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Lonsdorf AS, Edelmann D, Albrecht T, Brobeil A, Labrenz J, Johanning M, Schlenk RF, Goeppert B, Enk AH, Toberer F. Differential Immunoexpression of Inhibitory Immune Checkpoint Molecules and Clinicopathological Correlates in Keratoacanthoma, Primary Cutaneous Squamous Cell Carcinoma and Metastases. Acta Derm Venereol 2024; 104:adv13381. [PMID: 38323498 PMCID: PMC10863621 DOI: 10.2340/actadv.v104.13381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 12/20/2023] [Indexed: 02/08/2024] Open
Abstract
Beyond established anti-programmed cell death protein 1/programmed cell death ligand 1 immunotherapy, T-cell immunoreceptor with immunoglobulin and immunoreceptor tyrosine-based inhibition motif domain (TIGIT) and its ligand CD155 are promising novel inhibitory immune checkpoint targets in human malignancies. Yet, in cutaneous squamous cell carcinoma, evidence on the collective expression patterns of these inhibitory immune checkpoints is scarce. Complete tumour sections of 36 cutaneous squamous cell carcinoma, 5 cutaneous metastases and 9 keratoacanthomas, a highly-differentiated, squamoproliferative tumour, with disparately benign biologic behaviour, were evaluated by immunohistochemistry for expression of programmed cell death ligand 1 (Tumor Proportion Score, Immune Cell Score), TIGIT, CD155 and CD8+ immune infiltrates. Unlike keratoacanthomas, cutaneous squamous cell carcinoma displayed a strong positive correlation of programmed cell death ligand 1 Tumor Proportion Score and CD115 expression (p < 0.001) with significantly higher programmed cell death ligand 1 Tumor Proportion Score (p < 0.001) and CD155 expression (p < 0.01) in poorly differentiated G3-cutaneous squamous cell carcinoma compared with keratoacanthomas. TIGIT+ infiltrates were significantly increased in programmed cell death ligand 1 Immune Cell Score positive primary tumours (p = 0.05). Yet, a strong positive correlation of TIGIT expression with CD8+ infiltrates was only detected in cutaneous squamous cell carcinoma (p < 0.01), but not keratoacanthomas. Providing a comprehensive overview on the collective landscape of inhibitory immune checkpoint expression, this study reveals associations of novel inhibitory immune checkpoint with CD8+ immune infiltrates and tumour differentiation and highlights the TIGIT/CD155 axis as a potential new target for cutaneous squamous cell carcinoma immunotherapy.
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Affiliation(s)
- Anke S Lonsdorf
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany.
| | - Dominic Edelmann
- German Cancer Research Center, Heidelberg, Germany; NCT Trial Center, National Center for Tumor Diseases, German Cancer Research Center and Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Albrecht
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Alexander Brobeil
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany; Tissue Bank of the National Center for Tumor Diseases, Heidelberg, Germany
| | - Jannik Labrenz
- German Cancer Research Center, Heidelberg, Germany; NCT Trial Center, National Center for Tumor Diseases, German Cancer Research Center and Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz Johanning
- German Cancer Research Center, Heidelberg, Germany; NCT Trial Center, National Center for Tumor Diseases, German Cancer Research Center and Heidelberg University Hospital, Heidelberg, Germany
| | - Richard F Schlenk
- German Cancer Research Center, Heidelberg, Germany; NCT Trial Center, National Center for Tumor Diseases, German Cancer Research Center and Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Goeppert
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany; Institute of Pathology and Neuropathology, RKH Klinikum Ludwigsburg, Germany
| | - Alexander H Enk
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ferdinand Toberer
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
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Lonsdorf AS, Enk AH, Hartmann J. Patterns of photoprotective behavior, cumulative sun-exposure and skin cancer risk among solid organ transplant recipients: a dermatology transplant clinic experience. Eur J Cancer Prev 2023; 32:155-162. [PMID: 35671255 DOI: 10.1097/cej.0000000000000751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The risk for keratinocyte cancer is dramatically increased in solid organ transplant recipients (OTR) with a first post-transplant keratinocyte cancer conferring a high risk for subsequent keratinocyte cancer arising with accelerated dynamics. Despite cumulative ultraviolet radiation (UVR) being the primary responsible environmental carcinogen reduced compliance with photoprotective measures among OTR has been reported. Risk assessment tools could help guide clinical decision-making and targeted prevention strategies for patients at particularly high risk for post-transplant keratinocyte cancer. OBJECTIVES To evaluate cumulative sun exposure by means of an assigned total sun burden (TSB) score, sunscreen use and associated risk factors for keratinocyte cancer in the post-transplantation phase of OTR. METHODS A retrospective single-center cohort study analyzing medical records and standardized questionnaires of 290 OTR cared for at a German dermatology transplant clinic. RESULTS Significantly lower TSB scores were noted in OTR not developing a first keratinocyte cancer compared to OTR developing keratinocyte cancer during their follow-up period ( P = 0.005). Regression analysis assigned a significantly higher risk for the development of first keratinocyte cancer to OTR with TSB scores >10. In total 70.7% of OTR with a history of ≥1 keratinocyte cancer reported intermittent sunscreen use, while daily sunscreen use was overall associated with female gender (21.3%) and age >30 years (17.6%). CONCLUSIONS The risk of OTR for developing keratinocyte cancer is reflected by their UV-exposure patterns, which may be assessed by the TSB-score, a scored risk assessment tool. Complementing clinical data, the TSB score may help clinicians to identify OTR at particularly high risk for keratinocyte cancer and to endorse intensified prevention strategies and dermato-oncologic care.
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Affiliation(s)
- Anke S Lonsdorf
- Department of Dermatology, Ruprecht-Karls-University of Heidelberg
- Skin Cancer Center, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology, Ruprecht-Karls-University of Heidelberg
- Skin Cancer Center, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
| | - Julia Hartmann
- Department of Dermatology, Ruprecht-Karls-University of Heidelberg
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Klaus T, Wilson AS, Vicari E, Hadaschik E, Klein M, Helbich SSC, Kamenjarin N, Hodapp K, Schunke J, Haist M, Butsch F, Probst HC, Enk AH, Mahnke K, Waisman A, Bednarczyk M, Bros M, Bopp T, Grabbe S. Impaired Treg-DC interactions contribute to autoimmunity in leukocyte adhesion deficiency type 1. JCI Insight 2022; 7:162580. [PMID: 36346673 PMCID: PMC9869970 DOI: 10.1172/jci.insight.162580] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Leukocyte adhesion deficiency type 1 (LAD-1) is a rare disease resulting from mutations in the gene encoding for the common β-chain of the β2-integrin family (CD18). The most prominent clinical symptoms are profound leukocytosis and high susceptibility to infections. Patients with LAD-1 are prone to develop autoimmune diseases, but the molecular and cellular mechanisms that result in coexisting immunodeficiency and autoimmunity are still unresolved. CD4+FOXP3+ Treg are known for their essential role in preventing autoimmunity. To understand the role of Treg in LAD-1 development and manifestation of autoimmunity, we generated mice specifically lacking CD18 on Treg (CD18Foxp3), resulting in defective LFA-1 expression. Here, we demonstrate a crucial role of LFA-1 on Treg to maintain immune homeostasis by modifying T cell-DC interactions and CD4+ T cell activation. Treg-specific CD18 deletion did not impair Treg migration into extralymphatic organs, but it resulted in shorter interactions of Treg with DC. In vivo, CD18Foxp3 mice developed spontaneous hyperplasia in lymphatic organs and diffuse inflammation of the skin and in multiple internal organs. Thus, LFA-1 on Treg is required for the maintenance of immune homeostasis.
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Affiliation(s)
- Tanja Klaus
- Department of Dermatology,,Research Center for Immunotherapy, and
| | - Alicia S. Wilson
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | - Elisabeth Vicari
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Eva Hadaschik
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany.,Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Matthias Klein
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | | | - Nadine Kamenjarin
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | - Katrin Hodapp
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | - Jenny Schunke
- Department of Dermatology,,Research Center for Immunotherapy, and
| | - Maximilian Haist
- Department of Dermatology,,Research Center for Immunotherapy, and
| | | | - Hans Christian Probst
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | - Alexander H. Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Karsten Mahnke
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Ari Waisman
- Research Center for Immunotherapy, and,Institute for Molecular Medicine, University of Mainz Medical Center, Mainz, Germany
| | | | - Matthias Bros
- Department of Dermatology,,Research Center for Immunotherapy, and
| | - Tobias Bopp
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | - Stephan Grabbe
- Department of Dermatology,,Research Center for Immunotherapy, and
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Mitri F, Kälber KA, Enk AH, Toberer F. Persistent Facial Blanching after Botulinum Toxin Injection. Case Rep Dermatol 2022; 14:253-256. [PMID: 36158853 PMCID: PMC9459515 DOI: 10.1159/000525937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/30/2022] [Indexed: 11/19/2022] Open
Abstract
We report the case of a 38-year-old male patient who presented with blanching of the face after strenuous exercise or physical exertion. The symptoms regressed in a relaxed state. Three years before presentation, he underwent botulinum toxin injections in the affected areas of the face. Facial blanching is a rare side effect of botulinum toxin injection. The postulated pathophysiology involves different transmitters mainly acetylcholine as well as co-transmitters implicated in vasodilation. Usually, facial blanching resolves shortly after waning of the botulinum toxin. However, in our case, the symptoms persisted for a longer time. Till date, therapy options for post-botulinum facial blanching are lacking, mainly due to the temporary aspect of the disease.
