Management of adjuvant settings for Stage III melanoma patients in France prior to checkpoint inhibitors: epidemiological data from the RIC-Mel database

BACKGROUND

Targeted therapies such as BRAF and MEK inhibitors and immunotherapies have been made available to treat melanoma.

OBJECTIVES

To provide an overview of the management of the French Stage III melanoma population after complete lymph node resection prior to new adjuvant therapies.

MATERIALS AND METHODS

A subgroup data analysis.

RESULTS

Data from 1,835 patients were analysed (15.58% Stage IIIA, 39.24% Stage IIIB, 43.92% Stage IIIC and 1.25% Stage IIID). Superficial spreading melanoma was the most frequent (70.98% in Stage IIIA for whom mutation analysis was performed; BRAF mutation was identified in up to 62% Stage IIIA patients). Sentinel lymph node biopsy was performed in 88.46% of Stage IIIA patients, 42.36% of Stage IIIB, 53.97% of Stage IIIC and 34.78% of Stage IIID. Up to 80% of Stage IIIA patients had no adjuvant treatment follow-up. Ulceration (p = 0.004; RR: 2.98; 95% CI: 1.4-6.3) and age at diagnosis (p = 0.0002; RR: 1.04; 95% CI: 1.02-1.06) were significant predictive factors for survival. Adjuvant interferon-α was administered in up to 13.04% of Stage IIID patients.

CONCLUSION

Only a small number of Stage III melanoma patients were treated with interferon-α in adjuvant settings. New adjuvant therapies are currently having an effect on clinical practice in France, increasing survival and decreasing cost.

Impregnated acetate gauze compared with lipido-colloid contact layer at dressing removal pain: a single-blind cross-over randomised control trial

OBJECTIVE

To evaluate the performance of Jelonet Plus (JP) and UrgoTul (UT), assessing pain at dressing removal when managing acute or chronic wounds at granulation and epithelialisation stages.

METHODS

This was a randomised, multicentre, controlled single-blinded study using a cross-over design. Hospitalised and ambulatory patients presenting with non-infected acute or chronic wounds (at least 40% of wound area of ≤100cm² covered with granulation tissue) were randomly allocated to be treated with either JP or UT dressings applied according to a standardised local care procedure for two days. At the following visit, patients received the other dressing for a second 2-day period. Pain was evaluated after two days of dressing application and immediately after its removal using a 100mm Visual Analog Scale (VAS). A pain level >30mm was considered as clinically relevant. A lower limit of -12% was determined as the threshold necessary to demonstrate the non-inferiority of JP compared to UT.

RESULTS

For the 99 patients completing the study, a difference of 7.9% was observed in favour of JP (83.8% JP versus 75.9% UT) for pain immediately after dressing removal (VAS score < 30mm) with a confidence interval (CI) lower limit of -2.6%, demonstrating non-inferiority (pre-defined limit of -12%). Concerning pain at dressing removal, a difference of 19.6% was observed in favour of JP (81.6% versus 62.0%; p=0.029 for superiority analysis), with a CI lower limit ranging from 2.4% to 38.9%. Therefore, superiority could be concluded. A statistically significant period effect was detected (p=0.003) with fewer patients experiencing pain after the second period day 2 (D2) to day 4 (D4) than the first day 0 (D0) to D2. A statistically significant cross-over effect was also detected (p=0.047), with fewer patients experiencing pain when JP was applied first followed by UT. This suggests a carry-over effect thus preventing a full cross-over design analysis. Adherence of the dressing was less frequent with the JP than the UT dressing (2.0% JP versus 6.9% with UT).

CONCLUSION

Non-inferiority of pain at dressing removal was demonstrated with JP. Superiority on this criteria was non-significant but we found adherence of the dressing to the wound bed to be more rare.

[Bullous drug eruption with Nigella sativa oil]

BACKGROUND

Nigella sativa is classically used for its various therapeutic properties, particularly in the field of allergic diseases. We report a case of bullous eruption following application of Nigella sativa oil to the skin, possibly involving an associated systemic mechanism linked to ingestion of the oil.

