Filomena Azevedo

TERT Promoter Mutations in Skin Cancer: The Effects of Sun Exposure and X-Irradiation

The reactivation or reexpression of telomerase (TERT) is a widespread feature of neoplasms. TERT promoter mutations were recently reported that were hypothesized to result from UV radiation. In this retrospective study, we assessed TERT promoter mutations in 196 cutaneous basal cell carcinomas (BCCs), including 102 tumors from X-irradiated patients, 94 tumors from patients never exposed to ionizing radiation treatment, and 116 melanomas. We sought to evaluate the effects of UV and X-ray irradiation on TERT mutation frequency. TERT mutations were detected in 27% of BCCs from X-irradiated patients, 51% of BCCs from nonirradiated patients, and 22% of melanoma patients. TERT mutations were significantly increased in non-X-irradiated BCC patients compared with X-irradiated BCC patients; the mutations also presented a different mutation signature. In nonirradiated patients, TERT mutations were more frequent in BCCs of sun-exposed skin, supporting a possible causative role of UV radiation. In melanoma, TERT promoter mutations were generally restricted to intermittent sun-exposed areas and were associated with nodular and superficial spreading subtypes, increased thickness, ulceration, increased mitotic rate, and BRAFV600E mutations. Our results suggest that various carcinogenic factors may cause distinct TERT promoter mutations in BCC and that TERT promoter mutations might be associated with a poorer prognosis in melanoma.

mTOR pathway activation in cutaneous melanoma is associated with poorer prognosis characteristics

Dear Editor, The conserved serine ⁄ threonine kinase mTOR (the mammalian target of rapamycin), a downstream effector of the PI3K ⁄ AKT pathway, is a major regulator of survival, growth, proliferation and motility, in response to mitogens, energy and nutrient levels (reviewed in Guertin and Sabatini, 2007). mTOR is an attractive therapeutic target, and mTORC1 inhibitors, including the rapamycin analogues Deforolimus, Everolimus and Tensirolimus, alone or in combination with inhibitors of other pathways, are undergoing clinical trials for treating multiple cancers, including melanoma (reviewed in Dancey, 2006; Fecher et al., 2007). Alterations in molecules of the PI3K ⁄ AKT ⁄ mTOR pathway have been identified in cutaneous melanomas (reviewed in Hocker et al., 2008). In view of the possible involvement of the PI3K ⁄ AKT ⁄ mTOR pathway in melanoma, as well as its potential role as a therapeutic target, we aimed to clarify whether there is an association between the expression of the PI3K ⁄ AKT ⁄ mTOR pathway effectors, clinico-pathological and prognostic parameters, and BRAF and NRAS mutations in cutaneous melanomas. To evaluate mTOR pathway expression in cutaneous melanoma, tissue microarrays of 84 cutaneous melanomas cases (Supporting Information Table S1) were stained with antibodies against PI3K ⁄ AKT ⁄ mTOR and MAPK pathways effectors: PTEN, AKT, pAKT Ser473, pAKT Thr308, mTOR, pmTOR Ser2448, S6, pS6 Ser235 ⁄ 236, 4E-BP1, p4E-BP1 Thr37 ⁄ 46, ERK1 ⁄ 2 and pERK1 ⁄ 2 Thr202 ⁄ Tyr204 (methods detailed in Supporting Information Data S1 and Table S2). The results of examination of the stained sections were consistent with activation of the AKT ⁄ mTOR pathway in cutaneous melanoma, as we observed a high expression of its active forms in most of the cases studied (Figure 1). Similar conclusions were reported by Karbowniczek et al. (2008), who evaluated pS6 in a series of cutaneous melanomas. We found a significant positive association between pmTOR and the two phosphorylated forms of AKT – pAKT Ser473 (P < 0.01) and pAKT Thr308 (P = 0.03). pmTOR was also associated with the two downstream effectors of mTORC1 – pS6 (P = 0.01) and p4EBP1 (P < 0.01). A positive association was found between the staining level of pS6 and p4EBP1 (P = 0.01). Expression of pAKT Ser473 was positively associated with the two downstream effectors of mTORC1 – pS6 and p4EBP1 (P < 0.01). Moreover, we found that the two phosphorylated forms of AKT – pAKT Ser473 and pAKT Thr308 – were positively associated with pERK1 ⁄ 2 (P < 0.01 and P = 0.01, respectively). pmTOR expression was also positively associated with pERK1 ⁄ 2 (P = 0.04), along with its two effectors pS6 and p4EBP1 (P < 0.01 and P = 0.02, respectively). The positive correlations found between the expression of upstream and downstream effectors of the mTOR pathway suggest simultaneous activation of the signalling pathway in cutaneous melanoma. Also, the positive correlation observed between the expression of the phosphorylated forms of mTOR effectors and pERK1 ⁄ 2 suggests that the MAPK pathway is activated concurrently with the AKT ⁄ mTOR pathway in cutaneous melanoma, similar to the pattern seen by our group in ocular melanomas (Populo et al., 2010). The mean expression level of the studied markers was compared with the clinico-pathological parameters of the cases (Table 1). We found that expression of pAKT Ser473 was significantly elevated (P = 0.02) in tumours with more than 1 mm thick, and a borderline significant higher mean of pS6 was found in cases with epidermal ulceration (P = 0.05). A significantly higher mean expression of AKT (P = 0.04), pAKT Ser473 (P < 0.01) and pS6 (P = 0.02) was detected in cases with III ⁄ IV Clark level than in cases with I ⁄ II Clark level. pAKT Ser473, pmTOR and pS6 expression was also significantly elevated in tumours with a mitotic rate greater than 1 mitosis ⁄ 10 high-power fields (P = 0.01). The association found between the expression of several proteins of the mTOR pathway and a poorer prognosis suggests an association between mTOR pathway

