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Laparoscopic common bile duct exploration (LCBDE) utility in management of choledocholithiasis may decrease length of stay and patient cost, but postoperative management remains widely debated. We examined periprocedural LFTs for patients undergoing LCBDE and endoscopic retrograde cholangiopancreatography (ERCP) speculating for trend existence after successful LCBDE. We hypothesized that postoperative LCBDE LFTs would not downtrend even after successful ductal clearance. We identified 99 patients under 18 who underwent ERCP or LCBDE with at least one pre- and post-procedural LFT. Periprocedural LFTs between groups were compared using Wilcoxon signed-rank tests. The 22 ERCP patients demonstrated a significant downtrend across Tbili (P <.001), AST (P =.001), ALT (P =.002), and ALP (P <.001). The 27 LCBDE patients demonstrated a significant downtrend in Tbili (P =.002) only, while AST (P >.05), ALT (P >.05), and ALP (P >.05) were nonsignificant. Lack of consistent downtrend in the LCBDE group raises doubt regarding the utility of postoperative LFTs for post-procedural management. [ABSTRACT FROM AUTHOR]

Natural groundwater convection in fractures is an important mechanism of mass and heat transfer in the subsurface, locally altering temperature by several tens of degrees. The thermoelastic stresses resulting from these thermal anomalies induce thermal strains, which in turn alter the transmissivity (permeability times thickness) of the fracture and, therefore, the convective flow within. We investigate the effect of thermal strains on fracture convection patterns using a three‐dimensional thermo‐hydraulic‐mechanical numerical model, implementing the Barton‐Bandis relationship between fracture transmissivity and effective normal stress, which results in a downward‐narrowing of the fractures. When thermoelasticity is not taken into account, convection forms narrow upflow zones and wide downflow zones. Decreasing fracture stiffness results in similar upflow/downflow patterns, but restricted to the shallow portions of the fracture, creating relatively minor thermal changes. When thermo‐elasticity is included in the model, thermal strains induced by cool downflow zones create narrow high‐transmissivity channels within the fracture, allowing convective flow to reach greater depths and significantly reducing the geothermal gradient near the fracture. Fracture stiffness is a key parameter in determining convection depth and thermal perturbation strength for a given set of host rock mechanical properties. When fracture stiffness is below some threshold, subsequent contractive thermoelastic strains were found to induce tensile failure of the host rock below the fracture, propagating and deepening the fracture into the host rock. This observation provides support to the previously proposed concept of convective downward migration. Key Points: Natural convection of fluid within a fracture zone with a downward‐tapering transmissivity profile is confined to narrow depthsThermo‐mechanical strains induced by fracture convection create high‐transmissivity downflow channels and increase the depth of convectionThe thermal strain on the host rock may be large enough to propagate and deepen the initial fracture zone [ABSTRACT FROM AUTHOR]

Abstract: We present three‐dimensional numerical simulations of natural convection in buried, vertical en echelon faults in impermeable host rock. Despite the fractures being hydraulically disconnected, convection within each fracture alters the temperature field in the surrounding host rock, altering convection in neighboring fractures. This leads to self‐organization of coherent patterns of upward/downward flow and heating/cooling of the host rock spanning the entire fault array. This “synchronization” effect occurs when fracture spacing is less than the width of convection cells within the fractures, which is controlled by fracture transmissivity (permeability times thickness) and heterogeneity. Narrow fracture spacing and synchronization enhance convective fluid flow within fractures and cause convection to initiate earlier, even lowering the critical transmissivity necessary for convection initiation. Heat flow through the en echelon region, however, is enhanced only in low‐transmissivity fractures, while heat flow in high‐permeability fractures is reduced due to thermal interference between fractures. [ABSTRACT FROM AUTHOR]

Ixodes scapularis Say, 1821 (the black-legged tick) is becoming established in Canada. The northwards expansion of I. scapularis leads to contact between I. scapularis and Ixodes cookei Packard, 1869, a well-established tick species in Eastern Canada. Examination of I. cookei and I. scapularis collected from New Brunswick revealed ticks with ambiguous morphologies, with either a mixture or intermediate traits typical of I. scapularis and I. cookei, including in characteristics typically used as species identifiers. Genetic analysis to determine if these ticks represent hybrids revealed that four had I. cookei derived mitochondrial DNA but I. scapularis nuclear DNA. In one case, the nuclear sequence showed evidence of heterozygosity for I. scapularis and I. cookei sequences, whereas in the others, the nuclear DNA appeared to be entirely derived from I. scapularis. These data strongly suggest genetic hybridization between these two species. Ixodes cookei and hybrid ticks were readily collected from humans and companion animals and specimens infected with Borrelia burgdorferi Johnson et al., 1984, the causative agent of Lyme disease, were identified. These findings raise the issue of genetic introgression of I. scapularis genes into I. cookei and warrant reassessment of the capacity of I. cookei and I. cookei × I. scapularis hybrids to vector Borrelia infection. [ABSTRACT FROM AUTHOR]

