Complete spontaneous regression of Merkel cell carcinoma: a review of the 10 reported cases

BACKGROUND

Merkel cell (neuroendocrine) carcinoma (MCC) is a very aggressive primary cutaneous neoplasm occurring most often on the head and neck of the elderly. Complete spontaneous regression (CSR) of MCC was first described in 1986. Since then other cases have been reported bringing the total to 10.

OBJECTIVE

To review these 10 cases and obtain long-term follow-up data, to compare them for similarities and differences.

METHOD

Each original case report was extensively reviewed and authors contacted in most cases for confirmation and updated information.

RESULTS

In no case did MCC recur after CSR was noted, although follow-up information in some cases was short. When CSR occurred, it was swift and dramatic with complete regression of skin and lymph node metastasis in 1-3 months.

CONCLUSION

While only 10 cases of CSR is a small number, MCC is itself a rare malignancy with just over 600 reported cases. Today most cases of MCC receive aggressive combined therapy effectively precluding diagnosis of CSR. The nature of regression in these 10 cases may point toward future immunologic therapy just as similar cases of CRS in patients with melanoma have led to advances in the immunologic treatment for that malignancy.

Prevalence and strain differentiation of Giardia intestinalis in calves in the Manawatu and Waikato regions of North Island, New Zealand

Giardia intestinalis has been reported in newborn calves world-wide; however, information on the extent of G. intestinalis in New Zealand calves has to date been very limited. The current study attempted to establish the prevalence rate of G. intestinalis in calves up to 8 weeks old in New Zealand. More than 700 calf fecal specimens were collected during the spring calving seasons of 1998 and 1999 from two regions in North Island, New Zealand (Manawatu and Waikato) and tested for the presence of G. intestinalis. In addition to determining the presence of G. intestinalis in newborn calves, sequence analysis was performed using specific amplification primers developed to target a section of the ribosomal DNA (rDNA). This locus is considered to be rapidly evolving, and therefore, suitable for use in the elucidation of phylogenetic relationships between G. intestinalis isolates. Sequencing was performed using G. intestinalis DNA extracted from cysts collected directly from the calf fecal matter. There was no culturing of the G. intestinalis isolates either in vivo or in vitro. Over 40% of all collected calf fecal specimens contained G. intestinalis cysts and rDNA sequence analysis revealed two different sequences among calf isolates. These sequence differences were not found to correspond to a particular season, geographical region or farming practice. Preliminary phylogenetic analysis suggests that these two rDNA sequence types are indicative of calf hosts.

Simultaneous identification and typing of multi-drug-resistant Mycobacterium tuberculosis isolates by analysis of pncA and rpoB

In Mycobacterium tuberculosis there is a strong correlation between in-vitro resistance to rifampicin (RIF) and pyrazinamide (PZA) and mutations in rpoB and pncA, respectively. Approximately 50 mutations associated with resistance have been reported for rpoB and 70 for pncA, and, theoretically, many more are possible. Therefore, the identification of rpoB and pncA mutations in M. tuberculosis might be used for the simultaneous determination of resistance and for typing multi-drug-resistant (MDR) strains during possible outbreaks. The present study examined four sensitive and six MDR isolates of M. tuberculosis from Turkey and eight isolates from a nosocomial MDR tuberculosis (TB) outbreak in the UK. Gene mutations were identified by the Innogenetics LiPA rpoB assay or automated sequencing, or both. All the sensitive isolates had rpoB and pncA wild-type genotypes, whereas all the RIF- and PZA-resistant isolates had rpoB and pncA mutations. All four mutations seen in rpoB, but none of the six in pncA, had been reported previously. The rpoB and pncA mutations seen in the Turkish isolates defined six distinct genotypes amongst the six MDR isolates, while standard IS6110 typing discriminated only four. All isolates from the single strain MDR-TB outbreak had identical genotypes. Rapid genotyping was performed on the sputum from a patient who presented 2 years after the initial MDR-TB outbreak and this showed rpoB and pncA genotypes identical to the other outbreak isolates. This result was available within 36 h. The analysis of rpoB and pncA is a rapid and practical means of simultaneously identifying and typing MDR isolates of M. tuberculosis.

