Survey on Resident Education for Surgical Dermatology in South Korea.

BACKGROUND: With the increasing demand for surgical procedures in dermatology, resident education in surgical dermatology has become important for delivering high-quality treatment. However, it remains unclear if a sufficient number of residency programs with quality standards exist, as there has been little research on this subject in South Korea. OBJECTIVE: To identify the status of surgical dermatology education among residents and assess dermatologists' perceptions of the subject. METHODS: A 35-question survey was developed and distributed to all resident training hospitals and local clinics listed by the Korean Society of Dermatologic Surgery. Only third- and fourth-year residents were included and board-certified specialists from training hospitals and local clinics responded to the surveys. RESULTS: Survey participants included 88 residents and 120 specialists of whom one-quarter of the residents attended regular monthly educational sessions. Most residents (93%) participated in cosmetic procedures, and many performed laser therapy. However, the opportunity for toxin or filler injection was rare, with only 12% of the residents having experience with filler injections. In response, 49% of residents and 32% of specialists said that more cosmetic training was required, whereas 28% of residents and 50% of specialists said that more training for both cosmetic and conventional surgeries was necessary. CONCLUSION: The survey demonstrated a need for more training programs in surgical dermatology during residency and a perception gap between residents and specialists. Therefore, developing educational residency programs that focus on basic dermatologic surgery principles and their applications in cosmetic procedures is essential.

Evaluating a combination treatment of NK cells and reovirus against bladder cancer cells using an in vitro assay to simulate intravesical therapy.

Intravesical treatment using either reovirus or natural killer (NK) cells serves as an efficient strategy for the treatment of bladder cancer cells (BCCs); however, corresponding monotherapies have often shown modest cytotoxicity. The potential of a locoregional combination using high-dose reovirus and NK cell therapy in an intravesical approach has not yet been studied. In this study, we evaluated the effectiveness of reoviruses and expanded NK cells (eNK) as potential strategies for the treatment of bladder cancer. The anti-tumor effects of mono-treatment with reovirus type 3 Dearing strain (RC402 and RP116) and in combination with interleukin (IL)-18/-21-pretreated eNK cells were investigated on BCC lines (5637, HT-1376, and 253J-BV) using intravesical therapy to simulate in vitro model. RP116 and IL-18/-21-pretreated eNK cells exhibited effective cytotoxicity against grade 1 carcinoma (5637 cells) when used alone, but not against HT-1376 (grade 2 carcinoma) and 253J-BV cells (derived from a metastatic site). Notably, combining RP116 with IL-18/-21-pretreated eNK cells displayed effective cytotoxicity against both HT-1376 and 253J-BV cells. Our findings underscore the potential of a combination therapy using reoviruses and NK cells as a promising strategy for treating bladder cancer.

rhEGF Treatment Improves EGFR Inhibitor-Induced Skin Barrier and Immune Defects.

The mechanisms of epidermal growth factor (EGF) affecting EGF receptor inhibitor (EGFRI)-related skin toxicities are as yet unknown. We investigated which mechanisms are involved in EGF's positive effects. Two types of EGFRIs, cetuximab and gefitinib, were used to treat the cells or 3d-cultured human skin tissue with recombinant human EGF (rhEGF). As a result, rhEGF increased EGFR and pEGFR expression. Furthermore, rhEGF induces EGFR signaling by pAKT and pPI3K expression in gefitinib and rhEGF co-treated cells. In addition, rhEGF bound to EGFR after than cetuximab, but cetuximab bound to EGFR more strongly than rhEGF. Moreover, expressions of proliferation and differentiation proteins, both ki-67 and filaggrin, were decreased in EGFRI-treated tissue. However, in rhEGF and EGFRI co-treated tissue, those expressions were increased. Expression of IL-1α, IL-8, and TNF-α was increased by EGFRIs and down-regulated by rhEGF. Furthermore, hBD-2 and hBD-3 protein expressions were inhibited by cetuximab or gefitinib treatment, and those decrements were increased by rhEGF treatment. In patients' tissue evaluation, compared with controls, patients' Ki-67 and EGFR expression were decreased (p = 0.015, p = 0.001). Patients' IL-17 and TNF-α expression intensity was higher than that of the control group (p = 0.038, p = 0.037). After treatment with EGF ointment, average values of Ki-67, EGFR, and Melan-A were changed to normal values. Oppositely, patients' proportions of IL-17 and TNF-α were decreased to low stain level. In conclusion, treatment of rhEGF improved EGFRI-induced skin eruption via normalizing the proliferation and differentiation of keratinocytes, reducing inflammatory cytokines by the affected EGFRIs.

