Longitudinal gut microbiome changes in immune checkpoint blockade-treated advanced melanoma

Multiple clinical trials targeting the gut microbiome are being conducted to optimize treatment outcomes for immune checkpoint blockade (ICB). To improve the success of these interventions, understanding gut microbiome changes during ICB is urgently needed. Here through longitudinal microbiome profiling of 175 patients treated with ICB for advanced melanoma, we show that several microbial species-level genome bins (SGBs) and pathways exhibit distinct patterns from baseline in patients achieving progression-free survival (PFS) of 12 months or longer (PFS ≥12) versus patients with PFS shorter than 12 months (PFS <12). Out of 99 SGBs that could discriminate between these two groups, 20 were differentially abundant only at baseline, while 42 were differentially abundant only after treatment initiation. We identify five and four SGBs that had consistently higher abundances in patients with PFS ≥12 and <12 months, respectively. Constructing a log ratio of these SGBs, we find an association with overall survival. Finally, we find different microbial dynamics in different clinical contexts including the type of ICB regimen, development of immune-related adverse events and concomitant medication use. Insights into the longitudinal dynamics of the gut microbiome in association with host factors and treatment regimens will be critical for guiding rational microbiome-targeted therapies aimed at enhancing ICB efficacy.

Cutaneous manifestations induced by check point inhibitors in 120 melanoma patients - The European MelSkinTox study

BACKGROUND

Checkpoint inhibitors provide an effective approach for the melanoma treatment. They prolong lymphocyte effects, which explains the cytotoxicity underlying immune-related adverse events (IrAEs). Cutaneous IrAEs affect nearly 40% of PD-1i and 50% of CTLA4i treated patients. Severe cutaneous irAE do not often occur but could be life-threatening and may persist despite treatment discontinuation.

METHODS

We aim to investigate cutaneous IrAEs in a cohort of patients treated with ICI across Europe in an effort to characterize the reactions in a real-world, phase IV, post-marketing study using a follow-up questionnaire. Data since November 2016 until March 2021 were obtained from the Melskintox database, a European multicentric biobank dedicated to the follow-up of melanoma and cutaneous adverse events, supported by EADO. The dermatoses reported were pooled into 4 categories: inflammatory dermatosis, bullous diseases, drug-related eruptions and pigmentary diseases.

RESULTS

Inflammatory benign dermatoses (n=63) represented the most common group of reactions (52.5%), followed by drug-related eruptions (n=24, 20%), pigmentary diseases (n=23, 19.2%), and bullous diseases (n=10, 8.3%). Grade II (n=41, 34.2%) are represented by bullous pemphigoid, eczema, hypodermitis, lichenoid eruption, maculo-papular rash, pruritus, psoriasis-like rash, urticarial eruption and vitiligo. Grade III (n=18, 15.0%) are represented by bullous pemphigoid, lichenoid eruption, and rashes. Grade IV (n=2, 1.7%) is only represented by bullous disease. Most cutaneous IrAEs led to immunotherapy continuation (n=95, 88.0%). CR is associated with more severe the cutaneous irAEs. We report an average time-to-onset of 208 days and some late-onset events.

CONCLUSION

Our study has characterized the clinical spectrum of cutaneous irAEs, their timing and severity and their relationship with tumour response. Grade I-II cutaneous IrAE are easily managed allowing ongoing anti-cancer treatment. Severe late-onset cutaneous irAE are not uncommon. A dermatologic follow-up helps mitigate the risk of life-threatening adverse events. These findings highlight the importance of onco-dermatologic involvement in management of patients with melanoma receiving immunotherapy.

Association of a Mediterranean Diet With Outcomes for Patients Treated With Immune Checkpoint Blockade for Advanced Melanoma

Importance

Immune checkpoint blockade (ICB) has improved the survival of patients with advanced melanoma. Durable responses are observed for 40% to 60% of patients, depending on treatment regimens. However, there is still large variability in the response to treatment with ICB, and patients experience a range of immune-related adverse events of differing severity. Nutrition, through its association with the immune system and gut microbiome, is a poorly explored but appealing target with potential to improve the efficacy and tolerability of ICB.

Objective

To investigate the association between habitual diet and response to treatment with ICB.

Design, Setting, and Participants

This multicenter cohort study (the PRIMM study) was conducted in cancer centers in the Netherlands and UK and included 91 ICB-naive patients with advanced melanoma who were receiving ICB between 2018 and 2021.

Exposures

Patients were treated with anti-programmed cell death 1 and anti-cytotoxic T lymphocyte-associated antigen 4 monotherapy or combination therapy. Dietary intake was assessed through food frequency questionnaires before treatment.

Main Outcomes and Measures

Clinical end points were defined as overall response rate (ORR), progression-free survival at 12 months (PFS-12), and immune-related adverse events that were grade 2 or higher.

Results

There were a total of 44 Dutch participants (mean [SD] age, 59.43 [12.74] years; 22 women [50%]) and 47 British participants (mean [SD] age, 66.21 [16.63] years; 15 women [32%]). Dietary and clinical data were prospectively collected from 91 patients receiving ICB between 2018 and 2021 for advanced melanoma in the UK and the Netherlands. Logistic generalized additive models revealed positive linear associations between a Mediterranean dietary pattern that was high in whole grains, fish, nuts, fruit, and vegetables and the probability of ORR and PFS-12 (probability of 0.77 for ORR; P = .02; false discovery rate, 0.032; effective degrees of freedom, 0.83; probability of 0.74 for PFS-12; P = .01; false discovery rate, 0.021; effective degrees of freedom, 1.54).

Conclusions and Relevance

This cohort study found a positive association between a Mediterranean diet, a widely recommended model of healthy eating, and response to treatment with ICB. Large prospective studies from different geographies are needed to confirm the findings and further elucidate the role of diet in the context of ICB.

Cross-cohort gut microbiome associations with immune checkpoint inhibitor response in advanced melanoma

The composition of the gut microbiome has been associated with clinical responses to immune checkpoint inhibitor (ICI) treatment, but there is limited consensus on the specific microbiome characteristics linked to the clinical benefits of ICIs. We performed shotgun metagenomic sequencing of stool samples collected before ICI initiation from five observational cohorts recruiting ICI-naive patients with advanced cutaneous melanoma (n = 165). Integrating the dataset with 147 metagenomic samples from previously published studies, we found that the gut microbiome has a relevant, but cohort-dependent, association with the response to ICIs. A machine learning analysis confirmed the link between the microbiome and overall response rates (ORRs) and progression-free survival (PFS) with ICIs but also revealed limited reproducibility of microbiome-based signatures across cohorts. Accordingly, a panel of species, including Bifidobacterium pseudocatenulatum, Roseburia spp. and Akkermansia muciniphila, associated with responders was identified, but no single species could be regarded as a fully consistent biomarker across studies. Overall, the role of the human gut microbiome in ICI response appears more complex than previously thought, extending beyond differing microbial species simply present or absent in responders and nonresponders. Future studies should adopt larger sample sizes and take into account the complex interplay of clinical factors with the gut microbiome over the treatment course.