Introduction. Acroangiodermatitis is a rare skin disease characterised by hyperplasia of pre-existing vasculature due to venous hypertension from severe chronic venous stasis. Clinical appearance of this condition is often similar to Kaposi sarcoma and is creating serious differential diagnostic difficulties. Case report. A patient with acroangiodermatitis was presented and the differential diagnosis discussed. Examination of the patella of the affected area showed grayish-blue to brown infiltrates and reduced elasticity, located in the supra- and infrapatellar regions. Clinically, Kaposi's sarcoma was suspected. Histopathologically there were acanthosis and compact hyperkeratosis. The underlying papillary dermis showed fibrosis and edema. A subepidermal lobular vascular proliferation with hemosiderin deposition was also noted. This consisted of multiple newly formed capillaries, featuring small blood vessels with dilated, rounded lumina. Serologies for HIV and Borrelia burgdorferi were negative, as was a HHV-8 PCR in lesional tissue. Doppler analysis of the vessels of the extremities showed chronic venous insufficiency, insufficiency of v. perforantes, insufficiency of the Cockett II-III. No deep thromboses in the area of the shank and thigh were found. Initially, treatment consisted of clindamycin 600 mg 3 times per day, intravenously, during a 2-week period. After that the treatment was continued with prednisolone, 30 mg daily in combination with furosemide 40 mg/day, as well as lymph drainage and adequate compression therapy. The consequent clinical improvement allowed the patient to be discharged from the clinic. Conclusion. The most important differential diagnostic marker in distinguishing between acroangiodermatitis and Kaposi sarcoma seems to be the confirmation of the presence of genetic material of HHV-8 in the affected skin areas in patients with Kaposi sarcoma. [ABSTRACT FROM AUTHOR]

Erythema nodosum is the most common type of panniculitis; it may be due to a variety of underlying infectious or otherwise antigenic stimuli. The pathogenesis remains to be elucidated, but both neutrophilic inflammation and granulomatous inflammation are implicated. Beyond treating underlying triggers, therapeutic options consist mainly of nonsteroidal anti-inflammatory drugs, symptomatic care, potassium iodide, and colchicine. Erythema induratum (nodular vasculitis) is a related but distinctly different clinicopathologic reaction pattern of the subcutaneous fat. It is classically caused by an antigenic stimulus from Mycobacterium tuberculosis but may be associated with several other underlying disorders. After appropriate antimicrobial treatment in tuberculous cases, therapy for erythema induratum is similar to options for erythema nodosum. [ABSTRACT FROM AUTHOR]

• Context.-Pseudoneoplastic cutaneous lesions are diverse, not only morphologically but also with respect to their causes and cellular lineages. They include proliferations of epithelial, as well as mesenchymal, elements. Objective.-This review aims to consider selected lesions in the aforementioned groups, contrasting them with histologically similar neoplasms of the skin in a differential diagnostic setting. Data Sources.-Information used in assembling this discussion was drawn from the published literature on cutaneous pseudoneoplasms, using an Internet-based search engine. The authors' collective experience was also used in writing this review. Conclusions.-Sufficient clinical and morphologic differences exist in virtually all instances to separate pseudoneoplastic cutaneous proliferations from the tumors that they imitate. [ABSTRACT FROM AUTHOR]

Background: Melanoma vaccines have not been optimized. Adjuvants are added to activate dendritic cells (DCs) and to induce a favourable immunologic milieu, however, little is known about their cellular and molecular effects in human skin. We hypothesized that a vaccine in incomplete Freund's adjuvant (IFA) would increase dermal Th1 and Tc1-lymphocytes and mature DCs, but that repeated vaccination may increase regulatory cells. Methods: During and after 6 weekly immunizations with a multipeptide vaccine, immunization sites were biopsied at weeks 0, 1, 3, 7, or 12. In 36 participants, we enumerated DCs and lymphocyte subsets by immunohistochemistry and characterized their location within skin compartments. Results: Mature DCs aggregated with lymphocytes around superficial vessels, however, immature DCs were randomly distributed. Over time, there was no change in mature DCs. Increases in T and B-cells were noted. Th2 cells outnumbered Th1 lymphocytes after 1 vaccine 6.6:1. Eosinophils and FoxP3+ cells accumulated, especially after 3 vaccinations, the former cell population most abundantly in deeper layers. Conclusions: A multipeptide/IFA vaccine may induce a Th2-dominant microenvironment, which is reversed with repeat vaccination. However, repeat vaccination may increase FoxP3+T-cells and eosinophils. These data suggest multiple opportunities to optimize vaccine regimens and potential endpoints for monitoring the effects of new adjuvants. Trail Registration: ClinicalTrials.gov Identifier: NCT00705640 [ABSTRACT FROM AUTHOR]

The dermatological disorders associated with monoclonal gammopathies are clinically heterogeneous and may be divided into four groups with distinctive pathogenetic mechanisms (a) specific (infiltrative) disorders including primary and secondary cutaneous plasmacytoma and cutaneous lymphoplasmacytic infiltration of Waldenström’s disease (b) skin disorders because of the deposition of monoclonal immunoglobulin (M protein), including amyloidoisis macroglobulinemia cutis, light chain deposition of Randall’s disease, follicular spicules of the nose, and cryoglobulinemia (c) skin disorders associated with monoclonal gammopathies, including highly associated (>50%), weakly associated (<50%) or anecdotal and (d) miscellaneous (non specific). In most cases, histopathology is crucial to confirm or to diagnose those skin conditions and is also very useful to understand their pathogenetic mechanisms. [ABSTRACT FROM AUTHOR]

Presents the author index for the November 2005 issue of the "Journal of Cutaneous Pathology."

