Sexual development in a two-year-old boy induced by topical exposure to testosterone

Virilization, including penile enlargement and growth of pubic hair and facial acne, developed in a 2-year-old boy over a period of months. This sexual development was induced by incidental and unintentional dermal exposure to a testosterone cream that was applied to his father's arm and back as a part of body building regimen. Except for penile size, the other signs of virilization diminished several months after the exposure was discontinued.

Tumor progression, early diagnosis and prognosis of melanoma

Primary melanomas evolve from melanocytes or from precursor lesions through two stages: the radial and vertical growth phases. The radial growth phase may be in situ or microinvasive, but is a non-tumorigenic neoplastic process, while the vertical growth phase is tumorigenic. The prognosis in radial growth phase is excellent irrespective of thickness or other variables. Curable radial growth phase melanomas can be recognized by surveillance of patients identified by screening for risk markers which include dysplastic nevi, common nevi, freckles, and other indicators of chronic or acute sun exposure or sun sensitivity. The prognosis in vertical growth phase depends on attributes of the tumor and of the host. The tumor mitotic rate, the presence of host tumor-infiltrating lymphocytes (TIL) within the vertical growth phase, and tumor thickness are the most powerful predictors of survival. New prognostic attributes are needed not only to provide for more accurate prognosis and diagnosis, but also to test the relevance of in vitro or animal studies in a human neoplastic system. Such attributes will be developed in the future based on markers that are associated with tumor progression. Candidate markers include growth factors and cytokines and their receptors, adhesion molecules and their ligands, chemotactic and motility factors, immune response-related molecules, and tumor-associated proteases. Some of these markers that are represented in the transition from radial to vertical growth phase will be reviewed. The tumor progression model presented here has been of value in the development of more accurate prognostic models, and in the elucidation of mechanisms of the malignant phenotype in melanoma.

Control of transgenesis in higher cells: the procell transposon Tn10 TetR mRNA has several major hairpins and can be unstable in eucells

The TetR regulatory gene from the transposon Tn10 has some excellent characteristics for transgenic control in higher cells. However, we experienced severe problems with mRNA instability for this gene in eucells (CHO cells). This may be connected with the existence within the Tn10 TetR mRNA of several sizeable hairpins. They resemble canonical RNase E sites for mRNA destabilisation in procells and possibly also in eucells. Two of the hairpins also included sequences resembling eucell hnRNA polyadenylation or processing signals. The TetR counterpart from the plasmid RA1 appears to have less of the hairpin secondary structure; perhaps because of this, it did not present these mRNA instability problems in CHO cells, and it may prove a valuable alternative for transgene control in gene therapy and biotechnology.

Globin introns: ancient or modern?

Some globin introns appear to be ancestral features, others have been interpreted as later additions. However, these "anomalous" introns may be ancient relics of internal duplications within the original gene.

A model system for detection and isolation of a tumor cell surface antigen using antibody phage display

To establish a screening procedure for tumor cell-surface reactive Fabs, we used a model antigen/antibody system including the epidermal growth factor receptor (EGF-R) and the anti-EGF-R monoclonal antibody 425. The 425 Fab was displayed on the surface of M13 filamentous phage. In a screening assay for 425 phage binding to tumor cell surfaces, biotinylated 425-phage bound specifically to EGF-R-positive A431 epidermoid carcinoma cells and not to K562 non-expressor erythroleukemia cells. With a model library, the sensitivity of phage enrichment by phage binding to cell surfaces was one 425-phage in 20,000 unrelated phages after 4 rounds of panning on A431 cells. In a phage tissue screening assay, 425-phage, but not unrelated phage, bound specifically to melanoma cells expressing EGF-R. Epitope and idiotope specificity of 425-phage was demonstrated in phage competition assays, using as targets A431 cells and anti-idiotypic antibodies to monoclonal antibody 425, respectively. Finally, the EGF-R protein was directly isolated from A431 cell extracts, using biotinylated 425-phage. The data obtained with the 425 model library system demonstrate the usefulness of antibody phage display for the rapid identification and isolation of tumor or other disease-related cell surface antigens.

