REPORTS ON SEMINARS

(1) SEMINAR ON MELANOMA AND SKIN CANCER:
BIOLOGY AND COMPARATIVE FEATURES IN THE U.S. AND JAPAN

1. PARTICIPATORS, MEETING PLACE AND DATE:
US-Japan Co-operative Cancer Research Program, Melanoma and Skin Cancer; Biology and Comparative Features in the US and Japan was held from November 13 to November 15, 1987 at the International Lecture Hall, National Cancer Center in Tokyo, Japan. This seminar was supported by the Japan Society for the Promotion of Science to the Japanese side, and the National Cancer Institute on the US side. Nine participators from the US, twenty from Japan, and one from the United Kingdom gathered (see Appendix 1). Basides these members, Dr. Robert W. Miller, National Cancer Institute, Bethesada, and Dr. Haruo Sugano, Cancer Institute, Tokyo, also attended the whole meeting as the co-ordinators of the program. Other participators included twenty-five pre-registered discussants.
2. OVERALL PROGRAM:
A seminar reception was held on November 12, 1987, the night before the seminar in Togeki Sky Salon “Escargot” where approximately 50 people gathered and spent a pleasant time by introducing each other. The seminar started from 9:00 AM, November 13, with introductory remarks by Dr. Atsuhi Kukita, Dr. Thomas B. Fitzpatrick and Dr. Robert W. Miller. The three stressed the importance of having the meeting, not only with two specific nations where the incidence, clinical types, course and histopathologic types of melanoma are different, but also with the medical scientist and basic scientists together who are worldwide leaders in individual fields. The seminar dinner was held on November 14 with honorable attendance of Prince Masahito and Princess Hanako.
The summation and closing remarks were made by Dr. Michael Wick, Dr. Kowichi Jimbow and Dr. Haruo Sugano. Dr. Wick elegantly and concisely summarized the scientific merits of the whole meeting. Dr. Jimbow stressed the importance of medical collaboration between basic scientists and medical scientists in the study of malignant melanoma for the future in the US and Japan. Dr. Sugano made outstanding remarks for the importance and contributions of basic and clinical sciences in the field of Dermatology, by introducing Dr. Ota as an example of a best clinician, a best scientist and a best man of letters in the field of Dermatology in Japan.
3. SCIENTIFIC SESSIONS:
The seminar was organized by Dr. A. Kukita, Dr. K. Jimbow and Dr. Fitzpatric along multidisciplinary lines ranging from a study of the pigment cells of fish to human melanoma cells and clinical aspects. Specifically, topics were presented in the following five categories:
i) Epidemiology and comparative aspects
ii) The cellular and basic biology of melanoma
iii) Pathogenesis
iv) Biology of precursor lesion and early diagnosis
v) Methods of control and treatment.
A. EPIDEMIOLOGY AND COMPARATIVE ASPECTS:
Clues to pathogenesis of diseases can sometimes be summarized by comparing populations in which the disease is relatively rare with populations with a high incidence. Dr. M.A. Tucker first summarized the recent incidence rates of cutaneous malignant melanoma in three geographic locations:
INCIDENCE RATES/100,000/YEAR

