SlideShare a Scribd company logo
1 of 67
1
Leukocyte Trafficking in Health and Diseases
(細胞接着・遊⾛の⽣理的意義と疾患との関連)
• Cell adhesion molecules
(細胞接着分子とは、ケモカインとは)
• Genetic defects
(細胞接着分子の遺伝的欠損症とは)
• Therapeutic inhibition
(細胞接着分子を治療標的にする)
Motomu Shimaoka, M.D., Ph.D.
Mie University Medical School
Quiz-1	
Bacterial infections usually begin(細菌感染症は血管の
内側で始まるでしょうか、それとも血管の外側で始まる
でしょうか:
A)  inside of the vasculatures(内側)
B)  outside of the vasculature(外側)
Quiz-2	
Leukocytes usually circulate(白血球は血管の内側と
外側のどちらを循環しているでしょうか):
A)  inside of the vasculatures
B)  outside of the vasculature
Leukocyte Extravasation
白血球の血管外遊走
http://www.chronicprostatitis.com/	
ICAM-1	
Leukocyte Extravasation
血管外の感染巣へと遊走する白血球
Assignment: 2 Questions to Answer in English
(以下の問いをノートに写しなさい。授業中に英語で解答しなさい。ヒントは
授業中に言います)
1.  Explain the molecular mechanisms by which leukocyte
extravasation is regulated.(白血球の血管外遊走の
分子メカニズムを英語で説明せよ)
2.  Explain the genetic defect(s) causing leukocyte adhesion
deficiency (LAD)-I, II, and III.(LAD-I, II, IIIを起こす
遺伝子欠損について英語で説明せよ)
Leukocyte Adhesion Deficiency (LAD)
白血球接着不全症
Leukocyte Adhesion Deficiency (LAD)
白血球接着不全症
	Case(症例):15-year-old patient JT, who first presented as an infant
with severe and recurrent skin infections requiring prolonged
treatment with intra-venous antibiotics and surgery to remove necrotic
tissue. In spite of attentive oral hygiene, the patient suffered from
severe periodontitis and gingivitis. Otitis media and chest infections
had also been consistent features of this patient‘s condition.
Organisms isolated from infected sites included Staphylococcus
aureus, Pseudomonas, and Streptococcus species…….(Hogg M. JCI
1999)
	
•  Recurrent and often fatal bacterial infections	
•  Defects in leukocyte adhesion and phagocytosis
(modified from von Andrian, NEJM, 2000)
3-Steps in the leukocyte-endothelial interactions
Selectins
セレクチン
Selectins	
• P-selectin (Platelets, Endothelial cells)
• E-selectin (Endothelial cells)
• L-selectin (Leukocytes)
Selectins	
Bind to carbohydrate ligands (Sialyl LewisX: s-Lex)
特殊な糖鎖シアリルルイスXに結合する
Selectins(セレクチン)	
Tethering and Rolling
テザリングとローリング
Selectins	
Rolling is for what?
(ローリングは何の役に立つの?)
Rolling enables leukocytes(ローリングの役割は):
•  Slow down (減速)
•  Travel along the endothelial surface(血管内皮表面を走行)	
Probe for chemokines that are displayed on the endothelial surfaces
(血管内皮表面を探索することを助ける)
Chemokines
(ケモカイン)
Chemokines	
• Chemotactic cytokines (走化性制御、つまり細胞を引
きつけること、に特化したサイトカイン)
• Induce directed chemotaxis in nearby responsive cells(
細胞運動の方向性を決める)
Chemokines
ケモカインの濃度勾配に沿って細胞は惹(引)きつけられる
Chemokines
ケモカインの濃度勾配は空間的に広がる
Diffused to and transported through endothelial cells
ケモカインは血管内皮細胞の基底側から管腔側へと輸送される 	
Chemokines
Chemokines
ケモカインの細胞接着に対する活性	
• Activate integrins(インテグリンの活性化)
• Support firm adhesion to endothelial cells
(ローリングする白血球を血管内皮上に静止させる)
Integrins
(インテグリン)
Integrins	
• Firm adhesion(血流のずり応力に負けない強い細胞接着)
• Transendothelial migration (Diapedesis)(血管外への遊
走に必要な強弱がダイナミックに変化可能な細胞接着)
Integrins	
• Firm adhesion
• Transendothelial migration (Diapedesis)
Integrins
インテグリンの細胞接着性はダイナミックに制御されている	
• Activated by chemokine signaling
(ケモカイン刺激により活性化される)
• Conformational changes
(コンフォメーション変化、構造変化により制御)
• Affinity upregulation
(親和性の制御)
Integrins	
• Activated by chemokine signaling
• Conformational changes
• Affinity upregulation
α β
Integrin binding
factor
Integrin
binding
factor
2. Binding of factors
to integrin
cytoplasmic domains
1. Cellular
activation
LFA-1のグローバルな�
コンフォメーション変化�
β
Integrin
binding
factor
α
Integrin binding
factor
ICAM-1
7. Ligand binding
	
3. Separation
of α and β
tailpieces
2. Binding of factors
to integrin
cytoplasmic domains
1. Cellular
activation
5. Swing-out of hybrid
domain and activation of
I-like domain
4. Switchblade-like upward
movement of headpiece
6. Activation of I domain
by downward movement of
its C-terminal ”pull spring"
LFA-1のグローバルな�
コンフォメーション変化�
188
an interaction with the NHL-domain protein Wech (Löer et al., adhesions they lose ICAP1α (Fournier et al., 2002) and the actin-
Journal of Cell Science 122 (2)
Table 1. Adaptor proteins that bind to β-integrin cytoplasmic tails
Adaptor protein Integrin to which adaptor binds Reference
Structural adaptors
α-actinin β1, β2, β3 (Otey et al., 1993; Pavalko and LaRoche, 1993)
BP180 β4 (Koster et al., 2003; Schaapveld et al., 1998)
Filamin β1, β2, β3, β7 (Calderwood et al., 2001; Kiema et al., 2006; Loo et al., 1998; Pfaff et al., 1998;
Sharma et al., 1995; Travis et al., 2004; Zent et al., 2000)
Myosin β1, β3, β5 (Jenkins et al., 1998; Sajid et al., 2000; Zhang et al., 2004)
Plectin β4 (Geerts et al., 1999)
Skelemin β1, β3 (Reddy et al., 1998)
Talin β1, β2, β3, β5, β7 (Calderwood et al., 2003; Calderwood et al., 1999; Patil et al., 1999; Pfaff et al., 1998;
Sampath et al., 1998)
Tensin β1, β3, β5, β7 (Calderwood et al., 2003; McCleverty et al., 2007)
Scaffolding adaptors
14-3-3 β1, β2, β3 (Fagerholm et al., 2005; Han et al., 2001)
β3 endonexin β3 (Eigenthaler et al., 1997; Shattil et al., 1995)
CD98 β1, β3 (Zent et al., 2000)
Dab1 β1, β2, β3, β5, β7 (Calderwood et al., 2003)
Dab2 β3, β5 (Calderwood et al., 2003)
Dok1 β2, β3, β5, β7 (Calderwood et al., 2003)
Fhl2 β1, β2, β3, β6 (Wixler et al., 2000)
Fhl3 β1 (Samson et al., 2004)
Grb2 β3 (Blystone et al., 1996; Law et al., 1996)
IAP β3 (Brown et al., 1990)
JAB1 β2 (Bianchi et al., 2000)
Kindlin 2 β1, β3 (Ma et al., 2008; Montanez et al., 2008)
Kindlin 3 β1, β3 (Moser et al., 2008)
Melusin β1 (Brancaccio et al., 1999)
Numb β3, β5 (Calderwood et al., 2003)
Paxillin β1, β3 (Chen et al., 2000; Schaller et al., 1995)
Rack1 β1, β2, β5 (Liliental and Chang, 1998)
Shc β3, β4 (Dans et al., 2001; Law et al., 1996)
TAP20 β5 (Tang et al., 1999)
WAIT1 β7 (Rietzler et al., 1998)
Catalytic adaptors
Src β3 (Arias-Salgado et al., 2003; Arias-Salgado et al., 2005)
Yes β1, β2, β3 (Arias-Salgado et al., 2005)
Cytohesin 1 β2 (Kolanus et al., 1996)
Eps8 β1, β3, β5 (Calderwood et al., 2003)
ERK2 β6 (Ahmed et al., 2002)
FAK β1, β2, β3, β5 (Chen et al., 2000; Eliceiri et al., 2002; Schaller et al., 1995)
Fyn β3 (Arias-Salgado et al., 2005)
ILK β1, β3 (Hannigan et al., 1996; Pasquet et al., 2002)
Lyn β1, β2, β3 (Arias-Salgado et al., 2005)
PKD1 β1, β3 (Medeiros et al., 2005; Woods et al., 2004)
PP2A β1 (Kim et al., 2004)
Shp2 β4 (Bertotti et al., 2006)
Other adaptors
ICAP1α β1 (Chang et al., 1997; Zhang and Hemler, 1999)
MIBP β1 (Li et al., 1999)
JournalofCellScience
Cytoplasmic proteins interacting with β integrin tails	
Legate KR, J Cell Sci 2009
signaling). Integrins
low-affinity confor-
“inside-out” signal-
ins is regulated by
uced intracellularly
rect binding of reg-
ytoplasmic domains
w- to a high-affinity
vation” (1, 2).
with which integrins
for various cellular
uring development
vated integrins at
h newly protruded
face on which they
egrins at their rear.
brinogen receptors
are swiftly activated
and aggregation in
ause aIIbb3 integ-
to fibrinogen, it is
so as to prevent
tion and thrombus
nflammation leuko-
ion in order to ad-
he endothelium on
Abnormal function
ins or mutations in
quired for integrin
ant development or
sorders, leukocyte-
n blistering. In this
structural and bio-
om genetic manip-
new light on how
and b subunits. In mammals, 18 a and 8 b sub-
units combine in a restricted manner to form 24
specific dimers, which exhibit different ligand-
binding properties. Integrin subunits have large
dependent adhesion site (MIDAS), which binds
divalent cations required for ligand binding by
integrins. The b subunit is composed of a hybrid
domain that connects to the bI domain, which is
A Inactive
low affinity integrin
Active
high affinity integrin
B C D
βA
βα
βTD
β propeller
Hybrid
Thigh
Genu
Calf 1
MD NxxY
MP NPxY
Calf 2
PSI
Transmembrane
Cytoplasmic
Head
EGF
Rod
F1
F1
F2
F2F3
F3
F0
PH
N-term
Kindlin
Talin
Fig. 1. (A) Integrin architecture and schematic representation of integrin activation. Specific contacts
between the ectodomains, the TM, and cytoplasmic domains keep the integrin in its bent conformation.
onJwww.sciencemag.orgDownloadedfrom
タリンとキンドリンがインテグリンを活性化する
Talin and Kindlin activate integrin	
Moser M, Science 2009
egrins without an I domain, ligands bind to
crevice between the ab subunit interface,
here they interact with a metal ion–occupied
IDAS within the b subunit and the propeller
main of the a subunit.
The structure of the short TM domains is
orly defined because of the lack of high-
olution structures of heterodimeric TM do-
ains in their proper context, and only the
uctures of the b3 and the aIIb subunits are
lved in their entirety (3–5). The b3 TM do-
ain is a 30-residue linear a helix that is longer
an the width of a typical lipid bilayer, which
plies a pronounced helix tilt within the plas-
a membrane (5). The aIIb TM domain is a 24-
idue a helix followed by a backbone reversal
d does not exhibit a helix tilt (4). This unusual
otif is highly conserved in the 18 human
egrin a subunits and probably has an impor-
nt role in the transition from low- to high-
inity states.
A high degree of similarity is found in the
ort a and b cytoplasmic tails, especially in the
embrane proximal region where the GFFKR
d HDR(R/K)E sequences are conserved in
e a and b subunits, respectively (6). Nuclear
agnetic resonance (NMR) studies that used
egrin-derived aIIb3 polypeptides proposed
at integrins interact with each other through
drophobic and electrostatic interactions and a
t bridge between the R residue within the
FKKR motif and the D residue within the
DRRE motif (7, 8). However, these interactions
ere not seen by others, suggesting that tail
eractions are very weak at best (9). Almost
b tails have two well-defined motifs that are
rt of a canonical recognition sequence for
osphotyrosine-binding (PTB) domains (10),
nsisting of a membrane proximal NPxY (where
mains that regulates integrin subunit packing
(14). Separation of integrin TM domains has
been suggested to be a requirement for integrins
to adopt the high-affinity state. There are two
possible ways by which TM domain interactions
has been extensively examined in the rapidly
activated b2 and b3 integrins. Although muta-
tional analysis suggests that the salt bridge is
important for maintaining these integrins in a
low-affinity state (15), this might not be the case
for all integrins, especially the
b1 integrins (16). Despite the con-
troversial role of the salt bridge in
maintaining integrins in a low-
affinity state, high integrin affinity
is thought to be associated with
separation of the a and b cyto-
plasmic tails. Many proteins bind
directly to integrin tails, yet only
talin and kindlins can regulate
integrin affinity. The role of these
NxxY motifs–binding proteins in
integrin activation and function will
now be discussed in detail.
Talin Is an Essential Mediator
of Integrin Activation
Talin is a component of adhesion
plaques and interacts with integrin
cytoplasmic tails (17). Its role in
altering integrin function was orig-
inally demonstrated by its ability to
induce a shift in the affinity of a
normally inactive integrin expressed
in chinese hamster ovary (CHO)
cells (18, 19). Knockout and knock-
down experiments subsequently re-
inforced the notion that talin is a
key regulator of integrin affinity for
ligand, and many mutational and
structural studies have described
the mechanism by which it accom-
plishes this task. Talin orthologs
have been identified in all multi-
A
B
C
Autoinhibition
Binding
to the
MP NPxY
Binding
to the
MP helical
region
Integrin
PIP2 Calpain cleavage
Phosphorylation?
Talin
Activation
タリンのインテグリン細胞内ドメインへの結合が活性化をトリガーする
Talin activates integrin	
Moser M, Science 2009
mon binding motif for PTB domain–
roteins (18, 19, 29). Mutations with-
motif of both b1 (30) and b3 (31)
well as mutations in the talin PTB
abolish talin binding and
egrin affinity. Insights
n increases integrin af-
rom NMR experiments
t the talin head effec-
mpetes the aIIb tail for
he b3 tail (7). Fluores-
y transfer (FRET) ex-
n cells confirmed that
d induces separation of
ails (in this case aLb2),
comitant with increased
n ligand binding (33).
d of talin1 by small in-
A (siRNA) cannot re-
mmon activation stimuli
rmore, genetic experi-
norhabditis elegans (34),
35), and mice (36–38)
that talin1 ablation uni-
s to integrin-adhesion
se experiments led to
at talin was both nec-
sufficient to activate
owever, the claims of
were later shown to be
ification.
question is why talin
defect (42). Expressing the talin1 head in these
cells partially restored the spreading defect, but
FAs were still absent, demonstrating that the
clustering of integrins into larger adhesion struc-
elicits a conformational change that di
autoinhibitory interaction and enhances
talin binding (45, 46). Although phosph
binding can enhance the affinity of m
domains for their substrates
does not hold true for the iso
head (46). Talin binds to PI
directs it to focal adhesions
thus, a feed-forward loop m
enhance talin recruitment
adhesion formation.
In hematopoetic cells, t
sine triphosphatase (GTPa
has been implicated in tal
ment to integrin tails. Exp
constitutively active Rap1A
increases integrin activation
the deletion of Rap1B in
decreases aIIbb3 activation
sociation of the Rap1 effec
GTP–interacting adaptor
(RIAM) resulting in a Rap
talin ternarycomplex atthein
has been shown to be requir
interaction (49, 50). A simila
mediated activation mechan
also occur in nonhematopo
because a direct interaction
talin and lamellipodin, a mem
MRL (Mig-10/RIAM/Lam
family of adaptor proteins, a
in integrin activation (51).
Integrin
PIP binding?
Phosphorylation?
Fig. 3. Hypothetical model of kindlin recruitment and binding to the b
タリンの作用機序の詳細:Talin activates integrin at the
membrane-cytoplasmic interface	
Moser M, Science 2009
Activation
ionarily con-
oteins named
drome, a rare
hree kindlin
n-1 [Unc-112
(Mig2), and
which is pre-
s, is found in
ey; kindlin-2
st amounts in
nd kindlin-3
ematopoietic
localize to
dlin-1 and -2
3 localizes to
ent adhesion
of the integrin
ortholog of
rins in dense
ession results
t is similar to
s (66). Two
ne mutations
tive integrin
caused by the
matosis char-
esion defect
eous atrophy
mplicated in a
AD) type III
Kindlin-mediated integrin activation requires a
direct interaction between kindlin and b integrin
tails. The kindlin and talin FERM domains show
high levels of sequence similarity (73); however,
suggests that a lack of kindlin-3 binding might be
responsible for the bleeding phenotype (61).
Because kindlins and talin bind distinct re-
gions of the b integrin tail, they may cooperate to
Sequential binding
A B C
Cis co-operation Trans co-operation
Fig. 4. Putative crosstalk mechanisms between talin and kindlin during integrin activation. (A)
onJune7,2012www.sciencemag.orgdedfrom
タリンとキンドリンの協調作用
How do Talin and Kindlin act together on integrin?	
Moser M, Science 2009
Interim summary(中間まとめ):
Cell Adhesion Cascade(細胞接着のカスケード)
Multiple Steps Happen in Sequence Leading to Extravasation
複数のステップが連続して起こる。前のステップは次のステップに必須
What would happen to leukocytes,
if integrins were absent?
インテグリンが欠損すると白血球に
どんな問題がおこるか?	
X
Leukocyte Adhesion Deficiency Type-I
LAD-I
白血球接着不全症(1型)
Leukocyte Adhesion Deficiency Type-I
LAD-I
白血球接着不全症(1型)	
	