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Salzmann M, Hess K, Lang K, Enk AH, Jordan B, Hassel JC. Long-term neurocognitive function after whole-brain radiotherapy in patients with melanoma brain metastases in the era of immunotherapy. Strahlenther Onkol 2022; 198:884-891. [PMID: 35546362 PMCID: PMC9515012 DOI: 10.1007/s00066-022-01950-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/13/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Whole-brain radiotherapy (WBRT) used to be standard of care for patients suffering from melanoma brain metastases (MBM) and may still be applicable in selected cases. Deterioration of neurocognitive function (NCF) is commonly seen during and after WBRT. Knowledge on long-term effects in melanoma patients is limited due to short survival rates. With the introduction of immune checkpoint inhibitors, patients may experience ongoing disease control, emphasizing the need for paying more attention to potential long-term adverse effects. METHODS In this single-center study, we identified in a period of 11 years all long-term survivors of MBM who received WBRT at least 1 year prior to inclusion. NCF was assessed by Neuropsychological Assessment Battery (NAB) screening and detailed neurological exam; confounders were documented. RESULTS Eight patients (median age 55 years) could be identified with a median follow-up of 5.4 years after WBRT. Six patients reported no subjective neurological impairment. NAB screening revealed an average-range score in 5/8 patients. In 3/8 patients a NAB score below average was obtained, correlating with subjective memory deficits in 2 patients. In these patients, limited performance shown in modalities like memory function, attention, and spatial abilities may be considerably attributed to metastasis localization itself. Six out of 8 patients were able to return to their previous work. CONCLUSION Five of 8 long-term survivors with MBM after WBRT experienced little to no restriction in everyday activities. In 3 out of 8 patients, cognitive decline was primarily explained by localization of the metastases in functionally relevant areas of the brain. The results of our small patient cohort do not support general avoidance of WBRT for treatment of brain metastases. However, long-term studies including pretreatment NCF tests are needed to fully analyze the long-term neurocognitive effects of WBRT.
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Affiliation(s)
- Martin Salzmann
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
| | - Klaus Hess
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Berit Jordan
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Neurology, Halle University Hospital, Halle (Saale), Germany
| | - Jessica C Hassel
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
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Lonsdorf AS, Keller A, Hartmann J, Enk AH, Gholam P. Ablative Fractional Laser-assisted Low-irradiance Photodynamic Therapy for Treatment of Actinic Keratoses in Organ Transplant Recipients: A Prospective, Randomized, Intraindividual Controlled Trial. Acta Derm Venereol 2022; 102:adv00694. [PMID: 35356991 PMCID: PMC9558342 DOI: 10.2340/actadv.v102.1057] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pain and inferior efficacy are major limiting factors of conventional photodynamic therapy for the field treatment of actinic keratoses in immunosuppressed organ transplant recipients. This prospective randomized controlled study evaluates the efficacy and tolerability of ablative fractional laser system pretreatment combined with low-irradiance photodynamic therapy (18.5 mW/cm2) compared with conventional photodynamic therapy (61.67 mW/cm2) in the treatment of actinic keratoses on the face and scalp in organ transplant recipients, using a red light-emitting diode lamp at a total light dose of 37 J/cm2. Low-irradiance photodynamic therapy combined with Er:YAG pretreatment achieved a significantly superior lesion response rate (mean ± standard deviation 77.3 ± 23.6%) compared with conventional photodynamic therapy (61.8 ± 21.4%; p = 0.025) in intra-individual fields at 3 months without negatively impacting pain (p = 0.777) or cosmetic outcome (p = 0.157).
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Affiliation(s)
- Anke S Lonsdorf
- Department of Dermatology, University Hospital Heidelberg, Germany.
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Winkler JK, Toberer F, Enk AH, Haenssle HA. Ultrahochauflösende Dermatoskopie für die In‐vivo‐Darstellung von Scabies‐Milben. J Dtsch Dermatol Ges 2022; 20:215-217. [PMID: 35146876 DOI: 10.1111/ddg.14651_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Julia K Winkler
- Abteilung für Dermatologie, Universität Heidelberg, Heidelberg, Deutschland
| | - Ferdinand Toberer
- Abteilung für Dermatologie, Universität Heidelberg, Heidelberg, Deutschland
| | - Alexander H Enk
- Abteilung für Dermatologie, Universität Heidelberg, Heidelberg, Deutschland
| | - Holger A Haenssle
- Abteilung für Dermatologie, Universität Heidelberg, Heidelberg, Deutschland
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Sies K, Enk AH. Training and Retaining Physician‒Scientists in Dermatology: The German Perspective. JID Innov 2022; 2:100071. [PMID: 35005681 PMCID: PMC8717604 DOI: 10.1016/j.xjidi.2021.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In an ideal setting, physician‒scientists combine clinical practice and knowledge with scientific curiosity and research in synergy. Li et al. address the current challenges regarding the rare breed of physician‒scientists in the United States-much similar to those faced in German dermatology departments. The authors discuss multiple angles to transform the so-called leaky pipeline into a streamline of dermatologists in science.
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Affiliation(s)
- Katharina Sies
- Department of Dermatology, Heidelberg University, Heidelberg, Germany
| | - Alexander H. Enk
- Department of Dermatology, Heidelberg University, Heidelberg, Germany
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Winkler JK, Toberer F, Enk AH, Haenssle HA. Super-high magnification dermatoscopy for in-vivo imaging of scabies mites. J Dtsch Dermatol Ges 2021; 20:216-217. [PMID: 34914169 DOI: 10.1111/ddg.14651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Julia K Winkler
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Ferdinand Toberer
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Holger A Haenssle
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
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Hoffmann JHO, Enk AH. Evaluation of Psoriasis Area and Severity Index Thresholds as Proxies for Systemic Inflammation on an Individual Patient Level. Dermatology 2021; 238:609-614. [PMID: 34852349 DOI: 10.1159/000520163] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/09/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Psoriasis is a chronic and systemic inflammatory disease with a loss of up to 5 life years, which is thought to be reduced by biologic treatment. Disease severity and eligibility for systemic treatment are often based on the cutaneous psoriasis area and severity index (PASI) with a cut-off of 10 in several European countries. However, it is unclear how well this cut-off reflects systemic inflammation and, consequently, the risk for the development of comorbidity. OBJECTIVES (1) To assess whether specific PASI thresholds, in particular PASI 10, predict elevated biomarkers of systemic inflammation and cardiovascular risk on an individual patient level. (2) To assess the association of PASI and psoriatic arthritis with biomarkers of systemic inflammation and cardiovascular risk. METHODS Retrospective cross-sectional study of 72 psoriasis patients without systemic treatment. RESULTS Overall, 68, 42, and 50% of patients had cardiovascular risk level neutrophil-to-lymphocyte ratio (NLR), C-reactive protein, and elevated platelet-to-lymphocyte ratio (PLR) values, respectively. The respective positive predictive values of PASI 10 were 70, 45, and 70. The performance of the optimal PASI cut-offs according to the Youden index was similarly weak. Subgrouping of patients with a PASI below 10 did not result in a considerably improved reflection of systemic inflammation. PLR was significantly higher in patients with moderate-to-severe compared to mild psoriasis and significantly correlated with PASI in patients with a PASI above 2 (rs = 0.266, n = 64). NLR was significantly higher in patients with psoriatic arthritis. CONCLUSION Specific PASI thresholds were not well suited to predict elevated biomarkers of systemic inflammation and cardiovascular risk on an individual patient level. Therefore, PASI, and possibly other purely cutaneous measures, may not be ideal as stand-alone parameters to define disease severity and eligibility for systemic treatment. Our results are relevant for the ongoing discussion on the definition of psoriasis severity and eligibility for systemic treatment. Further research addressing the added value of a set of biomarkers of systemic inflammation in the assessment of psoriasis severity would be desirable.
