that induction of the neuronal marker MAP-2 in metastatic melanoma cells is accompanied by selective extinction of the melanocytic marker TYRP1. Our data show that neoplastic melanocytes, particularly at early stages, retain the plasticity to express the neuron-specific marker MAP-2. These observations are consistent with the premise that both benign and malignant melanocytes in the dermis can express markers of neuronal differentiation.

Benign cutaneous Degos' disease: a case report with emphasis on histopathology as papules chronologically evolve

The following case report details a 53-year-old man with a 6-year history of the benign cutaneous or skin-limited form of Degos' disease. Clinically, the patient demonstrated a diffuse eruption of papules on the upper trunk and arms. Many papules demonstrated the classic porcelain-white centers characteristic of Degos' disease, but others exhibited different clinical morphologies that corresponded to the evolutionary stages of papules originally described by Degos. Over the course of several clinic visits, the patient underwent a total of 5 punch biopsies, the histologies of which were correlated with their clinical morphologies. Early papules were skin-colored and demonstrated a superficial and deep perivascular, periadnexal, and perineural chronic inflammatory cell infiltrate associated with interstitial mucin deposition. The overlying epidermis showed a mild vacuolar interface reaction and the histologic appearances at this early stage resembled tumid lupus erythematosus. Fully developed papules were raised with umbilicated porcelain-white centers and a surrounding erythematous rim. Histologically these exhibited a prominent interface reaction with squamatization of the dermo-epidermal junction, melanin incontinence, epidermal atrophy, and a developing zone of papillary dermal sclerosis that resembled the early stages of lichen sclerosus et atrophicus in miniature. These interface reactions were invariably confined to the central portion of the punch biopsy specimen, corresponding to the central porcelain-white area seen clinically. Additional features of fully developed papules included a prominent lymphocytic vasculitis affecting venules, a mild periadnexal infiltrate of neutrophils and/or eosinophils, and interstitial mucin deposition. In late-stage papules, the porcelain-white areas were better developed and the lesion flattened. Histologically, the degree of inflammation was generally sparse and the overall picture mirrored the classic histologic description of Degos' disease with a central roughly wedge-shaped zone of sclerosis surmounted by an atrophic epidermis and hyperkeratotic compact stratum corneum. These late-stage papules closely resembled a miniaturized version of fully developed lichen sclerosus et atrophicus confined to the center of the punch biopsy specimen.

Rudimentary meningocele: remnant of a neural tube defect?

BACKGROUND

Rudimentary meningocele, a malformation in which meningothelial elements are present in the skin and subcutaneous tissue, has been described in the past under a variety of different terms and has also been referred to as cutaneous meningioma. There has been debate as to whether rudimentary meningocele is an atretic form of meningocele or results from growth of meningeal cells displaced along cutaneous nerves

OBJECTIVE

We reviewed the clinical, histological, and immunohistochemical characteristics of rudimentary meningocele in an attempt to assess the most likely pathologic mechanism for it.

DESIGN

Retrospective study.

SETTING

University hospitals.

PATIENTS

Thirteen children with rudimentary meningocele.

MAIN OUTCOME MEASURES

Medical records were reviewed and histopathologic examination as well as immunohistochemistry studies were performed for each case. A panel of immunoperoxidase reagents (EMA, CD31, CD34, CD57, S-100, and CAM 5.2) was used to assess lineage and to confirm the meningothelial nature of these lesions.

RESULTS

Recent evidence indicating a multisite closure of the neural tube in humans suggests that classic meningocele and rudimentary meningocele are on a continuous spectrum.

CONCLUSION

Rudimentary meningocele seems to be a remnant of a neural tube defect in which abnormal attachment of the developing neural tube to skin (comparable to that in classic meningocele) could explain the presence of ectopic meningeal tissue. In the majority of cases, no underlying bony defect or communication to the meninges could be detected. However, in light of the probable pathogenesis, imaging studies to exclude any communication to the central nervous system should precede any invasive evaluation or intervention.

Epithelioid blue nevus: neoplasm Sui generis or variation on a theme?

