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Vani NV, Madhanagopal R, Swaminathan R, Ganesan TS. Dynamics of oral human papillomavirus infection in healthy population and head and neck cancer. Cancer Med 2023. [PMID: 36846921 DOI: 10.1002/cam4.5686] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/16/2023] [Accepted: 01/31/2023] [Indexed: 03/01/2023] Open
Abstract
The recent increase in high-risk human papillomavirus (HR-HPV)-associated oral and oropharyngeal cancers has gained considerable importance due to their distinct clinical and molecular characteristics. However, the natural history of oral HPV from acquisition to persistence and malignant transformation is still unclear. The global prevalence of oral HPV infection in healthy individuals ranges from 0.67% to 35%, while 31%-38.5% in head and neck cancer (HNC). The persistence rate of oral HR-HPV infection is 5.5% -12.8% globally. India has the highest HNC burden due to apparent differences in predisposing factors compared with the West. The prevalence of oral HPV in healthy individuals and its contribution to HNC is less evident in Indian studies. HR-HPV-associated HNC in this region accounts for 26%, with an active infection in 8%-15% of these tumors. There is a lack of concordance in the expression of p16 as a surrogate marker for HPV detection in HNC because of differences in behavioral risk factors. Due to a lack of evidence, treatment de-escalation cannot be implemented despite the improved outcome of HPV-associated oropharyngeal cancers. This review critically analyzes the existing literature on the dynamics of oral HPV infection and HPV-associated HNC, identifying potential avenues for future research. A better understanding of the oncogenic role of HR-HPV in HNC will help to formulate novel therapeutic approaches and is expected to have a significant public health impact as preventive strategies can be implemented.
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Affiliation(s)
- N V Vani
- Epidemiology, Biostatistics, and Tumour Registry, Cancer Institute (WIA), Chennai, India
| | - R Madhanagopal
- Epidemiology, Biostatistics, and Tumour Registry, Cancer Institute (WIA), Chennai, India
| | - R Swaminathan
- Epidemiology, Biostatistics, and Tumour Registry, Cancer Institute (WIA), Chennai, India
| | - T S Ganesan
- Medical Oncology, Cancer Institute (WIA), Chennai, India
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2
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Tanaka H, Suzuki M, Takemoto N, Fukusumi T, Eguchi H, Takai E, Kanai H, Tatsumi M, Horie M, Takenaka Y, Yachida S, Inohara H. Performance of oral HPV DNA, oral HPV mRNA and circulating tumor HPV DNA in the detection of HPV-related oropharyngeal cancer and cancer of unknown primary. Int J Cancer 2022; 150:174-186. [PMID: 34486724 PMCID: PMC9290341 DOI: 10.1002/ijc.33798] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/12/2021] [Accepted: 08/31/2021] [Indexed: 01/21/2023]
Abstract
A biomarker that is useful for the detection of human papillomavirus (HPV)‐related oropharyngeal cancer (OPC) and cancer of unknown primary (CUP) is indispensable. We evaluated the diagnostic performance of HPV DNA and mRNA in oral gargle samples and circulating tumor HPV16 DNA (ctHPV16DNA) in blood samples. Oral HPV DNA and mRNA were analyzed using commercially available HPV assays of the GENOSEARCH HPV31 and Aptima, respectively. ctHPV16DNA was analyzed using in‐house droplet digital polymerase chain reaction. Seventy‐four patients with OPC and eight patients with CUP were included. The sensitivity and specificity of oral HPV DNA, oral HPV mRNA, and ctHPV16DNA were 82% (95% confidence interval [CI] = 66‐92) and 100% (95% CI = 88‐100), 85% (95% CI = 69‐94) and 94% (95% CI = 73‐100), and 93% (95% CI = 81‐99) and 97% (95% CI = 84‐100), respectively, for HPV16‐related OPC, while those were 20% (95% CI = 1‐72) and 100% (95% CI = 3‐100), 0% (95% CI = 0‐52) and 100% (95% CI = 3‐100), and 100% (95% CI = 54‐100) and 100% (95% CI = 16‐100), respectively, for HPV16‐related CUP. The sensitivity of ctHPV16DNA for HPV16‐related OPC was higher than that of oral biomarkers, though the difference was not statistically significant. ctHPV16DNA remarkably correlated with the anatomic extent of disease, total metabolic tumor volume and HPV16 copy number per tumor genome in patients with HPV16‐related OPC/CUP, whereas oral biomarkers did not. In conclusion, ctHPV16DNA is a potentially promising biomarker for HPV16‐related OPC, while further studies are required for HPV16‐related CUP.
