Faculty Bibliography

Background/UNASSIGNED:Two primary histologic subtypes, superficial spreading melanoma (SSM) and nodular melanoma (NM), comprise the majority of all cutaneous melanomas. NM is associated with worse outcomes, which have been attributed to increased thickness at presentation, and it is widely expected that NM and SSM would exhibit similar behavior once metastasized. Herein, we tested the hypothesis that primary histologic subtype is an independent predictor of survival and may impact response to treatment in the metastatic setting. Methods/UNASSIGNED:We examined the most recent Surveillance, Epidemiology, and End Results (SEER) cohort (n = 118 508) and the New York University (NYU) cohort (n = 1621) with available protocol-driven follow-up. Outcomes specified by primary histology were studied in both the primary and metastatic settings with respect to BRAF-targeted therapy and immunotherapy. We characterized known driver mutations and examined a 140-gene panel in a subset of NM and SSM cases using next-generation sequencing. All statistical tests were two-sided. Results/UNASSIGNED:NM was an independent risk factor for death in both the SEER (hazard ratio [HR] = 1.55, 95% confidence interval [CI] = 1.41 to 1.70, P < .001) and NYU (HR = 1.47, 95% CI = 1.05, 2.07, P = .03) cohorts, controlling for thickness, ulceration, stage, and other variables. In the metastatic setting, NM remained an independent risk factor for death upon treatment with BRAF-targeted therapy (HR = 3.33, 95% CI = 1.06 to 10.47, P = .04) but showed no statistically significant difference with immune checkpoint inhibition. NM was associated with a higher rate of NRAS mutation (P < .001), and high-throughput sequencing revealed NM-specific genomic alterations in NOTCH4, ANK3, and ZNF560, which were independently validated. Conclusions/UNASSIGNED:Our data reveal distinct clinical and biological differences between NM and SSM that support revisiting the prognostic and predictive impact of primary histology subtype in the management of cutaneous melanoma.

We present a case of necrobiosis lipoidica (NL) of the right abdomen in a 75-year-old man. A skin biopsy performed showed a layered infiltrate of mono and multinucleated histiocytes palisaded around degenerated collagen bundles. Laboratory workup was unremarkable. The patient was treated with topical corticosteroids with cessation of progression of his disease, although the eruption did not resolve. There are a number of treatments for NL reported in the literature, all with varying efficacy. Although NL lesions are usually asymptomatic, patients with NL must be monitored closely for signs of ulceration or malignant transformation, in which case more aggressive treatment options may be warranted.

Fibroadenoma of the breast is the most common benign breast condition found in up to 33% of women aged 35-50. Clinically, these are firm, mobile growths within the breast measuring 1-2 cm. The differential diagnosis include cysts, tubular adenoma and phyllodes tumors. The American College of Obstetricians and Gynecologists (ACOG) notes that fibroadenoma of the breast is associated with an elevated risk factor of 1.76 for future breast cancer. The clinician can differentiate between these growths using mammography and ultrasound. Therapy is based upon the findings of this work up. We present a 31-year-old woman with a new painful growth in the left axilla for several months. She had a history of cysts and methicillin sensitive S. aureus infections; past medical and family history were noncontributory. Physical examination of the left axilla revealed a subcutaneous tumor that was soft, mobile, tender and measured 5 x 5 cm. A punch biopsy taken featured neoplastic mature adipocytes consistent with the diagnosis of lipoma. Given the discomfort of the lesion, she opted for excision. We excised the tumor without complication. Microscopic examination revealed a relatively well circumscribed neoplasm comprised of discrete aggregates of glandular spaces lined by cuboidal cells with round uniform nuclei with peripheral myoepithelial cells within the deep dermis. The glands were set within a fibromyxoid stroma with surrounding fibrosis. These findings were consistent with the diagnosis of fibroadenoma of ectopic breast tissue. This discrepancy in diagnosis may be due to the limited depth of the specimen from the initial punch biopsy. Breast tissue is not strictly localized to the pectoral space and can appear anywhere along "milk lines" spanning from the axilla to the groin. These ectopic breast tissues are susceptible to the same neoplastic processes that affect normally distributed breast tissue and can mimic conditions such as lymphadenopathy or as in our case, a lipoma. In one case, a fibroadenoma of breast tissue was found in the vulva. Although a handful of cases exist in literature, this case underscores the importance of including ectopic breast tissue disorders in the differential diagnosis when evaluating new axillary growths in women. Furthermore, this case shows the inherent limitation of punch biopsies and the need for subsequent microscopic examination status post complete excision of suspicious lesions.
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We present a 57 year-old man presented with generalized hyperhidrosis and widespread, smooth, flesh colored papules on the torso and extremities.Histological examination from multiple biopsies demonstrated morphologic alteration of the eccrine glands with an apocrine phenotype, suggesting eitherapocrine metaplasia or the presence of "apoeccrine glands." The morphologic similarities between eccrine, apocrine, and apoeccrine as they relate to ourpatient's histologic findings are discussed. We consider secondary causes of generalized hyperhidrosis, which may also play a role in this patient's presentation. Treatment and further workup are discussed, whilemanagement of this patient remains in progress.

Anetoderma is a rare benign elastolytic disorder that is characterized by focal loss of elastin fibers on histopathology and is often recalcitrant to treatment. We present a case of a patient with a 20-year history of pruritic and painful hyperpigmented atrophic papules clustered on the neck, axillae, inframammary folds, and right medial thigh. Although the histopathologyof her axillary lesions was consistent with anetoderma, her clinical presentation is unusual given the extent of involvement, reported pain and pruritus, and sharp demarcation of the distribution. The diagnosticuncertainty of this case led to added difficulty in management of a disease that is already notoriously difficult to treat and may significantly impact patient's quality of life.