A Randomized Controlled Trial of Epidermal Growth Factor Ointment for Treating Epidermal Growth Factor Receptor Inhibitor-Induced Skin Toxicities.

BACKGROUND: The efficacy of epidermal growth factor (EGF) receptor (EGFR) inhibitors in patients with non-small cell lung cancer (NSCLC), pancreatic cancer (PC), or colorectal cancer (CRC) has been demonstrated. However, dermatological reactions to these inhibitors can cause significant physical and psychosocial discomfort. The objective of the present study was to evaluate the efficacy of EGF ointment for EGFR inhibitor-related skin adverse events (ERSEs). MATERIALS AND METHODS: This placebo-controlled, double-blind, multicenter, pilot phase III trial enrolled patients with NSCLC, PC, or CRC treated with EGFR inhibitors. Patients with grade ≥2 ERSEs were included. Patients were randomized to three treatment arms: arm 1, placebo; arm 2, 1 ppm of EGF ointment; and arm 3, 20 ppm of EGF ointment. Patients applied ointment to their skin lesions twice daily. RESULTS: Efficacy evaluation was available for 80 patients (9 for PC, 28 for NSCLC, and 43 for CRC). Responses were 44.4% in arm 1, 61.5% in arm 2, and 77.8% in arm 3. There was a linear correlation between EGF concentrations and responses (p = .012). Quality of life (QoL) was assessed for 74 patients. Maximum changes in composite scores by Skindex-16 after treatment were significantly different among arms (mean ± SD: -5.2 ± 8.6 for arm 1, -11.7 ± 14.2 for arm 2, and - 18.6 ± 17.7 for arm 3; p = .008). EGF arms showed significant improvement in emotions (p = .005) and functioning (p = .044) scores over the placebo arm. CONCLUSION: EGF ointment is effective for managing ERSEs. It can also improve patients' QoL compared with placebo. Clinical trial identification number. NCT02284139 IMPLICATIONS FOR PRACTICE: Patients with non-small cell lung cancer, pancreatic cancer, or colorectal cancer who are treated with epidermal growth factor (EGF) receptor (EGFR) inhibitors may experience dermatologic reactions to their treatment. This study investigated the benefit of an EGF ointment in the treatment of these adverse events and observed the ointment to be effective in managing EGFR inhibitor-related skin adverse events.

c-MYC Drives Breast Cancer Metastasis to the Brain, but Promotes Synthetic Lethality with TRAIL.

