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Other than the classic skin necrosis induced by oral anticoagulants (OAC) in patients with protein C and S deficiencies, other types of OAC induced-skin ulcers are little known. Herein, we describe an original case of recurrent pyoderma gangrenosum (PG)-like ulcers induced by OAC.A 70-year-old female heart-transplant recipient presented deep, hyperalgesic and quickly-spreading necrotic ulceration of the right leg 6 weeks after starting oral anticoagulant therapy with fluindione. Histological analysis revealed dermal infiltrate containing polynuclear neutrophils, which accords with the histopathological diagnosis of leukocytoclastic vasculitis or PG. Infectious, autoimmune and thrombophilic causes were ruled out. Fluindione was withdrawn and the ulcer healed completely within a month. Six months later, right leg ulceration recurred two weeks after the patient resumed fluindione but healed within 1 month of discontinuation of the drug. An OAC from another chemical family (warfarin) was then introduced, with further recurrence of ulceration after 2 weeks of treatment.The chronology of events and the negativity of aetiological explorations allowed a diagnosis to be made of OAC-induced skin ulcer, a rare complication of which the pathophysiology is unclear. This is the first case of PG-like ulcers induced by OAC.

Eccrine porocarcinoma is a rare cutaneous tumor arising from the intra-epidermal portion of eccrine sweat glands, the acrosyringium. Histoprognostic studies in large series are rare. Herein, we report a retrospective study of 50 cases.Fifty cases of porocarcinoma were retrieved from a histopathological register. Each histopathological sample was evaluated for the following criteria: presence or absence of dermal invasion, pattern of the infiltrative component (pushing or infiltrative), tumor thickness, lymphovascular emboli, perineural invasion and mitotic index. Clinical data and outcome were also retrieved for each patient.Mean patient age was 77 years (range: 43-99 years). The mean duration of progression prior to diagnosis was 4 years and 5 months. The 2 most common skin locations were the head (38%) and lower limbs (20%). The lesions showed no specific distinctive clinical features. Six cases were in situ, and 44 were invasive (23 with limited infiltration and 20 with scattered infiltration). Mean tumor thickness was 4.37 mm (range: 0.5 to 20 mm). Neighboring or remote epidermal involvement was noted in 7 cases. Lymphovascular emboli were observed in 3 cases. No cases of neurotropism were observed. The average mitotic index was 6.5 mitoses/high power (×400) field. A mean follow-up of 24.3 months was available for 48 patients. Local recurrence was noted in 5 patients, 4 of whom died from visceral metastases. These 5 cases showed no distinctive clinical features, a scattered pattern of the invasive component, cuticular cells, significant tumor thickness (mean 12.8 mm, range 9-20 mm), and an elevated mitotic index. Two histopathological criteria were significantly associated with a metastatic outcome: scattered pattern of the dermal invasive component (P=0.04) and significant tumor thickness, above 10mm (P0.01).Porocarcinoma is a tumor without any particular clinical criteria to distinguish it from squamous cell carcinoma. The architecture of the invasive component and tumor thickness constitute 2 important histoprognostic criteria.

New primary melanomas arising in patients with stage IV melanoma and receiving BRAF inhibitors have recently been reported. This raises the question of the nature of the earliest cellular events identifiable within pre-existing moles.To use reflectance confocal microscopy (RCM) to investigate changing moles in patients using vemurafenib.In the first part of the study 23 lesions were examined by RCM before excision (performed because of digital dermoscopy changes) and histopathological examination. In the second part, 10 randomly chosen lesions in two patients were examined before and after 3 months of vemurafenib treatment.The first step permitted the highlighting of an unusual RCM pattern identified in five lesions characterized by areas of marked atypia in otherwise nondysplastic lesions. In the second step, four initially nondysplastic lesions developed focal or multifocal areas of marked atypia under treatment, which were not always correlated with digital dermoscopy changes, but did correlate with histopathology. All four lesions were finally diagnosed as melanomas.Although the clinical relevance of such findings remains questionable, RCM allowed us to observe, at the cellular level, the earliest events occurring within vemurafenib-induced changing moles. Moreover, repeated RCM examinations permitted to confirm that microscopic marked atypia that led to the histopathological diagnosis of melanoma appeared under treatment and were not pre-existing.

