An update on oral human papillomavirus infection

Human papillomavirus (HPV) constitutes the majority of newly acquired sexually transmitted infections (STIs) in United States as per the centers for disease control factsheet 2013. Genital HPV is the most common STI with incidence of about 5.5 million world-wide, nearly 75% of sexually active men and women have been exposed to HPV at some point in their lives. Oral Sexual behavior is an important contributor to infection of HPV in the oral mucosa especially in cases known to practice high risk behavior and initiating the same at an early age. HPV infection of the oral mucosa currents is believed to affect 1-50% of the general population, depending on the method used for diagnosis. The immune system clears most HPV naturally within 2 years (about 90%), but the ones that persist can cause serious diseases. HPV is an essential carcinogen being implicated increasingly in association with cancers occurring at numerous sites in the body. Though there does not occur any specific treatment for the HPV infection, the diseases it causes are treatable such as genital warts, cervical and other cancers.

Immunostaining of p16(INK4a)/Ki-67 and L1 capsid protein on liquid-based cytology specimens obtained from ASC-H and LSIL-H cases

BACKGROUND

Atypical squamous cell cannot exclude high-grade squamous intraepithelial lesion (ASC-H) and low-grade intraepithelial lesion cannot exclude high-grade squamous intraepithelial lesion (LSIL-H) are ambiguous diagnostic entities for the prediction of high-grade cervical lesion. Objective and reproducible tests for predicting high-grade cervical lesions are needed to reduce unnecessary colposcopic referrals or follow-ups.

OBJECTIVE

We aimed to identify an adequate set of adjunctive markers to predict cervical intraepithelial neoplasia grade 2+ (CIN2+) in residual liquid-based cytology specimens (LBCS).

METHODS

We conducted p16 (INK4a)/Ki-67 and L1 capsid protein immunostaining and human papillomavirus (HPV) DNA typing on 56 LBCS diagnosed with ASC-H or LSIL-H, all of which were subjected to histologic confirmation or follow-up cytologic examination.

RESULTS

Positivity for p16 (INK4a)/Ki-67 was associated with a histology of CIN2+ (P=0.047) and CIN3+ (P=0.002). Negativity for L1 capsid protein was associated with CIN2+ confirmed at follow-up (P=0.02).Positivity for high-risk HPV (HR-HPV) was associated with CIN2+ confirmed at follow-up (P=0.036) and a histology of CIN2+ (P=0.037). The sensitivity, specificity, positive predictive value, and negative predictive value for predicting follow-up CIN2+ were 76.2%, 51.4%, 48.5%, and 78.3%, respectively, for p16 (INK4a)/Ki-67 immunostaining; 95.2%, 34.3%, 46.5%, and 92.3%, respectively, for L1 capsid protein; and 66.7%, 67.7%, 54.5%, and 77.8%, respectively, for HR-HPV. The classification and regression tree analysis showed that the combined results of p16 (INK4a)/Ki-67 andL1 capsid protein immunostaining and the HR-HPV test, conducted sequentially, correctly classified 81.8% of samples (27/33)in the prediction of a histology of CIN2 + in ASC-H or LSIL-H. For determination of the histology of cervical intraepithelial neoplasia grade 3+ (CIN3+)in ASC-H or LSIL-H, we found that the combined results of p16 (INK4a)/Ki-67 and L1 capsid protein immunostaining correctly classified 78.8% (26/33) of samples.

CONCLUSIONS

p16(INK4a)/Ki-67 and L1 capsid protein immunostaining and HR-HPV testing of residual LBCS diagnosed with ASC-H or LSIL-H are useful objective biomarkers for predicting CIN2+. Immunostaining for p16(INK4a)/Ki-67 and L1 capsid protein are sufficient to predict CIN3+.

Association of immune status with recurrent anal condylomata in human immunodeficiency virus-positive patients

Purpose

An anal condyloma is a proliferative disease of the genital epithelium caused by the human papillomavirus. This condition is most commonly seen in male homosexuals and is frequently recurrent. Some reports have suggested that immunosuppression is a risk factor for recurrence of a condyloma. Thus, we investigated the risk factors for a recurrent anal condyloma in human immunodeficiency virus (HIV)-positive patients.

Methods

We retrospectively analyzed 85 consecutive patients who were diagnosed with and underwent surgery for an anal condyloma from January 2007 to December 2011. Outcomes were analyzed based clinical and immunologic data.

Results

Recurrent anal condylomata were found in 25 patients (29.4%). Ten cases (40.0%) were within postoperative 3 months. At postoperative 6 months, the CD4 lymphocyte count in the recurrent group was lower than it was in the nonrecurrent group (P = 0.023).

Conclusion

CD4-mediated immunosuppression is a risk factor for recurrent anal condylomata in HIV-positive patients.

Genotype distribution of human papillomaviruses in Japanese women with abnormal cervical cytology

We report the prevalence and genotype distribution of human papillomaviruses (HPVs) among Japanese women with abnormal cervical cytology using the PGMY-CHUV assay, one of PGMY-PCR-based lineblot assays that was validated and shown to be suitable for the detection of multiple HPV types in a specimen with minimum bias. Total DNA was extracted from cervical exfoliated cells collected from 326 outpatients with abnormal Pap smears. Overall, 307 specimens (94%) were HPV-positive, 30% of which contained multiple genotypes. The prevalence of HPV DNA was 83% (49/59 samples) in atypical squamous cells of undetermined significance (ASC-US); 91% (20/22 samples) in atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H); 97% (130/134 samples) in low-grade squamous intraepithelial lesion (LSIL); and 99% (85/86 samples) in high-grade squamous intraepithelial lesion (HSIL). Three most frequent HPV types detected in HSIL were HPV16 (36%), HPV52 (24%), and HPV58 (14%). Our results suggest that multiple HPV infections are more prevalent in Japanese women than previously reported, and confirm that HPV52 and 58 are more dominant in their cervical precancerous lesions when compared to those reported in Western countries.

Expression of c-Met Is Different along the Location and Associated with Lymph Node Metastasis of Head and Neck Carcinoma

Background

Activation of the c-Met pathway is involved in cancer progression and the prognosis. We aimed to identify any association of c-Met protein expression with a number of clinicopathologic variables including infection of human papillomavirus and Epstein-Barr virus (EBV) in head and neck carcinomas (HNCa).

Methods

Eighty-two cases were enrolled in this study. Expression of c-Met and p16 was investigated immunohistochemically. EBV was detected by in situ hybridization and amplification of the c-Met gene by fluorescence in situ hybridization.

Results

The c-Met protein was expressed in 41.5% (34/82), and gene amplification was found in 1.4% (1/71). High expression of c-Met was associated with the primary location of the tumor; the hypopharynx showed the highest expression, followed by the oral cavity, larynx, and nasal cavity. Squamous cell carcinoma expressed c-Met more frequently than undifferentiated carcinoma. Also, p16 immunoreactivity or EBV infection was associated with the tumor location and well-differentiated histologic type, but were not linked to c-Met expression. The patients with positive c-Met expression showed frequent lymph node metastasis.

Conclusions

Activation of the c-Met pathway might be involved in a subset of HNCa. Cases showing positive c-Met expression should be carefully monitored because of the high probability of lymph node metastasis.