She stressed that (a) major host susceptibility factor is positive if there is a family history of melanoma, and (b) if a family member has dysplastic nevi, they have approximately 100% lifetime risk of melanoma.
Dr. Kukita and Dr. Ikeda implicated the unique location of the melanoma and nevi in Japanese vs Caucasians in the US: in the pigmented races including negroid races, many melanomas occur on the sun unexposed areas, i.e., soles of the feet, whereas they are more commonly seen in the sun-exposed areas, e.g., upper back, in white Caucasians. Among the main arguments in terms of this racial difference are:
i. A remarkably low incidence of high risk-group, i.e., patients with a family history of dysplastic melanocytic nevi is quite low in Japanese (Dr. D. Elder, Dr. Tucker, Dr. Fitzpatrick, Dr. Jimbow).
ii. A remarkably low incidence of a familial malignant melanoma in Japanese (Dr. Tucker, Dr. R.W. Miller).
iii. Low incidence of melanoma in Japanese may be related to one or more of the following factors, (a) better DNA repair system (Dr. Fitzpatrick, Dr. Takebe, Dr. D.M. Carter); (b) better immune-surveillance mechanism (Dr. Tucker); (c) age factor related to the exposure of children before certain age; (d) susceptibility of individuals to melanoma (Dr. M. Elwood).
It became clear that a low incidence of dysplastic melanocytic nevi (dysplastic nevus syndrome) in Japanese vs a very hlgh incidence of this syndrome in the US, may actually well correlate with the different incidence of melanoma in Japanese and US.
Dr. Fitzpatrick and Dr. A. Sober proposed elegantly the necessity of public education for the early recognition of malignant melanoma. Finally, Dr. Elwood showed the natural history of cutaneous melanoma of individuals living in North America, Australia and Europe. He also emphasized early diagnosis using professional and public education approaches. Identification of high risk individuals, followed by early diagnosis or prevention by removal of precancerous lesions is valuable for extreme high risk groups.
B. THE CELLULAR AND BASIC BIOLOGY OF MELANOMA
This session was designed (a) to clarify the regularity factors responsible for proliferation and differentiation of cells in the epidermis, and (b) to define the factors which might be relevant to prevention of skin cancer and melanoma.
First, Dr. S. Ito introduced a new method to quantitate the urinary melanogen, i.e., O-methyl derivatives of 5,6-dihydroxyindole and 5,6-dihydroxyindole-2-carboxylic acid. By this method, his research group was able to measure a 10 to 100 fold increase in the urinary excretion of “melanogene” in melanoma-bearing mice as compared with normal C57BL mice. A question was brought about whether such an excretion of urinary melanogen correlates with the content of eu/pheo-melanin in melanoma tissue (Dr. Y. Mishima, Dr. Jimbow). This analysis would provide, in future, a new information regarding the nature of a mixed content of eu/pheomelanin in melanoma tissues (Dr. M. Wick).
Tyrosinase is the enzyme responsible for the formation of melanin. Dr. Takeuchi, using organ culture method and special substrains of mice (lethal yellow mice, and recessive yellow mice), compared the biological effect of DbcAMP and!!!MSH. Importantly, through this study, his research group has succeeded to define the genetic control of the tyrosinace molecule for differentiation of pigment cells in hair follicles. The information provided is the first study which has clarified the nature of tyrosinase gene in “normal” tissue (Dr. T.B. Fitzpatrick). The biological role of DbcAMP and!!!MSH to pigment cells was also tested in cultured goldfish by Dr. J. Matsumoto to clarify (a) acquisition of phenotypic instability upon neoplastic transformation, and (b) the possible relationship between the stages of cyto-differentiation and susceptibility for neoplastic transformation.
Dr. M. Mihm contrasted the biological characteristics of melanoma in Japanese cases based upon his own review of 83 cases of melanoma and nevi in Japanese. An emphasis was made on the histology of the acral lentiginous melanoma in situ depending on the anatomic regions affected by the neoplasm. Dr. Mihm also defined a subtle histological change which would be the first sign in the development of melanoma in situ.
Dr. Kuroki introduced a new technique of explant outgrowth culture of pigment cells by which he could demonstrate (a) a defect of UV-induced unscheduled DNA synthesis (UVS) in epidermal cells of xeroderma pigmentosum, and (b) binding and action of EGF and TPA on epidermal cells He found different from pigment cells, essentially negative responses to TPA on epidermal cells.
Research groups of Dr. Y. Ishibashi and T. Hirone characterized a certain aspect in the nature of precancerous condition in the skin tumors. Dr. Ishibashi measured nuclear DNA content of epidermal cells for prokaryotic lesions using microfluorometry that are applied directly on paraffin sections. In contrast, Dr. Hirone and his associates showed loss or reduction in the expression of antigen properties in melanoma tissues using various forms of polyclonal and monoclonal antibodies.
C. PATHOGENESIS:
In this session, three major topics have been discussed; (a) pigment cells and tumors in fish, (b) sun exposure and DNA damage and (c) immunology and oncogene on melanoma. Prince Masahito, Dr. Ishikawa and Dr. Sugano demonstrated a beautiful work on how the neural crest cells differentiate into pigment cells of fish, i.e., melanophores, erythrophores and iridophores and on how these cells, when transformed, can be characterized, besides conventional histopathological studies for the genetic/oncogenic expressions. In addition, Prince Masahito emphasized not only the fine structure of the pigment cells but also transforming genes (ras gene) of the tumors. Several questions have been brought about regarding the nature of fish tumors; one of these questions included the difference in the site of point mutation to activate the ras gene (Dr. M. Wick and Dr. D.M. Carter). Following Prince Masahito’s presentation, another topic of fish tumors was presented by Dr. I. Kimura, who reported on how the environmental factors can activate or develop certain forms of pigmented tumors in fish. Dr Kimura beautifully has shown that Nibea mitsukurii, feral fish inhabiting the shallow waters produce pigment tumors which would probably reflect the environment pollutant, such as nifurpirinol, or 7,12-dimethylbenzanthracene. Removal of contaminated sediments from Kumano liver had reduced the incidence of tumors in Nibe fish at the rates ranging from40 50% (1983) to 20% (1986).
