Clinical Cancer Research Meeting Calendar Frontiers in Basic Cancer Research
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Cancer Research Clinical Cancer Research
Cancer Epidemiology Biomarkers & Prevention Molecular Cancer Therapeutics
Molecular Cancer Research Cancer Prevention Research
Cancer Prevention Journals Portal Cancer Reviews Online
Annual Meeting Education Book Meeting Abstracts Online
Clinical Cancer Research 14, 685, February 1, 2008. doi: 10.1158/1078-0432.CCR-07-1246
© 2008 American Association for Cancer Research
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Álvaro, T.
Right arrow Articles by Pons, L. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Álvaro, T.
Right arrow Articles by Pons, L. E.

Human Cancer Biology

Tumor-Infiltrated Immune Response Correlates with Alterations in the Apoptotic and Cell Cycle Pathways in Hodgkin and Reed-Sternberg Cells

Tomás Álvaro1, Marylène Lejeune1, Juan F. García2, Ma. Teresa Salvadó1, Carlos López1, Ramón Bosch1, Joaquín Jaén1, Patricia Escrivá1 and Lluis E. Pons1

Authors' Affiliations: 1 Department of Pathology, Hospital de Tortosa Verge de la Cinta, Tortosa, Spain and 2 Department of Pathology, M. D. Anderson Internacional, Madrid, Spain

Requests for reprints: Tomás Álvaro, Department of Pathology, Hospital de Tortosa Verge de la Cinta, C/ Esplanetes n° 14, 43500 Tortosa, Spain. Phone: 34-977-519104; Fax: 34-977-519104; E-mail: talvaro.htvc.ics{at}gencat.net.


   Abstract
Top
 Abstract
Materials and Methods
 Results
 Discussion
 References
 
Purpose: To analyze tumor-microenvironment relationships in Hodgkin lymphoma (HL) as potential determinants in the decision-making process related to the alterations in cell cycle and apoptotic pathways of Hodgkin/Reed-Sternberg (H/RS) cells.

Experimental Design: Based on a cohort of 257 classic HL patients, we carried out a global descriptive correlational analysis and logistic regression study to identify tumor-infiltrated immune cell rate in HL that could be interconnected with genes involved in the regulation of apoptotic/proliferative pathways in H/RS cells.

Results: Our results reveal the existence of a connection between the reactive microenvironment and molecular changes in apoptotic/proliferative pathways in H/RS cells. A lesser incidence of infiltrated cytotoxic cells in the tumor (CD8+ T lymphocytes, CD57+ natural killer, and granzyme B+ cells) was associated with overexpression of antiapoptotic proteins (Bcl-XL, survivin, caspase-3, and nuclear factor-{kappa}B) in tumoral cells. Increased incidence of general infiltrated immune cells, such as CD4+ T lymphocytes, CD57+ natural killer cells, activated CTL, and dendritic cells, in the microenvironment of the tumor was associated with increased growth fraction of tumoral cells, including G1-S checkpoint (cyclin D and cyclin E) and tumor suppressor pathways (p16 and SKP2), and with the presence of EBV (signal transducers and activators of transcription 1 and 3 expression; STAT1/STAT3).

Conclusions: A lower level of cytotoxic cells correlated with an increase of antiapoptotic mechanisms in H/RS cells, whereas the global infiltrated immune population correlated with the growth fraction of the tumor. Our collective data suggest a causal relationship between infiltrated immune response and concurrent changes of the different proliferative checkpoints, tumor suppressor, and apoptotic pathways of H/RS cells in HL.

Hodgkin/Reed-Sternberg (H/RS) cell clones of 25% of classic Hodgkin lymphoma cases have nonfunctional immunoglobulin gene rearrangements, whereas the remaining cases seem to have acquired somatic mutations preventing immunoglobulin expression (1, 2). Previous studies have described alterations in genes controlling apoptosis and proliferation of H/RS cells, such as p53 expression (3, 4), deregulation of the Bcl2 family (3–5), proliferative and/or apoptotic indices (3, 6), activation of the nuclear factor-{kappa}B (NF-{kappa}B) pathway (7), and biological factors such as EBV detection (8, 9), which influence the clinical aggressiveness of HL (5, 10–12).

