Atypical macular hole formation after Anti-VEGF therapy for neovascular age-related macular degeneration: Coincidence or consequence?

INTRODUCTION AND OBJECTIVES: Age-related macular degeneration (AMD) is the primary cause of blindness in developed countries, particularly in older adults. Anti-vascular endothelial growth factor (anti-VEGF) intravitreal injection is the current standard treatment for neovascular form of AMD. Studies reporting macular hole (MH) formation following anti-VEGF treatment are limited, and the exact pathogenesis is still under discussion. With the present study, we aim to analyse the clinical features of eyes developing MH after anti-VEGF therapy for neovascular AMD. MATERIALS AND METHODS: Patients were treated with intravitreal anti-VEGF agents for at least one year and stable for at least six months. Best-corrected visual acuity (BCVA) and optical coherence tomography findings were evaluated. RESULTS: Nineteen eyes of 18 patients were included in this study. Patients had an average age of 77.7 years at first visit and eight were female. The average number of injections before the MH formation was four. MH developed after a mean follow-up of 5.1 months after the last injection. Sixteen eyes had (84.2%) had choroidal neovascular membrane without any abnormal vitreomacular traction. Eleven eyes (57.8%) had retinal pigment epithelium detachment (PED), two (10.5%) had an epiretinal membrane (ERM), and one (5.2%) had retinal pigment epithelium (RPE) tear. The mean first and last BCVA was 1.07±0.48 LogMAR (0.3-1.8) and 1.16±0.38 logMAR (0.4-1.8), respectively. CONCLUSIONS: A macular hole can be observed in AMD patients receiving anti-VEGF therapy. Increased fibrovascular scar tissue due to subretinal fluid resolution, neovascular membrane contraction, and the presence of PED, RPE tear, and ERM may contribute to MH formation.

Indicators of a pro-tumor immune response are evident at early stages of breast cancer.

With advances in checkpoint inhibitor and CAR T-cell therapies, among other advances in immunotherapy, this is an exciting time to be a tumor immunologist. We are witnessing the transition of decades of work at the bench leading to substantial success in the clinic. While work continues developing new and improving existing immunotherapies, there remains a great deal of basic tumor immunology still to learn, information that can only lead to greater success in the clinic. One area in need of more attention is understanding the immune response at early stages of breast cancer. While there is no question that early diagnosis and treatment save lives, a greater understanding about the immune response during early stages of breast cancer may reveal information that could assist in monitoring individuals at risk of breast cancer, and could have implications for patients diagnosed at early stages of disease, and may provide important information about the origins of an immune-suppressive environment. Here, we review studies that have looked at the very early immune response to breast cancer focusing on patients with DCIS, before invasion in spontaneous transgenic murine mammary carcinoma models, and before transplantable or orthotopic murine mammary carcinoma models become palpable. The findings revealed that indicators of a pro-tumor immune response are already present at early stages of disease.

Well-circumscribed orbital venous-lymphatic malformations with atypical features in children.

AIM: To report well-circumscribed orbital lymphatic-venous malformations (VLMs) with atypical clinical, imaging and pathological features in four paediatric patients. METHODS: Retrospective non-comparative case series of four patients aged 5-18 years old having a well-circumscribed orbital mass diagnosed histopathologically as orbital VLM. All patients underwent orbitotomy and total excision of the VLM. Pre- and postoperative visual acuity, proptosis and globe displacement produced by the orbital VLM, MRI findings, histopathological features, treatment, follow-up and prognosis were evaluated. RESULTS: No proptosis, visual acuity change or globe displacement was induced by the orbital VLM. One lesion was located superiorly, one medially and two inferonasally. On MRI, the orbital VLMs were isointense on T1-weighted images and hyperintense on T2-weighted images, demonstrated moderate contrast enhancement and had a heterogenous internal structure. Signal void areas and fluid-fluid levels were not observed on MRI. At a mean follow-up of 50 months, all patients remained free of recurrence clinically and retained preoperative visual acuities. Several histopathological features of the excised lesions supported an initial diagnosis of cavernous haemangioma, but the lesions were subsequently rediagnosed as orbital VLM when aggregates of lymphocytes and randomly arranged smooth muscle were noted. CONCLUSIONS: Well-circumscribed orbital VLMs in children can display atypical clinical, imaging and pathological features. MRI features of this entity are not characteristic of typical orbital VLMs. It may be possible to totally excise well-circumscribed orbital VLMs as in this series of four patients. Careful histopathological evaluation indicates the correct diagnosis.

Impact of Tumor-Derived CCL2 on Macrophage Effector Function.

