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Mohanty C, Singh CK, Daccache JA, Damsky W, Kendziorski C, Yan D, Prasad A, Zhang D, Keenan T, Drolet B, Ahmad N, Shields BE. Granuloma Annulare Exhibits Mixed Immune and Macrophage Polarization Profiles with Spatial Transcriptomics. J Invest Dermatol 2025; 145:109-121. [PMID: 38844128 DOI: 10.1016/j.jid.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 04/11/2024] [Accepted: 04/27/2024] [Indexed: 07/16/2024]
Abstract
Granuloma annulare (GA) is an idiopathic condition characterized by granulomatous inflammation in the skin. Prior studies have suggested that GA develops from various triggers, leading to a complex interplay involving innate and adaptive immunity, tissue remodeling, and fibrosis. Macrophages are the major immune cells comprising GA granulomas; however, the molecular drivers and inflammatory signaling cascade behind macrophage activation are poorly understood. Histologically, GA exhibits both palisaded and interstitial patterns on histology; however, the molecular composition of GA at the spatial level remains unexplored. GA is a condition without Food and Drug Administration-approved therapies despite the significant impact of GA on QOL. Spatial transcriptomics is a valuable tool for profiling localized, genome-wide gene expression changes across tissues, with emerging applications in clinical medicine. To improve our understanding of the spatially localized gene expression patterns underlying GA, we profiled the spatial gene expression landscape from 6 patients with GA. Our findings revealed mixed T helper 1 and T helper 2 signals comprising the GA microenvironment and spatially distinct M1 and M2 macrophage polarization characteristics. IFN-γ and TNF signals emerged as important regulators of GA granulomatous inflammation, and IL-32 emerged as a key driver of granulomatous inflammation. Overall, our spatial transcriptomics data indicate that GA exhibits mixed immune and macrophage polarization.
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Affiliation(s)
- Chitrasen Mohanty
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Chandra K Singh
- Department of Dermatology, The School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Joseph A Daccache
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA; Department of Pathology, NYU Langone Health, New York, New York, USA
| | - William Damsky
- Department of Pathology, NYU Langone Health, New York, New York, USA; Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christina Kendziorski
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Di Yan
- Department of Dermatology, The School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Aman Prasad
- Department of Dermatology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Donglin Zhang
- Department of Dermatology, The School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Tom Keenan
- Department of Dermatology, The School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Beth Drolet
- Department of Dermatology, The School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Nihal Ahmad
- Department of Dermatology, The School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA; Department of Dermatology, William S. Middleton Memorial Veterans' Hospital, Madison, Wisconsin, USA
| | - Bridget E Shields
- Department of Dermatology, The School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA.
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Martel J, Hanania HL, Patel AB. Immune checkpoint inhibitor-induced cutaneous toxicities: a review of histopathologic and clinical features. Hum Pathol 2023; 140:144-172. [PMID: 37141978 DOI: 10.1016/j.humpath.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) represent an emerging treatment option for a variety of cancer types. Through inhibition of programmed cell death protein 1 (PD-1), programmed cell death ligand 1 (PD-L1), and/or cytotoxic lymphocyte-associated antigen-4 (CTLA-4), ICIs activate the host's immune system causing a heightened anti-tumor response. However, off-target effects of ICIs can result in numerous different immune-related cutaneous adverse events (irCAEs). Beyond impacting quality of life, irCAEs can lead to dose limitations or discontinuation of anti-cancer therapies. Correct diagnosis is necessary for expedient and appropriate management. Skin biopsies are often performed to increase diagnostic accuracy and guide clinical management. An extensive literature review was performed using the PubMed database to identify the reported clinical and histopathologic features of irCAEs. This comprehensive review primarily details the histopathologic features of various irCAEs reported to date. Clinical presentation and immunopathogenesis are also discussed in relation to histopathology.
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Affiliation(s)
- Julianna Martel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - Anisha B Patel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA.
