Assessment of reflectance confocal microscopy for monitoring treatment of actinic keratosis and field cancerization with daylight photodynamic therapy.

Actinic keratosis (AK) is the most common pre-malignant cutaneous lesion of the skin, often associated with field cancerization. Daylight photodynamic therapy (DL-PDT) is used as treatment, showing good histological results. Reflectance confocal microscopy (RCM) may be useful as a non-invasive, real-time approach to monitor treatment, however, there is a lack of data on the correlation between RCM and histopathological findings in AK patients treated with DL-PDT. To correlate histological and RCM findings and evaluate the efficacy of DL-PDT in patients with AK and field cancerization treated with DL-PDT. Patients with field cancerization and a minimum of six AK lesions on the face were included in the study. A single session combining methyl aminolevulinate followed by two-hour daylight exposure of the face was performed. RCM and biopsy were performed before and after three months of the intervention to compare efficacy between patients using the Wilcoxon test, and concordance of the findings based on the different methods was analysed using the Kappa test. Twenty-four patients completed the study. An improvement in photodamage and a decrease in the number of AK lesions (45.3% reduction) was observed. Regression in atypia and dysplasia was observed via histopathology and RCM, however, there was poor agreement between the methods. No changes were observed after treatment for inflammation, fibroplasia and acantholysis. Concordance between histological and RCM findings was poor, suggesting that RCM cannot replace the histopathological examination, however, it may be used as an adjuvant test for follow-up of patients. Despite this, DL-PDT proved to be an effective method for treating AK.

Complicações cutâneas da hospitalização por COVID-19 relacionadas à pronação / skin complications of hospitalization for COVID-19 related to pronation

Contexto: A pandemia da doença do coronavírus (COVID-19) revelou uma miríade de manifestações sistêmicas e cutâneas possivelmente relacionadas à infecção por síndrome respiratória aguda grave ocasionada pelo coronavírus (SARS-CoV-2). O comprometimento pulmonar é a causa mais frequente de hospitalização e a progressão para síndrome respiratória aguda grave geralmente requer tratamento com ventilação mecânica na posição pronada. Períodos prolongados e repetidos de pronação aumentam o risco de complicações, incluindo úlcera de pressão, cegueira e neuropatia periférica. Descrição do caso: Relatamos três casos de complicações cutâneas relacionadas à ventilação em pronação avaliadas durante interconsultas no maior hospital terciário universitário da América Latina, e salientamos potenciais causas e medidas de prevenção. Discussão: Complicações da ventilação em pronação para tratamento da COVID-19 são provavelmente resultantes da interação entre múltiplos fatores, dentre os quais as condições clínicas do paciente, períodos prolongados na posição pronada e limitações para mudanças de decúbito. Conclusões: Medidas de prevenção para complicações da pronação e diagnóstico precoce são fundamentais para evitar aumento da morbidade e sequelas graves e irreversíveis associadas à COVID-19.

Antitumor effect of cell therapy with mesenchymal stem cells on murine melanoma B16-F10.

In this study, the antitumor and immunomodulatory effects of mesenchymal stem cells (MSC) obtained from bone marrow in the treatment of dorsal melanoma B16-F10. The MSC cells were obtained from the bone marrow of isogenic C57BL/6J mice, characterized and inoculated by two routes, intratumor (it) and intravenous (iv). The hematological profile, expression markers and receptors, phases of the cell cycle and mitochondrial electrical potential were evaluated by flow cytometry. The dorsal tumor mass showed a significant reduction after treatment by the two routes of administration with a significant effect by the intravenous route. MSC showed immunomodulatory potential and did not induce an increase in the markers involved in tumor control and progression. The number of cells in the sub-G1 phase increased significantly after treatments compared to the control group. The percentage of cells in phases G0/G1, S and G2/M decreased, with only the group (it) showing a significant reduction. The intratumor group showed a significant decrease in the G2/M phase. Treatment with MSC provided a significant decrease in the percentage of metabolically active tumor cells, demonstrating its intrinsic effect in the control of cell proliferation. Regarding the mechanism of cell death, MSCs modulated the expression of proteins involved in the regulation of the cell cycle, angiogenesis receptors and pro-apoptotic proteins by intrinsic and extrinsic routes. Therefore, the use of undifferentiated MSC, administered intratumor and intravenous is possibly a promising treatment for melanoma.