Brain metastasis in breast cancer is particularly deadly, but effective treatments remain out of reach due to insufficient information about the mechanisms underlying brain metastasis and the potential vulnerabilities of brain-metastatic breast cancer cells. Here, human breast cancer cells and their brain-metastatic derivatives (BrMs) were used to investigate synthetic lethal interactions in BrMs. First, it was demonstrated that c-MYC activity is increased in BrMs and is required for their brain-metastatic ability in a mouse xenograft model. Specifically, c-MYC enhanced brain metastasis by facilitating the following processes within the brain microenvironment: (i) invasive growth of BrMs, (ii) macrophage infiltration, and (iii) GAP junction formation between BrMs and astrocytes by upregulating connexin 43 (GJA1/Cx43). Furthermore, RNA-sequencing (RNA-seq) analysis uncovered a set of c-MYC-regulated genes whose expression is associated with higher risk for brain metastasis in breast cancer patients. Paradoxically, however, increased c-MYC activity in BrMs rendered them more susceptible to TRAIL (TNF-related apoptosis-inducing ligand)-induced apoptosis. In summary, these data not only reveal the brain metastasis-promoting role of c-MYC and a subsequent synthetic lethality with TRAIL, but also delineate the underlying mechanism. This suggests TRAIL-based approaches as potential therapeutic options for brain-metastatic breast cancer. IMPLICATIONS: This study discovers a paradoxical role of c-MYC in promoting metastasis to the brain and in rendering brain-metastatic cells more susceptible to TRAIL, which suggests the existence of an Achilles' heel, thus providing a new therapeutic opportunity for breast cancer patients.

Ablative fractional laser-assisted photodynamic therapy provides superior long-term efficacy compared with standard methyl aminolevulinate photodynamic therapy for lower extremity Bowen disease.

BACKGROUND: Ablative fractional laser (AFL)-assisted methyl aminolevulinate (MAL) photodynamic therapy (PDT) (AFL-MAL-PDT) has shown significantly higher efficacy and lower recurrence rates at 12 months than conventional methyl aminolevulinate photodynamic therapy (MAL-PDT) for the treatment of Bowen disease (BD). However, long-term follow-up data are not available. OBJECTIVE: To compare the 5-year efficacy and recurrence rates of AFL-MAL-PDT with those of conventional MAL-PDT for the treatment of lower extremity BD. METHODS: A total of 60 patients with 84 BD lesions were randomly assigned to a single session of AFL-MAL-PDT or 2 sessions of MAL-PDT with a 1-week interval between sessions. Patients were followed up at 3, 12, 24, 36, 48, and 60 months after treatment. Efficacy, recurrence rates, and risk factors for unsuccessful treatments were assessed. RESULTS: After 5 years, the overall clearance rate of AFL-MAL-PDT (84.78%) was significantly better than that of MAL-PDT (44.74%) for BD lesions. The recurrence rate was significantly lower for AFL-MAL-PDT (9.3%) than for MAL-PDT (41.38%). Diameters larger than 20 mm and lesions with a history of previous treatment were independent factors for treatment failure. LIMITATIONS: The small sample size and single-center study design were limitations. CONCLUSIONS: For patients with lower extremity BD lesions, AFL-MAL-PDT showed significantly higher long-term efficacy and lower recurrence rates than standard MAL-PDT.

Clinical features and prognosis of Asian patients with acral lentiginous melanoma who have nodal nevi in their sentinel lymph node biopsy specimen.

BACKGROUND: Nodal melanocytic nevi (NNs) encountered during sentinel lymph node biopsy (SLB) for malignant melanoma are usually difficult to distinguish from metastatic melanoma. However, NNs have not been well studied in acral lentiginous melanoma (ALM) in Asian populations. OBJECTIVE: To investigate the clinical characteristics and significance of NNs in SLB specimens from patients with ALM. METHODS: We retrospectively analyzed 84 patients with ALM who underwent SLB between June 2010 and July 2017. RESULTS: Of the 84 patients with ALM, 9 (10.7%) had NNs in their SLB specimens. NNs were significantly more common in SLB specimens than in specimens not obtained by SLB. The presence of pre-existing melanocytic lesions was found to be associated with NNs (P < .001). The 5-year overall survival was significantly higher in patients with ALM with NNs than in patients with a positive SLB result (P = .047). Distant recurrence in patients with ALM with NNs was significantly lower than in patients a positive SLB result (P = .03). LIMITATIONS: The small sample size, single-center study design, and retrospective nature of the study were the limitations. CONCLUSION: In Asian populations, the prevalence of NNs in ALM is similar to that reported in Europe and the United States. The rates of distant recurrence and overall survival in patients with ALM who have NNs are similar to those of patients who do not have metastatic melanoma.

