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Karabatić Knezović S, Knezović D, Matana A, Puizina Ivić N, Drmić Hofman I. Strong association of TLR2 and TLR3 polymorphisms with keratoacanthoma and common warts: a case-control study. Croat Med J 2024; 65:232-238. [PMID: 38868969 PMCID: PMC11157254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 05/09/2024] [Indexed: 06/14/2024] Open
Abstract
AIM To determine variations in allele and genotype frequencies between keratoacanthoma (KA) and common warts (CW), compared with the control group, in three single nucleotide polymorphisms (SNPs) within the TLR2, TLR3, and TLR9 genes. METHODS This case-control study involved samples from 161 patients with KA, 152 patients with CW, and 469 controls. DNA was isolated from formalin-fixed paraffin-embedded tissue sections. Three SNPs - rs4696480 in TLR2, rs7657186 in TLR9, and rs35213 in TLR3 - were genotyped with TaqMan Genotyping Assays on the 7500 Real-Time PCR System. RESULTS TLR2 rs4696480 and TLR3 rs7657186 were significantly overrepresented in KA and CW compared with controls (P<0.001). The association was stronger for CW than for KA, as evidenced by higher frequencies of the A allele and AA genotype for rs4696480. Both KA and CW patients had higher frequencies of the G allele and GG genotype for rs7657186 than controls. rs7657186 was moderately associated with KA and CW, with the G allele and GG genotype being more prevalent in CW cases, where no AA homozygotes were found. CONCLUSION Genetic variants in TLR2 (rs4696480) and TLR3 (rs7657186) genes may affect KA and CW development, influencing immune responses and susceptibility to these skin lesions. Further research is required to elucidate TLR expression patterns and their role in KA development.
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Affiliation(s)
| | | | | | | | - Irena Drmić Hofman
- Irena Drmić Hofman, Department of Medical Chemistry and Biochemistry, University of Split School of Medicine, Šoltanska 2, 21000 Split, Croatia,
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Li X, Ning R, Xiao B, Meng S, Sun H, Fan X, Li S. A multi-variable predictive warning model for cervical cancer using clinical and SNPs data. Front Med (Lausanne) 2024; 11:1294230. [PMID: 38455474 PMCID: PMC10918689 DOI: 10.3389/fmed.2024.1294230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/23/2024] [Indexed: 03/09/2024] Open
Abstract
Introduction Cervical cancer is the fourth most common cancer among female worldwide. Early detection and intervention are essential. This study aims to construct an early predictive warning model for cervical cancer and precancerous lesions utilizing clinical data and simple nucleotide polymorphisms (SNPs). Methods Clinical data and germline SNPs were collected from 472 participants. Univariate logistic regression, least absolute shrinkage selection operator (LASSO), and stepwise regression were performed to screen variables. Logistic regression (LR), support vector machine (SVM), random forest (RF), decision tree (DT), extreme gradient boosting(XGBoost) and neural network(NN) were applied to establish models. The receiver operating characteristic (ROC) curve was used to compare the models' efficiencies. The performance of models was validated using decision curve analysis (DCA). Results The LR model, which included 6 SNPs and 2 clinical variables as independent risk factors for cervical carcinogenesis, was ultimately chosen as the most optimal model. The DCA showed that the LR model had a good clinical application. Discussion The predictive model effectively foresees cervical cancer risk using clinical and SNP data, aiding in planning timely interventions. It provides a transparent tool for refining clinical decisions in cervical cancer management.
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Affiliation(s)
- Xiangqin Li
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruoqi Ning
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bing Xiao
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Silu Meng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haiying Sun
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinran Fan
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuang Li
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Elkafas H, Walls M, Al-Hendy A, Ismail N. Gut and genital tract microbiomes: Dysbiosis and link to gynecological disorders. Front Cell Infect Microbiol 2022; 12:1059825. [PMID: 36590579 PMCID: PMC9800796 DOI: 10.3389/fcimb.2022.1059825] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/18/2022] [Indexed: 12/23/2022] Open
Abstract
Every year, millions of women are affected by genital tract disorders, such as bacterial vaginosis (BV), endometrial cancer, polycystic ovary syndrome (PCOS), endometriosis, and uterine fibroids (UFs). These disorders pose a significant economic burden on healthcare systems and have serious implications for health and fertility outcomes. This review explores the relationships between gut, vaginal, and uterine dysbiosis and the pathogenesis of various diseases of the female genital tract. In recent years, reproductive health clinicians and scientists have focused on the microbiome to investigate its role in the pathogenesis and prevention of such diseases. Recent studies of the gut, vaginal, and uterine microbiomes have identified patterns in bacterial composition and changes across individuals' lives associated with specific healthy and diseased states, particularly regarding the effects of the estrogen-gut microbiome axis on estrogen-driven disorders (such as endometrial cancer, endometriosis, and UFs) and disorders associated with estrogen deficiency (such as PCOS). Furthermore, this review discusses the contribution of vitamin D deficiency to gut dysbiosis and altered estrogen metabolism as well as how these changes play key roles in the pathogenesis of UFs. More research on the microbiome influences on reproductive health and fertility is vital.
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Affiliation(s)
- Hoda Elkafas
- Department of Pharmacology and Toxicology, Egyptian Drug Authority [EDA; formerly The National Organization for Drug Control and Research (NODCAR)], Cairo, Egypt
| | - Melinique Walls
- Pritzker School of Medicine, University of Chicago, Chicago, IL, United States
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, United States
| | - Nahed Ismail
- Department of Pathology, University of Illinois at Chicago, Chicago, IL, United States
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Kontomanolis EN, Koutras A, Fasoulakis Z, Syllaios A, Diakosavvas M, Angelou K, Symeonidis P, Samara AA, Pergialiotis V, Garmpis N, Schizas D, Pagkalos A, Chionis A, Daskalakis G, Ntounis T. A Brief Overview of Oncogenes and Signal Transduction Pathways in Gynecological Cancer. CANCER DIAGNOSIS & PROGNOSIS 2022; 2:134-143. [PMID: 35399174 PMCID: PMC8962808 DOI: 10.21873/cdp.10087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/05/2022] [Indexed: 06/14/2023]
Abstract
Gynecological cancer is the cancer that originates in the female reproductive system. According to the anatomical location of the cancer, it is distinguished into cervical, uterine, vaginal, ovarian, and vulvar cancer. Oncogenes and tumor catalytic genes play a key role in the genesis and development of gynecological cancer. This article presents the signaling pathways and expression of oncogenes that take place in the carcinogenesis of the female reproductive system.
