Primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in cutaneous melanoma: a clinical practice guideline.

Background: For patients who are diagnosed with early-stage cutaneous melanoma, the principal therapy is wide surgical excision of the primary tumour and assessment of lymph nodes. The purpose of the present guideline was to update the 2010 Cancer Care Ontario guideline on wide local excision margins and sentinel lymph node biopsy (slnb), including treatment of the positive sentinel node, for melanomas of the trunk, extremities, and head and neck. Methods: Using Ovid, the medline and embase electronic databases were systematically searched for systematic reviews and primary literature evaluating narrow compared with wide excision margins and the use of slnb for melanoma of the truck and extremities and of the head and neck. Search timelines ran from 2010 through week 25 of 2017. Results: Four systematic reviews were chosen for inclusion in the evidence base. Where systematic reviews were available, the search of the primary literature was conducted starting from the end date of the search in the reviews. Where systematic reviews were absent, the search for primary literature ran from 2010 forward. Of 1213 primary studies identified, 8 met the inclusion criteria. Two randomized controlled trials were used to inform the recommendation on completion lymph node dissection.Key updated recommendations include:■ Wide local excision margins should be 2 cm for melanomas of the trunk, extremities, and head and neck that exceed 2 mm in depth.■ slnb should be offered to patients with melanomas of the trunk, extremities, and head and neck that exceed 0.8 mm in depth.■ Patients with sentinel node metastasis should be considered for nodal observation with ultrasonography rather than for completion lymph node dissection. Conclusions: Recommendations for primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in patients with cutaneous melanoma have been updated based on the current literature.

Skin adnexal neoplasms--part 1: an approach to tumours of the pilosebaceous unit.

Skin adnexal neoplasms comprise a wide spectrum of benign and malignant tumours that exhibit morphological differentiation towards one or more types of adnexal structures found in normal skin. Most adnexal neoplasms are relatively uncommonly encountered in routine practice, and pathologists can recognise a limited number of frequently encountered tumours. In this review, the first of two, the normal histology of the skin adnexal structures is reviewed, and the histological features of selected but important benign and malignant tumours and tumour-like lesions of pilosebaceous origin discussed, with emphasis on the diagnostic approach and pitfalls in histological diagnosis.

Squamous cell carcinoma with rhabdoid phenotype and osteoclast-like giant cells in a renal-pancreas transplant recipient.

Squamous cell carcinoma (SCC) is the commonest non-melanotic malignant skin tumour encountered after solid-organ transplantation. In this setting it is associated with a worse prognosis than sun-damage-induced SCC. Rhabdoid cells and osteoclastic giant cells are infrequently seen in SCC. This case highlights the unusual occurrence of rhabdoid cells and osteoclastic giant cells in a post-transplant SCC.

Probable free radical effects on rat liver nuclei during early hepatocarcinogenesis with a choline-devoid low methionine diet.

Fischer-344 rats fed a choline-devoid diet show lipid peroxidation in the liver nuclei, beginning at 1 day, reaching a peak at 3 days, and subsequently declining by 35 days. Lipid peroxidation in the mitochondria was seen first at 3 days, increased to a maximum at 28 days, and decreased after 35 days to undetectable values at 49 days. Lipid peroxidation was found in both nuclear and mitochondrial fractions both before and after stripping of their outer membranes. No microsomal lipid peroxidation could be detected at any time up to 63 days. The animals fed the same diet supplemented with choline showed no lipid peroxidation in any liver fraction. Animals given CCl4 showed the expected lipid peroxidation in the microsomes but not in the nuclear fraction. The administration of the free radical trapping agent, N-tert-butyl-alpha-phenylnitrone, prevented completely or almost so, microsomal lipid peroxidation induced by CCl4 and nuclear lipid peroxidation in the animals fed the choline-devoid, low methionine diet. The genesis of free radicals in the livers of rats fed a choline-devoid diet is considered as a likely hypothesis for the observed lipid peroxidation. The lipid peroxidation in turn is considered to be closely related to the induction of liver cell death and to the production of alterations in DNA. The DNA alterations coupled with regenerative liver cell proliferation suggest an attractive hypothesis for the initiation of hepatocarcinogenesis in rats fed a choline-devoid diet.

