Somatic BRAF c.1799T>A p.V600E Mosaicism syndrome characterized by a linear syringocystadenoma papilliferum, anaplastic astrocytoma, and ocular abnormalities.

Genetic mosaicism for somatic mutations of oncogenes is common in genodermatoses, which can be complicated with extra-cutaneous abnormalities. Here we describe an infant with a congenital anaplastic astrocytoma, a linear syringocystadenoma papilliferum, and ocular abnormalities. The BRAF c.1799T>A p.V600E mutation was detected in both the brain and skin tumor cells but not in the blood or normal skin cells, suggesting somatic mosaicsism for the mutation. Clinically, the brain tumor gradually became life threatening without any response to conventional chemotherapies including carboplatin, etoposide, and temozolomide. Vemurafenib, a BRAF p.V600E inhibitor, was administered daily after the detection of the BRAF mutation. This single-agent therapy was dramatically effective against the anaplastic astrocytoma; the tumor regressed, the cerebrospinal fluid cell count and protein levels decreased to normal levels, and hydrocephalus resolved. Moreover, other lesions including a corneal cyst also responded to vemurafenib. The brain tumor continued shrinking after 6 months of treatment. We present a genodermatosis syndrome associated with BRAF c.1799T>A p.V600E mosaicism. This syndrome may represent a new entity in the mosaic RASopathies, partly overlapping with Schimmelpenning-Feuerstein-Mims syndrome, which is driven by mosaicism of HRAS and/or KRAS activating mutations. Screening for BRAF c.1799T>A p.V600E is especially useful for those with malignant tumors, because it is one of the most-druggable targets.

Transition from cylindroma to spiradenoma in CYLD-defective tumours is associated with reduced DKK2 expression.

Patients carrying heterozygous germline truncating mutations in the CYLD gene develop multiple primary hair follicle-related tumours. A highly patterned tumour, termed cylindroma, and a highly disorganized tumour, termed spiradenoma, may both develop in the same patient. Furthermore, histological features of both tumour types have been described within the same tumour specimen. We used three-dimensional computer-aided reconstruction of these tumours to demonstrate contiguous growth of cylindromas into spiradenomas, thus suggesting a transition between the two tumour types. To explore factors that may influence cutaneous tumour patterning, genome-wide transcriptomic analysis of 32 CYLD-defective tumours was performed. Overexpression of the Wnt/ß-catenin signalling pathway was observed relative to normal perilesional tissue. Morphometric analysis was used to investigate the relationship between Wnt pathway-related gene expression and tumour organization. This revealed an association between reduced Dickkopf 2 (DKK2-a negative regulator of the Wnt/ß-catenin signalling pathway) expression and loss of tumour patterning. Reduced DKK2 expression was associated with methylation of the DKK2 gene promoter in the majority of tumour samples assayed. RNA interference-mediated silencing of DKK2 expression in cylindroma primary cell cultures caused an increase in colony formation, cell viability, and anchorage-independent growth. Using these data, we propose a model where epigenetic programming may influence tumour patterning in patients with CYLD mutations.

Dysregulated TRK signalling is a therapeutic target in CYLD defective tumours.

Individuals with germline mutations in the tumour-suppressor gene CYLD are at high risk of developing disfiguring cutaneous appendageal tumours, the defining tumour being the highly organised cylindroma. Here, we analysed CYLD mutant tumour genomes by array comparative genomic hybridisation and gene expression microarray analysis. CYLD mutant tumours were characterised by an absence of copy-number aberrations apart from LOH chromosome 16q, the genomic location of the CYLD gene. Gene expression profiling of CYLD mutant tumours showed dysregulated tropomyosin kinase (TRK) signalling, with overexpression of TRKB and TRKC in tumours when compared with perilesional skin. Immunohistochemical analysis of a tumour microarray showed strong membranous TRKB and TRKC staining in cylindromas, as well as elevated levels of ERK phosphorylation and BCL2 expression. Membranous TRKC overexpression was also observed in 70% of sporadic BCCs. RNA interference-mediated silencing of TRKB and TRKC, as well as treatment with the small-molecule TRK inhibitor lestaurtinib, reduced colony formation and proliferation in 3D primary cell cultures established from CYLD mutant tumours. These results suggest that TRK inhibition could be used as a strategy to treat tumours with loss of functional CYLD.