Selective ET(A) antagonists. 5. Discovery and structure-activity relationships of phenoxyphenylacetic acid derivatives

The fifth paper in this series describes the culmination of our investigations into the development of a potent and selective ET(A) receptor antagonist for the treatment of diseases mediated by ET-1. Receptor site mapping of several ET(A) antagonists prepared previously identified a common cationic binding site which prompted synthesis of phenoxyphenylacetic acid derivative 13a, which showed good in vitro activity (IC(50) 59 nM, rat aortic ET(A)). Optimization of 13a led to the identification of 27b, which exhibited an IC(50) of 4 nM. Although this did not translate into the expected in vivo potency, a compound of comparable in vitro activity, 27a (RPR118031A), showed a far better pharmacokinetic profile and in vivo potency (75 micromol/kg) and was duly proposed and accepted as a development candidate.

Down-regulation of transforming growth factor beta receptors by androgen in ovarian cancer cells

Steroid hormones have been implicated in the etiology and/or progression of epithelial ovarian cancer. As ovarian surface epithelial cells are growth inhibited by transforming growth factor beta (TGF-beta), we tested whether steroid hormones could regulate the expression of TGF-beta1 or its receptors in ovarian cancer cells, as assessed by quantitative reverse transcription-PCR. Treatment of ovarian cancer HEY cells with 500 nM 5alpha-dihydrotestosterone (DHT), but not estradiol-17beta or progesterone, for 60 h down-regulated the expression of mRNA for TGF-beta receptors I and II (TbetaR-I and TbetaR-II), betaglycan, and endoglin but had no effect on TGF-beta1 mRNA levels. Androgen receptor (AR) mRNA expression in HEY cells was compared to other ovarian cancer cell lines. OVCAR-3 cells expressed AR mRNA levels similar to that of androgen-responsive LNCaP prostate cancer cells, whereas SKOV-3 and HEY cells expressed only 3 and 0.01%, respectively. Western blot analysis and saturation binding assays confirmed the expression of AR protein in these three cell lines, but at the limit of detection in SKOV-3 and HEY cells. Treatment of SKOV-3 and HEY cells for 24 h with 1-50 nM DHT resulted in a dose-dependent down-regulation of TbetaR-II mRNA. The AR antagonist hydroxyflutamide did not reverse the effect of DHT on SKOV-3 cells but by itself down-regulated TbetaR-II mRNA. This apparent androgen-mimetic action of hydroxyflutamide and the ability of SKOV-3 and HEY cells to respond to DHT may be due to their expression of AR-associating protein 70, an AR co-activator reported to amplify AR transactivation and to result in agonist activity of AR antagonists. DHT was able to reverse TGF-beta1 growth-inhibitory action in SKOV-3 cells and in a primary culture of ovarian cancer cells derived from ascites. Thus, androgens may promote ovarian cancer progression in part by decreasing TGF-beta receptor levels, thereby allowing ovarian cancer cells to escape TGF-beta1 growth inhibition.

Rapid diagnosis of bacteremia by universal amplification of 23S ribosomal DNA followed by hybridization to an oligonucleotide array

The rapid identification of bacteria in blood cultures and other clinical specimens is important for patient management and antimicrobial therapy. We describe a rapid (<4 h) detection and identification system that uses universal PCR primers to amplify a variable region of bacterial 23S ribosomal DNA, followed by reverse hybridization of the products to a panel of oligonucleotides. This procedure was successful in discriminating a range of bacteria in pure cultures. When this procedure was applied directly to 158 unselected positive blood culture broths on the day when growth was detected, 125 (79.7%) were correctly identified, including 4 with mixed cultures. Nine (7.2%) yielded bacteria for which no oligonucleotide targets were present in the oligonucleotide panel, and 16 culture-positive broths (10.3%) produced no PCR product. In seven of the remaining eight broths, streptococci were identified but not subsequently grown, and one isolate of Staphylococcus aureus was misidentified as a coagulase-negative staphylococcus. The accuracy, range, and discriminatory power of the assay can be continually extended by adding further oligonucleotides to the panel without significantly increasing complexity or cost.

