BRAF-V600 Mutation Heterogeneity in Primary and Metastatic Melanoma: A Study With Pyrosequencing and Immunohistochemistry.

BACKGROUND: The BRAF-V600 mutation is the most common mutation in cutaneous melanomas and is currently considered a target mutation when planning treatment for metastatic melanoma patients. Various techniques are used to determine the mutation status. The aim of this study was to determine the BRAF-V600 mutation status in primary and metastatic foci of melanoma cases and the consistency between the results of immunohistochemical and molecular methods. METHODS: A total of 48 primary or metastatic cases were included in the study. Pyrosequencing was used as the molecular method and the VE1 antibody for immunohistochemical evaluation when determining the BRAF-V600 mutation. RESULTS: The BRAF-V600 mutation was found in 75 of the 96 tumors (78.1%) from the 48 cases. V600E and V600K were present in 60 and 10 tumors, respectively, whereas V600R and V600M were present in 2 tumors and V600G in 1 tumor. There was no mutation in 5 metastases (12.8%) of the 39 cases with a V600 mutation in the primary tumor and no mutation in the primary tumor of 2 of the 36 cases (5.6%) with the V600 mutation in the metastasis. Fifty-six tumors were immunohistochemically positive where a V600E mutation was detected with pyrosequencing. Wild-type tumors (n = 20) and tumors with non-V600E mutations (n = 15) on pyrosequencing were immunonegative with VE1. The sensitivity and specificity of immunohistochemistry were 93.3% and 97.2%, respectively. CONCLUSIONS: In conclusion, BRAF-V600 mutation inconsistencies of up to 14.5% can be seen between the primary and metastatic foci in melanoma cases. These findings should be taken into account when planning targeted therapy and deciding on treatment responsiveness/unresponsiveness. An immunohistochemical method can be used as the first step to detect a BRAF-V600 mutation but additional molecular methods should be used when immunohistochemistry results are negative.

Terbinafine hydrochloride loaded liposome film formulation for treatment of onychomycosis: in vitro and in vivo evaluation.

Onychomycosis is a fungal infection of nail unit that is caused by dermatophytes. Oral Terbinafine hydrochloride (TBF-HCl) is being used for the treatment of onychomycosis since 24 years. The side effects caused by the systemic application and limitations of topical administration of this drug regarding the diffusion through nail lead to the development of a new formulation based on, TBF-HCl-loaded liposome. The newly obtained film formulations were prepared and characterized via several parameters, such as physical appearance, drug content, thickness, bioadhesive properties and tensile strength. In vitro and ex vivo permeation studies were performed to select an optimum film formulation for antifungal activity to show the efficiency of formulations regarding the treatment of onychomycosis. The in vitro release percentages of drug were found 71.6 ± 3.28, 54.4 ± 4.26, 56.1 ± 7.48 and 46.0 ± 2.43 for liposome loaded pullulan films (LI-P, LII-P) and liposome loaded Eudragit films (LI-E, LII-E), respectively. The accumulated drug in the nail plates were found 31.16 ± 4.22, 24.81 ± 5.35, 8.17 ± 1.81 and 8.92 ± 3.37 for LI-P, LII-P, LI-E and LII-E, respectively, which within therapeutic range for all film formulations. The accumulated drug in the nail plate was found within therapeutic range for all film formulations. The efficacy of the selected TBF-HCl-loaded liposome film formulation was compared with TBF-HCl-loaded liposome, ethosome, liposome poloxamer gel and ethosome chitosan gel formulations. It was found that TBF-HCl-loaded liposome film formulation had better antifungal activity on fungal nails which make this liposome film formulation promising for ungual therapy of fungal nail infection.

Clinicopathological characteristics and mutation profiling in primary cutaneous melanoma.

