2020年 · 第133卷第17期

The recent coronavirus disease 2019 (COVID-19) pandemic has completely disrupted hospital and outpatient activities.^[1,2]It has been reorganized to allow a lower inflow of patients, to reduce non-urgent out-patient visits and to concentrate public health forces in the fight against the COVID-19 outbreak. In this reorganization, dermatology departments have also adapted their activities suspending routine patient visits and providing only urgent surgical removal, urgent visits, consultations, and oncological examinations.

Youzhi artificial intelligence (AI) software is the AI-assisted decision-making system for diagnosing skin tumors. The high diagnostic accuracy of Youzhi AI software was previously validated in specific datasets. The objective of this study was to compare the performance of diagnostic capacity between Youzhi AI software and dermatologists in real-world clinical settings.

A total of 106 patients who underwent skin tumor resection in the Dermatology Department of China-Japan Friendship Hospital from July 2017 to June 2019 and were confirmed as skin tumors by pathological biopsy were selected. Dermoscopy and clinical images of 106 patients were diagnosed by Youzhi AI software and dermatologists at different dermoscopy diagnostic levels. The primary outcome was to compare the diagnostic accuracy of the Youzhi AI software with that of dermatologists and that measured in the laboratory using specific data sets. The secondary results included the sensitivity, specificity, positive predictive value, negative predictive value, F-measure, and Matthews correlation coefficient of Youzhi AI software in the real-world.

The diagnostic accuracy of Youzhi AI software in real-world clinical settings was lower than that of the laboratory data (P < 0.001). The output result of Youzhi AI software has good stability after several tests. Youzhi AI software diagnosed benign and malignant diseases by recognizing dermoscopic images and diagnosed disease types with higher diagnostic accuracy than by recognizing clinical images (P = 0.008, P = 0.016, respectively). Compared with dermatologists, Youzhi AI software was more accurate in the diagnosis of skin tumor types through the recognition of dermoscopic images (P = 0.01). By evaluating the diagnostic performance of dermatologists under different modes, the diagnostic accuracy of dermatologists in diagnosing disease types by matching dermoscopic and clinical images was significantly higher than that by identifying dermoscopic and clinical images in random sequence (P = 0.022). The diagnostic accuracy of dermatologists in the diagnosis of benign and malignant diseases by recognizing dermoscopic images was significantly higher than that by recognizing clinical images (P = 0.010).

The diagnostic accuracy of Youzhi AI software for skin tumors in real-world clinical settings was not as high as that of using special data sets in the laboratory. However, there was no significant difference between the diagnostic capacity of Youzhi AI software and the average diagnostic capacity of dermatologists. It can provide assistant diagnostic decisions for dermatologists in the current state.

Diagnoses of Skin diseases are frequently delayed in China due to lack of dermatologists. A deep learning-based diagnosis supporting system can facilitate pre-screening patients to prioritize dermatologists’ efforts. We aimed to evaluate the classification sensitivity and specificity of deep learning models to classify skin tumors and psoriasis for Chinese population with a modest number of dermoscopic images.

We developed a convolutional neural network (CNN) based on two datasets from a consecutive series of patients who underwent the dermoscopy in the clinic of the Department of Dermatology, Peking Union Medical College Hospital, between 2016 and 2018, prospectively. In order to evaluate the feasibility of the algorithm, we used two datasets. Dataset I consisted of 7192 dermoscopic images for a multi-class model to differentiate three most common skin tumors and other diseases. Dataset II consisted of 3115 dermoscopic images for a two-class model to classify psoriasis from other inflammatory diseases. We compared the performance of CNN with 164 dermatologists in a reader study with 130 dermoscopic images. The experts’ consensus was used as the reference standard except for the cases of basal cell carcinoma (BCC), which were all confirmed by histopathology.

