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Cutaneous squamous cell carcinomas (cSCC) have upstage rates of approximately 10.3% to 11.1%. Data are currently limited on the rate of upstaging for metastatic cSCC.The aim of this study was to determine the rates of upstaging, between diagnosis and surgery, and differences in management for metastatic and non-metastatic high-risk cSCC.This was a retrospective, case-control, single institution, multi-center study. Univariate analysis was used.Sixty-eight subjects (34 metastatic34 non-metastatic) with 69 tumors were included. The overall rate of upstaging was 46.4%. The most common reasons for upstage were undocumented tumor size and under-diagnosis of poor differentiation. There were no differences in rates of upstaging. Preoperative imaging was performed in 43.6% of wide local excisions (WLE) versus 3.3% of Mohs micrographic surgery (MMS; p.001). The median days from surgery to sentinel lymph node biopsy (SLNB), or nodal dissection was shorter for WLE versus MMS (0 vs 221 days, p.001).Improved clinical documentation, including documenting tumor size, and the identification of pathologic risk factors, including poor differentiation and depth of invasion, are needed for proper staging. Preoperative imaging and discussion of SLNB may be beneficial for high-risk T2b and T3 tumors.

The patient presented to our clinic from out of state in October 2018. Previously, in 2014, he underwent an elective left total hip arthroplasty with a ceramic-on-polyethylene prosthesis for osteoarthritis. The surgery and recovery were uneventful. In November 2014, hives developed on his upper arms. Within weeks, the hives spread to his trunk and thighs but spared his face, palms, and soles. The symmetric, nonpruritic, nonpainful rash was without angioedema. The hives initially persisted for 5 days, followed by resolution for several days.

Mucous membrane pemphigoid (MMP) is a rare chronic immunobullous disease that involves the mucous membranes and may result in significant scarring and complications if diagnosis is delayed. MMP typically occurs in elderly patients, with very few cases reported in children. Here, we present a 12-year-old female patient with childhood-onset oral and genital MMP, clinically suspected to be lichen sclerosus, but eventually diagnosed as MMP after multiple supportive biopsies and confirmatory direct immunofluorescence. Although treatment was challenging, the combined use of systemic corticosteroids, dapsone, and mycophenolate mofetil was ultimately successful in achieving disease control.

Graft-versus-host-disease (GVHD), a common complication after peripheral blood stem cell or bone marrow transplantation, rarely occurs in kidney and pancreas transplant recipients. The true incidence may be confounded by the rarity of the disorder, with a resultant lack of appreciation of the diagnosis as a potential cause of common clinical manifestations such as cytopenias and immune dysfunction. Reports of GVHD in kidney and pancreas transplant recipients almost uniformly describe patients in the early post transplant period (days to months) with the typical manifestations of acute GVHD involving the skin, liver and intestines. In contrast, reports of solid organ transplant recipients with clinical features more consistent with chronic GVHD (cGVHD) are lacking, raising concern of under-recognition of this severe complication. Occurrence later after transplant may be even more likely to result in lack of recognition. We report two cases of possible cGVHD occurring in recipients of pancreas after kidney transplantation, which were diagnosed at 5.5 and 42 months after pancreas transplant. Both patients presented with severe pancytopenia, multiple opportunistic infections and features suggestive of cGVHD. Transplant professionals should be aware of the possibility of acute and cGVHD in pancreas after kidney transplant recipients and be able to recognize the clinical manifestations.

Gamma-interferon-inducible lysosomal thiol reductase (GILT) is critical for MHC class II restricted presentation of multiple melanoma antigens. There is variable GILT protein expression in malignant melanocytes in melanoma specimens. High GILT mRNA expression in melanoma specimens is associated with improved overall survival, before the advent of immune checkpoint inhibitors (ICI). However, the association of GILT in metastatic melanoma with survival in patients treated with ICI and the cell type expressing GILT associated with survival have not been determined. Using RNA sequencing datasets, high GILT mRNA expression in metastatic melanoma specimens was associated with improved progression-free and overall survival in patients treated with ICI. A clinical dataset of metastatic melanoma specimens was generated and annotated with clinical information. Positive GILT immunohistochemical staining in antigen presenting cells and melanoma cells was observed in 100% and 65% of metastatic melanoma specimens, respectively. In the subset of patients treated with ICI in the clinical dataset, high GILT protein expression within melanoma cells was associated with improved overall survival. The association of GILT mRNA and protein expression with survival was independent of cancer stage. These studies support that high GILT mRNA expression in bulk tumor samples and high GILT protein expression in melanoma cells is associated with improved survival in ICI-treated patients. These findings support further investigation of GILT as a biomarker to predict the response to ICI.

