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Cell senescence is a physiological program of terminal growth arrest, which is believed to play an important role in cancer prevention. Senescent cells secrete multiple growth-regulatory proteins, some of which can affect tumor growth, survival, invasion, or angiogenesis. Changes in expression of different senescence-associated genes were analyzed in cultured human skin keratinocytes (KCs) that underwent replicative senescence or confluence-induced accelerated senescence. Senescent KC cultures showed a strong increase in mRNA and protein expression of maspin, a member of serine protease inhibitor family and an epithelial cell tumor suppressor with anti-invasive and antiangiogenic activities. Immunohistochemical analysis of 14 normal human skin samples (age range from 3 months to 84 years) showed that maspin is expressed by KCs in vivo and that the extent and intensity of maspin expression in the skin is significantly (P = 0.01) correlated with chronological age. Antiangiogenic activity of maspin secreted by senescent KCs was investigated in vitro by testing the effect of conditioned media from different KC cultures on endothelial cell migration in the presence or absence of several angiogenic factors. Media conditioned by senescent cultures (undergoing replicative or accelerated senescence), but not by proliferating KCs, strongly inhibited the stimulation of endothelial cell migration by all of the tested angiogenic factors. Neutralizing antibody against maspin abrogated this effect of conditioned media. These findings indicate that senescent KCs exert a paracrine antiangiogenic activity, and maspin is the principal contributor to this potentially tumor-suppressive effect of cellular senescence.

Recent studies have implicated interferon signaling in the regulation of cellular senescence. However, the role of specific interferon-inducible proteins in cellular senescence remains to be defined. Here we report that IFI 16, an interferon-inducible transcriptional modulator from the p200-protein family, contributes to cellular senescence of prostate epithelial cells. Normal human prostate epithelial cells (PrEC) in culture expressed detectable levels of IFI 16, and the levels increased more than fourfold when cells approached cellular senescence. Consistent with a role of IFI 16 in cellular senescence, human prostate cancer cell lines either did not express IFI 16 or expressed a variant form, which was primarily detected in the cytoplasm of prostate cancer cells and not in the nucleus. Moreover, overexpression of functional IFI 16 in human prostate cancer cell lines inhibited colony formation. Additionally, ectopic expression of IFI 16 in clonal prostate cancer cell lines was associated with a senescence-like phenotype, production of senescence-associated beta-galactosidase (a biochemical marker for cellular senescence), and reduction of S-phase cells in culture. Importantly, upregulation of p21WAF1 and inhibition of E2F-stimulated transcription accompanied inhibition of cell growth by IFI 16 in prostate cancer cell lines. Collectively, our observations support the idea that increased levels of IFI 16 in PrECs contribute to senescence-associated irreversible cell growth arrest.

Context.—While it is well known that both exogenous and endogenous stimuli can trigger appearance of psoriatic lesions, the initial cellular and molecular events mediated by immunocompetent cells normally resident in prepsoriatic (PN) skin are not well understood. Moreover, it is unclear whether there are any fundamentally important differences in the innate immune response of normal healthy skin (NN skin) versus PN skin. Since acute tissue responses to stimuli involve both resident cells and immunocytes recruited rapidly from circulation, it is difficult to discern the contribution of endogenous cells normally present in skin.Objective.—To solely characterize the reactivity of resident immunocytes using an experimental system.Design.—To probe the activation potential of resident immunocytes in NN (n = 18) and PN skin (n = 10), a short-term ex vivo organ culture system containing interleukin (IL)-2 was established and characterized. To mimic exogenous or environmental trigger factors, bacteria-derived superantigens and lipopolysaccharide were added to the skin-explant assays, whereas endogenous trigger factors were investigated using heat shock proteins.Results.—Using this skin-explant assay, both NN and PN skin gave rise to an expansion of various T-cell subsets, which could differentially produce various cytokines and a growth factor (keratinocyte growth factor), depending on the stimulus and source of skin. Bacterial superantigens were relatively potent inducers of interferon-γ, and natural killer–T cells were observed proliferating from PN skin.Conclusions.—Despite relatively few T cells normally residing in either NN or PN skin, initiation of skin explants from both sets of individuals in the presence of IL-2 triggered vigorous T-cell proliferation and cytokine/growth factor release. These results demonstrate the utility of this skin-explant assay system to further investigate quantitative and qualitative immune responses of NN and PN skin.

Evaluation of: Wagle N, Emery C, Berger MF et al. Dissecting therapeutic resistance to RAF inhibition in melanoma by tumor genomic profiling. J. Clin. Oncol. DOI: 10.1200/JCO.2010.33.2312 (Epub ahead of print) (2011).Melanoma is a deadly skin disease well known for resistance to chemotherapies and immunomodulating therapies. PLX4032 is a selective BRAF inhibitor and, in clinical trials, has consistently induced tumor responses in the majority of patients with BRAF V600E mutant melanoma. However, duration of response has been limited due to the development of acquired resistance. This article evaluates a recently published investigation evaluating the resistant mechanisms to BRAF therapy using tumor genomic profiling of isolated DNA from responsive and acquired resistant melanoma tissue in a patient treated with the BRAF inhibitor PLX4032.

Immunodeficiency-related lymphoproliferative disorders (IR-LPD) may occur in the setting of immunosuppressive therapy with methotrexate and TNF-α antagonists. As far as we are aware, this is the first report of an Epstein-Barr virus-associated B-cell lymphoproliferative disorder, secondary to methotrexate therapy in a patient with mycosis fungoides/Sézary syndrome.

Indeterminate dendritic cell tumor is an extremely rare neoplastic proliferation of dendritic cells that share immunophenotypic features of Langerhans cells and macrophages but lack Birbeck granules and Langerin expression.We report a 55-year-old female presenting with a leonine facies and generalized multiple confluent papules, nodules and plaques on neck, upper trunk, arms and thighs. Laboratory evaluations were performed including skin biopsies, peripheral blood flow cytometry and positron emission tomography-computed tomography.The lesional skin biopsy showed a dense dermal and perifollicular infiltrate composed of histiocytoid cells with nuclear grooves lacking dendritic processes in a background of lymphocytes. Eosinophils were absent. The histiocytoid cells were CD68+CD1a+Langerin- and only focally S100+. Special stains including GMS, Gram and Fite were all negative for infectious organisms. Although an initial diagnosis suggesting Langerhans cell histiocytosis was proposed due to CD1a positivity, a diagnosis of indeterminate dendritic cell tumor was finally rendered based on the histopathological findings and the lack of expression of Langerin.This case illustrates the variegated clinical presentation of indeterminate cell tumor and the necessity of appropriate immunohistochemical workup for its diagnosis.

