The estimated prevalence of chronic rhinosinusitis (CRS) is more than 10% in the European and US adult population.1 CRS can be subdivided into chronic rhinosinusitis with nasal polyps (CRSwNP) and chronic rhinosinusitis without nasal polyps (CRSsNP). Histopathologically, CRSwNP can be further classified into eosinophilic CRSwNP (with pronounced eosinophilic mucosal infiltration and type-2 inflammation) and noneosinophilic CRSwNP.2
Studies on cytokine profiles and transcription factor expression rates characterized eosinophilic CRSwNP by mucosal eosinophilia, Th2 and type 2 innate cell inflammation.3,4 Type 2 inflammation cytokines in CRSwNP are IL-4, IL-5 and IL-13, eosinophilic cationic protein (ECP) or Charcot Leyden Crystal protein.4,5,6 IL-5 is a key mediator in type 2 inflammation, providing survival, maturation and
activation of eosinophils at the bone marrow and the site of inflammation.7 Higher levels of mucosal and/or peripheral blood eosinophils are correlated with poor life quality, asthma comorbidity, recurrences after endoscopic surgery and CRSwNP disease severity, associated with inadequate defence against bacteria and viruses.8,9 Additionally, eosinophilic CRSwNP is associated with disrupted epithelial barrier and Staphylococcus aureus presence, which intramucosaly releases enterotoxins (SE). SE are immunogenic superantigens that bind to T cell receptors with unrestricted antigen specificity to activate T and B cells, finally leading to specific SE IgE production.10 SE IgE amplify the type 2 inflammation in eosinophilic CRSwNP and are an independent risk factor for asthma comorbidity.9,10 Staphylococcus aureus presence in nasal mucosal biofilm was associated with worse postoperative outcome after endoscopic surgery.11
Noneosinophilic CRSwNP was characterized by mixed Th1/ Th2/ Th17 pattern.4 A flow cytometric study showed a predominant Th1 endotype in CRSwNP in addition to Th2; however, in basal conditions, those Th1 cells were not activated, did not release cytokine IFNγ and thus the authors hypothesized that an increased number of Th1 in CRSwNP was not related to inflammation pathogenesis.12 Similarly, in our recent flow cytometric study, we found more abundant Th1 cells in CRSwNP compared to CRSsNP; however, we didn’t find any impact of Th1 cell count on disease control and speculated that Th1 cells were not important for the pathogenesis in CRSwNP.13
CRSsNP was found to have more heterogeneous endotypes, with either Th1, Th2 or Th17 cytokines; furthermore, the remodelling process was not in correlation with CRSsNP endotype.4,9,14 Th17 cells can secrete IL-17, IL-22 or IFN-γ upon stimulation.15 Moreover, in our recent flow cytometric study, we found that Th17 cells in CRSwNP were associated with well-controlled CRSwNP.13 Similarly, Th17 were reported to have a potentially protective immune homeostatic role in CRSwNP and to be a part of the normal homeostatic immune response in healthy nasal mucosa by IL-17 production.15
Regulatory T cells (Treg) control the CRS inflammation; the regulatory cells deficiency or dysfunction can lead to exaggerated inflammation; on the other hand, an elevated Treg number might be a sign of an unsuccessful inflammation control by immune system.16
Current therapeutic approaches still fail in a portion of patients with severe persistent CRS symptoms and recurrences after surgery.17 Future treatment concepts focus on up-stream targets like transcription factors;
Therefore, we decided to evaluate the gene expression of intrinsic cellular, lineage-defining, master transcription factors for effector T helper lymphocytes (Th) in relation to CRS phenotypes (CRSwNP compared to CRSsNP, eosinophilic CRSwNP compared to noneosinophilic CRSwNP): T-box transcription factor (T-bet
Twenty-two newly diagnosed, adult CRS patients (14 CRSwNP, 8 CRSsNP) were prospectively included at their first visit at the Department of Otorhinolaryngology and Head & Neck Surgery, University Medical Centre, Ljubljana, Slovenia. CRS diagnosis was established by symptoms, nasal endoscopy and a 2 or 3 mm computed tomography (CT) scan of paranasal sinuses. Included patients have never before used intranasal or systemic steroids. We took a biopsy of the middle meatal nasal polyp in CRSwNP patients or uncinate process mucosa in CRSsNP patients. Detailed patient inclusion data are shown in the flowchart in Figure 1 and detailed demographic data are summarized in Table 1. This study was conducted in accordance with the amended Declaration of Helsinki. The study was approved by the Slovenian National Medical Ethics Committee (approval number 34/10/12) and patients gave their written informed consent.
