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Sechi I, Muresu N, Di Lorenzo B, Saderi L, Puci M, Aliberti S, Maida I, Mondoni M, Piana A, Sotgiu G. Pulmonary Involvement in Recurrent Respiratory Papillomatosis: A Systematic Review. Infect Dis Rep 2024; 16:200-215. [PMID: 38525763 PMCID: PMC10961772 DOI: 10.3390/idr16020016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 03/26/2024] Open
Abstract
Recurrent respiratory papillomatosis (RRP) is a non-malignant disease, characterized by the production of wart-like growths in the respiratory tract, affecting both young people and adults (juvenile-onset recurrent respiratory papillomatosis, JORRP, and adult-onset recurrent respiratory papillomatosis, AORRP, respectively). Infection caused by human papillomavirus (HPV) is known as the main factor involved in RRP development. Complications of RRP may rarely occur, including lung involvement and malignant transformation. The present systematic review aimed to evaluate the prevalence of severe complications, such as lung involvement and lung tumor in JORRP and AORRP patients, and assess the role of HPV genotypes in the progression of disease severity following the guideline for reporting systematic reviews and meta-analysis (PRISMA Statement). A total of 378 studies were found on PubMed and Scopus using the following MESH terms: "recurrent respiratory papillomatosis and lung tumor" and "pulmonary tumor and recurrent respiratory papillomatosis". Basing on inclusion and exclusion criteria, a total of 11 studies were included in the systematic review. We found a pooled prevalence of 8% (95% CI: 4-14%; I2: 87.5%) for lung involvement in RRP patients. In addition, we found a pooled risk difference of 5% in lung involvement between JORRP and AORRP (95% CI: -7-18%; I2: 85.6%, p-value: 0.41). Among patients with lung involvement, we observed a pooled prevalence of lung tumor of 4% (95% CI:1-7%; I2: 67.1%) and a pooled prevalence mortality for this group of 4% (95% CI:2-6%; I2: 0%). Overall, the positivity rate for HPV-6 and -11 in patients with RRP was 91%. Considering only cases with pulmonary involvement, the pooled prevalence for HPV-11 was 21% (95% CI: 5-45%; I2: 77.2%). Our results evidenced a low/middle risk of pulmonary involvement and lung tumor in JORRP and AORRP patients, with an increased risk for HPV-11-positive patients. Further studies should be performed to improve knowledge and adopt preventive measures to contrast the progression to severe diseases in RRP patients.
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Affiliation(s)
- Illari Sechi
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (I.S.); (I.M.); (A.P.)
| | - Narcisa Muresu
- Department of Humanities and Social Sciences, University of Sassari, 07100 Sassari, Italy;
| | - Biagio Di Lorenzo
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Medicine, University of Sassari, 07100 Sassari, Italy; (B.D.L.); (M.P.)
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Medicine, University of Sassari, 07100 Sassari, Italy; (B.D.L.); (M.P.)
| | - Mariangela Puci
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Medicine, University of Sassari, 07100 Sassari, Italy; (B.D.L.); (M.P.)
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy;
| | - Ivana Maida
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (I.S.); (I.M.); (A.P.)
| | - Michele Mondoni
- Respiratory Unit, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, 20122 Milan, Italy;
| | - Andrea Piana
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (I.S.); (I.M.); (A.P.)
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Medicine, University of Sassari, 07100 Sassari, Italy; (B.D.L.); (M.P.)
