EUROPEAN JOURNAL
OF DERMATOLOGY
V o l u m e 1 • N u m b e r 1 • O c t o b e r 1991
EDITORIAL
W h y create a new journal of dermatology in 1991 ? Jean Thivolet
REVIEW ARTICLE
Skin ceramides : structure and function
M. Kerscher H.C. Korting M. Schafer-Korting
CLINICAL REPORTS
Primary cutaneous B-cell lymphoma as first manifestation of acquired immuno-deficiency syndrome A. Vicente
E. Campo
R. Marti A. Azon
T. Estrach M.Lecha
J. Palou J.M. Mascaro Acute monoblastic leukemia and histiocytosis X : a case report and review of the literature
F. Cambazard L. Misery J. Kanitakis E. Archimbaud C. Hermier
Acanthosis nigricans and insulin resistance in obese patients : a frequent but underestimated dermato- endocrinopathy
V. Martin Ch. Thivolet L. Bajard L. Thomas M. Faure
Occupational allergic contact
dermatitis from iatrogenic sensitization by a new acrylate dentin adhesive L Kanerva K. Turjanmaa R. Jolanki T. Estlander
CASE REPORTS
Digital extraskeletal chondroma A.L. Claudy W. Godard L. Jacquelin Infundibular keratosis : a distinctive infundibular tumour
M.J. Lopez Redondo C. Schoendorff L. Requena G . Roustan E. Sanchez Yus F. Sanchez de Paz
Polyeponychia bolboides : an unusual manifestation of factitious disorder ? R. Happle A. Chang
INVESTIGATIVE REPORTS
Conversion of human epidermal Langerhans cells into interdigitating cells in vitro is not associated with functional maturation
M.B.M. Teunissen J. Wormmeester
H.A.H. Rongen M l . Kapsenberg, J.D. Bos Levels of immunoreactive interleukin 1 a and p in basal, suprabasal and cornified epidermal cell
subpopulations of normal human epidermis. Comparison with keratinocytes cultured in defined medium
H. Gatto J. Viae A. Reano M.Charveron
SHORT COMMUNICATION
Increased binding sites of dansylated cyclosporin A in psoriatic epidermis grafted onto nude mice during cyclosporin A treatment
A. Urabe J. Nakayama H. Terao Y. Ori
THESIS
Cyclosporin A in the treatment of psoriasis
F. Henle
Sensory neuromediators in human skin/role in inflammation and other disorders
J. Wallengren
JohnLibbey
I EUROTEXT Fin
Investigative Report
European Journal of D e r m a t o l o g y 1991; 1 : 1 3 5 - 1 3 8
REINHARD DUMMER
( U )FRANK NESTLE
(1)JOHANNES WIEDE
(1)ERWIN SCHAFER
(2)JORGEN ROGER
(1)JORGEN C. BECKER
(1)THOMAS VOGT
( 1 )GUNTER BURG'
1'
3'
( 1 department of Dermatology, Univer- sity of Wurzbura Medical School, D 8700 Wurzburg, Germany.
( 2 ,Department of Nuclear Medicine,
University of Wurzburg Medical School, D 8700 Wurzburg, Germany.
( 3 )Department of Dermatology, Univer-
sity of Zurich Medical School, Gloria- strasse 31, C H 8091 Zurich, Switzer- land.
Reprints: R. Dummer( 3 ).
EJD n°2, vol. 1, november 1991
Coincidence of increased soluble interleukin-2 receptors, diminished natural killer cell activity and
progressive disease in cutaneous T- cell lymphomas
In 24 patients with cutaneous T-cell lymphomas (CTCL) the clinical course was documented by determination of a tumour burden index (TBI) on entering the study and six months later. In addition to the first TBI, soluble interleukin-2 receptor levels (slL-2R) in the serum were determined using an ELISA technique in 23 patients. In 18 patients natural killer cell (NK) activity was assessed by a 4 h chromium-51 release assay. Statistical analysis revealed a negative correlation between N K activity and an increase of TBI as well as N K activity and slL-2R. Furthermore, there was a strong positive correlation between the increase of TBI and slL-2R. slL-2R and N K activity might be prognostic factors in C T C L patients.
Keywords: cutaneous T-cell lymphomas, soluble interleukin-2 recep- tor, natural killer cell activity, prognostic factors.
