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Localization of Tumor Necrosis Factor ╨Ю┬▒ in Synovial Tissues and at the CartilagePannus Junction in Patients With Rheumatoid Arthritis.

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1125
LOCALIZATION OF TUMOR NECROSIS FACTOR a IN
SYNOVIAL TISSUES AND AT THE
CARTILAGE-PANNUS JUNCTION IN PATIENTS WITH
RHEUMATOID ARTHRITIS
C. Q. CHU, M. FIELD, M. FELDMANN, and R. N. MAIN1
Using immunoaffinity-purified polyclonal antihuman recombinant tumor necrosis factor a (TNFa)
F(ab’), fragments and immunohistochemical techniques, the cells that make TNFa were localized in the
inflamed synovial tissue of patients with rheumatoid
arthritis (RA) and osteoarthritis (OA). Anti-TNFa
antibody-stained cells were demonstrated in 9 of 11RA
and 2 of 4 OA but none of 5 normal synovial membranes
examined. In RA, 2644% of the lining layer cells were
positive for TNFa. In the interaggregate area, 1 6 3 0 %
of the cells contained TNFa, often in a perivascular
distribution, and up to 19% of the cells in lymphoid
aggregates stained for TNFa. Some endothelial cells also
stained with these antibodies. In OA tissues, the TNFacontaining cells were found predominantly in the deeper
layer. Cells containing TNFa were also found at the
cartilage-pannus junction in all 4 RA specimens examined. Double immunofluorescence analysis demonstrated that most TNFa-secreting cells in the RA synovial membrane expressed the monocyte/macrophage
marker antigens CDllb and CD14, and a few expressed
From the Division of Clinical Immunology, The Mathilda
and Terence Kennedy Institute of Rheumatology, Hammersmith,
and the Charing Cross Sunley Research Centre, London, England.
Supported by the Arthritis and Rheumatism Council and by
the Nuffield Foundation. Dr. Chu’s work is supported by the
Sino-British Friendship Scholarship Scheme.
C. Q . Chu, MB BS: Research Fellow, Kennedy Institute of
Rheumatology; M. Field, BSc, MD, MRCP: Lecturer, Kennedy
Institute of Rheumatology; M. Feldmann, PhD, FRCPath: Professor, Charing Cross Sunley Research Centre; R. N. Maini, FRCP:
Director, Kennedy Institute of Rheumatology.
Address reprint requests to M. Field, BSc, MD, MRCP,
Division of Clinical Immunology, The Mathilda and Terence Kennedy Institute of Rheumatology, 6 Bute Gardens, Hammersmith,
London W6 7DW, UK.
Submitted for publication August 28, 1990; accepted in
revised form April 8, 1991.
Arthritis and Rheumatism, Vol. 34, No. 9 (September 1991)
the T cell marker CD3. Our findings provide histologic
evidence that TNFa is locally produced in the lining and
deeper layers of the synovium by cells of the monocyte/
macrophage lineage, supporting its role in inflammation. Further, our findings demonstrate that TNFa is
produced by cells at the cartilage-pannus junction,
which could affect chondrocyte metabolism, leading to
the cartilage degradation in RA.
Human tumor necrosis factor a (TNFa) is a
17-kd nonglycosylated protein (1) originally defined by
its ability to induce hemorrhagic tumor necrosis in
animals (2). However, TNFa can also act on other
cells (3) that regulate the immune and inflammatory
responses, thereby causing damage to connective tissue. These properties suggest that TNFa may contribute to the pathogenesis of the synovitis and joint
destruction in rheumatic diseases by stimulating fibroblast growth (4), inducing prostaglandin E, and collagenase release from synovial cells ( 5 ) , inducing resorption of bone and cartilage (6,7), and inhibiting
synthesis of proteoglycan in cartilage (8). In addition,
it activates endothelial cells, which leads to induction
of procoagulant activity (9) and increased adherence of
granulocytes (10) and mononuclear cells (11). TNFa
also regulates interleukin-1 (IL-1) production not only
by endothelial cells (12) but also by mononuclear cells
of the rheumatoid synovial membrane (13). Because
both TNFa and IL-1 can induce synovitis and joint
destruction (3), we have postulated that TNFa plays a
pivotal role in perpetuating the disease process in
rheumatoid arthritis (RA).
