Ulrike Wehkamp

Serum levels of hepatocyte growth factor as a potential tumor marker in patients with malignant melanoma.

Serum markers can be important tools for prognostic classification and treatment monitoring in cancer patients. The MAP-kinase pathway, which is upregulated in the majority of melanoma patients, can be activated by hepatocyte-growth factor (HGF) through the proto-oncogene c-MET. The aim of this study was to evaluate the predictive and prognostic value of circulating HGF in terms of treatment outcome and survival compared with a widely established serum marker, protein S-100B, in patients with advanced metastatic melanoma. HGF and S-100B were measured in serum samples of 101 patients with metastatic melanoma (American Joint Committee on Cancer stage IV) before and after treatment and 50 patients with stage I/II melanoma. HGF and S-100B correlated significantly with the stage of disease (P=0.032 and P<0.001, respectively). In stage IV melanoma patients, baseline serum levels of HGF and S-100B were significantly associated with treatment response (P=0.012 and 0.006, respectively). Furthermore, the Cox regression analysis confirmed that serum levels of HGF and S-100B proved to have a significant prognostic impact on progression-free survival (hazard ratio=1.39 and 1.29, respectively) and overall survival (hazard ratio=1.27 and 1.29, respectively) in advanced metastatic melanoma patients. In melanoma patients, serum levels of HGF and S-100B correlate significantly with the stage of disease. In stage IV melanoma, both markers are prognostic factors and correlate significantly with progression-free survival and overall survival. Measurement of serum HGF levels might be a useful additional tool in the management of melanoma patients.

Tropomyosin Receptor Kinase A Expression on Merkel Cell Carcinoma Cells

Importance Merkel cell carcinoma (MCC) is a malignant neuroendocrine skin tumor frequently associated with the Merkel cell polyomavirus. Immune checkpoint therapy showed remarkable results, although not all patients are responsive to this therapy. Anti–tropomyosin receptor kinase A (TrkA)–targeted treatment has shown promising results in several tumor entities. Objective To determine TrkA expression in MCC as a rationale for potential targeted therapy. Design, Setting, and Participants This case series study investigated the MCC specimens of 55 patients treated at the Department of Dermatology, University Hospital of Schleswig-Holstein, Kiel, Germany, from January 1, 2005, through December 31, 2015. Thirty-nine of the 55 samples were suitable for further histopathologic examination. Expression of TrkA was explored by immunohistochemical analysis. Exposure Diagnosis of MCC was confirmed by staining positive for cytokeratin 20 (CK20) and synaptophysin. Main Outcomes and Measures Expression of TrkA on the tumor cells. Results Specimens of 39 patients (21 women and 18 men; mean [SD] age, 75.0 [7.8] years) underwent immunohistochemical investigation. Thirty-eight of 38 specimens expressed CK20 and synaptophysin on the MCC tumor cells (100% expression). Merkel cell polyomavirus was detected in 32 of 38 specimens (84%). Tropomyosin receptor kinase A was found in all 36 evaluable specimens on the tumor cells; 34 (94%) showed a weak and 2 (6%) showed a strong cytoplasmic expression. In addition, strongly positive perinuclear dots were observed in 30 of 36 specimens (83%). Conclusions and Relevance Tropomyosin receptor kinase A was expressed on MCC tumor cells in 100% of evaluable specimens. This result may lead to the exploration of new targeted treatment options in MCC, especially for patients who do not respond to anti–programmed cell death protein 1 treatment.

Sézary Syndrome and Atopic Dermatitis: Comparison of Immunological Aspects and Targets

Sézary syndrome (SS), an aggressive form of erythrodermic pruritic cutaneous T cell lymphoma (CTCL), from an immunological perspective characterized by increased Th2 cytokine levels, elevated serum IgE and impaired cellular immunity. Not only the clinical appearance but also the hallmark immunological characteristics of SS often share striking similarities with acute flares of atopic dermatitis (AD), a common benign chronic inflammatory skin disease. Given the overlap of several immunological features, the application of similar or even identical therapeutic approaches in certain stages of both diseases may come into consideration. The aim of this review is to compare currently accepted immunological aspects and possible therapeutic targets in AD and SS.

