Norbert Blödorn-Schlicht

Evidence that a neutrophil–keratinocyte crosstalk is an early target of IL-17A inhibition in psoriasis

The response of psoriasis to antibodies targeting the interleukin (IL)‐23/IL‐17A pathway suggests a prominent role of T‐helper type‐17 (Th17) cells in this disease. We examined the clinical and immunological response patterns of 100 subjects with moderate‐to‐severe psoriasis receiving 3 different intravenous dosing regimens of the anti‐IL‐17A antibody secukinumab (1 × 3 mg/kg or 1 × 10 mg/kg on Day 1, or 3 × 10 mg/kg on Days 1, 15 and 29) or placebo in a phase 2 trial. Baseline biopsies revealed typical features of active psoriasis, including epidermal accumulation of neutrophils and formation of microabscesses in >60% of cases. Neutrophils were the numerically largest fraction of infiltrating cells containing IL‐17 and may store the cytokine preformed, as IL‐17A mRNA was not detectable in neutrophils isolated from active plaques. Significant clinical responses to secukinumab were observed 2 weeks after a single infusion, associated with extensive clearance of cutaneous neutrophils parallel to the normalization of keratinocyte abnormalities and reduction of IL‐17‐inducible neutrophil chemoattractants (e.g. CXCL1, CXCL8); effects on numbers of T cells and CD11c‐positive dendritic cells were more delayed. Histological and immunological improvements were generally dose dependent and not observed in the placebo group. In the lowest‐dose group, a recurrence of neutrophils was seen in some subjects at Week 12; these subjects relapsed faster than those without microabscesses. Our findings are indicative of a neutrophil–keratinocyte axis in psoriasis that may involve neutrophil‐derived IL‐17 and is an early target of IL‐17A‐directed therapies such as secukinumab.

Mitoserate beim primären Melanom: Interobserver- und Intraobserver-Reproduzierbarkeit am HE-Schnitt und in der Immunhistologie.

Die Melanomklassifikation wurde 2009 durch die AJCC revidiert. Für die Klassifizierung primärer Melanome wurde als dritte Größe neben Tumordicke und Ulzeration die Angabe der Mitoserate neu eingeführt. Gemäß der AJCC‐2009‐Klassifikation des Melanoms führt der Nachweis nur einer oder mehrerer dermaler Tumormitosen bei Melanomen ≤ 1,0 mm Tumordicke zu einer Umgruppierung des Tumors von T1a nach T1b. Dies erklärt, wie wichtig die Frage nach der Reproduzierbarkeit dieses neuen Parameters ist.

Molecular diagnosis of skin infections using paraffin-embedded tissue - review and interdisciplinary consensus: Molecular diagnosis using paraffin-embedded tissue

Nucleic acid amplification techniques (NATs), such as PCR, are highly sensitive and specific methods that have become valuable supplements to culture and serology in the diagnosis of infectious disorders. However, especially when using formalin‐fixed and paraffin‐embedded tissue, these techniques are associated with both false‐negative and false‐positive results, a pitfall that is frequently misjudged. Representatives of the German Society of Hygiene and Microbiology (DGHM) and the German Society of Dermatology (DDG) therefore set out to develop a consensus – in the form of a review article – on the appropriate indications for NATs using paraffin‐embedded tissue, its contraindications, and the key points to be considered in the pre‐ and post‐analytical phase.

Histopathologische Befundung maligner Melanome in Übereinstimmung mit der AJCC‐Klassifikation 2009: Literaturübersicht und Empfehlungen zum praktischen Vorgehen

Schlüsselwörter • Melanom • Histopathologie • Mitoserate • Wächterlymphknoten • AJCC-Klassifikation Zusammenfassung Hintergrund: Die gültigen TNM-Klassifikationen sind die Grundlage für Entscheidungen zur Diagnostik und Therapie von Krebskrankheiten. Die Histopathologie muss die sachgerechte Einordnung des Tumorbefundes in diese Klassifikationen ermöglichen. Methoden: Zur Bestimmung der Mitoserate des primären Melanoms und zur Aufarbeitung und Beurteilung des Wächterlymphknotens wurde eine systematische Literaturrecherche durchgeführt. Auf der Grundlage der Literaturrecherche wurden Empfehlungen erarbeitet, die von einem Expertengremium aus Dermatohistologen und Pathologen diskutiert und abgestimmt wurden. Ergebnisse: Die folgenden Empfehlungen wurden mit hohem Konsens abgestimmt (93–100 % Übereinstimmung): Die Bestimmung der Mitoserate bei primären Melanomen erfolgt anhand von HE-Schnitten. Die Beurteilung von 1 mm ist ausreichend. Es werden lediglich dermale Mitosen berücksichtigt und in ganzen Zahlen angegeben. Die Mitoserate soll bei Primärtumoren 1,00 mm Tumordicke nach der Hot-Spot-Methode bestimmt werden und als ganze Zahl in Relation zu 1 mm Tumorfläche angegeben werden. Bei dickeren Primärtumoren ist die Angabe der Mitoserate wünschenswert. Für die Beurteilung des Wächterlymphknotens sollen in der Regel mindestens 4 Scheiben aus dem Lymphknoten entnommen und untersucht werden. Es sollen bei der Diagnostik der Wächterlymphknoten neben der HE-Färbung auch immunhistochemische Färbungen für jede Gewebescheibe – vorzugsweise mit Antikörpern gegen S100ß, Melan A und HMB-45 – durchgeführt werden. Im histopathologischen Befund sollen der Nachweis von Mikrometastasen und ihre größte Ausdehnung in 10tel Millimeter angegeben werden. Schlussfolgerungen: Die vorliegenden Empfehlungen sind geeignet, die Befundung maligner Melanome besser zu standardisieren und so eine bessere Histopathologische Befundung maligner Melanome in Übereinstimmung mit der AJCC-Klassifikation 2009: Literaturübersicht und Empfehlungen zum praktischen Vorgehen

