ESMO Expert Consensus Statements on the management of breast cancer during pregnancy (PrBC).

The management of breast cancer during pregnancy (PrBC) is a relatively rare indication and an area where no or little evidence is available since randomized controlled trials cannot be conducted. In general, advances related to breast cancer (BC) treatment outside pregnancy cannot always be translated to PrBC, because both the interests of the mother and of the unborn should be considered. Evidence remains limited and/or conflicting in some specific areas where the optimal approach remains controversial. In 2022, the European Society for Medical Oncology (ESMO) held a virtual consensus-building process on this topic to gain insights from a multidisciplinary group of experts and develop statements on controversial topics that cannot be adequately addressed in the current evidence-based ESMO Clinical Practice Guideline. The aim of this consensus-building process was to discuss controversial issues relating to the management of patients with PrBC. The virtual meeting included a multidisciplinary panel of 24 leading experts from 13 countries and was chaired by S. Loibl and F. Amant. All experts were allocated to one of four different working groups. Each working group covered a specific subject area with two chairs appointed: Planning, preparation and execution of the consensus process was conducted according to the ESMO standard operating procedures.

Extracellular vesicles in blood, milk and body fluids of the female and male urogenital tract and with special regard to reproduction.

Extracellular vesicles (EVs) are released from almost all cells and tissues. They are able to transport substances (e.g. proteins, RNA or DNA) at higher concentrations than in their environment and may adhere in a receptor-controlled manner to specific cells or tissues in order to release their content into the respective target structure. Blood contains high concentrations of EVs mainly derived from platelets, and, at a smaller amount, from erythrocytes. The female and male reproductive tracts produce EVs which may be associated with fertility or infertility and are released into body fluids and mucosas of the urogenital organs. In this review, the currently relevant detection methods are presented and critically compared. During pregnancy, placenta-derived EVs are dynamically detectable in peripheral blood with changing profiles depending upon progress of pregnancy and different pregnancy-associated pathologies, such as preeclampsia. EVs offer novel non-invasive diagnostic tools which may reflect the situation of the placenta and the foetus. EVs in urine have the potential of reflecting urogenital diseases including cancers of the neighbouring organs. Several methods for detection, quantification and phenotyping of EVs have been established, which include electron microscopy, flow cytometry, ELISA-like methods, Western blotting and analyses based on Brownian motion. This review article summarises the current knowledge about EVs in blood and cord blood, in the different compartments of the male and female reproductive tracts, in trophoblast cells from normal and pre-eclamptic pregnancies, in placenta ex vivo perfusate, in the amniotic fluid, and in breast milk, as well as their potential effects on natural killer cells as possible targets.

[Pregnancy and cystic fibrosis - an overview]. / Schwangerschaft bei Mukoviszidose - ein Überblick.

Life expectancy and quality of life of cystic fibrosis (CF) patients have been steadily increasing for many decades, due to intensified therapy and research. Correspondingly, the number of pregnancies in women with CF rises. Often it is not possible for the patients to assess the consequences of pregnancy in terms of their disease and the impact of their disease on the growing child. A pre-existing poor lung function, low body mass index, CF-related diabetes, chronic microbial colonisation, and transplanted lungs are the main risk factors for complications during pregnancy in CF. Generally, the best outcome for mother and child can be reached under exact planning and meshed multidisciplinary care. The purpose of this summary is to give a practical review of the risks and options associated with pregnancy in CF patients.

Anti-inflammatory properties of N-acetylcysteine on lipopolysaccharide-activated macrophages.

INTRODUCTION: Innate immune cells play a role in modulating host immune response. Part of the macrophage inflammatory response is the release of an array of inflammatory cytokines, important molecules during the development of innate and adaptative immunity. Several antioxidant agents have been used in the control of the inflammatory response. OBJECTIVE: To evaluate the anti-inflammatory effect of N-acetylcysteine (NAC) on the expression and secretion of inflammatory cytokines and interleukin (IL)-10 in lipopolysaccharide (LPS)-activated THP-1 macrophages under mild oxidative conditions. METHODS: Macrophages were activated by LPS (0.1 and 1 µg/ml) for up to 24 h. The effect of 15 mM NAC was evaluated at 2, 4, 6 and 24 h. mRNA expression of tumor necrosis factor (TNF)-α, IL-1ß, IL-6, IL-8 and IL-10 was assessed by real time PCR. The expression of the corresponding cytokines plus IL-12p70 was analyzed using a bead array for flow cytometry. RESULTS: NAC inhibits the inflammatory cytokines TNFα, IL-1ß and IL-6 in LPS-activated macrophages under mild oxidative conditions. IL-10 mRNA and protein expression are strongly downregulated in NAC-treated cells, which may further modify the inflammatory cytokine profile. CONCLUSION: NAC modulates immune functions during the inflammatory response.