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Affiliation(s)
- Emmanuel N Kontomanolis
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Antonios Koutras
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Zacharias Fasoulakis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Athanasios Syllaios
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Michail Diakosavvas
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Kyveli Angelou
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | | | - Athina A Samara
- Department of Surgery, University Hospital of Larissa, Larissa, Greece
| | - Vasilios Pergialiotis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Nikolaos Garmpis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimitrios Schizas
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Athanasios Pagkalos
- Department of Obstetrics and Gynecology, General Hospital of Xanthi, Xanthi, Greece
| | - Athanasios Chionis
- Department of Obstetrics and Gynecology, Laiko General Hospital of Athens, Athens, Greece
| | - Georgios Daskalakis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Thomas Ntounis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
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5
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Rogers LJ. Management of Advanced Squamous Cell Carcinoma of the Vulva. Cancers (Basel) 2021; 14:cancers14010167. [PMID: 35008331 PMCID: PMC8750777 DOI: 10.3390/cancers14010167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/15/2021] [Accepted: 12/23/2021] [Indexed: 01/13/2023] Open
Abstract
Simple Summary Vulvar cancer is a rare gynaecological malignancy that has an increasing incidence, particularly in younger women. Early vulvar cancer can be treated and cured with surgical excision. Approximately 30% of women present with advanced disease, which requires treatment either with mutilating surgery or a combination of chemotherapy and radiotherapy, which is an effective treatment but has many side effects. Current research is focused on new less morbid approaches to treatment, in which drugs that target various steps on the biological pathway from pre-cancer to cancer are used, with the aim of preventing the growth of vulvar cancers. This review is an update of the current management of women with advanced vulvar cancer. Abstract Vulvar cancer is a rare gynaecological malignancy, accounting for 2–5% of cancers of the female genital tract. Squamous cell carcinoma is the most frequently occurring subtype and, historically, has been a disease of older post-menopausal women, occurring with a background of lichen sclerosus and other epithelial conditions of the vulvar skin that may be associated with well-differentiated vulvar intra-epithelial neoplasia (dVIN). An increase in human papillomavirus (HPV) infections worldwide has led to an increase in vulvar squamous carcinomas in younger women, resulting from HPV-associated high-grade vulvar squamous intra-epithelial lesions (vHSIL). Surgical resection is the gold standard for the treatment of vulvar cancer. However, as approximately 30% of patients present with locally advanced disease, which is either irresectable or will require radical surgical resection, possibly with a stoma, there has been a need to investigate alternative forms of treatment such as chemoradiation and targeted therapies, which may minimise the psychosexual morbidity of radical surgery. This review aims to provide an update on management strategies for women with advanced vulvar cancer. It is hoped that investigation of the molecular biologies of the two different pathways to vulvar squamous cell carcinoma (HPV-associated and non-HPV-associated) will lead to the development of targeted therapeutic agents.
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Affiliation(s)
- Linda J. Rogers
- Department of Obstetrics and Gynaecology, Groote Schuur Hospital, The University of Cape Town, Cape Town 7505, South Africa;
- SAMRC/UCT Gynaecological Cancer Research Centre, University of Cape Town, Cape Town 7925, South Africa
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Xu Q, Li T, Chen H, Kong J, Zhang L, Yin H. Design and optimisation of a small-molecule TLR2/4 antagonist for anti-tumour therapy. RSC Med Chem 2021; 12:1771-1779. [PMID: 34778778 PMCID: PMC8528216 DOI: 10.1039/d1md00175b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/19/2021] [Indexed: 11/21/2022] Open
Abstract
In anti-tumour therapy, the toll-like receptor 2/4 (TLR2/4) signalling pathway has been a double-edged sword. TLR2/4 agonists are commonly considered adjuvants for immune stimulation, whereas TLR2/4 antagonists demonstrate more feasibility for anti-tumour therapy under specific chronic inflammatory situations. In individuals with cancer retaliatory proliferation and metastasis after surgery, blocking the TLR2/4 signalling pathway may produce favourable prognosis for patients. Therefore, here, we developed a small-molecule co-inhibitor that targets the TLR2/4 signalling pathway. After high-throughput screening of a compound library containing 14 400 small molecules, followed by hit-to-lead structural optimisation, we finally obtained the compound TX-33, which has effective inhibitory properties against the TLR2/4 signalling pathways. This compound was found to significantly inhibit multiple pro-inflammatory cytokines released by RAW264.7 cells. This was followed by TX-33 demonstrating promising efficacy in subsequent anti-tumour experiments. The current results provide a novel understanding of the role of TLR2/4 in cancer and a novel strategy for anti-tumour therapy.
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Affiliation(s)
- Qun Xu
- School of Pharmaceutical Sciences, Key Laboratory of Bioorganic Phosphorous chemistry and Chemical Biology (Ministry of Education), Tsinghua University Beijing 100084 China
| | - Tian Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University Beijing 100070 China
| | - Hekai Chen
- School of Pharmaceutical Sciences, Key Laboratory of Bioorganic Phosphorous chemistry and Chemical Biology (Ministry of Education), Tsinghua University Beijing 100084 China
| | - Jun Kong
- School of Pharmaceutical Sciences, Key Laboratory of Bioorganic Phosphorous chemistry and Chemical Biology (Ministry of Education), Tsinghua University Beijing 100084 China
| | - Liwei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University Beijing 100070 China
| | - Hang Yin
- School of Pharmaceutical Sciences, Key Laboratory of Bioorganic Phosphorous chemistry and Chemical Biology (Ministry of Education), Tsinghua University Beijing 100084 China
- Tsinghua-Peking Center for Life Sciences, Tsinghua University Beijing 100084 China
- Beijing Advanced Innovation Center for Structural Biology, Tsinghua University Beijing 100084 China
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7
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Genetic Predisposition to Persistent Human Papillomavirus-Infection and Virus-Induced Cancers. Microorganisms 2021; 9:microorganisms9102092. [PMID: 34683414 PMCID: PMC8539927 DOI: 10.3390/microorganisms9102092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/01/2021] [Accepted: 10/01/2021] [Indexed: 11/17/2022] Open
Abstract
Human papillomaviruses (HPVs) are the most common sexually transmitted pathogens worldwide and among the more than 200 identified HPV types, approximately 15 high risk (HR-HPV) types are oncogenic, being strongly associated with the development of cervical cancer, anogenital cancers and an increasing fraction of head and neck squamous cell carcinomas (HNSCC). HPV-associated cervix cancer accounts for 83% of HPV-attributable cancers, and more than two-thirds of those cases occur in developing countries. Despite the high frequency of HPV infections, in most cases, the virus is cleared by the host immune response and only a small proportion of infected individuals develop persistent infections that can result in malignant transformation, indicating that other elements, including biological, genetic and environmental factors may influence the individual susceptibility to HPV-associated cancers. Previous studies have quantified that heritability, in the form of genetic variants, common in the general population, is implicated in nearly 30% of cervical cancers and a large number of studies conducted across various populations have identified genetic variants that appear to be associated with genes that predispose or protect the host to HPV infections thereby affecting individual susceptibility to HPV-associated cancers. In this article, we provide an overview of gene association studies on HPV-associated cancers with emphasis on genome-wide association study (GWAS) that have identified novel genetic factors linked to HPV infection or HPV-associated cancers.
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8
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Comparing and contrasting clinical consensus and guidelines for anal intraepithelial neoplasia in different geographical regions. Updates Surg 2021; 73:2047-2058. [PMID: 34482519 PMCID: PMC8606379 DOI: 10.1007/s13304-021-01156-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/23/2021] [Indexed: 12/03/2022]
Abstract
Anal Squamous Cell Carcinoma (ASCC) is an uncommon cancer with a recognised precursor Anal Intraepithelial Neoplasia (AIN). Although there are consistent evidence-based guidelines for the management of ASCC, historically this has not been the case for AIN and as a result there have been geographical variations in the recommendations for the treatment of AIN. More recently there have been updates in the literature to the recommendations for the management of AIN. To assess whether we are now closer to achieving an international consensus, we have completed a systematic scoping review of available guidelines for the screening, treatment and follow-up of AIN as a precursor to ASCC. MEDLINE and EMBASE were systematically searched for available clinical guidelines endorsed by a recognised clinical society that included recommendations on either the screening, treatment or follow-up of AIN. Nine clinical guidelines from three geographical areas were included. The most recent guidelines agreed that screening for AIN in high-risk patients and follow-up after treatment was necessary but there was less consensus on the modality of screening. Six Guidelines recommended the treatment of high-grade AIN and four guidelines describe a follow-up protocol of patients diagnosed with AIN. There appears to be increasing consensus on the treatment and follow-up of patients despite a poor evidence base. There is still significant discrepancy in guidance on the method to identify patients at risk of ASCC and AIN despite consensus between geographical regions on which patient subgroups are at the highest risk.
