University of Groningen
Biological Pathways in the Development of Dupuytren’s and Peyronie’s Diseases
ten Dam, Evert-Jan
DOI:
10.33612/diss.146362351
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Publication date: 2020
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ten Dam, E-J. (2020). Biological Pathways in the Development of Dupuytren’s and Peyronie’s Diseases. University of Groningen. https://doi.org/10.33612/diss.146362351
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Chapter 1
Introduction and outline
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upuytren’s disease (DD) is a benign fibroproliferative disorder of the hand, which causes the formation of nodules and cords in the palm and fingers. It may eventually lead to the inability to fully extend the fingers, giving rise to functional problems, such as difficulties shaking hands, putting hands in the pocket and grabbing objects. Reports about prevalence vary widely, but in the Netherlands it is around 22% in people over 50 years of age. [1] The disease is more common in people of European ancestry, in older persons and in males. [2, 3]
Dupuytren’s disease is associated with Peyronie’s disease (PD), a fibrotic disorder of the penis. It causes deformities and pain in erection, ultimately impeding sexual intercourse. It is seen in up to 9% of men, although an underestimation due to shame is possible. [4] Both diseases seem to have a common histopathological phenotype, and show a concomitance of 20-40%. [5-7] Another disease that is associated with DD is Ledderhose disease, in which the plantar fascias are affected. This disease will not be subject of this thesis.
Descriptions of DD date back to the seventeenth century, but it was Baron Guillaume Dupuytren, a French surgeon, whose name became associated with the disease because of a lecture he gave in Paris in 1831. [8, 9] PD is named after François Gigot de la Peyronie, also a French surgeon, and first-surgeon to King Louis XV. He described the induration of the penis in 1743. Dupuytren performed open fasciotomies in patients with DD, dividing the cords that had formed in the palmar aponeurosis, together with overlying skin, and reached satisfying results. Today, the golden standard in treating the disease is still open surgery, in which the cords and nodules are being removed (limited fasciectomy), sometimes even with the overlying skin (dermofasciectomy). The use of less invasive methods, such as percutaneous needle fasciotomy and injections with collagenase Clostridium histolyticum (Xiapex) in the cords, is becoming more popular. [10, 11] The downside of these newer techniques is that recurrences are more frequent following treatment, [10] which is understandable from a biological point of view: the affected tissues are left in place, and so, proliferation and contraction may continue.
Treatment in PD is mostly conservative, that means counseling and sometimes using traction or vacuum devices to reduce penile deformity. Like in DD, injections with collagenase have shown efficacy and are the only FDA and EMA approved drug in treating PD. However, the manufacturer of Xiapex has withdrawn this medicine from the European market by the end of 2019. [35]
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Injections with steroids, and oral and topical medications haven’t proven effective. [12] Surgical therapy is only used in patients with deformity (curvature of more than 30 degrees) and stable, non-painful disease. [13] Penile shortening (plication, Nesbit procedure) and penile lengthening (grafting) techniques both have their pros and cons when it comes to results and complications.
Still, for both types of fibromatosis, there is no definitive cure, and therapies are still focused on the symptoms of this disease. An important question to raise is if in the near future, DD and PD can be treated causally, that means, preventing the progression of early disease to the stage where functional problems occur, by focusing on the genetic and environmental factors that contribute to it. From a biological point of view, most research is focusing on pathways that enhance fibrosis in general and in both the palmar fascia and tunica albuginea in particular. Some of these studies have inspiring results. Both DD and PD (as well as Ledderhose disease) are examples of fibromatoses, i.e. soft tissue tumors caused by cell proliferation with a locally infiltrative growth pattern and – after removal - frequent local recurrence. However, malignant features such as metastatizing are absent and survival is not affected directly. The underlying mechanism of fibromatosis is cell proliferation and extracellular matrix deposition that exists from a plethora of contributing factors and pathways. Generally speaking, fibrosis is an end stage disease following inflammation, that is looked upon as ‘normal’ in wound healing, but also occurs in many diseases. In its inflammatory phase, multiple cells and cytokines are involved, each having their own specific function in this complex process. The constitution and interplay of these contributors have been studied extensively, and some of them are very relevant for the research that is the subject of this thesis, and will be mentioned later. Ultimately, the endpoint of the tissue response is the deposition of collagen, which, in normal conditions, is to a larger extent reversible. In DD and PD on one hand and in fibrotic diseases on the other however, once the inflammatory processes have led to fibrosis, the accumulation of surplus extracellular matrix becomes excessive and the process irreversible. This eventually leads to scarring, which in the case of affecting vital organs may lead to organ failure and possibly, even death. [14] In DD and PD it leads to the formation of nodules and cords, which cause functional problems.
Pathophysiologically, key features of fibrosis are matrix deposition and contraction; both features are caused by uncontrolled myofibroblast activity.
