Bowen's Disease (Squamous Cell Carcinoma In Situ) in Immunosuppressed Patients Treated with Imiquimod 5% Cream and a COX Inhibitor, Sulindac: Potential Applications for This Combination of Immunotherapy

BACKGROUND: Patients with chronic lymphocytic leukemia (CLL) often have a protracted course. However, all these patients are immunosuppressed and may have a high incidence of cutaneous malignancies. OBJECTIVE: To determine if combination therapy using topical imiquimod cream 5% and the oral cyclooxygenase (COX) inhibitor are useful in the therapy of squamous cell carcinoma in situ (SCC in situ)/Bowen's disease in patients with long-standing CLL. METHODS: Five CLL patients with head and neck cutaneous SCC in situ, which met criteria for Bowen's disease, were treated with topical 5% topical imiquimod cream and an oral COX inhibitor, sulindac 200 mg twice a day. RESULTS: All patients showed clinical resolution and histologic clearing of the tumors after 16 weeks of therapy. CONCLUSION: The local immune modulator, 5% imiquimod, in combination with a COX inhibitor, with its many potential antitumor effects may stimulate the innate and possibly the adaptive immune responses to clear these malignancies.     

Arthroscopic treatment of acute patellar dislocations

Twenty-nine patients treated with arthroscopy alone for acute patellar dislocation were reviewed. All had a significant traumatic episode with hemarthrosis in a previously asymptomatic knee. Clinical follow-up averaged 25 months (range 5-64 months). Fifteen patients had concomitant percutaneous lateral release (LR). Significant-sized osteochondral defects not radiographically visible preoperatively were discovered in 40%. Fragments were excised and corresponding craters debrided or abraded. Additional intraarticular pathology discovered included two meniscal tears and one anterior cruciate tear. Overall excellent (E) and good (G) results were 83%. The recurrence rate was 14%, all of which occurred in the LR group. All recurrent dislocations occurred within 1-year post injury. The LR group had 73% G and E results compared with 93% in those without LR. Arthroscopy followed by immobilization was an efficacious approach to acute traumatic patellar dislocations in this specific group of patients. The addition of LR with early motion, however, detracted from the results.     

The Surgical Management of Spitz Nevi

BACKGROUND: The biologic behavior of Spitz nevi and atypical Spitz nevi ranges from completely benign to the rare malignant melanoma. Various recommendations for the surgical approach to these lesions have been proposed. OBJECTIVE: To determine any trend in the surgical management of Spitz nevi and atypical Spitz nevi among a community of dermatologists. METHODS: Retrospective review of the clinical features, surgical management and outcome of 89 patients with the diagnosis of Spitz nevus or atypical Spitz nevus. RESULTS: All biopsy techniques had a high incidence of involved margins: shave (67%), excision (28%), and punch (21%). Of the atypical Spitz nevi with positive margins on biopsy, there was a trend (7/9) toward reexcision with narrow margins (average 2.2 mm). CONCLUSION: The majority of atypical Spitz nevi incompletely removed by biopsy were excised with narrow uncontrolled margins. A stratified surgical approach depending on the clinical and histopathologic features of the Spitz lesion is proposed. More aggressive surgical management of Spitz lesions with atypical features may be warranted. Further studies to determine the biologic potential of these lesions are needed.     

Headache in a Hospitalized Military Population

SYNOPSIS
The problem of headache is ubiquitous in the medical profession, and is a very frequent complaint at military sick calls. In 1969 a retrospective study of 196 patients hospitalized at the Philadelphia Naval Hospital offered the opinion that "all patients had symptoms and signs of vascular headaches of the migraine type."Our study was done in a prospective manner to analyze the headache syndromes of 100 patients requiring admission to the Neurology Service at the National Naval Medical Center, Bethesda, Maryland. Only 33% of cases could be classified as vascular headache of the migraine type in this study, utilizing the criteria proposed by the Ad Hoc Committee on Classification of Headache. The other types varied considerably. Findings related to age, sex, circumstances of admission, expectations of hospitalization, history of headache in a primary relative, head trauma, neurologic examination, and laboratory studies are discussed.     

Immune response to polyvalent melanoma cell vaccine in AJCC stage III melanoma: An immunologic survival model

Background: Our polyvalent, allogeneic melanoma cell vaccine (MCV) induces immunoglobulin M (IgM) and immunoglobulin G (IgG) class antibodies to a 90-kDa glycoprotein melanoma-associated antigen (MAA). Additionally, MCV induces delayed-type hypersensitivity (DTH) responses that we previously correlated with survival. We hypothesized that early DTH responses to MCV and early humoral responses to the 90-kDa MAA expressed on MCV cells may be predictive of overall survival. We tested this hypothesis by monitoring immunologic profiles in 59 patients with melanoma who were receiving MCV after surgical resection of regional lymph node or soft-tissue metastases. Methods: Blood was drawn before vaccine administration, biweekly for 6 weeks, and then monthly. DTH to MCV was recorded at 0, 2, 4, and 8 weeks of MCV therapy. Mean antibody titers during the first 6-week interval were calculated. Changes in DTH were calculated as the difference between peak and prevaccine values (ΔDTH). Results: At a median follow-up of 75.6 months (range 5–138), univariate analysis assigned prognostic significance to gender (p=0.046), lymph node involvement (p=0.024), ΔDTH (p=0.044), mean anti-90-kDa MAA IgG (p=0.0009), and mean anti-90-kDa MAA IgM (p=0.0014). In multifactorial analysis, only the three immunologic variables significantly impacted survival (p=0.046, 0.0005, and 0.0053, respectively). A mathematical model based on ΔDTH and mean anti-90-kDa MAA IgG and IgM titers closely approximated the observed individual and overall survival rates. Conclusions: The correlation between overall survival and initial humoral/cellular immune responses to MCV immunotherapy may be useful in selecting patients most likely to benefit from prolonged adjuvant immunotherapy. Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996. Received SSO Annual Resident/Fellow Award for Best Clinical Research Paper. The views expressed herein are those of the authors and do not necessarily reflect the views of the US Army, US Navy, Uniformed Services University of the Health Sciences, or the Department of Defense.