Rosalie Elenitsas

Subcutaneous panniculitis-like T-cell lymphoma : Clinicopathologic, immunophenotypic, and genotypic analysis of alpha/beta and gamma/delta subtypes

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is an uncommon cutaneous lymphoma that has been proposed as a distinct clinicopathologic entity, but studies of SPTCL are limited. We studied the clinicopathologic, immunophenotypic, and genetic features of 11 SPTCLs. All cases had a variable admixture of pleomorphic small, medium, or large lymphocytes and histiocytes infiltrating the subcutis in a lobular panniculitis-like pattern. A granulomatous reaction was seen in three cases and erythrophagocytosis in four. Karyorrhexis and fat necrosis were present in all cases. Angioinvasion was seen in seven SPTCLs; four had areas of coagulation necrosis. All cases expressed T-cell-associated antigens (CD3epsilon, CD45RO, or CD43) and T-cell receptors (TCR); nine expressed alphabeta TCRs and two expressed gammadelta TCRs. T-cell receptor-gamma, TCRbeta, or TCRdelta genes were clonally rearranged in 8 of 10 cases studied. Both gammadelta SPTCLs expressed Vdelta2+ TCRs and were CD4-, CD8- and CD56+. CD56 was negative in seven of nine alphabeta SPTCLs and inconclusive in the other two. Six of nine alphabeta SPTCLs were CD8+; the CD4/CD8 phenotypes were indeterminate in the other three. Cytolytic granule-associated proteins were expressed by all SPTCLs (11 of 11 were TIA-1+, 4 of 4 were perforin+). In situ hybridization for Epstein-Barr virus-encoded RNA (EBER-1) was negative in all cases. Most patients responded to systemic chemotherapy or local radiation therapy. Seven patients are alive: four without disease (19-73 months) and three with disease (32-72 months); four died: three of disease (3-25 months) and one without disease (42 months). We conclude that SPTCLs are clonal, EBV-, cytotoxic T-cell lymphomas derived from alphabeta T-cells or gammadelta T-cells. The gammadelta SPTCLs appear to be preferentially derived from the Vdelta2+ subset. Subcutaneous panniculitis-like T-cell lymphoma may be rapidly fatal or indolent; local therapy may be appropriate for some patients.

A Prognostic Model for Predicting 10-Year Survival in Patients with Primary Melanoma

