- Open Access
Selective accumulation of langerhans-type dendritic cells in small airways of patients with COPD
© The Author(s) 2010
- Received: 11 June 2009
- Accepted: 22 March 2010
- Published: 22 March 2010
Dendritic cells (DC) linking innate and adaptive immune responses are present in human lungs, but the characterization of different subsets and their role in COPD pathogenesis remain to be elucidated. The aim of this study is to characterize and quantify pulmonary myeloid DC subsets in small airways of current and ex-smokers with or without COPD.
Myeloid DC were characterized using flowcytometry on single cell suspensions of digested human lung tissue. Immunohistochemical staining for langerin, BDCA-1, CD1a and DC-SIGN was performed on surgical resection specimens from 85 patients. Expression of factors inducing Langerhans-type DC (LDC) differentiation was evaluated by RT-PCR on total lung RNA.
Two segregated subsets of tissue resident pulmonary myeloid DC were identified in single cell suspensions by flowcytometry: the langerin+ LDC and the DC-SIGN+ interstitial-type DC (intDC). LDC partially expressed the markers CD1a and BDCA-1, which are also present on their known blood precursors. In contrast, intDC did not express langerin, CD1a or BDCA-1, but were more closely related to monocytes.
Quantification of DC in the small airways by immunohistochemistry revealed a higher number of LDC in current smokers without COPD and in COPD patients compared to never smokers and ex-smokers without COPD. Importantly, there was no difference in the number of LDC between current and ex-smoking COPD patients.
In contrast, the number of intDC did not differ between study groups. Interestingly, the number of BDCA-1+ DC was significantly lower in COPD patients compared to never smokers and further decreased with the severity of the disease. In addition, the accumulation of LDC in the small airways significantly correlated with the expression of the LDC inducing differentiation factor activin-A.
Myeloid DC differentiation is altered in small airways of current smokers and COPD patients resulting in a selective accumulation of the LDC subset which correlates with the pulmonary expression of the LDC-inducing differentiation factor activin-A. This study identified the LDC subset as an interesting focus for future research in COPD pathogenesis.
- Chronic Obstructive Pulmonary Disease
- Dendritic Cell
- Chronic Obstructive Pulmonary Disease Patient
- Lamina Propria
- Small Airway
Chronic Obstructive Pulmonary Disease (COPD) is characterized by destruction of alveolar walls (emphysema) and obstructive bronchiolitis resulting in a progressive airflow limitation that is not fully reversible . In industrialized countries, cigarette smoke is the most frequently encountered risk factor for the development of COPD. Currently, COPD is the fourth leading cause of death worldwide and according to the World Health Organization (WHO), mortality will further increase in the next 20 years [2, 3]. The exact pathogenetic mechanisms of continuing destructive inflammation in this disease are not completely understood. Several studies identified the important role of the activated innate immune response in the pathogenesis of COPD, with neutrophils and macrophages as major effector cells, inducing tissue destruction by proteolysis and oxidative stress [4–6]. Other studies addressed the role of the adaptive immune response in COPD, with increased numbers of lymphoid follicles and the presence of cytotoxic CD8+ T cells and B cells, reflecting a sustained immune response, even after smoking cessation [7–10].
Dendritic cells (DC) form the crucial link between the innate and adaptive immunity. Immature DC form a network in the different layers of the airway mucosa, specialized in internalizing antigens. Upon recognition of antigen in the context of a pathogen- or damage- associated danger signal, DC undergo a maturation process and migrate towards the draining lymph nodes. Mature DC present the processed antigen on Major Histocompability Complex (MHC) molecules and interact with naïve T lymphocytes to form an immunological synapse, selecting T cells that will target the presented antigen with specialized effector functions. In this key position, DC are able to orchestrate the nature and magnitude of the adaptive immune response to different antigens [11, 12].
Several groups already identified different subsets of DC in the human lung, mainly using antibodies against epitopes also present on circulating blood DC (such as Blood Dendritic Cell Antigen (BDCA) 1-4 and CD11c) [13–16]. However, no flowcytometric data are available about pulmonary tissue-resident myeloid DC, such as Langerhans-type DC (LDC) and Interstitial-type DC (intDC), two major DC subsets that are well characterized in the skin. In general, LDC are identified by the C-type lectin langerin (CD 207) and the presence of Birbeck granules. They are mainly localized in the epithelium, and are involved in activating cellular/cytotoxic immune responses. IntDC are identified by the C-type lectin DC-SIGN (Dendritic Cell-Specific Intracellular adhesion molecule-3-grabbing Non-integrin, CD 209), are localized in the subepithelial layers and are known to activate humoral immune responses . CD34+ stem cells and monocytes are known precursors of LDC and intDC [18, 19]. In addition, in vitro studies have shown that BDCA-1+ CD1a+ blood DCs are the direct precursors of LDC .