My approach to superficial inflammatory dermatoses.

Superficial inflammatory dermatoses are very common and comprise a wide, complex variety of clinical conditions. Accurate histological diagnosis, although it can sometimes be difficult to establish, is essential for clinical management. Knowledge of the microanatomy of the skin is important to recognise the variable histological patterns of inflammatory skin diseases. This article reviews the non-vesiculobullous/pustular inflammatory superficial dermatoses based on the compartmental microanatomy of the skin.

Perianal apocrine adenocarcinoma arising in a benign apocrine adenoma; first case report and review of the literature.

Benign apocrine lesions have been described in the anogenital region, although according to the World Health Organisation convincing examples of anal apocrine adenocarcinomas have not been published. This report describes the case of an invasive apocrine adenocarcinoma arising in a benign adenoma in the perianal region of a 45 year old woman. The origin and invasiveness are supported by histological and immunohistochemical studies.

Eruptive tufted angiomas in a patient with Crohn's disease.

Angioblastoma is a rare, benign vascular tumour composed of undifferentiated mesenchymal cells with a tendency to form lumina. This entity was first described by Nakagawa in 1949 as angioblastoma, and Wilson Jones was the first to use the term "tufted angioma" in 1976. Tufted angiomas usually occur in infancy and spread slowly. This report describes lesions from the right side of the forehead, forearms, and thighs of a 24 year old man with a four year history of Crohn's disease, who was receiving infliximab in addition to long standing azathioprine and ciprofloxacillin. He developed numerous small itchy erythematous vascular appearing papules, which on histological examination resembled tufted angiomas, showing the classic "cannon ball" appearance. The lesions regressed within three months. This case may represent an eruptive acquired tufted angioma in which immunosuppression or drug induced modification of angiogenesis played a role in its development and regression. One previous case of eruptive tufted angioma has been reported in an immunosuppressed patient.

Primary pleural epithelioid haemangioendothelioma with metastases to the skin. A case report and literature review.

Epithelioid haemangioendothelioma (EHE) is a rare vascular tumour of intermediate behaviour. It can arise from various sites including the liver, spleen, pleura, or lung. Cutaneous EHE can be primary or secondary. This report describes the case of a 51 year old man who presented with a history of dry cough, shortness of breath, and pleural effusion, and who developed two cutaneous nodules in the anterior abdominal wall a few weeks later. He had a previous history of asbestos exposure. Computed tomography scan showed a left sided pleural effusion and nodular pleural mass. Histology of both the pleural and cutaneous lesions was compatible with EHE. Electron microscopic examination demonstrated the presence of Weibel-Palade bodies. The patient underwent elliptical excision of the metastatic cutaneous nodules after decortication of the primary pleural tumour and adjuvant treatment. A few reports have described metastasis of intrathoracic EHE to the skin. Despite treatment with interferon, the patient developed more cutaneous lesions two years after the initial diagnosis. Even though the tumour has the classic light histological and ultrastructural features of EHE, it behaved in an aggressive manner.

An origin of presumptive preneoplastic foci and nodules from hepatocytes in chemical carcinogenesis in rat liver.

The sites and times of appearance of preneoplastic foci in rat liver acinus during the first 11 days after initiation with diethylnitrosamine and promotion with 2-acetylaminofluorene plus partial hepatectomy was observed in three separate experiments. Foci appeared as alterations of hepatocytes followed by focal proliferation in each of the three zones before any ductular epithelial cell ('oval cell') proliferation. The dissociation between foci and 'oval cell proliferation' is strong evidence against a role of the latter in generating preneoplastic hepatocytes in hepatocellular carcinogenesis.

Cutaneous manifestations of thyroid cancer: a report of four cases and review of the literature.

