Analysis of Damage and Wound Healing in the Retinal Pigmented Epithelium.

Previous studies of retinal pigment epithelium (RPE) morphology found cell-level and spatial patterning differences in many quantitative metrics in comparing normal and disease conditions. However, most of these studies examined eyes from deceased animals. Here we sought to compare noninvasively imaged RPE cells from live mice to histopathology. We describe changes to improve noninvasive imaging of RPE in the live mouse. In retinal diseases, there can be invasion by Iba1-positive cells, which can be detected by noninvasive imaging techniques. Here we can detect potential Iba1-positive cells at the level of the RPE noninvasively.

A procedure for image enhancement in chromosome painting.

An image enhancement procedure was developed to produce high-contrast chromosome paint images. This procedure is well suited for images where brightness-contrast enhancement is subjective. Three examples are given to show that the procedure is very efficient to remove non-specific hybridization signals from the chromosome paint image. Chromosomes of roe deer contain large amounts of centromeric heterochromatic DNA. Echidna chromosomes show specific heterochromatic DNA distributed over several chromosomes. In both cases chromosome identification was hampered by bright heterochromatic regions. The enhancement tool was fully used in cross-species chromosome painting, which is the last example. The three examples show that the procedure is very simple to use and removes background in a controlled and defined manner.

Topical imidazoquinoline therapy of cutaneous squamous cell carcinoma polarizes lymphoid and monocyte/macrophage populations to a Th1 and M1 cytokine pattern.

Imidazoquinolines are topical immune response modifiers. Imiquimod (IMI), the first imidazoquinoline, is approved for the treatment of genital human papillomavirus disease and has shown success as a therapeutic agent for cutaneous premalignant and malignant tumours. To define the pattern of polarization of the local immune response to invasive cutaneous squamous cell carcinoma (SCC) we pretreated 10 SCCs that were > 3 cm in diameter for 2 weeks with IMI. The tumours were treated on Monday, Wednesday and Friday and excised the next Monday. A battery of immunohistochemical markers was used to define the mononuclear cell populations in the diagnostic, and the excisional biopsy specimens. The total inflammatory infiltrate was increased after IMI therapy: the greatest increase was in the CD8 T cells with a marked relative decrease in the CD68 monocytic/macrophages; the majority of the CD8 T cells showed expression of cytotoxic granules, T cell-restricted intracellular antigen (TIA) and granzyme B. The relative numbers of monocytes/macrophages were decreased after therapy with IMI with a decrease in CD68+, CD23+, and CD14+ cells and an increase in MAC-397+, and factor XIIIa+ cells. The epidermal dendritic cells showed a > 75% decrease in CD1a+ cells. The immunohistochemical marker profile after IMI therapy is consistent with that induced by a Th1 and M1 cytokine polarization pattern. This cytokine pattern is known to be more effective in defence against tumours as well as viral infections.

Treatment of disseminated granuloma annulare with a 5-lipoxygenase inhibitor and vitamin E.

Histologically, granuloma annulare (GA) is a common non-infectious necrobiotic granulomatous reaction pattern that correlates with a number of different, but relatively specific clinical presentations. The cause or causes of GA are unknown: when localized, it is usually self-limiting, but it may be persistent when disseminated. We present three women who had had disseminated GA for more than 1 year. One patient had previously been treated with isotretinoin with no response. All three patients were treated with vitamin E 400 IU daily and zileuton 2400 mg daily. All responded within 3 months with complete clinical clearing. The anti-inflammatory and immune regulatory effects of vitamin E and zileuton may be an effective treatment in some patients with prolonged disseminated/generalized GA.

Cholesterol embolization syndrome: cutaneous histopathological features and the variable onset of symptoms in patients with different risk factors.

Cholesterol embolization syndrome (CES) may not only be due to direct dislodgement of cholesterol crystals from atherosclerotic plaques on the walls of arteries by surgery, angiogram or trauma, but may occur after anticoagulant and thrombolytic therapy. The latter two therapies both weaken the fibrin clot that stabilizes the atheromas in place; however, these two therapies commonly have different onsets of CES after their institution. We present three patients with different risk factors for CES who all presented with the pathognomonic triad of leg and/or foot pain, livedo reticularis and good peripheral pulses. In all three patients cholesterol emboli were demonstrated in cutaneous biopsy sections. In two patients there was associated renal involvement, which was fatal in one case. These cases illustrate that cutaneous biopsy may be diagnostic in patients with livedo reticularis, which progresses to necrosis and gangrene. In addition, they illustrate the problems and contradictions involved in treating patients with CES.

