The BRAAFF checklist: a new dermoscopic algorithm for diagnosing acral melanoma

BACKGROUND

The parallel ridge pattern (PRP) is considered the dermoscopic hallmark of acral melanoma (AM). However, it was recently shown that approximately one-third of AMs do not display a PRP dermoscopically, rendering their detection more troublesome.

OBJECTIVES

To investigate the diagnostic accuracy of dermoscopic criteria for the diagnosis of AM.

METHODS

Dermoscopic images of consecutive cases of histopathologically diagnosed AMs and acral naevi with histopathological diagnosis or with at least 1 year of follow-up were evaluated by three independent investigators for the presence of predefined criteria. Crude and adjusted odds ratios and their corresponding 95% confidence intervals were calculated by univariate and multivariate logistic regression, respectively. Receiver operating characteristic curves were used to choose among competing classification schemes.

RESULTS

In total 603 lesions (472 naevi and 131 AMs) were included in the study. A scoring system (named BRAAFF) composed of six variables was associated with optimal area under the curve and sensitivity for the diagnosis of AM. This method includes four positive (irregular blotches, ridge pattern, asymmetry of structures and asymmetry of colours) and two negative predictors (furrow pattern and fibrillar pattern).

CONCLUSIONS

The BRAAFF checklist significantly improves the diagnostic accuracy of dermoscopy for the diagnosis of AM.

Modification of a melanoma discrimination index derived from hyperspectral data: a clinical trial conducted in 2 centers between March 2011 and December 2013

BACKGROUND

The morphology of pigmented skin lesions (PSLs) is predominantly a result of varying concentrations and distributions of pigmented molecules such as melanin and hemoglobin. Based on these differences and the fact that their information is contained in cutaneous spectra, a hyperspectral imager (HSI) for pigmented melanoma and a single discrimination index derived from the resultant hyperspectral data are proposed.

OBJECTIVE

To develop and evaluate a new discrimination index for melanomas, compared to the previous index.

METHODS

A HSI, which is convenient for both patients and clinicians, was newly developed and used in a clinical trial conducted in 2 centers with 80 patients with primary lesions and 17 volunteers between March 2011 and December 2013. There were 24 melanomas and 110 other PSLs. A previously proposed discrimination index was used without modifications. A new index, which emphasized the essential features of melanoma, was proposed, and its performance was examined. For each index, a threshold value was set to minimize the average value of the false positive and false negative fractions. The performances of both indices were compared.

RESULTS

The sensitivity and specificity of the old index were 75% and 97%, respectively, while those of the new index were 96% and 87%.

CONCLUSION

The new index had a higher sensitivity and adequate specificity, indicating that it is more useful than the old index.

Dermoscopy of acral melanoma: a multicenter study on behalf of the international dermoscopy society

BACKGROUND

Most studies on dermoscopy of acral lesions were conducted in Asian populations. In this study, we analyzed these features in a predominantly Caucasian population.

OBJECTIVE

Estimate the prevalence of dermoscopic features in acral lesions, and assess their level of agreement between observers.

METHODS

In this retrospective multicenter study, 167 acral lesions (66 melanomas) were evaluated for 13 dermoscopic patterns by 26 physicians, via a secured Internet platform.

RESULTS

Parallel furrow pattern, bizarre pattern, and diffuse pigmentation with variable shades of brown had the highest prevalence. The agreement for lesion patterns between physicians was variable. Agreement was dependent on the level of diagnostic difficulty.

CONCLUSION

Lesions with a diameter >1 cm were more likely to be melanoma. We found as well that a benign pattern can be seen in parts of melanomas. For this reason one should evaluate an acral lesion for the presence of malignant patterns first.

A guide to facilitate the early treatment of patients with idiopathic demyelinating disease (multiple sclerosis and neuromyelitis optica)

Definite diagnosis of inflammatory demyelinating disease (multiple sclerosis (MS) and neuromyelitis optica (NMO)) may require time, but early treatment offers the opportunity to maximize patient outcomes. The purpose of this report is to provide guidance to facilitate early treatment decisions for patients with inflammatory demyelinating disease, before definitive diagnosis. Neurology experts reviewed the existing literature and clinical evidence. A treatment decision pathway was developed, defining patients for whom first-line MS disease-modifying therapies (a) are unlikely to be effective, (b) may be effective but require careful monitoring and (c) are likely to provide benefit. This algorithm seeks to ensure that patients, particularly those in Asia, receive appropriate treatment early in inflammatory demyelinating disease.

A simple scoring system for the diagnosis of palmo-plantar pigmented skin lesions by digital dermoscopy analysis

BACKGROUND

Many research groups have recently developed equipments and statistical methods enabling pattern classification of pigmented skin lesions. To differentiate between benign and malignant ones, the mathematical extraction of digital patterns together with the use of appropriate statistical approaches is a challenging task.

OBJECTIVE

To design a simple scoring model that provides accurate classification of benign and malignant palmo-plantar pigmented skin lesions, by evaluation of parameters obtained by digital dermoscopy analysis (DDA).

PATIENTS AND METHODS

In the present study we used a digital dermoscopy analyser to evaluate a series of 445 palmo-plantar melanocytic skin lesion images (25 melanomas 420 nevi). Area under the receiver operator curve, sensitivity and specificity were calculated to evaluate the diagnostic performance of our scoring model for the differentiation of benign and malignant palmo-plantar melanocytic lesions.

RESULTS

Model performance reached a very high value (0.983). The DDA parameters selected by the model that proved statistically significant were: area, peripheral dark regions, total imbalance of colours, entropy, dark area and red and blue multicomponent. When all seven model variables were used in a multivariate mode, setting sensitivity at 100% to avoid false negatives, we estimated a minimum specificity of about 80%.

CONCLUSIONS

Simplicity of use and effectiveness of implementation are important requirements for the success of quantitative methods in routine clinical practice. Scoring systems meet these requirements. Their outcomes are accessible in real time without the use of any data processing system, thus allowing decisions to be made quickly and effectively.

