Jürgen C. Becker

Activating mutations in serine-threonine protein kinase B-RAF (BRAF) are found in 50% of patients with advanced melanoma. Selective BRAF-inhibitor therapy improves survival, as compared with chemotherapy, but responses are often short-lived. In previous trials, MEK inhibition appeared to be promising in this population.In this phase 3 open-label trial, we randomly assigned 322 patients who had metastatic melanoma with a V600E or V600K BRAF mutation to receive either trametinib, an oral selective MEK inhibitor, or chemotherapy in a 2:1 ratio. Patients received trametinib (2 mg orally) once daily or intravenous dacarbazine (1000 mg per square meter of body-surface area) or paclitaxel (175 mg per square meter) every 3 weeks. Patients in the chemotherapy group who had disease progression were permitted to cross over to receive trametinib. Progression-free survival was the primary end point, and overall survival was a secondary end point.Median progression-free survival was 4.8 months in the trametinib group and 1.5 months in the chemotherapy group (hazard ratio for disease progression or death in the trametinib group, 0.45; 95% confidence interval [CI], 0.33 to 0.63; P<0.001). At 6 months, the rate of overall survival was 81% in the trametinib group and 67% in the chemotherapy group despite crossover (hazard ratio for death, 0.54; 95% CI, 0.32 to 0.92; P=0.01). Rash, diarrhea, and peripheral edema were the most common toxic effects in the trametinib group and were managed with dose interruption and dose reduction; asymptomatic and reversible reduction in the cardiac ejection fraction and ocular toxic effects occurred infrequently. Secondary skin neoplasms were not observed.Trametinib, as compared with chemotherapy, improved rates of progression-free and overall survival among patients who had metastatic melanoma with a BRAF V600E or V600K mutation. (Funded by GlaxoSmithKline; METRIC ClinicalTrials.gov number, NCT01245062.).

Thomas Wiesner and colleagues report that germline mutations in BAP1 predispose to melanocytic tumors ranging histopathologically from epithelioid nevi to atypical melanocytic proliferations. Some BAP1 mutation carriers also developed uveal or cutaneous melanomas. Common acquired melanocytic nevi are benign neoplasms that are composed of small, uniform melanocytes and are typically present as flat or slightly elevated pigmented lesions on the skin. We describe two families with a new autosomal dominant syndrome characterized by multiple, skin-colored, elevated melanocytic tumors. In contrast to common acquired nevi, the melanocytic neoplasms in affected family members ranged histopathologically from epithelioid nevi to atypical melanocytic proliferations that showed overlapping features with melanoma. Some affected individuals developed uveal or cutaneous melanomas. Segregating with this phenotype, we found inactivating germline mutations of BAP1, which encodes a ubiquitin carboxy-terminal hydrolase. The majority of melanocytic neoplasms lost the remaining wild-type allele of BAP1 by various somatic alterations. In addition, we found BAP1 mutations in a subset of sporadic melanocytic neoplasms showing histological similarities to the familial tumors. These findings suggest that loss of BAP1 is associated with a clinically and morphologically distinct type of melanocytic neoplasm.

Purpose The primary objective of this study was to confirm the efficacy of romidepsin in patients with treatment refractory cutaneous T-cell lymphoma (CTCL). Patients and Methods This international, pivotal, single-arm, open-label, phase II study was conducted in patients with stage IB to IVA CTCL who had received one or more prior systemic therapies. Patients received romidepsin as an intravenous infusion at a dose of 14 mg/m 2 on days 1, 8, and 15 every 28 days. Response was determined by a composite assessment of total tumor burden including cutaneous disease, lymph node involvement, and blood (Sézary cells). Results Ninety-six patients were enrolled and received one or more doses of romidepsin. Most patients (71%) had advanced stage disease (≥ IIB). The response rate was 34% (primary end point), including six patients with complete response (CR). Twenty-six of 68 patients (38%) with advanced disease achieved a response, including five CRs. The median time to response was 2 months, and the median duration of response was 15 months. A clinically meaningful improvement in pruritus was observed in 28 (43%) of 65 patients, including patients who did not achieve an objective response. Median duration of reduction in pruritus was 6 months. Drug-related adverse events were generally mild and consisted mainly of GI disturbances and asthenic conditions. Nonspecific, reversible ECG changes were noted in some patients. Conclusion Romidepsin has significant and sustainable single-agent activity (including improvement in pruritus) and an acceptable safety profile, making it an important therapeutic option for treatment refractory CTCL.

Regular exercise reduces the risk of cancer and disease recurrence. Yet the mechanisms behind this protection remain to be elucidated. In this study, tumor-bearing mice randomized to voluntary wheel running showed over 60% reduction in tumor incidence and growth across five different tumor models. Microarray analysis revealed training-induced upregulation of pathways associated with immune function. NK cell infiltration was significantly increased in tumors from running mice, whereas depletion of NK cells enhanced tumor growth and blunted the beneficial effects of exercise. Mechanistic analyses showed that NK cells were mobilized by epinephrine, and blockade of β-adrenergic signaling blunted training-dependent tumor inhibition. Moreover, epinephrine induced a selective mobilization of IL-6-sensitive NK cells, and IL-6-blocking antibodies blunted training-induced tumor suppression, intratumoral NK cell infiltration, and NK cell activation. Together, these results link exercise, epinephrine, and IL-6 to NK cell mobilization and redistribution, and ultimately to control of tumor growth.

Background: This randomized phase III trial was designed to demonstrate the superiority of autologous peptide-loaded dendritic cell (DC) vaccination over standard dacarbazine (DTIC) chemotherapy in stage IV melanoma patients.Patients and methods: DTIC 850 mg/m2 intravenously was applied in 4-week intervals. DC vaccines loaded with MHC class I and II-restricted peptides were applied subcutaneously at 2-week intervals for the first five vaccinations and every 4 weeks thereafter. The primary study end point was objective response (OR); secondary end points were toxicity, overall (OS) and progression-free survival (PFS).Results: At the time of the first interim analysis 55 patients had been enrolled into the DTIC and 53 into the DC-arm (ITT). OR was low (DTIC: 5.5%, DC: 3.8%), but not significantly different in the two arms. The Data Safety & Monitoring Board recommended closure of the study. Unscheduled subset analyses revealed that patients with normal serum LDH and/or stage M1a/b survived longer in both arms than those with elevated serum LDH and/or stage M1c. Only in the DC-arm did those patients with (i) an initial unimpaired general health status (Karnofsky = 100) or (ii) an HLA-A2+/HLA-B44− haplotype survive significantly longer than patients with a Karnofsky index <100 (P = 0.007 versus P = 0.057 in the DTIC-arm) or other HLA haplotypes (P = 0.04 versus P = 0.57 in DTIC-treated patients).Conclusions: DC vaccination could not be demonstrated to be more effective than DTIC chemotherapy in stage IV melanoma patients. The observed association of overall performance status and HLA haplotype with overall survival for patients treated by DC vaccination should be tested in future trials employing DC vaccines.

Cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers in Caucasian populations, accounting for 20% of all cutaneous malignancies. A unique collaboration of multi-disciplinary experts from the European Dermatology Forum (EDF), the European Association of Dermato-Oncology (EADO) and the European Organization of Research and Treatment of Cancer (EORTC) was formed to make recommendations on cSCC diagnosis and management, based on a critical review of the literature, existing guidelines and the expert’s experience. The diagnosis of cSCC is primarily based on clinical features. A biopsy or excision and histologic confirmation should be performed in all clinically suspicious lesions in order to facilitate the prognostic classification and correct management of cSCC. The first line treatment of cutaneous SCC is complete surgical excision with histopathological control of excision margins. The EDF–EADO–EORTC consensus group recommends a standardised minimal margin of 5 mm even for low-risk tumours. For tumours, with histological thickness of >6 mm or in tumours with high risk pathological features, e.g. high histological grade, subcutaneous invasion, perineural invasion, recurrent tumours and/or tumours at high risk locations an extended margin of 10 mm is recommended. As lymph node involvement by cSCC increases the risk of recurrence and mortality, a lymph node ultrasound is highly recommended, particularly in tumours with high-risk characteristics. In the case of clinical suspicion or positive findings upon imaging, a histologic confirmation should be sought either by fine needle aspiration or by open lymph node biopsy. In large infiltrating tumours with signs of involvement of underlying structures, additional imaging tests, such as CT or MRI imaging may be required to accurately assess the extent of the tumour and the presence of metastatic spread. Current staging systems for cSCC are not optimal, as they have been developed for head and neck tumours and lack extensive validation or adequate prognostic discrimination in certain stages with heterogeneous outcome measures. Sentinel lymph node biopsy has been used in patients with cSCC, but there is no conclusive evidence of its prognostic or therapeutic value. In the case of lymph node involvement by cSCC, the preferred treatment is a regional lymph node dissection. Radiation therapy represents a fair alternative to surgery in the non-surgical treatment of small cSCCs in low risk areas. It generally should be discussed either as a primary treatment for inoperable cSCC or in the adjuvant setting. Stage IV cSCC can be responsive to various chemotherapeutic agents; however, there is no standard regimen. EGFR inhibitors such as cetuximab or erlotinib, should be discussed as second line treatments after mono- or polychemotherapy failure and disease progression or within the framework of clinical trials. There is no standardised follow-up schedule for patients with cSCC. A close follow-up plan is recommended based on risk assessment of locoregional recurrences, metastatic spread or development of new lesions.

ABSTRACT Merkel cell carcinoma (MCC) is the most aggressive skin cancer. Recently, it was demonstrated that human Merkel cell polyomavirus (MCV) is clonally integrated in ∼80% of MCC tumors. However, direct evidence for whether oncogenic viral proteins are needed for the maintenance of MCC cells is still missing. To address this question, we knocked down MCV T-antigen (TA) expression in MCV-positive MCC cell lines using three different short hairpin RNA (shRNA)-expressing vectors targeting exon 1 of the TAs. The MCC cell lines used include three newly generated MCV-infected cell lines and one MCV-negative cell line from MCC tumors. Notably, all MCV-positive MCC cell lines underwent growth arrest and/or cell death upon TA knockdown, whereas the proliferation of MCV-negative cell lines remained unaffected. Despite an increase in the number of annexin V-positive, 7-amino-actinomycin D (7-AAD)-negative cells upon TA knockdown, activation of caspases or changes in the expression and phosphorylation of Bcl-2 family members were not consistently detected after TA suppression. Our study provides the first direct experimental evidence that TA expression is necessary for the maintenance of MCV-positive MCC and that MCV is the infectious cause of MCV-positive MCC.

Merkel cell carcinoma (MCC) is a rare but highly aggressive skin cancer with neuroendocrine features. MCC pathogenesis is associated with either the presence of Merkel cell polyomavirus or chronic exposure to ultraviolet light (UV), which can cause a characteristic pattern of multiple DNA mutations. Notably, in the Northern hemisphere, the majority of MCC cases are of viral aetiology; by contrast, in areas with high UV exposure, UV-mediated carcinogenesis is predominant. The two aetiologies share similar clinical, histopathological and prognostic characteristics. MCC presents with a solitary cutaneous or subcutaneous nodule, most frequently in sun-exposed areas. In fact, UV exposure is probably involved in both viral-mediated and non-viral-mediated carcinogenesis, by contributing to immunosuppression or DNA damage, respectively. Confirmation of diagnosis relies on analyses of histological features and immunological marker expression profiles of the lesion. At primary diagnosis, loco-regional metastases are already present in ∼30% of patients. Excision of the tumour is the first-line therapy; if not feasible, radiotherapy can often effectively control the disease. Chemotherapy was the only alternative in advanced-stage or refractory MCC until several clinical trials demonstrated the efficacy of immune-checkpoint inhibitors.

The immune system is a complex arrangement of cells and molecules that preserve the integrity of the organism by elimination of all elements judged dangerous. Within the immune system, a humoral and a cellular as well as an innate and an adaptive arm can be differentiated. The key players of adaptive cellular immune responses are T lymphocytes in general and, for the effector function, cytotoxic T lymphocytes (CTLs) in particular. T lymphocytes arise in the bone marrow and migrate to the thymus for maturation. During this process, T cells somatically rearrange gene segments, eventually leading to the expression of a unique antigen-binding molecule, the T-cell receptor (TCR). This receptor allows them to monitor all cells of the body, ready to destroy any cell posing a threat to the organism. Cytotoxicity is exerted directly through the Fas or perforin pathway and/or indirectly by the release of cytokines. Obviously, the activity of such a potent cell is tightly regulated. Indeed, a predominance of stimulatory over inhibitory signals is required for effective immune responses to pathogens, and a predominance of inhibitory over stimulatory signals is required for maintenance of self-tolerance. Still, several situations occur in which an inappropriate CTL response leads to either autoimmune disease or persistence of pathogens.

Induction of p53 activity in cells undergoing DNA synthesis represents a molecular conflict that can lead to apoptosis. During angiogenesis, proliferative endothelial cells become apoptotic in response to antagonists of integrin alphavbeta3 and this leads to the regression of angiogenic blood vessels, thereby blocking the growth of various human tumors. Evidence is presented that administration of alphavbeta3 antagonists during angiogenesis in vivo selectively caused activation of endothelial cell p53 and increased expression of the p53-inducible cell cycle inhibitor p21WAF1/CIP1. In vitro studies revealed that the ligation state of human endothelial cell alphavbeta3 directly influenced p53 activity and the bax cell death pathway. Specifically, agonists of endothelial cell alphavbeta3, but not other integrins, suppressed p53 activity, blocked p21WAF1/CIP1 expression, and increased the bcl-2/bax ratio, thereby promoting cell survival. Thus, ligation of vascular cell integrin alphavbeta3 promotes a critical and specific adhesion-dependent cell survival signal during angiogenesis leading to inhibition of p53 activity, decreased expression of p21WAF1/CIP1, and suppression of the bax cell death pathway.

Merkel cell carcinoma (MCC) is a rare tumour of the skin of neuro-endocrine origin probably developing from neuronal mechanoreceptors. A collaborative group of multidisciplinary experts form the European Dermatology Forum (EDF), The European Association of Dermato-Oncology (EADO) and the European Organization of Research and Treatment of Cancer (EORTC) was formed to make recommendations on MCC diagnosis and management, based on a critical review of the literature, existing guidelines and expert's experience. Clinical features of the cutaneous/subcutaneous nodules hardly contribute to the diagnosis of MCC. The diagnosis is made by histopathology, and an incisional or excisional biopsy is mandatory. Immunohistochemical staining contributes to clarification of the diagnosis. Initial work-up comprises ultrasound of the loco-regional lymph nodes and total body scanning examinations. The primary tumour should be excised with 1-2cm margins. In patients without clinical evidence of regional lymph node involvement, sentinel node biopsy is recommended, if possible, and will be taken into account in a new version of the AJCC classification. In patients with regional lymph node involvement radical lymphadenectomy is recommended. Adjuvant radiotherapy might be considered in patients with multiple affected lymph nodes of extracapsular extension. In unresectable metastatic MCC mono- or poly-chemotherapy achieve high remission rates. However, responses are usually short lived. Treatment within clinical trials is regarded as a standard of care in disseminated MCC.

Merkel cell carcinoma Merkel cell polyomavirus TO THE EDITOR Merkel cell carcinoma (MCC) is a rare, but highly aggressive neuroendocrine cancer of the skin that occurs primarily in elderly immune-suppressed individuals. Little is known about the pathogenesis of MCC. Now Feng et al., 2008Feng H. Shuda M. Chang Y. Moore P.S. Clonal integration of a polyomavirus in human Merkel cell carcinoma.Science. 2008; 319: 1096-1100Crossref PubMed Scopus (2378) Google Scholar have identified a new polyomavirus present in MCC (MCPyV). In this regard, viral proteins expressed by polyomaviruses are known to initiate transformation and immortalization of cultured cells. Accordingly, in experimental models, polyomaviruses induced tumors upon integration of the viral genome into the host genome (Poulin and DeCaprio, 2006Poulin D.L. DeCaprio J.A. Is there a role for SV40 in human cancer?.J Clin Oncol. 2006; 24: 4356-4365Crossref PubMed Scopus (105) Google Scholar). Therefore, the detection of MCPyV integrated into the host genome in six out of eight MCCs (75.0%) by Feng et al. argues for a causative role of this polyomavirus for MCC. Although polyomaviruses have been discussed for a long time to be involved in human tumorigenesis (Poulin and DeCaprio, 2006Poulin D.L. DeCaprio J.A. Is there a role for SV40 in human cancer?.J Clin Oncol. 2006; 24: 4356-4365Crossref PubMed Scopus (105) Google Scholar), this observation is the first clear hint for their impact on tumor etiology in humans as the other known human-specific polyomaviruses, that is, BKPyV, JCPyV, KIPyV, and WUPyV, have not yet been found to be integrated in tumor-derived genomic DNA. Notably, the patterns of integration indicated that viral infection by MCPyV precedes clonal expansion of tumor cells consistent with MCPyV's role in MCC. To expand the study of Feng et al., we analyzed 75 samples of 53 MCC patients for the presence of MCPyV by real-time PCR. To this end, DNA was obtained from formalin-fixed patient material and samples were analyzed for the presence of MCPyV by using TaqMan technology with primers (forward: 5′-CCAAACCAAAGAATAAAGCACTGA-3′; reverse: 5′-TCGCCAGCATTGTAGTCTAAAAAC-3′) and a respective probe (TP: FAM-AGCAAAAACACTCTCCCCACGTCAGACAG-BHQ) specific for the MCPyV large T-antigen gene. The Taqman probe, for example, was designed to have at least 11 mismatches to the other known human-specific polyomaviruses. By normalization to the highly repetitive DNA elements LINE1—for which the copy number even in cancer cells is largely constant—a relative quantification of the samples could be calculated by the ΔΔCt method. These analyses demonstrated that in the tumors of 45 patients (84.9%) the virus was present. The presence or absence of the virus was concordant in consecutive samples, that is, primary tumor and subsequent metastases for all patients. The clinical follow-up of a patient cohort for which the detailed clinical course was available suggests that MCC containing the viral genome display a more aggressive behavior than their virus-negative counterparts (Table 1). However, if all patients were stratified by tumor stage, that is, stage I or higher, there was no significant difference between these patient cohorts (P=0.4527 in Fisher's exact test) (Figure 1). Hence, as the rate of MCPyV-negative tumors is low, the impact of the MCPyV virus on clinical course has to be revealed in a larger patient population. It should be further noted that of 24 basal cell carcinomas, another skin cancer affecting mostly elderly patients, only three samples (12.5%) harbored the viral genome; moreover, the mean relative frequency of virus DNA in the positive basal cell carcinoma samples is about 4log lower than in MCC.Table 1Clinical course of a patient cohort for which detailed information was availablePatient idGenderAge at diagnosis1In years.Stage at diagnosisStage at date last seenFollow-up2In months. Time span between diagnosis and date last seen or date of death.Patients with MCPyV RFM91.4III64.1 RRM80.1III9.97 BEF68.7III48.8 GWM63.8IIIIII31.7 HWM80.9IIII6.47 KAM85.1IIII3.27 STF81.4II3.5 BRM89.8II0.0 NRM72.6IIII15.43 KMF72.9IIII26.83 HOM79.6II0.00 HWM93.7IIII27.5 PHF78.8II43.47 REF90.4II1.4 KRM63.1IIIIII6.57 SBF57.0IIIIII0.00 LHM72.9IIII1.80 LBM54.8IIII9.5Patients without MCPyV SRM76.8II88.47 KEM71.4IUnknown35.43 SMF83.4II0.00 HAF83.1II11.63 GHM84.4II10.03F, female; M, male; MCPyV, Merkel cell polyomavirus.1 In years.2 In months. Time span between diagnosis and date last seen or date of death. Open table in a new tab F, female; M, male; MCPyV, Merkel cell polyomavirus. In summary, our study unambiguously confirms the association of MCPyV with MCC reported by Feng et al. Given the oncogenic potential of polyomaviruses, and accounting for the lack of systemic therapies improving the survival of metastatic MCC, this observation may open new therapeutic options in this disease. Antivirals such as IFNs (Borden et al., 2007Borden E.C. Sen G.C. Uze G. Silverman R.H. Ransohoff R.M. Foster G.R. et al.Interferons at age 50: past, current and future impact on biomedicine.Nat Rev Drug Discov. 2007; 6: 975-990Crossref PubMed Scopus (872) Google Scholar) or—as proteins from polyomavirus are known to be immunogeneic (Binggeli et al., 2007Binggeli S. Egli A. Schaub S. Binet I. Mayr M. Steiger J. et al.Polyomavirus BK-specific cellular immune response to VP1 and large T-antigen in kidney transplant recipients.Am J Transplant. 2007; 7: 1131-1139Crossref PubMed Scopus (153) Google Scholar)—active immunotherapy has to be considered. The authors state no conflict of interest. This work was supported by the Wilhelm Sander Stiftung (Grant 2007.057.1).

