[Swiss clinical practice guidelines for skin cancer in organ transplant recipients]

Swiss clinical practice guidelines for skin cancer in organ transplant recipients Transplant patients have increased over the last decades. As a consequence of long-term immunosuppression, skin cancer, in particular squamous cell carcinoma (SCC), has become an important problem. Screening and education of potential organ transplant recipients (OTRs) regarding prevention of sun damage and early recognition of skin cancer are important before transplantation. Once transplanted, OTRs should be seen yearly by a dermatologist to ensure compliance with sun avoidance as well as for treatment of precancerosis and SCC. Early removal is the best treatment for SCC. Reduction of immunosuppression, switch to mTOR inhibitors and chemoprevention with acitretin may reduce the incidence of SCC. The dermatological follow-up of OTRs should be integrated into a comprehensive post-transplant management strategy.

Serum concentration of baseline mast cell tryptase: evidence for a decline during long-term immunotherapy for Hymenoptera venom allergy

BACKGROUND

Baseline serum mast cell tryptase concentration (BTC) is thought to reflect the constitutive mast cell load or activity of an individual patient. Little is known about the individual stability of BTC during long-term venom immunotherapy (VIT).

OBJECTIVE

To investigate the intra-individual stability of BTC over time in patients with Hymenoptera venom allergy.

METHODS

Three hundred and two patients were studied. BTC was measured before and at least twice during VIT. At least 4 weeks lay between BTC measurements and the most recent field sting, in-hospital sting, or preceding venom injection. Multifactorial mixed linear models were used to analyse BTC changes over time.

RESULTS

Median observation time was 4.2 years (range 2-12 years). Before VIT, the median BTC was 6.8 microg/L (range 1.14-177 microg/L). The median coefficient of variation (CV) over time was 15.3% (range 1.9-63.8%). The median CV was significantly smaller in patients presenting with an elevated BTC (>11.4 microg/L) than in patients with a normal BTC (11.4%, range 2.6-39.5%; vs. 17.6%, range 1.9- 63.8%; P<0.001). During VIT and after adjusting for age and gender, we found a slight but significant decrease of BTC over time (2.5% per year, 95% confidence interval 2.0-3.0%, P<0.001).

CONCLUSION

Individual variation of BTC during VIT does not rise when BTC is increased before therapy. VIT is associated with a small, but continuous decrease of BTC over time possibly indicating a dampened mast cell function or a decline in mast cell burden.

Bacterial burden of worn therapeutic silver textiles for neurodermitis patients and evaluation of efficacy of washing

To reduce pruritus and colonization with Staphylococcus aureus, textiles containing silver are increasingly used as therapeutic option for patients with atopic dermatitis (AD). While wearing such textiles, the contained silver is in close contact with the patient's skin. The silver serves two purposes: to reduce bacterial colonization of the skin, and to prevent contamination of the textile with ensuing growth of microorganisms. It is unknown whether the silver impregnation is able to reduce bacterial contamination of the textile during wearing and to prevent bacterial growth within the textile. The aim of this study was to investigate the bacterial contamination in textiles containing silver versus placebo worn by patients with AD and to determine the efficacy of processing worn textiles by manual and machine-based washing. Additionally, the effect of silver textiles on S. aureus and total bacterial counts colonizing the skin of AD patients was analyzed. The reduction factor of silver textile compared to placebo was 0.5 log steps against S. aureus and 0.4 log steps against total bacteria. Silver textiles exhibited significantly less S. aureus as well as total bacterial colonization after 2 days of wearing without washing, as compared with a placebo textile. On placebo textiles 385.6 +/- 63.5 CFU total bacteria and 236.5 +/- 49.9 CFU S. aureus, and on silver textiles 279.9 +/- 78.7 CFU total bacteria and 119.3 +/- 39.4 CFU S. aureus were found on the inner side of the textiles facing the neurodermitis lesions. However, the unexpectedly high residual contamination despite the silver exposure represents a potential risk as recontamination source of S. aureus that could maintain the proinflammatory process in AD. This contamination is nearly completely eliminated by machine-based washing at 60 degrees C using conventional washing powder. AD patients wearing silver textiles should change their used clothes at least daily and wash them in a washing machine at 60 degrees C.

