Rishi Patel

Amelanotic melanoma: a detailed morphologic analysis with clinicopathologic correlation of 75 cases

Amelanotic melanoma can have a varied appearance both clinically and microscopically. Here, we present our experiences with 75 cases of amelanotic melanoma defined clinically as a non‐pigmented lesion and histopathologically as a tumor lacking significant melanization. We evaluated microscopic features such as morphology, mitotic count, nuclear atypia and presence of solar elastosis. Our amelanotic melanomas exhibited the following morphology: epitheloid (72%), spindled (18.7%) or desmoplastic (5.3%). In addition, we obtained patient information and clinical presentations on most of the cases (74/75; 98.7%) and follow‐up data on 40% (30/75) of the cases. The majority of amelanotic melanomas in men were found on the trunk (13/45; 29%), head and neck (12/45; 26.7%), and lower limb (13/45; 29%) and in women were found on the lower limb (12/30; 40%), upper limb (10/30; 33.3%) and head and neck (6/30; 20%). In addition, we found that an increase in mitotic index correlated with worse survival (p < 0.026), whereas there were no differences in survival for other pathological features, such as nuclear atypia or solar elastosis. Furthermore, in cases with available tissue, all amelanotic melanoma expressed microphthalmia‐associated transcription factor and tyrosinase, suggesting that the tumor cells retained melanocytic lineage and an enzyme in melanin formation, respectively. As the occurrence of amelanotic melanoma and the expression melanoma markers were similar to pigmented melanoma, we favor that amelanotic melanoma represents a subtype of melanoma rather than poorly differentiated or de‐differentiated melanoma.

Intraepidermal and dermal Merkel cell carcinoma with squamous cell carcinoma in situ: a case report with review of literature

Merkel cell carcinoma (MCC), a rare aggressive primary cutaneous neuroendocrine carcinoma, occurs on sun‐damaged skin, especially in the elderly. Its unique co‐expression of cytokeratin 20 (CK20) and neuroendocrine markers, including neuron‐specific enolase (NSE), is diagnostic. Most MCCs are located in the dermis, rarely has an intraepidermal component been reported. We report a case of MCC with an intraepidermal component admixed with squamous cell carcinoma in situ (SCCIS). We were able to identify the differences in the immunohistochemical expression pattern between that of the intraepidermal and the dermal components. Most intraepidermal neoplastic cells of MCC in this case showed a less intense immunoreactivity to CK20 and NSE compared to that of dermal neoplastic cells. This case reports an unusual occurrence of combined SCC and MCC that shows both intraepidermal and dermal components.

The prevalence and analysis of risk factors for age-related macular degeneration: 18-year follow-up data from the Speedwell eye study, United Kingdom

Aims/PurposeTo determine the prevalence of age-related maculopathy (ARM) and age-related macular degeneration (AMD) in men aged 65–83 years living in the Speedwell region of Bristol, United Kingdom and identify modifiable risk factors.MethodsA total of 2348 men recruited to the Speedwell prospective cohort study in 1979 were followed up in 1997 with an eye questionnaire and had retinal photographs that were assessed using the International Classification System for ARM.ResultsIn all, 934 men (66.8% response rate) attended with a mean of 17.9 years (15.3–20.6 years) follow-up. Early ARM (grades 2–3) was found in 9.2% (95% confidence interval (CI) 7.4%, 11.4%) and late age-related maculopathy (grade 4, AMD) in 0.5% (95% CI 0.2%, 1.2%). The risk of ARM (grades 2–4) was increased with raised C-reactive protein and consumption of lard and solid fats, whereas triglyceride levels were associated with a lower risk. The latter were confirmed in multivariable analyses and in addition, haemodynamic measures also predicted risk (eg mean arterial pressure odds ratio (OR) per z-score 1.37, 95% CI 1.04, 1.79).ConclusionsIn a representative cohort of men aged 65–83 from Bristol, United Kingdom, many had macular changes that put them at higher risk of developing AMD. Various modifiable exposures were associated with an increased risk ARM/AMD. Opportunities for screening and undertaking secondary prevention interventions need to be explored to prevent progression of the disease and blindness.