The two papers of Prince Masahito and Dr. Kimura had been unfamiliar to most of the US participants. However, they indeed had struck the attendants, and the two talks were one of the highlights in this seminar which had brought about many questions. Among these included; Why the fish Nibe produced such a high incidence of pigmented tumors; How the incidence was so selective to pigmented tumors (Dr. Fitzpatrick, Dr. Mihm, Dr. Sober, Dr. Tucker and Dr. Elder).
Dr. D.M. Carter and Dr. I. Ishikawa discussed the DNA damage in skin cancer after exposure to ultraviolet (UV) irradiation. Dr. Carter stressed (a) that chronic exposure to UV irradiation and a high total cumulative dose may be less deleterious than are periodic bursts of large amounts of sun exposure leading to severe sunburn and (b) that damage which is apt to be most cytotoxic is probably less effective as an inducer of skin cancer than is more subtle damage which is tolerated but can irritate malignant transformation. Dr. Ishikawa, using polyclonal antibodies raised against DNA modified with carcinogen 4-hydroxyaminoquinoline 1-oxide or benzopyrene, succeeded to locate in situ DNA adducts on paraffin-embedded sections. He stressed that the intensity of staining correlates well with the level of unscheduled DNA synthesis. His answers to several questions raised Included (a) that aged mice are deficient in DNA repair after high doses of UV exposure and (b) that intermittent UV exposure is carcinogenic to the kelatinoocytes. Dr. H. Takebe and Dr. A. Oikawa discussed the nature of melanoma and other skin cancers in xeroderma pigmentosum (XP) patients. Dr. Takebe demonstrated several unique features of Japanese XP patients: (a) 12% of skin cancer in XP Japanese patients were malignant melanoma; (b) their histopathologic subtype was lentigo malignant melanoma while in US melanoma in XP patients were mostly superficial spreading subtype. He also indicated that minimum age of melanoma development was at the age of 3, many patients being at the age of 5 and (b) that eye melanoma can occur in XP patients, e.g., one male occurring at the age of 20. Dr. Oikawa presented a paper which was different from the one shown in the abstract. He, however, discussed the response of unscheduled DNA synthesis (UDS) induced by UV in patients suffering from XP and showed that UDS proficient XP cells reveal several unique responses to the treatment with caffeine after UV irradiation: (a) caffeine enhanced UV-induced Syster Chromatid Exchange (SCE) dose-dependently and synergistically; (b) the enhanced SCE was not reduced by holding cells in a growth-arrested state; (c) the SCE causing damage was retained in excision-proficient XP cells.
Immunological aspects of malignant melanoma were discussed by Dr. J.C. Bystryn and Dr. M. Taniguchi. Dr. Bystryn discussed the immunosurveillance and melanoma. He first showed the marked and specific increase in resistance to melanoma in animals (e.g. chimpanzee) by immunization to melanoma vaccines and then emphasized that the vaccines can help for the subjects in the melanoma prone family or patients with dysplastic melanocytic nevi. Some of these melanoma vaccines are ready for the control study. Dr. M. Tagawa and Dr. Taniguchi discussed the genomic cloning of DNA controlling expression of mouse melanoma antigen and transforming activity. They elegantly showed that pD2 (34.8 Kb) expresses M56 mouse melanoma determinants in human melanoma and possesses the transforming activity in NIH/3T3 cells.
Finally, Dr. T. Sekiya discussed the oncogenes in pigment cell neoplasms in general. He found transforming activity in one of the melanoma cell lines, SK2 maintained in nude mice The transforming gene was activated by a single point mutation at cordon 61 in the second axon. He further indicated that amplification of the C-H-ras-1 alle, in addition to the point of mutation, may pay a role in the development of the tumor. Questions brought about included; (a) Is DNA changes specific to primary melanoma? Or Can it be seen in other pigmented tumors, e.g. pigmented melanocytic nevi and dysplastic melanocytic nevi?; and (b) Can loss of chromosome 3 also be seen in other tumors? These questions must be solved out in the future.
D. BIOLOGY OF PRECURSOR LESIONS AND EARLY DIAGNOSIS:
In this session we discussed the nature and significance of dysplastic melanocytic nevi and giant melanocytic nevi. Dr. D.E. Elder first summarized concisely the present status of dysplastic melanocytic nevi, e.g. clinical features, histopathological diagnosis and relationship to the development of malignant melanoma. He indicated that a useful simple, clinical classification is divided into two categories; (a) high risk - DMN with a personal or family history of malignant melanoma; and (b) low risk - no melanoma history. Clinical management should reflect this risk heterogeneity, and should consist of patient education, periodic follow-up at intervals dependent on risk, and excision biopsy of lesions suspicious for malignant melanoma. He also indicated that future research should aim to define the significance of DMN as markers by means of epidemiologic case-control and cohort studies, and as precursors by means of laboratory investigation of the mechanisms of tumor progression and the factors that promote or inhibit it. Dr. K. Jimbow then demonstrated the clinical features and characteristics of Japanese dysplastic melanocytic nevi patients and their fine structural and immunohistochemical properties. Reports of dysplastic melanocytic nevus (DMN) have increased in number in recent Japanese literature. Most of these cases, however, belong to solitary, sporadic form and only two of them appear to be familiar and/or associated with malignant melanoma. Although he did not specifically give an answer regarding the two questions of why such a low incidence of dysplastic melanocytic nevus occurs in Japanese and why the incidence of dysplastic melanocytic nevus is high in caucasian patients, the new methodology he brought about, was the fine structural and immunohistochemical properties of dysplastic melanocytic nevus which were characterized by utilizing the monoclonal antibodies, MoAb HMSA. By demonstrating antigen protein reacting with MoAb HMSA, he could identify dysplastic melanocytes in situ on routine paraffin sections. An emphasis was also made that the fine structural changes in synthesis and melanization of melanosomes appear to be unique to dysplastic melanocytic nevus; they may fill the gap of abnormal melanogenesis existing between cutaneous malignant melanoma and common melanocytic nevus.
