호흡기 상피세포의 상피-간엽 전이가 코 폴립 형성에 미치는 영향에 대한 연구

학위논문(박사)--서울대학교 대학원 :의과대학 의과학과,2020. 2. 신현우.코 폴립은 만성 부비동염 환자에서 관찰되는 현상으로 고질적인 질환 이다. 일전의 연구에서, 비강 내 용종 이 hypoxia-inducible factor (HIF)에 의한 상피-간엽 전환 현상에 의해 매개 됨을 확인 하였다. 현재까지 저산소와 관련된 질환을 치료하기 위해 많은 HIF 타겟 약물들이 소개되었지만 대부분 함암제로서 개발되어 세포에 독성이 매우 강하고, 그래서 코 폴립과 같은 질환에 사용하기 에는 적합 하지 않았다. 한편, 최근 보고에서 히스톤 탈 아세틸화 효소인 Sirtuin 1 (SIRT1) 이 HIF1와 결합하여 HIF1의 전사 능력을 억제 시킬 수 있다는 사실이 규명 되었다. 따라서 본 연구에서는 SIRT1에 의한 HIF1 매개 상피-간엽 전환 능력의 감소가 코 폴립 형성을 억제 할 수 있는지 평가 하고자 하였다. 먼저, SIRT1이 과 발현 된 마우스의 비강 상피에서 코 폴립의 숫자와 상피세포의 결손이 감소하는 것을 관찰 하였다. 또한 SIRT1의 활성을 증가 시킬 수 있는 약물인 resveratrol (RSV)을 마우스 비강 내에 전달 하였 을 때 코 폴립의 숫자가 감소하는 반면, SIRT1의 활성을 억제하는 약물인 sirtinol을 처리하였을 때는 코 폴립 형성 능력이 다시 증가하는 것을 관찰 하였다. 실제로 SIRT1의 발현은 코 폴립을 동반한 만성 부비동염 환자의 상피 세포에서 크게 감소해 있었다. 코 상피세포에서 SIRT1을 과 발현 하거나 SIRT1의 활성을 증가 시켰을 때, HIF 매개 상피-간엽 전환 현상이 다시 회복 되는 것을 관찰 할 수 있었다. SIRT1이 과 발현 된 마우스의 비강 내에 SIRT1 small hairpin RNA (shRNA)를 탑재한 lentivirus를 주입 하게 되면 코 폴립의 숫자가 증가하는 것을 확인 할 수 있었다. 무엇보다도, 코 폴립을 동반한 환자의 조직 추출물을 코 상피세포에 처리 하였 을 때 SIRT1의 발현이 감소하고 그에 따라 HIF 의 활성이 증가 하는 현상을 볼 수 있었다. 이처럼, RSV는 만성 부비동염을 동반한 코 폴립 설치류 모델 에서 효과적으로 코 폴립의 형성을 억제 할 수 있다. 하지만, RSV 의 낮은 용해성과 비강내에서의 빠른 소실 때문에 RSV 의 생체 이용률은 매우 제한적이었고, 이러한 한계점을 극복하기 위해 접착 능력을 가진 나노 구조 입자의 파티클 (poly lactic-co-glycolic acid/polyethylene glycol nanostructured microparticle; PLGA/PEG NM)을 RSV 를 전달하는 재료로서 활용 해 보기로 하였다. PLGA/PEG NM는 장시간 동안 지속적으로 RSV를 방출 할 수 있었다. 나노 구조 입자 파티클의 확장된 표면 접착 부분 때문에 점막에 잔존 하는 시간이 크게 증가 하였고, 결과적으로 비강내 점막에서 PLGA/PEG NM이 오랜 시간 동안 제거되지 않고 남아 있는 것을 관찰 할 수 있었다. RSV의 증가된 약물 전달 능력을 설치류에서 평가하기 위해 코 폴립 마우스 모델을 활용 하였고, 이 때 RSV를 탑재한 PLGA/PEG NM의 마우스 비강 내 전달은 그렇지 않은 마우스에 비하여 코 폴립 형성 능력을 현저히 감소 시켰으며, 상피-간엽 전환을 다시 회복 시킬 수 있었다. 이러한 효과는 사용한 RSV 용량의 절반만 탑재한 PLGA/PEG NM를 전달 하였을 때도 관찰 할 수 있었다. 종합 하여 볼 때, SIRT1과 PLGA/PEG에 탑재된 RSV의 처리는 효과적으로 HIF 매개 상피-간엽 전환 현상을 억제하여 코 폴립 형성을 효과적으로 감소 시킬 수 있었고, 이는 SIRT1이 코 폴립의 치료 타겟으로서 가능성을 나타낸다고 할 수 있다. 그러므로, PLGA/PEG NM은 RSV의 생체 이용률을 향상시킬 수 있는 잠재력 높은 재료로서 활용 될 수 있을 것이며, 더 나아가 코 폴립의 치료에 활용 될 수 있을 것으로 기대한다.Nasal polyps (NPs) imply a refractory clinical course in chronic rhinosinusitis (CRS). Previous research showed that hypoxia-inducible factor (HIF)-1 could mediate nasal polypogenesis via epithelial-to-mesenchymal transition (EMT). Although several HIF-1 inhibitors were introduced for the treatment of hypoxia-related diseases, most were developed as anti-cancer drugs, and thus were cytotoxic. Sirtuin1 (SIRT1), a histone deacetylase, reportedly suppresses the transcriptional activity of HIF-1. Thus, I hypothesized that SIRT1 attenuates nasal polyposis by inhibiting HIF-1-induced EMT. SIRT1 transgenic (TG) mice had presented reduced mucosal lesions with epithelial disruption and fewer nasal polyps than wild-type (WT) mice. In addition, resveratrol (RSV), a polyphenolic SIRT1 activator, treatment suppressed nasal polypogenesis in WT mice; however, sirtinol (a SIRT1 inhibitor) administration increased the polyp burden in SIRT1 TG mice. In CRS sino-nasal specimens, SIRT1 was downregulated in the mucosa from patients with