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Dovnik A, Poljak M. The Role of Methylation of Host and/or Human Papillomavirus (HPV) DNA in Management of Cervical Intraepithelial Neoplasia Grade 2 (CIN2) Lesions. Int J Mol Sci 2023; 24:ijms24076479. [PMID: 37047452 PMCID: PMC10095339 DOI: 10.3390/ijms24076479] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023] Open
Abstract
Cervical intraepithelial neoplasia grade 2 (CIN2) is an intermediate stage between CIN 1, which is a low-grade lesion, and CIN3, which is the immediate precursor of cervical cancer (CC). Traditionally, CIN2 was regarded as a high-grade lesion and was treated with conization or ablative methods. In recent years, there has been a shift in the management of younger patients, who are now more often being managed conservatively due to frequent spontaneous CIN2 regression and possible adverse effects of treatment on future pregnancies. Because the risk of progression to CC still exists with conservative management, a personalized approach is needed to identify patients with a higher probability of progression. In this regard, research has focused on the role of host and human papillomavirus (HPV) gene methylation. This systematic review summarizes the current knowledge regarding conservative CIN2 management focusing on the main methylation markers and its implementation in conservative CIN2 management, and it describes major ongoing longitudinal studies on the subject. The review showed that DNA methylation is an accurate predictor of disease progression and a valid triage tool for HPV-positive women, with CIN2 performing better than triage cytology. Because virtually all CCs are methylation-positive, methylation-negative women at baseline have an extremely low risk of CC.
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Affiliation(s)
- Andraž Dovnik
- University Clinic for Gynecology and Obstetrics, Maribor University Medical Center, Ljubljanska 5, 2000 Maribor, Slovenia
- Correspondence: ; Tel.: +386-2-321-2178
| | - Mario Poljak
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Zaloška 4, 1000 Ljubljana, Slovenia;
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Herzog C, Vavourakis CD, Barrett JE, Karbon G, Villunger A, Wang J, Sundström K, Dillner J, Widschwendter M. HPV-induced host epigenetic reprogramming is lost upon progression to high-grade cervical intraepithelial neoplasia. Int J Cancer 2023; 152:2321-2330. [PMID: 36810770 DOI: 10.1002/ijc.34477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/11/2023] [Accepted: 02/07/2023] [Indexed: 02/23/2023]
Abstract
The impact of a pathogen on host disease can only be studied in samples covering the entire spectrum of pathogenesis. Persistent oncogenic human papilloma virus (HPV) infection is the most common cause for cervical cancer. Here, we investigate HPV-induced host epigenome-wide changes prior to development of cytological abnormalities. Using cervical sample methylation array data from disease-free women with or without an oncogenic HPV infection, we develop the WID (Women's cancer risk identification)-HPV, a signature reflective of changes in the healthy host epigenome related to high-risk HPV strains (AUC = 0.78, 95% CI: 0.72-0.85, in nondiseased women). Looking at HPV-associated changes across disease development, HPV-infected women with minor cytological alterations (cervical intraepithelial neoplasia grade 1/2, CIN1/2), but surprisingly not those with precancerous changes or invasive cervical cancer (CIN3+), show an increased WID-HPV index, indicating the WID-HPV may reflect a successful viral clearance response absent in progression to cancer. Further investigation revealed the WID-HPV is positively associated with apoptosis (ρ = 0.48; P < .001) and negatively associated with epigenetic replicative age (ρ = -0.43; P < .001). Taken together, our data suggest the WID-HPV captures a clearance response associated with apoptosis of HPV-infected cells. This response may be dampened or lost with increased underlying replicative age of infected cells, resulting in progression to cancer.
