Real-world clinical profile, treatment patterns and patient-reported outcomes for thyroid cancer in Japan.

Aim: To provide a real-world snapshot of the clinical profile, management, and patient-reported outcomes (PRO) for advanced medullary and papillary thyroid cancer prior to the availability of rearranged during transfection (RET) inhibitors in Japan. Materials & methods: Physicians completed patient-record forms for eligible patients seen during routine clinical practice. Physicians were also surveyed about their routine practice and patients were asked to provide PRO data. Results: RET testing patterns varied by hospital type; no therapeutic relevance was a commonly cited reason to not carry out testing. Multikinase inhibitors were the main systemic therapies prescribed, although timing to start multikinase inhibitors varied; adverse events were reported as challenges. PROs revealed high disease/treatment burden. Conclusion: More effective and less toxic systemic treatment targeting genomic alterations is needed to improve long-term outcomes of thyroid cancer.

This survey, conducted in Japan in 2020, included doctors who treat thyroid cancer and their patients. It is called a real-world survey because it provides information such as the types of tests and treatments used for thyroid cancer management in everyday clinical practice. The survey focused on two types of thyroid cancer: papillary thyroid cancer (PTC), a common type, and medullary thyroid cancer (MTC), an uncommon type. About 10­20% of people with PTC and most people with MTC have alterations in a gene called RET, which caused the cancer. Laboratory tests can identify these gene alterations, fusions (joining the parts of two different genes) or mutations (changes to a gene's DNA sequence) and results can help guide treatment decisions. The survey showed that testing for RET gene alterations was less than optimal and varied by the type of hospital/center. Common reasons provided by doctors for not testing for RET alterations were, "no therapeutic relevance for patient management" and "specific targeted therapies not available". However, the survey was conducted before the availability in Japan of the treatment selpercatinib, which selectively targets/inhibits tumors with RET alterations. Most patients in the survey, including those with RET alterations, received treatment with a type of inhibitor called multikinase inhibitors, as per available guidelines. Doctors considered side effects due to inhibition of multiple targets by multikinase inhibitors to be among areas for improvement needed. People with PTC and MTC also reported substantial burdens (i.e., negative impact on their lives) from the disease/treatment. The researchers concluded that barriers to RET testing need to be overcome, and more effective and less toxic treatments targeting gene alterations are needed to improve long-term outcomes.

Current perspectives on the management of patients with advanced RET-driven thyroid cancer in Europe.

The incidence of thyroid cancer is increasing worldwide with the disease burden in Europe second only to that in Asia. In the last several decades, molecular pathways central to the pathogenesis of thyroid cancer have revealed a spectrum of targetable kinases/kinase receptors and oncogenic drivers characteristic of each histologic subtype, such as differentiated thyroid cancer, including papillary, follicular, and medullary thyroid cancer. Oncogenic alterations identified include B-Raf proto-oncogene (BRAF) fusions and mutations, neurotrophic tyrosine receptor kinase (NTRK) gene fusions, and rearranged during transfection (RET) receptor tyrosine kinase fusion and mutations. Multikinase inhibitors (MKIs) targeting RET in addition to multiple other kinases, such as sorafenib, lenvatinib and cabozantinib, have shown favourable activity in advanced radioiodine-refractory differentiated thyroid cancer or RET-altered medullary thyroid cancer; however, the clinical utility of MKI RET inhibition is limited by off-target toxicity resulting in high rates of dose reduction and drug discontinuation. Newer and selective RET inhibitors, selpercatinib and pralsetinib, have demonstrated potent efficacy and favourable toxicity profiles in clinical trials in the treatment of RET-driven advanced thyroid cancer and are now a therapeutic option in some clinical settings. Importantly, the optimal benefits of available specific targeted treatments for advanced RET-driven thyroid cancer require genetic testing. Prior to the initiation of systemic therapy, and in treatment-naïve patients, RET inhibitors may be offered as first-line therapy if a RET alteration is found, supported by a multidisciplinary team approach.

Specific fibroblastic niches in secondary lymphoid organs orchestrate distinct Notch-regulated immune responses.

Fibroblast-like cells of secondary lymphoid organs (SLO) are important for tissue architecture. In addition, they regulate lymphocyte compartmentalization through the secretion of chemokines, and participate in the orchestration of appropriate cell-cell interactions required for adaptive immunity. Here, we provide data demonstrating the functional importance of SLO fibroblasts during Notch-mediated lineage specification and immune response. Genetic ablation of the Notch ligand Delta-like (DL)1 identified splenic fibroblasts rather than hematopoietic or endothelial cells as niche cells, allowing Notch 2-driven differentiation of marginal zone B cells and of Esam(+) dendritic cells. Moreover, conditional inactivation of DL4 in lymph node fibroblasts resulted in impaired follicular helper T cell differentiation and, consequently, in reduced numbers of germinal center B cells and absence of high-affinity antibodies. Our data demonstrate previously unknown roles for DL ligand-expressing fibroblasts in SLO niches as drivers of multiple Notch-mediated immune differentiation processes.

Notch signaling regulates follicular helper T cell differentiation.

Follicular helper T (TFH) cells are specialized in providing help for B cell differentiation and Ab secretion. Several positive and negative regulators of TFH cell differentiation have been described but their control is not fully understood. In this study, we show that Notch signaling in T cells is a major player in the development and function of TFH cells. T cell-specific gene ablation of Notch1 and Notch2 impaired differentiation of TFH cells in draining lymph nodes of mice immunized with T-dependent Ags or infected with parasites. Impaired TFH cell differentiation correlated with deficient germinal center development and the absence of high-affinity Abs. The impact of loss of Notch on TFH cell differentiation was largely independent of its effect on IL-4. These results show a previously unknown role for Notch in the regulation of TFH cell differentiation and function with implications for the control of this T cell population.