Schmerzhafte akrale Durchblutungsstörungen bei T-Zellymphomen

ZusammenfassungBei einer 50jährigen Patientin mit einem Sézary-Syndrom kam es ca. 2 Jahre nach Diagnosestellung zu anfallartig auftretenden schmerzhaften lschämien der Hände und Füße, die zur Ausbildung akraler Nekrosen führten. Ein 59jähriger Patient stellte sich mit akralen lschämien und starken Schmerzen in den Füßen als Erstsymptom einer chronisch lymphatischen Leukämie vom T-Zelltyp vor. Ähnliche Fälle sind in der Literatur selten beschrieben worden. Der Zusammenhang zwischen den akralen Durchblutungsstörungen und dem T-Zellymphom ist unklar und wird in der vorliegenden Arbeit diskutiert.SummaryTwo years after the diagnosis of Sézary syndrome, a 50-year old female patient experienced attacks of painful ischemia of both hands and feet, leading to acral necrosis. Another 59-year old patient presented with severe pain in his feet, secondary to ischemia. This was the first symptom of a T-cell-chronic lymphocytic leukemia. Similar cases have only occasionally been described. The relationship between acral ischemia and T-cell-lymphoma is not clear but is discussed in this article.

Molekulare Diagnostik von Hautinfektionen am Paraffinmaterial - Übersicht und interdisziplinärer Konsensus: Molekulare Infektionsdiagnostik am Paraffinmaterial

Nukleinsäure‐Amplifikations‐Techniken (NAT), wie die PCR, sind hochsensitiv sowie selektiv und stellen in der mikrobiologischen Diagnostik wertvolle Ergänzungen zur kulturellen Anzucht und Serologie dar. Sie bergen aber gerade bei formalinfixiertem und in Paraffin eingebettetem Gewebe ein Risiko für sowohl falsch negative als auch falsch positive Resultate, welches nicht immer richtig eingeschätzt wird. Daher haben Vertreter der Deutschen Gesellschaft für Hygiene und Mikrobiologie (DGHM) und der Deutschen Dermatologischen Gesellschaft (DDG) einen Konsensus in Form einer Übersichtsarbeit erarbeitet, wann eine NAT am Paraffinschnitt angezeigt und sinnvoll ist und welche Punkte dabei in der Präanalytik und Befundinterpretation beachtet werden müssen.

A Prognostic Gene Signature Expressed in Primary Cutaneous Melanoma: Synergism With Conventional Staging

Abstract Background Current clinico-pathological American Joint Committee on Cancer (AJCC) staging of primary cutaneous melanoma is limited in its ability to determine clinical outcome, and complementary biomarkers are not available for routine prognostic assessment. We therefore adapted a gene signature, previously identified in fresh-frozen (FF) melanomas and adjacent stroma, to formalin-fixed paraffin-embedded (FFPE) melanomas. The aim was to develop a gene expression profiling (GEP) score to define patient survival probability at the time of first diagnosis. Methods Expression of 11 FF melanoma signature genes was quantified by reverse transcription polymerase chain reaction in an FFPE melanoma training cohort (n = 125), corresponding to the combined FF melanoma training and validation cohorts. The resulting GEP score was validated technically and clinically in an independent FFPE melanoma cohort (n = 211). All statistical tests were two-sided. Results We identified a prognostic eight-gene signature in the tumor area (tumor and adjacent tissue) of AJCC stage I–III melanomas. A signature-based GEP score correlated with melanoma-specific survival (MSS; Kaplan-Meier analysis: P < .0001) was independent of tumor stage (multivariable regression analysis: P = .0032) and stroma content (<5%–90%) and complemented conventional AJCC staging (receiver operating characteristic curve analysis: area under the curve = 0.91). In the clinical validation cohort, the GEP score remained statistically significant (P = .0131) in a multivariable analysis accounting for conventional staging. The GEP score was technically robust (reproducibility: 93%; n = 84) and clinically useful, as a binary as well as a continuous score, in predicting stage-specific patient MSS. Conclusions The GEP score is a clinically significant prognostic tool, contributes additional information regarding the MSS of melanoma patients, and complements conventional staging.

