Detection of human papillomavirus types 16 and 18 in primary and in metastatic lesions of cervical carcinomas

Delayed Hematogenous Metastasis Versus Second Primary Squamous Cell Carcinoma of the Neck in a Patient With Previous Cancer of the Cervix

Squamous cell carcinoma (SCC) of the uterine cervix commonly spreads through direct infiltration and disseminates by lymphatic or hematogenous pathways. The most frequent locations for metastasis are lungs, liver, and bone. Other distant metastatic sites are rare, with only 1 reported case of neck metastasis. We present here a 73-year-old female with a prior human papillomavirus (HPV) + SCC of the cervix that had metastasized to her peri-aortic lymph nodes. Eight years after diagnosis and treatment, she returned with a hypermetabolic supraclavicular lymph node and new left-sided neck mass. Biopsy of the neck mass revealed invasive SCC positive for high-risk HPV genotype. The presence of high-risk HPV genotypes in both the cervix and supraclavicular lymph node, without evidence of second primary tumor, implies that the neck mass is a delayed metastasis of the patient's previous cervical cancer. This marks the second recorded case of neck metastasis from a SCC of the cervix.

Usefulness, methods and rationale of lymph nodes HPV-DNA investigation in estimating risk of early stage cervical cancer recurrence: a systematic literature review

Metastatic involvement of pelvic lymph-nodes (LNs), generally found in 0-29.3 % of early stages, is the most important prognostic factor in cervical cancer (CC). However, even in non-metastatic LNs, recurrence rate reaches 10-15 %. The role of HPV-DNA presence in pelvic LNs has been a point of debate in the last two decades. The aim of this systematic review is to collect all available data about LNs HPV-DNA detection in patients affected by early-stage CC in order to elucidate its clinical and surgical usefulness to choose the best surgical treatment, the necessity of adjuvant therapy and to estimate the overall oncological prognosis. The available data in this field results very patchy and often conflicting in the results. The high correlation between HPV-DNA genome detected in primary lesion and the one detected in LNs, as well as the high correlation between LNs metastatic involvement and HPV-DNA presence, lead to hypothesize that LNs HPV presence represents a potential risk-factor for recurrence and poor oncological prognosis. The large disparities in recurrence-rate of cases with LNs positive for HPV-DNA test and negative for metastases could be explained by the relative "inappropriateness" of PCR test to discriminate the presence of HPV-genome alone (condition necessary but not sufficient) or in association with squamous cells (condition necessary and sufficient). The use of ISH test for HPV-DNA detection in LNs, particularly if associated to CK19-assay, improve the accuracy of micro-metastasis detection, and the identification of patients with negative histology but potentially at high-risk of recurrence and poor oncological prognosis.

Micrometastases detected by cytokeratin 19 expression in sentinel lymph nodes of patients with early-stage cervical cancer

The purpose of this study was to detect micrometastases in sentinel lymph nodes (SLNs) by reverse transcriptase-polymerase chain reaction (RT-PCR) and immunohistochemistry (IHC) analyses for cytokeratin 19 (CK19) expression in early-stage cervical cancer. One hundred twenty-five SLNs were collected from 46 patients with early-stage cervical cancer. Conventional histopathologic techniques revealed 14 metastatic SLNs from 11 out of 46 patients. CK19 expression was detected by RT-PCR and IHC in all the 125 SLNs. Cervical cancer tissues from nine patients and five pelvic lymph nodes from the patients without tumor were utilized as positive and negative controls, respectively. All the metastastic SLNs on conventional histopathologic techniques were positive by either RT-PCR or IHC analyses, while all the positive controls were positive and all the negative controls were negative as expected. Of 35 patients without metastatic SLNs on conventional histopathologic techniques, the detection rate of micrometastases was 42.85% by RT-PCR and 20% by IHC analyses. RT-PCR and IHC were more sensitive to identify micrometastases in SLNs of patients with early-stage cervical cancer than routine pathology. These findings demonstrated that micrometastasis could be identified by molecular technique such as RT-PCR and IHC analyses for CK19 expression. RT-PCR was more sensitive to detect micrometastases in SLNs than IHC in patients with early-stage cervical cancer. Therefore, molecular assessment of the SLNs may be a valuable tool to complement routine histologic examination of cervical cancer. The importance of micrometastases in SLNs is under close clinical observation to determine whether it can be used as a predicting factor to help us make decision whether to proceed with whole-pelvic lymph node dissection or as a prognostic factor for clinical outcome.