Malignant melanoma is currently the eighth most common cancer in the United States; 10 years ago, it was the 20th most common. The population-based mortality rate has continued to increase, whereas the case fatality rate has steadily declined to less than 20% [1]. Diagnosis of malignant melanoma earlier than was previously possible is primarily responsible for this improved survival rate. Contributing to earlier recognition of malignant melanoma are the identification of risk markers (such as dysplastic nevi) and improved understanding of clinical characteristics of the biologically early forms [2-4]. Another substantive advance has been the clarification of prognostic factors for patients with primary American Joint Commission on Cancer stage I cutaneous melanoma ( 1.5 mm) and stage II cutaneous melanoma (>1.51 mm); these factors are predominantly pathologic variables that were described by Clark and colleagues [5], Breslow [6], and other investigators [7]. Survival is routinely predicted almost exclusively on the basis of tumor thickness. Although this is an excellent correlate of prognosis, it is imprecise. Death results from thin melanomas, and survival occurs with thick melanomas. Evaluation of other variables improves the ability to predict survival in patients with melanoma. Variables that can be added include the anatomical site of the primary tumor; sex and age of the patient; mitotic rate of the tumor; presence of ulceration, microscopic satellites, or tumor-infiltrating lymphocytes; tumor regression or angiogenesis; and the Clark level of invasion (maximum penetration of the melanoma lesion into levels of the dermis or subcutaneous tissue) [8, 9]. We previously described a multivariable model that predicted 8-year survival of patients with primary melanomas more accurately than did tumor thickness alone [10]. In that model, six variables were found to independently predict survival. These variables (in order of their relative predictive strength) are mitotic rate, presence of tumor-infiltrating lymphocytes, tumor thickness, site of the primary lesion, sex of the patient, and histologic regression of the tumor. Although this model includes powerful predictors of survival, some of the variables used to generate it are not routinely included in standard pathology reports. Therefore, the model cannot be readily generalized for clinical use. To document this, we reviewed 100 randomly selected pathology reports of primary melanomas from community-based hospital pathologists, independent pathology laboratories, and specialized dermatopathology laboratories. Tumor thickness was recorded in 76% of cases; Clark level, in 68%; and histologic subtype, in 64%. However, tumor infiltrating lymphocytes and tumor regression were described in fewer than 20% of cases, and the mitotic rate was reported even less frequently (fewer than 5% of cases). Notably, no pathologists specified pure, invasive, radial-growth-phase melanoma, although such lesions almost never metastasize [10]. Given the limited availability of these histologic variables, we sought to develop a prognostic model based on clinical and pathologic data that are routinely available to the clinician. The model is intended to estimate the chance of survival, within 10 years of definitive therapy, in a patient with primary malignant melanoma. The ability to predict outcome more accurately in these patients could identify patients who are at high risk for recurrence; these patients could then be included in trials of adjuvant therapy. Further trials are becoming increasingly important as effective therapies for post-surgical treatment of melanoma are identified and tested [11-13]. Methods Patients The Pigmented Lesion Group at the University of Pennsylvania prospectively evaluated 624 patients with primary melanoma between 1 September 1972 and 31 December 1979. The pathologic variables were ascertained in an independent study of the primary tumors on two separate occasions by two pathologists who had no knowledge of outcome. Definitive treatment of the primary melanoma consisted of wide re-excision of the primary site to yield negative margins. We excluded 136 cases from analysis. Reasons for exclusion were competing causes of death before 10 years of follow-up with no evidence of melanoma (n = 44), lack of prospective follow-up (n = 22), metastatic disease evident beyond the primary site at presentation (n = 29), inadequate surgical treatment (n = 14), unknown cause of death before 10 years of follow-up (n = 5), occurrence of a high-risk primary tumor after 1979 (n = 2), existence of noncutaneous primary tumors (n = 5), loss to follow-up (n = 10), and unclassified tumor thickness or level (n = 5). Therefore, the final study group consisted of 488 patients who were followed prospectively for at least 10 years. Surviving patients were followed for no more than 20 years. Five patients who died of melanoma after 10 years of follow-up were considered to be 10-year survivors. Our description of what is generally included in melanoma pathology reports was drawn from the last 100 cases submitted for review at the Hospital of the University of Pennsylvania. Forty-three percent of the reports were from community-based hospitals, 17% were from independent pathology laboratories, and 40% were from specialized dermatopathology practices. We did not intend to evaluate current melanoma pathology reporting in nonacademic settings but rather to evaluate which prognostic factors are frequently reported on pathology reports. Validation of the model required a test using patient data that had not been used to generate the model. This sample consisted of 142 patients who had primary melanoma and were identified in an identical manner in 1980 and 1981, with blinded histopathologic assessment of melanoma and 10 years of follow-up data. Clinical and pathologic variables that have been identified as prognostic indicators of survival and that are readily available to the clinician were used to develop the prediction model [7, 9]. Clinical variables included age and sex of the patient and site of the primary lesion. Pathologic variables included histologic subtype, Clark level, and tumor thickness. Tumor thickness was measured from the stratum granulosum epidermidis to the depth of the tumor at its thickest part, according to the method of Breslow [6]. Anatomical site of the primary melanoma was divided into two categories: extremity (upper and lower) and axis. Axial or volar primaries, including melanomas arising on the trunk, head, neck, and palms and soles (volar) and under the nails (subungual), were designated as axis lesions. Lesions on other parts of the body were designated as extremity lesions. Female and male patients were studied. Histologic subtypes of melanoma included superficial spreading melanoma (71%), nodular melanoma (12%), lentigo maligna melanoma (6%), acral-lentiginous melanoma (3%), and other lesions (8%), using standard pathologic criteria. Age at the time of diagnosis was recorded. The Clark level of invasion was determined as described elsewhere [5]. Patient outcome was assigned to two categories: alive at 10 years (with or without evidence of melanoma) or dead from melanoma before 10 years. The 10-year interval was chosen because death from melanoma beyond 10 years is uncommon. We chose to analyze survival as a binary outcome (alive at 10 years compared with dead before 10 years). This method was chosen instead of evaluating the survival time or time to death because our primary objective was to differentiate between patients with high and low probabilities for surviving disease. This differentiation, in turn, can aid patient management and identify candidates for adjuvant therapy trials. Therefore, we were not interested in determining the contribution of prognostic factors that lengthen survival but do not necessarily prevent death. Statistical Analysis We used a univariate logistic regression model to test the six clinical and pathologic variables for their association with death. Patient age and tumor thickness were tested as continuous and nominal variables, and the Clark level was tested as a nominal variable. Tumor site was initially evaluated as a variable falling into one of four categories (trunk, head or neck, subungual or volar location, and extremity) but was subsequently reduced to two categories, axis and extremity. Variables that were statistically significantly associated with survival were retained for testing in a multivariable logistic regression model [14]. A manual stepwise procedure was used to determine the best model. The predicted probability that a patient would survive 10 years was generated using the estimated model variables. The logistic equation is presented as a footnote in Table 1. Table 1. Adjusted Odds Ratios for Independent Predictors of Survival* Figure 1 is a box and whisker plot that shows the distribution of probabilities that were estimated by our model for survival of patients who were alive and those who were dead at 10 years [15]. The boundary lines of the boxes represent the 25th and 75th percentiles of the data; the lines drawn through the interior of the boxes mark the 50th percentiles (the medians). The whiskers are drawn from the edges of each box to the most extreme point a maximum distance of 1.5 times greater and 1.5 times less than the interquartile ranges. Any value more extreme is considered an outlier and is designated by an asterisk. The predictive ability of the four-variable model was compared with that of tumor thickness in two ways. First, receiver-operating characteristic (ROC) curves were calculated [16, 17]. Second, the McNemar test was used to compare the percentages of correct predictions. Goodness of fit was assessed by using the Hosmer-Lemeshow test [14]. Figure 1. Results Overall Of the 488 prospectively followed patients, 108 died of melanoma before 10 years. The median follow-up was 13.