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Affiliation(s)
- Chiara Herzog
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Hall in Tirol, Tirol, Austria.,Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Tirol, Austria
| | - Charlotte D Vavourakis
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Hall in Tirol, Tirol, Austria.,Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Tirol, Austria
| | - James E Barrett
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Hall in Tirol, Tirol, Austria.,Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Tirol, Austria
| | - Gerlinde Karbon
- Institute for Developmental Immunology, Biocenter, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Villunger
- Institute for Developmental Immunology, Biocenter, Medical University of Innsbruck, Innsbruck, Austria
| | - Jiangrong Wang
- Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Karin Sundström
- Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Stockholm, Sweden.,Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Joakim Dillner
- Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Widschwendter
- European Translational Oncology Prevention and Screening (EUTOPS) Institute, Universität Innsbruck, Hall in Tirol, Tirol, Austria.,Institute for Biomedical Aging Research, Universität Innsbruck, Innsbruck, Tirol, Austria.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Women's Cancer, UCL EGA Institute for Women's Health, University College London, London, UK
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Tu J, Chen S, Wu S, Wu T, Fan R, Kuang Z. Tumor DNA Methylation Profiles Enable Diagnosis, Prognosis Prediction, and Screening for Cervical Cancer. Int J Gen Med 2022; 15:5809-5821. [PMID: 35789774 PMCID: PMC9249661 DOI: 10.2147/ijgm.s352373] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
Background DNA-methylation-based machine learning algorithms have demonstrated powerful diagnostic capabilities, and these tools are currently emerging in many fields of tumor diagnosis and patient prognosis prediction. This work aimed to identify novel DNA methylation diagnostic biomarkers for differentiating cervical cancer (CC) from normal tissues, as well as a prognostic prediction model to predict survival of CC patients. Methods The methylation profiles with the available clinical characteristics were downloaded from the Gene Expression Omnibus (GEO) database and The Cancer Genome Atlas (TCGA) program. We first screened out the differential methylation sites in CC and normal tissues and performed multiple statistical analyses to discover DNA methylation diagnostic markers that are used to distinguish CC and normal control. Then, we developed a methylation-based survival model to improve risk stratification. Results A diagnostic prediction panel consists of five CpG markers that could predict cervical cancer versus normal tissue with highly correct rate of 100%, and cg16428251, cg22341310, and cg23316360 which in diagnostic prediction panel all could yield high sensitivity and specificity for detection of CC and normal in six cohorts (area under curve [AUC] > 0.8), in addition to excellent performance in discriminating between CC and normal sample. The diagnostic marker panel also effectively predicted the CIN3 versus normal tissue with high accuracy in two datasets (AUC = 0.80, 0.789, respectively). Furthermore, a prognostic prediction model aggregated two CpG markers that effectively stratified the prognosis of high-risk and low-risk groups (training cohort: hazard ratio [HR] 4, 95% CI: 1.7–9.6, P = 0.0021; testing cohort: hazard ratio [HR] 1.9, 95% CI: 1.2–3.1, P = 0.0072). Conclusion The findings of our study showed that DNA methylation markers are of great value in the diagnosis and prognosis of CC.
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Affiliation(s)
- Jiannan Tu
- Department of Oncology, Nanping First Hospital Affiliated to Fujian Medical University, Nanping, 353000, People’s Republic of China
| | - Shengchi Chen
- Department of Oncology, Nanping First Hospital Affiliated to Fujian Medical University, Nanping, 353000, People’s Republic of China
| | - Shizhen Wu
- Department of Oncology, Nanping First Hospital Affiliated to Fujian Medical University, Nanping, 353000, People’s Republic of China
| | - Ting Wu
- Department of Oncology, Nanping First Hospital Affiliated to Fujian Medical University, Nanping, 353000, People’s Republic of China
| | - Renliang Fan
- Department of Oncology, Nanping First Hospital Affiliated to Fujian Medical University, Nanping, 353000, People’s Republic of China
| | - Zhixing Kuang
- Department of Radiation Oncology, Nanping First Hospital Affiliated to Fujian Medical University, Nanping, 353000, People’s Republic of China
- Correspondence: Zhixing Kuang, Department of Radiation Oncology, Nanping First Hospital Affiliated to Fujian Medical University, Nanping, 353000, People’s Republic of China, Email
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Rubio-Ramos A, Labat-de-Hoz L, Correas I, Alonso MA. The MAL Protein, an Integral Component of Specialized Membranes, in Normal Cells and Cancer. Cells 2021; 10:1065. [PMID: 33946345 PMCID: PMC8145151 DOI: 10.3390/cells10051065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022] Open
Abstract
The MAL gene encodes a 17-kDa protein containing four putative transmembrane segments whose expression is restricted to human T cells, polarized epithelial cells and myelin-forming cells. The MAL protein has two unusual biochemical features. First, it has lipid-like properties that qualify it as a member of the group of proteolipid proteins. Second, it partitions selectively into detergent-insoluble membranes, which are known to be enriched in condensed cell membranes, consistent with MAL being distributed in highly ordered membranes in the cell. Since its original description more than thirty years ago, a large body of evidence has accumulated supporting a role of MAL in specialized membranes in all the cell types in which it is expressed. Here, we review the structure, expression and biochemical characteristics of MAL, and discuss the association of MAL with raft membranes and the function of MAL in polarized epithelial cells, T lymphocytes, and myelin-forming cells. The evidence that MAL is a putative receptor of the epsilon toxin of Clostridium perfringens, the expression of MAL in lymphomas, the hypermethylation of the MAL gene and subsequent loss of MAL expression in carcinomas are also presented. We propose a model of MAL as the organizer of specialized condensed membranes to make them functional, discuss the role of MAL as a tumor suppressor in carcinomas, consider its potential use as a cancer biomarker, and summarize the directions for future research.