The accuracies of multi-class and two-class models were 81.49% ± 0.88% and 77.02% ± 1.81%, respectively. In the reader study, for the multi-class tasks, the diagnosis sensitivity and specificity of 164 dermatologists were 0.770 and 0.962 for BCC, 0.807 and 0.897 for melanocytic nevus, 0.624 and 0.976 for seborrheic keratosis, 0.939 and 0.875 for the "others" group, respectively; the diagnosis sensitivity and specificity of multi-class CNN were 0.800 and 1.000 for BCC, 0.800 and 0.840 for melanocytic nevus, 0.850 and 0.940 for seborrheic keratosis, 0.750 and 0.940 for the "others" group, respectively. For the two-class tasks, the sensitivity and specificity of dermatologists and CNN for classifying psoriasis were 0.872 and 0.838, 1.000 and 0.605, respectively. Both the dermatologists and CNN achieved at least moderate consistency with the reference standard, and there was no significant difference in Kappa coefficients between them (P > 0.05).

The performance of CNN developed with relatively modest number of dermoscopic images of skin tumors and psoriasis for Chinese population is comparable with 164 dermatologists. These two models could be used for screening in patients suspected with skin tumors and psoriasis respectively in primary care hospital.

Long non-coding RNAs (lncRNAs) play key roles in human cancers. In our previous study, we demonstrated that lncRNA FKBP prolyl isomerase 9 pseudogene 1 (FKBP9P1) was highly expressed in head and neck squamous cell cancer (HNSCC) tissues. However, its functional significance remains poorly understood. In the present study, we identify the role and potential molecular biologic mechanisms of FKBP9P1 in HNSCC.

Quantitative real-time polymerase chain reaction was used to detect the expression of FKBP9P1 in HNSCC tissues, matched adjacent normal tissues, human HNSCC cells (FaDu, Cal-27, SCC4, and SCC9), and human immortalized keratinocytes cell HaCaT (normal control). Cal-27 and SCC9 cells were transfected with sh-FKBP9P1-1, sh-FKBP9P1-2, and normal control (sh-NC) lentivirus. Cell counting kit-8 assay, colony formation assay, wound healing assay, and trans-well assay were used to explore the biologic function of FKBP9P1 in HNSCC cells. Furthermore, western blotting was used to determine the mechanism of FKBP9P1 in HNSCC progression. Chi-squared test was performed to assess the clinical significance among FKBP9P1 high-expression and low-expression groups. Survival analyses were performed using the Kaplan-Meier method and assessed using the log-rank test. The comparison between two groups was analyzed by Student t test, and comparisons among multiple samples were performed by one-way analysis of variance and a Bonferroni post hoc test.

FKBP9P1 expression was significantly up-regulated in HNSCC tissues (tumor vs. normal, 1.914 vs. 0.957, t = 7.746, P < 0.001) and cell lines (P < 0.01 in all HNSCC cell lines). Besides, the median FKBP9P1 expression of HNSCC tissues (1.677) was considered as the threshold. High FKBP9P1 level was correlated with advanced T stage (P = 0.022), advanced N stage (P = 0.036), advanced clinical stage (P = 0.018), and poor prognosis of HNSCC patients (overall survival, P = 0.002 and disease-free survival, P < 0.001). Knockdown of FKBP9P1 led to marked repression in proliferation, migration, and invasion of HNSCC cells in vitro (P all < 0.01). Mechanistically, silencing FKBP9P1 was observed to restrain the PI3K/AKT signaling pathway.

Silencing lncRNA FKBP9P1 represses HNSCC progression and inhibits PI3K/AKT (phosphatidylinositol 3 kinase/AKT Serine/Threonine Kinase) signaling in vitro. Therefore, FKBP9P1 could be a potential new target for the diagnosis and treatment of HNSCC patients.

The classification criteria and staging groups for nasopharyngeal carcinoma described in the Union for International Cancer Control/American Joint Committee on Cancer (UICC/AJCC) staging system have been revised over time. This study assessed the proportion of patients whose staging and treatment strategy have changed due to revisions of the UICC/AJCC staging system over the past 10 years (ie, from the sixth edition to the eighth edition), to provide information for further refinement.

We retrospectively reviewed 1901 patients with non-metastatic nasopharyngeal carcinoma treated in our cancer center between November 2009 and June 2012. The Akaike information criterion and Harrell concordance index were applied to evaluate the performance of the staging system.