What's new?
A minimally‐invasive biomarker that allows the detection of human papillomavirus (HPV)‐related oropharyngeal cancer and cancer of unknown primary is indispensable. Here, the authors show that circulating tumour HPV DNA (ctHPVDNA) correlates with the tumour burden and HPV copy number per tumour genome in HPV‐related oropharyngeal cancer and cancer of unknown primary. Neither oral HPV DNA nor mRNA exhibits such a correlation. ctHPVDNA outperforms oral HPV DNA and mRNA in detecting HPV‐related oropharyngeal cancer and in distinguishing HPV‐related cancer of unknown primary from HPV‐unrelated cancers. ctHPVDNA emerges as a potentially useful biomarker for HPV‐related oropharyngeal cancer and cancer of unknown primary.
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Affiliation(s)
- Hidenori Tanaka
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.,Department of Cancer Genome Informatics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Motoyuki Suzuki
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Norihiko Takemoto
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takahito Fukusumi
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hirotaka Eguchi
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Erina Takai
- Department of Cancer Genome Informatics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Haruka Kanai
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.,Department of Cancer Genome Informatics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Mitsuaki Tatsumi
- Department of Nuclear Medicine and Tracer Kinetics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masafumi Horie
- Department of Cancer Genome Informatics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yukinori Takenaka
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shinichi Yachida
- Department of Cancer Genome Informatics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.,Integrated Frontier Research for Medical Science Division, Institute for Open and Transdisciplinary Research Initiatives (OTRI), Osaka University, Suita, Osaka, Japan.,Division of Genomic Medicine, National Cancer Center Institute, Tokyo, Japan
| | - Hidenori Inohara
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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3
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Giuliani E, Rollo F, Donà MG, Garbuglia AR. Human Papillomavirus Oral Infection: Review of Methodological Aspects and Epidemiology. Pathogens 2021; 10:pathogens10111411. [PMID: 34832567 PMCID: PMC8625118 DOI: 10.3390/pathogens10111411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/15/2021] [Accepted: 10/27/2021] [Indexed: 11/16/2022] Open
Abstract
Oral infection by Human Papillomavirus (HPV) has recently gained great attention because of its involvement in the development of a subset of head and neck squamous cell carcinoma. The role of specific Alpha-HPVs in this regard has been well established, whereas the contribution of other genera is under investigation. Despite their traditional classification as “cutaneous” types, Beta and Gamma HPVs are frequently detected in oral samples. Due to the lack of a standardized protocol, a large variety of methodologies have been used for oral sample collection, DNA extraction, HPV detection and genotyping. Laboratory procedures influence the evaluation of oral HPV prevalence, which largely varies also according to the population characteristics, e.g., age, gender, sexual behavior, Human Immunodeficiency Virus (HIV) status. Nevertheless, oral infection by Beta and Gamma HPVs seems to be even more common than Alpha-HPVs. The latter is 5–7% in the general population, and increases up to 30% approximately in HIV-infected men who have sex with men. Despite major advances in the evaluation of oral HPV prevalence, its natural history is still little understood, especially for Beta and Gamma HPVs. The latest technologies, such as Next Generation Sequencing (NGS), can be exploited to gain new insights into oral HPV, and to improve the identification of novel HPV types.
