Immune checkpoint analysis in ear cancer

BACKGROUND

Among cutaneous squamous cell carcinomas, the ear (ecSCC) is one of the most common sites. Loco regional lymph node metastasis is found in six to eleven percent of cases, corresponding to increased metastasis compared to other sites. The aim of this study was to test the markers PD-L1, PD-1, CD4, CD8, and FoxP3 for suitability as prognostic predictive markers.

METHODS

Sixty-four patients with ecSCC were included in this study. The expression of immunohistochemical markers (PD-L1, PD-1, CD4, CD8, FOXP3) was correlated with retrospective clinic pathological parameters (lymph node metastasis, distant metastasis, lymph node metastasis during follow-up, disease progression, disease-specific death).

RESULTS

There was a correlation between increased disease specific death and a weak Foxp3 (p = 0.003) or reduced CD8 (p = 0.04). A PD-L1 expression > 1% was found in 39.1% of patients.

CONCLUSION

The investigated markers (CD4, CD8, FoxP3, PD-1, PD-L1) seem overall rather inappropriate for prognostic evaluation in ecSCC. Only the correlation of disease specific death with CD8 or FoxP3 seems to be worth testing in larger collectives.

Patterns of care and follow-up care of patients with uveal melanoma in German-speaking countries: a multinational survey of the German Dermatologic Cooperative Oncology Group (DeCOG)

Purpose

Uveal melanoma (UM) is an orphan cancer of high unmet medical need. Current patterns of care and surveillance remain unclear as they are situated in an interdisciplinary setting.

Methods

A questionnaire addressing the patterns of care and surveillance in the management of patients with uveal melanoma was distributed to 70 skin cancer centers in Austria, Germany and Switzerland. Frequency distributions of responses for each item of the questionnaire were calculated.

Results

44 of 70 (62.9%) skin cancer centers completed the questionnaire. Thirty-nine hospitals were located in Germany (88.6%), three in Switzerland (6.8%) and two in Austria (4.5%). The majority (68.2%) represented university hospitals. Most patients with metastatic disease were treated in certified skin cancer centers (70.7%, 29/41). Besides, the majority of patients with UM were referred to the respective skin cancer center by ophthalmologists (87.2%, 34/39). Treatment and organization of follow-up of patients varied across the different centers. 35.1% (14/37) of the centers stated to not perform any screening measures.

Conclusion

Treatment patterns of patients with uveal melanoma in Germany, Austria and Switzerland remain extremely heterogeneous. A guideline for the treatment and surveillance is urgently needed.

Basal cell carcinoma risk and solar UV exposure in occupationally relevant anatomic sites: do histological subtype, tumor localization and Fitzpatrick phototype play a role? A population-based case-control study

Background

A two-fold risk increase to develop basal cell carcinoma was seen in outdoor workers exposed to high solar UV radiation compared to controls. However, there is an ongoing discussion whether histopathological subtype, tumor localization and Fitzpatrick phototype may influence the risk estimates.

Objectives

To evaluate the influence of histological subtype, tumor localization and Fitzpatrick phototype on the risk to develop basal cell carcinoma in highly UV-exposed cases and controls compared to those with moderate or low solar UV exposure.

Methods

Six hundred forty-three participants suffering from incident basal cell carcinoma in commonly sun-exposed anatomic sites (capillitium, face, lip, neck, dorsum of the hands, forearms outside, décolleté) of a population-based, case-control, multicenter study performed from 2013 to 2015 in Germany were matched to controls without skin cancer. Multivariate logistic regression analysis was conducted stratified for histological subtype, phototype 1/2 and 3/4. Dose-response curves adjusted for age, age², sex, phototype and non-occupational UV exposure were calculated.

Results

Participants with high versus no (OR 2.08; 95% CI 1.24–3.50; p = 0.006) or versus moderate (OR 2.05; 95% CI 1.15–3.65; p = 0.015) occupational UV exposure showed a more than two-fold significantly increased risk to develop BCC in commonly UV-exposed body sites. Multivariate regression analysis did not show an influence of phototype or histological subtype on risk estimates. The restriction of the analysis to BCC cases in commonly sun-exposed body sites did not influence the risk estimates. The occupational UV dosage leading to a 2-fold increased basal cell carcinoma risk was 6126 standard erythema doses.

Conclusion

The risk to develop basal cell carcinoma in highly occupationally UV-exposed skin was doubled consistently, independent of histological subtype, tumor localization and Fitzpatrick phototype.

Genome-wide association meta-analyses combining multiple risk phenotypes provide insights into the genetic architecture of cutaneous melanoma susceptibility

Most genetic susceptibility to cutaneous melanoma remains to be discovered. Meta-analysis genome-wide association study (GWAS) of 36,760 cases of melanoma (67% newly genotyped) and 375,188 controls identified 54 significant (P < 5 × 10-8) loci with 68 independent single nucleotide polymorphisms. Analysis of risk estimates across geographical regions and host factors suggests the acral melanoma subtype is uniquely unrelated to pigmentation. Combining this meta-analysis with GWAS of nevus count and hair color, and transcriptome association approaches, uncovered 31 potential secondary loci for a total of 85 cutaneous melanoma susceptibility loci. These findings provide insights into cutaneous melanoma genetic architecture, reinforcing the importance of nevogenesis, pigmentation and telomere maintenance, together with identifying potential new pathways for cutaneous melanoma pathogenesis.

Activation of human vascular endothelium in melanoma metastases induces ICAM-1 and E-selectin expression and results in increased infiltration with effector lymphocytes

Lymphocytic infiltration into melanoma tissue is an important prerequisite for effective antitumoral immunity. However, analysis of human metastatic melanoma has shown that leucocyte adhesion receptor expression on melanoma blood vessels is very low or absent, thereby impairing the entry of cytotoxic lymphocytes into tumor tissue. We hypothesized that adhesion molecules can be induced on melanoma vasculature allowing better infiltration of cytotoxic lymphocytes. Quantitative real-time PCR and immunofluorescence staining indicated that the adhesion molecules ICAM-1 (CD54) and E-selectin (CD62E) can be significantly induced by intralesional application of TNF alpha in tissue from human melanoma metastases either in vitro or in vivo when grafted onto immunodeficient NSG (NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ) mice that preserved human vessels. Furthermore, activated human autologous CD3⁺ lymphocytes were injected intravenously into mice bearing melanoma xenografts treated with TNF-α or PBS in addition to the leucocyte chemoattractant TARC (CCL17). Significantly increased numbers of CD8⁺ cells were detected in TNF-α-treated melanoma metastases compared with PBS-treated controls. In addition, tumor cell apoptosis was enhanced and melanoma cell proliferation reduced as shown by TUNEL assay and KI-67 staining. We conclude that adhesion molecules can be induced on human melanoma vasculature resulting in significantly improved homing of activated autologous cytotoxic T cells to melanoma tissue and inhibition of melanoma cell proliferation. These observations should be considered when designing protocols for immunotherapy of malignant melanoma.

A Prognostic Gene Signature Expressed in Primary Cutaneous Melanoma: Synergism With Conventional Staging

Background

Current clinico-pathological American Joint Committee on Cancer (AJCC) staging of primary cutaneous melanoma is limited in its ability to determine clinical outcome, and complementary biomarkers are not available for routine prognostic assessment. We therefore adapted a gene signature, previously identified in fresh-frozen (FF) melanomas and adjacent stroma, to formalin-fixed paraffin-embedded (FFPE) melanomas. The aim was to develop a gene expression profiling (GEP) score to define patient survival probability at the time of first diagnosis.