A randomized, controlled trial of fingolimod (FTY720) in Japanese patients with multiple sclerosis

BACKGROUND

Fingolimod (FTY720) has previously shown clinical efficacy in phase II/III studies of predominantly Caucasian populations with multiple sclerosis (MS).

OBJECTIVES

To report six-month efficacy and safety outcomes in Japanese patients with relapsing MS treated with fingolimod.

METHODS

In this double-blind, parallel-group, phase II study, 171 Japanese patients with relapsing MS were randomized to receive once-daily fingolimod 0.5 mg or 1.25 mg, or matching placebo for six months. The primary and secondary endpoints were the percentages of patients free from gadolinium (Gd)-enhanced lesions at months 3 and 6, and relapses over six months, respectively; safety outcomes were also assessed.

RESULTS

147 patients completed the study. Higher proportions of patients were free from Gd-enhanced lesions at months 3 and 6 with fingolimod (0.5 mg: 70%, p = 0.004; 1.25 mg: 86%, p < 0.001) than with placebo (40%). Odds ratios for the proportions of relapse-free patients over six months favoured fingolimod versus placebo but were not significant. Adverse events related to fingolimod included transient bradycardia and atrioventricular block at treatment initiation, and elevated liver enzyme levels.

CONCLUSIONS

This study demonstrated the clinical efficacy of fingolimod for the first time in Japanese patients with MS, consistent with the established effects of fingolimod in Caucasian patients.

Mutation analysis of BRAF and KIT in circulating melanoma cells at the single cell level

Background:

The availability of molecular-targeted therapies for the treatment of melanoma has emphasised the need to identify mutations in target genes such as BRAF and KIT. Circulating tumour cells (CTC) are present in the peripheral blood of a significant proportion of cancer patients.

Methods:

High molecular weight melanoma-associated antigen (HMW-MAA) was used to isolate melanoma cells from peripheral blood as it is selectively expressed at high levels on melanomas. The HMW-MAA-positive cells were isolated using immunomagnetic beads. After removing CD45⁺ cells, CTC were identified by staining with MART-1- and gp100-specific antibodies (HMW-MAA⁺, CD45⁻, MART-1/gp100⁺). Single, isolated CTC were then subjected to BRAF and KIT mutational analysis.

Results:

CTC (HMW-MAA⁺, CD45⁻, MART-1/gp100⁺) were isolated from the blood of 11 patients and BRAF and KIT were sequenced in nine and four patients, respectively. The BRAF sequences identified in the CTC were inconsistent with those identified in autologous melanoma tumours in three patients and the KIT sequences were inconsistent in three patients. In addition, polyclonal BRAF mutations were identified in one patient and concomitant mutations in BRAF and KIT were identified in another patient.

Conclusion:

Melanoma cells show clonal heterogeneity. Therefore, CTC genotyping may be crucial for successful molecular-targeted therapy.

Dermoscopy of pigmented lesions on mucocutaneous junction and mucous membrane

BACKGROUND

The dermoscopic features of pigmented lesions on the mucocutaneous junction and mucous membrane are different from those on hairy skin. Differentiation between benign lesions and malignant melanomas of these sites is often difficult.

OBJECTIVE

To define the dermoscopic patterns of lesions on the mucocutaneous junction and mucous membrane, and assess the applicability of standard dermoscopic algorithms to these lesions.

PATIENTS AND METHODS

An unselected consecutive series of 40 lesions on the mucocutaneous junction and mucous membrane was studied. All the lesions were imaged using dermoscopy devices, analysed for dermoscopic patterns and scored with algorithms including the ABCD rule, Menzies method, 7-point checklist, 3-point checklist and the CASH algorithm.

RESULTS

Benign pigmented lesions of the mucocutaneous junction and mucous membrane frequently presented a dotted-globular pattern (25%), a homogeneous pattern (25%), a fish scale-like pattern (18.8%) and a hyphal pattern (18.8%), while melanomas of these sites showed a multicomponent pattern (75%) and a homogeneous pattern (25%). The fish scale-like pattern and hyphal pattern were considered to be variants of the ring-like pattern. The sensitivities of the ABCD rule, Menzies method, 7-point checklist, 3-point checklist and CASH algorithm in diagnosing mucosal melanomas were 100%, 100%, 63%, 88% and 100%; and the specificities were 100%, 94%, 100%, 94% and 100%, respectively.

CONCLUSION

The ring-like pattern and its variants (fish scale-like pattern and hyphal pattern) are frequently observed as well as the dotted-globular pattern and homogeneous pattern in mucosal melanotic macules. The algorithms for pigmented lesions on hairy skin also apply to those on the mucocutaneous junction and mucous membrane with high sensitivity and specificity.

Temporal changes and geographical differences in multiple sclerosis phenotypes in Japanese: nationwide survey results over 30 years

Background

There are two distinct phenotypes of multiple sclerosis (MS) in Asians, manifesting as optic-spinal (OSMS) and conventional (CMS) forms. In Japan, four nationwide surveys of MS have been conducted. The first three were in 1972, 1982, and 1989, and we performed the fourth in 2004.

Results

The recent survey showed six main findings as follows: (1) a four-fold increase in the estimated number of clinically definite patients with MS in 2003 (9900; crude MS prevalence, 7.7/100,000) compared with 1972; (2) a shift in the peak age at onset from early 30s in 1989 to early 20s in 2003; (3) a successive proportional decrease in optic-spinal involvement in clinically definite patients with MS; (4) a significant north–south gradient for the CMS/OSMS ratio; (5) after subdivision of the mainland (30–45° North) into northern and southern parts at 37°N, northern-born northern residents (northern patients) showed a significantly higher CMS/OSMS ratio and higher frequency of brain lesions fulfilling the Barkhof criteria (Barkhof brain lesions) than southern-born southern residents (southern patients); (6) among northern patients, the absolute numbers of patients with CMS and those with Barkhof brain lesions rapidly increased with advancing birth year.

