Histologic and Phenotypic Factors and MC1R Status Associated with BRAF(V600E), BRAF(V600K), and NRAS Mutations in a Community-Based Sample of 414 Cutaneous Melanomas.

Cutaneous melanomas arise through causal pathways involving interplay between exposure to UV radiation and host factors, resulting in characteristic patterns of driver mutations in BRAF, NRAS, and other genes. To gain clearer insights into the factors contributing to somatic mutation genotypes in melanoma, we collected clinical and epidemiologic data, performed skin examinations, and collected saliva and tumor samples from a community-based series of 414 patients aged 18 to 79, newly diagnosed with cutaneous melanoma. We assessed constitutional DNA for nine common polymorphisms in melanocortin-1 receptor gene (MC1R). Tumor DNA was assessed for somatic mutations in 25 different genes. We observed mutually exclusive mutations in BRAF(V600E) (26%), BRAF(V600K) (8%), BRAF(other) (5%), and NRAS (9%). Compared to patients with BRAF wild-type melanomas, those with BRAF(V600E) mutants were significantly younger, had more nevi but fewer actinic keratoses, were more likely to report a family history of melanoma, and had tumors that were more likely to harbor neval remnants. BRAF(V600K) mutations were also associated with high nevus counts. Both BRAF(V600K) and NRAS mutants were associated with older age but not with high sun exposure. We also found no association between MC1R status and any somatic mutations in this community sample of cutaneous melanomas, contrary to earlier reports.

Transcriptional basis for hepatic fibrosis in cystic fibrosis-associated liver disease.

OBJECTIVES: Liver disease contributes to significant morbidity and mortality in cystic fibrosis (CF). Although all patients with CF express the defective CF transmembrane conductance regulator in cholangiocytes, many develop asymptomatic fibrosing liver disease. Only some develop cirrhosis, with pathogenesis remaining enigmatic. Available noninvasive diagnostic tools do not identify patients at risk before development of advanced fibrosis. We conducted a pilot study to identify genes associated with hepatic injury and fibrosis on liver biopsy that may help elucidate determinants of CF-associated liver disease (CFLD). METHODS: Liver tissue from children with CFLD with various stages of hepatic fibrosis was compared with pediatric controls using cDNA array analysis. Differential expression of genes of interest was then assessed relative to pediatric control liver and non-CF cholestatic disease control liver from patients with biliary atresia, using both real-time reverse transcription-polymerase chain reaction and immunohistochemistry. RESULTS: cDNA array demonstrated differential expression of numerous genes associated with hepatic fibrogenesis including collagens, matrix metalloproteinases, and chemokines in CFLD versus normal controls, particularly decreased expression in tissue remodeling genes including plasminogen activator inhibitor-1 (PAI-1, up to 25-fold) and tissue inhibitor of metalloproteinase-1 (TIMP-1); this was validated by real-time reverse transcription-polymerase chain reaction (PAI-1, P = 0.004; TIMP-1, P = 0.019). No significant decrease in PAI-1 or TIMP-1 mRNA was observed in biliary atresia versus normal control. Immunohistochemistry confirmed the decreased expression of hepatic PAI-1 and TIMP-1 protein in CFLD versus both normal and biliary atresia disease controls. CONCLUSIONS: The coordinated differential expression of these genes associated with liver fibrosis provides evidence for a transcriptional basis for the pathogenesis of CFLD and provides avenues for further study. Clarifying the pathogenesis of CFLD will facilitate techniques for early, precirrhotic detection and targeted interventions.

Periocular keratoacanthoma: clinical features, pathology, and management.

PURPOSE: To review the clinical features and results of surgical treatment of keratoacanthoma of the eyelids. DESIGN: Retrospective, interventional case series. PARTICIPANTS: Ten patients. METHODS: Chart review of all eyelid keratoacanthomas treated between 1992 and 2001. MAIN OUTCOME MEASURES: Adequate excision, recurrence rate, and complications. RESULTS: Patient ages ranged from 27 to 78 years, with a mean age of 59 years. Six patients were male and four were female. The lesion was found on the lower lid in five patients, upper lid in two, medial canthus in two, and lateral canthus in one. The maximum diameter of the lesion varied from 2 to 25 mm, with a mean of 7.2 mm. All lesions were treated by surgical excision, with frozen-section control of margins in five cases. All lesions were excised completely with clear resection margins, and there were no cases of recurrence. The only complication was a minor wound infection in one patient. Mean follow-up was 34.5 months. CONCLUSIONS: Because of the aggressive nature and uncertain relationship to squamous cell carcinoma, we recommend excision of periocular keratoacanthoma. Surgical excision of eyelid keratoacanthoma provides good results and a very low risk of recurrence. Frozen-section control of margins should be used in selected cases to ensure complete excision.