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Affiliation(s)
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
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Mitri F, Toberer F, Enk AH, Hartmann M. Acute Generalized Exanthematous Pustulosis in Close Temporal Association with mRNA-1273 Vaccine. Acta Derm Venereol 2021; 101:adv00596. [PMID: 34708247 PMCID: PMC9455331 DOI: 10.2340/actadv.v101.443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Fouad Mitri
- Department of Dermatology, University Hospital Heidelberg, DE-69120 Heidelberg, Germany.
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Cussigh CS, Hänßle H, Enk AH, Streit E. Juckende Hautläsionen während der Schwangerschaft. Geburtshilfe Frauenheilkd 2021. [DOI: 10.1055/a-1388-1537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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13
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Vicari E, Haeberle S, Bolduan V, Ramcke T, Vorobyev A, Goletz S, Iwata H, Ludwig RJ, Schmidt E, Enk AH, Hadaschik EN. Pathogenic Autoantibody Derived from Regulatory T Cell‒Deficient Scurfy Mice Targets Type VII Collagen and Leads to Epidermolysis Bullosa Acquisita‒Like Blistering Disease. J Invest Dermatol 2021; 142:980-984.e4. [PMID: 34678154 DOI: 10.1016/j.jid.2021.08.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Elisabeth Vicari
- Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Stefanie Haeberle
- Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Vanessa Bolduan
- Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Torben Ramcke
- Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Artem Vorobyev
- Department of Dermatology, University Medical Center Schleswig-Holstein, Lübeck, Germany; Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Stephanie Goletz
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Hiroaki Iwata
- Department of Dermatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ralf J Ludwig
- Department of Dermatology, University Medical Center Schleswig-Holstein, Lübeck, Germany; Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Department of Dermatology, University Medical Center Schleswig-Holstein, Lübeck, Germany; Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Alexander H Enk
- Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Eva N Hadaschik
- Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany; Department of Dermatology, Essen University Hospital, Essen, Germany
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Hoffmann JHO, Knoop C, Schäkel K, Enk AH, Hadaschik EN. Evaluation of Psoriasis Area and Severity Index as a Proxy for Bio-markers of Systemic Disease under Treatment with Tumour Necrosis Factor-alpha and Interleukin 12/23 Antagonists in Patients with Psoriasis: A Retrospective Cohort Study of 186 Treatment Cycles. Acta Derm Venereol 2021; 101:adv00462. [PMID: 33903917 PMCID: PMC9367049 DOI: 10.2340/00015555-3814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The efficacy of psoriasis treatments is usually evaluated using the Psoriasis Area and Severity Index (PASI). However, there is a lack of systematic statistical assessments of PASI as a proxy for systemic disease in individual patients. Therefore, a retrospective study of 186 treat-ments with adalimumab, etanercept, and ustekinumab for psoriasis (341 patient-years) was performed. While PASI significantly and independently correlated with biomarkers of systemic inflammation (especially neutrophil-to-lymphocyte ratio, C-reactive protein), the strengths were only weak-to-moderate and varied considerably inter-individually. A decrease in PASI indicated a neutrophil-to-lymphocyte ratio decrease and a C-reactive protein decrease or stable low margin C-reactive protein in ≥ 80%. Sensitivity, specificity, and positive predictive value of PASI 0 and PASI 2.75 (optimal Youden Index) for low cardiovascular risk C-reactive protein were 24%, 92%, 85%, and 62%, 61%, 76%, respectively. Performance was similar using absolute thresholds and PASI 100 or PASI 75, and overall worse for low cardiovascular risk neutrophil-to-lympho-cyte ratio and if psoriasis arthritis was present. In conclusion, PASI allows robust low-order estimates of systemic inflammation, but cannot substitute for laboratory biomarkers for more precise assessments.
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Affiliation(s)
- Jochen H O Hoffmann
- Department of Dermatology, University of Heidelberg, DE-69120 Heidelberg, Germany. E-mail:
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15
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Winkler JK, Keller A, Bochnig O, Enk AH, Toberer F, Haenssle HA. [Brownish-blue nodule on the lower leg in a woman with melanoma and chronic venous insufficiency]. Hautarzt 2021; 72:456-458. [PMID: 33141275 DOI: 10.1007/s00105-020-04714-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Julia K Winkler
- Universitäts-Hautklinik Heidelberg, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Deutschland.
| | - Aric Keller
- Universitäts-Hautklinik Heidelberg, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Deutschland
| | - Olivia Bochnig
- Universitäts-Hautklinik Heidelberg, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Deutschland
| | - Alexander H Enk
- Universitäts-Hautklinik Heidelberg, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Deutschland
| | - Ferdinand Toberer
- Universitäts-Hautklinik Heidelberg, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Deutschland
| | - Holger A Haenssle
- Universitäts-Hautklinik Heidelberg, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Deutschland
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Cussigh CS, Trenkler N, Hoffmann JH, Enk AH, Lonsdorf AS. Acute Variegate Porphyria in a Professional Bodybuilder after Starting a High-protein Diet and Treatment with Testosterone. Acta Derm Venereol 2021; 101:adv00412. [PMID: 33585946 PMCID: PMC9366503 DOI: 10.2340/00015555-3769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Christiane S Cussigh
- Department of Dermatology, University Hospital, Ruprecht-Karls-University of Heidelberg, DE-69120 Heidelberg, Germany
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17
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Hoffmann JHO, Knoop C, Schäkel K, Enk AH, Hadaschik EN. Long-term safety of combination treatment with methotrexate and tumor necrosis factor (TNF)-α antagonists versus TNF-α antagonists alone in psoriatic patients. J Dermatol 2021; 48:835-843. [PMID: 33470023 DOI: 10.1111/1346-8138.15754] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/08/2020] [Accepted: 12/18/2020] [Indexed: 02/06/2023]
Abstract
Methotrexate, a folic acid analog, is the conventional systemic anti-psoriatic agent most commonly chosen for combination with biologics in the treatment of psoriasis. Real-world long-term safety data of this combination versus biologic treatment alone in dermatological practice are sparse. Here, we present results of a comparative retrospective study of laboratory dynamics and adverse events in psoriatic patients receiving a tumor necrosis factor (TNF)-α antagonist (adalimumab or etanercept) with and without concomitant methotrexate (176 treatment courses, mean duration of 629 days). Co-treatment with methotrexate significantly (P < 0.05) correlated with a decrease of leukocyte, neutrophil and erythrocyte counts and an increase of glutamate pyruvate transaminase (GPT) (Pearson correlation, n > 148). The relative risk for a Common Terminology Criteria for Adverse Events (CTCAE) grade 1-2 laboratory adverse event was significantly elevated to 1.11 for anemia and 1.16 for a GPT increase if the patients received concomitant methotrexate at the time the laboratory test was performed. Combination treatment was given for equal or more than 30% of the time (MTX≥30% ) during 12% of the treatment courses. During these treatment courses, dynamics of leukocyte (-8.1%), neutrophil (-8.1%), erythrocyte (-3.2%) counts and GPT (+16.9%) from baseline to average under treatment were significantly more pronounced. CTCAE grade 3-4 laboratory adverse events occurred in 9.5% and 5.2% of treatment courses with and without MTX≥30% , respectively (p = 0.70), and affected transaminases in 90% of the cases. Methotrexate was discontinued due to CTCAE grade 3-4 laboratory adverse events in 4.25% of the treatment courses with MTX of 30% or more. Elevated baseline γ-glutamyl transferase levels significantly predicted the occurrence of CTCAE grade 3-4 laboratory adverse events and should trigger investigations for pre-existing liver disease or alcohol abuse. In conclusion, our comparative data supplement previous short-term studies and support a tolerable long-term safety profile of the combination treatment. However, given the additional toxicities and low evidence for benefits, alternative options such as biologic monotherapy or switching to a different biologic should be considered in a dermatological setting.
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Affiliation(s)
| | - Christian Knoop
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Kunt Schäkel
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Eva N Hadaschik
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
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18
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Hoffmann JHO, Enk AH. Skleromyxödem. J Dtsch Dermatol Ges 2020; 18:1449-1468. [PMID: 33373121 DOI: 10.1111/ddg.14319_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/10/2020] [Indexed: 11/30/2022]
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Abstract
Scleromyxedema is a rare, cutaneous deposition disorder from the group of mucinoses, which can affect multiple organs and is virtually always associated with a monoclonal gammopathy. Cutaneous manifestations are usually generalized, 2 to 3 mm sized, dome-shaped or flat-topped, waxy, slightly red to skin-colored papules and sclerodermoid indurations. Neurological, rheumatological, cardiovascular, gastrointestinal, respiratory tract, renal and ophthalmologic manifestations can occur, with decreasing frequency. A serious and potentially lethal complication is the dermato-neuro syndrome which manifests with flu-like prodromes followed by fever, convulsions and coma. Untreated, scleromyxedema usually takes an unpredictable and potentially lethal progressive disease course over several years. According to a widely acknowledged classification by Rongioletti a diagnosis of scleromyxedema can be rendered when (1) generalized, papular and sclerodermoid eruption, (2) a histological triad of mucin deposition, fibroblast proliferation and fibrosis, and (3) monoclonal gammopathy are present, and (4) thyroid disease is absent. Apart from the classic microscopic triad, an interstitial granuloma annulare like pattern was also described. The pathogenesis of scleromyxedema is unknown. A potential role for various, as yet unknown serum factors has been discussed. An unequivocal causal relationship between paraproteinemia and disease manifestations could not be established to date. High dose intravenous immunoglobulins (IVIg) are the first-line treatment of choice according to the most recent European guidelines.
