Metabolic reprogramming and angiogenesis in primary cutaneous Merkel cell carcinoma: expression of hypoxia-inducible factor-1α and its central downstream factors.

BACKGROUND: Metabolic reprogramming and altered gene expression mediated by hypoxia-inducible factors play crucial roles during tumour growth and progression. Nevertheless, studies analysing the expression of hypoxia-inducible factor-1α and its downstream targets in Merkel cell carcinoma (MCC) are lacking but are warranted to shed more light on MCC pathogenesis and to potentially provide new therapeutic options. OBJECTIVES: To analyse the immunohistochemical expression of hypoxia-inducible factor-1α (HIF-1α), vascular endothelial growth factor-A (referred to as VEGF throughout the manuscript), VEGF receptor-2 (VEGFR-2), VEGF receptor-3 (VEGFR-3), glucose transporter-1 (Glut-1), monocarboxylate transporter 4 (MCT4) and carbonic anhydrase IX (CAIX) in primary cutaneous MCC. METHODS: The 16 paraffin-embedded primary cutaneous MCCs (Merkel cell polyomavirus (McPyV) positive/negative: 11/5) were analysed by immunohistochemistry, namely HIF-1α, VEGF, VEGFR-2 (KDR), VEGFR-3 (FLT4), Glut-1, MCT4 and CAIX. An established quantification score (QS) was applied to quantitate the protein expression by considering the percentage of positive tumour cells (0: 0%; 1: up to 1%; 2: 2-10%; 3: 11-50%; 4: >50%) in relation to the staining intensity (0: negative; 1: low; 2: medium; 3: strong). RESULTS: HIF-1α was expressed in all MCCs and predominantly found at the invading edges of tumour margins. The HIF-1α downstream factors Glut-1, MCT4 and CAIX were expressed in 13 of 16 MCC (81%), 14 of 16 MCC (88%) and 16 of 16 MCC (100%), respectively. Interestingly, VEGF and VEGFR-2 were not expressed in tumour cells, whereas VEGFR-3 was expressed in all MCCs. HIF-1α was expressed significantly stronger in McPyV+ tumours (QS: 10.36 ± 2.41) than in McPyV- tumours (QS: 5.40 ± 1.34; P = 0.002). Similarly, VEGFR-3 was also expressed significantly stronger in McPyV+ tumours (QS: 10.00 ± 2.52) than in McPyV- tumours (QS: 5.40 ± 3.43, P = 0.019). CONCLUSIONS: Our data provide first evidence for a role of HIF-1α in induced metabolic reprogramming contributing to MCC pathogenesis. The metabolic signatures of McPyV+ and McPyV- tumours seem to show relevant differences.

[Nonviral sexually transmitted infections-epidemiology, clinical manifestations, diagnostic workup, therapy : Part 3: Treponemes, Gardnerella and trichomonads]. / Nichtvirale sexuell übertragene Infektionen ­ Epidemiologie, Klinik, Labordiagnostik und Therapie : Teil 3: Treponemen, Gardnerella und Trichomonaden.

In Germany, the reported syphilis prevalence has increased continuously since 2010, with a total of 6834 syphilis cases being reported in 2015. The largest increase of reported syphilis occurred in men who have sex with men (MSM). The antibiotic agent of choice for treatment of syphilis is still penicillin. There are no penicillin-resistant Treponema pallidum strains. Alternatives are ceftriaxone and doxycycline. In Germany, azithromycin is not approved for treatment of syphilis; however, therapy failures are increasingly reported. Bacterial vaginosis is accompanied by vaginal discharge. The vaginal secretion exhibits an increased pH value higher than 4.5. Clinical symptoms are pruritus, burning, and the characteristic amine odor. The probability for bacterial vaginosis is highest in women with higher numbers of sexual partners, unmarried women, early first sexual intercourse, in commercial female sex workers, and those women who regularly apply vaginal douches. The main pathogen of bacterial vaginosis is Gardnerella vaginalis. For oral therapy metronidazole is given, alternatively clindamycin; the latter should be applied additionally as topical agent. Trichomoniasis is considered as the nonviral sexually transmitted infection with the highest prevalence worldwide. Other than direct microscopic detection of the protozoa (trophozoites) in vaginal secretion or urine, PCR has been approved as the diagnostic method with the highest sensitivity. Oral metronidazole represents the therapy of choice in trichomoniasis.