Methods

Expression of 11 FF melanoma signature genes was quantified by reverse transcription polymerase chain reaction in an FFPE melanoma training cohort (n = 125), corresponding to the combined FF melanoma training and validation cohorts. The resulting GEP score was validated technically and clinically in an independent FFPE melanoma cohort (n = 211). All statistical tests were two-sided.

Results

We identified a prognostic eight-gene signature in the tumor area (tumor and adjacent tissue) of AJCC stage I–III melanomas. A signature-based GEP score correlated with melanoma-specific survival (MSS; Kaplan-Meier analysis: P < .0001) was independent of tumor stage (multivariable regression analysis: P = .0032) and stroma content (<5%–90%) and complemented conventional AJCC staging (receiver operating characteristic curve analysis: area under the curve = 0.91). In the clinical validation cohort, the GEP score remained statistically significant (P = .0131) in a multivariable analysis accounting for conventional staging. The GEP score was technically robust (reproducibility: 93%; n = 84) and clinically useful, as a binary as well as a continuous score, in predicting stage-specific patient MSS.

Conclusions

The GEP score is a clinically significant prognostic tool, contributes additional information regarding the MSS of melanoma patients, and complements conventional staging.

Deceptively bland cutaneous angiosarcoma on the nose mimicking hemangioma-A clinicopathologic and immunohistochemical analysis

BACKGROUND

We investigated 2 cases of deceptively bland cutaneous angiosarcoma (AS), which showed a uniform clinical presentation with a rapidly growing tumor on the nose. It remains unclear whether this was a primary cutaneous manifestation or a metastasis. Both tumors initially presented a high histologic overlap with a benign vascular tumor. The diagnosis was primarily based on the rapidly progressing clinical course and on the results of the staging procedures.

METHODS

Immunohistochemical stains were performed for cytokeratin (AE1/AE3 and MNF116), CD31, ERG, CD34 (HPCA1/my10), D2-40/podoplanin, LYVE-1, Ki67, PHH3, αSMA (1A4), MYC, FOS-B, CAMTA-1, TFE-3, WT1, nestin, VEGFR-2(KDR), VEGFR-3(FLT4), HHV8. MYC amplification was also investigated by fluorescence in situ hybridization.

RESULTS

The tumor cells were negative for MYC and revealed no D2-40/podoplanin expression. SMA-positive pericytes formed rims around the vessel. The proliferative activity (Ki-67) was elevated, in one case only in a later stage.

DISCUSSION

Cutaneous ASs can be rather bland and may easily be mistaken for benign vascular tumors. Both cases presented a uniform clinical picture, which implied a malignant vascular tumor. In contrast, the cytomorphology of the endothelial cells and the immunohistochemical profile were not suspicious. We worked out subtle histological criteria, which should allow an early detection of such tumors.

Advanced cutaneous squamous cell carcinoma: A retrospective analysis of patient profiles and treatment patterns-Results of a non-interventional study of the DeCOG

BACKGROUND

Advanced cutaneous squamous cell carcinoma (aSCC) is an area of unmet medical need and no treatment standards are established. Recently, an anti-PD-1 inhibitor received FDA breakthrough therapy designation. The aim of the study was to describe the clinical course, therapeutic management and prognosis of aSCC under real-life conditions.

PATIENTS AND METHODS

In a retrospective study performed in 24 German and Austrian hospitals and doctor's offices, patient and tumour characteristics of patients diagnosed with aSCC between January 1, 2010 and December 31, 2011 and their disease course was documented. Advanced SCC comprised either locally advanced SCCs (laSCC) or metastatic SCCs (mSCC) with any kind of metastatic spread.

RESULTS

Data of 190 patients with aSCC were analysed. Median age at time of diagnosis of aSCC was 78 years. LaSCC was diagnosed in 76 patients (40%), 114 patients (60%) had mSCC. Once diagnosed with laSCC, most patients (59%) did not receive any therapy, whereas in 92% of mSCC patients at least one type of therapy was performed. Only 32 patients (29 mSCC, 3 laSCC) received systemic antitumour therapies, mostly EGFR inhibitor-based regimens. Mean duration of response was short (17-months laSCC patients, 3-months mSCC patients). Only 2 patients achieved a complete response, 27% had a partial response, 43% disease stabilisation. At diagnosis of aSCC, ECOG status was 0-1 in most patients. Non-malignant comorbidities influenced the decision on SCC-specific therapy in 39 patients (21%).

CONCLUSIONS

Our data show the high medical need for efficient and tolerable antitumour therapies and demonstrate that despite older age and comorbidities, most patients can be expected to be fit for treatment. This study provides a historical context for emerging aSCC treatments.

Validation, in silico and in vitro, of a gene-signature based risk score in cutaneous melanoma

9560

Background: Melanoma staging, as defined by the American Joint Committee on Cancer (AJCC), is limited in its ability to predict outcome. We have previously identified and validated a prognostic gene signature expressed in primary cutaneous melanoma and adjacent stroma. The signature comprises seven protective genes (down-regulated with tumor progression) and one risk-associated gene (up-regulated). A signature-based risk score independently predicts patient survival, across AJCC stages IA-IIIC, in formalin-fixed, paraffin-embedded (FFPE) melanomas (training cohort, n = 125; p = 0.0003, hazard ratio 1.85). The score has been validated in 206 melanomas, selected to be significantly mis-prognosticated by AJCC staging regarding patient survival (40.8% mis-prognostication). In this cohort, the score outperforms AJCC staging (p = 0.0005, hazard ratio 1.41 vs. p = n.s.), correcting 34.9% of AJCC-based mis-prognostications. Methods: Here, we report twofold external validation of the risk score, (i) prognostic performance in silico using the SurvExpress web tool (Aguirre-Gamboa et al., 2013), and (ii) technical performance in vitro(Dermatologikum Hamburg; IMGM Munich) . Results: (i) Kaplan Meier analysis and log-rank testing demonstrated that all signature genes combined predicted survival in four different cohorts of metastatic melanoma (from GEO Expression Omnibus or Cancer Genome Atlas; cohorts dichotomized at the median): see table. (ii) The risk score was re-analyzed in melanomas of the training cohort (n=69). The overall concordance of duplicate determinations was 90% (average scores of 1.12 ± 0.14 and 0.97 ± 0.14). Conclusions: In conclusion, we have validated a signature-based FFPE melanoma risk score, complementary to AJCC staging in predicting outcome: (i) Signature genes predicted patient survival in silico(n=449) (ii) The risk score proved to be reproducible and technically robust in vitro. The score improves risk stratification and decision making in melanoma, particularly regarding new adjuvant therapies. [Table: see text]

Basosquamous carcinoma of the head and neck: clinical and histologic characteristics and their impact on disease progression

