Efficacy and safety of tirbanibulin 1% ointment in actinic keratoses: Data from two phase-III trials and the real-life clinical practice presented at the European Academy of Dermatology and Venereology Congress 2022.

BACKGROUND: The 31st European Academy of Dermatology and Venereology (EADV) Congress took place between 7th and 10th of September 2022 in Milan, Italy. OBJECTIVES: We report presented clinical data on the efficacy/effectiveness, safety and tolerability of tirbanibulin 1% ointment that has recently been licensed for actinic keratosis (AK) of the face or scalp in adults. METHODS: Summary of presentations given at the EADV Congress. RESULTS: Prof. Pellacani presented two post hoc analyses from two phase-III trials with AK patients (NCT03285477 [N = 351] and NCT03285490 [N = 351]): A descriptive analysis of medical history, concomitant medications, and safety results confirming a favourable profile for tirbanibulin showing that number of baseline AK lesions was not correlated to severity of local skin reactions. The latter analysis showed that cases of tirbanibulin application site pain or pruritus were few, and most were found to be mild. Prof. Kunstfeld reported six real-life clinical cases in Austria showing good tirbanibulin effectiveness, safety and tolerability for the treatment of new or recurring AK lesions. Results demonstrated that after 2- to 4-month follow-up, tirbanibulin was well tolerated and effective in AK patients. Presentations by Dr. Patel confirmed good outcomes and tolerability of tirbanibulin in Olsen grade 1-2 AK (N = 12) and porokeratosis patients (N = 4) treated once daily for 5 consecutive days in the United Kingdom. Furthermore, real-world experience in solid organ transplant recipients (N = 2) demonstrated effectiveness of tirbanibulin in skin field cancerization treatment. A symposium sponsored by Almirall was conducted during the congress in which Dr. Hadshiew and Dr. Lear brought together their clinical experience in Germany and the United Kingdom respectively. Interesting clinical cases of 5 consecutive days of tirbanibulin treatment compared to other treatments were discussed with attendees, as well as current treatment needs of AK patients. CONCLUSIONS: This article provides an overview of presentations and symposium discussions, summarizing key phase-III results and real-life clinical experience with tirbanibulin shared by dermatologists across Europe.

Long-term clinical outcomes of imiquimod 5% cream vs. diclofenac 3% gel for actinic keratosis on the face or scalp: a pooled analysis of two randomized controlled trials.

BACKGROUND: Actinic keratosis (AK) is an early in situ epidermal cancer which can progress to invasive squamous cell carcinoma (SCC). Imiquimod 5% cream (IMIQ) and diclofenac 3% gel (DIC) are frequently used to treat AK; however, their long-term effects following repeated treatment cycles have never been compared. OBJECTIVE: To compare IMIQ and DIC in the treatment of AK with respect to the risk of change to grade III AK or invasive SCC, after 3 years. METHODS: Data were pooled from two randomized, active-controlled, open-label, multicentre, multinational, phase IV studies (Clinicaltrials.gov NCT00777127/NCT01453179), with two parallel groups. Studies were conducted between 2008 and 2015 and were almost identical in design. Patients eligible for inclusion were immunocompetent adults with 5-10 visible AK lesions on the face/scalp and grade I/II AK. The primary endpoint was inhibition of histological change to grade III AK or invasive SCC in the study treatment area, observed until month 36. Patients applied either IMIQ or DIC for a maximum of six treatment cycles. RESULTS: In total, 479 patients (IMIQ 242; DIC 237) were included in the full analysis set. Histological change to grade III AK or invasive SCC was observed until month 36 in 13 (5.4%) patients treated with IMIQ, compared with 26 (11.0%) patients treated with DIC (absolute risk difference -5.6% [95% confidence interval -10.7%, -0.7%]). Time to histological change was greater in the IMIQ group than the DIC group (P = 0.0266). Frequency of progression to invasive SCC was lower with IMIQ than with DIC at all time points. Initial clearance rate was higher in the IMIQ group compared with the DIC group, while recurrence rate was lower. Both treatments were well tolerated. CONCLUSIONS: Over 3 years, IMIQ was superior to DIC in clearing AK lesions and preventing histological change to grade III AK or invasive SCC and recurrence.

Vismodegib in patients with advanced basal cell carcinoma: Primary analysis of STEVIE, an international, open-label trial.