New mutation in the CYLD gene within a family with Brooke-Spiegler syndrome.

Brooke-Spiegler syndrome is a rare, autosomal dominant disease characterized by multiple skin appendage tumors caused by various mutations in the CYLD gene on chromosome 16q12-q13. We describe a family, in which we performed a molecular-genetic examination and found a new mutation in exon 19 in the CYLD gene leading to a frameshift. It is important to be aware of this syndrome and its pathogenesis as its phenotypic features can vary so that apparently different diseases are caused by the same genetic defect. In addition, there may be malignant transformation of the generally benign tumors, so that a timely diagnosis is essential for appropriate monitoring and therapy.

Carcinoma ex spiradenoma/cylindroma confirmed by immunohistochemical and molecular loss-of-heterozygosity profiling.

We present a case of spiradenoma/cylindroma with admixed carcinoma of unknown origin, resolved using immunohistochemical and molecular loss-of-heterozygosity (LOH) profiling. The patient, a woman in her mid-70s, initially presented with separate mammary (ductal) carcinomas of the right and left breasts that were treated with radical mastectomies. For 9 years, the patient remained disease free until complaining of a slow-growing skin nodule on the lower back that was excised under clinical suspicion of metastatic mammary carcinoma. Histopathological exam revealed a benign eccrine spiradenoma/cylindroma and an intermixed carcinoma, with a differential diagnosis of either primary eccrine carcinoma or mammary carcinoma metastatic to the spiradenoma/cylindroma. Histological features and immunohistochemical staining favored eccrine carcinoma but not unequivocally; therefore, LOH profiles were performed on archival paraffin block tissue from the 3 neoplastic lesions (4 components). The mammary carcinomas showed disparate LOH at 5 of 7 (right breast) and 4 of 7 (left breast) informative genetic loci, establishing these carcinomas as separate primary neoplasms. Both the spiradenoma/cylindroma and eccrine carcinoma revealed no LOH at the tested loci, establishing the unknown carcinoma as an independent carcinoma arising within a spiradenoma/cylindroma. This neoplasm is referred to in the literature as carcinoma ex spiradenoma/cylindroma and spiradenocylindrocarcinoma.

Skin-type hidradenoma of the breast parenchyma with t(11;19) translocation: hidradenoma of the breast.

Skin adnexal type tumors situated in the parenchyma of the breast are very rare. We report herein a case of solid-cystic hidradenoma of the breast. The tumor was situated in the parenchyma of the breast of a 55-year-old female and showed no connection to the overlying skin on ultrasound and radiology investigations, grossly and microscopically. Histologically, the tumor was identical to its cutaneous counterpart and was surrounded by breast tissue. The neoplasm was composed of solid and cystic areas. The cystic component, which predominated in the lesion, was filled with homogeneous eosinophilic material. The solid component consisted of several nodules with vague lobulated architecture protruding into the cystic spaces. The nodules were composed of cuboidal monomorphous cells that were continuous with larger polygonal cells and rare, large mucinous cells with basophilic granular cytoplasm. Several mammary ducts in close proximity to the tumor showed features of columnar cell hyperplasia. A 120-bp METC1/MAML2 fusion transcript was identified by RT-PCR and subsequent sequencing technique. This t(11;19) translocation has been reported in approximately 50% of hidradenomas of the skin.

[Study of the ploidy and cellular cycle of hidradenomas and hidradenocarcinomas: a series of 13 cases]. / Etude de la ploïdie et du cycle cellulaire des hidradenomes et des hidradenocarcinomes: a propos d'une série de 13 cas.

