Punch Biopsy Specimens Research Articles

Fleshy Papules in Areas of Friction in a Man With Endocrine Neoplasms—Quiz Case

A 39-year-old African American man presented with a progressive eruption of fleshy papules on his neck, axillae, groin, and abdomen. The lesions first developed on his neck in his mid-20s and slowly progressed to involve other sites. They occasionally bled when traumatized. His more recent medical history was remarkable for multigland parathyroid hyperplasia, pituitary microadenoma, and neuroendocrine pancreatic tumors. Physical examination revealed dozens of 2to 10mm, flesh-colored to brown, pedunculated, verrucous papules located circumferentially around the neck (Figure 1), extending down to the anterior aspect of the chest, and in the axillae and bilateral groin folds. Scattered across the lower area of the abdomen, there were numerous hypopigmented to flesh-colored 4to 10-mm dome-shaped firmer papules (Figure 2). A 2-cm lightbrown patch was observed on the left upper arm area. There was also mild freckling around the posterior axillary folds. Punch biopsy specimens were obtained from a pedunculated papule on the neck and a dome-shaped papule on the abdomen. What is your diagnosis?

Golimumab-Exacerbated Subacute Cutaneous Lupus Erythematosus

Subacute cutaneous lupus erythematosus (SCLE) is characterized by annular, nonscarring, photodistributed, or papulosquamous lesions. The disease may be idiopathic, drug induced, or drug exacerbated. A 66-year-old woman with a history of hypertension, parkinsonism, rheumatoid arthritis, anxiety and depression, and symptoms of Sjögren syndrome was seen with a 1-month history of an eruption on her upper extremities and upper trunk. The eruption had begun 2 to 3 weeks after subcutaneous injection of golimumab for rheumatoid arthritis. She had developed SCLE 2 years previously due to furosemide use and 10 years previously due to hydrochlorothiazide use. Physical examination revealed scaly, annular, erythematous plaques photodistributed on the arms, legs, and upper trunk. A punch biopsy specimen demonstrated vacuolar interface dermatitis and lymphohistiocytic perivascular inflammation. Serological abnormalities included a positive antinuclear antibody, an elevated anti-La/SS-B antibody level, and an elevated anti-Ro/SS-A antibody level. She was diagnosed as having SCLE and was initially treated with desonide lotion, photoprotection, prednisone (40 mg/d) tapered over 6 weeks, and hydroxychloroquine sulfate (200 mg twice daily). Because of persistent disease, methotrexate sodium (12.5 mg/wk) was subsequently added to the regimen, and her eruption cleared completely. Golimumab should be added to the list of medications capable of inducing or exacerbating SCLE. Our patient demonstrated variable times to the resolution of SCLE, possibly attributable in part to the different half-lives of the agents administered.

Diffuse Hyperkeratosis in a Deaf and Blind 48-Year-Old Woman—Quiz Case

An 83-year-old man with a history of diabetes and chronic obstructive pulmonary disorder (COPD) (taking prednisone, 5 mg/d) was admitted to our facility with a monthlong history of persistent right arm swelling, erythema, and pain. He had multiple prior admissions for this issue and was treated with oral and intravenous antibiotics for a suspected “cellulitis.” His skin symptoms worsened despite treatment, and he developed an extensive superimposed pustular eruption with sinus tracts involving the entire forearm and a portion of the upper arm (Figure 1). Workup included ultrasonography, which showed no fluid collection, and magnetic resonance imaging, which showed soft-tissue swelling without evidence of any underlying myositis or osteomyelitis. A Tzanck smear failed to show multinucleated giant cells. Punch biopsy specimens for culture and histopathologic analysis were obtained (Figure 2 and Figure 3). What is your diagnosis?

