Comparative Effectiveness and Durability of Biologics in Clinical Practice: Month 12 Outcomes from the International, Observational Psoriasis Study of Health Outcomes (PSoHO)

INTRODUCTION

Given the chronic nature of psoriasis (PsO), more studies are needed that directly compare the effectiveness of different biologics over long observation periods. This study compares the effectiveness and durability through 12 months of anti-interleukin (IL)-17A biologics relative to other approved biologics in patients with moderate-to-severe psoriasis in a real-world setting.

METHODS

The Psoriasis Study of Health Outcomes (PSoHO) is an ongoing 3-year, prospective, non-interventional cohort study of 1981 adults with chronic moderate-to-severe plaque psoriasis initiating or switching to a new biologic. The study compares the effectiveness of anti-IL-17A biologics with other approved biologics and provides pairwise comparisons of seven individual biologics versus ixekizumab. The primary outcome was defined as the proportion of patients who had at least a 90% improvement in Psoriasis Area and Severity Index score (PASI90) and/or a score of 0 or 1 in static Physician Global Assessment (sPGA). Secondary objective comparisons included the proportion of patients who achieved PASI90, PASI100, a Dermatology Life Quality Index (DLQI) score of 0 or 1, and three different actions of durability of treatment response. Unadjusted response rates are presented alongside the primary analysis, which uses frequentist model averaging (FMA) to evaluate the adjusted comparative effectiveness.

RESULTS

Compared to the other biologics cohort, the anti-IL-17A cohort had a higher response rate (68.0% vs. 65.1%) and significantly higher odds of achieving the primary outcome at month 12. The two cohorts had similar response rates for PASI100 (40.5% and 37.1%) and PASI90 (53.9% and 51.7%) at month 12, with no significant differences between the cohorts in the adjusted analyses. At month 12, the response rates across the individual biologics were 53.5-72.6% for the primary outcome, 27.6-48.3% for PASI100, and 41.7-61.4% for PASI90.

CONCLUSIONS

These results show the comparative effectiveness of biologics at 6 and 12 months in the real-world setting.

TRIAL REGISTRATION

ClinicalTrials.gov identifier EUPAS24207.

Speed of clinical improvement in the real-world setting from patient-reported Psoriasis Symptoms and Signs Diary: Secondary outcomes from the Psoriasis Study of Health Outcomes through 12 weeks

BACKGROUND

Rapid skin improvement is a key treatment goal of patients with moderate-to-severe psoriasis (PsO).

OBJECTIVES

To compare the speed of clinical improvement of approved biologics on the symptoms and signs of psoriasis assessed by patients using the validated Psoriasis Symptoms and Signs Diary (PSSD) through 12 weeks.

METHODS

Psoriasis Study of Health Outcomes (PSoHO) is an international, prospective, non-interventional study that compares the effectiveness of anti-interleukin (IL)-17A biologics versus other biologics, together with pairwise comparisons of ixekizumab versus five individual biologics in patients with PsO. Using the PSSD 7-day recall period, patients assessed the symptoms (itch, skin tightness, burning, stinging and pain) and signs (dryness, cracking, scaling, shedding/flaking, redness and bleeding) of their psoriasis (0-10). Symptom and sign summary scores (0-100) are derived from the average of individual scores. Percentage change in summary scores and proportion of patients with clinically meaningful improvements (CMI) in PSSD summary and individual scores are evaluated weekly. Longitudinal PSSD data are reported as observed with treatment comparisons analysed using mixed model for repeated measures (MMRM) and generalized linear mixed models (GLMM).

RESULTS

Across cohorts and treatments, eligible patients (n = 1654) had comparable baseline PSSD scores. From Week 1, the anti-IL-17A cohort achieved significantly larger score improvements in PSSD summary scores and a higher proportion of patients showed CMIs compared to the other biologics cohort through 12 weeks. Lower PSSD scores were associated with a greater proportion of patients reporting their psoriasis as no longer impacting their quality-of-life (DLQI 0,1) and a high level of clinical response (PASI100). Results also indicate a relationship between an early CMI in PSSD score at Week 2 and PASI100 score at Week 12.

CONCLUSIONS

Treatment with anti-IL-17A biologics, particularly ixekizumab, resulted in rapid and sustained patient-reported improvements in psoriasis symptoms and signs compared with other biologics in a real-world setting.

Pregnancy outcomes in patients with psoriasis, psoriatic arthritis, or axial spondyloarthritis receiving ixekizumab

BACKGROUND

Psoriasis, psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) are chronic inflammatory diseases that often affect women of childbearing age. Detailed information about pregnancy and related outcomes across these indications in patients exposed to ixekizumab is lacking.

OBJECTIVES

To evaluate pregnancy outcomes after maternal or paternal exposure to ixekizumab in patients with psoriasis, PsA, or axSpA.

METHODS

Pregnancy cases from clinical trials and post-marketing reports, associated with either maternal or paternal exposure to ixekizumab cumulatively through 22 March 2019, were identified in the Eli Lilly Global Safety Database and described separately.

RESULTS

One hundred and ninety-three ixekizumab-exposed pregnancies were identified. Maternal exposure occurred in 51.3% of pregnancies (clinical trials: n = 58; post-marketing: n = 41). The majority of paternal exposure pregnancies occurred in clinical trials (91 of 94). Live births were reported for 53.8 and 61.1% of known outcomes in maternal exposure pregnancies during clinical trials and post-marketing surveillance, respectively. No congenital malformations resulting from maternal exposure were reported in clinical trials: one case, not causally related to ixekizumab therapy, was recorded in the post-marketing setting.

CONCLUSIONS

This integrated safety analysis provides relevant information for clinicians treating patients with psoriasis, PsA, or axSpA with ixekizumab. No new safety signals were identified in patients receiving ixekizumab.

Pooled safety analysis of baricitinib in adult patients with atopic dermatitis from 8 randomized clinical trials

BACKGROUND

Janus kinase (JAK) inhibition is a new mode of action in atopic dermatitis (AD); clarity about drug class safety considerations in the context of AD is important. Baricitinib, an oral, reversible, selective inhibitor of JAK1/JAK2, is in late-stage development for adult patients with moderate-to-severe AD.

