Pilot Study of Anti-Th2 Immunotherapy for the Treatment of Breast Cancer-Related Upper Extremity Lymphedema

Abstract

Recent studies suggest that Th2 cells play a key role in the pathology of secondary lymphedema by elaborating cytokines such as IL4 and IL13. The aim of this study was to test the efficacy of QBX258, a monoclonal IL4/IL13 neutralizing antibody, in women with breast cancer-related lymphedema (BCRL). We enrolled nine women with unilateral stage I/II BCRL and treated them once monthly with intravenous infusions of QBX258 for 4 months. We measured limb volumes, bioimpedance, and skin tonometry, and analyzed the quality of life (QOL) using a validated lymphedema questionnaire (Upper Limb Lymphedema 27, ULL-27) before treatment, immediately after treatment, and 4 months following treatment withdrawal. We also obtained 5 mm skin biopsies from the normal and lymphedematous limbs before and after treatment. Treatment was well-tolerated; however, one patient with a history of cellulitis developed cellulitis during the trial and was excluded from further analysis. We found no differences in limb volumes or bioimpedance measurements after drug treatment. However, QBX258 treatment improved skin stiffness (p < 0.001) and improved QOL measurements (Physical p < 0.05, Social p = 0.01). These improvements returned to baseline after treatment withdrawal. Histologically, treatment decreased epidermal thickness, the number of proliferating keratinocytes, type III collagen deposition, infiltration of mast cells, and the expression of Th2-inducing cytokines in the lymphedematous skin. Our limited study suggests that immunotherapy against Th2 cytokines may improve skin changes and QOL of women with BCRL. This treatment appears to be less effective for decreasing limb volumes; however, additional studies are needed.

Keywords: Th2 inflammation; breast cancer; immunotherapy; keratinocytes; lymphedema; skin.

Figure 1

Effects of QBX258 treatment on arm volume, bioimpedance (L-Dex), and tonometry measurements. (a) Quantification of arm volumes at baseline, following 4-month treatment with QBX258 (treatment), and 4 months after cessation of treatment (washout). Changes in each patient are shown over time. (b) L-Dex measurements at baseline, following treatment, and following washout period with QBX258. (c) Tonometry measurements at baseline, following treatment, and following washout period with QBX258.

Figure 2

Effects of QBX258 treatment on quality of life measured using the ULL-27. (a) Quantification of physical score at baseline, following treatment, and following washout period in each patient over time. Average score for the cohort ± SD is shown below the graph. (b) Quantification of social score at each time point for all patients. (c) Quantification of psychological score at each time point for all patients.

Figure 3

Treatment with QBX258 decreases hyperkeratosis and keratinocyte proliferation in lymphedematous skin. (a) Representative H&E images (right panels) and quantification (right panel; average ± SD) of matched normal, lymphedematous skin before treatment (LE), and lymphedematous skin biopsy specimens obtained 4 months after treatment with QBX258 (LE + tx). (b) Representative immunofluorescent staining of normal, LE, LE + tx biopsy specimens stained for DAPI (nuclear stain, blue) and Ki67 (nuclear stain, pink). (c) Representative immunofluorescent staining of normal, LE, LE + tx biopsy specimens stained for DAPI (nuclear stain, blue) and KRT14 (membrane stain, pink). Scale bars: 50 μm; * p < 0.05; ** p < 0.01.

Figure 4

Treatment with QBX258 decreases type III collagen deposition in lymphedematous tissues. Fibrosis after QBX258 treatment. (a,b) Representative immunofluorescent staining (left panels) and quantification (right panel) in normal, LE, LE + tx biopsy specimens for DAPI (blue) and type I collagen (green) in the papillary (a) and reticular (b) dermis. (c,d) Representative immunofluorescent staining (left panels) and quantification (right panel) in normal, LE, LE + tx biopsy specimens for DAPI (blue) and type III collagen (green) in the papillary (c) and reticular (d) dermis. (e) Representative immunofluorescent staining (left panels) and quantification (right panel) of normal, LE, LE + tx biopsy specimens for DAPI (blue) and periostin (red). Scale bar: 50 μm; * p < 0.05; ** p < 0.01.

Figure 5

Treatment with QBX258 decreases mast cell infiltration in lymphedematous skin. (a) Representative low-power (upper images) and high-power (lower images) immunofluorescent staining (left panels) and quantification (right panel) of DAPI (blue) and CD4⁺ cells (pink) in normal, LE, and LE + tx biopsy specimens. Area in dotted box is shown in high-power views. (b) Representative low-power (upper images) and high-power (lower images) immunofluorescent staining (left panels) and quantification (right panel) of DAPI (blue), LYVE-1 (red), and tryptase (green) in normal, LE, and LE + tx biopsy specimens. Area in dotted box is shown in high-power views. Scale bar (low-power images): 200 μm; scale bar (magnified images): 25 μm; * p < 0.05; ** p < 0.01.

Figure 6

Lymphedema results in increased epidermal expression of Th2-inducing cytokines. This phenotype is mitigated by treatment with QBX258. (a) Representative immunofluorescent staining (left panels) and quantification (right panel) of TSLP (green) in normal, LE, and LE + tx biopsy specimens. (b) Representative immunofluorescent staining (left panels) and quantification (right panel) of IL33 (red) in normal, LE, and LE + tx biopsy specimens. (c) Representative immunofluorescent staining (left panels) and quantification (right panel) of IL25 (green) in normal, LE, and LE + tx biopsy specimens. (d) Representative immunofluorescent staining (left panels) and quantification (right panel) of IL13R (green) in normal, LE, and LE + tx biopsy specimens. Scale bar: 100 μm; * p < 0.05; ** p < 0.01.