NUT midline carcinoma with cutaneous metastases

NUT midline carcinoma with cutaneous metastases

Longitudinal Deep Fissure and Distal Onycholysis of the Right Thumb—Quiz Case

A74-year-oldwhitewomanpresentedwithanapproximately 1-year history of median longitudinal ridging of the right thumb that had evolved in a deep fissure along with distal onycholysis. She had previously been diagnosed as having onychomycosis and had been treated with topical and systemic antimycotic drugs, with no improvement. The medial part of the nail plate had progressively become thin and brittle, causing median longitudinal fissuring of the whole nail and isolating 2 lateral parts of normal nail plate (Figure 1). The nail bed, which was exposed by onychodystrophy, was yellowish red and had a few scales. The nail fold was not involved, and the hyponychium was not ulcerated and looked only slightly hyperkeratotic. The digital pulp was normal and painless. A punch biopsy specimen of the lesion was obtained, and a total excision of the nail apparatus was subsequently performed. The specimens were stained with hematoxylin-eosin (Figure 2) and HMB-45 (Figure 3). What is your diagnosis?

Agreement between histological subtype on punch biopsy and surgical excision in primary basal cell carcinoma

Diagnosis of clinically suspected basal cell carcinoma (BCC) by histological confirmation with punch biopsy has been recommended before treatment. Even shave biopsy has been proposed as useful to predict the correct subtype in primary BCC in 76-81%, whereas the agreement between histological BCC subtype on punch biopsy and subsequent excision specimens in recurrent BCC is 67.1%. However, no large studies on the agreement between histological BCC subtype seen on punch biopsy and the following surgical excision are performed in primary BCC. The aims of this study were (i) to establish the agreement between histological BCC subtype on punch biopsy and the subsequent surgical excision of primary BCC and; (ii) to investigate the proportion of primary BCCs in which punch biopsy enables identification of the most aggressive growth pattern. Retrospective analyses of 243 primary BCCs with both punch biopsy and subsequent surgical excision. Analyses were based on the most aggressive histological subtype of the tumour. The agreement between BCC subtype on punch biopsy and the subsequent surgical excision of primary BCCs was 60.9%. A punch biopsy can predict the most aggressive growth pattern of primary BCCs in 84.4%. Seventy-four percentage of all primary BCCs consisted of more than one histological subtype. Dermatologists and other physicians have to be aware of the limited diagnostic value of a punch biopsy to determine the histological BCC subtype of the whole lesion. Misdiagnosis of the subtype will lead to undertreatment in one of six primary BCCs.

Hair Counts from Normal Scalp Biopsy in Taiwan

Horizontal scalp biopsy is a better method to use when evaluating hair disorders, but an accurate diagnosis requires quantitative data regarding normal hair counts to be used as a control, which are currently available only for Caucasians, African Americans, Koreans, and Iranians. To evaluate scalp hair counts in the Taiwanese population. Two 4-mm punch biopsies were taken from clinically normal-looking scalp skin of 31 patients who underwent scalp surgery for non-hair-loss disorders. Punch biopsy specimens were sectioned horizontally at the sebaceous gland level and the number of follicular units, terminal hairs including anagen and telogen hairs, and vellus hairs were counted and compared with other published data. The numbers of hairs were also compared between the sexes, different age groups, and different anatomical locations of the scalp. The average counts of total hairs, terminal hairs, vellus hairs, and follicular units per 4-mm punch scalp skin were 21.3, 20.5, 0.8, and 9.4, respectively. The mean ratio of anagen hair to telogen hair was 91.6:8.4 and of terminal hair to vellus hair was 25.3:1. The average density of hair follicles was 1.69 mm(2). The mean counts of terminal hairs, total hairs, follicular units, and hair follicles/mm(2) were significantly different between different age groups. Differences in hair count parameters were recognized between different ethnic groups. Parameters of hair density established in the Taiwanese population will provide clinicians with useful reference data for the evaluation of hair disorders in Asians.

TH2 cytokines increase kallikrein 7 expression and function in patients with atopic dermatitis

Here we report that Th2 cytokines increase kallikrein 7 expression and function in keratinocytes. Our finding describes a link between the Th2 environment and epidermal barrier dysfunction in atopic dermatitis.

