Topically applied treatments for external genital warts in nonimmunocompromised patients: a systematic review and network meta-analysis

Selecting a topical treatment from among the numerous topical agents for external genital warts remains challenging without clear evidence. Our aim was to evaluate comparatively the efficacy and safety of topical agents for external genital warts using a network meta-analysis. We included all randomized controlled trials that evaluated any topically applied treatment for external genital warts. Using the R package netmeta, network meta-analyses were performed with a frequentist approach. We identified 41 relevant studies comprising 6371 patients. Among conventional agents, podophyllotoxin 0·5% solution (odds ratio 1·94, 95% confidence interval 1·02-3·71) was significantly more efficacious than imiquimod 5% cream for lesion clearance; however, it was associated with a higher overall adverse event rate. Sinecatechins 15% ointment (odds ratio 0·21, 95% confidence interval 0·12-0·34) was significantly less efficacious than imiquimod 5% cream. Idoxuridine, polyhexamethylene biguanide, cidofovir and SB206 showed comparable therapeutic efficacies with conventional therapies. None of the treatments were significantly different from each other with respect to recurrence, patients with severe adverse events, or patients who withdrew because of treatment-related adverse events. Conventional modalities were efficacious and well tolerated, although each of them had their advantages and disadvantages. Additional efficacy and safety studies are warranted for unconventional agents.

Stuttering and gray matter morphometry: A population-based neuroimaging study in young children

Stuttering is a developmental speech disorder originating in early childhood. We aimed to replicate the association of stuttering and structural morphometry using a large, population-based prospective cohort, the Generation R Study, and explore the neurobiological mechanism of stuttering in children. Twenty-six children with a history of stuttering and 489 fluent speaking peers (ages 6-9) were included in the MRI sub-study. Cortical and subcortical regions of interest were analyzed using linear regression models. Compared to fluent speakers, children with a history of stuttering had less gray matter volume in the left inferior frontal gyrus and supplementary motor area. Exploratory surface-based brain analysis showed thinner cortex in the left inferior frontal gyrus, and in bilateral frontal and parietal areas. These findings corroborate previous studies that reported aberrant brain morphometry in speech motor and auditory regions in children who stutter. Future research is needed to explore the causal nature of this association.

Novel circulating tumor cell-based blood test for the assessment of PD-L1 protein expression in treatment-naïve, newly diagnosed patients with non-small cell lung cancer

We evaluated the analytical and clinical performance of a novel circulating tumor cell (CTC)-based blood test for determination of programmed death ligand 1 (PD-L1) protein expression status in real time in treatment-naïve non-small cell lung cancer (NSCLC) patients. CTCs were detected in 86% of patients with NSCLC (I-IV) at the time of diagnosis, with a 67% PD-L1 positivity rate (≥ 1 PDL + CTC). Among 33 NSCLC patients with PD-L1 results available via both tissue immunohistochemistry (IHC) and CTC assays, 78.9% were positive according to both methods. The CTC test identified an additional ten cases that were positive for PD-L1 expression but that tested negative via IHC analysis. Detection of higher PD-L1 expression on CTCs compared to that in the corresponding tissue was concordant with data obtained using other platforms in previously treated patients. The concordance in PD-L1 expression between tissue and CTCs was approximately 57%, which is higher than that reported by others. In summary, evaluation of PD-L1 protein expression status on CTCs isolated from NSCLC patients is feasible. PD-L1 expression status on CTCs can be determined serially during the disease course, thus overcoming the myriad challenges associated with tissue analysis.

Circulating tumor cell count from a blood sample for colorectal cancer (CRC) prevention: A 627-patient prospective study

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Background: Up to 25% of patients with adenomas progress to having colorectal cancer. If detected early, adenomas can be removed with a diagnostic colonoscopy procedure, preventing cancer. Invasive colonoscopy is the only screening method with the sensitivity to accurately detect adenomas, but has a low compliance rate of 38% for screening. Available non-invasive tests (including stool-based multi-analyte tests) have very limited sensitivity for adenomas. Hence, there is an unmet need for a non-invasive test for adenoma detection. Methods: IRB-approved prospective study was conducted in 627 subjects 50 years or older- recommended for routine CRC screening- 405 subjects had adenoma or CRC, confirmed by colonoscopy with tumor biopsy. Two mL peripheral blood was processed using the CellMax biomimetic platform (CMx), which uses a microfluidic biochip to enumerate circulating tumor cells (CTCs). Nominal logistic regression was used to assess performance while proportional odds logistic regression and Cuzick’s trend test were used to determine association of CTC counts with cancer stage. Results: An increase in CTC count was significantly correlated with an increase in disease burden (Cuzick’s Test p-value < 0.0001). Furthermore, there was a significant association between CTC counts and stages of adenoma-carcinoma progression (Likelihood ratio p-value < 0.0001). The CTC enumeration was able to differentiate between healthy and diseased patients (adenoma + cancer). Conclusions: To the best of our knowledge, these are the first reported results for a blood test that has high accuracy for adenoma detection, and truly enables colorectal cancer prevention. This test can be administered in the primary care setting and drive high compliance.[Table: see text]