TNFa has been detected in synovial fluid from
patients with various arthritides (14-16), and messenger RNA for TNFa has been detected in synovial
CHU ET AL
1126
cells, which suggests that there is local production of
the cytokine in inflamed tissues (17). After stimulation
of peripheral blood mononuclear cells in vitro, macrophages are the major source of TNFa (18), but cultured T cells can also secrete TNFa after appropriate
stimulation (19,20).
In the inflamed synovial tissue, where macrophages and T cells are found, the localization and
cellular source of TNFa remains obscure.
Using immunoaffinity-purified polyclonal antiTNFa F(ab’), fragments and an immunohistochemical
technique, we localized TNFa-secreting cells in the
synovial tissues of patients with RA and osteoarthritis
(OA) and identified the macrophage as the major
source of TNFa in RA synovial membranes.
Table 1. Clinical, serologic, and therapeutic data of patients
whose synovial membranes were examined for the presence of
tumor necrosis factor a*
Hemoglobin
(gddl)
ESR
(mm/
hour)
5
6
13.4
14.3
9.9
11.8
13.4
11.4
23
NT
25
65
21
320
1,280
5,120
1,280
40
Neg.
28
19
16
25
12
18
7
11.9
37
1,280
16
8
9
9.1
10.0
11.2
14.2
51
100
44
12
1,280
2,560
320
Neg.
15
1.5
4
10
10.8
12.3
NT
NT
NT
NT
NT
NT
Neg.
Neg.
Neg.
Neg.
NR
6
1
12.5
10.2
100
108
Neg.
Neg.
0.1
0.5
14.1
13.2
57
20
80
Neg.
NR
Rheumatoid
arthritis
1
2
3
4
10
PATIENTS AND METHODS
Recombinant cytokines. Recombinant human TNFa
(rHuTNFa) and recombinant human lymphotoxin (rHuLT)
were obtained from Genentech (San Francisco, CA).
Recombinant human IL-la (rHuIL-la) was donated by
Hoffmann-La Roche (Nutley, NJ), and rHuIL-6 was a generous gift from Prof. Kishimoto (Osaka, Japan).
Preparation of rabbit anti-TNFa antibody. New
Zealand lop-eared rabbits were immunized subcutaneously
with 30 pg of rHuTNFa emulsified in an equal volume of
Freund’s complete adjuvant (Difco, Detroit, MI) and were
given a booster injection with 30 pg of rHuTNFa in Freund’s
incomplete adjuvant (Difco) at two 1-week intervals. Serum
IgG was separated by staphylococcal-protein A (Pharmacia,
Milton Keynes, Buckinghamshire, UK) chromatography
and digested with pepsin (Sigma, Poole, Dorset, UK) for 20
hours at 37°C at an 1gG:pepsin ratio of 50: 1 in 0.1M sodium
acetate buffer, pH 4.0. Intact IgG and Fc fragments were
then removed by protein A chromatography. The anti-TNFa
F(ab’), fragments were purified by elution from a column
made with rHuTNFa linked to cyanogen bromideeactivated
Sepharose 4B (Pharmacia) using 3M guanidine (Sigma). These
were then labeled with biotin (Pierce, Rockford, IL) as previously described (21).
Normal rabbit F(ab’), fragments were obtained from
normal rabbit IgG by pepsin digestion followed by Sephacryl
S200 (Sigma) column separation. These fragments were also
labeled with biotin (21).
