Human papillomaviruses 6/11, 16/18 and 31/33/51 are not associated with squamous cell carcinoma of the urinary bladder

The association between the human papillomavirus (HPV) and the diagnosis of bladder cancer: systematic review and meta-analysis

BACKGROUND

Bladder cancer (BC) is the seventh most common cancer worldwide. Not every infection ends as cancer, although the HPV-induced carcinogenesis is a complex process consequence of inflammation. To determine the association between human papillomavirus (HPV) and the diagnosis of bladder cancer.

METHODS

We carried out a systematic review according to Cochrane and PRISMA recommendations. We searched in EMBASE, Medline (Ovid), and The Cochrane Central Register of Controlled Trials (CENTRAL), from inception to nowadays. We included case-control studies. The risk of bias assessment was performed based on QUADAS2. We performed a random effect Meta-analysis.

RESULTS

We included 14 studies in qualitative and quantitative analysis. There was mainly a low risk of bias. We finally found a strong association between the presence of HPV and bladder cancer diagnosis (OR 4.18 95%CI 2.63-6.66; I2 = 40%).

CONCLUSIONS

HPV is currently associated with the diagnosis of bladder cancer.

The association between human papillomavirus and bladder cancer: Evidence from meta-analysis and two-sample mendelian randomization

INTRODUCTION

Bladder cancer (BCa) is the 10th most common type of cancer worldwide, and human papillomavirus (HPV) is the most common sexually transmitted infection. However, the relationship between HPV infection and the risk of BCa is still controversial and inconclusive.

METHODS

This systematic review and meta-analysis were conducted following the PRISMA 2020 reporting guideline. This study searched four bibliographic databases with no language limitation. The databases included PubMed (Medline), EMBASE, Cochrane Library, and Web of Science. Studies evaluating the interaction between HPV infection and the risk of BCa from inception through May 21, 2022, were identified and used in this study. This study estimated the overall and type-specific HPV prevalence and 95% confidence intervals (95% CI) using Random Effects models and Fixed Effects models. In addition, this study also calculated the pooled odds ratio and pooled risk ratio with 95% CI to assess the effect of HPV infection on the risk and prognosis of bladder cancer. Two-sample mendelian randomization (MR) study using genetic variants associated with HPV E7 protein as instrumental variables were also conducted.

RESULTS

This study retrieved 80 articles from the four bibliographic databases. Of the total, 27 were case-control studies, and 53 were cross-sectional studies. The results showed that the prevalence of HPV was 16% (95% CI: 11%-21%) among the BCa patients, most of which were HPV-16 (5.99% [95% CI: 3.03%-9.69%]) and HPV-18 (3.68% [95% CI: 1.72%-6.16%]) subtypes. However, the study found that the prevalence varied by region, detection method, BCa histological type, and sample source. A significantly increased risk of BCa was shown for the positivity of overall HPV (odds ratio [OR], 3.35 [95% CI: 1.75-6.43]), which was also influenced by study region, detection method, histological type, and sample source. In addition, the study found that HPV infection was significantly associated with the progression of BCa (RR, 1.73 [95% CI: 1.39-2.15]). The two-sample MR analysis found that both HPV 16 and 18 E7 protein exposure increased the risk of BCa (HPV 16 E7 protein: IVW OR per unit increase in protein level = 1.0004 [95% CI: 1.0002-1.0006]; p = 0.0011; HPV 18 E7 protein: IVW OR per unit increase in protein level = 1.0003 [95% CI: 1.0001-1.0005]; p = 0.0089).

CONCLUSION

In conclusion, HPV may play a role in bladder carcinogenesis and contribute to a worse prognosis for patients with BCa. Therefore, it is necessary for people, especially men, to get vaccinated for HPV vaccination to prevent bladder cancer.

Prevalence of Human Papilloma Virus Infection in Bladder Cancer: A Systematic Review

The etiology of bladder cancer is known to be associated with behavioral and environmental factors. Moreover, several studies suggested a potential role of HPV infection in the pathogenesis with controversial results. A systematic review was conducted to assess the role of HPV. A total of 46 articles that reported the prevalence of HPV infection in squamous (SCC), urothelial (UC), and transitional cell carcinomas (TCC) were selected. A pooled prevalence of 19% was found, with a significant difference in SCC that was mainly driven by HPV-16. Moreover, infection prevalence in case-control studies showed a higher risk of bladder cancer in HPV-positive cases (OR: 7.84; p-value < 0.00001). The results may suggest an etiologic role of HPV in bladder cancer. HPV vaccine administration in both sexes could be key to prevent the infection caused by high-risk genotypes.