[PIBF - Progesterone-Induced Blocking Factor]. / PIBF - Progesteron induzierter Blockierfaktor.

Pregnancy is a unique immunological situation in which 2 allogeneic organisms live in intimate symbiosis without developing rejection reactions. At different locations, interfaces exist between mother and foetus with direct contact between both individuals: 1) maternal blood surrounds foetal villi, which are covered with syncitiotrophoblast cells; 2) cytotrophoblast cells invade the decidua, in which they touch tissue lymphocytes; 3) trophoblast cells, which substitute endothelium of maternal arterioles filled with maternal blood; and 4) trophoblast particles, which are expressed from syncytiotrophoblast and circulate within the maternal blood until they settle in the lung capillaries, where they become degraded by alveolar macrophages. Several factors are known which support the specific immunotolerance of the mother to her foetus and are focussed by current research in reproductive immunology. One of these factors is progesterone-induced blocking factor (PIBF). Originally, it was discovered as a 34 kDa protein, which is released from lymphocytes of healthy pregnant women under the influence of progesterone. PIBF has immunomodulatory functions in vivo and in vitro, which are important for the establishment of immunotolerance between mother and foetus and, thereby, for the regular course of pregnancy. Finally, during the last years, several tumours have been identified to produce PIBF, which supports their immune escape and which may have the potential to become a novel tumour biomarker and which may lead to the development of new therapeutic strategies.

Ex vivo human placental transfer study on recombinant Von Willebrand factor (rVWF).

Deficiency or mutation of von Willebrand factor (VWF) leads to a coagulation disorder (von Willebrand disease; VWD) which requires a lifelong therapy. For avoiding maternal complications treatment may be necessary also in pregnancy, but placental transfer to the fetus might impact its coagulation system and evoke undesired side effects. As VWF is a very large molecule it may be assumed that it does not pass the placental barrier. To prove this hypothesis the materno-fetal transfer of recombinant VWF (rVWF) has been analyzed ex vivo in a total of 21 valid dual side placenta perfusions. Three groups of five placentas each have been perfused with physiological and up to ten-fold increased concentrations of rVWF for 2 h. Six placentas have been used for control perfusions. A series of different control parameters has been assessed for documentation of intactness and functionality of the placenta and the perfusion system. In not a single analysis, independent of time and concentration, rVWF was detected in the fetal circuit. In the maternal circuit VWF concentration decreased slightly during perfusion. These results demonstrate that recombinant VWF does not pass the human placenta.

Higher prevalence of colonization with Gardnerella vaginalis and gram-negative anaerobes in patients with recurrent miscarriage and elevated peripheral natural killer cells.

The role of vaginal infections in recurrent miscarriage (RM) is discussed controversially and screening is not recommended in international guidelines. Peripheral and uterine NK cells (pNK, uNK) play an important role in the establishment of a healthy pregnancy and are targets of immune diagnostics in RM patients. The aim of this study was to analyze the composition of the vaginal microbiota in RM patients and to correlate the findings to clinical characteristics as well as NK cell parameters. In total, n=243 RM patients with ≥3 consecutive miscarriages were recruited between 11/2011 and 03/2016. Vaginal swabs were analyzed by microbiological culture. Further, a cervical swab was taken in n=187 patients and the presence of Chlamydia trachomatis was evaluated by a molecular assay. Peripheral blood levels of CD45+CD3-CD56+CD16+ pNK (determined by four-color fluorescence flow cytometry) and CD56+ uNK (uterine biopsy, determined by immunohistochemistry) were analyzed. The prevalence of Gardnerella vaginalis colonization in RM patients was 19.0%, gram-negative anaerobes 20.5%, Candida species 7.9%, group B Streptococcus 11.0% and Enterobacteriaceae 14.8%. Commensal lactobacilli were absent in 14.5% of the women. Chlamydia trachomatis was detected in n=1 case (0.53%). The prevalence of Gardnerella vaginalis and gram-negative anaerobes in RM patients with elevated pNK (>280/µl, n=69) was significantly higher (p=0.012, p=0.04) compared to patients with normal pNK (n=174). In conclusion, RM patients with elevated pNK suffer more often from colonization by Gardnerella vaginalis and gram-negative anaerobes. This might indicate an association between the vaginal microbiota, local inflammation, changes in immune parameters and miscarriage.