COVID-19 vaccines and skin manifestations

Linked Article: Català et al. Br J Dermatol 2022; 186:142–152.

Inherited duplications of PPP2R3B predispose to nevi and melanoma via a C21orf91-driven proliferative phenotype

PURPOSE

Much of the heredity of melanoma remains unexplained. We sought predisposing germline copy-number variants using a rare disease approach.

METHODS

Whole-genome copy-number findings in patients with melanoma predisposition syndrome congenital melanocytic nevus were extrapolated to a sporadic melanoma cohort. Functional effects of duplications in PPP2R3B were investigated using immunohistochemistry, transcriptomics, and stable inducible cellular models, themselves characterized using RNAseq, quantitative real-time polymerase chain reaction (qRT-PCR), reverse phase protein arrays, immunoblotting, RNA interference, immunocytochemistry, proliferation, and migration assays.

RESULTS

We identify here a previously unreported genetic susceptibility to melanoma and melanocytic nevi, familial duplications of gene PPP2R3B. This encodes PR70, a regulatory unit of critical phosphatase PP2A. Duplications increase expression of PR70 in human nevus, and increased expression in melanoma tissue correlates with survival via a nonimmunological mechanism. PPP2R3B overexpression induces pigment cell switching toward proliferation and away from migration. Importantly, this is independent of the known microphthalmia-associated transcription factor (MITF)-controlled switch, instead driven by C21orf91. Finally, C21orf91 is demonstrated to be downstream of MITF as well as PR70.

CONCLUSION

This work confirms the power of a rare disease approach, identifying a previously unreported copy-number change predisposing to melanocytic neoplasia, and discovers C21orf91 as a potentially targetable hub in the control of phenotype switching.

The gut microbiome: what the oncologist ought to know

The gut microbiome (GM) has been implicated in a vast number of human pathologies and has become a focus of oncology research over the past 5 years. The normal gut microbiota imparts specific function in host nutrient metabolism, xenobiotic and drug metabolism, maintenance of structural integrity of the gut mucosal barrier, immunomodulation and protection against pathogens. Strong evidence is emerging to support the effects of the GM on the development of some malignancies but also on responses to cancer therapies, most notably, immune checkpoint inhibition. Tools for manipulating the GM including dietary modification, probiotics and faecal microbiota transfer (FMT) are in development. Current understandings of the many complex interrelationships between the GM, cancer, the immune system, nutrition and medication are ultimately based on a combination of short‐term clinical trials and observational studies, paired with an ever-evolving understanding of cancer biology. The next generation of personalised cancer therapies focusses on molecular and phenotypic heterogeneity, tumour evolution and immune status; it is distinctly possible that the GM will become an increasingly central focus amongst them. The aim of this review is to provide clinicians with an overview of microbiome science and our current understanding of the role the GM plays in cancer.

Diagnostic value of cutaneous manifestation of SARS-CoV-2 infection

Background

One of the challenging aspects of SARS‐CoV‐2 infection is its diverse multisystemic disease presentation.

Objectives

To evaluate the diagnostic value of cutaneous manifestations of SARS‐CoV‐2 infection and investigate their duration and timing in relation to other COVID‐19 symptoms.

Methods

We used data from 336 847 UK users of the COVID Symptom Study app to assess the diagnostic value of body rash or an acral rash in SARS‐CoV‐2 infection, and data from an independent online survey of 11 544 respondents to investigate skin‐specific symptoms and collect their photographs.

Results

Using data from the app, we show significant association between skin rashes and a positive swab test result (odds ratio 1·67, 95% confidence interval 1·42–1·97). Strikingly, among the respondents of the independent online survey, we found that 17% of SARS‐CoV‐2‐positive cases reported skin rashes as the first presentation, and 21% as the only clinical sign of COVID‐19. Together with the British Association of Dermatologists, we have compiled a catalogue of images of the most common skin manifestations of COVID‐19 from 400 individuals (https://covidskinsigns.com), which we have made publicly available to assist clinicians in recognition of this early clinical feature of COVID‐19.

Conclusions

Skin rashes cluster with other COVID‐19 symptoms, are predictive of a positive swab test, and occur in a significant number of cases, either alone or before other classical symptoms. Recognizing rashes is important in identifying new and earlier cases of COVID‐19.

What is already known about this topic?

Several studies conducted in hospital settings reported that patients with COVID‐19 presented with unusual skin rashes, including urticarial rashes, vesicular lesions and, less frequently, chilblains in fingers or toes.

What does this study add?

We confirmed, in a community‐based setting that also includes milder forms of the disease, that the presence of a skin rash is predictive of SARS‐CoV‐2 infection.

We provide a website with photos of skin manifestations to help healthcare professionals in diagnosing COVID‐19.

Skin rashes should be taken into account to provide a quick COVID‐19 diagnosis to curb the spread of the disease.

Linked Comment: Naldi. Br J Dermatol 2021; 184:793–794.

Compared prognostic impact of incident atrial fibrillation versus history of atrial fibrillation in patients with AMI: the FAST-MI programme

Background

History of atrial fibrillation (HxAF) and new onset atrial fibrillation (NOAF) at acute stage of MI are associated with poorer survival. Whether both entities carry an increased risk of stroke is uncertain.

Using data from the FAST-MI 2010 and 2015 registries, we analysed the associations between HxAF and NOAF and risk of 3-year death, nonfatal stroke or combined death or stroke.

Methods

The FAST-MI registries are nationwide French cohorts consecutively including AMI patients admitted over a 1-month period every 5 years. Baseline characteristics, acute management and medications at discharge are collected. Among 9460 patients with STEMI or NSTEMI, 610 (6.4%) had HxAF, and 626 (6.6%) developed NOAF.

Main characteristics

Table 1 Overall, NOAF was associated with larger and more severe AMIs.

Results

In hospital survivors, 3-year death was 8.6% in patients without AF, 23.2% in those with NOAF and 29.2% in those with HxAF. 3-year Kaplan-Meier rates of non-fatal stroke were 1.1%, 0.3% and 3.6%, respectively (Figure).