Bladder cancer and human papillomavirus association: a systematic review and meta-analysis

BACKGROUND

The possible association of human papillomavirus (HPV) and bladder cancer has been controversial. Older findings suggest a significant association between the virus and bladder cancer. The aim of this study was to evaluate the data from the last ten years to estimate the prevalence of the virus in bladder cancer patients and to assess the association between the virus and cancer.

METHOD

A search of major databases was conducted to retrieve published English language studies between January 2011 and March 2021. In the present study overall prevalence of the virus in bladder cancer patients was estimated along with the prevalence of subgroups. Also, the possible associations between the prevalence of the virus and bladder cancer and the possible impact of variables in the geographical area and the type of sample were measured by comprehensive meta-analysis software (V2.2, BIOSTAT).

RESULTS

Unlike previous studies, despite the relatively high prevalence of the virus [pooled prevalence: 14.3% (95% CI 8.9-22.2%)] no significant association was found between HPV and bladder cancer (OR 2.077, 95% CI 0.940-4.587). No significant association was found between geographical area (except Asia) and type of sample with bladder cancer.

CONCLUSIONS

Given the significant prevalence, despite the insignificance of the association between virus and cancer, it seems that more studies with case-control design are needed to elucidate this association.

Prevalence of high-risk human papillomavirus in primary squamous cell carcinoma of urinary bladder

Studies have demonstrated an etiologic role of high-risk human papillomavirus (HR-HPV) infection for epithelial malignancies, including most cervical carcinomas, anogenital cancers, and carcinomas of the head and neck; however, a causative role of HPV infection for bladder cancer is controversial. The purpose of this study was to investigate the prevalence of HR-HPV in primary bladder carcinoma to determine the association between HPV infection and the squamous cell component of urothelial carcinoma of the bladder. Furthermore, we evaluated the utility of p16 overexpression as a surrogate marker for HPV infection in these cancers and the correlation of this with tumor stage. Our study included 33 cases of squamous cell carcinoma (SCC) of the urinary bladder. Tumors deemed primary from the bladder were selected and either showed predominant (>50 %) or pure squamous differentiation. Immunohistochemical study for p16 and HR-HPV by RNA in situ hybridization (ISH) was performed in all cases. p16 expression was detected in 7 cases (28 %, 7/25) of urothelial carcinoma with squamous differentiation and not detected in any of the 8 cases (0%, 0/8) of pure SCC. Detection of HR-HPV by ISH was negative in all 33 cases (0%, 0/33). There was no association between p16 overexpression and the presence of HPV infection in squamous cell carcinomas of the bladder. p16 should not be used as a surrogate marker for evidence of HPV infection. Our study suggests that HPV infection does not play an etiologic role in the development of bladder cancer and should not be used as a diagnostic adjunct for these cases.

Human papillomavirus and urinary bladder cancer revisited

This review aims to present data on the association between human papillomavirus (HPV) and urinary bladder cancer (BC), especially of the subtype squamous cell carcinoma (SCC). Furthermore, the current data on the relation between p16, HPV, and BC are reviewed. PubMed was searched for 'Humans' [MESH] AND 'Papillomaviridae' [MESH] AND 'Urinary Bladder Neoplasms' [MESH], resulting in 157 potential articles. After profound reviewing, 18 articles were included in this review. Only original articles in English were included. A variable number of HPV genotypes in a small number of cases have been investigated in several studies with various methodology. HPV was present in 0-100% of cases depending on inclusion and exclusion criteria. SCC studies are mostly hampered by low number of cases whereas the few studies with a high number show a slightly higher prevalence of different HPV genotypes compared to pure urothelial carcinoma. Studies on p16 status in HPV positive cases are even more scarcely reported and show conflicting results. Most studies fail to prove clear-cut relevance of HPV in BC irrespectively of histological subtype. Negative p16 staining cannot rule out positive HPV status.

Human papillomavirus types 44, 52, 66 and 67 detected in a woman with squamous cell carcinoma of the urinary bladder

Human papillomavirus (HPV) is an accepted causative agent in cervical cancer of the uterus, penile cancer, anal cancer and oropharyngeal carcinomas, while its role in other cancers such as urinary bladder cancer is still much discussed. This report presents a patient with multiple HPV types in a squamous cell carcinoma of the urinary bladder.

