Talimogene laherparepvec monotherapy for head and neck melanoma patients

Talimogene laherparepvec (T-VEC) is a modified herpes simplex virus, type 1, intralesionally administered in patients with stage IIIB/C-IVM1a unresectable melanoma. When surgery is not a treatment option in the head and neck region, T-VEC can be an elegant alternative to systemic immunotherapy. Ten patients with metastatic melanoma in the head and neck region started treatment with T-VEC monotherapy at the Netherlands Cancer Institute. We collected data on response, adverse events (AEs), and baseline characteristics. For response evaluation, we used clinical evaluation with photography, 3-monthly PET/computed tomography (PET/CT) using 18F-fluoro-2-D-deoxyglucose, and histological biopsies. Median age at baseline was 78.2 (35-97) years with a median follow-up of 11.6months. Of these 10 patients, 5 had a complete response (CR), 3 had a partial response, 1 had stable disease and 1 showed progressive disease (PD) as their best response. Best overall response rate (ORR) was 80%. Median progression-free survival was 10.8 months (95% confidence interval, 2.2-19.4). Grade 1 AEs occurred in all patients. Mostly, these consisted of fatigue, influenza-like symptoms, and injection site pain. PET-CT and histological biopsies proved to be clinically useful tools to evaluate treatment response for T-VEC monotherapy, confirming pCR or PD to stage IV disease requiring systemic treatment. ORR for T-VEC monotherapy for melanoma in the head and neck region at our institute was 80% with 50% achieving a CR. This realworld data demonstrates promising results and suggests T-VEC can be an alternative to systemic therapy in this select, mostly elderly patient population.

Neoadjuvant nivolumab + T-VEC combination therapy for resectable early stage or metastatic (IIIB-IVM1a) melanoma with injectable disease: study protocol of the NIVEC trial

Background

Trials investigating neoadjuvant treatment with immune checkpoint inhibitors (ICI) in patients with melanoma have shown high clinical and pathologic response rates. Treatment with talimogene laherparepvec (T-VEC), a modified herpes simplex virus type-1 (HSV-1), is approved for patients with unresectable stage IIIB-IVM1a melanoma and has the potential to make tumors more susceptible for ICI. Combination ICI and intralesional T-VEC has already been investigated in patients with unresectable stage IIIB-IV disease, however, no data is available yet on the potential benefit of this combination therapy in neoadjuvant setting.

Methods

This single center, single arm, phase II study aims to show an improved major pathologic complete response (pCR) rate, either pCR or near-pCR, up to 45% in 24 patients with resectable stage IIIB-IVM1a melanoma upon neoadjuvant combination treatment with intralesional T-VEC and systemic nivolumab (anti-PD-1 antibody). Patients will receive four courses of T-VEC up to 4 mL (first dose as seroconversion dose) and three doses of nivolumab (240 mg flatdose) every 2 weeks, followed by surgical resection in week nine. The primary endpoint of this trial is pathologic response rate. Secondary endpoints are safety, the rate of delay of surgery and event-free survival. Additionally, prognostic and predictive biomarker research and health-related quality of life evaluation will be performed.

Discussion

Intralesional T-VEC has the capacity to heighten the immune response and to elicit an abscopal effect in melanoma in combination with ICI. However, the potential clinical benefit of T-VEC plus ICI in the neoadjuvant setting remains unknown. This is the first trial investigating the efficacy and safety of neoadjuvant treatment of T-VEC and nivolumab followed by surgical resection in patients with stage IIIB-IVM1a melanoma, with the potential of high pathologic response rates and acceptable toxicity.

Trial registration

This trial was registered in the European Union Drug Regulating Authorities Clinical Trials Database (EudraCT- number: 2019–001911-22) and the Central Committee on Research Involving Human Subjects (NL71866.000.19) on 4th June 2020.

Secondary identifying number: NCT04330430.

