Dissertations / Theses on the topic 'Non-melanoma skin cancer'

Genetic changes are hallmarks of cancer development involving the activation and/or inactivation of oncogenes and tumour suppressor genes, respectively. In non-melanoma skin cancer (NMSC) development, the initiation of genetic mutations results from exposure to solar ultraviolet radiation. Non-melanoma skin cancers are comprised of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Several related cutaneous lesions also exist, of which solar keratoses (SK) are widely accepted as a precursor dysplasia to SCC development. The study of recurrent genetic changes present within NMSC and SK should help reveal causative mutations in skin cancer development. Such analysis could also elucidate links in the genetic similarity of these dysplasia. The rapid screening of numerical changes in DNA sequence copy number throughout the entire genome has been made possible by the advent of comparative genomic hybridisation (CGH). This technique enables the identification of net gains and loss of genetic material within a tumour DNA sample. Chromosomal regions of recurrent gain or loss identify loci containing putative oncogenes and tumour suppressor genes, respectively with potential roles in NMSC tumourigenesis. Used in conjunction with tissue microdissection and universal degenerate PCR techniques this can enable the elucidation of aberrations in small histologically distinct regions of tumour. Such a technique can utilize archival material such as paraffin embedded tissue, which is the major source of neoplastic material available for cancer research. This study used the CGH technique to investigate aberrations in BCC, SCC and SK samples. The screening of copy number abnormalities (CNAs) in BCC revealed that although these tumours were close to diploid and generally genetically stable, they did contain several recurrent aberrations. The loss of genetic material at 9q was identified in a third of BCC tumours studied. This is characteristic of inactivation of the PTCH tumour suppressor gene, a known attribute in some sporadic BCC development. Validation of this loss was performed via loss of heterozygosity, demonstrating good concordance with the CGH data. In addition the over-representation of the 6p chromosome arm was revealed in 47% of biopsies. This novel CNA is also commonly observed in other cutaneous neoplasias, including Merkel cell carcinoma and malignant melanoma. This suggests a possible common mechanism in development and or promotion in these cutaneous dysplasias, the mechanisms of which have yet to be clearly defined. In contrast to BCC, numerical genetic aberrations in SCC and SK were much more frequent. Several regions of recurrent gain were commonly shared between both dysplasias including gain of 3q, 4p, 5p, 8q, 9q, 14q, 17p, 17q and 20q. Common chromosomal regions of loss included 3p, 8p, 9p, 11p, 13q and 17p. In addition loss of chromosome 18 was significantly observed in SCC in comparison to SK, a possible defining event in SK progression to SCC. The identification of shared genetic aberrations suggests a clonal and genetic relationship between the two lesions. This information further supports the notion for re-classification of SK to an SCC in situ or superficial SCC. Finally, the CNAs detected have been similarly observed in other squamous cell-derived tumours, for example cervical and head and neck SCC. This provides further evidence to common mechanisms involved in the initiation, development and progression of SCC neoplasia. This study has identified a number of recurrent chromosomal regions, some of which are novel in NMSC development. The further delineation of these loci should provide additional evidence of their significance and degree of involvement in NMSC tumourigenesis. The identification of the cancer-causing genes mapped to these loci will further demarcate the genetic mechanisms of BCC and SCC progression. An understanding of the events involved in skin cancer formation and progression should shed additional light on molecular targets for diagnostics, management and therapeutic treatment.

Non-melanoma skin cancer (NMSC) is the most common cancer in the world with a lifetime risk for development as high as 2 in 3 in Queensland, Australia. Mortality is quite low, representing an approximate 360 deaths in Australia annually but cost of treatment is extremely high, estimated at $232 million each year. Squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) are the two most common forms of NMSC. Although BCC generally do not have the propensity to metastasise, they are highly invasive and can be locally destructive. SCC on the other hand is invasive and has metastatic potential. SCC is generally derived from a precursor lesion, solar keratosis (SK), which is also considered to be a biomarker of BCC, SCC and malignant melanoma. According to one theory, SKs actually represent the first recognisable stage of SCC development and therefore may be indicative of the earliest stage of NMSC development. In addition to these common forms of NMSC, rarer forms such as keratoacanthoma (KA), which spontaneously regress, and SCC in situ, which rarely become invasive, may provide clues into protective mechanisms associated with prevention of development. Like all other cancers, NMSC arises from an accumulation of genetic abnormalities that result in severe cellular dysfunction. A number of genes have been proposed in the development of NMSC, including p53, CDKN2a, Bcl-2 and the Ras family of genes, which are typically associated with proliferative and differentiation processes. Also, a number of genetic disorders that predispose individuals to NMSC have also been identified. Genetic abnormalities in these genes may be a result of somatic mutations that may be promoted by environmental carcinogens. For NMSC, ultraviolet (UV) radiation is the primary environmental stimulus that acts upon skin to generate mutations. UV effects are 2-fold; the first being direct damage produced by UVB radiation and the second being indirect damage as a result of UVA-induced oxidative stress. In addition to mutations of genes that directly result in carcinogenesis, polymorphic variants of genes may also play a role in susceptibility to NMSC. These susceptibility genes may have immunogenic, detoxifying or transcriptional roles that could be involved in increased mutagenesis or activation of cancer causing genes. The purpose of this study was ultimately to identify further molecular based mechanisms associated with the development of non-melanoma skin cancer. Initially, this study aimed to examine the effects of aberrant chromosomal regions on NMSC development and also to identify candidate genes within these regions that may be implicated in the development and progression of NMSC. Also, based on chromosomal and functional implications, a number of candidate genes were assessed using association analysis to determine their involvement in susceptibility to the earliest stages of NMSC development. Implicated susceptibility genes were then further investigated to determine their response to UV radiation. Therefore the methodological approach of these studies was based on three broad technical applications of cytogenetic, association and expression analyses. Previous comparative genomic hybridisation (CGH) studies implicated the 18q chromosomal region in progression of SK to SCC and this region was therefore suspected of harbouring one or more tumour suppressor genes that were associated with a more malignant phenotype. Following on from this analysis, loss of heterozygosity (LOH) analysis was used for further delineation of this region and possibly to implicate candidate genes involved in progression. Additionally, CGH was used to investigate keratoacanthoma to determine aberrant regions that might be involved in progression and also regression of this NMSC. Genes that had potential functional roles in NMSC development and that were located in or near regions implicated by these cytogenetic analyses were further investigated using association analysis. Association analysis was performed using polymerase chain reaction and subsequent restriction enzyme digestion or GeneScan analysis to determine genotype and allele frequencies in an SK affected versus control population for polymorphisms within a number of candidate genes. This population was carefully phenotyped so that not only genotypic factors could be analysed but also their interaction with a number of phenotypic and environmental risk factors. Genes with polymorphisms that did show association with solar keratosis development were then examined functionally. Specifically, gene expression analysis was undertaken to investigate their response to UV radiation. Both UVA only and combined UVA/UVB treatments were used for short term irradiation and also for long term irradiation with recovery to determine differential effects of UV range and dose in human skin. Relative mRNA expression analysis of these genes was performed using quantitative real time reverse transcription polymerase chain reaction to determine if UV radiation imposed gene expression changes in the skin. A combination of these methodologies provided a wide basis for investigation of NMSC. Cytogenetic, association and expression analyses all allow for the identification of molecular risk factors that cause or are associated with NMSC development and progression. These analyses provided diverse results that implicated various molecular mechanisms in the development of NMSC. Cytogenetic analysis is a powerful technique, especially for the identification of a broad range of aberrations throughout the genome. This study employed LOH analysis to investigate an implicated region involved in progression to SCC and to attempt identification of candidate genes that may be involved in this process. LOH analysis was successfully performed on 9 SCCs, 5 SCCs in situ and 2 SKs using 8 microsatellite markers within the 18q region. Polymerase chain reaction (PCR) was used to amplify polymorphic regions of these markers and genotypic composition was determined for normal and cancerous tissue within the specimen. In heterozygote individuals, determined by analysis of normal tissue, the cancerous tissue was examined to determine if alleles within the implicated region had been lost. However, after analysis of multiple different samples, there was no LOH detected in any of the samples examined for this analysis. This does not necessarily reject a role for 18q, or genes within this region, as the localisation of candidate tumour suppressor genes within a small region may indicate a tighter region of involvement than was expected. As such, a more targeted study may further delineate this region and implicate candidate genes in progression of SK to the more malignant phenotype of SCC. Further CGH analysis of keratoacanthoma was also undertaken to identify aberrations associated with development and also regression of this skin cancer. CGH was performed using universal amplification and nick translation to incorporate a fluorescent dye. Differentially labelled normal and tumour DNA were then competitively hybridised to a normal metaphase spread and fluorescence emission indicated either amplification or deletion of specific chromosomal regions. In total, 6 KA samples were analysed, with 2 samples each from evolving, matured and regressing stages of KA development. In general, regressing KAs appeared to be more highly associated with deleted regions than evolving and matured KAs. Specifically, the 15q chromosomal region that was deleted in regressing KAs but amplified in evolving or matured KAs, may be significantly involved in the process of KA regression. Also various candidate genes that were being considered for analysis were located in or near some of these implicated regions, including GSTM1, GSTP1 and SSTR2. As such, these candidate genes were targeted for further investigation. A number of susceptibility genes that were located in or near aberrant regions implicated in NMSC development were investigated using association analysis. These genes included members of the somatostatin receptor family (SSTR1 and SSTR2), members of the glutathione-S-transferase (GST) family (GSTM1, GSTT1, GSTP1 and GSTZ1) and the vitamin D receptor (VDR). Studies detected a number of interesting interactions between genetic, environmental and phenotypic factors in the development of the early stages of non-melanoma skin cancer. Additionally, genes implicated in NMSC development were further investigated using expression analysis to determine response to UV radiation. Association analysis was initially performed on members of the somatostatin receptor family. Somatostatin is a growth inhibiting factor, amongst other things, that mediates its actions through the somatostatin receptors (SSTRs). The presence of these receptors (SSTR1-5) in tumour cells indicates a potential for somatostatin to bind and suppress growth, as well as allowing for therapeutic treatment with somatostatin analogues. Additionally, expression of these receptors in normal tissue, including skin, should allow for potential protection against tumour growth. The genes for SSTR1 and SSTR2 have been shown to contain dinucleotide repeat polymorphisms, and although these polymorphisms may not directly result in altered expression or binding potential, they may be linked to another functional polymorphism that does. Using association analysis the SSTR1 and SSTR2 genes were investigated to determine whether they play a role in the development of solar keratosis. Results showed that there were no significant differences between SSTR1 and SSTR2 polymorphism frequencies in the tested solar keratosis population (P = 0.10 and P = 0.883, respectively) as compared to an unaffected population. Hence, these studies do not support a role for the SSTR1 or SSTR2 genes in solar keratosis development. Further association analysis and subsequent expression analysis was also performed on members of the glutathione-S-transferase family. The GST enzymes play a role in the detoxification of a number of carcinogens and mutagens, including those produced by UV-induced oxidative stress. This study examined the role of GSTM1, GSTT1, GSTP1 and GSTZ1 gene polymorphisms in susceptibility to SK development. Association analysis was performed to detect allele and genotype frequency differences in SK affected and control populations using PCR and restriction enzyme digestion. No significant differences were detected in GSTP1 and GSTZ1 allele or genotype frequencies, however polymorphisms within both genes were found to be in linkage disequilibrium, as previously reported, and a new allelic variant of the GSTZ1 gene was identified. Significant associations between GSTM1 (P = 0.003) and GSTT1 (P = 0.039) genotypes and SK development were detected, with the null variants of both genes conferring an approximate 2-fold increase in risk for solar keratosis development (OR: 2.1; CI: 1.3-3.5 and OR: 2.3; CI: 1.0-5.0 for GSTM1 and GSTT1, respectively). For the GSTM1 gene, this risk was significantly higher in conjunction with high outdoor exposure (OR: 3.4; CI: 1.9-6.3) and although the GSTT1 gene showed a similar trend (OR: 2.9; CI: 1.1-7.7), this did not reach significance. The increased risk of SK development associated with these genes is likely due to a decreased ability of the skin to detoxify mutagenic compounds produced by UV-induced oxidative stress, and hence a decreased ability to protect against carcinogenesis. Implication of the GSTM1 and GSTT1 null variants in solar keratosis development prompted interest in analysis of gene expression changes in response to UV radiation. Due to the high homology of the GSTM1 gene with other GSTM genes, and therefore potential issues with primer specificity, the GSTT1 gene was focussed on for the expression studies. Real time reverse transcription PCR, incorporating SYBR green fluorescence and 18S as a comparative gene, was used to study GSTT1 gene expression changes in response to both UVA and combined UVA/UVB radiation. It was found that only short term UV radiation had an effect on GSTT1 expression changes, whereas no alteration of gene expression was seen after 4 and 12 hours of recovery from long term irradiation between irradiated and matched non-irradiated skin samples. This indicated that changes in gene expression for the GSTT1 gene apparently occur relatively quickly after exposure to UV radiation. Analysis of both UVA only and combined UVA/UVB short term irradiation indicated that an initial decrease in expression, followed by an increase was likely to represent translation into protein and subsequent transcription of mRNA, and in some cases a second decrease indicated further translation. Hence, it appears as though UV radiation does have a significant effect on the expression of at least one GST gene, and that UV radiation in combination with genetic variation of these genes may play a role in the development of NMSC. Finally, association and subsequent expression analysis was also performed on the vitamin D receptor. The hormonal form of vitamin D, 1a25 dihydroxyvitamin D3, has been shown to have numerous cancer-related effects, including antiproliferative, differentiation, proapoptotic and antiangiogenic effects. These effects are mediated through the binding of 1a25 dihydroxyvitamin D3 to the vitamin D receptor and subsequent transcriptional pathways. Polymorphisms within the VDR are known to regulate its transcription and therefore expression, which is linked to the ability of 1a25 dihydroxyvitamin D3 to bind. Association analysis of a 5’ initiation codon variant (Fok I) and two 3’ variants (Apa I and Taq I) was performed in SK affected and control populations. Although the Fok I variant showed no association with SK development, both the Apa I and Taq I variants were found to be associated with SK development (P = 0.043 and P = 0.012, respectively). In particular, the Aa and Tt genotypes were associated with increased risk of SK. These results were however more complicated, as shown by further analysis. This showed that genotypes containing at least one allele that conferred decreased VDR transcription (ie. AA/Aa and Tt/tt) increased risk of SK development by 2-fold in fair skinned individuals (OR: 2.1; CI: 1.2-3.7 and OR: 1.7; CI: 1.1-2.7 for Apa I and Taq I variants, respectively) but also found to decrease the risk of SK development by 2-fold in medium skinned individuals (OR: 0.5; CI: 0.3-1.0 for Apa I variants). Additionally, genotypes containing 2 alleles conferring decreased transcription of the VDR gene were found to further increase the risk for SK development in fair skinned individuals (OR: 2.5; CI: 1.4-4.5 and OR: 2.4; CI: 1.2-5.0 for Apa I and Taq I variants, respectively), indicating a possible additive effect for the alleles. The highly differential association of the VDR gene polymorphisms amongst phenotypes may reflect a combination between the ability of an individual to synthesise 1a25 dihydroxyvitamin D3 with the binding availability of the VDR. To further investigate the role of VDR in NMSC, expression analysis of the VDR gene was undertaken using real time reverse transcription PCR, with SYBR green fluorescence and 18S as a comparative gene, to examine expression pattern changes associated with UV radiation. It was found that short term irradiation, as well as long term irradiation and recovery were associated with gene expression changes. Short term irradiation resulted in patterns indicative of translation and subsequent transcription, whereas long term irradiated samples resulted in reduction of VDR expression that was recovered after an extended period of time. Thus, VDR expression is clearly influenced by UV exposure. It would be very interesting to see more specifically if particular VDR genotypes, which appear to play a role in NMSC risk, also are affected differentially by UV exposure. It is possible that VDR expression is reduced to limit excessive binding of 1a25 dihydroxyvitamin D3, although since both UVA and UVB radiation affect VDR expression, this may not be mediated the effect of 1a25 dihydroxyvitamin D3 but rather a different pathway resulting from a general UV response. In summary, the detection of a number of susceptibility genes involved in SK development and their subsequent expression analysis in response to UV radiation has given further insight into the molecular changes associated with NMSC. In fact, both detoxification genes (GSTM1 and GSTT1) and a transcription related gene (VDR), were found to confer susceptibility to solar keratosis, an early stage skin lesion with tumourigenic potential. This suggests that even the earliest stages of skin cancer are mediated through a wide range of effects. Additionally, expression changes related to these genes indicate that they are associated with the well known environmental carcinogen of UV radiation and that their effects may be mediated through a wide range of pathways. Although implication of the 18q region in SCC progression was not confirmed in this study, it is still likely to play a role in malignant transformation. The implication of this region, as well as the implication of susceptibility genes has vastly increased knowledge into processes associated with NMSC. Although additional analysis can confirm and further implicate these molecular alterations, this study has resulted in a more comprehensive understanding of NMSC that may ultimately be of benefit in terms of prognosis and treatment.

