Histologic diagnosis of inflammatory skin diseases—An algorithmic method based on pattern analysis. Second edition

BOOK REVIEW

malignant melanoma remains highly unusual. Indeed, LCH is classically reported in association with other subtypes of Hodgkin's disease, but to our knowledge has never been described with N-LPHD. It has been previously described only once in lymph nodes draining the cutaneous site of a malignant melanoma .4 The pathogeny of LCH associated with neoplastic disorders is still unclear, and in our case, its association with two i n d e p e n d e n t but neighboring tumors raises some interesting questions. LCs belong to the dendritic cell (DC) lineage which is specialized in the processing and the presentation of antigens to T cells. 1 They may be recruited in several skin disorders including inflammatory diseases and tumors such as malignant melanoma. :,4 It is tempting to speculate that, in our case, these cells might have migrated from the melanoma site (where tumor antigens are shedded and processed) via the afferent lymphati£s to the T-dependent areas of the axil!ary lymph nodes (where antigens are presented to T cells) and accumulated there with the help of cytokines locally secreted by the adjacent N-LPHD neoplastic process. There is evidence that during their migration, DCs undergo a process of maturation characterized by the upregulatio n of several adhesion molecules and the acquisition of the full capacity of T-cell sensitization.: It has also be shown that on CD40 triggering (which mimicks interaction with T cells), cultured LCs acquire surface CD25 (Interleukin-2 receptor, IL-2R). 5 On the other hand, we have recently shown that reactive CD4+CD45RO+ T cells in LPHD exhibit a THl-type profile by producing high amounts ofinterleukin-2 (IL-2) and interferon-'y. ~ Although the signal that IL-2 provide s to LCs

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remains to be determined, we can speculate that, in our case, high levels of IL-2, produced locally by the reactive T cells associated with N-LPHD, might have contributed to the hyperactivation of LCs leading to LCH development. Although this explanation may appear too simplistic and still needs to be confirmed a n d / o r completed, we hope that our hypothesis contributes to a better understanding of the relationships between DCs and neoplastic disorders. CANDICEROUFOSSE,MD LAURENCE LESPAGNARD,PHD, FRANCOISSALI~S,MD, DOMINIQUE BRON, MD, JWXN-LOuISDARGENT,MD Department of Pathology C.H.U. Saint-Pierre/U.L.B. InstitutJules Bordet and the Departments of Hematology and Surgery, U.L.B. InstitutJules Bordet, Brussels, Belgium 1. Wright-Browne V, Mc Clain KL, Talpaz M, et al: Physiologyand pathophysio!ogyof dendriticcells.Ht~MPATHOL28:563-579,1997 2. Dargent JL, Schanden6 L, Kornreich A, et al: Nature of the T lymphocytesin lymphocytepredominanceHodgkin'sdisease.LeukLymphoma 24:545-551, 1997 3. EgelerRM, NegliaJP,PuccettiDM, et al: Associationof Langerhans cell histiocytosiswith malignantneoplasms.Cancer71:865-873,1993 4. Richmond I, Eyden BP, Baneljee SS: Intranodal Langerhans' cell histiocytosisassociatedwith malignant melanoma. Histopathology26:380-382, 1995 5. Caux C, Massacrier C, Vanbervliet B, et al: Activation of human dendriticcellsthrough CD40cross-linking.JExp Med 180, 1263-1272, 1994

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BOOK REVIEWS Acute Liver Failure William M. Lee, Roger Williams (eds), Cambridge University Press, $100.00 As noted by the editors, this book represents the outgrowth of two prior efforts to review current thinking on the topic of acute liver failure. These earlier efforts were published in monograph and j o u r n a l form and hence the current multi-authored text claims the distinction of constituting the first book dedicated to this subject. The target audience consists of internists, surgeons, intensivists, and other clinicians involved in diagnosis and treatment of persons with the disorder. As a consequence, the six primary sections of the book are as follows: (1) the clinical syndromes and etiologies of acute liver failure (viral, drug, etc,); (2) mechanisms of disease and multisystem involvement; (3) intensive care management; (4) transplantation; (5) artificial and bioartificial liver devices; (6) other therapeutic strategies. Section two will be of particular interest to pathologists with chapters on the role of cytokines and immune phenomena in acute liver failure (Kevork M, Peltichian and Gary A. Levy), the pathology of acute liver failure (Bernard Portmann and Romie Saxena) and replication and regeneration (Nelson Fausto). The quality of the pathology photographs is general!y excellent. This is not a book that the generally penurious general pathologist may wish to purchase. However, it would be a valuable addition to the hospital library.-ROBERT E, ANDERSON, MD, Professor,Laboratory Medicine and Pathology, University