The epithelioid blue nevus has recently been associated with the Carney complex, which is characterized by myxomas, spotty skin pigmentation, endocrine overactivity, and schwannomas. Using the general criteria proposed by Carney and Ferreiro, similar lesions were identified in 33 patients with no evidence of the Carney complex. Those lesions presented on the face, trunk and extremities of 15 males and 18 females. The mean age was 35 years, much older than those in the Carney complex (mean 16.3 years). Clinical diagnoses included malignant blue nevus, atypical nevus, melanoma, congenital nevus, and dermatofibroma. The lesions were symmetric, predominantly dermal melanocytic proliferations arranged as short fascicles, small nests, and single cells. Large polygonal and epithelioid melanocytes with moderate pleomorphism, and occasional nuclear pseudoinclusions were admixed with heavily pigmented dendritic and spindled melanocytes and melanophages. Rare mitotic figures were seen in some cases. The neoplasms showed a morphologic spectrum that encompassed a group of combined blue nevi with epithelioid melanocytes and other Spitz's nevus characteristics. These epithelioid combined nevi (ECN) fell into three phenotypes with morphologies that most closely paralleled those pictured by Carney and Ferreiro in the Carney complex: the classic or Carney complex pattern (ECN-CC), those that showed overlap with deep penetrating nevus (ECN-DPN), and those that have many dermal Spitz's nevus features, [BLue + SpITZ's nevus; (ECN-BLITZ)I. In six cases, there was such an admixture of features that it was difficult to ascribe them to one of the groups. Nine lesions had associated banal congenital nevus. Follow-up that averaged over 2.5 years (31 months) (range 6-162 months) showed no evidence of malignancy or recurrent disease after excision. Epithelioid combined nevus is a type of combined nevus with blue nevus and Spitz's nevus features, which may or may not be associated with the Carney complex. It shows morphologic overlap with the epithelioid blue nevus described by Carney (ECN-CC), deep penetrating nevus (ECN-DPN), and blue nevus with intradermal Spitz's (desmoplastic) nevus (ECN-BLITZ). Epithelioid combined nevus is thought to be a fitting nosologic designation for all of these lesions.

The role of recovering physicians in 19th century addiction medicine: an organizational case study

An elaborate network of inebriate homes, inebriate asylums, nationally franchised private addiction treatment institutes, and proprietary home cures for addiction arose on the American landscape between 1850 and 1900. The pinnacle of the movement to professionalize America's first addiction treatment field was the founding of the American Association for the Cure of Inebriety in 1870 and its publication of the first issue of the Journal of Inebriety in 1876. One of the most contentious issues among the various branches of this new professional field was the question of the use of "reformed men" as physicians, managers and attendants within treatment institutions. This article describes the employment of recovering physicians within one 19th century addiction treatment franchise--the Keeley Institutes--and documents the nature of the professional debate stirred by what was then a controversial practice.

Utility of rush paraffin-embedded tangential sections in the management of cutaneous neoplasms

BACKGROUND

Mohs micrographic surgery (MMS) modified by the use of tangential, formalin-fixed, paraffin-embedded histologic specimens is advantageous in treating selected skin neoplasms.

OBJECTIVE

To review the use of our experience with a modification of MMS to treat lentigo maligna melanoma (LMM), lentigo maligna (LM) and other melanoma in situ (MIS) lesions, dermatofibrosarcoma protuberans (DFSP), atypical fibroxanthoma (AFX), and angiosarcoma.

METHODS

Our experience utilizing a modification of MMS in the treatment of 77 patients with LM or other MIS, 23 patients with LMM, 11 patients with DFSP, 1 patient with AFX, and 1 patient with angiosarcoma was reviewed. Length of follow-up and rate of recurrence were examined. A literature review of this pertinent modification of the Mohs technique was performed.

RESULTS

One hundred fourteen patients underwent MMS for melanocytic (LM, MIS, LMM), spindle cell (DFSP, AFX), and vascular malignant neoplasms. One patient developed locally recurrent LM and one patient with LMM developed satellite metastasis. Regional lymph node metastasis occurred in one patient with LMM and in a patient with angiosarcoma.

CONCLUSION

The use of Mohs micrographic surgery in conjunction with rush formalin-fixed, paraffin-embedded tangential histologic sections provides the accuracy and tissue conservation of the Mohs procedure while ensuring more confident interpretation of histology in cases of lentigo maligna, lentigo maligna melanoma, dermatofibrosarcoma protuberans, atypical fibroxanthoma, and angiosarcoma.

Fusiform incisional biopsy for pigmented skin lesions

Current recommendations for biopsy of a pigmented skin lesion suspected of being melanoma include complete excision when possible. Because benign pigmented lesions do not warrant excisional biopsy, especially when they are large and/or on cosmetically sensitive sites, incisional biopsy is desirable. For such lesions we recommend a fusiform incisional biopsy. This tissue sampling technique not only yields an excellent cosmetic outcome, but also provides the pathologist with an optimal biopsy specimen in which he/she can assess the symmetry, circumscription, breadth, and depth of the lesion.

Cytomorphologic features of Merkel cell carcinoma in fine needle aspiration biopsies. A study of two atypical cases

OBJECTIVE

To report atypical cytomorphologic features in fine needle aspiration biopsies (FNABs) from two cases of Merkel cell carcinoma (MCC), a primary neuroendocrine neoplasm of skin.

