The spectrum of histopathologic findings in cutaneous lesions in patients with Still disease.

OBJECTIVES: Still disease is a rare disorder characterized by seronegative arthralgias/arthritis, spiking fever, and either an evanescent salmon-colored rash or persistent papules and plaques. METHODS: We describe the clinical and biopsy findings in 10 patients with the evanescent rash of Still disease. RESULTS: Fourteen biopsy specimens were studied from seven women and three men with a mean age of 44.4 years. The skin lesions were typically erythematous macules, papules, or plaques with a median duration of 5 weeks. All patients had systemic symptoms, including fever and arthralgias. The infiltrate was predominantly lymphocytic in six biopsy specimens, approximately equal lymphocytic and neutrophilic in four biopsy specimens, and predominantly (although never exclusively) neutrophilic in four biopsy specimens. Other findings included focal vacuolar interface changes, neutrophilic eccrine hidradenitis, epidermal neutrophils, dermal mucin, and acanthosis associated with numerous upper epidermal dyskeratotic cells. CONCLUSIONS: It is important to be aware of the broad histologic spectrum that may be encountered in Still disease and to consider Still disease in the differential diagnosis of neutrophil-rich, lymphocyte-rich, and mixed inflammatory dermatoses. While the histologic findings seen in biopsy specimens of the evanescent rash are nonspecific, a distinctive variant also exists characterized by prominent epidermal apoptosis, especially involving the upper layers.

Impact of the 2009 AJCC staging guidelines for melanoma on the number of mitotic figures reported by dermatopathologists at one institution.

BACKGROUND: In 2009 the revised seventh staging system for melanoma recommended the use of mitotic count to separate stage T1a from T1b. However, careful scrutiny of cases may lead to an inadvertent selection effect, with consequent increased reporting of mitotic counts. METHODS: We investigated whether there is a significant increase in mitotic counts reported since 2009 for melanomas with a Breslow thickness of 1.0 mm or less. We conducted a retrospective, case-controlled study examining invasive melanoma cases at a large academic center. Mitotic counts were compared between pathology reports before 2009 (n = 61) and after 2009 (n = 125), with a subset of slides re-examined in a blinded fashion. RESULTS: Before the 2009 staging guidelines, 51% of cases had one or more mitosis reported compared to 38% after 2009 (p = 0.113). Blinded re-counting did not yield a significant difference when compared with the original pathology reports in either group. CONCLUSIONS: There was not a significant difference in the number of mitoses reported after the implementation of the new guidelines.

Duration of symptoms does not correlate with results of T-cell gene rearrangement studies in patients evaluated for cutaneous T-cell lymphoma.

OBJECTIVES: We aimed to determine if clonality on T-cell gene rearrangement studies correlated with duration of cutaneous symptoms in patients with skin disease who are being evaluated for cutaneous T-cell lymphoma (CTCL). Specifically, our goal was to determine if symptom duration could help better optimize sample selection for T-cell gene rearrangement studies. METHODS: Biopsies were reviewed from patients within both general dermatology clinic and CTCL specialty clinic for clonality results in relation to disease duration. RESULTS: We did not find an association between duration and clonality in any group. CONCLUSIONS: The yield of T-cell gene rearrangement studies is similar between shorter and longer duration of disease implying that there is not an optimal duration range in which T-cell gene rearrangement studies are more likely to give a positive result.

Hypersensitivity reaction as a harbinger of acute myeloid leukemia: a case report and review of the literature.

Cutaneous paraneoplastic syndromes comprise a broad spectrum of cutaneous reactions to an underlying malignancy. These dermatoses are not the result of metastatic spread to the skin, but rather a reaction to the presence of malignancy. Cutaneous paraneoplastic syndromes often precede the identification of a malignancy. We describe the case of a 79-year-old man with a six-month history of recalcitrant treatment- resistant dermatitis. A complete blood count test performed at the time of initial presentation was normal. The patient ultimately presented with erythroderma and was diagnosed with acute myeloid leukemia (AML). The evolution of the dermatitis to erythroderma coincided with the clinical presentation of AML, and was therefore considered to be a paraneoplastic syndrome. The patient decided against therapy and died seven weeks after diagnosis. Physicians should consider a cutaneous paraneoplastic syndrome when faced with dynamic recalcitrant dermatoses that are difficult to treat and decide on laboratory testing accordingly. Patients should be evaluated regularly for two to three years after initial diagnosis with a physical exam and review of systems to monitor for signs and symptoms of malignancy.

Uncovering bias in the cytologic evaluation of cervical squamous lesions.

