p16INK4a overexpression as a predictor of survival in ocular surface squamous neoplasia

High-risk human papillomavirus-associated corneal/conjunctival intraepithelial neoplasia in a young patient

Purpose

To report a case of high-risk human papillomavirus (HPV)-associated corneal/conjunctival intraepithelial neoplasia (CIN) in a 17-year-old fair-skinned male with no other risk factors.

Observations

A 17-year-old Caucasian male presented with an 18-month history of left eye pain, redness, itchiness, and decreased vision. Examination revealed a leukoplakic nasal limbal/peripheral corneal lesion resistant to topical antibiotic and anti-inflammatory treatments. Excisional biopsy confirmed the diagnosis of CIN, and RNA in situ hybridization testing for high-risk HPV types 16/18 was positive. Subsequent testing of the patient for human immunodeficiency virus (HIV) returned negative.

Conclusions and Importance

The median age of CIN diagnosis in the United States is in the sixth decade of life and is usually associated with a history of ultraviolet (UV) light exposure. There are reports of CIN in young patients with systemic immunodeficiency, immunosuppression, xeroderma pigmentosum, atopic dermatitis, asthma, and vaping. Here we present a case of high-risk HPV-associated CIN in a young, fair-skinned patient with no other identifiable risk factors.

Promotor methylation in ocular surface squamous neoplasia development: epigenetics implications in molecular diagnosis

INTRODUCTION

Cancer is heavily influenced by epigenetic mechanisms that include DNA methylation, histone modifications, and non-coding RNA. A considerable proportion of human malignancies are believed to be associated with global DNA hypomethylation, with localized hypermethylation at promoters of certain genes.

AREA COVERED

The present review aims to emphasize on recent investigations on the epigenetic landscape of ocular surface squamous neoplasia, that could be targeted/explored using novel approaches such as personalized medicine.

EXPERT OPINION

While the former is thought to contribute to genomic instability, promoter-specific hypermethylation might facilitate tumorigenesis by silencing tumor suppressor genes. Ocular surface squamous neoplasia, the most prevalent type of ocular surface malignancy, is suggested to be affected by epigenetic mechanisms, as well. Although the exact role of epigenetics in ocular surface squamous neoplasia has mostly been unexplored, recent findings have greatly contributed to our understanding regarding this pathology of the eye.

Genetic predisposition to ocular surface disorders and opportunities for gene-based therapies

The ocular surface, comprised of the corneal and conjunctival epithelium, innervation system, immune components, and tear-film apparatus, plays a key role in ocular integrity as well as comfort and vision. Gene defects may result in congenital ocular or systemic disorders with prominent ocular surface involvement. Examples include epithelial corneal dystrophies, aniridia, ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome, xeroderma pigmentosum (XP), and hereditary sensory and autonomic neuropathy. In addition, genetic factors may interact with environmental risk factors in the development of several multifactorial ocular surface disorders (OSDs) such as autoimmune disorders, allergies, neoplasms, and dry eye disease. Advanced gene-based technologies have already been introduced in disease modelling and proof-of-concept gene therapies for monogenic OSDs. For instance, patient-derived induced pluripotent stem cells have been used for modelling aniridia-associated keratopathy (AAK), XP, and EEC syndrome. Moreover, CRISPR/Cas9 genome editing has been used for disease modelling and/or gene therapy for AAK and Meesmann's epithelial corneal dystrophy. A better understanding of the role of genetic factors in OSDs may be helpful in designing personalized disease models and treatment approaches. Gene-based approaches in monogenic OSDs and genetic predisposition to multifactorial OSDs such as immune-mediated disorders and neoplasms with known or possible genetic risk factors has been seldom reviewed. In this narrative review, we discuss the role of genetic factors in monogenic and multifactorial OSDs and potential opportunities for gene therapy.