Conclusions

These findings suggest that MS phenotypes are drastically altered by environmental factors, such as latitude and “Westernization.”

Genetic and epigenetic alterations in the differential diagnosis of malignant melanoma and spitzoid lesion

BACKGROUND

The histopathological differentiation of malignant melanoma and Spitz naevus often presents diagnostic problems.

OBJECTIVES

We aimed to find out applicable diagnostic parameters other than routine pathology.

METHODS

The cases included conventional melanomas and Spitz naevi as well as atypical spitzoid lesions that had posed diagnostic difficulties. We examined hotspots of mutation in the BRAF, NRAS and HRAS genes by polymerase chain reaction-based direct sequencing. We also analysed DNA copy number aberrations and the methylation of CpG sequences in several cancer-related genes by utilizing a novel methylation-specific multiplex ligation-dependent probe amplification method.

RESULTS

Twenty three of 24 conventional melanomas showed at least one of the genetic and epigenetic alterations examined, although one acral melanoma did not show any alteration. By sharp contrast, 12 Spitz naevi with an unambiguous histopathology showed no or few chromosomal aberrations, no oncogene mutations and no methylation of CpG sequences. Of the 16 ambiguous spitzoid lesions, most of which were designated atypical Spitz tumour by one of the authors, all but one showed no mutations, no methylations and few copy number aberrations. However, three tumours showed copy number loss of the cyclin-dependent kinase inhibitor 2A gene (CDKN2A), an alteration observed frequently in melanomas but not found in conventional Spitz naevi. These results show that, although most atypical Spitz tumours do not differ from conventional Spitz naevi showing virtually no genetic and epigenetic aberrations, some cases may have chromosomal aberrations that include copy number loss of the CDKN2A gene.

CONCLUSIONS

Genetic and epigenetic analyses may be useful as an additional diagnostic tool to distinguish between melanoma and Spitz naevus, and may help to define subgroups in atypical Spitz tumours.

Anti-aquaporin 4 antibody in selected Japanese multiple sclerosis patients with long spinal cord lesions

Multiple sclerosis (MS) in Asian populations is often characterized by the selective involvement of the optic nerve (ON) and spinal cord (SP) (OSMS) in contrast to classic MS (CMS), where frequent lesions are observed in the cerebrum, cerebellum or brainstem. In Western countries, inflammatory demyelinating disease preferentially involving the ON and SP is called neuromyelitis optica (NMO). Recently, Lennon et al. discovered that NMO-IgG, shown to bind to aquaporin 4 (AQP4), could be a specific marker of NMO and also of Japanese OSMS whose clinical features were identical to NMO having long spinal cord lesions extending over three vertebral segments (LCL). To examine this antibody in larger populations of Japanese OSMS patients in order to know its epidemiological and clinical spectra, we established an immunohistochemical detection system for the anti-AQP4 antibody (AQP4-Ab) using the AQP4-transfected human embryonic kidney cell line (HEK-293) and confirmed AQP4-Ab positivity together with the immunohistochemical staining pattern of NMO-IgG in approximately 60% of Japanese OSMS patients with LCL. Patients with OSMS without LCL and those with CMS were negative for this antibody. Our results accorded with those of Lennon et al. suggest that Japanese OSMS with LCL may have an underlying pathogenesis in common with NMO.

Estrogen-Receptor-Alpha-Positive Extramammary Paget’s Disease Treated with Hormonal Therapy

The patient was an 80-year-old man with scrotal and penile extramammary Paget's disease and prostate cancer. Both diseases were in advanced stages. Tumor cells of extramammary Paget's disease strongly expressed estrogen receptor alpha. The patient was concurrently treated with two kinds of hormonal therapy: the anti-estrogen tamoxifen (20 mg/day orally) for extramammary Paget's disease and the anti-androgen bicalutamide (80 mg/day orally) for prostate cancer. The toxicity of the therapy was mild. All of the metastatic lesions remained stable for 2 months after initiation of dual hormonal therapy. During a follow-up period of 22 months, performance status was well maintained for 17 months. Hormonal therapy may be an alternative for selected cases of advanced extramammary Paget's disease.

Optical circuit design based on a wavefront-matching method

We propose an optical circuit design method for coherent waves as a boundary value problem. The method produces a very compact circuit in which the refractive index pattern is automatically synthesized for given input and output fields with a numerical calculation. We employ the method to design a 1.3/1.55 microm wavelength demultiplexer and also describe the features of a circuit generated by use of the method.

Chronic obesity lymphoedematous mucinosis: three cases of pretibial mucinosis in obese patients with pitting oedema

Pretibial mucin deposition on the shins is known as pretibial myxoedema. We report three patients with pretibial mucinosis without thyroid disease. The patients were characterized clinically by morbid obesity and bilateral lower extremity pitting oedema with gradual and painless onset, and that did not involve the feet and ankles. Vesicles, semitranslucent papules or a woody plaque were found on the shins. Histologically, patients showed characteristic features of epidermal atrophy with effacement of the rete ridge pattern, separation of collagen bundles associated with oedema with stellate to linear fibroblasts, upward-running increased capillary and small vessels with haemosiderin deposition, and mucin deposition at the superficial papillary dermis and around the vessels. We propose that the present cases of 'chronic obesity lymphoedematous mucinosis' belong to the clinical entity of pretibial mucinosis.

Long-term treatment of generalised myasthenia gravis with FK506 (tacrolimus)

Efficacy and safety of long term use of FK506 (2-4.5 mg/day) for a maximum of two years were evaluated in 12 patients with generalised myasthenia gravis (MG). At the end of the study, eight patients (67%) showed improvement in either MG score or Activities in Daily Living score, and prednisolone dosage could be reduced in seven patients (58%), with a mean reduction ratio of 37%. Long term use of FK506 for MG can be more effective than short term administration, with no serious side effects.

