Reverting immune suppression to enhance cancer immunotherapy

Tumors employ strategies to escape immune control. The principle aim of most cancer immunotherapies is to restore effective immune surveillance. Among the different processes regulating immune escape, tumor microenvironment-associated soluble factors, and/or cell surface-bound molecules are mostly responsible for dysfunctional activity of tumor-specific CD8+T cells. These dynamic immunosuppressive networks prevent tumor rejection at several levels, limiting also the success of immunotherapies. Nevertheless, the recent clinical development of immune checkpoint inhibitors or of molecules modulating cellular targets and immunosuppressive enzymes highlights the great potential of approaches based on the selective disruption of immunosuppressive networks. Currently, the administration of different categories of immunotherapy in combination regimens is the ultimate modality for impacting the survival of cancer patients. With the advent of immune checkpoint inhibitors, designed to mount an effective antitumor immune response, profound changes occurred in cancer immunotherapy: from a global stimulation of the immune system to a specific targeting of an immune component. This review will specifically highlight the players, the mechanisms limiting an efficient antitumor response and the current immunotherapy modalities tailored to target immune suppressive pathways. We also discuss the ongoing challenges encountered by these strategies and provide suggestions for circumventing hurdles to new immunotherapeutic approaches, including the use of relevant biomarkers in the optimization of immunotherapy regimens and the identification of patients who can benefit from defined immune-based approaches

Granulocyte transfusions in children and adults with hematological malignancies: benefits and controversies

Bacterial and fungal infections continue to pose a major clinical challenge in patients with prolonged severe neutropenia after chemotherapy or hematopoietic stem cell transplantation (HSCT). With the advent of granulocyte colony-stimulating factor (G-CSF) to mobilize neutrophils in healthy donors, granulocyte transfusions have been broadly used to prevent and/or treat life-threatening infections in patients with severe febrile neutropenia and/or neutrophil dysfunction. Although the results of randomized controlled trials are inconclusive, there are suggestions from pilot and retrospective studies that granulocyte transfusions may benefit selected categories of patients. We will critically appraise the evidence related to the use of therapeutic granulocyte transfusions in children and adults, highlighting current controversies in the field and discussing complementary approaches to modulate phagocyte function in the host

Paradoxical Autoinflammatory Skin Reaction to Tumor Necrosis Factor Alpha Blockers Manifesting as Amicrobial Pustulosis of the Folds in Patients With Inflammatory Bowel Diseases

The therapy of inflammatory bowel disease, particularly with tumor necrosis factor (TNF) blockers, may be associated with a number of cutaneous adverse effects, including psoriasis-like, eczema-like, and lichenoid eruptions. Other rare skin complications are neutrophilic dermatoses such as amicrobial pustulosis of the folds (APF), which is a chronic relapsing pustular disorder classified in this spectrum.The authors analyzed clinical, histopathologic, and cytokine expression profiles of 3 inflammatory bowel disease patients with APF triggered by adalimumab (patient 1) and infliximab (patients 2 and 3).All 3 patients presented with sterile pustules involving the cutaneous folds, genital regions, and scalp 6 months after starting adalimumab (patient 1) and 9 months after starting infliximab (patients 2 and 3). Histology was characterized by epidermal spongiform pustules with a dermal neutrophilic and lymphocytic infiltrate. Tumor necrosis factor blocker withdrawal associated with topical and systemic corticosteroids induced complete remission of APF in all 3 patients. The expressions of interleukin (IL)-1 beta and its receptors as well as TNF alpha and its receptors were significantly higher in APF than in controls. Also IL-17, leukocyte selectin, and chemokines, such as IL-8, [C-X-C motif] chemokine ligand 1/2/3 (C\u200a=\u200acysteine, X\u200a=\u200aany amino acid), [C-X-C motif] chemokine ligand 16 (C\u200a=\u200acysteine, X\u200a=\u200aany amino acid), and RANTES (regulated on activation, normal T cell expressed and secreted) were significantly overexpressed. Finally, the authors found significant overexpression of both metalloproteinases 2/9 and their inhibitors 1/2.The observation of 3 patients with APF following anti-TNF therapy expands not only the clinical context of APF but also the spectrum of anti-TNF side effects. Overexpression of cytokines/chemokines and molecules amplifying the inflammatory network supports the view that APF is autoinflammatory in origin

Cytokine and Chemokine Profile in Amicrobial Pustulosis of the Folds: Evidence for Autoinflammation