Thin Primary Cutaneous Malignant Melanoma: A Prognostic Tree for 10-Year Metastasis Is More Accurate Than American Joint Committee on Cancer Staging

PURPOSE The majority of invasive primary melanomas are thin (< or = 1.00 mm). Since the current staging system imperfectly predicts outcome in patients with such lesions, we sought to develop a more effective classification scheme to better identify both patients at high risk of metastasis who are candidates for further staging and therapy and those with little risk. PATIENTS AND METHODS This prospective cohort study included 884 patients who had thin invasive melanomas. A tree-structured analysis of 10-year metastasis was used to develop a new classification scheme. RESULTS The overall 10-year metastasis rate was 6.5% (95% CI, 4.8% to 8.1%). The prognostic tree defined four risk groups: high-risk: men with vertical growth phase (VGP) lesions that had mitotic rates (MRs) greater than 0, and for whom the 10-year metastasis rate was 31% (22% to 42%; n = 90); moderate-risk: women with VGP lesions that had MRs greater than 0 and for whom the rate was 13% (9% to 18%; n = 136); low-risk: patients with VGP lesions that had MR of 0 for whom the rate was 4% (2% to 7%; n = 247); and minimal-risk: patients with invasive lesions without VGP for whom the rate was 0.5% (0% to 1.2%; n = 411). Survival curves differed significantly among the four groups (P <.001). CONCLUSION Growth phase, mitotic rate, and sex are important prognostic factors for patients with thin melanomas, and they identify subgroups at substantial risk for metastasis. After validation in other populations, the proposed prognostic tree will be useful in the design of clinical trials and clinical management.

Identification of High-Risk Patients Among Those Diagnosed With Thin Cutaneous Melanomas

PURPOSE Most patients with melanoma have microscopically thin (< or = 1 mm) primary lesions and are cured with excision. However, some develop metastatic disease that is often fatal. We evaluated established prognostic factors to develop classification schemes with better discrimination than current American Joint Committee on Cancer (AJCC) staging. PATIENTS AND METHODS We studied patients with thin melanomas from the US population-based Surveillance, Epidemiology, and End Results (SEER) cancer registry (1988 to 2001; n = 26,291) and those seen by the University of Pennsylvanias Pigmented Lesion Group (PLG; 1972 to 2001; n = 2,389; Philadelphia, PA). AJCC prognostic factors were thickness, anatomic level, ulceration, site, sex, and age; PLG prognostic factors also included a set of biologically based candidate prognostic factors. Recursive partitioning was used to develop a SEER-based classification tree that was validated using PLG data. Next, a new PLG-based classification tree was developed using the expanded set of prognostic factors. RESULTS The SEER-based classification tree identified additional criteria to explain survival heterogeneity among patients with thin, nonulcerated lesions; 10-year survival rates ranged from 89.1% to 99%. The new PLG-based tree identified groups using level, tumor cell mitotic rate, and sex. With survival rates from 83.4% to 100%, it had better discrimination. CONCLUSION Prognostication and related clinical decision making in the majority of patients with melanoma can be improved now using the validated, SEER-based classification. Tumor cell mitotic rate should be incorporated into the next iteration of AJCC staging.

