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Cutaneous S100-positive histiocytic proliferations mimicking malignant melanoma
Leners
sis in literature. By modifying the technique possibly these pulsed waves could induce: - production of angiogenetic factors via degranulation of mast cells (IL81 or stimulation of fibroblasts (FGF); - secretion of other immunological and/or non immunological cytokines which could stimulate growth of quiescent hair follicle; - expression of “dormant” genes which could trigger off formation of new follicles. Maddin [2,3] published his data on pulsed electrical fields and hair growth, suggesting that increased cell mitosis through calcium infhrx may be induced by the electrical pulse. At present I am carrying out serial histological studies, however more studies and clinical experi-
Cutaneous SlOO-positive bistiocytic mimicking malignant melanoma
proliferations
To the Editor: The histiocytoses are uncommon proliferations of hematopoetic cells which may involve the skin. They recently have been divided into the X-histiocytoses, characterized by a proliferation of Langerhans’ cells, and the non-X histiocytoses, in which the proliferating cells are histiocytic cells other than Langerhans’ cells [l]. Each of these groups of proliferations may involve the skin in a wide range of patterns. These lesions may bear a striking resemblance to other cutaneous lesions, and can present a diagnostic challenge when they occur. We saw a 76 year old healthy woman with an 8 month history of chronic vulvitis. There was a 3 by 5 cm area of vulvar erythema and erosion. The clinical differential diagnosis included atypical herpes simplex infection, moniliasis and chronic bacterial infection. She was treated symptomatically without resolution. Subsequently vesicles formed on the medial aspects of the labia majora and medial labia minora. Viral and bacterial cultures were negative and she did not respond to antibiotics, antifungal agents or topical steroids. A punch biopsy revealed a proliferation of large, slightly atypical cells with abundant eosinophilic cytoplasm at all levels of the epidermis and in the superficial portions of the papillary dermis (Fig. 1). There was no apparent tendency for the
to the Editor
ence are imperatively needed to comprehend how E.L.F. square waves induce growth of terminal hairs in androgenetic alopecia. Justina
Claudatus
Via Cancelb
Ron0 3/c,
Bari
70124, Italy
[l] Klemp P, Peters K, Hanstcd B. Subcutaneous blood flow in early male baldness. J Invest Dermatol1989;92:725-730. [2] Maddin WS, Bell PW, James JHM. The biological effects of a pulsed electrostatic field with specific reference to hair. Pharmacol ‘Iherapeutics 1990;29:446-450. [3] Maddin WS, Amara I, Sollecito WA. Electrotrichogenesis: further evidence of efficacy and safety on extended use. Int J Dermatol 1992 (12): 878-80. SSDI 0926-9959(95)00044-5
cells to form nests or clusters. The architectural pattern was suspicious for a malignant melanoma and immunoperoxidase studies demonstrated strong cytoplasmic and nuclear reactivity with antibodies against SlOO protein. A repeat biopsy was performed and additional immunoperoxidase studies performed on snap-frozen tissue revealed the tumor cells to express the CD1 antigen, as well as SlOO protein. These studies confirmed the diagnosis of Langerhans cell histiocytosis. Another recent patient is a 57 year old man who had a melanoma diagnosed in March, 1991. The superficial spreading type malignant melanoma, removed from his left medial arm, was a Clark’s level II lesion measuring approximately 0.45 mm. in thickness. The patient recently noted a firm, subcutaneous 1 by 1.5 cm nodule on the upper portion of his left arm. The clinical differential diagnosis included an epidermal cyst, lipoma, and a cutaneous metastasis from his malignant melanoma. A biopsy displayed a proliferation of large cells with abundant eosinophilic cytoplasm, and centrally located oval nuclei (Fig. 2). An admixture of plasma cells, neutrophils and other inflammatory cells was present within the sheets of larger cells and lining up along blood vessels. Because of the history, immunoperoxidase evaluation for expression of SlOO protein was performed and showed the large cells to be diffusely positive for SlOO protein. Further examination re-
Letters to the Editor
Fig. 1. Low power reveals a proliferation Original magnification 160 X .
of cells within
the papillary
vealed the emperiopolesis characteristic of sinus histiocytosis with massive lymphadenopathy (Rosai Dorfman disease) [2]. The histiocytoses are a group of disease which are only encountered infrequently by the dermatopathol-
Fig. 2. Higher power shows the tumor cells to be characterized Original magnification 400 X .
by vesicular
dermis,
with
extensive
involvement
of the overlying
epidermis.
ogist. Two histologic patterns are described in which the resemblance to melanoma was striking. In each case, the strong expression of SlOO protein further added to the similarity to malignant melanoma, making the ultimate diagnosis that much more difficult.
nuclei,
prominent
nucleoli
and abundant
eosinophilic
cytoplasm.