[Non-viral sexually transmitted infections - Epidemiology, clinical manifestations, diagnostics and therapy : Part 1: Gonococci]. / Nichtvirale sexuell übertragene Infektionen ­ Epidemiologie, Klinik, Labordiagnostik und Therapie : Teil 1: Gonokokken.

Approximately 1 million people are infected per day worldwide by one or more sexually transmitted infections (STI) as estimated by the World Health Organization (WHO). Gonorrhoea represents an almost exclusively sexually transmitted infection, which predominantly affects mucous membranes of the genitourinary tract. Extragenital localization of infections is also possible, e. g. in the anorectal region. Currently, only syphilis and human immunodeficiency virus (HIV) are notifiable diseases according to the Infection Protection Act in Germany. In Saxony, an extended registration ordinance according to the German Infection Protection Act is in force, which means that besides syphilis the laboratory detection of Neisseria gonorrhoeae, Chlamydia trachomatis and genital mycoplasms are also notifiable infections. In particular, beginning in 2009 in Saxony a spectacular increase of registered infections due to N. gonorrhoeae was observed and in 2015 altogether 824 infections due to N. gonorrhoeae were reported. Alarming is the increase in resistance of N. gonorrhoeae against penicillin, doxycycline, ciprofloxacin and recently also against azithromycin and third generation cephalosporins. The so-called superbug of N. gonorrhoeae, which originated in Japan with multidrug resistance against most of the currently available oral antibiotics, has now arrived in Europe. Intramuscular or intravenous injection of ceftriaxone plus oral azithromycin, each given as single dose is the standard therapy for gonorrhoea.

[Non-viral sexually transmitted infections - Epidemiology, clinical manifestations, diagnostics and therapy : Part 2: Chlamydia and mycoplasma]. / Nichtvirale sexuell übertragene Infektionen ­ Epidemiologie, Klinik, Labordiagnostik und Therapie : Teil 2: Chlamydien und Mykoplasmen.

Chlamydia trachomatis is the most common pathogen of sexually transmitted bacterial infections worldwide. Every year in Germany approximately 300,000 new infections are to be expected. Chlamydia infections occur nearly exclusively in the postpubertal period. The peak age group is 15-25 years. The infection usually runs an asymptomatic course and the diagnosis is made by nucleic acid amplification techniques (NAAT) often after chlamydial screening or if complications occur. For treatment of chlamydial infections oral doxycycline 100 mg twice daily over 7 days is initially used or alternatively oral azithromycin 1.5 g as a single dose is recommended. The sexual partner should also be investigated and treated. Genital Mycoplasma infections are caused by Ureaplasma urealyticum (pathogen of urethritis and vaginitis), Ureaplasma parvum (mostly saprophytic and rarely a cause of urethritis) and Mycoplasma hominis (facultative pathogenic). Mycoplasma genitalium represents a relatively new sexually transmitted Mycoplasma species. Doxycycline is effective in Ureaplasma infections or alternatively clarithromycin and azithromycin. Doxycycline can be ineffective in Mycoplasma hominis infections and an alternative is clindamycin. Non-gonococcal and non-chlamydial urethritis due to Mycoplasma genitalium can now be diagnosed by molecular biological techniques using PCR and should be treated by azithromycin.

[Diagnosis of intestinal metastases from malignant melanoma]. / Diagnostik intestinaler Metastasen bei Malignem Melanom.

The small bowel harbors metastases of malignant melanoma in 5 % to 72 %, dependent on tumor stage and evidence of intestinal blood loss. Capsule endoscopy is sensitive in detecting small bowel metastasis. Computed tomography, magnetic resonance imaging, and PET-CT demonstrate extraintestinal intraabdominal metastases. Melanoma patients with signs of intestinal blood loss should be endoscopically investigated, including small bowel endoscopy. Selected patients in advanced tumor stage should also undergo small bowel endoscopy to plan a treatment strategy. A resection of intestinal metastases can improve the prognosis, if all metastases are removed.

P-cadherin expression in Merkel cell carcinomas is associated with prolonged recurrence-free survival.