Confirmation of immunoreactivity. Immunoreactivity
was verified by 2 methods. An enzyme-linked immunosorbent assay (ELISA) was used to demonstrate antibody
specificity. Recombinant human T N F a or other cytokines
were coated onto 96-well plates (Falcon, Oxnard, CA) at 1
pg/ml and stored at 4°C until used. The plate was washed,
and nonspecific binding was prevented by incubating with
2% casein for 1 hour at 37°C. Rabbit serum, purified rabbit
IgG, or immunopurified F(ab’), fragments labeled with biotin
were added to the plates and incubated for 1 hour. The plate
was washed, and bound antibodies were detected with
anti-rabbit IgG conjugated with alkaline phosphatase (Sig-
Disease
RAHA duration Drug
(titer)
(years) therapy
II
Osteoarthritis
12
13
14
15
Other inflammatory
arthropathies
16
17
18
19
11
Pred.
None
Pred .
DP
Pred.,
AZA
Pred.,
MTX
Pred .
DP
Pred .
10
5
Pred.,
ssz
Pred.
* Synovium was obtained from the hip or knee joint at synovectomy
or arthroplasty in patients I , 3-8, and 12-14, and from the knee joint
at arthroscopy in all other patients. Patients 5 and 18 were rheumatoid factor positive (by latex fixation), but the rheumatoid arthritis
hemagglutination (RAHA) titer was not significant (<1: 160). All
patients were taking nonsteroidal antiinflammatory drugs and/or a
simple analgesic. ESR = erythrocyte sedimentation rate; Pred. =
prednisolone; NT = not tested; DP = D-penicillamine; Neg. =
negative; AZA = azathioprine; MTX = methotrexate; NR = no
record; SSZ = sulfasalazine (Salazopyrine).
ma), or avidin-alkaline phosphatase (Sigma) where appropriate, and incubated as described above. This was followed
by a 1-hour incubation with p-nitrophenylphosphate (disodium salt; Sigma) substrate. The optical density was measured at 405 nm using a microplate reader.
With the second technique, cells from the human T
lymphoma cell line, HUT78, which secretes TNFa (20),
were stimulated with phytohemagglutinin/phorbolmyristate
acetate (1 pg/ml and 50 n g h l ) . Cells were harvested onto
glass slides with a cytospin (Shandon Southern Instruments,
Runcorn, Cheshire, UK), at 1,200 revolutions per minute,
and then fixed in acetone:methanol (1:l) at -20°C. Subsequent procedures were performed at room temperature in a
humidity chamber. Cells were incubated with 20% normal
human serum (NHS) for 20 minutes to prevent nonspecific
adherence. Biotinylated anti-TNFa F(ab’), fragments (5
pg/ml) were added, incubated for 60 minutes, and the slides
T N F a I N RA SYNOVIUM AND PANNUS
1127
A
B
C
D
Figure 1. Distribution of tumor necrosis factor a (TNFatpositive cells in synovial membranes from patients with rheumatoid arthritis. Using
anti-TNFa F(ab’), fragments, as described in Patients and Methods, TNFa-containing cells were found A, mainly in the lining cell layer, B,
within cell aggregates, and C, in a perivascular distribution (upper arrow), with some endothelial cell staining (lower arrow). No cells stained
with normal rabbit F(ab’), fragments (D). (Original magnification X 80 for A and D, and x 320 for B and C.:I
washed. Binding was detected with a streptavidinfluorescein conjugate (Amersham International, Little Chalfont, Buckinghamshire, UK). Washed cells were examined
under ultraviolet light and photographed.
The specificity of antibody binding to the cells and
synovial sections was confirmed by: (i) overnight incubation
of the anti-TNFa F(ab’), fragments with rHuTNFa or
rHuIL-6 at 4°C before testing; (ii) passage of purified antiT N F a F(ab’), fragments through cyanogen bromideSepharose 4B columns linked to rHuTNFa or rHuIL-la,
and measurement of activity in the drop-through from each
column; and (iii) assessment of biotinylated normal rabbit
IgG F(ab’), fragments at equivalent protein concentration.
