Abstract 1258: Elevated serum DC-HIL is associated with poor response to immune checkpoint inhibitors (ICI) in metastatic renal cell carcinoma (mRCC)

ICI therapy has shown unprecedented clinical outcomes in mRCC patients, but durable responses have been limited by innate (never respond initially) and acquired resistance (initially respond but eventually develop cancer progression). Establishment of predictive biomarkers for response to ICI maximizes the therapeutic benefit. Since no such marker exists, we investigated DC-HIL/GPNMB as a possibility because we detected DC-HIL to be elevated in blood of patients with metastasis, as both a receptor on myeloid-derived suppressor cells (MDSC) and as a soluble form (sDC-HIL); and found DC-HIL to be relevant to ICI resistance in mice. We studied 27 mRCC patients treated with combination ICI (Ab to PD1/PDL1/CTLA4) and assessed tumor response (by RECIST) at 12 wk after therapy. Blood was collected before and after treatment and assayed by FACS for expression of DC-HIL and PDL1 on CD14+HLA-DRno/lo monocytic (mMDSC) and CD15+CD11b+ granulocytic MDSC (gMDSC). T-cell suppressor function was assayed by cell culture. We showed both MDSC subsets to express DC-HIL predominantly over PDL1. We also showed mMDSC to be more potent T-cell suppressors than gMDSC (85% vs. 58% suppression, p=0.012) and to also be more dependent on DC-HIL for such suppression (56% vs. 15% restoration of T-cell function after adding DC-HIL mAb, p=0.013). However, there was no significant difference in % DC-HIL+MDSC/PBMC between ICI responders and non-responders (p=0.15). We next examined the relationship between tumor response (at 12 wk) and blood sDC-HIL (by ELISA) in 31 mRCC patients. At baseline, non-responders (n=10) had a significantly higher sDC-HIL than responders (n=21) (14 ± 2.4 vs. 10 ± 4.6 ng/ml, p=0.004), but no difference in blood PDL1 or VEGF. Among initial responders (n=22), 50% maintained a positive response while the other half acquired resistance after 20 wk. Among initial non-responders (n=9), 77% never responded while 22% responded positively after 20 wk. We then analyzed changes over time in sDC-HIL levels after treatment (up to 60 wks) in individuals. Patients who responded positively to ICI at treatment inception and through 40 wk maintained blood sDC-HIL at levels lower than the median for all positive responders. Initial responders who acquired resistance (9 out of 11 patients) had low blood sDC-HIL that rose during cancer progression. All constant non-responders (n=7) had high blood sDC-HIL that remained high during the study. To our surprise, the 2 initial non-responders who responded positively after 20-40 wk of ICI displayed an abrupt rise in blood sDC-HIL during their positive response. Our results indicate blood sDC-HIL as a promising biomarker for prognosticating response to ICI in mRCC patients.

Citation Format: Jin-Sung Chung, Vijay Ramani, Ponciano D. Cruz, Hans J. Hammers, Kiyoshi Ariizumi. Elevated serum DC-HIL is associated with poor response to immune checkpoint inhibitors (ICI) in metastatic renal cell carcinoma (mRCC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1258.

Training Physician‒Scientists for Careers in Investigative Dermatology

Physician‒scientists have made countless discoveries, and their dwindling numbers are a significant concern. Although dermatology has become an increasingly popular destination for physician‒scientist trainees, the proportion of trainees who pursue scientific research careers after training is among the lowest of all medical specialties. To investigate this problem, we surveyed a national cohort of dermatology educators, physician‒scientist track program directors, and National Institute of Arthritis and Musculoskeletal and Skin Diseases T32 directors for opinions regarding physician‒scientist training in dermatology. On the basis of these findings and to help address the issue, we propose a training practicum and provide a resource for funding opportunities to help guide trainees and institutions interested in supporting investigative dermatologists. We also discuss the important roles of department chairs and institutions in fashioning an environment conducive to physician‒scientist training. The information and recommendations provided in this paper may help to improve the recruitment, training, development, and retention of investigative dermatologists and future leaders in this field.

DC-HIL/Gpnmb Is a Negative Regulator of Tumor Response to Immune Checkpoint Inhibitors

PURPOSE

Immune checkpoint inhibitors (ICI) benefit only a minority of treated patients with cancer. Identification of biomarkers distinguishing responders and nonresponders will improve management of patients with cancer. Because the DC-HIL checkpoint differs from the PD1 pathway in expression and inhibitory mechanisms, we examined whether DC-HIL expression regulates ICI responsiveness.

EXPERIMENTAL DESIGN

Plasma samples were collected from patients with advanced non-small cell lung carcinoma (NSCLC) (n = 76) at baseline and/or follow-up after ICI monotherapy. Blood-soluble DC-HIL (sDC-HIL) was determined and analyzed for correlation with the early tumor response. To study the mechanisms, we measured effect of anti-DC-HIL versus anti-PDL1 mAb on growth of mouse tumor cells in experimentally metastatic lung. Influence of DC-HIL to anti-PDL1 treatment was assessed by changes in tumor response after deletion of host-DC-HIL gene, injection of DC-HIL-expressing myeloid-derived suppressor cells (MDSC), or induction of sDC-HIL expression.

RESULTS

Nonresponders expressed significantly higher levels of baseline sDC-HIL levels than responders. Among patients (n = 28) for fluctuation with time, nonresponders (14/15 cases) showed increasing or persistently elevated levels. Responders (12/13) had decreasing or persistently low levels. Among various tumors, B16 melanoma exhibited resistance to anti-PDL1 but responded to anti-DC-HIL mAb. Using B16 melanoma and LL2 lung cancer, we showed that deletion of host-derived DC-HIL expression converted the resistant tumor to one responsive to anti-PDL1 mAb. The responsive state was reversed by infusion of DC-HIL⁺MDSC or induction of sDC-HIL expression.

CONCLUSIONS

sDC-HIL in the blood and probably DC-HIL receptor expressed by MDSC play an important role in regulating response to ICI in advanced NSCLC.