Evidence from experimental mouse models suggests a role for DC in the pathogenesis of COPD . Recently, we showed that LDC accumulate in the small airways of patients with COPD , while others reported a decreased number of electronmicroscopic defined DC in bronchial biopsies of smoking COPD patients . In contrast, Verhoeven et al and a recent study by Tsoumakidou et al found no differences in CD1a positive DCs in bronchial biopsies and small airways of COPD patients compared to asymptomatic smokers [24, 25]. Importantly, several studies indicated that smoking as such could alter the numbers of DCs in the lung [26–28].
In this study, we aimed to identify and characterize tissue resident pulmonary LDC and intDC, investigating the interrelationship of different myeloid DC markers such as langerin, BDCA-1, BDCA-3, CD1a and DC-SIGN. In addition, we aimed to quantify immature myeloid DC in small airways of never smokers and smokers with or without COPD, taking into account whether they were current or ex- smokers. Finally, we examined the pulmonary expression of factors such as activin-A , Notch ligand Delta-1 , RANK-ligand  and interleukin 15 , known from in vitro studies to modulate the differentiation process of monocytes towards myeloid DC.
This study shows the presence of two segregated myeloid tissue resident pulmonary DC populations: the intDC and the LDC. In the small airways of current smokers without COPD and in COPD patients, there is a selective accumulation of the LDC subset correlating with the pulmonary expression of the LDC inducing differentiation factor activin-A. This evidence is compatible with an altered differentiation process of myeloid DC in the small airways and identifies the LDC as an important focus for future research in COPD pathogenesis.
Lung tissue was obtained from surgical lung resection specimens of patients diagnosed with solitary pulmonary tumours at the Ghent University Hospital. Lung tissue at maximum distance from the pulmonary lesion and without signs of retro-obstructive pneumonia or tumour invasion was collected by a pathologist. None of the patients operated for malignancy were treated with neo-adjuvant chemotherapy. Lung tissue from end-stage COPD was obtained from explant lungs from patients undergoing lung transplantation (University Hospital Gasthuisberg, Leuven, Belgium). The study population from which tissue was obtained partially overlaps with and extends the one described in our previous study . All patients signed informed consent prior to surgery and were interviewed about their smoking habits and medication use. Patients were classified as ex-smokers when they had quit smoking at least 1 year prior to surgery. COPD diagnosis and severity was defined using pre-operative spirometry according to the GOLD classification . This study was approved by the Medical Ethical Committees of the Ghent University Hospital and the University Hospital Gasthuisberg Leuven.
Between the year 2002 and 2008, small tissue blocks from the peripheral lung tissue of 85 patients were stored for immunohistochemical analysis. Samples were immediately placed in OCT (Tissue-Tek, Sakura Finetek, Zoeterwoude, the Netherlands), snap-frozen in liquid nitrogen cooled isopentane and stored at minus 80° Celsius. Other samples from the same specimen were fixed in paraformaldehyde 4% (Sigma, Bornem, Belgium) during 12 hours and embedded in paraffin wax. In 44 of the 85 patients, RNA was extracted from a part of the resection specimen which was stored in RNA stabilizing agent (RNAlater, Qiagen, Hilden, Germany) at minus 80° Celcius. At the moment of designing the PCR experiments in total lung RNA, a set of 11 RNA samples from new subjects (not present in the immunohistochemical study) was additionally included.
In a separate study, the lung tissue sample from 6 individual cases (included in 2008-2009) was processed to obtain single cell suspensions for flowcytometry as described previously . There was no overlap between the subjects in the flowcytometric study and the immunohistochemical study. Single cells were pre-incubated with human IgG to reduce non-specific binding. Monoclonal antibodies used are FITC conjugated anti-human CD3 (clone UCTH1) and CD19 (clone HIB19), PERCP conjugated anti-HLA-DR (clone L243), APC conjugated anti- human CD14 (clone M5E2) and PE or APC conjugated anti human DC-SIGN (clone DCN46) (all from BD Biosciences, Erembodegem, Belgium). PE conjugated anti-human langerin (CD207, clone DCGM4) was purchased at Immunotech-Beckman-Coulter, Marseille, France. Anti-human biotinylated CD1a (clone HI149) was purchased at eBioscience, San Diego, CA. APC conjugated anti human BDCA-1 (CD1c, clone AD5-8E7), BDCA-2 (CD303, clone AC141), BDCA-3 (CD141, clone AD5-14H12) and BDCA-4 (CD304, clone AD5-17F6) were purchased at Miltenyi Biotec, Bergisch Gladbach, Germany. APC conjugated anti-human CD163 was purchased at R&D systems, Abingdon, UK. PERCP conjugated streptavidin was purchased at BD Biosciences, Erembodegem, Belgium. Appropriate monoclonal antibodies for isotype control staining were used.