Tissues from study patients. Synovial tissue was
obtained from the hip or knee joint at arthroplasty or from
the knee joint at arthroscopy from 11 patients with RA who
fulfilled the American College of Rheumatology (formerly,
the American Rheumatism Association) 1958 diagnostic criteria for RA (22). Tissue was also obtained from 4 patients
with OA and from 4 patients with other inflammatory polyarthropathies, 2 of whom had arthropathy in association with
hepatitis (1 of unknown cause and 1 with primary biliary
cirrhosis), 1 of whom had juvenile chronic arthritis, and 1 o f
whom had arthritis following bacille Calmette-Guerin instillation into the bladder for treatment for carcinoma (23).
Tissue samples were frozen and stored at -70°C until
used. Table I gives some of the clinical features of the study
patients. Normal synovial tissues were obtained from the
knee joint of patients undergoing amputation for osteogenic
sarcoma at a site distant from the knee joint (kindly provided
by Dr. M . Bayliss of the Kennedy Institute).
Tissue from the cartilage-pannus junction was taken
from the joints obtained from 4 RA patients at arthroplasty.
Samples were stored frozen at -70°C until used.
Immunohistochemical techniques. Cryostat sections
( 5 - 4 4 were fixed and incubated with 20% NHS as described
above. Sections to be stained with peroxidase were treated
for 30 minutes with 0.3% hydrogen peroxide in methanol.
Biotinylated anti-TNFa F(ab’), fragments at 5-10 pg/ml
were incubated with the sections for 60 minutes, and the
slides were washed. Binding was detected by streptavidinhorseradish peroxidase conjugate (Amersham International). Diaminobenzidine in phosphate buffered saline containing 0.03% hydrogen peroxide was subsequently added, and
after staining, the sections were counterstained with hematoxylin and examined.
CHU ET AL
1128
For double immunofluorescence staining, monoclonal cell marker antibodies, anti-CD3 (Becton Dickinson,
Mountain View, CA) for T cells, and 63D3 and anti-CD14
(donated by Dr. P. C. L. Beverley, UCL, London) for
macrophages, were detected with fluorescein-conjugated
goat anti-mouse IgG (Sigma). Fluorescein-conjugated
F(ab’), fragment of goat anti-human F(ab’), Ig (ICN, Lisle,
IL) was applied to detect B cells and plasma cells containing
immunoglobulin. In all these experiments, biotinylated antiT N F a F(ab’), fragments were detected with Texas red
linked to streptavidin (Amersham International).
Statistical analysis. The numbers of TNFa-staining
cells were graded by counting up to 200 cells in each area of
the tissue examined. The data were analyzed using Wilcoxon’s rank sum test.
RESULTS
Antibody reactivity and specificity. Rabbit antiTNFa antibody bound specifically to rHuTNFa in the
ELISA, but failed to bind to rHuIL-la, rHuIL-6, and
rHuLT. Immunopurified F(ab‘), fragments produced a
pattern of cytoplasmic staining on stimulated HUT78
cells; this was abolished by absorption of the antibody
with rHuTNFa linked to solid Sepharose, thus confirming antibody specificity. Normal rabbit F(ab’),
fragments at equivalent concentration did not stain the
HUT78 cells (results not shown).
Localization of TNFa-containing cells in synovial
tissue. Nine of the 11 RA patient synovial membranes
contained cells positive for cytoplasmic staining with
F(ab’), anti-TNFa antibodies. TNFa-containing cells
were found mainly in the synovial lining layer (mean
37%) (Figure 1A and Table 2). Some TNFa-positive
cells were also detected in the deeper interstitium, not
only in cell aggregates, where 6% of the cells stained
positive (Figure lB), but also in the interaggregate
areas, where 10% of the cells stained positive, often in
a perivascular distribution. In 3 specimens, endothelial
cells in some of the blood vessels also stained with
anti-TNFa F(ab’), fragments (Figure IC).