Non-melanoma skin cancer (NMSC) is the most common cancer in the world with a lifetime risk for development as high as 2 in 3 in Queensland, Australia. Mortality is quite low, representing an approximate 360 deaths in Australia annually but cost of treatment is extremely high, estimated at $232 million each year. Squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) are the two most common forms of NMSC. Although BCC generally do not have the propensity to metastasise, they are highly invasive and can be locally destructive. SCC on the other hand is invasive and has metastatic potential. SCC is generally derived from a precursor lesion, solar keratosis (SK), which is also considered to be a biomarker of BCC, SCC and malignant melanoma. According to one theory, SKs actually represent the first recognisable stage of SCC development and therefore may be indicative of the earliest stage of NMSC development. In addition to these common forms of NMSC, rarer forms such as keratoacanthoma (KA), which spontaneously regress, and SCC in situ, which rarely become invasive, may provide clues into protective mechanisms associated with prevention of development. Like all other cancers, NMSC arises from an accumulation of genetic abnormalities that result in severe cellular dysfunction. A number of genes have been proposed in the development of NMSC, including p53, CDKN2a, Bcl-2 and the Ras family of genes, which are typically associated with proliferative and differentiation processes. Also, a number of genetic disorders that predispose individuals to NMSC have also been identified. Genetic abnormalities in these genes may be a result of somatic mutations that may be promoted by environmental carcinogens. For NMSC, ultraviolet (UV) radiation is the primary environmental stimulus that acts upon skin to generate mutations. UV effects are 2-fold; the first being direct damage produced by UVB radiation and the second being indirect damage as a result of UVA-induced oxidative stress. In addition to mutations of genes that directly result in carcinogenesis, polymorphic variants of genes may also play a role in susceptibility to NMSC. These susceptibility genes may have immunogenic, detoxifying or transcriptional roles that could be involved in increased mutagenesis or activation of cancer causing genes. The purpose of this study was ultimately to identify further molecular based mechanisms associated with the development of non-melanoma skin cancer. Initially, this study aimed to examine the effects of aberrant chromosomal regions on NMSC development and also to identify candidate genes within these regions that may be implicated in the development and progression of NMSC. Also, based on chromosomal and functional implications, a number of candidate genes were assessed using association analysis to determine their involvement in susceptibility to the earliest stages of NMSC development. Implicated susceptibility genes were then further investigated to determine their response to UV radiation. Therefore the methodological approach of these studies was based on three broad technical applications of cytogenetic, association and expression analyses. Previous comparative genomic hybridisation (CGH) studies implicated the 18q chromosomal region in progression of SK to SCC and this region was therefore suspected of harbouring one or more tumour suppressor genes that were associated with a more malignant phenotype. Following on from this analysis, loss of heterozygosity (LOH) analysis was used for further delineation of this region and possibly to implicate candidate genes involved in progression. Additionally, CGH was used to investigate keratoacanthoma to determine aberrant regions that might be involved in progression and also regression of this NMSC. Genes that had potential functional roles in NMSC development and that were located in or near regions implicated by these cytogenetic analyses were further investigated using association analysis. Association analysis was performed using polymerase chain reaction and subsequent restriction enzyme digestion or GeneScan analysis to determine genotype and allele frequencies in an SK affected versus control population for polymorphisms within a number of candidate genes. This population was carefully phenotyped so that not only genotypic factors could be analysed but also their interaction with a number of phenotypic and environmental risk factors. Genes with polymorphisms that did show association with solar keratosis development were then examined functionally. Specifically, gene expression analysis was undertaken to investigate their response to UV radiation. Both UVA only and combined UVA/UVB treatments were used for short term irradiation and also for long term irradiation with recovery to determine differential effects of UV range and dose in human skin. Relative mRNA expression analysis of these genes was performed using quantitative real time reverse transcription polymerase chain reaction to determine if UV radiation imposed gene expression changes in the skin. A combination of these methodologies provided a wide basis for investigation of NMSC. Cytogenetic, association and expression analyses all allow for the identification of molecular risk factors that cause or are associated with NMSC development and progression. These analyses provided diverse results that implicated various molecular mechanisms in the development of NMSC. Cytogenetic analysis is a powerful technique, especially for the identification of a broad range of aberrations throughout the genome. This study employed LOH analysis to investigate an implicated region involved in progression to SCC and to attempt identification of candidate genes that may be involved in this process. LOH analysis was successfully performed on 9 SCCs, 5 SCCs in situ and 2 SKs using 8 microsatellite markers within the 18q region. Polymerase chain reaction (PCR) was used to amplify polymorphic regions of these markers and genotypic composition was determined for normal and cancerous tissue within the specimen. In heterozygote individuals, determined by analysis of normal tissue, the cancerous tissue was examined to determine if alleles within the implicated region had been lost. However, after analysis of multiple different samples, there was no LOH detected in any of the samples examined for this analysis. This does not necessarily reject a role for 18q, or genes within this region, as the localisation of candidate tumour suppressor genes within a small region may indicate a tighter region of involvement than was expected. As such, a more targeted study may further delineate this region and implicate candidate genes in progression of SK to the more malignant phenotype of SCC. Further CGH analysis of keratoacanthoma was also undertaken to identify aberrations associated with development and also regression of this skin cancer. CGH was performed using universal amplification and nick translation to incorporate a fluorescent dye. Differentially labelled normal and tumour DNA were then competitively hybridised to a normal metaphase spread and fluorescence emission indicated either amplification or deletion of specific chromosomal regions. In total, 6 KA samples were analysed, with 2 samples each from evolving, matured and regressing stages of KA development. In general, regressing KAs appeared to be more highly associated with deleted regions than evolving and matured KAs. Specifically, the 15q chromosomal region that was deleted in regressing KAs but amplified in evolving or matured KAs, may be significantly involved in the process of KA regression. Also various candidate genes that were being considered for analysis were located in or near some of these implicated regions, including GSTM1, GSTP1 and SSTR2. As such, these candidate genes were targeted for further investigation. A number of susceptibility genes that were located in or near aberrant regions implicated in NMSC development were investigated using association analysis. These genes included members of the somatostatin receptor family (SSTR1 and SSTR2), members of the glutathione-S-transferase (GST) family (GSTM1, GSTT1, GSTP1 and GSTZ1) and the vitamin D receptor (VDR). Studies detected a number of interesting interactions between genetic, environmental and phenotypic factors in the development of the early stages of non-melanoma skin cancer. Additionally, genes implicated in NMSC development were further investigated using expression analysis to determine response to UV radiation. Association analysis was initially performed on members of the somatostatin receptor family. Somatostatin is a growth inhibiting factor, amongst other things, that mediates its actions through the somatostatin receptors (SSTRs). The presence of these receptors (SSTR1-5) in tumour cells indicates a potential for somatostatin to bind and suppress growth, as well as allowing for therapeutic treatment with somatostatin analogues. Additionally, expression of these receptors in normal tissue, including skin, should allow for potential protection against tumour growth. The genes for SSTR1 and SSTR2 have been shown to contain dinucleotide repeat polymorphisms, and although these polymorphisms may not directly result in altered expression or binding potential, they may be linked to another functional polymorphism that does. Using association analysis the SSTR1 and SSTR2 genes were investigated to determine whether they play a role in the development of solar keratosis. Results showed that there were no significant differences between SSTR1 and SSTR2 polymorphism frequencies in the tested solar keratosis population (P = 0.10 and P = 0.883, respectively) as compared to an unaffected population. Hence, these studies do not support a role for the SSTR1 or SSTR2 genes in solar keratosis development. Further association analysis and subsequent expression analysis was also performed on members of the glutathione-S-transferase family. The GST enzymes play a role in the detoxification of a number of carcinogens and mutagens, including those produced by UV-induced oxidative stress. This study examined the role of GSTM1, GSTT1, GSTP1 and GSTZ1 gene polymorphisms in susceptibility to SK development. Association analysis was performed to detect allele and genotype frequency differences in SK affected and control populations using PCR and restriction enzyme digestion. No significant differences were detected in GSTP1 and GSTZ1 allele or genotype frequencies, however polymorphisms within both genes were found to be in linkage disequilibrium, as previously reported, and a new allelic variant of the GSTZ1 gene was identified. Significant associations between GSTM1 (P = 0.003) and GSTT1 (P = 0.039) genotypes and SK development were detected, with the null variants of both genes conferring an approximate 2-fold increase in risk for solar keratosis development (OR: 2.1; CI: 1.3-3.5 and OR: 2.3; CI: 1.0-5.0 for GSTM1 and GSTT1, respectively). For the GSTM1 gene, this risk was significantly higher in conjunction with high outdoor exposure (OR: 3.4; CI: 1.9-6.3) and although the GSTT1 gene showed a similar trend (OR: 2.9; CI: 1.1-7.7), this did not reach significance. The increased risk of SK development associated with these genes is likely due to a decreased ability of the skin to detoxify mutagenic compounds produced by UV-induced oxidative stress, and hence a decreased ability to protect against carcinogenesis. Implication of the GSTM1 and GSTT1 null variants in solar keratosis development prompted interest in analysis of gene expression changes in response to UV radiation. Due to the high homology of the GSTM1 gene with other GSTM genes, and therefore potential issues with primer specificity, the GSTT1 gene was focussed on for the expression studies. Real time reverse transcription PCR, incorporating SYBR green fluorescence and 18S as a comparative gene, was used to study GSTT1 gene expression changes in response to both UVA and combined UVA/UVB radiation. It was found that only short term UV radiation had an effect on GSTT1 expression changes, whereas no alteration of gene expression was seen after 4 and 12 hours of recovery from long term irradiation between irradiated and matched non-irradiated skin samples. This indicated that changes in gene expression for the GSTT1 gene apparently occur relatively quickly after exposure to UV radiation. Analysis of both UVA only and combined UVA/UVB short term irradiation indicated that an initial decrease in expression, followed by an increase was likely to represent translation into protein and subsequent transcription of mRNA, and in some cases a second decrease indicated further translation. Hence, it appears as though UV radiation does have a significant effect on the expression of at least one GST gene, and that UV radiation in combination with genetic variation of these genes may play a role in the development of NMSC. Finally, association and subsequent expression analysis was also performed on the vitamin D receptor. The hormonal form of vitamin D, 1a25 dihydroxyvitamin D3, has been shown to have numerous cancer-related effects, including antiproliferative, differentiation, proapoptotic and antiangiogenic effects. These effects are mediated through the binding of 1a25 dihydroxyvitamin D3 to the vitamin D receptor and subsequent transcriptional pathways. Polymorphisms within the VDR are known to regulate its transcription and therefore expression, which is linked to the ability of 1a25 dihydroxyvitamin D3 to bind. Association analysis of a 5Â’ initiation codon variant (Fok I) and two 3Â’ variants (Apa I and Taq I) was performed in SK affected and control populations. Although the Fok I variant showed no association with SK development, both the Apa I and Taq I variants were found to be associated with SK development (P = 0.043 and P = 0.012, respectively). In particular, the Aa and Tt genotypes were associated with increased risk of SK. These results were however more complicated, as shown by further analysis. This showed that genotypes containing at least one allele that conferred decreased VDR transcription (ie. AA/Aa and Tt/tt) increased risk of SK development by 2-fold in fair skinned individuals (OR: 2.1; CI: 1.2-3.7 and OR: 1.7; CI: 1.1-2.7 for Apa I and Taq I variants, respectively) but also found to decrease the risk of SK development by 2-fold in medium skinned individuals (OR: 0.5; CI: 0.3-1.0 for Apa I variants). Additionally, genotypes containing 2 alleles conferring decreased transcription of the VDR gene were found to further increase the risk for SK development in fair skinned individuals (OR: 2.5; CI: 1.4-4.5 and OR: 2.4; CI: 1.2-5.0 for Apa I and Taq I variants, respectively), indicating a possible additive effect for the alleles. The highly differential association of the VDR gene polymorphisms amongst phenotypes may reflect a combination between the ability of an individual to synthesise 1a25 dihydroxyvitamin D3 with the binding availability of the VDR. To further investigate the role of VDR in NMSC, expression analysis of the VDR gene was undertaken using real time reverse transcription PCR, with SYBR green fluorescence and 18S as a comparative gene, to examine expression pattern changes associated with UV radiation. It was found that short term irradiation, as well as long term irradiation and recovery were associated with gene expression changes. Short term irradiation resulted in patterns indicative of translation and subsequent transcription, whereas long term irradiated samples resulted in reduction of VDR expression that was recovered after an extended period of time. Thus, VDR expression is clearly influenced by UV exposure. It would be very interesting to see more specifically if particular VDR genotypes, which appear to play a role in NMSC risk, also are affected differentially by UV exposure. It is possible that VDR expression is reduced to limit excessive binding of 1a25 dihydroxyvitamin D3, although since both UVA and UVB radiation affect VDR expression, this may not be mediated the effect of 1a25 dihydroxyvitamin D3 but rather a different pathway resulting from a general UV response. In summary, the detection of a number of susceptibility genes involved in SK development and their subsequent expression analysis in response to UV radiation has given further insight into the molecular changes associated with NMSC. In fact, both detoxification genes (GSTM1 and GSTT1) and a transcription related gene (VDR), were found to confer susceptibility to solar keratosis, an early stage skin lesion with tumourigenic potential. This suggests that even the earliest stages of skin cancer are mediated through a wide range of effects. Additionally, expression changes related to these genes indicate that they are associated with the well known environmental carcinogen of UV radiation and that their effects may be mediated through a wide range of pathways. Although implication of the 18q region in SCC progression was not confirmed in this study, it is still likely to play a role in malignant transformation. The implication of this region, as well as the implication of susceptibility genes has vastly increased knowledge into processes associated with NMSC. Although additional analysis can confirm and further implicate these molecular alterations, this study has resulted in a more comprehensive understanding of NMSC that may ultimately be of benefit in terms of prognosis and treatment.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Health Sciences
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Genetic changes are hallmarks of cancer development involving the activation and/or inactivation of oncogenes and tumour suppressor genes, respectively. In non-melanoma skin cancer (NMSC) development, the initiation of genetic mutations results from exposure to solar ultraviolet radiation. Non-melanoma skin cancers are comprised of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Several related cutaneous lesions also exist, of which solar keratoses (SK) are widely accepted as a precursor dysplasia to SCC development. The study of recurrent genetic changes present within NMSC and SK should help reveal causative mutations in skin cancer development. Such analysis could also elucidate links in the genetic similarity of these dysplasia. The rapid screening of numerical changes in DNA sequence copy number throughout the entire genome has been made possible by the advent of comparative genomic hybridisation (CGH). This technique enables the identification of net gains and loss of genetic material within a tumour DNA sample. Chromosomal regions of recurrent gain or loss identify loci containing putative oncogenes and tumour suppressor genes, respectively with potential roles in NMSC tumourigenesis. Used in conjunction with tissue microdissection and universal degenerate PCR techniques this can enable the elucidation of aberrations in small histologically distinct regions of tumour. Such a technique can utilize archival material such as paraffin embedded tissue, which is the major source of neoplastic material available for cancer research. This study used the CGH technique to investigate aberrations in BCC, SCC and SK samples. The screening of copy number abnormalities (CNAs) in BCC revealed that although these tumours were close to diploid and generally genetically stable, they did contain several recurrent aberrations. The loss of genetic material at 9q was identified in a third of BCC tumours studied. This is characteristic of inactivation of the PTCH tumour suppressor gene, a known attribute in some sporadic BCC development. Validation of this loss was performed via loss of heterozygosity, demonstrating good concordance with the CGH data. In addition the over-representation of the 6p chromosome arm was revealed in 47% of biopsies. This novel CNA is also commonly observed in other cutaneous neoplasias, including Merkel cell carcinoma and malignant melanoma. This suggests a possible common mechanism in development and or promotion in these cutaneous dysplasias, the mechanisms of which have yet to be clearly defined. In contrast to BCC, numerical genetic aberrations in SCC and SK were much more frequent. Several regions of recurrent gain were commonly shared between both dysplasias including gain of 3q, 4p, 5p, 8q, 9q, 14q, 17p, 17q and 20q. Common chromosomal regions of loss included 3p, 8p, 9p, 11p, 13q and 17p. In addition loss of chromosome 18 was significantly observed in SCC in comparison to SK, a possible defining event in SK progression to SCC. The identification of shared genetic aberrations suggests a clonal and genetic relationship between the two lesions. This information further supports the notion for re-classification of SK to an SCC in situ or superficial SCC. Finally, the CNAs detected have been similarly observed in other squamous cell-derived tumours, for example cervical and head and neck SCC. This provides further evidence to common mechanisms involved in the initiation, development and progression of SCC neoplasia. This study has identified a number of recurrent chromosomal regions, some of which are novel in NMSC development. The further delineation of these loci should provide additional evidence of their significance and degree of involvement in NMSC tumourigenesis. The identification of the cancer-causing genes mapped to these loci will further demarcate the genetic mechanisms of BCC and SCC progression. An understanding of the events involved in skin cancer formation and progression should shed additional light on molecular targets for diagnostics, management and therapeutic treatment.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Health Sciences
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Human cancer stem cells are proposed to play a critical role in tumour initiation and maintenance by their exclusive ability to regenerate the tumour. Thus cancer stem cells share many of the properties of normal stem cell including self-renewal and ability to give rise to progeny which undergo tissue-specific differentiation. Thus we hypothesised that by determining the normal patterns of tissue differentiation within cancer we could identify tumour type specific factors that promote differentiation, for therapeutic development. Therefore the aim of this study is to define patterns of human hair follicle differentiation in human basal cell carcinoma (BCC) in order to elucidate potential drug-able targets that can promote tumour specific differentiation. To test this hypothesis we analysed 20 different hair follicle specific differentiation markers, which define distinct layers within the normal adult hair, in six different human BCC samples using RT-PCR with normal hair follicle tissue as control. For the 12 specific keratin genes expressed in the BCC, we analysed expression by immunofluorescence on 20 different BCC samples, using hair follicle samples as positive controls. Our findings suggest that human BCC demonstrates both inward and upward differentiation patterns similar to the hair follicle, with expression of: outer root sheath (K5,14,16,and k17), companion layer (K75), inner root sheath (K26,27,28,71,72,and k74), and cuticle (K32,35,82,and k85); but not hair shaft (K31) markers. Consistent with these findings we observed the mutually exclusive relationship between expression of the early differentiation marker K19 and cell proliferation in the hair follicle and BCC. Similarly, expression of the outer root sheath keratins coincided with nuclear translocation of both GLI1 and NFIL-6, suggesting that BCC also share normal hair follicle tissue regulatory pathways. To further test the hypothesis that normal tissue factors observed in the hair follicle regulate BCC differentiation we have developed an in vitro BCC assay. Using this tissue culture model we hypothesised that BCC’s are stuck in the telogen part of the hair follicle cycle, resulting from autocrine expression of bone morphogenic proteins 2 and 4. Inhibition of BMP signalling by addition of noggin as well as addition of TGF-β to BCC colonies in tissue culture led to further induction of inner root sheath, cuticle and medulla keratins. In summary we have shown that BCC exhibit hair follicle differentiation, which is similarly regulated, but is stuck in telogen arrest and can be rescued by addition of noggin and TGF- β2.

