Yoshihiro Umebayashi

Association between polymorphisms in the SPINK5 gene and atopic dermatitis in the Japanese

Atopy, which is characterized by increased levels of immunoglobulin E (IgE) against common environmental allergens, is considered the strongest predisposing factor for asthma and atopic dermatitis (AD). Mutations in the gene encoding serine protease inhibitor Kazal-type 5 (SPINK5) are responsible for Netherton syndrome, a rare skin disorder characterized by greatly elevated IgE levels with atopic manifestations. A recent study of Caucasian AD families showed that maternally derived alleles of the SPINK5 gene are associated with development of AD and asthma, suggesting the parent-of-origin effect for the development of atopic diseases in the SPINK5 gene. We studied the possible association of the SPINK5 gene for the development of atopic diseases by determining the genotypes of five polymorphisms in a Japanese population. Ttransmission disequilibrium tests revealed an association of SPINK5 polymorphisms with AD but not with asthma. Our data indicate that the SPINK5 gene is associated with AD across ethnicities.

Promoter methylation profiling of 30 genes in human malignant melanoma

Aberrant methylation and demethylation of promoter CpG islands lead to silencing of tumor‐suppressor genes and abnormal expression of normally methylated genes, respectively. Here, we analyzed human melanomas for their methylation and demethylation profiles. Methylation status of core regions in promoter CpG islands was examined for 20 (candidate) tumor‐suppressor genes, 4 genes that are not considered as tumor‐suppressors, but are frequently silenced in human cancers, and 6 normally methylated melanoma antigen genes (MAGEs). Analysis of 13 melanoma cell lines and 2 cultured normal human epidermal melanocytes (HEMs) showed that 9 tumor‐suppressor genes and all 4 non‐tumor‐suppressor genes were methylated in at least 1 cell line, but never in HEMs, and that all 6 MAGE genes were demethylated in 3 to 13 cell lines. Interestingly, we detected no methylation of MGMT, PTEN, MTAP and p27, which were previously reported as silenced in melanomas. Furthermore, 3 genes that were frequently methylated in the cell lines and 6 MAGE genes were analyzed in 25 surgical melanoma samples. RARB, RASSF1A and 3‐OST‐2 were methylated in 5 (20%), 9 (36%) and 14 (56%) samples, respectively. MAGE‐A1, A2, A3, B2, C1 and C2 were demethylated in 9 (36%), 22 (88%), 20 (80%), 7 (28%), 21 (84%) and 16 (64%) samples, respectively. At least 1 gene was methylated in 18 (72%) samples and at least 1 was demethylated in 24 (96%) samples. No correlation between frequent methylation and frequent demethylation was observed. These profiles showed that both aberrant methylation and demethylation occur widely in human melanomas.

Metastatic extramammary Paget's disease successfully controlled with tumour dormancy therapy using docetaxel

SIR, Extramammary Paget’s disease (EMPD) is fatal once the tumour invades the dermis and metastasizes to the visceral organs. As no significantly effective treatment has yet been established, it is still extremely difficult to treat patients in the advanced stages of this disease. We report a patient with multiple bone and lung metastases of EMPD who was treated with weekly docetaxel. The patient was a 69-year-old man who had developed a large papillomatous tumour in the inguinal region and scrotum which was treated by wide local excision and bilateral groin lymph node dissection in April 2000. Histopathological examination showed the tumour cells to be those of EMPD. There was no recurrence or metastasis for about 4 years, but the patient began to suffer from lower back pain in January 2004. Computed tomography (CT) revealed multiple osteolytic lesions in the vertebrae and ilium with multiple nodules in the lungs, and the patient was admitted to Tsukuba University Hospital the following month for treatment. On admission, the symptoms were found to be derived from nerve root disturbance: severe lumbago, dysaesthesia in the toes, and lower limb paralysis. Magnetic resonance imaging (MRI) indicated not only multiple metastases in the vertebrae and ilium but also severe destruction of the 9th)11th thoracic vertebrae; the vertebral canal was almost completely surrounded by the tumour. Laboratory examination indicated elevated serum alkaline phosphatase and carcinoembryonic antigen (CEA, 65 ng dL). It is well known that CEA level correlates with tumour progression in advanced EMPD; nevertheless, as the patient had been surgically treated for EMPD 4 years earlier, the possibility that the metastatic disease arose from another primary site had to be excluded. Therefore, CT and MRI of the colon, rectum, stomach, pancreas and prostate, as well as tests for occult blood in the stool and prostate-specific antigen were performed. Based on the negative results of the examinations, we eventually diagnosed this case as metastatic EMPD. Radiotherapy of the lower thoracic vertebrae was administered at a dose of 3 Gy per day in five fractions per week (total dose 39 Gy). In addition, the patient received intravenous docetaxel therapy at a dose of 25 mg m weekly for 2 weeks, followed by a 1-week rest. To avoid allergic reaction, the patient was given dexamethasone 8 mg prior to docetaxel administration. The course of treatment is shown in Figure 1. A gradual improvement in the patient’s condition was accompanied by a decrease in the serum CEA level. Sclerotic changes were observed in metastatic lesions in the vertebrae, suggesting tumour regression and regeneration of the bone. Moreover, some of the metastatic lesions in the lung disappeared on CT scan (Fig. 2). Other than mild general fatigue, no toxicity due to chemotherapy was observed. The patient was discharged after the 10th course of therapy and is still receiving chemotherapy on an outpatient basis without serious side-effects. His clinical progress has been satisfactory, and currently, 6 months after discharge, he has little limitation in daily life at home. The prognosis of EMPD is extremely poor once the tumour metastasizes. As metastatic EMPD is relatively rare, there has been little progress in the development of systemic chemotherapy regimens for this disease. Some authors have reported tumour response with combination chemotherapy, e.g. 5fluorouracil (5-FU) + mitomycin C, carboplatin + 5-FU + leucovorin, and low-dose 5-FU + cisplatin therapy. However, these chemotherapy regimens require daily intravenous drips and may require a week’s hospitalization in some cases. In contrast, weekly docetaxel administration can be applied on an outpatient basis with a reduction of acute toxicity and only mild myelosuppression. Based on the recent results of clinical trials, doses of 36–42 mg m were recommended for the weekly schedule, and the objective response rate was reported to be up to 53% in metastatic breast cancer, 46% in prostate cancer, and 23% in nonsmall cell lung cancer. In this range Fig 1. Treatment and clinical outcome. CEA, carcinoembryonic antigen.