BACKGROUND: Merkel cell carcinoma (MCC) is a highly aggressive skin cancer, associated with advanced age, immunosuppression and Merkel cell polyomavirus (MCV) infections. As development and progression of cancer can be promoted by changes in cell adhesion proteins, we have previously analysed homo- and heterotypic cell-cell contacts of normal Merkel cells and MCCs and obtained indications for cadherin switching. OBJECTIVES: To examine the prevalence and prognostic relevance of E-, N- and P-cadherin in MCCs. METHODS: Paraffin-embedded MCC samples (n = 148) from 106 different patients were analysed by double-label immunostaining and immunofluorescence microscopy. MCV status was determined by real-time polymerase chain reaction. The cadherin repertoire and MCV status were correlated to clinical data, including tumour stage and recurrence-free survival. RESULTS: Ninety-one per cent of all MCC were positive for N-cadherin whereas only 61·6% and 70·3% expressed E- and P-cadherin, respectively. P-cadherin was significantly more frequent in primary tumours than in lymph node metastases (81·9% vs. 40·9%, P = 0·0002). Patients with P-cadherin-positive primary tumours were in earlier tumour stages at initial diagnosis (P = 0·0046). Both in log-rank tests (P = 0·0474) and in multiple Cox regression analysis including age, sex, immunosuppression, stage at initial diagnosis and MCV status (hazard ratio 0·193, P = 0·0373), patients with P-cadherin-positive primary MCCs had significantly prolonged recurrence-free survival (mean 25·2 vs. 10·6 months; median 9·0 vs. 4·0 months). MCV DNA was detected in 78·2% of all MCC, more frequently in P-cadherin-positive MCC (P = 0·0008). CONCLUSION: P-cadherin expression in MCCs predicts prolonged recurrence-free survival and may therefore indicate favourable prognosis.

Algorithm for detection of small-bowel metastasis in malignant melanoma of the skin.

BACKGROUND AND STUDY AIM: The aim of this study was to develop an algorithm to detect small-bowel metastasis (SBM) of melanoma by sequential laboratory parameters and pan-intestinal endoscopy (PIE) including video capsule endoscopy (VCE). PATIENTS AND METHODS: A total of 390 melanoma patients (AJCC stage I/II/III/IV, 140/80/121/49) were screened for signs of intestinal blood loss (fecal occult blood test [FOBT] or overt bleeding) in an open, multicenter, prospective study, and those who were positive underwent PIE. Independent of the presence of intestinal bleeding, all stage IV patients were offered PIE. Follow-up was obtained in 357 patients (91.5 %) for a median of 16 months. We undertook to identify possible associations between SBM and clinical and laboratory data. Survival data were analyzed with regard to clinical and laboratory data and small-bowel findings. RESULTS: Intestinal blood loss was suspected in 49 of 390 patients (12.6 %), 38 of whom (77.6 %) agreed to undergo endoscopy. In 10 patients, SBM was detected by VCE (intention-to-diagnose, 20.4 %; AJCC III, n = 2; AJCC IV, n = 8). The SBM was resected in five patients. Total detection rates of SBM were 14 of 49 patients in stage IV (28.6 %, intention-to-diagnose), 2 of 121 in stage III (1.7 %), and 0 in stage I/II. In FOBT-positive patients, SBM detection rates were 72.7 %, 14.3 %, and 0 % in tumor stages IV, III, and I/II, respectively. Positive FOBT proved to be an independent negative prognostic factor for total survival in stage III and IV melanoma. CONCLUSIONS: SBMs are frequent in advanced melanoma. In stage III patients, screening for intestinal blood loss by PIE may help to identify SBMs. In stage IV, indication for PIE should depend on the individual consequences of detecting SBM, but not on bleeding symptoms alone.

[Merkel cell carcinoma: a highly aggressive tumor with possible viral etiology]. / Merkel-Zell-Karzinom: Ein hochaggressiver Tumor mit möglicher viraler Genese.