Non-melanoma skin cancer (NMSC), including basal and squamous cell carcinoma (BCC and SCC, respectively), is the most common malignancy among populations of European ancestry. It is estimated that over 2 million cases of NMSC occur each year in the United States, with the incidence continues to increase. This disease imposes a growing burden on healthcare system, making it an important public health issue. However, understanding of its etiology and biological mechanisms remains incomplete. In Chapter 1 of this dissertation, we applied a novel approach that integrates skin expression-related single-nucleotide polymorphisms (eSNPs) and pathway analysis to identify potential novel biological pathways that are associated with BCC risk. We evaluated the associations of skin eSNPs with BCC among 2,323 cases and 7,275 controls of European ancestry, and assigned them to the pathways defined by KEGG, GO, and BioCarta databases. Three KEGG pathways (colorectal cancer, regulation of actin cytoskeleton, and basal cell carcinoma) and two GO pathways (cellular component disassembly involved in apoptosis, and nucleus organization) showed significant association with BCC risk. Our results indicate that genes that are undetectable by conventional genome-wide association studies (GWASs) are significantly associated with risk of BCC as groups. In Chapter 2, we tested gene-caffeine consumption interaction on BCC risk in a genome-wide analysis. We determined that SNP rs142310826 shows a genome-wide significant interaction with caffeine consumption (p = 1.78x10-8 for interaction, p = 0.64 for heterogeneity between genders) on BCC risk. We also found several loci that modify the caffeine-BCC association differently in men and women. This study is proof of concept that inclusion of environmental factors can help identify genes that are missed in conventional GWASs. In Chapter 3, we prospectively examined the risk of SCC and BCC in relation to adult height. After controlling for potential confounding factors, the hazard ratios were 1.09 (95% CI: 1.03, 1.16) and 1.10 (95% CI: 1.07, 1.12) for the associations between every 10cm increase in height and risk of SCC and BCC respectively. However, no significant association was observed between height-related SNPs and risk of these diseases.

