Inhibition of transformation by levodopa-carbidopa in lymphocytes derived from patients with melanoma

Levodopa-carbidopa has been widely used in the treatment of Parkinson's disease. We are currently investigating the effectiveness of this combination for the treatment of patients with advanced malignant melanoma. As part of this study, we have examined the effects of this combination on the phytohemagglutinin-induced transformation of human lymphocytes, isolated from patients with malignant melanoma prior to undergoing treatment. Levodopa, as well as carbidopa and 3 additional levodopa synthetic analogs, inhibited the transformation of phytohemagglutinin-stimulated DNA synthesis at pharmacologically attainable levels. These results confirm our earlier preclinical observations suggesting that catechols have profound intracellular metabolic effects in a variety of cells other than melanoma cells. It is possible that some of the effects of catechols in other diseases might also be mediated by similar intracellular metabolic effects, and effects on human melanoma might be mediated in part through effects on the immune system. We are currently awaiting introduction of synthetic catechols, including 3,4-dihydroxybenzylamine (NSC 263475), to extend these observations to our clinical studies in patients with advanced metastatic disease.     

A case of epidermotropic metastatic malignant melanoma with multiple nodular lesions of the scalp

Epidermotropic metastatic malignant melanoma (EMMM) is a form of metastatic malignant melanoma that has dermal cell nests with epidermotropism and specific histopathological features. We report a patient with eight nodular lesions of the scalp with histopathological findings compatible with EMMM. The tumors developed one year before consultation and increased in size simultaneously. The histopathological findings of all eight tumors were very similar. The tumor cells were located mainly in the dermis and partly in the basal layer of the epidermis. They contained melanin pigments and were positive for anti-HMB45 antibody. The tumors did not respond to combination chemotherapy with dacarbazine, nimustine, vincristine, and interferon-beta. Therefore, all the tumors were surgically removed. No local relapse, distant metastasis or re-elevation of plasma 5-S-cysteinyldopa was identified during nine months of follow-up. Histopathologically, all eight tumors lacked apparent vascular invasion, which may be related to a slow clinical course of the present case.     

Serum 5-S-cysteinyldopa (5-S-CD) as a marker of melanoma progression.

We previously reported that serum 5-S-cysteinyldopa (5-S-CD) tended to elevate earlier and reflect melanoma progression better than urinary 5-S-CD. In patients without metastatic melanomas, serum concentration and urinary excretion of 5-S-CD and 6-hydroxy-5-methoxy-indole-2-carboxylic acid (6H5MI2C) were within the upper limits of normal controls. In this report, we presented more precisely the changes in these melanin-related markers and clinical courses of four melanoma patients. Serum and 24-hour urine samples were serially collected and assayed every 1 to 4 months. Three of them developed stage IV malignant melanomas and died of metastatic disease. 6H5MI2C in serum and urine did not reflect the progression of disease. Among the 4 parameters considered, 5-S-CD in serum appeared to be the best biochemical marker for melanoma progression. Serum 5-S-CD over the upper limit of 10 nmol/L was suggested as a serious sign of the progression of melanoma.     

Predictive value of serum S100B for monitoring patients with metastatic melanoma during chemotherapy and/or immunotherapy

In the immunohistology of malignant melanoma the use of polyclonal antibodies against protein S100 is well established. Recently, it was shown that S100B, a subunit of the S100 protein family, is detectable in the serum of melanoma patients and correlates with the stage of the disease in patients with metastatic melanoma. In the present study, the first evaluation of a large number of treatment observations (n = 77) in 64 different patients during chemotherapy and/or immunotherapy for advanced metastatic melanoma (stage IV) is presented. All patients received treatment according to standardized protocols comprising 8 weeks of treatment followed by routine staging procedures to evaluate therapeutic outcome. In 13 patients with tumour enlargement after first-line therapy, a second-line treatment was subsequently given. S100B immunoradiometric assay (IRMA) tests were performed before, during and after treatment at scheduled time points. In the interim analysis at 4 weeks 29 of 37 (78%) patients with tumour progression during treatment showed a raised S100B level. In the final analysis at 8 weeks, 31 of these 37 patients (84%) demonstrated rising S100B values (P < 0.001). Patients who responded to treatment (stable or regressing metastatic disease) showed constant or declining S100B levels in 38 of 40 patients (95%) at the interim analysis, at 8 weeks this was further increased to 39 of 40 patients (98%; P < 0.001). Thus, the use of S100B for monitoring treatment is adequate in the majority of cases. Our observations are of great interest for therapeutic trials of adjuvant and palliative therapies as the rise of S100B levels might indicate that re-staging and/or changes in therapy strategies should be chosen.     