DC-HIL/Gpnmb checkpoint blockade as a synergistic combination for stereotactic ablative radiation (SAbR)

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Background: The combination of radiotherapy (RT)/immunotherapy holds a promise as an innovative cancer treatment. Expansion of myeloid-derived suppressor cells (MDSC) dampens cancer immunity, and DC-HIL receptor is a potent mediator of the suppressor function. We examined whether DC-HIL blockade is useful as a synergistic combination for SAbR using mouse model and human clinical samples. Methods: After tumor-irradiation on mice with subcutaneous (sc) RM9 prostate cancer (PC), tumor-infiltrating lymphocytes were phenotypically analyzed. Mice with sc tumor were injected i.v. with RM9-GFP cells (lung mets); 4 d later tumor-irradiated and treated with Ab (6 x 200 μg/shot). Tumor growth was measured by volume or GFP+ cells. PC (n = 22, stages II-III) patients were treated with SAbR, and blood samples collected at week (w) 0, 2, 8 and assayed for % monocytic (m) and granulocytic (g) MDSC and their expression of DC-HIL vs. PDL1. Suppressor function of MDSC was assayed by fall in T cell IFN-γ response. Results: Tumor-RT increased MDSC by 40% on day 8; the most expanded subset Gr1hiLy6Clo gMDSC expressed DC-HIL highly but PDL1 lowly. Combination of anti-DC-HIL/RT inhibited tumor growth in RT-irradiated sc tumor and non-irradiated lung mets and converted tumor microenvironment from the suppressive to the competent milieu. PC patients (17/22 cases) showed elevated MDSC blood levels at w2, but markedly varied at w8 among individuals (2.7 ± 7.3%). DC-HIL+ MDSC levels were also upregulated. gMDSC showed small changes after RT, and DC-HIL (but not PDL1) expression was markedly upgraded by ~90% (n = 3). SAbR decreased the suppressor ability of both MDSC: ~93% T cell suppression at w0 down to ~56% at w8 by mMDSC; and ~76% to ~49% by gMDSC. However, anti-DC-HIL Ab reversed the suppressor ability of MDSC at w8 more than those at w0 (~59% reversal to ~89%), showing that SAbR increased the criticality of DC-HIL pathway in their function. Five cases showed a high rise in DC-HIL expression at w8, with no significant fall in PSA levels at ~13 mons, and one with a noticeable fall in both levels. Conclusions: DC-HIL blockers may amplify the therapeutic effects of SAbR for PC treatment. DC-HIL expression may be a predictive marker for PC response to SAbR.

Expression of soluble DC-HIL/gpnmb receptor in the blood of metastatic non-small cell lung carcinoma treated with anti-PD1/PDL1 monoclonal antibodies

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Background: Anti-PD1/PDL1 therapy benefits only a minority (10-20%) of treated NSCLC. Identifying markers distinguishing responders vs. non-responders will improve management of NSCLC. DC-HIL receptor is a new checkpoint whose inhibitory mechanisms are divergent from the PD1 pathway. Tumor cells express DC-HIL receptor and its soluble form (sDC-HIL). We tested whether sDC-HIL expression regulates NSCLC response to anti-PD1/PDL1 Ab using animal models and human clinical samples. Methods: Tet-Off controlled sDC-HIL-transfected LL2 lung cancer cells were i.v. injected into mice (lung mets) and treated with doxycycline (Dox). Day 6, mice were sorted into 2 groups with/without Dox and treated with i.p. 200 μg Ab, every 2 d /6 shots. Day 18, # of lung-LL2 cells were counted by FACS and IFN-γ+ T cells in tumors analyzed. Advanced NSCLC patients (n = 51) treated with immune checkpoint inhibitors were every 6 weeks evaluated for partial response (PR), stable (SD) and progressive disease (PD) by RECIST. Serum were collected on weeks 0, 2, and 6 and assayed for sDC-HIL amounts by ELISA. Results: In mice treated with Dox (halt sDC-HIL expression), anti-PDL1 Ab treatment markedly reduced lung mets and increased IFN-γ+ T cells (p < 0.001), whereas this excellent outcome was not noted in Dox-untreated mice (induce sDC-HIL). For NSCLC, PD1/PDL1 therapy produced PR (n = 3), SD (n = 25) and PD (n = 23) at week 6. sDC-HIL blood levels at week 0 did not correlate with tumor size, but the levels at week 6 of PD patients were significantly higher than PR/SD patients (8.4 ± 5.6 vs. 4.0 ± 1.6 ng/ml, p = 0.001, Mann-Whitney test) and healthy donors (2.6 ± 0.9 ng/ml). Most patients (26 out of 30 cases) showed fluctuation in sDC-HIL levels during treatment. PD-patients (14/15 cases) showed increasing or persistently elevated levels ( > 4 ng/ml), with one case at low levels ( < 4 ng/ml). SD/PR-patients (13/15) had decreasing or persistently low levels, with 2 exceptions with high levels in all time points. Conclusions: sDC-HIL blood level may serve as a biomarker to indicate tumor-resistance of advanced NSCLC patients to PD1/PDL1 therapy. The degree and direction of sDC-HIL fluctuation may be useful to predict prognosis for NSCLC.

Blocking Monocytic Myeloid-Derived Suppressor Cell Function via Anti-DC-HIL/GPNMB Antibody Restores the In Vitro Integrity of T Cells from Cancer Patients

PURPOSE

Blocking the function of myeloid-derived suppressor cells (MDSC) is an attractive approach for cancer immunotherapy. Having shown DC-HIL/GPNMB to be the T-cell-inhibitory receptor mediating the suppressor function of MDSCs, we evaluated the potential of anti-DC-HIL mAb as an MDSC-targeting cancer treatment.

EXPERIMENTAL DESIGN

Patients with metastatic cancer (n = 198) were analyzed by flow cytometry for DC-HIL or PDL1 expression on blood CD14+HLA-DRno/lo MDSCs. Their suppressor function was assessed by in vitro coculture with autologous T cells, and the ability of anti-DC-HIL or anti-PDL1 mAb to reverse such function was determined. Tumor expression of these receptors was examined histologically, and the antitumor activity of the mAb was evaluated by attenuated growth of colon cancers in mice.

