Expression of p16, CD95, CD95L and Helix pomatia agglutinin in relapsing and nonrelapsing very thin melanoma

BACKGROUND

The incidence of malignant melanoma is increasing worldwide and patients are being diagnosed earlier with thinner primary lesions. Most patients with very thin melanoma (Breslow thickness < 0.76 mm) are cured by surgery but 2-18% relapse locally or with distant metastases.

OBJECTIVES

The objective of this study was to establish potential new prognostic markers in very thin melanoma.

METHODS

We identified a group of subjects with relapsing very thin primary cutaneous melanoma and a matched control group who had not relapsed. We investigated the expression of p16, Helix pomatia agglutinin (HPA), CD95 and CD95 ligand (CD95L) by immunohistochemistry on paraffin-embedded tissue sections from the subject group, their subsequent metastases and the control group.

RESULTS

Reduced p16 expression was significantly associated with relapse in very thin melanoma (P = 0.0129). Loss of p16 expression was also found in 76% of metastases. There was no significant association between HPA, CD95 or CD95L expression and subsequent relapse.

CONCLUSIONS

This work is the first to show a significant loss of p16 in relapsing very thin melanoma.

The impact of immunohistochemistry on sentinel node biopsy for primary cutaneous malignant melanoma

Sentinel node biopsy (SNB) has emerged as an accurate means of identifying nodal disease in patients with malignant melanoma. Superselection of pathological nodes has allowed improved pathological staging of disease. The aim of this study was to look at the impact of immunohistochemistry on pathological staging of sentinel nodes. The first 100 patients undergoing SNB for primary cutaneous malignant melanoma were included in this study. Sentinel node harvesting was performed with the aid of preoperative lymphoscintigraphy and the intraoperative use of both a gamma probe and blue dye. If the sentinel nodes contained tumour on either routine pathology or immunohistochemistry, patients were offered a therapeutic lymph node dissection (TLND). Patients underwent no other treatment to the primary lymph node basin if the sentinel node was free of metastases. In all, 95 patients had at least one node identified, and 25 were staged SNB positive and offered subsequent TLND. We found that 76% (19/25) of SNB positive patients were staged positive on routine pathology, and 24% (6/25) were staged with immunohistochemistry. Immunohistochemistry upstaged disease in 8% of patients (6/76). In all, 21 of the patients staged positive with SNB underwent TLND; 50% (8/16) of the patients staged sentinel node positive with routine pathology showed no further disease in the TLND, compared with 100% (5/5) of the patients staged sentinel node positive with immunohistochemistry only (P<0.05). Three patients have developed recurrence within the nodal basin following a negative SNB. The sensitivity of the procedure is currently 89% (25/28), with a mean follow-up of 24 months. Immunohistochemistry is an essential part of identifying micrometastasis in sentinel nodes, upstaging 8% of patients in our series. Patients with micrometastatic disease may well have a different prognosis from those with occult disease, and careful delineation of these patients is required to determine the prognostic influence of micrometastasis.

The learning curve for sentinel node biopsy in malignant melanoma

Sentinel node biopsy (SNB) has emerged as an accurate means of identifying nodal micrometastasis in cutaneous melanoma. In order to assess our learning curve, we compared our first 30 cases with our subsequent 30 cases. A total of 60 patients underwent SNB for cutaneous melanoma, using preoperative lymphoscintigraphy together with the intraoperative use of a Neoprobe and Patent Blue V dye. At least one sentinel node was identified in 93% of patients (90% in our first 30 cases; 97% in our subsequent 30 cases). Sentinel nodes contained tumour in 21% of cases. Of the sentinel nodes that contained tumour in the first 30 cases, 87% were identified by Neoprobe examination and 60% using blue dye. In the second 30 cases, the tumour-containing sentinel nodes were identified in all cases by both the Neoprobe and the blue dye. The sentinel node appeared to be the only involved node in 71% of patients. In the first 30 patients, one patient with a negative sentinel node developed nodal recurrence. These data confirm the feasibility of the sentinel-node technique in cutaneous melanoma. However, there is a learning curve, and the technique should be performed only by limited numbers of people with suitable training.

