M. von Knebel Doeberitz

New markers for cervical dysplasia to visualise the genomic chaos created by aberrant oncogenic papillomavirus infections.

Abstract Extensive research over the past 20 years provided strong evidence that persistent infections with high risk type human papillomaviruses (HR-HPVs) cause cervical cancer. However, depending on their age, more than 20% of normal women are infected with these viruses and only very few develop clinically relevant dysplastic lesions or even cancer. During an acute HPV infection, expression of viral genes, in particular the viral E6 and E7 oncogenes is restricted to differentiated epithelial cells, which lost the capability to replicate their genomes and are therefore at no further risk for acquiring functionally relevant mutations upon genotoxic damage. High grade cervical dysplasia, however, is initiated by deregulated expression of viral oncogenes in replicating epithelial stem cells. Here, the E6–E7 gene products submerge control of the cell cycle and mitotic spindle pole formation through complex interactions with various cellular protein complexes and induce severe chromosomal instability. The detailed molecular analysis of these interactions allowed to define new biomarkers for dysplastic cervical cells. E7 for example induces increasing expression of the cyclin dependent kinase inhibitor p16ink4a in dysplastic cells. This can be used to identify dysplastic cells in histological slides, cytological smears or samples taken for biochemical analyses with an yet unmet fidelity. Detection of specific viral mRNAs derived from integrated HPV genomes in advanced precancers can be used to identify lesions with a particularly high risk for progression into invasive carcinomas (APOT assay). These new markers will result in a modified classification of cervical precancers and improved screening assays. Here, we review the basic concept and potential clinical applications of these new developments.

High density of FOXP3-positive T cells infiltrating colorectal cancers with microsatellite instability.

High-level microsatellite instability (MSI-H) in colorectal cancer accounts for about 12% of colorectal cancers and is typically associated with a dense infiltration with cytotoxic CD8-positive lymphocytes. The role of regulatory T cells that may interfere with the hosts antitumoural immune response in MSI-H colorectal cancers has not been analysed yet. Using an antibody directed against the regulatory T-cell marker transcription factor forkhead box P3 (FOXP3), regulatory T cells were examined in 70 colorectal cancers with known MSI status (MSI-H, n=37; microsatellite stable, n=33). In MSI-H colorectal cancers, we found a significantly higher intraepithelial infiltration with FOXP3-positive cells (median: 8.5 cells per 0.25 mm2 vs 3.1 cells per 0.25 mm2 in microsatellite stable, P<0.001), and a significantly elevated ratio of intraepithelial to stromal infiltration (0.05 vs 0.01 in microsatellite stable, P<0.001). CD8-positive cell counts were related positively to the number of FOXP3-positive cells (Spearmans ρ=0.56 and 0.55, respectively). Our results show that the elevated number of CD8-positive lymphocytes found in MSI-H colorectal cancers is paralleled by an enhanced infiltration with CD8-negative FOXP3-positive cells. These data suggest that FOXP3-positive cells may play a role in the regulation of the immune response directed against MSI-H colorectal cancers at the primary tumour site.

No evidence of p53 allele-specific predisposition in human papillomavirus-associated cervical cancer

The potential association of distinct polymorphisms of the tumor suppressor gene p53 with an increased susceptibility to malignant transformation has been reported for various cancer entities. Most recently, p53 protein containing an arginine residue in codon 72 was shown to be more effectively degraded by the E6 oncoprotein of human papillomavirus (HPV) than the corresponding proline isoform in cervical carcinoma cells. Additionally, a seven times higher risk of cervical cancer for Arg homozygotes was suggested. We set out to confirm this allele-specific predisposition on a larger population, comprising 87 cervical cancer and 151 normal control samples. However, there was no significant difference in the observed frequencies of homozygous Arg genotypes in cervical cancer patients (52.8%) and normal controls (55.7%). Furthermore, the prevalence of the Arg/Arg allelotype did not vary between HPV+ (n=75) and HPV– (n=12) carcinoma samples. Thus, our investigation of a larger set of clinical samples does not support the proposed association of any polymorphic status of p53 at codon 72 with an elevated risk for cervical cancer.

