Cytomorphological characteristics of low-grade papillary urothelial carcinoma for differential diagnosis from benign papillary urothelial lesions: logistic regression analysis in SurePath(™) liquid-based voided urine cytology.

OBJECTIVE: The diagnosis of low-grade papillary urothelial carcinoma (LGPUC) in urine cytology specimens is challenging because of its subtle, minimally atypical findings. Furthermore, as SurePath(™) liquid-based cytology (LBC) is becoming a widely used method in urine cytology, the inevitable cytomorphological alterations resulting from this technique call for new morphological diagnostic criteria in LGPUC. METHODS: Logistic regression analysis was carried out on SurePath slides from surgically proven voided urine specimens. The study was designed to include a test set (n = 141) and a validation set (n = 61), and evaluated significant discriminative parameters between LGPUC and benign papillary urothelial neoplasm (BPUN). RESULTS: Of the seven cytological findings that were found to have statistical significance in univariate analysis, five were found to be independent variables: loss of polarity of papillaroid clusters, irregular contours, absence of columnar cells, hobnail features and hyperchromasia. These independent variables had an area under the curve (AUC) of 0.781. CONCLUSIONS: The distinctive cytological criteria identified above may prove to be helpful in cases in which other conventional criteria for LGPUC are insufficient for diagnosis.

Secondary cutaneous lymphoma: comparative clinical features and survival outcome analysis of 106 cases according to lymphoma cell lineage.

BACKGROUND: The relative frequency, clinical features and survival outcomes of secondary cutaneous lymphoma remain poorly understood. OBJECTIVES: To determine the clinical characteristics and survival outcomes of secondary cutaneous lymphoma. MATERIALS AND METHODS: The present retrospective cohort study included all 106 patients who presented with secondary cutaneous lymphoma. Patient medical records were reviewed to determine the clinical features, survival outcomes and prognostic factors. Survival outcomes were analysed by using the Kaplan-Meier method and comparisons between lymphoma cell lineages [T or natural killer (T-/NK)-cell vs. B-cell lymphoma] were performed using the log-rank test. RESULTS: Secondary cutaneous lymphomas consisted of mature T-/NK-cell lymphomas (56%), mature B-cell lymphomas (35%), immature haematopoietic malignancies (8%) and Hodgkin lymphoma (1%). The T-/NK-cell lineage lymphoma cases were more likely to have multiple and disseminated skin lesions than the B-cell lineage lymphoma cases. The lymphoma cell lineage did not significantly influence survival outcomes. Patients who showed cutaneous involvement within 6 months of the initial diagnosis of primary disease had a poorer overall survival (OS) outcome than patients who developed cutaneous dissemination 6 or more months after the initial diagnosis (P < 0.001). Patients with disseminated skin lesions had a poorer OS than patients with localized skin lesions (P = 0.028). The two lymphoma cell lineages differed in terms of prognostic factors that influenced survival. CONCLUSIONS: Skin lesion characteristics such as time point of appearance and extent affect the survival outcomes of secondary cutaneous lymphoma. Cell lineage did not influence survival outcomes but the two lineages are associated with different prognostic factors.

Facial and extrafacial eosinophilic pustular folliculitis: a clinical and histopathological comparative study.

BACKGROUND: Although more than 300 cases of eosinophilic pustular folliculitis (EPF) have been reported to date, differences in clinicohistopathological findings among affected sites have not yet been evaluated. OBJECTIVES: To evaluate differences in the clinical and histopathological features of facial and extrafacial EPF. METHODS: Forty-six patients diagnosed with EPF were classified into those with facial and extrafacial disease according to the affected site. Clinical and histopathological characteristics were retrospectively compared, using all data available in the patient medical records. RESULTS: There were no significant between-group differences in subject ages at presentation, but a male predominance was observed in the extrafacial group. In addition, immunosuppression-associated type EPF was more common in the extrafacial group. Eruptions of plaques with an annular appearance were more common in the facial group. Histologically, perifollicular infiltration of eosinophils occurred more frequently in the facial group, whereas perivascular patterns occurred more frequently in the extrafacial group. Follicular mucinosis and exocytosis of inflammatory cells in the hair follicles were strongly associated with facial EPF. CONCLUSIONS: The clinical and histopathological characteristics of patients with facial and extrafacial EPF differ, suggesting the involvement of different pathogenic processes in the development of EPF at different sites.

