Use of a bioabsorbable mesh in midline laparotomy closure to prevent incisional hernia: randomized controlled trial.

INTRODUCTION: The objective was to assess the effectiveness and safety of a bioabsorbable mesh at the time of closure of a midline laparotomy for IH prevention. MATERIALS AND METHODS: A multicenter, randomized clinical trial including patients undergoing abdominal surgical procedures through a midline laparotomy incision was designed. In the group of mesh (n = 167) the incision was closed using a continuous polydioxanone suture (PDS) plus a bioabsorbable mesh. In the control group (n = 165) a continuous PDS single layer suture was only used. Patients were randomly assigned (1:1) to the two groups. The primary outcome was the incidence of IH at 6, 12 and 24 months. Assessment of IH was done using a CT scan. RESULTS: At 6 months, the rates of IH were 15.2% and 24.8% in the experimental and control groups, respectively (relative risk [RR] 0.66, 95% confidence interval [CI] 0.38-0.98, P = 0.042). At 12 months, the rate of IH continued to be significantly lower in the experimental group (21.4% vs. 33.1%, P = 0.033), but at 24 months, there were no significant differences between the study groups with a follow-up rate of only 37.5%. The number needed to treat (NNT) was 11 and 9 at 6 and 12 months, respectively. CONCLUSION: The bioabsorbable mesh significantly prevented IH during the first year. Not reliable conclusions can be drawn across the second year. This may suggest that the any of the closing technique assessed in this study would have a "palliative" transient effect for preventing IH in the long-term.

Is Sarcopenic Obesity an Indicator of Poor Prognosis in Gastric Cancer Surgery? A Cohort Study in a Western Population.

BACKGROUND: The prognostic value of sarcopenic obesity in gastric cancer surgery remains debated. We aimed to evaluate the impact on outcomes of body composition and sarcopenic obesity after gastrectomy for gastric cancer. METHODS: A retrospective review of prospectively maintained database of patients undergoing gastrectomy for gastric cancer from 2010 to 2017 was performed. Skeletal muscle mass and visceral adipose tissue were evaluated by preoperative computed tomography to define sarcopenia and obesity. Patients were classified in body composition groups according to the presence or absence of sarcopenia and obesity. Prognostic factors for survival were assessed by multivariate Cox analysis. RESULTS: Of the 198 patients undergoing gastrectomy for gastric cancer, 90 (45.4%) patients were sarcopenic, 130 (67.7%) obese, and in the subclassification for body composition categories: 33 (17%) nonsarcopenic nonobesity, 75 (38%) non sarcopenic obesity, 35 (17%) sarcopenic nonobesity, and 55 (28%) sarcopenic obesity. No category of body composition was a predictor of postoperative complications and worse overall and disease-free survival outcomes. Multivariable analysis identified ASA III classification, preoperative weight loss > 10%, postoperative surgical re-intervention, and advanced tumor stage as independent prognostic factors for overall survival, and patients aged 75 years or older, preoperative weight loss > 10%, elevated netrophil-lymphocyte ratio, and advanced tumor stage as independent prognostic factors for disease-free survival. CONCLUSIONS: Sarcopenia, obesity, and sarcopenic obesity were not associated with worse outcomes after gastric cancer surgery.

Molecular profile of urine extracellular vesicles from normo-functional kidneys reveal minimal differences between living and deceased donors.

BACKGROUND: Kidney transplantation (KTx) is the best therapeutic approach for chronic kidney diseases leading to irreversible kidney failure. Considering the origin of the graft, several studies have reported differences between living (LD) and deceased donors (DD) in graft and patient survival. These differences seem to be related to multiple factors including, donor age and time of cold ischemia among others. Many of transplanted organs come from old-aged DDs, in which pre-transplant biopsy is recommended. However, kidney biopsy has several limitations, and there is a need to develop alternatives to assess the status of a kidney before transplantation. As the analysis of urinary extracellular vesicles (uEVs) rendered promising results as non-invasive biomarkers of kidney-related pathologies, this pilot study aimed to investigate whether profiling uEVs of LDs and DDs may be of help to assess the quality of the kidney before nephrectomy. METHODS: uEVs from 5 living donors and 7 deceased donors were isolated by size-exclusion chromatography, and their protein and miRNA content were analysed by liquid chromatography followed by mass spectrometry and next generation sequencing, respectively. Then, hierarchical clustering and venn diagrams were done with Perseus software and InteractiVenn tool. Specific EVs data bases were also used for Gene Ontology analysis. RESULTS: Next generation sequencing revealed that uEVs from DDs contained less miRNAs than LDs, but most of the DD-expressed miRNAs were shared with LDs (96%). Only miR-326 (targeting the apoptotic-related Bcl2) was found significantly over-represented in LD. Focusing on the protein content, we detected a low intra-group correlation in both types of donors. Despite these differences, hierarchical clustering of either miRNA or protein data could not identify a differential profile between LDs and DDs. Of note, 90% of transplanted patients had a functional graft after a year from KTx. CONCLUSIONS: In this pilot study we found that, in normo-functional grafts, minor differences in uEVs profile could not discriminate between LDs and DDs.