Abstract 3635: CTC and ctDNA profiling to detect 6 NCCN-guideline recommended classes of alterations for immunotherapy and targeted therapy selection using sample from a single blood draw

Introduction The availability of targeted and immunotherapies has provided NSCLC patients with more effective treatment options. However, this has resulted in an increase in the number and modality of tests required for treatment selection. Given 30-50% of advanced lung cancer patients have insufficient or unavailable tissue for comprehensive genomic profiling, there is a need for a non-invasive assay that can accurately detect all guideline-recommended markers for NSCLC treatment selection. To meet this need, we have developed a blood test that detects six classes of alterations (SNV, Indels, Rearrangements, CNA, Microsatellite Instability and PD-L1 expression) for therapy selection.

Methods & Results Three tubes of blood from a routine blood draw were sent to our CLIA-certified and/or CAP accredited lab for analysis. PD-L1 expression was evaluated in circulating tumor cells (CTCs) utilizing two different assays; (i) Immunofluorescence (IF) antibody staining, (ii) mRNA qPCR. CTCs were captured on the CMxTM CTC Platform coated with lipid bilayer and antibodies to EpCAM. PD-L1 expression results were highly correlated between IF and qPCR assays in ten solid tumor cell lines (lung, breast, prostate and colorectal cancer) spiked into whole blood to mimic the actual patient CTC capture process. In an ongoing study on clinical samples from NSCLC patients (N=20), we observed greater than 90% concordance between tissue (IHC by 22C3 PD-L1 clone) and blood (CTC IF and mRNA assays). A proprietary Single Molecule Sequencing (SMSEQTM) NGS assay was performed on plasma in order to detect 5 classes of genomic alterations (SNV, Indels, Rearrangements, CNA, MSI) from ctDNA. This assay was validated in accordance with the latest ACMG and AMP guidelines to accurately detect variants at low mutant allele fraction (.1% for SNVs and Indels, 1% for rearrangements and 5 copies for CNA) with high sensitivity and specificity. MSI status was determined by assessing nucleotide repeat sequences in five standard markers (BAT-25, BAT-26, MONO-27, NR-21, NR-24), and was detectable down to a MAF of 1%. In an ongoing study on clinical samples from NSCLC patients (N=20), we observed high concordance of MSI status between tissue (immunohistochemistry for dMMR/MSI status) and blood (ctDNA SMSEQ assay).

Conclusion Tissue insufficiency and procurement challenges are the primary reasons why ~90% of patients diagnosed with advanced NSCLC are not comprehensively tested per NCCN-guidelines in the community setting where most cancer is treated, leading to suboptimal treatment selection. An accurate blood test that detects all 6 NCCN-recommended markers for immunotherapy and targeted therapy selection has the potential to significantly improve adherence to NCCN testing guidelines and enable optimal treatment selection.

Citation Format: Huangpin B. Hsieh, Jen-chia Wu, Feng-Ming Lin, Julian Lucas, Alex Atkins, Pratyush Gupta, Hung-Jen Shao, Yen-Lin Chen, Wen-Jie Huang, Chia-Hsun Hsieh, Ruey Kuen Hsieh, Kuo-Wei Chen, Ming-Hong Yen, Mana Javey, Shih-En Chang, Twinkal Marfatia, Drew Watson, Mahul Amin, Ashish Nimgaonkar, Oscar Segurado, Rui Mei. CTC and ctDNA profiling to detect 6 NCCN-guideline recommended classes of alterations for immunotherapy and targeted therapy selection using sample from a single blood draw [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3635.

Abstract 3652: Analytical validation of a novel circulating tumor DNA detection platform for targeted and immunotherapy selection

Introduction Comprehensive genomic profiling of solid tumors using circulating tumor DNA (ctDNA) has enabled the detection of all NCCN guideline-recommended somatic genomic classes of alterations from a single, non-invasive blood draw. However, current ctDNA tests still face two major challenges: the inability to reliably identify somatic variants at low mutant allele fraction (MAF), and inconsistency in how the tests have been validated. This study shows how the Single Molecule Sequencing (SMSEQ) platform addresses these challenges. The platform integrates innovative ctDNA extraction methodology, highly optimized library preparation and an error-based variant-calling algorithm to drastically improve sensitivity and specificity. The platform analyzes 5 classes of somatic variants: single nucleotide variants (SNVs), insertions and deletions (Indels), copy number variants (CNVs), fusions and microsatellite instability (MSI).