Delayed cutaneous hypersensitivity reactions to hirudin.

Hirudin is one of the new synthetic antithrombin agents, which is most commonly used in patients with type II heparin-induced thrombocytopenia and in patients with hypersensitivity reactions to unfractionated heparin as well as low-molecular-weight heparins. Hirudin is comparable to heparin as an antithrombotic agent and also has been studied as a primary treatment in patients who experienced acute myocardial infarctions. We describe a patient with a history of type II heparin-induced thrombocytopenia who was placed on intravenous hirudin therapy. After extravasation of the intravenous hirudin site, the patient developed a delayed hypersensitivity reaction that histologically showed an epithelioid granulomatous infiltrate. Although rare reports of hypersensitivity reactions to hirudin have been published, these reactions have not been well characterized and the histopathologic changes have not been described.

Histologic features seen in changing nevi after therapy with an 810 nm pulsed diode laser for hair removal in patients with dysplastic nevi.

BACKGROUND: The majority of lasers used for hair removal target melanin as the chromophore. In contrast with other cutaneous applications of lasers, lasers used for hair removal must generate a limited, controlled degree of thermal damage to permanently remove hairs. AIM: To remove excess back hair from two male patients, one with a history of multiple nevi, and prior biopsies showing features of dysplastic nevi, and the other with large nevi greater than 6 mm in diameter and a family history of malignant melanoma. METHODS: Both patients received monthly treatments with an 810 nm, pulsed, high-power diode laser using a fluence of 20 J/cm2 and 25-30 J/cm2, respectively, and a pulse duration of 30 ms. RESULTS: Both patients presented 1 month after their last treatment with changing nevi within the treatment areas. Neither patient had clinical inflammation or other alterations suggestive of change in the nevi related to treatment. Thus, the nevi were excised with no mention of the previous laser treatment. The histologic features in all nevi were similar. There was subepidermal blister formation with elongation and disruption of nevus cells. There was homogenization of the collagen within the papillary dermis in all lesions. Only small foci of nevus cells could be identified in the dermis in some of the biopsy specimens. In these biopsy specimens, the dermal stromal matrix homogenization extended into the reticular dermis. CONCLUSIONS: Laser targeting of nevus cells and surrounding structures may produce clinically atypical nevi in areas previously treated for hair removal. This should be kept in mind, especially in patients with a history of dysplastic nevi or with a personal or family history of malignant melanoma.

Basaloid/follicular hyperplasia overlying connective tissue/mesenchymal hamartomas simulating basal cell carcinomas.

BACKGROUND: Basaloid hyperplasia has been described overlying dermatofibromas as well as in the epidermis overlying nevus sebaceus. Although the morphology of these areas may resemble that of basal cell carcinoma (BCC), in the majority of cases aggressive behavior of the proliferation is not seen. In fact, the basaloid proliferation often shows follicular differentiation and may be stimulated and maintained by its relationship with the underlying stromal cells. OBJECTIVE: We wanted to determine whether immunohistochemical staining for antibodies, which may suggest differences in pathogenesis, were different in basaloid hyperplasia overlying connective tissue/mesenchymal hamartomas and BCC. METHODS: We report 3 cases of connective tissue/mesenchymal hamartomas with overlying basaloid hyperplasia, in which the areas of the basaloid proliferation showed follicular differentiation. Immunohistochemical stains included Ber-EP4, PCNA, Ki-67, Bcl-2, p53, SM-Actin, CD31, factor XIIIa, KP-1, and CD34. RESULTS: There was a diffuse positive reaction for Ber-EP4 in all specimens and there was increased nuclear staining for PCNA and Ki-67. There was focal cytoplasmic staining for Bcl-2 in the areas of basaloid hyperplasia. Immunohistochemical staining for p53 showed only scattered positive cells except in a small focus in the areas of basaloid hyperplasia. The connective tissue component of all lesions showed diffuse staining for CD34 surrounding areas of basaloid hyperplasia in the mesenchymal component as well as in abundant S-100(+) nerves. CONCLUSION: The areas of basaloid hyperplasia in these hamartomas exhibited an immature phenotype similar to that seen in both BCCs and follicular tumors; however, the patterns of proliferation markers, p53, Bcl-2, and the surrounding stromal cell markers were similar to those of benign follicular tumors. Thus the staining pattern for this group of antibodies suggests that areas of basaloid hyperplasia are not BCC.