Compared with no AF, NOAF was not associated with non-fatal stroke (Cox HR, 95% CI: 0.17, 0.02–1.21), while HxAF was (HR, 95% CI 2.04, 1.13–3.66, P=0.017). Risk of death or stroke was increased for both NOAF (HR, 95% CI 1.35, 1.10–1.65, P=0.004) and HxAF (HR 95% CI, 1.37, 1.14–1.65, P=0.001). Risk of all-cause death at 3 years was increased for NOAF (HR, 95% CI 1.32, 1.09–1.60) and HxAF (HR, 95% CI 1.30, 1.09–1.55). The results were concordant in patients not receiving oral anticoagulants at discharge.

Conclusion

Both NOAF and HxAF are associated with increased risk of death at 3 years after AMI. NOAF, however, is not associated with an increased risk of non-fatal stroke.

Figure 1. Non-fatal stroke

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Pharma companies

Compared presentation, management and long-term outcomes after acute myocardial infraction in men and women &lt;50 years of age. The FAST-MI programme

 

The number of young women suffering acute myocardial infarction (AMI) is increasing. There are conflicting results on the prognostic impact of gender in young patients with AMI. The aim of the present study was to assess in-hospital and 5-year outcomes in men and women ≤50 years old admitted for AMI and participating in the FAST-MI programme.

Methods

FAST-MI consists in one-month nationwide French surveys of patients admitted for a recent AMI, repeated every 5 years since 2005. We used the 2005, 2010 and 2015 data with up to 5-year follow-up, to describe baseline characteristics and outcomes according to gender in young patients. Of 13,130 patients included, 1,912 were ≤50 years old (335 women, 17.5%).

Results

Men and women had a similar age (44±5 years), BMI, current smoking (72% vs 75%), diabetes, family history, prior history of CVD, GRACE score (104±22 vs 106±23), and LVEF (54±10%). LDL at admission was lower in women (127±46 vs 138±46 mg/dl). Women had a higher admission heart rate (81±19 vs 78±17 BPM) and lower systolic blood pressure (133±26 vs 136±25 mm Hg). Presenting AMI was STEMI in 63% in women vs 68% in men (P=0.08).

All in-hospital complications except reinfarction (1.8 vs 0.6%, p&lt;0.03) were similar in women and men; in-hospital death was 1.5% vs 0.8%, P=0.20. Coronary angiography was performed slightly less often (97.6% vs 99.0%, P=0.047) and more women had non-significant coronary artery disease (CAD) (13% vs 6%, P&lt;0.001); PCI was less often used (74% vs 85.5%, P&lt;0.001). At discharge, ESC guidelines-recommended medical treatment was less often prescribed in women (41% vs 53%, P&lt;0.001), even in patients with significant CAD (46% vs 55%, P=0.004).

Kaplan-Meier 5-year survival did not differ in women (94.7%) and men (95.2%), P=0.56 (Figure). The respective figures for hospital survivors were 96.1% and 96.0% (HR 1.00, 95% CI 0.52–1.91; HR adjusted on age, type of MI, previous history of CAD, presence of significant CAD, LVEF, Killip class and appropriate medications at discharge: 0.99, 95% CI 0.51–0.92). Similar results were found for the combined end-point of death, AMI or stroke.

Conclusion

There were more similarities than differences between women and men who sustained an AMI at age ≤50 years. Women had lower LDL-c, lower haemoglobin, higher heart rate and lower blood pressure on admission. Non-significant CAD was more frequently found in women, who were less often treated with PCI and recommended medications at discharge. Five-year outcomes, however, did not differ according to gender.

Five-year mortality

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Pfizer, MSD, AstraZeneca

Are the results of clinical trials relevant in the real world? The applicability of REDUCE-IT to the FAST-MI Registry

Background

Large clinical trials are often criticized for testing therapeutic strategies in selected populations. The REDUCE-IT data revealed robust atherosclerotic cardiovascular risk reduction with a strategy comprising of high dose omega-3 icosapent ethyl versus placebo in statin treated patients with triglyceride values (TG) between 150 and 499 mg/dl and controlled LDL-C (41–100 mg/ dl).

Purpose

In order to evaluate the applicability of REDUCE-IT in a French population, we applied the inclusion and exclusion criteria in the French Registry on Acute ST- elevation and non-ST-elevation Myocardial Infarction (FAST-MI) [2010 and 2015].

Methods

From the FAST-MI registry, we included patients over 45 years, who had detailed lipid values post-acute hospitalization [11.1 months (median) after hospitalization for myocardial infarction]. We thus compared the applicability of REDUCE-IT [in patients with TG between 150 (or 200) and 500 mg/dl and an LDL-C between 40 and 100 mg/dl while treated with statin therapy] in the FAST-MI registry focusing on the general characteristics, the risk factors, and the cardiovascular prognosis i.e. the rate of total mortality, myocardial infarction and stroke.

Results

12.5% of the patients (5.5% if TG between 200 and 500 mg/dl) met the eligibility criteria for REDUCE-IT. The differences between the REDUCE-IT like (n=472) and REDUCE-IT excluded (n=3317) samples were related to age (61 vs 65, NS), male gender (79.5% vs 73.8%, p&lt;0.01), body mass index in kg/m2 (28 vs 26.2, p&lt;0.001), current smoking (45% vs 31.4%, p&lt;0.001), hypertension (56.5% vs 50.2%, p&lt;0.01), and the percentage of diabetic patients (29.5% vs 15.6%, p&lt;0.001). In the REDUCE-IT like sample, the mean values of total cholesterol, TG (median) and the HDL-C were respectively 159, 192, 43 and the LDL-C value was 72 mg/dl. The distribution of the statin regimens in the REDUCE-IT like sample was as follows: 65.3%, 32.4% and 2.3% had high, moderate and low intensity statin therapy. The distribution of TG categories in the REDUCE-IT like sample was as follows: 55.3% (150–199), 36.0% (200–299) and 8.7% (300–500 mg/dl). The subgroup with TGs greater than 200 mg/dl and HDL-C less than 35 mg/dl was 16.1% in the REDUCE-IT like group and 2.1% in the REDUCE-IT excluded group (p&lt;0.001). The cardiovascular event rate (death, nonfatal MI, nonfatal stroke) was respectively 36.7 for the FAST-MI REDUCE-IT like group and 36.9 persons-years (CVD death, nonfatal MI, nonfatal stroke) for the REDUCE-IT trial.

