Risk and protective factors for sporadic basal cell carcinoma: results of a two-centre case-control study in southern Germany. Clinical actinic elastosis may be a protective factor

BACKGROUND

There are very few data regarding sun exposure behaviour of patients with basal cell carcinoma (BCC) in central Europe.

OBJECTIVES

A case-control study of patients with sporadic BCC was conducted to assess the risk of occupational and leisure-time sun exposure behaviour, precursor lesions for skin cancer and phenotypic factors on the development of sporadic BCC in Ulm and Dresden, Germany.

METHODS

A comparison was made of 213 patients with BCC (128 from Ulm, 85 from Dresden; 103 men and 110 women; median age at diagnosis 69 years) and 411 controls (237 from Ulm, 174 from Dresden; 197 men and 214 women; median age 58 years). Crude odds ratios (ORs) and corresponding 95% confidence intervals for all of 64 possible risk factors revealed strong associations in 33 items. Selection of important risk factors was performed in a multiple logistic regression.

RESULTS

For sporadic BCC, an increased risk was shown for persons with actinic cheilitis (OR 7.1), actinic keratosis (OR 2.7) and solar lentigo (OR 2.5). The only phenotypic factor indicating risk of sporadic BCC was hair colour, with a higher risk for red/fair than brown/black hair (OR 4.3). There was an increased risk for persons with BCC in first-degree relatives (OR 5.1) and those with sunburn 20 years before sporadic BCC was diagnosed (OR 3.6). Additionally, occupational ultraviolet (UV) exposure appeared to be a risk factor (OR 2.4). In contrast, clinical actinic elastosis showed a protective effect (OR 0.1).

CONCLUSIONS

In contrast to earlier reports, clinical actinic elastosis turned out to be the only protective factor for sporadic BCC. A special relationship between wrinkling and BCC risk could not be shown. For basic research, future work should be aimed at elucidating further the different forms of collagen repair processes after intermittent and/or chronic UV exposure. The data strongly support the recommendation that a change in recreational UV exposure habits in individuals, and sunburn avoidance in particular, are necessary not only because of the increased long-term risk of melanoma, but also because of the risk of other skin cancers such as sporadic BCC.

Outdoor activities in childhood: a protective factor for cutaneous melanoma? Results of a case-control study in 271 matched pairs

BACKGROUND

A matched case-control study was performed in Munich, Germany, in 1996-97 to evaluate the risk of cutaneous melanoma due to ultraviolet (UV) exposure behaviour in Southern Bavaria, Germany.

OBJECTIVES

Patients with cutaneous melanoma and controls were investigated by two physicians using a standardized questionnaire to identify risk factors for the development of melanoma, such as professional and leisure sun exposure behaviour. In each person, a total body examination was performed to detect benign skin alterations, phenotypic characteristics and precursor lesions for skin cancer.

PATIENTS/METHODS

A total of 271 melanoma patients and 271 controls were individually matched for residence, age and gender. A multiple conditional logistic regression analysis was performed.

RESULTS

Of 56 factors, those risk factors with a strong effect on the development of melanoma were: the existence of melanoma in first degree relatives, solar lentigo, actinic keratosis, actinic cheilitis, skin phototype, immediate skin reaction to UV light at the start of the outdoor season, sunburn in childhood and sun exposure during holidays in sunny areas 20 years before melanoma was diagnosed; outdoor activities in childhood were found to be protective.

CONCLUSIONS

Sunburn in childhood and increased sun exposure during annual holidays in sunny areas should be avoided. In contrast, outdoor activities in childhood, including soccer and gardening, should be encouraged because they are associated with a lower risk of melanoma formation.

Activation by IKKalpha of a second, evolutionary conserved, NF-kappa B signaling pathway

In mammals, the canonical nuclear factor kappaB (NF-kappaB) signaling pathway activated in response to infections is based on degradation of IkappaB inhibitors. This pathway depends on the IkappaB kinase (IKK), which contains two catalytic subunits, IKKalpha and IKKbeta. IKKbeta is essential for inducible IkappaB phosphorylation and degradation, whereas IKKalpha is not. Here we show that IKKalpha is required for B cell maturation, formation of secondary lymphoid organs, increased expression of certain NF-kappaB target genes, and processing of the NF-kappaB2 (p100) precursor. IKKalpha preferentially phosphorylates NF-kappaB2, and this activity requires its phosphorylation by upstream kinases, one of which may be NF-kappaB-inducing kinase (NIK). IKKalpha is therefore a pivotal component of a second NF-kappaB activation pathway based on regulated NF-kappaB2 processing rather than IkappaB degradation.