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Di Lorenzo B, Scala C, Mangoni AA, Zoroddu S, Paliogiannis P, Pirina P, Fois AG, Carru C, Zinellu A. A Systematic Review and Meta-Analysis of Mean Platelet Volume and Platelet Distribution Width in Patients with Obstructive Sleep Apnoea Syndrome. Biomedicines 2024; 12:270. [PMID: 38397872 PMCID: PMC10887137 DOI: 10.3390/biomedicines12020270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
Obstructive sleep apnoea syndrome (OSAS) is a highly prevalent yet underestimated disorder caused by the complete or partial obstruction of the upper airways. Although polysomnography is the gold standard for OSAS diagnosis, there is an active search for easily accessible biomarkers of disease presence and severity, particularly those reflecting morphological changes in specific blood cells. We investigated the associations between the presence and severity of OSAS, continuous positive airway pressure (CPAP) treatment, mean platelet volume (MPV), and platelet distribution width (PDW), routinely assessed as part of the complete blood count. From 262 retrieved records from PubMed, the Web of Science, Scopus, and Google Scholar, 31 manuscripts were selected for a final analysis, 30 investigating MPV and 15 investigating PDW. MPV was not statistically different between OSAS patients and healthy controls; however, it progressively increased with disease severity. By contrast, OSAS patients had significantly higher PDW values than controls (SMD = 0.40, 95% CI: 0.25 to 0.56; p ˂ 0.001), and the difference increased with disease severity. In a univariate meta-regression, there were significant associations between the MPV and publication year, the apnoea-hypopnea index, and diabetes mellitus, while no associations were observed with the PDW. No significant between-group differences were observed in the subgroup analyses. These data suggest that PDW, and to a lesser extent, MPV, are potential biomarkers of OSAS and require further research to ascertain their pathophysiological significance (PROSPERO, CRD42023459413).
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Affiliation(s)
- Biagio Di Lorenzo
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy (C.C.); (A.Z.)
| | - Chiara Scala
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy (P.P.)
- Clinical and Interventional Pulmonology, University Hospital of Sassari (AOU), 07100 Sassari, Italy
| | - Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Bedford Park, SA 5042, Australia
- Department of Clinical Pharmacology, Flinders Medical Centre, Southern Adelaide Local Health Network, Bedford Park, SA 5042, Australia
| | - Stefano Zoroddu
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy (C.C.); (A.Z.)
| | - Panagiotis Paliogiannis
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy (P.P.)
| | - Pietro Pirina
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy (P.P.)
- Clinical and Interventional Pulmonology, University Hospital of Sassari (AOU), 07100 Sassari, Italy
| | - Alessandro G. Fois
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy (P.P.)
- Clinical and Interventional Pulmonology, University Hospital of Sassari (AOU), 07100 Sassari, Italy
| | - Ciriaco Carru
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy (C.C.); (A.Z.)
- Quality Control Unit, University Hospital of Sassari (AOU), 07100 Sassari, Italy
| | - Angelo Zinellu
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy (C.C.); (A.Z.)
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Di Lorenzo B, Pau MC, Zinellu E, Mangoni AA, Paliogiannis P, Pirina P, Fois AG, Carru C, Zinellu A. Association between Red Blood Cell Distribution Width and Obstructive Sleep Apnea Syndrome: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12093302. [PMID: 37176740 PMCID: PMC10179738 DOI: 10.3390/jcm12093302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/26/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
Although polysomnography is the gold standard method to diagnose obstructive sleep apnea syndrome (OSAS), there is an ongoing quest for simpler and relatively inexpensive biomarkers of disease presence and severity. To address this issue, we conducted a systematic review of the potential diagnostic role of the red blood cell distribution width (RDW), a routine hematological parameter of red blood cell volume variability, in OSAS. A total of 1478 articles were initially identified in the databases PubMed, Web of Science, Scopus, Embase, and Google Scholar, from their inception to February 2023, and 20 were selected for final analysis. The RDW was significantly higher in OSAS than in non-OSAS subjects (SMD = 0.44, 95% CI 0.20 to 0.67, p < 0.001; low certainty of evidence). In univariate meta-regression, the mean oxygen saturation (SpO2) was significantly associated with the effect size. No significant between-group differences were observed in subgroup analyses. Notably, in OSAS subjects, the RDW SMD progressively increased with disease severity. In conclusion, these results suggest that the RDW is a promising biomarker of OSAS (PROSPERO registration number: CRD42023398047).
