GWAS for systemic sclerosis identifies six novel susceptibility loci including one in the Fcγ receptor region

Here we report the largest Asian genome-wide association study (GWAS) for systemic sclerosis performed to date, based on data from Japanese subjects and comprising of 1428 cases and 112,599 controls. The lead SNP is in the FCGR/FCRL region, which shows a penetrating association in the Asian population, while a complete linkage disequilibrium SNP, rs10917688, is found in a cis-regulatory element for IRF8. IRF8 is also a significant locus in European GWAS for systemic sclerosis, but rs10917688 only shows an association in the presence of the risk allele of IRF8 in the Japanese population. Further analysis shows that rs10917688 is marked with H3K4me1 in primary B cells. A meta-analysis with a European GWAS detects 30 additional significant loci. Polygenic risk scores constructed with the effect sizes of the meta-analysis suggest the potential portability of genetic associations beyond populations. Prioritizing the top 5% of SNPs of IRF8 binding sites in B cells improves the fitting of the polygenic risk scores, underscoring the roles of B cells and IRF8 in the development of systemic sclerosis. The results also suggest that systemic sclerosis shares a common genetic architecture across populations.

OP0112 THE EVER-LARGEST ASIAN GWAS FOR SYSTEMIC SCLEROSIS AND TRANS-POPULATION META-ANALYSIS IDENTIFIED SEVEN NOVEL LOCI AND A CANDIDATE CAUSAL SNP IN A CIS-REGULATORY ELEMENT OF THE FCGR REGION

Background

Genome-wide association studies (GWASs) have identified 29 disease-associated single nucleotide polymorphisms (SNPs) for systemic sclerosis (SSc) in non-human leukocyte antigen (HLA) regions (1-7). While these GWASs have clarified genetic architectures of SSc, study subjects were mainly Caucasians limiting application of the findings to Asians.

Objectives

The study was conducted to identify novel causal variants for SSc specific to Japanese subjects as well as those shared with European population. We also aimed to clarify mechanistic effects of the variants on pathogenesis of SSc.

Methods

A total of 114,108 subjects comprising 1,499 cases and 112,609 controls were enrolled in the two-staged study leading to the ever-largest Asian GWAS for SSc. After applying a strict quality control both for genotype and samples, imputation was conducted using the reference panel of the phase 3v5 1,000 genome project data combined with a high-depth whole-genome sequence data of 3,256 Japanese subjects. We conducted logistic regression analyses and also combined the Japanese GWAS results with those of Europeans (6) by an inverse-variance fixed-effect model. Polygenicity and enrichment of functional annotations were evaluated by linkage disequilibrium score regression (LDSC), Haploreg and IMPACT programs. We also constructed polygenic risk score (PRS) to predict SSc development.

Results

We identified three (FCRLA-FCGR, TNFAIP3, PLD4) and four (EOMES, ESR1, SLC12A5, TPI1P2) novel loci in Japanese GWAS and a trans-population meta-analysis, respectively. One of Japanese novel risk SNPs, rs6697139, located within FCGR gene clusters had a strong effect size (OR 2.05, P=4.9×10-11). We also found the complete LD variant, rs10917688, was positioned in cis-regulatory element and binding motif for an immunomodulatory transcription factor IRF8 in B cells, another genome-wide significant locus in our trans-ethnic meta-analysis and the previous European GWAS. Notably, the association of risk allele of rs10917688 was significant only in the presence of the risk allele of the IRF8. Intriguingly, rs10917688 was annotated as one enhancer-related histone marks, H3K4me1, in B cells, implying that FCGR gene(s) in B cells may play an important role in the pathogenesis of SSc. Furhtermore, significant heritability enrichment of active histone marks and a transcription factor C-Myc were found in B cells both in European and Japanese populations by LDSC and IMPACT, highlighting a possibility of a shared disease mechanism where abnormal B-cell activation may be one of the key drivers for the disease development. Finally, PRS using effects sizes of European GWAS moderately fit in the development of Japanese SSc (AUC 0.593), paving a path to personalized medicine for SSc.

Conclusion

Our study identified seven novel susceptibility loci in SSc. Downstream analyses highlighted a novel disease mechanism of SSc where an interactive role of FCGR gene(s) and IRF8 may accelerate the disease development and B cells may play a key role on the pathogenesis of SSc.

References

[1]F. C. Arnett et al. Ann Rheum Dis, 2010.

[2]T. R. Radstake et al. Nat Genet, 2010.

[3]Y. Allanore et al. PLoS Genet, 2011.

[4]O. Gorlova et al. PLoS Genet, 2011.

[5]C. Terao et al. Ann Rheum Dis, 2017.

[6]E. López-Isac et al. Nat Commun, 2019.

[7]W. Pu et al. J Invest Dermatol, 2021.

Disclosure of Interests

None declared

Genomic landscape of circulating tumour DNA in metastatic extramammary Paget's disease

Although cancer personalized profiling by deep sequencing (CAPP-Seq) of cell-free DNA (cfDNA) has gained attention, the clinical utility of circulating tumour DNA (ctDNA) in extramammary Paget's disease (EMPD) has not been investigated. In this study, genomic alterations in the cfDNA and tumour tissue DNA were investigated in seven patients with metastatic EMPD. CAPP-Seq revealed mutations in 18 genes, 11 of which have not yet been reported in EMPD. The variant allele frequency of some of the mutated genes reflected the disease course in patients with EMPD. In one patient, the mutation was detected even though imaging findings revealed no metastasis. In another patient with triple EMPD (genital area and both axilla), cfDNA sequencing detected the mutation in a rib metastatic lesion, which was also detected in both axilla lesions but not the genital region. Investigations of the ctDNA may be useful towards the elucidation of clonal evolution in EMPD.