In total, 25 (1.3%) of the 1901 patients who were staged as T2a according to the sixth edition system were downgraded to T1 in the eighth edition; 430 (22.6%) staged as N0 in the sixth edition were upgraded to N1 in the eighth edition; 106 (5.6%) staged as N1/2 in the sixth edition were upgraded to N3 in the eighth edition. In addition, 51 (2.7%) and 25 (1.3%) of the study population were upstaged from stage I to stage II and stage II to stage IVa, respectively; 10 (0.5%) was downgraded from stage II to stage I. The survival curves of adjacent N categories and staging groups defined by eighth classification system were well-separated. However, there was no significant difference in the locoregional failure-free survival (P = 0.730) and disease-free survival (P = 0.690) rates between the T2 and T3 categories in the eighth edition classification system.

Modifications to the tumor-node-metastasis staging system over the past 10 years have resulted in N classification changes in numerous cases. Although the eighth edition tumor-node-metastasis staging system better predicts survival outcomes, the T classification could be simplified in future revisions.

Ectopic pregnancy (EP) is a common complication in women undergoing assisted reproductive treatment, but the underlying causes for this remain unclear. This study aimed to explore factors affecting the incidence of EP in in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).

This was a retrospective study on the incidence of EP in IVF/ICSI cycles between January 1, 2013 and December 31, 2017. Patient age, infertility diagnosis (tubal factor or not), primary or secondary infertility, type of cycle (frozen-thawed or fresh), type of embryo(s) transferred (cleavage embryo or blastocyst), number of embryos transferred (one, two, or three), previous history of EP, and endometrial combined thickness were analyzed to explore their relationships with the incidence of EP. Based on clinical typing results, the patients were divided into an EP group or a non-EP group. Categorical variables were analyzed using Chi-squared test or Fisher exact test. Logistic regression analysis was performed to explore their associations with the incidence of EP.

The percentage of patients with primary infertility in EP group was significantly lower than that in non-EP group (31.3% vs. 46.7%, χ² = 26.032, P < 0.001). The percentage of patients with tubal infertility in EP group was also significantly higher than that in non-EP group (89.2% vs. 63.6%, χ² = 77.410, P < 0.001). The percentages of patients with transfer of cleavage-stage embryo or blastocyst (91.4% vs. 84.4%, χ² = 10.132, P = 0.001) and different endometrial combined thickness (ECT) (χ² = 18.373, P < 0.001) differed significantly between EP and non-EP groups. For patients who had a previous history of one to four EPs, the percentage of patients undergoing transfer of a cleavage-stage embryo was significantly higher in EP group than that in non-EP group (92.2% vs. 77.6%, χ² = 13.737, P < 0.001). In multivariate logistic regression analysis, tubal infertility was strongly associated with EP (adjusted odds ratio: 3.995, 95% confidence interval: 2.706-5.897, P < 0.001).

In IVF/ICSI cycles, transfer of a blastocyst-stage embryo, especially for patients with a previous history of EP, reduced the rate of EP. Tubal infertility was strongly associated with EP.

The effects of oral contrast agents (OCAs) on dosimetry have not been studied in detail. Therefore, this study aimed to examine the influence of OCAs on dose calculation in volumetric-modulated arc therapy plans for rectal cancer.

From 2008 to 2016, computed tomography (CT) images were obtained from 33 rectal cancer patients administered OCA with or without intravenous contrast agent (ICA) and 14 patients who received no contrast agent. CT numbers of organs at risk were recorded and converted to electronic densities. Volumetric-modulated arc therapy plans were designed before and after the original densities were replaced with non-enhanced densities. Doses to the planned target volume (PTV) and organs at risk were compared between the plans.

OCA significantly increased the mean and maximum densities of the bowels, while the effects of ICA on these parameters depended on the blood supply of the organs. With OCA, the actual doses for PTV were significantly higher than planned and doses to the bowel increased significantly although moderately. However, the increase in the volume receiving a high-range doses was substantial (the absolute change of intestine volume receiving ≥52 Gy: 1.46 [0.05-3.99, cubic centimeter range: -6.74 to 128.12], the absolute change of colon volume receiving ≥50 Gy: 0.34 [0.01-1.53 cc, range: -0.08 to 3.80 cc]. Dose changes due to ICA were insignificant. Pearson correlation showed that dose changes were significantly correlated with a high intestinal volume within or near the PTV (ρ > 0.5, P < 0.05) and with the density of enhanced intestine (ρ > 0.3, P < 0.05).