OBJECTIVES: Basosquamous carcinoma (BSC) is a rare tumor entity, and the most common onset is in the head and neck region (BSC-HN). The data on diagnosis, treatment, and especially risk assessment concerning disease course and outcome are deficient or inconsistent. This study aimed to evaluate risk factors for local relapse (LR) and lymph node metastasis (LNM) and their impact on progression-free survival (PFS). MATERIALS AND METHODS: In a retrospective monocentric study, patients with BSC-HN treated between 1999 and 2011 were analyzed regarding clinical and histologic characteristics. Prognostic parameters for LR, LNM, and PFS were evaluated. In total, 89 patients (55 male, 34 female, mean age of 71.8 years) with a mean follow-up time of 47.7 months (range 12-112) were included. RESULTS: LR occurred in four patients (4.5%), LNM occurred in five patients (5.6%). Patients with LNM had a significantly shorter PFS time (16.1 months) compared with patients without LNM (154.2 months; P < .001). Tumor depth and size (T classification), incomplete resection, localization at the ear, deep maximal vertical infiltration, muscle and vessel invasion all showed significant (P < .05) associations with LR, LNM, and shorter PFS time. BSC showed more histologic features of basal cell carcinoma (BCC), especially with regard to BerEP4 expression. CONCLUSION: While histology shows some typical characteristics of BCC, the biologic behavior and aggressiveness of BSC are similar to those of cutaneous squamous cell carcinoma. This is the first study to show that LR and, especially, LNM indicate a higher risk of an unfavorable outcome.

Genome-wide meta-analysis identifies five new susceptibility loci for cutaneous malignant melanoma

Thirteen common susceptibility loci have been reproducibly associated with cutaneous malignant melanoma (CMM). We report the results of an international 2-stage meta-analysis of CMM genome-wide association studies (GWAS). This meta-analysis combines 11 GWAS (5 previously unpublished) and a further three stage 2 data sets, totaling 15,990 CMM cases and 26,409 controls. Five loci not previously associated with CMM risk reached genome-wide significance (P < 5 × 10(-8)), as did 2 previously reported but unreplicated loci and all 13 established loci. Newly associated SNPs fall within putative melanocyte regulatory elements, and bioinformatic and expression quantitative trait locus (eQTL) data highlight candidate genes in the associated regions, including one involved in telomere biology.

Treatment with two different doses of sonidegib in patients with locally advanced or metastatic basal cell carcinoma (BOLT): a multicentre, randomised, double-blind phase 2 trial

BACKGROUND

Patients with advanced basal cell carcinoma have limited treatment options. Hedgehog pathway signalling is aberrantly activated in around 95% of tumours. We assessed the antitumour activity of sonidegib, a Hedgehog signalling inhibitor, in patients with advanced basal cell carcinoma.

METHODS

BOLT is an ongoing multicentre, randomised, double-blind, phase 2 trial. Eligible patients had locally advanced basal cell carcinoma not amenable to curative surgery or radiation or metastatic basal cell carcinoma. Patients were randomised via an automated system in a 1:2 ratio to receive 200 mg or 800 mg oral sonidegib daily, stratified by disease, histological subtype, and geographical region. The primary endpoint was the proportion of patients who achieved an objective response, assessed in the primary efficacy analysis population (patients with fully assessable locally advanced disease and all those with metastatic disease) with data collected up to 6 months after randomisation of the last patient. This trial is registered with ClinicalTrials.gov, number NCT01327053.

FINDINGS

Between July 20, 2011, and Jan 10, 2013, we enrolled 230 patients, 79 in the 200 mg sonidegib group, and 151 in the 800 mg sonidegib group. Median follow-up was 13·9 months (IQR 10·1-17·3). In the primary efficacy analysis population, 20 (36%, 95% CI 24-50) of 55 patients receiving 200 mg sonidegib and 39 (34%, 25-43) of 116 receiving 800 mg sonidegib achieved an objective response. In the 200 mg sonidegib group, 18 (43%, 95% CI 28-59) patients who achieved an objective response, as assessed by central review, were noted among the 42 with locally advanced basal cell carcinoma and two (15%, 2-45) among the 13 with metastatic disease. In the 800 mg group, 35 (38%, 95% CI 28-48) of 93 patients with locally advanced disease had an objective response, as assessed by central review, as did four (17%, 5-39) of 23 with metastatic disease. Fewer adverse events leading to dose interruptions or reductions (25 [32%] of 79 patients vs 90 [60%] of 150) or treatment discontinuation (17 [22%] vs 54 [36%]) occurred in patients in the 200 mg group than in the 800 mg group. The most common grade 3-4 adverse events were raised creatine kinase (five [6%] in the 200 mg group vs 19 [13%] in the 800 mg group) and lipase concentration (four [5%] vs eight [5%]). Serious adverse events occurred in 11 (14%) of 79 patients in the 200 mg group and 45 (30%) of 150 patients in the 800 mg group.

INTERPRETATION

The benefit-to-risk profile of 200 mg sonidegib might offer a new treatment option for patients with advanced basal cell carcinoma, a population that is difficult to treat.

FUNDING

Novartis Pharmaceuticals Corporation.

Abstract 2861: Independent validation of a prognostic gene-signature based risk score in formalin-fixed paraffin-embedded melanomas

Current staging of melanoma, as defined in 2009 by the American Joint Committee on Cancer (AJCC), is based mainly on histopathological criteria but is limited in predicting outcome. Complementary molecular markers are not available for routine prognostic assessment.

We have previously identified and validated a prognostic nine-gene signature expressed in fresh-frozen (FF) primary cutaneous melanomas (training cohort: n=91; validation cohort: n=44). A signature-based risk score predicts patient overall survival (OS) independently of AJCC staging (multivariate regression analysis: p = 0.0004; hazard ratio: 3.8). However, clinical application requires adaptation to formalin-fixed, paraffin-embedded (FFPE) melanomas.

Therefore, we have transfered signature expression analysis onto FFPE melanomas. From FFPE melanomas matching the training and validation cohorts of the above FF melanoma study (n=125), RNA was prepared and transcribed into cDNA. Following cDNA pre-amplification, expression of the 9 signature genes, 2 additional candidate genes, and 3 housekeeping genes was quantified by real-time PCR. Correlation of gene expression with OS was evaluated using Cox regression analysis. Expression of a signature of 8 out of 11 genes (risk gene: KBTBD10; protective genes: DCD, GBP4, COL6A6, PIP, SCGB1D2, SCGB2A2, KRT9) was associated with OS in univariate regression and Kaplan Meier analysis. A signature-based risk score predicted OS independently of AJCC staging (multivariate analysis: p=0.0059, hazard ratio 3.09). The misclassification rates were 20% overall, 13.8% for low risk, and 5.7% for double low-risk (combined with AJCC staging). The risk score complemented and refined conventional AJCC staging. Thus, the FF melanoma risk score was successfully transfered onto FFPE melanomas.

In order to validate the FFPE melanoma risk score, we analyzed signature expression in an independent cohort of 130 selected FFPE melanomas, which were particularly difficult to classify by AJCC staging (misclassification rate 40.8%), in order to stringently test the performance of the risk score. The misclassification rate of the FFPE melanoma risk score was comparable, even slightly better (39.2%) than that of AJCC staging, confirming its prognostic performance.

The FFPE melanoma risk score was also externally validated in a Molecular Diagnostics Lab (Dermatologikum Hamburg). The concordance of melanoma classification exceeded 85%, demonstrating technical robustness of the risk score.

