Assessment of Pain, Healing Time, and Wound Contraction in Postoperative Auricular Defects Healing Secondarily With and Without the Use of a Porcine Xenograft, a Pilot Study.

BACKGROUND: Postoperative auricular defects heal well with secondary intention healing (SIH); however, potential complications include postoperative pain, perichondritis, and chondritis. OBJECTIVE: To compare postoperative pain and wound healing in auricular defects healing by secondary intention with and without the placement of a porcine xenograft. MATERIALS AND METHODS: Twenty-one subjects were enrolled in the study. The primary outcome was self-reported pain, measured on a 0 to 10 scale for 14 postprocedure days. Secondary outcomes included time to greater than 90% of reepithelialization and degree of wound contraction. RESULTS: There was a 1 to 2 point difference in median pain scores between the porcine graft and control groups during postoperative days 4 to 7, 12, and 13. Time to 90% or greater reepithelialization was not statistically different between groups (p = .94). The average wound contraction was 34.1% for the porcine group and 34.0% for the control group (p = .95). CONCLUSION: In this pilot study, overall pain scores were low in both groups. Placement of a porcine xenograft resulted in a slight reduction of median pain compared with traditional SIH. Patients in the control group were more likely to require analgesics. Similar rates of reepithelialization and degree of wound contracture were observed.

Metastatic Multiple Myeloma to the Skin.

Cutaneous involvement of multiple myeloma (MM) is uncommon, typically occurs in late stage disease, and is a poor prognostic indicator with an approximate eight month median survival. We present a 51-year-old man with relapsed lambda light chain MM who developed abrupt asymptomatic skin metastases. Biopsy revealed a dermis replete of atypical plasma cells, positive for CD138 and CD45. In situ hybridization confirmed lambda light chain restriction. Despite rescue antimyeloma therapy with the anti-CD38 drug daratumumab, he rapidly declined clinically and succumbed to the disease four weeks after presentation. A standard treatment approach for cutaneous MM does not currently exist; however, various techniques to detect cytogenetic abnormalities are emerging and will provide additional prognostic value and direct individualized therapy.

Benign Glandular Schwannoma With Ancient Change.

Benign glandular schwannomas are rare and should be distinguished from malignant peripheral nerve sheath tumors with similar divergent tissue differentiation. The authors present a benign glandular schwannoma with ancient change that developed in the subcutis of a 46-year-old man's posterior calf. He lacked stigmata of neurofibromatosis type 1 (NF1). The glandular elements stained positively for epithelial membrane antigen and pancytokeratin. The spindled cells stained positively for SOX10 and S100 protein, supporting schwannian (neural crest) differentiation. The tumor's location and histopathology suggest that the pathogenesis stems from entrapment of sweat glands. Finally, it must be recognized that ancient change may mimic malignancy in these neoplasms as the malignant counterparts have a greater association with NF1 and a poorer prognosis.

Type I Cutaneous Meningioma (Rudimentary Meningocele) With Intradural Attachment to the Phylum Terminale.

Cutaneous meningiomas (CM) are a small subset of meningiomas, further classified into three subtypes. The authors present a 15-year-old male with a symptomatic congenital type I CM and describe the histopathological and immunohistochemical findings. To the authors' knowledge, this is the first report of an extraspinal lumbar type I CM with intradural attachment to the phylum terminale.

Primary mucinous carcinoma of the skin: the Mayo Clinic experience over the past 2 decades.

BACKGROUND: Primary mucinous carcinoma of the skin (PMCS) is a rare adnexal eccrine sweat gland neoplasm, often mistaken for metastasis from extracutaneous sites or misdiagnosed. Primary mucinous carcinoma of the skin is a slow-growing tumor with a high recurrence rate after conventional excision. OBJECTIVE: To describe clinicopathologic features, rate of recurrence, and metastasis and to review relevant literature. MATERIALS AND METHODS: The authors identified patients with PMCS treated from January 1992 through December 2012 at Mayo Clinic. The authors retrospectively reviewed medical records and histology slides. Relevant publications were identified through Ovid MEDLINE and PubMed. RESULTS: Six patients with PMCS were identified (1 male). The average age at diagnosis was 63 years. Tumor size ranged from 0.5 to 2.0 cm, and all were confined within the dermis. No evidence of metastatic mucinous adenocarcinoma was documented at the time of diagnosis. Five patients underwent Mohs micrographic surgery, and 1 was treated with wide local excision. There were no episodes of recurrence or metastases after a median follow-up of 20 months (range, 0.5-207 months). CONCLUSION: Mohs micrographic surgery may offer reduced recurrence rates and better outcomes in PMCS. Further studies with longer follow-up and bigger cohorts of patients with PMCS are warranted.

Acute cutaneous graft-vs.-host disease compared to drug hypersensitivity reaction with vacuolar interface changes: a blinded study of microscopic and immunohistochemical features.

BACKGROUND: Complications from graft-vs.-host disease (GVHD), a major contributor to morbidity and mortality following hematopoietic cell transplantation, may be mitigated by early diagnosis and intervention. However, differentiation between acute cutaneous GVHD and other common skin eruptions that develop in the post-transplantation period, such as drug hypersensitivity reaction, can be challenging clinically and microscopically. Because recent evidence indicates that CD123, a marker of plasmacytoid dendritic cells, can help to distinguish gastrointestinal GVHD from the clinicopathologic mimic cytomegalovirus colitis, we aimed to determine whether CD123 could aid in the diagnosis of acute cutaneous GVHD. METHODS: We studied 12 skin specimens of patients with grades I-II cutaneous GVHD and 12 from patients who had drug hypersensitivity reaction with vacuolar interface changes on biopsy. RESULTS: No differences were seen between the two groups with regards to density or distribution of CD123 expression. Specimens representing GVHD showed significantly less spongiosis (P < 0.001) and fewer dermal eosinophils (P = 0.03) compared to those representing drug hypersensitivity reaction. CONCLUSIONS: We conclude that CD123 does not appear to be a useful ancillary test in the diagnosis of acute cutaneous GVHD. Careful correlation between clinical findings and features with microscopy remains the cornerstone of accurate diagnosis of acute cutaneous GVHD.