Minocycline-induced hyperpigmentation in multibacillary leprosy.

Minocycline has been used in the treatment of leprosy since the demonstration of its efficacy in inhibiting Mycobacterium leprae growth in 1987. Hyperpigmentation, a well-documented adverse effect, classically shows 3 clinical and histological patterns: type I consists of blue-black pigmentation in areas of current or previous inflammation, type II consists of blue-gray pigmentation of normal skin, often seen on the legs, and type III consists of diffuse muddy-brown pigmentation accentuated on sun-exposed sites. Whereas type I hyperpigmentation stains positively for hemosiderin and type III hyperpigmentation stains positively for melanin, type II hyperpigmentation stains positively for both. We describe 2 patients with leprosy on minocycline therapy who developed multiple patches of blue-gray pigmentation within preexisting leprosy lesions. Biopsies from both patients demonstrated deposition of brownish-black pigment granules within the cytoplasm of foamy histiocytes that was highlighted by both Perls and Fontana-Masson stains. Given the clinical and histological findings in our patients, it is as yet unclear whether this coexistent type I clinical pattern and type II histopathologic pattern of pigmentation is unique to multibacillary leprosy. These findings provide support for the existence of additional subtypes of minocycline-induced hyperpigmentation that do not adhere to the classic 3-type model described.

Acquired perforating calcific collagenosis after topical calcium chloride exposure.

A 24‐year‐old healthy man presented with a 6‐week history of numerous umbilicated coalescing erythematous papules with some scale and crust on his anterior medial thighs. The eruption began 1 to 2 weeks after he spilled calcium chloride rock salts on his pants while salting the sidewalk during a snow storm. The salts dissolved and remained in contact with his skin for at least 4 hours until he was able to change clothes. A skin biopsy shows thick and thin collagen fibers with partial calcification in the papillary and upper reticular dermis associated with a sparse infiltrate of neutrophils, lymphocytes and mononuclear histiocytes. There are foci of transepidermal elimination of calcified fibers with adjacent epidermal hyperplasia and ortho‐ and parakeratosis. Von Kossa stain highlights calcification of the fibers, and trichrome stain confirms the fibers are collagen. A Verhoeff‐van Gieson stain shows no abnormality of elastic fibers. The patient was treated with topical betametasone diproprionate cream twice daily for 3 weeks, as well as a short course of oral levofloxacin and topical gentamicin cream. The lesions resolved over 3 weeks with residual scarring. We report a unique case of acquired perforating calcific collagenosis secondary to topical calcium chloride exposure.

Polyurethane foam: an underrecognized cause of foreign body granulomas.

To the Editor, We recently received a shave biopsy, from the forearm of a 71-year-old patient, status post-multiple hospitalizations for orthopedic procedures. Two to three months after her most recent discharge, the patient noticed the development of an erythematous, slightly indurated black spot on her forearm. Histopathologic examination showed a dermal foreign body granulomatous reaction surrounding particles of refractile, non-polarizable foreign material (Fig. 1). The particles were angulated, nonpigmented and appeared porous. After excluding common dermal fillers and other foreign bodies, a careful search of the literature enabled us to identify the foreign material as degrading polyurethane foam. Polyurethane foam is widely used in medicine. First patented in the 1960s,1 polyurethane has long been popular as a dressing for burns, ulcers and surgical wounds. Its porous trabecular structure absorbs wound exudate, acts as a scaffold for fibroblasts and supports re-epithelialization.2 As the foam degrades, it may stimulate a granulomatous response, in which foreign body macrophages engulf broken struts of foam.3 In the 1980s, silicone breast implants were coated with polyurethane foam to reduce the incidence of capsular contracture.4 These coatings fragment over time,5 and particles of foam may migrate beyond the implant capsule to surrounding soft tissue and regional lymph nodes.6– 9 The foam fragments are readily identifiable by their characteristic angular morphology, and their nature may be confirmed by spectroscopy.8 Polyurethane foam may also comprise a minor component of some silicone granulomas induced by breast implant leakage.8 Concern that degradation of polyurethane foam could lead to release of toxic toluene diamine (TDA) led to Fig. 1. H&E stain 200X (above) and 400X (below). Angulated spicules of degenerating polyurethane foam, engulfed by foreign body macrophages.

