Multiparameter flow cytometry in the differential diagnosis of aberrant T-cell clones of unclear significance.

Immunophenotypic distinction between neoplastic and reactive T-cell clones can be challenging, as peripheral T-cell lymphomas (PTCLs) lack an immunophenotypic marker of clonality. Systematic screening of 10,510 cases analyzed by immunophenotyping at our institution between 2006 and 2012 resulted in 49 cases with aberrant T-cell populations of unclear significance. Review of patient charts allowed us to assign these cases to three categories. In 21 cases, PTCL could later be confirmed by complementary diagnostics (PTCL group). In 20 cases, follow-up confirmed the reactive nature of the aberrant T-cells (non-PTCL group). Eight cases remained of unclear significance. Neither the population size nor the number of aberrant markers differed significantly between the PTCL and non-PTCL groups. Only loss of CD7 was found significantly more often in patients with PTCL than in patients with non-PTCL (p = 0.037). Our data show that aberrant T-cell populations need to be interpreted in the clinicopathological context, as reactive and neoplastic phenotypes largely overlap.

Multidimensional scaling analysis identifies pathological and prognostically relevant profiles of circulating T-cells in chronic lymphocytic leukemia.

Antitumor immunity in chronic lymphocytic leukemia (CLL) is hampered by highly dysfunctional T-cells. Although certain T-cell subsets have been reported to be of prognostic significance in this disease, their interplay is complex and it remains incompletely understood which of these subsets significantly drive CLL progression. Here, we determined immunological profiles of 24 circulating T-cell subsets from 79 untreated individuals by multiparametric flow cytometry. This screening cohort included healthy donors, patients with monoclonal B-cell lymphocytosis (MBL), Rai 0 CLL and advanced CLL. We applied multidimensional scaling analysis as rigorous and unbiased statistical tool to globally assess the composition of the circulating T-cell environment and to generate T-cell scores reflecting its integrity. These scores allowed clear distinction between advanced CLL and healthy controls, whereas both MBL and Rai 0 CLL showed intermediate scores mirroring the biological continuum of CLL and its precursor stages. T-cell stimulation and suppression assays as well as longitudinal T-cell profiling showed an increasingly suppressive regulatory function initiating at the MBL stage. Effector function was impaired only after transition to CLL and partially recovered after chemoimmunotherapy. In an independent validation cohort of 52 untreated CLL cases, aberrant T-cell profiles were significantly associated with shorter time to treatment independently of other prognostic parameters. Random forest modeling predicted regulatory T-cell, gamma/delta and NKT-cells, as well as exhaustion of the CD8+ subset as potential drivers of progression. Our data illustrate a pathological T-cell environment in MBL that evolves toward a more and more suppressive and prognostically relevant profile across the disease stages.

High tissue density of FOXP3+ T cells is associated with clinical outcome in prostate cancer.

Cell-mediated immunity may impact prostate cancer progression and has great therapeutic potential. Here, we investigated the clinical significance of the numeric density of regulatory T cells (Tregs) in prostate cancer as the presence of such cells in the tumour microenvironment has been linked to clinical outcome in other tumour entities. We detected Tregs by FOXP3 immunohistochemistry in 88.8% of 2002 prostate cancer specimens in tissue microarray format, the largest cohort so far in which Tregs have been quantified. The density of Tregs in tumour tissue was compared with pathological parameters and clinical outcome. The number of Tregs identified per 0.6mm tissue spot ranged from 1 to 10 in normal and 1 to 103 FOXP3+ cells in tumour samples. Prostate-specific antigen (PSA) recurrence-free survival was significantly reduced in patients with higher numbers of Tregs (p=0.0151). Further, a higher number of intratumoural FOXP3+ Tregs was associated with a more advanced tumour stage (p=0.0355) and higher Ki67 labelling index (p<0.0001). The tissue density of Tregs was unrelated to other clinical parameters such as spread to lymph nodes, preoperative PSA level and Gleason score. Our study suggests that the intratumoural presence of regulatory T cells may have substantial functional impact and may confer an adverse clinical course in prostate cancer.

Intratumoral T but not B lymphocytes are related to clinical outcome in prostate cancer.