Introduction Les eruptions cutanees morbilliformes sont frequentes en periode d’aplasie post-chimiotherapie pour des hemopathies malignes ou des cancers solides. Elles posent des problemes diagnostiques entre les causes infectieuses, les toxidermies, les reactions post-transfusionnelles et les infiltrats de reconstitution lymphocytaire (IRL). Les IRL sont des eruptions cutanees survenant lors de l’aplasie medullaire post-chimiotherapie, lors d’une augmentation des lymphocytes dans la circulation peripherique. Patients et methodes Nous rapportons une serie de 12 patients (7 hommes et 5 femmes, mediane d’âge : 61 ans), avec un IRL atypique mimant un lymphome T cutane primitif ou une lymphoproliferation cutanee CD30+. Resultats Tous les patients presentaient une eruption erythemateuse maculopapuleuse du tronc et des membres associee a une fievre entre 38 et 39 °C, survenant 5 a 39 jours apres le debut de la chimiotherapie. Tous les patients, sauf un, avaient recu une polychimiotherapie pour une leucemie aigue myeloide ( n = 10) ou un carcinome urothelial avant l’apparition de l’eruption cutanee, et le dernier patient etait atteint d’un syndrome lymphoproliferatif auto-immun entrainant une agranulocytose chronique necessitant un traitement par G-CSF. L’eruption cutanee etait associee a une discrete augmentation des leucocytes peripheriques et etait suivie d’une sortie d’aplasie dans les semaines qui suivaient le diagnostic. L’examen histologique trouvait dans tous les cas un infiltrat lymphocytaire dermique perivasculaire comprenant des lymphocytes atypiques de taille moyenne a grande, CD3+, CD4+ et CD8+, CD25+, ICOS+, PD1−, non cytotoxiques et sans expression significative de FoxP3, avec une expression forte de CD30 dans la majorite des cas ( n = 10), suggerant le recrutement de cellules T activees dans la peau, sans clone T dominant identifiable. Chez 6 patients, le diagnostic de lymphome cutane avait ete propose ou suspecte a l’histologie, et seule la confrontation anatomoclinique permettait le diagnostic d’infiltrat de reconstitution lymphocytaire avec une presentation particuliere mimant un lymphome T cutane ou une lymphoproliferation T CD30+. Discussion Nous rapportons une forme particuliere d’IRL caracterisee par la presence de lymphocytes atypiques, actives. Cet aspect histologique particulier pourrait temoigner du recrutement de lymphocytes T actives par un agent viral ou medicamenteux chez des patients peut-etre favorise par un deficit en lymphocytes T regulateurs en rapport avec l’aplasie medullaire chimio-induite. Conclusion Cet aspect histologique particulier merite d’etre connu par les anatomopathologistes pour eviter de porter a tort un diagnostic de lymphome T cutane ou de lymphoproliferation CD30 dans ce contexte.

Although dermoscopy of the nail plate is helpful to discriminate between benign and malignant causes of nail pigmentations, there remain ambiguous cases in which a matricial biopsy is required. When a subungual melanoma is diagnosed histopathologically, a complementary surgical treatment is performed secondarily, the duration of postoperative disability being accordingly prolongated.The purpose of our study was to evaluate the feasibility of an intraoperative diagnosis by reflectance confocal microscopy (RCM).Our series included nine consecutive patients who underwent a matricial biopsy for an acquired melanonychia (one benign lentigo and eight melanomas). RCM examination was performed in vivo on the nail matrix after reclination of the nail plate, and/or ex vivo on the fresh tissue biopsy. RCM data were compared with histopathology.There was a good correlation between confocal and histopathological features. Seven melanoma cases were unequivocally diagnosed intraoperatively according to the confocal features, whereas the lentigo was correctly classified as a benign lesion according to RCM. The remaining lesion could not be unequivocally classified by RCM and corresponded histopathologically to an early melanoma that required immunostaining to be diagnosed.Intraoperative RCM examination of the nail matrix is an efficient diagnostic approach of melanonychia striata that permits an extemporaneous diagnosis of malignancy and therefore a one-step surgical treatment of in situ or minimally invasive melanoma, reducing dramatically the duration of postoperative disability.

The 'dermoscopic island' is a term that was recently proposed to design an area of a pigmented lesion with a uniform dermoscopic pattern different from the remainder of the lesion. The positive predictive value of this sign for the diagnosis of melanoma is about 50%.The purpose of our study was to see if reflectance confocal microscopy (RCM) permitted to accurately distinguish between nevi and melanoma in such lesions.Five lesions of five consecutive unselected patients, with a dermoscopic island but no feasible clear cut diagnosis on the basis of dermoscopy alone were examined by RCM before excision for histopathological evaluation.Two lesions corresponded to nevi, and three lesions were early melanomas arising on a benign naevus in one case, and on a dysplastic naevus in two cases. In all five cases, RCM permitted to make the correct diagnosis, with a very good correlation with conventional histopathology.Reflectance confocal microscopy appears as a promising tool not only to enhance the early diagnosis of melanoma but also to avoid unnecessary excisions of lesions with a dermoscopic island.

Indolent non-epidermotropic CD8+ lymphoid proliferation of the ear was recently reported in the literature by Petrella et al. This is a distinct entity related to cutaneous T-cell lymphomas. Herein, we report a case of indolent CD8+ lymphoid proliferation of the ear involving the nasal crest and we relate a number of cases recently published in the literature.An 87-year-old woman consulted for a pigmented papular lesion of the nasal crest present for 9 years that had begun to regress spontaneously. The remainder of the examination revealed nothing of note. The biopsy showed dense lymphoid infiltration within the dermis. Immunohistochemical analysis supported the diagnosis of indolent CD8+ lymphoid proliferation. Treatment with moderate topical corticosteroids was initiated.This novel entity is characterised by the presence of relatively non-symptomatic infiltrated lesions in the ear, which can occur bilaterally. Histological findings are frequently worrying with the presence of a dense cellular infiltrate comprising a relatively monomorphous population of CD8+ lymphocytes, although progression is usually indolent.