Histiocytoid Sweet syndrome may indicate leukemia cutis: a novel application of fluorescence in situ hybridization.

BACKGROUND: In patients with malignancy-associated Sweet syndrome, a thorough evaluation for leukemia cutis should be considered. OBJECTIVE: We sought to describe the clinicopathologic characteristics of histiocytoid Sweet syndrome. METHODS: We retrospectively identified patients with histiocytoid Sweet syndrome at our institution from January 1992 through December 2010. We evaluated the underlying cutaneous infiltrate using immunohistochemistry and fluorescence in situ hybridization. RESULTS: We re-evaluated all 22 patients with hematologic malignancy-associated Sweet syndrome. Six patients had a monocytoid infiltrate that was consistent with histiocytoid Sweet syndrome; subsequent evaluation of these patients demonstrated cytogenetic abnormalities on prior bone-marrow biopsy specimens. Fluorescence in situ hybridization analysis was feasible in cutaneous specimens from 5 of the 6 patients and demonstrated the same cytogenetic abnormalities that were identified on prior bone-marrow biopsy specimens in 4 patients. Therefore, these 4 patients may have had a form of leukemia cutis. LIMITATIONS: This was a retrospective study. CONCLUSION: For patients with histiocytoid Sweet syndrome, an underlying hematologic malignancy, and a monocytoid infiltrate on biopsy specimen, fluorescence in situ hybridization of the cutaneous infiltrate may be beneficial to identify cytogenetic abnormalities that may indicate leukemia cutis.

Sweet syndrome: clinical presentation, associations, and response to treatment in 77 patients.

BACKGROUND: Sweet syndrome is a neutrophilic dermatosis with cutaneous tender lesions that can be associated with malignancies, infections, systemic inflammatory disorders, and medications. Although numerous studies have described Sweet syndrome, few studies have systematically investigated Sweet syndrome. OBJECTIVE: We sought to describe characteristics and treatments of patients with Sweet syndrome and evaluate clinical differences depending on the underlying cause. METHODS: A retrospective study was conducted to identify patients with Sweet syndrome evaluated at Mayo Clinic from 1992 to 2010. RESULTS: Of 77 patients with Sweet syndrome (mean age of onset 57 years), 43 (56%) were male. Eighteen patients (23%) reported a preceding infection. A total of 41 (53%) patients were classified as having classic Sweet syndrome, 27 (35%) patients had malignancy-associated Sweet syndrome, and in 9 (12%) patients drug-induced Sweet syndrome was considered. In all, 21 patients had a hematologic malignancy or myeloproliferative/myelodysplastic disorder, whereas 6 patients had solid tumors. The mean hemoglobin level, in both male and female patients (P < .0443 and P < .0035, respectively), was significantly lower in malignancy-associated versus classic and drug-induced Sweet syndrome. Systemic corticosteroids were the most frequently used treatment (70%). LIMITATIONS: This is a retrospective study and represents patients from a single academic center. CONCLUSIONS: Sweet syndrome is a distinctive disorder with certain clinical and histologic characteristics, which usually has a complete response to systemic corticosteroids. It is important to evaluate Sweet syndrome patients who have laboratory evidence of anemia for an underlying malignancy.

Melanoma brain metastases and vemurafenib: need for further investigation.

Brain metastases are a major cause of morbidity and mortality in patients with advanced melanoma. With the development of targeted agents for the treatment of metastatic melanoma, a great deal of interest has focused on whether selective BRAF inhibitors may play a role in the treatment of brain metastases in lieu of or in addition to surgery and/or radiation therapy. However, relatively little is known about the intracranial effectiveness of vemurafenib, the only US Food and Drug Administration-approved selective BRAF V600E inhibitor, because patients with brain metastases have historically been excluded from vemurafenib clinical trials. We describe 3 patients with BRAF V600E mutation metastatic melanoma in whom treatment with vemurafenib resulted in prompt extracranial disease response but progression of metastatic disease in the brain. Further, we discuss possible mechanisms responsible for the suboptimal central nervous system response observed in these patients and alternative therapies for patients with melanoma metastatic to the brain.

Primary cutaneous angioimmunoblastic T-cell lymphoma histologically mimicking an inflammatory dermatosis.

Angioimmunoblastic T-cell lymphoma (AITL) is a systemic lymphoproliferative disease characterized by a polymorphous neoplastic infiltrate involving lymph nodes as well as extranodal locations, including the skin. Cutaneous involvement is seen in approximately 50 percent of cases and is usually secondary to systemic disease. Patients with cutaneous involvement classically present with a transient morbilliform eruption of the trunk; however, papules, nodules, urticarial plaques and erythroderma have also been reported. In contrast, primary cutaneous AITL is exceedingly rare. The authors report a case of a 79-year-old woman with AITL who presented with primary cutaneous tumors and ulcerated nodules, with no evidence of systemic involvement, hypergammaglobinemia, or B symptoms. Histologically, a subtle lymphoid infiltrate was present, dominated by marked fibrosis and a diffuse infiltrate of neutrophils, eosinophils and plasma cells, mimicking an inflammatory or infectious etiology. This presentation presents a unique diagnostic challenge; careful investigation and strong clinical suspicion must be utilized in order to correctly identify AITL in this setting.