Angiolo Cipriani

Bronchial carcinoids: A review of 60 patients

Sixty patients with a bronchial carcinoid underwent surgical treatment. Preoperative fiberoptic bronchoscopy revealed a characteristic pink, smooth, bleeding tumor in 71.4% of the patients with a typical carcinoid and 16.7% of those with an atypical carcinoid (p less than 0.05). Eight pneumonectomies, seven bilobectomies, 34 lobectomies, three lobectomies with bronchoplasty, six bronchotomies with bronchoplasty, and two segmental resections were performed. All patients entered follow-up, and 47 were followed for more than 5 years. Ten-year survival was 89.6% for patients with a typical carcinoid and 60% for those with an atypical carcinoid. Ten-year survival was 88.1% for patients with carcinoids without lymph node involvement. All patients with lymph node involvement died within 5 years. Overall, 5 of the 8 patients having pneumonectomy died of acute cardiorespiratory failure. We conclude that a limited surgical resection with or without bronchoplasty and systematic lymphadenectomy is the procedure of choice in patients with typical carcinoids. On the other hand, atypical carcinoids are comparable to well-differentiated malignancies of the lung. Whenever possible, pneumonectomy should be avoided in favor of bronchial sleeve resection.

Immunohistological study in sarcoidosis: Evaluation at different sites of disease activity

Sarcoidosis is a multisystem disease characterized by enhanced immune responses at sites of involvement. For this reason, an immunohistological study using monoclonal antibodies against T-cell subpopulations was carried out in order to evaluate the topographic distribution of immunocompetent cells in tissue sections obtained from a variety of involved organs, such as parenchymal lung, lymph nodes, eyes, skin, and liver. Biopsy specimens were also stained for detection of immunoglobulins, complement, and fibrinogen deposits. The data demonstrate a redistribution of T cells from the blood to all the sites of disease activity where they account for the large majority of infiltrating cells, both in the early lesions (merely a lymphocytic infiltrate) and in well-organized granulomas. Moreover, these cells express a helper-related phenotype, as demonstrated by the high Leu-3/Leu-2 ratios, at sites of involvement with respect to the blood (blood, 1.8/1; transbronchial lung biopsies, 10.5/1; lymph nodes, 19/1; skin, 28/1; liver, 22/1; eye, 14/1). In line with this helper infiltration is the presence of plasma cells and immunoglobulin deposits, suggesting a local hyperreactivity of the B-cell immune system. Both the hypergammaglobulinemia and the T lymphopenia usually observed in the blood of sarcoid patients could be explained by these observations. Comparative analysis of immunohistological data and bronchoalveolar lavage (BAL) findings provides further evidence that BAL cellularity reflects the changes already occurring in lung histology. The studies emphasize the importance that immunological phenomena play in the pathogenesis of sarcoidosis and provide new insights into the mechanisms leading to the formation and maintenance of the sarcoid granuloma.

Longitudinal study of alveolitis in hypersensitivity pneumonitis patients: An immunologic evaluation

Cells recovered from bronchoalveolar lavage were studied, both from a phenotypic and functional point of view, in 18 patients with hypersensitivity pneumonitis (HP) during a prolonged follow-up. A series of monoclonal antibodies against different lymphocyte subpopulations, including T cells, T cell subsets, and natural killer (NK) cells have been used. In some cases, an immunohistologic analysis of lung tissue sections has also been performed. The NK activity has been evaluated with regard to the in vitro function. At the time of the first evaluation, a high number of CD8+ cells with an imbalance of CD4/CD8 ratio had been demonstrated in patients with HP. Consecutive bronchoalveolar lavage evaluations demonstrated a persistent increase of CD8+ cells and a reversal of CD4/CD8 ratio in patients who continued to be regularly exposed to etiologic antigens at work (W+). In the same cases, a persistent increase of NK cells was demonstrated. Cytotoxic cells demonstrated a persistently enhanced in vitro lytic function during the follow-up, even though there appeared to be a trend toward the normal range. Patients who continued to live in agricultural environments but were not further exposed to specific antigens at work (W-) exhibited a recovery of CD4+ cells, a decrease in CD8+ cells, and an increase of CD4/CD8 ratio to the normal range 6 months after the first observation. Immunohistologic analysis, performed at the time of the first evaluation, demonstrated a diffuse infiltration of lung parenchyma by CD8+ cells, both in W+ and W- patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Activated T cells with immunoregulatory functions at different sites of involvement in sarcoidosis. Phenotypic and functional evaluations

