Head and neck cancer (HNC) is a molecularly heterogeneous group of multisite malignancies that arise through two major carcinogenic routes- first, chemical carcinogenesis associated with tobacco use and/or alcohol intake, and second, infection with oncogenic human papillomaviruses (HPVs) in a clinically distinct subset of HNCs. Unlike cervical cancer, where HPV infection is typically associated with aggressive invasive disease and poor prognosis, HPV-positive HNCs generally present a more favourable clinical outcome, particularly among non-tobacco users. Conversely, HPV-negative HNC patients who are predominantly tobacco and/or alcohol users, exhibit a poor prognosis and lower survival rate.Despite significant advances in treatment strategies for HNCs, therapy resistance leading to aggressive tumor recurrence and mortality remains to be a major clinical challenge. Transcription factors (TFs), as key regulators of gene expression and cellular signalling networks, play a critical role in head and neck carcinogenesis and represent promising targets for cancer therapy. A comprehensive understanding of the transcriptional and post-transcriptional/translational regulation of TFs, as well as the molecular mechanism(s) underlying their dual role as oncogenes or tumor suppressors, is essential for the development of effective therapies. This review focuses on major transcriptional regulators transcriptional regulators with establishd or emerging relevance in HNC pathobiology including AP-1, NF-κB, STAT3 MYC, SOX2, YY1, p53, p63 and NOTCH1. We discuss their oncogenic, tumor suppressive and context-dependent functions, with emphasis on how these factors coordinate downstream signalling networks during HNC development and progression, and therapeutic resistance. Overall, dysregulation of transcription factor in HNC is not limited to single pathway activation. Instead, TFs interact with non-coding RNAs and epigenetic mechanisms to form interconnected regulatory networks that promote both tumor plasticity and create potential therapeutic opportunities. Effective targeting of these networks will require biomarker-guided and rational combination strategies tailored to tumor type.

Triple-negative breast cancer (TNBC) is a clinically aggressive subtype characterized by poor prognosis and limited therapeutic options. Exosomal microRNAs (miRNAs), enclosed within secretory vesicles, have emerged as promising non-invasive biomarkers for cancer detection and disease monitoring. In this study, we identify a panel of five exosomal miRNAs: hsa-miR-6803, hsa-miR-1180, hsa-miR-4728, hsa-miR-1915, and hsa-miR-940, that are consistently overexpressed in TNBC cells, stem-like subpopulations, and patient tumor tissues. Integrated meta-analysis of public datasets combined with in-vitro validation revealed that elevated expression of these miRNAs correlates with poor overall survival. Functional assays further demonstrated that hsa-miR-1180 and hsa-miR-4728 enhance TNBC cell migration and invasion, implicating them in key oncogenic pathways such as Wnt, Notch, and EGFR. The consistent enrichment of these miRNAs in exosomes underscores their potential as exploratory biomarkers for future liquid-biopsy-based applications. To our knowledge, this discovery-phase investigation is the first to associate this exosomal miRNA panel with TNBC and its stem-like subpopulations, providing a preliminary framework for subsequent mechanistic and translational validation.

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive and often fatal cancer with limited treatment options. Small nucleolar RNA host gene 10 (SNHG10) has emerged as a key regulator in the progression and metastasis of human cancers. However, the potential of SNHG10 in PDAC tumorigenesis, gemcitabine resistance, and the underlying molecular mechanisms remains poorly understood. Our data analysis revealed significant upregulation of the SNHG10 transcript in 179 PDAC cases compared with 171 normal pancreatic specimens, with a positive association with clinical stages of PDAC. Further, we confirmed the significant overexpression of the SNHG10 transcript in several PDAC cell lines compared to normal pancreatic cells. Our results revealed that the downregulation of SNHG10 significantly decreased the cellular proliferation, clonogenic ability, cell migration, and the epithelial to mesenchymal transition, leading to the induction of cell cycle arrest and apoptosis of PDAC cells. Mechanistically, the downregulation of SNHG10 significantly inhibited the expression of vimentin, N-cadherin, survivin, CDK4, CDK6, cyclin B1, cyclin D1, aurora kinase A, and aurora kinase B, with an increased expression of E-cadherin and p21. The bioinformatics analysis, RNA Immunoprecipitation, and qRT-PCR results showed the physical interaction among SNHG10, miR-150-5p, and VEGF-A, which are the integral parts of the ternary complex in PDAC cell lines. Interestingly, silencing of SNHG10 led to the significant induction of miR-150-5p, which repressed the expression of VEGF-A in PDAC cells. Moreover, the miR-150-5p rescued the VEGF-A expression in PDAC cells even during the silencing of SNHG10. Interestingly, the downregulation of SNHG10 enhanced gemcitabine sensitivity in gemcitabine-resistant PDAC cells. The depletion of SNHG10 in the PDAC xenograft model significantly reduced tumor growth, volume, and weight. Importantly, downregulation of SNHG10 suppressed the phosphorylation of EGFR, AKT, ERK1/2, mTOR, and c-MET signaling pathways in both in vitro and xenograft models of PDAC. Our study unveils the oncogenic potential of SNHG10 in tumorigenesis through modulation of the EGFR/AKT/ERK/mTOR, and miR-150-5p/VEGF-A axis, as well as gemcitabine resistance of PDAC as a prospective therapeutic strategy.

