Effective anti-programmed death-1 therapy in a SUFU-mutated patient with Gorlin-Goltz syndrome.

We present the case of a 77-year-old male patient with more than 50 basal cell carcinomas on the head and upper trunk. The patient did not respond to several lines of treatment, including surgery, imiquimod, retinoids, itraconazole and therapy with the hedgehog inhibitor vismodegib. The patient responded well to off-label therapy with the anti-programmed death-1 antibody pembrolizumab after four infusions.

Acral lentiginous melanoma: a skin cancer with unfavourable prognostic features. A study of the German central malignant melanoma registry (CMMR) in 2050 patients.

BACKGROUND: Acral lentiginous melanoma (ALM) is one of the four major subtypes in cutaneous melanoma (CM). Although ALM has a poorer prognosis than other CM subtypes, the prognostic factors associated with ALM have only been verified in small-sized cohorts because of the low incidence of ALM worldwide. OBJECTIVES: To investigate the clinical characteristics of ALM and to evaluate their prognostic values based on a large dataset from the Central Malignant Melanoma Registry (CMMR) of the German Dermatologic Society. METHODS: The Kaplan-Meier method was used to estimate the potential influence of clinical and histological parameters on ALM disease-specific survival (DSS) curves, which were compared using the log-rank test. A Cox proportional hazards model was used to identify independent prognostic factors for DSS. RESULTS: In total, 2050 patients with ALM were identified from 58 949 patients with CM recorded by the CMMR with follow-up data. In multivariate analyses, age (P = 0·006), ulceration (P = 0·013), tumour thickness (P < 0·001) and tumour spread (P < 0·001) turned out to be significant prognostic factors for DSS in ALM whereas sex, nevus association and level of invasion were not independent factors. CONCLUSIONS: ALM has the same prognostic factors as other subtypes of melanoma. Unfavourable prognosis probably derives from the delay in diagnosis in comparison with other melanoma subtypes.

Daylight effect on melatonin secretion in adult female guanacos (Lama guanicoe).

The wild South American camelids developed a strategy of seasonal reproduction during spring and summer with singleton birth. The photoperiod is one of the factors that may modulate this seasonality where light would be translated into a hormonal signal. This study evaluated the influence of changes in daily light intensity on melatonin concentration in captive guanacos under a long-day photoperiod (16 hr light/8 hr dark; 33 '28'S). Mean melatonin concentration was 28.3 ± 20.3 pg/ml, with a maximum of 52.14 ± 17.19 pg/ml at 23:30 and minimum of 14.29 ± 6.64 pg/ml at 08:30 (p < .001). There was a negative association between light intensity and melatonin concentration (r = -0.57; p < .001). The results indicate that guanacos respond to variation in daily environmental light with a hormonal response and point to a circannual rhythm as a function of the photoperiod.

A new method to monitor antigen-specific CD8+ T cells, avoiding additional target cells and the restriction to human leukocyte antigen haplotype.

Therapeutic vaccination of cancer patients with dendritic cells aims at inducing a strong tumor-specific T-cell response. Testing new target antigens for their immunogenicity is crucial to evaluate their suitability for this approach. Here we demonstrate a comfortable and reliable method to detect antigen-specific CD8(+) T-cell responses without the knowledge of the precise T-cell epitope and without the usage of additional target cells. We used the CD8(+) T cells themselves and electroporated them with RNA encoding the respective tumor antigen. The cells expressed, processed and presented the antigen and were capable of stimulating each other in functional readouts. For the model antigen MelanA, the number of interferon-γ-secreting cells obtained with this method highly correlated with the numbers obtained by exogenous peptide loading (R(2)=0.8). The method was also applicable for the tumor-associated antigen Wilms' tumor protein 1. This system is quick and easy to perform, independent of the donors human leukocyte antigen type and circumvents the need for additional cells as targets. It can be used in preclinical research to test new antigens for their immunogenic potential and for immunomonitoring in cancer patients.