-Primary immundeficiency(原発性免疫不全のひとつ)
-Recurrent and often fatal bacterial infection
(繰り返し、しばしば致死的な細菌感染症)
-No pus formation(膿がない)
-Leukocytosis (30,000~100,000 / µl)(血中白血球数増加)
Case: 3-year-old female presented to her dentist
“Gums are red, painful, and bleeding for 3 months”
	
Genetic defect of β2 integrins (CD18)
(β2インテグリンの遺伝的欠損)
What would happen to leukocytes,
if Sialyl LewisX (s-Lex) was absent?
糖鎖シアリルルイスXが欠損すると
白血球にどのような問題がおこるか?
	
X
-Functional defects in selectin ligand(セレクチン・リガンドの機能不全)
-Rolling interactions perturbed(ローリングが阻害される)
-Recurrent and often fatal bacterial infection
-No pus formation
-Leukocytosis
Genetic defect of the enzyme to attach sialyl lewisx (s-Lex)
糖鎖シアリルルイスXをタンパクに付加する酵素の遺伝的欠損	
Leukocyte Adhesion Deficiency Type-II
LAD-II
白血球接着不全症(2型)
What would happen to leukocytes,
if kindlin-3 (an integrin-activating
signal) was absent?
キンドリンが欠損すると白血球にど
んな問題が起こるか?	
X
-Functional defects in integrin activation(インテグリン活性化不全)
-Integrins are present but unresponsive to chemokines
(インテグリン発現はあるが、ケモカイン刺激に反応しない)
-Recurrent and often fatal bacterial infection
-Platelet dysfunction(白血球だけでなく、血小板凝集不全も)
-No pus formation
-Leukocytosis
Genetic defect of kindlin-3	
Leukocyte Adhesion Deficiency Type-III
LAD-III
白血球接着不全症(3型)
Activation
ionarily con-
oteins named
drome, a rare
hree kindlin
n-1 [Unc-112
(Mig2), and
which is pre-
s, is found in
ey; kindlin-2
st amounts in
nd kindlin-3
ematopoietic
localize to
dlin-1 and -2
3 localizes to
ent adhesion
of the integrin
ortholog of
rins in dense
ession results
t is similar to
s (66). Two
ne mutations
tive integrin
caused by the
matosis char-
esion defect
eous atrophy
mplicated in a
AD) type III
Kindlin-mediated integrin activation requires a
direct interaction between kindlin and b integrin
tails. The kindlin and talin FERM domains show
high levels of sequence similarity (73); however,
suggests that a lack of kindlin-3 binding might be
responsible for the bleeding phenotype (61).
Because kindlins and talin bind distinct re-
gions of the b integrin tail, they may cooperate to
Sequential binding
A B C
Cis co-operation Trans co-operation
Fig. 4. Putative crosstalk mechanisms between talin and kindlin during integrin activation. (A)
onJune7,2012www.sciencemag.orgdedfrom
思い出そう:
How do Talin and Kindlin act together on integrin?	
Moser M, Science 2009
ZIP code theory
Different integrins determine “lymphocyte homing”
to specific organs	
Brain	 Gut	Organ
(destination)
Integrin α4β1
+
VCAM-1	
	
Integrin α4β7
+
MAdCAM-1	
	
Leukocyte
+
Endothelium
Integrins support immune cell
patrolling of specific organs	
Von Andrian UH, N Engl J Med 2000
Integrins support immune cell
accumulation to inflamed organs	
Von Andrian UH, N Engl J Med 2000
• Chronic, often disabling disease that attacks the central nervous system
• Immune system attack against the central nervous system
• Autoimmunity to myelin. 	
Multiple Sclerosis(MS, 多発性硬化症)	
< Pathogenesis >
• Paralysis or loss of vision
• Relapses leading to irreversible disability
	
Multiple Sclerosis
< Clinical symptoms >
• Integrin α4β1-VCAM-1 interaction supports immune cell trafficking
to the inflamed brain.
	