PATIENTS AND METHODS

A 53-year-old woman was hospitalized for febrile rash consisting of erythematous plaques with vesicles and bullous lesions. She had Nigella sativa oil applied to her skin and ingested it for two weeks. Cutaneous histopathology revealed sub-epidermal detachment and necrosis of the epidermal surface consistent with toxic epidermal necrolysis. The lesions healed slowly, but depigmented macules persisted three months later. Patch tests for Nigella sativa oil were strongly positive.

DISCUSSION

Erythema multiforme due to contact with Nigella sativa oil was initially diagnosed on the basis of lesions on skin where the oil was applied, as well as on cutaneous histopathology and positive patch tests. However, a systemic reaction such as toxic epidermal necrolysis could not be ruled out since the patient had also ingested the oil. The most likely diagnosis was thus systemic and contact bullous drug eruption. The discovery of new therapeutic properties of Nigella sativa in other clinical domains underscores the need for particular vigilance regarding future use of this substance on account of the risk of severe drug eruptions.

[Multiple cutaneous osteomas of the face in a setting of chronic acne]

BACKGROUND

Multiple cutaneous osteomas are a rare complication of chronic inflammatory acne that often goes unrecognized. We report a case concerning a 35-year-old woman.

PATIENTS AND METHODS

A 35-year-old woman had been treated for acne since the age of 22 years, as part of which she received two courses of oral isotretinoin. We noted the secondary appearance of several microcysts on the face for which the excision was very difficult. Curiously, these small formations did not contain keratin but were very callous. Histological examination revealed foci of osseous metaplasia, probably of postinflammatory origin. Treatment consisted solely of excision of the lesions.

DISCUSSION

Osteoma cutis comprises two distinct groups (primary and secondary). In our case, there were multiple cutaneous osteomas of the face resulting from chronic acne. The differential diagnosis was idiopathic miliary osteomatosis of the face, but this was ruled out by the young age of the patient, the improvement of the acneiform lesions under isotretinoin (confirming the initial diagnosis of acne) and the subsequent appearance of microcysts. Although there are as yet no codified treatments, excision appears to yield good results.

[Efficacy and risks of topical 5-fluorouracil in Darier's disease]

BACKGROUND

Darier's disease, an autosomal dominant disorder, is often resistant to therapy. There have been few encouraging reports in recent years of treatment using topical 5-fluorouracil (5FU) in this indication. We describe three cases of Darier's disease treated with Efudix: though it initially proved very effective, after several months this treatment became inefficacious.

PATIENTS AND METHODS

Case 1: a 16-year-old girl with Darier's disease refractory to conventional treatments. Treatment with topical 5FU was initiated. After 3 weeks, her cutaneous lesions had practically disappeared, leaving only pigmented scars. At 6 months, worsening of the disease was controlled by increasing 5FU. At 11 months, the disease worsened and 5FU, which proved inefficient, was stopped. Case 2: a 59-year-old woman presenting treatment-resistant Darier's disease was given 5FU. After 1 week, improvement began and was evident at 4 months. However, after 13 months of treatment, the disease progressed, and increased 5FU proved completely ineffective. Case 3: a 29-year-old woman was hospitalized for inflammatory Darier's disease. Topical 5FU was applied to the left half of the body and a short course of oral corticosteroids was prescribed. After 10 days of treatment, there was a clear improvement. After 6 weeks, the patient showed episodes of healthy skin. However after 3 months, the patient stopped taking her treatment due to inefficacy.

DISCUSSION

While topical 5FU seems to be effective initially in treating Darier's disease, this efficacy subsides over time. Although no adverse effects were noted in our patients, use of 5FU can result in serious adverse reactions. Because of the loss of efficacy of this treatment following initial success, coupled with its poorly evaluated safety, caution must be exercised when prescribing it, particularly in patients with dihydropyriminidine dehydrogenase (DPD) deficiency or for use on damaged skin.

Nécrose cutanée par calciphylaxie traitée par greffe de kératinocytes autologues et parathyroïdectomie partielle

BACKGROUND

Cutaneous calciphylaxis, seen most often in dialysis patients, is characterised by skin necrosis, and is a disabling and lifethreatening disease. Despite intensive topical treatment, recourse to parathyroidectomy is often necessary. We report the case of a female patient with skin necrosis due to calciphylaxis: pain and necrotic lesions were controlled by grafting of cultured autologous keratinocytes (Epibase).

