Holger A. Haenssle

Alleviation of chronic venous leg ulcers with a hand-held dielectric barrier discharge plasma generator (PlasmaDerm® VU-2010): results of a monocentric, two-armed, open, prospective, randomized and controlled trial (NCT01415622)

Cold atmospheric plasma (CAP, i.e. ionized air) is an innovating promising tool in reducing bacteria.

Postoperative morbidity of lymph node excision for cutaneous melanoma-sentinel lymphonodectomy versus complete regional lymph node dissection.

For patients with melanoma metastasis to a sentinel lymph node, subsequent complete regional lymph node dissection (CLND) is currently regarded to be the surgical standard. This approach, however, has not been confirmed by controlled studies, so that surgical morbidity is of primary importance. Using clinical examination and a questionnaire, we determined morbidity in 315 patients with axillary or inguinal lymph node excision on whom 275 sentinel lymphonodectomies (SLNEs) and 90 CLNDs were performed. The overall incidence of at least one complication following SLNE was 13.8%. The short-term complication rate was 11.3% (allergic reaction to blue dye 0%, wound breakdown 0%, haematoma 2.5%, wound infection 3.6%, seroma 6.9%). The incidence of long-term complications was 4.1% (persistent tattoo 0.4%, functional deficit 0.4%, nerve dysfunction/pain 0.7% or swelling 2.5%). All complications were mild. Significantly, the complication rate was not higher for patients aged 70 years or older. After CLND, the overall complication rate was significantly higher (65.5%, P<0.000001). The incidence of short-term complications was 50% (haematoma 0%, wound breakdown 6.7%, wound infection 24.7% or seroma 34.8%). The incidence of long-term complications was also 50% (nerve dysfunction/pain 8.9%, functional deficit 16.8%, swelling 37.1%). Overall, inguinal lymph node excision was burdened by a higher complication rate (P=0.015). Age and sex did not influence postoperative morbidity. No deaths linked to either procedure were noted. Complication rates after SLNE are low and most complications are minor and short-lasting. In contrast, CLND has been demonstrated to be a major and potentially morbid surgical procedure. This highlights the importance of testing the therapeutic value that CLND adds to the sentinel lymph node procedure.

Dynamic Changes in Nevi of a Patient With Melanoma Treated With Vemurafenib: Importance of Sequential Dermoscopy

BACKGROUND Therapy with vemurafenib, an inhibitor of mutated BRAF, yields a response rate of approximately 50% in patients with metastatic melanoma harboring a BRAF V600E mutation. As an adverse effect of vemurafenib, proliferative disorders of keratinocytes, including squamous cell carcinoma, have been described. Low concentration of vemurafenib as present in the epidermis were found to activate wild-type RAF, which, in combination with a preexisting RAS mutation, can promote keratinocyte proliferation. While activating BRAF mutations occur in approximately 50% of melanomas, they are even more frequently observed in melanocytic nevi. OBSERVATION We present the case of a patient with dynamic changes of melanocytic nevi well documented by sequential digital dermoscopy during vemurafenib therapy. A variety of dermoscopic changes were observed. First, nevi involuted, and all of these originally showed a centrally elevated papillomatous and predominant globular pattern. Second, preexisting nevi increased in size, and pigmentation that rendered them atypical. Such lesions were flat and showed a predominant reticular pattern at baseline. Third, multiple new nevi occurred. One example of each of the latter 2 categories was excised and showed wild-type BRAF. CONCLUSION Our findings of changing nevi in a patient treated with vemurafenib highlight the need for sequential skin examinations, including dermoscopy.