Cells from recovered BAL fluid and from infiltrates in different involved tissues (lungs, lymph nodes, conjunctiva, liver, spleen, and skin) were studied in 22 patients with active sarcoidosis in order to define the surface phenotype, functional in vitro properties, and topographic distribution of the cells in granulomatous lesions. Our data demonstrated a compartmentalization of activated T cells with immunoregulatory functions from the blood to all sites of disease activity. In fact, these cells were found to express the T4+ Leu 8- 5/9+ T17- phenotype, which belongs to cells with helper activity, and that provide heightened responses in functional assays of helper activity, IL-2 release, and the ability to respond in AMLRs. Both a cellular redistribution and a local in vitro replication account for this tissue compartmentalization in sarcoidosis. The microanatomic location of activated T cells, as defined by immunohistological evaluation, showed that the state of activation in these T cells may be a consequence of an intimate contact between helper cells and macrophages within the sarcoidosis granulomas.

Pulmonary alveolar macrophages in patients with sarcoidosis and hypersensitivity pneumonitis: Characterization by monoclonal antibodies

Using a panel of monoclonal antibodies (MoAbs), the frequency of cells bearing Class I and Class II major histocompatibility complex (MHC) determinants, transferrin receptor (TR) sites, and interleukin-2 receptors (IL-2R) has been evaluated on pulmonary alveolar macrophages (PAM) recovered from the bronchoalveolar lavage (BAL) fluid of 21 patients with pulmonary sarcoidosis (including 11 cases with active sarcoidosis and 10 cases with inactive disease), 8 patients with hypersensitivity pneumonitis (HP), and 6 normal non-smoking volunteers. When the frequency of Class II DR-positive cells was considered, 64.3% of control PAM expressed HLA-DR products. No statistically significant differences were observed between controls and sarcoid patients, while HP patients showed an enhanced proportion of DR+ PAM with respect to normal PAM (P<0.05). On the contrary, the frequency of PAM expressing HLA-DQ molecules was higher in both active sarcoidosis and HP patients with respect to patients with inactive sarcoidosis and normal subjects (P<0.001). A statistically significant increase in Class I antigen-positive PAM has been demonstrated in HP patients as compared to controls (P<0.05). Active sarcoid patients showed a higher number of PAM-bearing TR sites than controls and other groups of patients considered (P<0.001). An increase in the percentage of IL-2R-positive PAM has been demonstrated in active sarcoidosis (P<0.001). Our data suggest that (1) PAM of patients with the above-considered interstitial lung diseases are in a state of activation and exhibit structures which play a crucial role in antigenic recognition by T lymphocytes, such as HLA-DQ molecules; (2) the presence of TR in PAM of patients with active sarcoidosis could be related to a more advanced differentiation stage of these cells and/or to particular functional properties; and (3) a direct role of the IL-2/IL-2R system in the interaction between T cells and monocytes in sarcoid lung is crucial. Besides representing an additional parameter which differentiates BAL features of sarcoidosis from those of HP patients, these results could represent a useful tool in the evaluation of the macrophagic component of alveolitis by the BAL.

Immunoregulation in sarcoidosis.

