A case report of successful treatment of pyoderma gangrenosum in a patient with autoimmune hepatitis, and review of the literature.

BACKGROUND: Pyoderma Gangrenosum (PG) is a cutaneous condition, its diagnosis suggested by the presence of a painful cutaneous ulcer showing rapid progression. Pyoderma gangrenosum is associated with a concomitant systemic disease in 50 to 70 % of cases, including inflammatory bowel disease (IBD), rheumatoid arthritis, and lymphoproliferative disorders. Although PG has also been reported with viral hepatitis, it is rarely associated with autoimmune hepatitis. CASE PRESENTATION: A 19-year-old Caucasian female, with a prior diagnosis of autoimmune hepatitis (AIH) in remission, presented with bilateral lower limb ulcers 4 years after the diagnosis of AIH. She was diagnosed with PG and treated with high-dose prednisolone, methotrexate and cyclosporine. One year later she was well, the ulcers completely healed, and with the autoimmune hepatitis still in remission. CONCLUSION: We report a case of autoimmune hepatitis and the subsequent, rarely occurring, extra-hepatic onset of pyoderma gangrenosum, with the AIH in remission, strengthening the association between the two conditions. Since both the AIH and the PG can present serious diagnostic challenges, thus delaying vital therapy, it is important that the development of either prompts us to consider the possibility of the other developing in the future or if already present facilitate its diagnosis, such considerations making the case for a systematic follow up.

Epigenetic alterations in sporadic basal cell carcinomas.

Basal cell carcinoma (BCC) is the most common malignant human neoplasm characterized by slow growth and virtual absence of metastases. Recently, it has become evident that along with genetic mutations epigenetic alterations play a key role in the pathogenesis of human cancer. We searched for promoter methylation of hMLH1, RASSF1A, DAPK, APC, DCR1 and DCR2 genes and BRAF mutations in BCCs in association with the clinicopathological parameters and the histological subtypes of the tumours. Fifty-two BCCs, 17 FFPE along with 35 fresh tissue samples with matching normal tissues for 26 cases were analyzed by methylation-specific PCR to assess the methylation status of hMLH1, RASSF1A, DAPK, APC, DCR1 and DCR2 genes after sodium bisulfite treatment of the tumour and normal DNA. hMLH1 and DCR1 gene expression was investigated by immunohistochemistry. BRAF mutations were studied by high resolution melting analysis. Methylation was detected at a variable frequency of 44, 33, 32.5, 32 and 14 % of DCR2, APC, DCR1, RASSF1 and DAPK promoters, respectively, whereas methylation of hMLH1 promoter was absent. No BRAF mutations were found. There was no correlation between the frequency of the promoter methylation of the above-mentioned genes and the clinicopathological features or the histological subtypes of the tumours. The relatively high frequency of RASSF1A, DCR1, DCR2 and APC promoter methylation may imply that methylation constitutes an important pathway in the tumourigenesis of BCC that could provide new opportunities in developing epigenetic therapies for BCC patients. Nevertheless, further studies are needed to establish the above-mentioned hypothesis.

B-Raf mutations, microsatellite instability and p53 protein expression in sporadic basal cell carcinomas.

Basal Cell Carcinoma (BCC) is the most common skin malignancy. Genes related to the Ras/Raf signalling pathway have been implicated in the pathogenesis of skin cancer. The objective of this study was to investigate the presence of B-Raf mutations in sporadic BCCs as well as its correlation with the phenotype of microsatellite instability (MSI), the clinicopathological parameters of the tumours and p53 protein expression. 83 BCC specimens were screened for B-Raf mutations, applying polymerase chain reaction, single-stranded conformation polymorphism (PCR-SSCP) and DNA sequencing. MSI status was examined using mononucleotide microsatellite markers and p53 protein expression was demonstrated by immunohistochemical staining. A C to T transition at 1790 nucleotide leading to a silent mutation L597L; and a T to A transversion causing an amino acid change (F610I) have been found. MSI was detected in 5% of the cases and p53 accumulation was present in 37/83 samples studied. Although rare B-Raf alterations have been observed in BCC, none of them harboured the hot-spot mutation T1799A commonly present in melanomas and colon carcinomas. Consequently, no correlation could be determined between B-Raf alterations, MSI status, the clinicopathological features and p53 protein expression. Our results are in favour of a secondary importance for Ras signalling cascade genes in BCC pathogenesis.

