NY-ESO-1 and CTp11 expression may correlate with stage of progression in melanoma.

BACKGROUND: As tumor cells spread beyond their primary site they undergo changes in their gene expression that may be detectable and useful for microstaging. The cancer/testis (CT) antigens are a family of proteins that include MAGE 1-3, NY-ESO-1, SSX 1-5, and others that are potential markers for microstaging melanoma. CT antigens are produced by many tumor types but few normal tissues other than testis. One CT antigen, CTp11, was shown to be expressed by metastasizing melanoma cell lines but not by nonmetastasizing variants. We tested this finding by studying the expression of CTp11 and NY-ESO-1 by melanoma samples from different stages of progression. MATERIALS AND METHODS: We collected 20 primary, 22 locoregional, and 10 distant metastatic melanoma samples. We extracted total RNA, and reverse transcription yielded cDNA, which was PCR-amplified using primers to detect beta-actin, tyrosinase, MART-1, NY-ESO-1, and CTp11. The PCR products were separated on ethidium bromide-stained agarose gels and visualized by UV transillumination. RESULTS: All samples were positive for beta-actin and MART-1 and all but two were positive for tyrosinase, confirming RNA integrity and the presence of melanoma. Twenty-seven samples were positive for NY-ESO-1, CTp11, or both. CTp11 tended to be expressed by primary melanomas and NY-ESO-1 by metastatic samples (P < 0.02). CONCLUSIONS: There is a statistically significant difference in the distribution of the expression of CTp11 and NY-ESO-1 in melanoma from different stages of progression. NY-ESO-1 may be a marker of more advanced disease and CTp11 of less advanced disease.

A molecular technique useful in the detection of occult metastases in patients with melanoma : rt-PCR analysis of sentinel lymph nodes and peripheral blood.

When cutaneous melanoma is confined to the skin, simple excision with adequate margins will usually cure the patient (1,2). Local recurrences do occur but reexcision still results in a very high cure rate. When cutaneous melanoma spreads beyond the primary site, the metastases are predominantly by way of the lymphatics. If in-transit disease or regional lymph node involvement is present, the 5-yr survival rate drops to approx 60% (1-3). Accurate staging of the locoregional lymphatic basin is thus extremely important. Pre- operative lymphoscintigraphy followed by selective lymphadenectomy has revolutionized the staging of cutaneous melanoma by delivering to the pathologist only those nodes that are most likely to contain metastatic cells (4). A close examination of these sentinel lymph nodes (SLNs) by serial sectioning and immunohistochemical staining can detect very minute quantities of melanoma. This type of detailed examination is impossible in standard lymphadenectomy specimens that can contain 20-40 lymph nodes. The standard technique used to examine large numbers of lymph nodes is to examine only 1-5% of each node using hematoxylin and eosin staining. This can obviously miss micrometastatic disease and understage the patient.

Lymphatic mapping and intraoperative lymphoscintigraphy for identifying the sentinel node in penile tumors.

Lymph node mapping has become an integral part of the management of melanoma and breast cancer with regard to both staging and treatment. We report our technique for lymphatic mapping and intraoperative lymphoscintigraphy applied to a patient with penile melanoma. This technique may improve the sensitivity of identifying the sentinel lymph node in patients with malignant penile lesions.

Use of sentinel node lymphoscintigraphy in malignant melanoma.

Lymphoscintigraphy is a sensitive, inexpensive, relatively noninvasive method of identifying lymphatic drainage patterns and sentinel lymph nodes in patients with malignant melanoma. Lymphoscintigraphy with filtered technetium-99m sulfur colloid allows prompt visualization of the lymphatic system, produces high-quality images, and delivers a low radiation dose to the patient. In addition, good regional lymph node retention is seen with filtered Tc-99m sulfur colloid, improving the success rate of intraoperative gamma probe localization. In combination with surgical localization, lymphoscintigraphy allows preoperative and intraoperative identification of the sentinel node in patients with intermediate thickness melanomatous lesions, obviating radical lymph node dissection in most patients and possibly prolonging their survival. Variables such as tumor location, type and preparation of radiopharmaceutical, injection technique, imaging technique, and prior surgical intervention influence the efficacy of lymphoscintigraphy. Nevertheless, lymphoscintigraphy is recommended as a cost-effective preoperative procedure in all patients planning to undergo elective lymph node dissection. Because of the unpredictability of lymphatic drainage, preoperative scintigraphic findings may lead to changes in surgical management.