Letters
Attention to more subtle histologic clues, and additional immunoperoxidase studies provided insights into the correct diagnoses. Bruce R. Smaller qbl * , Susan E. Khdel a*b,Robert Walton b a Department Stanford CA b Department ter, Stanford
of Pathology, Stanford Universiy Medical Center 94305, USA of Dermatology, Stanford University Medical CenCA 94305, USA
Should we consider fibroepithelioma of Pinkus and basal cell carcinoma as expressions of a single pathological process? To the Editor: A 73-year-old man presented to our Out Patient Department with a verrucous and slowly growing lesion on his lowerback. The lesion was asymptomatic for several years until 1 month prior to consultation. At that time, the lesion was noted to be excoriated and bled occasionally when irritated. On examination, many small and large verrucous elements with the typical appearance of senile warts, with greasy yellow and brown scales, were observed on the upper part of the patient’s back. A pearly raised lesion was noted under the left scapula. This tumor was round and covered by a thin epithelium through which a few dilated superficial bloodvessels could be seen. The clinical impression was that of a basal cell carcinoma. On the lower back near the left waist line, a reddish, soft to touch, penduncular but non-ulcerated lesion of 3 to 4 cm in diameter was observed. A tentative diagnosis of papilloma was made. There were no palpable lymph nodes. The senile warts were removed by curettage. Histology showed a papillomatous tumor with horny recesses and cysts in the epidermoid epithelium, indicating a typical picture of seborrheic wart [l]. The other lesions were excised. Microscopic examination of the tumor from under the left scapula showed a down growth or buds from the basal layer of the follicles which produced islands showing peripheral palisading, characteristic of a basal cell carcinoma. The lesion from the lowerback showed long branching and anastomosing strands of basal cells, many showing connections with the surface epidermis in between the fibrous
to the Editor 111 Winkelmann RK. Cutaneous syndromes of non-X histiocytosis. A review of the macrophage-histiocyte diseases of the skin. Arch Dermatol 1981;117:667-672. 121 Foucar E, Rosai J, Dorfman RF. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman Disease): Review of the entity. Sem Diagnostic Pathology 1990,7:19-74.
* Corresponding
author.
SSDI 0926-9959(95)00051-8
stroma. However, in one area transformation features such as uniform cellularity, peripheral palisading and a distinctive connective tissue stroma which are characteristic of basal cell carcinoma were observed [l] (Figs. 1, 2). In 1953, Pinkus described an epithelial-stromal, basaloid, reticular lesion that was located primarily on the lower trunk with a particular predilection for the lumbosacral region [2]. Numerous cases were reported to occur at other sites including the thorax, periumbilical area, penis and sole of the foot [3-61. These tumors developed slowly, were single or multiple and occurred equally in both sexes. They were often found in association with seborrheic warts and basal cell carcinoma as seen in our patient [7]. Clinically, fibroepithelioma of Pinkus usually presents as papilloma or senile fibroma because it looks and feels fleshy, forms broad based flat plaques or peduncular elevations. It is skin colored or reddish, of a firm to spongy consistency and its surface may be smooth or scaly. It has a diameter of 5-30 mm
k-4. Fibroepithelioma, polyp, pyogenic granuloma, hemangioma, neurofibroma, amelanotic melanoma, seborrheic keratosis and superficial basal carcinoma should be considered in the differential diagnosis of this lesion [9]. Fibroepithelioma of Pinkus is usually reported in the literature as a form of basal cell carcinoma and referred to as premalignant fibroepithelioma [2,7]. In our patient, we observed the specific histological features of a basal cell carcinoma arising in a fibroepithelioma of Pinkus. These findings indicate that a basal cell carcinoma may arise from a fibroepithelioma of Pinkus or a fibroepithelioma of Pinkus may develop into an invasive or ulcerating basal cell carcinoma as reported by Degos [81. However, as
sis in literature. By modifying the technique possibly these pulsed waves could induce: - production of angiogenetic factors via degranulation of mast cells (IL81 or stimulation of fibroblasts (FGF); - secretion of other immunological and/or non immunological cytokines which could stimulate growth of quiescent hair follicle; - expression of “dormant” genes which could trigger off formation of new follicles. Maddin [2,3] published his data on pulsed electrical fields and hair growth, suggesting that increased cell mitosis through calcium infhrx may be induced by the electrical pulse. At present I am carrying out serial histological studies, however more studies and clinical experi-