Paediatric cutaneous lymphoma in Korea: a retrospective study at a single institution.

BACKGROUND: The clinical features and incidences of cutaneous lymphoma (CL) differ by ethnicity and age. However, there is to our knowledge no study to show characteristics and distribution of paediatric CL in Asian population. OBJECTIVE: The aim of this study was to investigate distinctive clinicopathological features of CL in paediatric population, particularly in Korea. METHODS: We conducted a clinicopathological review of 41 paediatric cases with CL, diagnosed at Asan Medical Center from January 1990 to December 2012. The clinical records, haematoxylin & eosin-stained slides and immunohistochemical stains from paediatric patients with CL were analyzed. In addition, the results in this present paediatric group were compared with previously reported studies in the Korean all-ages group and Western paediatric group. RESULTS: Lymphomatoid papulosis was more common in the present paediatric group than in the all-ages group (34.5% vs. 9.4%) and Western paediatric group (34.5% vs. 17.7%). Mycosis fungoides, the most common cutaneous lymphoma in the all-ages group and Western paediatric group, is the second most common subtype in this study. Three of nine paediatric mycosis fungoides patients (33%) have the follicular variant. Compared with all-ages group, B-lmphoblastic lymphoma was relatively higher incidence (10.3% vs. 1%) and NK-/T-cell lymphoma and subcutaneous panniculitis-like T-cell lymphoma was relatively in lower proportions in the paediatric group. CONCLUSION: The clinical features and distribution of paediatric CL in our study suggest that CL of Asian childhood is quite different from that of adulthood and Western childhood.

External validation of an online nomogram in patients undergoing radical nephroureterectomy for upper urinary tract urothelial carcinoma.

BACKGROUND: The objective was to validate an online nomogram developed based on the French collaborative national database on upper urinary tract urothelial carcinoma (UUT-UC) using a different cohort. METHODS: The study comprised 328 patients with UUT-UC who underwent radical nephroureterectomy. The discrimination of models was quantified using Harrell's concordance index. The relationship between the model-derived and actuarial cancer-specific mortality was graphically explored within calibration plots. Calibration was also assessed using the quartiles of the predicted survival at 3 and 5 years and calculation of the corresponding observed Kaplan-Meier estimates. Clinical net benefit was evaluated constructing decision curve analysis. RESULTS: The discrimination accuracy of the nomograms at 3 and 5 years was 71.6% and 71.8%, respectively. Although nomograms discriminated well by Kaplan-Meier curves, and log-rank tests were all highly significant, the calibration plots tended to exaggerate the overestimation of mortality between predicted and observed probabilities at 3 and 5 years for survival. When compared with the AJCC/UICC staging system, the nomograms performed well across a wide range of threshold probabilities using decision curve analysis. CONCLUSION: The online nomogram is a highly accurate prognostic tool for patients with UUT-UC treated with radical nephroureterectomy. The model can provide an accurate estimate of the individual risk of cancer-specific mortality. Further improvement and implementation of novel molecular marker is needed.

RimabotulinumtoxinB vs. onabotulinumtoxinA for the treatment of forehead lines: an evaluator-blind, randomized, pilot study.

BACKGROUND: Optimum dose ratios of rimabotulinumtoxinB (BTX-B) and onabotulinumtoxinA (BTX-A) have not been determined for forehead wrinkles. OBJECTIVE: To compare the efficacy and safety of BTX-B and BTX-A for the treatment of forehead lines. METHODS: Twenty-two women (mean age, 40 years) with symmetrical moderate to severe forehead lines were randomized to receive single intramuscular injections of BTX-A and BTX-B on either side of the forehead, at a potency ratio of 1 : 70 or 1 : 100. Subjects were followed-up for 16 weeks. Four physicians evaluated patients' photographs according to the 4-point Facial Wrinkling Grade (FWG). Clinical Improvement Scale (CIS) was calculated by subtracting FWG score at each visit from that at baseline. Patient satisfaction scores and adverse events were also recorded. RESULTS: Both BTX-A and BTX-B were effective for the treatment of forehead lines. At both potency ratios, BTX-A had a longer duration of action than BTX-B, while BTX-B led to faster improvement than BTX-A. There was no significant difference in CIS between 700 U and 1000 U BTX-B treatments. Adverse effects were mild and transient. CONCLUSION: Both BTX-A and BTX-B were effective and well tolerated for the treatment of forehead wrinkles at potency ratios of 1 : 70 and 1 : 100.

