Dense Inflammation Research Articles

Mo1190 Differential Diagnosis of Solid Pancreatic Lesions by Using Three-Dimensional Contrast Enhanced Ultrasonography With High Mechanical Index Mode

Background: We have shown that pancreas cells undergo an epithelial-to-mesenchymal transition (EMT), invade the stroma, and enter the blood circulation before tumor formation in epithelial lineage-labeled genetic mouse models of PanIN (Rhim et al., DDW 2011). Because EMT and invasion were most prevalent within areas of dense inflammation, we hypothesized that inflammation was required for early acquisition of a malignant phenotype. Methods: We bred Pdx-Cre; LSL-KrasG12D; p53fl/+; Rosa26LSL-YFPmice in which pancreatic epithelial cells were permanently labeled with yellow fluorescent protein (YFP) and aged 22.5 mo (deemed PanIN mice as only precancerous PanIN lesions and no cancer are found on HE Rosa26LSL-YFPmice (CY) were used as controls. Acute cerulein pancreatitis (AC) or main pancreatic duct ligation (PDL) was performed in PanIN and control animals as previously described (Siveke et al, 2008; Scoggins et al, 2000). Animals were analyzed 3 and 7d after AC and PDL, respectively. 2.5mo old control and PanIN mice were also treated with the potent anti-inflammatory agent dexamethasone (Dex, 10mg/kg daily) for 7d and analyzed 24h after the last dose. Results: Using the YFP label, we found that PanIN mice contained pancreas cells that sustained an EMT, invaded the stroma and seeded the blood, as we previously described. However, we found a significant increase in EMT and invasion in PanIN animals with ACand PDL-induced pancreatitis compared to vehicleand sham laparotomy-treated control PanIN mice (p<0.05 for AC v. vehicle and PDL v. Sham (n=12 & 8)). AC in control CY mice led to the emergence of EMT+ cells lining the pancreas capsule. There was a significant 3-fold increase in circulating YFP+ pancreatic cells (CPCs) in the blood of PDL-treated PanIN mice v. Sham-treated PanIN mice by FACS (p<0.04). Surprisingly, after only one week of PDL, 3/4 pancreases were found to have histologic (HE DK060694 to AKR), AGA/FDHN (Fellow to Faculty Transition Award to ADR), and NPF (MR, ADR).

Fine needle aspiration cytology of oral and oropharyngeal lesions with an emphasis on the diagnostic utility and pitfalls

This study was undertaken to evaluate the diagnostic utility and pitfalls of fine needle aspiration cytology (FNAC) in oral and oropharyngeal lesions. This was a retrospective audit of oral and oropharyngeal lesions diagnosed with FNAC over a period of six years (2005-2010). Oral/oropharyngeal lesions [n=157] comprised 0.35% of the total FNAC load. The age ranged 1-80 years with the male: female ratio being 1.4:1. Aspirates were inadequate in 7% cases. Histopathology was available in 73/157 (46.5%) cases. Palate was the most common site of involvement [n=66] followed by tongue [n=35], buccal mucosa [n=18], floor of the mouth [n=17], tonsil [n=10], alveolus [n=5], retromolar trigone [n=3], and posterior pharyngeal wall [n=3]. Cytodiagnoses were categorized into infective/inflammatory lesions and benign cysts, and benign and malignant tumours. Uncommon lesions included ectopic lingual thyroid and adult rhabdomyoma of tongue, and solitary fibrous tumor (SFT), and leiomyosarcoma in buccal mucosa. A single false-positive case was dense inflammation with squamous cells misinterpreted as squamous cell carcinoma (SCC) on cytology. There were eight false-negative cases mainly due to sampling error. One false-negative case due to interpretation error was in a salivary gland tumor. The sensitivity of FNAC in diagnosing oral/oropharyngeal lesions was 71.4%; specificity was 97.8% with diagnostic accuracy of 87.7%. Salivary gland tumors and squamous cell carcinoma (SCC) are the most common lesions seen in the oral cavity. FNAC proves to be highly effective in diagnosing the spectrum of different lesions in this region. Sampling error is the main cause of false-negative cases in this region.