Conclusion

The cardiovascular residual risk related to elevated TG in the applicable patient population in the FAST-MI registry was similar to the risk in REDUCE-IT. If the results of REDUCE-IT are applied to patients hospitalized for a myocardial infarction in France, on top of statins, 12.5% of these patients could benefit from a strategy of high dose omega-3 icosapent ethyl on top of contemporary medical therapy to improve their future cardiovascular health.

Funding Acknowledgement

Type of funding source: None

Campylobacteriosis following immunosuppression for immune checkpoint inhibitor-related toxicity

Five patients receiving checkpoint inhibitor immunotherapy (CPI) under our care across two cancer centers over a 12-month period have subsequently developed campylobacterosis. All had received immune-suppressive treatment for CPI-related colitis in the weeks or months preceding the detection of Campylobacter infection, with negative stool cultures at presentation of CPI-related colitis. The immune-suppression required to treat CPI-related toxicity may lead to an increased risk of enteric infection within the gut. While the underlying immune and biologic mechanisms are not well understood, perturbation of the gut microbiota is an increasingly recognized factor capable of influencing CPI-mediated immune reconstitution and response to therapy. Clinicians should be aware that worsening of colitic symptoms in patients with a history of treatment for CPI-related colitis may be due to enteric infection, and not simply a relapse/deterioration of a previously treated CPI-related colitis. Judicious infectious disease evaluation is necessary for patients receiving CPIs as symptoms can mimic immune-related adverse events (irAEs). Furthermore, the benefits of immune-suppressive therapy for the treatment of presumptive irAEs must be weighed against the possible increased risk for either enteric infection or opportunistic infection. Prospective studies are required to investigate microbiome perturbations, resulting from immune-suppression, and guide future treatment of this patient cohort.

The evolving field of Dermato-oncology and the role of dermatologists: Position Paper of the EADO, EADV and Task Forces, EDF, IDS, EBDV-UEMS and EORTC Cutaneous Lymphoma Task Force

BACKGROUND

The incidence of skin cancers has been increasing steadily over the last decades. Although there have been significant breakthroughs in the management of skin cancers with the introduction of novel diagnostic tools and innovative therapies, skin cancer mortality, morbidity and costs heavily burden the society.

OBJECTIVE

Members of the European Association of Dermato-Oncology, European Academy of Dermatology and Venereology, International Dermoscopy Society, European Dermatology Forum, European Board of Dermatovenereology of the European Union of Medical Specialists and EORTC Cutaneous Lymphoma Task Force have joined this effort to emphasize the fundamental role that the specialist in Dermatology-Venereology has in the diagnosis and management of different types of skin cancer. We review the role of dermatologists in the prevention, diagnosis, treatment and follow-up of patients with melanoma, non-melanoma skin cancers and cutaneous lymphomas, and discuss approaches to optimize their involvement in effectively addressing the current needs and priorities of dermato-oncology.

DISCUSSION

Dermatologists play a crucial role in virtually all aspects of skin cancer management including the implementation of primary and secondary prevention, the formation of standardized pathways of care for patients, the establishment of specialized skin cancer treatment centres, the coordination of an efficient multidisciplinary team and the setting up of specific follow-up plans for patients.

CONCLUSION

Skin cancers represent an important health issue for modern societies. The role of dermatologists is central to improving patient care and outcomes. In view of the emerging diagnostic methods and treatments for early and advanced skin cancer, and considering the increasingly diverse skills, knowledge and expertise needed for managing this heterogeneous group of diseases, dermato-oncology should be considered as a specific subspecialty of Dermatology-Venereology.

P906Impact of aortic valve calcification severity on device success after trans catheter aortic valve replacement

Methods

We included 352 consecutive patients who underwent TAVR with a preoperative standardized contrast enhanced MSCT. Valvular calcifications detection was defined by adding +100 Hounsfield Unit (HU) to mean HU determined by a Region Of Interest placed in the contrast enhanced ascending aorta. CS was then indexed to the aortic annulus surface (CSi). Endpoints were DS and 30-days MACE according to Valve Academic Research Consortium-2 consensus document, and PVL greater than or equal to grade 2.

Results

DS was obtained for 305 patients. In multivariate analysis, CS and CSi were negatively and independently associated with DS: OR=0.88, 95% CI 0.81–0.96, p=0.004; and OR=0.94, 95% CI 0.91–0.98, p=0.002 respectively. There was no association between MACE and CS (p=0,953) and CSi (p=0,757). PVL was positively associated with CS (p<0.001) and CSi (p<0.001).

Multivariate analysis for device success Multivariate analysis for device success procedure Initial Model Final Model OR (95% CI) p OR (95% CI) p Age (years) 1.06 (1–1.12) 0.058 Size (cm) 1.02 (0.98–1.07) 0.26 Hypertension 0.35 (0.13–0.92) 0.033 0.34 (0.13–0.87) 0.024 Diabete mellitus 1.72 (0.68–4.34) 0.249 Mean gradient 0.99 (0.97–1.02) 0.517 Mitral regurgitation 0.6 (0.28–1.27) 0.18 Valve size   ≤23 1 (REF)   26 1.85 (0.8–4.27) 0.152   29 4.08 (1.32–12.59) 0.015 4.72 (1.62–13.78) 0.004   31 1.42 (0.32–6.38) 0.647 CS (for an increase of 1000 pts) 0.89 (0.81–0.98) 0.017 0.88 (0.81–0.96) 0.004 CSi (for an increase of 100 pts) 0.94 (0.9–0.99) 0.013 0.96 (0.91–0.98) 0.002

Example of CS measurement

Conclusion

In TAVR, the aortic valvular CS, measured on preoperative contrast enhanced MSCT, is significantly associated with DS and PVL, but not with 30-days MACE. Its routine use could be relevant to appreciate success chances of TAVR.

P5473Perceived well-being after acute myocardial infarction according to diabetic status and its impact long-term mortality. The FAST-MI programme

Background

Little information is available regarding subjective well-being according to diabetic status in patients surviving an acute myocardial infarction (AMI).

Aims and methods

A health status questionnaire was sent to all patients participating in the nationwide French FAST-MI cohorts (2005, 2010 and 2015) one year after the acute episode of AMI, with a specific question on overall health condition (how do you feel: very well, well, fair, poor) (n=6082), and additional questions on the presence of any chest pain (n=4590), presence nuisance bleedings (n=3968), and reporting of perceived medication side-effects (n=2220). Answers were analysed according to diabetic status. We also analysed in the 2005 and 2010 cohorts whether subjective health status at one year was a correlate of 5-year mortality.