The tumor microenvironment has been considered to be a manifestation of host immune reactions to malignant cells (13). The immune response in HL is likely to be inadequate because of the poor immunogenicity, the immunosuppressive effect of tumoral cells (14), or the poor response of the host immune system. The abnormal cytokine pattern in HL may contribute not only to the proliferation of H/RS cells but also to the maintenance of an inappropriate environment in which an effective host immune response to H/RS cells cannot be achieved. The role of the reactive microenvironment was found to be associated with the number, subset type, and activation state of the reactive immune cells (15, 16), specifically the cytotoxic and regulatory T cells (17–19). However, the full significance of infiltrating immune cells in the pathology of HL continues to be controversial (20).

Approximately 20% to 30% of HL patients fail therapy and eventually die as a result of progressive disease or complications of therapy (21). Our knowledge of the molecular biology of HL is incomplete and has not been practically translated into an improvement in the treatment of this disease. Recently, a gene expression profile study in advanced classic HL identified signatures of tumoral growth/apoptosis that are associated with treatment response and outcome in these patients and two other signatures representing the tumor microenvironment and host immune response (22). This suggests that not only the biology of the tumor cell but also the characteristics of the immune response of the host could be factors determining the treatment response and clinical behavior of the tumor. Among these complex interactions, immune cells present in the infiltrate are able to modulate apoptosis and proliferation via death receptors, cytotoxic granule liberation, withdrawal of growth factors, and production of immunosuppressive cytokines (23–25). On the other hand, apoptosis and proliferation observed in H/RS cells have also been partially associated with the presence of alterations of these genes and microenvironmental signals due to the intervention of the reactive immune infiltrate (26). The evaluation of the possible interaction of H/RS cells with components of their microenvironment may be useful for determining new markers of therapeutic response, which should provide more accurate information pertinent to patient care. Bearing these considerations in mind, this study set out to explore the association between the tumor-infiltrated cells and the different genes involved in the defective regulation of apoptosis and cell cycle observed in H/RS cells of a series of 257 HL patients, with a view to thinking about new strategies for the design of future therapies.


   Materials and Methods
Top
 Abstract
 Materials and Methods
Results
 Discussion
 References
 
HL patients. The studied population consisted of 257 patients with the histologic and subtype confirmation (WHO classification) of HL who had been diagnosed between 1994 and 1998 by members of the Spanish Hodgkin Lymphoma Study group (3). All of the samples included represent at-diagnosis biopsies and all of the patients were treated following standard protocols (3, 12). The alterations in the major tumor suppressor pathways and cell cycle checkpoints, the biological markers, and the tumor-infiltrating cells of these tumors and patients have been described elsewhere (3, 12, 17, 18).

Immunohistochemistry and in situ hybridization. Immunohistochemistry and in situ hybridization of the different markers in H/RS and immune cells have been previously assessed using tissue microarray technology (18). Immunohistochemical staining of the cellular infiltrate surrounding tumoral H/RS cells was done in the Immunohistochemistry Unit of the Department of Pathology of the Hospital de Tortosa Verge de la Cinta. Infiltrated immune cells were quantified manually on two digital images of representative areas selected based on the presence of H/RS cells with an appropriate inflammatory background as previously described (18, 19). The mean number of positive cells/field for each antibody was calculated. For CD21, the positive zones were measured as areas, the mean was calculated, and the final result was expressed as total positive surface area (µm2)/field. The thresholds established for each marker, calculated after a careful preliminary evaluation and estimation of different cutoffs, and the related numbers of positive cases observed in the series for each of them were shown in Table 1 . The cutoffs were established according to statistical principles and based on the frequency of distribution of each of the immune-positive cells (histogram) in the series (18, 19).


View this table:
[in this window]
[in a new window]

  		Table 1. Protein, threshold, pattern of reactivity, and percentage of positive immune and H/RS cells: results from immunohistochemistry and in situ hybridization

 
Immunohistochemical expression of the different markers of apoptosis and proliferation in H/RS cells was done using the LSAB Visualization System (DAKO) in the Immunohistochemistry and Histology Unit of the Centro Nacional de Investigaciones Oncológicas (Madrid, Spain). The different patterns of staining of each apoptotic and proliferative markers were recorded as positive/negative or high/low expression, taking into account the expression in H/RS cells (Table 1). The different cutoffs for each marker were previously established by the reactivity of accompanying lymphocytes and macrophages and by internal controls included in the tissue microarray (3). The numbers of positive cases observed in the series in function of the threshold of each marker were shown in Table 1.