Methods We analyzed a 73 gene panel covering NCCN recommended actionable variants for solid tumors in 60 reference ctDNA samples with known variants to establish the limit of detection, sensitivity, specificity, accuracy and reproducibility of the SMSEQ platform. For clinical validation, we tested 36 patients with metastatic colorectal cancer (mCRC) and 34 healthy controls from the Chang Gung Memorial Hospital, and 227 patients diagnosed with solid tumor from Taiwan. Circulating DNA was extracted from plasma followed by library preparation using a highly optimized NGS workflow. Somatic variants in ctDNA are identified using locus-specific modeling to separate tumor variants from normal errors.

Results Validation according to recently published ACMG/AMP guidelines shows that the SMSEQ platform allows calling of variants with &gt;99.999% analytical specificity for SNVs, Indels and fusions; and &gt;99% analytical specificity for CNVs and MSI. The platform successfully detected variants at low MAF: 0.1% for SNVs and Indels, &lt;1% for fusions, 5 copies for CNVs, and 1% for MSI. Somatic variants were identified in 35 of 36 mCRC patient samples (97.2%). No false positives were observed within the targeted region for all 34 healthy controls tested. In paired samples, the SMSEQ platform showed 89.7% concordance with tissue biopsy. Observed gene mutation profiles from ctDNA were consistent with published tissue biopsy data: the most frequently mutated genes were TP53, APC, and KRAS; KRAS and BRAF variants were mutually exclusive. In addition to mCRC patients, we tested 227 patients diagnosed with various solid tumors from Taiwan. Actionable variants were detected in 170/227 (75%) patients.

Conclusion The CellMax 73-gene liquid biopsy test detects 5 NCCN-guideline recommended variant classes: MSI for immunotherapy and SNVS, Indels, CNVs, and fusions for targeted therapy selection at low variant allele fraction/copy number at high sensitivity and specificity.

Citation Format: Pratyush Gupta, Julian Lucas, Alex Atkins, Wen-Sy Tsai, Twinkal Marfatia, Shih-En Chang, Oscar Segurado, Rui Mei. Analytical validation of a novel circulating tumor DNA detection platform for targeted and immunotherapy selection [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3652.

Prospective clinical study of a prostate cancer (PCa) rule-out blood test for PSA gray zone patients using a sensitive circulating tumor cell assay

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Background: The diagnostic confirmation of prostate cancer in patients with a PSA in the gray zone (4–10 ng/ml) is controversial, often leading to unnecessary biopsies. The sensitivity of the PSA test at a 4 ng/mL cut-off can be as low as 21%. We introduce a new test for prostate cancer detection in PSA gray zone patients, with the potential to decrease the number of unnecessary prostate biopsies. Methods: A single-center, multi-year, IRB-approved, prospective, blinded clinical study was conducted in 200 high-risk subjects. 4 mL of blood was drawn and processed for CTC analysis using the CellMax biomimetic platform (CMx). The CMx CTC test uses a proprietary microfluidic biochip that accurately captures and enumerates CTCs with antibodies to EpCAM, CK18 and PSMA. All patients underwent routine screening including PSA and digital rectal exam (DRE). Gray zone and those diagnosed as ‘diseased’ based on PSA & DRE also underwent a biopsy. Multivariate generalized linear models incorporating CMx test results were utilized to derive age adjusted CTC scores predictive of clinical outcomes. Results: A subset of 84 subjects with PSA levels in the gray zone (4–10 ng/ml) were included in this study. Prostate biopsy results were available for 42 patients; 10 had confirmed cancer. A CTC Score was calculated as a nonlinear weighted combination of the CTCs captured with CK18 and PSMA antibodies. After adjustment for age and PSA, the CTC score remained a significant predictor of clinical outcome in the PSA “gray zone” (likelihood ratio p-value = .015) whereas PSA was not. The sensitivity and specificity of the CTC Score were 80.0% (95% CI: 44.4%, 97.5%) and 93.8% (95% CI: 79.2%, 99.2%). Negative % agreement and Positive % agreement was 93.8% (95% CI: 79.2%, 99.2%) and 80.0% (95% CI: 44.4%, 97.5%). Given the observed odds ratio for CTC score in the study- approximately 0.90 (95% CI 0.79, 0.98), the study is appropriately powered. Conclusions: The CMx CTC assay is an accurate, affordable blood based assay, with the potential to reduce unnecessary biopsies in PSA gray-zone patients by up to 90%.