Monocyte chemoattractant protein-1 (MCP-1, CCL2) is produced by many different types of cells. In the current investigation, the effect of tumor-derived CCL2 on macrophages was evaluated to determine the extent to which this chemokine influenced the innate immune response to cancer. To do this, we used the 4T1 murine mammary carcinoma cell line that constitutively expresses CCL2 and generated 4T1 expressing an antisense CCL2 transcript. The antisense-CCL2-expressing 4T1 produced no detectable CCL2. Macrophages from female BALB/c mice were exposed to supernatants from these tumor cells. The results showed that tumor-derived CCL2 was capable of modulating cytokine gene expression but not protein production in resting, activated, and tumor-associated macrophages. In addition, tumor-derived CCL2 did not affect phagocytic activity, nitric oxide production, or cytolytic activity of the macrophages. Overall, these data suggest that tumor-derived CCL2 does not directly influence macrophage-mediated antitumor activity.

Role of C chemokine lymphotactin in mediating recruitment of antigen-specific CD62L(lo) cells in vitro and in vivo.

In this study we investigated whether T cells expressing high or low levels of CD62L were differentially susceptible to the T cell chemokine lymphotactin. We found that lymphotactin induced preferential migration of antigen-specific (CD62L(lo)) T cells over the nonspecific (CD62L(hi)) T cells in vitro and in vivo. The differing migratory abilities correlated with higher levels of mRNA encoding the lymphotactin receptor (XCR1) on the CD62L(lo) cells compared to the CD62L(hi) cells. Thus, we have identified a coupling mechanism between the activation of T cells and acquisition of new homing properties, in this case conferred by XCR1 expression. These data confirm that at least one function of lymphotactin includes mediating the recruitment of recently activated antigen-specific T cells.

Chemokine receptor desensitization in tumor-bearing mice.

We found that the murine breast cancer cell line 4T1 constitutively produced several chemokines capable of recruiting T cells. Additionally, supernatants from the tumor cell line mediated chemotaxis of T cells in a pertussis toxin-sensitive manner, indicating that these chemokines were functional. However, we also found an impaired chemotactic ability of splenic T cells in mice bearing these same tumors. The receptors for RANTES, MCP-1, and SLC were desensitized. Thus, the impaired chemotactic ability of T cells in tumor-bearing mice may explain why tumors that secrete chemokines grow progressively in a host.

Spontaneous mammary carcinomas fail to induce an immune response in syngeneic FVBN202 neu transgenic mice.

FVBN202 mice, which are transgenic for the rat neu gene, spontaneously develop mammary carcinomas between 6 and 7 months of age. We investigated whether these spontaneous tumors (spontaneous breast carcinoma cells, SBCC) could elicit an immune response in naive 6- to 8-week-old FVBN202 transgenic and FVBN nontransgenic mice. After s.c. injection of SBCC, the recently activated T cells, which were identified by their reduced expression of CD62L (L-selectin), were isolated from the draining lymph nodes, expanded with anti-CD3 and IL-2, and their cytokine response to tumor cells in vitro was analyzed. Tumor-vaccine draining lymph node lymphocytes (TVDLN) from transgenic mice failed to make IFN-gamma in response to the tumor cells. However, TVDLN from the nontransgenic mice exhibited a tumor-specific IFN-gamma response against the SBCC. This indicates that the SBCC are immunogenic. The lack of response in transgenic mice could not be attributed to cytokine immune deviation or T-cell signaling defects. Although transgenic mice were tolerant to their own tumors, their immune competence was established by their ability to respond in an allogeneic mixed lymphocyte reaction, to reject an allogeneic breast carcinoma cell line, and to produce a tumor-specific IFN-gamma response against a syngeneic cancer cell line. This transgenic mouse model provides the opportunity to investigate the immune response against a primary tumor cell culture rather than cell lines or clones and should prove useful for developing immunotherapies that overcome tolerance to self-tumor antigens.

Isolation of genes overexpressed in freshly isolated breast cancer specimens.

