Indoleamine 2,3-dioxygenase, a new prognostic marker in sentinel lymph nodes of melanoma patients

doi:10.1016/j.ejca.2011.09.007

European Journal of Cancer

Volume 48, Issue 13, September 2012, Pages 2004-2011

https://doi.org/10.1016/j.ejca.2011.09.007 Get rights and content

Abstract

Background

Indoleamine 2,3-dioxygenase (IDO), an enzyme with immunosuppressive properties is considered as a factor that impairs the antitumour immune response in melanoma. In this study, we investigated the expression of IDO in sentinel nodes of melanoma patients to determine its prognostic relevance.

Patients and methods

One hundred and sixteen melanoma patients were enrolled in this study with a median follow-up time after diagnosis of 71 months. The expression of IDO and forkhead box P3 (Foxp3) in the sentinel lymph nodes was determined by immunohistochemistry and correlated with progression-free survival and overall survival. In 42 patients, regulatory T cells were investigated by flow cytometry.

Results

Cox regression survival analysis showed a significant negative effect of IDO expression on progression-free survival (p = 0.015) and overall survival (p = 0.010). High IDO expression was correlated with a significant higher frequency of Foxp3-positive cells in uninvaded lymph nodes (p = 0.016). The presence of IDO expression in the sentinel nodes was not associated with an increased frequency of circulating regulatory T cells (Tregs) but was significantly correlated with an increased mean fluorescence intensity of Cytotoxic T-Lymphocyte Antigen 4 (CTLA-4) in Tregs (p = 0.019). After CD3CD28 stimulation, peripheral blood mononuclear cells of patients with high IDO expression showed a lower production of interferon-gamma (IFN-γ) (p = 0.025).

Conclusions

This study points to an independent predictive role of IDO on survival, especially in melanoma patients with uninvolved sentinel nodes. Investigating IDO expression in the sentinel nodes of melanoma patients may be a useful marker to pre-identify patients with a less favourable prognosis in stage I and II disease.

Introduction

Indoleamine 2,3-dioxygenase (IDO) is an immunosuppressive enzyme physiologically expressed at the foetal–maternal barrier, being involved in the tolerance of the foetus by the maternal immune system. Increased IDO expression has been observed in specific pathological conditions such as viral infections and cancer.¹ IDO is a rate-limiting enzyme of the kynurenine pathway and catabolises tryptophan, an essential amino acid for the cell.² Depletion of tryptophan by the IDO activity in macrophages and dendritic cells (DCs) inhibits activation and proliferation of T cells and natural killer (NK−) cells in the G1 phase of the cell cycle. Moreover, tryptophan-depleted cells are more vulnerable to apoptosis.³ Tryptophan catabolites (such as l-kynurenine) also suppress the proliferation of activated T cells.4, 5, 6

In melanoma, IDO expression has been reported in tumoural cells and tumour-draining lymph nodes (TDLNs).7, 8, 9 Lee et al.⁸ described IDO expression in antigen presenting cells (APCs), located in the perisinusoidal and intrafollicular regions of the lymph nodes of melanoma patients. These cells were identified as mainly BDCA2+ plasmacytoid dendritic cells (pDCs). Circulating IDO-expressing pDCs could not be detected, suggesting that IDO expression in melanoma is a local process limited to the primary tumour and TDLNs.¹⁰

Increasing evidence points to a prognostic role of IDO in melanoma. Decreased serum tryptophan levels have been associated with a worse prognosis in melanoma patients and the expression of IDO by metastatic melanoma cells has also been linked with impaired survival.9, 11 IDO expression by immune cells in TDLNs has been suggested to predict a worse outcome in melanoma.7, 8 However, up till now, a study to confirm the independent prognostic effect of IDO expression by immune cells in the sentinel nodes of melanoma patients was lacking and is of major importance regarding the new insights in the key immunomodulating role of IDO which seems an attractive target for immunotherapy.¹²