Morbidity after laparoscopic and open rectal cancer surgery: a comparative analysis of morbidity in octogenarians and younger patients.

AIM: Although the oncological adequacy of laparoscopic rectal resection (LR) appears equivalent to open resection (OR), its benefit is controversial in the elderly. The aim of this study was to investigate the influence of LR on morbidity and mortality in octogenarians. METHOD: This was a retrospective analysis of all patients who underwent rectal surgery for cancer between 2003 and 2013 in a teaching hospital. The primary aim of the study was to assess the influence of surgical approach on mortality and morbidity of rectal resection in patients ≥ 80 years old. Regression analysis was performed to control the effect of covariables on the clinical outcome. RESULTS: Of 408 patients 203 were in the LR group and 205 in the OR group including 303 (74.3%) less than 80 years and 105 (25.7%) over 80 years. The mortality was lower in the LR group compared with the OR group for patients under 80 years (0% vs 4.6%; P = 0.049) and no different in the over 80 group (11.5% vs 9.4%; P = 0.859). In younger patients, the OR group showed longer hospital stay (9 vs 7 days; P < 0.001) and more complications (44.1% vs 29.8%; P = 0.042). Medical complications were more frequent in LR group than OR group octogenarians (40.4% vs 20.8%; P = 0.009) as well as grade C anastomotic leakage (13.8 vs 10.7; P = 0.041). CONCLUSION: LR for rectal cancer showed clinical advantages in patients under 80 years and was as safe as OR in patients over 80 years, although the advantages of laparoscopic surgery were lost in the elderly group due to a higher rate of medical complications. OR may be an option in elderly patients with important comorbidities.

Antibiotic-loaded polypropylene surgical meshes with suitable biological behaviour by plasma functionalization and polymerization.

Hernia repair is one of the most common operations in general surgery, and its associated complications typically relate to infections, among others. The loading of antibiotics to surgical meshes to deliver them locally in the abdominal hernia repair site can be one way to manage infections associated with surgical implants. However, the amount of drug loaded is restricted by the low wettability of polypropylene (PP). In this work, plasma has been used to tailor the surface properties of PP meshes to obtain high loading of ampicillin while conserving the desired biological properties of the unmodified samples and conferring them with antibacterial activity. It was demonstrated that the new surface chemistry and improved wettability led to 3-fold higher antibiotic loading. Subsequently, a PEG-like dry coating was deposited from tetraglyme with low-pressure plasma which allowed maintaining the high drug loading and kept cell properties such as chemotaxis, adhesion and morphology to the same levels as the untreated ones which have shown long-standing clinical success.

Use of images in a surgery consultation. Will it improve the communication?

INTRODUCTION: The interviews and interactions with patients are part of everyday health care provider. However, there is sometimes a difficulty in communication, linked to several factors. For this reason, the use of images to illustrate the medical conditions in the outpatient clinic can improve patient communication. We report our initial experience with the use of images to manage the quality of care to surigcal patients. METHODOLOGY: He used a computer to show pictures of the following conditions: surgery for an inguinal hernia, cholelithiasis, cholecystitis and the choledocholithiasis and finally thyroid pathology. Were randomized two groups of patients. Each of the affected patients in any stage of the disease, they explained their problems. In one of the groups also showed the patient was using the current image and continued to give appropriate explanations related to pathology. Thereafter, patients in both groups filled in an anonymous questionnaire in which they responded to what degree it was considered useful this methodology, and degree of satisfaction received outpatient treatment with or without the deployment of images by computer. We have analyzed the average time expected and made a visit. RESULTS: 187 patients will be visited in the consultations over a period of 8 months. In 83 patients have been using images to give the explanations in external consultations. Of these, 24 patients suffering from thyroid, 24 hernias or incisional hernias and 35 patients with biliary tract pathology. Patients in the group were shown images of conditions have responded mostly be very satisfied with the use of images while the explanations are given on the patient's illness. Also, over 80% of patients report being satisfied with this system. The visiting time was not lengthened. DISCUSSION: Despite the existence of different variables that can influence patient satisfaction, use of images to illustrate surgical diseases to patients improves communication and flow of the explanations of the physician. CONCLUSIONS: The relationship doctor-patient communication is the key event in an outpatient setting. It determines a good overall result of the clinical interview. The use of images in an outpatient improves communication between patients and doctors. Moreover, the degree of satisfaction is high and the degree of understanding of the disease. It seems useful to incorporate in our outpatient clinic.

