Alan S. Boyd

Cutaneous collision tumors. An analysis of 69 cases and review of the literature

The association of two different neoplasms in the same biopsy specimen is not uncommon and has been reported by numerous authors. Some associations may result from involvement of related cell types, however, most are serendipitous. Our study attempted to investigate the nature and types of contiguous or “collision” tumors seen in our dermatopathology service. A retrospective evaluation of ∼40,000 cutaneous biopsies was performed, yielding 69 examples of collision tumors. Excluded were biphasic lesions of the same cell type (e.g., basosquamous carcinomas or combined nevi). Results were as follows: The most common combinations included basal cell carcinoma and nevus (14), basal cell carcinoma and seborrheic keratosis (8), nevus and seborrheic keratosis (14), actinic keratosis and nevus (7), and basal cell carcinoma and neurofibroma (4). Adnexal tumors were found combined with other neoplasms in four patients and blue nevi were noted in three additional tumors. We believe that most of these represent the presence of two or more common lesions juxtaposed by coincidence. However, certain combinations are of similar cell lineages or contain a relatively uncommon tumor and may indicate a possible link between the different cell types.

Oestrogen receptor‐β expression in melanocytic lesions

Abstract:  Melanomas rarely occur before puberty, have a higher death rate for males, and tend to be more invasive during pregnancy. Prior to the discovery of a second oestrogen receptor (ERβ), studies with the initial oestrogen receptor, ERα, showed no obvious role for oestrogen in the pathophysiology of benign or malignant melanocytic lesions. To investigate the specific immunostaining patterns of ERα and ERβ, benign nevocytic nevi, dysplastic nevi with mild, moderate and severe cytological atypia, lentigo malignas and melanomas of varying depth (Clark) and thickness (Breslow) were studied. ERβ but not ERα was the predominant oestrogen receptor we found in all types of benign and malignant melanocytic lesions. The most intense ERβ immunostaining was seen in melanocytes in dysplastic nevi with severe cytological atypia and in lentigo malignas. ERβ expression levels also correlated with the malignant tumor microenvironment; i.e., melanocytes in proximity with keratinocytes>deeper dermal melanocytes in contact with stroma>minimally invasive melanomas>Clark Level III/IV or thick melanomas (Breslow). Discovery that ERβ expression varies in relation to the tumor microenvironment and increasing depth of invasion suggests its possible usefulness as a surrogate marker for neoplasia and prognosis in malignant melanoma.

PSORIASIS AND PREGNANCY: HORMONE AND IMMUNE SYSTEM INTERACTION

Background. Various hormonal states are known to be associated with the waxing and waning of psoriasis. Patients with psoriasis commonly experience changes in their cutaneous disease during pregnancy or post partum.

The effects of chronic sunscreen use on the histologic changes of dermatoheliosis

BACKGROUND Sunscreen application to the skin of hairless mice is effective in reversing the histologic changes associated with photoaging (solar elastosis, epidermal thickening, collagen depletion, glycosaminoglycan deposition). These reparative processes have not been studied in human beings. OBJECTIVE The aim of this study was to evaluate histologically the effects of daily application of a UVA/UVB sunscreen versus placebo. METHODS We examined 46 patients who were given either sunscreen or vehicle and asked to apply it daily for 24 months. Punch biopsy specimens were obtained from preauricular skin at 0, 12, and 24 months. Each specimen was examined for epidermal thickening and organization and dermal inflammatory infiltrate by light microscopy. Computer-generated analysis of tissue sections was used to evaluate solar elastosis. RESULTS A significant difference in solar elastosis was found between the treatment groups; however, the other features remained largely unchanged. CONCLUSION The dermal changes of photoaging may be affected differently than epidermal changes when UV radiation exposure is diminished. UVA and UVB may contribute diversely to these cutaneous changes. Computer-generated evaluation of dermatoheliosis may be more accurate than visual inspection.

Erythrodermic psoriasis: Precipitating factors, course, and prognosis in 50 patients

Erythroderma represents the most severe form of psoriasis. In addition to its morbidity and severe discomfort, erythrodermic psoriasis also may be potentially life-threatening. We present demographic, clinical, and laboratory findings of 50 patients with psoriatic erythroderma seen at our day-care center during a 9 1/2-year period. Precipitating factors included administration of systemic corticosteroids and the excessive use of topical steroids, phototherapy complications, severe emotional stress, and preceding illness. Treatment options are discussed on the basis of an average follow-up period of 34 months. There appears to be a certain subgroup of patients with highly unstable psoriasis for whom appropriately planned therapeutic regimens are essential.