Unique clinical features of giant pigment melanocytic nevus and malignant melanoma in Japan were demonstrated by Y. Hori and T. Arao. Dr. Hori first demonstrated the frequency of giant pigmented melanocytic nevi progressed into malignant melanoma. In the literature, it was estimated to be 2 to 31%; Lorentzen et al. (1977) estimated a lifetime risk of malignant transformation of giant melanocytic nevi to be 4.6% and Rhodes et al. (1981) estimated it to be at least 6.3%. He also showed his experience of the cases with congenital giant pigment melanocytic nevi which developed to malignant melanoma after abrasion of the nevi. Histopathologic and ultrastructural studies of non-malignant nodules in giant nevus revealed that nevus cells were atypical and contained abnormal melanosomes. Dr. Arao showed an unusual case of a 32-year-old Japanese female who suffered from a giant pedunculate, heavily pigmented tumor occurring on the external genitalia.
E. METHODS OF CONTROL AND TREATMENT
This session was aimed to first summarize the clinical features of melanoma and skin cancer in the US and Japan, secondly, to discuss the results of the treatment which have been currently engaged in both US and Japan, and thirdly, to study the possibilities for the development of rational and experimental approaches in the therapy. Dr. A.J. Sober beautifully compared the clinical characteristics of skin cancer and melanoma in Japanese and US populations. He defined the clinical and histopathological features that are unique to melanoma found in the Japanese and US groups. He emphasized the ability to predict the outcome for an individual patient with melanoma is important not only to the prognostic interests of the particular patient involved but also to the design and interpretation of surgical and adjuvant therapy studies. He also stressed the importance of teaching for the general practicioners and subspecialties of medicine to detect early lesions of malignant melanoma. A question brought about in his talk included whether the level of invasion or thickness of the primary tumor is a better prognostic sign for malignant melanoma. His answer was that the tumor thickness is a much better indication than level of invasion for estimating the prognosis of malignant melanoma.
Dr. K. Ishihara summarized the present status of the melanoma treatment by interferon, interleukin-2 and other Biologic Response Modifiers (BRM). In Japan many BRM have been applied in addition to chemotherapy of malignant melanoma. These include interferon (IFN), interleukin-2 (IL-2), tumor necrosis factor (TNF), living BCG, MY-1, WPG (CWS of Bifidobacterium bifidum), OK-432 (Picibanil, originating hemolytic streptococci), bestatin, forpfenlcinol, etc. Among IFN-!!!, -!!!and!!!, IFN-!!!showed better results for the treatment of melanoma than did IFN-!!!. Prolongation of survival time by the administration of IFN-!!!was observed. His opinion was that efficacy of IFN-!!!appears to be lower than IFN-!!!and -!!!.
Secondly, Dr. DuPont Guerry discussed the immune-based therapy of malignant melanoma. He summarized the current approaches to the therapy of melanoma using immune-based tactics in the following ways; (a) non-specific immune stimulation (e.g., with microbial products) or suppression of “suppressor” mechanisms (e.g., with low dose cyclophosphamide); (b) “active” vaccination with autologous or allogeneic tumor cells, tumor-associated antigens and anti-idiotypic antibodies; (c) “passive” therapy with naked or adorned monoclonal antibodies of at least relative specificity for melanoma; (d) the use of a heterogeneous group of biologic response modifies comprised of various cytokines including the interferons, interleukin-2, and tumor necrosis factor; and (e) autologous cellular therapy with lymphokine-activated killer cells (LAK cells’) or tumor infiltrating lymphocytes (TIL).
The current knowledge of the experimental chemotherapy for malignant melanoma was discussed by Dr. M. M. Wick and Dr. Y. Mishima. Dr. Wick first introduced the reducing agent as the controller of replication in malignant melanoma. The rationale for carrying out this approach of selective chemotherapy relies on (a) unique cellular target; (b) non-essential function to host; (c) non toxicity; and (d) complimentary with conventional agents (differentiation vs gross). He also introduced a new experimental chemotherapeutic agent, i.e., 3,4-dihydroxybenzylamine by which he found a marked inhibition of melanoma cells in vitro and in vivo (growth inhibition being 70% in 3,4-dihydroxybenzylamine and 48% in dopamine). He also indicated that this new agent can be a project for the phase I clinical study.
As the last topic of this session, Dr. Mishima showed selective thermal neutron capture therapy and diagnosis of malignant melanoma using its specific metabolic activity. The new compound which he introduced is ¹⁰B1-BPA. After Introducing the theory and rationale of this new chemo-radiotherapeutic agent, he showed the sufficient ¹⁰B accumulation in inoperable human melanoma lesion and its disappearance by a 10 minute neutron irradiation. He also indicated a possibility in performing successfully the first clinical trial.
F. SEMINAR SUMMARY:
Malignant melanoma has now become a major international health problem affecting all nations with increasing incidence and mortality. It may be epidemic in the western world, and of increasing importance in the eastern countries. The foremost basic biology in both melanoma and non-melanoma skin cancer has been carried out primarily by Japanese and US scientists. The present conference involving these two nations therefore has brought together leaders in the field from both countries and provided a new level of communication that serves to enhance progress in this significant area. During this seminar, recent advances regarding the contribution of basic knowledge of normal melanocytes to the study of melanoma, and oncogene structure, function, immunology of malignant melanoma as well as new therapeutic modalities have been discussed for exciting development in the potential application of these basic sciences to malignant melanoma. Special scientific advantages to better clinical management of Japan and the US resulting from this meeting include increased communication among the investigators and establishment of collaborative efforts between Japan, and the US investigators attending this seminar. This development of mutual collaboration should greatly increase the pace to which fundamental basic observation are being made as well as their potential application to clinical progress.
G. SEMINAR INFORMATION
The proceeding of this whole meeting seminar will be published in the special supplement of the Journal of Investigative Dermatology in the year, 1988. A publication committee was established to develop a consensus and conjections occurring from this seminar.
H. ACKNOWLEDGEMENT
We wish to tank Dr. R.W. Miller, National Cancer Institute, Bethesda, USA, and Dr. Haruo Sugano, Cancer Institute, Japan, who have provided strong support and encouragement. We also wish to thank all our colleagues who have given us excellent advice and help concerning this scientific program.