Squamous cell carcinoma of the urinary bladder: Systematic review of clinical characteristics and therapeutic approaches

OBJECTIVE

To highlight the current understanding of the epidemiology, clinicopathological characteristics, and management of squamous cell carcinoma (SCC) of the bladder, as it accounts for 2-5% of bladder tumours, with a focus on non-bilharzial-associated SCC (NB-SCC). The standard treatment for bladder SCC remains radical cystectomy (RC). We present an updated clinical profile of bladder SCC and a review of NB-SCC therapeutic approaches, including RC, neoadjuvant and adjuvant treatments, radiotherapy, chemotherapy, and immunotherapy.

METHODS

Using search terms relating to SCC, urinary bladder, and treatment modalities, we performed a search of the PubMed and Embase databases to identify NB-SCC treatment approaches and outcomes. Peer-reviewed English language reports from 1975 to present assessing SCC management were included. Two authors independently screened and extracted the data.

RESULTS

Of the 806 articles screened, 10 met the pre-defined inclusion criteria. RC was performed in seven of the 10 studies. Although radiotherapy alone yielded poor outcomes, preoperative radiotherapy and RC were associated with improved survival. There is little evidence supporting the use of chemotherapy in NB-SCC, and its efficacy in relation to RC is not known.

CONCLUSION

Based on current literature, there is insufficient evidence to provide a treatment recommendation for NB-SCC. Whilst RC is the standard of care, the role of preoperative radiotherapy should be revisited and compared to RC alone. Additional studies incorporating multimodal approaches, contemporary radiation techniques, and systemic therapies are warranted. Immunotherapy as a treatment for bladder SCC has yet to be investigated.

Role of Viral Infection in the Aetiology-Pathogenesis of Bladder Tumor: A Reality or Chimera?

The possible role of human papillomavirus (HPV) in the aetiology of papillary tumor of the bladder has been evaluated and a review of the literature concerning this issue was made. A group of 17 patients affected by bladder papillary tumor was analysed. Surgical specimens were collected for virological and histological analysis. The DNA of the following viruses was searched by polymerase chain reaction (PCR): Adenovirus, Herpes simplex virus type 1 (HSV-1), Herpes simplex virus type 2 (HSV-2), Human Papillomaviruses (HPV), Polyomaviruses (BKV and JCV). The results showed that 15/17 (88 %) patients with papillary bladder tumor were found negative for each viral-searched DNA; only one sample was positive for HPV (6 %) genotype 6, which is considered to convey a low risk for cancer development and only one was positive for BKV (6 %). From the results obtained there seems to be no relationship between viral infection and the presence of bladder papillary tumor. Moreover, in the examined population the association bladder carcinoma-HPV, found by others, has not been confirmed. The homogeneity of the specimens studied was such that it would not be affected by the temporal factor, as were cases of more or less advanced cancers. Nonetheless specimens from patients with advanced cancers (G III) were negative to HPV infection. The data do not appear indicative for a correlation between viral DNA presence and histological parameters. Thus, in the light of the data emerging from this investigation, no causal relationship can be established between HPV infection and papillary bladder tumors.

Carcinoma of the Uterine Cervix Involving the Genitourinary Tract: A Potential Diagnostic Dilemma

Uterine cervical carcinoma secondarily involving the genitourinary tract is rarely documented histologically. These tumors present a unique diagnostic challenge as they can appear morphologically similar to urothelial carcinoma as well as primary squamous cell carcinoma and primary adenocarcinoma of the bladder. Genitourinary consult cases at the Johns Hopkins Hospital from 1984 to the present were searched for cases in which the differential diagnosis was primary bladder carcinoma versus secondary involvement by cervical carcinoma. We identified 10 cases that met these criteria and evaluated them by immunohistochemistry for p16 and GATA3 and in situ hybridization for human papillomavirus (HPV). Six cases were received with a gynecologic history. Four cases had been misdiagnosed as urothelial carcinoma, and 1 case was favored to be cystitis cystica et glandularis by the submitting institutions. Morphologically, the majority of cases showed basaloid nests of tumor cells infiltrating muscle bundles, with several having foci that mimicked urothelial carcinoma in situ. Six tumors were found to be diffusely positive with p16, 1 tumor was patchy, 1 was weak, and 2 were negative. GATA3 staining was negative in 6 cases, and 4 showed weak to strong positivity. Eight cases were positive for high-risk HPV (6 were positive for HPV 16, and 1 was positive for HPV 18). In the 2 cases that were negative for HPV by in situ hybridization, characteristic morphologic features of HPV-unrelated type of endocervical adenocarcinoma were present. On the basis of our findings we advocate a multifaceted approach, combining morphologic evaluation with ancillary studies including immunohistochemistry and in situ hybridization in the evaluation of genitourinary specimens for secondary involvement by cervical carcinoma. Furthermore, gynecologic clinical history is absolutely critical and most important to the evaluation and diagnosis of these specimens, as these ancillary studies are not completely sensitive or specific.