Incidence of sentinel node metastasis in patients with thin primary melanoma (≤1 mm) with vertical growth phase

Background: Patients with thin primary melanomas (#1 mm) generally have an excellent prognosis. However, the presence of a vertical growth phase (VGP) adversely impacts the survival rate. We report on the rate of occurrence of nodal metastasis in patients with thin primary melanomas with a VGP who are offered sentinel lymph node (SLN) biopsy.Methods: Among 235 patients with clinically localized cutaneous melanomas who underwent successful SLN biopsy, 71 had lesions 1 mm or smaller with a VGP. The SLN was localized by using blue dye and a radiotracer. If negative for tumor by using hematoxylin and eosin staining, the SLN was further examined by immunohistochemistry.Results: The rate of occurrence of SLN metastasis was 15.2% in patients with melanomas deeper than 1 mm and 5.6% in patients with thin melanomas. Three patients with thin melanomas and a positive SLN had low-risk lesions, based on a highly accurate six-variable multivariate logistic regression model for predicting 8-year survival in stage I/II melanomas. The fourth patient had a low- to intermediate-risk lesion based on this model. At the time of the lymphadenectomy, one patient had two additional nodes with metastasis.Conclusions: VGP in a melanoma 1 mm or smaller seems to be a risk factor for nodal metastasis. The risk of nodal disease may not be accurately predicted by the use of a multivariate logistic regression model that incorporates thickness, mitotic rate, regression, tumor-infiltrating lymphocytes, sex, and anatomical site. Patients with thin lesions having VGP should be evaluated for SLN biopsy and trials of adjuvant therapy when stage III disease is found.

Cutaneous melanoma risk and phenotypic changes in large congenital nevi: A follow-up study of 46 patients

BACKGROUND Large congenital melanocytic nevi may undergo malignant transformation. Few prospective studies have evaluated the incidence of melanoma in large congenital nevi or have described how their phenotypic characteristics change over time. OBJECTIVE We attempted to ascertain the incidence of cutaneous melanoma in a cohort of patients with large congenital nevi and to evaluate the frequency and nature of several morphologic changes over time. METHODS Forty-six patients with large congenital nevi were prospectively followed up in our Pigmented Lesion Group. Large congenital nevi were defined as those occurring at birth and comprising 5% body surface area or greater in infants, children, and preadolescents and more than 20 cm in adolescents and adults. Information was obtained on location, satellitosis, changes in color and nodularity, and incidence of melanoma. The most atypical histologic findings from those who underwent biopsy were also noted. Standardized morbidity ratios (SMR) and 5-year cumulative risk were calculated and presented with corresponding 95% confidence intervals (CI). RESULTS Twenty-four male and 22 female patients (age range, 7 days to 36.7 years; mean, 8.4 years) with large congenital nevi were followed up prospectively for a total of 335 person-years (range, 0.17 to 17.5 person-years; mean, 7.3 person-years). Two patients (4.3%) experienced 3 cutaneous melanomas that originated in their primary congenital nevi. We found one case of neurocutaneous melanosis. No satellite, extremity, or extracutaneous melanomas were detected. The majority of nevi in our cohort were located on the posterior trunk, were accompanied by multiple satellite congenital nevi, and became lighter over time. In the 27 patients who underwent biopsies, the most atypical histologic findings included melanoma, atypical melanocytic dysplasia, neurocristic dysplasia, atypical neural crest hamartomas, atypical spindle cell tumors, and congenital nevi with dysplasia. The SMR comparing observed-to-expected melanoma incidence was 148 (95% CI 18, 535; P = .0002) indicating a substantially increased risk of melanoma in patients with large congenital nevi. The cumulative 5-year risk of cutaneous melanoma was 5.7% (95% CI 0%, 13.5%). CONCLUSION Our findings are consistent with the previously observed increased risk for the occurrence of cutaneous melanoma in patients with large congenital nevi. Although the number of patients with melanoma in this study is small, our observations and those of previous studies suggest that location and age correlates with melanoma risk. The majority of large congenital nevi are located on the trunk and may undergo several clinical changes as these patients age. Additional prospective studies are needed to gain more insight into the natural history and optimal management of large congenital nevi.