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Affiliation(s)
- Biagio Di Lorenzo
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy
| | - Maria Carmina Pau
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Elisabetta Zinellu
- Clinical and Interventional Pulmonology, University Hospital of Sassari (AOU), 07100 Sassari, Italy
| | - Arduino A Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Bedfor Park, SA 5042, Australia
- Department of Clinical Pharmacology, Flinders Medical Centre, Southern Adelaide Local Health Network, Bedford Park, SA 5042, Australia
| | | | - Pietro Pirina
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
- Clinical and Interventional Pulmonology, University Hospital of Sassari (AOU), 07100 Sassari, Italy
| | - Alessandro G Fois
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
- Clinical and Interventional Pulmonology, University Hospital of Sassari (AOU), 07100 Sassari, Italy
| | - Ciriaco Carru
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy
- Quality Control Unit, University Hospital of Sassari (AOU), 07100 Sassari, Italy
| | - Angelo Zinellu
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy
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Di Lorenzo B, Pacillo L, Milardi G, Jofra T, Di Cesare S, Gerosa J, Marzinotto I, Zapparoli E, Rivalta B, Cifaldi C, Barzaghi F, Giancotta C, Zangari P, Rapini N, Deodati A, Amodio G, Passerini L, Carrera P, Gregori S, Palma P, Finocchi A, Lampasona V, Cicalese MP, Schiaffini R, Di Matteo G, Merelli I, Barcella M, Aiuti A, Piemonti L, Cancrini C, Fousteri G. Natural history of type 1 diabetes on an immunodysregulatory background with genetic alteration in B-cell activating factor receptor: A case report. Front Immunol 2022; 13:952715. [PMID: 36090979 PMCID: PMC9459137 DOI: 10.3389/fimmu.2022.952715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/02/2022] [Indexed: 11/24/2022] Open
Abstract
The immunological events leading to type 1 diabetes (T1D) are complex and heterogeneous, underscoring the necessity to study rare cases to improve our understanding. Here, we report the case of a 16-year-old patient who showed glycosuria during a regular checkup. Upon further evaluation, stage 2 T1D, autoimmune thrombocytopenic purpura (AITP), and common variable immunodeficiency (CVID) were diagnosed. The patient underwent low carb diet, losing > 8 kg, and was placed on Ig replacement therapy. Anti-CD20 monoclonal antibody (Rituximab, RTX) was administered 2 years after diagnosis to treat peripheral polyneuropathy, whereas an atypical mycobacteriosis manifested 4 years after diagnosis and was managed with prolonged antibiotic treatment. In the fifth year of monitoring, the patient progressed to insulin dependency despite ZnT8A autoantibody resolution and IA-2A and GADA autoantibody decline. The patient had low T1D genetic risk score (GRS = 0.22817) and absence of human leukocyte antigen (HLA) DR3/DR4-DQ8. Genetic analysis identified the monoallelic mutation H159Y in TNFRSF13C, a gene encoding B-cell activating factor receptor (BAFFR). Significant reduced blood B-cell numbers and BAFFR levels were observed in line with a dysregulation in BAFF–BAFFR signaling. The elevated frequency of PD-1+ dysfunctional Tfh cells composed predominantly by Th1 phenotype was observed at disease onset and during follow-up. This case report describes a patient progressing to T1D on a BAFFR-mediated immunodysregulatory background, suggesting a role of BAFF–BAFFR signaling in islet-specific tolerance and T1D progression.