A number of approaches have been used to identify genes important in breast cancer. In one approach the genes already shown to be involved in other tumors, such as p53 and Her2neu, were examined. A second approach examined genes detected through genetic screening of families with a high incidence of breast cancer, for example, BRCA-1 and BRCA-2. We used a third approach, subtractive hybridization, to identify and clone genes that were preferentially expressed in breast cancer cells compared to normal mammary epithelium. Instead of analyzing breast cancer cell lines, we examined fresh human breast cancer specimens. By subtracting normal mammary epithelial cDNA from breast cancer cDNA, we were able to clone several genes overexpressed in breast cancer. Two of these genes, L19 and MLN70, were previously reported to be overexpressed in breast cancer. Three of these genes, L19, L34, and MLN70, were localized to a region on chromosome 17 where Her2/neu and BRCA-1 are found. In addition, we isolated a gene we call breast cancer associated gene-1 that was expressed almost exclusively in fresh breast cancer tissue and not in normal mammary epithelium or breast cancer cell lines. We were unable to detect expression of breast cancer associated gene-1 in cell lines from melanoma, renal cell carcinoma, lymphoma, or leukemia. The full-length sequence from two separate breast cancer specimens revealed one amino acid difference compared to the sequence from normal breast epithelial tissue. Further studies are necessary to determine whether these genes contribute to breast cancer development or can be used as therapeutic targets.

TCR v(beta) usage and clonality of T cells isolated from progressing and rejected tumor sites before and after in vitro culture.

A gelatin sponge model of concomitant tumor immunity was employed in order to examine the clonality of T cells associated with progressing and rejected tumor sites. Here we show that freshly isolated T cells bearing TCR V(beta)1, CDR3 RPGTGN, J(beta)1.1 and TCR V(beta)8, CDR3 GD, J(beta)1.6 predominated progressing and rejected tumor sites. Despite the similarity in T cell populations, the T cells from rejected tumor sites were capable of killing the autologous tumor cells, whereas T cells from progressing tumor sites were not able to do so. The differing cytolytic ability could not be attributed to a difference in TCR zeta chain protein expression levels between both T cell populations. After a 5 day mixed lymphocyte tumor culture the T cells from the progressing tumor site were capable of killing autologous tumor cells, which suggested changes took place within the cell population during in vitro culture. Further TCR analysis revealed T cells bearing TCR V(beta)1, CDR3 RPGTGN, J(beta)1.1 and TCR V(beta)8, CDR3 GD, J(beta)1.6 were not expanded following the in vitro culture. These data suggest that the lack of cytotoxicity of freshly isolated tumor-infiltrating lymphocytes (TIL) was not due to abnormal TCR zeta chain expression or major differences in the TCR V(beta) usage. Additionally, the gain of TIL effector function did not correlate with an expansion of the TCR bearing T cells found to predominate the in vivo response. These data suggest that the predominant TCR V(beta) used by lymphocytes infiltrating regressing or rejected tumors may not represent the tumor reactive T cells that grow in culture or respond to the autologous tumor in vitro.

Mutated cytochrome b as a determinant of a new monoclonal antibody (H8.98) on renal carcinoma cell lines recognized by a Vgamma3Vdelta1(+) T-cell clone.

We generated a monoclonal antibody (MAb), H8.98, that recognizes an antigen shared by 50% of examined renal carcinoma cell (RCC) lines and is susceptible to lysis by a Vgamma3Vdelta1(+) T-cell clone derived from RCC tumor-infiltrating lymphocytes. H8.98 inhibited Vgamma3Vdelta1(+ )T-cell clone-mediated lysis of RCC lines. It did not stain normal kidney lines, melanomas, fibroblasts, Burkitt's lymphoma or Epstein-Barr virus-transformed B-cell lines but it did stain 2 of 4 tested breast cancer lines. Through screening of a renal carcinoma cDNA library using H8.98, we isolated a cDNA clone which, upon sequencing, was found to be cytochrome b with 2 point mutations.

Peripheral T lymphocytes from women with breast cancer exhibit abnormal protein expression of several signaling molecules.

We examined signaling molecules of peripheral blood T lymphocytes obtained from women with breast cancer. In 6 of 14 patients, T lymphocytes displayed an impaired ability to translocate NFêB p65 (Rel-A) following activation by anti-CD3 and IL-2. This observation was made despite normal cytoplasmic levels of the Rel-A protein. We also detected abnormally low levels of the signaling molecules T-cell receptor (TCR)-zeta, ZAP-70 and p56lck in 4 of 14 breast cancer patients, i.e., defects in T-cell signaling molecules. T lymphocytes from 6 of the 14 patients also exhibited an increased expression of the dual specificity phosphatase, map kinase phosphatase-1 (MKP-1). MKP-1 inactivates MAP kinase and therefore may interfere with the activation of c-jun and c-fos. Abnormalities of I or more signaling molecules were found in 9 of 14 patients; however, only 3 patients had T cells that exhibited all 5 defects. Our data have implications for the detection of potentially dysfunctional T cells in patients with cancer. For example, the analysis of only 1 signaling molecule may allow patients with significant defects in T-cell signaling to go unnoticed. Finally, despite impaired Rel-A translocation, T cells were capable of transcribing IL-2. Impairments in the translocation of Rel-B and c-Rel further suggest that the NFKB family members Rel-A, Rel-B and c-Rel are not required for the transcription of IL-2 in the peripheral T lymphocytes of patients with breast cancer.

