Role of Volumetric Modulated Arc Technique Radiotherapy in a Rare Case of Intraductal Apocrine Carcinoma of Parotid Gland.

Introduction Apocrine carcinoma, a cancer of sweat glands, is very rare, with a global incidence of 0.0049 to 0.0173 cases per 100,000 persons annually. It is usually found in axilla and anogenital areas. The intraductal apocrine variety of salivary duct carcinoma in the parotid gland is very rare and aggressive and may be due to ectopic sweat glands in the parotid gland duct or metaplastic change of the salivary duct epithelium. It usually presents in an advanced stage. Even though surgery is the standard of care in most head and neck cancers, there are no standard guidelines for the treatment of intraductal apocrine parotid carcinoma, which is different from other head and neck cancers due to its rare incidence, aggressive behavior, and poor prognosis. Case presentation We present a rare case of intraductal apocrine salivary duct carcinoma of the left parotid gland, presented in a locally advanced stage with very high chances of recurrence after surgery, and discuss the role of volumetric modulated arc technique radiotherapy in its management. Conclusion Intraductal apocrine salivary duct carcinoma usually has androgen receptor expression, and lack of expression is associated poor prognosis. Even with complete resection, it has a high recurrence rate. Volumetric modulated arc technique radiotherapy (VMAT) decreases recurrence and increases survival by irradiating the areas more likely of recurrence, with minimal toxicity to surrounding normal tissues.

Reporting of Inter Fraction Dose Variations of Organs at Risk in Computed Tomography-Guided High Dose Rate Intracavitary Brachytherapy in Carcinoma Cervix.

Assess the interfraction dose variations of the organs at risk (OARs) in carcinoma cervix high dose rate (HDR) computed tomography (CT)-guided intra cavitary brachytherapy (ICBT). 120 CT scans of 40 patients who had undergone three fractions of ICBT (7 Gy/fr) were analyzed. Dose to Point A and the minimum doses to the volumes of 2, 1, and 0.1cc of bladder, rectum and sigmoid colon were recorded. Revised plans were generated in 20 patients. Paired t-test was used to compare the difference in the means. Point "A" mean dose difference was statistically significant between the treated and revised plans. For bladder, the difference in means of dosage to all volumes, whilst for the rectum and sigmoid colon, the low volume dosage (0.1cc) was statistically significant. Absence of individualized planning would have resulted in underdosage of tumor and increased dosage of up to 30% to OARs. CT-guided ICBT should be implemented for each HDR fraction treatment.

A rare synchronous presentation of double primary malignancies - lung and prostate.

Synchronous (SC) diagnosis of double primaries is not very rare in this era of advanced technology where underlying malignancies can easily be detected by the modern imaging techniques. However, the treatment of such patients is quite challenging and often a therapeutic dilemma. A 74-year-old male smoker with no significant past or family history, presented with cough, hemoptysis, and difficulty in voidance of urine within 1 month of each other, i.e., SC presentation. Abnormalities were detected on the clinical examination and radiological imaging in the lung and prostate, which confirmed to be double primary malignancies of different histology on histopathology and immunohistochemistry, i.e., adenocarcinoma prostate and squamous cell carcinoma of the right lung.

Endogenous IL-22 plays a dual role in arthritis: regulation of established arthritis via IFN-γ responses.

OBJECTIVE: IL-22 is elevated in patients with inflammatory arthritis and correlates with disease activity. IL-22 deficient mice have reduced incidence of arthritis. Recombinant IL-22 restrains progression of arthritis via increase in IL-10 responses when administered prior to onset of arthritis. These findings imply a possible dual role of IL-22 in inflammatory arthritis depending on the phase of arthritis. Experiments outlined here were designed to elucidate the contribution of endogenous IL-22 before and after the onset of arthritis. METHODS: Collagen induced arthritis (CIA) was induced in DBA1 or IFN-γ deficient mice following immunization with collagen and complete Freund's adjuvant. Anti-IL-22 antibody or isotype control were administered prior to or after onset of arthritis and disease progression assessed by clinical scoring and histopathology. IL-22, IL-17 and IFN-γ responses were measured by ELISA and flowcytometry. Anti-collagen antibody responses were analyzed by ELISA. Expression of IL-22R1 in CD4+ cells was elucidated by flowcytometry and real time PCR. RESULTS: Collagen specific IL-22 responses were expanded during arthritis and IL-22 producing cells were discrete from IL-17 or IFN-γ producing cells. Neutralization of IL-22 after onset of arthritis resulted in significant increase in Th1 responses and significantly reduced severity of arthritis. CD4+ cells from arthritic mice showed increased surface expression of IL-22R1. In vitro, CD4+T cells cultured with antigen presenting cells in the presence or absence of IL-22 suppressed or induced IFN-γ, respectively. The protective effect of anti-IL-22 was reversed in IFN-γ deficient mice. Moreover, administration of anti-IL-22 prior to onset of arthritis augmented arthritis severity. CONCLUSION: We show for the first time that IL-22 plays a dual role: protective prior to the onset of arthritis and pathogenic after onset of arthritis. The pathogenic effect of IL-22 is dependent on suppression of IFN-γ responses. IL-17 responses remained unchanged with the administration of anti-IL22 antibody. IL-22R1 is upregulated on CD4+T cells during arthritis and regulates IFN-γ in T cells.

