Prolonged overall survival following metastasectomy in stage IV melanoma.

BACKGROUND/OBJECTIVES: Current literature supports mixed conclusions regarding the outcomes of metastasectomy in Stage IV melanoma. The objective of this national study was to determine the associations of non-primary site surgery with overall survival (OS) in Stage IV melanoma. METHODS: The National Cancer Database (NCDB) was queried for all Stage IV melanoma cases diagnosed from 2004 to 2015. Cases missing treatment/staging data or undergoing palliative treatment were excluded (remaining n = 14 034). Patients were separated into 'metastasectomy' (n = 4214, 30.0%) and 'non-metastasectomy' (n = 9820, 70.0%) cohorts. Survival outcomes were analysed using Kaplan-Meier and Cox proportional hazards regressions. RESULTS: On univariate analysis, patients with Stage IV melanoma undergoing metastasectomy (median survival: 15.67 month) had greater overall survival compared with those not receiving non-primary surgery (median survival: 7.13 month; 5-year OS 13.2% vs. 5.6%, P < 0.001). M1a patients that underwent non-primary metastasectomy (median survival: 46.36 month) showed greater survival than those that did not (median survival: 15.31 month; P < 0.001). Metastasectomy was undertaken more frequently for cutaneous (M1a) metastasis compared with non-M1a metastasis (34.6% vs. 28.4%, P < 0.001). Of those receiving metastasectomy, 20.3% also received primary site resection, 33.6% radiation, 26.5% chemotherapy and 31.5% immunotherapy. Controlling for covariates on Cox proportional hazard analysis, all metastasectomy patients demonstrated longer survival [Hazard Ratio = 0.519, P < 0.001; CI 95% (0.495-0.545)] as well as when analysing solely M1a metastasectomy patients [Hazard Ratio = 0.546, P < 0.001; CI 95% (0.456-0.653)], lung (M1b) metastasectomy patients [Hazard Ratio = 0.389, P < 0.001; CI 95% (0.328-0.462)] and visceral (M1c) metastasectomy patients [Hazard Ratio = 0.474, P < 0.001; CI 95% (0.434-0.517)]. CONCLUSION: Metastasectomy for Stage IV melanoma is independently associated with improved OS in metastatic cases involving the skin, lung and visceral organs.

Langerhans cell: exciting developments in health and disease.

Langerhans cells (LCs) have been the subject of much research since their discovery in 1868. LCs belong to the subset of leucocytes called dendritic cells. They are present in the epidermis and the pilosebaceous apparatus and monitor the cutaneous environment for changes in homeostasis. During embryogenesis, a wave of yolk sac macrophages seed the fetal skin. Then, fetal liver monocytes largely replace the yolk sac macrophages and comprise the majority of adult LCs. In the presence of skin irritation, LCs process antigen and travel to regional lymph nodes to present antigen to reactive T lymphocytes. Changes in LCs' surface markers during the journey occur under the influence of cytokines. The difference in expression of surface markers and the ability to resist radiation have allowed researchers to differentiate LCs from the murine Langerin-positive dermal dendritic cells. Exciting discoveries have been made recently regarding their role in inflammatory skin diseases, cancer and HIV. New research has shown that antibodies blocking CD1a appear to mitigate inflammation in contact hypersensitivity reactions and psoriasis. While it has been established that LCs have the potential to induce effector cells of the adaptive immune system to counter oncogenesis, recent studies have demonstrated that LCs coordinate with natural killer cells to impair development of squamous cell carcinoma caused by chemical carcinogens. However, LCs may also physiologically suppress T cells and permit keratinocyte transformation and tumorigenesis. Although long known to play a primary role in the progression of HIV infection, it is now understood that LCs also possess the ability to restrict the progression of the disease. There is a pressing need to discover more about how these cells affect various aspects of health and disease; new information gathered thus far seems promising and exciting.

Topical antiviral and antifungal medications in pregnancy: a review of safety profiles.