Demographic features, investigations and histopathological findings
CRSwNP (n = 14) |
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Demographic features, investigations and histopathology | CRSwNP study population (n = 14) | eosinophilic CRSwNP (n = 10) | noneosinophilic CRSsNP (n = 4) | CRSwNP study population (n = 8) | ||
Age (years) | 52.1 (39.3–62.4) | 49.4 (39.3–58.4) | 63.3 (37.6–68.3) | 0.18 | 45.2 (33.3–51.3) | 0.23 |
Female sex, no. (%) | 5 (35.7) | 4 (40) | 1 (25) | 0.60 | 4 (50) | 0.51 |
Allergy, no. (%) | 3 (21.4) | 1 (10) | 2 (50) | 0.10 | 1 (12.5) | 0.60 |
Asthma, no. (%) | 3 (21.4) | 1 (10) | 2 (50) | 0.31 | 1 (12.5) | 0.84 |
COPD, no. (%) | 1 (7.1) | 1 (10) | 0 (0) | 0.89 | 0 (0) | 0.71 |
Smoking, no. (%) | 3 (21.4) | 3 (30) | 0 (0) | 0.22 | 1 (12.5) | 0.60 |
CRS duration (y) | 4 (3–10) | 5.5 (2.5–10) | 4 (3–10) | 0.91 | 3 (2.3–9.3) | 0.37 |
VAS (0–10) at inclusion | 8 (7.8–9.3) | 8.5 (7.8–10) | 8 (5.8–8.8) | 0.42 | 9.5 (7.3–10) | 0.38 |
CT Lund MacKay score at inclusion | 15 (12.8–18) | 14.5 (12.8–18) | 17.5 (12.8–23) | 0.36 | 12 (8.3–12.8) | N.A. |
Endoscopic Lund Kennedy score at inclusion | 8 (7–9.3) | 8 (7–8.3) | 9 (8–10) | 0.15 | 4 (3–4) | N.A. |
Tissue eosinophilia > 10 / HPF, no. (%) | 10 (71.4) | 10 (100) | 0 (0) | N.A. | 1 (13) | |
Neutrophil infiltration, no. (%) | 6 (42.9) | 4 (40) | 2 (50) | 0.73 | 2 (25) | 0.40 |
Basement membrane thickening ≥ 7.5μm, no. (%) | 11 (78.6) | 10 (100) | 1 (25) | 8 (100) | 0.16 | |
Moderate / severe subepithelial oedema, no. (%) | 12 (85.7) | 9 (90) | 3 (75) | 0.47 | 1 (12.5) | |
Hyperplastic / papillary change, no. (%) | 5 (35.7) | 4 (40) | 1 (25) | 0.51 | 2 (25) | 0.53 |
Squamous metaplasia, no. (%) | 4 (28.6) | 3 (30) | 1 (25) | 0.85 | 4 (50) | 0.31 |
Fibrosis, no. (%) | 10 (71.4) | 7 (70) | 3 (75) | 0.85 | 7 (87.5) | 0.39 |
*
After sampling, the biopsy specimen was immediately fixed in 10% neutral-buffered formalin. Each paraffin-embedded specimen was sectioned at 5 micrometers thickness and stained by hematoxylin-eosin. The histopathologic evaluation of nasal biopsy specimens was performed using a structured CRS inflammation report as described by.2 On hematoxylin-eosin-stained sections, the specimens were analyzed for eosinophil count per high
power field (HPF) (< 5, 5–10, > 10), neutrophilic infiltration, basement membrane thickening (≥ 7.5μm), subepithelial edema (absent to mild, moderate to severe) and presence of hyperplastic / papillary change, squamous metaplasia and fibrosis.
After sampling, tissue biopsy was stored in RNA
the formula RQ sample = 2−(ΔCt sample−ΔCt calibrator). Nasal mucosa from the uncinate process of a control subject, 55 years old healthy female without CRS was used as a calibrator.
The data generated in the study were analyzed using GraphPad Prism 6.0 (San Diego, CA, USA). Statistical analysis was performed using the Mann-Whitney and Chi-square tests as appropriate with 2-tailed p. The data are expressed as numbers (percentages) or medians (first quartile (Q1) – third quartile (Q3)). The significance level was set at a p value of 0.05.
Twenty-two newly diagnosed CRS patients (14 CRSwNP and 8 CRSsNP) were prospectively included in the study. They have not been treated yet and have never used intranasal or systemic steroids. Both groups were comparable in age, sex, smoking, allergy, asthma, chronic obstructive pulmonary disease (COPD) and severity of CRS symptoms on visual analog scale 0–10. As expected, patients with CRSwNP had higher endoscopic Kennedy Lund scores than patients with CRSsNP. Exact clinical data are summarized in Table 1.