Statistical methods. Statistical analysis was done using Statistical Package for the Social Sciences 11.0 (SPSS). All possible relationships between apoptosis and proliferative markers of tumoral cells and each one of the components of the immune response were evaluated using the unpaired t test or Mann-Whitney U test, as appropriate. For continuous variables, the results are expressed as means and SDs. Statistical relationships for dichotomized immune variables were also analyzed by the Pearson {chi}2 test or Fisher's exact test, as appropriate. To find the best-fitting model that describes these relationships, we also did a logistic regression analysis using the forward Wald variable selection method. The dependent variable consisted of the dichotomous levels of the immune infiltrate components. The independent variables included the complete set of proliferative and apoptotic markers in tumoral cells (independent variables). Odds ratios are presented with 95% confidence intervals. For all tests, values of P < 0.05 were considered to be statistically significant.


   Results
Top
 Abstract
 Materials and Methods
 Results
Discussion
 References
 
Immunohistochemical analysis. The results about the immunohistochemical detection of immune cells and apoptotic/proliferative protein of H/RS cells are summarized in Table 1. Classic HL tumors were principally infiltrated by CD4+ T lymphocytes (78% of cases), granzyme B+ cells (58%), and TIA-1+ cells (37%). The H/RS cells seem to express cyclins and cyclin-dependent kinases (CDK) involved in the G1-S and G2-M transitions, and molecules involved in apoptosis control, and exhibit multiple alterations in the expression of the CDK inhibitors that are involved in the various tumor suppressor pathways, such as p53-p21WAF1, p16INK4a-Rb, and p27KIP1. These data have been partially presented in previous articles (3, 18). In comparison with the patterns of staining of the different internal controls previously established according to the different thresholds, H/RS cells of this series present (a) an important increase in the expression (overexpression) of cyclin E, CDK2, CDK6, Bcl2, Bcl-XL, and survivin; (b) an increased nuclear expression of NF-{kappa}B, and signal transducers and activators of transcription 1 and 3 (STAT1 and STAT3); and (c) the loss of expression of p16INK4a p27KIP1, and the antiapoptotic Bax.

Relationship between tumor-infiltrated immune cells and H/RS cell apoptotic markers. The number of infiltrated immune cells, considered as continuous or dichotomized variables, varied between the apoptotic markers in H/RS cells. As illustrated in Table 2 , a significantly greater number of CD4+ T lymphocytes and fewer CD8+ T lymphocytes were clearly associated with the overexpression of the antiapoptotic genes Bcl-XL and Mcl1. A reduced number of CD56+ and CD57+ natural killer (NK) cells in the tumor were also significantly related to the overexpression of the antiapoptotic genes Bcl2 and NF-{kappa}B. Finally, a greater number of infiltrated S-100+ dendritic cells were significantly associated with the loss of expression of Bax. Using dichotomized immune variables, the significant relationship between CD8+ T lymphocytes and the antiapoptotic gene Bcl-XL was confirmed (P = 0.016, Pearson {chi}2 test), whereas the CD57+ NK cells seem related to the others antiapoptotic genes Bcl2, survivin, and NF-{kappa}B (P = 0.016, 0.031, and 0.008, respectively, Fisher's exact test). No significant relationship was found between lymphocytes and NK cells and the expression of the proapoptotic markers or between cytotoxic cells (identified by granzyme B and TIA-1) and the global markers of apoptosis.


View this table:
[in this window]
[in a new window]

  		Table 2. Number of infiltrated immune cells present in the reactive microenvironment of tumors of HL patients according to the staining patterns of the apoptotic markers expressed by H/RS cells

 
Relationship between tumor-infiltrated immune cells and H/RS cell proliferative markers. As shown in Table 3 , the principal relationships encountered in this study were restricted to the proteins of the G1-S transition. T lymphocytes, CTL, NK, dendritic cells, and regulatory T cells exhibited significant relationships with proteins involved in the G1-S checkpoint and tumor suppressor pathways defined by the p16INK4a-Rb, p53-p21WAF1, and p27KIP1 pathways. Most of these relationships were verified with the dichotomized immune variables (data not shown). This suggests that multiple components of the innate immune system are actively involved, presumably through a coordinated response with the apoptotic and cell cycle mechanisms of H/RS cells.


View this table:
[in this window]
[in a new window]

  		Table 3. Number of infiltrated immune cells present in the reactive microenvironment of tumors of HL patients according to the staining patterns of the proliferative markers expressed by H/RS cells

 
In particular, a generally higher number of infiltrated T lymphocytes, regulatory T cells, cytotoxic cells, and dendritic cells and a reduced number of NK cells in the tumors seemed significantly associated with the positive expression of cyclin D and the overexpression of CDK2 in H/RS.