of Minnesota, Minneapolis, MN 201

Lever's Histopathology of the Skin, Eighth Edition, David Elder with Rosalie Elenitsas, Christine Jaworsky, and Bernett Johnson, Jr., Philadelphia, PA, Lippincott-Raven Publishers, 1997, 1073 pages, $165.00. Histologic Diagnosis of Inflammatory Skin Diseases--An Algorithmic Method Based on Pattern Aualysis. Second Edition. A. Bernard Ackerman with Nidhi Chongchitnant, Jorge Sanchez, Ying Guo, Bruce Bennin, Martin Reichel, and M. Barry Randall. Baltimore, Williams & Wilkins, 1997, 943 pages, $250.00. The Eighth edition of Lever's Histopathology of the Shin represents a major metamorphosis from (1) a volume singularly published for almost 50 years by the late Walter E Lever with recent assistance by Gundula Schaumberg-Lever tO (2) a comprehensive tome with over 50 contributors. David Elder and the Editorial Board, the latter primarily from the University of Pennsylvania's Departments of Pathology and Dermato!ogy, have enlisted the assistance of an international group of distinguishe d pathologists and dermatopathologists to generate a well-written and up-to-date textbook that should cor!tinue to enjoy widespread use and authoritative respect. The 8th edition has been expanded from 34 to 37 chapters, covers more than 1,000 pages, cites more than 6,100 references and contains in excess of 800 photomicrographs. Although the current volume follows the previous edition's format and time-honored disease classfiication of both inflammatory and neoplastic process, the contributing authors have made significant attempts to reclassify selected entities into more biologi-

HUMAN PATHOLOGY

Volume 29, No. 2 (February 1998)

cally appropriate and precise categories based on current understanding of pathogenenc mechanisms both at the molecular and genetic levels. One of the most useful additions to the text is chapter 5 "Algorithmic Classification of Skin Disease for Differential Diagnosis." A series of original lectures in 1965 by the late Wallace Clark, while at Harvard, has formed the basis on which this and several subsequent "'pattern recognition" and "algorithmic" approaches to Cutaneous Pathology have been developed and published. The concept is one m which diseases are classified by location within the skin, reaction pattern, an d predominant cell type, This chapter is divided into four parts with a progressively more detailed and complete tabulation of the diseases encompassed by each category. Part 1 lists eight broad categories of cutaneous pathology, both neoplastic and inflammatory, extending from the stratum corneum to the subcutis. The concept of the superficial cutaneous reactive unit, as described by Clark, which includes the epidermis, papillary dermis, and superficially capillary-venular plexus, is introduced. From Part I the reader is referred by specific page number to Part 3 which is an expanded listing of diseases in each of the eight major categories. The reader is then referred, again by specific page, to Part 4. in which each of the major categories is further expanded. An introductory histological overview of each category is followed by an extensive tabulation of diseases within the category in outline form. Specific page references for the detailed description of each disease as found in the remaining 30 chapters are provided. Prototypical high quality scanning to medium power color photomicrographs representing t h e b r o a d categories of disease from Part 4 are presented in Part 2. This functions much like an index, except that the reader need only be able to identify in which anatomic compartment the disease is, the overall pattern, (ie, superficial versus superficial and deep) and predominate cell types involved to generate a differential diagnosis. The advantage for most practicing pathologists, particularly those with minimal training in dermatopathology, is obvious. Chapter 5 alone is worth the price of the book! In addition to Chapter 5's algorithmic classification of d!sease, four additional new chapters have been added. These include photosensitivity Disorders, Cutaneous Manifestations of Nutritional Deficiency States and Gastrointestinal Disease, Inflammatory Disease of the Nail, and The Histocytoses. These chapters represent a reclassification of specific entities from the 7th edition rather than newly described diseases. Material from the previous editions' chapters on "Embryology of the Skin" and "Morphology of the Cells in the Dermis" have been included in an excellent chapter on "Histology of the Skin." Although the glossary has been deleted, a definition of most key terms is included in others areas including most notably the algorithmic chapter. The 8th edition retains Lever's historical chapter organization with introductory comments and clinical information, histology (including special studies, EM, IF, etc.), pathogenesis (histogenesis), and differential diagnoses. Although some chapters have been updated only modestly, many have been completely rewritten with new tables, disease classifications, and photomicrographs. The chapters on "Cutaneous Lymp h o m a and Leukemia" and "Tumors of Neural Tissue" are two such examples, each reflecting the recent exponential increase in our understanding of these disease categories. Many other chapters have been expanded by more comprehensive discussions and an increased number of illustrations; this is especially evident in the chapters on Benign Melanocytic Lesions and Malignant Melanoma; Tumors of Fibrous Tissue involving the Skin; Tumors of Fat, Muscle, and Osseous Tissue; and Vascular Tumors. High quality photomicrographs