AIMS: To study by flow cytometry (FCM) the ploidy and the cellular cycle of nodular hidradenoma (NH) and hidradenocarcinoma (HC) and to assess the prognostic utility of this technique in such tumors. METHODS: We studied retrospectively 2 HC and 11 NH one of which was considered as an atypical NH. Monoparametric study by FCM was realized on paraffin-embedded material. The extracted cells were marked by Propidium's lodure and cellular cycle was analyzed by the software Mod-Fit LT. RESULTS: Our study showed eleven 100% diploid profiles, 10 of which had low S-phase varying between 2 and 12%. All of these 11 tumors were NH. S-phase was high (23.79%) in a single case that corresponded to the atypical NH. Two tumors showed aneuploid profiles; these corresponded to the 2 HC. CONCLUSION: The results of the cytometric study suit perfectly to those of the histopathologic examination. FCM could so help to establish the prognosis of these tumors. But further studies are necessary to determine the value of this technique.

Frequent fusion of the CRTC1 and MAML2 genes in clear cell variants of cutaneous hidradenomas.

Fusion of the CREB regulated transcription coactivator CRTC1 (a.k.a. MECT1, TORC1, or WAMTP1) to the Notch coactivator MAML2 is a characteristic feature of low-grade mucoepidermoid carcinomas of salivary and bronchial glands. The CRTC1-MAML2 fusion protein acts by inducing transcription of cAMP/CREB target genes, and this activity is crucial for the transforming properties of the protein. Here we show that the CRTC1-MAML2 gene fusion is also frequent in benign hidradenomas of the skin. FISH and RT-PCR analyses revealed that hidradenomas are genetically heterogeneous, and that 10 of the 20 tumors analyzed (50%) contained the CRTC1-MAML2 gene fusion and expressed the resulting fusion transcript. Immunohistochemical analysis demonstrated expression of the fusion protein in the majority of tumor cells, including clear cells, poroid cells, and cells with epidermoid and ductal differentiation. In addition, we could show that all fusion-positive tumors were morphologically distinguished by the presence of more or less abundant areas of clear cells whereas all fusion-negative tumors lacked clear cells. Our findings thus demonstrate that the CRTC1-MAML2 gene fusion is frequent in hidradenomas and is associated with clear cell variants of this tumor. Taken together, the present and previous observations indicate that the CRTC1-MAML2 fusion is etiologically linked to benign and low-grade malignant tumors originating from diverse exocrine glands rather than being linked to a separate tumor entity.

Metastatic hidradenocarcinoma with demonstration of Her-2/neu gene amplification by fluorescence in situ hybridization: potential treatment implications.

A 44-year-old man was referred for a right chest nodule of 3 months duration. A 'benign' nodule had been excised from this location 8 years prior. On examination, palpable nodes were noted in the right axilla. Radiographic studies were significant only for right axillary lymphadenopathy. Histologically, a nodular dermal proliferation composed of poorly differentiated epithelioid cells in nests and focally forming ducts with pseudopapillary architecture comprised the primary tumor. Features of a clear cell hidradenoma were noted focally. Immunohistochemical (IHC) analysis revealed reactivity for HMW cytokeratins, CK5 and CK7, p53, p63, CEA (focal), androgen receptor, EGFR, estrogen receptor (ER), MUC5AC, and strong/diffuse membranous staining for Her-2/neu. Negative stains included villin, TTF-1, CDX2, S-100 protein, vimentin, gross cystic disease fluid protein 15 (GCDFP-15), mammoglobulin, and MUC2. A wide local excision and axillary node dissection was performed. Metastatic tumor involved nine of 28 nodes. Interphase fluorescence in situ hybridization (FISH) demonstrated chromosomal amplification of the Her-2/neu locus within the tumor and a nodal metastasis. The patient has completed adjuvant and radiotherapy, including trastuzumab, and is asymptomatic. We believe this to be the first demonstration of Her-2/neu amplification in a malignant skin adnexal tumor. In analogy to breast carcinoma, these findings suggest the applicability of trastuzumab for patients with metastatic adnexal carcinomas demonstrating Her-2/neu amplification.

Familial eccrine spiradenoma: a case report and review of the literature.

