L. Frank Glass

Phase I/II trial for the treatment of cutaneous and subcutaneous tumors using electrochemotherapy

Electroporation is a process that causes a transient increase in the permeability of cell membranes. It can be used to increase the intracellular concentration of chemotherapeutic agents in tumor cells (electrochemotherapy; ECT). A clinical study was initiated to determine if this mode of treatment would be effective against certain primary and metastatic cutaneous malignancies. A group of six patients, three with malignant melanoma, two with basal cell carcinoma, and one with metastatic adenocarcinoma, were enrolled in the study. The treatment was administered in a two‐step process.

Merkel cell carcinoma. Diagnosis and treatment.

BACKGROUND Merkel cell carcinoma is an uncommon malignancy of the skin that often portends a poor prognosis. Since its first description by Taker in 1972, a plethora of case reports and articles regarding the etiopathogenesis and treatment have been published spanning multiple medical and surgical disciplines. Much confusion still exists regarding the diagnosis and treatment of this ominous tumor. OBJECT Through extensive review of the medical, surgical, and pathological literature, to collate the observations of multiple investigators and summarize these findings. METHODS Articles from journals of multiple subspecialties were carefully reviewed with particular emphasis placed on epidemiology, prognosis, histology, immunohistochemistry, electron microscopy, tumor origin, treatment, and work‐up of Merkel cell carcinoma. RESULTS Merkel cell carcinoma is an aggressive malignant neoplasm. Local recurrence develops in 26–44% of patients despite therapy. Up to three‐fourths of patients eventually develop regional nodal metastases with distant metastases occurring in one‐third of all patients. Reported overall 5‐year survival rates range from 30% to 64%. CONCLUSION Treatment recommendations unfortunately are based more on anecdotal than scientific data because of the rarity of the tumor and its recognized high risk. Most authors recommend wide local excision of the primary lesion and regional lymph node resection if lymph nodes are palpable followed by x‐irradiation of both the postsurgical bed and lymph node basin. The role of elective lymph node resection in the absence of clinically positive nodes remains controversial.

Selective lymphadenectomy in patients with Merkel cell (cutaneous neuroendocrine) carcinoma

AbstractBackground: Merkel cell carcinoma (MCC) is an aggressive cutaneous tumor with a propensity for local recurrence, regional and distant metastases. There are no well-defined prognostic factors that predict behavior of this tumor, nor are treatment guidelines well established. Methods: Staging of patients with a new diagnosis of MCC was attempted using selective lymphadenectomy concurrent with primary excision. Preoperative and intraoperative mapping, excision, and thorough histologic evaluation of the first lymph node draining the tumor primary site [sentinel node] was performed. Patients with tumor metastasis in the sentinel node underwent complete resection of the remainder of the lymph node basin. Results: Twelve patients underwent removal of 22 sentinel nodes. Two patients demonstrated metastatic disease in their sentinel lymph nodes, and complete dissection of the involved nodal basin revealed additional positive nodes. The node-negative patients received no further surgical therapy, with no evidence of recurrent local or regional disease at a maximum of 26 months follow-up (median 10.5 months). Conclusions: While the data are preliminary and initial follow-up is limited, early results suggest that sentinel lymph node mapping and excision may be a useful adjunct in the treatment of MCC. This technique may identify a population of patients who would benefit from further surgical lymph node excision.

Clinical relevance of molecular staging for melanoma: comparison of RT-PCR and immunohistochemistry staining in sentinel lymph nodes of patients with melanoma.