Re-introduction of T-VEC Monotherapy in Recurrent Melanoma is Effective

Talimogene laherparepvec (T-VEC) is a modified herpes simplex virus type 1, which can be administered intralesionally in patients with stage IIIB/C-IVM1a (American Joint Committee of Cancer; AJCC 7th edition) unresectable melanoma. In the case of disease recurrence, T-VEC can be re-introduced for the same category of patients. Five patients with recurrent disease after a prior achieved complete response (CR) recommenced treatment with T-VEC monotherapy at the Netherlands Cancer Institute. We collected data on response, adverse events and baseline characteristics. All 5 patients that were re-treated with T-VEC presented with in-transit metastases on the lower limb. Median age at baseline was 72.1 years with a median follow-up time of 30.4 months. Histologically proven CR was achieved after a median of 8 T-VEC courses on the initial exposure. Duration of response (time between first CR and recurrence) varied between 3.8 and 14.2 months. All 5 patients achieved a histologically and/or positron emission tomography/computed tomography proven CR again after re-introduction of T-VEC with a median of 5 courses. One patient (20%) developed a second recurrence and is currently still on treatment with T-VEC. No patients developed distant metastases. Grade 1 adverse events occurred in all patients. Mostly, these consisted of fatigue, influenza-like symptoms and injection site pain. Response to re-introduction of T-VEC monotherapy in this select patient population is promising. This real world data on re-introduction of T-VEC monotherapy in stage IIIB/C-IVM1a melanoma suggests T-VEC could be a treatment option for chronic disease control.

Cleidocervical muscle: a mini literature survey of a human muscle variation

Cleidocervical muscles (CCM) or levator claviculae muscles in humans can be found as supernumerary unilaterally or bilaterally on the neck attached proximally to the clavicle and distally to the transverse process of cervical vertebrae at various levels. Altogether 20 case reports from year 1994 till present including 25 subjects related to CCM were found and analysed where parameters such as cervical insertion level, clavicular insertion at the middle vs. lateral third, unilateral vs. bilateral presence of the muscle, study type, reported gender of the subjects were extracted. Our literature survey shows that the prevalence of CCM in male and female was equally presented in radiological studies whereas almost 3-fold higher prevalence of males was found in cadaver reports. Since body donor system worldwide is male dominant, a 1:1 proportion of male and female in radiological studies could show more reality-based distribution of this muscle. Nevertheless, the presentation of this muscle was found in over 90% of the case reports unilaterally with higher left sided dominance. Even though the attachment points of CCM varied from case to case, the proximal attachment was found slightly more frequent on the middle third of the clavicle whereas the distal insertion was present more often on the superior cervical vertebrae than the lower ones. With prevalence of CCM in the population around 2.0-2.5%, the clinical, radiological and surgical relevance of this variation has to be highlighted to avoid potential misleading diagnostics in the neck.

Neo-adjuvant T-VEC plus nivolumab combination therapy for resectable early-stage or metastatic (IIIB-IVM1a) melanoma with injectable disease: The NIVEC trial

TPS9607

Background: The prognosis of patients with melanoma is significantly correlated with disease stage and has greatly improved with the introduction of the currently approved therapies. Trials investigating neo-adjuvant treatment with immune checkpoint inhibitors (ICI) have shown high pathologic response rates up to 25-80%, however, still a large group of patients derive no (durable) clinical benefit. Treatment with talimogene laherparepvec (T-VEC), a modified herpes simplex virus type-1, is approved for patients with unresectable stage IIIB-IVM1a melanoma, with high and durable response rates and a mild toxicity profile. Earlier trials have suggested that T-VEC has the capacity to heighten the immune response and to elicit an abscopal effect in melanoma when given in combination with ICI. Combination ICI and intralesional T-VEC has already been investigated in patients with unresectable stage IIIB-IV disease, however, no data is available yet on the potential benefit of this combination therapy in neo-adjuvant setting. This is the first trial investigating the efficacy and safety of neo-adjuvant treatment of T-VEC in combination with nivolumab (anti-PD-1 antibody), followed by surgical resection in patients with resectable stage IIIB-IVM1a melanoma, with the potential of high pathologic response rates and acceptable toxicity. Methods: In this single center, single arm, phase II study, a total of 24 patients ≥18 years of age and a good clinical performance score with treatment naïve, stage IIIB-IVM1a melanoma (AJCC 8th edition) with injectable disease and resectable (sub)cutaneous satellite or in-transit metastases and/or tumor positive lymph nodes, will be included. Patients will receive four courses of T-VEC up to 4mL (first dose as seroconversion dose) and three doses of nivolumab (240mg flatdose) every two weeks, followed by surgical resection in week nine. The primary endpoint of this trial is pathologic response rate, with the aim to show a high major pathologic (near-complete or complete) response rate up to 45%. Secondary endpoints are safety according to CTCAE v5.0, the rate of delay of surgery and event free survival. Additionally, prognostic and predictive biomarker research and health-related quality of life evaluation will be performed. Enrollment started in June 2020 in the Netherlands Cancer Institute, with currently 13 of the 24 planned patients treated. Clinical trial information: NCT04330430.

T-VEC for stage IIIB-IVM1a melanoma achieves high rates of complete and durable responses and is associated with tumor load: a clinical prediction model

BACKGROUND

Talimogene laherparepvec (T-VEC) is a genetically modified herpes simplex type 1 virus and known as an effective oncolytic immunotherapy for injectable cutaneous, subcutaneous and nodal melanoma lesions in stage IIIB-IVM1a patients. This study set out to identify prognostic factors for achieving a complete response that can be used to optimize patient selection for T-VEC monotherapy.