Effect of adalimumab on axial manifestations in Japanese patients with psoriatic arthritis: a 24 week prospective, observational study

OBJECTIVES

PsA is characterized by enthesitis, synovitis and osseous involvement in the peripheral and axial joints. Few studies have examined axial involvement in PsA using imaging techniques. Here we examined axial involvement in PsA patients using MRI. In addition, we determined the efficacy of 24 week adalimumab treatment in improving the MRI findings of spondylitis and sacroiliitis.

METHODS

This was a prospective, open-label, single-arm study in patients with PsA. Adalimumab was administered to patients for a total of 24 weeks. MRI examinations were conducted at baseline and at week 24 of adalimumab treatment.

RESULTS

Thirty-seven patients with PsA were included in this study. Spondylitis was observed in at least one site of the positive scan in 91% (n = 31) of patients with PsA. The number of arthritic sites in the cervical, thoracic and lumbar regions of the spine was 48, 67 and 53, respectively. All patients had MRI-determined sacroiliitis of grade ≥1 severity while 28 patients (82%) had grade ≥2 sacroiliitis in at least one sacroiliac region. Sacroiliac arthritis was statistically more severe on the right side than on the left side (P < 0.05). In 34 patients with PsA, the thoracic spine was the most common site of spondylitis. In addition, 24 week adalimumab treatment led to an improvement in the mean number of spondylitis sites and the mean grade of sacroiliitis.

CONCLUSION

Treatment with adalimumab for 24 weeks resulted in improvement in spondylitis and sacroiliitis.

Overexpression of Janus kinase 2 protein in extramammary Paget's disease

Extramammary Paget's disease is a rare malignant tumor of the skin that occurs primarily in the genitocrural region. Although the prognosis of extramammary Paget's disease with distant metastasis is poor, an effective therapy has not been established. Because Janus kinase 2 has attracted attention as a therapeutic target in several cancers, we investigated the expression of the Janus kinase 2 protein and the relationship between its level of expression and clinical significance in 53 patients with extramammary Paget's disease in our hospital. Immunohistochemistry showed that most extramammary Paget's disease tissues were positive for Janus kinase 2 (50/53, 94.3%), and the immunostaining intensity of Janus kinase 2 was correlated with the degree of invasiveness, lymph node metastasis and distant metastasis. Based on these findings, Janus kinase 2 may be a promising therapeutic target in extramammary Paget's disease.

Absence of microsatellite instability in extramammary Paget's disease

Background

Deficiency of DNA mismatch repair (MMR) induces microsatellite instability (MSI). Pembrolizumab, an antibody targeting PD‐1 (an immune checkpoint inhibitor), is more effective against MMR‐deficient tumours than against MMR‐proficient tumours. The status of MMR is a useful biomarker for predicting the effectiveness of pembrolizumab administration. Although the status of MMR has attracted attention in skin tumours, there are few reports on MSI in extramammary Paget's disease (EMPD).

Objectives

To evaluate the status of MMR in patients with EMPD.

Materials & Methods

One hundred one patients with EMPD were included. MMR status of the genomic DNA of each subject was analysed using Promega panel (approved as a companion diagnostic agent for the administration of pembrolizumab).

Results

MSI testing showed the occurrence rates of MSI‐high (more than two markers are unstable), MSI‐low (one marker is unstable) and MSS (all markers are stable) tumour tissues were 0% (0/101), 1.0% (1/101) and 99.0% (100/101), respectively.

Conclusion

The status of MMR may not be useful for the potential therapeutic application of pembrolizumab.

Liquid biopsy-based analysis by ddPCR and CAPP-Seq in melanoma patients

BACKGROUND

The development of BRAF/MEK inhibitors in patients with metastatic melanoma harboring BRAF mutations has garnered attention for liquid biopsy to detect BRAF mutations in cell-free DNA (cfDNA) using droplet digital PCR (ddPCR) or next-generation sequencing methods.

OBJECTIVE

To investigate gene mutations in tumor DNA and cfDNA collected from 43 melanoma patients and evaluate their potential as biomarkers.

METHODS

ddPCR and CAncer Personalized Profiling by deep Sequencing (CAPP-Seq) techniques were performed to detect gene mutations in plasma cfDNA obtained from patients with metastatic melanoma.

RESULTS

Gene variants, including BRAF, NRAS, TP53, GNAS, and MET, were detectable in the plasma cfDNA, and the results were partially consistent with the results of those identified in the tissues. Among the variants examined, copy numbers of MET mutations were consistent with the disease status in two melanoma patients.

CONCLUSION

Liquid biopsy using CAPP-Seq and ddPCR has the potential to detect tumor presence and mutations, especially when tissue biopsies are unavailable. MET mutations in cfDNA may be a potential biomarker in patients with metastatic melanoma.