Interferon beta-1b is effective in Japanese RRMS patients: A randomized, multicenter study

OBJECTIVE

To assess the efficacy of interferon beta-1b (IFNB-1b) in Japanese patients with relapsing-remitting multiple sclerosis (RRMS).

BACKGROUND

The effects of IFNB in RRMS have been assessed in study populations comprised predominantly of white patients. MS in Japanese patients is different from that in white patients in that there are two different presentations--classic MS (C-MS) and optic-spinal MS (OS-MS)--and chronic progressive forms are infrequent.

METHODS

A total of 205 Japanese patients with RRMS were randomized to receive 50 microg or 250 microg (1.6 or 8.0 MIU) IFNB-1b administered SC every other day for up to 2 years. The primary endpoint was annual relapse rate. Secondary endpoints included further relapse-related and MRI outcome measures, as well as changes in Expanded Disability Status Scale and Neurologic Rating Scale. Efficacy was assessed in 188 patients, and safety was assessed in 192 patients. Supplemental ad hoc subgroup analyses were also performed for patients with OS-MS and those with C-MS.

RESULTS

Annual relapse rates were 0.763 in the 250 microg group and 1.069 in the 50 microg group, a relative reduction of 28.6% (p = 0.047). Results for all secondary endpoints favored 250 microg IFNB-1b. Subgroup analyses suggested that the magnitude and direction of treatment effect in patients with OS-MS and C-MS was similar, albeit not significant due to small sample size.

CONCLUSIONS

Interferon beta-1b (IFNB-1b) 250 microg significantly reduced relapse rates and change in MRI lesion area in Japanese patients with relapsing-remitting multiple sclerosis, and seemed to be comparably effective in optic-spinal multiple sclerosis (MS) and classic MS. The response to treatment with IFNB-1b in Japanese patients with MS suggests that a common pathogenesis and underlying genetic characteristics are shared with white patients.

Circulating lymphocyte subsets linked to intracellular cytokine profiles in normal humans

To determine whether there is an association between intracellular cytokine profiles and the expression of surface antigens, we performed a simultaneous flow cytometric analysis of these laboratory parameters in 11 healthy volunteers. Peripheral blood lymphocytes were double-stained for CD4 or CD8, as well as CD11a, CD25, CD26, CD29 and CD45RA or the chemokine receptors CCR3, CCR4, CCR5 or CXCR3. Portions of the cell samples were cultured for 4 h in the presence of 1 microm monensin and 20 microg/ml brefeldin A with or without stimulation by phorbol myristate acetate plus ionomycin for the detection of intracellular interferon-gamma (IFN-gamma), interleukin-2 (IL-2), tumour necrosis factor (TNF)-alpha, and IL-4. As a result, CD4+CD29high helper inducer T cells were closely associated with IFN-gamma and TNF-alpha producing CD4+ cells, while CD4+CXCR3+ cells showed a negative correlation with IL-4-producing cells, suggesting that both of these CD4+ subsets consist mainly of Th1 cells. In contrast, CD4+CD45RA+ cells were correlated inversely with IFN-gamma and TNF-alpha-producing cells, and CD8+CD11ahigh killer effector and total CCR5+ cells showed an inverse correlation with IL-2 producing cells, suggesting an immunoregulatory role for these three subsets in non-pathological conditions. Therefore, monitoring of lymphocyte subsets that express functional surface antigens could provide additional information concerning immune deviation, as assessed by the production of Th1/Th2 type cytokines. Further, this type of combined study may provide clues for the pathogenesis of immune-mediated disorders.

Reduced expression of actin-binding proteins, h-caldesmon and calponin h1, in the vascular smooth muscle inside melanoma lesions: an adverse prognostic factor for malignant melanoma

BACKGROUND

The structural integrity of the blood vessels such as small arteries and veins is studied less frequently in malignant tumours than is angiogenesis. Objectives To clarify the characteristics of small arteries and small veins of melanoma lesions.

METHODS

We immunohistochemically investigated various types of melanocytic tumours using antibodies specific for endothelial and vascular smooth muscle cells, and analysed the relationship between the expression of these molecules in the blood vessels and the biological characteristics of the tumours. Formalin-fixed, paraffin-embedded sections of 15 cases of benign melanocytic tumours and 64 cases of malignant melanomas were investigated.

RESULTS

Significant suppression of expression of h-caldesmon (h-CD) and calponin h1 (CNh1) was observed in the blood vessels of malignant melanomas compared with both benign melanocytic tumours and normal tissues. In particular, the level of h-CD expression was inversely correlated with the frequency of metastasis and positively correlated with the survival rate in patients with malignant melanoma.

CONCLUSIONS

These findings suggest that alterations of the tumour vessels are an important factor for the prognosis of malignant melanoma, and that suppression of h-CD and CNh1 in the blood vessels in malignant melanoma reflects a structural fragility of the vessels, leading to their easy penetration by tumour cells. Defective expression of these molecules is likely to be an important marker for metastatic potential and for poor prognosis of melanoma.

Expression of lamins depends on epidermal differentiation and transformation

BACKGROUND

It has been suggested that A- and B-type lamins, proteins of the nuclear lamina, play important roles in the morphogenesis of the nucleus and cellular differentiation.

OBJECTIVE

To investigate the expression of these nuclear proteins in normal skin and some keratinocytic tumours of the skin.

METHODS

We examined by means of immunohistochemistry the expression of lamins in normal skin and some keratinocytic tumours of the skin, such as squamous cell carcinoma (SCC), basal cell carcinoma (BCC), Bowen's disease, solar keratosis, keratoacanthoma and seborrhoeic keratosis.

RESULTS

In normal skin, A-type lamin was expressed in all epidermal cells, but the expression level of B-type lamins diminished from basal cells to granular cells. In keratinocytic tumours, the expression of A-type lamin was reduced, especially in BCCs, Bowen's disease and poorly differentiated SCCs. B-type lamins were reduced and exhibited heterogeneous expression patterns in most well-differentiated SCCs and keratoacanthomas. Antibodies against B-type lamins stained only peripheral cells of the lobules in keratoacanthomas, while no regular staining patterns were seen in well-differentiated SCCs.