Clinical analysis of deep cutaneous mycoses: a 12-year experience at a single institution.

Deep cutaneous mycoses can cause significant morbidity and mortality, especially in immunocompromised patients. There have been few studies focusing on deep cutaneous mycoses and there are no data from Asian countries. This study aimed to investigate clinical characteristics, underlying predisposing factors, aetiological organisms and outcomes in patients with deep cutaneous mycoses. A retrospective medical record review of patients with deep cutaneous mycoses treated at a tertiary referral centre in Korea from 1999 to 2010. Forty-one cases of deep cutaneous mycosis were identified (median age: 49). Most patients (32/41) had impaired immunological status, and seven of the remaining nine had a history of physical trauma. Neutropenia and long-term use of antibiotics were detected in 13 and 12 patients respectively. Nodular skin lesions were the most common type (17/41) and the morphology of the lesions varied. Fungal organisms were identified by culture and histopathology of skin specimens. Candida (16/41) was the most common organism, followed by Aspergillus, Alternaria, Fusarium (4/41 each). Systemic antifungal treatment was successful in 28 patients, while nine patients died from the fungal infection. Our study may lead to improved insights into deep cutaneous mycoses as their incidence is increasing and they vary in different clinical settings.

Synchronous infection with Mycobacterium chelonae and Paecilomyces in a heart transplant patient.

A 41-year-old male who was 3 years status post heart transplant presented with a 3-month history of painful erythematous nodules and ulcers on his lower legs and right hand. First, Mycobacterium chelonae infection was revealed through several biopsies with molecular sequence analysis, and combination treatment, including clarithromycin, was started. During the treatment, lesions of the legs showed an improvement, but a fluctuant erythematous nodule on the thumb did not respond. Repetitive biopsy from the thumb ultimately identified Paecilomyces species and the patient was treated with itraconazole and terbinafine sequentially. Our case is the first report, to our knowledge, of synchronous infection with non-tuberculous mycobacteria (NTM) and Paecilomyces in a solid organ transplant recipient. Our findings highlight the importance of recognizing cutaneous NTM infections or deep mycoses, as well as the importance of choosing an appropriate treatment.

Successfully treated multicentric Castleman's disease with renal thrombotic microangiopathy using rituximab and corticosteroid.

Thrombotic microangiopathy (TMA) is a rare renal complication accompanied with Castleman's disease. We report the first case of TMA combined plasma cell type multicentric Castleman's disease (MCD) which was successfully treated with rituximab and corticosteroid. A previously healthy 60-year-old Korean man was admitted due to acute renal failure, thrombocytopenia, and multiple lymphadenopathies. The result of lymph node biopsy was plasma cell type Castleman's disease and TMA was revealed by kidney biopsy. After treatment with rituximab, prednisolone and temporary hemodialysis, complete remission was achieved. The combination of corticosteroid and rituximab was associated with improvement for this patient.

Robotic-assisted latissimus dorsi muscle flap for autologous chest reconstruction in poland syndrome.

BACKGROUND: As chest reconstructions in Poland syndrome are performed for patients at young ages, patients are generally concerned about conspicuous scars. Meanwhile, a robotic-assisted latissimus dorsi (LD) muscle harvest with inconspicuous scars has been performed for autologous breast reconstruction. As our experience with robotic-assisted LD flap harvest has increased over the years, we have made improvements in surgical techniques to optimize results. The purpose of this study was to introduce and identify the role of the refined robotic-assisted LD muscle flap harvest technique in autologous chest reconstruction in patients with Poland syndrome. METHODS: Autologous chest reconstruction using a robotic-assisted LD muscle flap harvest was performed for 21 patients with Poland syndrome. Subjective assessments were performed to evaluate improvement in chest deformity, patient satisfaction with overall outcomes, chest symmetry, and scars. Assessments by the operator and two independent evaluating investigators were carried out with patients' photographs. The complication rates and the time for robotic surgery were also evaluated. RESULTS: At the last visit, the average patient grades for improvement in chest deformity, satisfaction with overall outcomes, chest symmetry, and scars were 4.80, 4.72, 4.18, and 4.87, respectively. Assessments by the operator and two independent evaluating investigators demonstrated that improvement in chest deformity was achieved in all patients. No serious complications such as flap loss were recorded for any patient. The time for robotic surgery markedly decreased as experience accumulated. CONCLUSIONS: Surgical refinements for robotic-assisted LD flap harvest might be effective and reduce operative times for patients with Poland syndrome.

