[Long-term locally-recurrent melanoma]

Malignant melanoma is a highly malignant skin tumor with a widely variable individual course. Currently, approximately 75% of German patients can be cured of malignant melanoma by early diagnosis and excision, while more than 20% die of distant metastases of the melanoma. In contrast, there are single cases of long-term locally recurrent melanomas with neither complete cure nor development of distant metastases. We report on a female patient with a nevus-associated melanoma who was treated in 1968 with X-ray radiation (Dermopan, 100 Gy) with curative intent. In the following 31 years, the patient developed four phases of in-transit and satellite metastases in a zosteriform pattern as well as ilioinguinal lymph node metastasis. Since 1999, the patient has been free of recurrence. Besides the unusual biological features of this case, this report reflects the changes of paradigms in the therapy of melanoma over the last forty years.

Angioödeme bei familiärem Mangel von Komplement-Faktor-1-Esterase-Inhibitor und α1-Antitrypsin

HISTORY AND CLINICAL FINDINGS

A 15-year-old girl had suffered from episodic, sometimes threatening angioedema of the face, nasopharyngeal space and distal extremities beginning at age 13.

EXAMINATIONS

A C1-esterase inhibitor (C1-INH) deficiency was revealed protein-chemically and functionally. There was also an alpha (1)-antitrypsin (AAT) deficiency with heterocygotic phenotype PiMZ. The combination of C1-INH and AAT deficiency was also found in the patient's mother and brother.

THERAPY AND COURSE

Under 8-month therapy with 200 mg/d danazol per os (reduction of the dosis in the last month to 100 mg/d), there was no further edema, the C1-INH concentration normalized and there was also an increase in C1-INH function. During the observation period, use of the emergency set with C1-INH concentrate was not required.

CONCLUSIONS

This is the first reported case of angioedema in combination of two hereditary enzyme defects C1-INH deficiency (autosomal-dominant genetics) and AAT deficiency (autosomal-recessive). In addition to a survey of current literature, the current state of diagnostics and therapy of the hereditary angioedema is presented.

Melanocytes express 3G5 surface antigen

The 3G5-reactive ganglioside antigen (3G5 antigen) is expressed on the surface of various cell types including pericytes, pancreatic islet cells, thyroid follicular cells, and cells of the pituitary and the adrenal medulla. Expression on melanocytes has not yet been reported. We examined 148 5-microm cryosections of 12 normal skin samples and 45 skin tumors (21 melanocytic nevi, 8 malignant melanoma primaries, 4 metastases of malignant melanoma, 3 basal cell carcinomas, and 9 pigmented seborrheic keratoses) by triple fluorescence technique with the monoclonal antibody 3G5, DNA fluorochrome, and the anti-melanocytic antibody A103 (Anti-Melan-A). In normal skin, 3G5 reactivity was detected in epidermal melanocytes of 4 of 12 cases with 14.8 +/- 24.1% positive melanocytes; 20 of 21 nevi (72.2 +/- 29.1% positive nevus cells, mean +/- SD), 8 of 8 primary melanomas (83.9 +/- 12.3% positive melanoma cells), and 4 of 4 melanoma metastases (82.5 +/- 6.5% positive melanoma cells) expressed the 3G5 antigen. All tumor cells of investigated basal cell carcinoma or seborrheic keratosis were 3G5 negative. This is the first report of 3G5 antigen expression in melanocytes. The data demonstrate high expression of this ganglioside in the aggregated melanocytes of malignant or benign tumors but low or absent expression in singular melanocytes (normal epidermis, seborrheic keratoses) reflecting a different biologic state.

Hyperplasia of dermal microvascular pericytes in scleroderma*

BACKGROUND

Pericytes (PCs) are smooth muscle-like mural cells of capillaries and venules, which can synthesize matrix components and fibroblast-activating cytokines, and are thus potential mediators of pathological changes in scleroderma. In this study, alterations in microvessels were quantitatively imaged, taking PC into account for the first time.

METHODS

Skin biopsies from systemic (12) and localized (14) scleroderma forms as well as age-, sex-, and body location-matched controls were examined with respect to capillary and venular densities as well as endothelial cell (EC) and PC counts using a newly developed (in respect of PC and EC) indirect collagen IV immunostaining-based method.