Histopathological analysis of chronic gastritis and correlation of pathological features with each other and with endoscopic findings

Chronic gastritis is a very common disorder which is commonly caused by Helicobacter pylori. Histopathological examination is the mainstay of the diagnosis. We evaluated 300 gastric antral biopsies using revised Sydney system and concluded that it helps to analyse gastric biopsies in a very comprehensive manner. It was seen that H. pylori, chronic inflammatory infiltrate, neutrophilic infiltration, presence of lymphoid follicles and aggregates and surface epithelial damage are strongly associated with each other. The presence of one of these histological feature is a strong indicator for presence of other features. On the other hand intestinal metaplasia and atrophy of gastric glands was not associated with the above mentioned histological features. In the presence of dense chronic inflammation and infiltration by neutrophils one should carefully search for H. pylori organism. We also correlated histological features with endoscopy and found that cases of duodenal ulcer had more severe antral gastritis on histology as compared to those with hyperemia or antral erosions.

Overcoming the challenges of robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) is the most commonly performed robotic procedure worldwide and is firmly established as a standard treatment option for localised prostate cancer. Part of the explanation for the rapid uptake of RARP is the reported gentler learning curve compared with the challenges of laparoscopic radical prostatectomy (LRP). However, robotic surgery is still fraught with potential difficulties and avoiding complications while on the steepest part of the learning curve is critical. Furthermore, as surgeons progress there is a tendency to take on increasingly complex cases, including patients with difficult anatomy and prior surgery, and these cases present a unique challenge. Significant intra-abdominal adhesions may be identified following open surgery, or dense periprostatic inflammation may be encountered following TURP; large prostate gland size and median lobes may alter bladder neck anatomy, making difficult subsequent urethro-vesical anastomosis. Even experienced robotic surgeons will be challenged by salvage RARP. Approaching these problems in a structured manner allows many of the problems to be overcome. We discuss some of the specific techniques to deal with these potential difficulties and highlight ways to avoid making serious mistakes.

Chronic sclerosing sialadenitis as one of the immunoglobulin G4-related diseases: a clinicopathological study of six cases from Central Europe

Chronic sclerosing sialadenitis (CSS) has been proposed recently to be a member of the group of IgG4-related diseases in Japanese and American series. The aim of our study was to validate these results in a cohort of European patients. Our CSS series included four females and two males, aged 32-76 years, all presenting with unilateral swelling of submandibular gland. Microscopically, all CSS-cases showed similar morphology with preservation of lobular architecture accentuated by cellular fibrous bands, dense lymphoplasmacytic inflammation and varied acinar atrophy. Ductal lymphocytes were detected in three cases. In five cases, the presence of intraductal secretory material accompanied by parenchymal neutrophils was observed. Obliterative phlebitis was seen in three cases. The inflammatory infiltrate was composed of T and B lymphocytes and polyclonal plasma cells. The median number of IgG-positive plasma cells per high-power field (HPF) was 157; median number of IgG4-positive plasma cells per HPF was 133. Median value of the IgG4:IgG ratio was 0.84. This is the first European series to demonstrate that CSS belongs to the family of IgG4-related disease. Unlike previous studies, in CSS we found rarely described ductal lymphocytes and parenchymal neutrophils. CSS displays consistent morphology with increased numbers of IgG4-positive plasma cells, and should be regarded as a member of the IgG4-related disease group.