The "killer cell story" in recurrent miscarriage: Association between activated peripheral lymphocytes and uterine natural killer cells.

Peripheral and uterine NK cells (pNK, uNK) can be distinguished according to their receptor expression. Recent studies indicate an association of elevated pNK and uNK with recurrent miscarriage (RM). This study aimed to analyze pNK and uNK in patients with RM and healthy controls. Out of n=590 RM patients screened according to a standard diagnostic protocol, n=268 couples with ≥3 consecutive RM were identified. Subgroups consisted of n=151 primary RM (pRM), n=85 secondary RM (sRM), n=32 tertiary RM (tRM) and n=42 healthy controls. Finally, n=147 idiopathic RM (iRM) and n=121 non-iRM patients were identified. Peripheral blood levels of CD45+CD3-CD56+CD16+ NK cells were determined in non-pregnant patients and controls in the mid-luteal phase by FACS. In n=129 RM patients a uterine biopsy was taken to evaluate CD56+ NK cells by immunohistochemistry. PRM showed higher absolute pNK than sRM (median/µl (Q1;Q3): 234 (147;306) vs 176 (128;245), p=0.02). Further a trend towards higher pNK percentages in pRM was detected. UNK numbers did not differ between RM subgroups and did not correlate with pNK. However, the rate of highly elevated uNK was increased in iRM compared to non-iRM patients (p=0.04). Further, higher numbers of CD45+CD3-DR+ (p<0.01) and CD45+CD3+CD8+DR+ (p=0.04) peripheral lymphocytes were associated with higher uNK numbers. In conclusion, elevated pNK were present in pRM patients. Although pNK and uNK numbers did not correlate, the association between high CD45+CD3-DR+ and CD45+CD3+CD8+DR+ peripheral lymphocytes and uNK might indicate that activated NK, B and T cells provide cytokines for the differentiation of uNK.

Trophoblast invasion: tuning through LIF, signalling via Stat3.

Aberrant activity of the signal transducer and activator of transcription 3 (Stat3) is believed to be essential for neoplastic cell behaviour and thus for the malignancy of tumor cells [Bowman T, Garcia R, Turkson J, Jove R. STATs in oncogenesis. Oncogene 2000;19:2474-88]. Extravillous trophoblast cells resemble malignancies in their invasive and destructive features, excluding the fact of sequential restriction to the first trimester of pregnancy. Trophoblast cells from term placentas have reduced invasive capacity [Hohn HP, Denker HW. Experimental modulation of cell-cell adhesion, invasiveness and differentiation in trophoblast cells. Cells Tissues Organs 2002;172:218-36]. Constitutively activated Stat3 DNA-binding activity in choriocarcinoma cells, carcinomatous derivates of trophoblast cells, have been reported to correlate with its invasiveness [Corvinus FM, Fitzgerald JS, Friedrich K, Markert UR. Evidence for a correlation between trophoblast invasiveness and STAT3 activity. Am J Reprod Immunol 2003;50:316-21]. Here we demonstrate using RNAi that Stat3 activation is necessary in the invasive phenotype of trophoblast cells and can be controlled via Leukemia Inhibitory Factor (LIF). LIF provides a soluble extracellular signal that stimulates invasion in trophoblast and Jeg-3 choriocarcinoma cells. Loss of LIF-mediated invasion in these cells subsequent to STAT3 knock-down strongly suggests that STAT3 plays a crucial role in mediating this invasion.