Cutaneous metastases from thyroid carcinoma are rare. This report describes four cases of thyroid carcinoma metastatic to the skin. Two cases were medullary carcinoma and two were papillary thyroid carcinoma. In two cases, skin metastases were the presenting feature of the underlying thyroid carcinoma. Examination of the skin lesions by conventional light microscopy suggested the possibility of metastatic carcinoma and immunohistochemical tests confirmed the diagnosis. Subsequent investigations identified primary thyroid lesions. In two cases, the skin metastasis was the first evidence of the recurrence of known thyroid carcinoma. These cases identify a novel presentation of thyroid carcinoma.

Histopathological patterns of melanoma metastases in sentinel lymph nodes.

AIMS: Sentinel lymph node biopsy (SLNB) is an important component in the staging and treatment of cutaneous melanoma (CM). The medical literature provides only limited information regarding melanoma sentinel lymph node (SLN) histology. This report details the specific histological patterns of melanoma metastases in sentinel lymph nodes (SLNs) and highlights some key factors in evaluating SLNs for melanoma. METHODS: From 281 SLNB cases between June 1998 and May 2002, 79 consecutive cases of SLN biopsies positive for metastases from CM were retrospectively reviewed. The important characteristics of the SLNs and the metastatic foci are described. RESULTS: The median size of positive SLNs was 17 mm (range, 5-38). SLNs had a median of two metastatic foci (range, 1-11), with the largest foci being a median of 1.1 mm in size (range, 0.05-24). S-100 and HMB-45 staining was positive in 100% and 92% of the detected metastatic foci, respectively. The metastatic melanoma cells were epithelioid, spindled, and mixed in 86%, 5%, and 9% of cases. Metastatic foci were most often (86%) found in the subcapsular region of the SLN. Benign naevic cells were found coexisting in 14% of positive SLNs. CONCLUSIONS: Staining for S100 is more sensitive than HMB-45 (100% v 92%), but HMB-45 staining helped to distinguish benign naevic cells from melanoma. The subcapsular region was crucial in SLN evaluation, because it contained the metastases in 86% of cases. Evaluation of the subcapsular space should not be compromised by cautery artefacts or incomplete excision of the SLN.

Paraneoplastic limbic encephalitis in Hodgkin's disease.

BACKGROUND: Oat cell carcinoma of the lung is the most common cause of paraneoplastic limbic encephalitis. Association with other malignancies, in particular Hodgkin's disease, is very rare. CASE REPORT: This 23-year-old male presented with a six month history of progressive alteration in mental status, which consisted of insomnia, short-term memory loss, depression and cognitive impairment. Gadolinium MRI of the head showed intense bilateral contrast enhancement affecting the medial aspects of the temporal lobes in the region of the amygdala and hippocampus. The brain biopsy showed minimal neuronal loss with intense perivascular lymphocytic cuffing and microglial nodules. Polymerase chain reaction for herpes simplex and cytomegalovirus were negative. With prednisone treatment, the patient's neurologic status stabilized but did not improve. Four months later, he presented with left axillary lymphadenopathy. Lymph node biopsy was diagnostic of Hodgkin's disease. During the chemotherapy, his lymphadenopathy subsided and his neurologic and mental status improved. When seen last after completion of his chemotherapy, one year after presentation, he had resumed normal social activities and was enrolled in a university language course. CONCLUSION: This is the first reported case in the English literature of a biopsy proven paraneoplastic limbic encephalitis associated with Hodgkin's disease. Hodgkin's disease should be thought of as a possible cause of paraneoplastic limbic encephalitis in the appropriate clinical setting.

Extraskeletal Ewing sarcoma in a 77-year-old woman.

