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Neoplasms Derived from Plasmacytoid Dendritic Cells Fabio Facchetti1, Marta Cigognetti1, Simona Fisogni1, Giuseppe Rossi2, Silvia Lonardi1 and William Vermi1

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Neoplasms Derived from Plasmacytoid Dendritic Cells Fabio Facchetti1, Marta Cigognetti1, Simona Fisogni1, Giuseppe Rossi2, Silvia Lonardi1 and William Vermi1 Modern Pathology (2016) 29, 98–111 98 © 2016 USCAP, Inc All rights reserved 0893-3952/16 $32.00 Neoplasms derived from plasmacytoid dendritic cells Fabio Facchetti1, Marta Cigognetti1, Simona Fisogni1, Giuseppe Rossi2, Silvia Lonardi1 and William Vermi1 1Section of Pathology, Department of Molecular and Translational Medicine, Spedali Civili, University of Brescia, Brescia, Italy and 2Department of Hematology, Spedali Civili, Brescia, Italy Plasmacytoid dendritic cell neoplasms manifest in two clinically and pathologically distinct forms. The first variant is represented by nodular aggregates of clonally expanded plasmacytoid dendritic cells found in lymph nodes, skin, and bone marrow (‘Mature plasmacytoid dendritic cells proliferation associated with myeloid neoplasms’). This entity is rare, although likely underestimated in incidence, and affects predominantly males. Almost invariably, it is associated with a myeloid neoplasm such as chronic myelomonocytic leukemia or other myeloid proliferations with monocytic differentiation. The concurrent myeloid neoplasm dominates the clinical pictures and guides treatment. The prognosis is usually dismal, but reflects the evolution of the associated myeloid leukemia rather than progressive expansion of plasmacytoid dendritic cells. A second form of plasmacytoid dendritic cells tumor has been recently reported and described as ‘blastic plasmacytoid dendritic cell neoplasm’. In this tumor, which is characterized by a distinctive cutaneous and bone marrow tropism, proliferating cells derive from immediate CD4+CD56+ precursors of plasmacytoid dendritic cells. The diagnosis of this form can be easily accomplished by immunohistochemistry, using a panel of plasmacytoid dendritic cells markers. The clinical course of blastic plasmacytoid dendritic cell neoplasm is characterized by a rapid progression to systemic disease via hematogenous dissemination. The genomic landscape of this entity is currently under intense investigation. Recurrent somatic mutations have been uncovered in different genes, a finding that may open important perspectives for precision medicine also for this rare, but highly aggressive leukemia. Modern Pathology (2016) 29, 98–111; doi:10.1038/modpathol.2015.145; published online 8 January 2016 Over 50 years ago, Lennert identified a novel nodal role in the organization of the adaptive immune – cell type,1 subsequently defined as plasmacytoid response.4 6 It has also been shown that plasmacy- dendritic cells. Studies by pathologists and toid dendritic cells may exert effector functions by immunologists (based on morphology, phenotype, releasing cytotoxic molecules, such as tumor and function) recognized the uniqueness of necrosis factor-related apoptosis-inducing ligand plasmacytoid dendritic cells among other cell (TRAIL) and granzyme B. On the basis of the types of the innate immune system. Specifically, recognition of the murine counterpart of plasmacy- 7–9 plasmacytoid dendritic cells are highly specialized toid dendritic cells, it is now possible to better circulating cells which are characterized by the understand the role of these cells in various diseases. ability to produce high levels of type I interferon Since the early 1980s, pathologists became aware (IFN-I)2 and to differentiate into antigen-presenting of the fact that plasmacytoid dendritic cells (or their dendritic cells in response to a variety of stimuli.3 precursors) could transform and eventually expand Circulating plasmacytoid dendritic cells home to clonally. In particular, plasmacytoid dendritic cell neoplasms manifest in two clinically and pathologi- diseased tissue, particularly skin and lymphoid cally distinct forms. The first reported variant organs, in various types of inflammatory conditions (‘Mature plasmacytoid dendritic cells proliferation (autoimmunity, cancer, virus infection), suggesting a associated with myeloid neoplasms’) is invariably associated with a myeloid neoplasm,10 whereas the Correspondence: Professor F Facchetti, MD, PhD, Section of second variant, reported as ‘blastic plasmacytoid Pathology, Department of Molecular and Translational Medicine, dendritic cell neoplasm’ likely stems from immedi- Spedali Civili, University of Brescia, Brescia, Brescia 25123, Italy. ate CD4+CD56+ precursors of plasmacytoid dendritic E-mail: [email protected] 11 Received 3 August 2015; accepted 10 November 2015; published cells. On the basis of histology, blastic plasmacy- online 8 January 2016 toid dendritic cell neoplasm is now recognizable www.modernpathology.org Plasmacytoid dendritic cells