UVB-induced decrease of p16/CDKN2A expression in skin cancer patients

The lack of p16 expression has been shown in cultured melanoma cells, however contradictory evidence for p16 expression in melanoma tissues exist. Ultraviolet (UV) C and UVB have been shown to affect p16 expression, which impairs cell cycle regulation in vitro and in vivo. In this study, p16/CDKN2A gene expression was determined by reverse transcription polymerase chain reaction in seven skin cancer patients, in one dysplastic nevus patient and in seven healthy individuals, prior to UVB exposure and at various times after application of one minimal erythema dose (MED). Five of the seven skin cancer patients showed a down-regulation of p16/CDKN2A expression after UVB exposure, while controls remained unaltered. The UVB-induced decline of p16/CDKN2A in skin cancer patients might offer new insights into photocarcinogenesis. The putative sequence of events could start with a down-regulation of p16/CDKN2A expression, which would lead to impaired cell cycle regulation. Altered expression patterns of p16/CDKN2A following UVB exposure could be of value for identifying people with an increased risk of UV-induced skin cancer.

Interlaboratory evaluation of a new reverse transcriptase polymerase chain reaction-based enzyme-linked immunosorbent assay for the detection of circulating melanoma cells: a multicenter study of the Dermatologic Cooperative Oncology Group

PURPOSE

Reverse transcription-polymerase chain reaction (RT-PCR)-based detection of tyrosinase mRNA is the most frequently used laboratory method for the detection of circulating tumor cells in melanoma patients. However, previously published results showed considerable variability in the PCR positivity rates.

MATERIALS AND METHODS

We designed a collaborative study to assess the sensitivity, specificity, and clinical relevance of a new standardized RT-PCR-based enzyme-linked immunosorbent assay (ELISA) for the detection of circulating melanoma cells. Blood samples of healthy donors mixed with cells of a melanoma cell line were prepared in a blinded fashion, and aliquots were sent to seven participating laboratories experienced in RT-PCR.

RESULTS

The results demonstrate a high sensitivity (1 melanoma cell/mL blood) and specificity (no false-negatives and 7.4% [2 of 28] false-positives) of the assay and a satisfactory rate of interlaboratory reproducibility. The analysis of aliquots of blinded samples derived from 60 melanoma patients identified tyrosinase mRNA in 17 of 60 (28.3%): three (20%) of 15 stage I patients, two (13.3%) of 15 stage II patients, five (35.7%) of 14 stage III patients, and seven (43.8%) of 16 stage IV patients. The interlaboratory reproducibility of positive samples, however, was extremely low and indicates the presence of low amounts of target mRNA.

CONCLUSION

Reverse transcriptase-PCR ELISA has a high sensitivity and specificity for the detection of tyrosinase mRNA in peripheral blood cells. The low interlaboratory reproducibility for the detection of tumor cells in blood samples of melanoma patients, however, raises the question of relevance of this assay for clinical use.

Quantitation of herpes simplex DNA in blood during aciclovir therapy with competitive PCR ELISA

BACKGROUND

Monitoring viral load in blood has already been introduced into clinical routine for human immunodeficiency virus and hepatitis C virus.

OBJECTIVE

This study was conducted to monitor the decline of herpes simplex (HSV) viral load in the blood of a patient with gingivostomatitis herpetica prior and during acyclovir therapy.

METHODS

Analysis was done by quantitative PCR ELISA using an internal quantitation standard.

RESULTS

Copy numbers were 66/microl blood prior to therapy, 60 during oral medication with valaciclovir, 97 and 72 copies/microl blood during the first 2 days of intravenous acyclovir therapy, followed by a sharp decline to 8 and 9 copies on days 3 and 4. During the following days, HSV was no longer detectable.

CONCLUSION

As this quantitative approach can be easily adjusted to any other PCR, it provides a reliable, easy-to-apply method for monitoring therapy, also during new antiviral clinical trials.

