Quantitative multiplex immunohistochemistry reveals inter-patient lymphovascular and immune heterogeneity in primary cutaneous melanoma

Introduction

Quantitative, multiplexed imaging is revealing complex spatial relationships between phenotypically diverse tumor infiltrating leukocyte populations and their prognostic implications. The underlying mechanisms and tissue structures that determine leukocyte distribution within and around tumor nests, however, remain poorly understood. While presumed players in metastatic dissemination, new preclinical data demonstrates that blood and lymphatic vessels (lymphovasculature) also dictate leukocyte trafficking within tumor microenvironments and thereby impact anti-tumor immunity. Here we interrogate these relationships in primary human cutaneous melanoma.

Methods

We established a quantitative, multiplexed imaging platform to simultaneously detect immune infiltrates and tumor-associated vessels in formalin-fixed paraffin embedded patient samples. We performed a discovery, retrospective analysis of 28 treatment-naïve, primary cutaneous melanomas.

Results

Here we find that the lymphvasculature and immune infiltrate is heterogenous across patients in treatment naïve, primary melanoma. We categorized five lymphovascular subtypes that differ by functionality and morphology and mapped their localization in and around primary tumors. Interestingly, the localization of specific vessel subtypes, but not overall vessel density, significantly associated with the presence of lymphoid aggregates, regional progression, and intratumoral T cell infiltrates.

Discussion

We describe a quantitative platform to enable simultaneous lymphovascular and immune infiltrate analysis and map their spatial relationships in primary melanoma. Our data indicate that tumor-associated vessels exist in different states and that their localization may determine potential for metastasis or immune infiltration. This platform will support future efforts to map tumor-associated lymphovascular evolution across stage, assess its prognostic value, and stratify patients for adjuvant therapy.

T cell egress via lymphatic vessels is tuned by antigen encounter and limits tumor control

Antigen-specific CD8+ T cell accumulation in tumors is a prerequisite for effective immunotherapy, and yet the mechanisms of lymphocyte transit are not well defined. Here we show that tumor-associated lymphatic vessels control T cell exit from tumors via the chemokine CXCL12, and intratumoral antigen encounter tunes CXCR4 expression by effector CD8+ T cells. Only high-affinity antigen downregulates CXCR4 and upregulates the CXCL12 decoy receptor, ACKR3, thereby reducing CXCL12 sensitivity and promoting T cell retention. A diverse repertoire of functional tumor-specific CD8+ T cells, therefore, exit the tumor, which limits the pool of CD8+ T cells available to exert tumor control. CXCR4 inhibition or loss of lymphatic-specific CXCL12 boosts T cell retention and enhances tumor control. These data indicate that strategies to limit T cell egress might be an approach to boost the quantity and quality of intratumoral T cells and thereby response to immunotherapy.

CXCR6 promotes dermal CD8+ T cell survival and transition to long-term tissue residence

Tissue resident memory T cells (TRM) provide important protection against infection, and yet the interstitial signals necessary for their formation and persistence remain incompletely understood. Here we show that antigen-dependent induction of the chemokine receptor, CXCR6, is a conserved requirement for TRM formation in peripheral tissue after viral infection. CXCR6 was dispensable for the early accumulation of antigen-specific CD8+ T cells in skin and did not restrain their exit. Single cell sequencing indicated that CXCR6-/- CD8+ T cells were also competent to acquire a transcriptional program of residence but exhibited deficiency in multiple pathways that converged on survival and metabolic signals necessary for memory. As such, CXCR6-/- CD8+ T cells exhibited increased rates of apoptosis relative to controls in the dermis, leading to inefficient TRM formation. CXCR6 expression may therefore represent a common mechanism across peripheral non-lymphoid tissues and inflammatory states that increases the probability of long-term residence.