Triple-negative breast cancer (TNBC) is characterised by aggressive pathobiology and frequent chemoresistance, yet the mechanisms underpinning treatment failure remain incompletely understood. Chemotherapy-induced autophagy has been implicated in small extracellular vesicle (sEV) biogenesis and cargo remodelling; whether the exosomal microRNA (exomiR) landscape of TNBC is altered under autophagy-inducing chemotherapy has not been established. sEVs were isolated from MDA-MB-231 and MDA-MB-468 cells under doxorubicin-induced autophagy-inducing conditions (10 nM, 48 h) and from matched vehicle controls, and were confirmed by CD81 and CD63 immunoblotting with Calnexin as a negative purity control. Autophagy induction was confirmed by Beclin-1 upregulation, p62/SQSTM1 turnover and LC3 puncta formation. Small RNA sequencing (12 libraries; n = 3 biological replicates per condition; DESeq2, nominal p < 0.01 with |log₂FC| > 1) identified 10 differentially expressed exomiRs in MDA-MB-231 and 7 in MDA-MB-468, of which three per cell line additionally satisfied a Benjamini-Hochberg false discovery rate threshold (adj. p < 0.05). In-silico target analysis of these 17 exomiRs identified eight convergent autophagy and apoptosis pathway nodes, most prominently BECN1 (targeted by 6 of the 17). Exploratory qRT-PCR confirmed increased hsa-miR-1468-5p in MDA-MB-231 (23.97-fold; adjusted p = 0.007) but did not confirm the remaining five candidates, one of which changed significantly in the opposite direction. Doxorubicin treatment under autophagy-inducing conditions is associated with cell-line-specific remodelling of the sEV miRNA cargo of TNBC cells. The present data do not provide direct evidence that autophagy causes these changes; establishing causality will require pharmacological or genetic disruption of the autophagy pathway. These discovery-phase findings identify hsa-miR-1468-5p as the priority candidate for prospective functional and clinical validation, and indicate that the remaining candidates require methodological refinement before their biological relevance can be assessed.

Triple-negative breast cancers (TNBCs) are the most aggressive, heterogeneous subtype of breast carcinoma with increased chemoradioresistance and a high rate of relapse. A compelling need exists to discover specific gene mutation(s) and the exomic mutational landscape associated with Indian TNBC patients to identify potential therapeutic target(s) for effective treatment of TNBC. Whole-exome sequencing (WES) was performed on 15 TNBC patients along with 5 random adjacent normal control tissue (ANCT) specimens. WES data alignment and mapping to the reference human genome (hg19) were done using BWA, SAMtools, and Picard tools. The data analysis and mutation calling were performed using the Genome Analysis Toolkit. The Signal Analyze and PANTHER pathways tools were utilized for mutational signature(s) and pathway(s) analysis, respectively. Our data revealed that the TNBC genomes carried an average of 106 mutations per sample. MutSig2CV analysis showed the most significant recurrent somatic mutations in CTNNB1 (47

Objectives:: The objective of this study is to assess the level of knowledge, practice, and usage of Unani medicine among 250 participants in different areas of New Delhi, India. Materials and Methods:: A cross-sectional, observational descriptive survey with a sample size of 250 people was carried out in New Delhi utilizing a pretested, predesigned, and structured questionnaire to evaluate the awareness and usage patterns of Unani medicine. The study was conducted at three different spots in different regions of New Delhi. Results:: With a mean age of 40.056 ± 10.77 years and a range of 18 to 65 years, the 250 participants were divided into 66% men and 34% women. 60% of the population who had been adopted had knowledge of Unani medicine, and 54.6% of them relied on Unani medicine as a treatment regime. 40% of users reported Unani medicine due to lack of no or minimal side effects. Contrary to this, among non-user (n = 68), 51.4% populace considers Unani medicine as the slow onset of action medication. Although a small percentage of users (6.1%) chose to use Unani completely, most preferred it as an adjunct to allopathic care. Conclusion:: Findings in the survey-based study depict that the awareness of Unani medicines is better than the utilization pattern. There is an urge and opportunity to advance health education and change people's perceptions of the Unani medical system.

The potential of the phytoconstituent, curcumin, as an adjuvant to chemoradiotherapy has been investigated because of its ameliorating effects, including the sensitization of cancer and cancer stem cells. Curcumin, a strong antioxidant with pharmacologically non-toxic effects, can be used as an adjuvant with enhanced bioavailability and administered along with chemotherapy to achieve better treatment outcomes. The present study was carried out with a total of 120 women with locally advanced/metastatic breast cancer, who were randomized to receive standard chemotherapy alone or chemotherapy with oral curcumin, a 500 mg capsule (1 g/day) containing 95% curcuminoid and 1% piperine given for 12 to 24 weeks. Primary outcomes were determined using the Response Evaluation Criteria in Solid Tumors (RECIST) to determine the objective response rate (ORR), progression-free survival (PFS), and time to tumor progression (TTP), including safety and adverse events, while the quality of life (QoL) and physical activity were secondary outcomes. ORR was significantly higher in the curcumin group than in those who received standard chemotherapy (38.33% vs. 8.33%, p < 0.01) at 4 weeks follow-up post-treatment, which further improved (43.40% vs. 10.64%, p < 0.0031) upon completion of 12 weeks post-treatment. Curcumin-treated women displayed higher physical performance, better prognosis and QoL, better tolerance to chemotherapy, fewer adverse effects, and better PFS. The study suggests that curcumin can be used as a safe adjuvant along with chemotherapeutic drugs for a better treatment outcome in breast cancer and also in other cancers.

