H.P. Bertsch

Postoperative morbidity of lymph node excision for cutaneous melanoma-sentinel lymphonodectomy versus complete regional lymph node dissection.

For patients with melanoma metastasis to a sentinel lymph node, subsequent complete regional lymph node dissection (CLND) is currently regarded to be the surgical standard. This approach, however, has not been confirmed by controlled studies, so that surgical morbidity is of primary importance. Using clinical examination and a questionnaire, we determined morbidity in 315 patients with axillary or inguinal lymph node excision on whom 275 sentinel lymphonodectomies (SLNEs) and 90 CLNDs were performed. The overall incidence of at least one complication following SLNE was 13.8%. The short-term complication rate was 11.3% (allergic reaction to blue dye 0%, wound breakdown 0%, haematoma 2.5%, wound infection 3.6%, seroma 6.9%). The incidence of long-term complications was 4.1% (persistent tattoo 0.4%, functional deficit 0.4%, nerve dysfunction/pain 0.7% or swelling 2.5%). All complications were mild. Significantly, the complication rate was not higher for patients aged 70 years or older. After CLND, the overall complication rate was significantly higher (65.5%, P<0.000001). The incidence of short-term complications was 50% (haematoma 0%, wound breakdown 6.7%, wound infection 24.7% or seroma 34.8%). The incidence of long-term complications was also 50% (nerve dysfunction/pain 8.9%, functional deficit 16.8%, swelling 37.1%). Overall, inguinal lymph node excision was burdened by a higher complication rate (P=0.015). Age and sex did not influence postoperative morbidity. No deaths linked to either procedure were noted. Complication rates after SLNE are low and most complications are minor and short-lasting. In contrast, CLND has been demonstrated to be a major and potentially morbid surgical procedure. This highlights the importance of testing the therapeutic value that CLND adds to the sentinel lymph node procedure.

High frequency of primary cutaneous lymphomas associated with lymphoproliferative disorders of different lineage

In patients suffering from primary cutaneous lymphomas, secondary malignancies of various origin may develop. However, the frequency of a second neoplasm deriving from another lymphoid lineage is still unclear and may be underestimated. We screened all our patients with primary cutaneous lymphomas from a 4-year recruitment period for a coexisting secondary lymphoproliferative disorder. The cohort comprised of a total of 82 patients with primary cutaneous lymphomas, 62 with primary cutaneous T-cell lymphoma (CTCL), 18 with primary cutaneous B-cell lymphomas, and two with CD4+/CD56+ hematodermic neoplasm/blastic lymphomas. Seven patients (8.5%) were identified with a coexisting lymphoma of a different lymphoid lineage. Four patients with Sézary syndrome (SS) suffered from systemic B-cell lymphoma. Two of these developed SS after chemotherapy of their B-cell lymphoma. The other three patients with various types of skin lymphomas (SS, Mycosis fungoides [MF], primary cutaneous marginal zone lymphoma) developed Hodgkin’s disease (hairy cell leukemia). Our data indicate that patients with primary cutaneous lymphomas have an elevated risk for the development of a secondary lymphoproliferative disorder even without previous chemotherapy. Possible explanations for this association include a genetic predisposition, alterations in early progenitor cells, underlying viral infections, and/or stimulation of a B-cell clone by the malignant helper T cells of the primary CTCL and vice versa.

Extracorporeal photochemotherapy for the treatment of exanthematic pityriasis rubra pilaris

Pityriasis rubra pilaris (PRP) is a rare papulosquamous skin disease of unknown aetiology that has been categorized into five clinical types based on age at onset, cutaneous features and prognosis. We present a patient with chronic exanthematic type II atypical adult PRP, whose skin status was significantly improved with monthly extracorporeal photochemotherapy (ECP). Various therapeutic regimens including narrow‐band UV‐B, bath PUVA therapy, systemic fumaric acid esters and systemic cyclosporin had failed. Oral retinoids could not be administered due to a type IIa hyperlipoproteinemia with profound hepatic steatosis and elevated liver transaminases. The observed clinical benefit may encourage future clinical studies analysing the effectiveness of ECP in otherwise unresponsive cases of type II PRP.

Insect bite-like reactions in a patient with B-cell chronic lymphocytic leukaemia: fluorescence in situ hybridization analysis revealed neoplastic B cells within the skin infiltrate