OBJECTIVES: It is well recognized that biases exist in medical decision making. We sought evidence for such bias in diagnostic testing. METHODS: We investigated whether a cytotechnologist's Papanicolaou (Pap) test interpretation of a squamous cell abnormality influenced the likelihood of making the same interpretation again that day using analysis based on the ß distribution. RESULTS: For squamous intraepithelial lesion (SIL) interpretations, significant deviation away from the mean daily diagnostic rate was seen within all three cytotechnologists and, for atypical squamous cells of undetermined significance interpretations, within two of three. CONCLUSIONS: Cytotechnologists are not influenced by an expected number of abnormal Pap cases per day since this would result in deviation toward the mean daily rate of diagnosis. Possible explanations for the unanticipated clustering of SIL interpretations include clinical clustering effects or, alternatively, the influence a SIL interpretation might have on lowering the threshold for this interpretation again in subsequent specimens on the same day. The analysis presented here could serve as a model to detect bias in other aspects of medical decision making.

Nestin depletion induces melanoma matrix metalloproteinases and invasion.

Matrix metalloproteinases (MMPs) are key biological mediators of processes as diverse as wound healing, embryogenesis, and cancer progression. Although MMPs may be induced through multiple signaling pathways, the precise mechanisms for their regulation in cancer are incompletely understood. Because cytoskeletal changes are known to accompany MMP expression, we sought to examine the potential role of the poorly understood cytoskeletal protein, nestin, in modulating melanoma MMPs. Nestin knockdown (KD) upregulated the expression of specific MMPs and MMP-dependent invasion both through extracellular matrix barriers in vitro and in peritumoral connective tissue of xenografts in vivo. The development of three-dimensional melanospheres that in vitro partially recapitulate noninvasive tumorigenic melanoma growth was inhibited by nestin KD, although ECM invasion by aberrant melanospheres that did form was enhanced. Mechanistically, nestin KD-dependent melanoma invasion was associated with intracellular redistribution of phosphorylated focal adhesion kinase and increased melanoma cell responsiveness to transforming growth factor-beta, both implicated in pathways of melanoma invasion. The results suggest that the heretofore poorly understood intermediate filament, nestin, may serve as a novel mediator of MMPs critical to melanoma virulence.

Airway recovery after face transplantation.

BACKGROUND: Severe facial injuries can compromise the upper airway by reducing airway volume, obstructing or obliterating the nasal passage, and interfering with oral airflow. Besides the significant impact on quality of life, upper airway impairments can have life-threatening or life-altering consequences. The authors evaluated improvements in functional airway after face transplantation. METHODS: Between 2009 and 2011, four patients underwent face transplantation at the authors' institution, the Brigham and Women's Hospital. Patients were examined preoperatively and postoperatively and their records reviewed for upper airway infections and sleeping disorders. The nasal mucosa was biopsied after face transplantation and analyzed using scanning electron microscopy. Volumetric imaging software was used to evaluate computed tomographic scans of the upper airway and assess airway volume changes before and after transplantation. RESULTS: Before transplantation, two patients presented an exposed naked nasal cavity and two suffered from occlusion of the nasal passage. Two patients required tracheostomy tubes and one had a prosthetic nose. Sleeping disorders were seen in three patients, and chronic cough was diagnosed in one. After transplantation, there was no significant improvement in sleeping disorders. The incidence of sinusitis increased because of mechanical interference of the donor septum and disappeared after surgical correction. All patients were decannulated after transplantation and were capable of nose breathing. Scanning electron micrographs of the respiratory mucosa revealed viable tissue capable of mucin production. Airway volume significantly increased in all patients. CONCLUSIONS: Face transplantation successfully restored the upper airway in four patients. Unhindered nasal breathing, viable respiratory mucosa, and a significant increase in airway volume contributed to tracheostomy decannulation.

Utility of immunofluorescence testing for vascular IgA in adult patients with leukocytoclastic vasculitis.

OBJECTIVES: The purpose of this study was to examine the utility of immunofluorescence (IF) testing in patients with leukocytoclastic vasculitis (LCV), particularly with regard to usefulness in the diagnosis of Henoch-Schönlein purpura (HSP). METHODS: We retrospectively analyzed the results of IF testing in 96 patients with LCV and compared results with clinical criteria and clinical impression at the time of biopsy by review of the medical record. RESULTS: Sensitivity and specificity of vascular immunoglobulin A (IgA) for the diagnosis of HSP were 0.86 and 0.84, respectively. Positive predictive value was 0.48 and negative predictive value was 0.97. Of the 53 patients with LCV who did not meet clinical criteria for HSP and carried a low clinical suspicion for the disease at the time of biopsy, seven had moderate to strong staining for vascular IgA. Only one of these patients was determined to have HSP. CONCLUSIONS: Our data confirm that vascular IgA is nonspecific and also demonstrate that the utility of IF studies for vasculitis is influenced by the clinical presentation and the clinician's level of suspicion for HSP. Our data show that the clinical features and the overall clinical impression are helpful in selecting which patients are most likely to benefit from IF testing.