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Affiliation(s)
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Germany
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20
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Trennheuser L, Fink C, Haenssle HA, Enk AH, Toberer F. Die diagnostische Aufarbeitung einer Akroangiodermatitis Mali (Pseudo‐Kaposi‐Sarkom) demaskiert ein epitheloides Angiosarkom. J Dtsch Dermatol Ges 2020; 18:1475-1477. [PMID: 33373128 DOI: 10.1111/ddg.14290_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Christine Fink
- Universitäts-Hautklinik, Ruprecht-Karls-Universität Heidelberg
| | | | - Alexander H Enk
- Universitäts-Hautklinik, Ruprecht-Karls-Universität Heidelberg
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21
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Trennheuser L, Fink C, Haenssle HA, Enk AH, Toberer F. Diagnostic workup of acroangiodermatitis of Mali (pseudo‐Kaposi sarcoma) demasking metastasized epithelioid angiosarcoma. J Dtsch Dermatol Ges 2020; 18:1475-1477. [DOI: 10.1111/ddg.14290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Lukas Trennheuser
- Department of Dermatology Venerology and Allergology University Medical Center Ruprecht‐Karls‐University Heidelberg Heidelberg Germany
| | - Christine Fink
- Department of Dermatology Venerology and Allergology University Medical Center Ruprecht‐Karls‐University Heidelberg Heidelberg Germany
| | - Holger A. Haenssle
- Department of Dermatology Venerology and Allergology University Medical Center Ruprecht‐Karls‐University Heidelberg Heidelberg Germany
| | - Alexander H. Enk
- Department of Dermatology Venerology and Allergology University Medical Center Ruprecht‐Karls‐University Heidelberg Heidelberg Germany
| | - Ferdinand Toberer
- Department of Dermatology Venerology and Allergology University Medical Center Ruprecht‐Karls‐University Heidelberg Heidelberg Germany
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22
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Salzmann M, Leiter U, Loquai C, Zimmer L, Ugurel S, Gutzmer R, Thoms KM, Enk AH, Hassel JC. Programmed cell death protein 1 inhibitors in advanced cutaneous squamous cell carcinoma: real-world data of a retrospective, multicenter study. Eur J Cancer 2020; 138:125-132. [PMID: 32882466 DOI: 10.1016/j.ejca.2020.07.029] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/30/2020] [Accepted: 07/26/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cutaneous squamous cell carcinoma (cSCC) is one of the most common malignancies of the skin. Even though most patients are sufficiently treated by surgical resection, some will eventually metastasize and need systemic therapy. Phase I and II studies have shown efficacy for programmed cell death protein 1 (PD-1) inhibitors, but cohort sizes are low and real-world data especially on long-term outcome are pending. METHODS Patients from six German skin cancer centers treated with PD-1 inhibitors (pembrolizumab, nivolumab or cemiplimab) for advanced cSCC were retrospectively studied. Internal patient records were analyzed for clinical outcome including response, progression-free survival (PFS), overall survival (OS) and toxicity. RESULTS Of 46 evaluable patients (median age: 76 years), the overall response rate (RR) was 58.7%, including 15.2% with complete response. The disease control rate was 80.4%. Both median PFS and OS were not reached, Kaplan-Meier estimated 1-year PFS was 58.8%. Patients responding to therapy showed durable remission. Response was independent of the PD-1 inhibitor used and also independent of the presence of distant metastases vs. locally advanced disease. Two predictive factors were found: Patients with primaries located on the leg had a poorer therapy outcome and patients with high lactate dehydrogenase serum levels at baseline. Treatment was overall tolerated well, with less than 10% of patients discontinuing therapy due to toxicity. CONCLUSIONS PD-1 inhibitors fulfill the need for an efficient systemic therapy for advanced cSCC and should be the new standard of care. With high RRs and durable disease control, neoadjuvant and adjuvant regimens should be evaluated.
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Affiliation(s)
- Martin Salzmann
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany.
| | - Ulrike Leiter
- Division for Dermatooncology, Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Carmen Loquai
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - Lisa Zimmer
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Selma Ugurel
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Ralf Gutzmer
- Department of Dermatology, Hannover Medical School, Skin Cancer Center Hannover, Hannover, Germany
| | - Kai-Martin Thoms
- Department of Dermatology, University Medical Center Goettingen, Goettingen, Germany
| | - Alexander H Enk
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica C Hassel
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
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23
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Reynolds NJ, Enk AH. The History and Future Prospects of ISID: A European Perspective. J Invest Dermatol 2020; 140:S178-S180. [PMID: 32800168 DOI: 10.1016/j.jid.2020.05.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/12/2020] [Accepted: 05/27/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Nick J Reynolds
- Institute of Translational and Clinical Medicine, Medical School, Newcastle University, Newcastle upon Tyne, England; Department of Dermatology, Royal Victoria Infirmary, Newcastle Upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, England.
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
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24
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Enk AH, Bachelez H. ESDR Academy for Future Leaders in Dermatology: A Modern Success Story to Foster Young Academic Dermatologists and Skin Scientists. J Invest Dermatol 2020; 140:S183-S184. [PMID: 32800170 DOI: 10.1016/j.jid.2020.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Alexander H Enk
- Department of Dermatology, Ruprecht Karls University, Heidelberg, Germany.
| | - Hervé Bachelez
- INSERM unit U1163, Necker Enfants Malades Hospital, Paris, France
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25
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Trennheuser L, Kölsche C, Enk AH, Hassel JC. Pleomorphes dermales Sarkom mit zerebralen Metastasen. J Dtsch Dermatol Ges 2020; 18:886-888. [DOI: 10.1111/ddg.14134_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Lukas Trennheuser
- Hautklinik und Nationales Zentrum für Tumorerkrankungen Universität Heidelberg
| | | | - Alexander H. Enk
- Hautklinik und Nationales Zentrum für Tumorerkrankungen Universität Heidelberg
| | - Jessica C. Hassel
- Hautklinik und Nationales Zentrum für Tumorerkrankungen Universität Heidelberg
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26
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Hartmann J, Enk AH, Gholam P. Sensitization following occupational exposure to methyl aminolevulinate: Report of two cases. Contact Dermatitis 2020; 83:50-52. [DOI: 10.1111/cod.13513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Julia Hartmann
- Department of Dermatology, Venerology and AllergologyUniversity Medical Center, Ruprecht‐Karls‐University Heidelberg Germany
| | - Alexander H. Enk
- Department of Dermatology, Venerology and AllergologyUniversity Medical Center, Ruprecht‐Karls‐University Heidelberg Germany
| | - Patrick Gholam
- Department of Dermatology, Venerology and AllergologyUniversity Medical Center, Ruprecht‐Karls‐University Heidelberg Germany
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27
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Trennheuser L, Kölsche C, Enk AH, Hassel JC. Pleomorphic dermal sarcoma with cerebral metastasis. J Dtsch Dermatol Ges 2020; 18:886-888. [PMID: 32558278 DOI: 10.1111/ddg.14134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Lukas Trennheuser
- Department of Dermatology and National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Kölsche
- Department of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology and National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Jessica C Hassel
- Department of Dermatology and National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
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28
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Lang N, Dick J, Slynko A, Schulz C, Dimitrakopoulou-Strauss A, Sachpekidis C, Enk AH, Hassel JC. Clinical significance of signs of autoimmune colitis in 18F-fluorodeoxyglucose positron emission tomography-computed tomography of 100 stage-IV melanoma patients. Immunotherapy 2020; 11:667-676. [PMID: 31088239 DOI: 10.2217/imt-2018-0146] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Aim: Autoimmune colitis is a typical and possible severe side effect among patients treated with ipilimumab. Patients & methods: We prospectively included 100 patients with metastasized melanoma under ipilimumab treatment in a radiological study of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT). PET evidence of pancolitis ('PET-colitis') was correlated with clinical variables. Results: We observed a significant correlation between PET-colitis and clinically significant diarrhoea, although PET-colitis was more frequent (49 vs 29% of patients, respectively). Neither PET-colitis nor diarrhoea was significantly correlated with response to therapy. Other immune-related adverse events, however, such as hypophysitis and hepatitis were associated with response to therapy and overall survival. Conclusion: Increased 18F-FDG uptake in the colon correlated with clinical symptoms but did not predict clinical outcome to ipilimumab.