Exposure to ultraviolet radiation and immunosuppression are the principal causes of non-melanoma skin cancer (NMSC). One of the skin’s main functions is to act as a barrier against environmental insults and transepidermal water loss (TEWL) is a marker of skin barrier function. Previous phase 2 studies have shown nicotinamide (NAM) to reduce premalignant actinic keratoses. Topical NAM has been shown to reduce TEWL. The effects of oral NAM were evaluated in two clinical trials. The Oral Nicotinamide To Reduce Actinic Cancer (ONTRAC) study was a multicentre phase 3, double-blind, randomised controlled trial in 386 immune-competent participants with at least 2 NMSCs in the past 5 years. Participants were randomised to receive 500mg of NAM or placebo twice daily for 12 months, with assessment at 3-monthly intervals for 18 months. TEWL measurements were taken 3-monthly for 12 months in 292 participants at a single study site. The primary end point was the number of new histologically-confirmed NMSCs during the 12-month intervention period. A second, phase 2 pilot study was undertaken in 22 immunosuppressed renal transplant recipients who were randomised to receive 500mg of NAM or placebo twice daily for 6 months, with assessments at 2-monthly intervals. The ONTRAC study found a 23% relative rate reduction in new NMSCs in the NAM group compared to the placebo group (p=0.02). The estimated relative reduction in TEWL with NAM at 12 months was 6% on the forehead (p=0.04) and 8% on the limbs (p=0.04). The nicotinamide renal transplant pilot study found new NMSCs to be 35% lower in the NAM group than the placebo group (p=0.4). Oral NAM was well-tolerated and safe. The work described in this thesis provides evidence that NAM is a new chemopreventive agent for NMSC in high-risk immune-competent patients. Phase 3 studies are now warranted in immunosuppressed organ transplant recipients. Nicotinamide is also a potential new systemic agent for improving skin barrier function.

Non-melanoma skin (NMSC) cancer is the most common human malignancy. Cutaneous squamous cell carcinoma (cSCC) and its precursor, actinic keratosis (AK) affect tens of thousands of people each year in the UK. Merkel cell carcinoma is a rare, yet aggressive type of NMSC recently linked with Merkel Cell Polyomavirus (MCPyV). In spite of the clinical burden of NMSC, key molecular regulatory patterns remain largely unknown. The aims of this thesis were to investigate genome-wide genetic, epigenetic and transcriptional changes in AK and cSCC, and assess the prevalence of MCPyV and its effect on methylation in NMSC. Copy-number analysis revealed that AK harbours significantly more genomic aberrations compared to skin, the majority of which occurs on chromosomes 8 and 9. Transcriptional profiling has found 292 and 308 genes as differentially expressed in AK compared to non-sunexposed and sun-exposed skin, respectively, and gene-set enrichment analysis (GSEA) revealed dysregulation of PPAR pathway in this lesion. Expression profiling of cSCC and AK has revealed 346 differentially expressed genes, and GSEA detected dysregulation in several canonical pathways including TGF-β and MAPK pathway. Aberrant methylation in cSCC cell lines occurs in the promoters of many developmental genes. A total of 1085 hyper- and 833 hypomethylated genes were detected in cSCCs, and GSEA revealed dysregulation of critical signalling pathways (WNT, MAPK signalling pathways). Methylation analysis of AK revealed a total of 4194 differentially methylated genes, and implicated FOXF2, PITX2, RUNX1 and SMAD3 transcription factors in this lesions. MiRNA profiling of cSCC and normal skin revealed significant dysregulation of 38 miRNAs including several of viral origin. MCPyV was shown to be common in NMSC, yet MCPyV nor human papillomavirus does not affect cSCC methylation. Taken together, this work provides novel insight into molecular regulation of cSCC oncogenesis, and identifies potential epigenetic targets for functional evaluation in this malignancy.