(2) Seminar on “THE FAMILY SYNDROME OF SARCOMA, BREAST CANCER, AND OTHER NEOPLASMS”
Geographic or ethnic differences in cancer occurrence can provide clues to etiology, as revealed by a variety of workshops held under the U.S.-Japan Cooperative Cancer Research Program. One neoplastic disorder, well known in the U.S. and the U. K. but not in Japan, is the Li-Fraumeni family cancer syndrome. It is of special interest because diverse cancers aggregate among family members or as multiple primary neoplasia. From this clinical oddity may come new understanding of a carcinogenic mechanism that accounts for these constellations of cancers. To explore the nature of the disease as defined thus far in the U.S., and to search for affected families in Japanese registries or case-series, a workshop on the syndrome was held under the U.S.-Japan Program in Honolulu on March 21-24, 1988.
Clinical Findings
The syndrome, delineated about 20 years ago, was described by Li (NCI, Boston). A registry of 24 U.S. families with the disorder has shown that the principal cancers In the syndrome are soft tissue sarcomas, breast cancer, adrenocortical carcinoma (ACC), osteosarcoma, brain tumors and leukemia (1, 2). All but breast cancer tend to occur in childhood and adolescence. The syndrome has also been well studied epidemiologically in Great Britain through the use of the Manchester Childhood Tumour Registry (3-5).
Seeking the Gene Locus
Strong (M.D. Anderson Cancer Center, Houston) described linkage and segregation analysis of 159 families in which a child had survived a soft tissue sarcoma for at least three years. The affected children had an excess of second cancers (8 observed vs. 0.5 expected), and, among their first-degree relatives, 34 developed cancer vs. 21 expected. The cancers included sarcomas. breast cancer and brain tumors. Eleven of the 159 families had clusters of cancer. which was transmitted in an autosomal dominant pattern. The risk of cancer among gene carriers in these families was 40 percent by age 30, and 90 percent by age 70. Cytogenetic studies revealed no constitutional deletions of chromosome 13q in the 13 members studied from nine families with cancer clusters. Furthermore, no evidence was found for linkage with chromosomes 11, 13, 16 or several other regions that accounted for nearly one-third of the genome.
Childhood Cancer Registry Data
Tsunematsu (National Children’s Hospital, Tokyo) sought families with this syndrome in a review of data from the Japanese Childhood Cancer Registry (1969-84) and the Childhood Multiple Primary Cancer Registry (1960-87). Analysis was made of the families histories of a total of 737 probands with a sarcoma or ACC, which are elements of the syndrome. The patients with ACC tended to have the more remarkable family histories of cancer, and the possibility of a bi-national study of the families of these patients was considered.
Of ten families, four were of unusual interest:

