The histomorphologic spectrum of primary cutaneous diffuse large B-cell lymphoma: a study of 79 cases

Primary cutaneous large B-cell lymphomas (PCLBCL) have historically been a matter of debate in the literature. The 2005 World Health Organization-European Organization for Research and Treatment of Cancer (WHO-EORTC) classification scheme segregated cutaneous B-cell lymphomas into 3 groups: primary cutaneous marginal zone B-cell lymphoma, primary cutaneous follicle center cell lymphoma, and primary cutaneous diffuse large B-cell lymphoma (PCDLBCL), "leg type" (PCDLBCL-LT). Additionally, the WHO-EORTC classification scheme utilized the term PCLBCL "other" not otherwise specified (NOS) type for rare cases of PCLBCL not belonging to either the "leg type" or the primary cutaneous follicle center cell lymphoma group. In this study, we retrospectively assessed the histomorphologic features of 79 cases of PCDLBCLs, including those of "leg type" and "other" NOS type, to further categorize the histologic spectrum of these unusual cutaneous neoplasms. The histologic diagnosis of PCLBCL usually poses little diagnostic difficulty; however, some cases may adopt unusual or unfamiliar appearances mimicking other lymphoproliferative disorders or other malignant neoplasms. Seventy-nine cases, occurring in 37 men and 42 women, aged 34-94 years, were analyzed. Fifty-three cases were classified as "leg type" and 26 cases were classified as "other" NOS type using the WHO-EORTC classification. Of the 53 cases classified as "leg type," 33 were women and 20 were men; of the 26 cases of "other" NOS type, 9 were women and 17 were men. In the "leg type" category, 31 cases were located on the lower extremities, 5 cases on the face, 5 cases on the arm, 3 cases on the chest, 2 cases on the shoulder, 2 cases on the back, 1 case on the trunk, 1 case on the buttock, 1 case on the supraclavicular area, 1 case on the head, and 1 case on the flank. Of the "other" NOS type category, 8 cases were located on the face, 5 cases on the shoulder, 3 cases on the head, 2 cases on the abdomen, 2 cases on the chest, 1 case on the trunk, 1 on the vulva, 1 on the axilla, 1 on the back, 1 on the neck, and 1 on the hip. Most cases assessed showed the classic morphologic appearance of PCDLBCL, but cases mimicking Burkitt lymphoma (starry-sky pattern), natural killer-cell (NK) lymphoma, mycosis fungoides (epidermotropism), low-grade B-cell lymphomas, epithelial malignancies, and Merkel cell carcinoma were encountered in this series. The high frequency of these rare histologic patterns can be explained by a bias associated with consultation practice. Careful histologic examination and immunohistochemical stains were used to establish the correct diagnosis. The differential diagnosis of PCDLBCL is broad and difficult to define histologically. Knowledge of these rare histologic variants is necessary to avoid misinterpretation of these cases as nonlymphoid malignancies.     

CHRONIC HYPERPLASTTC CANDIDIASIS—CANDIDAL LEUKOPLAKIA

SUMMARY. Twelve cases of chronic hyperplastic candidiasis of the oral mucosa are described.
Clinically the lesions could not be reliably differentiated from "leukoplakia" due to other causes. All but 2 of the patients were otherwise healthy.
The histological appearances were distinctive: there was invasion by hyphae of C. albicans of the superficial epithelium of an acanthotic and parakeratotic plaque, associated with a characteristic intraepithelial inflammatory reaction.
In 9 cases the antibody titres to C. albicans in serum and saliva supported a diagnosis of candidiasis.
The response of the lesions to oral Nystatin was good in 3 cases and incomplete in 4.
The evidence that C. albicans plays an essential causative rather than a secondary role is critically discussed.
Recognition of chronic hyperplastic candidiasis from other "leukoplakias" is of practical importance since this condition is potentially reversible by medical treatment.     

