A longitudinal study of antibody responses to selected host antigens in rheumatic fever and rheumatic heart disease

Introduction. Group A streptococci can trigger autoimmune responses that lead to acute rheumatic fever (ARF) and rheumatic heart disease (RHD).Gap Statement. Some autoantibodies generated in ARF/RHD target antigens in the S2 subfragment region of cardiac myosin. However, little is known about the kinetics of these antibodies during the disease process.Aim. To determine the antibody responses over time in patients and healthy controls against host tissue proteins - cardiac myosin and peptides from its S2 subfragment, tropomyosin, laminin and keratin.Methodology. We used enzyme-linked immunosorbent assays (ELISA) to determine antibody responses in: (1) healthy controls; (2) patients with streptococcal pharyngitis; (3) patients with ARF with carditis and (4) patients with RHD on penicillin prophylaxis.Results. We observed significantly higher antibody responses against extracellular proteins - laminin and keratin in pharyngitis group, patients with ARF and patients with RHD when compared to healthy controls. The antibody responses against intracellular proteins - cardiac myosin and tropomyosin were elevated only in the group of patients with ARF with active carditis. While the reactivity to S2 peptides S2-1-3, 8-11, 14, 16-18, 21-22 and 32 was higher in patients with ARF, the reactivity in the RHD group was high only against S2-1, 9, 11, 12 when compared to healthy controls. The reactivity against S2 peptides reduced as the disease condition stabilized in the ARF group whereas the reactivity remained unaltered in the RHD group. By contrast antibodies against laminin and keratin persisted in patients with RHD.Conclusion. Our findings of antibody responses against host proteins support the multistep hypothesis in the development of rheumatic carditis. The differential kinetics of serum antibody responses against S2 peptides may have potential use as markers of ongoing cardiac damage that can be used to monitor patients with ARF/RHD.

Biphasic Feline Mammary Carcinomas Including Carcinoma and Malignant Myoepithelioma

Feline mammary tumors are usually malignant and aggressive carcinomas. Most cases are simple monophasic carcinomas (1 epithelial population), and additional phenotyping is usually not needed. In this study, we describe 10 malignant mammary tumors from 9 female cats that had unusual histomorphology: they appeared biphasic, with 2 distinct cell populations. Initially, they were morphologically diagnosed as either carcinosarcoma (1/10) or malignant pleomorphic tumor (9/10) of the mammary gland, as the latter did not match any previously described histological subtype. Immunohistochemistry (IHC) was performed for pancytokeratin, cytokeratins 8 and 18, cytokeratin 14, cytokeratins 5 and 6, vimentin, p63, calponin, alpha-smooth muscle actin, Ki-67, ERBB2, estrogen receptor alpha, and progesterone receptor. In 7 of 10 cases, the biphasic nature was confirmed and, on the basis of the IHC results, they were classified as carcinoma and malignant myoepithelioma (4/10), ductal carcinoma (1/10), and carcinosarcoma (2/10). The other 3 of 10 cases were monophasic based on IHC. In the cases of carcinoma and malignant myoepithelioma, the malignant myoepithelial cells were 100% positive for vimentin (4/4) and variably positive for p63, calponin, and cytokeratins (4/4). These findings show that, although rare, biphasic mammary carcinomas do occur in cats. In dogs and humans, tumors composed of malignant epithelial and myoepithelial cells have a less aggressive behavior than certain simple carcinomas, and therefore, their identification might also be clinically significant in the cat.

Diagnostic accuracy of anti-keratin antibody for rheumatoid arthritis: a meta-analysis

OBJECTIVES

Anti-keratin antibody (AKA) is a serum antibody for patients with rheumatoid arthritis (RA), and it has a high specificity. Diagnostic role of AKA in RA was evaluated in this study.

METHODS

PubMed, EMBASE, and Web of Science were searched to acquire eligible studies. Articles published before 15 March 2018 were considered to be included. Quality Assessment of Diagnostic Accuracy Studies 2 was used to evaluate the risk of bias and application concern of the included articles. Pooled analysis of diagnostic indicators of AKA for RA was conducted by using a random effects model. Subgroup analysis was employed to explore the potential influencing factors. RevMan 5.3, Stata 11.0, and Meta-DiSc 1.4 software were used in this study.

RESULTS

A total of 15 studies (2350 positive and 2067 negative participants) were included. The pooled sensitivity was 0.46 (95% CI 0.44-0.48), pooled specificity was 0.94 (95% CI 0.93-0.95), and pooled diagnostic odds ratio was 15.86 (95% CI 9.48-26.52). In addition, the area under the curve was 0.7194.

CONCLUSIONS

The current evidence indicated that AKA has high diagnostic specificity in RA and may be useful for RA diagnostic application in clinic.

Preservation potential of keratin in deep time

Multiple fossil discoveries and taphonomic experiments have established the durability of keratin. The utility and specificity of antibodies to identify keratin peptides has also been established, both in extant feathers under varying treatment conditions, and in feathers from extinct organisms. Here, we show localization of feather-keratin antibodies to control and heat-treated feathers, testifying to the repeatability of initial data supporting the preservation potential of keratin. We then show new data at higher resolution that demonstrates the specific response of these antibodies to the feather matrix, we support the presence of protein in heat-treated feathers using ToF-SIMS, and we apply these methods to a fossil feather preserved in the unusual environment of sinter hot springs. We stress the importance of employing realistic conditions such as sediment burial when designing experiments intended as proxies for taphonomic processes occurring in the fossil record. Our data support the hypothesis that keratin, particularly the β-keratin that comprises feathers, has potential to preserve in fossil remains.

Synchronous hepatocellular carcinoma and lymphoepithelioma-like carcinoma arising from 2 different sites of the liver: A case report

RATIONALE

Most cases of primary liver cancer involve hepatocellular carcinoma (HCC). Lymphoepithelioma-like carcinoma (LELC) is defined as a tumor composed of undifferentiated epithelial cells with a prominent lymphoid infiltrate, which is rarely reported. Lymphoepithelioma-like HCC (LEL-HCC) is an uncommon variant of HCC, having an unclear process of development. Here, we report the first case involving simultaneous HCC and LEL-HCC.

PATIENT CONCERNS

A 77-year-old female was accidentally found to have a hypoechoic hepatic nodule via an abdominal ultrasound during a health examination. Abdominal computed tomography scan revealed 2 hepatic nodules with arterial phase enhancement and washout in the late phase.