Introduction Le lymphome T cutane epidermotrope agressif CD8+ (LTCPEA) est un lymphome rare caracterise par des lesions necrotiques cutanees progressant rapidement avec un infiltrat epidermotrope neoplasique T CD8+ a l’examen histopathologique. Il est associe a un mauvais pronostic, malgre l’utilisation de chimiotherapies multiples. Observations Nous rapportons deux cas de patients atteints de LTCPEA. Le patient 1 est un homme de 49 ans infecte par le virus de l’immunodeficience humaine (VIH), avec un exantheme maculo-papuleux febrile, un purpura diffus et l’apparition secondaire de lesions cutanees necrotiques. Le patient 2, un homme de 36 ans, avait depuis 2 mois une lesion ulceree isolee de la voute du pied droit traitee par radiotherapie, ayant recidive sous la forme de lesions papuleuses du tronc et des membres. La biopsie cutanee montrait dans les deux cas un infiltrat lymphocytaire forme d’elements de petite taille ou atypiques, avec un epidermotropisme marque. Pour le patient 1, en plus d’une atteinte epidermique lichenoide marquee, il existait des lesions de vascularite necrosante. L’analyse immuno-histochimique montrait que les cellules neoplasiques T exprimaient fortement CD8, les marqueurs de cytotoxicite et le CD30, ayant fait suspecter une lymphoproliferation cutanee CD30+ chez le patient 2. De facon interessante, il existait une expression des recepteurs des cellules natural killer CD158k/KIR3DL2 (immuno-histochimie et qRT-PCR) et NKp46 (qRT-PCR). Le patient 1 presentait de rares lymphocytes avec expression nucleaire des transcrits EBER du virus EBV. Malgre trois lignes de chimiotherapies agressives (CHOP-cyclophosphamide, doxorubicine, vincristine, prednisone, ACBVP-doxorubicine, cyclophosphamide, vindesine, bleomycin, prednisone, et bendamustine), le patient 1 est decede 3 mois apres son diagnostic. Apres remission partielle sous methotrexate, le patient 2 a progresse sur les plans cutane et ganglionnaire (adenopathie axillaire). Il est en remission complete apres 6 cures de CHOP. Discussion Le role possible de l’immunosuppression et/ou du virus VIH, jamais rapporte dans ce lymphome, peut etre suspecte, etant donne que les patients infectes par ce virus peuvent developper des lymphoproliferations CD8+ cytotoxiques. Les lesions vasculaires, rarement decrites dans ce lymphome, peuvent etre trompeuses, orientant a tort vers une lymphoproliferation EBV-induite (patient 1). La positivite du CD30 peut faire suspecter a tort une lymphoproliferation CD30+ (patient 2). Enfin, peu de donnees existent quant au phenotype des cellules, en particulier concernant CD158k/KIR3DL2 et NKp46, dont l’expression a ete montree dans le mycosis fongoide transforme et le syndrome de Sezary. Conclusion Meme si leur frequence d’expression dans le LTCPEA lymphome reste a valider, CD30, CD158k/KIR3DL2 et NKp46 pourraient representer des cibles therapeutiques d’interet.

Background/Objectives Seborrheic keratoses are ubiquitous benign epithelial skin tumours. A number of unusual locations have already been reported. We report herein the case of a seborrheic keratosis of the nail bed with typical histological features. Methods/Results A 58-year-old man presented with a 1-year-history of longitudinal leukoxanthonychia of the right hallux. Surgical treatment was performed. The diagnosis of typical seborrheic keratosis of the nail bed was made on histological examination. Conclusion To our knowledge, this is the first report of a typical, histologically documented seborrheic keratosis of the nail bed. Therefore, this condition should be added to the differential diagnosis of acquired longitudinal leukoxanthonychia. However, surgical treatment remains necessary to rule out other causes, including squamous cell carcinoma.

Acral lentiginous melanoma (ALM) is a rare but distinctive subtype of melanoma. The diagnosis is often delayed and misdiagnosis is common, due to frequently unusual clinical presentation and a higher rate of amelanosis than in other melanoma subtypes.We aimed to investigate the dermoscopic features of a large series of ALM in a white-skinned population, in order to emphasize their diagnostic value.All recorded dermoscopic photographs of ALM, including nail unit variants, were collected from the files of the University Hospital Department of Dermatology (Lyons, France) and reviewed.In total 110 lesions, including 66 (60%) palmoplantar ALM and 44 (40%) ALM of the nail apparatus, were analysed for dermoscopic characteristics. The mean Breslow thickness was 2.6 mm. In volar skin melanomas, the two most prevalent patterns were irregular diffuse pigmentation (60%) and the parallel-ridge pattern (53%). Minor dermoscopic patterns, commonly noted in benign lesions, were also detected but only focally within the lesions. Among the 44 nail unit lesions, 31 (70%) presented irregular lines with variegations in colours, spacing, width and disruption of parallelism. Two cases of melanonychia striata had a triangular shape. Both corresponded to early ungual ALM. Association with subungual haemorrhage was not uncommon. The study included 37 (34%) amelanotic melanomas. However, dermoscopy enabled detection of microscopic remnants of pigmentation in most cases. The vascular pattern found in almost half of these lesions was polymorphous, with combinations of milky-red areas (95%), linear irregular vessels (49%), dotted vessels (43%) and hairpin vessels (41%).The presence of a parallel-ridge pattern and/or irregular diffuse pigmentation within the lesion is highly indicative of melanoma on volar skin. An irregular lines pattern is the most prominent dermoscopic feature of pigmented ALM of the nail apparatus. Amelanotic ALM either in volar skin or in nail apparatus is characterized by remnants of pigmentation and a polymorphic vascular pattern.

