Effective photodynamic therapy of actinic keratoses on the head and face with a novel, self-adhesive 5-aminolaevulinic acid patch.

BACKGROUND: Photodynamic therapy (PDT) is increasingly used for the treatment of actinic keratosis (AK). OBJECTIVES: To investigate both the efficacy of different application times and the safety of a novel patch (PD P 506 A) containing aminolaevulinic acid in the PDT of mild to moderate AK. METHODS: Applications of PD P 506 A for 0.5, 1, 2 and 4 h were compared in a multicentre, randomized, blinded-observer, parallel-group study. After patch removal, study lesions were illuminated with red light (lambda(em) approximately 630 nm; 37 J/cm(2)). Study lesions were not pretreated (e.g. by curettage) prior to PDT. Efficacy was evaluated 4 and 8 weeks after treatment. Safety and tolerability were determined through laboratory analyses and documentation of both local reactions and adverse events. RESULTS: A total of 149 patients were initially enrolled. Of these, 140 patients (520 lesions) completed the study according to protocol. Eight weeks after treatment, 86% of the AK lesions (74% of the patients) treated with 4-h patch application showed complete clearance. The complete clearance rates of lesions (patients) for the 2-, 1- and 0.5-h treatment arms were 73% (47%), 72% (50%) and 51% (24%), respectively. Statistically, the 4-h application was identified as the 'best treatment'. Patients with clearance seemed to experience local reactions to a greater extent than patients without clearance. Local reactions to study treatments did not exceed the expected range. CONCLUSIONS: The results of this first clinical efficacy study suggest excellent therapeutic outcomes with a single PD P 506 A PDT with a 4-h application.

Melanocytic schwannoma of the cutaneous and subcutaneous tissues: three cases and a review of the literature.

Melanocytic schwannoma is a rare soft-tissue tumor, which arises most commonly in the paraspinal sympathetic chain. In general, 25% of the patients develop metastasis. To date, only 17 cases of a cutaneous and subcutaneous melanocytic schwannoma have been reported. None of these patients developed metastasis. Three cases of cutaneous melanocytic schwannoma, diagnosed in our institution are reported. For further literature overview we performed a search on Medline using the terms 'melanocytic schwannoma' or 'melanotic schwannoma' or 'Carney complex' combined with 'skin' or 'cutaneous', for the period 1970-2007. Seventeen patients were described to have melanocytic schwannoma of the skin or subcutaneous tissues. These papers were reviewed for clinical data. Two of the three patients showed metastatic disease, one of them died of disseminated metastases. In contrast, none of the reported cases of cutaneous or subcutaneous melanocytic schwannomas was characterized by a malignant course. The differential diagnosis, especially with regard to malignant melanoma, is made by histology and by its clinical course, which differs from melanoma in its tendency to recur at the site of excision and slow rate of growth. Commonly misdiagnosed as melanoma, this tumor reveals insights into the origin of both melanocytes and Schwann cells. It is likely that the biological bases for melanoma and melanocytic schwannoma differ. It is necessary to differentiate this tumor from melanoma because of the differing prognosis and the association of melanocytic schwannoma with the Carney complex. Owing to the lack of clinical trials, we recommend that patients be treated according to the existing guidelines for melanoma.

Simulating psoriasis by altering transit amplifying cells.

Computational models of tissue homeostasis will facilitate a deeper understanding of many diseases. They link molecular networks, cellular differentiation and the spatial and temporal organization of tissues. Here we show an approach which is able to computationally turn a healthy in silico epidermis into one with four central properties of psoriatic epidermis. We achieve this by altering a single simulation parameter in the cellular differentiation program of the simulated epidermal keratinocytes: the fractional time period during which transit amplifying cells proliferate (tau). Prolonging tau results in the four main pathological characteristics of psoriatic skin: (1) an absolute increase of the germinative compartment, (2) an absolute increase of the differentiated compartment, (3) a higher proportion of germinative cells and (4) a marked reduction in turnover time. The prolongation of tau is able to increase the proliferation capacity of the epidermal tissue without altering the cell cycle frequency.