CSF-ctDNA SMSEQ Analysis to Tailor the Treatment of a Patient with Brain Metastases: A Case Report

Brain metastases are the most common neurological complications of adult cancers, accounting for more than half of brain tumors. The incidence of brain metastases may be increasing due to improved detection of small lesions by advanced imaging technologies. Given the fast evolution of targeted and immunotherapy regimens, it is essential to serially assess brain malignancies during the disease course for disease monitoring and tailoring of the therapeutic management. For such serial and repetitive assessment, cerebrospinal fluid (CSF) could be the biological fluid of choice to supplement cytology examination for the presence or absence of CNS malignancy, as well as provide extensive information on tumor mutational profile for personalization of treatment. The case described here emphasizes the importance of CSF-ctDNA analysis with the CellMax SMSEQ technology that led to treatment adjustment resulting in clinical remission of the patient.

Liquid Biopsy Prevents Inaccurate Her2 Status Determination by in situ Hybridization in a Patient with Invasive Ductal Adenocarcinoma of the Breast: Case Report

Utilization of circulating tumor DNA as a novel and noninvasive test for diagnosis confirmation, therapy selection, and cancer surveillance is a rapidly growing area of interest. In the wake of FDA approval of a liquid biopsy test, it is important for clinicians to acknowledge the obvious clinical utility of liquid biopsy for cancer management throughout the course of the disease. This case report describes a female with invasive ductal adenocarcinoma of the breast, where liquid biopsy was instrumental for her cancer characterization and personalized therapy selection.

The Affinity of Elongated Membrane-Tethered Ligands Determines Potency of T Cell Receptor Triggering

T lymphocytes are important mediators of adoptive immunity but the mechanism of T cell receptor (TCR) triggering remains uncertain. The interspatial distance between engaged T cells and antigen-presenting cells (APCs) is believed to be important for topological rearrangement of membrane tyrosine phosphatases and initiation of TCR signaling. We investigated the relationship between ligand topology and affinity by generating a series of artificial APCs that express membrane-tethered anti-CD3 scFv with different affinities (OKT3, BC3, and 2C11) in addition to recombinant class I and II pMHC molecules. The dimensions of membrane-tethered anti-CD3 and pMHC molecules were progressively increased by insertion of different extracellular domains. In agreement with previous studies, elongation of pMHC molecules or low-affinity anti-CD3 scFv caused progressive loss of T cell activation. However, elongation of high-affinity ligands (BC3 and OKT3 scFv) did not abolish TCR phosphorylation and T cell activation. Mutation of key amino acids in OKT3 to reduce binding affinity to CD3 resulted in restoration of topological dependence on T cell activation. Our results show that high-affinity TCR ligands can effectively induce TCR triggering even at large interspatial distances between T cells and APCs.

A combination of excimer laser treatment and topical tacrolimus is more effective in treating vitiligo than either therapy alone for the initial 6 months, but not thereafter

BACKGROUND

There are insufficient data on the long-term outcome of a combination therapy that comprises phototherapy and topical administration of tacrolimus.

AIM

To evaluate the clinical efficacy according to the duration of treatment and in vitro results of a combination therapy involving topical tacrolimus and an excimer laser in the treatment of vitiligo.

METHODS

In total, 276 patients with nonsegmental vitiligo were treated with an excimer laser twice weekly, or with tacrolimus ointment twice daily, or both. The melanin contents and levels of melanogenic enzymes were measured in cultured human melanocytes treated with tacrolimus and/or excimer laser.

RESULTS

After adjusting for potential confounders, the combination of tacrolimus plus excimer laser was significantly more effective than either tacrolimus or excimer laser alone (P < 0.001 and P < 0.01, respectively) for the first 6 months. However, this superiority was not observed after the initial 6 months of treatment. In vitro, the combination of tacrolimus plus excimer laser led to a higher level of melanogenesis than with either treatment alone.

CONCLUSIONS

A combination treatment with topical tacrolimus and an excimer laser may be useful as an induction therapy for up to 6 months, but continuation of this therapy for > 6 months might not provide a better final outcome than monotherapy.

Secondary cutaneous lymphoma: comparative clinical features and survival outcome analysis of 106 cases according to lymphoma cell lineage

BACKGROUND

The relative frequency, clinical features and survival outcomes of secondary cutaneous lymphoma remain poorly understood.

OBJECTIVES

To determine the clinical characteristics and survival outcomes of secondary cutaneous lymphoma.

MATERIALS AND METHODS

The present retrospective cohort study included all 106 patients who presented with secondary cutaneous lymphoma. Patient medical records were reviewed to determine the clinical features, survival outcomes and prognostic factors. Survival outcomes were analysed by using the Kaplan-Meier method and comparisons between lymphoma cell lineages [T or natural killer (T-/NK)-cell vs. B-cell lymphoma] were performed using the log-rank test.