Background Human T-lymphotropic virus (HTLV)-1-associated infective dermatitis (ID) is a rare severe chronic eczema, considered as a harbinger for the development of cutaneous adult T-cell leukemia/lymphoma (ATLL) and/or HTLV-1-associated myelopathy (HAM)/tropical spastic paraparesis (TSP). The pathogenesis of ID remains unclear. High numbers of peripheral blood CD4+ CD25+ FoxP3+ regulatory T cells (Tregs) have been reported in ATLL and HAM/TSP. Objective To investigate the status of Tregs, unknown to date, and the histopathological features of ID. Methods We studied 16 skin biopsies from 15 Peruvian adults and children with ID by immunohistochemistry. Results Histopathological patterns were seborrheic dermatitis-like and lichenoid. Intraepidermal lymphocytes were conspicuous. The infiltrate was composed of a CD3+ T cell infiltrate with a predominance of CD8+ over CD4+ cells. CD4+ CD25+ FoxP3+ Tregs were rare and their numbers were significantly lower than those reported in other inflammatory dermatoses. Conclusion Tregs have an essential role in maintaining immune homeostasis of skin. Treg dysregulation ends in severe clinical manifestations. The clinical presentation of ID, with lesions resembling those seen in patients with atopic dermatitis and with mutations in the FoxP3 gene, is in agreement with a common Treg-deficient skin environment in these disorders, possibly secondary to HTLV-1 infection.

The discovery of BRAF mutation in ~50% of melanomas led to the development of small molecule BRAF inhibitors, including sorafenib, debrafenib, and vemurafenib. Clinical trials have shown these agents to be effective in treatment of metastatic and locally advanced melanoma, increasing overall and progression-free survival. However, some of the most common toxicities associated with BRAF inhibitor therapy include adverse skin events such as rashes, photosensitivity, hyperkeratosis, papillomas, keratoacanthomas, and squamous cell carcinomas. Here, the authors describe 3 patients who developed keratinocytic neoplasms on the eyelid, including invasive squamous carcinoma secondary to vemurafenib. Vigilant screening and a high index of suspicion for eyelid carcinomas are recommended in patients treated with vemurafenib.

The management of melanoma has evolved owing to improved understanding of its molecular drivers. To augment the current understanding of the prevalence, patterns, and associations of mutations in this disease, the results of clinical testing of 699 advanced melanoma patients using a pan-cancer next-generation sequencing (NGS) panel of hotspot regions in 46 genes were reviewed. Mutations were identified in 43 of the 46 genes on the panel. The most common mutations were BRAFV600 (36%), NRAS (21%), TP53 (16%), BRAFNon-V600 (6%), and KIT (4%). Approximately one-third of melanomas had >1 mutation detected, and the number of mutations per tumor was associated with melanoma subtype. Concurrent TP53 mutations were the most frequent events in tumors with BRAFV600and NRAS mutations. Melanomas with BRAFNon-V600mutations frequently harbored concurrent NRAS mutations (18%), which were rare in tumors with BRAFV600 mutations (1.6%). The prevalence of BRAFV600 and KIT mutations were significantly associated with melanoma subtypes, and BRAFV600 and TP53 mutations were significantly associated with cutaneous primary tumor location. Multiple potential therapeutic targets were identified in metastatic unknown primary and cutaneous melanomas that lacked BRAFV600and NRAS mutations. These results enrich our understanding of the patterns and clinical associations of oncogenic mutations in melanoma.

Granulomatous dermatitis (GD) is known to occur following varicella-zoster virus (VZV) infection. Lesions may appear at varying times after the acute eruption in both immunosuppressed and immunocompetent hosts. The etiology of GD is unclear, and findings of VZV in the lesions often are inconsistent. We describe 2 immunocompromised patients who presented with GD following VZV infection; their lesions were examined for the presence of VZV. We also review the literature on postzoster GD.

Mycosis fungoides (MF) is the most common cutaneous T-cell lymphoma and can have a variety of clinical and histological manifestations, including erythrodermic, pustular, bullous, hypo/hyperpigmented, and verrucous forms. We describe a case of a 59-year-old woman who presented with verrucous hyperkeratotic plaques on her distal fingertips, dorsal feet, and areolae that were subsequently biopsied and shown to be mycosis fungoides. This case highlights one of the many atypical manifestations of MF and underscores the need to have a high clinical suspicion for the disease.

Cellular angiofibroma (CAF) is a recently described rare soft tissue neoplasm of the vulva (with only four reported cases) that typically occurs as a well-circumscribed solid rubbery vulvar mass in middle-aged women. The distinct histologic features of bland spindle cells admixed with numerous hyalinized medium to small blood vessels, and a vimentin-positive desmin-negative immunoprofile differentiates this neoplasm from other vulvar tumors such as angiomyofibroblastoma and aggressive angiomyxoma. In this report an additional case of CAF is presented with DNA ploidy analysis and CD99 immunohistochemistry.

Since the skin produces POMC peptides, in the present work we investigated local production of urocortin, a peptide related to CRH, the normal endogenous stimulant for POMC. Urocortin immunoreactivity was detected by direct RIA in extracts of human skin, mouse skin (C57BL-6 strain), cultured cells from established lines of human melanoma and squamous cell carcinoma, human keratinocytes (HaCaT), and hamster melanomas. Addition of a reverse phase high performance liquid chromatography step before the RIA confirmed the presence of urocortin, as the immunoreactivity eluted at the same retention time as urocortin standard in extracts from HaCaT keratinocytes and mouse skin. Using the tandem technique of liquid chromatography-mass spectrometry, we identified a peptide with the same mass and retention time as the urocortin standard in human skin extracts. The urocortin antigen could be immunolocalized to normal keratinocytes of the epidermis and hair follicle, epithelium of sweat and sebaceous glands, dermal ske...