Topical imiquimod and intralesional interleukin-2 increase activated lymphocytes and restore the Th1/Th2 balance in patients with metastatic melanoma

Background  Patients with metastatic skin disease in malignant melanoma are difficult to treat, with unresectable lesions proving the biggest challenge. We have recently published data showing a significant clinical response in patients with multiple in-transit melanoma metastases treated with a combination of topical imiquimod and intralesional interleukin (IL)-2. Here we report the results of immunological analysis with the aim of highlighting correlations with our clinical findings.
Objectives  To investigate the systemic effects of our localized combination treatment in patients with accessible metastases of melanoma, and to correlate this with their clinical responses.
Methods  The peripheral blood mononuclear cells of patients were collected at various time points throughout the treatment. Using antibodies to T-cell subsets we measured the changes in cell populations, and along with polyclonal stimulation, changes in cytokine production from these cells over a treatment course.
Results  We report an increase in the mean CD4/CD8 ratio from 2·78 to 3·54 with treatment ( P  < 0·01), and a rise in the percentage of CD25+ cells in the CD4+ population from 14·52% to 38·56%. Furthermore, staining with activation and T-regulatory markers showed that the majority of this population is activated T cells. Cytokine analysis on polyclonally stimulated peripheral blood mononuclear cells showed an increase in the ability of cells to produce interferon (IFN)-γ over the treatment course, with an initial rise in the IFN-γ/IL-5 ratio in five of six patients.
Conclusions  The results of this study provide evidence that, in the majority of patients with in-transit metastases of melanoma, therapy with a combination of topical imiquimod and intralesional IL-2 induces a systemic immunological effect by reversing some of changes noted in patients with malignant disease.     

The Skin Cancer Quality of Life Impact Tool (SCQOLIT): a validated health‐related quality of life questionnaire for non‐metastatic skin cancers

Background Quality of life (QOL) issues in patients with non‐metastatic skin cancer are not satisfactorily demonstrated when using existing QOL questionnaires. Objective To construct and validate a 10 item disease‐specific QOL questionnaire, the Skin Cancer Quality of Life Impact Tool (SCQOLIT), for use in patients following treatment of non‐metastatic skin cancer. Methods The SCQOLIT was constructed and administered initially to 120 patients with non‐metastatic skin cancer, 60 with malignant melanoma (MM) and 60 with non‐melanoma skin cancer (NMSC) following treatment, then repeated in half this cohort at seven days, and the other half at three months. Data was collected on age, gender, skin cancer type and Breslow thickness. Statistical validation was undertaken. Results There were 113 valid SCQOLIT responses at initial completion (54 in the MM group, and 59 in the NMSC group). Initial SCQOLIT median scores (interquartile range [IQR], range) for the two groups were 10 (12, 0–28) MM, and 4 (5, 0–19) NMSC. Amongst the cohort readministered the SCQOLIT at three months (23 in the MM group, 25 in the NMSC group) median scores (IQR, range) were 6 (6, 0–26) MM and 3 (4, 0–20) NMSC. Conclusions The SCQOLIT is a validated disease‐specific QOL questionnaire for use in patients following treatment of non‐metastatic skin cancer. Higher SCQOLIT scores are observed in MM patients than NMSC patients, but diminish with time in the MM group. Patients with persistently elevated SCQOLIT scores merit additional attention.     