Modelling epidermal homeostasis as an approach for clinical bioinformatics.

Modelling in systems biology currently lacks clinical applications. As a possible approach leading to clinical relevance the modelling of tissue homeostasis is proposed. As an example a model of epidermal homeostasis is presented which reproduces central morphological and kinetic characteristics of epidermal tissue. Each individual cell is modelled as an agent. The tissue arises as an emergent phenomenon from the interactions of agents. Each agent's behaviour is qualitatively modelled by a simple differentiation state-flow program. Epithelialisation under the influence of parameters concerning stem-cell location is briefly demonstrated.

Expression of Fas ligand (CD95L) in primary malignant melanoma and melanoma metastases is associated with overall survival.

BACKGROUND: There is increasing evidence that the Fas/Fas ligand (FasL) system is involved in tumor-mediated immune suppression. The purpose of this study was to investigate the effect of Fas (CD95) as well as FasL (CD95L) expression in primary malignant melanoma and melanoma metastases on overall survival (OS). PATIENTS AND METHODS: 19 patients with metastatic malignant melanoma who were treated with different dacarbazine (DTIC)-based chemotherapy regimens were included in this study. From each patient, primary melanoma biopsies and biopsies from metastases were histologically evaluated. Immunohistology was performed with antibodies to Fas/CD95 and FasL/CD95L. Differences in OS were plotted using the Kaplan-Meier method and compared by the log rank test. RESULTS: Fas/CD95 and FasL/CD95L expression was detected in 73.7 and 63.2% of primary melanomas, respectively. In metastases, expression of both Fas/CD95 (63.2%) and FasL/CD95L (47.4%) was markedly decreased. Presence of FasL/ CD95L expression in primary melanoma resulted in significantly (p = 0.024) prolonged OS compared with FasL/CD95L-negative high-risk primary melanomas. In contrast, loss of FasL/CD95L expression in melanoma metastases resected before chemotherapy was associated with significantly prolonged median survival (p = 0.0139). CONCLUSION: Presence of FasL/CD95L expression in primary malignant melanoma and the loss of FasL/ CD95L expression in metastases seem to be positive prognostic factors.

In vitro drug sensitivity predicts response and survival after individualized sensitivity-directed chemotherapy in metastatic melanoma: a multicenter phase II trial of the Dermatologic Cooperative Oncology Group.

PURPOSE: In vitro sensitivity assays are promising tools to predict the individual outcome of different chemotherapy regimens. However, a direct association between in vitro and in vivo chemosensitivity has to be shown by clinical studies. This multicenter phase II trial was aimed to investigate the efficacy of a sensitivity-directed, first-line chemotherapy in metastasized melanoma patients, and to prove an association between in vitro sensitivity and therapy outcome. PATIENTS AND METHODS: The primary study end point was objective response; secondary end points were safety, overall survival, and progression-free survival. Viable tumor cells obtained from metastatic lesions were tested for chemosensitivity to seven single drugs and five drug combinations using an ATP-based luminescence viability assay. RESULTS: Out of 82 recruited patients (intention-to-treat), 57 received assay-directed chemotherapy and 53 were evaluable for all study end points (per protocol). The drug combinations used were gemcitabine+treosulfan, paclitaxel+cisplatin, paclitaxel+doxorubicin, and gemcitabine+cisplatin. The per protocol population could be divided into 22 (42%) chemosensitive and 31 (58%) chemoresistant patients by an arbitrary chemosensitivity index. Objective response was 36.4% in chemosensitive patients compared with 16.1% in chemoresistant patients (P=0.114); progression arrest (complete response+partial response+stable disease) was 59.1% versus 22.6% (P=0.01). Chemosensitive patients showed an increased overall survival of 14.6 months compared with 7.4 months in chemoresistant patients (P=0.041). CONCLUSION: In vitro chemosensitivity testing may be worthy of further exploration to see if it could be a useful tool to predict the outcome of melanoma patients treated with a sensitivity-directed chemotherapy. Therefore, these preliminary results will be evaluated by a planned phase III trial using a randomized, standard-regimen controlled setting.