CASE REPORT

A 75-year-old woman with a 5-year history of dialysis-dependent chronic renal failure secondary to nephroangiosclerosis presented a very painful necrotic ulceration on her left leg. In spite of an autologous patch grafts, the lesions rapidly deteriorated. Laboratory data showed high levels of calcium, phosphate and parathyroid hormone and imaging suggested parathyroidal adenoma. Although cutaneous biopsy was not performed, the diagnosis of cutaneous necrosis due to calciphylaxis with tertiary hyperparathyroidism was established. Treatment consisted of a low-calcium and low-phosphorus diet with autologous keratinocytes grafts (Epibase). After the third application of keratinocytes, the pain disappeared, necrosis ceased and wound healing began. Subtotal parathyroidectomy was performed two months after the start of grafts. At three months, the patient was cured.

DISCUSSION

. Calciphylaxis is an obstructive vascular disease secondary to calcification of the arterioles leading to ischemic tissue necrosis. Prompt diagnosis is essential since this disease is disabling and life-threatening due to sepsis and ischemic complications. In our case, autologous keratinocyte grafts allowed pain relief to be achieved within large expanses of cutaneous necrosis after correction of calcium and phosphorus levels, thereby allowing parathyroidectomy to be performed under optimal conditions.

[Efficacy of botulinum toxin A in the treatment of axillary and palmar hyperhidrosis: 10 cases]

Axilliary and palmar hyperhidrosis can become a considerable social and psychological handicap. Local treatments are not always effective and endoscopic thoracic sympathectomy is not without side effects. The efficacy of botulinum toxin has recently been demonstrated in axillary and palmar hyperhidrosis. Between June 2001 and June 2002, we treated all the patients presenting with axillary and palmar hyperhidrosis, resistant to classical treatments, with intradermal injections of botulinum toxin A (Dysport). The aim was to assess the interest of this technique at moderate doses, in a prospective, open, controlled study.

PATIENTS AND METHODS

The hyperhidrotic areas, revealed by Minor's test, were treated with intradermal injections of 100 U of Dysport in the axilliary form and 250 U in the palmar form. Patients were seen after 1 month and 6 months and underwent a Minor's test, photographic control and they filled-in a questionnaire to measure their satisfaction.

RESULTS

Ten patients: 9 women and 1 man aged 19 to 63, were included. Three of them consulted for palmar hyperhidrosis and 7 for auxiliary hyperhidrosis. Within 2 to 7 days, treatment was successful in all patients. The follow-up was of 3 to 12 months. The satisfaction index was comprised between 7/10 and 9/10. The relapse-free interval was of 2 to 9 months. Three patients were given a second injection, which doubled the relapse-free period. Side effects included pain with the palmar injections and moderate headaches.

DISCUSSION

This French study confirms the efficacy of botulinum toxin A in the treatment of axillary and palmar hyperhidrosis with relatively low doses (100 U of Dysport per armpit and 250 U per palm). This is an easily reproducible, well tolerated, method without major side effects.

Long-term interferon-alpha therapy induces autoantibodies against epidermis

BACKGROUND

While interferon (IFN) is known for its immunoregulatory properties, it has also been shown to induce autoimmune disorders such as lupus erythematosus, hypothyroidism, antiphospholipid syndrome and, recently, bullous pemphigus-like eruptions.

OBJECTIVE

The purpose of this study was to determine the percentage of antibodies against epidermis induced by IFN-alpha therapy, as detected by indirect immunofluorescence and Western blotting (WB).

METHOD

We have studied the sera of 47 patients treated with low doses of IFN-alpha 2a for malignant melanoma or cutaneous T cell lymphoma for a period of 12 months. These sera were tested by standard IIF and WB.

RESULTS

32% of patient sera were positive after 6 months of treatment. Antibodies against epidermis were most often of the pemphigus type as confirmed by WB. Two types of labeling were noted for anti-basement membrane antibodies: basal cytoplasmic pattern in 4 sera and along the dermal side of the basal keratinocytes in 2 sera.

CONCLUSION

This study brings biological arguments to confirm the direct role of IFN-alpha in the development of pemphigus-like eruption, and emphasizes the need for clinical follow-up of patients treated with IFN-alpha over a long period of time.

