Th2 Cytokine Profile in Cutaneous T-Cell Lymphoma

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R a i v i e b C^ I lellweg R . Kreittzherg ( i : NCII r e r e p t o t - t n e d i a t e d tednetion in a x o n n l NCif uptake attd r e t t o g t a d e Irattspiirt lollowittg seiatic nerve injury aud dnritlg regeneratiotl. \ctttvtt 7:1.^1-16-1. 1991 r-anlini T. Johansson O : i:xptvssiotl of growlb-assoeiated proteitt -l.^ and nerve i^rowth Iaetor reeeptoi in luunan skin: a e o n i p a r a t i \ e intiiiuin>ltisUHheiiiical investigatioit. / hurst t)crttt,ttol 99:7.VI-.742. 1992 l ) i Mareo I!. Matltor M . Botidan/a S. Citlttli N . Marebisio Ft:. Caneeilda R . l ) e I.uea M: N e r v e g r o w t h faetor bitids to n o n n a l bttttiatt keiatinoeytes tlirougb high

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atld low ailinity r e i e p t o t s attd stintttlates their growllt by a ttovel attloerine loop. ; ;i/ii/ Chcttt 2()X:22S.lS-22S4(t. 199.5 12. I'earee Tf. Ihonipsott 111: Some ebaraeteristies of bisl.ttttitte seetvtii.tt ttotn tat peritotteal tnasi eells slitnnlated with t t e r \ e gtowtlt taelor. / l'lty.
Th2 Cytokine Profile in Cutaneous T-Cell Lymphoma T o tbe Editor: \X/e read witb great interest tbe article by Saed ct al entitled "Mycosis fnngoides exbibits a Till-type cell-mediated cytokine profile wliereas Sezary syndrome expre.sses a Tli2-type profile" in t h e Jnly 1994 issue of the Jonrnal of Investigative Dermatology fl |. U s i n g reverse-transcriptasc-polymerase cbain reaction (RT-PCR) amplification, the anthors demonstrated the presence of mRNA for I L - 2 and interferon-gamma (IFN-y) bnt no evidence of niRNA for interlenkin 4 (IL-4). IL-.S, or IL-KI in tbe epidermis of seven patients with plaqne-type mycosis fnngoides (MF). This was in contrast to the epidermis (n = 3) and tbe blood (n = 7) of Sezar\ syndrome (SS) patients that demonstrated message for IL-4, IL-5, a n d lL-10, btit no evidence of lL-2 or IFN-y. The fmdings in the M F skin is in keeping with a Thl cytokine pattern and the fmdings in the Sezary syndrome skin and blood are in keeping with a Th2 cytokine pattern. As the title of the article implies, the author's interpretation of these findings is that the malignant T cells of inyco.sis fungoides elaborate a different set of cytokines than those o f Sezary syndrome. Our gronp has recently pnblisbed data on similar studies in cutaneous lesions taken from dilterent stages ol cutaneous T-cell lympbonia (CTCL) | 2 | . Onr data is in partial agreement with Saed et al; however, because ot differences in otir findings in normal controls, onr interpretation and conchision is t h a t the malignant T cells in cutaneons T-cell lymphoma, botb in niycosis fungoides and Sezary syndrome, are of a Th2 subtype based o n tbe expression of tbe Th2 cytokines. It must be first pointed out that RT-PC"R amplification stndies such as these provide a window into the miciro-enviromiient of the skin but cannot determine tbe precise source of a partictilar amplification signal, as do in sittt Iiybridization studies. To draw an\conclusions concerning thee sotirce of ainplification signals from F C R experiments, normal controls are critical. We believe subtle differences in our teclinic]nes bave led to different resnlts in normal skin controls that have led to differences in interpretation of otir respective clata. Unlike Saed cf al, we fotind amplification signals for IL-2 and I F N - y in KlO'Xi ofthe 12 normal skin controls we analyzed. Saed ct al reports that they have detected IPN-y liiRNA in fonr of 1 1 normal skins, bnt no IL-2. We believe that our technique is more sensitive than that of Saed et al; this may be related to primer selection. In addition, we analyzed whole pniich biopsies and did n o t separate epidermis and dermis hy heating. Potentially, heating of the samples may have affected more labile transcripts. Becatise there are no endogenous skin cells that have been docnmented to secrete IL-2 or IFN-y, inclucHing Langerbans cells \?i\, we interpreted onr data to indicate that the sotnce oi the lL-2 and lFN-y amplification products were from normal lymphocytes that traffic throtigh the skin in an activated state | 4 | . Furthermore, we reasoned that our assay's detection threshold was sensitive enough to consistently detect these cells. If lL-2 and IFN-y, cytokines that cotinteract the expression and effects of Th2 cytokines, are present in detectable qnantities in normal skin, then they may have the potential to down regtilate lL-4 and lL-5 secretion from infiltrating Th2 cells. Fnrthermore,