Interleukin-22 reduces the severity of collagen-induced arthritis in association with increased levels of interleukin-10.

OBJECTIVE: The mechanism of action of interleukin- 22 (IL-22) in inflammatory arthritis remains unknown. IL-22-deficient mice exhibit an intact humoral and cellular immune response to collagen and yet have a reduced incidence of collagen-induced arthritis (CIA). Further, administration of anti-IL-22 does not reduce the severity of clinical arthritis but rather improves only certain aspects of joint inflammation as assessed histologically. This study was undertaken to investigate the mechanism of action and role of systemic IL-22 in modulating target organ inflammation. METHODS: CIA was induced in DBA mice by immunization with collagen and Freund's complete adjuvant. Expression of IL-22 and its receptor (IL-22R) in lymphoid organ and target tissues was determined during various phases of arthritis. The effector functions of IL-22 on induction/regulation of various cytokines in in vitro restimulation cultures were analyzed by enzyme-linked immunosorbent assay (ELISA). Recombinant IL-22 with or without anti-IL-10 antibody was administered to mice following immunization with collagen and prior to the onset of arthritis, and the severity of arthritis was evaluated by clinical scoring and histopathologic assessment. Anticollagen antibodies in mouse sera were analyzed by ELISA. RESULTS: IL-22 and IL-22R were up-regulated in lymphoid organs and joints during the course of arthritis. IL-22 augmented IL-10, IL-17, and IL-6 in lymphoid tissues in vitro. Administration of recombinant IL-22 was associated with an increase in IL-10 levels in vivo and a significant reduction in the progression of arthritis severity. Anti-IL-10 antibody treatment was associated with the abrogation of this protective effect of IL-22. CONCLUSION: Our data demonstrate, for the first time, that IL-22 has a protective role in inflammatory arthritis.

Pharmacotherapy: concepts of pathogenesis and emerging treatments. Co-stimulation and T cells as therapeutic targets.

Full activation and differentiation of resting T cells into effector T cells requires at least two signals, the first through engagement of the T cell antigen receptor (TCR) by the antigen-major histocompatibility complex (MHC) on antigen-presenting cells (APCs), and the second by engagement of co-stimulatory molecules such as CD28, on T cells by ligands such as CD80/86 on APCs. Effector T cell differentiation is associated with proliferation, secretion of cytokines and expression of additional surface molecules. These inducible structures may have stimulatory (ICOS, OX40 and 4-1BB) or inhibitory (cytotoxic T-lymphocyte antigen (CTLA)-4) potential. To the extent that T cells have a role in particular immune-mediated diseases, interruption of T cell co-stimulation is a potentially worthwhile approach to the treatment of those conditions. This article summarises the experience in treating rheumatological disease by perturbation of T cell co-stimulation, and also describes structures that could be future targets for this type of therapeutic approach.

Targeting IL-17 and Th17 cells in rheumatoid arthritis.

Identification of interleukin-17 (IL-17) as a powerful proinflammatory cytokine and the recent recognition of a T-helper cell subset that secretes it have focused attention on the role of IL-17 and Th17 cells in rheumatoid arthritis (RA) and other immune-mediated diseases. While understanding of its role in RA is still evolving, evidence from both animal models and human systems provides a compelling rationale for therapeutic targeting of IL-17 in RA. Both direct and indirect approaches to accomplish this are feasible. Mechanistic studies in the context of clinical trials will be required to understand why some strategies may be preferable from the perspectives of efficacy and safety.

Regulation of pathogenic IL-17 responses in collagen-induced arthritis: roles of endogenous interferon-gamma and IL-4.