The first observation of the association of Merkel cell polyomavirus and Merkel cell carcinoma in Brazil.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare but aggressive primary cutaneous carcinoma with high mortality rates. The present study intends to delineate the epidemiological profile of patients with MCC seen at the Clinics Hospital of the Medical School at the University of São Paulo, Brazil, and its association with Merkel cell polyomavirus (MCPyV). METHODS: This is a retrospective study. A search was performed in the hospital's medical index for all cases of MCC from January 1994 to December 2012. Among patients with MCC, the available tumoral skin specimens were analyzed with two different techniques of polymerase chain reaction (PCR) (conventional and real-time) for detection of MCPyV DNA. Additionally, paraffin-embedded samples of patients with non-MCC skin cancers were also analyzed. Analyses suitable for categorical data (i.e., x² of Fisher) were used to compare the proportion of patients in each group. RESULTS: Nineteen patients with MCC and 20 patients with non-MCC skin cancers entered the study. All MCC samples available (13) tested positive for the presence of MCPyV DNA; however, in the non-MCC skin cancer samples, the MCPyV DNA was detected in 4 of 20 samples (20%). MCPyV DNA detection rate was higher in patients with MCC than in the other group, and its analysis was statistically significant (P < 0.01). CONCLUSIONS: This study demonstrates the association of MCPyV in Brazilian patients with MCC. However, further studies are necessary to determine the exact involvement of MCPyV in MCC pathogenesis and to define the significance of viral DNA detection in non-MCC skin cancers.

Evaluation of the efficacy of photodynamic therapy for the treatment of actinic cheilitis.

INTRODUCTION: Actinic cheilitis (AC) is a lip intraepithelial neoplasia, whose cells present alterations similar to those presented by invasive squamous cell carcinomas (SCCs). OBJECTIVE: To conduct clinical and laboratory evaluation by histopathology and immunohistochemistry of the efficacy of actinic cheilitis treatment using photodynamic therapy (PDT) with methyl aminolevulinate (MAL) and noncoherent red light. MATERIALS AND METHODS: Patients with actinic cheilitis detected by histopathological examination were submitted to two sessions of photodynamic therapy with a two-week interval between them. They were examined immediately after the sessions, four, six, and twelve weeks after beginning treatment when a new biopsy was carried out. Clinical histopathological and immunohistochemical parameters were evaluated before and after treatment. RESULTS: Of the 23 patients who underwent biopsy, 16 completed two photodynamic therapy sessions and the material of one patient was insufficient for immunohistochemistry. Complete clinical response was achieved in 62.5% (10 of 16 patients) and 37.5% still remained with clinical evidence of AC. In spite of this, no case of cure by histopathological analysis was found. There was no significant statistical change among the values of Ki-67, survivin, and p53 observed before and after treatment. CONCLUSION: Photodynamic therapy, as carried out in this trial, was not an efficacious therapeutic option for treating patients with actinic cheilitis included in this sample.

Use of Smartphones in Telemedicine: Comparative Study Between Standard and Teledermatological Evaluation of High-Complex Care Hospital Inpatients.

BACKGROUND: It is estimated that there are around 7 billion mobile phone subscriptions worldwide. Considering the availability and convenience, it appears to be a suitable device for store-and-forward (SF) consultations. INTRODUCTION: Although teledermatology has been suggested as an effective way of reducing costs and providing otherwise inaccessible expert evaluation, most studies have relied on high cost and high technological means. MATERIALS AND METHODS: We conducted a study with inpatients that required dermatological evaluation in a high-complexity university hospital, accessing the correlation between traditional face-to-face evaluation and SF teledermatology, with data and pictures collected by medical students using smartphone cameras and then sent to consultants by e-mail. RESULTS: For 2 months, we evaluated 100 patients and, as a result, the total agreement between both consultation modalities was 54%, the partial agreement was 27%, and the disagreement was 19%. DISCUSSION: This study points out that SF teledermatology with the use of mobile phone is comparable to traditional face-to-face evaluation. Furthermore, most of the disagreements were probably related to the inexperience of the medical residents. CONCLUSION: Our study suggests that a smartphone-based teledermatology inpatient consultation model could be a reasonable option for hospitals lacking dermatological services. Also, it may be as or more effective than face-to-face consultations, if performed by a more experienced dermatologist. When feasible, photographing training should be performed.