neoplams F Facchetti et al 99 from other leukemia; however, no major advances heterogeneous population of antigen-presenting have been made in terms of prognosis and treatment cells, found in blood and tissues, that are capable standardization. of initiating and fine-tuning immune responses to In this review, we will briefly provide a historical different pathogens, as well as contributing to immune background on the identification and characteriza- tolerance. In addition to type I IFN-producing tion of human plasmacytoid dendritic cells, and plasmacytoid dendritic cells, two myeloid dendritic discuss recent advances on their functional cell populations have been identified in blood and properties. A more detailed analysis of the role of peripheral tissues, namely the CD1c+(BDCA1+) plasmacytoid dendritic cells in various human dendritic cells and the CD141+(BDCA3+) dendritic diseases is provided in several reviews.5,6,12 Here cells.18 Their inclusion is based on the initial we provide a comprehensive overview of the two observation that plasmacytoid dendritic cells undergo forms of plasmacytoid dendritic cell neoplasm, with profound morphological, phenotypical, and a detailed analysis of clinical and histological functional changes upon stimulation with CD40 finding. The molecular basis of plasmacytoid ligand, interleukin-3, or a variety of microbial dendritic cells transformation and progression has stimuli.3,19 This functional dichotomy may represent remained unknown until recently. For the blastic two evolutionary distinct states, where the production plasmacytoid dendritic cell neoplasm entity, we of IFN-I is lost upon differentiation into dendritic have included and commented recent reports on its cells.20,21 Nevertheless, the term plasmacytoid den- genomic landscape, with the aim of identifying the dritic cell has been adopted to encompass all states. Achilles' heel of this highly aggressive neoplasm. In vitro, plasmacytoid dendritic cells are capable of inducing CD4 and CD8 T-cell proliferation and Th1 polarization after infection or immunization.22 Initial identification and characterization of However, it is still unclear whether these immuno- plasmacytoid dendritic cells logical functions are relevant during various types of immune responses,22 once plasmacytoid dendritic Plasmacytoid dendritic cells made their first appear- cells migrate to diseased tissues.6 A tolerogenic role ance over 50 years ago under the microscope of Karl has been proposed for plasmacytoid dendritic cells Lennert as nodal ‘lymphoblasts’.1 Subsequent mor- in several systems, by induction of regulatory T cells. phological and ultrastructural studies led to a series Tolerogenic plasmacytoid dendritic cells may be of plausible, although conflicting, designations such relevant in certain immune responses, however, a as ‘T-associated plasma cell’, ‘plasmacytoid T cell’, broad designation of steady-state plasmacytoid and ‘plasmacytoid T-zone cell’.13 The demonstration dendritic cells as tolerogenic would be misleading of the expression of myelomonocytic markers such at the present time.23 as CD15 (after neuraminidase treatment) and CD68, On the basis of their efficient production of IFN-I and lack of other T-lineage markers, prompted the and dendritic cell differentiation, plasmacytoid term ‘plasmacytoid monocyte’, thus questioning dendritic cells bridge the innate and acquired their lymphoid affiliation.14 In the late 1990s, it components of the immune responses, with became possible to purify plasmacytoid dendritic documented roles in defense against pathogens, cells from blood and tissues and better understand cancer, and autoimmunity.5,12,15,17,23,24 Interestingly, their origin and main functions. First, by sensing plasmacytoid dendritic cells may also exert direct nucleic acid sequences via the TLR7/9-MyD88-IRF-7 effector functions. In particular, their activation via pathway, plasmacytoid dendritic cells rapidly different stimuli might result in the release of TRAIL secrete large amounts of type I interferons (IFN-I) and Granzyme B. and, to a lesser extent, other cytokines, including Recently, progress has been made on the knowl- IL-6, IL-8, IL-12, tumor necrosis factor-α,2,15 as well edge of plasmacytoid dendritic cell development. as various pro-inflammatory chemokines.6 Although Plasmacytoid dendritic cells share with myeloid many cells can produce IFN-I, plasmacytoid dendri- dendritic cells a unique developmental pathway tic cells are the fastest responder to INF-I inducers from a common macrophage/dendritic cell progeni- and the major cellular source of the cytokine tor. The initial development of these dendritic cell (especially IFN-alpha). Other cytoplasmic nucleic populations is controlled by Flt3L (Fms-like tyrosine acid sensors (eg, RIG-I, MDA5, LGP2, and DDX) kinase 3 ligand).25,26 Subsequently, the sustained expressed by various nucleated cells, including upregulation of the basic helix-loop-helix
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