Somatic mutations in the Peutz-Jeghers (LKB1/STKII) gene in sporadic malignant melanomas

Germline mutations in the LKB1/STK11 gene cause characteristic hamartomas and freckling to develop in patients with Peutz-Jeghers syndrome (PJS). The hamartomas arise as a result of somatic "second hits" at LKB1/STK11 and therefore contain a neoplastic element. The origin of the pigmented lesions in PJS is unknown and difficult to test, as these are hardly ever biopsied. PJS patients are at increased risk of benign and malignant tumors, particularly of the colon, breast, pancreas, testis, and ovary, although the increased risk for any one of these sites may be quite modest. Somatic LKB1/STK11 mutations have been found, albeit at a low frequency, in sporadic tumors of the colon, stomach, ovary, and testis. Although PJS patients are not known to have an excess of skin tumors, if the freckles of PJS patients are actually small, benign tumors, LKB1/STK11 mutations must provide these lesions with a selective advantage, and similar mutations might also give a selective advantage to related malignant tumors, such as melanomas. We have therefore screened 16 melanoma cell lines, 15 primary melanomas, and 19 metastases for LKB1/STK11 mutations. Two LKB1/STK11 mutations were found: a missense change (Y49D) accompanied by allele loss in a cell line; and a missense change (G135R), without a detected mutation in the other allele, in a primary tumor. Both these mutations are highly likely to be pathogenic. Novel polymorphisms, including an unusual heptanucleotide repeat, were also found in introns 2 and 3. LKB1/STK11 mutations occur in a significant minority of tumors of several sites, including malignant melanomas.

A case-control study of melanomas of the soles and palms (Australia and Scotland)

OBJECTIVES

Because the factors that influence risk of acral melanomas on the soles and palms in White populations are unknown, we investigated these in a multi-center case-control study.

METHODS

Cases of melanoma of the feet and hands diagnosed from 1987-93 in persons aged over 18 years were ascertained in eastern Australia and western Scotland. There were 275 cases of melanoma on the soles and palms matched to 496 controls (selected from the electoral roll) in Australia, and 36 cases matched to 72 controls (nominated by general practitioners) in Scotland.

RESULTS

Acral melanoma was strongly associated with high total body nevus counts (adjusted relative risk [RR] = 6.3, 95% confidence interval [CI] = 2.5-15.6), and with nevi on the soles (RR = 7.5, CI = 3.0-18.6). There were also significant positive associations with a penetrative injury of the feet or hands (RR = 5.0, CI = 3.0-8.6) and with heavy exposure to agricultural chemicals (RR = 3.6, CI = 1.5-8.3). Sun-sensitive complexions, cumulative sun exposure and a past history of nonmelanoma skin cancer were also associated with increased risk of acral melanoma. Current cigarette smoking was inversely related to acral melanoma (RR = 0.6, CI = 0.4-0.9).

CONCLUSIONS

Melanomas of the soles and palms resemble other cutaneous melanomas in their association with sun exposure, but are distinguished from them by their strong positive associations with nevi on the soles, previous penetrative injury, and exposure to agricultural chemicals, and by their inverse association with smoking.

Telomerase activity in melanoma and non-melanoma skin cancer

Telomeres are specialized structures consisting of repeat arrays of TTAGGGn located at the ends of chromosomes. They are essential for chromosome stability and, in the majority of normal somatic cells, telomeres shorten with each cell division. Most immortalized cell lines and tumours reactivate telomerase to stabilize the shortening chromosomes. Telomerase activation is regarded as a central step in carcinogenesis and, here, we demonstrate telomerase activation in premalignant skin lesions and also in all forms of skin cancer. Telomerase activation in normal skin was a rare event, and among 16 samples of normal skin (one with a history of chronic sun exposure) 12.5% (2 out of 16) exhibited telomerase activity. One out of 16 (6.25%) benign proliferative lesions, including viral and seborrhoeic wart samples, had telomerase activity. In premalignant actinic keratoses and Bowen's disease, 42% (11 out of 26) of samples exhibited telomerase activity. In the basal cell carcinoma and cutaneous malignant melanoma (CMM) lesions, telomerase was activated in 77% (10 out of 13) and 69% (22 out of 32) respectively. However, only 25% (3 out of 12) of squamous cell carcinomas (SCC) had telomerase activity. With the exception of one SCC sample, telomerase activity in a positive control cell line derived from a fibrosarcoma (HT1080) was not inhibited when mixed with the telomerase-negative SCC or CMM extracts, indicating that, overall, Taq polymerase and telomerase inhibitors were not responsible for the negative results. Mean telomere hybridizing restriction fragment (TRF) analysis was performed in a number of telomerase-positive and -negative samples and, although a broad range of TRF sizes ranging from 3.6 to 17 kb was observed, a relationship between telomerase status and TRF size was not found.