METHODS

Patients with stage IIIB-IVM1a melanoma, treated with T-VEC at the Netherlands Cancer Institute between 2016-12 and 2020-01 with a follow-up time > 6 months, were included. Data were collected on baseline characteristics, responses and adverse events (AEs). Uni- and multivariable analyses were conducted, and a prediction model was developed to identify prognostic factors associated with CR.

RESULTS

A total of 93 patients were included with a median age of 69 years, median follow-up time was 16.6 months. As best response, 58 patients (62%) had a CR, and the overall response rate was 79%. The durable response rate (objective response lasting > 6 months) was 51%. Grade 1-2 AEs occurred in almost every patient. Tumor size, type of metastases, prior treatment with systemic therapy and stage (8Th AJCC) were independent prognostic factors for achieving CR. The prediction model includes the predictors tumor size, type of metastases and number of lesions.

CONCLUSIONS

This study shows that intralesional T-VEC monotherapy is able to achieve high complete and durable responses. The prediction model shows that use of T-VEC in patients with less tumor burden is associated with better outcomes, suggesting use earlier in the course of the disease.

A Retrospective Chart Review Study of Real-World Use of Talimogene Laherparepvec in Unresectable Stage IIIB-IVM1a Melanoma in Four European Countries

Introduction

Talimogene laherparepvec (T-VEC; IMLYGIC^®, Amgen Inc.) is an oncolytic immunotherapy approved in Europe for the treatment of unresectable metastatic melanoma (stage IIIB–IVM1a). This study characterised real-world use of T-VEC in four European countries.

Methods

Data on demographics, treatment pattern, safety, and clinical effectiveness were examined in a retrospective chart review of patients with stage IIIB–IVM1a unresectable melanoma treated with T-VEC in surgical (the Netherlands) and medical (Austria, Germany, UK) oncology settings.

Results

Overall, 66 patients were included (the Netherlands: n = 31; Austria, Germany, UK: n = 35). The median age was 69 years and 59.1% were female. At the time of T-VEC initiation, 47 patients (71.2%) had stage IIIB/C disease; of these, 30 were from the Netherlands. Although 72.7% patients overall received T-VEC as first-line therapy, this was higher in the Netherlands than the other countries (93.5% vs 54.3%). Of the 47 patients who discontinued T-VEC, 26 (55.3%) had no remaining injectable lesions (potentially indicating complete response); 20/26 of these patients were from the Netherlands. One patient discontinued T-VEC due to toxicity.

Conclusion

This study is the first comprehensive multinational evaluation of the use of T-VEC to treat unresectable stage IIIB/C–IVM1a melanoma in real-world clinical practice in Europe. The differences between European countries were apparent, with physicians in the Netherlands using T-VEC in patients with earlier advanced disease stage and in the first-line setting compared with other countries.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-020-01590-w.

Complete response to talimogene laherparepvec in a primary acral lentiginous melanoma

Talimogene laherparepvec (T-VEC) is an oncolytic virus, approved for the treatment of stage IIIb-IVM1a melanoma with injectable disease (cutaneous, subcutaneous or lymphatic). It is a modified herpes simplex virus type 1 that induces tumor-specific T-cell responses via reduction of virally mediated suppression of antigen presentation, stimulation of viral pathogenicity and enhancement of tumor-selective replication. Response rates up to 82.6% have been reported for stage III disease. Acral lentiginous melanoma (ALM) is a rare subtype of melanoma with a poor prognosis. Here, we present a case of an elderly and frail patient with primary ALM who refused surgical treatment and consented to receive T-VEC as first-line drug therapy. After 10 courses of treatment, a histopathologically confirmed complete response was achieved. To our knowledge, this is the first case ever reported in which a primary ALM is (successfully) treated with T-VEC.

Non-coding RNA transcriptome analysis of circulating human monocytes reveals subpopulation-enriched transcripts and selective isoforms differentially expressed during acute myocardial infarction

Background

Acute inflammation leads to increased myelopoiesis in the bone marrow and recruitment of immune cells to respective sites of injury. Yet, in certain cases of high demand such as acute tissue damage as in acute myocardial infarction (AMI), innate immune cells can be additionally recruited from lymphoid organs such as the spleen. Monocytes are important in both onset and resolution of inflammation comprising a huge repertoire of coding and non-coding RNA molecules regulating a fast-acting immune response. Long non-coding RNAs (lncRNA) emerge as novel regulatory cell-specific molecules, which are able to influence cell physiology in numerous ways.

