Immunologic mechanisms in UV radiation carcinogenesis

UV exposure causes energy trade-offs leading to increased chytrid fungus susceptibility in green tree frog larvae

Levels of ultraviolet (UV) radiation have increased in many parts of the world due to the anthropogenic destruction of the ozone layer. UV radiation is a potent immunosuppressant and can increase the susceptibility of animal hosts to pathogens. UV radiation can directly alter immune function via immunosuppression and photoimmunotolerance; however, UV may also influence pathogen defences by affecting the distribution of energy resources among competing physiological processes. Both defence against UV damage and repair of incurred damage, as well as the maintenance of immune defences and responding to an immune challenge, are energetically expensive. These competing demands for finite energy resources could trade off against one another, resulting in sub-optimal performance in one or both processes. We examined the potential for a disease-related energy trade-off in green tree frog (Litoria caerulea) larvae. Larvae were reared under high- or low-UV conditions for 12 weeks during which time we measured growth rates, metabolic rate and susceptibility to the amphibian fungal pathogen, Batrachochytrium dendrobatidis (Bd). We found that larvae exposed to high levels of UV radiation had higher rates of energy expenditure than those exposed to low UV levels; however, UV exposure did not affect growth rates or developmental timings. Larvae exposed to high UV radiation also experienced greater Bd infection rates and carried a higher infection burden than those not exposed to elevated UV radiation. We propose that the increased energetic costs of responding to UV radiation were traded off against immune defences to protect larval growth rates. These findings have important implications for the aetiology of some Bd-associated amphibian declines, particularly in montane environments where Bd infections are most severe and where UV levels are highest.

Dynamic Culture Systems and 3D Interfaces Models for Cancer Drugs Testing

The mass use of biological agents for pharmaceutical purposes started with the development and distribution of vaccines, followed by the industrial production of antibiotics. The use of dynamic systems, such as bioreactors, had been already applied in the food industry in fermentation processes and started being used for the development of pharmaceutical agents from this point on. In the last decades, the use of bioreactors and microfluidic systems has been expanded in different fields. The emergence of the tissue engineering led to the development of in vitro models cultured in dynamic systems. This is particularly relevant considering the urgent reduction of the total dependence on animal disease models that is undermining the development of novel drugs, using alternatively human-based models to make the drug discovery process more reliable. The failure out coming from animal models has been more prevalent in certain types of cancer, such as glioblastoma multiform and in high-grade metastatic cancers like bone metastasis of breast or prostatic cancer. The difficulty in obtaining novel drugs for these purposes is mostly linked to the barriers around the tumors, which these bioactive molecules have to overcome to become effective. For that reason, the individualized study of each interface is paramount and is only realistic once applying human-based samples (e.g. cells or tissues) in three-dimensions for in vitro modeling under dynamic conditions. In this chapter, the most recent approaches to model these interfaces in 3D systems will be explored, highlighting their major contributions to the field. In this section, these systems' impact on increased knowledge in relevant aspects of cancer aggressiveness as invasive or motile cellular capacity, or even resistance to chemotherapeutic agents will have particular focus. The last section of this chapter will focus on the integration of the tumor interfaces in dynamic systems, particularly its application on high-throughput drug screening. The industrial translation of such platforms will be discussed, as well as the main upcoming challenges and future perspectives.

A cross-sectional analysis of skin cancer risk in patients receiving narrow-band ultraviolet B phototherapy: an evaluation of 100 patients

Narrow-band ultraviolet B (NB-UVB) phototherapy is an effective and widely used treatment modality for psoriasis and other inflammatory skin diseases. The carcinogenic effect of PUVA treatment has been investigated extensively, but there is very scarce data about the role of NB-UVB in the development of skin cancer. The aim of this study was to investigate the potential carcinogenic risk of NB-UVB therapy in various skin disorders. In this cross-sectional study, we evaluated 100 patients who had received whole-body NB-UVB treatment and 100 age- and sex-matched controls. Phototherapy unit database was used to identify patients. A total of 100 patients (53 males and 47 females) treated with NB-UVB and 100 controls were included in the study. The patient group revealed no cases of melanoma or non-melanoma skin cancer, while ten of them were found to have solar lentigines. Basal cell carcinoma in a patient and nine patients with solar lentigines were detected in the control group. There was no statistically significant difference between patient and control groups in terms of skin cancer and solar lentigines. This study does not provide evidence for an increased skin cancer risk in patients treated with NB-UVB phototherapy. However, we have detected the occurence of 10 cases of solar lentigines. Still, definitive prospective longitudinal studies with a greater number of patients and prolonged follow-up are required to specifically address skin cancer risk in relation to NB-UVB phototherapy.

Exploring the link between ultraviolet B radiation and immune function in amphibians: implications for emerging infectious diseases

Amphibian populations the world over are under threat of extinction, with as many as 40% of assessed species listed as threatened under IUCN Red List criteria (a significantly higher proportion than other vertebrate group). Amongst the key threats to amphibian species is the emergence of novel infectious diseases, which have been implicated in the catastrophic amphibian population declines and extinctions seen in many parts of the world. The recent emergence of these diseases coincides with increased ambient levels of ultraviolet B radiation (UVBR) due to anthropogenic thinning of the Earth's protective ozone layer, raising questions about potential interactions between UVBR exposure and disease in amphibians. While reasonably well documented in other vertebrate groups (particularly mammals), the immunosuppressive capacity of UVBR and the potential for it to influence disease outcomes has been largely overlooked in amphibians. Herein, we review the evidence for UVBR-associated immune system disruption in amphibians and identify a number of direct and indirect pathways through which UVBR may influence immune function and disease susceptibility in amphibians. By exploring the physiological mechanisms through which UVBR may affect host immune function, we demonstrate how ambient UVBR could increase amphibian susceptibility to disease. We conclude by discussing the potential implications of elevated UVBR for inter and intraspecific differences in disease dynamics and discuss how future research in this field may be directed to improve our understanding of the role that UVBR plays in amphibian immune function.