Multiple Sclerosis
< Molecular mechanism>
• Integrin α4β1-VCAM-1 interaction supports immune cell
trafficking to the inflamed brain.
	 evaluate potential new therapies in proof-of-concept
trials.30
The effect of new gadolinium-enhancing lesions
was recognized as an appropriate outcome measure for
testing natalizumab’s efficacy, given its known mecha-
nism of action; it was investigated in a small, parallel-
group, placebo-controlled trial in which subjects re-
ceived 2 doses of placebo or natalizumab 1 month apart
and were followed up with regular MRI scans for 6
months. The trial was smaller than desirable for phase 2
evaluation of efficacy by MRI, necessitated in part by a
limited supply of drug. However, the study reached its
primary end point: the adjusted mean cumulative num-
ber of new active lesions was lower in the natalizumab-
treated group than in the placebo group (1.8 vs 3.6; P=.04,
analysis of covariance).25
Most of the new active lesions
were areas of new enhancement. In an accompanying edi-
torial,31
the trial finding was described as a “near hit.”
Had the study not reached its primary end point, one could
speculate that it would have been a near miss and that
the drug would not have been investigated further. Also,
a possible increase in relapse rate following withdrawal
of natalizumab therapy was noted in this trial; as in the
second study half, there were significantly more acute
clinical exacerbations in the natalizumab group.25
An-
other study failed to show more rapid or complete re-
lapse recovery with natalizumab treatment, although a
significant decrease in gadolinium-enhancing lesion vol-
ume was noted for both active treatment groups early in
the study. There was no evidence of increased relapses
following natalizumab withdrawal.26
27
A
B
α4 integrin
Lymphocyte
VCAM1Lumen
Endothelial cell
Parenchyma
Natalizumab
Lumen
Endothelial cell
Parenchyma
Lymphocyte
Figure 2. Schematic representations. A, Activated leukocytes expressing ␣4
integrin, which induces receptor-mediated adhesion to endothelial cells. This
interaction is required for transmigration of activated leukocytes into the
Rudick Lancet Neurol 2012	
Multiple Sclerosis
< Novel therapy (anti-integrin therapy)>
DISCOVERY
In the 1980s, analysis of lymphocyte migration oc-
curred in many centers. At Stanford and Harvard uni-
versities, Butcher and Picker11
and Springer12
were elu-
ous antibodies applied prior to the addition of lympho-
cytes to frozen sections. Attachment was almost en-
tirely blocked by antibodies to ␤1 integrin. The integrin
molecule’s ␤ chain binds to 1 of 6 unique ␣ chains. An-
tibodies specific for the ␣ chains were applied to the fro-
Phase 1
research begins
Alpha-4 integrin
discovered to be
key molecule
involved in
homing
to the brain
Biogen and Elan announce
collaboration on the
development/commercialization
of natalizumab for both MS and
Crohn disease indications
FDA approves
natalizumab for
relapsing
forms of MS
Natalizumab returns
to US market with
pharmacovigilance
plan in place; EMEA
approves natalizumab
US label lists
3 confirmed
risk factors
for PML
Phase 3 trial of
natalizumab in
RRMS begins
Drug voluntarily
suspended from US
market on the basis
of 3 PML cases
European label lists
3 confirmed risk factors
for PML
20121992 1997 2000 2001 2004 2005 2006 2011
Figure 1. Timeline of major natalizumab milestones.1-7
EMEA indicates European Medicines Agency; FDA, Food and Drug Administration; MS, multiple sclerosis;
PML, progressive multifocal leukoencephalopathy; RRMS, relapsing-remitting MS.
Rudick Lancet Neurol 2012	
Multiple Sclerosis
< A model for translational medicine >
Timeline from bench to bedside
What adverse effects would you expect,
if you block a4 integrins?
Iatrogenic immune defect
医原性免疫不全
PML: Progressive Multifocal Leukoencephalopathy
進行性多巣性白質脳症	
Fatal encephalitis
(致死性脳炎)
Re-activation of latent JC viurs infection 
(不顕性JCウィルス感染症の再活性化)
brief report
The new england journal of medicine
ProgressiveMultifocalLeukoencephalopathy
afterNatalizumabTherapyforCrohn’sDisease
Gert Van Assche, M.D., Ph.D., Marc Van Ranst, M.D., Ph.D.,
Raf Sciot, M.D., Ph.D., Bénédicte Dubois, M.D., Ph.D.,
Séverine Vermeire, M.D., Ph.D., Maja Noman, M.D.,
Jannick Verbeeck, M.Sc., Karel Geboes, M.D., Ph.D.,
Wim Robberecht, M.D., Ph.D., and Paul Rutgeerts, M.D., Ph.D.
The prior diagnosis of fatal astrocytoma in a 60-year-old man with Crohn’s disease
treatedwithnatalizumab,amonoclonalantibodyagainsta integrins,wasreclassified
summary
n engl j med 353;4 www.nejm.org july 28, 2005
s,natalizumab(Tysabri,ElanandBiogenIdec),incombinationwithinterferon
(Avonex,BiogenIdec).4 Oneofthesecasesisdescribedelsewhereinthisissue
urnal.5 WereportathirdcaseofPML—thisoneinapatientwithCrohn’sdis-
oreceived300mgofopen-labelnatalizumabintravenouslyeveryfourweeksas
clinicaltrial.PMLisanopportunistic,infectious,demyelinatingbraindisorder
edwithimpairedT-cellfunction.Therelationshipbetweennatalizumabtherapy
L in our patient is clearly illustrated by the gradual increase in the number of
fJCvirusinthebloodduringmonotherapyinthemonthsprecedingthedevel-
offatalPML.
r-oldpatientwithlong-standingilealCrohn’sdiseasepresentedtotheemergen-
withsevereconfusionanddisorientationonJuly3,2003.Treatmentwithnatal-
ahumanizedmonoclonalantibodyagainsta4 integrins,hadbeeninitiatedin
002.Hehadinitiallyreceivedthreemonthlyinfusionsof300mgintravenously
he Evaluation of Natalizumab as Continuous Therapy 1 (ENACT-1) trial, fol-
ytreatmentwithplaceboforninemonthsintheENACT-2trial.Open-labelna-
abatadoseof300mggivenintravenouslyeveryfourweekswasthenresumedin
case report
The new england journal of medicine
brief report
ProgressiveMultifocalLeukoencephalopathy
inaPatientTreatedwithNatalizumab
Annette Langer-Gould, M.D., Scott W. Atlas, M.D., Ari J. Green, M.D.,
Andrew W. Bollen, M.D., and Daniel Pelletier, M.D.
From the Departments of Neurology and
Health Research and Policy, Stanford Uni-
versity School of Medicine, Stanford, Cal-
if. (A.L.-G.); the Department of Radiology,
Hoover Institution at Stanford University,
Stanford, Calif. (S.W.A.); and the Depart-
ments ofPathology(A.W.B.)andNeurology
(A.J.G., D.P.), University of California, San
Francisco, San Francisco. Address reprint
requests to Dr. Annette Langer-Gould at
HRP Redwood Bldg., Rm. T202, Stanford,
CA 94305-5405, or at annette1@stanford.
edu.
This article was published at www.nejm.org
on June 9, 2005.
N Engl J Med 2005;353:375-81.
We describe the clinical course of a patient with multiple sclerosis in whom progres-
sivemultifocalleukoencephalopathy(PML),anopportunisticviralinfectionofthecen-
tralnervoussystem,developedduringtreatmentwithinterferonbeta-1aandaselective
adhesion-molecule blocker, natalizumab. The first PML lesion apparent on magnetic
resonanceimagingwasindistinguishablefromamultiplesclerosislesion.Despitetreat-
mentwithcorticosteroids,cidofovir,andintravenousimmuneglobulin,PMLprogressed
rapidly,renderingthepatientquadriparetic,globallyaphasic,andminimallyresponsive.
Threemonthsafternatalizumabtherapywasdiscontinued,changesconsistentwithan
immune-reconstitution inflammatory syndrome developed. The patient was treated
withsystemiccytarabine,andtwomonthslater,hisconditionhadimproved.
rogressivemultifocalleukoencephalopathy(pml)isarare,oli-
godendroglial infection caused by the polyomavirus JC virus. It usually occurs
in people infected with the human immunodeficiency virus (HIV), but it has
also been reported in immunocompromised patients receiving prolonged treatment
withmethotrexate,cyclophosphamide,andazathioprine.PMLhasnotbeenreportedin
persons with multiple sclerosis, despite the frequent use of these medications to treat
thedisease.
WedescribetheclinicalcourseofapatientwithmultiplesclerosisinwhomPMLde-
veloped during treatment with interferon beta-1a (Avonex, Biogen Idec) and natalizu-
mab(Tysabri,BiogenIdecandElan),amonoclonalantibodyagainsta4integrins.Despite
thediscontinuationofthesemedications,hisPMLprogressedrapidly.Animmune-recon-
stitutioninflammatorysyndromedevelopedthreemonthsafterthecessationofnatali-
zumabtherapy,andthepatientbecamebedriddenandminimallyresponsive.Treatment
withintravenouscytarabinewasbegun,andshortlythereafter,hisconditionimproved.
summary
p
n engl j med 353;4 www.nejm.org july 28, 2005 375
irst symptom of what proved to be relapsing–remitting multiple sclerosis.
condattackin1989andhadtwoorthreeattacksperyearbetween1989and
medicalhistorywasalsonotablefortheRamsayHuntsyndromewithauric-
in 1998, a malignant melanoma excised from his back with negative mar-
6, and a cleft lip and palate. A sister also had relapsing–remitting multiple
The New England Journal of Medicine
d from nejm.org at HARVARD UNIVERSITY on June 7, 2012. For personal use only. No other uses without permission.
Copyright © 2005 Massachusetts Medical Society. All rights reserved.
The new england journal of medicine
brief report
Progressive Multifocal Leukoencephalopathy
after Natalizumab Monotherapy
Hans Lindå, M.D., Ph.D., Anders von Heijne, M.D., Eugene O. Major, Ph.D.,
Caroline Ryschkewitsch, B.S., Johan Berg, M.D., Tomas Olsson, M.D., Ph.D.,
and Claes Martin, M.D., Ph.D.
Summary
We describe progressive multifocal leukoencephalopathy (PML) caused by infection
with human polyomavirus JC virus in a patient with multiple sclerosis who was
treated with natalizumab. The first PML symptoms appeared after 14 monthly infu-
sions of the drug. Magnetic resonance imaging (MRI) showed a presumed multiple
sclerosis lesion, and JC virus DNA was not detected on polymerase-chain-reaction
(PCR) assay of cerebrospinal fluid. The patient’s symptoms worsened, and the diag-
nosis of PML was established with a more sensitive quantitative PCR assay after 16
infusions of natalizumab. Plasma exchange was used to accelerate clearance of
natalizumab. Approximately 3 weeks after plasma exchange, an immune-reconsti-
tution inflammatory syndrome appeared. JC virus DNA was no longer detectable on
quantitative PCR assay, and the patient’s symptoms improved.
n engl j med 361;11 nejm.org september 10, 2009 1081
N Engl J Med 2009;361:1081-7.
Copyright © 2009 Massachusetts Medical Society.
umab monotherapy. We describe the development of PML in a patient
le sclerosis who had received natalizumab as monotherapy.
Pretreatment History
r 2006, a 35-year-old, left-handed man presented with a 1-year history
des of numbness in both legs and a tingling sensation in his hands. At
MRI of the brain with the use of a Gyroscan Intera 1.5T (Philips) showed
50 lesions on T2-weighted images. The patient’s reflexes were exagger-
legs. Sensation of vibration was absent in his feet, and there was par-
hesia on the left side. His only motor symptom was mild paresis in the
Analysis of the cerebrospinal fluid showed oligoclonal IgG bands. The
The New England Journal of Medicine
from nejm.org at HARVARD UNIVERSITY on June 7, 2012. For personal use only. No other uses without permission.
Copyright © 2009 Massachusetts Medical Society. All rights reserved.
AREV402-ME61-03 ARI 7 December 2009 18:7
• Clinical symptoms:
• Cognitive impairments
• Visual deficits
• Motor dysfunction
*Language disturbances,
seizures, and headaches are
more frequent in AIDS patients
• PML occurrence:
• Immune-compromised host
• 3–5% in HIV-1+ (global)
• AIDS-defining illness
• Not always fatal with
• immune reconstitution
• (inflammatory syndrome)
Figure 1
Progressive multifocal leukoencephalopathy (PML). Left: MRI scan of bilateral multifocal, subcortical
demyelinated lesions in the cerebral hemispheres of a PML patient. A representative lesion outlined in red is
shown on histopathology (top center) with a demyelinated plaque (d) on luxol fast blue stain resulting from
lytic infection with the human polyomavirus JCV. Bottom center: Mature virion particles are shown assembled
in a crystalline array in the nucleus of an oligodendrocyte. Right: The predominant clinical aspects and
occurrence of PML are highlighted.
common as cognitive problems at the time of
suspicion of PML. Visual deficits such as hemi-
anopsia can be present. Other clinical signs
that are not as common are seizures, language
problems, and headaches. The clinical course
of PML has been described as progressive and
nearly always fatal; death occurs from weeks to
the hope that JCV-infected cells can still be
cleared from the brain. Patients with substantial
levels of CD8+ cytotoxic T cells specific to the
viral capsid protein have a better prognosis that
correlates with a less progressive course of dis-
ease (12, 13). No such correlation exists with
humoral immunity; PML patients have sub-
Annu.Rev.Med.2010.61:35-47.Downloadedfromwww.annualreviews.org
byHarvardUniversityon06/07/12.Forpersonaluseonly.
PML associated with anti-integrin therapies	
Major EO, Annu Rev Med 2010
PML associated with anti-integrin therapies plus α	
Carson KR, Lancet Oncol 2009	
had AIDS. As the HIV epidemic grew in the 1980s, PML
emerged as a major complication of HIV infection (both
HIV-1 and HIV-2). The incidence of PML increased
50-fold between 1979 and 1994.12
Since then, highly active
antiretroviral therapy (HAART) has helped reduce the
progression and the severity of PML in individuals with
HIV, although HIV infection continues to account for
about 80% of all new PML diagnoses.13
However, even
with the use of HAART, the incidence of PML remains
between 3% and 5% in patients with AIDS, which is an
incidence similar to that reported in the pre-HAART
era.14
HIV-infected patients with PML who are treated
Correspondence to:
Charles L Bennett, Northwestern
University, 710 N Fairbanks Ct,
Olson Pavilion, Suite 8-250,
Chicago, IL 60611, USA
cbenne@northwestern.edu
Rituximab Natalizumab Efalizumab
Mechanism
Target Anti-CD20 Binds to the α4-integrin Anti-CD11
Lymphocytes mainly affected by the drug B lymphocytes T lymphocytes T cells
Number of confirmed cases of
drug-associated PML (mortality rate)
57 (mortality rate 89% [51 of 57])6
13 (mortality rate 23% [3 of 13]).Ten received
monotherapy (median 25 months
[range 12–25])7–9
Three (mortality rate 66·6% [2 of 3]; one
additional case clinically suspected). All had
received ≥3 years of monotherapy10
Number of PML cases identified in
epidemiology or clinical studies
One (a patient with rheumatoid arthritis
developed PML in a safety extension study)
Eight One
Epidemiological estimate for
drug-associated PML
One in 4000 estimated in rituximab-treated
patients with SLE (unapproved indication);
estimates in rituximab-treated patients with
lymphoid malignancies and rheumatoid
arthritis not available at this time
One in 1000 One in 400 in efalizumab-treated patients
who received ≥3 years of therapy
Safety actions of the FDA and the marketing authorisation holder in the USA
Dateof initial marketing approval bythe FDA November, 1997 November, 2004 October, 2003
Dates warnings on PML issued by FDA December, 2006; September, 2008 February, 2005; June, 2006; August, 2008 October, 2008; February, 2009; March, 2009
Dates manufacturer issued warning for PML September, 2008 (“Dear Healthcare
Provider” letter); February, 2007 (Black Box
warning); December, 2006 (“Dear
Healthcare Provider” letter)
June, 2006 (Black Box) October, 2008 (“Dear Healthcare Provider”
letter and Black Box warning); November, 2008
(“Dear Healthcare Provider” letter); February,
2009 (“Dear Healthcare Provider” letter)
Marketing suspension None Voluntary withdrawal (February, 2005 to June,
2006). Returned to market place as monotherapy
in conjunction with a risk management plan
Manufacturer-initiated voluntary withdrawal
(April, 2009)
Risk-management (USA) Enhanced pharmacovigilance plan for PML
implemented in 2007
Patient medication guide and revised
product label
TOUCH programme for all patients;Tysabri should
not be administered concurrently with other
immunosuppressants
Risk Evaluation and Mitigation Strategies
programme developed in March, 2009,
including Patient Medication Guide and
revised product label; manufacturer-initiated
voluntary withdrawal in April, 2009
Should we stop Tysabri?	
Tysabri is most effective for MS	
PML in 1:1000
If we were to continue to use Tysabri,
what should we do to prevent PML?
To identify MS patients at high risk of PML
New Analysis of Risk Stratification for TYSABRI®
- Use of Biomarker has Potential to Advance
Personalized Treatment for MS Patients -	
	 May 18, 2012
Art
Lancet Neu
Published O
January 6, 2
DOI:10.101
4422(11)70
See Comm
Departmen
Neuroinfla
(Prof D H M
NMR Resea
(D MacMan
Institute o
London, U
Marienkra
University
Hamburg,
(ProfTWeb
Neuroscien
Statistics,
(R Grove M
Medicine D
GlaxoSmit
(CWardell P
Research, A
Chapel Hill
(J Horrigan
Medicine D
(O Graff MD
Firategrast for relapsing remitting multiple sclerosis: a phase 2,
randomised, double-blind, placebo-controlledtrial
David H Miller, Thomas Weber, Richard Grove, Claire Wardell, Joseph Horrigan, Ole Graff, Gillian Atkinson, Pinky Dua, Tarek Yousry,
David MacManus, Xavier Montalban
Summary
Background Monoclonal antibody therapy against α4β-integrin is efficacious in patients with multiple sclerosis (MS)
with some safety concerns. We assessed the safety and efficacy of firategrast, a small oral anti-α4β-integrin molecule,
in patients with relapsing remitting MS.
Methods We did a multicentre, phase 2, randomised, double-blind, placebo-controlled, dose-ranging study in
participants with clinically definite relapsing-remitting MS. A 24-week treatment period was followed by 12 weeks of
core follow-up and 40 weeks of extended follow-up. Participants were randomly assigned, via computer-generated
block randomisation in a 1:2:2:2 ratio, to receive one of four treatments twice a day: firategrast 150 mg, firategrast
600 mg, or firategrast 900 mg (women) or 1200 mg (men), or placebo. Brain scans were obtained at 4-week intervals
to the end of core follow-up. The primary outcome was cumulative number of new gadolinium-enhancing brain
lesions during the treatment phase and was analysed using a generalised linear model with an underlying negative
binomial distribution, adjusted for sex, baseline number of new gadolinium-enhancing lesions, and country. This
study is registered with ClinicalTrials.gov, NCT00395317.
Findings Of 343 individuals enrolled, 49 received firategrast 150 mg, 95 received firategrast 600 mg, 100 received firategrast
900 mg or 1200 mg, and 99 received placebo. A 49% reduction (95% CI 21·2–67·6; p=0·0026) in the cumulative number
of new gadolinium-enhancing lesions was seen for the 900 mg or 1200 mg firategrast group (n=92, mean number of
lesions 2·69 [SE 1·18]) versus the placebo group (90, 5·31 [1·18]). In the 600 mg group (86, 4·12 [SE 1·19]), a non-
significant 22% reduction (95% CI –21·3 to 49·7; p=0·2657) occurred in mean number of new gadolinium-enhanced
lesions relative to placebo; for the 150 mg group (47, 9·51 [SE 1·24]), a 79% increase (95% CI 4·1–308·1; p=0·0353)
occurred relative to placebo. Firategrast was generally well tolerated at all doses. The frequency of all adverse events was
similar across all treatment groups except for an increased rate of urinary tract infections in the high-dose firategrast
group. No cases of progressive multifocal leukoencephalopathy or evidence of reactivation of JC virus were identified.
www.thelancet.com/neurology Vol 11 February 2012
prognosis.5–10
Orally administered disease-mo
treatments have only recently become available.11
Since 2006, natalizumab, a long-acting, hum
monoclonal antibody to α4β1 and α4β7 i
receptors, has been a treatment option for patien
highly active relapsing remitting MS. The drug
trafficking of mononuclear white blood cells acr
blood–brain barrier, and was associated with
Small-molecule inhibitor to α4 integrin alleviates MS	
No PML case was seen in 149 patients receiving firategrast
Advanced Topics
1: More than three steps
(Vestweber, “How leukocytes cross the vascular endothelium”
Nat Rev Immunol 2015)
2: Leukocyte migration in 3D
(Weninger et al., “Leukocyte migration in the interstitial space
of non-lymphoid organs” Nat Rev Immunol 2014)
More than 3 steps:
the updated multistep cascade model for leukocyte extravasation
Signaling steps initiating the opening of endothelial cell junctions
Amoeboid mode migration of leukocytes in a 3D-environment
The perivascular extravasation unit assists in leukocyte migration
Three-step cascade guides neutrophils to the site of sterile injury
Context-dependent mechanisms of neutrophil attraction to injury sites