TNFa-containing cells were also found at or
near the cartilage-pannus junction in all 4 RA specimens examined (Figure 2A). In 3 sections, small
fragments of bone were also present, and in 2 of these
specimens, TNFa-containing cells were detected adjacent to these areas.
Two of the 4 OA synovial membrane sections
(Table 2) showed TNFa-containing cells in a similar
distribution, but in lower proportion (mean 3.5%), in
the lining layer cells (P < 0.05 versus RA group mean).
In the synovial membranes from 4 patients with other
inflammatory polyarthropathies (Table 2), 2 had cells
that stained with the anti-TNFa F(ab’), antibodies.
Both patients had longstanding disease and in both,
the arthritis was associated with hepatitis (primary
biliary cirrhosis in one and unknown etiology in the
other). No cells in the 5 normal synovial membranes
stained with the antibodies against TNFa (results not
shown).
Staining of the RA synovial membranes with
anti-TNFa F(ab’), fragments was abolished by preincubation of the antibody with 50 pg/ml of rHuTNFa,
but not with 50 pg/ml of rHuIL-6. In addition, binding
was not observed after the antibody activity was
removed with the TNFa-Sepharose column (Figure
2B); it was still present, however, after passage
through an IL-la column (results not shown).
Characterization of cells containing TNFa. Double-immunofluorescence using a combination of antiTNFa F(ab’), antibodies and monoclonal cell marker
antibodies showed that 70-90% of the TNFacontaining cells in the RA synovial membrane (Figure
3A) expressed the monocyte/macrophage marker
Table 2. Percentages of cells staining for tumor necrosis factor a
(TNFa) in the lining cell layer, interstitium, and aggregate areas of
the synovial membrane*
Rheumatoid
arthritis
I
2
3
4
5
6
7
8
9
10
11
Mean
Osteoarthritis
12
13
14
15
Mean
Other inflammatory
arthropathies
16
17
18
19
Mean
Lining
Interstitium
Aggregate
30
32
54
57
64
38
35
26
62
37
10
10
27
30
10
14
13
10
NP
4
8
10
19
6
4
6
5
NP
NP
6
5
-
3.5
4
3
2
NP
NP
NP
NP
9
5
7
5
15
10
NP
NP
NP
NP
9
* Synovium was obtained from the hip or knee joint at synovectomy
or arthroplasty in patients 1, 3-8, and 12-14, and from the knee joint
at arthroscopy in all other patients. Synovium from patients 2, 3,
and 9 also showed T N F a in vascular endothelial cells. NP = not
present; - = no staining with anti-TNFa F(ab‘), antibodies.
TNFa IN RA SYNOVIUM AND PANNUS
A
1129
B
Figure 2. Presence of tumor necrosis factor a (TNFa)-containing cells in the rheumatoid pannus at the interface of the cartilage-pannus
junction (A). No staining was apparent in samples tested after the purified anti-TNFa F(ab’), fragments had been passaged through a column
containing TNFa-Sepharose (B). Synovial tissue is on the left and cartilage is on the right of each figure. (Original magnification x 160.)
antigens detected by 63D3 and anti-CD14 (Figure 3B).
Only 0-2.5% of these cells expressed CD3. None of
the immunoglobulin-positive cells from the B cell
lineage contained TNFa (Table 3).
A
DISCUSSION
To localize the cellular origin of TNFa in diseased synovial membranes, we generated monospe-
B
Figure 3. Double immunofluorescence analysis of rheumatoid synovial membranes, showing that streptavidin-Texas red-positive cells, which
contained tumor necrosis factor a (A), were also positive for monoclonal antibodies 63D3 and anti-CD14, using a fluorescein-conjugated
antibody ?gainst mouse IgG, which demonstrates macrophages (B). (Original magnification x 160.)