1. Childhood ACC and medulloblastoma occurred in siblings. Breast cancer had caused the deaths of their mother, grandmother and great-grandmother at 33-48 years of age. Two other maternal relatives developed ovarian cancer (type unknown) at 18 and 24 years, which, with isolated ovarian stromal and germ cell cancers noted in other families elsewhere, suggest that these cancers early in life may be another component of the syndrome.
   
2. Hepatoblastoma and ACC occurred among first cousins under 5 years of age. Both of these tumors occur excessively in Beckwith-Wiedemann syndrome. The father of the child with ACC developed an astrocytoma at 41 years. He had three siblings. One died at age 20 of urinary bladder cancer (most unusual, so young) and another, who was the mother of the child with hepatoblastoma, died of pancreatic cancer 36 years. Their mother and a sister died of stomach cancer at 33 and 30 years of age, respectively.
   
3. Siblings developed hepatoblastoma and malignant ependymoma at 9 and 2 years of age respectively. Their mother developed a brain tumor at 33 years.
   4. Rhabdomyosarcoma was diagnosed in a boy at 2 years. His mother and maternal grandmother developed breast cancer at 37 and 45 years respectively.

Breast Cancer Series
Sugano (Cancer Institute, Tokyo) described the family history data on 2,810 breast cancer patients treated at his Institute, 1976-84. Twenty-two (one percent) of them reported the occurrence of sarcoma in a close relative. In one family, a 30 year-old breast cancer patient had a sister with brain tumor at age 3 and a second sister with osteogenic sarcoma at age 14. A second family also had three sisters with cancer: a breast cancer at age 59, sarcoma at 46, and brain tumor at 5 years. Osteosarcoma was reported in four first-degree relatives of women with breast cancers, and in an uncle, aunt and grandfather of three others. These cases merit further study of bone-cancer histopathology and extended family histories.
Watanabe (National Cancer Center, Tokyo) examined the occurrence of second cancers among nearly 7,500 breast cancer cases, 322 of whom developed another primary cancer. Cancer in the opposite breast was the predominant second neoplasm and no excess of second cancers that comprise the syndrome was evident. However, in one family with breast cancer in three sisters, one affected case and her healthy mother had a constitutional translocation, t(15;19). Cytogenetic analysis of the other two breast cancer cases and publication of this family was suggested by discussants. Another interesting observation concerned an affected woman from one breast-cancer family whose husband, from another such family, also developed breast cancer. Their children are at increased risk from both parental lines, and screening for early detection of breast cancer is indicated.
Low Frequency of LFS Component Cancers in Japan
Part of the explanation for the relative rarity of the syndrome in Japan was suggested by Matsunaga (National Institute of Genetics, Mishima), who reported on childhood cancer incidence data for Kanagawa Prefecture, 1975-82. The incidence of childhood sarcoma in the Prefecture was less than 50% of that reported in SEER data for U.S. white children, but about the same as that for U.S. black children. In addition, Sugano noted that even though breast cancer incidence rates have nearly doubled in 15 years among post-menopausal women in Japan, the overall rates remain below those for U.S. white women. Thus, the cancer family syndrome may be less common in Japan because its two principal components, breast cancer and soft tissue sarcoma, occur with lower frequency in the general Japanese population.
Hepatoblastoma and Polyposis of the Colon
Garber (NCI, Boston) presented data from 20 patients listed in the Hepatoblastoma-Adenomatous Polyposis Registry at the Dana-Farber Cancer Center. They had hepatoblastoma and a family history of polyposis of the colon, and commonly had black spots in their ocular fundi (congenital hypertrophy of the retinal pigment epithelium). This funduscopic abnormality can help identify families with polyposis, and is thus of value in cancer prevention and early detection. There may be a relationship to LFS because isolated patients in these families have had polyposis, colonic carcinoma or hepatoblastoma.
Pathology
Newton (Columbus Children’s Hospital) described the pathology of sarcomas in children. Rhabdomyosarcomas comprise approximately 50 percent of these neoplasms, and embryonal rhabdomyosarcoma is the commonest subtype. A second subtype, alveolar rhabdomyosarcoma, carries a poorer prognosis for survival. Among patients with multiple primary cancers that include sarcoma, the histological distribution is similar to that in the general population; the exception may be leiomyosarcoma which had a higher relative frequency among those with multiple cancers. In the discussion of the sarcomas in the familial syndrome, the lack of thorough histological review of these familial cases was noted. Newton encouraged a centralized review of these sarcomas to look for histological features that may serve as markers of hereditary forms of sarcoma. He had studied 250 cases with detailed family histories as part of the (U.S.) Intergroup Rhabdomyosarcoma Study, and found none with LFS. Only one case was expected in this series at the rate (1 in 200) observed by Li and Fraumeni (6).
Enjoji (Kyushu University) had studied the histopathology of soft-tissue sarcoma at his Institute for over 20 years, and found 107 children with these neoplasms. Fifty percent had rhabdomyosarcoma, and the second most common type was fibrosarcoma (160%). None of the 107 were noted to have LFS, but one infant with neurofibromatosis type 1 had a botryoid sarcoma of the vagina.
Radiosensitivity