2011; 59:222–8. 4 Peus D, Vasa RA, Beyerle A et al. UVB activates ERK1 ⁄2 and p38 signaling pathways via reactive oxygen species in cultured keratinocytes. J Invest Dermatol 1999; 112:751–6. 5 Chen W, Tang Q, Gonzales MS et al. Role of p38 MAP kinases and ERK in mediating ultraviolet-B induced cyclooxygenase-2 gene expression in human keratinocytes. Oncogene 2001; 20:3921–6. 6 Mahns A, Wolber R, Stab F et al. Contribution of UVB and UVA to UV-dependent stimulation of cyclooxygenase-2 expression in artificial epidermis. Photochem Photobiol Sci 2004; 3:257–62. 7 Kim AL, Labasi JM, Zhu Y et al. Role of p38 MAPK in UVB-induced inflammatory responses in the skin of SKH-1 hairless mice. J Invest Dermatol 2005; 124:1318–25. 8 Athar M, An KP, Morel KD et al. Ultraviolet B (UVB)-induced cox2 expression in murine skin: an immunohistochemical study. Biochem Biophys Res Commun 2001; 280:1042–7. 9 de la Lastra CA, Villegas I. Resveratrol as an anti-inflammatory and anti-aging agent: mechanisms and clinical implications. Mol Nutr Food Res 2005; 49:405–30. 10 Sluyter R, Halliday GM. Enhanced tumor growth in UV-irradiated skin is associated with an influx of inflammatory cells into the epidermis. Carcinogenesis 2000; 21:1801–7.

[Intraoperative detection of sentinel lymph nodes in cutaneous malignant melanoma -- blue dye alone versus blue dye plus gamma detection].

Hintergrund: Im Vergleich zur alleinigen Vitalfärbung der Lymphabflusswege bei der Sentinel‐Lymphknotendissektion hat die intraoperative Anwendung einer Gamma‐Detektionssonde die Identifikationsraten verbessert. In der vorliegenden retrospektiven Studie wird der Einfluss der Gamma‐Detektion hinsichtlich weiterer Aspekte ausführlich analysiert.

Acroangiodermatitis Mali resulting from arteriovenous malformation : report of a case of Stewart-Bluefarb syndrome

We describe the rare Stewart–Bluefarb syndrome in a 15‐year‐old boy. This syndrome presents as a congenital arteriovenous malformation of the lower leg with multiple arteriovenous shunts accompanied by the benign acroangiodermatitis of Mali (pseudo‐Kaposis sarcoma). The clinical features of this disorder and the treatment options are reviewed.

Folliculotropic mycosis fungoides with CD30+ large-cell transformation in a young woman: beneficial effect of bexarotene.

gations; skin scrapings for mycology were negative and a skin biopsy showed mild chronic inflammation in the upper dermis with some mild pigmentary incontinence. Wood’s light examination was unremarkable. A skin swab and culture of skin scrapings on chocolate agar were negative. Following clinical and histological correlation a diagnosis of CRP was made. The patient was treated unsuccessfully with oral minocycline 100 mg daily for 3 months, and thereafter all treatment was stopped because the patient became pregnant. During pregnancy, she was treated with amoxicillin 250 mg (taken three times daily) for a coincidental lower respiratory tract infection and noted dramatic improvement in her CRP. Clinical examination confirmed complete clearance. A further 1-month course of amoxicillin 250 mg (taken three times daily) was prescribed 3 months later for disease relapse. Again, improvement was noted after approximately 1 week, with clearance of the eruption within 3 weeks (Fig. 2), confirming that the initial response was not coincidental. Several theories for the cause of CRP have been suggested, including an abnormal host response to Pityrosporum orbiculare and more recently infection with the Dietzia strain of Actinomycete. In conjunction with the microbiology team we attempted to isolate Dietzia strain X from culturing skin scrapings on chocolate agar but without success. Various antibiotics have been reported to treat CRP, including azithromycin, erythromycin and oral fusidic acid. A recent retrospective analysis of 39 cases with CRP from the Mayo Clinic reported complete clearance in 14 of 22 patients treated with minocycline therapy, partial response in a further four of 22 patients and four cases where a response to minocycline was not documented. Our patient was initially treated with minocycline but this was not beneficial. To the best of our knowledge this is the first report of successful treatment with amoxicillin in CRP.

Seltene ulzerierende kutane und systemische Sarkoidose

ZusammenfassungBei der Sarkoidose handelt es sich um eine granulomatöse Multisystemerkrankung unklarer Ätiologie, welche prinzipiell jedes Organ befallen kann. Bei kutaner Manifestation sind unterschiedliche klinische Verlaufsformen beschrieben. Sehr selten hat die kutane Sarkoidose einen ulzerativen Verlauf. Differentialdiagnostisch muss man sie von anderen granulomatösen Hauterkrankungen, insbesondere der Necrobiosis lipoidica, abgrenzen. Eine standardisierte Therapie gibt es bislang nicht- vielmehr stellt die oft langjährige, mit Nebenwirkungen behaftete Behandlung eine interdisziplinäre Herausforderung dar. Wir beschreiben hier den Fall einer 58-jährigen Patientin mit langjähriger kutaner, nodaler und pulmonaler Sarkoidose, welche kürzlich innerhalb der generalisierten Hautläsionen Ulzera an den unteren Extremitäten entwickelte. Unter einer Systemtherapie mittels Hydroxychloroquin in Kombination mit modernem Wundmanagement heilten die Ulzerationen vollständig ab und eine signifikante Besserung der übrigen kutanen Läsionen konnte verzeichnet werden.AbstractSarcoidosis is a granulomatous multisystemic disease of unclear etiology, which can affect any organ. The cutaneous manifestations are variable, but ulcerative cutaneous sarcoidosis is very yare. One must rule out other granulomatous skin diseases, especially necrobiosis lipoidica. There is no standarized therapy; usually an interdisciplinary acropachy over years taking multiple side effects into consideration is needed. A 58-year-old woman with a long history of cutaneous, nodal and pulmonary sarcoidosis suddenly developed ulcerations within the disseminated skin lesions on her legs. The combination of systemic hydroxychloroquine and modern wound management lead to complete healing of the ulcers and a significant improvement in the remaining skin lesions.Sarcoidosis is a granulomatous multisystemic disease of unclear etiology, which can affect any organ. The cutaneous manifestations are variable, but ulcerative cutaneous sarcoidosis is very rare. One must rule out other granulomatous skin diseases, especially necrobiosis lipoidica. There is no standarized therapy; usually an interdisciplinary approach over years taking multiple side effects into consideration is needed. A 58-year-old woman with a long history of cutaneous, nodal and pulmonary sarcoidosis suddenly developed ulcerations within the disseminated skin lesions on her legs. The combination of systemic hydroxychloroquine and modern wound management lead to complete healing of the ulcers and a significant improvement in the remaining skin lesions.

