Presence of Incipient Fungal Infection in Atypical Squamous Lesions of the Lip.

ABSTRACT: Epidermal barrier disruption caused by atypical squamous proliferations of the lip (SOL) creates an ideal environment for fungal growth. Histologic features of SOL include parakeratosis overlying partial- or full-thickness keratinocyte atypia with or without invasion of the dermis, dermal solar elastosis, and scattered inflammatory cells which are predominantly lymphocytes. Histologic features of SOL with fungal superinfections overlap those seen in primary fungal cheilitis with reactive atypia, creating a diagnostic challenge. One-hundred seventy SOL cases were examined for the presence of fungal elements, and the histological features associated with superinfection were identified. Cases diagnosed as actinic cheilitis with fungal superinfection were carefully examined to rule out the possibility of misdiagnosed primary fungal cheilitis with reactive atypia. Histopathological characteristics commonly present with fungal hyphae included intraepidermal or intradermal neutrophils, bacterial colonies, and erosion or ulceration. Medical record review of those patients treated conservatively with topical antifungals revealed persistent clinical neoplasm and histological evidence of residual SOL on repeat biopsy. Thus, when biopsies exhibit histological overlap between these 2 entities, clinicians should keep a high index of suspicion for underlying SOL and carefully follow these patients if conservative antifungal therapy is initially trialed.

Metastasizing basal cell carcinoma: A clinicopathologic and immunohistochemical study of 22 cases.

Basal cell carcinomas metastasize rarely, and there have been limited studies of potential drivers for this metastasis. Epithelial-mesenchymal transition (EMT) may play a role, although this has not been investigated in detail. We reviewed clinicopathologic features of 22 patients with metastasizing basal cell carcinoma (MBCC). Immunohistochemical markers of EMT, including CD44, E-cadherin, claudin, smooth muscle actin, beta-catenin, Twist1, and Oct 3/4, were evaluated on 10 MBCC (primary and metastases) and 18 non-metastasizing BCC. Primary sites included the head and neck, trunk, and extremity, while metastatic sites included lymph nodes, lung, bone, and soft tissue. Of 19 cases with follow-up, the range of follow-up after diagnosis of metastasis was 5 to 248 months (median: 50 months). Two cases were of unknown primary, nine metastases were diagnosed concurrently with primary tumors, and remaining cases showed a median latency between diagnosis of primary and metastatic tumors of 27.5 months (range: 3-81 months). Median survival was 66 months. Compared to non-metastasizing BCC, MBCC demonstrated reduced CD44 expression (primary [P = .0036], metastatic [P = .011]) and increased Twist1 expression (primary, P = .0017). MBCC shows variably aggressive behavior, and reduced CD44 and increased Twist1 expression may indicate significant EMT in metastasizing tumors and signify a metastatic phenotype.

Differential UBE2C and HOXA1 expression in melanocytic nevi and melanoma.

BACKGROUND: Recent molecular advances suggest that Spitz nevi and other spitzoid neoplasms are biologically distinct from melanoma and conventional nevi. The ubiquitin ligase UBE2C and the homeobox transcription factor HOXA1 are candidate oncogenes in melanoma. METHODS: Using RNA expression analysis and immunohistochemistry, we evaluated these biomarkers in Spitz nevi (n = 20), melanoma (n = 20), and by immunohistochemistry in conventional nevi (n = 20). RESULTS: RNA analysis with branched DNA multiplex assay identified upregulation of UBE2C in melanomas vs Spitz nevi (P = .003), whereas HOXA1 was downregulated in melanoma (P < .0001). Immunohistochemical analysis confirmed increased nuclear expression of UBE2C in melanoma (mean = 18% of cells; range 3%-44%) when compared with Spitz nevi (mean = 9%; range 2%-28%; P = .001) and conventional nevi (mean = 1.5%; range 0-9%; P < .0001). Strong UBE2C staining was identified in cells undergoing mitosis. UBE2C RNA and protein detection correlated with mitotic rate (P < .0001). On the other hand, HOXA1 nuclear staining was low in melanoma (mean = 69%; range 5%-100%) when compared with Spitz nevi (mean = 94%; range 66%-100%; P = .0024) and conventional nevi (mean = 94%; range 83%-99%; P = .009). CONCLUSIONS: UBE2C and HOXA1 RNA and protein are differentially expressed in conventional and Spitz nevi and melanoma.

Ischemic fasciitis: enhanced diagnostic resolution through clinical, histopathologic and radiologic correlation in 17 cases.

Ischemic fasciitis is a pseudosarcomatous nodule or mass resulting from sustained or repeated pressure and consequent ischemia of soft tissue. Fibrin and hemorrhage expand its hypocellular epicenter bordered by enlarged (atypical, ischemic) fibroblasts and reactive vascular prominence resulting in diagnostically important histologic zonation. Although classically in bedridden patients, ischemic fasciitis owing to posture-related intermittent pressure in ambulatory adults is not well characterized; there has not been a thorough review of its presentation in ambulatory patients in the dermatology/dermatopathology literature. This article reviews the clinical, pathologic and radiologic presentation of 17 cases of ischemic fasciitis diagnosed over a 14-year period. Eighty-six percent of the six cases submitted by non-dermatologists were limb girdle/trunk lesions averaging 6.7 cm in greatest diameter while 90% of the eleven lesions submitted by dermatologists were elbow and forearm lesions averaging 2.3 cm. In no case was the diagnosis anticipated pre-biopsy by clinician or radiologist. Dermatologists submitted the majority of cases. Because ischemic fasciitis may simulate soft tissue sarcoma clinically and histologically, diagnosis helps prevent overtreatment. Zonal histopathologic structure may be shown by any form of biopsy and should motivate correlation with available radiologic studies. Importantly, determining a history of postural pressure at the site confirms the histopathologic diagnosis and avoids unnecessary excision.

PD-1, S-100 and CD1a expression in pseudolymphomatous folliculitis, primary cutaneous marginal zone B-cell lymphoma (MALT lymphoma) and cutaneous lymphoid hyperplasia.

BACKGROUND: Pseudolymphomatous folliculitis is a lymphoid proliferation that clinically and histopathologically mimics primary cutaneous extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma). In this study, we assessed the diagnostic value of three immunohistochemical markers, programmed death-1 (PD-1), CD1a and S100. METHODS: We evaluated 25 cases of cutaneous lymphoid proliferations with established diagnoses, including 9 patients with pseudolymphomatous folliculitis, 11 with MALT lymphoma, and 5 with cutaneous lymphoid hyperplasia (CLH). The clinical, histopathologic and immunohistochemical characteristics were reviewed and three major characteristics assessed: (a) proportion of T cells expressing PD-1, (b) pattern of expression of CD1a by dendritic cells and (c) pattern of expression of S100 by dendritic cells. RESULTS: We found pseudolymphomatous folliculitis to have a significant increase in PD-1+ T cells compared with MALT lymphoma (p < 0.0001). The pattern of CD1a staining is also informative: MALT lymphoma is significantly more likely to demonstrate a peripheral concentration of CD1a+ dendritic cells around lymphoid nodules than pseudolymphomatous folliculitis (p < 0.0003) or CLH (p < 0.05). Pseudolymphomatous folliculitis demonstrates an interstitial distribution of CD1a+ cells more often than MALT lymphoma (p < 0.04). S100 staining was not a helpful discriminator. CONCLUSIONS: Histopathologic factors including PD-1 and CD1a staining patterns may allow for more certainty in distinguishing lymphoid hyperplasia, including pseudolymphomatous folliculitis, from MALT lymphoma.