Angiolymphoid hyperplasia with eosinophilia--an incidental finding after surgical excision.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare benign vasoproliferative lesion. Although it is a benign disease, lesions are often persistent and difficult to eradicate. ALHE typically presents clinically as papules or nodules, tan, brown, pink or dull red in colour, located predominantly in the head and neck region, especially around the ears and on the forehead and scalp.All races can be affected and no gender predominance exists. The disease also has nonspecific clinical features, hence it requires in most of the cases biopsy for accurate diagnosis. We present an uncommon clinical presentation of the disease, mimicking clinically a subcutaneous lipomatous mass, which has been treated successfully with surgical excision.

New caspase-independent but ROS-dependent apoptosis pathways are targeted in melanoma cells by an iron-containing cytosine analogue.

Chemotherapy resistance and related defects in apoptotic signaling are crucial for the high mortality of melanoma. Effective drugs are lacking, also due to the fact that apoptosis regulation in this tumor is essentially not understood. The cytosine analogue ferropoptoside (N69), which contains an iron carbonyl complex, resulted in strong induction of apoptosis in melanoma cells starting already after 2h, whereas cytotoxicity remained at a low level. Surprisingly, there was no indication for any caspase activation at early times, although cytochrome c was released from mitochondria. Indicative for new proapoptotic pathways was the production of reactive oxygen species (ROS) as an early effect, and the inhibition of apoptosis by the antioxidant vitamin E. Apoptosis was also blocked by exogenous Bcl-2 overexpression and by the pan-protease inhibitor zVAD. However, only zVAD also prevented ROS production, for which Bcl-2 remained without an effect. Thus, new proapoptotic pathways are described here for melanoma cells clearly related to ROS production. A cascade enclosing enhanced levels of intracellular iron, which lead to enhanced ROS production in a Fenton reaction, appears as suggestive. Whereas off-target effects of zVAD appear as upstream, Bcl-2 may exert its inhibitory activity downstream of ROS. New proapoptotic pathways are of particular interest for melanoma as they may open new options for targeting this highly therapy-refractory tumor.

Response of carcinoma in situ (actinic keratosis) to green tea concentrate plus capsicum.

A single case of carcinoma in situ (actinic keratosis) was treated topically with a patch consisting of an aqueous paste of a commercially available mixture (50:1) of green tea concentrate plus Capsicum (Capsol-T®) for approximately 14 days. The carcinoma responded by the formation of apoptotic blisters whereas surrounding normal tissue showed no response. A second untreated carcinoma 17 cm distant from the treated area also responded indicative of a systemic action of the substance.

Loss of proapoptotic Bcl-2-related multidomain proteins in primary melanomas is associated with poor prognosis.

Prognosis of primary melanoma is presently based on morphological parameters, mainly tumor thickness. However, more reliable prognostic markers are needed that allow a better stratification of patients, especially with regard to therapeutic options. Here, a retrospective study was performed on patients with primary superficial-spreading melanoma (SSM, n=44) or nodular melanoma (n=16) of 1.5-4 mm thickness. Thirty patients had survived the follow-up of 10 years, whereas the other 30 patients developed metastases. Tumor sections were analyzed by immunohistochemistry for the expression of regulators of the cell cycle (p21; retinoblastoma protein (pRb)), of the intrinsic or extrinsic proapoptotic pathways (p53; murine double minute gene 2 protein; tumour necrosis factor-related apoptosis-inducing ligand (TRAIL)-R1/DR4; TRAIL-R2/DR5) and of Bcl-2-related proteins (Bcl-2, Mcl-1, Bax, Bak, Bok), which regulate the common mitochondrial apoptotic pathway. In SSM, decrease of Bax and Bak was significantly correlated with a poor prognosis: high Bax was associated with 10-year survival rates of 68%, whereas low Bax resulted in only 26% survival, and high Bak was associated with 10-year survival rates of 62%, whereas low Bak resulted in only 10% survival. Regulators of apoptosis may therefore candidate for independent prognostic markers for primary melanomas. The study underlines the particular role of the mitochondrial apoptosis pathway and of proapoptotic Bcl-2-related proteins for melanoma progression.

Efficient TRAIL-R1/DR4-mediated apoptosis in melanoma cells by tumor necrosis factor-related apoptosis-inducing ligand (TRAIL).