Sun awareness in school teachers

School children are important targets for sun awareness education, but the knowledge, attitudes and behaviour of school teachers with respect to sun awareness are poorly understood. A questionnaire-based survey of 76 school teachers was undertaken. Twenty-four per cent of teachers indicated previous experience in teaching sun awareness, but 93% of teachers had no classroom resources for teaching sun awareness. Sun awareness was perceived by respondents as unimportant relative to other health education issues. There was considerable scope for improvement in attitudes and behaviour of teachers with respect to sun awareness. Teachers need more information about environmental factors which affect strength of sunlight, individual risk factors for sunburn and sunscreen strength. Intervention strategies involving school teachers need simple messages, emphasizing the importance of shade, clothing and hats in sun avoidance.

A controlled study of gold contact hypersensitivity

1203 patients attending for routine patch testing at 3 hospitals and 105 volunteers were tested with 0.5% and 0.05% gold sodium thiosulfate (GST). 38 patients (3.2%) and 5 volunteers (4.8%) had positive patch tests to GST. There were no significant differences between volunteers and patients with respect to age, sex, atopy or exposure to gold in dental restorations, jewellery or through occupation. There were no significant differences in prevalence of GST hypersensitivity in the 3 hospitals, or between patients and controls. This is the 1st controlled study of hypersensitivity to GST, and suggests that routine patch testing to gold is of limited clinical benefit.

Prevalence of gold contact hypersensitivity in the west of Scotland

373 patients attending for routine patch testing were tested with 0.5% and 0.05% gold sodium thiosulfate (GST). 8 (2.1%) patients had a positive patch test, and a further 4 (1.0%) patient reactions which were interpreted as irritant 2 out of 8 patients with a positive patch test to GST suspected gold allergy prior to testing, and both of these patients reported that their eczema resolved if they avoided gold jewellery. This is the lowest prevalence of hypersensitivity to GST reported and suggests that gold contact allergy may not be as widespread as has been recently proposed.

Dapsone therapy for the acute inflammatory phase of ocular pemphigoid

Oral dapsone was used to treat five patients who presented in the acute inflammatory phase of ocular pemphigoid. The diagnosis was made clinically by identifying cicatricial changes which were in some cases difficult to find. In all cases it was the inflammatory rather than the cicatricial features which responded to treatment. An initial dose of 100 mg/day was effective without toxicity. When 150 mg/day was used patients experienced side effects. A clinical response was obtained after 1-4 weeks and could be maintained on a dose of between 50 mg on alternate days and 100 mg/day. Therapy was withdrawn during remissions which lasted up to 32 weeks but all cases required continuing therapy which has remained effective. Immunopathological examination was carried out on two occasions in all cases and although positive on at least one occasion the results did not correlate with disease activity or treatment. The inflammatory phase of ocular pemphigoid should be added to the list of diseases responsive to dapsone.

Cutaneous malignant melanoma, Scotland, 1979-89. The Scottish Melanoma Group

The Scottish Melanoma Group (SMG) was established in 1979 to assess mortality from and incidence, features, pathological data, and management of cutaneous malignant melanoma in Scotland. Incidence during the first five years and five-year survival have already been reported. We now have data about incidence and mortality over eleven years in relation to anatomical site and pathological types. From 1979 to 1989, 1354 male and 2459 female patients with primary cutaneous malignant melanomas were first diagnosed in Scottish residents. The incidence rate per 100,000 population per year has increased from 3.4 in 1979 to 7.1 in 1989 for men, and from 6.6 to 10.4 for women. The overall increase over eleven years is 82% (7.4% per year). The greatest rates of increase are seen in lesions of the superficial spreading histogenetic type, arising on the female leg and the male trunk. Following public education programmes started in 1985, the proportion of all melanomas less than 1.5 mm thick has shown a sustained and significant increase. Mortality data for 1661 patients for whom a minimum of five-year follow-up is available shows five-year survival of 71.6% overall (77.6% for women, 58.7% for men). The survival advantage for women persists when appropriate statistical adjustment is made for thickness, ulceration, and histogenetic type. These data are useful in designing public education programmes aimed at both primary and secondary prevention of melanoma and in auditing changes in trends that might result from such education.