Trends in cervical cancer screening in developing countries

Developing countries suffer the highest burden of cervical cancers but have the lowest resources. Effective cervical cytology screening programme, along with a network of diagnostic and therapeutic colposcopy centres, like developed countries, is almost impossible to be reproduced in developing countries. Visual inspection methods [e.g., Visual inspection with Lugol’s iodine (VILI) and Visual Inspection with Acetic Acid (VIA)] which are cheaper, require less expertise and have the advantage of possible treatment in one setting have been shown to be effective alternatives. The sensitivity to detect CIN2+, by VIA and VILI, have been shown to be 80% and 91% respectively, with a specificity rate of 92% and 85% respectively. Screening by human papillomavirus (HPV) testing has high sensitivity (96.4%) but low specificity (94.1%) to detect CIN2+, when compared to Pap Smear (sensitivity, 55.4% and specificity, 96.8%). A single lifetime HPV testing in a large unscreened population has been shown to significantly reduce cervical cancer incidence and mortality when compared to cervical cytology, VIA or no screening. HPV testing of self-collected vaginal specimens also helps to overcome religious and socio-cultural barriers towards pelvic examination amongst women in developing countries. Current HPV testing methods are expensive, skill/infrastructure demanding and takes time to produce results. A cheaper HPV test, called careHPV™, which is able to provide results within 2.5 h and requires minimal skill/infrastructure to operate, was designed for use in developing countries. One stop screen and treat facilities using VIA or rapid HPV testing, and cryotherapy, can overcome non-compliance to follow-up which is a major issue in developing countries. Cure rates of 81.4% for CIN1, 71.4% for CIN2 and 68.0% for CIN3 at 6 mo after treatment have been reported. Incorporating telemedicine with cervicography of VIA or VILI or even telecolposcopy, has great potential in cervical cancer screening, especially in countries with vast geographical areas.

Human papillomavirus (HPV) infection and vaccines: knowledge, attitude and perception among female students at the University of Lagos, Lagos, Nigeria

Aim: This study sought to determine knowledge of and attitude towards human papillomavirus (HPV) infection, HPV-related diseases and HPV vaccines among female undergraduate students at the University of Lagos.

Methods: A self-administered questionnaire was administered between May and July 2010, to 368 female students aged 16–29 years, who were selected from two faculties of the University of Lagos using two-stage sampling method. Data collected included: socio-demographic characteristics, sexual history, awareness and knowledge of HPV infection, cervical cancer and genital warts, and HPV vaccine; the perceived risk of acquiring genital HPV infection and developing cervical cancer or genital warts, and the willingness to receive an HPV vaccine.

Results: Only 64 (17.7%) and 52 (14.4%) of the students had ever heard of HPV infection and HPV vaccines respectively. The median HPV knowledge on a 15-item score was 2. Overall, only 11.1% knew that genital HPV infection can cause cervical cancer. Fourteen (6.9%) of those who were aware of cervical cancer agreed they were at risk of developing the disease. Of the 52 students who had heard of the HPV vaccine, 24 (46.2%) knew it was given for cervical cancer prevention and 30 (57.7%) expressed their willingness to receive the vaccine.

Conclusion: The knowledge of and the perceived susceptibility to HPV infection and HPV-related diseases among female students in the University of Lagos were generally low. The need for a well-designed HPV-educational program to bridge the knowledge gap cannot be overemphasized.

The Prognostic Role of p16 Expression in Tonsil Cancer Treated by Either Surgery or Radiation

Objectives

Although human papillomavirus (HPV) infection is considered as a favorable prognostic factor in oropharyngeal cancer, the prognosis of HPV-associated tonsil cancer has rarely been studied especially when surgery was the main treatment. In this study, the authors investigated the effect of p16 over-expression (HPV infection) on tonsil cancer prognosis according to the type of treatment, HPV presence by PCR, and expression of p53 and epidermal growth factor receptor (EGFR) by immunohistochemistry (IHC).

Methods

Medical records of 33 tonsil cancer patients were reviewed. Using formalin-fixed and paraffin-embedded tumor specimens, PCR-based genotyping of HPV and IHC of p16, p53 and EGFR were performed. The effects of HPV presence and the expression of IHC markers were analyzed on the recurrence-free survival. Five-year disease-free survival (DFS) rates were evaluated according to p16 expression status.

Results

An over-expression of p16 was observed in 27 (81.9%) out of 33 cases. Surgery-based treatment was provided for 21 (63.6%) patients. There was no association between p16 immunoreactivity and HPV presence, nor with p53 and EGFR expression. Regardless of main treatment modalities, five-year DFS did not differ by p16 expression status (P=0.051). However, over-expression of p16 was associated with a lower recurrence in multivariable analyses (P=0.046).

Conclusion

Regardless of main treatment modalities, an over-expression of p16 (HPV infection) is associated with a lower recurrence in tonsil cancers. However it is not associated with simple HPV presence or p53 and EGFR over-expression.

Assessing the burden of HPV-related cancers in Appalachia

Appalachia is a geographic region with existing cancer disparities, yet little is known about its burden of HPV-related cancers outside of cervical cancer. We assessed the burden of HPV-related cancers in three Appalachian states and made comparisons to non-Appalachian regions. We examined 1996-2008 cancer registry data for Ohio, Kentucky, West Virginia and the Surveillance, Epidemiology and End Results (SEER) 9 program. For each gender, we calculated age-adjusted incidence rates per 100,000 population for each HPV-related cancer type (cervical, vaginal, vulvar, penile, anal and oral cavity and pharyngeal cancers) and all HPV-related cancers combined. Incidence rates among females for all HPV-related cancers combined were higher in Appalachian Kentucky [24.6 (95% CI: 23.5-25.7)], West Virginia [22.8 (95% CI: 22.0-23.6)] and Appalachian Ohio [21.9 (95% CI: 21.0-22.8)] than SEER 9 [18.8 (95% CI: 18.6-19.0)]. Similar disparities were found among females when examining cervical and vulvar cancers separately. Among males, Appalachian [21.3 (95% CI: 20.2-22.4)] and non-Appalachian [21.9 (95% CI: 21.2-22.7)] Kentucky had higher incidence rates for all HPV-related cancers combined than SEER 9 [18.3 (95% CI: 18.1-18.6)]. The incidence rate of all HPV-related cancers combined was higher among males from Appalachian Ohio compared with those from non-Appalachian Ohio [17.6 (95% CI: 16.8-18.5) vs. 16.3 (95% CI: 16.0-16.6)]. Our study suggests that HPV-related cancer disparities exist in Appalachia beyond the known high cervical cancer incidence rates. These results have important public health implications by beginning to demonstrate the potential impact that widespread HPV vaccination could have in Appalachia.

Oral squamous papilloma and condyloma acuminatum as manifestations of buccal-genital infection by human papillomavirus

Genital infection by human papillomavirus (HPV), a sexually transmitted disease (STD), has increased considerably due to the changes in sexual behaviour and an increase in the practice of oral sex. HPV, in a parallel manner, has been closely studied due to its oncogenic potential. We present the case of a 27-year-old patient, with a multi-partner sexual history and frequent practice of oral sex, who suffered from warts lesions on the genitalia and tongue. Squamous papilloma was diagnosed from a tongue biopsy. The treatment of the oral lesion was by way of surgery, without relapse in the first two years. Our discussion in this report is regarding the HPV infection in the oral cavity.

Early human papillomavirus testing predicts residual/recurrent disease after LEEP

Objective

The purpose of this study was to determine the predictive factors for residual/recurrent disease and to analyze the timing for Pap smears and human papillomavirus (HPV) testing during follow-up after loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia (CIN) 2 or worse.

Methods

We retrospectively analyzed 183 patients (mean age, 39.3 years) with CIN 2/3 who were treated with LEEP. Post-LEEP follow-up was performed by Pap smear and HPV hybrid capture2 (HC2) testing. The definition of persistent/recurrent disease was biopsy-proven CIN 2 or worse.

Results

Among 183 patients, punch biopsies were CIN 2 in 31 (16.9%) and CIN 3 in 152 (83.1%). HPV HC2 tests before LEEP were positive in 170 (95.5%) of 178 patients. During follow-up, 12 patients (6.6%) had residual/recurrent CIN 2+. LEEP margin status was a significant predictive factor for persistent/recurrent disease. Other factors such as age, HPV HC2 viral load (≥100 relative light units), and HPV typing (type 16/18 vs. other types) did not predict recurrence. Early HPV HC2 testing at 3 months after LEEP detected all cases of residual/recurrent disease. The sensitivity and negative predictive value of the HPV HC2 test for residual/recurrent disease were both 100% at 3 and 6 months.