Merkel cell carcinoma (MCC) or neuroendocrine carcinoma of the skin, is a rare and highly aggressive tumor which typically develops in chronically sun-damaged skin in aged or immunosuppressed patients. The clinical course is characterized by early local recurrence and lymphatic metastases. The current discussion on the etiology of MCC is dominated by the recently discovered Merkel cell polyoma virus (MCPyV). Apparently, MCPyV infection takes place early in life and the virus can also be found in healthy tissue. Possibly, a mutation of the viral genome is responsible for the development of the tumor. The 5 year survival rate of patients with primary MCC is only 30-40% after surgical therapy alone but can increase to about 75% after additional adjuvant radiotherapy. In cases with lymphatic or distant metastases various chemotherapy protocols in addition to operative and radiation therapy analogous to those for small cell lung cancer therapy have been found to be effective. Nevertheless, very high recurrence rates are typical in patients with distant metastases. Thus, MCC is regarded as chemosensitive but not chemocurable.Patients with MCC should be treated with an aggressive but individually adapted concept. The consequent integration of radiotherapy into the therapeutic approach can improve the prognosis.

[Bilateral periorbital metastases of transtional cell carcinoma of the bladder]. / Bilaterale periorbitale Metastasen eines Urothelkarzinoms der Harnblase.

Bladder cancers account about 3% of malignant tumors and often metastasize to regional lymph nodes, liver, lungs and skeleton. Metastases in the area of the orbital region are very rare. When eyelid swelling, proptosis, diplopia, or ocular pain occurs, an underlying neoplastic process should always be suspected. Due to the rapid progression of orbital metastases, diagnosis and early initiation of palliative therapy is important.

[65-year-old man with yellow-orange papules on both forearms. Eruptive xanthomas]. / 65-jähriger Patient mit gelb-orange farbenen Papeln an beiden Unterarmen. Eruptive Xanthome.

A 65-year-old man presented with disseminated yellow-orange soft painless papules on both forearms. They had developed over the past five weeks. Clinical and laboratory investigations revealed secondary hyperlipidemia and diabetes mellitus Type 2a. Histology revealed dermal xanthomas consisting of foam cells, giant cells, and a sparse lymphocytic infiltrate. The patient was treated with a low fat, sugar free diet, as well as bezafibrate and metformin. The xanthomas resolved over six months.

[Acute generalized exanthematous pustulosis associated with recurrent urinary tract infections]. / Akute generalisierte exanthematische Pustulose bei rezidivierendem Harnwegsinfekt.

Acute generalized exanthematous pustulosis (AGEP) is characterized by sudden onset of non-follicular aseptic pustules with erythema often accompanied by fever and leukocytosis. While the most frequent cause of AGEP is drug reactions, especially antibiotics. Occasional cases have been described as parainfectious. An 82-year-old female presented with recurrent AGEP along with a chronic urinary infection with Escherichia coli. Her cutaneous findings resolved following antibiotic therapy and prophylaxis. To the bets of our knowledge, this is the first case of AGEP associated with an Escherichia coli urinary tract infection.

Deletions of BRCA1/2 and p53 R248W gain-of-function mutation suggest impaired homologous recombination repair in fragile histidine triad-negative sebaceous gland carcinomas.

BACKGROUND: Sebaceous gland carcinomas represent rare malignancies of the skin and some 60% of them demonstrate high-grade microsatellite instability on the background of a defective mismatch repair system. However, a significant fraction of periocular sebaceous gland carcinomas exhibits microsatellite stability associated with a frequent loss of the candidate tumour suppressor fragile histidine triad (FHIT). OBJECTIVES: We hypothesized that in those sebaceous gland carcinomas with microsatellite stability and loss of FHIT, effector molecules participating in homologous recombination repair (HRR), such as BRCA1/2, could be somatically inactivated. METHODS: A pilot series of 10 paraffin-embedded sebaceous gland carcinoma specimens with a defined FHIT status was studied for loss of heterozygosity (LOH) events in the genes BRCA1, BRCA2, FHIT and WWOX. We sequenced the coding exons 5-8 of the p53 gene. RESULTS: Sebaceous gland carcinomas with FHIT negativity displayed LOH and biallelic deletions of the BRCA1 gene in five of 10 (50%) of the sebaceous gland carcinoma specimens analysed. Tumour-specific genomic losses close to BRCA2 were also uncovered. A homozygous p53 R248W gain-of-function mutation as the result of a CGG to TGG transition was identified in one of seven sebaceous gland carcinomas. It has been demonstrated previously that p53 R248W mutants inactivate ATM-directed HRR. This particular sebaceous gland carcinoma presented with concomitant genomic deletions at the BRCA1 and BRCA2 loci, and also at the constitutively fragile sites FRA3B/FHIT and FRA16D/WWOX. CONCLUSIONS: Our study demonstrates for the first time that microsatellite-stable FHIT-negative sebaceous gland carcinomas accumulate mutations that target central components of the HRR network. This observation will prompt investigations in synthetic lethality of BRCA-deficient sebaceous gland carcinomas by therapeutic poly(ADP-ribose) polymerase inhibitors.