A higher number of global reactive cells (T lymphocytes, NK, cytotoxic cells, dendritic cells, and regulatory T cells) were significantly associated with the alterations in the p16INK4a-Rb pathway, whereas a lower number of CD8+ T lymphocytes and FOXP3+ regulatory T cells were significantly associated with the alterations observed in the p53-p21WAF1 pathway. A greater infiltration of CD8+ T lymphocytes, NK, and activated cytotoxic cells was associated with the p27KIP1 pathway and the infiltration of granzyme B cytotoxic cells was associated with the expression of the Bcl6 gene.

The presence of CD4+ T lymphocytes and granzyme B+ cytotoxic cells was associated with the expression of the transcription factor STAT3, whereas a higher number of FOXP3+ regulatory T cells were significantly associated with the expression of the transcription factor STAT1.

Logistic regression analyses. Relationships encountered between each one of the components of the immune response with the different apoptotic and proliferative pathways of tumoral cells were verified with the logistic regression model (Table 4 ). In this model, the analysis indicates that a low level of infiltrated cytotoxic cells in the reactive microenvironment of HL patients (CD8+ T lymphocytes, CD57+ NK cells, and granzyme B+ cytotoxic cells) seems associated with the overexpression of antiapoptotic proteins observed in H/RS cells (Bcl-XL, survivin, caspase-3, and NF-{kappa}B). On the other hand, the analysis indicates also that a general high level of immune infiltrate CD4+ T lymphocytes, CD57+ NK cells, activated CTL, and dendritic cells in the same time that a low level of nonactivated CTL (TIA-1+ CTL) and dendritic cells in the reactive microenvironment of these patients was associated with the abnormal expression of the proliferative proteins regulating the transition from G1 to S in H/RS cells (cyclin D and cyclin E) and involved in the tumor suppressor pathways (p16 and SKP2). A low level of infiltrated CD4 T lymphocytes and a high level of activated CTL were associated with the STAT3 expression in tumoral cells, whereas a low level of infiltrated dendritic cells was associated with the STAT1 expression.


View this table:
[in this window]
[in a new window]

  		Table 4. Logistic regression analysis that best fits the relationship between the immune infiltrate and the set of apoptotic and proliferative markers of tumoral cells in HL patients

 

   Discussion
Top
 Abstract
 Materials and Methods
 Results
 Discussion
References
 
Tumor-microenvironment interactions seem to be possible determinants in the evolution of the tumor (27, 28). In this study, for the first time, we have undertaken a descriptive associational analysis of human HL to determine the possible relationships between the number and type of immune cells that have infiltrated the tumor and the expression of proteins involved in the tumoral apoptotic/proliferative pathways. Our results indicate that (a) there is a relationship between cells of the global reactive microenvironment and molecular changes in the cytoplasm and nucleus of H/RS cells, (b) these molecular changes affect the apoptotic/proliferative pathways of tumoral cells, (c) the cytotoxic immune response seems to be associated with the apoptotic pathway, (d) the global immune response seems to be associated only with the G1-S checkpoint and tumor suppressor pathways of the cell cycle, and (e) CD4+ T cells but also CTL and dendritic cells seem associated with the STAT pathway, which is involved in EBV infection.

In the complex scenario of immune response against the tumor, cumulative data on the descriptive changes of genes and proteins involved in the host immune response but also in the apoptotic/proliferative pathways of H/RS cells are currently available. Some of these data, included in the present study, have been correlated separately with the clinical outcome of HL patients (3, 17, 18, 22). Theoretical works are necessary to identify how immune response interacts with the apoptotic/proliferative mechanisms of H/RS cells that could participate and promote changes of the morphology, treatment response, and outcome in HL. Our results provide some evidences that the clinicobiological behavior of HL patients is subjected to the direct cross-talk between the immune response and H/RS cells. An up-to-date literature review (in vitro studies) indicates that the immune cells, by direct contact or by signals delivered within the tumor microenvironment, may be able to induce some of the changes involved in the apoptotic/proliferative pathways of H/RS cells that could explain the clinicobiological variability in this disease.