A new disorder of hyaluronan metabolism associated with generalized folding and thickening of the skin

OBJECTIVE

To describe and characterize a new disorder of hyaluronan metabolism associated with marked abnormalities of cutaneous tissue and to determine whether a relationship with a phenotypically similar disorder in the shar-pei dog exists.

METHODS

Biopsy specimens of the skin of a child with extreme cutaneous thickening and folding were examined by light and electron microscopy. The concentration of hyaluronan and the activity of hyaluronidase were measured in the patient's serum and plasma, respectively, and the activity of hyaluronan synthase was examined in cultured dermal fibroblasts. Hyaluronan concentration was also measured in the plasma of 23 shar-pei and 34 control dogs.

RESULTS

The patient's skin displayed gross accumulation of hyaluronan, and the serum concentration of hyaluronan was markedly elevated (up to 3100 microg/L) during infancy. Hyaluronan synthase activity of cultured dermal fibroblasts was increased, whereas hyaluronidase activity in plasma was normal (5.5 +/- 0.08 IU/L). Plasma hyaluronan concentration was higher in the shar-pei dogs than in control dogs (median, 378 microg/L vs 73 microg/L, respectively).

CONCLUSION

The child we describe has a novel disorder of hyaluronan metabolism, which appears to result from abnormal control of hyaluronan synthesis. An analogous disorder may be present in the shar-pei dog.

Absorption of hyaluronan applied to the surface of intact skin

Hyaluronan has recently been introduced as a vehicle for topical application of drugs to the skin. We sought to determine whether hyaluronan acts solely as a hydrophilic reservoir on the surface of intact skin or might partly penetrate it. Drug-free hyaluronan gels were applied to the intact skin of hairless mice and human forearm in situ, with and without [3H] hyaluronan. [3H]hyaluronan was shown by autoradiography to disseminate through all layers of intact skin in mouse and human, reaching the dermis within 30 min of application in mice. Cellular uptake of [3H]hyaluronan was observed in the deeper layers of epidermis, dermis, and in lymphatic endothelium. Absorption through skin was confirmed in mice by chromatographic analysis of blood, urine, and extracts from skin and liver, which identified 3H as intact hyaluronan and its metabolites, free acetate and water. Hyaluronan absorption was similarly demonstrated without polyethylene glycol, which is usually included in the topical formulation. [3H]hyaluronan absorption was not restricted to its smaller polymers as demonstrated by the recovery of polymers of (360-400 kDa) from both blood and skin. This finding suggests that its passage through epidermis does not rely on passive diffusion but may be facilitated by active transport. This study establishes that hyaluronan is absorbed from the surface of the skin and passes rapidly through epidermis, which may allow associated drugs to be carried in relatively high concentration at least as far as the deeper layers of the dermis.

An overview of sexually transmitted diseases. Part II

Sexually transmitted diseases are a persistent problem in the United States and throughout the world. Many of these infections involve the skin and may be encountered in the field of dermatology. This 3-part review highlights the cutaneous features, diagnosis, and treatment of 11 of the most common sexually transmitted diseases, other than AIDS. The second part of this series focuses on anogenital warts, chronic viral hepatitis, molluscum contagiosum, scabies, and pediculosis pubis. Additional features, such as epidemiology and transmission of the organism, are discussed when applicable. (J Am Acad Dermatol 1999;41:661-77.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the clinical features, diagnosis, and treatment of sexually transmitted diseases (excluding AIDS) which have cutaneous presentations or involvement.

