Reduction of immunosuppression for transplant-associated skin cancer: thresholds and risks.

BACKGROUND: Although evidence supports the efficacy of reducing immunosuppression for transplant-associated skin cancer, clinical thresholds for and risks associated with reduction are not well defined. OBJECTIVES: In this study, experienced transplant physicians were surveyed regarding appropriate thresholds for consideration of reduction of immunosuppression and the likelihood of rejection and allograft compromise associated with various levels of reduction. PATIENTS AND METHODS: Fifty-two transplant physicians reviewed 13 hypothetical patient scenarios with graduated morbidity and mortality risk and provided opinions on the degree of reduction of immunosuppression that was warranted and the risks associated with various degrees of reduction. RESULTS: Renal, liver and cardiac transplant physicians generally concurred on the level of reduction of immunosuppression warranted by various degrees of skin cancer. As morbidity and mortality from skin cancer increased, physicians were more likely to accept risk to allograft function from more aggressive reduction. CONCLUSIONS: Reduction of immunosuppression is considered a reasonable adjuvant strategy in recipients of solid organ transplants who have substantial morbidity and mortality risk from skin cancer. Physicians are willing to accept an increased risk of allograft compromise when confronted by severe or extensive skin cancer. Further research is needed to define the precise correlation among levels of reduction of immunosuppression, therapeutic efficacy, and concomitant risks.

Pilar leiomyoma: a case report and review of the literature.

Pilar leiomyoma is a benign smooth muscle tumor arising from the arrectores pili muscles associated with the hair follicles of the skin. The multiple biopsies and pathological consultations needed to obtain a diagnosis attest to the rarity of the disease and the difficult histological picture, which often requires an expert pathological consultation. Although a benign soft-tissue tumor, pilar leiomyoma often requires therapeutic intervention to alleviate pain or sensitivity. Medical therapy has been tried with some success to improve the pain and discomfort. The only potentially curative option, however, remains surgical excision. Although complete surgical excision may not be attained, it may achieve substantial symptomatic improvement.

Periocular deep cutaneous basal cell carcinoma.

PURPOSE: The distinction between benign and malignant cutaneous periocular lesions can be difficult, as the clinical history and appearance are often quite similar. When present, typical cutaneous changes are often helpful in distinguishing between benign and malignant neoplasms. However, when tumors lack characteristic epidermal change, histopathologic examination may be necessary to confirm the diagnosis. The authors present their experience in the evaluation and management of two patients with periocular basal cell carcinoma who were initially diagnosed as having benign cysts. METHODS: The case records for two patients with periocular basal cell carcinoma were reviewed. Preoperative and postoperative photographs were available for comparison in one case. For each patient, the medical history, clinical presentation, histology, and surgical outcome were reviewed. RESULTS: In each case, the periocular mass was initially diagnosed as a benign process. Histopathologic examination following excisional biopsy established the diagnosis of basal cell carcinoma in both patients. Following biopsy, residual tumor was removed by the Mohs micrographic technique. There were no surgical complications and no tumor recurrences during follow-up of one year and eight years. CONCLUSIONS: Periocular basal cell carcinoma may mimic benign cystic lesions of the central face. Incorrect diagnosis may result in delayed or inappropriate therapy, or failure to submit seemingly benign lesions for histopathologic examination. Definitive treatment requires complete excision with histologic margin control.

Vulvar basal cell carcinoma.

BACKGROUND: Vulvar basal cell carcinoma is a rare neoplasm that often displays aggressive biologic behavior. Recurrence after simple excision is common, and metastases have been reported. Early diagnosis is essential and rests upon histopathologic examination of biopsy specimens, since the clinical appearance of these neoplasms may be deceptively innocent. CASE: A 65-year-old woman was seen with a nonhealing skin lesion on the right vulva. Physical examination revealed a 0.3 X 0.3 cm crusted papule on the right labium majus. A saucerization biopsy was performed. Histopathologic examination of the biopsy specimen revealed basal cell carcinoma. The patient underwent Mohs micrographic excision of the tumor, the total extent of which measured 0.9 X 1.8 cm. CONCLUSION: Vulvar basal cell carcinoma is a rare but important consideration in the differential diagnosis of cutaneous vulvar lesions. Accurate diagnosis depends upon a high index of suspicion, biopsy, and histopathologic examination. Mohs micrographic excision is the treatment of choice.

Cutaneous squamous cell carcinoma metastatic to the parotid gland in a transplant patient.

Parotid metastases from cutaneous neoplasms are rare and have a relatively good prognosis if limited to the lymph nodes. When extension beyond the lymph nodes occurs, prognosis is grave. It has also been reported that transplant patients have a higher incidence of cutaneous carcinoma, which tends to be more aggressive. We report a case of an aggressive squamous cell carcinoma metastatic to the parotid gland in a liver transplant patient. The literature pertaining to parotid area metastasis and cancer in transplant recipients is reviewed. We conclude that clinicians should have a higher clinical index of suspicion for cutaneous lesions in transplant patients and that cutaneous lesions at risk for metastasis to the parotid should be treated more aggressively.

Cutaneous keratocyst in naevoid basal cell carcinoma syndrome.

We report a patient with naevoid basal cell carcinoma syndrome (NBCCS) who developed cutaneous cysts on her digits. Histological examination of one of the cysts showed a festooned lining epithelium maturing without a granular cell layer, similar to that of the jaw keratocyst characteristic of this syndrome. This type of cutaneous keratocyst has been reported only once previously. in two patients with NBCCS.

Cutaneous pseudolymphoma: an unusual presentation of a deep subcutaneous thigh mass.