Cutaneous dissemination of nasal NK/T-cell lymphoma in a young girl.

In Europe and the USA, the incidence of primary nasal natural killer (NK)/T-cell lymphoma is rare. The skin is one of the predilection sites for dissemination. Cutaneous dissemination is a poor prognostic sign and is consistently fatal. We describe the case of a 17-year-old white German girl with a primary nasal NK/T-cell lymphoma and cutaneous dissemination. She presented with multiple maculopapular patches involving the trunk and thighs, and a 4-week history of headache, fever and fatigue. Biopsies of the skin and the nasal mucosa were taken. Pathological examination of both specimens revealed a NK/T-cell lymphoma. Epstein-Barr virus RNA was detected in the lymphoma cells by in situ hybridization. Unfortunately, the patient died of disease within 1 week.

The spectrum of canine cutaneous perivascular wall tumors: morphologic, phenotypic and clinical characterization.

Perivascular wall tumors (PWTs) are defined as neoplasms deriving from mural cells of blood vessels, excluding the endothelial lining. The spectrum of human cutaneous PWT includes glomus tumor, hemangiopericytoma (HEP), myopericytoma, angioleiomyoma/sarcoma, angiomyofibroblastoma, and angiofibroma. The purpose of this study was to revise clinical presentation, cytology, histopathology, and immunohistology of canine cutaneous PWT with cytology typical of canine HEP. Diagnosis was established on the basis of vascular growth patterns (staghorn, placentoid, perivascular whorling, bundles from media) and immunohistology, including 7 smooth muscle markers and the cell membrane ganglioside of unknown origin recognized by the antibody 3G5 (CMG-3G5). Twenty cases were included. Ages ranged from 6 to 13 years; 12 dogs were males and 8 were females, and there was a prevalence of crossbreeds. Tumors arose from a single site with preferential acral location (10/20). Cytology revealed moderate to high cellularity in all cases, cohesive groups of cells (19/20), capillaries (18/20), and bi- to multinucleated cells (18/20). Six myopericytomas, 5 angioleiomyomas, 2 angioleiomyosarcomas, 2 HEP, 1 angiofibroma, and 1 adventitial tumor were identified. A definitive diagnosis was not possible in 3 cases. Smoothelin, heavy caldesmon, desmin, myosin, calponin, and CMG-3G5 were the most valuable markers to differentially diagnose canine PWT. Similar to reports in humans, canine HEP embodied a spectrum of neoplastic entities arising from different vascular mural cells. Before canine PWTs are assimilated into one prognostic category, a consistent classification and characterization of their biology is necessary. As proposed in humans, HEP should also be considered a diagnosis of exclusion in dogs.

[Merkel cell carcinoma--clinically often misjudged]. / Das Merkelzellkarzinom--klinisch oft verkannt.

Merkel cell carcinoma is a rare, rapidly growing, highly malignant dermal tumor which occurs preferentially on light-exposed skin in advanced age. The course of the disease is frequently characterized by the occurrence of lymph node metastases and local recurrences, even in the first year after removal of the primary tumour. The five-year overall survival rate is only about 65 %, despite rigorous therapy. The histological pattern is characterized by trabecular strands of small, uniform cells with large basophilic nuclei and typical neuroendocrine granules. The diagnosis is confirmed immunohistochemically by neuroendocrine and epithelial markers. The excision of the primary tumor is regarded as first-line therapy. Adjuvant radiatiotherapy is almost always indicated and should also include lymph node drainage. In the stage of nodal disease, a combination of excision and radiotherapy is recommended. Adjuvant chemotherapy can be applied in this stage, as in small-cell bronchial carcinoma. The prognostic advantage has, however, not been proven. Despite good response to radiatiotherapy and chemotherapy, with at least prolonged recurrence-free intervals, Merkel cell carcinoma is rarely curable at the distant metastasizing stage. Individually defined, aggressive treatment,including radiatiotherapy, may in future considerably improve the prognosis, especially in the early stages of the disease.