An overview of sexually transmitted diseases. Part I

Sexually transmitted diseases are a persistent problem in the United States and throughout the world. Many of these infections involve the skin and may be encountered in the field of dermatology. This 3-part review highlights the cutaneous features, diagnosis, and treatment of 11 of the most commonly encountered sexually transmitted diseases, other than AIDS. However, this review does not cover sexually transmitted diseases such as chlamydia, which do not regularly have cutaneous manifestations. Part 1 focuses on syphilis, disseminated gonococcal infection, chancroid, lymphogranuloma venereum, granuloma inguinale, and genital herpes. Additional features, such as epidemiology and transmission of the organism, are discussed when applicable.

Activation of SPARC expression in reactive stroma associated with human epithelial ovarian cancer

OBJECTIVE

SPARC (secreted protein, acidic, rich in cysteine) is a calcium-binding counteradhesive glycoprotein that has the potential to play an important role in promoting tumor progression and invasiveness. SPARC has been reported to be markedly down-regulated in ovarian carcinomas relative to the normal surface epithelium and has been suggested to act as a tumor suppressor in ovarian cancer. To more precisely define potential changes in SPARC expression associated with malignant transformation of the ovary, we compared the distribution of SPARC mRNA and protein expression in patient specimens of malignant and nonmalignant ovaries.

METHOD

SPARC mRNA and protein expression was examined in 24 human invasive ovarian cancers, 5 tumors of low malignant potential (LMP), and 8 nonmalignant ovaries by in situ hybridization and immunohistochemistry.

RESULTS

In nonmalignant ovaries, SPARC mRNA expression was restricted to thecal and granulosa cells of vessiculated follicles. Cytoplasmic SPARC immunoreactivity was observed in these compartments, whereas variable SPARC immunostaining was observed in normal surface epithelial cells. In contrast, high-level expression of SPARC mRNA and protein was detected in stroma of ovaries containing malignant tumor cells, particularly at the tumor-stromal interface of the invading tumors. Lower levels and a more diffuse pattern of SPARC mRNA expression were associated with LMP specimens. SPARC mRNA was not expressed by ovarian adenocarcinoma or by surface epithelial cells. Consistent with the in situ hybridization data, SPARC immunoreactivity was found throughout the reactive stroma of specimens containing ovarian carcinoma. However, despite the lack of detectable SPARC mRNA, SPARC immunoreactivity was consistently observed within the cytoplasm of cancer cells.

CONCLUSION

The pattern of SPARC expression shown in this study indicates that SPARC is up-regulated in reactive stroma associated with invasive ovarian cancer. Moreover, these results raise the possibility that SPARC secreted from the stroma is internalized by ovarian cancer cells and may exert important intracellular effects upon these cells.

Primary carcinosarcoma of the skin: report of a case and review of the literature

BACKGROUND

Carcinosarcoma is a biphasic tumor composed of intimately admixed epithelial and mesenchymal elements, both of which are malignant. Primary cutaneous involvement is extremely rare. Therefore it has been difficult to characterize the clinical course of carcinosarcoma of the skin.

OBJECTIVE

To describe a further case of carcinosarcoma of the skin and to provide a review of the literature.

METHODS

The clinical records of the patient and histopathology of the neoplasm are reviewed. In addition, the results of all previously reported cases of carcinosarcoma of the skin are compiled for reexamination.

RESULTS

After complete excision of the carcinosarcoma, the patient shows no evidence of disease for 9 months. Long-term follow-up is needed because of the risk of recurrence or metastasis that may occur with this neoplasm.

CONCLUSION

Carcinosarcoma of the skin appears to be associated with a good prognosis when compared with similar tumors located elsewhere. Metastasis (with or without documented mortality) has been reported in 3 of 16 patients (16.7%). Death from local disease has been reported in one additional patient (6.3%). However, further cases with long-term follow-up are needed in order to better understand the nature of this cutaneous neoplasm.