Infection-induced lymphatic zippering restricts fluid transport and viral dissemination from skin

Lymphatic vessels are often considered passive conduits that flush antigenic material, pathogens, and cells to draining lymph nodes. Recent evidence, however, suggests that lymphatic vessels actively regulate diverse processes from antigen transport to leukocyte trafficking and dietary lipid absorption. Here we tested the hypothesis that infection-induced changes in lymphatic transport actively contribute to innate host defense. We demonstrate that cutaneous vaccinia virus infection by scarification activates dermal lymphatic capillary junction tightening (zippering) and lymph node lymphangiogenesis, which are associated with reduced fluid transport and cutaneous viral sequestration. Lymphatic-specific deletion of VEGFR2 prevented infection-induced lymphatic capillary zippering, increased fluid flux out of tissue, and allowed lymphatic dissemination of virus. Further, a reduction in dendritic cell migration to lymph nodes in the absence of lymphatic VEGFR2 associated with reduced antiviral CD8+ T cell expansion. These data indicate that VEGFR2-driven lymphatic remodeling is a context-dependent, active mechanism of innate host defense that limits viral dissemination and facilitates protective, antiviral CD8+ T cell responses.

CXCR6 is required for tissue resident memory T cell formation across diverse peripheral non-lymphoid tissues

CD8 T cell control of viral infections in peripheral tissues is largely dependent upon their spatial positioning. Clearance of pathogens requires direct contact between CD8 T cells and infected cells. Chemokine receptors play an essential role in this process by facilitating T cell entry into tissues, directing T cell positioning within tissues and by influencing egress out of tissues. Tissue resident memory T cells (TRM), which fail to egress after pathogen clearance and scan cells for signs of infection, are potent sources of immunity to secondary encounters with pathogens. Here we show that expression of the chemokine receptor CXCR6 is a conserved feature of TRM after viral infection in many non-lymphoid tissues. Using CXCR6KO TCR-tg T cells, we found that CXCR6 is necessary for proper formation of TRM in all non-lymphoid tissues examined. CXCR6 was necessary for early accumulation of effector T cells in several tissues such as the kidney and salivary gland but CXCR6 was dispensable for early accumulation in the skin. After vaccinia infection in the skin, CXCR6 expression is reinforced upon antigen re-encounter and promotes CD8 T cell accumulation in a migration-independent manner. Using single cell transcriptional analysis, we show that CXCR6KO TRM appear to exhibit a survival disadvantage and are outcompeted by wildtype T cells. This work reveals a critical requirement for generating TRM in diverse anatomical locations and may benefit strategies for vaccine design, anti-tumor immunity and reducing T-cell mediated autoimmunity.

Supported by R01CA238163 T32Al100853-10

Afferent Lymphatic Transport and Peripheral Tissue Immunity

Lymphatic vessels provide an anatomical framework for immune surveillance and adaptive immune responses. Although appreciated as the route for Ag and dendritic cell transport, peripheral lymphatic vessels are often not considered active players in immune surveillance. Lymphatic vessels, however, integrate contextual cues that directly regulate transport, including changes in intrinsic pumping and capillary remodeling, and express a dynamic repertoire of inflammatory chemokines and adhesion molecules that facilitates leukocyte egress out of inflamed tissue. These mechanisms together contribute to the course of peripheral tissue immunity. In this review, we focus on context-dependent mechanisms that regulate fluid and cellular transport out of peripheral nonlymphoid tissues to provide a framework for understanding the effects of afferent lymphatic transport on immune surveillance, peripheral tissue inflammation, and adaptive immunity.

Quantifying Leukocyte Egress via Lymphatic Vessels from Murine Skin and Tumors

Leukocyte egress from peripheral tissues to draining lymph nodes is not only critical for immune surveillance and initiation but also contributes to the resolution of peripheral tissue responses. While a variety of methods are used to quantify leukocyte egress from non-lymphoid, peripheral tissues, the cellular and molecular mechanisms that govern context-dependent egress remain poorly understood. Here, we describe the use of in situ photoconversion for quantitative analysis of leukocyte egress from murine skin and tumors. Photoconversion allows for the direct labeling of leukocytes resident within cutaneous tissue. Though skin exposure to violet light induces local inflammatory responses characterized by leukocyte infiltrates and vascular leakiness, in a head-to-head comparison with transdermal application of fluorescent tracers, photoconversion specifically labeled migratory dendritic cell populations and simultaneously enabled the quantification of myeloid and lymphoid egress from cutaneous microenvironments and tumors. The mechanisms of leukocyte egress remain a missing component in our understanding of intratumoral leukocyte complexity, and thus the application of the tools described herein will provide unique insight into the dynamics of tumor immune microenvironments both at steady state and in response to therapy.