OBJECTIVE

To report pooled safety data for baricitinib in patients with moderate-to-severe AD in the clinical development program including long-term extension (LTE) studies.

METHODS

This analysis included patient-level safety data from six double-blinded, randomized, placebo-controlled studies (one phase 2 and five phase 3), one double-blinded, randomized, LTE study and one open-label LTE study, reported in three data sets: placebo-controlled, 2-mg - 4-mg extended and All-bari AD. Safety outcomes include treatment-emergent adverse events, adverse events of special interest and abnormal laboratory changes. Proportions of patients with events and incidence rates were calculated.

RESULTS

Data were collected for 2531 patients who were given baricitinib for 2247 patient-years (median duration 310 days). The frequency of serious infections, opportunistic infections and conjunctival disorders was low and similar between treatment groups in the placebo-controlled period. The most common serious infections were eczema herpeticum [n = 11, incidence rates (IR) = 0.5], cellulitis (n = 6, IR = 0.3) and pneumonia (n = 3, IR = 0.1). There were four opportunistic infections (IR = 0.2). No malignancies, gastrointestinal perforations, positively adjudicated cardiovascular events or tuberculosis were reported in the placebo-controlled period in baricitinib-treated patients. Frequency of herpes simplex was higher in the 4-mg group (6.1%) vs. the 2-mg (3.6%) and placebo group (2.7%); IRs in the extended data set (2-mg IR = 9.6; 4-mg IR = 14.5) were lower vs. the placebo-controlled data set (2-mg IR = 12.4; 4-mg IR = 21.3). In the All-bari AD data set, there were two positively adjudicated major adverse cardiovascular events (2-mg group): two venous thrombosis events (4-mg group) and one death.

CONCLUSION

This integrated safety analysis in patients with moderate-to-severe AD confirms the established safety profile of baricitinib.

Ixekizumab improves secondary lesional signs, pain and sexual health in patients with moderate-to-severe genital psoriasis

Background

Epithelial surface disruption in genital psoriatic lesions may manifest as erosions, fissures and/or ulcers, causing pain and significantly impacting a patient's sexual health.

Objective

To evaluate the impact of erosions, fissures and/or ulcers in genital psoriatic lesions on pain and sexual activity in patients with moderate‐to‐severe genital psoriasis (GenPs) and treatment responses to ixekizumab vs. placebo until Week 12.

Methods

This post hoc subgroup analysis of patients presenting with and without erosions, fissures and/or ulcers in genital lesions from a phase IIIb multicentre, randomized, double‐blind, placebo‐controlled study (IXORA‐Q; NCT02718898) in 149 adults with moderate‐to‐severe GenPs treated with subcutaneous ixekizumab (80 mg every 2 weeks; n = 75) or placebo (n = 74) evaluated outcomes for clinician‐rated GenPs severity (static Physician's Global Assessment of Genitalia; sPGA‐G) and patient‐reported genital pain and itch (Genital Psoriasis Symptoms Scale; GPSS) and sexual health (Genital Psoriasis Sexual Frequency Questionnaire; GenPs‐SFQ).

Results

At baseline, 38% (n = 57) of patients presented with genital erosions, fissures and/or ulcers independent of overall body surface area involvement (<10% or ≥10%). These signs were associated with higher scores for disease severity (sPGA‐G) and pain (GPSS) but not sexual health (GenPs‐SFQ). Complete resolution of these signs was observed in 62% of ixekizumab‐treated patients (25% for placebo) at Week 1 and 83% (21% for placebo) at Week 12. Patients treated with ixekizumab reported significant improvements in pain, itch, disease severity and sexual health over 12 weeks compared to placebo and irrespective of the presence/absence of genital erosions, fissures and/or ulcers at baseline.

Conclusion

Ixekizumab led to rapid and sustained resolution of erosions, fissures and/or ulcers and significant improvements in GenPs severity, genital pain and sexual health. Ixekizumab may help to improve the well‐being of patients with GenPs.

Comments on ‘French guidelines on the use of systemic treatments for moderate‐to‐severe psoriasis in adults’

Linked article: F. Amatore et al. J Eur Acad Dermatol Venereol 2019; 33: 464–483. https://doi.org/10.1111/jdv.15340

Analysis of anti-tumour necrosis factor-induced skin lesions reveals strong T helper 1 activation with some distinct immunological characteristics

BACKGROUND

Psoriasiform and eczematous eruptions are the most common dermatological adverse reactions linked to anti-tumour necrosis factor (TNF)-α therapy. Yet, a detailed characterization of their immune phenotype is lacking.

OBJECTIVES

To characterize anti-TNF-α-induced inflammatory skin lesions at a histopathological, cellular and molecular level, compared with psoriasis, eczema (atopic dermatitis) and healthy control skin.

METHODS

Histopathological evaluation, gene expression (quantitative real-time polymerase chain reaction) and computer-assisted immunohistological studies (TissueFAXS) were performed on 19 skin biopsies from patients with inflammatory bowel disease (n = 17) and rheumatoid arthritis (n = 2) with new-onset inflammatory skin lesions during anti-TNF-α-therapy.

RESULTS

Although most biopsies showed a psoriasiform and/or spongiotic (eczematous) histopathological architecture, these lesions were inconsistent with either psoriasis or eczema on a molecular level using an established chemokine (C-C motif) ligand 27/inducible nitric oxide synthase classifier. Despite some differences in immune skewing depending on the specific histopathological reaction pattern, all anti-TNF-α-induced lesions showed strong interferon (IFN)-γ activation, at higher levels than in psoriasis or eczema. IFN-γ was most likely produced by CD3/CD4/Tbet-positive T helper 1 lymphocytes.

CONCLUSIONS

New-onset anti-TNF-α-induced eruptions previously classified as psoriasis or spongiotic dermatitis (eczema) exhibit a molecular profile that is different from either of these disorders.

Tildrakizumab (MK-3222), an anti-interleukin-23p19 monoclonal antibody, improves psoriasis in a phase IIb randomized placebo-controlled trial

BACKGROUND

Tildrakizumab is a high-affinity, humanized, IgG1/κ, anti-interleukin (IL)-23p19 monoclonal antibody that does not bind human IL-12 or p40 is being developed for the treatment of chronic plaque psoriasis.

