Immune Responses to Bovine Collagen Implants Significance of Pretreatment Serology

8/13/2019 Immune Responses to Bovine Collagen Implants Significance of Pretreatment Serology

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II I

m m u n e r e s p o n s e s t o b o v i n eco l l a g en i m p l a n t significance o f pretreatment serology

J . P h i li p M c C o y , J r. , P h . D . , * W i l li a m S c h a d e, B . S . , * R o n a l d 1. S i e g l e , M . D . , * * *E v e l y n E . V a n d e r v e e n , M . D . , * * C h r is t op h e r B . Z a c h a r y , M . D . , * *T h o m a s P . W a l d i n g er , M . D . , * * a nd N e ff A . S w a g s o n , M . D . * * Ann Arbor MI andColumbus OH /

Bovine c o l l agen imp lan t s a r e i n widesp read use fo r t he co r rec t ion o f so f tt i s sue def i c ienc i es . A smal l po r t ion o f t he popu l a t i on r esponds adver se ly t othese imp lan t s , ev idenced by e i t her pos i t i ve sk in t es t s o r t r ea tmen t s i t er eac t i ons . A n t ibod i es aga ins t bov ine co l l agen imp lan t s have been de t ec t ed i nthe sera o f v i r t ua l l y a l l pa t i en t s wi th adver se t r ea tmen t r eac t i ons and i nsmal l percen t ages o f un t r ea t ed i nd iv idua l s and t r ea t ed i nd iv idua l s wi thou tadver se r eac t i ons . In t h i s s t udy we exam ined the l eve l s o f an t i -bov ine co l l agenimplan t an t i bod i es i n 150 i nd iv idua l s p ri o r t o bov ine co l l agen imp lan t t herapyand t hen mon i to red t hese pa t ien t s fo r adver se reac t i ons t o sk in tes t s an dbov ine co l l agen imp lan t t r ea tmen t s . S t a ti st ica l ana lyses were per fo rme d t ode t ermine t he va lue o f p re t r ea tmen t se ro logy i n p red i c t i ng pos i t ive sk in t es t so r adver se r eac t i ons . I t was de t e rmined t ha t i nd iv idua l s wi th g rea t l y e l eva t edl eve ls g rea t e r than 2 s t andard dev ia ti ons [SDs] above t he me an r eac t i v i ty o fp re t r ea tmen t se ra) o f an t i -bov ine co l lagen imp lan t an t i bod ies p r i o r t o t r ea tm en twere app rox imate ly s i x fo ld more l i ke ly t o su f fe r adver se r eac t i ons t hanpat ients wi th no elevat ion of ant ibodies pr ior to t reatment . J AM ACADDERMATOL 1987;16:95 5-60.)

The w ides p read us e o f bov ine co l l agen imp lan tsto correct dermal contour deformit ies has led tonumerous repor ts in the l i tera ture concerning theimm unogen ic i ty o f thes e imp lan t s , l ~ Whi le i t i sc lear that these bovine col lagen preparat ions areo f low immunogen ic i ty , due to the s e l ec t ive r e -mo va l o f the nonhe l i ca l ends o f the co l l agen mo l -

From the Departments of Pathology and Dermatology, Th e Uni-versity of Michigan Medical School, Ann Arbor, and the Divisionof Dermatology, Department of Internal Medicine, The OhioState University Medical School, Columbus.Accepted for publication Nov. 6, 1986.Rep rint requests to: Dr. J. Philip M cCoy, Jr. , T he Un iversity Hospital,Department of Pathology, Rm 2245, B ox 0602, 1500 East MedicalCenter Dr. , Ann Arbor , MI 48109-0602.

ecu le , i t i s unc lea r w hy s ome ind iv idua l s r eac tadver s e ly to thes e imp lan t s w hereas the ma jo r i tyo f pa t i en t s r ece ive the imp lan t s w i thou t immunerecogn i t ion . The na tu re o f the immune r eac t ionsaga ins t bov ine coU agen imp lan t s appea r s to bequ i t e va r i ed and to inc lude mi ld e ry thema , u r t i -ca r i a , l oca l i zed s w e l l ing and /o r r ednes s , g r anu -lomas , and s pec i f ic an t ibody p roduc t ion . Thes ign i f i cance o f thes e r e s pons es , pa r t i cu la r ly thedeve lopmen t o f an t i -bov ine co l l agen imp lan t an -t ibod ies , i s no t know n . T he ob s e rva t ion tha t s omeind iv idua l s r eac t to s k in t e s t s w i th bov in e co l l agenimp lan t s and /o r have an t ibod ies tha t r eac t w i thbov ine co l l agen imp lan t p r io r to t r ea tmen t w h i l eo the r ind iv idua l s become s ens i t i zed on ly a f t e rt r ea tmen t ind ica te s the h igh deg ree o f he te roge-

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9 5 6 M c o y e t a l J o u r n a l o f t h eA m e r i c a n A c a d e m y o fD e r m a t o l o g y

T a b l e I . S u m m a r y o f E L I S A d a t a f r o mp r e t r e a t m e n t s e r a *

M e a nS DM e a n 2 S D

i l u t i o n o f s e r a

U n d i -l u t e d 1 0 1 02 l i P

0 .092 0 .060 0 .018 0 .0090 .212 O. 120 0 .036 0 .0280 .5 1 6 0 .3 0 0 0 .0 9 0 0 .0 6 4ELISA : En z y me - l i n k e d i mmu n o so rb e n t a s sa y ; SD : s t a n d a rd d e -v ia t ion .