Vemurafenib and dabrafenib selectively inhibit the v-Raf murine sarcoma viral oncogene homolog B1 (BRAF) kinase, resulting in high response rates and increased survival in melanoma. Approximately 22% of individuals treated with vemurafenib develop cutaneous squamous cell carcinoma (cSCC) during therapy. The prevailing explanation for this is drug-induced paradoxical ERK activation, resulting in hyperproliferation. Here we show an unexpected and novel effect of vemurafenib/PLX4720 in suppressing apoptosis through the inhibition of multiple off-target kinases upstream of c-Jun N-terminal kinase (JNK), principally ZAK. JNK signaling is suppressed in multiple contexts, including in cSCC of vemurafenib-treated patients, as well as in mice. Expression of a mutant ZAK that cannot be inhibited reverses the suppression of JNK activation and apoptosis. Our results implicate suppression of JNK-dependent apoptosis as a significant, independent mechanism that cooperates with paradoxical ERK activation to induce cSCC, suggesting broad implications for understanding toxicities associated with BRAF inhibitors and for their use in combination therapies. DOI: http://dx.doi.org/10.7554/eLife.00969.001, eLife digest Over 50% of melanomas, a highly lethal form of skin cancer, carry mutations in a gene called BRAF. The BRAF gene encodes an enzyme that helps to regulate the proliferation of cells, but mutations in this gene lead to the excessive proliferation that is seen in cancer. Clinical trials have shown that a drug called vemurafenib can be used to treat patients who carry the mutated BRAF genes and go on to develop melanoma, but around one fifth of these patients developed another type of skin cancer called cSCC (cutaneous squamous cell carcinoma). The cSCC tumors often develop in areas where the sun has damaged the patient’s skin, and it is thought that their growth is then accelerated by vemurafenib activating another enzyme, ERK, which causes the excessive proliferation of skin cells. Vin et al. have now found that vemurafenib might also cause cSCC tumors by blocking another signaling pathway. The experiments were performed in human cells and also in mice, and the results were then verified in human cSCC samples. Cells that are exposed to UV radiation usually die, but when treated with vemurafenib, some 70% of the cells that would have died instead survived. The stress from the UV radiation activates the JNK signaling pathway, which causes the irradiated cells to die. However, Vin et al. found that cSCC cells had very low levels of JNK signaling because treatment with vemurafenib had the unintended effect of inhibiting three enzymes that are needed to fully activate the JNK signaling pathway. Vin et al. estimate that suppression of JNK signaling and cell death is responsible for about 17.6 to 40% of the effect on cSCC growth seen in melanoma patients, with activation of the ERK pathway accounting for the rest. These unexpected findings suggest that combining vemurafenib treatment with radiation or chemotherapy should be done with caution as these effects could affect their efficacy. It also suggests that future drugs should be designed in a way that avoids these types of effects by making sure they do not inhibit important ‘off-target’ enzymes. DOI: http://dx.doi.org/10.7554/eLife.00969.002

The adequate procurement and preservation of high-quality tissue specimens from patients with melanoma is a critical clinical issue as patients' tumor samples are now used not only for pathological diagnosis but are also necessary to determine the molecular signature of the tumor to stratify patients who may benefit from targeted melanoma therapy. Tissue resources available for physicians and investigators include formalin-fixed paraffin-embedded (FFPE) tissue and frozen tissue, either preserved in optimal cutting temperature (OCT) media or snap frozen. Properly preserved tissue may be used to evaluate melanoma biomarkers by immunohistochemistry (IHC) with tissue microarray (TMA) technology, to perform genetic and genomic analyses, and for other types of translational research in melanoma.

Extramammary Paget disease (EMPD) is an uncommon tumor that presents in apocrine-rich skin as an irregular, pruritic plaque. Histopathologically, EMPD consists of an intraepidermal proliferation of atypical epithelioid cells. Rarely, the tumor cells contain intracytoplasmic melanin pigment, and the lesion clinically and histopathologically can mimic a melanocytic proliferation.A 51-year-old female with a history of breast carcinoma presented with a pigmented patch on her right thigh of 6 months duration. The clinical impression was an atypical melanocytic nevus. Histopathologic examination revealed an intraepidermal proliferation of epithelioid cells along the dermal-epidermal junction with pagetoid migration. The tumor cells exhibited increased cytoplasm containing conspicuous melanin pigment and enlarged oval-irregular nuclei. Immunohistochemical studies showed the tumor cells to be strongly and diffusely positive for cytokeratin 8/18, cytokeratin 7 and p63; focally and weakly positive for epithelial membrane antigen (EMA), but negative for cytokeratin 5/6, Cam5.2, carcinoembryonic antigen (CEA), human melanoma black 45 (HMB-45), tyrosinase and Sox-10, supporting the diagnosis of pigmented EMPD. The lesion was subsequently excised, and the patient is free of disease after 24 months.We present this unusual case of pigmented EMPD arising on the thigh to draw attention to the entity and to underscore the potentially misleading clinical, histopathologic and immunophenotypic features that mimic other cutaneous intraepidermal lesions.

The diagnosis of benign versus malignant melanocytic proliferations remains an important challenge. The current diagnostic algorithm typically involves an assessment of histopathologic and immunohistochemical parameters by light microscopy. Recently, fluorescence in situ hybridization (FISH) was reported as a useful ancillary diagnostic tool in melanocytic lesions, but the utility of FISH in melanocytic tumors that are difficult to diagnose with standard morphologic analysis remains controversial. To address this issue, we collected 34 ambiguous melanocytic tumors for FISH testing (NeoGenomics). Before FISH testing, cases were designated as "favor benign" (n=24) or "favor malignant" (n=10) by a consensus group (up to 7 dermatopathologists) on the basis of clinical, histopathologic, and immunophenotypic parameters. FISH was positive in 3/24 "favor benign" lesions and in 5/10 "favor malignant" lesions. The histopathologic, immunophenotypic, and FISH parameters informing our diagnostic impression were correlated with the final consensus diagnosis and clinical follow-up; in all cases, the initial diagnosis remained unchanged. In this series, the sensitivity of FISH for the histopathologic diagnosis of melanoma was 50%, the specificity was 87.5%, the positive predictive value was 62.5%, and the negative predictive value was 80.7%. Follow-up information was available for 25 patients (17 benign and 8 malignant diagnoses). Among benign lesions, the mean follow-up was 16.8 months (range, 8 to 25 mo); no metastases have been reported to date. Among the malignant lesions, the mean follow-up was 14.6 months (range, 7 to 23 mo); a single lymph node metastasis was identified in a 4-year-old girl with a histopathologic diagnosis of melanoma, which was negative on FISH. In our experience, in the setting of a lesion with predominantly benign findings, a negative FISH test-given its high specificity-is a reassuring finding that supports a benign diagnosis. In contrast, a positive FISH test should be carefully interrogated in the context of the complete histopathologic findings.

Hotspot mutations in BRAF and NRAS are the most common somatic events in patients with melanoma. These mutations occur at highly conserved residues, but include several different substitutions. To determine whether specific mutations are clinically important to differentiate, tumor characteristics and clinical outcomes were compared among patients with advanced melanoma with 1) BRAF V600E versus V600K mutations and 2) NRAS exon 1 versus exon 2 mutations.Retrospective clinical and pathologic data were collected for patients with advanced melanoma with BRAF or NRAS mutations. The demographics, tumor characteristics, and clinical outcomes of the patients were compared to identify significant mutation-specific associations.Among 302 patients with activating BRAF mutations, 76% had BRAF V600E and 24% had V600K substitutions. Compared with V600E, the presence of a V600K mutation was significantly associated with older age (median, 60.0 years vs 44.7 years; P.001), male sex (80% vs 59%; P = .001), head/neck primary tumor location (30% vs 15%; P = .0026), shorter interval to stage IV disease (0.98 years vs 2.8 years; P = .015), and a shorter overall survival from the time of diagnosis of stage IV disease (median, 2.44 years vs 1.25 years; hazards ratio, 1.68 [P = .014]). Comparison of 136 patients with NRAS exon 1 (18%) and exon 2 (82%) mutations found an association with primary tumor histology (P = .0096) only.The presence of different substitutions at BRAF V600 correlates with patient demographics, tumor characteristics, and prognosis. These findings demonstrate the presence of mutation-specific clinical differences between different BRAF genotypes in patients with melanoma, and support the incorporation of this information in patient evaluation and clinical trial design.