Cutaneous pseudolymphoma is considered to be a benign (reactive) cutaneous lymphoid infiltrate; the term designates reactive diseases of the skin that histologically mimic cutaneous lymphoma. We report a case in which a 63-year-old female presented with a 5-month history of a progressive skin eruption and an enlarging subcutaneous mass following a presumed insect bite. Excisional biopsy showed this to be a pseudolymphoma extending from the dermis into the subcutaneous tissue. A number of pathological features that distinguish pseudolymphoma from cutaneous lymphoma, including histology, immunophenotype, and immunogenotype, are reviewed. The case herein challenges previous beliefs that pseudolymphoma is confined to cutaneous involvement and indicates that the process can involve deeper tissues. The final criterion for distinguishing benign from reactive processes is biological behavior. Since the depth of invasion in cutaneous pseudolymphoma has not previously been appreciated, the patient will need to be carefully examined periodically until the biological behavior of the process has been determined.

Expression pattern of the bullous pemphigoid-180 antigen in normal and neoplastic epithelia.

BP180 is a 180kDa hemidesmosomal protein recognized by bullous pemphigoid (BP) and pemphigoid gestationis (PG) autoantibodies. Recent cloning and sequence analysis performed by our laboratory have revealed that BP180 is a transmembrane protein with a long extracellular collagen-like region. A rabbit polyclonal antibody has been generated against a recombinant protein, designated GST-N delta 1, containing a segment of the BP180 ectodomain. The resulting antiserum, RN delta 1A, was shown to specifically react with BP180 on immunoblot, and labelled the extracellular region of the epidermal hemidesmosome on immunoelectron microscopy. A panel of normal and neoplastic human tissues were analysed by indirect immunofluorescence (IF) and RN delta 1A, to determine the distribution of BP180. A total of nine basal cell carcinomas (BCCs) and four squamous cell carcinomas (SCCs) of the skin were also studied. Intense IF staining was seen along the basement membrane zone (BMZ) of the epidermis, hair follicles, and the periphery of sebaceous gland lobules. The sebaceous lobules showed more intense staining in areas close to the duct. The epithelial BMZ of the following tissues also reacted with RN delta 1A: cornea, ocular conjunctiva, buccal mucosa, upper oesophagus, placenta (amnion placentum), umbilical cord and transitional epithelium of the bladder. The epithelium of the jejunum and ovary failed to react with RN delta 1A. Staining of the BCCs and SCCs was variable. Five of six nodular BCCs showed some anti-BP180 staining at the tumour-stromal interface, although the level of staining was less intense than that observed in the overlying normal epidermis. All three morphoeic BCCs analysed in this investigation did not show any staining with RN delta 1A. Three of four SCCs showed weak staining at the tumour-stromal interface. Thus, the tissue distribution of BP180 paralleled that of hemidesmosomes, and expression of this protein was found to be decreased or absent in cutaneous neoplasms.

Role of human papillomavirus in cutaneous oncogenesis.

There is a strong association between the human papillomavirus and cutaneous squamous cell carcinoma. If this association was merely random, one would expect an equal distribution of human papillomavirus types among affected individuals. However, only specific types of human papillomavirus are consistently found in cutaneous and genital squamous cell carcinomas. Immunosuppressed individuals clearly have a much higher incidence of cutaneous carcinomas. Immunosuppression, either local or systemic, not only decreases immune surveillance but may also dictate the amount and type of virus each individual may carry. Epidermodysplasia verruciformis and other rare hereditary disorders that combine specific immune defects and an increased incidence of malignancy are very useful models that clearly fulfill a multistep theory of oncogenesis. The precise mechanism of oncogenesis in these select human papillomavirus types is not yet fully understood. Intracellular interactions with the recently described tumor suppressor proteins may prove to be the primary site of action of these oncogenic viruses. Environmental cocarcinogens and activation of oncogenes are clearly important if not essential factors in human papillomavirus-associated tumors. As our knowledge and understanding of malignant transformation grows, it becomes apparent that this is a complex multistep process.

Instrumentation in dermatologic surgery.

The practice of dermatology has changed greatly over the past 2 decades. This change has been partly characterized by an increased emphasis on the surgical approach to the diagnosis and treatment of skin disease. This new emphasis within the practice of dermatology necessarily alters the basic equipment and instrumentation needed to begin and maintain a dermatology practice in the 1990s. The following article is intended to provide the interested reader with a sound and rational basis for selection of surgical instruments to incorporate into his or her particular level of surgical practice.

Instrumentation for the dermatologic surgeon.

Because dermatologic surgery continues to enjoy widespread popularity as a leading treatment modality for skin disease, the skill and training of the surgeon are critical to patient care. Equally important, however, are the tools the surgeon uses to perform each particular procedure. Surgical instrumentation has often been a confusing subject for the novice surgeon, one in which personal preference often outweighs technical considerations. This article will present the advantages and short-comings of several instruments that constitute the basic armamentarium of the dermatologic surgeon.

Herpes simplex virus shedding in genital secretions.

Nine women and eight men with a history of genital herpes had cultures taken for 60 consecutive days to assess the frequency and duration of viral shedding in the absence of symptoms. Daily self-obtained specimens (cervical-vaginal swabs from women and urethral swabs from men) were submitted for viral isolation. Five of 972 samples were found to contain infectious virus; two of the positive specimens correlated with overt disease. The other three positive cultures, two from the same individual, were not clearly associated with a genital infection. Thus, the overall frequency of asymptomatic viral shedding was 0.31% and occurred in two of 17 individuals. It is concluded that prolonged continuous sampling may be necessary to assess the risk of asymptomatic shedding. Infectious virus was not present in the genital secretions of most individuals (15 of 17) in the absence of a lesion, even when cultured on a daily basis for 60 days.