High-risk human papillomavirus in non-melanoma skin lesions from renal allograft recipients and immunocompetent patients

Background:High-risk human papillomaviruses (HR-HPVs) can be detected in a proportion of non-melanoma skin cancers. Data on prevalence are inconclusive, but are essential to estimate the relevance of HR-HPV, particularly with regard to prophylactic HPV vaccines for skin cancer prevention.Methods:High-risk human papillomavirus DNA was investigated in 140 non-melanoma skin lesions from 54 immunocompetent patients and 33 immunosuppressed renal allograft recipients. Expression of p16INK4a, a marker for HR-HPV oncogene expression in the uterine cervix, and of p53 and pRB was evaluated immunohistochemically.Results:The highest prevalence of HR-HPV was found in squamous cell cancer (SCC) (46.2% (6 out of 13) in immunosuppressed and 23.5% (4 out of 17) in immunocompetent patients). High-risk human papillomavirus positivity was accompanied by diffuse p16INK4a expression in most SCC (P<0.001) and basal cell cancers (P=0.02), while almost all SCC in situ were p16INK4a positive irrespective of HR-HPV presence (P=0.66). Diffuse p16INK4a expression was associated with lack of pRB expression (P=0.001). p53 was strongly expressed in 40.0% (56 out of 140) of the lesions irrespective of HR-HPV presence.Conclusion:High-risk human papillomavirus can be detected in lesions of keratinised squamous epithelia. The association of HR-HPV with diffuse p16INK4a expression might indicate HR-HPV oncogene expression in a proportion of lesions. Overexpression of p53 suggests p53 pathway alterations in HR-HPV-positive and -negative lesions.

Disseminierte Tumorzellen: Diagnostik, prognostische Relevanz, Phänotypisierung und therapeutische Strategien

Summary. The incidence of local relapse after complete (R0) resection of solid tumors is largely determined by the skill of the surgeon, whereas metastatic relapse in distant organs is caused by pre- or perioperative systemic dissemination of tumor cells. The presence of individual disseminated tumor cells – e. g., in bone marrow as indicator organ – can be detected by sensitive immunocytochemical and molecular methods and is increasingly considered as a clinically relevant prognostic indicator. In contrast to solid metastases, isolated micrometastatic tumor cells are appropriate targets for intravenously applied anti-cancer therapeutics because they are easily accessible to macromolecules and immunologic effector cells. The majority of these tumor cells appear to be nonproliferating (i. e., in the G0 phase of the cell cycle), which may explain the failure of adjuvant chemotherapy. Adjuvant therapeutic strategies aimed at quiescent tumor cells are therefore of increasing interest. This therapeutic rationale has been tested and confirmed in a randomized clinical trial using antibody 17–1A in patients with non-metastatic colorectal carcinoma (UICC stage III). The antibody therapy kills also quiescent tumor cells (“dormant cells”) and is independent from a potential chemotherapy resistance of the tumor cells. As treatment for minimal residual cancer, the clinical use of antibody therapy could be envisaged in conjunction with chemotherapy, applied either in parallel or sequentially. The aim of this review is to present and discuss the current state of research in the field of diagnosis and therapy of minimal residual cancer.Zusammenfassung. Während das Auftreten und die Häufigkeit von Lokalrezidiven bei der R0-Resektion solider Tumoren weitgehend in der Hand des Operateurs liegt, sind Fernrezidive nach derzeitigem Kenntnisstand auf die bereits prä- oder perioperativ erfolgte, systemische Disseminierung von Tumorzellen zurückzuführen. Das Vorliegen von einzelnen, disseminierten Tumorzellen – z. B. im Knochenmark als Indikatororgan – ist im Rahmen eines erweiterten Tumorstagings durch sensitive immuncytochemische und molekulare Methoden nachweisbar und wird zunehmend als klinisch relevanter Prognosefaktor angesehen. Im Gegensatz zu soliden Metastasen stellen isolierte mikrometastatische Tumorzellen aufgrund ihrer Zugänglichkeit für Makromoleküle und immunkompetente Effektorzellen geeignete Ziele für intravenös appplizierte Therapeutica dar. Der überwiegend nicht mitotisch aktive Zustand (G0-Phase) dieser Tumorzellen könnte eine Ursache für das Versagen einer adjuvanten Chemotherapie sein. Daher rücken adjuvante Therapiestrategien, die auch gegen ruhende Zellen wirksam sind, zunehmend in den Mittelpunkt des Interesses. Diese therapeutische Rationale ist mit dem Antikörper 17–1A bei Patienten mit colorectalem Carcinom im Stadium UICC III nach R0-Resektion randomisiert untersucht und bestätigt worden. Die Antikörpertherapie zeichnet sich dadurch aus, daß Antikörper sich im Gegensatz zur Chemotherapie auch gegen mitotisch nicht aktive Tumorzellen („dormant cells“) richten und zudem unabhängig von möglichen Chemotherapieresistenzen wirken. Als eine gegen den Zustand der minimalen residualen Krebserkrankung gerichtete Therapie wäre der adjuvante Einsatz von Antikörpern zukünftig auch als Kombinationsbehandlung mit der Chemotherapie parallel oder sequentiell sinnvoll. Ziel dieser Übersicht ist es, den momentanen Stand der Forschung auf dem Gebiet der Diagnostik und Therapie der minimalen residualen Krebserkrankung zu erläutern.