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Bagci B, Karakas C, Kaur H, Smoller BR. Histopathologic Aspects of Malignancy-Associated Granuloma Annulare: A Single Institution Experience. Dermatopathology (Basel) 2023; 10:95-103. [PMID: 36975384 PMCID: PMC10047897 DOI: 10.3390/dermatopathology10010015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Granuloma annulare (GA) is a benign, self-limiting granulomatous inflammatory disease that exhibits different histologic patterns. Infrequently, granuloma annulare can be associated with malignancy, the so-called malignancy-associated granuloma annulare (MGA). In this study, we aimed to compare the clinical and histopathological differences between GA and MGA. We retrospectively reviewed patient charts and identified 35 patients diagnosed with GA and concurrent hematological or solid organ malignancies as a case group. Additionally, we identified 33 patients without any known solid organ or hematological malignancy as a control group. MGA is commonly seen in the seventh decade of life, while GA affects the younger population. MGA is most commonly presented in the extremities of the body. The most common malignancy associated with MGA was chronic lymphocytic leukemia. Prostate cancer was the most common type of solid organ malignancy that was associated with MGA. The most common histopathological pattern seen in MGA was interstitial, comprising half of the cases. Multinucleated giant cells were present in half of the MGA cases and in most of the control group. In the literature, there are no established features that distinguish MGA from GA. Although MGA and GA have overlapping features, in our series, we found that the interstitial pattern was more common in MGA, while the necrobiotic pattern was more common in GA.
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Affiliation(s)
- Buket Bagci
- Department of Pathology and Laboratory Medicine, Loma Linda University, Loma Linda, CA 92354, USA
- Correspondence:
| | - Cansu Karakas
- Department of Pathology and Laboratory Medicine, University of Rochester Medical, Rochester, NY 14642, USA
| | - Harsimran Kaur
- Department of Pathology and Laboratory Medicine, University of Rochester Medical, Rochester, NY 14642, USA
| | - Bruce R. Smoller
- Department of Pathology and Laboratory Medicine, University of Rochester Medical, Rochester, NY 14642, USA
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Quach HT, Johnson DB, LeBoeuf NR, Zwerner JP, Dewan AK. Cutaneous adverse events caused by immune checkpoint inhibitors. J Am Acad Dermatol 2021; 85:956-966. [PMID: 34332798 DOI: 10.1016/j.jaad.2020.09.054] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/25/2022]
Abstract
IMPORTANCE Immune checkpoint inhibitors (ICIs) have emerged as active therapies for a variety of cancers. Cutaneous toxicities are common immune-related adverse events and patients will often be referred to dermatologists for evaluation. OBSERVATIONS Cutaneous adverse events to ICIs can have a variety of clinical presentations. Among the more common are eczematous, morbilliform, and lichenoid dermatoses, as well as vitiligo and pruritus. Less common adverse events include psoriasiform dermatoses, bullous disorders, and severe cutaneous adverse reactions, including Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug reaction with eosinophilia and systemic symptoms. Because of the immunologic mechanism of ICIs, there are also a variety of rheumatologic adverse reactions with cutaneous manifestations, such as scleroderma, dermatomyositis, cutaneous lupus erythematosus, and various vasculitides. These cutaneous reactions often respond to topical or systemic steroids, although specific toxicities may have alternative treatments available. CONCLUSIONS AND RELEVANCE As they become more widely prescribed, dermatologists will see an increasing number of patients with cutaneous adverse events caused by ICI therapies. Accurately diagnosing and treating these toxicities is paramount to achieving the most favorable outcomes for patients.
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Affiliation(s)
- Henry T Quach
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Nicole R LeBoeuf
- Department of Dermatology, The Center for Cutaneous Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeffrey P Zwerner
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna K Dewan
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee.