Mouse models in oncoimmunology

Fundamental cancer research and the development of efficacious antineoplastic treatments both rely on experimental systems in which the relationship between malignant cells and immune cells can be studied. Mouse models of transplantable, carcinogen-induced or genetically engineered malignancies - each with their specific advantages and difficulties - have laid the foundations of oncoimmunology. These models have guided the immunosurveillance theory that postulates that evasion from immune control is an essential feature of cancer, the concept that the long-term effects of conventional cancer treatments mostly rely on the reinstatement of anticancer immune responses and the preclinical development of immunotherapies, including currently approved immune checkpoint blockers. Specific aspects of pharmacological development, as well as attempts to personalize cancer treatments using patient-derived xenografts, require the development of mouse models in which murine genes and cells are replaced with their human equivalents. Such 'humanized' mouse models are being progressively refined to characterize the leukocyte subpopulations that belong to the innate and acquired arms of the immune system as they infiltrate human cancers that are subjected to experimental therapies. We surmise that the ever-advancing refinement of murine preclinical models will accelerate the pace of therapeutic optimization in patients.

Oral intake of heat-killed cells of Lactococcus lactis strain H61 promotes skin health in women

We conducted a double-blind, placebo-controlled trial to evaluate the effect of heat-killed cells of Lactococcus lactis strain H61 on various skin properties of Japanese women. Volunteers (age 31–62 years) were randomly assigned to receive test food with or without 60 mg of heat-killed strain H61 (fifteen women in each group; H61 and control groups, respectively) daily for 8 weeks. Results were analysed for three age categories (30s, 40s and 50–60s). Compared with that at week 0, skin hydration at the inner forearm at weeks 4 and 8 decreased in all volunteers (except those in their 50–60s) because of the environmental change from autumn to winter. The oldest H61 group maintained skin hydration at the inner forearm throughout the study. Skin elasticity and melanin content in the cheek decreased and sebum content increased throughout the test period due to seasonal environmental change, regardless of age or H61 treatment. Self-evaluation scores for apparent hair follicles and dryness of the throat at week 8 were higher in the overall H61 group than in the combined placebo group. The 30s H61 group noted marked improvements in self-surveyed skin elasticity at week 8 compared with at week 0 and with the placebo group at week 8. The results of the present study indicate that oral intake of heat-killed cells of L. lactis strain H61 can improve some skin properties and body characteristics in women. This strain would probably be useful in increasing the quality of life in an ageing population.

Ultraviolet light and resistance to infectious diseases

Exposure to ultraviolet (UV) radiation, as in sunlight, can modulate immune responses in animals and humans. This immunomodulation can lead to positive health effects especially with respect to certain autoimmune diseases and allergies. However, UV-induced immunomodulation has also been shown to be deleterious. Experimental animal studies have revealed that UV exposure can impair the resistance to many infectious agents, such as bacteria, parasites, viruses, and fungi. Importantly, these effects are not restricted to skin-associated infections, but also concern systemic infections. UV radiation induces a multistep process, locally in the skin as well as systemically, that ultimately leads to immunosuppression. The first event is the absorption of "UV" photons by chromophores, or so-called photoreceptors, such as DNA and urocanic acid (UCA) in the upper cell layers of the skin. Upon absorption of UV radiation, trans-UCA isomerizes to the cis-isomer. Cis-UCA is likely the most important mediator of UV-induced immunosuppression, as this compound has been shown to modulate the induction of contact type hypersensitivity and delayed type hypersensitivity, allograft rejection, and the functions of monocytes and T-lymphocytes as well as natural killer cells. The real consequences of UV-induced immunomodulation on resistance to infectious diseases for humans are not fully known. Risk estimations have been performed through extrapolation of animal data, obtained from infection models, to the human situation. This estimation indicated that UV doses relevant to outdoor exposure can impair the human immune system sufficiently to have effects on resistance to infections, but also indicated that human data are necessary to further quantify and validate this risk estimation. Further information has been obtained from vaccination studies in human volunteers as ethical reasons prohibit studies with infectious agents. Studies in mice and human volunteers on the effects of prior UVB exposure on hepatitis B vaccination responses revealed suppressed cellular and humoral immune responses in mice but not in human volunteers. However, subgroups within the performed human volunteer study made by determination of cytokine polymorphisms or UVB-induced mediators, revealed that some individuals have suppressed hepatitis B vaccination responses after UVB exposure. Thus, it might be concluded that the human immune system can be affected by UVB exposure, and decreased resistance to infectious diseases can be expected after sun exposure.

Introducing Cichorium Pumilum as a potential therapeutical agent against drug-induced benign breast tumor in rats

Cichorium Pumilum (chicory) is could be a promising cancer treatment in which a photosensitizing drug concentrates in benign tumor cells and activated by quanta at certain wavelength. Such activated extracts could lead to cell death and tumor ablation. Previous studies have shown that Cichorium Pumilum (chicory) contains photosensitive compounds such as cichoriin, anthocyanins, lactucin, and Lactucopicrin. In the present study, the protective effect of sun light-activated Cichorium against the dimethylbenz[a]anthracene (DMBA) induced benign breast tumors to female Sprague-Dawley rats was investigated. Chicory's extract has significantly increase P.carbonyl (PC) and malondialdehyde (MDA) and decreases the hepatic levels of total antioxidant capacity (TAC) and superoxide dismutase (SOD) in benign breast tumors-induced group compared to control. It also significantly decrease the number of estrogen receptors ER-positive cells in tumor masses. These results suggest that chicory extracts could be used as herbal photosensitizing agent in treating benign breast tumor in rats.

The mechanisms and consequences of ultraviolet-induced immunosuppression in the skin and eye

Ultraviolet radiation (UVR) of the skin results in immune suppression to antigens encountered shortly after the exposure. The pathways leading to the downregulation in immunity are complex, initiated by chromophores located at the surface of the skin and ending with the generation of immunosuppressive mediators and regulatory cells. Ultraviolet-induced immunosuppression can be considered not only as beneficial, such as in preventing chronic inflammatory responses and allergic and automimmune reactions, but it can also be detrimental, such as in the lack of control of skin tumors and infectious diseases. The eye is an immune privileged site through a wide variety of mechanisms that allow selected immune responses without causing inflammation. The role of UVR in altering immune responses in the eye is not clear and is discussed in relation to photokeratitis, herpetic stromal keratitis, and pterygium.