DIAGNOSES

We diagnosed the case with 2 distinct liver nodules, HCC and LEL-HCC.

INTERVENTIONS

With suspicion of HCC, tumor resection (liver segments 4 and 5) was then performed. Histopathological examination of tumor 1 showed a moderately differentiated HCC and tumor 2 demonstrated a LEL-HCC. Immunohistochemically, the cells of tumor 2 were immunoreactive for cytokeratin (CK), CK7, and CK19. Epstein-Barr virus encoding small RNA (EBER) in situ hybridization results were negative.

OUTCOMES

Six months after resection, intrahepatic tumor recurrence was noted. Radiofrequency ablation was conducted.

LESSONS

This is an interesting case providing circumstantial evidence of simultaneous development of HCC and LEL-HCC in distinct nodules of the liver with a background of chronic hepatitis B virus infection.

Tissue Polypeptide Antigen (TPA) in Pleural Effusions

The usefulness of tumor marker assay in pleural effusions for differential diagnosis is still debated. From the observation of common antigens on tissue polypeptide antigen (TPA) and keratins 8, 18 and 19 and vimentin, all substances contained in normal and neoplastic mesothelium, we felt it opportune to evaluate the use of TPA assay in 105 pleural effusions (46 benign and 59 malignant). The values were much higher than those found in blood. In hydrothorax the median value was 454 U/l (range, 59–1923), in exudative effusions 846 U/l (range, 258–4485), in metastatic pleural effusions 1277 U/l (range, 58–32352) and in mesotheliomas 7705 (range, 759–16000). The maximum value found in nonmalignant effusions was 4485 U/l; this value was taken as a cutoff level, so only 29.9 % of the tumors were positive to the test. Our results showed this assay to be not very important for a differential diagnosis of malignant and nonmalignant pleural effusions. Nevertheless, the different TPA patterns in mesotheliomas (66.6 % positive) and metastatic pleural effusions (15.9 %) suggest that further studies are warranted.

Development of a new Prolifigen TPA IRMA assay using monoclonal anti-cytokeratin antibodies

A new immunoassay for TPA determination has been developed in which anti-cytokeratin monoclonal antibodies are used. A three-MAb combination with different anti-cytokeratin antibody specificities has been selected to mimic the complex pattern found for the polyclonal anti-TPA antibody. The accuracy of the assay is good, as judged from analytical recovery experiments, analysis of quality-assessment samples and comparison with the polyclonal Prolifigen TPA IRMA. No significant interferences or cross-reactivities have been identified. The lower limit of detection of the assay (mean + 3 SD of the zero standard) is below 15 U/L and the imprecision in low, giving a working range of 15-4000 UIL.

The improved handling of the assay, including a single incubation step of 2 hours with shaking at room temperature, results in a narrower normal distribution, thereby giving a better separation of normal and pathological samples.

TPS Monitoring in Metastatic Breast Cancer

The management of metastatic breast cancer patients reflects the heterogeneous nature of the disease. While patients may benefit from hormonal treatment, in most cases more toxic chemotherapy is applied in the advanced stages. The pretreatment levels of TPS in patients with metastatic breast cancer are correlated with prognosis. Decreasing TPS levels (>50%) during treatment are indicative of response. The fastest decrease in TPS levels is obtained in patients with a favorable prognosis. Increasing TPS levels (>25%) predict disease progression with a considerable lead time (median 8 months). The clinical impact of these observations is discussed in this paper.

History and Diagnostic Value of Antibodies to Citrullinated Proteins in Rheumatoid Arthritis

Rheumatoid arthritis is a chronic inflammatory joint disease characterized by the presence of autoantibodies. The best known autoantibody is the rheumatoid factor. Another group of antibodies directed against citrullinated epitopes is proven to be more specific for rheumatoid arthritis. This review gives an overview of the history of the different anti-citrullinated protein antibody detection methods and their diagnostic and prognostic properties in RA.

Biological significance of dermal Merkel cells in development of cutaneous nerves in human fetal skin

We detected epidermal Merkel cells in 12-week fetuses with monoclonal antibodies (MAb) against simple epithelium keratin and epithelial membrane antigen. In 15-week fetuses these Merkel cells began to descend into the dermis and expressed nerve growth factor receptors (NGF-R). At approximately the same time, cutaneous nerves, as detected with an MAb against neurofilaments, extended from the subcutaneous trunk and branched to form the subepidermal nerve plexus. The expression of NGF-R on dermal Merkel cells preceded their connection with immunoreactive small nerves. Initially, most of these fine nerve endings were directed towards dermal Merkel cells. In 23-week fetuses the subepidermal nerve plexus was well developed and immunoreactive dermal Merkel cells began to disappear. At all stage of fetal development the epidermal Merkel cells did not strongly express NGF-R. We postulate that dermal Merkel cells play an inductive and a promotional role in development of the cutaneous nerve plexus in the upper dermis.

Enumeration, Dielectrophoretic Capture, and Molecular Analysis of Circulating Tumor Cells

The identification of therapeutically targetable mutations in circulating tumor cells (CTCs) from cancer patient blood is increasingly used to personalize patient care. Here, we describe a novel approach for the enumeration, capture, and molecular analysis of CTCs from blood using an FDA-approved CTC enrichment and enumeration platform followed by dielectrophoretic capture and next-generation sequencing.

Circulating Tumor Cells: Markers and Methodologies for Enrichment and Detection

Cancer is a leading cause of disease worldwide; however, nowadays many points of its initiation processes are unknown. In this chapter, we are focusing on the role of liquid biopsies in cancer detection and progression. CTCs are one of the main components of liquid biopsies, they represent a subset of tumor cells that have acquired the ability to disseminate from the primary tumor and intravasate to the circulatory system. The greatest challenge in the detection of CTCs is their rarity in the blood. Human blood consists of white blood cells (5-10 × 10⁶/mL), red blood cells (5-9 × 10⁹/mL), and platelets (2.5-4 × 10⁸/mL); very few CTCs will be present even in patients with known metastatic disease, with often less than one CTC per mL of blood. CTCs are found in frequencies on the order of 1-10 CTCs per mL of whole blood in patients with metastatic disease, and it is reduced in half for non-metastatic stages. Therefore, accurate methodologies for their capture and analysis are really important. The main aim of the present chapter is to describe different methodologies for CTCs capturing and analysis.