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Affiliation(s)
- Nina Lang
- Department of Dermatology & National Center for Tumor Diseases, University Hospital Heidelberg, Germany
| | - Julika Dick
- Department of Dermatology & National Center for Tumor Diseases, University Hospital Heidelberg, Germany
| | - Alla Slynko
- Department of Mathematics, Natural & Economic Sciences, University of Applied Sciences, Ulm, Germany
| | - Carsten Schulz
- Department of Dermatology & National Center for Tumor Diseases, University Hospital Heidelberg, Germany
| | | | - Christos Sachpekidis
- Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology & National Center for Tumor Diseases, University Hospital Heidelberg, Germany
| | - Jessica C Hassel
- Department of Dermatology & National Center for Tumor Diseases, University Hospital Heidelberg, Germany
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29
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Zielonka M, Debatin D, Rütten A, Fröhling S, Deimling A, Warth A, Toberer F, Enk AH, Hassel JC. Zerebral metastasiertes Dermatofibrosarcoma protuberans. J Dtsch Dermatol Ges 2020; 18:143-146. [DOI: 10.1111/ddg.13992_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mareen Zielonka
- Hautklinik und Nationales Centrum für Tumorerkrankungen (NCT) Universitätsklinikum Heidelberg
| | - Daniel Debatin
- Onkologische Onkologische Schwerpunktpraxis Heidelberg Heidelberg
| | | | - Stefan Fröhling
- Translationale Onkologie Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | - Andreas Deimling
- Neuropathologie Pathologisches Institut Universitätsklinikum Heidelberg
| | - Arne Warth
- Pathologisches Institut Universitätsklinikum Heidelberg
| | - Ferdinand Toberer
- Hautklinik und Nationales Centrum für Tumorerkrankungen (NCT) Universitätsklinikum Heidelberg
| | - Alexander H. Enk
- Hautklinik und Nationales Centrum für Tumorerkrankungen (NCT) Universitätsklinikum Heidelberg
| | - Jessica C. Hassel
- Hautklinik und Nationales Centrum für Tumorerkrankungen (NCT) Universitätsklinikum Heidelberg
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30
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Zielonka M, Debatin D, Rütten A, Fröhling S, Deimling A, Warth A, Toberer F, Enk AH, Hassel JC. Cerebral metastases of a dermatofibrosarcoma protuberans. J Dtsch Dermatol Ges 2019; 18:143-145. [PMID: 31846212 DOI: 10.1111/ddg.13992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Mareen Zielonka
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Germany
| | | | | | - Stefan Fröhling
- Department of Translational Oncology, National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andreas Deimling
- Department of Neuropathology, Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - Arne Warth
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - Ferdinand Toberer
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Germany
| | - Jessica C Hassel
- Department of Dermatology and National Center for Tumor Diseases, University Hospital Heidelberg, Germany
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31
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Martin-Garcia D, Silva-Vilches C, Will R, Enk AH, Lonsdorf AS. Tumor-derived CCL20 affects B16 melanoma growth in mice. J Dermatol Sci 2019; 97:57-65. [PMID: 31883833 DOI: 10.1016/j.jdermsci.2019.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 11/08/2019] [Accepted: 12/08/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Chemokine ligand-20 (CCL20) expressed in the epidermis is a potent impetus for the recruitment of CC-chemokine receptor 6 (CCR6)-expressing subsets of DCs, B-cells and memory T-cells into the skin. CCL20 and CCR6+ immune cells have been detected in chronic inflammatory skin diseases and several malignancies, including melanoma. Yet, the functional contribution of the CCR6/CCL20 axis for melanoma progression remains controversial. OBJECTIVE The functional contribution of CCR6-expressing immune cell subsets and local CCL20 in the tumor microenvironment for the immune control of melanoma was studied. METHODS Homeostatic and inducible CCL20 secretion of murine (B16, Ret) and human (A375, C32) melanoma cells was analyzed by ELISA. To assess the functional relevance of CCR6/CCL20 interactions on local tumor progression, prestimulated or retrovirally transduced B16/F1 melanoma cells overexpressing CCL20 (B16-CCL20) were injected subcutaneously into C57BL/6 Wt mice and congenic CCR6-deficient (CCR6-/-) mice. Infiltrating leucocytes were examined by flow cytometry in tumors and draining lymph nodes (DLNs). RESULTS Melanoma cell lines up-regulate CCL20 secretion upon stimulation with pro-inflammatory cytokines in vitro. While only moderate changes in phenotype and composition of leucocytes were detected in advanced tumors and DLNs, mice injected with CCR6+ B16-CCL20 cells developed smaller tumors compared to B16-Control injected littermates, with CCR6-/- mice displaying the most pronounced reduction in tumor growth and incidence. CONCLUSION Our results suggest that CCR6/CCL20 interactions and individual independent effects of CCL20 and CCR6 in the microenvironment may be essential for melanoma progression and suggest a decisive role of this chemokine axis for melanoma pathogenesis beyond chemoattraction.
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Affiliation(s)
- Diego Martin-Garcia
- Department of Dermatology, University Hospital, Ruprecht-Karls-University of Heidelberg, Germany
| | - Cinthia Silva-Vilches
- Department of Dermatology, University Hospital, Ruprecht-Karls-University of Heidelberg, Germany
| | - Rainer Will
- Genomics and Proteomics Core Facility, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology, University Hospital, Ruprecht-Karls-University of Heidelberg, Germany
| | - Anke S Lonsdorf
- Department of Dermatology, University Hospital, Ruprecht-Karls-University of Heidelberg, Germany.
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32
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Hekler A, Utikal JS, Enk AH, Hauschild A, Weichenthal M, Maron RC, Berking C, Haferkamp S, Klode J, Schadendorf D, Schilling B, Holland-Letz T, Izar B, von Kalle C, Fröhling S, Brinker TJ, Schmitt L, Peitsch WK, Hoffmann F, Becker JC, Drusio C, Jansen P, Klode J, Lodde G, Sammet S, Schadendorf D, Sondermann W, Ugurel S, Zader J, Enk A, Salzmann M, Schäfer S, Schäkel K, Winkler J, Wölbing P, Asper H, Bohne AS, Brown V, Burba B, Deffaa S, Dietrich C, Dietrich M, Drerup KA, Egberts F, Erkens AS, Greven S, Harde V, Jost M, Kaeding M, Kosova K, Lischner S, Maagk M, Messinger AL, Metzner M, Motamedi R, Rosenthal AC, Seidl U, Stemmermann J, Torz K, Velez JG, Haiduk J, Alter M, Bär C, Bergenthal P, Gerlach A, Holtorf C, Karoglan A, Kindermann S, Kraas L, Felcht M, Gaiser MR, Klemke CD, Kurzen H, Leibing T, Müller V, Reinhard RR, Utikal J, Winter F, Berking C, Eicher L, Hartmann D, Heppt M, Kilian K, Krammer S, Lill D, Niesert AC, Oppel E, Sattler E, Senner S, Wallmichrath J, Wolff H, Gesierich A, Giner T, Glutsch V, Kerstan A, Presser D, Schrüfer P, Schummer P, Stolze I, Weber J, Drexler K, Haferkamp S, Mickler M, Stauner CT, Thiem A. Superior skin cancer classification by the combination of human and artificial intelligence. Eur J Cancer 2019; 120:114-121. [DOI: 10.1016/j.ejca.2019.07.019] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
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Hekler A, Utikal JS, Enk AH, Solass W, Schmitt M, Klode J, Schadendorf D, Sondermann W, Franklin C, Bestvater F, Flaig MJ, Krahl D, von Kalle C, Fröhling S, Brinker TJ. Deep learning outperformed 11 pathologists in the classification of histopathological melanoma images. Eur J Cancer 2019; 118:91-96. [DOI: 10.1016/j.ejca.2019.06.012] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 12/29/2022]
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Brinker TJ, Hekler A, Enk AH, Berking C, Haferkamp S, Hauschild A, Weichenthal M, Klode J, Schadendorf D, Holland-Letz T, von Kalle C, Fröhling S, Schilling B, Utikal JS. Deep neural networks are superior to dermatologists in melanoma image classification. Eur J Cancer 2019; 119:11-17. [DOI: 10.1016/j.ejca.2019.05.023] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