Rapid onset of cutaneous squamous cell carcinoma in patients with rheumatoid arthritis after starting tumor necrosis factor alpha receptor IgG1-Fc fusion complex therapy.

Tumor necrosis factor alpha (TNF-alpha) is now believed to be a major contributor to the pathogenesis of the synovitis and joint destruction in rheumatoid arthritis. Etanercept is a recombinant human TNF-alpha receptor Fc fusion protein consisting of a dimer of the extracellular portion of two p75 TNF-alpha receptors fused to the Fc portion of human IgG1. Etanercept produces significant dose-dependent improvements in disease activity. We describe 7 patients who experienced 1 or more squamous cell carcinomas that showed rapid growth and arose over a 2- to 4-month period of etanercept therapy. Soluble TNF-alpha receptor therapy through inhibition of a T(H)1 cytokine pattern and inhibition of the direct and indirect cytotoxic effects of TNF-alpha may initially decrease mechanisms for controlling subclinical tumors and may contribute to the histologic features seen within these tumors. However, prolonged TNF-alpha inhibition may have some antitumor effects.

Peroxisomes in dermatology. Part I.

BACKGROUND: Peroxisomes are small cellular organelles that were almost ignored for years because they were believed to play only a minor role in cellular functions. However, it is now known that peroxisomes play an important role in regulating cellular proliferation and differentiation as well as in the modulation of inflammatory mediators. In addition, peroxisomes have broad effects on the metabolism of lipids, hormones, and xenobiotics. Through their effects on lipid metabolism, peroxisomes also affect cellular membranes and adipocyte formation, as well as insulin sensitivity, and peroxisomes play a role in aging and tumorigenesis through their effects on oxidative stress. OBJECTIVE: To review genetically determined peroxisomal disorders, especially those that particularly affect the skin, and some recent information on the specific genetic defects that lead to some of these disorders. In addition, we present some of the emerging knowledge of peroxisomal proliferator activator receptors (PPARs) and how ligands for these receptors modulate different peroxisomal functions. We also present information on how the discovery of PPARs, and the broad and diverse group of ligands that activate these members of the superfamily of nuclear binding transcription factors, has led to development of new drugs that modulate the function of peroxisomes. CONCLUSION: PPAR expression and ligand modulation within the skin have shown potential uses for these ligands in a number of inflammatory cutaneous disorders, including acne vulgaris, cutaneous disorders with barrier dysfunction, cutaneous effects of aging, and poor wound healing associated with altered signal transduction, as well as for side effects induced by the metabolic dysregulation of other drugs.

Trichophyton rubrum showing deep dermal invasion directly from the epidermis in immunosuppressed patients.

Trichophyton rubrum is the most widely encountered dermatophyte infection, and is usually regarded as exclusively keratinophilic often leading to chronic cutaneous and nail infections, even in healthy individuals. We present three patients with acute leukaemias, with ill-defined pre-existent cutaneous eruptions that were treated with a potent topical corticosteroid. All three patients received aggressive marrow toxic chemotherapy. These patients had progression of their cutaneous disease, which showed deep dermal invasion of T. rubrum, invading directly from the epidermis with no evidence of systemic spread. We conclude that systemic pancytopenia, in association with prolonged local immunosuppression, may increase the risk of direct dermal invasion of dermatophyte infections. However, even in these patients, the risk of systemic spread still appears very low. Amphotericin B did not appear effective in treating these dermatophyte infections.

Neonatal lupus erythematosus: factors which may lead to clinical disease in the foetus even in the absence of disease in the mother.

Neonatal lupus erythematosus (NLE) occurs in neonates of mothers who, in almost all cases, have auto-antibodies to the SSA/Ro associated proteins, but who may have no clinical disease. However, only a small percentage of mothers with SSA/Ro antibodies have affected babies, predisposing factors specific to the foetus or neonate (i.e. HLA pattern) and/or fetal maternal interactions have been proposed to be important. We present a mother with a family history of autoimmune disease, but without clinical disease, whose baby developed cutaneous NLE. Autoantibody determinations as well as the HLA-DR/DQ were performed in the mother and baby. Factors other than the HLA-DR/DQ status of the mother appear to be important in determining whether or not the neonate will develop NLE. Auto-antibodies to endogenous antigens common to the mother, transiently expressed developmental antigens, and the isotype specificity of transferred antibodies may be important in determining disease in the baby.