Human papillomavirus-related neoplasia of the ocular adnexa

Human papillomaviruses (HPV) are involved in approximately 5% of solid cancers worldwide. The mucosotropic genotypes infect the stratified epithelium of various locations, where persistent infection may lead to invasive carcinomas. While the causative role of HPV in certain anogenital and head and neck carcinomas is well established, the role of HPV in carcinomas arising in the mucosal membranes of the ocular adnexal tissue (the lacrimal drainage system and the conjunctiva) has been a topic of great uncertainty. Therefore, we conducted a series of studies to assess the correlation between HPV and carcinomas arising in the mucosa of the ocular adnexal tissue and characterize the clinical, histopathological, and genomic features of the tumors in the context of HPV status in a Danish nationwide cohort. We collected clinical and histopathological data and tumor specimens from patients with carcinomas of the conjunctiva and the lacrimal drainage system, and their potential precursors, identified in Danish nationwide registries. The HPV status of the tumors was determined by the combined use of HPV DNA polymerase chain reaction (PCR), HPV E6/E7 mRNA in-situ hybridization, and p16 immunohistochemistry. The genomic profile was investigated by high-throughput DNA sequencing targeting 523 cancer-relevant genes. The literature to date on carcinomas of the lacrimal drainage system and the conjunctiva was summarized. In the Danish cohort, 67% of all carcinomas of the lacrimal drainage system and 21% of all conjunctival carcinomas were HPV-positive. HPV16 was the most frequently implicated genotype. A full-thickness expression of the viral oncogenes E6 and E7 was evident in almost all HPV DNA-positive cases. The HPV-positive carcinomas of the conjunctiva and the lacrimal drainage system shared histopathological and genomic features distinct from their HPV-negative counterparts. The HPV-positive carcinomas were characterized by a non-keratinizing morphology, p16 overexpression, high transcriptional activity of HPV E6/E7, and frequent pathogenic variants in the PI3K-AKT signaling cascade. In contrast, the HPV-negative carcinomas were characterized by a keratinizing morphology, lack of p16 and E6/E7 expression, and frequent somatic pathogenic variants in TP53, CDKN2A, and RB1. Among the patients with conjunctival tumors, HPV positivity was associated with a younger age at diagnosis and a higher risk of recurrence. In conclusion, the results support an etiological role of HPV in a subset of conjunctival and LDS carcinomas and their precursor lesions. Our investigations have shown that the HPV-positive carcinomas of the ocular adnexa share genomic and phenotypic characteristics with HPV-positive carcinomas of other anatomical locations. Therefore, these patients may be eligible for inclusion in future basket trials and future treatment regimens tailored to the more frequently occurring HPV-positive carcinomas of other locations. Future research will further elucidate the diagnostic, prognostic, and predictive role of HPV in these carcinomas.

Clinical Significance of Cyclin Expression Profiling in Ocular Surface Squamous Neoplasia

Ocular surface squamous neoplasia (OSSN) can recur, metastasize, and even cause death. Cyclins regulate the cell cycle progression at different phases and its dysregulation is associated with uncontrollable cell growth and malignant transformation of the cell. Overexpression of cyclin has been reported in various malignancies and is associated with poor prognosis. However, the role of cyclins in OSSN remains unexplored. This study has been designed to assess the prognostic significance of cyclin (cyclin B1, E1, and D1) immunoexpression in 100 OSSN patients. The targeted proteins demonstrated overexpression of cyclin B1, cyclin E1, and cyclin D1 in 55%, 37%, and 56% OSSN cases prospectively. A gradual and significant increase in the cyclin B1 (P=0.01) and cyclin D1 (P=0.005) expression was seen from Tis to the T4 category. Overexpression of cyclin B1 was associated with poor disease-free survival and worst prognosis in both early (P=0.03) as well as advanced T staged (P=0.038) OSSN patients. Overexpression of cyclin E1 was associated with worst disease-free survival (P=0.01) and poor prognosis in advanced stage OSSN patients. Our findings suggest that cyclin B1 and cyclin E1 have prognostic relevance in OSSN patients, and therefore are recommended for detecting high-risk category cases. A significant increase in the expression of cyclins from early to advanced stage indicates that cyclins play an important role in the pathogenesis of OSSN patients.