The pathogenesis of livedoid vasculopathy (LV) is still unclear. However, with increasing knowledge of disorders of coagulation over the past few years, the cause of some cases of LV has been elucidated. LV has now been described in association with hyperhomocysteinaemia, activated protein C resistance, and prothombin gene mutations in the absence of significant underlying inflammatory disease. When LV is seen in association with systemic lupus erythematosus or polyarteritis nodosa, it is probably due to the pro-coagulable state induced by these diseases rather than being true vasculitis. We review recent insights into LV provided by published clinical cases and discuss its pathogenesis.

Summary We report a new case of ‘large plaque-type blue naevus (PTBN) with subcutaneous cellular nodules’ involving the breast. A 25-year-old-woman presented with a large plaque, 140 × 100 mm in size, on the right chest wall involving the right breast, associated with recent subcutaneous nodules. Histopathological examination revealed features of cellular and common blue naevus. Dermatoscopy was performed, and the diagnosis of PTBN was made. PTBN is a rare condition with an imprecise prognosis. In cases of PBTN lesions on the head, clinicians must keep in mind the risk of malignant transformation of PTBN or an association with cutaneous neurocristic hamartoma. For this new variant of PTBN appearing on the trunk, we propose close monitoring of the patient if surgical excision is impossible.

Epidermolysis bullosa acquisita (EBA) is a rare autoimmune subepidermal blistering disease; it is potentially serious and is often refractory to conventional treatments, including corticosteroids. We report a new case of successful treatment of EBA using rituximab (anti-CD20 antibody) without relapse after 1 year of follow-up.A 76-year-old man was seen for blisters of the skin and mucosa, atrophic scars and milia on areas of friction. The diagnosis of EBA was made on the basis of histological and immunohistochemical criteria. The patient was unsuccessfully treated with topical steroids, dapsone, topical tacrolimus, systemic steroids, mycophenolate mofetil, doxycycline and methotrexate. Four weekly infusions of rituximab of 375 mg/m(2) body area were performed, combined with systemic steroids: they proved beneficial within 3 weeks, with a noticeable improvement and no further blisters at 7 months. After 1 year of follow-up, the skin disease is still stable with 5 mg/day of prednisone alone being given.This is the eighth reported case of treatment of EBA with rituximab and the sixth successful therapeutic outcome, with good steroid sparing effect and undeniable improvement in quality of life within several months and good tolerability at 12 months of follow-up. This treatment may be proposed early in cases of EBA refractory to conventional treatments. However, clinical observation is necessary to study potential long-term adverse effects.

Providing thorough coverage of the methods and tools required in studying historical and contemporary theatre, this Introduction examines the complexities of a rapidly changing and dynamic discipline. Following a cross-cultural perspective, the book surveys the ways theatre and performance are studied by looking initially at key elements such as performers, spectators and space. The central focus is on methodology, which is divided into sections covering theatre theory, historiography and textual and performance analysis. The book covers all the main theatrical genres - drama, opera and dance - providing students with a comparative, integrated perspective. Designed to guide students through the academic dimension of the discipline, the volume emphasizes questions of methodology, research techniques and approaches, and will therefore be relevant for a wide variety of theatre studies courses. Informative textboxes provide background on key topics, and suggestions for further reading are included at the end of each chapter.

To state that performance analysis is at the centre of theatre studies is a claim that would have met twenty years ago with a degree of sceptical reserve. Until the mid 1980s, theatre studies had consisted either of theatre history or dramatic analysis, with an emphasis on questions of staging. The idea that the performance itself could be analysed and studied was certainly recognized as desirable but was generally regarded as an impossible task. How could one analyse something that is essentially ephemeral, that disappears the moment it has been enacted? Does not analysis presuppose the existence of observable elements that can be scrutinized at length and ideally be checked and verified by other scholars? The analysis and interpretation of texts and pictures in literary studies and art history respectively, or of films or television programmes in media studies, have recourse to more or less stable artefacts. Performance analysis, it would seem, does not. This apparent impasse was resolved by a combination of technological and theoretical advances. The technological aspect is linked to the development of cheap and accessible video technology, which made available to scholars an increasing number of recordings of performances for detailed study. While performance analysis today is not necessarily dependent on video recording (it can be done without), in most cases it is used because it allows study of movement, sound and image, albeit filtered through the perspective of one or more cameras (to this problem we shall return below).

Given the centrality of space in the performance experience, it is perhaps somewhat surprising to find that critics do not have a precise, widely shared vocabulary to enable them to name and talk about the multiple dimensions of the way space functions in performance. (Gay McAuley 1999) The Italian-style stage is the space of [a] lie: everything takes place in an interior which is surreptitiously opened, surprised, spied upon, savoured by a spectator hidden in the shadow. (Roland Barthes 1972) Roland Barthes's characterization of Western theatre's dominant spatial configuration as deceitful and voyeuristic is both overstated and accurate at the same time. In the context of his discussion of Japanese Bunraku puppet theatre, the European proscenium does indeed seem to hide the spectator from the stage. Yet the ‘spectator hidden in the shadow’ is, historically speaking, a late development (dating from the late nineteenth century), and is therefore by no means inherent in the Italian-style stage. Barthes's comment does, however, point to a question of central interest to theatre studies, and that is the close relationship between stage forms and spectatorial attitudes. In this respect, this chapter is in part a continuation of the discussion of spectators and audiences begun in Chap. 2. It will, however, concentrate primarily on the physical conditions of performance, and outline ways in which the discipline of theatre studies has studied this problem.