Candida balanitis: risk factors

Background  The amount of available information on the prevalence and incidence of candida balanitis is still surprisingly scarce.

Angiokeratomas of Fabry successfully treated with intense pulsed light.

Fabry disease (FD) is a rare X‐linked lysosomal storage disorder resulting from the deficient activity of the enzyme α‐galactosidase A. Angiokeratomas (AKs) are a frequent manifestation of this disease. They usually become apparent during childhood and can cause important cosmetic disability. Current treatment of this feature in the setting of FD has been mainly based on the application of laser systems, namely the argon laser, the variable pulse width 532‐nm Nd:YAG laser, the 578‐nm copper vapor laser and the flashlamp‐pumped pulsed dye laser. We report the case of a 31‐year‐old Caucasian woman with a clinical and molecular (GLA p.R118C) diagnosis of FD, presenting multiple AKs scattered over the buttocks and thighs. She was treated with 10 sessions of intense pulsed light (IPL), with a 4–8‐week interval between them. An almost complete clearance of the lesions was obtained, with no scars or significant complaints. No recurrence occurred during a 12‐month follow‐up period. The IPL source can be considered a suitable, effective and safe treatment modality for these cutaneous lesions that typically affect patients with FD, with no need for local anesthesia and with very satisfactory cosmetic results. To our best knowledge, there are no reports in the literature of Fabrys AKs treated with IPL.

Anti-TNF-alpha induced psoriasiform eruptions with severe scalp involvement and alopecia: report of five cases and review of the literature.

We describe 5 cases of anti-tumor necrosis factor-alpha (anti-TNF-α) induced psoriasiform eruptions with severe scalp involvement inducing inflammatory alopecia and review the literature on this subject. All our 5 patients were provided topical therapy, with good results in only 1 case. The remaining 4 were provided systemic therapy (methotrexate ± cyclosporine): 3 concomitantly suspended the anti-TNF-α treatment (2 are currently clear/almost clear but 1 has so far only observed mild improvement) and 1 switched anti-TNF-α (recurrent flare-ups of the disease continue). So far, no patient has developed scarring alopecia. To our knowledge, a total of 15 cases of anti-TNF-α induced psoriatic alopecia have been described. Anti-TNF-α was discontinued in 9 of the 15 patients and systemic therapy was provided to 9 of the 15 patients. Nonetheless, 2 patients developed scarring alopecia. We conclude that in anti-TNF-α induced psoriasiform eruptions some patients may respond to topical treatment, however in cases of severe scalp involvement anti-TNF-α suspension and systemic treatment should be considered in order to avoid scarring alopecia.

Efficacy and safety of propranolol in the treatment of parotid hemangioma

A 2-month-old female patient presented an extensive bilateral parotid hemangioma (PH) focally ulcerated. Additionally, hepatic ultrasonography revealed a hemangioendothelioma located at right lobe. She was treated with oral prednisolone (3 mg/kg/day) during 10 months with clinical improvement of PH, despite failure to thrive and arterial hypertension. However, regrowth of the lesion occurred after discontinuation of oral steroid. Propranolol hydrochloride (2 mg/kg/day divided into two doses) was then started and maintained for 16 months, with marked involution of the hemangioma and with no systemic side effects during treatment course. Curiously, also the liver hemangioendothelioma completely resolved after starting propranolol. PH is a threatening cervicofacial segmental hemangioma that frequently proliferates after the year of age and needs long-term treatment. On the other hand, hepatic hemangioendotheliomas may be associated with cutaneous hemangiomas in some patients and their natural history is similar to these, although patients may die of associated conditions. As for other infantile hemangiomas, propranolol proved to be an effective, safe, and well-tolerated treatment for PH. Its role in liver hemangiomas and hemangioendotheliomas should also be taken into account.