Results

Compared with non-diabetic patients (n=4692), those with diabetes (n=1390) had a poorer perceived health status (poor/fair health status: 40% vs 30%, P<0.001), more presence of chest pain (31% vs 23%, P<0.001), but less nuisance bleedings (47% vs 56%, P<0.001) and similar reported medication side-effects (37% vs 41%, P=0.12). Using logistic regression analysis, diabetes was an independent correlate of poorer health status (any diabetes OR vs non-diabetic 1.29, 1.13–1.49, P<0.001; non-insulin-treated: 1.17, 1.00–1.36, P=0.05, insulin-treated: 1.58, 1.29–1.94, P<0.001). In diabetic patients, perceived health condition at one year was an independent correlate of 5-year death (Cox multivariate analysis): compared with patients reporting very good health, HR (95% CI) 2.16 (1.08–4.32) for good health, 3.06 (1.53–6.11) for fair health, and 3.63 (1.55–8.55) for poor health; in non-diabetic patients, 5-year survival was similar in those reporting good or very good health status, but lower in those reporting fair or poor health status (Figure).

Figure 1. 5-year survival by health status

Conclusion

Compared with non-diabetic patients, patients with diabetes described a poorer general health and more residual chest pain after AMI, but had less nuisance bleedings. Health condition reported one year after AMI was an independent correlate of subsequent long-term mortality, particularly for diabetic patients.

Acknowledgement/Funding

Amgen, AstraZeneca, Bayer, Daiichi-Sankyo, Eli-Lilly, GSK, MSD, Novartis, Pfizer, Sanofi, Servier

Favourable prognostic role of histological regression in stage III positive sentinel lymph node melanoma patients

BACKGROUND

Sentinel lymph node (SLN)-positive melanoma patients are a heterogeneous group of patients with survival rates ranging from ∼20 to over 80%. No data are reported concerning the role of histological regression on survival in stage III melanoma.

METHODS

The study included 365 patients with positive SLN from two distinct hospitals. The model was developed on patients from 'AOU Città della Salute e della Scienza di Torino', and externally validated on patients from IRCCS of Candiolo. Survival analyses were carried out according to the presence of regression and adjusted for all other prognostic factors.

RESULTS

Among patients followed at 'AOU Città della Salute e della Scienza di Torino' (n=264), the median follow-up time to death or censoring (whatever two events occurred earlier) was 2.7 years since diagnosis (interquartile range: 1.3-5.8). In all, 79 patients died from melanoma and 11 from other causes. Histological regression (n=43) was associated with a better prognosis (sub-HR=0.34, CI 0.12-0.92), whereas the other factors above showed an inverse association. In the external validation, the concordance index was 0.97 at 1 year and decreased to 0.66 at 3 years and to 0.59 at 5 years. Adding histological regression in the prognostic model increased the discriminative ability to 0.75 at 3 years and to 0.62 at 5 years. Finally, using a cutoff of 20% for the risk of death led to a net re-classification improvement of 15 and 11% at 3 and 5 years after diagnosis, respectively.

CONCLUSIONS

Histological regression could lead to an improvement in prognostic prediction in patients with stage III-positive SLN melanoma.

Diagnosis and treatment of in-transit melanoma metastases

In transit metastases (ITM) from extremity or trunk melanomas are subcutaneous or cutaneous lymphatic deposits of melanoma cells, distant from the primary site but not reaching the draining nodal basin. Superficial ITM metastases develop in 5-10% of melanoma patients and are thought to be caused by cells spreading along lymphatics; ITM appear biologically different from distant cutaneous metastases, these probably due to a haematogenous dissemination. The diagnosis is usually clinical and by patients, but patients need to be adequately educated in the recognition of this clinical situation. Ultrasound or more sophisticated instrumental devices may be required if the disease develops more deeply in the soft tissues. According to AJCC 2009 staging classification, ITM are included in stages IIIb and IIIc, which are considered local advanced disease with quite poor 5-year survival rates and outcomes of 24-54% at 5 years.² Loco-regional recurrence is in fact an important risk factor for distant metastatic disease, either synchronous or metachronous. Therapy for this pattern of recurrence is less standardised then in most other clinical situations and options vary based on the volume and site of the disease. Definitive surgical resection remains the preferred therapeutic approach. However, when surgery cannot be performed with a reasonable cosmetic and functional outcome, other options must be utilized.^3-6 Treatment options are classified as local, regional or systemic. The choice of therapy depends on the number of lesions, their anatomic location, whether or not these are dermal or subcutaneous, the size and the presence or absence of extra-regional disease.

Skin phenotypes can offer some insight about the association between telomere length and cancer susceptibility

The role of telomere biology in cancer has been studied for a wide variety of different cancers but the association with telomere length has been controversial. This is because some cancers have been found to be associated with longer telomeres in circulating white cells whilst other cancer types are more common in individuals with shorter telomeres. Hence, there has been some skepticism as to whether telomere length may be helpful in estimating cancer risk. For melanoma, however, results have been fairly consistent showing that longer telomeres are associated with an increased risk. This link was first discovered because of a link between longer telomeres and a high number of naevi. In contrast, for cutaneous squamous cell carcinomas, the relationship is reversed with higher risk in individuals with shorter telomeres. Differences in skin phenotypes with the presence of high number of naevi versus photoageing with solar elastosis and solar keratoses have already been valuable for dermatologists as the former phenotype is associated with melanoma whilst the latter is more common in patients with squamous cell carcinoma of the skin. The hypothesis is that the differences in cutaneous phenotypes already observed by dermatologists for skin cancers may, in fact, be useful as well for cancer prediction in general as it may reflect underlying telomere biology. This manuscript will address the evidence for links between telomere biology, skin phenotypes and cancer risk.

Pregnancy and melanoma: a European-wide survey to assess current management and a critical literature overview

BACKGROUND

Management of melanoma during pregnancy can be extremely challenging. The reported incidence of melanoma in pregnancy ranges from 2.8 to 5.0 per 100 000 pregnancies. There are no guidelines for the management of melanoma during pregnancy.

METHODS

The survey was designed to investigate the opinions of melanoma physicians on decision making in relation to pregnancy and melanoma. A clinical scenario-based survey on management of pregnancy in melanoma was distributed all over Europe via the membership of the EORTC and other European melanoma societies.

RESULTS

A total of 290 questionnaires were returned with a larger participation from southern Europe. A large heterogeneity was found for the answers given in the different clinical scenarios with 50% of the answers showing discordance, especially regarding sentinel lymph node biopsy during pregnancy. Discordant answers were also found for the counselling of women about a potential delay in getting pregnant after a high-risk melanoma (35% for a 2 year wait minimum vs. 57% no waiting needed), while for thin melanomas, as expected, there was more concordance with 70% of the physicians recommending no delay. Fifteen per cent of physicians recommended an abortion in stage II melanoma during the third month of pregnancy. Twenty per cent of the responders advised against hormonal replacement therapy in melanoma patients.

