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Tang Y, Su Y, Xu Y, Zhang Y, Shen Y, Qin L, Zhang L, Cao L, Zhou Y, Zhang T, Zhang M. Therapeutic effects of topical photodynamic therapy with 5-aminolevulinic acid on cervical high-grade squamous intraepithelial lesions. Photodiagnosis Photodyn Ther 2022; 39:102884. [DOI: 10.1016/j.pdpdt.2022.102884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 01/10/2023]
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2
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Da Silva MLR, De Albuquerque BHDR, Allyrio TADMF, De Almeida VD, Cobucci RNDO, Bezerra FL, Andrade VS, Lanza DCF, De Azevedo JCV, De Araújo JMG, Fernandes JV. The role of HPV-induced epigenetic changes in cervical carcinogenesis (Review). Biomed Rep 2021; 15:60. [PMID: 34094536 PMCID: PMC8165754 DOI: 10.3892/br.2021.1436] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 03/10/2021] [Indexed: 12/12/2022] Open
Abstract
Cervical cancer is associated with infection by certain types of human papillomaviruses (HPVs), and this affects women worldwide. Despite the improvements in prevention and cure of HPV-induced cervical cancer, it remains the second most common type of cancer in women in the least developed regions of the world. Epigenetic modifications are stable long-term changes that occur in the DNA, and are part of a natural evolutionary process of necessary adaptations to the environment. They do not result in changes in the DNA sequence, but do affect gene expression and genomic stability. Epigenetic changes are important in several biological processes. The effects of the environment on gene expression can contribute to the development of numerous diseases. Epigenetic modifications may serve a critical role in cancer cells, by silencing tumor suppressor genes, activating oncogenes, and exacerbating defects in DNA repair mechanisms. Although cervical cancer is directly related to a persistent high-risk HPV infection, several epigenetic changes have been identified in both the viral DNA and the genome of the infected cells: DNA methylation, histone modification and gene silencing by non-coding RNAs, which initiate and sustain epigenetic changes. In the present review, recent advances in the role of epigenetic changes in cervical cancer are summarized.
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Affiliation(s)
- Martha Laysla Ramos Da Silva
- Department of Microbiology and Parasitology, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil.,Post-Graduate Program in Parasite Biology, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil
| | | | | | - Valéria Duarte De Almeida
- Department of Biomedical Sciences, State University of Rio Grande do Norte, Mossoro 59607-360, Brazil
| | | | - Fabiana Lima Bezerra
- Department of Microbiology and Parasitology, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil
| | - Vania Sousa Andrade
- Department of Microbiology and Parasitology, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil.,Post-Graduate Program in Parasite Biology, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil
| | - Daniel Carlos Ferreira Lanza
- Laboratory of Applied Molecular Biology, Department of Biochemistry, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil
| | | | - Josélio Maria Galvão De Araújo
- Department of Microbiology and Parasitology, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil.,Post-Graduate Program in Parasite Biology, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil
| | - José Veríssimo Fernandes
- Department of Microbiology and Parasitology, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil.,Post-Graduate Program in Parasite Biology, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil
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3
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Additional diagnostic capabilities in the practice of a PAP-test using liquid-based cytology. КЛИНИЧЕСКАЯ ПРАКТИКА 2021. [DOI: 10.17816/clinpract64982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The role of oncogenic strains of human papillomavirus in the development of cervical cancer is currently not in doubt. In cervical cancer screening, a co-testing strategy is used, in which cytology and HPV testing are performed. When performing a cytological examination by liquid-based cytology, it is possible to conduct additional diagnostic studies that can be used to more effectively sort patients in order to optimize the volume of diagnostic and therapeutic measures. The article highlights the possibilities of diagnostic tests based on the assessment of microRNA and mRNA expression, as well as tests based on the analysis of DNA methylation from the cytological material. The introduction of new molecular genetic predictors of the cervical cancer development into clinical practice can increase the effectiveness of currently used screening programs.
