Treatment patterns of elderly breast cancer patients at two Canadian cancer centres.

BACKGROUND: Treatment of breast cancer in elderly women is limited by declining functional status and life expectancy. The impact of providing less aggressive treatment remains controversial. This study assessed the treatment patterns of elderly breast cancer patients. METHODS: Retrospective chart review of women ≥70 y with breast cancer treated between 2004 and 2011 at two large Canadian cancer centres. Tumour and treatment characteristics were collected across three subgroups: 70-74 y (n = 314), 75-79 y (n = 233), and ≥80 y (n = 219). Comparisons were made using Chi-squared test, Fisher-Freeman-Halton exact test, or ANOVA. Disease free (DFS) and overall (OS) survival were estimated by Kaplan-Meier analysis and compared by log-rank test. RESULTS: Women ≥80 y had larger tumours that were better differentiated, hormone receptor-positive, HER2-negative, and lymph node (LN)-positive relative to younger women (p < 0.05). Women ≥80 y more frequently underwent mastectomy than breast conserving surgery and lacked LN staging (p < 0.05). Chemotherapy was provided in few patients, especially ≥80 y. Radiation therapy was provided less often in women ≥80 y despite indications. Hormone therapy was more frequently provided in women ≥80 y. Women ≥80 y had a significantly lower DFS (17.5 m) relative to women 70-74 y (31 m, p = 0.02) and 75-79 y (35 m, p = 0.006). Women ≥80 y had the lowest median OS (53 m) relative to 70-74 y (79 m, p = 0.001) and 75-79 y (75 m, p = 0.003) women. CONCLUSIONS: Women ≥80 y received less aggressive treatment than younger women and had less favourable DFS and OS. Until age-specific recommendations are available physicians must use clinical judgement and assess the tumour biology with the patient's comorbidties to make the best choice.

Restrictive dermopathy: report of a case and review of the literature.

BACKGROUND: Restrictive dermopathy is a rare autosomal recessive skin disorder that is fatal in the neonatal period. Clinical and pathologic findings are distinctive and allow for a specific diagnosis in most cases. METHODS: We present a case of an affected infant and a review of the previously reported cases in the literature. RESULTS: The infant had thick shiny skin with reduced compliance and multiple spontaneous linear splits. Additional findings included an abnormal facies with a distinctive small, round and open mouth, low set ears, small nose, widely spaced sutures, flexion contractures of the extremities, and poorly expanded lungs. The infant expired 65 h after birth. Histologic findings of the skin at autopsy included a relatively unremarkable epidermis, a flat dermal-epidermal junction (absent rete ridges), an overall thinned dermis with hypoplastic appendage structures, a dense fibrotic reticular dermis with collagen parallel to the epidermis, a sharp subcutaneous margin, and an abnormally thick layer of subcutaneous adipose tissue. Electron microscopic findings included dense dermal patches of collagen and fibroblasts with abundant endoplasmic reticulum and unusually small tonofilaments. Review of previously reported cases reveals strikingly consistent findings. CONCLUSIONS: This rare condition illustrates that abnormal cutaneous development may produce fetal hypokinesia, leading to profound effects on intrauterine growth and development. The autosomal recessive pattern of inheritance and morphologic changes of the skin and skeletal system in this disorder suggest that a structural protein or enzyme defect, perhaps of collagen metabolism, may underlie the pathogenesis.

Non-hematopoietic cutaneous metastases in children and adolescents: thirty years experience at St. Jude Children's Research Hospital.