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Toll-like Receptor 2 as a Marker Molecule of Advanced Ovarian Cancer. Biomolecules 2021; 11:biom11081205. [PMID: 34439871 PMCID: PMC8394498 DOI: 10.3390/biom11081205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/01/2021] [Accepted: 08/09/2021] [Indexed: 12/09/2022] Open
Abstract
Ovarian cancer is a global problem that affects women of all ages. Due to the lack of effective screening tests and the usually asymptomatic course of the disease in the early stages, the diagnosis is too late, with the result that less than half of the patients diagnosed with ovarian cancer (OC) survive more than five years after their diagnosis. In this study, we examined the expression of TLR2 in the peripheral blood of 50 previously untreated patients with newly diagnosed OC at various stages of the disease using flow cytometry. The studies aimed at demonstrating the usefulness of TLR2 as a biomarker in the advanced stage of ovarian cancer. In this study, we showed that TLR2 expression levels were significantly higher in women with more advanced OC than in women in the control group. Our research sheds light on the prognostic potential of TLR2 in developing new diagnostic approaches and thus in increasing survival in patients with confirmed ovarian cancer.
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Borella F, Carosso AR, Cosma S, Preti M, Collemi G, Cassoni P, Bertero L, Benedetto C. Gut Microbiota and Gynecological Cancers: A Summary of Pathogenetic Mechanisms and Future Directions. ACS Infect Dis 2021; 7:987-1009. [PMID: 33848139 DOI: 10.1021/acsinfecdis.0c00839] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Over the past 20 years, important relationships between the microbiota and human health have emerged. A link between alterations of microbiota composition (dysbiosis) and cancer development has been recently demonstrated. In particular, the composition and the oncogenic role of intestinal bacterial flora has been extensively investigated in preclinical and clinical studies focusing on gastrointestinal tumors. Overall, the development of gastrointestinal tumors is favored by dysbiosis as it leads to depletion of antitumor substances (e.g., short-chain fatty acids) produced by healthy microbiota. Moreover, dysbiosis leads to alterations of the gut barrier, promotes a chronic inflammatory status through activation of toll-like receptors, and causes metabolic and hormonal dysregulations. However, the effects of these imbalances are not limited to the gastrointestinal tract and they can influence gynecological tumor carcinogenesis as well. The purpose of this Review is to provide a synthetic update about the mechanisms of interaction between gut microbiota and the female reproductive tract favoring the development of neoplasms. Furthermore, novel therapeutic approaches based on the modulation of microbiota and their role in gynecological oncology are discussed.
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Affiliation(s)
- Fulvio Borella
- Obstetrics and Gynecology Unit 1, Sant’ Anna Hospital, Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Andrea Roberto Carosso
- Obstetrics and Gynecology Unit 1, Sant’ Anna Hospital, Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Stefano Cosma
- Obstetrics and Gynecology Unit 1, Sant’ Anna Hospital, Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Mario Preti
- Obstetrics and Gynecology Unit 1, Sant’ Anna Hospital, Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Giammarco Collemi
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | | | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Chiara Benedetto
- Obstetrics and Gynecology Unit 1, Sant’ Anna Hospital, Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
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Immunogenomic Identification for Predicting the Prognosis of Cervical Cancer Patients. Int J Mol Sci 2021; 22:ijms22052442. [PMID: 33671013 PMCID: PMC7957482 DOI: 10.3390/ijms22052442] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 12/12/2022] Open
Abstract
Cervical cancer is primarily caused by the infection of high-risk human papillomavirus (hrHPV). Moreover, tumor immune microenvironment plays a significant role in the tumorigenesis of cervical cancer. Therefore, it is necessary to comprehensively identify predictive biomarkers from immunogenomics associated with cervical cancer prognosis. The Cancer Genome Atlas (TCGA) public database has stored abundant sequencing or microarray data, and clinical data, offering a feasible and reliable approach for this study. In the present study, gene profile and clinical data were downloaded from TCGA, and the Immunology Database and Analysis Portal (ImmPort) database. Wilcoxon-test was used to compare the difference in gene expression. Univariate analysis was adopted to identify immune-related genes (IRGs) and transcription factors (TFs) correlated with survival. A prognostic prediction model was established by multivariate cox analysis. The regulatory network was constructed and visualized by correlation analysis and Cytoscape, respectively. Gene functional enrichment analysis was performed by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG). A total of 204 differentially expressed IRGs were identified, and 22 of them were significantly associated with the survival of cervical cancer. These 22 IRGs were actively involved in the JAK-STAT pathway. A prognostic model based on 10 IRGs (APOD, TFRC, GRN, CSK, HDAC1, NFATC4, BMP6, IL17RD, IL3RA, and LEPR) performed moderately and steadily in squamous cell carcinoma (SCC) patients with FIGO stage I, regardless of the age and grade. Taken together, a risk score model consisting of 10 novel genes capable of predicting survival in SCC patients was identified. Moreover, the regulatory network of IRGs associated with survival (SIRGs) and their TFs provided potential molecular targets.
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Tumor cell-specific Serpin A1 expression in vulvar squamous cell carcinoma. Arch Gynecol Obstet 2019; 299:1345-1351. [PMID: 30607583 PMCID: PMC6475512 DOI: 10.1007/s00404-018-5015-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 12/08/2018] [Indexed: 11/30/2022]
Abstract
Purpose The two main etiological factors for vulvar squamous cell carcinoma (vSCC) are the vulvar dermatosis lichen sclerosus (LS) and high-risk human papillomavirus (hrHPV). Serpin A1 (α1-antitrypsin) is a serine protease inhibitor, which plays a role in the tumorigenesis of various cancer types. The aim of the study was to evaluate the expressions of Serpin A1 in LS, premalignant vulvar lesions, and vSCC using immunohistochemistry (IHC) and serum analysis, and to compare Serpin A1 stainings to the tumor markers p53 and p16. Methods In total, 120 samples from 74 patients were studied with IHC for Serpin A1, p53 and p16: 18 normal vulvar skin, 53 LS, 9 premalignant vulvar lesions (dVIN/HSIL) and 40 vSCC samples. Serum concentrations of Serpin A1 were analyzed from 30 LS, 44 vSCC and 10 control patients. Expressions were compared to clinical data. Results Tumor cell-specific Serpin A1 overexpression was detected in 88% of vSCC samples, independent of the etiology. The intensity of Serpin A1 expression was significantly higher in vSCC than in healthy vulvar skin, LS, or premalignant vulvar lesions. Serpin A1 showed an association with p53 positivity. No difference in overall survival was found between Serpin A1-, p53-, or p16-positive vSCC patients. Serum concentrations of Serpin A1 were equal in the LS, vSCC, and control groups. Conclusion Tumor cell-specific Serpin A1 overexpression is a potential biomarker in vSCC.
