Brodalumab for the treatment of moderate-to-severe plaque-type psoriasis: a real-life, retrospective 24-week experience

BACKGROUND

Brodalumab was efficacious and safe in moderate-to-severe plaque-type psoriasis in the AMAGINE trials; published reports under real-life conditions are limited.

OBJECTIVES

To evaluate the effectiveness and safety of brodalumab in patients with moderate-to-severe plaque-type psoriasis in a real-world setting.

METHODS

This observational, retrospective study enrolled adult patients (≥18 years) with moderate-to-severe plaque-type psoriasis who underwent 24 weeks of treatment with brodalumab at 17 Italian dermatological centres. Baseline data included demographics, comorbidities, age of onset and duration of psoriasis and previous treatments. Psoriasis Area and Severity Index (PASI), Physician Global Assessment (PGA), static PGA of Genitalia, Dermatology Life Quality Index and patient satisfaction were assessed at weeks 0, 4, 12 and 24; adverse events were recorded.

RESULTS

Seventy-eight patients (mean age 47.9 years, 71.8% male, average disease duration 16.8 years) were enrolled. A rapid and significant reduction in mean PASI score was observed after 4 weeks of treatment, decreasing further at weeks 12 and 24 (all P < 0.0001 vs. baseline). A higher number of cardiometabolic comorbidities and previous therapies were negatively associated with the achievement of PASI 90 at all assessments. Brodalumab was effective in bio-experienced patients, including those who had failed on anti-interleukin (IL)-17 therapies. Quality of life and patient satisfaction increased significantly during treatment (P < 0.0001 and P < 0.01 vs. baseline, respectively). Treatment was interrupted in 9 (11.5%) patients due to adverse events (n = 4), lack of efficacy (n = 3), lost to follow-up (n = 1) and surgical procedure (n = 1).

CONCLUSIONS

Brodalumab is effective and safe in the treatment of moderate-to-severe psoriasis in a real-world setting, including in patients with failure to anti-IL17 therapies.

Effectiveness of cyclosporine A in patients with moderate to severe plaque psoriasis in a real-life clinical setting in Italy: the TRANSITION study

Background: Cyclosporine A (CsA) is one of the systemic therapeutic options for moderate-to-severe psoriasis, based on its efficacy and rapidity of action. The current study investigated the response to CsA in patients with moderate-to-severe plaque psoriasis.Materials and Methods: TRANSITION was an observational, cross-sectional, multicentre study which evaluated the proportion of partial- and suboptimal-responders among patients with moderate-to-severe plaque psoriasis treated with continuous CsA for ≥12 weeks. Patients demonstrating a Psoriasis Area and Severity Index (PASI) response of ≥90, ≥75 and <90, ≥50 and <75 and <50 were defined as responders, suboptimal-responders, partial-responders, and non-responders, respectively.Results: A total of 196 patients (mean age, 46.6 years; 62.8% males) from 14 sites in Italy were evaluated. At the study visit, the mean (SD) PASI score was 4.2(5.5) compared with 15.3(7.1) prior to the last CsA cycle. For response categories, 39.8%, 22.4%, 16.8%, and 20.9% of patients were responders, suboptimal-responders, partial-responders, and non-responders to CsA treatment. Overall, 28.6% of patients permanently discontinued treatment with CsA (lack of efficacy [10.2%], poor tolerability and voluntary discontinuation [3.6% each], and other [11.7%]).Conclusion: Patients were only partially satisfied with CsA treatment, reporting measurable impact on quality of life. Only 40% patients showed a satisfactory response to CsA.

Wide local excision vs. Mohs Tübingen technique in the treatment of dermatofibrosarcoma protuberans: a two-centre retrospective study and literature review

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare, low-grade mesenchymal skin tumour, characterized by slow infiltrative growth and common local recurrence, with infrequent distant metastases.

OBJECTIVE

The aim of this study is to better clarify clinicopathological characteristics of this tumour and to evaluate the cure rates of Mohs Tübingen technique (MTT) and wide local excision (WLE). Eventually, we perform a literature review to compare our experience with published data.