STUDY DESIGN

Retrospective review of FNABs with histologic correlation from six patients with MCC and a report of findings from two whose smears showed atypical features.

RESULTS

Typically the aspirates produce highly cellular smears of loosely clustered and individual, relatively monomorphic, small tumor cells with round to oval, regularly contoured nuclei. In two of our cases, the tumor cell nuclei exhibited a spectrum of pleomorphism ranging from moderately complex nuclear membranes with cleaves, indentations and protrusions in one case to large, markedly bizarre, convoluted nuclei and multinucleate tumor cells in the extreme case. Both cases were primary neoplasms, and the diagnosis was based on clinical, histologic and immunohistochemical data. Additionally, electron microscopy was performed on the tumor with bizarre nuclei and demonstrated rare, dense core neurosecretory granules and paranuclear bundles of intermediate filaments.

Pyoderma gangrenosum. A comparison of typical and atypical forms with an emphasis on time to remission. Case review of 86 patients from 2 institutions

Pyoderma gangrenosum (PG) is an idiopathic, inflammatory, ulcerative disease of undetermined cause. The diagnosis is based on clinical and pathologic features and requires exclusion of conditions that produce ulcerations. An atypical bullous variant (atypical pyoderma gangrenosum, APG) exists with clinical features similar to those of Sweet syndrome. Because PG is a rare disease, few large case series have been reported. Pyoderma gangrenosum was first recognized as a unique disease entity in the first half of the 20th century. Cumulative knowledge of PG is based on a handful of case series and multiple individual case reports. To augment that knowledge, we present our experience with a large number of patients over a significant time. We performed a retrospective analysis of the medical records of 86 patients with PG who were evaluated and treated over 12 years at 2 university-based dermatology departments. The mean (+/- standard deviation) age of onset of PG and APG, respectively, was 44.6 +/- 19.7 years and 52.2 +/- 15.3 years. Lower extremity involvement was most common in PG, whereas upper extremity involvement was most common in APG. Associated relevant systemic diseases were seen in 50% of patients. Inflammatory bowel disease was the most common association in patients with PG, whereas hematologic disease or malignancy was most common in those with APG. Although a few patients were managed with local measures or nonimmunosuppressive treatment, the majority required oral corticosteroid therapy, often with systemic immunosuppressive treatment. PG patients required a mean 11.5 +/- 11.1 months of treatment to achieve remission compared with 9.0 +/- 13.7 months for patients with APG. Five patients (5.8%) had disease that was extremely refractory to multiple intensive therapies. The prognosis and disease associations for PG and APG appear to be different. Compared with PG, APG is more often associated with hematologic disease or malignancy, and remits more quickly.

Testicular lymphoma is associated with a high incidence of extranodal recurrence

BACKGROUND

Testicular lymphoma is a rare extranodal presentation of non-Hodgkin lymphoma. The authors report long term follow-up information regarding a group of patients with testicular lymphoma evaluated at the Mayo Clinic and describe the outcome with special attention to patterns of recurrence.

METHODS

The medical records of patients with testicular lymphoma seen at the Mayo Clinic between January 1970 and March 1993 were reviewed. Patients were included if they had evidence of testicular involvement at the time of diagnosis of lymphoma. Pathology specimens were reviewed for confirmation of diagnosis.

RESULTS

Sixty-two patients with a diagnosis of testicular lymphoma were identified. Their median age was 68 years, and 60 patients underwent orchiectomy as the initial therapeutic and diagnostic procedure. Most of patients (79%) had localized or regional disease at the time of presentation. Other treatment modalities after diagnosis included radiotherapy (37%), combination chemotherapy (37%), and combination chemotherapy and radiotherapy (16%). Although 88% of patients had no residual disease after primary treatment, 80% subsequently experienced disease recurrence. There was no significant difference in the rate of recurrence, including Ann Arbor Stage I disease. Treatment did not appear to affect the recurrence rate. At a median follow-up of 2.7 years, 60% of patients had died of disease. Late recurrences were observed, and there appeared to be no plateau in the disease free survival curve. In half (51%) of the patients with disease recurrence, only extranodal locations were involved. Thirteen patients experienced recurrence in the central nervous system, 11 of whom had parenchymal lesions. In 8 of these 13 patients, the central nervous system was an isolated site of disease recurrence.

CONCLUSIONS

Testicular lymphoma is a unique and aggressive extranodal non-Hodgkin lymphoma. Better treatment strategies are needed to prevent recurrences. The risk of extranodal recurrence is high, especially in the central nervous system.

Combined intraepithelial squamous neoplasia and atypical fibroxanthoma of the cornea and limbus

PURPOSE

To investigate a case of an unusual neoplasm of the cornea and limbus.

