Joanna Domagała-Kulawik

The role of the immune system in non-small cell lung carcinoma and potential for therapeutic intervention.

Over a hundred years after the first description of this disease, lung cancer represents one of the major challenges in oncology. Radical treatment cannot be introduced in more than 70% of cases and overall survival rate does not exceed 15%. The immunosurveillance of lung cancer may be effective in early oncogenesis but is inhibited in the course of developing a clinically detectable tumor. Very low and heterogonous antigenicity of lung cancer cells leads to passive escape from anti-cancer immune defense. The cytotoxic lymphocytes (CTLs) that play a main role in the anticancer response are actively suppressed in the tumor environment and following regulatory mechanisms inhibit the recognition of tumor antigens by antigen presenting cells. The population of regulatory T cells (Tregs) is augmented and the expression of transcription factor-Foxp3 is markedly increased on tumor cells and tumor infiltrating lymphocytes (TIL). It is accomplished by M2 macrophage polarization, the activity of myeloid derived suppressor cells (MDSCs) and a significantly elevated concentration of cytokines: transforming growth factor beta (TGFβ) and IL-10 in the tumor microenvironment. Very active suppression of immune protection is the predominant role of the programmed death 1 (PD-1)-PD-L1 pathway. The blockage of this pathway was found to be an effective treatment approach; therefore the monoclonal antibodies are being intensively investigated in lung cancer patients. Cytotoxic T lymphocyte antigen-4 (CTLA-4) is the molecule capable of inhibiting the activation signal. The antibody anti-CTLA-4 improves CTLs function in solid tumors and lung cancer patients may benefit from use of this agent. The second way in lung cancer immunotherapy is production of anti-cancer vaccines using recognized cancer antigens: MAGE-A3, membrane associated glycoprotein (MUC-1), and EGF. It was recently shown in ongoing clinical trials that combined therapies: immune- and chemotherapy, radiotherapy or targeted therapy seem to be effective. Immunotherapy in lung cancer has an individual character-there is a need to assess the patients immune status prior to implementation of immunomodulating therapy.

IL-6 and IL-13 in Induced Sputum of COPD and Asthma Patients: Correlation with Respiratory Tests

Background: IL-6 is strongly implicated in the development of chronic obstructive pulmonary disease (COPD). IL-13 is the well-documented central mediator in allergic asthma. IL-6 is attributed to the proinflammatory activities in COPD as well as asthma. In COPD patients exacerbation is increased by serum IL-6. The association of IL-13 as well as IL-6 with the impaired respiratory function of asthma patients remains controversial. Objectives: The aim of this study was to compare the concentration of IL-6 and IL-13 in the induced sputum of asthma and COPD patients, and to assess the possible association of these cytokines with the impairment of lung function. Methods: Twenty-six subjects with COPD and 18 subjects with asthma were enrolled in this study. IL-6 and IL-13 levels were measured in induced sputum by ELISA and correlated with the results of respiratory tests. Results: The induced sputum of COPD patients had a significantly higher IL-6 level than the sputum of asthma subjects while no significant differences were found in the levels of IL-13. There was a statistically significant negative correlation between IL-6 level and FEV1 or FEV1/FVC in asthma patients (r = –0.59 and –0.54, respectively) and a negative correlation that did not reach statistical significance between IL-6 level and FEV1, FEV1% or FVC in COPD subjects (r = –0.30, –0.30 and –0.38, respectively). There was no relationship between concentrations of IL-13 and impaired respiratory function. Conclusions: Our results confirmed that IL-6, but not of IL-13, is associated with respiratory disorders in both asthma and COPD patients.