S100 beta is a more reliable tumor marker in peripheral blood for patients with newly occurred melanoma metastases compared with MIA, albumin and lactate-dehydrogenase

Lactate-dehydroxynase (LDH) has been described as a leading blood parameter in patients with melanoma metastases. However, recent data indicates that levels of S100 as well as melanoma inhibiting activity (MIA) in peripheral blood, correlate with melanoma progression. The aim of this study was to evaluate tumor markers S100, MIA, LDH and albumin in peripheral blood of 373 melanoma patients. 284 patients presented with in-situ or UICC stage I/II, and 89 with stage III/IV (54 tumor-free, 29 with newly occurred metastases). For newly occurred metastases, sensitivity was highest for S100 in peripheral blood (0.86), followed by MIA (0.80), LDH (0.48), and albumin (0.15). Specificity for albumin (0.99) and LDH (0.98) was higher than for S100 (0.91) and MIA (0.62). This data indicate that S100 in peripheral blood as compared to MIA, LDH and albumin appears to be the most appropriate tumor marker for newly occurred melanoma metastases.

Increased blood levels of human S100 in melanoma chick embryo xenografts' circulation

The chorioallantoic membrane (CAM) of the fertilized egg allows grafting of human melanomas for short-term investigations and offers the opportunity to investigate the behavior of metastasizing cells and the release of S100beta into peripheral blood. Tissue from one primary melanoma as well as cutaneous and subcutaneous metastases of 10 melanoma patients with elevated levels of S100 in the peripheral blood before surgery were transplanted onto the CAM of chick embryos at day 5/6 of development. Grafts were nourished by the host blood supply 2 days after transplantation. Histologically, 3 days after grafting, metastasizing melanoma cells could be found near the vessels of the host membrane, penetrating the endothelial layer and entering the blood system. Growth conditions remained stable for 6 days after transplantation. Blood samples were taken from a larger CAM vessel before collecting the xenografts 5 days after grafting. Measurement of human S100 in peripheral blood was performed in a blinded manner. No negative control showed elevated levels of human S100 protein. Samples deriving from melanoma xenografts contained highly elevated levels of S100 protein in 80% of cases. The data strongly support the concept of graft-host interaction concerning adherence of tumors and extravasation of human melanoma cells.

Coexpression patterns of EGFR, HER2, HER3 and HER4 in non-melanoma skin cancer

The receptor tyrosine kinases (RTKs) epidermal growth factor receptor (EGFR), HER2, HER3 and HER4 are involved in the pathogenesis of multiple human malignant neoplasias. However, their role in the carcinogenesis of basal cell carcinomas (BCC) and squamous cell carcinomas (SCC) remains to be elucidated. In order to further define the role of these RTKs, 56 human skin tissue samples of normal skin, BCC and SCC were studied by conventional and differential and quantitative reverse transcriptase-polymerase chain reaction (rtPCR). EGFR and HER3 were predominantly expressed in the BCCs and SCCs, while HER2 was ubiquitously expressed. HER4 was not expressed in any sample. Since in vitro studies have provided compelling evidence that heterodimer formation of these receptors are associated with different signal transduction processes, coexpression patterns might be decisive for the induction and maintenance of a malignant phenotype. These results confirm this concept: isolated HER2 expression and EGFR/HER2 were predominantly found in normal skin, while HER2/HER3 and the triple expression of EGFR/HER2/HER3 were seen more frequently in the BCCs and SCCs compared with normal skin (50% and 40% compared with 26%, respectively). The activation of HER3, in addition to EGFR and HER2, might therefore be associated with the malignant phenotype. However, due to the small numbers in this study, further confirmation of the patterns is needed.

Soluble p185/her2 and S100 in yolk sac blood from human melanoma metastases xenotransplanted to chick embryo chorioallantoic membrane

BACKGROUND

The chorionallantoic membrane (CAM) of the chick embryo has been used as an experimental model for studying tumor invasion and metastasis of human malignant melanoma. In search for a model to show graft-host-interactions in vivo, tumor markers in peripheral blood of the host were investigated.

MATERIALS AND METHODS

Before collecting melanoma metastasis xenografts, blood samples were taken from CAM and a control group. S100 and sp185/her2 in peripheral blood were evaluated in a blinded manner.

RESULTS

23/28 samples deriving from successfully performed human melanoma metastasis CAM xenografts were positive for S100 versus 2/22 samples for sp185/her2.

CONCLUSION

Regarding melanoma, in this model sp185/her2 gave no additional information. S100 levels corresponded to clinical and immunohistological findings concerning adherence of tumors and extravasation of human melanoma cells. Based on these data S100 levels in the peripheral blood could help to determine the effect of exogenous stimuli such as radiation and therapeutic agents on metastatisation of the xenografts.