The challenges of UV-induced immunomodulation for children's health

Exposure to solar ultraviolet radiation (UVR) is recognised to have both beneficial and harmful effects on human health. With regard to immune responses, it can lead to suppression of immunity and to the synthesis of vitamin D, a hormone that can alter both innate and adaptive immunity. The consequences in children of such UV-induced changes are considerable: first there are positive outcomes including protection against some photoallergic (for example polymorphic light eruption) and T cell-mediated autoimmune diseases (for example multiple sclerosis) and asthma, and secondly there are negative outcomes including an increased risk of skin cancer (squamous cell carcinoma, basal cell carcinoma and cutaneous malignant melanoma) and less effective control of several infectious diseases. Many uncertainties remain regarding the amount of sun exposure that would provide children with the most effective responses against the variety of immunological challenges that they are likely to experience.

The consequences of UV-induced immunosuppression for human health

Exposure to UV radiation can cause suppression of specific immune responses. The pathways leading to the down-regulation are complex, starting from the absorption of UV photons by chromophores in the skin and ending with local and systemic changes in immune mediators, the generation of T and B regulatory cells and inhibition of effector and memory T cell activation. The consequences for human health are thought to be both beneficial and adverse. The former are illustrated by protection against polymorphic light eruption, and possible protection against T cell-mediated autoimmune diseases and asthma. The latter are illustrated by skin cancer, cutaneous lupus erythematosus and infectious diseases including vaccination. Many outstanding questions remain in this rapidly developing and controversial area, not least what advice to give the general public regarding their sun exposure. While considerable advances have been made in the development of strategies that preserve the health benefits of sunlight exposure and decrease its detrimental effects, further research is required before optimal levels of protection are achieved.

UV-induced immunosuppression and the efficacy of vaccination

Exposure to ultraviolet radiation (UVR) suppresses immunity by complex pathways, initiated by chromophores located in the skin and ending with the generation of specific subsets of T and B regulatory cells. The primary and memory (recall) immune response to a wide variety of antigens, including microorganisms, can be reduced by UVR, leading to the possibility that the efficacy of vaccination could be similarly reduced. A limited number of animal models of vaccination demonstrate that this may indeed be the case. The situation in human subjects has not been rigorously assessed but there are indications from a variety of sources that UVR adversely affects the immune responses to several vaccines. These studies are reviewed and the implications for vaccine administration discussed. As vaccination represents a major public health measure world-wide for the control of an increasing number of common infections, it is important to maximise its efficacy; therefore further evaluation of UVR in the context of vaccination is required and warranted.

Non-melanoma skin cancers in elderly patients

Non-melanoma skin cancers are a common reality worldwide. The principal cause that determines the occurrence of these diseases is the exposition of the sun, which principally causes an alteration in the immune system. Therefore, it is possible that other forms of innate or acquired alterations of the immune system could favor the occurrence of non-melanoma skin cancers. For example, several studies have demonstrated that immunosenescence creates an immunosuppressive state that encourages the development of malignances, and new discoveries have noted the importance of T cells and in particular of T regulatory cells (Treg) and T receptor CD28 in this mechanism. Similar results are obtained analyzing the effect of immunosuppressive drugs. The importance of the immune system and its alteration in the genesis of non-melanoma skin cancers is fundamental for the creation of a new therapeutic and less invasive approach.

Absence of p53-dependent apoptosis leads to UV radiation hypersensitivity, enhanced immunosuppression and cellular senescence

Genotoxic stress triggers the p53 tumor suppressor network to activate cellular responses that lead to cell cycle arrest, DNA repair, apoptosis or senescence. This network functions mainly through transactivation of different downstream targets, including cell cycle inhibitor p21, which is required for short-term cell cycle arrest or long-term cellular senescence, or proapoptotic genes such as p53 upregulated modulator of apoptosis (PUMA) and Noxa. However, the mechanism that switches from cell cycle arrest to apoptosis is still unknown. In this study, we found that mice harboring a hypomorphic mutant p53, R172P, a mutation that abrogates p53-mediated apoptosis while keeping cell cycle control mostly intact, are more susceptible to ultraviolet-B (UVB)-induced skin damage, inflammation and immunosuppression than wild-type mice. p53(R172P) embryonic fibroblasts (MEFs) are hypersensitive to UVB and prematurely senesce after UVB exposure, in stark contrast to wild-type MEFs, which undergo apoptosis. However, these mutant cells are able to repair UV-induced DNA lesions, indicating that the UV hypersensitive phenotype results from the subsequent damage response. Mutant MEFs show an induction of p53 and p21 after UVR, while wild-type MEFs additionally induce PUMA and Noxa. Importantly, p53(R172P) MEFs failed to downregulate anti-apoptotic protein Bcl-2, which has been shown to play an important role in p53-dependent apoptosis. Taken together, these data demonstrate that in the absence of p53-mediated apoptosis, cells undergo cellular senescence to prevent genomic instability. Our results also indicate that p53-dependent apoptosis may play an active role in balancing cellular growth.

Nutritional approach to sun protection: a suggested complement to external strategies

The increasing incidence of skin cancer despite the use of externally applied sun protection strategies, alongside research showing that nutrients reduce photo-oxidative damage, suggest nutritional approaches could play a beneficial role in skin cancer prevention. Penetrating photo-oxidative ultraviolet A radiation reduces skin and blood antioxidants and damages cell components, including DNA. Dietary antioxidant vitamins, minerals, and phytochemicals in addition to n-3 polyunsaturated fatty acids, n-9 monounsaturated fatty acids, and low pro-inflammatory n-6 polyunsaturated fatty acids, have demonstrated protective properties. The presence of these elements in the traditional Greek-style Mediterranean diet may have contributed to the low rates of melanoma in the Mediterranean region despite high levels of solar radiation. This suggests a potentially relevant model for studying dietary/nutritional supplementation for lifelong internal support of sun-protection mechanisms, which could complement external strategies.

Treatments for psoriasis and the risk of malignancy

BACKGROUND

There are multiple therapeutic options for the treatment of moderate to severe psoriasis. The process of choosing among potential treatment options requires both the physician and the patient to weigh the benefits of individual modalities against their potential risks. Traditional systemic therapies for psoriasis, including methotrexate (MTX) and cyclosporine (CsA), have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. With the advent of these novel immunosuppressive therapies, one of the central safety issues surrounding these agents is their potential to increase the risk of malignancy.

OBJECTIVE

Our objective was to review the risk of malignancy associated with therapies for moderate to severe psoriasis, including phototherapy, traditional systemic therapies, and biologic therapies. We reviewed the existing body of literature in order to define the known incidence of malignancy associated with psoralen and ultraviolet A (PUVA), narrowband and broadband ultraviolet B (UVB), MTX, CsA, mycophenolate mofetil (MMF), and biologic therapies, including alefacept, efalizumab, infliximab, etanercept, adalimumab, and ustekinumab.