OBJECTIVES

To evaluate the safety and efficacy of subcutaneous tildrakizumab in patients with moderate-to-severe chronic plaque psoriasis.

METHODS

A three-part, randomized, double-blind, phase IIb trial was conducted in 355 adults with chronic plaque psoriasis. Participants were randomized to receive subcutaneous tildrakizumab (5, 25, 100, 200 mg) or placebo at weeks 0 and 4 (part I) and every 12 weeks thereafter until week 52 (part II). Study drug was discontinued at week 52 and participants were followed through week 72 (part III). Primary efficacy end point was Psoriasis Area and Severity Index (PASI) 75 response at week 16. Adverse events (AEs) and vital signs were monitored throughout the study.

RESULTS

At week 16, PASI 75 responses were 33·3% (n = 14), 64·4% (n = 58), 66·3% (n = 59), 74·4% (n = 64) and 4·4% (n = 2) in the 5-, 25-, 100- and 200-mg tildrakizumab and placebo groups, respectively (P ≤ 0·001 for each tildrakizumab dose vs. placebo). PASI 75 response was generally maintained through week 52; only eight of 222 participants who achieved PASI 75 response at week 52 and continued to part III relapsed following discontinuation up to week 72. Possible drug-related serious AEs included bacterial arthritis and lymphoedema (part I), and melanoma, stroke, epiglottitis and knee infection (part II).

CONCLUSIONS

Tildrakizumab had treatment effects that were superior to placebo, maintained for 52 weeks of treatment, and persisted for 20 weeks after cessation. Tildrakizumab was generally safe and well tolerated. These results suggest that IL-23p19 is a key target for suppressing psoriasis.

Carnosine treatment in combination with ACE inhibition in diabetic rats

In humans, we reported an association of a certain allele of carnosinase gene with reduced carnosinase activity and absence of nephropathy in diabetic patients. CN1 degrades histidine dipeptides such as carnosine and anserine. Further, we and others showed that treatment with carnosine improves renal function and wound healing in diabetic mice and rats. We now investigated the effects of carnosine treatment alone and in combination with ACE inhibition, a clinically established nephroprotective drug in diabetic nephropathy. Male Sprague-Dawley rats were injected i.v. with streptozotocin (STZ) to induce diabetes. After 4 weeks, rats were unilaterally nephrectomized and randomized for 24 weeks of treatment with carnosine, lisinopril or both. Renal CN1 protein concentrations were increased under diabetic conditions which correlated with decreased anserine levels. Carnosine treatment normalized CN1 abundance and reduced glucosuria, blood concentrations of glycosylated hemoglobin (HbA1c), carboxyl-methyl lysine (CML), N-acetylglucosamine (GlcNac; all p<0.05 vs. non-treated STZ rats), reduced cataract formation (p<0.05) and urinary albumin excretion (p<0.05), preserved podocyte number (p<0.05) and normalized the increased renal tissue CN1 protein concentration. Treatment with lisinopril had no effect on HbA1C, glucosuria, cataract formation and CN1 concentration, but reduced albumin excretion rate more effectively than carnosine treatment (p<0.05). Treatment with both carnosine and lisinopril combined the effects of single treatment, albeit without additive effect on podocyte number or albuminuria. Increased CN1 amount resulted in decreased anserine levels in the kidney. Both carnosine and lisinopril exert distinct beneficial effects in a standard model of diabetic nephropathy. Both drugs administered together combine the respective effects of single treatment, albeit without exerting additive nephroprotection.

Enzyme-linked immunosorbent assay for detection of peptide-specific human antidesmoplakin autoantibodies

BACKGROUND

Autoantibodies directed against desmoplakin (Dp) I and II have recently been characterized in a subset of patients with severe erythema multiforme (EM), a recurrent inflammatory skin disease with a broad spectrum of clinical manifestations. These autoantibodies recognize a peptide epitope localized within the extreme end of the carboxy terminal domain of Dp responsible for the assembly of keratin filaments to the desmosomal plaque. Using dot blot analysis with overlapping synthetic peptides, the binding epitope YSYSYS has been identified.

OBJECTIVES

To establish an enzyme-linked immunosorbent assay (ELISA) for detection of peptide-specific anti-Dp autoantibodies in sera of patients with EM.

METHODS

A synthetic peptide containing the respective amino acid sequence was used as matrix for ELISA plates. Serum samples from patients with known EM and peptide-specific anti-Dp autoantibodies verified by immunoblotting, immunoprecipitation and epitope mapping were used.

RESULTS

Establishing an index value of 42.0, 25 of 25 serum samples from five patients with peptide-specific anti-Dp autoantibodies were positive in the ELISA. From control sera, none of 31 bullous disease sera and only one (1.2%) of 83 normal human sera were positive.

CONCLUSIONS

These data show that the ELISA presented in this study represents a sensitive and highly specific tool for the detection of peptide-specific anti-Dp autoantibodies in patients with EM.

[Retrospective evaluation of surgically treated cases of non-palpable breast tumor]

Between 10.01.1997 and 09.30.1999 authors performed operations on 78 patients who had nonpalpable breast tumors. If mammography was considered abnormal during breast screening program patients were recalled. Besides clinical investigation complimentary mammograms were performed. After sonogram, and if needed, aspiration biopsy cytology (ABC) if necessary core biopsy (CB) was the next investigation. 79 operations were performed on 78 patients (one was patient had synchronous breast tumor). The mean age of the patients was 56.3 years. If the radiological investigations (R4-R5) and/or the ABC (C4-C5) or CB suggested malignancy operation was performed. Mammography suggested malignancy in 60.75% of the patients, it was suggested by ABC in 30.18%, and by CB in 55.5%. The nonpalpable tumor, suspected to be malignant was marked with a wire loop and was excised under anesthesia along with the affected breast sector. The excision and tissue-border around the tumor was checked by specimen mammography performed during the narcosis. No cryohistology was performed. After the specimen mammography, the wound was closed. The final histology of the operations showed malignancy in 40.5%. In their retrospective study the authors evaluated the complete sensitivity and the positive predictive value (PPV) of the preoperative investigations regarding the final histology. They analyse the value of preoperative mammogram, the ABC and CB in malignant and in benign cases. Early diagnosis and surgical treatment is expected to improve significantly the survival of patients with breast cancer. Reduction in the number of unnecessary operations can be expected from increasing the accuracy of radiological and cytological investigations and the adequate usage of core biopsy.