METHODS

A retrospective review was conducted on 135 patients diagnosed, treated and followed up between 1997 and 2014 at two different institutions. Sixty-two patients underwent to WLE and 73 to MTT. The primary end-points were the following: percentage of recurrences, time to progression and recurrence annual risk rate. Then, the PubMed database was searched for DFSP case series treated with standard surgical resection (SSR), WLE, Mohs' micrographic surgery (MMS) and MTT. The annual risk rate of recurrence calculated and reported for the four separate procedures was pooled to compare them.

RESULTS

Five of the 62 patients with WLE (8.1%) experienced recurrences after a mean follow-up of 4.7 years; the percentage of recurred patients 9 years after MTT was 5.5%, and the annual recurrence risk rate of 0.6%. Pooling these data with those from literature, the recurrence rate varies from 26% to 60% for SSR, from 0% and 41% for WLE, from 0% and 8.3% for MMS and from 0% to 5.5% for MTT. The lowest annual recurrence risk rate was found for MTT.

CONCLUSION

Significantly lower recurrence rates were recorded in patients treated with classic or Tübingen Mohs' technique. To the best of our knowledge, our case series is the widest treated with MTT ever described in the literature; these data may be useful to guide clinicians in the choice of the gold standard treatment for Dermatofibrosarcoma protuberans.

Clinical series of patients with cutaneous melanoma followed-up at the Novara Melanoma Centre from 1983 to 2009: description of the cohort and prognostic factors

AIM

The aim of this study was to review our experience with regards to patients with cutaneous melanoma diagnosed from 1983 to 2009, followed-up in our Dermatological Department of Novara.

METHODS

A retrospective study of 762 patients diagnosed with cutaneous melanoma in the Dermatological Department of Novara between 1983 and 2009 was conducted. Information was extracted from our melanoma patient database. The database included demographical, clinical and pathological variables of the patient. Clinical and pathological factors predicting survival were analyzed using the Kaplan-Meier curves and the Log-Rank Test (univariate analysis).

RESULTS

Staging (American Joint Committee on Cancer 2001) of patients (P=0.000), Breslow thickness (P=0.000), primary ulceration and regression of the lesion (P=0.000), type of first (P<0.039) and second recurrence (P<0.011) were strongly correlated with overall and disease free survival. Sentinel lymph node biopsy was not correlated with disease free survival (P=0.153), it influences only overall survival (P=0.007) CONCLUSION: Our results confirms that sentinel node biopsy, Breslow thickness, ulceration, regression, staging, first and second recurrence are important variable for overall survival and disease free survival, sentinel lymph node status influence only overall survival instead.

Pigmented basal cell carcinomas in Gorlin syndrome: two cases with different dermatoscopic patterns

We describe two nonconsanguineous white patients with multiple pigmented basal cell carcinomas (BCCs) that were histopathologically confirmed. The first patient had calcification of the cerebral falx, multiple keratocysts in the jaw, and other malformations of the cranial and finger bones. The second patient presented with multiple dermoid cysts, calcification of the cerebral falx, keratocysts of the mandible, and agenesis of left kidney. Both patients had palmar pits. Both denied any family history of cutaneous tumours. On dermatoscopic examination of patient 1, multiple, bluish, confluent and large globules were seen. The second patient had blue ovoid globules, arborizing vessels, and areas shaped like maple leaves and spoke-wheels. Based on the clinical and radiological features we diagnosed both patients as having Gorlin syndrome (GS). To our knowledge, there are no previous reports of white patients with GS showing only pigmented BCCs. The dermatoscopic patterns were different in the two patients, and to our knowledge, this is the first report of a patient with GS showing a spoked-wheel dermatoscopic pattern.

[Dermatofibrosarcoma protuberans: surgical treatment using the Tübingen technique (31 cases)]

BACKGROUND

Dermatofibrosarcoma protuberans is a rare cutaneous sarcoma that progresses slowly. Although it exhibits pronounced local aggressiveness, it rarely metastasises. The condition is difficult to treat on account of asymmetric and unpredictable growth as well as the frequency of relapse. Treatment is primarily surgical.