We have established and independently as well as externally validated a quantitative, robust prognostic FFPE melanoma risk score that is complementary to AJCC staging in predicting outcome. This demonstrates clinical applicability and allows retrospective risk assessment of melanomas. The score identifies patients at low risk, not identified by AJCC staging, and defines high-risk patients in need of adjuvant therapy.

Citation Format: Georg Brunner, Achim Heinecke, Ludwig Suter, Norbert Blödorn-Schlicht, Hans-Joachim Schulze, Jens Atzpodien. Independent validation of a prognostic gene-signature based risk score in formalin-fixed paraffin-embedded melanomas. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2861. doi:10.1158/1538-7445.AM2014-2861

Cutaneous and oral squamous cell carcinoma-dual immunosuppression via recruitment of FOXP3+ regulatory T cells and endogenous tumour FOXP3 expression?

Regulatory T cells (Tregs) are an essential component of the immune system, but are also involved in the suppression of anti-tumour immune responses. The study examines their immunoregulatory role including their transcription factor, FOXP3, in oral and cutaneous SCC. Tregs were detected by double-immunohistochemistry. FOXP3-mRNA-expression was examined in tumour tissue, as well as in skin-derived primary cells and cell lines of different malignancy. Tregs were found in the tumour microenvironment, and FOXP3-mRNA-expression was significantly higher than in normal skin. Intriguingly, single FOXP3(+) cells exhibited morphologic characteristics of SCC cells. Consistent with this, endogenous FOXP3-mRNA-expression was indeed detected in the epidermal cell lineage and dramatically increased with increasing malignancy of the cells. SCCs recruit Tregs into their microenvironment, presumably in order to suppress immunosurveillance, thus avoiding destruction by the immune system. Endogenous FOXP3-expression in malignant epidermoid cells might present a novel mechanism of immune escape.

New and established treatment options for mycosis fungoides and Sézary syndrome - an update

At the time of diagnosis primary cutaneous lymphomas are limited to the skin. T-cell lymphomas represent at least two thirds of all primary cutaneous lymphomas with mycosis fungoides and Sézary syndrome being the most frequent entities. A precise staging based on clinical, histological, immunohistological and molecular biological criteria is crucial for selecting the appropriate therapy. Since curative treatment is only possible in exceptional cases, the aim of any therapy is to achieve healing of the skin lesions, minimizing relapses, preventing progression and maintaining the quality of life. While in early disease stages skin-directed therapy is being used, in later stages systemic treatments become more important. This work aims to provide an overview of established and new therapies for the treatment of mycosis fungoides and Sézary syndrome.

A tumor suppressor function for the lipid phosphatase INPP4B in melanocytic neoplasms

The phosphoinositide-3 kinase (PI3K) pathway is deregulated in a significant proportion of melanomas, and PI3K pathway activation in combination with constitutively active mitogen-activated protein kinase signaling shows synergistic effects in the process of melanoma tumorigenesis. Recently, a tumor suppressor function for the lipid phosphatase inositol polyphosphate 4-phosphatase type II (INPP4B) has been described in breast and prostate cancers, with impact on PI3K signaling output. Given the importance of PI3K pathway activity for melanoma formation and growth, we aimed to assess the role of INPP4B in melanocytic tumors. Our studies in native tumors suggest that decreased INPP4B expression is an event correlating with tumor progression in melanocytic neoplasms. We further demonstrate that INPP4B regulates PI3K/Akt signaling and exerts a tumor suppressor effect, impacting the proliferative, invasive, and tumorigenic capacity of melanoma cells. INPP4B expression in melanocytic neoplasms may therefore have potential as a biomarker for disease progression and as a modulator for the prediction of treatment outcome.

Survival data for 299 patients with primary cutaneous lymphomas: a monocentre study

The aim of this study was retrospectively to assess the validity of the 2005 WHO-EORTC classification for primary cutaneous lymphomas (PCL) in a large cohort of patients of a single German skin cancer unit. All patients with PCLs consecutively visiting our hospital between January 1980 and December 2005 were included in a retrospective monocentre study, analysing their histological and clinical data. A total of 312 patients fulfilled the inclusion criteria for PCL. In 299 patients clinical information and paraffin material were sufficient for detailed classification. Of the 299 patients, 63% expressed a T-cell and 37% a B-cell phenotype. Mycosis fungoides was the entity with the highest frequency (30.9%), followed by primary cutaneous follicle centre lymphomas (16.9%) and lymphomatoid papulosis (15.9%). The mean follow-up period was 38.4 months. Five-year disease-specific survival was 80.5% for mycosis fungoides, 92.5% in primary cutaneous anaplastic large cell lymphoma, 100% in lymphomatoid papulosis, 98.1% in primary cutaneous follicle center lymphoma, 100% in primary cutaneous marginal zone lymphoma and 63.2% in diffuse large B-cell lymphoma, leg type. Our data are in line with the data collected by the WHO-EORTC. This is further evidence for the reliability of the WHO-EORTC classification and staging system.

Abstract 5070: Validation of a fresh-tissue based prognostic gene signature in formalin-fixed, paraffin-embedded melanomas

Melanoma incidence is rapidly increasing – with a doubling rate of 10-20 years. Precision and reliability of conventional histological and clinical staging, however, remain limited in predicting clinical outcome. On the other hand, complementary molecular prognostic markers are not yet available.

We have recently identified, for the first time, a prognostic gene signature expressed in fresh-frozen primary melanomas (n = 135), which is associated with overall survival (multivariate Cox regression analysis: p = 0.0004, hazard ratio 3.83). The clinical value of a signature-based risk score is its ability to identify patients at low risk, not identified by conventional AJCC staging, and to define risk patients in need of adjuvant therapy. The purpose of the present study was to establish analysis of the signature genes in formalin-fixed, paraffin-embedded (FFPE) melanoma tissue and to validate prognostic significance.

We developed a sensitive and robust methodology to analyze and normalize gene expression in FFPE tissue samples (some of them more than 20 years old): Total RNA was prepared from FFPE sections matching the above fresh-frozen primary melanomas (131 out of 135), quality-controled, and transcribed into cDNA. Human reference RNA was included as an internal standard. Following pre-amplification of the cDNA, expression of the nine signature genes (KRT9, KBTBD10, DCD, ECG2/SPINK7, PIP, SCGB1D2, SCGB2A2, COL6A6, HES6) and of four house-keeping genes (18S rRNA, GAPDH, GUSB, BPNT1) was quantified by real-time PCR using TaqMan assays specific for short amplicons. Gene expression data were normalized, in two steps, to correct for inter-assay technical variability (based on the reference RNA data) and inter-sample variability of RNA quality (based on the data for the house-keeping genes). Significance of correlation of FFPE gene expression data (CT values or estimated mRNA copy numbers) with data from matched fresh-frozen tissue samples (two-sided t-test) or with patient overall survival (univariate Cox regression analysis; clinical follow-up data up to 273 months) was evaluated.

The majority of FFPE primary melanomas (125 out of 131) yielded mRNA of sufficient quality. Expression of all nine signature genes in FFPE melanomas correlated with that in matched fresh-frozen samples. Significance of correlation was higher with CT values (r = 0.58 – 0.19; p = 0.001 – 0.05) than with estimated mRNA copy numbers. Expression of 7 out of the 9 genes (dichotomized CT values) in FFPE melanomas was significantly associated with patient overall survival (p = 0.0001 – 0.0335).