Merkel cell carcinoma expresses vasculogenic mimicry: demonstration in patients and experimental manipulation in xenografts.

Merkel cell carcinoma (MCC) is a highly virulent cutaneous neoplasm that, like melanoma, is a frequent cause of patient morbidity and mortality. The cellular mechanisms responsible for the aggressive behavior of MCC remain unknown. Vasculogenic mimicry (VM) is a phenomenon associated with cancer virulence, including in melanoma, whereby anastomosing laminin networks form in association with tumor cells that express certain endothelial genes. To determine whether VM is a factor in MCC, we employed a relevant xenograft model using two independent human MCC lines. Experimentally induced tumors were remarkably similar histologically to patient MCC, and both contained laminin networks associated with vascular endothelial-cadherin (CD144) and vascular endothelial growth factor receptor 1, as well as Nodal expression typical of VM in melanoma. Moreover, two established chemotherapeutic agents utilized for human MCC, etoposide and carboplatin, induced necrosis in xenografts on systemic administration while enriching for laminin networks in apparently resistant viable tumor regions that persisted. These findings for the first time establish VM-like laminin networks as a biomarker in MCC, demonstrate the experimental utility of the MCC xenograft model, and suggest that VM-rich regions of MCC may be refractory to conventional chemotherapeutic agents.

Loss of 5-hydroxymethylcytosine correlates with increasing morphologic dysplasia in melanocytic tumors.

DNA methylation is the most well-studied epigenetic modification in cancer biology. 5-hydroxymethylcytosine is an epigenetic mark that can be converted from 5-methylcytosine by the ten-eleven translocation gene family. We recently reported the loss of 5-hydroxymethylcytosine in melanoma compared with benign nevi and suggested that loss of this epigenetic marker is correlated with tumor virulence based on its association with a worse prognosis. In this study, we further characterize the immunoreactivity patterns of 5-hydroxymethylcytosine in the full spectrum of melanocytic lesions to further validate the potential practical application of this epigenetic marker. One hundred and seventy-five cases were evaluated: 18 benign nevi, 20 dysplastic nevi (10 low-grade and 10 high-grade lesions), 10 atypical Spitz nevi, 20 borderline tumors, 5 melanomas arising within nevi, and 102 primary melanomas. Progressive loss of 5-hydroxymethylcytosine from benign dermal nevi to high-grade dysplastic nevi to borderline melanocytic neoplasms to melanoma was observed. In addition, an analysis of the relationship of nuclear diameter with 5-hydroxymethylcytosine staining intensity within lesional cells revealed a significant correlation between larger nuclear diameter and decreased levels of 5-hydroxymethylcytosine. Furthermore, borderline lesions uniquely exhibited a diverse spectrum of staining of each individual case. This study further substantiates the association of 5-hydroxymethylcytosine loss with dysplastic cytomorphologic features and tumor progression and supports the classification of borderline lesions as a biologically distinct category of melanocytic lesions.

Evaluation of stromal HGF immunoreactivity as a biomarker for melanoma response to RAF inhibitors.

Of more than 150 000 published studies evaluating new biomarkers, fewer than 100 biomarkers have been implemented for patient care. One reason for this is lack of rigorous testing by the medical community to validate claims for biomarker clinical relevance, and potential reluctance to publish negative results when confirmation is not obtained. Here we sought to determine the utility and reproducibility of immunohistochemical detection of hepatocyte growth factor (HGF) in melanoma tissue, an approach of potential assistance in defining patients with innate resistance to BRAF inhibitor therapy. To this end, a published and a revised method that retained sensitivity but with greater specificity for HGF detection, were evaluated in cells known to endogenously express HGF, and in models where HGF is upregulated via cytokine induction and via overexpression by gene transfection. Consequent patient evaluation in collaboration with the Melanoma Institute Australia of a cohort of 41 melanoma specimens with extensive clinical annotation failed to validate HGF immunohistochemistry as a predictor of response to BRAF inhibitors. Targeted therapies for advanced melanoma and other cancers show great promise, and rigorous validation studies are thus indicated for approaches that seek to personalize such therapies to maximize therapeutic efficacy.