Flowcytometric data acquisition was performed on a FACS Calibur equipped with 488 and 633 nm lasers and running Cellquest Software (Becton Dickinson, San Diego, CA, USA). Flowjo software was used for data analysis (Treestar, OR, USA).
7 μm thick cryosections were cut on poly-L-lysine-coated microscopic slides (Sigma, Bornem, Belgium). Sections were dried for 24 hours and stored at minus 80° Celsius until use. Prior to the immunohistochemical procedure, cryosections were defrosted to room temperature, dried and fixed in aceton for 10 minutes. After fixation, tissue sections were rinsed with phosphate-buffered saline (PBS, pH 7.8).
Sections were incubated with mouse anti-human monoclonal antibody directed against BDCA-1 (AD5-8E7) (Miltenyi Biotec, Bergisch Gladbach, Germany) following incubation with normal goat serum (CLB, Amsterdam, the Netherlands). Sections were then incubated with biotinylated goat anti-mouse antibody (Biogenics, Klinipath, Duiven, the Netherlands). Next, sections were incubated with streptavidin alkaline phosphatase (ss-AP, Biogenics, Klinipath, Duiven, the Netherlands). Sections were then rinsed with PBS containing TRIS buffer (0.2 mol/L, pH 8.5) and incubated with new fuchsine (Chroma, Kongen, Germany) substrate (containing levamisole to block endogenous alkaline phosphatase enzyme activity), counterstained with hematoxylin and mounted in Vecta Mount (Vector, Burlingame, CA, USA).
Aceton-fixed cryosections were stained with mouse anti-human DC-SIGN ((clone DCN46), BD Biosciences, Erembodegem, Belgium) following incubation with blocking reagent (Roche 1096176, Basel, Switzerland). Sections were then incubated with poly-alkaline phosphatase goat anti-mouse (Klinipath, Duiven, the Netherlands). Sections were incubated with new fuchsine (Dako, Heverlee, Belgium) with levamisole during 7 minutes, counterstained with Mayer's hematoxylin (Sigma, Belgium), rinsed with distilled water and mounted in Aquatex (Klinipath).
Immunohistochemical staining for langerin was carried out on cryosections as described previously .
For immunohistochemical double staining, aceton fixed cryosections were incubated with blocking reagent (Ultra V Block : Klinipath: TA-125-UB), followed by the first monoclonal antibody (anti human BDCA-1, (clone AD5-8E7) (Miltenyi Biotec, Bergisch Gladbach, Germany) or anti human DC-SIGN (clone DCN46, BD Biosciences, Erembodegem, Belgium) during 1 hour at room temperature. Sections were then incubated with poly-Alkaline phosphatase (DPVM 55AP, Klinipath, Duiven, The Netherlands) stained with new fuchsin as described above. After rinsing, streptavidin/biotin blocking was applied (SP-2002, Vector, Burlingame, CA) followed by blocking reagent (Roche 1096176, Basel, Switzerland). Sections were incubated overnight with mouse anti-human CD207 (langerin, clone DCGM4, Immunotech, Marseille, France) diluted in PBS. Sections were rinsed with PBS and incubated with biotinylated goat-anti-mouse IgG1 (Southern Biotech Birmingham, USA). Sections were rinsed in PBS and incubated with streptavidin-AP (Vector, Burlingame, CA). Finally, sections were stained with Vector Blue diluted in PBS with 0.3% Triton (Sigma, Belgium) at pH 8.2 combined with levamisole. After terminating the staining process with PBS with 0.3% Triton at pH 7.5, sections were rinsed with distilled water and covered with Aquatex as described above.