SNHG10 emerged as a key regulator in progression and metastasis of cancers. However, potential of SNHG10 in PDAC tumorigenesis, gemcitabine resistance, and underlying mechanisms remains poorly understood. We observed significant upregulation of SNHG10 in 179 PDAC cases, revealing a positive correlation with clinical stages. Our results showed a significant SNHG10 overexpression in several PDAC cells. Downregulation of SNHG10 significantly decreased the proliferation, clonogenicity, EMT, tumor growth in the xenograft model, and the induction of cell cycle arrest and apoptosis of PDAC cells. Mechanistically, SNHG10 knockdown significantly inhibited the expression of vimentin, N-cadherin, survivin, CDK4, CDK6, cyclin B1, cyclin D1, aurora kinase A, and B, with an increased expression of E-cadherin and p21. RNA Immunoprecipitation data displayed physical interaction among SNHG10, miR-150-5p, and VEGFA in PDAC cells. SNHG10 silencing led to the significant induction of miR-150-5p, which repressed VEGFA expression in PDAC cells. SNHG10 downregulation enhanced gemcitabine sensitivity in PDAC cells. SNHG10 silencing suppressed the phosphorylation of EGFR, AKT, ERK1/2, mTOR, and c-MET pathways. Silencing SNHG10 and its regulated signalling offers a novel prospective therapeutic strategy. The TCGA RNA sequencing datasets used for analysis are available at the TCGA portal. Original uncropped blots are provided in the supplementary information.

Human Papillomavirus (HPV) is the most prevalent sexually transmitted infection (STI) globally and contributor to a significant proportion of infection-related cancers, including oral squamous cell carcinomas (OSCCs). Persistent infection with oncogenic HPV strains is increasingly recognized as a critical cause of oral cancers, particularly in India. While HPV infections are often asymptomatic and transient, those that persist for year or more can lead to malignancies following integration into host cell genome and disrupting tumor-suppressor genes. HPV vaccination, including vaccines such as Cervarix, Gardasil or Gardasil-9, and the more recently introduced CERVAVAC in India, has significantly reduced the incidence of cervical and other HPV-related anogenital cancers. However, the potential of these vaccines in preventing HPV-linked OSCCs remains underexplored, especially in the Indian context, where the incidence of these cancers, particularly among younger populations, is on the rise. This review critically examines the role of HPV vaccination in preventing HPV-associated OSCCs. It explores the biological mechanisms by which HPV contributes to oral carcinogenesis, focusing on the most common HPV strains linked to these cancers. The review also assesses the effectiveness of existing HPV vaccines in preventing oral-HPV infections, drawing on the latest epidemiological and clinical studies. Despite promising evidence supporting the efficacy of HPV vaccines, challenges such as low vaccine uptake, limited public awareness, and socio-economic barriers hinder their widespread adoption in low-income countries including India. This review also discusses the early outcomes of vaccination programs on OSCC incidence and discusses strategies to enhance vaccine coverage, including targeted public health initiatives and policy interventions. By addressing these gaps, this review aims to provide a comprehensive understanding of the potential impact of HPV vaccination in reducing the burden of HPV-associated oral cancers in India and offering insights for future research and public health strategies.

BackgroundAbatacept (Abata, CTLA4Ig), was originally explored for blockade of CD28-B7 costimulation pathway in organ transplantation. However, Abata had sparing effect on NK cells, resulting in NK-mediated rejection in preclinical models. We explored this caveat of abatacept to augment NK cell mediated anti-leukemia effect without invoking T cell mediated GVHD, where unmodified DLI were administered 6 hours following administration of Abata in-vivo (Abata-DLI) to patients with R/R leukemia undergoing haploidentical (Haplo)-HCT, on days +7, +21 and +35, resulting in proliferation of mature NK with reduction in both relapse and GVHD. To explore this further, we studied the effect of Abata on cytotoxicity and cytokine profile of NK cells both in-vitro as well as in-vivo (CTRI:2021/08/046552).MethodsNK cells and monocytes were isolated from PBMC of 11 healthy donors and 20 haplo-HCT recipients. NK cells ± monocytes, were incubated with IL2, IL15 and IL12/15/18 with or without Abata. They were assessed for cytotoxicity and IFN-g and perforin expression against K562 cell lines at E:T ratio of 5:1 and 1:1 at 72 hrs & 7 days. In HCT recipients, PBMC were obtained at day +20 (baseline), +30, +45, +60, and 6, 12 and 18 months. Cytokine profile was analysed in NKG2A+ and NKG2C+ subsets.ResultsNK cells from healthy donors showed significant increase in cytotoxicity at 72 hours in presence of Abata+ IL2 and IL15 (Figure1, p<0.01) at all E:T ratios and time points, but not with IL12/15/18, independent of monocytes. Perforin tended to be upregulated with Abata+ IL15.In patients receiving Abata-DLI, cytotoxicity of NK cells was significantly increased compared to baseline at both E:T ratios (Fig 2, P < 0.01), as well as the corresponding donor samples (p<0.05). This was particularly so in 11 patients without any event compared to 4 patients with relapse/GVHD. Cytotoxicity at D +45 and +60 was significantly greater in the Abata-DLI group than the Abata-only group (p<0.01).In Abata-DLI group, IFN-g was significantly upregulated in the NKG2C+ subset at day +60 at 1:1 ratio. Perforin expression was significantly higher at both ratios in the Abata-DLI cohort, for both NKG2C+ and NKG2A+ subsets and IFN-g and perforin, both were upregulated in the NKG2C+ subset at all time points. 3 patients transplanted with active leukemia, assessed beyond day +60, showed greater cytotoxicity compared to the corresponding donors at 6-18 months.ConclusionIn this study, Abata was shown to increase cytotoxicity of NK cells, independent of monocytes, in the presence of IL2 and IL15, but not with IL12/15/18. In Haplo-HCT with Abata-DLI, there was marked increase in NK-cytotoxicity with upregulation of both IFN-g and Perforin in the NKG2C+ subset. This provides the rationale for exploring Abata-augmented NK cell therapy as a novel approach to augment NK-mediated GVL effect without invoking T cell mediated GVHD.