Identification of FRA-1 as a novel player in pancreatic cancer in cooperation with a MUC1: ERK signaling axis

The MUC1 glycoprotein is overexpressed and aberrantly glycosylated in >90% of pancreatic ductal adenocarcinoma cases and impacts tumor progression by initiating downstream signaling through phosphorylation of its cytoplasmic tail. Previous studies have demonstrated that MUC1 alters expression of known targets of activator protein 1 (AP-1); however, no studies have evaluated the precise impact of MUC1 signaling on the activity and formation of AP-1. Given the known role of these proteins in modulating migration, invasion, and tumor progression, we explored the effects of MUC1 on AP-1 dimer formation and function. We determined that MUC1 increased the protein levels of c-Jun, the major component of AP-1, and promoted dimerization of c-Jun with the Fos-protein FRA-1. We demonstrate that FRA-1 acts as a potent mediator of migration and invasion in a manner that is modulated by signals through MUC1, which acts as a dominant regulator of specific AP-1 and FRA-1 target genes. Our results provide the first in vivo evidence of a FRA-1 mediated expression profile that impacts pancreatic tumor growth properties. In summary, we show that MUC1 enhancement of ERK activation influences FRA-1 activity to modulate tumor migration, invasion and metastasis in a subset of pancreatic cancer cases.

Emerging roles of the CXCL12/CXCR4 axis in pancreatic cancer progression and therapy

Chemokine networks regulate a variety of cellular, physiological, and immune processes. These normal functions can become appropriated by cancer cells to facilitate a more hospitable niche for aberrant cells by enhancing growth, proliferation, and metastasis. This is especially true in pancreatic cancer, where chemokine signaling is a vital component in the development of the supportive tumor microenvironment and the signaling between the cancer cells and surrounding stromal cells. Although expression patterns vary among cancer types, the chemokine receptor CXCR4 has been implicated in nearly every major malignancy and plays a prominent role in pancreatic cancer development and progression. This receptor, in conjunction with its primary chemokine ligand CXCL12, promotes pancreatic cancer development, invasion, and metastasis through the management of the tumor microenvironment via complex crosstalk with other pathways. Thus, CXCR4 likely contributes to the poor prognoses observed in patients afflicted with this malignancy. Recent exploration of combination therapies with CXCR4 antagonists have demonstrated improved outcomes, and abolishing the contribution of this pathway may prove crucial to effectively treat pancreatic cancer at both the primary tumor and metastases.

Abstract A30: AR20.5-based novel immunotherapy for pancreatic cancer

Pancreatic cancer is a fourth leading cause of cancer death in United States. Recent advances in tumor immunology have provided evidence for immune surveillance against pancreatic cancer. Previous studies have documented the presence of specific antibodies and cytotoxic T cell activities to Mucin 1 (MUC1), an antigen that is expressed in most pancreatic cancers. Hence, MUC1 remains a candidate for immunotherapeutic strategies for pancreatic cancer. Numerous attempts have been made to target this mucin glycoprotein; however, these efforts have shown only moderate success in part due to the complexity of the pancreatic tumor microenvironment. Previously, administration of murine monoclonal antibody BrevaRexAb-AR20.5 alone produced MUC1 specific immune response in a phase I study of advanced cancer patients, including increased human anti-MUC1 antibody levels and MUC1 specific T cell response in few patients. Though this was a phase I study, modest changes in tumor marker (CA15.3) but no anecdotal anti-tumor activity was observed in this small group of patients. Moving forward it is obvious that future immunization strategies should include other immune-modulators to amplify MUC1 specific immune responses of mAbAR20.5 and enhance other factors that contribute to tumor rejection. To that end, we investigated the anti-tumor effect of mAbAR20.5 in combination with anti-PD-L1 and poly (I:C) in murine models of pancreatic adenocarcinoma using human MUC1 expressing transgenic (hMUC1.Tg) mice, which are immunologically tolerant to MUC1. The therapeutic combination of mAb-AR20.5+anti-PD-L1+Poly (I:C) induced rejection or significant inhibition of tumor growth for two different MUC1 expressing pancreatic tumor cell lines, which was accompanied by persistent MUC1 specific memory immune response, which could be adoptively transferred to other mice and shown to protect against subsequent tumor challenge. We show that the anti-tumor response was effected by CD8 T cells, as their abrogation attenuated the anti-tumor response. Flow cytometric analysis of immunized mice demonstrated progressive increases in activated CD8 T cells in the peripheral circulation of combination treated mice. Together, these data support the hypothesis that targeting checkpoint induced immunosuppression (anti-PD-L1) together with the use of toll-like receptor 3 agonist as an adjuvant (poly (I:C) ) enhances the capacity of mAbAR20.5 to induce specific cell mediated immune responses to MUC1, which in turn provide long lasting anti-tumor response against pancreatic tumors. Our study supports the rapid translation of this strategy into clinical trials for pancreatic cancer patients.

