Human papillomavirus status in extragenital nonmelanoma skin cancers

The role of HPV in keratinocyte skin cancer development: A systematic review

Keratinocyte skin cancers are the most frequent malignancy, accounting for approximately 30% of all cancers. Although beta genus HPV are the main etiologic agents for squamous cell carcinoma development in patients with epidermodysplasia verruciformis and organ transplant recipients, their role in non-melanoma skin cancer (NMSC) progression in the general population remains controversial. The aim of our review is to summarize current scientific data and to systematically analyse evidence regarding the role of HPV in keratinocyte skin cancers. A total of 2284 patients were included, of which 724 with actinic keratoses, 290 with Bowen's disease, 949 with cutaneous squamous cell carcinomas and 321 with keratoacanthomas. In the case of actinic keratoses, the majority were positive for beta (n = 372, 58.49%) and gamma HPV (n = 256, 40.25%) and only a few (n = 6, 0.94%) were positive for alpha subtypes. Similarly, most of the cutaneous squamous cell carcinomas were positive for beta (n = 248, 55.98%) and gamma HPV (n = 172, 33.82%) and 23 cases (2.42%) were positive for alpha subtypes. Bowen's disease lesions were mostly positive for beta (n = 43, 55.84%) and alpha HPV (n = 30, 38.96%), in contrast to the gamma genus (n = 4, 5.19%). Keratoacanthomas showed a high distribution among beta genus (n = 79, 50.31%) and an equal proportion between alpha (n = 39, 24.84%) and gamma (n = 39, 24.84%) genera. Studies published so far identifying HPV in keratinocyte skin cancers reflect the difference in detection methods rather than a type-specific tendency towards either actinic keratoses, Bowen's disease, squamous cell carcinoma or keratoacanthoma. On the other hand, recent evidence regarding the role of HPV vaccination in patients with non-melanoma skin cancer brings into perspective the idea of a beta-HPV vaccine or a combined alpha and beta-HPV vaccine that could be used as an adjuvant treatment measure in patients with recalcitrant non-melanoma skin cancer.

Off-Label 9-Valent Human Papillomavirus Vaccination for Actinic Keratosis: A Case Series

Background

The suspected link between human papillomavirus (HPV) and the development of premalignant and malignant skin lesions remains inadequately examined in clinical settings. This case series describes HPV vaccination as an off-label adjuvant therapy for actinic keratosis (AK).

Methods

Twelve immunocompetent AK patients underwent HPV vaccination at a private dermatology clinic in Naestved, Denmark. Prior to vaccination, all patients demonstrated a high AK burden that required regular control visits. At 0, 2, and 6 months, the patients received an intramuscular injection of a commercially available 9-valent HPV vaccine. Concurrently, patients continued conventional AK therapies at 3-month intervals. Clinical response, consisting of reduction in AK number and general change in skin appearance, was assessed by a dermatologist over 12 months following first vaccination.

Results

All patients (mean age 76.2 years; 10 M and 2 F) completed the vaccine schedule. Overall, an average 85% reduction in total AK burden was recorded 12 months after beginning vaccination. Median AK burden thus fell from 56 (IQR: 44–80) to 13.5 (IQR: 1–18) lesions after 12 months. Lesion reduction was observable by the second inoculation at month 2 (34 AKs; IQR 22–80), continuing steadily until month 6 (15 AKs; IQR 5–30) and plateauing between 6 and 12 months. Clinically, HPV vaccination elicited fading of lesions' erythematous background after the first dose, often followed by sloughing of hyperkeratotic elements in subsequent weeks. Patients reported no adverse effects related to HPV vaccination.

Conclusion

This case series introduces the possibility that 9-valent HPV vaccination in combination with conventional treatments may be used as a therapeutic strategy for AK.

Human Papillomavirus (HPV)-Associated Squamous Cell Carcinoma In situ With Positive p16 and Ki-67 Immunohistochemical Stains in a Young Immunocompetent Patient

There is an oncogenic role of human papillomavirus (HPV) in the development of premalignant and malignant skin cancers, especially squamous cell carcinomas (SCCs). Some of the major risk factors for SCC include older age, fair skin types, immunosuppression, ultraviolet radiation (UVR), history of epidermodysplasia verruciformis (EV), and co-carcinogenesis by the HPV. Our case report exemplifies a unique case of a low-risk, 34-year-old female who developed an HPV-associated squamous cell carcinoma in situ (SCCIS) on her left palmar hand, despite having none of the contributing risk factors. The biopsy also showed full-thickness keratinocyte atypia and increased mitotic activity throughout all the layers of the epidermis. Immunohistochemical stains showed strong and diffuse nuclear staining of p16 and Ki-67 throughout the SCCIS, confirming HPV etiology. We speculate that tumor development in our patient relied on the combined effects of UVR exposure, localized immunosuppression, and the co-carcinogenic effects of HPV infection.