Neuroendocrine differentiation in basal cell carcinomas

Ten consecutive cases of basal cell carcinomas were reviewed. Nine of these displayed the typical histology of basal cell carcinoma, the other case was composed of small spindle to ovoid cells with scant cytoplasm and a high mitotic rate, resembling an "oat cell" carcinoma. These were studied using the immunoperoxidase technique for tissue localization of calcitonin, insulin, glucagon, somatostatin, ACTH, gastrin and nerve growth factor. Three cases were negative for all hormones tested. Three cases were focally positive for a single hormone; one each for calcitonin, somatostatin, and ACTH. Two cases were focally positive for ACTH and somatostatin and two cases were focally positive for calcitonin, somatostatin and ACTH. None of the other hormones displayed activity. The positive staining was eliminated after absorption by the specific antigen. This immunohistochemical study illustrated neuroendocrine differentiation in basal cell carcinomas as has previously been suggested by the Grimelius stain and electron microscopy. Thus, as demonstrated in other epithelial neoplasms, basal cell carcinoma may also display neuroendocrine differentiation. This illustrates the potential multidirectional differentiation in neoplastic epithelial cells.     

Bubble hair

An unusual hair dystrophy was studied by means of light and electron microscopy. Hair fibers demonstrated a boomerang deformity containing small and large "bubbles". Electron microscopy revealed a loss of cortical cells and medulla at these sites. Cross-section images showed either a single large cavity or a reticulated, "swiss cheese-like" loss of cells. These two cases represent the second and third reported cases of bubble hair deformity. We present the second light and electron microscopic study of this disorder, including new electron microscopic findings. The cause of bubble hair deformity remains obscure. The involved tufts of wiry hair resolved with gentle hair care. This suggests that trauma to the hair shaft may play a role. It is likely that additional cases of bubble hair remain unrecognized. Investigation of other patients with localized tufts of wiry hair is likely to reveal additional cases.     

Granuloma annulare with prominent lymphoid infiltrates ("pseudolymphomatous" granuloma annulare)

Granuloma annulare (GA) is characterized histopathologically by 3 patterns: necrobiotic granuloma, interstitial incomplete form and, rarely, sarcoidal or tuberculoid granuloma. The amount of lymphoid infiltrate in GA is usually limited. We describe 10 cases of GA with prominent "pseudolymphomatous" lymphoid infiltrates mimicking cutaneous lymphoid hyperplasia. Patients were 6 males and 4 females (mean age 49.9 years, median age 47 years, age range 25-70). Lesions were localized to a limited area of the body (n = 6), or involved the entire trunk (n = 3), or were generalized (n = 1). The correct clinical diagnosis of GA was provided only in 30% of the cases. In all cases, histopathologic features were characterized by dense, nodular, superficial, and deep infiltrates of lymphocytes. Immunohistology revealed predominance of T lymphocytes in 7 of 7 tested cases. This "pseudolymphomatous" variant of GA represents a pitfall in the histopathologic diagnosis of the disease and may be misinterpreted as other types of cutaneous lymphoproliferative disorders.     

Palisading cutaneous fibrous histiocytoma

We report 6 cases of an unusual variant of cutaneous fibrous histiocytoma in which nuclear palisading is a prominent feature. The lesions were equally distributed between males and females with a widely variable age range. Half of the cases occurred on the digits. Histopathologically, the lesions were characterized by areas of nuclear palisading with formation of Verocay-like bodies in addition to the more typical features of the "fibrous" variant of cutaneous fibrous histiocytoma. The differential diagnostic features between these lesions and those of other tumors in which nuclear palisading is seen are discussed.     

Transmission of HIV-1 infection by oroanal intercourse.

We report the cases of two homosexual men, one of whom is believed to have been infected with HIV-1 during oroanal intercourse with the other, his only current sexual partner. Both patients had sero-conversion illnesses with similar symptoms and signs, and of similar duration. The practise of oroanal intercourse is known to be associated with the transmission of enteric infections and has been implicated in the epidemiology of Kaposi's sarcoma. These well-documented cases indicate that HIV-1 may also be transmitted by this route and supports a cautious approach to recommendations regarding "safer" sex.     