Can HPV DNA testing on FNA material determine anogenital origin in metastatic squamous cell carcinoma?

AIMS

Currently there are no diagnostic techniques that can precisely determine the primary site of a metastatic squamous cell carcinoma (SCC). Anogenital SCC has a high prevalence of high-risk (HR) human papillomavirus (HPV) DNA, particularly in the cervix where the value approaches 100%, whereas non-anogenital SCC generally has a low prevalence. The aim of this study was to examine whether the finding of HR HPV DNA in a fine needle aspiration (FNA) of metastatic SCC could be used to determine a likely anogenital origin.

METHODS

Polymerase chain reaction (PCR) and viral sequencing were used to identify HR HPV DNA in cell block and needle rinse material derived from FNA samples in a series of metastatic SCC.

RESULTS

HPV DNA was detected in nine of 12 (75%) metastatic anogenital SCC, and type 16 was sequenced in seven. HPV DNA was detected in only one of 18 (5.6%) metastatic SCC from other sites such as lung, oral cavity and skin. The positive control case was an oral cavity tumour and type 33 was sequenced.

CONCLUSIONS

Although reservations remain, particularly in relation to the prevalence of HPV DNA in non-anogenital sites, HPV DNA testing by PCR: (1) can be successfully performed on FNA material, and (2) in the correct clinical context, can guide clinicians in assigning a site of origin. HPV DNA detection was the major indicator to the primary site in one occult tumour and several where the previous diagnosis of anogenital cancer was not known at presentation.

Human papillomaviruses in lymph node neck metastases of head and neck cancers

CONCLUSION

The results of this study corroborate earlier findings that human papillomavirus (HPV)16 is the most prevalent type of HPV in squamous cell carcinomas of the head and neck (SCCHNs) and reinforce a possible influence of HPV on SCCHN progression by showing that the majority of HPV-positive patients harbor HPV16 (or HPV33) both in their primary tumors and in lymph node neck metastases (LNNMs).

OBJECTIVE

HPVs are causally associated with carcinomas of the uterine cervix and have also been linked to a subset of SCCHNs. In order to further investigate the predicted causative role of HPV in SCCHNs, we analyzed pairs of primary tumors and LNNMs or LNNMs alone for the presence of HPV DNA using polymerase chain reaction (PCR).

MATERIAL AND METHODS

DNA was extracted from fresh frozen tissue samples of primary tumors and the corresponding LNNMs of 18 patients and from LNNMs alone in 17 patients. For the detection and typing of HPV, PCR was performed using both type-specific and consensus primer pairs, followed by Southern hybridization and, in selected cases, sequencing of the PCR products.

RESULTS

Of the 35 patients investigated, 22 (63%) were found to have HPV DNA in their tumors: HPV16 DNA in 21 cases and HPV33 in 1. The highest HPV prevalence was detected in tumors of Waldeyer's tonsillar ring (8/9 patients; 89%). Of the 18 patients in whom primary tumors and LNNMs were analyzed, 7 (39%) were HPV-positive in both samples (HPV16, n = 6; HPV33, n = 1), in 3 (17%) the primary tumors were HPV-negative and the LNNMs HPV16-positive and in 1 (5.5%) the primary tumor contained HPV16 and the LNNM was negative. Interestingly, of the 7 patients in whom LNNMs had been detected only several months after diagnosis and treatment of the primary tumors, only 1 showed infection with HPV (HPV33).

