Mastocytosis is a rare disease due to the abnormal accumulation of mast cells in various tissues. Its clinical presentation is heterogeneous depending on mast cell infiltration and mediators release. ...In some cases, it is associated with hematological malignancies. Prognosis varies from very good with a life expectancy similar to the general population in indolent forms of the disease to a survival time of just a few months in mast cell leukemia. Although in most cases a somatic
KIT D816V mutation is found in tumor mast cells, the physiopathology of the disease is not yet fully understood. Additional germline and somatic mutations may explain this heterogeneity. Treatments aim at blocking effect of mast cell mediators, reducing mast cell activation and tumor burden. New drugs mainly directed against the tyrosine kinase activity of KIT have dramatically changed the quality of life and prognosis of mast cell diseases. Present and future therapeutic strategies are discussed in this review.
Lupus panniculitis is a rare manifestation of cutaneous lupus erythematosus, which may lead to major aesthetic sequelae with a severe impact on patients’ quality of life. We report 2 cases supporting ...the short- and long-term efficacy and safety of lipofilling in the treatment of lupus panniculitis-induced atrophy. These observations pave the way for prospective, larger-scale studies in patients with scarring lupus panniculitis, provided that the autoimmune pathogenic process is in complete, stable remission.
Inherited desmosomal diseases are characterised by skin and/or cardiac features. Dermatological features might be a clue in the determination of the underlying life-threatening cardiac disease. This ...article aims to propose a dermatological algorithm for the diagnosis of desmosomal diseases after a systematic review of published articles. Palmoplantar keratoderma (PPK), hair shaft anomalies and skin fragility are the major features in the 458 patients analysed. Isolated PPK or isolated hair shaft anomalies are associated with a desmosomal disease limited to skin. The combination of PPK and hair shaft anomalies was recorded in 161 patients, and this association is at high risk of cardiac disease (129/161, 80.1%). Skin features had led to cardiac monitoring in only 2.3% of those patients. We delineated three major phenotypes: the PPK-hair shaft anomalies-non-fragile skin subtype (77%), always associated with cardiac involvement; the PPK-hair shaft anomalies-skin fragility-normal cardiac function subtype (19.9%), frequently associated with PKP1 mutations; the PPK-hair shaft anomalies-skin fragility-cardiac involvement subtype (3.1%), always due to DSP mutations. Three mutation hotspots in DSP and JUP account for 90.8% of the patients with cardiac involvement. The combination of PPK and hair shaft anomalies justifies long-term cardiac monitoring.
In COLXVII-junctional epidermolysis bullosa, mucosal involvement remains inconsistent and is limited to the oral cavity and the oesophagus. We documented the observation of a patient presenting with ...tracheal damage.
Autoimmune polyendocrine syndrome type-1 (APS-1) is caused by mono- or biallelic loss-of-function variants of the autoimmune regulator gene
AIRE
underlying early-onset multiorgan autoimmunity and the ...production of neutralizing autoantibodies against cytokines, accounting for mucosal candidiasis and viral diseases. Medical intervention is essential to prevent or attenuate autoimmune manifestations. Ruxolitinib is a JAK inhibitor approved for use in several autoimmune conditions. It is also used off-label to treat autoimmune manifestations of a growing range of inborn errors of immunity. We treated three APS-1 patients with ruxolitinib and followed them for at least 30 months. Tolerance was excellent, with no medical or biological adverse events. All three patients had remarkably positive responses to ruxolitinib for alopecia, nail dystrophy, keratitis, mucosal candidiasis, steroid-dependent autoimmune hepatitis, exocrine pancreatic insufficiency, renal potassium wasting, hypoparathyroidism, and diabetes insipidus. JAK inhibitors were therefore considered an effective treatment in three patients with APS-1. Our observations suggest that JAK/STAT pathways are involved in the pathogenesis of APS-1 autoimmune manifestations. They also suggest that JAK inhibitors should be tested in a broader range of APS-1 patients.
*° contributed equally to this work.
Introduction:
Systemic Mastocytosis (SM) is a heterogeneous disorder characterized by mast cells (MCs) accumulation in various tissues and associated with KIT ...mutations (KIT D816V) in more than 90% of the cases. It includes indolent (ISM) and advanced diseases (advSM), which are associated with additional molecular abnormalities. For advSM, recent clinical studies have shown that Midostaurin, a kinase inhibitor of WT and mutant KIT, induces high rate of responses associated with significant improvement of prognosis. However, complete responses are infrequent and relapses occur in a significant proportion of patients. Therefore, combination therapies are needed to increase overall response rate and prevent relapses. Venetoclax is a selective orally bioavailable BCL-2 inhibitor that induces cell death and is currently used for treatment of various lymphoid and myeloid malignancies. In an attempt to identify novel diagnostic and prognostic markers and potentially new therapeutic targets for mastocytosis, bone marrow sections of patients with different categories of mastocytosis were analyzed by IHC using anti-BCL-2 antibodies. BH-3 profiling was used to assess BH-3 proteins dependency, and sensitivity to Venetoclax alone or in combination of Midostaurin.