In concordance with CRS phenotypes, patients with CRSwNP had higher CT Lund MacKay scores at inclusion than patients with CRSsNP. Exact CT scores are summarized in Table 1. Representative CT scans of one CRSwNP and one CRSsNP patient are shown (Figure 2, 3).
Tissue eosinophilia > 10 per HPF was significantly more frequent (71%) in CRSwNP patients compared to CRSsNP patients (13%); meanwhile, there was no difference in tissue neutrophil infiltration between groups. As expected, moderate to severe subepithelial oedema was more pronounced in CRSwNP patients compared to CRSsNP patients. 10 CRSwNP patients with > 10 tissue eosinophils per HPF represented the eosinophilic CRSwNP group, the other 4 CRSwNP patients with < 10 tissue eosinophils per HPF represented the noneosinophilic CRSwNP group. More eosinophilic CRSwNP patients had basement membrane thickening ≥ 7.5μm compared to noneosinophilic CRSwNP patients. There was no difference in hyperplastic or papillary change, squamous metaplasia and fibrosis between groups. Exact histopathological data are summarized in Table 1.
T-bet
CRSwNP study population (n = 14) | CRSwNP (n =14) |
CRSsNP study population (n = 8) | ||||
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eosinophilic CRSwNP (n = 10) | noneosinophilic CRSwNP (n = 4) | |||||
1.6 (0.5–2.4) | 2.0 (0.5–3.9) | 1.1 (0.5–2.0) | 0.43 | 7.9 (4.4–11.8) | ||
0.6 (0.3–0.8) | 0.7 (0.6–1.3) | 0.3 (0.1–0.4) | 4.1 (2.3–9.6) | |||
1.7 (0.5–4.0) | 1.7 (0.5–5.0) | 1.3 (0.3–3.3) | 0.71 | 6.9 (3.8–13.3) | ||
1.6 (1.2–3.7) | 1.6 (1.1–3.7) | 1.6 (1.2–4.5) | 0.76 | 3.8 (1.0–10.8) | 0.73 |
*
In this prospective study, we analyzed histopathological characteristics and master transcription
factors gene expression levels of nasal mucosa T cells in newly diagnosed CRSwNP and CRSsNP patients, who have not been treated yet and have never used intranasal or systemic steroids.
We confirmed previous findings that CRSwNP is characterized by mucosal eosinophilia and pronounced subepithelial oedema.2 Additionally, basement membrane thickening ≥ 7.5μm as a sign of remodeling and more severe inflammation was more pronounced in eosinophilic CRSwNP patients with > 10 tissue eosinophils per HPF compared to noneosinophilic CRSwNP patients with < 10 tissue eosinophils per HPF, in concordance with previous reports.17 Tissue eosinophilia in CRSwNP mucosa is known to be associated with type 2 cytokines and inflammation.9,17
Surprisingly, we found significantly upregulated T-bet gene expression level in CRSsNP patients compared to CRSwNP. In contrast, one earlier study has reported downregulated T-bet in healthy patients inferior turbinates mucosa and CRSsNP mucosa compared to CRSwNP mucosa6, mean- while, other studies haven’t found any difference in T-bet expression between CRSwNP and CRSsNP groups.20,21 T-bet is the master transcription factor of Th1 cells and type 1 innate lymphoid cells (ILC1), it promotes their differentiation, activation and interferon-γ (IFN-γ) secretion.22,23 In response to IFN-γ signaling, T-bet can either activate type 1 inflammation or modulate it in case of exaggerated type 1 response.24 Additionally, in effector cytotoxic type CD8+ T cells, T-bet is highly expressed.25 Furthermore, in many acute and chronic viral infections, T-bet expression in effector CD8+ cells correlates with infection clearance or improved infection control.26,27,28 In our recent study, we found significantly depleted Th1 and abundant, effector cytotoxic CD8+ cells in CRSsNP nasal mucosa compared to CRSwNP.13 We might speculate here that highly upregulated T-bet in CRSsNP patients could originate from expanded effector cytotoxic CD8+ cells in CRSsNP nasal mucosa.
In this analysis, significantly elevated
Unexpectedly,
We found significantly higher
Importantly, transcription factor-targeted future treatment strategies might have a positive impact on CRS mucosa by blocking the inflammatory pathway and, on the other hand, a negative impact by targeting co-expression in Tregs and their corresponding inflammation suppression.
This study has some limitations. No control group was included. The groups of patients were relatively small. However, all participants were newly diagnosed and have not been treated with intranasal or systemic steroids yet. Finally, we have only analyzed master transcription factors gene expression levels and not protein expression levels. We plan to expand gene expression investigation in CRS mucosa further to RNA sequence analysis.
To conclude, the type-2 inflammation was confirmed by elevated