Pregnancy-Associated Plasma Protein-A Is Markedly Expressed by Monocyte-Macrophage Cells in Vulnerable and Ruptured Carotid Atherosclerotic Plaques
A Link Between Inflammation and Cerebrovascular Events
Giuseppe Sangiorgi, MD, FESC*,*,
Alessandro Mauriello, MD ,
Elena Bonanno, MD,
Claus Oxvig, PhD¶,
Cheryl A. Conover, MD ,
Michael Christiansen, MD#,
Santi Trimarchi, MD ,
Vincenzo Rampoldi, MD,
David R. Holmes, Jr, MDFACC||,
Robert.S. Schwartz, MD, FACC** and
Luigi Giusto Spagnoli, MD
* Cardiovascular Disease
Vascular Surgery, Istituto Policlinico San Donato, San Donato Milanese, Milan, Italy
Department of Pathology, University of Rome Tor Vergata, Rome, Italy
Endocrinology Research Unit
|| Department of Cardiovascular Disease, Mayo Clinic and Foundation, Rochester, Minnesota
¶ Department of Molecular and Structural Biology, University of Aarhus, Aarhus, Denmark
# Department of Clinical Biochemestry, Staten Serum Institute, Copenhagen, Denmark
** Department of Cardiovascular Disease, Minneapolis Heart Foundation, Minneapolis, Minnesota
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Figure 1 Graphs showing linear regression between pregnancy-associated protein-A (PAPP-A) score versus plaque thickness (A) and PAPP-A score versus total cells' plaque cap inflammatory infiltrate (B) for the 65 carotid atherosclerotic plaques submitted to histopathologic examination. A decrease in cap thickness and an increase in inflammatory infiltrate in the cap region of the plaque are both strongly correlated with increase in PAPP-A expression.
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Figure 2 Photomicrographs of a carotid atherosclerotic plaque removed by carotid endarterectomy from a patients who suffered a major stroke. A vulnerable plaque characterized by a large lipidic-necrotic core, a thin fibrous cap (A, Movat pentachrome, 4x) associated to a heavy inflammatory infiltrate constituted mainly by macrofagic foam cells, CD68-positive (B, 10x). A strong positive reaction for pregnancy-associated protein-A was observed (C, 20x). (D, 10x and G, 20x) show CD68 antibody revealed by streptavidin-Texas Red fluorescent conjugate. (E, 10x and H, 20x) Show pregnancy-associated protein-A reaction revealed by streptavidin-fluorescin conjugate. Two dimension confocal analysis of the two fluorochromes (F and I) clearly showed a strong and diffuse positive reaction for pregnancy-associated protein-A in macrophagic cells (concordant double positivity appears as a yellow stain). (K) Shows confocal analysis of the two fluorochromes, smooth muscle actin immunostain (red) and pregnancy-associated protein-A stain (green). Smooth muscle cells observed in this plaque gave rise to a strong positive reaction for pregnancy-associated protein-A (yellow stain). (L) Shows confocal analysis of the two fluorochromes, CD3 immunostain (red) and pregnancy-associated protein-A stain (green). Almost all T lymphocytes (red) observed were negative for pregnancy-associated protein-A in plaques where a diffuse positive reaction was observed (green). Only occasional T lymphocytes were pregnancy-associated protein-A-positive (double positivity, yellow stain, arrow).
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Figure 3 Photomicrographs of a stable carotid atherosclerotic plaque removed by carotid endarterectomy from an asymptomatic patient. In the shoulder of the plaque (A, Movat pentachrome, 4x), there is a moderate inflammatory infiltrate, constituted mainly by macrophagic foam cells, CD68-positive (B, a contiguous section of A). The expression of pregnancy-associated protein-A is very low (C, contiguous section of A). Only few cells are pregnancy-associated protein-A-positive (inset). (D) (20x) Shows CD68 antibody revealed by streptavidin-Texas Red fluorescent conjugate. (E) (20x) Pregnancy-associated protein-A reaction revealed by streptavidin-fluorescin conjugate. Two dimension confocal analysis of the two fluorochromes reported in F shows that monocytes/macrophages resident in this "stable" plaque were almost negative for pregnancy-associated protein-A. The pregnancy-associated protein-A reaction showed only slight and focal positivity. Smooth muscle cells were almost negative for pregnancy-associated protein-A. The pregnancy-associated protein-A reaction showed only slight and focal positivity (G, concordant double positivity appears as a yellow stain, arrow, 10x). (H) T lymphocytes and pregnancy-associated protein-A double immunostain (10x). Few T lymphocytes (CD3 antibody revealed by streptavidin-Texas Red fluorescent conjugate) were observed in this plaque, and the reaction for pregnancy-associated protein-A was negative (pregnancy-associated protein-A revealed by streptavidin-fluorescin conjugate).
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Figure 4 Bar graphs showing pregnancy-associated protein-A (PAPP-A) messenger ribonucleic acid (mRNA) expression in carotid plaques collected by surgical carotid endarterectomy from symptomatic patients relative to plaque from an asymptomatic patient. All samples had detectable PAPP-A mRNA from one- to four-fold greater than control. All data represent means of three samples from at least three separately performed experiments. Data are presented as means ± SD. S = stroke; T = transient ischemic attack.
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