Medications should be employed with caution in women of childbearing age who are pregnant or considering pregnancy. Compared to oral or parenteral agents, topical medications have limited systemic absorption and are deemed safer. However, their safety profile must be assessed cautiously due to the limited available data. In this article, we aggregate human and animal studies to provide recommendations on utilizing topical antiviral and antifungal medications in pregnancy. For antiviral medications, acyclovir and trichloroacetic acid are safe to use in pregnancy. Docosanol, imiquimod and penciclovir are likely safe, but should be utilized as second-line agents. Podofilox and podophyllin resin should be avoided. For antifungal medications, clotrimazole, miconazole and nystatin are considered first-line agents. Butenafine, ciclopirox, naftifine, oxiconazole and terbinafine may be utilized after the above agents. Econazole should be avoided during the first trimester and used sparingly during 2nd and 3rd trimester. Ketoconazole and selenium sulphide are likely safe, but should be employed in limited areas for brief periods.

Bullous pemphigoid and its association with neurological diseases: a systematic review and meta-analysis.

Bullous pemphigoid (BP) is a chronic, autoimmune vesiculobullous disease that frequently occurs in the elderly population. Previous epidemiological studies have suggested an association between BP and neurological diseases; some studies, however, showed conflicting results. This study aimed to investigate if patients with BP have significantly higher risks for neurological disorders, compared to controls. A comprehensive search was performed using MEDLINE, EMBASE and Cochrane library databases. Case-control and cohort studies that assessed the relationship between BP and neurological diseases were included. DerSimonian and Laird random-effects models were utilized to calculate the pooled relative risks (RRs). Publication bias was evaluated qualitatively by constructing a funnel plot and quantitatively by conducting Egger's test. Fourteen studies, with 23 369 BP cases and 128 697 controls were included in this meta-analysis. Patients with BP were significantly more likely to have stroke (RR 2.68, 95% CI: 2.07-3.46), Parkinson's disease (PD; RR 3.42, 95% CI: 3.01-3.87), dementia (RR 4.46, 95% CI: 3.23-6.16), epilepsy (RR 2.98, 95% CI: 1.42-6.28), multiple sclerosis (RR 12.40, 95% CI: 6.64-23.17) and any aforementioned neurological disease (RR 4.93, 95% CI: 3.62-6.70), compared to controls. Moderate to high heterogeneity were observed for analyses of most neurological diseases, except for PD and multiple sclerosis. This study provided support for a significant association between BP and neurological diseases. Clinicians should be aware of this association and manage modifiable risk factors for neurological diseases accordingly.

DNA repair and chromatin structure in genetic diseases.

Interaction of DNA repair proteins with damaged DNA in eukaryotic cells is influenced by the packaging of DNA into chromatin. The basic repeating unit of chromatin, the nucleosome, plays an important role in regulating accessibility of repair proteins to sites of damage in DNA. There are a number of different pathways fundamental to the DNA repair process. Elucidation of the proteins involved in these pathways and the mechanisms they utilize for interacting with damaged nucleosomal and nonnucleosomal DNA has been aided by studies of genetic diseases where there are defects in the DNA repair process. Two of these diseases are xeroderma pigmentosum (XP) and Fanconi anemia (FA). Cells from patients with these disorders are similar in that they have defects in the initial steps of the repair process. However, there are a number of important differences in the nature of these defects. One of these is in the ability of repair proteins from XP and FA cells to interact with damaged nucleosomal DNA. In XP complementation group A (XPA) cells, for example, endonucleases present in a chromatin-associated protein complex involved in the initial steps in the repair process are defective in their ability to incise damaged nucleosomal DNA, but, like the normal complexes, can incise damaged naked DNA. In contrast, in FA complementation group A (FA-A) cells, these complexes are equally deficient in their ability to incise damaged naked and similarly damaged nucleosomal DNA. This ability to interact with damaged nucleosomal DNA correlates with the mechanism of action these endonucleases use for locating sites of damage. Whereas the FA-A and normal endonucleases act by a processive mechanism of action, the XPA endonucleases locate sites of damage distributively. Thus the mechanism of action utilized by a DNA repair enzyme may be of critical importance in its ability to interact with damaged nucleosomal DNA.

Nuclear deoxyribonuclease activities in human lymphoblastoid and mouse melanoma cells. A comparative study.