Deleterious Effect of Radiation Therapy on Epidermodysplasia Verruciformis Patients.

BACKGROUND: Epidermodysplasia verruciformis (EV) is a rare genodermatosis caused by specific human papillomavirus (HPV) types associated with the development of multiple squamous cell carcinomas (SCC). The treatment for this skin tumour may be difficult. Among the therapy options, radiotherapy (RT) should be avoided due to its deleterious effects on HPV-induced carcinogenesis. OBJECTIVE: To describe 4 patients with EV who underwent radiotherapy to treat cutaneous SCC. METHODS: This is a retrospective study. The evolution of cutaneous SCC after adjuvant radiotherapy in 4 patients with EV was observed. RESULTS: This study included 4 patients with diagnosis of EV. All 4 of the patients had cutaneous SCC. They underwent surgical resection and adjuvant radiotherapy. Over a period of up to 2 years, there was aggressive tumour recurrence. CONCLUSION: Radiotherapy might be associated with progression of SCC in patients with EV, and it is recommended that radiotherapy should be avoided in this patient population.

Inpatient dermatology: profile of patients and characteristics of admissions to a tertiary dermatology inpatient unit in São Paulo, Brazil.

BACKGROUND: Dermatology is primarily an outpatient clinical and surgical specialty, but substantial numbers of patients are admitted to hospital for inpatient treatment in dermatology wards. METHODS: We performed a retrospective study of patients admitted to dermatology beds between September 1, 2002, and September 30, 2010. Patient data were analyzed for age, gender, ethnicity, length of stay (LoS), dermatologic disease, comorbidities, hospital-acquired infection (HAI), transfer to the intensive care unit (ICU), and mortality. RESULTS: A total of 3308 patients admitted during this 8-year period were identified for analysis. The most frequent admissions were for eczema/dermatitis (17.5%) and cutaneous infections (15.9%). The mean LoS was 13.0 days. The mean ± standard deviation (SD) number of comorbidities per patient was 1.0 ± 1.2, among the most frequent of which were hypertension and diabetes mellitus. The rate of HAI was 6.2%; bloodstream infection was regarded as the most commonly acquired type and Staphylococcus aureus as the infectious agent most commonly found in culture. Of the patients admitted, 3.7% were transferred to the ICU and 2.5% died. In these latter two groups, the most common dermatologic diagnoses were immunobullous diseases, and the mean hospital LoS and rate of HAI were higher than in the total admissions cohort. CONCLUSIONS: Higher value should be placed on dermatology inpatient services in order to expand the availability of dermatology beds, mainly in tertiary hospitals, in view of the potentially high severity of the dermatologic diseases found in many patients referred to this type of service.

Oral mucosal melanoma of the mandibular gingiva: a case report.

Oral mucosal melanoma is rare and is reported to be more aggressive than cutaneous melanoma. The incidence of oral mucosal melanoma peaks at 41 to 60 years of age and the male to female ratio is 2 to 1. Preferred sites in the oral mucosa include the hard palate and maxillary alveolar crests. Risk factors have not been clearly identified, but melanotic pigmentation is present in one-third of patients prior to the diagnosis of melanoma. We report an unusual case of oral mucosal melanoma of the mandibular gingiva with the main characteristics of an in situ lesion and areas of superficial invasion in a 45-year-old woman. The patient was treated with surgical resection of the lesion and a 54-month follow-up shows no evidence of recurrence. Oral mucosal melanomas are aggressive neoplasms that may arise from prior pigmented lesions in the oral mucosa. Classification of these tumors is not well-established and the main prognostic factor appears to be lymph node compromise. The main treatment modality is surgical resection.

[Photodynamic therapy in dermatology: basic principles]. / Terapia fotodinâmica em dermatologia: princípios básicos e aplicações.

