Ciaran Woodman

The natural history of cervical HPV infection: unresolved issues

The identification of high-risk human papillomavirus (HPV) types as a necessary cause of cervical cancer offers the prospect of effective primary prevention and the possibility of improving the efficiency of cervical screening programmes. However, for these opportunities to be realized, a more complete understanding of the natural history of HPV infection, and its relationship to the development of epithelial abnormalities of the cervix, is required. We discuss areas of uncertainty, and their possible effect on disease prevention strategies.

Expression of the Epstein-Barr Virus-Encoded Epstein-Barr Virus Nuclear Antigen 1 in Hodgkin's Lymphoma Cells Mediates Up-Regulation of CCL20 and the Migration of Regulatory T Cells

In approximately 50% of patients with Hodgkins lymphoma (HL), the Epstein-Barr virus (EBV), an oncogenic herpesvirus, is present in tumor cells. After microarray profiling of both HL tumors and cell lines, we found that EBV infection increased the expression of the chemokine CCL20 in both primary Hodgkin and Reed-Sternberg cells and Hodgkin and Reed-Sternberg cell-derived cell lines. Additionally, this up-regulation could be mediated by the EBV nuclear antigen 1 protein. The higher levels of CCL20 in the supernatants of EBV-infected HL cell lines increased the migration of CD4(+) lymphocytes that expressed FOXP3, a marker of regulatory T cells (Tregs), which are specialized CD4(+) T cells that inhibit effector CD4(+) and CD8(+) T cells. In HL, an increased number of Tregs is associated with the loss of EBV-specific immunity. Our results identify a mechanism by which EBV can recruit Tregs to the microenvironment of HL by inducing the expression of CCL20 and, by doing so, prevent immune responses against the virus-infected tumor population. Further investigation of how EBV recruits and modifies Tregs will contribute not only to our understanding of the pathogenesis of virus-associated tumors but also to the development of therapeutic strategies designed to manipulate Treg activity.

Young age as a prognostic factor in cervical cancer: analysis of population based data from 10,022 cases.

The effect of young age on survival in cervical cancer is not fully known, although evidence has suggested that it is a poor prognostic factor and that young patients should therefore be treated differently from older patients. All 10 022 cases of invasive cervical cancer in the west Midlands during 1957-81, which comprised 10% of the cases in England and Wales, were analysed to determine the prognostic effect of age. Univariate analysis showed a median survival time of 54 months for all cases, with survival rates at five years of 69% for patients aged under 40 and 45% for those aged 40 or older (χ12 (log rank)=331·4; p<0·0001). This difference remained significant after stratification for stage (χ12 (log rank)=7·1; p=0·008). Cox regression analysis with nine covariables, including age and year of registration, reaffirmed the importance of conventional prognostic factors such as stage of disease, size of tumour, state of lymph nodes, and differentiation of the tumour. After allowance was made for the effects of other prognostic factors young age was found to be a small but significant favourable factor that did not change during the period of the study. Estimated survival distributions obtained from the Cox model showed that for women presenting with the common characteristics associated with stage Ib disease who were treated with radical radiotherapy the survival rate at five years fell non-linearly from 71% in the group aged 25-29 to 65% in the group aged 65-69. Young age alone is not a reason to alter existing policies for treatment for patients with invasive cervical cancer.

Epstein-Barr virus (EBV) and its associated human cancers - Genetics, epigenetics, pathobiology and novel therapeutics

Epstein-Barr virus (EBV) is a B-lymphotropic virus that is associated with a range of human malignancies. Although for many of these tumors the association has long been established, unraveling the precise role of EBV in disease pathogenesis has been more difficult. This review summarizes current knowledge concerning the association between EBV and human cancers, and illustrates how a deeper insight into viral latent gene expression, regulation and functions in different cell environments is already helping towards a better understanding of both the natural history of infection in normal individuals and how EBV contributes to malignant transformation. Finally, therapeutic strategies targeting EBV in tumors are discussed.

The H3K27me3 demethylase, KDM6B, is induced by Epstein–Barr virus and over-expressed in Hodgkin's Lymphoma

There is now evidence for both increased and decreased activity of the enzymes controlling the methylation of lysine 27 on histone 3 (H3K27) in cancer. One of these enzymes, KDM6B formally known as JMJD3, a histone demethylase, which removes the trimethyl mark from H3K27, is required for the lineage commitment and terminal differentiation of neural stem cells and of keratinocytes. Our results suggest that KDM6B may also have a role in antigen-driven B-cell differentiation. KDM6B expression increases in B-cell subsets with increasing stage of differentiation, and gene expression profiling shows that KDM6B transcriptional targets in germinal centre B (GC B) cells are significantly enriched for those differentially expressed during memory and plasma cell differentiation. Our results also suggest that aberrant expression of KDM6B may contribute to the pathogenesis of Hodgkins Lymphoma (HL), an Epstein–Barr virus (EBV) associated malignancy. KDM6B is over-expressed in primary HL and induced by the EBV oncogene, latent membrane protein (LMP1) in GC B cells, the presumptive progenitors of HL. Consistent with these observations, we found that KDM6B transcriptional targets in GC B cells are enriched for genes differentially expressed in HL, and that KDM6B depletion can restore the tri-methylation of H3K27 on these genes.