n = 1 5 0 ; a l l v a l u e s e x p re s se d a s A , ~ me a su re m e n t s .

n e i t y i n v o l v e d i n i m m u n e r e s p o n s e s t o t h e b o v i n ec o l l a g e n i m p l a n ts . S u g g e s t i o n s h a v e b e e n o f f e r e dc o n c e r n i n g t h e i n v o l v e m e n t o f d ie t o r h is t o c o m -p a t i b i l i t y a n t i g e n s i n t h e s e i m m u n e r e a c t i o n s , a l -t h o u g h a p r e v i o u s s t u d y f a i l e d t o d e m o n s t r a t e ac o r r e l a t i o n b e t w e e n h u m a n l y m p h o c y t e a n t i g e n( H L A ) t y p e a n d t h e o c c u r r e n c e o f a d v e r s e r e-ac t io ns . 11

T h e p u r p o s e o f t h e c u r r e n t s t u d y w a s t o e x a m i n et h e p r o g n o st i c s i g n i f ic a n c e o f a n t i - b o v i n e c o l la g e ni m p l a n t a n t i b o d i e s i n u n t r e a t e d i n d i v i d u a l s . I n ap r e v i o u s s t u d y , p o s i t i v e s e r o l o g y f o r a n t i - b o v i n ec o l l a g e n im p l a n t a n t i b o d i e s w a s o b s e r v e d i n 8 .4o f t h e u n t r e a t e d p a t i e n ts , lo T h e f a c t t h a t s o m e i n -d i v i d u a l s a r e p r e s e n s i t i z e d t o b o v i n e c o l l a g e n i m -p l a n t s i s w e l l e s t a b l i s h e d a n d i s t h e r e a s o n p a t i e n t sa r e s u b j e c t e d t o s k i n t e s t s p r i o r t o t r e a t m e n t . T h ec a u s e o r r o u t e o f th i s p r e s e n s i t i z a t i o n h a s y e t t ob e d e t e r m i n e d , a n d t h e s i g n i f i c a n c e o f c ir c u l a t in ga n t i - b o v i n e c o l l a g e n im p l a n t a n t i b o d ie s b e f o r et r e a t m e n t r e q u i r e s e l u c i d a t i o n . T o a d d r e s s t h e t a t-t e r q u e s t i o n , t h e p r e s e n t i n v e s t i g a t i o n i n v o l v e ds c r e e n i n g a l a r ge n u m b e r o f p a t ie n t s f o r a n t i - b o -v i n e c o l l a g e n i m p l a n t a n t i b o d i e s p r io r t o b o v i n ec o l l a g e n i m p l a n t t h e r a p y a n d t h e n m o n i t o r i n g t h er e s p o n s e s , b o t h c l i n i c a l l y a n d s e r o l o g i c a l l y , t o b o -v i n e c o l l a g e n i m p l a n t t r e a t m e n t s .M A T E R I A L S A ND M E T H O D SP a t i e n t s a n d b o v i n e c o l l a g e ni m p l a n t t r e a tm e n t s

Individua ls sele cted for part icipat ion in th is s tudywere pa t i en t s seek ing bov ine co l lagen implan t therapyat the Derm ato logy Outpa t ien t C l in ics a t the Un ivers i tyo f M i c h i g an o r D u k e U n i v e r s it y . A l l p a t ie n t s w e re f r e eo f any con t ra ind ica t ions fo r bov ine co l lagen implan t

therapy ~ and, prior to t reatment , we re skin-tes ted withbovine col lagen implant and screened for preexis t ingantibodies in the circulation against bovin e collag en. Atotal of 150 individuals wer e screened for the presenceof ant i -bov ine col lagen implant an t ibodies prior to ad-ministrat ion of implants. The num ber and extent ofbovine col lagen implant t reatments receiv ed by eachpat ient depended upon need and pat ient desire and wastherefore qui te varied.B ovi n e c o l l age n i m p l an ts

The bovine col lagen implants are commercial lyavai lable suspensions of purified bovine dermal col-lagen (35 rag/m1) in phosphate-buffered sal ine, pH7.0-7 .4 with 0 .3 l idocaine. App roxim ately 95 ofthe col lagen present in these implants is type I , withtype III col lagen compris ing the m ajori ty of the re-maining material.S e r u m s a m p l e s

Blood was ob ta ined f rom pa t ien t s by rou t ine ven i -puncture under asept ic condit ions in to tubes free ofheparin . Blood wa s drawn prior to implantat ion o f theskin tes t and before each bo vine col lag en imp lant t reat-ment . The b lood w as al lowed to clot overnight at 4 Cand the serum was separated by low-speed centri -fugat ion. The sera were then divided in to al iquots ands t or e d a t - 2 0 C .M e a s u r e m e n t o f a n t i b o v i n e c o l l a g e ni m p l an t an t i b od i e s

Circulating ant ibodies against the bovin e col lagenimplants were measured using an enzyme-l inked im-munosorben t as say (ELISA) descr ibed in a p rev iouspublicat ion. 7 M any of the characterist ics of the se an-t ibod ies hav e been descr ibed p rev ious ly , m Sera wereassayed in tenfold di lu t ions ranging from undilute to1 : 1000.Cl i n i c a l ob se r vat i on sThrough out the s tudy, pat ients w ere closely observe dfor the onset of adverse react ions to bovine col lagenimplant that might be of an immun e nature. Clinically ,these react ions are characterized by the developm ent ofedem a, erythem a, indurat ion, and/o r urticaria at im-plantation sites that lasted longer than 24 hours.S ta t i s t i c a l an a l yse s