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The myofibroblast is found in wound healing tissue and shares characteristics from both fibroblasts (secretion of extracellular matrix and prominent endoplasmatic reticulum) and smooth muscle cells (contraction forces and presence of microfilament bundles). [15] Whereas the fibroblast is omnipresent in healthy tissue, myofibroblasts are almost absent under normal circumstances, but present in both normal and dysregulated wound healing, and fibrotic disorders. They are recognized as α-smooth muscle actin (α-SMA) positive cells. [16] Normally, the development of myofibroblasts depends on a number of different environmental cues, including tension in the matrix and exposure to a variety of different mediators. [16] Myofibroblasts have been identified as the key cell type in forming and occupying the early stage nodules in Dupuytren’s disease, with cords being less cellular and more tendon-like. [17, 18]
Hallmarks of the fibromatoses are excessive collagen deposition in and around normal fascial structures in the palm of the hand in DD, and in the tunica albuginea in PD. According to Luck, DD develops in three progressive stages. [19] First, there is proliferation with high cellularity and random arrangements. This is followed by an involutional stage in which lines of tension appear along which the cells start to align. Lastly, the tissues end up in a residual stage with relatively acelullar structures surrounded by extracellular matrix. The distribution in certain types of collagen is dynamic in scars and DD. Collagen type III is mainly found in immature scar tissue and is known to have thinner fibrils than collagen type I. In progression of DD, there is a gradual decrease of collagen type III in relation to collagen type I. Also, the collagen type III is mainly found at the periphery of DD’s tissues, while type I makes up the majority of central portions. [20] As mentioned before, inflammation is an essential factor in the induction of fibrosis. A variety of pro-inflammatory cytokines are known, too many to discuss in this thesis. However, we know that tumor necrosis factor (TNF) and transforming growth factor beta (TGF-β) both have a strong pro-fibrotic effect, as they are important regulators of the myofibroblast phenotype (e.g. differentiation and proliferation). [14] Elevated levels of TGF-β are seen in nodules and cords from patients with DD. [16, 21, 22]
The involvement of Wnt signaling in fibrosis as induced by TGF-β is clear, and there is reciprocity between the Wnt and TGF-β signaling pathways. [23, 24] Moreover, TGF-β is involved in the Hippo signaling cascade, by activating Yes-associated protein 1 (YAP1). [25] The expression of YAP1 is increased in nodular tissues from DD patients, and a deficiency of YAP1 leads to a
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decreased contraction force of the myofibroblasts. [26] The cross talk between these different pathways eventually leads to fibrosis, and in our case, to DD and PD. However, we still do not know how to interfere in these pathways to reduce fibrosis or cure the disease.
The focus of this thesis is mainly on Wnt signaling, one of the many pathways involved in developmental processes. There are multiple Wnt genes and proteins that have specific, but similar functions, in the signaling pathway. [27] Wnt signaling has our special interest, as a result of the remarkable findings of our research group in 2010. This first of its kind genome-wide association study in DD probants revealed several loci in the human genome in DD for the first time, the majority of them being associated with the Wnt signaling pathway. [28] A subsequent study of our British colleagues and co-workers once more confirmed the relevance of Wnt signaling in Dupuytren’s disease. [29] The previously found susceptibility loci containing Wnt related genes were reconfirmed and others found. We started studying the functional impact of the expression of these Wnt genes found in our 2011 GWAS study and expanded it to the whole Wnt signaling pathway as well as its contributing genes in the following chapters. Variations in the Wnt pathway might predispose to Dupuytren’s disease, and maybe, fibrosis in general.
The canonical pathway of Wnt signaling is the most extensively studied and has been shown to promote cell proliferation and survival via β-catenin. [30, 31] Alternatively, Wnt proteins may signal via the non-canonical Wnt pathway, defined as all Wnt signaling activities that are apparently independent of β-catenin. [32] During the research period that led to this thesis, it has become evident that canonical and non-canonical Wnt ligands and pathways are more diverse and also context-dependent. [27, 33] Therefore, this nomenclature has now become obsolete, but has been used in our already published papers and chapters. As far as possible, we will use the more correct terms β-catenin dependent and independent signaling. It is suggested that some environmental and genetic factors play an identical role in the development of Dupuytren’s and Peyronie’s diseases, such as Wnt signaling. [34] If this common pathway, or maybe different ones too, turn out to be equally important in both diseases, it might be helpful in the search for treatment options for these conditions.
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Aims of this thesis
The main objective of this thesis was to elucidate some of the biological backgrounds of Dupuytren’s disease and Peyronie’s disease. Main research questions were the following:
1. Are the Wnt genes as described by our research group in 2011 indeed dysregulated in Dupuytren’s cords and nodules?
2. Is there a general alteration in Wnt signaling in Dupuytren’s tissues and does this connect to the fibrosis as seen in Dupuytren’s disease? 3. What are the molecular differences between cords and nodules in
Dupuytren’s disease?
4. Will inhibiting the Wnt signaling pathway result in a less fibrotic phenotype in Dupuytren’s disease?
5. Do we find a similar dysregulation in genes and pathways in plaques from Peyronie’s disease patients?
Outline of this thesis
Chapter 2 focuses on the results of a study on the expression of the Wnt-related genes and proteins, in affected and non-affected tissues from Dupuytren’s patients, to answer our first research objective.
Chapter 3 presents the results on the correlation of Wnt signaling and fibrosis and in Dupuytren’s disease and shows how intervening in the Wnt signaling pathway may change the fibrotic properties in diseased cells.
Since both cords and nodules are a characteristic of Dupuytren’s disease, we investigated the differences between these two types of tissue on a molecular level. The results are described in Chapter 4.
Knowing that the Wnt signaling pathway is involved in Dupuytren’s disease, we tried to block the production of Wnt proteins with a low-molecular weight Wnt-inhibiting molecule in normal dermal and affected Dupuytren’s fibroblasts. The outcomes of these experiments are presented in Chapter 5. Peyronie’s disease shares a common etiology with Dupuytren’s disease and about 20% of Peyronie’s patients show the typical cords and/or nodules of Dupuytren. Not much is known about the pathophysiology of Peyronie’s disease. In Chapter 6, we present the results on Wnt and YAP1 signaling in
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plaques from patients with Peyronie’s disease, and we focus on the dysregulations in collagens and collagen-modifying genes.
Finally, Chapter 7 offers a general discussion on the above-mentioned studies and provides future perspectives regarding the pathophysiology of Dupuytren’s and Peyronie’s disease. Suggestions are given concerning new therapeutic targets, since a curative treatment does not yet exist for either one of the fibromatoses.
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