PATIENTS AND METHODS

We report 31 cases of dermatofibrosarcoma protuberans operated at the Dermatology Clinic of Novara between 1997 and 2004 using the Tübingen technique. An immunohistochimical study was performed and screening was carried out for possible extension of the neoplasm into muscle.

RESULTS

Muscular involvement was seen in 4 cases. No relapses were seen over a median survival period of 3 years and no patients were lost to follow-up.

DISCUSSION

The Mohs technique is the surgical method of reference and allows tumour eradication with sparing of healthy tissue. The Tübingen method constitutes an alternative approach requiring fewer histological sections. The results obtained in our series were good and no relapses were seen over a median survival period of 3 years.

Thysanoptera dermatitis

Thysanoptera dermatitis is caused by the bite of small (1-2 mm) insects (generally thrips). Thrips usually feed on the juices of vegetables but if they reach human skin they can suck the epidermal lymph after biting. The cutaneous lesions formed are small pink and itchy papules localized mainly on the trunk and the arms. Diagnosis is only possible by demonstrating that the insect is present inside one of the lesions of the skin. Thysanoptera dermatitis is often misdiagnosed as mosquito bites. Although self-resolving in a few days, Thysanoptera dermatitis should be known not only for the cultural and scientific training of the dermatologist but also to add more detailed diagnostic information to the generic diagnosis of 'entomodermatosis' and to confirm the benign evolution of the bites.

Extension cutanée d’un chordome

INTRODUCTION

Chordomas are rare extradural bone tumors arising from notochord remnants, the embryonic structure forming the original axis of the spine. They represent 0.1p. 100 of all intra-cranial tumors. The chordoma is a locally malignant cancer that tends to invade the surrounding tissues. Its localization in the skin is exceptional.

OBSERVATION

A 56 year-old man developed a nut-sized vegetating nodule on the nasal groove. This lesion appeared a few months following surgery for a frontoglabellar relapse of a chordoma that had developed six years earlier at the base of the skull.

DISCUSSION

We report this case because of the rareness of cutaneous involvement and the particular conditions in which it occurred. It may have been due to tumoral seeding during the previous surgical interventions.

Image sharpness and contrast transfer in coherent confocal microscopy

Confocal microscopes provide clear, thin optical sections with little disturbance from regions of the specimen that are not in focus. In addition, they appear to provide somewhat greater lateral and axial image resolution than with non-confocal microscope optics. To address the question of resolution and contrast transfer of light microscopes, a new test slide that enables the direct measurement of the contrast transfer characteristics (CTC) of microscope optics at the highest numerical aperature has been developed. With this new test slide, the performance of a confocal scanning laser microscope operating in the confocal reflection mode and the non-confocal transmission mode was examined. The CTC curves show that the confocal instrument maintains exceptionally high contrast (up to twice that with non-confocal optics) as the dimension of the object approaches the diffraction limit of resolution; at these dimensions, image detail is lost with non-confocal microscopes owing to a progressive loss of image contrast. Furthermore, we have calculated theoretical CTC curves by modelling the confocal and non-confocal imaging modes using discrete Fourier analysis. The close agreement between the theoretical and experimental CTC curves supports the earlier prediction that the coherent confocal and the incoherent non-confocal imaging mode have the same limit of resolution (defined here as the inverse of the spatial frequency at which the contrast transfer converges to zero). The apparently greater image resolution of the coherent confocal optics is a consequence of the improved contrast transfer at spacings which are close to the resolution limit.

Biosynthesis of isochorismate in Klebsiella pneumoniae: origin of O-2

The shikimate metabolites are key precursors to a large number of natural products, including aromatic amino acids. Chorismic acid is an important branch point in the biosynthetic pathway to aromatic amino acids. Chorismic acid is also unique among natural products since it is the only compound known to undergo an enzymatic Claisen rearrangement. A metabolite of chorismic acid, isochorismic acid, first observed in Aerobacter aerogenes differs in its chemical structure by the location of the hydroxyl group and the double bonds. Isochorismic acid is a precursor to a growing number of shikimate-derived metabolites. Isochorismic acid has also been postulated to be an intermediate of m-carboxyaromatic amino acids, implying another enzymatic Claisen rearrangement. In this publication, we have isolated isochorismate synthase and found that on lyophilization the enzyme is stable for at least 6 months at -20 degrees C. Incubation of chorismate with this preparation in water enriched with 18O led to incorporation of one atom of 18O as proven from the fast atom bombardment mass spectra of the HPLC purified derived isochorismate.