Posi t ive sera we re defined as those yielding A405 val-ues in ELISA grea te r than 2 SDs above the mean o fthe pretreatment sera at two consecu t ive dilu tions; 2 2


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Volume 16Number 5 Part 1May 1987 Immune responses to bovine col lagen implants 9 5 7

contingency tables were used to analyze whether anyassociation e xisted betwe en pretreatment serology an dsubsequent clinical reactions. Using BMDP statisticalsoftware, '4 p values we re calculated from Fisher's t testto determine statistical significance. Relative risks werecalculated using the m ethod o f Kahn . ~ T tests we redone to tes t for di fferences betw een me an age andmean amount of Zyderm injected in the di fferentgrou ps. ,6R E S U L T Sm mu ne re sponses pr i or to bovine co l lageni mpl ant therapy

A t o ta l o f 1 50 p a t ie n t s w e r e b l e d a n d s k i n - te s t e dp r i o r t o p o t e n t ia l b o v i n e c o l l a g e n i mp l a n t t h e r a p y .T h e r e su l ts o f t h e E L I S A s o n p r e t r e a tm e n t s e r aa n d s k i n t e st s a r e s u m m a r i z e d in T a b le I. Po s i t i v es e r a w e r e t h e n d e f i n e d a s t h o s e t h at y i e l d e d E L I S Av a l u e s g r e a t e r t h a n t h e m e a n a n d 2 SD s a t t w oc o n s e c u t i v e d i l u t i o n s o f a l l o f t h e p r e t r e a t me n ts e r a . I n t h i s ma n n e r , f i v e p r e t r e a t me n t s e r a w e r edef ined as pos i t ive . Tab le I I i nd ica tes the co r re -l a t i o n b e t w e e n p o s i t i v e p r e t r e a t me n t a n t i b o d i e sa n d p o s i t i v e s k i n t e s t s o r t r e a t m e n t re a c t i o n s .T h r e e o f t h e f i v e p a t i e n t s w i t h p o s i t i v e p r e t r e a t -m e n t s e r o l o g y s u f f e r e d a d v e r s e r e ac t io n s ; o n e h a da p o s i t iv e s k i n t e s t a n d t w o s u f f e r e d a d v e r s e t r e a t -me n t r e a c t i o n s .

mm une re sponses d ur i ng bovine co ll ageni mpl ant therapyOf the in i t i a l 150 pa t i en t s , s ix had pos i t ive sk in

t e st s a n d w e r e e x c l u d e d f r o m r e c e i v i n g b o v i n e c ol -l a g e n i mp l a n t t h e r a p y . A n o t h e r 2 1 d i d n o t r e c e i v et r e a t me n t f o r a v a r i e t y o f r e a s o n s , a l t h o u g h f o l l o w -u p b l o o d w a s o b t a i n e d f r o m f i v e o f t h e s e p a t i e n ts .T h u s 1 2 3 p a t i e n t s r e c e i v e d t h e r a p e u t i c i n j e c t i o n sof bo~) ine co l l agen implan t . In i t i a l t rea tmen t s typ -i c a l l y c o n s i s t e d o f ~ 1 . 0 ml g i v e n a p p r o x i ma t e l y4 w e e k s a f t e r s k i n t e s t i n g . Su b s e q u e n t i n j e c t i o n sw e r e g i v e n a s n e c e s s a r y in e a c h c a s e ; t h u s th e n u m-b e r a n d v o l u me o f i n j e c t i o n s , a s w e l l a s i n t e r v a lb e t w e e n i n j e c t i o n s , v a r i e d f r o m p a t i e n t to p a ti e n t.T w e l v e o f t h e s e 1 23 p a t i e n t s s u f f e r e d a d v e r s e r e -a c t i o n s d u r i n g t h e c o u r s e o f t h e r a p y ( T a b l e I I I ) .

O f t h e 1 2 3 p a t i e n t s r e c e i v i n g b o v i n e c o l l a g e ni m p l a n t th e r a p y , b l o o d w a s o b t a in e d f r o m 8 p a -t i e n ts d u r i n g t h e c o u r s e o f t r e a t me n t . L e v e l s o fa n t i - b o v i n e c o l l a g e n i mp l a n t c i r c u l a t i n g a n t i b o d -

T abl e 1 I . C o n t i n g e n c y t a b l e i n d i c a t i n g t h ep r o g n o st ic v a l u e o f p r e t r e a t m e n t l ev e l s o fc i r c u l a t i n g a n t i - BCI a n t i b o d i e s

ntibody levelsGreater thanN + 2 S DLess thang + 2 S Dn = 129

Nor e a c t i o n

os i t ive reac t ion sT r e a t m e n t

S k in t es t reac t ion

2 1 2109 5 10

p = 0.019(Fi sher ' s exac t t es0BCI: Bovine collagen implant.