Management of periocular basal cell carcinoma with modified en face frozen section controlled excision.

PURPOSE: To determine the rate of recurrence of basal cell carcinomas (BCCs) after modified en face frozen section-controlled excision in a high-risk population in Queensland, Australia. METHODS: Retrospective, noncomparative interventional case series. A review was conducted of all patients with periocular BCCs examined between 1992 to 2001 in a tertiary oculoplastics practice. Basal cell carcinomas were surgically excised, and the recurrence rates under modified en face frozen section control, Mohs micrographic surgery, and no frozen section control were documented. Epidemiologic aspects of periocular BCC in Queensland, Australia were also studied. RESULTS: In patients with primary BCCs, 0.71% (3 of 423 lesions) recurred when excised under frozen section control (mean follow-up, 2.6 years). At 5-year follow-up, the recurrence rate was 2.1% (2 of 97 lesions). Excision without frozen section control yielded a recurrence rate of 1.8% (2 of 113 lesions; mean follow-up, 2.6 years). There were 6 additional lesions, however, that were incompletely excised. At 5 years, the recurrence rate was 5%. Six patients had lesions removed with Mohs micrographic surgery. There were no recurrences after a mean follow-up of 1.7 years. Of 653 total lesions, 361 involved the right eye (55%). Most BCCs were on the lower eyelid (53%) and inner canthus (29%). Solid BCCs were the most common type (54%), followed by the infiltrative type (15%). The majority of complications were minor and caused no ocular damage. CONCLUSIONS: Carefully performed, modified en face frozen section controlled excision of periocular BCCs yields cure rates comparable to Mohs micrographic surgery at 5-year follow-up. Close communication with a skilled pathologist is essential to achieve these low recurrence rates. The fact that lesions involved the right periocular region more than the left may reflect greater sun exposure on that side from driving.

Myeloma-associated systemic amyloidosis presenting with acquired digital cutis laxa-like changes.

A 59-year-old woman presented with a 6-year history of lax skin on the distal fingers of both hands, as well as a recent increase in the size of her tongue. Histopathology of skin from her distal finger showed amyloid deposition and bone marrow biopsy revealed an underlying plasma cell dyscrasia. Initial treatment with cyclophosphamide, vincristine, adriamycin and methylprednisolone has produced a significant reduction in the swelling of both her hands and tongue. Acquired digital cutis laxa-like changes are a rare cutaneous manifestation of systemic amyloidosis.

The role of hepatic stellate cells and transforming growth factor-beta(1) in cystic fibrosis liver disease.

Liver disease causes significant morbidity and mortality from multilobular cirrhosis in patients with cystic fibrosis. Abnormal bile transport and biliary fibrosis implicate abnormal biliary physiology in the pathogenesis of cystic fibrosis-associated liver disease (CFLD), yet the mediators linking biliary events to fibrosis remain unknown. Activated hepatic stellate cells (HSCs) are the pre-eminent mediators of fibrosis in a range of hepatic disorders. The dominant stimulus for matrix production by HSCs is the cytokine transforming growth factor (TGF)-beta(1). In CFLD, the role of HSCs and the source of TGF-beta(1) have not been evaluated. Liver biopsy tissue obtained from 38 children with CFLD was analyzed. Activated HSCs, identified by co-localization of procollagen alpha(1)(I) mRNA and alpha-smooth muscle actin, were demonstrated as the cellular source of excess collagen production in the fibrosis surrounding the bile ducts and the advancing edge of scar tissue. TGF-beta protein and TGF-beta(1) mRNA expression were shown to be predominantly expressed by bile duct epithelial cells. TGF-beta(1) expression was significantly correlated with both hepatic fibrosis and the percentage of portal tracts showing histological abnormalities associated with CFLD. This study demonstrates a definitive role for HSCs in fibrogenesis associated with CFLD and establishes a potential mechanism for the induction of HSC collagen gene expression through the production of TGF-beta(1) by bile duct epithelial cells.