A Novel Microfluidic Device for Isolation of Circulating Tumor Cells from Pancreatic Cancer Blood Samples

Enumeration of circulating tumor cells (CTCs) can provide valuable prognostic information to guide cancer treatment as well as help monitor disease progression. Analysis of these rare malignant cells has the potential to further our understanding of cancer metastasis by gaining insights into CTC characteristics and properties. Microfluidics presents a unique platform to isolate and study CTCs. In this chapter, we describe the detailed procedures for the fabrication and use of a microfluidic device to detect CTCs from the blood of pancreatic cancer patients.

Microscale Laminar Vortices for High-Purity Extraction and Release of Circulating Tumor Cells

Circulating tumor cells (CTCs) are disseminated tumor cells that reflect the tumors of origin and can provide a liquid biopsy that would potentially enable noninvasive tumor profiling, treatment monitoring, and identification of targeted treatments. Accurate and rapid purification of CTCs holds great potential to improve cancer care but the task remains technically challenging. Microfluidic isolation of CTCs within microscale vortices enables high-throughput and size-based purification of rare CTCs from bodily fluids. Collected cells are highly pure, viable, and easily accessible, allowing seamless integration with various downstream applications. Here, we describe how to fabricate the High-Throughput Vortex Chip (Vortex-HT) and to process diluted whole blood for CTC collection. Lastly, immunostaining and imaging protocols for CTC classification and corresponding CTC image galleries are reported.

Utilizing Matrigel Transwell Invasion Assay to Detect and Enumerate Circulating Tumor Cells

Metastasis is the cause of 90% of human cancer deaths. Circulating tumor cells (CTCs) in the peripheral blood and/or lymphatic vessels are cells shed from primary tumors and considered to be precursors of metastasis. Study of CTCs allows the serial monitoring of tumor progression and may provide predictive and prognostic biomarkers in clinic. Current CTC isolation and detection technologies encounter several challenges, including: heterogeneity of CTCs, low cell viability and/or high rate of contamination post-isolation, and the inability to distinguish viable/invasive from nonviable/nonfunctional CTCs, all of which can limit in vitro and in vivo characterization of CTCs. Here, we describe a new method to detect and enumerate of CTCs based on their invasive property.

Fiber-Optic Array Scanning Technology (FAST) for Detection and Molecular Characterization of Circulating Tumor Cells

Circulating tumor cell (CTC) as an important component in "liquid biopsy" holds crucial clinical relevance in cancer prognosis, treatment efficiency evaluation, prediction and potentially early detection. Here, we present a Fiber-optic Array Scanning Technology (FAST) that enables antigen-agnostic, size-agnostic detection of CTC. By immunofluorescence staining detection of a combination of a panel of markers, FAST technology can be applied to detect rare CTC in non-small cell lung cancer (NSCLC) setting with high sensitivity and specificity. In combination with Automated Digital Microscopy (ADM) platform, companion markers on CTC such as Vimentin and Programmed death-ligand 1 (PD-L1) can also be analyzed to further characterize these CTCs. FAST data output is also compatible with downstream single cell picking platforms. Single cell can be isolated post ADM confirmation and used for "actionable" genetic mutations analysis.

Automated Microfluidic Filtration and Immunocytochemistry Detection System for Capture and Enumeration of Circulating Tumor Cells and Other Rare Cell Populations in Blood

Isolation by size using a filter membrane offers an antigen-independent method for capturing rare cells present in blood of cancer patients. Multiple cell types, including circulating tumor cells (CTCs), captured on the filter membrane can be simultaneously identified via immunocytochemistry (ICC) analysis of specific cellular biomarkers. Here, we describe an automated microfluidic filtration method combined with a liquid handling system for sequential ICC assays to detect and enumerate non-hematologic rare cells in blood.

Immunocytochemical analysis of AE1/AE3, CK 14, Ki-67 and p53 expression in benign, premalignant and malignant oral tissue to establish putative markers for progression of oral carcinoma

Squamous cell carcinoma (SCC) is the most common form of oral malignancy and is often preceded by premalignant lesions, some of which are more likely to progress to carcinoma than others. In this study, a panel of monoclonal antibodies (AE1/AE3, cytokeratin [CK] 14, Ki-67 and p53) is applied to 10 cases of human oral tissue in each of six categories to establish staining patterns indicative of which lesions are more likely to progress to malignancy. The six tissue categories are normal tissue; abnormal benign lesions; mild, moderate and severe dysplasia; and SCC. A statistical analysis of Ki-67 and p53 immunoexpression is performed. The results showed that AE1/AE3 and CK 14 expression was reduced as a late event in oral carcinogenesis, particularly in poorly differentiated SCC. Expression of Ki-67 and p53 proved to be a weak but statistically significant predictor of malignant progression in oral tissue.

GITRL is associated with increased autoantibody production in patients with rheumatoid arthritis

The study aimed to determine the serum level of glucocorticoid-induced tumor necrosis factor receptor family-related protein ligand (GITRL) in patients with rheumatoid arthritis (RA) and investigate its clinical significance. GITRL levels were measured by enzyme-linked immunosorbent assay (ELISA) in 88 RA patients, 20 osteoarthritis (OA) patients, and 20 healthy controls (HCs). Anti-cyclic citrullinated peptide (anti-CCP) antibodies and rheumatoid factor immunoglobulin G (RF-IgG) were also tested by ELISA. RF-IgM, anti-keratin antibody (AKA), and anti-perinuclear factor (APF) antibodies and the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and immunoglobulins were measured by standard laboratory techniques. The disease activity was evaluated by the 28-joint count Disease Activity Score (DAS28). GITRL concentrations were significantly elevated in both serum and synovial fluid (SF) of RA patients. GITRL levels in RA sera were significantly higher than those in matched SFs. Positive correlations were found between serum GITRL levels and inflammation parameters or autoantibody production. GITRL levels are significantly elevated in RA serum and SF and are positively correlated with autoantibody production in RA, suggesting a role of GITRL in the development of RA.