Skin Involvement of Mantle Cell Lymphoma May Mimic Primary Cutaneous Diffuse Large B-cell Lymphoma, Leg Type.

Mantle cell lymphoma (MCL) is a B-cell neoplasm with a variable and generally aggressive clinical course. So far our knowledge of skin involvement of MCL is limited. To understand the clinical and histopathologic features of MCL with skin involvement, the files of the Lymph Node Registry Kiel were screened for MCL diagnosed in the skin. Over a period of 13 years, 1321 biopsy specimens were diagnosed as MCL; among them, 14 patients (1%) showed skin involvement. Of these, skin was the initial site of manifestation in 6/11 (55%) cases. One patient presented with a skin-limited lymphoma. Furthermore, 7/12 (58%) patients presented with lesions on the leg. The lymphomas were highly proliferative with blastoid cytology in 12/14 (86%) cases. Moreover, the immunophenotype with expression of BCL2 (100%), MUM-1/IRF4 (83%), and IgM (82%) and lack of CD10 (25%) and BCL6 (0%) closely resembled the features of primary cutaneous diffuse large B-cell lymphoma, leg type. Solely the expression of cyclin D1 (100%) and the presence of t(11;14) (100%) allowed a distinction from cases of primary cutaneous diffuse large B-cell lymphoma, leg type. Only 2 MCL cases with skin involvement presented with classical cytology. Interestingly, in these 2 cases skin involvement occurred simultaneously in a lesion of coexisting primary cutaneous marginal zone lymphoma. Our data suggest that clinical presentation on the leg and blastoid cytology along with high proliferation and expression of Bcl2, Mum-1/IRF4, and IgM are typical for MCL involving the skin. Lymphomas with these features might be erroneously diagnosed as diffuse large B-cell lymphoma, leg type, if cyclin D1 staining is not performed.

ALK‐positive primary cutaneous T‐cell‐lymphoma (CTCL) with unusual clinical presentation and aggressive course

Anaplastic lymphoma kinase (ALK) expression is uncommon in primary cutaneous T‐cell‐lymphomas (CTCL). We report the case of a patient who was initially diagnosed with small plaque parapsoriasis, and eventually developed an unusual manifestation of CTCL 6 years later. The disease was characterized by aggressively ulcerating plaques and tumors of the entire skin. Histopathology revealed monoclonal proliferation of atypical T‐lymphocytes and CD30‐positive blasts with expression of ALK and identification of an ATIC‐ALK fusion protein. Extensive staging confirmed the primary cutaneous origin of the lymphoma. After failure of several conventional treatments including polychemotherapy, the patient finally achieved remission after receiving brentuximab‐vedotin, alemtuzumab and subsequent allogeneic stem cell transplantation. In the following, the patient developed inflammatory cutaneous lesions that pathologically showed no evidence for lymphoma relapse or classical cutaneous graft‐versus‐host disease. The patient responded to immunosuppression, but finally died from multi‐organ failure due to sepsis 8 months after stem cell transplantation. This is a rare instance of ALK positivity in a CTCL, most likely resembling CD30+ transformed mycosis fungoides, because it was not typical for cutaneous anaplastic large cell lymphoma (ALCL). In contrast to its role in systemic ALCL as favorable prognostic marker, ALK expression here was associated with an aggressive course.