Commensal gut flora reduces susceptibility to experimentally induced colitis via T-cell-derived interleukin-10.

BACKGROUND: Regulatory cytokines are well known to modify experimental colitis in mice. The aim of this study was to elucidate the effect of interleukin (IL)-10 derived from different cellular sources and the effect of commensal gut flora in dextran sulfate sodium (DSS)-induced colitis in mice. METHODS: Wildtype (WT) and IL-10 deficient (IL-10(-/-) ) mice either harboring a characterized specific pathogen-free (SPF) gut flora or germfree were exposed to 2% DSS. Moreover, cell type-specific IL-10, IL-4, and IL-12 knockout mice and animals combining the T-cell-specific IL-10 knockout with a deficiency in IL-12 or IL-4 were exposed to DSS. RESULTS: SPF IL-10(-/-) mice showed an increased susceptibility to DSS-induced colitis compared to WT mice determined by histopathology and proinflammatory cytokine and chemokine responses. Under germfree conditions, both WT and IL-10(-/-) mice were highly susceptible to DSS. IL-10 mRNA was increased upon DSS exposure in WT SPF but not in germfree mice. Mice carrying a specific deletion of IL-10 in T-cells exhibited a tendency towards an enhanced susceptibility to DSS. The lack of T-cell-derived IL-10 in combination with the lack of IL-4 increased the susceptibility to DSS colitis, as did the lack of IL-12 alone. CONCLUSIONS: IL-10 is a crucial factor inhibiting the innate proinflammatory immune response induced by DSS. Intestinal bacteria are necessary for the induction of protective IL-10, which is mainly T-cell-derived. T-cell-derived IL-10 can only mediate its protective effect in a Th1-dominated milieu. If the balance is shifted towards a Th2 response, IL-10 is not protective.

Notch signaling in the immune system.

The Notch signaling pathway regulates many aspects of embryonic development, as well as differentiation processes and tissue homeostasis in multiple adult organ systems. Disregulation of Notch signaling is associated with several human disorders, including cancer. In the last decade, it became evident that Notch signaling plays important roles within the hematopoietic and immune systems. Notch plays an essential role in the development of embryonic hematopoietic stem cells and influences multiple lineage decisions of developing lymphoid and myeloid cells. Moreover, recent evidence suggests that Notch is an important modulator of T cell-mediated immune responses. In this review, we discuss Notch signaling in hematopoiesis, lymphocyte development, and function as well as in T cell acute lymphoblastic leukemia.

Monocytes/macrophages and/or neutrophils are the target of IL-10 in the LPS endotoxemia model.

IL-10 is a potent regulator of the innate and adaptive immune responses. Several cell types produce IL-10 and its receptor chains and these may regulate different immune responses. Here we report that inactivation of the IL-10 receptor (IL-10R1) gene in mice leads to an increased susceptibility to chemically induced colitis as in the classical IL-10-deficient mutant. To identify the cells regulated by IL-10 in immune responses, we generated several cell type specific IL-10R1-deficient mutants. We show that, in an IL-10-dependent LPS model of endotoxemia, dampening of the immune response requires expression of IL-10R1 in monocytes/macrophages and/or neutrophils but not in T cells nor B cells. As the macrophage and/or neutrophil-specific IL-10-deficient mutants also display the same phenotype, our results suggest that an autocrine loop in monocytes/macrophages is the most probable mechanism for the regulation of an LPS-induced septic shock. In contrast, in an IL-10-regulated T-cell response to Trichuris muris infection, IL-10 acting on T cells or monocytes/macrophages/neutrophils is not critical for the control of the infection.

T-cell-specific deletion of gp130 renders the highly susceptible IL-10-deficient mouse resistant to intestinal nematode infection.

Gp130 is the common receptor of the IL-6 family of cytokines and is involved in many biological processes, including acute phase response, inflammation and immune reactions. To investigate the role of gp130 under inflammatory conditions, T-cell-specific conditional gp130 mice were first bred to the IL-10-deficient background and were then infected with the gastrointestinal nematode Trichuris muris. While IL-10(-/-) mice were highly susceptible to T. muris, developed a mixed Th1/Th17 response and displayed severe inflammation of the caecum, infection of mice with an additional T-cell-specific deletion of gp130 signalling completely reversed the phenotype. These mice showed an accelerated worm expulsion that was associated with the rapid generation of a strong Th2 immune response and a significant increase in Foxp3-expressing Treg. Therefore, gp130 signalling in T cells regulates a switch between proinflammatory and pathogenic Th1/Th17 cells and regulatory Th2/Treg in vivo. Taken together, the data demonstrate that gp130 signalling in T cells is a positive regulator of inflammatory processes, favouring the Th1/Th17 axis.

Conditional gp130 deficient mouse mutants.

The common cytokine receptor chain, gp130, controls the activity of a group of cytokines, namely, IL-6, IL-11, IL-27, ciliary neurotrophic factor (CNTF), leukemia inhibitory factor (LIF), oncostatin M (OSM), cardiotrophin-1 (CT-1), cardiotrophin-like cytokine (CLC) and neuropoietin (NPN). This family of cytokines is involved in multiple different biological processes, including inflammation, acute phase response, immune responses and cell survival. To analyze the different components of the gp130 network, mouse mutants for the single cytokine were generated by conventional gene targeting. However, since the cytokines of the IL-6 family show redundancy, it does not reveal the complete picture. Therefore, the study of mice with a cell type specific inactivation of the gp130 receptor chain is an approach that will subsequently allow the dissection of the cellular cytokine network. Here, we summarize the experimental results of the conditional gp130 mutants published so far.