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Vitaliani, Roberta (2009) PNS-EURONETWORK DATABASE: Encefaliti limbiche paraneoplastiche. [Tesi di dottorato]

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Abstract (inglese)

Background: Paraneoplastic limbic encephalitis (PLE) has been identified as a separated clinical entity by Corsellis et al. in 1965. It is clinically characterized by short term memory loss, psychiatric symptoms, confusion and seizures. To date there are only two case series with a limited number of patients describing PLE (Gultekin et al., 2000 and Lawn et al 2003).
Aims: This European multicenter study was designed to investigate the clinical, oncological and immunological profiles in a larger PLE population and to search for new antibodies targeted towards relevant neuronal antigens.
Methods: Patients. In 2002 a European network for Paraneoplastic neurological syndromes was developed (PNS-Euronetwork) thanks to the support of the European commission (QLGT-CT-2002-01756; LSSM-CT-2005 518174), which allowed the creation of a PNS database. The members of the network were invited to include in that database patients with PNS diagnosed after the year 2000. In this particular study we analyzed all PLE patients included in the database up till September 2008.
Antibodies detection. The patients’ sera were analyzed by immunohistochemistry on rat brain sections and western blot on brain protein homogenate or immunoblot with recombinant proteins. The presence of voltage gated potassium channel (VGKC) antibodies or voltage gated calcium channel (VGCC) antibodies was confirmed by radioimmunoprecipitation assay. Atypical reactivities were studied on hippocampal cells cultures and in particular cases immunocytochemistry on transfected HEK-293 cells was employed.
Statistical analysis. Proportional terms were used as descriptive statistics for categorical variables and median and mean for continue ones. A t-Student test was used to compare quantitative variables, whereas a Chi-square test or a Fisher exact test for qualitative ones. Survival curves were obtained using the Kaplan-Mayer method and the differences compared with the Log-rank test. The analysis were performed using SAS (version 9.02, SAS system, Cary NC)
Results: In the PNS-database 917 patients were included and 104 of these were affected by PLE. The latter group was made up of 66 males and 38 females, and their median age was 61.5 years. The clinical picture was characterized by short term memory loss (77%), confusional state (54.8%), seizures (44.2%) - mainly partial seizures (complex 37%, simple 32.6%)- and psychiatric disorders (52.8%) -mostly abnormal behavior (54.5%) and depression (32.7%). In 49 of our patients other symptoms were also detected: ataxia (n=15), neuropathy (n=11), brainstem encephalitis (n=9) and dysautonomia (n=8). These patients were referred as having PLE “plus”. A tumor was identified in 90.4% of patients: the more frequent ones were small cell lung cancer (SCLC) (39.4%) and testicular cancer (9.6%); worthy of note was the detection in two cases of a gastric cancer, which has never been reported in association with PLE. Anti-neuronal antibodies were present in 87.5% of patients and the most frequent ones were anti-Hu (56%) and anti-Ma2 (24.2%). Anti-Hu patients had more often SCLC (p<0.0001) and a worse response to tumor treatment (p=0.044) than patients with anti-Ma2 or patients without antibodies. On the other hand, other reactivities such as anti-VGKC (n=2), anti-N-metil-D-aspartate receptor (anti-NMDAR) (n=2) and anti-Tr (n=1) were rarely identified. Moreover in one patient we detected a new antibody directed against the gluR2 sub-unit of the AMPA (?-ammino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) glutamate receptor. Only 12.5% of patients with PLE did not have anti-neuronal antibodies, compared to 40% of cases reported in literature.
The CSF showed inflammatory signs (increased cells and/or proteins content and/or positive presence of oligoclonal bands) in 58 out of 83 available exams. There was no difference among CSF results regardless of the timing of lumbar puncture (before or after 3 months from the clinical onset). The brain MRI was unremarkable in 26% of cases, but 11% of these had a positive FDG-PET brain scan. Forty-six patients received and immunomodulatory treatment (mainly steroids) and 16 improved by at least 1 point on the modified Rankin Scale. Instead, by treating the tumor, a significant improvement of the neurological syndrome was obtained in 23 out of 76 patients in whom the tumor was detected after the neurological onset. The different clinical, oncological and immunological characteristics of the patients with PLE “plus” and PLE “pure” were compared. We did not find significant differences between these two groups with the exception of the prevalence of testicular cancer in the “pure” PLE cohort. In the PLE “plus” group, 21 patients could be classified as having paraneoplastic encephalomyelitis (PEM). This subgroup was then compared with the PLE “plus” cohort (28 patients): PEM patients were older (p=0,0221), and were more frequently associated with SCLC (p=0.0111), anti-Hu antibodies (p=0.0024), pathological MRI (p=0.0272) and mortality for PNS (p= 0.0160).
Conclusion: To our knowledge, this represents the largest series on PLE patients ever reported. We found that PLE is more frequent in males and it could be associated with different tumours including gastric cancer: this association has never been reported before. Moreover we observed a lower percentage of patients without antibodies compared to the literature and detected a new antibody (anti-AMPAR) which widens the spectrum of PLE associated with anti-neuronal surface antigens. We also found no significance difference between PLE “pure” and PLE “plus”, except for a higher prevalence of testicular cancer in the former group. Finally, the PLE “plus” cohort differs from the PEM group for age, association with SCLC, anti-Hu antibodies and mortality due to PNS.