RESULTS

Patients with metastatic cancer had high blood levels of DC-HIL+ MDSCs compared with healthy controls. Anti-DC-HIL mAb reversed the in vitro function in ∼80% of cancer patients tested, particularly for colon cancer. Despite very low expression on blood MDSCs, anti-PDL1 mAb was as effective as anti-DC-HIL mAb in reversing MDSC function, a paradoxical phenomenon we found to be due to upregulated expression of PDL1 by T-cell-derived IFNγ in cocultures. DC-HIL is not expressed by colorectal cancer cells but by CD14+ cells infiltrating the tumor. Finally, anti-DC-HIL mAb attenuated growth of preestablished colon tumors by reducing MDSCs and increasing IFNγ-secreting T cells in the tumor microenvironment, with similar outcomes to anti-PDL1 mAb.

CONCLUSIONS

Blocking DC-HIL function is a potentially useful treatment for at least colorectal cancer with high blood levels of DC-HIL+ MDSCs.See related commentary by Colombo, p. 453.

Melanoma-Derived Soluble DC-HIL/GPNMB Promotes Metastasis by Excluding T-Lymphocytes from the Pre-Metastatic Niches

Soluble factors from the primary tumor induce recruitment of bone marrow-derived progenitors to form tumor-supportive microenvironments or pre-metastatic niches in distal organs before metastasis. How tumor-secreted factors condition the sites for tumor progression remains ambiguous. B16 melanoma produces the secreted form of T cell-inhibitory DC-HIL (sDC-HIL) that travels to distal organs and potentiates the metastatic capacity of tumor cells. We studied the molecular mechanisms and found that sDC-HIL binds to select endothelial cells that co-localize with the sites where bone marrow-derived progenitors and tumor cells migrate. sDC-HIL-bound endothelial cells exist at a similar frequency in mice with or without tumors, and they are strongly associated with survival of intravenously injected tumor cells in the lung. sDC-HIL binding conferred T-cell suppressor function on the ECs and awakened the angiogenic property by inducing vascular endothelial growth factor expression, resulting in enhanced transendothelial migration of bone marrow-derived progenitors and tumor cells, but not for T cells. This selectivity is achieved by the T-cell binding of sDC-HIL, which prevents formation of the leading edges required for chemotaxis. Finally, inducing tumor expression of sDC-HIL significantly reduced tumor-infiltrated T cells. Therefore, the highly metastatic attribute of B16 melanoma can be explained by the endothelial gatekeeper function of sDC-HIL that limits lymphocyte transmigration to pre-metastatic niches.

Photodermatitis for the Allergist

PURPOSE OF REVIEW

The photodermatoses represent a group of disorders of sensitivity to light that continue to pose difficulties in diagnosis and management. Photodermatoses are of interest to allergists because many photosensitive skin disorders have immunologic underpinnings, and patients often present to clinic complaining of "allergy" to the sun. We provide a concise reference for allergists on the clinical recognition and management of photodermatitis.

RECENT FINDINGS

New developments in the understanding of immunomodulatory effects of light have demonstrated normally immunosuppressive responses in the skin to light exposure, and a blunted immunosuppressive response in the pathogenesis of many photodermatoses. Vitamin D plays an important role in immunomodulation and itself may be affected by photodermatoses due to the impact of photoprotective treatment strategies on circulating vitamin D levels. The elucidation of the immunological basis of many photodermatoses may provide guidance for developing new treatment modalities. Further research is necessary to determine the optimal management of vitamin D metabolism in patients with photodermatoses.

Abstract 3660: Blocking the DC-HIL receptor reverses the T-cell suppression induced by proliferating myeloid-derived suppressor cells in common cancer types

Myeloid-derived suppressor cells (MDSC) are the most potent suppressors of T-cell function, and their exponential proliferation in cancer states counteracts the benefits of immunotherapy given to these patients. Having discovered the T cell-inhibitory DC-HIL receptor, we showed that DC-HIL is responsible for MDSC’s T-cell suppressive function. We found that melanoma patients (but not healthy controls) harbor in the blood an expanded population of DC-HIL+ MDSC, whose suppressor effects in vitro can be blocked by our 3D5 anti-DC-HIL mAb. To determine whether similar outcomes apply to non-melanoma cancers, we recruited patients with metastases from bladder (BL, n=4), breast (BR, n=11), colon (CO, n=44), kidney (KI, n=6), lung (LU, n=20), pancreatic (PA, n=17), and prostate (PR, n=9) cancer. FACS analysis of blood samples showed all cancer types (except LU) were associated with elevated blood HLA-DRno/low CD14+ MDSC vs. age-matched controls (n=21, median of 0.5%). % DC-HIL+ MDSC in PBMC was also significantly high in all cancer types; median of 2.5% for BL; 1.7% for BR; 3.5% for CO; 3.6% for KI; 0.3% for LU; 1.8% for PA; and 4.8% for PR, vs. 0.04% for healthy controls. MDSC in all cancer types showed high DC-HIL-positivity (20-90% vs. 8% for controls). We assayed T-cell suppressor activity by purifying MDSC and T-cells from the same patient and co-culturing them at varying cell ratios, with co-stimulators. Activity was determined by % suppression in IFN-γ secretion, which was correlated with % DC-HIL-positivity of MDSC. MDSC from KI (n=3) were more suppressive than those from CO and PA, with suppressor activity correlating with DC-HIL-positivity: Pearson’s r for 0.5 for CO (n=13) and 0.73 for PA (n=8). We evaluated effects of anti-DC-HIL mAb on co-cultures of MDSC/ T-cells from cancer patients (n=25). The mAb restored IFN-γ secretion by &gt;30% in 8/15 cases of CO; 4/8 of PA, and 2/2 of KI. To determine whether DC-HIL+ MDSC migrate into cancer sites, lesional specimens from CO patients (n=5) with high blood counts of DC-HIL+ MDSC were immunohistochemically stained for CD14 and DC-HIL expression: DC-HIL was absent from all cancer cells, but present strongly in many CD14+ cells surrounding the cancers. This outcome contrasts starkly with melanoma, in which DC-HIL was expressed highly by the cancer cells surrounded by only a few DC-HIL+ CD14+ cells. Finally we evaluated in vivo effects of blocking DC-HIL using a mouse model of MC38 colon cancer, which is DC-HILneg. MC38 tumor challenge induced DC-HIL+ Gr1lowLy6Chigh MDSC in the tumor site. Intravenous infusion of anti-DC-HIL mAb into mice with pre-established MC38 tumor significantly inhibited tumor growth by 50-70%, reduced blood levels of MDSC, and enhanced cytotoxic T-lymphocyte response. Our findings support DC-HIL blockade as a potential treatment for metastatic cancers, with high blood levels of DC-HIL+ MDSC as a prognostic marker for the best responders.