i es w e r e m o n i t o r e d b y E L I S A . A s c a n b e s e e n inT a b l e s I V a n d V , a d v e r s e r e a c t i o n s w e r e m o s t o f t e na c c o m p a n i e d b y a n t i - b o v i n e c o l l a g e n i m p l a n t a n -t i b o d i e s ( e v e n i f t h e p a t i e n t ' s t e s t r e s u l ts w e r e n e g -a t i v e f o r a n t i b o d i e s p r i o r t o t r e a t me n t ) . T h e e x -i s t e n c e o f p r e t r e a t m e n t a n t i b o d i e s d i d l e a d t o a ni n c r e a s e d i n c i d e n c e o f a d v e r s e r e a c t i o n s . S t a t i s -t ic a l a n a l y s es w e r e p e r f o r m e d t o d e t e r m i n e t h e r i s kr a t i o s o f p a ti e n t s e v e n t u a l l y s u f f e r i n g a d v e r s e t r e a t -m e n t r e a c t io n s b a s e d u p o n t h e i r p r e t r e a t m e n t l e v el so f a n t i - b o v i n e c o l l a g e n i m p l a n t a n t i b o d i e s. B a s e du p o n t h e o b s e r v e d f r e q u e n c i e s o f s u b s e q u e n t a d -v e r s e t r e a t me n t r e a c t i o n s ( e x c l u d i n g p a t ie n t s w i t hp o s i t i v e s k in t e s ts ) , i t w a s d e t e r m i n e d t h a t c o m -p a r i s o n o f p a ti e n ts w i t h p r e t r e a t m e n t s e r o l o g y v a l -u e s g r e a te r t h a n th e m e a n p l u s 2 S D s a t tw o c o n -s e c u t i v e d i l u t i o n s w i t h t h e r e ma i n i n g p a t i e n t sy i e l d e d a r i s k r a ti o o f 5 . 9 5 ( p = 0 . 0 4 7 ) . I n o t h e rw o r d s , p a t ie n t s w i t h e l e v a t e d p r e t r e a t r n e n t a n t i -b o v i n e c o l l a g e n i m p l a n t a n t i b o d i e s a n d n e g a t i v es k in t e s ts w e r e a p p r o x i m a t e l y s ix t i m e s m o r e l i k e l ys u b s e q u e n t ly t o s u f f e r h d v e r s e t r e a t m e n t r e a c t i o n st h a n t h e r e s t o f t h e p a ti e n t s w i t h n e g a t i v e s k i n t e st s .I t s h o u l d b e e mp h a s i z e d t h a t t h e c o r r e l a t i o n i s n o ta b s o l u t e - - h a l f ( 2 o f 4 ) o f t h e p a t i e n t s w i t h p r e -t r e a t m e n t a n t i- b o v i ne c o l a g e n i m p l a n t a n t ib o d i e sa n d n e g a t i v e s k i n t e s t s d i d n o t d e v e l o p a d v e r s er e a c t i o n s . E l e v a t i o n o f p o s t t r e a t m e n t l e v e l s o f c i r -c u l a t i n g a n t i - b o v i n e c o l l a g e n i mp l a n t a n t i b o d i e sw a s o b s e r v e d i n i n d iv i d u a l s r e c e i v i n g b o v i n e c o l -l a g e n i m p l a n t t h e r a p y w i t h o u t o v e r t a d v e r s e r e -a c t i o n s a s W e l l a s i n t h o s e p a t i e n t s w i t h a d v e r s e


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9 5 8 Mc oy et aIJournal of theA m e r i c a n A c a d e m y o f

De r ma t o l ogy

Table I I I . C h a r a c t e r i s t i c s o f c l i n i c a l r e a c t i o n sNo of In terval be tween las t In terval be tween in i t ia lB C I i n j e c t i o n a n d C I i n j e c t i o n a n dP a t i e n t i n j e c ti o n s t r e a t m e n t r e a c t i o n [ t r e a t m e n t r e a c t i o n

1 1 7 w k 7 w k

2 1 9 w k 9 w k3 2 4 w k 8 w k4 4 4 w k 1 1 m o5 2 1 d a y 1 8 m o6 2 1 w k 3V 2 m o

7 1 6 w k 6 w k8 6 2 r no 2 yr9 1 4 w k 4 w k

1 0 2 7 w k 9 w k1 1 3 3 w k 3 m o1 2 2 8 w k 4 m o

D e s c r i p t i o n o f r e a c t i o nL o c a l i z e d , p e r s i s t e n t ( > 6 w k ) , f i r m n e s s o v e rin jec t ion s i t e ; sw e l l s w i th d i r ec t exposur eto sunP e r s is t e n t ( > 2 w k ) , l o c a l i z e d , p a i n , s w e l l -i n g , e r y t h e m a t o u s , s w o l l e nL o c a l i z e d , p r u r i t u s , e r y t h e m a t o u s , s w o l l e nI n t e r m i t t e n t , e r y t h e m a t o u s , s w o l l e nE r y t h e m a t o u s , s w o l l e n , t e s t s i t e i n v o l v e m e n tL o c a l i z e d , e r y t h e m a t o u s , s w e l l i n g , p e r s i s -t e n t ( > 4 w k ) , f i r m , e r y t h e m a t o u s , g r a n u -l o m a t o u sP e r s is t e n t ( 1 4 w k ) , f i n n , e r y t h e m a t o u s ,g r a n u l o m a t o u sL o c a l i z e d , s w o l l e n , e r y t h e m a t o u sL o c a l i z e d , c o n t i n u o u s , e r y t h e m a t o u s ,s w o l l e nP e r s is t e n t ( s e v e ra l w k ) , e r y t h e m a t o u s ,e d e m a , p a l p a b le l u m pL o c a l i z e d , s w o l l e n r e d l u m p , i n t e r m i t t e n tP e r s i s t e n t ( > 1 m o ) , s w o l l e n , e r y t h e m a t o u s ,loca l ized

BCI: B ovine collagen implant

r e a c t io n s ; h o w e v e r , t h e i n c r e a s e d f r e q u e n c y o f el -e v a t e d a n t i b o d i e s i n p a t i e n t s w i t h a d v e r s e r e a c t io n sw a s s t a t i s t i c a l l y s i g n i f i c a n t c o m p a r e d w i t h t r e a t e dp a t i e n t s n o t s u f f e r i n g a d v e r s e r e a c t i o n s .