Diffuse systemic sclerosis (DSS) is an autoimmune disease that is most often endogenous but which can also be induced by exogenous substances of occupational origin.We report a case of DSS involving prolonged intermittent occupational exposure to solvents (trichloroethylene [TCE] and perchloroethylene [PCE]). The disease was rapidly fatal with cardiac arrest secondary to myocardial fibrosis.In the event of exposure to TCE/PCE, we suggest more systematic prevention and diagnosis of DSS.

Summary Background Desmoplastic melanoma (DM) is a rare variant of cutaneous melanoma. Its diagnosis is often delayed by an unusual clinical presentation. The dermoscopic features of DM have not yet been described. Objective To define the dermoscopic features of DM. Patients and methods A single-institution register-based retrospective study of six cases of histology-proven desmoplastic melanoma for which dermoscopy data were available. The criteria we studied included: network, dots and globules, streaks, regression features, ulceration, number of colours, blue/white veil, and vascular pattern. Results Only three cases exhibited one classical feature for a melanocytic lesion; other cases were recognized on the basis of the presence of figures of regression (all six), i.e. white scar-like areas and ‘peppering’ (three of six), multiple (> 4) colours (five of six), and of melanoma-related vascular patterns (five) such as linear-irregular vessels (four) and milky-red areas (two). Discussion We believe that dermoscopy could help in the accurate diagnosis of this rare neoplasm. In the absence of a pigmented network, attention should be given to the identification of features of regression and to melanoma-associated vascular patterns.

No histological or clinical criteria allow distinction between primary cutaneous marginal zone B-cell lymphoma (MZL) and secondary cutaneous forms of systemic marginal zone B-cell lymphoma. Consequently, staging alone can indicate the origin of lymphoma. Lymphoma is considered as primary cutaneous only if no other extracutaneous sites are found. We studied the histological appearance of 49 cutaneous lymphomas in order to find distinctive criteria indicative of an extracutaneous origin.This was a retrospective descriptive study of histological appearance for 49 patients with cutaneous marginal lymphoma: 29 cases of the primary form and 20 cases with extracutaneous involvement.Comparison of histological criteria did not reveal any differences between the primary cutaneous form and others forms. No prognostic criteria for relapse were found.A cutaneous tropism of primary MZL suggested the hypothesis of specific cutaneous receptors on B-cells that could have led to different histological appearances depending on the origin of the lymphoma. However, our study did not confirm this hypothesis.

Lymphomatoid papulosis (LyP) is a rare lymphoproliferative disorder. It is now included in the World Health Organisation (WHO) classification of cutaneous lymphomas. Although frequently described in adults, there have been only a few reported cases of LyP in children; diagnosis is often difficult in this population and no clear guidelines have been established regarding management or monitoring. In this article we report six new cases of LyP in children.This is a retrospective study of six children, aged between two and 11 years, seen at the Hôtel-Dieu Hospital in Lyon and at the Grenoble Hospital Centre between 2005 and 2008. Each child underwent skin biopsy for histological and immunohistochemical analysis.All six children presented papulonodular lesions on the limbs and trunk, in some cases necrotic, present for different times and developing in episodes. Histology and immunolabelling announces in all six cases militated in favour of LyP type A, with large CD30+ and CD15- cells dispersed in an inflammatory dermal infiltrate made up for the most part of lymphocytes, polynuclear neutrophils, eosinophils and a small number of histiocytes.Only around 60 cases of LyP have so far been reported in children, principally type A. Association with malignant lymphoma occurs, with high risk in relation to the general population of the same age. Clinical diagnosis is confirmed histopathology and immunolabelling. There is currently no consensus regarding therapeutic management. First-line treatment generally comprises therapeutic abstention or dermal corticosteroids. Methotrexate and phototherapy constitute possible alternatives but should be used only in very disseminate or debilitating forms of the disease.The presentation and course of LyP of childhood differs very little from the adult form. Cases of associated lymphoma have been reported. Although regular clinical monitoring is recommended, there is no call for routine laboratory testing.

Summary Background Sentinel lymph node (SLN) positivity has been found to be strongly associated with a poor prognosis in melanoma. Objectives This large referral centre study was conducted: (i) to confirm the powerful prognostic value of SLN biopsy (SLNB); (ii) to correlate patient prognosis to the micromorphometric features of SLN metastasis in SLN-positive patients; and (iii) to correlate these micromorphometric features to the likelihood of positive completion lymph node dissection (CLND). Patients and methods SLNB was performed in 455 cases of primary melanoma between January 1999 and December 2004; for patients with positive SLN, the following micromorphometric features were registered: size of the largest metastasis (two diameters), depth of metastasis, number of millimetric slices involved, maximum number of metastases on a single section, presence of intracapsular lymphatic invasion and extracapsular spread. Kaplan–Meier survival curves were compared with the log-rank test; multivariate analysis was performed using a Cox regression model. Dependence of CLND status on micromorphometric features of SLN was assessed by the χ2 test and predictive values of the different features were evaluated by multivariate analysis using a logistic regression model. Results A positive SLN was identified in 98 of our 455 cases. Survival was significantly shorter in SLN-positive patients than in SLN-negative patients. Extracapsular invasion was found to be an independent prognostic factor of disease-free survival; ulceration of the primary and the maximum diameter of the largest metastasis were identified as independent predictive factors of disease-specific survival. Age and the lowest diameter of the largest metastasis were identified as independent predictive criteria of positive CLND, whereas depth of metastasis was not. Positivity of CLND was not significantly associated with a worse prognosis. Conclusions Our study confirms the previously demonstrated strong prognostic value of SLNB. It also confirms the relationship between tumour burden in the SLN (evaluated by the maximum diameter of the largest metastasis) and clinical outcome. We point out a new micromorphometric feature of SLN, which seems to be predictive of CLND status: the lowest diameter of the largest metastasis.