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Affiliation(s)
- Eugenia Giuliani
- Scientific Direction, San Gallicano Dermatological Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy;
| | - Francesca Rollo
- Pathology Department, Regina Elena National Cancer Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy;
| | - Maria Gabriella Donà
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy
- Correspondence: ; Tel.: +39-0652665393
| | - Anna Rosa Garbuglia
- Laboratory of Virology, National Institute for Infectious Diseases, INMI Lazzaro Spallanzani IRCCS, Via Portuense 292, 00149 Rome, Italy;
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Giuliani M, Gheit T, Rollo F, Tommasino M, Latini A, Benevolo M, Pichi B, Pellini R, McKay-Chopin S, Cristaudo A, Giuliani E, Morrone A, Donà MG. Predictors of Oral Infection by Mucosal and Cutaneous Human Papillomaviruses in HIV-Infected and Uninfected Men Who Have Sex with Men of the OHMAR Study. J Clin Med 2021; 10:2804. [PMID: 34202235 PMCID: PMC8269418 DOI: 10.3390/jcm10132804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/09/2021] [Accepted: 06/22/2021] [Indexed: 02/04/2023] Open
Abstract
Mucosal Human Papillomaviruses (HPVs) play a role in the development of a subset of head and neck cancers. Cutaneous HPVs are abundantly present in the oral cavity. The determinants of these infections have not been extensively investigated. We assessed the correlates of oral infection by alpha and beta and/or gamma HPVs in HIV-infected and uninfected men who have sex with men (MSM). Oral rinse-and-gargles were collected with a mouthwash. Alpha and beta/gamma HPVs were detected using the Linear Array HPV genotyping test and a multiplex PCR combined with Luminex technology, respectively. Multiple logistic regression was performed to identify independent predictors of oral HPV infection. Overall, 193 HIV-uninfected and 117 HIV-infected MSM were enrolled. Among HIV-infected MSM, the only determinant of alpha HPV infection was the number of lifetime oral sex partners (AOR: 8.26, 95% CI: 2.26-30.16). The strongest determinant of beta/gamma HPV infection was represented by practicing condomless receptive oral sex (AOR: 10.76, 95% CI: 1.56-74.17). Age was independently associated with alpha HPV infection in HIV-uninfected MSM. Beta/gamma HPV infection was not associated with sexual behavior in these subjects. In conclusion, predictors of oral infection differ between HIV-infected and uninfected MSM, as well as between alpha and beta/gamma HPVs.
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Affiliation(s)
- Massimo Giuliani
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.G.); (A.L.); (A.C.); (M.G.D.)
| | - Tarik Gheit
- Infections and Cancer Biology Group, International Agency for Research on Cancer, 69372 Lyon, France; (T.G.); (M.T.); (S.M.-C.)
| | - Francesca Rollo
- Pathology Department, Regina Elena National Cancer Institute IRCCS, 00144 Rome, Italy;
| | - Massimo Tommasino
- Infections and Cancer Biology Group, International Agency for Research on Cancer, 69372 Lyon, France; (T.G.); (M.T.); (S.M.-C.)
| | - Alessandra Latini
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.G.); (A.L.); (A.C.); (M.G.D.)
| | - Maria Benevolo
- Pathology Department, Regina Elena National Cancer Institute IRCCS, 00144 Rome, Italy;
| | - Barbara Pichi
- Otolaryngology Head&Neck Surgery Department, Regina Elena National Cancer Institute IRCCS, 00144 Rome, Italy; (B.P.); (R.P.)
| | - Raul Pellini
- Otolaryngology Head&Neck Surgery Department, Regina Elena National Cancer Institute IRCCS, 00144 Rome, Italy; (B.P.); (R.P.)
| | - Sandrine McKay-Chopin
- Infections and Cancer Biology Group, International Agency for Research on Cancer, 69372 Lyon, France; (T.G.); (M.T.); (S.M.-C.)
| | - Antonio Cristaudo
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.G.); (A.L.); (A.C.); (M.G.D.)
| | - Eugenia Giuliani
- Scientific Direction San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (E.G.); (A.M.)
| | - Aldo Morrone
- Scientific Direction San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (E.G.); (A.M.)
| | - Maria Gabriella Donà
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.G.); (A.L.); (A.C.); (M.G.D.)