The cutting (w)edge--comparative evaluation of renal baseline biopsies obtained by two different methods

The assessment of donor-derived damage of transplanted kidneys might be instrumental for estimating donor organ quality and for predicting short- and long-term organ outcome. In the present study, we report a new standardized method for obtaining pre-transplant kidney biopsy specimens. Instead of taking wedge biopsies (WBs), a skin punch biopsy (PB) tool was utilized to obtain standardized biopsy samples that also represented deeper cortical zones. We compared 147 PB specimens and 114 WBs with respect to the number of glomeruli and arterial vessels they contained. The performance of the two biopsy methods in detecting glomerular damage, interstitial fibrosis/tubular atrophy (IF/TA) and arteriosclerosis was determined by evaluation of subsequent transplant core biopsies of the patients. Statistical comparison employed Kruskal-Wallis and kappa (κ) tests. Significantly more PB samples (89%) than WBs (66%) were diagnostically adequate according to the Banff criteria. Despite a higher number of glomeruli in WBs (34.6 versus 21.7 in punch biopsies), arteries were present in only 68% of WBs but could be found in 93% of punch biopsies. The comparison of findings in pre-transplant biopsies with lesions in corresponding post-transplant core biopsies revealed a superior diagnostic concordance for IF/TA and arteriosclerosis for punch biopsies than for WBs, reaching kappa values of 0.823 versus 0.729 and 0.661 versus 0.516, respectively. The use of skin PB tools for obtaining baseline biopsies from transplanted kidneys is a safe and effective method for assessment of donor-derived damage of the organ.

Pruritic erythematous papules on an actinically damaged scalp

An 88-year-old man presents with a 3-year history of pruritus on his actinically damaged scalp, treated unsuccessfully with triamcinolone cream. The physical examination reveals shiny, nonindurated, nonscaly erythema on the scalp with barely palpable papules scattered throughout (Fig 1). A punch biopsy specimen and pathologic examination of one of the papules reveals a deep, diffuse, atypical CD20+/CD79a+/bcl-2+ lymphoid infiltrate with a Grenz zone (Fig 2). Positron emission tomography suggests a focus of activity in the bilateral pulmonary hila (Fig 3).

Erosive plaques on the dorsal surfaces of the hands

From Yo D M Fund Conf Repr D An otherwise healthy 58-year-old woman presents with a 10-day history of ulcers on the dorsal surfaces of both hands. The initial lesion, an expanding pustule, became bullous and erosive. She subsequently developed large bullous hemorrhagic plaques on both forearms. The patient denies systemic symptoms, oral or genital ulcers, sick contacts, recent travel, contact with chemicals, or new medications. The physical examination reveals large eroded exophytic erythematous plaques with overlying bullae on the dorsal surfaces of her hands and forearms (Fig 1). An outside punch biopsy specimen is obtained and reveals a diffuse neutrophilic infiltrate throughout the dermis with focal vasculitis. Stains for fungi and bacteria are negative. A repeat biopsy is performed (Fig 2). Based on clinical and histopathologic findings, the patient is diagnosed with neutrophilic dermatosis of the dorsal hands (NDDH), a rare entity included in a spectrum of conditions known as neutrophilic dermatoses (characterized by a predominantly neutrophilic inflammatory infiltrate). NDDH classically presents acutely as violaceous indurated plaques on the dorsal radial surfaces of the hands.

Blistering Mucosal Eruption in a Young Woman With Systemic Lupus Erythematosus —Quiz Case

A 32-year-old female smoker presented with a 3-day history of painful ulceration and cracking of her lips (Figure 1). Her medical history included a 12-year history of systemic lupus erythematosus (SLE), well controlled by treatment with 200 mg/d of hydroxychloroquineand5mg/dofprednisone. Shepracticedconscientious sun protection with a hat and broad-spectrum sunscreen. She denied the use of new topical products. Physical examination revealed numerous confluent erosions of the upper and lower lips, with overlying serosanguineous crust, clustered near the vermillion border. In the oral cavity, there were erosions of the labial and buccal mucosa, with sparing of the gingival mucosa. Two 2-mm punch biopsy specimens were obtained: one from the upper lip for hematoxylin-eosin staining, the other from the lower lip for direct immunofluorescence microscopy (Figure 2 and Figure 3). What is your diagnosis?

