In vivo confocal laser scanning microscopy of melanocytic skin tumours: diagnostic applicability using unselected tumour images

BACKGROUND: In vivo confocal laser scanning microscopy (CLSM) represents a novel imaging tool that allows the noninvasive examination of skin cancer morphology in real time at a 'quasi-histopathological' resolution viewing microanatomical structures and individual cells. OBJECTIVES: To validate diagnostic confocal examination of melanocytic skin tumours using unselected tumour images. METHODS: In the present study, we used a total of 3709 unselected CLSM tumour images obtained from 20 malignant melanomas and 50 benign naevi. The entire set of images derived from each tumour was evaluated by independent observers. Classification tree analysis based on a subsample of 857 tumour images was performed to develop a diagnostic algorithm. RESULTS: Overall, sensitivity and specificity of 97.5% and 99% could be achieved by the independent observers (positive predictive value 97.5%, negative predictive value 99%). Classification tree analysis yielded a three-step algorithm based on only three morphological CLSM features, facilitating a correct classification in 92.4% of the benign naevus images and 97.6% of melanoma images. CONCLUSIONS: In vivo CLSM augurs a sea change in the way we will view skin tumour processes clinically at the bedside and merits application for use as a screening tool in skin oncology.     

T-regulatory cells predict clinical outcome in soft tissue sarcoma patients: a clinico-pathological study

Background Soft tissue sarcomas (STS) are generally considered non-immunogenic, although specific subtypes respond to immunotherapy. Antitumour response within the tumour microenvironment relies on a balance between inhibitory and activating signals for tumour-infiltrating lymphocytes (TILs). This study analysed TILs and immune checkpoint molecules in STS, and assessed their prognostic impact regarding local recurrence (LR), distant metastasis (DM), and overall survival (OS).Methods One-hundred and ninety-two surgically treated STS patients (median age: 63.5 years; 103 males [53.6%]) were retrospectively included. Tissue microarrays were constructed, immunohistochemistry for PD-1, PD-L1, FOXP3, CD3, CD4, and CD8 performed, and staining assessed with multispectral imaging. TIL phenotype abundance and immune checkpoint markers were correlated with clinical and outcome parameters (LR, DM, and OS).Results Significant differences between histology and all immune checkpoint markers except for FOXP3+ and CD3−PD-L1+ cell subpopulations were found. Higher levels of PD-L1, PD-1, and any TIL phenotype were found in myxofibrosarcoma as compared to leiomyosarcoma (all p < 0.05). The presence of regulatory T cells (Tregs) was associated with increased LR risk (p = 0.006), irrespective of margins. Other TILs or immune checkpoint markers had no significant impact on outcome parameters.Conclusions TIL and immune checkpoint marker levels are most abundant in myxofibrosarcoma. High Treg levels are independently associated with increased LR risk, irrespective of margins.Subject terms: Tumour biomarkers, Prognostic markers     

Iatrogenic ulnar nerve injury after pin fixation and after antegrade nailing of supracondylar humeral fractures in children

Background and purpose

Ulnar nerve injury may occur after pinning of supracondylar fractures in children. We describe the outcome and compare the rates of iatrogenic injuries to the ulnar nerve in a consecutive series of displaced supracondylar humeral fractures in children treated with either crossed pinning or antegrade nailing.

Methods

Medical charts of all children sustaining this fracture treated at our department between 1994 and 2009 were retrospectively reviewed regarding the mode of treatment, demographic data including age and sex, the time until implant removal, the outcome, and the rate of ulnar nerve injuries.

Results

503 children (55% boys) with an average age of 6.5 years sustained a type-II, type-III, or type-IV supracondylar fracture. Of those, 440 children were included in the study. Antegrade nailing was performed in 264 (60%) of the children, and the others were treated with crossed pins. Iatrogenic ulnar nerve injury occurred in 0.4% of the children treated with antegrade nailing and in 15% of the children treated with crossed pinning. After median 3 (1.6–12) years of follow-up, the clinical outcome was good and similar between the 2 groups.

Interpretation

Intramedullary antegrade nailing of displaced supracondylar humeral fractures can be considered an adequate and safe alternative to the widely performed crossed K-wire fixation. The risk of iatrogenic nerve injury after antegrade nailing is small compared to that after crossed pinning.In children, supracondylar fractures are the most common type of fracture of the elbow region (Omid et al. 2008). Boys usually have a higher incidence of this type of fracture but some recent reports in the literature describe rising rates in girls (Cheng et al. 2001). Most of the patients are 5–7 years old (Davis et al. 2000, Omid et al. 2008, Zamzam and Bakarman 2009). At this age, the potential for fracture remodeling decreases; therefore, malreduction may lead to persistent deformity (Wessel et al. 2003).In displaced fractures, the most common operative treatment is closed reduction and pin fixation. Different techniques have been reported, but crossed pinning with postoperative immobilization is the preferred technique (Brauer et al. 2007, Kocher et al. 2007, Zamzam and Bakarman 2009). Iatrogenic injury to the ulnar nerve has been described in up to 20% of the cases treated with crossed pinning (Lyons et al. 1998). In addition, radial pinning may damage the radial and anterior interosseous nerve (Brauer et al. 2007, Kocher et al. 2007, Omid et al. 2008).In 1990, a technique with antegrade nailing for supracondylar fractures was first described by Prevot et al. (1990). Schaffer et al. (2007) and Weinberg et al. (2003) treated 60 and 50 children with this technique and reported no iatrogenic injuries to the ulnar nerve.We determined the outcome and compared the rates of iatrogenic injuries to the ulnar nerve in a consecutive series of displaced supracondylar humeral fractures in children treated with either crossed pinning or antegrade nailing.     