Trauma and melanoma formation: a true association?

BACKGROUND

Little is known about the role of mechanical trauma in the pathogenesis of malignant melanoma. In individual patients, traumatic events have been discussed as a causative factor for the induction of melanoma and diagnosis of melanoma following trauma may raise medico-legal questions.

OBJECTIVES

To evaluate the relationship between traumatic single or recurrent events and melanoma characteristics.

METHODS

Retrospective questionnaire in 369 melanoma patients.

RESULTS

A large number of patients (337 of 369; 91.3%) denied an association between a possible traumatic event and melanoma formation. Thirty-two of 369 patients (8.7%) considered an association of trauma and melanoma formation likely. Of these 32 patients, 22 patients (13 men, nine women) reported a single event, and 10 patients (four men, six women) a persisting irritation. An irritation of a pre-existing melanocytic naevus was reported by two patients with histologically confirmed melanoma on acquired or congenital naevus.

CONCLUSIONS

As most of the patients who mentioned a trauma in this study suffered from acral melanoma, or melanoma located on the extremities, a history of trauma should be expected more frequently at these body sites. A review of epidemiological, clinical and scientific research indicates that there seems to be no evidence for single or persistent traumatic events as a causative factor for melanoma formation.

[Cutaneous radiation syndrome: clinical features, diagnosis and therapy]

Accidental exposure to ionizing radiation may occur during such catastrophic events as the Chernobyl accident in 1986 or over days to weeks as in Goiania in 1987 and in the military camp during the training of soldiers in Lilo/Georgia in 1997, as well as in medical institutions. The cutaneous symptoms after radiation exposure are based on a combination of inflammatory processes and alteration of cellular proliferation as a result of a specific pattern of transcriptionally activated proinflammatory cytokines and growth factors. They follow a time course consisting of prodromal erythema, latency period, acute stage, chronic stage and late stage. The entire complex is referred to as cutaneous radiation syndrome. The time course depends on several factors such as the radiation dose, radiation quality, individual radiation sensitivity, the extent of contamination and absorption and amount of skin exposed. For the diagnosis of the cutaneous radiation syndrome the following procedures are used: 7.5 MHz to 20 MHz-B-scan sonography, thermography, capillary microscopy, profilometry, nuclear magnetic resonance imaging, bone scintigraphy and histology. Based on the results of experimental and clinical research, today treatment may include topical or systemic corticosteroids, gamma-interferon, pentoxifylline, vitamin E and superoxide dismutase. The treatment depends on the stage of the cutaneous radiation syndrome. Due to the complexity of the clinical manifestations of radiation disease, most patients require interdisciplinary treatment in specialized centres. Dermatologists are essential partners in the life-long follow-up and therapy of such patients.

Lymph node dissection in cutaneous melanoma: surgical and oncological implications

The concept of Sentinel Lymph Node Dissection (SLND) has strongly influenced the surgical approach towards primary melanoma in the last decade. Initiated by the disappointing results of elective lymph node dissection (ELND) in this malignancy, the concept of analyzing the first draining lymph node (Sentinel) of a regional basin was developed as a diagnostic means to avoid unnecessary ELND in case of negative SLNs. According to recent standards detection of the SLN should be performed by a triple approach: injection of 90 nm Technetium and patent blue in the periphery of the primary melanoma, and intraoperative tracing of radioactivity with the aid of a hand-held gamma probe. Histopathological examination of alternating series sections of the whole lymph node appears to be the best analytic approach. Molecular biologic procedures such as tyrosinase RT-PCR are time-consuming to perform and produce contradictory results. SLND for cutaneous melanoma is an interdisciplinary diagnostic approach involving surgery, dermatology, pathology, and nuclear medicine. In spite of a variety of published promising results derived from clinical trials ranging from a few dozens to several hundred included patients the diagnostic and prognostic value of SLND remains to be confirmed by ongoing controlled prospective clinical trials. At this stage, SLND can by no means be considered a therapeutic procedure. These aspects have to be kept in mind when informed consent is obtained from patients as well as in the individual determination of the risk-benefit ratio.

c-MYC and nodular malignant melanoma. A case report

BACKGROUND

The incidence of skin cancer has been rising since the 1950s. About 75% of skin cancer-associated deaths are caused by malignant melanoma. Nodular malignant melanoma accounts for 20% of melanocytic malignant tumors and is associated with a relatively poor prognosis. Extensive research has been undertaken, but a molecular marker that can predict a more aggressive course of melanoma still has not been found.