Upcoming strategies for the treatment of metastatic melanoma

Prognosis for advanced and metastatic melanoma is poor, with a 5-year survival of 78, 59 and 40% for patients with stage IIIA, IIIB and IIIC, respectively, and a 1-year survival of 62% for M1a, 53% for M1b and 33% for M1c. The unsatisfactory results of actual standard therapies for metastatic melanoma highlight the need for effective new therapeutic strategies. Several drugs, including BRAF, KIT and MEK inhibitors, are currently being evaluated after promising data from Phase I and Phase II studies; Vemurafenib, a BRAF-inhibitor agent, has been approved by the Food and Drug Administration (FDA) for the treatment of patients with unresectable or metastatic melanoma with the BRAF V600E mutation after a significant impact on both progression-free and overall survival was demonstrated compared with dacarbazine in a Phase III trial. Ipilimumab, an immunotherapeutic drug, has proven to be capable of inducing long-lasting responses and was approved for patients with advanced melanoma in first- and second-line treatment by the FDA and in second-line treatment by the European Medicines Agency. Furthermore, a significant survival benefit of the combination of ipilimumab with dacarbazine compared with dacarbazine alone for first-line treatment was reported. In the near future, patients with BRAF mutations could have the chance to benefit from treatment with BRAF inhibitors; patients harboring BRAF or NRAS mutations could be treated with MEK inhibitors; finally, the subgroup of patients with acral, mucosal or chronic sun-damaged melanoma harboring a KIT mutation could benefit from KIT inhibitors. Ipilimumab could become a standard treatment for metastatic melanoma, both as a single agent and in combination; its efficacy has been proven, and researchers should now address their efforts to understanding the predictive variables of response to treatment.     

Optimal Management of Metastatic Melanoma: Current Strategies and Future Directions

Melanoma is increasing in incidence and remains a major public health threat. Although the disease may be curable when identified early, advanced melanoma is characterized by widespread metastatic disease and a median survival of less than 10 months. In recent years, however, major advances in our understanding of the molecular nature of melanoma and the interaction of melanoma cells with the immune system have resulted in several new therapeutic strategies that are showing significant clinical benefit. Current therapeutic approaches include surgical resection of metastatic disease, chemotherapy, immunotherapy, and targeted therapy. Dacarbazine, interleukin-2, ipilimumab, and vemurafenib are now approved for the treatment of advanced melanoma. In addition, new combination chemotherapy regimens, monoclonal antibodies blocking the programmed death-1 (PD-1)/PD-ligand 1 pathway, and targeted therapy against CKIT, mitogen-activated protein/extracellular signal-regulated kinase (MEK), and other putative signaling pathways in melanoma are beginning to show promise in early-phase clinical trials. Further research on these modalities alone and in combination will likely be the focus of future clinical investigation and may impact the outcomes for patients with advanced melanoma.     

Metastasiertes malignes Melanom

A 73-year-old man, in whom 26 years ago a malignant melanoma with cervical lymph node metastases of the right retroauricular region was diagnosed, developed BRAF V600E-negative distant metastases, which progressed during both monochemotherapy and polychemotherapy. Therefore he was started on ipilimumab in a dose of 3 mg/kg body weight four times in intervals of 3 weeks. Subsequently, there was an almost complete regression of distant metastases. In several phase III trials a significant survival benefit has been identified for patients treated with ipilimumab. The human monoclonal antibody has been approved since July 2011 as a second-line treatment in Germany and was incorporated in January 2013 into the new guidelines for the treatment of malignant melanoma. The CTLA-4 antibody is the first drug that can improve significantly survival in patients with metastatic melanoma. In advanced (unresectable or metastatic) melanoma, immunostimulatory treatment with ipilimumab represents a new therapeutic option.     

Treatment of Cutaneous Melanoma of the Face by Mohs Micrographic Surgery

Background: The treatment of cutaneous malignant melanoma of the face presents a challenge to ensure eradication of disease with maximum preservation of tissue. Mohs micrographic surgery provides a means for histologically controlled removal of malignant melanoma. Objective: This study evaluates the efficacy of Mohs micrographic surgery, at a single institution, for the treatment of facial melanoma and assesses the accuracy of margin control by frozen section techniques. Methods: Ninety-seven patients with biopsy-confirmed melanoma in situ or invasive melanoma of the face were treated by Mohs micrographic surgery over a 6-year period. In 25 patients, tissue margins defined as negative for melanoma at the time of frozen section were re-evaluated on permanent section histology of formalin-fixed, paraffin-embedded tissue. Results: Ninety-two of 97 patients had followup information available (8–72 months; mean 33 months). There were no cases of local recurrence. Eighty-nine of the 92 patients were alive and well with no evidence of disease. One patient died of metastatic melanoma. In situ or invasive melanoma was not identified on permanent sections of 117 tissue margins which had been interpreted as negative on frozen section. Conclusion: Mohs micrographic surgery appears to be an effective treatment for facial melanomas. Our study showed complete correlation between frozen section tissue margins and permanent section controls.     