RESULTS

PUVA, when given long term, is associated with increased risks of cutaneous squamous cell carcinoma and malignant melanoma. Reviews of studies on UVB, both narrowband and broadband, do not indicate any increased risk of nonmelanoma skin cancer or melanoma. The traditional systemic psoriasis therapies-MTX, CsA, and MMF-may be associated with an increased risk of lymphoproliferative disorders during treatment, demonstrated in clinical trials in patients with rheumatoid arthritis and documented in case reports concerning psoriasis patients. The risk of malignancy with biologic therapy is still unclear. However, the majority of studies examining this carcinogenic risk suggest that tumor necrosis factor-alpha inhibitors may cause a slightly increased risk of cancer, including nonmelanoma skin cancer and hematologic malignancies.

LIMITATIONS

The majority of studies cited in this review lack the power and randomization of large clinical trials, as well as the long-term follow-up periods which would further substantiate the hypothetical link between these antipsoriatic treatment regimens and the potential for malignancy. Because of the substantial lack of clinical data, the majority of studies evaluated focus on the treatment of patients with rheumatoid arthritis, which is a systemic inflammatory disorder comparable to psoriasis. Additionally, the increased risk of malignancy associated with psoriasis itself is a confounding factor.

CONCLUSION

Many of the therapies for moderate to severe psoriasis, including PUVA, traditional systemic therapies, and some biologic therapies, may increase the risk of malignancy. Appropriate patient counseling and selection, as well as clinical follow-up, are necessary to maximize safety with these agents. Further long-term study is necessary to more precisely quantify the risks associated with biologic therapies.

The adaptive immune response to sporadic cancer

Most of the current experimental cancer models do not reflect the pathophysiology of real-life cancer. Cancer usually occurs sporadically and is clonal in origin. Between tumor initiation and progression, clinically unapparent pre-malignant cells may persist for years or decades in humans. Recently, mouse models of sporadic cancer have been developed. The mouse germ-line can be engineered with high precision so that defined genes can be switched on and off in the adult organism in a targeted manner. Analysis of the immune response against sporadic tumors requires the knowledge of a tumor antigen. Ideally, a silent oncogene, for which the mice are not tolerant, is stochastically activated in individual cells. This approach offers the opportunity to analyze the adaptive immune response throughout the long process of malignant transformation and most closely resembles cancer in humans. In such a model with the highly immunogenic SV40 large T antigen as a dormant oncogene, we discovered that sporadic cancer is recognized by the adaptive immune system at the pre-malignant stage, concomitant with the induction of tumor antigen-specific tolerance. These results demonstrated that even highly immunogenic sporadic tumors are unable to induce functional cytotoxic T lymphocytes. Based on this model, we conclude that immunosurveillance plays little or no role against sporadic cancer and that tumors must not escape immune recognition or destruction.

UV Light and Its Interaction with Cutaneous Receptors

Phototherapy (UV-A and UV-B) has become one of the most commonly used modalities for the treatment of a variety of skin diseases, although the action mechanisms have not been fully understood. Inhibition of DNA synthesis by UV radiation may be one of the therapeutic effects in proliferating skin diseases; however, phototherapy is also used for the treatment of allergic or autoimmune diseases.

Immunosuppression in phototherapy

The successful use of phototherapy, especially psoralen plus UVA (PUVA) therapy, in the treatment of a variety of skin diseases is well known. Because the pathology of diseases such as vitiligo, alopecia and lichen planus is thought to involve immune mechanisms, the beneficial effect of PUVA may be due to immunosuppression. PUVA treatment can induce suppression in two ways. In the first (local suppression) psoralen is applied topically, the skin is irradiated with UVA and the contact allergen is applied directly to the irradiated skin. The induction of contact hypersensitivity (CHS) is suppressed and suppressor cells are found in the spleens of treated animals. Systemic suppression results from the injection of psoralen followed by exposure to UVA. The contact allergen is then applied at a distant non-irradiated site. CHS is suppressed and antigen-specific suppressor cells are found in the spleens of treated mice. The ability to induce specific immunosuppression may provide novel methods of inhibiting unwanted immune responses. We have demonstrated that graft rejection and the induction of graft-versus-host disease can be suppressed in an antigen-specific manner by UV radiation. Thus phototherapy may provide promising new treatments for suppressing graft rejection and perhaps may be beneficial in the treatment of autoimmune disease and allergic reactions.

Protective effect of the isoflavone equol against DNA damage induced by ultraviolet radiation to hairless mouse skin

Equol, an isoflavonoid metabolite produced from the dietary isoflavone daidzein by the gut microflora in mammals, has been found to protect not only against ultraviolet (UV) radiation-induced cutaneous inflammation and photoimmune suppression, but also have anti-photocarcinogenic properties in mice. Because the state of DNA damage has been correlated with suppression of the immune system and photocarcinogenesis, we have therefore examined the potential of equol to offer protection from solar-simulated UV (SSUV) radiation-induced DNA damage in hairless mice by the immunohistochemical approach using monoclonal antibody specific for cyclobutane pyrimidine dimers (CPDs; H3 antibody). Topical application of 20 µM equol lotion, which was applied both before and after SSUV significantly reduced the number of CPDs. This reduction was evident immediately after SSUV exposure, at 1 h after exposure, and at 24 h after exposure, revealing 54%, 50%, and 26% reduction in CPDs, respectively. When the same concentration was applied for 5 consecutive days after SSUV exposure, there was no significant difference in the reduction of CPDs immediately after SSUV irradiation or at 1 hour afterwards, but there were significant reductions of 23% and 42% at 24 and 48 h after SSUV exposure, respectively. Despite apparently reducing the number of CPDs post-SSUV, topically applied equol did not appear to increase the rate of dimer removal. To conclude, equol applied topically prior to SSUV irradiation offers protection against CPD formation in hairless mice, possibly by acting as a suncreen and thus inhibiting DNA photodamage.

Mast cells in photodamaged skin: what is their role in skin cancer?