Purpose

Delineate monocyte subpopulations from patients with AMI compared to healthy controls based on their non-coding transcriptome, different isoform usage and associated source of origin.

Methods and results

Next generation bulk RNA sequencing has been performed from human monocytes after pre-sorting for CD14 expression and subsequent separation into three major subpopulations based on their surface markers CD14 and CD16 using a FACS Aria II cell sorter. Non-coding RNA expression shows clear differences between cells from healthy controls versus patients with AMI and among subpopulations. Intensive bioinformatics analysis revealed numerous annotated lncRNA, antisense, pseudogene and circular RNAs displaying significant differences in their expression profiles. Some lncRNA show positive or negative correlations with their respective coding antisense gene or their convergent or divergent sense neighbouring gene, such as linc02207 vs MCTP2, SAP30-AS vs SAP30, BID-AS vs BID, HLX-AS vs HLX or TNFAIP3-AS vs TNFAIP3. We also identified the existence of different isoforms of certain lncRNA and a distinct preference thereof, such as linc02207- 217 isoform being most abundant.

Real-time PCR was applied for validation of lncRNA expression profile and their nucleocytoplasmic distribution observing preferential nuclear expression for most lncRNA. In vitro assays for silencing and overexpression approaches as well as treatment with inflammatory stimuli and in silico bioinformatics analysis will help to unravel their functionality. Additionally mapping our bulk RNA data to deconvoluted single cell RNAseq data from publicly available human cell atlas (HCA), is applied to additionally unravel the origin of particular subpopulations within the AMI monocytes, associating their origin to either spleen or bone marrow.

Conclusions

High read depth bulk RNA sequencing revealed a human monocyte-specific long non-coding RNA transcriptome differentially expressed in three predefined subpopulations and disease stages. Distinct expression of lncRNA and associated coding genes as well as distinct isoform preference implies specific functionalities. Studying these molecules and their interaction partners will unravel functional participants in the development of therapeutic approaches for cardiovascular diseases.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): DZHK, SNF

Challenges in sentinel node pathology in the era of adjuvant treatment

BACKGROUND

With the approval of adjuvant therapy for stage III melanoma, accurate staging is more important than ever. Sentinel node biopsy (SNB) is an accurate staging tool, yet the presence of capsular nevi (CN) can lead to a false-positive diagnosis.

PATIENTS AND METHODS

Retrospective analysis of the American Joint Committee on Cancer 7th edition stage IIIA melanoma patients who were treated at our institute between 2000 and 2015. SNB slides were reviewed for this study by an expert melanoma pathologist.

RESULTS

Of 159 eligible patients, 14 originally diagnosed with metastatic melanoma merely had CN (8.8%). Another two merely had melanophages (1.3%). Thus, 10.1% of SNs were considered false positive after revision. In 12 patients, the SN tumor burden was originally reported as larger than 1 mm but turned out to be less than 1 mm. Four patients originally reported as SN tumor burden less than 1 mm before revision turned out to have larger than 1 mm. These patients might have been over- or undertreated in the current era of adjuvant therapy for stage III melanoma.

CONCLUSIONS

Distinguishing metastatic melanoma from benign CN and melanophages can be a diagnostic challenge. We plead for an expert pathologists' review, especially when using the SNB + results to determine treatment consequences.

The extent of surgery for stage III melanoma: how much is appropriate?

Since the first documented lymph node dissection in 1892, many trials have investigated the potential effect of this surgical procedure on survival in patients with melanoma. Two randomised controlled trials were unable to demonstrate improved survival with completion lymph node dissection versus nodal observation in patients with sentinel node-positive disease, although patients with larger sentinel node metastases (>1 mm) might benefit more from observation than from dissection, and could potentially be considered for adjuvant systemic therapy instead of complete dissection. Adjuvant immunotherapy with high-dose ipilimumab has led to improvements in overall survival, whereas therapy with nivolumab and pembrolizumab has improved relapse-free survival with greater safety. Furthermore, adjuvant-targeted therapy with dabrafenib and trametinib has improved survival outcomes in BRAF^V600E and BRAF^V600K-mutated melanomas. Three neoadjuvant trials have all shown high response rates, including complete responses, after short-term combination therapy with ipilimumab and nivolumab with no recurrences so far, although follow-up is still short. Despite the absence of a survival benefit with completion lymph node dissection in patients with sentinel node-positive or negative disease, the use of sentinel node staging will increase because of the introduction of effective adjuvant therapies. However, routine completion lymph node dissection for sentinel node-positive disease should be reconsidered. Accordingly, existing clinical guidelines are currently being revised. For palpable (macroscopic) nodal disease, the type and extent of surgery could be reduced if the index node can accurately predict the response and if studies show that lymph node dissection can be safely foregone in patients with a complete response. Overall, the appropriate type and extent of surgery for stage III melanoma is changing and becoming more personalised.