Merkel cell polyomavirus (MCV) is a newly-discovered human tumor virus found in approximately 80% of Merkel cell carcinoma (MCC). The rate of MCV infection among persons without MCC is unknown. We developed a MCV virus-like particle (VLP) enzyme-linked immunoassay (EIA) that does not cross-react with human BK or murine polyomaviruses. Peptide mapping of the MCV VP1 gene and immunoblotting with denatured MCV VLP are less sensitive than the MCV EIA in detecting MCV antibodies suggesting antibody reactivity in this assay primarily targets conformational but not linear epitopes. Among MCC patients, all 21 (100%) patients tested with MCV-positive tumors had high serum MCV IgG but not high MCV IgM levels. Only 3 of 6 (50%) MCC patients with MCV-negative tumors were positive for MCV antibodies. Sera from most adults, including 107 of 166 (64%) blood donors, 63 of 100 (63%) commercial donors and 37 of 50 (74%) systemic lupus erythematosus patients, show evidence for prior MCV exposure. Age-specific MCV prevalence was determined by examining a cross-sectional distribution of 150 Langerhans cell histiocytosis (an unrelated neoplasm) patient sera. MCV prevalence increases from 50% among children age 15 years or younger to 80% among persons older than 50 years. We did not find evidence for vertical transmission among infants. Although past exposure to MCV is common among all adult groups, MCC patients have a markedly elevated MCV IgG response compared with control patients. Our study demonstrates that MCV is a widespread but previously unrecognized human infection.

<h2>Abstract</h2><h3>Background</h3> Acquired resistance to <i>BRAF</i> inhibitors (BRAFi) is a near-universal phenomenon caused by numerous genetic and non-genetic alterations. In this study, we evaluated the spectrum, onset, pattern of progression, and subsequent clinical outcomes associated with specific mechanisms of resistance. <h3>Methods</h3> We compiled clinical and genetic data from 100 patients with 132 tissue samples obtained at progression on BRAFi therapy from 3 large, previously published studies of BRAFi resistance. These samples were subjected to whole-exome sequencing and/or polymerase chain reaction-based genetic testing. <h3>Results</h3> Among 132 samples, putative resistance mechanisms were identified in 58%, including <i>NRAS</i> or <i>KRAS</i> mutations (20%), <i>BRAF</i> splice variants (16%), <i>BRAF</i>^V600E/K amplifications (13%), <i>MEK1/2</i> mutations (7%), and non-mitogen-activated protein kinase pathway alterations (11%). Marked heterogeneity was observed within tumors and patients; 18 of 19 patients (95%) with more than one progression biopsy had distinct/unknown drivers of resistance between samples. <i>NRAS</i> mutations were associated with vemurafenib use (p = 0.045) and intracranial metastases (p = 0.036), and <i>MEK1/2</i> mutations correlated with hepatic progression (p = 0.011). Progression-free survival and overall survival were similar across resistance mechanisms. The median survival after disease progression was 6.9 months, and responses to subsequent <i>BRAF</i> and MEK inhibition were uncommon (2 of 15; 13%). Post-progression outcomes did not correlate with specific acquired BRAFi-resistance mechanisms. <h3>Conclusions</h3> This is the first study to systematically characterise the clinical implications of particular acquired BRAFi-resistance mechanisms in patients with <i>BRAF</i>-mutant melanoma largest study to compile the landscape of resistance. Despite marked heterogeneity of resistance mechanisms within patients, <i>NRAS</i> mutations correlated with vemurafenib use and intracranial disease involvement.

A full morphology (FM) model has been developed for studying the two-phase characteristics of the gas diffusion medium in a polymer electrolyte fuel cell (PEFC). The three-dimensional (3D) fibrous microstructure for the nonwoven gas diffusion layer (GDL) microstructure has been reconstructed using a stochastic technique for Toray090 and SGL10BA carbon papers. The FM model directly solves for the capillary pressure-saturation relations on the detailed morphology of the reconstructed GDL from drainage simulations. The estimated capillary pressure-saturation curves can be used as valuable inputs to macroscopic two-phase models. Additionally, 3D visualization of the water distribution in the gas diffusion medium suggests that only a small number of pores are occupied by liquid water at breakthrough. Based on a reduced compression model, the two-phase behavior of the GDL under mechanical load is also investigated and the capillary pressure-saturation relations are evaluated for different compression levels.

Merkel cell carcinoma (MCC) is a relatively uncommon but highly lethal form of skin cancer. A majority of MCC tumors carry DNA sequences derived from a newly identified virus called Merkel cell polyomavirus (MCV or MCPyV), a candidate etiologic agent underlying the development of MCC. To further investigate the role of MCV infection in the development of MCC, we developed a reporter vector-based neutralization assay to quantitate MCV-specific serum antibody responses in human subjects. Our results showed that 21 MCC patients whose tumors harbored MCV DNA all displayed vigorous MCV-specific antibody responses. Although 88% (42/48) of adult subjects without MCC were MCV seropositive, the geometric mean titer of the control group was 59-fold lower than the MCC patient group (p<0.0001). Only 4% (2/48) of control subjects displayed neutralizing titers greater than the mean titer of the MCV-positive MCC patient population. MCC tumors were found not to express detectable amounts of MCV VP1 capsid protein, suggesting that the strong humoral responses observed in MCC patients were primed by an unusually immunogenic MCV infection, and not by viral antigen expressed by the MCC tumor itself. The occurrence of highly immunogenic MCV infection in MCC patients is unlikely to reflect a failure to control polyomavirus infections in general, as seroreactivity to BK polyomavirus was similar among MCC patients and control subjects. The results support the concept that MCV infection is a causative factor in the development of most cases of MCC. Although MCC tumorigenesis can evidently proceed in the face of effective MCV-specific antibody responses, a small pilot animal immunization study revealed that a candidate vaccine based on MCV virus-like particles (VLPs) elicits antibody responses that robustly neutralize MCV reporter vectors in vitro. This suggests that a VLP-based vaccine could be effective for preventing the initial establishment of MCV infection.

In recent studies, convolutional neural networks (CNNs) outperformed dermatologists in distinguishing dermoscopic images of melanoma and nevi. In these studies, dermatologists and artificial intelligence were considered as opponents. However, the combination of classifiers frequently yields superior results, both in machine learning and among humans. In this study, we investigated the potential benefit of combining human and artificial intelligence for skin cancer classification.Using 11,444 dermoscopic images, which were divided into five diagnostic categories, novel deep learning techniques were used to train a single CNN. Then, both 112 dermatologists of 13 German university hospitals and the trained CNN independently classified a set of 300 biopsy-verified skin lesions into those five classes. Taking into account the certainty of the decisions, the two independently determined diagnoses were combined to a new classifier with the help of a gradient boosting method. The primary end-point of the study was the correct classification of the images into five designated categories, whereas the secondary end-point was the correct classification of lesions as either benign or malignant (binary classification).Regarding the multiclass task, the combination of man and machine achieved an accuracy of 82.95%. This was 1.36% higher than the best of the two individual classifiers (81.59% achieved by the CNN). Owing to the class imbalance in the binary problem, sensitivity, but not accuracy, was examined and demonstrated to be superior (89%) to the best individual classifier (CNN with 86.1%). The specificity in the combined classifier decreased from 89.2% to 84%. However, at an equal sensitivity of 89%, the CNN achieved a specificity of only 81.5% INTERPRETATION: Our findings indicate that the combination of human and artificial intelligence achieves superior results over the independent results of both of these systems.

The study aimed at investigating the impact of two surface debridement/decontamination (DD) methods on the clinical outcomes of combined surgical treatment of peri-implantitis.Thirty-two patients suffering from advanced peri-implantitis (n=38 combined supra- and intra-bony defects) were treated with flap surgery, granulation tissue removal, and implantoplasty at buccally and supracrestally exposed implant parts. The intra-bony aspects were randomly allocated to surface DD using either (i) an Er:YAG laser (ERL) device, or (ii) plastic curets+cotton pellets+sterile saline (CPS). In both groups, the intra-bony component was augmented with a natural bone mineral and covered with a collagen membrane. Clinical and radiographic parameters were recorded at baseline and after 6 months of non-submerged healing.Two patients were lost during follow-up. At 6 months, ERL-treated sites failed to reveal higher reductions in mean bleeding on probing (ERL: 47.8 ± 35.5 versus CPS: 55.0 ± 31.1%) and CAL values (ERL: 1.5 ± 1.4 versus CPS: 2.2 ± 1.4 mm) when compared with the CPS group. Both groups exhibited a comparable radiographic bone fill at the intra-bony defect component.The study failed to demonstrate a significant impact of the method of surface DD on the clinical outcome following combined surgical therapy of advanced peri-implantitis lesions.

<h2>Summary</h2><h3>Background</h3> Nivolumab and ipilimumab, alone or in combination, are widely used immunotherapeutic treatment options for patients with advanced—ie, unresectable or metastatic—melanoma. This criterion, however, excludes patients with stage IV melanoma with no evidence of disease. We therefore aimed to evaluate the safety and efficacy of adjuvant nivolumab plus ipilimumab or nivolumab monotherapy versus a placebo in this patient population. <h3>Methods</h3> We did a randomised, double-blind, placebo-controlled, phase 2 trial in 20 German academic medical centres. Eligible patients were aged 18–80 years with stage IV melanoma with no evidence of disease after surgery or radiotherapy. Key exclusion criteria included uveal or mucosal melanoma, previous therapy with checkpoint inhibitors, and any previous immunosuppressive therapy within the 30 days before study drug administration. Eligible patients were randomly assigned (1:1:1), using a central, interactive, online system, to the nivolumab plus ipilimumab group (1 mg/kg of intravenous nivolumab every 3 weeks plus 3 mg/kg of intravenous ipilimumab every 3 weeks for four doses, followed by 3 mg/kg of nivolumab every 2 weeks), nivolumab monotherapy group (3 mg/kg of intravenous nivolumab every 2 weeks plus ipilimumab-matching placebo during weeks 1–12), or double-matching placebo group. The primary endpoint was the recurrence-free survival in the intention-to-treat population. The results presented in this report reflect the prespecified interim analysis of recurrence-free survival after 90 events had been reported. This study is registered with ClinicalTrials.gov, NCT02523313, and is ongoing. <h3>Findings</h3> Between Sept 2, 2015, and Nov 20, 2018, 167 patients were randomly assigned to receive nivolumab plus ipilimumab (n=56), nivolumab (n=59), or placebo (n=52). As of July 2, 2019, at a median follow-up of 28·4 months (IQR 17·7–36·8), median recurrence-free survival was not reached in the nivolumab plus ipilimumab group, whereas median recurrence-free survival was 12·4 months (95% CI 5·3–33·3) in the nivolumab group and 6·4 months (3·3–9·6) in the placebo group. The hazard ratio for recurrence for the nivolumab plus ipilimumab group versus placebo group was 0·23 (97·5% CI 0·12–0·45; p<0·0001), and for the nivolumab group versus placebo group was 0·56 (0·33–0·94; p=0·011). In the nivolumab plus ipilimumab group, recurrence-free survival at 1 year was 75% (95% CI 61·0–84·9) and at 2 years was 70% (55·1–81·0); in the nivolumab group, 1-year recurrence-free survival was 52% (38·1–63·9) and at 2 years was 42% (28·6–54·5); and in the placebo group, this rate was 32% (19·8–45·3) at 1 year and 14% (5·9–25·7) at 2 years. Treatment-related grade 3–4 adverse events were reported in 71% (95% CI 57–82) of patients in the nivolumab plus ipilimumab group and in 27% (16–40) of those in the nivolumab group. Treatment-related adverse events of any grade led to treatment discontinuation in 34 (62%) of 55 patients in the nivolumab plus ipilimumab group and seven (13%) of 56 in the nivolumab group. Three deaths from adverse events were reported but were considered unrelated to the study treatment. <h3>Interpretation</h3> Adjuvant therapy with nivolumab alone or in combination with ipilimumab increased recurrence-free survival significantly compared with placebo in patients with stage IV melanoma with no evidence of disease. The rates of grade 3–4 treatment-related adverse events in both active treatment groups were higher than the rates reported in previous pivotal trials done in advanced melanoma with measurable disease. <h3>Funding</h3> Bristol-Myers Squibb.

We previously reported a disease segregating causal germline mutation in a melanoma family and recurrent somatic mutations in metastasized tumours from unrelated patients in the core promoter region of the telomerase reverse transcriptase (TERT) gene. Here we show that the TERT promoter mutations, besides causing an increased gene expression, associate with increased patient age, increased Breslow thickness and tumour ulceration in 287 primary melanomas. The mutations are more frequent at both intermittently and chronically sun-exposed sites than non-exposed sites and tend to co-occur with BRAF and CDKN2A alterations. The association with parameters generally connected with poor outcome, coupled with high recurrence and mechanistic relevance, raises the possibility of the eventual use of TERT promoter mutations in the disease management.

Recently, convolutional neural networks (CNNs) systematically outperformed dermatologists in distinguishing dermoscopic melanoma and nevi images. However, such a binary classification does not reflect the clinical reality of skin cancer screenings in which multiple diagnoses need to be taken into account.Using 11,444 dermoscopic images, which covered dermatologic diagnoses comprising the majority of commonly pigmented skin lesions commonly faced in skin cancer screenings, a CNN was trained through novel deep learning techniques. A test set of 300 biopsy-verified images was used to compare the classifier's performance with that of 112 dermatologists from 13 German university hospitals. The primary end-point was the correct classification of the different lesions into benign and malignant. The secondary end-point was the correct classification of the images into one of the five diagnostic categories.Sensitivity and specificity of dermatologists for the primary end-point were 74.4% (95% confidence interval [CI]: 67.0-81.8%) and 59.8% (95% CI: 49.8-69.8%), respectively. At equal sensitivity, the algorithm achieved a specificity of 91.3% (95% CI: 85.5-97.1%). For the secondary end-point, the mean sensitivity and specificity of the dermatologists were at 56.5% (95% CI: 42.8-70.2%) and 89.2% (95% CI: 85.0-93.3%), respectively. At equal sensitivity, the algorithm achieved a specificity of 98.8%. Two-sided McNemar tests revealed significance for the primary end-point (p < 0.001). For the secondary end-point, outperformance (p < 0.001) was achieved except for basal cell carcinoma (on-par performance).Our findings show that automated classification of dermoscopic melanoma and nevi images is extendable to a multiclass classification problem, thus better reflecting clinical differential diagnoses, while still outperforming dermatologists at a significant level (p < 0.001).

Abstract Anti-PD-1 therapy is used as a front-line treatment for many cancers, but mechanistic insight into this therapy resistance is still lacking. Here we generate a humanized (Hu)-mouse melanoma model by injecting fetal liver-derived CD34 + cells and implanting autologous thymus in immune-deficient NOD- scid IL2Rγ null (NSG) mice. Reconstituted Hu-mice are challenged with HLA-matched melanomas and treated with anti-PD-1, which results in restricted tumor growth but not complete regression. Tumor RNA-seq, multiplexed imaging and immunohistology staining show high expression of chemokines, as well as recruitment of FOXP3 + Treg and mast cells, in selective tumor regions. Reduced HLA-class I expression and CD8 + /Granz B + T cells homeostasis are observed in tumor regions where FOXP3 + Treg and mast cells co-localize, with such features associated with resistance to anti-PD-1 treatment. Combining anti-PD-1 with sunitinib or imatinib results in the depletion of mast cells and complete regression of tumors. Our results thus implicate mast cell depletion for improving the efficacy of anti-PD-1 therapy.

