ParaneoPlastic neurological syndromes associated with anti-hu antibodies

103 Pages·2011·1.78 MB·English

ParaneoPlastic neurological syndromes
associated with anti-hu antibodies:
are t lymPhocytes involved or not?
marieke t. de graaf
Paraneoplastic neurological syndromes
associated with anti-hu antibodies:
are t lymphocytes involved or not?
Paraneoplastische Neurologische Syndromen
geassocieerd met anti-Hu antistoffen:
betrokkenheid van T lymfocyten of niet?
Proefschrift
colofon
ter verkrijging van de graad van doctor
The studies described in this thesis were performed at the Departments of Neurology aan de Erasmus Universiteit Rotterdam
and Medical Oncology from the Erasmus University Medical Center in Rotterdam, op gezag van de rector magnificus
The Netherlands. Prof.dr. H.G. Schmidt
en volgens besluit van het College voor Promoties.
This research project was supported by the Gratama Foundation (Teteringen, De openbare verdediging zal plaatsvinden op
The Netherlands), Erasmus MC Grant (Rotterdam, The Netherlands) and ZonMW woensdag 5 oktober 2011 om 15:30 uur
AGIKO Stipendium (Den Haag, The Netherlands).
Printing of this thesis was sponsored by Sysmex, Duke Scientific Corporation, Beckman
Coulter, BD Biosciences and Zebra Bioscience. door

ISBN: 978-90-8891-305-1
Copyright © 2011 Marieke T. de Graaf, Rotterdam, The Netherlands marieke theodora de graaf
All rights reserved. No part of this thesis may be reproduced, stored in a retrieval system, geboren te Alkmaar
or transmitted in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise without the prior written permission of the copyright owner.
Lay out and cover design: Jan Heijnen, Hieke Denijs
Printed by: Proefschriftmaken.nl || Printyourthesis.com
Published by: Uitgeverij BOXPress, Oisterwijk
Promotiecommissie contents
Chapter 1 general introduction 9
Promotor: Prof.dr. P.A.E. Sillevis Smitt
Chapter 2 neurological Paraneoplasias 17
overige leden: Prof.dr. M.J. van den Bent In: Wick MR: Metastatic carcinomas of unknown origin; Chapter 2:
Prof.dr. H. Hooijkaas Paraneoplastic syndromes associated with MCUOs. New York, Demos,
Prof.dr. F. Claas 2008: pp 27-41
copromotor: Dr. J.W. Gratama Chapter 3 flow cytometric characterization of cerebrospinal 39
fluid cells
Cytometry Part B: Clinical Cytometry, 2011 May 12 (Epub)
Chapter 4 addition of serum-containing medium to 59
cerebrospinal fluid prevents cellular loss over time
Journal of Neurology, 2011 March 12 (Epub)
Chapter 5 central memory cd4+ t cells dominate the normal 71
cerebrospinal fluid
Cytometry Part B: Clinical Cytometry 2011;80:43-50
Chapter 6 b and t cell imbalances in csf of patients with 87
hu-antibody associated Pns
Journal of Neuroimmunology 2008;195:164-170
Chapter 7 no evidence for the presence of hud-specific t cells in the 101
cerebrospinal fluid of patients with hu-associated
paraneoplastic neurological syndromes
Journal of Neurology 2009;256:279-282
Chapter 8 hla-dQ2+ individuals are susceptible to hu-ab associated 107
paraneoplastic neurological syndromes
Journal of Neuroimmunology 2010;226:147-9
Chapter 9 contamination of synthetic hud protein spanning peptide 117
pools with a cmv-encoded peptide
Cytometry Part A 2008;73:1079-1085
Chapter 10 human chorionic gonadotropin treatment of anti-hu 133
associated paraneoplastic neurological syndromes
Journal of Neurology, Neurosurgery & Psychiatry 2010;81:1341-4
Chapter 11 general discussion 143
Chapter 12 summary/samenvatting 151
references 160
list of abbreviations 190
dankwoord 197
Phd Portfolio 200
curriculum vitae 203
list of publications 204
chapter 1
general introduction
10 Chapter 1 General Introduction 11
ParaneoPlastic neurological syndromes tissue distress, e.g., cytokine production by the tumor25, in SCLC patients developing Hu-
PNS which is absent in SCLC patients without Hu-PNS. Apparently, this tissue distress is
clinical aspects present in a minority of SCLC patients, given that only a small population of SCLC patients
Paraneoplastic neurological syndromes (PNS) are remote effects of cancer that are not succumbs to neuronal degeneration.