Thus, our prognostic melanoma gene signature was successfully transfered from fresh-frozen onto FFPE tissue samples. This facilitates clinical use of a gene-signature based prognostic risk score and, in addition, allows the retrospective prognostic analysis of primary melanomas.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 5070. doi:10.1158/1538-7445.AM2011-5070

New prognostic relevant factors in primary cutaneous diffuse large B-cell lymphomas

BACKGROUND

There is a growing body of literature that has enhanced our understanding of the biology of primary cutaneous diffuse large B-cell lymphoma (PCDLBCL) including in the context of gene profiling studies. Recent studies have demonstrated an activated proliferation profile associated with leg type lymphoma including overexpression of proto-oncogenes PIM1, PIM2, and cMYC, and the transcription factors MUM1 and OCT2. Although gene profiling is very useful in understanding the molecular basis of diffuse large B-cell lymphoma (LBCL), it is not practical from a routine diagnostic perspective. In this regard, the purpose of the study was to further define an armamentarium of easily applied immunohistochemical stains to accurately prognosticate PCDLBCL.

METHODS

In all, 35 patients with PCDLBCL, 14 of follicle center and 21 of leg type, were analyzed using antibodies against CD5, CD138, BCL2, BCL6, OCT2, MUM1, FOXP1, and cMYC. Findings were correlated with clinical data.

RESULTS

All cases stained negative for CD5 and CD138. Both subtypes differed in distinct staining patterns for BCL6, BCL2, OCT2, MUM1, and FOXP1. Staining for BCL2, OCT2, and/or MUM1 was associated with poor, and BCL6 with a favorable prognosis. Expression of cMYC was irrespective of prognosis or subtype, whereas ulceration or primary manifestation on the leg or multiple lesions was indicative for worse prognosis.

LIMITATIONS

Case number was a limitation.

CONCLUSION

Discriminating PCDLBCL supports the validity of the World Health Organization/European Organization for Research and Treatment of Cancer classification. To identify risk factors in patients with PCDLBCL we recommend thorough evaluation of clinical presentation and exploratory staining pattern for BCL2, BCL6, MUM1 and OCT2.

Regulatory T-cell phenotype in association with large cell transformation of mycosis fungoides

INTRODUCTION

Tumor cells of primary cutaneous T-cell lymphomas are able to adopt a regulatory T-cell phenotype in vitro. The significance of this finding in vivo is matter of debate.

METHODS

We stained five cases with transformed mycosis fungoides (MF) with an antibody against FOXP3, which is a sensitive and specific marker for the regulatory T-cell phenotype.

RESULTS

Transformed T cells in four of five patients with MF stained positive for FOXP3. One patient who showed no CD30 expression of large transformed T cells was also negative for FOXP3. Comparison of plaques and tumors in one patient showed that FOXP3 and CD30 expression was exclusively observed in large transformed tumor cells whereas malignant T cells without large cell transformation were negative.

CONCLUSION

Transformation of MF to high grade lymphoma may be associated with the adoption of a regulatory T-cell phenotype. FOXP3 expression may contribute to aggressive behavior of MF after large cell transformation via immune escape mechanism. The significance of this observation is limited by the low case number in this study.

Glycoconjugate profiling of primary melanoma and its sentinel node and distant metastases: implications for diagnosis and pathophysiology of metastases

Aiming at more precise detection of melanoma cells in sentinel lymph nodes and better understanding of the mechanisms underlying metastatic spread, expression of L1, CEACAM1, and binding of the lectins HPA, ML-I and PNA, was assessed in benign nevi (n=12), primary melanomas (PTs: n=67), their corresponding sentinel lymph nodes (SLNs: n=40), and distant metastases (DMs: n=35). Sensitivity and specificity of CEACAM1 (95-97%; 66%) and L1 (90-93%; 100%) exceeded that of the standard markers MelanA, S100, and HMB45 in single marker use. Lectin binding was found in PTs and DMs (HPA: 69% and 77%; ML-I: 82% and 77%, respectively), but rarely in SLNMs (HPA: 20%, ML-I: 20%, PNA: 5%, respectively). The highly specific and sensitive L1-11A against L1 and 4D1/C2 against CEACAM1 antibodies are a worthy completion to standard antibody panels for diagnosis of melanoma cells. Both CAMs seem to be functionally involved in lymphatic and haematogenous spread, and are thus promising target molecules for immunotoxins.

Imiquimod 5% cream for the treatment of superficial basal cell carcinoma: results from a randomized vehicle-controlled phase III study in Europe

BACKGROUND

Imiquimod is an immune response modifier that acts through toll-like receptor 7 to induce cytokine production and a subsequent innate and adaptive cell-mediated immune response. Clinical studies have demonstrated clinical and histological clearance of superficial basal cell carcinoma (sBCC) after treatment with imiquimod 5% cream.

OBJECTIVES

To evaluate the safety and clinical efficacy of imiquimod (Aldaratrade mark; 3M Pharmaceuticals, St Paul, MN, U.S.A.) 5% cream for the treatment of sBCC in a multicentre, randomized, parallel, vehicle-controlled, double-blind, phase III clinical study conducted at 26 centres in Europe.

METHODS

Subjects who had at least one histologically confirmed sBCC tumour were randomized to apply imiquimod or vehicle cream to the target tumour once daily, seven times per week (7 x/week) for 6 weeks. The target tumour location was identified with an indelible ink mark before treatment initiation. The treated tumour site was clinically assessed for treatment response at 12 weeks post-treatment and was then excised for histological evaluation. Efficacy assessments included the composite response rates (proportion of subjects with clinical and histological clearance) and response rates solely based on histology (proportion of subjects with histological clearance). Safety assessments, which included adverse events and scoring of local skin reactions (LSRs), were carried out throughout the study.

RESULTS

In total, 166 subjects were enrolled in this study. For the intent-to-treat dataset, there was a statistically significant difference between imiquimod and vehicle groups for both composite clearance rates (clinical and histological assessments) and histological clearance rates. Composite clearance was demonstrated in 77% and 6% of subjects treated with imiquimod and vehicle cream, respectively. Histological clearance was demonstrated in 80% and 6% of subjects treated with imiquimod and vehicle cream, respectively. The most frequently reported safety findings were investigator-assessed LSRs and spontaneous reports by subjects of application site reactions, which occurred more frequently in the imiquimod group than in the vehicle group.

CONCLUSIONS

Imiquimod 5% cream administered 7 x/week for 6 weeks is a safe and effective treatment for sBCC when compared with vehicle cream.

The developmentally regulated neural crest-associated glycotope HNK-1 predicts metastasis in cutaneous malignant melanoma

Aberrant glycosylation is a common feature of metastatic sub-clones of malignant tumours and in uveal melanoma in particular, the HNK-1 glycotope has been positively correlated with poor prognosis. So far, no such correlation has been investigated in cutaneous melanoma. In order to do so, HNK-1 expression was evaluated immunohistochemically in 100 primary cutaneous melanomas and correlated with metastasis after up to 10-years' follow-up. Furthermore, HNK-1 expression was analysed in metastatic deposits (19 distant cutaneous metastases and six sentinel lymph node metastases), as well as in benign nevi. Kaplan-Meier analysis revealed a positive association between HNK-1 expression and metastasis (p < 0.005) and multivariate Cox regression analysis adjusted for the standard prognostic markers ulceration and vertical tumour thickness confirmed HNK-1 expression as an independent prognostic marker. HNK-1 expression was preserved in 42% of the distant cutaneous metastases, but metastatic cells in lymph nodes were devoid of HNK-1 immunoreactivity. None of the benign pigmented lesions exhibited HNK-1 immunoreactivity. Expression of the HNK-1 glycotope in cutaneous malignant melanoma is an independent prognostic marker of metastasis. Differential HNK-1 expression at the metastatic sites implies that its expression is modulated by the surrounding environment. As HNK-1 is also transiently expressed during migration of melanocyte precursor cells derived from the neural crest, recapitulation of this transient expression might occur during metastatic spread of cutaneous malignant melanoma.

