Mari-Anne Hedblad

Accuracy in the clinical diagnosis and pattern of malignant melanoma at a dermatological clinic.

The diagnostic pattern of malignant melanoma and clinical suspicion rate has been investigated at a dermatological university clinic. Of 174 histologically proven malignant melanomas, 60 (34%) were not clinically suspected as melanomas. The accuracy of clinical diagnosis increased with level of experience. Physicians with <1 year experience in dermatology were able to detect malignant melanoma as the first diagnosis in 31% of the cases in contrast to 63% for those with >10 years experience. Of 50 patients immediately referred from the dermatologic clinic to surgery departments, 12 did not have melanoma.

Mortality and clinicopathological features of cutaneous squamous cell carcinoma in organ transplant recipients: a study of the Swedish cohort.

Solid organ transplant recipients have a high incidence of cutaneous squamous cell carcinoma and often develop multiple and aggressive tumours. This retrospective study based on the Swedish organ transplant cohort, focuses on the deaths caused by cutaneous squamous cell carcinoma and aims to elucidate the clinicopathological features of these tumours. The cohort comprised 5931 patients who underwent organ transplantation during the period 1970 to 1997 and were registered in the Swedish In-patient Registry, Cancer Registry and Causes-of-Death Registry. A total of 544 cutaneous squamous cell carcinomas in 201 patients were re-examined. The dominating size of the tumours was 5-10 mm and one-third of the tumours were removed by methods other than excision surgery. Well-differentiated tumours and Clark level IV were predominant. Seven patients died from their tumours, all of which were localized on the head. The principal site of metastasis was the parotid gland. The mean duration between date of transplantation and death was 10.4 years (range 6-17 years). Mortality from cutaneous cell carcinoma was compared with that of the general population. There was a highly increased risk; standardized mortality ratio 52.2; 95% confidence interval 21.0-107.6. However, the mortality rate in the Swedish cohort appears to be lower than what has been reported previously from other countries.

The contribution of the Fas/FasL apoptotic pathway in ulcer formation during Leishmania major-induced cutaneous Leishmaniasis.

Cutaneous leishmaniasis (CL), caused by the intracellular protozoan Leishmania major, is characterized by lesion formation and ulceration at the site of infection. The mechanism of ulcer formation during CL is not fully understood. The expression of Fas and FasL and the levels of apoptosis in skin biopsies and in restimulated blood mononuclear cells from patients with 1 to 7 months of L. major-induced CL were analyzed using immunohistochemistry and fluorescence-activated cell sorting analysis. The levels of soluble Fas and FasL were also analyzed by enzyme-linked immunosorbent assay. A substantial number of apoptotic keratinocytes were observed mainly in the superficial epidermis of morphologically active and healing CL skin samples. Fas expression was increased on epidermis in active CL, whereas Fas expression was similar in healing and healthy epidermis. FasL-expressing macrophages and T cells were found in subepidermal infiltrate, mainly in active disease. When CL peripheral blood mononuclear cells were restimulated with L. major, Fas was up-regulated on effector T cells, and high levels of sFasL were secreted. Supernatants from restimulated cultures induced apoptosis in human keratinocytes (HaCaT), possibly through Fas/FasL interactions. Our results indicate that FasL-expressing effector T cells and macrophages may act to induce apoptosis and ulcer formation in Fas-expressing keratinocytes during L. major infection.

Long-term Follow-up of Photodynamic Therapy for Mycosis Fungoides

disease (2). We did not observe any local reaction at the site of injection in this case, but the patient complained of asthenia after morning injections, which prompted us to propose evening injections instead. Finally, we wish to speculate on alternative treatments blocking the IL-1 pathway (9), such as IL-1 soluble receptor (IL-1 trap) or caspase-I inhibitor (pralnacasan), or the IL-6 pathway, such as tocilizumab, a monoclonal antibody against human IL-6 receptor (10), as elevated IL-6 levels were observed in some patients (11,12). These treatments are still under development, but they may prove helpful in the future in the management of refractory SS. The authors declare no conflicts of interest.

Penile intraepithelial neoplasia: histopathological evaluation, HPV typing, clinical presentation and treatment

Background  Genital human papillomavirus (HPV) infection in male patients can cause great variety of lesions, most of which are benign, but some are categorised as penile intraepithelial neoplasia (PIN).

Interobserver variability of histopathological prognostic parameters in cutaneous malignant melanoma: impact on patient management.