Photodynamic therapy involves the administration of a photosensitizing drug and its subsequent activation by light at wavelengths matching the absorption spectrum of the photosensitizer. Currently, topical photodynamic therapy has received approval for the treatment of cutaneous oncologic conditions such as actinic keratoses, Bowen's disease and superficial basal cell carcinoma in many countries in the world. Multicenter randomized controlled studies have demonstrated high efficacy and superior cosmetic outcome over standard therapies. For many non-oncologic dermatological diseases such as acne vulgaris, viral warts and localized scleroderma, case reports and small series have confirmed the potential of photodynamic therapy. After the development of topical photosensitizers 5-aminolevulinic acid (ALA) or its methyl ester (MAL), photodynamic therapy has gained worldwide popularity in dermatology, as these drugs do not induce prolonged phototoxicity as the systemic photosensitizing hematoporphyrin derivatives do. The production of reactive oxygen intermediates such as singlet oxygen depends on the concentration and localization of the photosensitizer in the diseased tissue as well as the applied light dose. Either incoherent lamps or LED arrays are suitable for the cytotoxic effects resulting in tumor destruction or immunomodulatory effects improving inflammatory condition.

Accuracy of store-and-forward diagnosis in leprosy.

Telemedicine might increase the speed of diagnosis for leprosy and reduce the development of disabilities. We compared the accuracy of diagnosis made by telemedicine with that made by in-person examination. The cases were patients with suspected leprosy at eight public health clinics in outlying areas of the city of São Paulo. The case history and clinical examination data, and at least two clinical images for each patient, were stored in a web-based system developed for teledermatology. After the examination in the public clinic, patients then attended a teaching hospital for an in-person examination. The benchmark was the clinical examination of two dermatologists at the university hospital. From August 2005 to April 2006, 142 suspected cases of leprosy were forwarded to the website by the doctors at the clinics. Of these, 36 cases were excluded. There was overall agreement in the diagnosis of leprosy in 74% of the 106 remaining cases. The sensitivity was 78% and the specificity was 31%. Although the specificity was low, the study suggests that telemedicine may be a useful low-cost method for obtaining second opinions in programmes to control leprosy.

High numbers of human skin cancers express MMP2 and several integrin genes.

BACKGROUND: Basal cell carcinomas (BCC), squamous cell carcinomas (SCC) and cutaneous malignant melanoma (MM) are solid skin cancers derived from different cell types, with different ability to metastasize. Several subtypes of integrins and matrix metalloproteinases (MMP) have been related to malignization and metastasis processes. This work aimed at a quantitative evaluation of skin cancers expressing eight integrins and MMP2 genes. METHODS: Expression of integrins and MMP2 genes was evaluated on fresh tumor biopsies from BCC, SCC and MM, and respective controls, by the reverse transcriptase polychain reaction (RT-PCR) technique. RESULTS: More than 90% tumors expressed alpha6a, beta1, beta3 and beta6 (non-melanoma), and alpha5a, alpha6a and MMP2 (MM). Up to 100% controls also expressed beta1 and beta3. The results were significant for alpha6a in BCC (p = 0.026), alpha6b in SCC (p = 0.035), alpha2a in BCC (p = 0.003), beta5 and beta6 in BCC (p = 0.005). MMP2 was expressed in 100% MM (p = 0.0004). CONCLUSION: Integrin subunits alpha2a and alpha6a would be interesting targets for BCC anti-tumor therapy, as well as alpha6b in case of SCC. The elevated number of BCC expressing alpha2 and alpha6, and of MM expressing alphav and MMP2, corroborate literature data.

Nucleolar organizer region staining patterns in paraffin-embedded tissue cells from human skin cancers.

BACKGROUND: Increased number of nucleoli (nucleolar organizer regions, NORs) with abnormal shapes and sizes, including small dots, has been used as prognostic tools to evaluate tumor proliferation levels and troublesome borderline lesions. In this study, NOR patterns of skin cancers were performed in the search of a valuable prognostic method to complement other histological procedures. METHODS: Paraffin-embedded tumor tissue was obtained from basal and squamous cell carcinomas, cutaneous malignant melanoma, premalignant lesions, and Skmel-28 human melanoma cells. Slices were dewaxed and AgNOR stained. The patterns were scored and submitted for statistical analyses. RESULTS: All types of cancer cells showed variable numbers of abnormally shaped nucleoli and dot-like structures. Only tumor cells presented four or more nucleoli, with or without dots, while 85% of the normal cells had one single NOR without dots. Most data were statistically significant when compared to normal cells. As a whole, squamous cell carcinoma and malignant melanoma tumor cells had less NOR alterations than basal cell carcinoma (BCC) tumor types. CONCLUSIONS: Changes in the number and shape of nucleoli present in malignant cells could be attributed to increased levels on rDNA transcription on cancer cells, besides abnormal remodeling of chromatin, which could disrupt proper nucleoli association. Increased genetic alterations on malignant basal cells could contribute to impair invasive and migration abilities of BCC tumors.

