Majda Vučić

Dermatitis artefacta: unusual appearance in an older woman

Dermatitis artefacta is a rare and difficult condition for diagnosis and treatment, with the highest incidence of onset in late adolescence to early adult life. Most patients are young women who have a personality disorder; borderline features are common and the patients denial of psychological distress makes management and treatment difficult. Patients use a variety of means to cause the skin changes. Clinical presentation of the skin lesions does not conform to those of known dermatoses and are located on easily reached parts of the skin. We report an unusual case of a 72‐year‐old woman with symmetrical changes under the breasts and in the right inguinal region. The lesions were composed partly of haemorrhagic round lesions and partly of scars. A skin biopsy was taken and consultations with the psychiatrist, internist and the patients family led to the diagnosis of self‐induced dermatitis. The skin lesions were covered by occlusion techniques and the lesions improved very rapidly. The patient was discharged from the hospital under psychiatric and family care.

Syringoid eccrine carcinoma.

A rare case of a syringoid eccrine carcinoma in a 52‐year‐old male patient is described. During the first hospitalization, syringoma was diagnosed, both clinically and histologically, keeping in mind the possibility of its malignant alteration. Difficulties in making a diagnosis with histological and immunohistochemical examinations are reported. The possibility of differential diagnosis of primary breast carcinoma and methods of its exclusion are also described. Treatment of the patient was surgical with good results.

Melanoma with second myxoid stromal changes after personally applied prolonged phototherapy

Most malignant melanomas are easily diagnosed; however, melanoma is also one of the lesions most frequently reported to mimic other tumors. One of the most difficult patterns to recognize is characterized by prominent myxoid matrix. A case is presented of primary cutaneous melanoma with abundant myxoid matrix in a patient who underwent prolonged phototherapy. Three years before, after getting sunburns, the patient noticed changes of a congenital nevus located in the area of sunburns. It became darker, started to blanch, and grew, with occasional bleeding. Without consulting a physician, the patient applied phototherapy onto the area for 30 months. He used a Bioptron lamp with polarized, polychromatic, incoherent light, at a wavelength from 480 to 3400 nm, without ultraviolet radiation. Clinically, the lesion was unevenly pigmented, ulcerated, covered with hemorrhagic crust, and measuring 3.5 cm in greatest dimension, with a satellite nodule. Multiple metastatic subcutaneous nodules were also found on the scalp and trunk. Histologically, the primary tumor and metastases were composed of nests and pseudotubular formations of polygonal, spindle, and stellate cells embedded in abundant myxoid stroma that comprised more than 80% of the tumor mass. Focally, in the epidermis and papillary dermis, nests of atypical melanocytes and numerous melanophages were observed. Chemotherapy and immunotherapy were administered as suggested by an oncologist. The patient died from distant metastases 6 months after the diagnosis. Although some authors believe that myxoid changes do not seem to alter the behavior of melanoma, it remains an important differential diagnosis issue.

Hybrid myxoinflammatory fibroblastic sarcoma/hemosiderotic fibrolipomatous tumor of the ankle following repeated trauma