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The Relationship of the TLR9 and TLR2 Genetic Polymorphisms with Cervical Cancer Risk: a Meta-Analysis of Case-Control Studies. Pathol Oncol Res 2018; 26:307-315. [PMID: 30215163 DOI: 10.1007/s12253-018-0465-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 08/23/2018] [Indexed: 02/06/2023]
Abstract
This meta-analysis aimed to assess the association of common TLR9 and TLR2 gene polymorphisms (TLR9 1486 T/C, TLR9 G2848A, and TLR2-196 to -174 del/ins) with cervical cancer risk. Studies were searched in Scopus, Pubmed, Embase, and CNKI until December 2017. Both fixed-effects and random-effects models were applied to combine odds ratio (OR) and 95% confidence intervals (95% CI). A total of 11 studies including 7856 participants were identified. The pooled estimation revealed an increased risk of cervical cancer in Caucasian subjects carrying the C allele of the TLR9 1486 T/C polymorphism (OR = 1.46, 95% CI: 1.11-1.92, p = 0.007), while there was a decreased risk in Mixed subjects carrying the C allele (OR = 0.35, 95% CI: 0.15-0.82, p = 0.016). Concerning the TLR9 G2848A polymorphism, the A allele was associated with an increased risk of cervical cancer in Caucasians (OR = 1.19, 95% CI: 1.02-1.40, p = 0.030), whereas Asian and Mixed subjects showed no significant associations. No significant associations were demonstrated between the TLR2-196 to -174 del/ins polymorphism and cervical cancer. Our findings suggest that the TLR9 1486 T/C and G2848A polymorphisms contribute to cervical cancer risk, but there is no association of the TLR2-196 to -174 del/ins polymorphism with cervical cancer.
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The Associations between Toll-Like Receptor 9 Gene Polymorphisms and Cervical Cancer Susceptibility. Mediators Inflamm 2018; 2018:9127146. [PMID: 30147445 PMCID: PMC6083594 DOI: 10.1155/2018/9127146] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 06/27/2018] [Indexed: 12/22/2022] Open
Abstract
This meta-analysis systematically reviews the association between Toll-like receptor 9 polymorphisms and the risk of cervical cancer. Case-control studies focused on the association were collected from the PubMed, Web of Science, Cochrane Library, Embase, MEDLINE, CNKI, VIP, and Wanfang databases from inception to July 2017. We screened the studies and assessed the methodological quality of the included studies and extracted data. A meta-analysis was performed using RevMan 5.3 and Stata 12.0 software. Pooled odds ratios and 95% confidence intervals were employed to evaluate the strength of the associations between Toll-like receptor 9 polymorphisms and cervical cancer risk. A total of 9 studies comprising 3331 cervical cancer patients and 4109 healthy controls met the inclusion criteria. Of these, 8 studies contained information about G2848A (rs352140) and 4 studies contained information about −1486T/C (rs187084). Our results revealed that the associations between rs187084 and cervical cancer risk in the dominant model (p = 0.002) and heterozygous model (p = 0.002) were significant, with 1.30- and 1.32-fold increases in susceptibility, respectively, compared to that in the wild-type model. However, rs352140 was not related to cervical cancer regardless of whether the subgroup analysis was conducted (p > 0.05). In conclusion, there is a significant correlation between rs187084 and cervical cancer risk with the minor C allele increasing the risk of occurrence of cervical cancer. However, rs352140 is not associated with the occurrence of cervical cancer.
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15
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Viarisio D, Gissmann L, Tommasino M. Human papillomaviruses and carcinogenesis: well-established and novel models. Curr Opin Virol 2017; 26:56-62. [PMID: 28778034 DOI: 10.1016/j.coviro.2017.07.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 06/20/2017] [Accepted: 07/18/2017] [Indexed: 10/19/2022]
Abstract
Human papillomaviruses (HPVs) infect the cutaneous or mucosal epithelia and are classified phylogenetically as genera and species. Persistent infections by the mucosal high-risk (HR) HPV types from genus alpha are associated with cancer development of the genital and upper respiratory tracts. The products of two early genes, E6 and E7, are the major HR HPV oncoproteins, being essential in all steps of the carcinogenic process. Cutaneous beta HPV types are proposed, together with ultraviolet (UV) radiation, to promote non-melanoma skin cancer development. However, in contrast to the HR HPV types, beta HPV types appear to be required only at an early stage of carcinogenesis, facilitating the accumulation of UV-induced DNA mutations. Although findings in experimental models also suggest that beta HPV types and other carcinogens may synergize in the induction of malignancies, these possibilities need to be confirmed in human studies.
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Affiliation(s)
| | - Lutz Gissmann
- DKFZ, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Massimo Tommasino
- International Agency for Research on Cancer, World Health Organization, 150 Cours Albert Thomas, 69372 Lyon Cedex 08, France.
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Abstract
Human papillomavirus (HPV) is involved in one of the at least 2 pathways leading to vulvar squamous cell carcinoma (VSCC). Inactivation of p53 and retinoblastoma by the viral products E6 and E7 is involved in malignant transformation. The percentage of HPV-positive VSCCs ranges from 18% to 75%, depending on the geographical area. HPV-associated tumors affect relatively young women and arise from high-grade intraepithelial lesions, identical to other HPV-associated premalignant lesions of the anogenital tract. HPV-independent tumors tend to affect older women and usually arise in a background of inflammatory skin disorders and a subtle variant of in situ lesion called differentiated vulvar intraepithelial neoplasia. HPV-positive tumors tend to be of basaloid or warty types, whereas HPV-independent tumors tend to be of keratinizing type, but there is frequent overlap between histologic types. There is no conclusive evidence yet on the best strategy in terms of determining HPV attribution. HPV DNA detection is generally considered the gold standard although there is some concern about misclassification when using this technique alone. p16 immunostaining has shown to be an excellent surrogate marker of HPV infection. Positive results for both techniques are considered the best evidence for HPV-association. The prognostic role of HPV in VSCC is still contradictory, but increasing evidence suggests that HPV-associated tumors are less aggressive. Currently, there are no differences in treatment between HPV-associated and HPV-independent VSCC, but novel immunological strategies based on anti-HPV antigens are being evaluated in clinical trials.
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Weberpals JI, Lo B, Duciaume MM, Spaans JN, Clancy AA, Dimitroulakos J, Goss GD, Sekhon HS. Vulvar Squamous Cell Carcinoma (VSCC) as Two Diseases: HPV Status Identifies Distinct Mutational Profiles Including Oncogenic Fibroblast Growth Factor Receptor 3. Clin Cancer Res 2017; 23:4501-4510. [PMID: 28377483 DOI: 10.1158/1078-0432.ccr-16-3230] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 01/30/2017] [Accepted: 03/31/2017] [Indexed: 11/16/2022]
Abstract
Purpose: Patients with advanced or recurrent invasive vulvar squamous cell carcinoma (VSCC) have limited treatment options and a grave prognosis. Understanding the genomic landscape may facilitate the identification of new therapies and improve clinical outcomes.Experimental Design: A retrospective chart review and molecular analysis of patients with VSCC from 2000 to 2016 was performed at the Ottawa Hospital Research Institute. The presence of oncogenic human papillomavirus (HPV) was determined by nested PCR and amplified DNA was sequenced using the Ion AmpliSeq Cancer Hotspot v2 Panel. The patients were divided into two groups according to HPV status (HPV-positive versus HPV-negative) and clinical outcome correlated with mutation status using descriptive statistics.Results: In 43 VSCC patients, there was a high mutation rate in both HPV-positive (73%) and HPV-negative (90%) disease with the two subgroups expressing distinct genetic profiles. HPV-positive tumors were characterized by oncogenic mutations in PIK3CA (27%), FGFR3 (14%), and PTEN (9%), whereas HPV-negative tumors were found to have mutations in TP53 (57%), HRAS (24%), PI3KCA (19%), and CDKN2A (14%). Mutation S249C in FGFR3 occurred in 14% of HPV-positive tumors. While there were notable differences in the occurrence of TP53, HRAS, PTEN, and FGFR3 mutations according to HPV status, only the rate of TP53 mutations was statistically significant (P = 0.0004). No significant difference in prognosis was found between patients with HPV-positive and HPV-negative VSCC.Conclusions: HPV-positive VSCC is characterized by oncogenic FGFR3 mutations that helps classify this subtype as a separate disease. Inhibitors of FGFR3 merit consideration as a therapeutic strategy in this neglected cancer in women. Clin Cancer Res; 23(15); 4501-10. ©2017 AACR.