Radiosensitization by BRAF inhibitor therapy-mechanism and frequency of toxicity in melanoma patients.

BACKGROUND: Recent evidence suggests that ionizing radiation may be associated with unexpected side-effects in melanoma patients treated with concomitant BRAF inhibitors. A large multicenter analysis was carried out to generate reliable safety data and elucidate the mechanism. METHODS: A total of 161 melanoma patients from 11 European skin cancer centers were evaluated for acute and late toxicity, of whom 70 consecutive patients received 86 series of radiotherapy with concomitant BRAF inhibitor therapy. To further characterize and quantify a possible radiosensitization by BRAF inhibitors, blood samples of 35 melanoma patients were used for individual radiosensitivity testing by fluorescence in situ hybridization of chromosomal breaks after ex vivo irradiation. RESULTS: With radiotherapy and concomitant BRAF inhibitor therapy the rate of acute radiodermatitis ≥2° was 36% and follicular cystic proliferation was seen in 13% of all radiotherapies. Non-skin toxicities included hearing disorders (4%) and dysphagia (2%). Following whole-brain radiotherapy, rates of radiodermatitis ≥2° were 44% and 8% (P < 0.001) for patients with and without BRAF inhibitor therapy, respectively. Concomitant treatment with vemurafenib induced acute radiodermatitis ≥2° more frequently than treatment with dabrafenib (40% versus 26%, P = 0.07). In line with these findings, analysis of chromosomal breaks ex vivo indicated significantly increased radiosensitivity for patients under vemurafenib (P = 0.004) and for patients switched from vemurafenib to dabrafenib (P = 0.002), but not for patients on dabrafenib only. No toxicities were reported after stereotactic treatment. CONCLUSION: Radiotherapy with concomitant BRAF inhibitor therapy is feasible with an acceptable increase in toxicity. Vemurafenib is a more potent radiosensitizer than dabrafenib.

[Myocarditis in the differential diagnosis of cardiomyopathies. Endomyocardial biopsy or MRI?]. / Myokarditis in der Differenzialdiagnose von Kardiomyopathien. Endomyokardiale Biopsie oder MRT?

Myocarditis is an inflammatory disease of the heart muscle commonly caused by viral pathogens. Dilated cardiomyopathy is a major long-term sequela of myocarditis and at least in part related to post-viral immune-mediated responses. Establishing a diagnosis of myocarditis represents a major challenge because of the variable clinical picture and the lack of readily available, non-invasive diagnostic tests. In recent years, cardiac magnetic resonance imaging (cMRI) has emerged as a promising additional diagnostic tool in patients with suspected myocarditis: cMRI not only provides important insights into structural and functional abnormalities of the heart but relevant tissue pathologies can also be visualized. The diagnostic accuracy of three tissue criteria, i.e. the edema ratio, early gadolinium enhancement ratio and late gadolinium enhancement, has been characterized in several studies. Endomyocardial biopsy (EMB) is widely considered to be the reference standard for diagnosis of myocarditis. Although limited by sampling error, EMB is the only diagnostic procedure that can be used to confirm myocarditis. Laboratory analyses of EMB may provide information about specific causes of myocarditis and are, at least in part, of prognostic relevance. In a subset of patients the results of EMB may guide therapeutic decision-making. Additional efforts are needed in cardiac imaging, molecular characterization of EMB and evaluation of serum biomarkers to improve the diagnostic work-up in patients with suspected myocarditis and to identify potential novel targets for a cause-specific therapy of myocarditis.

Ovarian follicular activity during late gestation and postpartum in guanaco (Lama guanicoe).

