Cutaneous Histiocytic Sarcoma With Cellular Cannibalism.

Cutaneous histiocytic sarcoma (HS) is a rare malignant tumor. An 82-year-old woman presented with a 4 × 2-cm irregular-shaped red nodule on the left posterior scalp. A biopsy specimen revealed sheets of pleomorphic atypical cells in the dermis and subcutis. A diagnosis of HS was made based on the results of a panel of immunohistochemical stains that revealed positivity of leukocyte common antigen, CD4, CD163, and HLA-DR. At the time of resection, the tumor grew rapidly to 12 × 6.5 × 5 cm in size in 2 months. The resected tumor comprised round, oval, plasmacytoid, and spindled cells. Signet-ring cell type tumor cells were also observed. The histiocytic nature of HS was confirmed owing to the presence of cellular cannibalism, emperipolesis, Langhans giant cell-like cells, Touton giant cell-like cells, foreign-body giant cell-like cells, and hemosiderin laden cells. In some foci, a storiform pattern and fascicular pattern were occasionally observed. Local recurrence occurred shortly after resection. Subsequent radiation therapy showed insufficient effectiveness. It is challenging to make a diagnosis of HS without performing immunohistochemical studies; however, a variety of histiocytic features confirmed in hematoxylin and eosin-stained sections may suggest HS.

The rate of facial nerve dysfunction and time to recovery after intraparotid and extraparotid facial nerve exposure and protection in head and neck cutaneous tumor surgery.

BACKGROUND: Most patients with head and neck skin tumors present with normal facial nerve function. A common treatment strategy for these patients is facial nerve preservation surgery, although the degree to which the nerve is successfully preserved is still unclear. Data on the incidence and recovery of facial nerve dysfunction are woefully lacking in the field of dermato-oncology. METHODS: In 23 patients with normal preoperative facial nerve function, we retrospectively reviewed twenty-six head and neck surgical interventions that included facial nerve exposure and protection, focusing particularly on the differences in outcome between intraparotid and extraparotid exposure of the facial nerve branches. RESULTS: Eleven of the 26 cases (42.4%) developed transient paresis, but only one (3.8%) developed permanent paresis. Of 41 dissected facial nerve branches, 14 developed transient paresis (34.1%) and one, a marginal mandibular branch, developed permanent paresis (2.4%). The branches most susceptible to developing paresis were the temporal (4/6 branches, 66.7%) and marginal mandibular branches (8/17 branches, 47.1%). Although the rate of paresis was higher, and ensuing recovery period slightly longer in the extraparotid dissection group compared to the intraparotid dissection group, there were no statistically significant differences between the two groups. The extraparotid and intraparotid rates of paresis were 48% (11/23 branches) and 21.1% (4/19 branches), respectively, P = 0.139; and the average recovery periods were 10.3 and 9.3 weeks, respectively, P = 0.64. CONCLUSIONS: The functional outcome, regardless of the different sites of facial nerve exposure, was almost always either complete facial nerve sparing or transient dysfunction that resolved within 6 months.

Hematopoietic stem cell transplantation in advanced cutaneous T-cell lymphoma.

We retrospectively reviewed data pertaining to five patients with cutaneous T-cell lymphoma (CTCL) who had received hematopoietic stem cell transplantation (HSCT) between 2004 and 2015 at Kurume University Hospital, along with their clinical data until March 2016. For patients with advanced CTCL eligible for HSCT, autologous HSCT was performed when they responded well to chemotherapy, and allogeneic HSCT was selected for patients with advanced mycosis fungoides (MF)/Sézary syndrome (SS) and CTCL other than MF/SS with poor chemosensitivity. Two patients (primary cutaneous anaplastic large cell lymphoma and primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma) who responded well to chemotherapy received autologous HSCT: one patient was alive in partial remission and the other died due to therapy-related acute myeloid leukemia without disease relapse. In the remaining three patients with MF or SS, allogeneic HSCT was performed. Although one patient with MF died due to disease progression, the remaining two patients were alive in complete remission. Although there were two deaths in this study, the outcomes were considered satisfactory.

Cutaneous surgery under local anesthesia in very elderly patients 90 years of age and older is as safe as in elderly patients ranging in age from 75 to 80 years old.

BACKGROUND: The number of very elderly patients who require surgery for cutaneous tumors is increasing. However, there is limited information on the safety of cutaneous surgery in such patients. METHODS: To evaluate the safety of cutaneous surgery in patients 90 years of age and older, we retrospectively reviewed the elderly patients who underwent surgery for cutaneous tumors under local anesthesia. Consecutive patients 90 years of age and older and 75-80 years old were included in the elderly group and the control group. RESULTS: The elderly and control groups included 104 and 106 patients, respectively. The mean age of the patients was 93.4 years (range, 90-101 years) in the elderly group and 77.4 years (range, 75-80 years) in the control group. The preoperative performance status was significantly worse in the elderly group than in the control group (P < 0.001). The surgical time was not significantly different between the two groups (P = 0.09). The occurrences of intraoperative and postoperative complications were not significantly different between the two groups (P = 0.19 and P = 0.07, respectively). CONCLUSIONS: The result of the present study indicates that cutaneous surgery for very elderly patients 90 years of age and older is as safe as for patients ranging in age from 75-80 years old.

A Rare Case of a Primary Cutaneous Desmoplastic Atypical Granular Cell Tumor.