Polarization of human monocyte-derived dendritic cells to DC1 by in vitro stimulation with Newcastle Disease Virus

PURPOSE

Dendritic cell (DC)-based tumor vaccines have been tested extensively to treat cancer patients. However, the results of several DC-based clinical trials have been disappointing. Amelioration of such a modality for cancer treatment seems warranted, i.e. by improving DC immunogenicity and polarization. The goal of our study was to evaluate the potential for immune activation of human DCs by incubating them in vitro with the Newcastle Disease Virus (NDV), a paramyxovirus with strong immunostimulatory properties.

RESULTS

In vitro infection with NDV of human monocyte-derived DCs--generated from peripheral monocytes cultured with IL-4 and GM-CSF--induces the generation of viral M gene transcripts and RIG-I expression within DCs. Expression of both genes was increased upon co-stimulation with LPS. Surprisingly, LPS and NDV had opposite effects on induction of interferon (IFN)-alpha. Furthermore, NDV induced DC maturation (as measured by TNF-alpha production and CD80 cell surface expression) only in the presence of LPS. Most interestingly, an optimal combination of NDV and LPS caused polarization of the DCs to Th1 type cytokines with a high ratio of interleukin (IL)-12 to IL-10.

CONCLUSION

These in vitro results provide a means and protocol for maturation and activation of DCs with enhanced and sustained T helper type 1-polarizing capacity. Such pretreated DCs may significantly improve DC-based cancer immunotherapy. The data encourage the use of RNA-based viral vectors as potential novel and powerful gene transfer modality for cytoplasmic gene expression in professional antigen-presenting cells (APC) to overcome immunosuppression in cancer patients.

Swiss clinical practice guidelines for skin cancer in organ transplant recipients

Patients with a solid organ transplant have increased in numbers and in individual survival in Switzerland over the last decades. As a consequence of long-term immunosuppression, skin cancer in solid organ recipients (SOTRs) has been recognized as an important problem. Screening and education of potential SOTRs about prevention of sun damage and early recognition of skin cancer are important before transplantation. Once transplanted, SOTRs should be seen by a dermatologist yearly for repeat education as well as early diagnosis, prevention and treatment of skin cancer. Squamous cell carcinoma of the skin (SCC) is the most frequent cancer in the setting of long-term immunosuppression. Sun protection by behaviour, clothing and daily sun screen application is the most effective prevention. Cumulative sun damage results in field cancerisation with numerous in-situ SCC such as actinic keratosis and Bowen's disease which should be treated proactively. Invasive SCC is cured by complete surgical excision. Early removal is the best precaution against potential metastases of SCC. Reduction of immunosuppression and switch to mTOR inhibitors and potentially, mycophenolate, may reduce the incidence of further SCC. Chemoprevention with the retinoid acitretin reduces the recurrence rate of SCC. The dermatological follow-up of SOTRs should be integrated into the comprehensive post-transplant care.

A randomized placebo-controlled study of tamoxifen after adjuvant chemotherapy in premenopausal women with early breast cancer (National Cancer Institute of Canada--Clinical Trials Group Trial, MA.12)

BACKGROUND

In the early 1990s, the role of adjuvant tamoxifen in premenopausal women with early breast cancer (EBC) was not established. Similarly, optimum timing relative to adjuvant chemotherapy and efficacy of tamoxifen in hormone receptor-negative tumors were unclear.

PATIENTS AND METHODS

Premenopausal women with EBC, any hormone receptor status, after surgery received standard adjuvant chemotherapy [doxorubicin (adriamycin)/cyclophosphamide, cyclophosphamide/methotrexate/5-fluorouracil, or cyclophosphamide/epirubicin/5-fluorouracil] followed by randomization to tamoxifen or placebo for 5 years. Outcomes were overall survival (OS), disease-free survival (DFS), toxicity, and compliance with therapy.

RESULTS

Median follow-up for 672 women was 9.7 years. Multivariate analysis showed improved DFS [78.2% versus 71.3% at 5 years; hazard ratio (HR) 0.77; P = 0.056] and a trend for improved OS (86.6% versus 82.1% at 5 years; HR 0.78; P = 0.12). There was no evidence of greater benefit for the receptor-positive subgroup. Compliance with treatment was suboptimal in both arms, with 103 (31%) women on tamoxifen and 70 (21%) on placebo-stopping therapy early because of toxicity, refusal, or other choices.