Combinatorial antibodies against human malignant melanoma

The general responsiveness of human melanoma to immunotherapy has been well established, but active immunotherapy of melanoma has been hampered by insufficient information on the immunogenicity of melanoma antigens in patients. We have attempted to identify melanoma-associated antigens recognized by patients' B cells using an antibody phage display approach. Antibody display on filamentous phages allows direct screening of cDNA libraries for expression of cell-surface-reactive antibodies, without the need for antibody production and purification using bacteria or eukaryotic cell systems. This approach was used to identify melanoma-associated cell-surface antigens recognized by patients' B cells. Antibodies produced by the B cells of a melanoma patient (in remission for > 7 years following periodic vaccination with allogeneic melanoma cell vaccine) were displayed as Fabs on the surfaces of filamentous phages. A library of 10(8) phages was absorbed to normal melanocytes, followed by phage binding to and elution from melanoma cells (human lymphocyte antigen nonmatched and vaccine melanoma cells). Phages were further selected for reactivities with tunicamycin-treated melanoma cells. These procedures resulted in a > 10(6)-fold enrichment of tumor-specific phages from the original phage library. One phage-Fab bound to melanoma cells, other tumor cells, and a few normal cells in cultured cell lines and in tissue sections.

Dysplastic nevi and other risk markers for melanoma

Risk markers for cancer are genetic or behavioral attributes that are statistically associated with increased incidence of cancer. Risk may be assessed either in case-control studies, or in cohort studies in which individuals with particular attributes are followed and cancer risk is determined by direct observation. Both of these methods have been used to determine the major risk markers for melanoma. The single most important risk marker is the presence on the skin of dysplastic nevi. Dysplastic nevi may be regarded as intermediate lesions of tumor progression, in that approximately 30% of melanomas arise in association with a precursor nevus, which is most commonly dysplastic. However, paradoxically, because they are vastly more numerous than melanoma, most dysplastic nevi are stable lesions that do not progress. Additional important melanoma risk factors include a family and/or personal history of melanoma. A third major category of risk markers includes indicators of acute and chronic exposure to the sun, including freckles, actinic skin damage, and a history of sunburn. Evaluation of these markers in oncological patients and their first-degree relatives can identify a population of individuals whose risk for melanoma ranges from several-fold to more than 100-fold greater than that of random population members. Efforts directed at early diagnosis in these individuals can result in recognition of melanomas in their early, curable stages.

A unique case of long-term survival in a male patient with malignant melanoma of the distal urethra

Primary malignant melanoma of the urethra in male patients is a rare entity, noted to have a dismal prognosis in recent reviews. No case of long-term disease-free survival in patients with primary malignant melanoma has been previously reported. We report the first such case, and review briefly the factors that could have contributed to our patient's long-term survival. We also illustrate the precursor lesion present six years prior to diagnosis.

Volunteer low-risk outpatient surgery for uninsured patients in San Francisco. The Ambulatory Surgery Access Coalition

OBJECTIVE

To provide uncompensated elective low-risk outpatient surgery for uninsured patients through a coalition of volunteer physicians, nurses, and hospitals.

DESIGN

Description of the process of establishing the Ambulatory Surgery Access Coalition (ASAC), the political and administrative obstacles encountered, and the clinical results of treatment of the first 25 patients in the pilot project.

SETTING

The ASAC includes the Kaiser Foundation Hospital, San Francisco, Calif, the University of California, San Francisco, the San Francisco General Hospital (SFGH), the San Francisco Department of Public Health, the San Francisco Consortium of Community Clinics, the Northern California Chapter of the American College of Surgeons, and the San Francisco Medical Society. A pilot program of uncompensated outpatient surgery was performed at the Kaiser Foundation Hospital.

PATIENTS

Twenty-nine patients were referred to the ASAC between January 1 and November 1, 1994. Twenty-six patients were judged to be candidates for surgery, and 25 patients met the criteria for the ASAC program. One patient was referred to SFGH for treatment because of a perceived increased risk for hospitalization after surgery.

RESULTS

Twenty-one patients underwent herniorrhaphy; three, excision of large inclusion cysts; and one, anal fistulotomy. Seventeen procedures were done under local anesthesia, seven under general anesthesia, and one under spinal anesthesia. None of the patients required hospital admission. No wound infections occurred.

CONCLUSION

The ASAC successfully provided uncompensated low-risk outpatient surgery to 25 low-income uninsured patients in San Francisco. The coalition hopes, first, to include other San Francisco hospitals and surgical specialties, and second, to serve as a model for other communities throughout the country.

Recognition and classification of clinically dysplastic nevi from photographs: a study of interobserver variation

The recognition of dysplastic nevi from photographs can aid in population surveys of nevi and in epidemiological studies of melanoma risk. The reproducibility of techniques for recognizing nevi as dysplastic or for scoring them according to the degree of dysplasia has not been measured. Using photographs of 300 nevi taken in the course of a case-control study of melanoma, we assessed the agreement among six clinicians in independently categorizing nevi as dysplastic and in grading the degree of dysplasia. On average, reviewers agreed with each other 77% of the time in classifying a nevus as dysplastic or normal. Pairwise agreement within one point on a six-point scale occurred 87% of the time on average. These results suggest that criteria for recognizing nevi as clinically dysplastic from photographs can be applied reproducibility.