OBJECTIVE To determine the clinical significance of a molecular assay based on the reverse transcriptase polymerase chain reaction (RT-PCR) for the presence of micrometastatic melanoma cells in sentinel lymph nodes (SLNs). SUMMARY BACKGROUND DATA Routine histologic examination of lymph nodes often underestimates the presence of micrometastatic disease. The authors have previously shown that an RT-PCR assay designed to detect melanocyte-specific expression of the tyrosinase gene could be used to define a population of patients at higher risk for both recurrence and death compared with routine hematoxylin and eosin (H&E) histology. In this study, the authors used the tyrosinase RT-PCR assay in a patient population examined by a more detailed histologic analysis, including S-100 immunohistochemistry. METHODS Patients underwent lymphatic mapping and SLN biopsy. SLN specimens were bivalved, and half of each specimen was serially sectioned and examined by routine H&E histology and S-100 immunohistochemistry. The other half of each specimen was analyzed by a nested RT-PCR assay. RESULTS Hematoxylin and eosin histology detected metastatic disease in 36 (16%) of the 233 patients tested. S-100 immunohistochemistry detected micrometastatic disease in another 16 patients, and 114 (63%) of 181 patients with histology-negative nodes had positive findings on RT-PCR. There were significant differences between PCR-positive and PCR-negative patient groups in Breslow thickness, Clark level, and the presence of ulceration of the primary tumor, factors that have been shown to correlate with recurrence and survival. CONCLUSIONS These results suggest that RT-PCR can increase the sensitivity of detection of metastatic melanoma cells in SLNs over the current standard methods, including H&E histology and S-100 immunohistochemistry. Further long-term follow-up is needed to detect actual differences in recurrence and overall survival.

The Progression of Melanoma Nodal Metastasis Is Dependent on Tumor Thickness of the Primary Lesion

Background: Recent results of several clinical trials using the technique of intraoperative lymphatic mapping and sentinel lymph node (SLN) biopsy confirm the validity of the concept of there being an order to the progression of melanoma nodal metastases. This report reviews the H. Lee Moffitt Cancer Center experience with this procedure, one of the largest series described to date. These data demonstrate that the involvement of the SLNs, as well as higher-echelon nodes, is directly proportional to the melanoma tumor thickness, as measured by the method of Breslow.Methods: The investigators at the H. Lee Moffitt Cancer Center retrospectively reviewed their experience using lymphatic mapping and SLN biopsies in the treatment of malignant melanoma. All eligible patients with primary malignant melanomas underwent preoperative and intraoperative mapping of the lymphatic drainage of their primary sites, along with SLN biopsies. All patients with positive SLNs underwent complete regional basin nodal dissection. For 20 consecutive patients with one positive SLN, all of the nodes from the complete lymphadenectomy were serially sectioned and examined by S-100 immunohistochemical analysis, to detect additional metastatic disease.Results: Six hundred ninety-three patients consented to undergo lymphatic mapping and SLN biopsy. The SLNs were successfully identified and collected for 688 patients, yielding a 99% success rate. One hundred patients (14.52%) showed evidence of nodal metastasis. The rates of SLN involvement for primary tumors with thicknesses of <0.76 mm, 0.76–1.0 mm, 1.0–1.5 mm, 1.5–4.0 mm, and >4.0 mm were 0%, 5.3%, 8%, 19%, and 29%, respectively. Eighty-one patients underwent complete lymph node dissection after observation of a positive SLN, and only six patients with positive SLNs demonstrated metastatic disease beyond the SLN (7.4%). The tumor thicknesses for these six patients ranged from 2.8 to 6.0 mm. No patient with a tumor thickness of <2.8 mm was found to have evidence of metastatic disease beyond the SLN in complete lymph node dissection. All 20 patients with a positive SLN for whom all of the regional nodes were serially sectioned and examined by S-100 immunohistochemical analysis failed to show additional positive nodes.Conclusions: These results suggest that regional lymph node involvement may be dependent on the thickness of the primary tumor. As the primary tumor thickness increases, so does the likelihood of involvement of SLNs and higher regional nodes in the basin beyond the positive SLNs.

Bleomycin-mediated electrochemotherapy of basal cell carcinoma

BACKGROUND A new technique, electroporation, enhances the antitumor effects of a variety of chemotherapeutic agents. When used in combination with conventional chemotherapy, the procedure is termed electrochemotherapy. Exposure of cancerous tissues to pulses of electricity during electrochemotherapy appears to increase cell membrane permeability and thus intracellular access to cytotoxic drugs. Electrochemotherapy has been shown to have potent antitumor activity in a variety of in vitro studies, animal tumor models, as well as in clinical trials with squamous cell carcinomas of the head and neck. OBJECTIVE The purpose of the study was to determine the effects of bleomycin-mediated electrochemotherapy on several basal cell carcinomas (BCCs) in two patients with nevoid BCC syndrome. METHODS Electrical pulses were delivered to tumor nodules by means of caliper electrodes after systemic doses of bleomycin were administered. Vital signs were closely monitored during application of the electrical pulses. RESULTS Partial responses were observed in tumors from both of the patients treated with electrochemotherapy; three partial responses were observed in one patient, and one partial response was observed in the other patient. Complete responses were seen in two lesions. Only minimal local or systemic side effects were noted in response to the therapy. CONCLUSION To our knowledge, this is the first study that documents the effects of bleomycin-mediated electrochemotherapy on BCC. Studies are ongoing with intralesional bleomycin during electrochemotherapy to see whether additional antitumour effects can be produced in patients with BCC by this route of administration.