METHODS

A 59-year-old man presented with a highly vascularized, nodular mass involving the left cornea and limbus. An excisional biopsy and, subsequently, a superficial lamellar keratectomy and multiple conjunctival biopsies were performed. At the 6-month follow-up examination, repeat conjunctival biopsies were performed.

RESULTS

Histopathologic examination of the corneal specimen showed a high-grade intraepithelial squamous neoplasia (in situ carcinoma) overlying an atypical fibroxanthoma.

CONCLUSION

We report the clinical and histologic appearance of a corneal/limbal neoplasm consisting of an intraepithelial squamous neoplasia and an atypical fibroxanthoma.

Cutaneous melanoma with myxoid features: twelve cases with differential diagnosis

Substantial myxoid change can occur in malignant melanoma, but its importance in primary disease has not been systematically evaluated. This report describes the clinical, microscopic, histochemical, and immunohistochemical findings in 12 patients with primary cutaneous malignant melanoma with myxoid features. The tumors presented as solitary lesions situated on the limbs (six lesions), trunk (four lesions), and head and neck (two lesions). The patients included six women and six men, whose ages ranged from 26 to 95 years, with a mean of 63 years. Breslow thickness varied from 0.48 mm to more than 12 mm, with a mean of more than 3.2 mm. Clinical follow-up for an average of 22 months showed one local recurrence, but no evidence of metastases yet. In all cases, there was a combination of myxoid and nonmyxoid areas. A minimum of 15% myxoid cross-sectional area was required for inclusion in the study, and up to 80% was observed. The pale blue mucin identified on hematoxylin and eosin staining was sensitive to hyaluronidase and positive for alcian blue in the 10 cases stained. Immunohistochemical staining was positive for S-100 in all 9 cases stained, positive for HMB-45 in 9 (90%) of 10, and negative for cytokeratin in all 9 cases in which myxoid melanoma remained in the block after previous sections. The presence of myxoid stroma did not define a biologically significant subgroup of melanoma. Only in cases with extensive (>50%) myxoid stromal effacement of the melanoma was there a major diagnostic hurdle. The diagnosis of primary cutaneous melanoma with myxoid features was seldom as problematic as metastatic myxoid melanoma. Positive S-100 stains, negative cytokeratin immunohistochemical stains, and hyaluronidase-sensitive alcian blue staining assisted in the diagnosis of this entity.

Persistent and recurrent blue nevi

Persistence of common melanocytic nevi has been fairly well characterized, clinically and histologically. In contrast, persistence of blue nevi has been reported infrequently. To define this entity better, nine cases of biologically persistent and clinically recurrent blue nevi are described. The persistent lesions in four cases were spindle-fascicular blue nevi; one showed senescent or "ancient" change and one had additional deep penetrating/epithelioid blue nevus features with atypical changes worrisome for malignancy. These changes included increased cellularity, cellular pleomorphism, mitotic figures, and a lymphocytic infiltrate. Three were biphasic dendritic-sclerotic/spindle-fascicular blue nevi, one of which had atypical changes. One case was a dendritic-sclerotic ("common") blue nevus. The original histology in one case was unavailable, but the recurrence was a combined blue nevus. The interval from initial biopsy to biopsy of the recurrent lesion was often longer (mean 2.7 years) for recurrent blue nevi than for recurrent common compound or intradermal melanocytic nevi. In addition, in contrast to recurrent common melanocytic nevi, the recurrence, in at least one case, extended beyond the scar of the original excision. These cases demonstrated that blue nevi of all histiotypes and combinations are capable of persistence with clinical recurrence. The persistence usually was histologically similar to the original, but in some cases was more "cellular" because, for the most part, the excisions of the persistent lesion revealed a deeper spindle-fascicular ("cellular") component not evident in the original superficial biopsy. In two cases, the original blue nevus appeared completely banal, but the persistent/recurrent lesions were histologically distinct and demonstrated atypical histologic features. Yet, follow-up (average 3.7 years) supports benign biology. Clinical recurrence is often associated with malignant transformation in blue nevus, but this series demonstrates that malignant tumor progression is not necessarily the case. In the absence of necrosis en mass, marked cytologic atypia, and frequent mitotic figures, the described atypical morphologic parameters in previously biopsied small blue nevi are probably reactive and "pseudomalignant." Awareness of this potential change may avoid diagnostic and prognostic errors.

Treatment of unfavorable myelodysplastic syndrome with all-trans-retinoic acid and subcutaneous Ara C

Thirty patients with high-risk myelodysplastic syndrome, defined as > 5% bone marrow blasts, were treated with a combination of oral all-trans-retinoic acid (45 mg/m2 daily) and subcutaneous AraC (10 mg/m2) on days 1-14 of each 28-35 day cycle repeated for 2-6 cycles. Complete remission lasting 9, 12, and 15 months was achieved in three patients. Partial and minor response did not translate into meaningful clinical improvement, like complete responders. Overall incidence of leukemia transformation and survival of this cohort of patients was no different from the expected outcome for a group of patients with similar characteristics.

