We therefore propose classification of LCH as a myeloid neoplasia and hypothesize that high-risk
Mature no 669 arises from somatic Mature no 669 of a hematopoietic progenitor, whereas low-risk disease arises from somatic mutation of tissue-restricted precursor DCs. LCH has pleotropic clinical presentations ranging from single lesions cured by curettage to potentially fatal multi-system disease.
Despite clinical Mature no 669, LCH lesions are generally indistinguishable by histology, which led to the notion that the spectrum of clinical manifestations represents a single disorder, histiocytosis X Lichtenstein, Birbeck granules are intracytoplasmic organelles whose role has remained poorly understood since their first identification in Birbeck et al.
Recent data revealed that the formation of the Birbeck granules Mature no 669 a consequence of the antigen capture function Mature no 669 a C—type II lectin receptor called langerin, recently named CD Valladeau et al. Langerin was initially described specifically on human and mouse epidermal Langerhans cells and subsequently found on histiocytosis X lesions, further supporting the epidermal Langerhans cell origin of the disease Chikwava and Jaffe, However, recent discoveries question the model of LCH arising from transformed or pathologically activated epidermal Langerhans cells.
Furthermore, mouse studies demonstrate that langerin is more promiscuous than previously appreciated Ginhoux et al. In addition to epidermal Langerhans cells, langerin is also expressed on a subset of DC expressing the integrin CD in non-lymphoid tissues Merad et Mature no 669. In this study, we investigate the clinical significance of the BRAF-VE molecular signature and identify cells carrying the mutation to further define the cellular origins of LCH. Importantly, we found that BRAF-VE expression in circulating cells Mature no 669 also associated with disease severity in Mature no 669. These results support a pivotal functional role of the mutation in LCH pathogenesis.
Clinical characteristics of the patients represent a range of age, extent of disease, and clinical risk categories. Median follow-up for data from time of diagnosis was 2. The significance of the BRAF mutation was analyzed by comparing BRAF genotype with categorical clinical variables including gender, age, single lesion versus multifocal lesions, high-risk versus low-risk clinical assessment, CNS risk location skull base and orbit lesion Mature no 669 associated with increased risk of LCH-associated neurodegeneration; Grois et al.
BRAF genotype did not correlate with gender, age, extent of lesions, clinical risk status, CNS risk, or development of diabetes insipidus Table 1. High-risk clinical status, regardless of BRAF genotype, was associated with significantly higher frequency of relapse and lower survival Fig. Despite the increased risk of recurrence from
Mature no 669 mutation was not associated with any difference in overall survival Fig. Clinical status, BRAF genotype, and clinical outcomes.
A Estimates for refractory or recurrent disease in the study population by disease risk red: B Estimates for survival based on disease risk red: Every bar represents a single blood sample; technical duplicates were used in all experiments. Every data point represents a single blood sample; Mature no 669 duplicates were in all Mature no 669. This series included three patients with a biopsy reported with features with LCH, and also with a history of other histiocytic disorders.
From the Mature no 669 with BRAF genotype, peripheral blood samples were collected from 77 patients with clinically detectable active disease: Clinical risk categories were assigned according to the medical record. For example, patient LCH had biopsy-proven skin and bone lesions, but splenic lesions noted on abdominal ultrasound were not biopsied and the patient was regarded as multi-system low-risk by the treating team.
Because the initial therapy is the same for low-risk and high-risk LCH patients, the risks of proving liver or spleen involvement in cases where imaging is equivocal may not be warranted. Interestingly, the described splenic lesions resolved after successful therapy.
This example highlights the limitations of conventional staging strategies. In one case of a patient who developed symptoms of high-risk LCH at 6 mo of age LCHBRAF-VE cells were identified in multiple lesion samples and peripheral blood at the time of diagnosis; however, BRAF-VE was not identified in a cord blood sample harvested at birth, suggesting that a precursor population was too rare to identify or that the somatic mutation was acquired at a later time see Fig.