Citation Format: Masato Kobayashi, Jin-Sung Chung, Muhammad Beg, Yull Arriaga, Udit Verma, Kevin Courtney, John Mansour, Barbara Haley, Saad Khan, Yutaka Horiuchi, David Harker, Purva Gopal, Ponciano D. Cruz, Kiyoshi Ariizumi. Blocking the DC-HIL receptor reverses the T-cell suppression induced by proliferating myeloid-derived suppressor cells in common cancer types [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3660. doi:10.1158/1538-7445.AM2017-3660

Myeloid-Derived Suppressor Cells in Psoriasis Are an Expanded Population Exhibiting Diverse T-Cell-Suppressor Mechanisms

Psoriasis vulgaris is an inflammatory skin disease caused by hyperactivated T cells regulated by positive and negative mechanisms; although the former have been much studied, the latter have not. We studied the regulatory mechanism mediated by myeloid-derived suppressor cells (MDSCs) and showed that MDSCs expanded in melanoma patients express dendritic cell-associated heparan sulfate proteoglycan-dependent integrin ligand, a critical mediator of T-cell suppressor function. We examined expansion of DC-HIL(+) MDSCs in psoriasis and characterized their functional properties. Frequency of DC-HIL(+) monocytic MDSCs (CD14(+)HLA-DR(no/low)) in blood and skin was markedly increased in psoriatic patients versus healthy control subjects, but there was no statistically significant relationship with disease severity (based on Psoriasis Area and Severity Index score). Blood DC-HIL(+) MDSC levels in untreated patients were significantly higher than in treated patients. Compared with melanoma-derived MDSCs, psoriatic MDSCs exhibited significantly reduced suppressor function and were less dependent on DC-HIL, but they were capable of inhibiting proliferation and IFN-γ and IL-17 responses of autologous T cells. Psoriatic MDSCs were functionally diverse among patients in their ability to suppress allogeneic T cells and in the use of either IL-17/arginase I or IFN-γ/inducible nitric oxide synthase axis as suppressor mechanisms. Thus, DC-HIL(+) MDSCs are expanded in psoriasis patients, and their mechanistic heterogeneity and relative functional deficiency may contribute to the development of psoriasis.

DC-HIL-expressing myelomonocytic cells are critical promoters of melanoma growth

A major barrier to successful cancer immunotherapy is the tumor’s ability to induce T-cell tolerance by exploiting host regulatory mechanisms. Having discovered the DC-HIL receptor, which inhibits T-cell responses by binding to syndecan-4 on effector T-cells, we posited the DC-HIL/syndecan-4 pathway to play an important role in cancer promotion. Among DC-HIL⁺ myelomonocytic cells, during growth of implanted mouse melanoma, CD11b⁺Gr1⁺ cells were the most expanded population and the most potent at suppressing T-cell activation. Deletion of the DC-HIL gene or infusion of anti-DC-HIL mAb abrogated these cells’ suppressor function and expansion, and markedly diminished melanoma growth and metastasis. IL-1β and IFN-γ were elevated in mice bearing melanoma, and concurrent exposure to both cytokines optimally induced DC-HIL expression by tumor-infiltrating CD11b⁺Gr1⁺ cells. Ligation of DCHIL transduced phosphorylation of its intracellular immunoreceptor tyrosine-based activation motif (ITAM), that in turn induced intracellular expression of IFN-γ and inducible nitric oxide synthase (iNOS), known to mediate T-cell suppression by CD11b⁺Gr1⁺ cells. Thus DC-HIL is the critical mediator of these cells’ suppressor function in melanoma-bearing mice and a potential target for improving melanoma immunotherapy.

The DC-HIL/syndecan-4 pathway regulates autoimmune responses through myeloid-derived suppressor cells

Having discovered that the dendritic cell (DC)-associated heparan sulfate proteoglycan-dependent integrin ligand (DC-HIL) receptor on APCs inhibits T cell activation by binding to syndecan-4 (SD-4) on T cells, we hypothesized that the DC-HIL/SD-4 pathway may regulate autoimmune responses. Using experimental autoimmune encephalomyelitis (EAE) as a disease model, we noted an increase in SD-4(+) T cells in lymphoid organs of wild-type (WT) mice immunized for EAE. The autoimmune disease was also more severely induced (clinically, histologically, and immunophenotypically) in mice knocked out for SD-4 compared with WT cohorts. Moreover, infusion of SD-4(-/-) naive T cells during EAE induction into Rag2(-/-) mice also led to increased severity of EAE in these animals. Similar to SD-4 on T cells, DC-HIL expression was upregulated on myeloid cells during EAE induction, with CD11b(+)Gr-1(+) myeloid-derived suppressor cells (MDSCs) as the most expanded population and most potent T cell suppressor among the myeloid cells examined. The critical role of DC-HIL was supported by DC-HIL gene deletion or anti-DC-HIL treatment, which abrogated T cell suppressor activity of MDSCs, and also by DC-HIL activation inducing MDSC expression of IFN-γ, NO, and reactive oxygen species. Akin to SD-4(-/-) mice, DC-HIL(-/-) mice manifested exacerbated EAE. Adoptive transfer of MDSCs from EAE-affected WT mice into DC-HIL(-/-) mice reduced EAE severity to the level of EAE-immunized WT mice, an outcome that was precluded by depleting DC-HIL(+) cells from the infused MDSC preparation. Our findings indicate that the DC-HIL/SD-4 pathway regulates autoimmune responses by mediating the T cell suppressor function of MDSCs.