Rate of complete and durable responses of intralesional therapy with talimogene laherparepvec for stage IIIB-IVM1a melanoma and association with tumor load

e22089

Background: Talimogene laherparepvec (T-VEC) is a genetically modified herpes simplex type 1 virus, which is used as an oncolytic immunotherapy in stage IIIB-IVM1a melanoma patients. It is known to be an effective therapy for injectable cutaneous, subcutaneous and nodal melanoma lesions, as approved by the European Medicines Agency (EMA). Combination therapy is not yet approved by EMA pending the results of the phase 3 Masterkey-265 trial. The objective of the current study was to identify prognostic factors for achieving a complete response (CR) that can be used to select patients for treatment with T-VEC monotherapy. Methods: Patients with stage IIIB-IVM1a melanoma, treated with T-VEC at the Netherlands Cancer Institute between 2016-12 and 2019-05 with a follow-up time > 6 months, were included. Data was collected on baseline characteristics, responses and adverse events (AEs). Durable response rate (DRR) was defined as the percent of patients with a CR or partial response (PR) maintained continuously > 6 months. Univariable analyses were conducted and a prediction model was developed to identify prognostic factors associated with complete response. Results: For this study, a total of 71 patients were included with a median follow-up of 16.1 months. The median age was 70 years (range: 35-90). As best response, 47 patients (66%) had a CR and 10 patients (14%) had a PR, resulting in an overall response rate of 80%. Twenty-one patients (30%) stopped treatment because of progressive disease and sixteen patients (23%) developed a recurrence during follow-up after achieving a PR or CR. Median duration of CR was 11 months. The durable response rate was 42%. Grade 1-2 AEs occurred in almost every patient. Tumor size, type of metastases, previous treatment with systemic therapy and stage (8Th AJCC) were independent prognostic factors for achieving a CR and for progression-free survival. Achieving a CR was associated with a reduced risk of death. The prediction model includes tumor size, type of metastases (only cutaneous vs. subcutaneous (+/- cutaneous) vs. nodal (+/- cutaneous/subcutaneous)) and number of lesions as predictors. Conclusions: This study shows that intralesional T-VEC monotherapy for stage IIIB-IVM1a melanoma is able to achieve high complete and durable response rates. The prediction model shows that use of T-VEC in patients with less tumor burden is associated with better outcomes, suggesting T-VEC should perhaps be used earlier in the course of the disease.

P5394Whole transcriptome sequencing to define monocyte subpopulation-specific lncRNA profiles in acute myocardial infarction patients and healthy controls

Background

Monocytes are important immune cells in both onset and resolution of inflammation during pathologies such as acute myocardial infarction (AMI) and atherosclerosis. Long non-coding RNAs (lncRNAs) have emerged as novel regulatory and highly cell-specific molecules that can modulate cell physiology in numerous ways such as mRNA (de-)stabilization, micro RNA sponging or scaffolding of RNA binding proteins.

Purpose

Define a complete human monocyte subpopulation-specific transcriptome of long non-coding RNAs and characterize the difference in the profile of these RNA molecules in AMI patients.

Methods and results

Human monocyte subpopulations, defined as classical, intermediate and non-classical based on the expression of the surface markers CD14 and CD16, were collected on a FACS Aria II. Ribosomal-depleted cDNA libraries generated from total RNA were processed for Next Generation Sequencing on a HiSeq Illumina 2000. Computationally intensive bioinformatics revealedannotated lncRNAs, antisense, pseudogene and circular RNAs with significant difference in their expression profiles within subpopulations of healthy donors such as MEG3 or TERC, potential role players in cardiovascular disease. Our data also unraveled novel non-annotated ncRNAs not yet reported to reference databases, which are expected to be monocyte-specific. We applied certain criteria to identify potential candidate molecules such as annotation with existing Ensembl ID and a pre-determined expression level. Thereupon we selected differentially regulated long non-coding RNAs differentially expressed in cardiovascular disease and discovered 18 annotated potential lncRNAs dysregulated in classical monocytes of AMI patients such as HLX antisense, which might be involved in monocyte differentiation. Additional 5 targets appeared specific only for differences in intermediate and 3 with additional specific differences only in non-classical monocytes.Real-time PCR was applied for validation of long non-coding linear and circular RNAs differential expression and also to determine their nucleocytoplasmic distribution. We observed preferential nuclear expression for most lncRNAs in contrast to cytoplasmic circRNAs. In vitro assays for silencing and overexpressing certain target molecules as well astreatment withinflammatory stimuli and in silicoanalysis with different bioinformatics tools such as FANTOM and UCSC browser will help to unravel their functionality.