Mutation and association analysis of the interferon regulatory factor 2 gene (IRF2) with atopic dermatitis

AbstractInterferon regulatory factor 2 (IRF-2) is a member of a family of transcriptional factors involved in the modulation of cellular responses to interferons (IFNs) and viral infection as well as in the regulation of cell growth and transformation. Irf2 knockout mice show T helper 1 (Th1) cell development defect and spontaneous development of an inflammatory skin disease. To determine if there are any mutations in IRF2 associated with development of atopic dermatitis (AD), we screened for mutations in the 5′ flanking and coding regions of IRF2 in AD patients and control subjects by single-strand conformational polymorphism (SSCP) analysis. We found three mutations in the promoter region ([−829C>T, −830C>T], −684C>T, and −467G>A), one silent mutation in exon 9 (921G>A), and a 10-bp deletion in the 3′ untranslated region (1739[ATCCC]8>6). Among them, the −467G allele and the haplotype of the −467G, 921A, and 1739(ATCCC)8 alleles were transmitted preferentially to AD-affected children (P = 0.02 and P = 0.007, respectively). Our data suggest that IRF-2 plays some role in the development of AD in the Japanese population.

Silencing of the thrombomodulin gene in human malignant melanoma.

The loss of thrombomodulin (TM) expression is associated with tumour growth, infiltration and lymph node metastasis in human tumours. In melanoma cell lines, TM is reported to mediate cell adhesion, and its introduction into TM-negative melanoma cell lines suppresses their growth. In this study, we analysed TM expression in surgical melanoma specimens and the role of its promoter methylation in the loss of its expression. In 15 (75%) of the 20 specimens (five from a primary site and 15 from metastatic sites), melanoma cells lacked TM immunoreactivity. Methylation of the TM promoter region was detected in 10 (67%) of the 15 TM-negative specimens by methylation-specific polymerase chain reaction, whereas methylation was detected in two (40%) of the five TM-positive specimens. In cell lines, complete methylation of the TM promoter CpG island was detected in six (46%) of 13 melanoma cell lines, whereas no methylation was detected in two cultured normal melanocytes. There was a good correlation between the methylated status of the CpG island and the loss of TM messenger RNA (mRNA) expression. Treatment of melanoma cell lines with a demethylating agent, 5-aza-2′-deoxycytidine, induced demethylation of the promoter CpG island and the restoration of mRNA and protein expression. These findings suggest that most human melanomas lack TM expression, and that methylation of the promoter CpG island is one of the mechanisms responsible.

METASTASIS OF ESOPHAGEAL CARCINOMA MANIFESTING AS WHITLOW-LIKE LESIONS

A rare case of phalangeal metastasis of esophageal carcinoma in an 81‐year‐old man is described. The patient developed a tender, red, and swollen right index finger. From the clinical features, he was erroneously diagnosed with whitlow at first and treated with antibiotics with no success. A bone X‐ray showed that the distal phalanx of the index finger was completely dissolved. Histopathological examination revealed proliferation of squamous cell carcinoma into the deep dermis. It is important to understand that the phalangeal metastases commonly display inflammatory symptoms that mimic acute infection.