CHU ET AL
1130
Table 3. Cell phenotype of tumor necrosis factor a (TNFa)containing cells in rheumatoid synovial membranes
% of total TNFa-
Cell phenotype
Antibody
positive cells
Monocytehacrophage
T cells
B cells
63D3, aCD14
aCD3
aIgG
70-90
0-2.5
0
cific polyclonal rabbit antibodies against rHuTNFa.
Our anti-TNFa antibodies showed no cross-reaction in
an ELISA with rHuIL-la and rHuIL-6 (data not
shown), and in particular, none with rHuLT, which
shares 28% homology of amino acid sequence and has
similar biological effects (18). F(ab’), fragments were
made in order to prevent binding of rabbit antibodies
to locally produced rheumatoid factors, and these
fragments stained the cytoplasm of the TNFasecreting HUT78 cell line (data not shown). Specificity
was established by showing that the staining reaction
could be abolished by prior absorption with TNFa but
not with IL-la.
With the use of F(ab’), fragments of anti-TNFa
antibodies, TNFa was found in cells throughout the
RA synovial membrane. Although this could conceivably represent uptake of secreted TNFa by cell surface receptors, the pattern of staining in the synovial
tissue cells (Figure 1A) was similar to the cytoplasmic
pattern seen in the HUT78 cells. We conclude that the
demonstration of TNFa in the intracellular compartment of RA synovial cells suggests local production of
this cytokine.
TNFa can be localized to 4 sites in inflamed
synovial tissue. The lining layer is the major area in
which TNFa-secreting cells can be detected; this
finding is consistent with those of other recent studies
(16,24). Production close to the joint space may be
responsible for the presence of TNFa in the synovial
fluid (14,15). Two cell types are found in the lining cell
layer: one derived from macrophages and the other
presumed to be of mesenchymal (fibroblast) origin
(25). TNFa has been shown to stimulate fibroblast
growth (4) and to induce collagenase and prostaglandin
release from adherent synovial cells and fibroblasts
(5). Hence, TNFa production in the lining cell layer
may also be one of the factors responsible for the
release of inflammatory mediators into the synovial
space and the increase in the numbers of fibroblasts.
Our studies have demonstrated TNFa-containing cells in the deeper areas of the synovium, frequently in a perivascular distribution in the intersti-
tium. Here, TNFa could be sustaining activation of
immune cells in the vicinity. In vitro studies have
implicated TNFa in T cell activation (26) and B cell
differentiation (27). Thus, in these aggregates, TNFa
may contribute to continued T cell activation (28), and
being in close proximity to appropriately primed B
cells, TNFa may, in conjunction with other activation
and differentiation factors, stimulate the B cell to
differentiate and produce rheumatoid factors in vivo.
These studies also show TNFa in the endothelial cells of some, but not all, blood vessels in the RA
synovial membrane. Although TNFa has been shown
to have diverse effects on endothelial cells, including
the production of IL-l(9-12) and the increased expression of adhesion molecules (29), there is only limited
evidence that TNFa can be made by endothelial cells
(30). Nevertheless, immunohistochemical localization
of TNFa to endothelial cells suggests that these cells
can product TNFa. This feature further indicates
involvement of TNFa in the regulation of cell adhesion
prior to migration into diseased joints.
Of potential relevance to joint destruction,
TNFa was demonstrated at the interface of the distinct
cartilage-pannus junction, the major target of joint
damage in RA (31). Previous in vitro studies have
demonstrated that TNFa has the potential to cause
cartilage degradation (8). Our studies provide “in
vivo” evidence linking TNFa with this target organ.