3 μm thick paraffin embedded sections were cut on poly-L-lysin coated slides. After dewaxing with Ultra Clear (Klinipath, Duiven, The Netherlands) and rehydration, antigen retrieval was performed using preheated Citrate buffer pH 6.0 (ScyTek Laboratories, Logan, Utah, USA) 10% at 78°C. After blocking of endogenous peroxidase activity with 3% hydrogen peroxide (Dako, Heverlee, Belgium) and application of blocking reagent (Roche 1096176, Basel, Switzerland) 1% in PBS with 0.3% Triton, sections were incubated with mouse anti-human CD1a monoclonal antibody (M3571, Dako, Heverlee, Belgium) followed by incubation with biotinylated link antibody and application of streptavidin-HRP (LSAB system K0679, DAKO, Heverlee, Belgium). Slides were rinsed in PBS containing 0.3% Triton. Finally, diaminobenzidine substrate was added for 30 minutes, sections were rinsed in demineralised water, counterstained with Mayer's hematoxylin (Sigma, Belgium), dehydrated and mounted in DPX (Klinipath, Duiven, The Netherlands).
Immunohistochemical staining for for Activin-A was also performed on paraffin-embedded sections, using the same dewaxing and rehydration protocol as described above. Antigen retrieval was performed using EDTA-buffer. After blocking for endogenous peroxidase activity and application of Fc block, slides were incubated with anti-human Activin-A ((Clone E4) ABD Serotec, Kidlington, United Kingdom) during 12 h at 4°C. Next, sections were further stained as described in the protocol for CD1a.
For each primary antibody used, appropriate isotype control stainings were performed.
Images of tissue sections were recorded using a computerized image analysis system (KS400, Zeiss, Oberkochen, Germany). Airways without cartilage that had a perimeter of the basement membrane of less than 6000 μm were selected for analysis . The area of epithelium was defined by the region between the luminal border and the basement membrane, the lamina propria as the region between the basement membrane and the outer edge of the smooth muscle and the adventitia as the region between the outer border of the smooth muscle and the outer border of the small airway. The total airway wall was defined as the sum of these 3 regions. The number of positive cells in the epithelium was counted and the results were normalized to the area of the epithelium and to the length of the basement membrane. For the lamina propria, adventitia and total airway wall, the number of positive cells were normalized to the surface of the respective area. Cells were regarded positive when showing DC morphology and contained a nucleus. The observer (GRVP) was blinded for clinical data. A random sample of 45 slides was analysed by a second blinded observer (KD), showing good interobserver agreement (paired T test p = 0.18) and a good correlation between the two observers (p < 0.001, Pearson correlation coefficient 0.85).
mRNA expression study
Total lung RNA was extracted with the RNeasy Mini Kit (Qiagen, Hilden, Germany). RNA quality was checked on a bioanalyser and samples with an RNA-integrity number (RIN) below 5.5 were excluded from the analysis. Subsequently cDNA was obtained by reverse transcription of RNA with the Transcriptor First Strand cDNA synthesis kit (Roche, Basel, Switzerland) following manufacturer's instructions and using a 2:1 ratio of hexa:oligodT primers. Expression of target genes Activin A (Inhibin beta A), RANKL, Notch Ligand Delta-1 and IL-15 and reference genes GAPDH (glyceraldehyde-3-phosphate dehydrogenase), HPRT1 (hypoxanthine phosphoribosyltransferase 1) and PPIA (peptidylprolyl isomerase 1) mRNA was analysed with the TaqMan Gene Expression Assays (Applied Biosystems, Forster City, CA, USA). Real-time PCR reactions were performed in duplicate using diluted cDNA template and the LightCycler480 Probes Master (Roche, Basel, Switzerland). A standard curve derived from the serial dilutions of a mixture of all samples was included on each plate. Amplifications were performed on a LightCycler480 detection system (Roche, Basel Switzerland) with the following cycling conditions: 10 min incubation at 95°C and 50 cycles of 95°C for 10 sec and 60°C for 15 sec. Data were processed using the standard curve based method. Expression of target genes was corrected by a normalisation factor that was calculated based on the expression of three reference genes (GAPDH, HPRT1, PPIA), using the geNorm applet according to the guidelines and theoretical framework previously described http://medgen.ugent.be/~jvdesomp/genorm/ In 44 patients, both total lung RNA and langerin stained cryosections were available.
Statistical analysis was carried out in SPSS 16.0 (SPSS inc. Chicago, IL, USA). When evaluating differences in continuous variables between multiple independent groups, the Kruskal-Wallis test was used. Where values of probability were <0.05, selected pairs of groups were investigated by the Mann-Whitney U test. Correlation coefficients were calculated using Spearman's rank method. Linear regression analysis was performed on log-transformed data, using the enter method. P values < 0.05 were considered significant.