Conclusion

Margin involvement in conization specimens was a significant factor predicting residual/recurrent disease after LEEP. HPV test results at 3 and 6 months after treatment were comparable. Early 3-month follow-up testing after LEEP can offer timely information about residual/recurrent disease and alleviate patient anxiety early about treatment failure.

Primary endometrial squamous cell carcinoma: a case report and review of relevant literature on korean women

Primary endometrial squamous cell carcinoma (PESCC) is an extremely rare tumor with unclear pathogenesis. A 54-year-old postmenopausal woman presented with a 6-month history of vaginal bleeding. The patient was provisionally diagnosed with uterine submucosal leiomyoma. This was followed by total hysterectomy with a bilateral salpingo-oophorectomy under the laparoscopic guidance. Histopathologically, the tumor was PESCC which was accompanied by a lack of the tumor in the uterine cervix. The tumor showed positive immunoreactivity for p^16INK4a. But there was no evidence of human papillomavirus (HPV) on in situ hybridization and HPV DNA chip analysis. We also present a review of the relevant literature on Korean women.

Role of human papillomavirus in the pathogenesis of oral squamous cell carcinoma

Oral cancer is one of the most common cancers and it constitutes a major health problem particularly in developing countries. Oral squamous cell carcinoma (OSCC) represents the most frequent of all oral neoplasms. Several risk factors have been well characterized to be associated with OSCC with substantial evidences. While tobacco and alcohol are the primary risk factors for OSCC development, many epidemiological studies report a strong association with human papillomavirus (HPV) in a subset of OSCC. This article presents our current knowledge on the relationship between HPV and development of OSCC. HPVs are DNA viruses that specifically target the basal cells of the epithelial mucosa. Most experimental data are consistent with the hypothesis that HPV plays a causal role in oral carcinogenesis. Genotypes, such as HPV1 infect epidermal cells, whereas HPV6, 11, 16 and 18 infect epithelial cells of the oral cavity and other mucosal surfaces. Several studies have shown that there is an increased risk of head and neck cancer in the two major HPV 16 oncogenes E6 and E7 -positive patients. The presence of antibodies to HPV E6 and E7 proteins was found to be more associated with tumors of the oro-pharynx than of the oral cavity. However, HPV alone appears to be insufficient as the cause of OSCC but requires other co-factors. Although a viral association within a subset of OSCC has been shown, the molecular and histopathological characteristics of these tumors have yet to be clearly defined.

Human papillomavirus infection in human immunodeficiency virus-positive Taiwanese women incarcerated for illicit drug usage

BACKGROUND

The number of female injection drug users infected with human immunodeficiency virus (HIV) is increasing in Taiwan. Their human papillomavirus (HPV) infection has not been fully discussed.

METHODS

A cross-sectional study was conducted in a prison for women. Both HIV-positive and HIV-negative women were enrolled voluntarily. All patients answered self-administered questionnaires, had a Pap smear, and underwent linear array HPV genotype tests.

RESULTS

A total of 72 female patients infected with HIV and 76 women who were not infected with HIV were enrolled in this cross-sectional study (mean age, 33.4 years). HPV infection was detected in 63.9% of patients infected with HIV and 47.4% of HIV-negative counterparts (p=0.043). Oncogenic HPV was detected in 41.6% of patients infected with HIV and 28.9% of their counterparts (p=0.10). A mean of 2.41 types of HPV were detected in HIV-positive women and 1.53 types were detected in the HIV-negative counterparts (p=0.014). HPV 52 was the most commonly encountered oncogenic type. Only 10.2% of the patients (10.9% of HIV-positive patients) had vaccine-preventable HPV types. Patients with abnormal cytology (81.3%) tended to have oncogenic types of HPV infection. HIV serostatus was the significant factor associated with oncogenic HPV infection (odds ratio=2.583, 95% confidence interval 1.071-6.231, p=0.0347).

CONCLUSION

Drug-using women infected with HIV had significantly higher rates of HPV infections, justifying the aggressive screening for cervical dysplasia.

A Community-Based Approach to Enhancing Anal Cancer Screening in Hawaii's HIV-Infected Ethnic Minorities

OBJECTIVE

Disparities in anal cancer incidence among Hawaii's HIV-infected minority population is an emerging health concern. Although anal cytology/anoscopy are effective anal cancer screening tools, social barriers exist that prevent individuals from seeking appropriate care.

DESIGN

Community based participatory research (CBPR) principles were applied to develop resources, including testing a self-obtained anal specimen procedure, to increase anal cancer screening among Hawaii's underserved/ minority populations.

METHODS

A team of community members, academic researchers, and health care providers developed culturally-sensitive educational/recruitment materials regarding anal cancer risk targeting underserved/minority HIV-infected individuals. Self- and health care provider (HCP)-obtained anal cancer screening specimens were reviewed for cytology and tested for human papillomavirus DNA. A follow-up evaluation elicited feedback on attitudes and experiences.

RESULTS

Community discussion sessions identified key messages about anal cancer, anal cancer screening, and HPV infection for materials and were used, that successfully recruited 46 individuals (38 males/8 females; 9 Native Hawaiians/Pacific Islanders/Asians, 2 Blacks, 6 Hispanics, 6 American Indian/Alaskan Natives, 23 Whites). Concordance in cytology results between self- and HCP-obtained specimens was moderated (kappa=0.37) with the perception that the self-obtained specimen procedure was private (93%), safe (100%), and easy to manage (100%); and a majority (92%) willing to use the self-obtained method again.

CONCLUSIONS

CBPR was a practical approach in engaging Hawaii's HIV-infected minority participation in anal cancer screening research. Community outreach and recruitment efforts suggested that self-obtained screening specimens could be an acceptable and effective means to reach Hawaii's HIV-infected ethnic minorities.

The role of Human papilloma virus (HPV) genotyping in recurrent respiratory papillomatosis in Rasoul Akram Hospital

BACKGROUND

The most common laryngeal mass in children is recurrent respiratory papillomatosis (RRP). Studies have attempted to correlate viral typing and its aggressiveness.

METHOD

29 patients with histologically confirmed RRP enrolled in adjuvant therapies. Patients underwent several surgical interventions.

RESULTS

HPV genotyping demonstrated 45% HPV-6 and 55% HPV-11. The mean age at the first surgical intervention was 52.39 months (SD=102.28) (range from 4 months to 426 months). The mean number of surgical intervention was 10.39 (SD=7.76) (range from 2 to 30). The mean time of surgical intervals was 4.63 months (SD=4.02) (range from 2 to 24 months). In fourteen patients (48%) tracheotomy was done. All patients who had tracheotomy received alpha-interferon. One of our cases was a male who had pulmonary extension with HPV-6.

CONCLUSION

A review of patients with RRP was regarding to HPV genotyping and need for adjuvant therapy and tracheostomy. Mean number of surgical procedure was 10/40 and nearly fourteen patients (48%) need to tracheotomy. The clinical differences between HPV6 and HPV11 disease may not be accurately predictable. Patients with less age and with HPV-11 seemed to have more severe problems, but these differences were not statistically significant which needs much more investigations for reasonable starting point of evaluation for these differences.

Comparison of the AdvanSure human papillomavirus screening real-time PCR, the Abbott RealTime High Risk human papillomavirus test, and the Hybrid Capture human papillomavirus DNA test for the detection of human papillomavirus

BACKGROUND

We evaluated the performance of various commercial assays for the molecular detection of human papillomavirus (HPV); the recently developed AdvanSure HPV Screening real-time PCR assay (AdvanSure PCR) and the Abbott RealTime High Risk HPV PCR assay (Abbott PCR) were compared with the Hybrid Capture 2 HPV DNA Test (HC2).