Merkel cell carcinoma (MCC) is a rare skin cancer, accounting for less than 1% of all cutaneous malignancies. It is found predominantly in white populations and risk factors include advanced age, ultraviolet exposure, male sex, immunosuppression, such as AIDS/HIV infection, haematological malignancies or solid organ transplantation, and Merkel cell polyomavirus infection. MCC is an aggressive tumour with 26% of cases presenting lymph node involvement at diagnosis and 8% with distant metastases. Five-year overall survival rates range between 48% and 63%. Two subsets of MCC have been characterised with distinct molecular pathogenetic pathways: ultraviolet-induced MCC versus virus-positive MCC, which carries a better prognosis. In both subtypes, there are alterations in the retinoblastoma protein and p53 gene structure and function. MCC typically manifests as a red nodule or plaque with fast growth, most commonly on sun exposed areas. Histopathology (small-cell neuroendocrine appearance) and immunohistochemistry (CK20 positivity and TTF-1 negativity) confirm the diagnosis. The current staging systems are the American Joint Committee on Cancer/Union for international Cancer control 8th edition. Baseline whole body imaging is encouraged to rule out regional and distant metastasis. For localised MCC, first-line treatment is surgical excision with postoperative margin assessment followed by adjuvant radiation therapy (RT). Sentinel lymph node biopsy is recommended in all patients with MCC without clinically detectable lymph nodes or distant metastasis. Adjuvant RT alone, eventually combined with complete lymph nodes dissection is proposed in case of micrometastatic nodal involvement. In case of macroscopic nodal involvement, the standard of care is complete lymph nodes dissection potentially followed by post-operative RT. Immunotherapy with anti-PD-(L)1 antibodies should be offered as first-line systemic treatment in advanced MCC. Chemotherapy can be used when patients fail to respond or are intolerant for anti-PD-(L)1 immunotherapy or clinical trials.

Background The IMMUNED trial previously showed significant improvements in recurrence-free survival for adjuvant nivolumab plus ipilimumab as well as for adjuvant nivolumab alone in patients with stage IV melanoma with no evidence of disease after resection or radiotherapy. Here, we report the final analysis, including overall survival data. Methods IMMUNED was an investigator-sponsored, double-blind, placebo-controlled, three-arm, phase 2 trial conducted in 20 academic medical centres in Germany. Eligible patients were aged 18–80 years with stage IV melanoma with no evidence of disease after surgery or radiotherapy. Patients were randomly assigned (1:1:1) to either nivolumab plus ipilimumab (nivolumab 1 mg/kg plus ipilimumab 3 mg/kg every 3 weeks for four doses followed by nivolumab 3 mg/kg every 2 weeks), nivolumab monotherapy (nivolumab 3 mg/kg every 2 weeks), or matching placebo, for up to 1 year. The primary endpoint was recurrence-free survival in the intention-to-treat population. Secondary endpoints were time-to-recurrence, overall survival, progression-free survival or recurrence-free survival 2 (in patients in the placebo group who crossed over to nivolumab monotherapy after experiencing disease recurrence), and safety endpoints. This trial is registered on ClinicalTrials.gov (NCT02523313), and is complete. Findings Between Sept 2, 2015, and Nov 20, 2018, 175 patients were enrolled in the study, and 167 were randomly assigned to receive either nivolumab plus ipilimumab (n=56), nivolumab plus ipilimumab-matching placebo (n=59), or double placebo control (n=52). At a median follow-up of 49·2 months (IQR 34·9–58·1), 4-year recurrence-free survival was 64·2% (95% CI 49·2–75·9) in the nivolumab plus ipilimumab group, 31·4% (19·7–43·8) in the nivolumab alone group, and 15·0% (6·7–26·6) in the placebo group. The hazard ratio (HR) for recurrence for the nivolumab plus ipilimumab group versus placebo was 0·25 (97·5% CI 0·13–0·48; p<0·0001), and for the nivolumab group versus placebo was 0·60 (0·36–1·00; p=0·024). Median overall survival was not reached in any treatment group. The HR for overall survival was significantly in favour of the nivolumab plus ipilimumab group versus placebo (HR 0·41; 95% CI 0·17–0·99; p=0·040), but not for the nivolumab group versus placebo (HR 0·75; 0·36–1·56; p=0·44). 4-year overall survival was 83·8% (95% CI 68·8–91·9) in the nivolumab plus ipilimumab group, 72·6% (57·4–83·2) in the nivolumab alone group, and 63·1% (46·9–75·6) in the placebo group. The median progression-free survival or recurrence-free survival 2 of patients in the placebo group who crossed over to nivolumab monotherapy after experiencing disease recurrence was not reached (95% CI 21·2 months to not reached). Rates of grade 3–4 treatment-related adverse events remained largely unchanged compared with our previous report, occurring in 71% (95% CI 57–82) of the nivolumab plus ipilimumab group, and 29% (95% CI 17–42) of patients receiving nivolumab alone. There were no treatment-related deaths. Interpretation Both active regimens continued to show significantly improved recurrence-free survival compared with placebo in patients with stage IV melanoma with no evidence of disease who were at high risk of recurrence. Overall survival was significantly improved for patients receiving nivolumab plus ipilimumab compared with placebo. Use of subsequent anti-PD-1-based therapy was high in patients in the placebo group after recurrence and most likely impacted the overall survival comparison of nivolumab alone versus placebo. The recurrence-free and overall survival benefit of nivolumab plus ipilimumab over placebo reinforces the change of practice already initiated for the treatment of patients with stage IV melanoma with no evidence of disease. Funding Bristol-Myers Squibb.

Cutaneous T-cell lymphoma (CTCL) is a devastating lymphoid malignancy characterized by the accumulation of malignant T cells in the dermis and epidermis. Skin lesions cause serious symptoms that hamper quality of life and are entry sites for bacterial infection, a major cause of morbidity and mortality in advanced diseases. The mechanism driving the pathological processes that compromise the skin barrier remains unknown. Here, we report increased transepidermal water loss and compromised expression of the skin barrier proteins filaggrin and filaggrin-2 in areas adjacent to TOX-positive T cells in CTCL skin lesions. Malignant T cells secrete mediators (including cytokines such as interleukin 13 [IL-13], IL-22, and oncostatin M) that activate STAT3 signaling and downregulate filaggrin and filaggrin-2 expression in human keratinocytes and reconstructed human epithelium. Consequently, the repression of filaggrins can be counteracted by a cocktail of antibodies targeting these cytokines/receptors, small interfering RNA-mediated knockdown of JAK1/STAT3, and JAK1 inhibitors. Notably, we show that treatment with a clinically approved JAK inhibitor, tofacitinib, increases filaggrin expression in lesional skin from patients with mycosis fungoides. Taken together, these findings indicate that malignant T cells secrete cytokines that induce skin barrier defects via a JAK1/STAT3-dependent mechanism. As clinical grade JAK inhibitors largely abrogate the negative effect of malignant T cells on skin barrier proteins, our findings suggest that such inhibitors provide novel treatment options for patients with CTCL with advanced disease and a compromised skin barrier.

Five papillomas, five leukoplakias, and six carcinomas were investigated for the presence of papillomavirus group-specific antigens and viral DNA. Viral proteins were identified with genus-specific papillomavirus antibodies. Cloned human papillomavirus (HPV) 11 and 16 DNA were used as probes in Southern blot hybridization at conditions of different stringency in order to determine viral DNA. Four of five papillomas, four of five leukoplakias, and three of six carcinomas reacted with HPV DNA probes and revealed some stained cells after exposure to HPV antibodies. HPV type 16 was found in one carcinoma and HPV type 11 was demonstrated in another case of carcinoma.

Genes of the Raf family encode kinases that are regulated by Ras and mediate cellular responses to growth signals. Recently, it was shown that activating mutations of BRaf are found with high frequency in human melanomas. The Ras family member most often mutated in melanoma is NRas.The constitutive activation of the Ras/Raf signaling pathway suggests an impact on the clinical course of the tumor. To address this notion, we analyzed tumor DNA from 114 primary cutaneous melanomas and of 86 metastatic lesions obtained from 174 patients for mutations in BRaf (exons 15 and 11) and NRas (exons 1 and 2) by direct sequencing of PCR products and correlated these results with the clinical course.In 57.5% of the tumors either BRaf or NRas were mutated with a higher incidence in metastatic (66.3%) than in primary lesions (50.9%). Although the majority of BRaf mutations affected codon 599, almost 15% of mutations at this position were different from the well-described exchange from valine to glutamic acid. These mutations (V599R and V599K) also displayed increased kinase and transforming activity. Surprisingly, the additional BRaf variants D593V, G465R and G465E showed a complete loss of activity in the in vitro kinase assay; however, cells overexpressing these mutants displayed increased Erk phosphorylation. The correlation of mutational status and clinical course revealed that the presence of BRaf/NRas mutations in primary tumors did not negatively impact progression free or overall survival. In contrast, however, for metastatic lesions the presence of BRAF/NRAS mutations was associated with a significantly poorer prognosis, i.e. a shortened survival.We demonstrate a high - albeit lower than initially anticipated - frequency of activating BRaf mutations in melanoma in the largest series of directly analyzed tumors reported to date. Notably, the clinical course of patients harboring activating BRaf mutations in metastatic melanoma was significantly affected by the presence of a constitutive BRaf activation in these.

Abstract ICAM-1-mediated cell-cell adhesion is essential for various immunologic functions, including non-MHC-restricted cytotoxicity. The present study was designed to establish whether shedding of ICAM-1 from melanoma cells occurred and to characterize the effects of soluble ICAM-1 on some cell adhesion-dependent functions. The shed soluble ICAM-1 molecule was detected and quantified by a specific ELISA. Shedding of ICAM-1 could be induced by IFN-gamma and TNF-alpha alone, or more effectively, by a combination of the two cytokines together. The use of purified soluble ICAM-1 enabled us to test for the functional significance of the ICAM-1 shedding from tumor cells. Conjugate formation between the cloned NK cell line CNK6 and the erythromyeloid cell line K562, as well as between lymphokine-activated killer cells and the melanoma cell line M26, could be inhibited by purified soluble ICAM-1 and cell-free supernatants from melanoma cell cultures containing shed ICAM-1. Furthermore, the non-MHC-restricted cytotoxicity mediated by NK and lymphokine-activated killer cells could be abrogated either by purified soluble ICAM-1 or by melanoma cell culture supernatants containing shed ICAM-1. Thus, shedding of ICAM-1 may be one of the mechanisms by which neoplastic cells escape immunosurveillance.

Integrin alpha v beta 3 is distinct in its capacity to recognize the sequence Arg-Gly-Asp (RGD) in many extra-cellular matrix (ECM) components. Here, we demonstrate that in addition to the recognition of ECM components, alpha v beta 3 can interact with the neural cell adhesion molecule L1-CAM; a member of the immunoglobulin superfamily (IgSF). M21 melanoma cells displayed significant Ca(++)-dependent adhesion and spreading on immunopurified rat L1 (NILE). This adhesion was found to be dependent on the expression of the alpha v-integrin subunit and could be significantly inhibited by an antibody to the alpha v beta 3 heterodimer. M21 cells also displayed some alpha v beta 3-dependent adhesion and spreading on immunopurified human L1. Ligation between this ligand and alpha v beta 3 was also observed to promote significant haptotactic cell migration. To map the site of alpha v beta 3 ligation we used recombinant L1 fragments comprising the entire extracellular domain of human L1. Significant alpha v beta 3-dependent adhesion and spreading was evident on a L1 fragment containing Ig-like domains 4, 5, and 6. Importantly, mutation of an RGD sequence present in the sixth Ig-like domain of L1 abrogated M21 cell adhesion. We conclude that alpha v beta 3-dependent recognition of human L1 is dependent on ligation of this RGD site. Despite high levels of L1 expression the M21 melanoma cells did not display significant adhesion via a homophilic L1-L1 interaction. These data suggest that M21 melanoma cells recognize and adhere to L1 through a mechanism that is primarily heterophilic and integrin dependent. Finally, we present evidence that melanoma cells can shed and deposit L1 in occluding ECM. In this regard, alpha v beta 3 may recognize L1 in a cell-cell or cell-substrate interaction.

The present study aimed at investigating the impact of defect configuration on the clinical outcome of surgical regenerative therapy of peri-implantitis lesions using a natural bone mineral in combination with a collagen membrane (NBM+CM).Twenty-seven patients (n=27 defects) exhibited three different types of peri-implantitis lesions including either Class Ib (buccal dehiscence+semicircumferential), Class Ic (buccal dehiscence+circumferential), or Class Ie (circumferential) intra-bony defects (n=9 defects per group). All defects were treated with access flap surgery and the application of NBM+CM.At 6 and 12 months, Class Ie defects tended to reveal higher changes in the mean probing depth (PD) and clinical attachment level (CAL) values when compared with Class Ib and Class Ic groups. However, significant differences were only observed at 6 months (PD: 2.9 +/- 0.3 versus 1.4 +/- 0.5 versus 1.3 +/- 0.7 mm; CAL: 2.5 +/- 0.5 versus 0.9 +/- 0.8 versus 0.9 +/- 0.7 mm). Site-level analysis has pointed to lowest PD and CAL changes at the midbuccal aspect of Class Ib and Class Ic groups.Defect configuration may have an impact on the clinical outcome following surgical regenerative therapy of peri-implantitis lesions. While Class Ie defects seem to be promising in conjunction with NBM+CM, Class Ib and Class Ic may be considered as unfavourable.

Merkel cell carcinoma (MCC) is a highly aggressive skin cancer that frequently harbours Merkel cell polyomavirus (MCV) DNA integrated in the genome of the tumor cells. In our study, we elaborate our recent finding that MCV-positive MCC cell lines require the expression of the viral T antigens (TA). Indeed, in a xeno-transplantation model, we prove that TA expression is essential also in an in vivo situation, as knock down of TA leads to tumor regression. Moreover, rescuing TA short hairpin RNA (shRNA)-treated MCV-positive MCC cells by ectopic expression of shRNA-insensitive TAs clearly demonstrates that the observed effect is caused by TA knockdown. Notably, introduction of a mutation in the LTA protein interfering with LTA binding to the retinoblastoma protein (RB) ablated this rescue. The importance of this interaction was further confirmed as LTA-specific knockdown leads to explicit cell growth inhibition. In summary, the presented data demonstrate that established MCV-positive MCC tumors critically depend on TA expression, in particular the LTA and RB interaction, for sustained tumor growth. Consequently, interference with LTA/RB interaction appears as promising strategy to treat MCC.

Understanding the transport properties of porous materials plays an important role in the development and optimization of polymer electrolyte fuel cells (PEFCs). In this study numerical simulations of different transport properties are compared and validated with data obtained using recently developed experimental techniques. The study is based on a Toray TGP-H-060 carbon paper, a common gas diffusion layer (GDL) material in PEFC. Diffusivity, permeability, and electric conductivity of the anisotropic, porous material are measured experimentally under various levels of compression. A sample of the GDL is imaged with synchrotron-based X-ray tomography under three different compression levels. Based on these three-dimensional images, diffusivity, permeability, and conductivity are calculated numerically. Experimental and numerical results agree in general. Deviations are observed for the through-plane conductivity. An explanation for the discrepancy is presented and affirmed by numerical simulations on a virtually created structure model. This proves that numerical simulation based on tomography data is a versatile tool for the investigation and development of porous structures used in PEFCs.

The majority of Merkel cell carcinomas (MCCs) are associated with the recently identified Merkel cell polyomavirus (MCV). However, as it is still unclear to which extent the presence of MCV impacts tumor characteristics or clinical outcome, we correlated the MCV status of tumor lesions obtained from 174 MCC patients including 38 MCC patients from Australia and 138 MCC patients from Germany with clinical characteristics, histomorphology, immunohistochemistry, and course of the disease. MCV DNA was present in 86% of MCCs and, in contrast to previous reports, no significant difference in MCV prevalence was present between Australian and German MCC cases. When patients were stratified according to their MCV status, only tumor localization (P=0.001), gender (P=0.024), and co-morbidity, i.e., frequency of patients with previous skin tumors (P=0.024), were significantly different factors. In contrast, year of birth and diagnosis, age at diagnosis, or histological type and features representing the oncogenic phenotype such as mitotic rate or expression of p16, p53, RB1, and Ki67 were not significantly different between MCV-positive and MCV-negative MCCs. MCV status also did not influence recurrence-free, overall, and MCC-specific survival significantly. In summary, although MCV-positive and MCV-negative MCCs may have different etiologies, these tumors have comparable clinical behaviors and prognosis.

Cytotoxic lymphocytes interact with human tumor cells via the activating immunoreceptor NKG2D, recognizing a variety of stress-associated MIC and ULBP surface molecules. However, tumors can escape from this immunosurveillance by shedding NKG2D ligands (NKG2DL), rendering the soluble products detectable in patients' sera.To elucidate the clinical significance of NKG2DL diversity, we studied their expression on melanoma tissues and their presence as soluble molecules in sera from >200 melanoma patients and compared the latter with the well-established serum marker S100B.Immunohistochemistry revealed a heterogeneous expression of MIC and ULBP2 molecules between and within melanoma metastases. Compared with MIC, ULBP2 was less frequently expressed. Accordingly, elevated levels of soluble ULBP2 (sULBP2) were detected in sera of melanoma patients less frequently than elevated levels of soluble MICA (sMICA), although both soluble NKG2DL (sNKG2DL) were significantly increased compared with sera of healthy controls (P < 0.0001). Strikingly, elevated concentrations of sULBP2, but not of sMICA, were strongly associated with disease progression (P < 0.0001) and tumor load (P = 0.0003). Elevated serum levels of either sNKG2DL correlated with reduced overall survival, albeit considerably stronger for sULBP2 (P < 0.0001) than for sMICA (P = 0.011). In early-stage (I-III) melanoma patients, only sULBP2 (P < 0.0001) but neither sMICA nor S100B revealed prognostic significance. Multivariate analysis identified sULBP2 (P = 0.0015) and S100B (P = 0.013) but not sMICA as independent predictors of prognosis.Our data reveal marked differences in the clinical significance of individual sNKG2DL. Only sULBP2 is an independent predictor of prognosis, the significance of which is superior to the well-established and widely used melanoma serum marker S100B.

Virus-related cancer is cancer where viral infection leads to the malignant transformation of the host's infected cells. Seven viruses (e.g., human papillomavirus (HPV), Epstein–Barr virus (EBV), Kaposi's sarcoma herpesvirus (KSHV), Hepatitis B virus (HBV), Hepatitis C virus (HCV), Human T-lymphotropic virus (HTLV), and Merkel cell polyomavirus (MCV)) that infect humans have been identified as an oncogene and have been associated with several human malignancies. Recently, growing attention has been attracted to exploring the pathogenesis of virus-related cancers. One of the most mysterious molecules involved in carcinogenesis and progression of virus-related cancers is circular RNAs (circRNA). These emerging non-coding RNAs (ncRNAs), due to the absence of 5′ and 3′ ends, have high stability than linear RNAs and are found in some species across the eukaryotic organisms. Compelling evidence has revealed that viruses also encode a repertoire of circRNAs, as well as dysregulation of these viral circRNAs play a critical role in the pathogenesis and progression of different types of virus-related cancers. Therefore, understanding the exact role and function of the virally encoded circRNAs with virus-associated cancers will open a new road for increasing our knowledge about the RNA world. Hence, in this review, we will focus on emerging roles of virus-encoded circRNAs in multiple cancers, including cervical cancer, gastric cancer, Merkel cell carcinoma, nasopharyngeal carcinoma, Kaposi cancer, and liver cancer.