BACKGROUND: The spectrum of cutaneous metastasis of non-hematopoietic neoplasms in the pediatric population is not well documented. We report the histologic diversity of this unusual process over a 30-year period at a tertiary care center for pediatric malignancy (St. Jude Children's Research Hospital, Memphis, TN, USA). METHODS: Of 1,971 pathology accessions which included histologic material on skin (1,604 surgical cases and 367 autopsy cases) we found 40 cases (2% of total skin accessions) coded for metastatic non-hematopoietic malignancy. RESULTS: The patients (n=34) ranged in age from 1 month to 20 years (mean=9.8 years) and had a male:female ratio of 1:1. The histologic diagnoses were as follows: rhabdomyosarcoma NOS (6 cases), embryonal rhabdomyosarcoma (4 cases), alveolar rhabdomyosarcoma (4 cases), neuroblastoma (8 cases), osteosarcoma (2 cases), choriocarcinoma (2 cases), peripheral neuroepithelioma or Ewing's sarcoma (2 cases), malignant rhabdoid tumor (1 case), paraganglioma (1 case), nasopharyngeal carcinoma (1 case), sarcoma NOS (1 case), colon adenocarcinoma (1 case), and malignant melanoma (1 case). CONCLUSIONS: Cutaneous or subcutaneous metastasis of non-hematopoietic malignancies in children and adolescents is a rare occurrence but in a high percentage of cases may be the first manifestation of disease. The tumors most likely to metastasize to the skin in children are rhabdomyosarcoma and neuroblastoma and they are more likely than adult malignancies to disseminate to multiple distant sites.

A fatal case of pancreatic panniculitis presenting in a young patient with systemic lupus.

BACKGROUND: Subcutaneous fat necrosis associated with pancreatic disease is a rare event. The clinical cutaneous findings are non-specific erythematous nodules with central softening located predominantly on the lower extremities. The histopathologic features of these lesions are very characteristic and diagnostic. METHODS: We present an unusual case of pancreatic panniculitis associated with lupus pancreatitis in a 21-year-old African American female. The patient presented with lower extremity skin nodules, arthralgia, and serositis prior to the diagnosis of systemic lupus and pancreatitis. The skin lesions progressed despite normalization of serum pancreatic enzymes. Following femoral vein catheterization for renal dialysis, she developed a large indurated area over the left lower quadrant, flank, groin, and upper thigh measuring 25 cm. She was treated with repeated debridement, tissue grafts, and hyperbaric oxygen because of a clinical suspicion of necrotizing fasciitis. RESULTS: Examination of skin biopsies and debrided tissue revealed the pathognomonic features of pancreatic panniculitis without any evidence of necrotizing fasciitis. Organisms were not detected by tissue examination or microbiologic cultures. CONCLUSIONS: This case illustrates the potential role of vascular trauma in the pathogenesis of pancreatic panniculitis.

Spindle cell hemangioendothelioma. Report of three cases and review of the literature.

BACKGROUND: Spindle cell hemangioendothelioma lesions are uncommon, affect a wide age range in both sexes, and show a predilection for skin and subcutaneous tissue of the extremities. OBJECTIVE: To present three cases of spindle cell hemangioendothelioma and review the literature. METHODS: Three cases of spindle cell hemangioendothelioma are presented. RESULTS: Two of our cases first presented very early in life and progressed by local recurrences over many years. None of our cases showed evidence of metastases, but the lesions exhibited local aggressive and invasive behavior. Histologically, the lesions consist of alternating areas of dilated, thin walled cavernous vascular spaces and solid areas composed predominantly of spindle cells and clusters of epithelioid endothelial cells with intracytoplasmic vacuoles. That spindle cell hemangioendothelioma is a non-neoplastic lesion and not a neoplasm of borderline malignancy is suggested by the following observations from our cases: the repeated presence of organized intravascular thrombi in all cases, the early clinical presentation in two cases, and the presence of some degree of vascular malformation at the periphery of lesions. CONCLUSION: Both clinicians and pathologists should be aware of the existence of this lesion in order to diagnose and treat an affected patient correctly.

Metastatic adenocarcinoma of the breast located within a benign intradermal nevus.

We report an exceptional case of metastatic adenocarcinoma of the breast occurring within a benign intradermal nevus. An extensive review of the literature on metastatic breast carcinoma is included.

Necrosis of the hand after extravasation of intravenously administered phenytoin.