Reassessing the role of lymphatic mapping and sentinel lymphadenectomy in the management of cutaneous malignant melanoma

Lymphatic mapping and sentinel lymphadenectomy was developed as a minimally invasive technique to provide regional lymph node staging information for patients at high risk for metastatic melanoma, but without clinically palpable disease. Only patients who demonstrate micrometastases undergo complete regional lymphadenectomy, sparing approximately 80% of patients the expense and morbidity of an elective lymph node dissection. This technique has been widely accepted as the preferred method to determine the pathologic status of the regional lymph nodes and the staging information gained is incorporated into the latest version of the American Joint Committee on Cancer staging system for cutaneous melanoma. Still, there is much controversy as to the use of this technique as a staging procedure and its overall therapeutic benefit in the treatment of patients with melanoma. Currently ongoing clinical trials will determine if lymphatic mapping and sentinel lymphadenectomy directly influences overall survival for patients with malignant melanoma. We review the latest technical aspects of this procedure and discuss the controversies surrounding its use.

Alkaptonuria and ochronosis: Case report and review

Alkaptonuria is a rare genetic disorder in which the enzyme homogentisic acid oxidase is deficient, resulting in the accumulation of homogentisic acid in various bodily tissues. This is a multisystem disorder with a characteristic blue-black discoloration of the skin and cartilage, which is termed ochronosis. Herein we report a profound case of ochronosis secondary to alkaptonuria. Furthermore, we review the clinical manifestations of alkaptonuria and discuss the spectrum of ochronosis, both endogenous and exogenous.

Merkel cell carcinoma: a clinical, histopathologic, and immunohistochemical review.

Merkel cell carcinoma is a rare aggressive neoplasm, with about 400 cases diagnosed in the United States each year. Among the cutaneous-derived neoplasms, it is the most deadliest, with a higher mortality rate than melanoma. Although the classic clinical presentation as a rapidly growing papule in a sun-exposed site of an elderly patient is not specific, certain histopathologic and ancillary pathologic features allow for its discrimination in most cases. Herein, we review the etiology, pathogenesis, clinical, and pathologic attributes as well as the staging treatment and prognosis of this important public health menace.

Use of Anti-phosphohistone H3 Immunohistochemistry to Determine Mitotic Rate in Thin Melanoma

The seventh edition of the American Joint Committee on Cancer (AJCC) melanoma staging system, slated for release in 2010, will introduce mitotic rate (MR) as one of the primary criteria for staging thin melanoma (≤1.0 mm). Accurate counts are essential because the finding of a single mitotic figure (MF) will alter the staging and management of these patients. The traditional manner of counting of mitotic figures (MFs) using a ×40 objective is time consuming and prone to inter- and intraobserver variability. We employed an antibody to phosphohistone H3 (pHH3, ser10) that labels MFs in all stages of mitosis, to evaluate mitotic counts at ×20 in tissue sections from 30 melanoma patients with thin lesions 0.45 to 1.2 mm in depth, and compared results with routine hematoxylin and eosin (H&E) in a double-blind fashion. The mean MR was 1.63 by anti-pHH3, and 0.67 for H&E, representing a mean increase of 243%. The Spearman correlation coefficient for MR in H&E and anti-pHH3 sections was 0.88 (P < 0.0001). When melanomas were designated as “mitotically active,” if the MR by anti-pHH3 was ≥2 and ≥1 by H&E, the correlation coefficient increased to 1.0. No thin melanomas were mitotically inactive on anti-pHH3 but active on H&E. Results indicate that anti-pHH3 is a useful immunostain for labeling melanocytes in mitosis. Subsequent studies will be needed confirm the accuracy of this staining technique, which has the potential to be used as a screening method for counting MFs before conventional H&E methodology in the microstaging of thin melanoma.