Prognosis of acute respiratory distress syndrome in neutropenic cancer patients

To date, no study has been specifically designed to identify determinants of death in neutropenic cancer patients presenting with acute respiratory distress syndrome (ARDS). The aim of this study was to identify early predictive factors of 28-day mortality in these patients. Factors associated with 28-day mortality during intensive care unit (ICU) stay were also described. 70 consecutive cancer patients with ARDS and neutropenia were prospectively analysed over a 6-yr period. Mortality at 28 days was 63%. Factors independently associated with good prognosis were: lobar ARDS (OR 0.10, 95% CI 0.02–0.48), use of initial antibiotic treatment active on difficult to treat bacteria (ticarcillin-resistant Pseudomonas aeruginosa, Stenotrophomonas maltophilia or extended-spectrum &bgr;-lactamase-producing strains) (OR 0.08, 95% CI 0.02–0.33) and first-line chemotherapy (OR 0.08, 95% CI 0.02–0.37). During the ICU stay, mortality was associated with the markers of organ dysfunctions, the absence of neutropenia recovery and the use of vasopressors. During the first 3 weeks, the conditional probability of discharge alive from ICU did not decrease. At ICU admission, first-line chemotherapy, lobar ARDS and antibiotic treatment active on difficult-to-treat bacteria were associated with survival. During ICU stay, mortality was associated with organ dysfunctions and use of vasopressors. Most survivors have an ICU stay of >3 weeks.

Mechanisms of immune response regulation in lung cancer.

Lung cancer is a leading cause of cancer deaths. As a solid tumor with low antigenicity and heterogenic phenotype lung cancer evades host immune defense. The cytotoxic anticancer effect is suppressed by a complex mechanism in tumor microenvironment. The population of regulatory T cells (Tregs) plays a crucial role in this inhibition of immune response. Tregs are defined by presence of forkhead box P3 (Foxp3) molecule. The high expression of Foxp3 was found in lung cancer cells and in tumor infiltrating lymphocytes (TIL). Cytotoxic T-lymphocyte antigen 4 (CTLA4) is constitutively expressed on Tregs and suppresses T cell activation. The elevated CTLA4 expression in lymphocytes in patients with lung cancer was found. Recently the antibodies blocking CTLA4 showed some clinical efficacy in patients with lung cancer. Cancer cells and immune cells release many cytokines capable to show suppressive immune effect in cancer microenvironment. The most active are transforming growth factorβ (TGFβ) and IL-10. The pleiotropic function of Th17 population is TGFβ related. The myeloid lineage of suppressor cells in lung cancer is represented by tumor associated macrophages (TAM) with phenotype of M2 macrophages and some regulatory properties with releasing amounts of IL-10 and TGFβ. The myeloid derived suppressor cells (MDSCs) control cytotoxic T cell activity in mechanisms which are highly dependent on the context of tumor environment. The mechanisms of anticancer immune response regulation need further investigation as an important target to new way of treatment.

Interstitial lung disease in systemic sclerosis: comparison of BALF lymphocyte phenotype and DLCO impairment.

Patients with scleroderma (systemic sclerosis-SSc) frequently develop an interstitial lung disease. The role of lymphocytes in fibrosing alveolitis preceding lung fibrosis has been established. The purpose of this work was to evaluate cell profiles and lymphocyte phenotypes in the bronchoalveolar lavage (BAL) fluid and to correlate them with depression in lung function tests detected by depletion of diffusing capacity (DLCO). BAL was carried out in 25 untreated, non-smoking patients suffering from diffuse scleroderma and in 12 healthy non-smoking volunteers. For the analysis of lymphocyte sub-sets flow cytometry and monoclonal antibodies were used. The following cell sub-types were counted: T lymphocytes, B lymphocytes, helper lymphocytes, suppressor/cytotoxic lymphocytes, natural killer cells, cytotoxic T lymphocytes and activated T lymphocytes. The total cell count was higher in the group of patients with mild and moderate impairment in DLCO. The percentage of lymphocytes was greater in patients with DLCO lower than 65% of the predicted value since neutrophilia was found in patients with severe DLCO depletion, i.e. significant when compared with healthy subjects. The proportions of suppressor/cytotoxic lymphocytes and of activated T lymphocytes were higher in patients than in controls. The statistical analysis revealed significant differences between patients with moderate and mild changes in DLCO and the healthy volunteers. A decreased helper/suppressor ratio was noticed in these patients. We concluded that the BALF lymphocyte phenotype analysis may reflect the features of alveolitis in patients with SSc.

