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Wang BG, Li W, Lee IH, Mani H. Mimickers of neuroendocrine tumors on endoscopic ultrasound-guided fine-needle aspirate material: Need for caution. Diagn Cytopathol 2023; 51:E308-E313. [PMID: 37533282 DOI: 10.1002/dc.25204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/04/2023]
Abstract
Cytologic diagnosis of neuroendocrine tumors can be straightforward on cytologic preparations, given the classical neuroendocrine morphology and expression of neuroendocrine markers confirmed by immunohistochemistry. However, overreliance on neuroendocrine markers can lead to misdiagnosis even if individual cell features suggest a neuroendocrine tumor. We present three unusual cases, two of which were initially diagnosed as neuroendocrine tumors and the third one carried preliminary diagnosis of neuroendocrine tumor on endoscopic ultrasound-guided fine-needle aspirates. These cases subsequently turned out to be cholangioblastic cholangiocarcinoma, metastatic melanoma, and gastric glomus tumor, respectively. We suggest approaches that could have pointed us towards the correct diagnosis at the outset and discuss potential pitfalls.
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Affiliation(s)
- Brant G Wang
- Department of Pathology, Inova Fairfax Hospital, Falls Church, Virginia, USA
- School of Medicine Inova Campus, University of Virginia, Falls Church, Virginia, USA
- Department of Pathology, Georgetown University Medical Center, Washington, DC, USA
| | - Wenping Li
- Department of Pathology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Iris H Lee
- Division of Gastroenterology, Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Haresh Mani
- Department of Pathology, Inova Fairfax Hospital, Falls Church, Virginia, USA
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2
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Plotzke JM, Zhao R, Hrycaj SM, Harms PW, Mehra R, Chan MP. Immunohistochemical expression of PAX8, PAX2, and cytokeratin in melanomas. J Cutan Pathol 2021; 48:1246-1251. [PMID: 33934372 DOI: 10.1111/cup.14041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Deviations from the classic melanocytic immunophenotype in melanoma can present a diagnostic challenge. PAX8 and PAX2 are common markers for renal or Müllerian differentiation. While most PAX8+ or PAX2+ carcinomas are seldom confused with melanoma, some cases may show a more ambiguous immunophenotype, especially when MiTF family altered renal cell carcinoma (MiTF-RCC) is in the differential diagnosis. Neither PAX8 nor PAX2 expression has been reported in melanoma to date. We aimed to better characterize PAX8, PAX2, and cytokeratin immunoreactivity in a large series of melanomas. METHODS Tissue microarrays consisting of 263 melanomas were immunostained for PAX8, PAX2, and cytokeratin and graded by an h-score. RESULTS PAX8 expression was seen in 7.9% of melanomas and was significantly associated with spindle cytomorphology. PAX2 was positive in one (0.4%) melanoma. Cytokeratin positivity was seen in three (1.2%) cases and was associated with metastases. CONCLUSIONS PAX8 is expressed in a subset of melanomas and may be strong/extensive. As PAX8 positivity does not exclude a diagnosis of melanoma, it should be used in conjunction with other immunohistochemical markers, such as cytokeratin and PAX2, when melanoma, MiTF-RCC, and other PAX8+ tumors are in the differential diagnosis.