Little (Harvard School of Public Health, Boston) reviewed his data on response of cultured fibroblasts to killing by ionizing radiation. In 4 affected patients from different families with the syndrome, no evidence of “radioresistance” was found to support a prior report of this phenomenon. In addition, no abnormal responses were found to ultra-violet radiation, mitomycin C or MNNG (an alkylating agent). A review of data from his laboratory on response to ionizing radiation shows a wide range of D₀ and D₁₀ values among 65 normal stains. Therefore, other reports of relative radioresistance in cancer cases might be due in part to the failure to appreciate the wide range of values that should be considered as within normal limits. The D₀ and D₁₀ values tend to be stable on repeat study, are independent of passage number, and show no correlation with age or sex of the patient. Dr. Little is studying cell lines from fresh skin biopsy specimens that have recently been obtained from the patient previously reported by others to be unusually “radioresistant”.
Somatic cell genetics
Yoshida (Hokkaido University) described the current state of knowledge about chromosomal rearrangements, localization of proto-oncogenes and other genes related to cancer. None have been associated yet with LFS.
Koufos (Ludwig Institute, Montreal) used Wilms’ tumor to illustrate the accumulating evidence for molecular heterogeneity of some human cancers. Wilms’ tumor is associated with a variety of birth defects. The association with aniridia led to cytogenetic and molecular studies showing a constitutional deletion of chromosome 11p13 in patients with both disorders. The same deletion has also been found in Wilms’ tumors from some patients without aniridia. In addition, Wilms’ tumor is associated in other patients with hemihypertrophy, a feature of the Beckwith-Wiedemann (B-W) syndrome. Koufos has shown linkage of B-W syndrome to chromosome 11q15, and evaluated whether tumors associated with B-W syndrome also show changes in that band. He had previously shown 11p15 deletion in three associated neoplasms (hepatoblastoma, ACC and rhabdomyosarcoma), and reported for the first time the same deletion in 5 of 40 Wilms’ tumors. In another study, linkage with chromosome 11p13 and 11p15 was excluded in a family with 7 cases of Wilms’ tumor. He concluded that two, perhaps three, loci may be involved in the development of Wilms’ tumor. The genetic basis of Wilms’ tumor appears therefore to be more complex than that of retinoblastoma.
Diverse soft tissue sarcomas also occur in neurofibromatosis, study of which might serve as a prototype for LFS. Korf (Children’s Hospital, Boston) reviewed the inherited syndromes that predispose to neural tumors and the current status of mapping genes for such disorders as neurofibromatosis type 1 (chromosome 17), neurofibromatosis type 2 (chromosome 22), multiple endocrine neoplasia (MEN) syndrome type 1 (chromosome 11), MEN type 2 (chromosome 10), and von Hippel-Lindau disease (chromosome 3). In neuroblastoma, n-myc is often amplified in double minutes and homogeneous staining regions visible in tumor chromosomes of patients with advanced stage disease, and is associated with poor prognosis. Chromosome 1p deletions are also found in neuroblastomas. He went on to discuss brain tumors. In childhood they tend to arise in the posterior fossa, and are predominantly cerebellar gliomas and medulloblastomas. Cytogenetic differences have been found by age of occurrence of brain tumors: +7, +19, and +20 in affected adults, and isochromosome 17 in some children.
General Discussion
In discussing the presentations it was noted that the goal in studying LFS is not to explain the cause of cancer in these rare families, but to uncover basic principles in human biology that can be applied to cancer in general. LFS involves a variety of cancers that are not explained by knowledge thus far of oncogenes or tumor suppressor genes (anti-oncogenes), ACC may provide a key because the neoplasm is rare except in LFS, and a high proportion of ACC occurs in families or with other primary cancers. The possibility of formes fruste of LFS was raised. Might familial occurrence of ACC, osteosarcoma or breast cancer be explained in this way? The question illustrated the need for a test or marker to identify persons with the syndrome, which is now recognized mostly in retrospect. It was noted that diverse cancers are induced by a single gene in neurofibromatosis, including tumors of the nerve sheath, brain, adrenal (pheochromocytoma), muscle, and blood (non-lymphocytic leukemia) (7). Also, exposure to ionizing radiation can induce many, but not all forms of human cancer (8), e.g., it is not known to induce ACC.
Opportunities were noted for further study of unusual histories of familial cancer described during the workshop, and it was suggested that an exchange of clinical scientists between the two countries could be of benefit to both.
To identify LFS families an efficient approach would be to seek pairs of sibs with rhabdomyosarcoma, ACC, or osteosarcoma for further study. Clinical participants in the workshop were urged to seek LFS families through data collected by collaborative treatment groups, general tumor registries and special disease registries, such as those in each country for a) hepatic cancer, looking for colonic polyposis or b) polyposis of the colon, looking for hepatoblastoma. Family histories of patients with Beckwith-Wiedemann syndrome would also be of interest because the syndrome predisposes to ACC. hepatoblastoma Wilms’ tumor. An attempt should be made to collect histologic specimens from LFS families of be evaluated for unusual features that distinguish the cancers in the syndrome from the same types of cancers in the population at large. Future laboratory research will be greatly aided by establishing both tumor and transformed lymphoblastoid cell lines.
References