Abatacept (Abata, CTLA4Ig), an inhibitor of a key costimulation pathway has recently been approved for GVHD prophylaxis following unrelated donor HCT in combination with CNI/MTX. Since 2015, we had developed a novel protocol combining Abata and PTCy for HCT from haploidentical family donors. We analysed the impact of donor immunogenetics and immune reconstitution on the long-term outcome of 182 patients receiving HFD-HCT on this protocol.MethodsIn patients with nonmalignant diseases (NMD), Abata was administered on D 0, +5, +20, +35 and every 4 weeks thereafter until day +180, with PTCy at 50 mg/kg on D +3, +4 and sirolimus for 9 months (AbaCyS). In those with malignant diseases (MD), Abata was administered on D+7, +21 and +35 followed 6 hours later by DLI, along with low dose cyclosporin to day +60 and PTCy (AbaDCyC). Immunogenetic parameters (KIR genotype/ KIR-ligand/ HLA-B leader peptide dimorphism/ KLRC2 genotype encoding NKG2C receptor, [KLRC2 deletion (del) vs wildtype (wt]) and T and NK cell subset reconstitutions were analysed with respect to primary (OS, NRM, Relapse) and secondary (acute & chronic GVHD, and GVHD & Event-free survival (GVHEFS) endpoints.Results179 patients engrafted at a median time of 16 days (12-26). Incidence of aGVHD 2-4 was 4.7% in NMD and 9.8% in MD (p=0.3). Donor KLRC2del (D-KLRC2del) genotype was the only risk factor (33.8% vs 2.2% in dKLRC2wt, p<0.001, Fig 1) for aGVHD. This translated to a significantly improved NRM (overall 9.5%) in dKLRC2wt group (5.2% vs 28.9% in dKLRC2del, p<0.001). Incidence of cGVHD was 15.3%. Relapse incidence (RI) was 21.4%, with no impact of disease status. Donor KIR B haplotype was associated with a lower RI (p=0.01). OS was 84.3%, with a significant impact of dKLRC2 genotype (90% in wt vs 63% in del, p<0.001, Fig 2). The overall GVHEFS was also impacted by dKLRC2 genotype (38.2% vs 77.8% in dKLRC2wt, p<0.001). None of the other immunogenetic parameters had any impact on the outcome.T cell subset reconstitution was robust in both groups, predominantly of memory phenotype, which tended to be more rapid with AbaDCyC protocol in MD. However, recovery of Tregs was more rapid with AbaCyS protocol in NMD and the kinetics of Treg recovery correlated with reduced cGVHD in this group. Even though NK cell maturation was brisk in both groups, this was prompter at day+30 in the AbaDCyC protocol group. Kinetics of NKG2C+adaptive NK cell (ANK) recovery was the only determinant of RI (p<0.01).ConclusionThe synergistic effect of Abata and PTCy proved to be exceptionally potent in diminishing the incidence of aGVHD. This effect was influenced by the dKLRCdel genotype, thereby exerting a consequential adverse impact on NRM, OS and GVHEFS. Recovery of Tregs correlated with cGVHD. The introduction of Abatacept-primed DLI as seen in the AbaDCyC protocol, resulted in reduced RI as well as GVHD in patients with advanced malignancies, which was influenced by ANK recovery.

Head and neck squamous cell carcinomas (HNSCCs) are the most devastating diseases in India and southeast Asia. It is a preventable and curable disease if detected early. Tobacco and alcohol consumption are the two major risk-factors but infection of high-risk HPVs are also associated with development of predominantly oral and oropharyngeal carcinomas. Interestingly, unlike cervical cancer, HPV-induced HNSCCs show good prognosis and better survival in contrast, majority of tobacco-associated HPV−ve HNSCCs are highly aggressive with poor clinical outcome. Biomarker analysis in circulatory body-fluids for early cancer diagnosis, prognosis and treatment monitoring are becoming important in clinical practice. Early diagnosis using non-invasive saliva for oral or other diseases plays an important role in successful treatment and better prognosis. Saliva mirrors the body's state of health as it comes into direct contact with oral lesions and needs no trained manpower to collect, making it a suitable bio-fluid of choice for screening. Saliva can be used to detect not only virus, bacteria and other biomarkers but variety of molecular and genetic markers for an early detection, treatment and monitoring cancer and other diseases. The performance of saliva-based diagnostics are reported to be highly (≥95 %) sensitive and specific indicating the test's ability to correctly identify true positive or negative cases. This review focuses on the potentials of saliva in the early detection of not only HPV or other pathogens but also identification of highly reliable gene mutations, oral-microbiomes, metabolites, salivary cytokines, non-coding RNAs and exosomal miRNAs. It also discusses the importance of saliva as a reliable, cost-effective and an easy alternative to invasive procedures.

