Graft-versus-host disease (GVHD) is a principal cause of morbidity following allogeneic hematopoietic cell transplantation (HCT). Standard therapy for GVHD, high-dose steroids, results in complete responses (CRs) in 35% of patients. Because tumor necrosis factor-␣ (TNF␣) is an important effector of experimental GVHD, we treated patients with newonset GVHD with steroids plus the TNF␣ inhibitor etanercept on a previously reported pilot trial (n ؍ 20) and a phase 2 trial (n ؍ 41). We compared their outcomes with those of contemporaneous patients with GVHD (n ؍ 99) whose initial therapy was steroids alone. Groups were similar with respect to age, conditioning, donor, degree of HLA match, and severity of GVHD at onset. Patients treated with etanercept were more likely to achieve CR than were patients treated with steroids alone (69% vs 33%; P < .001). This difference was observed in HCT recipients of both related donors (79% vs 39%; P ؍ .001) and unrelated donors (53% vs 26%; P < .001). Plasma TNFR1 levels, a biomarker for GVHD activity, were elevated at GVHD onset and decreased significantly only in patients with CR. We conclude that etanercept plus steroids as initial therapy for acute GVHD results in a substantial majority of CRs. This trial was referenced at www.clinicaltrials.gov as NCT00141713.(Blood.
Lichen planus (LP) is a chronic debilitating inflammatory disease of unknown etiology affecting the skin, nails, and mucosa with no current FDA-approved treatments. It is histologically characterized by dense infiltration of T cells and epidermal keratinocyte apoptosis. Using global transcriptomic profiling of patient skin samples, we demonstrate that LP is characterized by a type II interferon (IFN) inflammatory response. The type II IFN, IFN-γ, is demonstrated to prime keratinocytes and increase their susceptibility to CD8+ T cell–mediated cytotoxic responses through MHC class I induction in a coculture model. We show that this process is dependent on Janus kinase 2 (JAK2) and signal transducer and activator of transcription 1 (STAT1), but not JAK1 or STAT2 signaling. Last, using drug prediction algorithms, we identify JAK inhibitors as promising therapeutic agents in LP and demonstrate that the JAK1/2 inhibitor baricitinib fully protects keratinocytes against cell-mediated cytotoxic responses in vitro. In summary, this work elucidates the role and mechanisms of IFN-γ in LP pathogenesis and provides evidence for the therapeutic use of JAK inhibitors to limit cell-mediated cytotoxicity in patients with LP.
IntroductionAllogeneic stem cell transplantation (allo-SCT) is an important therapy for a number of malignant and nonmalignant diseases. The broader application of allo-SCT is limited by several complications, including the development of graft-versus-host disease (GVHD) and pulmonary toxicity. Diffuse lung injury can occur in 25% to 55% of allo-SCT recipients. [1][2][3][4][5][6] In approximately 50% of patients, infectious organisms are not identified, and these cases have been defined as idiopathic pneumonia syndrome (IPS). IPS is associated with mortality rates of more than 70% despite the use of high-dose steroids, broad-spectrum antimicrobial agents, and aggressive supportive measures. 1,4 This form of lung injury is characterized by complex pathophysiology involving cytotoxicity from irradiation and chemotherapy, 7,8 the production of inflammatory cytokines, 9-14 and the recruitment of both donor T cells and accessory cells. 12,[15][16][17] The expression of several chemokines is also increased in the lung after allogeneic SCT, [18][19][20][21] and recent data from our group have shown mechanistic links between specific chemokine receptor-toligand interactions and the recruitment of donor T cells, monocytes, and macrophages to the lung during IPS. 19,21 Regulated on activation, normal T-cell-expressed and secreted (RANTES/ CCL5) is a member of the CC chemokine family of proteins that is strongly chemoattractant for activated T cells, monocytes, eosinophils, and basophils. 22,23 Increased RANTES expression has been shown in a number of experimental systems, including those modeling transplantation rejection, 24 sclerodermatous GVHD, 25 and acute lung injury after allo-SCT. [18][19][20] RANTES can be produced by several cell types including fibroblasts, 26 epithelial [27][28][29] and endothelial cells, 30,31 activated T cells, 32 and macrophages, 33 and its expression can be induced by proinflammatory cytokines including tumor necrosis factor ␣ (TNF␣), interleukin-1  (IL-1), and interferon ␥ (IFN␥). 20,[26][27][28][29]31 CCR1 and CCR5 are the primary receptors for RANTES. These receptors are expressed on a variety of cells including activated Th1/Tc1 lymphocytes, macrophages, and immature dendritic cells, but neither receptor binds exclusively to RANTES. 34 We used a well-established murine SCT model, wherein IPS develops following myeloablative conditioning and in the context of major and minor histocompatibility differences between donor and recipient, to study the role of RANTES of leukocyte infiltration into the lung. IPS in this system is dependent upon the infusion of allogeneic T cells, along with the pretransplant radiation dose, 35 and involves the recruitment of alloreactive CD4 ϩ and CD8 ϩ T cells to the lung. 19,20,35 Although the severity of IPS is exacerbated by the addition of cytoxan to total body irradiation (TBI) in a related SCT model, 16 the effects of "chemotherapy only" conditioning regimens on For personal use only. on June 19, 2019. by guest www.bloodjournal.org From the develop...
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