J Cutan Pathol 2010: 37: 1108–1109

John Wiley & Sons. Printed in Singapore

Copyright © 2010 John Wiley & Sons A/S

Journal ofCutaneous Pathology

Letter to the Editor

Anatomic variability in superficialblood vessel and lymphaticvessel densityTo the Editor,

It has been difficult to study lymphatic vessels untilthe development of newer specific markers for lym-phatic endothelium. D2-40, a monoclonal antibodyto podoplanin, is a relatively specific immunohisto-chemical marker that can identify lymphatic vesselsin paraffin sections.1 Many studies have been pub-lished in dermatology, particularly in the melanomaliterature, correlating increased lymphatic densityand lymphanigiogenesis with metastatic spread anda poorer prognosis of these tumors.2,3 These stud-ies have looked at outcomes based on intratumoraland peritumoral lymphatic density in comparisonwith other matched melanocytic tumors. However,a study establishing baseline superficial cutaneouslymphatic density with the D2-40 antibody is lacking.

The aim of our study was to carry out acomparative analysis of the investiture of blood andlymphatic vessels in the superficial cutaneous tissueof the scalp, torso, and upper extremities. Approvalfor the study was granted by the institutional reviewboard at the University of Utah. We performed6 mm punch biopsies from standardized sites on thescalp, chest, and upper extremity of 10 cadavers.All samples came from patients with fair skin, ninewere male, and the age ranged from 19 to 68 years.Immunoperoxidase staining to CD-31 (1 : 100dilution, Dako, Capenteria, CA, USA) and D2-40 (1 : 500 dilution, Signet, Cambridge, MA, USA)was performed (Fig. 1) with appropriate positive andnegative controls. Gross counts of both anti-CD31and anti-D2-40 positive vessels were performed andtotal area of the dermis and available subcutis wascalculated for each specimen (Olympus DP2-BSW,Version 1.4, 2006, Olympus America, Centre Valley,PA, USA). The vessel counts and area calculationswere performed by a single blinded observer (KLD).

On the scalp, arm, and torso the average numberof CD31 positive vessels per mm2 were 6.74(SD ± 2.61), 4.32 (SD ± 1.54), and 3.10 (SD ± 0.94)

A

B

Fig. 1. Immunohistochemical sections of the same representativearea in the scalp specimen of patient 3. A) Anti-CD31 (Dako,Carpenteria, CA) highlighting all vascular endothelium and B) antiD2-40 (Signet, Cambridge, MA) highlighting lymphatic endothelium(100× magnification).

respectively. On the scalp, arm, and torso the averagenumber of D2-40 positive vessels per mm2 were2.10 (SD ± 0.88), 1.44 (SD ± 0.79), and 1.24 (SD ±0.64) respectively (Fig. 2). There was a statisticallysignificant difference in the numbers of both CD31

1108

Letter to the Editor

Fig. 2. Chart representing mean density (vessels/mm2) of anti-CD31 and D2-40 labeling in the scalp, upper extremity, and torso. Differencein scalp density of both CD31 and D2-40 positive vessels reached statistical significance in regard to both extremity and torso (∗p < 0.0001and p = 0.0008). ∗∗This difference was not significant in regard to density of vessels between extremity and torso for CD31 or D2-40 density.

and D2-40 vessel densities between the scalp andboth upper extremity and torso biopsies, p < 0.0001and p = 0.0008 respectively. The difference inthe density of CD31 and D2-40 positive vesselsbetween the arm and torso biopsies did notreach statistical significance, p = 0.57 and 0.19respectively. Additional information regarding theeffect of hair density on the scalp was also addressed.For both CD31 and D2-40 densities, there was asignificant difference between hair bearing (n = 4)and bald (n = 6) patients, 7.5 vs. 5.0 mm−2 for CD31(p = 0.023) and 2.4 vs. 1.3 mm−2 for D2-40 (p =0.004). Age had no effect on CD 31 or D2-40 density.

We have shown in the standardized tissue fromthe scalp, torso, and upper extremity that there isa significant difference in both the density of allsuperficial vessels, as well as lymphatic vessels in thescalp. This baseline anatomic difference may be animportant factor in determining the metastatic poten-tial and locoregional spread of primary cutanaeoustumors, such as cutaneous squamous cell carcinomaand melanoma. Specifically, this question should beaddressed with respect to scalp melanoma, whichhas been shown to have a worse prognosis thantheir counterparts in well-controlled epidemiologicstudies.4 Further investigation will be needed to

determine if this anatomic difference is significant incontributing to hematogenous or lymphatic spreadof scalp tumors.

Keith Duffy1, Mark A. Hyde2, Brad Tanner2, David Goldgar1,

Anneli Ririe Bowen1, Scott R. Florell1 and Glen M. Bowen2

1Department of Dermatology, University of Utah, SaltLake City, 84132 UT, USA and

2Department of Dermatology, Huntsman CancerInstitute, Salt Lake City,

UT, USAe-mail: klxduffy@gmail.com

References1. Ordonez NG. Podoplanin: a novel diagnostic immunohisto-

chemical marker. Adv Anat Pathol 2006; 13: 83.2. Dadras SS, Lange-Asschenfeldt B, Velasco P, et al. Tumor

lymphangiogenesis predicts melanoma metastasis to sentinellymph nodes. Mod Pathol 2005; 18: 1232.

3. Massi D, Puig S, Franchi A, et al.Tumour lymphangiogenesis isa possible predictor of sentinel lymph node status in cutaneousmelanoma: a case-control study. J Clin Pathol 2006; 59: 166.

4. Lachiewicz AM, Berwick M, Wiggins CL, Thomas NE. Survivaldifferences between patients with scalp or neck melanomaand those with melanoma of other sites in the Surveillance,Epidemiology, and End Results (SEER) program. Arch Dermatol2008; 144: 515.

1109