More Related Content

What's hot

Id4 suppresses MMP2-mediated invasion of glioblastoma-derived cells by direc...
Id4 suppresses MMP2-mediated invasion of glioblastoma-derived cells  by direc...Id4 suppresses MMP2-mediated invasion of glioblastoma-derived cells  by direc...
Id4 suppresses MMP2-mediated invasion of glioblastoma-derived cells by direc...Ahmad Usama
 
The Impact of Lysogenic and Tail Assembly Chaperone Proteins on the Life Cycl...
The Impact of Lysogenic and Tail Assembly Chaperone Proteins on the Life Cycl...The Impact of Lysogenic and Tail Assembly Chaperone Proteins on the Life Cycl...
The Impact of Lysogenic and Tail Assembly Chaperone Proteins on the Life Cycl...Wyatt Nelson
 
Escrt proteins in physiology and diseases
Escrt proteins in physiology and diseasesEscrt proteins in physiology and diseases
Escrt proteins in physiology and diseasesSandeep Kumar
 
Chromosome analysis
Chromosome analysisChromosome analysis
Chromosome analysisnaren
 
Biophysical Society Poster
Biophysical Society PosterBiophysical Society Poster
Biophysical Society PosterBilly Nicholson
 
Kumar-igmposter_enhancer_2013_FINAL
Kumar-igmposter_enhancer_2013_FINALKumar-igmposter_enhancer_2013_FINAL
Kumar-igmposter_enhancer_2013_FINALshantanu kumar
 
Glypican and Biglycan in the Nuclei of Neurons and Glioma Cells
Glypican and Biglycan in the Nuclei of Neurons and Glioma CellsGlypican and Biglycan in the Nuclei of Neurons and Glioma Cells
Glypican and Biglycan in the Nuclei of Neurons and Glioma CellsYu Liang
 

What's hot (20)

Id4 suppresses MMP2-mediated invasion of glioblastoma-derived cells by direc...
Id4 suppresses MMP2-mediated invasion of glioblastoma-derived cells  by direc...Id4 suppresses MMP2-mediated invasion of glioblastoma-derived cells  by direc...
Id4 suppresses MMP2-mediated invasion of glioblastoma-derived cells by direc...
 
The Impact of Lysogenic and Tail Assembly Chaperone Proteins on the Life Cycl...
The Impact of Lysogenic and Tail Assembly Chaperone Proteins on the Life Cycl...The Impact of Lysogenic and Tail Assembly Chaperone Proteins on the Life Cycl...
The Impact of Lysogenic and Tail Assembly Chaperone Proteins on the Life Cycl...
 
Escrt proteins in physiology and diseases
Escrt proteins in physiology and diseasesEscrt proteins in physiology and diseases
Escrt proteins in physiology and diseases
 
CE-Symm jLBR talk
CE-Symm jLBR talkCE-Symm jLBR talk
CE-Symm jLBR talk
 
Chromosome analysis
Chromosome analysisChromosome analysis
Chromosome analysis
 
finalposterapril13
finalposterapril13finalposterapril13
finalposterapril13
 
1-s2.0-S1357272513001234-main
1-s2.0-S1357272513001234-main1-s2.0-S1357272513001234-main
1-s2.0-S1357272513001234-main
 
Biophysical Society Poster
Biophysical Society PosterBiophysical Society Poster
Biophysical Society Poster
 
Scientific Report
Scientific ReportScientific Report
Scientific Report
 
Ojchd.000534
Ojchd.000534Ojchd.000534
Ojchd.000534
 
Mutations
MutationsMutations
Mutations
 
zmk2820
zmk2820zmk2820
zmk2820
 
Kumar-igmposter_enhancer_2013_FINAL
Kumar-igmposter_enhancer_2013_FINALKumar-igmposter_enhancer_2013_FINAL
Kumar-igmposter_enhancer_2013_FINAL
 
PIIS089662731300319X
PIIS089662731300319XPIIS089662731300319X
PIIS089662731300319X
 
Summer project poster
Summer project posterSummer project poster
Summer project poster
 
Huang-2004
Huang-2004Huang-2004
Huang-2004
 
2006 O'Leary et al MBC
2006 O'Leary et al  MBC2006 O'Leary et al  MBC
2006 O'Leary et al MBC
 
Glypican and Biglycan in the Nuclei of Neurons and Glioma Cells
Glypican and Biglycan in the Nuclei of Neurons and Glioma CellsGlypican and Biglycan in the Nuclei of Neurons and Glioma Cells
Glypican and Biglycan in the Nuclei of Neurons and Glioma Cells
 
KATYOTYPING
KATYOTYPINGKATYOTYPING
KATYOTYPING
 
B10vrv4133
B10vrv4133B10vrv4133
B10vrv4133
 

Viewers also liked

Discovery of Novel Shp2 inhibitors
Discovery of Novel Shp2 inhibitorsDiscovery of Novel Shp2 inhibitors
Discovery of Novel Shp2 inhibitorsLiwei Chen
 
臨床研究医の仕事術
臨床研究医の仕事術臨床研究医の仕事術
臨床研究医の仕事術BostonIDI
 
Shimaoka Lecture on Integrins and Immune Cell Trafficking at Hiroshima Univer...
Shimaoka Lecture on Integrins and Immune Cell Trafficking at Hiroshima Univer...Shimaoka Lecture on Integrins and Immune Cell Trafficking at Hiroshima Univer...
Shimaoka Lecture on Integrins and Immune Cell Trafficking at Hiroshima Univer...BostonIDI
 
SSH Physician-Scientists(臨床研究者への道)
SSH Physician-Scientists(臨床研究者への道)SSH Physician-Scientists(臨床研究者への道)
SSH Physician-Scientists(臨床研究者への道)BostonIDI
 
MedicalValley Talks am 14.04.2011 mit Prof. Fabry
MedicalValley Talks am 14.04.2011 mit Prof. FabryMedicalValley Talks am 14.04.2011 mit Prof. Fabry
MedicalValley Talks am 14.04.2011 mit Prof. FabryMedical Valley EMN
 
Uremia and endothelial cells
Uremia and endothelial cellsUremia and endothelial cells
Uremia and endothelial cellskyste
 
Presentation format4 posttranslational modification in cell adhesion and migr...
Presentation format4 posttranslational modification in cell adhesion and migr...Presentation format4 posttranslational modification in cell adhesion and migr...
Presentation format4 posttranslational modification in cell adhesion and migr...Birgit Kastberger
 
İng tip adezyonmoleküll
İng tip adezyonmoleküllİng tip adezyonmoleküll
İng tip adezyonmoleküllDrAlirza
 
Lymphocyte Migration
Lymphocyte MigrationLymphocyte Migration
Lymphocyte Migrationraj kumar
 
L02 cell membrane_
L02 cell membrane_L02 cell membrane_
L02 cell membrane_MUBOSScz
 
Adhesion molecules in skin seminar (2)
Adhesion molecules in skin  seminar (2)Adhesion molecules in skin  seminar (2)
Adhesion molecules in skin seminar (2)Dr Daulatram Dhaked
 
Morphogenesis and cell adhesion.
Morphogenesis and cell adhesion.Morphogenesis and cell adhesion.
Morphogenesis and cell adhesion.Bhupen Koch
 
Adhesion molecules
Adhesion moleculesAdhesion molecules
Adhesion moleculesaljeirou
 
2. inflammation cellular events dr ashutosh kumar
2. inflammation cellular events dr ashutosh kumar2. inflammation cellular events dr ashutosh kumar
2. inflammation cellular events dr ashutosh kumarDrAshutosh Kumar
 
Cell adhesion molecules and matrix proteins
Cell adhesion    molecules and matrix proteinsCell adhesion    molecules and matrix proteins
Cell adhesion molecules and matrix proteinsUSmile Ï Ṩṃïlệ
 

Viewers also liked (20)

Discovery of Novel Shp2 inhibitors
Discovery of Novel Shp2 inhibitorsDiscovery of Novel Shp2 inhibitors
Discovery of Novel Shp2 inhibitors
 
臨床研究医の仕事術
臨床研究医の仕事術臨床研究医の仕事術
臨床研究医の仕事術
 
Shimaoka Lecture on Integrins and Immune Cell Trafficking at Hiroshima Univer...
Shimaoka Lecture on Integrins and Immune Cell Trafficking at Hiroshima Univer...Shimaoka Lecture on Integrins and Immune Cell Trafficking at Hiroshima Univer...
Shimaoka Lecture on Integrins and Immune Cell Trafficking at Hiroshima Univer...
 
SSH Physician-Scientists(臨床研究者への道)
SSH Physician-Scientists(臨床研究者への道)SSH Physician-Scientists(臨床研究者への道)
SSH Physician-Scientists(臨床研究者への道)
 
MedicalValley Talks am 14.04.2011 mit Prof. Fabry
MedicalValley Talks am 14.04.2011 mit Prof. FabryMedicalValley Talks am 14.04.2011 mit Prof. Fabry
MedicalValley Talks am 14.04.2011 mit Prof. Fabry
 
Uremia and endothelial cells
Uremia and endothelial cellsUremia and endothelial cells
Uremia and endothelial cells
 
Hungary2002
Hungary2002Hungary2002
Hungary2002
 
Presentation format4 posttranslational modification in cell adhesion and migr...
Presentation format4 posttranslational modification in cell adhesion and migr...Presentation format4 posttranslational modification in cell adhesion and migr...
Presentation format4 posttranslational modification in cell adhesion and migr...
 
İng tip adezyonmoleküll
İng tip adezyonmoleküllİng tip adezyonmoleküll
İng tip adezyonmoleküll
 
Lymphocyte Migration
Lymphocyte MigrationLymphocyte Migration
Lymphocyte Migration
 
L02 cell membrane_
L02 cell membrane_L02 cell membrane_
L02 cell membrane_
 
adhesion_proteins
adhesion_proteinsadhesion_proteins
adhesion_proteins
 
Adhesion molecules in skin seminar (2)
Adhesion molecules in skin  seminar (2)Adhesion molecules in skin  seminar (2)
Adhesion molecules in skin seminar (2)
 
Morphogenesis and cell adhesion.
Morphogenesis and cell adhesion.Morphogenesis and cell adhesion.
Morphogenesis and cell adhesion.
 