In situ photoimmunotherapy: a tumour-directed treatment for melanoma

We report a new immunological treatment for advanced cutaneous melanoma which combines laser stimulation with topical application of a toll-like receptor agonist. This treatment, in situ photoimmunotherapy (ISPI), provides an alternative to traditional therapies for melanoma patients with cutaneous metastases. A 6-week cycle of ISPI is carried out on cutaneous metastases located in a designated 20 x 20 cm treatment area: 2 weeks of pretreatment with twice-daily topical applications of imiquimod (5% cream under plastic occlusion), with a laser treatment session at week 2 and again at week 4. Topical imiquimod is continued for the entire 6-week cycle. Two patients with late-stage melanoma were treated with ISPI. Patient 1 had the primary tumour and local metastases on the left arm, as well as metastatic tumours in the lungs [American Joint Committee on Cancer (AJCC) stage IV]. Patient 2 had a head and neck melanoma with multiple local metastases (AJCC stage IIIC), which had failed repeated attempts at surgical resection and high-dose radiation therapy. Patient 1 is now free of all clinically detectable tumours (including the lung metastases) >20 months after the first treatment cycle. Patient 2 has been free of any clinical evidence of the tumour for over 6 months. These two cases demonstrate that ISPI can clear local tumour and trigger beneficial systemic responses, with a side-effect profile that compares favourably with other treatments for advanced melanoma.     

Improving survival in patients with high-risk and metastatic melanoma: immunotherapy leads the way

Melanoma is a neoplasm with an incidence in the US that is rising at a rate second only to lung cancer in women. Early stage melanoma is curable, but advanced metastatic melanoma is almost uniformly fatal, even in 2003. The close relationship of melanoma with the immune system has led to a recent resurgence in the investigation of immunotherapy in the treatment of this disease. The two most widely investigated immunotherapy drugs for melanoma are interferon (IFN)-alpha and interleukin-2 (IL-2). The role of IFNalpha-2b in the adjuvant therapy of patients with localized melanoma at high risk for relapse has recently been established by the results of three large randomized trials conducted by the US Intergroup; all three trials demonstrated an improvement in relapse-free survival and two in overall survival. Recombinant IL-2 (rIL-2) has an overall response rate of 15-20% in metastatic melanoma and is capable of producing complete and durable remissions in about 6% of patients treated. Based upon these data, the US FDA has recently approved the use of high-dose bolus administration of rIL-2 for the therapy of patients with metastatic melanoma. Results of combination chemotherapy and immunotherapy regimens containing rIL-2 and IFNalpha (biochemotherapy) are promising, but conclusions regarding an advantage for this therapy in terms of survival must await the completion of ongoing randomized trials. The use of therapeutic vaccines is an ongoing area of research, and clinical trials of several types of vaccines (whole cell, carbohydrate, peptide) are being conducted in patients with intermediate and late-stage melanoma. In the setting of adjuvant therapy, to date, no vaccine has demonstrated a survival benefit in comparison with either observation or IFNalpha. Vaccines are also being tested in patients with metastatic melanoma to determine their immune effects and to define their activity in combination with other immunotherapeutic agents such as IL-2 or IFNalpha.     