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Affiliation(s)
- Biagio Di Lorenzo
- Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Lucia Pacillo
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesú Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Giulia Milardi
- Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Tatiana Jofra
- Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Silvia Di Cesare
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Jolanda Gerosa
- Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Ilaria Marzinotto
- Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Ettore Zapparoli
- Center for Omics Sciences, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milano, Italy
| | - Beatrice Rivalta
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesú Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Cristina Cifaldi
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesú Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Federica Barzaghi
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Carmela Giancotta
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesú Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Paola Zangari
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesú Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Novella Rapini
- Unit of Endocrinology, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Annalisa Deodati
- Unit of Endocrinology, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Giada Amodio
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Laura Passerini
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Paola Carrera
- Unit of Genomics for Human Disease Diagnosis and Laboratory of Clinical Molecular Biology, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Silvia Gregori
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Palma
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesú Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Andrea Finocchi
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesú Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Vito Lampasona
- Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Maria Pia Cicalese
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
- Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy
| | - Riccardo Schiaffini
- Unit of Endocrinology, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Gigliola Di Matteo
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Ivan Merelli
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
- Department of Bioinformatics, Institute for Biomedical Technologies National Research Council, Segrate, Italy
| | - Matteo Barcella
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
- Department of Bioinformatics, Institute for Biomedical Technologies National Research Council, Segrate, Italy
| | - Alessandro Aiuti
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
- Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy
- *Correspondence: Alessandro Aiuti, ; Caterina Cancrini, ; Georgia Fousteri, ; Lorenzo Piemonti,
| | - Lorenzo Piemonti
- Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
- *Correspondence: Alessandro Aiuti, ; Caterina Cancrini, ; Georgia Fousteri, ; Lorenzo Piemonti,
| | - Caterina Cancrini
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesú Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
- *Correspondence: Alessandro Aiuti, ; Caterina Cancrini, ; Georgia Fousteri, ; Lorenzo Piemonti,
| | - Georgia Fousteri
- Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
- *Correspondence: Alessandro Aiuti, ; Caterina Cancrini, ; Georgia Fousteri, ; Lorenzo Piemonti,
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Muresu N, Di Lorenzo B, Saderi L, Sechi I, Del Rio A, Piana A, Sotgiu G. Prevalence of Human Papilloma Virus Infection in Bladder Cancer: A Systematic Review. Diagnostics (Basel) 2022; 12:diagnostics12071759. [PMID: 35885662 PMCID: PMC9318826 DOI: 10.3390/diagnostics12071759] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022] Open
Abstract
The etiology of bladder cancer is known to be associated with behavioral and environmental factors. Moreover, several studies suggested a potential role of HPV infection in the pathogenesis with controversial results. A systematic review was conducted to assess the role of HPV. A total of 46 articles that reported the prevalence of HPV infection in squamous (SCC), urothelial (UC), and transitional cell carcinomas (TCC) were selected. A pooled prevalence of 19% was found, with a significant difference in SCC that was mainly driven by HPV-16. Moreover, infection prevalence in case-control studies showed a higher risk of bladder cancer in HPV-positive cases (OR: 7.84; p-value < 0.00001). The results may suggest an etiologic role of HPV in bladder cancer. HPV vaccine administration in both sexes could be key to prevent the infection caused by high-risk genotypes.
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Affiliation(s)
- Narcisa Muresu
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (N.M.); (I.S.)
| | - Biagio Di Lorenzo
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Medicine, University of Sassari, 07100 Sassari, Italy; (B.D.L.); (L.S.); (G.S.)
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Medicine, University of Sassari, 07100 Sassari, Italy; (B.D.L.); (L.S.); (G.S.)
| | - Illari Sechi
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (N.M.); (I.S.)
| | - Arcadia Del Rio
- Department of Biomedical Science, University of Sassari, 07100 Sassari, Italy;
| | - Andrea Piana
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (N.M.); (I.S.)
- Correspondence:
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Medicine, University of Sassari, 07100 Sassari, Italy; (B.D.L.); (L.S.); (G.S.)