Cell Adhesion and Cell Migration
Cell Adhesion and Cell MigrationCell Adhesion and Cell Migration
Cell Adhesion and Cell Migration
 
Cellular Adhesion in Inflammation
Cellular Adhesion in InflammationCellular Adhesion in Inflammation
Cellular Adhesion in Inflammation
 
Neutrophils
NeutrophilsNeutrophils
Neutrophils
 
Adhesion molecules
Adhesion moleculesAdhesion molecules
Adhesion molecules
 
2. inflammation cellular events dr ashutosh kumar
2. inflammation cellular events dr ashutosh kumar2. inflammation cellular events dr ashutosh kumar
2. inflammation cellular events dr ashutosh kumar
 
Cell adhesion molecules and matrix proteins
Cell adhesion    molecules and matrix proteinsCell adhesion    molecules and matrix proteins
Cell adhesion molecules and matrix proteins
 

Similar to Leukocyte Trafficking in Health and Diseases 2016

Bs963 apoptosis 09-10
Bs963 apoptosis 09-10Bs963 apoptosis 09-10
Bs963 apoptosis 09-10antavait
 
4. 2 Intracellular Binding Partners Of Podocalyxin Lab Study
4. 2 Intracellular Binding Partners Of Podocalyxin Lab Study4. 2 Intracellular Binding Partners Of Podocalyxin Lab Study
4. 2 Intracellular Binding Partners Of Podocalyxin Lab StudyStephanie Roberts
 
Essay On Folding Analysis Of Protein
Essay On Folding Analysis Of ProteinEssay On Folding Analysis Of Protein
Essay On Folding Analysis Of ProteinKerry Lewis
 
Li et al Oncogene 1997 (dragged)
Li et al Oncogene 1997 (dragged)Li et al Oncogene 1997 (dragged)
Li et al Oncogene 1997 (dragged)Hyunsun Park
 
##S And How Deletion Of Ykl Affects The Processes
##S And How Deletion Of Ykl Affects The Processes##S And How Deletion Of Ykl Affects The Processes
##S And How Deletion Of Ykl Affects The ProcessesJackie Ramirez
 
1901711085034_T4 BACTERIOPHAGE_ALOK KUMAR.pptx
1901711085034_T4 BACTERIOPHAGE_ALOK KUMAR.pptx1901711085034_T4 BACTERIOPHAGE_ALOK KUMAR.pptx
1901711085034_T4 BACTERIOPHAGE_ALOK KUMAR.pptxAlok Kumar
 
Metabolic co-dependence gives rise to collective oscillations within biofilms.
Metabolic co-dependence gives rise to collective oscillations within biofilms.Metabolic co-dependence gives rise to collective oscillations within biofilms.
Metabolic co-dependence gives rise to collective oscillations within biofilms.Kazuya Horibe
 
Organelles In Animal Cells Essay
Organelles In Animal Cells EssayOrganelles In Animal Cells Essay
Organelles In Animal Cells EssayJennifer Letterman
 
Senior Thesis-Analyzing the interactions between MYOGEF and a component of er...
Senior Thesis-Analyzing the interactions between MYOGEF and a component of er...Senior Thesis-Analyzing the interactions between MYOGEF and a component of er...
Senior Thesis-Analyzing the interactions between MYOGEF and a component of er...Dougan McGrath
 
Chitin gama delta linfocitos
Chitin gama delta linfocitosChitin gama delta linfocitos
Chitin gama delta linfocitosUFRJ
 
Dominant Pathogenic Disease Research Paper
Dominant Pathogenic Disease Research PaperDominant Pathogenic Disease Research Paper
Dominant Pathogenic Disease Research PaperAngela Gibbs
 
Horizantal gene transfer in evolution of nematodes
Horizantal gene transfer in evolution of nematodesHorizantal gene transfer in evolution of nematodes
Horizantal gene transfer in evolution of nematodespriyank mhatre
 
Endothelial Cell Mediated Delay of Blood Brain Barrier Recovery Following Tra...
Endothelial Cell Mediated Delay of Blood Brain Barrier Recovery Following Tra...Endothelial Cell Mediated Delay of Blood Brain Barrier Recovery Following Tra...
Endothelial Cell Mediated Delay of Blood Brain Barrier Recovery Following Tra...Arthur Stem
 
Final Poster-Ryan Skaar
Final Poster-Ryan SkaarFinal Poster-Ryan Skaar
Final Poster-Ryan SkaarRyan Skaar
 
Early Nuclear Physics Essay
Early Nuclear Physics EssayEarly Nuclear Physics Essay
Early Nuclear Physics EssayKelly Flores
 

Similar to Leukocyte Trafficking in Health and Diseases 2016 (20)

Integrins
IntegrinsIntegrins
Integrins
 
Bs963 apoptosis 09-10
Bs963 apoptosis 09-10Bs963 apoptosis 09-10
Bs963 apoptosis 09-10
 
4. 2 Intracellular Binding Partners Of Podocalyxin Lab Study
4. 2 Intracellular Binding Partners Of Podocalyxin Lab Study4. 2 Intracellular Binding Partners Of Podocalyxin Lab Study
4. 2 Intracellular Binding Partners Of Podocalyxin Lab Study
 
Essay On Folding Analysis Of Protein
Essay On Folding Analysis Of ProteinEssay On Folding Analysis Of Protein
Essay On Folding Analysis Of Protein
 
Wagner chapter 3
Wagner chapter 3Wagner chapter 3
Wagner chapter 3
 
H2A Case Study
H2A Case StudyH2A Case Study
H2A Case Study
 
Li et al Oncogene 1997 (dragged)
Li et al Oncogene 1997 (dragged)Li et al Oncogene 1997 (dragged)
Li et al Oncogene 1997 (dragged)
 
##S And How Deletion Of Ykl Affects The Processes
##S And How Deletion Of Ykl Affects The Processes##S And How Deletion Of Ykl Affects The Processes
##S And How Deletion Of Ykl Affects The Processes
 
1901711085034_T4 BACTERIOPHAGE_ALOK KUMAR.pptx
1901711085034_T4 BACTERIOPHAGE_ALOK KUMAR.pptx1901711085034_T4 BACTERIOPHAGE_ALOK KUMAR.pptx
1901711085034_T4 BACTERIOPHAGE_ALOK KUMAR.pptx
 
Metabolic co-dependence gives rise to collective oscillations within biofilms.
Metabolic co-dependence gives rise to collective oscillations within biofilms.Metabolic co-dependence gives rise to collective oscillations within biofilms.
Metabolic co-dependence gives rise to collective oscillations within biofilms.
 
Organelles In Animal Cells Essay
Organelles In Animal Cells EssayOrganelles In Animal Cells Essay
Organelles In Animal Cells Essay
 
Senior Thesis-Analyzing the interactions between MYOGEF and a component of er...
Senior Thesis-Analyzing the interactions between MYOGEF and a component of er...Senior Thesis-Analyzing the interactions between MYOGEF and a component of er...
Senior Thesis-Analyzing the interactions between MYOGEF and a component of er...
 
Chitin gama delta linfocitos
Chitin gama delta linfocitosChitin gama delta linfocitos
Chitin gama delta linfocitos
 
Dominant Pathogenic Disease Research Paper
Dominant Pathogenic Disease Research PaperDominant Pathogenic Disease Research Paper
Dominant Pathogenic Disease Research Paper
 
Altered neutrophil functions
Altered neutrophil functionsAltered neutrophil functions
Altered neutrophil functions
 
Horizantal gene transfer in evolution of nematodes
Horizantal gene transfer in evolution of nematodesHorizantal gene transfer in evolution of nematodes
Horizantal gene transfer in evolution of nematodes
 
Oliver_2014
Oliver_2014Oliver_2014
Oliver_2014
 
Endothelial Cell Mediated Delay of Blood Brain Barrier Recovery Following Tra...
Endothelial Cell Mediated Delay of Blood Brain Barrier Recovery Following Tra...Endothelial Cell Mediated Delay of Blood Brain Barrier Recovery Following Tra...
Endothelial Cell Mediated Delay of Blood Brain Barrier Recovery Following Tra...
 
Final Poster-Ryan Skaar
Final Poster-Ryan SkaarFinal Poster-Ryan Skaar
Final Poster-Ryan Skaar
 
Early Nuclear Physics Essay
Early Nuclear Physics EssayEarly Nuclear Physics Essay
Early Nuclear Physics Essay
 

More from BostonIDI

CTGHMS: Synthetic life JCV
CTGHMS: Synthetic life JCVCTGHMS: Synthetic life JCV
CTGHMS: Synthetic life JCVBostonIDI
 
Ctghms(コーディネーター:島岡要)
Ctghms(コーディネーター:島岡要)Ctghms(コーディネーター:島岡要)
Ctghms(コーディネーター:島岡要)BostonIDI
 
2013 Summner Seminar Endocrinology & Metabolism at Yufuin, Dr. Shimaoka
2013 Summner Seminar Endocrinology & Metabolism at Yufuin, Dr. Shimaoka2013 Summner Seminar Endocrinology & Metabolism at Yufuin, Dr. Shimaoka
2013 Summner Seminar Endocrinology & Metabolism at Yufuin, Dr. ShimaokaBostonIDI
 
The role of luck in the discovery of nuetrino; An amazing story about Dr. Kos...
The role of luck in the discovery of nuetrino; An amazing story about Dr. Kos...The role of luck in the discovery of nuetrino; An amazing story about Dr. Kos...
The role of luck in the discovery of nuetrino; An amazing story about Dr. Kos...BostonIDI
 
共通教育「生命医科学の現代的課題」島岡1
共通教育「生命医科学の現代的課題」島岡1共通教育「生命医科学の現代的課題」島岡1
共通教育「生命医科学の現代的課題」島岡1BostonIDI
 
Neutrophil ‘Slings’ facilitates Rolling
 Neutrophil ‘Slings’ facilitates Rolling  Neutrophil ‘Slings’ facilitates Rolling
Neutrophil ‘Slings’ facilitates Rolling BostonIDI
 

More from BostonIDI (6)

CTGHMS: Synthetic life JCV
CTGHMS: Synthetic life JCVCTGHMS: Synthetic life JCV
CTGHMS: Synthetic life JCV
 
Ctghms(コーディネーター:島岡要)
Ctghms(コーディネーター:島岡要)Ctghms(コーディネーター:島岡要)
Ctghms(コーディネーター:島岡要)
 
2013 Summner Seminar Endocrinology & Metabolism at Yufuin, Dr. Shimaoka
2013 Summner Seminar Endocrinology & Metabolism at Yufuin, Dr. Shimaoka2013 Summner Seminar Endocrinology & Metabolism at Yufuin, Dr. Shimaoka
2013 Summner Seminar Endocrinology & Metabolism at Yufuin, Dr. Shimaoka
 
The role of luck in the discovery of nuetrino; An amazing story about Dr. Kos...
The role of luck in the discovery of nuetrino; An amazing story about Dr. Kos...The role of luck in the discovery of nuetrino; An amazing story about Dr. Kos...
The role of luck in the discovery of nuetrino; An amazing story about Dr. Kos...
 
共通教育「生命医科学の現代的課題」島岡1
共通教育「生命医科学の現代的課題」島岡1共通教育「生命医科学の現代的課題」島岡1
共通教育「生命医科学の現代的課題」島岡1
 
Neutrophil ‘Slings’ facilitates Rolling
 Neutrophil ‘Slings’ facilitates Rolling  Neutrophil ‘Slings’ facilitates Rolling
Neutrophil ‘Slings’ facilitates Rolling
 

Recently uploaded

Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.raviapr7
 
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptxPISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptxEduSkills OECD
 
In - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxIn - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxAditiChauhan701637
 
Practical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptxPractical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptxKatherine Villaluna
 
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxPractical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxKatherine Villaluna
 
Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.EnglishCEIPdeSigeiro
 
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdf
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdfP4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdf
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdfYu Kanazawa / Osaka University
 
HED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdfHED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdfMohonDas
 
UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE
 
Benefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationBenefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationMJDuyan
 
M-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxM-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxDr. Santhosh Kumar. N
 
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxAUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxiammrhaywood
 
How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17Celine George
 
What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?TechSoup
 
The Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George WellsThe Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George WellsEugene Lysak
 
How to Solve Singleton Error in the Odoo 17
How to Solve Singleton Error in the  Odoo 17How to Solve Singleton Error in the  Odoo 17
How to Solve Singleton Error in the Odoo 17Celine George
 
General views of Histopathology and step
General views of Histopathology and stepGeneral views of Histopathology and step
General views of Histopathology and stepobaje godwin sunday
 
How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17Celine George
 
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfMaximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfTechSoup
 

Recently uploaded (20)

Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.
 
Prelims of Kant get Marx 2.0: a general politics quiz
Prelims of Kant get Marx 2.0: a general politics quizPrelims of Kant get Marx 2.0: a general politics quiz
Prelims of Kant get Marx 2.0: a general politics quiz
 
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptxPISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
 
In - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxIn - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptx
 
Practical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptxPractical Research 1 Lesson 9 Scope and delimitation.pptx
Practical Research 1 Lesson 9 Scope and delimitation.pptx
 
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxPractical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
 
Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.
 
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdf
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdfP4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdf
P4C x ELT = P4ELT: Its Theoretical Background (Kanazawa, 2024 March).pdf
 
HED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdfHED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdf
 
UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024
 
Benefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationBenefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive Education
 
M-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxM-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptx
 
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxAUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
 
How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17
 
What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?
 
The Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George WellsThe Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George Wells
 
How to Solve Singleton Error in the Odoo 17
How to Solve Singleton Error in the  Odoo 17How to Solve Singleton Error in the  Odoo 17
How to Solve Singleton Error in the Odoo 17
 
General views of Histopathology and step
General views of Histopathology and stepGeneral views of Histopathology and step
General views of Histopathology and step
 
How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17
 
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfMaximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
 

Leukocyte Trafficking in Health and Diseases 2016

  • 1. 1 Leukocyte Trafficking in Health and Diseases (細胞接着・遊⾛の⽣理的意義と疾患との関連) • Cell adhesion molecules (細胞接着分子とは、ケモカインとは) • Genetic defects (細胞接着分子の遺伝的欠損症とは) • Therapeutic inhibition (細胞接着分子を治療標的にする) Motomu Shimaoka, M.D., Ph.D. Mie University Medical School
  • 2. Quiz-1 Bacterial infections usually begin(細菌感染症は血管の 内側で始まるでしょうか、それとも血管の外側で始まる でしょうか: A)  inside of the vasculatures(内側) B)  outside of the vasculature(外側)
  • 6. Assignment: 2 Questions to Answer in English (以下の問いをノートに写しなさい。授業中に英語で解答しなさい。ヒントは 授業中に言います) 1.  Explain the molecular mechanisms by which leukocyte extravasation is regulated.(白血球の血管外遊走の 分子メカニズムを英語で説明せよ) 2.  Explain the genetic defect(s) causing leukocyte adhesion deficiency (LAD)-I, II, and III.(LAD-I, II, IIIを起こす 遺伝子欠損について英語で説明せよ)
  • 7. Leukocyte Adhesion Deficiency (LAD) 白血球接着不全症
  • 8. Leukocyte Adhesion Deficiency (LAD) 白血球接着不全症 Case(症例):15-year-old patient JT, who first presented as an infant with severe and recurrent skin infections requiring prolonged treatment with intra-venous antibiotics and surgery to remove necrotic tissue. In spite of attentive oral hygiene, the patient suffered from severe periodontitis and gingivitis. Otitis media and chest infections had also been consistent features of this patient‘s condition. Organisms isolated from infected sites included Staphylococcus aureus, Pseudomonas, and Streptococcus species…….(Hogg M. JCI 1999) •  Recurrent and often fatal bacterial infections •  Defects in leukocyte adhesion and phagocytosis
  • 9. (modified from von Andrian, NEJM, 2000) 3-Steps in the leukocyte-endothelial interactions
  • 11. Selectins • P-selectin (Platelets, Endothelial cells) • E-selectin (Endothelial cells) • L-selectin (Leukocytes)
  • 12. Selectins Bind to carbohydrate ligands (Sialyl LewisX: s-Lex) 特殊な糖鎖シアリルルイスXに結合する
  • 14. Selectins Rolling is for what? (ローリングは何の役に立つの?)
  • 15. Rolling enables leukocytes(ローリングの役割は): •  Slow down (減速) •  Travel along the endothelial surface(血管内皮表面を走行) Probe for chemokines that are displayed on the endothelial surfaces (血管内皮表面を探索することを助ける)
  • 20. Diffused to and transported through endothelial cells ケモカインは血管内皮細胞の基底側から管腔側へと輸送される Chemokines
  • 21. Chemokines ケモカインの細胞接着に対する活性 • Activate integrins(インテグリンの活性化) • Support firm adhesion to endothelial cells (ローリングする白血球を血管内皮上に静止させる)
  • 23. Integrins • Firm adhesion(血流のずり応力に負けない強い細胞接着) • Transendothelial migration (Diapedesis)(血管外への遊 走に必要な強弱がダイナミックに変化可能な細胞接着)
  • 25. Integrins インテグリンの細胞接着性はダイナミックに制御されている • Activated by chemokine signaling (ケモカイン刺激により活性化される) • Conformational changes (コンフォメーション変化、構造変化により制御) • Affinity upregulation (親和性の制御)
  • 26. Integrins • Activated by chemokine signaling • Conformational changes • Affinity upregulation
  • 27. α β Integrin binding factor Integrin binding factor 2. Binding of factors to integrin cytoplasmic domains 1. Cellular activation LFA-1のグローバルな� コンフォメーション変化�
  • 28. β Integrin binding factor α Integrin binding factor ICAM-1 7. Ligand binding 3. Separation of α and β tailpieces 2. Binding of factors to integrin cytoplasmic domains 1. Cellular activation 5. Swing-out of hybrid domain and activation of I-like domain 4. Switchblade-like upward movement of headpiece 6. Activation of I domain by downward movement of its C-terminal ”pull spring" LFA-1のグローバルな� コンフォメーション変化�
  • 29. 188 an interaction with the NHL-domain protein Wech (Löer et al., adhesions they lose ICAP1α (Fournier et al., 2002) and the actin- Journal of Cell Science 122 (2) Table 1. Adaptor proteins that bind to β-integrin cytoplasmic tails Adaptor protein Integrin to which adaptor binds Reference Structural adaptors α-actinin β1, β2, β3 (Otey et al., 1993; Pavalko and LaRoche, 1993) BP180 β4 (Koster et al., 2003; Schaapveld et al., 1998) Filamin β1, β2, β3, β7 (Calderwood et al., 2001; Kiema et al., 2006; Loo et al., 1998; Pfaff et al., 1998; Sharma et al., 1995; Travis et al., 2004; Zent et al., 2000) Myosin β1, β3, β5 (Jenkins et al., 1998; Sajid et al., 2000; Zhang et al., 2004) Plectin β4 (Geerts et al., 1999) Skelemin β1, β3 (Reddy et al., 1998) Talin β1, β2, β3, β5, β7 (Calderwood et al., 2003; Calderwood et al., 1999; Patil et al., 1999; Pfaff et al., 1998; Sampath et al., 1998) Tensin β1, β3, β5, β7 (Calderwood et al., 2003; McCleverty et al., 2007) Scaffolding adaptors 14-3-3 β1, β2, β3 (Fagerholm et al., 2005; Han et al., 2001) β3 endonexin β3 (Eigenthaler et al., 1997; Shattil et al., 1995) CD98 β1, β3 (Zent et al., 2000) Dab1 β1, β2, β3, β5, β7 (Calderwood et al., 2003) Dab2 β3, β5 (Calderwood et al., 2003) Dok1 β2, β3, β5, β7 (Calderwood et al., 2003) Fhl2 β1, β2, β3, β6 (Wixler et al., 2000) Fhl3 β1 (Samson et al., 2004) Grb2 β3 (Blystone et al., 1996; Law et al., 1996) IAP β3 (Brown et al., 1990) JAB1 β2 (Bianchi et al., 2000) Kindlin 2 β1, β3 (Ma et al., 2008; Montanez et al., 2008) Kindlin 3 β1, β3 (Moser et al., 2008) Melusin β1 (Brancaccio et al., 1999) Numb β3, β5 (Calderwood et al., 2003) Paxillin β1, β3 (Chen et al., 2000; Schaller et al., 1995) Rack1 β1, β2, β5 (Liliental and Chang, 1998) Shc β3, β4 (Dans et al., 2001; Law et al., 1996) TAP20 β5 (Tang et al., 1999) WAIT1 β7 (Rietzler et al., 1998) Catalytic adaptors Src β3 (Arias-Salgado et al., 2003; Arias-Salgado et al., 2005) Yes β1, β2, β3 (Arias-Salgado et al., 2005) Cytohesin 1 β2 (Kolanus et al., 1996) Eps8 β1, β3, β5 (Calderwood et al., 2003) ERK2 β6 (Ahmed et al., 2002) FAK β1, β2, β3, β5 (Chen et al., 2000; Eliceiri et al., 2002; Schaller et al., 1995) Fyn β3 (Arias-Salgado et al., 2005) ILK β1, β3 (Hannigan et al., 1996; Pasquet et al., 2002) Lyn β1, β2, β3 (Arias-Salgado et al., 2005) PKD1 β1, β3 (Medeiros et al., 2005; Woods et al., 2004) PP2A β1 (Kim et al., 2004) Shp2 β4 (Bertotti et al., 2006) Other adaptors ICAP1α β1 (Chang et al., 1997; Zhang and Hemler, 1999) MIBP β1 (Li et al., 1999) JournalofCellScience Cytoplasmic proteins interacting with β integrin tails Legate KR, J Cell Sci 2009
  • 30. signaling). Integrins low-affinity confor- “inside-out” signal- ins is regulated by uced intracellularly rect binding of reg- ytoplasmic domains w- to a high-affinity vation” (1, 2). with which integrins for various cellular uring development vated integrins at h newly protruded face on which they egrins at their rear. brinogen receptors are swiftly activated and aggregation in ause aIIbb3 integ- to fibrinogen, it is so as to prevent tion and thrombus nflammation leuko- ion in order to ad- he endothelium on Abnormal function ins or mutations in quired for integrin ant development or sorders, leukocyte- n blistering. In this structural and bio- om genetic manip- new light on how and b subunits. In mammals, 18 a and 8 b sub- units combine in a restricted manner to form 24 specific dimers, which exhibit different ligand- binding properties. Integrin subunits have large dependent adhesion site (MIDAS), which binds divalent cations required for ligand binding by integrins. The b subunit is composed of a hybrid domain that connects to the bI domain, which is A Inactive low affinity integrin Active high affinity integrin B C D βA βα βTD β propeller Hybrid Thigh Genu Calf 1 MD NxxY MP NPxY Calf 2 PSI Transmembrane Cytoplasmic Head EGF Rod F1 F1 F2 F2F3 F3 F0 PH N-term Kindlin Talin Fig. 1. (A) Integrin architecture and schematic representation of integrin activation. Specific contacts between the ectodomains, the TM, and cytoplasmic domains keep the integrin in its bent conformation. onJwww.sciencemag.orgDownloadedfrom タリンとキンドリンがインテグリンを活性化する Talin and Kindlin activate integrin Moser M, Science 2009
  • 31. egrins without an I domain, ligands bind to crevice between the ab subunit interface, here they interact with a metal ion–occupied IDAS within the b subunit and the propeller main of the a subunit. The structure of the short TM domains is orly defined because of the lack of high- olution structures of heterodimeric TM do- ains in their proper context, and only the uctures of the b3 and the aIIb subunits are lved in their entirety (3–5). The b3 TM do- ain is a 30-residue linear a helix that is longer an the width of a typical lipid bilayer, which plies a pronounced helix tilt within the plas- a membrane (5). The aIIb TM domain is a 24- idue a helix followed by a backbone reversal d does not exhibit a helix tilt (4). This unusual otif is highly conserved in the 18 human egrin a subunits and probably has an impor- nt role in the transition from low- to high- inity states. A high degree of similarity is found in the ort a and b cytoplasmic tails, especially in the embrane proximal region where the GFFKR d HDR(R/K)E sequences are conserved in e a and b subunits, respectively (6). Nuclear agnetic resonance (NMR) studies that used egrin-derived aIIb3 polypeptides proposed at integrins interact with each other through drophobic and electrostatic interactions and a t bridge between the R residue within the FKKR motif and the D residue within the DRRE motif (7, 8). However, these interactions ere not seen by others, suggesting that tail eractions are very weak at best (9). Almost b tails have two well-defined motifs that are rt of a canonical recognition sequence for osphotyrosine-binding (PTB) domains (10), nsisting of a membrane proximal NPxY (where mains that regulates integrin subunit packing (14). Separation of integrin TM domains has been suggested to be a requirement for integrins to adopt the high-affinity state. There are two possible ways by which TM domain interactions has been extensively examined in the rapidly activated b2 and b3 integrins. Although muta- tional analysis suggests that the salt bridge is important for maintaining these integrins in a low-affinity state (15), this might not be the case for all integrins, especially the b1 integrins (16). Despite the con- troversial role of the salt bridge in maintaining integrins in a low- affinity state, high integrin affinity is thought to be associated with separation of the a and b cyto- plasmic tails. Many proteins bind directly to integrin tails, yet only talin and kindlins can regulate integrin affinity. The role of these NxxY motifs–binding proteins in integrin activation and function will now be discussed in detail. Talin Is an Essential Mediator of Integrin Activation Talin is a component of adhesion plaques and interacts with integrin cytoplasmic tails (17). Its role in altering integrin function was orig- inally demonstrated by its ability to induce a shift in the affinity of a normally inactive integrin expressed in chinese hamster ovary (CHO) cells (18, 19). Knockout and knock- down experiments subsequently re- inforced the notion that talin is a key regulator of integrin affinity for ligand, and many mutational and structural studies have described the mechanism by which it accom- plishes this task. Talin orthologs have been identified in all multi- A B C Autoinhibition Binding to the MP NPxY Binding to the MP helical region Integrin PIP2 Calpain cleavage Phosphorylation? Talin Activation タリンのインテグリン細胞内ドメインへの結合が活性化をトリガーする Talin activates integrin Moser M, Science 2009
  • 32. mon binding motif for PTB domain– roteins (18, 19, 29). Mutations with- motif of both b1 (30) and b3 (31) well as mutations in the talin PTB abolish talin binding and egrin affinity. Insights n increases integrin af- rom NMR experiments t the talin head effec- mpetes the aIIb tail for he b3 tail (7). Fluores- y transfer (FRET) ex- n cells confirmed that d induces separation of ails (in this case aLb2), comitant with increased n ligand binding (33). d of talin1 by small in- A (siRNA) cannot re- mmon activation stimuli rmore, genetic experi- norhabditis elegans (34), 35), and mice (36–38) that talin1 ablation uni- s to integrin-adhesion se experiments led to at talin was both nec- sufficient to activate owever, the claims of were later shown to be ification. question is why talin defect (42). Expressing the talin1 head in these cells partially restored the spreading defect, but FAs were still absent, demonstrating that the clustering of integrins into larger adhesion struc- elicits a conformational change that di autoinhibitory interaction and enhances talin binding (45, 46). Although phosph binding can enhance the affinity of m domains for their substrates does not hold true for the iso head (46). Talin binds to PI directs it to focal adhesions thus, a feed-forward loop m enhance talin recruitment adhesion formation. In hematopoetic cells, t sine triphosphatase (GTPa has been implicated in tal ment to integrin tails. Exp constitutively active Rap1A increases integrin activation the deletion of Rap1B in decreases aIIbb3 activation sociation of the Rap1 effec GTP–interacting adaptor (RIAM) resulting in a Rap talin ternarycomplex atthein has been shown to be requir interaction (49, 50). A simila mediated activation mechan also occur in nonhematopo because a direct interaction talin and lamellipodin, a mem MRL (Mig-10/RIAM/Lam family of adaptor proteins, a in integrin activation (51). Integrin PIP binding? Phosphorylation? Fig. 3. Hypothetical model of kindlin recruitment and binding to the b タリンの作用機序の詳細:Talin activates integrin at the membrane-cytoplasmic interface Moser M, Science 2009