Metastatic adenocarcinoma of the esophagus to the skin: new patterns of tumor recurrence and alternate treatments for palliation.

BACKGROUND: Esophageal cancer, particularly adenocarcinoma of the esophagus (ACE), has been steadily increasing in incidence in the United States. In the past, patients usually died rapidly with locoregional disease that leads to inanition and aspiration. However, today when patients with ACE are treated successfully with induction chemotherapy and radiation therapy, followed by surgical excision, ACE usually does not recur locally, but presents with metatastic disease. We present a 62-year-old white male with ACE, which was treated with induction chemotherapy and radiation therapy followed by surgical excision. After approximately 1 year with no evidence of locoregional recurrence, the patient presented with diffuse cutaneous metastatic disease. METHODS: In addition to routine staining immunohistochemical stains for CK(AE1/AE3), CK7, CK 20, EMA, alpha-smooth muscle (SM) actin, S-100 protein, CD34, P53, Bcl-2, c-erbB-2 were performed. RESULTS: The immunohistochemical profile was consistent with an esophageal origin showing positive staining with CK20 and CK7 as well as AE1/AE3 and EMA. In addition, there was marked nuclear expression of p53, as well as membrane expression of c-erb-B2; consistent with progression of the disease and poor response to further cytotoxic therapeutic regimes. CONCLUSIONS: With new therapeutic protocols, we can expect to see more metastatic disease with recurrences of ACE. The histopathologic features and the immunohistochemical profile of the recurrent tumors may be helpful in determining alternate forms of therapy that either alone or in combination could be useful in palliation and delaying progression.

Telomerase activity in Kaposi's sarcoma, squamous cell carcinoma, and basal cell carcinoma.

Patients with acquired immune deficiency syndrome (AIDS) often develop Kaposi's sarcoma (KS), an unusual skin tumor. The malignant nature of KS has long been disputed. Telomerase activity that maintains telomere length and ensures chromosomal stability, a frequently appearing marker in human malignancies, has been proposed to play a critical role in supporting continued cell growth, hence formation of tumors. We examined telomerase activity in tissue extracts from 22 KS, 10 squamous cell carcinoma (SCC), and 22 basal cell carcinoma (BCC) using the telomeric repeat amplification protocol (TRAP). All of the tumor tissues were previously cryopreserved at -80 degrees C. In this study, all tumor samples tested were positive for telomerase activity. Consistent with the presence of the enzyme activity, the skin tumors had relatively long telomeres. Inhibitors in the tissue extracts of some samples needed to be diluted or extracted by phenol before the enzyme activity was detected in the TRAP assay. All KS as well as two other skin carcinoma samples revealed positive telomerase activity. Our finding supports telomerase's role in tumor cell immortality and suggests the true neoplastic nature of KS.

Squamous cell carcinoma in situ (Bowen's disease) in renal transplant patients treated with 5% imiquimod and 5% 5-fluorouracil therapy.

BACKGROUND: Depending upon the patient's age at transplant, skin type, sun exposure, and the need for immunosuppressive therapy to prevent rejection, there is escalation in the development of cutaneous malignancies in organ transplant patients a number of years after transplantation. Thus, with the expansion in these procedures over the past decades, and the ever-lengthening survival of these patients, we are seeing an increase in cutaneous malignancies in this patient population. OBJECTIVE: To determine if combined therapy with 5% 5-fluorouracil and 5% imiquimod may be useful in the treatment of squamous cell carcinoma in situ. METHODS: We present five renal transplant patients, all more than 10 years posttransplantation, three with insulin-dependent diabetes, who developed multiple areas of squamous cell carcinoma (SCC) in situ. All these patients were on chronic immunosuppressive chemotherapy to prevent rejection, but were otherwise doing well. All the patients had biopsy-proven SCC in situ on their lower extremities that even in normal patients may be a challenge to treat. RESULTS: We treated these five patients with a combination of a local immune therapy, imiquimod cream, and a topical chemotherapeutic agent, 5% 5-fluorouracil (5-FU), with clearing of the areas of SCC in situ. CONCLUSION: Although immunotherapy must be used with caution in organ transplant patients to avoid graft rejection, topical imiquimod is a local immune modulator that potentiates local innate and possible adaptive immunity without measurable effects on systemic immunity. In addition, there is evidence that cytokines induced by imiquimod may improve the therapeutic efficacy of topical 5% 5-FU in the treatment of SCC in situ.