Single incision laparoscopic surgery (SILS) cholecystectomy. A novel technique.

INTRODUCTION: Since early nineties, laparoscopic cholecystectomy has become gold standard for cholecystectomy. Also, a high tendency of minimizing surgical trauma encourages the use of new approaches in laparoscopic surgery. A novel approach such as Single incision laparoscopic surgery (SILS) cholecystectomy has been describes. CASE REPORT: We report on a case of a 33-year-old female patient scheduled for elective laparoscopic cholecystectomy due to symptomatic ultrasonography verified cholelithiasis. A single 2.5-cm long semicircular infraumbilical skin incision was used. Pneumoperitoneum was established alter introduction of the predesigned trocar. Antegrade cholecystectomy was performed without stay suture placement. Postoperative course was uneventful. DISCUSSION: This article reports the authors' method of performing SILS cholecystectomy. SILS approach is feasible with new standard devices from the industry that offers slightly modified instruments for standard laparoscopic cholecystectomy. CONCLUSION: Single-incision laparoscopic surgery is a feasible way to perform cholecystectomy. A learning-curve is required and further work in the form of randomized controlled trials is needed to investigate the advantages of this new technique.

Lipoma of the uterine corpus: exceptional eventuality combined with an ovarian thecoma.

Uterine lipomas are very uncommon with symptoms that are similar to leiomyomas. Their diagnosis is always histological although some radiological methods may suggest their existence prior to surgery. They are sometimes associated with endometrial pathology, but there are no previous reported cases related to ovarian thecoma. Their prognosis is excellent. Clinical, radiological, morphologic, and immunohistochemical findings are shown which correspond to uterine lipoma associated with endometrial polyps and ovarian thecoma.

Guidelines for colorectal cancer: effects on nutritional intervention.

INTRODUCTION: Although parenteral nutrition is a vital method of delivery essential nutrients in patients with malnutrition associated to gastro-intestinal insufficiency, its inappropriate use can increase the risk of complications and incur unnecessary expenses. OBJECTIVE: Our goal was to evaluate the influence of both, the presence of the Nutritional Support Unit and the implementing clinical practice guidelines on post-operative nutritional status, complications and length of stay among patients undergoing elective colorectal cancer surgery. METHODS: Prospective and observational study: Three period times were included-the year during the guidelines elaboration (A), and the first (B) and the second year (C) after their implementation. All patients submitted to elective colorectal cancer surgery at least 18 years of age were included (A: n=297; B: n=103, and C: n=149). WE ANALYSED: Nutritional status (NS) on admission to hospital and at discharge, use of post-operative parenteral nutrition (PPN), incidence of post-operative complications (PC), number of days of nil by mouth following surgery (NPO), and hospital length of stay (LOS). RESULTS: Although the prevalence of malnutrition on admission was low, an increment was observed during the hospitalisation time. However, only in the first period time, the increment was significantly different (A: from 8.4% to 19.5%, p<0.001; B: from 3.9% to 8.7%, and C: from 4.7% to 6.7%). Globally, the use of PPN decreased (A: 79.1%, B: 47.0%, and C: 12.8%; p<0.001). This behaviour was mainly observed in well-nourished patients (use of PPN in well nourished, A: 79.3%, B: 44.4%, and C: 11.3%; p<0.001). Significant differences were observed in the global incidence of PC (A: 27.9%, B: 28.2%, and C: 8.1%, p<0.001). Furthermore, PC was higher in well-nourished patients with PPN versus without PPN, with significant differences in B and C periods (A: 29.3% vs. 25.0%; B: 38.6% vs. 18.8%, p=0.004; C: 31.3% vs. 4.8%, p=0.003). The NPO was higher in patients without PPN in period A (7 d vs. 5 d, p<0.001) and higher in those with PPN in period C (8 d vs. 6 d, p=0.035). All in all, LOS decreased significantly during the study period time (A: 16 d, B: 13 d, and C: 11 d, p<0.001). CONCLUSION: The presence of Nutritional Support Unit and clinical practice guidelines for colorectal cancer management and treatment, optimised the use of hospital resources, namely unnecessary use of parenteral nutrition, reduction along with decrease in number of complications and length of hospital stay.

