Zendee Elaba

CD10-positive blastoid mantle cell lymphoma with secondary cutaneous involvement

To the Editor, Mantle cell lymphoma (MCL) comprises 3–10% of all non-Hodgkin lymphoma subtypes and usually pursues an aggressive clinical course.1– 4 Skin involvement is found in 2–6% of patients. Classical MCL (constituting the majority of cases) shows a monotonous proliferation of smallto mediumsized centrocyte-like lymphoid cells with slightly irregular nuclear contours, low mitotic index and expression of pan B-cell antigens and CD5 but not CD23 or bcl-6. The hallmark of MCL is the t(11;14)(q13;q32)/CCND1-IGH translocation, resulting in aberrant expression of the CCND1 gene and expression of cyclin D1 protein by tumor cells.1– 4 The vast majority of cases are negative for CD10 protein expression.1– 5 In concert with the typical chromosomal translocation and other immunophenotypic findings, the absence of CD10 reactivity is commonly used to distinguish MCL from other subtypes of B-cell lymphoma. The blastoid variant of MCL develops in 10–30% of patients with classical MCL and likely represents transformation of the original clone.1– 4 Blastoid MCL may be cytologically indistinguishable from other high-grade B-cell lymphomas, in particular lymphoblastic lymphoma.4 There are rare reports of cutaneous involvement by blastoid MCL, with most examples representing secondary involvement of the skin by underlying widespread systemic disease.1– 4 A 71-year-old man presented to his dermatologist with rapidly growing papules of recent onset on his right cheek (Fig. 1). The patient had a history of classical MCL of the left tonsil 5 years before with multiple subsequent recurrences involving the base of the tongue, but no evidence of oral disease at present. A skin punch biopsy Fig. 1. Rapidly growing papules of recent onset are noted on the right cheek.

Development of a curriculum in molecular diagnostics, genomics and personalized medicine for dermatology trainees.

Results of molecular studies are redefining the diagnosis and management of a wide range of skin disorders. Dermatology training programs maintain a relative gap in relevant teaching.

Basal cell carcinoma with matrical differentiation.

incontinentia pigmenti-like distribution. Eur J Dermatol 2008; 18: 477–478. 7 Wu JJ, Su YN, Hsiao CH, et al. Macular amyloidosis presenting in an incontinentia pigmenti-like pattern with subepidermal blister formation. J Eur Acad Dermatol 2008; 22: 635–637. 8 Partington MW, Marriott PJ, Prentice RS, et al. Familial cutaneous amyloidosis with systemic manifestations in males. Am J Med Genet 1981; 10: 65–75.

Molluscum contagiosum virus infection in benign cutaneous epithelial cystic lesions-report of 2 cases with different pathogenesis?

To the Editor: The coexistence of molluscum contagiosum virus (MCV) infection in an epidermal inclusion cyst is rarely described. We report 2 additional cases of MCV infection in benign cutaneous epithelial cystic lesions with different histopathologic features. The possible different pathogenesis of these cystic skin lesions with regard to MCV infection is discussed. Case 1 is a 51-year-old woman presented to her dermatologist with a flesh-colored papule (approximately 0.7 cm in diameter) on her left upper posterior thigh. A small central ostium was noted. The lesion was present for approximately 2 months but was asymptomatic. The patient had no known history or evidence at presentation of MCV lesions on the skin surface. The preliminary clinical diagnosis was of an epidermal inclusion cyst (EIC). A shave excision of the lesion was performed. The specimen was routinely formalin fixed, paraffin embedded and entirely sectioned with 5-mM sections stained with hematoxylin and eosin (H+E) for histopathologic review. H+E-stained sections revealed a small unilocular cyst with scattered foci of eosinophilic inclusion bodies within the cyst wall, consistent with MCV cytopathic changes. The intervening cyst wall showed an intact granular layer with overlying cornified cells in a laminated and basket weave pattern (Fig. 1). Case 2 is a 32-year-old man presented to his dermatologist with

Nodular localized primary cutaneous amyloidosis: a bullous variant

Primary cutaneous amyloidosis describes a group of disorders in which amyloid is deposited in the skin without evidence of systemic involvement. Nodular localized primary cutaneous amyloidosis (NLPCA) is a rare form of these skin‐restricted amyloidoses. We present an unusual case of NLPCA in a 51‐year‐old man, who had clinical and histopathological evidence of subepidermal bullous formation, a unique feature in NLPCA. The possible pathogenesis of this change is discussed.

Molecular diagnostic strategies: a role in the practice of dermatology

Molecular diagnostic strategies are gaining wider acceptance and use in dermatology and dermatopathology as more practitioners in this field develop an understanding of the principles and applications of genomic technologies. Molecular testing is facilitating more accurate diagnosis, staging, and prognostication, in addition to guiding the selection of appropriate treatment, monitoring of therapy, and identification of novel therapeutic targets, for a wide variety of skin diseases.

Molecular Pathogenesis of Melanoma: Established and Novel Pathways

Melanoma is the eighth most common malignancy in the USA and has shown a rapid increase in its incidence rate over the past two decades, especially for early-stage disease [1–4] A recent analysis of data from the Surveillance Epidemiology and End Results (SEER) Program indicates that the incidence of melanoma increases with age, showing somewhat different patterns in men and women [3]. This cancer arises from melanocytes, which are specialized pigmented cells that are predominantly found in the skin and eyes, where they produce melanin, the pigment responsible for skin and hair color.