Dusky Red Swelling of the Penis in Association with Fever and Diarrhoea: A Quiz

A 22-year-old man presented with a 4-week history of painless, persistent swelling of the penis, accompanied by fever, recurrent diarrhoea, weight loss, and increased erythrocyte sedimentation rate (ESR). The patient’s family and medical history were unremarkable; he denied taking any medications in the months prior to onset of symptoms, or ever self-injecting foreign substances in the genital area. A 10-day course of cephalexin had been ineffective. Physical examination revealed diffuse, non-pitting induration of the shaft and dusky erythema of overlying skin (Fig. 1A); the scrotum and inguinal folds were uninvolved. Neither additional changes of skin or mucosae, nor inguinal lymphadenopathy could be seen. A 4-mm punch biopsy specimen was obtained from the base of the penis and sent for histopathological analysis (Fig. 1B, 1C).

Trucut biopsy - An effective diagnostic tool in laryngeal and hypopharyngeal cancers: A preliminary study

Background: Laryngeal and hypopharyngeal cancers are commonly diagnosed by histopathological examination of a punch biopsy specimen from the lesion. The histopathological report of the punch biopsy specimen in certain cases is inconclusive, most commonly in cases of endophytic growths. Objective: To evaluate the efficacy of trucut biopsy as a diagnostic procedure in such cases of laryngeal and hypopharyngeal growth which are clinically malignant but histopathology report by punch biopsy is inconclusive. Materials and Methods: Seven cases with clinical suspicion of laryngeal or hypopharyngeal malignancies but with inconclusive histopathological examination on punch biopsy were included. Trucut biopsy was performed in them. 6 out of the 7 trucut biopsies were found to be malignancies on histopathological examination. Conclusion: Trucut biopsy is promising diagnostic tool in laryngeal and hypopharyngeal malignancies especially in those cases where there is strong suspicion of malignancy and the punch biopsy does is inconclusive.

A Rare Cause of Acquired Telangiectases Extending From the Feet to Arms —Quiz Case

A 65-year-old woman presented with a several-day history of tender necrotic lesions on her extremities. The lesions were preceded by erythema of her right great toe that did not respond to -lactam antibiotic therapy for presumed staphylococcal paronychia. Her medical history was remarkable for aplastic anemia status post induction therapy with antithymocyte globulin, methylprednisolone, and cyclosporine. Physical examination revealed multiple erythematous, edematous nodules with central necrotic eschars on the patient’s extremities; the largest one, measuring 3.5 cm, was located on her right wrist (Figure 1). Also, there was periungual erythema with associated vesiculation on her right great toe (Figure 2). Laboratory studies at the time of evaluation were notable for a white blood cell count of 1400/μL, with an absolute neutrophil count of 700/μL (to convert values to 10/L, multiply by 0.001). A punch biopsy specimen was obtained from the lesion on the right thigh (Figure 3) for histologic evaluation and culture studies. What is your diagnosis?