Sweet's syndrome, one of the neutrophilic dermatoses, is idiopathic in most cases. In 10-20% of cases it is paraneoplastic, associated with a solid tumour or haematological malignancy. An association with carcinoma of the bronchus has been only rarely described.We report the case of a 56 year old man who presented with Sweet's syndrome two months before the diagnosis of a squamous cell carcinoma of the bronchus. The dermatosis responded well to corticosteroids. The progress of the tumour was favourable, with stabilisation following 3 courses of chemotherapy and local radiotherapy.This case report updates this rare association and underlines the importance of undertaking appropriate thoracic investigations in the presence of this dermatosis. A paraneoplastic secretion of interleukin-8, GM-CSF and/or G-CSF by the bronchial tumour cells facilitating the recruitment of neutrophils, particularly in the skin, may account for the pathophysiology of this condition.

Ever since Columbus’s exploration of the New World, the notion of a ‘first encounter’ has exerted continual fascination in Western discourse. Two cultures entirely unaware of one another attempt communication by any means at their disposal except natural language. The situation poses, in Anthony Pagden’s words, ‘the possibility, and for many the impossibility, of cultural commensurability’.1 The literature treating European incursions into the Pacific contains perhaps the richest documentation of such encounters, which, in the case of James Cook’s first and second expeditions, took place at regular, sometimes (in the course of his circumnavigation of New Zealand) at almost daily intervals. First encounter or contact situations are located in a liminal space between imprevu and deja vu, between wonder and recognition. While most discussions tend to stress the moment of imprevu — the experience of wonder, surprise and astonishment — recent theories have begun to question whether there can be such a thing as genuine ‘first’ encounter, devoid of any premeditation.2 It can be argued that ostensible first-contact scenes are always haunted by a moment of deja vu and are therefore always at some level recognition scenes. The Other is never totally strange, because at some fundamental level a common ‘humanity’ is apprehended. As we shall see, the cultures involved in these encounters immediately integrated the foreign culture into pre-existing matrices of response.

In 1951, shortly after his return to Frankfurt from American exile, the German philosopher and connoisseur of avant-garde music Theodor W. Adorno recalled that the sound of a kettledrum invariably produced associations with the Samoan troupes he had seen as a 7-year-old child in the Frankfurt zoo: In the Zoological Garden there were not just the animals but there was a music pavilion and occasionally exhibitions of exotic tribes, of Samoans and Senegalese. … Whether it is the memory of it or simply the condensation of things long past — even today I associate with the beat of a kettledrum the name Tamasese and at the same time: the drum is played on his prisoners’ heads, or it is the pestle in which the savages cook human flesh.1 Adorno’s associative recollections are remarkably accurate on a number of counts. In 1910 a troupe of Samoan performers spent almost a month in the Frankfurt zoo performing dances and songs, cavorting on specially constructed water-slides and paddling their imported canoes. While the demonstration of cannibalistic practices was certainly not on the menu, boxing, wrestling, knife-dances and Samoan earth-cooking were. Even for a precocious child the conflation was understandable.

As we saw in the last chapter, Bloody Mary’s trade in yellow grass-skirts, shrunken heads and model canoes documented that the South Pacific had well and truly become a tourist space. Her US servicemen customers were evidently more than eager to document their Pacific experience (which for many would end in death or wounding) in terms of authentic native curios. By this time, the Pacific had begun to trade on its discursive history. It had become a sign of itself, which is a prerequisite of the tourist experience. For a place or culture to attain this state of virtual existence, whereby the phoney and contrived version of cultural experience is perceived as more authentic than the actual state, a sustained process of verbal, visual and very often performative representation must have occurred. The preceding chapters have engaged in different ways with this historical process. The redefinition of hula and haka in the nineteenth century (Chapter 4) created two performance forms that, in their versions at least, became metonymic representations of their respective indigenous cultures. The popular ethnographic spectacles of late nineteenth-century Europe (Chapter 5) could be considered as armchair-tourist performances. The popularization of Hawaiian music and dance in the wake of Richard Walton Tully’s play The Bird of Paradise (Chapter 6) had an important influence on the growing tourist trade to Hawai‘i.

As we saw in the last chapter, the Polynesian Cultural Center is predicated on a number of practices that are characteristic of cross-cultural theatricality. As constructed in the Center, Pacific cultures are presented primarily by performative metonymy. A number of putative traditional performances provide a citable set of recognizable and appealing signs of cultural authenticity. Since the villages stage a prelapsarian Polynesia pre-dating Western contact the representational function of these metonymies is in actual fact ahistorical and has little or no connection with contemporary Pacific cultures. It is only in the subversive performances of the Samoan and Tongan villages that this discrepancy is made manifest when the touristic expectations of a mythologized Pacific are refracted back to the spectators. In this fictional theatre of an authentic Polynesian past the actualities of contemporary Pacific cultures are intentionally obscured.

