Maria Lentini

Melanocytic nevi of the breast: a histologic case‐control study

Background:  Melanocytic nevi in the genital, acral, and flexural sites often display clinical and histologic features that may simulate melanoma. We verified whether this is the case also for nevi of the breast.

Histological features used in the diagnosis of melanoma are frequently found in benign melanocytic naevi

Aims: The histological features used in the diagnosis of melanoma may be present in benign naevi, but quantitative data are not available. The aim of this study was to establish the real prevalence of such features in naevi. Methods: Ten dermatopathologists, from nine Italian institutions, studied a series of naevi. Eleven histological parameters currently used in melanoma diagnosis were analysed: asymmetry, poor circumscription, predominance of single melanocytes, irregular confluent nests, suprabasal melanocytes, hair follicle involvement, absence of maturation, cytological atypia, dermal lymphocytic infiltrate, mitoses, and necrosis. Results: Ninety one naevi were examined: 22 junctional, 59 compound, and 10 intradermal. None of the studied parameters was seen in 22 of the benign naevi studied. One or more investigated features were found in 69 naevi. Poor circumscription was found in 49 cases, single melanocytic predominating in 42, asymmetry in 41, irregular confluent nests in 16, cytological atypia in 14, suprabasal melanocytes in seven, and hair follicle involvement in seven; absence of maturation, mitoses and necrosis were not found. Conclusions: The histological features used for the histological diagnosis of melanoma are often present in benign melanocytic naevi. This suggests a critical, non-mechanical use of them in melanoma diagnosis.

Interobserver reproducibility of histological features in cutaneous malignant melanoma

Aims: To assess the interobserver reproducibility of certain histological features proposed for the diagnosis of melanoma. Methods: In a series of melanomas, 13 histological parameters were analysed: dimension > 6 mm, asymmetry, poor circumscription, irregular confluent nests, single melanocytes predominating, absence of maturation, suprabasal melanocytes, asymmetrical melanin, melanin in deep cells, cytological atypia, mitoses, dermal lymphocytic infiltrate, and necrosis. Results: The agreement (reproducibility) between the nine observers was excellent (κ > 0.75) for 10 of the 13 examined features (dimension > 6 mm, poor circumscription, irregular confluent nests, single melanocytes predominating, absence of maturation, suprabasal melanocytes, asymmetrical melanin, melanin in deep cells, mitoses, and necrosis). The agreement for asymmetry was very close to excellence (κ  =  0.74), and that for cytological atypia (κ  =  0.65) and dermal lymphocytic infiltrate (κ  =  0.47) was slightly lower, but in the fair to good agreement range. The κ values obtained by comparison with the majority diagnosis were generally high (⩾ 0.85); the mean value of κ was lower (0.70) for only one parameter (dermal lymphocytic infiltrate). Conclusions: The parameters investigated showed an overall good reproducibility.

ACE-Inhibitor-Induced Drug Eruption Resembling Lymphocytic Infiltration (of Jessner-Kanof) and Lupus erythematosus tumidus

A 40-year-old man under treatment for hypertension for almost 1 year with an angiotensin-converting enzyme (ACE) inhibitor (enalapril) presented with recurrent chronic dermatitis of the face and trunk for several months. Physical examination revealed 2 nonpruriginous, erythematous, arciform plaques located in the thoracomammary region (fig. 1). A less infiltrated oval plaque was located in the left preauricular region. The lesions resolved after interruption of enalapril and application of topical steroids. A relapse was observed in the same region after reintroduction of the drug. Discontinuation of the treatment with enalapril was followed again by resolution of the lesions. The subsequent administration of valsartan, an angiotensin II receptor antagonist similar to enalapril, caused the appearance of similar lesions within few weeks. We performed a 5-mm punch biopsy from one of the chest lesions. Histology showed micronodular inflammatory infiltrates scattered in the dermis around the small vessels and the adnexal structures, with a pattern typical of the so-called lymphocytic infiltration of Jessner-Kanof (fig. 2). The cells were T lymphocytes, mainly CD8 positive, and histiocytes scattered and in small clusters, with sporadic fragmentation of the collagen fibers. The direct immunofluorescence and the iron staining for mucin were negative. The ACE inhibitor therapy was discontinued, and the hypertension was treated with an ·-blocker medication. Complete resolution of the dermatitis was observed within a couple of weeks, and at 6 months of follow-up no signs of relapse were observed. A 48and 72-hour patch test reading with enalapril did not show any positive reaction. This clinical case is an example of druginduced cutaneous reaction (specifically by ACE inhibitors) with a histological pattern resembling lymphocytic infiltration of JessnerKanof. There are several reports in the literature regarding skin disorders following treatment with ACE inhibitor drugs, especially enalapril. In the cases reported, the clinical diagnoses were granuloma annu-