Unilateral hemispheric primary angiitis of the central nervous system

Dear Sirs, A 52-year-old Hispanic man was admitted to hospital with a history of seizures, right sided hemiparesis, and new onset of aphasia. He complained of seizures that began 3 years prior which were characterized by 5 min episodes of right leg twitching, spreading to his right arm. The patient had no known risk factors for seizures, and the addition of topiramate had reduced his seizure frequency to about once every 2–3 days. A previous MRI of his brain showed nonspecific fluid attenuation inversion recovery (FLAIR) hyperintensities in the left cerebral hemisphere; however, his EEG was normal. In the past, the patient had a brain biopsy for a workup of the FLAIR hyperintensities in the left hemisphere, which was inconclusive due to inadequate tissue sampling. His neurological examination was remarkable for a global aphasia, 4/5 strength on the right upper and lower extremities, and a right sided spastic gait with right sided internal circumduction of the foot. MRI scan of the brain showed extensive fluid attenuation inversion recovery (FLAIR) hyperintensities restricted to the left cerebral hemisphere, with multiple foci of nodular and ring enhancement, along with involvement of the left calvarium (Fig. 1a–c). Serum rheumatologic and infectious studies were negative outside of a positive serum Bartonella antibody titer. Cerebrospinal fluid results were unremarkable. Since the patient had a history of working with farm animals, he was treated empirically with doxycycline for 4 weeks, but with no noticeable improvement. MRI scans of the brain over the next few months showed progression of the FLAIR hyperintensities in the left hemisphere. Since the patient was a recent immigrant from Mexico, he was also treated with RIPE (rifampin, isoniazid, pyrazinamide and ethambutol) therapy for presumed tuberculosis with no noticeable improvement. Fig. 1 MRI brain revealing extensive fluid attenuated inversion recovery (FLAIR) lesions restricted to the left cerebral hemisphere (a), with multiple foci of nodular and ring enhancement (b), along with involvement of the left calvarium (c). After treatment ... After a month, the patient presented to another hospital because of worsening aphasia and headaches. An MRI scan showed further progression of the left hemispheric lesions. Four-vessel cerebral angiogram was notable for a small left middle cerebral artery saccular aneurysm and a right pericallosal anterior cerebral artery aneurysm, which were both surgically clipped, but no beading or stensoses were visualized. He then had a left frontal stereotactic brain biopsy performed revealing dense perivascular chronic inflammation with mixed T and B lymphocytes, along with reactive astrocytosis in surrounding brain. The inflammatory infiltrates were sharply demarcated from the surrounding brain and did not extend into the surrounding neuroglial tissue. The findings were consistent with primary angiitis of the CNS (PACNS) (Fig. 2a–f). The patient returned to our care and was treated with corticosteroids and cyclophosphamide. Within days after initial treatment the patient noticed improvement of speech and strength. Fig. 2 H&E stained section of a vessel, cut in longitudinal section, shows polymorphous transmural inflammatory infiltrate between the arrows (a). Note effacement of normal vessel wall by the inflammatory infiltrate (b). Sections of the ... At a follow up visit 3 months later, the patient reported near complete resolution of his aphasia, seizures and right sided hemiparesis. He has not had a seizure in over 6 months, and a follow up MRI brain revealed significant improvement of the FLAIR and significantly decreased areas of enhancement in the left hemisphere (Fig. 1d, e). Our case is the first in the literature that reports a slowly progressive, single hemispheric involvement of PACNS. The patient’s focal, unilateral lesion on MRI and slow indolent course initially raised the question of infection, tumor, or even a progressive demyelinating disease. In addition, the unusual manifestation of focal involvement of the overlying calvarium raised the possibility of granulomatous disease, such as vasculitis occurring in the setting of tuberculous meningitis. However, the diagnostic studies for tuberculosis including tuberculin skin test, sputum cultures, and cerebrospinal fluid cultures were all negative, and the MRI did not reveal the basilar meningeal thickening that might suggest tuberculous meningitis. Our patient required two brain biopsies before there was adequate sampling of the tissue and vessels involved to make the diagnosis, which is often the case in PACNS [1–3]. He also had a four vessel cerebral angiogram which revealed anterior cerebral and middle cerebral artery aneurysms, which have been described in the literature in association with PACNS [4]. This represents the first case report of focal PACNS. Glucocorticoid and immunosuppressive therapy are first-line treatments for PACNS based on extrapolations from treatment of other systemic vasculitides and from expert consensus groups, although intravenous immunoglobulin, plasmapharesis, and mycophenolate mofetil have also shown some success [5–7]. Our case describes an unusual presentation of PACNS which had an excellent response to corticosteroid and immunosuppressive therapy.