Necrobiosis lipoidica (NL) is an uncommon granulomatous dermatosis that can occur in patients with or without associated diabetes mellitus (DM). Prior studies have attempted to determine distinctive histopathologic features of NL in patients with and without DM.A retrospective review of 97 patients with NL was performed to determine the similar and distinctive histopathologic features in patients with DM and without DM.Of the 97 patients, 32% (n = 31) had DM. Epidermal acanthosis was seen more commonly in diabetics than nondiabetics (32.3% vs. 12.1%; p = 0.017). Naked (sarcoidal/tuberculoid) granulomas were more frequently observed in nondiabetics than diabetics (22.7% vs. 3.2%; p = 0.016). Eosinophils were more common in nondiabetics than diabetics (38.5% vs. 9.7%; p = 0.004), while neutrophilic infiltration was more common in diabetics than nondiabetics (45.2% vs. 17.5%; p = 0.004).This study corroborates well-documented histopathologic features of NL and shows distinctive histopathologic features of NL among patients with DM-I, DM-II, and without DM. These results support the hypothesis that there are different underlying drivers of NL between diabetics and nondiabetics.

Cutaneous B cell pseudolymphoma (CBPL), or cutaneous lymphoid hyperplasia, is the most common pseudolymphoma. It typically responds well to local treatment and follows a benign course. Herein, we describe the unique case of a patient with CBPL that was refractory to a variety of treatments, with subsequent response to rituximab followed by methotrexate. This case explores the complex interplay of T and B lymphocytes, and the potential role of perifollicular T cells in treatment resistant CBPL. Further, it describes the additive therapeutic effect of rituximab and methotrexate to target both B cell and T cell populations in CBPL, a strategy already employed in a number of other conditions.

Recent advances in chimeric antigen receptor (CAR) T-cell therapy have demonstrated promising results for diseases ranging from acute lymphoblastic leukemia (ALL) to glioblastoma.1,2 Leukemia cutis is a rare manifestation of leukemia, in which leukemic cells infiltrate the skin; as such, there is a paucity of literature describing the effects of CAR T-cell therapy in the context of leukemia cutis. Here we present a case of B-cell lymphoblastic leukemia cutis flaring and spontaneously resolving following CAR T-cell therapy.

We report a case of a 13-year-old boy with extensive lymphomatoid papulosis (LyP) involving his elbows, forearms, proximal thighs, and right hip, with treatment-resistant nodules on his right forearm. He was treated with full-body narrowband ultraviolet B and targeted photodynamic therapy (PDT) with 20% aminolevulinic acid (ALA). After two months, there was complete resolution of the right forearm nodules. Due to its minimal toxicity, PDT offers unique advantages and may be considered for pediatric LyP patients with symptomatic, localized disease resistant to conventional treatments.

Plasmablastic lymphoma (PBL) is a rare subtype of large B-cell lymphoma most commonly seen in immunocompromised patients, particularly in those with HIV infection. In these patients, PBL often affects the oral mucosa.1 Other immunocompromised states, including immunosuppression for organ transplant and immunosenescence, have been linked to PBL.1 Epstein-Barr virus (EBV) reactivation is thought to be a major driver of PBL.1 PBL is characterized histologically by an absence of B- and T-cell markers and expression of plasma cell markers CD38 and CD138. The median overall survival of HIV-positive and HIV-negative patients with PBL is 15 months and 9 months, respectively.1 Some patients with PBL present with primary cutaneous disease (pcPBL), defined as no systemic involvement. These patients have a unique clinical presentation and an indolent course. We report the first case of iatrogenic pcPBL secondary to romidepsin therapy for primary cutaneous peripheral T-cell lymphoma not otherwise specified (pcPTCL-NOS).