C
utaneous T-cell lymphomas (CTCL) a r e a heterogeneous g r o u p of lym- phoproliferative disorders originat- ing in the skin. In g e n e r a l , the term d e s i g - nates a clinically, histologically a n d phe- notypically v a r i a b l e spectrum of diseases which a r e slowly progressive a n d show striking interindividual differences [1].A n increased risk of s e c o n d malignancy [2] a n d a d e c r e a s e in natural killer cell
activity [3, 4] indicate i m b a l a n c e d im- munofunctions in these patients. Recently, w e a n d others [5, 6] reported elevated serum levels of soluble interleukin-2 receptors (TAC-protein) in some of these patients. Yet, the b i o l o g i c a l relevance of this phenomenon is unclear.
In the present study we a n a l y s e d the interactions of N K activity, slL-2R a n d the clinical outcome in C T C L patients.
Table I. Patients characteristics: slL-2R, NK activity, and clinical course described by A TBI Pat.
(n = 24)
Stage TNM[19]
Histol. diagnosis Pretreatment therapy during follow-up period
(6 months)
slL-2R (U/ml) (n = 23)
Spec, lysis (%) (n = 18)
A TBI (n = 24) G E IIA low-grade peripheral e.b.r
e. ster.
e. ster. 1690 5.0 18
HE MB low-grade peripheral e. ster. e. ster. 385 13.0 5
W A IA low-grade peripheral e. ster. e. ster. 405 16.5 0
BA IIA low-grade peripheral e. ster. e. ster. 330 4.0 0
H O IIB high-grade peripheral high-grade peripheral MTX, IFN-a MTX, e. ster. 538 30.7 0 PUVA
ST IIB low-grade peripheral B C N U , topical, B C N U topical 3000 6.4 30 e. ster. e. ster.
Tl III low-grade peripheral e. ster. BCNU topical 1320 4.0 12
KA IIA low-grade peripheral e. ster., IFN-a e. ster. 3570 6.0 20
KAI IIB high-grade peripheral PUVA, e. ster. e. ster. 10700 6.0 20
KE IIA low-grade peripheral e. ster. e. ster. 1190 21.9 20
SCH IA low-grade peripheral e. ster. e. ster. 950 10.5 0
H O IVB low-grade peripheral low-grade peripheral PUVA, e. ster. e. ster., MTX 9230 n.d. 40 B C N U , MTX
I RE IIA high-grade peripheral e. ster. e. ster. 720 15.0 0
TR IA low-grade peripheral PUVA, e. ster. IFN-a, e. ster. 800 42.3 0
GEI IIB high-grade peripheral e. ster. e. ster. 570 n.d. 0
BET IIA low-grade peripheral none PUVA 7330 2.3 20
HER IA low-grade peripheral PUVA, e. ster. e. ster. 1110 6.9 0
KG IB low-grade peripheral e. ster. e. ster. 650 24.7 2
prednimustine
V A IIB low-grade peripheral e. ster. e. ster. 300 22.5 0
GR IA low-grade peripheral e. ster. B C N U topical 790 n.d. 0
D O IVA low-grade peripheral PUVA, e. ster. e. ster. 12300 n.d. 40
K U N IVA low-grade peripheral PUVA, e. ster. e. ster. 1190 n.d. 40
Yl IA low-grade peripheral PUVA, e. ster. e. ster. 510 n.d. 0
WAL IA high-grade peripheral none e. ster. n.d. 19.8 0
MTX: methothrexate, B C N U : carmustine, IFN-a: interferon-a2a, e. ster.: external steroids, e.b.r.: electron beam radiation, n.d.: not done.
Patients and methods
Patients
Twenty four patients with histologically proven C T C L in different stages w e r e investigated. Before entering the study, systemic treatment h a d been stopped for at least two w e e k s . Physical examinations w e r e d o n e on d a y 0 a n d repeated six months later (for a l l 24 patients). Staging procedures a n d histological classifica- tion w e r e d o n e a c c o r d i n g to the r e c o m - mendations for staging a n d therapy of cutaneous l y m p h o m a s of the E u r o p e a n O r g a n i z a t i o n for Research a n d Treat- ment of C a n c e r , cutaneous l y m p h o m a project g r o u p [7]. O n d a y 0. p e r i p h e r a l b l o o d m o n o n u c l e a r cells for C r release assay w e r e taken in 18 patients, a n d serum s a m p l e s w e r e collected in 23 patients. Patients' characteristics includ- ing pretreatment a n d therapy during the f o l l o w - u p p e r i o d a r e s u m m a r i z e d in Table I. T h e r a p y in the f o l l o w - u p p e r i o d w a s a p p l i e d a c c o r d i n g to the c l i n - i c a l necessities.
number of patients
10 10
slL-2R < 1000 U slL-2R > 1000 U patients with progressive disease (ATBI > 10) patients with stable disease (ATBI < 10)
Figure 1. Clinical outcome according to soluble interleukin-2 receptor serum levels.
