A case of epidermolysis bullosa acquisita with unusual clinical features.

A 30-year-old woman developed epidermolysis bullosa acquisita (EBA) with unusual clinical features. Initially, only prurigo-like nodules were seen, which lasted for > 2 years and then blisters appeared. Eruptions resembling the rash in systemic lupus erythematosus were also seen on the face. Histopathological examination of a biopsy specimen revealed subepidermal blisters containing eosinophils and neutrophils. Direct immunofluorescence examination, indirect immunofluorescence examination using skin split with 1 mol/L sodium chloride, and immunoblotting analysis using extracts of normal human dermis gave results compatible with EBA. This case shows that EBA can present with nodular lesions as seen in pemphigoid nodularis or epidermolysis bullosa pruriginosa.

Genetic and epigenetic alterations in the differential diagnosis of malignant melanoma and spitzoid lesion.

BACKGROUND: The histopathological differentiation of malignant melanoma and Spitz naevus often presents diagnostic problems. OBJECTIVES: We aimed to find out applicable diagnostic parameters other than routine pathology. METHODS: The cases included conventional melanomas and Spitz naevi as well as atypical spitzoid lesions that had posed diagnostic difficulties. We examined hotspots of mutation in the BRAF, NRAS and HRAS genes by polymerase chain reaction-based direct sequencing. We also analysed DNA copy number aberrations and the methylation of CpG sequences in several cancer-related genes by utilizing a novel methylation-specific multiplex ligation-dependent probe amplification method. RESULTS: Twenty three of 24 conventional melanomas showed at least one of the genetic and epigenetic alterations examined, although one acral melanoma did not show any alteration. By sharp contrast, 12 Spitz naevi with an unambiguous histopathology showed no or few chromosomal aberrations, no oncogene mutations and no methylation of CpG sequences. Of the 16 ambiguous spitzoid lesions, most of which were designated atypical Spitz tumour by one of the authors, all but one showed no mutations, no methylations and few copy number aberrations. However, three tumours showed copy number loss of the cyclin-dependent kinase inhibitor 2A gene (CDKN2A), an alteration observed frequently in melanomas but not found in conventional Spitz naevi. These results show that, although most atypical Spitz tumours do not differ from conventional Spitz naevi showing virtually no genetic and epigenetic aberrations, some cases may have chromosomal aberrations that include copy number loss of the CDKN2A gene. CONCLUSIONS: Genetic and epigenetic analyses may be useful as an additional diagnostic tool to distinguish between melanoma and Spitz naevus, and may help to define subgroups in atypical Spitz tumours.

Staphylococcal scalded skin syndrome with prosthetic valve endocarditis.

We report staphylococcal scalded skin syndrome (SSSS) in a 67-year-old man. He showed diffuse erythema with erosion on his face and erythema with giant desquamation on his neck, axilla, genitalia, chest and abdomen 39 days after a coronary artery bypass graft and aortic valve replacement. He died of cardiac rupture caused by myocardial necrosis, and autopsy findings demonstrated prosthetic valve endocarditis due to a strain of exfoliative toxin-B producing methicillin-resistant Staphylococcus aureus. To the best of our knowledge, this is the first case of SSSS caused by prosthetic valve endocarditis.

Sebaceous carcinoma arising on actinic keratosis.

We report two cases of sebaceous carcinoma arising on actinic keratosis. The first patient, a 75-year-old female, had a granuloma pyogenicum-like tumor on her left temple, and the second patient, an 81-year-old female, developed a tumor with erythema on her left cheek. In both cases, histopathological examination revealed findings typical of sebaceous carcinoma in the center of the tumors, and in the periphery, actinic elastosis and intraepidermal proliferation of squamoid atypical cells without vacuolation was observed. Immunohistochemical examinations using six antibodies also revealed that neoplastic cells of both cases demonstrated sebaceous differentiation. These cases suggest that extraocular sebaceous carcinoma may arise from actinic keratosis.

E-cadherin expression in skin tumors using an AMeX immunohistostaining method.