Minimally invasive staging of patients with melanoma: sentinel lymphadenectomy and detection of the melanoma-specific proteins MART-1 and tyrosinase by reverse transcriptase polymerase chain reaction.

BACKGROUND: A minimally invasive standard has yet to be developed for sentinel lymphadenectomy, and many patients undergo this procedure in the main operating room under general anesthesia. These patients often have microscopic metastases in sentinel nodes that could be missed by histopathologic examination. Techniques of reverse transcriptase polymerase chain reaction (RT-PCR) could detect these metastases if the nodes could be preserved intraoperatively. STUDY DESIGN: Fifty patients with melanoma > or = mm thick underwent sentinel lymphadenectomy under local anesthesia in an outpatient surgical unit. Sentinel nodes were identified using blue dye and technetium-99 sulfur colloid and a hand-held gamma probe. Each node was sectioned, with half sent for routine histopathologic study and half preserved in liquid nitrogen. We used RT-PCR to detect mRNA for tyrosinase and Melanoma Antigen Recognized by T cells-1 (MART-1). RESULTS: All patients were able to tolerate sentinel lymph node biopsy under local anesthesia. Sentinel lymph nodes were obtained in 100% of our patients, and usable mRNA was harvested from all but five. Ten patients had positive sentinel node(s) by standard histopathologic examination, and all of these nodes were also positive for MART-1 and tyrosinase. Three patients with negative results by histopathology had positive results by RT-PCR analysis. The average cost of these outpatient operations was 38% less than the same operations performed in the main operating room under general anesthesia. CONCLUSIONS: Sentinel lymphadenectomy under local anesthesia in an outpatient setting and intraoperative lymph node preservation in liquid nitrogen are both feasible. Both tyrosinase and MART-1 are promising markers in the detection of occult melanoma in lymph nodes.

Sentinel lymph node mapping in melanoma of the ear.

Primary nodal drainage basins in melanoma of the head and neck are often unpredictable. The ear is a notorious example of an anatomic site with ambiguous patterns of lymphatic drainage. Preoperative lymphoscintigraphy has recently emerged as one modality to assist in identifying clinically relevant nodes. We propose that the addition of intraoperative lymph node mapping techniques that utilize radioactive tracers ("intraoperative lymphoscintigraphy") can increase the accuracy of identifying sentinel nodes and help to determine which patients may benefit from a complete neck dissection. This report demonstrates the ambiguity in identifying drainage patterns in melanoma of the ear and offers a reliable method of sentinel lymph node mapping. This report also addresses current issues regarding treatment protocols of patients with micrometastatic disease in the periauricular region.

Marked elevation of serum interleukin-6 in patients with cholangiocarcinoma: validation of utility as a clinical marker.

OBJECTIVE: To determine if the serum level of interleukin-6 (IL-6) was elevated in patients with hepatic malignancies or correlated with radiologic tumor burden. SUMMARY BACKGROUND DATA: High serum levels of IL-6 signify an adverse prognosis in many patients with cancer. IL-6 is a growth factor for bile duct epithelium. METHODS: Using bioactive and enzyme-linked immunosorbent assays, serum level of IL-6 was measured in 35 healthy adults and in 60 patients presenting for definitive management of cholangiocarcinoma (CC) (15 patients), hepatocellular carcinoma (HCC) (14), metastatic colorectal cancer (MCRC) (26), and benign biliary disease (BBD) (5). Patients with clinical conditions known to raise the serum level of IL-6 were excluded. Tumor burden was calculated from concurrent computed tomography scans. IL-6 levels were measured 2 weeks after resection in 3 CC patients. Secretion of IL-6 was examined in 3 human CC cell lines. RESULTS: An elevated level of bioactive IL-6 was detected in every patient with CC and in 13 of 14 patients with HCC, 14 of 26 patients with MCRC, 2 of 5 patients with BBD, and 3 of 35 healthy adults. Median and mean levels of bioactive IL-6 were higher in CC than in other neoplasms (p < 0.026) and for all tumor groups differed from healthy adults (p < or = 0.026). IL-6 level was elevated more often in primary than in secondary liver neoplasms (p = 0.02), distinguished patients with CC or MCRC from BBD (p = 0.014 and 0.031, respectively), correlated with tumor burden in CC (p < 0.001), and dropped sharply after CC resection. CC line SG231 secreted bioactive IL-6. CONCLUSIONS: In selected patients, a high serum level of IL-6 marks patients with CC and correlates with tumor burden both before and after resection. IL-6 levels are elevated in patients with other liver neoplasms and may distinguish patients with hepatic malignancies from those with benign disease.