BACKGROUND: The SafeTy Events in VIsmodEgib study (STEVIE, ClinicalTrials.gov, NCT01367665), assessed safety and efficacy of vismodegib-a first-in-class Hedgehog pathway inhibitor demonstrating clinical benefit in advanced basal cell carcinoma (BCC)-in a patient population representative of clinical practice. Primary analysis data are presented. PATIENTS AND METHODS: Patients with locally advanced or metastatic BCC received oral vismodegib 150 mg/d until progressive disease, unacceptable toxicity, or withdrawal. Primary objective was safety. Efficacy variables were assessed as secondary end-points. RESULTS: Evaluable adult patients (N = 1215, 1119 locally advanced; 96 metastatic BCC) from 36 countries were treated; 147 patients (12%) remained on study at time of reporting. Median (range) treatment duration was 8.6 (0-44) months. Most patients (98%) had ≥1 treatment-emergent adverse event (TEAE). The incidence of the most common TEAEs was consistent with reports in previous analyses. No association between creatine phosphokinase (CPK) abnormalities and muscle spasm was observed. Serious TEAEs occurred in 289 patients (23.8%). Exposure ≥12 months did not lead to increased incidence or severity of new TEAEs. The majority of the most common TEAEs ongoing at time of treatment discontinuation resolved by 12 months afterwards, regardless of Gorlin syndrome status. Response rates (investigator-assessed) in patients with histologically confirmed measurable baseline disease were 68.5% (95% confidence interval (CI) 65.7-71.3) in patients with locally advanced BCC and 36.9% (95% CI 26.6-48.1) in patients with metastatic BCC. CONCLUSIONS: The primary analysis of STEVIE demonstrates that vismodegib is tolerable in typical patients in clinical practice; safety profile is consistent with that in previous reports. Long-term exposure was not associated with worsening severity/frequency of TEAEs. Investigator-assessed response rates showed high rate of tumour control. CLINICALTRIALS.GOV: NCT01367665.

MCP-1 and MIP-1alpha are most efficient in recruiting T cells into the skin in vivo.

To analyze T cell recruitment by chemokines in vivo, we used SCID mice grafted with human skin onto their backs and human T cells into their peritoneal cavities. rh MIP-1alpha and rh MCP-1, as well as mouse MCP-1, attracted significant amounts of human T cells into human skin grafts, whereas effects of rh RANTES, rh SDF-1, or rh IP-10 were minimal. Human T cells were found in a striking perivascular position exclusively at sites of human endothelium. None of the chemokines recruited human T cells across mouse endothelial barriers. For control purposes, chemokines were injected into the abdominal wall directly above the peritoneal cavity, where human T cells had been injected and were not subjected to flow. At this site all tested chemokines attracted human T cells to an equal extent. In summary, our experiments point towards an important role for MCP-1 and MIP-1alpha as T cell chemoattractants for skin inflammatory conditions.

HECA-452+ T cells migrate through superficial vascular plexus but not through deep vascular plexus endothelium.

The skin is nourished by two interconnected vascular systems, the superficial vascular plexus coursing just beneath the epidermis and the deep vascular plexus located above the subcutaneous tissue. Skin inflammatory T cells in diseases, such as psoriasis or dermatitis, strikingly aim for the superficial vascular plexus without involving the deep vascular plexus, and the infiltrating T cells bear a distinct phenotype expressing the cutaneous lymphocyte-associated antigen, which is recognized by mAb HECA-452. We wanted to know whether HECA-452+ lymphocytes indeed are able to distinguish between superficial and deep vascular plexus homing sites. Employing the hu-SCID mouse model grafted with human skin and human T cells, as described previously, we developed a new skin-grafting strategy providing superficial and deep vascular plexus skin specimens placed separately onto the same mouse. Fourteen days after allogeneic human T cell grafting, both human skin sites were densely infiltrated by human T cells, but only T cells within the superficial vascular plexus, but not within the deep vascular plexus, expressed the cutaneous lymphocyte-associated antigen. IL-2 and IFN-gamma expression and allogeneic vessel destruction were present within both superficial and deep vascular plexus skin. This model provides direct evidence that expression of a specific homing receptor is indeed able to direct lymphocyte traffic, not only to a distinct organ but also to a distinct vascular bed within one organ.

Human delayed-type hypersensitivity reaction in a SCID mouse engrafted with human T cells and autologous skin.