Sentinel lymphadenectomy in the management of primary cutaneous malignant melanoma. An update

The management of lymph nodes in melanoma patients who have no clinical evidence of nodal disease has changed dramatically with the development of selective lymph node biopsy. This procedure localizes the node in a regional basin most likely to contain a metastasis (the sentinel node) and averts the morbidity of unnecessary elective node dissection. This update reviews the rationale for this procedure and describes the methodology used by the surgeon and the pathologist. A progress report highlights the promise and limitation of this procedure. Sentinel node biopsy is currently the standard for staging select groups of melanoma patients, but the field is rapidly evolving and may eventually be surpassed by even newer molecular diagnostic techniques.

Atypical Spitz nevi/tumors: lack of consensus for diagnosis, discrimination from melanoma, and prediction of outcome

The biological nature of Spitz nevi/tumors and their diagnostic distinction from, or relationship to, melanoma remain unresolved issues. In this report, a series of 30 melanocytic lesions removed from 28 patients, including atypical Spitz nevi/tumors and metastasizing Spitzoid tumors/melanomas, were evaluated by a panel of dermatopathologists to evaluate interobserver diagnostic concordance and to assess the prognostic power of histological criteria. For inclusion in the study, each lesion had to display some criteria for the Spitz nevus, and in addition one of the following was required: (1) definitive clinical outcome such as metastasis or death of disease, or (2) long-term follow-up if the patient remained disease free. Each lesion was reviewed independently and blinded as to the clinical data by 10 pathologists, who categorized them as (1) typical Spitz nevus/tumor, (2) atypical Spitz nevus/tumor, (3) melanoma, (4) tumor with unknown biological potential, or (5) other melanocytic lesion. There was limited discussion of criteria before the review. Evaluation of 17 Spitzoid lesions yielded no clear consensus as to diagnosis; in only one case did six or more pathologists agree on a single category, regardless of clinical outcome. Notably, however, some lesions that proved fatal were categorized by most observers as either Spitz nevi or atypical Spitz tumors. Conversely, seven or more pathologists scored 13 lesions as melanoma. These results illustrate (1) substantial diagnostic difficulties posed by many Spitz tumors, especially those with atypical features, even among experts, and (2) the lack of objective criteria for their distinction from melanoma and for gauging their malignant potential. Nevertheless, our observations do suggest that a biological relationship exists between the Spitz nevus/tumor and melanoma.

Epstein Barr virus-associated lymphoproliferative-disorders primarily involving the skin

In cases of solid organ or bone marrow transplantation, up to 2 to 10% of patients may develop lymphoproliferative disorders (LPD), often induced by Epstein-Barr virus (EBV). Despite a morphology mimicking malignant lymphoma, in some cases the lesions will disappear completely after the degree of immunosuppression is lowered. Lately, similar processes have been described in non-transplant, immunosuppressed patients. A SNOMED search was performed on the database of three hospitals between 1990 and 1997, to identify patients with immunosuppression-related lymphoproliferative disorders (IR-LPD) involving primarily the skin. Two patients were identified. One was 2 years after kidney transplantation, and the other was being treated with methotrexate for dermatomyositis. In both biopsies, there was a diffuse perivascular proliferation of large lymphocytes with ample cytoplasm and pleomorphic nuclei, associated with extensive dermal and subcutaneous necrosis. Immunohistochemical studies revealed expression of CD20, CD45RO, CD43, CD30, EBV-LMP1, and EBV-NA2 by the atypical lymphocytes in both cases and, in one case, of the EBV-transcriptional replication activation protein. In both cases the lesions completely disappeared and have not recurred. Primary involvement of the skin by IR-LPD is very rare. Based on our results, it is possible that some of these cases in the skin contain EBV and co-express CD30 and T- and B-cell markers. The diagnosis of IR-LPD should be considered in cutaneous lymphoid proliferations in immunosuppressed patients. Before rendering an unequivocal diagnosis of malignant lymphoma, reduction of immunosuppression and follow-up of 4-8 weeks should be considered.

Diagnosis: erythema nodosum or not?

Erythema nodosum is the final common pathway to a myriad of insults and is thought to be a hypersensitivity reaction centered in the subcutis. To recognize the histological spectrum of erythema nodosum, one must be aware of the morphologic chronology of the disease (early, fully developed, late) and its clinical variants (erythema nodosum migrans). This article reviews the range of changes that can be seen in this prototype of a septal panniculitis and describes the diversity that may be accepted in the diagnosis. Differential diagnoses at each stage of disease development are discussed. The criteria elaborated should assist the pathologist in answering the clinician's query, "Erythema nodosum, or not?"