Citation Format: Kamiya Mehla, James A. Grunkemeyer, Kelly A. O'Connell, Maria M. Steele, Thomas Caffrey, Ragupathy Madiyalakan, Christopher F. Nicodemus, Michael A. Hollingsworth. AR20.5-based novel immunotherapy for pancreatic cancer. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2016 Oct 20-23; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2017;5(3 Suppl):Abstract nr A30.

Abstract 902: A small molecule glycomimetic antagonist of E-selectin and CXCR4 (GMI-1359) delays pancreatic tumor metastasis and significantly alters the pancreatic tumor microenvironment

The cellular and molecular composition of the pancreatic tumor microenvironment includes a complex matrix that encases tumor cells and presents a conundrum in respect to therapy. The dense desmoplasia that accompanies tumor growth reduces blood flow to tumors and creates an environment that compromises delivery of therapeutics. As well, elimination of certain stromal elements enhances the aggressiveness and metastatic potential of pancreatic cancer cells. Recent studies attempt to target stroma in an effort to enhance delivery and efficacy of therapeutic agents and to block metastasis. In this context we have investigated the activity of GMI-1359, a potent dual antagonist that targets both E-selectin and CXCR4. Adhesion protein E-selectin is crucial for regulating vascular and lymphatic endothelial cell (EC) interactions with tumor cells during transmigration. The CXCL12-CXCR4 chemokine axis contributes to the formation of the tumor microenvironment including fibroblast and immune cell recruitment, lymph- and angiogenesis, tumor cell proliferation/survival, and tumor stem cell mobilization. Our in vitro results demonstrate that pancreatic fibroblasts secrete significant amounts of CXCL12 which promotes tumor cell and lymphatic and vascular EC directional migration; this migration toward CXCL12-secreting fibroblasts was completely blocked by GMI-1359. Additionally, CXCL12-stimulated ECs facilitated increased transendothelial migration (TEM) by pancreatic tumor cells. Dual antagonist GMI-1359 inhibited this CXCL12-dependent increase in pancreatic tumor cell TEM and was more effective than an independent small molecule E-selectin only inhibitor. Using an in vivo orthotopic model of pancreatic cancer in athymic mice, we evaluated the ability of GMI-1359 (with and without co-administration Gemcitabine (Gem)) to suppress tumor progression, modulate tumor microenvironment composition, and prolong survival. Our work demonstrated GMI-1359 slightly inhibited tumor growth when used alone or in combination with Gem but did not prolong survival in this immune compromised model. However, GMI-1359 inhibited tumor metastasis to the spleen, liver, and lungs. Interestingly, GMI-1359 significantly modulated the cellular composition of the tumor microenvironment. Immunohistochemical analysis revealed mice treated with GMI-1359 (with or without Gem administration) had drastically reduced desmoplasia and reduced lymphatic and blood vessel densities compared to mice treated with vehicle control or Gem alone. The E-selectin only inhibitor had no effect on tumor microenvironment composition. Further studies of GMI-1359, particularly in immune competent models, are warranted to understand its potential for disrupting the pancreatic tumor microenvironment, inhibiting dissemination, and enhancing anti-tumor immune responses.

