Yoshie Sanayama

Prediction of Relapse After Discontinuation of Biologic Agents by Ultrasonographic Assessment in Patients With Rheumatoid Arthritis in Clinical Remission: High Predictive Values of Total Gray‐Scale and Power Doppler Scores That Represent Residual Synovial Inflammation Before Discontinuation

This prospective study aimed to determine whether the comprehensive ultrasonographic assessment of synovial inflammation predicts relapse after discontinuation of treatment with a biologic agent in patients with rheumatoid arthritis (RA) in clinical remission.

Prediction of Therapeutic Responses to Tocilizumab in Patients With Rheumatoid Arthritis: Biomarkers Identified by Analysis of Gene Expression in Peripheral Blood Mononuclear Cells Using Genome‐Wide DNA Microarray

The aim of this prospective multicenter study was to identify biomarkers that can be used to predict therapeutic responses to tocilizumab in patients with rheumatoid arthritis (RA).

[18F]FDG uptake in proximal muscles assessed by PET/CT reflects both global and local muscular inflammation and provides useful information in the management of patients with polymyositis/dermatomyositis

OBJECTIVE This study aimed to determine whether [(18)F]fluorodeoxyglucose-PET/CT ([(18)F]FDG-PET/CT) discriminates PM/DM from non-muscular diseases and also whether FDG uptake in proximal muscles reflects the activity and severity of muscular inflammation in PM/DM. METHODS Twenty treatment-naïve PM/DM patients who underwent [(18)F]FDG-PET/CT were retrospectively identified by reviewing medical records. The same number of age- and sex-matched control patients with non-muscular diseases were also identified. Standardized uptake value (SUV) was calculated for each of the seven proximal muscles. For patient-based assessment, mean proximal muscle SUV was calculated by averaging the SUVs for these proximal muscles bilaterally. RESULTS Mean proximal muscle SUVs were significantly greater in PM/DM patients than in control patients (median 1.05 vs 0.69, P < 0.001). Mean proximal muscle SUVs significantly correlated with mean proximal manual muscle test scores (ρ = 0.49, P = 0.028) and serum levels of creatine kinase (ρ = 0.54, P = 0.015) and aldolase (ρ = 0.64, P = 0.002). Furthermore, SUVs in proximal muscles from which biopsy specimens were obtained significantly correlated with histological grade for inflammatory cell infiltration (ρ = 0.66, P = 0.002). CONCLUSION Our results suggest that [(18)F]FDG-PET/CT is useful in the diagnosis of PM/DM when inflammation in proximal muscles is globally assessed with quantitative measurements. Our results also indicate that local FDG uptake in a proximal muscle reflects the activity of inflammation in the same muscle and provides useful information in determining the region for muscle biopsy.

Correlation of Radiographic Progression with the Cumulative Activity of Synovitis Estimated by Power Doppler Ultrasound in Rheumatoid Arthritis: Difference Between Patients Treated with Methotrexate and Those Treated with Biological Agents

Objective. Our prospective study aimed to demonstrate that the cumulative synovial power Doppler (PD) ultrasound scores correlate with radiographic progression better than conventional measures in patients with rheumatoid arthritis (RA). We also investigated the difference between antirheumatic agents. Methods. Sixty-nine patients with RA who had recently received either methotrexate (MTX; n = 23), tumor necrosis factor (TNF) antagonists (n = 28), or tocilizumab (TCZ; n = 18) were enrolled. Patients underwent clinical, laboratory, and ultrasonographic assessment at baseline, 12 weeks, and 24 weeks. Radiographic damage was evaluated using van der Heijde modified total Sharp score (TSS) at baseline and 24 weeks. Results. Fifty-seven patients continued the same treatment regimen for 24 weeks and completed the study, and 21 patients (36.8%) showed radiographic progression during the study period. In all patients, ΔTSS significantly correlated both with cumulative 28-joint Disease Activity Score–C-reactive protein (DAS28-CRP; ρ = 0.342, p = 0.009) and cumulative total PD scores (ρ = 0.357, p = 0.006). In MTX-treated patients, cumulative total PD scores significantly correlated with ΔTSS (ρ = 0.679, p = 0.004), whereas cumulative DAS28-CRP did not (ρ = 0.487, p = 0.056). However, cumulative total PD scores did not correlate with ΔTSS in TNF antagonist–treated or TCZ-treated patients. Conclusion. Our data confirm the evidence that synovial PD activity more accurately reflects active synovial inflammation (which actually causes joint destruction) than do conventional measures in patients treated with MTX. Our data also indicate that TNF antagonists can inhibit short-term radiographic progression in the presence of active synovitis.