polyps as compared with patients without polyps. SIRT1 overexpression or activation reversed hypoxia-induced EMT in human nasal epithelial cells (hNECs). The intranasal transfection of a sh-SIRT1 lentiviral vector induced more nasal polypoid lesions in SIRT1 TG mice. Importantly, mucosal extracts from CRS without nasal polyps increased SIRT1 expression in nasal epithelial cells, and those from CRS with nasal polyps did not. RSV has been shown to effectively suppresses CRSwNP in a mouse model; however, when locally administered to the sino-nasal cavity, bolus RSV is limited by low drug bioavailability owing to its low aqueous solubility and relatively rapid clearance from the administration site. To address this limitation, I proposed muco-adhesive nanostructured micro-particles (PLGA/PEG NM) as a potential carrier for the sino-nasal delivery of RSV. PLGA/PEG NM released RSV in a sustained manner. Owing to the enlarged specific surface area of the nanostructures, PLGA/PEG NM had synergistically enhanced muco-adhesiveness and thus showed improved in vivo retention properties in the sino-nasal cavity. Therefore, RSV encapsulated with PLGA/PEG NM treatment mitigated nasal polyp formation and restored epithelial integrity better than the control treatments in a NP murine model. The therapeutic effect was similar at half the dose of PLGA/PEG NM, suggesting improved local bioavailability of RSV in the sino-nasal cavity. Taken together, SIRT1 and RSV treatment efficiently suppressed nasal polyp formation, possibly due to inhibition of HIF-1-induced EMT, and thus indicating that SIRT1 may be a therapeutic target for nasal polyps. Therefore, RSV encapsulated with PLGA/PEG NM, potential material for delivering RSV, can be utilized for treating NPs.GENERAL BACKGROUND 1 MATERIAL AND METHODS 5 CHAPTER 1. SIRT1 attenuates nasal polypogenesis by suppressing epithelial-to-mesenchymal transition 18 1.1 INTRODUCTION 19 1.2 RESULTS 21 1.2.1. Reduced polyp burden in SIRT1 TG mice 21 1.2.2. Reciprocal expression of SIRT1 and HIF-1a in chronic rhinosinusitis tissues 21 1.2.3. Effects of a SIRT1 activator and/or inhibitor on polyp formation in a murine NP model 22 1.2.4. SIRT1 attenuates HIF-1 activity via de-acetylation in nasal epithelial cells 22 1.2.5. Tissue-specific SIRT1 knockdown restores polyp formation in SIRT1 TG mice 23 1.2.6. SIRT1 expression is enhanced by mucosal extracts from CRS patients, but not by extracts from NPs 23 1.3 DISCUSSION 45 CHAPTER 2. Sinonasal Delivery of Resveratrol via Mucoadhesive Nanostructured Micro-particles in a Nasal Polyp Mouse Model 49 2.1 INTRODUCTION 50 2.2 RESULTS 52 2.2.1. Micro-particle characterization 52 2.2.2. In vitro release profile of RSV 52 2.2.3. In vivo sino-nasal retention properties 53 2.2.4. In vivo effects on nasal polyps and epithelial disruptions 55 2.2.5. In vivo evaluation of inflammatory surrogates 55 2.2.6. In vivo efficacy on E-cadherin restoration 56 2.2.7. Biocompatibility evaluation 57 2.3 DISCUSSION 76 REFERENCES 78 ABSTRACT IN KOREAN 100Docto

