We recently reported that CTLA-4, a molecule previously thought to be expressed only by T cells, is also expressed by pituitary endocrine cells. This finding has opened a new area of investigation in pituitary autoimmunity, and it is clinically relevant because therapeutic injections of CTLA-4 blocking antibodies, used as a form of cancer immunotherapy, cause secondary hypophysitis in a significant percentage of the patients (about 12%). There is a fundamental gap in the understanding of the role of pituitary CTLA-4, and in the ability to diagnose and treat hypophysitis. The long-term goals of our research program are to elucidate the pathophysiological role of pituitary CTLA-4 and to prevent secondary hypophysitis. The goals of this application are to identify factors that modulate the expression of pituitary CTLA-4 and to develop a non-invasive and reliable serum test based on pituitary antibodies for diagnosis of hypophysitis. In fact, although hypophysitis was first reported in 1962 in its primary form and in 2003 in the form secondary to cancer immunotherapy, such a diagnostic test is not currently available. Our central hypothesis is that CTLA-4 functions in the pituitary gland as an immunological shield. Under normal conditions, the shield prevents infiltration of autoreactive lymphocytes, thus establishing the pituitary gland as an immuno-privileged site and explaining the rarity of primary hypophysitis. In the context of cancer immunotherapy, however, the same pituitary CTLA-4 shield becomes the target of the injected therapeutic anti-CTLA-4 antibody, thus initiating an autoimmune reaction that damages the pituitary cells. The rationale for the proposed research is that understanding the function of pituitary CTLA-4 and the associated autoimmune phenomena will lead to innovative approaches for the diagnosis and treatment of hypophysitis. Guided by strong preliminary data, we will test our hypothesis using two specific aims.
Aim 1 focuses on elucidating the role and regulation of CTLA-4 expression in pituitary endocrine cells, using banked and prospective human pituitary tissues (1A), pituitary cell lines in vitro (1B), and functional studies in mice (1C).
Aim 2 focuse on improving the diagnosis and treatment of hypophysitis secondary to CTLA-4 blockade, by discovering pituitary autoantigens using Phage ImmunoPrecipitation sequencing technology (2A), by establishing the analytical (2B) and clinical (2C) validity of antibody-based diagnostic tests, and by identifying small bioactive molecules potentially capable of modulating pituitary CTLA- 4 expression (2D). Our research is innovative because it opens a new area of investigation centered on pituitary CTLA-4, and uses a high throughput autoantigen identification methodology as the foundation for developing novel diagnostic tools. The research is significant because it will enhance human health by improving diagnosis of hypophysitis and generating fundamental knowledge about pituitary CTLA-4.

Public Health Relevance

The proposed research is relevant to public health because elucidating the role of pituitary CTLA-4 and developing a diagnostic test based on serum antibodies will increase our understanding of pituitary pathophysiology and ultimately improve the care of patients with cancer immunotherapy-induced (and possibly primary) hypophysitis. Thus, the proposed research is relevant to the part of the NIH's mission that pertains to enhance human health and advance the understanding of biological systems.

National Institute of Health (NIH)
National Cancer Institute (NCI)
Research Project (R01)
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Integrative and Clinical Endocrinology and Reproduction Study Section (ICER)
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Mckee, Tawnya C
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Johns Hopkins University
Schools of Medicine
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Chalan, P; Di Dalmazi, G; Pani, F et al. (2018) Thyroid dysfunctions secondary to cancer immunotherapy. J Endocrinol Invest 41:625-638
Corsello, Andrea; Di Dalmazi, Giulia; Pani, Fabiana et al. (2017) Walter E. Dandy: his contributions to pituitary surgery in the context of the overall Johns Hopkins Hospital experience. Pituitary 20:683-691
Lin, Han-Huei; Gutenberg, Angelika; Chen, Tzu-Yu et al. (2017) In Situ Activation of Pituitary-Infiltrating T Lymphocytes in Autoimmune Hypophysitis. Sci Rep 7:43492
Sharma, Rajni; Di Dalmazi, Giulia; Caturegli, Patrizio (2016) Exacerbation of Autoimmune Thyroiditis by CTLA-4 Blockade: A Role for IFN?-Induced Indoleamine 2, 3-Dioxygenase. Thyroid 26:1117-24
Caturegli, Patrizio; Di Dalmazi, Giulia; Lombardi, Martina et al. (2016) Hypophysitis Secondary to Cytotoxic T-Lymphocyte-Associated Protein 4 Blockade: Insights into Pathogenesis from an Autopsy Series. Am J Pathol 186:3225-3235