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Milardi G, Di Lorenzo B, Gerosa J, Barzaghi F, Di Matteo G, Omrani M, Jofra T, Merelli I, Barcella M, Filippini M, Conti A, Ferrua F, Pozzo Giuffrida F, Dionisio F, Rovere‐Querini P, Marktel S, Assanelli A, Piemontese S, Brigida I, Zoccolillo M, Cirillo E, Giardino G, Danieli MG, Specchia F, Pacillo L, Di Cesare S, Giancotta C, Romano F, Matarese A, Chetta AA, Trimarchi M, Laurenzi A, De Pellegrin M, Darin S, Montin D, Marinoni M, Dellepiane RM, Sordi V, Lougaris V, Vacca A, Melzi R, Nano R, Azzari C, Bongiovanni L, Pignata C, Cancrini C, Plebani A, Piemonti L, Petrovas C, Di Micco R, Ponzoni M, Aiuti A, Cicalese MP, Fousteri G. Follicular helper T cell signature of replicative exhaustion, apoptosis, and senescence in common variable immunodeficiency. Eur J Immunol 2022; 52:1171-1189. [PMID: 35562849 PMCID: PMC9542315 DOI: 10.1002/eji.202149480] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 02/08/2022] [Accepted: 05/09/2022] [Indexed: 11/06/2022]
Abstract
Common variable immunodeficiency (CVID) is the most frequent primary antibody deficiency whereby follicular helper T (Tfh) cells fail to establish productive responses with B cells in germinal centers. Here, we analyzed the frequency, phenotype, transcriptome, and function of circulating Tfh (cTfh) cells in CVID patients displaying autoimmunity as an additional phenotype. A group of patients showed a high frequency of cTfh1 cells and a prominent expression of PD-1 and ICOS as well as a cTfh mRNA signature consistent with highly activated, but exhausted, senescent, and apoptotic cells. Plasmatic CXCL13 levels were elevated in this group and positively correlated with cTfh1 cell frequency and PD-1 levels. Monoallelic variants in RTEL1, a telomere length- and DNA repair-related gene, were identified in four patients belonging to this group. Their blood lymphocytes showed shortened telomeres, while their cTfh were more prone to apoptosis. These data point toward a novel pathogenetic mechanism in CVID, whereby alterations in DNA repair and telomere elongation might predispose to antibody deficiency. A Th1, highly activated but exhausted and apoptotic cTfh phenotype was associated with this form of CVID.
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Affiliation(s)
- Giulia Milardi
- Division of Immunology, Transplantation, and Infectious DiseasesDiabetes Research InstituteIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Biagio Di Lorenzo
- Division of Immunology, Transplantation, and Infectious DiseasesDiabetes Research InstituteIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Jolanda Gerosa
- Division of Immunology, Transplantation, and Infectious DiseasesDiabetes Research InstituteIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Federica Barzaghi
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Gigliola Di Matteo
- Department of Systems Medicine, University of Rome Tor VergataVia Cracovia 50Rome00133Italy
- Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, Academic Department of PediatricsBambino Gesù Children's HospitalIRCCSPiazza di Sant'Onofrio 4Rome00165Italy
| | - Maryam Omrani
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
- Department of Computer Science, Systems and Communication, University of Milano‐BicoccaPiazza dell'Ateneo Nuovo 1Milan20126Italy
| | - Tatiana Jofra
- Division of Immunology, Transplantation, and Infectious DiseasesDiabetes Research InstituteIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Ivan Merelli
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
- Department of BioinformaticsInstitute for Biomedical TechnologiesNational Research CouncilVia Fratelli Cervi 93Segrate20090Italy
| | - Matteo Barcella
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Matteo Filippini
- Division of Immunology, Transplantation, and Infectious DiseasesDiabetes Research InstituteIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Anastasia Conti
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Francesca Ferrua
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Francesco Pozzo Giuffrida
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Francesca Dionisio