This study evaluated ovarian activity in late gestation and post-partum in guanacos in captivity. Follicular dynamics was monitored every second day from 40 days before and other 40 after delivery by transrectal sonography and by plasma steroids concentrations. Seven out of eight (87.5%) of gestating females presented ovarian follicular activity under progesterone levels >3 nmol/l with maximum follicular size of 8.42 ± 0.83 mm from days 23 to 1 before delivery. After delivery, all females have follicular wave development from day 0 to 38, with larger follicular size and longer follicular wave phases and interwave interval when compared with pre-partum data. During post-partum period, there was a close relationship between follicle size and estradiol-17ß concentration, with r = 0.69 at the beginning of growth phase and r = 0.86 in association with the largest dominant follicle. Plasma estradiol-17ß concentration varied from 11.92 to 198.55 pmol/l. Plasma estrone sulfate, free estrone and progesterone returned to baseline concentrations during peripartal period and remained basal thereafter. The results described follicular activity during late gestation and early post-partum period. These findings provide relevant information to understand physiological changes occurring during this reproductive key period in seasonal breeders with long gestation duration as New and Old World camelids.

Free and sulfated steroids secretion in postpubertal boars (Sus scrofa domestica).

Sulfated steroids have been traditionally regarded as inactive metabolites. However, they may also serve as precursors for the production of active free steroids in target cells. In this study, we used the boar as a model to study the metabolism, transport, and function of steroid sulfates due to their high production in the porcine testicular-epididymal compartment, of which the role is unknown. To characterize the secretion of free and sulfated steroids, plasma samples were collected from six postpubertal boars over 6  h every 20  min from the jugular vein. Long-term secretion profiles were also established in seven boars stimulated with human chorionic gonadotropin. To directly characterize the testicular output, samples were collected from superficial testicular arterial and venous blood vessels. Testosterone, androstenedione and sulfated pregnenolone, DHEA, estrone (E1), and estradiol-17ß (E2) were determined by liquid chromatography-tandem mass spectrometry. Free E1 and E2 were measured by RIA. Irrespective of a high variability between individuals, the results suggest that i) all steroids assessed are primarily produced in the testis, ii) they exhibit similar profiles pointing to a pulsatile secretion with low frequency (three to five pulses per day), and iii) after synthesis at least a major proportion is immediately released into peripheral circulation. The fact that all steroid sulfates assessed are original testicular products and their high correlations with one another suggest their role as being intermediates of testicular steroidogenesis rather than as being inactivated end products. Moreover, a substantial use of sulfated steroids in porcine testicular steroidogenesis would assign a crucial regulatory role to steroid sulfatase, which is highly expressed in Leydig cells.

[Risk factor management of coronary heart disease : what is evidence-based?]. / Risikofaktorenmanagement bei koronarer Herzerkrankung : Was ist evidenzbasiert?

In patients with coronary heart disease the further course of the disease can be substantially influenced by means of a targeted treatment of risk factors. A reduction of hospital referrals, an improvement in quality of life and an extension in life expectation by secondary prophylactic measures have been well documented. In addition to an optimized medicinal therapy, an often drastic change in lifestyle with a focus on a consistent abstinence from nicotine, a healthy diet and regular physical exercise is necessary. Data from healthcare research show that these targets are only insufficiently achieved. The implementation of current guidelines should therefore be rigorously applied. There is a need for research particularly with respect to the prognostic significance of beta blocker therapy for patients with stable coronary heart disease and preserved left ventricular function, the prognostic significance of targeted weight loss for overweight or obese coronary heart disease patients, the effectiveness of psychosocial interventions in the various patient groups and their implementation into routine care. Research is also necessary with respect to optimization of structured rehabilitation programs and improvement in patient compliance.

[Treatment of cardiogenic shock complicating acute myocardial infarction]. / Behandlung des kardiogenen Schocks im Rahmen eines akuten Myokardinfarkts.