Microbiological analysis of the ejaculate in andrology

Microbiological analysis of semen in andrology is mainly performed in cases of infertility and artificial insemination. In order to localize the suggested infection and to detect urethral (asymptomatic) colonization, we recommend to analyse additional specimens of the patient, i.e. urethral swabs and first portion of urine. As a rule, quantitative microbiological analysis is necessary in cases of bacteria belonging to the group of potentially pathogenic flora. In isolating pathogenic ("specific") bacteria, the detection of a few microorganisms indicates an infectious process. We recommend the careful microscopical examination of the ejaculate to detect phagocytes, abnormal spermatozoa, trichomonads, yeasts and other cells. As a rapid microscopical examination we employ the DAPI-fluorochrome-technique. Microbiological cultures should take into consideration the isolation and identification of ureaplasmas and chlamydia trachomatis. In order to achieve a comparison of microbiological results with those of other laboratories, it is essential to define the terms "significant bacteriospermia" and "significant leukocytospermia". In other words, it is necessary to introduce a borderline between contamination and infection concerning the "nonspecific" potentially pathogenic flora.     

Trichotillomania associated with the "Friar Tuck sign" and nail-biting

Trichotillomania is a form of traction alopecia resulting from compulsive repetitive removal of one's own hair. This entity can mimic the clinical appearance of many other forms of hair loss including alopecia areata, androgenetic alopecia, and tinea capitis. It is important to differentiate trichotillomania from other forms of alopecia because its treatment is quite different. We present three cases of trichotillomania demonstrating the "tonsure pattern" or "Friar Tuck sign" and onychophagia (nail-biting), which we describe as clinical identifying features of this syndrome.     

Cutaneous lesions in POEMS syndrome. Apropos of 3 case reports and a review of the literature

We present three new cases of POEMS syndrome with the most common cutaneous signs of this entity. The syndrome is a multivisceral complex, mostly described in Japanese patients, which includes polyneuropathy, organomegaly, endocrine disorders, monoclonal gammopathy and skin changes. The latter are constant but sometimes reduced to one type of lesion. The most frequent are hyperpigmentation sparing the mucosae, hypertrichosis, scleroderma-like skin thickening and capillary angiomas. The other signs are much less common, as shown in table I. Histological findings are seldom reported and usually have little specificity. None of these abnormalities is pathognomonic, but their predominance at the extremities may be suggestive and leads to a search for other elements of the syndrome, notably gammopathy. The main differential diagnostic problem is with scleroderma, sometimes circumscribed and often systemic. Some cases are very ambiguous. The relationship between the two diseases would suggest the existence of one or several common pathogenic factors. The overall physiopathology of POEMS syndrome is obscure. The role of endocrine disorders in the genesis of the cutaneous signs is subject to discussion: hyperoestrogenism may explain some of these signs, but hypertrichosis is incompatible with the frequent finding of low androgen secretion. The role of one or several "toxic" substances secreted by plasmocytes is highly hypothetical. In some cases, the skin abnormalities have regressed after treatment of gammopathy, and in rare patients the recurrence of gammopathy was followed by that of skin lesions. In a few cases, a "paraneoplastic" character may be suspected.     

Basal cell carcinoma with matrical differentiation. Matrical carcinoma

Three unusual cases of basal cell carcinoma showing matrical differentiation as evidenced by the focal presence of "shadow cells" within basaloid islands are described. The term basal cell tumor with matrical differentiation seems to be appropriate for this type of tumor. Its differentiation from other tumors, particularly malignant pilomatricoma, is also discussed.     

Cutaneous Psammomatous Melanotic Schwannoma

Background: Melanotic schwannoma is a pigmented nerve tumor that may be located in the skin and express local aggressivity. This tumor may occur singly. It may also be part of the Carney complex which consists of various, but specific, tumors. Objective: We report two cases of subcutaneous melanotic schwannoma localized on the trunk in two men aged 37 and 45 years. Methods: Conventional histology and immunohistochemistry were performed. Results: One melanotic schwannoma was associated with a cutaneous atypical myxoma and multiple melanocytic lesions, all being part of the Carney complex. The other case had no associated signs. In both cases, the melanotic schwannoma was completely excised and did not recur. Conclusion: Melanotic schwannoma is rare and curable by surgery. It must not be confused with malignant melanoma and other pigmented neoplasms. The Carney complex should be carefully ruled out.     