Granular cell tumors are uncommon neoplasms and a small number of these neoplasms have been reported as showing malignant behavior. Here, we report a rare case of a solitary granular cell tumor that exhibited atypical histology, including an extensive desmoplastic stroma, in a 69-year-old woman. The surgical specimen revealed localized areas of spindling cells, areas of cellular pleomorphism, and p53 overexpression. Based on previously published criteria, we classified this lesion as an atypical granular cell tumor. To date, only very few case reports have documented this desmoplastic variant of granular cell tumor. However, the classifications of benign, atypical, and malignant granular cell tumors are still controversial, owing to an overlap of morphological and immunohistochemical profiles and lack of consistent histological criteria. Additionally, it is unknown whether the histology of the desmoplastic variant in the present case is significant for the classification of granular cell tumors and prediction of patient prognosis. Regardless of these issues, awareness, and close follow-up are required because of potential recurrences of this rare variant of granular cell tumor.

Correlation between vitiligo occurrence and clinical benefit in advanced melanoma patients treated with nivolumab: A multi-institutional retrospective study.

Vitiligo is occasionally seen in melanoma patients. Although several studies indicate a correlation between vitiligo occurrence and clinical response in melanoma patients receiving immunotherapy, most studies have included heterogeneous patient and treatment settings. The aim of this study is to investigate the correlation between the occurrence of vitiligo and clinical benefit of nivolumab treatment in advanced melanoma patients. We retrospectively reviewed unresectable stage III or IV melanoma patients treated with nivolumab. Of 35 melanoma patients treated with nivolumab, 25.7% (9/35) developed vitiligo during treatment. The time from the start of nivolumab treatment to occurrence of vitiligo ranged 2-9 months (mean, 5.2). Of nine patients who developed vitiligo, two (22.2%) had a complete response to nivolumab and two (22.2%) had a partial response. The objective response rate was significantly higher in patients with vitiligo than in patients without vitiligo (4/9 [44.4%] vs 2/26 [7.7%]; P = 0.027). The mean time to vitiligo occurrence in patients achieving an objective response was significantly less than that in patients who showed no response (3.1 vs 6.8 months, P = 0.004). Vitiligo occurrence was significantly associated with prolonged progression-free and overall survival (hazard ratio, 0.24 and 0.16; 95% confidence interval, 0.11-0.55 and 0.03-0.79; P = 0.005, and 0.047, respectively). At the 20-week landmark analysis, however, vitiligo was not associated with a statistically significant overall survival benefit (P = 0.28). The occurrence of vitiligo during nivolumab treatment may be correlated with favorable clinical outcome.

Increased incidence of hypotension in elderly patients who underwent emergency airway management: an analysis of a multi-centre prospective observational study.

BACKGROUND: Although the number of elderly increases disproportionately throughout the industrialised nations and intubation-related cardiovascular compromise is associated with hospital mortality, no emergency medicine literature has reported the direction and magnitude of effect of advanced age on post-intubation hypotension. We seek to determine whether advanced age is associated with an increased rate of hypotension at airway management in emergency departments (EDs). METHODS: We conducted an analysis of a multi-centre prospective observational study of 13 Japanese EDs from April 2010 to March 2012. Inclusion criteria were all adult non-cardiac-arrest patients who underwent emergency intubation. We excluded patients in whom airway management was performed for shock or status asthmaticus as the principal indication. Patients were divided into two groups defined a priori: age ≥ 65 years old (elderly group) and age < 65 years old (younger group). The primary outcome measure was post-intubation hypotension in the ED. RESULTS: During the 24-month period, 4,043 subjects required emergency airway management at 13 EDs. Among these, the database recorded 3,872 intubations (capture rate 96%). Of 1,903 eligible patients, 975 patients were age ≥ 65 years (51%) and 928 patients were age < 65 years (49%). The elderly group had a significantly higher rate of post-intubation hypotension compared with the younger group [3% vs. 1%; unadjusted OR 2.7 (95% CI, 1.3-5.6); P = 0.005]. In a model controlling for potential confounders (sex, principal indication, method, medication used to intubate, multiple intubation attempts), advanced age had an adjusted OR for post-intubation hypotension of 2.6 (95% CI, 1.3-5.6; P = 0.01). CONCLUSIONS: In this large multi-centre study of ED patients who underwent emergent airway management, we found that elderly patients have a significantly higher risk of post-intubation hypotension. These data provide implications for the education and practice of ED airway management that may lead to better clinical outcomes and improved patient safety.

Emergency airway management in geriatric and younger patients: analysis of a multicenter prospective observational study.

OBJECTIVES: There is little information on geriatric emergency airway management. We sought to describe intubation practices and outcomes for emergency department (ED) geriatric and younger patients in Japan. METHOD: We formed the Japanese Emergency Airway Network, a consortium of 11 medical centers, and prospectively collected data on ED intubations between 2010 and 2011. All patients 18 years or older who underwent emergent airway management were included in our study. Patients were divided to into 2 groups: 18 to 64-year olds and 65 years or older. We present descriptive data as proportions with 95% confidence intervals (CI). RESULTS: The database recorded 3277 patients (capture rate 96%), and 3178 met the inclusion criteria. Of 3178 patients, 1844 (58%) were 65 years or older, 1334 (42%) were 18 to 64 years old, 809 (25%) were 80 years or older, and 407 (50%) of them were in the state of cardiac arrest. The geriatric group, compared to the younger group, had a higher success rate on the initial attempt (71% vs 64%; difference 7%; 95% CI 4%-10%;) and in 2 attempts (90% vs 88%; difference 3%; 95% CI 1%-5%) or less. There was no significant difference in the adverse event rates by age group (difference 0%; 95% CI -2% to 3%). CONCLUSION: In our multicenter study involving a large geriatric population, we found that geriatric patients were intubated with a higher success rate, compared to younger patients. These data provide implications for the geriatric ED airway practice that may lead to better patient-centered emergency care.