Contrast agents applied in simulation cause underestimation of doses in actual treatment. The overdose due to ICA was slight, while that due to OCA was moderate. The bowel volume receiving ≥50Gy was dramatically increased when OCA within the bowel was absent. Physicians should be aware of these issues if the original plan is barely within clinical tolerance or if a considerable volume of enhanced intestine is within or near the PTV.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Genome-wide association studies in non-Asian population revealed a link between COPD and mutations in the PTCH1 gene encoding Patched1, a receptor in the Hedgehog signaling pathway important for lung morphogenesis and pulmonary function. The aim of this study was to investigate the association between PTCH1 polymorphisms and the COPD risk in the Chinese Han population.

We performed a case-control study including 296 patients with COPD and 300 healthy individuals. Single-nucleotide polymorphisms in the PTCH1 gene were identified and genotyped based on the linkage disequilibrium analysis in all participants. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated using logistic regression analysis after adjustment for age, gender, and smoking.

In total, 28 single-nucleotide polymorphisms were identified in patients with COPD. Among them, "A" allele of rs28491365 (OR: 1.388, 95% CI: 1.055-1.827, P = 0.018), and "G" alleles of rs10512248 (OR: 1.299, 95% CI: 1.021-1.653, P = 0.033) and rs28705285 (OR: 1.359, 95% CI: 1.024-1.803, P = 0.033; respectively) were significantly associated with an increased COPD risk. Genetic model analysis revealed that the "T/T" genotype of rs34695652 was associated with a decreased COPD risk under the recessive model (OR: 0.490, 95% CI: 0.270-0.880, P = 0.010), whereas rs28504650/rs10512248 haplotype CG was significantly associated with an increased COPD risk after adjustment for age, gender, and smoking status (OR: 6.364, 95% CI: 1.220-33.292, P = 0.028).

The study provides a new insight into the role of PTCH1 polymorphisms in the susceptibility to COPD in the Chinese Han population.

Renal cell carcinoma (RCC) has the propensity to lead to venous tumor thrombus (VTT). Nephrectomy with tumor thrombectomy is an effective treatment option but is a technically challenging surgical procedure that is accompanied by a high rate of complications. The aims of this study were to investigate pre-operative imaging parameters for the assessment of inferior vena cava (IVC) wall invasion due to a tumor thrombus in patients with RCC and to identify predictors from the intra-operative findings.

Clinical and imaging data were collected from 110 patients who underwent nephrectomy with IVC tumor thrombectomy (levels I-IV) for RCC and IVC tumor thrombus at the Peking University Third Hospital between May 2015 and March 2018. Univariable and multivariable logistic regression and receiver operating characteristic curves were used to assess the correlations between pre-operative imaging features and intra-operative macroscopic invasions of the IVC wall by tumor thrombus.

Among the 110 patients, 41 underwent partial or segmental resection of IVC. There were univariate associations of pre-operative imaging parameters that could be used to predict the need for IVC resection, including those of the Mayo classification, maximum anterior-posterior (AP) diameter of the renal vein at the renal vein ostium (RVo), maximum AP diameter of the VTT at the RVo and IVC occlusion. For the multivariable analysis, the AP diameter of the VTT at the RVo and IVC occlusion were associated with a significantly increased risk of invasion of the IVC wall by tumor thrombus. The optimum imaging thresholds included an AP diameter of the VTT at the RVo larger than 17.0 mm and the presence of IVC occlusion, with which we predicted invasions of the IVC wall requiring IVC resection. The probabilities of intra-operative IVC resection for patients without both independent factors, with an AP diameter of the VTT at the RVo larger than 17.0 mm, with IVC occlusion, and with both concurrent factors were 5%, 23%, 56%, and 66%, respectively.