Deoxyribonuclease activities were examined in isoelectric focusing fractions of non-histone, chromatin-associated and nucleoplasmic proteins of isolated normal human lymphoblastoid and mouse melanoma cell nuclei using parallel procedures. A very similar series of eight DNA endonucleases, each active on calf thymus DNA and containing no exonuclease activity, were found in the chromatin proteins of both cell lines. Several differences were observed: an activity in human cells at pI 6.6 was absent from murine cells, and there was an increased activity in mouse cells at pI 4.4 and a decreased activity at pI 7.3, as compared with corresponding human cell activities. Assay of these fractions against supercoiled, circular phage PM2 DNA showed greater activity among the fractions with acidic pI valves and slightly lower activities in the murine cells than in the human cells. Analysis of the nucleoplasmic fractions showed a series of DNA endonuclease and exonuclease activities which were again very similar between the two cell lines, although greater endonuclease activity at pI 4.4 occurred in mouse than in human nucleoplasm. These results demonstrate an entire series of deoxyribonuclease activities in both chromatin and nucleoplasm which are nearly identical in two very different mammalian cell lines, suggesting that many of these enzymes are ubiquitous in mammalian cell nuclei.

Localization of B-DNA and Z-DNA in terminally differentiating fiber cells in the adult lens.

We examined histochemically and immunohistochemically the distribution of B- and Z-DNA in the epithelium and terminally differentiating dog lens fiber cells. On the basis of anti-DNA antibody reactivity, qualitative and quantitative data on B- and Z-DNA in cells were determined. Anti-B-DNA immunoreactivity gradually declined throughout nucleated fibers, with a precipitous decrease at approximately 90 microns. Anti-Z-DNA antibody binding decreased with a sudden loss of immunoreactivity at approximately 90 microns. The pattern of anti-B- and Z-DNA staining correlates with the loss of alpha-crystallin immunoreactivity, the major lens crystallin, and decreased eosin staining of proteins. Germinative zone cell nuclei showed the highest DNA probe binding values, followed by the superficial fibers, central zone, middle fibers, and deep fibers. The presence of single-stranded (ss)DNA in deeper fibers was detected by anti-ss-DNA antibodies. This is indicative of DNA degradation. These observations suggest that a dramatic reorganization of lens fiber cells' supramolecular order occurs at approximately 90 microns, the phase transition zone.

Comparison of apoptosis and terminal differentiation: the mammalian aging process.

Apoptosis is the ordered chain of events that lead to cell destruction. Terminal differentiation (denucleation) is the process in which cells lose their nuclei but remain functional. Our group examined cell death in three tissues using two different fixatives and a postfixation procedure, involving young (5 months) and old (2 years) guinea pigs. The data reveal that B-DNA and Z-DNA content decreases, whereas single-stranded (ss-) DNA increases, in older tissues undergoing apoptosis (skin and cornea) and terminal differentiation (ocular lens). We speculate that some of the factors that contribute to the aging process might also be responsible for the enhanced amount of damaged DNA in older tissues undergoing cell death. (J Histochem 49:929-930, 2001)

Prognostic value of morphometry in papillary thyroid carcinoma.

The value of morphometric analysis in addition to standard prognostic indicators was studied in 28 cases of papillary thyroid carcinoma. Standard features included age, sex, lymph node status, tumor size, and encapsulation. The mean follow-up was 47 months (maximum, 140 months). Recurrences were documented in six patients at a mean time of 34 months; five patients recurred with distal metastases and one patient recurred with local disease. Univariate analysis most closely associated tumor recurrence with nuclear anisotropism (the standard deviation of the estimated nuclear area [ENASD]) and tumor size. With forward stepwise incremental analysis, the value of tumor size was lost and only the ENASD and the cellularity mean index (CMI), defined as the percentage of tumor volume composed of tumor cells, significantly correlated with recurrence. Fifty-five percent of patients with an ENASD greater than 17 microns2 and a CMI greater than 40% developed recurrence as compared with 5% of patients with lesser values (P = .0001). Morphometric analysis may significantly contribute to the role of histopathology in the evaluation of papillary thyroid carcinoma and may also provide information regarding prognosis not obtained by standard methods.

Nodal and subcutaneous cellular blue nevi. A pseudometastasizing pseudomelanoma.

A 20-year-old white woman had extensive surgery for "metastatic melanoma" of the dorsum of the right foot and surgical removal of two regional inguinal lymph nodes. Review of the histopathological sections ten years later revealed all three lesions to be cellular blue nevi. Cellular blue nevi may resemble melanoma histologically and, relative to their incidence, are quite frequently found in lymph nodes. Thus they may present a uniquely challenging differential diagnosis with metastatic melanoma.