To the Editor: Myxoinflammatory fibroblastic sarcoma (MIFS) is a low grade sarcoma with predilection for the distal portions of the extremities, first described in 1998 under different names by three independent groups of authors, as ‘inflammatory myxoid tumor of the soft parts with bizarre giant cells’, ‘inflammatory myxohyaline tumor of distal extremities with virocyte or ReedSternberg-like cells’ and ‘acral myxoinflammatory fibroblastic sarcoma’. As the tumor is not entirely restricted to acral sites, the term ‘acral’ was withdrawn from the latter to reach a consensus name. MIFS is characterized by proliferation of low grade atypical spindle cells embedded in myxoid and inflammatory stroma with a proportion of larger cells resembling Reed-Sternberg cells and showing characteristic intranuclear virocyte-like inclusions. To date, there have been very few reports of high grade transformation and metastasis. In 2000, Marshall-Taylor and Fanburg-Smith first reported a distinctive soft tissue proliferation characterized by lipomatous/hemosiderotic spindle cell histology and predilection for the ankle of female patients. ‘Hemosiderotic fibrohistiocytic lipomatous lesion’ was the original name, which was later abbreviated to ‘hemosiderotic fibrolipomatous tumor’ (HFLT). More recently, several studies have demonstrated a consistent t(1;10)(p22;q24) translocation in both tumors, showing evidence for a common origin. Further findings from the few recently reported hybrid HFLT/MIFS cases give evidence that HFLT and MIFS could represent different levels of tumor progression within the same entity. A 57-year-old woman was admitted for treatment of a large soft tissue tumor surrounding the right ankle and extending distally along the foot arch (Fig. 1a). Clinical history showed multiple repeated injuries in the ankle and foot area, which started 40 years prior, when the patient suffered a right ankle fracture. Twelve years later, the patient developed frostbite in the same area. A year later, a tractor spreader drove across the same foot. In 1996, 23 years after the incipient injury, lymphedema of the right foot started to develop. Two years later, the patient spilt boiling water across the foot. In a few days, the patient fell and broke the ankle again. Six years later, the foot was traumatized in a traffic accident. It was only in 2006 that the patient was admitted for treatment of lymphedema. Two tumors measuring 6 × 5 cm and 3 × 5 cm, respectively, were excised from the ankle and foot region and confirmed as lipomas by the pathologist at an external institution. In 2013, the patient underwent another biopsy in our institution because of tumor recurrence, which raised suspicion for high grade liposarcoma. Radiography revealed a multinodular tumor untreatable by local excision, measuring up to 15 cm. PET-CT scan confirmed the finding, and also revealed increased fluorodeoxyglucose (FDG) uptake in an enlarged right inguinal lymph node. The patient underwent transtibial amputation and biopsy of the enlarged lymph node. Six months after amputation, the patient is without signs of recurrence.

Spinal spindle cell haemangioma: an atypical location

SummaryWe present a case of the 31-year-old male patient who complained of weakness in both legs and progressed slowly. Neuroimagine of the thoracic spine showed an intraspinal, extradural mass lesion, measuring 5.3 × 1.2 cm at the Th1–Th3 level. Histologically the lesion was a spindle cell haemangioma composed of dilated vascular spaces and a proliferation of bland appearing interspersed spindle cells. Immunohistochemical analysis was diffusely positive for VIM, SMA and focally for CD34. This lesion is uncommon and shows a predilection for distal extremities. Spindle cell haemangioma within the spine has not been previously reported in the literature.

Platelet-rich plasma as a novel treatment for lichen planopillaris

Treatment of lichen planopillaris (LPP) remains a significant challenge due to the irreversible damage inflicted on hair follicles combined with the low efficacy of existing treatments. We hypothesized that growth factors released by the use of platelet‐rich plasma (PRP) may arrest the development of LPP. To test our hypothesis, we treated an LPP patient that has failed previous treatments with a new PRP regimen. Following PRP treatment and six months follow‐up, the patient experienced complete regression of itching and hair shedding. To the best of our knowledge, this is the first report of successful treatment of LPP with a PRP regimen.

Full manuscript title: Early subungual melanoma: A diagnostic and treatment challenge