RESULTS

Hyperplasia of the PC that doubled the microvascular PC density was the most conspicuous characteristic. In the capillaries of the upper dermal plexus of the periphery of the sclerotic zones, median ratios of PC : EC were 0.23 (controls 0.10) or 0.18 (controls 0.11) in systemic or localized scleroderma, respectively. Furthermore, an increase in capillary density in the upper dermal plexus could be demonstrated in the marginal zones of both types of disease.

CONCLUSIONS

The observed PC increase in the peripheral zones of active disease supports the hypothesis of a vascular pathogenesis of scleroderma and directs the focus to microvascular PC.

[Long-term results of adjuvant chemotherapy after therapeutic lymph node dissection in patients with cutaneous malignant melanoma]

BACKGROUND AND OBJECTIVE

224 patients with malignant melanoma and palpable axillary or inguinal lymphadenopathy underwent therapeutic lymph node dissection at the Martin-Luther-University in Halle, Germany. between 1983 and 1994. 120 received adjuvant chemotherapy; we evaluated the effects of various regimens in this group.

PATIENTS/METHODS

Surgical treatment alone was performed in 104 patients. This group's results were compared to those of 94 patients who additionally received an adjuvant polychemotherapy [dacarbazine (DTIC), vincristine, 5-fluorouracil and hydroxyurea] and 26 patients who received either DTIC monotherapy or DTIC plus interferon-alfa.

RESULTS

The median follow-up was 88 months. The 5-year survival rates were 31.0+/-5% after surgery alone, 26.4+/-4% after adjuvant polychemotherapy and 27.0+/-9% after DTIC based chemotherapy. The three survival curves did not differ significantly. In a multifactorial analysis, the number of metastatic lymph nodes was the single significant predictor of survival after therapeutic lymph node dissection, whereas Breslow thickness, ulceration, site of the primary melanoma, age, sex and adjuvant therapy were not significant.

CONCLUSION

No beneficial effect of adjuvant chemotherapies could be demonstrated.

Keloidartiger Granularzelltumor

A 27-year-old man presented with multiple granular cell tumors of the skin. One tumor presented clinically as a dermatofibrosarcoma or a spontaneous keloid. Histologically, both this tumor and another cutaneous lesion showed striking peritumoral fibrosis. Granular cell tumor should be included in the differential diagnosis of keloidal lesions. The tumors should be removed completely and patients then examined regularly to detect new tumors in a timely fashion.

[Recurrent chancriform mucous membrane ulcer in plasmacytoma with secondary IgA deficiency. Pyoderma chancriforme of the tongue]

A 66 year old patient presented with a nine month history of recurrent oral ulcerations involving the tongue. We diagnosed chancriform pyoderma and a previously not identified multiple myeloma with secondary immunoglobulin deficiency. Clinically and histologically we excluded a necrotizing ulcerative stomatitis as found in individuals with cellular immunodeficiency as in late-stage HIV-infection. On culture only Neisseria catarrhalis was found. Chancriform pyoderma is often associated with local bacterial infections, especially Staphylococcus aureus. The most common sites are the genitalia and periorbital region; involvement of the oral mucosa is uncommon. To the best of our knowledge, this is the fourth reported case with tongue lesions. The multiple myeloma-associated immunoglobulin deficiency might have facilitated the oral manifestations of chancriform pyoderma.

The NO release test as a functional reference standard for laser Doppler fluxmetry in cutaneous microangiology

BACKGROUND/AIMS

The application of one-dimensional laser Doppler fluxmetry (LDF) to clinical research is widespread. Large intra- and interindividual fluctuations in perfusion impede the objective evaluation of studies and hinder a standardised reproducibility. Attempts are made to minimise these biological fluctuations of the measured values by means of functional tests, standardised measuring conditions and large study populations. An intraindividual fixed standard that also facilitates interindividual comparability as a reference parameter would be desirable.

METHODS

By applying a nitric oxide (NO) release cream, a maximal vasodilatation is produced in a circumscribed skin area and optically registered by means of LDF. An LDF quotient is defined as a measure of the reproducibility. A total of 123 test subjects with dermatological diseases were measured at intervals of 60 min on the volar underarm on clinically normal skin with and without NO release cream.

RESULTS

The LDF quotient of the NO release test represents a stable, readily reproducible individual parameter and is appropriate as a reference standard for resting flux measurements. Therefore, we define an LDF factor that includes the maximal vasodilatation as a specific assessment characteristic and thus allows a more powerful, functionally oriented assessment of the individual measurements.