Abstract (italiano)

Background: L’encefalite limbica paraneoplastica (ELP) è stata identificata per la prima volta come entità clinica distinta da Corsellis et al., nel 1965 e si caratterizza sotto il profilo clinico per la presenza di deficit della memoria a breve termine, confusione, sintomi psichiatrici e crisi epilettiche. A oggi lo stato dell’arte relativo a tale patologia deriva principalmente dalla descrizione di due serie con un numero limitato di pazienti (Gultekin et al., nel 2000 e Lawn et al., nel 2003). Più recentemente le conoscenze sull’ELP si sono ampliate grazie all’identificazione di nuove reattività anticorpali e al riconoscimento di diversi quadri di presentazione clinica.
Scopo: Questo studio Europeo multicentrico è stato disegnato per analizzare le caratteristiche cliniche, oncologiche e immunologiche di un ampio gruppo di pazienti affetti da ELP e per identificare eventuali nuove reattività anticorpali dirette contro importanti antigeni neuronali.
Metodi: Pazienti. Nel 2002 è stato costituito un Network Europeo per le sindromi neurologiche paraneoplastiche (PNS-Euronetwork) supportato dalla Commissione Europea (QLGT-CT-2002-01756; LSSM-CT-2005 518174). È stato in seguito, costruito un database (PNS-database) in cui tutti i centri partecipanti dovevano inserire i pazienti con sindrome neureurologica paraneoplastica (SNP) diagnosticata dopo il 2000. Nel nostro studio, sono stati inclusi tutti i pazienti in cui fosse presente una diagnosi di ELP inclusi nel database fino al settembre 2008.
Analisi delle reattività anticorpali. I sieri dei pazienti sono stati analizzati mediante immunoistochimica su sezioni di encefalo di ratto, western blot su estratti proteici neuronali e immunoblot con proteina ricombinate. La presenza di anticorpi anti-canali per il potassio voltaggio dipendenti (VGKC) o per canali per il calcio voltaggio dipendenti (VGCC) è stata confermata mediante radioimmunoprecipitazione. Reatività anticorpali atipiche sono inoltre state studiate su colture di cellule ippocampali. In casi particolari è stata inoltre utilizzata immunocitochimica su cellule HEK-293 transfettate.
Analisi statistica. Termini proporzionali sono stati usati come statistica descrittiva per variabili categoriche e media e mediana per variabili continue. Per confrontare variabili qualitative sono stai utilizzati Test Chi quadro o test di Fisher. Mentre per variabili quantitative è stato utilizzato il test T-Student. Analisi sulla sopravvivenza sono state ottenute attraverso il metodo di Kaplan Mayer e le differenze confrontate attraverso il Log-rank test. Le analisi sono state eseguite mediante SAS (versione 9.02, SAS system, Cary NC)
Risultati: Nel PNS database sono stati inclusi 917 pazienti di cui 104 risultarono affetti da PLE. I pazienti erano 66 maschi e 38 femmine di età media pari a 59.5 anni. La sindrome clinica si caratterizzava per la presenza di: deficit della memoria a breve termine (77%), stato confusionale (54.8%), crisi epilettiche (44.2%) -soprattutto di tipo parziale complesso (37%) o focale motorio (32.6%)- e sintomi psichiatrici (52.8%) -principalmente alterazione della personalità (54.5%) e depressione (32.6%). In 49 pazienti sono stati definiti come affetti da ELP “plus” in quanto presentavano sintomi indicativi del coinvolgimento di aree extralimbiche quali per esempio: atassia (n=15), neuropatia (n=11), encefalite del tronco (n=9), disautonomia (n=8). Un tumore è stato riconosciuto nel 90.4% dei pazienti ed i più frequenti sono stati lo SCLC (39.4%) ed il tumore testicolare (9.6%). Tra gli altri tumori, degno di nota è stato il riconoscimento in due casi dell’associazione con un tumore gastrico. Anticorpi anti-neurone sono stati riconosciuti nel 87.5% dei pazienti quelli più frequentemente riscontrati erano gli anti-Hu (56%) ed anti Ma2 (24.2%). I pazienti con anticorpi anti-Hu avevano più spesso uno SCLC (p<0.0001) ed avevano una SNP che rispondeva meno al trattamento del tumore (p=0.044) dei pazienti con anticorpi anti-Ma2 o senza anticorpi. Mentre raramente sono state riconosciute altre reattività anticorpali come anti-VGKC (n=2), anti-NMDAR (recettore N-Metil-D-aspartato) (n=2) and anti-Tr (n=1). Inoltre in un caso è stata riconosciuta una nuova reattività anticorpale diretta contro la sub unità gluR2 del recettore per il glutammato di tipo AMPA (?