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The Clinical and Histopathological Features of Cutaneous Immune-Related Adverse Events and Their Outcomes. J Clin Med 2021; 10:jcm10040728. [PMID: 33673164 PMCID: PMC7918541 DOI: 10.3390/jcm10040728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/01/2021] [Accepted: 02/09/2021] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) cause a variety of inflammatory eruptions. The understanding of ICI-induced inflammatory eruptions with detailed histopathological findings is not adequate, particularly in Asian populations. In this study, we retrospectively reviewed 51 patients who were histopathologically diagnosed with cutaneous immune-related adverse events (irAEs) following ICI therapy between 2014 and 2020 at the Department of Dermatology of Kyushu University Hospital. Of the 51 patients (30 men, 21 women), maculopapular rash (38/51, 74.5%), erythema multiforme (2/51, 3.9%), lichenoid reaction (3/51, 5.9%), psoriasiform reaction (3/51, 5.9%), bullous pemphigoid (3/51, 5.9%), scleroderma-like reaction (1/51, 2.0%), and Stevens–Johnson syndrome (1/51, 2.0%) were observed. The clinical and histopathological findings of these eruptions were equivalent to typical cases of common drug eruptions. The onset of maculopapular rash was relatively early (more than half of events occurred within 1 month), whereas lichenoid reactions and autoimmune diseases occurred relatively late (4–8 months). With appropriate treatment and/or interruption of ICIs, most rashes improved (50/51, 98.0%). The ICI-induced inflammatory eruptions shared similar clinical and histopathological features with classical inflammatory eruptions, but a variety of inflammatory eruptions may occur with different degrees of severity. Dermatologists play an important role in providing specialized care for cutaneous irAEs.
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Ehret M, Lenormand C, Scrivener JN, Gusdorf L, Lipsker D, Cribier B. [Generalized granuloma annulare: A clinicopathological study]. Ann Dermatol Venereol 2020; 147:271-278. [PMID: 32171551 DOI: 10.1016/j.annder.2019.09.617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 02/13/2019] [Accepted: 09/06/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Granuloma annulare (GA) is a benign granulomatous skin disorder that is generalized (GGA) in 15 % of cases. Although many case reports describe a relationship between GGA and systemic diseases, few large series have been published, and their association is debated. We present herein a series of GGA in order to describe their clinical and histological features. PATIENTS AND METHODS We included all biopsy-proven cases of GA presenting at the dermatopathology laboratory of Strasbourg where generalized (i.e. over 10 lesions). Clinical features were obtained from patients' medical files. RESULTS We included 35 GGA, with a sex ratio of 0.5. The mean age was 54 years. Lesions were annular or non-annular in equal measure and were symptomatic in 25 % of cases. Most patients (77 %) had an associated disease, already known in 60 % of cases, including dyslipidemia (27 %), diabetes mellitus (20 %), immunosuppressive drugs (17 %), atopy (17 %), auto-immune disease (17 %), hematological disease (14 %), and cancer (9 %). Histological analysis revealed the predominant pattern to be interstitial (54 %) rather than palisading (20 %), having no correlation with clinical type. Eosinophils were frequent (46 %) in GA but were not correlated with systemic disease or drug taking. Among the 40 % of patients treated, 50 % had a successful outcome on topical corticosteroids, doxycycline, antimalarial drugs or phototherapy. DISCUSSION GGA differs from localized GA, which is mostly associated with an already known systemic disease, whether metabolic, infectious or neoplastic, uncorrelated with clinical or histological features, and screening is necessary.
