Supplementary Table 1 and Figure 1 from 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

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 (λem ≈ 630 nm; 37 J/cm2). 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 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.

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.

8551 Background: Melanoma is a cutaneous neoplasm known for its high agressiveness and its poor prognosis once metastasized. Dacarbacine chemotherapy is actually considered standard first-line treatment of metastatic melanoma, with reported response rates of 6–7%. Due to this unsatisfactory situation, a number of non-standard anti-cancer drugs have been tested for improved efficacy. The present study was aimed to test doxorubicin plus paclitaxel in metastatic melanoma patients based on in-vitro chemosensitivity of this drug combination in fresh tumor samples. Methods: The primary study endpoint was objective response, secondary endpoints were safety and overall survival. Patients with histologically confirmed metastatic melanoma (AJCC stage IV), measurable tumor parameters, and an in-vitro chemosensitivity to doxorubicin plus paclitaxel which is superior to other test drugs determined by an ATP-based luminescence viability assay, were eligible. Patients received paclitaxel 175 mg/m2 i.v. followed by pegylated liposomal doxorubicin 30 mg/m2 i.v. at d1 every 28 days. Tumor assessment was performed every 8 weeks and evaluated according to RECIST. Treatment was continued at a tumor response of stable disease (SD) or better, and stopped in case of disease progression (PD) or intolerable side effects. Results: Out of 14 patients enrolled into this study, 12 received study treatment as first-line, and two as second-line therapy. Objective response was 14.3% (1 CR, 1 PR); progression arrest was 28.6% (1 CR, 1 PR, 2 SD). Median overall survival was 9.7 months. Common slight to moderate side effects were myelosuppression and neurotoxicity. Severe toxicities (CTC grade 3/4) were experienced by three patients (21.4%), with two of them presenting severe myelosuppression, and one experiencing myocardial infarction. Conclusions: Pegylated liposomal doxorubicin combined with paclitaxel shows significant efficacy in advanced metastatic melanoma if applied in an individualized, sensitivity- directed regimen. The observed side effects were comparable to other combination chemotherapies. This treatment regimen needs further evaluation in larger clinical trials containing standard therapy control groups. No significant financial relationships to disclose.

8536 Background: Major problems of high-dose interferon (HDI) in patients with malignant melanoma (MM) result from side effects and impairment of quality of life (QoL). Up to now it is unclear whether intraveneous (iv), subcutaneous (sc), or both components of HDI treatment are necessary for the efficacy in adjuvant treatment of MM. The adjuvant phase III DeCOG MM-ADJ-5 trial evaluates efficacy, safety, and tolerability of pulsed high-dose intravenous IFNa2b. In this prospective, randomized trial, 3 courses of IFNa2b 20 Mio IU/m2 iv on 5 days a week for 4 weeks repeated every 4 months are compared to the standard HDI regimen. The higher iv dosage produces more toxicity, but for a shorter period of time, since patients in the pulsed treatment arm are 9 months off treatment as compared to the conventional sc treatment with 10 Mio IU/m2 three times a week given for 11 months after 4 weeks of iv therapy. Methods: With a planned recruitment of 600 patients, an interim analysis of QoL has been performed after half of the patients completed treatment. EORTC QLQ- C30 questionnaire modified for interferon side effects was obtained before therapy, and at 4, 16, 24, and 40 weeks of treatment. The global QoL items were obtained weekly by a visual analogue scale over the whole year of treatment. Additionally, the side effects were scored using CTC- AE toxicity levels, and dose modifications were recorded. Results: A total of 300 patients were evaluated. After 4 weeks of initial iv HDI treatment the global QoL score decreased similarly in both treatment groups (35% vs. 41%). Four weeks after the initial iv pulse, the global QoL score completely recovered in the experimental arm (104%). In the conventional HDI, QoL remained reduced by an average 22% during the whole subcutaneous treatment phase. During the second and third iv-pulse in the experimental arm, QoL again decreased and completely recovered thereafter. Overall, the cumulative QoL score measured for 12 months treatment was significantly in favour of the pulsed regimen (+16% AuC value). Conclusions: Patients under pulsed adjuvant HDI treatment experience significantly less impairment of QoL and may therefore have a higher rate of completing the scheduled dosage. [Table: see text]

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.

The B7-1/B7-2-CD28/CTLA-4 pathway is crucial in regulating T cell activation and tolerance. Autoantibodies to surface molecules on lymphocytes have already been described in various immune conditions, such as autoimmune diseases, infections and blood transfusions. The objective of this study was to test sera from healthy individuals and from patients for association of CD28 autoantibodies with inflammatory and non-inflammatory diseases. First, CD28 was obtained by digestion of CD28-Ig fusion protein with trypsin. The cleavage products were separated by sodium dodecyl sulphate-page gel electrophoresis. Additionally, a CD28/GST fusion protein was expressed in Escherichia coli and was used to establish an enzyme-linked immunosorbent assay for detection of autoantibodies against CD28. Sera from healthy individuals (n = 72) and patients with different inflammatory and noninflammatory skin diseases (n = 196) were tested for the presence of autoantibodies against CD28. Using mixed lymphocyte reaction (MLR), purified autoantibodies against CD28 were tested for their effects on CTLA-4-Ig-induced T cell anergy. In this study, for the first time, we describe the existence of autoantibodies against CD28 in humans which are associated with atopic diseases, e. g. allergic rhinitis and asthma. These antibodies stimulate T cells and overcome the CTLA-4-Ig-induced anergy of T cells in an MLR. The existence of autoantibodies against CD28, which may have a T cell-stimulating function, has been shown. The data indicate that autoantibodies against CD28 could be a new immunological mechanism in allergic inflammation. Additionally, autoantibodies against CD28 could be an important new marker to discriminate between atopic diseases and other inflammatory skin diseases.