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Affiliation(s)
- Jaclyn M Plotzke
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Raymond Zhao
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Steven M Hrycaj
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul W Harms
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Rohit Mehra
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - May P Chan
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
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Wu Y, Lai Y, Zhang M, Li Z. Prognostic significance of the aberrant expression of neuroendocrine markers in melanomas. Diagn Pathol 2021; 16:78. [PMID: 34454530 PMCID: PMC8403415 DOI: 10.1186/s13000-021-01135-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 07/22/2021] [Indexed: 01/12/2023] Open
Abstract
Background Melanoma is a highly malignant tumor with diverse histopathological morphology and frequent aberrant expression of immunohistochemical markers. An occasionally reported phenomenon is the abnormal expression of neuroendocrine markers. Awareness of this situation is essential because such tumors need to be differentiated from neuroendocrine tumors because of their significant therapeutic and prognostic implications. Methods We retrospectively analyzed the expression of chromogranin A (CgA), synaptophysin (Syn) and CD56 as neuroendocrine markers in 308 cases with melanomas. Kaplan-Meier curves and Cox regression analyses were used for overall survival (OS) and progression-free survival (PFS) evaluation and comparison between neuroendocrine markers expression status in all melanoma cases or stage I–II cases. Results The expression of neuroendocrine markers in melanomas is not uncommon. CgA was positive in 6/304 (2.0%) cases, Syn in 26/304 (8.6%), and CD56 in 56/189 (29.6%). None of the cases co-expressed all the three markers. Focal or weak expression of at least one neuroendocrine marker was identified in 70/188 (37.2%) cases. The expression of CgA was correlated with age (p = 0.019), while the positive expression of Syn and CD56 showed borderline significance (p = 0.078 and 0.083, respectively), but not for any neuroendocrine marker expression. The expression of any neuroendocrine marker showed borderline significance with staging (p = 0.066). The expression of CgA, Syn, CD56, or any neuroendocrine marker did not correlate with clinicopathological features including sex, specimen type, origin, location, and histology subtype. Survival analyses revealed that the expression of neuroendocrine markers was not associated with OS or PFS. Conclusions Our study confirms that neuroendocrine marker expression is a common phenomenon in melanomas, but it has no prognostic significance. Nevertheless, awareness can avoid misdiagnosis in cases of melanomas with unusual morphology and immunophenotypes.
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Affiliation(s)
- Yan Wu
- Department of Pathology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, No. 52, Fucheng Road, Haidian District, Beijing, 100142, China
| | - Yumei Lai
- Department of Pathology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, No. 52, Fucheng Road, Haidian District, Beijing, 100142, China
| | - Miao Zhang
- Department of Pathology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, No. 52, Fucheng Road, Haidian District, Beijing, 100142, China
| | - Zhongwu Li
- Department of Pathology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, No. 52, Fucheng Road, Haidian District, Beijing, 100142, China.
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Kasajima A, Konukiewitz B, Schlitter AM, Weichert W, Bräsen JH, Agaimy A, Klöppel G. Mesenchymal/non-epithelial mimickers of neuroendocrine neoplasms with a focus on fusion gene-associated and SWI/SNF-deficient tumors. Virchows Arch 2021; 479:1209-1219. [PMID: 34350470 PMCID: PMC8724147 DOI: 10.1007/s00428-021-03156-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 12/24/2022]
Abstract
Mimickers of neuroendocrine neoplasms (NEN) include a number of important pitfall tumors. Here, we describe our experience with mesenchymal mimics of NENs to illustrate their spectrum and draw the attention particularly to a group of mesenchymal/non-epithelial neoplasms (MN) that combine epithelioid histology with neuroendocrine (NE-) features and peculiar genetic abnormalities. In a consultation series of 4498 cases collected between 2009 and 2021, 2099 neoplasms expressing synaptophysin and/or chromograninA were reviewed and analyzed. A total of 364 (18%) were diagnosed as non-NENs, while the remaining tumors were NEN. The group of mesenchymal/non-epithelial neoplasms with NE-features (MN-NE) included 31/364 (8%) cases. These mostly malignant neoplasms showed an epithelioid morphology. While all but one tumor expressed synaptophysin, mostly patchy, only 10/29 (34%) co-expressed chromograninA. A total of 13/31 (42%) of the MN-NE showed EWSR1-related gene fusions (6 Ewing sarcomas, 5 clear cell sarcomas, and 1 desmoplastic small round cell tumor, 1 neoplasm with FUS-CREM gene fusion) and 7 (23%) were SWI/SNF (SMARCB1 or SMARCA4)-deficient neoplasms. The remaining MN-NE included synovial sarcoma, sclerosing epithelioid mesenchymal neoplasm, melanoma, alveolar soft part sarcoma, solitary fibrous tumor, and chordoma. A total of 27/31 MN-NE were from the last 8 years, and 6 of them were located in the pancreas. Eleven MN-NE were initially diagnosed as neuroendocrine carcinomas (NECs). MN-NE with epithelioid features play an increasing role as mimickers of NECs. They mostly belong to tumors with gene fusions involving the EWSR1 gene, or with SWI/SNF complex deficiency. Synaptophysin expression is mostly patchy and chromograninA expression is infrequent in MN-NE of this series and data extracted from literature.