Human papillomavirus infection and pathogenesis in urothelial cells: a mini-review

Several recent studies described that high-risk human papillomavirus (HPV) infection could have a potential role in the development of malignancies other than cervical cancer, such as laryngeal carcinoma, penile carcinoma, and anal carcinoma. However, the etiological role of HPV infection in the pathogenesis of urinary tract has not been clarified. Many epidemiological studies demonstrated that HPV infections frequently occur in the external genitalia through sexual contact; however, it was reported that HPV infection could also occur in the urinary tract, including the urethra and urinary bladder. Some morphological changes of cells associated with HPV infection and mild atypical cells, suspected to be intraneoplasia, were seen in HPV-positive samples obtained from the urinary tract. Some clinical studies and meta-analysis have indicated that HPV infection is likely to have a certain etiological correlation with the development of bladder carcinoma, although its prevalence may vary according to HPV type, study population, region, histological type, detection methods, and other variables. According to the results of previous studies, the prevalence of HPV greatly widely varies in cases of bladder carcinoma. Further research by case-control or large-scales studies is thus required to reach a more definite conclusion.

Best practices recommendations in the application of immunohistochemistry in the bladder lesions: report from the International Society of Urologic Pathology consensus conference

The bladder working group of the 2013 International Society of Urologic Pathology (ISUP) Conference on Best Practices Recommendation in the Application of Immunohistochemistry (IHC) in Urologic Pathology discussed 5 settings in which IHC is commonly used in clinical practice. With regard to markers for urothelial differentiation, the committee found that there is no ideal marker or established panel to confirm urothelial differentiation. On the basis of the differential diagnostic consideration, positivity for GATA3, CK20, p63, and either high-molecular weight cytokeratin (HMWCK) or cytokeratin (CK)5/6 is of value in proving urothelial differentiation in the appropriate morphologic and clinical context. With regard to the role of IHC in the distinction of reactive atypia from urothelial carcinoma in situ, the committee recommended that morphology remains the gold standard in this differential diagnosis and that, at best, the IHC panel of CK20/p53/CD44(s) has potential utility but is variably used and has limitations. The immunostaining pattern must be interpreted with strict morphologic correlation, because overreliance on IHC may be misleading, particularly in the posttreatment setting. IHC has no role in the distinction of dysplasia versus carcinoma in situ and in the grading of papillary urothelial carcinoma. IHC may have a limited but distinct role in staging of bladder cancer. In a subset of cases, depending on the clinical and histologic context, broad-spectrum cytokeratins (to identify early or obscured invasion) and desmin (distinction of muscle from desmoplasia and to highlight muscle contours for subclassification) may be helpful. Limited experience and conflicting data preclude smoothelin or vimentin to be recommended routinely for subclassifying muscle type at this time. In the workup of a spindled cell proliferation of the bladder and in limited specimens, we recommend an immunohistochemical panel of 6 markers including ALK1, SMA, desmin, cytokeratin (AE1/AE3), and p63 with either of HMWCK or CK5/6. Currently, there are no prognostic immunohistochemical or molecular studies that are recommended to be routinely performed on biopsy or resection specimens.

