Antoinette F. Hood

Guidelines of care for the management of primary cutaneous melanoma.

The incidence of primary cutaneous melanoma has been increasing dramatically for several decades. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is nearly always curative with early detection of disease. In this update of the guidelines of care, we will discuss the treatment of patients with primary cutaneous melanoma. We will discuss biopsy techniques of a lesion clinically suspicious for melanoma and offer recommendations for the histopathologic interpretation of cutaneous melanoma. We will offer recommendations for the use of laboratory and imaging tests in the initial workup of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, we will provide recommendations for surgical margins and briefly discuss nonsurgical treatments. Finally, we will discuss the value and limitations of sentinel lymph node biopsy and offer recommendations for its use in patients with primary cutaneous melanoma.

Atypical melanocytic nevi of the genital type with a discussion of reciprocal parenchymal-stromal interactions in the biology of neoplasia

UNLABELLEDnMelanocytic lesions of the genital area, especially those on the vulva, may present great difficulty in histological interpretation. A histological diagnosis of malignant melanoma was made in more than one third of 56 genital area melanocytic lesions submitted in consultation to the authors. The median age of the patients with these lesions was 25 years. This article is a clinicopathological study of these lesions and distinguishes them from malignant melanoma. The stroma of the lesions of the genital area was different from the stroma seen in the dysplastic nevi and melanoma. The differences in the stromal form in the diverse lesions is useful in diagnosis and is of profound biological significance. The stroma in the reported lesions and in some lesions of melanocytic neoplasia is described in detail, and its biological significance is discussed. Three sets of cases are used in this comparative study to delineate the clinicopathological nature and the biology of the genital nevi. The 56 cases submitted in consultation constitute the primary series of our work (The Clark Cutaneous Pathology Laboratory Series). These are compared with a series of cases from the Pigmented Lesion Group of the University of Pennsylvania and Pathology Services, Inc, and another series of cases from the Genetic Epidemiology Branch of the National Cancer Institute. The two series used for comparative study contain approximately the same number of cases of dysplastic nevi and malignant melanoma as there are atypical melanocytic nevi of the genital type in the primary series. The total number of cases was studied by comparison of their attributes in a relational database. The clinical data of the primary series was acquired through the use of a questionnaire completed by the contributors. The 56 cases presented two distinctive pathological pictures. One of these is termed atypical melanocytic nevi of the genital type (AMNGT), whereas dysplastic nevi (DN) formed the second of the two pathological pictures. There were 36 AMNGT and 14 DN. The remaining six cases were common nevi without atypia or ill-defined melanocytic hyperplasias. The lesions of AMNGT are usually located on the vulva, but they are seen on the perineum and, rarely, on the mons pubis and in the axilla. Lesions similar to AMNGT have been seen uncommonly on the male genitalia. The stromal patterns were distinctive and related to specific melanocytic lesions. An unclassified (unclass) or nonspecific stromal pattern was associated with AMNGT; a pattern of regression with differentiation (diff-regress) dominated the stroma of common dermal nevi; concentric eosinophilic fibroplasia (cef) and lamellar fibroplasia (lf) were present in dysplastic nevi; fibroplasia with a plaquelike lymphocytic infiltrate (fl) and diffuse eosinophilic fibroplasia (def) were noted in radial growth phase melanoma; and fibroplasia with angiogenesis (fa) or an absence of evidence for parenchymal stromal reciprocal interactions (nopsi) marked thick or deeply invasive vertical growth phase melanomas. Recommendations for management of the lesions are suggested.nnnCONCLUSIONSnOne kind of atypical melanocytic proliferation in the genital area forms a distinctive clinicopathological entity that can be distinguished from melanoma and dysplastic nevi, the AMNGT. Such lesions are more common on the labia minora or the mucosa of the clitoral region than they are on the labia majora. The other common atypical melanocytic proliferation of this area is a dysplastic nevus, which is much more common on the labia majora than on the labia minora. The reciprocal interactions between parenchyma and stroma are discussed as homeostatic processes, a continually functioning template maintaining tissue, organ, and organismal form and function. The progressive disorganization of this template in neoplasia is illustrated and is considered to be a cardinal element in the biology of neoplasia.