Ungual hyalohyphomycosis caused by Fusarium cugenangense

Fusarium onychomycosis is uncommon in the temperate climate zone of Japan. Based on the morphological characteristics and a gene analysis, we diagnosed a patient with ungual hyalohyphomycosis caused by Fusarium cugenangense belonging to the F oxysporum complex. This intractable disease was cured by 6-month treatment with efinaconazole 10% solution.

miR-524-5p reduces the progression of the BRAF inhibitor-resistant melanoma

BRAF inhibitors were approved for the treatment of BRAF-mutant melanoma. However, most patients acquire the resistance to BRAF inhibitors after several months of treatment. miR-524-5p is considered as a tumor suppressor in many cancers, including melanoma. In this study, we investigated the biological functions of miR-524-5p in melanoma with acquired resistance to BRAF inhibitor and evaluated the endogenous miR-524-5p expression as a biomarker for melanoma. The results showed that the expression of miR-524-5p was 0.481-fold lower in melanoma tissues (n = 117) than in nevus tissues (n = 40). Overexpression of miR-524-5p significantly reduced proliferative, anchorage-independent growth, migratory and invasive abilities of BRAF inhibitor-resistant melanoma cells. Moreover, the introduction of miR-524-5p led to a reduced development of BRAF inhibitor-resistant melanoma in vivo. Remarkably, the MAPK/ERK signaling pathway was decreased after treatment with miR-524-5p. Furthermore, next-generation sequencing analysis implied that the complement system, leukocyte extravasation, liver X receptor/retinoid-X-receptor activation, and cAMP-mediated signaling may be related to miR-524-5p-induced pathways in the resistant cells. The miR-524-5p level was higher on average in complete response and long-term partial response patients than in progressive disease and short-term partial response patients treated with BRAF inhibitors. Our results proposed that miR-524-5p could be considered as a target for treatment BRAF inhibitor-resistant melanoma and a prognostic marker in the response of patients to BRAF inhibitors for melanoma.

Fosravuconazole to treat severe onychomycosis in the elderly

Fosravuconazole is a novel oral antifungal drug developed in Japan and used to treat tinea unguium since 2018. Its excellent oral absorbability and systemic bioavailability has enabled short-duration therapy of 3 months. Furthermore, no concomitant drugs are contraindicated due to the presence of the mild inhibitor of cytochrome P450 enzyme which is responsible for polypharmacy adverse effects. Therefore, it can be safely administrated to elderly patients. Elderly patients (≥65 years old) with severe onychomycosis (≥50% nail involvement) were treated with oral fosravuconazole 100 mg once daily for 12 weeks. The rate of involvement improved from 86.6% to 28.1% (P < 0.01). The efficacy (i.e. percentage of those rated as "improved" and better) and cure rate was 83.8% (31/37) and 29.7% (11/37), respectively. Furthermore, when focusing on the thin nail group (<3 mm), the efficacy and cure rate was 88.2% (15/17) and 58.8% (10/17), respectively. Although the serum γ-glutamyltransferase levels increased in 21.6% (8/37), all patients recovered without any specific treatments.

Overexpression of MUC16 (CA125) in extramammary Paget's disease

In this study, we identified the mucin-16 (CA125), a well-known disease marker for ovarian cancer, is overexpressed in the lesions of Extramammary Paget’s disease.

CXCL17-mediated downregulation of type I collagen via MMP1 and miR-29 in skin fibroblasts possibly contributes to the fibrosis in systemic sclerosis

BACKGROUND

Systemic sclerosis (SSc) is characterized by excessive deposition of collagen in the skin and internal organs. Recent studies have shown that chemokine (C-X-C motif) ligands (CXCLs) are involved in the pathogenesis of SSc.

OBJECTIVE

Our aim was to examine the anti-fibrotic potential of CXCL17, a newly discovered chemokine, in cultured skin fibroblasts and in a bleomycin-induced SSc mouse model. Moreover, we examined serum level of CXCL17 in patients with SSc.

METHODS

Type I collagen expression was evaluated in SSc skin and cultured fibroblasts treated with CXCL17 using immunoblotting and quantitative reverse transcription-PCR. Serum CXCL17 levels were determined using enzyme-linked immunosorbent assay in 63 patients with SSc and 17 healthy subjects. A bleomycin-induced SSc mouse model was used to evaluate the effect of CXCL17 on skin fibrosis.

RESULTS

CXCL17 reduced the expression of type I collagen in healthy control fibroblasts. CXCL17 also induced matrix metalloproteinase 1 (MMP1) and miR-29 expression in fibroblasts, indicating that CXCL17 regulates type I collagen expression in part via post-transcriptional mechanisms through MMP1 and miR-29. We found that local injection of CXCL17 attenuated bleomycin-induced skin fibrosis in mice. CXCL17 levels in SSc skin were lower than those in healthy controls, in contrast to the high serum CXCL17 levels in patients with SSc. The low expression of CXCL17 in SSc skin possibly affects type I collagen accumulation in this disease.

CONCLUSION

Our data indicate that understanding CXCL17 signaling may lead to a better therapeutic approach for SSc.

Methyl-CpG binding domain protein 3: a new diagnostic marker and potential therapeutic target of melanoma

Methyl-CpG binding domain protein 3 (MBD3) belongs to the methyl-CpG binding protein family. MBD3 facilitates the initiation of neural stem cell reprogramming. Melanoma originates in melanocytes derived from neural crest stem cells; therefore, we investigated the role of MBD3 in melanoma. MBD3 was overexpressed in melanoma compared with pigmented nevi. MBD3 knockdown had no effect on the proliferation of melanoma cells (A375 and A2058 cells). Contrarily, it significantly reduced the migration and invasion of A375 cells, but had no significant effect on A2058 cells. Furthermore, MBD3 knockdown reduced N-cadherin protein levels and matrix metalloproteinase-2 (MMP-2) activity in A375 cells, but had no significant effect on A2058 cells. Based on these results, the MBD3 expression level may be a useful biomarker for the diagnosis of melanoma. Thus, MBD3 has potential as a novel therapeutic target for some melanoma patients.