Eccrine angiomatous hamartoma (EAH) is a rare benign vascular hamartoma characterized histologically by an increased size and number of mature eccrine glands associated with multiple foci of dilated capillaries in the dermis and subcutis. EAH typically presents in children as discrete, solitary nodules, or plaques most commonly located on the extremities. Some cases of EAH have an agminated distribution involving classic locations, or present as solitary lesions in less common locations such as the face, scalp, or trunk. We report the case of congenital EAH in a child with atypical morphological features and pattern of distribution further expanding on the range of presentations classically described.

OPINION STATEMENT Choice of therapy in mycosis fungoides is based on both patient- and lymphoma-specific factors, such as disease characteristics, comorbidities, symptoms and effect on quality of life, potential associated toxicities of therapy, response and tolerance to prior lines of therapy, and convenience and practicality. Generally, we sequence therapies from least toxic, targeted, nonimmunosuppressive to more toxic, immunosuppressive and from single agent to multiple agents, as necessary. If more toxic, immunosuppressive agents are required to alleviate disease burden or symptoms, we generally use them just long enough to control the disease, then transition to a maintenance regimen with less toxic, less immunosuppressive agents.

The reactogenicity profile of the Pfizer-BioNTech COVID-19 vaccine approved by the U.S. Food and Drug Administration has demonstrated generally transient, mild-to-moderate local and systemic respon...

NK/T-cell lymphomas are extremely rare lymphomas in the western world. The population of CD3+CD56+ NK/T-cells that seems to be the progenitor cells for those types of lymphomas is not homogeneous, which may explain the reason for polymorphic presentation. Several functionally distinct NK/T-cell subsets diverge after their development in the thymus. Organ-specific antigen-presenting cells may modulate NK/T-cell function and post-thymic development. The organs with the highest content of NK/T cells are tonsils, lymph nodes, spleen, skin, testis, and stomach. Not surprisingly, those are the places of the most frequent localization of NK/T-cell lymphoma. The Waldeyer’s tonsillar ring is involved most commonly. The patient sometimes may present with a single cutaneous nodule, but the asymptomatic nasal involvement could be detected on PET/CT frequently, still placing the patient into “the nasal” category. Extranasal presentation comprises around 20% of all cases and most likely arises from the dermal NK/T cells in contrast to tonsillar NK/T cells in “the nasal” cases. Unusual cases of such rare cancer are characterized by the unusual expression of non-NK/T-cell markers and rare morphologic presentations. The aberrant expression of γδ TCR on EBV+ CD56+ cells is still a matter of debate of appropriate classificational categorization. Despite semantics, the prognosis is universally gravid.

A 71-year-old female was diagnosed with localized renal cell carcinoma in July 2008 with subsequent metastasis in 2012 to the right adrenal gland, lungs, and brain. Due to disease progression, she was started on pazopanib 800 mg daily in October 2012. In November 2016, the patient developed an ill-defined, red, 10 × 15 cm indurated plaque on the left lateral upper thigh with a discrete 3 cm firm tender tumor without ulceration. An incisional biopsy was performed and showed panniculitis with features resembling sclerosing lipogranuloma. Alternative causes including rheumatologic disease and trauma were ruled out. We report the first case of pazopanib-induced panniculitis. Key clinical and histopathological features include tender subcutaneous nodules, exclusion of other causes, and fatty microcysts within a densely sclerotic background on pathology. As targeted therapies are becoming increasingly common in the field of oncology, prompt identification and reporting of adverse reactions is critical for proper management.

Background The purpose of this study was to retrospectively assess clinical characteristics and mortality rate of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in patients who developed disseminated intravascular coagulation (DIC). Methods A systematic retrospective chart review of all patients with concurrent clinical diagnosis of DIC and SJS/TEN between July 1, 2012, and January 1, 2020, at the Mayo Clinic was performed. Results The incidence of DIC in patients with SJS/TEN was 1.3% at our institution (5 of 396 DIC patients). Triggers of SJS/TEN included lamotrigine, clofarabine, antibiotics, and sepsis. Two patients diagnosed with SJS and two patients with TEN succumbed to the disease. Conclusion DIC is a rare underlying risk in patients with SJS/TEN and is associated with increased mortality. Early clinician awareness and aggressive intervention is advised.