Laparoscopic cholecystectomy (LC) with laparoscopic common bile duct exploration (LCBDE) is gaining traction for the management of choledocholithiasis. Liver function tests (LFTs) are often used to determine the success of ductal clearance, yet the impact of differing therapeutic interventions, endoscopic retrograde cholangiopancreatography (ERCP) or LCBDE, have on postprocedure LFT is insufficiently described. We hypothesize that these interventions have different postoperative LFT profiles. The preprocedural and postprocedural total bilirubin (Tbili), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were analyzed of 167 patients who had successful ERCPs (117) or LCBDEs (50). Endoscopic retrograde cholangiopancreatography patients demonstrated a significant decrease in all LFTs postprocedure (n = 117; P = <0.001 for all) with a continued downtrend when a second set of LFTs was obtained (n = 102; P = <0.001 for all). For successful LC+LCBDEs, there was no significant change between preoperative and 1st postoperative Tbili, AST, ALT, and ALP and the 2nd postoperative labs. [ABSTRACT FROM AUTHOR]

The steep learning curve associated with learning laparoscopic techniques and limited training opportunities represents a challenge to general surgery resident training. The objective of this study was to use a live porcine model to improve surgical training in laparoscopic technique and management of bleeding. Nineteen general surgery residents (ranging from PGY 3 to 5) completed the porcine simulation and completed pre-lab and post-lab questionnaires. The institution's industry partner served as sponsors and educators on hemostatic agents and energy devices. Residents had a significant increase in confidence with laparoscopic techniques and the management of hemostasis (P =.01 and P =.008, respectively). Residents agreed and then strongly agreed that a porcine model was suitable to simulate laparoscopic and hemostatic techniques, but there was no significant change between pre- and post-lab opinions. This study demonstrates that a porcine lab is an effective model for surgical resident education and increases resident confidence. [ABSTRACT FROM AUTHOR]

Dermatopathologists are often confronted with tissue sections that show vacuolar degeneration of the basilar layer, necrotic keratinocytes and upper dermal infiltrates of varying intensity. These are components of the lichenoid tissue reaction (LTR), so named because these are characteristic changes of the prototype disorder, lichen planus. The spectrum of clinical disease within the general category of LTR is quite broad. Ultrastructuraly, lichenoid changes include intercellular edema, separation of basal cells and detachment of their plasma membranes from the lamma densa. These events are reflected in changes in glycoproteins of the basement membrane zone.

Henoch–Schönlein purpura is an acute leukocytoclastic vasculitis that primarily affects children. Henoch–Schönlein purpura is often associated with an infection, and a wide variety of infectious agents have been implicated in the pathogenesis. We report a child with Henoch–Schönlein purpura associated with Helicobacter pylori infection. Treatment of the Helicobacter pylori infection was accompanied by prompt resolution of the Henoch–Schönlein purpura. [ABSTRACT FROM AUTHOR]

The article focuses on how the author met his mentor William Osler who is a professor of medicine at the Johns Hopkins University School of Medicine. Osler was a brilliant teacher and in fact the leading champion of teaching medicine. He was a premier internist, whose own investigations expanded the field

• We study the effect of thermo-mechanics on the temperature evolution of production from a vertically extensive fracture zone. • Simulations include an injector-producer doublet, fracture aperture response to depth-dependent stress, and the geothermal gradient. • The depth-dependent initial aperture and temperature distribution lead to very different thermo-elastic effects and feedbacks on production. • This finding is very different from previous studies that considered either horizontal fracture zones that are geologically less representative for most EGS setting, or employed a constant reservoir temperature that ignores the geothermal gradient. • We think that economic assessment of production from such settings may possibly require revision to become more realistic. Injection of cold water into fracture zones in Enhanced Geothermal Systems (EGS) induces contractive thermo-elastic strains in the host rock, locally altering the stress state of the reservoir. Building on previous studies with horizontal fractures we examined how such thermo-elastic effects act during injection and production from a doublet intersecting a vertically extensive fracture zone embedded in impermeable host rock with a vertical geothermal gradient and with vertical aperture variations in response to stress increase with depth. As in horizontal fracture zones, contractive strains propagate outward from point of injection of cold water and are surrounded, due to stress re-distribution, by a ring zone with increased effective normal stress and, therefore, reduced aperture. The reduced aperture ring affects production temperature evolution to different degrees: for fracture zones with initially homogeneous transmissivity the effect on temperature decline is most pronounced for injection in the deeper well while it is small to negligible for injection in the shallower well. Fractures zones with initially heterogeneous transmissivity distribution experience highly channelized flow and the enhanced normal stresses develop preferentially at the sides of the channels, having little effect on flow along the channel and temperature decline. The effects show systematic variation with the rock's Young's modulus as does the tendency to induce shear failure by thermo-elastic effects. The simulated temperature evolutions deviate significantly from previous models that assessed the economics of EGS with sub-horizontal wells intersecting vertically extensive fractures in which the geothermal gradient and thermo-mechanical were not included. [ABSTRACT FROM AUTHOR]

We present a 32‐year‐old man with successful treatment and remission of mycosis fungoides of both axillae in 2016 after PUVA therapy and systemic and local administration of corticosteroids. Subsequently, in 2017, the patient also achieved remission of a T‐cell CD 30 positive, ALK‐1 negative large‐cell lymphoma of a retroperitoneal and inguinal lymph node after chemotherapy and radiotherapy. One year later, in 2018, the patient presented to our clinic with progression of skin lesions in both axillary areas and the appearance of а tumor in the right gluteal region.Dermatological examination showed livid‐to‐erythematous, partly sclerotic plaques in the right inguinal area, cutis laxa‐like plaque formations in the right axillary region with similar but less‐developed changes in the left axillary fold, a solitary subcutaneous tumor formation affecting the entire right gluteal region, and enlarged, palpable lymph nodes in the right para‐axillary area. Biopsies were obtained from an axillary lesion and the surgically removed axillary lymph nodes, and histological examination revealed changes of granulomatous slack skin in the axilla and reactive inflammatory changes in the lymph nodes. Histology of gluteal tissue showed a "foreign body" type of reaction with sarcoid‐like features, where the patient in the past have been injected with anabolic and steroidal drugs. Herein we describe a patient with simultaneous occurrence of granulomatous slack skin type mycosis fungoides and a sarcoid‐like reaction. The question remains open whether this represents the so‐called sarcoidosis‐lymphoma syndrome or, more likely, granulomatous slack skin MF associated with a sarcoid‐like reaction of "foreign body" type. The possibility that disturbance of tissue homeostasis by incorporation of certain adjuvants within injections (for example) in the past might have been an inducer of cutaneous T cell lymphoma and sarcoidosis/sarcoid like lesions seems reasonable but also speculative. [ABSTRACT FROM AUTHOR]