An increase in the AP VTT diameter at the RVo and the presence of complete occlusion of the IVC are independent risk factors for a high probability of IVC wall invasion by tumor thrombus.

Circular RNA ciRS-7 has been reported to be involved in the progression of various cancers. However, ciRS-7 expression and its role in clear cell renal cell carcinoma (ccRCC) progression remains unclear. This study aimed to investigate the effect of ciRS-7 expression on ccRCC and the related signaling pathway.

ciRS-7 expression was analyzed using quantitative reverse transcription polymerase chain reaction in 87 pairs of ccRCC and matched adjacent normal tissues. The role of ciRS-7 in ccRCC cell proliferation and invasion was determined using the cell counting kit-8 and invasion assays, respectively. Potential mechanisms underlying the role of ciRS-7 in promoting ccRCC progression were explored by Western blotting. The relationship between the expression of ciRS-7 and features of ccRCC was analyzed by the Chi-square test and progression-free survival was determined using a Kaplan-Meier plot.

ciRS-7 was overexpressed in ccRCC tissues compared with that in matched adjacent normal tissues. In addition, ciRS-7 up-regulation was closely associated with tumor diameter (P = 0.050), clinical stage (P = 0.009), and distant metastasis (P = 0.007). ciRS-7 knockdown in 786O and 769P cells markedly inhibited their proliferative and invasive abilities. In addition, ciRS-7 inhibition reduced phosphorylated epidermal growth factor receptor (p-EGFR) and phosphorylated serine/threonine kinase (p-Akt) levels.

ciRS-7 up-regulation could promote ccRCC cell proliferation and invasion, which may be related with the EGFR/Akt signaling pathway. ciRS-7 might be a potential ccRCC therapeutic target.

TOSO, also named Fas inhibitory molecule 3 (FAIM3), has recently been identified as an immunoglobulin M (IgM) Fc receptor (FcμR). Previous studies have shown that TOSO is specifically over-expressed in chronic lymphocytic leukemia (CLL). However, the functions of TOSO in CLL remain unknown. The B-cell receptor (BCR) signaling pathway has been reported to be constitutively activated in CLL. Here, we aimed to investigate the functions of TOSO in the BCR signaling pathway and the pathogenesis of CLL.

We over-expressed TOSO in B-cell lymphoma cell lines (Granta-519 and Z138) by lentiviral transduction and knocked down TOSO by siRNA in primary CLL cells. The over-expression and knockdown of TOSO were confirmed at the RNA level by polymerase chain reaction and protein level by Western blotting. Co-immunoprecipitation with TOSO antibody followed by liquid chromatography coupled with tandem mass spectrometry (IP/LCMS) was used to identify TOSO interacting proteins. Western blotting was performed to detect the activation status of BCR signaling pathways as well as B-cell lymphoma 2 (BCL-2). Flow cytometry was used to examine the apoptosis of TOSO-over-expressing B lymphoma cell lines and TOSO-down-regulated CLL cells via the staining of Annexin V and 7-AAD. One-way analyses of variance were used for intergroup comparisons, while independent samples t tests were used for two-sample comparisons.

From IP/LCMS, we identified spleen tyrosine kinase (SYK) as a crucial candidate of TOSO-interacting protein and confirmed it by co-immunoprecipitation. After stimulation with anti-IgM, TOSO over-expression increased the phosphorylation of SYK, and subsequently activated the BCR signaling pathway, which could be reversed by a SYK inhibitor. TOSO knockdown in primary CLL cells resulted in reduced SYK phosphorylation as well as attenuated BCR signaling pathway. The apoptosis rates of the Granta-519 and Z138 cells expressing TOSO were (8.46 ± 2.90)% and (4.20 ± 1.21)%, respectively, significantly lower than the rates of the control groups, which were (25.20 ± 4.60)% and (19.72 ± 1.10)%, respectively (P < 0.05 for both). The apoptosis rate was reduced after knocking down TOSO in the primary CLL cells. In addition, we also found that TOSO down-regulation in primary cells from CLL patients led to decreased expression of BCL-2 as well as lower apoptosis, and vice versa in the cell line.