Cytokeratin 15 expression in trichoepitheliomas and a subset of basal cell carcinomas suggests they originate from hair follicle stem cells

Trichoepitheliomas and many basal cell carcinomas appear to arise from the hair follicle, and in particular from the hair follicle bulge. This histogencsis is suggested from both morphological and immunohisto‐chemical studies on tumor cells and siroma. Epithelial stem cells are thought to be important in tumorigenesis, and we previously localized a population of stem ceils to the bulge area of the outer root sheath. We recently identified an anti‐CD8 monoclonal antibody (DAKO clone C8/144B) that cross‐reacts with cytokeratin 15 (K15), and serves as a specific marker for the bulge. In this study, we screened a Series of trichocpitheliomas (n=13), basal cell carcinomas (n=37) and a variety of other skin tumors with this antibody, All trichocpitheliomas (100%) showed keratin 15 expression, while only a subset of basal cell carcinomas (27%) was K15‐positive. Epidermal tumors, including squamous cell carcinomas, were K15‐negative. Tumors of follicular derivation such as proliferating trichilemmal cysts were also K15‐positive, while others such as pilomatricoma were K15‐negative. Expression of K15 in trichoepitheliomas, some basal cell carcinomas and other follicular tumors suggests that these tumors are related to hair follicle stem cells in the bulge.

Evaluation of AJCC Tumor Staging for Cutaneous Squamous Cell Carcinoma and a Proposed Alternative Tumor Staging System

IMPORTANCE This study proposes an alternative tumor staging system for cutaneous squamous cell carcinoma (CSCC) that more precisely defines the small subset of tumors with a high risk of metastasis and death. OBJECTIVE To identify risk factors for poor outcomes in CSCC and evaluate the 2010 American Joint Committee on Cancer (AJCC) tumor (T) staging systems ability to stratify occurrence of these outcomes. DESIGN Retrospective cohort study. SETTING A single academic hospital. PARTICIPANTS Study participants were identified via a pathology and dermatopathology database search for patients diagnosed as having high-risk CSCC. RESULTS Two hundred fifty-six primary high-risk CSCCs were included. Outcomes for AJCC tumor stages T2 to T4 were statistically indistinguishable because only 4 cases (<2% of the cohort) were AJCC stages T3 or T4, which require bone invasion. Subsequently, the bulk of poor outcomes (83% of nodal metastases, 92% of deaths from CSCC) occurred in AJCC stage T2 cases. An alternative tumor staging system was developed with the aim of better stratifying this stage T2 group. Four risk factors were found to be statistically independent prognostic factors for at least 2 outcomes of interest in multivariate modeling. These factors (poor differentiation, perineural invasion, tumor diameter ≥2 cm, invasion beyond subcutaneous fat) were incorporated in the alternative staging with 0 factors indicating T1, 1 factor indicating T2a; 2 to 3 factors, T2b; and 4 factors or bone invasion, T3. Stages T2a and T2b significantly differed in incidences of all 4 end points. Stage T2b tumors comprised only 19% of the cohort but accounted for 72% of nodal metastases and 83% of deaths from CSCC. CONCLUSIONS AND RELEVANCE The proposed alternative tumor staging system offers improved prognostic discrimination via stratification of stage T2 tumors. Validation in other cohorts is needed. Meanwhile, stage T2b tumors are responsible for most poor outcomes and may be a focus of high-risk CSCC study.

Progression-related expression of β3 integrin in melanomas and nevi

The expression of the beta3 integrin subunit was investigated in 130 fixed, paraffin-embedded specimens of human melanomas and nevi using two different monoclonal antibodies. Expression was not observed in melanocytes and was absent or low in most nevi. In primary melanomas, expression was absent or low in the nontumorigenic radial growth phase, which includes the classes of in situ and microinvasive melanomas. In contrast, expression was high in the tumorigenic or vertical growth phase compartment of many primary melanomas and in most metastatic melanomas. Expression patterns were similar with the two antibodies, SSA6 and SAP, and was membrane-related as well as cytoplasmically expressed. In those nevi that reacted focally, the reactivity tended to occur in the dermal component of neurotized nevi, and in Spitz nevi, where the reactivity was stronger and more diffuse. A few dysplastic nevi showed focal reactivity of the junctional component. These results are consistent with tumor progression-related expression of the beta3 integrin, which is expressed in melanocytic tumors as the alphavbeta3 integrin, having affinity for matrix molecules, including vitronectin and fibronectin. In all melanomas, and in the subset of tumorigenic vertical growth phase melanomas, expression increased with thickness (P < .01). For this reason, and because ligation of this integrin has been shown in vitro to have several properties that may be related to the malignant phenotype, it is likely that expression of this marker may have prognostic value. However, because of its consistent and strong expression in Spitz nevi, the diagnostic utility of this marker will likely be limited.

Predicting sentinel node status in AJCC stage I/II primary cutaneous melanoma

Sentinel lymph node (SLN) status is an important prognostic factor for survival for patients with primary cutaneous melanoma. To address the issue of selecting patients at high and low risk for a positive SLN, prognostic factors were sought that predict SLN involvement by examining characteristics of both the primary tumor and the patient within the context of a biological model of melanoma progression.