Methods:
Thirty-three adult patients were included in this preliminary study. According to the WHO classification, patients were classified as having ISM (n=10), Smoldering SM (SSM n=1), advSM (n=16, including SM-AHN (n=9), MC leukemia (MCL n=4), MC sarcoma (MCS n=2)). Most patients were KIT D816V (n=30; 90.9%); two MCL and one MCS exhibited extracellular and juxtamembrane mutations, respectively. Among these patients, 9 were treated with Midostaurin as first line therapy. Formalin fixed bone marrow sections were performed at diagnosis and during follow up. Mast cells were identified by Giemsa staining and as CD117 and tryptase positive cells. BCL-2 staining was performed by immunohistochemistry in formalin paraffin embedded fixed section. BCL-2 staining was considered as positive (>5%), heterogeneous (partial staining) or homogeneous (>80% positive cells), of high or low intensity (> or = or < to residual T cells). BH3 profiling was performed in ROSA KIT WT and ROSA KIT D816V using Cytochrome C upon exposure to distinct BH3 peptides/mimetics.
Results:
In ISM, BCL-2 staining was negative (n= 2/10) or when positive only in rare MCs (n=8/10), with low intensity. In contrast, all advSM cases were positive (16/16) with high (13/16), and homogeneous (6/16) staining. In MCL and MCS, BCL-2 staining was always positive with a homogeneous and high staining. In patients treated with Midostaurin, BCL-2 staining was performed before and three months after treatment initiation. Although MCs infiltration was reduced at least by 50% in all cases, number of BCL-2 positive cells and intensity of staining remain unchanged.
In vitro, flow cytometry analysis showed that both MCL-like cell lines (ROSA KIT WT and ROSA KIT D816V) expressed BCL-2, MCL-1 and BCL-XL proteins. When treated with Midostaurin (200nM) for 48 hours, expression of BCL-XL and MCL-1 significantly decreased in MC lines especially the one with KIT D816V mutation. Interestingly, BCL-2 expression remained unchanged upon Midostaurin treatment, which was consistent with in vivo observations. Dynamic profiling performed in ROSA cell lines revealed that priming by midostaurin dramatically enhanced apoptotic dependencies to BCL-2 and other BH-3 proteins (>20% of apoptosis), especially in ROSA KIT D816V (figure).
Conclusion:
High expression of BCL-2 is associated with advSM and may participate to the pathogenesis of the disease, to its resistance to conventional chemotherapies and to partial resistance to Midostaurin. Consistent with its effect in reducing MCL-1 and BCL-XL expression, Midostaurin restored apoptotic dependency to BCL2 in human MCL-like cells, thereby suggesting that midostaurin could sensitize mast cell tumor to venetoclax. Our results provide thus a rationale to use a combination of Midostaurin and Venetoclax to treat AdvSM patients.
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Dubreuil:AB Science: Employment, Membership on an entity's Board of Directors or advisory committees, Research Funding. Hermine:AB science: Consultancy, Equity Ownership, Honoraria, Research Funding; Celgene: Research Funding; Novartis: Research Funding.
Venetoclax preclinical studioes on mastocytosis
Aims
The diagnosis of mastocytosis in skin biopsies can be challenging ‐ particularly in cases with very few mast cells. More diagnostic criteria are needed.
Methods and results
We analyzed 103 skin ...biopsies from patients with mastocytosis and compared them with biopsies from inflammatory skin lesions and normal skin. Using CD117 immunostaining, we determined the mast cell distribution pattern, the percentage of mast cells in the inflammatory infiltrate, and the mast cell count per mm². We found that a sheet‐like or subepidermal distribution of mast cells was specific for mastocytosis. The most significant feature was the percentage of mast cells and not the mast cell count. We found that a mast cell percentage above 40% was fully specific in both adults and children but lacked sensitivity, especially in adults. In children, all cases with a percentage below 40% harbored a number of mast cells above 90 per mm², allowing a straightforward diagnosis. In adults, the diagnosis was more challenging and cases with less than 40% of mast cells could be diagnosed on account of a number of mast cells above 40 per mm², with 88.5% sensitivity and 95.2% specificity. Additional signs might be useful in difficult cases. However, CD25 immunostaining was not useful.
Conclusions
We confirmed that the criteria currently applied in the bone marrow were not appropriate for the skin. Accordingly, we developed an algorithm for the diagnosis of mastocytosis in skin biopsies with a high level of interrater reproducibility (mean kappa 0.8).
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