Risk of synchronous and metachronous second nonmelanoma skin cancer when referred for Mohs micrographic surgery.

BACKGROUND: Patients with basal cell carcinoma and cutaneous squamous cell carcinoma are at substantial risk for the onset of a second nonmelanoma skin cancer (NMSC). OBJECTIVE: Our purpose was to determine the incidence of multiple (synchronous) NMSC at presentation to an academic Mohs micrographic surgery referral center and to note the incidence of second lesions occurring in a metachronous fashion. METHODS: A retrospective study was conducted of 456 consecutive patients who presented for Mohs surgery over a 2-year period. Patients were assessed at initial visits for the presence of multiple NMSCs and were subsequently examined over 2 years for the onset of new NMSCs. RESULTS: More than 39% of patients initially referred for Mohs surgery with a basal cell or squamous cell carcinoma either presented with multiple primary lesions or experienced a subsequent NMSC within 2 years. These tumors were divided almost equally between multiple primary NMSC at presentation and subsequent (metachronous) tumors. CONCLUSION: Patients referred for Mohs surgery in an academic setting are a select group at extremely high risk of additional NMSCs at or shortly after presentation for the index lesion.

Potential effect of cytokines on transgene expression in primary fibroblasts implanted into the rat brain.

Fibroblasts genetically modified with retroviral vectors fail to demonstrate long-term transgene expression upon implantation into the body. Although the mechanisms behind this phenomenon have not been elucidated, one likely cause is the response of the host to the graft. For example, genetically modified fibroblasts grafted into the brain are surrounded by activated microglia and astrocytes. The apparent inflammatory response can last for several weeks. In addition, the center of the graft is typically infiltrated with macrophage-like cells that appear to reside continuously within the graft. This proximity of inflammatory cells to the graft suggests that these cells may somehow influence transgene expression. In the current study, an in vitro model was used to test the effect cytokines [transforming growth factor-beta1 (TGF-beta1), interleukin-1beta, (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha)] that are typically released by peripheral macrophages, activated microglia and/or astrocytes have on long-terminal repeat (LTR)-driven transgene expression in primary fibroblasts. Our data demonstrate that these cytokines can significantly reduce the steady-state level of proviral mRNA. The amount of proviral mRNA returned to control levels within 24 h if the cytokines were removed. In addition, the down-regulation of proviral mRNA levels could be prevented if the cells were incubated with dexamethasone (25 microM) concurrent with the introduction of cytokines. These data demonstrate that cytokines can down-regulate LTR-driven transgene expression in primary fibroblasts maintained in culture. This interaction may be a major reason why transduced cells do not demonstrate long-term transgene expression in vivo.

5-Azacytidine and BDNF enhance the maturation of neurons derived from EGF-generated neural stem cells.

EGF-generated neural stem cells can form astrocytes, neurons, and oligodendrocytes upon differentiation; however, the proportion of cells that actually form neurons is very small. In the present study, we have studied the effect that 5-azacytidine (5AzaC), a demethylation agent, and brain-derived growth factor (BDNF) have on the differentiation and maturation of neurons originating from EGF-generated neural stem cells. Stem cells were maintained under a variety of culture conditions using combinations of 5AzaC and BDNF either alone or together. More neurons, as determined by the number of beta-tubulin III-immunoreactive somata, were present in cultures maintained in BDNF medium (a nearly fourfold increase compared to control cultures). 5AzaC did not significantly affect neuronal number, regardless of the presence of BDNF. In addition to neuronal number, the effect of 5AzaC and BDNF on the distribution of the microtubule proteins MAP2 and Tau was analyzed. In most cultures, MAP2 and Tau were colocalized throughout the neuron. In contrast, neurons cotreated with 5AzaC and BDNF contained neurons that began to exhibit cytoskeletal segregation of MAP2 into the somatodendritic compartments. Tau remained dispersed within the somata and the axon. This effect was not produced when 5AzaC or BDNF was used individually. These results demonstrate that 5AzaC and BDNF cooperate to produce more mature neurons from EGF-generated neural stem cells then either molecule can alone.

Expression of neuronal antigens by astrocytes derived from EGF-generated neuroprogenitor cells.