caused by invasion of the tumor or its metastases, nor by infection, ischemia, metabolic The immune response that is triggered in Hu-PNS, not only reacts with the tumor but
and nutritional deficits, surgery or other forms of tumor treatment1. PNS may effect any is also directed against HuD expressed in the nervous system. Ninety-five percent of
level of the nervous system (central or peripheral nervous system, including neuromuscular SCLC patients with Hu-PNS have limited disease26, 27, which could partly be explained
junction and muscle), and are devastating neurological syndromes leaving most of the by lead time bias as a search is performed towards an asymptomatic SCLC in 60%-80%
patients severely disabled within a few months. In Chapter 2 the diagnosis and clinical of patients26. Alternatively, the anti-tumor immune response might be responsible for
management of PNS are reviewed. One of the most frequently involved tumors in PNS is the indolent course and extended survival in many Hu-PNS patients20, 26, 27. However,
small cell lung cancer (SCLC), and approximately 50% of patients with PNS and SCLC have the price of tumor control is high, because PNS also cause neuronal damage resulting in
high-titer antibodies against the onconeural HuD antigen (anti-Hu)2. Detection of anti-Hu severe neurological symptoms. While all patients with high anti-Hu titers suffer from PNS,
antibodies in serum or cerebrospinal fluid (CSF) definitively diagnoses the neurological an additional 16% of SCLC patients have low-titer anti-Hu antibodies without PNS19, 20,
syndrome as paraneoplastic3, 4. The first goal of treatment for PNS is antitumor therapy, 27. In these patients, the presence of low-titered anti-Hu antibodies was correlated with
which halts neurological deterioration and improves functional outcome5-9. Additional limited stage disease, complete response to chemotherapy, and improved survival9, 15, 19,
immunotherapy with steroids, cyclophosphamide, rituximab, intravenous immunoglobulin 27. Although, in another study, no association between the presence of anti-Hu antibodies
(IVIg) or plasma exchange has disappointing results6, 9-16. This thesis will focus on PNS and the extent of disease or survival was found28. The lack of neurological symptoms in
associated with anti-Hu antibodies (Hu-PNS). patients with low titers of anti-Hu antibodies suggests that antitumor immunity can be
dissected from neurological autoimmunity.
Pathogenesis of hu-Pns
The general model for Hu-PNS is that the normally neuron-specific expression of the HuD cellular immunity
antigen, combined with immune privilege in the brain, accounts for the immunogenicity Previous studies have clearly demonstrated that anti-Hu antibodies do not play a
of the HuD antigen when it is expressed in SCLC17. However, the observation that all SCLC pathogenic role in Hu-PNS and tumor control29-36, but rather are a useful diagnostic
express the HuD antigen18, while only 1% of patients develop Hu-PNS with high-titer marker4. Pathological examination of affected areas of the nervous system in Hu-PNS
anti-Hu antibodies1 and low-titer anti-Hu antibodies are present in an additional 16% of shows loss of neurons with localized inflammatory cell infiltrates, containing B cells, CD4+
SCLC patients19, 20, does not fit into this model. Therefore, an alternative model has been T-helper lymphocytes and cytotoxic CD8+ T lymphocytes34, 37-43. T lymphocyte receptor
proposed recently in which a natural immune response to HuD is absent - to keep the analysis supported a direct effector role of cytotoxic CD8+ T lymphocytes, the same
nervous system from autoimmune attack - and HuD tolerance has to be broken before clones being likely operative in neuronal damage and immune-mediated tumor growth
Hu-PNS develops21. This alternative model is based on the danger theory22, which states control39, 44. The cerebrospinal fluid (CSF) of Hu-PNS patients generally is abnormal,
that the default reaction of T lymphocytes to antigens on non-hematopoietic tissues is showing signs of inflammation, including mononuclear pleocytosis, intrathecal synthesis
tolerance, and it is the role of blood-derived antigen presenting cells, particularly dendritic of IgG and HuD-specific oligoclonal bands8, 45-49. In blood, Hu-PNS patients had a variety
cells, to detect and report to T lymphocytes in situations of dangerous tissue distress23. of imbalances within their lymphocyte subsets as compared with SCLC patients and
The finding that there is a strong tolerance to HuD in normal resting mice, while HuD- healthy controls: i. a lymphopenia of B, CD4+ and CD8+ T lymphocytes50; ii. increased
deficient mice generate HuD-specific T lymphocytes without peptide stimulation21, proportions of activated CD4+ and CD8+ T lymphocytes41, 50; iii. increased numbers of
supports this model. In cancer, only if tissue cells are damaged by tumor cell infiltration, CD4+ memory T lymphocytes41; iv. reduced numbers of terminally differentiated effector
or made to die necrotically due to severe ischemia or infection, danger signals will be CD8+ T lymphocytes and lymphocytes with a cytotoxic phenotype (CD56+ and CD57+)50;
produced to stimulate antigen presenting cells and subsequently an antitumor response and v. down-regulation of expression levels of FOX-P3, TGF-β and CTLA-4 mRNA in
will be generated24. If this model holds true for Hu-PNS, there has to be some kind of regulatory T-lymphocyte subsets suggesting regulatory T-lymphocyte dysfunction51.