CONCLUSIONS

Lamin expression depends on the differentiation and transformation of the human skin. This finding should be useful for the diagnosis of keratinocytic tumours.

Chlamydia pneumoniae infection associated with enhanced MRI spinal lesions in multiple sclerosis

Cerebrospinal fluid (CSF) from 66 patients with multiple sclerosis (MS) and 25 patients with other neurological diseases (OND) were examined for the infection of Chlamydia pneumoniae by culture, polymerase chain reaction (PCR) assay, and determination of antibodies to C. pneumoniae. PCR was positive not only in 9 of 28 (32%) patients with MS but also in 2 patents with inflammatory disorders in 15 (13%) OND controls (p = 0.18). Viable C. pneumoniae was isolated from one patient with MS and one with paraneoplastic encephalomyelitis. C. pneumoniae could be detected only in cell-containing CSF. In MS, enhanced spinal magnetic resonance imaging (MRI) lesions were detected in all of four PCR-positive patents but none of five PCR-negative patients, and the difference was significant (p = 0.0079). However, no correlation was found between enhanced brain MRI lesions and CSF C. pneumoniae DNA. Elevated titers of anti-C. pneumoniae IgG were detected in CSF in 13 of 66 (20%) patients with MS and 1 of 25 (4%) OND controls (p = 0.064). CNS C. pneumoniae infection is not uncommon in MS as well as in other inflammatory disorders of the nervous system. The association of active spinal lesions with Chlamydia in CSF collected by lumber puncture suggests the detection of a recent infection. On the other hand, the lack of association of active MS brain lesions with CSF Chlamydia and the presence of PCR-positive patents who are clinically stable and have no enhancing MRI lesions imply the existence of a chronic infectious process.

Relationship between urinary symptoms and disease-related parameters in multiple sclerosis

OBJECTIVE

To find the prevalence of voiding dysfunction in patients with multiple sclerosis and to examine the relationship between the voiding dysfunction and various parameters of the disease (disease severity, disease duration, lesion site, age and sex).

METHODS

Using the International prostate symptom score, lower urinary tract symptoms were quantitatively evaluated in all patients with multiple sclerosis who had visited our neurological department during three months. The lesion site in the central nervous system was determined by a combination of neurological and magnetic resonance imaging findings.

RESULTS

Of the 47 patients who had completed the questionnaire, 25 (53 %) were considered to have symptomatic voiding dysfunction. Even at early stage of the disability, 6 of 19 (32 %) patients were symptomatic. Eight (17 %) patients had irritative urinary symptoms alone, whereas 9 (19 %) patients had obstructive urinary symptoms alone. The irritative and obstructive symptoms were concomitant in 10 (21 %) patients. Compared with reports from Western countries, the ratio of obstructive symptoms to irritative symptoms was high in Japan. The degree of irritative symptoms was well correlated with the disease severity, whereas the correlation of obstructive symptoms with the disease severity was less significant. Irritative symptoms also showed a weak correlation with the disease duration, but obstructive symptoms did not. Among the lesion sites in the central nervous system, only the presence of the spinal cord lesion was related to the degree of urinary symptoms. Urinary symptoms were not significantly influenced by the age or the sex. Quality of life was disturbed by urinary symptoms, and this disturbance paralleled the disease severity.

CONCLUSION

Urinary symptoms, especially irritative symptoms, reflect the condition of the disease. Thus, the quantified urinary symptoms may assist neurological diagnosis.

Evaluation of 5-S-cysteinyldopa as a marker of melanoma progression: 10 years' experience

5-S-Cysteinyldopa (5-S-CD) has been used as a biochemical marker of melanoma progression. In this study, we measured serum levels of 5-S-CD in 2648 samples taken from 218 patients in order to evaluate the usefulness of this parameter in following melanoma progression and prognosis. 5-S-CD levels were significantly elevated above the upper limit of the normal range (10 nmol/l) in stage IV melanoma patients. The sensitivity of elevated serum 5-S-CD levels in detecting distant metastasis was 73%, while the specificity was 98% and the positive predictive value 94%. The sensitivity was improved to 77% when cases of amelanotic melanoma were excluded. Patients without metastases had elevated 5-S-CD values in 5% of the 1480 serum samples. Changes in serum 5-S-CD levels were followed during disease progression until the end stage in 49 patients. In 33% of the patients, elevation of serum 5-S-CD levels preceded clinical detection of visceral metastases, and in 37% elevation of 5-S-CD levels occurred at the same time as visceral metastasis. Patients with elevated 5-S-CD levels before or after surgical treatment had significantly shorter survival times than those with normal levels. These results show that the level of 5-S-CD in the serum is a sensitive and specific marker in predicting distant metastases. Elevated serum levels of 5-S-CD, before or after surgical treatment, is associated with a poor prognosis.

Tumor antigens isolated from a patient with vitiligo and T-cell-infiltrated melanoma