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4
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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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5
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Performance of DNA methylation assays for detection of high-grade cervical intraepithelial neoplasia (CIN2+): a systematic review and meta-analysis. Br J Cancer 2019; 121:954-965. [PMID: 31616037 PMCID: PMC6889421 DOI: 10.1038/s41416-019-0593-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 12/16/2022] Open
Abstract
Background To conduct a meta-analysis of performance of DNA methylation in women with high-grade cervical intraepithelial neoplasia (CIN2+). Methods Medline and Embase databases were searched for studies of methylation markers versus histological endpoints. Pooled sensitivity, specificity and positive predictive value (PPV) for CIN2+ were derived from bivariate models. Relative sensitivity and specificity for CIN2+ compared to cytology and HPV16/18 genotyping were pooled using random-effects models. Results Sixteen thousand three hundred thirty-six women in 43 studies provided data on human genes (CADM1, MAL, MIR-124-2, FAM19A4, POU4F3, EPB41L3, PAX1, SOX1) and HPV16 (L1/L2). Most (81%) studies evaluated methylation assays following a high-risk (HR)-HPV-positive or abnormal cytology result. Pooled CIN2+ and CIN3+ prevalence was 36.7% and 21.5%. For a set specificity of 70%, methylation sensitivity for CIN2+ and CIN3+ were 68.6% (95% CI: 62.9–73.8) and 71.1% (95% CI: 65.7–76.0) and PPV were 53.4% (95% CI: 44.4–62.1) and 35.0% (95% CI: 28.9–41.6). Among HR-HPV+ women, the relative sensitivity of methylation for CIN2+ was 0.81 (95% CI: 0.63–1.04) and 1.22 (95% CI: 1.05–1.42) compared to cytology of atypical squamous cells of undetermined significance, or greater (ASCUS+) and HPV16/18 genotyping, respectively, while relative specificity was 1.25 (95% CI: 0.99–1.59) and 1.03 (95% CI: 0.94–1.13), respectively. Conclusion DNA methylation is significantly higher in CIN2+ and CIN3+ compared to ≤CIN1. As triage test, DNA methylation has higher specificity than cytology ASCUS+ and higher sensitivity than HPV16/18 genotyping.
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6
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Olusola P, Banerjee HN, Philley JV, Dasgupta S. Human Papilloma Virus-Associated Cervical Cancer and Health Disparities. Cells 2019; 8:cells8060622. [PMID: 31234354 PMCID: PMC6628030 DOI: 10.3390/cells8060622] [Citation(s) in RCA: 185] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/15/2019] [Accepted: 06/19/2019] [Indexed: 12/25/2022] Open
Abstract
Cervical cancer develops through persistent infection with high-risk human papilloma virus (hrHPV) and is a leading cause of death among women worldwide and in the United States. Periodic surveillance through hrHPV and Pap smear-based testing has remarkably reduced cervical cancer incidence worldwide and in the USA. However, considerable discordance in the occurrence and outcome of cervical cancer in various populations exists. Lack of adequate health insurance appears to act as a major socioeconomic burden for obtaining cervical cancer preventive screening in a timely manner, which results in disparate cervical cancer incidence. On the other hand, cervical cancer is aggressive and often detected in advanced stages, including African American and Hispanic/Latina women. In this context, our knowledge of the underlying molecular mechanism and genetic basis behind the disparate cervical cancer outcome is limited. In this review, we shed light on our current understanding and knowledge of racially disparate outcomes in cervical cancer.
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Affiliation(s)
- Patti Olusola
- Departments of Family Medicine, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA.
| | - Hirendra Nath Banerjee
- Natural, Pharmacy and Health Sciences, Elizabeth City State University, North Carolina, Elizabeth City, NC 27909, USA.
| | - Julie V Philley
- Medicine, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA.
| | - Santanu Dasgupta
- Medicine, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA.
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7
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van Dam PA, Rolfo C, Ruiz R, Pauwels P, Van Berckelaer C, Trinh XB, Ferri Gandia J, Bogers JP, Van Laere S. Potential new biomarkers for squamous carcinoma of the uterine cervix. ESMO Open 2018; 3:e000352. [PMID: 30018810 PMCID: PMC6045706 DOI: 10.1136/esmoopen-2018-000352] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/11/2018] [Accepted: 05/11/2018] [Indexed: 12/26/2022] Open
Abstract
Aim An in silico pathway analysis was performed in an attempt to identify new biomarkers for cervical carcinoma. Methods Three publicly available Affymetrix gene expression data sets (GSE5787, GSE7803, GSE9750) were retrieved, vouching for a total 9 cervical cancer cell lines, 39 normal cervical samples, 7 CIN3 samples and 111 cervical cancer samples. An Agilent data set (GSE7410; 5 normal cervical samples, 35 samples from invasive cervical cancer) was selected as a validation set. Predication analysis of microarrays was performed in the Affymetrix sets to identify cervical cancer biomarkers. We compared the lists of differentially expressed genes between normal and CIN3 samples on the one hand (n=1923) and between CIN3 and invasive cancer samples on the other hand (n=628). Results Seven probe sets were identified that were significantly overexpressed (at least 2 fold increase expression level, and false discovery rate <5%) in both CIN3 samples respective to normal samples and in cancer samples respective to CIN3 samples. From these, five probes sets could be validated in the Agilent data set (P<0.001) comparing the normal with the invasive cancer samples, corresponding to the genes DTL, HMGB3, KIF2C, NEK2 and RFC4. These genes were additionally overexpressed in cervical cancer cell lines respective to the cancer samples. The literature on these markers was reviewed. Conclusion Novel biomarkers in combination with primary human papilloma virus (HPV) testing may allow complete cervical screening by objective, non-morphological molecular methods, which may be particularly important in developing countries.