12 Chapter 1 General Introduction 13
Additionally, difficulty in treating these disorders with strategies directed at the humoral Hu-PNS patients58. Additionally, eight different HuD-peptides elicited specific cytotoxic T
immune response11, 16 support a role for T-lymphocyte mediated mechanisms in PNS, lymphocytes in a humanized murine model after peptide vaccination59. Several studies
although therapies directed at the cellular immune response alone or both humoral and directly looking for circulating HuD-specific CD8+ T lymphocytes were either negative60 or
cellular immunity5, 10, 14 have not been successful either. Overall, these findings suggest inconclusive showing specific T-lymphocyte responses in controls38, 59. The failure to detect
the occurrence of both B- and T-lymphocyte mediated immune responses in blood and HuD-specific CD8+ T lymphocytes could be related to the limited sensitivity of the assays
CSF of Hu-PNS patients34, 40, 47. used and the low frequency and affinity of cytotoxic T lymphocytes involved in antitumor
and autoimmunity when compared to e.g., virus-specific cytotoxic T lymphocytes53.
cerebrospinal fluid in hu-Pns However, recently HuD133-specific CD8+ T lymphocytes were detected in blood of one
In CSF of Hu-PNS patients, high-titered anti-Hu antibodies can be detected. Furthermore, HLA-A0301 Hu-PNS patient and HuD157-specific CD8+ T lymphocytes in blood and CSF
93% of patients have an abnormal CSF45: pleocytosis (38%), elevated protein levels (80%) of two HLA-A0201 Hu-PNS patients61. These HuD157-specific CD8+ T lymphocytes were
or presence of oligoclonal bands (59%). These oligoclonal bands are HuD-specific47. A shown to exhibit a different phenotype, producing type 2 cytokines including IL-13 and IL-5
study in 295 PNS patients with anti-Hu (58%), anti-Yo (20%), anti-CV2 (8%), anti-Ma (6%), instead of IFN-g61. This is an alternative explanation for the failure to detect HuD-specific T
anti-Ri (5%), or anti-Tr (3%) antibodies showed elevated numbers of CSF cells in 47% of lymphocytes in earlier studies.
patients before the 3rd month after disease onset, while after the 3rd month only 28% of
patients had a CSF pleocytosis45. This evolution suggests a (sub)acute inflammation phase
in the central nervous system (CNS) during the first months of PNS, followed by a non- immuno assays
inflammatory phase45. Moreover, this CSF pleocytosis is consistent with a cellular immune
response in this compartment49. In patients with paraneoplastic cerebellar degeneration flow cytometry
(PCD) and anti-Yo antibodies directed against the cdr2 antigen, this CSF pleocytosis has A very useful technique to investigate leukocyte and lymphocyte populations in blood
been shown to contain increased percentages of activated T lymphocytes52. In CNS viral and CSF is flow cytometry. With this technique it is possible to detect a large spectrum of
infections and multiple sclerosis (MS), antigen-specific T lymphocytes have been identified cellular characteristics even in samples with low-cellularity like CSF62, which also facilitates
in relatively high concentrations in CSF53-56. This suggest that the T lymphocytes located the detection of low-frequency cells63. Additionally, absolute cell numbers can be
within the CSF may reflect a T-lymphocyte response in the CNS parenchyma. Because fresh counted63. Examination of blood and CSF cell populations in various neuro-inflammatory
brain biopsies of Hu-PNS patients are generally unavailable for functional T-lymphocyte disorders by flow cytometry is used to further elucidate the immunopathogenesis of these
studies, investigation of CSF samples of Hu-PNS patients is a good alternative. diseases. For example, in multiple sclerosis various studies have examined frequencies
of different lymphocyte subsets in CSF in order to study pathogenesis64-77, determine
hud-specific t lymphocytes disease activity78-83 and evaluate therapy84-86. In Chapter 3 applications, possibilities and
The current hypothesis is that the ectopic expression of HuD in tumor cells18 elicits a HuD- technical challenges of CSF flow cytometry are reviewed.
specific T-lymphocyte response that subsequently attacks both the tumor and neurons.