The AMeX (acetone-methylbenzoate-xylene) method results in good preservation of tissue and morphological details, almost equivalent to that of routinely processed formalin-fixed and paraffin-embedded tissue specimens, and of antigenicity equivalent to that of fresh frozen tissue specimens. It has been reported that the expression of the cell-cell adhesion molecule E-cadherin is often decreased in some types of carcinomas. A decrease in E-cadherin expression is associated with the invasive or metastatic potential of tumor cells. We immunohistochemically examined the expression of E-cadherin with anti-E-cadherin monoclonal antibody in various skin tumors (25 basal cell carcinomas, 11 squamous cell carcinomas, 9 keratoacanthomas, and 11 Bowen's disease) using the AMeX method and found that this method preserved antigenicity well without pretreatment. E-cadherin expression was decreased in 18.2% of squamous cell carcinomas and 33.3% of keratoacanthomas. On the other hand, it was preserved in almost all Bowen's disease and basal cell carcinomas. From the results of our study, we suggest that Bowen's disease and basal cell carcinoma do not have much metastatic potential due to retention of high levels of E-cadherin expression. We hope to apply the AMeX method to other immunohistochemical examinations because this is a very useful staining method.

Localization of the Netherton syndrome gene to chromosome 5q32, by linkage analysis and homozygosity mapping.

Netherton syndrome (NS [MIM 256500]) is a rare and severe autosomal recessive disorder characterized by congenital ichthyosis, a specific hair-shaft defect (trichorrhexis invaginata), and atopic manifestations. Infants with this syndrome often fail to thrive; life-threatening complications result in high postnatal mortality. We report the assignment of the NS gene to chromosome 5q32, by linkage analysis and homozygosity mapping in 20 families affected with NS. Significant evidence for linkage (maximum multipoint LOD score 10.11) between markers D5S2017 and D5S413 was obtained, with no evidence for locus heterogeneity. Analysis of critical recombinants mapped the NS locus between markers D5S463 and D5S2013, within an <3.5-cM genetic interval. The NS locus is telomeric to the cytokine gene cluster in 5q31. The five known genes encoding casein kinase Ialpha, the alpha subunit of retinal rod cGMP phosphodiesterase, the regulator of mitotic-spindle assembly, adrenergic receptor beta2, and the diastrophic dysplasia sulfate-transporter gene, as well as the 38 expressed-sequence tags mapped within the critical region, are not obvious candidates. Our study is the first step toward the positional cloning of the NS gene. This finding promises a better understanding of the molecular mechanisms that control epidermal differentiation and immunity.

Netherton's syndrome in siblings.

We report the perinatal presentation and evolution of Netherton's syndrome in siblings. The first patient, a female infant, presented with asphyxia at birth due to aspiration of desquamated scale, non-bullous ichthyosiform erythroderma, and hypernatraemic dehydration which she had for several days. Subsequently, she failed to thrive, with recurrent bacterial infections until 5 months of age, and very high serum IgE levels (1200 U/mL). Trichorrhexis invaginata and pili torti were identified at 18 months. The second patient was the younger brother of the first. Hydramnios and hyperechoic material in the amniotic fluid were observed by ultrasound at 35 weeks gestation, and he was delivered by elective Caesarian section at 40 weeks. At birth, no hair abnormality was demonstrated but, like his sister, his body was covered with thick caseous material, and he was erythrodermic. He failed to thrive, but serum IgE levels were normal until 5 months of age. Typical trichorrhexis invaginata was not observed until 7 months of age. Thus, the hair abnormality and high serum IgE levels in Netherton's syndrome appear late relative to the ichthyosiform erythroderma.

An immunohistochemical study of E-cadherin expression in human squamous cell carcinoma of the skin: relationship between decreased expression of E-cadherin in the primary lesion and regional lymph node metastasis.