The potential role of peak nasal inspiratory flow to evaluate active sinonasal inflammation and disease severity

Although the pathophysiology of nasal polyposis is incompletely understood, rhinologists have seldom studied it with rhinomanometry or peak nasal inspiratory flow (PNIF) due to technical limitations and the perception that polyp size might impair reproducibility and the usefulness of recordings. The objective of this study is to assess how measures of rhinomanometry and PNIF relate to disease activity. Nineteen patients with polyps, 15 patients with chronic sinusitis without polyps and 11 negative controls were evaluated with active anterior rhinomanometry and PNIF. Sinusitis and polyp patients were re-evaluated after medical treatment. Polyp patients had the highest median Lund-Mackay score (14) and a median Johansen score of 1. PNIF and its variation after treatment were also lowest in this group (median 90 L/min before and after treatment; median variation of 0 L/min). Nasal resistance was similar between groups, and only correlated with Johansen score (Spearman = 0.517, p = 0.048) after treatment. Our study suggests that evaluating polyp patients using rhinomanometry and PNIF may provide useful and reproducible data. Several findings considered together suggest that polyp size is not the main determinant of nasal functional changes in these patients, warranting further studies to verify whether PNIF changes reflect sinus inflammation or merely airway obstruction.publishersversionpublishe

Hyperplasia and Fluid Accumulation in Epithelial Cyst Formation and Growth

Epithelial cysts may develop in virtually any epithelium. All cysts, regardless of their origins, are characterized by epithelial hyperplasia and fluid accumulation. Additional features may include tubular atrophy, basement membrane alterations and association with inflammatory cells. In spite of the intense research effort in recent years directed at uncovering the cellular mechanisms of cyst development and growth, we still do not know the primary events that lead to cyst formation. However, there are at least three candidate mechanisms. These include: 1) increased cell proliferation (epithelial hyperplasia) in the cyst wall, 2) net fluid accumulation in the cyst cavity and 3) alterations of extracellular matrix components linked to cyst formation and growth. This review discusses the evidence to support the role of each mechanism as a possible primary event necessary for cyst initiation and continued enlargement. Present data on the pathogenesis of epithelial cyst formation strongly suggests that no single mechanism, as yet described, can adequately account for all situations of cyst occurrence

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise. The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included.Peer reviewe

European position paper on rhinosinusitis and nasal polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included

Neurology and the histiocytoses: a case of Rosai-Dorfman-Destombes disease

The histiocytoses are a group of rare disorders characterised by the accumulation of neoplastic or non-neoplastic activated histiocytes in various tissues. Phenotypes vary widely from cutaneous lesions or lymphadenopathy that regress spontaneously to disseminated disease with poor prognosis. Neurological symptoms can be a presenting feature or appear during the course of disease. We present a challenging diagnostic and management case of Rosai-Dorfman-Destombes disease in a 48-year-old woman with a relapsing, partially steroid-responsive syndrome comprising patchy, non-length-dependent radiculoneuropathy with diffuse pachymeningitis and widespread systemic disease, and recent dramatic response to novel mitogen-activated kinase pathway inhibition. We discuss the clinical characteristics, diagnosis, recent breakthroughs in pathogenesis and emerging treatment options for Rosai-Dorfman disease and for the histiocytoses with neurological sequelae, including Langerhans cell histiocytosis and Erdheim-Chester disease

Lymphoma

Lymphoma is a group of malignant diseases caused by the clonal proliferation of lymphocytes. Current treatment options include chemotherapy, radiotherapy, and bone marrow/stem cell transplantation. Development of new treatment options for cancer medications include small molecules and monoclonal antibodies for immunotherapy. In addition, the discovery of new phytochemical agents used in complementary and alternative medicine adds perspective to the treatment of lymphoma. This book highlights recent developments in the treatment of lymphoma. Chapters discuss different types of lymphomas, such as follicular lymphoma, gastrointestinal lymphoma, splenic B-cell lymphoma, and others, as well as the available treatment options for each