While the mortality rate of acute myocardial infarction has decreased drastically in the last decades, the outcome of patients with cardiogenic shock complicating acute myocardial infarction is still devastating. The effectiveness of supportive medicinal therapy of cardiogenic shock is often limited by undesired side effects (e.g. arrhythmia and increased myocardial oxygen consumption) or inadequate hemodynamic support. Mechanical circulatory support in cardiogenic shock failed to show beneficial effects on short-term and long-term survival; however, there are hints for a survival benefit in therapy refractory cardiogenic shock. Therefore, future trials need to evaluate further medicinal treatment options and also the best type of mechanical support as well as the optimal time of initiation to improve the success of therapeutic management.

The spatio-temporal distribution of aromatase cytochrome in ovary throughout the canine oestrous cycle.

CONTEXT: New animal welfare legislation and ethical guidelines encourage alternative approaches for canine contraception, instead of surgical gonadectomy which is considered invasive and unjustified in healthy dogs. AIMS: Reversible contraception might be achieved by inhibition of aromatase (CYP19), an enzyme catalysing the conversion of androgens to oestrogens. This study provides insights into the spatio-temporal expression and distribution of aromatase in canine ovarian tissue. METHODS: Ovarian tissue was collected from 39 healthy and sexually mature bitches during different stages of the oestrous cycle: pro-oestrus (n =8), oestrus (n =12), dioestrus (n =9) (luteal phase) and anoestrus (n =10). Localisation of cytochrome P450 aromatase was determined by immunohistochemistry. KEY RESULTS: Aromatase activity in the dog is high during pro-oestrus, ovulation and early dioestrus. Comparing types of follicles and corpora lutea, the highest aromatase abundance was found in antral follicles and luteinising follicles, whereas corpora lutea and early antral follicles showed an intermediate presence of the enzyme. Interesting was the high abundance of aromatase in luteinising theca interna cells, prevailing over granulosa cells. CONCLUSIONS AND IMPLICATIONS: Understanding of cells involved in oestradiol production is important for targeted inhibition of oestradiol synthesis, possibly offering an approach for contraception and suppression of oestrus.

Mutation landscape in melanoma patients clinical implications of heterogeneity of BRAF mutations.

BACKGROUND: The detection of V600E BRAF mutations has fundamental clinical consequences as the treatment option with BRAF inhibitors such as vemurafenib or dabrafenib yields response rates of ~48%. Heterogeneity with respect to BRAF mutation in different metastases has been described in single cases. As this has important implications for the determination of BRAF status and treatment of patients, it is essential to acquire more data. METHODS: A total of 300 tumour samples from 187 melanoma patients were analysed for BRAF mutations by pyrosequencing. Equivocal results were confirmed by capillary sequencing. Clinical data with respect to melanoma type, tumour site and survival were summarised for 53 patients with multiple analysed tumour samples (2-13 per patient). RESULTS: BRAF mutations were found in 84 patients (44.9%) and 144 tumour samples (48%) with BRAF mutations in 45.5% of primary tumours and 51.3% of metastases, respectively. In 10 out of 53 patients (18.9%) where multiple samples were analysed results were discordant with respect to mutation findings with wild-type and mutated tumours in the same patient. Mutations did not appear more frequently over the course of disease nor was its occurrence associated with a specific localisation of metastases. CONCLUSION: As heterogeneity with respect to BRAF mutation status is detected in melanoma patients, subsequent testing of initially wild-type patients can yield different results and thus make BRAF inhibitor therapy accessible. The role of heterogeneity in testing and for clinical response to therapy with a BRAF inhibitor needs to be further investigated.

Rare BRAF mutations in melanoma patients: implications for molecular testing in clinical practice.