Abstract The immunoregulatory function of lymphocyte subpopulations was studied in 38 sarcoidosis patients subdivided according to their clinical stage and disease phase. Functions studied included the percentage and absolute numbers of TG and TM lymphocytes and their ability to help and suppress the PWM-induced B-cell differentiation of normal allogenic and autologous B cells. The percentage of TG cells was increased in both active and inactive sarcoidosis, whereas their absolute number was increased only in the active phase of disease. This increase in TG cells was unaffected by pronase treatment and the Fc-IgG receptors were modulated as well as normal TG lymphocytes. The percentage of TM cells appeared statistically reduced only in active sarcoidosis while their absolute number, considering the lymphopenia, appears uniformly reduced in both phases of the disease. Functional analysis in the PWM-induced plasma cell generation assay revealed that TG sarcoid lymphocytes retain the property of suppressing B-cell differentiation, suggesting a quantitative imbalance without qualitative alterations. Aside from being diminished, the TM cells were not able to provide an optimal intracytoplasmic Ig production thereby supporting the presence of a qualitative deficiency. B sarcoid cells when cocultured with autologous Tnon-G populations in the presence of a polyclonal activator showed an impairment in plasma cell production; however, B-cell function was almost completely restored when the help was provided by normal Tnon-G lymphocytes, suggesting that the abnormalities observed in sarcoid patients are entirely related to alterations in the T immunoregulatory functions. The implications of the finding of increased suppressor and diminished helper activity in sarcoidosis patients are discussed.

Skewing of the T-cell receptor repertoire in the lung of patients with HIV-1 infection

ObjectivesA bias of the use of T-cell receptor (TCR) Vβ regions has been reported both in peripheral blood and in several tissues in patients with AIDS, including lymph nodes, spleen and salivary glands. Although the disease is frequently characterized by an infiltration of T cells in the lung interstitium, no information is presently available on the configuration of the TCR repertoire in this microenvironment. This study was performed to address the question of whether a bias in T-cell selection occurs in the lung of patients with AIDS. MethodsTCR β-chain variable region (TCR-Vβ) repertoire was analysed by flow cytometry and polymerase chain reaction (PCR) analyses in blood and lung lymphocytes of 13 patients with HIV-1 infection at different stages of the disease. Blood and lung lymphocytes were also assessed for their responsiveness to different superantigenic stimuli represented by staphylococcal enterotoxins (SEA, SEB, SEC1, SEC2, SED and SEE). ResultsFlow cytometry analysis in AIDS patients demonstrated an overexpression of cells bearing Vβ2 and Vβ3 gene segments in the lung compared with peripheral blood of the same subjects, as well as to lung and blood lymphocytes of normal controls. PCR analysis performed in AIDS patients extended these observations and demonstrated a significant bias also in the use of T cells bearing Vβ7 and Vβ9 gene regions in the lung compartment with respect to the blood. Virtually all T cells bearing the over-represented Vβ segment belong to the CD8 subset. Interestingly, T-lymphocyte response to different superantigens demonstrated a low proliferative rate in the lung with respect to the blood in HIV-1-infected patients. ConclusionsThese findings indicate a compartmentalization of cells bearing discrete Vβ gene products in the pulmonary microenvironment of patients with AIDS and suggest that the expansion of specific-Vβ region subsets occurring in the lung might result from triggering by a superantigen.

Phenotypical and functional analysis of natural killer cells in sarcoidosis

The frequency of cells reactive with natural killer (NK)-related monoclonal antibodies (MoAbs) HNK-1, NKP-15, B73.1, VEP-13, Ab8.28 has been evaluated in the peripheral blood and bronchoalveolar lavage (BAL) fluid of 39 patients with pulmonary sarcoidosis (including 19 cases with active sarcoidosis and 20 cases with inactive disease). This phenotypic analysis was carried out together with the NK in vitro functional evaluation of cell populations from peripheral blood and BAL fluid. In addition, inhibition studies were performed in order to evaluate the ability of alveolar macrophages (M phi) to modulate NK activity. Data from peripheral blood showed an increased number of mononuclear cells bearing HNK-1, NKP-15, Ab8.28, VEP-13, and B73.1 determinants in patients with active sarcoidosis with respect to patients with inactive disease and controls. The majority of HNK-1-positive cells lacked both Leu2 and Leu3 antigens when investigated in a double marker system. A parallel increase in the in vitro cytotoxicity assay has been demonstrated. On the other hand, only a few mononuclear cells recovered from BAL fluid displayed a surface pattern of NK cells. This small population of HNK-1-positive cells expresses the HNK-1/Leu3 phenotype and does not exhibit NK activity. The alveolar M phi from sarcoid patients, as well as alveolar M phi from controls, have the property of inhibiting the NK activity of autologous peripheral blood lymphocytes. The lack of lung NK function in patients with active sarcoidosis may be related to the presence of immature forms of NK cells and/or to the release of soluble factors by alveolar macrophages.