[The new German educational law for medical schools: the Hamburg concept in dermatology and venereology]. / Die neue Approbationsordnung für Arzte: Das Hamburger Konzept im Fach Dermatologie und Venerologie.

Medical school graduates are required to deal with complex situations in their future work which require profound theoretical knowledge as well as many practical skills. The University of Hamburg used a new educational law (AappO 2002) as catalyst to define learning objectives relevant for practice and to guarantee a close connection between theory and practice. A newly founded curriculum committee with twelve members developed a strategy and structure for the new clinical curriculum (KliniCuM) in weekly sessions. The subject dermatology and venereology is taught in the thematic block "The Internal and External Human Being" in integrated courses with the subjects internal medicine, pathology and pharmacology. The teaching modules (introductory lectures, symptom-oriented lectures, problem-based tutorials and bedside-teaching) are practice oriented and teach diseases and skills of dermatology which are important for "general medicine". Written and practical exams take place at the end of the block. Although there is more required attendance and increased demands on students' time, dermatology has received very positive evaluation results. Students consider their gain in knowledge and skills as very high. The new curriculum in Hamburg could provide helpful orientation for other medical faculties in changing their curricula for the subject "dermatology and venereology" according to the new educational law.

[Is a reformation of the medical training worthwhile? The quality of the Hamburg curriculum under the old and the new board certification law]. / Lohnt sich eine Reform der klinischen Ausbildung? Die Qualität des Hamburger Curriculums unter der alten und der neuen Approbationsordnung im Vergleich.

This paper presents the results of the evaluation of a new undergraduate curriculum at the Medical Faculty of Hamburg University. This curriculum is based on the new law on medical board certification of 2002, and was tested for the first time in the summer term of 2004. The results were compared with those obtained under the previous law. The data show a substantial increase in student subjective learning effectiveness and satisfaction with the new program. The reasons discerned were the increased practice orientation of the program, the problem-oriented seminars, and the increased motivation of the teaching staff.

A multicellular systems biology model predicts epidermal morphology, kinetics and Ca2+ flow.

MOTIVATION: Systems biology is currently focused on integrating intracellular networks, although clinically, diseases are largely defined by their histological features. For example, no computational model can simulate today the formation of a horizontally layered epidermis. Since the epidermis is the most complex structured epithelial tissue, systems biology models could yield important insights in epithelial tissue, in which most of all human cancers arise. RESULTS: We describe the algorithms of a system, capable of simulating the tissue homeostasis in human epidermis leading to a horizontally layered tissue with cells of different differentiation stages. The system predicts epidermal morphology, tissue kinetics and 2D flow of Ca2+ ions. Predicted properties of an epidermis with a healthy and a disturbed barrier are compared with the literature. The system closely mimics the respecting physiological situations. AVAILABILITY: Additional information and films of the simulation are available at the website. Source code is available on request. http://www.zbh.uni-hamburg.de/research/ESB/index.php CONTACT: grabe@zbh.uni-hamburg.de

Total and specific serum IgE decreases with age in patients with allergic rhinitis, asthma and insect allergy but not in patients with atopic dermatitis.

Concerning allergic diseases, the incidence of allergic symptoms, as well as their severity, seems to decrease with age. The decline of onset of allergic symptoms observed in ageing might result from a decrease of serum total and specific IgE. Atopic disorders are complex diseases that involve interactions among several physiological systems, e.g. skin, lung, mucosae, and the immune system. It was the aim of this study to compare the effects of age on total and specific IgE in patients with atopic dermatitis (AD), allergic rhinitis or asthma, and insect allergy, respectively.The study population consisted of 559 individuals (male: 229 and female: 330). Total and allergen specific IgE was measured in every individual. From the whole study population, 113 patients suffered from atopic dermatitis (AD), 132 had allergic rhinitis or asthma, and 314 were tested because of insect allergy. Total and specific serum IgE was significantly decreased as a function of age in patients with allergic rhinitis and asthma and with insect allergy. In contrast, no significant decrease of total and specific serum IgE in old individuals with AD was observed. Additionally, in the group of patients with a total IgE < 300 kU/l a reduction of total serum IgE was significantly correlated with age. In contrast, patients with IgE levels > 300 kU/l showed no correlation with age.Immunosenescence does not affect increased IgE levels in atopic patients with AD and/or high serum IgE levels indicating that in these subgroups of patients the atopic propensity remains into advanced age. One may hypothesize that either onset of allergic sensitization during life or the kind of atopic disease influences the correlation between age and IgE synthesis.