BACKGROUND: The incidence of mutations in malignant melanoma varies remarkably according to the subtype of melanoma, and this in itself is affected by racial and geographical factors. Studies screening melanoma case series for different types of mutations are relatively rare. METHOD: The authors analyzed the frequency of various somatic point mutations of 10 genes in 106 primary cutaneous melanoma cases. The mutations (BRAF, NRAS, KIT, CDKN2A, KRAS, HRAS, PIK3CA, STK11, GNAQ, CTNNB1) were evaluated with real-time PCR-based PCR-Array through allele-specific amplification, and the results were correlated with various clinicopathological characteristics. RESULTS: Mutations were found in 64.2% of the melanomas overall. BRAF (42.5%), NRAS (15.1%), and CDKN2A (13.2%) were the 3 most common mutations. BRAF and NRAS mutations were more frequent in nodular and superficial spreading melanomas (P < 0.001). Associations with BRAF mutation were as follows: male gender [odds ratio (OR) = 2.4], younger age (OR = 2.7), superficial spreading (OR = 15.6) and nodular melanoma (OR = 9.5), trunk localization (OR = 6.3), and intermittent sun exposure (OR = 4.6). A considerable percentage of V600K (44.4%) mutations were found among the BRAF mutations, whereas KIT mutations (3.8%) were less frequent. Multiple mutations were detected in 13.2% of the melanomas. The most common co-occurrences were in the BRAF, NRAS, and CDKN2A genes. CONCLUSIONS: The authors analyzed 10 somatic mutations in the main subtypes of primary cutaneous melanomas from the western region of Turkey. Mutations were found in 64.2% of the melanomas overall. The most common mutations were in the BRAF and NRAS genes. In addition to other less common mutations, a notable number of multiple mutations were encountered. The multiplicity and concurrence of mutations in this study may provide further study areas for personalized targeted therapy.

Accuracy in melanoma detection: a 10-year multicenter survey.

BACKGROUND: Early excision is the only strategy to reduce melanoma mortality, but unnecessary excision of benign lesions increases morbidity and healthcare costs. OBJECTIVE: To assess accuracy in melanoma detection based on number-needed-to-excise (NNE) values over a 10-year period. METHODS: Information was retrieved on all histopathologically confirmed cutaneous melanomas or melanocytic nevi that were excised between 1998 and 2007 at participating clinics. NNE values were calculated by dividing the total number of excised lesions by the number of melanomas. Analyses included changes in NNE over time, differences in NNE between specialized clinical settings (SCS) versus non-specialized clinical settings (NSCS), and patient factors influencing NNE. RESULTS: The participating clinics contributed a total of 300,215 cases, including 17,172 melanomas and 283,043 melanocytic nevi. The overall NNE values achieved in SCS and NSCS in the 10-year period were 8.7 and 29.4, respectively. The NNE improved over time in SCS (from 12.8 to 6.8), but appeared unchanged in NSCS. Most of the effect on NNE in SCS was due to a greater number of excised melanomas. Higher NNE values were observed in patients younger than 40 years and for lesions located on the trunk. LIMITATIONS: No data concerning the use of dermatoscopy and digital monitoring procedures were collected from the participating centers. CONCLUSION: Over the 10-year study period, accuracy in melanoma detection improved only in specialized clinics maybe because of a larger use of new diagnostic techniques such as dermatoscopy.

Cellular blue nevus of the vulva mimicking Bartholin's gland abscess in a 15-year-old girl: a case report.

INTRODUCTION: Literature review revealed descriptions of three cellular blue nevus (CBN) in the gynecologic tract. Two of them were myometrial CBN and incidental findings in hysterectomies performed in women aged 37 and 48 years. The single ectocervical CBN involving the hymenal ring and vagina was reported in a 19-year-old woman. The other reported cases of cervical blue nevi were common type and have been localized to endocervix. CASE REPORT: Vulvar CBN in left labia majora mimicking Bartholin's gland abscess in a 15-year-old white virgin girl and also the youngest case has not been reported previously. CONCLUSION: CBN should be considered in the differential diagnosis of vulvar masses in adolescent period.

Development of squamous cell carcinoma on an inflammatory linear verrucous epidermal nevus in the genital area.

Inflammatory linear verrucous epidermal nevus is a rare cutaneous disorder characterized by pruritic, erythematous, and verrucous papules and plaques along the lines of Blaschko. Histopathologically, there is a benign verrucous proliferation of keratinocytes together with alternating parakeratosis and orthokeratosis as well as inflammatory changes. We report a patient who developed squamous cell carcinoma (SCC) on an inflammatory linear verrucous epidermal nevus and we discuss the importance of regular follow-up of patients with epidermal nevi.

Exanthematous drug eruption due to valsartan.