SummaryMedical 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 (ÄappO 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 venerology” according to the new educational law.

JDDG: Journal der Deutschen Dermatologischen GesellschaftVolume 4, Issue 3 Die neue Approbationsordnung für Ärzte: Das Hamburger Konzept im Fach Dermatologie und Venerologie Karsten Neuber, Karsten Neuber Department of Dermatology and Venereology, University Clinic Eppendorf, Hamburg, GermanySearch for more papers by this authorKatja Weidtmann, Katja Weidtmann Office of the Vice Dean for Education, University Clinic Eppendorf, Hamburg, GermanySearch for more papers by this authorEsther Coors, Esther Coors Department of Dermatology and Venereology, University Clinic Eppendorf, Hamburg, GermanySearch for more papers by this authorSigrid Harendza, Sigrid Harendza III. Medical Clinic, University Clinic Eppendorf, Hamburg, GermanySearch for more papers by this author Karsten Neuber, Karsten Neuber Department of Dermatology and Venereology, University Clinic Eppendorf, Hamburg, GermanySearch for more papers by this authorKatja Weidtmann, Katja Weidtmann Office of the Vice Dean for Education, University Clinic Eppendorf, Hamburg, GermanySearch for more papers by this authorEsther Coors, Esther Coors Department of Dermatology and Venereology, University Clinic Eppendorf, Hamburg, GermanySearch for more papers by this authorSigrid Harendza, Sigrid Harendza III. Medical Clinic, University Clinic Eppendorf, Hamburg, GermanySearch for more papers by this author First published: 07 March 2006 https://doi.org/10.1111/j.1610-0387.2006.05924_1.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume4, Issue3March 2006 RelatedInformation

Interactions between keratinocytes and mononuclear cells via cytokines and adhesion molecules are thought to play a crucial part in inflammatory skin diseases. The cytokine-mediated effects of peripheral blood mononuclear cells (PBMC) from patients with atopic eczema (AE) and healthy individuals on keratinocytes (HaCaT) were investigated in vitro. A new coculture model (Transwell system) which consists of a lower and an upper compartment, which are separated by a polycarbonate-treated membrane, was established. 3[H]thymidine incorporation of keratinocytes and lymphocytes, as well as IL-6, IL-8 and IFN-gamma synthesis, were measured. Keratinocyte proliferation was significantly enhanced in the presence of PBMC from patients with AE. In contrast, PBMC from normal donors did not enhance HaCaT cell proliferation when they were cocultured. Lymphocytes from patients with AE showed a significantly enhanced proliferation after coculture with keratinocytes. However, PBMC from normal donors did not proliferate in the presence of HaCaT cells. Keratinocyte supernatants incubated with PBMC from either atopic or normal volunteers induced a suppression of lymphocyte 3[H]thymidine incorporation. In supernatants from cocultures of PBMC from patients with AE and keratinocytes, significantly enhanced amounts of IL-6 and IL-8, compared with normal donor's lymphocytes and HaCaT cells, were measured. No differences in IFN gamma production were observed. When PBMC were cultured without HaCaT cells, supernatants contained equal levels of IL-6, IL-8 and IFN-gamma in normal donors and in patients with AE. Interestingly, HaCaT cells spontaneously secrete measurable amounts of IL-6, IL-8 and IFN-gamma. Blocking experiments with neutralizing antibodies against these interleukins showed a complete inhibition of keratinocyte proliferation when PBMC from normal donors were used whereas the proliferative potency of PBMC supernatants from patients with AE on keratinocytes remained. Our data indicate that (i) PBMC from patients with AE stimulate keratinocyte proliferation via soluble factor(s) that are different from IL-6, IL-8 and IFN-gamma; (ii) probably, HaCaT cells spontaneously produce lymphocyte/monocyte inhibitory soluble factors and IL-6, IL-8 as well as IFN-gamma; and (iii) secretion and/or activity of keratinocyte-derived inhibitory mediators is regulated via cytokines of PBMC infiltrating inflammatory skin.

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.

Abstract 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.

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.

In 1995, Candida dubliniensis was described as a new species in the genus Candida. Its close relationship to C. albicans has proved problematic in the identification of C. dubliniensis in clinical specimens. The objective of this study was to determine if reproducible differentiation between both species can be obtained by phenotypic assays. Therefore, 100 strains from 86 patients with the ability to produce chlamydospores were examined with different methods including API ID 32 C, colour development on CHROMagar, chlamydospore formation on Staib agar, growth at different temperatures and germ tube formation at 39degreesC. Additionally, polymerase chain reaction (PCR) was used as gold standard. Six of the investigated strains were C. dubliniensis. The results suggest that there is still no single phenotypic method satisfactory to distinguish between C. albicans and C. dubliniensis.

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.