BACKGROUND: The detection of V600E BRAF mutation in melanoma is fundamental since here BRAF inhibitors represent an effective treatment. Non-V600E BRAF mutations that may also respond are not detected by certain screening methods. Thus, knowledge about detection of these mutations is needed. METHODS: A total of 276 tumour samples from 174 melanoma patients were investigated for BRAF mutations by pyrosequencing. Rare mutations were confirmed by capillary sequencing and compared with findings from COBAS test and immunohistochemistry using a novel BRAF antibody. Melanoma type, localisation, and survival were summarised. RESULTS: BRAF mutations were found in 43% of patients (124 tumours in 75 patients). Among those, 14 patients (18.7%) exhibited rare mutations. The V600EK601del and V600DK601del mutations have never been described before in melanoma. Furthermore, V600K, V600E2, and V600D, V600G, V600R, and L597S mutations were detected. Mutations were not detected by COBAS test in 7 out of these 14 patients and immunohistochemistry only reliably detected patients with the V600E2 and V600EK601del mutation. CONCLUSION: Accurate diagnosis of rare BRAF mutations is crucial. We show that pyrosequencing is accurate, highly sensitive, reliable, and time saving to detect rare BRAF mutations. Missing these rare variant mutations would exclude a subset of patients from available effective BRAF-targeting therapy.

[ESC guidelines on the management of valvular heart disease. What has changed and what is new?]. / ESC-Leitlinien zu Herzklappenerkrankungen. Was ist neu und anders?

In 2012 the new and collaborative "Guidelines on the management of valvular heart disease (version 2012)" were published by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). These guidelines emphasize that decision-making in patients with valvular heart disease should ideally be carried out by a"heart team" with particular expertise in valvular heart disease. In aortic regurgitation pathologies of the aortic root are frequent and in patients with Marfan syndrome, surgery is indicated when the maximal ascending aortic diameter is ≥50 mm, while the threshold for intervention should be lower in patients with risk factors for progression. Regarding aortic stenosis, transcatheter aortic valve implantation (TAVI) should be performed only in hospitals with on-site cardiac surgery and with a"heart team" available to assess patient risks. The TAVI procedure is indicated in patients with severe symptomatic aortic stenosis who are judged by the"heart team" to be unsuitable for surgery but have sufficient life expectancy. It should be considered for high-risk patients with severe symptomatic aortic stenosis based on the individual risk profile assessed by the"heart team". Furthermore, low flow - low gradient aortic stenosis with normal ejection fraction and the difficult topic of asymptomatic severe aortic stenosis and the indications for aortic valve replacement are discussed. With respect to mitral regurgitation, valve repair should be the preferred technique when it is expected to be durable. The topics of asymptomatic mitral regurgitation as well as percutaneous mitral valve repair using the edge to edge technique as an alternative for high risk patients are discussed. Tricuspid disease should not be forgotten and during left-sided valve surgery, tricuspid valve surgery should be considered in the presence of mild to moderate secondary regurgitation if there is significant annular dilatation. Last but not least, in patients with aortic bioprostheses the use of low-dose aspirin is now favored for a 3-month postoperative period.

Is percutaneous coronary intervention as effective as bypass surgery in left main stem coronary artery stenosis?

Recent advances in percutaneous coronary intervention (PCI) have rekindled interest in this treatment modality also in the setting of unprotected left main stenosis. Randomized trials reported a similar risk of death or myocardial infarction between PCI and coronary artery bypass grafting (CABG). However, rates of stroke were higher after CABG, whereas patients undergoing PCI had a higher risk of repeat revascularization. Although CABG remains the standard of care for left main stenosis in current guideline recommendations, PCI is considered a reasonable alternative in patients with low to intermediate anatomical complexity and at increased surgical risk. An interdisciplinary assessment is indispensable in order to choose the best treatment option for each individual patient.

[Diagnosis and therapy of chronic myocardial ischemia. Role of cardiac magnetic resonance imaging]. / Diagnostik und Therapie der chronischen Myokardischämie. Rolle der kardialen Magnetresonanztomographie.