Context. The 7th (2009) edition of the AJCC melanoma staging system incorporates tumor (Breslow) thickness, MR, and ulceration in stratifying T1 primary melanomas. Compared to the prior 6th (2001) edition, MR has replaced CL for thin melanomas. Objective. We sought to identify and report differences of the classification of thin melanomas as well as outcome of SLNB in patients according to the 6th and 7th editions at our institution. Results. 106 patients were identified with thin melanomas verified by wide excision. 31 of 106 thin melanomas were reclassified according to the 7th edition of the AJCC. Of those 31, 15 CL II/III patients (6th edition T1a) were reclassified as T1b based on the presence of mitoses while 16 CL IV patients (6th edition T1b) were categorized as T1a based on the absence of mitoses. 26/31 reclassified patients underwent SLNB, and all were negative. Patients with thin melanoma and a +SLNB (N = 3) were all classified as T1b according to both staging systems. Conclusions. In our experience, 29% of thin melanomas were reclassified according to the 7th edition with similar proportions of patients re-distributed as T1a (14%) and T1b (15%). Cases with +SLN corresponded with T1b lesions in both 6th and 7th editions.

In the American Joint Committee on Cancer (AJCC)-TNM (2009) staging system, the key prognostic factor in cutaneous melanoma is the depth of dermal invasion (Breslow thickness) with further refinement according to the presence of epidermal ulceration or dermal mitoses. Immunodetection of phosphohistone H3 has been shown to facilitate the identification of mitotic figures in various neoplasms. We selected 120 cases of primary cutaneous melanoma with completely annotated histopathologic parameters and clinical outcomes and performed double immunohistochemical staining for MLANA (Mart-1/Melan-A) and phosphohistone H3. One hundred and thirteen cases were amenable to antiphosphohistone H3 staining from 66 men and 47 women, with mean age of 64 years (9-93), including 61 superficial spreading type, 24 nodular, 6 lentigo maligna, 8 acral lentiginous, and 14 unclassified. The mean Breslow thickness was 2.53 mm (0.20-25), ulceration was present in 25/113 (22%) and the mean mitotic count was 3.2/mm(2) (1-29/mm(2)). In 27/113 (24%) of the cases, antiphosphohistone H3 failed to highlight mitotic figures anywhere in the tissue (normal or tumor cell), whereas in 86/113 (76%) antiphosphohistone H3 detected at least one mitotic figure. Among the latter, antiphosphohistone H3 did not detect mitotic figures in dermal tumor cells in 37/86 cases (43%), whereas anti-PHH3 identified at least one melanocytic mitotic figure in the other 49/86 cases (57%; range: 1-66/mm(2)). The relationship between phosphohistone H3 and manual mitotic count was statistically significant (Pearson correlation=0.59, P0.0001). Logistic regression analyses demonstrated an association between the development of subsequent metastatic disease and the following variables: mitotic figures (odds ratio (OR)=5.7; P=0.0001); phosphohistone H3-positive mitotic figures (OR=3.0; P=0.008); Breslow thickness (OR=4.0 per mm; P=0.0002); ulceration (OR=3.94; P=0.008). The application of phosphohistone H3 immunohistochemistry to the description of primary cutaneous melanoma is useful in identifying mitotic figures, improves upon the specificity of this designation when used together with MLANA, and correlates with an increased risk for metastasis in univariate analyses.

Cutaneous CD8(+) CD30(+) lymphoproliferative lesions are difficult to classify and encompass entities that follow a benign course to overt lymphoma. In order to identify histopathologic criteria for lesions in this spectrum, a series of such cases was reviewed.Twenty-eight biopsies from 27 patients with CD8(+) CD30(+) cutaneous lymphoid proliferations were evaluated.Seventeen cases were classified as lymphomatoid papulosis (LyP) 'type D', eight as cutaneous anaplastic large cell lymphoma (C-ALCL) and two as CD8(+) mycosis fungoides (MF) with CD30 expression. Features of LyP included spongiosis and/or parakeratosis (90%), epidermotropism by large lymphocytes (90%), with (80%) or without (10%) small lymphocytes; wedge-shaped infiltrate (70%) with perivascular (100%) and interstitial (80%) pattern; and relative uniformity of CD30(+) large atypical cells (90%). C-ALCL was characterized by ulceration (63%), epidermotropism restricted to small lymphocytes (100%), marked density (63%) and pleomorphism (62%) of CD30(+) large atypical cells, and at least focal extension of infiltrate to subcutaneous tissue (88%). CD8(+) CD30(+) MF had vacuolar interface change and a lichenoid pattern (100%).We concur with previous authors that distinction of CD8(+) LyP from lymphoma in its differential diagnosis is difficult based on histopathology alone. Nonetheless, we propose that certain histopathologic clues may be helpful in this differential diagnosis.

Metastatic melanoma (MM) is a deadly skin disease refractory to standard chemotherapy. Despite numerous clinical and pathological parameters derived to guide patient management, clinical outcomes in melanoma patients remain difficult to predict. There is a critical need to delineate the important biomarkers typical of this disease. These biomarkers will ideally illuminate those key biochemical pathways responsible for the aggressive behavior of melanoma and, in the process, unveil new opportunities for the design of rational therapeutic interventions in high-risk patients. The most common recurring mutation in cutaneous melanoma is the prooncogenic BRAF V600E mutation that drives melanoma cell proliferation. The development of RAF inhibitors targeted against BRAF V600E mutant melanoma cells has revolutionized the treatment of MM. Clinical trials with BRAF inhibitor vemurafenib have shown objective clinical response and improved survival in patients with MM; therefore, knowledge of the molecular signature of melanoma in patients will be important in directing management decisions. Several molecular platforms exist to analyze the mutation status of melanoma. These include Sanger sequencing, pyrosequencing, allele-specific reverse transcriptase polymerase chain reaction, mass spectrometry base sequencing (Sequenom), high-resolution melting curve analysis, and next-generation sequencing methods using microfluidics technology. The Food and Drug Administration has approved the cobas BRAF V600 Mutation Test developed by Roche to analyze BRAF mutation status in formalin-fixed paraffin-embedded tumor samples. The cobas Mutation Test has been designed specifically to detect BRAF V600E mutations, and the analytic performance of this assay has demonstrated >99% sensitivity in the detection of BRAF V600E mutation when compared with the Sanger sequencing method and confirmed with the next-generation sequencing 454-pyrosequencing technology. The lower limit of detection of the percentage of mutant alleles in a tissue sample for the cobas test is less than 4%-5%. Some cross-reactivity with other variants of mutant BRAF was seen with the cobas V600 platform; however, this clinical test offers highly sensitive reproducible BRAF V600E mutation analysis in formalin-fixed paraffin-embedded tumor samples.