Selection of Patients for Long-term Surveillance With Digital Dermoscopy by Assessment of Melanoma Risk Factors

OBJECTIVE To identify patients at increased melanoma risk who benefit from long-term surveillance with digital dermoscopy. DESIGN Prospective, nonrandomized, observational study. SETTING University-based surveillance program. PARTICIPANTS Six hundred eighty-eight patients prospectively categorized into defined melanoma risk groups and followed up (mean, 44.3 months) by clinical examinations, dermoscopy, and, for atypical nevi, sequential digital dermoscopy. MAIN OUTCOME MEASURE Association between patient risk factors and detection of melanomas. RESULTS Odds ratios from a multivariate logistic regression analysis indicated a highly increased melanoma risk for patients with familial atypical mole and multiple melanoma (FAMMM) syndrome, atypical mole syndrome (AMS), or previous melanoma. Each digitally documented atypical lesion (range, 1-17 lesions per patient) denoted a significant 10% increase in melanoma risk. Patients with higher melanoma risk (1) showed a higher percentage of melanomas detected by digital dermoscopy (FAMMM syndrome group, 50%; AMS group, 22%), (2) more often developed multiple melanomas within shorter intervals, and (3) showed a ratio of melanoma to benign results for lesions excised because of dynamic changes of 1:15 (AMS group) or 1:4 (FAMMM syndrome group). Melanomas detected by digital dermoscopy were significantly thinner (0.41 mm in mean Breslow thickness) compared with melanomas detected by other means (0.62 mm; P = .04). CONCLUSIONS We suggest an individualized surveillance plan, with digital dermoscopy performed at follow-up intervals of 3 months for patients with FAMMM syndrome and 6 to 12 months (depending on additional risk factors) for those with AMS. Patients with multiple common nevi and no additional risk factors had no benefit from sequential digital dermoscopy.

Hybrid cell vaccination in metastatic melanoma: clinical and immunologic results of a phase I/II study.

Hybrid cell vaccination with cell fusion products (CFPs) of autologous tumor cells and mature allogenic MHC II bearing dendritic cells has been described to induce cytotoxic T lymphocyte (CTL)-mediated immune responses. The aim of this study was to assess safety, antitumor activity, and immune responses of a CFP-vaccine in patients with disseminated malignant melanoma. In a phase I/II study, we treated 11 patients by monthly intracutaneous or subcutaneous application of a CFP vaccine generated by electrofusion of autologous melanoma cells with mature allogenic dendritic cells. In addition, patients received subcutaneous low-dose interleukin-2 injections for 6 days after each vaccination. No serious adverse effects were observed. Ten patients showed progressive disease and one patient had a short-lasting stable disease. None of the patients developed a positive delayed-type hypersensitivity reaction against irradiated autologous melanoma cells. In 2 patients, who were monitored in more detail, we found no evidence of induction of a specific antimelanoma T-cell response by analyzing the proliferation, cytokine secretion, and cytotoxicity of their T cells toward autologous melanoma cells. No unequivocal beneficial effects of the used CFP vaccine could be demonstrated.

Seven-point checklist for dermatoscopy: Performance during 10 years of prospective surveillance of patients at increased melanoma risk

BACKGROUND The retrospectively developed 7-point checklist is one of the most applicable dermatoscopic algorithms for clinical use. However, until today no prospective data on the diagnostic performance of this algorithm were reported. OBJECTIVE Our aim was to assess the sensitivity, specificity, and diagnostic accuracy of the 7-point checklist in the setting of a prospective long-term study. METHODS Patients at increased melanoma risk (n = 688) were screened at regular intervals by naked-eye examination, the dermatoscopic 7-point checklist, and digital dermatoscopy follow-up (10-year study interval). RESULTS We detected 127 melanomas including 50 melanomas in situ. The mean Breslow thickness of invasive melanomas was 0.57 mm. A total of 79 melanomas displayed the 7-point checklist melanoma threshold of 3 or more points (62% sensitivity, compared with 78%-95% in retrospective settings). In all, 48 melanomas scored fewer than 3 points and were excised because of complementary information (eg, lesional history, dynamic changes detected by digital dermatoscopy). The specificity of the 7-point checklist was 97% (compared with 65%-87% in retrospective settings). Regression patterns, atypical vascular patterns, and radial streaming were associated with the highest relative risk for melanoma (odds ratio 3.26, 95% confidence interval 2.05-5.16; odds ratio 3.04, 95% confidence interval 1.70-5.46; odds ratio 2.91, 95% confidence interval 1.64-5.15; P < .0003, respectively). Melanomas thicker than 0.5 mm exhibited significantly more regression patterns and atypical vascular patterns (P < .02). The malignant versus benign ratio for all excised lesions was 1:8.6 (127 melanomas, 1092 nonmelanomas). LIMITATIONS Calculation of the specificity was a limitation. True negative lesions were defined by a score less than 3 points and either the histopathological diagnosis of nonmelanoma or the absence of dynamic changes during digital dermatoscopy follow-up (nonexcised, nonsuspicious, no change). CONCLUSIONS The 7-point checklist for dermatoscopy was less sensitive but highly specific in this prospective clinical setting. Complementary information clearly increased the sensitivity. Regression patterns or radial streaming in nevi of patients at high risk should raise a higher melanoma suspicion than might be concluded from retrospective studies.