Combined Systemic and Intratumoral Administration of Human Papillomavirus Vaccine to Treat Multiple Cutaneous Basaloid Squamous Cell Carcinomas

Importance

Squamous cell carcinoma (SCC) is the second most common form of skin cancer, and its incidence is increasing. When surgical management is not an option, finding a safe and efficacious treatment is a challenge. Mounting evidence suggests that the human papillomavirus (HPV) is involved in the pathogenesis of some SCCs.

Objective

To assess whether the 9-valent HPV vaccine could be an effective treatment strategy for cutaneous SCC.

Design, Setting, and Participants

A woman in her 90s with multiple, inoperable cutaneous basaloid SCCs was successfully treated at a university-based outpatient dermatology clinic with a combination of systemic and intratumoral delivery of the 9-valent HPV vaccine from March 17, 2016, through February 27, 2017, and then followed up through May 21, 2018.

Main Outcomes and Measures

Reduction in tumor size and number after a combination of systemic and intratumoral administration of the HPV vaccine.

Results

All tumors resolved 11 months after the first intratumoral injection of the vaccine. The patient remained free of tumors at the end of follow-up.

Conclusions and Relevance

This is the first report, to our knowledge, of complete regression of a cutaneous malignant tumor after combined systemic and direct intratumoral injection of the 9-valent HPV vaccine. This report suggests that the HPV vaccine may have therapeutic utility for SCCs in patients who are poor surgical candidates, have multiple lesions, or defer surgery.

Interplay Between the Immunohistochemical Expression of P53 and the Proliferation Index in the Keratinocyte Tumors of the Skin

P53 is important for cell cycle regulation, and its overexpression is seen in malignant tumors. We examined correlation between p53 expression and cell proliferation, and its role in the pathogenesis of keratinocyte skin tumors. We used biopsies from patients with squamous cell carcinoma, actinic keratosis and keratoacanthoma. We examined crosssections stained with HE and using anti-cytokeratin, antip53 and anti-Ki67 antibodies.

Expression of p53 is found in 87, 85% of SCC, in 83. 3% of AK and 13. 4% KA. The high index of p53 expression was higher in SCC and AK compared to KA. We also observed a positive correlation between the expression of p53 and localization of the tumors. The largest proportion of subjects with AK and SCC has a high index of p53 expression on photoexposed region. We also observed that p53 expression correlates with age whereby in AK p53 expression increases with age. The high index of proliferation is most frequent in SCC and KA. Also at AK we found a strong correlation between a moderate proliferation index and tumor localization in photoexposed region. Between the proliferation index and p53 expression we observed a significant positive correlation only in SCC.

Proliferation index and the expression of p53 are useful for the differentiation of precursor keratinocyte lesions and skin carcinoma. High p53 expression has been associated with the aging and significantly correlates with the exposure to UV radiation in SCC and AK. High expression of p53 in AK and SCC supports the importance of this oncoprotein in carcinogenesis of the skin.

Association of Human Papillomavirus Vaccine With the Development of Keratinocyte Carcinomas

Importance

Keratinocyte carcinomas (KCs), consisting of squamous cell carcinomas (SCCs) and basal cell carcinomas (BCCs), are the most common human malignant neoplasms. Several risk factors have been implicated in KC development. For some SCCs, particularly those in immunocompromised patients, human papillomavirus (HPV) may be an important factor.

Objective

To determine whether quadrivalent HPV vaccination would affect the development of KCs in immunocompetent patients with a history of multiple KCs.

Design, Setting, and Participants

Two patients with a history of multiple KCs-a man in his 70s (patient 1) and a woman in her 80s (patient 2)-were treated in a private dermatology practice. Each patient received 3 doses of the quadrivalent HPV vaccine at 0, 2, and 6 months in 2013, and both patients underwent full-body skin examinations at least every 3 months. Biopsy-proven skin cancers were recorded for 16 months (for patient 1) or 13 months (for patient 2) after the first dose of vaccine and then compared with the number of biopsy-proven skin cancers recorded over a similar period before the first dose of vaccine. The period of observation was from October 18, 2011, to June 21, 2014.

Main Outcomes and Measures

The numbers of new SCCs and BCCs after the first dose of the quadrivalent HPV vaccine.

Results

Patient 1 had a mean of 12 new SCCs and 2.25 new BCCs per year before vaccination. After vaccination, he developed 4.44 SCCs and 0 BCCs per year, a 62.5% reduction in SCCs and a 100% reduction in BCCs. Patient 2 had a mean of 5.5 new SCCs and 0.92 new BCCs per year before vaccination. After vaccination, she developed 1.84 SCCs and 0 BCCs per year, a 66.5% reduction in SCCs and a 100% reduction in BCCs. The quadrivalent HPV vaccine was well tolerated by both patients and had no adverse effects.

Conclusions and Relevance

A reduction of SCCs and BCCs was observed in 2 patients after administration of the quadrivalent HPV vaccine. These findings highlight the possibility that cutaneous SCC development, and perhaps BCC development, may be driven in part by HPV in immunocompetent patients. Human papillomavirus vaccination may represent an efficacious, cost-effective, readily available, and well-tolerated strategy for preventing KCs.