Solitary mastocytoma in an adult with an unusual clinical presentation

To the Editor: A 30-year-old woman presented with a 10-year history of headaches, flushing, and anaphylaxis triggered by exercise, stress, heat, or scalp friction. Recently, she noticed a poorly circumscribed scalp mass. Computed tomography imaging confirmed a 3.3- × 1.5-cm subcutaneous mass, without bone involvement. The mass fluctuated in size (up to 10 cm), and episodes of anaphylaxis occurred with manipulation. Interestingly, the patient experienced no flushing or anaphylaxis while pregnant, but her symptoms returned after delivery. A punch biopsy specimen of the skin obtained from the edge of the tumor showed subtle histopathologic changes with a mild perivascular, perifollicular lymphocytic infiltrate and scattered mast cells (Fig 1). Surgical resection was performed and revealed a scalp mass with lobulated appearance. Histopathologically the tumor was composed of a dense monomorphous population of mast cells, with abundant granular cytoplasm; positive Giemsa and tryptase stains confirmed the diagnosis of mastocytoma (Fig 2). Postoperatively, the patient made a complete recovery and had no further symptoms at 27 months’ follow-up.Fig 2A and B, Intraoperative photographs of the solitary mastocytoma in vivo and after surgical resection. C and D, Hematoxylin-eosin sections showing dense population of mast cells with round nuclei, bland chromatin, and abundant granular cytoplasm. D (insert), There is diffuse immunoreactivity to mast cell tryptase.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Solitary mastocytoma is primarily a disease of young children, with adult cases rarely reported.1Pandhi D. Singal A. Aggarwal S. Adult onset, hypopigmented solitary mastocytoma: report of two cases.Indian J Dermatol Venereol Leprol. 2008; 74: 41-43Crossref PubMed Scopus (2) Google Scholar Lesions are typically cutaneous, involving the extremities, face, scalp, and trunk. Cutaneous mastocytomas may be associated with systemic disease, but up to 15% of patients with a mast cell disorder may develop a solitary mastocytoma without systemic involvement.2Castells M.C. Extracutaneous mastocytoma.J Allergy Clin Immunol. 2006; 117: 1513-1515Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar In our case, a diagnosis of concurrent systemic mastocytosis was suspected, but not confirmed. The bone marrow biopsy specimen showed few clusters of mast cells (>15 cells). The serum tryptase level ranged from 11 to 14 ng/mL; therefore, under the World Health Organization (WHO) threshold of 20 ng/mL. Thus, by WHO criteria, one major criterion was met (clusters of >15 mast cells), but no minor criteria were satisfied for the diagnosis of systemic mastocytosis.3Valent P. Horny H.P. Li C.Y. Longley J.B. Metcalfe D.D. Parwaresch R.M. et al.Mastocytosis.in: Jaffe E.S. Harris N.L. Stein H. Vardiman J.W. World Health Organization Classification of Tumors: Tumours of the Haematopoietic and Lymphoid Tissues. IARC Press, Lyon, France2001: 291-300Google Scholar Molecular studies showed no D816V mutation in the KIT gene and no evidence of the FEP1L1-PDGFRA fusion transcript. Adult-onset mastocytoma has a less favorable rate of spontaneous resolution compared with the childhood lesions, and surgical excision may be necessary.1Pandhi D. Singal A. Aggarwal S. Adult onset, hypopigmented solitary mastocytoma: report of two cases.Indian J Dermatol Venereol Leprol. 2008; 74: 41-43Crossref PubMed Scopus (2) Google Scholar Preoperative collaboration with the anesthesiology team is important to avoid hemodynamic instability during surgical manipulation. Our patient was premedicated with oral cetirizine. It is noteworthy that in this case the tumor became evident only years after the onset of nonspecific clinical symptoms. The initial histopathologic changes were very subtle, offering only a hint of what would later be seen in the surgical specimen. This fact may be explained by the superficial nature of the biopsy and illustrates the necessity of close follow-up and clinical-pathologic correlation when similar findings are encountered on the biopsy specimen. Interestingly, the patient had a complete lack of symptoms during pregnancy, with symptoms returning postpartum. To our knowledge, this is the first report of concurrent solitary mastocytoma and pregnancy, with complete control of mastocytoma-related symptoms during pregnancy. It has been previously reported that pregnancy may worsen the symptoms of mastocytosis.4Donahue J.G. Lupton J.B. Golichowski A.M. Cutaneous mastocytosis complicating pregnancy.Obstet Gynecol. 1995; 85: 813-815Crossref PubMed Scopus (19) Google Scholar, 5Worobec A.S. Akin C. Scott L.M. Metcalfe D.D. Mastocytosis complicating pregnancy.Obstet Gynecol. 2000; 95: 391-395Crossref PubMed Scopus (37) Google Scholar

Features of Plexiform Fibrohistiocytic Tumor in Skin Punch Biopsies: A Retrospective Study of 6 Cases