BACKGROUND:Resveratrol has demonstrated its ability to regulate BRCA1 gene expression in breast cancer cells, and previous studies have established the binding of MBD proteins to BRCA1 gene promoter regions. However, the molecular mechanism underlying these interactions remains to be elucidated. The aimed to evaluate the impact of MBD proteins on the regulation of BRCA1, BRCA2, and p16 genes and their consequential effects on breast cancer cells.METHODS:Efficacy of resveratrol was assessed using the MTT assay. Binding interactions were investigated through EMSA, ChIP, & MeIP assay. Expression analyses of MBD genes and proteins were conducted using qRT-PCR and western blotting, respectively. Functional assays, including clonogenic, migratory, and sphere formation assays were used to assess cancer cells' colony-forming, metastatic, and tumor-forming abilities. The cytotoxicity of resveratrol on cancer cells was also tested using an apoptosis assay.RESULTS:The study determined an IC50 of 30µM for resveratrol. MBD proteins were found to bind to the BRCA1 gene promoter. Resveratrol exhibited regulatory effects on MBD gene expression, subsequently impacting BRCA1 gene expression and protein levels. Higher concentrations of resveratrol resulted in reduced colony and sphere formation, decreases migration of cancer cells, and an increases number of apoptotic cells in breast cancer cells. Impact Identification of MBD2-BRCA1 axis indicates their significant role in the induction of apoptosis and reduction of metastasis and proliferation in breast cancer cells. Further therapy can be designed to target these MBD proteins and resveratrol could be used along with other anticancer drugs to target breast cancer.CONCLUSIONS:In conclusion MBD2 protein interact to the BRCA1 gene promoter, and resveratrol modulates MBD2 gene expression, which in turn regulates BRCA1 gene expression, and inhibits cell proliferation, migration, and induces apoptosis in ER+, PR+ & Triple negative breast cancer cells.