TOSO might be involved in the pathogenesis of CLL by interacting with SYK, enhancing the BCR signaling pathway, and inducing apoptosis resistance.

Melasma is a common, chronic, acquired, and refractory hyperpigmentation, the etiopathogenesis of which is multifactorial.^[1,2]Current treatments include topical or systemic agents, chemical peels, laser- and light-based therapies, and traditional Chinese medicine.^[3]At present, the therapeutic evaluation of melasma can be mainly summarized into four categories: (1) Patient self-assessments^[4]; (2) Scoring systems used by dermatologists^[5]; (3) Non-invasive detection techniques^[6,7]; (4) Histopathological and immunohistochemical assessments.^[8]Providing a non-invasive, objective, and reproducible methodology to evaluate treatment efficacy in melasma has become the focus of many researchers. In the current review, the commonly used and the latest non-invasive detection techniques which have been applied in the therapeutic evaluation of melasma in recent years are discussed.

Eccrine hidrocystoma (EH) is a benign tumor derived from the cystic dilatation of the eccrine sweat ducts caused by the retention of eccrine secretions. EH is rare and is found most often in middle-aged women, especially those who work or stay for a long duration in hot and humid environments. The lesions usually involve periocular and malar areas, manifesting as multiple translucent skin-colored to bluish cysts. The sizes and numbers of the lesions can fluctuate according to the season, with exacerbation in warm weather and alleviation in cold weather. EH is histopathologically characterized by unilocular dermal cysts lined by two layers of cuboidal to flattened epithelial cells.

Morphea and extragenital lichen sclerosus (ELS) are chronic inflammatory dermatoses that can be clinically similar. Morphea is typically characterized by successive development of erythematous patches, central hypopigmented sclerosis, and atrophic plaques. ELS manifests as blue-whitish papules, coalescing or enlarging into shiny, sclerotic, scar-like plaques. The differentiation between morphea and ELS can be difficult, especially in an early stage or in atypical cases. Moreover, coexistence of these two conditions can be observed, and biopsy is often necessary to distinguish them. Dermoscopy, as a non-invasive technology, is effective in assisting the diagnosis of cutaneous tumors and non-neoplastic dermatoses. Studies reporting the use of dermoscopy for the diagnosis of morphea and ELS in Caucasian patients have been published in succession.^[1,2,3,4,5]We designed this prospective study to analyze and compare the dermoscopic features of morphea and ELS in Chinese patients.

There is controversy regarding the perioperative complications, safety, and long-term quality of life for duodenum-preserving pancreatic head resection (DPPHR) and pancreaticoduodenectomy (PD). We performed a comparative analysis of DPPHR and PD in the treatment of benign and low-grade malignant diseases of the pancreatic head. The study was approved by the Institutional Review Board of the Ethics Committee of the First Affiliated Hospital of Xinjiang Medical University (No. K202001-14), and was in accordance with theDeclaration of Helsinki. Because this was a retrospective study and the data analysis was performed anonymously, this study was exempt from informed consent from patients.

Colorectal cancer (CRC) is the third most commonly diagnosed malignant tumor in the world. The past few years have seen a remarkable increase in both incidence and mortality of CRC in developing countries like China, posing a serious threat to human health. It is currently believed that about 70% of colorectal cancers are derived from conventional adenomas and 30% are derived from serrated adenomas.^[1]As reported, CRC incidence rates per 10,000 person-years were 20.0 for advanced adenoma and 9.1 for non-advanced adenoma.^[2]Colonoscopy, as an important tool for CRC screening and follow-up, can prevent the development of CRC by detecting and removing precancerous lesions, thereby effectively reducing the incidence and mortality. Current guidelines for post-polypectomy surveillance mostly recommend a 3- to 10-year interval according to baseline risk stratification.^[3]However, there is no such guideline in China yet and doctors tend to perform the next colonoscopy within 1 year, which is much shorter than current international recommendations.