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Affiliation(s)
- Atsuko Kasajima
- Department of Pathology, Technical University Munich, Trogerstr. 18, 81675, Munich, Germany.
- The German Cancer Consortium (DKTK), Heidelberg, Germany.
| | - Björn Konukiewitz
- Department of Pathology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Anna Melissa Schlitter
- Department of Pathology, Technical University Munich, Trogerstr. 18, 81675, Munich, Germany
- The German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Wilko Weichert
- Department of Pathology, Technical University Munich, Trogerstr. 18, 81675, Munich, Germany
- The German Cancer Consortium (DKTK), Heidelberg, Germany
| | | | - Abbas Agaimy
- Institute of Pathology, Friedrich-Alexander-University, Erlangen-Nürnberg, University Hospital, Erlangen, Germany
| | - Günter Klöppel
- Department of Pathology, Technical University Munich, Trogerstr. 18, 81675, Munich, Germany
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Saliba E, Bhawan J. Aberrant Expression of Immunohistochemical Markers in Malignant Melanoma: A Review. Dermatopathology (Basel) 2021; 8:359-370. [PMID: 34449584 PMCID: PMC8395931 DOI: 10.3390/dermatopathology8030040] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 11/16/2022] Open
Abstract
Immunohistochemical stains are increasingly used to aid in the diagnosis of malignant melanoma, especially when the differentiation of the tumor is unclear based on examination with hematoxylin and eosin. However, aberrant expression of non-melanocytic markers has been reported in melanomas, which can sometimes be further complicated by the loss of conventional melanocytic markers. This review aims to summarize available data regarding unusual staining patterns in primary and metastatic malignant melanoma. It also raises awareness of the potential pitfalls and highlights the importance of appropriate use and interpretation of broad immunohistochemical markers in the context of clinical and histopathologic findings to facilitate the diagnosis of atypical cases of malignant melanoma.
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Bourhis A, Trabelsi N, Karachi C, Idbaih A, Bielle F. [A pigmented brain lesion]. Ann Pathol 2020; 41:219-223. [PMID: 33317851 DOI: 10.1016/j.annpat.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/30/2020] [Accepted: 11/11/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Amélie Bourhis
- CHU Brest, service d'anatomie et cytologie pathologiques, Brest, France
| | - Nesrine Trabelsi
- Sorbonne Université, Inserm, CNRS, Paris Brain Institute, ICM, AP-HP, Sorbonne Université, Paris, France; SiRIC CURAMUS (Cancer United Research Associating Medicine, University & Society) - site de recherche intégrée sur le cancer IUC-AP-HP.6-Sorbonne Université, Paris, France
| | - Carine Karachi
- Sorbonne Université, Inserm, CNRS, Paris Brain Institute, ICM, AP-HP, Sorbonne Université, Paris, France; AP-HP, Hôpital de la Pitié-Salpêtrière, Service de Neurochirurgie, Paris, France
| | - Ahmed Idbaih
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurologie 2-Mazarin, 75013, Paris, France
| | - Franck Bielle
- Sorbonne Université, Inserm, CNRS, Paris Brain Institute, ICM, AP-HP, Sorbonne Université, Paris, France; SiRIC CURAMUS (Cancer United Research Associating Medicine, University & Society) - site de recherche intégrée sur le cancer IUC-AP-HP.6-Sorbonne Université, Paris, France; AP-HP, hôpital de la Pitié-Salpêtrière, service de neuropathologie, Paris, France.