PGP 9.5 expression in cutaneous keratoacanthomas and squamous cell carcinomas.

The aim of the study was to investigate the expression of PGP 9.5 in cutaneous keratoacanthomas (KAs) and squamous cell carcinomas (SCCs). Thirty-one cases of KA (10 in the growth stage, 9 in the mature phase and 12 in the involution stage) and 36 SCCs including 13 well differentiated cases, 12 moderately differentiated tumors, 7 poorly differentiated lesions and 4 pseudoadenoid entities were investigated. PGP 9.5 expression was positively correlated with tumor stage (P < 0.001) and potential perineural invasion (P < 0.001). There was no significant difference in the distribution of patients presenting variable levels of PGP 9.5 staining with regard to maximal tumor size and the extent and degree of stromal invasion. PGP 9.5 expression proved closely associated with tumor aggressiveness and is classified as a marker for predicting the outcome of resection-treated skin cancer patients.

PGP 9.5 and cyclin D1 coexpression in cutaneous squamous cell carcinomas.

BACKGROUND: squamous cell carcinoma (SCC) consists of altered keratinocytes, presents variable differentiation, inexorably progresses, and on occasion metastasizes. OBJECTIVE: to investigate the biological activity of epidermal cells in SCCs by estimating the expression of PGP 9.5 and cyclin D1 using immunohistochemistry. METHODS: the sample included 13 well-differentiated cases of cutaneous SCC (grade I), 12 moderately differentiated tumors (grade II), and 7 poorly differentiated lesions (grade III). Four cases belonged to the distinct entity of pseudoadenoid SCC. RESULTS: PGP 9.5 expression was positively correlated with tumor stage (P < .001) and potential perineural invasion ( P < .001), whereas cyclin D1 expression correlated inversely with the degree of cellular differentiation (P < .001) and PGP 9.5 immunostaining (P < .001). CONCLUSION: PGP 9.5 and cyclin D1 coexpression was closely associated with tumor aggressiveness and can be classified as a marker for predicting the outcome of resection-treated skin cancer patients.

Immunoglobulin A pemphigus associated with immunoglobulin A gammopathy and lung cancer.

Immunoglobulin (Ig)A pemphigus is a rare disease marked by a vesiculopustular eruption characterized by intercellular IgA deposition in the epidermis. It has clinical and histopathological heterogeneity and encompasses two subgroups: subcorneal pustular dermatosis type and intraepidermal neutrophilic IgA dermatosis type. IgA pemphigus has been rarely associated with monoclonal IgA paraprotein, myeloma and B-cell lymphoma in the past. We report the first case, to our knowledge, of a 47-year-old male patient with a subcorneal pustular dermatosis type of IgA pemphigus associated with IgA gammopathy and lung cancer.

Silver-stained nucleolar organizer regions and immunoglobulins in cutaneous squamocellular tumors.

This study was conducted to elucidate the biological activity of epidermal cells in cutaneous squamocellular tumors by counting the number of silver-stained nucleolar organizer regions (AgNORs), to estimate the quantity of Ig-producing cells and the inflammatory cellular infiltrate (ICI), and to achieve a comparative evaluation. Twenty cases of actinic keratosis (AK), 20 in situ squamous cell carcinomas (ISC), and 20 invasive squamous cell carcinomas (SCCs) were assessed using a silver colloid technique. Ig-producing or binding cells and ICI were also investigated immunohistochemically. In all samples, AgNORs, Ig-producing cells, and ICI increased in proportion to the degree of malignancy. With regard to AgNORs values, a statistically significant difference was confirmed between AK and ISC (p<0.01), AK and SCC (p<0.001), and ISC and SCC (p<0.05). IgG-producing cells predominated in each case. Furthermore, a linear correlation was detected between ICI and AgNORs in AK and ISC. The significant difference in the number of AgNORs among the 3 stages of involution of SCC reinforces the value of AgNORs as a marker for malignant potential. Despite the absence of a correlation between AgNORs and the proportion of Ig-producing cells, the association between ICI and AgNORs in AK and ISC was obvious.

Mutations of microsatellite instability target genes in sporadic basal cell carcinomas.