CONCLUSIONS

The management of melanoma during pregnancy varies widely in Europe. At present, there is a lack of consensus in Europe, which may lead to very important decisions in women with melanoma, and guidelines are needed.

Pro-invasive activity of the Hippo pathway effectors YAP and TAZ in cutaneous melanoma

YAP and its paralog protein TAZ are downstream effectors of the Hippo pathway. Both are amplified in many human cancers and promote cell proliferation and epithelial-mesenchymal transition. Little is known about the status of the Hippo pathway in cutaneous melanoma. We profiled Hippo pathway component expression in a panel of human melanoma cell lines and melanocytic lesions, and characterized the capacity of YAP and TAZ to control melanoma cell behavior. YAP and TAZ immuno-staining in human samples revealed mixed cytoplasmic and nuclear staining for both proteins in benign nevi and superficial spreading melanoma. TAZ was expressed at higher levels than YAP1/2 in all cell lines and in those with high invasive potential. Stable YAP or TAZ knockdown dramatically reduced the expression of the classical Hippo target CCN2/connective-tissue growth factor (CTGF), as well as anchorage-independent growth, capacity to invade Matrigel, and ability form lung metastases in mice following tail-vein injection. YAP knockdown also reduced invasion in a model of skin reconstruct. Inversely, YAP overexpression increased melanoma cell invasiveness, associated with increased TEA domain-dependent transcription and CCN2/CTGF expression. Together, these results demonstrate that both YAP and TAZ contribute to the invasive and metastatic capacity of melanoma cells and may represent worthy targets for therapeutic intervention.

An investigation of rheumatoid arthritis loci in patients with early-onset psoriasis validates association of the REL gene

BACKGROUND

Phenotypically diverse autoimmune conditions share common genetic susceptibility loci and underlying molecular pathways.

OBJECTIVES

By systematically searching for single nucleotide polymorphisms (SNPs) associated with another autoimmune disease, rheumatoid arthritis (RA), we aimed to elucidate novel genetic markers of psoriasis.

METHODS

We investigated 18 SNPs, previously confirmed as being associated with RA, in a U.K. cohort of 623 patients with early-onset psoriasis (presenting before age 40 years), comparing them with 2662 control subjects.

RESULTS

Our findings confirm the association of early-onset psoriasis with REL (rs13031237, P=0·0027). The minor allele of REL had opposing effects upon susceptibility to disease in patients with psoriasis and RA.

CONCLUSION

Similar exploration of additional autoimmune loci and fine mapping of such regions may provide further insight into the genetics and molecular pathophysiology of psoriasis.

The French registry of Acute ST elevation or non-ST-elevation Myocardial Infarction (FAST-MI): study design and baseline characteristics

The FAST MI registry was designed to evaluate the 'real world' management of patients with acute myocardial infarction (MI), and to assess their in-hospital, medium- and long-term outcomes. Patients were recruited consecutively from intensive care units over a period of one month (from October 2005), with an additional one-month recruitment period for diabetic patients. The study included 3059 MI patients in phase 1 and an additional 611 diabetic patients in phase 2. Altogether, 53% of the patients had a final diagnosis of Q wave MI and 47% had non Q wave MI. Patients with Q wave MI were more likely to be men, younger, more frequently with a family history or a history of smoking. Patients with non Q wave MI had worst baseline demographic and clinical characteristics mainly explained by their older age. Time from symptom onset to hospital admission was less than three hours for 22% of the patients with Q wave MI and for 14% of the non Q wave MI patients. Among patients with Q wave MI, 64% received reperfusion therapy, 35% with primary percutaneous coronary interventions, 19% with pre-hospital thrombolysis and 10% with in-hospital thrombolysis. Over 70% of patients received statin therapy during the hospital stay and over 90% anti platelet agents. In-hospital mortality was 5.8% in patients with Q wave MI and 4.9% in patients with non Q Wave MI. At discharge beta-adrenergic blockers and statins and, to a lesser extent, medications of the renin angiotensin system were commonly prescribed. Over 90% received antiplatelet agents.

Metabolic syndrome and coronary heart disease risk in a population-based study of middle-aged men from France and Northern Ireland

Metabolic Syndrome (MetS) was found associated with an increased CHD risk in several studies but data about this relationship in Southern Europe are lacking. We studied the association of MetS according to three different indexes (the National Cholesterol Education Program's definition (NCEP), a modified World Health Organization's definition (WHO) and the recent International Diabetes Federation's definition (IDF)) with CHD risk in a case-control study nested within the PRIME cohort, composed of subjects from France (Southern Europe) and Belfast (Northern Europe). The PRIME prospective study is composed of 10 592 men, aged 50-59 at baseline and followed for 5 years. Subjects included in this nested case-control study were 296 cases of incident CHD and 540 controls, who remained free of CHD during the 5 years of follow-up of the PRIME cohort and matched for age, recruitment centre and recruitment date. All subjects had questionnaires and a medical examination at baseline, and a blood sample was taken. Using the IDF's, the WHO's and the NCEP's definitions respectively, the frequency of MetS was 38.9%, 35.5% and 29.7% in cases and 32.4%, 28.7% and 22.6% in controls. After adjustment for physical activity, smoking and drinking habits, MetS was associated with CHD risk whichever the definition used (ORIDF=1.41 [1.02-1.95], P<0.04, ORWHO=1.40 [1.01-1.94], P<0.05 and ORNCEP=1.46[1.04-2.04], P<0.04). These results were homogeneous in France (low risk of CHD) and Belfast (high risk of CHD). Our results add further evidence that MetS is predictive of CHD risk in middle-aged men from Northern and Southern Europe, and highlight differences between the three definitions studied.