Background: Australia has the highest incidence of non-melanoma skin cancer (NMSC) in the world. These cancers are predominantly caused by exposure to ultraviolet radiation (UVR) in sunlight. Brm is an ATPase subunit that drives chromatin remodelling via the SWI/SNF complex. Thus, Brm is able to regulate access to transcription factors and repair enzymes to DNA, in addition to cell division. The loss of Brm has been observed in several cancer types, where its loss correlates with decreased patient survival. The loss of Brm has been identified in NMSC, but not pre-malignant lesions, suggesting Brm plays a role in the progression of a benign skin lesion into a malignant skin cancer. Brm-deficient mice also harbour excessive levels of epidermal hyperplasia as well as heightened tumour incidence following UVR as compared to mice with wildtype Brm. Moreover, a novel hotspot mutation of Brm (Q203K) has also been discovered in 17% of NMSC studied, which was the first mutation of Brm discovered in any type of cancer. Aims: This thesis aims to study the function of the Q203K mutation as compared to the loss of Brm in several key aspects of keratinocyte responses to UV-induced DNA damage: proliferation, cell cycle regulation, UVR-induced cell death and DNA repair. Methods: The loss of Brm was studied with keratinocytes grown ex vivo from neonatal Brm-/- mice and compared to keratinocytes grown from Brm+/+ mice. Further, a human keratinocyte cell line, HaCaT was also studied, in combination with Brm miRNAs to knockdown Brm expression in these cells. The overexpression of either wildtype or Q203K Brm was also studied in HaCaTs. These cells were treated with UV, and their responses were observed using assays for cell growth, cell death, cell cycle regulation and DNA repair. Results: In neonatal mouse keratinocytes, as well as HaCaT cells, the loss of Brm expression led to an altered cellular response to UVR. Cells lacking Brm exhibited increased proliferative potential following UVR due to a reduced time spent in G1 cell cycle arrest. Further, Brm-deficient cells displayed increased formation of UVR-induced cyclobutane pyrimidine dimers (CPDs) in the dark. Interestingly, when Brm was knocked down in the immortalised human keratinocyte cell line HaCaT, these cells were not as sensitive to the loss of Brm in combination with UVR, and showed less prominent effects on both cell cycle regulation and CPD formation. It was hypothesised that primary neonatal keratinocytes were more sensitive to UVR due to these cells being naïve, whereas HaCaT cells already exhibit several UVR-induced mutations, such as that of p53. Therefore, the loss of Brm in mouse neonatal keratinocytes was more catastrophic to the cell. Lastly, the mutation of Q203K did not lead to increased cellular sensitivity to UVR, suggesting the presence of this mutation in NMSC was most likely non-functional. However, increasing levels of Brm in HaCaT cells did lead to enhanced levels of cell viability at high density, which the Q203K mutation was able to reverse, suggesting Q203K does display some functionality, and thus may play a role in other functions not studied in this thesis. Conclusions: The loss of Brm but not the Q203K mutant in combination with UVR is enough to cause increased cellular sensitivity in the cell, leading to the proliferation of cells whilst harbouring DNA damage via defective cell cycle checkpoints. This would likely lead to heightened levels of mutations in the cell, and increased carcinogenesis downstream, as previously witnessed in Brm-deficient mice. The Q203K mutation was not comparable to the loss of Brm, and this thesis suggests that the Q203K mutation in NMSC is not likely to contribute to increased carcinogenesis, however further testing would have to be conducted to fully determine this.

Non-melanoma skin cancer, comprising basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) is the most commonly diagnosed cancer in Caucasian populations. Established risk factors include exposure to solar ultra-violet radiation and immunosuppression, such as that experienced by organ transplant recipients (OTR). A role for cutaneous human papillomaviruses (HPV) in the aetiology of SCC has been suggested, but remains uncertain. The aims of this thesis were to examine the association between SCC and antibodies against the L 1 antigen of 38 HPV types using Luminex technology among Caucasian individuals and to investigate the seroepidemiology of cutaneous HPV types. Data came from a small prospective study of 39 cases and 80 controls (the Oxford component of the European Prospective Investigation into Cancer and Nutrition) and from case-control studies nested among high-risk cohorts of OTR from London and from Oxford (119 prevalent cases and 425 controls). Around 85% of controls were seroactive to at least one HPV type. In the prospective study, there were no statistically significant differences in the seroprevalence of antibodies against any of the HPV types examined between incident cases and controls. In the case-control studies, as expected, antibodies against HPV 16 were associated with a self-reported history of an abnormal cervical smear and antibodies against HPV 6 were associated with a self-reported history of genital warts, validating the methodology. However, no clear associations between any of the HPV types examined (including betaHPVs) and prevalent SCC were identified. Adjustment for potential confounding factors, such as self-reported history of sun exposure made no material difference to the results. Limitations of the studies are the low statistical power and the use of new serological assays. These serological data do not provide evidence in support of a role for HPV in the aetiology of cutaneous SCC.

Sulforaphane is a natural product found in cruciferous vegetables which is known to have many chemopreventive properties including the induction of apoptosis and the inhibition of inflammation, cellular proliferation, and reactive oxygen species (ROS) formation. The reduction of ROS activity by sulforaphane is likely linked to the activation of NF-E2 related factor-2 (Nrf2), a transcription factor involved in cytoprotection against ROS and electrophilic stress. The skin is particularly vulnerable to oxidative stress caused by ultraviolet (UV) light, which is an established complete carcinogen. Sulforaphane has been shown to reduce both chemical and UVB-induced skin carcinogenesis in mouse models. Suppression of DMBA/TPA-induced skin tumorigenesis by sulforaphane has been shown to be dependent upon Nrf2 activity. Additional studies have shown that genetic activation of Nrf2 can protect keratinocytes against UVB-induced ROS. Nrf2 has also been implicated in regulating inflammatory responses after UVB exposure in the skin. However, the role of Nrf2 in the antitumorigenic activity of sulforaphane in the context of UVB-induced skin tumors is not well understood. We therefore performed murine experiments in order to clarify whether sulforaphane requires Nrf2 in order to block UVB-induced non-melanoma skin cancer. Consistent with the literature, we observed that wildtype (WT) mice topically treated with sulforaphane were less susceptible to UVB-induced tumor incidence and tumor burden compared to the vehicle control WT group. However, Nrf2 KO mice treated with sulforaphane presented with significantly greater UVB-induced tumor incidence and burden compared to the WT sulforaphane group, suggesting that sulforaphane may potentiate tumorigenesis in the context of UVB exposure if Nrf2 is absent. We therefore performed acute in vivo and in vitro experiments using topical sulforaphane (as per the tumor experiment) to investigate why Nrf2 KO mice developed more tumors than WT mice during UVB and sulforaphane treatment. Topical treatment of SKH-1 mice with sulforaphane did result in slight reduction of UV-induced epidermal hyperplasia in wildtype mice which was not present in Nrf2 KO mice (trends were not significant). Surprisingly, while wildtype mice developed significantly more epidermal inflammation in our acute treatment model than did the Nrf2 KO strain (as measured by skin fold thickness), inflammation was not significantly influenced by topical sulforaphane treatment in either strain of mice. However, cell culture studies using primary mouse keratinocytes indicate that sulforaphane’s ability to block UVB-induced ROS is lost in Nrf2 KO cells. Taken together, our ROS data may strengthen the hypothesis that sulforaphane increases the oxidative stress of cells during UVB treatment in the absence of Nrf2.

The ultraviolet (UV) component of sunlight has been identified as a major etiological factor in the development of non-melanoma skin cancer (NMSC). Upregulation of Activator Protein-1 (AP-1) and Cyclooxygenase-2 (COX-2) have clearly demonstrated a functional role in skin tumor promotion. The goal of this work was to contribute to the growing knowledge of UVA and UVB induced signaling events leading to increases in AP-1 and COX-2. We show that UVA induces COX-2 expression in the human keratinocyte cell line, HaCaT through a post-transcriptional mechanism involving the 3 ' untranslated region (3'UTR). Use of a pharmacological inhibitor of p38 MAPK, SB202190, decreased UVA-induced COX-2 steady-state mRNA and protein levels. The stability of COX-2 mRNA is increased in UVA-irradiated cells and dependent upon p38 MAPK activity. We further explored the role of UVA-induced p38 MAPK activity in apoptosis in both HaCaT cells and primary keratinocytes. Dramatic increases in apoptosis were observed in UVA-irradiated cells treated with SB202190 or through the use of a dominant-negative construct. UVA induced expression of Bcl-X L with abrogation of expression using SB202190. Overexpression of Bcl-X L prevented PARP (Poly ADP-ribose Polymerase) cleavage induced by the combination of UVA and p38 MAPK inhibition. We further demonstrated that UVA enhanced the stability of Bcl-XL mRNA through increases in p38 MAPK activity mediated through the 3' UTR. p38 MAPK and Bcl-XL expression play critical roles in the survival of UVA-irradiated keratinocytes. Previous investigations from the laboratory identified p38 MAPK and PI3-Kinase as the major mediators of UVB-induced AP-1 and COX-2 in the HaCaT cell line. To further validate p38 MAPK and PI3-Kinase as potential molecular targets we investigated whether an acute UVB dose activated the p38 MAPK and PI3-Kinase pathways in vivo. We observed rapid increases in both p38 MAPK and PI3-Kinase signaling in mouse epidermis. Activation of these pathways resulted in the phosphorylation of cyclic AMP response element binding protein (CREB). Topical treatment with SB202190 or LY294002 (a specific inhibitor of PI3-Kinase) significantly decreased UVB-induced COX-2 expression and AP-1 activation in vivo. Our data suggest that p38 MAPK and PI3-Kinase may serve as significant molecular targets for the chemoprevention of UVB-induced NMSC.