Loco-regional nodal relapse in melanoma

Two-hundred and seven patients without evidence of disease following lymph node dissection (LND) were stratified into three groups: Group A, lymph node relapse within the site of prior LND; Group B, lymph node relapse in a different, but regional, lymph node group; Group C, no lymph node relapse. Decreased survival was noted in both Groups A and B versus Group C. Prognostic factors were identified as: (i) axial or subungal/volar (subvolar) location and the number of positive lymph nodes at initial LND for nodal relapse within the same lymph node group; (ii) male gender, axial/subvolar location, and the number of histologically positive lymph nodes at initial LND for nodal relapse in a different, but regional lymph node group; (iii) relapse within the initial LND site for a decreased survival. Six of 10 patients with both axial/subvolar primaries and four or more positive lymph nodes developed a relapse within the dissection site post-LND. These prognostic factors describe a subset of patients who would be candidates for postoperative adjuvant local/regional and systemic therapy trials.

Orbital involvement with desmoplastic melanoma

A 79-year-old woman developed an orbital mass five and a half years after excision of a cutaneous melanoma from the side of the nose. The initial orbital biopsy was interpreted histopathologically as a malignant fibrous histiocytoma, but special stains and electron microscopy showed it to be a desmoplastic malignant melanoma which had apparently spread to the orbit from the prior skin lesion by neurotropic mechanisms. The occurrence of a desmoplastic neurotropic melanoma in the orbit has not been previously recognised. The problems in the clinical and pathological diagnosis of this rare type of melanoma are discussed.

Staphylococcus aureus colonization and infection after discharge from a term newborn nursery

During a 6-month period, term infants underwent nasal and umbilical swabbing within 96 hours of delivery and again at 1 to 18 (mean 3.8) weeks after discharge. Swabs were inoculated onto horse blood agar and all S aureus isolates were phage typed. Two hundred three infants were enrolled and follow-up was obtained for 181 (89%). Thirty-two of 181 (17.6%) were initially colonized, of whom 12 (37.5%) were colonized on follow-up. Thirty-two of 181 became colonized subsequent to hospital discharge. No single phage type predominated. Twenty-five patients were diagnosed to have clinical illness--omphalitis (11), conjunctivitis (10), and pustulosis (5). Six of these were colonized with S aureus initially, although organisms of the same phage type were not recovered from cultures obtained at the time of clinical illness. There was no significant difference in the rate of infections in colonized (19%) versus non-colonized (12%) infants. In five patients where S aureus was recovered at the time of symptoms, all organisms were acquired subsequent to discharge. We conclude that nursery colonization with S aureus did not lead to clinical illness, and clinical illnesses previously ascribed to S aureus frequently occur in the absence of these bacteria.

Staphylococcal resistance to aminoglycosides before and after introduction of amikacin in two teaching hospitals

A prospective study was conducted to determine the prevalence of aminoglycoside-resistant Staphylococcus aureus and coagulase-negative staphylococci before and after the introduction of amikacin as the sole aminoglycoside used in our burn unit, adult intensive care unit, and neonatal intensive care unit. Pharyngeal or endotracheal cultures, as well as superficial surveillance cultures, were collected weekly during the following four study periods: all units for 4 months before amikacin introduction, all units 4 to 8 months after, all units 12 to 13 months after, and the neonatal intensive care unit 30 months after. A total of 2,613 strains of coagulase-negative staphylococci and 316 strains of S. aureus were obtained from 916 patients. During the course of the study, amikacin-resistant coagulase-negative staphylococci increased from 0 to 22%, colonizing 43% of patients, whereas no amikacin-resistant S. aureus was detected. During the preamikacin survey, 68% of the coagulase-negative staphylococci and 12% of the S. aureus strains were resistant to tobramycin and gentamicin. This resistance did not decrease after amikacin was introduced. Initially, 83% of the aminoglycoside-resistant coagulase-negative staphylococci were resistant to both tobramycin and gentamicin. During the last surveillance this value dropped to 40%, and 48% of the strains had become resistant to all three aminoglycosides. Resistance to aminoglycosides, including amikacin, develops quickly in coagulase-negative staphylococci from clinical areas where these antimicrobial agents are widely used. However, aminoglycoside resistance in S. aureus is much less frequent.