OBJECTIVE: Valsartan is an angiotensin II receptor blocker (ARB) used for treatment of hypertension. The well-known adverse effects of valsartan are dizziness, headache and cough. Valsartan-related cutaneous side effects have been reported previously in a limited number of case reports. MATERIALS AND METHODS: A 47-year-old man admitted with diffuse, itchy erythematous maculopapular eruption all over the body. He has been taking 160 mg valsartan daily for 10 days before onset of the eruption. On the third day of valsartan therapy, erythema had appeared over the face and spread throughout the whole body within a week. Histopathologic examination of the lesions showed lymphocyte exocytosis, spongiosis, necrotic keratinocytes in the epidermis, and mixed inflammatory cell infiltrates including perivascular eosinophils in the dermis. The patient was diagnosed as drug reaction due to valsartan with historical, clinical and histopathologic features. DISCUSSION AND CONCLUSION: Most common antihypertensive agents including diuretics, beta blockers, calcium-channel blockers, angiotensin-converting enzyme inhibitors have many cutaneous side effects. However, there are a few reports about the cutaneous side effects of ARBs. Physicians should be aware of the cutaneous side effects of this commonly used agent and valsartan should be considered as a triggering factor of an exanthematous drug reactions.

Generalized pustular eruptions due to terbinafine.

Terbinafine, a widely used antifungal agent, may rarely cause cutaneous side effects with an incidence of 2.7%. Generalized pustular eruptions are quite uncommon but severe adverse cutaneous reactions of terbinafine have been reported. The main pustular eruptions due to terbinafine include acute generalized exanthematous pustulosis and drug induced pustular psoriasis. In this report, two cases of acute generalized exanthematous pustulosis and one case of generalized pustular psoriasis triggered with terbinafine are presented.

Perianal fibroadenoma, case report.

Extramammary fibroadenomas, occurring in the anogenital region, are rare lesions thought to be arising from "mammary-like anogenital sweet glands" described by van der Putte. We present a 42-year-old woman with a slow-growing, 4-cm, well-circumscribed but nonencapsulated mass in perianal region. The cut surface of the lesion was bulging, gray-white, and slightly lobulated. Microscopically, it was identical to mammary fibroadenoma and composed of concurrent glandular and stromal elements. Low columnar or cuboidal cells with focal, apical cytoplasmic snouts lined the glands, whereas the underlying layer had myoepithelial cell features, expressing smooth muscle actin and S-100. Epithelial component was immunoreactive for human milk fat globulin I. Progesterone receptor positivity was 80%, whereas the estrogen receptor expression was 60%. Gross cystic disease fluid protein and human milk fat globulin II were negative. The case is presented to increase the awareness on mammary-like glands of anogenital region, which may give rise to not only fibroadenomas but also fibrocystic disease, phyllodes tumor, carcinoma in situ, invasive carcinoma and lactating adenoma, hidrocystoma, hidradenoma papilliferum, intraductal papilloma, and sclerosing adenosis, although very rare.

Public health education in Ege University Medical Faculty: developing a community-oriented model.

BACKGROUND: Ege University Medical Faculty (EUMF) introduced a community-oriented curriculum in 2001. AIMS: To evaluate the new public health education program in EUMF curriculum. METHOD: The study adopted triangulated methods. Quantitatively, a comparison of the students who were exposed to a community-oriented curriculum (Year 4 in 2007) was made with the students who were exposed to the traditional curriculum (Year 4 in 2005) in terms of their assessment of their achievement of our learning objectives. A total of 255 students in 2005 (80.7%) and 243 students in 2007 (81.5%) were surveyed using a questionnaire. Qualitatively, five focus group- and five individual interviews were performed with the 2007 cohort. RESULTS: Except the one related to teamwork (p > 0.05) all learning objectives yielded significantly higher scores in the 2007 cohort than in the 2005 cohort (p < 0.05). The qualitative analysis supported the achievement of objectives in the 2007 cohort. The students appreciated the relevance of public health education with clinical subjects and interactive methods, but criticized didactic lectures and written assignments. CONCLUSIONS: A community-oriented approach is more effective in achieving a holistic approach to health problems. Improving community-based activities and assessment methods would be more successful in integrating population health into medical training.