TNF-alpha-mediated stress-induced early pregnancy loss: a possible role of leukemia inhibitory factor.

BACKGROUND: Leukemia inhibitory factor (LIF) is at present suggested to be essential for implantation in mammals. In parallel, the possibility that it may also be involved in the pathogenesis of stress-induced early embryonic death seems to emerge from studies, which addressed the embryotoxic potential of another cytokine, tumor necrosis factor-alpha (TNF-alpha). In this brief review, we discuss this possibility based on these studies as well as on those addressing TNF-alpha and LIF signaling. METHODS: Existing data were reviewed critically. RESULTS: Data summarized in this review suggest that: (1) TNF-alpha may act as a mediator of stress-induced early embryonic death, (2) TNF-alpha-mediated early embryonic death induced by some detrimental stimuli may be attributed to a dysfunction of mechanisms, which are critical for the ability of the uterus to become receptive to blastocysts, allowing implantation, (3) one such mechanism was shown to be associated with LIF signaling in uterine cells, and (4) TNF-alpha seems to have the potential to affect LIF signaling. CONCLUSION: Data presented in the this review suggest LIF as a good candidate for further studies addressing molecular mechanisms underlying stress-induced early embryonic death.

Therapeutic procedures of sublingual immunotherapy in clinical practice.

Clinical practice shows that a number of important measures are required to reach a high efficacy of sublingual immunotherapy. These measures include a specific and exact diagnosis of allergy, a high and reliable compliance of the patient, detailed guidance and explanation by the physician, and a strict monitoring of clinical symptoms and possible side effects. The complex inflammatory situation of the allergic patient, especially concerning the conjunctival, nasal and bronchial mucosa as well as eczema, should be explored in detail and treated with anti-inflammatory medication. After having reviewed the international literature combined with personal practical experience, we interpret and suggest that noninflammatory circumstances increase the chances of success of immunotherapies in allergy; nonetheless, several of these interpretations have not yet been confirmed by clinical studies.

Nonspecific plasma proteins during sublingual immunotherapy.

Usually, specific allergy-related plasma proteins such as immunoglobulin E (IgE) and immunoglobulin G (IgG) are used for estimating the grade of sensitization and follow-up of immunotherapy. In recent years, several nonspecific inflammatory markers, such as sICAM-1 and sIL-2R, have been shown as being suitable for therapy control in allergy. In our investigation of patients under sublingual immunotherapy (SLIT), plasma from 42 healthy controls and 133 children with single inhalation allergies to grass pollen, birch pollen or house dust mites was obtained during the symptom-free period. Patients showed symptoms including allergic rhinitis, dermatitis and allergic asthma with one single RAST class 3 or higher. Plasma concentrations of soluble intercellular adhesion molecule-1 (sICAM-1), soluble interleukin-2 receptor (sIL-2R), sE-selectin, interleukin-12 (IL-12) and specific IgG4 were analyzed with the ELISA technique. After 1 year of SLIT, concentrations of sICAM-1, sIL-2R and sE-selectin declined significantly when results from all patients were taken as one group. Regarding the single allergen groups, the sICAM-1 and sIL-2R decrease was significant in the grass and mite group, but not in the birch group, while the sE-selectin decline was only significant in the birch group after 1 year of SLIT, but not in the grass and the mite group. No difference was observed in IL-12 and IgG4 expression. In two groups of controls with a mean age of 9.5 versus 17.5 years, the analyzed parameters were not age-dependent. The increased proteins may be useful as additional markers for the evaluation of immunological effects and follow-up investigations of allergy therapies.

Selective T-cell deficiency in Turner's syndrome.

The case of a 29-year-old Caucasian woman with 45 X0 karyotype, known as Turner's syndrome, and a recently diagnosed selective T-cell deficiency is reported. The main clinical features of the patient were recurrent sinopulmonary infections and a negative skin test with seven common recall antigens. Laboratory findings included lymphocytopenia, highly elevated CD45RA/CD45R0 ratio, as well as reduced expression of the co-stimulatory molecules CD154, CD86, CD80 and CD28 on CD4+ cells in combination with disturbed lymphocyte transformation in vitro. Markedly decreased levels of interleukin (IL)-2R, both on lymphocyte surface as well as the soluble analog, suggest a new form of x-linked immunodeficiency associated with Turner's syndrome.