RESULTS

Secondary cutaneous lymphomas consisted of mature T-/NK-cell lymphomas (56%), mature B-cell lymphomas (35%), immature haematopoietic malignancies (8%) and Hodgkin lymphoma (1%). The T-/NK-cell lineage lymphoma cases were more likely to have multiple and disseminated skin lesions than the B-cell lineage lymphoma cases. The lymphoma cell lineage did not significantly influence survival outcomes. Patients who showed cutaneous involvement within 6 months of the initial diagnosis of primary disease had a poorer overall survival (OS) outcome than patients who developed cutaneous dissemination 6 or more months after the initial diagnosis (P < 0.001). Patients with disseminated skin lesions had a poorer OS than patients with localized skin lesions (P = 0.028). The two lymphoma cell lineages differed in terms of prognostic factors that influenced survival.

CONCLUSIONS

Skin lesion characteristics such as time point of appearance and extent affect the survival outcomes of secondary cutaneous lymphoma. Cell lineage did not influence survival outcomes but the two lineages are associated with different prognostic factors.

A case of xanthoma disseminatum: evaluation and monitoring by 18F-fluorodeoxyglucose positron emission tomography/computed tomography

Xanthoma disseminatum (XD) is a rare benign histiocytic disorder with extensive mucocutaneous xanthomas that often involves other sites such as the central nervous system (CNS), respiratory tract and abdominal organs. Evaluation of the extent of disease is important because lesions in critical locations may increase morbidity and mortality. However, there are no well-established tools for the evaluation and monitoring of XD. Here, we report a case of XD in a 21-year-old male patient showing skin, mucous membrane, CNS and internal organ involvement. In this case, (18) F-fluorodeoxyglucose positron emission tomography/computed tomography was useful in detecting the extent of the disease and in estimating the therapeutic response.

Autoimmune bone marrow environment severely inhibits B cell development by inducing extensive cell death and inhibiting proliferation

The spontaneous scurfy (sf) mutation in mice results in a complete loss of Tregs, leading to a lethal, multi-system autoimmune syndrome. We have carefully examined B lymphopoiesis in sf mice. Paradoxically, the B cell numbers at all developmental stages including pro-B, pre-B, immature and mature B cells are significantly decreased in the BM and spleen of sf mice, compared to that of wild-type littermate controls. The developing B cells in sf mice exhibit profoundly elevated cell death induced by down-regulation of Bcl-XL expression and up-regulation of Fas expression. In addition, the clonal expansion of pre-B and immature B cells in sf mice is significantly reduced compared to wild-type controls. Foxp3 expression is not detectable in all stages of developing B cells in wild-type mice, indicating that the defects are B-cell extrinsic, which is further supported by the recovery of B cell maturation in BM chimeric mice. Remarkably, IFN-γ production is significantly elevated in numerous cell types in the BM of sf mice. Taken together, these results indicate that the autoimmune inflammatory marrow environment has dramatic inhibitory effects on B cell development by inducing apoptosis and suppressing proliferation of developing B cells.

Foxo1 is essential for germinal center B cell functions and the development of collagen-induced arthritis (101.15)

Foxo1 has been shown to be critical for B-cell lymphopoiesis by regulating several genes involved in immunoglobulin (Ig) rearrangement. However, the role of Foxo1 in germinal center (GC) B cell functions remains unclear. Unlike being downregulated in activated B cells, Foxo1 expression is elevated in GC B cells, suggesting a distinctive regulatory role. In Foxo1 GC B-cell conditional knockout (CKO) mice, both primary and memory antibody responses are severely impaired after immunization with T-dependent antigen NP-CGG. The numbers of NP-specific IgG1-secreting B-cells, as well as the NP-specific IgG1 antibody titer in the serum, are dramatically reduced in the mutant mice. The results indicate an inability to undergo Ig class-switch recombination (CSR) in Foxo1-deficient GC B cells, possibly due to the abolished expression of activation-induced cytidine deaminase. In addition, analysis of mutation rate of Ig genes in the NP-specific B cells reveals that Ig somatic hypermutation (SHM) is impaired in the Foxo1-deficient GC B cells. The clonotypes of B cells responding to NP are also altered in the mutant mice. Remarkably, using collagen-induced arthritis model, we have found that Foxo1 GC B-cell CKO mice are resistant to arthritis induction. Taken together, our data indicate that Foxo1 is essential for normal antibody responses, CSR and SHM of GC B cells. The absence of Foxo1 in GC B cells prevents the development of autoimmune arthritis.

Cutaneous adverse effects in patients treated with the multitargeted kinase inhibitors sorafenib and sunitinib

BACKGROUND

The multitargeted kinase inhibitors sorafenib and sunitinib have improved treatment of solid tumours including renal cell carcinoma and hepatocellular carcinoma by offering better clinical responses. However, sorafenib and sunitinib are commonly associated with cutaneous toxicity.