emographic informationA s u r v e y w a s c o n d u c t e d t o d e t e r m i n e i f s ig n i f-

i c a n t a s s o c i a t i o n s e x i s t e d b e t w e e n p o s i t i v e s e r o l -o g y o r a d v e r s e r e a c ti o n s a n d a n y o f th e f o l l o w i n gp a r a m e t e r s : a g e , s e x , v o l u m e o f b o v i n e c o l la g e ni m p l a n t r e c e i v e d , b l o o d t y p e , a n d r ac e . N o a s so -c i a t io n w a s f o u n d b e t w e e n a n y o f t h e s e p a r a m e t e rsa n d s e r o l o g ic o r t r e a t m e n t r e a c t i o n s .D I S C U S S I O N

T h e t h e r a p e u t i c u t i li t y o f b o v i n e c o l l a g e n i m -p l a n t s i s c l e a r; s o f t t i ss u e a u g m e n t a t i o n c a n b ea c c o m p l i s h e d w i t h m i n i m a l r i s k a n d d i s c o m f o rt .T h e u s e o f p a rt i a ll y d i g e s t e d c o l l a g e n l a c k i n g t h en o n h e l i c a l a m i n o a n d c a r b o x y t e r m i n a l s u n d o u b t -e d l y r e d u c e s t h e a n t i g e n i c i t y o f th e i m p l a n t s ; h o w -e v e r , n u m e r o u s r e p o r t s a p p e a r i n t h e l i te r a t u r e d e -s c r i b i n g a d v e r s e t r e a t m e n t r e a c t i o n s t h a t a r e a p -p a r e n t l y o f a n i m m u n e n a t u re . l 3 T h e s e r e a c ti o n s

i n c l u d e e r y t h e m a , u r t ic a r i a, i n d u r a t i o n , a n d g r a n -u l o m a t o u s r e a c t i o n s a t t h e s i t e o f i n j e c t i o n .O u r d a t a i n d i c a t e t h e h e t e r o g e n e i t y o f i m m u n e

r e s p o n s iv e n e s s to b o v i n e c o l l a g e n i m p l a n t s a m o n ga l a r g e p a t i e n t p o p u l a t i o n . O n l y a s m a l l p e r c e n t a g eo f b o v i n e c o l l ag e n i m p l a n t - t r e a t e d p a t i e n ts s u f fe ro v e r t a d v e r s e r e a c ti o n s . M o s t o f t e n t h e s e r e a c t i o n so c c u r a f t e r t h e f i r s t o r s e c o n d i n j e c t i o n a n d a r ea c c o m p a n i e d b y t h e a p p e a r a n c e o f a n t i b o d i e sa g a i ns t th e b o v i n e c o l l a g e n i m p l a n t s . A n t i - b o v i n ec o l la g e n i m p l a n t a n ti b o d i es m a y a l so b e f o u n d i np a t i en t s p r i o r to t r e a t m e n t o r p a t i e n t s m a y d e v e l o pe l e v a t e d l e v el s o f a n t i - b o v i n e c o l l a g e n i m p l a n t a n -t i b o d i e s w i t h o u t c o n c o m i t a n t o v e r t a d v e r s e r e a c -t i o n s . P r e vi o u s w o r k f o u n d n o a p p a r e n t d i f fe r e n c e si n t h e n a t u r e o r s p e c i f i c i t y b e t w e e n a n t i - b o v i n ec o l l a g e n i m p l a n t a n t i b o d i e s f r o m p a t i e n t s w i t h a d -v e r s e r e a c t i o n s a n d f r o m s e r o l o g i c a l l y p o s i t i v e p a -t i en t s n o t s u f f e r i n g o v e r t r e a c t i o n s . '

T h e u n d e r l y i n g f a c to r , o r f a c t o r s, l e a d i n g t o t h i sh e t e ro g e n e i ty in i m m u n e r e s p o n s i v e n e s s t o b o v i n ec o l la g e n i m p l a n t s re m a i n s t o b e d e l i n e a t e d . R e c e n td a ta f r o m o u r l a b o r a t o ry i n d i c a t e d n o p r e c i s e h u -m a n l y m p h o c y t e a n t ig e n ( H L A ) a s s o c i a t i o n w i t h


5/6

V o l u m e 1 6N u m b e r 5 , P a r t 1M a y 1 9 8 7 Imm une responses to bovine c ol lagen implants 9 5 9

t h e o v e r t a d v e r s e r e a c t i o n s n o r w i t h t h e a p p e a r a n c eof c i rcu la t ing an t i -bov ine co l l agen implan t an t i -bod ies , a l though s t a t i s t i ca l ly s ign i f i can t d i f fe r -e n c e s i n f r e q u e n c y o f l o ci w e r e o b s e r v e d b e t w e e nr e a c t o r s a n d n o n r e a c t o r s . N o r e q u i r e me n t f o rH L A - D R4 t o r e s p o n d t o b o v i n e c o l l a g e n i mp l a n tw a s o b s e r v e d a s c o u l d b e s u g g e s t e d b y p r e v io u swork .17 Among o ther poss ib i l i t i es , d i e t has beens u g g e s t e d a s o n e o f t h e f a c t o r s u n d e r l y i n g t he h e t -e r o g e n e i t y i n i m mu n e r e s p o n s e s t o b o v i n e c o l l a g e nimplan t . Cu rren t ly no da ta ex i s t to subs tan t ia t e th isposs ib i l i t y . In the p resen t s tudy , no demograph icp a r a me t e r s w e r e f o u n d t h a t w e r e a s s o c i a t e d w i t hi n c r e a s e d r i s k o f a d v e r s e r e a c t i o n s .