Ultraviolet radiation (UVR) from sunlight is the main environmental risk factor in the development of non-melanoma skin cancer (NMSC). Squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) make up almost all NMSC. Actinic keratosis (AK), SCC precursor lesion, is often used as surrogate endpoint biomarker in skin cancer chemoprevention trial. UVR damages DNA directly, resulting in formation of cyclobutane pyrimidine dimers (CPDs), and also indirectly by inducing oxidative photolesion 8-oxo-7,8-dihydro-2’-deoxyguanine (8-oxodG). This project examines the role of nicotinamide, an amide form of vitamin B3, in DNA repair and prevention of NMSC. The effect of nicotinamide on nuclear DNA repair in solar-simulated (ss)UV-irradiated HaCaT keratinocytes was assessed using unscheduled DNA synthesis (UDS). Nicotinamide significantly increased both the rates of UDS in each cell and the percentage of cells showing UDS. Using comet assay to measure photolesions in HaCaTs, nicotinamide was shown to enhance repair of ssUV-induced CPDs and 8-oxodG. Immunostaining of whole human skin using antibody specific to CPDs and 8-oxodG allows localization of these photolesions in human skin. Nicotinamide significantly enhanced repair of both CPD and 8-oxodG in ssUV-irradiated whole human skin. Phase II double-blinded randomized placebo controlled clinical trials on healthy subjects with an average of more than 30 AKs each were conducted and showed that nicotinamide given at doses of 500mg twice daily (study 1) and 500mg once daily (study 2) significantly reduced AKs by 35% and 29% respectively, relative to placebo within 4 months. Nicotinamide is a promising agent for skin cancer chemoprevention

Non-melanoma skin cancers (NMSC) are the most common malignant neoplasms in the White population, afflicting about 20% at some point in life (1, 2). The incidence of NMSC is increasing by two to three percent per year (2). Strategies for NMSC prevention are important because, although NMSC does not result in substantial mortality, it does have the ability to cause substantial morbidity, including disfigurement and loss of function, and treatment is costly (3).The goals of the dissertation were to explore the reliability, clinical, epidemiological, pharmacoepidemiological and statistical issues that potentially affect studies of NMSC prevention. This dissertation utilized three studies designed to examine ways to prevent NMSC recurrence or identify early markers in the development of NMSC (SKICAP-AK trial, n=2,297, SKICAP-SCC/BCC trial, n=525, and Biomarkers 1 Study, n=91). The goals of this research were to examine the impact of non-steroidal anti-inflammatory drugs (NSAIDs) on NMSC recurrence, determine if there was a dose response for treatment with the drugs isotretinoin and retinol on the recurrence of NMSC, and examine factors related to reliability of NMSC risk assessment questionnaires often used in epidemiological and clinical studies.Overall, the findings of this research indicated that NSAIDs likely play a role in reducing the risk of developing an SCC in those at high risk, and that the use of oral isotretinoin and retinol play little role in reducing the risk of redevelopment of NMSC in those who have had a previous NMSC. In addition, there was evidence of substantial reproducibility for factors related to assignment into skin cancer risk group and self-reported history of skin lesions, with self-reported sun sensitivity questions being somewhat less reliable. More research should be done to address the role of NSAIDs in chemoprevention at both the basic science level and epidemiological level. Additional secondary analyses of large data sets that contain information on NMSC and NSAIDs use should be conducted in order to further strengthen the argument that NSAIDs play a role in reducing NMSC occurrence. Future work should focus on determining the specific populations that could benefit from NSAIDs use for the reduction of NMSC.

Sunlight is the main aetiological agent in the development of non melanoma skin cancer (NMSC), the most commonly diagnosed cancer in the fair skinned population. Mounting epidemiological and molecular data suggest that infection with cutaneous Human papillomavirus (HPV) may act as a co-factor in the early stages of NMSC development. The viral E6 protein can inhibit the apoptotic response to UV induced damage, partly through proteasomal degradation of the pro-apoptotic protein BAK. Upon UV damage, BAK undergoes a series of activating modifications that are linked to changes in phosphorylation status. BAK activation commits a cell to apoptosis through mitochondrial permeabilisation. The aim here was to elucidate the underlying mechanism of HPV5 E6-mediated BAK degradation. Mutation of lysine 113 in BAK and siRNA knockdown of a novel HPV5 E6 associated ubiquitin ligase, HERC1, prevented HPV5 E6 mediated-BAK degradation. A proximity ligation in situ assay showed an interaction between HERC1 and BAK in cells, which was dependent on the presence of the E6 protein and UV irradiation. Probing the BAK conformation and phosphorylation status suggests E6 targets a dephosphorylated BAK monomer before mitochondrial permeabilisation occurs, leading to the proposal of a mechanism for the interaction of BAK with HERC1 which depends on the activation status of BAK and a putative BH3 domain identified in HERC1. Additional work identifies β1-integrin as an interacting protein of a conserved YHDW amino acid motif at the C-terminus of certain β1 HPV E6 proteins. Only expression of E6 proteins with the YHDW motif (HPV5 and 8) in keratinocytes disrupted β1 integrin membrane localisation, altered expression of β1 integrin downstream effectors, such as focal adhesion kinase, and increased cell migration. Mutation of W157A in the HPV5 E6 YHDW motif reduced these effects. Together, this work furthers the understanding of mechanisms by which infection with HPV may promote the early stages of NMSC development.

Non-melanoma skin cancer (NMSC) is the most common human cancer worldwide. Squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) make up almost all NMSC. SCC usually arises from actinic keratosis (AK) as a result of exposure to sunlight. SCC and AK provide a useful clinical model to investigate changes involved in the progression of NMSC. This project examines the expression of Brm, Brg-1, Snail 1 and Snail 2 in the progression of NMSC. Brm and Brg-1 are subunits of the SWI/SNF chromatin-remodelling complex which is involved in regulating the access of cell machinery to DNA by altering the structure of chromatin. It has been suggested that loss of this function is involved in carcinogenesis as the cell is unable to access to DNA normally in order to repair mutations or activate apoptosis. The loss of Brm or Brg-1 has been described in several human cancers. Snail 1 and Snail 2 are zinc-finger transcription factors that are known for their role in epithelial to mesenchymal transition (EMT), a process vital to embryological development. Increased expression of these factors leads to a loss of cell-cell adhesion and a migratory phenotype and has been described in some human cancers. In this project, double-label immunohistochemistry was used to determine the relative expression of these proteins in human SCC, BCC, AK and normal skin. The expression of Snail was unable to be determined due to poor specificity of the antibodies used. The expression of both Brm and Brg-1 proteins was found to be dramatically and consistently decreased in SCC and BCC when compared to normal skin and AK. This loss of Brm and Brg-1 occured as the tumour progressed from benign AK to malignant SCC. This finding suggests that the loss of either Brm or Brg-1 constitutes a key step in carcinogenesis. The results of this study identify Brm and Brg-1 as putative tumour suppressors involved in the progression of non-melanoma skin cancer from benign to malignant.

Master of Medicine
Non-melanoma skin cancer (NMSC) is the most common human cancer worldwide. Squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) make up almost all NMSC. SCC usually arises from actinic keratosis (AK) as a result of exposure to sunlight. SCC and AK provide a useful clinical model to investigate changes involved in the progression of NMSC. This project examines the expression of Brm, Brg-1, Snail 1 and Snail 2 in the progression of NMSC. Brm and Brg-1 are subunits of the SWI/SNF chromatin-remodelling complex which is involved in regulating the access of cell machinery to DNA by altering the structure of chromatin. It has been suggested that loss of this function is involved in carcinogenesis as the cell is unable to access to DNA normally in order to repair mutations or activate apoptosis. The loss of Brm or Brg-1 has been described in several human cancers. Snail 1 and Snail 2 are zinc-finger transcription factors that are known for their role in epithelial to mesenchymal transition (EMT), a process vital to embryological development. Increased expression of these factors leads to a loss of cell-cell adhesion and a migratory phenotype and has been described in some human cancers. In this project, double-label immunohistochemistry was used to determine the relative expression of these proteins in human SCC, BCC, AK and normal skin. The expression of Snail was unable to be determined due to poor specificity of the antibodies used. The expression of both Brm and Brg-1 proteins was found to be dramatically and consistently decreased in SCC and BCC when compared to normal skin and AK. This loss of Brm and Brg-1 occured as the tumour progressed from benign AK to malignant SCC. This finding suggests that the loss of either Brm or Brg-1 constitutes a key step in carcinogenesis. The results of this study identify Brm and Brg-1 as putative tumour suppressors involved in the progression of non-melanoma skin cancer from benign to malignant.

Projeto de Pós-Graduação/Dissertação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Mestre em Ciências Farmacêuticas
A psoríase é uma doença crónica autoimune e inflamatória, considerada uma das dermatoses mais frequentes na prática clínica. Os doentes que sofrem desta patologia podem manifestar diferentes variantes, nomeadamente, psoríase em placa, inversa, gutata, pustular, eritrodérmica e artrite psoriática. Esta doença apresenta um carácter multifatorial com uma forte componente genética, no entanto, as suas manifestações clínicas podem resultar de outros tipos de fatores tais como, imunológicos e ambientais. A prevalência psoriática, de um modo geral, abrange cerca de 1 a 3% da população mundial, sendo que, em Portugal, existem aproximadamente 250 000 indivíduos diagnosticados com psoríase. Independentemente da abordagem teórica, muitos autores consideram a pele como o primeiro meio de contacto do indivíduo com o meio. Partindo desta posição, pode-se pensar nos prejuízos causados no bem-estar psicológico de indivíduos acometidos por este tipo de doença, uma vez que, os mesmos podem desenvolver comportamentos de ansiedade, depressão, exclusão social e em situações mais graves, podem exibir intensões suicidas. Além do impacto da sua vida social, a vida familiar e a dieta alimentar são, igualmente, afetadas. O tratamento das lesões psoriáticas envolve terapia tópica, sistémica, fototerapia e, mais recentemente, terapia biológica. A escolha farmacoterápica é efetuada de acordo com a gravidade da patologia e tendo em conta que, apenas se fará a manutenção das lesões, dado tratar-se de uma doença sem cura. Com o tempo, o doente pode exibir certas comorbilidades relacionadas com o seu quadro clínico, entre elas, cancro. Os dados bibliográficos publicados até ao ano corrente descrevem vários tipos de cancro, sendo que, os mais comuns são os linfomas e o cancro de pele não-melanoma. Este trabalho consiste num estudo meta-analítico, que pretende desenvolver mais estas temáticas. Psoriasis is chronic, autoimmune and inflammatory disease, considered to be one of the most frequent dermatitis in clinical practice. This condition has several variants that can manifest in patients. These subtypes are: plaque psoriasis, gutata, pustular, eritrodermic, inverse and psoriatic arthritis. Being a disease with multifactorial influences, psoriasis has a strong genetic association, nevertheless, its clinical manifestations may also come from several other types of interactions, such as immunologic and environmental factors. Psoriatic prevalence in the world varies from 1 to 3%. In Portugal there are approximately 250 000 individual diagnosed with this condition. Despite the theoretic approach that may be picked, many authors consider the skin as the first barrier of contact between the individual and the outside world. Taking this into account, it´s possible to imagine the damage caused in the well being of individuals who suffer from this condition, considering that they may develop behaviors of anxiety, depression and social exclusion. In more severe situations, patients may even exhibit suicidal tendencies. Besides the social impact shown, family life and individual diet are equally affected. The treatment for psoriatic lesions entails topical and systemic drugs, phototherapy and, more recently, biologic therapy. Pharmacotherapeutic choices are made based on the condition’s gravity and keeping in mind that the aim is to control the lesions, considering this disease has no cure. As time goes by, individuals can exhibit comorbidities associated with psoriasis. Cancer is one of these conditions. The bibliographic data published until the present year, describes several types of cancer, but the ones most often mentioned are lymphomas and non melanoma skin cancer. This essay is a meta-analytic study aiming to further discuss these issues.

