[A case of Carney complex]

HISTORY AND CLINICAL FINDINGS

For some months a 57-year-old woman had noted increasing shortness of breath, associated in the last few weeks with undirected vertigo and several brief periods of lost consciousness. She was finally admitted because of additional central facial paresis. On auscultation a high-frequency systolic murmur was heard over the apex and a discrete diastolic murmur over Erb's point. There were numerous facial freckles and three cutaneous myxomas.

INVESTIGATIONS

Echocardiography revealed irregular tumours throughout the left atrium and a large broad-based one prolapsing through the mitrale valve in diastole. Computed tomography demonstrated a 6 x 6 cm tumour in the left lower abdomen, probably arising from the left ovary, and a second 3 x 3 cm presacral tumour.

TREATMENT AND COURSE

At cardiac surgery four tumours were found in the left atrium and resected: histologically they were benign myxomas. Removal required extensive resection in the area of the interatrial septum and the atrial wall, resulting in 2 degrees AV block for which a VDD pacemaker was implanted.

CONCLUSION

Atrial myxomas may be the cardinal sign of the Carney Complex, an autosomal dominant syndrome with cutaneous myxomas, myxoid abdominal tumours, hormone-producing tumours in the testicles, adrenal cortex or hypophysis, schwannoma as well as lentigines. For this reason, further tumours should be looked for if freckles and/or cutaneous tumours are found in association with an atrial myxoma. The patient and family should be informed about the genetic aspects.

[Allopurinol in treatment of cutaneous sarcoidosis]

Several reports more than ten years ago provided evidence that allopurinol may be effective for cutaneous sarcoidosis. We therefore treated two patients with histologically confirmed scar sarcoidosis and two with nodular sarcoidosis. A daily dosage of 300 mg allopurinol was given over a period of 4-7 months as single drug therapy. In both patients with scar sarcoidosis, the skin manifestations completely regressed while in the patients with nodular sarcoidosis there was significant improvement. The concomittant pulmonary involvement in two patients was unpredictable, in one patient improved while the other was deteriorated, The mode of action is still unclear but because of the positive results and the low rate of side effects, allopurinol seems a reasonable agent for treating cutaneous sarcoidosis.

[Minocycline-induced hyperpigmentation]

A common adverse effect of minocycline therapy is cutaneous pigmentation. We describe two patients who presented with hyperpigmentation caused by minocycline. One patient, aged 54 years, had taken minocycline due to lung silicosis for 3 years before black pigmentation of the face occurred. The other 49 year-old patient developed grey-black hyperpigmentation on both lower legs after a 6-month therapy with minocycline for folliculitis. This patient was treated with the Q-switched ruby laser and the pigmentation resolved in the treated area. The different clinical and histological forms of minocycline-induced hyperpigmentation are discussed.

Overexpression of Lerk-5/Eplg5 messenger RNA: a novel marker for increased tumorigenicity and metastatic potential in human malignant melanomas

The Lerks, ligands of eph-related receptor tyrosine kinases, are a rapidly expanding family of genes thought to play an important role in the development and oncogenesis of various tissues. However, very little experimental evidence supports this hypothesis. Using RNA fingerprinting, we detected increased expression of Lerk-5 mRNA in human melanocytes as a response to the tumor-promoting drug 12-O-tetradecanoylphorbol-13-acetate, which suggests a possible role of the Lerks in melanoma tumorigenesis and progression. Therefore, we studied Lerk-5 mRNA expression in various melanoma cell lines and tissues of melanocytic tumors by semiquantitative reverse transcription-PCR. Modest expression of Lerk-5 mRNA was found in two melanoma cell lines derived from early primary tumors (WM35 and WM1645B); two metastatic cell lines tested showed a 3.9-fold increased transcript abundance when compared to the primary cell lines (RPMI-7951 and SK-Mel5). Progeny of a melanoma cell line with very low Lerk-5 mRNA abundance (WM35) showed a 5-fold increase in Lerk-5 mRNA expression when it was selected for higher tumorigenicity and multicytokine resistance by passaging in nude mice or repeated high-dose UVB irradiation. Consistent with these experimental data, we found high levels of Lerk-5 mRNA expression in advanced primary malignant melanomas and metastases (n = 22) but significantly lower or undetectable mRNA expression in benign melanocytic nevi (n = 9; P < 0.001). We conclude that increased Lerk-5 expression possibly reflects or induces an increased potential of growth, tumorigenicity, and metastatic abilities in human melanomas. This makes the yet to be elucidated eph-related receptor tyrosine kinase/Lerk signaling system a potential new source for molecular markers as well as a target for new therapies.