Previous studies have studied the presence of these HuD-specific T lymphocytes, but most antigen-specific t lymphocytes
evidence is circumstantial. Stimulation with the HuD antigen resulted in higher proliferative Numerous techniques to measure antigen-specific T lymphocytes are also based on
responses of peripheral blood mononuclear cells (PBMC) in Hu-PNS patients compared flow cytometry. For this purpose, flow cytometry is the only platform that combines the
to SCLC patients and healthy controls41, while ELISPOT assays with 19 different HuD- detection of antigen-specific T lymphocytes with multi-parametric analysis of these cells,
peptides showed a significant IFN-g secretion in 7/10 Hu-PNS patients38. The presence of including phenotypic markers, intracellular molecules, function and proliferation87. The
HuD-specific CD8+ T lymphocytes is suggested by the observation that activated CD8+ following techniques are all based on flow cytometry. Secreted mediators (e.g., cytokines)
T lymphocytes from a Hu-PNS patient lysed autologous fibroblasts injected with the in antigen-activated cells are directly visualized by intracellular cytokine staining88, while
recombinant HuD protein57, while human leukocyte antigen (HLA) class I-restricted CD8+ the cytokine capture assay permits the detection, analysis and isolation of viable cytokine-
cytotoxic T-lymphocyte activity directed against five HuD-peptides was observed in three secreting T lymphocytes89. Upon CD4+ T-lymphocyte activation, CD154 expression, which
14 Chapter 1 General Introduction 15
is transiently expressed on the cell surface, is measured90 and for cytotoxicity, CD107 (chapter 4) and determined reference values for absolute numbers and percentages
expression on the cell surface is determined91. Major histocompatibility complex (MHC)- of leukocyte and lymphocyte subsets in CSF (chapter 5). In CSF of Hu-PNS patients, we
peptide multimers bind directly to the antigen receptor of a specific T lymphocyte and are studied lymphocyte subsets (chapter 6) and searched for the presence of HuD-specific T
detected by flow cytometry92. Furthermore, antibodies specific for a unique T cell receptor lymphocytes (chapter 7). The second part of this thesis is attributed to studies in blood of
(TCR) or surface activation markers (e.g., upregulation of CD25 or CD69) can be used to Hu-PNS patients. In earlier studies, detection of HuD-specific T lymphocytes by stimulation
detect antigen-specific T lymphocytes by flow cytometry. Specific proliferation of cells can of PBMC or T lymphocytes of Hu-PNS patients has been shown to be extremely difficult
be measured with the carboxyfluoroscein diacetate succinimidyl ester (CFSE)-dilution or (see above). The finding of a predisposition of HLA-DQ2+ individuals to develop Hu-PNS
bromo-deoxy-uridine (BrdU)-incorporation assays93, 94. (chapter 8) gives us the opportunity to stimulate more specifically. However, false-positive
In addition, several techniques without using flow cytometry are used for detection of findings in T-lymphocyte stimulations due to peptide contamination (chapter 9) is another
antigen-specific T lymphocytes. Proliferation of lymphocytes is studied by measuring the challenge in these stimulation assays. Our ultimate goal is development of a treatment for
incorporation of 3H-thymidine into the DNA of proliferating lymphocytes95. In cytotoxicity Hu-PNS. Therefore, we conducted a clinical trial in which we treated Hu-PNS patients with
assays, 51Chromium labelled target cells are incubated with cytolytic effector lymphocytes human chorionic gonadotropin (hCG) (chapter 10). Our main findings, discussion and
and release of radioactivity is measured96. Alternatively, non-radioactive labelling dyes future perspectives are presented in chapter 11 and chapter 12 summarizes this thesis.
can be used97. Another way to measure cellular activation is through the quantification
of secreted mediators (e.g., cytokines) by specific ligand assays (e.g., enzyme-linked
immunosorbent assay [ELISA])98 and with the enzyme-linked immunosorbent spot-forming
assay (ELISPOT) in which mediator-secreting cells can be enumerated99.