Porokeratosis large skin lesions are susceptible to skin cancer development : histological and cytological explanation for the susceptibility

Porokeratosis (PK), an autosomal dominant inherited skin disorder, is known to develop malignant skin tumors on its skin lesions. Our recent literature survey has revealed that large PK skin lesions are frequently a precursor of malignant changes. In the study, large and small PK skin lesions were investigated in terms of histological features of the epidermis and of the cellular DNA content of epidermal cells. Large PK lesions frequently showed hypertrophic epidermis with many epidermis without such mitotic cells. Abnormal cells, like those containing hyperchromatic, large, and/or irregularly shaped nuclei, were present in the epidermis of both large and small lesions with a preponderance in the former over the latter. DNA polyploidy was seen more frequently in large PK lesions than in small ones. DNA index values were significantly higher in large lesions than in small ones. The histological features and DNA ploidy abnormalities probably reflect the higher proliferation and the greater potential for malignant changes of large PK skin lesions. Our study helps to explain the clinical evidence that large PK skin lesions are frequently a precursor of malignant skin tumors.

Proton radiotherapy of skin carcinomas

Summary At the Proton Medical Research Center, University of Tsukuba, we performed a pilot study of protonbeam radiotherapy in 12 patients with the following types of carcinoma: Bowens disease (4), oral verrucous carcinoma (5), and squamous cell carcinoma (3). They received total doses of 51–99.2 Gy in fractions of 2–12.5 Gy. All of the tumours responded well to the treatment. All four lesions of Bowens disease, three of the five oral verrucous carcinomas, and the three squamous cell carcinomas completely regressed following irradiation. Two squamous cell carcinomas recurred during the followup period. One recurrent squamous cell carcinoma was successfully treated by a salvage surgical operation, and in the other case the patient refused further therapy. In two verrucous carcinomas there was 90% regression of tumour volume. No severe radiation‐related complication occurred. As proton radiotherapy produces good local tumour control without significant morbidity to the surrounding normal tissues, it may prove to be a useful therapeutic modality for the treatment of skin carcinomas.

Drug Eruption Due to Peplomycin : An Unusual Form of Stevens-Johnson Syndrome with Pustules

A rare case of Stevens‐Johnson syndrome (SJS) due to peplomycin in a 48‐year‐old man is described. The patient had squamous cell carcinoma on the scalp and underwent preoperative neoadjuvant chemotherapy with peplomycin. On the fifth day of the chemotherapy, he developed a fever and multiple dusky violaceous erythematous areas and pustules on his trunk, thighs, and palms. Erosive erythema and erosions also developed on his soles, scrotum, and oral mucosa. A biopsy specimen taken from the eruption on the thigh revealed marked liquefaction degeneration of the basal layer of the epidermis. Laboratory examinations demonstrated aggravation of liver function. Additionally, the patient developed conjunctivitis and corneal erosions. Although he had some subcorneal pustules, we diagnosed the case as an unusual form of SJS because of severe mucous membrane involvement. Oral prednisolone was administered, and the symptoms subsided. Then the patient underwent wide local excision. One month after surgery, we performed patch tests and a lymphocyte stimulation test with negative results. Then we re‐administered peplomycin starting with 1/20 of a daily dose and gradually increasing the dose each day. After administration of the regular daily dose, the patient had a relapse of fever, eruptions, stomatitis, corneal erosions, and liver dysfunction. Therefore, a definite diagnosis of drug eruption due to peplomycin was made.

Cutaneous Bronchogenic Cyst of the Chin

A 30-year-old woman who was otherwise healthy visited our hospital for treatment of an asymptomatic subcutaneous cystic mass on her chin. It was noticed from her childhood but had recently increased in size. Physical examination revealed a nonadhesive, nontender, soft cystic mass measuring 20 ! 16 mm in the subcutaneous tissue of the center of the chin. The overlying skin appeared normal (fig. 1a). The cyst was surgically enucleated, and no connection to deeper structures was found. It was unilocular and contained a gelatinous yellowish mucoid material. On pathological findings, the cyst wall was lined with a ciliated pseudostratified columnar epithelium (fig. 1b). Phosphotungstic acid hematoxylin stain revealed a ciliated lining inside the cyst (fig. 1c). Some epithelial cells were also found to be Alcian blue positive and had diastase-resistant PAS-positive granules in their cytoplasms. They were thought to be goblet cells. There was no cartilage, thyroid tissue, smooth muscle, seromucinous glands, lymphoid follicles or salivary glands in or around the cyst. An electron-microscopic view showed ciliated cells with cilia, brush cells with microvilli and mucous cells with many mucinous granules without cilia or microvilli (fig. 2). All of them are equivalent to the normal components of bronchial epithelial [1]. This finding is evidence that the cyst was of bronchial origin. A cross-section revealed the structure of cilia, which consisted of 2 central microtubules surrounded by 9 paired microtubules, as previously reported [2]. We diagnosed the cyst as a cutaneous bronchogenic cyst in light of the above microscopic and electron-microscopic findings and in light of its anatomical location. The bronchogenic cyst is one of several cysts of embryonic foregut origin. Enteric cysts and esophageal cysts are also known as foregut origin cysts, but they rarely appear in the skin. Bronchogenic cysts usually occur in the mediastinum or pulmonary parenchyma, and they too are rarely found in the skin. Seybold and Clagett [3] first described a case of a cutaneous bronchogenic cyst in 1945. Subsequently, a total of 56 cases, including ours, have been reported in the