The DC-HIL ligand syndecan-4 is a negative regulator of T-cell allo-reactivity responsible for graft-versus-host disease

Acute graft-versus-host disease (GVHD) is the most important cause of mortality after allogeneic haematopoietic stem cell transplantation. Allo-reactive T cells are the major mediators of GVHD and the process is regulated by positive and negative regulators on antigen-presenting cells (APC). Because the significance of negative regulators in GVHD pathogenesis is not fully understood, and having discovered that syndecan-4 (SD-4) on effector T cells mediates the inhibitory function of DC-HIL on APC, we proposed that SD-4 negatively regulates the T-cell response to allo-stimulation in acute GVHD, using SD-4 knockout mice. Although not different from their wild-type counterparts in responsiveness to anti-CD3 stimulation, SD-4(-/-) T cells lost the capacity to mediate the inhibitory function of DC-HIL and were hyper-reactive to allogeneic APC. Moreover, infusion of SD-4(-/-) T cells into sub-lethally γ-irradiated allogeneic mice worsened mortality, with hyper-proliferation of infused T cells in recipients. Although there my be little or no involvement of regulatory T cells in this model because SD-4 deletion had no deleterious effect on T-cell-suppressive activity compared with SD-4(+/+) regulatory T cells. We conclude that SD-4, as the T-cell ligand of DC-HIL, is a potent inhibitor of allo-reactive T cells responsible for GVHD and a potentially useful target for treating this disease.

T-cell inhibitors: a bench-to-bedside review

Allergic contact dermatitis is the quintessential example of a delayed-in-time and T-cell-mediated immune response. In the last decade, many of the molecular events required to initiate (or block) such a response have been uncovered. Textbook and journal reviews have emphasized the costimulatory requirements, with less focus on the coinhibitory signals that are of equal importance in understanding this central event of adaptive immunity. To fill this gap, we offer a compendium of discoveries characterizing the ligand-receptor pairs inhibiting T-cell activation and of selected illnesses and therapeutic applications that illuminate their role in health and disease.

Willingness to pay in dermatology: assessment of the burden of skin diseases

Willingness to pay (WTP) is a monetary, preference-based, burden-of-disease measure with a potential role in dermatology, where many conditions are temporary and/or mild, and many treatments are inexpensive and one might be able to imagine paying out of pocket. We assessed construct validity by interviewing 254 consecutive dermatology patients at Stanford Medical Center, Grady Hospital, and Parkland Hospital. Instruments asked about an individual's own health status and elicited WTP, time-trade-off (TTO) utilities, and health status quality of life (QOL). We measured WTP cure (short treatment course to eliminate disease) and WTP control (lifelong medication). Our data indicate greater construct validity in non-Medicaid (n=163) than Medicaid (n=91) patients. Non-Medicaid subjects had greater WTP as percent of income for cure (median: 2%) than control (median: 1.6%), P<0.01; Medicaid WTP amounts for control and cure did not differ. Non-Medicaid subjects with verrucae had little QOL impact, no measurable burden by TTO, and a correspondingly low WTP. Medicaid subjects with basal cell carcinoma had a strong, negative QOL impact and high burden by TTO, but had relatively moderate WTP. WTP appears promising in certain income categories. More studies are needed for conclusions about specific diagnoses.

Inhibition of T-cell activation by syndecan-4 is mediated by CD148 through protein tyrosine phosphatase activity

Most coinhibitory receptors regulate T-cell responses through an ITIM that recruits protein tyrosine phosphatases (PTPs) to mediate inhibitory function. Because syndecan-4 (SD-4), the coinhibitor for DC-associated heparan sulfate proteoglycan integrin ligand (DC-HIL), lacks such an ITIM, we posited that SD-4 links with a PTP in an ITIM-independent manner. We show that SD-4 associates constitutively with the intracellular protein syntenin but not with the receptor-like PTP CD148 on human CD4(+) T cells. Binding to DC-HIL allowed SD-4 to assemble with CD148 through the help of syntenin as a bridge, and this process upregulated the PTP activity of CD148, which is required for SD-4 to mediate DC-HIL's inhibitory function. Using a mouse model, we found SD-4 to be located away from the immunological synapse formed between T cells and APCs during activation of T cells. These findings indicate that SD-4 is unique among known T-cell coinhibitors, in employing CD148 to inhibit T-cell activation at a site distal from the synapse.

DC-HIL/glycoprotein Nmb promotes growth of melanoma in mice by inhibiting the activation of tumor-reactive T cells

DC-HIL/glycoprotein nmb (Gpnmb) expressed on antigen-presenting cells attenuates T-cell activation by binding to syndecan-4 (SD-4) on activated T cells. Because DC-HIL/Gpnmb is expressed abundantly by mouse and human melanoma lines, we posited that melanoma-associated DC-HIL/Gpnmb exerts similar inhibitory function on melanoma-reactive T cells. We generated small interfering RNA-transfected B16F10 melanoma cells to completely knock down DC-HIL/Gpnmb expression, with no alteration in cell morphology, melanin synthesis, or MHC class I expression. This knockdown had no effect on B16F10 proliferation in vitro or entry into the cell cycle following growth stimulation, but it markedly reduced the growth of these cells in vivo following their s.c. injection into syngeneic immunocompetent (but not immunodeficient) mice. This reduction in tumor growth was due most likely to an augmented capacity of DC-HIL-knocked down B16F10 cells (compared with controls) to activate melanoma-reactive T cells as documented in vitro and in mice. Whereas DC-HIL knockdown had no effect on susceptibility of melanoma to killing by cytotoxic T cells, blocking SD-4 function enhanced the reactivity of CD8(+) T cells to melanoma-associated antigens on parental B16F10 cells. Using an assay examining the spread to the lung following i.v. injection, DC-HIL-knocked down cells produced lung foci at similar numbers compared with that produced by control cells, but the size of the former foci was significantly smaller than the latter. We conclude that DC-HIL/Gpnmb confers upon melanoma the ability to downregulate the activation of melanoma-reactive T cells, thereby allowing melanoma to evade immunologic recognition and destruction. As such, the DC-HIL/SD-4 pathway is a potentially useful target for antimelanoma immunotherapy.