Regulation of inflammatory responses by oncostatin M

Oncostatin M (OM) is a pleiotropic cytokine produced late in the activation cycle of T cells and macrophages. In vitro it shares properties with related proteins of the IL-6 family of cytokines; however, its in vivo properties and physiological function are as yet ill defined. We show that administration of OM inhibited bacterial LPS-induced production of TNF-alpha and lethality in a dose-dependent manner. Consistent with these findings, OM potently suppressed inflammation and tissue destruction in murine models of rheumatoid arthritis and multiple sclerosis. T cell function and Ab production were not impaired by OM treatment. Taken together these data indicate the activities of this cytokine in vivo are antiinflammatory without concordant immunosuppression.

Malignant melanoma: a clinical review

The incidence of cutaneous malignant melanoma is increasing at an alarming rate. It is projected that Americans born in the year 2000 will have a 1 in 75 lifetime risk of developing melanoma. Long-term survival for patients with metastatic disease is only 5% and approximately 15% of patients diagnosed with melanoma eventually die from their disease. Conversely, the prognosis for early disease is excellent and often simple surgical excision is curative. It is therefore crucial that the practicing physician becomes familiar with all of the clinical and histologic presentations in order to ensure an accurate and prompt diagnosis. This, in turn, should lead to earlier detection and a more favorable prognosis.

Characterisation of constrictor endothelin receptors in the human internal thoracic artery and saphenous vein

We studied the endothelin receptors mediating contraction in the human saphenous vein (SV) and internal thoracic artery (ITA). In the SV, the ET(A)-receptor antagonist BQ123 (1 microM) did not significantly shift the ET-1 concentration-response curve but did cause a parallel shift in the ITA. In the SV, the ET(A)-receptor agonist sarafotoxin 6b (S6b) produced a monophasic concentration-response curve that was antagonised biphasically by BQ123 (0.1-1 microM). In the ITA, S6b was an ineffective agonist with contractions seen only at 3 x 10(-9) M upward. The ET(B)-receptor agonist sarafotoxin 6c (S6c) caused constrictions in only 74% of SV rings and 42% of ITA rings. In the tissues that did respond, S6c caused a monophasic concentration-response curve with a lower maximal response than ET-1. The ET(B) antagonist BQ788 did not antagonise the responses to ET-1 in either the SV or the ITA but did antagonise the responses to S6c in the SV. The results from this study suggest that mainly ET(A) receptors mediate the contractile responses in the human SV and ITA. There is also evidence for an ET(B)-mediated response, although the contractions were much smaller than those elicited by ET-1. We also conclude that the ET(A) receptors mediating responses in these human vessels are atypical because of the different effects of BQ123 on the two vessels.

Evaluation of three commercial detection systems for Mycobacterium tuberculosis where clinical diagnosis is difficult

AIMS

To assess the performance of three commercially available Mycobacterium tuberculosis detection systems employing nucleic acid amplification, when applied directly to respiratory and non-respiratory specimens from patients where the diagnosis of tuberculosis is difficult using clinical and traditional bacteriological methods.

METHODS

42 respiratory and 21 non-respiratory specimens were concentrated, examined with auramine staining, and cultured on Lowenstein-Jensen slopes. These specimens were also assayed using the Amplicor Mycobacterium tuberculosis test (AM) (Roche Diagnostic Systems), the Amplified Mycobacterium tuberculosis direct test (AMD) (Gen-Probe), and the LCx Mycobacterium tuberculosis assay (LMA) (Abbott Laboratories).

RESULTS

All three amplification systems used in this study gave specificities of 100% when used on respiratory specimens. When used on non-respiratory specimens, AM and LMA gave specificities of 100% and AMD 75%. With respiratory specimens the AM, AMD, and LMA systems gave sensitivities of 75%, 65.2%, and 79.2%, respectively. With non-respiratory specimens the sensitivities were 50%, 66.7%, and 60%, while with smear negative, culture positive specimens they were 33.3%, 66.7%, and 55.6%. Positive predictive values of 100% were seen with all specimens except non-respiratory specimens assayed using AMD where the value was 66.7%.