Till cytokines inhibit Th2 c\tokine niRNA expression. The concept of immnnoregnlation ofthe malignant cells in earh' C I XT. fits the natnral histor\' and indolent nattire of the early stages of the disease. Stndies have shown IFN-y—secreting cytotoxic f cells to be present in tbe infiltrate of MF lesions |.S| and tbese ina\ iiiHtience tlle cytokine expression of malignant CD4 cells. It is noteworthy that our studies pro\ide clear evidence of Th2 c\ tokines in ctitaneous MF lesions, partictilarK' ttimor stage disease 111 which the disease is aggressne and potirl)' regulated. In si.\ of si.x biopies from ctitaneotis tnmors Iriini MF patients, we cietected Fh2 cytokine iiiRNA. Moreover, we also detectcil Th2 c\'tokiiie iiiRNA in three of six samples from patients \\iih early patch- or placiue-stage disease. 1 btis, we interpret Fhl signals in early MF lesions to be a result of either normal trafficking lymphocytes or a tumor-infiltrating host response with a predominance of Thl c\ tokines that ma}' supress cytokine gene transcription of MF tumor cc-lls. The most cohesive, biological!) relevant model to explain the Thl findings in early MF is that C I CL is a malignancy of a Th2 t ; n 4 T-cell that is down regtilated in early disease by Thl cells. This would explain why RT-PC^R demonstrates a Fhl profile in earl)' skin disease. This model excludes the tmproved spectilation that a htinian Thl cell is capable of differentiating into a Tli2 cell as suggested by Saed cr al. We believe that the findings ofthe Fhl profile in both papers are compatible with a Tli2 model of C" FCL and that the attempt to nse a dichotomons paradigm of cNtokine secretion of nncosis fnngoides and Sezary syndrome is misleading and inaccurate. //( .
RF^FERFNCES 1. .Saed C;. l i v e n s o n HI-. Naidn Y. Niekoloti' Bl: .Mycosis ttitigoides exbibils a l b 1-type eell-ttiediateil evtokitte protile whereas .Se/ary syttdt'otne expresses a I h 2-type profile. ; Itifc.it l'>intt,it,tl I t).5:29-.i,5. I <)9.( 2. Vowels B R . I.essiti S R . (:assitt M . j a w o r s k y t \ Benoit B. W o l t e j I . K o o k A l l : r b 2 eyiokiite expression itt skiti of entatieotis l-eell lyitiphotiia. / ttnr.tt licttiuitol Ill.5:(,(i9-()7.1. 199-1 .5. Matsni 1 1. t a t t / I'll. Hergstresser I'R. lakasbittia A: I angerhatts cells are the iiiaior source oC tiiRNA for II -I beta aud M I l ' - l alpba auioiig nttstitititlaled titoitse epidertnal cells. / Itn'cst Omihi/o; 99:5.57-.^-l 1. 1992 -I. Bos i n . /.otineveld 1. Das I'K. Kreig S R . vati der I oos CIM. Kapsetiberg M l : I be skill itiiuuitte sysletii (SIS): distribulioii atid itiitiuitloiibetiot) pe ot" lyittpboc\te intpnlations in tioruial bttittati skiti. / tttt'c^t /)crij/e\'te p b e n o t \ p e . / C.ut
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LliTIERS TO