METHODS

The authors applied cytogenetic and molecular genetic techniques to a case of nodular malignant melanoma. They used comparative genomic hybridization (CGH) to identify chromosomal regions affected by genomic changes and interphase fluorescence in situ hybridization (FISH) on touch preparations of the tissue to elucidate the CGH findings further. To investigate the functionality of the affected c-MYC gene, the authors detected its transcript via reverse transcription and polymerase chain reaction.

RESULTS

CGH revealed a copy number gain in the 6p and 8q24-8qter region. FISH with c-MYC and centromere eight specific probes revealed that the tumor, in contrast to unaffected skin, was characterized by a gain in copy numbers of the c-MYC gene. The c-MYC gene transcript was detected at higher levels in the tumor than in the tissue taken from the safety margin.

CONCLUSIONS

The WAF1 gene located on chromosome 6p, which in this case had a copy number gain, might be involved in melanoma pathogenesis. The authors suggest that the c-MYC gene plays an important role in melanoma development and progression. The c-MYC gene seems to be affected by gaining functional copies, leading to a change in the normally regulated gene-dose effect.

Antiapoptotic bcl-2 and bcl-xL in advanced malignant melanoma

Apoptosis is an important cofactor in the pathogenesis of a plethora of malignancies. However, little is known about modulation of the expression of bcl gene family in melanocytic tumors. To determine the role of bcl-2, bcl-x and bax in melanocytic tumors we investigated the differential expression of these genes via RT-PCR in tissue samples from human benign nevi, primary melanomas and melanoma metastases in comparison with normal skin. Bcl-2 was strongly expressed in 14/16 metastases (87.5%), whereas only 7/13 primary melanomas (53%), 7/15 nevi (46%) and 7/16 normal tissue samples (43%) showed expression of bcl-2 (P < 0.05). There was a strong indication of a correlation between tumor thickness and bcl-2 expression in nodular malignant melanomas. Expression of bcl-x was found in 16/16 melanoma metastases (100%), 11/13 primary melanomas (84%), 12/15 nevi (80%) and 10/16 normal tissue samples (62%) (P < 0.05). Bcl-xL expression increased from primary melanoma to melanoma metastases, whereas bcl-xS showed a decreasing expression level during melanoma progression. No differences in bax expression were seen between melanoma metastases, primary melanoma, nevi and normal tissue. Immunohistochemical investigations of another 53 tissue samples showed similar results. Our results strongly indicate that bcl-2 and bcl-xL gene expression increases with progression of malignant melanoma. Bcl-2 and bcl-xL expression could reflect an increased malignant potential caused by an inhibition of apoptosis and growth advantage for metastatic melanoma cells.

Receptor tyrosine kinase and p16/CDKN2 expression in a case of tripe palms associated with non-small-cell lung cancer

BACKGROUND

Tripe palms is a descriptive term for a cutaneous paraneoplastic keratoderma. Tripe palms are frequently associated with gastric and pulmonary carcinoma. The pathogenetic mechanism remains unknown.

OBJECTIVE

To determine the influence of receptor tyrosine kinases, which are both expressed in pulmonary carcinomas and in human skin, we performed expression studies on epidermal growth factor receptor (EGFR), HER2, HER3 in a skin sample of tripe palms obtained from a patient with non-small-cell lung cancer with lymph node involvement. Two months after diagnosis, the patient had developed palmoplantar 'tripe palms'. Additionally, the expression of SRC, c-myc and p16/ CDKN2 were studied.

METHOD

Conventional reverse-transcription polymerase chain reaction was performed on a tissue sample of tripe palms.

RESULTS

Weak expression of HER2 and of p16/CDKN2 was found. EGFR, HER3, c-myc and SRC were not expressed.

CONCLUSION

Receptor tyrosine kinases of subclass I, the tyrosine kinase SRC and the oncogene c-myc play no major role in the pathogenesis of this case of tripe palms.

S-100 protein in peripheral blood: a marker for melanoma metastases: a prospective 2-center study of 570 patients with melanoma

BACKGROUND

S-100 protein, commonly used in the immunohistochemical diagnosis of malignant melanoma and melanoma metastases, has recently been introduced as a tumor marker in peripheral blood.