Previous studies have demonstrated that astrocytes reacting to CNS injury can express antigens normally associated with neurons. The origin of the reactive astrocytes, i.e., whether they are newly differentiated glial cells or preexisting astrocytes somehow triggered to express neuronal markers, remains difficult to determine using an in vivo model system. An in vitro model may prove more manageable. In the present study, primary brain cultures and EGF-generated neuroprogenitor cells were used to study the expression of neuronal antigens by established (primary) and nascent astrocytes, respectively. Astrocytes derived directly from dissociated mouse brains exhibited a flat morphology typical of type 1 astrocytes. These cells were nestin and GFAP positive and, in most cases, the antigens were colocalized. Primary astrocytes did not appear to express the putative neuronal markers GABA, Tau, or MAP2. Nascent astrocytes derived from EGF-generated progenitor cells showed a similar pattern of GFAP and nestin immunoreactivity. Contrary to primary astrocytes, many GFAP-intensive, stellate astrocytes exhibited Tau and MAP2. These cells also exhibited an intense nestin immunoreactivity. These data suggest that the reactive astrocytes expressing neuronal antigens in response to CNS trauma may be derived from neural progenitor cells rather than from previously differentiated astrocytes.

Polymer-encapsulated Schwannoma cells expressing human nerve growth factor promote the survival of cholinergic neurons after a fimbria-fornix transection.

Many investigators have recently used genetically modified primary fibroblasts of fibroblast cell lines (e.g., 3T3, 208F, or BHK cells) to deliver recombinant nerve growth factor (NGF) into the CNS. In the current study, SCT-1 cells, a Schwannoma cell line derived from a transgenic mouse, were transfected with a human NGF (hNGF) cDNA. After selection, these cells were encased within a polymer capsule and implanted into the ventricles of fimbria-fornix lesioned rats. Encapsulated, non-transfected cells served as controls. Results demonstrated that the hNGF transgene is expressed for at least 3 weeks after implantation. Moreover, the cells did not overgrow the capsule. Recombinant hNGF was able to save > 70% of lesioned cholinergic neurons, as assessed by NGF-receptor (NGFr) and choline acetyltransferase (ChAT) immunohistochemistry, from cell death. The number of cholinergic neurons in animals that received control capsules (i.e., nontransfected SCT-1 cells) was similar to lesion only animals (i.e., approximately 27% and approximately 33% for NGFr- and ChAT-positive neurons, respectively. These results show that SCT-1 cells can be used to deliver biologically active hNGF into the lesioned rat brain.

In vivo production and release of acetylcholine from primary fibroblasts genetically modified to express choline acetyltransferase.

Primary rat fibroblasts genetically modified to express Drosophila choline acetyltransferase (dChAT) synthesize and release acetylcholine (ACh) in vitro. The ACh produced from the transduced fibroblasts was found to be enhanced by increasing amounts of choline chloride in the culture media. These dChAT-expressing cells were then implanted into the intact hippocampus of adult rats and in vivo microdialysis was performed 7-10 days after grafting to assess the ability of the cells to produce ACh and respond to exogenous choline in vivo. Samples collected from anesthetized rats revealed fourfold higher levels of ACh around dChAT grafts than from either non-grafted or control-grafted hippocampi. Localized choline infusion (200 microM) through the dialysis probes was found to induce a selective twofold increase in ACh release only from the dChAT-expressing fibroblasts. These results indicate not only that dChAT-expressing fibroblasts continue to synthesize and secrete ACh for at least 10 days after intracerebral grafting, but that the levels of ACh can be manipulated in vivo. The ability to regulate products within genetically modified cells in vivo may provide a powerful avenue for exploring the role of discrete substances within the CNS.

Proliferation, differentiation, and long-term culture of primary hippocampal neurons.

Primary embryonic hippocampal neurons can develop morphologically and functionally in culture but do not survive more than a few weeks. It has been reported that basic fibroblast growth factor (bFGF) promotes the survival of and neurite elongation from fetal hippocampal neurons. We report that bFGF, in a dose-dependent manner, can induce the survival (50 pg to 1 ng/ml) and proliferation (10-20 ng/ml) of embryonic hippocampal progenitor neurons in vitro. In serum-free medium containing high concentrations of bFGF, neurons not only proliferated (4-day doubling time) and differentiated morphologically but also could be passaged and grown as continuous cell lines. The neuronal nature of the proliferating cells was positively established by immunostaining with several different neuron-specific markers and by detailed ultrastructural analyses. The proliferative effect of bFGF was used to generate nearly pure neuronal cell cultures that can be passaged, frozen, thawed, and cultured again. Neurons have been maintained > 5 months in culture. The ability to establish long-term primary neuronal cultures offers the possibility that clonal lines of distinct neuronal cell types may be isolated from specific areas of the central nervous system. Such long-term neuronal cultures should prove valuable in studying neurons at the individual cell level and also in exploring interactions between neurons in vitro. The observed dose dependence raises the possibility that cell survival and proliferation in vivo may be influenced by different levels of bFGF.