Monoclonal antibodies to normal and abnormal epithelial antigens

Mouse monoclonal antibodies to various human epidermal and basement membrane components were formed by immunizing Balb/c mice with ME-180, a line of human cervical carcinoma cells. The spleen cells from hyperimmunized mice were fused with a nonsecreting mouse myeloma cell line using polyethylene glycol. The resulting hybrids were selected by growth in media containing 20% fetal calf serum, hypoxanthine, thymidine, and methotrexate in RPMI-1640 in 24-well Linbro plates. Wells producing antibodies of interest were grown and eventually cloned over an HGPRT- rat fibroblast feeder layer. These cultures were expanded and recloned. Two cloned antibodies of interest are DUX 5.2 and DUX 1.1.3. DUX 5.2 is the mouse IgG1 subclass and reacts with the membranes of ME-180 cells and the human skin epidermal basement membrane zone as shown by direct immunofluorescent microscopy. Ultrastructural localization using electron microscopic immunoperoxidase techniques showed localization of the DUX 5.2 antigen to be beneath the lamina densa; the reaction product may include the anchoring fibrils. Although DUX 5.2 reacts with the normal human basement membrane zone and the basement membrane zone in several diseases, there is no reactivity in the normal, never-blistered skin of patients with dystrophic epidermolysis bullosa (DEB). This suggests that the increased collagenase in the disease may be destroying antigenicity of the antigen recognized by DUX 5.2 or that the antigen may not be present in DEB. This antibody will thus allow early neonatal and prenatal diagnosis in DEB and allow isolation of the structural moiety which is deficient in DEB. DUX 1.1 is an IgM mouse immunoglobulin specific for the cytoplasm of human basal cells. Its reactivity with upper epidermis is significantly less than that seen in the basal layer. All cells of the basal layer stain uniformly. The slight amount of staining in upper cells probably represents dilution of antigen which is not synthesized beyond the basal layer. Basal cells of hair follicles and sweat glands are stained to some degree.

Microfluidic immunocapture of circulating pancreatic cells using parallel EpCAM and MUC1 capture: characterization, optimization and downstream analysis

We have developed and optimized a microfluidic device platform for the capture and analysis of circulating pancreatic cells (CPCs) and pancreatic circulating tumor cells (CTCs). Our platform uses parallel anti-EpCAM and cancer-specific mucin 1 (MUC1) immunocapture in a silicon microdevice. Using a combination of anti-EpCAM and anti-MUC1 capture in a single device, we are able to achieve efficient capture while extending immunocapture beyond single marker recognition. We also have detected a known oncogenic KRAS mutation in cells spiked in whole blood using immunocapture, RNA extraction, RT-PCR and Sanger sequencing. To allow for downstream single-cell genetic analysis, intact nuclei were released from captured cells by using targeted membrane lysis. We have developed a staining protocol for clinical samples, including standard CTC markers; DAPI, cytokeratin (CK) and CD45, and a novel marker of carcinogenesis in CPCs, mucin 4 (MUC4). We have also demonstrated a semi-automated approach to image analysis and CPC identification, suitable for clinical hypothesis generation. Initial results from immunocapture of a clinical pancreatic cancer patient sample show that parallel capture may capture more of the heterogeneity of the CPC population. With this platform, we aim to develop a diagnostic biomarker for early pancreatic carcinogenesis and patient risk stratification.

Detection of circulating tumor cells in hepatocellular carcinoma using antibodies against asialoglycoprotein receptor, carbamoyl phosphate synthetase 1 and pan-cytokeratin

Background

Asialoglycoprotein receptor (ASGPR)-ligand-based separation combined with identification with Hep Par 1 or pan-cytokeratin (P-CK) antibody have been demonstrated to detect circulating tumor cells (CTCs) in hepatocellular carcinoma (HCC). The aim of this study was to develop an improved enrichment and identification system that allows the detection of all types of HCC CTCs.

Methods

The specificity of the prepared anti-ASGPR monoclonal antibody was characterized. HCC cells were bound by ASGPR antibody and subsequently magnetically isolated by second antibody-coated magnetic beads. Isolated HCC cells were identified by immunofluorescence staining using a combination of anti-P-CK and anti-carbamoyl phosphate synthetase 1 (CPS1) antibodies. Blood samples spiked with HepG2 cells were used to determine recovery and sensitivity. CTCs were detected in blood samples from HCC patients and other patients.

Results

ASGPR was exclusively expressed in human hepatoma cell line, normal hepatocytes and HCC cells in tissue specimens detected by the ASGPR antibody staining. More HCC cells could be identified by the antibody cocktail for CPS1 and P-CK compared with a single antibody. The current approach obtained a higher recovery rate of HepG2 cells and more CTC detection from HCC patients than the previous method. Using the current method CTCs were detected in 89% of HCC patients and no CTCs were found in the other test subjects.

Conclusions

Our anti-ASGPR antibody could be used for specific and efficient HCC CTC enrichment, and anti-P-CK combined with anti-CPS1 antibodies is superior to identification with one antibody alone in the sensitivity for HCC CTC detection.

Slanted spiral microfluidics for the ultra-fast, label-free isolation of circulating tumor cells

The enumeration and characterization of circulating tumor cells (CTCs), found in the peripheral blood of cancer patients, provide a potentially accessible source for cancer diagnosis and prognosis. This work reports on a novel spiral microfluidic device with a trapezoidal cross-section for ultra-fast, label-free enrichment of CTCs from clinically relevant blood volumes. The technique utilizes the inherent Dean vortex flows present in curvilinear microchannels under continuous flow, along with inertial lift forces which focus larger CTCs against the inner wall. Using a trapezoidal cross-section as opposed to a traditional rectangular cross-section, the position of the Dean vortex core can be altered to achieve separation. Smaller hematologic components are trapped in the Dean vortices skewed towards the outer channel walls and eventually removed at the outer outlet, while the larger CTCs equilibrate near the inner channel wall and are collected from the inner outlet. By using a single spiral microchannel with one inlet and two outlets, we have successfully isolated and recovered more than 80% of the tested cancer cell line cells (MCF-7, T24 and MDA-MB-231) spiked in 7.5 mL of blood within 8 min with extremely high purity (400-680 WBCs mL(-1); ~4 log depletion of WBCs). Putative CTCs were detected and isolated from 100% of the patient samples (n = 10) with advanced stage metastatic breast and lung cancer using standard biomarkers (CK, CD45 and DAPI) with the frequencies ranging from 3-125 CTCs mL(-1). We expect this simple and elegant approach can surmount the shortcomings of traditional affinity-based CTC isolation techniques as well as enable fundamental studies on CTCs to guide treatment and enhance patient care.