HRAS mutations are frequent in inverted urothelial neoplasms

Inverted urothelial papilloma (IUP) is an uncommon neoplasm of the urinary bladder with distinct morphologic features. Studies regarding the role of human papillomavirus (HPV) in the etiology of IUP have provided conflicting evidence of HPV infection. In addition, little is known regarding the molecular alterations present in IUP or other urothelial neoplasms, which might demonstrate inverted growth pattern like low-grade or high-grade urothelial carcinoma (UCA). Here, we evaluated for the presence of common driving somatic mutations and HPV within a cohort of IUPs, (n = 7) noninvasive low-grade papillary UCAs with inverted growth pattern (n = 5), and noninvasive high-grade papillary UCAs with inverted growth pattern (n = 8). HPV was not detected in any case of IUP or inverted UCA by either in situ hybridization or by polymerase chain reaction. Next-generation sequencing identified recurrent mutations in HRAS (Q61R) in 3 of 5 IUPs, described for the first time in this neoplasm. Additional mutations of Ras pathway members were detected including HRAS, KRAS, and BRAF. The presence of Ras pathway member mutations at a relatively high rate suggests this pathway may contribute to pathogenesis of inverted urothelial neoplasms. In addition, we did not find any evidence supporting a role for HPV in the etiology of IUP.

The expression patterns of p53 and p16 and an analysis of a possible role of HPV in primary adenocarcinoma of the urinary bladder

BACKGROUND

Primary adenocarcinoma of the urinary bladder is rare. The molecular and cellular events leading to its pathogenesis are not well delineated. The goal of this study was to investigate p53 and p16 expression, as well as HPV status, in a relatively large series of primary bladder adenocarcinomas.

MATERIALS AND METHODS

Thirty six cases of urinary bladder adenocarcinoma were chosen from participating institutions. The diagnosis and available clinical history were reviewed in each case. Immunostains for p53, p16 and HPV and high-risk and low-risk HPV-ISH were performed on all tumors.

RESULTS

Patients had an average age of 61 years with a male predominance (1.5 ∶ 1 male ∶ female ratio). The average tumor size in cystectomy specimens was 4.3 cm. Of the cases managed by transurethral resection, 40% were pT2 at the time of diagnosis. In cystectomy specimens, 77% were either pT3 or pT4. Strong nuclear p16 expression was seen in 67% of all cases and p53 expression was present in 58% of the cases. Expression of both markers was seen in 33% of cases. Expression of p16 or p53 alone was present in 12 (33%) and 9 (25%) cases, respectively. Neither marker was expressed in only 3 (8%) of the tumors. No significant correlation between clinical variables and any of the markers we studied was identified. No HPV infection was detected in any case.

CONCLUSIONS

Expression of p53 and/or p16 is very common in urinary bladder adenocarcinoma. These findings implicate a high likelihood that alterations in these cell cycle proteins contribute to the pathogenesis of these tumors. Despite frequent immunohistochemical labeling for p16, no evidence of HPV infection was found.

[Squamous cell lesions of the urinary bladder]

BACKGROUND

Squamous cell carcinoma (SCC) and transitional carcinoma with squamous differentiation (SCC/TCC) are rare in western countries. Chronic inflammation and irritation of the urothelium are common risk factors for the development of SCC and TCC/SCC. Tumour biology of squamous cell cancer and precancerous squamous lesions is different from transitional cell cancer (TCC). Recent advances in molecular analysis of benign and malignant squamous cell lesions indicate that they are closely associated and might lead to improved bladder cancer subclassification in the future.

AIM

At present, the clinical management and therapy of SCC remains challenging, as scientific evidence based on prospective clinical trials is not available. We performed an analysis of available literature on natural history, treatment, and prognosis of SCC, SCC/TCC and metaplastic lesions. Furthermore, recent findings in molecular cancer biology are discussed with a focus on their relevance for SCC carcinogenesis.

Human papillomavirus is not an etiologic agent of urothelial inverted papillomas

Inverted papilloma of the urinary bladder is rare, accounting for <1% of all bladder neoplasms. Although there is general consensus that inverted papilloma is benign in nature, little is known about its pathogenesis. Some have suggested that human papillomavirus (HPV) plays an etiologic role in the development of this neoplasm. These claims have not been adequately substantiated, and there is controversy as to the role of HPV in other urinary bladder neoplasms as well. To further investigate a possible etiologic role of HPV in urothelial neoplasia, we evaluated 27 inverted papillomas of the urinary bladder for the presence of HPV. Both immunohistochemical and in situ hybridization (ISH) studies for HPV and immunohistochemical analysis for p16, a surrogate marker for HPV infection, were used to assess HPV infection status. In the urinary bladder inverted papillomas of these 27 patients (age range, 35 to 78 y; M:F ratio, 11:1), no HPV was detected by HPV immunohistochemistry or by ISH. Immunoreactivity to p16 was detected in 11/27 (41%) of the cases. Expression of p16 is seen inconsistently within these neoplasms and does not correlate with the presence of HPV antigens or genes by immunohistochemistry or ISH, respectively. Therefore, p16 is not a reliable surrogate marker for HPV infection in urothelial inverted papilloma. Our findings indicate the absence of HPV in urothelial inverted papillomas. HPV testing should not be used as a diagnostic adjunct for inverted papilloma cases.