Microsatellite instability (MSI) caused by a defective DNA mismatch repair (MMR) system is one of the phenotypes of genomic instability, accounting for the tumorigenesis of certain types of cancers conveying clinical and prognostic significance. Genes such as TGF-betaRII, IGFIIR, hMSH3, and hMSH6 include coding mononucleotide repeats that are known targets for mutations in MSI-high tumors. The aim of our study was to investigate the prevalence of mutations in the above 4 MSI target genes in correlation with the MSI status of 75 basal cell carcinomas (BCCs), including aggressive-growth BCCs and cases with perineural invasion. TGF-betaRII or hMSH3 frameshift mutations were identified in 5% of the BCCs, including two cases of aggressive-growth subtype, whereas there were no microsatellite alterations in the IGFIIR and hMSH6 genes. Mutations at the mononucleotide repeats within the hMSH3 and TGF-betaRII genes occurred in certain BCCs, not always in association with MSI. It seems likely that microsatellite alterations may be important in the development of individual cases of BCCs despite the low frequency of MSI in our cohort.

Silver-stained organizer regions and immunoglobulins in cutaneous keratoacanthomas and squamous cell carcinomas.

The aim of this study was to investigate the biologic activity of epidermal cells in keratoacanthomas (KAs) and squamous cell carcinomas (SCCs) by counting the number of silver-stained nucleolar organizer regions (AgNORs), to estimate the quantity of Ig-producing cells and the inflammatory cellular infiltrate (ICI), and to make a comparative evaluation. Thirty KAs (10 at growth stage, 10 at mature stage, and 10 at involution stage) and 28 SCCs (nine well differentiated-Grade 1 (G1), seven moderately differentiated-Grade 2 (G2), five poorly differentiated-Grade 3 (G3), and seven pseudoadenoid) were investigated. The KAs examined had a mean number of 1.727 AgNORs (S.D. 0.232), and IgG predominated in most cases. IgG and IgE increase at the involution, IgA remains at almost the same level, and IgM decreases during the maturity stage. The SCCs examined had a mean number of 2.105 AgNORs (S.D. 0.446). IgG predominated and gradually increased in proportion to the degree of malignancy. There is a significant difference in the number of AgNORs and the proportion of Ig subclasses in contrast to the cellular infiltrate among the three stages of KA. In SCCs, the number of AgNORs and the percentage of Igs and ICI increased gradually in proportion to the degree of malignancy.

Expression of mismatch repair enzymes, hMLH1 and hMSH2 is not associated with microsatellite instability and P53 protein accumulation in basal cell carcinoma.

Microsatellite instability (MSI) constitutes an alternative-to the chromosomal instability-pathway of carcinogenesis for certain tumour types with prognostic and therapeutic significance for the respective patients. MSI is caused by mutations in mismatch repair (MMR) genes, mainly hMLH1, hMSH2, leading to a defective MMR system. The role of MSI in basal cell carcinoma (BCC) has not been clearly delineated yet. p53 gene as a target for ultraviolet radiation-induced mutations may enhance genomic instability in BCC, with loss of its function. Our aim was to investigate the involvement of MSI and expression of hMLH1 and hMSH2 in parallel with P53 protein accumulation in the pathogenesis of BCC and its possible correlation to the clinicopathological features of the patients. The presence of MSI was investigated in 76 BCCs using mononucleotide microsatellite markers, BAT-25, BAT-26 and TGF-beta receptor type II (TGF-beta-RII). Additionally, 3 dinucleotide markers were analysed in 20 cases in which matched normal tissue was available. The expression of hMLH1, hMSH2 and P53 proteins was evaluated by immunohistochemical analysis. Alterations of the BAT-26 marker were observed in one fibroepithelioma of Pincus, one nodular and one multifocal superficial BCC. A keratotic BCC showed an altered BAT-25 locus. Two samples, a multifocal superficial and a nodular BCC, displayed MSI at two markers (BAT-25 and BAT-26; and BAT-25 and TGF-beta-RII, respectively). Three more cases, a metatypical, a multifocal superficial and a signet ring BCC exhibited frameshift mutations in the TGF-beta-RII. No sample showed length alterations at the dinucleotide markers examined. hMLH1 and hMSH2 protein immunohistochemical expression was scored positive in 46 and 49 out of 52 cases respectively. P53 accumulation was observed in 27 out of 56 samples. Correlation of the molecular and immunohistochemical findings with the clinicopathological parameters produced no statistically significant results. No correlation between MSI and hMLH1, hMSH2 or P53 protein expression was determined. MSI appears to play a minor role in the pathogenesis of BCCs being present only in a small subset of such tumours.