Acral melanocytic neoplasms: A histologic analysis of 158 lesions

BACKGROUND Acral nevi occasionally demonstrate pagetoid spread of melanocytes. This feature may be of considerable concern because it is commonly associated with melanoma. Other features of melanoma must be assessed to accurately classify these neoplasms as benign. OBJECTIVE We examined acral melanocytic lesions, benign and malignant, to evaluate their features. METHODS A retrospective analysis during 3 years was performed on 158 acral pigmented lesions diagnosed by the dermatopathology service. Blue nevi, intradermal nevi, lentigines, and Spitz nevi were excluded. The specimens were divided into three groups: benign nevi, benign nevi with pagetoid spread, and melanoma. They were evaluated for circumscription, symmetry, papillary dermal fibroplasia, bridging between rete ridges, inflammatory infiltrate, pagetoid spread, cytologic atypia, and mitotic activity. RESULTS Most lesions (60%) were compound nevi and 84% were from the foot. Ten specimens were melanomas (6%) and 28 (18%) were nevi with architectural disorder. Pagetoid spread of melanocytes, often minimal, was found in 57 benign lesions. However, these nevi did not demonstrate the degree of pagetoid spread, cellular atypia, inflammation, and asymmetry found in malignant lesions. CONCLUSIONS The presence of pagetoid spread of melanocytes is common in otherwise benign acral nevi. Other parameters of malignancy in these neoplasms must be evaluated to determine their biologic potential.

Cutaneous manifestations of Prototheca infections

The genus Prototheca comprises several species, the most prevalent of which is Prototheca wickerhamii. These achlorophyllic algae are found in the slime flux of trees and in freshwater environs. Cutaneous infection with these microbes was first reported 30 years ago. Subsequent case reports have described other manifestations including systemic disease. Asymptomatic and stationary cutaneous plaques may be seen in otherwise healthy patients. Susceptibility to infection is ill defined but may involve an inability of neutrophils to effectively eradicate phagocytosed organisms. Characteristic morula are seen histologically. Antifungal medications are the most effective therapy.

Oral antimycobacterial therapy in chronic cutaneous sarcoidosis: a randomized, single-masked, placebo-controlled study.

IMPORTANCE Sarcoidosis is a chronic granulomatous disease for which there are limited therapeutic options. This is the first randomized, placebo-controlled study to demonstrate that antimycobacterial therapy reduces lesion diameter and disease severity among patients with chronic cutaneous sarcoidosis. OBJECTIVE To evaluate the safety and efficacy of once-daily antimycobacterial therapy on the resolution of chronic cutaneous sarcoidosis lesions. DESIGN AND PARTICIPANTS A randomized, placebo-controlled, single-masked trial on 30 patients with symptomatic chronic cutaneous sarcoidosis lesions deemed to require therapeutic intervention. SETTING A tertiary referral dermatology center in Nashville, Tennessee. INTERVENTIONS Participants were randomized to receive either the oral concomitant levofloxacin, ethambutol, azithromycin, and rifampin (CLEAR) regimen or a comparative placebo regimen for 8 weeks with a 180-day follow-up. MAIN OUTCOMES AND MEASURES Participants were monitored for absolute change in lesion diameter and decrease in granuloma burden, if present, on completion of therapy. OBSERVATIONS In the intention-to-treat analysis, the CLEAR-treated group had a mean (SD) decrease in lesion diameter of -8.4 (14.0) mm compared with an increase of 0.07 (3.2) mm in the placebo-treated group (P = .05). The CLEAR group had a significant reduction in granuloma burden and experienced a mean (SD) decline of -2.9 (2.5) mm in lesion severity compared with a decline of -0.6 (2.1) mm in the placebo group (P = .02). CONCLUSIONS AND RELEVANCE Antimycobacterial therapy may result in significant reductions in chronic cutaneous sarcoidosis lesion diameter compared with placebo. These observed reductions, associated with a clinically significant improvement in symptoms, were present at the 180-day follow-up period. Transcriptome analysis of sarcoidosis CD4+ T cells revealed reversal of pathways associated with disease severity and enhanced T-cell function following T-cell receptor stimulation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01074554.

Diffuse dermal angiomatosis.

Abstract:  Diffuse dermal angiomatosis (DDA) is an acquired, benign vascular proliferation characterized clinically by poorly circumscribed, violaceous, livedoid plaques with frequent ulceration. Histologically, a diffuse interstitial proliferation of CD31‐positive endothelial cells is present within the papillary and reticular dermis. Endothelial atypia, atypical mitoses, and vasculitis are lacking. We describe a case of DDA in a 53‐year‐old man with peripheral vascular atherosclerosis that resolved following revascularization. Early correction of the associated ischemic peripheral vascular disease promotes resolution of this unusual clinicopathologic entity.

Intravascular large cell lymphoma: A patient with asymptomatic purpuric patches and a chronic clinical course

Intravascular large cell lymphoma (malignant angioendotheliomatosis) is a rare, multifocal, intravascular neoplasm of lymphoid cells that preferentially involves the vasculature of the skin and central nervous system. We describe a 54-year-old man with asymptomatic purpuric patches on the lower extremities for 10 years duration and a more recent lesion on the right arm. A biopsy specimen showed intravascular collections of tumor cells with irregular nuclear contours and prominent nucleoli. These cells were leukocyte common antigen (CD45), CD20, and CDW75 positive, but CD3, CD43, CD45RO, and cytokeratin negative. Polymerase chain reaction analysis of the skin for immunoglobulin heavy chain gene rearrangement detected a clonal population of B cells, supporting the diagnosis of a B-cell lymphoma. Peripheral blood showed no abnormal circulating cells. This case of malignant angioendotheliomatosis is unusual for its prolonged clinical course and presence of purpuric patches.