Acral lentiginous melanoma accounts for less than 5% of all melanomas, and most often appears on palmar, plantar, subungual, and mucosal surfaces (Wolff, Goldsmith, Katz, Gilchrest, Paller, Leffell, 2008). Subungual melanoma (SM) is a rare type of acral lentiginous melanoma that represents only 0.7–3.5% of reported melanoma cases (Levit, Kagen, Scher, Grossman, & Altman, 2000). SM is often misdiagnosed and improperly treated as various benign conditions including onychomycosis, pigmented nevus, as well as drug induced or malnutrition induced hyperpigmentation. Therefore, most SMs are in advanced stages at the time of diagnosis, therefore, associated with a poor prognosis (Cochran, Buchanan, Bueno, & Neumeister, 2014). Early stage of SM is often difficult to differentiate from benign melanocytic lesions. However, making the correct diagnosis is crucial, as treatment and prognosis of these two entities significantly differ. Typically, SM initially present as melanonychia striata, often followed by development of the Hutchinson sign, which is the most significant clinical sign in differentiating SM from benign melanocytic lesions. In situ melanoma usually arises in the nail matrix, from where it can extend to the ventral part of the proximal nail fold or to the nail bed. Furthermore, in cases of in situ melanoma, single melanocytes predominate over nests in most fields, however rare small nests are occasionally present upon histopathologic evaluation. In these early lesions, the atypia is often focal and moderate, and displays pagetoid spread (Calonje, Brenn, & McKee, 2011).

Comparison of Syndecan-1 Immunohistochemical Expression in Lobular and Ductal Breast Carcinoma with Nodal Metastases

Syndecan-1 (Sdc1) is a transmembrane heparan sulfate proteoglycan, an extracellular matrix receptor involved in intercellular communication, proliferation, angiogenesis, and metastasis. This study determined and compared Sdc1 expression in the tumor cells and stroma of 30 invasive lobular and 30 invasive ductal breast carcinomas (ILCs/IDCs), also in the axillary node metastases of ductal type, and correlated it with clinical and tumor parameters. Sdc1 was expressed in the epithelium of 90% carcinoma of both histological types. Also, it was most frequently expressed in their tumor stroma, but in ILC, stromal expression was negative in 40%. Sdc1 was expressed in 86.7% of the metastatic epithelium of IDC nodal metastases (in even 50% as high expression), while the nodal stroma was negative in 46.7%. Primary IDC showed a negative correlation between epithelial Sdc1 and progesterone receptors (PRs), whereas ILC showed a positive correlation between stromal Sdc1 and histological gradus. In the metastatic epithelium, Sdc1 was negatively correlated with a patients age, estrogen receptors (ERs), and PRs in the primary tumors, while the stroma of metastases demonstrated a positive correlation with the focus number in primary tumors and a negative correlation with PRs in primary tumors. This research revealed identical overall epithelial Sdc1 expression in both breast carcinomas with no statistically significant difference in its stromal expression and confirmed the role of Sdc1 in the progression of both tumor types and in the development of ductal carcinomas metastatic potential.

Platelet-rich plasma as novel treatmment for lichen planopillaris

Treatment of lichen planopillaris (LPP) remains a significant challenge due to the irreversible damage inflicted on hair follicles combined with the low efficacy of existing treatments. We hypothesized that growth factors released by the use of platelet‐rich plasma (PRP) may arrest the development of LPP. To test our hypothesis, we treated an LPP patient that has failed previous treatments with a new PRP regimen. Following PRP treatment and six months follow‐up, the patient experienced complete regression of itching and hair shedding. To the best of our knowledge, this is the first report of successful treatment of LPP with a PRP regimen.

Mixed vitiligo of Blaschko lines: a newly discovered presentation of vitiligo responsive to combination treatment

Vitiligo, depigmenting disorder of the skin and mucous membranes, affects up to 1% of the population worldwide. It is classified into four major types: segmental, non‐segmental, mixed, and unclassified type. Non‐segmental vitiligo refers to non‐dermatomal distribution of lesions, while dermatomal distribution of lesions is present in patients with segmental vitiligo. Segmental vitiligo can also follow Blaschko lines – pathways of epidermal cell migration and proliferation during the development of the fetus. Here, we present patient with segmental and non‐segmental vitiligo following Blaschko lines with excellent therapeutic response to combined therapy. Prior to our report, a case of segmental and non‐segmental vitiligo followed by Blaschko lines was never described, therefore we suggest the term “mixed vitiligo of Blaschko lines” to describe this entity. This is also a rare case in which 90% repigmentation was achieved in patient with segmental and nonsegmental vitiligo following Blaschko lines in only 2 months of combined therapy.