Helios Enhances Treg Cell Function in Cooperation With FoxP3.

Helios+FoxP3+CD4+ (Helios+) Treg cells are believed to be involved in the regulation of various autoimmune diseases; however, the regulatory mechanisms underlying the development of Helios+ Treg cells remain uncertain. This study was undertaken to elucidate the regulatory mechanisms of Helios expression in CD4+ T cells and its roles in transforming growth factor β (TGFβ)–induced Treg cell function.

AT-Rich–Interactive Domain–Containing Protein 5A Functions as a Negative Regulator of Retinoic Acid Receptor–Related Orphan Nuclear Receptor γt–Induced Th17 Cell Differentiation

The proinflammatory cytokines tumor necrosis factor α and interleukin‐6 (IL‐6) and the Th17 cell cytokine IL‐17A are implicated in the pathogenesis of rheumatoid arthritis (RA), and the blockade of these cytokines by biologic agents provides clinical benefits for RA patients. We undertook this study to clarify the mechanisms underlying the efficacy of IL‐6 blockade in RA and to find a novel target for treatment of RA.

Efficacy of abatacept for arthritis in patients with an overlap syndrome between rheumatoid arthritis and systemic lupus erythematosus.

Introduction. This study aimed to investigate the efficacy of abatacept for arthritis in patients with rhupus, an overlap syndrome between rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Methods. Patients who fulfilled both the 2010 ACR/EULAR criteria for RA classification and the 1997 ACR revised criteria for classification of SLE and received abatacept treatment for arthritis were retrospectively studied. Results. Six rhupus patients who fulfilled the inclusion criteria above were identified. All patients had active arthritis despite receiving antirheumatic drugs including methotrexate when abatacept was initiated. Clinical Disease Activity Index (CDAI) significantly decreased between baseline and 12 weeks (P = 0.028) and remained low through 24 weeks. All patients achieved either a good or moderate response according to the EULAR response criteria at 24 weeks. Health Assessment Questionnaire-Disability Index (HAQ-DI) also significantly decreased between baseline and 24 weeks (P = 0.043). In addition, the levels of immunoglobulin G and anti-DNA antibody significantly decreased between baseline and 24 weeks (P = 0.028 and P = 0.043, resp.). Conclusions. Treatment with abatacept is likely to be efficacious in patients with rhupus whose arthritis is refractory to methotrexate. In addition, abatacept may have a moderate effect on abnormal antibody production in rhupus patients.

Role of Bcl‐3 in the Development of Follicular Helper T Cells and in the Pathogenesis of Rheumatoid Arthritis

We have previously shown that expression of the Bcl‐3 gene, a member of the IκB family, is down‐regulated in CD4+ T cells from patients with rheumatoid arthritis (RA) following tocilizumab therapy. The objective of this study was to examine the role of Bcl‐3 in the pathogenesis of RA.

OP0120 Roles of B Cell Leukemia/Lymphoma 3 in The Development of T Follicular Helper Cells and the Pathogenesis of Rheumatoid Arthritis