Randomized comparison of virtual microscopy and traditional glass microscopy in diagnostic accuracy among dermatology and pathology residents

Virtual microscopy is being used in medical schools to teach histology and pathology. It is also being used in resident education, in-training examinations (dermatology), and certification examinations (pathology). There are, however, few studies comparing its diagnostic accuracy and acceptability compared with traditional glass slides. This study sought to compare residents abilities in diagnosing dermatopathology disorders in 2 image formats (traditional microscopic slides and whole mount digitized images) and to assess their perceptions of virtual microscopy in dermatopathology. Residents in dermatology and pathology training programs at 14 institutions were given a randomized combination of 20 virtual and glass slides and were asked to identify the diagnoses from multiple foils. They were then asked to give their impressions about the virtual images. Descriptive data analysis and comparison of groups using Pearson chi(2) and Fisher exact tests for categorical variables and Student t test for continuous variables were performed. Residents in dermatology and pathology performed similarly in diagnosing dermatopathology disorders using virtual slides or glass slides (mean [SD] correct for virtual versus glass, 5.48 (1.72) versus 5.57 (2.06); P = .70). The order of administration of virtual versus glass slides did not affect the percentage of questions answered correctly. Most residents supported the use of virtual microscopy as a learning aid, whereas fewer favored its use in testing (79% versus 44%, respectively). Residents performed similarly in making dermatologic diagnoses using virtual slides compared with glass slides despite the residents preference for the latter.

Comparative diagnostic accuracy in virtual dermatopathology

Background: Virtual microscopy can be used to teach histology and pathology and for in‐training and certification examinations. A few online consultation websites already utilize virtual microscopy, thereby expanding the role of telemedicine in dermatopathology. There are, however, relatively few studies comparing the diagnostic accuracy and acceptability of virtual slides compared to traditional glass slides.

Proliferative nodules with balloon-cell change in a large congenital melanocytic nevus

Abstract:u2002 The balloon‐cell nevus was first described over 100 years ago. Since then, balloon‐cell changes of melanocytes have been noted in numerous tumors, including melanoma, blue nevus, and Spitz nevus. Whether these changes reflect cellular deterioration or proliferative changes is a matter of debate. We report a case in which balloon‐cell changes were found within proliferative nodules occurring in a large congenital melanocytic nevus.

Nevi of special sites.

Melanocytic nevi can have a wide range of histologic appearances. Within the spectrum of nevi, there exists a group that presents in certain anatomic locations with histologically worrisome features but nonetheless benign behavior. This group of nevi has been broadly categorized as nevi of special sites. The anatomic locations affected by this group include the embryonic milkline (breast, axillae, umbilicus, genitalia), flexural areas, acral surfaces, ear, and scalp. Nevi in these locations may be mistaken for melanomas because of their histologic appearance, resulting in inappropriate overtreatment of patients. In this article, the authors review the histologic features of these special site nevi and discuss the criteria that help distinguish them from melanoma.

Subungual pleomorphic fibroma

Background:u2002 Pleomorphic fibroma is a benign fibroblastic tumor characterized by pleomorphic, hyperchromatic cells or giant multinucleated cells embedded in a collagenous stroma. These cytologic features may lead to an incorrect diagnosis of malignancy. Most cases reported in the literature are located on trunk or extremities; the presentation as a subungual mass is rare.

Diagnostic accuracy in virtual dermatopathology

Virtual microscopy is used for teaching medical students and residents and for in‐training and certification examinations in the United States. However, no existing studies compare diagnostic accuracy using virtual slides and photomicrographs. The objective of this study was to compare diagnostic accuracy of dermatopathologists and pathologists using photomicrographs vs. digitized images, through a self‐assessment examination, and to elucidate assessment of virtual dermatopathology.

Erythema Multiforme-Like Bullous Pemphigoid Associated with Furosemide

The clinical diagnosis of bullous pemphigoid (BP) can be challenging given the polymorphic nature of the disease. We present a case of erythema multiforme (EM)-like BP in an 80-year-old woman with celiac disease. Skin biopsies showed intraepidermal and subepidermal bullae with direct immunofluorescence (DIF) demonstrating IgG and C3 linear deposition at the basement membrane. The etiology of our patients BP is unclear but may be associated with furosemide usage and is temporally associated with a flare of celiac sprue. To our knowledge, only four other published cases document EM-like lesions in BP. Atypical presentations of BP should be confirmed with histology and direct immunofluorescence.

Nonneoplastic Skin Diseases

This chapter will discuss an approach to inflammatory skin disease. Recognition of inflammatory diseases of the skin is highly dependent on a group of histologic patterns: spongiotic, psoriasiform, interface, superficial perivascular, superficial and deep perivascular, interstitial, sclerosing, panniculitis, and alopecia. (Bullous disease is covered in Chapter 18.) The histologic patterns shape the differential diagnosis. The differential diagnosis is further refined by individual histologic features including specific epidermal (e.g., pattern of parakeratosis) or dermal (e.g., hemorrhage) findings and the nature of the inflammatory infiltrate. This chapter discusses common/important inflammatory dermatoses and their differential diagnosis. Immunodermatology is covered in Chapter 18.