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Affiliation(s)
- Armando Rubio-Ramos
- Centro de Biología Molecular “Severo Ochoa”, Consejo Superior de Investigaciones Científicas and Universidad Autónoma de Madrid, 28049 Madrid, Spain; (A.R.-R.); (L.L.-d.-H.); (I.C.)
| | - Leticia Labat-de-Hoz
- Centro de Biología Molecular “Severo Ochoa”, Consejo Superior de Investigaciones Científicas and Universidad Autónoma de Madrid, 28049 Madrid, Spain; (A.R.-R.); (L.L.-d.-H.); (I.C.)
| | - Isabel Correas
- Centro de Biología Molecular “Severo Ochoa”, Consejo Superior de Investigaciones Científicas and Universidad Autónoma de Madrid, 28049 Madrid, Spain; (A.R.-R.); (L.L.-d.-H.); (I.C.)
- Department of Molecular Biology, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | - Miguel A. Alonso
- Centro de Biología Molecular “Severo Ochoa”, Consejo Superior de Investigaciones Científicas and Universidad Autónoma de Madrid, 28049 Madrid, Spain; (A.R.-R.); (L.L.-d.-H.); (I.C.)
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Mendaza S, Fernández-Irigoyen J, Santamaría E, Arozarena I, Guerrero-Setas D, Zudaire T, Guarch R, Vidal A, Salas JS, Matias-Guiu X, Ausín K, Gil C, Hernández-Alcoceba R, Martín-Sánchez E. Understanding the Molecular Mechanism of miR-877-3p Could Provide Potential Biomarkers and Therapeutic Targets in Squamous Cell Carcinoma of the Cervix. Cancers (Basel) 2021; 13:cancers13071739. [PMID: 33917510 PMCID: PMC8038805 DOI: 10.3390/cancers13071739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/31/2021] [Indexed: 12/12/2022] Open
Abstract
No therapeutic targets and molecular biomarkers are available in cervical cancer (CC) management. In other cancer types, micro-RNA-877-3p (miR-877-3p) has been associated with events relevant for CC development. Thus, we aimed to determine miR-877-3p role in CC. miR-877-3p levels were examined by quantitative-PCR in 117 cervical lesions and tumors. Effects on CC cell proliferation, migration, and invasion were evaluated upon anti-miR-877-3p transfection. miR-877-3p dependent molecular mechanism was comprehensively explored by proteomics, dual-luciferase reporter assay, western blot, and immunohistochemistry. Cervical tumors expressed higher miR-877-3p levels than benign lesions. miR-877-3p promoted CC cell migration and invasion, at least partly by modulating cytoskeletal protein folding through the chaperonin-containing T-complex protein 1 complex. Notably, miR-877-3p silencing synergized with paclitaxel. Interestingly, miR-877-3p downregulated the levels of an in silico-predicted target, ZNF177, whose expression and subcellular location significantly distinguished high-grade squamous intraepithelial lesions (HSILs) and squamous cell carcinomas of the cervix (SCCCs). Cytoplasmic ZNF177 was significantly associated with worse progression-free survival in SCCC. Our results suggest that: (i) miR-877-3p is a potential therapeutic target whose inhibition improves paclitaxel effects; (ii) the expression and location of its target ZNF177 could be diagnostic biomarkers between HSIL and SCCC; and (iii) cytoplasmic ZNF177 is a poor-prognosis biomarker in SCCC.
