Experimental rationale for treatment of high-risk human melanoma with zinc chloride fixative paste. Increased resistance to tumor challenge in murine melanoma model.

BACKGROUND: Fixed-tissue micrographic surgery (Mohs) of melanoma has been shown by retrospective analysis to improve 5-year survival. OBJECTIVES: To determine whether zinc chloride fixative paste acts as an immune adjuvant to increase host resistance to melanoma. METHODS: We performed a murine study using the poorly immunogenic B16 melanoma of C57Bl6J mice, and the more immunogenic K1735p melanoma of C3H/HeN mice. Tumors were treated with zinc chloride paste and excised 24 hours later (Group 1), or simply excised (Group 2). Mice were challenged 7 days later with injection of melanoma cells at a distant site, and tumor growth in this second site was followed. RESULTS: K1735p melanomas developed at the challenge site in 69% of mice treated with excision versus 32% of mice treated with zinc chloride fixation (P < 0.025). Development of B16 melanoma was not altered by zinc chloride fixation. CONCLUSION: Zinc chloride fixation of the more immunogenic K1735p melanoma increased resistance to subsequent tumor challenge, suggesting that zinc chloride fixative paste acts as an immune adjuvant.

A reevaluation of the effect of occlusion on the trichloroacetic acid peel.

BACKGROUND: Prior studies have demonstrated reduced wounding with trichloracetic acid (TCA) peels after tape occlusion. It is therefore reasonable to question whether or not other types of occlusion may have similar effects, particularly those used in routine postoperative care. OBJECTIVE: To reevaluate the effect of occlusion after TCA peels in multiple human models using various forms of dressings, at various times postoperatively, and to make recommendations regarding wound care that will not adversely affect the efficacy of the peel. METHODS: Equal-sized sections of anterior alopecic scalps of four patients were peeled with 50% TCA, occluded with bacitracin, Vigilon, or Tegaderm at various times postoperatively, and biopsied 1 day later. Depths of necrosis were measured and compared with nonoccluded controls. RESULTS: Bacitracin ointment and Vigilon did not lessen TCA wounding, and sometimes actually enhanced it. Conversely, Tegaderm lessened the degree of the TCA wound. Timing of application played a role in the case of occlusion with Vigilon. CONCLUSION: Occlusives used in conjunction with TCA peels do not have a uniform effect on depth of necrosis. Ointments and Vigilon can be used without reducing the efficacy of the TCA peel. Multiple subjects and rigid control of variables are necessary in studies of TCA-induced necrosis.

Unilateral linear lichenoid eruption after bone marrow transplantation: an unmasking of tolerance to an abnormal keratinocyte clone?

Chronic cutaneous graft-versus-host disease may appear clinically as a lichenoid eruption. We describe a 26-year-old man who developed a unilateral linear lichenoid eruption 7 months after allogeneic bone marrow transplantation. We believe this represents an unusual form of localized, chronic graft-versus-host disease. The possible relationship to viral infection or cellular mosaicism and the clinical, histologic, and immunologic similarities to idiopathic lichen planus are discussed.

Malignant melanoma with evidence of maturation arising from a giant congenital nevocellular nevus.

The association between melanoma and giant congenital nevocellular nevus has been well documented, although controversy still exists regarding the precise incidence. The following patient report illustrates the excision of malignant melanoma arising from a giant congenital nevocellular nevus in a 4-month-old infant. The child had malignant melanoma with deep dermal involvement diagnosed by incisional biopsy with positive margins. She underwent subsequent en bloc resection of the original biopsy site and nevus. The reexcision specimen showed no evidence of malignancy. No adjuvant chemotherapy was used. The child is disease free at 5 years. It is possible that very young children (infants) with melanoma arising in a giant congenital nevocellular nevus may have a good prognosis.

Evaluation of spindle cell tumors.

The most important aspect of any evaluation of spindle cell tumors in the skin or superficial soft tissues is the clinical examination, as a great deal can be learned from the location, appearance, and size of the tumor in question. As recounted in this chapter, the histologic features of these tumors may also be distinctive; however, in some instances, histologic examination alone is insufficient for diagnosis. In such cases, electron microscopy holds considerable promise, but the technique is too dependent upon both the availability of adequately preserved tissues and access to the technique itself. As a result, immunohistochemistry remains the favored approach to most problematic lesions. In our experience, at least 90% of histologically enigmatic tumors will exhibit a characteristic immunophenotype, the remainder usually being indeterminant for a specific pattern of differentiation. The latter outcome is often the result of improper tissue preservation, but may also reflect the primitive nature of some neoplasms. Fortunately, the least common outcome is an ambiguous or "mixed-lineage" phenotype, in which neither one of two or more patterns of differentiation is resolved with certainty. The most common settings in which these problems arise are the separation of MPNST from LMS, and the recognition of melanocytic lesions as distinct from tumors of peripheral nerve sheath. The latter is clearly of greatest clinical concern, and should be the focus of additional study.

Spindle and epithelioid cell nevus (Spitz nevus). Natural history following biopsy.

A clinical follow-up study of 49 cases of spindle and epithelioid cell nevus is presented to address the question about the potential for local recurrence. Only 19 (39%) of the 49 lesions were initially excised en toto, and the remainder (30 cases) had positive margins; six of the latter spindle and epithelioid cell nevi were reexcised, and no evidence of a residual nevus was found in five of the six cases. There were no recurrences in the 49 patients during an average follow-up period of 5.0 years (range, 1 to 10 years). The rarity of recurrent spindle and epithelioid cell nevus would justify a conservative approach to management, with clinical follow-up alone recommended after a subtotal excision, when the pathologic diagnosis is unequivocal.