  • 33. Activation ionarily con- oteins named drome, a rare hree kindlin n-1 [Unc-112 (Mig2), and which is pre- s, is found in ey; kindlin-2 st amounts in nd kindlin-3 ematopoietic localize to dlin-1 and -2 3 localizes to ent adhesion of the integrin ortholog of rins in dense ession results t is similar to s (66). Two ne mutations tive integrin caused by the matosis char- esion defect eous atrophy mplicated in a AD) type III Kindlin-mediated integrin activation requires a direct interaction between kindlin and b integrin tails. The kindlin and talin FERM domains show high levels of sequence similarity (73); however, suggests that a lack of kindlin-3 binding might be responsible for the bleeding phenotype (61). Because kindlins and talin bind distinct re- gions of the b integrin tail, they may cooperate to Sequential binding A B C Cis co-operation Trans co-operation Fig. 4. Putative crosstalk mechanisms between talin and kindlin during integrin activation. (A) onJune7,2012www.sciencemag.orgdedfrom タリンとキンドリンの協調作用 How do Talin and Kindlin act together on integrin? Moser M, Science 2009
  • 34. Interim summary(中間まとめ): Cell Adhesion Cascade(細胞接着のカスケード) Multiple Steps Happen in Sequence Leading to Extravasation 複数のステップが連続して起こる。前のステップは次のステップに必須
  • 35. What would happen to leukocytes, if integrins were absent? インテグリンが欠損すると白血球に どんな問題がおこるか? X
  • 36. Leukocyte Adhesion Deficiency Type-I LAD-I 白血球接着不全症(1型)
  • 37. Leukocyte Adhesion Deficiency Type-I LAD-I 白血球接着不全症(1型) -Primary immundeficiency(原発性免疫不全のひとつ) -Recurrent and often fatal bacterial infection (繰り返し、しばしば致死的な細菌感染症) -No pus formation(膿がない) -Leukocytosis (30,000~100,000 / µl)(血中白血球数増加) Case: 3-year-old female presented to her dentist “Gums are red, painful, and bleeding for 3 months” Genetic defect of β2 integrins (CD18) (β2インテグリンの遺伝的欠損)
  • 38. What would happen to leukocytes, if Sialyl LewisX (s-Lex) was absent? 糖鎖シアリルルイスXが欠損すると 白血球にどのような問題がおこるか? X
  • 39. -Functional defects in selectin ligand(セレクチン・リガンドの機能不全) -Rolling interactions perturbed(ローリングが阻害される) -Recurrent and often fatal bacterial infection -No pus formation -Leukocytosis Genetic defect of the enzyme to attach sialyl lewisx (s-Lex) 糖鎖シアリルルイスXをタンパクに付加する酵素の遺伝的欠損 Leukocyte Adhesion Deficiency Type-II LAD-II 白血球接着不全症(2型)
  • 40. What would happen to leukocytes, if kindlin-3 (an integrin-activating signal) was absent? キンドリンが欠損すると白血球にど んな問題が起こるか? X
  • 41. -Functional defects in integrin activation(インテグリン活性化不全) -Integrins are present but unresponsive to chemokines (インテグリン発現はあるが、ケモカイン刺激に反応しない) -Recurrent and often fatal bacterial infection -Platelet dysfunction(白血球だけでなく、血小板凝集不全も) -No pus formation -Leukocytosis Genetic defect of kindlin-3 Leukocyte Adhesion Deficiency Type-III LAD-III 白血球接着不全症(3型)
  • 42. Activation ionarily con- oteins named drome, a rare hree kindlin n-1 [Unc-112 (Mig2), and which is pre- s, is found in ey; kindlin-2 st amounts in nd kindlin-3 ematopoietic localize to dlin-1 and -2 3 localizes to ent adhesion of the integrin ortholog of rins in dense ession results t is similar to s (66). Two ne mutations tive integrin caused by the matosis char- esion defect eous atrophy mplicated in a AD) type III Kindlin-mediated integrin activation requires a direct interaction between kindlin and b integrin tails. The kindlin and talin FERM domains show high levels of sequence similarity (73); however, suggests that a lack of kindlin-3 binding might be responsible for the bleeding phenotype (61). Because kindlins and talin bind distinct re- gions of the b integrin tail, they may cooperate to Sequential binding A B C Cis co-operation Trans co-operation Fig. 4. Putative crosstalk mechanisms between talin and kindlin during integrin activation. (A) onJune7,2012www.sciencemag.orgdedfrom 思い出そう: How do Talin and Kindlin act together on integrin? Moser M, Science 2009
  • 43. ZIP code theory Different integrins determine “lymphocyte homing” to specific organs Brain Gut Organ (destination) Integrin α4β1 + VCAM-1 Integrin α4β7 + MAdCAM-1 Leukocyte + Endothelium
  • 44. Integrins support immune cell patrolling of specific organs Von Andrian UH, N Engl J Med 2000
  • 45. Integrins support immune cell accumulation to inflamed organs Von Andrian UH, N Engl J Med 2000
  • 46. • Chronic, often disabling disease that attacks the central nervous system • Immune system attack against the central nervous system • Autoimmunity to myelin. Multiple Sclerosis(MS, 多発性硬化症) < Pathogenesis >
  • 47. • Paralysis or loss of vision • Relapses leading to irreversible disability Multiple Sclerosis < Clinical symptoms >
  • 48. • Integrin α4β1-VCAM-1 interaction supports immune cell trafficking to the inflamed brain. Multiple Sclerosis < Molecular mechanism>
  • 49. • Integrin α4β1-VCAM-1 interaction supports immune cell trafficking to the inflamed brain. evaluate potential new therapies in proof-of-concept trials.30 The effect of new gadolinium-enhancing lesions was recognized as an appropriate outcome measure for testing natalizumab’s efficacy, given its known mecha- nism of action; it was investigated in a small, parallel- group, placebo-controlled trial in which subjects re- ceived 2 doses of placebo or natalizumab 1 month apart and were followed up with regular MRI scans for 6 months. The trial was smaller than desirable for phase 2 evaluation of efficacy by MRI, necessitated in part by a limited supply of drug. However, the study reached its primary end point: the adjusted mean cumulative num- ber of new active lesions was lower in the natalizumab- treated group than in the placebo group (1.8 vs 3.6; P=.04, analysis of covariance).25 Most of the new active lesions were areas of new enhancement. In an accompanying edi- torial,31 the trial finding was described as a “near hit.” Had the study not reached its primary end point, one could speculate that it would have been a near miss and that the drug would not have been investigated further. Also, a possible increase in relapse rate following withdrawal of natalizumab therapy was noted in this trial; as in the second study half, there were significantly more acute clinical exacerbations in the natalizumab group.25 An- other study failed to show more rapid or complete re- lapse recovery with natalizumab treatment, although a significant decrease in gadolinium-enhancing lesion vol- ume was noted for both active treatment groups early in the study. There was no evidence of increased relapses following natalizumab withdrawal.26 27 A B α4 integrin Lymphocyte VCAM1Lumen Endothelial cell Parenchyma Natalizumab Lumen Endothelial cell Parenchyma Lymphocyte Figure 2. Schematic representations. A, Activated leukocytes expressing ␣4 integrin, which induces receptor-mediated adhesion to endothelial cells. This interaction is required for transmigration of activated leukocytes into the Rudick Lancet Neurol 2012 Multiple Sclerosis < Novel therapy (anti-integrin therapy)>
  • 50. DISCOVERY In the 1980s, analysis of lymphocyte migration oc- curred in many centers. At Stanford and Harvard uni- versities, Butcher and Picker11 and Springer12 were elu- ous antibodies applied prior to the addition of lympho- cytes to frozen sections. Attachment was almost en- tirely blocked by antibodies to ␤1 integrin. The integrin molecule’s ␤ chain binds to 1 of 6 unique ␣ chains. An- tibodies specific for the ␣ chains were applied to the fro- Phase 1 research begins Alpha-4 integrin discovered to be key molecule involved in homing to the brain Biogen and Elan announce collaboration on the development/commercialization of natalizumab for both MS and Crohn disease indications FDA approves natalizumab for relapsing forms of MS Natalizumab returns to US market with pharmacovigilance plan in place; EMEA approves natalizumab US label lists 3 confirmed risk factors for PML Phase 3 trial of natalizumab in RRMS begins Drug voluntarily suspended from US market on the basis of 3 PML cases European label lists 3 confirmed risk factors for PML 20121992 1997 2000 2001 2004 2005 2006 2011 Figure 1. Timeline of major natalizumab milestones.1-7 EMEA indicates European Medicines Agency; FDA, Food and Drug Administration; MS, multiple sclerosis; PML, progressive multifocal leukoencephalopathy; RRMS, relapsing-remitting MS. Rudick Lancet Neurol 2012 Multiple Sclerosis < A model for translational medicine > Timeline from bench to bedside
  • 51. What adverse effects would you expect, if you block a4 integrins?
  • 53. PML: Progressive Multifocal Leukoencephalopathy 進行性多巣性白質脳症 Fatal encephalitis (致死性脳炎) Re-activation of latent JC viurs infection  (不顕性JCウィルス感染症の再活性化)
  • 54. brief report The new england journal of medicine ProgressiveMultifocalLeukoencephalopathy afterNatalizumabTherapyforCrohn’sDisease Gert Van Assche, M.D., Ph.D., Marc Van Ranst, M.D., Ph.D., Raf Sciot, M.D., Ph.D., Bénédicte Dubois, M.D., Ph.D., Séverine Vermeire, M.D., Ph.D., Maja Noman, M.D., Jannick Verbeeck, M.Sc., Karel Geboes, M.D., Ph.D., Wim Robberecht, M.D., Ph.D., and Paul Rutgeerts, M.D., Ph.D. The prior diagnosis of fatal astrocytoma in a 60-year-old man with Crohn’s disease treatedwithnatalizumab,amonoclonalantibodyagainsta integrins,wasreclassified summary n engl j med 353;4 www.nejm.org july 28, 2005 s,natalizumab(Tysabri,ElanandBiogenIdec),incombinationwithinterferon (Avonex,BiogenIdec).4 Oneofthesecasesisdescribedelsewhereinthisissue urnal.5 WereportathirdcaseofPML—thisoneinapatientwithCrohn’sdis- oreceived300mgofopen-labelnatalizumabintravenouslyeveryfourweeksas clinicaltrial.PMLisanopportunistic,infectious,demyelinatingbraindisorder edwithimpairedT-cellfunction.Therelationshipbetweennatalizumabtherapy L in our patient is clearly illustrated by the gradual increase in the number of fJCvirusinthebloodduringmonotherapyinthemonthsprecedingthedevel- offatalPML. r-oldpatientwithlong-standingilealCrohn’sdiseasepresentedtotheemergen- withsevereconfusionanddisorientationonJuly3,2003.Treatmentwithnatal- ahumanizedmonoclonalantibodyagainsta4 integrins,hadbeeninitiatedin 002.Hehadinitiallyreceivedthreemonthlyinfusionsof300mgintravenously he Evaluation of Natalizumab as Continuous Therapy 1 (ENACT-1) trial, fol- ytreatmentwithplaceboforninemonthsintheENACT-2trial.Open-labelna- abatadoseof300mggivenintravenouslyeveryfourweekswasthenresumedin case report The new england journal of medicine brief report ProgressiveMultifocalLeukoencephalopathy inaPatientTreatedwithNatalizumab Annette Langer-Gould, M.D., Scott W. Atlas, M.D., Ari J. Green, M.D., Andrew W. Bollen, M.D., and Daniel Pelletier, M.D. From the Departments of Neurology and Health Research and Policy, Stanford Uni- versity School of Medicine, Stanford, Cal- if. (A.L.