Systemic lupus erythematosus-associated neutrophilic dermatosis--an underrecognized neutrophilic dermatosis in patients with systemic lupus erythematosus.

Neutrophilic dermatoses are an uncommon manifestation of lupus. We describe the clinical and histopathologic features of 14 patients with systemic lupus erythematosus (SLE) and neutrophilic dermatoses, 2 of whom had no prior history of SLE. Thirteen patients were female, ranging in age from 27 to 62 years (mean age, 42.8 years). One patient was a 20-year-old man. Most lesions were described as erythematous papules and plaques and showed annular morphology in 6 patients and a photodistribution in 2 patients. Histopathologic examination in all cases showed an interstitial neutrophilic infiltrate with leukocytoclasis that ranged from sparse in 5 cases and moderate to dense in 9 cases. With one exception, those cases with moderate to dense infiltrates resembled Sweet's syndrome at scanning magnification. Two cases resembled bullous SLE, and 1 case showed overlapping features of bullous SLE and Sweet's syndrome. Interface changes were seen in 8 patients, which were subtle and vacuolar in 7. One case was associated with a florid interface tissue reaction. Dermal mucin was seen in 4 cases and was a prominent feature in only one of these. One case showed a minute discrete focus resembling palisaded neutrophilic and granulomatous dermatitis. It is important to consider SLE-associated neutrophilic dermatosis in the differential diagnosis of neutrophilic tissue reactions particularly because some patients will have no prior history of lupus. It is also important to be aware of the broad histologic spectrum that may be encountered in SLE-associated neutrophilic dermatosis, ranging from subtle paucicellular lesions to florid Sweet's-like lesions associated with a dense neutrophilic infiltrate.

Melanoma spheroid formation involves laminin-associated vasculogenic mimicry.

Melanoma is a tumor where virulence is conferred on transition from flat (radial) to three-dimensional (tumorigenic) growth. Virulence of tumorigenic growth is governed by numerous attributes, including presence of self-renewing stem-like cells and related formation of patterned networks associated with the melanoma mitogen, laminin, a phenomenon known as vasculogenic mimicry. Vasculogenic mimicry is posited to contribute to melanoma perfusion and nutrition in vivo; we hypothesized that it may also play a role in stem cell-driven spheroid formation in vitro. Using a model of melanoma in vitro tumorigenesis, laminin-associated networks developed in association with three-dimensional melanoma spheroids. Real-time PCR analysis of laminin subunits showed that spheroids formed from anchorage-independent melanoma cells expressed increased α4 and ß1 laminin chains and α4 laminin expression was confirmed by in situ hybridization. Association of laminin networks with melanoma stem cell-associated nestin and vascular endothelial growth factor receptor-1 also was documented. Moreover, knockdown of nestin gene expression impaired laminin expression and network formation within spheroids. Laminin networks were remarkably similar to those observed in melanoma xenografts in mice and to those seen in patient melanomas. These data indicate that vasculogenic mimicry-like laminin networks, in addition to their genesis in vivo, are integral to the extracellular architecture of melanoma spheroids in vitro, where they may serve as stimulatory scaffolds to support three-dimensional growth.

Leukotriene B4-driven neutrophil recruitment to the skin is essential for allergic skin inflammation.

Scratching triggers skin flares in atopic dermatitis. We demonstrate that scratching of human skin and tape stripping of mouse skin cause neutrophil influx. In mice, this influx was largely dependent on the generation of leukotriene B4 (LTB4) by neutrophils and their expression of the LTB4 receptor BLT1. Allergic skin inflammation in response to epicutaneous (EC) application of ovalbumin to tape-stripped skin was severely impaired in Ltb4r1(-/-) mice and required expression of BLT1 on both T cells and non-T cells. Cotransfer of wild-type (WT) neutrophils, but not neutrophils deficient in BLT1 or the LTB4-synthesizing enzyme LTA4H, restored the ability of WT CD4(+) effector T cells to transfer allergic skin inflammation to Ltb4r1(-/-) recipients. Pharmacologic blockade of LTB4 synthesis inhibited allergic skin inflammation elicited by cutaneous antigen challenge in previously EC-sensitized mice. Our results demonstrate that a neutrophil-T cell axis reliant on LTB4-BLT1 interaction is required for allergic skin inflammation.

Loss of 5-hydroxymethylcytosine is an epigenetic hallmark of melanoma.