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Affiliation(s)
- M Ehret
- Clinique dermatologique, université de Strasbourg et hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France.
| | - C Lenormand
- Clinique dermatologique, université de Strasbourg et hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - J-N Scrivener
- Clinique dermatologique, université de Strasbourg et hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - L Gusdorf
- Clinique dermatologique, université de Strasbourg et hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - D Lipsker
- Clinique dermatologique, université de Strasbourg et hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - B Cribier
- Clinique dermatologique, université de Strasbourg et hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
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Coleman E, Ko C, Dai F, Tomayko MM, Kluger H, Leventhal JS. Inflammatory eruptions associated with immune checkpoint inhibitor therapy: A single-institution retrospective analysis with stratification of reactions by toxicity and implications for management. J Am Acad Dermatol 2018; 80:990-997. [PMID: 30399387 DOI: 10.1016/j.jaad.2018.10.062] [Citation(s) in RCA: 128] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/04/2018] [Accepted: 10/28/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is increasing recognition of distinct inflammatory eruptions associated with checkpoint inhibitors. A better understanding of their severity, therapeutic response, and impact on cancer treatment is needed. OBJECTIVE To analyze the different rashes associated with immunotherapy referred to our institution's oncodermatology clinic and inpatient consultative service and to evaluate their therapeutic response and impact on immunotherapy. METHODS We retrospectively reviewed the medical records of patients referred to the oncodermatology clinic or inpatient dermatology service during 2016-2018 at Yale-New Haven Hospital for eruptions that developed during immunotherapy. RESULTS In total, 98 patients (51 men, 47 women) treated with checkpoint inhibitors developed 103 inflammatory eruptions, with a range of mean latency of 0.2-17.7 months. A minority of patients (25/103; 24.3%) required immunotherapy interruption; most of these cases involved immunobullous (7/8; 87.5%), lichenoid (8/26; 30.8%), maculopapular (6/18; 33.3%), and Stevens-Johnson syndrome-like (2/2, 100%) reactions. Only 3 of 16 (18.8%) patients who had their immunotherapy interrupted had a grade 2 or 3 flare on rechallenge. Most reactions (93/103; 90.3%) responded to dermatologic therapy or immunotherapy interruption. LIMITATIONS This was a retrospective study from a single tertiary care center. CONCLUSION A variety of inflammatory reactions might occur from immunotherapy with differing degrees of severity. While most rashes responded to topical treatment, immunobullous and exfoliative presentations frequently interrupted immunotherapy. Increased awareness and early recognition could reduce the need for unnecessary immunotherapy interruption.
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Affiliation(s)
- Emily Coleman
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Christine Ko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut; Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Feng Dai
- Yale Center for Analytical Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Mary M Tomayko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Harriet Kluger
- Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan S Leventhal
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut.
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Mangold AR, Cumsky HJ, Costello CM, Xie DY, Buras MR, Nelson SA, DiCaudo DJ, Sekulic A, Pittelkow MR. Clinical and histopathologic features of paraneoplastic granuloma annulare in association with solid organ malignancies: A case–control study. J Am Acad Dermatol 2018; 79:913-920.e1. [DOI: 10.1016/j.jaad.2018.06.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 06/02/2018] [Accepted: 06/12/2018] [Indexed: 11/25/2022]
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Kubicki SL, Welborn ME, Garg N, Aung PP, Patel AB. Granulomatous dermatitis associated with ipilimumab therapy (ipilimumab associated granulomatous dermatitis). J Cutan Pathol 2018; 45:636-638. [PMID: 29704281 DOI: 10.1111/cup.13267] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/13/2018] [Accepted: 04/24/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Shelby L Kubicki
- Department of Dermatology, McGovern Medical School at UTHealth at Houston, Houston, Texas
| | - Macartney E Welborn
- Department of Dermatology, McGovern Medical School at UTHealth at Houston, Houston, Texas
| | - Naveen Garg
- Department of Diagnostic Radiology, UT MD Anderson Cancer Center, Houston, Texas
| | - Phyu P Aung
- Department of Pathology, UT MD Anderson Cancer Center, Houston, Texas
| | - Anisha B Patel
- Department of Dermatology, McGovern Medical School at UTHealth at Houston, Houston, Texas.,Department of Dermatology, UT MD Anderson Cancer Center, Houston, Texas
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