[Development of interferon antibodies during the treatment of skin diseases with low-dose recombinant interferon alpha-2a]

In this study, we determined the frequency of interferon antibodies in patients with skin diseases treated with low doses of recombinant interferon alpha 2a (1.5 - 18 x 10(6) IU). We assayed serum specimens from 181 patients with malignant melanoma or cutaneous T cell lymphomas (78 patients treated with recombinant interferon alpha 2a and 103 patients in control group) for interferon antibodies before treatment and every 6 months for at least 18 months. Neutralizing interferon alpha 2a antibodies were detected in 27 of 77 treated patients (35%), but none in control group (p < 10(-6)): 38.2% in melanoma and 12.5% in T cell lymphomas. However antibody formation was not correlated with nonresponse or with frequency of interferon antibodies in patients receiving the combined therapy: interleukin-2 and interferon alpha 2a.

Presence of Epstein-Barr virus in cutaneous lesions of mycosis fungoides and Sézary syndrome

It has been suggested that prolonged antigenic stimulation contributes to the development of epidermotropic cutaneous T cell lymphoma (CTCL), mycosis fungoides and Sézary syndrome, characterized by a cutaneous infiltration of proliferating helper T cells. Since Epstein-Barr virus (EBV) antibodies were increased in CTCL sera, we investigated a possible etiologic role for EBV in epidermotropic CTCL by looking for the EBV genome in 25 cutaneous biopsies of mycosis fungoides or Sézary syndrome and 12 reactional inflammatory skin lesions. The use of a non-isotopic in situ hybridization procedure based on the detection of Epstein-Barr encoded RNAs with biotinylated oligonucleotide probes (EBER) revealed 32% of the lesions with CTCL to be positive for EBV (3 in dermis, 3 in epidermis, 2 both in dermis and epidermis), as compared to no detection of the EBV genome in the reactional inflammatory skin lesions. Moreover, a combined hybridization (EBER probe) and immunochemistry technique (anti-CD3 or anti-Kil monoclonal antibody) permitted the identification of EBV in T cells of dermis and in keratinocytes, respectively. The identification of EBV in epidermotropic CTCL suggests that this virus could play a role in the development of these CTCLs, either as an etiological agent or more probably as a chronic activating agent. Indeed, the infection of keratinocytes by EBV could activate them and so induce the production of in situ cytokines (IL1a, IL6, TNFa) playing a role in the development of tumoral infiltrate.

Serum selenium in melanoma and epidermotropic cutaneous T-cell lymphoma

As several studies have demonstrated a relationship between decreased serum selenium concentrations and the frequency of certain cancers, we studied these concentrations in two kinds of cutaneous tumour cancer: melanoma and epidermotropic cutaneous lymphoma. We first determined the predictive value of the selenium assay for the frequency of recurrences in stage I and II melanomas and then considered the relationship between serum selenium concentrations before treatment and therapeutic response. Two hundred melanomas (81 stage I, 63 stage II, 56 stage III) and 51 epidermotropic cutaneous T-cell lymphomas (CTCL) (8 stage I, 24 stage II, 10 stage III, 9 stage IV) were included in the study. Selenium assays were performed by atomic absorption spectrophotometry (92 +/- 16 micrograms/l in 30 normal subjects). Our study showed decreased serum selenium concentrations for melanoma (81 +/- 27 micrograms/l) and lymphoma (78 +/- 36 micrograms/l) relative to disease severity. The concentration was significantly lower (76 +/- 22) for stage I and II melanomas with recurrence within 2 years (31 patients), compared to those without recurrence (113 patients) (p < 0.05). Before treatment, it was higher in CTCL with good response to treatment (89 +/- 36) than in those without response (62 +/- 30) (p < 0.01). This study thus demonstrates the prognostic value of selenium assays in the follow-up of melanoma and CTCL.

In vitro induction of basal keratinocyte MY7 antigen expression in cutaneous T-cell lymphoma is associated with response to interferon-alfa therapy

BACKGROUND

Normal basal cell keratinocytes express an antigen recognized by monoclonal antibody MY7. This expression is lost in cutaneous T-cell lymphoma (CTCL) and may be reinduced under interferon-alfa-2a therapy. We investigated whether similar modulation of MY7 antigen could be obtained in vitro and determined the relationship between in vitro modulation and clinical response.