Conclusions

Next generation sequencing allowed us to define a human monocyte subpopulation-specific long non-coding transcriptome that presented significant differences in both lncRNA and circRNAs within monocyte subpopulations of healthy subjects and AMI patients. Studying functional mechanisms of identified lncRNAs and their interaction with the coding genome will help to unravel novel regulatory means of monocytes in acute myocardial infarction providing new opportunities for therapeutic approaches.

Acknowledgement/Funding

DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany;Berlin Institute of Health (BIH);Swiss National Science Foundation (SNF)

Challenges in sentinel node (SN) pathology in the era of adjuvant treatment: The risk of over and undertreatment stress the need for expert pathology review

9593

Background: With the approval of adjuvant therapy for stage III melanoma, accurate staging in melanoma patients is important more than ever to prevent over- or undertreatment. Sentinel node biopsy (SNB) is an accurate staging tool, yet the presence of capsular nevi (CN) can lead to a false positive diagnosis. We compared positive SNB and CN patient outcomes and aimed to evaluate the cause of false positive SNB and discern diagnostic pitfalls in their evaluation. Methods: Retrospective analysis of AJCC 7th Edition stage IIIA melanoma patients (N1-2a, non-ulcerated primary tumor) who were treated at our institute between 2000 and 2015. SNB slides were reviewed for this study by an expert melanoma pathologist. Baseline characteristics were assessed for SN+ and CN+ patients. Concordance rates for SNB evaluation before and after revision were documented and diagnostic pitfalls were discerned. Results: 169 patients were diagnosed, 10 could not be reviewed due to lack of evaluable slides. Of these 159 cases, 14 patients originally diagnosed with metastatic melanoma were shown to have capsular nevi (8.8%). Another 2 patients were shown to have melanophages that were incorrectly interpreted as metastases (1.3%). Thus, 10.1% was considered false positive after revision. In 14 patients the SN tumor burden was originally reported > 1 mm, but turned out to have < 1 mm SN tumor burden. 4 patients originally reported as SN tumor burden < 1 mm before revision turned out to have > 1 mm SN tumor burden. These 32 patients (20%) might have potentially been over- or undertreated in the current era of adjuvant therapy for stage III melanoma. Conclusions: False positive sentinel node results in melanoma are real, they can occur for a number of reasons, but distinguishing metastatic melanoma from benign capsular nevi and melanophages can be a diagnostic challenge. We plead for an expert pathologists’ review in any case, but certainly when using the SNB+ results to determine treatment consequences for SN+ melanoma patients.

Surgical removal of the index node marked using magnetic seed localization to assess response to neoadjuvant immunotherapy in patients with stage III melanoma

This pilot study explored the value of localized index node removal after neoadjuvant immunotherapy in patients with stage III melanoma, for use as a response indicator to guide the extent of completion lymph node dissection. Promising technology.

Development and validation of a nomogram to predict recurrence and melanoma-specific mortality in patients with negative sentinel lymph nodes

Background

Patients with melanoma and negative sentinel nodes (SNs) have varying outcomes, dependent on several prognostic factors. Considering all these factors in a prediction model might aid in identifying patients who could benefit from a personalized treatment strategy. The objective was to construct and validate a nomogram for recurrence and melanoma‐specific mortality (MSM) in patients with melanoma and negative SNs.

Methods

A total of 3220 patients with negative SNs were identified from a cohort of 4124 patients from four EORTC Melanoma Group centres who underwent sentinel lymph node biopsy. Prognostic factors for recurrence and MSM were studied with Cox regression analysis. Significant factors were incorporated in the models. Performance was assessed by discrimination (c‐index) and calibration in cross‐validation across the four centres. A nomogram was developed for graphical presentation.

Results

There were 3180 eligible patients. The final prediction model for recurrence and the calibrated model for MSM included three independent prognostic factors: ulceration, anatomical location and Breslow thickness. The c‐index was 0·74 for recurrence and 0·76 for the calibrated MSM model. Cross‐validation across the four centres showed reasonable model performance. A nomogram was developed based on these models. One‐third of the patients had a 5‐year recurrence probability of 8·2 per cent or less, and one‐third had a recurrence probability of 23·0 per cent or more.

Conclusion

A nomogram for predicting recurrence and MSM in patients with melanoma and negative SNs was constructed and validated. It could provide personalized estimates useful for tailoring surveillance strategies (reduce or increase intensity), and selection of patients for adjuvant therapy or clinical trials.