In the previous chapter we observed how the first encounters between Pacific Islanders and Europeans were marked by various manifestations of theatricality. In this chapter we will examine how these events, already framed within tropes of theatricality and the spectacular, were translated into theatrical genres on the European stage. The focus will be on the early period, roughly between 1785 and 1830, which sees a shift in discursive interest from representations claiming a high degree of authenticity to those maximizing exoticism. Roughly speaking we can follow a narrative whereby the theatrical representations, whatever their genre, seek in the immediate aftermath of the voyages and their published reports to present these experiences in the theatrical equivalent of the new ‘discourse of authenticity’ emerging in the second half of the eighteenth century. The apparent antithetical nature of the terms ‘authenticity’ and ‘theatrical’ produces a tension that is the subject of this chapter. Defining authenticity is notoriously difficult, as we noted in the introduction. On the one hand, it seems to defy identification according to any essentialist categories. On the other, it is a crucial discursive concept with far-reaching ramifications. It is a central concept for media representations, particularly those emanating from the mass media.

As we have seen in the previous chapter, missionary opposition to indigenous performance forms could be implacable and was very often efficacious. The first missionary in Hawai‘i, the American Congregationalist Hiram Bingham, opposed hula in all its forms and with the help of the powerful queen regent Ka’ahumanu managed to ban all public performances in 1830. Despite such opposition hula did not disappear, but continued to be practised covertly and eventually overtly after Ka’ ahumanu’s death in 1832. By this time, however, Hawai‘i was being gradually Christianized so that the religious aspects of the performance form became obsolete. Rather than withering away or fossilizing into touristic folklore hula returned with a vengeance in the second half of the nineteenth century, where it came to occupy important cultural and political functions that continue until the present day. Every year, the foremost hula troupes of the various islands compete for prizes in a variety of disciplines, traditional and modern, in the Merrie Monarch Festival, a cultural event of considerable magnitude.

In the 1890s the United States emerged as a fully-fledged imperialist and colonialist power in the Pacific. In 1893 American settlers in Hawai‘i staged a coup d’etat and deposed the ruling Hawaiian queen Liliuokalani. The so-called ‘revolutionary government’ aggressively petitioned the US government to annex the Hawaiian islands, which was formally enacted in 1898. In 1899 the United States was granted Eastern Samoa as a territory, a colonial possession it still holds. Between 1941 and 1945 in the course of the Pacific war against Japan, the US military occupied many islands throughout the Pacific, a presence with far-reaching ramifications for the islands’ economies and cultures. This de jure or de facto colonial presence led to an upsurge of interest in the territories which found expression on the US stage in three major works.1 In 1912, Richard Walton Tully’s Hawaiian drama The Bird of Paradise premiered in New York and was performed for over 12 years in North America and London. Ten years later, in 1922, Rain, an adaptation of Somerset Maugham’s novella of the same title, opened to critical and popular acclaim. In 1949 the Rodgers and Hammerstein musical South Pacific dramatized the Pacific theatre of war. In all three plays internal racial issues were played out in Pacific island settings. In all cases we can observe a strategy of geographical displacement and semiotic substitution, whereby theatrical performance functions to camouflage and reveal unresolved domestic conflicts.

Introduction Les lymphomes B primitifs cutanes a grandes cellules (LBCGC) correspondent a 2 diagnostics de pronostic different : le lymphome B centrofolliculaire a grandes cellules (LBCF) et le lymphome B a grandes cellules de type jambe (LBTJ). Bien que ces 2 lymphomes aient une cytologie et un profil phenotypique differents, il est parfois difficile de les differencier. Recemment, un nouvel outil diagnostique pour le LBTJ a ete decrit, la presence de la mutation activatrice de MYD88 L265P dans 69 % des LBTJ. Nous avons recherche la presence de cette mutation sur une serie de cas de LBCF et LBTJ typiques. Materiel et methodes Tous les patients etaient inclus dans la base du groupe francais d’etude des lymphomes cutanes (GFELC). Trente-quatre cas de LBCGC ont fait l’objet d’une relecture anatomopathologique. Cinq cas ont ete exclus : localisation cutanee d’un lymphome systemique, lymphome B centrofolliculaire cutane a petites cellules. Au total, 29 dossiers de LBCGC ont ete selectionnes : 24 de Bordeaux, 3 de l’hopital Saint-Louis (Paris) et 2 de Lyon. Cette serie regroupait 10 LBTJ typiques, 9 LBCF typiques et 10 cas douteux. Les cas typiques correspondaient a des lymphomes dont la morphologie et le profil phenotypique etaient sans equivoque. Chaque cas a beneficie d’une analyse en biologie moleculaire par PCR quantitative a la recherche de la mutation MYD88. Resultats La mutation MYD88 a ete trouvee dans 8 des 10 cas de LBTJ (80 %). Absence de mutation mise en evidence dans les 9 cas de LBCF (0 %). Parmi les cas douteux de LBCGC, la mutation MYD88 etait presente chez 4 des 10 cas (40 %). En considerant la presence de MYD88 comme un outil diagnostique pour les LBCGC entre LBTJ et LBCF, on trouve une sensibilite de 80 %, une specificite de 100 %, une valeur predictive positive de 100 % et une valeur predictive negative de 82 %. Discussion Ces resultats montrent que la presence de la mutation MYD88 semble specifique du LBTJ. La recherche de la mutation MYD88 pourrait etre un outil diagnostique important dans les LBCGC pour faire la difference entre un LBTJ et un LBCF. Un nombre de cas plus consequent serait souhaitable pour confirmer cette tendance. La relecture anatomo-pathologique de ces LBCGC a classe de nombreux cas douteux. Une analyse anatomo-clinique plus approfondie des cas douteux permettrait de savoir si la presence de la mutation MYD88 peut aider au diagnostic dans ces cas particuliers. Conclusion Parmi les LBCGC, comprenant les LBTJ et les LBCF, la presence de la mutation MYD88 semble specifique des LBTJ. Dans cette serie, elle n’est jamais trouvee parmi les cas de LBCF typiques. La recherche de la mutation MYD88 pourrait donc etre un outil diagnostique important dans les LBCGC pour faire la difference entre un LBTJ et un LBCF, en plus de l’histologie et du profil phenotypique.