Serological identification of tumor antigens by cDNA expression cloning is a technique used to isolate cDNAs encoding tumor antigens that are recognized by IgG antibodies in sera from cancer patients. It is also useful for the isolation of tumor antigens recognized by T cells. We applied this method to identify melanoma antigens recognized by the serum from a patient with a good prognosis who had T-cell-infiltrated melanoma and vitiligo. By screening a lambda phage cDNA library constructed from a highly pigmented melanoma cell line, SKmel23, with the patient's serum, 50 positive cDNA clones consisting of 26 distinct antigens were isolated. Of these, 20 encoded known proteins, and 6 encoded previously uncharacterized ones. The most frequently isolated clone, which we named KU-MEL-1, was unknown previously but was homologous to partial cDNA sequences registered in the expressed sequence tag database. Reverse transcription-PCR and Northern blot analysis demonstrated that KU-MEL-1 was strongly expressed in most melanoma cell lines, melanoma tissue samples, and cultured melanocytes and weakly expressed in cell lines derived from other types of tumors, as well as in some normal tissues, including testis. Western blot analysis with polyclonal murine antibody generated by immunization with the recombinant KU-MEL-1 protein demonstrated that the KU-MEL-1 protein was preferentially expressed in melanoma cells and melanocytes. IgG antibodies against KU-MEL-1 were detected in the sera from 9 of 26 melanoma patients and from some patients with other cancers, including brain tumor, esophageal cancer, colon cancer, and chronic myelogenous leukemia, but were not detected in sera from 30 healthy individuals. Although the IgG specific for KU-MEL-1 was not detected in sera from 12 vitiligo patients, it was detected in sera from 7 of 11 patients with Vogt-Koyanagi-Harada disease that is thought to be an autoimmune disease against melanocytes. These results suggest that KU-MEL-1 may be a useful target for the development of diagnostic and therapeutic methods for patients with various cancers, particularly with melanoma, as well as patients with autoimmune diseases against melanocytes.

Loricrin keratoderma: a cause of congenital ichthyosiform erythroderma and collodion baby

A group of hereditary palmoplantar keratodermas due to heterozygous mutation in the loricrin gene has recently been identified. Of five reported pedigrees, four presented as mutilating keratoderma with ichthyosis (variant Vohwinkel syndrome), and one as progressive symmetric erythrokeratoderma. We report a new Japanese pedigree of loricrin keratoderma. A 14-year-old male and his 11-year-old female sibling had both been born as collodion babies and were initially diagnosed as having non-bullous congenital ichthyosiform erythroderma, but later developed palmoplantar keratoderma with pseudoainhum. Their father was similarly affected. Direct sequencing of genomic DNA revealed a G residue insertion at codon 230-231 of the loricrin gene. Antibody studies confirmed the presence of mutant loricrin in the retained nuclei. We conclude that loricrin gene mutation may present as congenital ichthyosiform erythroderma, and should be included in the differential diagnosis of collodion baby.

Growth inhibition of human malignant melanoma transfected with the human interferon-beta gene by means of cationic liposomes

Among the various types of human interferons, human interferon-beta (HuIFNbeta) has the strongest anti-proliferative activity against human melanoma cell lines. Therefore, we investigated the growth inhibitory effect of a cationic liposome containing the HuIFNbeta gene on human melanoma cell lines in vitro and in vivo. After transfection with liposomes containing the HuIFN-beta gene, human melanoma cell lines produced HuIFNbeta in the culture medium at levels ranging from 67 to 3.8 IU/ml on day 6, and growth of the cells was inhibited by 71-92%. Moreover, six injections of liposomes containing the HuIFNbeta gene completely eradicated human melanoma nodules transplanted onto the backs of nude mice 40 days after the first injection. Histological analysis of the injected nodules revealed that the HuIFNbeta gene transfection induced apoptosis of the human melanoma cells. These data suggest that transfection of the HuIFNbeta gene using cationic liposomes is a promising candidate for gene therapy of human melanoma.

Loss of beta-catenin expression associated with disease progression in malignant melanoma

BACKGROUND

beta-catenin plays a crucial role in the function of cell adhesion molecules and also participates in growth regulatory signalling pathways that may be involved in malignant transformation.

OBJECTIVES

To examine beta-catenin expression in lesions of melanocytic origin for associations with clinicopathological markers of disease progression and for its significance as a predictor of disease recurrence and prognosis.

METHODS

beta-catenin expression was examined by immunoperoxidase staining in 50 melanocytic naevi and 91 primary and 50 metastatic melanomas.

RESULTS

beta-catenin was expressed in 96% of melanocytic naevi, in 94% and 65%, respectively, of radial and vertical growth phase primary melanomas, and in 38% of metastatic melanomas. Benign and malignant melanocytic lesions had distinct patterns of beta-catenin localization. Most lesions expressing beta-catenin exhibited cytoplasmic staining; however, over 40% of benign lesions also displayed nuclear staining, which was present only in 10% of primary and 15% of metastatic melanomas. Absent or weak expression of beta-catenin in primary melanomas was associated with several markers of disease progression, including tumour thickness and presence of lymph node metastases. A similar but not statistically significant trend was observed for the association of beta-catenin expression with disease recurrence and prognosis.

CONCLUSIONS

These results suggest that loss or downregulation of beta-catenin expression in melanoma cells plays a significant role in progression of the disease.

Three patients with ophthalmoplegia associated with Campylobacter jejuni

Cranial polyneuropathy is idiopathic in most patients. Idiopathic cranial polyneuropathy is an acute postinfectious syndrome, along with Guillain-Barré syndrome and Miller Fisher syndrome, in which the common preceding pathogen is Campylobacter jejuni. Serum anti-GQ1b antibodies are elevated in Miller Fisher syndrome and Guillain-Barré syndrome with ophthalmoplegia. Three patients with idiopathic cranial polyneuropathy with predominant ocular involvement are presented. C. jejuni isolated from stool specimens belonged to Penner serotypes O:4, O:23, and O:33. Serum anti-GQ1b antibodies were elevated in all patients but demonstrated rapid reduction concomitant with clinical recovery. All patients recovered completely. Because both preceding C. jejuni infection and elevated anti-GQ1b antibodies decreasing with time were seen in all patients, the pathogenesis of idiopathic cranial polyneuropathy with ophthalmoplegia may be similar to that of Miller Fisher syndrome.

Updated statistical data for malignant melanoma in Japan

BACKGROUND

A statistical investigation was conducted of Japanese melanoma patients who had been registered by the Prognosis and Statistical Investigation Committee of the Japanese Skin Cancer Society. The data were obtained from 24 main medical institutions in Japan in the period 1987 to 1996. The patients were classified into two chronological groups; group A, 535 patients registered from 1987 to 1991; and group B, 639 patients registered from 1992 to 1996. As the preliminary data for group A has been reported previously (Gann Monograph on Cancer Research 43), in this report, the survival data of group B were assessed, and compared with the data for group A.