Lack of effect of spironolactone on hair shaft diameter in hirsute females

Because of its anti-androgenic activity spironolactone 50-200 mg daily is advocated widely for the management of female hirsutism but this practice lacks adequately controlled experimental support. In a double-blind placebo controlled study of the efficacy of spironolactone 100 mg daily in idiopathic hirsutism we were unable to demonstrate objective benefit from spironolactone treatment. The mean effect of spironolactone given over a 9 month period was to increase hair shaft diameter by +15% with 95% CI (-0.4% to +29%). In addition there were no changes in circulating serum androgen concentrations.

The significance of conversion of skin reactivity to efficacy of bacillus Calmette-Guérin (BCG) vaccinations given immediately after radical surgery in stage II melanoma patients

A group of 668 stage II melanoma patients was entered into a randomized prospective study aimed at evaluating the efficacy of adjuvant BCG, 5-(dimethyltriazeno)imidazole-4-carboxamide (DTIC), or a combination of the two, given immediately after radical lymph node dissection. Of these, 176 patients received BCG and 164 BCG plus DTIC. These 340 patients had histologically proven metastatic nodes and 156 had a negative skin reactivity to BCG at the beginning of treatment. The distribution of known prognostic factors (sex, age, number of positive nodes, extracapsular invasion) was balanced in the groups of patients either with initially negative or with positive skin reactivity. All patients who were initially non-reactive to BCG developed skin reactivity after 6.7 +/- 9 BCG vaccinations. Disease-free and overall survival of patients receiving BCG or BCG + DTIC with an initially negative skin reactivity to BCG was significantly (P = 7 x 10(-3) better than that observed in patients with an initial positive skin reactivity. This finding was still evident after adjustment for other known prognostic criteria (P = 0.02). It seems likely that the initial BCG skin reactivity as such marks the prognosis; however, some therapeutic effect of BCG treatment in patients having initially no skin reactivity to BCG, can not be ruled out.

A comparison of the dermal lymphoid infiltrates in discoid lupus erythematosus and Jessner's lymphocytic infiltrate of the skin using the monoclonal antibody Leu 8

Jessners lymphocytic infiltration of the skin (14 cases) and discoid lupus erythematosus (13 cases) were studied and the lymphoid infiltrates in the dermis were compared in the two conditions, using a standard immunoperoxidase technique. Mouse monoclonal antibodies were used to identify T helper lymphocytes, T suppressor lymphocytes and, using the antibody Leu 8, "immunoregulatory lymphocytes". It was shown that the proportions of Leu 8 positive cells was significantly different in the two conditions. The average percentage of Leu 8 positive lymphocytes in the dermal infiltrate found in the cases of Jessner's was 65% (range 40-80%) whereas the average percentage in the cases of discoid LE was 15% (range 2-30%). This observation is further evidence that Jessner's lymphocytic infiltration and chronic discoid lupus erythematosus should be regarded as separate entities.

Immunophenotyping of the cutaneous infiltrate and of the mononuclear cells in the peripheral blood in patients with atopic dermatitis

Fourteen adult patients with chronic atopic dermatitis and active skin lesions had a skin biopsy and venous blood sample taken on the same day. Absolute numbers of circulating lymphocytes were normal in all patients. Fluorescence-activated cell sorter (FACS) analysis revealed normal numbers of total T lymphocytes and T-helper and T-suppressor subsets (helper:suppressor ratio, 2:1) in the atopic patients' peripheral blood, but an increase in circulating B lymphocytes and in HLA-D-related antigen-bearing cells. The skin biopsy showed a dermal infiltrate of predominantly T-helper lymphocytes (helper:suppressor ratio, 7:1). These cells showed strong HLA-DR plasma membrane staining. There was no HLA-DR staining in the membranes of epidermal keratinocytes. Using a monoclonal antihuman IgE, positive staining was observed in the dermis, though none was identified in the epidermis. The dermal anti-IgE staining was concentrated around clusters of T lymphocytes.

A case-control study of possible causative factors in mycosis fungoides

A detailed case control study was carried out on 53 patients (33 males and 20 females) with histologically proven mycosis fungoides and on an age- and sex-matched control population. Possible causative factors investigated included occupation, recreation, and exposure to petrochemicals, pesticides, insecticides, and potential carcinogens. Exposure to plants of the Compositae family, tanning history, and chronic sun exposure were also investigated, as were smoking history, drug ingestion history, and other skin disease. Personal and family histories of other malignancies were also investigated. The only statistically significant difference to emerge was that the patients with mycosis fungoides had significantly more family history of atopic dermatitis. In view of the absence of any significant difference between patients and controls with regard to personal history of atopic dermatitis, this difference may be the result of multiple statistical testing rather than a phenomenon of true biological significance.