CD40 ligation during dendritic cell maturation reduces cell death and prevents interleukin-10-induced regression to macrophage-like monocytes.

Abstract:  Dendritic cells (DCs) have become popular candidates in cancer vaccination because of their crucial role in inducing T‐cell responses. However, clinical studies greatly differ in their protocols for generating DCs and the efficacy in treating established tumors needs to be improved. We systematically analyzed DCs maturated by five different protocols for surface markers, the alloproliferative T‐cell response, the DC survival after cytokine deprivation, the stability of surface markers under the influence of interleukin‐10 (IL‐10) and the DC cytokine secretion pattern. Monocyte‐derived DCs were maturated by CD40‐ligand (CD40‐L), unmethylated cytosine–guanosine dinucleotides‐oligodinucleotides (CpG‐ODN), an inflammatory cytokine cocktail (ICC), a combination of ICC and CD40‐L, or ICC, CD40‐L and CpG‐ODN. A high co‐expression of DC maturation and costimulation markers was found after treatment with ICC plus CD40‐L (69.3 ± 9.6% CD83/CD80 double positive staining) and correlated with a significantly increased cell survival, a high expression of the antiapoptotic factor bcl‐XL, a stable CD83high/CD14low expression under the influence of IL‐10, and a strong alloproliferative T‐cell response. In conclusion, our data support the use of maturation protocols containing ICC plus CD40‐L in order to generate highly mature, phenotypically stable, cell‐death resistant, and T‐cell stimulatory DCs for clinical application in cancer patients.

Association of Patient Risk Factors and Frequency of Nevus-Associated Cutaneous Melanomas