References
1- Burg G , Braun-Falco O. Cutaneous lym- phomas, pseudolymphomas and related dis- orders. Berlin, Heidelberg, New York, Tokyo:
^ringer 1983.
2. Kantor AF, Rochelle EC, Vonderheid EC,
von Scott EJ, Fraumeni JF. Risk of second Malignancy after cutaneous T-cell lympho- mas. Cancer 1989; 63: 1612-1615.
3. Laroche L, Kaiserlian D. Decreased natural killer cell activity in cutaneous T-cell lympho- mas. N Engl J Med 1983; 306: 101 -102.
Levy S, Tempe JL, Caussade P, Aleksijevic A, Grosshans E, Mayer S, Lang JM. Stage related decrease in natural killer cell activity
•n untreated patients with mycosis fungoides.
Cancer Immunol Immunother 1984; 18: 138- 140.
5. Kaudewitz P, Josimovic-Alasevic O, Diamantstein T, Eckert F, Klepzig K, Burg G.
Soluble IL-2 receptor serum levels in cuta- neous T-cell lymphomas: Correlation with cli- nical stage and IL-2 receptor status in cutane- ous infiltrates. J Invest Dermatol 1988; 91:
386-387.
6. Dummer R, Nestle F, Schafer E, Wiede J, Roger J, Hartmann A, Burg G. Influence of soluble interleukin-2 receptors and soluble CD 8 proteins on natural killer cell activity and clinical course in cutaneous T-cell lymphoma Patients. Arch Dermatol Res 1990; 8: 557- 558.
7. Kerl K, Sterry W. Classification and staging, h: Burg G , Sterry W, eds. EORTC/BMFT Cuta- neous Lymphoma Project Group: Recommen- dations for staging and therapy of cutaneous lymphomas. 1987; 1-10.
B. Goldstein AM, Marcon L, Cullen BR, Nel- son DL. A competive enzyme-linked immuno- assay (ELISA) for the measurement of soluble human interleukin-2 receptors (IL-2R, Tac- protein). J Immunol Methods 1988; 107:103- 109.
°. Yamada S, Ruscetti FW, Overton WA, Her- bermann RB, Birchenall-Sparks MC, Ortaldo JR. Regulation of human large granular lym- phocyte growth by recombinant interleukin 2:
Induction of interleukin-2 receptor and prom- otion of growth of cells with enhanced cytoto- xicity. J Leak Biol 1987; 41: 505-517.
Clinical course
In o r d e r to estimate the cutaneous tumour mass in a semiquantitative manner, a tumour burden index w a s introduced.
Physical examinations w e r e d o n e by one investigator, only. The percentage of involved skin w a s documented using the rule of the nines. Speci-fic skin lesions were differentiated in patches (flat lesions, diameter larger than 1 cm), p l a - ques (flat or slightly elevated lesions with increased consistency) a n d tumours (large nodular lesions, diamter larger than 1 cm) [7]. The extension of tumours, patches a n d plaques w a s noted a n d the tumour burden index (TBI) w a s c a l c u l a t e d a s :
tumour p l a q u e patch TBI = x % x 4 + x % x 2 + x % x 1 x % = involved skin in %
U n d e r these conditions the maximal a c h i e v a b l e TBI w a s 400. In our patients the TBI w a s 41 ± 59 (mean ± standard deviation, minimal 2, maximal 280).
The clinical course of progressing patients w a s determined by the difference of the tumour burden index ( A TBI) at day 0 a n d six months later.
It w a s calculated a s : A TBI = TBI6 - TBI0;
TBI* = after six months, TBI0 = TBI d a y 0.
Patients with a stable disease or regress-
Statistical tests
A computerized correlation analysis was performed using a new statistical p r o g - ramme ( M E D A S ) d e v e l o p e d by G r u n d C , Haubitz I. a n d Rausche A . Institute for Biostatistics, University of W u r z b u r g . C o r r e l a t i o n between slL-2R a n d N K acti- vities w a s a n a l y s e d by the calculation of S p e a r m a n ' s correlation coefficient, p.