I n c r e a se d l e n g t h o f t r e a t m e n t o r v o l u m e o f b o -v i n e c o l l a g e n i mp l a n t s d i d n o t i n f l u e n c e t h e r a t eo f a d v e r s e r e a c t i o n s . A s s t a t e d a b o v e , mo s t a d -v e r s e r e a c t i o n s o c c u r r e d e a r l y i n t h e c o u r s e o f t h e r -a p y . T h u s , i t w o u l d s e e m t h a t mo s t p a ti e n ts s u f -f e t i n g a d v e r s e t r e a tm e n t r e a c t io n s h a d i n s o m e w a yb e e n p r i m e d t o b o v i n e c o l l a g e n s i nc e c h a r a c -t e r is t ic s a s s o c i a t e d w i t h i mm u n i z a t i o n ( s u c h a s re -p e a t e d i n j e c t i o n w i t h s ma l l a mo u n t s o f a n t i g e n )d i d n o t a p p e a r p e r t i n e n t t o t h i s s t u d y .

P r e t r e a t m e n t s k i n te s t i n g is o n e m e t h o d o f i d e n -t i f y i n g p a t i e n t s w h o a r e p r e s e n s i t i z e d t o b o v i n ec o l l a g e n i mp l a n t s . W h i l e o f g r e a t v a l u e i n re d u c -i n g t h e i n c i d e n c e o f a d v e r s e t r e a t me n t r e a c t i o n s ,s k i n t e s t i n g d o e s n o t e l i m i n a t e t h e o c c u r r e n c e o ft r e a t me n t r e a c t i o n s . P r e v i o u s w o r k i n o u rl a b o r a t o r f i n d i c a t e d t h a t s o m e i n d i v i d u a l s h a v ee l e v a t e d l e v e ls o f a n t i - b o v i n e c o l l a g e n i mp l a n t a n -t i b o d i e s p r i o r t o e x p o s u r e t o b o v i n e c o l l a g e n i m-p l a n t s. T h e s i g n i f i c a n c e o f t h e s e a n t i b o d i e s is u n -c l e a r . Sk i n t e s t r e a c t i o n s a n d a d v e r s e c l i n i c a l r e -a c t i o n s a r e p r i m a r i l y m a n i f e s t a t i o n s o f t h e c e l lu l a ra r m o f t h e i m m u n e s y s t e m , y e t t h e m e a s u r e m e n to f a n t i - b o v i n e c o l l a g e n i mp l a n t a n t i b o d i e s re f l e c t st h e h u m o r a l a r m o f t h e i m m u n e s y s t e m . I n c a s e so f a d v e r s e t r e a t m e n t r e a c t i o n s , b o t h b r a n c h e s o ft h e i m m u n e s y s t e m a p p e a r t o b e i n v o l v e d q a s i nt h i s s t u d y in w h i c h 1 1 o f 1 2 p a t i e n t s w i t h a d v e r s er e a c t i o n s a l s o d i s p l a y e d e l e v a t e d a n t i - b o v i n e c o l -l a g e n i mp l a n t a n t i b o d i e s .

I n c o n t r a s t , f i v e o f s i x p a t ie n t s w i t h p o s i t i v e s k i nt e s t s d i d n o t h a v e e l e v a t e d p r e t r e a t me n t a n t i - b o -v i n e c o l l a g e n i mp l a n t a n t i b o d i e s , t w o o f fi v e p a -t i e n ts w i t h p o s i t i v e p r e t r e a t me n t s e r o l o g y d i d n o td e v e l o p a p o s i t i v e s k i n t e s t n o r a n a d v e r s e t r e a t -

T a b l e I V . E L I S A d e t e r m i n a t i o n o fp r e - a n d p o s t t r e a t me n t a n t i - BCI a n t i b o d yi n p a t i e n t s w i t h o r w i t h o u t a d v e r s et r e a t me n t r e a c t i o n s

Clinicalr e sponse 11)

Pr e t r e a tmen tA bde te rminat i on s

{ n )

Pos t tr ea tmen tA bde te rminat i on s(n)

Nonreac tors + (1) + (7)(69)- 6 8 ) - 6 2 )

Reactors + (2) + (1 1)(12)- l o ) - 1 )

A b : A n t ib o d y ; B C I : b o v i n e c o l la g e n i m p l a n t s; n : n u m b e r o f s a m p l e s .E L I S A : e n z y m e -l in k e d i m m u n o s o r b e n t a s s a y .

T a b l e V . Co n t i n g e n c y t a b l e i n d i c a t i n g t h ec o r r e la t io n b e t w e e n p o s t t r e a t m e n t l e v el so f c i r c u l a t i n g a n t i - BCI a n t i b o d i e s a n dc l i n i c a l r e s p o n s e

dve r s e c l i n i ca lr eac t i on

N o 1 Yesntibody levelsGrea ter than ~ + 2 SD 7 11Less than ~ + 2 SD 62 l

n = 81 p < 0.0001(Fisher 's exact tes t )B C I : B o v i n e c o l l a g e n i m p l a n t s .