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Cesati M, Scatozza F, D’Arcangelo D, Antonini-Cappellini GC, Rossi S, Tabolacci C, Nudo M, Palese E, Lembo L, Di Lella G, Facchiano F, Facchiano A. Investigating Serum and Tissue Expression Identified a Cytokine/Chemokine Signature as a Highly Effective Melanoma Marker. Cancers (Basel) 2020; 12:cancers12123680. [PMID: 33302400 PMCID: PMC7762568 DOI: 10.3390/cancers12123680] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/26/2020] [Accepted: 12/04/2020] [Indexed: 12/11/2022] Open
Abstract
Simple Summary In this study, we investigated the expression of 27 cytokines/chemokines in the serum of 232 individuals (136 melanoma patients vs. 96 controls). It identified several cytokines/chemokines differently expressed in melanoma patients as compared to the healthy controls, as a function of the presence of the melanoma, age, tumor thickness, and gender, indicating different systemic responses to the melanoma presence. We also analyzed the gene expression of the same 27 molecules at the tissue level in 511 individuals (melanoma patients vs. controls). From the gene expression analysis, we identified several cytokines/chemokines showing strongly different expression in melanoma as compared to the controls, and the 4-gene signature “IL-1Ra, IL-7, MIP-1a, and MIP-1b” as the best combination to discriminate melanoma samples from the controls, with an extremely high accuracy (AUC = 0.98). These data indicate the molecular mechanisms underlying melanoma setup and the relevant markers potentially useful to help the diagnosis of biopsy samples. Abstract The identification of reliable and quantitative melanoma biomarkers may help an early diagnosis and may directly affect melanoma mortality and morbidity. The aim of the present study was to identify effective biomarkers by investigating the expression of 27 cytokines/chemokines in melanoma compared to healthy controls, both in serum and in tissue samples. Serum samples were from 232 patients recruited at the IDI-IRCCS hospital. Expression was quantified by xMAP technology, on 27 cytokines/chemokines, compared to the control sera. RNA expression data of the same 27 molecules were obtained from 511 melanoma- and healthy-tissue samples, from the GENT2 database. Statistical analysis involved a 3-step approach: analysis of the single-molecules by Mann–Whitney analysis; analysis of paired-molecules by Pearson correlation; and profile analysis by the machine learning algorithm Support Vector Machine (SVM). Single-molecule analysis of serum expression identified IL-1b, IL-6, IP-10, PDGF-BB, and RANTES differently expressed in melanoma (p < 0.05). Expression of IL-8, GM-CSF, MCP-1, and TNF-α was found to be significantly correlated with Breslow thickness. Eotaxin and MCP-1 were found differentially expressed in male vs. female patients. Tissue expression analysis identified very effective marker/predictor genes, namely, IL-1Ra, IL-7, MIP-1a, and MIP-1b, with individual AUC values of 0.88, 0.86, 0.93, 0.87, respectively. SVM analysis of the tissue expression data identified the combination of these four molecules as the most effective signature to discriminate melanoma patients (AUC = 0.98). Validation, using the GEPIA2 database on an additional 1019 independent samples, fully confirmed these observations. The present study demonstrates, for the first time, that the IL-1Ra, IL-7, MIP-1a, and MIP-1b gene signature discriminates melanoma from control tissues with extremely high efficacy. We therefore propose this 4-molecule combination as an effective melanoma marker.
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Affiliation(s)
- Marco Cesati
- Department of Civil Engineering and Computer Science Engineering, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Francesca Scatozza
- Istituto Dermopatico dell’Immacolata, IDI-IRCCS, via Monti di Creta 104, 00167 Rome, Italy; (F.S.); (D.D.); (G.C.A.-C.); (M.N.); (E.P.); (L.L.); (G.D.L.)
| | - Daniela D’Arcangelo
- Istituto Dermopatico dell’Immacolata, IDI-IRCCS, via Monti di Creta 104, 00167 Rome, Italy; (F.S.); (D.D.); (G.C.A.-C.); (M.N.); (E.P.); (L.L.); (G.D.L.)
| | - Gian Carlo Antonini-Cappellini
- Istituto Dermopatico dell’Immacolata, IDI-IRCCS, via Monti di Creta 104, 00167 Rome, Italy; (F.S.); (D.D.); (G.C.A.-C.); (M.N.); (E.P.); (L.L.); (G.D.L.)
| | - Stefania Rossi
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy; (S.R.); (C.T.)