Comparison of the content of tobacco alkaloids and tobacco-specific nitrosamines in 'heat-not-burn' tobacco products before and after aerosol generation.

Standardized methods for collecting smoke and for measuring smoke components in heat not burn tobacco product (HTP) are yet to be established, and there is a lack of consensus as to whether the content of HTP cigarettes can be assayed in the same manner as for conventional cigarettes. Since HTPcigarettes do not generate ash when smoked, we compared the levels of tobacco alkaloids (TAs) and tobacco-specific nitrosamines (TSNAs) of HTP cigarettes before and after aerosol generation. HTP cigarettes were smoked according to two international standardization methods. The TAs and TSNAs contents of the cigarettes were analyzed by UPLC-Q-TOF and UPLC-MSMS, respectively. Smoking was found to significantly decrease the content of nicotine, nornicotine, anatabine, and anabasine by 53 ∼ 100% in all samples, and the maximum inhalable amounts of these entities were determined to be 4.24 mg/cig, 103.52 µg/cig, 258.72 µg/cig, and 33.03 µg/cig, respectively. By contrast, smoking significantly increased the content of NNK and NAB. we suggested that the reduced nicotine content minus the nicotine content remaining in the filter is an amount that could potentially be inhaled during smoking. The increase of NNK and NAB in HTP cigarette after aerosol generation is expected to be caused by the precursor, but more specific behavioral studies should be performed.

Investigation of Health Effects According to the Exposure of Low Concentration Arsenic Contaminated Ground Water.

Recent epidemiological studies have reported adverse health effects, including skin cancer, due to low concentrations of arsenic via drinking water. We conducted a study to assess whether low arsenic contaminated ground water affected health of the residents who consumed it. For precise biomonitoring results, the inorganic (trivalent arsenite (As III) and pentavalent arsenate (As V)) and organic forms (monomethylarsonate (MMA) and dimethylarsinate (DMA)) of arsenic were separately quantified by combining high-performance liquid chromatography and inductively coupled plasma mass spectroscopy from urine samples. In conclusion, urinary As III, As V, MMA, and hair arsenic concentrations were significantly higher in residents who consumed arsenic contaminated ground water than control participants who consumed tap water. But, most health screening results did not show a statistically significant difference between exposed and control subjects. We presume that the elevated arsenic concentrations may not be sufficient to cause detectable health effects. Consumption of arsenic contaminated ground water could result in elevated urinary organic and inorganic arsenic concentrations. We recommend immediate discontinuation of ground water supply in this area for the safety of the residents.

Case-control study of chronic low-level exposure of inorganic arsenic species and non-melanoma skin cancer.

A significant relationship between arsenic exposure and non-melanoma skin cancer (NMSC) is well known. The toxicity of arsenics which develop NMSC is dependent on their species. Accordingly, total arsenic levels are unreliable for risk assessment of NMSC. However, there are few studies on quantitative exposure assessment of arsenic species in NMSC patients. To validate the contribution of each arsenic species to NMSC, we compared the creatinine-adjusted urinary concentration of arsenic species in NMSC patients and community controls. A total of 124 biopsy-proven NMSC cases and 125 age- and sex-matched community controls, drinking tap water with low-level arsenic concentration (<5 µg/L), were included in the study. High-performance liquid chromatography and inductively coupled plasma mass spectrometry were used for the measurement. The NMSC group was found to have significantly higher levels of total inorganic arsenic, trivalent and pentavalent arsenic and monomethylarsonic acid than the control group. Total arsenic, organic arsenic and dimethylarsonic acid levels were lower in the NMSC group. We suggest that inorganic arsenic species, trivalent arsenic and pentavalent arsenic may influence the prevalence of NMSC, in spite of these levels being lower than the Agency for Toxic Substances and Disease Registry-recommended standard or the levels reported by other highly contaminated areas and neighboring countries in East Asia. Furthermore, it also suggests that total arsenic level cannot represent the risk of NMSC.

