An Epigenetically Derived Monoclonal Origin for Recurrent Respiratory Papillomatosis
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ORIGINAL ARTICLE An Epigenetically Derived Monoclonal Origin for Recurrent Respiratory Papillomatosis Josena Kunjoonju Stephen, MD; Lori E. Vaught, MD; Kang Mei Chen, MD; Veena Shah, MD; Vanessa G. Schweitzer, MD; Glendon Gardner, MD; Michael S. Benninger, MD; Maria J. Worsham, PhD Objective: To investigate the contribution of pro- cer genes in the multigene panel had altered DNA meth- moter methylation-mediated epigenetic events in recur- ylation in at least 1 laryngeal papilloma biopsy speci- rent respiratory papillomatosis tumorigenesis. men. Identical abnormally methylated genes were found in 5 of 15 recurrent cases, of which the CDKN2B gene Design: Archival tissue DNA, extracted from microdis- was hypermethylated in all 5 cases. Dissimilar epige- sected papilloma lesions, was interrogated for methyl- netic events were noted in the remaining cases. ation status by means of the novel, multigene methylation- specific multiplex ligation-dependent probe amplification Conclusions: A clonal origin was derived for 5 of 15 assay. recurrent respiratory papillomatosis biopsy specimens based on identical epigenetic events. The high fre- Subjects: Fifteen subjects with recurrent respiratory pap- quency of epigenetic events, characterized by consis- illomatosis, 3 females and 12 males, all with adult onset tent promoter hypermethylation of multiple tumor of illness (age range, 23-73 years) except for 1 female pa- suppressor genes, points to the use of gene silencing tient with juvenile onset (1 year old). mechanisms in the pathogenesis of recurrent respira- tory papillomatosis. Results: Promoter hypermethylation was recorded in 14 of 15 cases, and 19 of 22 unique methylation-prone can- Arch Otolaryngol Head Neck Surg. 2007;133(7):684-692 ECURRENT RESPIRATORY small percentage of RRP cases progress to (laryngeal) papillomatosis malignancy.9 (RRP), an extremely rare Laryngeal papillomas usually run a be- condition, is characterized nign but recurrent course. Spontaneous by benign neoplasms transformation of RRP to squamous cell car- Rwithin the respiratory tract and can be cinoma is not easily characterized by a his- potentially life threatening because of tologic progression through dysplasia over airway obstruction.1 Recurrent respiratory time, making these lesions difficult to di- papillomatosis presents primarily as tiny or agnose histologically and clinically early in larger warts on the vocal chords. Preva- the course of the transformation of the lence of RRP worldwide is approximately disease. 100 000, with 2300 new cases in the United Clonality, the property that the cells States each year.2-4 Juvenile-onset disease oc- within a tumor are derived from a single curs in patients from younger than 1 year parent cell, is often indicated by unifor- to 8 years old; shows no sex difference5,6; mity or relative uniformity of genetic ab- has a rapid but often unpredictable pattern errations contained within many or all cells of recurrence5; tends to be a long-term, of- of the tumor. Such aberrations are as- ten lifelong disease; and exhibits a con- sumed to confer or reflect biological dis- Author Affiliations: Research tinuum of severity and aggressiveness. The tinctions relevant to tumor behavior, and Division, Department of adult form of RRP has a variable age at on- thus to be relevant to tumor initiation and Otolaryngology–Head and Neck set (peak, approximately 20-30 years),6,7 clonal expansion.10-13 Surgery (Drs Stephen, Vaught, 6 Chen, Schweitzer, Gardner, with a higher incidence in males. The se- Epigenetics is the regulation of changes Benninger, and Worsham), and verity, aggressiveness, and recurrence of the in gene expression by mechanisms that do Department of Pathology adult form tend to be less than in the juve- not involve changes in DNA sequence. Es- (Dr Shah), Henry Ford nile form.6 Human papillomavirus types 6 tablishment and maintenance of epige- Hospital, Detroit, Michigan. and 11 account for 80% to 90% of RRP.8 A netic control (gene silencing) has several (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 133 (NO. 7), JULY 2007 WWW.ARCHOTO.COM 684 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 MS-MLPA: Hhal digest Amplification of methylated target Antisense primer Antisense primer Labeled sense primer Labeled sense primer Ligation PCR Stuffer sequence Stuffer sequence with variable length Methylated with variable length Target DNA target CG CH Undigested by Methylated → no digestion → ligation 3 Antisense HhaI, binds to → Antisense primer probe PCR primer Labeled sense primer Labeled Hhal sense primer No PCR digestion Unmethylated target Target DNA CG Unmethylated → cut by Hhal → no ligation Digested by HhaI → does not bind to probe → no PCR Figure 1. Methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA).17 Probes designed to