| | - Claudio Tabolacci
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy; (S.R.); (C.T.)
| | - Maurizio Nudo
- Istituto Dermopatico dell’Immacolata, IDI-IRCCS, via Monti di Creta 104, 00167 Rome, Italy; (F.S.); (D.D.); (G.C.A.-C.); (M.N.); (E.P.); (L.L.); (G.D.L.)
| | - Enzo Palese
- Istituto Dermopatico dell’Immacolata, IDI-IRCCS, via Monti di Creta 104, 00167 Rome, Italy; (F.S.); (D.D.); (G.C.A.-C.); (M.N.); (E.P.); (L.L.); (G.D.L.)
| | - Luigi Lembo
- Istituto Dermopatico dell’Immacolata, IDI-IRCCS, via Monti di Creta 104, 00167 Rome, Italy; (F.S.); (D.D.); (G.C.A.-C.); (M.N.); (E.P.); (L.L.); (G.D.L.)
| | - Giovanni Di Lella
- Istituto Dermopatico dell’Immacolata, IDI-IRCCS, via Monti di Creta 104, 00167 Rome, Italy; (F.S.); (D.D.); (G.C.A.-C.); (M.N.); (E.P.); (L.L.); (G.D.L.)
| | - Francesco Facchiano
- Department of Oncology and Molecular Medicine, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy; (S.R.); (C.T.)
- Correspondence: (F.F.); (A.F.)
| | - Antonio Facchiano
- Istituto Dermopatico dell’Immacolata, IDI-IRCCS, via Monti di Creta 104, 00167 Rome, Italy; (F.S.); (D.D.); (G.C.A.-C.); (M.N.); (E.P.); (L.L.); (G.D.L.)
- Correspondence: (F.F.); (A.F.)
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Wahl RU, Leijs M, Araujo A, Rübben A. Correlative Monitoring of Immune Activation and Tissue Damage in Malignant Melanoma-An Algorithm for Identification of Tolerance Breakage During Immune Checkpoint Inhibitor Therapy of Cancer. Int J Mol Sci 2020; 21:E2020. [PMID: 32188047 PMCID: PMC7139313 DOI: 10.3390/ijms21062020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/29/2020] [Accepted: 03/09/2020] [Indexed: 12/22/2022] Open
Abstract
We describe an innovative approach for identification of tolerance breakage during immune checkpoint inhibitor therapy in malignant melanoma. Checkpoint inhibitor therapy enhances the immunologic clearance of cancer by suppressing pathways which induce immune suppression and tolerance. We posit that by analyzing temporal correlations of key markers of immune activation and tissue damage it would be possible to detect the onset of anticancer immune reaction as well as of immunologic adverse effects which might become crucial for optimization as well as safety of immune checkpoint inhibitor treatment. We analyzed time courses of routine laboratory values of serum tumor markers as well as of markers of immune activation in 17 patients with metastasized malignant melanoma receiving checkpoint inhibition and weekly laboratory controls. A parallel serum level increase of interleukin-6 and the tumor marker S100B could be identified in 13 patients, suggesting that the onset of tolerance breakage under checkpoint inhibition may be identified and measured. Immune-related adverse events in the patients were also accompanied by a peak of IL-6. In six patients, the onset of a putative anticancer immune reaction and the beginning of immunologic adverse events occurred in the same treatment cycle; in six patients the immunologic adverse reactions took place in separate cycles.
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Affiliation(s)
- Renate U. Wahl
- Department of Dermatology, Euregio Skin Cancer Center, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; (R.U.W.)
| | - Marike Leijs
- Department of Dermatology, Euregio Skin Cancer Center, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; (R.U.W.)
- Department of Dermatology, Sint-Nikolaus Hospital, Hufengasse 4-8, 4700 Eupen, Belgium
| | - Arturo Araujo
- The AIWorks Research Lab, 7 Gower St, London WC1E 6HA, UK;
- Department of Computer Science, University College London, Malet Place, London WC1E 6BT, UK
| | - Albert Rübben
- Department of Dermatology, Euregio Skin Cancer Center, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany; (R.U.W.)
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