Epidermal Elafin Expression Is an Indicator of Poor Prognosis in Cutaneous Graft- versus-Host Disease Marie-Charlotte Brüggen, Peter Petzelbauer, Hildegard.

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Epidermal Elafin Expression Is an Indicator of Poor Prognosis in Cutaneous Graft- versus-Host Disease Marie-Charlotte Brüggen, Peter Petzelbauer, Hildegard Greinix, Emmanuel Contassot, Dragana Jankovic, Lars French, Gérard Socié, Werner Rabitsch, Zoya Kuzmina, Peter Kalhs, Robert Knobler, Georg Stingl, Georg Stary Journal of Investigative Dermatology Volume 135, Issue 4, Pages 999-1006 (April 2015) DOI: 10.1038/jid.2014.489 Copyright © 2015 The Society for Investigative Dermatology, Inc Terms and Conditions

Figure 1 Various elafin expression patterns in cutaneous graft-versus-host disease (GVHD). (a) mRNA expression of elafin in acute graft-versus-host disease (aGVHD) and drug hypersensitivity reaction (DHR), normalized to healthy control (HC) skin. Quantitative real-time reverse transcriptase-PCR (RT-PCR) was performed after TRizol lysis of skin biopsies. (b, c) Representative pictures (scale bar=100 μm in all pictures) of immunohistochemistry (IH) elafin staining in DHR, HC, and psoriasis. Images were taken using a PixeLINK PL-B623CF color digital camera (Zeiss, Oberkochen, Germany). (d) The percentage of elafin-positive keratinocytes in aGVHD as compared with DHR measured using HistoQuest imaging analysis software. Expression in HC and lesional psoriatic skin is shown as a negative control and a positive control, respectively. (e, f) Pictures of elafin staining in aGVHD and chronic lichenoid graft-versus-host disease (clGVHD) skin (two different patients each) with corresponding hematoxylin and eosin (HE) sections shown below (scale bar=100 μm in all pictures). Blue arrows indicate correlation of epidermal thickness with increased elafin expression. The orange arrow points to the prominent inflammatory infiltrate in an elafin-high skin area. (g) Percentage of elafin-positive keratinocytes in aGVHD vs. clGVHD. Cutoff (at 20%) between the elafin-high and the elafin-low groups. Journal of Investigative Dermatology 2015 135, 999-1006DOI: (10.1038/jid.2014.489) Copyright © 2015 The Society for Investigative Dermatology, Inc Terms and Conditions

Figure 2 Epidermal thickening and a prominent CD4+ T-cell infiltrate in elafin-high graft-versus-host disease (GVHD) lesions. (a) Mean number of epidermal cell layers and the percentage of elafin-positive keratinocytes in acute graft-versus-host disease (aGVHD)/chronic lichenoid graft-versus-host disease (clGVHD) patients. The mean number of cell layers was calculated as (minimal number of cell layers epidermis+maximal number of layers epidermis)/2. (b, c) Quantification of the overall inflammatory infiltrate in elafin-low versus elafin-high groups of the aGVHD and clGVHD cohorts. (d) Quantitative analysis of the dermal T-cell infiltrate (T cells: CD3+, CD4+ T cells: CD3+CD4+, CD8+ T cells: CD3+CD8+; regulatory T cells (Treg) cells: CD4+Foxp3+) in elafin-high as compared with elafin-low aGVHD skin lesions. (e) Representative images of immunofluorescence (IF) stainings of CD4+ T cells merged with DAPI in an elafin-high and an elafin-low aGVHD skin lesion. Scale bar=50 μm in both pictures. The epidermis is located on the upper side in both images. Images were taken using a PCO PixelFly camera (Zeiss). Journal of Investigative Dermatology 2015 135, 999-1006DOI: (10.1038/jid.2014.489) Copyright © 2015 The Society for Investigative Dermatology, Inc Terms and Conditions

Figure 3 High elafin expression in graft-versus-host disease (GVHD) is associated with corticosteroid unresponsiveness and decreased overall survival (OS). (a,b) Comparison of mRNA expression of tumor necrosis factor alpha (TNFα), IL-1β, and transforming growth factor beta (TGFβ) in elafin-high as compared with elafin-low groups of (a) acute graft-versus-host disease (aGVHD) and (b) chronic lichenoid graft-versus-host disease (clGVHD) patients. Quantitative real-time reverse transcriptase-PCR (RT-PCR) was performed after TRizol lysis of skin biopsies. Data are normalized to β2m of each specimen and represent the mean±SD of (log2) fold change in mRNA expression relative to healthy control (HC) skin (n=10). (c) Cumulative survival after 2 years of elafin-high versus elafin-low aGVHD patients shown as a Kaplan–Meier curve. (d) Percentage of corticosteroid-resistant clGVHD patients in the elafin-high versus elafin-low groups. Journal of Investigative Dermatology 2015 135, 999-1006DOI: (10.1038/jid.2014.489) Copyright © 2015 The Society for Investigative Dermatology, Inc Terms and Conditions