Microsatellite instability and Beta2-Microglobulin mutations as prognostic markers in colon cancer: results of the FOGT-4 trial.

Background:High-level microsatellite instability (MSI-H) has been reported as a prognostic marker in colon cancer. We here analysed the prognostic significance of MSI and mutations of the Beta2-Microglobulin (B2M) gene, which occur in about 30% of MSI-H colon cancer, in the cohort of the prospective FOGT-4 (Forschungsruppe Onkologie Gastrointestinale Tumoren, FOGT) trial.Methods:Microsatellite instability status was determined using standard protocols (NCI/ICG-HNPCC panel and CAT25) in 223 colon cancer lesions. Beta2-Microglobulin mutation status was evaluated by exon-wise sequencing in all MSI-H lesions.Results:Patients with MSI-H (n=34) colon cancer presented with a significantly lower risk of relapse after 12 months of follow-up compared with MSS (n=189) colon cancer patients (5 year time to relapse: MSI-H 0.82 vs MSS 0.66, P=0.03). No significant difference in overall survival was detected. Beta2-Microglobulin mutations were identified in 10 (29.4%) out of 34 MSI-H colon cancers and were associated with a complete absence of disease relapse or tumour-related death events (P=0.09).Conclusion:The risk of late disease relapse was significantly lower in patients with MSI-H compared with MSS colon cancer. Moreover, B2M mutations may contribute to the favourable outcome of MSI-H colon cancer patients and should therefore be evaluated as a potential prognostic marker in future clinical trials.

Expression of cytokeratin 20 in thyroid carcinomas and peripheral blood detected by reverse transcription polymerase chain reaction

We investigated a nested reverse transcriptase polymerase chain reaction (RT-PCR) system to detect CK20 mRNA in thyroid carcinomas, benign thyroid diseases and peripheral blood to improve diagnosis of thyroid carcinoma and to detect disseminated tumour cells. Frozen tissue samples of 46 thyroid carcinomas and 30 benign thyroid diseases (14 multinodular goiters, 14 follicular adenomas, two Hashimoto’s hyroiditis) were obtained intraoperatively. Preoperative blood samples were drawn from 31 patients with thyroid cancer, nine patients with benign thyroid disorders and 20 healthy volunteers. Nine out of nine medullary, 9/12 follicular, 7/19 papillary and 2/6 anaplastic carcinomas expressed CK20 transcripts. CK20 mRNA was undetectable in 30 tissue sections of benign thyroid diseases. Circulating tumour cells were found in the blood of 3/8 patients with medullary carcinoma, 2/8 patients with follicular carcinoma, 2/11 patients with papillary carcinoma and 1/4 patients with an anaplastic carcinoma. Nine blood samples of patients with benign thyroid diseases and 20 healthy volunteers tested negative. For the first time CK20 mRNA could be detected in tissue sections of thyroid carcinomas and peripheral blood samples of patients with thyroid cancer. It was not detectable in benign thyroid diseases. Our results therefore strongly suggest that CK20 RT-PCR assays may improve the diagnosis of thyroid carcinoma and is able to detect circulating tumour cells in peripheral blood of thyroid carcinoma patients.