Type I Interferon Delivery by iPSC-Derived Myeloid Cells Elicits Antitumor Immunity via XCR1+ Dendritic Cells

Type I interferons (IFNs) play important roles in antitumor immunity. We generated IFN-α-producing cells by genetically engineered induced pluripotent stem cell (iPSC)-derived proliferating myeloid cells (iPSC-pMCs). Local administration of IFN-α-producing iPSC-pMCs (IFN-α-iPSC-pMCs) alters the tumor microenvironment and propagates the molecular signature associated with type I IFN. The gene-modified cell actively influences host XCR1⁺ dendritic cells to enhance CD8⁺ T cell priming, resulting in CXCR3-dependent and STING-IRF3 pathway-independent systemic tumor control. Administration of IFN-α-iPSC-pMCs in combination with immune checkpoint blockade overcomes resistance to single-treatment modalities and generates long-lasting antitumor immunity. These preclinical data suggest that IFN-α-iPSC-pMCs might constitute effective immune-stimulating agents for cancer that are refractory to checkpoint blockade.

A successful case of lupus myelitis treated with intravenous pulse methylprednisolone and pulse cyclophosphamide therapy

Lupus myelitis is a rare but serious condition characterized by myelopathy in patients with systemic lupus erythematosus (SLE). Its presentation is usually acute or subacute, and it is often refractory to treatment. We reported a rare presentation of lupus myelitis in a 38-year-old Japanese woman with a 20-year history of SLE. She developed paraparesis and bladder/bowel dysfunction 6 months prior to presentation. Magnetic resonance imaging revealed atrophy of the entire thoracic spinal cord with high intensity on T1-weighted sequence. She was initially treated with intravenous pulse steroid therapy, and prednisolone (20 mg/day) was continued; mizoribine was changed to azathioprine (100 mg/day). In addition, she underwent a rehabilitation program to improve lower-extremity muscle weakness. Moreover, because of the refractory clinical condition, intravenous cyclophosphamide pulse therapy was added. Within 1 month, she could walk with a cane and had a desire to urinate and defecate. In conclusion, early and aggressive treatment improves the permanent damage of lupus myelitis.

Matrin-3 plays an important role in cell cycle and apoptosis for survival in malignant melanoma

BACKGROUND

A previous study revealed that matrin-3 is an essential component in maintaining fibroblast growth factor 2 (FGF2)-mediated undifferentiation of neural stem cells (NSCs) using a proteomics approach. Malignant melanoma (MM) arises from melanocytes that originate from neural crest stem cells during development. Additionally, it has been reported that the expression of FGF2 is positively correlated with the progression of MM.

OBJECTIVE

We expected that matrin-3, as a downstream component of FGF2, might be associated with the aggressiveness or differentiation of MM.

METHODS

Matrin-3 expression was measured in human melanoma patient tissues and human MM cell lines. We analyzed the effect of matrin-3 siRNA on the proliferation of human MM cell lines and focused on cell cycle progression and apoptosis. We carried out in vivo xenograft tumor experiments by implanting A375 cells transfected with matrin-3 shRNA.

RESULTS

Matrin-3 was highly expressed in MM, and matrin-3 knockdown inhibited the proliferation of melanoma cellsin vivo and in vitro. Furthermore, we found that matrin-3 knockdown led to an accumulation of cells in the G1 phase and an increase in apoptotic cell number.

CONCLUSION

Our results suggest that matrin-3 could be a new therapeutic target for the treatment of MM.

Characteristics of Japanese patients with eosinophilic fasciitis: A brief multicenter study

Eosinophilic fasciitis is a relatively rare cutaneous fibrotic condition affecting the deep fascia of the extremities, with or without peripheral blood eosinophilia. To examine the characteristics of Japanese patients with eosinophilic fasciitis, we conducted a brief, multicenter, retrospective survey at seven university hospitals. In total, 31 patients were identified as having eosinophilic fasciitis, among whom 30 patients fulfilled the Japanese diagnostic criteria. The male : female ratio was 2.3:1, and the mean age was 47.7 years. Three of the patients were under 20 years old. The possible triggering factors included muscle training, sports, walking or sitting for a long time, physical work, insect bite and drug. Co-occurrence of morphea was observed in nine cases (29%), and malignancies were associated in three (two hematological malignancies and one internal malignancy). Immunological abnormalities in the serum showed positive antinuclear antibody, positive rheumatoid factor, increased aldolase levels and increased immunoglobulin G levels. The patients were treated with either monotherapy or combination therapy by oral prednisolone (20-80 mg/day), methotrexate (6-10 mg/week), cyclosporin (100-150 mg/day), mizoribine, infliximab and phototherapy. Methylprednisolone pulse therapy was performed in six cases. By contrast, spontaneous improvement due to resting only was observed in two cases, and skin hardening was improved by withdrawal of the anticancer drug in one case. This study suggests several characteristics of Japanese patients with eosinophilic fasciitis, namely male predominance, rare pediatric occurrence, immunological abnormalities and coexistence with morphea. Systemic prednisolone is the first-line therapy, but pulse therapy is occasionally required for severe cases. The triggering events of physical stress are not so frequent as have previously been reported, and various factors or even unknown factors may be associated with the induction of eosinophilic fasciitis.

Non-dermatophyte Mould Onychomycosis in Japan

The incidence of non-dermatophyte mould onychomycosis has been increasing worldwide for the past several decades, but it is not well recognized in Japan. Recent molecular techniques and phylogenetic analyses contributed to the identification of uncommon and emerging species. We came across 13 (0.5%) cases of non-dermatophyte onychomycosis among a total of 2,591 onychomycosis cases in 106,703 outpatients during the past 5 years (January 2015-December 2019). The cases included 5 patients with Aspergillus species, 4 patients with Fusarium species, and one patient each with Scopulariopsis brevicaulis and Botryosphaeria dothidea, respectively. Botryosphaeria dothidea is closely related phylogenetically to Neoscytalidium dimidiatum. In Japan, at the time of writing this report, there are 26 reported cases of ungual aspergillosis and 18 cases of hyalohyphomycosis caused by Fusarium species. We summarize these cases and report the symptoms and mycological features.