In patients with chronic coronary artery disease different therapeutic strategies, such as optimal medical therapy, revascularization by percutaneous coronary intervention or coronary artery bypass grafting have been shown to improve the prognosis and symptoms and yield proven superiority over other treatment strategies in different patient populations. Thus, individual assessment of cardiac function and structure is of paramount importance to choose the optimal therapeutic strategy and subsequently improve patient prognosis. In this setting cardiac magnetic resonance imaging (CMR) has been shown to provide important diagnostic information. Myocardial ischemia can be detected by either perfusion stress CMR demonstrating perfusion deficits indicative of hemodynamically relevant coronary artery stenosis or dobutamin stress CMR for objectifying wall motion abnormalities during stress. Both techniques are superior to single photon emission computerized tomography and stress echocardiography in specific patient populations. Myocardial viability can be assessed by means of end-diastolic wall thickness or delayed enhancement imaging which allows quantification of the transmural extent of scarring. Furthermore, low-dose dobutamin stress CMR can detect a contractile reserve. Delayed enhancement imaging leads to accurate results due to its high resolution, can be performed at rest requiring no stress within a short time period and is easy to analyze. Thus this technique can be recommended as the favored technique to assess myocardial viability. In the following article the CMR techniques for ischemia and viability testing will be presented and their role in diagnosis and therapy of chronic myocardial ischemia will be discussed.

Bypass surgery versus percutaneous coronary intervention for the treatment of unprotected left main disease. A meta-analysis of randomized controlled trials.

OBJECTIVE: We performed a meta-analysis of randomized controlled trials to compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for the treatment of de novo unprotected left main disease. BACKGROUND: Although CABG is accepted to be standard of care for revascularization of unprotected left main stenosis, PCI is increasingly being used as an alternative primary approach. METHODS: We searched for randomized, controlled trials comparing CABG and PCI for the treatment of unprotected left main disease. Major adverse cardiac and cerebrovascular events (all-cause death, myocardial infarction, stroke, and repeat revascularization) were analyzed. RESULTS: The search strategy identified 4 randomized controlled trials enrolling a total of 1,611 patients. Follow-up ranged between 1 and 2 years. There were no significant differences in the risk of death or myocardial infarction between the two treatment modalities. While the risk of stroke was significantly lower in patients undergoing PCI (risk ratio (RR) 0.26, 95% confidence interval (CI) 0.10-0.69, p = 0.007), the risk of repeat revascularization was higher among patients undergoing PCI (RR 1.94, 95% CI 1.43-2.61, p < 0.001). No relevant statistical heterogeneity across studies could be found. CONCLUSION: In this largest series of randomized patients with unprotected left main stenosis to date, the risk of death and myocardial infarction was comparable between CABG and PCI. However, patients undergoing CABG had a higher risk of stroke, whereas patients undergoing PCI were at a higher risk for repeat revascularization.

Impact of coronary artery disease on in-hospital mortality in patients with aortic valve disease. Results from the German ALKK registry.

OBJECTIVE: Although aortic valve disease (AVD) is frequently associated with coronary artery disease (CAD), little is known about the impact of significant coronary artery disease on mortality after diagnostic cardiac catheterization in patients with AVD. METHODS: We analyzed data of the coronary angiography registry of the "Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte" (ALKK) in Germany. The primary endpoint was in-hospital mortality. RESULTS: A total of 1427 consecutive patients with AVD (438 patients with CAD versus 989 patients without CAD) underwent diagnostic catheterization in 2006 in 42 hospitals. All cause in-hospital mortality was more than threefold higher in patients with CAD (16/438; 3.7%) as compared to patients without CAD (12/989; 1.2%; p < 0.01; OR 3.09, 95% CI 1.45-6.58). Even after adjustment for age, sex, presence of diabetes mellitus and renal insufficiency, in-hospital all cause mortality remained statistically significant different between the two groups (OR 2.4; 95% CI 1.09-5.28; p < 0.01). Several factors, such as transient ischemic attack/stroke, volume of contrast agent, and left heart catheter-associated complications could not be identified as possible causes for the increase in mortality. CONCLUSION: This analysis in patients with the leading diagnosis of AVD shows a significantly higher in-hospital mortality after diagnostic cardiac catheterization in case of an accompanying CAD. However, further studies are necessary to identify the driving force for the increase in mortality.