Apocrine poroma: a distinctive case in a patient with nevoid basal cell carcinoma syndrome

Traditionally, poromas have been classified as eccrine neoplasms, but several recent reports of poroid tumors with sebaceous, follicular, and apocrine differentiation have challenged this idea. In support of alternative differentiation, a case of an "apocrine" poroma is reported in a 19-year-old man with the nevoid basal cell carcinoma syndrome. A papule on the right cheek, thought clinically to be a basal cell carcinoma, was excised. Anastomosing lobules of small uniform basaloid (poroid) cells formed small ductular structures lined by eosinophilic cuticles and extended into the superficial reticular dermis. The neoplasm originated from follicular infundibula and was surrounded by a myxoid stroma. Focally, primitive hair bulb and papillae differentiation was present, and some of the ducts were lined by cells suggesting decapitation secretion. The histologic pattern and the common embryologic origin of the folliculosebaceous-apocrine unit support apocrine differentiation of this tumor. The association with the nevoid basal carcinoma syndrome appears to be unique. This case, in addition, demonstrates overlapping features with the infundibulocystic type of basal cell carcinoma commonly seen in the basal cell nevus syndrome.

Use of subatmospheric pressure to prevent progression of partial-thickness burns in a swine model

The poorly understood, complex series of events that follows thermal injury frequently results in progressive loss of tissue. The concept of reversing this distinctive series of events has focused on the zone of stasis. Tissues in the zone of stasis that surround burn injuries usually die over a period of 48 to 72 hours postinjury, resulting in a more severe injury. Application of a controlled subatmospheric pressure (125 mm Hg) in an artificially closed space to partial-thickness burns in pigs significantly decreased the maximum depth of cellular death under the burn when the pressure was applied within 12 hours after burn creation (depth of control burns = 0.885 +/- 0.115 mm; subatmospheric pressure treated burns (0-hour delay) = 0.095 +/- 0.025 mm). A decrease in the depth of cell death was noted when subatmospheric pressure was applied for as little as 6 hours. In summary, the application of the negative pressure to partial-thickness burn injuries prevented progression of the wound to a deeper injury in this experimental pig model. A 12-hour working window exists between injury and treatment with reduced pressure, with an application time of as little as 6 hours for successful prevention of injury progression. This technique may represent a new, inexpensive, 'low tech' method for the treatment of partial-thickness burn injuries.

Anemia after orchiectomy

The decrease in testosterone production associated with bilateral orchiectomy may result in normocytic anemia in men. We sought to determine the effect of orchiectomy on hemoglobin concentration. Patients were evaluated at the Mayo Clinic in 1993 and 1994 and underwent bilateral orchiectomy for prostate carcinoma. All patients were seen by one of the staff urologists. Patients were included if they had a normal preoperative complete blood cell count and serum levels of creatinine, if they remained without disease progression (suppressed prostate-specific antigen level and no evidence of clinical progression on review), and if they had normal serum levels of creatinine and mean corpuscular volume during the follow-up period. The patients could have no other cause of anemia. The complete blood cell count, prostate-specific antigen level, and serum level of creatinine were determined preoperatively and at least once (>90 days) after orchiectomy. Sixty-four patients were included in the analysis (median age, 68 years). The median decrease in hemoglobin concentration was 1.2 g/dL after orchiectomy. There was a statistically significant difference in the hemoglobin concentration before orchiectomy compared with postoperative values at all the intervals studied, both by the paired group t-test and the Kruskal-Wallis test. There is a clinically and statistically significant decrease in hemoglobin concentration after orchiectomy. Knowledge of this phenomenon may prevent unnecessary diagnostic work-up in men with normocytic anemia after bilateral orchiectomy.

A case control study of proximal calciphylaxis

The purpose of this investigation was to describe the clinical presentation of nine patients with calciphylaxis involving the proximal lower extremities or trunk and to compare the clinical characteristics of these patients with those of 347 hemodialysis patients from the same geographic area. Patients were identified primarily through a computer search of pathology records, identifying patients with the term "calciphylaxis" in the biopsy report. All patients had pathologic specimens consistent with calciphylaxis. All the calciphylaxis patients were white and were markedly obese. While two patients had markedly elevated parathyroid hormone levels, most patients did not show severe derangements of calcium phosphate metabolism compared with other dialysis patients. A logistic regression model identified body mass index and low serum albumin 3 months before diagnosis as being highly associated with a diagnosis of calciphylaxis. Diabetes mellitus and parameters of calcium-phosphate metabolism were not significantly associated with proximal calciphylaxis. These findings suggest that white race, morbid obesity, and poor nutritional status are associated with proximal calciphylaxis in dialysis patients.