Cutaneous adverse effects in patients treated with the multitargeted kinase inhibitors sorafenib and sunitinib.

BACKGROUND: The multitargeted kinase inhibitors sorafenib and sunitinib have improved treatment of solid tumours including renal cell carcinoma and hepatocellular carcinoma by offering better clinical responses. However, sorafenib and sunitinib are commonly associated with cutaneous toxicity. OBJECTIVES: We conducted this study to make a clinical assessment of the cutaneous toxicities induced by the oral multitargeted kinase inhibitors sorafenib and sunitinib. METHODS: Retrospectively, we reviewed medical records of patients receiving multitargeted kinase inhibitors, including 109 patients on sorafenib for the treatment of renal cell carcinoma or hepatocellular carcinoma and 119 patients receiving sunitinib for treatment of renal cell carcinoma or a gastrointestinal stromal tumour. Clinical data on cutaneous toxicities were collated. We describe the incidences and intensities of toxicities, and analyse the data statistically. RESULTS: The most common cutaneous toxicity was hand-and-foot skin reaction (HFSR). Other cutaneous toxicities included alopecia, stomatitis, skin discoloration (hair or face), subungual splinter haemorrhage, facial swelling, facial erythema and xerosis. HFSR and severe stomatitis required therapy modifications to relieve symptoms, but other cutaneous toxicities did not affect treatment course. HFSR was observed in 48% of patients treated with sorafenib and 36% of those treated with sunitinib. Median time to onset was 18.4 days in patients receiving sorafenib and 32.4 days in those receiving sunitinib. HFSR and stomatitis were early symptoms compared with other cutaneous toxicities. Patients with severe HFSR were likely to develop the symptoms at early phases of therapy. A significant correlation between the severity of HFSR and development of alopecia and stomatitis was found. CONCLUSIONS: Multitargeted kinase inhibitors are associated with a significant risk of various cutaneous adverse events. HFSR is the commonest and most serious cutaneous toxicity in patients treated with these drugs.

Focal myositis of the tongue presenting as macroglossia.

Focal myositis (FM) is a benign localized inflammatory process of unknown aetiology, which presents as a rapidly enlarging soft-tissue mass that evolves into a localized lesion. It is most often mistaken for a neoplasm. Histologically, it is characterized by marked myopathic changes of the muscle fibres, lymphocytic infiltration and interstitial fibrosis. We describe a case of focal myositis of the tongue and review this rare condition.

A case of botryoid-type embryonal rhabdomyosarcoma.

We describe an infant with a congenital polypoid anal mass, diagnosed as botryoid-type embryonal rhabdomyosarcoma. Histological examination revealed myxoma-like appearance and cells with greater differentiation with elongated streaming eosinophilic cytoplasm and one or two nuclei, suggestive of rhabdomyoblasts. Tumour cells were strongly immunoreactive for desmin and 10% of cells displayed immunoreactivity for myoglobin. We present this case with a view to highlighting the benign clinical and histological appearance of botryoid-type embryonal rhabdomyosarcoma. Early biopsy is essential for improving prognosis.

Multiple cutaneous metastases from hilar cholangiocarcinoma.

The most common metastatic sites of cholangiocarcinoma are the retroperitoneal lymph nodes, peritoneum, liver and lungs, and cutaneous metastases of cholangiocarcinoma are rare. Although cutaneous metastases of internal malignancies most commonly present clinically as nontender nodules appearing in a particular area of body, other presentations can occur. Cutaneous metastases of cholangiocarcinoma can appear as a solitary tumour at the therapeutic drainage site. We report a 60-year-old man with unusual cutaneous metastases from hilar cholangiocarcinoma, which presented as multiple indurated plaques and papules on the anterior chest.