METHODS

All 3 tests were performed on 177 samples, and any sample that showed a discrepancy in any of the 3 tests was genotyped using INNO-LiPA HPV genotyping and/or sequencing. On the basis of these results, we obtained a consensus HPV result, and the performance of each test was evaluated. We also evaluated high-risk HPV 16/18 detection by using the 2 real-time PCR assays.

RESULTS

Among the 177 samples, 65 were negative and 75 were positive in all 3 assays; however, the results of the 3 assays with 37 samples were discrepant. Compared with the consensus HPV result, the sensitivities and specificities of HC2, AdvanSure PCR, and Abbott PCR were 97.6%, 91.7%, and 86.9% and 83.9%, 98.8%, and 100.0%, respectively. For HPV type 16/18 detection, the concordance rate between the AdvanSure PCR and Abbott PCR assays was 98.3%; however, 3 samples were discrepant (positive in AdvanSure PCR and negative in Abbott PCR) and were confirmed as HPV type 16 by INNO-LiPA genotyping and/or sequencing.

CONCLUSIONS

For HPV detection, the AdvanSure HPV Screening real-time PCR assay and the Abbott PCR assay are less sensitive but more specific than the HC2 assay, but can simultaneously differentiate type 16/18 HPV from other types.

Meta-analysis of studies analyzing the role of human papillomavirus in the development of bladder carcinoma

PURPOSE

We aimed to ascertain the degree of association between bladder cancer and human papillomavirus (HPV) infection.

MATERIALS AND METHODS

We performed a meta-analysis of observational studies with cases and controls with publication dates up to January 2011. The PubMed electronic database was searched by using the key words "bladder cancer and virus." Twenty-one articles were selected that met the required methodological criteria. We implemented an internal quality control system to verify the selected search method. We analyzed the pooled effect of all the studies and also analyzed the techniques used as follows: 1) studies with DNA-based techniques, among which we found studies with polymerase chain reaction (PCR)-based techniques and 2) studies with non-PCR-based techniques, and studies with non-DNA-based techniques.

RESULTS

Taking into account the 21 studies that were included in the meta-analysis, we obtained a heterogeneity chi-squared value of Q(exp)=26.45 (p=0.383). The pooled odds ratio (OR) was 2.13 (95% confidence interval [CI], 1.54 to 2.95), which points to a significant effect between HPV and bladder cancer. Twenty studies assessed the presence of DNA. The overall effect showed a significant relationship between virus presence and bladder cancer, with a pooled OR of 2.19 (95% CI, 1.40 to 3.43). Of the other six studies, four examined the virus's capsid antigen and two detected antibodies in serum by Western blot. The estimated pooled OR in this group was 2.11 (95% CI, 1.27 to 3.51), which confirmed the relationship between the presence of virus and cancer.

CONCLUSIONS

The pooled OR value showed a moderate relationship between viral infection and bladder tumors.

Expression of human papillomavirus-related proteins and its clinical implication in tonsillar squamous cell carcinoma

BACKGROUND

Human papillomavirus (HPV) is known to cause of oropharyngeal squamous cell carcinoma (SqCC). HPV positive SqCCs overexpress p16 and are associated with better survival. Several markers of cell cycles and apoptosis have been reported as a prognostic value. We examined the prognostic value of HPV status, p16, cyclin D1, and Bcl-2 in patients with tonsillar SqCC.

METHODS

Tissue microarrays were constructed in 56 cases of tonsillar SqCC for which we performed an immunohistochemistry and an in situ hybridization (ISH) of the HPV.

RESULTS

Of the 56 cases, 31 (55.3%) were positive for p16 and 20 (35.7%) were positive for HPV ISH. The expressions of p16, cyclin D1, and Bcl-2 were not correlated with the clinicopathologic variables including smoking status, differentiation and pT- and pN-stages. The HPV ISH positive group showed a better overall survival than the HPV negative group (p=0.04), and the p16 positive group showed a better disease free survival (DFS) than the negative group (p=0.016). Cox regression analysis showed that only p16 positivity was an independent prognostic factor for DFS (p=0.03; hazard ratio, 10.1).

CONCLUSIONS

Our results indicate that both p16 expression and HPV status are useful indicators for risk stratification in patients with tonsillar SqCC.

Preventive and Therapeutic Vaccines against Human Papillomaviruses Associated Cervical Cancers

Cervical cancer is, globally known to be, one of the most common cancers among women especially in developing countries. More than 90% of cervical cancers are associated with high-risk human papillomaviruses (HPVs) particularly HPV types 16 and 18. Two major strategies have been developed for prevention and treatment of cervical cancer and other HPV-associated malignancies; the first one is based on HPV virus-like particles (VLPs) containing HPV structural proteins. VLP based vaccines can induce genotype specific virus neutralizing antibodies for preventing HPV infections. The other strategy is based on HPV early genes especially E6 and E7 for eliminating the established HPV infections; therefore they are classified as HPV therapeutic vaccines. This article reviews the preventive and therapeutic vaccines against HPV infections and cervical cancer.

Human papillomavirus in upper digestive tract tumors from three countries

AIM: To clarify human papillomavirus (HPV) involvement in carcinogenesis of the upper digestive tract of virological and pathological analyses.

METHODS: The present study examined the presence of HPV in squamous cell carcinomas of the oral cavity (n = 71), and esophagus (n = 166) collected from Japan, Pakistan and Colombia, with different HPV exposure risk and genetic backgrounds. The viral load and physical status of HPV16 and HPV16-E6 variants were examined. Comparison of p53 and p16^INK4a expression in HPV-positive and HPV-negative cases was also made.

RESULTS: HPV16 was found in 39 (55%) oral carcinomas (OCs) and 24 (14%) esophageal carcinomas (ECs). This site-specific difference in HPV detection between OCs and ECs was statistically significant (P < 0.001). There was a significant difference in the geographical distribution of HPV16-E6 variants. Multiple infections of different HPV types were found in 13 ECs, but multiple infections were not found in OCs. This difference was statistically significant (P = 0.001). The geometric means (95% confidence interval) of HPV16 viral load in OCs and ECs were 0.06 (0.02-0.18) and 0.12 (0.05-0.27) copies per cell, respectively. The expression of p16^INK4a proteins was increased by the presence of HPV in ECs (53% and 33% in HPV-positive and -negative ECs, respectively; P = 0.036), and the high-risk type of the HPV genome was not detected in surrounding normal esophageal mucosa of HPV-positive ECs.

CONCLUSION: Based on our results, we cannot deny the possibility of HPV16 involvement in the carcinogenesis of the esophagus.

Bowenoid Papulosis of the Vulva and Subsequent Periungual Bowen's Disease Induced by the Same Mucosal HPVs

We report the case of a 23-year-old woman who developed bowenoid papulosis of the vulva and subsequent periungual Bowen's disease. She had a history of a long standing periungual wart on her right thumb before the outbreak of periungual Bowen's disease. By HPV DNA chip, human papillomavirus (HPV) 11, 18 and 31 were identified from the periungual lesions, and HPV 11, 18 and 33 from the vulvar lesion. This case supports the theory of anogenital-digital spread of HPV, and proposes that the periungual wart may change into Bowen's disease by mucosal HPVs. To the best of our knowledge, this case is important as the first Korean case of periungual Bowen's disease concurrent with bowenoid papulosis of the vulva.

Integration of human papillomavirus 18 DNA in esophageal carcinoma 109 cells

AIM: To detect human papillomavirus (HPV) DNA in esophageal carcinoma (EC) 109 cells and investigate the relationship between HPV and EC.