The chemokine network. II. On how polymorphisms and alternative splicing increase the number of molecular species and configure intricate patterns of disease susceptibility.

In this second review on chemokines, we focus on the polymorphisms and alternative splicings and on their consequences in disease. Because chemokines are key mediators in the pathogenesis of inflammatory, autoimmune, vascular and neoplastic disorders, a large number of studies attempting to relate particular polymorphisms of chemokines to given diseases have already been conducted, sometimes with contradictory results. Reviewing the published data, it becomes evident that some chemokine genes that are polymorphic have alleles that are found repeatedly, associated with disease of different aetiologies but sharing some aspects of pathogenesis. Among CXC chemokines, single nucleotide polymorphisms (SNPs) in the CXCL8 and CXCL12 genes stand out, as they have alleles associated with many diseases such as asthma and human immunodeficiency virus (HIV), respectively. Of CC chemokines, the stronger associations occur among alleles from SNPs in CCL2 and CCL5 genes and a number of inflammatory conditions. To understand how chemokines contribute to disease it is also necessary to take into account all the isoforms resulting from differential splicing. The first part of this review deals with polymorphisms and the second with the diversity of molecular species derived from each chemokine gene due to alternative splicing phenomena. The number of molecular species and the level of expression of each of them for every chemokine and for each functionally related group of chemokines reaches a complexity that requires new modelling algorithms akin to those proposed in systems biology approaches.

Short postal questionnaire and selective clinical examination combined with repeat mailing and telephone reminders as a method of follow-up in hernia surgery.

BACKGROUND: We assessed the usefulness of a short postal questionnaire and selective clinical examination combined with repeat mailing and telephone reminders for quality assessment in hernia surgery. METHODS: All patients (n = 1153) who underwent tension-free hernioplasty through an open preperitoneal approach between 1999 and 2003 received a six-item questionnaire with a covering letter and a stamped addressed envelope. Nonresponders received two successive new questionnaires and a telephone call. RESULTS: A total of 841 (72.9%) patients returned questionnaires after three reminders (512 after the first mailing, 205 after the second, and 124 after the third). Positive questionnaire answers were documented for 152 (18.1%) of repairs and negative answers for 689 (81.9%). Of the 152 patients who answered "yes" to either of the questions regarding recurrence and/or current pain, 91 declined clinical appointments, 24 could not be contacted by phone, and 37 underwent physical examination. Of the 312 patients who did not return the questionnaire, eight had died, 124 did not want to be visited, and 180 could not be located. The recurrence rate was 2.7% and the chronic pain rate 5.9%. CONCLUSIONS: Repeat mailing was a useful strategy to improve response to self-administered postal questionnaires on hernia surgery quality assessment. However, contacting the group that responded with positive questionnaire answers was a poorly effective way to encourage subjects to come for a physical examination.

High EPHB2 mutation rate in gastric but not endometrial tumors with microsatellite instability.

The EPH/EFN family of receptor tyrosine kinases regulates cell adhesion and migration and has an important role in controlling cell positioning in the normal intestinal epithelium. Inactivation of EPHB2 has recently been shown to accelerate tumorigenesis in the colon and rectum, and we have previously demonstrated frequent frameshift mutations (41%) in an A9 coding microsatellite repeat in exon 17 of EPHB2 in colorectal tumors with microsatellite instability (MSI). In this study, we extended these analyses to extracolonic MSI cancers, and found frameshift EPHB2 mutations in 39% (25/64) of gastric tumors and 14% (8/56) of endometrial tumors. Regression analysis of these EPHB2 mutation data on the basis of our previously proposed statistical model identified EPHB2 as a selective target of frameshift mutations in MSI gastric cancers but not in MSI endometrial carcinomas. These results suggest a functional role for EPHB2 in gastric tumor progression, and emphasize the differences between the tumorigenic processes in MSI gastrointestinal and endometrial cancer.

One-tube-PCR technique for CCL2, CCL3, CCL4 and CCL5 applied to fine needle aspiration biopsies shows different profiles in autoimmune and non-autoimmune thyroid disorders.