Update on the Management of Ocular Surface Squamous Neoplasia

Purpose of review

To review and update the latest findings in diagnosis and management of ocular surface squamous neoplasia (OSSN).

Recent findings

OSSN is the most common anterior segment neoplastic disease process. Several ocular surface imaging techniques have been developed for the early diagnosis and management of clinical and subclinical ocular surface squamous neoplasia, including high-resolution optical coherence tomography (HR-OCT), in vivo confocal microscopy, and ultrasound biomicroscopy. Treatment modalities include both surgical and medical management, with a recent trend towards primary and adjunctive pharmacotherapy.

Summary

There is increasing use of HR-OCT for the diagnosis and monitoring of clinical and subclinical OSSN lesions. Topical pharmacotherapy agents, including interferon α-2b, 5-fluorouracil, and mitomycin C, have demonstrable efficacy in the treatment of OSSN and their use may be dictated based upon tumor factors, patient factors, cost, and side effect profile. Both surgical excision and adjunctive topical medications have excellent success, with the favored treatment method trending towards topical pharmacotherapy as primary therapy.

Human Papillomavirus Related Neoplasia of the Ocular Adnexa

Human papillomaviruses (HPV) are a large group of DNA viruses that infect the basal cells of the stratified epithelium at different anatomic locations. In the ocular adnexal region, the mucosa of the conjunctiva and the lacrimal drainage system, as well as the eyelid skin, are potential locations for HPV-related neoplasia. The role of HPV in squamous cell neoplasia of the ocular adnexa has been debated for several decades. Due to the rarity of all these tumors, large studies are not available in the scientific literature, thereby hampering the precision of the HPV prevalence estimates and the ability to conclude. Nevertheless, increasing evidence supports that defined subsets of conjunctival papillomas, intraepithelial neoplasia, and carcinomas develop in an HPV-dependent pathway. The role of HPV in squamous cell tumors arising in the lacrimal drainage system and the eyelid is still uncertain. Further, the potential of HPV status as a diagnostic, prognostic, or predictive biomarker in these diseases is a topic for future research.

Keratin 17 Suppresses Cell Proliferation and Epithelial-Mesenchymal Transition in Pancreatic Cancer

Keratin 17 (K17), a member of type I acidic epithelial keratin family, has been reported to be upregulated in many malignant tumors and to be involved in promoting the development of tumors. However, the precise role of K17 in progression of pancreatic cancer is still unknown. In this study, we found that K17 expression was highly expressed in pancreatic cancer tissues and cell lines and that upregulated expression was associated with the pathological grade and poor prognosis. K17 expression served as an independent predictor of pancreatic cancer survival. Meanwhile, we showed that knocking down K17 induced pancreatic cancer cell proliferation, colony formation and tumor growth in xenografts in mice. However, K17 upregulation inhibited pancreatic cancer cell proliferation and colony formation. Further mechanistic study revealed that K17 knockdown promoted cell cycle progression by upregulating CyclinD1 expression and repressed cell apoptosis. However, K17 upregulation suppressed cell cycle progression by decreasing CyclinD1 expression, and induced apoptosis by increasing the levels of cleaved Caspase3. In addition, K17 knockdown promoted pancreatic cancer cell migration and invasion, but K17 upregulation suppressed cell migration and invasion. Moreover, knocking down K17 promoted epithelial-mesenchymal transition (EMT) in pancreatic cancer cell by inhibiting E-cadherin expression and inducing Vimentin expression, and the effects of K17 upregulation were opposite to that of K17downregulation. Taken together, our findings suggest that K17 functions as a potential tumor suppressor, even though it is upregulated in pancreatic cancer.