Cervical cancer (CaCx) is the fourth most predominant cancer among women the world over with an estimated 604,127 new cases and about 341,831 deaths reported in 20201. Reportedly, one woman dies due to CaCx every 3 min globally. Despite CaCx is fully preventable and curable if detected early, in India, it is still a major public health problem and ranks second in women and the leading cause of deaths (77,348) annually2,3. The infection of human papillomavirus (HPV) is established to be the prime causative agent for CaCx, the prevalence of which has been found to be the highest in India2,3. Therefore, the role of regular screening, early detection and treatment are most essential in reducing morbidity, mortality and burden of cervical cancer. In 2018, the World Health Organization (WHO) called for the global elimination of CaCx by 2030, by implementing three coordinated interventive actions; (i) 90 per cent HPV vaccination, (ii) 70 per cent high-performance cervical screening and (iii) 90 per cent early effective treatment for those already infected and have diseases1. However, eradication of CaCx in low- and middle -income countries (LMICs), particularly in India and southeast Asia, is highly challenging, hence inordinately delayed. The question arises whether LMICs, in particular India, will at all be able to achieve this goal even with the availability of an affordable new single-dose HPV vaccine, (CERVAVAC®, Serum Institute of India Pvt. Ltd., Pune). India with a population of more than 1.4 billion along with a relatively low socioeconomic status, inadequate health infrastructure, lack of trained workforce, limited budget, absence of universal screening, lack of awareness, vaccine hesitancy, social/religious stigma and no effective curative care when compared to those available in developed countries. Numerous epidemiological, experimental, molecular, pathological and clinical studies2 have established that infection of HPV, a DNA tumour virus, is the principal aetiologic human carcinogen that causes CaCx in women. For this discovery, a Nobel Prize was awarded in 2008 to Harald zurHausen from the German Cancer Research Center, Heidelberg, Germany (https://www.dkfz.de/en/zurhausen/). Of all cancers, it is the first cancer among women which has the effective vaccines to prevent it, early detection methods to screen pre-cancer lesions and access to early treatment as it takes 10-20 years to develop an invasive cancer. An estimated 341,831 deaths were recorded around the globe in 2020 while ~91 per cent (312,373) of CaCx-related deaths were recorded in LMICs compared to only 8.6 per cent in high-income countries (HICs)4. This is mainly due to inadequate control/prevention and treatment facilities5. There are neither many attempts till date to introduce the HPV vaccine in its National Immunization Programme (NIP) nor any initiative for a universal screening programme in India despite the high annual incidence of CaCx and high associated mortalities. It indicates that CaCx is primarily a disease of poor women from LMICs which have no affordable HPV immunization, organized national screening programmes and adequate treatment and follow up facilities are in place. In India, not only almost 100 per cent of CaCx but also 90 per cent of anal, 20-70 per cent head-and-neck and 9-35 per cent oesophageal cancers are also associated with high-risk (HR) oncogenic HPV infection, specifically type 166. HPV vaccination is challenging and delayed in India Although till date more than 100 countries have introduced the HPV vaccines in their NIP, India and all of South Asian countries which needed this vaccine, most have not been able to introduce it. In fact, in 2009, a 'demonstration pilot project' on HPV vaccine the immunogenicity testing was launched in India by the Programme for Appropriate Technology in Health (PATH) in the States of Gujarat and Andhra Pradesh, but the trial was suspended due to the death of a few adolescent school girls after HPV vaccination3. The deaths were, however, later proved to be unrelated to HPV vaccination. However, it is still not cleared of litigation, and the controversy still exists about the safety as well as the efficacy of HPV vaccines in the public mind leading to negligible coverage (~1%) of HPV vaccination in India. Current HPV vaccines are all preventive and not therapeutic At present, there are three major Food and Drug Administration (FDA)-approved HPV preventive vaccines: (i) Gardasil (a tetravalent against HPV types 6, 11, 16 and 18), (ii) Cervarix (a bivalent against HR-HPV types 16 and 18) and (iii) Gardasil-9 (a nonavalent against HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58) are available since 20087. Besides these, there are three more vaccines: Cecolin and Walvax are for girls aged 9-14 yr as a two-dose schedule while CERVAVAC® is for both girls and boys aged 9-14 yr for a single-dose or two-dose schedule for six months apart. These vaccines reportedly provide ≥90 per cent protection against major oncogenic HPV types. Although these vaccines are based on recombinant DNA technology using VLPs (virus-like particles), which have been found to be highly immunogenic, 100 per cent safe, reportedly develop herd immunity and produce high antibody titre if given to adolescent girls aged between 9 -19 yr7. However, the benefit of eliminating the pre-existing infections is not possible as these vaccines have no therapeutic efficacy, so it is not effective if one has already been infected with HPV. Therefore, women vaccinated before their sexual debut or prior to HPV infection will receive the highest protection against the virus infection. HPV vaccination strategies in developed countries: A path to eradicating cervical cancer Since serious challenges to HPV immunization exist in India, the success stories of HPV vaccination from developed nations can serve as a roadmap for developing countries. Notably, European countries, the United States and Australia have achieved the highest immunization and screening rates, particularly for adolescent girls but also including boys2,8-10. Developed nations exhibit a tangible impact, with 88 per cent of these introducing HPV immunization programmes, more than 30 per cent of adolescents receiving the vaccine and over 60 per cent of women undergoing cervical cancer screening11. Their success in reducing incidence and mortality of CaCx can be attributed to comprehensive HPV vaccination strategies, school-based initiatives, expanded age groups, technological advancements, public education and awareness with robust monitoring. A remarkable example from the European nations is Belgium's Flanders region, achieving a 91 per cent vaccination coverage. Their awareness programmes on available vaccines for healthcare professionals, parents and school-based vaccination programme with digital vaccine approaches were highly successful12. Recently survey in Sweden also suggested a 93 per cent coverage rate, showing positive attitude and importance of health information among healthcare workers13. Australia's National HPV Immunization Programme stands out, with vaccine coverage rates exceeding 89 per cent for girls and 86 per cent for boys at the age of 15 yr for the single dose in 20179,14. The high coverage of HPV vaccination in developed countries indicates that they may soon be able to achieve successful elimination of cervical cancer. India develops a cost-effective single-dose HPV vaccine, CERVAVAC®: Opportunity for elimination of cervical cancer Recently, a new cheaper (₹ 200-400 equivalent to US$ 2.5-5) HPV vaccine, 'CERVAVAC®', is approved by the Drug Controller General of India (DCGI) and is being introduced in India as a single dose for girls aged between 9 and 19 yr15. However, despite having this opportunity, it is still doubtful to achieve the goal of complete elimination of HPV and CaCx by 2030 or later in India as there are a huge number of issues including ethical, moral, societal, religious, vaccine acceptance, myths, misinformation, lack of awareness, lack of an organized screening programme, adequate trained manpower, and access to effective treatment. It will be successful only if an active initiative is taken by the Government of India to introduce this vaccine as a mandatory vaccine through NIP for adolescents taking cues of our success story of polio, smallpox and COVID-19 vaccination. Furthermore, the vaccine may also be made free for all girls and boys. A working model for universal elimination of cervical cancer (i) Smart HPV-Immunization and Awareness Programme: 'Smart HPV-immunization and screening programme' for rapid scale-up of HPV vaccination in India using the COVID-19 vaccination model should be developed. There is need for a strong awareness programme for teachers, students, parents, adolescents, policymakers, social workers and political leaders including gynaecologist, paediatrician and public health professionals and the public at large. The use of print and electronic media, mobile health and artificial intelligence for success of such an immunization programme is recommended. (ii) School/college/university-based vaccination programmes: A compulsory school- and college-based HPV immunization programme for 9-19 yr adolescents is required to scale up HPV vaccination for both boys and girls. Help from parents and teachers for successfully implementing such a programme is recommended. (iii)Difficult-to-reach populations: Targeting adolescents at the worksite for difficult-to-reach teenagers not attending school or college will allow for a better coverage. (iv) Only one dose schedule: Since single-dose HPV vaccine is equally effective and gives long-term protection comparable to three doses, it will help in preventing and reducing CaCx burden. The low-cost single-dose Indian-made new HPV vaccine, CERVAVAC®, is effective and a game changer for India as it is capable of increasing acceptability, feasibility and affordability. (v) Door-to-door or camp-based mass vaccination programme: Such a drive will lead to success of mass vaccination of HPV and be useful to catch-up hard-to-reach adolescents. (vi) Gender-neutral HPV vaccination: A step towards inclusive public health comprises inclusion of both adolescent girls and boys in India's immunization programme, a promising strategy to combat CaCx and HPV-related diseases in a full-proof manner because males are the host of HPV. HPV testing offers reliable cervical cancer screening Since HPV cannot be cultured in vitro, HPV diagnostics rely mainly on nucleic acid technologies that detect HPV DNA/RNA in cervical samples. Several molecular techniques are available for the detection of HPV infection and are proven to be highly sensitive and specific than conventional Pap test (Papanicolaou) and VIA (visual inspection with acetic acid). Before the introduction of CERVAVAC® or any available HPV vaccines in India, it is important to know the prevalence of HR-HPV types in different geographic regions (high in Chennai and low in Kashmir) and among communities such as significant high prevalence in tribal population16 whereas low prevalence in Muslim population5,6. Investigations are also needed to discover additional HPV types, subtypes/variants or new HPV types circulating in Indian population. It is intriguing that no new HPV genotype has been described yet despite global HPV prevalence being highest in India. Alternative approaches for prevention or elimination of HPV infection Currently, no therapeutic vaccine or drug is available for the treatment of HPV, but several alternative anti-HPV preventive/ therapeutic formulations/drugs are available, which have been clinically validated to show clearance of HPV infection or stop viral replication at early pre-cancer (CIN1-CIN2) stages when HPV is not integrated into the host cell genome. Several products, for example, Wartec17, cidofovir18, hexaminolevulinate19, curcumin20,21, berberine22 and sulindac23, have strong anti-HPV effects and either clear (80-90%) or inhibit progression/viral replication or oncogene expression when used as topical intravaginal applications (4 wk ± menstrual days)24. The polyherbal creams, such as Praneem (Panacea biotec, New Delhi) and Basant (Bipha Bioscience, Kerala), can reportedly clear ≥90 per cent HPV infection in women with pre-cancerous lesions in phase II randomized controlled trials25,26. These derivatives are commonly used for elimination of HPV infection at an early stage, but there is inadequate evidence to introduce these in general clinical practice. Challenges in India The WHO's proposed triple interventional approaches appear to be feasible in HICs for global elimination of HPV, but it is challenging in LMICs including India. In LMICs and India, national HPV immunization and cytology-based screening programmes such as Pap test or even VIA have not yet been implemented at national level, in spite of the fact that ≥85 per cent of mortalities occur due to cervical and other HPV-related cancers in India3. There are several factors such as inadequate infrastructure, trained human resource, low budget; vaccine safety, supply and hesitancy, religious/social beliefs/culture, myths, poor vaccine acceptance, illiteracy and lack of knowledge and awareness are responsible for low coverage of HPV vaccination. Therefore, HPV vaccination and screening essential for reducing/eliminating CaCx are of enormous challenge. It requires coordinated efforts of all stakeholders, specifically the government, NGOs, the public healthcare system and the population at large including awareness through social, electronic and print media including mobile health and other available methods. In addition, training of gynaecologists, paediatricians, cytopathologists, public health and social workers in primary health centres, community health centre and Mohalla (community) clinics, ESIC (Employees' State Insurance Corporation) hospitals and regional cancer centres with clear, realistic and focussed goals is crucial for successful elimination of HPV and CaCx in India and LMICs by 2047, if not by 2030. Future perspectives (i) Gender-neutral HPV vaccination for both boys and girls is most essential for the drastic reduction or complete elimination of HPV infection/transmission of HPV-related diseases. Males are also affected by HPV for tongue/oropharyngeal, oesophageal and head-and-neck, penile, anal, mouth, larynx and tonsil cancers27,28, and most importantly, males serve as reservoirs/hosts of HPV which is sexually transmitted to females. Almost ~91 per cent of men and 85 per cent of women who have had a sexual relationship will have HPV infection at any time in their lifetime and more than 50 per cent of men remain as carrier29. It has been also shown that men are more vulnerable to HPV infection as they have low immune response against HPV than women30. Therefore, the universal HPV vaccination programme can offer the greatest protection against the virus for both men and women contributing towards the effective elimination of HPV. Further, the risk of HPV transmission in gay and bisexual men is high and they are reportedly 17 times more likely to develop anogenital cancer than heterosexual males (https://www.cdc.gov/msmhealth/STD.htm). (ii) Non-invasive point-of-care method with self-sampling for quick test of HPV will improve easy screening and testing of HPV using urine or saliva samples which have been well correlated with gold standard biopsy31-33. (iii) The development of oral vaccination and its inclusion in childhood immunization (within five years of age) would be desirable instead of the present intramuscular injectable vaccine. This will be an easy approach for effective vaccination which will be highly acceptable the world over. (iv) Development of DNA/mRNA universal HPV vaccine for all HR-HPV types to prevent their infection and associated cancer. This is now essential because, as reported, there is development of cervical lesions in already vaccinated women by non-vaccine HPV types9. It is a natural phenomenon that when some pathogenic viruses/bacteria are controlled, often the other related microbes/viruses get activated to cause similar diseases. To sum up, cervical cancer continues to be a major public health problem affecting middle-aged women, particularly in India and other LMICs where the highest burden of all infection-associated cancers is often linked with low economic status and lack of knowledge and awareness among medical/public health professionals and the public at large. The recent landmark discovery of a cost-effective and single-dose indigenous HPV vaccine, CERVAVAC®, should be accepted and implemented without further delay for an effective prevention and control of cervical cancer and other HPV-related diseases in India which need it the most. Financial support & sponsorship: None. Conflicts of Interest: None.

