Clinicopathologic Features and Prognostic Significance of Immunohistochemistry and In Situ Hybridization Based Molecular Classification in Gastric Carcinoma.

BACKGROUND/AIM: Gastric carcinoma (GC) is a highly heterogeneous disease with many subtypes that have different morphologic and molecular characteristics. In the current study, we analyzed immunohistochemical (IHC) and in situ hybridization (ISH) features of GCs and evaluated their association with prognosis and clinicopathological features. MATERIALS AND METHODS: Three hundred cases analyzed by IHC and ISH for microsatellite stability, p53, e-cadherin, HER2, PD-L1 expression, and Epstein-Barr virus (EBV) status. Cases were classified into five subgroups based on expression profile. The relationships between subgroups, clinicopathological features, and survival were determined. RESULTS: Ten (3.3%) cases were classified as EBV-associated, 45 (15%) as microsatellite instable (MSI), 73 (24.3%) as EBV-/microsatellite-stable (MSS)/epithelial-mesenchymal-transformation (EMT)-like, 75 (25%) as EBV-/MSS/ non-EMT-like/p53+, and 97 (32.3%) as EBV-/MSS/non-EMT-like/p53-. The MSI subtype had the best overall survival (OS). In contrast, the EBV-/MSS/EMT-like subtype had the poorest OS. The MSI subtype was also related with old age of the patient and antrum-corpus localized tumors, whereas the EBV-/MSS/EMT-like was associated with young age, larger tumor size, and advanced stage presentation. PD-L1 positivity is highly correlated with MSI and EBV-associated subtypes. CONCLUSION: Our data demonstrated a link between IHC/ISH characteristics of GC and clinical outcomes. IHC/ISH based molecular classification may be helpful in predicting the survival.

Anti-TNF agent etanercept augments UV-induced skin cancer development in SKH-1 mice.

BACKGROUND: Despite being employed in the treatment of inflammatory disorders for more than 20 years all over the world, data regarding photocarcinogenic risks of anti-TNF agents is scarce. OBJECTIVE: To assess photocarcinogenic potential of anti-TNF agents. METHODS: This was a placebo controlled, split-body (UVB-treated versus -untreated) study on mice. Treatment groups were infliximab (n = 11), etanercept (n = 11), cyclosporine (n = 11) and vehicle control (n = 11). Agents were introduced on the 10th week of phototherapy and continued through 24th week. The macroscopic, histological and immunohistochemical analysis of test sites were carried out. RESULTS: Overall 132 tumors were detected on test sites. All of these tumors developed on UV-exposed sides. Histologic examination of these tumors was compatible with keratinocytic neoplasia in 128, mastocytosis in 3, epidermal cyst in 1. Median tumor burden in the UVB exposed areas for ETN, IFX, CYC, and control groups were 14.91, 10.20, 6.28, and 3.14 cm2, respectively. ETN group demonstrated both higher tumor burden and keratinocytic neoplasia numbers than controls (p = .03, p = .025). Although there were 1.8 and 1.7 times more keratinocytic neoplasms in IFX and CYC groups compared to controls, these differences didn't reach statistically significant levels (p = .14; p = .19). CONCLUSION: This study points out to a significant photocarcinogenic potential of anti-TNF agent etanercept.

Nevus sebaceus with basal cell carcinoma, poroma, and verruca vulgaris.

Nevus sebaceus (NS) is a congenital, benign, hamartomatous lesion and it is possible to see several benign or malignant tumors accompanying it. One of these is the poroma, which is very rare, and has only been reported twice before, in the English literature. In this paper, we presented two new cases of NS. One of them was a 40-year-old male who presented with a congenital skin lesion on his temporoparietal region. This lesion was composed of four different lesions, including NS, poroma, basal cell carcinoma (BCC), and verruca vulgaris. The second patient was a 41-year-old male presenting with a yellow-brown patch on the scalp. This lesion was comprised of NS and BCC. In addition to these presentations, we discussed the differential diagnosis between BCC and trichoblastoma, both of which are likely to be seen with NS. For this purpose, we recommended an immunohistological panel, which may be useful for differentiating these two morphologically similar lesions.