A Study of Correlation Between Clinical and Histopathological Findings of Erythroderma in North Bengal Population

Background:

Erythroderma is a reaction pattern characterized by erythema and desquamation of 90% or more body surface area along with some metabolic alterations.

Materials and Methods:

Here we studied 32 patients of erythroderma at of North Bengal Medical College for a period of 1 year to find the etiology, clinical features and histological changes. Detailed history was taken from all the patients followed by relevant biochemical investigations and histological examination. To correlate the clinical and histopathological findings chi square test was used.

Results:

Male preponderance was present and most of them were in the 4^th or 5^th decade. Etiologically the patients were divided into secondary erythroderma developing over pre-existing dermatoses, and idiopathic erythroderma. Secondary erythroderma (n = 24) cases outnumbered the idiopathic cases (n = 8). Among the pre-existing dermatoses, psoriasis was found to be the most common etiologic agent. Apart from erythema the other common presenting features were scaling and itching. Histopathological categorization was possible in 59.3% cases, rest of the cases showed non-specific dermatitis. The most common histopathologic diagnosis was psoriasis (21.8% of cases).

Conclusions:

Our study of clinicopathological correlation of erythroderma patients among north bengal population corroborates with most of the previous studies done in other areas. As ours is a cross-sectional study in a undefined population so we could not determine the true incidence of erythroderma in north bengal population. We might have missed lymphoma as a cause of erythroderma in idiopathic cases due to lack of long follow-up, so we understand that further studies over a defined population with long follow-up is needed to determine the true incidence and causes of idiopathic erythroderma.     

Epidermotropic metastases from internal carcinomas

Four cases of epidermotropically metastatic carcinoma are reported. One of them originated from a breast adenocarcinoma; in two other cases, the primary tumor was located in the large intestine; and, in the fourth case, the primary malignancy was a laryngeal squamous cell carcinoma. Clinically, the cutaneous metastases were nodular lesions and histologically, in addition to the involvement of the dermis by malignant cells, in three cases there was intraepidermal involvement by glandular structures. In the fourth case, the cutaneous metastatic tumor cells showed striking "folliculotropism." We review the literature of epidermotropically metastatic carcinoma and discuss its differential diagnosis.     

Plexiform spitz nevus: an intradermal spitz nevus with plexiform growth pattern

Two cases of a distinctive variant of Spitz (spindle and epithelioid cell) nevus are described. One lesion developed on the lower leg of a 17-year-old boy and the other lesion on the back of a 52-year-old man. The microscopic appearance was characterized by a plexiform arrangement of bundles and lobules of enlarged spindle to epithelioid melanocytes throughout the superficial and deep dermis. Intraepidermal melanocytic proliferation was unappreciated. Some lobules were circumscribed by a thin rim of compressed fibrous tissue. In both cases a myxoid stroma was present. The cells had abundant eosinophilic cytoplasm with well-defined borders. The nuclei were enlarged, consistently ovoid and vesicular, with small nucleoli. Both cases contained scattered multinucleate giant cells similar to those observed in classical form of Spitz nevi. No melanin pigment was detectable by light microscopy. No mitoses were observed in one case and a rare mitosis was present in the other. Tumor cells were strongly immunoreactive for S-100, but not for HMB-45, desmin, and actin. The differential diagnosis of this distinctive tumor includes desmoplastic/neurotropic melanoma, plexiform spindle cell nevus, cellular blue nevus, plexiform neurofibroma, and cellular neurothekeoma. The designation of "plexiform Spitz nevus" is chosen to emphasize its distinctive plexiform growth pattern.     

Incidence and ten-year follow-up of primary cutaneous lymphomas: a single-centre cohort study

Background

Primary cutaneous lymphomas (PCLs) are a rare group of extranodal non-Hodgkin lymphomas, and epidemiological data in Mediterranean countries are scarce.

Objective

To investigate the incidence and characteristics of PCL in a single tertiary referral centre in Italy.

Materials & methods

A total of 141 PCL patients, seen over a 10-year follow-up period, were investigated.