Cutaneous SlOO-positive bistiocytic mimicking malignant melanoma
proliferations
To the Editor: The histiocytoses are uncommon proliferations of hematopoetic cells which may involve the skin. They recently have been divided into the X-histiocytoses, characterized by a proliferation of Langerhans’ cells, and the non-X histiocytoses, in which the proliferating cells are histiocytic cells other than Langerhans’ cells [l]. Each of these groups of proliferations may involve the skin in a wide range of patterns. These lesions may bear a striking resemblance to other cutaneous lesions, and can present a diagnostic challenge when they occur. We saw a 76 year old healthy woman with an 8 month history of chronic vulvitis. There was a 3 by 5 cm area of vulvar erythema and erosion. The clinical differential diagnosis included atypical herpes simplex infection, moniliasis and chronic bacterial infection. She was treated symptomatically without resolution. Subsequently vesicles formed on the medial aspects of the labia majora and medial labia minora. Viral and bacterial cultures were negative and she did not respond to antibiotics, antifungal agents or topical steroids. A punch biopsy revealed a proliferation of large, slightly atypical cells with abundant eosinophilic cytoplasm at all levels of the epidermis and in the superficial portions of the papillary dermis (Fig. 1). There was no apparent tendency for the
to the Editor
ence are imperatively needed to comprehend how E.L.F. square waves induce growth of terminal hairs in androgenetic alopecia. Justina
Claudatus
Via Cancelb
Ron0 3/c,
Bari
70124, Italy
[l] Klemp P, Peters K, Hanstcd B. Subcutaneous blood flow in early male baldness. J Invest Dermatol1989;92:725-730. [2] Maddin WS, Bell PW, James JHM. The biological effects of a pulsed electrostatic field with specific reference to hair. Pharmacol ‘Iherapeutics 1990;29:446-450. [3] Maddin WS, Amara I, Sollecito WA. Electrotrichogenesis: further evidence of efficacy and safety on extended use. Int J Dermatol 1992 (12): 878-80. SSDI 0926-9959(95)00044-5
cells to form nests or clusters. The architectural pattern was suspicious for a malignant melanoma and immunoperoxidase studies demonstrated strong cytoplasmic and nuclear reactivity with antibodies against SlOO protein. A repeat biopsy was performed and additional immunoperoxidase studies performed on snap-frozen tissue revealed the tumor cells to express the CD1 antigen, as well as SlOO protein. These studies confirmed the diagnosis of Langerhans cell histiocytosis. Another recent patient is a 57 year old man who had a melanoma diagnosed in March, 1991. The superficial spreading type malignant melanoma, removed from his left medial arm, was a Clark’s level II lesion measuring approximately 0.45 mm. in thickness. The patient recently noted a firm, subcutaneous 1 by 1.5 cm nodule on the upper portion of his left arm. The clinical differential diagnosis included an epidermal cyst, lipoma, and a cutaneous metastasis from his malignant melanoma. A biopsy displayed a proliferation of large cells with abundant eosinophilic cytoplasm, and centrally located oval nuclei (Fig. 2). An admixture of plasma cells, neutrophils and other inflammatory cells was present within the sheets of larger cells and lining up along blood vessels. Because of the history, immunoperoxidase evaluation for expression of SlOO protein was performed and showed the large cells to be diffusely positive for SlOO protein. Further examination re-
Letters to the Editor
Fig. 1. Low power reveals a proliferation Original magnification 160 X .
of cells within
the papillary
vealed the emperiopolesis characteristic of sinus histiocytosis with massive lymphadenopathy (Rosai Dorfman disease) [2]. The histiocytoses are a group of disease which are only encountered infrequently by the dermatopathol-
Fig. 2. Higher power shows the tumor cells to be characterized Original magnification 400 X .
by vesicular
dermis,
with
extensive
involvement
of the overlying
epidermis.
ogist. Two histologic patterns are described in which the resemblance to melanoma was striking. In each case, the strong expression of SlOO protein further added to the similarity to malignant melanoma, making the ultimate diagnosis that much more difficult.
nuclei,
prominent
nucleoli
and abundant
eosinophilic
cytoplasm.