Depleting syndecan-4+ T lymphocytes using toxin-bearing dendritic cell-associated heparan sulfate proteoglycan-dependent integrin ligand: a new opportunity for treating activated T cell-driven disease

Because syndecan-4 (SD-4) is expressed by some (but not all) T cells following activation and serves as the exclusive ligand of dendritic cell-associated heparan sulfate proteoglycan-dependent integrin ligand (DC-HIL), we envisioned the DC-HIL/SD-4 pathway to be a therapeutic target for conditions mediated by selectively activated T cells. We conjugated soluble DC-HIL receptor with the toxin saporin (SAP; DC-HIL-SAP) and showed it to bind activated (but not resting) T cells and become internalized by and deplete SD-4(+) T cells. In hapten-sensitized mice, DC-HIL-SAP injected i.v. prior to hapten challenge led to markedly suppressed contact hypersensitivity responses that lasted 3 wk and were restricted to the hapten to which the mice were originally sensitized. Such suppression was not observed when DC-HIL-SAP was applied during sensitization. Moreover, the same infusion of DC-HIL-SAP produced almost complete disappearance of SD-4(+) cells in haptenated skin and a 40% reduction of such cells within draining lymph nodes. Our results provide a strong rationale for exploring use of toxin-conjugated DC-HIL to treat activated T cell-driven disease in humans.

The DC-HIL/syndecan-4 pathway inhibits human allogeneic T-cell responses

T-cell activation is regulated by binding of ligands on APC to corresponding receptors on T cells. In mice, we discovered that binding of DC-HIL on APC to syndecan-4 (SD-4) on activated T cells potently inhibits T-cell activation. In humans, we now show that DC-HIL also binds to SD-4 on activated T cells through recognition of its heparinase-sensitive saccharide moiety. DC-HIL blocks anti-CD3-induced T-cell responses, reducing secretion of pro-inflammatory cytokines and blocking entry into the S phase of the cell cycle. Binding of DC-HIL phosphorylates SD-4's intracellular tyrosine and serine residues. Anti-SD-4 Ab mimics the ability of DC-HIL to attenuate anti-CD3 response more potently than Ab directed against other inhibitory receptors (CTLA-4 or programmed cell death-1). Among leukocytes, DC-HIL is expressed highest by CD14(+) monocytes and this expression can be upregulated markedly by TGF-beta. Among APC, DC-HIL is expressed highest by epidermal Langerhans cells, an immature type of dendritic cells. Finally, the level of DC-HIL expression on CD14(+) monocytes correlates inversely with allostimulatory capacity, such that treatment with TGF-beta reduced this capacity, whereas knocking down the DC-HIL gene augmented it. Our findings indicate that the DC-HIL/SD-4 pathway can be manipulated to treat T-cell-driven disorders in humans.

Recognition of non-self-polysaccharides by C-type lectin receptors dectin-1 and dectin-2

The discovery of several transmembrane receptors expressed by antigen presenting cells, including those that detect and interact with specific sugar moieties on the surface of microbes, has improved our understanding of how immunity against infection is generated. This knowledge, in turn, prompted us to review such interactions with emphasis on C-type lectin receptors and a focus on the roles of dectin-1 and dectin-2 in anti-fungal immunity.

Gpnmb is a melanosome-associated glycoprotein that contributes to melanocyte/keratinocyte adhesion in a RGD-dependent fashion

Gpnmb is a glycosylated transmembrane protein implicated in the development of glaucoma in mice and melanoma in humans. It shares significant amino acid sequence homology with the melanosome protein Pmel-17. Its extracellular domain contains a RGD motif for binding to integrin and its intracellular domain has a putative endosomal and/or melanosomal-sorting motif. These features led us to posit that Gpnmb is associated with melanosomes and involved in cell adhesion. We showed that human Gpnmb is expressed constitutively by melanoma cell lines, primary-cultured melanocytes and epidermal melanocytes in situ, with most of it found intracellularly within melanosomes and to a lesser degree in lysosomes. Our newly developed monoclonal antibody revealed surface expression of Gpnmb on these pigment cells, albeit to a lesser degree than the intracellular fraction. Gpnmb expression was upregulated by UVA (but not UVB) irradiation and by alpha-melanocyte-stimulating hormone (MSH) (but not beta-MSH); its cell surface expression on melanocytes (but not on melanoma cells) was increased markedly by IFN-gamma and TNF-alpha. PAM212 keratinocytes adhered to immobilized Gpnmb in a RGD-dependent manner. These results indicate that Gpnmb is a melanosome-associated glycoprotein that contributes to the adhesion of melanocytes with keratinocytes.

Grenz ray therapy in the new millennium: still a valid treatment option?

Grenz ray therapy has declined in the United States during the past several decades with respect to availability, use, and resident training. However, it remains a simple, affordable, and effective option for managing several refractory dermatoses, especially psoriasis, hand eczema, and allergic contact dermatitis. Though high-dose grenz irradiation has been associated with the development of nonmelanoma skin cancers, grenz ray therapy is considered a safe treatment modality when administered according to the guidelines recommended herein. We review the value of grenz irradiation in contemporary dermatology.