Humidity-regulated CLCA2 protects the epidermis from hyperosmotic stress

High environmental humidity rescues atopic dermatitis-like signs in mice, and CLCA2 protects the epidermis from hyperosmotic stress. Humidity—Harbinger of health? Low environmental humidity can aggravate symptoms of atopic dermatitis (AD), an inflammatory skin disease. Seltmann et al. investigated the link between humidity and epidermal barrier function. Using a mouse model that exhibits AD-like symptoms, they found that high humidity reduced epidermal thickness and skin inflammation. Chloride channel accessory 2 protein was highly expressed in keratinocytes in response to hyperosmotic stress, and it increased cell-cell adhesions and protected cells from apoptosis. This osmoregulated protein was up-regulated in skin samples from patients with AD, which suggests a compensatory mechanism to maintain epidermal barrier function. Low environmental humidity aggravates symptoms of the inflammatory skin disease atopic dermatitis (AD). Using mice that develop AD-like signs, we show that an increase in environmental humidity rescues their cutaneous inflammation and associated epidermal abnormalities. Quantitative proteomics analysis of epidermal lysates of mice kept at low or high humidity identified humidity-regulated proteins, including chloride channel accessory 3A2 (CLCA3A2), a protein with previously unknown function in the skin. The epidermis of patients with AD, organotypic skin cultures under dry conditions, and cultured keratinocytes exposed to hyperosmotic stress showed up-regulation of the nonorthologous human homolog CLCA2. Hyperosmolarity-induced CLCA2 expression occurred via p38/c-Jun N-terminal kinase–activating transcription factor 2 signaling. CLCA2 knockdown promoted keratinocyte apoptosis induced by hyperosmotic stress through impairment of cell-cell adhesion. These findings provide a mechanistic explanation for the beneficial effect of high environmental humidity for AD patients and identify CLCA3A2/CLCA2 up-regulation as a mechanism to protect keratinocytes from damage induced by low humidity.

Unilesional locally recurrent lymphomatoid papulosis with variable histological presentation

We report a female patient, today 72 years old. She was referred to our department in 2004 with one solitary non-ulcerated nodular lesion under the right knee of approximately 0.5 cm in diameter. No other skin lesions and no concomitant diseases were present. The lesion was completely surgically removed and histologic examination showed a dense dermal infiltrate of atypical blastic and pleomorphic lymphoid cells with strong CD30, CD43 and perforin expression and loss of CD3 compatible with the diagnosis of lymphomatoid papulosis (LyP) type C (Figure 1). Blood examination and lymph node ultrasound did not show any abnormalities. The patient reported about a dermatologist consultation in 2001 because of a nodule in the same area, which was excised. The histopathology was reported as an unspecific lymphoid mononuclear infiltration. Five years after initial presentation (in 2009) the patient came back with a 5mm nodular lesion for the third time in the same place (Figure 2). A complete excision was performed, revealing in the histopathological examination a dermal lymphohistiocytic infiltration with a small-cell atypical lymphoid component with expression of CD43 and perforin. At that time, only a few intermingled medium-sized CD30 positive cells were seen (Figure 1). In 2013, another relapse with a 5mm nodule localized in the same area surrounded by an erythematous slightly hyperpigmented plaque lesion occurred (Figure 2). The nodule was removed and histology showed now an atypical small cell lymphoid population infiltrating the basal layer of the epidermis in a lining pattern resembling epidermotropic mycosis fungoides combined with a dermal infiltration containing larger blastoid cells. The same immunohistochemical phenotype with positivity for CD43 and perforin in absence of CD3 like in the preceding biopsies (2004 and 2009) was present. CD30 was exclusively expressed by a subpopulation of dermal large cells (Figure 1). The correlation between clinical and histological features led to the diagnosis of LyP type B in both lesions 2009 and 2013. Molecular T-cell receptor gene rearrangement was performed for all available biopsies (2004, 2009, 2013) revealing polyclonality. The patient reported about three episodes of waxing and waning lesions in the same localization in the meantime between the excisions. The lesions appeared as small nodules, smaller than 1 cm in diameter and, according to her description, lasted for four to six weeks before resolving spontaneously. Lymphomatoid papulosis is a rare disease. It is classified in the group of CD30þ lymphoproliferative diseases, though the course of disease usually is benign but associated in 10-20% with second lymphoproliferative malignancies [1]. Clinical criteria include recurrent grouped or disseminated papulonodular skin lesions with spontaneous regression of lesions [2]. LyP is divided into several subgroups by histological criteria, depending on the pattern of infiltration, cell size and immunophenotype including the degree of CD30-expression (type A–E according to WHO-criteria) [1,3–5]. Different histological subtypes may occur in one individual [6]. The here presented case is peculiar because of its unilesional relapses and appearance with different histological subtypes in the identical localization over time. Type B is one of the rare subtypes. Histological criterion is an epidermotropic infiltrate of small atypical CD30þ or CD30 lymphoid cells with cerebriform nuclei that histologically resembles MF [1]. In our case, the clinical presentation is uncommon for a classic LyP. Patients usually present with multiple lesions distributed over the whole body. Time between relapses varies from days to months. Nevertheless, we classified the disease in our patient as LyP and not as a recurrent anaplastic large cell lymphoma for the following reasons: The nodular lesions were small in size (<1 cm in diameter), the lesions were recurrent and spontaneous resolution of some of the lesions could be observed. In addition the histopathological features of the lesions were more in line with the different described LyP variants. In our case the described atypical T-cell population