The role of STIR MRI sequence in the evaluation of the breast following conservative surgery and radiotherapy

The purpose of the study was to define the value of fat suppressed STIR sequence in the MRI of the conserved breast. To our knowledge, this study is the first clinical evaluation of STIR sequence in post-therapy conditions. Forty patients with early (T1-2, N0-1) invasive breast cancer underwent conservative surgery and postoperative radiotherapy. Routine follow-up examinations, including physical examination and mammography were supplemented with breast MRI in all cases 6-166 months (mean 27.6) after initial treatments. Three patients had bilateral cancer. Including follow-up (9 patients) MRI examinations, altogether 53 MRIs were available for analysis. An 0.5 T MRI (Elscint, Haifa, Israel) was used with double breast coil. Axial T1 and T2 weighted spin echo, STIR and 3D gradient echo dynamic sequences were performed. Pre- and postcontrast slices underwent serial subtraction. Twenty-eight circumscribed lesions were identified. All were well visualised on STIR sequence, regardless of histologic nature of lesions. One low grade DCIS was not detected by any sequence. Differential diagnosis between benign and malignant lesions was not possible by STIR sequence alone. STIR sequence was found to be more sensitive in the detection of treatment related breast edema and fluid collection, than T2 SE (spin-echo) sequence. Even the patients who were not good candidates for subtracted contrast enhanced dynamic studies - because of motion artefacts - could have been examined with satisfactory results. STIR is a very sensitive sequence for depicting circumscribed lesions and post-therapy complications, but not suitable for differentiation. It is a useful tool in the follow-up of patients with conserved breast subjected to radiotherapy.

Ligation of E-cadherin on in vitro-generated immature Langerhans-type dendritic cells inhibits their maturation

Epithelial tissues of various organs contain immature Langerhans cell (LC)-type dendritic cells, which play key roles in immunity. LCs reside for long time periods at an immature stage in epithelia before migrating to T-cell-rich areas of regional lymph nodes to become mature interdigitating dendritic cells (DCs). LCs express the epithelial adhesion molecule E-cadherin and undergo homophilic E-cadherin adhesion with surrounding epithelial cells. Using a defined serum-free differentiation model of human CD34(+) hematopoietic progenitor cells, it was demonstrated that LCs generated in vitro in the presence of transforming growth factor beta1 (TGF-beta1) express high levels of E-cadherin and form large homotypic cell clusters. Homotypic LC clustering can be inhibited by the addition of anti-E- cadherin monoclonal antibodies (mAbs). Loss of E-cadherin adhesion of LCs by mechanical cluster disaggregation correlates with the rapid up-regulation of CD86, neo-expression of CD83, and diminished CD1a cell surface expression by LCs-specific phenotypic features of mature DCs. Antibody ligation of E-cadherin on the surfaces of immature LCs after mechanical cluster disruption strongly reduces the percentages of mature DCs. The addition of mAbs to the adhesion molecules LFA-1 or CD31 to parallel cultures similarly inhibits homotypic LC cluster formation, but, in contrast to anti-E-cadherin, these mAbs fail to inhibit DC maturation. Thus, E-cadherin engagement on immature LCs specifically inhibits the acquisition of mature DC features. E-cadherin-mediated LC maturation suppression may represent a constitutive active epithelial mechanism that prevents the uncontrolled maturation of immature LCs. (Blood. 2000;96:4276-4284)

Functional involvement of E-cadherin in TGF-beta 1-induced cell cluster formation of in vitro developing human Langerhans-type dendritic cells

Epithelial Langerhans cells (LC) represent immature dendritic cells that require TGF-beta 1 stimulation for their development. Little is known about the mechanisms regulating LC generation from their precursor cells. We demonstrate here that LC development from human CD34+ hemopoietic progenitor cells in response to TGF-beta 1 costimulation (basic cytokine combination GM-CSF plus TNF-alpha, stem cell factor, and Flt3 ligand) is associated with pronounced cell cluster formation of developing LC precursor cells. This cell-clustering phenomenon requires hemopoietic progenitor cell differentiation, since it is first seen on day 4 after culture initiation of CD34+ cells. Cell cluster formation morphologically indicates progenitor cell development along the LC pathway, because parallel cultures set up in the absence of exogenous TGF-beta 1 fail to form cell clusters and predominantly give rise to monocyte, but not LC, development (CD1a-, lysozyme+, CD14+). TGF-beta 1 costimulation of CD34+ cells induces neoexpression of the homophilic adhesion molecule E-cadherin in the absence of the E-cadherin heteroligand CD103. Addition of anti-E-cadherin mAb or mAbs to any of the constitutively expressed adhesion molecule (CD99, CD31, LFA-1, or CD18) to TGF-beta 1-supplemented progenitor cell cultures inhibits LC precursor cell cluster formation, and this effect is, with the exception of anti-E-cadherin mAb, associated with inhibition of LC generation. Addition of anti-E-cadherin mAb to the culture allows cell cluster-independent generation of LC from CD34+ cells. Thus, functional E-cadherin expression and homotypic cell cluster formation represent a regular response of LC precursor cells to TGF-beta 1 stimulation, and cytoadhesive interactions may modulate LC differentiation from hemopoietic progenitor cells.

[Reexcision and perioperative brachytherapy in the treatment of local relapse after breast conservation: a possible alternative to mastectomy]

Breast conserving surgery and postoperative radiotherapy became widely accepted in the last two decades for the treatment of early invasive breast cancer. In spite of adequate surgery and radiotherapy, the rate of ipsilateral breast tumor recurrence is approximately 10%. In such cases salvage mastectomy is the standard treatment, however wide reexcision of the recurrent tumor is also a reasonable option for selected patients. The risk of second local relapse is higher following further breast conservation compared to mastectomy. The authors report the technique of tumor reexcision combined with intraoperative implantation and perioperative high dose rate (HDR) bracytherapy of the tumor bed for the salvage of recurrence in a previously irradiated breast. One can perform two operative interventions at the same time with this method. Irradiation can be started safely within 48 hours after surgery. A review of the literature is also performed by the authors to demonstrate the role and indication of perioperative brachytherapy in the treatment of breast tumor relapse and other cancer recurrences. Reexcision is a practicable alternative to mastectomy for solitary, parenchymal breast tumor relapse measured 2 cm or less in diameter. Perioperative brachytherapy may decrease the risk of second relapse without increasing radiation side effects. Further prospective study is required to define the value of the prescribed method in comparison with salvage mastectomy.