Cellular immune responses to melanoma are tightly regulated and include specific T cell responses to self antigens such as Mart-1 and gp100. Thus, additional signals apart from those mediated by the T cell receptor are needed to ensure T cell activation. Recently, the stress inducible major histocompatibility complex molecules, MHC class I related chain, were identified as an activator of both natural killer and T cells via interaction with their receptor NKG2D. Herein, we report the expression of MIC in 31 of 40 primary cutaneous melanomas and in 13 of 20 metastatic lesions. Moreover, lymphocytes infiltrating the tumor were found to express NKG2D. Detailed analysis identified both CD3⁺ T cells as well as CD56⁺ natural killer cells contributing to this NKG2D⁺ tumor infiltrating lymphocyte population present.

Abstract Survivin is expressed in most human neoplasms, but is absent in normal, differentiated tissues. Survivin is a bifunctional inhibitor of apoptosis protein that has been implicated in protection from apoptosis and regulation of mitosis. Several clinical trials targeting survivin with a collection of different approaches from small molecule antagonists to immunotherapy are currently under way. With regard to the latter, spontaneous anti-survivin T-cell reactivity has been described in cancer patients suffering from a huge range of cancers of different origin, e.g., breast and colon cancer, lymphoma, leukemia, and melanoma. Thus, survivin may serve as a universal target antigen for anticancer immunotherapy. Accordingly, down-regulation of survivin as a means of immune escape would severely inflict the survival capacity of tumor cells, which highlights this protein as a prime target candidate for therapeutic vaccinations against cancer. Data from several ongoing phase I/II trials targeting survivin for patients with advanced cancer will provide further information about this idea.

Cutaneous melanomas are notorious for their tendency to metastasize. Essential steps in this process are the degradation of basement membranes and remodeling of the extracellular matrix (ECM) by proteolytic enzymes such as matrix metalloproteinases (MMPs), which are regulated by their tissue inhibitors (TIMPs). An MMP expression is not restricted to tumor cells but is also found in stromal cells, indicating that stroma-derived proteases may contribute to melanoma progression. The MMPs have been shown to interact with a broad range of non-matrix proteins including adhesion molecules, growth factors and mediators of angiogenesis and apoptosis. In this review, we evaluate new insights into the interplay of MMPs and their molecular partners in melanoma progression.

The proinflammatory cytokine macrophage migration inhibitory factor (MIF) stimulates tumor cell proliferation, migration, and metastasis; promotes tumor angiogenesis; suppresses p53-mediated apoptosis; and inhibits antitumor immunity by largely unknown mechanisms. We here describe an overexpression of MIF in ovarian cancer that correlates with malignancy and the presence of ascites. Functionally, we find that MIF may contribute to the immune escape of ovarian carcinoma by transcriptionally down-regulating NKG2D in vitro and in vivo which impairs NK cell cytotoxicity toward tumor cells. Together with the additional tumorigenic properties of MIF, this finding provides a rationale for novel small-molecule inhibitors of MIF to be used for the treatment of MIF-secreting cancers.

The present case series aimed at investigating the 4-year clinical outcomes following surgical regenerative therapy of peri-implantitis lesions using either a nanocrystalline hydroxyapatite (NHA) or a natural bone mineral in combination with a collagen membrane (NBM+CM).Twenty patients suffering from moderate peri-implantitis (n=20 intrabony defects) were randomly treated with (1) access flap surgery (AFS) and the application of NHA (n=9), or with AFS and the application of NBM+CM (n=11). Clinical and radiographic (R) parameters were recorded at baseline (R) and after 36 and 48 (R) months of non-submerged healing.One patient from the NBM+CM group was discontinued from the study due to severe pus formation at 36 months. Compared with NHA, the application of NBM+CM resulted in higher mean PD reductions (NBM+CM: 2.5 +/- 0.9 mm versus NHA: 1.1 +/- 0.3 mm) and clinical attachment-level gains (NBM+CM: 2.0 +/- 1.0 mm versus NHA: 0.6 +/- 0.5 mm) at 48 months. A radiographic bone fill was observed for five sites in the NHA group, and eight sites in the NBM+CM group.While the application of NBM+CM resulted in clinical improvements over a period of 4 years, the long-term outcome obtained with NHA without barrier membrane must be considered as poor.

Abstract Purpose: Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous tumor. COL1A1–PDGFB gene fusion is frequent in DFSP, rendering tumor cell proliferation and survival dependent on PDGFRβ (platelet-derived growth factor receptor β) signaling. This trial investigated imatinib as neoadjuvant treatment of DFSP, including long-term follow-up. Experimental Design: The primary endpoint of this multicenter phase II trial was response; secondary endpoints were safety, tumor relapse, and response biomarkers. Patients with advanced primary or locally recurrent DFSP and measurable disease by RECIST (response evaluation criteria in solid tumors) were eligible and received imatinib 600 mg/d until definitive surgery with histopathologic proof of tumor-free margins. Results: Sixteen patients received imatinib, and 14 patients were evaluable for all endpoints. Median treatment duration was 3.1 months; median tumor shrinkage was 31.5%. Best overall response was 7.1% complete response (CR), 50.0% partial response (PR), 35.7% stable disease, and 7.1% progressive disease (PD). Toxicity was moderate with 25.0% grade 3 and 4 events. During a median follow-up of 6.4 years, one patient developed secondary resistance to imatinib but responded to second-line sunitinib. This patient also presented local recurrence, distant metastasis, and death from DFSP. Exploratory analysis showed that response to imatinib was associated with decreased tumor cellularity and formation of strong hyalinic fibrosis. Weak PDGFRB phosphorylation and pigmented-type DFSP were associated with nonresponse. Additional to PDGFRB, the kinases EGFR and insulin receptor were found activated in a high percentage of DFSPs. Conclusion: The neoadjuvant use of imatinib 600 mg/d in DFSP is efficacious and well tolerated. Long-term follow-up results do not definitely support smaller surgical margins after successful imatinib pretreatment, and presume that secondary resistance to imatinib might promote accelerated disease progression. Clin Cancer Res; 20(2); 499–510. ©2013 AACR.

Effective diffusivity of porous media in fuel cells has been identified as a relevant material property in automotive applications. Pore-scale simulations utilizing imaging data sets of real materials or virtual model representations provide such diffusivity numbers. However, components like the microporous layer (MPL) or the gas diffusion electrode have not been covered adequately so far by efficient and practical modeling approaches due the small pore sizes and resulting Knudsen contribution to diffusion. In this publication we report the development of a numerical method which allows for the determination of binary diffusion coefficients for all Knudsen numbers and demonstrate the application to fuel cell diffusion media in a multi-scale modeling approach. For high Knudsen numbers effective diffusivity is determined by tracking a large number of individual molecules that collide with the pore walls. For low Knudsen numbers, effective diffusivity is determined by solving the Laplace equation on the pore space. Both contributions to the overall diffusivity are merged by applying Bosanquet’s formula. The resulting diffusivity can be used as an effective number for a microporous layer coating of a spatially resolved fibrous diffusion medium. As this multi-scale method is also based on a 3D voxel grid, we could study any distribution of the MPL on and inside the gas diffusion layer (GDL) with this model, e.g. cracks, different penetration depths, etc.

Abstract Objectives The study aimed at evaluating the 2‐year results obtained following combined surgical resective and regenerative treatment of advanced peri‐implantitis defects comparing two methods of surface debridement/decontamination ( DD ). Material &amp; Methods Twenty‐four patients ( n = 26 combined supra‐ and intrabony defects) completed the 24 months follow‐up observation following access flap surgery, granulation tissue removal and implantoplasty at bucally and supracrestally exposed implant parts. The remaining aspects were randomly allocated to surface DD using either (i) an Er: YAG laser ( ERL ) device, or (ii) plastic curets + cotton pellets + sterile saline ( CPS ) were augmented with a natural bone mineral and covered with a collagen membrane. Results At 24 months, ERL treated sites failed to reveal significantly higher reductions in mean BOP ( ERL : 75.0 ± 32.6% versus CPS : 54.9 ± 30.3%) and CAL values ( ERL : 1.0 ± 2.2 mm versus CPS : 1.2 ± 2.2 mm) when compared with the CPS group. In both groups, mean CAL values were not significantly different when compared with baseline. Conclusion The long‐term stability of clinical outcomes obtained following combined surgical therapy of advanced peri‐implantitis may be influenced by factors other than the method of surface debridement/decontamination.

Although trastuzumab (Herceptin) has substantially improved the overall survival of patients with mammary carcinomas, even initially well-responding tumors often become resistant. Because natural killer (NK) cell-mediated antibody-dependent cell-mediated cytotoxicity (ADCC) is thought to contribute to the therapeutic effects of trastuzumab, we have established a cell culture system to select for ADCC-resistant SK-OV-3 ovarian cancer and MCF7 mammary carcinoma cells. Ovarian cancer cells down-regulated HER2 expression, resulting in a more resistant phenotype. MCF7 breast cancer cells, however, failed to develop resistance in vitro. Instead, treatment with trastuzumab and polyclonal NK cells resulted in the preferential survival of individual sphere-forming cells that displayed a CD44(high)CD24(low) "cancer stem cell-like" phenotype and expressed significantly less HER2 compared with non-stem cells. Likewise, the CD44(high)CD24(low) population was also found to be more immunoresistant in SK-BR3, MDA-MB231, and BT474 breast cancer cell lines. When immunoselected MCF7 cells were then re-expanded, they mostly lost the observed phenotype to regenerate a tumor cell culture that displayed the initial HER2 surface expression and ADCC-susceptibility, but was enriched in CD44(high)CD24(low) cancer stem cells. This translated into increased clonogenicity in vitro and tumorigenicity in vivo. Thus, we provide evidence that the induction of ADCC by trastuzumab and NK cells may spare the actual tumor-initiating cells, which could explain clinical relapse and progress. Moreover, our observation that the "relapsed" in vitro cultures show practically identical HER2 surface expression and susceptibility toward ADCC suggests that the administration of trastuzumab beyond relapse might be considered, especially when combined with an immune-stimulatory treatment that targets the escape variants.

Panobinostat is a potent, oral pan-deacetylase inhibitor (pan-DACi) that increases the acetylation of proteins involved in multiple oncogenic pathways. Here, panobinostat is studied in bexarotene-exposed and -naïve patients with refractory cutaneous T-cell lymphoma (CTCL).Patients with CTCL subtypes mycosis fungoides and Sézary syndrome who received ⩾2 prior systemic therapy regimens received panobinostat (20mg) three times every week. The primary objective was overall response rate (ORR) as determined by a combined evaluation of skin disease and involvement of lymph node and viscera. Disease progression was defined as an unconfirmed, ⩾25% increase in modified Severity Weighted Assessment Tool (mSWAT) compared with nadir.Seventy-nine bexarotene-exposed and 60 bexarotene-naïve patients were enrolled. Reductions in baseline mSWAT scores were observed in 103 patients (74.1%). The ORR was 17.3% in all patients in the primary analysis (15.2% and 20.0% in the bexarotene-exposed and -naïve groups, respectively). The median progression-free survival was 4.2 and 3.7 months in the bexarotene-exposed and -naïve groups, respectively. The median duration of response was 5.6 months in the bexarotene-exposed patients and was not reached at data cutoff in the bexarotene-naïve patients. Additional responses were observed when less-stringent progression criteria were used. The most common adverse events were thrombocytopenia, diarrhoea, fatigue and nausea. Thrombocytopenia and neutropenia were the only grade 3/4 adverse events in >5% of patients and were manageable.Despite a very conservative definition of disease progression, panobinostat demonstrated activity with a manageable safety profile in bexarotene-exposed and -naïve CTCL patients. ClinicalTrials.gov Identifier: NCT00425555.

Abstract Objectives To assess the long‐term outcomes (&gt;4 years) following combined surgical resective/regenerative therapy of advanced peri‐implantitis lesions using two surface decontamination methods. Material &amp; Methods Fifteen patients ( n = 15 combined supra‐ and intrabony defects) completed a follow‐up observation period of 7 years. The treatment procedure included access flap surgery, granulation tissue removal and implantoplasty at buccally and supracrestally exposed implant parts, and a randomly assigned decontamination of the unmodified intrabony implant surface areas using either (i) an Er: YAG laser ( ERL ) or (ii) plastic curettes + cotton pellets + sterile saline ( CPS ). Intrabony defects were filled using a natural bone mineral and covered by a native collagen membrane. Results At 7 years, both ERL and CPS were associated with similar mean bleeding on probing reductions ( CPS : 89.99 ± 11.65% versus ERL : 86.66 ± 18.26%) and clinical attachment level gains ( CPS : 2.76 ± 1.92 mm versus ERL : 2.06 ± 2.52 mm). Conclusion Combined surgical resective/regenerative therapy of advanced peri‐implantitis was effective on the long‐term, but not influenced by the initial method of surface decontamination.

Aim: Merkel cell carcinoma (MCC) is a rare neuroendocrine, cutaneous malignancy with poor prognosis once metastasized. The aim of this study was to conduct a systematic literature review to assess clinical outcomes associated with chemotherapy regimens in metastatic MCC. Materials &amp; methods: Embase ® , MEDLINE ® , MEDLINE ® -In-Process and CENTRAL were searched for studies published in January 2016. Results &amp; conclusion: Overall, the literature on chemotherapy in patients with metastatic MCC is sparse, with most studies being case series/reports. Across all studies, response rates ranged from 20 to 61%, with higher response rates in first-line setting (53–61%) versus second-line setting (23–45%). Among responders, duration of response was short (≤8 months) in both first- and second-line settings. There is a need for novel agents that can induce durable responses in metastatic MCC.

Abstract Merkel cell carcinoma (MCC) is an aggressive, polyomavirus-associated skin cancer. Robust cellular immune responses are associated with excellent outcomes in patients with MCC, but these responses are typically absent. We determined the prevalence and reversibility of major histocompatibility complex class I (MHC-I) downregulation in MCC, a potentially reversible immune-evasion mechanism. Cell-surface MHC-I expression was assessed on five MCC cell lines using flow cytometry as well as immunohistochemistry on tissue microarrays representing 114 patients. Three additional patients were included who had received intralesional IFN treatment and had evaluable specimens before and after treatment. mRNA expression analysis of antigen presentation pathway genes from 35 MCC tumors was used to examine the mechanisms of downregulation. Of note, 84% of MCCs (total n = 114) showed reduced MHC-I expression as compared with surrounding tissues, and 51% had poor or undetectable MHC-I expression. Expression of MHC-I was lower in polyomavirus-positive MCCs than in polyomavirus-negative MCCs (P &amp;lt; 0.01). The MHC-I downregulation mechanism was multifactorial and did not depend solely on HLA gene expression. Treatment of MCC cell lines with ionizing radiation, etoposide, or IFN resulted in MHC-I upregulation, with IFNs strongly upregulating MHC-I expression in vitro, and in 3 of 3 patients treated with intralesional IFNs. MCC tumors may be amenable to immunotherapy, but downregulation of MHC-I is frequently present in these tumors, particularly those that are positive for polyomavirus. This downregulation is reversible with any of several clinically available treatments that may thus promote the effectiveness of immune-stimulating therapies for MCC. Cancer Immunol Res; 2(11); 1071–9. ©2014 AACR.

Purpose of review Merkel cell carcinoma (MCC) is a highly aggressive neuroendocrine carcinoma of the skin demonstrating a high propensity of recurrence and metastasis. Its 5-year disease-specific survival rate is only about 60%. Although MCC is still regarded as a very rare tumor entity, its incidence is rapidly increasing. In this regard, the American Cancer Society estimated almost 1500 new cases in the United States in 2008. Recent findings The newly identified Merkel cell polyomavirus (MCV) has been found associated to most MCC cases. Nevertheless, the distinct molecular pathogenesis of MCC and its link to MCV is not yet fully understood. Moreover, the impact of MCV positivity on the course of disease and prognosis of MCC patients is controversially discussed. Summary This review summarizes recent findings on MCC pathogenesis with a special emphasis on the impact of MCV, presents an overview of clinical aspects, and discusses treatment options.

Merkel cell carcinoma (MCC) is a rare and aggressive, yet highly immunogenic skin cancer. The latter is due to its viral or UV-associated carcinogenesis. For tumor progression MCC has to escape the host's immuno-surveillance, e.g. by loss of HLA class-I expression. Indeed, a reduced HLA class-I expression was observed in MCC tumor tissues and MCC cell lines. This reduced HLA class-I surface expression is caused by an impaired expression of key components of the antigen processing machinery (APM), including LMP2 and LMP7 as well as TAP1 and TAP2. Notably, experimental provisions of HLA class-I binding peptides restored HLA class-I surface expression on MCC cells. Silencing of the HLA class-I APM is due to histone deacetylation as inhibition of histone deacetylases (HDACs) not only induced acetylation of histones in the respective promoter regions but also re-expression of APM components. Thus, HDAC inhibition restored HLA class-I surface expression in vitro and in a mouse xenotransplantation model. In contrast to re-induction of HLA class-I by interferons, HDAC inhibitors did not interfere with the expression of immuno-dominant viral proteins. In summary, restoration of HLA class-I expression on MCC cells by epigenetic priming is an attractive approach to enhance therapies boosting adaptive immune responses.

<h2>Abstract</h2><h3>Background</h3> Advanced cutaneous squamous cell carcinoma (aSCC) is an area of unmet medical need and no treatment standards are established. Recently, an anti-PD-1 inhibitor received FDA breakthrough therapy designation. The aim of the study was to describe the clinical course, therapeutic management and prognosis of aSCC under real-life conditions. <h3>Patients and methods</h3> In a retrospective study performed in 24 German and Austrian hospitals and doctor's offices, patient and tumour characteristics of patients diagnosed with aSCC between January 1, 2010 and December 31, 2011 and their disease course was documented. Advanced SCC comprised either locally advanced SCCs (laSCC) or metastatic SCCs (mSCC) with any kind of metastatic spread. <h3>Results</h3> Data of 190 patients with aSCC were analysed. Median age at time of diagnosis of aSCC was 78 years. LaSCC was diagnosed in 76 patients (40%), 114 patients (60%) had mSCC. Once diagnosed with laSCC, most patients (59%) did not receive any therapy, whereas in 92% of mSCC patients at least one type of therapy was performed. Only 32 patients (29 mSCC, 3 laSCC) received systemic antitumour therapies, mostly EGFR inhibitor-based regimens. Mean duration of response was short (17-months laSCC patients, 3-months mSCC patients). Only 2 patients achieved a complete response, 27% had a partial response, 43% disease stabilisation. At diagnosis of aSCC, ECOG status was 0–1 in most patients. Non-malignant comorbidities influenced the decision on SCC-specific therapy in 39 patients (21%). <h3>Conclusions</h3> Our data show the high medical need for efficient and tolerable antitumour therapies and demonstrate that despite older age and comorbidities, most patients can be expected to be fit for treatment. This study provides a historical context for emerging aSCC treatments.