Haploidentical (haplo) hematopoietic cell transplantation (HCT) for nonmalignant disease (NMD) carries inherent challenges of both alloreactivity and graft failure. Building on promising results from pilot studies in which abatacept was combined with posttransplantation cyclophosphamide (PTCy) and sirolimus (AbaCyS) in younger NMD patients undergoing haplo-HCT, we present the long-term outcomes of this protocol. On the back of uniform disease-speci fic conditioning regimens containing antithymocyte globulin 4.5 mg/kg from day -9 to day -7, GVHD prophylaxis with AbaCyS consisted of abatacept administered on days 0, +5, +20, +35, and monthly until 180 days with PTCy and sirolimus. The patients were followed up with longitudinal assessment of immune reconstitution, growth, and reproductive development and quality of life (QoL) analyses. Among 40 patients (aplastic anemia, n = 24; hemoglobinopathies, n = 14; and primary immunodeficiencies, n = 2) with a median age of 10 years (range, 2 to 25 years), 95% achieved sustained engraftment. Post -transplantation hemophagocytic syndrome was detected in 3 patients, leading to graft failure in 2 cases. The incidence of acute graft-versus-host disease (GVHD) was 2.6%, and that of chronic GVHD (cGVHD) was 14.3%. Cytomegalovirus, adenovirus, and Epstein-Barr virus infections were observed in 45%, 5%, and 0% respectively. Rates of nonrelapse mortality, overall survival, event-free survival, and GVHD-free, eventfree survival were 5%, 95%, 90%, and 82%, respectively, at a median follow-up of 4.6 years. Absence of cGVHD correlated with younger patient age and early sustained recovery of regulatory T cells and mature natural killer cells, which in turn was associated with improved QoL and lack of late infections. The AbaCyS protocol was associated with excellent long-term survival, with attenuation of both early and late alloreactivity in >80% of younger patients undergoing haplo-HCT for NMD. This study sheds light on predispositions to cGVHD and its impact on QoL, warranting further optimization of this approach. (c) 2024 The American Society for Transplantation and Cellular Therapy.