Clinical evaluation of TIELLE* Plus dressing in the management of exuding chronic wounds

This clinical evaluation, which was carried out between May 2000 and January 2001, measured the efficacy and safety of TIELLE* Plus dressing, a novel hydropolymer dressing with super-absorbent properties. In total 2121 patients with leg ulcers (59.1%), pressure ulcers (20.7%), diabetic foot ulcers (10.9%) or other chronic wounds (9.4%) were included in the study. These were recruited by 624 physicians in a German post-marketing study. All wounds had been present for at least 4 weeks prior to treatment with TIELLE* Plus dressings and many had been treated with other dressings previously. Within the observation period of 12 weeks, 43% of the wounds healed and 50.4% were considered as 'improved'. With this combined total of about 95% the subjects clearly benefited from a change in therapy from conventional regimes (in Germany) such as ointments and gauze, but also from modern, moist wound healing dressings such as hydrocolloids. The frequency of side-effects was low at 4.8%. Over 90% of the patients rated the TIELLE* Plus dressing therapy as 'much better' or 'better' tolerated than the previous treatment regime. For the large majority of the patients the quality of life also improved. On the basis of the positive experiences with respect to effectiveness, safety and handling, 96.8% (604) of the participating doctors wanted to adopt TIELLE* Plus dressings in their therapy plan. TIELLE* Plus dressings can be considered as an effective, safe and simple-to-handle wound dressing for therapy of chronic wounds in daily practice. The shortening of healing time and the less frequent change of dressing also make this therapy regime attractive on cost grounds.

Overexpression of the cell adhesion molecule L1 is associated with metastasis in cutaneous malignant melanoma

Modulation of cell adhesion molecule expression plays a key role in melanoma metastasis. In particular, the expression of the cell adhesion molecule L1 has been associated with the metastatic phenotype in a murine model of malignant melanoma. However, no such association between L1 expression and metastasis has been investigated in a clinical study. Therefore, L1 expression was determined immunohistochemically in 100 cases of malignant melanoma and correlated with metastasis in a 10-year retrospective study. Furthermore, nine distant metastases and five sentinel lymph node metastases were analysed for their L1 expression. Additionally, the expression of alpha2,3 sialic acid residues, which are recognised by the siglec domain of L1, was determined by Maackia amurensis agglutinin (MAA) lectin histochemistry. The log-rank test between Kaplan-Meier curves revealed a positive association between L1 expression and metastasis (P<0.0001) and multivariate Cox regression analysis adjusted for tumour thickness, ulceration and mitotic rate confirmed the prognostic power of L1 in malignant melanoma. As alpha2,3 sialic acid residues were absent in melanoma cells, homotypic adhesion between melanoma cells via their siglec domain can be excluded, suggesting a different adhesive function of L1 during melanoma metastasis. The functional role of L1 was further stressed by the fact that its expression was preserved in metastatic lesions.

CEACAM1 expression in cutaneous malignant melanoma predicts the development of metastatic disease

PURPOSE

The cell adhesion molecule CEACAM1 is involved in intercellular adhesion and subsequent signal transduction events in a number of epithelia. CEACAM1 downregulation has been demonstrated in colorectal and prostate carcinomas. This study sought to analyze whether its expression in malignant melanoma is associated with metastasis.

PATIENTS AND METHODS

CEACAM1 expression was immunohistochemically evaluated in 100 primary cutaneous malignant melanomas and correlated with metastasis in a 10-year follow-up. Furthermore, CEACAM1 expression was analyzed in metastatic lesions (11 distant metastases and six sentinel lymph node metastases). Univariate Kaplan-Meier analysis and multivariate Cox proportional hazard regression analysis adjusted for standard prognostic indicators were performed to assess the prognostic relevance of CEACAM1 expression.

RESULTS

A total of 28 of 40 patients with CEACAM1-positive primary melanomas developed metastatic disease, compared with only six of 60 patients with CEACAM1-negative melanomas. Often, the strongest CEACAM1 expression was observed at the invading front. In addition, CEACAM1 expression was preserved in the metastatic lesions. Kaplan-Meier analysis revealed a highly significant association between CEACAM1 expression and metastasis (P <.0001); multivariate Cox regression analysis, including CEACAM1 expression status adjusted for tumor thickness, presence of ulceration, and mitotic rate, confirmed that CEACAM1 is an independent factor for the risk of metastasis and demonstrated that the predictive value of CEACAM1 expression is superior to that of tumor thickness.

CONCLUSION

Expression of the cell adhesion molecule CEACAM1 in the primary tumors in melanoma patients is associated with the subsequent development of metastatic disease. This raises the possibility of a functional role for this cell adhesion molecule in the metastatic spread it indicates.

Cyclosporine in severe psoriasis. Results of a meta-analysis in 579 patients

OBJECTIVE

A meta-analysis of 3 major German studies conducted between 1989 and 1994 with cyclosporine in severe psoriasis was performed to allow an integrated evaluation of the efficacy and tolerability of cyclosporine in this indication.

DESIGN AND SETTING

All 3 studies were prospective, randomized, parallel group studies. The studies were conducted in 61 dermatologic centers in Germany.

PATIENTS AND INTERVENTIONS

The studies involved 597 patients with severe plaque type psoriasis. Treatment consisted of cyclosporine (at a dosage of 1.25, 2.5 or 5 mg/kg/day), etretinate (at a mean daily dose of 0.53 mg/kg/day) or placebo in a total of 756 treatment cycles with a maximum duration of 12 weeks.

MAIN OUTCOME MEASURES

The main outcome measures were the psoriasis area and severity index (PASI) and serum creatinine level.

RESULTS

The meta-analysis revealed that cyclosporine given in a dosage of 2.5 and 5 mg/kg/day was significantly superior to etretinate. In addition cyclosporine 1.25 mg/kg/day proved to be significantly more effective than placebo. An increase in serum creatinine level that required intervention occurred in 3.4% of cyclosporine treatment cycles.

CONCLUSION

Cyclosporine is highly effective and well tolerated in the short term treatment of severe psoriasis.