Citation Format: Maria M. Steele, William E. Fogler, John L. Magnani, Michael A. Hollingsworth. A small molecule glycomimetic antagonist of E-selectin and CXCR4 (GMI-1359) delays pancreatic tumor metastasis and significantly alters the pancreatic tumor microenvironment. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 902.

The lymphatic system and pancreatic cancer

This review summarizes current knowledge of the biology, pathology and clinical understanding of lymphatic invasion and metastasis in pancreatic cancer. We discuss the clinical and biological consequences of lymphatic invasion and metastasis, including paraneoplastic effects on immune responses and consider the possible benefit of therapies to treat tumors that are localized to lymphatics. A review of current techniques and methods to study interactions between tumors and lymphatics is presented.

Abstract 425: A small molecule glycomimetic antagonist of E-selectin and CXCR4 (GMI-1359) prevents pancreatic tumor metastasis and improves chemotherapy

The tumor microenvironment's cellular and molecular composition includes a complex matrix that encases tumor cells and presents a conundrum in respect to pancreatic tumor therapy. On one hand, the dense desmoplastic reaction that accompanies growth of well differentiated pancreatic tumors reduces blood flow to tumors and creates an environment in which it is difficult to deliver therapies. On the other hand, elimination of certain stromal elements enhances the aggressiveness and metastatic potential of pancreatic cancer cells. Several current studies are attempting to target stroma in an effort to enhance delivery and efficacy of therapeutic agents and to block metastasis. We have investigated the activity of GMI-1359, a potent dual antagonist that targets both E-selectin and CXCR4. Adhesion protein E-selectin plays an important role in the tumor microenvironment by regulating cell contacts, including tumor cell binding to vascular and lymphatic endothelial cells during extravasation. Chemokine receptor CXCR4's role in the chemoattraction of tumor cells toward endothelial cells (ECs) contributes to tumor microenvironment remodeling by influencing lymphangiogenesis/angiogenesis, tumor cell survival/proliferation, and tumor stem cell mobilization. Our in vitro studies show that pancreatic ductal adenocarcinoma (PDAC) cells do not attract growth of lymphatic nor vascular ECs toward themselves. However, tumor associated fibroblasts, a major component of the PDAC tumor microenvironment, significantly increase EC directional migration. GMI-1359 completely blocked lymphatic and vascular EC migration toward fibroblast cells and disrupted these cell-cell interactions. In addition, GMI-1359 inhibited the capacity of invasive PDAC cell lines S2.013 and Colo357 to bind and migrate across EC barriers. The dual antagonist was more effective than an independent small molecule E-selectin inhibitor. We evaluated the capacity of GMI-1359 to inhibit growth and metastasis of orthotopically implanted S2.013 cells with and without administration of Gemcitabine. Two weeks post implantation, mice were treated by intraperitoneal injection for 4 weeks with either PBS once daily; 40 mg/kg GMI-1359 once daily; 100 mg/kg Gemcitabine every 4 days; or a combination of GMI-1359 and Gemcitabine. GMI-1359 treatment slightly, but not significantly, decreased primary tumor size as compared to the vehicle control. However, GMI-1359 in combination with Gemcitabine significantly reduced metastasis of this tumor to liver and diaphragm as compared to mice that received only Gemcitabine. Further studies of GMI-1359 are warranted to understand its potential for disrupting cellular contacts and blocking pancreatic tumor dissemination through the vascular and lymphatic systems, and for enhancing the efficacy of chemotherapeutic approaches to pancreatic cancer.

Citation Format: Maria M. Steele, William E. Fogler, John L. Magnani, Michael A. Hollingsworth. A small molecule glycomimetic antagonist of E-selectin and CXCR4 (GMI-1359) prevents pancreatic tumor metastasis and improves chemotherapy. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 425. doi:10.1158/1538-7445.AM2015-425

Nerve growth factor regulates neurolymphatic remodeling during corneal inflammation and resolution