A phase I trial of a synthetic mucin peptide vaccine. Induction of specific immune reactivity in patients with adenocarcinoma.

We tested a 105 amino acid synthetic mucin MUC-1 peptide that has 5 repeated immunodominant epitopes to evaluate toxicity and detect mucin-specific immune responses in patients with adenocarcinoma. We also studied the enhancement of these responses by vaccinating patients with the synthetic mucin peptide admixed with BCG. Mucins are glycoproteins present on the luminal surface of ductal epithelial cells and on tumors derived from them. The MUC-1 mucin is hypoglycosylated and nonpolarized on tumors and this exposes epitopes that can stimulate cytotoxic T-Cells (CTL). We vaccinated 63 patients with 100 micrograms of the 105aa mucin peptide mixed with BCG. Two additional vaccinations were given at 3-week intervals. All patients were able to tolerate vaccination, with most experiencing local ulceration at the vaccination site. All patients underwent hypersensitivity (DTH) testing with the 105aa and shorter mucin peptides, prior to vaccination. DTH responses were evaluated at 48 hr and the sites of highest peptide concentration were biopsied. Only 3 patients had a strong skin response to the long peptide. Examination of 55 biopsies showed intense T-Cell infiltration in 37 patients and lesser infiltration in 7. Seven of 22 patients tested had a 2- to 4-fold increase in mucin-specific CTLp. Serum levels of IL-6 were measured sequentially using the B9 hybridoma bioassay. Increasing serum levels of IL-6 correlated with constitutional symptoms (significance 0.001) and hypoalbuminemia (significance 0.007) but not with the extent of skin breakdown at vaccination sites. We conclude that mucin vaccination is safe and might serve to enhance specific responses to tumor antigens. IL-6 may be responsible for the constitution symptoms and hypoalbuminemia in these patients.

Unrecognized pertussis infection in adolescents.

Little information is available regarding the level of immunity to Bordetella pertussis among adolescents. We measured serum antibodies in 156 healthy adolescents to the following pertussis antigens: pertussis toxin, filamentous hemagglutinin, and 69-kd outer membrane protein. In an attempt to identify intercurrent pertussis infections, we also obtained a total of 43 repeated samples during the following 5 years. Using a 50% or greater rise in IgG enzyme-linked immunosorbent assay titers to define seroconversion, we found an annual incidence of 6.1%; by alternative definitions of seropositivity, the predicted annual incidence of infection ranged from 1.2% to 8.2%. These data suggest that infection with B pertussis is common in the adolescent population.

Optimal electrode location for monitoring the ECG and breathing in neonates.

Continuous monitoring of breathing in infants is commonly performed using transthoracic impedance. This method employs skin surface electrodes measuring changes in electrical impedance and relates these changes to respiratory events. Typically, two electrodes on the infant's chest monitor both the ECG and breathing. We have attempted to identify separate electrode locations that give the best signal for breathing and ECG, and a single location that optimizes both of these signals. Thirty-seven infants were studied by placing 12 electrodes on the infant's chest and abdomen, and serially sampling pairwise combinations of electrodes. The optimal signal for breathing was obtained when electrodes spanned the diaphragm. Optimal ECG signal was seen with one electrode at the right mid-clavicle and one at the xyphoid. Clinicians should be aware of these locations in order to provide the best signal available.