Acrokeratosis paraneoplastica (Bazex' syndrome). Report of a case and review of the literature.

Acrokeratosis paraneoplastica (Bazex' syndrome) is a rare but clinically distinctive dermatosis that has been associated in all reported cases, to our knowledge, with either a primary malignant neoplasm of the upper aerodigestive tract or metastatic cancer to the lymph nodes of the neck. Acrokeratosis paraneoplastica was found in a 53-year-old black man with squamous cell carcinoma of the tonsil. A distinctive series of changes was found on histopathologic examination of biopsy specimens taken from his skin lesions, and direct immunofluorescence microscopy of both lesional and nonlesional skin specimens showed immunoglobulin and complement deposition on the epidermal basement membrane. The skin lesions largely resolved following radiation therapy of the neoplasm and of the presumably involved lymph nodes.

Keratosis punctata and atopy. Report of 31 cases with a prospective study of prevalence.

We report 31 cases of keratosis punctata palmaris et plantaris in blacks. Eleven of these were found in a prospective study of 573 consecutive black private dermatologic outpatients, a prevalence of 1.9%, and 20 cases were randomly encountered over a three-year period in the same office. Five of the 30 patients able to give a history were symptomatic, and they and ten others came to the office because of this disease, where as 15 came for other reasons, two of whom were unaware of the disease. Four of the 31 patients also had foot lesions. Four patients were aware of relatives with palmar keratoses. The mean duration of disease was 4.3 years, the median was three years, and the range was zero to 38 years. The mean age at onset was 30.3 years, the median was 29 years, and the range was 12 to 70 years, with one case beginning in infancy. Each patient in the prospective study was examined for personal atopy or for a family history of atopy. Nine (82%) of the 11 patients with keratosis punctata had atopy and/or a family history of atopy. Statistical analysis confirmed the association between keratosis punctata and atopy in the prospective study.

Dermatopathia pigmentosa reticularis.

Dermatopathia pigmentosa reticularis is a rare disorder that presents as reticulate pigmentation distributed widely all over the cutaneous surface. Only nine patients with this disease have been described previously. Our patient had no fingernail and toenail prints, a striking finding also noted in some, but not all, of the other nine patients. Our patient also had a history of a seizure disorder and had two cutaneous neurofibromas, unlike the other patients with this disorder. However, there were no other findings, such as Lisch nodules of the iris, to suggest a diagnosis of von Recklinghausen's disease.

The role of sunlight and DNA repair in melanoma and nonmelanoma skin cancer. The xeroderma pigmentosum paradigm.

BACKGROUND AND DESIGN: The frequency of melanoma and nonmelanoma skin cancer is increasing rapidly in the United States. However, the linkage of these cancers to sun exposure has been questioned because of differences in anatomic site distribution. To obtain insights into the development of these skin cancers, we examined reports of 132 patients with xeroderma pigmentosum (XP), an inherited cancer-prone, DNA repair-deficient disorder with marked clinical and laboratory UV hypersensitivity. RESULTS: Malignant skin neoplasms were present in 70% of the patients with XP at a median age of 8 years, which is 50 years earlier than in the US white population. Fifty-seven percent of the patients had basal cell or squamous cell carcinoma, and 22% had melanoma. The frequency of melanomas, like the frequency of nonmelanoma skin cancers (basal cell and squamous cell carcinomas), anterior eye cancers, and tongue cancers, but unlike that of internal neoplasms, was increased 1000-fold or more in patients with XP who were younger than 20 years. As in the general population, the anatomic distribution of melanomas was different from that of nonmelanomas in the patients with XP. CONCLUSIONS: These data suggest that (1) DNA repair plays a major role in the prevention of cutaneous cancers in the general population and (2) sunlight exposure is responsible for the induction of melanoma as well as nonmelanoma skin cancer in patients with XP, although acting by different mechanisms for the two types of skin cancer.

Trichoepithelioma in a systematized epidermal nevus with acantholytic dyskeratosis. Its occurrence in a black man.

A 2-cm nodular neoplasm in the left parietal region developed in a 52-year-old black man with a 20-year history of a systematized epidermal nevus of the scalp. On biopsy, the epidermal nevus showed both "church spire" papillary changes and multiple foci of acantholytic dyskeratosis. The neoplasm showed quite distinct histopathologic patterns of trichoepithelioma.