hla association
Another way to study autoimmune diseases in which T lymphocytes are involved, is by
looking at possible HLA-association. T-lymphocyte mediated immune responses are
elicited by peptide fragments derived from antigens bound to HLA molecules on the cell
surface of antigen-presenting lymphocytes. These HLA molecules are polygenic; every
individual possesses a set of HLA molecules, determined in the HLA genes, which have
different ranges of peptide-binding specificities. In other autoimmune diseases, including
myasthenia gravis, type I diabetes mellitus and celiac disease100-102, these HLA genes play
an important role in an individual’s susceptibility to the disease. Individuals with a specific
HLA haplotype have an increased risk of mounting an autoimmune reaction against a
specific antigen and thereby developing an autoimmune disease103.
scoPe of this thesis
In this thesis we aimed to further investigate the role of T lymphocytes in the pathogenesis
of Hu-PNS. The clinical aspects of Hu-PNS are reviewed in chapter 2. To reach our goal,
we studied CSF as well as blood of Hu-PNS patients. The first part of this thesis describes
CSF studies. To optimize the use of flow cytometry in CSF (chapter 3), we investigated
the effect of adding medium directly after CSF sampling on the viability of CSF cells
chapter 2
neurological Paraneoplasias
Marieke T. de Graaf and Peter A.E. Sillevis Smitt
In: Wick MR: Metastatic carcinomas of unknown origin; Chapter 2: Paraneoplastic syndromes
associated with MCUOs. New York, Demos, 2008: pp 27-41
18 Chapter 2 Neurological Paraneoplasias 19
introduction table 1 | Paraneoplastic syndromes associated with carcinomas
neurological systemic
Central nervous system Cachexia, anorexia, weight lossb
Paraneoplastic syndromes are defined as remote effects of cancer that are not caused by
Encephalomyelitisa Fever
invasion of the tumor or its metastases, nor by infection, ischemia, metabolic and nutritional
Limbic encephalitisa Nonbacterial thrombotic endocarditis
deficits, surgery or other forms of tumor treatment2, 104. Paraneoplastic syndromes Brainstem encephalitis Orthostatic hypotension
can present with a plethora of symptoms affecting many organ systems (Table 1). The Subacute cerebellar degenerationa Systemic lupus erythematosus
Opsoclonus-myoclonus
incidence of paraneoplastic syndromes varies widely both by the type of syndrome and
Stiff-person syndrome endocrine/metabolic
by the underlying cancer. Cachexia, anorexia, and weight loss are for instance extremely Paraneoplastic visual syndromes Acromegaly
common in advanced cancer patients. On the other hand, most of the antibody-associated Cancer-associated retinopathy Carcinoid syndrome
Melanoma-associated retinopathy Cushing’s syndrome
paraneoplastic neurological syndromes (PNS) are very rare, with an incidence of well below
Paraneoplastic optic neuropathy Galactorrhea
1% of cancer patients2.
Motor neuron syndromes Gynecomastia
Subacute motor neuronopathy Hyperamylasemia
Other motor neuron syndromes Hypercacitonemia
Hypercalcemiab
Peripheral nervous system Hyperglycemia
Subacute sensory neuronopathya Hypertension
Acute sensorimotor neuropathy Hyperthyroidism
Chronic sensorimotor neuropathyb Hypoglycemia
Association with M-proteins Hyponatremiab
Subacute autonomic neuropathy Hypophosphatemia
Paraneoplastic peripheral nerve vasculitis Hypouricemia
Lactic acidosis
Neuromuscular junction and muscle
Lambert-Eaton myasthenic syndromea,b cutaneous
Myasthenia gravis Acanthosis nigrans
Neuromyotonia Acquired hypertrichosus lanuginose
Dermatomyositisa Acquired ichthyosis
Acute necrotizing myopathy Acquired palmoplantar keratoderma
Cachectic myopathyb Acrokeratosis (Bazex’s syndrome)
Clubbingb
hematologic Dermatomyositis
Anemiab Erythema annulare centrifugum
Dysproteinemia (amyloidosis) Erythema gyratum repens
Eosinophilia Exfoliative dermatitis
Hypercoagulability Florid cutaneous papilllomatosis
Leukocytosis/leukoerythroblastic reaction Hypertrophic pulmonary osteoarthropathy
Polycythemia Pemphigus vulgaris
Thrombocytopenic purpura Pityriasis rotunda
Pruritus
renal Sign of Leser-Trélat
Glomerulopathies Superficial thromboflebitisb
Tubulointerstitial disorders Sweet’s syndrome
Tripe palms
Vasculitis
aClassical paraneoplastic neurological syndromes.
bMore common paraneoplastic syndromes.