Diagnosis and Management of Premature Ventricular Complexes-Associated Chronic Cough

BACKGROUND Chronic cough frequently remains unexplained. Although various cardiac arrhythmias have already been reported as a cause of chronic cough, this phenomenon has not been evaluated prospectively. Therefore, we studied the incidence and management of cough associated with premature ventricular complexes (PVCs) in a population of patients with this condition. METHODS Patients without organic heart disease who had been referred for the management of symptomatic PVC were evaluated prospectively. PVC-associated cough was recognized if cough episodes occurred just after spontaneous or induced PVC or observed in an ECG or a multichannel recording system that included ECG. A differential diagnosis of cough was performed according to the guidelines on cough. Afterward, antiarrhythmic therapy was instituted to eliminate PVC and cough. RESULTS Of the 120 patients who were referred for the management of PVC, 10 had a chronic cough. After extensive workup for the cause of chronic cough, the cough was thought to be solely due to PVC in one patient, partially due to PVC plus another cause in five patients, and not due to PVC but to nonasthmatic eosinophilic bronchitis, gastroesophageal reflux disease, and chronic sinusitis in four patients. Patients with PVC-associated cough reported more severe perception of symptoms associated with arrhythmia than patients without cough (mean [+/- SD] visual analog scale score, 8.2 +/- 0.5 vs 5.7 +/- 1.6, respectively; p < 0.01). PVC-associated cough disappeared after antiarrhythmic treatment (radiofrequency ablation [n = 4], oral antiarrhythmic agent [n = 1]), or after spontaneous remission of PVC (n = 1). CONCLUSIONS PVC may be a cause of chronic cough. Interdisciplinary cooperation is warranted for the proper diagnosis and management of PVC-associated cough.

Th1/Th2/Th17‑related cytokines in the bronchoalveolar lavage fluid of patients with sarcoidosis: association with smoking.

INTRODUCTION Sarcoidosis is a multiorgan granulomatous disease of unknown etiology. The predominance of Th1‑related cytokines is observed in the bronchoalveolar fluid (BALF) in pulmonary sarcoidosis. Recently, Th17 cells have been postulated to be involved in the pathogenesis of sarcoidosis. Sarcoidosis is more prevalent in nonsmokers than in smokers. The exact effect of smoking on granulomatous inflammation in this disease remains unclear. OBJECTIVES The aim of the study was to evaluate the Th1/Th2/Th17‑related cytokine concentration in the BALF of patients with pulmonary sarcoidosis in relation to smoking status. PATIENTS AND METHODS The study included 74 patients with confirmed pulmonary sarcoidosis. Data on smoking status were available for 61 patients (26 ever‑smokers, 35 never‑smokers; mean 11 ±9.1 pack-years in smokers). The concentrations of interleukin (IL) 17A (IL‑17A), IL‑10, IL‑6, IL‑4, and IL‑2 as well as interferon γ (IFN‑γ) and tumor necrosis factor α (TNF‑α) were measured in BALF supernatants using a flow cytometry method--the Cytometric Bead Array. RESULTS The median concentration of IL‑6, IFN‑γ, and IL‑17A (2.19 pg/ml, 1.28 pg/ml, and 6.08 pg/ml, respectively) did not differ significantly between smokers and nonsmokers. TNF‑α, IL‑10, IL‑4 and IL‑2 levels were below the detection limit in most patients. We observed a significant correlation between IFN‑γ concentration and the number of macrophages in BALF (r = 0.66, P <0.05) and between IL‑17A and IL‑6 levels (r = 0.94, P <0.05). CONCLUSIONS We confirmed a significant role of IL‑6, IFN‑γ, and IL-17A in the local inflammatory response in sarcoidosis. However, the interpretation of the limited number of cytokine measurements should be made with caution. Further studies are needed to explain the effect of smoking on the pathomechanism of inflammation in sarcoidosis.