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Maron RC, Weichenthal M, Utikal JS, Hekler A, Berking C, Hauschild A, Enk AH, Haferkamp S, Klode J, Schadendorf D, Jansen P, Holland-Letz T, Schilling B, von Kalle C, Fröhling S, Gaiser MR, Hartmann D, Gesierich A, Kähler KC, Wehkamp U, Karoglan A, Bär C, Brinker TJ, Schmitt L, Peitsch WK, Hoffmann F, Becker JC, Drusio C, Jansen P, Klode J, Lodde G, Sammet S, Schadendorf D, Sondermann W, Ugurel S, Zader J, Enk A, Salzmann M, Schäfer S, Schäkel K, Winkler J, Wölbing P, Asper H, Bohne AS, Brown V, Burba B, Deffaa S, Dietrich C, Dietrich M, Drerup KA, Egberts F, Erkens AS, Greven S, Harde V, Jost M, Kaeding M, Kosova K, Lischner S, Maagk M, Messinger AL, Metzner M, Motamedi R, Rosenthal AC, Seidl U, Stemmermann J, Torz K, Velez JG, Haiduk J, Alter M, Bär C, Bergenthal P, Gerlach A, Holtorf C, Karoglan A, Kindermann S, Kraas L, Felcht M, Gaiser MR, Klemke CD, Kurzen H, Leibing T, Müller V, Reinhard RR, Utikal J, Winter F, Berking C, Eicher L, Hartmann D, Heppt M, Kilian K, Krammer S, Lill D, Niesert AC, Oppel E, Sattler E, Senner S, Wallmichrath J, Wolff H, Giner T, Glutsch V, Kerstan A, Presser D, Schrüfer P, Schummer P, Stolze I, Weber J, Drexler K, Haferkamp S, Mickler M, Stauner CT, Thiem A. Systematic outperformance of 112 dermatologists in multiclass skin cancer image classification by convolutional neural networks. Eur J Cancer 2019; 119:57-65. [DOI: 10.1016/j.ejca.2019.06.013] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 01/07/2023]
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Zielonka M, Keller A, Enk AH, Toberer F. Suprapubische, erythematöse Nodi und Papeln bei einem 58‐jährigen Patienten. J Dtsch Dermatol Ges 2019; 17:848-851. [DOI: 10.1111/ddg.13893_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Mareen Zielonka
- Klinik für DermatologieVenerologie und Allergologie am Universitätsklinikum Heidelberg, Ruprecht‐Karls‐Universität Heidelberg
| | - Aric Keller
- Klinik für DermatologieVenerologie und Allergologie am Universitätsklinikum Heidelberg, Ruprecht‐Karls‐Universität Heidelberg
| | - Alexander H. Enk
- Klinik für DermatologieVenerologie und Allergologie am Universitätsklinikum Heidelberg, Ruprecht‐Karls‐Universität Heidelberg
| | - Ferdinand Toberer
- Klinik für DermatologieVenerologie und Allergologie am Universitätsklinikum Heidelberg, Ruprecht‐Karls‐Universität Heidelberg
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Zielonka M, Keller A, Enk AH, Toberer F. Erythematous suprapubic nodules and papules in a 58-year-old patient. J Dtsch Dermatol Ges 2019; 17:848-851. [PMID: 31305002 DOI: 10.1111/ddg.13893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Mareen Zielonka
- Department of Dermatology, Venereology and Allergology, Heidelberg University Medical Center, Ruprecht Karl University, Heidelberg, Germany
| | - Aric Keller
- Department of Dermatology, Venereology and Allergology, Heidelberg University Medical Center, Ruprecht Karl University, Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology, Venereology and Allergology, Heidelberg University Medical Center, Ruprecht Karl University, Heidelberg, Germany
| | - Ferdinand Toberer
- Department of Dermatology, Venereology and Allergology, Heidelberg University Medical Center, Ruprecht Karl University, Heidelberg, Germany
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Brinker TJ, Hekler A, Enk AH, von Kalle C. Enhanced classifier training to improve precision of a convolutional neural network to identify images of skin lesions. PLoS One 2019; 14:e0218713. [PMID: 31233565 PMCID: PMC6590821 DOI: 10.1371/journal.pone.0218713] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 06/09/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND In recent months, multiple publications have demonstrated the use of convolutional neural networks (CNN) to classify images of skin cancer as precisely as dermatologists. However, these CNNs failed to outperform the International Symposium on Biomedical Imaging (ISBI) 2016 challenge which ranked the average precision for classification of dermoscopic melanoma images. Accordingly, the technical progress represented by these studies is limited. In addition, the available reports are impossible to reproduce, due to incomplete descriptions of training procedures and the use of proprietary image databases or non-disclosure of used images. These factors prevent the comparison of various CNN classifiers in equal terms. OBJECTIVE To demonstrate the training of an image-classifier CNN that outperforms the winner of the ISBI 2016 CNNs challenge by using open source images exclusively. METHODS A detailed description of the training procedure is reported while the used images and test sets are disclosed fully, to insure the reproducibility of our work. RESULTS Our CNN classifier outperforms all recent attempts to classify the original ISBI 2016 challenge test data (full set of 379 test images), with an average precision of 0.709 (vs. 0.637 of the ISBI winner) and with an area under the receiver operating curve of 0.85. CONCLUSION This work illustrates the potential for improving skin cancer classification with enhanced training procedures for CNNs, while avoiding the use of costly equipment or proprietary image data.
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Affiliation(s)
- Titus J. Brinker
- National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
- * E-mail:
| | - Achim Hekler
- National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Alexander H. Enk
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christof von Kalle
- National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
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Abstract
The immunomodulatory potential and low incidence of severe side effects of high-dose intravenous immunoglobulin (IVIg) treatment led to its successful application in a variety of dermatological autoimmune diseases over the last two decades. IVIg is usually administered at a dose of 2 g per kg body weight distributed over 2–5 days every 4 weeks. They are most commonly used as a second- or third-line treatment in dermatological autoimmune disease (pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, dermatomyositis, systemic vasculitis, and systemic lupus erythematosus). However, first-line treatment may be warranted in special circumstances like concomitant malignancy, a foudroyant clinical course, and contraindications against alternative treatments. Furthermore, IVIg can be considered first line in scleromyxedema. Production of IVIg for medical use is strictly regulated to ensure a low risk of pathogen transmission and comparable quality of individual batches. More common side effects include nausea, headache, fatigue, and febrile infusion reactions. Serious side effects are rare and include thrombosis and embolism, pulmonary edema, renal failure, aseptic meningitis, and severe anaphylactic reactions. Regarding the mechanism of action, one can discriminate between functions of the Fcγ region and the F(ab)2 region and their effects on a cellular level. These functions are not mutually exclusive, and more than one pathway may contribute to the beneficial effects. Here, we present a historical background, details on manufacturing, hypotheses on the mechanisms of action, information on the clinical application in the abovementioned conditions, and a brief outlook on future directions of IVIg treatment in dermatology.
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Affiliation(s)
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
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Hekler A, Utikal JS, Enk AH, Berking C, Klode J, Schadendorf D, Jansen P, Franklin C, Holland-Letz T, Krahl D, von Kalle C, Fröhling S, Brinker TJ. Pathologist-level classification of histopathological melanoma images with deep neural networks. Eur J Cancer 2019; 115:79-83. [PMID: 31129383 DOI: 10.1016/j.ejca.2019.04.021] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND The diagnosis of most cancers is made by a board-certified pathologist based on a tissue biopsy under the microscope. Recent research reveals a high discordance between individual pathologists. For melanoma, the literature reports 25-26% of discordance for classifying a benign nevus versus malignant melanoma. Deep learning was successfully implemented to enhance the precision of lung and breast cancer diagnoses. The aim of this study is to illustrate the potential of deep learning to assist human assessment for a histopathologic melanoma diagnosis. METHODS Six hundred ninety-five lesions were classified by an expert histopathologist in accordance with current guidelines (350 nevi and 345 melanomas). Only the haematoxylin and eosin stained (H&E) slides of these lesions were digitalised using a slide scanner and then randomly cropped. Five hundred ninety-five of the resulting images were used for the training of a convolutional neural network (CNN). The additional 100 H&E image sections were used to test the results of the CNN in comparison with the original class labels. FINDINGS The total discordance with the histopathologist was 18% for melanoma (95% confidence interval [CI]: 7.4-28.6%), 20% for nevi (95% CI: 8.9-31.1%) and 19% for the full set of images (95% CI: 11.3-26.7%). INTERPRETATION Even in the worst case, the discordance of the CNN was about the same compared with the discordance between human pathologists as reported in the literature. Despite the vastly reduced amount of data, time necessary for diagnosis and cost compared with the pathologist, our CNN archived on-par performance. Conclusively, CNNs indicate to be a valuable tool to assist human melanoma diagnoses.