Effects of choline and quiescence on Drosophila choline acetyltransferase expression and acetylcholine production by transduced rat fibroblasts.

Rat-1 fibroblasts were transduced to express Drosophila choline acetyltransferase. The presence of an active enzyme in these cells (Rat-1/dChAT) was confirmed using various methods. Rat-1/dChAT fibroblasts released acetylcholine (ACh) into the culture medium. Moreover, intra- and extracellular levels of ACh could be increased by adding exogenous choline chloride. In addition, serum starvation or confluence-induced quiescence caused an 80% decrease in recombinant choline acetyltransferase activity (compared with actively growing cells). ACh release was also repressed in quiescent fibroblast cultures. Exogenous choline could mitigate the decrease in ACh release. These results indicate that Rat-1 fibroblasts can be genetically modified to produce ACh and that ACh release can be controlled by introducing choline into the culture medium. Furthermore, these data demonstrate that the expression of the retroviral promoter used in this study decreases with the onset of quiescence; however, exogenous choline can increase the amount of ACh released by quiescent fibroblasts.

Cellular replacement therapy for neurologic disorders: potential of genetically engineered cells.

Neural transplantation, a mode of cellular replacement, has been used as a therapeutic trial for Parkinson's disease. Studies indicate that tonic release of the metabolites from the graft that can be utilized by the host brain, is likely to be the major mechanism responsible for the therapeutic effect. The use of fetal tissue is complicated by ethical controversy and immunological incompatibility. Autografting adult tissue has not been successful mainly due to poor survival. Genetically engineered cells are promising alternative sources of donor cells. We have investigated the potential of primary skin fibroblasts as donor cells for intracerebral grafting. Primary skin fibroblasts survive in the brain and remain in situ. A number of genes (nerve growth factor, tyrosine hydroxylase, glutamic acid decarboxylase, and choline acetyltransferase) have been successfully introduced and expressed in the primary fibroblasts. The L-dopa-secreting primary fibroblasts exhibited a behavioral effect in a rat model of Parkinson's disease up to 8 weeks after being grafted into denervated striatum. Factors that can maximize gene transfer, transgene expression, and fibroblast survival in the brain make up the future direction of investigation.

Intracerebral delivery of growth factors: potential application of genetically modified fibroblasts.

To date, a number of different growth factors (e.g. nerve growth factor, brain-derived neurotrophic factor, neurotrophin-3, ciliary neurotrophic factor, and fibroblast growth factor) have been shown to act as a neurotrophic and/or neurotrophic agents on distinct neuronal populations within the peripheral and central nervous system. Knowledge as to how most of these factors influence the development and regeneration of growth factor-sensitive neurons has been obtained from in vitro examination. A new approach that can be used to assess the effects of growth factors on neuronal groups in vivo is the combined use of gene transfer and intracerebral grafting techniques. The present article explores the potential use of grafting genetically modified fibroblasts within the nervous system as a delivery method for growth factors.

Axotomy enhances the outgrowth of neurites from embryonic rat septal-basal forebrain neurons on a laminin substratum.

Previous studies have suggested that embryonic (nonaxotomized) and regenerating central nervous system neurons differentially respond to the same substrata. In the present study, we have used an in vitro model to test the ability of laminin and type I collagen to promote the outgrowth of neurites from nonaxotomized and axotomized, embryonic septal-basal forebrain (SBF) neurons. Neurons within explants derived from Embryonic Day (E) 15 rats extended neurites that demonstrated similar growth characteristics on a collagen or laminin substratum. E15 neurons could be induced to extend longer neurites on laminin if they were axotomized in vitro and subsequently replated onto a laminin substratum. The carbocyanine dye DiI indicated that neurons which were axotomized could survive and regenerate processes. These regenerating neurites grew 27% longer on laminin than they did on collagen. Similarly, neurons that were axotomized in situ, i.e., E18 SBF neurons, extended neurites that were 29% longer on a laminin substratum. In contrast, E15 explants that were maintained in suspension culture prior to being plated onto a substratum exhibited similar growth on laminin or collagen. The increase in regeneration by E15 neurons on laminin was augmented, by 22%, if nerve growth factor was supplemented to the culture medium. These results demonstrate that laminin is a better substratum, as compared to collagen, for the elongation of neurites from axotomized SBF neurons. Nonaxotomized neurites, on the other hand, do not appear to prefer one substratum over the other. Furthermore, regeneration from embryonic, SBF neurons on laminin is augmented if NGF is used simultaneously.