Therapy resistance is crucial for the high mortality of melanoma. The death ligand tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) bears high potential as a new anticancer agent, as binding to the death receptors TRAIL receptor 1/death receptor 4 (TRAIL-R1/DR4) or TRAIL receptor 2/death receptor 5 (TRAIL-R2/DR5) triggers apoptosis in most cancer cells. For melanoma, however, only a weak responsiveness of primary cultures was reported, and in particular the role of DR4 was neglected. For evaluating melanoma susceptibility, we studied the functionality of DR4 and DR5 in melanoma cells as well as their expression in vivo. DR5 was consistently expressed in melanoma cell lines, whereas DR4 was found in only 2/7 cell lines. High sensitivity to TRAIL-induced apoptosis was characteristic for DR4-positive melanoma cells, whereas DR4-negative cells showed less and delayed response or were resistant. The use of selective DR4/DR5 blocking antibodies unequivocally proved the prevalent role of DR4 in those melanoma cells, where it was expressed. The significance of these data for the in vivo situation was finally evaluated by immunohistochemistry, which proved pronounced expression of DR4 as well as of DR5 in melanoma primary tumors. Thus, DR4 expression in vivo and the high efficiency of DR4-mediated apoptosis may suggest reassessment of the suitability of TRAIL and especially of DR4-based strategies for melanoma treatment.

Caspase-independent induction of apoptosis in human melanoma cells by the proapoptotic Bcl-2-related protein Nbk / Bik.

The proapoptotic BH3-only protein natural born killer / Bcl-2 interacting killer (Nbk/Bik) has been described to inhibit Bcl-2 and Bcl-xL, thereby supporting the death promoting ability of Bax. In order to evaluate its function in melanoma, we investigated the response after Nbk/Bik overexpression in cultured human melanoma cells and in a melanoma mouse model. Untransfected melanoma cell lines expressed Nbk/Bik only weakly at the mRNA and protein level. Conditional expression of Nbk/Bik by applying the inducible tetracycline-responsive expression system triggered apoptosis and enhanced sensitivity to proapoptotic stimuli as to agonistic CD95 activation and to chemotherapeutics etoposide, doxorubicin and pamidronate. For investigating the effects of Nbk/Bik in vivo, stably transfected melanoma cells were subcutaneously injected into nude mice. Significantly delayed tumor growth was the result when mice received doxycycline for induction of Nbk/Bik expression. By investigating the mechanism of Nbk/Bik-induced cell death, typical hallmarks of apoptosis such as DNA fragmentation and chromatin condensation were seen after induction. Interestingly, no indications for cytochrome c release and caspase processing were found, and selective caspase inhibition remained without effect. These data indicate the high potential of Nbk/Bik in regulating apoptosis in melanoma by a caspase-independent pathway and may corroborate the potency of novel antimelanoma strategies based on activation of BH3-only proteins such as Nbk/Bik.

Sphingosine kinase activity counteracts ceramide-mediated cell death in human melanoma cells: role of Bcl-2 expression.

While most of the pharmacological therapies for melanoma utilize the apoptotic machinery of the cells, the available therapeutic options are limited due to the ability of melanoma cells to resist programmed cell death. Human melanoma cell lines A-375 and M186 are sensitive to ceramide- and Fas-induced cell death, while Mel-2a and M221 are resistant. We have now found that Mel-2a and M221 cells have a significantly higher ceramide/sphingosine-1-phosphate (S1P) ratio than A-375 and M186 cells. As sphingosine kinase (SphK) type 1 plays a critical role in determining the dynamic balance between the proapoptotic sphingolipid metabolite ceramide and the prosurvival S1P, we examined its role in apoptosis of melanoma cells. Increasing SphK1 expression reduced the sensitivity of A-375 melanoma cells to Fas- and ceramide-mediated apoptosis. Conversely, downregulation of SphK1 with small interfering RNA decreased the resistance of Mel-2a cells to apoptosis. Importantly, overexpression of the prosurvival protein Bcl-2 in A-375 cells markedly stimulated SphK1 expression and activity, while downregulation of Bcl-2 reduced SphK1 expression. This link between Bcl-2 and SphK1 might be an additional clue to chemotherapy resistance of malignant melanoma.

Selective induction of apoptosis in melanoma cells by tyrosinase promoter-controlled CD95 ligand overexpression.