Extravascular escape of intravenously administered phenytoin can result in serious local soft tissue complications. Injury can range from simple phlebitis to chemical cellulitis or, in extreme cases, frank tissue necrosis that necessitates amputation. The histopathologic findings include extensive necrosis and sloughing of epidermis, widespread necrosis of dermis, subcutaneous tissue, muscles and nerves, and extensive thrombotic occlusion of vessel lumens. Results of elastic tissue stains reveal that the thrombosed vessels are exclusively veins and venules. Vascular fibrinoid necrosis, leukocytoclasis, and true inflammatory vasculitis are not features. This is the first detailed report of the histopathologic alterations associated with this therapeutic misadventure.

Efficacy of bimolane in the Malassezia ovalis model of psoriasis.

Bimolane, an analog of razoxane has been used in China with comparable efficacy but less toxicity than razoxane in the treatment of psoriasis. In an attempt to characterize further its mode of action it was administered both systemically and topically in the Malassezia ovalis animal model of psoriasis. Intravenous methotrexate and topical 0.1% betamethasone valerate were also used as positive control treatments. The animal model of psoriasis was effectively treated by bimolane, both systemically and topically, and also by parenteral methotrexate and topical betamethasone valerate. The time course of bimolane's effect with this model was different from methotrexate's suggesting the possibility of a different mode of action. Because bimolane, like razoxane, is an ethylene diamino tetraacetate acid (EDTA) derivative, it is possible that its effects on this reaction relate to its chelating properties and that inhibition of complement activation is important to its mode of action.

Squamous cell carcinoma of the breast: a clinicopathologic analysis of eight cases and review of the literature.

Malignant neoplasms of the female breast composed of squamous cells are rare and constitute a particularly poorly understood facet of breast disease. Two pure squamous cell carcinomas ( SCCs ) of the breast and six tumors that displayed various combinations of malignant squamous elements and ductal breast adenocarcinoma were identified. Electron microscopy confirmed the diagnosis of SCC in two cases by the demonstration of regularly spaced desmosomes, tonofilament bundles, and keratohyaline granules. A review of the literature indicated that breast cancers with components of SCC are histologically variable. Approximately 30 cases of pure SCC and 80 cases of mixed adenocarcinoma and SCC (adeno-SCC) have been reported. Some of these squamous epithelium-containing tumors have displayed areas of cyst formation, spindle cell metaplasia, and pseudosarcomatous desmoplastic response, or origins in preexisting breast lesions, such as cystosarcoma phyllodes or dermoid cysts. Although this variability indicates a heterogeneous group of neoplasms, the overall prognosis for carcinomas of the breast with malignant squamous elements appears to be quite similar to that for ordinary breast adenocarcinomas of similar size and stage.

Human pulmonary dirofilarial granuloma.

A case of pulmonary dirofilariasis in a human being is presented in which the lesion was visible roentgenographically for eighteen months prior to resection and in which the correct etiological diagnosis was made on frozen-section examination at the time of thoracotomy. The documented geographical spread of dirofilariasis in the canine population in the United States and southern Canada suggests that pulmonary dirofilariasis in human beings may be seen with increasing frequency by thoracic surgeons. The epidemiological and pathogenetic features of this unusual disease are discussed. A serological test for dirofilariasis is now available that may allow some patients to escape thoracotomy for this self-limited disorder.

Atheromatous embolization to the skin.

Atheromatous emboli were found in arterioles in the dermis of the ear of a 74-year-old man. This distinctive form of arteriosclerosis disease is well recognized as a cause of renal failure in nephropathology, but its significance is not sufficiently appreciated in dermatopathology. Atheromatous emboli may cause infarcts in the skin and biopsy of the skin may be a reliable method for diagnosis of systemic atheromatous emboli.

Cytomegalovirus infection of the skin.

A case of fatal generalized cytomegalovirus infection with particular attention to lesions involving the skin is reported. Characteristic cytomegalovirus inclusion bodies were present within nuclei of endothelial cells in the dermis beneath ulcerations. Skin biopsy may be useful in the diagnosis of disseminated infections by cytomegalovirus.