BACKGROUND: Familial eccrine spiradenoma is a rare autosomal dominant condition that is characterized by slow-growing, benign adnexal tumors. OBJECTIVE: We investigated a case of familial eccrine spiradenoma displaying an autosomal dominant inheritance pattern. To our knowledge, only two previously reported cases of familial eccrine spiradenoma exist in the literature. METHODS: A case report and review of the literature are given. RESULTS: We report a case of familial eccrine spiradenoma in a mother and daughter and present successful treatment using surgical extirpation and CO2 laser ablation. CONCLUSION: Familial eccrine spiradenoma is a benign autosomal dominantly inherited condition that is characterized by tender, slow-growing, adnexal tumors of the head and neck. Surgical tumor extirpation and CO2 laser ablation offer both an effective symptomatic and cosmetically elegant treatment option.

[Systematic sebaceous nevus with multiple secondary tumors as the chief symptom of Schimmelpenning-Feuerstein-Mims syndrome]. / Systematisierter Naevus sebaceus mit multiplen sekundären Neubildungen als Leitsymptom des Schimmelpenning-Feuerstein-Mims-Syndroms.

A women presented with a systematized sebaceous nevus of the head and neck. She had developed multiple basal cell carcinomas and sebaceomas in the nevus over the past 3 years after a period of about 55 years without any changes. Detailed medical history and physical examination revealed a constellation of findings suggesting a syndrome. Besides ptosis and a congenital, vascular corneal clouding at the right, there was hypoplasia of the right maxillary sinus, a right labyrinthine deafness and recurrent inguinal herniae on the right. The Schimmelpenning-Feuerstein-Mims-Syndrome was diagnosed.

Syringocystadenoma papilliferum: a study of potential tumor suppressor genes.

Syringocystadenoma papilliferum (SP) is a benign tumor most commonly located on the scalp or face, which frequently arises from a nevus sebaceus (NS). Transition of SP to basal cell carcinoma (BCC) and, albeit rarely, to metastatic adenocarcinoma may occur. Allelic deletions of the human homologue of the drosophila patched gene (PTCH) occur in both NS and BCC. To search for genetic changes in SP, a microdissection-based genetic analysis using polymorphic markers at 9q22 (PTCH; D9S15, D9S303, D9S287, D9S252) as well as markers at 9p21 flanking the tumor suppressor gene p16 (IFNA, D9S171) was performed. Glandular epithelium consisting of two rows of cells as well as adjacent normal tissue or inflammatory infiltrates in the stroma, when present, was dissected and subjected to single-step DNA extraction and loss of heterozygosity (LOH) analysis. Two of 10 informative SP cases showed LOH at 9q22 (PTCH). Three of 7 informative SP cases showed allelic deletions at 9p21 (p16). Allelic loss at 9q22 is consistent with the clinical observation of transition of SP to BCC. The finding of frequent allelic loss at 9p21 is unlikely to be related to the rare transition of SP to metastatic adenocarcinoma. Our study supports the hypothesis of a gatekeeper role of the tumor suppressor gene p16 in a variety of benign and malignant tumors, including SP.

DNA image cytometry in malignant and benign sweat gland tumours.

The histopathological differentiation between well-differentiated carcinomas and atypical adenomas of sweat gland origin may be difficult, even if immunohistochemical methods are used. Therefore, additional techniques may be helpful. We previously demonstrated that DNA image cytometry (ICM-DNA) can be useful in distinguishing between malignant and benign clear cell hidradenoma. In the present study, a larger series of sweat gland tumours, with a clear-cut diagnosis as malignant or benign on histopathological criteria, was examined by ICM-DNA. Enzymatic cell separation specimens were prepared from paraffin-embedded tissues of 18 sweat gland carcinomas (14 porocarcinomas, one classic eccrine adenocarcinoma, two microcystic adnexal carcinomas and one mostly ductal apocrine carcinoma) and 47 benign sweat gland tumours (three syringocystadenomas, five spiradenomas, 14 cylindromas, three syringomas, seven nodular hidradenomas, 10 cutaneous mixed tumours, four poromas and one apocrine hidrocystoma). Specimens were examined by ICM-DNA according to the current recommendations of the European Society for Analytical Cellular Pathology with the AutoCyte QUIC-DNA workstation using mesenchymal cells as an internal reference. DNA aneuploidy was detected by the stemline interpretation according to Böcking and/or at least three 5[c]-exceeding events. DNA aneuploidy was detected in 16 of 18 (89%) of the sweat gland carcinomas, but in none of the 47 adenomas. These results suggest that the detection of DNA aneuploidy in sweat gland tumours using ICM-DNA is a clear and specific indicator of prospective malignancy.