Structure of D-prephenyllactate. A carboxycyclohexadienyl metabolite from Neurospora crassa

A novel natural product structurally related to prephenate and arogenate was isolated from a mutant of Neurospora crassa. This D-beta-(1-carboxy-4-hydroxy-2,5-cyclohexadiene-1-yl)-lactic acid is herein given the trivial name of D-prephenyllactate. The new metabolite is even more acid labile than is prephenate and is quantitatively converted to phenyllactate at mildly acidic pH. The structure characterization of prephenyllactate was performed using spectroscopic techniques (ultraviolet, 1H NMR, 13C NMR, two-dimensional heteronuclear experiments and mass spectrometry). Circular dichroism proved conclusively the R configuration of the asymmetric carbon at C-8 of prephenyllactate. Enzymatic utilization of prephenyllactate by cyclohexadienyl dehydratase and by cyclohexadienyl dehydrogenase from Klebsiella pneumoniae was demonstrated.

Enzymatic and nonenzymatic dehydration reactions of L-arogenate

L-Arogenate, an immediate precursor of either L-tyrosine, L-phenylalanine, or both in many microorganisms and plants, may undergo two types of dehydration reactions that yield products of increased stability. Under acidic conditions, a facile aromatization attended by loss of the C-4 hydroxyl and the C-1 carboxyl moieties results in quantitative conversion to L-phenylalanine. When aromatization was largely prevented by maintaining pH in the range of 7.5-12, a second dehydration reaction occurred in which the alanyl side chain and the carboxyl group at C-1 formed a lactam ring to yield spiro-arogenate. The latter reaction occurs at 100 degrees C, roughly 50% conversion being obtained in 2 h. The product formed from L-arogenate was authentic spiro-arogenate, as demonstrated by high-performance liquid chromatography and thin-layer chromatography identification procedures. Further confirmation was obtained by 1H nuclear magnetic resonance, ultraviolet spectroscopy, and mass spectrometry. Thus far, the conversion of L-arogenate to spiro-arogenate is not known to be enzyme catalyzed. The other dehydratase reaction, however, is catalyzed in nature by an enzyme denoted arogenate dehydratase. An improved assay is described for this in which [3H]dansyl derivatives of L-arogenate (substrate) and L-phenylalanine (product) are separated by using bidimensional thin-layer chromatography. The radioactive reaction product is then quantitated. This assay was used to study partially purified arogenate dehydratase from Pseudomonas diminuta, an organism that depends upon the arogenate pathway for L-phenylalanine biosynthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolation and structure determination of a novel spiro-gamma-lactam, spiro-arogenate

The eucaryotic microorganism, Neurospora crassa, is able under specified conditions (Zamir, L.O., Jung, E., and Jensen, R.A. (1982) J. Biol. Chem. 258, 6492-6496) to synthesize a cyclohexadienyl derivative of prephenic acid having the novel structure of a spiro-gamma-lactam. This L-gamma-(spiro-4-hydroxy-2,5-cyclohexadienyl)-pyroglutamate is herein given the trivial name, spiro-arogenate, to indicate its close relationship to the amino acid, L-arogenate. Spiro-arogenate is quantitatively converted to phenylalanine at mildly acidic pH and can be converted to arogenate by boiling at basic pH. The structure of spiro-arogenate was established through the application of spectroscopic techniques (ultraviolet, 1H-NMR, 13C-NMR, and mass spectrometry). The 1H-NMR and 13C-NMR spectra of spiro-arogenate isolated as the natural product conformed to the spectrum of spiro-arogenate prepared by chemical synthesis by S. Danishefsky and co-workers (Danishefsky, S., Morris, J., and Clizbe, L.A. (1981) J. Am. Chem. Soc. 103, 1602-1604). Circular dichroism established the S configuration of the asymmetric carbon at C-8 of spiro-arogenate.