Choriocarcinoma-induced suppression of lymphocyte activity.

The aim of the investigation was to study the influence of human choriocarcinoma cell culture supernatants (HCS) on the expression of lymphocyte surface molecules. Lymphocytes were stimulated with phytohemagglutinin in culture medium supplemented with 50% HCS. After 12 h and 60 h, fluorescence-activated cell sorter analysis was performed with specific monoclonal antibodies. After 12 h of incubation, the cell surface expression of the classical activation markers CD25, CD69, CD71, CD134 and CD3/HLA-DR, as well as of the apoptosis marker CD95 were significantly suppressed by HCS. Qualitatively similar results were obtained after 60 h. It was concluded that choriocarcinoma-induced suppression might be related to a nearly complete block in the cell cycle at early activation steps. The clinical and biological relevance of this phenomenon for the maternal-fetal tolerance are briefly discussed.

IL-4 supplemented B-cell cultures of allergic children show reduced IgA and IgG production in response to additional stimulation with IL-10.

BACKGROUND: Cytokines play an important role in mediating immunoglobulin switch, the secretion of protective mucosal immunoglobulins, and the development of allergic diseases. This study investigates whether B cells from allergic and healthy children have different capacities to secrete immunoglobulins after stimulation with IL-4, IL-6, IL-10, IL-11, and IL13. METHODS: We analyzed the peripheral venous blood of 44 healthy probands and of 109 allergic patients with a mean age of 13 years, allergic to grass pollen, birch pollen, and house dust mites. Lymphocytes were isolated by a density gradient and B cells were enriched by using a Magnetic Activated Cell Separator (MACS) and anti-CD19 microbeads. B Cells were co-cultured with human CDw32 (Fc gammaRII) expressing mouse Ltk fibroblasts and mouse anti-human CD40 monoclonal antibodies (CD40 system). The interleukins IL-4, IL-6, IL-10, IL-11, and IL-13 were supplemented in various combinations. After 14 days, concentrations of IgE, IgG, IgA, and IgM were measured in the supernatants with ELISA. RESULTS: Suppression of IgA-, IgG, and IgM- synthesis was induced by stimulation of B cells with IL-4. After additional application of IL-10, IgA, IgG, and IgM synthesis was significantly increased. When cultures stimulated with IL-4 were additionally supplemented with IL-10, IgA, and IgG synthesis of B cells obtained from allergic individuals was significantly decreased compared to nonallergic individuals. IgE-secretion of B cells from allergic individuals was significantly increased compared to nonallergic individuals after stimulation with IL-4. CONCLUSION: Our results implicate that IL-4 is essential for the regulation of immunoglobulin class switch to IgE and that IL-4 is an important cytokine for the development of allergic diseases. The capacity of B cells in allergic children to produce less IgA and IgG in response to additional stimulation with IL-10 of cultures supplemented with IL-4 could play an important role in mediating a mucosal immune system vulnerable to allergens. This phenomenon could contribute to the pathogenesis of allergic diseases.

Elevated nonspecific plasma proteins in allergic patients.

Several allergen-specific plasma proteins, such as IgE and IgG subclasses, are commonly used for the evaluation of grade of allergy. In the present investigation, we compared the concentration of various nonspecific plasma proteins, mostly known as inflammation markers, in an allergic and a healthy population. Plasma from 130 children with single inhalation allergies to grass pollen, birch pollen, or house dust mites as well as from 42 healthy children was obtained during the symptom-free period. Patients showed symptoms including allergic rhinitis, dermatitis, and asthma with one single radioallergosorbent test (RAST) class 3 or higher. Plasma concentrations of soluble intercellular adhesion molecule-1(sICAM-1), soluble interleukin-2 receptor(sIL-2R), sE-selectin, and soluble vascular cell adhesion molecule-1 (1sVCAM-1) were analyzed by enzyme linked immunosorbent assay (ELISA) technique. Concentrations of sICAM-1 and sE-selectin were significantly increased in all patients compared to controls. In the single allergen groups, sICAM-1 elevation was significant in the grass and mite groups, but not in the birch group; while sE-selection increase was significant in the birch and mite groups, but not in the grass group. The elevation of sIL-2R in the allergic patients was obvious in each single allergen group, but not significant. No difference was observed in sVCAM-1 expression. In two groups of patients with mean age of 9.5 years versus 17.5 years, the analyzed parameters were not age dependent. The increased proteins may be useful as additional markers for efficacy and follow-up investigations of allergy therapies.