Enhanced Sensitivity of Small Cell Lung Cancer Cell Lines to Cisplatin and Etoposide After Infection with Adeno-associated Virus Type 2

In previous studies we have reported the sensitisation of human tumour cells to gamma irradiation and chemotherapeutic drugs upon infection with the human non-pathogenic adeno-associated virus type 2 (AAV-2) in vitro and in vivo. Treatment of small cell lung cancer (SCLC) is consistently hampered by relapses due to the selection of chemotherapy-resistant cell clones. Hence, we were interested to test whether selection of chemotherapy-resistant SCLC cells might be reduced or even prevented if chemotherapy is applied in combination with AAV-2 infection. In vitro proliferation assays indicated that the number of proliferating cells, after combined treatment with cisplatin and etoposide, can be significantly reduced by concomitant AAV-2 infection, as compared with treated but non-infected controls. H446 SCLC cells, which show resistance to etoposide/cisplatin chemotherapy (compared with a cell line which was never chemotherapeutically treated before, like NCI-H209) were significantly more sensitive after AAV-2 infection, suggesting that the therapeutic efficacy of chemotherapy in SCLC can be enhanced even if the cells are already relatively resistant to chemotherapy. Similarly, in vivo growth of tumours induced by inoculation of SCLC cells into immunocompromised nude mice was reduced more efficiently in AAV-2-infected animals compared with tumours in mice treated with chemotherapeutic drugs alone. These data extend and further support our previous reports on AAV functions which might be useful in improving the efficacy of chemotherapeutic drugs used in human cancer treatment.

No evidence for cancer-related CD44 splice variants in primary and metastatic colorectal cancer

The expression of alternatively spliced CD44 adhesion molecules has been implicated in the pathogenesis and metastasis of colorectal cancer. Using a new set of primers for exon-specific reverse transcription-polymerase chain reaction (RT-PCR) we delineated the exact exon composition of CD44 mRNAs in normal colorectal mucosa, including isolated colonic crypts, in colorectal carcinomas and in their hepatic metastases. In addition, the surface expression of CD44 isoforms was analysed by immunohistochemistry. We identified by RT-PCR eight variant transcripts expressed in colorectal carcinomas and their metastases, but also constitutively in normal colorectal epithelia. In the normal colorectal epithelium, the surface expression of CD44 standard and variant molecules was restricted to proliferating cells at the bottom of the crypts. Despite expression of these transcripts in colorectal cancers and their metastases, monoclonal antibodies specific for standard or variant epitopes encoded by exons v5 and v6 stained only a few neoplastic lesions. These data point to a differentiation-specific CD44 expression and splicing pattern in proliferating colorectal epithelia. However, they do not support a cancer- or metastasis-specific CD44 splicing pattern. Instead, cell surface availability of CD44 epitopes was reduced rather than increased in primary tumours and particularly in liver metastases.

Improved efficacy of chemotherapy by parvovirus-mediated sensitisation of human tumour cells

Increasing resistance of tumour cells towards the cytotoxic action of chemotherapeutic drugs is a major limitation in the treatment of cancer patients. The non-pathogenic human adeno-associated viruses (AAV) have been reported to sensitise HeLa cervical cancer cells to gamma irradiation in vivo and in vitro. To test whether these parvoviruses might render other human tumour cells more sensitive towards chemotherapeutic drugs, we analysed the effects of AAV type 2 (AAV-2) infection on established cancer cell lines and freshly explanted tumour biopsies treated with chemotherapeutic agents (e.g. cisplatin). AAV-2 infection significantly increased the cytotoxic activity of chemotherapeutic drugs compared with uninfected controls. AAV-2 infection without concomitant chemotherapeutic treatment had no significant effect on viability of the cells. In nude mice, combined application of AAV-2 infection and chemotherapeutic treatment significantly increased the therapeutic activity on tumours arising from subcutaneously injected tumour cells compared with tumours treated by chemotherapeutics only. These results indicate that AAV-2 infection sensitises human cancer cells towards the cytotoxic action of chemotherapeutic drugs.