[Radiologic follow-up after breast-conserving surgery: value of MRI examination of the breast]

The aim of the study was to establish an objective method for evaluation the extent, topography and quantity of skin and soft tissue side effects after tele- and/or brachyradiotherapy of the conserved breast and to compare the sequales of different radiation methods. 26 patients operated on for T1-2 N0-1 breast cancer underwent the following kinds of postoperative radiotherapy: 1. 46-50 Gy whole breast teletherapy + 10-16 Gy electron boost (5 patients), 2. 46-50 Gy teletherapy + 10-15 Gy HDR brachytherapy boost (12 patients), 3. 46-50 Gy teletherapy (6 patients), 4. 36,4 Gy sole HDR brachytherapy of the tumour bed (5 patients). The postirradiation side effects were examined by MRI, mammogram, US and physical examination, as well. MRI was performed on a 0.5 T, double breast coil, with SE-T1, SE-T2 and 3D-GE sequences. The findings of MRI and mammography were compared to physically detectable side effects using the RTOG/EORTC late radiation morbidity scoring scheme. US is useful in the measurement of skin thickening and in the diagnosis of fat necrosis. Mammography and physical examination are very subjective and low specificity methods to evaluate postirradiation side effects. MRI is a suitable and more objective method to detect the real extent and quantity of skin thickening and fibrosis. The incidence of > or = G2 side effects of skin and breast parenchyma were 64.5 and 32.2%, respectively. The differences between the side effects of whole breast irradiation and sole brachytherapy of the tumour bed are also clearly demonstrated. Brachytherapy alone is feasible without compromising cosmetic results. The authors established the MRI criteria for categorization the extent and grade of skin thickening and fibrosis (focal vs diffuse, grade 1-4). Breast MRI is an objective tool for assisting to the evaluation of the side effects of postoperative radiotherapy.

Identification of CD68+lin- peripheral blood cells with dendritic precursor characteristics

Expression of CD68 (macrosialin) in the absence of surface and lysosomal lineage marker molecules is a characteristic feature of T zone-associated plasmacytoid monocytes, which were recently shown to represent precursors of dendritic cells (DC). We demonstrate here a minor population of strongly CD68-positive (CD68bright) blood cells that lack all analyzed myeloid surface (CD14-, CD33-, CD13-, CD11b-, CD11c-) and lysosomal (myeloperoxidase, MPO- and lysozyme, LZ-) marker molecules (0.4 +/- 2% of the total mononuclear cells). These CD68bright, lineage marker-negative (lin-) cells can be induced to proliferate in the presence of IL-3. They do not acquire myeloid features even upon stimulation with granulocyte-macrophage CSF plus IL-1, IL-3, and IL-6. Instead, these cells develop typical DC characteristics upon culture. Furthermore, these CD68brightlin- DC precursors acquire mature DC characteristics (CD86+, CD83+, CD54bright) upon stimulation with CD40 ligand plus IL-3. A second subset of DC precursor-like blood cells was found to weakly express CD68 (0.3 +/- 0.2% of the total mononuclear cells) and to coexpress several myeloid lineage associated molecules (LZ+, CD11c+, CD33+, CD13+). Cells of this second subset resemble both previously described myeloid-related peripheral blood DC and germinal center DC. Analysis of peripheral blood leukocytes for CD68 thus revealed the existence of two cell subsets that phenotypically resemble lymphoid tissue-associated DC. The unique phenotype CD68brightlin- is highly reminiscent of T zone-associated plasmacytoid monocytes. CD68brightlin- blood leukocytes also functionally resemble plasmacytoid monocytes. The lack of all analyzed myeloid features by CD68brightlin- blood leukocytes suggests that these cells arise from a novel nonmyeloid human DC differentiation pathway.

Neutrophil granulocyte-committed cells can be driven to acquire dendritic cell characteristics

Polymorphonuclear granulocytes (PMNs) are thought to fulfill their role in host defense primarily via phagocytosis and release of cytotoxic compounds and to be inefficient in antigen presentation and stimulation of specific T cells. Dendritic cells (DCs), in contrast, are potent antigen-presenting cells with the unique capacity to initiate primary immune responses. We demonstrate here that highly purified lactoferrin-positive immediate precursors of end-stage neutrophilic PMN (PMNp) can be reverted in their functional maturation program and driven to acquire characteristic DC features. Upon culture with the cytokine combination granulocyte/macrophage colony-stimulating factor plus interleukin 4 plus tumor necrosis factor alpha, they develop DC morphology and acquire molecular features characteristic for DCs. These molecular changes include neo-expression of the DC-associated surface molecules cluster of differentiation (CD)1a, CD1b, CD1c, human leukocyte antigen (HLA)-DR, HLA-DQ, CD80, CD86, CD40, CD54, and CD5, and downregulation of CD15 and CD65s. Additional stimulation with CD40 ligand induces also expression of CD83 and upregulates CD80, CD86, and HLA-DR. The neutrophil-derived DCs are potent T cell stimulators in allogeneic, as well as autologous, mixed lymphocyte reactions (MLRs), whereas freshly isolated neutrophils are completely unable to do so. In addition, neutrophil-derived DCs are at least 10,000 times more efficient in presenting soluble antigen to autologous T cells when compared to freshly isolated monocytes. Also, in functional terms, these neutrophil-derived DCs thus closely resemble "classical" DC populations.