m e n t r e a c t i o n , a n d s e v e n o f 1 8 p a t i e n t s w i t h e l e -v a t e d a n t i - b o v i n e c o l l a g e n i m p l a n t a n t i b o d i e s fo l -l o w i n g t r e a t m e n t d id n o t h a v e a n y e v i d e n c e o f a na d v e r s e c l i n i c a l r e a c t i o n . T h i s i n d i c a t e s t h a t e x -a m i n a t i o n o f th e h u m o r a l r e s p o n s e s d o e s n o t a c -c u r a t e l y r e f le c t c e ll u l a r i m m u n i t y i n a ll i n s t a n c e s.H u m o r a l r e s p on s e s m a y o c c u r w i t h o u t o v e r t ev i-d e n c e o f c e ll u l a r r e s p o n s e s , a n d v i c e v e r s a . T h ep i v o t a l c o n c e r n O f t h is s t u d y w a s w h e t h e r t h e r ew a s s u f f i c ie n t o v e r l a p b e t w e e n t h e t w o a r m s o ft h e i m m u n e r e s p o n s e i n r e c o g n i z i n g b o v i n e c o l -l a g e n i mp l a n t s f o r t h e s e r o l o g i c s t u d i e s t o b e o fv a l u e i n i d e n t i f y i n g p a ti e n t s a t h i g h e r r i s k o f s u f -f e r i n g a n a d v e r s e r e a c t i o n .

A l t h o u g h t h e n u m b e r o f p a t ie n t s i n t h e c u r r e n ts t u d y w a s n o t a s l a r g e a s w o u l d b e d e s i r e d , t h e


6/6

9 6 0 Mc oy et alJ o u r n a l o f t h e

A m e r i c a n A c a d e m y o fD e r m a t o l o g y

d a t a s h o w t h a t p a ti e n t s w i t h e l e v a t e d p re t r e a t m e n tl eve l s o f an t i -bov ine co l l agen imp lan t an t ibod iesw e r e a p p r o x i m a t e l y s i x fo l d m o r e l i k e l y t o s u f fe ran adver s e t r ea tmen t r eac t ion . E leva ted p re t r ea t -men t an t ibod ies iden t i f i ed on ly tw o o f the 12 pa -t i en ts w i th s ubs eq t i en t adver s e t r ea tm en t r eac t ions ,a l t h o u g h it m u s t b e r e m e m b e r e d t h a t s k in t e st i ngm i s s e d a l l t w e l v e .Thus in the cu r r e n t s tudy , i f pos i t ive p r e tr ea t -m e n t s e r o l o g y w e r e u s e d a s a c o n t r a in d i c a t io n o ft r ea tmen t , f ive o f 129 pa t i en t s w o u ld no t haver e c e i v e d t h e r a p y b a s e d u p o n s e r o l o g y . O f t h e s ef ive , one s u f f e r ed a pos i t ive s k in t e s t and w ou ldno t have r ece ived t r ea tmen t O n tha t bas i s . There -f o r e fo u r p a t ie n t s w o u l d h a v e b e e n e x c l u d e d f r o mrece iv ing bov ine co l l agen imp la ia t the r apy w hon o r m a l l y w o u l d h a v e r e c e i v e d t re a t m e n t . O f t h e sefou r , tw o ev en tua l ly s u f f e r ed adver s e t r ea tmen t r e -ac t ions . Thu s o n ly i~w o pa t i en t s o f 129 (1 .6 )w o u l d h a v e b e e n d e n i e d t r e a t m e n t u n n e c e s sa r i ly ,w h i l e tw o Of 12 r eac to r s (17 ) w ou ld have beeniden t i f i ed p r io r to t r ea tmen t .

R s hou ld be no ted tha t th i s s tudy w as no t o r -c h e s t r a t e d i n a t r u l y r a n d o m i z e d f a s h i o n a n d t h einc ide t l ce o f adver s e c l in i ca l r eac t ions s hou ld no tbe cons ide red r ep res en ta t ive o f ou r ac tua l ove ra l lexper i ence . P a t i en t pa r t i c ipa t ion w as s t r i c t ly vo l -un ta ry and the re w as g r ea t va r i ab i l i ty in pa t i en tcoopera t ion and in te r es t, Th i s i s r e f l ec ted by therather subs tant ia l a t t r i t ion ra te in th is s tudy. Then o n r a n d o m n a t u r e o f t h e s t u d y m a y a l s o h a v e co n -t r ibu ted to the apparen t inc idence o f adver s e r e -ac t ions . P a t i en t s pa r t i c ipa t ing in the s tudy w erein te r es t ed in c lo s e eva lua t ion o f the i r bov ine co l -l a g e n i m p l a n t t h e r a p y a n d m a y h a v e b e e n m o r el ike ly to r epo r t s e l f -ob s e rved a dver s e r eac t ions tha tw er e l a t e r con f i rm ed in a c l in i c v i s i t.I t wou ld th~is app ear tha t sero logy, p ar t icu lar lyp re t r ea tmen t s e ro logy , has a p lace in the manage-m e n t o f p a ti e n ts u n d e r g o i n g b o v i n e c o l l ag e n i m -p lan t the r apy . C lea r ly i t cou ld s e rve on ly a s anad junc t to s k in t e s t ing in the cons e rva t ive man-agem en t o f pa t i en t s . I n the cu r r en t s tudy , l e ss than2 o f t h e p a t i e n ts w o u l d h a v e b e e n e r ro n e o u s lyd e n i e d t r e a tm e n t , w h i l e t h e n u m b e r o f a d v e rs et r e a tm e n t r e a c t i o n s w o u l d h a v e b e e n r e d u c e d b ya lmos t 20 . Th us p r es c r ee n ing p ros pec t ive pa -

t ien ts des i r ing bov ine co l l agen imp lan t the r apy b ys k in t e s t ing and p re t r ea tmen t s e ro logy s hou ld r e -duce , bu t no t e l imina te , t he inc idence o f adver s et reatment react ions .R E F E R E N C E S