Epidermolytic hyperkeratosis with palmoplantar keratoderma in a patient with KRT10 mutation

We report the case of a 12-year-old girl presenting at birth with erythroderma, erosions and blisters scattered over the integument. By the age of 3 she presented generalized hyperkeratotic plaques with a cobblestone pattern and a pungent odour, most prominently around flexures, scalp and palmoplantar areas. Clinical, histological and ultrastructural findings confirmed the diagnosis of epidermolytic hyperkeratosis (EHK). Molecular genetic analysis revealed a mutation in the KRT10 gene. Treatment with oral acitretin was attempted but it was discontinued due to hepatic dysfunction and marked desquamation and blistering. EHK is a rare autosomal dominant disorder of keratinization, caused by mutations in either the KRT1 or KRT10 genes. Although palmoplantar keratoderma is typically found in patients with KRT1 mutation, our patient presents EHK with palmoplantar involvement and KRT10 mutation. Moreover, a poor response to systemic retinoids was observed, contrary to what is expected in patients with KRT10 mutation. Even though management is usually unsatisfactory, some patients with this lifelong and serious condition may experience improvement with age.

Etoricoxib-induced fixed drug eruption with positive lesional patch tests

Fixed drug eruption (FDE) is most commonly associated with antibiotics, anticonvulsants, and nonnarcotic analgens, including nonsteroidal anti-inflammatory drugs (NSAIDs). However, the newer cyclooxygenase 2 (COX-2) inhibitors have been rarely reported to cause FDE. We report the case of a 52-year-old Caucasian woman with erythematous pruritic plaques on the neck, left forearm, and second finger of the right hand, healing with hyperpigmentation and recurring in the same locations. The patient was sporadically taking oral etoricoxib 90 mg for her back pain and noticed the relation between administration of the drug and skin lesions, the time interval decreasing progressively from 1 week to 30 minutes. No other signs, symptoms, or drug intake was mentioned. The patch tests with etoricoxib 1% and 5% in petrolatum were positive at the location of the lesions and negative on the back (nonlesional skin). Standard European and NSAID series were negative. Patch tests of 10 healthy controls with etoricoxib 1% and 5% in petrolatum were negative. After the avoidance of the drug, no relapse was mentioned. The patch test was reliable for the diagnosis of FDE, avoiding the need for subsequent oral provocation testing and therefore preventing the possible adverse effects. Despite being regarded as a safe drug, the occurrence of cutaneous adverse reactions to etoricoxib should be considered, especially in the setting of its increasing use in pain control.

Thrombophilia in venous leg ulcers: a comparative study in early and later onset.

BACKGROUND Several studies found that the patients with chronic venous ulcers (CVU) have an increased prevalence of thrombophilia (44-75%), similar to that observed in deep vein thrombosis (DVT). The patients who develop CVU before their 50 th birthday appear to represent a distinct group in terms of etiology, natural history and prognosis. AIM To analyze the nature and prevalence of thrombophilia in patients with early onset of CVU (before 50-years old) compared with a group of patients with later onset. METHODS Twenty-seven consecutive patients of each group were studied. They underwent clinical assessment and blood testing for factor V Leiden, prothrombin G20210A, methyltetrahydrofolate reductase C677T, plasminogen activator inhibitor type 1 (PAI-1) mutations, antithrombin, proteins C and S levels, and also antiphospholipid antibodies (anticardiolipin antibodies and lupus anticoagulant), cryoglobulins and cryoagglutinins. RESULTS All the patients had at least one thrombophilia. The prevalences of single, 2 and ≥3 thrombophilias were 29.6%, 40.7% and 29.6%, respectively, in the early onset group, compared with 33.3%, 59.2% and 7.4% in the later onset group. The PAI-1 4G/4G homozygous mutation was significantly more common in patients with early onset of ulcer. The prevalences of factor V Leiden, prothrombin G20210A, elevated titer of antiphospholipid antibodies and the presence of cryoglobulins were higher in the early onset group, although the differences were not statistically significant. CONCLUSION Our study brings evidence of a higher thrombophilic risk among the patients with early onset of the CVU as they had significantly higher prevalence of multiple (≥3) thrombophilias (P=0.03), homozygous mutations (P=0.03) and family history of leg ulcer (P=0.02) when compared with patients with later onset. Thrombophilia screening is important in patients with CVU before the age of 50 in order to stratify the thrombotic risk and to allow an appropriate prophylactic and therapeutic management.

Genital candidosis in heterosexual couples

Background  Evidence suggests that Candida can be sexually transmitted; however, the contribution of sexual transmission to the pathogenesis of genital candidosis needs further elucidation.