The histopathologic distinction between benign and malignant cutaneous keratinocytic proliferations can pose a difficult diagnostic challenge - often with important clinical implications. Activating transcription factor 3 (ATF3) has emerged as a potential biomarker which may aid in the segregation of these lesions, and we hypothesize that ATF3 expression may be a specific marker of cutaneous squamous cell carcinoma (SCC). Using immunohistochemistry, we characterized ATF3 expression in a series of 126 cutaneous epithelial proliferations, including SCC (n = 27), basal cell carcinomas (BCC, n = 59), seborrheic keratoses with atypia (SK, n = 16), hyperplastic actinic keratoses (AK, n = 12) and prurigo nodularis cases (PN, n = 12). We showed strong, nuclear and/or nucleolar expression of ATF3 in a statistically significant number of cases of SCC compared to BCC, SK and PN. We conclude that ATF3 expression is a surrogate of malignancy (or pre-malignancy) in keratinocytic epithelial proliferations and thus helps distinguish SCC from other cutaneous epithelial neoplasms.

Syringocystadenocarcinoma papilliferum (SCACP) is an exceedingly rare cutaneous adnexal neoplasm, which is typically located in the head and neck, and perianal area. Very few cases have been reported in the literature. Here, we report a case of SCACP with evident transition to squamous differentiation. A 75-year-old white woman presented with 1-year history of a solitary tender nodule in the left upper arm. Physical examination revealed a single, 1.5 × 1.1-cm, erythematous ulcerated nodule within a background of red patch. Biopsy showed an adnexal carcinoma connected to the epidermis and composed of cystic papillary projections admixed with solid basaloid areas with marked cytologic atypia. The basaloid tumor cells appeared to blend with the squamous component that demonstrated ductal formation, which was highlighted by carcinoembryonic antigen. Tumor cells were reactive for both cytokeratins 5/6 and 7. This case represents SCACP arising from syringocystadenoma papilliferum in the upper arm, with distinct transition to areas of squamous differentiation.

Anaplastic oligodendroglioma [AO, World Health Organization (WHO) grade III] is an uncommon but aggressive tumor of the central nervous system that typically arises in adults. Clinically, patients present with seizures, and the prognosis is considered poor. Metastatic spread is extremely rare. We report an exceptional case of AO with extracranial scalp involvement, which arose in a patient with recurrent primary AO of the brain after chemoradiation, multiple cranial surgical resections, and subsequent scalp reconstruction. On histopathology, the subcutaneous tissue of the scalp contained several clusters and infiltrating cords of relatively small, epithelioid cells with hyperchromatic nuclei, scant eosinophilic cytoplasm, and perinuclear halos, which gave the cells a characteristic fried-egg appearance. By immunohistochemistry, the lesional cells were positive for glial fibrillary acidic protein and S-100. It is likely that surgical implantation and direct extracranial extension after craniotomy were the mechanisms responsible for dissemination of the patient's tumor.

Cutaneous epithelioid angiomatous nodule (CEAN) is a rare vascular proliferation that develops on the trunk and extremities. The lesion arises over weeks to months and affects both sexes without age predilection. Histologically, CEAN is characterized by a circumscribed proliferation of epithelioid endothelial cells in the superficial dermis with a background of lymphocytes, plasma cells and eosinophils. The epithelioid cells are positive for CD31, CD34 and/or D2-40. We report a case of CEAN that had remained stable for more than 30 years on the chest wall of a woman with a history of breast cancer. The lesional cells were epithelioid in appearance and positive for estrogen receptor (ER), raising suspicion for breast carcinoma. However, the cells were positive for CD31, CD34, D2-40 and EMA (epithelial membrane antigen); they were negative for cytokeratins, carcinoembryonic antigen (CEA), CD1a, gross cystic disease fluid protein (GCDFP-15), S-100, a melanocytic cocktail, HHV-8 and progesterone receptor. The histologic and immunohistochemical features, including a low proliferation index (10% by Ki-67), helped to distinguish this lesion from carcinoma and other vascular lesions. This is the most comprehensive immunohistochemical profile reported for CEAN to date and the first time that ER expression has been described.

A case of extraskeletal mesenchymal chondrosarcoma of the thigh metastatic to the posterior mediastinum 2 yr after the initial diagnosis was studied. The metastatic tumor was entirely composed of primitive small blue cells, which showed strong coexpression of CD99 and Bcl-2. Differen tial diagnoses can include PNET/Ewing's sarcoma and monophasic synovial sarcoma. Although morphological and immunohistochemical findings allow diagnoses in large samples, small biopsies are more difficult. Finding must be interpreted with great care in such circumstances. (The J Histotechnol 24:117, 2001 )Submitted: February 12, 2001; Accepted with revisions: February 14, 2001

Background Alopecia can be a manifestation of mycosis fungoides (MF) and Sezary syndrome (SS), but the prevalence is unknown. Objective We sought to describe the clinicopathologic presentation and molecular features of alopecia in patients with MF/SS. Methods A retrospective chart review of a prospectively collected MF/SS database was used to identify patients with alopecia. The National Alopecia Areata Registry was used to identify patients with self-reported cutaneous T-cell lymphoma. Results Among 1550 patients with MF/SS, 38 patients with patchy, total-scalp, or universal alopecia were identified. Thirteen of 38 (34%) had patchy alopecia clinically identical to alopecia areata. Scalp biopsy specimens were available in 5 of the 13 patients. Specimens from 4 patients had atypical T lymphocytes within the follicular epithelium or epidermis, and that from two patients had a histology of follicular mucinosis. The remaining 25 of 38 (66%) patients with MF/SS included 20 with alopecia within discreet patch/plaque or follicular lesions of MF and 5 with total-body hair loss, which presented only in those with generalized erythroderma and SS. Limitations This was a retrospective study done at one cancer center. Biopsy specimens of alopecia were not available for every patient. Conclusions Alopecia was observed in 2.5% of patients with MF/SS, with alopecia areata–like patchy loss in 34% and alopecia within MF lesions in 66%.