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Affiliation(s)
- Achim Hekler
- National Center for Tumor Diseases, German Cancer Research Center, Heidelberg, Germany
| | - Jochen Sven Utikal
- Department of Dermatology, Heidelberg University, Mannheim, Germany; Skin Cancer Unit, German Cancer Research Center, Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Carola Berking
- Department of Dermatology, University Hospital Munich (LMU), Munich, Germany
| | - Joachim Klode
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Philipp Jansen
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Cindy Franklin
- Department of Dermatology, University Hospital Cologne, Cologne, Germany
| | - Tim Holland-Letz
- Department of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg
| | - Dieter Krahl
- Private Laboratory of Dermatohistopathology, Mönchhofstraße 52, 69120 Heidelberg
| | - Christof von Kalle
- National Center for Tumor Diseases, German Cancer Research Center, Heidelberg, Germany
| | - Stefan Fröhling
- National Center for Tumor Diseases, German Cancer Research Center, Heidelberg, Germany
| | - Titus Josef Brinker
- National Center for Tumor Diseases, German Cancer Research Center, Heidelberg, Germany; Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany.
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Dick J, Kroehl V, Enk AH, Toberer F. Reticular erythematous mucinosis in a young woman: Complete remission following oral hydroxychloroquine. Australas J Dermatol 2019; 60:e343-e345. [DOI: 10.1111/ajd.13075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Julika Dick
- Department of Dermatology, Venerology and Allergology University Medical Center Ruprecht‐Karls‐University Heidelberg Heidelberg Germany
| | | | - Alexander H Enk
- Department of Dermatology, Venerology and Allergology University Medical Center Ruprecht‐Karls‐University Heidelberg Heidelberg Germany
| | - Ferdinand Toberer
- Department of Dermatology, Venerology and Allergology University Medical Center Ruprecht‐Karls‐University Heidelberg Heidelberg Germany
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Wald A, Schmidt E, Toberer F, Gutschalk A, Rentzsch K, Enk AH, Hoffmann JHO. Overlap of Bullous, Anti-Laminin-332, and Anti-p200 Pemphigoid With Concomitant Anti-Contactin-1-Positive Inflammatory Polyneuropathy Treated With Intravenous Immunoglobulins as a Manifestation of Epitope Spreading. JAMA Dermatol 2019; 155:631-633. [PMID: 30892575 DOI: 10.1001/jamadermatol.2018.5536] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Alexander Wald
- Department of Dermatology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Enno Schmidt
- Department of Dermatology, University Hospital of Lübeck, Lübeck, Germany
| | - Ferdinand Toberer
- Department of Dermatology, University Hospital of Heidelberg, Heidelberg, Germany
| | | | | | - Alexander H Enk
- Department of Dermatology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Jochen H O Hoffmann
- Department of Dermatology, University Hospital of Heidelberg, Heidelberg, Germany
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Hartmann J, Enk AH, Toberer F. Hautinfiltrate einer chronisch lymphatischen Leukämie getriggert durch topische Imiquimodtherapie. J Dtsch Dermatol Ges 2019; 17 Suppl 2:9-11. [DOI: 10.1111/ddg.13781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Julia Hartmann
- Universitäts‐HautklinikRuprecht‐Karls‐Universität Heidelberg Im Neuenheimer Feld 440 69120 Heidelberg
| | - Alexander H. Enk
- Universitäts‐HautklinikRuprecht‐Karls‐Universität Heidelberg Im Neuenheimer Feld 440 69120 Heidelberg
| | - Ferdinand Toberer
- Universitäts‐HautklinikRuprecht‐Karls‐Universität Heidelberg Im Neuenheimer Feld 440 69120 Heidelberg
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Yilmaz OK, Haeberle S, Zhang M, Fritzler MJ, Enk AH, Hadaschik EN. Scurfy Mice Develop Features of Connective Tissue Disease Overlap Syndrome and Mixed Connective Tissue Disease in the Absence of Regulatory T Cells. Front Immunol 2019; 10:881. [PMID: 31068947 PMCID: PMC6491778 DOI: 10.3389/fimmu.2019.00881] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/05/2019] [Indexed: 01/12/2023] Open
Abstract
Due to a missense mutation in the Foxp3 gene, scurfy mice are deficient in functional regulatory T cells (Treg). The consequent loss of peripheral tolerance manifests itself by fatal autoimmune mediated multi-organ disease. Previous studies have outlined the systemic inflammatory disease and demonstrated production of anti-nuclear antibodies (ANA) in scurfy mice. However, specific autoantibody targets remained to be defined. ANA are immunological markers for several connective tissue diseases (CTD) and target a large number of intracellular molecules. Therefore, we examined scurfy sera for the presence of different ANA specificities and further assessed the organ involvement in these animals. Indirect immunofluorescence was used as a screen for ANA in the sera of scurfy mice and dilutions of 1/100 were considered positive. Addressable laser bead immunoassays (ALBIA) were used to detect specific autoantibody targets. Subsequent histological tissue evaluation was verified by hematoxylin and eosin (H&E) staining. In our study, we observed that nearly all scurfy mice produced ANA. The most prevalent pattern in scurfy sera was nuclear coarse speckled, also known as the AC-5 pattern according to the International Consensus on ANA Patterns. U1-ribonucleoprotein (U1RNP) was found to be the most common target antigen recognized by autoantibodies in scurfy mice. Additionally, scurfy mice exhibited a mild myositis with histological characteristics similar to polymyositis/dermatomyositis. Myopathy-specific autoantibody profile revealed significantly increased levels of anti-SMN (survival of motor neuron) as well as anti-Gemin3 antibodies in scurfy sera. Overall, we demonstrate that the impaired peripheral tolerance in the absence of regulatory T cells in scurfy mice is associated with features of mixed connective tissue disease (MCTD). This includes, along with our previous findings, very high titers of anti-U1RNP antibodies and an inflammatory myopathy.
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Affiliation(s)
- Osman K Yilmaz
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Stefanie Haeberle
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Meifeng Zhang
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Marvin J Fritzler
- Mitogen Advanced Diagnostics Laboratory, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Eva N Hadaschik
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany.,Department of Dermatology, University Hospital of Essen, Essen, Germany
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Brinker TJ, Buslaff F, Suhre JL, Silchmüller MP, Divizieva E, Wilhelm J, Hillebrand G, Penka D, Gaim B, Swoboda S, Baumermann S, Walther JW, Brieske CM, Jakob L, Baumert HM, Anhuef O, Schmidt SM, Alfitian J, Batra A, Taha L, Mons U, Hofmann FJ, Haney AC, Haney CM, Schaible S, Tran TA, Beißwenger H, Stark T, Groneberg DA, Seeger W, Srivastava A, Gall H, Holzapfel J, Rigotti NA, Baudson TG, Enk AH, Fröhling S, von Kalle C, Bernardes-Souza B, Pereira RMDOS, Thomas R. Process Evaluation of a Medical Student-Delivered Smoking Prevention Program for Secondary Schools: Protocol for the Education Against Tobacco Cluster Randomized Trial. JMIR Res Protoc 2019; 8:e13508. [PMID: 30973348 PMCID: PMC6482400 DOI: 10.2196/13508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 03/22/2019] [Accepted: 03/23/2019] [Indexed: 01/10/2023] Open
Abstract
Background Most smokers start smoking during their early adolescence under the impression that smoking entails positive attributes. Given the addictive nature of cigarettes, however, many of them might end up as long-term smokers and suffering from tobacco-related diseases. To prevent tobacco use among adolescents, the large international medical students’ network Education Against Tobacco (EAT) educates more than 40,000 secondary school students per year in the classroom setting, using evidence-based self-developed apps and strategies. Objective This study aimed to evaluate the long-term effectiveness of the school-based EAT intervention in reducing smoking prevalence among seventh-grade students in Germany. Additionally, we aimed to improve the intervention by drawing conclusions from our process evaluation. Methods We conduct a cluster-randomized controlled trial with measurements at baseline and 9, 16, and 24 months postintervention via paper-and-pencil questionnaires administered by teachers. The study groups consist of randomized schools receiving the 2016 EAT curriculum and control schools with comparable baseline data (no intervention). The primary outcome is the difference of change in smoking prevalence between the intervention and control groups at the 24-month follow-up. Secondary outcomes are between-group differences of changes in smoking-related attitudes and the number of new smokers, quitters, and never-smokers. Results A total of 11,268 students of both sexes, with an average age of 12.32 years, in seventh grade of 144 secondary schools in Germany were included at baseline. The prevalence of cigarette smoking in our sample was 2.6%. The process evaluation surveys were filled out by 324 medical student volunteers, 63 medical student supervisors, 4896 students, and 141 teachers. Conclusions The EAT cluster randomized trial is the largest school-based tobacco-prevention study in Germany conducted to date. Its results will provide important insights with regards to the effectiveness of medical student–delivered smoking prevention programs at school. International Registered Report Identifier (IRRID) DERR1-10.2196/13508
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Affiliation(s)
- Titus Josef Brinker
- Department of Translational Oncology, National Center for Tumor Diseases, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany.,Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Fabian Buslaff
- Department of Translational Oncology, National Center for Tumor Diseases, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany
| | | | | | | | - Jilada Wilhelm
- Faculty of Medicine, University of Düsseldorf, Düsseldorf, Germany
| | - Gabriel Hillebrand
- National Center for Tumor Diseases, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany
| | - Dominik Penka
- Faculty of Medicine, Justus-Liebig-University of Gießen, Gießen, Germany
| | - Benedikt Gaim
- Faculty of Medicine, University of Regensburg, Regensburg, Germany
| | - Susanne Swoboda
- Faculty of Medicine, University of Regensburg, Regensburg, Germany
| | | | - Jörg Werner Walther
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr-University Bochum (IPA), Bochum, Germany
| | | | - Lena Jakob
- Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Ole Anhuef
- Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Tübingen, Germany
| | - Selina Marisa Schmidt
- Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Tübingen, Germany
| | - Jonas Alfitian
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Anil Batra
- Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Tübingen, Germany
| | - Lava Taha
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Erlangen, Erlangen, Germany
| | - Ute Mons
- Cancer Prevention Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Ailís Ceara Haney
- National Center for Tumor Diseases, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany
| | - Caelán Max Haney
- National Center for Tumor Diseases, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany
| | - Samuel Schaible
- National Center for Tumor Diseases, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany
| | - Thien-An Tran
- National Center for Tumor Diseases, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany
| | - Hanna Beißwenger
- Faculty of Medicine, University of Göttingen, Göttingen, Germany
| | - Tobias Stark
- Faculty of Medicine, University of Regensburg, Regensburg, Germany
| | - David A Groneberg
- Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University of Frankfurt am Main, Frankfurt am Main, Germany
| | - Werner Seeger
- Faculty of Medicine, Justus-Liebig-University of Gießen, Gießen, Germany
| | - Aayushi Srivastava
- National Center for Tumor Diseases, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany
| | - Henning Gall
- Faculty of Medicine, Justus-Liebig-University of Gießen, Gießen, Germany
| | - Julia Holzapfel
- Faculty of Medicine, Justus-Liebig-University of Gießen, Gießen, Germany
| | - Nancy A Rigotti
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Tanja Gabriele Baudson
- Cognitive Science and Assessment Institute, University of Luxembourg, Luxembourg, Luxembourg
| | - Alexander H Enk
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Fröhling
- National Center for Tumor Diseases, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany
| | - Christof von Kalle
- Department of Translational Oncology, National Center for Tumor Diseases, German Cancer Research Center (DKFZ), University of Heidelberg, Heidelberg, Germany
| | | | | | - Roger Thomas
- Health Sciences Centre, University of Calgary, Calgary, AB, Canada
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Brinker TJ, Hekler A, Enk AH, Klode J, Hauschild A, Berking C, Schilling B, Haferkamp S, Schadendorf D, Holland-Letz T, Utikal JS, von Kalle C. Deep learning outperformed 136 of 157 dermatologists in a head-to-head dermoscopic melanoma image classification task. Eur J Cancer 2019; 113:47-54. [PMID: 30981091 DOI: 10.1016/j.ejca.2019.04.001] [Citation(s) in RCA: 176] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/19/2019] [Accepted: 04/02/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Recent studies have successfully demonstrated the use of deep-learning algorithms for dermatologist-level classification of suspicious lesions by the use of excessive proprietary image databases and limited numbers of dermatologists. For the first time, the performance of a deep-learning algorithm trained by open-source images exclusively is compared to a large number of dermatologists covering all levels within the clinical hierarchy. METHODS We used methods from enhanced deep learning to train a convolutional neural network (CNN) with 12,378 open-source dermoscopic images. We used 100 images to compare the performance of the CNN to that of the 157 dermatologists from 12 university hospitals in Germany. Outperformance of dermatologists by the deep neural network was measured in terms of sensitivity, specificity and receiver operating characteristics. FINDINGS The mean sensitivity and specificity achieved by the dermatologists with dermoscopic images was 74.1% (range 40.0%-100%) and 60% (range 21.3%-91.3%), respectively. At a mean sensitivity of 74.1%, the CNN exhibited a mean specificity of 86.5% (range 70.8%-91.3%). At a mean specificity of 60%, a mean sensitivity of 87.5% (range 80%-95%) was achieved by our algorithm. Among the dermatologists, the chief physicians showed the highest mean specificity of 69.2% at a mean sensitivity of 73.3%. With the same high specificity of 69.2%, the CNN had a mean sensitivity of 84.5%. INTERPRETATION A CNN trained by open-source images exclusively outperformed 136 of the 157 dermatologists and all the different levels of experience (from junior to chief physicians) in terms of average specificity and sensitivity.
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Affiliation(s)
- Titus J Brinker
- National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany; Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany.
| | - Achim Hekler
- National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
| | - Alexander H Enk
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Joachim Klode
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Axel Hauschild
- Department of Dermatology, University Hospital Kiel, Kiel, Germany
| | - Carola Berking
- Department of Dermatology, University Hospital Munich (LMU), Munich, Germany
| | - Bastian Schilling
- Department of Dermatology, University Hospital Würzburg, Würzburg, Germany
| | - Sebastian Haferkamp
- Department of Dermatology, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Tim Holland-Letz
- Department of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Jochen S Utikal
- Department of Dermatology, Heidelberg University, Mannheim, Germany; Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christof von Kalle
- National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
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Hartmann J, Schüler S, Enk AH, Lonsdorf AS. Skin cancer in organ transplant recipients: dynamics in the incidence and clinical predictors for the first and subsequent post-transplant non-melanoma skin cancer. J Eur Acad Dermatol Venereol 2019; 33:1281-1289. [PMID: 30811675 DOI: 10.1111/jdv.15538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 02/11/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Risk factors for primary non-melanoma skin cancer (NMSC) in organ transplant recipients (OTR) have been well described. Data for subsequent NMSC and dynamics in their occurrence in OTR are limited. OBJECTIVE To study long-term risks of primary and subsequent NMSC and associated risk factors in OTR. METHODS A retrospective single-centre cohort study analysing medical records from a dermato-oncological specialty clinic. RESULTS Of 464 OTR 110 (23.7%) developed at least one, 73 (15.7%) two and 51 (11%) three NMSC during a median follow-up of 9.6 years. Cumulative incidences at 5, 10 and 15 years were 14.7%, 23.5% and 34.5% for the first and 75.8%, 86.5% and 93.3% for the second. Median time-to-diagnosis declined from 22 years (95% CI 19-25) to 2 years (1-3) and about 1 year (0-2) for the first, second and third NMSC. Risk for subsequent NMSC only partially related to risk factors for the primary NMSC. Histologic type of the first NMSC predicted subtype and time-to-diagnosis of the subsequent NMSC. CONCLUSIONS A first post-transplant NMSC, particularly a SCC, confers a high risk for subsequent NMSC arising with accelerated dynamics. Risk-adapted dermato-oncologic surveillance is advisable for all OTR.
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Affiliation(s)
- J Hartmann
- Department of Dermatology, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | - S Schüler
- Medical Biometry, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | - A H Enk
- Department of Dermatology, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany.,National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
| | - A S Lonsdorf
- Department of Dermatology, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany.,National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
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Winkler JK, Enk AH, Haenssle HA, Toberer F. Retikuläre Hyperpigmentierungen an Rumpf und Beugen bei einem 16-jährigen Jungen. J Dtsch Dermatol Ges 2019; 17:201-204. [DOI: 10.1111/ddg.13738_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hartmann J, Haenssle HA, Enk AH, Toberer F. Fast-growing Painful Leg Ulcers in a 26-year-old Woman with Systemic Lupus Erythematosus: A Quiz. Acta Derm Venereol 2019; 99:250-252. [PMID: 30229266 DOI: 10.2340/00015555-3044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Julia Hartmann
- Department of Dermatology, Venerology and Allergology, University Medical Center, Ruprecht-Karls-University, Im Neuenheimer Feld 440, DE-69120 Heidelberg, Germany.
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Winkler JK, Enk AH, Haenssle HA, Toberer F. Reticular hyperpigmentation on the trunk and flexures of the extremities in a 16-year-old boy. J Dtsch Dermatol Ges 2018; 17:201-204. [DOI: 10.1111/ddg.13738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Julia K. Winkler
- University Hospital Heidelberg, Department of Dermatology; Heidelberg Germany
| | - Alexander H. Enk
- University Hospital Heidelberg, Department of Dermatology; Heidelberg Germany
| | - Holger A. Haenssle
- University Hospital Heidelberg, Department of Dermatology; Heidelberg Germany
| | - Ferdinand Toberer
- University Hospital Heidelberg, Department of Dermatology; Heidelberg Germany
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