Spontaneous Regression of Highly Immunogenic Molluscum contagiosum Virus (MCV)-Induced Skin Lesions Is Associated with Plasmacytoid Dendritic Cells and IFN-DC Infiltration

Molluscum contagiosum virus (MCV) infection induces self-limiting cutaneous lesions in an immunocompetent host that can undergo spontaneous regression preceded by local inflammation. On histology, a large majority of MCV-induced lesions are characterized by islands of hyperplastic epithelium containing infected keratinocytes and surrounded by scarce inflammatory infiltrate. However, spontaneous regression has been associated with the occurrence of a dense inflammatory reaction. By histology and immunohistochemistry, we identified MCV-induced lesions showing a dense inflammatory infiltrate associated with cell death in keratinocytes (inflammatory Molluscum contagiosum (I-MC)). In I-MC, hyperplastic keratinocytes were highly immunogenic as demonstrated by the expression of major histocompatibility complex class I and II molecules. Immune cell infiltration consisted of numerous cytotoxic T cells admixed with natural killer cells and plasmacytoid dendritic cells (PDCs). Accordingly, a type I IFN signature associated with PDC infiltration was demonstrated in both keratinocytes and inflammatory cells. Among the latter, a cell population resembling IFN-DC (CD123(+)CD11c(+)CD16(+)CD14(+)MxA(+)) was identified in proximity to islands of apoptotic keratinocytes. In vitro-generated IFN-DCs expressed a strong cytotoxic signature, as demonstrated by high levels of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) and Fas ligand (FasL). This study establishes a previously unreported model to underpin the role of innate immune cells in viral immune surveillance.

A Case of Unresectable Rectal Necrosis

Introduction. Necrosis of the rectum is an uncommon finding due to abundant collateral vasculature. Its management remains challenging, without clear consensus in the literature. Case Report. We describe a case of a 53-year-old woman with multiple medical comorbidities that presented in septic shock and hematochezia. Colonoscopy revealed ischemic colitis. Conservative management was instituted. At two weeks, she presented evidence of peritonitis. Exploratory laparotomy revealed extensive necrosis of the left colon and rectum. Due to dense inflammation, resection was deemed unsafe. Therefore, a transverse ostomy with mucosal fistula was preformed. Multiple drains were left in place. The patient healed uneventfully. Conclusion. This case illustrates that, if extensive dissection of the distal colon and rectum is unsafe due to the patient's critical condition or technical feasibility, then a diverting ostomy of the proximal viable bowel along with a mucus fistula and good drainage of the abdomen represents an acceptable alternative.

Incidental Strongyloides stercoralis Infection in Colonoscopic Mucosal Biopsies in the United States

Purpose:Strongyloides stercoralis, a worldwide parasitic nematode, can persist indefinitely within a host, usually asymptomatic, through a mechanism known as autoinfection. Immunosuppression may cause rapid increases in the numbers of re-infecting larvae (hyperinfection), which can disseminate throughout the body, usually with a fatal outcome. The diagnosis is made by finding larvae in the stools, but in some patients larvae can be found incidentally in colonic biopsy specimens. The purpose of this study was to review all cases of strongyloidiasis detected in colonic biopsies in patients who had not been suspected of harboring a parasite. Methods: This study was conducted at Caris Life Sciences, a specialized gastrointestinal pathology laboratory receiving specimens from private outpatient endoscopy centers across the U.S. We analyzed electronic data from the Caris database, which includes demographic, clinical, and endoscopic information, site of origin, and histopathologic report for each biopsy. From a series of 515,724 patients who underwent colonoscopy with mucosal biopsies between 1/2008 and 5/2010, we extracted data for all patients who had nematode larvae detected in their colonic biopsies. Results: A total of 13 patients (10 men and 3 women; age range 40-89) had larvae or fragments of larvae consistent with S. stercoralis in the colonic mucosa. Nine patients were from southern states, 2 from the Northeast, and one from the Midwest. The reasons for colonoscopy were screening colonoscopy (8 patients), follow-up of inflammatory bowel disease (2 patients), abdominal pain with diarrhea (2 patients), and a history of rectal ulcer (one patient). Colonoscopy showed polyps in 6 patients, colitis in 4, polyps and colitis in 2, and a cecal ulcer in one patient. Parasitic larvae identified as or suspicious for S. stercoralis were surrounded by intense eosinophilic responses in all patients; in 7 cases the inflammation around the larvae elicited a polypoid inflammatory response. In none of the cases had the infection been known or suspected. Conclusion: Although foci of S. stercoralis endemicity may still exist in the Appalachian region of the U.S., most cases are diagnosed in immigrants from tropical developing areas. Because the infection is extremely uncommon and usually asymptomatic, it is rarely suspected. In our series, it was found unexpectedly in 2/100,000 patients who had a colonoscopy with mucosal biopsies. In patients with clinically manifest colitis it could not be determined whether the parasitic infection was incidental or causative; however, the dense eosinophilic inflammation present in most cases also in areas where parasites were not detected suggests that S. stercoralis may have played an etiologic role.