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Affiliation(s)
- Saioa Mendaza
- Molecular Pathology of Cancer Group, Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008 Pamplona, Spain; (S.M.); (D.G.-S.)
| | - Joaquín Fernández-Irigoyen
- Proteored-ISCIII, Proteomics Unit, Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008 Pamplona, Spain; (J.F.-I.); (E.S.); (K.A.)
| | - Enrique Santamaría
- Proteored-ISCIII, Proteomics Unit, Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008 Pamplona, Spain; (J.F.-I.); (E.S.); (K.A.)
| | - Imanol Arozarena
- Cancer Cell Signalling Group, Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008 Pamplona, Spain;
| | - David Guerrero-Setas
- Molecular Pathology of Cancer Group, Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008 Pamplona, Spain; (S.M.); (D.G.-S.)
- Department of Pathology, Complejo Hospitalario de Navarra (CHN), Irunlarrea 3, 31008 Pamplona, Spain; (T.Z.); (R.G.)
| | - Tamara Zudaire
- Department of Pathology, Complejo Hospitalario de Navarra (CHN), Irunlarrea 3, 31008 Pamplona, Spain; (T.Z.); (R.G.)
| | - Rosa Guarch
- Department of Pathology, Complejo Hospitalario de Navarra (CHN), Irunlarrea 3, 31008 Pamplona, Spain; (T.Z.); (R.G.)
| | - August Vidal
- Department of Pathology, Hospital Universitari de Bellvitge, IDIBELL, Carrer de la Feixa Llarga, 08907 L’Hospitalet de Llobregat, Spain; (A.V.); (X.M.-G.)
- CIBERONC, Centro de Investigación Biomédica en Red—Cáncer, 28029 Madrid, Spain
| | - José-Santos Salas
- Department of Pathology, Complejo Asistencial Universitario, Altos de Nava, 24071 León, Spain;
| | - Xavier Matias-Guiu
- Department of Pathology, Hospital Universitari de Bellvitge, IDIBELL, Carrer de la Feixa Llarga, 08907 L’Hospitalet de Llobregat, Spain; (A.V.); (X.M.-G.)
- CIBERONC, Centro de Investigación Biomédica en Red—Cáncer, 28029 Madrid, Spain
- Department of Pathology and Molecular Genetics, Hospital Universitari Arnau de Vilanova, University of Lleida, Alcalde Rovira Roure 80, 25198 Lleida, Spain
| | - Karina Ausín
- Proteored-ISCIII, Proteomics Unit, Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008 Pamplona, Spain; (J.F.-I.); (E.S.); (K.A.)
| | - Carmen Gil
- Microbial Pathogenesis Group, Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008 Pamplona, Spain;
| | - Rubén Hernández-Alcoceba
- Gene Therapy Program, Center for Applied Medical Research (CIMA), University of Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pío XII 55, 31008 Pamplona, Spain;
| | - Esperanza Martín-Sánchez
- Molecular Pathology of Cancer Group, Navarrabiomed, Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008 Pamplona, Spain; (S.M.); (D.G.-S.)