[Brooke-Spiegler syndrome]. / Syndrome de Brooke-Spiegler.

BACKGROUND: Brooke-Spiegler syndrome is an association of multiple trichoepitheliomas and cylindromas, sometimes accompanied by other adnexal tumors. CASE REPORT: A 44-year-old woman with trichoepitheliomas involving the naso-genal and mental areas associated with cylindromas and spiradenomas on the forehead and pretragal regions creating a turban effect. Other complete or diassociated syndromes were found in family members. No neoplastic tumor was identified. DISCUSSION: Brooke-Spiegler syndrome is an hereditary disease with autosomal dominant transmission. Both benign and malignant neoplasias can be associated. The concomitant existence of different tumors could be helpful in understanding the pathophysiology. There is some debate about the exact origin of the trichoepitheliomas, cylindromas and spiradenomas. Several single-cause theories have been put forward but remain to be confirmed as the genetic anomalies identified for trichoepitheliomas and cylindromas map to different sites. Patients with Brooke-Spiegler syndrome should be explored for malignant neoplasia. A family study is indicated.

Identification of aneuploidy in recurrent clear cell hidradenoma by DNA image cytometry (ICM-DNA).

Since malignant clear cell hidradenoma (CCH) is often characterized by only slight and sometimes by absent nuclear anaplasia, even in metastases, definitive differentiation from its benign counterpart by light microscopy may be very difficult. Herein, we report the case of a 72-year-old woman suffering from a CCH on the back, which showed local recurrence following incomplete excision. By light microscopy no unequivocal signs of malignancy were found either in the primary or the recurrent tumor. However, unusual deep extension to the subcutis with some architectural disorder was seen in the latter. Identification of prospective malignancy in such cases of borderline histopathological features is one of the main indications for diagnostic DNA image cytometry (ICM-DNA). Application of this method to enzymatic cell separation specimens of the recurrence detected marked DNA-aneuploidy with a stemline ploidy of 2.60 c and single events up to 6.7 c, whereas a nearly exact diploid DNA-stemline was found in the primary. We suppose from our results that a prospective malignant CCH with aneuploid DNA-stemline has developed out of its DNA-diploid counterpart. The need for total surgical removal of apparently benign clear cell hidradenomas is further stressed by this observation. Criteria for the diagnosis of malignancy in CCH are reviewed.

Dysregulated expression of transforming growth factor beta and its type-I and type-II receptors in basal-cell carcinoma.

In mammals, transforming growth factor-beta (TGF-beta) is found in 3 highly homologous isoforms that exert their effects via heteromeric complexes of type-I and type-II receptors (TbetaR-I and TbetaR-II). TGF-beta regulates the growth and metabolism of various cell types, including keratinocytes. We have investigated the immunohistological localization of TGF-beta1, TGF-beta2, TbetaR-I and TbetaR-II in normal human skin, basal-cell carcinoma (BCC), Bowen's disease, seborrheic keratosis, eccrine poroma and eccrine spiradenoma using frozen tissue specimens. In normal human skin, the immunoreactive TGF-beta2, but not TGF-beta1, was detected predominantly in the epidermis, follicles and sebaceous glands. The epidermal expression of TbetaR-I and TbetaR-II was very weak in the majority of normal skins. In BCC, TGF-beta2 expression was markedly reduced or completely negative. In addition, TbetaR-I- and TbetaR-II-positive stromal cells were accumulated in the fibrotic stroma in some BCCs. These stromal cells were partly but moderately positive for TGF-beta1. Decreased expression of TGF-beta2 was likely to be associated with the differentiation state of BCC cells, since TGF-beta2 expression was clearly observed in the squamoid foci of BCC. In addition, no expression of TGF-beta2 was detected in the eccrine secretory portion or in eccrine spiradenoma, but it was detected in the upper eccrine ducts and in eccrine poroma.