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Affiliation(s)
- Johanne I Weberpals
- Division of Gynaecologic Oncology, The Ottawa Hospital, Ottawa, Canada. .,Ottawa Hospital Research Institute, Centre for Cancer Therapeutics, Ottawa, Canada
| | - Bryan Lo
- Ottawa Hospital Research Institute, Centre for Cancer Therapeutics, Ottawa, Canada.,Molecular Oncology Diagnostics Laboratory, The Ottawa Hospital, Ottawa, Ontario.,Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Canada
| | - Marc M Duciaume
- Ottawa Hospital Research Institute, Centre for Cancer Therapeutics, Ottawa, Canada
| | - Johanna N Spaans
- Ottawa Hospital Research Institute, Centre for Cancer Therapeutics, Ottawa, Canada
| | - Aisling A Clancy
- Department of Obstetrics and Gynaecology, University of Ottawa, Ottawa, Ontario
| | - Jim Dimitroulakos
- Ottawa Hospital Research Institute, Centre for Cancer Therapeutics, Ottawa, Canada
| | - Glenwood D Goss
- Ottawa Hospital Research Institute, Centre for Cancer Therapeutics, Ottawa, Canada.,Division of Medical Oncology, University of Ottawa, Ottawa, Canada
| | - Harman S Sekhon
- Ottawa Hospital Research Institute, Centre for Cancer Therapeutics, Ottawa, Canada.,Molecular Oncology Diagnostics Laboratory, The Ottawa Hospital, Ottawa, Ontario.,Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Canada
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Fehri E, Ennaifer E, Ardhaoui M, Ouerhani K, Laassili T, Bel Haj Rhouma R, Guizani I, Boubaker S. Expression of Toll-like receptor 9 increases with progression of cervical neoplasia in Tunisian women--a comparative analysis of condyloma, cervical intraepithelial neoplasia and invasive carcinoma. Asian Pac J Cancer Prev 2017; 15:6145-50. [PMID: 25124588 DOI: 10.7314/apjcp.2014.15.15.6145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Toll-like receptors (TLRs) are expressed in immune and tumor cells and recognize pathogen-associated molecular patterns. Cervical cancer (CC) is directly linked to a persistent infection with high risk human papillomaviruses (HR-HPVs) and could be associated with alteration of TLRs expression. TLR9 plays a key role in the recognition of DNA viruses and better understanding of this signaling pathway in CC could lead to the development of novel immunotherapeutic approaches. The present study was undertaken to determine the level of TLR9 expression in cervical neoplasias from Tunisian women with 53 formalin-fixed and paraffin-embedded specimens, including 22 samples of invasive cervical carcinoma (ICC), 18 of cervical intraepithelial neoplasia (CIN), 7 of condyloma and 6 normal cervical tissues as control cases. Quantification of TLR9 expression was based on scoring four degrees of extent and intensity of immunostaining in squamous epithelial cells. TLR9 expression gradually increased from CIN1 (80% weak intensity) to CIN2 (83.3% moderate), CIN3 (57.1% strong) and ICC (100% very strong). It was absent in normal cervical tissue and weak in 71.4% of condyloma. The mean scores of TLR9 expression were compared using the Kruskall-Wallis test and there was a statistical significance between normal tissue and condyloma as well as between condyloma, CINs and ICC. These results suggest that TLR9 may play a role in progression of cervical neoplasia in Tunisian patients and could represent a useful biomarker for malignant transformation of cervical squamous cells.
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Affiliation(s)
- Emna Fehri
- HPV Unit Research. Laboratory of Molecular Epidemiology and Experimental Pathology Applied to Infectious Diseases, le Belvedere, Tunis, Tunisia E-mail :
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Clancy A, Spaans J, Weberpals J. The forgotten woman's cancer: vulvar squamous cell carcinoma (VSCC) and a targeted approach to therapy. Ann Oncol 2016; 27:1696-705. [DOI: 10.1093/annonc/mdw242] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/08/2016] [Indexed: 01/22/2023] Open
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20
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Zhou X, Xu CJ, Wang JX, Dai T, Ye YP, Cui YM, Liao WT, Wu XL, Ou JP. Metastasis-Associated in Colon Cancer-1 Associates With Poor Prognosis and Promotes Cell Invasion and Angiogenesis in Human Cervical Cancer. Int J Gynecol Cancer 2016; 25:1353-63. [PMID: 26332389 PMCID: PMC5106080 DOI: 10.1097/igc.0000000000000524] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Supplemental digital content is available in the text. Objective The aim of this study is to investigate the clinicopathologic significance and potential role of metastasis-associated in colon cancer-1 (MACC1) in the progression of cervical cancer. Methods MACC1 expression was examined in cervical cancer cell lines, 6 matched cervical cancer tissues, and adjacent noncancerous tissues using Western blotting and real-time reverse transcriptase polymerase chain reaction. MACC1 protein expression and localization were determined in 181 paraffin-embedded archived cervical cancer samples using immunohistochemistry. Statistical analyses were applied to evaluate the clinicopathologic significance. The effects of MACC1 on cell migration, invasion, and angiogenesis were examined using migration assay, wound healing assay, 3-dimensional morphogenesis assay, and chicken chorioallantoic membrane assay. Western blotting was performed to examine the impact of MACC1 on the Akt and nuclear factor κB signaling pathways. Results Both protein and messenger RNA levels of MACC1 was up-regulated in cervical cancer cell lines and cervical cancer tissues, as compared with normal tissues. High MACC1 expression was detected in 96 (53%) of 181 of the cervical cancer tissues. In addition, high MACC1 expression correlated significantly with aggressiveness of cervical cancer, including International Federation of Gynecology and Obstetric stage (P = 0.001), pelvic lymph node metastasis (P = 0.004), recurrence (P = 0.037), and poor survival (P = 0.001). Moreover, enforced expression of MACC1 in cervical cancer cell lines significantly enhanced cell migration, invasion, and angiogenesis. Conversely, knockdown of MACC1 caused an inhibition of cell migration, invasion, and angiogenesis. Up-regulation of MACC1 increased, but knockdown of MACC1 decreased the expression of matrix metalloproteinase-2 and matrix metalloproteinase-9. Furthermore, enforced expression of MACC1 could enhance, but knockdown of MACC1 could reduce AKT and nuclear factor κB pathway activity. Conclusions Our findings suggest that MACC1 protein, as a valuable marker of cervical cancer prognosis, plays an important role in the progression of human cervical cancer cells.