Utility of HPV Analysis for Evaluation of Possible Metastatic Disease in Women With Cervical Cancer

In a woman with cervical cancer and a distant lesion, the histologic distinction of metastatic cervical cancer versus another primary tumor or metastases from another cancer can be difficult and has important clinical implications. Criteria for inclusion in the study were a history of primary cervical cancer and a new lesion in which the pathologic differential diagnosis was metastatic cervical cancer versus new primary versus metastatic ovarian carcinoma. Ten cases were identified. The cervical cancers and the other lesion(s) were tested for human papillomavirus DNA by in situ hybridization and human papillomavirus RNA (E6/E7) by reverse transcriptase in situ polymerase chain reaction. Human papillomavirus DNA was detected in the primary cervical cancer by in situ hybridization in five of nine cases; viral RNA was detected by reverse transcriptase in situ polymerase chain reaction in nine of nine cases (one case was not available for viral testing). In six cases, human papillomavirus was detected in the subsequent lesion (three lung, one cervical lymph node, two retroperitoneum), documenting the latter was metastatic cervical cancer. Human papillomavirus was not detected in the other four cases (two lung, two retroperitoneum in women with ovarian cancer), documenting that they were either primary lung cancers or metastatic ovarian cancers, respectively. Reverse transcriptase in situ polymerase chain reaction for human papillomavirus RNA is a reliable method to differentiate metastatic cervical carcinoma from either a new primary tumor or a metastasis from another cancer.

Oral squamous carcinoma in a patient with cervix cancer: use of human papillomavirus analysis to differentiate synchronous versus metastatic tumor

BACKGROUND

Cervical cancer usually spreads by direct infiltration and disseminates by lymphatic and hematogenous pathways. The common sites of distant metastases are the lungs, liver, and bones. Other rare metastatic sites have been previously described including only one case of oral cavity metastasis.

CASE

We present here the second case of a patient with apparent oral cavity metastasis from cervical cancer. By cloning specific human papilloma virus (HPV) genomic regions, the two lesions showed HPV genomic sequences from different viruses (18 and 33, for the uterine cervix and the oral cavity, respectively), thus indicating the oral lesion as a synchronous second primary tumor.

CONCLUSION

The use of molecular markers to distinguish between a secondary and a primary lesion is recommendable in cervical cancer, particularly when reporting rare site metastases.

HPV in situ hybridization with catalyzed signal amplification and polymerase chain reaction in establishing cerebellar metastasis of a cervical carcinoma

We report an unusual case of cerebellar metastasis from a cervical adenosquamous carcinoma in which molecular techniques assisted in establishing the correct diagnosis. The patient was a 43-year-old woman with surgically unresectable cervical carcinoma diagnosed 2 years before presenting with neurological symptoms. A magnetic resonance imaging scan showed a large, enhancing cerebellar lesion with significant brain stem compression. The excised cerebellar tumor resembled a small cell carcinoma and was initially not thought to be a metastasis from the cervical adenosquamous carcinoma. In situ hybridization with catalyzed signal amplification and polymerase chain reactions with primers specific for human papilloma virus (HPV) types 16 and 18 were used to determine the relationship between the cervical and the cerebellar neoplasms. A positive signal was present in the nuclei of both neoplasms by in situ hybridization using HPV16/18 DNA probes. Polymerase chain reaction revealed the presence of HPV-18 DNA sequences in the cervical and cerebellar neoplasms confirming that the cerebellar neoplasm was a metastasis from the cervical primary.

Utilization of polymerase chain reaction technology in the detection of solid tumors

BACKGROUND

Most cancer detection tests currently performed are based on either antibody assays to a marker protein with altered expression in cancer patients or on imaging studies to identify characteristic lesions. Generally, for a positive result, these detection assays require that a tumor have a significant volume of cancer cells. Advances in diagnostic techniques and technology may allow for cancer detection at earlier stages, when the tumor burden is smaller and potentially more curable. The molecular techniques of polymerase chain reaction (PCR) and reverse transcriptase PCR (RT-PCR) are highly sensitive methods for detecting a small number of cancer cells. Over the past few years, numerous clinical studies have used PCR techniques to detect physical alterations of genes, such as mutations, deletions, translocations and amplification, the presence of oncogenic viruses, and the expression of genes specific to tissue, cancer, and metastasis. The current status of PCR as a method for detecting marker genes in the management of solid tumors is reviewed.