-ammino-3-idrossi-5-metil-4-isossazolpropionico acido). Solo il 12.5% dei casi non aveva anticorpi anti-neurone a confronto del 40% riportato in letteratura. All’esame del liquor si sono riconosciuti segni d’infiammazione (aumento delle cellule e/o delle proteine e/o presenza di bande oligoclonali) in 58 su 83 esami disponibili. Non si sono inoltre riscontrate differenze significative quando sono stati confrontati gli esami liquorali eseguiti a più o meno di 3 mesi dall’esordio clinico. La RNM encefalica è risultata normale nel 26% dei casi. Nell’11% dei pazienti in cui la RNM era negativa è invece stata dimostrata la presenza di una positività alla FDG-PET encefalica. 46/104 pazienti sono stati trattati con farmaci immunomodulatori (soprattutto steroidi) e 16 hanno mostrato un miglioramento di almeno un punto alla scala di Rankin modificata. Mentre con il trattamento del tumore si è ottenuto un miglioramento della sindrome neurologica in 23 su 76 pazienti in cui la diagnosi di neoplasia era successiva all’esordio della sindrome neurologica. Dal confronto delle caratteristiche cliniche, oncologiche ed immunologiche dei pazienti con ELP pura e plus non sono emerse differenze statisticamente significative se non per una maggiore frequenza del tumore testicolare nel primo gruppo. Nel gruppo con ELP plus inoltre, abbiamo identificato 21 soggetti che potevano essere riclassificati come affetti da encefalomielite paraneoplastica (EMP). Questi pazienti sono stati confrontati con i rimanenti 28 affetti da ELP plus. Da quest’analisi è emerso che i pazienti con EMP erano più anziani (p=0.0221) ed avevano più comunemente SCLC (p=0.0111), anticorpi anti-Hu (p=0.0024), RNM patologica (p=0.0272) e mortalità dovuta alla SNP (p=0.0160).
Conclusioni: La nostra è la più ampia casistica mai riportata in letteratura. I pazienti con ELP erano prevalentemente maschi ed avevano associate varie tipologie di tumore tra cui quella con tumore gastrico non precedentemente segnalata. Abbiamo inoltre osservato che una minor percentuale di pazienti, rispetto a quanto riportato in letteratura, non avevano anticorpi anti-neurone ed abbiamo anche identificato un nuovo anticorpo (anti-AMPAR) che allarga lo spettro delle ELP associate ad anticorpi diretti contro antigenti di superficie. Non abbiamo trovato differenze significative tra i casi con ELP pura e quelli con ELP plus tranne che per la maggior frequenza di tumore testicolare nel primo gruppo. Infine abbiamo osservato che la popolazione con ELP “plus” differiva da quella con EMP per età, maggiore associazione con SCLC, anticorpi anti-Hu e mortalità per patologia neurologica.

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Tipo di EPrint:Tesi di dottorato
Relatore:Tavolato, Bruno
Dottorato (corsi e scuole):Ciclo 21 > Scuole per il 21simo ciclo > SCIENZE MEDICHE, CLINICHE E SPERIMENTALI > NEUROSCIENZE
Data di deposito della tesi:28 Gennaio 2009
Anno di Pubblicazione:2009
Parole chiave (italiano / inglese):encefaliti limbiche paraneoplastiche; anticorpi anti-neurone; sindromi neurologiche paraneoplastiche; database
Settori scientifico-disciplinari MIUR:Area 06 - Scienze mediche > MED/26 Neurologia
Struttura di riferimento:Dipartimenti > Dipartimento di Neuroscienze
Codice ID:1565
Depositato il:28 Gen 2009
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