Blue nevus (BN) is a benign, acquired pigmented lesion characterized by a bluish or dark-bluish pigmentation. Most lesions are benign and stable over time, sometimes developing into malignant blue nevus (MBN), a variant of malignant melanoma. The prognosis in MBN is at least as serious as in conventional melanoma.^[1]Additionally, a differential diagnosis of BN including nodular melanoma, pigmented basal cell carcinoma, and cutaneous metastasis of melanoma may lead to excessive surgical excisions.

To the Editor:A 50-year-old man presented with a 1-month history of pruritic papules and nodules on his trunk and extremities. The patient had a 20-year history of alcoholism, and a 10-year history of Meniere’s disease. He was treated with intravenous sodium aescinate for 5 days because of Meniere’s disease 2 months ago. Other chronic diseases or special family histories were denied. Upon physical examination, red or brown papules, and nodules with diameter of 3 to 5 mm were noted on his limbs, shoulders, and dorsum, with central umbilicated necrosis, or keratin plug, accompanied by Kobner Phenomenon [Figure 1A]. Ultrasonic examination, peripheral blood cell count and biochemical examination were basically normal. Dermoscopic examination revealed a red-brown structureless area covered with crusts and scales centrally, surrounded by a white rim, and a reddish inflammatory circle with looped and dotted vessels peripherally in polarization mode [Figure 1B]. Histopathology showed neutrophils and degenerated keratin components in central goblet necrotic epidermis, degenerated collagen fibers beneath the necrotic epidermis, and sheet of lymphocytes and scattered eosinophils around blood vessels in the dermis [Figure 1C]. Masson staining [Figure 1D] and Verhoeff-van Gieson staining [Figure 1E] confirmed the penetration of collagen fibers and fragmented elastic fibers in the necrotic epidermis. Acquired reactive perforating collagenosis was diagnosed, which reacted well to 5-week treatment of oral anti-histamines, topical steroids, and narrow-band ultraviolet B. The patient reported clearance of the lesions for 4 months, but recurrence after alcohol intake again in telephone follow-up.

To the Editor:Sebaceous carcinoma (SC) is a rare cutaneous malignant tumor differentiated from the epithelium lining and arising from the sebaceous gland.^[1]Consequently, nevus sebaceous (NS) tends to develop into a benign or malignant neoplasm.^[2]Herein, we report dermoscopic findings in a rare case of SC arising in NS with protruding nodule in erosive erythematous surface rapidly arising from yellow pigment plaque resulting in no recurrence. Dermoscopy is a powerful diagnostic tool to generate a preoperative diagnosis.

To the Editor: Programmed death-1 (PD-1) inhibitors are new and effective anti-tumor drugs, but they may cause serious immune-related adverse events, such as toxic epidermal necrolysis and psoriasis.^[1]The first recombinant human-derived anti-PD-1 monoclonal antibody, Sintilimab (Innovent Biologics, Inc., Suzhou, China), was approved for listing at the end of 2018 in China. Here, we reported the dermoscopic features of acutely exacerbated plaque psoriasis induced by anti-PD-1 for lung cancer to direct clinicians’ attention to this potential adverse reaction.

To the Editor: Lymphangioma circumscriptum (LC) is a rare benign skin disorder involving hamartomatous lymphatic malformation of deep dermal and subcutaneous lymphatic channels. Cutaneous LC (CLC) is the most common lymphangioma. It rarely occurs in the scrotum. The ability of dermoscopy to help clinicians make the correct diagnosis of CLC has been investigated in previous studies.

To the Editor:The continuous development and maturity of imaging science and technology have made skin imaging one of the essential subspecialties of dermatology. This has had an objective and comprehensive impact in changing the dermatology diagnosis mode. Thus, skin imaging has become one of the diagnostic skills that all dermatologists must master. Skin imaging equipment plays a crucial role in clinical and scientific research. It is not only a necessary aid to correct diagnose of skin diseases, but also a crucial link and hardware foundation for skin imaging capacity strengthening. Dermoscopy, reflectance confocal microscopy (RCM) and very high frequency (VHF) skin ultrasound imaging diagnostic system (VHF skin ultra-sound) have become skin imaging equipments commonly used in Chinese dermatological practice. In recent years, with the growing emphasis on dermatology in hospitals at all levels, investment in medical equipment has been increasing and skin imaging equipment has been continuously optimized. As far as we know, there is no literature report on the skin imaging equipment current status in Chinese public hospitals. This study intended to investigate and analyze the current status of skin imaging equipment in the country, and to provide an objective basis for further standardizing and strengthening the development of skin imaging equipment and dermatology construction. In this way, it is expected to lay the foundations to meet clinical needs and achieve the optimal allocation of medical resources.