Quantitative assessment of epidermal Langerhans cells using automated image analysis

Background/aims: Langerhans cells play a central role In the skin immune system. Quantitative changes have been observed in a variety of dermatological conditions. This paper presents a user-independent automated measurement procedure for Langerhans cells in vertical skin sections. Methods: Frozen sections were stained immunohistochemically with a CD1 monoclonal antibody. Counterstaining was performed with Mayer's hematoxylin. An image analysis procedure was developed, which automatically recognizes the area occupied by the epidermis and the CD1 -positive structures, respectively. Results: The procedure was tested on specimens of normal skin and of chronic cutaneous lupus erythematosus. The results significantly reflect the decrease of Langerhans cells in the latter condition. Conclusion: The proposed image analysis program facilitates a fully automated measurement of immunohistochemically stained epidermal structures in vertical skin sections.     

Classification and prognosis of cutaneous T-cell lymphomas

Modern concepts on the classification and prognosis of cutaneous T-cell lymphomas are discussed in this paper. The full spectrum of cutaneous T-cell lymphomas is not yet known. A new classification of histomorphological types of mycosis fungoides and Sézary's syndrome in correlation with prognostic features is proposed.     

Cutaneous metastases of a giant cell tumor of bone: case report

A 47-year-old patient with the previous history of a giant cell tumor of the left femur presented with 3 cutaneous nodules located on the face. Histologic examination revealed skin metastases of a giant cell tumor of bone, with dermal and subcutaneous nodules characterized by multinucleate giant cells and mononuclear cells. The patient died 10 months later from widespread metastases to the lung and brain. A panel of enzymo- and immunohistochemical markers reactive and osteoclastic, fibroblastic and histiocytic determinants was tested on the cutaneous lesions. The results indicated osteoclastic lineage of the multinucleate giant cells whereas the mononuclear cells showed features of fibroblastic differentiation. Cutaneous metastasis from a giant cell tumor of bone is an extraordinary event and so far has only been reported once.     

Sensitivity and specificity of confocal laser-scanning microscopy for in vivo diagnosis of malignant skin tumors

BACKGROUND: Melanoma and nonmelanoma skin cancer are the most frequent malignant tumors by far among whites. Currently, early diagnosis is the most efficient method for preventing a fatal outcome. In vivo confocal laser-scanning microscopy (CLSM) is a recently developed potential diagnostic tool. METHODS: One hundred seventeen melanocytic skin lesions and 45 nonmelanocytic skin lesions (90 benign nevi, 27 malignant melanomas, 15 basal cell carcinomas, and 30 seborrheic keratoses) were sampled consecutively and were examined using proprietary CLSM equipment. Stored images were rated by 4 independent observers. RESULTS: Differentiation between melanoma and all other lesions based solely on CLSM examination was achieved with a positive predictive value of 94.22%. Malignant lesions (melanoma and basal cell carcinoma) as a group were diagnosed with a positive predictive value of 96.34%. Assessment of distinct CLSM features showed a strong interobserver correlation (kappa >0.80 for 11 of 13 criteria). Classification and regression tree analysis yielded a 3-step algorithm based on only 3 criteria, facilitating a correct classification in 96.30% of melanomas, 98.89% of benign nevi, and 100% of basal cell carcinomas and seborrheic keratoses. CONCLUSIONS: In vivo CLSM examination appeared to be a promising method for the noninvasive assessment of melanoma and nonmelanoma skin tumors.     

Melanoma ex naevo: a study of the associated naevus

It has been shown that the co-occurrence of melanoma and pre-existing naevus is not a random event and that acquired naevi may be precursors of melanoma. A critical area of chromosomal loss at 9p21 has been implicated in the genesis of malignant melanoma, representing a site of frequent somatic chromosomal deletions in melanoma. Allelic deletions within this chromosomal region most often include the tumour suppressor gene p16. The objective of this study was to search for allelic deletions on chromosome 9p21 in naevus cell clusters. A microdissection-based approach was used to analyse 30 archived primary cutaneous melanomas and associated naevi for loss of heterozygosity (LOH) at 9p21 using the polymorphic DNA markers D9S171 and IFNA. LOH was detected in 10 out of 27 informative naevi (37%) at D9S171 and in eight out of 19 (42%) at IFNA in the dissected naevus cell clusters, and in nine out of 27 (33%) at D9S171 and seven out of 19 (36%) at IFNA in the associated melanomas. In eight out of 46 (17%) cases, LOH was detected simultaneously in the naevus and the associated melanoma using both markers. Our results suggest a causal relationship for the development of melanoma within a pre-existent associated naevus. These data support the hypothesis that lesions within 9p21 play an important role in early melanoma development, since these genetic alterations are found in histologically benign melanoma-associated naevi.