Jeffrey P. Zwerner

Whole-genome sequencing reveals oncogenic mutations in mycosis fungoides

The pathogenesis of mycosis fungoides (MF), the most common cutaneous T-cell lymphoma (CTCL), is unknown. Although genetic alterations have been identified, none are considered consistently causative in MF. To identify potential drivers of MF, we performed whole-genome sequencing of MF tumors and matched normal skin. Targeted ultra-deep sequencing of MF samples and exome sequencing of CTCL cell lines were also performed. Multiple mutations were identified that affected the same pathways, including epigenetic, cell-fate regulation, and cytokine signaling, in MF tumors and CTCL cell lines. Specifically, interleukin-2 signaling pathway mutations, including activating Janus kinase 3 (JAK3) mutations, were detected. Treatment with a JAK3 inhibitor significantly reduced CTCL cell survival. Additionally, the mutation data identified 2 other potential contributing factors to MF, ultraviolet light, and a polymorphism in the tumor suppressor p53 (TP53). Therefore, genetic alterations in specific pathways in MF were identified that may be viable, effective new targets for treatment.

Severe Cutaneous and Neurologic Toxicity in Melanoma Patients during Vemurafenib Administration Following Anti-PD-1 Therapy

Severe systemic toxicities developed in two patients during vemurafenib therapy following disease progression after treatment with anti-PD-1 agents; these results have important implications for the management of melanoma patients and future clinical trials involving anti-PD-1 and BRAF inhibitors. Immune checkpoint inhibitors such as ipilimumab and targeted BRAF inhibitors have dramatically altered the landscape of melanoma therapeutics over the past few years. Agents targeting the programmed cell death-1/ligand (PD-1/PD-L1) axis are now being developed and seem to be highly active clinically with favorable toxicity profiles. We report on two patients with BRAF V600E–mutant melanoma who were treated with anti-PD-1 agents as first-line therapy without significant toxicity, followed by vemurafenib at disease progression. Both patients developed severe hypersensitivity drug eruptions with multiorgan injury early in their BRAF inhibitor treatment course. One patient subsequently developed acute inflammatory demyelinating polyneuropathy, and the other developed anaphylaxis upon low-dose vemurafenib rechallenge. Further investigation of the immune response during combination or sequences of melanoma therapeutics is warranted. Furthermore, clinicians should maintain a high index of suspicion for these toxicities when vemurafenib is administered following an anti-PD-1 agent. Cancer Immunol Res; 1(6); 373–7. ©2013 AACR.

miR-223 regulates cell growth and targets proto-oncogenes in mycosis fungoides/cutaneous T-cell lymphoma.

The pathogenesis of the cutaneous T-cell lymphoma (CTCL), mycosis fungoides (MF) is unclear. MicroRNA (miRNA) are small non-coding RNA that target mRNA leading to reduced mRNA translation. Recently, specific miRNA were shown to be altered in CTCL. We identified significantly reduced expression of miR-223 in early stage MF skin, and the levels of miR-223 diminished further in advanced stage disease. CTCL peripheral blood mononuclear cells and cell lines also had reduced miR-223 as compared to controls. Elevated expression of miR-223 in these cell lines reduced cell growth and clonogenic potential, whereas inhibition of miR-223 increased cell numbers. Investigations into putative miR-223 targets with oncogenic function, including E2F1 and MEF2C, and the predicted miR-223 target, TOX, revealed all three are targeted by miR-223 in CTCL. E2F1, MEF2C, and TOX proteins were decreased with miR-223 overexpression, while miR-223 inhibition led to increased protein levels in CTCL. In addition, we showed the 3′-UTR of TOX mRNA was a genuine target of miR-223. Therefore, reduced levels of miR-223 in MF/CTCL lead to increased expression of E2F1, MEF2C, and TOX, which likely contribute to the development and/or progression of CTCL. Thus, miR-223 and its targets may be useful for the development of new therapeutics for MF/CTCL.

Contribution of beta-HPV infection and UV damage to rapid-onset cutaneous squamous cell carcinoma during BRAF-inhibition therapy

Purpose: BRAF-inhibition (BRAFi) therapy for advanced melanoma carries a high rate of secondary cutaneous squamous cell carcinoma (cSCC) and risk of other cancers. UV radiation and α-genus human papillomavirus (HPV) are highly associated with SCC, but a novel role for β-genus HPV is suspected in BRAFi-cSCC. Cutaneous β-HPV may act in concert with host and environmental factors in BRAFi-cSCC. Experimental Design: Primary BRAFi-cSCC tissue DNA isolated from patients receiving vemurafenib or dabrafenib from two cancer centers was analyzed for the presence of cutaneous oncogenic viruses and host genetic mutations. Diagnostic specimens underwent consensus dermatopathology review. Clinical parameters for UV exposure and disease course were statistically analyzed in conjunction with histopathology. Results: Twenty-nine patients contributed 69 BRAFi-cSCC lesions. BRAFi-cSCC had wart-like features (BRAFi-cSCC-WF) in 22% of specimens. During vemurafenib therapy, BRAFi-cSCC-WF arose 11.6 weeks more rapidly than conventional cSCC when controlled for gender and UV exposure (P value = 0.03). Among all BRAFi-cSCC, β-genus HPV-17, HPV-38, HPV-111 were most frequently isolated, and novel β-HPV genotypes were discovered (CTR, CRT-11, CRT-22). Sequencing revealed 63% of evaluated BRAFi-cSCCs harbored RAS mutations with PIK3CA, CKIT, ALK, and EGFR mutations also detected. Conclusions: We examined clinical, histopathologic, viral, and genetic parameters in BRAFi-cSCC demonstrating rapid onset; wart-like histomorphology; β-HPV-17, HPV-38, and HPV-111 infection; UV damage; and novel ALK and CKIT mutations. Discovered β-HPV genotypes expand the spectrum of tumor-associated viruses. These findings enhance our understanding of factors cooperating with BRAF inhibition that accelerate keratinocyte oncogenesis as well as broaden the knowledge base of multifactorial mediators of cancer in general. Clin Cancer Res; 21(11); 2624–34. ©2015 AACR.