<h2>Abstract</h2><h3>Aim</h3> The aim of this article was to provide worldwide, population-based incidence rates for Merkel cell carcinoma (MCC). <h3>Methods</h3> We included 11,576 cases from 20 countries for time trend analyses (1990–2007) and 11,028 cases (2.5 billion person-years) from 21 countries for the period 2003–2007 extracted from Cancer Incidence in Five Continents. We computed age-standardised incidence rates (World Standard population) per million person years and sex ratios of these rates. We estimated annual percentage changes (EAPCs) of the incidence and studied the association between geographic latitude and MCC incidence. We examined the body site distribution of MCC. <h3>Findings</h3> In the majority of populations, the incidence has increased over time (EAPC, men 2.0–21.0%; women 1.6–27.2%). Rate differences between 1995 and 2007 were typically small (men: 0.8–2.2; women: 0.2–1.7). The incidence was relatively stable in some populations (men: U.S. blacks, Japan, Norway, Denmark; women: Denmark, Norway, Sweden). Incidences from 2003 to 2007 were highest in Australia, New Zealand, the United States and Israel among men and in New Zealand, Australia, Ireland and the Netherlands among women. The incidence of MCC and melanoma among white non-Hispanic males in North America was positively associated with living closer to the equator. The proportion of MCC on the head was higher with advanced age. The head was a less likely primary site among blacks as compared with any other ethnicity. <h3>Interpretation</h3> Several countries showed increases in MCC incidence among white non-Hispanics over time. Latitude closer to the equator was associated with the MCC incidence in North American men, but barely in women, possibly due to occupational sunlight exposure patterns.

Abstract This paper reports that aggressive antibiotic treatment inhibits disease activity and lymphocyte proliferation in cutaneous T-cell lymphoma (CTCL). The study offers important evidence for a link between bacterial infection, activation of the immune system, and CTCL progression.

Merkel cell carcinoma (MCC) is an aggressive neuroendocrine tumor of the skin with a rising incidence. MCC has metastatic potential regardless the size of the primary tumor and a 5-year disease associated mortality rate is 46 %. Surgery and radiation are the mainstays of management for primary MCC. There is no evidence-based effective chemotherapy for recurrent or metastatic diseases to date. In-depth mechanistic studies in MCC have uncovered important cellular events and the association with a polyomavirus, which has provided direct evidence for molecular targeted and immunotherapy. Further perspective studies and clinical trials are warranted to provide reliable evidence of possible pitfalls and effectiveness of molecular targeted immunotherapy alone or in combination with chemotherapy in MCC.

Abstract Objectives To investigate the impact of two surface decontamination methods on the long‐term outcomes following combined surgical resective/regenerative therapy of advanced peri‐implantitis lesions. Material and Methods Seventeen patients ( n = 17 combined supra‐ and intrabony‐defects) completed the 48 months follow‐up observation following access flap surgery, granulation tissue removal and implantoplasty at bucally and supracrestally exposed implant parts. The remaining unmodified implant surface areas were randomly treated using either (i) an Er: YAG laser ( ERL ), or (ii) plastic curets + cotton pellets + sterile saline ( CPS ), and augmented with a natural bone mineral + collagen membrane. Results At 48 months, CPS ‐treated sites tended to reveal higher reductions in mean BOP ( CPS : 85.2 ± 16.4% versus ERL : 71.6 ± 24.9%) and CAL values ( CPS : 1.5 ± 2.0 mm versus ERL : 1.2 ± 2.0 mm) when compared with the ERL group. In both groups, clinical outcomes were not directly influenced by the initial defect configuration. Conclusion The 4‐year clinical outcomes obtained following combined surgical resective/regenerative therapy of advanced peri‐implantitis were not influenced by the method of surface decontamination.

Merkel cell carcinoma (MCC) is a highly aggressive, often lethal neuroendocrine cancer. Its carcinogenesis may be either caused by the clonal integration of the Merkel cell polyomavirus into the host genome or by UV-induced mutations. Notably, virally-encoded oncoproteins and UV-induced mutations affect comparable signaling pathways such as RB restriction of cell cycle progression or p53 inactivation. Despite its low incidence, MCC recently received much attention based on its exquisite immunogenicity and the resulting major success of immune modulating therapies. Here, we summarize current knowledge on epidemiology, biology and therapy of MCC as conclusion of the project 'Immune Modulating strategies for treatment of Merkel Cell Carcinoma', which was funded over a 5-year period by the European Commission to investigate innovative immunotherapies for MCC.

<h3>Background</h3> Programmed cell death protein 1 (PD-1) checkpoint inhibition has recently advanced to one of the most effective treatment strategies in melanoma. Nevertheless, a considerable proportion of patients show upfront therapy resistance and baseline predictive biomarkers of treatment outcome are scarce. In this study we quantified PD-1 and programmed death-ligand 1 (PD-L1) in baseline sera from melanoma patients in relation to therapy response and survival. <h3>Patients and methods</h3> Sera taken at therapy baseline from a total of 222 metastatic melanoma patients (two retrospectively selected monocentric discovery cohorts, <i>n</i> = 130; one prospectively collected multicentric validation cohort, <i>n</i> = 92) and from 38 healthy controls were analyzed for PD-1 and PD-L1 concentration by sandwich enzyme-linked immunosorbent assay. <h3>Results</h3> Melanoma patients showed higher serum concentrations of PD-1 (<i>P</i> = 0.0054) and PD-L1 (<i>P</i> < 0.0001) than healthy controls. Elevated serum PD-1 and PD-L1 levels at treatment baseline were associated with an impaired best overall response (BOR) to anti-PD-1 (<i>P</i> = 0.014, <i>P</i> = 0.041), but not to BRAF inhibition therapy. Baseline PD-1 and PD-L1 serum levels correlated with progression-free (PFS; <i>P</i> = 0.0081, <i>P</i> = 0.053) and overall survival (OS; <i>P</i> = 0.055, <i>P</i> = 0.0062) in patients who received anti-PD-1 therapy, but not in patients treated with BRAF inhibitors. By combining both markers, we obtained a strong discrimination between favorable and poor outcome of anti-PD-1 therapy, with elevated baseline serum levels of PD-1 and/or PD-L1 associated with an impaired BOR (<i>P</i> = 0.037), PFS (<i>P</i> = 0.048), and OS (<i>P</i> = 0.0098). This PD-1/PD-L1 combination serum biomarker was confirmed in an independent multicenter validation set of serum samples prospectively collected at baseline of PD-1 inhibition (BOR, <i>P</i> = 0.019; PFS, <i>P</i> = 0.038; OS, <i>P</i> = 0.022). Multivariable Cox regression demonstrated serum PD-1/PD-L1 as an independent predictor of PFS (<i>P</i> = 0.010) and OS (<i>P</i> = 0.003) in patients treated with PD-1 inhibitors. <h3>Conclusion</h3> Our findings indicate PD-1 and PD-L1 as useful serum biomarkers to predict the outcome of PD-1 inhibition therapy in melanoma patients and to select patients for PD-1-based versus BRAF-based therapy strategies.

Background Recent therapeutic strategies, particularly MAP kinase pathway inhibitors (BRAF, MEK) and immune checkpoint blockers (CTLA-4, PD-1), have been put on the test for their differential impact on long-term survival of metastatic melanoma patients. Various agents, dose regimens and combinations have been tested against each other vigorously within these two therapy groups. However, results from prospective head-to-head comparative trials comparing both strategies against each other are still lacking. Methods We performed an exploratory analysis of survival data from selected clinical trials representative for these two treatment strategies in advanced metastatic melanoma. 84 Kaplan–Meier survival curves from 26 trials were digitised and grouped by therapy strategy and treatment line. For each of these groups, mean survival curves were generated for progression-free (PFS) and overall survival (OS) by weighted averaging. Results Survival curves grouped together by therapy strategy revealed a high concordance, with a larger extent in the first-line setting compared to higher treatment lines. In first-line therapy, the averaged 3-year OS proportions were 41.3% for BRAF plus MEK inhibition, 49.9% for PD-1 inhibition, and 58.4% for CTLA-4 plus PD-1 inhibition. Comparison of the mean PFS and OS curves of kinase inhibition and checkpoint blockade revealed a superiority of combined BRAF plus MEK inhibition within the first 12 months, later changing to a superiority of PD-1 blockers alone or in combination with CTLA-4 blockade. In second-line or higher, BRAF plus MEK inhibition was superior to anti-PD-1 monotherapy throughout the first three years; averaged 3-year OS proportions were 42.4% for BRAF plus MEK inhibition, and 40.1% for PD-1 inhibition. Conclusions and relevance: These results need confirmation by head-to-head comparative randomised clinical trials.

To assess the prevalence of peri-implant health or disease for a two-piece implant system with a tube-in-tube internal connection on the short-, medium- and long term.For this cross-sectional analysis, 238 patients with a total of n = 512 implants were screened in six private practices and one university clinic in Germany. Peri-implant health and disease was assessed according to strict case definitions. Binary logistic regression was used to assess the correlation with systemic factors.After a median function time of 23 months, the prevalence of peri-implant mucositis and peri-implantitis amounted to 41.6% and 13.9%, corresponding to 35.6% and 7.6% at the implant level, respectively. Factors plaque (odds ratio [OR], 8.415) and gender "male" (OR, 2.003) were significantly correlated with the event peri-implant mucositis. The event peri-implantitis was significantly correlated with plaque (OR, 9.250) and smoking (OR, 2.679).The prevalence of peri-implant diseases was correlated with patient-specific factors.

Merkel cell carcinoma (MCC) is a highly aggressive skin cancer with strong evidence of viral carcinogenesis. The association of MCC with the Merkel cell polyomavirus (MCPyV) may explain the explicit immunogenicity of MCC. Indeed, MCPyV-encoded proteins are likely targets for cytotoxic immune responses to MCC as they are both foreign to the host and necessary to maintain the oncogenic phenotype. However, to date only a single MCPyV-derived CD8 T-cell epitope has been described, thus impeding specific monitoring of T-cell responses to MCC.To overcome this limitation, we scanned the MCPyV oncoprotein large T and small T antigens and the virus capsid protein VP1 for potential T-cell epitopes, and tested for MHC class I affinity. We confirmed the relevance of these epitopes using a high-throughput platform for T-cell enrichment and combinatorial encoding of MHC class I multimers.In peripheral blood from 38 patients with MCC and 30 healthy donors, we identified 53 MCPyV-directed CD8 T-cell responses against 35 different peptide sequences. Strikingly, T-cell responses against oncoproteins were exclusively present in patients with MCC, but not in healthy donors. We further demonstrate both the processing and presentation of the oncoprotein-derived epitopes, as well as the lytic activity of oncoprotein-specific T cells toward MHC-matched MCC cells. Demonstrating the presence of oncoprotein-specific T cells among tumor-infiltrating lymphocytes further substantiated the relevance of the identified epitopes.These T-cell epitopes represent ideal targets for antigen-specific immune therapy of MCC, and enable tracking and characterization of MCPyV-specific immune responses.

L19-IL2 is a recombinant protein comprising the cytokine IL2 fused to the single-chain monoclonal antibody L19. In previous studies, intralesional injection with IL2 has shown efficacy for the locoregional treatment of cutaneous/subcutaneous metastases in patients with advanced melanoma. The objectives of this study were to investigate whether (i) intralesional delivery of a targeted form of IL2 would yield similar results, with reduction of injection frequency and treatment duration; and (ii) systemic immune responses were induced by the local treatment. Patients with stage IIIB/IIIC melanoma and cutaneous/subcutaneous injectable metastases received weekly intratumoral injections of L19-IL2 at a maximum dose of 10 MIU/week for 4 consecutive weeks. Tumor response was evaluated 12 weeks after the first treatment. Twenty-four of 25 patients were evaluable for therapy-induced responses. A complete response (CR) by modified immune-related response criteria (irRC) of all treated metastases was achieved in 6 patients (25%), with long-lasting responses in most cases (5 patients for ≥24 months). Objective responses were documented in 53.9% of all index lesions [44.4% CR and 9.5% partial responses (by irRC)], and 36.5% of these remained stable, while 9.5% progressed. Toxicity was comparable with that of free IL2, and no serious adverse events were recorded. A significant temporary increase of peripheral regulatory T cells and natural killer cells, sustained increase of absolute CD4(+) lymphocytes, and decrease of myeloid-derived suppressor cells were observed upon treatment. Finally, we recorded encouraging data about the progression time to distant metastases and overall survival.

The relative affinity of T cell receptors for different peptide–MHCs is measured at high throughput, revealing T cell cross-reactivity. The promiscuous nature of T-cell receptors (TCRs) allows T cells to recognize a large variety of pathogens, but makes it challenging to understand and control T-cell recognition1. Existing technologies provide limited information about the key requirements for T-cell recognition and the ability of TCRs to cross-recognize structurally related elements2,3. Here we present a 'one-pot' strategy for determining the interactions that govern TCR recognition of peptide–major histocompatibility complex (pMHC). We measured the relative affinities of TCRs to libraries of barcoded peptide–MHC variants and applied this knowledge to understand the recognition motif, here termed the TCR fingerprint. The TCR fingerprints of 16 different TCRs were identified and used to predict and validate cross-recognized peptides from the human proteome. The identified fingerprints differed among TCRs recognizing the same epitope, demonstrating the value of this strategy for understanding T-cell interactions and assessing potential cross-recognition before selection of TCRs for clinical development.

Background and aims: Merkel cell carcinoma (MCC) is a rare, aggressive skin cancer; few treatments exist for patients with advanced disease.Once tumors metastasize to distant sites, patients generally receive chemotherapy, but response duration and progression-free survival (PFS) are typically short.Few studies have assessed the efficacy of second-line chemotherapy for metastatic MCC.Here, we studied outcomes in patients who received ≥ 2 lines of chemotherapy for metastatic MCC.Materials and Methods: Patients in an MCC-specific registry diagnosed with stage IV MCC between November 1, 2004, and September 15, 2015, and treated with second-line or later chemotherapy were analyzed retrospectively.Patient records, including baseline characteristics, immunocompetent status, and responses to prior chemotherapy, were evaluated.Patients meeting eligibility criteria were followed through December 31, 2015.Results: Of 29 patients with metastatic MCC and immunocompetent status who had received ≥ 2 lines of chemotherapy, 3 achieved a partial response, for an objective Clinical Research Paper Oncotarget 79732 www.impactjournals.com/oncotargetresponse rate (ORR) of 10.3% (95% CI, 2.2-27.4).In the overall population including patients with immunocompetent and immunocompromised status (n = 34), the ORR was 8.8% (95% CI, 1.9-23.7).The median duration of response was 1.9 months (range, 1.3-2.1 months; 95% CI, 1.3-2.1).In the immunocompetent population, median PFS and overall survival were 3.0 months (95% CI, 2.5-6.0) and 5.3 months (95% CI, 4.3-6.0),respectively.Conclusions: The low response rates and limited durability confirm previous reports of the ineffectiveness of second-line or later chemotherapy in patients with metastatic MCC and provide a benchmark for assessing clinical benefit of new treatments.

Abstract Melanoma cells have the ability to switch to a dedifferentiated, invasive phenotype in response to multiple stimuli. Here, we show that exposure of melanomas to multiple stresses including BRAF–MEK inhibitor therapy, hypoxia, and UV irradiation leads to an increase in histone deacetylase 8 (HDAC8) activity and the adoption of a drug-resistant phenotype. Mass spectrometry–based phosphoproteomics implicated HDAC8 in the regulation of MAPK and AP-1 signaling. Introduction of HDAC8 into drug-naïve melanoma cells conveyed resistance both in vitro and in vivo. HDAC8-mediated BRAF inhibitor resistance was mediated via receptor tyrosine kinase activation, leading to MAPK signaling. Although HDACs function at the histone level, they also regulate nonhistone substrates, and introduction of HDAC8 decreased the acetylation of c-Jun, increasing its transcriptional activity and enriching for an AP-1 gene signature. Mutation of the putative c-Jun acetylation site at lysine 273 increased transcriptional activation of c-Jun in melanoma cells and conveyed resistance to BRAF inhibition. In vivo xenograft studies confirmed the key role of HDAC8 in therapeutic adaptation, with both nonselective and HDAC8-specific inhibitors enhancing the durability of BRAF inhibitor therapy. Our studies demonstrate that HDAC8-specific inhibitors limit the adaptation of melanoma cells to multiple stresses including BRAF–MEK inhibition. Significance: This study provides evidence that HDAC8 drives transcriptional plasticity in melanoma cells in response to a range of stresses through direct deacetylation of c-Jun.

Summary Actinic keratoses (AK) are common lesions in light‐skinned individuals that can potentially progress to cutaneous squamous cell carcinoma (cSCC). Both conditions may be associated with significant morbidity and constitute a major disease burden, especially among the elderly. To establish an evidence‐based framework for clinical decision making, the guideline “actinic keratosis and cutaneous squamous cell carcinoma” was developed using the highest level of methodology (S3) according to regulations issued by the Association of Scientific Medical Societies in Germany (AWMF). The guideline is aimed at dermatologists, general practitioners, ENT specialists, surgeons, oncologists, radiologists and radiation oncologists in hospitals and office‐based settings as well as other medical specialties involved in the diagnosis and treatment of patients with AK and cSCC. The guideline is also aimed at affected patients, their relatives, policy makers and insurance funds. In the first part, we will address aspects relating to diagnosis, interventions for AK, care structures and quality‐of‐care indicators.

To evaluate the pan-immune-inflammation value (PIV) and systemic immune-inflammation index (SII) in patients with cutaneous melanoma (CM) under immune checkpoint inhibitor (ICI) therapy.PIV and SII were calculated before the start of ICI therapy and at time of progression/death in patients with metastatic CM (stage III/IV). Sex-age-matched CM patients in stage I/II and healthy subjects (HC) served as controls.The median PIV of stage III/IV patients was significantly (P = 0.0011) higher than in stage I/II patients and HC. SII was significantly (P = 0.00044) lower in HC than in CM patients. At baseline, PIV and SII did significantly correlate with lactate dehydrogenase (P = 0.045/0.017). However, ROC curve statistics revealed that SII and PIV were not significantly associated with clinical parameters, including best response to ICI treatment (P = 0.87/0.64), progression-free survival (P = 0.73/0.91), and melanoma-specific survival (P = 0.13/0.17). Moreover, there were no significant changes of PIV and SII from baseline to progression/death (P = 0.38/0.52).Even though both immune-inflammation biomarkers showed some power to differentiate between CM stages and HC, respectively, PIV and SII seem not to be significant predictors for clinical outcome measures of CM patients under ICI therapy.