In this review, changes that we have observed in the prevalence of mast cells in human sun-exposed skin, and their potential immunoregulatory role, are discussed. More specifically, in a study of Australian volunteers, the prevalence of dermal mast cells was increased in back-of-hand skin, anecdotally the most sun-exposed site of the body, but not in skin from buttock, inner arm or shoulder. By histological analysis of back-of-hand skin, there was a significant correlation between dermal mast cell prevalence and elastin content suggesting increased mast cell prevalence with photodamage. We hypothesised that these mast cells were immunomodulatory upon activation by sun exposure. However, no link was found between dermal mast cell prevalence in hand skin and the presence of basal cell carcinomas. Finally, we discuss other roles for increased numbers of mast cells in UV-exposed photodamaged skin.

Expression of apoptotic and cell proliferation regulatory proteins in actinic cheilitis

BACKGROUND

Actinic cheilitis (AC) is a pre-malignant lesion caused by ultraviolet (UV) radiation. The apoptotic proteins p53, bax, bcl-2, and the proliferation marker Ki-67, are known to play an important role in UV-exposed skin and carcinomas, therefore, these markers were assessed in AC and compared with normal lip and oral mucosa.

METHODS

AC (n = 13), normal lip (n = 7) and oral mucosa (n = 6) biopsies were stained immunohistochemically for p53, bax, bcl-2 and Ki-67, to determine their expression and distribution.

RESULTS

p53 was over-expressed in AC as compared with normal lip and oral mucosa (P < 0.003). Although bcl-2 expression was higher in AC than in oral mucosa (P < 0.002), it was significantly reduced as compared with normal lip (P < 0.04). Bax expression remained unchanged, and Ki-67 was significantly increased in AC and normal lip as compared with oral mucosa (P < 0.05).

CONCLUSION

The results suggest that DNA-damaged cells by UV radiation in AC are eliminated by apoptosis.

[Socio-legal evaluation of UV-induced skin tumors]

The present work deals with insurance and legal issues on the prevention of UV-induced skin tumors. We are convinced that squamous cell carcinoma of the skin fulfils the socio-legally required conditions according to paragraph 9 Abs. 2 SGB VII for approval as an occupational disease. In malignant melanoma evidence also exists for its induction through UV exposure and increased risk for occupational UV exposure, thus, making approval as an occupational disease possible in individual cases. According to the currently available medical knowledge on basal cell carcinoma and malignant melanoma, there is no sufficient basis for the approval of these as occupational disorders. Therefore, significant actions should not only be taken in the context of primary disease prevention, but also within the framework of secondary and tertiary disease prevention in occupational UV exposure.

Sunlight exposure and (sero)prevalence of epidermodysplasia verruciformis-associated human papillomavirus

Ultraviolet radiation (UVR) is associated with an increased risk of squamous cell carcinoma (SCC), which is in part due to immunomodulation. In addition, human papilloma virus (HPV), especially the epidermodysplasia verruciformis (EV)-associated types, may be involved. In view of the capacity of UVR to impair host resistance to infections, we investigated the relationship between solar exposure and the prevalence of cutaneous HPV. In a case-control study on skin cancer (320 controls and 156 patients) a lifetime-retrospective questionnaire on sun exposure was administered. The presence of DNA of HPV types 5, 8, 15, 20, 24, and 38 in plucked eyebrow hair and type-specific seroreactivity were assessed and analyzed in relation to estimated exposure. Sunburn episodes in the past, especially at age 13-20 y, appeared to be associated with an enhanced risk of EV-HPV DNA positivity. In contrast, a higher lifetime sun exposure was associated with a lower risk of HPV infection. These results indicate that UVR at erythematogenic doses increases the risk of EV-HPV infection, possibly due to impaired host resistance to HPV and/or a direct effect of UVR on viral replication. The favorable association between lifetime sun exposure and HPV prevalence, however, underscores the enigmatic role of HPV in skin carcinogenesis.

Association between melanoma and dermal mast cell prevalence in sun-unexposed skin

BACKGROUND

Both exposure to intermittent intense sunlight during childhood and ultraviolet (UV) radiation-induced immunomodulation have been directly associated with melanoma development. In mice, the prevalence of dermal mast cells determines susceptibility to UVB-induced systemic suppression of contact hypersensitivity responses and thus may affect immunological responses to melanoma antigens.

OBJECTIVES

To determine the relevance of murine studies of dermal mast cell prevalence to human melanoma pathogenesis.

METHODS

The prevalence of mast cells was examined in sun-unexposed buttock skin of 45 melanoma patients and 68 control volunteers who had no history of skin cancer development. Buttock skin was studied because mast cell prevalence is stable with ageing and the confounding effects of environmental UV exposure are minimized.

RESULTS

Using tissue immunostaining, the buttock skin from melanoma patients had a significantly higher dermal mast cell prevalence (mean +/- SEM 38 +/- 2 mast cells mm(-2)) than controls (32 +/- 2 mast cells mm(-2)) (P = 0.02). Analysis by binary logistic regression showed that the association between mast cell prevalence and melanoma outcome was not significantly altered by skin phototype.

CONCLUSIONS

The immunomodulatory effects of mast cell products in UV-irradiated skin may contribute significantly to the initiation and development of human cutaneous malignant melanoma.

Cytokine polymorphisms play a role in susceptibility to ultraviolet B-induced modulation of immune responses after hepatitis B vaccination

UVB exposure can alter immune responses in experimental animals and humans. In an earlier human volunteer study, we demonstrated that hepatitis B-specific humoral and cellular immunity after vaccination on average were not significantly affected by UVB exposure. However, it is known that individuals differ in their susceptibility to UVB-induced immunomodulation, and it was hypothesized that polymorphisms in specific cytokines may play a role in this susceptibility. In this respect, we previously demonstrated that immune responses after hepatitis B vaccination are influenced by the minor allelic variant of IL-1 beta in the general population. For all volunteers, single nucleotide polymorphisms were determined for the following UV response-related cytokines: IL-1 receptor antagonist (+2018), IL-1 alpha (+4845), IL-1 beta (+3953), TNF-alpha (-308), and TNF-alpha (-238). Exposure to UVB significantly suppressed Ab responses to hepatitis B in individuals with the minor variant for the IL-1 beta polymorphism. Increased minimal erythema dose values (just perceptible), which resulted in higher absolute UVB exposures, were observed in the same individuals. There were no associations observed between UVB-induced immunomodulation and the other cytokine polymorphisms examined. This study indicates that individual susceptibility to UVB radiation needs to be considered when studying the effects of UVB in humans.