- Correspondence:
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Sawada Y, Mashima E, Saito-Sasaki N, Nakamura M. The Role of Cell Adhesion Molecule 1 (CADM1) in Cutaneous Malignancies. Int J Mol Sci 2020; 21:E9732. [PMID: 33419290 PMCID: PMC7766610 DOI: 10.3390/ijms21249732] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 12/22/2022] Open
Abstract
Cell adhesion ability is one of the components to establish cell organization and shows a great contribution to human body construction consisting of various types of cells mixture to orchestrate tissue specific function. The cell adhesion molecule 1 (CADM1) is a molecule of cell adhesion with multiple functions and has been identified as a tumor suppressor gene. CADM1 has multifunctions on the pathogenesis of malignancies, and other normal cells such as immune cells. However, little is known about the function of CADM1 on cutaneous cells and cutaneous malignancies. CADM1 plays an important role in connecting cells with each other, contacting cells to deliver their signal, and acting as a scaffolding molecule for other immune cells to develop their immune responses. A limited number of studies reveal the contribution of CADM1 on the development of cutaneous malignancies. Solid cutaneous malignancies, such as cutaneous squamous cell carcinoma and malignant melanoma, reduce their CADM1 expression to promote the invasion and metastasis of the tumor. On the contrary to these cutaneous solid tumors except for Merkel cell carcinoma, cutaneous lymphomas, such as adult-T cell leukemia/lymphoma, mycosis fungoides, and Sézary syndrome, increase their CADM1 expression for the development of tumor environment. Based on the role of CADM1 in the etiology of tumor development, the theory of CADM1 contribution will desirably be applied to skin tumors according to other organ malignancies, however, the characteristics of skin as a multicomponent peripheral organ should be kept in mind to conclude their prognoses.
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Affiliation(s)
- Yu Sawada
- Department of Dermatology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan; (E.M.); (N.S.-S.); (M.N.)
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Elsayed FM, Nafea DA, El-Attar LM, Saied MH. Epigenetic silencing of the DAPK1 gene in Egyptian patients with chronic myeloid Leukemia. Meta Gene 2020. [DOI: 10.1016/j.mgene.2020.100779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Franciosi JR, Gelmini GF, Roxo VS, de Carvalho NS, Bicalho MDG. Is there a role played by HLA-E, if any, in HPV immune evasion? Scand J Immunol 2020; 91:e12850. [PMID: 31733115 DOI: 10.1111/sji.12850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 10/19/2019] [Accepted: 11/12/2019] [Indexed: 12/14/2022]
Abstract
Cervical cancer incidence worldwide exceeds half a million new cases per year. The human papillomavirus (HPV) being the major causative agent of CC uses a variety of strategies to evade immune surveillance, where the immune status varies amongst individuals. This immune evasion altered by HPV is reflected in persistent infections, causing the evolution of cervical neoplasia. The role of the immune system in viral recognition and elimination is of extreme relevance in the development of CC. The interactions of the HLA-E ligand in the target cell along with CD94/NKG2 receptors, which are expressed predominantly, but not exclusively, on NK cells' surface, are responsible for activating or inhibiting cytotoxic activity according to their function. The engagement between HLA-E and CD94/NKG2 molecules is one of the fundamental surveillance mechanisms in patients with CIN I, II and III, where HLA-E expression increases significantly, especially in HPV 16 and 18 infections. Higher HLA-E expression was observed in most histopathological types of CC, and at the same time was correlated to best survival of the patient. This review aims to summarize and discuss the immunological role of HLA-E in the context of HPV infection and immune system evasion, and the oncogenic process of cervical cancer.
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Affiliation(s)
- Jackline Rachel Franciosi
- Departamento de Tocoginecologia, Hospital de Clínicas, Universidade Federal do Parana (UFPR), Curitiba, Brazil
| | - Georgia Fernanda Gelmini
- Laboratório de Imunogenética e Histocompatibilidade, Departamento de Genética, Universidade Federal do Paraná (UFPR), Curitiba, Brazil
| | - Valeria Sperandio Roxo
- Laboratório de Imunogenética e Histocompatibilidade, Departamento de Genética, Universidade Federal do Paraná (UFPR), Curitiba, Brazil
| | - Newton Sergio de Carvalho
- Departamento de Tocoginecologia, Hospital de Clínicas, Universidade Federal do Parana (UFPR), Curitiba, Brazil
| | - Maria da Graça Bicalho
- Departamento de Tocoginecologia, Hospital de Clínicas, Universidade Federal do Parana (UFPR), Curitiba, Brazil
- Laboratório de Imunogenética e Histocompatibilidade, Departamento de Genética, Universidade Federal do Paraná (UFPR), Curitiba, Brazil
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