Copper ions play an important role in several physiological processes, including angiogenesis, growth factor induction and extracellular matrix remodeling, that modulate wound healing and tissue repair. In this work, copper-loaded alginate fibers were generated and used as surgical sutures for repair of incisional wounds in live mice. Approximately 95% of initially loaded copper ions were released from the sutures within the first 24 hours following an initial burst release. This localized delivery of copper at the incision site resulted in significantly higher recovery in tissue biomechanical strengths compared to conventional nylon and calcium-alginate sutures at early times following surgery. Irradiation of copper-alginate sutures with near infrared light resulted in a robust photothermal response and led to efficacies similar to those seen with non-irradiated sutures. Histopathology and immunohistological analyses indicated significantly reduced epithelial gap and higher number of CD31(+) cells, which is indicative of increased angiogenesis around the incision site. Delivery of copper ions did not result in toxicity under the conditions employed. Our findings demonstrate that delivery of ionic copper from sutures resulted in efficacious approximation and healing of incisional wounds, and copper-eluting fibers may have translational potential for accelerating repair in surgical and trauma wounds.

This pathology PILOT study aims to define the role and feasibility of centralized pathology review in a cohort of 75 patients from different centers in the United States and Europe using digital slide scanning. The pathologic material from 75 patients who had been diagnosed with mycosis fungoides/Sézary syndrome and were clinically staged as IIb or above was retrieved from 11 participating centers. Each pathology reviewer was provided with the pathologic diagnosis (by the referring pathologist), and the following list of histopathologic criteria (presence or absence) from the initial report: epidermotropism, folliculotropism (FT), large cell transformation, syringotropism, and granulomas. Patients with advance stage were selected for this study as this is a population where there is significant variability in the diagnosis of pathologic prognostic and predictive biomarkers. The slides were digitally scanned with an Aperio scanner and consensus review of cases occurred when major or minor discrepancies between the referral diagnosis and central pathology review occurred. Among the 75 cases, 70 (93.3%) had a final consensus diagnosis between the 3 central review pathologists. The overall agreement between the consensus review and the referring pathologist was 60%. The overall agreement was also higher between the reviewers and consensus review, compared with the referring pathologist and consensus. 65.3% of cases had some type of discrepancy (major or minor) between the outside and consensus review. Major discrepancies were seen in 34 of 73 cases (46.6%; 73 cases indicated a yes or no response). Minor discrepancies were seen in 32 of 75 (42.7%) of cases. Most of the major discrepancies were accounted by a difference in interpretation in the presence or absence of large cell transformation or FT. Most minor discrepancies were explained by a different interpretation in the expression of CD30. We found digital slide scanning to be a beneficial, reliable, and practical for a methodical approach to perform central pathology review in the context of a large clinical prospective study.

Despite well-defined clinical and histopathological features of melanoma, atypical presentations mimicking other skin disorders can result in a delayed diagnosis or misdiagnosis and subsequent inappropriate treatment. Rosai-Dorfman disease (RDD) is a rare histiocytic disorder with unique clinical and histopathological features. We report a case of melanoma treated with cryotherapy that mimicked RDD both clinically and histopathologically. We compare this RDD-like melanoma to classic RDD, outlining the importance of clinicopathological correlation prior to treatment, as well as the potential pitfalls in diagnosis after cryotherapy of pigmented lesions.

Coccidioidomycosis is a fungal infection that is endemic to the semiarid regions of the southwestern United States, particularly Arizona and California.1, 2 It is primarily a pulmonary infection, acquired via the inhalation of fungal spores. Cutaneous manifestations of coccidioidomycosis are common and can occur via 3 pathogenic mechanisms: reactive eruptions, primary cutaneous infection, and secondary dissemination to the skin.2 Reactive skin manifestations tend to occur early in the disease course and include generalized exanthem, Sweet syndrome, erythema nodosum, interstitial granulomatous dermatitis, and an erythema multiforme–like eruption.2, 3, 4 Primary cutaneous infection is rare and occurs via inoculation of fungus directly into the skin from the environment. Secondary dissemination occurs via hematogenous spread from the lungs (the primary area of infection, in most cases) to other organs such as the skin, bones, and meninges. The skin is one of the most common sites of secondary dissemination. Disseminated cutaneous infection is characterized by the presence of fungal spherules in the skin. Immunosuppressed patients, as well as certain ethnic and racial groups, such as African Americans and Filipinos, have an increased propensity for severe disease and secondary dissemination.5, 6 Disseminated cutaneous coccidioidomycosis has a highly variable clinical and histologic appearance.5 Here, we report a unique case of disseminated infection mimicking cicatricial alopecia.