Syndecan-4 mediates the coinhibitory function of DC-HIL on T cell activation

Receptor-ligand interactions between APCs and T cells determine whether stimulation of the latter leads to activation or inhibition. Previously, we showed that dendritic cell-associated heparin sulfate proteoglycan-dependent integrin ligand (DC-HIL) on APC can inhibit T cell activation by binding an unknown ligand expressed on activated T cells. Because DC-HIL binds heparin/heparan sulfate and heparin blocks the inhibitory function of DC-HIL, we hypothesized that a heparin/heparan sulfate proteoglycan on activated T cells is the relevant ligand. Screening assays revealed that syndecan-4 (SD-4) is the sole heparan sulfate proteoglycan immunoprecipitated by DC-HIL from extracts of activated T cells and that blocking SD-4 abrogates binding of DC-HIL to activated T cells. Moreover, cell-bound SD-4 ligated by DC-HIL or cross-linked by anti-SD-4 Ab attenuated anti-CD3 responses, whereas knocked-down SD-4 expression led to enhanced T cell response to APC. Blockade of endogenous SD-4 using specific Ab or soluble SD-4 receptor led to augmented T cell reactions to syngeneic and allogeneic stimulation in vitro and exacerbated contact hypersensitivity responses in vivo. We conclude that SD-4 is the T cell ligand through which DC-HIL mediates its negative coregulatory function.

Photoimmunology--illuminating the immune system through photobiology

We review the field of photoimmunology with emphasis on immunosuppression induced by ultraviolet B radiation. Recent studies have focused on UVB-induced alterations in epidermal Langerhans cell function, resulting in a shift from Th1 to Th2 phenotype and the activation of regulatory T cells as the source of IL-10 that is central to this form of immunosuppression.

DC-HIL is a negative regulator of T lymphocyte activation

T-cell activation is the net product of competing positive and negative signals transduced by regulatory molecules on antigen-presenting cells (APCs) binding to corresponding ligands on T cells. Having previously identified DC-HIL as a receptor expressed by APCs that contains an extracellular immunoglobulin (Ig)-like domain, we postulated that it plays a role in T-cell activation. To probe this function, we created soluble recombinant DC-HIL, which we observed to bind activated (but not resting) T cells, indicating that expression of the putative ligand on T cells is induced by activation. Binding of DC-HIL to naive T cells attenuated these cells' primary response to anti-CD3 antibody, curtailing IL-2 production, and preventing entry into the cell cycle. DC-HIL also inhibited reactivation of T cells previously activated by APCs (secondary response). By contrast, addition of soluble DC-HIL to either allogeneic or ovalbumin-specific lymphocyte reactions augmented T-cell proliferation, and its injection into mice during the elicitation (but not sensitization) phase of contact hypersensitivity exacerbated ear-swelling responses. Mutant analyses showed the inhibitory function of DC-HIL to reside in its extracellular Ig-like domain. We conclude that endogenous DC-HIL is a negative regulator of T lymphocyte activation, and that this native inhibitory function can be blocked by exogenous DC-HIL, leading to enhanced immune responses.

Dectin-2 is a pattern recognition receptor for fungi that couples with the Fc receptor gamma chain to induce innate immune responses

Antigen presenting cells recognize pathogens via pattern recognition receptors (PRR), which upon ligation transduce intracellular signals that can induce innate immune responses. Because some C-type lectin-like receptors (e.g. dectin-1 and DCSIGN) were shown to act as PRR for particular microbes, we considered a similar role for dectin-2. Binding assays using soluble dectin-2 receptors showed the extracellular domain to bind preferentially to hyphal (rather than yeast/conidial) components of Candida albicans, Microsporum audouinii, and Trichophyton rubrum. Selective binding for hyphae was also observed using RAW macrophages expressing dectin-2, the ligation of which by hyphae or cross-linking with dectin-2-specific antibody led to protein tyrosine phosphorylation. Because dectin-2 lacks an intracellular signaling motif, we searched for a signal adaptor that permits it to transduce intracellular signals. First, we found that the Fc receptor gamma (FcRgamma) chain can bind to dectin-2. Second, ligation of dectin-2 on RAW cells induced tyrosine phosphorylation of FcRgamma, activation of NF-kappaB, internalization of a surrogate ligand, and up-regulated secretion of tumor necrosis factor alpha and interleukin-1 receptor antagonist. Finally, these dectin-2-induced events were blocked by PP2, an inhibitor of Src kinases that are mediators for FcRgamma chain-dependent signaling. We conclude that dectin-2 is a PRR for fungi that employs signaling through FcRgamma to induce innate immune responses.

Educational conferences in dermatology residency programs

To characterize conferences in dermatology residency programs, we surveyed directors and chief residents. Most respondents thought their amount of conference time was just right (7-8 hours/wk); they also identified grand rounds, dermatopathology, and clinical images as best implemented, whereas journal club and basic science needed most improvement. By contrast, respondents diverged regarding conferences they wanted to establish; directors identified research and basic science, whereas chief residents listed pediatrics and surgery.

Stevens-Johnson syndrome associated with glipizide therapy

We describe a patient with Stevens-Johnson syndrome (erythema multiforme major) associated with an increase in glipizide dosage administration. Glipizide is a second-generation sulfonylurea commonly used to treat patients with noninsulin-dependent diabetes mellitus. Although several reports have documented Stevens-Johnson syndrome caused by first-generation sulfonylureas, our case appears to be the first report of a second-generation sulfonylurea associated with Stevens-Johnson syndrome.

Canine epidermal langerhans cells express alpha and gamma but not beta chains of high-affinity IgE receptor

Epidermal Langerhans cells (LC) express a high-affinity receptor for IgE (FcepsilonRI), consisting of two chains (alpha and gamma chains) in humans that allows LC to perform Fc receptor-mediated uptake of allergens. We found that canine LC express alpha and gamma chains but not beta chain of FcepsilonRI, identical to human but not to mouse LC, which do not express functional FcepsilonRI (only gamma chain is expressed). This finding indicates that canine LC have FcepsilonRI-mediated function similar to or identical to human LC, raising the possibility that canine species provides a better model than mouse to understand the pathogenesis of human atopic dermatitis and investigate the therapeutic effect of drugs.