Isolation and mutational analysis of circulating tumor cells from lung cancer patients with magnetic sifters and biochips

Detection and characterization of circulating tumor cells (CTCs) may reveal insights into the diagnosis and treatment of malignant disease. Technologies for isolating CTCs developed thus far suffer from one or more limitations, such as low throughput, inability to release captured cells, and reliance on expensive instrumentation for enrichment or subsequent characterization. We report a continuing development of a magnetic separation device, the magnetic sifter, which is a miniature microfluidic chip with a dense array of magnetic pores. It offers high efficiency capture of tumor cells, labeled with magnetic nanoparticles, from whole blood with high throughput and efficient release of captured cells. For subsequent characterization of CTCs, an assay, using a protein chip with giant magnetoresistive nanosensors, has been implemented for mutational analysis of CTCs enriched with the magnetic sifter. The use of these magnetic technologies, which are separate devices, may lead the way to routine preparation and characterization of "liquid biopsies" from cancer patients.

Presence of keratin-specific antibody-forming cells in palatine tonsils of patients with pustulosis palmaris et plantaris (PPP) and its correlation with prognosis after tonsillectomy

CONCLUSION

Keratin-specific immune responses in tonsils may be associated with the pathogenesis of pustulosis palmaris et plantaris (PPP). Evaluation of keratin-specific immune responses in tonsils might be useful to predict the effectiveness of tonsillectomy for patients with PPP.

OBJECTIVES

The aim of the present study was to clarify the role of keratin-specific immune responses in the pathogenesis of PPP in tonsils. It has been reported that anti-keratin antibodies in serum were higher in patients with PPP and decreased after tonsillectomy, indicating that anti-keratin antibodies might be generated in tonsils.

METHODS

In order to demonstrate the presence of keratin-specific immune responses in tonsils, the numbers of keratin-specific antibody-forming cells (AFCs) in tonsillar and peripheral blood lymphocytes were examined by enzyme-linked immunospot assay. The prognosis of PPP was compared after tonsillectomy.

RESULTS

The numbers of keratin-specific IgM and IgG AFCs in tonsils and of IgG AFCs in peripheral blood were significantly increased in patients with PPP. The numbers of keratin-specific IgG AFCs in peripheral blood correlated positively with tonsil and serum IgG antibodies specific to keratin. Our data show that a good prognosis in patients with PPP depended on the numbers of keratin-specific IgG and IgM AFCs in peripheral blood and the levels of keratin-specific IgG antibodies in serum being significantly decreased 6 months after tonsillectomy.

The effect of antigen retrieval on cells fixed in 10% neutral buffered formalin followed by transfer to 70% ethanol

Fixation in 10% neutral buffered formalin prior to transfer to 70% ethanol for one week has been shown to adequately preserve immunorecognition of PCNA, cytokeratins AE1/AE3 and EGFr. This study investigated whether 12 hrs fixation in 10% NBF plus transfer to 70% ethanol for 4 weeks would similarly preserve immunorecognition to an extent where antigen retrieval (AR) used to reverse the masking effects of fixation on some antigens would not be necessary. Two cell lines, DU145 and SKOV3 were grown on coverslips and fixed either for 684 hrs in 10% NBF or for 12 hrs in 10% NBF which was then replaced with 70% ethanol for 672 hrs. The second experiment had the same design except an additional set of cells were subjected to heat-induced AR concomitantly. PCNA, cytokeratins AE1/AE3, and EGFr (membrane and cytoplasmic) were used to evaluate the effects of immunorecognition. Fixation in 10% NBF for 12 hrs plus transfer to 70% ethanol for 672 hrs did not preserve immunorecognition of PCNA adequately in either cell lines. Cytokeratins immunoreactivity was preserved by transfer to 70% ethanol. Cytoplasmic EGFr antigens were not adversely affected by 10% NBF fixation in either cell line and transfer to 70% ethanol had limited effects. With AR, there was little recovery of PCNA immunorecognition on cells fixed in only 10% NBF, but almost complete recovery for cells transferred to 70% ethanol. For cytokeratins there was complete recovery of immunorecognition either with only 10% NBF or 12 hrs plus transfer to 70% ethanol. For EGFr, AR resulted in complete loss of immunorecognition following either treatment. This study indicated that 12 hrs of fixation in 10% NBF plus transfer to 70% ethanol for 4 weeks with AR resulted in recovery of immunorecognition for PCNA and cytokeratins, but standard methods of AR caused loss of immunorecognition of EGFr.

Diffuse pigmentation of back and arms: macular amyloidosis or other?

The study was undertaken to answer the question that how many patients with pigmentation of back and arms actually have amyloid deposits in pathology. 44 patients presenting with diffuse pigmentation of back and arms (DPOBA) were selected. Skin biopsies were performed in all cases from the affected sites. On all formalin fixed and paraffin embedded specimens, the following histochemical stains were performed: Haematoxylin and eosin (H&E), Congo red and immunohistochemical staining using anti-cytokeratin monoclonal antibody. In 9 of 44 cases (20%), amyloid deposits were found. In the remaining 35 cases (80%), H&E, Congo red and immunohistochemical staining failed to show any amyloid deposition. We were unable to find amyloid deposition in most of the patients presented with DPOBA. It seems that the signs may be attributable other disorders with similar clinical but different pathophysiologic aspects.

[Value of four serum markers in the diagnosis of rheumatoid arthritis]

OBJECTIVE

To systematically evaluate the values of 4 serum markers in the diagnosis of rheumatoid arthritis (RA).

METHODS

Serum samples were obtained from 278 RA patients and 510 control subjects and the levels of rheumatoid factor (RF), anticyclic citrullinated peptide antibody (CCP), antikeratin antibody (AKA), and glucose-6-phosphate isomerase (GPI) were detected using immune turbidimetry, ELISA, indirect immunofluorescence, and ELISA, respectively. The values of these 4 serum markers and their combinations in RA diagnosis were systemically assessed.

RESULTS

In RA diagnosis using one serum marker, two markers, and three or four markers, RF, RF+CCP, RF+CCP+GPI, respectively, had the highest sensitivity; CCP, CCP+AKA, and RF+CCP+AKA+GPI, respectively, had the highest specificity; CCP, CCP+GPI, and RF+CCP+AKA+GPI, respectively, had the highest positive predictive value; GPI, RF+CCP, and RF+CCP+GPI, respectively, had the highest negative predictive value; CCP, CCP+GPI, and RF+CCP+AKA+GPI, respectively, had the highest positive likely ratio; GPI, RF+CCP, and RF+CCP+GPI, respectively, had the lowest negative likely ratio.