Autoinflammation has recently been suggested in the pathogenesis of neutrophilic dermatoses but systematic studies on their cytokine profile are lacking. Notably, amicrobial pustulosis of the folds (APF), classified among neutrophilic dermatoses, has been studied only in small case series.In our University Hospital, we conducted an observational study on 15 APF patients, analyzing their clinical and laboratory features with a follow-up of 9 months to 20 years. Skin cytokine pattern of 9 of them was compared to that of 6 normal controls.In all patients, primary lesions were pustules symmetrically involving the skin folds and anogenital region with a chronic-relapsing course and responding to corticosteroids. Dapsone, cyclosporine, and tumor necrosis factor blockers were effective in refractory cases. In skin samples, the expressions of interleukin (IL)-1\u3b2, pivotal cytokine in autoinflammation, and its receptors I and II were significantly higher in APF (P\u200a=\u200a0.005, 0.018, and 0.034, respectively) than in controls. Chemokines responsible for neutrophil recruitment such as IL-8 (P\u200a=\u200a0.003), CXCL 1/2/3 (C-X-C motif ligand 1/2/3) (P\u200a=\u200a0.010), CXCL 16 (P\u200a=\u200a0.045), and RANTES (regulated on activation, normal T cell expressed and secreted) (P\u200a=\u200a0.034) were overexpressed. Molecules involved in tissue damage like matrix metalloproteinase-2 (MMP-2) (P\u200a=\u200a0.010) and MMP-9 (P\u200a=\u200a0.003) were increased.APF is a pustular neutrophilic dermatosis with a typical distribution in all patients. The disorder may coexist with an underlying autoimmune/dysimmune disease but is often associated only with a few autoantibodies without a clear autoimmunity. The overexpression of cytokines/chemokines and molecules amplifying the inflammatory network supports the view that APF has an important autoinflammatory component

Espressione di tissue factor da parte degli eosinofili in pazienti con orticaria cronica

Sebbene numerosi casi di orticaria cronica siano attualmente considerati di origine autoimmune e associati alla presenza di autoanticorpi circolanti che inducono il rilascio di istamina, vi sono chiare evidenze sul ruolo fisiopatologico dell\u2019attivazione della coagulazione mediata dal tissue factor (TF), il principale iniziatore della cascata coagulatoria. E\u2019 stato di recente dimostrato che gli eosinofili, peraltro presenti nella cute lesionale di pazienti con orticaria cronica, sono la maggiore fonte di TF nel sangue umano. In questo studio abbiamo valutato se gli eosinofili esprimano TF nella cute lesionale di pazienti con orticaria cronica. Abbiamo studiato 20 pazienti con orticaria cronica grave, prelevando campioni bioptici cutanei da lesioni pomfoidi attive. Come gruppo di controllo sono stati utilizzati campioni di cute sana perilesionale ottenuti dall\u2019escissione chirurgica di diversi tipi di tumori cutanei (10 casi) e varie patologie cutanee caratterizzate da infiltrati usualmente privi di eosinofili, quali vasculite leucocitoclasica (7 casi), lichen planus (8 casi) e mastocitosi (3 casi). L\u2019espressione del TF \ue8 stata valutata con metodica immunoistochimica utilizzando un anticorpo monoclonale anti-TF. Sono stati inoltre eseguiti esperimenti di colocalizzazione del TF con la proteina cationica eosinofila (ECP), considerata un marcatore classico degli eosinofili, con la tecnica del doppio marcaggio mediante due anticorpi monoclonali specifici. In tutti i campioni di cute dei pazienti con orticaria cronica \ue8 stata osservata un\u2019intensa espressione del TF che era invece assente nei controlli normali (P=0.0001) e nelle malattie cutanee non eosinofilo-mediate (P=0.001-0.0001). Le indagini di doppio marcaggio per TF e ECP hanno dimostrato che le cellule positive per TF erano eosinofili. In conclusione, gli eosinofili rappresentano la principale fonte di TF nella cute lesionale di pazienti con orticaria cronica. I nostri risultati enfatizzano il ruolo di queste cellule nella fisiopatologia dell\u2019orticaria cronica fornendo il razionale per nuove strategie terapeutiche