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Affiliation(s)
- Xiang Zhou
- *Department of Microscurgery and Hand Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; †Department of Pathology of Basic Medical Sciences, Southern Medical University, Guangzhou, China; and ‡Department of Gynaecology and Obstetrics, the 157 Affiliated Hospital, General Hospital of Guangzhou Military Command of PLA, Guangzhou, China; §Department of Traditional Chinese Medicine, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; and ∥Center for Reproductive Medicine, the Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Gene Polymorphisms of Toll-Like Receptor 9 -1486T/C and 2848G/A in Cervical Cancer Risk. Int J Gynecol Cancer 2016; 25:1173-8. [PMID: 26270118 DOI: 10.1097/igc.0000000000000494] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE This work aims to explore whether Toll-like receptor 9 (TLR9) -1486T/C and 2848G/A polymorphisms are associated with cervical cancer risk. METHODS A comprehensive electronic search of studies published from January 1999 to October 2014 was conducted in Medline (Ovid), Embase, PubMed, Wanfang, Weipu, and CNKI. The algorithm included "TLR," "Toll-like receptor," "polymorphism," "variant," "mutation," and "cervical cancer." Seven articles, including 9 studies, were pooled using Revman 5.2 (Cochrane Collaboration, Copenhagen, Denmark). Odds ratio (OR) was used to explore the involvement of minor allele C (C vs T and CC + CT vs TT) of TLR9 (-1486T/C, rs187084) and minor allele A (A vs G and AA + AG vs GG) of TLR9 (2848G/A, rs352140) in cervical cancer risk. RESULTS Toll-like receptor 9 (-1486T/C, rs187084) polymorphisms were associated with an elevated risk of cervical cancer (C vs T: OR, 1.15; 95% confidence interval [CI], 1.03-1.29; CC + CT vs TT: OR, 1.30; 95% CI, 1.11-1.53). We found no significant association between TLR9 (2848G/A, rs352140) polymorphisms and cervical cancer risk (A vs G: OR, 1.15; 95% CI, 0.87-1.54; AA + AG vs GG: OR, 1.27; 95% CI, 0.75-2.17). CONCLUSIONS This meta-analysis indicates that TLR9 (-1486T/C, rs187084)-but not TLR9 (2848G/A, rs352140)-may be a risk factor for cervical cancer.
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Fehri E, Ennaifer E, Bel Haj Rhouma R, Guizani-Tabbane L, Guizani I, Boubaker S. The role of Toll-like receptor 9 in gynecologic cancer. Curr Res Transl Med 2016; 64:155-159. [PMID: 27765276 DOI: 10.1016/j.retram.2016.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 01/27/2016] [Indexed: 12/14/2022]
Abstract
Toll-like receptor 9 (TLR9) plays a major role in the fight against DNA viruses infections. Despite its antitumor properties, inappropriate activation of TLR9 during chronic inflammation may cause the activation of transcription factors inducing pro-cancerous activities. Thus, the relationship between TLR9 and cancer remains highly confrontational especially in gynecological cancers and cervical cancer induced by viruses. In this review, we focus on the beneficial and detrimental role of TLR9 in gynecological carcinogenesis. TLR9 contributes to tumor regression by inducing cytotoxic T cell response (CTL), reducing the numbers of myeloid-derived suppressor cells (MDSCs), the tumor-associated macrophages (TAMs) and the regulatory T cells (T regs). It can however, also promote tumor progression and invasiveness of cervical tissue. Therefore, the dichotomous role of TLR9 needs to be carefully investigated in the setting of neoplastic disease.
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Affiliation(s)
- E Fehri
- HPV Unit Research, Laboratory of Molecular Epidemiology and Experimental Pathology Applied to Infectious Diseases, Pasteur Institute of Tunis, BP 74, 1002, le Belvédère, Tunis, Tunisia; Department of Human and Experimental Pathology, Pasteur Institute of Tunis, BP 74, 1002, le Belvédère, Tunis, Tunisia.
| | - E Ennaifer
- HPV Unit Research, Laboratory of Molecular Epidemiology and Experimental Pathology Applied to Infectious Diseases, Pasteur Institute of Tunis, BP 74, 1002, le Belvédère, Tunis, Tunisia; Department of Human and Experimental Pathology, Pasteur Institute of Tunis, BP 74, 1002, le Belvédère, Tunis, Tunisia
| | - R Bel Haj Rhouma
- HPV Unit Research, Laboratory of Molecular Epidemiology and Experimental Pathology Applied to Infectious Diseases, Pasteur Institute of Tunis, BP 74, 1002, le Belvédère, Tunis, Tunisia
| | - L Guizani-Tabbane
- Laboratory of Medical Parasitology Biotechnology and Biomolecules, Pasteur Institute of Tunis, BP 74, 1002, le Belvédère, Tunis, Tunisia
| | - I Guizani
- HPV Unit Research, Laboratory of Molecular Epidemiology and Experimental Pathology Applied to Infectious Diseases, Pasteur Institute of Tunis, BP 74, 1002, le Belvédère, Tunis, Tunisia
| | - S Boubaker
- Department of Human and Experimental Pathology, Pasteur Institute of Tunis, BP 74, 1002, le Belvédère, Tunis, Tunisia
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23
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Zhang M, Huang J, Tan X, Bai J, Wang H, Ge Y, Xiong H, Shi J, Lu W, Lv Z, Liang C. Common Polymorphisms in the NFKBIA Gene and Cancer Susceptibility: A Meta-Analysis. Med Sci Monit 2015; 21:3186-96. [PMID: 26488500 PMCID: PMC4621165 DOI: 10.12659/msm.895257] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background NFKBIA encodes the inhibitors of nuclear factor-κB (NF-κB), which regulate the translation of the genes involved in the inflammatory and immune reactions. Polymorphisms (rs2233406, rs3138053, and rs696) of NFKBIA have been implicated in susceptibility to many cancer types. Material/Methods To evaluate the association between polymorphisms of NFKBIA and cancer susceptibility, a meta-analysis including a total of 7182 cancer cases and 10 057 controls from 28 case-control studies was performed. Data were extracted and pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Results Combined data demonstrated that rs3138053 polymorphism of NFKBIA was associated with cancer susceptibility in an allelic model (C vs. T: OR=10.754, 95%CI=4.175–27.697, Pheterogeneity=0.000), while the polymorphism of rs696 appeared to play a protective role in tumorigenesis (CC+CT vs. TT: OR=0.879, 95%CI=0.787–0.982, Pheterogeneity=0.107). When stratification analysis was performed by cancer type, an increased association of rs3138053 was recognized in hepatocarcinoma (C vs. T: OR=42.180, 95%CI=27.970–63.612, Pheterogeneity=0.007), while a decreased association of rs696 was identified in Hodgkin lymphoma (C vs. T: OR=0.792, 95%CI=0.656–0.956, Pheterogeneity=0.116; CC vs. TT: OR=0.658, 95%CI=0.448–0.965, Pheterogeneity=0.076; CC vs. CT+TT: OR=0.734, 95%CI=0.562–0.958, Pheterogeneity=0.347). By ethnicity, rs696 appears to be a protective candidate among Caucasians (CT vs. TT: OR=0.809, 95%CI=0.676–0.969, Pheterogeneity=0.459). Conclusions Our data demonstrated that the rs3138053 polymorphism of NFKBIA gene is a candidate for susceptibility to overall cancers, while rs696 plays a protective role.