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Affiliation(s)
- Peter A van Dam
- Multidisciplinary Oncologic Centre Antwerp (MOCA), Antwerp University Hospita, Edegem, Belgium.,Centre of Oncologic Research (CORE) Antwerp University, Edegem, Belgium
| | - Christian Rolfo
- Multidisciplinary Oncologic Centre Antwerp (MOCA), Antwerp University Hospita, Edegem, Belgium.,Centre of Oncologic Research (CORE) Antwerp University, Edegem, Belgium.,Fase 1 Unit for Experimental Oncology, Antwerp University Hospital, Edegem, Belgium
| | - Rossana Ruiz
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplásicas (INEN), Lima, Peru
| | - Patrick Pauwels
- Centre of Oncologic Research (CORE) Antwerp University, Edegem, Belgium.,Department of Histopathology, Antwerp University Hospital, Edegem, Belgium
| | | | - Xuan Bich Trinh
- Multidisciplinary Oncologic Centre Antwerp (MOCA), Antwerp University Hospita, Edegem, Belgium.,Centre of Oncologic Research (CORE) Antwerp University, Edegem, Belgium
| | - Jose Ferri Gandia
- Fase 1 Unit for Experimental Oncology, Antwerp University Hospital, Edegem, Belgium
| | - Johannes P Bogers
- AMBIOR Laboratory of Cell Biology and Histology, Antwerp University, Antwerp, Belgium
| | - Steven Van Laere
- Centre of Oncologic Research (CORE) Antwerp University, Edegem, Belgium
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8
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Kocsis A, Takács T, Jeney C, Schaff Z, Koiss R, Járay B, Sobel G, Pap K, Székely I, Ferenci T, Lai HC, Nyíri M, Benczik M. Performance of a new HPV and biomarker assay in the management of hrHPV positive women: Subanalysis of the ongoing multicenter TRACE clinical trial (n > 6,000) to evaluate POU4F3 methylation as a potential biomarker of cervical precancer and cancer. Int J Cancer 2017; 140:1119-1133. [PMID: 27874187 DOI: 10.1002/ijc.30534] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 10/28/2016] [Accepted: 11/08/2016] [Indexed: 12/11/2022]
Abstract
The ongoing Triage and Risk Assessment of Cervical Precancer by Epigenetic Biomarker (TRACE) prospective, multicenter study aimed to provide a clinical evaluation of the CONFIDENCE™ assay, which comprises a human papillomavirus (HPV) DNA and a human epigenetic biomarker test. Between 2013 and 2015 over 6,000 women aged 18 or older were recruited in Hungary. Liquid-based cytology (LBC), high-risk HPV (hrHPV) DNA detection and single target host gene methylation test of the promoter sequence of the POU4F3 gene by quantitative methylation-specific polymerase chain reaction (PCR) were performed from the same liquid-based cytology sample. The current analysis is focused on the baseline cross-sectional clinical results of 5,384 LBC samples collected from subjects aged 25 years or older. The performance of the CONFIDENCE HPV™ test was found to be comparable to the cobas® HPV test with good agreement. When applying the CONFIDENCE Marker™ test alone in hrHPV positives, it showed significantly higher sensitivity with matching specificity compared to LBC-based triage. For CIN3+ histological endpoint in the age group of 25-65 and 30-65, the methylation test of POU4F3 achieved relative sensitivities of 1.74 (95% CI: 1.25-2.33) and 1.64 (95% CI: 1.08-2.27), respectively, after verification bias adjustment. On the basis of our findings, POU4F3 methylation as a triage test of hrHPV positives appears to be a noteworthy method. We can reasonably assume that its quantitative nature offers the potential for a more objective and discriminative risk assessment tool in the prevention and diagnostics of high-grade cervical intraepithelial neoplasia (CIN) lesions and cervical cancer.