Assessment of survival rates with metastatic malignant melanomas

Ten patients who survived for at least five years after the development of metastatic melanoma were compared with 45 other patients who died of disseminated disease. The difference between the groups was the persistent absence of internal organ involvement in the first group and its invariable presence in the latter group. In addition, it appeared that several of the primary tumors from the nonlethal group were thinner, located in a more favorable location and occurred with greater frequency in women. All of these features tend to be indicative of a lesser degree of biologic aggressiveness of these tumors. They may prove helpful in identifying those patients with metastatic disease who are potential long term survivors and, therefore, require continued aggressive treatment.

Proton NMR and fast-atom bombardment mass spectrometry analysis of the melanoma-associated ganglioside 9-O-acetyl-GD3

A glycolipid antigen, detected by a monoclonal antibody (ME 311) obtained by immunizing mice with a human metastatic melanoma cell line (WM 46), was isolated and structurally characterized. Using immunostaining on thin-layer chromatograms for monitoring, 1.0 mg of a pure alkali-labile disialoganglioside was obtained from 23 g of packed melanoma cells (WM 164). Fractionation of the lipid extract was done on DEAE-Sepharose columns into total disialogangliosides which were repeatedly separated by high-pressure liquid chromatography. On mild alkaline treatment, the ganglioside was converted to a slower migrating species identical with a ganglioside GD3 isolated from the same source (Neu5Ac alpha 2----8Neu5Ac alpha 2----3Gal beta 1----4Glc beta 1----1-cer-amide) and specifically detected by monoclonal antibody R24. Comparison of the two gangliosides by fast-atom bombardment mass spectrometry (revealing an acetyl group on the terminal sialic acid on the alkali-labile species) and by 1H NMR (indicating the position of the acetyl group) suggested the following structure: Neu5,9Ac2 alpha 2----8Neu5Ac alpha 2----3Gal beta 1----4Glc beta 1----1-ceramide. This is identical with a ganglioside proposed earlier to exist in melanoma cells (Cheresh, D. A., Varki, A. P., Varki, N. M., Stallcup, W. B., Levine, J., and Reisfeld, R. A. (1984) J. Biol. Chem. 259, 7453-7459). Immunostaining with ME 311 antibody of cell extracts on thin-layer chromatography chromatograms revealed only this ganglioside in the melanoma cells, while normal human brain was negative. However, in one of the total ganglioside extracts tested for presence of binding with antibody ME 311, three gangliosides were found to bind. No evidence was obtained for the presence of the antigenic epitope in mucins or glycoproteins of the melanoma cells.

Theory of epigenetic coding

The logic of genetic control of development may be based on a binary epigenetic code. This paper revises the author's previous scheme dealing with the numerology of annelid metamerism in these terms. Certain features of the code had been deduced to be combinatorial, others not. This paradoxical contrast is resolved here by the interpretation that these features relate to different operations of the code; the combinatiorial to coding identity of units, the non-combinatorial to coding production of units. Consideration of a second paradox in the theory of epigenetic coding leads to a new solution which further provides a basis for epimorphic regeneration, and may in particular throw light on the "regeneration-duplication" phenomenon. A possible test of the model is also put forward.

Target blue nevus

In two cases of target blue nevi of the foot, both lesions displayed a distinctive concentric pigmentary variation. This correlated histologically with a peripheral alteration of dermal collagen accompanied by a focal regression or differentiation of blue nevus cells. The resulting distinctive target blue nevus can be clinically differentiated from a malignant melanoma.

Melanoma of the male urethra: surgical approach and pathological analysis

Primary urethral melanoma in male subjects is rare and optimum therapy has not been established. We described a male patient with a primary urethral melanoma that arose in a precursor nevus and was treated by excision, bilateral groin dissections and postoperative radiation therapy. Urinary and sexual functions have been maintained. We review the previously reported cases of urethral melanoma in male subjects. The biologic relationship of melanoma to precursor lesions in mucosal sites is discussed.

Topical chemotherapy of dysplastic melanocytic nevi with 5% fluorouracil

A therapeutic response to topical fluorouracil in a patient with the large atypical nevus syndrome is presented. Six of the patients' dysplastic melanocytic nevi were treated with topical fluorouracil. Four common acquired melanocytic nevi from normal individuals were also treated. All six dysplastic nevi responded with inflammation, ulceration, and subsequent disappearance of the lesion, while the four control melanocytic nevi remained unchanged. Although we do not presently advocate the therapeutic use of fluorouracil for large atypical nevi until its safety and efficacy have been established, the response reported herein may herald an important advance in the therapy of these troublesome lesions that are known to be histogenetic precursors of malignant melanoma.