Malignant melanoma is an oncologic disease, whose current management among others includes surgical and immunological therapy. According to the current recommendations of the American Joint Committee on Cancer, the surgical excision of the primary tumor should be performed in two operative sessions, which has several consequences. The following paper will present and discuss six cases of pigmented lesions and the advantages of the one‐step melanoma surgery in their management. [ABSTRACT FROM AUTHOR]

Offers observation on the accusations against the U. S. Environmental Protection Agency (EPA) of abrogation of its congressionally mandated mission to protect human health and the environment. Purported examples of dereliction of agency duty; Information on a report issued on August 21, 2003 by U.S. EPA Inspector General Nikki L. Tinsley which focuses on air quality and associated health concerns;

This article focuses on a case study of a 48 year old woman, who had developed contact dermatitis from sodium lauryl sulfate (SLS) in hydrocortisone cream. The woman developed an eczematous otitis externa and was treated with 1.0% hydrocortisone cream U.S.P. After one month an open patch test to the hydrocortisone 1.0% cream U.S.P. was applied. The results of patch test were found to be negative. The patient was then patch tested to the individual components of the hydrocortisone cream, which were supplied by the manufacturer. With the exception of SLS all patch tests were negative.

Although described as early as 1975 as a distinct, rare form of cancer with diverse localization, primary cutaneous adenoid cystic carcinoma (PCACC) remains a mystery and challenge for both clinicians and pathologists. The clinical presentation cannot be clearly distinguished from amelanotic melanoma or intradermal nevus, Merkel cell carcinoma, trichofolliculoma, trichoepithelioma or other rare tumors of the adnexa, or dermatofibrosarcoma protuberans. The histopathological diagnosis requires not only careful evaluation of standard hematoxylin/eosin preparations, but also immunohistochemical staining with a number of markers such as epithelial membrane antigen (EMA), S-100, SOX-10, Ki-67, CD-117 (c-kit), Vimentin, carcinoembryonic antigen (CEA), Ber-EP4 and many others. The surgical approach should consist of excision with margins between 1 and 2 cm, with the choice of margins depending upon the histopathological findings in the primary excisional specimen. We present a 31-year-old patient with an enlarging, amelanotic, plaque-like tumor of the scalp with a duration of no more than 18-24 months. Surgical treatment was performed within two surgical sessions with a total resection field of 1.3 cm. A good cosmetic result was achieved. [ABSTRACT FROM AUTHOR]

In this article the author discusses various developments related to the journal. He informs about the appointment of journal's new editor Timothy H. McCalmont and acknowledges the contribution of several people in the periodical's success including members of editorial board and publishers. He also expresses gratitude for the support given by the journal's contributors and readers, and gives suggestions to the authors on sending publishing material to the journal.

The author of the article offers an opinion regarding plagiarism in an article previously published in the journal in 2008. According to the article, the protocols of the Committee on Publication Ethics were followed when dealing with the incident. The article concludes that despite the oversight on the part of the authors of the original article, the scientific work was valid and the materials, methods, and results of the research were original.

A preface for the previous issue of the "Journal of Cutaneous Pathology" is presented.

The author comments on the growth of the "Journal of Cutaneous Pathology" concerning the increasing popularity of dermatopathology as a specialty. He introduces the monthly features of the said journal. He includes the critical reviews of selected papers related to dermatopathology and a formal Continuing Medical Education (CME) Continuing Medical Education program. Moreover, article features will offer readers the opportunity to obtain CME credits by reading selected articles.

Focuses on the vision and background of the "Journal of Cutaneous Pathology." Aim of the founder of the journal to provide a forum for communication between clinicians and researchers in the field of skin pathology; Recognition of the contribution of the past editors of the journal on its development; Supremacy of the journal among publications devoted to pathology and dermatology.

The article presents a message from the outgoing chairman of the board of editorial review for "Water Environment Research." The author reflects on the opportunity given to him to work with an outstanding group of colleagues on behalf of the journal. This also gave him the opportunity to work with dedicated professionals and the patient staff of the journal. The author officially transferred the position to incoming chairman Dr. Prakasam Tata.