The p27(KIP1) and p57(KIP2) proteins belong to the CIP/KIP family of cyclin-dependent kinase inhibitors involved in the growth arrest and cellular senescence. High levels of p27(KIP1) unexpectedly have been detected in invasive malignant melanomas (MM), whereas the role of p57(KIP2) in melanocytic lesions is unknown. We therefore chose to study the expression of p27(KIP1) and p57(KIP2) in melanocytic neoplasms.The expression of p27(KIP1) and p57(KIP2) were examined by immunohistochemistry in 40 melanocytic neoplasms and by Western blot analysis in cultured human melanocytes.Expression of both nuclear p27(KIP1) and p57(KIP2) (10% of cells with nuclear labeling) was observed in most cases with non-proliferating melanocytes (8/10, benign nevi and 9/10 DN, dysplastic nevi), but in only a few cases containing proliferating melanocytes (3/11 RN, recurrent nevi and 2/9 MM, melanoma) (p0.002). In proliferating melanocytes, there was an inverse correlation of nuclear expression of p27(KIP1) and p57(KIP2) in both RN (p27(KIP1) = 3/11 RN and p57(KIP2) = 8/11 RN) and MM (p27(KIP1) = 7/9 MM and p57(KIP2) = 2/9 MM) (p0.05). Western blot analysis detected p57(KIP2) only in proliferating melanocytes. p27(KIP1) was detected in both proliferating and senescent melanocytes.The difference in expression patterns of p27(KIP1) and p57(KIP2) in proliferating and senescent melanocytes suggests the interplay between these proteins may play a functional role in melanocytic tumorigenesis.

The retinoblastoma (RB)/p16(INK4a) pathway regulates senescence of human melanocytes in culture and oncogene-induced senescence of melanocytic nevi in vivo. This senescence response is likely due to chromatin modifications because RB complexes from senescent melanocytes contain increased levels of histone deacetylase (HDAC) activity and tethered HDAC1. Here we show that HDAC1 is prominently detected in p16(INK4a)-positive, senescent intradermal melanocytic nevi but not in proliferating, recurrent nevus cells that localize to the epidermal/dermal junction. To assess the role of HDAC1 in the senescence of melanocytes and nevi, we used tetracycline-based inducible expression systems in cultured melanocytic cells. We found that HDAC1 drives a sequential and cooperative activity of chromatin remodeling effectors, including transient recruitment of Brahma (Brm1) into RB/HDAC1 mega-complexes, formation of heterochromatin protein 1 beta (HP1 beta)/SUV39H1 foci, methylation of H3-K9, stable association of RB with chromatin and significant global heterochromatinization. These chromatin changes coincide with expression of typical markers of senescence, including the senescent-associated beta-galactosidase marker. Notably, formation of RB/HP1 beta foci and early tethering of RB to chromatin depends on intact Brm1 ATPase activity. As cells reached senescence, ejection of Brm1 from chromatin coincided with its dissociation from HP1 beta/RB and relocalization to protein complexes of lower molecular weight. These results provide new insights into the role of the RB pathway in regulating cellular senescence and implicate HDAC1 as a likely mediator of early chromatin remodeling events.

Background: Melanoma is an aggressive cancer with high metastatic potential, and is the most lethal skin malignancies. Ephrin receptor tyrosine kinase B4 (EphB4) modulates diverse physiologic and developmental processes, and may play an important role in melanoma tumorigenesis. In addition, Mertens-Walker et al., reported nuclear translocalization of EphB4 and hypothesized that it may directly regulate gene expression contributing to more aggressive biologic behavior in prostate cancer (Cancer Res 2011; 71 (8 Suppl): Abstract nr 1085). It is unknown whether differential cellular expression of EphB4 contributes to the pathogenesis of melanoma. Methods: To explore the role of EphB4 in melanomagenesis, we have performed semiquantitative immunohistochemical analysis of EphB4 expression as measured by percentage and intensity of cells immunoreactive with anti-EphB4 in melanocytic nevi (n = 59), primary melanomas without metastasis during follow-up (n = 22), primary melanomas with metastasis (n = 17), and metastatic melanoma (n = 32). Results: Melanocytic nevi had significantly higher nuclear EphB4 expression (p = 0.007) and lower cytoplasmic EphB4 expression (p = 0.002) when compared to all categories of melanoma. In fact we observed a dramatic decrease in nuclear EphB4 expression in metastatic melanoma compared to melanocytic nevi (p = 0.0009). In contrast, compared to melanocytic nevi, cytoplasmic expression for EphB4 were higher in primary melanoma (p = 0.005) as well as in melanoma metastases (p = 0.03). Although there was no significant difference in nuclear or cytoplasmic EphB4 expression between primary melanomas with or without metastasis, primary melanomas without metastasis showed significantly higher number of tumor cells having intense nuclear immunoreactivity for EphB4 protein than did metastatic melanomas (p = 0.006). Conclusion: In conclusion, our data indicated that there is a gradual loss of nuclear EphB4 protein as well as increase in the levels of cytoplasmic expression of EphB4 protein associated with melanomagenesis. In addition, our results suggest a potential role for EphB4 as a therapeutic target in melanoma. Citation Format: Nitin Chakravarti, Jonathan L. Curry, Roland L. Bassett, Victor G. Prieto. Differential cellular localization of Ephrin receptor tyrosine kinase B4 (EphB4) in melanoma progression. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 596. doi:10.1158/1538-7445.AM2015-596

Melanoma is a lethal skin disease with a mostly predictable clinical course according to a known constellation of clinical and pathologic features. The distinction of melanoma from benign melanocytic nevus is typically unequivocol; however, there is a subset of tumors known for its diagnostic challenges, development of late metastases, and difficulties in treatment. Several melanocytic tissue biomarkers are available that can facilitate the histopathologic interpretation of melanoma as well as provide insight into the biologic potential and mutational status of this disease. This review describes the clinical application of some of these established and emerging tissue biomarkers available to assess melanocytic differentiation, vascular invasion, mitotic capacity, and mutation status. The selected tissue biomarkers in this review include MiTF, Sox10, D2-40, PHH3, H3KT (anti-H3K79me3T80ph), anti-BRAFV600E, and anti-BAP-1.

Sinus histiocytosis with massive lymphadenopathy, or Rosai-Dorfman disease, is a benign idiopathic histiocytic proliferative disorder that commonly involves the lymph nodes but secondarily may involve the skin. However, purely cutaneous disease without lymphadenopathy or internal organ involvement rarely may occur. We present case reports of three patients who presented with asymptomatic nonspecific enlarging skin nodules without evidence of lymphadenopathy or internal disease. Histopathologic examination of skin lesions in all patients showed proliferation of large histiocytes with phagocytosed inflammatory cells characteristic of Rosai-Dorfman disease. However, the diagnoses of dermatofibroma, other spindle cell neoplasm, infectious granulomatous process, and other xanthohistiocytic proliferations were also considered due to the presence of storiform spindle cells and foamy cells in the first case. One patient experienced regression during a course of oral steroids, while another patient cleared spontaneously. In the absence of massive lymphadenopathy characteristic of Rosai-Dorfman disease, the diagnosis of purely cutaneous Rosai-Dorfman disease may be complicated by the rarity, non-specific clinical appearance of skin lesions, and broad histopathological differential diagnosis of this disorder. A high index of suspicion of the clinician and pathologist is often required.