Bronchoalveolar lavage total cell count in interstitial lung diseases--does it matter?

Bronchoalveolar lavage (BAL) is a useful technique for differential diagnosis of various interstitial lung diseases (ILDs) and is usually realized by analysis of the differential cell count. This study was conducted to estimate the value of bronchoalveolar lavage fluid (BALF) total cell count (TCC) in the diagnosis of ILD. We analyzed 237 BAL samples from patients with ILD: sarcoidosis (SA), idiopathic pulmonary fibrosis (IPF), cryptogenic organizing pneumonia (COP), hypersensitivity pneumonitis (HP), chronic eosinophilic pneumonia (CEP), and smoking-related ILD (sr-ILD). The control group consisted of 30 healthy volunteers. The statistical analysis revealed significant differences in the BALF TCC between healthy controls and patients with SA, IPF, HP, COP, sr-ILD, and eosinophilic disorders (mean values 6.9 vs. 14.5, 22.5, 22.8, 20.7, 64.5, and 27.3 × 106, respectively). Logistic regression revealed a significant relation between the TCC and ILD diagnosis. We conclude that the TCC, as well as the value of total number of inflammatory cells, should be reported in the description of BAL.

BAL in the diagnosis of smoking-related interstitial lung diseases: Review of literature and analysis of our experience

The group of interstitial lung diseases (ILDs) is formed by respiratory tract disorders, whose aetiology is unknown in the majority of cases, the clinical course differs and the prognosis is generally serious. Some of the ILDs have a potential relation to tobacco smoking and are known as smoking‐related ILDs (sr‐ILD). Bronchoalveolar lavage fluid (BALF) examination is one of the initial procedures in the diagnosis of ILD. Despite the fact that histological confirmation is the gold standard in ILD diagnosis in many studies, the number of reported biopsies was low. In this review we present the results of BALF examinations of patients with sr‐ILD and discuss their value in the differential diagnosis with other types of ILD.

Macrophage polarization in interstitial lung diseases.

The role of bronchoalveolar lavage fluid (BALf) examination in differential diagnosis of interstitial lung diseases (ILD) was established. Currently, functional polarization into M1 (pro-inflammatory) and M2 (anti-inflammatory) subpopulations is emphasized. The aim of our study was to compare the proportion of M1 and M2 in BALf of patients with different ILD. BALf samples were collected from 75 ILD patients: sarcoidosis (SA, 36), hypersensitivity pneumonitis (HP, 10), non-specific interstitial pneumonia (NSIP, 8), idiopathic pulmonary fibrosis (IPF, 6) and other ILD (15). Phenotyping was performed by immunocytochemistry with anti-CD40 and CD163 antibodies (for M1 and M2, respectively). For both, CD40 and CD163, three populations of cells have been specified: small cells with strong (+++), large cells with weak (+) and cells with no (–) reaction. Due to lack of statistically significant differences between patients with HP, NSIP and IPF, they were classified into a common group and compared to the group of patients with sarcoidosis. The median proportion of macrophage population was as follows: for CD40: 61%, 35%, 2% in patients with SA and 49%, 47%, 3% in patients with other ILD and for CD163: 55%, 35%, 5% in SA and 53%, 43%, 1% in ILD patients, respectively. We found a significantly higher proportion of M1 in SA when compared with other ILD. Our study showed no evidence of defined polarization of alveolar macrophages in different types of interstitial lung diseases. However, we emphasized the role of CD40 positive cells in sarcoidosis and the role of CD163 positive cells in fibrotic diffuse lung diseases.