Phenotypic heterogeneity of nodular hidradenoma. Immunohistochemical analysis with emphasis on cytokeratin expression.

We studied the immunohistochemical phenotype in 13 cases of the nodular hidradenoma (NH), with special emphasis on the expression of different types of keratins (cytokeratins, 7, 10, 6/18, 8/18, and 10/17/18 and their distribution in normal sweat glands. Variable reactions with keratins, alpha-smooth muscle actin, and epithelial membrane antigen (EMA) were found, as these markers were present in different cellular components of the tumors. The most constant finding was almost complete absence of cytokeratins (all but keratin 10/17/18, which was positive in two of 13 cases) in clear cells, which yet were positive for EMA. The tumors expressed mostly cytokeratin 6/18, 7, 8/18, and 10/17/18, which were found in 11, 13, 11, and 12 cases, respectively. The cellular distribution and quantity of stained cells differed, as keratins 6/18, 8/18, and 7 produced the most abundant staining and were predominantly localized in small squamoid cells and the cells lining the tubular and cystic spaces. Cytokeratin 10/17/18 was expressed in smaller or larger clusters of squamoid cells and rarely in clear cells. Cytokeratins 10, 19, and 20 were found sporadically in single cells or small cellular clusters. alpha-Smooth muscle actin was expressed in four cases, whereas we did not find reactivity of S-100 protein. Comparing these results with the pattern of keratin distribution and antigenic reactivity in eccrine sweat glands, we conclude that NH presents cellular heterogeneity of its elements and differentiation toward different parts of the sweat gland.

The pathogenesis of familial multiple cylindromas, trichoepitheliomas, milia, and spiradenomas.

Early stages in the development of hereditary cylindromas associated with trichoepitheliomas, milia, and spiradenomas revealed that (a) trichoepitheliomas were derived from the bulges of hair follicles and probably represented an abnormal histogenesis from which rarely poorly differentiated trichoepitheliomas developed; (b) milia were the result of cystic alteration of the trichoepitheliomatous bulge proliferations; and (c) cylindromas and spiradenomas were different appearances of the same tumor and developed from two separate sources, follicular bulge proliferations and eccrine glands. From the bulge proliferations multiple cylindromatous buds developed that, by increasing in number, formed the classical cylindroma and, by increasing in size rather than in number, gave the spiradenomatous variant. Eccrine glands transformed into cylindromas by cylindromatous growth from the basal cell layer. Connections between the original structures and the tumors were mostly lost. Tumors from both sources revealed the same morphology, which was most indicative of eccrine differentiation including secretory and excretory elements. Apocrine differentiation was a rare and possibly secondary event. The multiplicity in derivation and differentiation suggest an adnexal progenitor cell as the most likely source.

[Muir-Torre syndrome. Diagnostic criteria and review of the literature]. / Muir-Torre-Syndrom. Diagnosekriterien und Literaturübersicht.

We report on a 63-year-old female patient with Muir-Torre syndrome (MTS). In the course of this disease two carcinomas of the colon, a kerato-acanthoma and multiple sebaceous gland tumours, including four sebaceous carcinomas, appeared. This case is thought to be a hereditary form as one of daughters was also found to have a sebaceous epithelioma. MTS is a mostly autosomal-dominant disease with the association of sebaceous gland tumours and internal carcinomas. As the malignant tumours only show slight aggressiveness the prognosis is quite favourable. Oral isotretinoin therapy was successfully used for the inhibition of sebaceous gland proliferation. A narrower definition is presented and an updated survey of the published cases is given. Furthermore, the histopathologic peculiarities of sebaceous gland tumours, especially of sebaceous gland carcinomas, are discussed and compared to sebaceous gland tumours not connected with MTS. A total number of 100 of the 135 published cases of MTS were included and analysed regarding sebaceous gland tumours and other skin tumours. The data on internal carcinomas were taken from the work of Cohen et al. (1991) and 11 current cases were added.