Letters
Attention to more subtle histologic clues, and additional immunoperoxidase studies provided insights into the correct diagnoses. Bruce R. Smaller qbl * , Susan E. Khdel a*b,Robert Walton b a Department Stanford CA b Department ter, Stanford
of Pathology, Stanford Universiy Medical Center 94305, USA of Dermatology, Stanford University Medical CenCA 94305, USA
Should we consider fibroepithelioma of Pinkus and basal cell carcinoma as expressions of a single pathological process? To the Editor: A 73-year-old man presented to our Out Patient Department with a verrucous and slowly growing lesion on his lowerback. The lesion was asymptomatic for several years until 1 month prior to consultation. At that time, the lesion was noted to be excoriated and bled occasionally when irritated. On examination, many small and large verrucous elements with the typical appearance of senile warts, with greasy yellow and brown scales, were observed on the upper part of the patient’s back. A pearly raised lesion was noted under the left scapula. This tumor was round and covered by a thin epithelium through which a few dilated superficial bloodvessels could be seen. The clinical impression was that of a basal cell carcinoma. On the lower back near the left waist line, a reddish, soft to touch, penduncular but non-ulcerated lesion of 3 to 4 cm in diameter was observed. A tentative diagnosis of papilloma was made. There were no palpable lymph nodes. The senile warts were removed by curettage. Histology showed a papillomatous tumor with horny recesses and cysts in the epidermoid epithelium, indicating a typical picture of seborrheic wart [l]. The other lesions were excised. Microscopic examination of the tumor from under the left scapula showed a down growth or buds from the basal layer of the follicles which produced islands showing peripheral palisading, characteristic of a basal cell carcinoma. The lesion from the lowerback showed long branching and anastomosing strands of basal cells, many showing connections with the surface epidermis in between the fibrous
to the Editor 111 Winkelmann RK. Cutaneous syndromes of non-X histiocytosis. A review of the macrophage-histiocyte diseases of the skin. Arch Dermatol 1981;117:667-672. 121 Foucar E, Rosai J, Dorfman RF. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman Disease): Review of the entity. Sem Diagnostic Pathology 1990,7:19-74.
* Corresponding
author.
SSDI 0926-9959(95)00051-8
stroma. However, in one area transformation features such as uniform cellularity, peripheral palisading and a distinctive connective tissue stroma which are characteristic of basal cell carcinoma were observed [l] (Figs. 1, 2). In 1953, Pinkus described an epithelial-stromal, basaloid, reticular lesion that was located primarily on the lower trunk with a particular predilection for the lumbosacral region [2]. Numerous cases were reported to occur at other sites including the thorax, periumbilical area, penis and sole of the foot [3-61. These tumors developed slowly, were single or multiple and occurred equally in both sexes. They were often found in association with seborrheic warts and basal cell carcinoma as seen in our patient [7]. Clinically, fibroepithelioma of Pinkus usually presents as papilloma or senile fibroma because it looks and feels fleshy, forms broad based flat plaques or peduncular elevations. It is skin colored or reddish, of a firm to spongy consistency and its surface may be smooth or scaly. It has a diameter of 5-30 mm
k-4. Fibroepithelioma, polyp, pyogenic granuloma, hemangioma, neurofibroma, amelanotic melanoma, seborrheic keratosis and superficial basal carcinoma should be considered in the differential diagnosis of this lesion [9]. Fibroepithelioma of Pinkus is usually reported in the literature as a form of basal cell carcinoma and referred to as premalignant fibroepithelioma [2,7]. In our patient, we observed the specific histological features of a basal cell carcinoma arising in a fibroepithelioma of Pinkus. These findings indicate that a basal cell carcinoma may arise from a fibroepithelioma of Pinkus or a fibroepithelioma of Pinkus may develop into an invasive or ulcerating basal cell carcinoma as reported by Degos [81. However, as