Carcinoma of the lungs is one of the common causes of death among adult males and females. There is a great variety of causes involved in the pathogenesis of the disease and among the most frequent ones, is smoking, exposure to pollutants, asbestos and changes in the genome. Furthermore, viral infection and more specifically infection by Human Papilloma Virus, which is one of the main risk factor of the majority of cervical and oropharyngeal cancers, is also considered one of the possible etiologic factors for lung cancer. Immunohistochemistry is one of the methods used to detect Human Pappiloma Virus in specimens taken from patients with lung cancers. Herein; we describe the steps needed to detect Human Pappiloma Virus by using the immunohistochemistry methodology in cancer patients and specifically those suffering from various types of lung cancer.
Lung cancer is one of the common and devastating types of malignancies. Approximately 50,000 people per year are diagnosed with the specific type of malignancy in the UK (https://www.nhs.uk). Primary, is the type of cancer which starts from the lungs while secondary is the one which reaches the lung from another site. There are two categories of primary lung cancer according to the type of origin cells. The most common type is the non-small-cell lung cancer which could be squamous cell carcinoma, adenocarcinoma or large-cell carcinoma. The other type is the small-cell lung cancer which is not a frequent type but has a quick rate of metastasis in comparison to the non-small-cell lung type (Brambilla et al, 2001).
The main reason why lung cancer is frequent both among men and women is the increased exposure of both sexes to cigarette smoke (active and passive smoking). Studies has shown that stopping smoking at any age could decrease the risk of death from all pathologic conditions directly related to smoke and lung cancer is one of them (Thun et al,2013). It is obvious that there are other factors which cause the development of the specific pathology with environmental factors, genetic reasons and infections being the most frequent ones (Wood et al, 2000). It is estimated that exposure to microbiologic pathogens could cause cancer to 16% of the population. Human papilloma virus (HPV) was found to be involved in the pathogenesis of some type of cancers (cervix, uterus and oropharynx). Interesting enough, it is also involved in the carcinogenesis of the lung. There is a theory that the HPV could affect the lung tissue through the blood when there is a primary infection site in another system usually the genital one (Grulich et al, 2010).
HPV belongs to the papilloma viruses, a large family of DNA viruses. According to the character of HPV, it has a high degree of affinity to the squamous epithelium which is similar like the bronchial type.
Immunohistochemistry (ICH) is a technique for staining tissue using antibodies against a particular antigen. One of the detection strategies regarding the specific virus is initially to identify the virus itself in the provided specimen and along with the ability to induce production of malignant cells. The objective of this essay is to describe the steps needed to identify HPV from a tissue taken by a patient with lung cancer. (Painter JT, Clayton NP, Herbert RA, 2010)
Using the right antibodies to target the correct antigens and intensify the signal is crucial for better identification by immunohistochemistry method. It is also important to prepare the sample in such a way to maintain the morphology of the cells, the tissue architecture and the antigenicity of target epitopes. Tissue from the target organ is received by various methods like lobectomy, or bronchogenic biopsy. It must be rapidly preserved to prevent the breakdown of cellular protein and disruption of the normal tissue structure. Sample could be simply rinsed to clear from the blood, before proceeding to fixation. The aim is to remove the antigens of blood origin that make the detection of target antigens difficult.
Most tissue fixatives chemically crosslink proteins and reduce protein solubility, which can hide target antigens during prolonged or incorrect fixation. “Formaldehyde (formalin), a semi-reversible, covalent crosslinking reagent is usually used for perfusion or immersion fixation” (http://fac.ksu.edu.sa). “Tissues which are fixed in formaldehyde are typically embedded in paraffin wax in order to permit sectioning and further processing” (www.thermofisher.com/uk). It also helps to maintain their natural shape and structure during long-term storage and to make sectioning prior to IHC easier.