METHODS: Genomic DNA and total RNA from EC109 cells were isolated. HPV DNA was detected by polymerase chain reaction (PCR) with the general primer sets of My09/11 and GP5 +/6 + for the HPV L1 gene and type-specific primer sets for HPV18 E6 and HPV18 E6-E7. Reverse transcription (RT) of mRNA isolated from EC109 cells was performed to produce a cDNA. And then a PCR-based protocol for the amplification of papillomavirus oncogene transcripts was used to analyze HPV18 DNA and integrated transcripts of HPV18 in the chromosomes of EC109 cells. The final nested PCR products were cloned into a pMD-18T vector and sequenced to analyze the chromosomal location of HPV integration.

RESULTS: HPV18 DNA was detected in EC109 cells by PCR using the general primer sets of My09/11 and GP5 +/6 + for HPV L1 and the type-specific primer sets for HPV18 E6 and E6-E7 to generate products of 450 bp, 150 bp, 335 bp and 944 bp, respectively. Approximately 600 bp of integrated HPV18-specific transcript was identified. The final nested PCR product of integrated HPV18 DNA was cloned into a pMD-18T vector and sequenced to analyze the chromosomal location of HPV integration. Sequence alignment showed that the HPV18 sequence from EC109 cells was identical to that of the encoded early protein E7-E1 of the standard HPV18 strain X05015, and another partial gene sequence was identical to a partial sequence of human chromosome 8.

CONCLUSION: Integration of the HPV genome into the host cell chromosome suggests that persistent HPV infection is vital for malignant cell transformation and carcinogenesis.

Prevalence of HPV Infection and High Risk HPV Genotypes (16, 18), among Monogamous and Polygamous Women, In Zabol, Iran

BACKGROUND

This study was performed to compare the prevalence of HPV infection and high risk HPV genotypes [16, 18] between monogamous and polygamous women, in Zabol, Iran.

METHODS

This cross sectional study was conducted in Zabol in 2006 - 2007. Two hundred sixty five married women attending the Gynecology Clinic for Cervical Disease Screening entered to this study. One hundred sixty two cases had monogamous, and 103 had polygamous husbands. HPV PCR samples were obtained from scrape of papsmear specimens. The biotinylated primers MY09/MY11, GP5+/GP6+, were utilized to enable amplification and detection of positive PCR products. Confirmation of HPV-16 and -18 were done by type-specific PCR primers HPV-16/F, HPV-16/R and HPV-18/F, HPV-18/R.

RESULTS

Prevalence of HPV infection in monogamous and polygamous groups was 29% and 37.9%, respectively. The most HPV infection was found in 15-25 years group. The most prevalence of infection in monogamous group was HPV-18 and HPV-non16, 18 in 15-25 years, and HPV-16 in 26-35 years group. In polygamous group the most prevalent type was HPV-16, 18 in 15-25 years group. The most prevalent HPV-16 was seen in sever inflammation and dysplasia cytology in both groups.

CONCLUSION

Prevalence of HPV infection in Zabol is high, and in women with polygamous husbands group is slightly more than monogamous. Screening for this infection must be recommended in this region of Iran.

Pediatric vulvar squamous cell carcinoma in a liver transplantation recipient: a case report

Here we report the first Korean case of a girl who developed noninvasive squamous cell carcinoma of the vulva at the age of 16 years. She was taking tacrolimus, an immunosuppressive agent, after living-related liver transplantation. The vulvar masses were microscopically proved as vulvar intraepithelial neoplasm II and III, even squamous cell carcinoma in situ. Human papillomavirus subtypes (69 and 73) and human papillomavirus types (66, 70, 73, and 43) were detected in the vulvar mass and the cervicovaginal smear, respectively. The outcome of liver transplantation for children has been markedly improved during the last several decades. However, the present case highlights the need to perform periodic genital examinations for the adolescents after liver transplantation. In addition to the high risk and probable high subtypes, uncommonly found human papillomavirus subtypes were extracted from her vulvar cancer. The present case is the first to show the possible relationship between previously unknown and uncommon human papillomavirus subtypes and pediatric post-transplant vulvar squamous cell carcinoma. More attention should be paid to the vulvar and cervical surveillance of pediatric transplant recipients by both medical specialists and general physicians.

Molecular Signature of HPV-Induced Carcinogenesis: pRb, p53 and Gene Expression Profiling

The infection by mucosal human papillomavirus (HPV) is causally associated with tumor development in cervix and oropharynx. The mechanisms responsible for this oncogenic potential are mainly due to the product activities of two early viral oncogenes: E6 and E7. Although a large number of cellular targets have been described for both oncoproteins, the interaction with tumor suppressors p53 and retinoblastoma protein (pRb) emerged as the key functional activities. E6 degrades tumor suppressor p53, thus inhibiting p53-dependent functions, whereas E7 binds and degrades pRb, allowing the transcription of E2F-dependent genes. Since these two tumor suppressors exert their actions through transcriptional modulation, functional genomics has provided a large body of data that reflects the altered gene expression of HPVinfected cells or tissues. Here we will review the similarities and differences of these findings, and we also compare them with those obtained with transgenic mouse models bearing the deletion of some of the viral oncogene targets. The comparative analysis supports molecular evidences about the role of oncogenes E6 and E7 in the interference with the mentioned cellular functions, and also suggests that the mentioned transgenic mice can be used as models for HPV-associated diseases such as human cervical, oropharynx, and skin carcinomas.

A Case Report of Focal Epithelial Hyperplasia (Heck's disease) with PCR Detection of Human Papillomavirus

Focal epithelial hyperplasia or Heck's disease, is a rare viral infection of the oral mucosa caused by human papillomavirus. The frequency of this disease varies widely from one geographic region to another. In Caucasians there have been only few cases reported. This paper reports a case of focal epithelial hyperplasia and demonstrates the association with HPV subtype 32 through polymerase chain reaction (PCR) and sequencing of PCR products. A 7-year-old Caucasian girl was admitted to our clinic for investigation of multiple oral mucosal lesions in the mouth. Lesion was excised under local anesthesia without any complication. The lesion was diagnosed as focal epithelial hyperplasia according to both clinical and histopathological features. Dental staff should be aware of these kind of lesions and histopathological examination together with a careful clinical observation should be carried out for a definitive diagnosis.

Human papillomavirus DNA and P16INK4A expression in concurrent esophageal and gastric cardia cancers

AIM: To investigate the relationship between human papillomavirus (HPV) infection and concurrent esophagus and gastric cardia cancer from the same patient (CC) and examine the significance of P16^INK4A protein expression.

METHODS: Polymerase chain reaction was used to detect the presence of HPV type16 (HPV16). The expression of P16^INK4A protein was detected using immunohistochemistry.

RESULTS: Among the CC specimens, HPV16-DNA was found in eight cases of esophageal squamous cell carcinoma (ESCC) and five cases of gastric cardia adenocarcinoma (GCA), respectively (47% vs 29%), and two of both ESCC and GCA. P16^INK4A was highly expressed in both ESCC and GCA. In the HPV-associated positive CC, higher P16^INK4A expression was observed in the GCA than in the ESCC (75% vs 25%, P < 0.05).

CONCLUSION: HPV16 as a correlated risk factor may play an important role in the development of ESCC and GCA. P16^INK4A may be a screening index in the HPV-associated carcinoma of gastric cardia.

Informatics methods for laboratory evaluation of HPV ordering patterns with an example from a nationwide sample in the United States, 2003-2009

Background:

Laboratory data is a rich source of information that can be used to estimate adherence to physician guidelines and motivate improvement in clinical practice. Human papillomavirus (HPV) testing is an important component of cervical cancer screening programs with established screening guidelines. The purpose of this study was to develop methods to estimate concordance with published guidelines for HPV testing in order to provide clinicians and payors specific feedback about overscreening.