OBJECTIVE

This prospective, observational, 2-center study evaluates S-100 in peripheral blood of patients with melanoma as a marker for metastasis.

METHODS

With application of an immunoluminometric assay, S-100 levels in 1396 samples of 570 patients with melanoma and 53 control subjects were measured in a blinded manner.

RESULTS

The cut-off level for patients with melanoma without medical history of metastases versus patients with newly occurring lymph node, visceral, and/or brain metastases was 0.114 microg/L, with a sensitivity of 94% (95% confidence interval, 86.4%-98.5%) and a specificity of 91% (95% confidence interval, 87.7%-93.6%). False-negative results included patients with unknown primary melanoma and those with amelanotic melanoma metastases.

CONCLUSION

The data suggest that S-100 in the peripheral blood of patients with melanoma could serve as a marker indicating new melanoma metastases and could help to monitor the course of the disease.

Interferon gamma in survivors of the Chernobyl power plant accident: new therapeutic option for radiation-induced fibrosis

BACKGROUND

One of the remarkable clinical consequences of the Chernobyl accident was skin involvement, leading to extensive cutaneous fibrosis. Apart from surgery, no established treatment is available.

METHODS

A group of survivors, working in or present at the accident site on April 26, 1986, and a few days thereafter, were examined, treated, and followed-up in 6-month intervals from September 1991 to November 1995. Eight individuals were identified as suffering from excessive cutaneous fibrosis. Skin thickness was measured with high-frequency (20 MHz) ultrasound in a clinically well-defined target skin lesion, in addition to histologic confirmation of radiation fibrosis. Interferon gamma was scheduled for all patients on a low-dose regimen (3 x 50 microg/week s.c.). In 2 patients, interferon was discontinued after the first injection, due to withdrawal of consent. In 6 patients, interferon was continued for 30 months, with 1 injection weekly for a further 6 months. Treatment was discontinued in November 1994. Four patients in the treated group and 1 of the 2 patients treated only once ("untreated patients") were reexamined 1 year later.

RESULTS

In all individuals treated for 36 months, a significant (p < 0.005) reduction of radiation fibrosis could be determined, in contrast to a significant (p < 0.005) increase in the 2 untreated patients. Follow-up 1 year after discontinuation of the interferon treatment demonstrated significant (p < 0.005) recurrence of fibrosis.

CONCLUSION

Low-dose interferon appears to be a safe and effective treatment of cutaneous radiation fibrosis following accidental exposure to high doses of ionizing radiation. Long-term supportive therapy may be required.

Mycophenolate mofetil: a new therapeutic option in the treatment of blistering autoimmune diseases

BACKGROUND

Mycophenolate mofetil (MMF), an ester of mycophenolic acid (MPA), was approved by the Food and Drug Administration in 1995 and is currently primarily indicated for the prophylaxis of rejection in renal transplant patients. The drug seems also to be of value in the treatment of psoriasis and rheumatic arthritis. Recently there have been 6 reported cases of successful treatment of blistering autoimmune diseases with MMF in combination with high dose prednisone therapy.

OBJECTIVE

On the basis of these reports we administered this new treatment regimen to several patients with blistering autoimmune diseases. Besides using a combination of MMF and high-dose prednisone we wanted to evaluate whether MMF monotherapy is also effective in the treatment of blistering autoimmune diseases.

METHODS

We administered MMF to 5 patients who had severe pemphigus vulgaris or bullous pemphigoid. Two patients received MMF in combination with high-dose prednisone therapy and 3 patients received MMF monotherapy. To our knowledge, this is the first report of successful treatment of pemphigus vulgaris and bullous pemphigoid with MMF monotherapy.

RESULTS

All patients were completely free of symptoms within 8 to 11 weeks of therapy. Patients who had received MMF monotherapy responded as well to treatment as those who received a combination of MMF and high-dose prednisone.

CONCLUSION

Our experiences strongly suggest that MMF monotherapy may be effective for patients even with severe pemphigus vulgaris and bullous pemphigoid. In addition, MMF monotherapy, at least over the short term, offers the advantage of fewer side effects in comparison to immunosuppressive combination therapy and was well tolerated by our patients.