Based on its viral-associated or UV-associated carcinogenesis, Merkel cell carcinoma (MCC) is a highly immunogenic skin cancer. Thus, clinically evident MCC occurs either in immuno-compromised patients or based on tumor-intrinsic immune escape mechanisms. This notion may explain that although advanced MCC can be effectively restrained by treatment with PD-1/PD-L1 immune checkpoint inhibitors (ICIs), a considerable percentage of patients does not benefit from ICI therapy. Biomarkers predicting ICI treatment response are currently not available.The present multicenter retrospective study investigated clinical and molecular characteristics in 114 patients with unresectable MCC at baseline before treatment with ICI for their association with therapy response (best overall response, BOR). In a subset of 21 patients, pretreatment tumor tissue was analyzed for activation, differentiation and spatial distribution of tumor infiltrating lymphocytes (TIL).Of the 114 patients, n=74 (65%) achieved disease control (BOR=complete response/partial response/stable disease) on ICI. A Bayesian cumulative ordinal regression model revealed absence of immunosuppression and a limited number of tumor-involved organ systems was highly associated with a favorable therapy response. Unimpaired overall performance status, high age, normal serum lactate dehydrogenase and normal serum C reactive protein were moderately associated with disease control. While neither tumor Merkel cell polyomavirus nor tumor PD-L1 status showed a correlation with therapy response, treatment with anti-PD-1 antibodies was associated with a higher probability of disease control than treatment with anti-PD-L1 antibodies. Multiplexed immunohistochemistry demonstrated the predominance of CD8+ effector and central memory T cells (TCM) in close proximity to tumor cells in patients with a favorable therapy response.Our findings indicate the absence of immunosuppression, a limited number of tumor-affected organs, and a predominance of CD8+ TCM among TIL, as baseline parameters associated with a favorable response to PD-1/PD-L1 ICI therapy of advanced MCC. These factors should be considered when making treatment decisions in MCC patients.

JDDG: Journal der Deutschen Dermatologischen GesellschaftVolume 20, Issue 4 p. 537-554 GuidelineOpen Access S2k-Guidelines – Cutaneous lymphomas (ICD10 C82 - C86): Update 2021 Edgar Dippel, Corresponding Author Edgar Dippel dippele@klilu.de Department of Dermatology, Hospital Ludwigshafen, Germany Correspondence to Prof. Dr. med. Edgar Dippel Hautklinik Ludwigshafen Bremserstraße 79 67063 Ludwigshafen am Rhein Germany E-mail: dippele@klilu.deSearch for more papers by this authorChalid Assaf, Chalid Assaf Department of Dermatology and Venereology, Helios Hospital Krefeld, GermanySearch for more papers by this authorJürgen C. Becker, Jürgen C. Becker West German Tumor Center, University Hospital Essen, GermanySearch for more papers by this authorMichael von Bergwelt-Baildon, Michael von Bergwelt-Baildon Department I of Internal Medicine, University Hospital Cologne, GermanySearch for more papers by this authorSophie Bernreiter, Sophie Bernreiter Department of Dermatology, Hospital Ludwigshafen, GermanySearch for more papers by this authorAntonio Cozzio, Antonio Cozzio Department of Dermatology, Venereology and Allergology, Canton Hospital St. Gallen, SwitzerlandSearch for more papers by this authorHans T. Eich, Hans T. Eich Department of Radiation Therapy and Radio-Oncology, University Hospital Münster, GermanySearch for more papers by this authorKhaled Elsayad, Khaled Elsayad Department of Radiation Therapy and Radio-Oncology, University Hospital Münster, GermanySearch for more papers by this authorMarkus Follmann, Markus Follmann German Cancer Society, Berlin, GermanySearch for more papers by this authorStephan Grabbe, Stephan Grabbe Department of Dermatology, University Hospital Mainz, GermanySearch for more papers by this authorUwe Hillen, Uwe Hillen Department of Dermatology, University Hospital Essen, GermanySearch for more papers by this authorWolfram Klapper, Wolfram Klapper Institute of Pathology, University Hospital Schleswig-Holstein, Campus Kiel, GermanySearch for more papers by this authorClaus-Detlev Klemke, Claus-Detlev Klemke Department of Dermatology, Municipal Hospital of Karlsruhe, Academic Teaching Hospital for the University of Freiburg, Karlsruhe, GermanySearch for more papers by this authorCarmen Loquai, Carmen Loquai Department of Dermatology, University Hospital Mainz, GermanySearch for more papers by this authorFrank Meiss, Frank Meiss Department of Dermatology and Venereology, University Hospital Freiburg, medical Faculty, Albert-Ludwigs University Freiburg, GermanySearch for more papers by this authorChristina Mitteldorf, Christina Mitteldorf Department of Dermatology, Venereology and Allergology, University Hospital Göttingen, GermanySearch for more papers by this authorUlrike Wehkamp, Ulrike Wehkamp Department of Dermatology, Venereology and Allergology, University Hospital Schleswig-Holstein, Campus Kiel, GermanySearch for more papers by this authorDorothee Nashan, Dorothee Nashan Department of Dermatology, Dortmund Hospital GmbH, Dortmund, GermanySearch for more papers by this authorJan P. Nicolay, Jan P. Nicolay Department of Dermatology, Venereology and Allergology, University Hospital Mannheim, GermanySearch for more papers by this authorIlske Oschlies, Ilske Oschlies Institute of Pathology, University Hospital Schleswig-Holstein, Campus Kiel, GermanySearch for more papers by this authorMax Schlaak, Max Schlaak Charité – Universitätsmedizin Berlin, Department of Dermatology, Venereology and Allergology, Berlin, GermanySearch for more papers by this authorRené Stranzenbach, René Stranzenbach Department of Dermatology, Venereology and Allergology, University Hospital at Ruhr University Bochum, GermanySearch for more papers by this authorRose Moritz, Rose Moritz Department for Dermatology, University Hospital Halle, GermanySearch for more papers by this authorChristoph Stoll, Christoph Stoll Rehabilitation Hospital, Herzoghöhe Bayreuth, GermanySearch for more papers by this authorTibor Vag, Tibor Vag Department of Nuclear Medicine, Technical University of Munich, GermanySearch for more papers by this authorMichael Weichenthal, Michael Weichenthal Department of Dermatology, Venereology and Allergology, University Hospital Schleswig-Holstein, Campus Kiel, GermanySearch for more papers by this authorMarion Wobser, Marion Wobser Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, GermanySearch for more papers by this authorRudolf Stadler, Rudolf Stadler Department of Dermatology, Venereology, Allergology, and Phlebology, Johannes Wesling University Hospital Minden, University Hospital at Ruhr University Bochum, GermanySearch for more papers by this author Edgar Dippel, Corresponding Author Edgar Dippel dippele@klilu.de Department of Dermatology, Hospital Ludwigshafen, Germany Correspondence to Prof. Dr. med. Edgar Dippel Hautklinik Ludwigshafen Bremserstraße 79 67063 Ludwigshafen am Rhein Germany E-mail: dippele@klilu.deSearch for more papers by this authorChalid Assaf, Chalid Assaf Department of Dermatology and Venereology, Helios Hospital Krefeld, GermanySearch for more papers by this authorJürgen C. Becker, Jürgen C. Becker West German Tumor Center, University Hospital Essen, GermanySearch for more papers by this authorMichael von Bergwelt-Baildon, Michael von Bergwelt-Baildon Department I of Internal Medicine, University Hospital Cologne, GermanySearch for more papers by this authorSophie Bernreiter, Sophie Bernreiter Department of Dermatology, Hospital Ludwigshafen, GermanySearch for more papers by this authorAntonio Cozzio, Antonio Cozzio Department of Dermatology, Venereology and Allergology, Canton Hospital St. Gallen, SwitzerlandSearch for more papers by this authorHans T. Eich, Hans T. Eich Department of Radiation Therapy and Radio-Oncology, University Hospital Münster, GermanySearch for more papers by this authorKhaled Elsayad, Khaled Elsayad Department of Radiation Therapy and Radio-Oncology, University Hospital Münster, GermanySearch for more papers by this authorMarkus Follmann, Markus Follmann German Cancer Society, Berlin, GermanySearch for more papers by this authorStephan Grabbe, Stephan Grabbe Department of Dermatology, University Hospital Mainz, GermanySearch for more papers by this authorUwe Hillen, Uwe Hillen Department of Dermatology, University Hospital Essen, GermanySearch for more papers by this authorWolfram Klapper, Wolfram Klapper Institute of Pathology, University Hospital Schleswig-Holstein, Campus Kiel, GermanySearch for more papers by this authorClaus-Detlev Klemke, Claus-Detlev Klemke Department of Dermatology, Municipal Hospital of Karlsruhe, Academic Teaching Hospital for the University of Freiburg, Karlsruhe, GermanySearch for more papers by this authorCarmen Loquai, Carmen Loquai Department of Dermatology, University Hospital Mainz, GermanySearch for more papers by this authorFrank Meiss, Frank Meiss Department of Dermatology and Venereology, University Hospital Freiburg, medical Faculty, Albert-Ludwigs University Freiburg, GermanySearch for more papers by this authorChristina Mitteldorf, Christina Mitteldorf Department of Dermatology, Venereology and Allergology, University Hospital Göttingen, GermanySearch for more papers by this authorUlrike Wehkamp, Ulrike Wehkamp Department of Dermatology, Venereology and Allergology, University Hospital Schleswig-Holstein, Campus Kiel, GermanySearch for more papers by this authorDorothee Nashan, Dorothee Nashan Department of Dermatology, Dortmund Hospital GmbH, Dortmund, GermanySearch for more papers by this authorJan P. Nicolay, Jan P. Nicolay Department of Dermatology, Venereology and Allergology, University Hospital Mannheim, GermanySearch for more papers by this authorIlske Oschlies, Ilske Oschlies Institute of Pathology, University Hospital Schleswig-Holstein, Campus Kiel, GermanySearch for more papers by this authorMax Schlaak, Max Schlaak Charité – Universitätsmedizin Berlin, Department of Dermatology, Venereology and Allergology, Berlin, GermanySearch for more papers by this authorRené Stranzenbach, René Stranzenbach Department of Dermatology, Venereology and Allergology, University Hospital at Ruhr University Bochum, GermanySearch for more papers by this authorRose Moritz, Rose Moritz Department for Dermatology, University Hospital Halle, GermanySearch for more papers by this authorChristoph Stoll, Christoph Stoll Rehabilitation Hospital, Herzoghöhe Bayreuth, GermanySearch for more papers by this authorTibor Vag, Tibor Vag Department of Nuclear Medicine, Technical University of Munich, GermanySearch for more papers by this authorMichael Weichenthal, Michael Weichenthal Department of Dermatology, Venereology and Allergology, University Hospital Schleswig-Holstein, Campus Kiel, GermanySearch for more papers by this authorMarion Wobser, Marion Wobser Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, GermanySearch for more papers by this authorRudolf Stadler, Rudolf Stadler Department of Dermatology, Venereology, Allergology, and Phlebology, Johannes Wesling University Hospital Minden, University Hospital at Ruhr University Bochum, GermanySearch for more papers by this author First published: 21 April 2022 https://doi.org/10.1111/ddg.14706AboutSectionsPDF 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 onFacebookTwitterLinked InRedditWechat 1 General Remarks 1.1 Epidemiology, clinical presentation Statements Cutaneous lymphomas are a heterogeneous group of lymphoproliferative skin diseases with very variable clinical presentations and prognoses. Their incidence in Germany is estimated at about one per 100,000 inhabitants per year. Cutaneous lymphomas (CL) are categorized as extranodal non-Hodgkin lymphomas, constituting the second most common form in this group (MALT lymphomas of the stomach are the most common extranodal form). Their incidence is estimated at one new diagnosis per 100,000 inhabitants per year in Germany [1-3]. Primary CL, by definition, present in the skin first, and at the time of diagnosis after staging is completed do not show any involvement of other organs. Secondary CL, on the other hand, are cutaneous manifestations of disseminated [4], primarily nodal lymphomas or leukemias. Primary CL comprise a large, clinically and histologically heterogeneous spectrum, with 73 % of CL categorized as cutaneous T-cell lymphomas (CTCL) and 22 % as cutaneous B-cell lymphomas (CBCL). There are other, rare forms of CL as well. Primary CL and nodal or extracutaneous lymphomas with the same cytomorphology actually differ greatly as to clinical presentation, but also prognosis and indicated treatments [5]. CL patients should therefore be treated in close collaboration between a specialized center and the primary physician. Cutaneous lymphomas are usually characterized by clonality of lymphocytes in the skin (with the exception of CD4+/CD56+ blastic plamacytoid dendritic cell neoplasia). Their cytomorphological presentation is comparable to lymphomas in other locations. Based on the specific cutaneous microenvironment, clinical and histological presentation will vary. It is essential to differentiate primary CL from skin manifestations of extracutaneous lymphomas or leukemias. 2 Classification Statements Cutaneous lymphomas are classified according to the current WHO/EORTC classification [6-8], based on clinico-pathological (respectively, immunohistological and molecular biological) correlation. Cutaneous lymphomas are differentiated from extracutaneous (disseminated) lymphomas based on their primary manifestation in the skin. Thus, primary cutaneous lymphomas are defined as lymphomas that at the time of diagnosis after staging according to current guidelines are limited to the skin. Despite sometimes similar names (such as in marginal zone lymphoma and diffuse large B-cell lymphoma), cutaneous and extracutaneous/disseminated lymphomas differ as to their clinical as well as histopathological and molecular properties. One special feature in the classification of cutaneous lymphomas is the importance of clinical presentation for the final classification and prognosis. For example: A γ/δ-T-cell phenotype in itself is not sufficient for a classification as a cutaneous γ/δ-T-cell lymphoma. The classification also includes entities with unclear malignant potential (such as lymphomatoid papulosis, primary cutaneous CD4-positive small-medium T-cell lymphoproliferative disease). In analogy to systemic lymphomas, we differentiate between T-cell and B-cell neoplasias (Table 1); blastic plasmacytoid dendritic cell neoplasia is itemized as a hematological myeloic precursor neoplasia with typical primary manifestation in the skin.The new provisional WHO category of EBV-positive mucocutaneous ulcer should be mentioned as an Epstein-Barr virus (EBV)-associated skin disease, and must be differentiated from the rare EBV-positive diffuse large B-cell lymphoma. EBV-associated hydroa-vacciniforme-like lymphoproliferative disease is almost never seen in Germany. Consensus: 100 %, modified 2021 Table 1. WHO-EORTC classification of cutaneous lymphomas Cutaneous T-cell and NK-cell lymphomas Cutaneous B-cell lymphomas Mycosis fungoides (MF) Mycosis fungoides variants: – Folliculotropic MF – Pagetoid reticulosis – Granulomatous slack skin Sézary syndrome (SS)** Entities that manifest as primary cutaneous lymphomas but are often already disseminated/systemic at the time of diagnosis.Adult T-cell leukemia/lymphoma (HTLV+)** Entities that manifest as primary cutaneous lymphomas but are often already disseminated/systemic at the time of diagnosis.Primary cutaneous CD30+ lymphoproliferative diseases – Primary cutaneous anaplastic large cell lymphoma (PCALCL) – Lymphomatoid papulosis (LyP) Subcutaneous panniculitis-like T-cell lymphoma (SPTCL)Extranodal NK/T-cell lymphoma, nasal type** Entities that manifest as primary cutaneous lymphomas but are often already disseminated/systemic at the time of diagnosis.Primary cutaneous peripheral T-cell lymphoma, rare subtypes: – Primary cutaneous γ/δ-T-cell lymphoma – Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma – Primary cutaneous CD4+ small-medium T-cell lymphoproliferative disease – Primary cutaneous acral CD8+ T-cell lymphoma Primary cutaneous peripheral T-cell lymphoma, not otherwise specified (NOS) Primary cutaneous follicle center lymphoma (PCFCL)**** Primary cutaneous follicle center lymphoma: Synonymous with German term "primär kutanes Keimzentrumslymphom (PCFCL)"Primary cutaneous marginal zone B-cell lymphoma (PCMZL)Primary cutaneous diffuse large B-cell lymphoma, leg type (PCBLT)EBV-positive mucocutaneous ulcer(EBV-positive diffuse large B-cell lymphoma, not otherwise specified)****** The EBV-positive diffuse large B-cell lymphoma is not explicitly classified as a "cutaneous lymphoma", but can present as isolated skin involvement and remains an important differential diagnosis to PCBLT and EBV-positive mucocutaneous ulceration.Primary cutaneous intravascular large B-cell lymphoma** Entities that manifest as primary cutaneous lymphomas but are often already disseminated/systemic at the time of diagnosis.Hematological precursor neoplasmsBlastic plasmacytoid dendritic cell neoplasm (BPDCN)** Entities that manifest as primary cutaneous lymphomas but are often already disseminated/systemic at the time of diagnosis. * Entities that manifest as primary cutaneous lymphomas but are often already disseminated/systemic at the time of diagnosis. ** Primary cutaneous follicle center lymphoma: Synonymous with German term "primär kutanes Keimzentrumslymphom (PCFCL)" *** The EBV-positive diffuse large B-cell lymphoma is not explicitly classified as a "cutaneous lymphoma", but can present as isolated skin involvement and remains an important differential diagnosis to PCBLT and EBV-positive mucocutaneous ulceration. Provisional entities are presented in italics The WHO classification does not classify the cutaneous lymphomas in groups with indolent, intermediary, or aggressive growth. 3 Diagnostics Recommendations The primary examination must include an inspection of the whole skin, palpation of all lymph node stations, and a general physical examination. Diagnosis of a cutaneous lymphoma shall be performed via biopsy with histological examination of a representative lesion.Precise classification requires additional immunohistological investigations which should therefore be part of the diagnostic process.If involvement of the blood is suspected, FACS analysis/flow cytometry is recommended, see Table 2.Molecular biological clonality analysis should be performed. Consensus: 100 %, modified 2021 Imaging procedures, lymph node/bone marrow biopsy, and laboratory invest igations to exclude extracutaneous involvement or secondary cutaneous lymphoma should be performed depending on the histological subtype of the lymphoma and the tumor stage according to Tables 2 and 3.Consensus: 100 %, modified 2021 Table 2. Diagnostics for cutaneous lymphomas Investigations Remarks Medical history Duration, type, and extent as well as temporal development of skin manifestations, B symptomatology. Clinical examination Precise skin findings (Recommended: investigation record and photographic documentation) lymph node status, palpation of liver and spleen. Laboratory investigations CRP, differential blood count, liver enzymes, creatinine, LDH, electrolytes.Immune electrophoresis if indicated** The recommendations apply for first-time staging. Staging examinations adapted to the individual patient situation should be performed after therapy, in case of disease progression, and for aggressive types of lymphoma.Borrelia serology in B-cell lymphoma if indicated** The recommendations apply for first-time staging. Staging examinations adapted to the individual patient situation should be performed after therapy, in case of disease progression, and for aggressive types of lymphoma.Special hematological investigations if indicated** The recommendations apply for first-time staging. Staging examinations adapted to the individual patient situation should be performed after therapy, in case of disease progression, and for aggressive types of lymphoma.Further laboratory investigations depending on planned treatments For B-cell lymphomas: – Bone marrow biopsy (cytology and histology) – mandatory for PCBLT, optional for PCMZL and PCFCL [9] – Immune electrophoresis of serum and urine – Borrelia serology For T-cell lymphomas: – Blood smear for Sézary cells**** Blood smears for Sézary cells: optional, as FACS analysis is the primary diagnostic tool. – FACS, CD4/CD8 ratio, investigation of CD4+CD7– cells and/or CD4+CD26– cells (Tab.4) (optional: CD158k/KIR3DL2 expression) [10, 11] – Clonality analysis in the blood (PCR, BIOMED-2 protocol) – Bone marrow biopsy is not indicated for diagnosis Biopsy Histology, immune histochemistry, and molecular biological diagnostics (including clonality analysis according to the BIOMED-2 protocol if indicated) from lesional skin as well as from suspiciously enlarged lymph nodes and (if applicable) if organ infiltration is suspected Molecular biological investigationsFor B-cell lymphomas: – PCR for immunoglobulin according to BIOMED-2 protocol For T-cell lymphomas: – PCR for T-cell receptor gene rearangement according to BIOMED-2 protocol [12] * The recommendations apply for first-time staging. Staging examinations adapted to the individual patient situation should be performed after therapy, in case of disease progression, and for aggressive types of lymphoma. ** Blood smears for Sézary cells: optional, as FACS analysis is the primary diagnostic tool. Table 3. Staging studies in cutaneous lymphoma** The recommendations apply for first-time staging. Staging examinations adapted to the individual patient situation should be performed after therapy, in case of disease progression, and for aggressive types of lymphoma. Cutaneous B-cell lymphomas Instrumental diagnostics Primary cutaneous follicle center lymphoma (PCFCL) Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography [13], PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances. Primary cutaneous marginal zone lymphoma (PCMZL) Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography, PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances. Primary cutaneous diffuse large B-cell lymphoma, leg type (PCBLT) Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography, MRI of the affected limb if indicated + PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances. Primary cutaneous diffuse large B-cell lymphoma, other types Full-bod y CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography, PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances. Primary cutaneous intravascular large B-cell lymphoma Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography, skull MRI, PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances. Cutaneous T-cell and NK-cell lymphomas Instrumental diagnostics Mycosis fungoides (MF) Chest X-ray, abdominal and lymph node sonography Mycosis fungoides variants – folliculotropic MF – pagetoid reticulosis – granulomatous slack skin Chest X-ray, abdominal and lymph node sonography Mycosis fungoides from stage IIB onwards Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography, PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances. [14–17] Sézary syndrome (SS) Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography, PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances. Adult T-cell leukemia/lymphoma (HTLV+) Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography, PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances. Primary cutaneous CD30+ lymphoproliferative diseases – primary cutaneous anaplastic large cell lymphoma (PCALCL) – lymphomatoid papulosis (LyP) Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography, PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances.Chest X-ray, lymph node sonography Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography, PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances. Extranodal NK/T-cell lymphoma, nasal type Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography, PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances. Primary cutaneous peripheral T-cell lymphoma, rare subtypes – primary cutaneous γ/δ-T-cell lymphoma – primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma (provisional) Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, lymph node sonography, PET CT scan if indicated°°°° Retrospective examinations with small number of cases predominantly showed a significant superiority of 18F-FDG PET/CT scans compared to conventional imaging methods, especially in the detection of lymph node and organ manifestations [14-17]. Nevertheless, larger prospective studies with sufficient evidence are currently lacking. In general, the costs for PET-CT-examinations for this indication are not covered by the statutory health insurances. – Primary cutaneous CD4+ small-medium T-cell lymphoproliferative disease (provisional) – Primary cutaneous acral CD8+ T-cell lymphoma (provisional) – Primary cutaneous peripheral T-cell lymphoma, not otherwise specified (NOS) Chest X-ray, abdominal and lymph node sonography (in cases of clinical uncertainty, staging may be performed via sectional imaging) Blastic plasmacytoid dendritic cell neoplasia (BPDCN) Full-body CT scan°° Full-body CT scans: neck, thorax, abdomen, pelvis using intravenous contrast agents, cMRI, (lymph node sonography), PET CT if indicated°°°° Retrospective examinations with small