Every bar represents a single sorted blood sample; technical duplicates were used in all experiments. One case, LCH, was initially Mature no 669 as low-risk multisystem by the treating team but with splenic lesions of uncertain etiology as described above. This patient was found to have 1. However, the statistically significant frequency in patients with high-risk LCH and failure to identify any circulating cells in patients with large single-lesion tumor burden favor a precursor versus a lesional origin of these cells.
Due to the small Mature no 669 no 669 of cells, colonies were pooled to perform BRAF genotyping. Together, these data suggest that BRAF-VE mutations may arise in hematopoietic stem cells and promote stem cell differentiation into myelomonocytic precursor cells in patients with high-risk LCH.
These observations are consistent with the potential of hematopoietic progenitors with BRAF hyper-activation to develop into B cells as well as monocytes and myeloid DCs.
In mice, langerin is absent from DC progenitors and is expressed only in differentiated tissue-resident DCs including epidermal Langerhans cells and a subset of tissue DCs that also express the integrin CD Merad et al. BRAFVE langerin mice were viable and developed normally without gross phenotypical alterations compared with control littermates.
Immunofluorescence IF staining further confirmed that a significant proportion of liver tissue—infiltrating cells also expressed langerin Fig. BRAFVE langerin mice spontaneously developed progressive accumulation of inflammatory infiltrates in peripheral tissue.
C and D Lung and liver tissue of BRAFVE langerin mice and
Mature no 669 littermates were harvested at 12 of age
Mature no 669 single cells suspensions were analyzed by multicolor flow cytometry analysis after digestion Mature no 669 collagenase. Along with severe hepatosplenomegaly and lymphadenopathy, organized histiocytic infiltrates were identified in the skin, liver, spleen, and lungs of all mice by 8 wk of age, resulting in a broad destruction of tissue architecture by 16 wk of Mature no 669 Fig.
Histologically, the histiocytic lesions observed in BRAFVE CD11c mice exhibited classical
Mature no 669, including multinucleated giant cell formation which is frequently observed in human LCH da Costa et al. Expression of the mutation in DC-restricted precursors was associated with severe anemia, confirming BM involvement in these mice Fig. The etiology of LCH has intrigued and eluded the medical community for the past century as a paradox of a collection of highly variable clinical manifestations connected by common histopathology.
The resulting debate on LCH pathogenesis has recently focused on aberrant activation versus malignant transformation of the Langerhans cell. We also demonstrate that BRAF-VE mutation in patients with high-risk LCH is a somatic event that seems to arise in very early myelomonocytic precursors or in stem cells that may be subsequently driven to myelomonocytic differentiation, whereas BRAF-VE mutation in patients with low-risk LCH was not routinely identified in cells, suggesting it may be restricted to differentiated tissue-resident DCs in these
Mature no 669. CD34 is a major positive marker of human HSPCs and is not expressed by mature blood cells or tissue-restricted myeloid cells Kondo et al.
As lesional cells display only low proliferation rate Senechal et al. Although these mouse models recapitulate several features of Mature no 669 LCH, the extent to which these results can be translated to human Mature no 669 pathology remains a matter for investigation.
Based on our results, we propose a new Mature no 669 model of LCH in which the initiating cell defines the extent of the disease.
Mature no 669 The mixed inflammatory lesion that defines LCH clinically is indistinguishable between different LCH clinical risk groups. However, LCH lesions may represent only a superficial downstream manifestation of pathogenesis. If BRAF-VE is the activating event, somatic mutation in a hematopoietic stem cell or myeloid DC restricted precursors may determine progression to high-risk disease, potentially with lesions in BM, liver, spleen, or virtually any organ system.
We further hypothesize that if the initiating mutation occurs in tissue-restricted DC progenitors, multifocal low-risk disease could result. Finally, if an initiating mutation arises in a differentiated DC Mature no 669 restricted tissue tropism, low-risk LCH with a single lesion could result.
Based on the misguided differentiation of the pathological DC and
Mature no 669 ability to recruit and activate additional inflammatory cells, we propose that the answer to the neoplasia versus inflammation debate is that both processes may be essential to LCH pathogenesis.