Single administration of avelumab induced a complete response in thyroid transcription factor 1-positive combined Merkel cell carcinoma

Merkel cell carcinoma (MCC) is an aggressive neoplasm and patients with metastasis have poor survival outcomes. Recently, avelumab, an anti-programmed death ligand 1 (PD-L1) immune checkpoint inhibitor, was approved for first-line treatment in patients with metastatic MCC. While the administration interval of avelumab is every 2 weeks, the durable effect of a single administration of avelumab is unknown. Additionally, the effect of avelumab in pure MCC or combined MCC concurrent with non-MCC histology has not been fully elucidated. Herein, we report a case of combined MCC concurrent with squamous cell carcinoma; the patient had a complete response after a single administration of avelumab. Although the levels of avelumab were outside the detection limit within 12 weeks, a remarkable efficacy remained for more than 28 weeks after administration. Immunohistochemical analyses revealed that the expression of PD-L1 and Merkel cell polyomavirus large T antigen was almost negative or only partial in the primary tumor lesion of this patient. Conversely, thyroid transcription factor 1 (TTF-1) expression was positive in the primary MCC lesion, which is consistent with a previous report that combined MCC is positive for TTF-1 expression. In conclusion, this case study presents a rare case of TTF-1-positive combined MCC showing complete response after a single administration of avelumab.

Initial predictors of skin thickness progression in patients with diffuse cutaneous systemic sclerosis: Results from a multicentre prospective cohort in Japan

OBJECTIVE

To identify initial parameters that predict worsening of skin thickening in patients with diffuse cutaneous systemic sclerosis (dcSSc) using a multicentre, prospective, observational cohort in Japan.

METHODS

A total of 171 patients with dcSSc were selected from a prospective cohort database based on the following criteria: dcSSc, modified Rodnan total skin thickness score (mRSS) ≥7, disease duration <60 months, and valid mRSS data at one year. Worsening of skin thickness was defined as an increase in mRSS ≥3 points and an increase ≥25% from baseline to one year. Initial demographic and clinical parameters useful for predicting the progression of skin thickness were identified using univariate and multivariable analysis, and prediction models of skin thickening progression were built based on combinations of independent predictive parameters.

RESULTS

Only 23 patients (13.5%) experienced worsening mRSSs at one year. Short disease duration, low mRSS, absence of nailfold bleeding, arthritis, and a high erythrocyte sedimentation rate at diagnosis were identified as predictors of subsequent worsening of the mRSS even after adjusting for the treatment. Assessment of the best predictive model revealed that patients with a disease duration ≤12 months and mRSS ≤19 had a risk of mRSS worsening within one year, with a sensitivity of 73.9% and specificity of 81.1%.

CONCLUSION

Identification of predictors of subsequent worsening of skin thickness in dcSSc patients is useful for identifying patients who require intensive treatment with potential disease-modifying agents and for improving clinical trial design by characterizing eligible progressors in the Japanese population.

Wound, pressure ulcer and burn guidelines - 1: Guidelines for wounds in general, second edition

The Japanese Dermatological Association prepared the clinical guidelines for the "Wound, pressure ulcer and burn guidelines", second edition, focusing on treatments. Among them, "Guidelines for wounds in general" is intended to provide the knowledge necessary to heal wounds, without focusing on particular disorders. It informs the basic principles of wound treatment, before explanations are provided in individual chapters of the guidelines. We updated all sections by collecting references published since the publication of the first edition. In particular, we included new wound dressings and topical medications. Additionally, we added "Question 6: How should wound-related pain be considered, and what should be done to control it?" as a new section addressing wound pain, which was not included in the first edition.

IL-16 expression is increased in the skin and sera of patients with systemic sclerosis

OBJECTIVES

SSc is an autoimmune disease with chronic and persistent inflammation in its pathogenesis. To examine the expression pattern of IL-16 in SSc lesions, the serum concentration of IL-16 in SSc patients and the relationship between serum IL-16 levels and the clinical symptoms of SSc were investigated.

METHODS

Using immunohistochemical analysis, we examined the quantity and localization of IL-16 in affected skin obtained from SSc patients. We also measured serum levels of IL-16 in SSc patients using an ELISA. We then validated the correlation between serum IL-16 levels and clinical symptoms in patients with SSc.

RESULTS

In the skin, IL-16 was expressed on the lymphocytes around the capillaries. Furthermore, the proportion of IL-16-positive cells was statistically higher in patients with dcSSc than in those with lcSSc patients (43.9 vs 29.1%, P < 0.05). The serum IL-16 levels in SSc patients were statistically significant elevated compared with healthy controls (297.0 vs 194.9 pg/ml, P < 0.05). Increased serum IL-16 levels in SSc patients were correlated with the proportion classified as dcSSc, skin score and the presence of cutaneous symptoms of erythema and pigmentation.

CONCLUSION

The regional up-regulation of IL-16 in the skin is not only associated with skin sclerosis, but also with systemic IL-16 activation. IL-16 may play a role in the pathogenesis of SSc. Moreover, serum IL-16 levels may be useful as a biomarker for determining the severity of the skin sclerosis. Inhibiting IL-16 activation may be effective in treating SSc.