The cell cycle and apoptotic functions are coordinately regulated (29, 30) and the balance between the two signaling cascades can be influenced by the reactive microenvironment of the tumor. The deregulation of H/RS cell apoptotic pathway seems to be significantly associated with infiltrated CTLs (CD8+ T cells, NK cells, and cytotoxic cells) that are able to activate apoptotic caspase proteolytic cascade through tumor necrosis factor receptor superfamily interactions (FasL/Fas and CD40/CD40L). The different members of this superfamily share common cell signaling pathways that mediate the activation of nuclear factor NF-{kappa}B and mitogen-activated protein kinases. In this case, CD40/CD40L interactions are known to induce the up-regulation of Bcl-XL and Mcl1 expression (26, 31) and to mediate the activation of NF-{kappa}B (32, 33), which induces changes in the expression of a set of proteins regulating apoptosis, such as survivin and Bcl-XL (7, 34). CTLs are also able to trigger a second proapoptotic pathway through the protease granzyme B, which, once released from CTLs, is translocated into the target cell by perforin, where it activates the effector caspase cascade (35). On the other hand, the wide variety of cytokines and chemokines present in HL tumoral tissue (interleukin-2, interleukin-4, interleukin-6, and interleukin-13), responsible for the massive influx of activated immune cells (36), has been shown to regulate the expression of the various members of Bcl2 family, such as the antiapoptotic Bcl2 homologues Bcl-XL and Mcl1 and the proapoptotic Bax (37–41).

Alterations observed in the G1-S checkpoint of H/RS cell cycle and in the principal tumor suppressor pathways Rb-p16INK4a and p27KIP1 are significantly associated with the global immune infiltrate present in the tumor. Likewise for the apoptotic markers, the physiologic signals present in the reactive microenvironment also interfere with components of the G1-CDK checkpoint (cyclin D3, CDK6, and p27; refs. 42, 43). The constitutively activated NF-{kappa}B has also been shown to induce changes in the expression of a set of proteins regulating cell cycle progression and gene transcription, including cyclin D1, p53, p16INK4a, and p27KIP1 (7, 44). Cytotoxic cells are able to induce directly the permanent down-regulation of p27KIP1, probably as a consequence of increased degradation mediated by SKP2, a ubiquitin ligase for p27KIP1 (43, 45, 46). Related with the heightened proliferative state in these tumors is the high level of expression of Bcl6, a multifunctional regulator that is able not only to down-regulate cyclin D2 and p27KIP1 expression (47) but also to repress Bcl-XL (40).

The presence of EBV was significantly associated with the overexpression of STAT1 and STAT3. STAT3 was found to be associated with a low infiltration of CD4 T lymphocytes and a high infiltration of activated cytotoxic cells. Although STAT1 is considered to be a potential tumor suppressor (promoting apoptosis), STAT3 is thought to be an oncogene because it leads to the activation of cyclin D1 and Bcl-XL expression and is involved in promoting cell cycle progression and cellular transformation and in preventing apoptosis (48).

The physiologic relevance of these relationships could be related to the different probabilities of survival of HL patients. Previous results from this cohort showed that lower infiltration of CD8+ T cells, NK cells, and regulatory T cells and greater infiltration of cytotoxic cells (granzyme B+ and TIA-1+) are unfavorable prognostic factors (18) and that shorter survival is associated with Bcl2, p53, Bcl-XL, and Bax expression in H/RS cells (3, 12). Recently, four different sets of these deregulated genes have shown to be associated with a therapeutically unfavorable response in HL patients (22). Under these conditions, the concomitant analysis of the immune infiltrate and the apoptotic/proliferative pathways of tumoral cells should provide more accurate information about the specific molecular pathways critical for cancer cell growth. Possible molecules that interfere with these molecular links, particularly some enzymes representative of the immune metabolic state or tumoral cell cycle (22), might be pharmaceutically manipulated and could be candidates for new therapeutic targets pertinent to patient care.

In conclusion, our results highlight the possible causal relationship between the characteristics of the tumor microenvironment and the expression of proteins that regulate apoptosis and cell cycle in H/RS cells. This interaction could probably explain the chain of events with clinicobiological implications for HL patients established in several investigations relating immune response markers and apoptotic/proliferative molecules separately with clinicobiological data. These results should be further evaluated by experimental observations of functional models to put in evidence the possible cross-talk between the immune response and the apoptotic/proliferative mechanism in tumoral cells and should be considered for new strategic therapeutic approaches.


   Acknowledgments
 
We thank all the participants of the Spanish Hodgkin Lymphoma Study Group for their cooperation and Maria del Mar Barberà, Rosa Risa, Bàrbara Tomàs, Vanesa Gestí, Ana Suñé, and Marc Iniesta for their technical assistance.