Attivazione della coagulazione nelle dermatosi bollose autoimmuni

Pemfigo volgare (PV) e pemfigoide bolloso (PB) sono dermatosi bollose di origine autoimmune che si differenziano principalmente per la sede di formazione delle bolle e per l\u2019intensit\ue0 del processo infiammatorio ad esse associato. Nel PV la bolla \ue8 infatti intraepidermica e consegue al danneggiamento delle giunzioni intercellulari dovuto al legame di autoanticorpi IgG con le desmogleine desmosomiali 3 e 1, mentre nel BP lo scollamento bolloso avviene a livello della giunzione dermoepidermica ed \ue8 causato da autoanticorpi diretti contro due antigeni emidesmosomiali, BP180 e BP 230. L\u2019infiltrato infiammatorio \ue8 denso e ricco in eosinofili nel BP e scarso nel PV. E\u2019 noto che l\u2019infiammazione attivi la cascata coagulatoria in diverse patologie. In questo studio abbiamo valutato l\u2019attivazione della coagulazione a livello sia locale che sistemico nel BP e nel PV. Sono stati studiati 20 pazienti affetti da BP (10 in fase attiva e 10 in remissione), 23 pazienti con PV (13 attivi e 10 in remissione) e 10 soggetti sani. Sono stati misurati due marcatori di attivazione della coagulazione, il frammento della protrombina F1+2 e il D-dimero, con metodiche ELISA nel plasma dei pazienti e dei controlli. L\u2019espressione del tissue factor (TF), il principale iniziatore della cascata coagulatoria, \ue8 stata valutata con metodica immunoistochimica su campioni cutanei di 10 pazienti con PV, 10 pazienti con BP attivo e sulla cute sana di 10 controlli. I livelli plasmatici di F1+2 e D-dimero erano elevati nei pazienti con BP attivo (P = 0\ub7001), mentre nel PV attivo i livelli di entrambi i parametri erano normali. In fase di remissione i livelli plasmatici di F1+2 e D-dimero erano normali sia nel BP che nel PV. E\u2019 stata dimostrata immunoreattivit\ue0 cutanea per TF nel BP attivo ma non nel PV attivo n\ue9 nella cute sana. Lo score di reattivit\ue0 del TF era pi\uf9 elevato nel BP attivo rispetto ai controlli sani e al PV attivo (P = 0\ub70001). Non vi erano differenze nello score di TF tra PV attivo e controlli. In conclusione, il BP si associa ad attivazione della coagulazione che invece \ue8 assente nel PV. I nostri dati forniscono una possibile spiegazione fisiopatologica dell\u2019aumentato rischio trombotico osservato nei pazienti con BP ma non in quelli con PV

Ongoing contact activation in patients with hereditary angioedema

Hereditary angioedema (HAE) is predominantly caused by a deficiency in C1 esterase inhibitor (C1INH) (HAE-C1INH). C1INH inhibits activated factor XII (FXIIa), activated factor XI (FXIa), and kallikrein. In HAE-C1INH patients the thrombotic risk is not increased even though activation of the contact system is poorly regulated. Therefore, we hypothesized that contact activation preferentially leads to kallikrein formation and less to activation of the coagulation cascade in HAE-C1INH patients. We measured the levels of C1INH in complex with activated contact factors in plasma samples of HAE-C1INH patients (N=30, 17 during remission and 13 during acute attack) and healthy controls (N=10). We did not detect differences in enzyme-inhibitor complexes between samples of controls, patients during remission and patients during an acute attack. Reconstitution with C1INH did not change this result. Next, we determined the potential to form enzyme-inhibitory complexes after complete in vitro activation of the plasma samples with a FXII trigger. In all samples, enzyme-C1INH levels increased after activation even in patients during an acute attack. However, the levels of FXIIa-C1INH, FXIa-C1INH and kallikrein-C1INH were at least 52% lower in samples taken during remission and 70% lower in samples taken during attack compared to samples from controls (p<0.05). Addition of C1INH after activation led to an increase in levels of FXIIa-C1INH and FXIa-C1INH (p<0.05), which were still lower than in controls (p<0.05), while the levels of kallikrein-C1INH did not change. These results are consistent with constitutive activation and attenuated depletion of the contact system and show that the ongoing activation of the contact system, which is present in HAE-C1INH patients both during remission and during acute attacks, is not associated with preferential generation of kallikrein over FXIa

Bradykinin and des-Arg(9)-bradykinin metabolic pathways and kinetics of activation of human plasma

In the serum of 116 healthy individuals, exogenous bradykinin (BK) half-life (27 +/- 10 s) was lower than that of des-Arg(9)-BK (643 +/- 436 s) and was statistically different in men compared with women. The potentiating effect of an angiotensin-converting enzyme (ACE) inhibitor was, however, more extensive for BK (9.0-fold) than for des-Arg(9)-BK (2.2- fold). The activities of ACE, aminopeptidase P (APP), and kininase I were respectively 44 +/- 12, 22 +/- 9, and 62 +/- 10 nmol x min(-1) x ml(-1). A mathematical model (y = kt(alpha)e(-beta t), t > 0), applied to the BK kinetically released from endogenous high-molecular-weight kininogen (HK) during plasma activation in the presence of an ACE inhibitor, revealed a significant difference in the rate of formation of BK between men and women. For des-Arg(9)-BK, the active metabolite of BK, the rate of degradation was higher in women compared with men, correlating significantly with serum APP activity (r(2) = 0.6485, P < 0.001). In conclusion, these results constitute a basis for future pathophysiological studies of inflammatory processes where activation of the contact system of plasma and the kinins is involve