Previous studies have not characterized the
cellular source of TNFa production in rheumatoid
tissues (17,32). After stimulation of peripheral blood
lymphocytes with endotoxin in vitro (33), the macrophages are the major source of TNFa, but T cells can
also secrete TNFa (19,20). Our results show that cells
of the monocyte/macrophage lineage are the major
source of TNFa in RA synovial membrane, but 2.5%
of T cells also contained TNFa. Although we have not
directly examined the possibility that synovial fibroblasts could secrete TNFa, some cells with a fibroblast
morphology stained with anti-TNFa F(ab’), antibodies, and the mouse L cell fibroblast line has previously
been shown to produce TNFa (34). Thus, fibroblasts
in the rheumatoid synovial membrane may also secrete TNFa, which may explain why not all the
TNFa-containing cells have been characterized with
antibodies 63D3 and aCD14 for macrophages, aCD3 for
T cells, and anti-immunoglobulin for B cells (Table 3).
There are conflicting data concerning TNFa
production in OA synovial tissues (16,24). Our study
samples may not be truly representative of OA, in that
3 patients from whom tissues were obtained were
T N F a IN RA SYNOVIUM AND PANNUS
undergoing knee/hip replacement surgery, and the
fourth patient was undergoing arthroscopy because of
a significant knee effusion. However, we confirmed
the presence of TNFa (16) in 2 of the 4 samples and
demonstrated that there is a lower frequency of positive cells in OA than in the RA tissues ( P < 0.05).
These cells are located mainly in the deeper interstitium in OA and have not been phenotypically characterized. They are also seen in a perivascular pattern,
however, which suggests that they may be of similar
phenotype as those seen in RA, but in contrast to RA,
the cells are not so commonly located in the hypertrophied lining layer. Thus, the presence of TNFa is not
specific for RA, since TNFa has been shown to be
present in other inflammatory arthropathies. Contrary
to other studies (16), we did not detect TNFa in
normal synovial tissue; this may indicate that our
technique is not sufficiently sensitive to detect very
low amounts of TNFa.
Only 9 of 1 1 RA synovial membranes showed
TNFa-containing cells. Samples from 2 patients
showed no staining with the anti-TNFa antibodies:
one of them, patient 10, showed little evidence of
active disease at arthroplasty, and in the other, patient
1 1 , the active knee synovitis improved coincidentally
after the arthroscopic biopsy and remained quiescent,
although an episode of vasculitis subsequently developed. This absence of TNFa in patients with inactive
disease and with rapidly resolving synovitis suggests
an apparent inverse link between TNFa production
and duration of symptoms in RA. Similarly, 2 patients
with chronic nonrheumatoid inflammatory synovitis
(patients 18 and 19) had TNFa in the lining cell layer
and interstitium. The other patients with short-lived
synovitis due to reactive arthritis (patient 16) and
adult-onset juvenile arthritis (patient 17) had no TNFa
detectable in the synovium, despite active clinical
disease. This relationship between TNFa and chronicity of disease is supported by in vitro studies which
have shown that anti-TNFa antibodies can reduce
IL-1 production in RA synovial membrane mononuclear cells (13). Thus, TNFa may play a role in the
perpetuation of chronic synovitis.
The pathogenesis of rheumatoid synovitis is
clearly a complex process. Current evidence suggests
that important among the factors in the pathogenesis
are immune complexes, IL-1, TNFa, and IL-6. Thus,
immune complexes could stimulate monocytes to secrete IL-1 (35) and TNFa (36). The immune complexes
(37), IL-1 (38), and TNFa in rheumatoid joints may,
together, perpetuate synovitis by stimulating IL-6 syn-
1131
thesis, which if found in close proximity to plasma
cells (39), could lead to autoantibody production by
plasma cells. Subsequent iritraarticular formation of
immune complexes could then stimulate cytokine production by the monocytes in the lining cell layer of the
synovial membrane, thus perpetuating the chronic
rheumatoid disease process. Our study demonstrates
that immunohistologic studies are useful for localizing
cytokines, and that information gained from these
techniques may define further the role of cytokines in
developing dynamic concepts of disease mechanisms.
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necrosis, factors, patients, cartilagepannus, junction, arthritis, localization, tissue, synovial, tumors, rheumatoid
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