1. ENT Department Upper Airways Research Laboratory New insights in the pathophysiology of chronic rhinosinusitis Upper Airways Research Laboratory Department of Otorhinolaryngology PAUL VAN CAUWENBERGE, THIBAUT VAN ZELE, CLAUS BACHERT Ghent University, Belgium

2. Upper Airways Research Laboratory Department of Otorhinolaryngology Case report Male, 46 years ENT: nasal polyps since 12 years, 3 FESS surgeries, continuous use of topical GCS No smell, nasal obstruction and PND Pneumo: moderate-severe asthma, AERD, inhalant and oral steroid use  Your therapy?

3. Upper Airways Research Laboratory Department of Otorhinolaryngology CRS without NPCRS with NP EG2, X 100 H, X 100 CRS without and with NP Remodelling

4. ENT Department Upper Airways Research Laboratory TGF-beta in chronic sinus disease Dual role: inflammation and remodelling –Immunmodulatory properties –Master switch in the induction of fibrosis Three isoforms and three receptors described in humans TGF-β1, TGF-β2, TGF-β3, TGF-β4, TGF-β5 prevalent form, until now most studied humans Three receptors: TGFβrec1 TGFβrec2 TGFβrec3 or betaglycan

5. ENT Department Upper Airways Research Laboratory * ** * * TGF-beta 1 and 2 protein in CRSs/wNP Van Bruaene et al, JACI 2009

6. ENT Department Upper Airways Research Laboratory * ** * ** Immunostaining Phospho-smad 2 Picrosirus red staining for collagen Van Bruaene et al, JACI 2009

7. ENT Department Upper Airways Research Laboratory ABC D E F CON CRSsNP CRSwNP Picrosirius red polarized light 400× Picrosirius red 400× Li X. et al, JACI 2010

8. ENT Department Upper Airways Research Laboratory CRS without NPCRS with NP EG2, X 100 H, X 100 CRS without and with NP TGFß1 high FIBROSIS TGFß1 low OEDEMA

9. ENT Department Upper Airways Research Laboratory Lack of T- regulatory cells in nasal polyps N. Van Bruaene, et al JACI, 2008

10. ENT Department Upper Airways Research Laboratory Inflammation in nasal polyposis: increased levels of inflammatory mediators Bachert et al. J Allergy Clin Immunol. 2001;107:607. P<0.001 P=0.016 IL-5 P<0.001 P=0.086 ECP IL-5 (pg/mL) ECP (µg/mL) Non-polypNP INP IINP IIINon-polypNP INP IINP III

11. ENT Department Upper Airways Research Laboratory Treg and T H 17: major revisions in the T H 1/T H 2 hypothesis of T cell differentiation Steinman, Nat Med, 2007

12. ENT Department Upper Airways Research Laboratory South Chinese controls South Chinese nasal polyps Belgian controlsBelgian nasal polyps ANOVA * Fisher’s Exact test N 29 2126 Age, yr (range) 38·6 (33·2-43·5)36·4 (28·6-46·5)30·3 (21·3-37·9)46·2 (38·4-55·5) Female / Male 10/199/209/1211/15 0.767 Asthma 0/292/292/2114/26<0.0001* Phadiotop positive 11/299/298/2111/26 0.845 Aspirin intolerance 0/29 0/217/26<0.0001* CT score (Lund & Mackay) 0 16 (11-20) 1 (0-2) 13 (11-20) <0.0001 Polyp score (Davos) 0 (0-0) 5 (4-6) 0 (0-0) 4 (4-6) <0.0001 Total symptom score 5 (3-6) 10 (7-11) 5 (3-7) 9 (7-11) <0.0001 Nasal congestion 2 (2-3)3 (2-3)2 (1-3)3 (2-3) 0.033 Rhinorrhea 0 (0-1)2 (1-3)0 (0-2)1 (0-2) 0.008 Sneezing 0 (0-1)1 (0-2)0 (0-2)0 (0-1) 0.093 Loss of smell 0 (0-1)2 (2-3)0 (0-1)3 (2-3) <0.0001 Headache 1 (0-2)2 (1-3)1 (0-2)2 (1-2) 0.006 Different types of T effector cells orchestrate mucosal inflammation in chronic sinus disease Nan Zhang ; T Van Zele; Claudina Perez-Novo; N Van Bruaene; Gabriele Holtappels; Natalie DeRuyck; C Bachert. JACI 2008

13. ENT Department Upper Airways Research Laboratory Different types of T effector cells orchestrate mucosal inflammation in chronic sinus disease Nan Zhang ; T Van Zele; C Perez- Novo; N Van Bruaene; G Holtappels; N Deruyck; C Bachert. JACI 2008

14. ENT Department Upper Airways Research Laboratory Different types of T effector cells orchestrate mucosal inflammation in chronic sinus disease Nan Zhang ; T Van Zele; C Perez- Novo; N Van Bruaene; G Holtappels; N Deruyck; C Bachert. JACI 2008

15. ENT Department Upper Airways Research Laboratory 70 nasal polyp tissue homogenates (Belgian patients) IL-5+ (58; 83%) IL-5- (12; 17%) 93 nasal polyp tissue homogenates (Chinese patients) IL-5+ (15; 16%) IL-5- (78; 84%) EOSINOPHILIC ?NEUTROPHILIC ?