Sinus histiocytosis with massive lymphadenopathy, or Rosai-Dorfman disease, is a benign idiopathic histiocytic proliferative disorder that commonly involves the lymph nodes but secondarily may involve the skin. However, purely cutaneous disease without lymphadenopathy or internal organ involvement rarely may occur. We present case reports of three patients who presented with asymptomatic nonspecific enlarging skin nodules without evidence of lymphadenopathy or internal disease. Histopathologic examination of skin lesions in all patients showed proliferation of large histiocytes with phagocytosed inflammatory cells characteristic of Rosai-Dorfman disease. However, the diagnoses of dermatofibroma, other spindle cell neoplasm, infectious granulomatous process, and other xanthohistiocytic proliferations were also considered due to the presence of storiform spindle cells and foamy cells in the first case. One patient experienced regression during a course of oral steroids, while another patient cleared spontaneously. In the absence of massive lymphadenopathy characteristic of Rosai-Dorfman disease, the diagnosis of purely cutaneous Rosai-Dorfman disease may be complicated by the rarity, non-specific clinical appearance of skin lesions, and broad histopathological differential diagnosis of this disorder. A high index of suspicion of the clinician and pathologist is often required.

Ultraviolet (UV) light exposure is a common cause of epithelial-derived skin cancers, and the epidermal response to UV-light has been extensively studied using both mouse models and cultured human keratinocytes (KCs). Elimination of cells with UV-induced DNA damage via apoptosis provides a powerful mechanism to minimize retention or expansion of genetically abnormal cells. This cell editing function has largely been ascribed to the biological role of the p53 tumor suppressor gene, as mutations or deletions involving p53 have been linked to skin cancer development. Rather than introducing mutations, or using cells with complete loss of wild-type p53, we used an siRNA-based approach to knockdown, but not eliminate, p53 levels in primary cultures of human KCs followed by UV-irradiation. Surprisingly, when p53 levels were reduced by 50-80% the apoptosis induced by exposure to UV-light was accelerated and markedly enhanced (two- to three- fold) compared to control siRNA treated KCs. The p53 siRNA treated KCs were characterized by elevated E2F-1 levels accompanied by accelerated elimination of the Mcl-1 and Bcl-x(L) antiapoptotic proteins, as well as enhanced Bax oligomerization. Forced overexpression of either Mcl-1 or Bcl-x(L) reduced the UV-light enhanced apoptotic response in p53 siRNA treated KCs. We conclude that p53 not only can provide proapoptotic signals but also regulates a survival pathway influencing Mcl-1 and Bcl-x(L) levels. This overlooked survival function of p53 may explain previous paradoxical responses noted by investigators using p53 heterozygous and knockout mouse models, and opens up the possibility that not all liaisons within the cell involving p53 necessarily represent fatal attractions.

To identify histologic criteria and prognostic significance in patients with toxic epidermal necrolysis (TEN), a frequently lethal disease that usually represents an adverse drug reaction.Retrospective analysis of clinical records and histologic material from a 10-year period (1994-2004). Two investigators blinded to clinical data reviewed hematoxylin-eosin-stained sections.North American tertiary care, university-based burn unit. Patients Thirty-seven patients treated for TEN between 1994 and 2004 who had sloughing of 30% or more of their total body surface area and who underwent skin punch biopsies immediately following admission. Main Outcome Measure The degree of dermal mononuclear (DM) inflammation was graded (sparse, moderate, or extensive) at least 2 high-power fields (HPF) away from the perimeter of epidermal detachment, and the mean number of DM cells/5 HPF was quantified for each patient. Clinical records were reviewed and the following data extracted: age, history of cancer, percentage of total body surface area slough, heart rate, and serum glucose, bicarbonate, and serum urea nitrogen values on admission. Severity scores for TEN (SCORTEN) were calculated, and clinical outcome was recorded as survived or died during hospitalization.Extent of inflammation was assessed by categorizing the mean +/- SD DM cell counts as follows: sparse, 161 +/- 36 cells/HPF (n = 15); moderate, 273 +/- 76 cells/HPF (n = 15); and extensive, 392 +/- 124 cells/HPF (n = 7). There was good concordance between observer ratings (P.001). While 73% of patients (n = 11) with sparse inflammation survived, only 47% (n = 7) with moderate and 29% (n = 2) with extensive inflammation survived. The accuracy in predicting patient outcome was 65% using grade of inflammation, 68% with mean cell count, and 71% with SCORTEN.There is a histologic spectrum with TEN that ranges from sparse to extensive DM inflammation, and degree of inflammation predicts clinical outcome approximately as well as SCORTEN. Future clinical trials should consider the possibility that various patient subsets exist within the TEN population, and a role for immunocytes needs to be critically reevaluated in this devastating disease.

A 30-year-old woman with primary hyperoxaluria type I (PHI) developed livedo reticularis with overlying ulcerations on her legs 16 months after receiving a liver-kidney transplant. A skin biopsy of the lesion showed deposits of calcium oxalate. To our knowledge, there have been no reported cases of livedo reticularis in patients with PH1 after a combined liver-kidney transplant.

Context.—A precise role for the innate immune system in psoriasis remains to be determined. Surface receptors, including Toll-like receptors (TLRs) that recognize bacterial ligands and CD91, which recognizes heat shock proteins (HSPs), are implicated in both innate and adaptive immunity. Objective.—Since skin is exposed to various exogenous stimuli, which can provoke or exacerbate psoriasis, we characterized expression and function of TLRs, CD91, and HSPs in normal and psoriatic skin. Design.—A variety of skin-derived cells and blood-derived cells were analyzed both in vivo and in vitro; samples were obtained from 24 different individuals for innate immune-related receptor expression and function. By comparing and contrasting individuals with healthy skin and psoriatic patients, several specific differences were identified. Results.—Immunohistochemistry-based expression profiling revealed TLR1 expression in epidermal dendritic cells (DCs) and dermal dendritic cells (DDCs) in normal skin, as well as in pre-psoriatic skin and psoriatic plaques, with enhanced basal layer keratinocyte (KC) expression in pre-psoriatic and psoriatic plaques compared with normal skin; TLR2 expression primarily by DDCs; and TLR4 expression by epidermal DCs and DDCs, with mid-epidermal-layer KCs displaying cell surface staining. No TLR9 or CD14 was detected on DCs or KCs, although psoriatic plaques contained CD14-positive macrophages. Analysis of psoriatic epidermis revealed HSPs 27, 60, and 70. Keratinocytes were CD91 negative, but CD91 was expressed by fibroblasts and DDCs in normal and pre-psoriatic skin, with prominent accumulation of CD91-positive DDCs in psoriatic plaques. Cultured KCs revealed no surface expression of TLR2, TLR4, TLR9, or CD91. Exposure of fibroblasts, but not KCs, to lipopolysaccharide or HSPs triggered nuclear factor (NF)-κB activation. Heat shock proteins did induce maturation of blood-derived DCs accompanied by increased interleukin-12 production and enhanced antigen-presenting function. Conclusions.—These data demonstrate distinctive patterns of innate immune-related receptors by specific subsets of cells in normal and psoriatic skin, suggesting functional roles for HSPs and DCs in psoriasis.