Expression analysis of the Candida albicans lipase gene family during experimental infections and in patient samples.

Secreted lipases of Candida albicans are encoded by a gene family with at least 10 members (LIP1-LIP10). The expression pattern of this multigene family was investigated using reverse transcription polymerase chain reaction in experimental infections and in samples of patients suffering from oral candidosis. The findings illustrate that individual lipase genes are differentially regulated in a mouse model of systemic candidosis with some members showing sustained expression and others being transiently expressed or even silent. The lipase gene expression profile depended on the stage of infection rather than on the organ localization. This temporal regulation of lipase gene expression was also detected in an experimental model of oral candidosis. Furthermore, the expression of candidal lipase genes in human specimens is shown for the first time.

Treosulfan and gemcitabine in metastatic uveal melanoma patients: results of a multicenter feasibility study.

No effective treatment currently exists for metastatic uveal melanoma. However, recent results obtained by an ATP-based tumor chemosensitivity assay have shown consistent activity of treosulfan+gemcitabine in up to 80% of tumor specimens tested. In this study we describe the first clinical results observed with this drug combination at different European centers in patients with metastatic uveal melanoma. Clinical case series of patients with metastatic uveal melanoma were treated with treosulfan+gemcitabine at seven different centers. Fourteen patients, 13 previously untreated and one pretreated with chemoimmunotherapy, were included in the study. Patients received treosulfan+gemcitabine in four different dose regimens. The response rates, progression-free and overall survival, and toxicity were evaluated. The analysis of 14 patients revealed one complete response, three partial responses and a stable disease in eight cases. The objective response rate was 28.6%, the median overall survival was 61 weeks [95% confidence interval (CI) 54-133 weeks], the progression-free survival was 28.5 weeks (95% CI 13-62 weeks) and the 1-year survival rate was 80%. The drugs were well tolerated. The most common side-effects were leuko- and thrombocytopenia. These preliminary results suggest potential therapeutic benefit of treosulfan+gemcitabine treatment in metastatic uveal melanoma and warrant further controlled studies.

Telomere length measurement and determination of immunosenescence-related markers (CD28, CD45RO, CD45RA, interferon-gamma and interleukin-4) in skin-homing T cells expressing the cutaneous lymphocyte antigen: indication of a non-ageing T-cell subset.

The purpose of this study was to investigate the immunosenescence of skin-homing T cells expressing the cutaneous lymphocyte antigen (CLA). Peripheral blood lymphocytes from 72 healthy individuals (33 male and 39 female; median age 54 years; age-range: 18-94 years) were investigated. The expression of CD28, CD45RA and CD45RO, as well as intracellular interferon-gamma (IFN-gamma) and interleukin-4 (IL-4) formation of CLA+ 'skin homing' T cells, was analysed. In addition, T cells were detected immunohistologically in skin specimens from 15 young and 15 old, healthy individuals. The relative telomere length (RTL) was measured by fluorescence in situ hybridization using flow cytometry (flow FISH). The total number of CLA+ T cells was found to remain constant with increasing age. In contrast to peripheral blood T cells (CD3+ CLA-), which showed significantly decreased CD28 and CD45RA expression in donors > 60 years of age, no age-related alterations of either CD28+ CLA+ T cells or CD45RA+ CLA+ T cells were observed. In the group of donors > 60 years of age, the proportion of intracellular IFN-gamma-producing CD3+ CLA- cells showed a significant increase, whereas the number of IFN-gamma- and IL-4-producing CLA+ T cells was not affected by age. After stimulation with phytohaemagglutinin (PHA) or staphylococcal enterotoxin B (SEB), CLA+ T cells from old donors did not show a reduced response compared with CLA+ T cells from young donors. Additionally, the counts of T cells in healthy skin from young and old adults were statistically not different. Furthermore, the RTL was significantly shortened in enriched CD45RO+ CLA- T cells from healthy old individuals, but not in aged CLA+ T cells. The present data suggest that CLA+ T cells might be a T-cell subpopulation which does not undergo immunosenescence. This may explain why the intensity of inflammatory skin reactions (e.g. psoriasis or eczema) seems to be independent of the patients' age.