Epidermal Langerhans cell development and differentiation

Epidermal Langerhans cells (LC) play a critical role in host defense. Still we know rather little about the development and functional specialization of these bone marrow-derived dendritic cells (DC) located in the most peripheral ectodermal tissue of the mammalian organism. How LC develop from their primitive progenitors in bone marrow and to what extent LC are related in their development to other lineages of the hemopoietic system is still under debate. There are currently 3 major areas of debate: 1) which are the signals required for LC development and differentiation to occur, 2) what are the (molecular) characteristics of the intermediate stages of LC differentiation, and 3) how are LC related in their development and/or function to other cells of the hemopoietic system? A better understanding of LC development and answers to these questions can be expected from recently developed technologies which allow the in vitro generation of DC with the typical molecular, morphological and functional features of LC from purified CD34+ progenitor cells under defined serum-free culture conditions. TGF-beta 1 was found to be an absolute requirement for in vitro LC development under serum-free conditions upon stimulation with the classical DC growth and differentiation factors GM-CSF, TNF-alpha and SCF. The recently identified cytokine FLT3 ligand further dramatically enhanced in vitro LC development and even allowed efficient in vitro generation of LC colonies from serum-free single cell cultures of CD34+ hemopoietic progenitor cells.

flt3 ligand in cooperation with transforming growth factor-beta1 potentiates in vitro development of Langerhans-type dendritic cells and allows single-cell dendritic cell cluster formation under serum-free conditions

Using a recently described serum-free culture system of purified human CD34+ progenitor cells, we show here a critical cooperation of flt3 ligand (FL) with transforming growth factor-beta1 (TGF-beta1) in the induction of in vitro dendritic cell/Langerhans cell (DC/LC) development. The addition of FL to serum-free cultures of CD34+ cells supplemented with TGF-beta1, granulocyte-macrophage colony-stimulating factor, tumor necrosis factor alpha, and stem cell factor strongly increases both percentages (mean, 36% +/- 5% v 64% +/- 4%; P = .001) and total numbers (4.4- +/- 0.8-fold) of CD1a+ dendritic cells. These in vitro-generated CD1a+ cells molecularly closely resemble a particular type of DC known as an epidermal Langerhans cell. Generation of DC under serum-free conditions was found to strictly require supplementation of culture medium with TGF-beta1. Upon omission of TGF-beta1, percentages of CD1a+ DC decreased (to mean, 10% +/- 8%; P = .001) and, in turn, percentages of granulomonocytic cells (CD1a- cells that are lysozyme [LZ+]; myeloperoxidase [MPO+]; CD14+) increased approximately threefold (P < .05). Furthermore, in the absence of TGF-beta1, FL consistently promotes generation of LZ+, MPO+, and CD14+ cells, but not of CD1a+ cells. Serum-free single-cell cultures set up under identical TGF-beta1- and FL-supplemented culture conditions showed that high percentages of CD34+ cells (mean, 18% +/- 2%; n = 4) give rise to day-10 DC colony formation. The majority of cells in these DC-containing colonies expressed the Langerhans cell/Birbeck granule specific marker molecule Lag. Without TGF-beta1 supplementation, Lag+ colony formation is minimal and formation of monocyte/macrophage-containing colonies predominates. Total cloning efficiency in the absence and presence of TGF-beta1 is virtually identical (mean, 41% +/- 6% v 41% +/- 4%). Thus, FL has the potential to strongly stimulate DC/LC generation, but has a strict requirement for TGF-beta1 to show this costimulatory effect.

Expression of Wiskott-Aldrich syndrome protein (WASP) gene during hematopoietic differentiation

The Wiskott-Aldrich syndrome (WAS) is an X-linked recessive disorder described as a clinical triad of thrombocytopenia, eczema, and immunodeficiency. The gene responsible for WAS encodes a 502-amino acid proline-rich protein (WASp) that is likely to play a role in the cytoskeleton reorganization and/or in signal transduction of hematopoietic cells. However, the function and the regulation of the WAS gene (WASP) have not yet been clearly defined. We have studied WASP expression at the transcriptional level in freshly isolated mature peripheral blood cells and during hematopoietic development. For this purpose, we have isolated CD34+ hematopoietic precursor cells from cord blood. These cells were cultured in vitro with various growth factors to generate committed or mature cells belonging to different hematopoietic differentiation pathways, such as granulocytic (CD15+) cells, monocytic (CD14+) cells, dendritic (CD1a+) cells, erythroid lineage (glycophorin A+) cells, and megakaryocytic cells (CD41+). We have shown by reverse transcriptase polymerase chain reaction analysis that the WASP transcript is ubiquitously detectable throughout differentiation from early hematopoietic progenitors, including CD34+CD45RA- and CD34+CD45RA+ cells, to cells belonging to different hematopoietic lineages, including erythroid-committed and dendritic cells. In addition, Northern blot analysis showed that peripheral blood circulating lymphocytes (CD3+ and CD19+ cells) and monocytes express WASP mRNA. Several hematopoietic cell lines were tested and higher levels of expression were consistently detected in myelomonocytic cell types. By contrast, primary nonhematopoietic cells, including fibroblasts, endothelial cells, and keratinocytes, were consistently negative for WASP mRNA.

TGF-beta 1 promotes in vitro generation of dendritic cells by protecting progenitor cells from apoptosis

Our previous studies demonstrated that TGF-beta 1 is required for efficient in vitro generation of dendritic cells (DC) from CD34+ progenitor cells under serum-free conditions. Here we show that TGF-beta 1 promotes the growth and differentiation of DC primarily by protecting the viability of DC precursors and not by enhancing their proliferative response. Addition of TGF-beta 1 to TNF-alpha, granulocyte-macrophage CSF, and stem cell factor-supplemented cultures had no significant effect on the proportions of cycling cells. Already at 72 h of culture, however, the proportion of apoptotic cells was reduced by more than 60% in the presence of TGF-beta 1. This early protective effect of TGF-beta 1 correlates with the outgrowth of higher numbers and proportions of CD1a+ DC at day 7 of culture. It also correlates with a significantly reduced Fas/APO-1 expression on TGF-beta 1 cultured cells. In contrast, granulomonocytic cells, also arising under these culture conditions, are not affected to such an extent. They are found at equal proportions, both in the presence and absence of TGF-beta 1. The striking DC growth-promoting effect of TGF-beta 1 could only be observed when both TGF-beta 1 and TNF-alpha were present in the cultures. TGF-beta 1, in the absence of TNF-alpha, rather inhibited than enhanced cell expansion. Thus, for optimal in vitro DC development to occur, all four cytokines must obviously act in concert and the combination of TGF-beta 1 with TNF-alpha seems to be particularly critical.