I I IE JOURNAL OF 1NVL;S"I KiA 1 IVE 1)|;RMA1"C")LOGY

IE HDITCIR

REPLY "We do not believe there is a controversy regarding our publisbed conclusion (1| tliat the malignant V cells in cutaueotis T-cell lymphoma (CTCL) most closely resemble mnrine T-lielper type 2 cells. Our overall fmdings dealt with cytokine networks that were establisbed in patients witb diffi;rent clinical manifestations of CTCL. Many diverse cell types contribute to tbe establishment ot such networks including endogenotis cells of the skin as well as recrnited benign reactive T cells and malignant T cells. Despite widely divergent clinical presentations and tbe confederacy of cell types that can produce cytokines, it was clear that reprodncible patterns of cytokine networks were present in the epidermal and dermal compartments of CTCL patients. In our report we presented tbree possible explanations for tbe RT-PCR-based results in which skin biopsies of mycosis tungoides lesions were totmd to contahi cytokines closely resembling the mnrine T-belper type 1 response, whereas Sezary syndrome samples bad cytokines closely resembling the mnrine T helper type 2 response. Our first and favored conclusion of tbese results, as mentioned above | 1 | , was; "The tirst of tbese is that all malignant T cells in CTCL are of Th2 type. . . " We believe tbat tbis sentence, conveys tbe same message as the letter of Lessin ct nt. Indeed, we had previously observed in 1989 the inability of circulating Sezary cells to produce IFN-7 [2|, which supports our contention that tbe malignant tumor cells belong in the category of the T-belper type 2 cells. More recently, using immunostaining we localized an important Tb-2 type cytokine, 1L-1(), to tbe malignant T cells iti vivo and to a Sezary cell line

|9J. Tbus, it is possible that by acquiriug co-expression of both ligand and receptor (CD28 and B7-1) the malignant T-cell clone conld perpetuate itself in an APC-independent fashion and prodnce predominantly Th-2 type cytokines. A recent abstract |1()] demonstrates that ctiUiired Sezary cells utilize CD28 mediated co-stiinulatiou for tbeir proliferation, although no itt vitto cytokiue prodtiction profiles were indicated. Many new aud exciting revelations regarding the immunology and pathopby.siology of CTCL are emerging. Microenvironmental factors may be important in CTCL, and tbe Th-2 type nature ot malignant T-cell clones may well represent the collective intltience of neighbboring professional and non-protessional APCs (keratinocytes and dendritic cells), via tbeir expression of relevant costimulatory signals (mediated via CD28) and production of cytokines (IL-10 and IL-1 2), Sucb new insigbts may lead to a better tinderstandiug of the factors that are important in tbe emergence of such malignant T cell clones iti t'ivo and to better success in propagating tbese Tb-2 type cells itt vitto. Ghassan M. Saed David P. Fivenson Henry Ford Hospital Detroit Brian J. Nickoloff University of Michigan Anil Arbor, Micbigan

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"We believe that the cytokine production profile of an individual T cell could be iiiHuenced by local microenviromnental factors. "We have demonstrated that local factors such as the natnre of tbe antigen-presenting cell (APC) can significantly determine wbetber a T-cell—proliferative response is accompanied by a Th-1 type versus Tb-2 type cytokiue production profile |.S|. Using resting peripheral blood-derived T cells and an identical autigenic stimulus (bacterial-derived superautigen-relevant to CTCL |6|), a Tb-2 type cytokine profile results if keratinocytes were used as the "uonprofessional" type of APC, whereas a Th-1 type cytokine response was produced using dermal dendritic cells as tl-.e "professional" type of APC |7|. Becatise tbe Tb-2 response cotild be converted to a Tb-1 type response by adding lL-12, we e.xplored the possible involvement of IL-1 2 in CTCL. In a study tbat is currently subitted for publication, we bave observed tbat treatment regimens used tor CTCL sucb as pbotopberesis and psoralen plus ultraviolet A greatly increased IL-1 2 levels, which cotild retard the proliferation of the malignant Th-2 type cells. Another intriguing observation relevant to the characterization of tbe malignant T cells iu CTCL |8] bad been tbe recognition tbat tbese cells co-express CI)28 and the co-stiniulatory molecule 137-1 (CD8()). Such dual expression could facilitate atitostitntilatiou between malignant T cells and lead to their proliferation becoming independent of tbe necessity for interaction witb APC's to provide co-stimulation. At least one report bas demonstrated wben I cells interact with APCs in a Cl)28;B7-dependeiit fashion that a Tli-1 type response ensued, whereas, if this pathway is blocked, a Tb-2 type response occurs

