Protocol Title : A Randomised, open labelled study in anti ... - EME
Protocol Title : A Randomised, open labelled study in anti ... - EME
Protocol Title : A Randomised, open labelled study in anti ... - EME
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<strong>Protocol</strong> Version 3 14/01/2013<br />
• Functional B cell studies<br />
Lab: QMUL, Experimental Medic<strong>in</strong>e and Rheumatology - B cells after sort<strong>in</strong>g will be placed <strong>in</strong><br />
culture <strong>in</strong> complete RPMI medium with the presence of IL4/BAFF cytok<strong>in</strong>es. Culture supernatant<br />
will be collected after 7 days for measurement of RF and <strong>anti</strong>-CCP <strong>anti</strong>body production as well as<br />
<strong>anti</strong>bodies to recall <strong>anti</strong>gens such as tetanus toxoid. Peripheral blood auto<strong>anti</strong>body and cytok<strong>in</strong>e<br />
production. Serum levels of RF and <strong>anti</strong>-CCP <strong>anti</strong>bodies and cytok<strong>in</strong>e measurement (e.g. BAFF,<br />
APRIL) will be determ<strong>in</strong>ed by ELISA.<br />
5.12.2 Radiology Assessments<br />
Pla<strong>in</strong> radiographs of the hands and feet will be recorded at basel<strong>in</strong>e, 6, 12 months and 24 months<br />
follow up as per rout<strong>in</strong>e cl<strong>in</strong>ical practise.<br />
A chest x-ray will be acquired as per rout<strong>in</strong>e screen<strong>in</strong>g for TB prior to biological therapy<br />
5.13 Synovial biopsies and tissue analysis<br />
Synovial biopsies under ultrasound guidance (m<strong>in</strong>imally <strong>in</strong>vasive) will be performed at basel<strong>in</strong>e and<br />
6 months. Synovial fluid will also be collected and stored concurrently with each biopsy. Tissue will<br />
be processed for paraff<strong>in</strong> embedd<strong>in</strong>g, snap frozen for histological analysis and immersed <strong>in</strong> RNA-<br />
Later for later RNA extraction.<br />
• Histopathological characterisation<br />
Lab: Barts Healthcare NHS Trust, Pathology and QMUL, Experimental Medic<strong>in</strong>e and<br />
Rheumatology - The tendency and the acquisition of the typical features of secondary lymphoid<br />
organs (SLOs) and total number of B-cells by immunohistochemistry (IHC) and digital image<br />
analysis as described <strong>in</strong> 5.2.1 above and previously reported 14, 21 . Infiltrat<strong>in</strong>g B-cells will be<br />
qu<strong>anti</strong>fied by CD20, CD79a sta<strong>in</strong><strong>in</strong>g and further characterised for the expression of IgD (naïve) and<br />
CD27 (memory) markers. In addition we shall determ<strong>in</strong>e the number of plasma cells (CD138),<br />
FDCs (CD35-CD21L) and activation-<strong>in</strong>duced-cytid<strong>in</strong>e-deam<strong>in</strong>ase (AID) <strong>in</strong> order to identify the<br />
presence of functional Germ<strong>in</strong>al Centre (GC) supported by FDC networks.<br />
B Cell Score:<br />
Lab: Barts Healthcare NHS Trust, Pathology - The level of B cell <strong>in</strong>filtration <strong>in</strong> synovial tissues is<br />
base on a 5-po<strong>in</strong>t scale: 0-4 depend<strong>in</strong>g on the <strong>in</strong>creas<strong>in</strong>g number of positively sta<strong>in</strong>ed cells<br />
calibrated aga<strong>in</strong>st a standardized atlas (Appendix II). Accord<strong>in</strong>gly synovial biopsies will be<br />
categorized <strong>in</strong> B Cell Poor (0-1), B Cell Rich (2-3) and Germ<strong>in</strong>al Centre (GC) Rich (4). GC will be<br />
further identified by the presence of CD21 +ve follicular dendritic cells (FDC) networks. This will be<br />
undertaken by an accredited NHS histopathology department at The Royal London.<br />
• Gene expression profil<strong>in</strong>g<br />
Lab: QMUL, Experimental Medic<strong>in</strong>e and Rheumatology -To determ<strong>in</strong>e whether cl<strong>in</strong>ical<br />
response to Rituximab therapy is associated with modulation of specific molecular pathways<br />
<strong>in</strong>volved <strong>in</strong> lymphoid organization and B-cell growth and differentiation we will <strong>in</strong>vestigated by QT-<br />
PCR expression levels of the follow<strong>in</strong>g genes: LTα, LTβ, TNFα, RANKL, CXCL13, CCL19, CCL21,<br />
BAFF, APRIL, PBEF, TSLP, SLPI and AID. Similar considerations will apply with regard to<br />
pathways <strong>in</strong>volved <strong>in</strong> response to IL-6 receptor blockade and IL-12, IL-17, IL-23, IL-21 amongst<br />
others will be also analysed by QT-PCR. In addition, a more comprehensive micro-array based<br />
gene expression profil<strong>in</strong>g of synovial tissue before and after Rituximab and Tocilizumab therapy<br />
will be performed us<strong>in</strong>g the Illum<strong>in</strong>a micro-array platform at WHRI-Genome-Centre that will also<br />
provide bio-<strong>in</strong>formatic analyses expertise (see letter of collaboration from Dr Michael Barnes).<br />
Previous studies, performed with a variety of micro-array technologies, have revealed the validity<br />
of large-scale transcriptional analysis 22 .<br />
• Local auto<strong>anti</strong>body and cytok<strong>in</strong>e production<br />
Lab: QMUL, Experimental Medic<strong>in</strong>e and Rheumatology -Synovial fluid levels of auto<strong>anti</strong>bodies<br />
(RF, <strong>anti</strong>-CCP) and cytok<strong>in</strong>es (i.e. BAFF, APRIL) will be determ<strong>in</strong>ed pre and post-Rituximab by<br />
ELISA. To assess whether the survival of autoreactive B-cells with<strong>in</strong> “protected” synovial niches is<br />
responsible for B-cell jo<strong>in</strong>t re-population and disease resistance/relapse we will determ<strong>in</strong>e clonal<br />
relationship analysis pre- and post-treatment. This will be carried out <strong>in</strong> collaboration with Barts<br />
Cancer Institute, where all the techniques for clonal analysis of B-cell lymphomas have been<br />
Study: R4RA EudraCT: 2012-002535-28 28 / 34