Nucleolar organizer region staining patterns in paraffin-embedded tissue cells from human skin cancers

Increased number of nucleoli (nucleolar organizer regions, NORs) with abnormal shapes and sizes, including small dots, has been used as prognostic tools to evaluate tumor proliferation levels and troublesome borderline lesions. In this study, NOR patterns of skin cancers were performed in the search of a valuable prognostic method to complement other histological procedures.All types of cancer cells showed variable numbers of abnormally shaped nucleoli and dot-like structures. Only tumor cells presented four or more nucleoli, with or without dots, while 85% of the normal cells had one single NOR without dots. Most data were statistically significant when compared to normal cells. As a whole, squamous cell carcinoma and malignant melanoma tumor cells had less NOR alterations than basal cell carcinoma (BCC) tumor types.Changes in the number and shape of nucleoli present in malignant cells could be attributed to increased levels on rDNA transcription on cancer cells, besides abnormal remodeling of chromatin, which could disrupt proper nucleoli association. Increased genetic alterations on malignant basal cells could contribute to impair invasive and migration abilities of BCC tumors.

Repetitive DNA alterations in human skin cancers.

Repetitive sequences constitute landmarks for genome regulation, evolution, and chromatin architecture. Patterns of specific and non-specific repetitive sequences change in many types and stages of tumor cells, characterized by band loss, gain, and (de) increased staining of pre-existing bands. In this work, repetitive DNA was studied in search of genome instability of skin cancers: basal and squamous cell carcinomas (BCC and SCC), malignant melanoma (MM), melanocytic nevus (MN), and actinic keratosis (AK) lesions. DNAs were extracted from blood and tumor samples from 21 BCC, 7 SCC, 11 MM and 7 lesions. Banding patterns were obtained by random amplification of polymorphic DNA (RAPD), and specific D9S50 and D9S52 microsatellites (9p21). D9S50 patterns revealed microsatellite instability (MSI) and/or loss of heterozygosity (LOH) in 36% BCC, 25% SCC, and 57% MM tumors. D9S52 microsatellite showed 28.5%; 42.8%; and 71.4% altered tumors, respectively. No microsatellite alterations were found in MN and AK. On the other hand, genomic rearrangements detected by RAPD were present in 100% tumors. In BCC, the mean number of tumor DNA alterations showed predominant gain of bands. On the contrary, MM samples presented loss, or decreased intensity signal of RAPD bands. Genome alterations in skin cancers would result from chromosomal rearrangements, aneuploidy and/or polysomies. The low-cost and quick RAPD technique may reveal unknown genes or DNA sequences associated with tumor development and progression, and may be easily implemented in clinical diagnosis.

HPV typing in Brazilian patients with epidermodysplasia verruciformis: high prevalence of EV-HPV 25.

BACKGROUND: Epidermodysplasia verruciformis is a rare genetic disorder characterized by development of lesions associated with HPV#5 or HPV#8 in early childhood; malignant transformation occurs in approximately half of individuals during adulthood. OBJECTIVE: Our goal was to study the presence and spectrum of EV-HPV types in Brazilian EV patients, a population that had never been studied in this regard. PATIENTS AND METHODS: Forty-one biopsies from different lesions (benign and skin tumors) and one biopsy from clinically normal skin from each of 20 Brazilian patients with EV were studied for HPV typing using nested PCR. RESULTS: EV-HPV DNA was detected in all 41 skin lesions of the patients and was also identified in specimens considered as normal skin from 8 patients (40%). In this study HPV-EV 25 was the most prevalent (70%), and HPV 14d (67%) was highly associated with malignant lesions. CONCLUSION: EV-HPV 25 was the most prevalent in our study. The noteworthy association of EV-HPV type 14d with skin cancers suggests its possible oncogenic role in malignant transformation in this population.