TGF-beta 1 promotes in vitro generation of dendritic cells by protecting progenitor cells from apoptosis

Our previous studies demonstrated that TGF-beta 1 is required for efficient in vitro generation of dendritic cells (DC) from CD34+ progenitor cells under serum-free conditions. Here we show that TGF-beta 1 promotes the growth and differentiation of DC primarily by protecting the viability of DC precursors and not by enhancing their proliferative response. Addition of TGF-beta 1 to TNF-alpha, granulocyte-macrophage CSF, and stem cell factor-supplemented cultures had no significant effect on the proportions of cycling cells. Already at 72 h of culture, however, the proportion of apoptotic cells was reduced by more than 60% in the presence of TGF-beta 1. This early protective effect of TGF-beta 1 correlates with the outgrowth of higher numbers and proportions of CD1a+ DC at day 7 of culture. It also correlates with a significantly reduced Fas/APO-1 expression on TGF-beta 1 cultured cells. In contrast, granulomonocytic cells, also arising under these culture conditions, are not affected to such an extent. They are found at equal proportions, both in the presence and absence of TGF-beta 1. The striking DC growth-promoting effect of TGF-beta 1 could only be observed when both TGF-beta 1 and TNF-alpha were present in the cultures. TGF-beta 1, in the absence of TNF-alpha, rather inhibited than enhanced cell expansion. Thus, for optimal in vitro DC development to occur, all four cytokines must obviously act in concert and the combination of TGF-beta 1 with TNF-alpha seems to be particularly critical.

Molecular and functional characteristics of dendritic cells generated from highly purified CD14+ peripheral blood monocytes

Dendritic cells (DC) are the most potent APCs within the immune system. We show here that highly purified CD14(bright) peripheral blood monocytes supplemented with granulocyte-monocyte (GM)-CSF plus IL-4 develop with high efficacy (&gt;95% of input cells) into DC. They neo-expressed CD1a, CD1b, CD1c, CD80, and CD5; they massively up-regulated CD40 (109-fold) and HLA-DQ and DP (125- and 87-fold); and significantly (&gt;5-fold) up-regulated HLA-DR, CD4, CD11b, CD11c, CD43, CD45, CD45R0, CD54, CD58, and CD59. CD14, CD15s, CD64, and CDw65 molecules were down-regulated to background levels, and no major changes were observed for HLA class I, CD11a, CD32, CD33, CD48, CD50, CD86, CDw92, CD93, or CD97. Monocytes cultured in parallel with GM-CSF plus TNF-alpha were more heterogeneous in expression densities but otherwise similar in their surface molecule repertoire. They clearly differed, however, in their accessory cell capacity. Only GM-CSF plus IL-4-cultured cells were found to be potent stimulators in allogeneic and autologous MLR and they presented tetanus toxoid 100- to 1000-fold more efficiently than other cell populations tested. Furthermore, only cytokine-treated monocytes formed clusters with resting T cells. At variance from all these similarities between in vitro-generated monocyte-derived DC and in vivo-developing DC, the DC populations generated by us contained significant amounts of myeloperoxidase and also expressed lysozyme. At least in this respect they, thus, differ from "classical" DC types.

Molecular and functional characteristics of dendritic cells generated from highly purified CD14+ peripheral blood monocytes

Dendritic cells (DC) are the most potent APCs within the immune system. We show here that highly purified CD14(bright) peripheral blood monocytes supplemented with granulocyte-monocyte (GM)-CSF plus IL-4 develop with high efficacy (>95% of input cells) into DC. They neo-expressed CD1a, CD1b, CD1c, CD80, and CD5; they massively up-regulated CD40 (109-fold) and HLA-DQ and DP (125- and 87-fold); and significantly (>5-fold) up-regulated HLA-DR, CD4, CD11b, CD11c, CD43, CD45, CD45R0, CD54, CD58, and CD59. CD14, CD15s, CD64, and CDw65 molecules were down-regulated to background levels, and no major changes were observed for HLA class I, CD11a, CD32, CD33, CD48, CD50, CD86, CDw92, CD93, or CD97. Monocytes cultured in parallel with GM-CSF plus TNF-alpha were more heterogeneous in expression densities but otherwise similar in their surface molecule repertoire. They clearly differed, however, in their accessory cell capacity. Only GM-CSF plus IL-4-cultured cells were found to be potent stimulators in allogeneic and autologous MLR and they presented tetanus toxoid 100- to 1000-fold more efficiently than other cell populations tested. Furthermore, only cytokine-treated monocytes formed clusters with resting T cells. At variance from all these similarities between in vitro-generated monocyte-derived DC and in vivo-developing DC, the DC populations generated by us contained significant amounts of myeloperoxidase and also expressed lysozyme. At least in this respect they, thus, differ from "classical" DC types.

TGF-beta 1 promotes in vitro development of dendritic cells from CD34+ hemopoietic progenitors

Several studies have demonstrated that dendritic cells (DC) can be generated in vitro from CD34+ hemopoietic progenitor cells. The growth requirements for these cells are poorly characterized, however. In particular, undefined serum/plasma components seem to significantly contribute to in vitro DC development. We report here that the cytokine combination granulocyte-macrophage CSF (GM-CSF) plus TNF-alpha and stem cell factor (SCF) commonly used for the in vitro generation of DC in serum/plasma-supplemented medium is, in the absence of serum supplementation, very inefficient in inducing DC development. We further demonstrate that supplementation with TGF-beta 1 is required for substantial DC development to occur in the absence of serum. Culture of CD34+ cells under serum-free conditions with TGF-beta 1 plus GM-CSF, TNF-alpha, and SCF strongly induces DC differentiation. This culture condition is even more efficient than culturing CD34+ cells with GM-CSF plus TNF-alpha and SCF in the presence of cord blood plasma. The proportions and total yields of cells with typical DC morphology and CD1a molecule expression are higher. The allostimulatory capacity of DC from TGF-beta 1-supplemented, cultures exceeds allostimulation by cells grown in plasma-containing medium. Substantial numbers (21 +/- 7%) of cells grown in TGF-beta 1-supplemented, but not plasma-supplemented, cultures express the Birbeck granule marker molecule Lag and display numerous Birbeck granules. Cells with distinct monocytic features are less frequently observed in TGF-beta 1-supplemented serum-free cultures. The addition of neutralizing anti-TGF-beta 1 Ab abrogates the observed TGF-beta 1 effects.