Molecular alterations in malignant blue nevi and related blue lesions.

Malignant blue nevi (MBN) are extremely rare dermal melanocytic tumors that arise in association with atypical cellular blue nevi (ACBN), cellular blue nevi (CBN), common blue nevi (BN), or de novo. The frequency of BRAF, NRAS, and KIT mutations in malignant melanoma varies according to histological subtype and localization. These mutations are rarely observed in blue nevi, which have recently been shown to carry activating mutations in GNAQ/GNA11 genes. Only few small molecular studies of MBN have been published. The aim of the present study was to analyze in MBN and related blue lesions such as ACBN, CBN, and BN the prevalence of BRAF, NRAS, KIT, GNAQ, and GNA11 gene mutations and their association with clinicopathological features. We included in our study 12 MBN, 6 ACBN, 29 CBN, and 35 common BN diagnosed between 1996 and 2014. Sanger sequencing method was used for mutation analysis. Overall, GNAQ exon 5 mutation was the most frequent alteration (46 %), in 2 of 12 (17 %) MBN, 1 of 6 (17 %) ACBN, 22 of 29 (76 %) CBN, and 13 of 35 (37 %) common BN. BRAF V600E and GNA11 exon 5 mutations were respectively detected in 3 of 12 (25 %) and in 2 of 12 (17 %) MBN while none in ACBN, CBN, and common BN. None of the cases harbored NRAS exon 2/3, KIT exon 9/11/13/17/18, or GNAQ/GNA11 exon 4 mutations. GNAQ gene exon 5 mutations are rare in MBN and ACBN but frequent in CBN and common BN. Remarkably, BRAF V600E and GNA11 exon 5 mutations were only detected in MBN, whereas none were found in ACBN, CBN, or common BN. Our data contribute new elements to the limited data on molecular alterations in MBN.

A case of pachyonychia congenita with unusual manifestations: an unusual type or a new syndrome?

A 30-year-old man presented with lesions on his oral mucosa and soles. There were no similar complaints in his family members. The dermatological examination revealed follicular hyperkeratosis on his trunk and upper extremities and flesh-colored, firm cystic lesions on his axillae. He had focal, painful, hyperkeratotic areas sited particularly on both his soles and palms. In addition to these, leukokeratosis and ulcerative areas on buccal, labial mucosa, tongue, and at corners of the mouth, and complete loss of teeth was observed. The proximal layering was revealed on all of his nails. The laboratory investigations produced normal results except the deficiency of immunoglobulin A. The psychiatric examination revealed mild mental retardation. Keratin gene (KRT6a, KRT6b, KRT16, and KRT17) mutations for pachyonychia congenita were negative. He got removable dental prosthesis because of inadequate alimentation. Squamous cell cancer developed on lower lip mucosa during follow-up. We present an individual who had different nail dystrophy, epidermal cysts, mental retardation, blepharitis, complete loss of teeth, and negative keratin gene mutations for pachyonychia congenita and developed squamous cell cancer on the oral leukokeratosis lesions. We think that the present case may be an unusual new type of pachyonychia congenita.

Cerebral vein thrombosis in a four year old with Behçet's disease.

Behçet's disease (BD) is a multisystem disorder. The main pathology in BD is vasculitis that involves arteries and veins of all calibers. Central nervous system involvement occurs in 5-10% of patients. Increased morbidity and mortality is rarely observed in children. The mean age at onset in pediatric BD is approximately 7 years. Neurologic involvement in BD is usually observed after 3-6 years. We report the case of a four-year-old Turkish boy with BD with sagittal sinus thrombosis treated with infliximab. The patient presented papilledema without neurologic signs. Although long-term efficacy evaluations are needed in this case, infliximab therapy may be a good option in childhood BD with refractory sinus thrombosis. This is the youngest case of BD with sagittal sinus thrombosis reported so far.