Variations in the concentrations of heavy metals through enforcement of a rest-year system and dredged sediment capping at the Yellow Sea-Byung dumping site, Korea.

In 2014, the concentrations of 13 heavy metals in surface sediments from 14 sampling stations were analyzed and compared to samples from previous years to evaluate the remediation effectiveness of the "rest-year" (RY) system and capping with dredged material at the Yellow Sea-Byung dumping site offshore Korea. Since the 2006 introduction of the RY system, annual variations in metal concentrations at stations within the RY zone have gradually decreased over time. Heavy metal concentrations at most stations were lower than sediment quality guidelines, indicating the success of the RY system. Additionally, the effects of capping the contaminated sediment with dredged materials were investigated. The results indicate that dredged materials successfully capped the contaminated sediment within the dredged material dumping area, as the concentrations of Cr and total organic carbon were significantly reduced. We conclude that dredged materials may be used as capping materials for the remediation of contaminated sediments.

Antibody targeting intracellular oncogenic Ras mutants exerts anti-tumour effects after systemic administration.

Oncogenic Ras mutants, frequently detected in human cancers, are high-priority anticancer drug targets. However, direct inhibition of oncogenic Ras mutants with small molecules has been extremely challenging. Here we report the development of a human IgG1 format antibody, RT11, which internalizes into the cytosol of living cells and selectively binds to the activated GTP-bound form of various oncogenic Ras mutants to block the interactions with effector proteins, thereby suppressing downstream signalling and exerting anti-proliferative effects in a variety of tumour cells harbouring oncogenic Ras mutants. When systemically administered, an RT11 variant with an additional tumour-associated integrin binding moiety for tumour tissue targeting significantly inhibits the in vivo growth of oncogenic Ras-mutated tumour xenografts in mice, but not wild-type Ras-harbouring tumours. Our results demonstrate the feasibility of developing therapeutic antibodies for direct targeting of cytosolic proteins that are inaccessible using current antibody technology.

The Contributory Roles of Th17 Lymphocyte and Cytotoxic T Lymphocyte at the Hair Bulge Region as Well as the Hair Bulb Area in the Chronic Alopecia Areata Patients.

BACKGROUND: Alopecia areata (AA) is a T cell-mediated autoimmune disease that targets hair follicles and interrupts hair regrowth. The microenvironment of the effector T cells and their related cytokines may affect immunopathogenesis around the hair bulb/bulge. OBJECTIVE: To determine the contributory roles of the effector T cell subsets and related cytokines to the pathogenesis of AA. METHODS: We investigated the correlation between histopathological grades and four clinical prognostic factors in 331 patients with AA, and analyzed the topography of T cell infiltrates and related cytokines around the hair bulb/bulge according to histopathological grades through immunohistochemical and double immunofluorescence studies on a subset of AA specimens. RESULTS: First, the groups with more severe histopathological grades were associated with earlier onset, longer duration, more hair loss, as well as poorer therapeutic outcomes. Second, the pattern of CD4 and CD8 expression around the hair bulb/bulge varied by histopathological grade, with staining density decreasing in the following order: type 1>type 2>type 3. In addition, interferon-γ and transforming growth factor-ß1 expression appeared denser in the peribulbar area. Interestingly, the denser CCR6+ cells (Th17 cells) showed more infiltration than CCR5+ cells (Th1 cells) around the hair bulb/bulge as histopathological grade worsened. CONCLUSION: The insidious destruction of bulge stem cells and hair bulb matrix stem cells results in more severe hair loss in patients with chronic AA, which is mediated by Th17 lymphocyte and cytotoxic T lymphocyte infiltration. Furthermore, Th17 lymphocytes may play an even more important role than cytotoxic T cells in the development of AA.