METHODS

A review of the literature on the clinical utility of PCR and RT-PCR in the detection of solid tumor micrometastasis was conducted.

RESULTS

Amplification by PCR is a highly sensitive method to determine gene expression. A single cell expressing a tumor marker among 10-100 million lymphocytes can be detected by the PCR assay. This approach has been used to detect tumor cells in approximately 18 different solid tumor types, with melanoma and carcinoma of the breast and prostate the most widely investigated to date. PCR-based assays have been used to detect cancer cells in biopsies of solid tissue, lymph nodes, bone marrow, peripheral blood, and other body fluids. Several studies have reported a high specificity and sensitivity of tumor marker detection and a high correlation between PCR results and the presence of metastatic disease. However, in a few studies, PCR assays have not consistently demonstrated a higher sensitivity and specificity of detection than traditional modalities for many types of cancer. There has been a wide range in sensitivity and specificity among the studies, which may be partly attributed to the lack of uniformity among the PCR protocols used in different studies.

CONCLUSIONS

PCR can detect tumor marker-expressing cells that are otherwise undetectable by other means in patients with localized or metastatic cancer. Reports from various study groups have lacked uniformity in their protocols, and this has prevented adequate comparison. The clinical utility of this assay as a tool for the prognosis and management of cancer patients remains and area of active investigation. PCR is a powerful tool in the study of the biology of cancer metastasis and will likely serve as a useful adjunct to clinical decision-making in the future.

Utilization of polymerase chain reaction technology in the detection of solid tumors

BACKGROUND

Most cancer detection tests currently performed are based on either antibody assays to a marker protein with altered expression in cancer patients or on imaging studies to identify characteristic lesions. Generally, for a positive result, these detection assays require that a tumor have a significant volume of cancer cells. Advances in diagnostic techniques and technology may allow for cancer detection at earlier stages, when the tumor burden is smaller and potentially more curable. The molecular techniques of polymerase chain reaction (PCR) and reverse transcriptase PCR (RT-PCR) are highly sensitive methods for detecting a small number of cancer cells. Over the past few years, numerous clinical studies have used PCR techniques to detect physical alterations of genes, such as mutations, deletions, translocations and amplification, the presence of oncogenic viruses, and the expression of genes specific to tissue, cancer, and metastasis. The current status of PCR as a method for detecting marker genes in the management of solid tumors is reviewed.

METHODS

A review of the literature on the clinical utility of PCR and RT-PCR in the detection of solid tumor micrometastasis was conducted.

RESULTS

Amplification by PCR is a highly sensitive method to determine gene expression. A single cell expressing a tumor marker among 10-100 million lymphocytes can be detected by the PCR assay. This approach has been used to detect tumor cells in approximately 18 different solid tumor types, with melanoma and carcinoma of the breast and prostate the most widely investigated to date. PCR-based assays have been used to detect cancer cells in biopsies of solid tissue, lymph nodes, bone marrow, peripheral blood, and other body fluids. Several studies have reported a high specificity and sensitivity of tumor marker detection and a high correlation between PCR results and the presence of metastatic disease. However, in a few studies, PCR assays have not consistently demonstrated a higher sensitivity and specificity of detection than traditional modalities for many types of cancer. There has been a wide range in sensitivity and specificity among the studies, which may be partly attributed to the lack of uniformity among the PCR protocols used in different studies.

CONCLUSIONS

PCR can detect tumor marker-expressing cells that are otherwise undetectable by other means in patients with localized or metastatic cancer. Reports from various study groups have lacked uniformity in their protocols, and this has prevented adequate comparison. The clinical utility of this assay as a tool for the prognosis and management of cancer patients remains and area of active investigation. PCR is a powerful tool in the study of the biology of cancer metastasis and will likely serve as a useful adjunct to clinical decision-making in the future.