SUBJECTS

We studied MY7 expression by basal cell keratinocytes in reconstituted skin specimens from 10 patients with CTCL and from skin specimens from five control patients and determined its modulation by interferon-alfa-2a and interleukin 1 using the indirect immunofluorescence technique. Concurrently, clinical examination and in vivo immunologic study on cutaneous biopsy specimens were carried out for these 10 patients before and while receiving interferon-alfa-2a therapy.

RESULTS

In vitro studies showed that in five control specimens MY7 expression by basal cells was constant without modulation by interferon-alfa-2a or interleukin 1. Two of 10 CTCL specimens spontaneously expressed MY7 antigen while an additional five did so after incubation with interferon-alfa-2a and the last three never did.

CONCLUSION

The three patients with CTCL for whom no MY7 expression was observed in reconstituted skin studies were "poor responders" to interferon-alfa-2a therapy. The five patients with CTCL for whom in vitro MY7 expression was induced by interferon-alfa-2a were responders. For the last two patients, results were variable. Thus, in vitro MY7 antigen is expressed in normal basal cell keratinocytes, absent in CTCL basal cell keratinocytes, but can be induced by interferon-alfa-2a. Moreover this in vitro modulation appears to be possibly correlated with interferon-alfa efficacy in vivo.

Roferon-A in combination with Tigason in cutaneous T-cell lymphomas

In cutaneous T-cell lymphomas (CTCL; mycosis fungoides and Sézary syndrome), the standard therapies tend to be effective but not curative. Single drug therapy with either interferon-alpha or retinoids shows a response rate of about 45%. In this article, we report the results obtained in the treatment of CTCL with a combined therapy. To date, four clinical studies have been carried out using a combination of low doses of interferon-alpha and retinoids for treatment in the early stages of CTCL. The mechanism of action of this combination therapy is unknown.

Effect of two successive annual treatments with single doses of ivermectin on microfilaraemia due to Wuchereria bancrofti var. pacifica

Between 1986 and 1988 a single-blind, dose-ranging study was carried out in French Polynesia to determine the efficacy and tolerability of single 50, 100, 150 and 200 micrograms/kg doses of ivermectin in Wuchereria bancrofti carriers. Forty male microfilariae (mf) carriers between 18 and 50 years of age, in whom mf density was greater than or equal to 20 mf/ml, were treated twice at a one-year interval. Twelve months after the second treatment, in carriers who were given a dose greater than or equal to 100 micrograms/kg, mean mf density was 4-7% of the initial pretreatment mf density. Therefore, several successive annual treatments with single doses greater than or equal to 100 micrograms/kg of ivermectin should result in reducing mf densities to a very low level. Nevertheless, at 9 months after the second treatment, residual parasitaemia ranged from 1 to 2182 mf/ml (median 85) in 30 patients. Finally, in patients with pretreatment mf counts less than or equal to 150 mf/ml, mean mf density was 2.8 and 8.9 mf/ml, respectively, during the 2 six-month periods following treatment, while in patients with pretreatment mf densities greater than 150 mf/ml (median 1500) it was 92.3 and 334.1 mf/ml during the same periods. These results suggest that, when implementing filariasis control programmes, the best strategy might be administration of several treatments with a single dose of ivermectin every 6 months to the entire population, at least in French Polynesia. Afterwards, when mf densities had been reduced to a relatively low level (100-150 mf/ml), annual treatments could be considered.

Ivermectin for treatment of bancroftian filariasis in French Polynesia: efficacy in man, effect on transmission by vector Aedes polynesiensis