E-cadherin is a Ca(2+)-dependent, intercellular adhesion molecule that is specifically expressed in epithelial tissues and is essential for maintaining intercellular connections. It has been reported that E-cadherin expression of tumor cells is often decreased in some types of metastasizing carcinomas as compared with those without metastasis. We immunohistochemically examined the expression of E-cadherin with anti-E-cadherin monoclonal antibody and compared primary lesions of human squamous cell carcinoma of the skin (SCC) with regional lymph node metastasis to those without regional lymph node metastasis. Tumor samples from fifty-five cases of SCC (32 cases of SCC without metastasis and 23 cases with metastasis) were formalin-fixed, paraffin-embedded, and examined. E-cadherin was reduced or absent in 39 (70.9%) out of 55 cases of SCC, and in 21 (91.3%) of 23 cases with regional lymph node metastasis. Our results suggest that the decreased expression of E-cadherin in the primary lesion is correlated with regional lymph node metastasis in SCC and that it is more frequently correlated with well-differentiated than with poorly differentiated SCC. E-cadherin may be useful as a marker for metastatic potential in well-differentiated SCC.

Two cases of cutaneous apocrine ductal carcinoma of the axilla. Case report and review of the literature.

We report 2 cases of cutaneous apocrine ductal carcinoma (CADC) of the axilla in a 64- and a 54-year-old male. Histological examination revealed 2 solid, ductal and glandular tumors with decapitation secretion. Tumor cells showed cellular and nuclear atypism, and infiltrative growth of tumor cell nests was also observed. Although there were no characteristic features of extramammary Paget's disease on the overlying skin, case 1 exhibited a typical Paget's phenomenon. We concluded that the Paget's phenomenon of case 1 was a result of upward extension of the tumor in the dermis. The neoplastic cells of both cases were immunohistochemically positive for gross cystic disease fluid protein, lysozyme, CD15 and carcinoembryonic antigen but negative for S-100 protein. Based on these findings, we concluded that these tumors were cutaneous apocrine ductal carcinomas. There was no evidence of tumor remnants in the axilla, and the patients have shown no signs of local recurrence or metastasis. We also reviewed the literature and summarize here the clinical features of CADC.

CD56-positive (nasal-type T/NK cell) lymphoma arising on the skin. Report of two cases and review of the literature.

Several authors have reported cases of patients with malignant lymphoma with unique characteristics, designated nasal-type T/NK cell lymphoma, which expresses the natural killer (NK) cell marker and shows frequent extra-nodal involvement and poor prognosis. We report 2 cases of this type of lymphoma which were CD56-positive and showed a histopathologically angiocentric pattern with cutaneous and subcutaneous tumorous lesions. Patient 1 had extensive invasion of skin, underlying skeletal muscle, spleen and bone marrow, and died of sepsis 34 months after onset. Patient 2 had multiple subcutaneous nodules and invasion to mammary gland, lung, lymph node and spleen at the time of her first visit. She died of a rapid invasion of lymphoma cells to the liver 5 months after onset. Both patients showed similar immunophenotypes of tumor cells (CD2+, CD3-, CD4-, CD8-, CD20-, CD56+) and germ line configuration of the heavy chain of immunoglobulin (JH), T-cell receptor C beta-1 subunit DNA and T-cell receptor J gamma subunit DNA. Epstein-Barr virus early regions RNA was demonstrated in the nuclei of tumor cells of both patients with in situ hybridization. The histopathological examination of the skin lesions of both patients revealed the features of angiocentric lymphoma. The detection of CD56 in the tumor cells of cutaneous lymphomas should be routinely performed for the early diagnosis of this type of lymphoma with extremely poor prognosis.

Ocular sebaceous carcinoma. Two unusual cases, and their histochemical and immunohistochemical findings.

BACKGROUND: Since sebaceous carcinomas with a poor prognosis arising from the cutaneous adnexae of the eyelid are sometimes difficult to differentiate from squamous cell carcinoma or basal cell carcinoma on clinical and histopathological findings, definite differentiation between these tumors by additional methods is necessary. OBJECTIVE AND METHODS: To clarify the usefulness of histochemical and immunohistochemical examinations in diagnosing ocular sebaceous carcinoma, histochemical and immunohistochemical studies were carried out on the 2 patients with unusual ocular sebaceous carcinoma. RESULTS: The findings of ocular sebaceous carcinoma, at least in our 2 cases, were almost identical to those of extraocular sebaceous carcinoma. CONCLUSION: Immunohistochemical detection of human milk fat globules subclass 1, human milk fat globules subclass 2, and breast carcinoma-associated antigen 225 was useful for diagnosing ocular sebaceous carcinomas as well as extraocular ones.