Uncommon cutaneous ulcerative and systemic sarcoidosis. Successful treatment with hydroxychloroquine and compression therapy

ZusammenfassungBei der Sarkoidose handelt es sich um eine granulomatöse Multisystemerkrankung unklarer Ätiologie, welche prinzipiell jedes Organ befallen kann. Bei kutaner Manifestation sind unterschiedliche klinische Verlaufsformen beschrieben. Sehr selten hat die kutane Sarkoidose einen ulzerativen Verlauf. Differentialdiagnostisch muss man sie von anderen granulomatösen Hauterkrankungen, insbesondere der Necrobiosis lipoidica, abgrenzen. Eine standardisierte Therapie gibt es bislang nicht- vielmehr stellt die oft langjährige, mit Nebenwirkungen behaftete Behandlung eine interdisziplinäre Herausforderung dar. Wir beschreiben hier den Fall einer 58-jährigen Patientin mit langjähriger kutaner, nodaler und pulmonaler Sarkoidose, welche kürzlich innerhalb der generalisierten Hautläsionen Ulzera an den unteren Extremitäten entwickelte. Unter einer Systemtherapie mittels Hydroxychloroquin in Kombination mit modernem Wundmanagement heilten die Ulzerationen vollständig ab und eine signifikante Besserung der übrigen kutanen Läsionen konnte verzeichnet werden.AbstractSarcoidosis is a granulomatous multisystemic disease of unclear etiology, which can affect any organ. The cutaneous manifestations are variable, but ulcerative cutaneous sarcoidosis is very yare. One must rule out other granulomatous skin diseases, especially necrobiosis lipoidica. There is no standarized therapy; usually an interdisciplinary acropachy over years taking multiple side effects into consideration is needed. A 58-year-old woman with a long history of cutaneous, nodal and pulmonary sarcoidosis suddenly developed ulcerations within the disseminated skin lesions on her legs. The combination of systemic hydroxychloroquine and modern wound management lead to complete healing of the ulcers and a significant improvement in the remaining skin lesions.Sarcoidosis is a granulomatous multisystemic disease of unclear etiology, which can affect any organ. The cutaneous manifestations are variable, but ulcerative cutaneous sarcoidosis is very rare. One must rule out other granulomatous skin diseases, especially necrobiosis lipoidica. There is no standarized therapy; usually an interdisciplinary approach over years taking multiple side effects into consideration is needed. A 58-year-old woman with a long history of cutaneous, nodal and pulmonary sarcoidosis suddenly developed ulcerations within the disseminated skin lesions on her legs. The combination of systemic hydroxychloroquine and modern wound management lead to complete healing of the ulcers and a significant improvement in the remaining skin lesions.

Papular exanthem discloses acute myeloid leukaemia: interphase fluorescence in situ hybridization revealed deletion of p53 and gain at 8q22/8q24/Tel8q without trisomy 8

We describe a 79‐year‐old patient who presented with fatigue, weight loss, pancytopenia and a papular exanthem. Previous attempts to taking bone‐marrow biopsies had resulted in a ‘dry tap’, with no material collected, suggesting idiopathic myelofibrosis. Histological examination of skin biopsies showed dermal infiltration of monocytoid cells, resulting in a diagnosis of acute myeloid leukaemia (French–American–British M5 morphology) with leukaemia cutis (LC). Numerous abnormalities of chromosome 8 (trisomy or tetrasomy) have been identified in association with LC. We performed fluorescent in situ analysis on cutaneous tissue using directly labelled probes for various gene loci often involved in patients with AML; these tests showed deletion of p53 and excluded trisomy 8. However, application of probes for AML/ETO, MYC and telomere 8q revealed a gain at 8q22/8q24/8q telomere in a significant number of infiltrating cells. We hypothesize that a partial gain at 8q rather than trisomy of the whole chromosome 8 exhibits an association with LC in AML.