Subcutaneous zygomycosis: report of 10 cases from two institutions in North India

Subcutaneous zygomycosis is an uncommon condition observed in tropics. Few series have been published, particularly from the northern regions of India. The aim of this study was to describe clinical, investigative and therapeutic details in subcutaneous zygomycosis observed in two teaching hospitals in Delhi. Ten patients seen over a period of 10 years (1999-2009) form the material for this report. There were four children and six adults. In four children, the presentation was a subcutaneous localized mass or gradually spreading plaque. In the others, it was observed over nasal region of face, spreading inward into mucosal sites and paranasal sinuses, and outward to the contiguous areas. Regional lymphadenopathy was present in two with facial lesions. Majority showed a granulomatous infiltrate with admixture of other cells, mainly eosinophils. Aseptate or poorly septate hyphae were observed in seven. In one patient in whom no hyphae were observed, there was dense perivascular inflammation. Organisms were cultured from four patients, Basidiobolus ranarum in two and Syncephalastrum racemosum in two. The main therapy used was a saturated solution of potassium iodide (KI). Four received only KI of which two attained cure after 3 months and 9 months respectively, and the other two showed signs of regression. In one boy subsidence was associated with reduced circumference of thigh. Ketoconazole or itraconazole was given with KI to hasten regression when response was slow or there were side-effects to KI. Awareness and early recognition will prevent disfigurement produced by advanced disease, misdiagnosis and unnecessary surgical intervention.

Lichenoid Inflammation in Cutaneous Cysts

To the Editors: We recently observed a case of a benign epidermoid cyst with a prominent lichenoid reaction. A 49-year-old man with a history of hyperlipidemia controlled on simvastatin presented with a “boil” on his back of 2 weeks duration. It was felt to be a carbuncle and treated with incision and drainage, iodoform gauze packing, and the cephalexin before excision. Histologic exam revealed a cyst lined by stratified squamous epithelium with a granular layer. The cyst cavity contained orthokeratin, foreign body giant cells, neutrophils, and early granulation tissue. Nearly the entire epithelial lining demonstrated a saw-toothed rete pattern, dense band-like lymphoplasmacytic inflammation, and prominent Civatte bodies (Figs. 1 and 2).FIGURE 1: Low power of ruptured cyst with lichenoid inflammation throughout the majority of the cyst lining.FIGURE 2: High power of the lichenoid inflammation.Typically, when an epidermoid cyst ruptures, a suppurative and granulomatous foreign-body response is seen. As discussed by Weedon, a number of histologic changes have been seen in the lining of epidermoid cysts: epidermal proliferation, basal hyperpigmentation, melanophagic proliferation, pilomatricoma-like changes, clear cell change, coronoid lamellation, epidermolytic hyperkeratosis, changes of Darier disease, pyogenic granuloma formation, and a number of tumors.1 We are unaware of previous reports of a lichenoid interface dermatitis found in the lining of an epidermoid cyst. A Medline search using the methodology “cyst AND (lichenoid OR interface AND dermatitis)” failed to reveal prior reports. However, an electronic search of our pathology database over the last 10 years revealed 9 additional cases of cutaneous cysts with a lichenoid inflammatory response. All cases involved epidermoid cysts, and in all cases the lichenoid pattern was only focal. In 2 cases, there was overlying lichenoid inflammation and lichen simplex chronicus-like epidermal changes (Table 1).TABLE 1: Retrieved Cases of Cutaneous Cysts With Lichenoid InflammationThe significance of these changes is not known. Lichenoid interface dermatitis is felt to be mediated by cytotoxic CD8+ T cells that are responding to an unknown stimulus causing destruction of the basal layer epidermal keratinocytes.2 Many lichenoid conditions are linked epidemiologically to autoimmune phenomena and autoantibody formation. Our patient was taking simvastatin, a known cause of lichenoid drug eruptions.3 However, we think the drug is an unlikely cause of the lichenoid tissue reaction in our patient. Eric W. Hossler, MD Morgan L. Wilson, MD Department of Dermatopathology Geisinger Medical Center Danville, PA MAJ Scott R. Dalton, DO, MC, USA Department of Dermatology Geisinger Medical Center Danville, PA Dirk M. Elston, MD Departments of Dermatology and Dermatopathology Geisinger Medical Center Danville, PA