Epidermally-limited non melanoma skin cancer (NMSC), defined as superficial basal cell carcinoma and squamous cell carcinomas in-situ, is associated with significant morbidity and cost. This study examined the patterns, outcomes, and satisfaction for NMSC treatment. The study consisted of a retrospective single institution analysis of 550 patients diagnosed with 678 NMSCs treated from Jan 2008 to Mar 2014. A satisfaction survey was then administered to 142 patients from May 2014 to Jun 2014. A total of 329 tumors (49%) were treated with Mohs micrographic surgery (MMS), 292 tumors (43%) with topical medication (TM), and 57 tumors (8%) with cryotherapy (CT). Of the 11 clinical recurrences (2%), 7 (64%) were treated with TM, 2 (18%) with MMS, and 2 (18%) with CT. The difference in recurrence risk (3.3% non-MMS vs. 0.7% MMS) was not significant. Independent predictors for recurrence were tumor diameter greater than 2.0 cm (HR, 5.1 [95% CI, 1.3-19.5]) and immunosuppression (3.6 [1.0-12.5]). Of patients surveyed, 97% who received MMS were satisfied/very satisfied versus 91% who received non-MMS treatment (p=0.092). This study indicates that surgical and non-surgical treatments for NMSC may have more equivalent efficacy than previously reported and a large majority of patients are satisfied with their treatment.

Non-melanoma skin cancers (NMSCs) are one of the most frequent cancers diagnosed in the elderly Caucasian population. Among several factors that contribute to NMSCs development, ultraviolet (UV) radiations are the main responsible for cancer degeneration. UV can damage cell DNA, trigger ROS production, which oxidize DNA bases causing mutations. Besides, UV inhibit immune response, activate local inflammation, trigger the production of metalloproteinases, and induce cell senescence. Most of the modifications UV-induced contribute to photocarcinogenesis and photoaging. To prevent UV-induced damages especially on high-risk patients, the use of inexpensive chemopreventive molecules with low side effects could help to prevent NMSC development. So, this thesis aims to provide new insights on the role of vitamin B3, D3, and E, in their active forms, as photoprotectors against UVB-induced damages on human primary keratinocytes and fibroblasts. We firstly demonstrated that keratinocytes isolated from field cancerization are more sensible to UV radiations in comparison with normal keratinocytes. However, nicotinamide (NAM) at 25 μM given 24h before irradiation efficiently protected keratinocytes from UVB damages reducing ROS production and DNA damages and blocking the inflammatory response. Then, we proved that NAM and vitamin D3 analog, calcipotriol, can protect human fibroblasts from photoaging by inhibiting ROS release, reducing DNA damages, restoring cell cycle, and decreasing cell senescence. Overall, our results suggest that NAM could be an efficient photoprotector against photocarcinogenesis and photoaging on both keratinocytes and fibroblasts. Moreover, vitamin D3 seems to be protect efficiently fibroblasts from premature aging. Our results might suggest that nicotinamide and vitamin D3 could be used for non-invasive treatment of field cancerization and chronically photoexposed skin areas, in order to prevent NMSC relapse and to reduce demand for surgical treatment.

O câncer não-melanoma corresponde a 25% de todos os tumores e é caracterizado por uma neoplasia dos queratinócitos. Evidências mostram que a resistência a apoptose é uma das características para o surgimento e evolução dos tumores malignos. A proposta deste trabalho foi estudar quais funções as moléculas BIM, PUMA e Fas desempenham nos queratinócitos quando submetidas à transformações celulares, como UVB e DMBA, e indutores de apoptose. Para isso foi estabelecido cultura primaria de queratinócitos de neonatos das linhagens C57Bl/6 WT; PUMA KO; LPR. As células foram tratadas com AD, VP-16, CHX, UVB e DMBA in vitro. Observamos a expressão de Bid, Bim, Bax no tratamento com UVB. Avaliamos o perfil de desenvolvimento do tumor nesses animais utilizando um modelo de tumorigenese química in vivo. Os queratinócitos deficientes em PUMA e Fas se comportam de maneira semelhante no tratamento com quimioterápicos, no entanto, no tratamento com carcinógenos a molécula Fas desempenha um papel mais relevante na indução de morte celular e no desenvolvimento da carcinogênese.
The non-melanoma cancer accounts for 25% of all tumors and is characterized by a neoplasm of keratinocytes. Evidence shows that apoptosis resistance is one of the characteristics for the emergence and development of malignant tumors. The This study investigated what roles the BIM, PUMA and Fas molecules play in keratinocytes when subjected to cell transformations, such as UVB and DMBA, and apoptosis inducers. For this, keratinocytes primary culture was established from neonatal skin to C57BL / 6 WT; PUMA KO; LPR. The cells were treated with AD, VP-16, CHX, UVB and DMBA in vitro. We observed the expression of Bid, Bim, Bax in treatment with UVB. We evaluated tumor development profile in these animals using a model of chemical tumorigenesis in vivo. PUMA-deficient keratinocytes and Fas mutant have similarly behave in chemotherapy treatment, however, Fas molecule plays a more important role in the induction of cell death with the treatment with carcinogens in the development and carcinogenesis.

Background. The development of non-invasive imaging techniques has been stimulated by the shortcomings of histopathology. Currently the only valid diagnostic technique in dermatology is skin biopsy which remains a painful, invasive intervention for the patient. Moreover, this approach is not always convenient for monitoring and follow-up of a skin disease. Optical imaging technologies could solve these shortcomings as they are fast, precise, repeatable and painless. There are four established non-invasive skin imaging techniques used in daily practice: dermoscopy, high-frequency ultrasound, reflectance confocal microscopy (RCM) and conventional optical coherence tomography (C-OCT). In imaging there is a trade-off between resolution and penetration depth. The former permits the visualization of cells, if the resolution is at least 3 µm. The latter enables the recognition of patterns and structures in deeper layers of the skin if the penetration depth is deeper than 150 µm. New non-invasive techniques using infrared light sources have been developed recently. The technique used in this work is a high-definition optical coherence tomography (HD-OCT).Objectives. The overall aims of this thesis were the feasibility of HD-OCT to visualize in/ex vivo, in real time and in 3-D the cellular and structural morphology of the skin, secondly the assessment of the capability of this technology to measure in vivo and real time the cutaneous optical properties, and finally the determination of the contribution of this technique to the non-invasive near-infrared imaging technologies. Five specific objectives have been established: i) could cells be observed in their 3-D microenvironment in normal and diseased skin, ii) could we describe morphologic features of cells and structures in normal and diseased skin (m_HD-OCT), iii) could these morphologic features be quantified by optical property analysis (o_HD-OCT), iv) was it possible to perform accurate thickness measurements in normal and diseased skin, and finally v) what was the diagnostic potential of this technique?Methodology. HD-OCT uses a combination of parallel time-domain interferometry, high power tungsten lamp (with Gaussian filter, very low lateral coherence and ultra-high bandwidth (1300 nm +/- 100 nm)), and last but not least, full field illumination with real time focus tracking. A constant homogeneous resolution of 3 µm resolution in all three dimensions is obtained up to a depth of 570 µm. Hence, the system is capable of capturing real time full 3-D images. Moreover, the in vivo assessment of optical properties of the skin is only applicable to OCT when operating in focus-tracking mode, which is the case for HD-OCT. The means to obtain answers to the five specific questions were the comparison of en face HD-OCT images with RCM and HD-OCT cross-sectional images with histopathology and C-OCT. Results. At least 160 line pares were observed by imaging a high resolution phantom with HD-OCT. This suggested a 3 µm lateral resolution. The presence of cells such as keratinocytes, melanocytes, inflammatory cells, fibroblasts and melanophages in their 3-D cutaneous microenvironment in vivo as well as ex vivo has been demonstrated .A qualitative description of structures and patterns in normal and diseased skin could be performed by HD-OCT. Clear structural changes of the epidermis, dermo-epidermal junction, papillary dermis and reticular dermis related to intrinsic skin ageing could be observed. Lobulated structures, surrounded by stretched stromal fibers and arborizing vessels, could be demonstrated in nodular basal cell carcinoma (BCC). The o_HD-OCT of normal and diseased skin could be assessed in vivo. This approach permitted the quantitative assessment of the OCT signal attenuation profiles of normal healthy skin, actinic keratosis (AK) and squamous cell carcinoma (SCC). Differences in signal attenuation profiles could be demonstrated between these three groups. These differences were also observed between BCC subtypes. The slope of the exponential attenuation of the signal in the upper part of the epidermis was very high in benign nevi. The more malignant the lesion the lower the slope. Thickness measurements of epidermis and papillary dermis could be performed by m_HD-OCT, based on a cross-sectional images and their corresponding en face image. More accurate measurements of epidermal and papillary dermal thickness could be performed based on the optical analysis of a skin volume by o_HD-OCT. The diagnostic potential of HD-OCT in comparison with dermoscopy, RCM and C-OCT could be assessed regarding i) melanoma, ii) BCC differentiation from BCC imitators and BCC sub-differentiation and iii) SCC differentiation from AK. A much higher diagnostic potential could be demonstrated for o_HD-OCT in comparison with m_HD-OCT concerning melanoma detection. The diagnostic potential of HD-OCT to discriminate BCC from clinical BCC imitators was moderate. However, HD-OCT seemed to have high potential in sub-differentiation of BCC subtypes: i) it seemed to be the best technique to include and exclude a superficial BCC, ii) the technique appeared to be the best approach to exclude nodular BCC, and iii) HD-OCT looked to be the best technique to include an infiltrative BCC. Finally, HD-OCT has proven to be a powerful method to discriminate AK from SCC.Conclusions. HD-OCT is able to capture real time 3-D imaging with a sufficiently high optical resolution and penetration depth to allow the visualization of cells in and ex vivo in their micro-architectural context. At the same time, HD-OCT permits the recognition of patterns and structures in a sufficiently large volume of skin (1.5 mm³). HD-OCT closes therefore the gap between RCM with a high resolution but low penetration depth and C-OCT with a low resolution but high penetration depth. Moreover, HD-OCT permits, in contrast to RCM and C-OCT, the real time in vivo analysis of optical properties of the skin. HD-OCT seems to be a promising tool for early diagnosis of melanoma, BCC sub-differentiation and differentiation between SCC and AK.Future perspectives. Multicenter validation studies are needed to determine the diagnostic performance of this promising new technology, especially in other clinical settings combining both morphological and optical property analysis. This combined analysis could be a valuable method not only for diagnosis, monitoring and therapeutic guidance of dermatologic diseases but it could also be helpful in the management of non-dermatologic conditions such as diabetic micro-angiopathy, infantile cystinosis or even osteoporosis.
Doctorat en Sciences médicales (Santé Publique)
info:eu-repo/semantics/nonPublished