The ingestion of large amounts of boric acid, a component of household insecticides, is a rare occurrence, characterized by a diffuse desquamative skin eruption, neutropenia, thrombocytopenia, delirium, acute renal failure and prolonged ileus. A 56-year-old male with a history of multiple previous suicide attempts was witnessed ingesting household roach killer and 4 days later presented to the hospital with lethargy, stiffness and a diffuse erythematous and desquamative eruption with bullous formation. He subsequently developed erythema of both palms as well as alopecia totalis. Histopathology from a right arm shave biopsy revealed a mostly intact epidermis with subtle vacuolar alteration of the basal layer, scattered intraepidermal apoptotic keratinocytes, parakeratosis with alternating layers of orthokeratosis and considerable superficial exfoliation; accompanying dermal changes included vasodilatation and mild perivascular inflammation. This report describes the cutaneous and systemic complications in a rare case of boric acid ingestion. There is little published material on the symptoms and histopathology following boric acid ingestion, but knowledge of this entity is important, both to differentiate it from other causes of desquamative skin rashes and to allow the initiation of appropriate clinical care. [ABSTRACT FROM AUTHOR]

Background: Atypical fibroxanthoma (AFX) is a pleomorphic spindle cell lesion of the skin; it is considered in the differential diagnosis with spindle cell malignant melanoma (MM) and sarcomatoid carcinoma/spindle cell squamous cell carcinoma (SCC). An optimum approach has yet to fully emerge with respect to the immunohistochemical discrimination of these lesions. Methods: Departmental archives from 1978 onwards were searched for clinicopathologically confirmed cases of AFX, MM and SCC. Immunostains for CD10, CD99 and p63 were performed in each case. Scored staining results were analyzed using Fisher's Exact Test. Results: Twenty-seven of 31 cases of AFX were positive for CD10, as compared with 3 of 22 SCCs and 0 of 20 MMs. CD10 positivity was preferentially associated with the diagnosis of AFX (p < 0.001). p63 reactivity was observed in 15/22 cases of SCCs, 5/31 AFXs and 1/20 MMs. CD99 reactivity was observed in 3/31 cases of AFX, 2/22 SCCs and 3/20 MMs. Conclusion: CD10 positivity is relatively specific in this context for the diagnosis of AFX. Its utility is enhanced when only strong, diffuse membranocytoplasmic staining is considered as a positive result. In contrast to prior reports, p63 was not found to be highly sensitive for SCC. Similarly, CD99 showed no preferential staining of any single diagnostic group of lesions. Kanner WA, Brill LB, Patterson JW, Wick MR. CD10, p63 and CD99 expression in the differential diagnosis of atypical fibroxanthoma, spindle cell squamous cell carcinoma and desmoplastic melanoma. [ABSTRACT FROM AUTHOR]

Background: In 1952, Zoon described a series of patients with dense plasma-cell infiltrates in the glans penis. Since then, similar Zoon-like lesions (ZLL) have been described on the external female genitalia and in the airways, for which over 20 designations currently exist. Methods: Twenty-eight cases of ZLL, twenty-two cases of lichen planus, eight cases of plasmacytoma and two cases of syphilis were evaluated from the surgical pathology archive at the University of Virginia. Twenty-four histologic data points were tabulated in each case, including 12 epidermal and 12 dermal features. Results: Histopathologic findings were similar in the majority of cases of ZLL, regardless of their location. They demonstrated superficial cutaneous erosions, basal vacuolar alteration and many showed lozenge-shaped keratinocytes in the epiderms. The dermis contained a dense inflammatory infiltrate composed predominantly of plasma cells, with scattered neutrophils and lymphocytes. Dense fibrosis was seen in the upper dermis. Conclusions: A uniform nomenclature for ZLL does not exist. Based on the results of this analysis, we suggest that the generic term idiopathic lymphoplasmacellular mucositis-dermatitis be considered to encompass the lymphoplasmacellular infiltrates in the skin and mucosal surfaces considered herein. This designation is morphologically descriptive and can be applied regardless of anatomic location. Brix WK, Nassau SR, Patterson JW, Cousar JB, Wick MR. Idiopathic lymphoplasmacellular mucositis-dermatitis. [ABSTRACT FROM AUTHOR]

CD34-positive stromal cells (CD34SC) are distributed throughout the body, including the dermis. They are thought to play a role in maturation and proliferation of adjacent mesenchymal and epithelial stem cells and in immune responses. To investigate the role of such cells in wound healing after excision of cutaneous lesions, we examined the distribution and quantity of CD34SC in scars from the sites of removal of malignant skin tumors and from reconstructive surgery, as well as in samples of normal skin. In normal skin, CD34 staining was confined to dendritic cells in the dermis, endothelial cells, perifollicular cells and eccrine glands. In cutaneous scars, the cicatricial tissue was totally devoid of CD34SC. However, the dermis adjacent to scar showed increased numbers of CD34SC as compared with normal skin [41.5 cells/mm2 vs . 24.5 cells/mm2 (p < 0.001)]. We conclude that CD34SC disappears from scars but are induced to proliferate in pericicatricial tissue. The cells in question may play a role in remodeling of scarred skin. One should be aware that augmented labeling for CD34SC around scars is common; it should not be interpreted as evidence for the persistence or recurrence of tumors that may also express CD34. [ABSTRACT FROM AUTHOR]