TGF-beta 1 promotes in vitro development of dendritic cells from CD34+ hemopoietic progenitors

Several studies have demonstrated that dendritic cells (DC) can be generated in vitro from CD34+ hemopoietic progenitor cells. The growth requirements for these cells are poorly characterized, however. In particular, undefined serum/plasma components seem to significantly contribute to in vitro DC development. We report here that the cytokine combination granulocyte-macrophage CSF (GM-CSF) plus TNF-alpha and stem cell factor (SCF) commonly used for the in vitro generation of DC in serum/plasma-supplemented medium is, in the absence of serum supplementation, very inefficient in inducing DC development. We further demonstrate that supplementation with TGF-beta 1 is required for substantial DC development to occur in the absence of serum. Culture of CD34+ cells under serum-free conditions with TGF-beta 1 plus GM-CSF, TNF-alpha, and SCF strongly induces DC differentiation. This culture condition is even more efficient than culturing CD34+ cells with GM-CSF plus TNF-alpha and SCF in the presence of cord blood plasma. The proportions and total yields of cells with typical DC morphology and CD1a molecule expression are higher. The allostimulatory capacity of DC from TGF-beta 1-supplemented, cultures exceeds allostimulation by cells grown in plasma-containing medium. Substantial numbers (21 +/- 7%) of cells grown in TGF-beta 1-supplemented, but not plasma-supplemented, cultures express the Birbeck granule marker molecule Lag and display numerous Birbeck granules. Cells with distinct monocytic features are less frequently observed in TGF-beta 1-supplemented serum-free cultures. The addition of neutralizing anti-TGF-beta 1 Ab abrogates the observed TGF-beta 1 effects.

[Sclerosing hemangioma of the lung]

The authors review the theories of origin of the so-called sclerosing heamangioma of the lung. The results of immunohistochemical studies--epithelial membrane antigen positivity and vimentin and factor VIII. related antigen negativity--support the hypothesis of epithelial origin. The problems of clinical and pathological differential diagnosis are discussed.

Quantification of motor deficit in Parkinson's disease with a motor performance test series

It was the purpose of the present study to quantify the expected motor deficit in parkinsonian patients with the computer assisted Motor Performance Test Series (MPS), version 05.87 by Schuhfried (1987) and to examine which of the motor test variables found correlate at a significance level of p less than 0.01 with items of "motor examination" recorded at neurological examination and "activities of daily living" of the Unified Parkinson's Disease Rating Scale (UPDRS), version 3.0. 38 patients with idiopathic Parkinson's disease (PD) stages I-IV according to Hoehn and Yahr, aged 41 to 73 years were studied. The study design, i.e. initial rating by the physician followed immediately by testing of motor function with MPS was strictly adhered to in each patient. Physician's rating of rigor and the scores of the semiquantitative tests (finger taps, hand movements and alternating movements) as expression of hypokinesia and the "activities of daily living" correlated with the 3 factors of the Motor Performance Test Series at a highly significant level independent of disease stage. Tremor is only partly and never significantly reflected in the motor data measured. Stages I-II and II-IV (Hoehn and Yahr) differ significantly in the representative data of the Motor Performance Test Series. The results of the study support the assumption that MPS is a valid instrument for quantitative measurement of the motor deficit in parkinsonian patients, but that only some subtests are "pathognomonic".

[Etiology and consequences of postoperative wound infection]

The incidence of postoperative wound infection ranges between 4.6% and 36% after gastrointestinal operations respectively. To evaluate the factors which influence the postoperative wound infection we prospectively analyzed our patients between 1/1989 and 1/1990. 444 patients from three general surgical units of our clinic entered this study. The overall wound infection rate was 6.3%. We classified the patients into 3 operative groups: Group I: subcutaneous operations; Group II: intraabdominal operations without opening the GI-tract; Group III: gastrointestinal operations. Wound infection rate in group I was 1.8%, in group II 7.3% and in group III 13.7%. The differences were highly significant. Both univariate (chi 2-test) as well as a multivariate (Cox-Model) analysis were done. We figured out that classification of patients (p = 0.000), operation time (p = 0.009), operating room (p = 0.000), intensive care unit (p = 0.026), long-term antibiotic prophylaxis (p = 0.001), subcutaneous haematoma (p = 0.000) and length of closed drainage time (p = 0.001) are of significant value. In the Cox model the classification of patients into 3 groups surpassed all the other factors. Postoperative hospital stay was lengthened in patients with wound infection significantly (p = 0.0025).

[Effect of a modified struma resection technic on the rate of lesions of the recurrent laryngeal nerve]

Recurrent laryngeal nerve injury still remains the major problem in thyroid gland surgery and is influenced both by morphology and function of the goitre and essentially by the resection technique. Between 1982 and 1985 a total of 825 patients was operated on for the first time due to a benign goitre. In period A (Jan. 1982 to Dec. 1983) we always-- preceding the resection of the goitre--performed the ligature of the A.thyreoidea inferior (n = 412) whereas in period B (Jan. 1984 to Dec. 1985) we dispensed with it (n = 413). In neither of the two periods the preparation of the N.laryngeus recurrens--save few exceptional cases--was performed. The immediate postoperative recurrent laryngeal nerve palsy rate decreased from 4.9% in period A to 2.2% in period B, the persistent palsy rate (laryngeal control half a year postoperatively) from 2.18% to 0.48%. Due to the change to smaller, more hyperfunctional goitres in endemic areas we believe it possible to perform the resection of benign goitres without the preliminary ligature of the A.thyreoidea inferior and the preparation of the recurrent laryngeal nerve. On one hand this can lead to the facilitation of the surgical task, on the other hand to the decrease of the injury risk on the recurrent laryngeal nerve.