C o r r e l a t i o n between A T B I a n d slL-2R a n d N K activity, respectively, w a s deter- mined by the calculation of K e n d a l ' s cor- relation coefficient, r.
Results
The results of slL-2R, N K activity a n d clinical course a r e s u m m a r i z e d in Table I.
Statistical analysis of our data revealed correlations between N K activity, slL-2R a n d disease p r o g r e s s i o n , which was d e s c r i b e d by the A T B I .
There w a s a negative correlation between N K activity a n d A T B I (r =
- 0 . 3 4 9 2 , P< 0.05). A strong positive cor- relation w a s found between slL-2R a n d Soluble interleukin-2 receptors
Soluble interleukin-2 receptors (slL-2R) in the serum were determined by sandwich ELISA (T C e l l Sciences Inc., C a m b r i d g e , USA) [8]. The test employs two non- competing murine m o n o c l o n a l anti- bodies to the a-chain of human IL-2R. It w a s done a c c o r d i n g to the manufactur- er's instructions. The microtiter plates were read at 490 nm using a Dynatech M R 700 microplate reader. Units of slL-2R were calculated from a standard curve constructed on the basis of a supernatant from phytohemagglutinin-stimulated peripheral b l o o d mononuclear cells.
Interassay variation w a s 5 % . Natural killer cell activity
Peripheral mononuclear cells (PMC) were separated by F i c o l l - H y p a q u e c e n - trifugation. N K activity w a s determined in a 4 h 5 1 C r release assay as previously d e s c r i b e d [9], using the NK-sensitive erythroblastoma cell line K562 as target cells. The effectontarget ratio was 40 : 1.
Spon-taneous release w a s assessed by incubating l a b e l l e d K 562 in medium a l o n e , a n d total release was evaluated by a solution of S D S . After harvesting the supernatants using a Skatron filterstick system, radioactivity w a s measured in a P h a r m a c i a gamma-counter.
Specific lysis (SL) was calculated a s :
0.3492, P < 0.05). A strong positive corre- lation was found between slL-2R a n d A T B I (r = 0.6091, P < 0.0005). N o c o r r e - lation between staging a n d slL-2R or staging a n d N K activity w a s o b s e r v e d . N K activity a n d slL-2R s h o w e d a negative correlation (p = - 0 . 5 4 2 3 , P < 0.03).
A n a l y s i n g the reliability of slL-2R as a prognostic factor, w e suggest that a A T B I of at least 10 should be considered as a significant c h a n g e . M o r e o v e r , slL-2R should e x c e e d the upper normal range by a factor of 2 (> 1000 U/ml). U n d e r these conditions the specificity of slL-2R for tumour progression w a s 9 0 . 0 % (n = 11).
There w a s no false-positive value, indicating high sensitivity (Fig. 1).
Discussion
Recent reports of successful transplanta- tion of cutaneous lymphomas on natural killer cell-depleted severe c o m b i n e d immunodeficient (SCID) mice [10] as well S L ( 7 ) M e a n experimental release - mean spontaneous release ^
M e a n total release - mean spontaneous release
References
10. Charley MR, Tharp M, Locker J, Deng J-S, Goslen JB, Mauro T, McCoy P, Abel I E, Jega- sothy B. Establishment of a human cutaneous T-cell lymphoma in C.B.-17 SCID mice. J Invest Dermatol 1990; 94: 381-384.
11. Gause A, Roschansky V, Tschiersch A, Schmits R, Diehl V, Pfreundschuh M. The prog- nostic value of low pretreatment serum interleukin-2 receptor (slL-2R) in patients with Hodgkin's disease (HD). J Cancer Res Clin Oncol 1990; 116: 320S.
12. Wagner DK, Kiwanuka J, Edwards BK, Rubin LA, Nelson DL, Magrath IT. Soluble interleukin-2 receptor levels in patients with undifferentiated and lymphoblastic lympho- mas: Correlation with survival. J Clin Oncol 1987; 5: 1262-1274.
13. Kapp A, Piskorski A, Schopf E. Elevated levels of interleukin-2 receptor in sera with atopic dermatitis and psoriasis. Br J Dermatol 1988;119:707-710.
14. DiGiovine FS, Duff GW. Interleukin-l: the first interleukin. Immunol Today 1990; 11:13- 20.
15. Tron VA, Rosenthal DR, Sauder DN. Epi- dermal interleukin-l is increased in cuta- neous T-cell lymphoma. J Invest Dermatol 1988; 90: 378-381.