Elevated CD154 (CD40 ligand) synthesis in T-cells from allergic patients after nonspecific stimulation in vitro.

The interaction of the CD154 molecule (CD40 ligand, gp39) on activated T-cells with the CD40 antigen on B-cells seems to play a key role in immunoglobulin class switching. We aimed to compare the capacity of intracellular CD154 expression after nonspecific stimulation with phorbol-12-myristate-13-acetate and ionomycin on separated T-cells from allergic patients and healthy donors. We analyzed blood from 104 patients allergic to grass pollen, house dust mites or birch pollen, and from 44 healthy donors. Lymphocytes were isolated using a density gradient and B-cells were extracted by magnet-activated cell separation (MACS) using anti-CD19 microbeads. Cells were nonspecifically stimulated for 5 h, permeabilized and stained with anti-CD154 for fluorescence-activated cell sorter analysis. It was found that stimulation induced a 1.4% increase of intracellular CD154+ T-cells; a 4.6% increase of mean channel fluorescence of all T-cells from healthy donors; a 6.1% increase in intracellular CD154+ T-cells; and a 28.1% increase of mean channel fluorescence of all T-cells from allergic patients. The data demonstrated an elevated capability of B-cell independent CD154 synthesis in T-cells from allergic patients when compared to healthy individuals. It is possible that the enhanced IgE production of B-cells from allergic patients might be partly due to the phenomena described.

Case report: successful pregnancy and delivery after myocardial infarction and essential thrombocythemia treated with clopidrogel.

We describe a case of a woman with essential thrombocythemia (ET) who had a subsequent successful pregnancy after a myocardial infarction and aortocoronary bypass grafting. We report the therapeutic management with clopidogrel and low molecular weight heparin. A healthy child was born spontaneously after 41 weeks of pregnancy. The placenta was morphologically normal. No maternal cardiac problems occurred.

Elsevier Trophoblast Research Award Lecture: origin, evolution and future of placenta miRNAs.

MicroRNAs (miRNAs) regulate the expression of a large number of genes in plants and animals. Placental miRNAs appeared late in evolution and can be found only in mammals. Nevertheless, these miRNAs are constantly under evolutionary pressure. As a consequence, miRNA sequences and their mRNA targets may differ between species, and some miRNAs can only be found in humans. Their expression can be tissue- or cell-specific and can vary time-dependently. Human placenta tissue exhibits a specific miRNA expression pattern that dynamically changes during pregnancy and is reflected in the maternal plasma. Some placental miRNAs are involved in or associated with major pregnancy disorders, such as preeclampsia, intrauterine growth restriction or preterm delivery and, therefore, have a strong potential for usage as sensitive and specific biomarkers. In this review we summarize current knowledge on the origin of placental miRNAs, their expression in humans with special regard to trophoblast cells, interspecies differences, and their future as biomarkers. It can be concluded that animal models for human reproduction have a different panel of miRNAs and targets, and can only partly reflect or predict the situation in humans.

Expression of serum amyloid A4 in human trophoblast-like choriocarcinoma cell lines and human first trimester/term trophoblast cells.

Trophoblast invasion into uterine tissues represents a hallmark of first trimester placental development. As expression of serum amyloid A4 (SAA4) occurs in tumorigenic and invasive tissues we here investigated whether SAA4 is present in trophoblast-like human AC1-M59/Jeg-3 cells and trophoblast preparations of human first trimester and term placenta. SAA4 mRNA was expressed in non-stimulated and cytokine-treated AC1-M59/Jeg-3 cells. In purified trophoblast cells SAA4 mRNA expression was upregulated at weeks 10 and 12 of pregnancy. Western-blot and immunohistochemical staining of first trimester placental tissue revealed pronounced SAA4 expression in invasive trophoblast cells indicating a potential role of SAA4 during invasion.