METHODS

The data analyzed included age, sex, anatomical distribution, clinical features of primary lesions, Clark's subtype, tumor thickness, Clark's level, disease stage, and treatment. The survival rate was assessed by the Kaplan-Meier method, and the significance of differences was determined with the log-rank test. In addition, the results of a nationwide survey of various types of skin malignancies, obtained from 101 medical institutions in Japan between 1987 and 1996, were analyzed.

RESULTS

The nationwide survey revealed that the number of patients with malignant melanoma showed a steady increase during the period 1987-1996 in Japan. It is noteworthy that the numbers of actinic keratoses, a type of early squamous cell carcinoma in situ, showed a steep increase in recent years. Results revealed in our study of the melanoma registry for the period 1987-1996 were as follows: (1) the male-to-female ratio was 1 to 1.06, (2) the survival rate of female patients was higher than that of male patients (10-year survival in group B: female, 71.6% vs male, 55.9%), (3) the commonest site of melanoma in both sexes was the sole of the foot, (4) with respect to Clark's subtype, acral lentiginous melanoma was commonest, accounting for about half of all melanomas, (5) nodular melanoma showed the worst prognosis among the subtypes, (6) patients in stage IIIB and stage IV had an unfavorable outcome, with 10-year survivals of less than 50% and less than 10%, respectively, (7) Clark's level of invasion, as well as Breslow's tumor thickness of the primary lesions, were confirmed to be important prognostic factors, and (8) prophylactic lymph node dissection in stage II and IIIA and chemotherapy in stage IV seemed to have limited effect on the prognosis.

CONCLUSION

The prognosis of advanced melanoma is poor, as it is highly resistant to chemotherapy. Thus, to improve the prognosis, early detection is mandatory, and this is possible because this neoplasm appears as a distinctive pigmented lesion on the skin.

Recent advances in melanoma research

Recent advancement in the research of malignant melanoma is reviewed. Among many gene alterations detected in human melanoma, defect of CDKN2A located at chromosome 9p21 seems to be most important in the earlier developmental phase, though significance of this gene in the evolution of melanoma in situ has not been confirmed yet. Deletions of PTEN/MMAC1 on 10q23.3 and AIM1 on 6q21 as well as mutations of ras gene are involved in the later progression stages of melanoma. Adhesion molecules relevant to development and progression of melanoma have been intensely investigated in recent years, revealing crucial roles of cadherins and alpha(v)beta(3) integrin in the biologic behaviors of melanoma cells. Melanoma is characterized by extremely high potential of developing metastases. Dynamic changes of matrix metalloproteinase activity during invasion and movement of melanoma cells may be a major concern in this field. Fragility of blood vessels in melanoma lesions is another important point related to hematogeneous metastases. Acral lentiginous melanoma is a unique subtype of melanoma, because, in contrast to other subtypes, ultraviolet irradiation is not a major factor in its development. Investigation of pathogenesis of acral lentiginous melanoma surely provides us with new information about mechanism of melanocyte transformation. Recent advances in the management of malignant melanoma are also briefly reviewed, such as biochemotherapy, immunotherapy, and gene therapy. Finally, the concept of molecular classification of melanoma by gene expression profile is introduced, which possibly enables us to give the tailor-made therapy for each melanoma patient in the near future.

Malignant melanoma on the sole: how to detect the early lesions efficiently

Early detection of malignant melanoma (MM) is essential to improve the prognosis. In non-white populations, including Japanese, the sole is the most prevalent site of MM. On the sole, however, melanocytic nevus is also frequently found. Clinical differentiation of early MM from benign melanocytic nevus on the sole is sometimes difficult because both are observed as a brownish-black macule. For the effective early detection of MM on the sole, the author has proposed guidelines based on the data of hundreds of melanocytic lesions on the sole. The algorithmic guidelines are as follows: when you see a pigmented lesion on the sole, first exclude congenital melanocytic nevus and some other specified disorders, and then measure the maximum diameter of the lesion. If it is more than 7 mm, biopsy it for histopathologic evaluation. If it is 7 mm or less, just follow the course of the lesion and advise the patient to come back if it enlarges to more than 7 mm. Even when the lesion is 7 mm or less, a biopsy is recommended on it, if it shows marked irregularity in shape and/or color or it shows the parallel ridge pattern with epiluminescence microscopy (ELM). The author believes the guidelines surely work efficiently in screening early MM on the sole.

What is the most promising strategy for the treatment of metastasizing melanoma?

The treatment of patients with metastasizing melanoma, still one of the most deadly diseases in modern medicine, ranks among the greatest challenges that a clinician has to face. Metastatic melanoma also is one of the most profound sources of clinical frustration, since it provides far more ultimately defeating experiences than clinical victories. At the same time, the fascinating biology of melanoma has invited the study of this neuroectodermal tumor as a model system for dissecting many of the key problems of modern oncology, ranging from molecular oncogenesis via the controls of tumor proliferation, apoptosis, invasion, metastasis, and angiogenesis to tumor immunosurveillance and tumor drug resistance. Together with the dire need to develop more effective treatment modalities for improving both life expectancy and quality of life of affected patients, this has made metastatic melanoma a favorite model for the exploration of innovative strategies for tumor management. Encouragingly, many of these have already generated very promising results in animal models. However, this impressive level of research progress in conquering melanoma in the animal room contrasts rather pitifully with the actual progress made on the ward. This CONTROVERSIES feature, therefore, critically and soberly reviews the state of the art of treating metastatic melanoma today (distinguishing between nodal and distant metastases), and sharply defines unresolved or comparatively neglected key problems. In addition, this feature highlights several novel, provocative, hitherto underappreciated, yet potentially promising treatment approaches that deserve systematic exploration. Hopefully, this will offer further inspiration for the design and pursuit of innovative anti-melanoma strategies off-the-beaten-track.