Giant dermatofibroma with granular cell changes: side-effect of bee-venom acupuncture?

Dermatofibroma (DF) is a common benign fibrohistiocytic tumour with a predilection for the legs in middle-aged women. Giant DF, a rare clinical variant of DF, is characterized by its unusually large size. Granular cell change is typical of granular cell tumour, but can be observed in diverse cell lineages. Traumatic factors may be involved in the pathogenesis of giant DF and cellular granularity. We describe a 49-year-old Korean man with a giant DF showing granular cell differentiation, which may have been caused in part by multiple treatments with bee-venom acupuncture.

Paradoxical darkening of unperceived tattoo ink after relatively low fluence from a Q-switched Nd:YAG (1064-nm) laser in the course of treatment for melasma.

Although Q-switched (QS) lasers are the mainstay of modern tattoo removal, paradoxical darkening of tattoo ink may occur. This darkening of tattoo ink is dependent on laser wavelength, pulse duration and fluence, with high-energy, nanosecond-pulsed lasers more prone to induce tattoo-ink darkening. Laser toning, consisting of multiple-passed QS neodymium:yttrium-aluminum-garnet (Nd:YAG), 1064-nm laser treatment with low fluence, short pulse duration (< 10 ns), and a repetition rate of 10 Hz has been successful in the treatment of melasma. A mistake commonly made during laser toning is to scorch scalp hair, eyebrows or eyelashes, but this phenomenon is reversible. A more problematic error is caused by treatment of eyeliner or eyebrow tattoos. We report a patient who experienced changes in unperceived, skin-coloured tattoos, turning them blue after QS Nd:YAG laser treatment of melasma.

Expression of extracellular signal-regulated kinase1/2 and p38 mitogen-activated protein kinase in the invasive trophoblasts at the human placental bed.

BACKGROUND: Mitogen-activated protein kinases (MAP kinases) participate in signal transduction pathways that control embryogenesis, cell differentiation, cell proliferation and cell death. The roles of extracellular signal-regulated kinase1/2 (ERK1/2) and p38 MAP kinase in the differentiation and invasion of human trophoblasts have been studied. However, the in vivo expression and activation of ERK1/2 and p38 at the placental bed have not been elucidated. METHODS: The study group consisted of placental bed biopsy tissues obtained from the pregnancies without preeclampsia (n=24) and with preeclampsia (n=8) between 31 and 40 weeks of gestation. We evaluated the expressions and phosphorylations of ERK1/2 and p38 MAP kinase in the invasive trophoblasts in the placental bed tissues using immunohistochemistry. RESULTS: p38 and phospho-p38 MAP kinase were not detected in invasive trophoblasts in cases or controls. ERK1/2 and phospho-ERK1/2 were positive in invasive trophoblasts albeit with variable staining. Phosphorylation of ERK1/2 was significantly less frequent in invasive trophoblasts in placental bed biopsies from women with preeclampsia compared with normotensive controls. CONCLUSION: These findings suggest that preeclampsia is associated with decreased activation of ERK1/2 in invasive trophoblasts in vivo.

Clinical and radiological outcomes of transoral endoscope-assisted treatment of mandibular condylar fractures.

Fractures of the mandibular condyle are one of the most common craniofacial fractures. However, the diagnosis and treatment of these fractures is controversial because of the multiple surgical approaches available. The purposes of this study were to identify surgery-related technical tips for better outcomes and to evaluate the results as well as complications encountered during 7 years of endoscope use to supplement the limited intraoral approach in the treatment of mandibular condylar fractures. Between 2005 and 2012, 50 patients with condylar fractures underwent endoscope-assisted reduction surgery. Postoperative facial bone computed tomography and panoramic radiography demonstrated adequate reduction of the condylar fractures in all patients. No condylar resorption was detected, and most patients displayed a satisfactory functional and structural recovery. There was no facial nerve damage or transitory hypoesthesia, and there were no visible scars after the surgery. Transoral endoscope-assisted treatment is a challenging but reliable method with lower morbidity and a rapid recovery.