CONCLUSION

CCP, RF+CCP, and RF+CCP+GPI are the most ideal for RA diagnosis using one, two, and three or more markers, respectively. CCP is the essential marker for RA diagnosis, and a combined detection of the serum makers can significantly improve the diagnostic accuracy.

Humanized mouse model of skin inflammation is characterized by disturbed keratinocyte differentiation and influx of IL-17A producing T cells

Humanized mouse models offer a challenging possibility to study human cell function in vivo. In the huPBL-SCID-huSkin allograft model human skin is transplanted onto immunodeficient mice and allowed to heal. Thereafter allogeneic human peripheral blood mononuclear cells are infused intra peritoneally to induce T cell mediated inflammation and microvessel destruction of the human skin. This model has great potential for in vivo study of human immune cells in (skin) inflammatory processes and for preclinical screening of systemically administered immunomodulating agents. Here we studied the inflammatory skin response of human keratinocytes and human T cells and the concomitant systemic human T cell response.

As new findings in the inflamed human skin of the huPBL-SCID-huSkin model we here identified: 1. Parameters of dermal pathology that enable precise quantification of the local skin inflammatory response exemplified by acanthosis, increased expression of human β-defensin-2, Elafin, K16, Ki67 and reduced expression of K10 by microscopy and immunohistochemistry. 2. Induction of human cytokines and chemokines using quantitative real-time PCR. 3. Influx of inflammation associated IL-17A-producing human CD4+ and CD8+ T cells as well as immunoregulatory CD4+Foxp3+ cells using immunohistochemistry and -fluorescence, suggesting that active immune regulation is taking place locally in the inflamed skin. 4. Systemic responses that revealed activated and proliferating human CD4+ and CD8+ T cells that acquired homing marker expression of CD62L and CLA. Finally, we demonstrated the value of the newly identified parameters by showing significant changes upon systemic treatment with the T cell inhibitory agents cyclosporine-A and rapamycin.

In summary, here we equipped the huPBL-SCID-huSkin humanized mouse model with relevant tools not only to quantify the inflammatory dermal response, but also to monitor the peripheral immune status. This combined approach will gain our understanding of the dermal immunopathology in humans and benefit the development of novel therapeutics for controlling inflammatory skin diseases.

Hidradenitis suppurativa: viewpoint on clinical phenotyping, pathogenesis and novel treatments

Hidradenitis suppurativa (HS) is an inflammatory, debilitating follicular skin disease with recurring flare-ups. The painful, deep-seated, inflamed lesions in the inverse areas of the body cause severe discomfort, and hence, serious psycho-social and economic costs. HS is common, but often misdiagnosed and mechanistically poorly understood. Furthermore, HS is notoriously difficult to treat resulting in a high unmet medical need. To provoke debate, rational experimentation and initiate strategic studies, we here present a concise viewpoint on seven topics: the diagnosis of HS, the role of mechanical friction, the critical importance of accurate clinical subgrouping, smoking and obesity, the role of bacteria, and our comprehensive view on HS pathogenesis with a central role for keratin clearance, and novel treatment approaches.

Detection of circulating tumor cells in blood of metastatic breast cancer patients using a combination of cytokeratin and EpCAM antibodies

BACKGROUND

Circulating tumor cells (CTCs) are detectable in peripheral blood of metastatic breast cancer patients (MBC). In this paper we evaluate a new CTC separation method based on a combination of anti-EpCAM- and anti-cytokeratin magnetic cell separation with the aim to improve CTC detection with low target antigen densities.

METHODS

Blood samples of healthy donors spiked with breast cancer cell line HCC1937 were used to determine accuracy and precision of the method. 10 healthy subjects were examined to evaluate specificity. CTC counts in 59 patients with MBC were measured to evaluate the prognostic value on overall survival.

RESULTS

Regression analysis of numbers of recovered vs. spiked HCC1937 cells yielded a coefficient of determination of R(2) = 0.957. The average percentage of cell recovery was 84%. The average within-run coefficient of variation for spiking of 185, 85 and 30 cells was 14%. For spiking of 10 cells the within-run CV was 30%. No CTCs were detected in blood of 10 healthy subjects examined. A standard threshold of 5 CTC/7.5 ml blood as a cut-off point between risk groups led to a highly significant prognostic marker (p < 0.001). To assess the prognostic value of medium CTC levels we additionally considered a low (CTC-L: 0 CTC), a medium (CTC-M: 1-4 CTC) and a high risk group (CTC-H: ≥5 CTC). The effect of this CTC-LMH marker on overall survival was significant as well (p < 0.001). A log-ratio test performed to compare the model with 3 vs. the model with 2 risk groups rejected the model with 2 risk groups (p = 0.026). For CTC as a count variable, we propose an offset reciprocal transformation 1/(1 + x) for overall survival prediction (p < 0.001).

CONCLUSIONS

We show that our CTC detection method is feasible and leads to accurate and reliable results. Our data suggest that a refined differentiation between patients with different CTC levels is reasonable.

A preliminary investigation of the relationship between circulating tumor cells and cancer stem cells in patients with breast cancer

In this study, we explored the relationship between the circulating tumor cells (CTC) and the CTC-cancer stem cells (CSC) in the patients with breast cancer. The magnetic-activated cell separation (MACS) method and flow cytometry (FCM) for selection of epithelial cells from the peripheral blood mononuclear cells (PBMC) were used to analyze the enriched epithelial cells that were labeled with anti-cytokeratin(CK)-fluorescein isothiocyanate, anti-CD44-phycoerythrin (PE) and anti-CD24-PE, respectively. The CK+ cells were attributed to CTC and the CK+CD44+ CD24-/low cells were thought as to CTC-CSC in 26 breast cancer patients, respectively. Our results showed the CK+ tumor cells were detected in 19 of 26 patients, with the CK+ tumor cells varying from 0.11% to 5.42 %. The CTC-CSC were identified in 18 of the 19 patients with CTC and the percentage of CTC-CSC in CTC was 19.01%. The results yet suggested the breast cancer patients with high-rate CK+ tumor cells were at the advanced tumor node metastases (TNM) stage III, and the patients with low-rate CK+ cells were at the modest TNM stage I. The difference between the two groups was statistically significant (p<0.001). We concluded that there is a significant relationship between CTC and CTC-CSC, but not among TNM stages, in breast cancer metastasis.