Extraskeletal Ewing sarcoma (EES) is a rare soft tissue tumor that is morphologically indistinguishable from Ewing sarcoma of bone. It is usually found in young people, but several cases have occurred in patients older than 50 years. The differential diagnoses include other small, blue round cell tumors (SBRCTs) and other members of the Ewing family of tumors such as the primitive neuroectodermal tumor. We present a case of EES in the left inguinal region of a 77-year-old woman. The tumor was distinguished from other SBRCTs by lack of immunoreactivity for epithelial, lymphoid, vascular, neuroendocrine, neural, histiocytic, and muscle markers. Primitive neuroectodermal tumor was excluded because of the lack of neural differentiation by histologic analysis, immunohistochemistry, and electron microscopy. Extraskeletal Ewing sarcoma was confirmed by characteristic features on histologic analysis, histochemistry, immunohistochemistry, and electron microscopy and by the presence of the t(11;22)(q24;q12) fusion transcript detected by reverse transcriptase-polymerase chain reaction. This case serves to remind the reader that EES is not a tumor that occurs exclusively in young patients.

Syringoid eccrine carcinoma: a clinicopathological and immunohistochemical study of four cases.

BACKGROUND: Syringoid eccrine carcinoma (SEC) is a rare malignant adnexal tumour with variable presentations. AIM: To examine the clinicopathological and immunohistochemical features of SEC. METHODS: Four cases were reviewed by three dermatopathologists and the immunohistochemical profile was examined using antibodies against CK5/6, CK7, CK14, CK20, LMWK, HMWK, EMA, mCEA, p63, ER, PR, AR, S-100 and Ber-EP4. RESULTS: The cases occurred in two men and two women, ranging in age from 61 to 87 years (mean 68.5). Two of the lesions were from the face and two from the trunk. All four lesions were composed of an atypical infiltrative mass with syringoma-like tadpole morphology with ductular differentiation and prominent desmoplasia. Three cases demonstrated perineural invasion and two had positive lymph node metastases. Immunostaining was variable. Immunohistochemistry positivity was as follows: three out of four cases were positive for CK5/6, CK7 (2/4), CK14 (1/3), CK20 (0/2), HMWK (0/2), LMWK (1/2), EMA (3/4), mCEA (4/4), p63 (2/3), ER (2/3), PR (1/2), AR (0/3), S-100 (0/3) and Ber-EP4 (2/2). CONCLUSION: SEC can present on the trunk and are not limited to the head and neck region. In addition to syringoma-like tadpole structures and glandular differentiation, these tumours can also exhibit squamoid and cribriform growth patterns. Immunostaining in SEC is variable and this variability is believed to stem from this tumour's ability to differentiate along multiple routes, including sweat secretory and/or ductal differentiation.

Primitive non-neural granular cell tumour with lymph node metastasis.

Primitive non-neural granular cell tumour (PNGCT) is a rare tumour of uncertain lineage. This report describes a case of PGNCT with lymph node metastasis. This is thought to be only the second reported case with lymph node involvement.

Non-melanocytic mimics of melanoma, part II: intradermal mimics.

Intradermal melanoma diagnosis poses a great deal of confusion on many occasions since it can mimic almost any tumour within the dermis. In part I, the different features of intraepidermal mimics were discussed. In this part, there is discussion of the clinical, cytomorphological and immunohistochemical features of intradermal mimics of melanoma and how to distinguish these conditions from melanoma. There is also a description of the ultrastructural features of some of these conditions that may help to distinguish melanoma from its mimics. It is hoped that this approach, together with part I of the non-melanocytic mimics of melanoma, will aid in better overall understanding of melanoma and its mimics.

Non-melanocytic mimics of melanoma: part I: intraepidermal mimics.

Melanoma comprises a wide range of cytological and architectural features histopathologically and hence can mimic many benign and malignant lesions of epithelial, mesenchymal and hematopoietic cell lines of differentiation. Therefore, analysis and close clinical, histological, histochemical and immunohistochemical correlation is vital in distinguishing challenging melanoma cases from their mimics. In this review, the different features of the benign, pre-malignant and malignant intraepidermal non-melanocytic tumours and tumour-like lesions that can closely mimic intraepidermal melanoma (melanoma in situ) are emphasised.