CDK8 Expression in Extrauterine Leiomyosarcoma Correlates With Tumor Stage and Progression.

Mediator is a multiprotein complex that acts as a versatile transcription coactivator in eukaryotes. CDK8 kinase complex is a 4-protein subunit of the mediator complex that can act as a transcriptional repressor or coactivator, depending on the specific pathways involved. Although the role of MED12 exon 2 mutations is documented in the pathogenesis of uterine leiomyomas, its role in extrauterine smooth muscle tumorigenesis is less clear. Similarly, there is a paucity of data on the role of CDK8 in extrauterine smooth muscle tumorigenesis and progression. Our study correlates immunohistochemical expression of CDK8 and MED12 with clinical and pathologic parameters in extrauterine leiomyosarcomas. Immunohistochemical expression of CDK8 and MED12 in leiomyosarcomas was correlated with the tumor grade, stage, and the presence of local recurrence or metastasis. MED12 was expressed in the majority of leiomyosarcomas regardless of their stage or grade. CDK8 expression was lost in 1 of 6 pT1 tumors, compared with 9 of 10 pT2 tumors (P=0.0076). When the second group was expanded to include those tumors that did not have a recorded pathologic stage but had local recurrence and distant metastases, the difference in CDK8 expression was also statistically significant. Loss of CDK8 expression by immunohistochemistry is more prevalent in somatic leiomyosarcomas presenting at a higher histopathologic stage, as well as with local and distant recurrence, and can be used to enhance the current predictive parameters.

Annular atrophic lichen planus responds to hydroxychloroquine and acitretin.

Annular atrophic lichen planus (AALP) is a rare variant of lichen planus. The clinical presentation of AALP shows distinct atrophic plaques with elevated borders on the trunk and extremities. Histopathologic findings generally reveal a lichenoid dermatitis in active lesions with a distinct loss of elastic fibers in the center of the lesions. We report a unique case of AALP, which highlights the chronicity of the eruption. Our patient showed early signs of improvement with hydroxychloroquine and acitretin, suggesting a role for systemic therapy in the treatment of AALP.

Novel Use of Preoperative Epidermal Coloring of Very Small Dermatological Specimens-Protocol for Reduction of Lost Specimens.

Small tissue biopsies are often difficult to visualize and can be easily lost or mishandled. The authors hypothesized that full epidermal surface coloration of small skin lesions with a sterile skin marker (gentian violet ink) before performing shave biopsy would make small gross specimens easier to identify without impacting microscopic appearance. Live evaluation of 4 inked and 4 noninked gross (2-3 mm) specimens in covered and uncovered formalin-containing jars by 50 consecutive health care personnel demonstrated that inked specimens were significantly (P < 0.001) easier to visualize than noninked specimens. Additionally, a blinded dermatopathologist evaluated 25 inked and 25 noninked specimens microscopically. Utilization of this inking process did not interfere with histopathologic assessment or impede diagnosis. This pilot study describes an easily implementable quality improvement measure that may decrease the rate of loss and mishandling of specimens.

Actinic Keratosis, Transected: What Lies Beneath?

Evaluation of superficial transected shave biopsies of squamous neoplasms often presents a diagnostic dilemma for the dermatopathologist because of the lack of complete visualization of the base of the epidermis. Fear of "missing" an invasive carcinoma must be balanced with avoidance of overdiagnosis of precancerous actinic keratosis (AK), especially on cosmetically sensitive areas such as the face. If a concern exists that a more invasive component may be present, a diagnosis of AK transected at the base (AKT) will often be rendered to alert the dermatologist of this concern. Because of lack of objective data regarding the malignant transformation of this diagnosis, the method of treatment is often based on the clinical appearance of the residual lesion or the lesion is rebiopsied to establish a more definitive diagnosis, costing patient and physician time and increasing health care costs. This study aims to provide objective data regarding (1) how often dermatologists are resampling these lesions and (2) how accurately an AKT diagnosis identifies patient risk for a more aggressive lesion, to establish whether there is a benefit in providing more tissue for the initial biopsy. We performed a retrospective study examining 274 biopsies with a diagnosis of AKT. We found only 27% had follow-up rebiopsy or excision. Of these 73 cases, 63% showed residual AK and 20% showed a more serious lesion, which warrants more aggressive treatment. Because the health care culture slowly shifts to metric-driven medicine and value-based payment, providing objective data for the progression of diagnosis, such as AKT, will be important (1) to aid the clinician in taking adequate tissue samples for diagnosis to make adequately informed management decisions, (2) to reduce the conversion of AK to squamous cell carcinoma, the resultant depth of squamous cell invasion, and the patient's risk of metastases to improve the patient's long-term outcomes, and (3) to decrease the overall cost of the patient's health care by improving the patient's long-term outcomes.

Autosomal-dominant familial angiolipomatosis.

Angiolipomas are among the most common benign soft-tissue tumors and usually present as solitary nodules; however, angiolipomas also may present as multiple subcutaneous nodules, typically on the arms and trunk of young men. Although multiple angiolipomas most often occur sporadically, a family history can be identified in a minority of cases. Familial angiolipomatosis is a rare condition with an autosomal-recessive transmission pattern that is characterized by multiple subcutaneous tumors and a family history of similar lesions, which are not associated with malignant neoplasms. We report a case of familial angiolipomatosis with an unusual autosomal-dominant transmission pattern. Our patient presented with multiple angiolipomas that were highly suggestive of familial angiolipomatosis transmitted in an autosomal-dominant fashion, as he had several family members with a history of similar fatty tumors. Autosomal-dominant familial angiolipomatosis may be misdiagnosed as neurofibromatosis type I. Therefore, in cases of multiple subcutaneous tumors and a family history of similar lesions, histologic examination is important to establish the correct diagnosis.

Atypical presentation of exophytic herpes simplex virus type 2 with concurrent cytomegalovirus infection: a significant pitfall in diagnosis.

We report 3 unusual cases of atypical exophytic cutaneous herpes simplex virus (HSV) type 2 with concurrent cytomegalovirus (CMV) infection in immunosuppressed patients and raise awareness to the significant clinical and pathologic challenges in establishing the correct diagnosis. In all the 3 cases, the lesions presented as fungating plaques and nodules with areas of superficial erosion. Initial clinical differential included genital warts, syphilis, versus cutaneous malignancy. All the 3 patients were referred to the dermatology clinic where a combination of cutaneous biopsies, viral cultures of the lesions, polymerase chain reaction, CMV antigenemia, and immunoperoxidase stains for CMV and HSV confirmed the diagnosis of HSV type 2 with concurrent CMV infection. All the 3 patients were treated with oral valganciclovir with significant improvement noted at the follow-up visit. In addition, we review the previously reported HSV/CMV cutaneous coinfection cases.