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Affiliation(s)
- Meng Zhang
- Department of Urology, Shenzhen Second People's Hospital, Clinical Medicine College of Anhui Medical University, Shenzhen, Anhui, China (mainland)
| | - Junjie Huang
- Department of Medicine, Shenzhen University, Shenzhen, Anhui, China (mainland)
| | - Xiuxiu Tan
- Department of Urology, Shenzhen Second People's Hospital, Clinical Medicine College of Anhui Medical University, Shenzhen, Anhui, China (mainland)
| | - Jian Bai
- Department of Urology, Shenzhen Second People's Hospital, Clinical Medicine College of Anhui Medical University, Shenzhen, Anhui, China (mainland)
| | - Hao Wang
- Department of Urology, Shenzhen Second People's Hospital, Clinical Medicine College of Anhui Medical University, Shenzhen, Anhui, China (mainland)
| | - Yukun Ge
- Department of Urology, Shenzhen Second People's Hospital, Clinical Medicine College of Anhui Medical University, Shenzhen, Anhui, China (mainland)
| | - Hu Xiong
- Department of Urology, Shenzhen Second People's Hospital, Clinical Medicine College of Anhui Medical University, Shenzhen, Anhui, China (mainland)
| | - Jizhou Shi
- Department of Medicine, Shengli Oilfield Central Hospital, Dongying, Shandong, China (mainland)
| | - Wei Lu
- Department of Urology, Shenzhen Second People's Hospital, Clinical Medicine College of Anhui Medical University, Shenzhen, Anhui, China (mainland)
| | - Zhaojie Lv
- Department of Urology, Shenzhen Second People's Hospital, Clinical Medicine College of Anhui Medical University, Shenzhen, Anhui, China (mainland)
| | - Chaozhao Liang
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China (mainland)
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Hardikar S, Johnson LG, Malkki M, Petersdorf EW, Galloway DA, Schwartz SM, Madeleine MM. A population-based case-control study of genetic variation in cytokine genes associated with risk of cervical and vulvar cancers. Gynecol Oncol 2015; 139:90-6. [PMID: 26241630 PMCID: PMC4587291 DOI: 10.1016/j.ygyno.2015.07.110] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Persistent infection with oncogenic human papillomavirus (HPV) is known to be the necessary cause of cervical cancer and a majority of vulvar cancers. Persistent HPV infections must evade host immune responses, including cytokines released by activated T-helper (Th) cells. In this study, we investigated the risk of cervical and vulvar cancers associated with common genetic variations in 560 tagging single-nucleotide polymorphisms (SNPs) in candidate cytokine genes. METHODS The study included 399 invasive squamous cell carcinomas (SCCs) and 502 in situ or invasive adenocarcinomas (AC) of the cervix; 357 in situ or invasive vulvar SCC; and 1109 controls from the Seattle-area case-control studies of HPV-related cancers. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) using a log additive model, with adjustment for multiple testing. RESULTS Statistically significant risks were observed for HPV16-containing SCC of the cervix with the variant allele rs879576 in IL17RA and rs2229094 in TNF [OR, 95% CI and multiple-testing corrected p: 1.91 (1.30-2.79), p=0.018 and 0.61 (0.45-0.83), p=0.02, respectively]. We also observed significantly increased risk of HPV-positive vulvar cancers associated with variant alleles in CSF2 (rs25882 and rs27438, 26-28% increased risk) and IL-12B (rs2569254 and rs3181225, 40-41% increased risk) genes. CONCLUSIONS We found that variation in several Th-cytokine genes is significantly associated with cervical and vulvar cancer risk. The strong association between these HPV-related cancers and common variation in cytokine genes in the Th1 and Th17 pathways may be important for development of new therapies.
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Affiliation(s)
- Sheetal Hardikar
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Lisa G Johnson
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Mari Malkki
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Effie W Petersdorf
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Denise A Galloway
- Human Biology Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Stephen M Schwartz
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Margaret M Madeleine
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA.
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Tummers B, Burg SHVD. High-risk human papillomavirus targets crossroads in immune signaling. Viruses 2015; 7:2485-506. [PMID: 26008697 PMCID: PMC4452916 DOI: 10.3390/v7052485] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 05/08/2015] [Indexed: 12/21/2022] Open
Abstract
Persistent infections with a high-risk type human papillomavirus (hrHPV) can progress to cancer. High-risk HPVs infect keratinocytes (KCs) and successfully suppress host immunity for up to two years despite the fact that KCs are well equipped to detect and initiate immune responses to invading pathogens. Viral persistence is achieved by active interference with KCs innate and adaptive immune mechanisms. To this end hrHPV utilizes proteins encoded by its viral genome, as well as exploits cellular proteins to interfere with signaling of innate and adaptive immune pathways. This results in impairment of interferon and pro-inflammatory cytokine production and subsequent immune cell attraction, as well as resistance to incoming signals from the immune system. Furthermore, hrHPV avoids the killing of infected cells by interfering with antigen presentation to antigen-specific cytotoxic T lymphocytes. Thus, hrHPV has evolved multiple mechanisms to avoid detection and clearance by both the innate and adaptive immune system, the molecular mechanisms of which will be dealt with in detail in this review.
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Affiliation(s)
- Bart Tummers
- Department of Clinical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
| | - Sjoerd H Van Der Burg
- Department of Clinical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
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Differential expression of TLR3 and TLR4 in keratocystic odontogenic tumor (KCOT): A comparative immunohistochemical study in primary, recurrent, and nevoid basal cell carcinoma syndrome (NBCCS)--associated lesions. J Craniomaxillofac Surg 2015; 43:733-7. [PMID: 25976039 DOI: 10.1016/j.jcms.2015.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 02/03/2015] [Accepted: 03/18/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Toll-like receptors (TLRs) play an essential role in the activation of innate immunity and they can promote cancer cell survival and tumor progression. It has been claimed that TLRs can somehow predict the clinical behavior in oral squamous cell carcinoma (OSCCs). AIM To elucidate the molecular basis underlying keratocystic odontogenic tumor (KOCTs) aggressive behavior and recurrence we carried out this immunohistochemical study on TLR3 and TLR4 expression in sporadic primary KCOTs (sp-KCOTs), sporadic recurrent KCOTs (sp-KCOTs), and NBCCS-associated KCOTs (NBCCS-KCOTs). METHOD 40 cases of KOCTs removed from 23 men and 17 women were the sample. Paraffin-embedded blocks were processed for immunohistochemistry. Sections were incubated with TLR3 and TLR4 antibodies and immunoreactivity evaluated on a semi-quantitative score. RESULTS Both TLR3 and TLR4 were expressed in KCOTs epithelium, although with a different extent. TLR3 was not expressed in sp-KCOTs and sr-KCOTs, but it showed a faint staining in NBCCS-KCOTs. On the other hand, both cytoplasmic and nuclear staining for TLR4 was detected in all the 3 types of lesions; however being significantly more expressed in sr-KCOT and NBCCS-KCOTs (p < 0.0001). Our results, demonstrated an association between TLR4, but not TLR3 expression to recurrence behavior of KCOTs. In fact, TLR4 was up-regulated in sr-KCOTs and NBCCS-KCOTs but not in sp-KCOTs. CONCLUSIONS According these findings it seems conceivable to assume that the up-regulation of TLR4 in some KCOTs can be correlated somehow to their tendency recurrence.
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Husseinzadeh N, Davenport SM. Role of Toll-like receptors in cervical, endometrial and ovarian cancers: A review. Gynecol Oncol 2014; 135:359-63. [DOI: 10.1016/j.ygyno.2014.08.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 08/06/2014] [Accepted: 08/09/2014] [Indexed: 12/30/2022]
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Cannella F, Pierangeli A, Scagnolari C, Cacciotti G, Tranquilli G, Stentella P, Recine N, Antonelli G. TLR9 is expressed in human papillomavirus-positive cervical cells and is overexpressed in persistent infections. Immunobiology 2014; 220:363-8. [PMID: 25454809 DOI: 10.1016/j.imbio.2014.10.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 09/19/2014] [Accepted: 10/12/2014] [Indexed: 01/16/2023]
Abstract
Control of human papillomavirus (HPV) infection involves the activation of Toll-like receptors (TLRs), key components of the mucosal antiviral response. Available studies on TLR expression in HPV-positive cervical cells are limited and reported conflicting results. This study quantified TLR 2, 3, 4, 7 and 9 transcripts in low-risk (LR) and high-risk (HR) HPV-positive and HPV-negative cervical samples from 154 women attending a gynaecological clinic. Expression levels of TLR 2, 3, 4 and 7 did not differ among samples, whereas TLR9 levels were quite significantly higher in LR and marginally significant in HR HPV-positive samples, with respect to the HPV-negative samples. Interestingly, in a subgroup of women with documented previous HPV-infection, TLR9 levels were extremely higher in patients persistently positive to the same HPV genotype for more than 1 year, with respect to women who cleared HPV infection and to those re-infected with a different genotype. These findings implicate TLR9 in the response to LR and HR HPVs, including HPV 16 known to interfere with TLR9 transcription in cell lines. Elevated TLR9 levels without HPV clearance in persistently infected women could drive inflammation thereby contributing to cervical cancer risk.