Methods:

This retrospective analysis of laboratory test ordering patterns evaluated 454,532 HPV tests ordered from September 2003 to October 2009 from 110 facilities and performed at ARUP laboratories. We used laboratory data including patient demographics, ordering frequency, timestamps and results to examine the proportion of HPV tests ordered on women under 21 years, ordered on women between 21 and 29 years apparently before cytological examination, repeated less than 1 year after a positive HPV result in women over 30 years, and repeated less than 3 years after a negative HPV result in women over 30 years.

Results:

The absolute number and proportion of HPV tests performed on women under 21 years declined from 20% in 2005 to 5% in October 2009. The proportion of HPV tests performed women between 21 and 29 years also declined during this period. Approximately one-third of HPV tests performed on women between 21 and 29 years arrived for HPV testing before cervical screening had presumably been completed. The most common follow-up intervals for HPV testing on women over 30 years were 6 months following a positive HPV result and 12 months following a negative HPV result. Only 6% of repeat HPV testing in women over 30 years followed a negative HPV result by 3 years or more. Approximately one-fourth of HPV tests ordered the year ending October 2009 were unnecessary based on the American Society for Colposcopy and Cervical Pathology guideline.

Conclusions:

We demonstrate simple methods to evaluate appropriate utilization of HPV testing using laboratory data. Our data illustrates that some aspects of HPV test ordering have become more consistent with guidelines over time. However, a large portion of HPV testing in the United States is unnecessary. This highlights opportunities for optimization of a rational cancer prevention strategy to reduce unnecessary screening, colposcopy and biopsies.

Vaccination with a human papillomavirus (HPV)-16/18 AS04-adjuvanted cervical cancer vaccine in Korean girls aged 10-14 years

The human papillomavirus (HPV)-16/18 AS04-adjuvanted cervical cancer vaccine has been demonstrated to be highly efficacious and immunogenic with a favorable safety profile. This study assessed the immunogenicity and safety of the HPV-16/18 AS04-adjuvanted vaccine in healthy Korean girls aged 10-14 yr. This multi-center, observer-blind trial randomly assigned 321 healthy girls to receive three doses (0, 1, 6-month schedule) of HPV-16/18 AS04-adjuvanted vaccine or hepatitis A vaccine. Immunogenicity against vaccine antigens was assessed one month post-Dose 3. Solicited and unsolicited adverse events (AEs) and serious AEs (SAEs) were recorded. In the according-to-protocol analysis, all initially seronegative subjects vaccinated with the HPV-16/18 AS04-adjuvanted vaccine had seroconverted at Month 7, with a peak geometric mean titer (GMT) that was 600-fold higher than the natural infection titer of 29.8 EU/mL for HPV-16 and a peak GMT that was 400-fold higher than the natural infection titer of 22.6 EU/mL for HPV-18. The vaccine was well tolerated with no increase in reactogenicity with subsequent doses and no reports of vaccine-related SAEs. In conclusion, the HPV-16/18 AS04-adjuvanted vaccine is shown to be highly immunogenic and generally well-tolerated in Korean girls aged 10-14 yr.

Human papillomavirus infection in women from tlaxcala, Mexico

Cervical cancer is an important health problem in women living in developing countries. Infection with some genotypes of human papillomavirus (HPV) is the most important risk factor associated with cervical cancer. Little information exists about HPV genotype distribution in rural and suburban regions of Mexico. Thus, we determined the prevalence of HPV genotypes in women from Tlaxcala, one of the poorest states in central Mexico, and we evaluated age infection prevalence and risk factors associated with cervical neoplasm. A cross-sectional study was conducted in 236 women seeking gynecological care at the Mexican Institute for Social Security in Tlaxcala, Mexico. Cervical scrapings were diagnosed as normal, low-grade, and high-grade squamous intraepithelial lesions (LGSIL, HGSIL). Parallel samples were used to detect HPV genotypes by PCR assays using type-specific primers for HPV 6, 11, 16, 18, and 31. An epidemiological questionnaire was applied. Prevalence of HPV infection was 31.3%. From the infected samples, prevalence of HPV 16 was 45.9%; HPV 18, 31.1%; HPV 31, 16.2%; HPV 6, 10.8%; HPV 11, 6.7%. With regard to age, the highest HPV prevalence (43.5%) was found in the 18- to 24-year-old group and the lowest (19%) in the 45- to 54-year-old group. None of the risk factors showed association with cervical neoplasia grade. HPV 16 was the most common in cervical lesions. HPV was present in 22% of normal samples and, of these, 82.6% represented high-risk HPVs. Tlaxcala showed HPV prevalence comparable to that of the largest cities in Mexico, with higher prevalence for HPV 31.

Absence of dysplasia in the excised cervix by a loop electrosurgical excision procedure in the treatment of cervical intraepithelial neoplasia

OBJECTIVE

Absence of dysplasia in the excised specimen following loop electrosurgical excision procedure (LEEP) for treatment of cervical intraepithelial neoplasia (CIN) 2/3 is an occasional finding of uncertain clinical significance. We evaluated several factors including age, liquid-based Pap (LBP) test, human papillomavirus (HPV) load before treatment, and HPV typing as predictors for absence of dysplasia. Absence of dysplasia in LEEP specimens was analyzed in terms of factors for recurrent disease after LEEP conization

METHODS

In total, 192 women (mean age, 39.3+/-8.4 years; range, 24 to 70 years) with biopsy-proven CIN 2/3 were treated by LEEP conization. Age, LBP test, histological grade, HPV load, and HPV DNA typing were evaluated as possible predictors of the absence of residual dysplasia or recurrent disease.

RESULTS

Of the LEEP specimens, 34 (17.7%) showed no dysplasia in preoperative biopsies from patients with proven CIN 2/3. Low HPV load (<100 relative light units [RLU]) was significantly related to the absence of dysplasia in LEEP specimens, using logistic regression. Margin involvement and high HPV load (>/=400 RLU) were significant factors for recurrence.

CONCLUSION

Absence of dysplasia in LEEP specimens occurred in 17.7% of our specimens. Prediction of the absence of dysplasia in LEEP specimens was associated with low HPV load. Residual/recurrent disease after LEEP was associated with a positive resection margin and high viral load, and was not associated with absence of dysplasia in LEEP specimens. Even if there is no dysplasia in conization specimens, close follow-up for residual/recurrent disease is needed.

DNA vaccines for cervical cancer

Human papillomavirus (HPV), particularly type 16, has been associated with more than 99% of cervical cancers. There are two HPV oncogenic proteins, E6 and E7, which play a major role in the induction and maintenance of cellular transformation. Thus, immunotherapy targeting these proteins may be employed for the control of HPV-associated cervical lesions. Although the commercially available preventive HPV vaccines are highly efficient in preventing new HPV infection, they do not have therapeutic effects against established HPV infection or HPV-associated lesions. Since T cell-mediated immunity is important for treating established HPV infections and HPV-associated lesions, therapeutic HPV vaccine should aim at generating potent E6 and E7-specific T cell-mediated immune responses. DNA vaccines have now developed into a promising approach for antigen-specific T cell-mediated immunotherapy to combat infection and cancer. Because dendritic cells are the most potent professional antigen-presenting cells, and are highly effective in priming antigen-specific T cells, several DNA vaccines have employed innovative strategies to modify the properties of dendritic cells (DCs) for the enhancement of the DNA vaccine potency. These studies have revealed impressive pre-clinical data that has led to several ongoing HPV DNA vaccine clinical trials.

Epidermodysplasia verruciformis: An early and unusual presentation

Epidermodysplasia verruciformis is a rare, heritable disease characterized by an unusual susceptibility to infection with specific types of human papillomavirus and a propensity for developing malignant skin tumours. Partial defects in cell-mediated immunity have been demonstrated in this disease. In the present report, a young patient with epidermodysplasia verruciformis who was treated successfully with surgical treatment is described.