Solitary fibrous tumor (SFT) is a relatively uncommon neoplasm that most commonly arises in the pleura. However, SFT is now known to affect various other anatomic sites as well, including rare examples in the skin, where the histologic features of this lesion may create diagnostic confusion with a variety of other spindle-cell tumors. In order to further the characterization of cutaneous SFT, all available cases of that entity were retrieved from the authors’ institutional files. Immunohistochemical analysis for CD-34, CD-99, vimentin, bcl-2, factor XIIIa, S100 protein, smooth muscle actin, pankeratin, epithelial membrane antigen (EMA) and desmin was performed on those neoplasms and the corresponding clinical information was obtained whenever possible. There were eight men and two women in the study group, with a median age of 43 years. Sites of involvement included the trunk (two cases), cheek (two), scalp (one), forehead (one), lip (one), temple (one), heel (one) and toe (one). All patients were treated with local excision; only one lesion recurred locally, but it required multiple re-excisions. All of the neoplasms were composed of bland spindle cells with a variably fibrous but focally hyalinized collagenous stroma. A variety of case-specific growth patterns were observed. Mitoses were generally rare, ranging from 0 to 3 per 10 ×400 microscopic fields. Immunostains showed reactivity for vimentin in all SFTs, CD-34 in 8 of 10 cases, CD-99 and bcl-2 in 4 of 10 (each) and smooth-muscle actin in 3 of 10 cases. None of the lesions was labeled for factor XIIIa, keratin, EMA, desmin or S100 protein. SFT of the skin appears to be a ‘borderline’ neoplasm that only uncommonly recurs. Immunoreactivity for CD-34, – especially together with bcl-2 or CD-99, or both – is helpful in identifying this tumor. [ABSTRACT FROM AUTHOR]

The histopathologic distinction between pigmented actinic keratosis (PAK) and atypical junctional melanocytic proliferations (AJMP) is a common problem, and it is one with meaningful clinical significance. Previous publications have suggested that Melanocyte Antigen Related to T-cells-1 (MART-1) – a melanocytic marker related to host immune response – was not useful in making this interpretative separation. To revisit that assertion, the authors selected 68 specimens that concerned the diagnosis of PAK vs. AJMP. The degree of morphologic difficulty attached to each case was rated semiquantitatively using a three-tiered scale, and interpretative problems were caused by cytologic similarity between atypical keratinocytes and aberrant melanocytes, obscuring lichenoid inflammation, subepidermal fibrosis, and an absence of clearly defined cell nests at the dermoepidermal junction. Each biopsy sample was immunostained for MART-1 (using antibody clone A103) with azure-B counterstaining; the principal criterion for a diagnosis of AJMP was that of confluent cellular positivity over at least 1 high-power (×400) microscopic field, in conjunction with nested cell growth. The specimens were then re-examined diagnostically. Immunostaining definitely improved interpretative certitude in 65 examples (96% effectiveness); the final diagnosis was that of PAK for 21 lesions and AJMP for 47. Three specimens – all of which represented AJMP – did not benefit by MART-1 staining. It is concluded that MART-1 immunostaining with azure-B counterstaining is a useful adjunct in the interpretation of problematic intra-epidermal pigmented lesions. [ABSTRACT FROM AUTHOR]

Calciphylaxis and metastatic calcification are known complications of chronic renal failure. Recently, a sclerosing condition of the skin termed nephrogenic fibrosing dermopathy (NFD) has been described in patients with renal disease, many of whom have undergone hemodialysis and/or renal transplantation. To our knowledge, the simultaneous occurrence of both conditions in the same patient, in the same lesion, has not been previously reported. We report the clinical, microscopic, and immunohistochemical features of two patients with chronic renal failure whose lesional skin biopsies showed both subcutaneous calcification and NFD. We consider the possible mechanisms that might explain the coexistence of these two disorders. Both patients presented with erythematous, indurated skin over the lower extremities. Purpuric, reticulated patches, necrosis, or ulceration were not observed. Microscopic examination showed the characteristic changes of NFD involving dermis and subcutaneous septa. In addition, biopsies of both individuals showed subcutaneous calcification, one in a diffuse distribution and the other involving the walls of subcutaneous vessels, as seen in calciphylaxis. Calcification was not suspected clinically in either case. Metastatic calcification or calciphylaxis and NFD can occur simultaneously in patients with chronic renal failure and may be found together in the same lesion. Because subcutaneous calcification may not be suspected clinically in these cases, and in view of the adverse outcomes frequently associated with calciphylaxis, we recommend deep incisional biopsy of patients presenting with the clinical features of NFD. Both the fibrosis and the calcification of chronic renal failure may be related to the activity of transforming growth factor-β/Smad signaling cascades. Edsall LC, English III JC, Patterson JW. Calciphylaxis and metastatic calcification associated with nephrogenic fibrosing dermopathy. [ABSTRACT FROM AUTHOR]

Background: A new formulation of doxorubicin (pegylated liposomal doxorubicin) has been developed to attenuate the systemic side effects produced by this agent. Although pegylated liposomal doxorubicin has a much lower risk for cardiotoxicity, it has been associated with cutaneous side effects that differ from, and may also be more frequent than, those produced by the free form of the drug. Methods: We report a case of interface dermatitis with keratinocyte dysmaturation, limited to the intertriginous areas, in a patient who received pegylated liposomal doxorubicin, and we review the literature. Results: It is possible that the enhanced delivery of doxorubicin in liposomal form promotes cutaneous side effects of the drug. We consider the possible mechanisms for keratinocyte dysmaturation produced by this form of doxorubicin. Conclusions: Our findings further suggest that inflammatory changes seen on biopsy may not always allow a reliable histopathologic distinction between this chemotherapy effect and graft-versus-host disease. [ABSTRACT FROM AUTHOR]