1 . Z y d e r m C o l l a g en I m p l a n t - - P h y s i c i a n r e f e r e n c e g u i d e .P a l o A l t o , C A : C o l l a g e n C o r p . , 1 9 8 1 .2 . B r o o k s N . A f o r e i g n b o d y g r a n u l o m a p r o d u c e d b y a ni n j e c t a b le c o l l a g e n i m p l a n t a t a t e s t s i t e . J D e r m a t o l S u r gOn eo l 1982 ;8 :111-4 ,3 . B a r r R J , K i n g D F , M c D o n a l d R M , B a r t l o w G A . N e c -r o b i o t i c g r a n u lo m a s a s s o c i a t e d w i t h b o v i n e c o l l a g e n t e s ts i te in jec t ions , J AM ACAD DERMA'rOt, 1982 ;6 :867-9 .4 . S w a n s o n N A , S t o n e r J G , S i e g l e R J , S o l o m o n A R , T r e a t -m e n t s i t e r e a c t i o n s t o Z y d e r m c o l l a g e n i m p l a n t a t i o n . JDermato l Su rg Onco l 1983 ;9 :377-80 .5 . B a n R J , S t e g m a n S J , D e l a y e d s k in t e s t r e a c t i o n t o i n -j e c t a b l e c o l l a g e n i m p l a n t ( Z y d e r m ) , J A M A C A D D ~ R -MATOL 1984;10:652-8.6 , H a n k e C W , R o b i n s o n J K . I n j e c t a b l e c o l l a g e n i m p l a n t s .A r c h D e r m a t o l 1 9 8 3 ; 1 1 9 : 5 3 3 - 4 ,7 . S i e g l e R J , M c C o y J P , S c h a d e W , S w a n s o n N A , I n t r a -d e r m a l i m p l a n t a t i o n o f b o v i n e c o l la g e n : h u m o r a l i m m u n er e s p o n s e s a s s o c i a t e d w i t h c l i n i c a l r e a c t i o n s , A r c h D e r -ma to l 1984 ;120 :183-7 .8 , C o o p e r m a n L , M i c h a e l i D , T h e i m m u n o g e n i e i t y o f i n -j e c t a b l e c o ll a g e n . I . A l - y e a r p r o s p e c t i v e s t u d y , J A MA c h o DERM TOL 984; 10:638-46,9 , C o o p e r m a n L , M i c h a e l i D , T h e i m m u n o g e n i c i t y o f i n -j e c t a b l e c o l la g e n , I I . A r e t r o s p e c t i v e r e v i e w o f 7 2 t e s t e dand t rea ted pa t ien ts . J AM ACA D DERMATOL 1984 ;10 :647-51.1 0 . M c C o y J P , S c h a d e W J , S i e g l e R J , W a l d i n g e r T P , V a n -d e r v e e n E E , S w a n s o n N A . C h a r a c t e r i z a t i o n o f t h e h u -m o r a l i m m u n e r e s p o n s e t o b o v i n e c o l l a g e n i m p l a n t s .Arch D erm ato l 1985 ; 121 :990-4 .1 1 . V a n d e r v e e n E E , M c C o y JP , S c h a d e W , e t a l . T h e a s -s o c ia t io n o f H L A a n d i m m u n e r e s p o n s e s t o b o v i n e c o l -l ~t ge n i m p l a n t s . A r c h D e r m a t o l 1 9 8 6 ; 1 2 2 : 6 5 0 - 4 .1 2. E l l i n g sw o r t h L R , D e L u s t r o F , B r e n n an J E , S a w a m u r aS , M c P h e r s o n J. T h e h u m a n i m m u n e r e s p o n s e t o r e c o n -s ti tu t ed b o v i n e c o l l a g e n . J I m m u n o l 1 9 8 6 ; 1 3 6 : 8 7 7 - 8 2 .1 3 , K a m e r F M , C h u r u k i a n M M . C l i n ic a l u s e o f i n j e c ta b l ec o l l a g e n : a t h r e e y e a r r e t r o s p e c t i v e r e v i e w . A r c h O t o -laryngol 1984;110:93-8.1 4 . D i x o n W J . B M D P s t a t i s t i c a l s o f t w a r e , D e p a r t m e n t o fB i o m a t h e m a t i c s , U C L A . B e r k l ey : U n i v e r s i t y o f C a l i -f o m i a P r e s s , 1 9 8 1 .1 5 . K a h n H A , A n i n t r o d u c t i o n t o e p i d e m i o l o g i c m e t h o d s .N e w Y o r k: O x f o r d U n i v e r s i t y , 1 9 8 3,I 6 . M e d e n h a l l W . I n t r o d u c t i o n t o p r o b a b i l i t y a n d s t a t i s t i c s .N o r t h S o l t u a t e , M A : D u x b u r y P r e s s , 1 9 7 5 .1 7 . S o l i n g e r A M , S t o b o J D . I m m u n e r e s p o n s e g e n e c o n t r o lo f c o l la g e n r e a c t i v i t y i n m a n : c o l l a g e n u n r e s p o n s i v e n e s si n H L A - D R 4 n e g a t i v e n o n r e s p o n d e r s i s d u e t o t h e p r e s -e n c e o f T - d e p e n d e n t s u p p r e s s i v e in f l u e n c e s . J I m m u n o l1982;129:1916-20.

Immune Responses to Bovine Collagen Implants Significance of Pretreatment Serology

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