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Patrizia Rovere‐Querini
- Department of ImmunologyTransplantation and Infectious DiseasesIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Sarah Marktel
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Andrea Assanelli
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Simona Piemontese
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Immacolata Brigida
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Matteo Zoccolillo
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Emilia Cirillo
- Department of Translational Medical SciencesSection of PediatricsFederico II University of NaplesCorso Umberto I, 40, 80138Italy
| | - Giuliana Giardino
- Department of Translational Medical SciencesSection of PediatricsFederico II University of NaplesCorso Umberto I, 40, 80138Italy
| | - Maria Giovanna Danieli
- Department of Clinical and Molecular SciencesMarche Polytechnic University of AnconaClinica MedicaVia Tronto 10/aAncona60126Italy
| | - Fernando Specchia
- Department of PediatricsS. Orsola‐Malpighi HospitalUniversity of BolognaVia Giuseppe Massarenti 9Bologna40138Italy
| | - Lucia Pacillo
- Department of Systems Medicine, University of Rome Tor VergataVia Cracovia 50Rome00133Italy
- Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, Academic Department of PediatricsBambino Gesù Children's HospitalIRCCSPiazza di Sant'Onofrio 4Rome00165Italy
| | - Silvia Di Cesare
- Department of Systems Medicine, University of Rome Tor VergataVia Cracovia 50Rome00133Italy
- Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, Academic Department of PediatricsBambino Gesù Children's HospitalIRCCSPiazza di Sant'Onofrio 4Rome00165Italy
| | - Carmela Giancotta
- Department of Systems Medicine, University of Rome Tor VergataVia Cracovia 50Rome00133Italy
- Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, Academic Department of PediatricsBambino Gesù Children's HospitalIRCCSPiazza di Sant'Onofrio 4Rome00165Italy
| | - Francesca Romano
- Pediatric Immunology DivisionDepartment of PediatricsAnna Meyer Children's University HospitalViale Gaetano Pieraccini 24Florence50139Italy
| | - Alessandro Matarese
- Department of Respiratory MedicineSanti AntonioBiagio and Cesare Arrigo HospitalVia Venezia 16Alessandria15121Italy
| | - Alfredo Antonio Chetta
- Department of Medicine and SurgeryRespiratory Disease and Lung Function UnitUniversity of ParmaStr. dell'Università 12Parma43121Italy
| | - Matteo Trimarchi
- Otorhinolaryngology Unit, Head and Neck Department, IRCCS San Raffaele Scientific InstituteVia Olgettina 60Milan20132Italy
- Pathology UnitIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Andrea Laurenzi
- Division of Immunology, Transplantation, and Infectious DiseasesDiabetes Research InstituteIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Maurizio De Pellegrin
- Unit of Orthopaedics, IRCCS San Raffaele Scientific InstituteVia Olgettina 60Milan20132Italy
| | - Silvia Darin
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Davide Montin
- Department of Pediatrics and Public HealthRegina Margherita HospitalPiazza Polonia 94Turin10126Italy
| | - Maddalena Marinoni
- Pediatric UnitOspedale “F. Del Ponte”Via Filippo del Ponte 19Varese21100Italy
| | - Rosa Maria Dellepiane
- Department of PediatricsFondazione IRCCS Cà Granda Ospedale Maggiore PoliclinicoUniversity of MilanVia Francesco Sforza 35Milan20122Italy
| | - Valeria Sordi
- Division of Immunology, Transplantation, and Infectious DiseasesDiabetes Research InstituteIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Vassilios Lougaris
- Department of Clinical and Experimental SciencesPediatrics Clinic and Institute for Molecular Medicine A. NocivelliUniversity of BresciaPiazza del Mercato 15Brescia25121Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human OncologyUniversity of Bari Medical SchoolPiazza Umberto I, 1Bari70121Italy
| | - Raffaella Melzi
- Division of Immunology, Transplantation, and Infectious DiseasesDiabetes Research InstituteIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Rita Nano
- Division of Immunology, Transplantation, and Infectious DiseasesDiabetes Research InstituteIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Chiara Azzari
