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Re: Immunoexpression of p53 in cutaneous and subcutaneous leiomyosarcomas
Annals of Diagnostic Pathology xxx (2016) xxx
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Annals of Diagnostic Pathology
Re: Immunoexpression of p53 in cutaneous and subcutaneous leiomyosarcomas Dear Editor-in-Chief, I have read, with much interest, the paper of Flores-Fernandez and Monteagudo [1] on immunoexpression of p53 in cutaneous and subcutaneous leiomyosarcomas. Nevertheless, I would like to make two comments. Like already stated by the authors, there is much controversy in the nomenclature of cutaneous and subcutaneous atypical smooth muscle neoplasms. In my opinion, if dealing with a cutaneous atypical smooth muscle tumor and using strict histopathological criteria (e.g. cutaneous tumors which are purely confined to the dermis and show no subcutaneous extension), there is no evidence that these tumors ever metastasize [2]. In these cases (like cases 4, 5, 13, 15 and 19 in the study of Flores-Fernandez and Monteagudo) labelling patients with a diagnosis of cutaneous leiomyosarcoma should be avoided and the alternate diagnostic term ‘atypical intradermal smooth muscle neoplasm’ should be considered to avoid the designation sarcoma. The prognostic significance of extension into the subcutis in these cutaneous atypical smooth muscle tumors is still debatable. In a study of Massi et al. [3], it was postulated that minimal extension into the subcutis is a negative prognostic factor for recurrence and metastasis. However, in my experience and in a large clinicopathological series of Kraft et al. [2], focal and very superficial subcutaneous extension (e.g. focal superficial extension into the fibrous septae or focal growth into the superficial subcutis with pushing borders) is, apart from margin status, not a significant pathological predictor of recurrence and is still compatible with a diagnosis of an ‘atypical intradermal smooth muscle neoplasm’. Secondly, the mitotic index is the most important histological criterium to discriminate between cutaneous leiomyomas and atypical smooth muscle tumors of the skin (‘atypical intradermal smooth muscle neoplasms’/cutaneous leiomysarcomas), which may exhibit a range of cytological atypia [4]. The mitotic marker phosphohistone-H3 (PHH3) immunostain is therefore extremely useful (and in my opinion a much stronger diagnostic marker than p53 staining) in the histological assessment of cutaneous smooth muscle neoplasms because it can simplify counting of mitotic figures in cutaneous smooth muscle neoplasms, especially in situations where counting of mitotic figures is more difficult (especially in tumors with many pyknotic nuclei or apoptosis).
Competing interest The author has no conflict of interest to declare.
Funding sources None. Local Committee Approval: not required.
Acknowledgments None. David Creytens Department of Pathology Ghent University, Ghent University Hospital, Ghent, Belgium Department of Pathology, Ghent University Hospital De Pintelaan 185, 9000 Ghent, Belgium E-mail address: [email protected]
Available online xxxx
References [1] Fernandez-Flores A, Monteagudo C. Immunoexpression of p53 in cutaneous and subcutaneous leiomyosarcomas. Ann Diagn Pathol 2016;24:25–9. [2] Kraft S, Fletcher CD. Atypical intradermal smooth muscle neoplasms: clinicopathologic analysis of 84 cases and a reappraisal of cutaneous “leiomyosarcoma”. Am J Surg Pathol 2011;35:599–607. [3] Massi D, Franchi A, Alos L, Cook M, Di Palma S, Enguita AB, et al. Primary cutaneous leiomyosarcoma: clinicopathological analysis of 36 cases. Histopathology 2010;56: 251–62. [4] Idriss MH, Kazlouskaya V, Malhotra S, Andres C, Dm E. Phosphohistone-H3 and Ki-67 immunostaining in cutaneous pilar leiomyoma and leiomyosarcoma (atypical intradermal smooth muscle neoplasm). J Cutan Pathol 2013;40:557–63.