Expression of an antisense transforming growth factor-beta1 transgene reduces tumorigenicity of EMT6 mammary tumor cells.

Transforming growth factor-beta (TGF-beta) is a potent immunosuppressive cytokine produced by many tumor cells. Secretion of TGF-beta by malignant cells may therefore be a mechanism by which tumor cells escape destruction by tumor-specific T lymphocytes. In order to evaluate the role of tumor-derived TGF-beta on tumor progression, we have inhibited the production of this cytokine by introducing a gene encoding antisense TGF-beta1 into the EMT6 murine mammary tumor cell line using a retroviral vector (Las-TGF-beta1SN). EMT6 cells transduced with this vector (EMT6as-TGF-beta1) stably expressed the antisense gene and secreted 52% less TGF-beta than did tumor cells transduced with the backbone vector alone. Supernatant fluid recovered from tumor cells expressing the antisense TGF-beta1 gene also exhibited a decreased capacity to inhibit alloantigen-specific cytotoxic T-cell responses in vitro. Furthermore, tumor growth in mice injected with EMT6as-TGF-beta1 tumor cells was inhibited compared to mice injected with control tumor cells. These results demonstrate that expression of antisense TGF-beta1 by transduced EMT6 cells decreases their tumorigenicity and suggest that this approach of eliminating immune suppression is a potentially useful strategy to enhance antitumor responses.

Studies of in vivo recruitment and activation of cytotoxic lymphocytes using a gelatin-sponge model of concomitant tumor immunity.

We have earlier described a sponge model of concomitant tumor immunity that permits the capture and isolation of effector T lymphocytes that mediate the rejection of a secondary EMT6 tumor implant. In this study, we have employed the sponge model to study lymphocyte homing and in situ activation during the development of concomitant tumor immunity. Our results demonstrate that EMT6-specific CTL in animals bearing primary EMT6 tumors home preferentially to sponges implanted with EMT6 tumor cells, as compared with contralateral sponges lacking tumor cells or sponges injected with antigenically distinct 168 tumor cells. We further show that recruitment is selective and is not in response to a foreign-body reaction to the sponge. In addition, we show that EMT6-specific CTL were recovered from sponges injected either with intact EMT6 tumor cells or with a mixture of EMT6-derived membranes and supernatant. In contrast, cells accumulating in sponges injected with membranes or supernatant alone were not cytolytic. Thus, maximal recruitment, retention, and activation of CTL precursors require putative chemo-attractive factors secreted by tumor cells as well as interaction with tumor antigen.

T lymphocytes infiltrating sites of tumor rejection and progression display identical V beta usage but different cytotoxic activities.

Most tumors grow progressively and overwhelm the host. The rare but documented cases of spontaneous regression of primary tumors are indicative of the potential of tumor-bearing hosts to develop a significant antitumor response. Because most tumors grow progressively in the host, it is not surprising that the majority of studies have focused on T lymphocytes that infiltrate these tumors. Although these studies have generated significant and useful information during the period of tumor growth, they can only speculate on the mechanisms that are involved in tumor rejection. We have used a well developed sponge model of concomitant tumor immunity that allows us to compare the immunologic events that occur during tumor progression vs rejection. In this model, an animal harboring a primary EMT6 mammary tumor is challenged with a secondary tumor implant through a pre-implanted gelatin sponge. During the manifestation of concomitant tumor immunity, the secondary tumor is rejected and the effector cells mediating the response are retained within the sponge matrix. Using this model we analyzed the TCR usage, cytotoxic activity of lymphocytes, and cytokine production at both tumor sites. The data revealed that tumor-rejecting lymphocytes isolated from the site of secondary tumor implant were cytotoxic toward EMT6 cells, whereas tumor-infiltrating lymphocytes isolated from the progressing primary tumor were not. Interestingly, the TCR-V beta repertoire of the tumor-infiltrating lymphocytes and tumor-rejecting lymphocytes were identical with V beta 1 and V beta 8 being predominant at both sites. Furthermore, the rejection site showed higher gene expression of IFN-gamma, TNF-alpha, and IL-10 whereas TGF-beta expression was slightly higher in the progressing tumors. These findings suggest that the disparate effector functions observed during tumor progression vs rejection are not caused by different T cell phenotypes but may be due instead to influences exerted by cytokines produced at the tumor sites.