CONCLUSION

The NO release test is appropriate as a reference standard for laser Doppler fluxmetry and realises a high reproducibility of individual measurements.

[Merkel cell carcinoma: a diagnostic and therapeutic challenge]

Merkel cell carcinoma (cutaneous neuroendocrine carcinoma) is a highly malignant, neuroendocrine skin tumor. It mostly occurs in elderly patients in the sun-exposed skin of the head and neck and the extremities. Merkel cell carcinomas develop as fast-growing dermal tumors. They are characterized by a high frequency of lymph-node metastases (50%) and local recurrences (25-77%). The 5-year survival rate is 30-74%. Histology reveals uniform, round cells with a small cytoplasmic rim expressing cytokeratin 20, neurofilament, synaptophysin, chromogranin, and neuron-specific enolase. Ultrastructurally, 100-200 nm electron dense granules are typical findings. Wide surgical excision, followed by radiotherapy, is the treatment of choice. Regional lymph-node metastases should be treated by radical lymph-node excision and radiotherapy. In advanced metastatic Merkel cell carcinoma, a remission can be achieved by different chemotherapy schedules or the somatostatin analogue octreotide. However, the prognosis remains poor. The current knowledge about this disease and guidelines for effective diagnosis and treatment are given.

Human dermal pericytes express 3G5 ganglioside--a new approach for microvessel histology in the skin

BACKGROUND

Pericytes cover the abluminal surface of microvessels and play an important role in capillary regulation and pathology. Studies on pericytes have been hindered by the lack of specific markers with which to facilitate microscopic identification of this cell type. Expression of the cell surface 3G5 ganglioside antigen has been reported in cultured retinal and cardiac pericytes. The objective of this study was to determine the usefulness of monoclonal antibody 3G5 as a pericyte marker in human skin.

METHODS

Cryosections of 21 skin biopsies were examined by direct fluorescence technique with anti-3G5, anti-von Willebrand factor, anti-alpha-smooth muscle actin or DNA fluorochrome.

RESULTS

In human dermis, 3G5 expression is limited to pericytes discriminating this cell type from all other cells including smooth muscle cells, myofibroblasts and myoepithelial cells. We found a pericyte: endothelial cell ratio of 1:12.4 (+/-7.1), and a difference of alpha-smooth muscle actin expression between the subpapillary plexus and the microvessels of the Stratum reticulare.

CONCLUSIONS

3G5 mAB is an excellent and so far the only reported tool for identification of dermal pericytes by fluorescent light microscopy. Moreover, this is the first report of the application of 3G5 technique to the microvasculature in tissue sections at the light microscopic level.

Isolation and in vitro characterization of human dermal microvascular pericytes

Pericytes cover the abluminal surface of capillaries and venules and are thought to play an important role in microvascular regulation and pathology. The purpose of this study was to isolate and characterize human dermal microvascular pericytes (HDMPC), a minor cell type in the skin but a relatively easily obtainable human source of tissue. We developed and compared two procedures that differed in the preselection method. Isolation of dermal microvessel fragments from neonatal foreskins by trypsin digestion was followed by mechanical release of subepidermal tissue, collagenase treatment, and sieving through 100- and 30-microm meshes. After subcultivation, pericytes were preselected either by isolation of outgrowing capillary fragments or by 3G5-coupled magnetic beads. Pericytes were selected finally by cultivation of single cells in endothelial cell-conditioned media. Cultured HDMPC were seen to be large and well spread with irregular edges and prominent stress fibers. They lack contact inhibition, are positive for 3G5 antigen, alpha-smooth muscle actin, and vimentin, and are negative for the endothelial cell marker CD31, diI-acetylated low-density lipoprotein uptake, cytokeratin 5, 6, and 18, and S100 protein. Using both preselection methods, we could establish purified cell cultures of HDMPC. The results of these studies represent the first report of HDMPC isolation.