OBJECTIVES

We conducted this study to make a clinical assessment of the cutaneous toxicities induced by the oral multitargeted kinase inhibitors sorafenib and sunitinib.

METHODS

Retrospectively, we reviewed medical records of patients receiving multitargeted kinase inhibitors, including 109 patients on sorafenib for the treatment of renal cell carcinoma or hepatocellular carcinoma and 119 patients receiving sunitinib for treatment of renal cell carcinoma or a gastrointestinal stromal tumour. Clinical data on cutaneous toxicities were collated. We describe the incidences and intensities of toxicities, and analyse the data statistically.

RESULTS

The most common cutaneous toxicity was hand-and-foot skin reaction (HFSR). Other cutaneous toxicities included alopecia, stomatitis, skin discoloration (hair or face), subungual splinter haemorrhage, facial swelling, facial erythema and xerosis. HFSR and severe stomatitis required therapy modifications to relieve symptoms, but other cutaneous toxicities did not affect treatment course. HFSR was observed in 48% of patients treated with sorafenib and 36% of those treated with sunitinib. Median time to onset was 18.4 days in patients receiving sorafenib and 32.4 days in those receiving sunitinib. HFSR and stomatitis were early symptoms compared with other cutaneous toxicities. Patients with severe HFSR were likely to develop the symptoms at early phases of therapy. A significant correlation between the severity of HFSR and development of alopecia and stomatitis was found.

CONCLUSIONS

Multitargeted kinase inhibitors are associated with a significant risk of various cutaneous adverse events. HFSR is the commonest and most serious cutaneous toxicity in patients treated with these drugs.

Multiple cutaneous metastases from hilar cholangiocarcinoma

The most common metastatic sites of cholangiocarcinoma are the retroperitoneal lymph nodes, peritoneum, liver and lungs, and cutaneous metastases of cholangiocarcinoma are rare. Although cutaneous metastases of internal malignancies most commonly present clinically as nontender nodules appearing in a particular area of body, other presentations can occur. Cutaneous metastases of cholangiocarcinoma can appear as a solitary tumour at the therapeutic drainage site. We report a 60-year-old man with unusual cutaneous metastases from hilar cholangiocarcinoma, which presented as multiple indurated plaques and papules on the anterior chest.

A randomized controlled trial of the efficacy and safety of a fixed triple combination (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) compared with hydroquinone 4% cream in Asian patients with moderate to severe melasma

BACKGROUND

Melasma is an acquired, chronic hypermelanosis for which therapy remains a challenge.

OBJECTIVES

To compare the efficacy and safety of a triple combination [TC: fluocinolone acetonide 0.01%, hydroquinone (HQ) 4%, tretinoin 0.05%] vs. HQ 4% after 8 weeks of treatment of moderate to severe facial melasma in Asian patients.

METHODS

This was a multicentre, randomized, controlled, investigator-blinded, parallel comparison study. East and South-East Asian patients aged 18 years or older, with a clinical diagnosis of moderate to severe melasma, were enrolled in this study. Patients were enrolled at baseline and treated daily for 8 weeks with TC cream (one application at bedtime) or HQ cream (twice daily). There were four study visits: at baseline and weeks 2, 4 and 8. The primary efficacy variable was the melasma global severity score (GSS). Other outcome measures included Melasma Area and Severity Index, global improvement and patient satisfaction. Safety was assessed through the reporting of adverse events.

RESULTS

TC had superior efficacy to HQ for the primary variable: 77/120 patients (64.2%) on TC had GSS 'none' or 'mild' at week 8 vs. 48/122 patients (39.4%) on HQ (P < 0.001). The secondary efficacy variables confirmed these results. Patient satisfaction was in favour of TC (90/127, 70.8%, vs. 64/129, 49.6%; P = 0.005). More patients had related adverse events on TC (63/129, 48.8%) than on HQ (18/131, 13.7%) but most were mild and none was severe.

CONCLUSIONS

Efficacy in Asians and patient satisfaction were superior with the fixed TC than with HQ 4%.

Percutaneous direct puncture glue embolization of high-flow craniofacial arteriovenous lesions: a new circular ring compression device with a beveled edge

SUMMARY

The purpose of this study was to evaluate the efficacy of a newly designed circular ring compression device that allows safe and effective glue injection during preoperative embolization of high-flow superficial craniofacial arteriovenous malformations (AVMs). The device was used in 4 cases of craniofacial AVM with multiple feeding arteries and draining veins. It provided a safe glue injection route as well as effective compression of radiating multiple venous drainage routes.

Majocchi's granuloma of the vulva caused by Trichophyton mentagrophytes

We report a case of Majocchi's granuloma caused by Trichophyton mentagrophytes on the vulva in a 23-year-old girl who had used topical steroids for many years. Her dog was a source of the infection.