Serum anti-p53 autoantibodies in angiosarcoma

There is no biomarker for detecting the status of angiosarcoma patients. Studies have reported that serum anti-p53 antibody (Ab) levels are often high in patients with various types of malignant tumors, suggesting the potential use of this Ab as a biomarker for various tumors, including angiosarcoma. The aim of this study was to assess the usefulness of serum anti-p53 Ab as a potent angiosarcoma biomarker. Nineteen angiosarcoma patients were included. All patients had histologically been diagnosed with cutaneous angiosarcoma. We compared p53 protein expression and serum p53 Ab levels between angiosarcoma in the scalp patients (n = 19) and normal controls (n = 30). We evaluated Ab levels before and after therapy. Increased p53 expression was detected in angiosarcoma skin tissues compared with that observed in normal skin tissues. We evaluated serum from angiosarcoma patients and controls for the presence of the anti-p53 Ab. Serum anti-p53 Ab levels were significantly higher in angiosarcoma patients than in controls．Serum anti-p53 Ab levels of patients who showed disease progression after therapy increased in correlation with the medical condition. The Ab levels of three patients, who showed partial response after therapy, decreased in correlation with the medical condition. The Ab levels of the other three patients were low at all time points. Anti-p53 Ab levels were significantly higher in angiosarcoma patients than in the controls. We demonstrated that serum anti-p53 Ab levels would reflect the clinical course of angiosarcoma patients, suggesting that serum anti-p53 Ab can be a potent diagnostic and prognostic biomarker of angiosarcoma.

Clinicopathological demographics of malignant melanoma of the vulva and vagina in Japan: Japanese Gynecologic Oncology Group (JGOG)/Japanese Skin Cancer Society (JSCS)—Intergroup Study

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Background: Malignant melanomas of the vulva (VuM) and vagina (VaM) represent a unique subgroup of malignant melanomas with important differences in biological properties and treatment. In Japan adequate surveys have not been performed.The objective of this study was to elucidate the clinicopathological demographics and outcomes of VuM and VaM in Japan. Methods: Women with invasive VuM or VaM were identified from a medical records. Data on clinician (Gynecologist or Dermatologist), age, location, node status, ulceration, mitotic count, histologic subtype, American Joint Committee on Cancer (AJCC) stage, primary surgery, and surgical margin were collected. The Kaplan-Meier method was used to analyze progression free survival (PFS) and overall survival (OS). Univariate and multivariate regression models were used to identify factors significantly related to survival. Results: A total of 217 patients (pts) were identified; 109 (50.2%) had VuM and 108 (49.8%) had VaM. The median age of the subjects was 67 years (range [R], 29-96 years). Surgery was performed in 84.3% of the women with VuM and 83.3% of those with VaM. The median depth of invasion was 4.5 mm (R, 0.1-12 mm). Ulceration was documented in 47.9% (104/217) of the lesions. Nodal status was positive in 60 pts (27.6%), negative in 149 pts (68.7%), and unknown in 8 (3.7%) pts. The AJCC stage was stage I in 37 pts (17.1%), II in 106 pts (48.8%), III in 46 pts (21.2%), and IV in 28 pts (12.9%). Nodular melanoma was the most common subtype (48.8%). The median PFS was 16.8 months in pts with VuM (95% confidence interval [CI] 23.1-87.7) and 15.6 months in pts with VaM (95% CI 8.4-12.6). The median OS was 43.9 months (95% CI 60-138) in pts with VuM and 31.1 months (95% CI 24.8-45.3) in pts with VaM. Univariate analysis showed that vaginal location, nodal metastases, stage, surgery, and surgical margin were associated with poorer PFS, whereas nodal status, histologic subtype, stage, surgery, and surgical margin were associated with poorer OS. Multivariate analysis showed that only disease stage (hazard ratio [HR] = 3.09; 95% CI = 1.73-5.49) was associated with poorer PFS. Surgical margin was the only independent factor influencing OS (HR = 2.39; 95% CI = 1.48-3.80). Conclusions: The overall outcomes of VuM and VaM remain poor in Japan. In particular, the outcomes of VaM are worse than those reported previously. AJCC stage and surgical margin are important predictors of survival. Regardless of disease stage, suitable surgical resection is required. Clinical trial information: UMIN000025968.

Induced pluripotent stem cell-derived myeloid cells expressing OX40 ligand amplify antigen-specific T cells in advanced melanoma

Immune checkpoint inhibitors improved the survival rate of patients with unresectable melanoma. However, some patients do not respond, and variable immune-related adverse events have been reported. Therefore, more effective and antigen-specific immune therapies are urgently needed. We previously reported the efficacy of an immune cell therapy with immortalized myeloid cells derived from induced pluripotent stem cells (iPS-ML). In this study, we generated OX40L-overexpressing iPS-ML (iPS-ML-Zsgreen-OX40L) and investigated their characteristics and in vivo efficacy against mouse melanoma. We found that iPS-ML-Zsgreen-OX40L suppressed the progression of B16-BL6 melanoma, and prolonged survival of mice with ovalbumin (OVA)-expressing B16 melanoma (MO4). The number of antigen-specific CD8⁺ T cells was higher in spleen cells treated with OVA peptide-pulsed iPS-ML-Zsgreen-OX40L than in those without OX40L. The OVA peptide-pulsed iPS-ML-Zsgreen-OX40L significantly increased the number of tumor-infiltrating T lymphocytes (TILs) in MO4 tumor. Flow cytometry showed decreased regulatory T cells but increased effector and effector memory T cells among the TILs. Although we plan to use allogeneic iPS-ML in the clinical applications, iPS-ML showed the tumorgenicity in the syngeneic mice model. Incorporating the suicide gene is necessary to ensure the safety in the future study. Collectively, these results indicate that iPS-ML-Zsgreen-OX40L therapy might be a new method for antigen-specific cancer immunotherapy.