BACKGROUND Historically, the diagnostic accuracy of urine cytology for the detection of urothelial carcinoma has been low, particularly for low-grade lesions. In 1998, the World Health Organization and International Society of Urologic Pathologists (WHO/ISUP) established a new classification system for urothelial neoplasms. It has been postulated that the accuracy of urine cytology for the detection of low-grade carcinomas should improve, because the current WHO/ISUP system classifies bladder lesions that lack any significant cytologic atypia as papillary urothelial neoplasms of low malignant potential (PUNLMP). Also, the accuracy of urinary cytology for the detection of high-grade lesions is expected to decrease, because the criteria for high-grade lesions is lowered, placing most of the previous WHO Grade 2 tumors into the current high-grade carcinoma category. METHODS One hundred bladder biopsies that were classified according to the previous WHO classification system were examined by one pathologist and were reclassified according to the new WHO/ISUP scheme. All biopsies had corresponding urine specimens that had been diagnosed previously by a different cytopathologists. The patients' previous WHO and current WHO/ISUP surgical diagnoses were compared with the corresponding urine cytology. In addition, cytospins obtained from 40 patients with a histologic diagnosis of low-grade urothelial carcinoma (n = 20 patients) and high-grade urothelial carcinoma (n = 20 patients) according to the WHO/ISUP classification system were reviewed to identify any outstanding cytologic features. RESULTS According to the original WHO classification system, there were 26 patients with Grade 1 transitional cell carcinoma (TCC), 61 patients with Grade 2 TCC, and 13 patients with Grade 3 TCC. The corresponding cytology was positive in 11 of 26 Grade 1 tumors, 28 of 61 Grade 2 tumors, and 12 of 13 Grade 3 tumors. After the reclassification, there was 1 papilloma, 12 PUNLMP lesions, 50 low-grade urothelial carcinomas, and 37 high-grade carcinomas. The cytology was positive in 0 of 1 papillomas, 5 of 7 PUNLMP lesions, 18 of 50 low-grade carcinomas, and 28 of 37 high-grade carcinomas. In addition, morphologic uniformity and cytoplasmic homogeneity (50.0% and 45.0%, respectively) were seen more commonly in low-grade bladder tumors. CONCLUSIONS The diagnostic accuracy of urine cytology for high-grade lesions decreased, as expected; however, cytologic detection of low-grade urothelial carcinomas was remarkably lower than expected. In addition, no outstanding cytologic features could be identified to make a definitive diagnosis. Cancer (Cancer Cytopathol) 2002. © 2002 American Cancer Society.

Background Ipsilateral salivary gland tumors of different histologic types are rare and make up less than 0.3% of all salivary gland neoplasms. Only nine cases of synchronous benign and malignant ipsilateral parotid gland tumors have been described in the literature. Methods Two additional cases of synchronous benign and malignant neoplasms in the parotid gland are reported and discussed with a review of literature. Results Our first case describes a pleomorphic adenoma and a salivary duct carcinoma, an entity not previously reported in the literature. The second case documents the most common benign and malignant ipsilateral parotid gland neoplasm reported in this case series, a Warthin's tumor and a mucoepidermoid carcinoma. Conclusions Synchronous salivary gland tumors exhibiting both benign and malignant components are uncommonly observed, with only nine cases published to date. We describe two additional cases of a synchronous benign and malignant ipsilateral parotid gland tumor. © 2002 Wiley Periodicals, Inc. Head Neck 24: 301–306, 2002; DOI 10.1002/hed.10048

Background Mucosal melanomas represent about 1% of all melanoma cases and classically have a worse prognosis than cutaneous melanomas. Due to the rarity of mucosal melanomas, only limited clinical studies with metastatic mucosal melanoma are available. Mucosal melanomas most commonly contain mutations in the gene CKIT, and treatments have been investigated using targeted therapy for this gene. Mutations in mucosal melanoma are less common than in cutaneous or uveal melanomas and occur in descending order of frequency as: CKIT (20%), NRAS (5%) or BRAF (3%). Mutations in G-alpha proteins, which are associated with activation of the mitogen-activated protein kinase pathway, have not been reported in mucosal melanomas. These G-alpha protein mutations occur in the genes GNAQ and GNA11 and are seen at a high frequency in uveal melanomas, those melanomas that begin in the eye. Case presentation A 59-year old Caucasian male was diagnosed with a mucosal melanoma after evaluation for what was thought to be a hemorrhoid. Molecular analysis of the tumor revealed a GNAQ mutation. Ophthalmologic exam did not disclose a uveal melanoma. Conclusion Here we report, to our knowledge, the first known case of GNAQ mutation in a patient with metastatic mucosal melanoma.

Metanephric neoplasms are uncommon renal tumors that arise in both children and adults. They may be composed of small epithelial cells or benign stroma, or both, and are termed metanephric adenoma, metanephric stromal tumor, or metanephric adenofibroma, respectively. Thus far, these tumors have been known for their benign behavior. We present the case of a 21-year-old woman who developed a neoplasm composed of a renal epithelial component identical to metanephric adenoma combined with a malignant spindle cell sarcoma. The epithelial component was positive for pankeratin AE1/3, whereas the sarcomatous component was negative for epithelial markers and positive for vimentin, CD34, and CD117. No smooth muscle differentiation was apparent in the sarcoma by immunohistochemistry or ultrastructural analysis. By fluorescent in situ hybridization analysis of the sarcomatous component there was monosomy of the X chromosome, but no apparent variation from the normal diploid pattern for chromosomes 3, 7, 12, and 17. We conclude that the spectrum of metanephric neoplasia should be expanded to include malignant stromal variants, and we propose the term "metanephric adenosarcoma" for the present case.

Psoriasis is a common and chronic inflammatory skin disease that afflicts 2–3% of the world population. There is no cure and the precise cause of psoriasis is unknown. Cytokines however, have been established as critical mediators in the immunopathogenesis of psoriasis. EGR-2 is an immediate early serum response gene that codes for Krox-20, a zinc finger transcription factors that is important in resisting TGF-? mediated apoptosis. The aim of this study was to evaluate Krox-20 expression in epidermal keratinocytes in psoriasis where aberrant response to TGF-? signaling has been shown to occur. Formalin-fixed paraffin-embedded tissue (N = 38) including nine psoriatic plaques (PP), nine lichen planus (LP), ten lichen simplex chronicus (LSC), and ten normal skin (NS) were evaluated for expression of Krox-20 by immunohistochemistry. Frequency and relative intensity of nuclear labeling were evaluated. Strong and diffuse nuclear labeling of keratinocytes was observed in all PP and LSC. The frequency of labeling was significantly greater (p