Background: The delineation of radial and vertical growth phases in primary cutaneous malignant melanomas has contributed to our understanding of melanoma progression and has enhanced the ability of pathologists to provide clinicians with meaningful prognostic information. Vertical growth phase (VGP) lesions have the potential to metastasize, but radial growth phase (RGP) melanomas are believed to lack competence for metastasis. Methods: We have identified three cases in which metastasis occurred in association with lesions initially interpreted as RGP melanomas. To determine whether these cases truly represented exceptional metastasizing RGP melanomas or VGP lesions incorrectly identified as RGP lesions, careful microscopic re-review of these cases was performed. Results: In one case, additional microscopic sectioning revealed a focus of vertical growth that was not evident on the original sections. In the other two cases, only radial growth was found. In one of these cases there was melanoma in situ with regressive changes, but no evidence for invasive melanoma. In the other, a RGP lesion was associated with an adjacent compound nevus with periadnexal involvement. Conclusions: These cases suggest that, while true RGP melanomas have an excellent prognosis, caution must be exercised in defining a lesion as having no metastatic potential when multiple sections of the primary lesion are unavailable, when the lesion is accompanied by regressive changes, or when there is an associated melanocytic nevus. It is possible that strictly defined RGP melanomas may metastasize in very rare cases. Our observations also suggest that metastatic potential is a function of numerous factors, and may not be evaluable on morphological grounds alone. [ABSTRACT FROM AUTHOR]

Provides information on male breast cancer in the United States. Epidemiology; Etiology; Clinical presentation; Clinical evaluation; Histopathology; Disease staging; Prognosis; Therapy.

Lipedematous alopecia is a rare condition of unknown etiology characterized by a thick, boggy scalp with varying degrees of hair loss that occurs in adult black females, with no clearly associated medical or physiologic conditions. The fundamental pathologic finding consists of an approximate doubling in scalp thickness resulting from expansion of the subcutaneous fat layer in the absence of adipose tissue hypertrophy or hyperplasia. Observations by light and electron microscopy detailed in this report suggest that this alteration principally manifests by localized edema with disruption and degeneration of adipose tissue. Some diminution in the number of follicles as well as focal bulb atrophy is noted. Aberrant mucin deposition such as that seen in myxedema or other cutaneous mucinoses is not a feature. The histologic findings bear some resemblance to those seen in lipedema of the legs, a relatively common but infrequently diagnosed condition. We present a case of lipedematous alopecia with emphasis on histologic and ultrastructural features. The etiology is unknown. [ABSTRACT FROM AUTHOR]

The article discusses the diagnosis for disseminated gonococcal infection (DGI), also referred to as arthritis-dermatitis syndrome. It presents the case of a 22-year-old African-American female patient who presented with rash and severe ankle pain. The first-line treatment for DGI is intravenous ceftriaxone, with conversion to oral cefixime.

Liesegang rings represent an in vivo chemical precipitation phenomenon representing a potential diagnostic pitfall for misdiagnosis as parasitic infections. These acellular patterns of lamellar concretions are rare in human tissue. The authors report a case of Liesegang rings observed within an intradermal apocrine hidrocystoma and review the literature for reports of these structures, with particular emphasis on mucocutaneous lesions. Gilchrist HM, Wick MR, Patterson JW. Liesegang rings in an apocrine hidrocystoma. [ABSTRACT FROM AUTHOR]

Background Mycosis fungoides ( MF) is the most common primary cutaneous T-cell lymphoma ( CTCL), followed by CD30+ lymphoproliferative disorders, including lymphomatoid papulosis ( Ly P) and primary cutaneous anaplastic large cell lymphoma (pc ALCL). The objective was to report on a series of patients with different types of CTCL at different times in their clinical course, with a focus on clonality studies. Methods Four patients with multiple diagnoses of CTCLs were identified. The clinical information, treatment interventions, and histopathology were reviewed. T-cell receptor ( TCR) gene rearrangement studies were performed on all available specimens. Results The four patients carried diagnoses of: (1) pc ALCL and MF; (2) pc ALCL, Ly P, and pc ALCL; (3) Ly P, MF, and pc ALCL; (4) Ly P, pc ALCL, and MF; each with characteristic presentation and histopathologic findings. The results of the TCR polymerase chain reaction showed that all tumors expressed and retained a TCR clone(s) as follows: (1) biallelic clone; (2) single clone; (3) biallelic clone with additional clone; and (4) single clone, respectively. Conclusion We report a series of four cases of individual patients with coexisting diagnoses of some combination of MF, Ly P, and pc ALCL, whose lesions presented in nontraditional sequence and demonstrated a retained clone by gene rearrangement analysis. [ABSTRACT FROM AUTHOR]

Objective To characterize epidemiologic and clinical features of red primary amelanotic melanomas, an atypical presentation of melanoma that is underemphasized in patient and physician education. Patients and methods Review of a prospectively collected melanoma database identified 46 patients with red amelanotic melanomas, whose clinical features were compared with 329 patients with pigmented melanomas from the same database and same timeframe from January 1964 to September 2005. Results Red amelanotic melanomas represented 3.9% of all melanomas recorded in our database and accounted for nearly 70% of amelanotic melanomas. Melanoma was included in the clinical differential diagnosis in 32% of red amelanotic melanomas vs. 94% of pigmented melanomas ( P < 0.001). Red amelanotic melanomas more commonly underwent shave biopsy (55 vs. 12%, P < 0.001) and more likely had positive deep margins (35 vs. 9%, P < 0.001) but had comparable risks of metastasis and mortality. Conclusion Red amelanotic melanomas are often misdiagnosed clinically but carry a mortality risk comparable to pigmented melanomas. Clinicians screening for melanoma should be more vigilant in considering melanoma in the differential diagnosis of red skin lesions. [ABSTRACT FROM AUTHOR]