An immunohistochemical study of lysozyme, CD-15 (Leu M1), and gross cystic disease fluid protein-15 in various skin tumors. Assessment of the specificity and sensitivity of markers of apocrine differentiation.

We investigated immunohistochemically the localization of lysozyme and Leu M1 in normal skin, 76 cases of benign sweat gland tumors, 28 cases of malignant sweat gland tumors, 23 cases of extramammary Paget's disease, 7 cases of sebaceous carcinoma, 6 cases of malignant trichilemmoma, 10 cases of squamous cell carcinoma, and 10 cases of basal cell carcinoma and compared the results with those for gross cystic disease fluid protein (GCDFP)-15 to assess the sensitivity and specificity of our assay conditions for apocrine differentiation. Normal apocrine glands were stained with all three antibodies, while eccrine glands were positive only for GCDFP-15, and other portions of normal skin were not stained with any of the antibodies used. In neoplastic tissue thought to be from apocrine tumors, antibodies raised against lysozyme and GCDFP-15 had a greater specificity (100%) for apocrine differentiation, while Leu M1 had a greater sensitivity (88%). Tissues that were stained with two or three of these antibodies appeared to exhibit apocrine differentiation. In the tumors examined, the specificity for apocrine differentiation was 100% and the sensitivity for such differentiation was 92% by these criteria. According to these criteria, some cases of syringocystadenoma papilliferum, primary mucinous carcinoma of the skin, and extramammary Paget's disease with underlying adenocarcinoma showed apocrine differentiation.

Assessment of cellular proliferation of sebaceous neoplasms by AgNOR counts and immunohistochemical demonstrations of PCNA and Ki-67.

We assessed cellular proliferation of sebaceous neoplasms by AgNOR counts and the immunohistochemical demonstration of proliferating cell nuclear antigen (PCNA) and Ki-67, using formalin-fixed and paraffin-embedded tissue specimens. We used three categories of sebaceous neoplasms: four cases of sebaceoma, three cases of basal cell carcinoma with sebaceous differentiation (BCSD), and seven cases of sebaceous carcinoma (SC). Significant differences were noted between SC and non-SC tumors (sebaceoma and BCSD) in AgNOR counts and semi-quantitative grading of PCNA and Ki-67 labelling indices (P < 0.01). When a cut-off value of 6 was chosen, the AgNOR value discriminated SC from non-SC tumors with high specificity and sensitivity. When a cut-off value of 25% was chosen, PCNA and Ki-67 labelling indices also discriminated between these tumors. Significant differences were not observed between sebaceoma and BCSD with PCNA and Ki-67 labelling indices. AgNOR counts of BCSD were a little higher than those of sebaceoma, but the number of cases was too small to perform statistical assessment. We consider AgNOR counts and semi-quantitative grading of PCNA and Ki-67 labelling indices to be useful in differentiating SC from BCSD and sebaceoma.

Assessment of cellular proliferation of eccrine acrospiromas and eccrine sweat gland carcinomas by AgNOR counting and immunohistochemical demonstration of proliferating cell nuclear antigen (PCNA) and Ki-67.