1. Li, FP, Fraumeni JF, Jr. Soft-tissue sarcomas, breast cancer, and other neoplasms: A familial syndrome? Ann Intern Med 1969; 71:747-752.
   
2. Li, FP, Fraumeni JF, Jr. Prospective study of a familial cancer syndrome. JAMA 1982; 247:2692-2694.
   
3. Birch, JM, Hartley, AL, Marsden, HB, et al. Excess risk of breast cancer in the mothers of children with soft tissue sarcomas. Br J Cancer 1984; 49:325-331.
   
4. Hartley, AL, Birch JM, Marsden, HB, et al. Breast cancer risk in mothers of children with osteosarcoma and chondrosarcoma. Br J Cancer 1986; 54:819-823.
   
5. Hartley, AL, Birch, JM, Marsden, HB, et al. Malignant disease in the mothers of children with Ewing’s tumour. Med Pediatr Oncol 1988; 16:95-97.
   
6. Li, FP, Fraumeni, JF, Jr. Rhabdomyosarcoma in children: Epidemiologic study and identification of a familial cancer syndrome. J Natl Cancer Inst 1969; 43:1365-1373.
   
7. Hope DG, Mulvihill, JJ. Malignancy in neurofibromatosis. Adv Neurol 1981;29:33-55.
   
8. Kohn, HI, Fry, RJM. Radiation carcinogenesis. N Engl J Med 1984;504-511.

SEMINAR AGENDA AND PARTICIPANTS

(1) SEMINAR ON MELANOMA AND SKIN CANCER: BIOLOGY AND COMPARATIVE FEATURES IN THE US. AND JAPAN
Tokyo, Japan, November 13-15, 1987

AGENDA

Friday, November 13, 1987
9:00	Opening Remarks	Atsushi Kukita Thomas B. Fitzpatrick Robert W. Miller
I. EPIDEMIOLOGY AND COMPARATIVE ASPECTS Chairperson. Kowichi Jimbow
9:30	Comparison of biologic factors implicated in the development of melanoma in the US and Japan.	Margaret Tucker
	Clinical features and distribution of melanoma and pigmented nevi of the soles in Japanese.	Atsushi Kukita
	Coffee break
10:45	Factors underlying the divergent incidence of cutaneous melanoma in the east (Japan) and the west (United States and Western Europe)	Thomas B. Fitzpatrick
	Comparative aspects of melanoma and non-melanoma in Japan.	Shigeo Ikeda
	The melanoma problem in Asia and the West.	Mark Elwood
	Lunch
II. THE CELLULAR AND BASIC BIOLOGY OF MELANOMA Chairperson: Michael Wick
13:30	Melanin chemistry and melanin precursors in melanoma.	Shosuke Ito
	Gene-action-mediated interaction between melanocytes and epidermal cells.	Takuji Takeuchi
	Neural crest cell differentiation and carcinogenesis.	Jiro Matsumoto
	Coffee break
15:30	Comparative evolution of melanocytic atypism in Japanese and Caucasians: Premalignant melanocytic lesions and the development of’ melanoma in situ.	Martin C. Mihm
	The use of’ human epidermal cells for study of carcinogenesis.	Toshio Kuroki
	Porokeratosis as a precancerous condition on the skin. Cytological demonstration of abnormal DNA ploidy in cells of the epidermis.	Yasumasa Ishibashi
	Expression of!!!2-mlcroglobulin on the cell surface of malignant melanomas of the skin.	Takae Hirone
Saturday, November 14, 1987 III. PATHOGENESIS Chairperson: Thomas B. Fitzpatrick
9:00	Pigment cells and pigment cell tumors in fish.	Prince Masahito
	Environment; peculiar melanoma of fish.	Ikuo Kimura
	Exposure to ultraviolet irradiation, DNA damage, and skin cancer.	D. Martin Cater
	Coffee break
10:45	In vivo studies on DNA repair in the skin.	Takatoshi Ishikawa
	Melanoma and other skin cancers in xeroderma pigmentosum patients, and mutation in their cells.	Hiraku Takebe
	Sister chromatid exchange-related characteristics of excision-proficient xeroderma pigmentosum cells.	Atushi Okikawa
	Lunch
13:15	Immunology: Immunosurveillance and melanoma.	Jean-Ciaude Bystryn
	Genomic cloning of DNA controlling expression of mouse melanoma antigen and transforming activity.	Masaru Taniguchi
	Oncogenes in pigment cell neoplasms.	Takao Sekiya
	Coffee break
IV. BIOLOGY OF PRECURSOR LESIONS AND EARLY DIAGNOSIS Chairperson: Atsushi Kukita
15:00	Nature and significance of dysplastic melanocytic nevi (DMN).	David E. Elder
	Dysplastic melanocytic nevus in Japanese and their fine structural and immunohistochemical properties.	Kowichi Jimbow
	Giant pigmented nevi and malignant melanoma.	Yoshiaki Hori
	A case of proliferating giant pigmented nevus.	Tatsuyoshi Arao
19:00	Seminar Dinner
Sunday, November 15, 1987 IV. METHODS OF CONTROL AND TREATMENT Chairpeson: Yoshiaki Hori
9:00	Cutaneous melanoma in Japan and the United States: Comparative prognostic factors.	Arthur J. Sober
	Interferon, Interleukin-2 and other BRM in melanoma.	Kazuyuki Ishihara
	Immune-based therapy of melanoma.	DuPont Guerry
	Coffee break
10:45	Chemotherapy: Reducing agents as controllers of replication in melanoma.	Michael Wick
	Selective thermal neutron capture therapy and diagnosis of malignant melanoma using its specific metabolic activity.	Yutaka Mishima
11:45	Summation and closing remarks	Michael Wick Kowichi Jimbow Haruo Sugano