Identification of Differentially Expressed Genes in Actinic Keratosis Samples Treated with Ingenol Mebutate Gel
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PLOS ONE RESEARCH ARTICLE Identification of differentially expressed genes in actinic keratosis samples treated with ingenol mebutate gel Sonia Segura1, Alejandra Gadea2,3, Lara Nonell4, Evelyn Andrades2, Silvia SaÂnchez2, 1 2 5,6 Ramon Pujol , Inmaculada HernaÂndez-Muñoz , Agustõ TollID * 1 Department of Dermatology, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain, 2 Group of Inflamatory and Neoplasic Dermatological Diseases, IMIM (Hospital del Mar Medical Research Institute), Barcelona, a1111111111 Spain, 3 Centre National de la Recherche Scientifique (CNRS), Centre de Recherche Paul Pascal (CRPP), a1111111111 Universite de Bordeaux, Pessac, France, 4 MARGenomics, IMIM (Hospital del Mar Medical Research a1111111111 Institute), Barcelona, Spain, 5 Department of Dermatology, Hospital ClõÂnic de Barcelona, University of a1111111111 Barcelona, Barcelona, Spain, 6 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain a1111111111 * [email protected] OPEN ACCESS Abstract Citation: Segura S, Gadea A, Nonell L, Andrades E, Actinic keratosis is a common skin disease that may progress to invasive squamous cell car- SaÂnchez S, Pujol R, et al. (2020) Identification of cinoma if left untreated. Ingenol mebutate has demonstrated efficacy in field treatment of differentially expressed genes in actinic keratosis samples treated with ingenol mebutate gel. PLoS actinic keratosis. However, molecular mechanisms on ingenol mebutate response are not ONE 15(5): e0232146. https://doi.org/10.1371/ yet fully understood. In this study, we evaluated the gene expression profiles of actinic kera- journal.pone.0232146 tosis lesions before and after treatment with ingenol mebutate using microarray technology. Editor: Liang Liu, University of Minnesota, UNITED Actinic keratoses on face/scalp of 15 immunocompetent patients were identified and evalu- STATES ated after treatment with topical ingenol mebutate gel 0.015%, applied once daily for 3 con- Received: December 18, 2019 secutive days. Diagnostic and clearance of lesions was determined by clinical, Accepted: April 7, 2020 dermoscopic, and reflectance confocal microscopy criteria. Lesional and non-lesional skin biopsies were subjected to gene expression analysis profiled by Affymetrix microarray. Dif- Published: May 15, 2020 ferentially expressed genes were identified, and enrichment analyses were performed using Copyright: © 2020 Segura et al. This is an open STRING database. At 8 weeks post-treatment, 60% of patients responded to ingenol mebu- access article distributed under the terms of the Creative Commons Attribution License, which tate therapy, achieving complete clearance in 40% of cases. A total of 128 differentially permits unrestricted use, distribution, and expressed genes were identified following treatment, and downregulated genes (114 of reproduction in any medium, provided the original 128) revealed changes in pathways important to epidermal development, keratinocyte dif- author and source are credited. ferentiation and cornification. In responder patients, 388 downregulated genes (of 450 differ- Data Availability Statement: All microarray data entially expressed genes) were also involved in development/differentiation of the files are available from the Gene Expression epidermis, and immune system-related pathways, such as cytokine and interleukin signal- Omnibus database (accession number GSE142108). ing. Cluster analysis revealed two relevant clusters showing upregulated profile patterns in pre-treatment actinic keratoses of responders, as compared to non-responders. Again, dif- Funding: Funding Source: This study was sponsored by LEO Pharma S.A. (http://www.leo- ferentially expressed genes were mainly associated with cornification, keratinization and pharma.es/). The sponsor had no role in study keratinocyte differentiation. Overall, the present study provides insight into the gene expres- design, collection and analysis, decisioÂn to publish, sion profile of actinic keratoses after treatment with ingenol mebutate, as well as identifica- or preparation of the manuscript. tion of genetic signatures that could predict treatment response. Competing interests: Agustõ Toll received research funds from LEO Pharma S.A. for this work. The PLOS ONE | https://doi.org/10.1371/journal.pone.0232146 May 15, 2020 1 / 20 PLOS ONE Gene profiles of ingenol-treated actinic keratoses other authors have indicated they have no financial Introduction relationships or conflicts of interest to disclose. This does not alter our adherence to PLOS ONE Actinic keratosis (AK) is a common skin disease characterized by thick, scaly, cutaneous policies on sharing data and