A multicentre epidemiological study on sunbed use and cutaneous melanoma in Europe

A large European case-control study investigated the association between sunbed use and cutaneous melanoma in an adult population aged between 18 and 49 years. Between 1999 and 2001 sun and sunbed exposure was recorded in 597 newly diagnosed melanoma cases and 622 controls in Belgium, France, The Netherlands, Sweden and the UK. Fifty three percent of cases and 57% of controls ever used sunbeds. The overall adjusted odds ratio (OR) associated with ever sunbed use was 0.90 (95% CI: 0.71-1.14). There was a South-to-North gradient with high prevalence of sunbed exposure in Northern Europe and lower prevalence in the South (prevalence of use in France 20%, OR: 1.19 (0.68-2.07) compared to Sweden, prevalence 83%, relative risk 0.62 (0.26-1.46)). Dose and lag-time between first exposure to sunbeds and time of study were not associated with melanoma risk, neither were sunbathing and sunburns (adjusted OR for mean number of weeks spent in sunny climates >14 years: 1.12 (0.88-1.43); adjusted OR for any sunburn >14 years: 1.16 (0.9-1.45)). Host factors such as numbers of naevi and skin type were the strongest risk indicators for melanoma. Public health campaigns have improved knowledge regarding risk of UV-radiation for skin cancers and this may have led to recall and selection biases in both cases and controls in this study. Sunbed exposure has become increasingly prevalent over the last 20 years, especially in Northern Europe but the full impact of this exposure on skin cancers may not become apparent for many years.

Public awareness about risk factors could pose problems for case-control studies: The example of sunbed use and cutaneous melanoma

In a large case-control study we found no association between sunbed use and melanoma risk, but indications for potential recall and recruitment biases made the interpretation of the results difficult. Associations with skin phototype (adj OR for skin type I vs. IV: (2.6, 95% CI 1.5-4.8)), hair colour (adj OR red/blond vs. brown/black 2.0 (95% CI 1.4-2.8)) and number of naevi on both arms (OR>10 vs. 10 3.13 (95% CI: 2.47; 3.97)) were comparable to previous studies, but negative associations were found between sun exposure and melanoma risk (adj. OR 0.87 (95% CI: 0.65-1.18)) and in cases between sun exposure and naevus count. These observations led us to speculate that cases may have underreported their sun exposure and, most likely, their sunbed exposure. High percentages of sunbed use among controls indicated possible recruitment bias: eligible controls who were sunbed users were probably more likely to accept the invitation to participate than non-users, possibly due to a feeling of 'guilt' or 'worry' about their habits. Such selective participation may have strongly influenced the risk estimates of sunbed use in our study.

Exposure to the sun and sunbeds and the risk of cutaneous melanoma in the UK: a case-control study

Migration, latitude and case-control studies have clearly established a link between melanoma and sun exposure. This case-control study of melanoma was set up to examine the role of sun exposure and sunbeds in the pathogenesis of melanoma in the United Kingdom (UK), a country with low levels of ultraviolet radiation. The study included 413 cases and 416 controls. More than 10 severe sunburns compared with less than 10 sunburns was associated with an Odds Ratio (OR) of 1.98 (95% Confidence Interval (CI) 1.02-3.86) (P=0.04) when adjusted for age, gender and skin type. Sunburns before the age of 15 years were not associated with melanoma once adjustments for age, gender and skin were made. 31% of women and 16% of the men had used sunbeds. Sunbed users were younger than non-users (40 years versus 51 years, P<0.0001). Ever use of sunbeds gave an adjusted OR of 1.19 (95% CI 0.84-1.68) (P=0.33). The risk of melanoma did not increase with increasing hours or years of sunbed exposure. The risk associated with sunbed use was only significant for young individuals with fair skin for whom there was a significant OR of 2.66 (95% CI 1.66-6.09) (P=0.02) after adjustment for the sun exposure variables. Outdoor occupation and residence in hot countries were not associated with an increased risk of melanoma. The only significant associations in this study were with 10 or more sunburns and the use of a sunbed in young subjects with fair skin. Sunbed use is now becoming more prevalent in Caucasian populations and the results of this study suggest that sunbed usage may moderately affect individuals with sun-sensitive skin types. However, the magnitude of melanoma risk in association with natural and artificial sun exposure is small compared with phenotypic risk factors such as skin type and naevus counts. However, it is possible that the mean lag time of 7 years between exposure to sunbed and melanoma in this study may have led to an under-estimation of the long-term melanoma risk.

Genetic epidemiology of melanoma

Melanoma incidence has risen in many Caucasians populations over the last 20 years and research on the potential environmental and genetic risk factors has led to some interesting new findings but also to many more questions. The relationship between melanoma and ultraviolet radiation is complex and this area of research is controversial especially regarding the use of sunbeds and sunscreens. In terms of genetic factors, the discovery of two genes CDKN2A and CDK4 has been a great advance with more understanding of melanocyte biology in relation to defects in senescence. For phenotypic risk factors such as fair skin and high numbers of naevi, the role of genetic factors is clearly evident but these traits are complex and the discovery of genes involved in skin pigmentation and naevi formation is not an easy task. Research on the MC1R gene has not only shown the importance of this gene in hair and skin pigmentation but also in senescence and immunity. Functional studies involving CDKN2A and MC1R are leading to important new findings. There is also some hope regarding the use of micro-arrays in helping to dissect many genetic events in melanoma. The collection of large datasets including family, twin and case-control studies as well as tumour banks with collaborations between countries will hopefully lead to more discoveries. For the primary and secondary prevention of this tumour, efforts need to be sustained in public health campaigns on sun exposure and the recognition of individuals at high risk.

Recombinant adenovirus shedding after intratumoral gene transfer in lung cancer patients

We conducted two phase 1 trials of direct intratumoral injection of a recombinant E1E3-deleted adenovirus (AdR) encoding either the bacterial enzyme beta-galactosidase (Ad.RSVbetagal) or interleukin 2 (IL2, AdTG5327) into primary nonsmall-cell lung cancers of 21 patients. We report here virus shedding and the duration of virus expression in the tumor after intrabronchial injection of 10(7), 10(8) or 10(9) PFU of adenovirus. The infectious AdR and the viral DNA were detected in PBL, plasma, stool and aerodigestive samples in a dose-dependent manner, since cell cultures and PCRs were found to be positive mainly for samples from patients who received the highest AdR dose (10(9) PFU). We detected beta-galactosidase activity in the tumor biopsy samples of 66% of the patients, seemingly dose related, and only low levels of IL2 mRNA could be detected in tumor biopsy samples. E1 sequences were not detected by PCR in any of the PBL and bronchial samples collected after virus delivery, except in one patient. In this patient, E1 sequences were detected in PBL as well as in tumor biopsy samples collected at days 8, 30 and 60 and were correlated with longer beta-galactosidase expression in tumor samples. PBL tested before and after virus delivery contained both E1 sequences indicating that they did not result from replication-competent adenovirus (RCA) E1 sequences present in the inoculum. In addition, only on the day of the injection was Ad.RSVbetagal also detected in E1-positive PBL, indicating that virus replication in blood was very unlikely.