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Affiliation(s)
- Adrienn Kocsis
- NEUMANN Diagnostics Ltd., Budapest, Hungary.,Cellcall Ltd., Budapest, Hungary
| | - Tibor Takács
- NEUMANN Diagnostics Ltd., Budapest, Hungary.,Cellcall Ltd., Budapest, Hungary.,SYNLAB Hungary Ltd., GenoID Molecular Diagnostic Laboratory, Budapest, Hungary
| | - Csaba Jeney
- Institute of Medical Microbiology, Semmelweis University, Budapest, Hungary
| | - Zsuzsa Schaff
- Second Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Róbert Koiss
- Department of Obstetrics and Gynaecology, St. Stephan Hospital, Budapest, Hungary
| | - Balázs Járay
- Second Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Gábor Sobel
- Second Department of Obstetrics and Gynaecology, Semmelweis University, Budapest, Hungary
| | - Károly Pap
- Jósa András Regional Central Hospital, Nyíregyháza, Hungary
| | - István Székely
- Department of Obstetrics and Gynaecology, St. Stephan Hospital, Budapest, Hungary
| | | | - Hung-Cheng Lai
- Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Miklós Nyíri
- NEUMANN Diagnostics Ltd., Budapest, Hungary.,Cellcall Ltd., Budapest, Hungary
| | - Márta Benczik
- NEUMANN Diagnostics Ltd., Budapest, Hungary.,Cellcall Ltd., Budapest, Hungary.,SYNLAB Hungary Ltd., GenoID Molecular Diagnostic Laboratory, Budapest, Hungary
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Panagopoulou M, Lambropoulou M, Balgkouranidou I, Nena E, Karaglani M, Nicolaidou C, Asimaki A, Konstantinidis T, Constantinidis TC, Kolios G, Kakolyris S, Agorastos T, Chatzaki E. Gene promoter methylation and protein expression of BRMS1 in uterine cervix in relation to high-risk human papilloma virus infection and cancer. Tumour Biol 2017; 39:1010428317697557. [PMID: 28381193 DOI: 10.1177/1010428317697557] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cervical cancer is strongly related to certain high-risk types of human papilloma virus infection. Breast cancer metastasis suppressor 1 (BRMS1) is a tumor suppressor gene, its expression being regulated by DNA promoter methylation in several types of cancers. This study aims to evaluate the methylation status of BRMS1 promoter in relation to high-risk types of human papilloma virus infection and the development of pre-cancerous lesions and describe the pattern of BRMS1 protein expression in normal, high-risk types of human papilloma virus-infected pre-cancerous and malignant cervical epithelium. We compared the methylation status of BRMS1 in cervical smears of 64 women with no infection by high-risk types of human papilloma virus to 70 women with proven high-risk types of human papilloma virus infection, using real-time methylation-specific polymerase chain reaction. The expression of BRMS1 protein was described by immunohistochemistry in biopsies from cervical cancer, pre-cancerous lesions, and normal cervices. Methylation of BRMS1 promoter was detected in 37.5% of women with no high-risk types of human papilloma virus infection and was less frequent in smears with high-risk types of human papilloma virus (11.4%) and in women with pathological histology (cervical intraepithelial neoplasia) (11.9%). Methylation was detected also in HeLa cervical cancer cells. Immunohistochemistry revealed nuclear BRMS1 protein staining in normal high-risk types of human papilloma virus-free cervix, in cervical intraepithelial neoplasias, and in malignant tissues, where staining was occasionally also cytoplasmic. In cancer, expression was stronger in the more differentiated cancer blasts. In conclusion, BRMS1 promoter methylation and aberrant protein expression seem to be related to high-risk types of human papilloma virus-induced carcinogenesis in uterine cervix and is worthy of further investigation.
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Affiliation(s)
- Maria Panagopoulou
- 1 Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Maria Lambropoulou
- 2 Laboratory of Histology-Embryology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ioanna Balgkouranidou
- 1 Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece.,3 Department of Oncology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Evangelia Nena
- 4 Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Makrina Karaglani
- 1 Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Christina Nicolaidou
- 2 Laboratory of Histology-Embryology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anthi Asimaki
- 5 Fourth University Clinic of Obstetrics and Gynecology, Hippokrateion Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theocharis Konstantinidis
- 4 Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Theodoros C Constantinidis
- 4 Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - George Kolios
- 1 Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Stylianos Kakolyris
- 3 Department of Oncology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Theodoros Agorastos
- 5 Fourth University Clinic of Obstetrics and Gynecology, Hippokrateion Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ekaterini Chatzaki
- 1 Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
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