16. Dummer R, Wiede J, Nestle F, Schafer E, Burg G . Diminished natural killer cell activity in mycosis fungoides patients can be partially restored by IL-2. J Invest Dermatol 1989; 93:
298.
17. Rubin LA, Jay G , Nelson DL. The released interleukin-2 receptor binds interleukin-2 efficiently. J Immunol 1986; 137: 3841-3844.
18. Symons JA, Wood NC, Di Giovine FS, Duff GW. Soluble IL-2 receptor in rheumatoid arthritis: Correlation with disease activity, IL-1 and IL-2 inhibition. J Immunol 1988; 141:
2612-2618.
19. Bunn PA, Lamberg SI. Report of the com- mittee on staging and classification of cuta- neous T-cell lymphomas. Cancer Treat Rep 1979; 63:725-728.
as an e n h a n c e d risk of d e v e l o p i n g s e c o n - d a r y n e o p l a s i a s [2] point to i m p a i r e d immunofunctions in C T C L patients. A n a - lysing N K activity a n d clinical course in these patients w e found a correlation between the d e c r e a s e of N K activity a n d the progression of the disease. W e c o n - clude that N K activity might be a p r o g n o s - tic factor f o r C T C L patients.
Elevated levels of slL-2R w e r e found in the serum of patients suffering from lym- phoproliferative d i s o r d e r s [5,6,11,12] a s well a s in the serum of patients suffering from inflammatory skin diseases [13].
R e g a r d i n g the strong correlation between tumour progression in C T C L p a - tients a n d slL-2R, w e suggest that this soluble protein may be of high prognostic value. This is consistent with the detection of slL-2R as a n unfavourable prognostic sign in other lymphoproliferative disor- ders such a s H o d g k i n ' s d i s e a s e [11] a n d lymphoblastic lymphomas [12].
From a n i m m u n o l o g i c a l point of view, the negative correlation between slL-2R a n d N K activities offers interesting p e r s p e c - tives. U n d e r p h y s i o l o g i c circumstances, m e m b r a n e - b o u n d a n d soluble forms of the T A C protein a r e o b s e r v e d after T-cell stimulation, f o r e x a m p l e by antigen pre- senting cells a n d interleukin 1. A s a c o n - sequence, the stimulated T lymphocytes p r o d u c e interleukin-2 [14]. In C T C L patients this mechanism seems to b e dis- turbed. In some C T C L patients, interleukin 1 [15] might enhance expression of T A C protein, albeit, without a d d i t i o n a l induc- tion of interleukin-2, which is a b l e to res- tore diminished N K activity [16] a n d is known to be a potent stimulating cytokine for N K activity [9]. This d i s c o r d a n c e c o u l d be a n important factor f o r tumour s p r e a d - ing. W e p r o p o s e , that slL-2R might be responsible f o r the d e c r e a s e d N K activity by neutralizing interleukin-2 [17, 18] •
Abbreviations
C T C L : cutaneous T-cell l y m p h o m a . S C I D : severe c o m b i n e d immune
deficiency.
slL-2R: s o l u b l e interleukin-2 receptor.
N K : natural killer c e l l . TBI: tumour burden index.
Zusammenfassung
Bei 24 Patienten mit cutanem T-Zell Lymphom (CTCL) w u r d e d e r klinische V e r l a u f mittels eines " T u m o r burden index (TBI)" b e i Beginn d e r B e o b a c h - tung und sechs M o n a t e spdter d o k u - mentiert. Z u s a m m e n mit d e m ersten TBI w u r d e d e r losliche Interleukin-2
Rezeptor (slL-2R) im Serum mittels ELISA und d i e naturliche K i l l e r z e l l - (NK-) Aktivitat d e r peripheren mono- nukledren Z e l l e n mittels " C r - 5 1 Release A s s a y " bestimmt. D i e statistis- che A u s w e r t u n g d e r drei Parameter e r g a b eine negative K o r r e l a t i o n zwis- chen N K - A k t i v i t a t und Z u n a h m e des TBI, s o w i e z w i s c h e n N K - A k t i v i t a t und slL-2R. A u f i e r d e m f a n d sich eine hoch- signifikante K o r r e l a t i o n zwischen sIL- 2R und Z u n a h m e d e s TBI. slL-2R und N K - A k i v i t d t sind m o g l i c h e r w e i s e von prognostischer Bedeutung bei Patien- ten mit C T C L .
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