The number of tumor-infiltrating lymphocytes is functionally important and correlates with clinical outcome in several tumor entities. Herein we explore the impact of the density of T and B lymphocytes in prostate cancer tissue on prostate-specific antigen (PSA) recurrence after prostatectomy in 3261 prostate cancer tissue samples. The number of prostate cancer-infiltrating CD3-positive T cells and CD20-positive B cells per tissue spot in a tissue microarray format was determined by immunohistochemistry and was correlated with clinical and pathological data from the same patient cohort. Patients with very low and very high numbers of CD3-positive T cells per tissue spot had a significantly shorter PSA recurrence-free survival compared to patients with intermediate numbers of T cells (p = 0.0188). Furthermore, a high number of CD3-positive T cells per tissue spot was associated with fusion type prostate cancer identified by ERG expression analysis. The number of CD20-positive B cells per tissue spot was not associated with other clinical and histopathological parameters. This study indicates that the density of T but not B cells plays a functional role in the biology of prostate cancer and may have an impact on clinical outcome in this frequent neoplasia.

Critical imbalance of TNF-α and soluble TNF receptor 1 in a patient with macrophage activation syndrome: potential implications for diagnostics and treatment.

Macrophage activation syndrome (MAS) is a life-threatening disease with sustained activation of inflammatory cells and release of proinflammatory TNF-α. Under physiological conditions, TNF-α initiates a negative feedback mechanism, mediated by shedded, soluble TNF receptor ectodomains, eventually limiting the inflammatory reaction. Here, we report on a 27-year-old critically ill patient with refractory MAS and an insufficient negative feedback regulation, resulting in an overwhelming inflammatory response. A personalized treatment with soluble TNF receptor etanercept resulted in a durable remission. Further studies are warranted to establish whether the TNF cytokine profile may help to successfully guide patient selection for biological therapies.

SOX9 and SOX10 but not BRN2 are required for nestin expression in human melanoma cells.

Nestin is an intermediate filament protein and a marker of neuroectodermal stem cells indicating multipotentiality and regenerative capability. In melanoma tissues, nestin re-expression was correlated with tumor progression. Activation of the nestin neural enhancer was shown to be dependent on the binding of class III POU transcription factors, with brain-2 (BRN2) suggested to play a key role. We found both nestin and BRN2 mRNA in almost all of 13 analyzed melanoma cell lines of different progression stages, but expression levels did not correlate. Nestin protein was detected in 11 of 13 and BRN2 protein in 7 of 13 melanoma cell lines independent of progression stage. Downregulation of BRN2 by small-interfering RNA did not alter nestin expression in melanoma cells. However, POU proteins, such as BRN2, commonly cooperate with transcription factors of the Sry-box (SOX) family by binding to a nearby DNA site necessary for their action. SOX9 and SOX10 have been shown to be expressed in melanocyte precursors, with SOX10 downregulated upon differentiation. We now demonstrate SOX9 and SOX10 protein expression in melanoma tissues and cell lines. Downregulation of SOX9 and of SOX10 markedly decreased nestin levels in melanoma cells in a cooperative manner. Thus, SOX9 and SOX10 but not BRN2 seem to be required for nestin expression in human melanoma.

Sulfuric acid burns (corrosion and acute irritation): evidence-based overview to management.

Concentrated sulfuric acid causes severe skin injury. To prevent skin destruction, efficient early treatment is of utmost importance. However, regimens suggested in the literature are not always supported by experimental data. Further studies are needed. To improve early management of sulfuric acid burns, future experiments need careful extrapolation between animal skin and human skin. The benefit of water, neutralizer, or alternative agents has to be established by precisely defining acid concentration and time of exposure.

Drug dosage in the elderly: dermatological drugs.

Drug pharmacokinetics and pharmacodynamics may be altered in the elderly. An important contribution is made by decreased renal function, but biotransformation in the liver may also play a role. Commonly prescribed dermatological drugs such as methotrexate and cetirizine are likely to be eliminated more slowly in the elderly and potentially hepatotoxic drugs such as itraconazole and acitretin should be used with caution. Altered drug distribution as a result of body composition changes can lead to prolonged half-life or higher plasma concentrations of many drugs. Higher prevalence of adverse drug reactions and multidrug regimens, and large interindividual variability in drug response make drug dosage and administration in the elderly challenging. New immunobiological agents such as alefacept, efalizumab and etanercept, which are approved for treatment of psoriasis, seem to be as well tolerated in the elderly as in younger patients. A recommended approach when prescribing drugs to the elderly would be to start with a small initial dose and to reduce the number of drugs administered simultaneously. It is crucial to simplify the drug regimen as much as possible in order to enhance drug management in the elderly. To improve pharmacotherapy in the elderly, we review age-related changes in pharmacokinetics that are likely to play a role in dermatological practice.