María Francisca Garijo

Nuclear morphometry in prognosis of renal adenocarcinoma

Nuclear morphometry was carried out on 95 parenchymatous adenocarcinomas of the kidney treated by radical nephrectomy and hilar lymphadenectomy and followed up for at least five years. The study assessed nuclear area, nuclear perimeter, major diameter, nucleolar area, nuclear shape factor, and nuclear size. There was a significant statistical correlation between survival and the morphometric parameters and between the parameters themselves except for nuclear shape factor. The multiple regression proved that nuclear area is the factor which shows the greatest statistical significance for prognosis. Taking a mean nuclear area of 35 microns 2 allowed two prognostic groups to be established regardless of stage, with those below the threshold having a good prognosis and those above it having a poor prognosis: 96.7 percent of patients with a good prognosis survived after five years (60 months) compared with 17.2 percent of those with a poor prognosis.

Cardiac papillary fibroelastoma: Retrospective clinicopathologic study of 17 tumors with resection at a single institution and literature review

Cardiac papillary fibroelastomas (PFEs), which are mainly found in the valves, are rare benign tumors that can cause embolism. Single-center surgical experience in the treatment of this tumor is uncommon. All patients surgically treated for this neoplasm at our institution from January 1995 to October 2012 (15 patients with 17 lesions) were queried for clinical and pathologic characteristics, and the literature was reviewed. The mean age of detection was 55.8±11.48 years. Twenty percent of the patients were male. The tumor was an incidental finding in 60%. Symptoms directly related to PFEs occurred in 40% of patients. The most common clinical presentation in symptomatic cases was embolism (40%), mostly transient ischemic attack or stroke. Cardiac valves were predominantly involved (76.5%); the most commonly valve affected was the aortic valve (29.4%), followed by the mitral valve (17.6%). Concurrent valvular disease was observed in 41.7% of patients. The mean size of tumors was 11.4±7.9mm (range 2-25mm). In 86.7% of the patients, the tumor was solitary. The mitral valve was the most common origin of tumor systemic embolism. Fronds core could be the end stage of hypermature elastic fibers, which grows in apposition to young fibers. Simple surgical excision or valvular reconstruction was accomplished in most patients (58.3%). PFE is usually small, appears singly, and can cause potentially serious complications. Symptomatic and left side tumors should undergo surgical excision with valve-spare surgery when possible. Surgical removal of PFE is safe, efficacious, and definitive.

Postoperative spindle cell nodule of the breast: Pseudosarcomatous myofibroblastic proliferation following endo-surgery.

Despite the frequent use of fine‐needle aspiration, core biopsy and surgery, postoperative spindle cell nodule (PSCN) is a rare pathological complication that may be diagnostically treacherous. Presented herein is the case of a 52‐year‐old woman who developed a 7 mm mammary nodular lesion 66 days after removal of an area of columnar cell hyperplasia involving cellular and architectural atypia, performed with the Mammotome Breast Biopsy System. The lesion was highly cellular and composed of intersecting fascicles of plump spindle cells with blunt‐ended elongated nuclei and nucleoli easily visible. Interspersed mononuclear cells and hemosiderin‐laden macrophages were evident. PSCN is a reactive, benign myofibroblastic proliferation. Differential diagnosis includes benign and malignant spindle cell lesions of the breast. Recognition of this reactive lesion will avoid overdiagnosis of spindle cell malignant tumor. Attention to clinicopathological and histological features should result in accurate recognition of this lesion.

The nipple-areola complex epidermis: a prospective systematic study in adult autopsies.

The prevalence of different types of clear cells and of the mite Demodex in the nipple-areola complex of adult autopsies of both sexes not suffering from breast cancer was studied in a total of 140 nipples. The epidermis of the nipple-areola complex shows squamous cells and 3 types of clear cells: Toker cells, pagetoid dyskeratosis cells, and signet ring-like cells. Toker cells were identified by standard light microscopy in 13 of 140 nipples (9.3%). Reactivity of these cells for CK7 was observed in 35 nipples (25%). They are derived from the lactiferous duct epithelium. Pagetoid dyskeratosis cells were identified in 56 of 140 nipples (40%). In 12 nipples, these cells were conspicuous (8.6%). It is suggested that the proliferation of these cells is induced by friction. Signet ring-like cells were identified in 71 nipples (50.7%). In 2 nipples, these cells were conspicuous (1.4%). They are a consequence of artefact related to formalin fixation. The prevalence of all these clear cells has no relationship with gender. Routine histopathological examination is usually enough to distinguish the characteristic features of the clear cells involving the nipple epidermis and permits differentiation of other entities with epidermal pale cells. Demodex mites were observed in 58 nipple-areola complexes (41.4%). They were more common in male nipple-areola complexes (P < 0.05). The prevalence of these mites was seen to remain steady along the years since the third decade. Demodex mites are common parasites of human nipple and are apparently of no pathologic significance.

PILONIDAL SINUS ASSOCIATED WITH CELLULAR BLUE NEVUS ,A PREVIOUSLY UNRECOGNIZED ASSOCIATION

A neoplasm associated with a pilonidal sinus (PS) is a rare occurrence in the course of a common disease. Early detection is imperative. To our knowledge, pilonidal disease associated with a cellular blue nevus (CBN) has not been reported. There is a 10% diagnostic error rate with this last lesion. Here we report the case of a 19‐year‐old man with recurrent sacrococcygeal PS infection associated with an indurated dome‐shaped blue‐black nodule 1.7 cm in diameter. Clinical diagnosis of the nodule was uncertain suggesting a pigmentary or a vascular tumor. A complete resection of the two lesions was achieved. Pathological study showed a CBN showing a predominantly alveolar pattern associated with a chronic pilonidal disease. The tumor cells showed diffuse strong reactivity for melan‐A and HMB‐45, and focal reactivity for S‐100 protein. Staining for Ki‐67 (MIB1) was virtually negative. Differential diagnoses included atypical CBN, borderline melanocytic tumor and malignant melanoma. Radical excision provides a good prognosis for the rare association consisting of a common disease such as PS with the uncommon CBN.