Cutaneous melanoma: new advances in treatment

Cutaneous melanoma is a challenge to treat. Over the last 30 years, no drug or combination of drugs demonstrated significant impact to improve patient survival. From 1995 to 2000, the use of cytokines such as interferon and interleukin become treatment options. In 2011, new drugs were approved by the U.S. Food and Drug Administration, including peginterferon alfa-2b for patients with stage III disease, vemurafenib for patients with metastatic melanoma with the BRAF V600E mutation, and ipilimumab, a monoclonal antibody directed to the CTLA-4 T lymphocyte receptor, to combat metastatic melanoma in patients who do not have the BRAF V600E mutation. Both ipilimumab and vemurafenib showed results in terms of overall survival. Other trials with inhibitors of other genes, such as the KIT gene and MEK, are underway in the search for new discoveries. The discovery of new treatments for advanced or metastatic disease aims to relieve symptoms and improve patient quality of life.     

Case of metastatic melanoma in an epitrochlear lymph node arising in a pregnant woman

We describe a rare case of metastatic melanoma in an epitrochlear lymph node in a 29-year-old female patient. The patient had been aware of a brown macule on her right posterior forearm at puberty. Because the lesion had enlarged rapidly, she was referred to our hospital. Histological examination revealed a malignant melanoma. She underwent wide local excision with 3-cm margins and split thickness skin graft closure, but we were not able to perform sentinel node biopsy. She also received three cycles of systemic chemotherapy with dacarbazine, nimustine, vincristine and interferon-beta. However, an epitrochlear node (interval node) metastasis occurred during pregnancy (seventh week) 2 years after the operation. We emphasize that it is important for clinicians to pay attention to the possibility of epitrochlear node metastasis in patients with malignant melanoma in the upper extremity and that it is necessary to perform sentinel node biopsy to identify uncommon lymph node metastasis.     

Synergistic effects of hyperthermia and peplomycin against human malignant melanoma xenografts

Two types of human malignant melanoma were treated either with peplomycin alone, hyperthermia alone, or a combination of peplomycin and hyperthermia. The antitumor effect of combination therapy was evaluated by tumor growth curves, maximal suppression rate, and histopathology. A marked antitumor effect of combination therapy with peplomycin (5 mg/kg) and hyperthermia (43°C, 30 min) was obtained for both types of melanoma. Histopathologic findings revealed advanced central necrosis and pyknotic nuclei in the tumor cells. Although peplomycin alone (20 mg/kg, 6 times) had no antitumor effect on C24 melanoma, the peplomycin (5 mg/kg, 6 times) + heat group showed complete inhibition of the tumor growth. These results suggest that hyperthermia enhances the antitumor effect of peplomycin even against peplomycin-resistant tumor cells.     

Interferon-β therapy for malignant melanoma: the dose is crucial for inhibition of proliferation and induction of apoptosis of melanoma cells

We investigated the anti-tumor effect of human interferon-beta (HuIFN-beta) against malignant melanoma. In vitro study revealed that HuIFN-beta not only inhibited proliferation of melanoma cells (seven cell lines: MM-AN, MM-BP, MM-LH, MM-RU, PM-WK, RPM-EP, RPM-MC) but also induced apoptosis in a dose dependent fashion, though the sensitivity to HuIFN-beta was different among cell lines. In addition, we administered HuIFN-beta into cutaneous metastatic lesions of melanoma and evaluated clinical and histopathological effects. Although the size of the metastatic cutaneous lesion did not change by the intralesional injection of HuIFN-beta, histopathological examination revealed apoptotic changes of melanoma cells along with dense lymphohistiocytic infiltration. The present study confirmed direct and indirect inhibitory effects of HuIFN-beta on human melanoma cells and suggests that local higher concentration of HuIFN-beta is needed to eradicate melanoma lesions.     