Dying dogma: the pathological diagnosis of epidermotropic metastatic malignant melanoma

Distinguishing primary cancer from a metastasis is a fundamental task in surgical pathology that has crucial therapeutic and prognostic implications. When metastatic melanoma involves the skin and extends into the epidermis (epidermotropic), differentiating it from primary cutaneous melanoma may be particularly difficult. Early investigators dismissed this issue as a nonproblem and dogmatically declared that junctional change was requisite for the diagnosis of primary cutaneous melanoma. Epidermotropic metastases of malignant melanoma (EMMM) are now recognized to have many features in common with primary melanoma, which can include involvement of the dermal-epidermal junction, extension of the intraepidermal component beyond the dermal component, and even an epidermal-only pattern. This article traces the evolution in criteria used to diagnose EMMM and highlights why much of the original thinking is no longer accepted. Current concepts in EMMM morphology are elaborated and illustrated. The role of immunomicroscopy and molecular pathology in the detection of EMMM is also discussed.

Histogenetic relations between giant cell fibroblastoma and dermatofibrosarcoma protuberans. CD34 staining showing the spectrum and a simulator

The authors describe three lesions that provide further evidence for a close, possibly histogenetic relation between giant cell fibroblastoma and dermatofibrosarcoma protuberans. The first case involves a dermatofibrosarcoma protuberans that contained a single giant cell fibroblastoma-like focus of multi-nucleate giant cells. A second tumor, a giant cell fibroblastoma, recurred 6 years later as a dermatofibrosarcoma protuberans. In the third lesion, there was a juxtaposition and co-mingling of dermatofibrosarcoma protuberans and giant cell fibroblastoma within the same primary lesion. In all cases, both the giant cell fibroblastoma areas and dermatofibrosarcoma protuberans areas stained positively with CD34. A fourth case, a dermatofibrosarcoma protuberans infiltrated skeletal muscle, creating giant cell fibroblastoma-like giant cell mimics--a result of skeletal muscle degeneration or atrophy with nuclear conglomeration. The latter giant cells failed to express CD34 but did show immunoreactivity with desmin. These findings support the concept that giant cell fibroblastoma and dermatofibrosarcoma protuberans probably represent a histologic spectrum of a single CD34 positive (perhaps, dermal dendrocytic) neoplasm, a conclusion supported by a recently cloned t(7;22) breakpoint demonstrated in both neoplasms.

Malicious masquerade: myxoid melanoma

The morphological spectrum of malignant melanoma is broad. Unusual stromal changes can distract pathologists from the correct diagnosis. Fibroblastic, chondroid, osteoid, and myxoid stroma have been documented in melanomas. Myxoid melanoma is problematic--introducing carcinomas and soft tissue sarcomas into the differential diagnosis. This review examines the clinicopathologic aspects of myxoid malignant melanoma, with emphasis on its differential diagnosis.

Grover's-like disease in the setting of bone marrow transplantation and autologous peripheral blood stem cell infusion

Four cases of a Grover's-like disease in patients with leukemia/lymphoma, who underwent high-dose chemotherapy and either allogeneic/autologous bone marrow transplantation or autologous stem cell infusion, are described. Three of four patients had fever prior to the onset of their rash. In addition to suprabasilar clefts, acantholysis, and dyskeratosis, typical of Grover's disease, there was a chemotherapeutic effect in the form of keratinocytes with atypical nuclei. So-called "starburst cells," which have been purported to be specific for high-dose etoposide (VP-16) therapy, were seen in two cases, but only one of these patients received etoposide. In one patient with clinical vesicles, direct immunofluorescence ruled out paraneoplastic pemphigus. In conjunction with 18 similar cases in the literature, the following conclusions were reached: (a) the pathogenesis probably involves the combined effects of fever (with sweating), occlusion, and chemo/radiation therapy; (b) no single chemotherapeutic agent can be consistently implicated; and (c) in addition to graft-versus-host disease, the eruption of lymphocyte recovery, and other cutaneous eruptions in the setting of bone marrow transplantation, the differential diagnosis includes paraneoplastic pemphigus, which direct immunofluorescence excludes.

A controlled subatmospheric pressure dressing increases the rate of skin graft donor site reepithelialization

The ability to increase the rate of skin graft donor site reepithelialization significantly in a cost-effective manner has important implications for the patient undergoing major reconstructive procedures. In this study the effect of externally applied reduced pressure (the V.A.C.) on the rate of healing of donor site wounds was initially investigated using a porcine model (N = 4), then repeated on humans (N = 10). Split-thickness skin grafts were harvested from the backs of pigs using standard technique. Half of the donor sites were treated with subatmospheric pressure (125 mmHg) and half were treated with an OpSite dressing. Biopsies taken every 48 hours demonstrated that sites exposed to reduced pressure healed at a much faster rate than sites treated with a standard occlusive dressing. Similarly, donor sites in humans reepithelialized faster in 7 of 10 patients, the rate was the same in 2 of 10 patients, and OpSite was faster in 1 of 10 patients. We believe this technology has the potential to be a relatively simple and cost-efficient method for increasing the rate of donor site healing.