A case of advanced gynecologic pelvic tumors showing the diagnostic utility of HPV analysis

Gynecologic malignancies may have similar histological characteristics. This may lead to difficulties in determining the origin of the cancer and to distinguish a synchronous neoplasm from a metastatic cancer in advanced cases. Recently, we treated a 59-year-old patient with adenocarcinoma of the uterine cervix, endometrium, fallopian tubes, and ovaries. It was difficult to determine whether the cancer was a single origin metastatic cancer or a synchronous neoplasm. The patient was finally diagnosed with metastatic cancer that originated from the uterine cervix by human papillomavirus (HPV) test. Here we report the case and briefly review of the medical literature.

The utility of the human papillomavirus DNA load for the diagnosis and prediction of persistent vaginal intraepithelial neoplasia

OBJECTIVE

We evaluated the human papillomavirus (HPV) DNA load for the diagnosis and prediction of persistent vaginal intraepithelial neoplasia (VAIN).

METHODS

A retrospective review of the medical records of patients with a pathological diagnosis of VAIN was performed. Eligible women (N=48) were followed for cytology and HPV DNA test, and colposcopic biopsies were taken at 3- to 6-month intervals. Thirty-seven patients were followed for more than 6 months; their HPV DNA test results were compared to the cytology results for the prediction of disease prognosis.

RESULTS

The degree of VAIN was more severe in patients with a high initial HPV DNA load (p=0.009). Patients with VAIN 2 and VAIN 3 were older than those with VAIN 1 (p=0.005 and 0.008, respectively). In 26 out of 37 patients (70.3%), the VAIN resolved. The other patients had persistent lesions with no progression to invasive vaginal carcinoma. The last follow-up HPV DNA load was significantly higher in the group with persistent VAIN compared to the group with resolved VAIN (p<0.0001). Negative cytology was observed in 25 out of 26 patients in the VAIN resolved group and in nine out of 11 patients in the VAIN persistent group (p=0.205).

CONCLUSION

These results suggest that the HPV DNA test, especially for viral load, was more effective for the diagnosis and prediction of persistent VAIN than cytology.

HPV-related nonkeratinizing squamous cell carcinoma of the oropharynx: utility of microscopic features in predicting patient outcome

Human papilloma virus (HPV) is an etiologic agent in a subset of oropharyngeal squamous cell carcinomas (SCCs). The aim of this study was to sub-classify SCC of the oropharynx based upon histologic features into nonkeratinizing (NK) SCC, keratinizing (K) SCC, and hybrid SCC, and determine the frequency of HPV and patient survival in each group. Patients with oropharyngeal SCC with a minimum of 2 years of clinical follow-up were identified from radiation oncology databases from 1997 to 2004. All patients received either up front surgery with postoperative radiation or definitive radiation based therapy. In situ hybridization (ISH) for high-risk HPV subtypes and immunohistochemistry for p16, a protein frequently up-regulated in HPV-associated carcinomas, were performed. Overall and disease-specific survival were assessed. Of 118 cases, 46.6% were NK SCC, 24.6% K SCC and 28.8% hybrid SCC. NK SCC occurred in slightly younger patients that were more often male. It more frequently presented with lymph node metastases and was surgically resected compared to K SCC. NK SCC was significantly more likely to be HPV and p16 positive than KSCC (P < 0.001) and to have better overall and disease-specific survival (P = 0.0002; P = 0.0142, respectively). Hybrid SCC was also more likely than K SCC to be HPV and p16 positive (P = 0.003; P = 0.002, respectively) and to have better overall survival (P = 0.0105). Sub-classification of oropharyngeal SCC by histologic type provides useful clinical information. NK SCC histology strongly predicts HPV-association and better patient survival compared to K SCC. Hybrid SCC appears to have an intermediate frequency of HPV-association and patient survival.

Human Papilloma Virus (HPV) in head and neck region: review of literature

The evidence that human papillomavirus infection is related to head and neck squamous cell carcinoma is supported by molecular and epidemiological data. The definition of a distinct subset of head and neck squamous cell carcinoma, independent of the traditional risk factors and with different clinical presentation and outcome, has led to increasing interest in human papillomavirus infection. This review summarizes current knowledge regarding human papillomavirus biology, oncogenic mechanisms, risk factors for transmission, clinical significance and prophylactic strategies.

Comparison between L and E gene amplification analytical methods for human papillomavirus typing

OBJECTIVE

L and E6/E7 gene amplification analyses were compared to identify human papillomavirus (HPV) infection and verify the HPV type, with the intent to minimize HPV typing errors.

METHODS

L1 gene verified HPV typing was accomplished via polymerase chain reaction (PCR) and membrane assays. Verification of HPV typing via E6/E7 genes was accomplished through nested multiplexed PCR. The results from 104 samples were compared.

RESULTS

The rates of accordance and difference were 35% and 65%, respectively. For 29% of the analyses, nested multiplexed PCR was more diversified than the membrane assay.

CONCLUSION

HPV can be classified into low-risk HPV and high-risk HPV groups. In parallel amplifications of the L and E genes is more efficient for accurate diagnosis in light of the different symptoms and attendant precautions of the risk groups.

Meta-analysis of relationship between tumorigenesis of esophageal carcinoma and human papillomavirus infection

AIM: To synthetically evaluate the relationship between human papillomavirus (HPV) infection and the tumorigenesis of esophageal carcinoma.

METHODS: Research articles about HPV infection and the development of esophageal carcinoma were collected from journals published from Jan 1987 to Nov 2008. The searching criteria included all randomized evidence for HPV DNA detection with polymerase chain reaction (PCR) or in situ hybridization (ISH). Meta-analysis was performed to re-analyze those references synthetically.

RESULTS: A total of 15 trials including 1174 esophageal carcinoma patients and 988 normal controls were collected. Meta-analysis revealed that the combined odds ratios (ORc) for HPV infection in esophageal carcinoma was 4.29 (95%CI: 2.38-7.70) times higher than that of normal esophagus mucosa. The mean positive rates for HPV infection in esophageal carcinoma and normal esophageal mucosa tissues were both significantly higher in areas with high prevalence than in areas with low prevalence (59.26% vs 34.66%, χ² = 66.05, P < 0. 001; 42.50% vs 15.82%, χ² = 66.02, P < 0. 001).

CONCLUSION: HPV infection increases the risk of tumorigenesis of esophageal carcinoma, especially in areas with high prevalence of esophageal carcinoma in China.

The changing face of head and neck cancer in the 21st century: the impact of HPV on the epidemiology and pathology of oral cancer

The longstanding notion that head and neck squamous cell carcinoma (HNSCC) is a uniform disease process is changing. Divergence in epidemiologic trends among HNSCCs arising in different anatomic subsites has introduced a view that HNSCC is a heterogeneous group. Analysis of molecular genetic changes discloses not just individual tumor differences, but also consistent large-scale differences that permit the recognition of important tumor subtypes. One recently recognized subtype is the human papillomavirus (HPV)-positive oropharyngeal carcinoma. HPV-positive oropharyngeal cancer now dominates the head and neck oncology landscape, and its escalating incidence is impacting on diagnostic, preventive and therapeutic practices.

Oral squamous papilloma and condyloma acuminatum as manifestations of buccal-genital infection by human papillomavirus

Genital infection by human papillomavirus (HPV), a sexually transmitted disease (STD), has increased considerably due to the changes in sexual behaviour and an increase in the practice of oral sex. HPV, in a parallel manner, has been closely studied due to its oncogenic potential. We present the case of a 27-year-old patient, with a multi-partner sexual history and frequent practice of oral sex, who suffered from warts lesions on the genitalia and tongue. Squamous papilloma was diagnosed from a tongue biopsy. The treatment of the oral lesion was by way of surgery, without relapse in the first two years. Our discussion in this report is regarding the HPV infection in the oral cavity.