   Footnotes
 
Grant support: Ministerio de Sanidad y Consumo, Spain, grants FIS 05/1527 (T. Álvaro) and 04/1440 (J. Jaén) and Fundación Mutua Madrileña FMMA, Spain (J.F. García).

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

Received 5/21/07; revised 10/ 2/07; accepted 10/23/07.


   References
Top
 Abstract
 Materials and Methods
 Results
 Discussion
 References
 

  1. Marafioti T, Hummel M, Foss HD, et al. Hodgkin and Reed-Sternberg cells represent an expansion of a single clone originating from a germinal center B-cell with functional immunoglobulin gene rearrangements but defective immunoglobulin transcription. Blood 2000;95:1443–50.[Abstract/Free Full Text]
  2. Schwering I, Brauninger A, Klein U, et al. Loss of the B-lineage-specific gene expression program in Hodgkin and Reed-Sternberg cells of Hodgkin lymphoma. Blood 2003;101:1505–12.[Abstract/Free Full Text]
  3. Garcia JF, Camacho FI, Morente M, et al. Hodgkin and Reed-Sternberg cells harbor alterations in the major tumor suppressor pathways and cell-cycle checkpoints: analyses using tissue microarrays. Blood 2003;101:681–9.[Abstract/Free Full Text]
  4. Smolewski P, Robak T, Krykowski E, et al. Prognostic factors in Hodgkin's disease: multivariate analysis of 327 patients from a single institution. Clin Cancer Res 2000;6:1150–60.[Abstract/Free Full Text]
  5. Rassidakis GZ, Medeiros LJ, Vassilakopoulos TP, et al. BCL-2 expression in Hodgkin and Reed-Sternberg cells of classical Hodgkin disease predicts a poorer prognosis in patients treated with ABVD or equivalent regimens. Blood 2002;100:3935–41.[Abstract/Free Full Text]
  6. Smolewski P, Niewiadomska H, Los E, Robak T. Spontaneous apoptosis of Reed-Sternberg and Hodgkin cells; clinical and pathological implications in patients with Hodgkin's disease. Intern J Oncol 2000;17:603–9.[Medline]
  7. Hinz M, Loser P, Mathas S, Krappmann D, Dorken B, Scheidereit C. Constitutive NF-{kappa}B maintains high expression of a characteristic gene network, including CD40, CD86, and a set of antiapoptotic genes in Hodgkin/Reed-Sternberg cells. Blood 2001;97:2798–807.[Abstract/Free Full Text]
  8. Glavina-Durdov M, Jakic-Razumovic J, Capkun V, Murray P. Assessment of the prognostic impact of the Epstein-Barr virus-encoded latent membrane protein-1 expression in Hodgkin's disease. Br J Cancer 2001;84:1227–34.[CrossRef][Medline]
  9. Montalban C, Abraira V, Morente M, et al. Epstein-Barr virus-latent membrane protein 1 expression has a favorable influence in the outcome of patients with Hodgkin's disease treated with chemotherapy. Leuk Lymphoma 2000;39:563–72.[Medline]
  10. Morente MM, Piris MA, Abraira V, et al. Adverse clinical outcome in Hodgkin's disease is associated with loss of retinoblastoma protein expression, high Ki67 proliferation index, and absence of Epstein-Barr virus-latent membrane protein 1 expression. Blood 1997;90:2429–36.[Abstract/Free Full Text]
  11. Sanchez-Aguilera A, Garcia JF, Sanchez-Beato M, Piris MA. Hodgkin's lymphoma cells express alternatively spliced forms of HDM2 with multiple effects on cell cycle control. Oncogene 2006;25:2565–74.[CrossRef][Medline]
  12. Montalban C, Garcia JF, Abraira V, et al. Influence of biologic markers on the outcome of Hodgkin's lymphoma: a study by the Spanish Hodgkin's Lymphoma Study Group. J Clin Oncol 2004;22:1664–73.[Abstract/Free Full Text]
  13. Maggio E, van den Berg A, Diepstra A, Kluiver J, Visser L, Poppema S. Chemokines, cytokines and their receptors in Hodgkin's lymphoma cell lines and tissues. Ann Oncol 2002;Suppl 1:52–6.
  14. Marshall NA, Christie LE, Munro LR, et al. Immunosuppressive regulatory T cells are abundant in the reactive lymphocytes of Hodgkin lymphoma. Blood 2004;103:1755–62.[Abstract/Free Full Text]