Induction of apoptosis has been demonstrated previously by overexpression of CD95 ligand (CD95L) in cultured human melanoma cells. For in vivo approaches based on CD95L, however, targeted expression is a prerequisite and tyrosinase promoters have been considered for selection. Luciferase reporter gene assays performed for a representative panel of melanoma cell lines characterized by strong (SK-Mel-19), moderate (SK-Mel-13, MeWo), weak (A-375), and missing expression (M-5) of endogenous tyrosinase revealed high tyrosinase promoter activities in SK-Mel-19, SK-Mel-13, and MeWo, but only weak activities in A-375 and M-5 as well as in non-melanoma cell lines. After transfection of a CMV promoter CD95L expression construct, melanoma cells were found highly sensitive, as compared with non-melanoma cells. By applying a tyrosinase promoter CD95L construct, apoptosis was selectively induced in SK-Mel-19, SK-Mel-13, MeWo as well as in A-375, which was characterized by high CD95 surface expression and high sensitivity to agonistic CD95 activation. M5 and non-melanoma cell lines remained uninfluenced. Also, resistance to agonistic CD95 activation seen in MeWo characterized by weak CD95 surface expression was overcome by overexpression of CD95L. Our investigations provide evidence that tyrosinase promoter CD95L constructs may be of value for selective induction of apoptosis in therapeutic strategies for melanoma.

Early TCR-beta and TCR-gamma PCR detection of T-cell clonality indicates minimal tumor disease in lymph nodes of cutaneous T-cell lymphoma: diagnostic and prognostic implications.

The lymph nodes are generally the first extracutaneous manifestation in patients with cutaneous T-cell lymphoma (CTCL); however, their early involvement is difficult to assess. The aim of our study was to define the diagnostic and prognostic value of T-cell clonality analysis for a more precise assessment of lymph node involvement in CTCL. T-cell clonality was determined by 2 independent polymerase chain reaction (PCR) assays, namely a recently developed T-cell receptor-beta (TCR-beta) PCR technique as well as an established TCR-gamma PCR. T-cell clonality was found in 22 of 22 lymph nodes with histologically detectable CTCL involvement as well as in 7 of 14 histologically noninvolved dermatopathic lymph nodes. The clonal T-cell populations in the lymph nodes were in all cases identical to those detected in the corresponding skin lesions, identifying them as the tumor cell population. T-cell clonality was not found in any of the 12 dermatopathic lymph nodes from 12 patients with inflammatory skin diseases. Clonal T-cell detection in 7 of 14 dermatopathic lymph nodes of patients with CTCL was associated with limited survival (74 months; confidence interval [CI], 66-82 months) as in patients with histologically confirmed lymph node involvement (41 months; CI, 35-47 months), whereas all patients without T-cell clonality in the lymph nodes (7 patients) were alive at the last follow-up. Thus, T-cell clonality analysis is an important adjunct in differentiating benign dermatopathic lymphadenitis from early CTCL involvement.

Tumor necrosis factor alpha sensitizes malignant cells to chemotherapeutic drugs via the mitochondrial apoptosis pathway independently of caspase-8 and NF-kappaB.

The Hodgkin cell line HD-MyZ is resistant to apoptosis induced by tumor necrosis factor alpha (TNFalpha). In the present work, we show that pretreatment with TNFalpha sensitized the cells to apoptosis induced by antineoplastic agents and ceramide. TNFalpha pretreatment resulted in enhanced cleavage and activity of caspase-3 upon addition of etoposide, epirubicin or ceramide. No caspase-8 activation was detectable, although caspase-8 could be activated in cell-free extracts. Inhibition of caspase-8 by z-IETD-fmk did not block the sensitizing effect of TNFalpha. Furthermore, exogenous ceramide, a mediator of TNFalpha signaling, could not substitute for TNFalpha in sensitization to drug-induced apoptosis. In contrast, we observed mitochondrial changes following cotreatment of cells with TNFalpha and drugs. Mitochondrial permeability transition, cytochrome c release and subsequent processing of caspase-9 preceded the onset of apoptosis, and were enhanced by TNFalpha pretreatment. Interestingly, although transcription factor NF-kappaB protected HD-MyZ cells from drug-induced apoptosis, TNFalpha-mediated sensitization was independent of NF-kappaB, since overexpressing a dominant-negative IkappaB mutant did not alter the TNFalpha effect. Sensitization for drug-induced apoptosis by TNFalpha was abrogated by Bcl-x(L). Thus, the sensitizing effect of TNFalpha is mediated by the mitochondrial pathway and involves processing of caspase-2, -3 and -9, but appears to be independent of caspase-8 processing, Bid cleavage and NF-kappaB signaling. Therefore, sensitization by TNFalpha is mediated at least in part through different pathways, as reported for TRAIL. There, sensitization occurs through a FADD/caspase-8-dependent mechanism. Regarding TNFalpha, the sensitizing effect was also observed in myeloid leukemia cells. Therefore, TNFalpha or alternate molecules activating its pathways might be useful as sensitizers for chemotherapy in hematological malignancies.