CONCLUSIONS

Adjuvant tamoxifen, given after chemotherapy to premenopausal women with EBC, improved 5-year DFS. Poor compliance may have reduced treatment efficacy.

Hypertension (HTN) in National Cancer Institute of Canada Clinical Trials Group study BR.24: A randomized, double-blind phase II trial of carboplatin (C) and paclitaxel (P) with either daily oral cediranib (CED), an inhibitor of vascular endothelial growth factor receptors, or placebo, in patients with advanced non-small cell lung cancer

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Background: CED 30 mg/d with C+P increased response rate (RR: 38 vs 16% p < 0.0001) and median progression free survival (PFS: 5.6 vs 5 m, hazard ratio [HR] 0.77) over C+P alone. HTN is a known effect of angiogenesis inhibitors (AI). For BR.24, we describe the incidence of HTN, effects on drug delivery, predictors of its development/worsening, and assess the predictive effect of HTN on efficacy. Methods: Pts received C+P plus either placebo (n =146) or CED (n = 148). HTN as an adverse event (HTN AE: defined as either new onset HTN, or worsening grade HTN in a previously hypertensive pt), was managed with a protocol-defined algorithm. Exploratory analyses characterized the relationship between HTN AE and baseline characteristics and treatment arm. Kaplan Meier curves summarized time to event outcomes and Cox regression models with time dependent covariates correlated HTN AE to outcomes. Results: Rate of pts with a history of HTN were similar: CED 26 %, placebo 33 %. CED pts had significantly higher HTN AE (any: 38 vs 12%, p < 0.0001; grade 3 or 4: 19 vs 2 %). With the treatment algorithm, HTN AE had minimal impact on drug delivery (1 pt interrupted C+P, 11 pts [3.7%] reduced /discontinued CED / placebo). Headache was the only other AE that correlated with HTN AE. Predictors of HTN AE included: CED arm (p < 0.0001), good ECOG (p = 0.02), female (p = 0.006), history of HTN (p = 0.06). CED pts with HTN AE had significantly higher RR (51.8 vs 32.6%, p = 0.025) and PFS (8.5 vs 5.1 m; HR 0.45, 95% CI 0.29 to 0.72, p = 0.0007); similar but not significant findings were observed with placebo (RR 35.3 vs 17.2%, p= 0.098; PFS 5.6 vs 4.9 m; HR 0.84, 95 % CI 0.45–1.54); the interaction term by treatment arm was not significant. Conclusions: CED pts had greater HTN AE, but this did not impact drug delivery. Certain baseline characteristics predicted HTN AE in all pts. Unexpectedly, development of on-study HTN predicted improved outcome in all pts, although to a greater extent for those on CED. Additional evaluation of the role of HTN AE as a predictor of efficacy of both AI and cytotoxics is warranted.

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Treatment and outcome of patients with brain metastases from non-small cell lung cancer (NSCLC)

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Background: The prognosis of patients with brain metastases from NSCLC is generally poor. However, some reports suggest that the outlook of patients with brain metastases at the time of diagnosis may be similar to that of patients with advanced NSCLC without brain metastases. We undertook a retrospective review of NSCLC patients with brain metastases to examine the outcomes of care for patients with brain metastases from NSCLC. Methods: All new lung cancer patients seen in our institution between July 2005 and June 2007 were assessed for the development of brain metastases. Baseline characteristics, treatment and outcome data were extracted from the chart. The primary outcome of interest was a comparison of survival of patients with brain metastases at diagnosis compared with patients who developed brain metastases later. Results: 91 of 878 (10.4%) new patients seen over the 2 years developed brain metastases. There were 43 men and 48 women. The median age was 64 yrs (sd 10.6yrs). 45 patients had brain metastases at presentation while 46 developed brain metastases later. 34 (37%) had a solitary brain metastasis. 18 (20%) underwent surgical resection. The median overall survival for all patients was 7.8m. Patients with brain metastases at diagnosis had a significantly shorter overall survival than patients who developed brain metastases later (9.8m v 4.3m, p=0.001). Survival following diagnosis of brain metastases was similar for both groups (3.7m v 4.8m, p=0.53). Patients presenting with brain metastases were less likely to be referred to a medical oncologist (51% v 74%, p=0.02) and less likely to receive chemotherapy (18% v 41%, p=0.01). Conclusions: These data suggest that NSCLC patients with brain metastases at diagnosis have a significantly worse outcome than patients who develop brain metastases at a subsequent time point in their illness. Few patients received systemic therapy following diagnosis of brain metastases and further research is needed to determine the utility of chemotherapy in this patient group.