Immunological disorders and DNA repair

Cellular DNA continuously incurs damage and a range of damage response mechanisms function to maintain genomic integrity in the face of this onslaught. During the development of the immune response, the cell utilises three defined processes, V(D)J recombination, class switch recombination and somatic hypermutation, to create genetic diversity in developing T and B cells. Curiously, the damage response mechanisms employed to maintain genomic stability in somatic cells have been exploited and adapted to help generate diversity during immune development. As a consequence of this overlap, there is mounting evidence that disorders attributable to impaired damage response mechanisms display associated immunodeficiency. Since double strand breaks (DSB) are created during at least two of the mechanisms used to create immunoglobulin diversity, namely V(D)J recombination and class switch recombination, it is not surprising that disorders associated with defects in the response to double strand breaks are those most associated with immunodeficiency. Here, we review the steps involved in the generation of genetic diversity during immune development with a focus on the damage response mechanisms employed and then consider human immunodeficiency disorders associated with impaired damage response mechanisms.

Risk of subsequent cancer following invasive or in situ squamous cell skin cancer

PURPOSE

Determine the risk of subsequent cancer following squamous cell skin cancer.

METHODS

Using computerized surgical pathology records and membership data from a health maintenance organization, we retrospectively identified 822 individuals with primary squamous cell skin cancer (SCSC) and 3662 comparison subjects matched for age, sex, race, residence area, and length of membership. Patients were included in the study if they had no prior history of cancer, and received at least one multiphasic health checkup and questionnaire (MHC). Patients were followed for subsequent invasive cancer up to 24 years, with a mean follow-up time of 7.8 years.

RESULTS

SCSC patients had a significantly greater risk [adjusted for body mass index (BMI) and education] for subsequent cancer overall (excluding non-melanoma skin cancer) [risk ratio (RR) = 1.4, 95% confidence interval (CI) = 1.2-1.6], and for basal cell skin cancer (RR = 13.8, 95% CI = 8.8-21.9), digestive (RR = 1.6, 95% CI = 1.1-2.4), and genitourinary cancers (RR = 1.5, 95% CI = 1.0-2.0). An increased, but not statistically significant, adjusted risk (RR > or = 1.4) was also observed for lip, oral cavity, and pharynx cancer (RR = 3.9, 95% CI = 0.6-25.0); non-cutaneous squamous cell cancer (RR = 1.9, 95% CI = 0.9-4.4); and respiratory and intrathoracic cancer (RR = 1.4, 95% CI = 0.8-2.6). The addition of alcohol consumption, combined occupational exposure, marital status, and smoking history to the multivariate model did not materially change any significant positive associations with SCSC.

CONCLUSIONS

Our results suggest that patients diagnosed with SCSC may be at an increased risk of subsequent cancer at many sites, although several estimated risk estimates were within the limits of chance given no true association.

Repeated subinflammatory ultraviolet B irradiation increases substance P and calcitonin gene-related peptide content and augments mustard oil-induced neurogenic inflammation in the skin of rats

The cutaneous neurosensory system is suggested to be involved in the pathophysiology of pruritus and skin diseases such as psoriasis. We investigated if repeated subinflammatory doses of ultraviolet B (UVB) irradiation similar to those used to treat pruritus or psoriasis would affect the cutaneous neurosensory system. Sprague-Dawley rats were irradiated thrice weekly for 2-4 weeks with subinflammatory doses of UVB. Three days after the last UVB exposure: (i), the skin contents of substance P (SP), calcitonin gene-related peptide (CGRP), and nerve growth factor (NGF) were quantified; (ii), the skin nerve fiber density was observed; and (iii), the effect of UVB on mustard oil-induced neurogenic inflammation was determined. UV exposure significantly increased SP and CGRP content and mustard oil-induced neurogenic inflammation in UV-irradiated but not non-irradiated skin; however, it did not affect cutaneous NGF content or overall nerve fiber density. These data suggest that repeated subinflammatory UVB irradiation locally increases the content of cutaneous SP and CGRP by an increase of neuropeptide content of nerve fibers rather than by an increase of overall nerve fiber density.

Increased dermal mast cell prevalence and susceptibility to development of basal cell carcinoma in humans

Exposure to ultraviolet B (UVB) radiation (280-320 nm) is the primary etiologic factor associated with the development of basal cell carcinoma (BCC). The outgrowth of these keratinocyte-derived skin lesions is enhanced by the ability of UVB to impair an immune response that would otherwise eliminate them. Studies in a range of inbred mouse strains as well as mast cell-depleted mice reconstituted with mast cell precursors support a functional link between histamine-staining dermal mast cells and the extent of susceptibility to UVB-induced systemic immunomodulation. Humans, like mouse strains, display variations in dermal mast cell prevalence. In a study of Danish and South Australian BCC patients and control subjects, one 4-mm punch biopsy of non-sun-exposed buttock skin was sampled from each participant. This skin site was investigated to avoid any changes in mast cell prevalence caused by sun exposure. Two sections (4 microm) per biopsy were immunohistochemically stained for detection of histamine-containing dermal mast cells. Computer-generated image analysis evaluated dermal mast cell prevalence in both sections by quantifying the total number of mast cells according to the total dermal area (expressed as mast cells per square millimeter). This technique enabled us to detect heterogeneity of dermal mast cell prevalence in buttock skin between individuals and provided evidence of an association between high dermal mast cell prevalence and BCC development in two diverse populations. We hypothesize that mast cells function in humans, as in mouse strains, by initiating immunosuppression following UV irradiation and, thereby, allowing a permissive environment for the development of BCC. Thus, a high dermal mast cell prevalence as demonstrable in buttock skin is a significant predisposing factor for development of BCC in humans.