A retrospective multicenter evaluation of cutaneous melanomas in Turkey.

BACKGROUND: We defined melanoma distribution in a large series of Turkish patients and evaluated the prognostic parameters of melanomas. MATERIALS AND METHODS: A total of 1574 patients' data was retrospectively collected at 18 centers in Turkey. Demographic characteristics were questioned and noted. Prognostic parametres were evaluated based on sentinel lymph node involvement. RESULTS: Mean age was 56.7 (4-99) years. While 844 (53.6%) cases were male, 730 (46.4%) cases were female. One thousand four hundred forty-seven (92%) cases were invasive melanoma and 127 (8%) cases were in-situ melanoma. The most common histopathological form was the superficial spreading melanoma (SSM) which was found in 549 patients (37.9%). It was followed by nodular melanoma in 379 (26.2%), acral lentiginous melanoma (ALM) in 191 (13.2%) and lentigo maligna melanoma in 132 (9.1%), respectively. On univariate analysis, lymphovascular invasion (p<0.001), tumor thickness (p<0.001), histopathological subtype (p<0.001), Clark level (p=0.001), ulceration (p<0.001), ≥6/mm2 mitosis (p=0.005), satellite formation (p=0.001) and gender (p=0.03) were found to be associated with sentinel lymph node positivity. Regression was associated with sentinel lymph node negativity (p=0.017). According to multivariate analysis, lymphovascular invasion and tumor thickness were significant independent predictive factors of SLN positivity. Patient age, tumor localization, precursor lesions, lymphocytic infiltration and neurotropism were not related with sentinel lymph node involvement. CONCLUSIONS: In this retrospective analysis, it was found that the prevalence of SSM is at a lower rate while the prevalence of ALM is at a higher rate when compared to western countries. According to Breslow index; most of the melanoma lesions' thickness were greater than 2 mm, corresponding Clark IV. Vascular invasion and tumor thickness are the most important factors for sentinel lymph node involvement.

Clinical, dermoscopic and immunohistochemical assessment of actinic keratoses and evaluation of the effectiveness of diclofenac therapy with immunohistochemical analysis.

Actinic keratoses (AKs) is a keratinocytic neoplasm that typically develops on the face of elderly patients. Little is known regarding the clinical, dermatoscopic and immunohistochemical assessments of AK using topical diclofenac therapy. We sought to determine these assessments and evaluate the efficacy of topical diclofenac gel in AK. In this prospective, open-label study, 44 patients with 66 AKs were treated for 12 weeks with topically applied diclofenac (3% gel in 2.5% hyaluronic acid). Immunohistopathologic analyses were performed before and after diclofenac treatment using epidermal stem cell markers such as Cytokeratin 15 (CK15), Cytokeratin 19 (CK19) and p63, in addition to proliferation markers (Bcl-2, Ki-67). Diclofenac gel was found to be effective in AK, including the hyperkeratotic type. Surprisingly, complete remission was observed at a significantly higher rate in Grade 3 lesions (p = 0.017). However, imunohistochemical and histopathologic examinations revealed that 12-week treatment periods may not be sufficient to fully cure AK. The immunohistochemical analyses revealed no change in the expression levels of CK15, CK19 and Bcl-2 following diclofenac therapy. However, the expression of Ki-67 (p = 0.042) and p63 (p = 0.030) exhibited a significant decrease after therapy. Dermatoscopy is an effective method for diagnosis of AK, and topical diclofenac sodium gel was found as an effective additional treatment modality. Since positive histopathological findings were detected in some patients even with significant remission, a 12-week treatment period should be extended even in patients presenting with positive clinical response. Importantly, anti-proliferative effects of diclofenac were demonstrated by decreased Ki-67 and p63 expression levels.

Giant Mongolian macules with bilateral ocular involvement: case report and review.