Increased CD27 expression in the skins and sera of patients with systemic sclerosis

Systemic sclerosis (SSc) is a kind of collagen disease and has an acquired autoimmune activation as represented by the production of autoantibodies. CD27 is a type I glycoprotein and a member of the tumor necrosis factor receptor family. It binds to the CD70 ligand, CD27-CD70 signaling is implicated in the development of various autoimmune diseases, but its role in the regulation of extracellular matrix expression and its contribution to the phenotype of SSc both remain to be elucidated. This study aimed to investigate the associations between CD27 and SSc in the skins and sera. Immunohistochemistry were performed to determine the expression of CD27 in the skin. Enzyme-linked immunosorbent assays were done to the sera of the 54 patients with SSc and 23 normal healthy controls. CD27 expression was significantly increased in the affected regions of the skin and the sera of patients of SSc. Thereafter, we evaluated the correlation between the serum soluble CD27 (sCD27) levels and the clinical symptoms. The study subjects with increased sCD27 levels had a significantly higher ratio of dcSSc and to showed higher modified Rodnan's total skin thickness scores (mRSS) than those with normal sCD27 levels. These results suggest that sCD27 levels might be useful for diagnosis of SSc and its severity.

Non-small-cell Lung Cancer with Severe Skin Manifestations Related to Radiation Recall Dermatitis after Atezolizumab Treatment

Radiation recall dermatitis (RRD) is an inflammatory reaction that occurs at previously irradiated skin regions after drug administration. We herein report a patient with non-small-cell lung cancer treated previously with thoracic radiotherapy who developed severe RRD induced by atezolizumab [anti-programmed death 1 ligand 1 (PD-L1) antibody]. Immunohistochemistry of the skin biopsy showed dermatitis with infiltration of CD8+ lymphocytes, suggesting that atezolizumab might provoke an immune-related inflammatory reaction at previously irradiated skin regions. When administering anti-PD-L1 antibody to patients who have undergone radiotherapy previously, physicians should carefully monitor the irradiated skin for the potential occurrence of RRD.

Clinical course of Japanese patients with early systemic sclerosis: A multicenter, prospective, observational study

OBJECTIVES

To investigate the clinical course of Japanese patients with early diffuse cutaneous systemic sclerosis (dcSSc) and early SSc with interstitial lung disease (ILD).

METHODS

We prospectively analyzed the clinical features of 207 Japanese patients with early dcSSc (n = 150) and limited cutaneous SSc (lcSSc) with ILD (n = 57) in 10 medical centers every year for 7 consecutive years.

RESULTS

Mean modified Rodnan total skin thickness score (mRSS) was 18.3 and 67.4% of the cohort had ILD. Most patients started immunosuppressive therapy and vasodilators during 7 years (83.4% and 87.9%, respectively). Mean value of mRSS of total patients was significantly reduced from the initial registration after the first year. However, other parameters for physical function associated with skin sclerosis including fist closure, hand extension, and oral aperture were not so ameliorated during the study period. Health Assessment Questionnaire-disability index and serum KL-6 levels were constant throughout the course. Percent vital capacity and the presence of ILD, clinically suspected pulmonary arterial hypertension, and digital ulcers were gradually exacerbated during the period.

CONCLUSION

In Japanese early dcSSc patients and SSc patients with ILD, mRSS was continuously reduced during 7 years of follow-up, but there was little improvement of physical disability and organ involvement.

Cutaneous Cryptococcosis

Cutaneous cryptococcosis is classified either as primary or secondary based on the route of infection. The disease can also be classified either as localized cutaneous cryptococcosis or cutaneous manifestations of disseminated cryptococcosis. However, from a physician's point of view, whether lesions are localized to the skin or are disseminated/systemic is more important than the route of infection. The Clinical Practice Guidelines for Diagnosis and Treatment of Cryptococcosis, which was established in 2019 by the Japanese Society for Medical Mycology, adopted the latter classification. Localized cutaneous cryptococcosis is defined as a condition in which lesions are confined within a limited part of the skin, not systemically disseminated at the same time, and are associated with neither cryptococcal fungemia nor antigenemia. This type of cutaneous cryptococcosis is uncommon in Japan. Only 65 cases were reported during the 50-year study period from 1968 to August 2018, with the patients divided into two groups: immunocompromised patients (n=44, 68%) and immunocompetent patients (n=21, 32%). None of the patients were infected with the human immunodeficiency virus (HIV). Localized cutaneous cryptococcosis can also occur in non-HIV-infected patients and well-appearing individuals, therefore, it is considered an important infection in routine dermatology practice. Here, we outline the classification, diagnosis, and treatment of cutaneous cryptococcosis and present a summary of cutaneous cryptococcosis cases reported in Japan.

Effect of topical immunotherapy with squaric acid dibutylester for alopecia areata in Japanese patients

BACKGROUND

The Japanese guidelines for the treatment of alopecia areata list topical immunotherapies as a drug therapy for this condition. However, there is insufficient evidence of its efficacy to support this recommendation. Thus, we sought to clarify the effect of topical immunotherapy on the progression and severity of alopecia areata in Japanese patients.

METHODS

To evaluate the effect of topical immunotherapy with squaric acid dibutylester (SADBE) in alopecia areata patients, we performed a retrospective cohort study on 49 alopecia patients who had received topical immunotherapy with SADBE. Patients were evaluated by the change in alopecia severity at 6 and 12 months after the initiation of topical immunotherapy. The improvement rate was calculated by determination of the complete and partial responses rate to treatment with topical immunotherapy by application of SADBE.

RESULTS

The improvement rate in all alopecia patients treated with SADBE topical immunotherapy was 57.8% (complete response; 11.1% and partial response; 46.7%).

CONCLUSIONS

Topical immunotherapy with SADBE is an effective treatment for alopecia areata. Therefore, the current treatment recommendations for alopecia areata with topical immunotherapies are appropriate.

