"Puffy shirt appearance": Cell crowding at low magnification may represent nevoid melanoma.

BACKGROUND: Melanoma, particularly nevoid melanoma, can masquerade as benign. Helpful differentiating features include nuclear pleomorphism, atypia, prominent nucleoli, absent maturation, and increased mitotic figures. These can be subtle and easily missed unless carefully sought. Thus, the "puffy shirt appearance" concept was born from a Seinfeld episode in which the namesake character unintentionally agreed to wear a pirate-like puffy shirt. Consequently, he found himself out of place, sporting an outfit with "too much shirt in too little space". Similarly, at low-power, nevoid melanoma appears to have "too many cells in too little space". This is more pronounced and easier to appreciate when there is an associated nevus, where crowded, subtly malignant melanocytes stand out from the evenly distributed, more spaced out benign melanocytes. METHODS: Twelve practicing dermatopathologists familiar with the puffy shirt concept in the context of melanoma were surveyed. RESULTS: Hundred percent of participants found it most helpful as a triaging tool, prompting additional work up including higher magnification evaluation, additional levels, consultation, and/or immunohistochemistry. CONCLUSIONS: The crowded cells in the "puffy shirt appearance" catch the eye and should provoke a more thorough inspection of the lesion. This sign is not pathognomonic for melanoma, but prompts more careful evaluation and helps prevent misdiagnosis.

Human Papillomavirus-Driven Squamous Lesions: High-Risk Genotype Found in Conjunctival Papillomas, Dysplasia, and Carcinoma.

BACKGROUND: Human papillomavirus (HPV) is a causative agent for intraepithelial squamous neoplasms, particularly on mucosal surfaces. HPV has a well-established association with squamous cell carcinoma (SCC) of the oropharynx and genital tract, and recent studies suggest a potential role in ocular and periocular squamous neoplasms. Multiple high-risk HPV genotypes are associated with histologically similar squamous neoplasms, and some HPV genotypes have been differentially associated with high- or low-grade lesions. METHODS: Squamous lesions were screened with immunohistochemical markers p16 and Ki-67 to compare expression in conjunctival papillomas (n = 21) to papillomas with high-grade dysplasia, SCC in situ, and invasive SCC (n = 40). Polymerase chain reaction was performed using the Roche COBAS HPV assay to identify the 14 most common high-risk HPV genotypes. RESULTS: Compared with squamous papillomas, the lesions showing high-grade dysplasia or worse expressed p16 with greater intensity and in a greater percentage of the lesion. A trend toward mild Ki-67 expression in papillomas versus marked Ki-67 expression in high-grade squamous lesions was also observed. HPV-16 was present in 7 of the SCC in situ and invasive SCC lesions but none of the papillomas. CONCLUSIONS: HPV may have an important role in squamous lesions of the conjunctiva. In addition to positive polymerase chain reaction results, strong and diffuse p16 expression with marked Ki-67 is strongly suggestive of an HPV-driven lesion.

Corrigendum: Leukemia cutis as the presenting symptom of acute myeloid leukemia: report of three cases.

The original article was published on July19, 2017 and corrected on June 15, 2018.The revised version of the article adds appropriate in-text references to Figures 3B, C and 5B, C, and correctly renumbers the list of References. The changes appear in the revised online PDF copy of this article.

Leukemia cutis as the presenting symptom of acute myeloid leukemia: report of three cases.

Leukemia cutis (LC), a rare cutaneous manifestation of leukemia, can precede, follow, occur concurrently with, or present in the absence of (aleukemic) systemic leukemia. Leukemia cutis is especially rare as the presenting symptom of leukemia and is associated with a poor prognosis. Although more commonly seen in acute leukemias of myeloid and monocytic lineage, lymphocytic/lymphoblastic leukemias can also involve the skin. Three cases of LC presented with diverse skin lesions ranging from an erythematous rash to violaceous macules and papules to subcutaneous nodules. One case clinically mimicked fixed drug eruption. All the patients had acute myeloid leukemia (AML). Lesions showed two overarching histologic patterns: atypical perivascular infiltrate or nodular dermal histiocytoid infiltrate. Our cases expressed myeloperoxidase (MPO), a helpful marker to distinguish myeloid from non-myeloid cells, and CD68, a monocytic marker frequently expressed in cutaneous AML. CD14, a marker of monocyte maturity, was negative. In the absence of systemic leukemia, common diagnostic tools for hematologic malignancies such as bone marrow biopsy and flow cytometry are non-contributory, making morphologic and immunohistochemical analysis of the skin lesions key to diagnosis.

The effects of the Bethesda System 2014 on endometrial cell reporting and follow-up endometrial biopsies in women 45 years of age and over.

INTRODUCTION: The Bethesda System (TBS) guidelines for reporting the presence of endometrial cells on Papanicolaou tests increased the reporting age from 40 (TBS 2001) to 45 (TBS 2014) years. Exfoliated endometrial cells (EMC) are usually a normal finding. Nevertheless, benign-appearing EMC occasionally correspond to endometrial hyperplasia or malignancy, especially in older, postmenopausal women. This study assesses the impact of this age cutoff change. MATERIALS AND METHODS: This retrospective review compares endometrial biopsies following TBS 2001 and TBS 2014. Papanicolaou tests with EMC reported in women older than age 40 or 45 years were correlated with follow-up endometrial biopsies performed between May 25, 2014, to May 26, 2015, and May 27, 2015, to May 26, 2016, respectively. RESULTS: The number of reported EMC declined from 770 to 492 (a 36.1% decrease). The follow-up endometrial biopsy rate for Papanicolaou tests reporting EMC using TBS 2001 was 13.6% (105 of 770) versus TBS 2014 at 13.8% (68 of 492; P = 0.92). For TBS 2001, 15% of women aged 45 and older had follow-up biopsies (65 of 434; P = 0.62). Most follow-up biopsies showed benign endometrium. In the TBS 2001 group, 1 biopsy showed malignancy and another showed complex hyperplasia with atypia. Both patients were older than 45 years. The TBS 2014 group contained 1 biopsy of malignancy and 1 with simple hyperplasia with focal atypia. CONCLUSIONS: The implementation of TBS 2014 reduced the frequency of reporting benign-appearing endometrial cells. The follow-up biopsy rate has remained essentially the same, but the total number of biopsies performed decreased, with a similar low yield of significant abnormalities.