Plexiform fibrohistiocytic tumor (PFHT) is a mesenchymal neoplasm of intermediate malignant potential, which typically presents as a dermal or subcutaneous nodule, and is therefore often sampled by skin punch biopsy where diagnostic features may be subtle or absent. We retrospectively analyzed a series of 6 cases of PFHT to highlight for dermatopathologists the features of PFHTs useful to distinguish it from the other entities in the differential diagnosis. On the basis of the proportion of spindled fibroblastic cells to histiocytoid nodules in the biopsy specimen, we divided PFHT into 3 histologic variants: cellular, fibrous, and mixed. The biopsies also were compared with the final resection specimens, in an attempt to determine which histologic features in the original biopsies were most helpful in establishing a diagnosis. Clinical follow-up and immunohistochemistry were performed on all cases. The cellular and mixed variants were a lesser diagnostic challenge inasmuch as the distinctive features were more easily identifiable in small punch biopsy specimens. The fibrous variant proved more difficult to diagnose. Features most helpful in the diagnosis of PFHT were biphasic appearance with small, cellular, histiocytoid aggregates and accompanying plump spindled cells in the deep dermis and subcutis. Negative staining for CD34, NK1/C3, factor XIIIa, and beta-catenin by immunohistochemistry proved useful in excluding some of its mimics.

Accuracy of biopsy sampling for subtyping basal cell carcinoma

Basal cell carcinoma (BCC) is a common skin cancer for which the treatment and recurrence risk correlate with the histologic subtype. Limited information is available regarding the accuracy of biopsy in diagnosing BCC subtypes. We sought to determine the correlation between BCC subtypes present in a biopsy specimen and the actual subtypes present in a tumor. In this retrospective study, skin biopsy specimens and corresponding excisions were reviewed. All histologic subtypes present in the biopsy specimen were reported and compared with the composite BCC subtype present in the biopsy specimen and excision. A total of 232 biopsy specimens and corresponding wide excisions were examined. The biopsy specimen accuracy rate was 82% for punch and shave biopsy specimens. Mixed histologic subtypes were seen in 54% of the cases, half of which contained an aggressive subtype (infiltrative, morpheaform, or micronodular). There was an 18% discordance rate between the biopsy specimen subtype and the composite subtype. Importantly, 40% of these discordant cases (7% of all cases examined) had an aggressive subtype that was not sampled in the initial biopsy specimen. Furthermore, some cases were misidentified as infiltrative subtype in the biopsy specimen as a result of misinterpretation of surface ulceration and reactive stromal changes. The limited number of punch biopsy specimens and the fact that Mohs excisions were not included are limitations. Punch and shave biopsy specimens provided adequate sampling for correct BCC subtyping in 82% of the cases examined. However, 18% of the biopsy specimens were misidentified, some of which missed an aggressive component. Thus, there are potential pitfalls in the identification of BCC subtypes in biopsy specimens, which may have important implications in treatment outcome.

A case of hemorrhagic colitis after influenza A infection

The pandemic (H1N1) influenza virus continues to be the predominant circulating virus in both the northern and southern hemispheres. In February 2009, during the early stage of the worldwide H1N1 influenza virus (influenza A) pandemic, we experienced a case of hemorrhagic colitis after infection with influenza A. A 21-year-old man with no serious disease in his past history visited our hospital with chief complaints of a high body temperature and pharyngeal pain. A diagnosis of influenza A was made using a rapid diagnosis kit (Capilia Flu A+B), and the patient was admitted to our hospital. After admission, the patient complained of a lower abdominal pain, diarrhea, and hematochezia. An emergency colonoscopy revealed active bleeding colitis from the sigmoid to descending colon. Hemorrhagic colitis was confirmed by the pathological findings of a punch biopsy specimen. After the administration of an antiviral drug, zanamivir hydrate (10 mg/d), the patient's general condition and colonoscopic findings improved significantly. The findings of both sequential colonoscopies and intestinal histology strongly suggested that infection with influenza A could induce hemorrhagic colitis, though the incidence is quite low.

Regression of CD30+ cutaneous anaplastic large-cell lymphoma with denileukin diftitox

To the Editor: A 46-year-old woman presented with rapid development of ulcerating nodules on her right leg during the 3 months before presentation (Fig 1, A). A punch biopsy specimen of one of two 2-cm nodules revealed dense nodular infiltrates of atypical mononuclear cells with pleomorphic nuclei and moderate pink cytoplasm in the mid and deep reticular dermis (Fig 2, A). Mitotic figures and necrotic cells were scattered throughout the lesion. These atypical cells stained positively for CD30 (Fig 2, B) and CD3, but negatively for CD20, S-100, CD1a, and anaplastic lymphoma kinase.