Autopsy-proven demyelination associated with infliximab treatment

Tumor necrosis factor–α (TNF-α) is a well-studied proinflammatory cytokine that contributes to the pathogenesis of immune and infectious diseases. TNF-α effects are mediated by signaling through TNF-α receptors, which are present ubiquitously.1 Limiting the actions of TNF-α, either by blocking the receptor or inhibiting circulating (free) TNF-α, is a useful treatment strategy in autoimmune disorders with prominent inflammation, such as inflammatory bowel disease and rheumatoid arthritis (RA). However, when treatment with agents that inhibit TNF-α function was applied to multiple sclerosis (MS), an unanticipated worsening was observed. The clinical trial of lenercept (a recombinant TNF-α receptor–immunoglobulin 1g fusion protein that protected against experimental autoimmune encephalitis) for the treatment of relapsing-remitting multiple sclerosis was stopped prematurely when the treatment arm was noted to have earlier and more frequent exacerbations.2 TNF-α antagonists are therefore contraindicated in patients with MS. In patients with no history of demyelinating disease, TNF-α antagonism has led to unmasking of demyelinating events with a clinical pattern typical of that seen in MS.3 All CNS cases of demyelinating disease to date have been based on clinical, laboratory, and radiographic findings. Herein we present a unique case of histologically confirmed demyelination following treatment with TNFα inhibitors.

Herpes simplex virus-induced plasmacytic atypia.

The clinical and histopathological features of cutaneous herpes simplex virus (HSV) infection have been well described. Genital herpetic infections are largely induced by HSV type 2, but 30% of cases can be caused by HSV type 1. Immunocompromised patients are known to exhibit atypical patterns of clinical presentation with variable lesion morphology and anatomic location. A subset of patients may show morphology such as nodules or verrucous lesions. Analogously, some biopsy specimens may show unusual microscopical features, such as a lack of keratinocyte cytopathology, lymphocyte infiltration or vasculopathic changes that are expected irrespective of the patients immune status. We present the case of a patient carrying a previous diagnosis of pemphigus vulgaris, status posttreatment with methotrexate and prednisone, who developed a perineal ulcer exhibiting significant numbers of plasma cells, many of which were cytologically atypical. This morphology was suggestive of a hematopoietic malignancy. Immunoperoxidase staining for HSV decorated a focal collection of keratinocytes that lacked appreciable viral changes expected of HSV infection.

Chronic, dusky, indurated plaques on the legs of a 31-year-old woman.

A 31-year-old woman presented with a 14-year history of progressive discolouration and firm induration of both lower legs and her trunk. She had a history of systemic lupus erythematosus (SLE), having been diagnosed at 12 years of age when she developed alopecia, fever and a malar rash. Following an acute ischaemic stroke at the age of 19 years, she underwent several radiographic evaluations including magnetic resonance imaging and angiography. At that time, she was diagnosed with biopsy-proven lupus nephritis, but her creatinine and glomerular filtration rate were normal (0.6 mg/dL and 155 mL/min/ 1.73 m, respectively). Calcium level, white blood cell count and absolute eosinophil count were within normal limits. Months later, she noticed hyperpigmentation and ‘thickening’ of her lower legs. Her nephritis eventually required renal transplantation. Despite her kidney function normalizing after surgery, her skin findings did not resolve. Physical examination revealed symmetrical, diffuse, dusky-grey to erythematous plaques with woody induration on the patient’s legs, extending from her ankles to upper thighs, and on her lower back (Fig. 1). A punch biopsy was taken from a lesion on the right thigh.

Intraocular involvement of mycosis fungoides associated with immunophenotypic switch from CD4+ to CD8+

TO THE EDITOR: Alibert first described mycosis fungoides (MF) in 1806, and Bazin later defined the natural evolution into the stages known today as patch, plaque, and tumor.[1][1] In the earliest stage, known as IA, MF is indolent. As progression ensues, extracutaneous invasion is not uncommon;

Painful, violaceous plaques in a patient with pruritus

A 51-year-old man presented with a 2-week history of acute-onset, painful, violaceous plaques involving the bilateral medial thighs. The patient’s medical history included end-stage renal disease requiring haemodialysis, along with lichen simplex chronicus and prurigo nodularis, which had failed to respond to topical steroids and narrowband ultraviolet B phototherapy. After discussion with his nephrologist, the patient had been started on weekly low-dose methotrexate for persistent pruritus. At his presentation to us 2 weeks later, physical examination revealed ill-defined, violaceous indurated plaques with central erosion and surrounding scale on the bilateral medial thighs and inguinal folds (Fig. 1). Laboratory investigation revealed pancytopenia, elevated creatinine (8.5 mg/dL; normal range 0.7–1.3 mg/dL), and normal hepatic transaminases. Histopathological findings

Subcutaneous Colletotrichum truncatum Infection in a Child.

Human infection with Colletotrichum species is typically limited to ophthalmologic manifestations. We present the first reported pediatric case of subcutaneous Colletotrichum truncatum infection. This case highlights the potential importance of C. truncatum as an agent of subcutaneous or disseminated disease in immunocompromised children.