The cellular and physiologic mechanisms that regulate the resolution of inflammation remain poorly defined despite their widespread importance in improving inflammatory disease outcomes. We studied the resolution of two cardinal signs of inflammation–pain and swelling–by investigating molecular mechanisms that regulate neural and lymphatic vessel remodeling during the resolution of corneal inflammation. A mouse model of corneal inflammation and wound recovery was developed to study this process in vivo. Administration of nerve growth factor (NGF) increased pain sensation and inhibited neural remodeling and lymphatic vessel regression processes during wound recovery. A complementary in vivo approach, the corneal micropocket assay, revealed that NGF-laden pellets stimulated lymphangiogenesis and increased protein levels of VEGF-C. Adult human dermal lymphatic endothelial cells did not express canonical NGF receptors TrkA and p75^NTR or activate downstream MAPK- or Akt-pathway effectors in the presence of NGF, although NGF treatment increased their migratory and tubulogenesis capacities in vitro. Blockade of the VEGF-R2/R3 signaling pathway ablated NGF-mediated lymphangiogenesis in vivo. These findings suggest a hierarchical relationship with NGF functioning upstream of the VEGF family members, particularly VEGF-C, to stimulate lymphangiogenesis. Taken together, these studies show that NGF stimulates lymphangiogenesis and that NGF may act as a pathogenic factor that negatively regulates the normal neural and lymphatic vascular remodeling events that accompany wound recovery.

MUC1 regulates cyclin D1 gene expression through p120 catenin and β-catenin

MUC1 interacts with β-catenin and p120 catenin to modulate WNT signaling. We investigated the effect of overexpressing MUC1 on the regulation of cyclin D1, a downstream target for the WNT/β-catenin signaling pathway, in two human pancreatic cancer cell lines, Panc-1 and S2-013. We observed a significant enhancement in the activation of cyclin D1 promoter-reporter activity in poorly differentiated Panc1.MUC1F cells that overexpress recombinant MUC1 relative to Panc-1.NEO cells, which express very low levels of endogenous MUC1. In stark contrast, cyclin D1 promoter activity was not affected in moderately differentiated S2-013.MUC1F cells that overexpressed recombinant MUC1 relative to S2-013.NEO cells that expressed low levels of endogenous MUC1. The S2-013 cell line was recently shown to be deficient in p120 catenin. MUC1 is known to interact with P120 catenin. We show here that re-expression of different isoforms of p120 catenin restored cyclin D1 promoter activity. Further, MUC1 affected subcellular localization of p120 catenin in association with one of the main effectors of P120 catenin, the transcriptional repressor Kaiso, supporting the hypothesis that p120 catenin relieved transcriptional repression by Kaiso. Thus, full activation of cyclin D1 promoter activity requires β-catenin activation of TCF-lef and stabilization of specific p120 catenin isoforms to relieve the repression of KAISO. Our data show MUC1 enhances the activities of both β-catenin and p120 catenin.

MicroRNA-200c modulates the expression of MUC4 and MUC16 by directly targeting their coding sequences in human pancreatic cancer

Transmembrane mucins, MUC4 and MUC16 are associated with tumor progression and metastatic potential in human pancreatic adenocarcinoma. We discovered that miR-200c interacts with specific sequences within the coding sequence of MUC4 and MUC16 mRNAs, and evaluated the regulatory nature of this association. Pancreatic cancer cell lines S2.028 and T3M-4 transfected with miR-200c showed a 4.18 and 8.50 fold down regulation of MUC4 mRNA, and 4.68 and 4.82 fold down regulation of MUC16 mRNA compared to mock-transfected cells, respectively. A significant reduction of glycoprotein expression was also observed. These results indicate that miR-200c overexpression regulates MUC4 and MUC16 mucins in pancreatic cancer cells by directly targeting the mRNA coding sequence of each, resulting in reduced levels of MUC4 and MUC16 mRNA and protein. These data suggest that, in addition to regulating proteins that modulate EMT, miR-200c influences expression of cell surface mucins in pancreatic cancer.