Could personalize care

Exogenous Cushing's syndrome due to a Chinese herbalist's prescription of ointment containing dexamethasone

Eczema in children is a chronic disabling condition. The impact of this condition on the lives of families is often underestimated by conventional physicians. As a consequence parents may investigate complementary treatment options. Close monitoring by a paediatrician is essential, considering that a variety of adverse effects can occur during the use of complementary treatment. We present a 5-year-old girl with eczema. She visited a Chinese herbalist who prescribed an ointment. The parents noticed that the eczema resolved fast, itching decreased and she was finally sleeping well. However, her behaviour changed and appetite increased. Undetectable levels of serum cortisol were found, which was indicative of exogenous Cushing's syndrome. Analysis of the ointment revealed the presence of dexamethasone. Hydrocortisone substitution and subsequently a reduction schedule were implemented, after which endogenous cortisol production recovered after 4 months. Physicians should be aware that unregistered herbal medicine can contain potent drugs such as glucocorticoids.

Characterisation of deep arterio-venous anastomoses within monochorionic placentae by vascular casting

OBJECTIVE

To characterise arterio-venous anastomoses (AVA) in monochorionic (MC) placentae and determine (i) whether shared cotyledons lie beneath the co-termination of an artery from one twin and a vein to the contralateral twin and (ii) whether all AVA can be detected by visual inspection of the chorionic plate.

METHODS

Vascular casts were made of 15 MC placentae. The number of typical AVAs suspected visually before digestion was compared with the number of AVAs identified after acid digestion.

RESULTS

Thirty-three of 67 (49%) suspected typical AVAs were confirmed as typical after casting. There were five false positives and no false negatives. The remainder were classified as atypical AVAs, found in > or =90% of MC placentae. Type I (small vascular connections between two apparently normal cotyledons not seen before casting) and Type II (shared cotyledons arising within larger apparently normal cotyledons) atypical AVAs were found in 53% and 73% of placentae, respectively.

CONCLUSIONS

Only half the shared cotyledons in MC placentae are characterised by co-termination of an artery and vein on the chorionic plate. We report the existence of deep anastomoses beneath the chorionic plate that cannot be visualised by chorionic plate inspection. These findings have implications for laser treatment of twin-twin transfusion syndrome.

Do anaesthetics and surgical stress increase the risk of post-exposure rabies treatment failure?

Rabies is fatal in humans and, after exposure, only correct postexposure treatment as outlined in World Health Organization guidelines can prevent the disease. Analysis of case reports of treatment failures has shown that recommendations have not been followed and that patients presenting risk factors should receive additional care. Known risk factors are delay of more than 24 h in starting postexposure treatment, multiple wounds (especially on head, neck, arm or fingers), incorrect initial wound treatment, immunodepression and non-application of anti-rabies immunoglobulins or serum. We present a case, recently reported from India to Drug Surveillance Behringwerke AG, Marburg, Germany, in which surgery under ketamine anaesthesia might have been an additional risk factor for postexposure treatment failure.

[Itching following therapy with hydroxyethyl starch (HES) in otoneurological diseases]

It is generally assumed, that a disturbance of microcirculation is the common pathogenetic end factor in various cochleovestibular disorders of different etiology. Therefore improvement of microcirculation is an important therapeutic goal. Several studies demonstrated, that hydroxyethylstarch (HES) has better haemorheological effects than Dextran and less side effects. For this reason we have changed the therapy with Dextran since 1987 to hydroxyethylstarch in several oto-neurological disorders (as sudden hearing loss, neuronopathia vestibularis, idiopathic facial palsy). As after the therapy with HES--generally after dismissal from the ENT-department--some patients complained of general pruritus, so we performed a retrospective study with a standardized interview-protocol. Of 481 treated patients we investigated 237 (49%): of 149 patients treated with HES 200/0.5, 43 patients (28.8%) complained of pruritus; from 88 patients treated with Dextran 40, only 5 patients (5.7%) reported pruritus. The difference is significant (p less than 0.0001). In nearly half of the patients (more than 40%) the pruritus started in normal skin 1 to 3 weeks after the HES-therapy and lasted for 6 weeks to 6 months; the itching was very resistant to therapy (f.e. with antihistaminics). We want to draw the attention to this possible, in the literature until now quite neglected, for some patients extremely uncomfortable and socially embarrassing side effects after HES-therapy when given in relatively high doses. It is therefore suggested therapeutic recommendations should be developed to prevent this undesired side effect.