Results

Incidence rate of PCL was 0.8 cases/100,000 person years. T-cell lymphoma represented 78.7% of all cases, the majority being early mycosis fungoides (MF) (64%; median age: 66 years), followed by lymphomatoid papulosis (LyP) (19%; median: age 48 years), and others (median age: 72 years), including eight cases of anaplastic large CD30+ T-cell lymphoma, four CD4+ smallmedium pleomorphic T-cell lymphoproliferative disorder, four Sézary syndrome, one subcutaneous panniculitis-like T-cell lymphoma, one extranodal NK/T-cell lymphoma nasal-type, and one angioimmunoblastic T-cell lymphoma. B-cell lymphoma accounted for 21.3% of PCL, with 20 cases of cutaneous follicular centre B-cell (median age: 63 years), four primary cutaneous marginal zone, three primary cutaneous diffuse large B-cell, and three leg-type lymphoma. Complete remission within the first year after diagnosis occurred in 70.4% of MF, 61.9% of LyP, 78.9% of other T-cell lymphoma, and 93.1% of B-cell lymphoma cases. Based on a Cox proportional hazard regression model, age, gender, stage, and lactate dehydrogenase and β2-microglobulin blood levels did not predict clinical remission ofMFor LyP.

Conclusions

The incidence and characteristics of PCL in Italy are similar to those in other European countries. PCLs may be diagnosed at very early stages with good prognosis.

     

Digital imaging: a diagnostic screening tool?

BACKGROUND: Much interest has been shown in the possibility of using digital images to aid in the more rapid diagnosis of patients with dermatologic disease. A study was undertaken to test the efficacy of the "teledermatology" screening of referrals, and thereby to triage the patients to appropriate care. METHODS: A retrospective comparison of digital and "face-to-face" diagnoses by two consultant dermatologists was made. Eighty-four images from 75 patients seen in general dermatology clinics were studied. The clinical diagnosis and treatment plan of the patients seen in the clinic by one dermatologist were then compared with those suggested on digital image only, as seen by the other dermatologist. RESULTS: The diagnostic correlation between the two observers was fair, with full agreement in 47 of 84 cases (56%) and partial agreement in a further 10 (12%). There was no agreement in 14 cases (16.7%); in a further 13 cases, the images and history were not sufficient to allow a diagnosis to be made. The image quality was considered to be poor in 18 cases, but in six of these a diagnosis was still attempted. It was recommended that 66 patients (88%) should be seen in the hospital setting. Thirty patients (40%) received treatment at their visit. CONCLUSIONS: Teledermatology is not likely to have a great impact on reducing waiting lists. It is possible that it may help to prioritize referrals from remote areas.     

Tinea capitis: 73 cases observed in Bordeaux (author's transl)

73 cases of tinea capitis were observed in the "H?pital des Enfants" in Bordeaux during these last five year. 71 children under 14 years of age and only 2 adults have seen. The dermatophytic spectrum transformation noticed in other parts of Western Europe is also encountered in Bordeaux. 83 p. 100 are affected by zoo-antropophilic dermatophytes, M. canis chiefly in town, T. mentagrophytes, T. verrucosum in rural aeras. The cases are often familial, from an infected animal, but without any interhuman transmission. Only 8 out of 73 cases are due to strict antropophilic dermatophytes and are found in newly arrived immigrants from North Africa (T. violaceum, T. sch?nleini) of from West Africa (M. langeroni, T. ferrugineum, T. soudanense). Not a single case of scholar transmission could be observed. Cure by micronised griseofulvine per os (15 mg/kg/day) associated with local care was effective in all cases.     

青岛宰猪加工厂职业性皮肤病的调查研究

本文报告了青岛某宰猪加工厂发生职业性皮肤病的情况.该厂主要的职业性皮肤病是手部皮炎,患病率为26.2%.它可分为两型:指间浸演糜烂型和角层剥脱辍裂型.另外还有甲床炎、甲沟炎及皮肤外伤等.猪胰腺组织的皮肤斑试结果88%为阳性,证明摘胰工人的手部皮炎、甲床炎及甲沟炎主要是由于接触胰腺引起的.至于其他工人的手部皮炎,笔者认为水的长期浸演是主要的原因.根据调查情况及病因探讨本文提出了几项预防建议.