Characterization of pulmonary Langerhans-type and interstitial-type DC
Characteristics of the Study Population (flowcytometry) (n = 6)
Smoking history (packyear)
Current or ex smoker
FEV 1 (L)
FEV 1 /FVC (%)
Inhaled CS (Yes/No)
Systemic CS (Yes/No)
% Langerin + cells
% DC-SIGN + cells
% BDCA-1 + cells
% BDCA-3 high + cells
% BDCA-1+ cells on LDC
LDC and intDC were consistently identified as two separate populations (figure 1A). A large proportion of LDC expressed the myeloid DC marker BDCA-1 (figure 1B), but in multiple independent experiments, a small population of BDCA-1 negative LDC was consistently found. The majority of CD1a+ DC expressed BDCA-1 (figure 1C), but only a minor subset of CD1a+ DC expressed langerin. Moreover, the majority of LDC was CD1a negative (figure 1D).
Expression of Surface Markers on interstitial-type and langerhans-type DC (flowcytometric analysis of lung digest)
% positive cells
Mean Fluorescence Intensity
Distribution and quantification of dendritic cells in small airways
Clinical characteristics of the study population
Characteristics of the Study Population (immunohistochemical study) (n = 85)
Sex ratio (M/F)
Smoking history (packyear)
Years quit smoking
FEV 1 (%pred)
FEV 1 (L)
FEV 1 /FVC (%)
Inhaled corticosteroids (Y/N)
Inhaled corticosteroid dose (μg BDP/24 h)
Systemic corticosteroids (Y/N)
Systemic corticosteroid dose (mg prednisolon/24 h)
DC-SIGN positive interstitial-type DC
Langerin positive Langerhans-type DC
Representative cryosections showing langerin+ DC are displayed in figure 5 D-F. Langerin+ DCs were mainly found in the epithelium and to a lesser extent in the lamina propria and the adventitia. In the total airway wall, the number of langerin+ DC was significantly higher in all COPD groups compared to ex-smokers without COPD (figure 6B). This increase was due to a significant accumulation of these cells in the epithelium and adventitia, with additional higher numbers of langerin+ DC in the adventitia of the patients with COPD GOLD stage III&IV (p = 0.045). (figure 7D-F).
Linear Regression Analysis (Quantification Langerin+ DC in small airways)
DC surface marker
Langerin+ DC in Total Airway Wall
Langerin+ DC in Epithelium
Langerin+ DC in Lamina Propria
Langerin+ DC in Adventitia
BDCA-1 positive DC
Representative cryosections are shown in figure 5 G-I. BDCA-1+ DC were mainly found in the epithelium and the lamina propria. The number of BDCA-1+ DC was significantly lower in the total airway wall of all COPD groups compared to never smokers (p = 0.042 for COPD GOLD I&II current smokers, p = 0.032 for COPD GOLD I&II ex-smokers and p < 0.001 for COPD GOLD III&IV ex-smokers) (figure 6C). Importantly, the number of these DC in the total airway wall was lower in COPD GOLD stage III/IV compared to the milder stages of the disease (p = 0.003 versus COPD GOLD I&II current smokers and p = 0.058 vs COPD GOLD I-II ex-smokers).
There were no significant differences between current and ex-smoking COPD GOLD I&II and between current and ex-smokers without airway obstruction. When focusing on the lamina propria and adventitia (fig 7H-I), the number of BDCA-1 positive DC was significantly lower in current smokers without airway obstruction compared to never smokers (p = 0.044 and p = 0.032, respectively) There was a significant positive correlation between the FEV1 (% predicted) and the number of BDCA-1+ DC in the epithelium (rs 0.39; p < 0.001), lamina propria (rs 0.35; p = 0.001), adventitia (rs 0.36 ; p = 0.001) and total airway wall (rs 0.40; p < 0.001). The association between FEV1 (% pred) and the number of BDCA-1 positive DC in the small airways was investigated by linear regression analysis (Table 5). This revealed that the decrease in BDCA-1 positive DC in the lamina propria is predominantly associated with the use of inhaled corticosteroids, which are mostly prescribed in the COPD patients with the lowest FEV1. In contrast, an independent association of FEV1 and BDCA-1+ DC was still observed in the epithelium and the adventitia. Gender did not influence the association between FEV1 and the number of BDCA-1 positive DC (data not shown).