[Experiences with a new cat coryza-panleukopenia-rabies combined vaccine]

The development of a new combined vaccine against cat flu, panleukopenia and rabies should lead to a simplification of the vaccination calendar in small animal practice. In order to judge the suitability of the new vaccine, its efficacy, local tolerability, and safety were evaluated. All vaccinated cats developed high antibody titres against herpes-, calici-, panleukopenia- and rabies virus that persisted well during the trial of 18 months. In comparison to other vaccines containing a smaller number of antigens the suitability of the vaccine on trial could be shown.

Purified chick-embryo-cell (PCEC) rabies vaccine: its potency performance in different test systems and in humans

The potency of purified chick embryo cell rabies vaccine Rabipur was evaluated by four different in vivo test systems: (1) NIH test with homologous strain LEP challenge; (2) intramuscular challenge of vaccinated laboratory animals; (3) postexposure vaccine treatment trials in laboratory animals; and (4) antibody induction tests in laboratory animals. These different test systems were compared with the Standard NIH test and an in vitro test, the modified ABT. Each of the four in vivo methods chosen demonstrated potency values superior to that of the Standard NIH test in which challenge was with CVS strain. Potency relations were: Standard NIH test versus alternative methods versus modified ABT 1.0-2.2-1.85 respectively. There was good correlation between alternative in vivo methods and the ABT. In addition examples of antibody induction in man following administration of various postexposure treatment regimens are presented which lead to the conclusion that postexposure vaccination method and composition of the study group play a more important role in achieving optimum treatment results than vaccine potency, provided that it corresponds to WHO requirements (minimum 2.5 IU per dose).

Production of antibodies to canine distemper virus in chicken eggs for immunohistochemistry

The present study describes the application of egg yolk antibodies in immunohistochemistry. In order to obtain specific antibodies against canine distemper virus (CDV), chickens were immunized with attenuated virus. Distinct antibody titres in serum and yolk could be detected by means of a modified plaque/focus immunoassay (ELISA) two weeks after a second immunization. The lower concentrations in corresponding yolk globulin preparations are attributed to the loss of antibodies caused by the isolation procedure (dextran and ammonium sulfate precipitation). After verification of the antibody specificity by indirect immunofluorescence technique high titred globulin fractions were employed in immunohistochemistry using the Avidin-Biotin-Complex method. A specific and distinct immunostaining in formalin fixed and paraffin embedded brain sections of CDV-infected dogs was obtained. The advantages of egg yolk antibodies for immunological purposes are discussed in detail.

Preclinical investigations of the safety, immunogenicity and efficacy of a purified, inactivated tick-borne encephalitis vaccine

A new tick-borne encephalitis (TBE) vaccine for human use has been developed. TBE virus (TBEV) was propagated in primary chick embryo cells, inactivated by formalin and purified by continuous-flow density gradient centrifugation. The TBE vaccine was tested for innocuity, immunogenicity and protective capacity in a series of laboratory tests. The results indicated that the vaccine is outstandingly well tolerated, highly immunogenic in various laboratory animals, and induces protective immunity in mice. These data suggest that this new vaccine should be studied in clinical trials.

[The prevention of distemper in zoo animals]

The distemper virus infection of different non-domestic carnivorous zoo animals is known since long. All species involved belonged to the suborder Fissipedia. In 1988 a distemper or morbillivirus-like infection occurred in harbour seals, a member of the suborder pinnipedia. For the prophylaxis of distemper in dogs attenuated live vaccines are commonly used. In zoo animals, however, these vaccines caused distemper several times. In contrast, an inactivated virus vaccine proved both its safety and efficacy in more than hundred zoo animals of various species.

[Occurrence and identification of enterotoxin-producing E. coli strains in milk and dairy products]

Enteric diseases caused by enterotoxigenic E. coli strains (ETEC) become more and more important all over the world. Frequently food is implicated as a vector. --From this the necessity arises to identify ETEC strains and/or their heatlabile (LT) and heat-stable enterotoxins (ST). The examinations carried out for the presented paper showed the following results: Detection of LT by coagglutination is a simple and rapid test and may be helpful for screening. Most suitable, however, is the application of ELISA which enables the detection of 1 ng/ml LT with a good reproducibility. For identification of ST the suckling mouse assay (SMA) yields reliable results. ELISA and SMA have proved to be useful in practice for examination of food samples. By means of these methods 157 E. coli strains predominantly isolated from milk and milk products were examined. Hereby, five ETEC strains could be identified (3.2%). For the purpose of food examination a procedure was developed which ensures a reliable and efficient identification of E. coli enterotoxin. The essential steps are enrichment in E.E.-broth, subcultivation in CAYE-2-broth, identification of LT by ELISA resp. coagglutination and the detection of ST with aid of the SMA. So, isolation of single colonies can be omitted, which is an essential advantage.