Geriatric urologic dermatology.

Most diseases involving the skin affect all age groups; however, some are more common in old age. The skin of the genital area may be involved as an isolated process or as part of more generalized disease. Clinical features and management of some of the more common dermatologic conditions affecting the genital area in the elderly are discussed.

Microcystic adnexal carcinoma. An immunohistochemical comparison with other cutaneous appendage tumors.

Since its initial description, microcystic adnexal carcinoma (MAC) of the skin has been controversial. In particular, it features keratin production of the type seen in some pilar neoplasms , and has been thought to pursue partial follicular differentiation. Diagnostically, MAC may be difficult to separate from desmoplastic trichoepithelioma (DTE) in superficial biopsy specimens. We studied 12 MACs, 22 malignant eccrine acrospiromas, 7 sudoriferous syringometaplasias, 6 syringomas, 5 DTEs, and 40 other benign pilar neoplasms immunohistochemically. Paraffin sections and antibodies to "hard" (pilar) keratins. epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA), Leu-M1, and S100 protein were employed. The MACs exhibited reactivity for hard keratin subclasses AE 13 and AE 14, EMA, CEA, and Leu-M1. Desmoplastic trichoepitheliomas expressed positivity for AE 14, EMA, and Leu-M1 focally, but lacked the other specified markers. Syringomas and malignant acrospiromas displayed EMA, CEA, and AE 14 reactivity, and 5 syringometaplastic lesions were AE 14-reactive. Benign pilar tumors aside from DTEs were reactive only for AE 13, AE 14, or both. These data indicate that MAC exhibits an immunophenotype that is a "hybrid" of those seen in pure sweat glandular and follicular neoplasms, and suggest that it may indeed show combined pilar and sudoriferous differentiation. Based on these results, it also appears that immunohistochemical analysis may be useful in the diagnostic separation of MAC and DTE.

Spindle-cell and pleomorphic neoplasms of the skin. A clinicopathologic and immunohistochemical study of 30 cases, with emphasis on "atypical fibroxanthomas".

Atypical fibroxanthoma belongs to the family of spindle-cell and pleomorphic neoplasms of the skin. The lineage of differentiation of this tumor and the means whereby it can be diagnostically separated from other similar morphologic entities have been controversial. In order to address these issues, the authors studied 30 spindle-cell and/or pleomorphic cutaneous tumors, including atypical fibroxanthomas (AFXs), superficial malignant fibrous histiocytomas (MFHs), dermatofibrosarcoma protuberans (DFSPs), sarcomatoid squamous-cell carcinomas (SCCs), spindle-cell malignant melanomas (MMs), and leiomyosarcomas, (LMSs). These cases were analyzed using a panel of eight antibodies and the immunoperoxidase technique. AFXs were reactive for vimentin, alpha-1-antichymotrypsin (AACT), alpha-1-antitrypsin (AAT), and cathepsin-B (CB) but failed to display cytokeratin (CK), epithelial membrane antigen (EMA), S-100 protein, and desmin. MFHs and DFSPs exhibited immunophenotypic profiles that were nearly identical to that just described. In contrast, SCCs were typified by positivity for CK and EMA; MMs exhibited uniform reactivity for S-100 protein; and LMSs contained desmin in four of five cases. A surprising result was the expression of S-100 by LMSs. Also, all tumors displayed at least one of the three proteolytic enzymes assessed in this study (AAT, AACT, and CB), demonstrating the relative diagnostic nonspecificity of these determinants. It is concluded that AFXs are "fibrohistiocytic" neoplasms, with substantial morphologic and immunohistochemical similarity to MFHs. The immunohistochemical classification of spindle-cell and pleomorphic tumors of the skin necessitates the use of antibody panels to assess the presence of markers that are characteristic of each diagnostic group.

Sweat gland carcinoma ex eccrine spiradenoma.

We herein report two cases of sweat gland carcinoma that arose in association with eccrine spiradenoma. These lesions presented as enlarging masses that previously had been stable for many years. One produced widespread metastasis and death 5 months after diagnosis. Immunohistochemical studies demonstrated an antigenic relationship between the benign and malignant components of sweat gland carcinoma ex eccrine spiradenoma, but ultrastructural analyses showed a paucity of specialized differentiation. This neoplasm appears to display a range of microscopic appearances and has proven fatal in 20% of reported cases.

Primary neuroendocrine carcinoma and small-cell malignant lymphoma of the skin. A discriminant immunohistochemical comparison.

In selected instances, primary cutaneous neuroendocrine carcinoma (PCNEC) and small-cell malignant lymphoma (SCML) of the skin may display similar clinical presentations and microscopic appearances, leading to diagnostic uncertainty. We applied monoclonal antibodies to epithelial membrane antigen (EMA), Ia antigen, and leukocyte common antigen (LCA) to 31 cases of PCNEC and 12 of small-cell lymphoma cutis, using a combined PAP and ABC procedure, to determine whether or not such stains were capable of separating the two neoplasms. All cases of SCML were reactive for LCA, while this determinants was not seen in any example of PCNEC. Anti-Ia antigen labelled 11 of 12 cases of SCML, and also failed to stain neuroendocrine carcinomas. Lastly, EMA was observed in 25 of 31 cases of PCNEC, but it was found in one lymphoplasmacytoid lymphoma as well. Bayes' univariate statistical analysis of these data indicates that anti-LCA, anti-EMA, and anti-Ia antigen are capable of discriminating between the tumors in question, with anti-LCA being the most effective.