Emergency Laparoscopic Surgery for Right Colonic Diseases with Peritonitis

Laparoscopic bowel resection for right colonic diseases with peritonitis is technically difficult and time-consuming, particularly in the presence of hard adhesion and dense inflammation. Moreover, peritonitis frequently leads to an emergency operation. Therefore, we evaluated the feasibility and effectiveness of emergency laparoscopic bowel resection in patients with these diseases. During 3 years (November 2006 to October 2009), we enrolled 31 consecutive patients who underwent an emergency laparoscopic bowel resection for right colonic disease with peritonitis. In 2 patients, perforated malignancy was suspected preoperatively, but there was no patient with malignancy at pathologic finding. We analyzed the clinical outcomes, including complications. The mean operating time was 140 minutes, and the mean hospital stay was 10 days. There was 1 conversion (3%), and the other intraoperative procedures were uneventful. Four complications (13%) occurred after treatment (1 intra-abdominal abscess, 2 wound abscesses, and 1 adhesive ileus). The intra-abdominal abscess was treated by subsequent percutaneous drainage; the wound abscesses were treated conservatively. One patient with an adhesive ileus 12 months after treatment was managed with a bowel resection. After a median follow-up of 16 months, the other patients had no complications. Emergency laparoscopic bowel resection may be a feasible, effective method for the treatment of right colonic diseases with peritonitis.

Use of immunohistochemistry for IgG4 in the distinction of autoimmune pancreatitis from peritumoral pancreatitis

The patients with autoimmune pancreatitis usually present with jaundice and a pancreatic head mass, presumed to have pancreatic cancer, and they often undergo pancreatic resection. Elevated serum IgG4 levels (>135 mg/dL) help to distinguish autoimmune pancreatitis from pancreatic cancer. However, when the biopsy from a pancreatic mass shows dense chronic inflammation and fibrosis and the serum IgG4 level is not available, it presents a diagnostic dilemma whether it represents autoimmune pancreatitis or peritumoral pancreatitis. We performed IgG4 immunohistochemistry on 25 cases of autoimmune pancreatitis-lymphoplasmacytic sclerosing pancreatitis, 7 cases of autoimmune pancreatitis with granulocytic epithelial lesions, 8 cases of nonspecific pancreatitis, 15 cases of pancreatitis associated with pancreatic ductal adenocarcinoma, and 5 biopsies of pancreatic adenocarcinoma with variable inflammation. The distribution of IgG4-positive cells was noted in each case. Eighty-four percent (21/25) of autoimmune pancreatitis-LPSP cases showed diffuse and dense staining for IgG4, with more than 50 positive plasma cells per high-power field (range, 50-150 cells/hpf) in the highest density area. Most (5/7) cases of autoimmune pancreatitis-granulocytic epithelial lesions were negative for IgG4. Thirty-nine percent of nonspecific pancreatitis and peritumoral pancreatitis cases stained positive for IgG4, but the distribution was focal and none of the cases showed more than 50 IgG4-positive cells/hpf in the highest density area of IgG4 staining. IgG4-positive cells in peritumoral pancreatitis and nonspecific pancreatitis cases were closely associated with malignant glands and areas of acute inflammation in some cases. Using a cutoff of 50 IgG4-positive cells/hpf, the sensitivity of IgG4 staining for classical autoimmune pancreatitis-LPSP versus other types of pancreatitis was 84%, the specificity was 100%, and the P value was significant (<.0001). Hence, we conclude that diffuse and dense staining (>50 positive cells/hpf) for IgG4 is specifically seen in autoimmune pancreatitis-LPSP, and IgG4 staining along with the histologic features and serum IgG4 levels may be very helpful in diagnosing autoimmune pancreatitis.