Cross-immunoreactivity between the LH1 antibody and cytokeratin epitopes in the differentiating epidermis of embryos of the grass snake Natrix natrix L. during the end stages of embryogenesis

The monoclonal anti-cytokeratin 1/10 (LH1) antibody recognizing K1/K10 keratin epitopes that characterizes a keratinized epidermis of mammals cross-reacts with the beta and Oberhäutchen layers covering the scales and gastrosteges of grass snake embryos during the final period of epidermis differentiation. The immunolocalization of the anti-cytokeratin 1/10 (LH1) antibody appears in the beta layer of the epidermis, covering the outer surface of the gastrosteges at the beginning of developmental stage XI, and in the beta layer of the epidermis, covering the outer surface of the scales at the end of developmental stage XI. This antibody cross-reacts with the Oberhäutchen layers in the epidermis covering the outer surface of both scales and gastrosteges at developmental stages XI and XII just before its fusion with the beta layers. After fusion of the Oberhäutchen and beta layers, LH1 immunolabeling is weaker than before. This might suggest that alpha-keratins in these layers of the epidermis are masked by beta-keratins, modified, or degraded. The anti-cytokeratin 1/10 (LH1) antibody stains the Oberhäutchen layer in the epidermis covering the inner surface of the gastrosteges and the hinge regions between gastrosteges at the end of developmental stage XI. However, the Oberhäutchen of the epidermis covering the inner surfaces of the scales and the hinge regions between scales does not show cytokeratin 1/10 (LH1) immunolabeling until hatching. This cross-reactivity suggests that the beta and Oberhäutchen layers probably contain some alpha-keratins that react with the LH1 antibody. It is possible that these alpha-keratins create specific scaffolding for the latest beta-keratin deposition. It is also possible that the LH1 antibody cross-reacts with other epidermal proteins such as filament-associated proteins, i.e., filaggrin-like. The anti-cytokeratin 1/10 (LH1) antibody does not stain the alpha and mesos layers until hatching. We suppose that the differentiation of these layers will begin just after the first postnatal sloughing.

Anti-CCP antibodies, rheumatoid factors and anti-keratin antibodies: clinical value in established rheumatoid arthritis

BACKGROUND

It is well documented that in early rheumatoid arthritis, anti-CCP antibodies have better diagnostic value than rheumatoid factors and anti-keratin antibodies. However, their role is less well defined in patients with established or long duration disease.

AIM

To evaluate and to compare diagnostic performances of anti- CCP, anti-keratin, IgM and IgA rheumatoid factors in established rheumatoid arthritis.

METHODS

In a cross-sectional study, 90 patients with established rheumatoid arthritis and 100 controls were tested for these autoantibodies. The association of these markers with disease activity and severity was investigated. The sensitivity and specificity were calculated for each of four tests, using the clinical diagnosis as the gold standard.

RESULTS

The anti-CCP and IgM rheumatoid factor exhibited the best diagnostic value. None of the tested antibodies had any significant association with the disease activity score (DAS28). After adjustment by multiple linear regression, only anti-CCP positivity was found to be significantly associated with erosive disease.

CONCLUSION

In long duration rheumatoid arthritis, anti-CCP and IgM rheumatoid factor have similar diagnostic value. However anti- CCP are useful in seronegative patients. They are also a reliable marker of severe erosive disease.

Multiple immunoenzyme labeling using heat treatment combined with the polymer method: an analysis of the appropriate inactivation conditions of primary antibodies

Multiple immunoenzyme labeling is of considerable value to detect several antigens in the same specimen, although this technique is limited when the primary antibodies have been raised in the same animal species. Multiple immunoenzyme labeling using heat treatment is a simple, reliable and straightforward technique wherein the heat treatment prevents mixed labeling and cross-reaction. The present study determined the inactivation time for primary antibodies by heat treatment in order to apply this procedure to routine histopathological diagnosis and research, and found that the inactivation time differed among the primary antibodies. The secondary antibodies and the labeling enzyme were completely inactivated by heating for 10 min. Therefore, the inactivation of the primary antibodies is crucial to perform multiple immunoenzyme labeling using heat treatment. The sequential combination of the primary antibodies is also important; in the study presented here, an anti-thyroid transcription factor-1 (TTF-1) antibody should be used first and anti-cytokeratin AE1/AE3 antibody second, but not in the opposite sequence, to avoid a mixed-colour-labeling reaction. The present data provided the optimum combination of primary antibodies for multiple immunoenzyme labeling using heat treatment.

[Clinicopathologic analysis of 52 cases of thymic epithelial tumor]

OBJECTIVE

To study the clinicopathologic characteristics of thymic epithelial tumors and to evaluate the diagnostic reproducibility and clinical relevance of the 2004 WHO histologic classification system.

METHODS

The morphology and immunophenotype of 52 cases of thymic epithelial tumor were reviewed. The tumors were classified according to the new WHO classification system and the clinical data were analyzed.

RESULTS

Of the 52 cases studied, 45 were thymomas and 7 were thymic carcinomas. Amongst the 45 cases of thymoma, 6 (13.4%) were type A, 15 (33.3%) were type AB, 4 (8.9%) were type B1, 9 (20.0%) were type B2, 9 (20.0%) were type B3 and 2 (4.4%) were metaplastic thymoma. Amongst the 7 cases of thymic carcinoma, 6 were squamous cell carcinomas and 1 was neuroendocrine carcinoma. The commonest presentations were cough and chest pain. Some cases were incidentally discovered by routine physical examination. Thirteen cases (25.0%) of thymoma were associated with myasthenia gravis. CT scan showed that 49 cases (94.2%) were located in the anterior mediastinum. All cases of type A, AB and B1 thymoma and most cases of B2 thymoma appeared as well-defined homogeneous mass, whereas a few cases of type B2 thymoma and most cases of type B3 thymoma and thymic carcinoma were poorly demarcated and heterogeneous. According to Masaoka staging system, 20 cases (41.7%) belonged to stage I, 15 cases (31.3%) stage II, 11 cases (22.9%) stage III and 2 cases (4.1%) stage IV. The histologic subtypes of thymic epithelial tumors significantly correlated with the clinical stages (chi(2) = 32.5, P < 0.01).

CONCLUSIONS

The 2004 revision of WHO histologic classification system for thymic epithelial tumors shows a high degree of reproducibility. Correlation with the radiologic, clinical and prognostic parameters is helpful in determining the management strategy for individual patients.