The influence of genetics and environmental factors in the pathogenesis of acne: a twin study of acne in women

Acne is common and often leads to significant psychologic and physical morbidity. From clinical experience, acne appears to run in families; however, very few studies have investigated the genetic basis of this very common skin disease. A large twin study based on 458 pairs of monozygotic and 1099 pairs of dizygotic twins, all women with a mean age of 46 y was performed to investigate the relative contribution of genetic and environmental factors on the liability to acne. In addition, potential risk factors were assessed in twins with and without acne in a nested cross-sectional design. Fourteen percent of the twins reported a history of acne. Genetic modeling using acne scores showed that 81% (95% confidence interval 73-87%) of the variance of the disease was attributable to additive genetic effects. The remaining 19% was attributed to unique (i.e., unshared) environmental factors. Of the potential risk factors tested in 400 acne twins and 2414 unaffected twins, only apolipoprotein A1 serum levels were significantly lower in acne twins even after adjusting for age and weight. Family history of acne was also significantly associated with an increased risk. No significant differences were found between acne twins and nonacne twins for weight, body mass index, height, birth weight, hair thinning, reproductive factors as well as cholesterol, triglycerides, high-density lipoprotein, and glucose levels. The lower serum levels of apolipoprotein A1 in acne twins were also confirmed when analyzing acne discordant twin pairs. The evidence of a major genetic influence on acne should stimulate the search for potential genes that may lead to new therapeutic approaches.

Eating frequency and body fatness in middle-aged men

OBJECTIVE

The relationship between eating frequency and body fatness was tested in a population sample.

DESIGN

A cross-sectional survey on cardiovascular risk factors and a nutritional survey were carried out from June 1996 to April 1997.

SUBJECTS

Population sample of 330 free-living middle-aged men (45-64 y).

MEASUREMENTS

Body mass index (BMI), waist-to-hip ratio (WHR) and nutritional survey (3-day record).

RESULTS

In the whole sample, BMI and WHR decreased significantly (P<0.05) along with the increase of the number of eating occasions. When low energy records were excluded, the trend for BMI and WHR according to eating categories remained significant. For WHR, averages were 0.98, 0.95, 0.94 and 0.93 for 1-2, 3, 4 or 5 or more feedings a day, respectively. For BMI, mean values were 28.1, 26.2, 26.2 and 24.5 kg/m(2), respectively. After adjustment for confounders (total energy intake or macronutrients, age, educational level, smoking habits, physical activity and restrained diet), the linear trend for BMI and WHR throughout feeding categories was significant when the whole sample was considered. This relationship remained similar when low energy records or when dieters were excluded.

CONCLUSION

These results suggest that for an isoenergetic intake the increase of eating frequency is associated with lower body fatness.

Photoadaptation to ultraviolet (UV) radiation in vivo: photoproducts in epidermal cells following UVB therapy for psoriasis

BACKGROUND

Ultraviolet (UV) radiation is mutagenic and induces specific DNA lesions in human skin that are often found at dipyrimidine sites. These photoproducts are likely to be biologically relevant regarding skin carcinogenesis, as p53 mutations in skin tumours are most often found at these UV radiation-specific sites within DNA. Psoriasis patients receiving long-term phototherapy are at an increased risk of non-melanoma skin cancers.

OBJECTIVES

The aim of this study was to quantify DNA photoproducts in human epidermis in vivo following consecutive doses of UVB and to investigate variations in DNA damage according to skin type, UVB dose and age.

METHODS

Eleven psoriasis patients receiving UVB phototherapy three times a week were recruited and underwent skin biopsies on a non-sun-exposed site before starting phototherapy and after three, nine and 18 UVB exposures. A biopsy was also taken at least 4 weeks after stopping phototherapy. DNA was extracted from separated epidermis and three types of photoproducts were quantified using a novel 32P high-performance liquid chromatographic technique.

RESULTS

The mean level of cyclobutane dipyrimidine dimers (CPDs) after three doses of UVB (dose range 0.03-0.15 J cm-2) was 3.2 (range 0.8-8.9) photoproducts per 106 normal nucleotides for TT=T dimers and 4.5 (range 0-14) per 106 normal nucleotides for TT=C dimers. The mean levels of TT-C 6-4 photoproducts after three doses of UVB were very low (0.2, range 0-1.8). Overall, the levels of TT=T and TT=C reached a plateau at three exposures and were found to decrease for subsequent exposures despite increasing UVB doses. Skin type was negatively associated with mean levels of CPDs. However, significant differences in levels of photoproducts were seen between individuals, even after adjusting for skin type. No association was found between challenge dose of UVB and photoproduct yield in this study.

CONCLUSIONS

This study showed a great individual variation in the accumulation of DNA photoproducts following exposure to repetitive doses of UVB. Photoadaptive responses of human skin involving DNA repair, tanning and epidermal thickening are likely to explain the overall lack of increase in DNA lesions throughout phototherapy. This in vivo study confirms that psoriasis patients produce a significant amount of DNA photolesions at suberythemal doses of UVB. Further work is needed to investigate which host factors are most likely to predict susceptibility to UV radiation-induced DNA damage.

The heritability of polymorphic light eruption

Polymorphic light eruption is classified as an acquired idiopathic photodermatosis, yet it appears to cluster in families, suggesting a possible genetic component. In this study, we assess the heritability of polymorphic light eruption using the classical twin model. Polymorphic light eruption was investigated by a nurse-administered questionnaire in a sample of 420 pairs of adult female twins from St Thomas' Hospital UK Adult Twin Registry, including 119 monozygotic and 301 dizygotic pairs. Probandwise concordance for the presence and absence of disease was calculated and the heritability of polymorphic light eruption assessed by a quantitative genetic model fitting approach using Mx software. The prevalence of polymorphic light eruption was 21% and 18% in monozygotic and dizygotic twins, respectively. A family history of polymorphic light eruption in first-degree relatives (not including the cotwin) was present in 12% of affected twin pairs (where at least one twin had polymorphic light eruption) compared with 4% of unaffected twin pairs, providing evidence of familial clustering (p < 0.0001). The probandwise concordance for polymorphic light eruption was higher in monozygotic (0.72) than in dizygotic twin pairs (0.30), indicating a strong genetic effect. Quantitative genetic modeling found that a model comprising additive genetic (A) and unique environmental (E) factors provided the most parsimonious fit, although a dominant gene effect could also explain our data. In the AE model, 84% (95% confidence interval 65-94%) of the variance in susceptibility to polymorphic light eruption is attributed to additive genetic factors with the remaining 16% (95% confidence interval 6-35%) to unique environmental effects. These data establish a clear genetic influence in the expression of polymorphic light eruption and provide a basis for examining candidate genes that may be pathogenic in this common condition.