Immune cells infiltrating the microenvironment of melanoma metastases may either limit or promote tumor progression, but the characteristics that distinguish these effects are obscure. In this study, we systematically evaluated the composition and organization of immune cells that infiltrated melanoma metastases in human patients. Three histologic patterns of immune cell infiltration were identified, designated immunotypes A, B, and C. Immunotype A was characterized by no immune cell infiltrate. Immunotype B was characterized by infiltration of immune cells limited only to regions proximal to intratumoral blood vessels. Immunotype C was characterized by a diffuse immune cell infiltrate throughout a metastatic tumor. These immunotypes represented 29%, 63%, and 8% of metastases with estimated median survival periods of 15, 23, and 130 months, respectively. Notably, from immunotypes A to C, there were increasing proportions of B cells and decreasing proportions of macrophages. Overall, the predominant immune cells were T cells (53%), B cell lineage cells (33%), and macrophages (13%), with natural killer and mature dendritic cells only rarely present. Whereas higher densities of CD8+ T cells correlated best with survival, a higher density of CD45+ leukocytes, T cells, and B cells also correlated with increased survival. Together, our findings reveal striking differences in the immune infiltrate in melanoma metastases in patients, suggesting microenvironmental differences in immune homing receptors and ligands that affect immune cell recruitment. These findings are important, not only by revealing how the immune microenvironment can affect outcomes but also because they reveal characteristics that may help improve individualized therapy for patients with metastatic melanoma. [ABSTRACT FROM AUTHOR]

The clinical and histopathological diagnosis of pityriasis rubra pilaris (PRP) can be difficult because clinical findings are often subtle in early stages, and microscopic findings can overlap with those of other skin diseases. Focal acantholytic dyskeratosis (FAD) can rarely be seen in PRP and can mimic Darier's disease, Grover's disease or other disorders characterized by these histopathologic features. Kaposi's varicelliform eruption is a widespread infection due to herpes simplex virus (HSV) types 1 and 2, coxsackievirus A16 or vaccinia virus, occurring in a preexisting dermatosis; only one case has been reported in PRP. We report a patient with PRP whose biopsies showed both herpes simplex infection and FAD. A complete understanding of the mechanism behind this eruption evolved gradually, aided in great measure by the histopathologic findings. Erdag G, Lockman D, Tromberg J, Cropley T, Patterson JW. A case of pityriasis rubra pilaris with associated focal acantholytic dyskeratosis complicated by Kaposi's varicelliform eruption. [ABSTRACT FROM AUTHOR]

Two of the most challenging areas in dermatopathology are lymphoproliferative disorders and melanocytic lesions. We present a case of peripheral T-cell lymphoma occurring with an intradermal melanocytic proliferation. A 63-year-old Caucasian man presented with a 12-cm edematous, erythematous to violaceous, scalp ulceration that had enlarged over six months. Previous biopsies showed reactive changes which were concerning for infection. The last biopsies showed small to intermediate sized, angulated cells with clear cytoplasm within the dermis, with extension into the epidermis. These cells stained positive with markers for CD3, CD45RO and CD43, yet showed decreased expression of pan-T-cell markers CD5 and CD7, and absent expression of CD4, CD8, CD56 and CD57 and EBV. Molecular studies showed a clonal T-cell receptor gamma chain gene rearrangement. The diagnosis was peripheral T-cell lymphoma, unspecified. Another biopsy from an indurated area separate from the ulcer showed scattered, enlarged cells embedded in the same lymphocytic infiltrate. No mitotic figures were identified. These cells stained for S100 and Melan-A, in a partly nested arrangement. This was felt to represent a melanocytic nevus. This case likely represents an extraordinary coincidence of two distinctly different neoplasms. Kanner WA, White KP, Barry CI, Lee AJ, Cousar JB, Wick MR, Patterson JW. Cutaneous T-cell lymphoma occurring with a melanocytic proliferation, masquerading as a nonhealing ulcer with reactive changes. [ABSTRACT FROM AUTHOR]

Large-cell acanthoma (LCA) is a sharply demarcated epidermal lesion composed of large keratinocytes and characterized by hyperkeratosis, hypergranulosis and orthokeratosis. It usually affects actinically damaged skin. LCA is currently believed to be a distinct entity with an unclear pathogenesis and a benign biologic behavior. Here, we describe the first occurrence of LCA in the conjunctiva. The lesion recurred following initial excision, and later recurred as a carcinoma in situ following a second excision. This case suggests that LCA may have a malignant and transformation potential. Ghazi NG, Patel BS, Olsakovsky Leslie A, White K, Patterson JW. A conjunctival lesion with histological features similar to large-cell acanthoma of the skin. [ABSTRACT FROM AUTHOR]

Successful management of epithelial skin cancers with imiquimod 5% cream (Aldara®), an immunomodulatory agent, led to speculation that it may promote an immune response against melanoma. Studies, mostly case reports, have assessed the value of imiquimod as a topical treatment for dermal melanoma metastases that prove difficult to manage surgically. The precise value of imiquimod, however, in treatment of dermal and subcutaneous metastases remains unclear. A case at our institution elucidates histopathologically that subcutaneous metastases may progress despite excellent treatment of superficial dermis in the same location. In preparation for a clinical trial using imiquimod to treat patients with dermal melanoma metastases, we have treated several patients off protocol. We present a case report in which the observed changes are documented photographically and histologically. The patient experienced dramatic improvement in the locally treated dermis with concurrent regional treatment failure in the subcutaneous space. Our experience supports growing evidence that imiquimod for some provides an effective option for dermal disease. The unique histological documentation we provide regarding the differential effectiveness of imiquimod in treating various tissue components may help guide future investigations regarding optimal clinical application of imiquimod therapy for melanoma metastases. [ABSTRACT FROM AUTHOR]