  15. Oudejans JJ, Jiwa NM, Kummer JA, et al. Activated cytotoxic T cells as prognostic marker in Hodgkin's disease. Blood 1997;89:1376–82.[Abstract/Free Full Text]
  16. Baur AS, Meuge-Moraw C, Michel G, Delacretaz F. Prognostic value of follicular dendritic cells in nodular sclerosing Hodgkin's disease. Histopathology 1998;32:512–20.[Medline]
  17. Alvaro T, Lejeune M, Salvado MT, et al. Outcome in Hodgkin's lymphoma can be predicted from the presence of accompanying cytotoxic and regulatory T cells. Clin Cancer Res 2005;11:1467–73.[Abstract/Free Full Text]
  18. Alvaro-Naranjo T, Lejeune M, Salvado-Usach MT, et al. Tumor-infiltrating cells as a prognostic factor in Hodgkin's lymphoma: a quantitative tissue microarray study in a large retrospective cohort of 267 patients. Leuk Lymphoma 2005;46:1581–91.[CrossRef][Medline]
  19. Bosch Princep R, Lejeune M, Salvado Usach MT, Jaen Martinez J, Pons Ferre LE, Alvaro Naranjo T. Decreased number of granzyme B+ activated CD8+ cytotoxic T lymphocytes in the inflammatory background of HIV-associated Hodgkin's lymphoma. Ann Hematol 2005;84:661–6.[CrossRef][Medline]
  20. de Visser KE, Coussens LM. The inflammatory tumor microenvironment and its impact on cancer development. Contrib Microbiol 2006;13:118–37.[Medline]
  21. Yung L, Linch D. Hodgkin's lymphoma. Lancet 2003;361:943–51.[CrossRef][Medline]
  22. Sanchez-Aguilera A, Montalban C, de la Cueva P, et al. Tumor microenvironment and mitotic checkpoint are key factors in the outcome of classic Hodgkin lymphoma. Blood 2006;108:662–8.[Abstract/Free Full Text]
  23. Berke G. The CTL's kiss of death. Cell 1995;81:9–12.[CrossRef][Medline]
  24. de Visser KE, Kast WM. Effects of TGF-β on the immune system: implications for cancer immunotherapy. Leukemia 1999;13:1188–99.[CrossRef][Medline]
  25. O'Connell J, O'Sullivan GC, Collins JK, Shanahan F. The Fas counterattack: Fas-mediated T cell killing by colon cancer cells expressing Fas ligand. J Exp Med 1996;184:1075–82.[Abstract/Free Full Text]
  26. Metkar SS, Manna PP, Anand M, Naresh KN, Advani SH, Nadkarni JJ. CD40 ligand—an anti-apoptotic molecule in Hodgkin's disease. Cancer Biother Radiopharm 2001;16:85–92.[CrossRef][Medline]
  27. Witz IP. Tumor-microenvironment interactions: the selectin-selectin ligand axis in tumor-endothelium cross talk. Cancer Treat Res 2006;130:125–40.[Medline]
  28. Whiteside TL. The role of immune cells in the tumor microenvironment. Cancer Treat Res 2006;130:103–24.[Medline]
  29. Zinkel S, Gross A, Yang E. BCL2 family in DNA damage and cell cycle control. Cell Death Differ 2006;13:1351–9.[CrossRef][Medline]
  30. Hemann MT, Lowe SW. The p53-Bcl-2 connection. Cell Death Differ 2006;13:1256–9.[CrossRef][Medline]
  31. Kater AP, Evers LM, Remmerswaal EB, et al. CD40 stimulation of B-cell chronic lymphocytic leukaemia cells enhances the anti-apoptotic profile, but also Bid expression and cells remain susceptible to autologous cytotoxic T-lymphocyte attack. Br J Haematol 2004;127:404–15.[CrossRef][Medline]
  32. Inoue J, Ishida T, Tsukamoto N, et al. Tumor necrosis factor receptor-associated factor (TRAF) family: adapter proteins that mediate cytokine signaling. Exp Cell Res 2000;254:14–24.[CrossRef][Medline]
  33. Lee HH, Dadgostar H, Cheng Q, Shu J, Cheng G. NF-{kappa}B-mediated up-regulation of Bcl-x and Bfl-1/A1 is required for CD40 survival signaling in B lymphocytes. Proc Natl Acad Sci U S A 1999;96:9136–41.[Abstract/Free Full Text]
  34. Hong SY, Yoon WH, Park JH, Kang SG, Ahn JH, Lee TH. Involvement of two NF-{kappa}B binding elements in tumor necrosis factor {alpha}-, CD40-, and Epstein-Barr virus latent membrane protein 1-mediated induction of the cellular inhibitor of apoptosis protein 2 gene. J Biol Chem 2000;275:18022–8.[Abstract/Free Full Text]