Argyrophil nucleolar organizer regions (AgNORs) were counted and immunostaining using antibodies raised against proliferating cell nuclear antigen (PCNA) and Ki-67 was carried out on eccrine acrospiroma and eccrine sweat gland carcinoma, to determine the malignant potential and prognosis of these tumours. Formalin-fixed and paraffin-embedded tissue specimens surgically excised from 25 patients with eccrine sweat gland carcinoma (20 cases of eccrine porocarcinoma, four cases of ductal sweat gland carcinoma and one case of malignant clear cell hidradenoma) and 25 patients with eccrine acrospiroma (16 cases of eccrine poroma, four cases of poroid hidradenoma and five cases of clear cell hidradenoma) were used. PCNA and Ki-67 labelling indices were categorized semiquantitatively into four grades. Significant differences were noted between eccrine sweat gland carcinoma and eccrine acrospiroma with these three methods (P < 0.01). When a cut-off of 5 was chosen, the AgNOR value distinguished eccrine sweat gland carcinoma from eccrine acrospiroma with high specificity and sensitivity. Moreover, we compared the results of these three methods between stages 1 or 2 (17 cases) and stage 3 (eight cases) eccrine sweat gland carcinomas, and no significant differences were observed. From these findings, these three methods are useful in discriminating malignant from benign lesions of eccrine tumours, but have no value in estimating the aggressiveness of eccrine sweat gland carcinomas.

A case of ductal sweat gland carcinoma connected to syringocystadenoma papilliferum arising in nevus sebaceus.

We report a case of a tumor arising in the preauricular region in a 50-year-old woman. The histopathological findings revealed it to be a ductal sweat gland carcinoma connected to a syringocystadenoma papilliferum (SCAP) arising in a nevus sebaceus. Mucinous stroma, considered to be deposition of hyaluronic acid, was also observed in the ductal carcinoma portion. The immunohistochemical and ultrastructural findings in the ductal carcinoma were compared with those in the SCAP. The proliferating cell nuclear antigen labeling index of the cells in the ductal carcinoma was higher than that of those in the SCAP. Both the ductal sweat gland carcinoma and SCAP showed findings compatible with the ductal segment of a sweat gland.

A patient with rhabdomyosarcoma and clear cell sarcoma of the skin.

We describe a patient with rhabdomyosarcoma of the posterior cervical region and clear cell sarcoma on the occipital scalp. These two tumors later metastasized to distant skin. We differentiated these tumors by histopathologic, histochemical, immunohistochemical, and ultrastructural findings. Cells of the posterior cervical tumor showed differentiation toward striated muscle, whereas those of the occipital tumor showed findings compatible with melanocytic differentiation.

Usefulness of the AMeX method for immunostaining with antikeratin antibodies.

We performed an immunohistochemical study with 11 antikeratin antibodies using the newly developed AMeX (acetone-methylbenzoate-xylene) tissue processing method. Specimens processed with this method showed almost as good preservation and morphological detail as routinely processed, formalin-fixed and paraffin-embedded tissue specimens, and as good preservation of antigenicity as fresh frozen tissue specimens. Thus, we propose the wide use of this method in dermatology.

An immunohistochemical study of sebaceous carcinoma with anti-keratin monoclonal antibodies: comparison with other skin cancers.

Formalin-fixed and paraffin-embedded tissue specimens of six cases of extraocular sebaceous carcinoma were studied immunohistochemically with eight anti-keratin monoclonal antibodies, 34 beta B4, 35 beta H11, Ks13.1, Ks19.1, PKK1, LP34, KL1 and AE1. The staining patterns of sebaceous carcinoma were compared with those of normal sebaceous glands and other skin cancers which should be distinguished from sebaceous carcinoma histopathologically. The other skin cancers compared were eccrine porocarcinoma, malignant clear cell hidradenoma, extramammary Paget's disease with underlying adenocarcinoma, malignant trichilemmoma, and squamous cell carcinoma. Most cases of sebaceous carcinoma were stained with 35 beta H11, Ks19.1, LP34, KL1 and AE1, while normal sebaceous glands were positive only with 35 beta H11, LP34, KL1 and AE1. By immunostaining, sebaceous carcinoma was distinguishable from extramammary Paget's disease with underlying adenocarcinoma, squamous cell carcinoma, malignant trichilemmoma, and eccrine porocarcinoma, but was not clearly distinguishable from malignant clear cell hidradenoma. These findings demonstrate that sebaceous carcinoma shows positive reactions with antibodies to simple epithelial keratin, probably as a result of neoplastic transformation, and that immunohistochemical examination using anti-keratin monoclonal antibodies is useful in distinguishing sebaceous carcinoma from several other skin cancers.