Epidemiological Analysis and Prognosis of Conjunctival Cancer in the Past Twenty Years: A Population-Based Retrospective Study Using SEER Data

Epidemiological studies of malignant primary conjunctival tumors are rare. We extracted data pertaining to primary site-labeled conjunctival cancer patients present within the Surveillance, Epidemiology, and End Results (SEER) database from 1992 to 2001 and from 2002 to 2011. The Kaplan-Meier approach was used for comparisons of overall survival (OS) between patients, while OS-related risk factors were identified via a Cox proportional hazards regression approach. We then constructed a nomogram that could be used to predict the 3- and 5-year OS, with the accuracy of this predictive model based on receiver operating characteristic (ROC) curve. We observed a significant reduction in age-adjusted incidence of conjunctival cancer in the 50-69-year-old age group of the 2002-2011 cohort relative to the 1992-2001 cohort (APC, P < 0.05). There were no significant differences in OS between the 1992-2001 and 2002-2011 conjunctival cancer patient cohorts. Being ≥30 years old (P < 0.05), male (P < 0.001), single (P < 0.05), divorced (P < 0.001), or widowed (P < 0.001) were all associated with an increased OS-related risk of primary conjunctival cancer (1992-2011). Our nomogram was able to accurately predict 3- and 5-year OS in conjunctival cancer patients. In verification mode, the 3-year area under the curve (AUC) was 0.697 and the 5-year AUC was 0.752. We found that age, sex, and marital status were all associated with primary conjunctival cancer survival. Our results further suggest that conjunctival cancer incidence and survival rates have been relatively stable over the last two decades, and using these data, we were able to generate a satisfactory risk prediction model for this disease.

p16 Expression Correlates with Invasive Ocular Surface Squamous Neoplasms in HIV-Infected Mozambicans

BACKGROUND

p16 immunohistochemistry is widely used to diagnose human papillomavirus (HPV)-related squamous neoplasms of cervix, anogenital, head, and neck tissues. The incidence of these HPV-related squamous neoplasms is markedly increased in the HIV-infected population. Ocular surface squamous neoplasia (OSSN) is also more common in HIV-infected patients. However, the expression pattern of p16 in OSSN among HIV-infected patients is unclear. Here, we examined the expression of p16 in OSSN surgical excisions collected from a large HIV-infected cohort from -Mozambique.

METHODS

OSSN surgical tissue specimens were collected from 75 Mozambican patients. Formalin-fixed, paraffin-embedded tissue blocks from these OSSNs were sectioned, stained with hematoxylin and eosin (H&E), and p16 expression by immunohistochemistry. H&E slides were reviewed to determine if OSSNs were noninvasive conjunctival intraepithelial neoplasms or invasive squamous cell carcinomas (SCC). Cases were classified as p16 positive or negative based on diffuse nuclear and cytoplasmic expression of p16 in neoplastic cells.

RESULTS

p16 positivity was found in a minority of OSSN cases (14/75). p16 positivity was significantly associated with the invasive SCC type of OSSN in HIV-infected patients (p value of 0.026).

CONCLUSIONS

The majority of OSSNs in our HIV-infected cohort do not express p16. However, those cases that are p16-positive are significantly more likely to be the invasive SCC form of OSSN. We propose that p16 expression may identify more aggressive OSSNs in HIV-infected populations.

Clinical Management of Ocular Surface Squamous Neoplasia: A Review of the Current Evidence

Ocular surface squamous neoplasia (OSSN) is the most common non-pigmented malignancy of the ocular surface and is represented in a wide range of histologic diagnoses, ranging from mild epithelial dysplasia to invasive squamous carcinoma. Although surgical excision is still the gold standard for OSSN treatment, interest in conservative medical approaches is steadily growing. We have reviewed all of the literature on OSSN published in English in the MEDLINE database up to May 2018, using the keywords “ocular surface squamous neoplasia,” “squamous conjunctival carcinoma,” and “conjunctival carcinoma in situ,” with the aim to provide a comprehensive review of the most recent evidence on this distinct clinical entity.