Longitudinal case analysis in atopic dermatitis

The current knowledge on atopic dermatitis comes mainly from cross-sectional studies, which are not suited to establish time-courses or causal links in complex diseases. As an alternative approach, the method of longitudinal case analysis by the autoregressive integrated moving average (ARIMA) method has been introduced to investigate the pathogenesis of atopic dermatitis. The method was applied to the investigation of 2 patients suffering from severe and moderate atopic dermatitis. Disease activity, peripheral blood parameters (differential blood count, lymphocyte subpopulations, immunoglobulin E, eosinophilic cationic protein, soluble interleukin-2 receptor), mental stress and environmental factors were determined daily for 50 days. Both patients showed a positive correlation between CD4+ and CD25+ T-cells, a negative correlation between CD16/56+ natural killer cells and CD4+ T-cells, a negative correlation between eosinophils and polymorphonuclear leukocytes, and a time-shifted positive correlation of up to 2 days between scores quantifying mental stress and disease activity. A positive correlation between T-cells and polymorphonuclear leukocytes, CD4+ T-cells and the CD45RA+ subtype, as well as a negative correlation between stress and eosinophils, sports and eosinophils, and sports and disease activity were found only in one patient with more severe atopic dermatitis. In conclusion, longitudinal time-series analysis might represent an interesting and adequate method to generate and test new hypotheses on biomedical problems which cannot be addressed by cross-sectional studies.

[Congenital melanocytic nevi]

Congenital melanocytic nevi are benign skin tumours with a population-based prevalence of 1-6%. They run an increased life-time risk of transformation into malignant melanoma. Additionally, they can be associated with an involvement of the leptomeninges (neurocutaneous melanosis), and may cause considerable cosmetic and psychic problems. In contrast to the past, the risk of congenital melanocytic nevi developing into melanoma is now regarded as well-established. Thus, excision is recommended whenever possible. Large lesions which do not allow complete excision should be treated by dermabrasion within the first weeks of life.

Contiguous inflammation of the skin

Contiguous inflammation of the skin (CIS) is a condition comprising localized inflammatory skin reactions which are secondary to a source of infection originating in deeper anatomical structures (bacterial or sterile abscesses, neoplasm-associated inflammations, foreign bodies, osteomyelitis, sinusitis, etc.). The main clinical symptom of contiguous inflammation of the skin is an asymmetrical, localized and painful erythema in combination with different case-specific symptoms. Four patients are presented below, who developed CIS caused by an ethmoidal carcinoma with superinfection, a postoperative mediastinal abscess, an odontogenic staphylococcal abscess and a purulent sinusitis maxillaris. The purpose of this paper is to bring attention to this condition and to offer guidelines for a rapid diagnosis of its underlying, potentially life-threatening, causal inflammatory focus.

Low-dose oral etoposide monotherapy in adult Langerhans cell histiocytosis

BACKGROUND

The purpose of this study was to test the disease-controlling effect of low-dose oral etoposide monotherapy in adult-onset multisystem Langerhans cell histiocytosis. There are no previous reports of low-dose etoposide monotherapy for this condition.

OBSERVATIONS

A 27-year-old man with a 7-year history of multifocal chronic Langerhans cell histiocytosis presented with severe disabling ulcers in intertriginous areas. He had previously been treated with 2 different regimens of antitumoral chemotherapy; one had to be discontinued due to myelosuppression and the other had proved ineffective. We treated with oral etoposide monotherapy at 50 mg/d (22 mg/m2 per day) for 21 days. The treatment was repeated at 28-day intervals for a total of 6 cycles. A rapid initial response with subtotal diminution of the involved skin area was found. No adverse effects were observed. The clinical picture has remained stable during the 7 months following cessation of therapy.

CONCLUSION

Low-dose oral etoposide treatment is an adequate therapeutic measure for prolonged disease control in adult-type Langerhans cell histiocytosis.

Induction of type IV hypersensitivity to contact allergens in guinea pigs by in vitro haptenized allogenic peritoneal exudate cells

The induction of type IV hypersensitivity to contact allergens in guinea pigs has been studied by using allogenic peritoneal exudate cells (> 90% macrophages), which had been incubated primarily in vitro with dinitrochlorobenzene, formaldehyde, potassium dichromate, nickel II sulphate or para-aminobenzoic acid. In these guinea pig sensitization experiments Freund's complete adjuvant was used. In all haptens investigated the sensitization rates of the presented method were parallel to the known contact allergenicity in humans and, apart from the potassium dichromate results, comparable with those of the guinea pig maximization test. Because of its alternative immunization procedure, in which only few or no allergen molecules escape the effective presentation pathway, the authors conclude that this method could be developed into a predictive test assay for the evaluation of the contact allergenicity of water-soluble substances.