[Treatment of uterine leiomyoma with depot leuprorelin acetate (Enantone-Gyn monthly depot). Effect on leiomyoma volume and operability. German Leuprorelin Study Group]

In an open, non-comparative clinical phase IV multicentre study the efficacy and safety of the GnRH agonist leuprorelin acetate depot (LAD) for patients with at least one symptomatic uterine leiomyoma was assessed. 144 premenopausal patients were enrolled and treated with up to six injections of 3.75 mg LAD/month subcutaneously prior to surgical intervention, e.g. either hysterectomy or myoma enucleation. Due to a profound suppression of serum-estradiol levels to castration range (< or = 30 pg/ml) an average volume reduction of all myomas from 86.6 +/- 101.3 ml to 38.5 +/- 63.5 ml became obvious for 90% of all patients. In parallel a significant shrinkage of uterine volume was observed. At baseline 43 patients were planned to undergo a hysterectomy. 29 of these 43 patients could be switched after therapy with LAD to an enucleation as appropriate surgical treatment. In addition a number of patients with scheduled myoma enucleations which were planned to be performed via laparotomy could definitely be operated laparoscopically. Treatment was generally well tolerated. Most of the observed side effects were related to hypoestrogenism. The results of this study have shown that medical pretreatment for patients with uterine fibroids with LAD prior to surgical intervention is an effective measure to improve operability and could lead for several patients to minimal invasive surgery.

[p16(INK4A)/CDKN2--the "melanoma gene"? Status of research and outlook]

The gene of the cyclin-dependent kinase 4 (CDK4)-inhibitor p16INK4A (CDKN2/MTS1) has been proposed as a candidate for a tumor-suppressor gene located on chromosome 9p21, a frequently deleted region in a series of human cancers including malignant melanoma. An increasing and sometimes conflicting body of data has accumulated regarding the frequency of homozygous deletions and mutations as well as the importance of p16INK4A in malignant melanoma. The purpose of this review is therefore to summarize the current knowledge on p16INK4A and to discuss its biologic significance in the pathogenesis of melanocytic tumors.

[Clinical and flow cytometry outcome of improved photopheresis methods in dermatologic patients]

In photopheresis, 8-methoxypsoralen (8-MOP) is added to a mononuclear cell concentrate and then activated by UVA light, thus forming covalent bonds between DNA strands. Infusion of these modified cells that are not able to replicate any more seems to lead to the elimination of pathogenic T-cell clones and clinical improvement in patients suffering from cutaneous T-cell lymphoma, graft versus host reactions, and various autoimmune diseases. The original method described by Edelson et al. (1987) was improved by the following modifications proposed by Andreu et al. (1994): i) by using a cell separator (COBE Spectra) that produced purer concentrate with less red blood cells absorbing UVA light. ii) By applying 8-MOP directly into the collection bag, the drug side effects due to the oral application of the thousandfold dose and varying serum levels were avoided. iii) By irradiating the concentrate after collection, all cells received the same irradiation dosage. We treated 2 men with cutaneous T-cell lymphoma, 2 women with atopic eczema and 1 man with severe pustular psoriasis with overall 123 extracorporeal photochemotherapy (ECPC) sessions. In addition to routine laboratory analysis, detailed characterization of lymphocyte subpopulations was carried out by flow cytometry to differentiate T-helper and T-suppressor cells and their activation (HLA-DR, CD 25), B, NK cells, and monocyte subpopulations. The following mediators soluble were analyzed as well: Il-2-receptor and as indicators of acute phase reaction Il-8, neopterin and Il-1 beta. We observed a good clinical improvement independent of no significant trend in the immunological phenotype of circulating blood leukocytes. Our results suggest that ECPC effects are not mediated by a systemic immune response or alternatively are not measured in the blood compartment.

[Eruptive melanocytic nevi after chemotherapy]

BACKGROUND

Induction of melanocytic naevi by chemotherapy in children is reported in the literature. The reason for this phenomenon is not known yet.