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represent the vast majority of the disease discussed in the text unlike the previous editions in which many diseases were discussed but not illustrated. In addition to reflecting revised thinking about certain disease classifications, the current edition also reflects the growing use of immunohistochemistry for delineating histogenesis and understanding disease dynamics. A reduced number of electron rnicrographs reflects this technological shift. Certainly one of the major weaknesses in all of the previous Lever volumes has been the quality of the photomicrographs. The 8th edition makes significant progress in this area. however, falls short Of what is undoubtedly the editors goal of uniform, high quality illustrations. It appears that many of the "recycled" photomicrographs are of uneven quality whereas the newer and updated ones set a new, significantly higher standard. We can't wait for the 9th edition! The new edition of Lever's Histopathology of the Skin, while representing a major departure from the previous edition's authorship, maintains a n d significantly expands the scope and quality of the work. As an authoritative, well-written, and easy to use reference text, the 8th edition will maintain the previous editions place of preeminence among dermat0pathology textbooks. The second edition of Histologic Diagnosis of Inflammatory

Skin Disease An Algorithmic Method Based on Pattern Analysis is much more than the emperor's new clothes. The entire pattern analysis concept has been expanded, refined, and extended beyond the 1st edition's "A Method of Pattern Analysis" to a more comprehensive algorithmic approach. Although much of the content from the 1st edition ts preserved, the present volume has been rewritten, reformatted, and represents a significantly improved, user-friendly reference text. The fundamental tenant which unifies the text and provides the cement which forms a cohesive structure is the algorithm, defined as " . . . a process for calculation based on logical thought and orderly s e q u e n c e . . . " The work is divided into four major sections totaling nine chapters, somewhat less than the previous edition's 15. The unifying theme is the "specific diagnosis." Part I - - P r e p a r i n g for Specific Diagnosis: Part I ! P r o c e e d i n g to Specific Diagnosis; Part III--Specific Diagnosis; and Part IV--Coming to Specific Diagnosis by Another Route. The first four chapters set the stage for the algorithmic approach with in-depth discussions of embryology, histology, regional gross cutaneous variations, and biopsy techniques. Although many of the previous edition's diagrams and photographs have been retained, they generally have revised legends and have often been supplemented by additional images. Chapter 5 introduces the nine major reaction patterns of inflammatory skin disease with usable schematic diagrams and an abbreviated or truncated algorithm for each pattern. As an interesting aside, Dr. Ackerman's perspective on the historical evolution of the algorithmic approach is presented. The important practical and philosophical notion that the histopathologist must Fender diagnoses " . . . in the language of clinical dermatology" i s introduced, one that practicing histopathologists would do well to keep in mind when signing out cases as "nonspecific chronic dermatitis!" Chapter 6 explains in further detail the basic inflammatory patterns, advantages, and limitations of the algorithmic method. It is emphasized that not all lesions may fit neatly into one of the categories depending on the evolutionary stage, prior treatment, or true nature of the process (ie, not inflammatory but neoplastic Or hamartomatous ) . Experienced words of caution about interpreting a biopsy when unduly influenced by the cl!nical findings, the necessity

BOOK REVIEW

for recuts or deeper levels, the need to be able to separate the important pathology from "bystanders or e p i p h e n o m e n o n , " to recognize noninflammatory simulants of inflammatory diseases, and lastly knowing one's own diagnostic limitations and the imperative for outside consultation on occasion are discussed with considerable insight and vigor. Part III includes two chapters, "Specific Diagnoses" and '"Simulators of Inflammatory Diseases." Chapter 7, "Specific Diagnoses" comprises roughly two-thirds of the text. The diseases are alphabetically arranged by groups that fall into the same histologic or pathogenic category. The presentation of each disease follows a uniform format with stereotypical presentation (age, sex, distribution, gross morphology); clinical variations; clinical differential diagnosis; histopathologic findings (early, fully developed, and late lesions when applicable); clinicopathological correlations; histopathologic differential diagnosis; laboratory confirmation; cause and mechanism; comment; and bibliography sections. These exhaustive descriptions are followed by pairs of superb scanning magnification and higher power color photomicrographs, each with a succinct description. The paired photomicrographs, when viewed together may lead one to the specific diagnosis. The comment section is more freeform in style in which the authors wander through the fields of their combined experience, musing over questions of histogenesis, disease dynamics and evolution, and on occasion, tirade against " c o m m o n wisdom and prevailing precepts." It is an entertaining and sometimes informative diversion. Chapter 8, "Simulators of Inflammatory Disease," is an eclectic and diverse group of entities including those from neoplastic, metabolic, endocrine related, and mechanicalinduced diseases. The presentation is the same as in Chapter 7, again with excellent color photomicrographcs and interesting ff not somewhat controversial commentary. One of the most innovative and useful additions in the 2nd edition is found in Chapter 9, "Nonspecific Findings as Vehicles to Specific Histologic Diagnosis." This section presents essentially an inverse algorithmic approach to diagnosis in which ones goes from the nonspecific to the specific. This chapter has two parts with the first functioning as an abbreviated glossary with high quality color photomicrographs and a brief description of each coupled with a short list of the most