Primary Sinonasal Malignant Melanoma: Effect of Clinical and Histopathologic Prognostic Factors on Survival.

BACKGROUND: Mucosal melanoma is a rare malignancy arising from melanocytes of the mucosal surfaces. The pattern and frequency of oncogenic mutations and histopathological biomarkers have a role on distinct tumour behaviour and survival. AIMS: To assess the rate of C-KIT positivity and its effect on survival of surgically treated sinonasal malignant melanoma patients with other histopathological biomarkers and clinical features. STUDY DESIGN: Retrospective cross-sectional study. METHODS: Seventeen sinonasal malignant melanoma patients with a mean age of 65.41 (39-86) years were included. Overall survival and disease-specific survival rates were calculated. The impact of age, gender, stage and extent of the disease, type of surgery, and adjuvant therapies were also taken into consideration. The effect of mitotic index, pigmentation, S100, HMB-45, Melan-A and C-KIT on survival were evaluated. RESULTS: Median tumour size was 20 mm (interquartile range=27.5 mm). Pigmentation was present in 7 (41.2%) cases. Median number of mitoses per millimetre squared was 11 (interquartile range=13). Melan A was positive in 7 (41.2%) patients, ulceration was present in 6 cases (35.3%), and necrosis was present in (47.1%) 8 cases. Six patients (35.3%) were positive for S100, 14 (82.4%) specimens stained positive for HMB-45 and C-KIT (CD117) was positive in 9 cases (52.9%). Three patients (16.7%) developed distant metastasis. Five year overall and disease free survival rates were 61.4% and 43.8%, respectively. CONCLUSION: Although C-KIT positive sinonasal malignant melanoma patients (52.9%) can be candidates for targeted tumour therapies, the studied clinical or histopathological features along with C-KIT seem to have no significant effect on survival in a small group of patients with sinonasal malignant melanoma.

The Importance of Minor Salivary Gland Biopsy in Sjögren Syndrome Diagnosis and the Clinicopathological Correlation.

OBJECTIVE: Minor salivary gland biopsy is one of the objective tests used in the diagnosis of Sjögren syndrome. The aim of our study was to compare the clinical and laboratory data of primary and secondary Sjögren syndrome cases with a lymphocyte score 3 and 4 in the minor salivary gland biopsy. MATERIAL AND METHOD: Data from a total of 2346 consecutive minor salivary gland biopsies were retrospectively evaluated in this study. Clinical and autoantibody characteristics of 367 cases with lymphocyte score 3 or 4 and diagnosed with primary or secondary Sjögren syndrome were compared. RESULTS: There was no difference between lymphocyte score 3 and 4 primary Sjögren syndrome patients in terms of dry mouth, dry eye symptoms and Schirmer test results but Anti-Ro and Antinuclear Antibody positivity was statistically significantly higher in cases with lymphocyte score 4 (p= 0.025, p= 0.001). Anti-Ro test results were also found to be statistically significantly higher in secondary Sjögren syndrome patients with lymphocyte score 4 (p= 0.048). CONCLUSION: In this study, the high proportion of cases with negative autoantibody but positive lymphocyte score is significant in terms of showing the contribution of minor salivary gland biopsy to Sjögren syndrome diagnosis. Lymphocyte score 3 and 4 cases were found to have similar clinical findings but a difference regarding antibody positivity in primary Sjögren syndrome. We believe that cases with lymphocyte score 4 may be Sjögren syndrome cases whose clinical manifestations are relatively established and higher autoantibody levels are therefore found.

ITP as an initial manifestation of subacute cutaneous lupus erythematosus.

Subacute cutaneous lupus erythematosus (SCLE) is an entity characterized by widespread polycyclic lesions that heal without scarring. Skin lesions with marked ultraviolet sensitivity are distributed in an annular and/or psoriasiform configuration. Idiopathic thrombocytopenic purpura, which is an autoimmune disease (ITP), is mediated by a destructive immunoglobulin G antibody response to the platelets' membrane components. We report a case of subacute cutaneous lupus erythematosus initially manifested as thrombocytopenia, which was diagnosed as idiopathic thrombocytopenic purpura (ITP) and treated with splenectomy. Seven months later, development of cutaneous involvement followed the diagnosis of ITP. The clinical and histological features of the lesions were compatible with SCLE. Serological evaluations showed a negative anti-nuclear antibody test and an elevated anti-SSB/La antibody level. Symptoms for systemic involvement were negative. Although the clinical features such as photosensitivity, discoid rash, and thrombocytopenia were in favor of SLE, the patient did not fulfill the criteria of the American Rheumatism Association (ARA) for SLE.