-G.); the Department of Radiology, Hoover Institution at Stanford University, Stanford, Calif. (S.W.A.); and the Depart- ments ofPathology(A.W.B.)andNeurology (A.J.G., D.P.), University of California, San Francisco, San Francisco. Address reprint requests to Dr. Annette Langer-Gould at HRP Redwood Bldg., Rm. T202, Stanford, CA 94305-5405, or at annette1@stanford. edu. This article was published at www.nejm.org on June 9, 2005. N Engl J Med 2005;353:375-81. We describe the clinical course of a patient with multiple sclerosis in whom progres- sivemultifocalleukoencephalopathy(PML),anopportunisticviralinfectionofthecen- tralnervoussystem,developedduringtreatmentwithinterferonbeta-1aandaselective adhesion-molecule blocker, natalizumab. The first PML lesion apparent on magnetic resonanceimagingwasindistinguishablefromamultiplesclerosislesion.Despitetreat- mentwithcorticosteroids,cidofovir,andintravenousimmuneglobulin,PMLprogressed rapidly,renderingthepatientquadriparetic,globallyaphasic,andminimallyresponsive. Threemonthsafternatalizumabtherapywasdiscontinued,changesconsistentwithan immune-reconstitution inflammatory syndrome developed. The patient was treated withsystemiccytarabine,andtwomonthslater,hisconditionhadimproved. rogressivemultifocalleukoencephalopathy(pml)isarare,oli- godendroglial infection caused by the polyomavirus JC virus. It usually occurs in people infected with the human immunodeficiency virus (HIV), but it has also been reported in immunocompromised patients receiving prolonged treatment withmethotrexate,cyclophosphamide,andazathioprine.PMLhasnotbeenreportedin persons with multiple sclerosis, despite the frequent use of these medications to treat thedisease. WedescribetheclinicalcourseofapatientwithmultiplesclerosisinwhomPMLde- veloped during treatment with interferon beta-1a (Avonex, Biogen Idec) and natalizu- mab(Tysabri,BiogenIdecandElan),amonoclonalantibodyagainsta4integrins.Despite thediscontinuationofthesemedications,hisPMLprogressedrapidly.Animmune-recon- stitutioninflammatorysyndromedevelopedthreemonthsafterthecessationofnatali- zumabtherapy,andthepatientbecamebedriddenandminimallyresponsive.Treatment withintravenouscytarabinewasbegun,andshortlythereafter,hisconditionimproved. summary p n engl j med 353;4 www.nejm.org july 28, 2005 375 irst symptom of what proved to be relapsing–remitting multiple sclerosis. condattackin1989andhadtwoorthreeattacksperyearbetween1989and medicalhistorywasalsonotablefortheRamsayHuntsyndromewithauric- in 1998, a malignant melanoma excised from his back with negative mar- 6, and a cleft lip and palate. A sister also had relapsing–remitting multiple The New England Journal of Medicine d from nejm.org at HARVARD UNIVERSITY on June 7, 2012. For personal use only. No other uses without permission. Copyright © 2005 Massachusetts Medical Society. All rights reserved. The new england journal of medicine brief report Progressive Multifocal Leukoencephalopathy after Natalizumab Monotherapy Hans Lindå, M.D., Ph.D., Anders von Heijne, M.D., Eugene O. Major, Ph.D., Caroline Ryschkewitsch, B.S., Johan Berg, M.D., Tomas Olsson, M.D., Ph.D., and Claes Martin, M.D., Ph.D. Summary We describe progressive multifocal leukoencephalopathy (PML) caused by infection with human polyomavirus JC virus in a patient with multiple sclerosis who was treated with natalizumab. The first PML symptoms appeared after 14 monthly infu- sions of the drug. Magnetic resonance imaging (MRI) showed a presumed multiple sclerosis lesion, and JC virus DNA was not detected on polymerase-chain-reaction (PCR) assay of cerebrospinal fluid. The patient’s symptoms worsened, and the diag- nosis of PML was established with a more sensitive quantitative PCR assay after 16 infusions of natalizumab. Plasma exchange was used to accelerate clearance of natalizumab. Approximately 3 weeks after plasma exchange, an immune-reconsti- tution inflammatory syndrome appeared. JC virus DNA was no longer detectable on quantitative PCR assay, and the patient’s symptoms improved. n engl j med 361;11 nejm.org september 10, 2009 1081 N Engl J Med 2009;361:1081-7. Copyright © 2009 Massachusetts Medical Society. umab monotherapy. We describe the development of PML in a patient le sclerosis who had received natalizumab as monotherapy. Pretreatment History r 2006, a 35-year-old, left-handed man presented with a 1-year history des of numbness in both legs and a tingling sensation in his hands. At MRI of the brain with the use of a Gyroscan Intera 1.5T (Philips) showed 50 lesions on T2-weighted images. The patient’s reflexes were exagger- legs. Sensation of vibration was absent in his feet, and there was par- hesia on the left side. His only motor symptom was mild paresis in the Analysis of the cerebrospinal fluid showed oligoclonal IgG bands. The The New England Journal of Medicine from nejm.org at HARVARD UNIVERSITY on June 7, 2012. For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society. All rights reserved. AREV402-ME61-03 ARI 7 December 2009 18:7 • Clinical symptoms: • Cognitive impairments • Visual deficits • Motor dysfunction *Language disturbances, seizures, and headaches are more frequent in AIDS patients • PML occurrence: • Immune-compromised host • 3–5% in HIV-1+ (global) • AIDS-defining illness • Not always fatal with • immune reconstitution • (inflammatory syndrome) Figure 1 Progressive multifocal leukoencephalopathy (PML). Left: MRI scan of bilateral multifocal, subcortical demyelinated lesions in the cerebral hemispheres of a PML patient. A representative lesion outlined in red is shown on histopathology (top center) with a demyelinated plaque (d) on luxol fast blue stain resulting from lytic infection with the human polyomavirus JCV. Bottom center: Mature virion particles are shown assembled in a crystalline array in the nucleus of an oligodendrocyte. Right: The predominant clinical aspects and occurrence of PML are highlighted. common as cognitive problems at the time of suspicion of PML. Visual deficits such as hemi- anopsia can be present. Other clinical signs that are not as common are seizures, language problems, and headaches. The clinical course of PML has been described as progressive and nearly always fatal; death occurs from weeks to the hope that JCV-infected cells can still be cleared from the brain. Patients with substantial levels of CD8+ cytotoxic T cells specific to the viral capsid protein have a better prognosis that correlates with a less progressive course of dis- ease (12, 13). No such correlation exists with humoral immunity; PML patients have sub- Annu.Rev.Med.2010.61:35-47.Downloadedfromwww.annualreviews.org byHarvardUniversityon06/07/12.Forpersonaluseonly. PML associated with anti-integrin therapies Major EO, Annu Rev Med 2010
  • 55. PML associated with anti-integrin therapies plus α Carson KR, Lancet Oncol 2009 had AIDS. As the HIV epidemic grew in the 1980s, PML emerged as a major complication of HIV infection (both HIV-1 and HIV-2). The incidence of PML increased 50-fold between 1979 and 1994.12 Since then, highly active antiretroviral therapy (HAART) has helped reduce the progression and the severity of PML in individuals with HIV, although HIV infection continues to account for about 80% of all new PML diagnoses.13 However, even with the use of HAART, the incidence of PML remains between 3% and 5% in patients with AIDS, which is an incidence similar to that reported in the pre-HAART era.14 HIV-infected patients with PML who are treated Correspondence to: Charles L Bennett, Northwestern University, 710 N Fairbanks Ct, Olson Pavilion, Suite 8-250, Chicago, IL 60611, USA cbenne@northwestern.edu Rituximab Natalizumab Efalizumab Mechanism Target Anti-CD20 Binds to the α4-integrin Anti-CD11 Lymphocytes mainly affected by the drug B lymphocytes T lymphocytes T cells Number of confirmed cases of drug-associated PML (mortality rate) 57 (mortality rate 89% [51 of 57])6 13 (mortality rate 23% [3 of 13]).Ten received monotherapy (median 25 months [range 12–25])7–9 Three (mortality rate 66·6% [2 of 3]; one additional case clinically suspected). All had received ≥3 years of monotherapy10 Number of PML cases identified in epidemiology or clinical studies One (a patient with rheumatoid arthritis developed PML in a safety extension study) Eight One Epidemiological estimate for drug-associated PML One in 4000 estimated in rituximab-treated patients with SLE (unapproved indication); estimates in rituximab-treated patients with lymphoid malignancies and rheumatoid arthritis not available at this time One in 1000 One in 400 in efalizumab-treated patients who received ≥3 years of therapy Safety actions of the FDA and the marketing authorisation holder in the USA Dateof initial marketing approval bythe FDA November, 1997 November, 2004 October, 2003 Dates warnings on PML issued by FDA December, 2006; September, 2008 February, 2005; June, 2006; August, 2008 October, 2008; February, 2009; March, 2009 Dates manufacturer issued warning for PML September, 2008 (“Dear Healthcare Provider” letter); February, 2007 (Black Box warning); December, 2006 (“Dear Healthcare Provider” letter) June, 2006 (Black Box) October, 2008 (“Dear Healthcare Provider” letter and Black Box warning); November, 2008 (“Dear Healthcare Provider” letter); February, 2009 (“Dear Healthcare Provider” letter) Marketing suspension None Voluntary withdrawal (February, 2005 to June, 2006). Returned to market place as monotherapy in conjunction with a risk management plan Manufacturer-initiated voluntary withdrawal (April, 2009) Risk-management (USA) Enhanced pharmacovigilance plan for PML implemented in 2007 Patient medication guide and revised product label TOUCH programme for all patients;Tysabri should not be administered concurrently with other immunosuppressants Risk Evaluation and Mitigation Strategies programme developed in March, 2009, including Patient Medication Guide and revised product label; manufacturer-initiated voluntary withdrawal in April, 2009
  • 56. Should we stop Tysabri? Tysabri is most effective for MS PML in 1:1000
  • 57. If we were to continue to use Tysabri, what should we do to prevent PML?
  • 58. To identify MS patients at high risk of PML
  • 59. New Analysis of Risk Stratification for TYSABRI® - Use of Biomarker has Potential to Advance Personalized Treatment for MS Patients - May 18, 2012
  • 60. Art Lancet Neu Published O January 6, 2 DOI:10.101 4422(11)70 See Comm Departmen Neuroinfla (Prof D H M NMR Resea (D MacMan Institute o London, U Marienkra University Hamburg, (ProfTWeb Neuroscien Statistics, (R Grove M Medicine D GlaxoSmit (CWardell P Research, A Chapel Hill (J Horrigan Medicine D (O Graff MD Firategrast for relapsing remitting multiple sclerosis: a phase 2, randomised, double-blind, placebo-controlledtrial David H Miller, Thomas Weber, Richard Grove, Claire Wardell, Joseph Horrigan, Ole Graff, Gillian Atkinson, Pinky Dua, Tarek Yousry, David MacManus, Xavier Montalban Summary Background Monoclonal antibody therapy against α4β-integrin is efficacious in patients with multiple sclerosis (MS) with some safety concerns. We assessed the safety and efficacy of firategrast, a small oral anti-α4β-integrin molecule, in patients with relapsing remitting MS. Methods We did a multicentre, phase 2, randomised, double-blind, placebo-controlled, dose-ranging study in participants with clinically definite relapsing-remitting MS. A 24-week treatment period was followed by 12 weeks of core follow-up and 40 weeks of extended follow-up. Participants were randomly assigned, via computer-generated block randomisation in a 1:2:2:2 ratio, to receive one of four treatments twice a day: firategrast 150 mg, firategrast 600 mg, or firategrast 900 mg (women) or 1200 mg (men), or placebo. Brain scans were obtained at 4-week intervals to the end of core follow-up. The primary outcome was cumulative number of new gadolinium-enhancing brain lesions during the treatment phase and was analysed using a generalised linear model with an underlying negative binomial distribution, adjusted for sex, baseline number of new gadolinium-enhancing lesions, and country. This study is registered with ClinicalTrials.gov, NCT00395317. Findings Of 343 individuals enrolled, 49 received firategrast 150 mg, 95 received firategrast 600 mg, 100 received firategrast 900 mg or 1200 mg, and 99 received placebo. A 49% reduction (95% CI 21·2–67·6; p=0·0026) in the cumulative number of new gadolinium-enhancing lesions was seen for the 900 mg or 1200 mg firategrast group (n=92, mean number of lesions 2·69 [SE 1·18]) versus the placebo group (90, 5·31 [1·18]). In the 600 mg group (86, 4·12 [SE 1·19]), a non- significant 22% reduction (95% CI –21·3 to 49·7; p=0·2657) occurred in mean number of new gadolinium-enhanced lesions relative to placebo; for the 150 mg group (47, 9·51 [SE 1·24]), a 79% increase (95% CI 4·1–308·1; p=0·0353) occurred relative to placebo. Firategrast was generally well tolerated at all doses. The frequency of all adverse events was similar across all treatment groups except for an increased rate of urinary tract infections in the high-dose firategrast group. No cases of progressive multifocal leukoencephalopathy or evidence of reactivation of JC virus were identified. www.thelancet.com/neurology Vol 11 February 2012 prognosis.5–10 Orally administered disease-mo treatments have only recently become available.11 Since 2006, natalizumab, a long-acting, hum monoclonal antibody to α4β1 and α4β7 i receptors, has been a treatment option for patien highly active relapsing remitting MS. The drug trafficking of mononuclear white blood cells acr blood–brain barrier, and was associated with Small-molecule inhibitor to α4 integrin alleviates MS No PML case was seen in 149 patients receiving firategrast
  • 61. Advanced Topics 1: More than three steps (Vestweber, “How leukocytes cross the vascular endothelium” Nat Rev Immunol 2015) 2: Leukocyte migration in 3D (Weninger et al., “Leukocyte migration in the interstitial space of non-lymphoid organs” Nat Rev Immunol 2014)
  • 62. More than 3 steps: the updated multistep cascade model for leukocyte extravasation
  • 63. Signaling steps initiating the opening of endothelial cell junctions
  • 64. Amoeboid mode migration of leukocytes in a 3D-environment
  • 65. The perivascular extravasation unit assists in leukocyte migration
  • 66. Three-step cascade guides neutrophils to the site of sterile injury
  • 67. Context-dependent mechanisms of neutrophil attraction to injury sites