Frequent intra-tumoural heterogeneity of promoter hypermethylation in malignant melanoma.

To investigate intra-tumoural coexistence and heterogeneity of aberrant promoter hypermethylation of different tumour suppressor genes in melanoma, we analyzed the intra-tumoural distribution of promoter methylation of RASSF1A, p16, DAPK, MGMT, and Rb in 339 assays of 34 tumours (15 melanoma primaries, 19 metastases) by methylation-specific PCR, correlation to histopathology and RASSF1A expression. We detected promoter hypermethylation of at least one gene in 74% of tumours (30%, 52%, 33%, 20%, and 40% for RASSF1A, p16, DAPK, MGMT and Rb, respectively). 70% of the cases exhibited an inhomogeneous methylation pattern (17%, 45%, 33%, 20%, and 40% for RASSF1A, p16, DAPK, MGMT and Rb, respectively). Samples from the core of the tumours represented the methylation state of the whole tumours more accurately than the periphery. Local intra-tumoural correlation was found between the promoter hypermethylation state of p16 and Rb or p16 and DAPK, or epitheloid tumour cell type and RASSF1A or p16 methylation. Mitosis rate and sex was correlated with methylation of RASSF1A. Histological results confirmed that promoter hypermethylation of RASSF1A led to aberrant expression patterns. We conclude that intra-tumoural inhomogeneity of promoter hypermethylation is frequent in melanoma and this supports the hypothesis of clonal instability during progression of melanomas. In prognosis studies, missing the intra-tumoural sample representativeness may result in a reduction of the sensitivities or specificities.

[Primary nasal natural killer/T-cell lymphomas: classification and clinicopathological features]. / Primäre nasale NK/T-Zell-Lymphome: Klinisch-pathologisches Erscheinungsbild und Einteilung.

BACKGROUND: Nasal NK/T-cell lymphomas are rare malignancies in Europe or North America. Histological diagnosis is difficult, because tumors imbedded in large necrotic areas and neoplastic infiltrates may be admixed with small lymphocytes, plasma cells, eosinophils, and histiocytes, and thus the process could be misdiagnosed as chronic inflammation. Progression of the disease leads to septal perforation and may also result in destruction of the hard palate, and if left untreated it ends fatally. This introduced the term "lethal midline granuloma", a term which should not be used any more. MATERIAL AND METHODS: Clinical features, pathohistology, and current classification of primary nasal NK/T-cell lymphomas are described against the background of the recent literature and a case report. RESULTS: Immunophenotyping is essential for the diagnosis. Tumor cells are uniformly infected by Epstein-Barr virus, which could be verified by EBER in situ hybridization. Immunohistochemically, tumor cells are positive for CD56, cytoplasmic CD3epsilon, and CD2 and they express cytotoxic molecules like granzyme B, TIA-1, GMP17, and perforin. Therapeutic options are radio- or radiochemotherapy. On average, 2- and 5-year survival rates of 50% are obtained in stages I and II. The prognosis of advanced tumor stages is very poor. CONCLUSIONS: Immunohistochemical and molecular genetic early diagnosis is of crucial prognostic relevance.

The hand-foot syndrome--a frequent secondary manifestation in antineoplastic chemotherapy.

The hand-foot syndrome (HFS) (palmoplantar erythrodysesthesia) designates acute, painful erythemas of the palms and soles of the feet caused by antineoplastic chemotherapies. The most frequent trigger substances are 5-fluoruracil and its derivates. At maximum severity, the HFS is bullous to erosive or ulcerous in character. The pathogenesis has not yet been clarified. Histologically, the HFS is characterized by a toxic keratinocyte reaction. Furthermore, there is sub-basal edema with a tendency to bullae, dilated blood and lymph capillaries and usually only mild perivascular lymphocytic infiltration. Early recognition and delineation from other differential diagnoses is prerequisite to targeted management of the disease. Depending on the severity, HFS requires dose reduction, interruption or switch in the antineoplastic chemotherapy.