Cyclin-dependent kinase-inhibitor 1 (CDKN1A) in the squamous epithelium of the oropharynx: possible implications of molecular biology and compartmentation

The cdknlA gene encodes CDKN1A, a protein that regulates cell cycle progression, terminal differentiation, and apoptosis. Polymorphisms or loss of heterozygosity of this usually biallelically expressed gene have no major impact on carcinogenesis. The prevalence of somatic mutations in malignancies is low. Gene rearrangements involving cdknlA are scarce. CDKN1A is expressed in both premalignant and malignant lesions. While the prognostic value of nuclear CDKN1A expression is controversial, the prognostic value of its recently discovered cytoplasmic accumulation is simply unknown. CDKN1A translocates from the nucleus to the cytoplasm when cleaved by caspase-like activities during early apoptosis. The presence of cytoplasmic catabolites (e.g.: p14) might therefore indicate apoptosis. We found no correlation between nuclear and cytoplasmic anti-CDKN1A immunoreactivity in our samples of oropharyngeal squamous cell carcinoma. CDKN1A Cap20, CDKN1, CDKN1A, CDKNA1, Cip-1, Mda-6, P21, Pic1, Sdi-1, Waf-1.

Evaluating a superabsorbent hydropolymer dressing for exuding venous leg ulcers

A new hydropolymer dressing was compared with an alginate dressing in a multicentre, prospective, controlled, randomised, stratified, open label trial of 113 patients with exuding venous leg ulcers. The study aimed to evaluate the performance of the dressings in terms of their ability to handle exudate, patient and user acceptability and cost-effectiveness. Patients were stratified according to volume of wound exudate (moderate/heavy) and randomised to the hydropolymer dressing or the alginate plus a secondary dressing. A statistically significant difference between treatment groups was observed in mean wear time, with a longer wear time observed in the hydropolymer group (3.91 days) compared with the alginate group (3.09 days, p = 0.001). In terms of patient and user acceptability, all 10 overall evaluations made by both patient and investigator were markedly in favour of the hydropolymer dressing (p < 0.001 to p = 0.020). The use of the hydropolymer dressing for patients with moderate to heavily exuding venous leg ulcers has statistically significant advantages over the alginate dressing in terms of wear time and investigator and patient acceptability. It is anticipated that this reduction in dressing frequency will translate into a cost-effective wound treatment.

Effects of the propofol combination anesthesia on the intrinsic blood-clotting system

Fat emulsions can cause changes in blood-clotting and fibrinolysis. The aim of this study was to examine the relation between the use of the short-acting hypnotic propofol and alteration of the blood clotting system. In a double-blind randomized study, 36 patients with an aortocoronary bypass operation were given either midazolam/fentanyl or propofol/alfentanil. Eleven blood samples were taken at fixed times pre-, intra- and postoperatively to determine changes caused by the anesthetic agents on the hemostaseologic parameters during the whole operation. Perioperative blood pressures of both groups were measured at seven fixed points. From the beginning of the extracorporeal circulation (ECC) to the end of the operation, the measured values of the factor XIIa- and kallikrein-like activity in the propofol group were significantly higher than those of the midazolam group. Also the values of the kallikrein inhibition capacity and the indicators of fibrinolysis (t-PA and D-dimers) suggest a stronger activation of the contact phase at the start of the recirculation and as a result of it a stronger fibrinolysis within the propofol group. Besides, the hypotensive side-effect in the propofol group was evident in contrast to the midazolam group. With this investigation, a correlation between the application of propofol/alfentanil, contact phase activation with activation of the kallikrein-kinin-bradykinin system and the observed hypotension can be set up.

Evaluation of markers of deep vein thrombosis in patients undergoing surgery for maxillofacial malignancies

During and following significant surgical intervention, deep venous thrombosis prophylaxis by application of anticoagulants is routinely used. However, patients with malignant disorders are subject to an especially high risk of deep venous thrombosis progressing in severe cases to subsequent pulmonary embolism. The present study focuses on appraising modern markers of deep vein thrombosis in 34 patients undergoing major maxillofacial surgery, with some malignant disorders. No significant differences between the two patient groups were noted using the markers of the kallikrein-kinin-system. From the first postoperative day plasma levels of the coagulation indicator thrombin-antithrombin-III complexes were significantly higher in the group of tumour patients. Markers of fibrinolysis indicated corresponding results: on the first postoperative day tissue-plasminogen activator values rose to 18.9 +/- 3.2 micrograms/l in the group of malignant patients, but only to 7.4 +/- 1.1 micrograms/l (P < 0.05) in the control group. Also postoperative D-dimer concentrations in the malignancy group were significantly above those of the control group. In the present study it could be demonstrated that patients with malignant neoplasia undergoing major maxillofacial surgery are exposed postoperatively to a particularly high risk of developing thromboembolic complications. All in all, the status of anti-thrombotic therapy requires reappraisal with respect to the current treatment approach adopted in tumour patients.

Platelet protection in coronary artery surgery: benefits of heparin-coated circuits and high-dose aprotinin therapy

OBJECTIVE

To examine the extent of platelet activation during extracorporeal circulation by using the combination of heparin-coated oxygenation systems and high-dose aprotinin therapy, and to examine the affinity and thereby the protective capacity of aprotinin to the glycoprotein (GP) receptors of the platelet membrane.

DESIGN

Experimental in vitro study.

SETTING

Research laboratory of a university hospital.

PARTICIPANTS

Thirty-two volunteers (blood donors).

MEASUREMENTS AND MAIN RESULTS

Thirty-two oxygenation circuits of the same construction series (16 heparin-coated and 16 noncoated) were investigated in a closed system of a heart-lung machine model with fresh human whole blood. In each of these two groups, eight circuits with and eight without a high-dose aprotinin application (250 kallikrein inhibitory units [KIU]/mL) were investigated. In all four groups, the number of platelets declined continuously during the 90-minute recirculation period. Group I (no heparin coating, no aprotinin) showed the greatest reduction; group IV (heparin coating, aprotinin) had a significantly smaller decrease in platelet number (p < 0.01). Platelet factor 4 (PF-4) levels, released from the alpha-granule, were in inverse proportion to the platelet loss. After 90 minutes of recirculation, the PF-4 values increased to 615.8% +/- 559.5% and 237.2% +/- 179.0% of the initial value for groups I and IV, respectively (p < 0.01). Affinity chromatography and immunoblotting techniques were used to evaluate the affinity of aprotinin for the GP receptors of the platelet membrane. The affinity appeared in the following order: GPIIb < GPIIIa < GPIb.

CONCLUSION

Heparin-coated oxygenation systems and additional aprotinin caused significantly less platelet damage in an in vitro cardiopulmonary bypass model. Chromatographic and immunologic methods could prove aprotinin's affinity for the platelet receptor proteins GPIb and GPIIb-IIIa and therefore its probable role in diminishing the triggering of the platelet activation cascade.

Radiation-induced hyposalivation and its treatment with oral pilocarpine

OBJECTIVE

The aim of this study was to determine the effects of radiation on the secretion of saliva from mucous salivary glands in comparison with serous salivary glands.

STUDY DESIGN

The minor salivary glands of the palate were used as an example of mucous glands, while the parotid glands were used as an example of a serous secretion organ. Serial flow rate measurements of the parotid and palatal glands were taken over a period of approximately 9 months in 13 patients who suffered from malignancies of the head and neck region. Twelve patients consented to take part in a second study in which salivary flow was stimulated by oral pilocarpine before and at the conclusion of radiotherapy and 7 months later. Complaints and symptoms were recorded at each time of measurement.