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Gheit T, Rollo F, Brancaccio RN, Robitaille A, Galati L, Giuliani M, Latini A, Pichi B, Benevolo M, Cuenin C, McKay-Chopin S, Pellini R, Cristaudo A, Morrone A, Tommasino M, Donà MG. Oral Infection by Mucosal and Cutaneous Human Papillomaviruses in the Men Who Have Sex with Men from the OHMAR Study. Viruses 2020; 12:E899. [PMID: 32824507 PMCID: PMC7472018 DOI: 10.3390/v12080899] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 12/12/2022] Open
Abstract
Both mucosal and cutaneous Human Papillomaviruses (HPVs) can be detected in the oral cavity, but investigations regarding the epidemiology of cutaneous HPVs at this site are scarce. We assessed mucosal (alpha) and cutaneous (beta and gamma) HPV infection in oral samples of HIV-infected and uninfected men who have sex with men (MSM). Oral rinse-and-gargles were collected from 310 MSM. Alpha HPVs were detected using the Linear Array, whereas beta and gamma HPVs were detected using multiplex PCR and Luminex technology. An amplicon-based next-generation sequencing (NGS) protocol was applied to a subset of samples collected from 30 HIV-uninfected and 30 HIV-infected MSM. Beta HPVs were significantly more common than alpha types (53.8% vs. 23.9% for HIV-infected subjects, p < 0.0001; 50.3% vs. 17.1% for HIV-uninfected subjects, p < 0.0001). Gamma HPVs were also frequently detected (30.8% and 25.9% in HIV-infected and uninfected MSM, respectively). NGS produced 2,620,725 reads representative of 146 known HPVs (16 alpha-PVs, 53 beta-PVs, 76 gamma-PVs, one unclassified) and eight putative new HPVs, taxonomically assigned to the beta genus. The oral cavity contains a wide spectrum of HPVs, with beta types representing the predominant genus. The prevalence of beta and gamma HPVs is high even in immunorestored HIV-infected individuals. NGS confirmed the abundance of cutaneous HPVs and identified some putative novel beta HPVs. This study confirms that cutaneous HPVs are frequently present at mucosal sites and highlights that their pathological role deserves further investigation since it may not be limited to skin lesions.
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Affiliation(s)
- Tarik Gheit
- International Agency for Research on Cancer, 150 Cours Albert Thomas, CEDEX 08, 69372 Lyon, France; (T.G.); (R.N.B.); (A.R.); (L.G.); (C.C.); (S.M.-C.); (M.T.)
| | - Francesca Rollo
- Pathology Department, Regina Elena National Cancer Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy; (F.R.); (M.B.)
| | - Rosario N Brancaccio
- International Agency for Research on Cancer, 150 Cours Albert Thomas, CEDEX 08, 69372 Lyon, France; (T.G.); (R.N.B.); (A.R.); (L.G.); (C.C.); (S.M.-C.); (M.T.)
| | - Alexis Robitaille
- International Agency for Research on Cancer, 150 Cours Albert Thomas, CEDEX 08, 69372 Lyon, France; (T.G.); (R.N.B.); (A.R.); (L.G.); (C.C.); (S.M.-C.); (M.T.)
| | - Luisa Galati
- International Agency for Research on Cancer, 150 Cours Albert Thomas, CEDEX 08, 69372 Lyon, France; (T.G.); (R.N.B.); (A.R.); (L.G.); (C.C.); (S.M.-C.); (M.T.)
| | - Massimo Giuliani
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy; (M.G.); (A.L.); (A.C.)
| | - Alessandra Latini
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy; (M.G.); (A.L.); (A.C.)
| | - Barbara Pichi
- Otolorayngology Head&Neck Surgery Department, Regina Elena National Cancer Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy; (B.P.); (R.P.)
| | - Maria Benevolo
- Pathology Department, Regina Elena National Cancer Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy; (F.R.); (M.B.)
| | - Cyrille Cuenin
- International Agency for Research on Cancer, 150 Cours Albert Thomas, CEDEX 08, 69372 Lyon, France; (T.G.); (R.N.B.); (A.R.); (L.G.); (C.C.); (S.M.-C.); (M.T.)