Photodynamic therapy (PDT) is a multimodality cancer treatment available for the palliation or eradication of systemic and cutaneous malignancies. In this thesis, the application of PDT is for the treatment of non-melanoma skin cancer (NMSC). While PDT has a well-documented track record, there are, at this time no significant indicators to suggest the superiority of one treatment regime over the next. The motivation for this work is to provide additional evidence pertaining to PDT treatment variables, and to assist in optimising PDT treatment regimes. One such variable is the treatment light dose. Determining the light dose more accurately would assist in optimising treatment schedules. Furthermore, choice of photosensitiser pro-drug type and application times still lack an evidence base. To address issues concerning treatment parameters, fluorescence spectroscopy – a valuable optical diagnostic technique – was used. Monitoring the in vivo PpIX fluorescence and photobleaching during PDT was employed to provide information pertaining to the progression of treatment. This was demonstrated by performing a clinical study at the Photobiology Unit, Ninewells Hospital and Medical School, Dundee. Two different photosensitiser pro-drugs – either 5-aminolaevulinic acid (ALA) or its methyl ester (MAL) – were investigated and based on the fluorescence and pain data recorded both may be equally suitable for topical PDT. During PDT, surface fluorescence is observed to diminish with time – due to photobleaching – although cancerous cells may continue to be destroyed deep down in the tissue. Therefore, it is difficult to ascertain what is happening at depth in the tumour. This raised the questions; How long after surface PpIX fluorescence has diminished is the PDT treatment still effective and to what depths below the surface is effective treatment provided? In order to address these important questions, a three-dimensional (3D) Monte Carlo radiation transfer (MCRT) model was used to compute the light dose and the ¹O₂ production within a tumour, and the PpIX fluorescence emission from the tumour. An implicit dosimetry approach based on a single parameter – fluorescence photobleaching – was used in order to determine the ¹O₂ generation, which is assumed to be related to tissue damage. Findings from our model recommended administering a larger treatment light dose, advocating an increase in the treatment time after surface PpIX fluorescence has diminished. This increase may ultimately assist in optimising PDT treatment regimes, particularly at depth within tumours.

In den letzen Jahren gab es durch epidemiologische und molekularbiologische Studien vermehrt Hinweise, dass kutane humane Papillomviren (HPV) ursächlich an der Entstehung nicht-melanozytärer Hauttumore (engl. NMSC) beteiligt sind. Ziel der vorliegenden Arbeit war die Identifizierung molekularer Mechanismen der viralen Proteine E6 und E7 kutaner HPV-Typen. Die E6 oder E7 Gene der verschiedenen HPV-Typen 1, 4, 5, 8, 20, 38 und RTRX7 wurden untersucht. Natürliche Wirtszellen dieser Viren, humane primäre Keratinozyten (HPK) der Haut, wurden mit rekombinanten, für E6 oder E7 kodierenden Retroviren infiziert. Die Analysen erfolgten in Monolayer-Kultur (undifferenzierte Keratinozyten) oder in organotypischen Hautmodellen (Induktion der Keratinozytendifferenzierung). Die Expression von E6 oder E7 führte in Monolayer-HPK zu einer Verlängerung der Lebensspanne und zu einer deutlich erhöhten Verdoppelungsrate. Eine Telomeraseaktivierung, die charakteristisch für immortale Zellen ist, wurde nur in HPV 8 E6 positiven HPK nachgewiesen. In organotypischen Hautmodellen induzierte das E7 Protein von HPV 1, 4 und 38 starke Veränderungen in der Differenzierung sowie eine Zunahme der Proliferation. Weiterhin wurde eine Aufhebung der normalen Zellzykluskontrolle in suprabasalen HPV 5 E7 oder HPV 8 E7 beobachtet. Hinweise auf ein starkes invasives Potential von E7-infizierten HPK wurden für HPV 8 E7 bestätigt und für HPV 4 E7, HPV 38 E7 und RTRX7 E7 erweitert. Molekulare Mechanismen der viralen Gene E6 und E7 kutaner HPV unterscheiden sich von mukosalen Typen. Das Mehrstufenmodell der Karzinogenese beinhaltet eine Reihe fundamentaler Zelltransformationen, die für eine Tumorgenese nötig sind. In dieser Arbeit beschriebene Mechanismen der Modulation der Zelldifferenzierung und Zellproliferation durch die kutanen HPV-Typen 4, 5, 8 und 38 können unter Umständen zur Induktion und Progression früher Stadien von Plattenepithelkarzinomen (SCC) beitragen.
In the last years epidemiologic and molecular biological studies accumulated increasing evidence that cutaneous human papillomaviruses are etiologically involved in the formation of non-melanoma skin cancer (NMSC). The presented work aims to identify the underlying molecular mechanisms of the viral proteins E6 and E7 of cutaneous HPV types. The E6 and E7 genes of the different HPV types 1, 4, 5, 8, 20, and RTRX7, which are in vivo associated with cutaneous benign or malignant lesions, were studied. Natural host cells of these viruses, human primary keratinocyts (HPK) of the skin, were infected with recombinant E6 and E7 encoding retroviruses. The following analyses were performed in monolayer culture (non-differentiated keratinocytes) or in organotypic skin culture (induction of keratinocyte differentiation). The expression of E6 and E7 elongated the life span of monolayer HPK and significantly increased the doubling rate. An activation of the telomerase, characteristic for immortalized cells, was only detected in HPV 8 E6 positive cells. In organotypic skin cultures E7 of HPV 1, 4 and 38 induced drastic changes in differentiation and proliferation. Additionally an impairment of the normal cell cycle control in suprabasale HPV 5 E7 and 8 E7 cultures was seen. Hints for a strong invasive potential of E7 infected HPK were proven for HPV 8 E7 and expanded to HPV 4 E7, HPV 38 E7 and RTRX E7. The viral E6 and E7 genes of cutaneous and mucosal HPV types exhibit different molecular mechanisms. The multistep model of carcinogenesis includes a series of fundamental cell transformations necessary for tumorigenesis. Mechanisms for the modulation of cell differentiation and proliferation by cutaneous HPV types 4, 5, 8 and 38 described in this work could potentially contribute to the induction and progression of early stages of squamous cell carcinoma.

The incidence of skin cancer is increasing and conventional treatments such as surgery are not suitable for all patients. This study aimed to develop an elastic liposomal gel to be applied directly to the tumour for the controlled release of anti-cancer agents to the dermal layer. The proposed anti-cancer flavonoids EGCG and naringenin as well as the novel potent cytotoxic agent MTL-004 were loaded into the bilayer of liposomes. Furthermore, aqueous gels HEC and HPMC were investigated as carriers for the liposomes to be applied topically. Liposomes loaded with either Tween 80, Tween 20 or sodium cholate were found to have increased elastic properties, liposomes with an average size of 400 nm were able to pass through a pore size of 100 nm. Release studies from liposomes loaded with either EGCG, naringenin and MTL-004 as well as varying ratios of Tween 20 were carried out. Within 24 hours, EGCG liposomes loaded with 0% or 10% w/w Tween 20 gave a release of 13.7 ± 1.1 % and 94.4 ± 4.9 % respectively; naringenin liposomes loaded with 0% or 10% w/w Tween 20 gave a release of 109.7 ± 5.0 % and 48.5 ± 2.1 % respectively; MTL-004 liposomes loaded with 0% or 10% w/w Tween 20 gave a release of 59.8 ± 1.2 % and 74.0 ± 1.8 % respectively. This indicates a compounds individual physiochemical properties influences release of compound from liposomes. EGCG, naringenin and MTL-004 loaded liposomes added into the aqueous gel HEC or HPMC gels may have had an additive effect in terms of retarding drug release. Release was faster from HEC gels and liposomes formulated with Tween 20. In vitro cellular uptake of liposome uptake into HDFa and HaCat cells was apparent. Thus it appears elastic liposomes are useful in enhancing drug penetration into dermal cells and furthermore may be useful in the development of a controlled release formulation.

A previous population-based study of survival in Chronic Lymphocytic Leukemia (CLL) patients in the province of Manitoba demonstrated a lower five-year relative survival among CLL patients compared with the age- and gender-adjusted general population. This decreased relative survival was most pronounced among elderly male CLL patients. In this study, we have demonstrated that the reduced five-year relative survival observed in CLL patients compared to the general population of Manitoba may partially be attributed to increased risk of second cancers and non-referral to specialized CLL clinics. The increased risk of second cancers in CLL patients compared to Follicular Lymphoma (FL), a similar indolent B cell malignancy, was only observed after CLL diagnosis indicating that a CLL-specific factor may be responsible for the increased risk of second cancers in these patients. The risk of second cancers is independent of treatment and surveillance bias but is further increased with chemotherapy. A superior outcome in CLL patients who have been referred to the CancerCare Manitoba (CCMB) specialized CLL clinic was observed that was independent of age, gender, treatment and history of previous cancers. This superior outcome was most pronounced in the elderly CLL patients. We propose that CLL patients should be referred to CLL-specific hematologists and, where not possible, that guidelines created by such experts be followed. Appropriate screening for second cancers should be performed during routine follow up of CLL patients.