The clinical and histologic spectrum of cutaneous fibrous perineuriomas.

Cutaneous fibrous perineuriomas (CFPs) and the closely related sclerotic perineuriomas are recently reported tumors. We present nine additional cases of CFPs. All tumors were small nodules on the extremities; however, they were not limited to a distal acral location as previously reported. In addition to tabulation of the histologic features, we performed a battery of immunohistochemical stains, including S-100 protein, CD34, cytokeratin, epithelial membrane antigen (EMA), KP-1, and collagen type IV. Histologically, these tumors presented with sharp circumscription of their deep aspect, as previously reported, or were not circumscribed on any side. The cells ranged from plump and spindled with one or more nuclei to thin, elongated, spindled cells with slender nuclei. A variably fibrotic stromal matrix surrounded these components. Immunohistochemical staining showed EMA-positive staining of the cellular component, with collagen type IV-positive staining surrounding the cells. The tumor cells were negative for S-100 protein, factor XIIIa, CD34, cytokeratin, and KP-1. The tumors reported here add to the clinical and histopathologic spectrum of CFPs.

Peroxisomal proliferator-activated ligand therapy for HIV lipodystrophy.

Lipodystrophies associated with HIV disease have been reported in recent years and have included a general redistribution of fat with more central fat and increased dorsocervical fat. These lipodystrophies are commonly associated with hyperlipidemia and in some cases with insulin resistant diabetes. Although a similar redistribution of fat is seen in hypercortisolism, in general, serum and urinary cortisol levels are normal in these HIV-positive patients. However cortisol/dehydroepaindrosterone (DHEA) ratios are increased in HIV disease and may result in a relative hypercortisolism. Seven HIV-positive male patients on multidrug antiviral therapy including HIV protease inhibitors had developed increased central and dorsocervical fat over 1 year. All patients had increased serum lipids and three had insulin resistant diabetes. Four patients were treated initially with DHEA 100-200 mg/day, with addition of a cyclo-oxygenase (COX) inhibitor (indomethacin 100 mg/day) and three others were treated from the onset with a combination of DHEA 200 mg/day and a COX inhibitor (indomethacin 100 mg/day or naprosyn 1000 mg/day). All patients reported moderation or normalization of their serum lipids and some moderation of blood sugars while on DHEA alone. More marked improvement in blood sugar and noticeable decreases in the dorsocervical fat; however, occurred only with addition a COX inhibitor. Both DHEA and COX inhibitors have a number of mechanisms of action; among these is their role as a peroxisome proliferator-activator receptor ligand. Dysregulation of peroxisome function is associated with the spectrum of biochemical changes seen within these HIV associated lipodystrophies. Use of HIV protease inhibitors is reported in the majority of patients with these lipodystrophies, and protease inhibitors may accentuate the underlying peroxisome dysregulation. Supplementation with DHEA and a COX inhibitor may improve peroxisomal function.

Spindle cell epithelioma of the vagina shows immunohistochemical staining supporting its origin from a primitive/progenitor cell population.

Spindle cell epitheliomas of the vagina (SCEVs) coexpresses epithelial and mesenchymal markers and were first described as a "mixed tumors of the vagina." However, unlike mixed tumors of other organs, which are believed to originate from myoepithelial cells, SCEVs neither immunohistochemically nor ultrastructurally show features of myoepithelial cells. The present expanded battery of immunohistochemical stains is presented on this rare tumor, including cytokeratin AE1/AE3, CK7, CK20, S100 protein, epithelial membrane antigen, alpha-smooth muscle actin, desmin, CD34, CD99, Bcl-2, vimentin, estrogen and progesterone receptors, and Ki-67. There was minimal expression of alpha-smooth muscle actin and negative staining with S100 protein, with coexpression of cytokeratins and vimentin and expression of estrogen and progesterone receptors, as previously reported in SCEVs. In addition, diffuse expression of CD34, CD99, and Bcl-2 immunohistochemical stains was found, which has not previously been reported. The coexpression of CD34, CD99, and Bcl-2 in SCEVs is consistent with its origin from a primitive/progenitor cell population.