CONCLUSIONS

The manufacturers of these systems recommend that they should only be used for the direct analysis of respiratory specimens, and the US Food and Drug Administration has approved them for use only with smear positive specimens. This study confirms that sensitivities are lower for non-respiratory and smear negative specimens, but positive predictive values are high. Provided they are interpreted with caution, positive results with these tests in respiratory and non-respiratory specimens are useful in tuberculous patients who are otherwise difficult to diagnose. Each amplification has advantages and disadvantages compared with the others.

Merkel cell carcinoma: spontaneous resolution and management of metastatic disease

BACKGROUND

Merkel cell carcinoma (MCC) is a rare, aggressive, cutaneous neoplasm. The primary form of initial treatment is wide surgical excision. The use of Mohs micrographic surgery as the primary form of treatment in MCC has been controversial. The course of MCC is often aggressive, with early metastasis, widespread disease, and death. Despite the poor prognosis, spontaneous regression has occasionally been reported.

OBJECTIVE

We describe the clinical course of two patients with Merkel cell carcinoma who underwent treatment with Mohs micrographic surgery for the primary MCC. Metastases were excised in the first case and spontaneously regressed in the second. Both patients are without clinical disease at the time of this report.

METHODS

Histopathology, clinical records, and the current literature are reviewed.

RESULTS

One patients was without recurrence of MCC for 13 years of follow-up. The other patient experienced clinical spontaneous remission after nodal spread of the disease, with no recurrence for 18 months after clinical remission and 24 months after surgery.

CONCLUSION

The treatment of Merkel cell carcinoma with Mohs micrographic surgery (MMS) has been successful for the control of primary skin disease, and is at least comparable to wide excision. Spontaneous regression may occur in the course of this usually relentless and aggressive disease. The explanation for spontaneous regression of MCC is unknown.

Hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a recurrent, suppurative disease manifested by abscesses, fistulas, and scarring.

METHODS

We reviewed the literature to identify reliable information regarding epidemiology, pathogenesis, clinical manifestations, evaluation and differential diagnosis, treatment, complications, and prognosis.

RESULTS

Hidradenitis suppurativa usually affects young women, with a prevalence of 0.3% to 4% in industrialized countries. Once considered to be "apocrine acne," HS is actually a defect of terminal follicular epithelium. Obesity, chemical irritants, or hyperandrogenism are not consistently associated; bacterial involvement is secondary. Hidradenitis suppurativa should be suspected in young adults with recurrent, deep furuncular lesions in flexural sites, especially when such lesions respond poorly to antibiotic therapy. Clindamycin and isotretinoin may be useful, though wide excision with healing by granulation is considered most efficacious. Anemia, arthropathy, and squamous cell carcinoma are potential complications.

CONCLUSIONS

Since spontaneous resolution is rare and progressive disability the rule, early definitive surgical treatment of HS is advisable.

The diagnosis and treatment of common birthmarks

In the management and evaluation of several of these birthmarks, it is advantageous, if not imperative, to apply a multidisciplinary approach. The patients benefit most from a cooperative team of physicians, often including the pediatrician, dermatologist, plastic surgeon, radiologist, and pathologist. Because of the often extensive presentation of many of these lesions, such an approach is extremely useful in planning their evaluation and management.

Genital ulcers. Evaluation and treatment

Ulcerations may appear on the genitalia in a variety of both infectious and noninfectious conditions. The vast diversity of etiologies, coupled with the often overlapping morphological features, make the diagnosis of genital ulcerations a challenging endeavor. This article highlights the most important clinical manifestations and laboratory findings which aid in the proper diagnosis of genital ulcerations.

Cutaneous manifestations of sexually transmitted diseases

Sexually transmitted diseases remain a prevalent problem in the United States and throughout the world, despite efforts in prevention and education. This review highlights the cutaneous manifestations of the following sexually transmitted diseases: syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale, genital herpes, genital warts, scabies, and pediculosis pubis. Emphasis is placed on the clinical findings, diagnostic methodology, and recommended treatment for each disease.