INTRODUCTION: Interleukin (IL)-17 plays an important role in the pathogenesis of rheumatoid arthritis and the mouse model collagen-induced arthritis (CIA). Interferon(IFN)-gamma and IL-4 have been shown to suppress Th17 development in vitro, but their potential immunoregulatory roles in vivo are uncertain. The goals of this study were to determine the relationship between Th17 responses and disease severity in CIA and to assess regulation of IL-17 by endogenous IFN-gamma and IL-4. METHODS: DBA1/LacJ mice were immunized with type II collagen in complete Freund's adjuvant (CFA) to induce arthritis, and treated with neutralizing antibody to IFN-gamma and/or IL-4. Systemic IL-17, IFN-gamma, and IL-4 were measured in serum. At the peak of disease, cytokine production was measured by ELISA of supernatants from spleen, lymph node and paw cultures. Paws were also scored for histologic severity of arthritis. RESULTS: Joint inflammation was associated with a higher ratio of systemic IL-17/IFN-gamma. Neutralization of IFN-gamma accelerated the course of CIA and was associated with increased IL-17 levels in the serum and joints. The IFN-gamma/IL-4/IL-17 responses in the lymphoid organ were distinct from such responses in the joints. Neutralization of IL-4 led to increased arthritis only in the absence of IFN-gamma and was associated with increased bone and cartilage damage without an increase in the levels of IL-17. CONCLUSIONS: IL-4 and IFN-gamma both play protective roles in CIA, but through different mechanisms. Our data suggests that the absolute level of IL-17 is not the only determinant of joint inflammation. Instead, the balance of Th1, Th2 and Th17 cytokines control the immune events leading to joint inflammation.

Abatacept in the treatment of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a chronic inflammatory arthritis affecting 1% of the population. The immunologic dysfunction underlying this immune disorder is complex and intricate with the involvement of various immune cells as well as cytokines and surface molecules. While inhibition of TNF-alpha has changed the outlook of patients with this disorder, it regulates only one aspect of the inflammatory cascade associated with RA. This is corroborated by experience in the clinic, where a significant proportion of the patients do not have clinical benefit with such therapies. Furthermore, a number of patients experience blunting of the initial therapeutic benefits of TNF-alpha-targeted therapies. Thus, a different approach to regulate the immune dysfunction associated with RA is necessary. T cells are considered important in the pathogenesis of RA and abatacept, a fusion protein, was developed to abolish the activation of the T cell by blocking its interaction with the antigen-presenting cell. Abatacept has demonstrated promising clinical improvements in patients with RA. Although clinical experience with this new drug is limited and its mechanism of action remains to be understood, the data on the safety profile are reassuring.

Regulatory T cells in rheumatoid arthritis.

Regulatory T cells have attracted substantial interest in connection with their role in controlling autoimmunity and the possibility that they could be used therapeutically. Here, we summarize the current understanding of the several subsets of regulatory T cells and defects in their function in rheumatoid arthritis. In evaluating the possibility of using regulatory T cells to treat rheumatoid arthritis, the relationship between these cells and the development and function of Th17 cells must be understood fully.

Th17 cells in human disease.

SUMMARY: Our understanding of the role of T cells in human disease is undergoing revision as a result of the discovery of T-helper 17 (Th17) cells, a unique CD4(+) T-cell subset characterized by production of interleukin-17 (IL-17). IL-17 is a highly inflammatory cytokine with robust effects on stromal cells in many tissues. Recent data in humans and mice suggest that Th17 cells play an important role in the pathogenesis of a diverse group of immune-mediated diseases, including psoriasis, rheumatoid arthritis, multiple sclerosis, inflammatory bowel disease, and asthma. Initial reports also propose a role for Th17 cells in tumorigenesis and transplant rejection. Important differences, as well as many similarities, are emerging when the biology of Th17 cells in the mouse is compared with corresponding phenomena in humans. As our understanding of human Th17 biology grows, the mechanisms underlying many diseases are becoming more apparent, resulting in a new appreciation for both previously known and more recently discovered cytokines, chemokines, and feedback mechanisms. Given the strong association between excessive Th17 activity and human disease, new therapeutic approaches targeting Th17 cells are highly promising, but the potential safety of such treatments may be limited by the role of these cells in normal host defenses against infection.

Cells of the synovium in rheumatoid arthritis. T lymphocytes.

Recent findings have substantiated the importance of T lymphocytes to the pathogenesis of rheumatoid arthritis (RA). Here, we review emerging data regarding genetic predisposition, spontaneous animal models of arthritis, and cell-cell interactions that implicate T cells as driving synovial inflammation and joint destruction. Information regarding the proinflammatory role of interleukin-17-producing T cells and the functional state of regulatory T cells both in animal models and in patients with RA is also discussed. In light of the overwhelming evidence that disrupted T-cell homeostasis greatly contributes to joint pathology in RA, the therapeutic potential of targeting activators of pro-inflammatory T cells or their products is compelling.

Interleukin-17 as a molecular target in immune-mediated arthritis: immunoregulatory properties of genetically modified murine dendritic cells that secrete interleukin-4.