Second-line chemotherapy of metastatic malignant melanoma with intravenous treosulfan: a phase II multicentre trial.

The purpose of this multicentre phase II trial was to evaluate time to progression, survival time, rate of objective tumour response and toxicity of second-line intravenous treosulfan chemotherapy in stage IV melanoma patients. Thirty-one patients with measurable stage IV malignant melanoma and prior chemotherapy with a dacarbazine-containing regimen were included. Of this group, 26 patients were evaluable. All patients received treosulfan (8 g/m intravenously on day 1; cycle repeated every 28 days up to six courses). Patients were evaluated for tumour response, survival time and toxicity. No objective responses (complete or partial) were observed. Five patients (19%) showed no change and 21 had progressive disease after treosulfan treatment. Four patients experienced a minor or mixed response. The median time to progression was 1.8 months (95% confidence interval [CI] 1.6-2.1 months) and the median overall survival was 6.5 months (95% CI 3.1-10 months). The 1 year survival rate was 33.9% (95% CI 15.4-52.3%). Leukocytopenia and thrombocytopenia (Common Toxicity Criteria grades 3 and 4) occurred in 15% and 18% of cases, respectively. The non-haematological toxicity of this outpatient regimen was mild. In conclusion, intravenous treosulfan treatment does not induce objective response rates when used as a second-line treatment of metastatic malignant melanoma.

Treosulfan in the treatment of metastatic melanoma: from chemosensitivity testing to clinical trials.

The therapy of metastatic malignant melanoma is limited by poor responses and short overall survival. Thus it remains important to identify and test potential new drugs in this disease. To examine the effects of the bifunctional alkylating cytostatic treosulfan, an in vitro microplate ATP bioluminescence assay (ATP-TCA) was used. Five highly chemoresistant melanoma cell lines and melanoma cells freshly isolated from metastases surgically resected from stage IV melanoma patients (n = 10) were incubated with treosulfan. Three cell lines and eight of ten tested tumor cells isolated from melanoma metastases showed tumor growth inhibition after incubation with treosulfan. Therefore, 14 patients with rapidly progressing stage IV malignant melanoma who were pretreated with at least one standard chemotherapy regimen received treosulfan. In this population of patients with highly refractory advanced melanoma one complete remission (7.1%), two partial remissions (14.3%), and three cases of stable disease (21.4%) were observed. Median time to progression and median overall survival for all patients measured from the beginning of treosulfan treatment were 5 months [95% confidence interval (CI) 1.98-2.57 months] and 9 months (95% CI 3.92-8.69 months), respectively. On the basis of these data a multicenter phase II trial was initiated. A total of 31 patients with stage IV melanoma were included and treated second-line with 8 g/m2 i.v. treosulfan. From this group 26 patients were evaluable. No objective remission (CR, PR) was observed, 5 of 26 patients (19%) had stable disease, and 21 patients had progressive disease. Median overall survival was 6.5 months (95% CI 3.1-10 months). Toxicity of treosulfan was moderate. Patients with treosulfan-sensitive melanoma metastases showed better response rates and prolonged survival compared with patients who were not tested before treosulfan treatment. We therefore suggest further studies with first-line treosulfane alone or in combination with gemcitabine or cytosine arabinoside together with pretherapeutic chemosensitivity testing that may help to select patients who might benefit from specific chemotherapy.