Blastoid mantle cell lymphoma with cutaneous involvement and aberrant immunophenotype.

1. Rongioletti F, Gallo R, Cozzani E, et al. Leprosy: a diagnostic trap for dermatopathologists in nonendemic area. Am J Dermatopathol. 2009;31:607–610. 2. World Health Organization. Global leprosy situation, 2009. Wkly Epidemiol Rec. 2009;84: 333–340. 3. Jolliffe DS. Leprosy reactional states and their treatment. Br J Dermatol. 1977;97:345–352. 4. Gomes JG, Penna GO, Castro LCM, et al. Erythema nodosum leprosum: clinical and therapeutic update. An Bras Dermatol. 2002;4:389– 407. 5. Lopez C, Oliver M, Olavarria R, et al. KikuchiFujimoto necrotizing lymphadenitis associated with cutaneous lupus erythematosus: a case report. Am J Dermatopathol. 2000;22:328–333. 6. Toll A, Gilaberte M, Matias-Guiu X, et al. Kikuchi’s disease (necrotizing lymphadenitis) with cutaneous involvement associated with subacute cutaneous lupus erythematosus. Clin Exp Dermatol. 2004;29:240–243. 7. Yen A, Fearneyhough P, Raimer SS, et al. EBV-associated Kikuchi’s histiocytic necrotizing lymphadenitis with cutaneous manifestations. J Am Acad Dermatol. 1997;36:342–346.

Randomized comparison of virtual microscopy and glass microscopy among dermatology and pathology residents during a simulated in‐training examination

To the Editor, Virtual microscopy (VM) is increasingly being used in medical education. The technique is also being incorporated into board certification examinations in dermatology and pathology. However, relatively few studies exist to compare diagnostic accuracy using VM with that of traditional glass slide microscopy (GM) in the setting of graduate medical education in these specialties. Among those studies that have, either both dermatology and pathology residents were not tested or the examinations were not timed. The purpose of this study was to determine whether examination scores of dermatology and pathology residents would be equivalent when tested using these 2 microscopy formats under timed conditions. In addition, the opinions of examinees regarding the 2 techniques were assessed. The study protocol was approved by the Institutional Review Board of Quinnipiac University, UConn Health and Hartford Hospital. Dermatopathology cases of a similar level of diagnostic difficulty (12 inflammatory/12 neoplastic, Table 1) were selected. Whole-slide images were created using a digital slide scanner at ×20 magnification (Aperio Technologies, Vista, California). Image files were held on the server at Quinnipiac University and viewed remotely at the UConn Health Department of Dermatology and the Hartford Hospital Department of Pathology. Examinees included 8 residents in dermatology (PGY2-4) and 13 residents and fellows in pathology (PGY1-5). All trainees had completed a rotation in dermatopathology. Examinees were randomly assigned to view 12 cases by GM and 12 cases by VM, and allotted 30 minutes to complete the examination via each modality. Following the examination, participants were required to provide their opinions regarding the 2 techniques by completing a questionnaire. Residents performed similarly using the 2 methods, with mean number correct [SD] out of a possible 12 found to be 8.00 [1.90] and 8.64 [1.79] for VM and GM, respectively. The 95% confidence interval for the difference in mean scores was determined to be −0.14 to 1.42. Therefore, the test of the null hypothesis that a difference in scores greater than 2 exists between methods was rejected (t test, P = .0008). Thus, no meaningful difference in diagnostic accuracy was found. On a scale of 1-5 (1 = Poor, 2 = Fair, 3 = Good, 4 = Very Good, 5 = Excellent), participants evaluated the ease of viewing glass slides (4.2 [1.1]) as significantly greater than that for virtual slides (3.3 [0.9]) (mean score [SD], Wilcoxon signed rank P = .012). No examinee reported difficulty in use of the glass slides. However, 65% of participants described minor issues viewing the virtual slides, with perceived slow loading times being the most commonly reported. Two participants also felt they needed higher magnification (×40) of the scanned digital slides. Overall, 75% of examinees stated that they would prefer GM to be utilized for histopathology instruction during residency training, while 25% favored the virtual format. However, many participants provided comments stating that with improved image loading speeds, they would be interested in using, or even prefer to use, VM in the setting of residency education. The ability of residents to accurately diagnose dermatopathology cases was equivalent when tested using VM and GM, despite their overall preference for the latter. The partiality of some examinees for the virtual technique may be attributed to their willingness to embrace new technology. This study demonstrated that it is possible to access VM slides remotely, albeit with potentially slow loading times. It should be noted that loading speeds are generally faster when image files are kept on a server within the testing institution. Limitations in this work included the number of trainees and types of dermatopathology cases examined. Future studies are needed in which access to a larger number of examinees would permit evaluation of test scores relative to years of postgraduate training and experience with VM. A broader array of cases, as well as ×40 magnification, would allow a more accurate or rigorous assessment of the digital technique’s usefulness to dermatology and pathology graduate medical education. For the purpose of providing information to institutions interested in this technology, the following are estimated costs to adopt VM. The current price of an Aperio digital slide scanner equivalent to the unit employed in our study, with installation and training, is

Recurrent CD4−/CD8− peripheral T‐cell lymphoma with change in cytoarchitectural features and immunophenotype over the course of disease

160 000. Estimated data storage cost is