Linear Regression Analysis (Quantification BDCA-1+ DC in small airways)
DC surface marker
BDCA-1+ DC in Total Airway Wall
BDCA-1+ DC in Epithelium
BDCA-1+ DC in Lamina Propria
BDCA-1+ DC in Adventitia
CD1a positive DC
Representative paraffin embedded sections showing CD1a+ DC are presented in figure 5J-L. CD1a + DC were mainly present in the adventitia and the lamina propria of the small airways. There were no significant changes in the number of CD1a+ DC in either the total airway wall (fig 6D), the epithelium, the lamina propria or the adventitia between the different groups (figure 7:J-K). No significant correlations with the post-bronchodilator FEV1 (% predicted) were found (data not shown).
Factors involved in Langerhans-type DC differentiation and survival
The characteristics of the study population are shown in Table 6.
Characteristics of the Study Population (mRNA expression study) (n = 55)
Current Smokers without COPD
Ex-Smokers without COPD
COPD Current Smokers
Sex ratio (M/F)
Smoking history (packyear)
34.8 (12) *
37.5 (20.6) *
41.2 (16.9) †
56.1 (24.1) *
Years quit smoking
9.0 (10.7) †
Inhaled corticosteroids (Y/N)
Inhaled corticosteroid dose (μg BDP/24 h)
Systemic corticosteroids (Y/N)
Systemic corticosteroid dose (mg prednisolon/24 h)
This is the first study characterizing langerin+ Langerhans-type and DC-SIGN+ interstitial type DC as two separate populations in single cell suspensions of digested human lung tissue. Moreover, the extensive immunohistochemical study showed a selective accumulation of the LDC subset in small airways of current smokers and COPD patients, which correlated with its differentiation factor Activin-A. These data suggest a role for the LDC subset in the initiation of airway inflammation in susceptible smokers and perpetuation of this destructive process in COPD, even after smoking cessation.
Flowcytometric characterization of the segregation of LDC and intDC was confirmed in small airways using immunohistochemical double staining, which also showed that LDC are mainly present in the epithelium, whereas intDC are mainly localized in the lamina propria and adventitia. These findings are parallel to the known distribution of these two DC subsets in human skin .
In contrast, pulmonary intDC do not express BDCA-1 and CD1a, indicating that these DC are in a separate differentiation axis, more closely related to monocytes and macrophages, as hypothesized previously .
Although BDCA-3 can be expressed at an intermediate level on both the mDC1 related LDC and on intDC, BDCA-3 high expression is confined to a separate population of DC, that does not express BDCA-1, langerin, DC-SIGN or the pDC marker BDCA-2. This separate BDCA-3 high DC population could be regarded as a more accurate definition of the previously described myeloid DC type 2 (mDC2) . It is unclear how this pulmonary mDC2 population is exactly related to the other DC subsets in terms of differentiation pathways, as there are currently no in vitro data available on this issue. Since we demonstrated that mDC2 also partially express CD14, we suggest that mDC2 are a fourth modality of differentiating monocytes (apart from macrophages, interstitial type DC and the mDC1-LDC axis).
A recent study by Tsoumakidou et al addressed the issue of different myeloid DC subsets in human lung digests by immunocytochemical staining of in vitro adhered pulmonary cells . The target cell population of that study was mainly a mature CD83+ CD1a+ population. They also found that langerin, BDCA-1 and CD1a are not necessarily co-expressed. In addition, a substantial percentage of these cells also expressed BDCA-3. These results are generally in line with our findings. Unexpectedly, a high percentage of the cells in the study by Tsoumakidou et al also expressed the plasmacytoid DC (pDC) marker BDCA-2. This finding is in sharp contrast to the results of other research groups, including ours, showing that pDC are truly separated from myeloid DC. Our study has the advantage of the real-time simultaneous analysis of the different DC surface markers by flowcytometry, which generates more accurate results than the quantification of sequential immunocytochemical single stainings of adhered DC that could be phenotypically altered by the incubation in vitro.
Importantly, the relative proportions of different DC subsets differ, depending on the technique used for quantification. As lung digests contain cells from the different compartments of the lung specimen (airways, alveoli, lymphoid follicles, blood vessels and blood), the proportion of DC markers which are both expressed on circulating blood DC and tissue resident DC (such as BDCA-1) is generally higher compared to the tissue resident DC markers langerin and DC-SIGN in flowcytometric experiments. In contrast, when the focus is strictly on the small airway (in the immunohistochemical analysis), the tissue resident DC markers outnumber the BDCA-1 positive DC.