A simple method for the production of recombinant proteins from mammalian cells

Expression of recombinant proteins in mammalian cells is useful for obtaining products with normal post-translational modifications. We describe a simple and economical method for the production of milligram levels of proteins in murine fibroblasts. Retroviral or LIPOFECTAMINE (Gibco Laboratories) transduction was employed to generate stable murine-fibroblast producer cells. Confluent cultures of stable fibroblast clones were maintained for up to 1 month in 0.5% serum. Culture medium was collected every 2-3 days and polyhistidine-tagged proteins were purified by ammonium sulphate precipitation and Ni(2+)-nitrilotriacetic acid affinity chromatography. Highly pure, active, glycosylated recombinant proteins, including human beta-glucuronidase, mouse beta-glucuronidase, aminopeptidase N (CD13) and a single-chain antibody-enzyme fusion protein, were obtained with yields of 3-6 mg/l of culture medium. Fc-tagged proteins were also produced and purified in a single step by Protein A affinity chromatography with yields of 6-12 mg/l. The techniques described here allow simple and economical production of recombinant mammalian proteins with post-translational modifications.

Kikuchi-Fujimoto disease with papulopustular skin manifestations

Kikuchi-Fujimoto disease commonly presents with cervical lymphadenopathy accompanied by fever, myalgia, neutropaenia, and rarely cutaneous eruption. Most cutaneous lesions present as erythematous macules, papules, plaques, nodules, or ulcers on the upper part of the body such as trunk, upper extremities, and face. We present a case of Kikuchi-Fujimoto disease with a papulopustular eruption on the whole body including the lower extremities.

A case of Trichosporon cutaneum folliculitis and septicaemia

Trichosporon cutaneum, a saprophytic fungal organism normally found in the soil, has been increasingly recognized as a cause of life-threatening systemic illness in immunosuppressed patients including those with leukaemia. Cutaneous involvement occurs in about 30% of patients with T. cutaneum septicaemia although disseminated folliculitis has not been described to our knowledge. We now describe a case of T. cutaneum follicultis due to fungaemia in a neutropenic patient.

Myxoid plexiform fibrohistiocytic tumour

Plexiform fibrohistiocytic tumour is a low-grade malignant mesenchymal neoplasm of myofibroblastic origin with the capacity for biphasic differentiation toward a fibroblastic or histiocyte-like morphology. We report a case of this rare tumour presenting as a tender subcutaneous nodule on the scalp of a 58-year-old man. Histopathological examination revealed multinodular biphasic proliferation of fibroblast-like and histiocyte-like cells with a few osteoclast-like giant cells. This case is notable for the rare myxoid changes, which may reflect a different behaviour of this tumour when occurring in older people.

Two cases of late onset Ota's naevus

Ota's naevus is among the dermal melanocytoses that show a distinct pattern involving skin innervated by the trigeminal nerve. Most cases present at birth or manifest clinically in early childhood. Cases of acquired lesions in adult onset have been reported rarely. We present two cases of late onset Ota's naevus which were confirmed by skin biopsies. Both patients underwent Q-switched alexandrite laser treatment with a dose of 8.0 J/cm2 given four or five times at 6 weekly intervals and showed some improvement.

Coexistence of CD30-positive anaplastic large cell lymphoma and mycosis fungoides

Primary cutaneous T-cell lymphomas, including lymphomatoid papulosis, mycosis fungoides and CD30+ anaplastic large cell lymphoma (ALCL) overlap clinicopathologically and form part of a spectrum of lymphoproliferative disorders. There have been several case reports of these diseases coexisting. We describe a 59-year-old Korean man who presented with a recurrent, solitary CD30+ ALCL of 25 years' duration as well as patch stage mycosis fungoides of 11 years' duration. Such occurrences may represent different clinical manifestations of the same clonal T-cell abnormality, and provide further insight into the pathogenesis of these related disorders.

Widespread skin-limited adult Langerhans cell histiocytosis: long-term follow-up with good response to interferon alpha

Langerhans cell histiocytosis (LCH) most frequently involves bone, but also involves the skin in 40% of cases; in 10% of patients it is limited to the skin. Cutaneous findings of skin-limited LCH are scaly papules, vesicles, nodules, tumours with erosion, ulceration, or crusting and/or purpura. We report a case of widespread adult-onset LCH confined to skin in which topical carmustine, photochemotherapy, systemic steroids, and 2-chlorodeoxyadenosine were only partially effective. However, longer remission was achieved by the use of subcutaneous interferon-alpha2b.