Frequency of facial angiofibromas in Japanese patients with multiple endocrine neoplasia type 1

The high frequency of cutaneous manifestations in patients with multiple endocrine neoplasia type 1 (MEN 1) has recently been reported. Since prevalence of some cutaneous diseases varies among different ethnic groups, we examined the frequency of facial angiofibromas in Japanese patients with familial MEN 1. Among 27 patients with germline MEN1 gene mutation and one asymptomatic gene carrier, angiofibromas were identified in 43% (12/28) of the subjects. This frequency was significantly lower than that of Caucasian patients, but nonetheless almost equaled those of pituitary tumors and pancreas endocrine tumors. Angiofibromas should be considered as one of major manifestations in MEN 1 regardless of patients' ethnic origin, and clinicians should pay careful attention to the cutaneous lesions in patients with endocrine tumors.

Determination of medullasin levels for the diagnosis of multiple sclerosis

OBJECTIVES

To obtain a simple and reliable clinical parameter for the diagnosis of multiple sclerosis among patients with neurological diseases.

PATIENTS AND METHODS

Heparinized peripheral blood was obtained from patients with multiple sclerosis and those with non-inflammatory neurological diseases and healthy volunteers. A new enzyme immunoassay method determining medullasin levels in human granulocytes was developed by using mouse monoclonal antibody against medullasin.

RESULTS

A newly developed enzyme immunoassay method for medullasin can detect as little as 1 ng/ml medullasin and results can be obtained within 2 h. Eighty-five out of 112 patients with multiple sclerosis (75.8%) showed positive results (above means of normals + 2 SD) in the medullasin test, while 15.4% (12/78) of patients with non-inflammatory neurological disease had positive results.

CONCLUSION

This newly developed enzyme immunoassay method for medullasin is considered to be a useful paraclinical test for the diagnosis of multiple sclerosis.

Clinical and analytical evaluation of an enzyme immunoassay for myelin basic protein in cerebrospinal fluid

BACKGROUND

RIA of myelin basic protein (MBP) in cerebrospinal fluid (CSF) is commonly used as a biochemical marker of demyelination in patients with multiple sclerosis (MS). Our aim was to develop a sufficiently sensitive ELISA for MBP and evaluate it clinically in patients with MS.

METHODS

The ELISA used anti-bovine MBP antibody coated on plates and biotinylated anti-MBP antibody. The bound antibody complex was quantified with streptavidin-horseradish peroxidase. MBP was determined in CSF from 84 MS patients and 55 patients with other neurological diseases.

RESULTS

The respective within- and between-assay CVs were 4.7% and 7.2% at 200 ng/L, and 6. 3% and 8.8% at 2000 ng/L. The detection limit was 30 ng/L. Most of the MS patients with acute exacerbations had markedly increased MBP in the CSF. Longitudinal studies of six MS patients with recurrent exacerbation confirmed this observation. MBP concentrations from 78 MS patients, as tested with our ELISA, correlated well with those obtained by RIA (r = 0.9; P: <0.01), but the detection limit of the ELISA was much lower than that of the RIA.

CONCLUSIONS

This convenient ELISA with higher sensitivity than the existing assays is a suitable routine assay that provides a diagnostic indicator of myelin breakdown in the central nervous system; moreover, it is an excellent indicator of MS disease activity.

A case of an inflammatory variant of epidermolysis bullosa acquisita: chronic bullous dermatosis associated with nonscarring mucosal blisters and circulating IgG anti-type-VII-collagen antibody

A 42-year-old man showed prominent blistering lesions of the mouth and esophagus in addition to a few bullous lesions of the skin. Direct immunofluorescence microscopy revealed distinct linear deposition of IgG and C3 at the epidermal basement membrane zone where slight deposition of IgA and IgM was also observed. In direct immunoelectron-microscopic examination, antibody was detected in the sublamina densa of the basement membrane zone. Immunoblot analysis with dermal extracts demonstrated that the patient's serum contained circulating IgG antibodies against the 290-kD protein, which comigrated with type VII collagen. The lesions healed without any scars. The results of these studies corresponded to the laboratory findings in epidermolysis bullosa acquisita (EBA), although the clinical features were distinct from classic EBA.

Sequential chemoimmunotherapy with cisplatin, interferon-beta and interleukin-2 inhibits the growth of B16-F1 melanoma in syngeneic mice

Sequential combinations of chemotherapy with biological response modifiers has recently been evaluated as systemic treatment for patients with advanced melanoma. The response rates of the chemoimmunotherapy were reported to be higher than conventional treatment using chemotherapy or biological agents alone. To investigate the effectiveness of such chemoimmunotherapy, we evaluated the antitumour effect of sequential chemoimmunotherapy in vivo using a B16 mouse melanoma system. In this sequential regimen, administration of cisplatin (CDDP) was followed by interferon-beta (IFNbeta) and interleukin-2 (IL-2). This combination therapy synergistically inhibited the growth of B16-F1 melanoma and prolonged the survival of mice bearing B16-F1. In contrast, this therapy did not show any antitumour effect on B16-F10 melanoma. The exact mechanism of the antitumour effect is not clear, but the following results were noted: no synergistic effect of this therapy was detected in nude mice, neutralizing anti-IFNgamma antibody significantly blocked the antitumour effect of this therapy, and the number of apoptotic melanoma cells was significantly increased in melanoma tissues removed from mice treated with this therapy. These results demonstrated the potent immunological antitumour effect of this sequential chemoimmunotherapy.

Kaposi's varicelliform eruption of an elderly patient with multiple myeloma

Kaposi's varicelliform eruption (KVE) is characterized by disseminated vesiculopustules and erosions due to a herpes virus infection superimposed on a preexisting dermatosis such as atopic dermatitis. However, the occurrence of KVE in patients with multiple myeloma seems to be very rare; to our knowledge, only one such case has been reported. This report documents a second case of KVE in a patient with multiple myeloma.