OBJECTIVE: Our previous studies have shown that murine dendritic cells (DCs) genetically modified to express interleukin-4 (IL-4) reduce the incidence and severity of murine collagen-induced arthritis. The present studies were performed to assess the immunoregulatory mechanisms underlying this response, by assessing the effects of IL-4 DCs on cytokine production by subsets of T helper cells. METHODS: Male DBA mice ages 6-8 weeks old were immunized with type II collagen. Splenic T cells obtained during the initiation phase and the end stage of arthritis were cultured with IL-4 DCs or untransduced DCs in the presence of collagen rechallenge. Interferon-gamma (IFNgamma) and IL-17 responses were measured. Antibodies to IL-4, IL-12, and IL-23, and recombinant IL-4, IL-12, and IL-23 were used to further study the regulation of T cell cytokine production by IL-4 DCs. RESULTS: Splenic T cells obtained during the initiation phase of arthritis produced less IL-17 when cultured in the presence of IL-4 DCs, despite their production of increased quantities of other proinflammatory cytokines (IFNgamma and tumor necrosis factor). T cell IL-17 production after collagen rechallenge was not inhibited by a lack of IL-23, since IL-4-mediated suppression of IL-17 was not reconstituted by IL-23, an otherwise potent inducer of IL-17 production by T cells. Although IL-4 DCs can produce increased quantities of IL-12 and IFNgamma, suppression of IL-17 production by IL-4 DCs was independent of both. While IL-17 production by T cells obtained during the initiation phase of arthritis was regulated by IL-4 DCs, IL-17 production by T cells obtained during end-stage arthritis was not altered. CONCLUSION: Our data suggest that IL-4 DCs exert a therapeutic effect on collagen-induced arthritis by targeting IL-17. IL-17 suppression by IL-4 DCs is robust and is not reversed by IL-23. Timing might be important in IL-17-targeted therapy, since IL-17 production by T cells obtained during end-stage arthritis did not respond to suppression by IL-4 DCs.

Dendritic cells in rheumatoid arthritis.

Dendritic cells are the most potent subset of antigen presenting cells. They are derived from bone marrow stem cells and reside in peripheral tissues or blood. Upon exposure to antigens and cytokines the peripheral DC s, express high amounts of peptide-MHC, and upregulate their costimulatory molecules, migrate to draining lymph nodes, and interact with T cells to stimulate or tolerize them. Dendritic cells have been found in synovium and joint fluid in rheumatoid arthritis, often at the center of a cluster of T cells. These DC s express MHC II, the costimulatory molecules CD40, CD80, CD86, adhesion molecules such as DC-SIGN and chemokine receptors such as CCR7. DC s can polarize T cells into Th1 or Th2 phenotypes depending on the cytokine environment. Th1 responses are initiated in context of IL-12 and IL-23. The cytokine milieu of the RA synovium promotes DC differentiation and function that could lead to autoantigen presentation to T cells. Dendritic cells may be central to the pathogenesis of RA and could also be logical targets for treatment. DC s themselves could be used to deliver therapeutic gene products in autoimmune disease. DC s genetically modified to express IL-4 have been used to treat or prevent collagen arthritis in mice.

Expression and characterization of a novel CD6 ligand in cells derived from joint and epithelial tissues.

CD6 is a T cell surface glycoprotein that plays an important role in interactions of thymocytes with thymic epithelial cells and in mature T cell interactions with selected nonprofessional tissue APCs. We describe a novel CD6 ligand (CD6L) 3A11 Ag that is distinct from the known CD6L (CD166). The 3A11 protein is expressed on cells derived from human thymus, skin, synovium, and cartilage, and its expression is enhanced by IFN-gamma. mAbs directed against the 3A11 Ag and CD166 exhibit distinct patterns of binding to a panel of cell lines. Confocal microscopy shows that both CD166 and the 3A11 Ag are expressed at the cell surface, and that these proteins colocalize. The 3A11 Ag has a molecular mass of 130 kDa and is immunoprecipitated using either mAb 3A11 or soluble CD6-Ig fusion protein. mAbs directed against individual CD6L were less potent than was soluble CD6-Ig fusion protein in reducing adhesion of T cells to adherent 3A11-positive epithelial cells in vitro, suggesting that these Abs recognize epitopes on the 3A11 Ag and CD166 that are distinct from CD6 binding sites. Finally, transfection of epithelial cells with CD166-specific small interfering RNAs significantly decreased CD166 expression without alteration in 3A11 Ag levels, and thus confirmed that these two CD6L are distinct. Taken together, our data identifies a novel 130-kDa CD6L that may mediate interactions of synovial and epithelial cells with T lymphocytes.