Introduction Les dermatoses de l’interface representent un groupe de pathologies comportant des modifications histologiques caracteristiques touchant la jonction dermo-epidermique (JDE). Ces modifications comprennent une degenerescence vacuolaire de la basale, la presence de keratinocytes apoptotiques et un infiltrat inflammatoire dense et en bande de la JDE. Le lupus erythemateux, le lichen plan, la dermatomyosite, la reaction du greffon contre l’hote, l’erytheme polymorphe, l’erytheme pigmente fixe, le lichen striatus et le pityriasis lichenoide representent les dermatoses de l’interface les plus importantes. A ce jour, les modifications cytologiques des dermatoses de l’interface n’ont pas ete etudiees en microscopie confocale. L’objectif de cette etude etait de caracteriser la morphologie des cellules a la JDE de differentes dermatoses de l’interface en microscopie confocale. Observations Un enregistrement en microscopie confocale (Vivascope 1500) a ete realise sur les plaques de 5 cas de dermatoses de l’interface incluant 2 lichens plans, une toxidermie lichenoide, un lupus erythemateux dissemine et une dermatomyosite. Nous avons observe, a la JDE, la presence de nombreuses cellules ayant un aspect annulaire avec un renforcement polaire brillant et entourant une partie centrale sombre assimilees a des cellules en « bagues a chaton ». Discussion A ce jour, deux etudes pilotes ont decrit l’aspect en microscopie confocale du lichen plan et du lupus erythemateux discoide. Les alterations decrites concernaient les modifications architecturales de la JDE. Les modifications cytologiques des cellules vacuolisees de la couche basale n’ont pas ete rapportees. Nous avons mis en evidence des cellules en bague a chaton a la JDE de 4 grands groupes de dermatose de l’interface. Le nombre important de ces cellules a la JDE pourrait etre en rapport au plan de coupe horizontale visualise par la microscopie confocale. La confrontation histologique correspondrait a des cellules comportant un cytoplasme vacuolise (centre sombre) et un noyau picnotique refoule (anneau brillant). Conclusion La recherche de cellules en bague a chaton a la JDE pourrait representer un indice supplementaire dans le diagnostic des dermatoses de l’interface en microscopie confocale.

Schnitzler syndrome is a rare condition defined by chronic urticaria and monoclonal IgM gammopathy. Malignant evolution to Waldenström disease (WD) has been reported in several cases. We report a 49-year-old man who developed a marginal zone B-cell lymphoma (MZL) 3 years after the beginning of Schnitzler syndrome. This is the first report of MZL in association with Schnitzler syndrome. IgM gammopathy is a clue for the diagnosis of Schnitzler syndrome. This condition needs to be closely monitored; it can precede the onset of an authentic lymphoproliferative disorder including WD and rarely MZL.

Although the histopathological subtype of melanoma has not been clearly proven to carry independent prognostic significance, acral lentiginous melanoma (ALM) seems to confer a poorer prognosis mainly because disease is often more advanced at the time of diagnosis.To investigate the distinctive epidemiological and clinical characteristics of ALM, a peculiar histological entity, and to identify prognostic factors.We performed a register-based review of cases from a single large referral centre, the University Hospital Department of Dermatology, Lyons, France. We reviewed patient demographics, the initial presentation of the lesion, and clinical outcome. ALM-specific and disease-free survival were estimated using the KaplanMeier method and compared using the log-rank test. A Cox model was used to identify prognostic factors.One hundred and twenty-six patients were identified as having histopathology-proven ALM in our melanoma patient register from 1996 to 2004. There were 46 (37%) subungual ALM and 80 (63%) ALM on soles, palms and nonvolar sites. The mean age at diagnosis was 63 years. There were 44 (35%) men and 82 (65%) women, sex ratio M/F 1 : 1.86. The mean Breslow thickness was 2.51 mm (range: in situ to 20 mm). There was no evidence of overexposure to ultraviolet radiation, nor was there found a predisposing genetic trait. Only 16 (13%) patients recalled a history of trauma. Thirty-four ALM (28%) were unpigmented. The median ALM-specific and disease-free survival were 13.5 and 10.1 years, respectively. The 5-year survival rate was 76%. Multivariate analysis identified tumour thickness, male gender and amelanosis as independent clinical prognostic factors for both ALM-specific and disease-free survival.Our study provides specific information on the clinical characteristics and outcome of this uncommon histological subtype of melanoma. However, the pathogenesis remains unknown. Breslow thickness, male gender and amelanosis were significantly associated with a poorer prognosis.