Death receptor-independent apoptosis in malignant melanoma induced by the small-molecule immune response modifier imiquimod.

Bypassing molecular mechanisms of apoptosis deficiency may be of great utility for the successful treatment of malignant tumors. We have discovered that imiquimod, a small-molecule immunomodulator, exerts rather tumor-selective direct pro-apoptotic activity in vivo and in vitro towards cutaneous metastases of malignant melanoma, an aggressive skin tumor. This pro-apoptotic activity was not detectable with resiquimod, a closely related structural analogue whose pro-inflammatory activity is even greater than that of imiquimod. Unresponsiveness of some melanoma metastases to imiquimod in vivo corresponded to resistance towards imiquimod-induced apoptosis in vivo and in vitro. At the molecular level, the pro-apoptotic activity of imiquimod was independent of membrane-bound death receptors, but depended on Bcl-2 expression as demonstrated by overexpression of Bcl-2 in melanoma cells. Imiquimod is the first topical compound with the potential to bypass molecular mechanisms of apoptosis deficiency, a concept that may be relevant for other tumors as well.

Dacarbazine but not temozolomide induces phototoxic dermatitis in patients with malignant melanoma.

Ten patients with malignant melanoma and phototoxic reactions under dacarbazine or 5-(3,3-dimethyl-1-triazeno) imidazole-4-carboxamide (DTIC) chemotherapy were investigated. All patients available for testing showed increased ultraviolet A-sensitivity (n = 5); patch testing revealed no type IV allergies (n = 6). In 5 patients intravenous DTIC was replaced by oral temozolomide, and no phototoxicity occurred. Temozolomide may represent an alternative for patients with DTIC-induced phototoxic skin reactions.

Verrucous carcinoma of the axilla: case report and review.

BACKGROUND: Verrucous carcinoma, a variant of squamous cell carcinoma, is distinct from squamous cell carcinoma in morphology and behavior. It preferentially occurs on the oropharyngeal mucosa, the urogenital mucosa, and the soles. In contrast to its malignant clinical picture, the tumor grows locally invasive but is histologically benign and metastasizes rarely. METHODS: We report the uncommon occurrence of a large verrucous carcinoma on apparently uninvolved skin in the right axilla in a 47-year-old male. RESULTS: Histologic examination reveals a cauliflower-like tumor consisting of deep invaginated epidermal proliferation with rabbit burrow-like, keratin-filled sinus formations; the basement membrane, however, remains intact. Immunohistology showed positivity for pancytokeratin (KL-1) and cytokeratin (CK) 18 and negativity for CK7, and assessment of the proliferative activity of the tumor cells revealed low percentage of Ki-67 expression. Furthermore, there were only scattered cells expressing p53 or bcl-2. Polymerase chain reaction excluded the presence of human papillomavirus. After complete excision, no signs of recurrence occurred over a follow-up period of three years. CONCLUSION: Verrucous carcinoma should be distinguished from typical squamous cell carcinoma. The clinicopathological features, differential diagnosis, and therapy are discussed here together with the molecular biologic aspects of the tumor.

Expression and regulation of phospholipase D isoenzymes in human melanoma cells and primary melanocytes.