DNA methylation at the 5 position of cytosine (5-mC) is a key epigenetic mark that is critical for various biological and pathological processes. 5-mC can be converted to 5-hydroxymethylcytosine (5-hmC) by the ten-eleven translocation (TET) family of DNA hydroxylases. Here, we report that "loss of 5-hmC" is an epigenetic hallmark of melanoma, with diagnostic and prognostic implications. Genome-wide mapping of 5-hmC reveals loss of the 5-hmC landscape in the melanoma epigenome. We show that downregulation of isocitrate dehydrogenase 2 (IDH2) and TET family enzymes is likely one of the mechanisms underlying 5-hmC loss in melanoma. Rebuilding the 5-hmC landscape in melanoma cells by reintroducing active TET2 or IDH2 suppresses melanoma growth and increases tumor-free survival in animal models. Thus, our study reveals a critical function of 5-hmC in melanoma development and directly links the IDH and TET activity-dependent epigenetic pathway to 5-hmC-mediated suppression of melanoma progression, suggesting a new strategy for epigenetic cancer therapy.

Id1 promotes tumor cell migration in nonsmall cell lung cancers.

Id1, which belongs to the Id family of helix-loop-helix transcription factors has been most associated with tumor progression and metastatsis; however, its significance in lung cancers has not been extensively explored. Here we seek to evaluate the expression of Id1 in a pilot study of nonsmall-cell lung cancers (NSCLCs) and determine its diagnostic and functional significance in these tumors. Paired normal and malignant lung tissues as well as a panel of NSCLC primary tumors and cell lines were evaluated for Id1 expression using Western blotting and quantitative RT-PCR. Functional assays were performed to evaluate the role of Id1 in tumor cell growth, migration and progression. We find Id1 expression is upregulated in squamous cell carcinoma when compared to adenocarcinoma of the lung and that expression of Id1 versus the normal control is variable in NSCLCs. We also note that Id1 expression in NSCLC cells is largely growth factor dependant and constitutive expression of Id1 in NSCLC cells significantly increases tumor cell migration without affecting cell proliferation. We conclude that Id1, as a mediator of tumor cell migration, may be an indicator of aggressive potential in nonsmall-cell lung cancers.

Tibial nerve decompression in patients with tarsal tunnel syndrome: pressures in the tarsal, medial plantar, and lateral plantar tunnels.

BACKGROUND: The anatomical basis for the surgical techniques used to treat tarsal tunnel syndrome is not well studied. The authors sought to evaluate their hypotheses that (1) pronation and pronation with plantar flexion of the intact foot would have higher pressures than the intact foot in other positions; (2) decompression surgery would significantly lower the pressure in all three tunnels in all foot positions, and roof incision plus septum excision would lower the pressure further in some positions; and (3) the pressures in symptomatic patients would be significantly higher than those in an analogous cadaver study. METHODS: In 10 patients with tarsal tunnel syndrome, the authors intraoperatively measured pressures in the tarsal, medial plantar, and lateral plantar tunnels in multiple foot positions before and after excision of the tunnel roofs and intertunnel septum. RESULTS: The authors found that (1) pronation and plantar flexion significantly increased pressures in the medial and lateral plantar tunnels, to levels sufficient to cause chronic nerve compression; (2) tunnel release and septum excision significantly decreased those pressures; and (3) compared with cadaver pressures, patients had similar tarsal tunnel pressures but higher lateral plantar tunnel pressures in some positions. CONCLUSIONS: Many surgeons operating on patients with tarsal tunnel syndrome do not decompress the respective medial plantar and lateral plantar nerves and excise the septum. The authors' study validates the hypotheses that patients who are clinically suspected of having chronic compression of the tibial nerve and its branches at the ankle have higher tunnel pressures and that releasing these structures decreases the pressures.

Melanoma biomarkers: current status and vision for the future.

Melanoma is the leading cause of death from skin cancer in industrialized countries. Clinical and histological variables such as primary tumor invasion, ulceration, and lymph node status might fail to identify early-stage disease that will eventually progress. Tumor biomarkers might help to identify patients with early-stage melanoma who are likely to develop advanced disease and would benefit from additional therapies. These biomarkers offer the possibility of improved tumor staging through the molecular detection of microscopic lymph node metastases that are not visible on routine histological examination. We focus on biomarkers localized to the tumor tissue and those of prognostic value. We give an overview of the melanoma biomarkers that are most helpful for prediction of patients' outcomes, and discuss the primary melanoma biomarkers that have been shown to be of prognostic significance independent of primary tumor thickness and other common clinical prognostic indicators. Although such tumor-associated biomarkers are thought to have the greatest potential, a lack of reliable data makes their true clinical utility difficult to determine. We conclude that several biomarkers show promise in early studies; however, additional large-scale studies are warranted. We suggest cautious optimism for the field of melanoma biomarkers, which we expect to be translated into clinical practice over the next few years.