Inhibition of Endoglin Exerts Antitumor Effects through the Regulation of Non-Smad TGF-β Signaling in Angiosarcoma

Angiosarcoma is a rare malignant tumor derived from endothelial cells, and its prognosis is poor because advanced angiosarcoma is often resistant to taxane therapy. Endoglin (CD105) acts as a coreceptor for TGF-β signaling and is overexpressed in tumor-associated endothelial cells and enhances tumor angiogenesis. Numerous clinical trials are testing the effectiveness of anti-endoglin antibodies in various types of malignancies. Here, we investigated the role of endoglin in the pathogenesis of angiosarcoma and whether endoglin inhibition results in antitumor activity. Endoglin was overexpressed in angiosarcoma, and its inhibition was effective in promoting apoptosis and the suppression of migration, invasion, tube formation, and Warburg effect in angiosarcoma cells. Knockdown of endoglin activated caspase 3/7 that is essential for apoptosis, reduced survivin levels, and decreased paxillin and vascular endothelial cadherin phosphorylation and matrix metalloproteinase 2 and matrix metalloproteinase 9 activities in angiosarcoma cells. Although endoglin is a coreceptor that regulates TGF-β signaling, the antitumor effect of endoglin in angiosarcoma was not based on Smad signaling regulation but on non-Smad TGF-β signaling. Taken together, these results indicated that endoglin could be a novel therapeutic target for angiosarcoma.

Cutaneous lymphoma in Japan, 2012-2017: A nationwide study

BACKGROUND

The types of cutaneous lymphoma (CL) and their incidences can vary among geographic areas or ethnic groups.

OBJECTIVE

This study aimed to investigate the incidence of various CL types in Japan using epidemiological data from a nationwide registration system for CL.

METHODS

A questionnaire was sent to participating hospitals, all of which had been approved to conduct residency programs for board-certified dermatologists by the Japanese Dermatological Association. Data from patients newly diagnosed with CL were collected electronically.

RESULTS

Between 2012 and 2017, 2547 new patients with CL from the dermatological institutes were registered. In total, 2090 patients had primary CL and 453 had secondary CL. Those with primary CL included 1609 (77.0 %) patients with mature T- and natural killer (NK)-cell neoplasms, 442 (21.1 %) with B-cell neoplasms, and 39 (1.9 %) with blastic plasmacytoid dendritic cell neoplasms. Mycosis fungoides (MF) was the most common CL subtype in the present study (1003 patients, 48.0 %), and 72.4 % of MF patients had early-stage disease, similar to observations in previous studies on other cohorts. Primary cutaneous CD30+ T-cell lymphoproliferative disorders and adult T-cell leukemia/lymphoma were the second and third most common subtypes, respectively.

CONCLUSION

Compared to that in our previous cohort (2007-2011), the number of registered T- and NK-cell CL cases decreased, whereas that of B-cell CL cases increased from 44.8-73.7 patients/year. These results provide insight into CL trends within the Japanese population, which might contribute to a better understanding of the disease.

The Warburg effect and tumour immune microenvironment in extramammary Paget's disease: overexpression of lactate dehydrogenase A correlates with immune resistance

BACKGROUND

Extramammary Paget's disease (EMPD) is a rare malignant skin cancer. One of the hallmarks of cancers, including EMPD, is an enhancement of aerobic glycolysis, which is also known as the Warburg effect. In the last step of glycolysis, the enzyme lactate dehydrogenase A (LDHA) catalyzes the conversion of pyruvate to lactic acid, the accumulation of which contributes to the creation of an acidic tumour microenvironment. This in turn results in immunosuppression in various types of cancers. However, the contribution of these pathways has not been well-studied in EMPD.

OBJECTIVE

To investigate the significance of the Warburg effect and its contribution to the tumour immune microenvironment in EMPD.

METHODS

The mRNA expression levels of molecules involved in glycolysis and immune-related cytokines were examined by ddPCR. The number of immune cells was assessed by immunohistochemistry (IHC).

RESULTS

The levels of two glycolytic enzymes, HK2 and LDHA, in tumour tissues were significantly increased compared to those in paired-normal tissues. IHC analyses revealed increased numbers of PD-L1⁺ , PD-1⁺ , CD163⁺ M2 macrophages, Iba1⁺ macrophages and Foxp3⁺ Tregs that were associated with high LDHA levels in EMPD. ddPCR demonstrated that multiple cytokines including IL-4, IL-6, IL-10, TGF-β and CCL-2 were upregulated and associated with high LDHA levels in EMPD. Statistical analyses showed that IL-6 mRNA expression correlated with the number of CD163⁺ , Iba-1⁺ and Foxp3⁺ cells.

CONCLUSION

The Warburg effect contributes to immunomodulation in the tumour microenvironment and further elucidation may lead to better understanding of the pathogenesis of EMPD.

Wound, pressure ulcer and burn guidelines - 4: Guidelines for the management of connective tissue disease/vasculitis-associated skin ulcers

The Japanese Dermatological Association prepared guidelines focused on the treatment of skin ulcers associated with connective tissue disease/vasculitis practical in clinical settings of dermatological care. Skin ulcers associated with connective tissue diseases or vasculitis occur on the background of a wide variety of diseases including, typically, systemic sclerosis but also systemic lupus erythematosus (SLE), dermatomyositis, rheumatoid arthritis (RA), various vasculitides and antiphospholipid antibody syndrome (APS). Therefore, in preparing the present guidelines, we considered diagnostic/therapeutic approaches appropriate for each of these disorders to be necessary and developed algorithms and clinical questions for systemic sclerosis, SLE, dermatomyositis, RA, vasculitis and APS.