http://dx.doi.org/10.1016/j.anndiagpath.2016.10.008 1092-9134/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Creytens D, , Annals of Diagnostic Pathology (2016), http://dx.doi.org/10.1016/j.anndiagpath.2016.10.008
Contents lists available at ScienceDirect
Annals of Diagnostic Pathology
Re: Immunoexpression of p53 in cutaneous and subcutaneous leiomyosarcomas Dear Editor-in-Chief, I have read, with much interest, the paper of Flores-Fernandez and Monteagudo [1] on immunoexpression of p53 in cutaneous and subcutaneous leiomyosarcomas. Nevertheless, I would like to make two comments. Like already stated by the authors, there is much controversy in the nomenclature of cutaneous and subcutaneous atypical smooth muscle neoplasms. In my opinion, if dealing with a cutaneous atypical smooth muscle tumor and using strict histopathological criteria (e.g. cutaneous tumors which are purely confined to the dermis and show no subcutaneous extension), there is no evidence that these tumors ever metastasize [2]. In these cases (like cases 4, 5, 13, 15 and 19 in the study of Flores-Fernandez and Monteagudo) labelling patients with a diagnosis of cutaneous leiomyosarcoma should be avoided and the alternate diagnostic term ‘atypical intradermal smooth muscle neoplasm’ should be considered to avoid the designation sarcoma. The prognostic significance of extension into the subcutis in these cutaneous atypical smooth muscle tumors is still debatable. In a study of Massi et al. [3], it was postulated that minimal extension into the subcutis is a negative prognostic factor for recurrence and metastasis. However, in my experience and in a large clinicopathological series of Kraft et al. [2], focal and very superficial subcutaneous extension (e.g. focal superficial extension into the fibrous septae or focal growth into the superficial subcutis with pushing borders) is, apart from margin status, not a significant pathological predictor of recurrence and is still compatible with a diagnosis of an ‘atypical intradermal smooth muscle neoplasm’. Secondly, the mitotic index is the most important histological criterium to discriminate between cutaneous leiomyomas and atypical smooth muscle tumors of the skin (‘atypical intradermal smooth muscle neoplasms’/cutaneous leiomysarcomas), which may exhibit a range of cytological atypia [4]. The mitotic marker phosphohistone-H3 (PHH3) immunostain is therefore extremely useful (and in my opinion a much stronger diagnostic marker than p53 staining) in the histological assessment of cutaneous smooth muscle neoplasms because it can simplify counting of mitotic figures in cutaneous smooth muscle neoplasms, especially in situations where counting of mitotic figures is more difficult (especially in tumors with many pyknotic nuclei or apoptosis).
Competing interest The author has no conflict of interest to declare.
Funding sources None. Local Committee Approval: not required.
Acknowledgments None. David Creytens Department of Pathology Ghent University, Ghent University Hospital, Ghent, Belgium Department of Pathology, Ghent University Hospital De Pintelaan 185, 9000 Ghent, Belgium E-mail address: [email protected]
Available online xxxx
References [1] Fernandez-Flores A, Monteagudo C. Immunoexpression of p53 in cutaneous and subcutaneous leiomyosarcomas. Ann Diagn Pathol 2016;24:25–9. [2] Kraft S, Fletcher CD. Atypical intradermal smooth muscle neoplasms: clinicopathologic analysis of 84 cases and a reappraisal of cutaneous “leiomyosarcoma”. Am J Surg Pathol 2011;35:599–607. [3] Massi D, Franchi A, Alos L, Cook M, Di Palma S, Enguita AB, et al. Primary cutaneous leiomyosarcoma: clinicopathological analysis of 36 cases. Histopathology 2010;56: 251–62. [4] Idriss MH, Kazlouskaya V, Malhotra S, Andres C, Dm E. Phosphohistone-H3 and Ki-67 immunostaining in cutaneous pilar leiomyoma and leiomyosarcoma (atypical intradermal smooth muscle neoplasm). J Cutan Pathol 2013;40:557–63.
http://dx.doi.org/10.1016/j.anndiagpath.2016.10.008 1092-9134/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Creytens D, , Annals of Diagnostic Pathology (2016), http://dx.doi.org/10.1016/j.anndiagpath.2016.10.008