Cutaneous dissemination of nasal NK/T-cell lymphoma with bone marrow, liver and lung involvement

We describe a 32-year-old Korean man with a primary nasal natural killer (NK)/T-cell lymphoma (NKTCL). Combination chemotherapy and radiotherapy resulted in initial complete remission. However, cutaneous dissemination to the trunk and proximal extremities occurred 16 months later and further investigations revealed involvement of the liver, lymph nodes, lung and bone marrow. Nasal CD56+ NKTCL is mostly localized to the nasal area but also shows a predilection for other sites, such as skin. Cutaneous dissemination may be an indicator of widespread metastasis to internal organs and is consistently fatal.

Periungal hyperpigmentation induced by cisplatin

A number of anticancer drugs are known to produce pigmentary changes affecting the skin or nails. Among them, cisplatin (cis-diamminedichloroplatinum)-induced hyperpigmentation has been described previously in only two cases. We describe an unusual case with hyperpigmentation confined to periungal areas of the hands and feet after treatment with cisplatin.

Carcinoma erysipeloides associated with anaplastic thyroid carcinoma

Cutaneous metastases from carcinoma of the thyroid gland are rare and carcinoma erysipeloides is even rarer. We present the clinical, histological, and immunohistochemical features of inflammatory erysipeloid metastases arising from an anaplastic carcinoma of the thyroid gland. In this case the anaplastic carcinoma probably transformed from a pre-existing, long-standing papillary carcinoma of the thyroid gland. Although visible inflammation is a hallmark of many benign skin disorders, it is not commonly present in cutaneous malignant metastases. As a result, the significance of a marked inflammatory changes in association with metastatic skin disease may not be recognized. Dermatologists need to be aware of the potential for inflammatory manifestations in cutaneous metastases from a thyroid carcinoma.

Waldenström's macroglobulinaemia presenting as reticulate purpura and bullae in a patient with hepatitis B virus infection

Cutaneous manifestations of Waldenström's macroglobulinaemia (WM) include purpura, ulcers, urticaria, leukocytoclastic vasculitis, and immunobullous dermatoses. No association has been reported previously of WM and hepatitis B virus (HBV) infection. A 40-year-old female HBV carrier was admitted to hospital because of generalized oedema, oliguria, haematuria, hypertension, fever and blood-tinged sputum. Cutaneous manifestations included generalized petechiae, palpable purpura mainly on the legs, multiple necrotic ulcerations and gangrenous changes on the toes, and necrotic, giant confluent reticulate purpura on the trunk surmounted by several tense bullae. Laboratory investigations revealed monoclonal gammopathy of IgM kappa type (6.7 g/L), membranoproliferative glomerulonephritis associated with HBV infection, Bence Jones proteinuria, and an increased number of abnormal plasmacytoid cells in the bone marrow. Pathologic examination demonstrated immune complex-mediated vasculitis with deposits of IgM in the walls of dermal vessels and secondary subepidermal bulla formation. HBV infection may have caused WM or modified the clinical course in this fatal case.

A case of juvenile xanthogranuloma arising on a nevus sebaceus

Various epithelial and mesenchymal neoplasms can arise in nevus sebaceus (NS). Juvenile xanthogranuloma arising on an NS has not been reported previously. Juvenile xanthogranuloma, a disease characterized by reactive histiocytic proliferation, could be included in the list of secondary alterations arising on an NS.

Clinicohistopathologic comparison of adult type and juvenile type xanthogranulomas in Korea

Xanthogranuloma (XG) is an uncommon benign disorder characterized by solitary or multiple yellow-red papulonodules on the skin, and occasionally, in other organs. It is predominantly a disease of infancy or early childhood, although adults may rarely be affected. To compare the clinicohistopathological featues of juvenile-type xanthogranulomas UXGs) and adult-type xanthogranulomas (AXGs) (>14 years) in Korea, 30 cases of JXGs and 15 cases of AXGs were compared clinically and histopathologically. Except for the fact AXGs were more often solitary and larger and showed neither other associated systemic diseases nor spontaneous regression, the clinical features such as color, mean number, or site of the lesions in AXGs were not statistically different from JXGs. Histologically, AXCs were not significantly different in amounts of foamy cells, giant cells including Touton cells, and inflammatory cells, although subcutaneous involvement was seen only in the two infant cases. In conclusion, in contrast to AXGs, JXGs need special attention to accompanying systemic diseases and do not need excisional procedures, considering their frequent spontaneous regression.

A case of cutaneous low-grade myofibroblastic sarcoma

A 28-year-old woman presented with a recurrent nodule on the lower margin of her left nostril after laser surgery. Histologically, the nodule had an indistinct margin and was composed of interlacing fascicles of plump, spindled or stellate tumor cells with mild cytologic atypia. The tumor cells were revealed to be myofibroblasts by positivity to smooth muscle actin and negativity to desmin. A diagnosis of low grade myofibroblastic sarcoma (LGMS) was made.