No significant financial relationships to disclose.

Mammary tumor phenotypes in wild-type aging female FVB/N mice with pituitary prolactinomas

Prolactin-secreting pituitary adenomas are common spontaneous lesions in aging FVB females. Prolactin-secreting pituitary proliferations play a significant role in mouse mammary tumorigenesis generally producing adenosquamous carcinomas. Since genetically engineered FVB mice are frequently used to study mammary tumor biology, we have examined a cohort of 64 aging wild-type FVB/N females to establish the prevalence and the nature of spontaneous mammary and pituitary tumors. Tissues from mammary and pituitary glands were studied by histopathology and immunohistochemistry. Of the 64 examined mice, 20 had pituitary tumors and 20 had mammary tumors. Mammary and pituitary tumors were associated in 17 mice. All pituitary tumors were prolactin-positive by immunohistochemistry and classified as prolactinomas. Fourteen mammary tumors, including 12 cases with and 2 without concurrent prolactinomas, were adenocarcinomas with different combinations of epithelial growth patterns. Five mice with prolactinomas had mammary tumors characterized by the epithelial-mesenchymal transition (EMT) phenotype. Estrogen receptor alpha (ERalpha)-positivity was observed for 14 of the 18 mammary tumors tested, including both adenocarcinomas with nuclear immunoreactivity and EMT-phenotype tumors with both nuclear and cytoplasmic immunoreactivity. No immunoreactivity for the progesterone receptor was observed. This study confirms that spontaneous prolactinomas and mammary tumors are both common and significantly associated lesions in FVB mice. Parity and age represented risk factors for the development of these tumors. Compared with previous reports, prolactinoma-associated mammary tumors displayed a broader morphologic spectrum, including cases with the EMT phenotype. The elevated number of prolactinoma-associated and ERalpha-positive mammary tumors opens intriguing possibilities concerning the role of ERalpha cytoplasmic localization during EMT tumorigenesis.

Diagnosis of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop

OBJECTIVE

Asymptomatic primary hyperparathyroidism (PHPT) is a common clinical problem. The purpose of this report is to guide the use of diagnostic tests for this condition in clinical practice.

PARTICIPANTS

Interested professional societies selected a representative for the consensus committee and provided funding for a one-day meeting. A subgroup of this committee set the program and developed key questions for review. Consensus was established at a closed meeting that followed. The conclusions were then circulated to the participating professional societies.

EVIDENCE

Each question was addressed by a relevant literature search (on PubMed), and the data were presented for discussion at the group meeting.

CONSENSUS PROCESS

Consensus was achieved by a group meeting. Statements were prepared by all authors, with comments relating to accuracy from the diagnosis subgroup and by representatives from the participating professional societies.

CONCLUSIONS

We conclude that: 1) reference ranges should be established for serum PTH in vitamin D-replete healthy individuals; 2) second- and third-generation PTH assays are both helpful in the diagnosis of PHPT; 3) DNA sequence testing can be useful in familial hyperparathyroidism or hypercalcemia; 4) normocalcemic PHPT is a variant of the more common presentation of PHPT with hypercalcemia; 5) serum 25-hydroxyvitamin D levels should be measured and, if vitamin D insufficiency is present, it should be treated as part of any management course; and 6) the estimated glomerular filtration rate should be used to determine the level of kidney function in PHPT: an estimated glomerular filtration rate of less than 60 ml/min.1.73 m2 should be a benchmark for decisions about surgery in established asymptomatic PHPT.