The Effects of Cyclin D1 and Bcl-2 Expression on Aggressive Behavior in Basal Cell and Basosquamous Carcinoma.

BACKGROUND AND OBJECTIVE: Clinical behavior of basal cell carcinoma (BCC) is known to be different according to histological growth pattern and basosquamous cell carcinomas (BSC) are known with their aggressive behavior and metastatic capacity. In this study, we evaluated bcl-2 and cyclin D1 expressions in BCC and BSC cases comparatively, to explore their predictive value on the aggressive behavior of these tumors. METHODS: One hundred tumors belong to 92 patients diagnosed as basal cell carcinoma and basosquamous carcinoma were studied. Basal cell carcinomas were classified as aggressive and non-aggressive types according to growth pattern. Number of Cyclin D1 and bcl-2 positive cells in immunohistochemically stained serial sections were scored as low (0-1 +) and high (2 and 3+) in all tumors. RESULTS: A statistically significant difference was found between non-aggressive (nodular type) and aggressive types (micronodular, infiltrative types and BSC) for these markers ( P <0.005). Cyclin D1 was higher in the aggressive group, while bcl-2 was lower in the aggressive group compared to the non-aggressive group. CONCLUSION: Higher Cyclin D1 and lower bcl-2 scores was correlated with aggressive tumor types and these results could be used as markers to predict aggressive behavior in BCC and BSCs.

Atypia and differential diagnosis in cellular blue nevi: clinicopathological study of 21 cases.

OBJECTIVE: Cellular blue nevus differs from the classic blue nevus with characteristics such as large size, cellularity, intense pigmentation, and growing pattern with subcutaneous infiltration. It is a dermal melanocytic tumor that can be confused with melanoma due to the atypia it may contain. MATERIAL AND METHOD: Hematoxylin-eosin and MIB-1 stained slides of 21 cases diagnosed between 2000-2014 were re-evaluated. In order to attract attention to this rare lesion, 21 cases are presented with the clinical and above-mentioned histopathological findings. RESULTS: Thirteen (61.9%) cases were females and eight (38.1%) were male. The mean age was 25.4 (2-73). The most frequent localization was the sacral and gluteal region (11 cases). The mean diameter was 14.4 mm (4-60 mm). From the parameters defined to assess the atypia, ulceration was identified in four cases. Prominent cellularity and subcutaneous infiltration were seen in three and 16 cases, respectively. Mitosis was seen in six tumors. Immunohistochemically, MIB-1 was present in two cases as 3% and 2% respectively, while in others it was 1% or less. Although there is no precise definition for the "atypical cellular blue nevus", five patients were assessed as atypical cellular blue nevus (a case with infiltrative development of six cm tumor diameter, two cases with two mitosis and a MIB-1 index 3% and 2%, a case with one mitosis and confluent development and a case with one mitosis in addition to focal necrosis areas). No lymph node and/or distant metastasis was observed during follow-up. CONCLUSION: We think it is more important to rule out the possibility of conventional melanoma in cellular blue nevus with exaggerated morphological findings alongside low proliferative activity rather than to determine the atypia.

Prognostic significance of bcl-2, c-myc, survivin and tumor grade in synovial sarcoma.