IMPORTANCE The reported frequencies of associations between primary cutaneous melanomas and melanocytic nevi vary widely between 4% and 72%. However, earlier histopathologic studies were limited by their retrospective design and did not assess the influence of important patient-related risk factors. OBJECTIVES To identify the frequency of nevus-associated melanomas and correlate patient- and melanoma-related factors. DESIGN, SETTING, AND PARTICIPANTS A prospective, single-center, observational study with systematic documentation of melanoma risk factors, clinical and dermoscopic criteria of excised lesions, and results of histopathologic examination was conducted at a university-based dermatology clinic. Participants included 832 patients at high risk for developing melanoma. Evaluation was performed at regular intervals between April 1, 1997, and May 31, 2012, and data analysis was conducted between September 1, 2012, and December 31, 2013. MAIN OUTCOMES AND MEASURES Assessment of the frequency of nevus-associated melanoma and the influence of patient- and melanoma-related factors on their manifestation. RESULTS During the study, 190 melanomas (81 [42.6%] in situ and 109 [57.4%] invasive) were diagnosed in 113 of the 832 patients (13.6%); there were 42 women (37.2%) and 71 men (62.8%). The median (SD) Breslow thickness of invasive melanomas was 0.42 (0.43) mm. Histopathologic examination revealed remnants of melanocytic nevi in 103 melanomas (54.2%). Most nevus-associated melanomas were found on the trunk (67 [65.1%]); however, statistical significance for the localization was not present (P = .06). In univariate analyses, reported as odds ratios (95% CIs), nevus-associated melanomas were found significantly more frequently in patients of lower melanoma risk (risk group 1 [>50 common and/or ≤ 3 atypical nevi], 2.75 [1.14-6.64]; P = .02), with more than 100 nevi (1.63 [1.02-3.60]; P = .04), or with the diagnosis of in situ melanoma (14.01 [6.14-31.96]; P < .001). In contrast, nevus-associated melanomas were found significantly less frequently in patients with 1 or more previous melanomas (0.28 [0.21-0.83]; P = .005). All other factors (eg, age, skin type, hair color, and melanoma thickness) showed no significant influence on the manifestation of nevus-associated melanomas. These observations were confirmed in a separate analysis including all 109 invasive melanomas. Multivariate regression analysis identified 3 independent patient-related factors (high nevus count, low risk for melanoma, and female sex) and 1 melanoma-related factor (in situ melanoma) to be indicative of a significantly increased probability of nevus-associated melanomas. CONCLUSIONS AND RELEVANCE In this prospective study of a high-risk patient cohort, 54.2% of primary melanomas were associated with melanocytic nevi. Patients with many nevi and without previous melanomas or traits of familial atypical mole and multiple melanoma syndrome had a higher frequency of nevus-associated melanomas. These patients could thus benefit from sequential digital dermoscopy in addition to total-body photography.

Next-Generation Sequencing of Nevus Spilus–Type Congenital Melanocytic Nevus: Exquisite Genotype–Phenotype Correlation in Mosaic RASopathies