Expression of a functional p75 interleukin-2 receptor on lung lymphocytes from patients with human immunodeficiency virus type 1 (HIV-1) infection

Lung involvement in patients affected by HIV-1 infection is characterized by an alveolitis sustained by the accumulation of CD8+ T lymphocytes. To investigate whetherin situ T cell growth plays a relevant role in the pooling of CD8+ lymphocytes, we have analyzed the activity of two lymphokines involved in the mechanisms of T cell proliferation, i.e., interleukin-2 (IL-2) and interleukin-4. To this aim, following appropriate triggering and blocking, the expression and the functional role of IL-2 receptors (IL-2R) (both p55 and p75 chains) and IL-4 receptors have been analyzed on T lymphocytes obtained from the bronchoalveolar lavage (BAL) of 16 HIV-1+ patients. Molecular and phenotypic studies we performed demonstrated that CD8+ lymphocytes from the BAL of HIV-1 + patients strongly expressed the p75 chain of IL-2 receptor, while neither p55 mRNA nor its surface membrane product (Tac antigen) was detectable; in addition, there was no expression of IL-4 receptors. IL-2 stimulation was able to induce T cell growth in a dose-dependent manner, whereas IL-4 did not. Finally, using mAbs which specifically block the p55 or p75 IL-2R, we showed that both subunits of IL-2R were involved in the proliferative activity of lung lymphocytes. The results obtained in the present study directly demonstrate that BAL T lymphocytes of HIV-1 + patients express a fully functional IL-2 receptor apparatus, pointing to the role for this lymphokine in maintaining the alveolitis taking place in the lungs of AIDS patients.

Lysis of pulmonary fibroblasts by lymphokine (IL‐2)‐activated killer cells—a mechanism affecting the human lung microenvironment?

In this study we investigated whether IL‐2‐activated killer cells may bind and exert lytic activity against non‐transformed lung fibroblasts. We demonstrated that human lymphokine‐activated killer (LAK) cells generated in vitro following incubation with recombinant IL‐2 of either peripheral blood mononuclear cells (PB‐LAK) or lymphocytes obtained from bronchoalveolar lavage (BAL‐LAK), but not resting cells, can lyse normal lung fibroblasts obtained from transbronchial lung biopsies in a 4‐h 51Cr release assay. Both autologous and allogeneic fibroblasts were consistently lysed by LAK cells, thus suggesting that the phenomenon we observed is not MHC‐restricted. Since fibroblasts can bind IL‐2 through specific receptors, we evaluated whether long‐term culture with rIL‐2 could modulate the susceptibility to lysis of target cells. Our data showed that autologous fibroblasts were more resistant to lysis than allogeneic fibroblasts when they were cultured with rIL‐2. Since LAK cells have been demonstrated to release a series of different immunomodulatory cytokines, we evaluated the effect of short‐term incubation of fibroblasts with different factors, including IL‐1, IL‐2, IL‐3, IL‐4, IL‐6, tumour necrosis factor‐alpha (TNF‐α), and interferon‐gamma (IFN‐γ), on the binding and the lysis mediated by LAK cells. These cytokines were not directly cytotoxic on fibroblasts. Only IFN‐γ was found to have a significant protective effect against the lysis. Our data support the concept that a self‐directed cytotoxicity against pulmonary fibroblasts is generated during lymphocyte activation with rIL‐2.