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Affiliation(s)
- Fabiana Cannella
- Virology Laboratory, Department of Molecular Medicine, Sapienza University, Viale di Porta Tiburtina 28, 00185 Rome, Italy
| | - Alessandra Pierangeli
- Virology Laboratory, Department of Molecular Medicine, Sapienza University, Viale di Porta Tiburtina 28, 00185 Rome, Italy.
| | - Carolina Scagnolari
- Virology Laboratory, Department of Molecular Medicine, Sapienza University, Viale di Porta Tiburtina 28, 00185 Rome, Italy
| | - Giulia Cacciotti
- Virology Laboratory, Department of Molecular Medicine, Sapienza University, Viale di Porta Tiburtina 28, 00185 Rome, Italy
| | - Giulia Tranquilli
- Virology Laboratory, Department of Molecular Medicine, Sapienza University, Viale di Porta Tiburtina 28, 00185 Rome, Italy
| | - Patrizia Stentella
- Department of Obstetric and Gynaecological Sciences and Urologic Sciences, Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy
| | - Nadia Recine
- Department of Obstetric and Gynaecological Sciences and Urologic Sciences, Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy
| | - Guido Antonelli
- Virology Laboratory, Department of Molecular Medicine, Sapienza University, Viale di Porta Tiburtina 28, 00185 Rome, Italy
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Levovitz C, Chen D, Ivansson E, Gyllensten U, Finnigan JP, Alshawish S, Zhang W, Schadt EE, Posner MR, Genden EM, Boffetta P, Sikora AG. TGFβ receptor 1: an immune susceptibility gene in HPV-associated cancer. Cancer Res 2014; 74:6833-44. [PMID: 25273091 DOI: 10.1158/0008-5472.can-14-0602-t] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Only a minority of those exposed to human papillomavirus (HPV) develop HPV-related cervical and oropharyngeal cancer. Because host immunity affects infection and progression to cancer, we tested the hypothesis that genetic variation in immune-related genes is a determinant of susceptibility to oropharyngeal cancer and other HPV-associated cancers by performing a multitier integrative computational analysis with oropharyngeal cancer data from a head and neck cancer genome-wide association study (GWAS). Independent analyses, including single-gene, gene-interconnectivity, protein-protein interaction, gene expression, and pathway analysis, identified immune genes and pathways significantly associated with oropharyngeal cancer. TGFβR1, which intersected all tiers of analysis and thus selected for validation, replicated significantly in the head and neck cancer GWAS limited to HPV-seropositive cases and an independent cervical cancer GWAS. The TGFβR1 containing p38-MAPK pathway was significantly associated with oropharyngeal cancer and cervical cancer, and TGFβR1 was overexpressed in oropharyngeal cancer, cervical cancer, and HPV(+) head and neck cancer tumors. These concordant analyses implicate TGFβR1 signaling as a process dysregulated across HPV-related cancers. This study demonstrates that genetic variation in immune-related genes is associated with susceptibility to oropharyngeal cancer and implicates TGFβR1/TGFβ signaling in the development of both oropharyngeal cancer and cervical cancer. Better understanding of the immunogenetic basis of susceptibility to HPV-associated cancers may provide insight into host/virus interactions and immune processes dysregulated in the minority of HPV-exposed individuals who progress to cancer.
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Affiliation(s)
- Chaya Levovitz
- The Icahn School of Medicine at Mount Sinai, New York, New York. Department of Immunology, Icahn School of Medicine at Mount Sinai, New York, New York. Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dan Chen
- SciLifeLab Uppsala, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - Emma Ivansson
- SciLifeLab Uppsala, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - Ulf Gyllensten
- SciLifeLab Uppsala, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - John P Finnigan
- The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sara Alshawish
- The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Weijia Zhang
- Mount Sinai Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Eric E Schadt
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, New York. Mount Sinai Institute for Genomics and Multiscale Biology, New York, New York
| | - Marshal R Posner
- The Icahn School of Medicine at Mount Sinai, New York, New York. Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Eric M Genden
- The Icahn School of Medicine at Mount Sinai, New York, New York. Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York. Department of Immunology, Genetics and Pathology, Tisch Cancer Institute, New York, New York
| | - Paolo Boffetta
- The Icahn School of Medicine at Mount Sinai, New York, New York. Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York. Department of Immunology, Genetics and Pathology, Tisch Cancer Institute, New York, New York
| | - Andrew G Sikora
- The Icahn School of Medicine at Mount Sinai, New York, New York. Department of Immunology, Icahn School of Medicine at Mount Sinai, New York, New York. Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, New York. Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York. Department of Immunology, Genetics and Pathology, Tisch Cancer Institute, New York, New York.
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McWhirter RE, Marthick JR, Boyle JA, Dickinson JL. Genetic and epigenetic variation in vulvar cancer: Current research and future clinical practice. Aust N Z J Obstet Gynaecol 2014; 54:406-11. [DOI: 10.1111/ajo.12241] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 06/22/2014] [Indexed: 12/25/2022]
Affiliation(s)
- Rebekah E. McWhirter
- Menzies Research Institute Tasmania; University of Tasmania; Hobart Tasmania Australia
- Menzies School of Health Research; Charles Darwin University; Darwin Northern Territory Australia
| | - James R. Marthick
- Menzies Research Institute Tasmania; University of Tasmania; Hobart Tasmania Australia
| | - Jacqueline A. Boyle
- Monash Centre for Health Research and Implementation; School of Public Health and Preventive Medicine; Monash University; Clayton Victoria Australia
| | - Joanne L. Dickinson
- Menzies Research Institute Tasmania; University of Tasmania; Hobart Tasmania Australia
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Runs of homozygosity and a cluster of vulvar cancer in young Australian Aboriginal women. Gynecol Oncol 2014; 133:421-6. [PMID: 24690477 DOI: 10.1016/j.ygyno.2014.03.566] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 03/20/2014] [Accepted: 03/23/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE A cluster of vulvar cancer exists in young Aboriginal women living in remote communities in Arnhem Land, Australia. A genetic case-control study was undertaken involving 30 cases of invasive vulvar cancer and its precursor lesion, high-grade vulvar intraepithelial neoplasia (VIN), and 61 controls, matched for age and community of residence. It was hypothesized that this small, isolated population may exhibit increased autozygosity, implicating recessive effects as a possible mechanism for increased susceptibility to vulvar cancer. METHODS Genotyping data from saliva samples were used to identify runs of homozygosity (ROH) in order to calculate estimates of genome-wide homozygosity. RESULTS No evidence of an effect of genome-wide homozygosity on vulvar cancer and VIN in East Arnhem women was found, nor was any individual ROH found to be significantly associated with case status. This study found further evidence supporting an association between previous diagnosis of CIN and diagnosis of vulvar cancer or VIN, but found no association with any other medical history variable. CONCLUSIONS These findings do not eliminate the possibility of genetic risk factors being involved in this cancer cluster, but rather suggest that alternative analytical strategies and genetic models should be explored.
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