The Epstein-Barr virus oncoprotein, latent membrane protein-1, reprograms germinal centre B cells towards a Hodgkin's Reed-Sternberg-like phenotype

Although the latent membrane protein‐1 (LMP1) of the Epstein–Barr virus (EBV) is believed to be important for the transformation of germinal centre (GC) B cells, the precise contribution of this viral oncogene to lymphoma development is poorly understood. In this study, we used a non‐viral vector‐based method to express LMP1 in primary human GC B cells. Gene expression profiling revealed that LMP1 induced in GC B cells transcriptional changes characteristic of Hodgkins lymphoma cell lines. Strikingly, LMP1 down‐regulated the expression of B‐cell‐specific genes including B‐cell receptor components such as CD79A, CD79B, CD19, CD20, CD22, and BLNK. LMP1 also induced the expression of ID2, a negative regulator of B‐cell differentiation. Our data suggest that in EBV‐positive cases, LMP1 is likely to be a major contributor to the altered transcriptional pattern characteristic of Hodgkin/Reed–Sternberg cells, including the loss of B‐cell identity. Copyright

Costs and benefits of a one stop clinic compared with a dedicated breast clinic: randomised controlled trial

Abstract Objective: To determine the cost to the NHS and the impact on anxiety of a one stop clinic for assessing women with suspected breast cancer. Study design: Randomised controlled trial. Participants: Women aged 35 or over referred with a breast lump. Study setting: Teaching hospital, north west England. Interventions: Women were randomly allocated to attend a one stop clinic or a dedicated breast clinic. Outcome measures: Reduction in mean anxiety from baseline at 24 hours after the first visit and at 3 weeks and 3 months after diagnosis; mean cost per patient. Results: 670 women were randomised. Compared with women who attended the dedicated clinic, patients attending the one stop clinic were less anxious 24 hours after the visit (adjusted mean change in state anxiety −5.7 (95% confidence interval −8.4 to −3.0)) but not at 3 weeks or 3 months after diagnosis. The additional cost to the NHS of a one stop attendance was £32 per woman; this was largely explained by greater cytopathological and radiological staff costs. Conclusion: One stop clinics may not be justified in terms of a reduction in short term anxiety.

A retrospective review of adenocarcinoma‐in‐situ and glandular atypia of the uterine cervix

Between 1978 and 1985, 19 cases of adenocarcinoma‐in‐situ and 12 cases of glandular atypia have been identified at the Birmingham and Midland Hospital for Women. In 19 cases an associated dysplastic squamous element was identified, 20 of 28 pre‐diagnosis smears correctly predicted a glandular lesion, 5 of 17 colposcopically directed biopsies predicted the findings in a larger biopsy (cone biopsy or hysterectomy). Colposcopy provided no additional information with regard to diagnosis. Twelve of 13 patients managed by cone biopsy and 16 of 17 by abdominal hysterectomy have been treated successfully as defined by subsequent normal cytology.

Cigarette smoking is an independent risk factor for cervical intraepithelial neoplasia in young women: A longitudinal study

Repeated measurements of smoking, cervical human papillomavirus (HPV) status and sexual behaviour were used to measure the risk of high-grade cervical intraepithelial neoplasia (CIN) in relation to changes in smoking and cervical HPV status, and to explore the impact of smoking on the acquisition and duration of incident cervical HPV infection. Included in this longitudinal analysis are 1485 women aged 15–19 years: 1075 were HPV-negative and cytologically normal at recruitment; 410 were HPV-positive, cytologically abnormal or both, at this time. Women re-attended every 6 months, when samples were taken for cytological and virological examination. Current smoking intensity was associated with an increased risk of high-grade CIN, after controlling for cervical HPV status (compared to non-smokers, hazards ratio (HR) for 10 or more cigarettes per day = 2.21, 95% confidence interval (CI) 1.19–4.12, p-trend = 0.008). In women who were HPV-negative and cytologically normal at recruitment, current smoking was not significantly associated with the risk of acquiring a cervical HPV infection, after controlling for life-time number of partners and age of oldest partner (HR = 1.13, 95% CI 0.90–1.41); nor did it prolong the length of time during which HPV could be detected (HR = 1.03, 95% CI 0.78–1.34). Current smoking intensity is an independent risk factor for high-grade CIN in young women, after controlling for cervical HPV infection.

Down-regulation of BLIMP1α by the EBV oncogene, LMP-1, disrupts the plasma cell differentiation program and prevents viral replication in B cells: implications for the pathogenesis of EBV-associated B-cell lymphomas

An important pathogenic event in Epstein-Barr virus (EBV)-associated lymphomas is the suppression of virus replication, which would otherwise lead to cell death. Because virus replication in B cells is intimately linked to their differentiation toward plasma cells, we asked whether the physiologic signals that drive normal B-cell differentiation are absent in EBV-transformed cells. We focused on BLIMP1α, a transcription factor that is required for plasma cell differentiation and that is inactivated in diffuse large B-cell lymphomas. We show that BLIMP1α expression is down-regulated after EBV infection of primary germinal center B cells and that the EBV oncogene, latent membrane protein-1 (LMP-1), is alone capable of inducing this down-regulation in these cells. Furthermore, the down-regulation of BLIMP1α by LMP-1 was accompanied by a partial disruption of the BLIMP1α transcriptional program, including the aberrant induction of MYC, the repression of which is required for terminal differentiation. Finally, we show that the ectopic expression of BLIMP1α in EBV-transformed cells can induce the viral lytic cycle. Our results suggest that LMP-1 expression in progenitor germinal center B cells could contribute to the pathogenesis of EBV-associated lymphomas by down-regulating BLIMP1α, in turn preventing plasma cell differentiation and induction of the viral lytic cycle.