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Winnie Wing Yin Tong Winnie Wing Yin Tong BSc(Med) MBBS FRACP FRCPA This thesis is submitted in fulfilment of the requirements for the degree of Doctor of Philosophy St Vincent’s Clinical School Faculty of Medicine February 2016 PLEASE TYPE THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname or Family name: TONG First name: Winnie Other name/s: Wing Yin Abbreviation for degree as given in the University calendar: PhD School: St Vincent’s Clinical School Faculty: Faculty of Medicine Title: T-cell responses to human papillomavirus in men with anal high-grade squamous intraepithelial lesions Abstract 350 words maximum: (PLEASE TYPE) Anal cancer incidence in men who have sex with men (MSM) infected with human immunodeficiency virus (HIV) is three times greater than cervical cancer incidence was before Papanicolaou screening. Analogous to cervical cancer, most anal cancers are caused by human papilloma virus type 16 (HPV16) and is preceded by a precancerous stage termed high-grade squamous intraepithelial lesion (HSIL). Unlike cervical cancer, the natural history of anal HSIL is poorly understood, and there is little evidence to inform prevention guidelines. In a retrospective audit of 574 men (73% HIV-infected) attending our anal cancer screening clinic, annual progression rate to HSIL was 7.4%, and for HSIL to cancer was 1.2%. This was the first study to quantify a spontaneous regression rate from HSIL, which was common at 23.5% per year. To further understand the role of the cellular immune response in anal HSIL spontaneous regression, two assays were developed to measure systemic HPV16-specific T-cell responses and applied to a cross-sectional substudy of the Study of the Prevention of ANal Cancer (SPANC), a prospective, natural history study of anal cancer precursors and HPV in MSM ≥35 years. CD4+ T-cell responses to the HPV16 oncogenic protein E6 were detected in 80 (N=134, 60%) men. These responses may be associated with recent HSIL regression – five of six (83%) regressors had these responses compared to seven of 20 (35%) non-regressors (Pexact=0.065). T-cell immune responses in the anal mucosa were also studied in the above 26 men with HSIL at study entry. 24 (55%) biopsies had stromal lymphoid aggregates. Using whole slide imaging (600x) and two-colour immunofluorescent staining, CD4+ and CD8+ T-cell densities were measured. Lymphoid aggregates were CD4+ T-cell enriched (2.8-fold higher in density, P<0.01) compared to CD8+ T-cells (1.7-fold higher, P=0.08). Biopsies with HSIL diagnosis and having anal HPV16 detected were associated with higher total T-cell density. In summary, anal HSIL spontaneous regression is common. A T-cell mediated mechanism for regression is plausible. This should be taken into account when developing screening and treatment strategies for anal HSIL. Declaration relating to disposition of project thesis/dissertation I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral theses only). …………………………………………………………… ……………………………………..……………… ……….……………………...…….…5th June 2016 Signature Witness Signature Date The University recognises that there may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years must be made in writing. Requests for a longer period of restriction may be considered in exceptional circumstances and require the approval of the Dean of Graduate Research. FOR OFFICE USE ONLY Date of completion of requirements for Award: THIS SHEET IS TO BE GLUED TO THE INSIDE FRONT COVER OF THE THESIS ORIGINALITY STATEMENT ‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged.’ Signed …………………………………………….............. Date …………………………………………….............. COPYRIGHT STATEMENT ‘I hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International (this is applicable to doctoral theses only). I have either used no substantial portions of copyright material in my thesis or I have obtained permission to use copyright material; where permission has not been granted I have applied/will apply for a partial restriction of the digital copy of my thesis or dissertation.' Signed ……………………………………………........................... Date ……………………………………………........................... AUTHENTICITY STATEMENT ‘I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has occurred and if there are any minor variations in formatting, they are the result of the conversion to digital format.’ Signed ……………………………………………........................... Date ……………………………………………........................... Originality Statement ........................................................................................................ 7 Acknowledgements ........................................................................................................... 8 Publications ..................................................................................................................... 11 List of Figures ................................................................................................................. 12 List of Supplementary Figures ........................................................................................ 13 List of Tables................................................................................................................... 14 List of Abbreviations....................................................................................................... 16 Chapter 1 - Literature review .......................................................................................... 21 1.1 Introduction .................................................................................................................... 22 1.2 Human papillomavirus (HPV) ....................................................................................... 22 1.2.1 Life cycle ............................................................................................................ 26 1.2.2 Classification ....................................................................................................... 27 1.3 Clinical manifestations of HPV infection ...................................................................... 29 1.3.1 With primary immunodeficiency ........................................................................ 29 1.3.2 With secondary immunodeficiencies .................................................................. 30 1.3.2.1 Human immunodeficiency virus (HIV) ...................................................... 30 1.3.2.2 Transplant recipients ................................................................................... 31 1.4 The immune response to HPV infection ........................................................................ 33 1.4.1 Innate ................................................................................................................... 33 1.4.2 Humoral .............................................................................................................. 35 1.4.3 Cellular ................................................................................................................ 36 1.5 Anal HPV, squamous intraepithelial lesions and cancer ............................................... 38 1.5.1 Epidemiology....................................................................................................... 38 1.5.1.1 Anal HPV and AIN ...................................................................................... 38 1.5.1.2 Anal cancer .................................................................................................. 39 1.5.2 Pathogenesis .......................................................................................................
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