Autoimmune thyroid diseases are characterized by lymphocytic infiltration of the thyroid gland. Chemokines are crucial in the recruitment of lymphocytes and might play an important role in the pathogenesis of autoimmune thyroid disease. The aim of this study was to test the feasibility of analysing by one-tube reverse-transcriptase polymerase chain reaction (RT-PCR) technique CC chemokine profiles in samples obtained by fine needle aspiration biopsy (FNAB). In 27 out of 35 (77%) samples, the material was sufficient for analysis and in 16 (59%) chemokines were detected, thus demonstrating the potential of this technique. Moreover, even in this small group, a statistically significant increase of CCL3 and CCL4 was found in samples from patients with autoimmune thyroid disease as compared to those with multinodular goiter. Chemokine profile measured by improved multiamplification techniques in FNAB thyroid samples may become a useful complementary tool for the management of thyroid autoimmune disease as it constitutes a source of data for research of their pathogenesis.

Improved surgical mesh integration into the rat abdominal wall with arginine administration.

Prosthetic meshes are used as the standard of care in abdominal wall hernia repair. However, hernia recurrences and side effects remain unsolved problems. The demand by health care providers for increasingly efficient and cost-effective surgery encourages the development of newer strategies to improve devices and outcomes. Here, we evaluated whether l-arginine administration was able to ameliorate long-term polypropylene prostheses incorporation into the abdominal wall of Sprague-Dawley rats. Meshes were placed on-lay and continuous l-arginine was administered. In vivo biocompatibility was studied at 7, 25 and 30 days post-implantation. Effectively, l-arginine administration in combination with mesh triggered subtle changes in ECM composition that impinged on critical biochemical and structural features. Lastly, tensile strength augmented and stiffness decreased over the control condition. This could help to restructure the mechanical load transfer from the implant to the brittle surrounding tissues, i.e., impact load and fatigue load associated with mechanical tensions could be distributed between the mesh and the restored tissue in a more balanced manner, and ultimately help to reduce the incidence of loosening, recurrences, and local wound complications. Since the newly formed tissue is more mechanically stable, this approach could eventually be introduced to human hernia repair.

Long-term results of tacrolimus in cyclosporine- and prednisone-dependent myasthenia gravis.

Seventy-nine patients with cyclosporine- and prednisone-dependent myasthenia gravis (MG) after thymectomy received tacrolimus for a mean of 2.5 +/- 0.8 years. Prednisone was withdrawn in all but two patients. Anti-acetylcholine antibodies and MG score for disease severity decreased significantly and muscular strength increased by 39%. Complete stable remission was achieved in 5% of patients and pharmacologic remission in 87.3%. All patients resumed full activities of daily living.

BRAF screening as a low-cost effective strategy for simplifying HNPCC genetic testing.

BACKGROUND: According to the international criteria for hereditary non-polyposis colorectal cancer (HNPCC) diagnostics, cancer patients with a family history or early onset of colorectal tumours showing high microsatellite instability (MSI-H) should receive genetic counselling and be offered testing for germline mutations in DNA repair genes, mainly MLH1 and MSH2. Recently, an oncogenic V600E hotspot mutation within BRAF, a kinase encoding gene from the RAS/RAF/MAPK pathway, has been found to be associated with sporadic MSI-H colon cancer, but its association with HNPCC remains to be further clarified. METHODS: BRAF-V600E mutations were analysed by automatic sequencing in colorectal cancers from 206 sporadic cases with MSI-H and 111 HNPCC cases with known germline mutations in MLH1 and MSH2. In addition, 45 HNPCC cases showing abnormal immunostaining for MSH2 were also analysed. RESULTS: The BRAF-V600E hotspot mutation was found in 40% (82/206) of the sporadic MSI-H tumours analysed but in none of the 111 tested HNPCC tumours or in the 45 cases showing abnormal MSH2 immunostaining. CONCLUSIONS: Detection of the V600E mutation in a colorectal MSI-H tumour argues against the presence of a germline mutation in either the MLH1 or MSH2 gene. Therefore, screening of these mismatch repair (MMR) genes can be avoided in cases positive for V600E if no other significant evidence, such as fulfilment of the strict Amsterdam criteria, suggests MMR associated HNPCC. In this context, mutation analysis of the BRAF hotspot is a reliable, fast, and low cost strategy which simplifies genetic testing for HNPCC.

Stress relaxation tests in polypropylene monofilament meshes used in the repair of abdominal walls.