recognize HhaI sites within unmethylated regions will not generate a signal because these sequences have become cut by HhaI and cannot bind to the probe. Conversely, an MLPA probe will bind to an intact methylated site, spared by HhaI, and generate an amplification signal, producing 15 separate peaks (Figure 2) in a normal control DNA sample. Aberrant methylation is identified as the appearance of a signal peak that is otherwise absent in normal DNA samples (Figures 2, 3, and 4). CH3 indicates methyl group; PCR, polymerase chain reaction. aspects, which include promoter region hypermethyl- lowed to cool to 60°C. Next, 6 µL of 20-mg/mL proteinase K ation, methyl-binding proteins, DNA methyltransfer- was added, mixed, overlaid with 3 drops of mineral oil, and ases, histone deacetylases, and chromatin state. Aber- spun for 5 seconds at 13 000g. This was followed by a 4- to 16- rant methylation of CpG islands is a hallmark of human hour (overnight) incubation at 60°C. The tube was heated for cancers and is found early during carcinogenesis.14 Genes 10 minutes at 90°C to denature the proteinase K and to dis- rupt nucleic acid formaldehyde adducts. On removal of the oil, in cellular pathways that are inactivated by promoter re- the tube was centrifuged for 15 minutes (at 13 000g) at room gion hypermethylation include MGMT (DNA repair), temperature. Next, 250 µL of the supernatant was transferred INK4a INK4b p16 , p15 (cell cycle), DAPK (apoptosis), and to a clean 1.5-mL tube. On addition of 10 µL of 5M sodium GSTP1 (detoxification).15 chloride and 1000 mL of ethanol to the 250-µL supernatant, We investigated alterations in DNA methylation in bi- the tube was incubated at −20°C for least 60 minutes. This was opsy specimens of recurrences from patients with RRP followed by centrifugation for 15 minutes at 13 000g at −4°C. to assess the contribution of promoter methylation- On removal of the supernatant, an additional centrifugation step mediated epigenetic events in RRP tumorigenesis. for 10 seconds ensured removal of the last traces of the super- Aberrant promoter methylation of 22 methylation- natant. Finally, the pellet was air dried and dissolved in 100 prone tumor suppressor genes was evaluated by means µL of double-distilled water. of a high-throughput multigene probe panel (41 gene probes, 35 unique genes, including control probes) in MS-MLPA ASSAY 15 RRP cases by using the methylation-specific multi- The MS-MLPA assay allows for the relative quantification of ap- plex ligation-dependent probe amplification (MS-MLPA) 16,17 proximately 41 different DNA sequences in a single reaction re- assay. quiring only 20 ng of human DNA. The standard use of the tech- nique to observe quantitative changes in copy number has been METHODS outlined in other studies.18-21 Adaptation of the MLPA to detect aberrant methylation (MS-MLPA) has been detailed elsewhere.16,17 The probe design is similar to that of ordinary MLPA probes. RRP COHORT For 26 of 41 probes, the recognition sequence detected by the MLPA probe is contained within a restriction site for the methyl- The RRP cohort comprised 15 subjects, 3 females and 12 males, sensitive enzyme HhaI(Figure 1). all with adult onset of respiratory papillomatosis (age range, The41-gene-probepanel(Table 1)interrogates35uniquegenes 23-73 years) except for 1 female patient with juvenile onset (1 implicated in cancer, including head and neck squamous cell car- year old). The number of biopsy specimens from patients with cinoma, for losses and gains in a separate reaction in the absence recurrences ranged from 1 to 6. Archival tissue DNA, ex- of the methyl-sensitive enzyme HhaI. Because there are 2 probes tracted from microdissected papilloma lesions, was interro- eachforVHL,CDKN2A,BRCA1,andBRCA2,and3probesforMLH1, gated for methylation status by means of the MS-MLPA assay. a normal control DNA sample will generate 41 individual peaks in the absence of HhaI(Figure 2). A concurrently run reaction DNA EXTRACTION with the 41-gene-probe set in the presence of HhaI is designed to detect aberrant promoter hypermethylation by taking advantage As a first step, 300 µL of P-buffer (50mM Tris hydrochloride, of an HhaI site in the promoter region of 22 of the 35 unique genes pH 8.5; 100mM sodium chloride; 1mM EDTA; 0.5% Triton (note that 1 of the 2 BRCA1 probes is designed to recognize a re- X100; 20mM dithiothreitol) was added to tubes containing whole gion outside the HhaI recognition site; Table 1). Fifteen of the 41 5-µm tissue sections or microdissected tissue. The tube was gene probes are designed outside an HhaI site and serve as undi- heated for 15 to 20 minutes at 90°C in a water bath and al- gested controls (Figure 2). On digestion of the sample DNA with (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 133 (NO. 7), JULY 2007 WWW.ARCHOTO.COM 685 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 and 1 minute at 72°C; and 30 cycles of 30 seconds at 95°C, 30 Table 1.