Dermal melanocytosis is characterized by the presence of spindle-shaped melanocytes in the dermis. The most common form is Mongolian spots. A 15-month-old girl from Azerbaijan had a systematized dark blue-gray hyperpigmentation on her shoulder, back and extremities. The hyperpigmentation was also found on both sclera and choroidal areas, without any other facial involvement. On histopathological examination, dense melanocytes were found on the intermediate and deep dermis. Her physical and mental development was normal. This association of blue macules and involvement of both sclerae does not represent a distinct entity and cannot be categorized as an example of nevus of Ota.

Toluidine blue staining in the diagnosis of endometrial pathologies: a preliminary study before chromohysteroscopy.

OBJECTIVE: To assess the efficacy of toluidine blue (TBlue) staining in the detection of endometrial premalignant or malignant lesions in uterine specimens obtained from hysterectomies. We hoped that the results of this preliminary study would help us in our future studies which may be on chromohysteroscopy. STUDY DESIGN: We developed an endometrium staining technique in which TBlue solution was used as a vital dye. The study enrolled 50 patients. Of these, 20 patients known to have a premalign or malign lesion of the uterus constituted the study group and 30 patients were recruited as the control group who were operated for leiomyoma of the uterus. Immediately after hysterectomy, all specimens were dyed with TBlue solution and a frozen section procedure was performed on the positively stained areas. The pre- and post-operative histopathological diagnoses of the participants were compared and the reliability of the new method was calculated. RESULTS: The sensitivity of TBlue staining in the determination of endometrial pathologies was 100% (95%, CI 0.83-1) with a specificity of 90% (95%, CI 0.74-0.96). As a diagnostic test, the positive predictive value (PPV) was 87% with a negative predictive value (NPV) of 100%. The positive likelihood ratio (+LR) was 10 (95%, CI 3.41-29.2). CONCLUSIONS: Our preliminary results demonstrated that TBlue staining of endometrium is a reliable and highly sensitive technique that may be used in the frozen section examination of uterine specimens if a malignancy is suspected. Moreover, TBlue staining of endometrium may prove useful in hysteroscopy, although the technique, interpretation, and indications require further studies.

An uncommon presentation of the co-existence of morphea and vitiligo in a patient with chronic hepatitis B virus infection: is there a possible association with autoimmunity?

A 30-year-old man presented with indurated violaceous plaques all over his body that had been present for 7 months. The patient had also had vitiligo for 3.5 years, and hepatitis B virus (HBV) infection and cirrhosis for a 2-year period. Histopathologic examination of the indurated plaques confirmed the diagnosis of morphea. Localized scleroderma and vitiligo have only rarely been reported to occur simultaneously. Although the etiologies of vitiligo and morphea are both uncertain, their association with autoimmune diseases favors an autoimmune hypothesis. Both vitiligo and morphea might have appeared coincidentally. However, this association could be significant because it may be related to the presence of HBV and alterations in the immune system that are caused by this virus. Therefore, this rare combination of vitiligo and morphea in a patient with chronic HBV infection warrants attention because it suggests a possible immunologic association, which may merit future study.

Uncommon presentation of mycosis fungoides: eyelid margin involvement.

Mycosis fungoides is a cutaneous T-cell lymphoma that has been rarely reported to involve ocular structures. A 33-year-old woman who had received therapy for mycosis fungoides on the trunk for 11 years, presented to our clinic with new plaques and tumors on her eyebrows and eyelid margin, and alopecia of her eyelashes and eyebrow. The histopathological examinations supported the diagnosis of mycosis fungoides. There was no intraocular involvement with tumor. The mycosis fungoides was of stage II B, and the patient was referred to medical oncology and radiation oncology clinics for treatment. She was placed on a radiotherapy schedule. The involvement of mycosis fungoides in the ocular area is rare in the published work. The importance of eye involvement is being seen in advanced cases, and there is a possible association between mycosis fungoides and poor prognosis by being an indicator of systemic involvement.