  35. Thome M, Tschopp J. Regulation of lymphocyte proliferation and death by FLIP. Nat Rev 2001;1:50–8.[CrossRef]
  36. Poppema S, Potters M, Emmens R, Visser L, van den Berg A. Immune reactions in classical Hodgkin's lymphoma. Semin Hematol 1999;36:253–9.[Medline]
  37. Akbar AN, Borthwick NJ, Wickremasinghe RG, et al. Interleukin-2 receptor common {gamma}-chain signaling cytokines regulate activated T cell apoptosis in response to growth factor withdrawal: selective induction of anti-apoptotic (bcl-2, bcl-xL) but not pro-apoptotic (bax, bcl-xS) gene expression. Eur J Immunol 1996;26:294–9.[Medline]
  38. Puthier D, Derenne S, Barille S, et al. Mcl-1 and Bcl-xL are co-regulated by IL-6 in human myeloma cells. Br J Haematol 1999;107:392–5.[CrossRef][Medline]
  39. Jourdan M, De Vos J, Mechti N, Klein B. Regulation of Bcl-2-family proteins in myeloma cells by three myeloma survival factors: interleukin-6, interferon-{alpha} and insulin-like growth factor 1. Cell Death Differ 2000;7:1244–52.[CrossRef][Medline]
  40. Tang TT, Dowbenko D, Jackson A, et al. The forkhead transcription factor AFX activates apoptosis by induction of the BCL-6 transcriptional repressor. J Biol Chem 2002;277:14255–65.[Abstract/Free Full Text]
  41. Song L, Li Y, Sun Y, Shen B. Mcl-1 mediates cytokine deprivation induced apoptosis of human myeloma cell line XG-7. Chin Med J Engl 2002;115:1241–3.[Medline]
  42. Malumbres M, Barbacid M. To cycle or not to cycle: a critical decision in cancer. Nat Rev Cancer 2001;1:222–31.[CrossRef][Medline]
  43. Wagner EF, Hleb M, Hanna N, Sharma S. A pivotal role of cyclin D3 and cyclin-dependent kinase inhibitor p27 in the regulation of IL-2-, IL-4-, or IL-10-mediated human B cell proliferation. J Immunol 1998;161:1123–31.[Abstract/Free Full Text]
  44. Sanchez-Beato M, Sanchez-Aguilera A, Piris MA. Cell cycle deregulation in B-cell lymphomas. Blood 2003;101:1220–35.[Abstract/Free Full Text]
  45. Blanchard DA, Affredou MT, Vazquez A. Modulation of the p27kip1 cyclin-dependent kinase inhibitor expression during IL-4-mediated human B cell activation. J Immunol 1997;158:3054–61.[Abstract]
  46. Ren F, Zhan X, Martens G, et al. Pro-IL-16 regulation in activated murine CD4+ lymphocytes. J Immunol 2005;174:2738–45.[Abstract/Free Full Text]
  47. Shaffer AL, Yu X, He Y, Boldrick J, Chan EP, Staudt LM. BCL-6 represses genes that function in lymphocyte differentiation, inflammation, and cell cycle control. Immunity 2000;13:199–212.[CrossRef][Medline]
  48. Calo VV, Migliavacca M, Bazan V, et al. STAT proteins: from normal control of cellular events to tumorigenesis. J Cell Physiol 2003;197:157–68.[CrossRef][Medline]



This article has been cited by other articles:


Home page
 J. Am. Med. Inform. Assoc.Home page
C. Lopez, M. Lejeune, P. Escriva, R. Bosch, M. T. Salvado, L. E. Pons, J. Baucells, X. Cugat, T. Alvaro, and J. Jaen
Effects of Image Compression on Automatic Count of Immunohistochemically Stained Nuclei in Digital Images
J. Am. Med. Inform. Assoc., November 1, 2008; 15(6): 794 - 798.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Álvaro, T.
Right arrow Articles by Pons, L. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Álvaro, T.
Right arrow Articles by Pons, L. E.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Cancer Research Clinical Cancer Research
Cancer Epidemiology Biomarkers & Prevention Molecular Cancer Therapeutics
Molecular Cancer Research Cancer Prevention Research
Cancer Prevention Journals Portal Cancer Reviews Online
Annual Meeting Education Book Meeting Abstracts Online