HISTORY AND CLINICAL FINDINGS

We present a 6-year-old girl who fell ill with acute lymphoblastic leukemia at the age of 2 years. After a combined chemotherapeutic treatment for 2 years followed by complete remission of leukemia, many (> 100) small pigmented naevi appeared over the whole body. The naevi did not show features suggestive of dysplasia.

CONCLUSIONS

Patients with excess numbers of melanocytic naevi constitute a risk group for malignant melanoma, therefore periodic skin examination is recommended.

RNA fingerprinting displays UVB-specific disruption of transcriptional control in human melanocytes

In mammalian cells, UV induces a limited set of early transcribed genes, which overlaps with the set of genes induced by tumor promoting drugs such as 12-O-tetradecanoyl phorbol-13-acetate (TPA). Among these are genes for transcription factors, the activation of which leads to complex secondary changes in expression of multiple target genes. How these delayed pleiotropic UV effects on transcription may contribute to initiation of melanoma skin cancer is poorly understood. We analyzed changes in the relative abundances of 1900 transcripts in newborn human melanocytes 8 h after treatment with UVB, TPA, and cycloheximide in all combinations, using RNA arbitrarily primed PCR for differential display. The relative abundances of 205 transcripts (11% of all transcripts surveyed) were altered by one or more of the treatment combinations. Fourteen of the 77 genes up-regulated by TPA were also up-regulated by UVB, but 60 of the TPA up-regulated genes were down-regulated by UVB, indicating both intersecting and independent signal transduction pathways for UVB and TPA. A number of UVB and TPA target genes were identified by cDNA cloning. Consistent with UVB induction of a partly transformed phenotype in mammalian cells, UVB antagonized the TPA-inducible expression of tumor-suppressive tropomyosin 3 mRNA. In addition, UVB may impair mitochondrial functioning and induce oxidative stress by strong down-regulation of mitochondrial transcription. Finally, increased expression of the dihydropteridine reductase gene, a major regulator of the cellular tetrahydrobiopterin pool, was linked to the UV pathway.

Melanoma-inhibiting activity, a novel serum marker for progression of malignant melanoma

Melanoma-inhibiting activity (MIA) was isolated previously as a small soluble protein secreted from malignant melanoma cell lines in vitro. In vivo, highly restricted expression patterns in melanocytic tumors were identified. We therefore quantitated serum levels of MIA protein by means of a nonradioactive ELISA and investigated whether MIA provides a clinically useful parameter in patients with malignant melanomas. Here, we report enhanced MIA serum levels in 13 and 23% of patients with stage I and II disease, respectively, and in 100% with stage III or IV disease. Compared with S-100 and soluble intercellular adhesion molecule 1 serum levels in these patients, MIA was the most sensitive marker. Response to therapy in stage IV disease correlated with changes in MIA serum levels. Measuring repeatedly sera of 350 patients with a history of stage I or II melanoma during follow-up, we detected 32 patients developing positive MIA values. At the time of serum analysis, 15 of them had developed metastases, and one presented with metastatic disease 6 months later. In contrast, none of the patients with normal MIA serum levels developed metastases during the follow-up period of 6-12 months. In conclusion, MIA represents a novel serum marker for systemic malignant melanoma revealing the highest sensitivity and specificity among currently available markers. Useful clinical applications include staging of primary melanomas, detection of progression from localized to metastatic disease during follow-up, and monitoring therapy of advanced melanomas.

[Steroid-induced scabies norvegica]

Two patients aged 50 and 84 years presented with generalized itching eczema that has been treated with external and internal steroids for months. Despite therapy, the condition worsened continuously. Examination of skin scrapings revealed numerous mites, so Norwegian scabies was diagnosed. General examinations excluded underlying diseases. Treatment with steroids over months most likely led via immunosuppression to the exacerbation of the disease.

Two-dimensional visualization of liquid layers on transparent walls

A new two-dimensional visualization technique based on laser-induced fluorescence for investigation of liquid-fuel films on transparent walls was applied in an SI engine. For optical access the upper part of the engine cylinder is replaced with a quartz ring. An UV laser beam is coupled into the ring, forcing total reflection at quartz-air interfaces. Because of the similar indices of refraction of quartz and fuel, laser light penetrates into the liquid. The corresponding fluorescence signal visualizes areas where wall film is present. It is shown that the technique is an excellent tool for investigation of wall-film development in combustion engines.

p53-protein and Ki-67-antigen expression are both reliable biomarkers of prognosis in thick stage I nodular melanomas of the skin