Background Merkel cell carcinoma (MCC) is an immunogenic but aggressive skin cancer. Even after complete resection and radiation, relapse rates are high. PD-1 and PD-L1 checkpoint inhibitors showed clinical benefit in advanced MCC. We aimed to assess efficacy and safety of adjuvant immune checkpoint inhibition in completely resected MCC (ie, a setting without an established systemic standard-of-care treatment). Methods In this multicentre phase 2 trial, patients (any stage, Eastern Cooperative Oncology Group performance status 0–1) at 20 academic medical centres in Germany and the Netherlands with completely resected MCC lesions were randomly assigned 2:1 to receive nivolumab 480 mg every 4 weeks for 1 year, or observation, stratified by stage (American Joint Committee on Cancer stages 1–2 vs stages 3–4), age (<65 vs ≥65 years), and sex. Landmark disease-free survival (DFS) at 12 and 24 months was the primary endpoint, assessed in the intention-to-treat populations. Overall survival and safety were secondary endpoints. This planned interim analysis was triggered when the last-patient-in was followed up for more than 1 year. This study is registered with ClinicalTrials.gov (NCT02196961) and with the EU Clinical Trials Register (2013-000043-78). Findings Between Oct 1, 2014, and Aug 31, 2020, 179 patients were enrolled (116 [65%] stage 3–4, 122 [68%] ≥65 years, 111 [62%] male). Stratification factors (stage, age, sex) were balanced across the nivolumab (n=118) and internal control group (observation, n=61); adjuvant radiotherapy was more common in the control group. At a median follow-up of 24·3 months (IQR 19·2–33·4), median DFS was not reached (between-groups hazard ratio 0·58, 95% CI 0·30–1·12); DFS rates in the nivolumab group were 85% at 12 months and 84% at 24 months, and in the observation group were 77% at 12 months and 73% at 24 months. Overall survival results were not yet mature. Grade 3–4 adverse events occurred in 48 [42%] of 115 patients who received at least one dose of nivolumab and seven [11%] of 61 patients in the observation group. No treatment-related deaths were reported. Interpretation Adjuvant therapy with nivolumab resulted in an absolute risk reduction of 9% (1-year DFS) and 10% (2-year DFS). The present interim analysis of ADMEC-O might suggest clinical use of nivolumab in this area of unmet medical need. However, overall survival events rates, with ten events in the active treatment group and six events in the half-the-size observation group, are not mature enough to draw conclusions. The explorative data of our trial support the continuation of ongoing, randomised trials in this area. ADMEC-O suggests that adjuvant immunotherapy is clinically feasible in this area of unmet medical need. Funding Bristol Myers Squibb.

A recombinant antibody-lymphotoxin-alpha fusion protein induced an adaptive immune response protecting mice from melanoma. Importantly, this fusion protein elicited the formation of a lymphoid-like tissue in the tumor microenvironment containing L-selectin+ T cells and MHC class II+ antigen-presenting cells, as well as B and T cell aggregates. Furthermore, PNAd+/TCA4+ high endothelial venules were observed within the tumor, suggesting entry channels for naive T cell infiltrates. Over the course of therapy, a marked clonal expansion of certain TCR specificities occurred among tumor-infiltrating lymphocytes that displayed reactivity against melanoma cells and the TRP-2(180-188) peptide. Consequently, naive T cells may have been recruited to as well as primed and expanded in the lymphoid-like tissue induced by the lymphotoxin-alpha fusion protein at the tumor site.

Induction of a T-cell mediated antitumor response is the ultimate goal for tumor immunotherapy. We demonstrate here that antibody-targeted IL2 therapy is effective against established pulmonary and hepatic melanoma metastases in a syngeneic murine tumor model. The effector mechanisms involved in this tumor eradication are not dependent on NK cells, since the therapeutic effect of antibody-IL2 fusion protein was not altered in NK cell-deficient mice. In contrast, T cells are essential for the observed antitumor effect, since therapy with antibody IL2 fusion proteins is unable to induce tumor eradication in T cell-deficient SCID mice. In vivo depletion studies characterized the essential effector cell population further as CD8 + T cells. Such CD8 + T cells, isolated from tumor bearing mice after antibody-directed IL2 therapy, exerted a MHC class I-restricted cytotoxicity against the same tumor in vitro. These data demonstrate the ability of antibody-targeted IL2 delivery to induce a T cell-dependent host immune response that is capable of eradicating established melanoma metastases in clinically relevant organs.

Background: Non‐surgical periodontal treatment with an Er:YAG laser has been shown to result in significant clinical attachment level gain; however, clinical results have not been established on a long‐term basis following Er:YAG laser treatment. Therefore, the aim of the present study was to present the 2‐year results following non‐surgical periodontal treatment with an Er:YAG laser or scaling and root planing. Methods: Twenty patients with moderate to advanced periodontal destruction were treated under local anesthesia, and the quadrants were randomly allocated in a split‐mouth design to either 1) Er:YAG laser (ERL) using an energy level of 160 mJ/pulse and 10 Hz, or 2) scaling and root planing (SRP) using hand instruments. The following clinical parameters were evaluated at baseline and at 1 and 2 years after treatment: plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD), gingival recession (GR), and clinical attachment level (CAL). Subgingival plaque samples were taken at each appointment and analyzed using dark‐field microscopy for the presence of cocci, non‐motile rods, motile rods, and spirochetes. The primary outcome variable was CAL. No statistically significant differences between the groups were found at baseline. Power analysis to determine superiority of ERL treatment showed that the available sample size would yield 99% power to detect a 1 mm difference. Results: The sites treated with ERL demonstrated mean CAL change from 6.3 ± 1.1 mm to 4.5 ± 0.4 mm ( P &lt;0.001) and to 4.9 ± 0.4 mm ( P &lt;0.001) at 1 and 2 years, respectively. No statistically significant differences were found between the CAL mean at 1 and 2 years postoperatively. The sites treated with SRP showed a mean CAL change from 6.5 ± 1.0 mm to 5.6 ± 0.4 mm ( P &lt;0.001) and to 5.8 ± 0.4 mm ( P &lt;0.001) at 1 and 2 years, respectively. The CAL change between 1 and 2 years did not present statistically significant differences. Both groups showed a significant increase of cocci and non‐motile rods and a decrease in the amount of spirochetes. However, at the 1‐ and 2‐year examination, the statistical analysis showed a significant difference for the CAL ( P &lt;0.001, respectively) between the 2 treatment groups. Conclusion: It was concluded that the CAL gain obtained following nonsurgical periodontal treatment with ERL or SRP can be maintained over 2‐year period. J Periodontol 2003;74:590‐596 .

Intercellular adhesion molecule-1 (ICAM-1)/LFA-1-mediated cell-cell adhesion is essential for various immunologic functions. It was previously shown that some of these, including non-MHC-restricted cytotoxicity, could be inhibited by soluble forms of ICAM-1. Here, we characterize the effects of soluble ICAM-1 on MHC-restricted specific T cell/melanoma interactions. Tumor-infiltrating lymphocyte (TIL) clones, as well as melanoma lines from the same tumor specimens, were established. The TIL clones used were able to form conjugates with the autologous tumor and to kill it in an MHC-restricted way. TIL/melanoma interaction also induced increased cytokine production in TIL. Using this system, we could demonstrate that purified soluble ICAM-1 (950 ng/ml) or 12-fold concentrated cell-free melanoma supernatants, containing shed ICAM-1 (1000 ng/ml), were able to inhibit conjugate formation between T cell clones and the autologous melanoma cells as efficiently as mAb against CD11a. In addition, free ICAM-1 abrogated the MHC-restricted killing of the melanoma exerted by T cell clones and blocked the induction of cytokines in T cells due to the contact with autologous tumor cells.

In melanoma, the RAS/RAF/MEK/ERK signalling pathway is an area of great interest, because it regulates tumor cell proliferation and survival. A varying mutation rate has been reported for B-RAF and N-RAS, which has been largely attributed to the differential source of tumor DNA analyzed, e.g., fixed tumor tissues or in vitro propagated melanoma cells. Notably, this variation also interfered with interpreting the impact of these mutations on the clinical course of the disease. Consequently, we investigated the mutational profile of B-RAF and N-RAS in biopsies and corresponding cell lines from metastatic tumor lesions of 109 melanoma patients (AJCC stage III/IV), and its respective impact on survival. 97 tissue biopsies and 105 biopsy-derived cell lines were screened for B-RAF and N-RAS mutations by PCR single strand conformation polymorphism and DNA sequencing. Mutations were correlated with patient survival data obtained within a median follow-up time of 31 months. B-RAF mutations were detected in 55% tissues and 51% cell lines, N-RAS mutations in 23% tissues and 25% cell lines, respectively. There was strong concordance between the mutational status of tissues and corresponding cell lines, showing a differing status for B-RAF in only 5% and N-RAS in only 6%, respectively. Patients with tumors carrying mutated B-RAF showed an impaired median survival (8.0 versus 11.8 months, p = 0.055, tissues; 7.1 versus 9.3 months, p = 0.068, cell lines), whereas patients with N-RAS-mutated tumors presented with a favorable prognosis (median survival 12.5 versus 7.9 months, p = 0.084, tissues; 15.4 versus 6.8 months, p = 0.0008, cell lines), each in comparison with wildtype gene status. Multivariate analysis qualified N-RAS (p = 0.006) but not B-RAF mutation status as an independent prognostic factor of overall survival. Our findings demonstrate that B-RAF and N-RAS mutations are well preserved during short term in vitro propagation and, most importantly, differentially impact the outcome of melanoma patients.

Recent advances in therapeutic tumor vaccinations necessitate the identification of broadly expressed, immunogenic tumor antigens that are not prone to immune selection. To this end, the human inhibitor of apoptosis, survivin, is a prime candidate because it is expressed in most human neoplasms but not in normal, differentiated tissues. Here, we demonstrate spontaneous cytotoxic T-cell responses against survivin-derived MHC class I-restricted T-cell epitopes in breast cancer, leukemia, and melanoma patients both in situ as well as ex vivo. Moreover, survivin-reactive T cells isolated by magnetic beads coated with MHC/peptide complexes were cytotoxic against HLA-matched tumors of different tissue types. Being a universal tumor antigen, survivin may serve as a widely applicable target for anticancer immunotherapy.

Since tacrolimus ointment was approved by the U.S. Food and Drug Administration (FDA) as a promising treatment for atopic dermatitis, it has been approved in more than 30 additional countries, including numerous European Union member nations. Moreover, in the current clinical routine the use of this drug is no longer restricted to the approved indication, but has been extended to a wide variety of inflammatory skin diseases including some with the potential of malignant transformation. So far, the side-effects reported from the topical use of tacrolimus have been relatively minor (e.g. burning, pruritus, erythema). Recently, however, the FDA reviewed the safety of topical tacrolimus, which resulted in a warning that the use of calcineurin inhibitors may be associated with an increased risk of cancer.Oral lichen planus (OLP) was diagnosed in a 56-year-old women in February 1999. After several ineffective local and systemic therapeutic measures an off-label treatment of this recalcitrant condition using Tacrolimus 0.1% ointment was initiated in May 2002. After a few weeks of treatment most of the lesions ameliorated, with the exception of the plaques on the sides of the tongue. Nevertheless, the patient became free of symptoms which, however, reoccurred once tacrolimus was weaned, as a consequence treatment was maintained. In April 2005, the plaques on the left side of the tongue appeared increasingly compact and a biopsy specimen confirmed the suspected diagnosis of an oral squamous cell carcinoma.The suspected causal relationship between topical use of tacrolimus and the development of a squamous cell carcinoma prompted us to test the notion that the carcinogenicity of tacrolimus may go beyond mere immune suppression. To this end, tacrolimus has been shown to have an impact on cancer signalling pathways such as the MAPK and the p53 pathway. In the given case, we were able to demonstrate that these pathways had also been altered subsequent to tacrolimus therapy.

The aim of the present study was to characterize the composition of the organic matrix in alveolar jaw bone and dentine using antibodies against pro-collagens Types I and III and collagens Types IV, V, and VI. After demineralization of oral hard tissues in 0.2 N HCl, antigenicity was well preserved and the distribution of the pro-collagens and collagens could be demonstrated. Staining for pro-collagen Type I was prominent around osteoblasts and in pre-dentine, indicating active de novo synthesis of Type I pro-collagen. Pro-collagen Type I was ubiquitous but was less abundant in bone and dentine, whereas pro-collagen Type III was seen only in areas of bone remodeling, in peritubular spaces, and in pre-dentine. Type IV collagen was limited to the basement membranes of vessels in osteons and bone marrow. Type V collagen was detected neither in pre-dentine nor in bone. In contrast, Type VI collagen was found in dentine and bone, showing a faint but homogeneous staining which, similarly to pro-collagen Type III, was pronounced around osteoblasts and in pre-dentine, areas of active bone and dentine formation. This study showed that the organic matrix of dentine and bone contains Type VI as well as Type I collagen. Pro-collagen Type III (and to a lesser extent collagen Type VI) is transiently produced during new formation and remodeling of oral hard tissues, and disappears once the matrix calcifies. Type I pro-collagen qualifies as a general marker protein for increased osteoblastic activity. We conclude that immunostaining for the different collagen/pro-collagen types can be used to assess normal or abnormal stages of bone/dentine formation.