| | - Sandrine McKay-Chopin
- International Agency for Research on Cancer, 150 Cours Albert Thomas, CEDEX 08, 69372 Lyon, France; (T.G.); (R.N.B.); (A.R.); (L.G.); (C.C.); (S.M.-C.); (M.T.)
| | - Raul Pellini
- Otolorayngology Head&Neck Surgery Department, Regina Elena National Cancer Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy; (B.P.); (R.P.)
| | - Antonio Cristaudo
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy; (M.G.); (A.L.); (A.C.)
| | - Aldo Morrone
- Scientific Direction, San Gallicano Dermatologic Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy;
| | - Massimo Tommasino
- International Agency for Research on Cancer, 150 Cours Albert Thomas, CEDEX 08, 69372 Lyon, France; (T.G.); (R.N.B.); (A.R.); (L.G.); (C.C.); (S.M.-C.); (M.T.)
| | - Maria Gabriella Donà
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, Via Elio Chianesi 53, 00144 Rome, Italy; (M.G.); (A.L.); (A.C.)
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Giuliani M, Rollo F, Vescio MF, Pichi B, Latini A, Benevolo M, Pellini R, Cristaudo A, Dona' MG. Oral human papillomavirus infection in HIV-infected and HIV-uninfected MSM: the OHMAR prospective cohort study. Sex Transm Infect 2020; 96:528-536. [PMID: 32001661 DOI: 10.1136/sextrans-2019-054301] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/30/2019] [Accepted: 01/12/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE We aimed to assess incidence and clearance of oral human papillomavirus (HPV) infection and the respective risk factors in HIV-infected and uninfected men who have sex with men (MSM). METHODS Oral rinse and gargles were collected semiannually from 244 MSM (103, 42.2% HIV-infected). HPV-DNA testing was performed with the Linear Array HPV Genotyping test. A Markov model was used for estimation of incidence, clearance and risk factor analysis. RESULTS Incidence rates for any HPV were 21.2 and 15.0×1000 person-months in HIV-infected and uninfected MSM, respectively. The respective figures for high-risk HPVs were 10.7 and 6.5×1000 person-months. The clearance rate was 4-12 times higher than the respective incidence rate. HIV-infected MSM with >95 lifetime oral sex partners showed increased incidence of any HPV (adjusted HR, aHR: 8.46, 95% CI 1.89 to 37.92). Condomless oral sex appeared the strongest predictor for incident infection by high-risk HPVs in this group (aHR: 13.40, 95% CI 2.55 to 70.53). Those aged >46 years (aHR: 0.30, 95% CI 0.12 to 0.74) and those with nadir CD4+ T count of <200 cells/mm3 (aHR: 0.14, 95% CI 0.03 to 0.75) displayed a significantly reduced clearance of any and high-risk HPVs, respectively. HIV-uninfected MSM aged >46 years had increased risk of acquiring any HPV (aHR: 3.70, 95% CI 1.30 to 10.52) and high-risk HPV (aHR: 5.33, 95% CI 1.06 to 26.68). Any HPV clearance declined in those with more than six recent oral sex partners (aHR: 0.18, 95% CI 0.05 to 0.65). CONCLUSIONS Acquisition of oral HPV infection in MSM seems to occur rarely, whereas clearance seems to be a frequent event. Oral HPV natural history in these at-risk subjects is differently influenced by age and sex behaviour, depending on HIV status.
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Affiliation(s)
- Massimo Giuliani
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Francesca Rollo
- Pathology Department, Regina Elena National Cancer Institute IRCCS, Rome, Italy
| | - Maria Fenicia Vescio
- Department of Infectious, Parasitic and Immunomediated Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Barbara Pichi
- Otolaryngology Head and Neck Surgery Department, Regina Elena National Cancer Institute IRCCS, Rome, Italy
| | - Alessandra Latini
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Maria Benevolo
- Pathology Department, Regina Elena National Cancer Institute IRCCS, Rome, Italy
| | - Raul Pellini
- Otolaryngology Head and Neck Surgery Department, Regina Elena National Cancer Institute IRCCS, Rome, Italy
| | - Antonio Cristaudo
- STI/HIV Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
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