Undifferentiated pleomorphic sarcoma in a child with type 1 neurofibromatosis

the start of the treatment. The areas of both wrists, where erythema and lichenification were most severe, underwent PDT. A galenical preparation of ALA 20% cream was applied onto lesional skin and, after 2 h of light occlusion, the area was irradiated with narrowband red light (630 nm, 75 J cm) for 10 min. The treatment was carried out three times, every other week. During the irradiation the woman did not report any pain, but experienced an increase of itch for about 15 min immediately after the end of the application. No complication associated with the photosensitizing effect of concurrent ciclosporin therapy was noted. As soon as a few hours after the first treatment a reduction of erythema was already appreciable and the patient reported a decrease of itch, and as short as 1 week after the first PDT treatment the irradiated skin showed a dramatic improvement (Fig. 1b). At the end of the three courses of PDT the skin was finally healing, with a gradual disappearance of lichenification. Although PDT has never been used in patients with AD before, our findings are not surprising. Recent studies show that PDT exerts significant immunosuppressive effects that are likely to rely on the generation of reactive oxygen species and a reduced expression of and cellular responsiveness to various cytokines. Although limited to one single patient in whom we cannot exclude the additional effect of concurrent ciclosporin treatment (which was, however, ineffective until PDT was started), our observations suggest that PDT is harmless and might represent a viable alternative to more toxic treatments such as local or systemic corticosteroids and tacrolimus in patients with limited, severe AD lesions.

A Vascular Growth Following Radiation Therapy for Breast Carcinoma Treatment

AVascular Growth Following Radiation Therapy for Breast Carcinoma Treatment Stephanie Baum, BS; Rishi Patel, MD; BethMcLellan, MD Awomaninher70spresentedwithanasymptomaticerythematous papuleofunknowndurationontherightbreast.Fouryearspreviously, shehadbeentreatedforductalcarcinomainsituoftherightbreastwith alumpectomyandradiationtherapy.Thephysicalexaminationrevealed numerous telangiectasias involving the rightbreast andanerythematous vascular papule on the superior lateral right breast (Figure, A). A shavebiopsy of the lesionwas performed (Figure, B andC). What is your diagnosis?

Leukemia cutis in association With Grover's disease.

Grovers disease (GD), or transient acantholytic dermatosis, is a persistent recurrent dermatosis that usually occurs in men older than 50 years. Rare cases of GD and hematologic malignancy in the same cutaneous biopsy specimen have been reported. We report a case of GD in association with leukemia cutis. A 72-year-old man with a history of myelodysplastic syndrome presented with numerous pruritic papules on the torso, which were clinically diagnosed as GD. A skin biopsy revealed foci of suprabasal acantholysis and dyskeratosis consistent with GD and dense aggregates of mononuclear atypical cells in the superficial dermis consistent with leukemia cutis. Direct immunofluorescence was negative. This case illustrates the need to consider a diagnostic skin biopsy in any patient who presents with classic clinical findings of GD if there is any indication that the patient may be at higher risk for a hematologic malignancy.

Crystal deodorant‐induced axillary granulomatous dermatitis

A healthy 54-year-old Caucasian woman presented with a bilateral axillary eruption for one year. The patient began using a ‘‘natural’’ and unscented crystal deodorant two years before developing skin lesions. Previous medical history was significant for an urticarial reaction to latex. The eruption did not improve after discontinuation of the deodorant or shaving or during treatment with hydrocortisone, topical antifungals, or oral antibiotics. She was not taking any medications. She denied pain, pruritus, fever, or chills. Physical examination revealed monomorphic, red– brown, follicular papules coalescing into plaques in the axillae but was otherwise unremarkable (Fig. 1). A 3 mm punch biopsy of a representative papule revealed well-circumscribed epithelioid granulomatous inflammation within the dermis with multinucleated giant cells and an associated sparse, predominantly lymphocytic infiltrate (Fig. 2). PAS-D, GMS, AFB, and Fite stains failed to reveal microorganisms. Examination under polarized light failed to reveal foreign material. The patient improved using topical tacrolimus within two weeks.