Clinically defined subgroups of mycosis fungoides display differing histopathological features at initial biopsy

Abstract Most patients with mycosis fungoides (MF) remain in early disease stages but some progress to tumor stage. The individual course of the disease cannot be predicted. We wanted to assess the clinical and histological characteristics of the first available biopsy. An end-of-spectrum approach with two groups was used, comparing MF remaining long-term stable in T1a (‘MF stable’) and MF with later tumor development or present T3 stage (‘MF tumor’). The clinical and histomorphological features of the initial skin biopsy were compared. Patients in the ‘MF tumor’ group presented initially with higher disease stages. The first biopsies of ‘MF tumor’ patients showed significantly higher infiltrate density and depth, more large cells and a higher proliferative index. In summary, long-term stable MF seems to differ in clinical and histopathological parameters from MF with T3 evolution/presence already at the time point of the initial biopsy. Our findings might indicate a predetermined biologic behavior.

Co-expression of NGF and PD-L1 on tumor-associated immune cells in the microenvironment of Merkel cell carcinoma

PurposeMerkel cell carcinoma (MCC) is a malignant neuroendocrine skin tumor with known viral association. The microenvironment and its interaction with the tumor via the programmed cell death protein 1 (PD-1) pathway are crucial for response to anti-PD-1/anti-PD-L1 treatments. However, not all patients respond, which is suggestive of additional mechanisms for tumor growth and/or persistence. We previously detected tropomyosin receptor kinase A (TrkA) expression on MCC tumor cells and, therefore, gained interest in the expression of its ligand nerve growth factor (NGF).MethodsThirty-nine patients from our department were studied for immunohistochemical NGF, PD-1, and PD-L1 expression and clinico-pathological correlation.ResultsPD-L1 was expressed on the tumor cells in 42%. In 95%, PD-L1 expression was also found on CD68+ spindle cells at the tumor border, which co-expressed NGF in 71%. 66% contained PD-1+ tumor infiltrating lymphocytes. PD-1, PD-L1, and NGF expression seems to correlate with a worse outcome.ConclusionsThe present study shows that PD-L1 and NGF are co-expressed on spindle cells in the microenvironment. The expression of NGF might be a link of the microenvironment to the TrkA-positive tumor cells. Whether this mechanism is critical for tumor growth and lack of response to anti-PD-1/L1 treatment has to be investigated in further studies.

Decreased expression of G-protein-coupled receptors GPR43 and GPR109a in psoriatic skin can be restored by topical application of sodium butyrate

The G-protein-coupled receptors GPR43 and GPR109a are known to play an important role in mediating anti-inflammatory and anti-cancer functions in the gut. Short-chain fatty acids, such as sodium butyrate (SB), are activators of GPR43 and GPR109a and thereby promote anti-inflammatory effects. The present study aimed to examine the expression of these receptors and their reaction to SB in psoriasis. Lesional and non-lesional biopsies of 6 psoriasis patients and of 4 controls were obtained and stained for GPR109a and GPR43. Ex vivo stimulation with SB was performed on fresh biopsy material. Lesional and non-lesional psoriatic skin showed a decreased expression of GPR109a and GPR43 on keratinocytes in comparison with control skin. Topical application of SB was able to increase the low-level expression of both receptors. The data suggest that SB by restoring the impaired expression of GPR109a and GPR43 might exert anti-inflammatory effects and may be utilized as a topical tool for the treatment of psoriasis, which has to be proven in future clinical trials.