Clinical management of primary cutaneous melanomas is based on histopathological staging of the tumour. The aim of this study was to investigate, in a non-selected population in clinical practice, the agreement rate between general pathologists and pathologists experienced in melanoma in terms of the evaluation of histopathological prognostic parameters in cutaneous malignant melanomas, and to what extent the putative variability affected clinical management. A total of 234 cases of invasive cutaneous malignant melanoma were included in the study from the Stockholm-Gotland Healthcare Region in Sweden. Overall interobserver variability between a general pathologist and an expert review was 68.8-84.8%. Approximately 15.5% of melanomas ≤1 mm were re-classified either as melanoma in situ or melanomas >1 mm after review. In conclusion, review by a pathologist experienced in melanoma resulted in a change in recommendations about surgical excision margins and/or sentinel node biopsy in subgroups of T1 melanomas.

The spectrum of genital human papillomavirus infection among men attending a Swedish sexually-transmitted infections clinic: human papillomavirus typing and clinical presentation of histopathologically benign lesions.

There have been a number of Swedish studies on human papillomavirus (HPV) typing in men, most of which have used less sensitive HPV-typing techniques. The present study included male patients with genital HPV-induced lesions planned for surgery. Samples were prepared for histopathology and PCR. HPV was detected in 233/253 (92%) and HPV 6 or 11 in 89% of the HPV-positive lesions. There were statistically significant differences regarding morphology (p=0.002), location (p=0.000001) and colour (p=0.005) of the lesions for low- vs. mixed or high-risk HPV types. For example, acuminate lesions were mostly found among men with low-risk HPV types, whereas macular lesions were over-represented among them with mixed or high-risk types. The HPV type distribution is similar to that in earlier studies, but we also found correlations with some clinical parameters.

Human papillomavirus-associated balanoposthitis--a marker for penile intraepithelial neoplasia?

The purpose of this study was to analyse, among men treated with diathermy, whether there was a difference in balanoposthitis between men with histopathologically benign human papillomavirus–associated lesions and those with penile intraepithelial neoplasia. Data were derived from patient material from a previously published study. Two clinically identical lesions from the same genital site were collected for analysis with routine histopathology and with nested PCR. In total, 292 men were included, of which 47 (16%) had penile intraepithelial neoplasia. Of those with penile intraepithelial neoplasia, 19/47 (40%) reported problems consistent with balanoposthitis, compared with only 15/245 (6%) patients with benign lesions (p < 0.0001). A statistical difference in percentage distribution was also seen regarding morphology (p = 0.001) and location (p = 0.0003) of the lesions among the men having benign lesions with and without balanoposthitis. It is not possible to take biopsies from patients with genital warts, but this study suggests that one probably should be more observant for genital dysplasia among those men with warts with a history of balanoposthitis than those with no such history.

Rapidly Involuting Congenital Melanocytic Naevi in Two Children

Congenital melanocytic naevi (CMN) are considered to be neural crest-derived hamartomas, which are visible at, or shortly after, birth as pigmented tumours (1). The incidence of any size of CMN of neonates ranges from 0.2 to 2.1% (2, 3). They are categorized according to the maximum diameter that the naevus will achieve; small ( 10–20 cm) and giant (> 20 cm) (4). In addition to the cosmetic concern, CMN pose several problems, such as neurocutaneous melanosis, and risk of malignant transformation (5, 6). In a systematic review the risk of melanoma in CMN was estimated to be 0.7%, with a higher risk of malignant transformation occurring during childhood and adoles-cence for giant CMN (2, 7, 8). CMN have a dynamic course and may change over time. They can increase in size during childhood, be-come darker in colour, become hairy, or show pigmen -tary regression (9). Spontaneous involution is a rare phenomenon with few cases described in the literature and, when it occurs, it is often associated with a hypo- or de-pigmented halo (6, 9, 10). We report here 2 cases of spontaneous rapid involution without the halo pheno-menon, in medium to large CMN in 2 children referred to the Karolinska University Hospital.CASE REPORTS

Skin Discoloration Caused by Iron Salts

Monsel’s solution (ferric subsulphate) is an iron salt first described in the literature in 1856 by Leon Monsel (1). Since then it has been widely used by dermatologists as a haemostatic agent in minor surgical procedures, such as tangential excision and punch biopsy (2). Ferric chloride is also a source of ferric ions, which is used in dermatological procedures and is considered more convenient because of its higher solubility compared with ferric subsulphate (1). It has been described previously that iron salts may produce hyperpigmentation of the skin (3). Microscopically, iron salts present as pigmented artefacts in the dermis with foreign-body reaction that may resemble malignant melanoma (3, 4). We describe here a case of extensive reddish-brown discolouration following topical application of ferric chloride solution after dermabrasion.