Cutaneous angiosarcoma of the face

Cutaneous angiosarcoma is a rare tumour of vascular origin, which has a poor prognosis because of its high potential for metastasis. We report the case of a 57‐year‐old man with an 8‐month history of a progressively enlarging, asymptomatic red patch over the left periorbital region of the face, previously diagnosed as angiolupoid leishmaniasis, insect‐bites, ‘cellulitis’ and treated with several topical antibiotic and steroid therapy, without any improvement. A skin biopsy of the lesion was performed and histological and immunohistochemical examination revealed a pattern of poorly differentiated angiosarcoma. The peculiarity of the localization at the periorbital area and the particular clinical presentation are emphasized.

Solitary asymptomatic nodule of the great toe

Subungual exostosis is a benign osteocartilaginous tumor of the ungual apparatus, particularly of the toes. It affects both sexes equally, more frequently in the second and third decades of life. We describe a 6‐year‐old girl who came to our attention because of the enlargement of a pinkish nodule in the distal part of the nail bed of the first toe, progressively elevating the nail plate. History, X‐ray imaging and histopathologic examination led us to confirm our clinical suspicion, excluding any other possible cause of the subungual mass. The peculiar features of this clinical entity, and the possibility of effective treatment by practical surgical techniques, are discussed.

Twisted ovarian fibroma with high signal intensity on T1-weighted MR image: a new sign of torsion of ovarian tumors?

Abstract. Torsion of ovarian tumors is often difficult to diagnose, because of non-specific clinical, laboratory, and imaging findings. We report a case of twisted ovarian fibroma whose main characteristic was the presence of large areas of high signal intensity on both T1- and T2-weighted MR images due to the passive congestion of the mass. This previously unreported finding should be considered a sign of ovarian torsion and may facilitate prompt surgical intervention.

Polypoid Giant Cell Tumor of the Skin

Giant cell tumor of soft tissue is a rare neoplasm named for its resemblance to giant cell tumor of bone. According to World Health Organization classification of soft tissue tumors, it belongs to the category of the so-called fibrohistiocytic tumors of intermediate malignancy, characterized by frequent local recurrences unless widely excised, but only rarely metastases to lymph nodes and lungs. Cutaneous presentation is extremely rare. We described a case occurring in a 79-year-old woman who presented with a nodular, polypoid, ulcerated lesion on the paranasal region. The histomorphological features were consistent with the diagnosis of primary giant cell tumor of the skin. Clinical informations and immunohistochemistry are useful in distinguishing this neoplasm from other neoplastic and reactive lesions of the superficial soft tissues containing giant cells.

Tenascin expression in actinic keratosis.

Background:  Tenascin is an extracellular matrix protein frequently expressed around neoplastic and non‐neoplastic lesions of the skin. Actinic keratoses (AKs) are intraepidermal neoplastic lesions of the sun‐exposed skin. They are classified according to the extension of dysplasia in four stages; they also present different histological varieties.

Standardized AgNOR analysis in actinic keratosis.

To assess if the quantity of silver-stained nucleolar organizer region (AgNOR) proteins predicts the behavior of actinic keratosis (AK), we performed a standardized AgNOR analysis on 51 cases of AK; in addition, 10 cases of squamous cell (SCC) and 10 cases of basal cell (BCC) carcinomas and 10 normal skin samples were also studied. AgNOR analysis was performed on formalin-fixed and paraffin-embedded sections according to the guidelines of the Committee on AgNOR Quantification (1995), evaluating the mean area (&mgr;m 2 ) of AgNORs per nucleus (NORA). A highly significant P value (< 0.001) was found in the comparison among NORA values of normal skin (1.869 &mgr;m 2 ; SD + 0.332), AK (3.988 &mgr;m 2 ; SD + 0.914), BCC (3.044 &mgr;m 2 ; SD + 0.254), and SCC (5.286 &mgr;m 2 ; SD + 0.920). In AK, a progressive increase of mean NORA values was observed moving from Stage I (3.161 &mgr;m 2 ; SD + 0.600) to Stage II (3.455 &mgr;m 2 ; SD + 0.562), Stage III (4.360 &mgr;m 2 ; SD + 0.295), and Stage IV (5.168 &mgr;m 2 ; SD + 0.694); highly significant differences (P < 0.001) were noted when Stages I or II were compared with Stage III or Stage IV or between these latter stages. The AgNOR quantity may identify AKs with high proliferative activity and increased tendency to develop into invasive SCC.