The immunohistochemical study of the different myeloid DC subsets in the small airways revealed a shift of the myeloid DC population towards a Langerhans phenotype with higher numbers of LDC in COPD patients compared to never smokers and ex-smokers without COPD. Moreover, the number of LDC further increased with the severity of the disease, confirming the results of our previous observations . In accordance with previous studies in BAL [27, 28], the number of LDC was higher in current smokers without COPD compared to never smokers or ex-smokers. In contrast, the number of LDC was not different between current smoking and ex-smoking COPD patients, supporting the concept of ongoing inflammation in COPD, despite smoking cessation.
Quantification of BDCA-1 positive DC revealed a completely different result with a significantly lower number of these DC in COPD patients compared to never smokers, especially in the lamina propria. Moreover, the number of BDCA-1+ DC further decreased with the severity of the disease. In line with the results of Soler et al , we found no differences in the number of epithelial BDCA-1+ cells between current smokers and ex-or never smokers. In addition, there was no effect of current smoking on the numbers of BDCA-1 positive DC in COPD patients. This marked divergence between the numbers of LDC and BDCA-1 positive DC could be explained by an alteration in the DC differentiation process. Indeed, adding TNF-alpha - a factor that is capable of driving the differentiation towards LDC - to a monocyte derived DC culture system, induces a lower expression of BDCA-1, compared to IL-4 generated DCs . The fact that in our study the number of LDC tended to be inversely correlated with the number of BDCA-1+ DC in the small airways further supports this concept of an enhanced DC differentiation process towards a LDC phenotype in patients with COPD. Finally, this concept of enhanced LDC differentiation is compatible with the flowcytometric results on lung digests as shown in table 1. This revealed that the percentage of LDC expressing BDCA-1 tended to be lower in patients with moderate COPD (subject 3 and 6) compared to never smokers, suggesting that in COPD, BDCA-1 expression on LDC is reduced.
Quantification of CD1a, a marker present on both the BDCA-1+ precursors of LDC and on a subset of LDC, showed no differences between groups, indicating that smoking or COPD does not alter the number of CD1a positive DC in the small airways. These data confirm and extend the data of Soler et al in bronchiolar epithelium of smokers and non-smokers , and the previously published studies investigating the number of CD1a positive DC in bronchial biopsies and small airways of COPD patients [24, 25]. These findings are in contrast with the clear accumulation of CD1a positive DCs in airways of asthmatics and of patients with diffuse panbronchiolitis [36, 37].
To our knowledge, this is the first study evaluating the number of IntDC in small airways of smokers and COPD patients. Importantly, our study showed no significant differences in numbers of intDC in small airways between groups.
Taken together, these data suggest an alteration of the differentiation process of myeloid DC in small airways of COPD patients resulting in a selective accumulation of the LDC subset. The predominant accumulation of LDC in COPD patients is an important finding, as LDC are known to be potent activators of T helper1 cells and cytotoxic T cell responses, both involved in COPD pathogenesis . Freeman et al recently showed that the production of CD8+ T cell attracting chemokines CCL-3 and CXCL-9 by CD1a positive lung DC (which are closely related to LDC) increases with COPD severity . Moreover, recent publications also highlight the importance of LDC cells in activating Th17 cells , a T cell subset that could contribute to the adaptive immune response in COPD. In addition, LDC have different Toll-Like receptor expression compared to non- LDC, making them less capable to pick up certain microbial danger signals [41–43]. This could impair antimicrobial defence, leading to low grade infections that contribute to the destructive inflammation in COPD. This functional evidence on LDC is derived from skin DC or in vitro generated LDC. Further investigations to elucidate the functional differences between pulmonary Langerhans-type and non-Langerhans-type DC are warranted in order to better understand the role of the different DC subsets in the initiation and perpetuation of inflammation in COPD.
Recently, other factors capable of inducing LDC differentiation and survival such as activin-A, notch ligand delta-1, RANK-ligand and IL-15 were identified in vitro and in the human skin. This study identifies pulmonary expressed activin-A as the differentiation factor correlating with the accumulation of LDCs in the small airways, highlighting its importance especially in current smokers. In addition, we describe for the first time the expression of activin-A in the small airways of human lungs, especially in the area that contains the highest concentration of langerin positive cells: the airway epithelium. Activin-A is a TGFβ superfamily member known for its activity on growth and differentiation of various cell types during organogenesis, and for its role in wound healing and inflammation . Apart from inducing DC differentiation, activin-A is known to attenuate the pro-inflammatory response of DC in the context of stimulation with CD40 ligand, but not in the context of Toll-Like Receptor 4 stimulation . Moreover, activin-A is also involved in promoting the chemotaxis of immature myeloid DC .