Undulin, a novel noncollagenous extracellular matrix protein, was isolated from skin and placenta. In polyacrylamide gels most of the unreduced protein migrates with Mr above 1,000,000 yielding bands A (Mr 270,000), B1 (Mr 190,000), and B2 (Mr 180,000) after reduction. Undulin is biochemically and immunochemically distinct from other previously characterized large matrix glycoproteins. Immunoblotting using monoclonal antibodies suggests that bands A and B are closely related. Electron microscopy reveals undulin as structures consisting of an approximately 80-nm-long-tail with a nodule on one end and with one or two shorter arms on the other. Ultrastructurally immunolabeled undulin is found mainly between densely packed mature collagen fibrils. Indirect immunofluorescence shows bundles of uniform wavy fibers in dense connective tissues superimposable on a subpopulation of type I collagen structures. This suggests that undulin serves a specific yet unknown function in the supramolecular organization of collagen fibrils in soft tissues.

Laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS) was used for the quantitative imaging of nutrient elements (such as K, Mg, Mn, Cu, P, S and B) in the leaves of Elsholtzia splendens. The plant leaves were scanned directly with a focused Nd:YAG laser in the laser ablation chamber. The ablated material was transported with argon as carrier gas to a quadrupole-based ICP-MS (ICP-QMS), and the ion intensities of (39)K(+), (24)Mg(+), (55)Mn(+), (63)Cu(+), (31)P(+), (34)S(+) and (11)B(+) were measured by ICP-QMS to study the distribution of the elements of interest. The imaging technique using LA-ICP-MS on plant leaves does not require any sample preparation. Carbon ((13)C(+)) was used as an internal standard element to compensate for the difference in the amount of material ablated. Additional experiments were performed in order to study the influence of the water content of the analyzed leaves on the intensity signal of the analyte. For quantification purposes, standard reference material (NIST SRM 1515 Apple Leaves) was selected and doped with standard solutions of the analytes within the concentration range of 0.1-2000 mg L(-1). The synthetic laboratory standards together with the samples were measured by LA-ICP-MS. The shape and structure of the leaves was clearly given by LA-ICP-MS imaging of all the elements measured. The elemental distribution varied according to the element, but with a high content in the veins for all the elements investigated. Specifically, Cu was located uniformly in the mesophyll with a slightly higher concentration in the main vein. High ion intensity was measured for S with a high amount of this element in the veins similar to the images of the metals, whereas most of the B was detected at the tip of the leaf. With synthetic laboratory standard calibration, the concentrations of elements in the leaves measured by LA-ICP-MS were between 20 microg g(-1) for Cu and 14,000 microg g(-1) for K.

Prognosis of disseminated melanoma remains gloomy as neither chemotherapeutic nor unspecific immune modulatory approaches were able to improve the overall survival of these patients. Hence, specific immunotherapy has received increasing attention. Disappointing clinical results, however, indicate that the choice of suitable antigens is of special importance. To this end, the inhibitor of apoptosis (IAP) protein survivin, which is over-expressed in several tumours but is largely undetectable in adult tissues, appears to be a promising target for vaccination purposes, since down-regulation or loss of expression is associated with impaired tumour progression. Consequently, five heavily pretreated stage IV melanoma patients were vaccinated with the HLA-A2 restricted survivin96–104 epitope presented by autologous dendritic cells (DCs) in a compassionate use setting. Four of these patients mounted strong T cell responses to this epitope as measured by ELISPOT assay. Furthermore, in situ peptide/HLA-A2 multimer staining confirmed that these survivin reactive cells infiltrated both visceral and soft tissue metastases.

Temozolomide (TMZ) has shown efficacy in metastatic melanoma equal to that of dacarbazine (DTIC), the standard chemotherapeutic agent for melanoma. As the combination with interferon-alfa (IFN-alpha) appears superior to single-agent DTIC regarding response rates, the purpose of this study was to compare TMZ alone and TMZ plus IFN-alpha in terms of objective response (OR), overall survival, and safety in a prospective, randomized, multicenter trial.Two hundred ninety-four patients with untreated stage IV metastatic melanoma (American Joint Committee on Cancer staging system) were randomly assigned to receive either oral TMZ alone (200 mg/m2/day; days 1 through 5 every 28 days) or in combination with subcutaneous IFN-alpha (5 MU/m2; days 1, 3, and 5 every week).Two hundred eighty-two patients were eligible for an intent-to-treat analysis, 271 patients were treated per protocol. In the TMZ + IFN-alpha arm, 33 (24.1%) of 137 patients responded to therapy (partial or complete remission) whereas in the monotherapy arm, in 18 (13.4%) of 134 patients, a response was evident. Thus, the response rate was significantly higher in the combination arm (P = .036). Median survival time was 8.4 months for patients treated with TMZ (95% CI, 7.07 to 9.27) and 9.7 months for those treated with the combination (95% CI, 8.26 to 11.18; P = .16). Dose modifications and interval prolongations due to hematologic toxicity were significantly more frequent in the TMZ + IFN-alpha arm (P < .001).In metastatic melanoma treatment with TMZ + IFN-alpha leads to a significantly superior OR rate compared to treatment with TMZ alone, which did not translate into prolonged survival in our study population.

Biopsies from patients with cutaneous T-cell lymphoma (CTCL) exhibit stage-dependent increase in angiogenesis. However, the molecular mechanisms responsible for the increased angiogenesis are unknown. Here we show that malignant CTCL T cells spontaneously produce the potent angiogenic protein, vascular endothelial growth factor (VEGF). Dermal infiltrates of CTCL lesions show frequent and intense staining with anti-VEGF antibody, indicating a steady, high production of VEGF in vivo. Moreover, the VEGF production is associated with constitutive activity of Janus kinase 3 (Jak3) and the c-Jun N-terminal kinases (JNKs). Sp600125, an inhibitor of JNK activity and activator protein-1 (AP-1) binding to the VEGF promoter, downregulates the VEGF production without affecting Jak3 activity. Similarly, inhibitors of Jak3 inhibit the VEGF production without affecting JNK activity. Downregulation of Stat3 with small interfering RNA has no effect, whereas curcumin, an inhibitor of both Jak3 and the JNKs, almost completely blocks the VEGF production. In conclusion, we provide evidence of VEGF production in CTCL, which is promoted by aberrant activation of Jak3 and the JNKs. Inhibition of VEGF-inducing pathways or neutralization of VEGF itself could represent novel therapeutic modalities in CTCL.

Heat management is crucial to polymer electrolyte membrane (PEM) fuel cell commercialization. Numerical modeling is often used to simulate heat transfer in the various components of the cell and specifically the gas diffusion layer (GDL). Due to the porous nature of the gas diffusion layer and its complexity of anisotropy, the effect of the structure on the thermal conductivity is usually taken into account by introducing an effective thermal conductivity. In this study, the effective thermal conductivity of carbon paper diffusion media was estimated numerically. Carbon paper is often used as the GDL in PEM fuel cells due to its ability to efficiently transport electrons, heat and gaseous species. Using the GeoDict code, a realistic three-dimensional pore morphology of carbon paper was used as the modeling domain and the governing mathematical equations were solved using the commercial software package Fluent (6.3.26) and the ThermoDict solver. The geometrical effects on the effective thermal conductivity were investigated for different geometries. It was found that the effective thermal conductivity is highly sensitive to the geometry of the porous material under investigation. The effective thermal conductivity is much larger in the in-plane direction when compared with the value in the through-plane direction. Further, the change of the effective thermal conductivity due to porosity and compression was studied. Finally, correlations for the through-plane and in-plane effective thermal conductivity were developed.

The aim of the present case series was to evaluate the 2-year results obtained following treatment of peri-implantitis lesions using either a nanocrystalline hydroxyapatite (NHA) or a natural bone mineral in combination with a collagen membrane (NBM+CM).Twenty-two patients suffering from moderate peri-implantitis (n=22 intra-bony defects) were randomly treated with (i) access flap surgery (AFS) and the application of NHA, or with AFS and the application of NBM+CM. Clinical parameters were recorded at baseline and after 12, 18, and 24 months of non-submerged healing.Two patients from the NHA group were excluded from the study due to severe pus formation at 12 months. At 24 months, both groups revealed clinically important probing depth (PD) reductions (NHA: 1.5+/-0.6 mm; NBM+CM: 2.4+/-0.8 mm) and clinical attachment level (CAL) gains (NHA: 1.0+/-0.4 mm; NBM+CM: 2.0+/-0.8 mm). However, these clinical improvements seemed to be better in the NBM+CM group (difference between groups: PD reduction: 0.9+/-0.2 mm; CAL gain: 1.0+/-0.3 mm).Both treatment procedures have shown efficacy over a period of 24 months, however, the application of NBM+CM may result in an improved outcome of healing.

Detection du virus du SIDA. Caracteristiques generales des retrovirus et classification du VIH. Proprietes du HIH. Immunologie orale et infection par le HIV. Manifestations orales associees a l'infection par le HIV

Abstract: Merkel cell carcinoma (MCC) is a highly aggressive neuroendocrine skin cancer which is twice as lethal as melanoma as more than one‐third of MCC patients will die from this cancer. Although MCC, which primarily affects elderly and immune suppressed individuals, is very rare to date, its incidence is rapidly increasing. In contrast to the immense progress that has been made in the elucidation of the molecular pathogenesis of other cancer entities, until recently there were no clear‐cut indications which events drive the carcinogenesis of MCC. Important findings published last year have changed this radically. Hypermethylation of the p14 ARF promoter and a striking correlation between expression of p63 and the clinical course of MCC have been reported. Most important, however, is the discovery that MCC development in the majority of cases is preceded by the integration of genomic sequences of the hitherto unknown Merkel cell polyomavirus (MCPyV). Now a fundamental improvement in the understanding of MCC pathogenesis as well as the development of new therapeutic approaches based on this knowledge appear to be possible within the near future.

Purpose Mycosis fungoides (MF) is the most common primary cutaneous T-cell lymphoma. There is a need for multicenter trials involving defined patient populations using rigorous assessment criteria. We have investigated pegylated liposomal doxorubicin (PLD) in a clearly defined patient population with advanced MF. Patients and Methods Eligible patients had stage IIB, IVA, or IVB MF, refractory or recurrent after at least two previous systemic therapies. Patients were registered to receive a maximum of six cycles of PLD 20 mg/m 2 on days 1 and 15, every 28 days (one cycle). The primary end point was response rate (RR). Results Nine centers recruited 49 eligible patients. The median number of chemotherapy cycles received was five. There were no grade 3 to 4 hematologic toxicities. Grade 3 or 4 nonhematologic/nonbiochemical toxicities included cardiac symptom (2%), allergy/hypersensitivity (2%), constitutional symptom (4%), hand and foot reaction (2%), other dermatologic toxicity (6%), other GI toxicity (4%), infection (4%), pulmonary embolism (2%), and cardiac ischemia (2%). Of 49 patients, 20 (40.8%) were responders (complete clinical response [CCR] or partial response [PR] as overall response): three (6.1%) experienced CCRs, and 17 (34.7%) experienced PRs. A 50% or greater reduction of cutaneous manifestations was observed in 26 (60.5%) of 43 assessable patients. Two early deaths were reported, resulting from related cardiovascular toxicity and disease progression. The lower limit of the one-sided 90% CI for RR was 31.2%. Median time to progression and median duration of response were 7.4 and 6 months, respectively. Conclusion PLD has an acceptable safety profile in patients with advanced MF. The efficacy of PLD seems promising.

Investigation of the role in which the microporous layer (MPL) affects the overall diffusion of gases and conduction of heat in polymer electrolyte membrane (PEM) fuel cells is of great interest. In this study, we used stochastic models to generate a three-dimensional reconstruction of the MPL. This work is a continuation of the methods presented in [10]. A parametric study was carried out to investigate the effects of the MPL structure and MPL porosity on its diffusion coefficient and thermal conductivity. It was found that increasing the volume of the small pores of the MPL while keeping its overall porosity constant results in an increase in the Knudsen diffusion; hence a decrease of the overall diffusion coefficient. This similar trend is observed again once the porosity of the MPL is decreased. An increase in the volume of small pores also resulted in an increase of the thermal conductivity of the MPL. The parametric study was also extended to understand the effect of applying the MPL onto the gas diffusion layer (GDL). In this case, we investigated the effect of MPL thickness, porosity and its penetration into the GDL. The effect of the thickness on the thermal conductivity and diffusion coefficient of an MPL/GDL assembly can be explained using a resistance network. An increase in the penetration depth of the MPL results in an increase of the thermal conductivity and a decrease of the diffusion coefficient.

To address the following focused question: What is the impact of implant-abutment configuration and the positioning of the machined collar/microgap on crestal bone level changes?Electronic databases of the PubMed and the Web of Knowledge were searched for animal and human studies reporting on histological/radiological crestal bone level changes (CBL) at nonsubmerged one-/two-piece implants (placed in healed ridges) exhibiting different abutment configurations, positioning of the machined collar/microgap (between 1992 and November 2012: n = 318 titles). Quality assessment of selected full-text articles was performed according to the ARRIVE and CONSORT statement guidelines.A total of 13 publications (risk of bias: high) were eligible for the review. The weighted mean difference (WMD) (95% CI) between machined collars placed either above or below the bone crest amounted to 0.835 mm favoring an epicrestal positioning of the rough/smooth border (P < 0.001) (P-value for heterogeneity: 0.885, I2: 0.000% = no heterogeneity). WMD (95% CI) between microgaps placed either at or below the bone crest amounted to -0.479 mm favoring a subcrestal position of the implant neck (P < 0.001) (P-value for heterogeneity: 0.333, I2: 12.404% = low heterogeneity). Only two studies compared different implant-abutment configurations. Due to a high heterogeneity, a meta-analysis was not feasible.While the positioning of the machined neck and microgap may limit crestal bone level changes at nonsubmerged implants, the impact of the implant-abutment connection lacks documentation.

We present a new method to quantify tortuosity in the porous, LiCoO2 cathode of a Li-ion battery. The starting point is a previously published 3D reconstruction from FIB/SEM images with three phases, the active material domain, carbon-binder domain and pore space. Based on this geometrical configuration, we compute effective diffusivities, from which we in turn derive tortuosity values for the pore space ranging between 5 and 11.6 for the three spatial directions. In a next step, we compare our approach to an imaging method that employs back-filling material. These methods do not differentiate between the carbon-binder domain and the pore space. Thus we remove the carbon-binder domain from our 3D reconstruction and add its volume to the pore space. As a result of this procedure, the tortuosity is greatly reduced to values between 1.5 and 1.9. Experiments suggest that both results for tortuosity are inaccurate and that the real values lie somewhere between these parameter sets. Hence, based on experimental data, we propose a nanoporous carbon-binder domain and derive intermediate tortuosity values between 4.2 and 6.1. These values are consistent with experimental values for similar Li-ion cathodes reported previously.

Water management in polymer electrolyte membrane (PEM) fuel cells is of importance due to its impact on the performance, durability and ultimately the cost of the cell. In the gas diffusion layer (GDL), liquid water has a direct effect on species and heat transport. The amount of liquid water in the GDL affects the relative permeability and capillary pressure, which govern the convective and diffusive transport of liquid water. Liquid water acts as a barrier to the diffusion of gases through the void region and facilitates in heat transfer. In this study, the full morphology model was used in order to investigate the effects of liquid water presence on the transport properties of the carbon paper GDL and examine the applicability of using various laws to estimate the transport properties in the presence of liquid water. The numerical results were compared against published experimental data. Further, the method of standard porosimetry was used to experimentally measure the effect of Teflon treatment on the capillary pressure of carbon paper. It was found that the addition of PTFE to the GDL results in the increase of capillary pressure; however, further increases to the PTFE loading did not result in additional changes to the capillary pressure.

To investigate the impact of residual defect height (RDH) following guided bone regeneration (GBR) in dehiscence-type defects on the long-term stability of peri-implant health after a period of 4 years.The RDH values in dehiscence-type defects at titanium implants were clinically assessed after 4 months of submerged healing following augmentation using a natural bone mineral (NBM) and a randomized application of either a cross-linked- (VN) or a native collagen membrane (BG) (n=12 patients each). The RDH values were classified as absent (0 mm, control; n=8), minimal (1 mm, test 1; n=8), or advanced (>1 mm, test 2; n=8). Clinical parameters (i.e. bleeding on probing [BOP], probing pocket depth [PD], mucosal recession [MR]) were recorded (mesio-, mid-, and disto-buccal aspects) at 4 years after prosthesis installation.The mean PD (2.9±0.7, 2.8±0.7, 2.7±0.8 mm) values at 4 years were comparable in all the groups investigated. The mean MR values tended to be increased in both the test groups (0.5±0.7, 0.4±0.6 mm, respectively), when compared with the control group (0.2±0.3 mm) (P>0.05, respectively). The mean BOP values were also increased in both the test groups (45.8±30.5%, 54.1±24.8%, respectively), even reaching statistical significance when comparing test 2 and control (29.1±21.3%) groups (P=0.02).The present study indicated that (i) implants exhibiting RDH values >1 mm are at a higher risk of developing peri-implant disease and (ii) positive RDH values may be associated with an increase in MR and may therefore compromise the overall esthetic outcome of implant therapy.

Therapeutic vaccination directed to induce an anti-tumoral T-cell response is a field of extensive investigation in the treatment of melanoma. However, many vaccination trials in melanoma failed to demonstrate a correlation between the vaccine-specific immune response and therapy outcome. This has been mainly attributed to immune escape by antigen loss, rendering us in the need of new vaccination targets.This phase-II trial investigated a peptide vaccination against survivin, an oncogenic inhibitor-of-apoptosis protein crucial for the survival of tumor cells, in HLA-A1/-A2/-B35-positive patients with treatment-refractory stage-IV metastatic melanoma. The study endpoints were survivin-specific T-cell reactivity (SSTR), safety, response, and survival (OS).Sixty-one patients (ITT) received vaccination therapy using three different regimens. 55 patients (PP) were evaluable for response and survival, and 41/55 for SSTR. Patients achieving progression arrest (CR + PR + SD) more often showed SSTRs than patients with disease progression (p = 0.0008). Patients presenting SSTRs revealed a prolonged OS (median 19.6 vs. 8.6 months; p = 0.0077); multivariate analysis demonstrated SSTR as an independent predictor of survival (p = 0.013). The induction of SSTRs was associated with gender (female vs. male; p = 0.014) and disease stage (M1a/b vs. M1c; p = 0.010), but not with patient age, HLA type, performance status, or vaccination regimen.Survivin-specific T-cell reactivities strongly correlate with tumor response and patient survival, indicating that vaccination with survivin-derived peptides is a promising treatment strategy in melanoma.