Ultraviolet radiation, resistance to infectious diseases, and vaccination responses

Exposure to ultraviolet (UV) radiation, as in sunlight, can modulate immune responses in animals and humans. This immunomodulation can lead to positive health effects especially with respect to certain autoimmune diseases and allergies. However, UV-induced immunomodulation has also been shown to be deleterious. Experimental animal studies have revealed that UV exposure can impair resistance to many infectious agents, such as bacteria, parasites, viruses, and fungi. Importantly, these effects are not restricted to skin-associated infections, but also concern systemic infections. The real consequences of UV-induced immunomodulation on resistance to infectious diseases are not known for humans. Risk estimations have been performed through extrapolation of animal data, obtained from infection models, to the human situation. This estimation indicated that UV doses relevant to outdoor exposure can impair the human immune system sufficiently to have effects on resistance to infections. To further quantify and validate this risk estimation, data, e.g., from human volunteer studies, are necessary. Infection models in humans are not allowed for ethical reasons. However, vaccination against an infectious disease evokes a similar immune response as the pathogen and thereby provides an opportunity to measure the effect of UV radiation on the immune system and an estimate of the possible consequences of altered resistance to infectious agents. Effects of controlled UVB exposure on immune responses after hepatitis B vaccination have been established in mice and human volunteers. In mice, cellular and Th1-associated humoral immune responses to hepatitis B were significantly impaired, whereas in human volunteers no significant effect of UVB on these responses could be found. Preliminary data indicate that cytokine polymorphisms might be, at least in part, responsible for interindividual differences in immune responses and in susceptibility to UVB-induced immunomodulation. In addition, adaptation to UV exposure needs to be considered as a possible explanation for the difference between mice and humans that was observed in the hepatitis B vaccination model.

Nerve growth factor, neuropeptides, and mast cells in ultraviolet-B-induced systemic suppression of contact hypersensitivity responses in mice

The induction of systemic immunosuppression following ultraviolet B radiation exposure has been linked with the release of inflammatory and immunomodulatory mediators by cells of the epidermis and dermis. Nerve growth factor has not previously been linked with ultraviolet-B-induced immunosuppressive effects. Nerve growth factor antibodies abrogated ultraviolet-B-induced systemic suppression of contact hypersensitivity responses in BALB/C mice. Subcutaneous injection of nerve growth factor (20 microg per mouse) into dorsal skin 5 d before hapten sensitization on ventral skin suppressed contact hypersensitivity responses in mast-cell-replete but not Wf/Wf mast-cell-depleted mice. Nerve growth factor injected 24 h prior to challenge was not able to suppress the efferent phase of the contact hypersensitivity response. Subcutaneous injection of nerve growth factor (20 microg per mouse) did not suppress contact hypersensitivity responses in capsaicin-pretreated (neuropeptide-depleted) BALB/c mice, and thus sensory c-fibers are necessary for nerve-growth-factor-mediated systemic suppression of contact hypersensitivity responses. Increased concentrations of nerve growth factor within epidermal keratinocytes 8 h after ultraviolet B irradiation were confirmed immunohistochemically. These findings support a role for keratinocyte-derived nerve growth factor via its action on sensory c-fibers, and subsequent release of neuropeptides to mediate mast cell degranulation in systemic suppression of contact hypersensitivity responses in mice following ultraviolet B exposure.

A single-institution case series of patients with cutaneous melanoma and non-Hodgkin's lymphoma

BACKGROUND

Over the past two decades, cutaneous melanoma (CM) and non-Hodgkin's lymphoma (NHL) have both experienced unabated increases in incidence. Population-based studies have documented an elevated risk of subsequent NHL among patients with CM and vice versa.

METHODS

To better characterize the clinical features of patients who have had both malignancies, we retrospectively identified all patients with CM at the Massachusetts General Hospital (MGH) who subsequently had NHL and all NHL patients who later developed CM.

RESULTS

A total of 2461 CM and 2708 NHL patients were registered at MGH between 1973 and 1998. Out of these groups, 10 CM patients (0.4%) eventually developed NHL and 11 NHL patients (0.4%) subsequently had CM. The mean age at the first CM diagnosis was 56 years, wheras the mean age at the first NHL diagnosis was 67 years. The mean interval to NHL among the CM group was 119 months, whereas the mean interval to CM among the NHL patients was 36 months. All primary CMs were relatively thin (0.95 mm, first diagnosis; 1.07 mm, second diagnosis), and most NHL subtypes were indolent in nature.

CONCLUSION

The rates of developing a second NHL among CM patients and vice versa are low. Any interactions between CM and NHL may be due to factors such as detection bias, shared environmental ultraviolet carcinogenesis, or possibly, posttreatment effects.

Photoimmunology and nucleotide excision repair: impact of transcription coupled and global genome excision repair

Ultraviolet (UV) light generates damage to DNA which is removed by a versatile mechanism called nucleotide excision repair (NER). There are two subpathways for NER: the transcription coupled repair (TCR) pathway which removes DNA damage from actively transcribed genes and the global genome repair pathway which removes damage throughout the genome. Most types of DNA lesions are processed more rapidly by TCR than by GGR. It is widely accepted that immunological processes play a pivotal role in the generation of skin tumours induced by exposure to ultraviolet light and first evidence is emerging that GGR and TCR play different roles in skin reactions such as erythema and delayed type hypersensitivity. The relationship between UV-induced responses of the skin and the two NER subpathways is discussed.

Effect of xenogenic repair enzymes on photoimmunology and photocarcinogenesis

Exposure to ultraviolet B (UVB) radiation leads to an increased generation of UVB-induced skin damage in humans. The most important UVB-induced side effects are UVB-induced immunosuppression and photocarcinogenesis and there is a large body of evidence that cyclobutane pyrimidine dimers (CPD) induced by UVB radiation play a pivotal role in both processes. The topical application of DNA repair enzymes is a new innovative strategy to reduce the amount of CPDs in human skin. Two different methods have recently been established. The use of T4 endonuclease V was of clinical efficacy in protecting patients with a nucleotide excision repair defect from premalignant and malignant skin lesions. Application of photolyase, a xenogenic enzyme which has been found in different organisms is also capable of removing UVB-induced CPD from normal human skin cells in vivo and appears to be more effective than T4 endonuclease V in damage removal. Photolyase encapsulated in liposomes may have in the near future a broad use as an active ingredient in modern skin care products.