- Pediatric Immunology DivisionDepartment of PediatricsAnna Meyer Children's University HospitalViale Gaetano Pieraccini 24Florence50139Italy
| | - Lucia Bongiovanni
- Pathology UnitIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Claudio Pignata
- Department of Translational Medical SciencesSection of PediatricsFederico II University of NaplesCorso Umberto I, 40, 80138Italy
| | - Caterina Cancrini
- Department of Systems Medicine, University of Rome Tor VergataVia Cracovia 50Rome00133Italy
- Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, Academic Department of PediatricsBambino Gesù Children's HospitalIRCCSPiazza di Sant'Onofrio 4Rome00165Italy
| | - Alessandro Plebani
- Department of Clinical and Experimental SciencesPediatrics Clinic and Institute for Molecular Medicine A. NocivelliUniversity of BresciaPiazza del Mercato 15Brescia25121Italy
| | - Lorenzo Piemonti
- Division of Immunology, Transplantation, and Infectious DiseasesDiabetes Research InstituteIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
- Faculty of MedicineUniversity Vita‐Salute San RaffaeleVia Olgettina 60Milan20132Italy
| | - Constantinos Petrovas
- Tissue Analysis Core, Immunology LaboratoryVaccine Research CenterNational Institute of Allergy and Infectious DiseasesNational Institutes of Health9000 Rockville PikeBethesdaMD20892USA
| | - Raffaella Di Micco
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Maurilio Ponzoni
- Pathology UnitIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
- Faculty of MedicineUniversity Vita‐Salute San RaffaeleVia Olgettina 60Milan20132Italy
| | - Alessandro Aiuti
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
- Faculty of MedicineUniversity Vita‐Salute San RaffaeleVia Olgettina 60Milan20132Italy
| | - Maria Pia Cicalese
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
- Pathogenesis and therapy of primary immunodeficiencies UnitSan Raffaele Telethon Institute for Gene TherapySr‐TIGETIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
| | - Georgia Fousteri
- Division of Immunology, Transplantation, and Infectious DiseasesDiabetes Research InstituteIRCCS San Raffaele HospitalVia Olgettina 60Milan20132Italy
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7
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Di Lorenzo B, Ravens S, Silva-Santos B. High-throughput analysis of the human thymic Vδ1 + T cell receptor repertoire. Sci Data 2019; 6:115. [PMID: 31273218 PMCID: PMC6609709 DOI: 10.1038/s41597-019-0118-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 05/29/2019] [Indexed: 12/11/2022] Open
Abstract
γδ T cells are a relatively rare subset of lymphocytes in the human peripheral blood, but they play important roles at the interface between the innate and the adaptive immune systems. The γδ T cell lineage is characterized by a signature γδ T cell receptor (γδTCR) that displays extensive sequence variability originated by DNA rearrangement of the corresponding V(D)J loci. Human γδ T cells comprise Vγ9Vδ2 T cells, the major subset in the peripheral blood; and Vδ1+ T cells, the predominant subpopulation in the post-natal thymus and in peripheral tissues. While less studied, Vδ1+ T cells recently gathered significant attention due to their anti-cancer and anti-viral activities. In this study we applied next-generation sequencing (NGS) to analyse the γδTCR repertoire of highly (FACS-)purified Vδ1+ T cells from human thymic biopsies. Our analysis reveals unsuspected aspects of thymically rearranged and expressed (at the mRNA level) TRG and TRD genes, thus constituting a data resource that qualifies previous conclusions on the TCR repertoire of γδ T cells developing in the human thymus. Design Type(s) | transcription profiling design • cellular data analysis objective | Measurement Type(s) | gamma delta T-lymphocyte | Technology Type(s) | RNA sequencing | Factor Type(s) | sex • gene | Sample Characteristic(s) | Homo sapiens • thymus |
Machine-accessible metadata file describing the reported data (ISA-Tab format)
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Affiliation(s)
- Biagio Di Lorenzo
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Sarina Ravens
- Institute of Immunology, Hannover Medical School, Hannover, Germany.