There are several factors that strengthen this study. First of all, this study is, to our knowledge, the largest study (85 patients) addressing the quantification of myeloid DC in human lungs, using different markers and taking into account not only the disease-effect (COPD), but also the current smoking effect. Secondly, as COPD is defined as a small airway disease, assessing the number of DC in this location yields more relevant results compared to endobronchial biopsies, which only sample the central airways. Thirdly, the interrelationship of the different myeloid DC markers was elucidated by flowcytometry and crucial segregations were confirmed on immunhistochemical staining. Finally, this study provides insight in new mechanisms that contribute to the alterations in the composition of the DC population in the small airways.
However, there are also several limitations to this study which should be addressed.
Firstly, tissue was obtained from surgical resection specimens from patients undergoing thoracotomy for solitary pulmonary lesions. In theory, the presence of this pathologic lesion could influence the number of DCs in the small airways. However, samples were obtained at maximum possible distance of this lesion, assuring the absence of retro-obstructive pneumonia or tumour invasion. Moreover, all groups, except GOLD stage III&IV contained patients with these lesions, minimizing their influence.
Secondly, the difference in gender ratio between the study groups (with a higher proportion of women in the never smoking group and a predominant male COPD population) could influence the results of this study. Recent publications suggest indeed a role for sex and gender in the susceptibility and pathogenesis of COPD . However, significant associations between DC subsets and FEV1 were not influenced by adjusting for gender in the linear regression model, suggesting that our findings regarding LDC and BDCA-1 DC are not due to gender differences between groups.
Thirdly, the use of inhaled and systemic corticosteroids, especially in the most severe stages of COPD, could influence the DC numbers and differentiation. Indeed, several studies reported a decrease of circulating myeloid BDCA-1+ DC in patients treated with systemic corticosteroids [49, 50]. Moreover, inhaled corticosteroids reduced the number of CD1a positive DCs in bronchial biopsies of atopic asthma patients . In contrast, use of inhaled corticosteroids did not affect the number of CD1a positive DCs in bronchial biopsies of COPD patients . Importantly, we demonstrated by linear regression analysis that the number of LDC in the small airways remained significantly associated with FEV1, even after adjustment for possible confounders such as the treatment with inhaled and oral corticosteroids. In contrast, we found that FEV1 was no longer associated with the number of BDCA-1 positive DC in lamina propria of the small airways when the treatment with corticosteroids was taken into account, suggesting that the lower number of BDCA-1 positive DC observed in COPD patients could at least be partially attributed to the treatment with corticosteroids, as these medications are mainly prescribed in the more severe stages of COPD.
Finally, identification of DC using immunohistochemical staining for a single marker is hazardous as some markers are also expressed on other cell types. For instance, BDCA-1 is also expressed on B cells, whereas DC-SIGN expression is also reported on macrophages. Therefore, only cells with a morphology compatible with a DC were regarded as positive cells.
This flowcytometric and immunohistochemical study characterized for the first time pulmonary Langerhans-type DC, which are related to their known BDCA-1+ precursors and which are segregated from interstitial-type DC. In addition, we showed that DC differentiation is altered in small airways of current smokers and COPD patients with a selective accumulation of the Langerhans-type DC, correlating with the expression of Langerhans-type DC-inducing differentiation factor activin-A. This study identified the Langerhans-type DC subset as an interesting focus for future research in COPD pathogenesis.
The authors would like to thank A. Neesen, I. De Borle, K. De Saedeleer, E. Castrique, A. Goethals, E.J.J. Vulto-De Groot, E.J. van der Toom and D. Van Egmond for their technical contribution to this work and H. Middendorp, F. Vandewalle and T. Verstraete for their support in data management. The authors would also like to thank Dr. M. Hamels for carefully reading the manuscript and Dr. D. Testelmans for providing the patient characteristics of the transplant patients. The authors would also like to thank Prof. Dr. M. Praet and Dr. L. Ferdinande (dept. of Pathology, Ghent University Hospital) for their advice on the immunohistochemical staining procedures and providing the samples for the positive control stainings.
This work was supported by the Fund for Scientific Research in Flanders (FWO Vlaanderen, research projects G.0011.03, G.0195.09N and G0343.01N), by Project grant 01251504 from the Concerted Research Initiative of the Ghent University and by the Interuniversity Attraction Poles programme (IUAP) - Belgian state - Belgian Science Policy P6/35. GRVP is a doctoral research fellow of the Fund for Scientific Research in Flanders. KRB is a post-doctoral research fellow of the Fund for Scientific Research in Flanders.
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