To the Editor:Rosacea is a common chronic inflammatory skin disease of the central facial skin, with typical manifestations such as flushing, erythema, papules, pustules, and phymatous changes.^[1]Erythema is the most common manifestation among all types of rosacea. Sensitive skin (SS) is commonly defined as the occurrence of unpleasant sensations (pruritus, burning, pain, and tingling) upon exposure to certain physical, thermal, or chemical stimuli that normally cause no such sensations on healthy skin. It was reported that erythema might also be present in 74% of SS patients.^[2]The pathogenesis, medication, and prognosis of rosacea and SS are quite different, so it is necessary to find reliable non-invasive methods to differentiate between the two conditions.

To the Editor:Perforating dermatoses is a group of diseases characterized by papulonodular rashes with the elimination of endogenous or exogenous materials through the epidermis. The primary perforating disorders include reactive perforating collagenosis, elastosis perforans serpiginosa, Kyrle disease, perforating folliculitis, and acquired perforating dermatosis. The perforating phenomenon could also be secondary to some other skin disorders, such as calcinosis cutis, granuloma annulare, chromoblastomycosis, lichen planus, lichen striatus, and rarely, lichen nitidus. Herein, we report a case of extensive perforating lichen nitidus in a Chinese patient.

To the Editor:Livedoid vasculopathy (LV) is a thromboocclusive disorder involving superficial and mid-dermis vessels, characterized by painful erythematous or purpuric macules or papules, small crusted ulcers, and porcelainwhite atrophic scars that remain after several months.^[1,2]Dermoscopy is a non-invasive and effective image analysis technology^[3]that can aid dermatologists in visualization of the pigmentation pattern and vascular structure, as well as other morphologic features of the epidermis and dermis. This study was performed to identify the clinical and dermoscopic features of LV in patients with LV who were treated in our hospital from October 2017 to August 2018. The study was approved by the Ethical Committee of the First Affiliated Hospital of Zhengzhou University (No. 2018-YB-05). The study was performed in accordance with the established guidelines and regulations. We have obtained all appropriate patient consent forms. In the form, the patients have given their consents for their images and other clinical information to be reported in the journal.

To the Editor:Seborrheic keratosis (SK) is one of the most common benign skin tumors in clinic. Due to the wide variation in its clinical features, however, and particularly when both its manifestations and dermoscopic findings of its lesion are atypical, it may be challenging to differentiate SK lesions from other benign or malignant skin tumors.^[1,2]We here report a case of SK of an adenoid type that initially imitated pigmented basal cell carcinoma (BCC) upon dermoscopy.

To the Editor: Gastric ulceration caused by stress is one example of stress-induced organ injuries. Stress-induced ulcer is commonly seen in critically ill patients and can result in significant upper gastrointestinal bleeding associated with a highly increased mortality. Water immersion and restraint stress (WIRS), which is a complex of physical and psychological stressors, causes damage that mimics the gastric lesions caused by sepsis, trauma, or surgery.^[1]Notably, it is well established that adequate mucosal blood flow plays an important role in protecting the gastric mucosa from injuries. Inorganic nitrate exists in everyday diet especially in some vegetables. Dietary nitrate can be rapidly converted to nitrite by oral bacteria, and further reduced to nitric oxide (NO) in the acidic stomach. It has been reported that nitrate serves as biological reservoirs for NO in hypoxia or acidic conditions.^[2]Dietary nitrate, as NO donor, has the potential to prevent cardiovascular disease, vascular damage, and high blood pressure in animal models and humans.^[3,4]Our previous study has showed that dietary nitrate enhances blood flow in ischemic skin flap.^[5]Here, we explore the role of nitrate therapy in stressinduced gastric mucosal injury in Mongolian gerbils.