Fig. S3 Cell surface analysis of SP and Non-SP cells reveal phenotypically and functionally distinct populations.

Background: Abatacept (Abata, CTLA4Ig), an inhibitor of a key T cell costimulation pathway has recently been approved for GVHD prophylaxis following unrelated donor HCT in combination with CNI/MTX. In 2015, we had developed a novel protocol combining Abata and PTCy for HCT from haploidentical family donors (HFD). We analysed the impact of donor immunogenetics and immune reconstitution on the long-term outcome of 182 patients receiving HFD-HCT on this protocol. Methods: In patients with nonmalignant diseases (NMD), Abata was administered on days 0, +5, +20, +35 and every 4 weeks thereafter until day +180. PTCy was administered at 50 mg/kg on days +3 and +4 and sirolimus was given from day -7 to 9 months post-HCT (AbaCyS protocol). In those with malignant diseases (MD), PTCy was administered as usual and Abata was administered on day 0 followed by PBSC infusion and on days+7, +21 and +35, followed 6 hours later by donor lymphocyte infusions (DLI). Cyclosporin was administered from day +5 to day +60 (AbaDCyC protocol). NK cell related immunogenetic parameters (KIR genotype/ KIR-ligand/ HLA-B leader peptide dimorphism/ KLRC2 genotype encoding NKG2C receptor, [KLRC2 deletion (del) vs wildtype (wt]) and T and NK cell subset reconstitution were analysed with respect to primary (OS, NRM, Relapse) and secondary (acute & chronic GVHD, CMV reactivation and GVHD & Event-free survival (GVHEFS) endpoints. Results: Primary graft failure was seen in 2/46 with NMD and 1/136 with MD, with median time to engraftment being 16 days (12-26). No secondary graft failure was observed. Incidence of aGVHD 2-4 was 8.5%, 4.7% in NMD and 9.8% in MD (p=0.3). Donor KLRC2del (D-KLRC2del) genotype was the only risk factor (33.8%{12/38} vs 2.2%{3/144} in dKLRC2wt, p<0.001, Figure-1) for aGVHD. This translated to a significantly improved NRM (overall 9.5%) in dKLRC2wt group (5.2% vs 28.9% in dKLRC2del, p<0.001). Incidence of cGVHD (mostly mild-moderate) was 15.3% and was not impacted by NMD vs MD or KLRC2 genotype. Relapse incidence (RI) was 21.4%, with no impact of pretransplant disease status (DRI low vs high) or any immunogenetic factors apart from KIR haplotype (lower RI in donor KIR B haplotype, p=0.01). OS was 84.3% at a median follow-up of 4 years, with a significant impact of dKLRC2 genotype (90% in wt vs 63% in del, p<0.001, Figure-2). The overall GVHEFS was 70% and this was also impacted by dKLRC2 genotype (38.2% vs 77.8%in dKLRC2wt, p<0.001). None of the other immunogenetic parameters had any impact on the outcome. T cell subset reconstitution was robust in both groups, predominantly of memory phenotype, which tended to be more rapid with AbaDCyC protocol in MD. However, recovery of Tregs was more rapid with AbaCyS protocol in NMD and the kinetics of Treg recovery positively correlated with reduced cGVHD in this group. Even though NK cell maturation was brisk in both groups, this was prompter at day+30 in the AbaDCyC protocol group. More importantly, kinetics of NKG2C+adaptive NK cell (ANK) recovery was the only determinant of RI (p<0.01). Conclusion: The combination of Abata and PTCy was extremely effective in reducing the incidence of aGVHD, which was strongly influenced by dKLRCdel genotype, which in turn adversely impacted NRM, OS and GVHEFS. AbaCyS protocol was associated with better recovery of Tregs vis-à-vis reduced cGVHD. Abata-primed DLI as in AbaDCyC was not associated with increase in GVHD and seemed to moderate the RI in patients with advanced malignancy, which was influenced by ANK recovery. Thus, immunogenetics and immune reconstitution related to ANK subset of NK cells strongly influenced the outcome with Aba-PTCy based GVHD prophylaxis. DLI could be safely administered with Abata priming without increase in GVHD and yet result in attenuation of RI, suggesting the potential of this approach to dissociate GVHD from a NK-mediated GVL effect.

Fig. S4 SP cells show accumulation of slow dividing cells and express pluripotency markers Oct4 and Nanog.