Phospholipase D (PLD) is a highly regulated enzyme involved in lipid-mediated signal transduction processes affecting vesicular trafficking and cytoskeletal reorganization. It is regulated by protein kinase C, adenosine diphosphate (ADP)-ribosylation factors and Rho family proteins, and both protein kinase C and Rho family proteins have been implicated in the metastatic potential of melanoma. We analysed PLD in four human melanoma cell lines and in primary human melanocytes. Melanoma cell lines showed phosphatidylcholine-hydrolysing, phosphatidylinositol 4,5-bisphosphate-dependent PLD activity, which was activated by phorbol ester and a non-hydrolysable guanosine triphosphate (GTP) analogue in a dose-dependent and synergistic manner, whereas primary melanocytes exhibited only low PLD activity compared with the melanoma cell lines. As determined by reverse transcription polymerase chain reaction, both splicing variants of PLD1, PLD1a and PLD1b, and the isoenzyme PLD2, are expressed in melanoma cells and melanocytes. Western blot analysis showed that PLD1 expression was low in primary melanocytes in contrast to melanoma cells, which is in agreement with our finding of low activity. Interestingly, Rho protein mRNA was elevated in all melanoma cell lines. We conclude that in human melanoma cells, the PLD activity that is stimulated by phorbol ester requires ADP-ribosylation factor, protein kinase C and Rho proteins for full activity, and most probably represents the isoenzyme PLD1.

CD95/Fas signaling in human melanoma cells: conditional expression of CD95L/FasL overcomes the intrinsic apoptosis resistance of malignant melanoma and inhibits growth and progression of human melanoma xenotransplants.

The significance of CD95/Fas ligand expression by melanoma cells has remained a controversial matter in recent years. On the other hand, CD95 activation may represent a powerful tool for eliminating tumor cells. Here, we demonstrate expression of CD95 in 15/17 human melanoma cell lines analysed, but complete lack of CD95 ligand (CD95L). Overexpression of CD95 in a tetracycline-inducible expression system enhanced melanoma cell sensitivity to CD95 ligation but was unable to trigger apoptosis by itself. In clear contrast, all melanoma cells tested responded with increased apoptosis to conditional expression of CD95L (2-10-fold), both after transient and after stable transfection. Activation of caspase-8, Bid cleavage, cytochrome c release and caspase-3 activation followed after CD95L induction indicating a functional CD95-signaling cascade. CD95L was also able to enhance the proapoptotic effect of chemotherapeutics applied in parallel. Nude mouse experiments revealed that tumorigenicity was lost when melanoma xenografts were triggered to express CD95L. In addition, further progression of pre-existing melanomas was inhibited and even regression was seen after induction of CD95L expression. Due to these data, transfection of CD95L proofs as a highly efficient tool against melanoma cells in vitro and in vivo, and targeted expression of CD95L may thus represent a suitable strategy for melanoma therapy.

Conditional expression of exogenous Bcl-X(S) triggers apoptosis in human melanoma cells in vitro and delays growth of melanoma xenografts.

The Bcl-2-related proteins Bcl-X(L) and Bcl-X(S) represent alternative splice products and exert opposite activities in the control of apoptosis, but their significance for melanoma is not yet clear. Applying the tetracycline-inducible expression system Tet-On, we found overexpression of Bcl-X(S) by itself sufficient to induce apoptosis in vitro in stably transfected human melanoma cell lines. Combination with proapoptotic agents such as etoposide, pamidronate, and ceramide resulted in additive proapoptotic effects, whereas Bcl-X(L) protected from apoptosis caused via CD95/Fas stimulation. In nude mice growth of melanoma xenotransplants derived from stably transfected cells was significantly reduced after induction of Bcl-X(S) by doxycycline. Our results indicate that Bcl-X proteins are of major importance for control of apoptosis in malignant melanoma.

Atypical generalized eruptive histiocytosis associated with acute monocytic leukemia.

Histiocytoses are diseases caused by proliferation of either dendritic cells/Langerhans cells or of monocytes/macrophages. Generalized eruptive histiocytosis belongs to the cutaneous non-Langerhans cell histiocytoses and is a rare monocyte-macrophage proliferative disorder that usually follows a benign clinical course. We present the case of a 59-year-old man who presented with a 7-month history of progressively developing erythematous macules and slightly elevated papules widely distributed over the trunk, neck, face, and thighs. Ultrastructurally, no Birbeck granules were observed, and immunochemistry did not reveal any S-100 protein or CD1a antigen in any of the lesional cells, excluding Langerhans cell histiocytosis. In addition, the histiocytic infiltrate in the skin of our patient was shown to strongly express MS-1 high molecular weight protein, a marker described as highly characteristic for cutaneous non-Langerhans cell histiocytoses. Bone-marrow smear examination and flow cytometric analysis revealed monocytic leukemia. This is the second report of generalized eruptive histiocytosis associated with acute monocytic leukemia. We discuss the differential diagnoses of the clinical picture and stress that this benign cutaneous disorder may indicate an underlying hematologic malignancy.