Cervical cancer: a preventable death

Cervical cancer kills 260,000 women annually, and nearly 85% of these deaths occur in developing nations, where it is the leading cause of cancer deaths in women. Disparities of health and poverty play a large role in this high mortality rate. Whereas routine Papanicolaou and human papillomavirus (HPV) testing has dramatically reduced cervical cancer deaths in Western nations, without proper infrastructure, facilities, and medical training, the rates of cervical cancer in developing nations will remain high. Studies on HPV DNA testing and the low-technology method of "screen and treat" are promising. In addition, reducing the cost and increasing the availability of HPV vaccines in developing nations brings hope and promise to the next generation of women.

Identification of human papillomavirus in esophageal squamous papillomas

AIM: To investigate the presence of human papillomavirus (HPV) in esophageal squamous papilloma (ESP) and determine p16, p53 and Ki67 expression in a Mexican cohort.

METHODS: Nineteen cases diagnosed as ESP, corresponding to 18 patients were reviewed; nineteen cases of normal esophageal mucosa were used as negative controls. HPV detection was performed by amplified chromogenic in situ hybridization (ACISH) using a wide spectrum-cocktail probe and PCR.

RESULTS: The average age at presentation was 46.3 years (range 28-72 years). Patients included four (22.22%) males and 14 (77.77%) females. The most frequent location was upper third (11 cases), followed by middle third (3 cases) and unknown site (5 cases). Immunohistochemistry (IHC) revealed basal and focal p53 expression in 17 cases (89%); p16 was expressed in eight cases (42.10%) and the Ki67 index ranged from 10% to 30%. HPV was detected in 14 out of 16 cases (87.5%) by ACISH: Twelve showed diffuse nuclear patterns and two showed granular patterns. HPV DNA was identified by PCR in 12 out of 14 cases (85.7%). Low-risk HPV types were detected in the most of the cases.

CONCLUSION: This study provides identification of HPV infection in almost 80% of ESP using either ACISH or PCR; overall, all of these lesions show low expression of cell-cycle markers. We suggest ACISH as an alternative diagnostic tool for HPV detection in ESP.

Human papillomavirus infection in women attended at a cervical cancer screening service in Natal, Brazil

We analyzed cervical specimens of 202 women, aged 15 to 64 years, attended at Luis Antonio Hospital, Natal, Brazil, to determine the prevalence of HPV and identify the more frequent genotypes and risk factors for HPV infection in women attended at a cervical cancer screening service. Two specimens were collected from each patient: one for cytological examination and the other to detect HPV DNA by PCR, and typing by dot blot hybridization. A total of 54.5% of the sample had normal cytology and 45.5% had cytological alterations. HPV was detected in 24.5% of the cytologically normal women and in 59.8% of those with altered cytology. Both single and double HPV infection increased the likelihood of cytological alterations. Thirteen types of HPV were identified, most of which were high risk. HPV 16 was the most prevalent single-type infection, followed by HPV 58. The most frequent double infection was the association between HPV 56 and 57. The prevalence of HPV in cytologically normal women was greater than that reported for countries on all the continents except Africa. The inverse was observed in women with cytological alterations. The distribution of HPV types was similar to that described for the Americas, with some differences. Multiple sexual partners was the only risk factor showing an association with the presence of HPV infection.

Human Papillomavirus (HPV), HPV-Related Disease, and the HPV Vaccine

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, and persistent HPV infection is strongly associated with risk of cervical cancer and genital warts. The recently approved quadrivalent HPV vaccine targets the HPV strains responsible for approximately 70% of cervical cancers and 90% of genital warts. It is also effective in reducing the incidence of HPV-related conditions, especially when given prior to exposure to HPV. The vaccine is recommended for all girls aged 11 to 12 with catch-up vaccination for women up to age 26, and most insurance plans cover the vaccine. A second bivalent HPV vaccine is currently pending approval by the US Food and Drug Administration (FDA). HPV vaccination reduces the incidence of HPV-related cancers and precancerous lesions in the United States and abroad, though decisions regarding implementation of vaccination remain.

Human papillomavirus: the usefulness of risk factors in determining who should get vaccinated

Vaccination against human papillomavirus (HPV) promises to dramatically decrease the incidence of HPV-related diseases, including cervical cancer. Although this vaccine is recommended by the Advisory Committee on Immunization Practices and The American College of Obstetricians and Gynecologists for all age-eligible women, challenges related to the vaccine's high cost and the difficulty in reaching some patients for vaccination may make implementation of this recommendation difficult. As an alternative strategy, some may consider targeting HPV vaccines to specific patients based on their risk for HPV infection or HPV-related disease. This article reviews what is known about risk factors for HPV, and discusses why using risk factors as the basis for targeting HPV vaccination is unlikely to be a viable vaccination strategy.

Human papillomavirus-related gynecologic neoplasms: screening and prevention

The recent recognition of oncogenic human papillomavirus (HPV) as a key component of female lower genital tract malignancies has led to significant changes in many screening and prevention guidelines for cervical cancer, and, combined with the advent of vaccination, will likely have sweeping repercussions on the incidence of cervical, vulvar, and vaginal carcinoma. This article focuses on the specific principles of cancer screening and prevention with an emphasis on HPV-mediated disease.

Analysis of human papillomavirus DNA infection in Kazakh esophageal carcinomas in Xinjiang province

AIM: To detect the infection rate of three high-risk human papillomavirus (HPV) DNA gene subtypes (HPV18, 31 and 45E7) in Xinjiang Kazakh esophageal carcinoma and their association with esophageal carcinoma.

METHODS: We detected HPV18, 31 and 45E7 infections in 316 Kazakh esophageal carcinoma cases by polymerase chain reaction (PCR), and validated them by sequencing PCR products randomly selected from the 316 samples.

RESULTS: The positive rate of HPV18, 31 and 45E7 in Kazakh esophageal carcinoma was 25.3% (80/316), 14.2% (45/316) and 7.3% (23/316), respectively. Genotype distribution had no correlation with age or gender; however, there was a significant difference between moderate-to-low-differentiation esophagus squamous cell carcinoma and high-differentiation esophagus squamous cell carcinoma with HPV18 infection (29.6% vs 17.7%, χ² = 5.398, P < 0.05).

CONCLUSION: HPV18E7 infection may be important for the development of esophageal carcinoma and be associated with the degree of differentiation of Kazakh esophageal carcinoma. HPV31 and 45 are not important high-risk factors in the development of Kazakh esophageal carcinomas in Xinjiang province.

CHAPTER 8 HPV vaccines

Vaccines to prevent infection with high-risk human papillomaviruses (HPV) will help protect women against cervical cancer, and some are likely to be available within the next year. One vaccine, a quadrivalent vaccine against HPV types 6, 11, 16 and 18 and known as Garadsil ©(Merck &Co., Inc), was approved by the Federal Drug Administration (FDA) for the prevention of cervical cancer, cervical cancer precursors and vulval and vaginal cancer precursors associated with HPV 16 and 18 in June 2006. In addition, the vaccine has been approved for the prevention of genital warts and low grade cervical lesions e.g. cervical intraepithelial neoplasia1. The main vaccines components are recombinant viral capsid proteins assembled into virus-like particles and alum-based adjuvants. If given before HPV infection, the vaccines, which induce HPV type-specific, virus-neutralizing antibodies, have proven safe and highly effective at preventing HPV infection and its clinical consequences, including high-grade cervical lesions. Their use should not immediately alter existing screening programs for cervical cancer, however. Because they incorporate only the 2 HPV types most commonly associated with cervical cancer (HPV-16 and HPV-18), they can only prevent about 70% of cervical cancers. Vaccines to treat existing HPV infection are under development but are unlikely to become clinically available in the near future.