We have developed and animal model to study human delayed-type hypersensitivity reactions occurring in a human environment within a mouse host. Human skin was grafted onto the backs and autologous human immune cells were injected into the peritoneal cavity of mice with severe combined immunodeficiency. Seven and 14 d after grafting, 2-50% of total white blood and spleen cells were of human origin. Mouse spleen-derived human T cells from tetanus toxoid-sensitized donors proliferated in response to tetanus toxoid as measured by [3H]thymidine uptake, and the strength of this proliferative response equaled that with pre-graft T cells from the same donor. Proliferation was blocked with monoclonal antibodies to human but not to mouse major histocompatibility complex antigens and with anti-human CD4 monoclonal antibodies. In vivo vaccination of mice with tetanus toxoid did not enhance proliferation of mouse spleen-derived human T cells in response to antigen. Injection of tetanus toxoid into the human skin graft caused a perivascular human CD4+/CD25+ T-cell infiltrate, which was not present when tetanus toxoid was injected into adjacent mouse skin. We conclude that human T cells grafted into mice with severe combined immunodeficiency retain their function, that human T cells specifically recognize human but not mouse skin as homing sites, and that human T-cell responses depend on the human micro-environment. This model lends itself to studies of endothelium-T-cell interactions, T-cell activation within skin, and chronic inflammatory skin diseases.

Peripheral lymph node addressins are expressed on skin endothelial cells.

The term "peripheral node addressins" describes a set of several endothelial adhesion molecules, which collectively bind to L-selectin and react with monoclonal antibody MECA-79. They regulate lymphocyte recirculation through peripheral nodes. Their expression is thought to be restricted to a specialized vascular segment within the node, called the high endothelial venule. In certain chronic skin diseases, however, postcapillary venules of the skin may also acquire a high endothelial venule-like morphology. Employing immunohistochemistry on cryostat sections, we found these skin endothelial cells - like peripheral node high endothelial venules - to be reactive with monoclonal antibody MECA-79. Tissue lysates from the same specimens were then analyzed by immunoprecipitation using recombinant human L-selectin Fc-chimeras followed by immunoblotting using monoclonal antibody MECA-79. In contrast to peripheral node endothelium, which mainly expressed peripheral node addressin moieties of molecular sizes 90-110 kDa and 160 kDa, endothelial cells in cutaneous T cell lymphoma skin lesions expressed an additional and not yet defined 220 kDa peripheral node addressin-like molecule. Most surprisingly, even in normal skin specimens, we found a distinct subset of endothelial cells located around hair follicles constitutively expressing 90-110 kDa peripheral node addressin-like moieties. It is intriguing to speculate that - in analogy to the role of peripheral node addressins in peripheral nodes - the induced expression of peripheral node addressins in chronic T cell mediated skin diseases is responsible for a sustained lymphocyte recruitment. The constitutive expression of peripheral node addressins on perifollicular endothelium may serve for a continuous lymphocyte recirculation through normal skin.

Long-term results after surgical basal cell carcinoma excision in the eyelid region.

AIMS: To evaluate the data for patients with basal cell carcinoma (BCC) in the eyelid region, to demonstrate histologically controlled tumour excision, and to prove the efficacy of the treatment on the basis of long term observations. METHODS: Retrospective analysis of 382 microscopically controlled BCC excisions in the eyelid apparatus (350 patients) in a follow up study over 5.7 (SD 1.1) years. Tumour location, tumour size, and histological results were recorded. The same procedure was followed for recurrences. Follow up examinations were carried out 1, 3, 6, and 12 months after the operation, and then annually for a further 4 years or longer. RESULTS: A recurrence rate of 5.36% was observed after the primary operation. 60.3% of first recurrences occurred in the medial canthus, 41.2% showed in depth extension, and sclerosing types were overly represented at 35.3%. After the second operation the recurrence rate increased to 14.7% and reached 50% after a third and fourth operation. CONCLUSIONS: The greatest risk of recurrence exists for BCCs of the medial canthus with in depth extension, and for sclerosing types. The recurrence rate increases after every operation. For high risk cases, consideration should be given to adjuvant treatment such as radiotherapy.

The dermis-prelaminated scapula flap for reconstructions of the hard palate and the alveolar ridge: a clinical and histologic evaluation.