Dermatoscopy and high frequency sonography: two useful non-invasive methods to increase preoperative diagnostic accuracy in pigmented skin lesions

Dermatoscopy and high frequency sonography have recently been combined to increase diagnostic preoperative accuracy in the treatment of pigmented skin lesions. In this monocentric study 80 patients with pigmented skin lesions were evaluated clinically, by dermatoscopy, and 20 MHz-sonography followed by dermatohistopathological evaluation; 39 malignant melanomas, 37 common nevi, 3 dysplastic nevi, and 1 nevus Spitz were diagnosed histologically. In 72 of the 80 cases (91.3%) dermatoscopical diagnoses were confirmed by histopathology, compared to only 79% correct clinical diagnoses. For the mere clinical diagnosis of melanoma sensitivity was 79%, specificity was 78% and diagnostic accuracy was 65%. All diagnostic values increased by dermatoscopy: sensitivity reached 90%, specificity was 93%, and diagnostic accuracy was 83%. In order to determine tumor thickness preoperatively tumor thickness was measured by 20 MHz sonography. The correlation of tumor thickness between histometric and sonographic results was determined for nevi (r = 0.93) and melanoma (r = 0.95); 74.3% of melanomas were diagnosed correctly within an 0.2 mm range. Regarding the clinical important limit of 1 mm tumor thickness, 87.2% were diagnosed in accordance with histometric evaluation. An increase of 18% in diagnostic accuracy by dermatoscopy and 87.2% of correctly diagnosed cases of tumor thickness of malignant melanoma by high frequency sonography clearly demonstrate that these methods should be considered standard procedures in the diagnosis of pigmented skin lesions and will facilitate the decision on necessary surgical treatment.

Radiation lentigo. A distinct cutaneous lesion after accidental radiation exposure

BACKGROUND

Accidental exposure of skin to ionizing radiation leads to long-term alterations such as fibrosis, keratosis, and teleangiectasias. Also, noncharacteristic hyperpigmentation and hypopigmentation may be noted.

OBSERVATIONS

A distinct lesion is described on the calves of a white male survivor of the 1986 nuclear accident at Chernobyl, Ukraine. Several years after the accident at Chernobyl, characteristic pigmented macules developed in the areas of skin that had previously been exposed to ionizing radiation: there was a marked, sharply demarcated lentiginous hyperpigmentation of epidermal and basal keratinocytes and melanocytes, as well as an increase in the number of melanocytes. No cellular atypia was noted.

CONCLUSIONS

This case demonstrates the potential of high single doses of ionizing radiation to induce pigmented lesions with similar clinical and histological features as they have been described after exposure to natural UV radiation or radiation from a tanning bed or sunlamp or after therapy with oral psoralen with long-wave UV-A radiation (PUVA), described as solar, tanning bed, and PUVA lentigines. The absence of cellular atypia may account for a favorable prognosis and enables clear distinction from more serious diagnoses such as lentigo maligna melanoma.

[The treatment of cutaneous radiation-induced fibrosis with pentoxifylline and vitamin E. An empirical report]

BACKGROUND

Radiation fibrosis represents a severe complication of radiation therapy; standardized treatment protocols are lacking so far. Surgical excision rarely results in complete healing.

PATIENT AND METHODS

We report on a 58-year-old female patient who developed a squamous cell carcinoma within the fibrotic area of the irradiation field on the right chest, resulting from a radiotherapy following mastectomy for breast cancer 17 years ago. After surgical excision of the carcinoma a combined treatment with pentoxifylline tablets (3 x 400 mg/d p.o.) and vitamin-E capsules (1 x 400 mg/d p.o.) was initiated. Skin thickness was quantified by 20 MHz-ultrasound before and during treatment.

RESULTS

The patient noted an increasing improvement of the condition of the affected skin starting from 4 months. A continuing decrease of skin thickness as documented by 20 MHz-ultrasound could be demonstrated from the 6th month on. The treatment was tolerated well, no side effects were observed.

CONCLUSION

The data indicate a beneficial therapeutic effect of pentoxifylline and vitamin E on radiation-induced fibrosis. Little is known about the mechanism of action of this combined treatment protocol including pentoxifylline and vitamin E. Controlled clinical trials should be performed to confirm this observation.

[Two superficially spreading malignant melanomas on nevus spilus]

A case of a 49-year-old patient with two superficial spreading melanomas arising from a naevus spilus is presented. Although opinions differ on the potential for malignant transformation in naevi spili, they should be carefully watched, and if changes are found these lesions should be subjected to histopathologic examination.