RESULTS

After radiotherapy, the secretory performance of the parotid glands dropped off rapidly and irreversibly. Salivary secretion from the palatal glands was not totally diminished as a result of radiation. Clinical complaints and histologic findings indicate a serious alteration of the tissues irradiated; however, residual secretion from the remaining parenchyma of the mucous glands still remains. Pilocarpine produced a clinically significant increase of salivary flow from the palatal glands before and 7 months after radiation. Secretory performance of the parotid glands could not be sufficiently increased by stimulation with pilocarpine after radiotherapy. Clinical side effects and risks for the treatment of symptomatic postradiation xerostomia with pilocarpine were minimal.

CONCLUSIONS

These findings emphasize the greater resistance and recoverability of the mucous secreting minor palatal glands in comparison with the serous secreting parotid glands. They also indicate the significant postradiation ability of the mucous secreting glands to be stimulated by pilocarpine.

Human pathogenic virus-associated pseudolymphomas and lymphomas with primary cutaneous manifestation in humans and animals

The etiologic role of viruses in cutaneous lymphoproliferative disorders is still controversial. In benign cutaneous pseudolymphomas of the human skin, human T-cell leukemia/lymphoma virus (HTLV) type I (HTLV-I), varicella zoster virus, Epstein-Barr virus (EBV), and human herpesvirus (HHV) 6 (HHV-6) are the viruses most often identified, whereas in malignant lymphoproliferation human immunodeficiency virus type 1 (HIV-1), HTLV-I/II, and EBV are more common. Coinfections with more than one virus species have occurred in a number of cases. HHV-8 in association with a lymphoproliferative lesion appears to be indicative of a malignant cutaneous lymphoma rather than of pseudolymphoma. Negative results are of no diagnostic value because of the relatively low number of virus-positive cases: a considerable proportion of studies (with a large number of subjects) have documented virus-negative findings. Perhaps with the exception of HIV-1, findings of viral infections seem to indicate secondary rather than primary infections. Reports on animal models associated with human pathogenic viruses are scarce.

High-resolution MR imaging of the cutis and subcutis. Histological correlation

OBJECTIVE

To determine whether the spatial resolution that can be achieved with currently available MR devices is adequate for the evaluation of skin disease.

MATERIAL AND METHODS

We correlated high-resolution MR images of the skin with dermatohistopathology in 26 patients. The examinations were carried out on a 1.0 T imager using a commercially available surface coil (ID 7.5 cm) and optimized SE and GE sequences. Image quality was assessed by four readers on a questionnaire.

RESULTS

The visualization of the dermis, subcutaneous tissue, and muscle fascia allowed a pattern analysis that gave findings identical to those at dermatohistopathology. It was possible to distinguish septal from lobular panniculitis, and lipatrophia from sclerodermia. Images with contrast media infusion were useful in the differential diagnosis.

CONCLUSION

High-resolution MR imaging may narrow down the differential diagnosis of various skin diseases and may help to reduce the number of skin biopsies on certain indications.

Effects of the combinations propofol/alfentanil and midazolam/fentanyl on blood pressure and contact phase system during coronary surgery

Perioperative haemodynamic changes leading to severe circulatory problems during open-heart surgery still represent dreaded complications. The aim of this study was to examine the relationship between the use of applied anaesthetic agents and alterations of the contact phase of the intrinsic blood-clotting system, as changes within the kallikrein-kinin system can lead to a fall in blood pressure. In a randomized study, parameters of the kallikrein-kinin system, coagulation and fibrinolysis were determined for 36 patients with aortocoronary bypass operations. The patients had been given either midazolam/fentanyl or propofol/alfentanil to maintain anaesthesia. Perioperative blood pressure values were registered at seven fixed points. The measured values of the factor XIIa-like activity and the kallikrein-like activity suggested a higher activation of the contact phase, when propofol/alfentanil was given. From the start of the extracorporeal circulation (ECC) to the end of the operation, the kallikrein-like activities in the propofol/alfentanil group were significantly higher than those of the midazolam/fentanyl group. Also, the results of the kallikrein inhibition capacity and the indicators of fibrinolysis (t-PA and D-dimers) indicate a stronger activation of the contact phase--at least at the beginning of recirculation--and as a result of it, a stronger fibrinolysis within the propofol/alfentanil group. In addition, the hypotensive side-effects differed significantly between the two groups. Patients receiving propofol/alfentanil needed the triple amount of antihypotonicum to maintain the mean arterial blood pressure above 75 mmHg. With the results of this study, a correlation between the application of propofol/alfentanil, contact phase activation, with activation of the kallikrein-kinin-bradykinin system and the observed hypotension, can be presumed.

[Correlation of MRI and histopathological findings in inflammatory skin diseases]

PURPOSE

Can spatial and contrast resolution be achieved with currently available MR devices for the successful assessment of inflammatory diseases of the skin?

METHOD

High resolution MRI was performed in 20 patients with non-malignant diseases of the dermis and subcutis. The skin biopsies subsequent to the MR examinations were indicated for clinical reasons. The MR examinations were done in the location of later performed skin biopsies using a 1.0 Tesla system (Gyroscan T10 NT, Philips, Best, the Netherlands) and a surface coil of 7.5 cm inner diameter. Conventional spin-echo (SE-Sequenz)- and gradient-echo (GRE)-sequences were optimised to obtain maximum spatial resolution with a sufficient signal-to-noise ratio within a tolerable examination time. MR visualisation of histopathology was assessed by four readers using a questionnaire.

RESULTS

In 15 of 20 cases, high resolution MRI allowed a correct classification of the visualised dermal and subcutaneous patterns, in accordance with the histological work-up of the corresponding specimen. Due to the still only suboptimal spatial and contrast resolution the structure of the epidermis could not be assessed adequately. Determination of contrast enhancement or non-enhancement after administration of intravenous contrast agent provided information on the degree of tissue perfusion in 19 patients, which complemented the morphological assessment.

CONCLUSION

High resolution MRI allows to identify non-invasively histological main patterns of inflammatory skin diseases. However, final diagnosis often depends on higher microscopic resolution and special staining.

Effect of IFN-alpha on normal human hematopoiesis: an immunohistochemical and morphometric study on trephine biopsy specimens

To elucidate the effects of interferon-alpha (IFN-alpha) on normal human bone marrow in vivo, an immunomorphometric study was performed using trephine biopsy specimens without hematopoietic pathology. Samples were derived from patients with mycosis fungoides but no marrow involvement, who were undergoing low-dose IFN-alpha treatment. Parameters included density of reticulin (argyrophilic) fibers, CD61+ megakaryocytes, PGM1+ macrophages, the GSA-I lectin-expressing (activated) macrophage subpopulation, proliferative activity (PCNA staining), and apoptosis. Following IFN-alpha therapy (3 x 3 x 10(6) U/week between 6 and 21 months), morphometric evaluation of sequential bone marrow examinations revealed a significant increase in the number of megakaryocytes and the amount of reticulin fibers. Additionally, there was an overall decrease in PCNA+ cells, accompanied by a reduction in the incidence of apoptotic bodies. On the other hand, total number of macrophages and their activated subfraction remained unchanged. Opposed to in vitro findings, a fibrogenetic capacity of IFN-alpha associated with megakaryocyte growth was detectable. Moreover, contrasting with effects of IFN-alpha treatment in chronic myelogenous leukemia, the incidence of apoptosis was significantly reduced. This feature was assumed to contribute to a maintenance of steady-state hematopoiesis expressed by a nonaltered bone marrow cellularity in our specimens.