The objective of this work has been to characterize stress relaxation in the polymer material on applying different levels of constant strain. The meshes were strained at values of 5.2%, 5.4% and 5.6% which are the values at which the mesh is strained in clinical use for the repair of abdominal walls. Laws have been obtained to model the viscoelastic behavior at different strains for this material. Finally, fracture studies were carried out by environmental scanning electron microscopy to determine the fracture mechanisms of these meshes. Besides, the implantation of the meshes was practised in two different layers of abdominal wall: the superficial or preaponeurotic layer and deep or preperitoneal layer, showing the neoformation of connective tissue on the mesh, which tended to be organized differently in each layer studied; more roughly and densely in the superficial layer than in the deep one.

Somatic mutations in the DNA damage-response genes ATR and CHK1 in sporadic stomach tumors with microsatellite instability.

Maintenance of genomic stability depends on the appropriate cellular responses to DNA damage and the integrity of the DNA repair systems. We analyzed stomach tumors with microsatellite instability (MSI) for frameshift mutations in several potential targets of the mutator phenotype involved in DNA damage-response pathways, such as the ataxia telangiectasia mutated protein-related protein (ATR)-CHK1-Cdc25c pathway, and DNA repair. High frequency of mutations was found within ATR [5 (21%) of 23], MED1 [10 (43%) of 23], hMSH3 [13 (56%) of 23], and hMSH6 [10 (43%) of 23] genes. Also, a low frequency of mutations within the CHK1 gene was detected in 9% (2 of 23) of tumors. No mutations of hMLH3, ATM, BRCA1, or NBS1 genes were detected. These results confirm ATR, MED1, and CHK1 as targets of the mutator pathway in stomach tumorigenesis, and also suggest a potential role of MED1 increasing, together with hMSH3 and hMSH6, the genomic instability in the mutator pathway as a secondary mutator. Furthermore, these results suggest that the inhibition of the ATR-CHK1 DNA damage-response pathway might be involved in the tumorigenesis of gastric cancer with microsatellite instability.

Early imaging of integration response to polypropylene mesh in abdominal wall by environmental scanning electron microscopy: comparison of two placement techniques and correlation with tensiometric studies.

The repair of incisional hernias has taken advantage of the strength provided by prosthetic mesh grafts, but the best position for inserting the materials has not been conclusively established. Environmental scanning electron microscopy (ESEM) provides imaging of biologic samples with minimal manipulation. We used ESEM for early imaging of the integration response to polypropylene meshes placed in two anatomic positions in the abdominal wall and correlated results with tensiometric studies. Two macroporous polypropylene prostheses were implanted in a rat model--one on the abdominal aponeurotic layer and one on the peritoneal surface--without creating a wall defect. Studies were performed over implantation intervals of 7, 15, and 30 days in strips obtained from the polypropylene fiber-receptor repair tissue interface. Microscopic appearance, tensile strength, percent elongation, and stiffness were evaluated. Meshes implanted on the abdominal aponeurotic layer showed better early tissue incorporation (higher collagen deposition, capillary density, cell accumulation) and increased tensile strength, reflecting tighter anchorage to the abdominal wall. The percent elongation increased from day 7 to day 30 after implantation, mainly in the deep stratum. The ESEM images correlated well with biomechanical results, indicating the potential of this technique as a powerful, effective tool for use in wound-healing studies.

Cutaneous angiolymphoid hyperplasia with high endothelial venules is characterized by endothelial expression of cutaneous lymphocyte antigen.

Two cases in which the presence of cutaneous lesions with a characteristic admixture of lymphoid hyperplasia and vascular proliferation lead to the diagnosis of so-called acral pseudolymphomatous angiokeratoma (APA) of children are reported. Owing to the prominence of its blood vessels, so striking as to be reminiscent of high endothelial venules (HEVs), APA was initially interpreted as a vascular lesion rather than a pseudolymphoma. This resemblance is further compounded by our finding that cutaneous lymphocyte antigen (CLA), an HEV marker, is also expressed in APA epithelioid blood vessels. Consequently, we believe that "cutaneous angiolymphoid hyperplasia with high endothelial venules" (ALH-HEV), which alludes to the dual nature of proliferating elements and the HEV-like phenotype of the vascular component, would be a better denomination for this entity. Additionally, we speculate that ALH-HEV lymphoid hyperplasia self-perpetuates through the transformation of dermal capillaries into HEVs, which would bind non-skin homing lymphocytes expressing L-selectin and promote their local recruitment and recirculation.