REFERENCES 1. Sacd (I, I'ivetisott DP, Naidtt Y. NickolollHJ: Mycosis fttngnides exhibits a Tlt-1 type cell-tiK'diateil cjtokitic profile wheteas Sezaty syiidrottic expresses a TH-2 type prol"tle. / /ncc.sl f>crm,ttol \[>?,:29-.Vi, 1994 2. Nickololilij! Griliiths CE.M, liaailsgaard O. Viiorhees ||. Cooper KD: Matkedly diittitlished epidettttal ketalitiocyte expression of"itltercellttlaf aditesiott ntolectile-1 itt .Sezaty syndrotiie. J .-liM \tcil Assoc 2(i 1:2217-222 I. I')K') i. Nickololt" IS|. l-iveiisoii DP. Ktitikel SL. .Strieler RM. Itrtka LA: Keratittocyte II.-IO expressioti is upregulated in tape-strippeil skin, poison ivy derittatitis. and .Sc/ary syndfotne. hnt tiot in psotiatic plaques. Clin immimol linmttiiopatli 7.1:6.i-(iS. 1994 4. Livensoii DP. NickoloH" BJ. .Saed GM: Quantitative I'CK attalysis ol" cylokittes iti HUT 7K cells after PUVA exposure (abstr). / Invest Uettniitol U12:.i«.'i, 1994 5. Nickololf HJ. Ittrka LA: linuiutiolopc function of uon-professiotial atitipeii ]iresetiting cells. Insights frotii keratitiocyte: T cell interactiotis. Innnimol 'Itnhiy 15:464-49(1, 1994 fl. I'okttra Y. Iieald PW. Yati SL. Edelson RL: Stinittlation of cutatieous T-cell lyniphoina cells with siiperatitigenic stapltylocoecal ti>xitis. / ini'e.
7. Goodtiian R. Naidu Y. Nestle P O . G i e e t t J . Nickololf BJ. "Fuika LA: Ketatitiolyte-derived L cell et)-sliinulatioii indttces preferential prodttttioti of IL-2 and 11,-4. bttt not I P N - 7 . / Imtitimol 1 .S2:51 K9-51 9K. 1994 H. Ni(ki)loff 1!J. Nestle P O , Z h e n g XC;. I utka LA: f Lymphocytes in skin lesiotts of psoriasis atid niyiosis t"titii;oides express 117: a ligand for ( : i ) 2 S . Hlood 8.1:2.i8(l2X6. 1994 9. Tatl P. Atiasetti C, ManseitJA, M e l r o s e J . Biunvand M . HtadshavvJ, LedbetterJA. Litisley PS: Itiduttiiin ot" alloantigen-speciftc hy|iorespotisiveness itt litttiiatt I lytupbocytes by blockittg ititeraction of C:i)2K witb its tiatutal ligand l i 7 / l i B l . ; ;:".v/i Med l77:16S-16."i 199.1 I(). McCttsker M . Garifallow M . Hogen SA: I he S e / a i y cell in I'ityo proliferatiott defect is explained by dependenee on C D 2 8 mediated co-stitnulatiotl (abstr). t'liotoiiicti l'lunobiol

(in i>tcss)

Mutations in the Laniinin 5 LAMB3 Gene in Generalized Atrophic Benign Epidermolysis Bullosa To tbe Editor; I bave read witb interest tbe paper of McGrath ct ni 111 in tbe April 199.S issue and congratulate the authors, especially Drs. Cluistiano aud Uitto, for successfully identitying tbe mutations in domain VI of tbe lauiiniii S fii cbain short arm as tmderlying molecular detects in tbeir family with the non-lethal mitis type of jtmctional EB.

Nevertheless, I would like to comment on tbe authors' citation mode stating that this type of junctional EB had been described tor the first time by Hintuer and "WoltFin 1982 |2|. Tbis is not correct. In fact, tbe first case of tbis benign, non-lethal junctional EB type in the world literature had been reported by Hashimoto ct nl in 1976 |3], cielineating tbis form as a distinct variant of EB and describing