Forty male Polynesian W. bancrofti carriers with mf counts greater than or equal to 20/ml were treated with a single ivermectin 50, 100, 150 or 200 mcg/kg dose. Following therapy, mf levels fell to less than 1% of pretreatment levels in the carriers treated with the 3 highest doses. After one month, negativation rate was 40% in patients treated with a 50 mcg/kg dose, significantly lower than in patients treated with higher doses. Recurrence of microfilaremia was observed by 3 months, mf recurrence percentages were significantly lower in patients treated with the 3 highest doses than in patients treated with a 50 mcg/kg dose. At 6 months, mf recurrence percentages reached 49.8, 12.6, 14 and 5.4% of pretreatment levels in carriers treated with 50, 100, 150 and 200 mcg/kg, respectively. No significant difference was observed between mf levels by group at 6 and 12 months. With respect to efficacy, a dose greater than or equal to 100 mcg/kg appeared superior to 50 mcg/kg dose; no significant difference between the 3 highest doses was observed. Some patients developed headache, myalgia and fever within 24 hours following therapy, none of adverse reactions were considered serious. In vector Ae. polynesiensis fed on carriers 6 months after treatment, average numbers of mf ingested and average numbers of L3 cephalic larvae were lower than those observed in mosquitoes fed on non-treated carriers with comparable mf counts.(ABSTRACT TRUNCATED AT 250 WORDS)

A single diethylcarbamazine dose for treatment of Wuchereria bancrofti carriers in French Polynesia: efficacy and side effects

In the fall of 1988, 14 Tahitian Wuchereria bancrofti carriers were treated by a single diethylcarbamazine (DEC) 3 mg/kg dose. Determination of blood microfilarial (mf) density was carried out on days 0, 7, 14, 30, 90 and 180 using the membrane filtration technique. Clinical signs and side effects were noted during the 3 days following treatment. Complete clearance of microfilaremia was observed in two carriers (negativation rate 14%). A decrease of mf density was noted in all of the 14 carriers, ranging from 35.2 to 99.2% (median 78.75%). The percentage decrease in mf density, determined for the whole group from the geometric mean of the 14 mf counts, was 86% by day 7 and reached 95% by day 180. Side effects were observed in 10 patients (71%) of whom 3 only were unable to perform usual activities for less than 24 hours. Though it induced an incomplete initial mf clearance, a single DEC 3 mg/kg dose was effective in reducing about 90% of the microfilaremia and in sustaining this reduction over a period of six months. Such long-term reduction (comparable to that observed in W. bancrofti carriers treated with a daily DEC 6 mg/kg dose during 12 days) is likely responsible for the consistent decrease of total mf counts observed in the Tahitian population which has been treated for years with single DEC doses given every six months.

PGL-I antigen and antibody detection in leprosy patients: evolution under chemotherapy

Multibacillary (MB) and paucibacillary (PB) leprosy patients were tested for circulating phenolic glycolipid-I (PGL-I) antigen and antibodies before treatment. In the 27 MB patients tested, 27 (100%) were antigen positive with levels ranging from 50 to 5000 ng/ml, and 26 (96%) were antibody positive with titers ranging from 1000 to 64,000. Although the antigen and antibody levels were much higher in MB than in PB patients, we could not demonstrate a correlation between the number of acid-fast bacilli/mg of skin biopsy and these two parameters in 14 MB patients. After starting daily multidrug therapy, 10 MB patients were monitored monthly. As much as 88.75% +/- 10.8% of the PGL-I antigen was cleared from the bloodstream after 1 month while the anti-PGL-I antibody remained stable. This rapid decrease in the PGL-I antigen level strongly suggests the usefulness of this test for monitoring MB patients under chemotherapy.

Implementation of chemoprophylaxis of leprosy in the Southern Marquesas with a single dose of 25 mg per kg rifampin

Between 1967 and 1987 in the Southern Marquesas, a remote archipelago in French Polynesia, the detection rate of leprosy was 48.9 per 100,000 when it was 8.6 per 100,000 for French Polynesia as a whole. In 1988, a program of chemoprophylaxis of leprosy with a single dose of 25 mg/kg rifampin was implemented, and 2751 persons (98.7% of the population) were treated in the Southern Marquesas. In addition, 678 South Marquesans and 2466 members of their families living in the Northern Marquesas and in the Society Archipelago, received the same chemoprophylaxis. Among 2676 persons studied in the Southern Marquesas (97.4% of the treated population), 130 had elevated IgM anti-phenolic glycolipid-I antibodies by ELISA without any evidence of leprosy. The onset of a skin lesion of borderline leprosy in a boy 3 months after chemoprophylaxis raises the question of the nature of such a skin lesion and, indirectly, of the effectiveness of the chemoprophylaxis.