Regressed lymphatic vessels develop during corneal repair

The fate of newly synthesized lymphatic vessels induced by inflammation is poorly understood. To address this question, we designed experiments to determine the morphologic, phenotypic, and functional differences in regressing lymphatic vessels in the context of corneal recovery after an inflammatory response. A suture removal modification was used to induce corneal recovery after suture induced inflammation. We identified an increase in markers of corneal inflammation in sutured cornea that resolved in 14 days after suture removal. Sprouting newly synthesized lymphatic vessels trafficking MHC-II-positive leukocytes were visualized in sutured cornea. Following suture removal and recovery, the visualized lymphatic vessels were thin and fragmented, had bulbous termini, discontinuous expression of CD31 and VE-cadherin, and excluded MHC-II-positive leukocytes. VEGF-A, VEGF-C, and TGF-β mRNA levels were increased during corneal recovery, suggesting a complex interaction between lymphangiogenic factors and the mechanisms that regulate corneal recovery. The balance of lymphatic vessel growth and regression is likely to have a central role in the pathogenesis of corneal inflammatory diseases.

β1 integrin regulates MMP-10 dependant tubulogenesis in human lymphatic endothelial cells

Lymphatic vessel growth requires extensive remodeling of the extracellular matrix, a process hypothesized to be related to the expression and function of the matrix metalloproteinases. We used a protein based screening strategy to demonstrate increased matrix matalloproteinase-10 expression in human lymphatic endothelial cells undergoing collagen I induced tubulogenesis. Knock-down experiments showed that matrix metalloproteinase-10 regulated lymphatic endothelial cell tubulogenesis. β1 integrin signaling via the ERK/MAPK pathway increased matrix metalloproteinase-10 mRNA and protein expression in human lymphatic endothelial cells. These findings demonstrate a novel mechanism by which β1 integrin regulates matrix metalloproteinase-10 expression during lymphatic vessel remodeling.

Brief report: A case of autism with interstitial deletion of chromosome 13

A case of an 18-year-old male who meets the DSM-IV criteria for autistic disorder and borderline intelligence is described. Cytogenetic evaluation revealed a karyotype of 46, XY, del(13)(q14q22). The relevance of this case to the etiology of autism is discussed.

Child psychiatry practice patterns in Ontario

OBJECTIVES

To examine the demographics, training, distribution, venues of practice, remuneration patterns, and professional affiliations of child psychiatrists in Ontario.

METHOD

In July 1997, questionnaires were sent to 229 Ontario psychiatrists. A second mailing was sent to nonresponders in the fall of 1997. The overall response rate was 66.8%.

RESULTS

Compared with other research regarding the ratio of child psychiatrists to children with mental health problems, Ontario fares relatively well (1:6148). Generally, Ontario child psychiatrists report having received formalized training in the speciality. Child psychiatrists are disproportionately concentrated in Toronto and in midsize cities with medical schools compared with rural regions. Out-reach services to smaller communities are provided by 30% of child psychiatrists, but it is not clear whether the services are sufficient and equitably available. Approximately 50% of current psychiatrists will be aged 65 years or older in 15 years, and it is unclear whether sufficient numbers will replace them. The profession appears to be reaching an equitable gender representation. Most child psychiatrists belong to the professional organizations that support the profession; however, they are least likely to belong to the Ontario Psychiatric Association (OPA).

CONCLUSIONS

An optimal ratio of child psychiatrists per population served still needs to be determined, with special consideration given to the needs of rural communities. The small ratio of child psychiatrists to the population of children with mental health needs highlights the importance of collaborating with other medical and mental health professionals. Recruiting and retaining child psychiatrists will need to be monitored. Child psychiatrists in Ontario need a unified voice to address these issues.

Teaching child and adolescent psychiatry to family medicine trainees: a pilot experience

OBJECTIVE

To develop learning objectives for teaching child psychiatry to family medicine trainees and to evaluate the best method of teaching these objectives.

METHOD

For this descriptive study, knowledge, attitude, and skill objectives were presented to trainees at the start of a 6-month rotation, and an evaluation mechanism was developed based on the learning objectives. The method of instruction in each of the training locations was described independently by the child psychiatry consultant and attending family physician. The trainees' evaluations were presented according to training locations.

RESULTS

Family medicine trainees perceived the teaching-consultation method, with live interviews, to be the most helpful and the didactic lecture format to be least helpful.

CONCLUSION

The importance of teaching family medicine residents to recognize mental health problems in children and adolescents, preferably by using live interviews, and the implications for postresidency practice are emphasized.