| | - Bruno Silva-Santos
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
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8
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Di Lorenzo B, Simões AE, Caiado F, Tieppo P, Correia DV, Carvalho T, da Silva MG, Déchanet-Merville J, Schumacher TN, Prinz I, Norell H, Ravens S, Vermijlen D, Silva-Santos B. Broad Cytotoxic Targeting of Acute Myeloid Leukemia by Polyclonal Delta One T Cells. Cancer Immunol Res 2019; 7:552-558. [PMID: 30894378 DOI: 10.1158/2326-6066.cir-18-0647] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 12/12/2018] [Accepted: 01/30/2019] [Indexed: 11/16/2022]
Abstract
Acute myeloid leukemia (AML) remains a clinical challenge due to frequent chemotherapy resistance and deadly relapses. We are exploring the immunotherapeutic potential of peripheral blood Vδ1+ T cells, which associate with improved long-term survival of stem-cell transplant recipients but have not yet been applied as adoptive cell therapy. Using our clinical-grade protocol for expansion and differentiation of "Delta One T" (DOT) cells, we found DOT cells to be highly cytotoxic against AML primary samples and cell lines, including cells selected for resistance to standard chemotherapy. Unlike chemotherapy, DOT-cell targeting did not select for outgrowth of specific AML lineages, suggesting a broad recognition domain, an outcome that was consistent with the polyclonality of the DOT-cell T-cell receptor (TCR) repertoire. However, AML reactivity was only slightly impaired upon Vδ1+ TCR antibody blockade, whereas it was strongly dependent on expression of the NKp30 ligand, B7-H6. In contrast, DOT cells did not show reactivity against normal leukocytes, including CD33+ or CD123+ myeloid cells. Adoptive transfer of DOT cells in vivo reduced AML load in the blood and target organs of multiple human AML xenograft models and significantly prolonged host survival without detectable toxicity, thus providing proof-of-concept for DOT-cell application in AML treatment.
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Affiliation(s)
- Biagio Di Lorenzo
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - André E Simões
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Lymphact - Lymphocyte Activation Technologies S.A., Coimbra, Portugal
| | - Francisco Caiado
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Paola Tieppo
- Department of Pharmacotherapy and Pharmaceutics, Institute for Medical Immunology, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel V Correia
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,GammaDelta Therapeutics, London, United Kingdom
| | - Tânia Carvalho
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | | | | | | | - Immo Prinz
- Hannover Medical School, Hannover, Germany
| | - Haakan Norell
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | | | - David Vermijlen
- Department of Pharmacotherapy and Pharmaceutics, Institute for Medical Immunology, Université Libre de Bruxelles, Brussels, Belgium
| | - Bruno Silva-Santos
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
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9
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Simões AE, Di Lorenzo B, Silva-Santos B. Molecular Determinants of Target Cell Recognition by Human γδ T Cells. Front Immunol 2018; 9:929. [PMID: 29755480 PMCID: PMC5934422 DOI: 10.3389/fimmu.2018.00929] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/16/2018] [Indexed: 12/22/2022] Open
Abstract
The unique capabilities of gamma-delta (γδ) T cells to recognize cells under stressed conditions, particularly infected or transformed cells, and killing them or regulating the immune response against them, paved the way to the development of promising therapeutic strategies for cancer and infectious diseases. From a mechanistic standpoint, numerous studies have unveiled a remarkable flexibility of γδ T cells in employing their T cell receptor and/or NK cell receptors for target cell recognition, even if the relevant ligands often remain uncertain. Here, we review the accumulated knowledge on the diverse mechanisms of target cell recognition by γδ T cells, focusing on human γδ T cells, to provide an integrated perspective of their therapeutic potential in cancer and infectious diseases.
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Affiliation(s)
- André E Simões
- Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal
| | - Biagio Di Lorenzo
- Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal.,Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Bruno Silva-Santos
- Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal
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