CD34-positive eruptive fibromas

The list of entities comprising a proliferation of CD34 (+) spindle cells continues to grow. Described, herein, is a patient who had an indolent eruption of scattered papules composed of CD34 (+) spindle cells, beginning in adolescence. An 18-year-old female patient presented with asymptomatic, tan/brown papules over the neck, chest, and proximal extremities. They appeared 6 years previously and had slowly increased in number. Biopsy from the neck showed a proliferation of plump spindle cells, associated with delicate collagen, in the upper reticular dermis. No atypia nor mitotic figures were present. The spindle cells were negative for S-100, muscle actins, and Factor XIIIa, but stained intensely with CD34. This unusual mesenchymal proliferation of CD34 (+) apparent dermal dendrocytes did not have the storiform pattern, short fascicles, nor mitotic figures of DFSP. The completely negative muscle markers helped to exclude dermatomyofibroma, and no morphological evidence of vasoformative differentiation was seen. The clinical picture militated against solitary fibrous tumor. These eruptive tumors are benign and thought to represent a distinctive fibroma produced by proliferated CD34 (+) stromal cells.

The evaluation of human herpesvirus 8 (Kaposi's sarcoma-associated herpesvirus) in cutaneous lesions of Kaposi's sarcoma: a study of formalin-fixed paraffin-embedded tissue

The etiologic role of human herpesvirus 8 (HHV8) in Kaposi's sarcoma (KS) remains controversial. This polymerase chain reaction (PCR)-based study was undertaken to evaluate the relationship of HHV8 in KS from our geographical region and to determine its utility in formalin-fixed, paraffin-embedded biopsy specimens. Forty-two biopsy specimens were studied, including nine AIDS-associated cases and four from classic KS. Of the 39 patients included, 21 were HIV+ and 18 had no clinical evidence of HIV infection. Only a single (internal) primer pair was used in the PCR. All PCR products were tested with an HHV8 specific probe by dot blot analysis. Seven of the nine AIDS KS specimens were positive for HHV8 on electrophoresis, and all nine were positive after dot blot. Two of four specimens from classic KS were positive for HHV8 on the gel electrophoresis, and three of four were positive on blot confirmation. Non-KS specimens from 15 HIV+ patients yielded one positive venous hemangioma from a man with HHV8-positive KS at another site. Specimens from HIV-unrelated controls with a variety of diagnoses were negative by PCR with blot. The predominant negativity for HHV8 in non-KS lesions suggests that HHV8 is not widespread in our patients. These results demonstrate yet another series linking KS with HHV8 and show that paraffin-embedded biopsy specimens are satisfactory for this technique.

Expanded profile of the SHAFT syndrome

The SHAFT syndrome is a factitious disorder in which a patient manipulates the surgeon to perform operations to fulfill his or her psychological needs. The acronym describes patients who are sad, hostile, anxious, frustrating, and tenacious. A chart review from January 1990 to June 1996 was undertaken to provide a profile to aid in the recognition and diagnosis of the SHAFT syndrome. An analysis of 28 patients revealed characteristics supporting a definitive SHAFT profile. Patients with SHAFT syndrome seek physicians to perform invasive procedures. Their typical complaint is pain, usually without objective physical findings that would support a more definitive diagnosis. Such patients tend to be women, cry with pain, describe symptoms out of proportion to objective findings, and have a history of psychiatric care.

Granulomatous blepharitis as a sign of Melkersson-Rosenthal syndrome

OBJECTIVE

The objective of our study was to describe the ophthalmic features and histologic eyelid findings of Melkersson-Rosenthal syndrome.

DESIGN

Three patients with eyelid edema underwent eyelid biopsy to establish the diagnosis of Melkersson-Rosenthal syndrome.

RESULTS

Of the three patients, only one patient manifest the classic triad of facial edema, facial paralysis, and furrowed tongue. Histoloppgically, the eyelid skin in all patients showed characteristic perilymphatic granulomas with marked dermal edema.

CONCLUSIONS

The histopathologic features assist in establishing the diagnosis of Melkersson-Rosenthal syndrome in oligo- and monosymptomatic patients. Melkersson-Rosenthal syndrome should be considered in patients presenting with eyelid edema of unknown etiology and biopsy performed.