IDO expression leads to a shift in lymphocytes to a regulatory T cell (Treg) phenotype.¹³ Regulatory T cells (Tregs) are an extensively investigated subset of lymphocytes exerting immunosuppressive activities. Several studies have shown a higher prevalence of forkhead box P3 (Foxp3)⁺ Tregs in different cancer types and the eradication of Tregs seems to be associated with increased antitumoural responses.¹⁴ In melanoma, Tregs are increased around the primary lesion and in the sentinel nodes.15, 16 A recent study could not demonstrate an independent prognostic effect of the frequency of Tregs in primary melanoma lesions.¹⁶

In this study, we investigated the expression of IDO in the sentinel nodes of melanoma patients to determine the prognostic relevance and to correlate IDO expression with systemic immunosuppressive factors. As IDO activity leads to a shift in lymphocytes to a Treg phenotype, Foxp3 expression in the lymph nodes and circulating Tregs were also investigated.

Section snippets

Patients selection

One hundred and sixteen melanoma patients (46 males, 70 females) with a median age of 52 years at the time of diagnosis (Table 1) were enrolled in this study. The study was approved by the medical ethical committee of Ghent University Hospital. All patients signed written informed consent. Median follow up after diagnosis was 71 months (Interquartile Range (ICQ): 45–97). In 42 melanoma patients venous blood samples were drawn in sterile ethylene diamine tetra-acetic acid (EDTA) vacutainers (9 mL)

IDO and Foxp3 expression in the sentinel node

IDO expression was observed in the cytoplasm of immune cells mainly situated in the perisinusoidal areas of the lymph nodes (Fig. 1A and C). More centrally in the lymph node, CD31+ cells of high endothelial venules showed IDO expression (Fig. 1B and D). The expression pattern of IDO showed an almost dichotomous distribution between lymph nodes with strong expression (30.2%) and lymph nodes with almost none or very little expression (69.8%). The ratio of strong versus none/weak IDO expression

Discussion

Despite all current insights in prognostic factors for melanoma, this tumour can behave aggressively in all stages of disease. There is a need to pre-identify the subgroup of patients with a bad prognosis in order to develop adequate management strategies. Immune escape could be one of the mechanisms opening a way for an aggressive behaviour of the tumour. Given the quest for effective immunotherapeutic strategies, the in vivo implications of specific immune-suppressing markers are interesting

Conflict of interest statement

None declared.

Acknowledgments

Financial support: R. Speeckaert is funded by a BOF Grant from the Ghent University, Belgium. M. Van Gele is a postdoctoral research fellow of the Fund for Scientific Research-Flanders (Belgium).

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Indoleamine 2,3-dioxygenase, a new prognostic marker in sentinel lymph nodes of melanoma patients

Abstract

Background

Patients and methods

Results

Conclusions

Introduction

Section snippets

Patients selection

IDO and Foxp3 expression in the sentinel node

Discussion

Conflict of interest statement

Acknowledgments

Immunol Today

Lab Invest

J Invest Dermatol

Blood

Blood

Blood

Blood

Transcriptional regulation of indoleamine 2,3-dioxygenase (IDO) by tryptophan and its analogue: down-regulation of the indoleamine 2,3-dioxygenase (IDO) transcription by tryptophan and its analogue

Cytotechnology

Prevention of allogeneic fetal rejection by tryptophan catabolism

Science

Tryptophan deprivation densitizes activated T cells to apoptosis prior to cell division

Immunology

Tryptophan-derived catabolites are responsible for inhibition of T and natural killer cell proliferation induced by indoleamine 2,3-dioxygenase

J Exp Med

Evidence for a tumoral immune resistance mechanism based on tryptophan degradation by indoleamine 2,3 dioxygenase

Nat Med

Expression of indoleamine 2,3-dioxygenase by plasmacytoid dendritic cells in tumor-draining lymph nodes

J Clin Invest

Expression of indoleamine 2, 3-dioxygenase in metastatic malignant melanoma recruits regulatory T cells to avoid immune detection and affects survival

Cell Cycle