In silico und in vitro-Validierung eines Genexpressions-basierten Risikoscores zur Bewertung des Rückfallrisikos für das kutane Melanom

Question : Lymphangiogenesis is a crucial step in the progression of cancer. Formation of new lymphatic vessels provides an additional route for tumor cells to metastasize. Therefore, infl uencing lymphangiogenesis is an interesting target in cancer therapy. Signaling via the vascular endothelial growth factor receptor-2/-3 (VEGFR-2/3), Lyve-1 and Tie-2 pathways are critical for lymphangiogenic responses. Arsenic trioxide (As 2 O 3 ), which is used as an effective treatment against relapsed acute promyelocytic leukemia, is characterized by low cytotoxicity. As As 2 O 3 promotes anti-angiogenic effects on endothelial cells, we hypothesized that As 2 O 3 may have impact on lymphangiogenesis. Therefore, we explored whether the known anti-tumorigenic properties of As 2 O 3 might be additionally mediated in part by anti-lymphangiogenic effects through the reduction in VEGFR-2/3, Lyve-1 and Tie-2 expressions in primary human lymphatic endothelial cells. Methods : Human lymphatic endothelial cells (LEC) were cultured in vitro and treated with or without As 2 O 3 . Effects of As 2 O 3 on proliferation, apoptosis and expression of the important endothelial receptors VEGFR-2/3, Lyve-1and Tie-2 were analyzed mainly by BrdU-Assay, cell death assay, caspase-9 activity assay, cytochrome c assay and immunoblotting. In vitro angiogenesis was investigated using the matrigel tube formation assay. Results : As 2 O 3 inhibited cell proliferation in a concentration-dependent manner. In our study we found that As2O3 induced apoptosis by activating caspase-9, cytochrome c release and down-regulating the anti-apoptotic proteins cIAP-2 and survivin. Furthermore, we could demonstrate an inhibition of the formation of lymphatic capillary like structures by As 2 O 3 treatment. In addition, we demonstrated that As 2 O 3 signifi cantly inhibited VEGFR-3 and Lyve-1 protein expression whereas VEGFR-2 and Tie-2 expression was unaffected after treatment with As 2 O 3 . Conclusion : In conclusion, our results provide for the fi rst time clear evidence, that As 2 O 3 has distinct anti-lymphangiogenic effects mainly by inhibition of the endothelial VEGFR-3 and Lyve-1 and activating the intrinsic apoptotic pathway.

In silico und in vitro Validierung des Genexpressions- basierten Risikoscores GRS für das kutane Melanom

1 Philipps-Universität Marburg, Dermatologie, Marburg, Deutschland 2 Ludwig-Maximilians-Universität, Klinik für Dermatologie und Allergologie, München, Deutschland 3 Universitätsklinikum Lübeck, Klinik für Dermatologie und Allergologie, Lübeck, Deutschland 4 Ludwig-MaximiliansUniversität, Klinik für Anästhesiologie, München, Deutschland 5 Ludwig-Maximilians-Universität, Klinik für Medizin I, München, Deutschland

Genetic diagnostics in inflammatory dermatoses--from insights into pathophysiology to individualized patient management.

The determination of somatic mutations in various cancers is of prognostic value and a requirement in the process of selecting the appropriate therapy. Progress in the fields of molecular biology and biomathematics have enabled genome-wide association studies (GWAS) which have significantly paved the way towards a better understanding of the contribution of genetic variations to the disease process of complex trait dermatoses, particularly psoriasis. In the latter, almost 40 associated susceptibility loci have currently been identified. The related candidate genes are involved in the regulation of innate and acquired immune pathways as well as epidermal barrier function. From GWAS and candidate gene studies various genetic factors have also emerged to play a part in atopic dermatitis, alopecia areata and allergic contact dermatitis. In addition to augment the insight into disease mechanisms and promote the identification of potential therapeutic targets, there is increasing evidence that genetic testing may also allow a better estimate of disease progression and the development of special manifestations, such as arthritis and pustular skin lesions in psoriasis, and help to predict the response to and safety of certain therapies. The latter is also true for genetic variations that directly influence the metabolism of drugs such as azathioprine and methotrexate. The integration of next generation sequencing into patient registries appears as an important step in the validation of this diagnostic tool as a relevant component on the way towards an optimized and individualized patient management. On this way, however, its ethical and legal facets will need to be clarified. Kristian Reich , Norbert Blödorn-Schlicht , Thomas M. Falk