The diagnostic value of cytokeratins expression in the renal parenchyma tumors

Renal carcinomas are a heterogeneous group of tumors, difficult to classify and identify precisely. Since their prognosis depends very much upon their type, precise diagnosis might mean the difference between therapeutic success and patient death. Cytokeratins are particularly useful for the identification of the epithelial nature of the tumors, because their expression is maintained even in poorly differentiated tumors. Monoclonal cytokeratins such as CK7 and CK20 stain different components of the renal tubular system and are a useful duo for the identification of the origin of the different tumors that might arise in the kidney. Along with polyclonal cytokeratins such as AE1/AE3 and high molecular weight cytokeratin antibodies (34betaE12, Cam 5.2), epithelial membrane antigen (EMA) and vimentin, they are included in every diagnostic panel for renal tumors. We have selected 138 renal parenchyma tumor specimens, performed morphological diagnosis and then stained them with polyclonal cytokeratin antibody AE1/AE3, and monoclonal antibodies to CK7 and CK20. AE1/AE3 was expressed in 61.7% of the renal parenchyma tumors, with high intensity and percentage of positive cases in the papillary carcinomas (100%), and with rare and weakly positive cells in chromophobic cells carcinomas, clear cells carcinomas and sarcomatous carcinomas. CK7 was positive in 68% of the renal parenchyma tumors, with positive reaction in 100% of the cases of chromophobic cells and sarcomatous carcinomas. Clear cells carcinomas had the less percentage of positive cells, whereas papillary carcinomas were positive in seven out of eight cases. No difference in the staining pattern was noticed between type I and type II papillary carcinomas. CK20 was negative in all cases studied.

[Clinical characteristics of rheumatoid arthritis with interstitial pulmonary fibrosis]

OBJECTIVE

To analyze the clinical characteristics of interstitial pulmonary fibrosis (IPF) in patients with Rheumatoid arthritis (RA).

METHODS

We retrospectively analyzed 198 RA patients with or without IPF. Characteristics of RA-IPF in clinical and lab data were analyzed. Age, duration of disease, clinical and laboratory parameters, history of smoking and medicine were compared between the patients with and without IPF.

RESULTS

(1) Among the 198 RA patients, 15.2% (30/198) were found with IPF. 100% RA-IPF patients had HRCT findings. However, 63.3% (19/30) had positive findings in chest X-ray, and only 46.7% (14/30) had the complaints of cough and short breath. Velcro rales were found in 50.0% (15/30) patients with IPF and no acropachy occurred. Only one patient suffered from hypoxemia. IPF presented after the joint symptoms in most patients. (2) RA-IPF patients were older than those without IPF [(65.50 +/- 9.71) vs (55.22 +/- 12.98) years, P<0.01]; Higher positivity of anti-keratin antibodies (AKA) were found in RA-IPF compared to patients without IPF (61.5% vs 35.9%, P=0.014). Furthermore, the levels of anti-cyclic citrullinated peptide (CCP) antibody were significantly higher in RA-IPF [(4.38 +/- 2.08) vs (3.20 +/- 2.12), P=0.01]. No differentiation of duration of disease, history of smoking and medicine, IgM rheumatoid factor, IgG rheumatoid factor, anti-nuclear antibody, anti-SSA antibody and levels of immunoglobins and complements were found between the two groups of RA patients with and without IPF.

CONCLUSION

The clinical symptoms of IPF in RA patients are mild and more common in older patients. AKA and anti-CCP antibody might be important antibodies associated with RA-IPF.

A biphasic malignant mesothelioma of the peritoneum and pleura in a horse

This report describes the macroscopic, histologic, immunohistologic and ultrastructural characteristics ofa biphasic malignant mesothelioma in the peritoneal and pleural cavity of a 13-year-old Icelandic pony mare, which exhibited recurrent ascites clinically. Immunohistology was performed employing multiple monoclonal antibodies against cytokeratins (CK) and vimentin. The ultrastructural examination included the quantitative evaluation of the length to diameter ratio of the microvilli. Post mortem examination revealed a severe ascites and hydrothorax. The serosal surfaces of the peritoneum and pleura displayed poorly-demarcated, multifocal to coalescing laminar masses and small nodules. Histology revealed a bimorphic mass consisting of spindle-shaped cells and microcystic epithelioid areas. A transcoelomic and local invasive growth pattern as well as lymph node metastases were noticed. Immunohistology revealed a strong expression of CK. Though a low and moderate expression of CK5/6 and CK20 was present, respectively, CK7 and CK10-antigens were lacking. Ultrastructurally, the epithelioid mesothelioma cells displayed long microvilli, cytoplasmic tonofilaments, and desmosomes. Quantitative evaluation of the length to diameter ratio of the 10 longest microvilli revealed a mean value of approximately 16.2. Summarized, this report described the case of a malignant biphasic mesothelioma with an atypical CK20 expression but a characteristic ultrastructural morphology including long microvilli.

[Predictive values of anti-cyclic citrullinated peptide antibody, antikeratin antibody and rheumatoid factor in diagnosing articular erosions in patients with rheumatoid arthritis]

OBJECTIVE

To explore the diagnostic significance of anti-cyclic citrullinated peptide (CCP) antibody (anti-CCP), antikeratin antibody (AKA) and rheumatoid factor (RF) for predicting articular erosions in patients with rheumatoid arthritis (RA).

METHODS

One hundered and fifty eight RA patients were devided into 2 groups [limited radiographic damage group (Group 1) and severe radiographic damage group (Group 2)] based on the Larsen's score system. Enzyme linked immunosorbent assay, indirect immunofluorescence and rate naphelometry were used to measure anti-CCP, AKA and RF, respectively.

RESULTS

The sensitivity and specificity of Anti-CCP, AKA and RF for detecting RA were 49% and 94%, 50% and 93%, and 79% and 67%, respectively. The specificity increased when any two markers were combined. The patients with severe radiographic damage had higher positive rates of these three antibodies than the patients with limited radiographic damage. Anti-CCP had the highest OR (6.71) for predicting articular erosions in RA patients. The logistic regression analysis showed a strong correlation between anti-CCP, AKA, CRP or cutaneous nodules and the severity of articular erosions. Anti-CCP had the strongest correlation with the severe radiographic damages.

CONCLUSION

Anti-CCP has advantages over the other two antibodies in diagnosing RA. However, the diagnostic accuracy can be improved when anti-CCP is combined with AKA or RF. Anti-CCP and AKA have strong correlations with severe articular erosions, which will be helpful for predicting the outcomes of RA.