TO THE EDITOR Nevus spilus is a descriptive term used to denote any cutaneous lesion with a cafe-au-lait macular background and superimposed on more pigmented areas. Small single nevus spilus are relatively common, and they have recently been described to be due to somatic activating HRAS mutations (Sarin et al., 2014). Larger superficial lesions with small superimposed junctional nevi in association with phakomatosis pigmentokeratotica have also been found to contain HRAS mutations (Groesser et al., 2013). However, another nevus spilus–type phenotype has also been well described in which large cafe-au-lait macules have superimposed lesions that are indistinguishable both clinically and histopathologically from medium/large congenital melanocytic nevi (CMN), exhibit a wide variety of colors and sizes (Schaffer et al., 2001a, 2001b), and continue to develop postnatally in many cases. This is termed nevus spilus–type CMN. In our experience, there may be delayed appearance of the cafe-au-lait background after birth, but the lesion is still usually predictable on the basis of clustering of many CMN in one anatomical area. Smaller separate lesions in the same individual are often indistinguishable clinically from cafe-au-lait macules, and are so faint that they can be easily missed (Figure 1). Our primary aim in this study was to look for the genetic basis of this defined phenotypic subset of CMN, in the context of the recent discovery that NRAS Q61K and Q61R mutations are the cause of most causes of multiple CMN (Kinsler et al., 2013b). In particular, we were interested in determining the mutation in the background macular portion of the nevus spilus–type CMN, working on the hypothesis that this could be the “first hit” in a two-hit model of nevogenesis. Figure 1 Clinical images of nevus spilus–type CMN in six different patients. The cafe-au-lait macule background is often invisible at birth. Two separate lesions are indicated in one patient. CMN, congenital melanocytic nevi. Written consent was ... These studies were approved by the appropriate Research Ethics Committee, written consent was taken from participants, and the Declaration of Helsinki Principles protocols were followed. A blood sample and skin biopsies of both the cafe-au-lait macule background and a banal superimposed CMN were taken from three children with large nevus spilus–type CMN, from a total of 17 patients from our combined practices (patients 5, 12, and 13 in Supplementary Table S1 online), and DNA was extracted directly by standard methods. Whole-exome sequencing using Nextera library preparation and an ABI Hi-Seq bioanalyser was undertaken on all three samples from two patients, and data were analyzed using an in-house pipeline designed for somatic mosaicism. The principal governing analysis was to look for a mutation present in the cafe-au-lait that was not present in the blood, and a further mutation in the CMN not present in the cafe-au-lait or the blood. In all, 1,991,478 variants were called automatically in the overlying CMN, affecting 20,693 genes. After filtering, the sequencing files of 133 variants in 39 genes were reviewed manually. A single mutation was found in the cafe-au-lait macule and the superimposed CMN, with no further mutation confirmed despite extensive analysis. These mutations were missense activating mutations in NRAS in the skin, absent from the blood, and this pattern of somatic mosaicism was confirmed in the third patient by Sanger sequencing. The mutations, however, are undescribed so far in typical CMN, being 1:115256528 c.183A>C p.Q61H (two patients, Figure 2) and 1:115258745 c.37G>C p.G13R. Both mutations have been described at a somatic level in non-CMN-related malignant melanoma (Forbes et al., 2008). Independently, a fourth patient (patient 17, Supplementary Table S1 online) had targeted exon capture of two skin samples, and analysis also revealed only the same NRAS p.Q61H mutation in both the cafe-au-lait macule and the superimposed CMN. Figure 2 Sequencing results showing NRAS mutation. Next-generation sequencing reads of blood (upper left), cafe-au-lait macule (upper centre), and overlying CMN (upper right) from the same patient showing mutation NRAS c.183A>C p.Q61H. Note the ... In conclusion, nevus spilus–type CMN are a phenotypically and genotypically distinct variant of CMN, and are phenotypically and genotypically distinct from nevus spilus maculosus and papulosus due to HRAS mutations (Groesser et al., 2013; Sarin et al., 2013). This further extends the exquisite mutation specificity of the newly characterized mosaic RASopathies. We found no evidence of a second mutation to explain the superimposed nevi on the macular background. It is, however, possible that there could be a mutation that does not appear pathogenic to us and to the analysis pipelines at the present time. Alternatively, there could be either a translocation that does not disrupt exonic DNA sequence, or a growth-promoting copy number change, although CMN have previously been documented as having few such changes on array comparative genomic hybridization (Bastian et al., 2002). The data at the moment suggest that only one sequence-level mutation occurs, and that these specific NRAS mutations are sufficient to cause cafe-au-lait macular pigmentation, which can lead to macroscopic nevus formation over time. Other experimental evidence supports that nevi can evolve in this way, from a cell or collection of cells in the skin not visible to the naked eye, as nevus cells have been found in normal skin in patients with acquired melanocytic nevi and typical CMN (Dadzie et al., 2008; Kinsler et al., 2013a). It is important to note for clinical management that malignant melanoma has been described in patients with nevus spilus–type CMN (Kinsler et al., 2009), and on current knowledge we would consider nevus spilus–type CMN patients at the same risk of malignancy as other genotypes. Similarly, although interestingly none of the 17 patients described here have neurological abnormalities on magnetic resonance imaging scan (Supplementary Table S1 online), these numbers are too small to draw any conclusions about a possible low risk of neurological phenotype. Management of nevus spilus–type CMN should therefore be the same as for other CMN.

Extracorporeal photochemotherapy for the treatment of exanthematic pityriasis rubra pilaris

Pityriasis rubra pilaris (PRP) is a rare papulosquamous skin disease of unknown aetiology that has been categorized into five clinical types based on age at onset, cutaneous features and prognosis. We present a patient with chronic exanthematic type II atypical adult PRP, whose skin status was significantly improved with monthly extracorporeal photochemotherapy (ECP). Various therapeutic regimens including narrow‐band UV‐B, bath PUVA therapy, systemic fumaric acid esters and systemic cyclosporin had failed. Oral retinoids could not be administered due to a type IIa hyperlipoproteinemia with profound hepatic steatosis and elevated liver transaminases. The observed clinical benefit may encourage future clinical studies analysing the effectiveness of ECP in otherwise unresponsive cases of type II PRP.