common diseases associated with that reaction pattern. The second part includes photomicrographs of general reaction patterns that one may see in a variety of diseases with an accompanying branched algorithm based on specific findings that, when added to the general reaction pattern, comprise a specific diagnostic entity. For example, a photomicrograph of "broad zones of parakeratosis that contain neutrophils" plus "scale-crusts at lips of follicular ostia" yields seborrheic dermatitis, whereas the same photomicrograph plus "hyphae in the stratum corneum" leads one to dermatophytosis. This rather ingenious method for gaining specificity from general reaction patterns should prove quite useful for both the novice and more experienced pathologist. We all struggle to make something specific and therefore clinically meaningful, out of what we initially interpret as nonspecific. The index is complete, easy to use, and well crossreferenced. The strength of this work reflects the authors' lifelong commitment to bring order and reproducible specificity to an otherwise chaotic field, namely dermatopathology. This is particularly valuable to those who are just beginning to study the intricacies of cutaneous biology, delve deeply into its mysteries, and begin to behold the beauty of its true nature. If there is a perceived deficiency in this work it may well be the bibliography. Although the authors appear to have intended that the focus be on historically significant citations, those seminal works that define a disease or field, the lack of emphasis on an exhaustive compilation of current references may frustrate some readers. Can one compare Lever's Histopathology of the Skin and

Histologic Diagnosis of Inflammatory Skin Diseases--An Algorithmic Method Based on Pattern Analysis?Yes, one may. I've attempted to elucidate the strengths and weaknesses of both from the vantage point of a practitioner of cutaneous pathology. But, perhaps more importantly, one should ask the question of needs, both in terms of daily dermatopathology problems but also in terms of intellectual stimulation, style, and the necessit,/ for scientific thoroughness and completeness. It will become readily obvious that these two texts fill distinctly different, albeit partially overlapping, spheres. For the wellheeled practitioner both books are a must. See you at the b o o k s t o r e ! - - P d c r ~ D T. CgENEY, MD, Department of Pathology,

RosweU Park Cancer Institute, Buffalo, NY

NOTICES Postgraduate Course in Gynecologic and Obstetric Pathology

Diagnostic Approaches to Lymphoproliferative Disorders

March 23-27, 1998 Boston, MA: Four Seasons Hotel The course has Category 1 accreditation for approximately 36 hours CME credit by the American Medical Association. The fee for the course is $850.00 (residents and fellows $650.00). For further information, contact: Department of Confinuing Education, Harvard Medical School, EO. Box 825, Boston, MA 02117-0825; TEL: 617432-1525; FAX: 617-432-1562.

March 30-April 3, 1998 Maui, Hawaii: The Grand Wailea Resort & Spa For further information, contact: Laurie A. Regis, Conference Coordinator, Department of Academic Affairs, 403C, Scripps Clinic and Research Foundation, 10666 N. Torrey Pines Road, La Jolla, CA 92037; TEL: (619) 554-8556; FAX: (619) 5546310.

Postgraduate Course in Urologic Surgical Pathology Type 2 Diabetes in the Elderly

May 1-3, 1998 The course has Category I accreditation for 23 hours CME credit by the American Medical Association. The fee for the course is $575.00 (residents and fellows $425.00). For further information, contact: Department of Continuing Education, Harvard Medical School, P.O. B o x 825, Boston, MA 02115; TEL: 617-432-0195; FAX: 617-432-1562.

March 2%29, 1998 Tempe (Phoenix), AZ: The Buttes Resort Presented by the American Diabetes Association of Arizona with the NIDDK (National Institute of Diabetes and Digestive Kidney Disease). Forfurther information, pleasefax your request to: (602) 861-0542.

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