The results from this study also revealed some innovative diagnostic tools that will need to be validated in future prospective clinical studies. Future multi-center prospective studies will determine if multifocal clinical low-risk disease with circulating BRAF-VE cells represents an independent clinical risk category or simply reflects the limitation of existing clinical scoring strategies to accurately categorize versus high-risk disease.
In addition to potential clinical utility in risk stratification, BRAF mutation status might also be useful for
Mature no 669 surveillance. The potential value of surveillance strategies in LCH is indicated by the published very high rates of treatment failure or disease Mature no 669, which may represent persistence of LCH precursor cells.
We question the wisdom of generally treating clinical high-risk, or even clinical low-risk patients, with BRAF-VE lesions initially vinblastine, prednisone, or etoposide with such high rates of failure. As we are now able to identify BRAF-VE minimal residual disease, future clinical trials will test sustained responses to experimental therapies more efficiently.
In light of the findings of this study, we hypothesize that optimal therapy for LCH would specifically impact immature myeloid DC precursors. Even if effective, the relative mortality in most patients with LCH and the known toxicities of BRAF inhibition make optimal use of these agents an uncertain equation, especially in children where the effects of BRAF inhibition on development are unknown Chapman et al.
Mature no 669 addition to chemotherapy or BRAF inhibition, novel strategies could include inhibition of myeloid growth factors, inhibition of maturation or migration of pathological DCs, and disruption Mature no 669 cell—cell interactions that recruit and activate bystander inflammatory cells.
Until now, development and evaluation Mature no 669 novel therapies for patients have been limited by a lack of animal models of LCH. This model not only supports a model of pathogenesis in which LCH may arise through expression of BRAF-VE in precursor cells and DCs but may also represent a valuable tool with which
Mature no 669 develop and evaluate future therapeutic strategies.
Clinical data were collected from approved chart reviews. Studies with patient tissue and clinical data Mature no performed according to protocols approved by the Institutional Review Board of Baylor College of Medicine. Frequency distributions of demographic and clinical characteristics were tabulated for those with and without the BRAF-VE mutation. The sensitivity and specificity of circulating cells with BRAF-VE were compared with the clinical assessment of disease risk i.
All statistical analyses were performed using Intercooled Stata version BRAF mutation and primers were included in each reaction. Duplicate reactions were performed for each sample.
Buffy coat from fresh peripheral blood, BM aspirate, and cord blood samples was purified by spinning an equal volume over Histopaque Sigma-Aldrich at g for 30 min. All flow cytometry analysis was performed using FlowJo software Tree Star. Subsequently, biotin was detected Mature no 669 streptavidin-APC eBioscience. All animals Mature no 669 housed under specific pathogen-free SPF conditions and sacrificed Mature 669 the indicated time points.
All experiments were controlled using littermates negative for the cre recombinase transgene construct. Endogenous peroxidase activity was blocked by incubating the sections in methanol with 0.
Heat-induced antigen retrieval was performed with citrate buffer, pH 6. To block nonspecific staining, Rodent Block M Biocare Medical was incubated with the section for 1 h at room temperature.
Single cell suspension was obtained from indicated tissues after digestion with 0. Table S4 shows LCH peripheral blood analysis: Online supplemental material is available at http: We also appreciate the support of shared resources by Dan L.
Finally, we would like to acknowledge this collaboration as a result of the Nikolas Symposia on the Histiocytoses, organized and supported by the Kontoyannis family. Simkothe Histiocytosis Association C. National Center for Biotechnology InformationU.
Mature no 669 J Exp Med v. Lira3 Kenneth M. Author information
Mature no Mature no 669 notes Mature no 669 and License information Disclaimer. Peters contributed equally to this paper. Received May 11; Accepted Feb This article
Mature no 669 distributed under the Mature no 669 of an Attribution—Noncommercial—Share Alike—No Mirror Sites license for the first six months after the publication date see http: This article has been corrected.
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