A 16-year old male with cortical blindness and focal motor seizures

A 16-year old male with cortical blindness and focal motor seizures

Plasma cell hepatitis in hepatitis C virus patients post-liver transplantation: Case-control study showing poor outcome and predictive features in the liver explant

Plasma cell hepatitis (PCH) is characterized by plasma cell infiltration seen in allografts of patients who underwent liver transplantation (LT) for conditions other than autoimmune hepatitis. We identified 40 PCH patients who underwent LT for hepatitis C virus (HCV) by searching our pathology database (1994-2006) for the keywords liver allograft, lymphoplasmacytic, and plasma cell(s). We selected 2 control patients who received LT for HCV for each PCH case. The control patients were matched according to date of LT and availability of biopsy material at the time interval to development of PCH in PCH patients. Explant and post-LT biopsy slides were blindly reviewed by 2 liver pathologists and the severity of the plasma cell infiltrate was scored. A score of 3 (plasma cells composing >30% of the infiltrate) defined PCH in allograft biopsies. Five random areas of dense inflammation were also examined in explant livers and the highest score was used. Poor outcome was defined as death or advanced fibrosis (stage >or= 4 of 6). We found that PCH patients were more likely to have worse outcomes than control patients (65% versus 40%, P < 0.01), including increased mortality (50% versus 30%, P < 0.05). Kaplan-Meier survival analysis showed significantly worse survival for PCH patients from 4 to 10 years post-LT (P < 0.05). Explants from 40% of PCH patients had a score of 3 compared to 18% of control patients (P < 0.01). We found that the development of PCH is associated with poor outcome in patients undergoing LT for HCV. The association of significant plasma cell infiltrates in native livers of HCV patients developing PCH suggests that some patients may have a predisposition to developing PCH.

The use of elastin immunostain improves the evaluation of melanomas associated with nevi

Twenty to 30% of malignant melanomas are associated with melanocytic nevi; however, sometimes it is difficult to distinguish the melanoma from the nevus by routine histology. We have previously described distinctive patterns of elastic fibers in nevi and in melanomas. We analyzed elastic fiber patterns using elastin immunostain and elastic van Gieson (EVG) stain in 30 cases of invasive melanomas associated with nevi, 12 control melanocytic nevi and 14 control invasive melanomas. Elastin immunostain was superior to EVG in showing the elastic fiber patterns. In nevi, the elastic fibers were preserved between nests and often around individual melanocytes. In contrast, melanomas had markedly decreased elastic fibers in the stroma and within the nests of melanocytes. The melanoma pushed down the pre-existing thin elastic fibers of the papillary dermis, forming a compressed layer at its base, which separated the melanoma from the nevus. On sun-damaged skin, the solar elastosis had similar elastin and EVG patterns. In three cases with dense inflammation, the layer of elastic fibers between melanoma and nevus was still present but less evident. The distinctive patterns of elastic fibers, best shown by the elastin immunostain, were helpful in evaluating melanomas associated with melanocytic nevi.

Innovative 19-Minute Rapid Cytokeratin Immunostaining of Nonmelanoma Skin Cancer in Mohs Micrographic Surgery

Dense inflammation can obscure nonmelanoma skin cancer (NMSC) on frozen sections, prompting removal of additional layers to ensure negative margins. Cytokeratin (CK) immunostaining in Mohs micrographic surgery (MMS) has been examined and found to be useful but is limited by lengthy 1-hour processing. Our objective was to develop an effective ultrarapid CK frozen section immunostain to be used during MMS in cases of NMSC with dense or perineural inflammation. An ultrarapid immunostain with a mixture of AE1/AE3 monoclonal antibodies was performed in 21 MMS cases and compared with permanent sections prepared from the same material. The ultrarapid CK protocol stained all of the cells in each of the 21 examples of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) in frozen tissue in a way equivalent to immunostains being applied to permanent sections. The 19-minute CK immunohistochemistry protocol in frozen tissue appears to be as effective at labeling tumor cells of SCC and BCC as methods requiring permanent sections. It is hopeful that this technique may prevent recurrences after MMS and limit the number of Mohs layers required to obtain free margins when inflammation is abundant. It also is effective in uncovering subtle perineural invasion.