The alternatively spliced domain TnFnIII A1A2 of the extracellular matrix protein tenascin-C suppresses activation-induced T lymphocyte proliferation and cytokine production

Several lines of evidences have suggested that T cell activation could be impaired in the tumor environment, a condition referred to as tumor-induced immunosuppression. We have previously shown that tenascin-C, an extracellular matrix protein highly expressed in the tumor stroma, inhibits T lymphocyte activation in vitro, raising the possibility that this molecule might contribute to tumor-induced immunosuppression in vivo. However, the region of the protein mediating this effect has remained elusive. Here we report the identification of the minimal region of tenascin-C that can inhibit T cell activation. Recombinant fragments corresponding to defined regions of the molecule were tested for their ability to inhibit in vitro activation of human peripheral blood T cells induced by anti-CD3 mAbs in combination with fibronectin or IL-2. A recombinant protein encompassing the alternatively spliced fibronectin type III domains of tenascin-C (TnFnIII A-D) vigorously inhibited both early and late lymphocyte activation events including activation-induced TCR/CD8 down-modulation, cytokine production, and DNA synthesis. In agreement with this, full length recombinant tenascin-C containing the alternatively spliced region suppressed T cell activation, whereas tenascin-C lacking this region did not. Using a series of smaller fragments and deletion mutants issued from this region, we have identified the TnFnIII A1A2 domain as the minimal region suppressing T cell activation. Single TnFnIII A1 or A2 domains were no longer inhibitory, while maximal inhibition required the presence of the TnFnIII A3 domain. Altogether, these data demonstrate that the TnFnIII A1A2 domain mediate the ability of tenascin-C to inhibit in vitro T cell activation and provide insights into the immunosuppressive activity of tenascin-C in vivo.

Influence of ultraviolet B exposure on immune responses following hepatitis B vaccination in human volunteers

Exposure to ultraviolet radiation can modulate immune responses in animal and humans. Remarkably, the ultraviolet-induced immunosuppression is not restricted to the exposed skin but is also found at other body sites, i.e., systemic immunosuppression. Effects of ultraviolet radiation on infections cannot be determined by experimentation on humans, but the effects of ultraviolet on vaccination may serve as a model. Moreover, it is important in its own right to assess whether ultraviolet radiation affects vaccination responses. In this study the effect of ultraviolet B exposure on the development of immune responses after hepatitis B vaccination in human volunteers was investigated. To this end, 191 human volunteers were vaccinated against hepatitis B with the Engerix-B vaccine. Ninety-seven of them were prior to the first vaccination exposed to ultraviolet B on 5 consecutive days with one personal minimal erythema dose per day. At several time-points before and after the ultraviolet B exposure regimen and the vaccination, blood samples were taken. Parameters for specific as well as nonspecific cellular and humoral immunity were analyzed. It was demonstrated that ultraviolet B exposure prior to hepatitis B vaccination did not alter the cellular (lymphocyte stimulation test) nor the humoral (antibody titers) immune response against hepatitis B surface antigen significantly. In contrast, contact hypersensitivity to diphenylcyclopropenone was significantly suppressed after ultraviolet B exposure, as was natural killer cell activity. These latter results confirm earlier findings and demonstrate immunosuppressive effectiveness of the ultraviolet regimen. In summary, although natural killer cell activity and contact hypersensitivity responses were suppressed, the ultraviolet B radiation protocol did not alter the humoral nor the cellular immune responses against hepatitis B surface antigen after vaccination.

cis-Urocanic acid stimulates neuropeptide release from peripheral sensory nerves

Previous studies using an antibody to cis-urocanic acid and mast-cell-depleted mice implicated both cis-urocanic acid and mast cells in the mechanisms by which ultraviolet B light suppresses systemic contact hypersensitivity responses in mice. In the absence of a direct stimulatory effect of cis-urocanic acid on connective tissue mast cells, an indirect association was investigated. A blister induced in the rat hind footpad was used to examine the effects of slowly perfused cis-urocanic acid on cutaneous blood flow. cis-Urocanic acid but not trans-urocanic acid increased microvascular flow by a mechanism largely dependent on the combined activity of the neuropeptides, substance P and calcitonin gene-related peptide. Perfusion of cis-urocanic acid over the base of blisters induced in sensory-neuropeptide-depleted rats did not have any stimulatory effect above that seen with perfusion of cis-urocanic acid together with neuropeptide receptor antagonists in control rats. There was a small direct effect of cis-urocanic acid on microvascular blood flow. As both substance P and calcitonin gene-related peptide could directly degranulate connective tissue mast cells, this study suggests that cis-urocanic acid indirectly activates mast cells via its effects on peripheral terminals of unmyelinated primary afferent sensory nerves. cis-Urocanic-acid-induced neuropeptides may also contribute to ultraviolet-B-induced cutaneous inflammation and alterations to Langerhans cell activity.

Effects of solar radiation on the human immune system

On UV irradiation of the skin, a complex cascade of immunological changes results, initiated by cutaneous chromophores and ending in suppression of some local and systemic immune responses. In this review, the stages in this process are outlined first, concentrating on the roles of DNA and urocanic acid as photoreceptors. Evidence indicating UV-induced immunomodulation of delayed hypersensitivity and resistance to infectious diseases in human subjects follows. Aspects of genetic susceptibility to the immunosuppressive effects of UV exposure and extrapolation of the data obtained in animal models to the human situation are included. Finally uncertain and unknown factors relating to the impact of UV on the human immune system are discussed.

Occupational sunlight exposure and cancer incidence among Swedish construction workers

We studied sunlight exposure from outdoor work in relation to cancer, using data from 323,860 men participating in an occupational health service program of the Swedish construction industry. An experienced industrial hygienist assessed the exposure for 200 job tasks. We estimated relative risks (RRs) adjusted for age, smoking, and magnetic field exposure. There was an increased RR in the high-exposure group for myeloid leukemia [RR = 2.0, 95% confidence interval (95% CI) = 1.1-3.6] and lymphocytic leukemia (RR = 1.7, 95% CI = 0.9-3.2). For non-Hodgkin's lymphoma there was a 30% increase in risk in the high-exposure group (95% CI = 0.9-1.9). There was no increased risk of malignant melanoma, except for tumors of the head, face, and neck in the high-exposure group (RR = 2.0, 95% CI = 0.8-5.2), and we also found an increased risk for malignant melanoma of the eye in this group (RR = 3.4, 95% CI = 1.1-10.5). Outdoor workers had no increased risk of nonmelanoma skin cancer. Nevertheless, the RR for lip cancer (squamous cell carcinoma) among the high-exposure group was estimated at 1.8 (95% CI = 0.8-3.7). Among other sites, an increased risk of stomach cancer was suggested in this group (RR = 1.4, 95% CI = 1.0-1.9). The results for lymphoma, leukemia, and possibly also for stomach cancer might reflect a suppression of the immune system from ultraviolet light in outdoor workers.