Sclerotic fibroma (storiform collagenoma)‐like stroma in a fibroadenoma of axillary accessory breast tissue

Accessory breast tissue is a subcutaneous remnant persisting after normal embryological development of the breast. It occurs most frequently in the axilla. Fibroadenomas in axillary breast tissue are rare. We report the case of a 29‐year‐old female patient who presented a fibroadenoma arising in the accessory breast tissue of the right axillary fossa. The neoplasm showed foci of sclerotic fibroma‐like stroma. The patient had no signs of Cowdens syndrome. To the best of our knowledge, a lesion of this kind has not been previously reported. This stromal change suggests an uncommon involutional phase of the fibroadenoma with production of sclerotic and hypocellular collagen. The lesion should be differentiated from extraneural perineuroma, from the changes in fibroadenomas in Cowdens syndrome, from sclerosing lobular hyperplasia (fibroadenomatoid mastopathy) and from pseudoangiomatous stromal hyperplasia.

Hypodermal decidualized endometrioma with aberrant cytokeratin expression. A lesion mimicking malignancy.

Decidualized endometrioma is a pseudoneoplastic lesion that may appear as a solitary nodule in the hypodermis, simulate a malignant epithelioid tumor, and can represent a diagnostic challenge. A 36-year-old woman delivered a full-term baby by cesarean. At the immediate puerperium, she complained of a subcutaneous nodule measuring 2.5 cm, underneath a previous caesarean scar from the former full-term delivery 3 years earlier. Histologic features included a nodular growth pattern of large monomorphic epithelioid cells showing diffuse positivity for cytokeratin (AE1/AE3, 18), human placental lactogen, and CD10 and focal positivity for inhibin alpha. The main differential diagnoses include trophoblastic neoplasia and deciduoid mesothelioma. Good clinicopathological correlation is essential for the correct diagnosis. Immunohistochemical stains can be misleading. An important clue is the combination of large decidualized cells and lumens lined by flat or low cuboidal cells that are atrophic endometrial glands. This lesion has a benign behavior.

Verruciform xanthoma is another condition associated with pseudoepitheliomatous hyperplasia.

To the Editor: We read with interest the authoritative study by Zayour and Lazova on pseudoepitheliomatous hyperplasia (PEH) published in the April issue. In their review, the authors describe the diverse conditions associated with PEH under the headings of infections, neoplasia, dermatosis with chronic inflammation and irritation, and miscellaneous processes. An interesting condition not mentioned by the authors is verrucciform xanthoma (VX). PEH can be exophytic (verrucoid epidermal hyperplasia) or endophytic (invasive acanthosis). Thus, VX can be classified as a kind of verrucoid epidermal hyperplasia. VX is an uncommon, benign, mucocutaneos, nondestructive lesion that can mimic verrucous carcinoma or squamous cell carcinoma both clinically and histopathologically. Furthermore, the lesion can recur. The lesion may be verrucous, papillary, and flat in type and has a typical rough and granular surface. This entity is most frequently located in the oral mucosa but has also been described in other mucocutaneous locations including penis, scrotum, anal region, extremities, digits, axilla, neck, nose, lips, larynx, glottis, epiglottis, and esophagus. This lesion is commonly solitary but may be multifocal. It is usually sporadic and can be associated with acquired or congenital lesions such as lichen planus, lichen sclerosus, warty dyskeratoma, epidermal nevi, pemphigus vulgaris, recessive epidermolysis bullosa, in situ or invasive squamous cell carcinoma, discoid lupus erithematosus, psoriasis under PUVA therapy, odontogenic keratocyst, arteriovenous hemangioma, lymphedema, graft versus host disease, CHILD (congenital hemidysplasia, ichthyosiform erythroderma, and limb defect) syndrome, nevus syndrome, and systemic lipid storage disease. VX etiology is unknown, but several inciting agents, including cutaneous trauma, could play a role. Mohsin et al proposed that chemotactic factors released from damaged squamous cells attract neutrophils toward the intraepithelial compartment. These cells induce keratinolysis and disintegration of the lipid components of membranes, which leads to the appearance of lipid-laden macrophages in the adjacent dermis. It is commonly believed that VX is an unusual reaction pattern, rather than a specific lesion, present exclusively in organs lined by stratified squamous epithelium. We recently observed a case that exemplifies the features of this process. A 65-year-old man consulted for a verrucous scrotum lesion that had gradually increased in size. Physical examination revealed a reddish verrucous pedunculated lesion measuring 1 cm in its larger diameter. The histopathologic

Well-differentiated papillary mesothelioma manifesting in a hernia sac.

Well-differentiated papillary mesothelioma (WDPM) is a tumor of uncertain malignant potential that usually occurs as a multifocal lesion of the female peritoneum, and is incidentally found at the time of surgery. We present here a multifocal case that had arisen from the lining of a hernia sac. To our knowledge, only four cases of this event have been previously described. A review of the five cases reported, including our case, revealed that the mean age of the patients was 56.6±8.35 years. There was predominance in men (4:1). In four cases, the lesion was incidental. Most tumors were found in inguinal hernias. Four cases presented with gross abnormalities in the hernia sac. All the five patients were alive with no evidence of WDPM after a mean follow-up of 38.6 months. Extensive sampling of this rare lesion helps to rule out an epithelial malignant mesothelioma and prevents overtreatment.

Cutaneous metastases can be the initial presenting sign of a cardiac sarcoma.

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