The maximum tumour thickness is the most important prognostic factor in malignant melanomas of the skin. However, the clinical outcome of thick nodular melanomas remains unpredictable. Therefore, we investigated possible prognostic markers in this subset of melanomas. From a melanoma data base, 12 patients with thick (> 3 mm) stage I nodular melanomas of the skin were identified, who were still without signs of progression after five years of follow-up. These tumours were compared to randomly selected series of 12 cases, who did not survive the first five years after removal of the tumours. We performed immunostaining for the p53-protein and the proliferation associated Ki-67-antigen. For quantification of immunostaining the tumours were entirely scanned. In addition, all tumours were investigated for any differences with conventionally applied prognostic features: the tumour thickness: the level of invasion; the prognostic index (tumour thickness multiplied by mitotic count); and the mean volume-weighted mean nuclear volume. We demonstrated significant differences between survivors and non-survivors exclusively in respect of the staining indices for p53 and Ki-67 (P < 0.03 and 0.02, respectively). With both antibodies the tumours of survivors showed lower counts as compared to non-survivors survivors. However, within both groups we found no significant correlations between the p53- and Ki-67-staining results. We conclude that immunostaining for p53-protein and Ki-67-antigen is helpful to identify individuals with thick nodular melanomas who are at risk of metastatic disease.

[Elastolysis of the mid-dermis and annular elastolytic giant cell granuloma: different stages in the clinical spectrum of dermal elastolysis? Case report and review of the literature]

In recent years there has been increased interest in diseases showing degeneration of dermal elastic tissue. Mid dermal elastolysis is a rare dermatosis, which is histopathologically characterized by mid dermal loss of elastic tissue. Both papular and patchy forms, as well as inflammatory and non-inflammatory variants, have been described. A 70-year-old woman had annular patches. In their center the clinical and histopathological findings suggested non-inflammatory mid dermal elastolysis whereas the red and slightly elevated margins showed clinical and histopathological features of annular elastolytic giant cell granuloma. Based on our case and a review of the literature, we discuss the differential diagnosis of dermal elastolysis and hypothesize that a number of lesions histologically showing mid dermal elastolysis may represent different inflammatory or non-inflammatory stages of one disease which may overlap or change from one form into another.

Ex vivo quality-switched ruby laser irradiation of cutaneous melanocytic lesions: persistence of S-100-, HMB-45- and Masson-positive cells

AIM

To assess changes in human pigmented melanocytic skin lesions after quality-switched ruby laser (QSRL) irradiation.

METHODS

Investigations were performed ex vivo on 21 melanocytic pigmented lesions (10 nevus cell nevi, 2 pigmented dermal nevi, 4 congenital nevi, 3 lentigo maligna lesions, 2 superficial spreading melanomas) immediately after surgical excision. A total of 42 biopsy specimens was obtained for comparative investigations before and after QSRL impact. Electron microscopy was performed in 3 lesions.

RESULTS

Hematoxylin-eosin stainings showed selective vacuolization of pigmented structures (melanin granules, melanophages, pigmented melanocytes, pigmented keratinocytes) immediately after QSRL irradiation due to selective photothermolysis. Cryosections stained with nitroblue tetrazolium chloride featured minimal thermal damage of the surrounding tissue proving the high selectivity of QSRL light. Immunohistochemical techniques employing anti-S-100, HMB-45 antimelanoma antibody and Fontana-Masson staining revealed selective photothermal damage (vacuolization) of basal melanin granules, pigmented basal melanocytes and epidermal keratinocytes, as well as pigmented superficial dermal melanocytes. Deeper melanocytes and nests of nonpigmented melanocytes persisted unaltered and retained their S-100 and HMB-45 positivity. Masson's staining revealed persisting dermal melanophages. Electron microscopy showed specific damage of both keratinocytes and melanocytes with numerous melanosomes and confirmed the light-microscopic findings. Deeper dermal melanocytes containing only few melanin granules remained unaltered.

CONCLUSION

In pigmented lesions extending into the dermis, deeper pigmented melanocytic cells (nevus cells) persist throughout a single course of QSRL exposure. Nonpigmented melanocytic cells remain totally unaffected by QSRL irradiation. Therefore QSRL therapy of melanocytic nevi and congenital nevi should only be performed in controlled studies. Long-term results have to be evaluated before recommendations can be given.