The formalin fixed tissue should be subjected to section of 4µm in thickness, and then labelled on charged slides (Robertson D, Savage K, Reis-Filho JS, Isacke CM ,2008). All sections will be dried out by set the slides in a 60 °C oven for 60 minutes. The specimen should be further processed by endogenous peroxidase with 0.3% H2O2 methanol for 30 min followed by three short washes (5 min) in distilled water and then one wash in phosphate buffer saline (PBS) (http://www.amsbio.com/protocols/IHC)
The paraffin in formalin-fixed, paraffin-embedded (FFPE) sections must be completely removed before IHC staining. If de-paraffinization is not complete, the target antigens will accessible and the antibodies will be unable to react with them.
“Formaldehyde fixation forms methylene bridges that crosslink protein in tissue samples. As a result, FFPE sections typically require treatment to uncover the antigenic epitopes prior to staining. This is called epitope or antigen retrieval” (www.thermofisher.com/uk/en).
Antigen retrieval is an important step for extended exposure of antigenic epitopes in formalin fixed tissues. Formalin helps to form bridges between adjacent protein molecules. Furthermore, processing of the specimen masks antigens and decreases the sites available for protein demonstration and needs to be reversed in order for the diagnosis to be more precise. Enzyme digestion is one of the types of antigen retrieval which could be used in the case of specimens to detect lung cancer.
Although antibodies show preferential avidity and affinity for specific epitopes, antibodies could also bind without specificity to sites on non-antigen proteins that look similar to the wright binding sites on the target antigen. To reduce the background staining in IHC, prior to staining, the samples are incubated with a buffer that blocks the non-specific sites to which the primary or secondary antibodies may otherwise bind. Common blocking buffers include normal serum, BSA (bovine serum albumin), gelatin (Okoye JO, Nnatuanya IN, 2015).
Since the aim is to detect HPV in lung cancer tissue, it would be helpful to add monoclonal antibody anti (HPV) protein. By using the indirect detection method, we check the affinity of proteins to bind biotin to detect a biotinylated antibody that is bound to the target antigen.
The antigen-bound antibody is then localized by adding an conjugate which is responsible for an amplified signal when appropriate substrates are added. “A solid carcinoma without glandular structures or mucin production, but with immunohistochemical positivity for “TTF-1, is diagnosed as an adenocarcinoma, a carcinoma with immunohistochemical positivity for CK5/6, and TP63, is diagnosed as Squamous cell carcinoma” (Kentaro Inamura, 2010). “The use of specific dye like DAB (3,3′-diaminobenzidine) which is oxidized in the presence of peroxidase and hydrogen peroxide, lead to the deposition of a brown, alcohol-insoluble precipitate at the site of enzymatic activity” (www.thermofisher.com/uk/). Finally the use of counterstain will provide contrast to the primary stain and can provide more information regarding the structure of the cell. They are usually added after antibody staining and most common one are hematoxylin and eosin which could be also used in this case. The slide is then ready to be seen under the microscope.
Depending on the type of tissue which is under investigation, the use of negative controls could help towards the diagnosis of a true positive result. Positive controls could also be used to make sure that there is no malfunction of the antibodies and other reagents.
The standard positive immunoreaction is dark brown, spontaneous in the nucleus for HPV.
Lung cancer is one of the most common causes of the malignancy related death worldwide. One of the main risk factors is smoking. However, less than 1/3 of those who smoke develop lung cancer, which leads to the conclusions that additional risk factors are involved. The role of HPV as one possible cause of lung cancer was hypothesised as a proportion of morphological changes seen in lung tumours closely resembled those seen in genital HPV lesions. This observation led to intense studies in order to identify possible connection between them (Tommasino M, 2014). IHC could be one potentially effective method to identify the connection lung cancer and HPV but it is influenced by a variety of factors like gender, smoking habits, HPV subtype, material, histological type and differentiation, clinical stage. Whether lung cancer patients are carrying an HPV infection is not totally clear and there should be further studies in order to identify markers of the infection in the specific type of malignant tissue.