Melan-A-Positive “Pseudomelanocytic Nests”: A Pitfall in the Histopathologic and Immunohistochemical Diagnosis of Pigmented Lesions on Sun-Damaged Skin

We encountered recently 3 cases with a histopathologic diagnosis of melanoma in situ on sun-damaged skin (male = 2, female = 1; median age: 59 years; range: 52-60 years). The diagnosis was based mainly on the finding of actinic elastosis in the dermis and increased number of melanocytes in the epidermis and was confirmed by strong positivity for Melan-A in single cells and in small nests ("pseudomelanocytic nests"), located at the dermoepidermal junction. Indeed, examination of slides stained with hematoxylin and eosin revealed the presence of marked hyperpigmentation and small nests of partially pigmented cells at the dermoepidermal junction, positive for Melan-A. The histologic and especially the immunohistochemical features were indistinguishable from those of melanoma in situ on chronic sun-damaged skin. In addition, a variably dense lichenoid inflammation was present. Clinicopathologic correlation, however, showed, in all patients, the presence of a lichenoid dermatitis (phototoxic reaction, 1 case; lichen planus pigmentosus, 1 case; and pigmented lichenoid keratosis, 1 case). Our cases clearly show the histopathologic pitfalls represented by lichenoid reactions on chronic sun-damaged skin. Immunohistochemical investigations, especially if performed with Melan-A alone, may lead to confusing and potentially disastrous results. The unexpected staining pattern of Melan-A in cases like ours raises concern about the utility of this antibody in the setting of a lichenoid tissue reaction on chronic sun-damaged skin. It should be underlined that pigmented lesions represent a paradigmatic example of how immunohistochemical results should be interpreted carefully and always in conjunction with histologic and clinical features.

Physiologic alterations in the murine model after nasal fungal antigenic exposure

To determine whether a recently developed murine model of fungus-induced sinonasal inflammation demonstrated alterations in ciliary activity and expression of inflammatory cytokines. A prospective randomized controlled study of rhinosinusitis after fungal antigenic sensitization was performed with intraperitoneal aspergillus antigen injection followed by intranasal antigen challenge for 4 weeks. Saline solution was used in a parallel fashion for control animals. Six mice were used to validate the model. Additional 15 mice were used for ciliary beat frequency (CBF) analysis and cytokine expression with multiplex technology. Mean values for degree of inflammation, secretory hyperplasia, CBF, and cytokine expression were compared. Histologic analyses demonstrated dense chronic inflammation in aspergillus-challenged animals versus sparse inflammatory cells in controls. Significant differences in mean of aspergillus-challenged versus control animals were observed in degree of inflammation (P < 0.01), secretory hyperplasia (P < 0.01), CBF (P < 0.00002), IL-1alpha (P < 0.0002), IL-1beta (P < 0.0003), IL-4 (P < 0.02), TNF-alpha (P < 0.02), and RANTES (P < 0.01). Alteration in baseline CBF accompanied by increased expression of specific inflammatory cytokines was observed in aspergillus-challenged mice.

Current Progress of Immunostains in Mohs Micrographic Surgery: A Review

Mohs micrographic surgery is often considered the treatment of choice for a variety of skin malignancies. In recent years, the application of immunostaining techniques has facilitated the successful removal of a number of common and less common cutaneous malignancies, including basal cell carcinoma, squamous cell carcinoma, malignant melanoma, dermatofibrosarcoma protuberans, microcystic adnexal carcinoma, sebaceous carcinoma, atypical fibroxanthoma, extramammary Paget's disease, and even sarcomas. Immunostains highlight the tumor cells and allow the Mohs surgeons to pinpoint and eliminate the residual tumor at the surgical margin. It is especially helpful when a tumor presents with subtle or nonspecific histologic features or when a tumor is masked in a pocket of dense inflammation. However, the cost, the labor, and the time consumption are of concern to many of our peers, as are the diversity of antigens, which may overwhelm some. This article serves as a review of the literature on current uses of immunostaining in Mohs micrographic surgery and as a summary of their realistic applications in the dermatologic surgeon's practice. We conclude that immunohistochemical technique has played an important role in Mohs surgery advancement. With greater use and more cost-effective staining methods, we believe that the use of immunostains in a Mohs practice will become routine.