materials. lesions on chronic sun-exposed areas, and histologically by atypical keratinocytes extending to the basal layer of the epidermis, that may progress to invasive squamous cell carcinoma (SCC) if left untreated [1,2]. The risk to develop a cutaneous SCC is approximately 0.03±20% per year for any single lesion [3±6], and the risk of malignant progression for a patient affected by mul- tiple AK lesions has been estimated within a wide range between 0.15% and 80% [7]. The high- est malignant transformation rates are found in males, elderly patients, individuals with phototypes I and II, human papillomavirus infection, a family history of skin cancer, and in immune-suppressed individuals [8±10]. However, despite the advances in the recognition of clinic, dermoscopic and histologic patterns, it is not yet possible to predict which lesions will advance to SCC [11]. For this reason, an early diagnosis and effective treatment are recommended. There are many variables that may influence the therapy choice in an individual, such as the number and location of lesions, age and immunological status of the patient, personal his- tory of previous skin lesions and previous treatments [11]. Nevertheless, since AKs are usually multiple and often subclinical, a field-directed approach is suggested to remove clinically visi- ble as well as non-visible lesions within the treatment area to prevent the development to inva- sive SCC [12]. Among the topical field therapies available, ingenol mebutate (IM) has demonstrated to be an ef-fective and well tolerated option for the treatment of AK, with a simple dosing regimen and a short treating course [13,14]. However, the precise mechanism of action by which the drug induces cell death is not fully understood, neither are the molecular mechanisms involved in the lack of response to IM. Herein, we report the results of a prospective study investigating the transcriptomic profile of AK lesions before and after treatment with IM gel. Our study included clinical and dermo- scopic evaluations together with a monitoring of the histological patterns of AKs by in vivo reflectance confocal microscopy (RCM), a non-invasive imaging technique. We also per- formed a comparative analysis of gene expression profiles of AKs responsive and unresponsive to the study treatment, in order to gain a better understanding of the molecular mechanisms involved and to identify potential genetic signatures of response to IM therapy. Materials and methods Study design and patient population This was a single-center, single-arm, prospective observational study conducted in Hospital del Mar in Barcelona from April 2016 to April 2018, to evaluate the mRNA expression profile of AKs before and after treatment with IM. We prospectively enrolled fifteen immunocompe- tent adult patients aged � 18 years, who were clinically diagnosed with at least one AK (grade I-II, according to Olsen's classification [15]) on the head and/or scalp larger than 8 mm in diameter. All patients were regularly being followed-up for previous history of non-melanoma skin cancer at the Skin Cancer Clinic of the Hospital del Mar. Patients could not have received any pharmacological treatment for AK within 6 months before inclusion. Subjects were excluded if they were pregnant, breastfeeding, or planning on becoming pregnant during the course of the trial. All individual participants received written and verbal information con- cerning the study, provided signed written informed consent, and allowed photographs of the selected treatment areas to be taken. Data confidentiality and anonymity will be ensured, according to the provisions of the Spanish Organic Law 3/2018, of December 5, on Personal PLOS ONE | https://doi.org/10.1371/journal.pone.0232146 May 15, 2020 2 / 20 PLOS ONE Gene profiles of ingenol-treated actinic keratoses Data Protection and Digital Rights, and the provisions of Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016. The study was approved by the local ethics committee (Comite EÂtico de InvestigacioÂn ClõÂnica- Parc de Salut Mar, nÊ 2016/6597/I) and conducted in accordance with the Declaration of Helsinki (Fortaleza, Brazil, October 2013). Study assessments At the initial screening visit (visit 0), participants provided informed consent, and study der- matologists collected demographic data and performed a clinical evaluation of the lesions on the head suggestive of AK. AK lesions larger than 8 mm in diameter were identified, evaluated, and subsequently monitored at the pre-treatment visit (visit 1), at 4±2 days after treatment (visit 2), and at 8±1 weeks after treatment (visit 3). Clinical assessment of AKs and photographs with a digital camera (Canon Powershot G101, OÅ ita, Japan) were made at each study visit. At visits 1 and 3, dermoscopic images (DermliteFoto1, 3Gen, San Juan