Background Rheumatoid arthritis (RA) is a chronic inflammatory disease and proinflammatory cytokines such as TNFα and IL-6 play critical roles in the pathogenesis of RA. The blockade of IL-6 signaling by Tocilizumab (TCZ) has shown the clinical efficacy for patients with RA. To clarify the roles of IL-6 signaling in CD4+ T cells in the pathogenesis of RA, we previously compared gene expression profiles of CD4+ T cells by DNA microarray analysis before and after the treatment with TCZ in RA patients who exhibited good clinical responses to the treatment (1, 2), and identified that B cell leukemia/lymphoma 3 (Bcl3), an IκB family member, was down-regulated by TCZ therapy (1). However, the role of Bcl3 expressed in CD4+ T cells in the pathogenesis of RA remains unclear. Objectives The objective of this study is to examine the role of Bcl3 expressed in CD4+ T cells in the pathogenesis of RA. Methods We compared signal intensity of Bcl3 in CD4+ T cells between untreated RA patients and healthy controls by DNA microarray analysis. We examined the roles of IL-6-STAT3 signaling in Bcl3 induction. We also analyzed gene expression profiles of Bcl3-transduced CD4+ T cells by RNA-sequencing analysis. We examined the effect of enforced expression as well as gene silencing of Bcl3 on the development of T follicular helper (Tfh) cells. Finally, we examined a correlation between signal intensities of Bcl3 and Tfh cell-related genes in CD4+ T cells in untreated RA patients. Results Bcl3 levels were significantly higher in RA patients than those in healthy controls. IL-6 induced Bcl3 expression in CD4+ T cells in a STAT3-dependent manner. Transcriptome analysis revealed that the expression of Bcl6, a master regulator of Tfh cell differentiation, was significantly upregulated by the enforced Bcl3 expression (Figure1). The enforced Bcl3 expression increased but the Bcl3 silencing decreased IL-21-producing Tfh-like cells. Bcl3 levels were positively correlated with those of Tfh cell-related genes such as CXCR5, ICOS, and ASCL2 in CD4+ T cells in RA patients. Conclusions Bcl3 is involved in the development of Tfh cells and the pathogenesis of RA presumably by inducing IL-21 production. References Saito Y, Kagami SI, Sanayama Y, Ikeda K, Suto A, Kashiwakuma D, et al. AT-rich interactive domain-containing protein 5a functions as a negative regulator of RORγt-induced Th17 cell differentiation. Arthritis Rheum. 2014;66(5):1185-94. Sanayama Y, Ikeda K, Saito Y, Kagami S, Yamagata M, Furuta S, et al. Prediction of therapeutic responses to tocilizumab in patients with rheumatoid arthritis: biomarkers identified by analysis of gene expression in peripheral blood mononuclear cells using genome-wide DNA microarray. Arthritis Rheum. 2014;66(6):1241-31. Disclosure of Interest K. Meguro: None declared, K. Suzuki: None declared, J. Hosokawa: None declared, Y. Sanayama: None declared, S. Tanaka: None declared, S. Furuta: None declared, K. Ikeda: None declared, H. Takatori: None declared, A. Suto: None declared, O. Ohara: None declared, H. Nakajima Grant/research support from: Chugai Pharmaceutical Co., Ltd, Bristol-Myers Squibb, and Mitsubishi Tanabe Pharma Co.

Reply: To PMID 24591094.

To the Editor: I read with interest the article by Sanayama et al on the biomarkers they identified using genome-wide DNA microarray analysis of gene expression in peripheral blood mononuclear cells from rheumatoid arthritis (RA) patients treated with tocilizumab (TCZ) for the first time (1). Sanayama and colleagues studied a training cohort, a validation cohort, and a cohort of healthy volunteers to compare those who responded to TCZ to those who did not. I have several concerns about the methodology and conclusions of this study. The authors claim that they have identified candidate biomarkers that may be used to predict response to TCZ. I find it difficult to reach this conclusion given that TCZ-treated patients were not compared to control treatment arms/ patients. How do we know these candidate biomarkers do not work exactly the same way in patients treated with tumor necrosis factor inhibitors, other biologic agents, or diseasemodifying antirheumatic drugs only, let alone untreated patients? We do not even know if this is specific to RA patients, since a disease control cohort was not studied. Unfortunately, inattention to the need for appropriate control groups is nothing new to the basic sciences (2). Further, the authors included a healthy control group with subjects who were, on average, a decade younger than subjects in the treatment cohorts, even though one of the main criteria for choosing a control group is that characteristics of the control subjects should match, as much as possible, characteristics of the subjects in the treatment groups, at least with regard to demographic characteristics. Is this what is considered “good” matching of the control groups? Finally, the above issues become even more troublesome when the very small number of patients studied is considered, although the authors note this as a limitation in their study. Sanayama et al also state that they did not have enough patients to exclude Type I or II errors or perform multivariate analyses. This raises questions as to how they decided on the number of patients to include in their study. How would they determine if there were enough patients to show a real difference, or if the difference they found was not a statistical fluke? Was there no hypothesis development involved in the design? When none of the fundamental statistical testing is performed, how do they conclude that their results are scientifically valid and, more importantly, clinically useful? Recognizing and listing limitations is a good start, but it should be noted that these are not simply limitations; they are incompatible with good science. In short, a very small number of patients was studied (which did not allow for adequate statistical analysis), control groups of patients with other diseases or receiving other treatments were not used, and the healthy control group was not adequately matched. The search for biomarkers seems to be a never-ending quest. However, we need to be comfortable with the idea that there may not be any biomarker that will be useful in individual patients, where the real clinical applicability of any biomarker would be tested as physicians treat patients one at a time, not as groups. Emerging data suggest that clinically useful biomarkers are unlikely to be found for our common diseases (3–5). Therefore, we need vigorous, scientifically sound methodology for any investigation looking into these issues to shield us from premature findings and to prevent further waste of research resources. This study falls short of that goal. Dr. Yazici has received consulting fees, research support, and/or honoraria from Bristol-Myers Squibb, Celgene, Genentech, and UCB (less than