OBJECTIVE: We aimed to determine the prognostic value of bcl-2, c-myc and survivin in synovial sarcoma cases and to evaluate the relationship between the conventional morphological findings with prognosis. MATERIAL AND METHOD: In this study, we evaluated 81 synovial sarcoma cases referred to our tertiary tumor center during a period of 20 years. We applied bcl-2, c-myc and survivin immunohistochemically and investigated the relationship with prognosis for those 65 cases with follow-up. The relationship between the conventional morphological findings (mitosis, necrosis, grade) with prognosis was also investigated. RESULTS: Five-year disease free survival rate was 44% and ten-year progression free survival rate was 38%, reflecting the aggressive behavior of synovial sarcoma. Tumor grade (according to FNCLCC) was the most significant prognostic input in this study. We obtained a significant difference between grade II (40 cases) and grade III (24 cases) group regarding progression-free survival and overall survival (p < 0.001 and p < 0.001 respectively). Grade II was divided into two groups according to mitotic index and necrosis (grade IIa and IIb) and there was a significant difference between them regarding prognosis (p=0.013 for progression free survival, p=0.003 for overall survival). There was a significant relationship between bcl-2 negative plus focally weak positive cases (9 cases) and focally strong cases (21 cases) and diffuse strong cases (35 cases) (p=0.042 and p=0.016 respectively). There was a significant relation between c-myc negative cases (25 cases) and nuclear positive cases (17 cases) regarding overall survival (p=0.043) and between c-myc negative cases and cytoplasmic positive cases (23 cases) regarding progression free survival (p=0.05). The relation between survivin and prognosis was not significant. CONCLUSION: Tumor grade was the most significant prognostic parameter in this study. The grade IIa group (with less than 10 mitoses in 10 HPF, without necrosis) had a better prognosis than both the grade IIb and III groups. The grade IIb group was closer to grade III regarding the prognosis. Bcl-2 and c-myc (nuclear and/or cytoplasmic) immunohistochemical positivity had prognostic value but this finding has to be confirmed by large series.

Primary systemic Al amyloidosis presenting as temporal arteritis.

Temporal arteritis is most common vasculitis in elderly and imitated by miscellaneous disorders. Temporal artery biopsy is the gold standard test in the diagnosis of giant cell arteritis (GCA). Hereby, we describe a case of a 67-year-old man who presented initially with temporal arteritis; however, a lip biopsy then revealed AL amyloidosis. In this respect, temporal artery biopsy should be performed for definitive diagnosis of GCA particularly patients with systemic symptoms and treatment resistant.

Follicular mucinosis and follicular mycosis fungoides: clinicopathological evaluation of seven cases.

OBJECTIVE: Follicular mucinosis is a disease characterized by follicular degeneration and mucin accumulation. It can be seen in mycosis fungoides, although idiopathic or forms associated with other diseases are also known. Follicular mycosis fungoides is a type of mycosis fungoides with different clinicopathological and prognostic features. MATERIAL AND METHOD: Seven cases with follicular centered lesions and multiple biopsies (2-6) were included. Cases were evaluated according to their clinical, histological and immunophenotypical features and follow-up data. RESULTS: All cases were male, and the mean age was 40.3 (range 18-61). Clinical complaints were follicular prominence, erythema and alopecia at head and neck, trunk, and lower limbs. Follicular mucinosis (6/7), and dermal lymphoid infiltration showing minimal-intensive folliculotropism accompanied by eosinophils was seen. Lymphoid infiltration was composed of small-medium sized cells, with scattered hyperchromatic nuclei in six cases. In one case there was only minimal cytological atypia. Intense folliculotropism of atypical lymphocytes and dense dermal infiltration without follicular mucinosis was seen in one case. Local and/or systemic treatments were applied and partial remission was achieved histologically. In three cases new and increasing lesions were seen. Density of infiltration and atypia were increased. CONCLUSION: The findings supported the opinion that follicular mucinosis is an important finding seen in mycosis fungoides. There can be important differences concerning the amount of infiltration and degree of atypia. In cases where the density of infiltration associated with follicular mucinosis is not diagnostic for MF, there can be progression over time. Long-term follow up is necessary in such cases where the differential diagnosis is difficult.

Pesticide-induced scleroderma and early intensive immunosuppressive treatment.

The authors report 2 children with generalized cutaneous sclerosis exposed to pesticides containing malathion and diniconazole. Treatment with immunosuppressives resulted in partial improvement in the cutaneous signs, particularly over the face, trunk, and proximal limbs. The considerable exposure to chemicals related with the initiation of symptoms and absence of organ involvement suggested a diagnosis of chemically induced scleroderma-like disorder. Although autoantibodies were negative, previously reported relevant associations of anti-kinetochore and anti-topoisomerase function of active ingredients-diniconazole and phosphorodithioate-and solvents of these pesticides are also discussed. Careful follow-up for systemic involvement is warranted, since these agents may have triggered systemic scleroderma in these patients. Elimination of chemical exposure of children is stressed.