Interactions of like-charged rods at low temperatures: analytical theory vs. simulations

We investigate a system consisting of two like-charged infinitely long rods and neutralizing counterions at low temperatures, using both analytic theory and simulations. With some reasonable approximations we can analytically solve for several ground-state structures of the model, starting with states where all counterions are lined up in the gap between the rods, over planar configurations, where the counterions are divided up into a fraction which resides between the rods, and counterions which are located on the outer surfaces, up to configurations which cover the full rod surfaces. Using parallel tempering simulations, we are able to study the system over a wide range of temperatures. At low temperatures we find good agreement with our T = 0 results. At higher temperatures, the strong coupling (SC) theory delivers qualitatively better results. We furthermore demonstrate that for the SC theory and our ground-state approximations to yield quantitative agreement, three parameters are required to be large, the strong-coupling parameter, the Rouzina-Bloomfield parameter, and the ratio of the average distance of the counterions to the radius of the rods. In the case of the latter ratio being small, our T = 0 results show better agreement with the simulation data at very low temperatures.

Detection of HLA antigens on progeria syndrome fibroblasts

It has been suggested that cultured skin fibroblasts derived from patients with progeria, a premature aging syndrome, have absent or markedly reduced HLA antigen expression, thus implicating a possible immunological role in the pathogenesis of this disease. An analysis of HLA expression in nine progeric fibroblast strains and related familial strains is reported. Normal HLA expression and inheritance were found. No significant association between HLA type and progeria was detected. Therefore, we conclude an abnormality of HLA expression is unlikely to be an underlying defect in progeria.

Mutational analysis of CDKN1B, a candidate tumor-suppressor gene, in refractory secondary/tertiary hyperparathyroidism

Most patients with refractory secondary/tertiary hyperparathyroidism have monoclonal parathyroid tumors. Inactivating mutations of CDKN1B, encoding the p27 cyclin-dependent kinase inhibitor, were reported to cause hyperparathyroidism in a multiple endocrine neoplasia type 1-like syndrome. Further, there was decreased expression of CDKN1B in parathyroid tumors of patients with chronic kidney disease. We sequenced the entire coding region and splice sites of CDKN1B in 50 parathyroid tumors from 35 patients to see if inactivating mutations could cause monoclonal tumorigenesis in refractory secondary/tertiary hyperparathyroidism. No frameshift, nonsense, or other clearly inactivating mutations were found, nor was there evidence of homozygous deletion or loss of heterozygosity. The absence of clonal inactivating mutations suggests that CDKN1B is not a classical tumor-suppressor gene in secondary/tertiary parathyroid tumors.

The reliability of nipple aspirate and ductal lavage in women at increased risk for breast cancer--a potential tool for breast cancer risk assessment and biomarker evaluation

PURPOSE

Ductal lavage, a technique used to sample epithelial cells from breast ducts, has potential use in risk assessment and biomarker evaluation among women at increased risk for breast cancer. However, little is known about the reliability of the procedure.

METHODS

We evaluated the reliability of nipple aspirate (NAF) and ductal lavage at two time points 6 months apart in women at increased risk for breast cancer. Eligible women had a 5-year Gail risk >or=1.66% or lifetime risk of >20%, and/or a family history or personal history of breast cancer. All ducts that produced NAF were cannulated. The kappa statistic was used to evaluate reliability of NAF production, cellular yield, and cytologic diagnosis.

RESULTS

Sixty-nine women (mean age, 47 years) were enrolled over 35 months. Forty-seven returned for a second visit. At baseline, 65% of premenopausal and 41% of postmenopausal women produced NAF (P = 0.05), of which 72% underwent successful lavage of at least one duct. Samples of inadequate cellular material for diagnosis were significantly more likely in postmenopausal women than in premenopausal women (P = 0.04). Of the women who returned for a second visit, 18 of 24 who produced NAF had at least one duct successfully cannulated. Twenty-four ducts in 14 women were lavaged twice. Among these ducts, cellular yield for the two time points was inconsistent (kappa = 0.33 +/- 0.13), and only fair cytologic agreement was observed (kappa = 0.32 +/- 0.15). Ductal lavage was associated with moderate discomfort.

CONCLUSION

Currently, the use of ductal lavage is limited by technical challenges in duct cannulation, inconsistent NAF production, a high rate of inadequate cellular material for diagnosis, fair cytologic reproducibility, and low participant return rates.