Effect of nerve growth factor on the elongation of neurites from axotomized rat embryonic septal-basal forebrain neurons: an in vitro analysis.

The administration of nerve growth factor (NGF) into the brain of a fornix-fimbria lesioned rat can rescue many cholinergic, septal-basal forebrain (SBF) neurons from imminent cell death. Unfortunately, it is unclear if NGF can stimulate regenerative growth from axotomized, SBF neurons. In the present study, we used an in vitro model system to determine if NGF could affect neurite outgrowth from nonaxotomized and/or axotomized, embryonic SBF neurons. Axotomized neurons were obtained by severing the neuritic fields surrounding embryonic day (E) 15 SBF explants maintained in primary culture. Acetylcholinesterase (AChE) histochemistry was used to assess the effects of NGF on cholinergic neurites. We report that 1) neurite outgrowth on type I collagen from E15 SBF neurons in primary culture (nonaxotomized neurons) was not affected by NGF. 2) NGF enhanced the outgrowth (regeneration) of axotomized, SBF neurons on a collagen substratum; however, neurons had to be treated with NGF both before and after axotomy to stimulate regeneration effectively. Application of NGF either before or after axotomy did not enhance regenerative neurite outgrowth. 3) SBF neurons had to be axotomized for NGF to facilitate neurite outgrowth. This is supported by the observation that SBF explants, initially maintained in NGF-supplemented medium in suspension culture, did not demonstrate enhanced neurite outgrowth in the presence of NGF when plated onto a substratum. 4) The regenerative growth of AChE-negative, as well as AChE-positive, neurites was facilitated by NGF treatment. In addition to data concerning neurite outgrowth, we also found that the NGF receptor, as recognized by the antibody 192-IgG, expands its distribution as time in culture progresses; i.e., staining, originally confined to cell bodies and proximal processes within the explant, later included neurites that emanated from the explant. Thus, our results demonstrate that NGF can stimulate regenerative growth from axotomized, but not nonaxotomized, embryonic SBF neurons. We hypothesize that, given the appropriate substratum for axon elongation in vivo, NGF can stimulate the regeneration of SBF neurons in the injured adult brain.

Age-dependent patterns and rates of neurite outgrowth from CNS neurons on Schwann cell-derived basal lamina and laminin substrata.

In the present study, we have examined the growth characteristics of CNS neurons on type I collagen, detergent-treated collagen (dColl), Schwann cell-derived basal lamina (SC-BL), and purified laminin substrata. Neurons from the cerebral cortex, septal basal forebrain, and lumbosacral spinal cord were obtained from embryonic age (E) 15 and E18 rats and grown in vitro as explants on the test substrata. Neurons from either embryonic age displayed radial neurite outgrowth on collagen and dColl substrata. However, pretreatment of collagen with detergents slightly diminished its ability to support neurite outgrowth, as evidence by the 20-40% decrease in the rate of neurite growth on dColl versus the rate calculated for neurons on collagen. In contrast to the similar growth characteristics of E15 and E18 neurons on collagen and dColl, the pattern of neurite outgrowth for CNS neurons on SC-BL and laminin substrata was age dependent. Most E15 neurons grown on SC-BL extended neurites that grew identically to those observed on dColl; these 'non-orienting' neurites maintained a radial orientation to their outgrowth despite encountering interposing channels of SC-BL and grew at rates equal to that calculated for neurons on dColl. E15 neurons placed on laminin substrata showed similar growth patterns and rates equal to that calculated for neurons on dColl. E15 neurons placed on laminin substrata showed similar growth patterns and rates to neurons on collagen. In contrast, neurons from E18 rats exhibited neurites that preferentially grew in intimate association with SC-BL channels once contact with the channels was established. These 'orienting' neurites faithfully elongated within the SC-BL and demonstrated a 1.4- to 2.0-fold increase in growth rate compared with the sister cultures of neurons grown on dColl. Furthermore, E18 neurons exhibited a 1.4-fold increase in growth on laminin compared with E18 neurons grown on collagen. A minor population of neurites exhibiting similar characteristics to orienting neurites was also observed in E15 cultures. It is hypothesized that orienting and non-orienting neurites reflect the outgrowth of 'regenerating' and 'developing' neurons, respectively, and may indicate an inherent difference in the ability of regenerating and developing neurons to recognize and respond to the same guidance signals.