Malignant melanoma--future prospects

As the incidence and already high mortality rates of malignant melanoma have been steadily increasing in recent decades, the early detection and excision of malignant melanoma have imposed as the most important task. Staging of malignant melanoma is determined according to the level of invasion (Clark level) and vertical thickness (Breslow scale). Besides operative therapy, which is the only effective treatment for malignant melanoma, postoperative adjuvant chemotherapy, immunotherapy, radiotherapy, and biologic therapy also are of great importance. In recent years, immunologic strategies including tumor vaccine and adjuvant therapy with interferon-alfa have been attempted to improve survival of patients with more advanced malignant melanoma. A recent melanoma research has focused on target therapy such as immunotherapy (vaccines, monoclonal antibodies, dendritic cells) and gene therapy. Genetic immunization has become an attractive strategy for the development of melanoma vaccines, because a number of antigens recognized by cellular components of the immune system have been identified at the molecular level. Numerous chemotherapeutic agents have shown activity in the treatment of metastatic malignant melanoma, such as dacarbazine (dimethyl triazene imidazole carboxamide); other agents have been used, however, with less success. However, a very modest effect was recorded in advanced malignant melanoma. There are many experimental trials using combined therapy for malignant melanoma, including chemotherapy (dimethyl triazene imidazole carboxamide) and biologic therapy (interleukin (IL)-2, interferon (IFN)-gamma, IFN-alfa). The results obtained open particularly interesting prospects in the field of malignant melanoma with high relevance for its development and progression. Molecular therapeutics and vaccine development will probably be an important focus for the future melanoma treatment.     

恶性黑素瘤患者T细胞化学趋化功能

目的　探讨恶性黑素瘤患者循环T细胞在体外对单核细胞化学趋化蛋白 1 (MCP 1 )的化学趋化功能及其与肿瘤浸润淋巴细胞 (TIL)及与肿瘤转移之间的关系。方法　用微量化学趋化装置和免疫组化方法测定患者T细胞对MCP 1的化学趋化功能和TIL计数。结果　原发性和转移性黑素瘤患者T细胞对MCP 1的化学趋化功能均明显低下 ,而基底细胞癌患者T细胞的化学趋化功能正常。免疫组化研究发现原发性恶性黑素瘤TIL数量与T细胞的化学趋化功能之间无关。结论　原发性和转移性恶性黑素瘤患者循环T细胞特异性地对MCP 1的化学趋化反应低下。这可能是由于这些细胞上的MCP 1受体表达或调节异常所致     

The cutaneous manifestations of metastatic malignant melanoma

Cutaneous metastases are common sequelae of primary malignant melanoma. Because patients with melanoma are examined frequently after diagnosis, it is important that dermatologists are aware of the range of findings that may represent metastatic disease. Many case reports and a few retrospective series have been published detailing the wide variety of clinical presentations of cutaneous metastatic melanoma. This article reviews the various manifestations of metastatic melanoma of the skin and oral mucous membranes and summarizes treatment options for metastatic disease.     

Hemophagocytic syndrome and metastatic melanoma: 3 cases

BACKGROUND: Macrophage activation syndrome was initially described during viral infections in immunocompromised patients. Since the original report, many diseases have been found to be associated with macrophage activation syndrome. Lymphoproliferative disorders have been more frequently reported to be associated with macrophage activation syndrome than solid tumors. We herein report three cases of macrophage activation syndrome in patients with metastatic malignant melanoma. CASE-REPORTS: Two young 32 and 40 year-old men with a liver metastatic malignant melanoma and a 62 year-old woman with a polymetastatic malignant melanoma presented a sudden deterioration of general health with hyperthermia and biological abnormalities: liver cytolysis, leucocytosis, thrombocytopenia, hypertriglyceridaemia. A fatal clinical outcome occurred rapidly despite corticotherapy and/or chemotherapy. For the first two patients the macrophage activation syndrome diagnosis was delayed because of the similarities of macrophage activation syndrome and metastatic malignant melanoma symptoms. DISCUSSION: The diagnosis of macrophage activation syndrome in patients with metastatic malignant melanoma may be difficult because of the similarities between clinical features of macrophage activation syndrome and those of metastatic malignant melanoma. Hypertriglyceridaemia is present in 60 p. 100 of macrophage activation syndrome and should lead to process a bone marrow aspirate. The search for a triggering infection should be systematically carry out because it is implicated in more than half of macrophage activation syndrome whatever the associated disease may be: neoplasia, autoimmune disease. The pathogenesis of macrophage activation syndromes occurring in patients with metastatic cancer remains unexplained. Treatment of macrophage activation syndrome is not unanimously established and usually consists in the treatment of the associated condition as well as a corticosteroid and/or an immunosuppressive treatment regimens. Prognosis of macrophage activation syndrome is usually poor especially when it is associated with a neoplasia since a fatal outcome occurs in 40 to 60 p. 100 of cases.