16. ENT Department Upper Airways Research Laboratory CRS without NPCRS with NP EG2, X 100 H, X 100 CRS without and with NP Th1 Th2– Th17 Treg deficit Zhang N, Bachert C et al. JACI 2008

17. ENT Department Upper Airways Research Laboratory Zhang Nan, URL Ghent Staphylococcus aureus superantigens 33 27 64 67 88 14 6 28 54 80 0 10 20 30 40 50 60 70 80 90 100 Controls (n=9) CRS (n=22) NP (n=53) NP + asthma NP + ASS S. aureus colonization SAE-IgE+ * * * * * * S. aureus colonization and IgE antibodies to S. aureus enterotoxin mix in mucosal tissue

18. ENT Department Upper Airways Research Laboratory Nasal polyp tissue stained for S. aureus with PNA-FISH M-N. Corriveau, Zhang N Am J Rhinol, 2009

19. ENT Department Upper Airways Research Laboratory IL4 (pg/ml) Medians (error bars: 25-75 percentiles) 35 30 25 20 15 10 5 0 RPMI SEB 0.5µg/ml RPMI SEB 0.5µg/ml CONP IL5 (pg/ml) Medians (error bars: 25-75 percentiles) 140 120 100 80 60 40 20 0 RPMI SEB 0.5µg/ml RPMI SEB 0.5µg/ml CONP IL13 (pg/ml) Medians (error bars: 25-75 percentiles) 300 250 200 150 100 50 0 RPMI SEB 0.5µg/ml RPMI SEB 0.5µg/ml CONP 24 hours stimulation ** * ** p<0.01 * p<0.05 (paired samples; Wilcoxon test/ Intergroup variability; Mann-Whitney U test) CO n=13 NP n=12 Patou J et al, JACI 2008

20. ENT Department Upper Airways Research Laboratory

21. ENT Department Upper Airways Research Laboratory Follicle-like structures and lymphocyte accumulations in NP CD3 CD20 CD38 IgE SEA Gevaert P et al, Allergy 2005

22. ENT Department Upper Airways Research Laboratory Multiclonal IgE Chemokines Massive polyclonal lymphocyte activation TB Cytokines  Hyper IgE  Eosinophil survival Superantigens Epithelial damage (barrier dysfunction) colonisation S. aureus superantigens as disease modifiers Review: Bachert C et al. Clin Allergy Immunol. 2007 Mast cell degranulation Fibroblast PGE2 prod.

23. ENT Department Upper Airways Research Laboratory Management of Nasal Polyposis

24. Upper Airways Research Laboratory Department of Otorhinolaryngology 24 Thibaut Van Zele, Philippe Gevaert, Gabriele Holtappels, Achim Beule, Peter John Wormald, Susanne Mayr, Greet Hens, Peter Hellings, Fenna A Ebbens, Paul Van Cauwenberge, Claus Bachert Oral steroids in nasal polyps: a 3-month double blind, randomized, placebo-controlled trial DBPC in 32 patient with nasal polyps, 20days methylprednisolon (Day 1-5 32 mg, day 6-10 16 mg, day 11-20 8 mg)

25. ENT Department Upper Airways Research Laboratory Anti-MMPs IL-5 ECP IgE Anti-IL-5 IKK2, SYK, iCRAC, PDE4 The future of treating persistent inflammation in polyp disease Anti- IgE Anti-CCR3 ? Antibiotics

26. ENT Department Upper Airways Research Laboratory Doxycycline reduces nasal polyp size in a DBRPC multicenter trial. * P Gevaert, T Van Zele, G Holtappels, A Beule, PJ Wormald, S Mayr, G Hens, P Hellings, FA Ebbens, P Van Cauwenberge, C Bachert 20 days doxycycline (100mg/d) Area under the curve Placebo: -145,4 Methylprednisolon: 530,6

27. ENT Department Upper Airways Research Laboratory Local anti-inflammatory effects of doxycyclin * p<0,05 (Mann-Whitney) p<0,05 (paired Wilcoxon)

28. ENT Department Upper Airways Research Laboratory Anti-MMPs IL-5 ECP IgE Anti-IL-5 IKK2, SYK, iCRAC, PDE4 The future of treating persistent inflammation in polyp disease Anti- IgE Anti-CCR3 ? Antibiotics