Ultraviolet-B radiation upregulates expression of dectin-2 on epidermal Langerhans cells by activating the gene promoter

Epidermal Langerhans cells (LC) belong to the antigen-presenting cell (APC) family of dendritic cells that can initiate antigen-specific immunogenic or tolerogenic responses. In mice, we have shown ultraviolet-B (UV-B) irradiation to induce long-lasting suppression (tolerance) of contact hypersensitivity responses by converting LC from immunogenic to tolerogenic APC. The C-type lectin receptor, dectin-2, expressed preferentially by LC and dendritic cells, has also been shown to be involved in inducing this form of UV-B-induced immunosuppression. These observations led us to question whether UV-B can modulate dectin-2 expression by LC. In ICR mice engineered to express the dectin-2 gene promoter linked to a luciferase reporter gene, we found broadband UV-B treatment in vivo to activate the promoter in LC. In wild-type C3H/HeN mice, we found such treatment in vivo to yield LC with increased dectin-2 expression at both mRNA and protein levels. Broadband UV-B treatment in vitro of bone marrow-derived dendritic cells from these mice also showed upregulated expression of dectin-2 mRNA. These findings lead us to conclude that broadband UV-B upregulates dectin-2 expression in LC by activating the dectin-2 gene promoter. Such amplification suggests that UV-B-induced immunosuppression may be due (at least in part) to augmented dectin-2 expression in LC.

Selective expression of vacuolar H+-ATPase subunit d2 by particular subsets of dendritic cells among leukocytes

Dendritic cells (DC) are far more potent to activate T cells than other antigen presenting cells (e.g., macrophages) and distributed to many organs where DC develop to functionally and phenotypically distinctive subsets. To isolate DC-differentially expressed genes, we used a subtractive cDNA cloning (XS52 DC minus J774 macrophages), resulting in the identification of d2 isoform of vacuolar (V) H+-ATPase subunit d. Unlike the ubiquitously expressed isoform (d1), d2 mRNA manifested expression restricted to particular subsets of DC (e.g., skin- and bone marrow-derived DC) among leukocytes and encoded two transcripts (1.6 and 3.0 kb) that differed in the length of the 3'-untranslated region. The d2 protein displayed association with membranes and the localization in lysosomes and antigen-containing endosomes. Interestingly, XS52 DC expressed seven-fold higher V-ATPase proton-pump activity than J774 macrophages and distinguished from the macrophage by high levels of isoforms a1 and a2 expression among V-ATPase subunits. These results indicated that d2 is a new marker for DC and it may, co-operatively with subunit a isoforms, regulate V-ATPase activity.

Identification and expression profiling of a human C-type lectin, structurally homologous to mouse dectin-2

A number of C-type lectins on antigen-presenting cells play an important role in regulating innate immunity. Previously, we identified the mouse C-type lectins (dectin-1, and dectin-2) and human DECTIN-1. To identify human DECTIN-2, we employed degenerative polymerase chain reaction-based cDNA cloning using RNA from human Langerhans cell (LC)-like dendritic cells (DCs). This process yielded a cDNA encoding a C-type lectin with 66.5% amino acid sequence homology to mouse dectin-2, the same gene reported by Kanazawa et al. (J Invest Dermatol 2004: 122: 1522-1524) using the disparate approach of analyzing coding sequences in chromosome 12. Similar to their findings, we found gene expression in lung, spleen, and lymph node. Among resting leukocytes, it was expressed at highest levels by CD14+ monocytes, at lower levels by CD19+ B cells, and not at all by CD4+ T cells. Activation of CD19+ B cells with pokeweed mitogen down-regulated gene expression, whereas expression in CD4+ T cells was induced by Con A. Among our novel findings are an alternatively spliced transcript lacking exon 2, expression in bone marrow and tonsil, expression in CD8+ T cells that is abrogated following activation with phytohemagglutinin, restricted expression to CD1a+ LC within epidermis, and preferential expression by plasmacytoid (rather than myeloid) DC. Finally, we found that treatment with interleukin-4 (IL-4), IL-10, or UVB down regulated gene expression in CD14+ monocytes, whereas granulocyte-macrophage colony-stimulating factor, transforming growth factor-beta1, or tumor necrosis factor-alpha treatment up-regulated it. Our findings may form the basis for understanding the function of human DECTIN-2 in innate immunity.

Transcriptional regulation of dectin-2 promoter in transgenic mouse

Despite a preeminent role of epidermal Langerhans cells (LC) in inducing primary immunity, application of gene-based modification to LC function is limited by lack of well-defined transcription regulatory units that can direct LC-specific gene expression. Previously we reported that the promoter activity of a 5'-flanking region of the dectin-2 gene (Dec2FR) is highly targeted to epidermal LC of transgenic mice bearing a Dec2FR-driven Luc gene. Using the mice, in which transcription activity of Dec2FR is measured by Luc assays, presently we characterized regulation of Dec2FR activity in leukocyte subpopulations under resting and activation status. Luc activity was highly variable in LC isolated from different skin areas and detected in other DC subset (dermal DC) but the levels were much lower than in resting LC. Activation of leukocytes markedly up-regulated Luc activity in all four subpopulations (CD11c+ splenic DC, Mac-1high peritoneal macrophages, splenic B220+ B cells, and CD3+ T cells). However, these levels remained lower than those in the resting and activated LC. These findings indicate that dectin-2 promoter activity remains targeted to epidermal LC even after activation of leukocytes, suggesting a high potential of Dec2FR to engineer LC-targeted gene expression to heighten efficacy of genetic vaccination and to manipulate phenotypes of preexisting immunity (Th1 vs. Th2).

Allergic contact dermatitis: pathophysiology applied to future therapy

Contact dermatitis is a common reason for patient visits to primary-care clinics and represents up to 7% of all dermatologic consultations in the US. Substantial progress has been made in elucidating the pathophysiology of contact dermatitis, particularly the allergic form. A better understanding of pathologic mechanisms has led to improved management of cases and will continue to advance treatment modalities. The present paper reviews the pathogenesis and current treatment of allergic contact dermatitis and speculates on the prospects for improved future therapy.