Cytotoxicity of etretinate and vindesine

The effects of an aromatic retinoid, etretinate and a vinca alkaloid, vindesine were investigated by culture of malignant melanoma cells in vitro with these two agents; either separately or in combination. Etretinate inhibited growth of a murine melanoma but only minimal effects were recorded with two human melanomas. Vindesine however, was inhibitory for all of the cell lines and this effect was enhanced in the presence of the retinoid. Entry of 3H labelled vindesine or etretinate into drug free cells was followed in the absence or presence of unlabelled drug. It was found that etretinate enhanced cellular uptake of vindesine in two of the cell lines and this may be responsible for the enhanced toxicity of vindesine in the presence of etretinate. The human melanoma which did not exhibit retinoid stimulated vindesine uptake, appeared to be intrinsically sensitive to the vinca alkaloid. No effect on cellular retinoid uptake by vindesine was recorded in any of the melanomas. The results indicate that the intracellular concentrations combined with the intrinsic sensitivities of each cell line to etretinate and vindesine determines the toxic response.

DNA repair in cells from patients with actinic keratosis

UV-induced DNA repair was studied in peripheral blood lymphocytes from patients with multiple actinic keratoses (AK) requiring surgical therapy and from age-matched normal control individuals. The DNA repair activity in lymphocytes from AK patients at 4 h after UV-irradiation was 50% of that in control lymphocytes, but at 21 h the extent of DNA repair synthesis was similar to that in control cells.

A randomized trial of adjuvant chemotherapy and immunotherapy in cutaneous melanoma

In a randomized trial of adjuvant chemotherapy, immunotherapy, or immunochemotherapy, 761 evaluable patients with pathological Stage II cutaneous melanoma anywhere on the body or with pathological Stage I melanoma of the trunk (Clark's level 3 to 5) were studied by the World Health Organization International Melanoma Group. Wide local excision and excisional regional lymphadenectomy alone were performed in 185 patients and the results were compared with those of surgery plus chemotherapy with dacarbazine (in 192 patients), surgery plus immunotherapy with bacille Calmette-Guérin vaccine (in 203), and surgery plus chemotherapy combined with immunotherapy (in 181). The rates of disease-free survival and overall survival at 36 months were 30.4 +/- 8.3 per cent (mean +/- S.E.) and 41.6 +/- 10.0 per cent, respectively, after surgical treatment alone; 37.2 +/- 7.9 per cent and 46.5 +/- 8.3 per cent after surgery plus chemotherapy; 34.8 +/- 7.9 per cent and 48.7 +/- 8.7 per cent after surgery plus immunotherapy; and 33.6 +/- 7.9 per cent and 50.0 +/- 8.8 per cent after surgery plus a combination of chemotherapy and immunotherapy. None of the differences between groups was significant, and thus no effect of adjuvant therapy could be demonstrated in this study.

Vitiligo patterns simulating autoimmune and rheumatic diseases

Several variants of generalised vitiligo can be recognised by their cutaneous distribution. In some, certain anatomical regions--e.g., hands--are predominantly affected while the cutaneous depigmentation in other variants shows a similar anatomical distribution to that of the internal structures affected in some of the autoimmune and rheumatic diseases. Five patients have been seen, and three described by others, with vitiligo affecting skin of eyelids and lower front of neck, reminiscent of the anatomical distribution of lesions in thyrotoxicosis with exophthalmos: two of these patients have thyrotoxicosis. Another variant of vitiligo mimicks the anatomical distribution of lesions in ankylosing spondylitis, Reiter's syndrome, and ulcerative colitis and there are cases simulating lupus erythematosus, rheumatoid arthritis, and psoriasis. It is suggested that the parts of the body affected in each vitiligo variant and its corresponding internal disease constitute a set os mosiac patches with distinctive shared characters. These may have morphogenetic functions during embryonic development and be potentially autoantigenic later in life.

Lymphocyte abnormalities in mycosis fungoides

Fourteen patients with clinical and histological evidence of mycosis fungoides have undergone a series of immunological tests. Significant findings include the presence of low numbers of E and EAC rosette-forming cells in the peripheral circulation of the mycosis fungoides patients. Elevated levels of IgE were seen in five of the mycosis fungoides patients, and the mean IgE level was significantly higher than in the control series. Possible explanations of these findings are considered.