Ideal reconstructions of complex defects in the midface require the restitution not only of bone and soft tissue, but also of a thin and durable lining of the oral cavity. So far, split-thickness skin grafts, intestinal grafts, and in vitro cultured mucosal grafts have been used for the reconstruction of the oral lining. The use of skin as a substitute for oral mucosa is controversial because contraction, hair growth, maceration, and dysplastic changes can occur. This clinical and histologic study was performed to evaluate the suitability of dermis as a substitute for oral lining. Twelve complex defects of the midface were reconstructed with dermis-prelaminated scapula flaps. A bony flap from the lateral border of the scapula was prepared, and osseointegrated implants were placed. The bone flap was then prelaminated with dermis and covered with a Gore-Tex membrane to prevent adhesions. The composite flap was transferred to the midface 2 to 3 months later. The oral lining of the flap was evaluated clinically and histologically at 2, 4, and 6 weeks and at 3 to 41 months after the reconstruction. In all patients, the reconstructed bone was covered with a thin and lubricated surface without hair growth. None of the patients showed any signs of maceration. Histologically, these findings corresponded to a keratinized stratified squamous epithelium with highly developed connective-tissue papillae. These features closely resemble those of the normal mucosa of the hard palate and the gingiva. Thus, dermis prelamination is an effective method for reconstructing the mucosa of the alveolar ridge and the hard palate.

The prefabricated scapula flap consists of syngeneic bone, connective tissue, and a self-assembled epithelial coating.

The reconstruction of maxillary defects is a challenge in plastic surgery. The so-called prefabricated scapula flap consists of syngeneic bone covered with syngeneic dermis and is used to reconstruct maxillary defects. After placing these flaps into the oral cavity, they are reepithelialized within a short time period, raising the question of the cellular origin of the "neomucosa." We therefore obtained sequential biopsy samples of the prefabricated flap and of the flap after being placed into the oral cavity and analyzed the keratin expression profile of epithelial cells. We expected that after placing the prefabricated flap into the oral cavity, keratinocytes from adnexal structures of the dermal component of the graft would migrate onto the surface and reepithelialize the flap. Unexpectedly, reepithelialization occurred earlier. The flap had acquired a mucosa-like epithelium at the interface between the Gore-Tex coating and the dermis while still being positioned within the scapular region. The keratin expression profile of this epithelium was very similar to that of mucosal epithelium. Thus, the prefabricated scapula flap not only consisted of bone covered with connective tissue, but was also covered with epithelial cells derived from adnexal structures of the dermal graft. This seems to be the reason for the rapid restoration of an intact mucosa and the excellent outcome achieved with this surgical technique.

A unique case of a benign disseminated angioproliferation combining features of Kaposi's sarcoma and diffuse dermal angioendotheliomatosis.

A female patient undergoing chronic hemodialysis had disseminated, violaceous, and partly ulcerated plaques develop on the trunk. Lesions had erupted simultaneously over a period of 4 weeks and resolved within 5 months after steroid treatment. By histopathology, the papillary dermis was densely filled with blood vessels lined by a single layer of differentiated endothelial cells, a growth pattern resembling diffuse dermal angioendotheliomatosis. In some areas, endothelial cells were spindle shaped and formed discontinuous lumina. Red blood cells were interspersed within these slits, giving the lesions a kaposiform appearance. By immunohistochemistry, endothelial cells reacted with the antibodies anti-von Willebrand factor, anti-CD31, and anti-CD34 and with the lectin Ulex europaeus-1. The course of the disease combined with the unusual histopathology makes this case a unique form of a benign disseminated kaposiform angioproliferation.

Anti-Her-2/neu antibody induces apoptosis in Her-2/neu overexpressing breast cancer cells independently from p53 status.

Anti-Her-2/neu antibody is known to induce apoptosis in HER-2/neu overexpressing breast cancer cells. However, exact regulatory mechanisms mediating and controlling this phenomenon are still unknown. In the present study, we have investigated the effect of anti-Her-2/neu antibody on apoptosis of HER-2/neu overexpressing human breast cancer cell lines SK-BR-3, HTB-24, HTB-25, HTB-27, HTB-128, HTB-130 and HTB-131 in relation to p53 genotype and bcl-2 status. SK-BR-3, HTB-24, HTB-128 and HTB-130 cells exhibited mutant p53, whereas wild type p53 was found in HTB-25, HTB-27 and HTB-131 cells. All seven cell lines weakly expressed bcl-2 protein (10-20%). Anti-Her-2/neu antibody, irrespective of p53 and bcl-2 status, induced apoptosis in all 7 cell lines dose- and time-dependently and correlated with Her-2/neu overexpression. In addition, incubation of cell lines with anti-Her-2/neu antibody did not alter p53 or bcl-2 expression. Anti-HER-2/neu antibody did not induce apoptosis in HER-2/neu negative HBL-100 and HTB-132 cell lines. Our results indicate that within the panel of tested breast cancer cell lines, anti-Her-2/neu antibody-induced apoptosis was independent from the presence of intact p53.