29. ENT Department Upper Airways Research Laboratory Study design Anti-IL-5 study Mepolizumab 2 x 750mg IV 30 Subjects Severe nasal polyps 20 Subjects 10 Subjects Weeks 0 1 4 128 * MEPO 750mg IV Placebo Dosing Follow up * Primary endpoints: polyp score, CT scan 24 3648 Mepolizumab = a humanized anti-human IL-5 monoclonal antibody 30 NP patients with recurrent bilateral nasal polyps after surgery or massive bilateral nasal polyps (Grade 3 or 4)

30. Upper Airways Research Laboratory Department of Otorhinolaryngology Endpoints Primary endpoint Endoscopic Nasal polyp score 8 weeks post 1 st dosing Secondary endpoints CT scan assessment (blinded) Symptom score Peak nasal inspiratory flow Local (nasal secretions) and systemic Inflammatory mediators UPSIT smell test 0 1 2 3 4Score 0 1 4 3 2

31. ENT Department Upper Airways Research Laboratory Endoscopic nasal polyp score improvement * *  intranasal steroids permitted 10/2 0 12/2 0 13/2 0

32. ENT Department Upper Airways Research Laboratory Anti-MMPs IL-5 ECP IgE Anti-IL-5 IKK2, SYK, iCRAC, PDE4 The future of treating persistent inflammation in polyp disease Anti- IgE Anti-CCR3 ? Antibiotics

33. Upper Airways Research Laboratory Department of Otorhinolaryngology Objective and study design To asses the therapeutic potential of SC injections of anti-IgE Omalizumab (XOLAIR) endoscopic score symptom scores CT scan Two-arm, randomized, double blind, placebo controlled, trial 24 Subjects Severe nasal polyps With asthma 8 Subjects 16 Subjects Weeks 0 2 4 6 8 10 12 16 20 * SC OMALIZUMAB PLACEBO Dosing Follow up * Primary endpoint

34. Upper Airways Research Laboratory Department of Otorhinolaryngology Inclusion criteria At least 18 years of age Bilateral severe nasal polyps with asthma  Recurrent nasal polyps after surgery OR  Grade 3 or 4 in both nares Asthma defined on GINA guidelines (symptoms and lung function) Serum IgE between 30 to 700 IU/ml Good health, free of any clinically significant disease Subjects with concurrent asthma must be maintained on no more than 1000 mcg/day BDP or the equivalent

35. Upper Airways Research Laboratory Department of Otorhinolaryngology Dosage and administration Xolair  75 to 375mg is administered SC every 2 to 4 weeks (3 months) following official drug leaflet Doses (mg) and dosing frequency are determined by total serum IgE level (IU/ml) measured at the start of treatment and body weight (kg) Doses of more than 150mg are divided among more than 1 injection site Injection every 4 weeks (4 injections) or 2 weeks (8 injections)

36. ENT Department Upper Airways Research Laboratory

37. ENT Department Upper Airways Research Laboratory Improvement in symptoms Omalizumab (n=15) versus placebo (n=8)

38. Upper Airways Research Laboratory Department of Otorhinolaryngology CT-scans before and after Anti-IgE

39. Upper Airways Research Laboratory Department of Otorhinolaryngology Practical management of Nasal Polyposis Nasal corticosteroids GCS sprays: 2x/d, symptoms↓ GCS drops: symptoms↓, surgery↓ Oral corticoids: effective but fast recurrence Antibiotics: Antibiotic ointment Long-term antibiotics: macrolides 500mg/d for 2m doxycycline 100 mg/d for 2m Future: Omalizumab (antiIgE; xolair) ? Mepolizumab (anti-IL5) ?

40. Upper Airways Research Laboratory Department of Otorhinolaryngology Case report Male, 46 years: nasal polyps, asthma, AERD Nasal polyp score after 4 injections Omalizumab

41. ENT Department Upper Airways Research Laboratory Claus Bachert, MD, PhD Paul van Cauwenberge, MD PhD Philippe Gevaert, MD, PhD Nan Zhang, MD, PhD Thibaut Van Zele, MD, PhD Sofie Claeys, MD, PhD Claudina Novo-Perez, PhD Koen Van Crombruggen, PhD Olga Krysko, PhD Lara Derycke, PhD Joke Patou, MD Nicholas Van Bruaene, MD Wouter Huvenne, MD Peter Tomassen, MD Lien Devuyst, MD Takajuki Sejima, MD Marie-Noelle Corriveau, MD Gabi Holtappels Nathalie Deruyck Katrien Blomme Upper Airways Research Laboratory Department of Otorhinolaryngology

42. ENT Department Upper Airways Research Laboratory