Squamous cell carcinogenesis and squamous cell carcinoma of the urinary bladder: a contemporary review with focus on nonbilharzial squamous cell carcinoma

Bladder squamous cell carcinoma, squamous metaplasia, and transitional cell carcinoma with squamous differentiation are infrequent findings in Western countries. A common risk factor for their development consists of chronic bladder irritation and inflammation. The prognostic and clinical relevance and natural history of squamous cell lesions has been under investigation, revealing individual premalignant characteristics. Recent developments in molecular characterization of squamous alterations of the urinary tract indicate pathogenetic similarities and interrelations and might lead to more precise tumor classification and risk stratification in the future. Nevertheless, current clinical management of patients with premalignant and malignant bladder squamous cell lesions remains challenging, as high evidence level studies are not available and prognosis of invasive squamous carcinoma is poor. Our review summarizes the available data on clinical presentation, treatment, and outcome of bladder squamous cell carcinoma, metaplastic lesions, and transitional cell carcinoma with squamous differentiation and discusses implementable current advances in the understanding of bladder cancer tumorigenesis.

Urothelial carcinoma with prominent squamous differentiation in the setting of neurogenic bladder: role of human papillomavirus infection

Squamous cell carcinomas of the urinary bladder are rare in the Western world; the majority of cases are reported in countries endemic to Schistosoma parasitic infections. Unlike squamous tumors of the uterine cervix or oropharynx, the human papillomavirus (HPV) is not commonly associated with bladder squamous cell carcinomas. We report on two cases of HPV-positive urothelial carcinomas of the urinary bladder with extensive squamous differentiation showing the typical basaloid, poorly differentiated morphology of HPV-associated tumors. These occurred in patients with neurogenic bladders who had long-standing histories of self-catheterization with tumors that tested positive for HPV by in situ hybridization. A retrospective review of our institutional database revealed four additional patients with bladder tumors showing squamous differentiation arising in the setting of neurogenic bladder. Review of these cases showed the more common well-differentiated keratinizing appearance of squamous cell carcinomas of the bladder. These tumors showed only patchy positivity for p16 immunohistochemical stain (not the diffuse strong staining seen in HPV-positive tumors), and the one tested case was negative for HPV by in situ hybridization. HPV infection and neurogenic bladder have been independently associated with increased risk of developing carcinoma in the urinary bladder; however, this is the first report of squamous tumors arising in the setting of concurrent neurogenic bladder and HPV infection. The morphology of these tumors is similar to that of other high-risk HPV-associated squamous carcinomas with a basaloid, poorly differentiated appearance and little to no keratin formation.

p16 expression is not associated with human papillomavirus in urinary bladder squamous cell carcinoma

Squamous cell carcinoma of the urinary bladder is unusual and of unknown etiology. There is a well-established association between human papillomavirus (HPV) infection and the development of cervical and head/neck squamous cell carcinomas. However, the role of HPV in the pathogenesis of squamous cell carcinoma of the urinary bladder is uncertain. The purposes of this study were to investigate the possible role of HPV in the development of squamous cell carcinoma of the urinary bladder and to determine if p16 expression could serve as a surrogate marker for HPV in this malignancy. In all, 42 cases of squamous cell carcinoma of the urinary bladder and 27 cases of urothelial carcinoma with squamous differentiation were investigated. HPV infection was analyzed by both in situ hybridization at the DNA level and immunohistochemistry at the protein level. p16 protein expression was analyzed by immunohistochemistry. HPV DNA and protein were not detected in 42 cases of squamous cell carcinoma (0%, 0/42) or 27 cases of urothelial carcinoma with squamous differentiation (0%, 0/15). p16 expression was detected in 13 cases (31%, 13/42) of squamous cell carcinoma and 9 cases (33%, 9/27) of urothelial carcinoma with squamous differentiation. There was no correlation between p16 expression and the presence of HPV infection in squamous cell carcinoma of the bladder or urothelial carcinoma with squamous differentiation. Our data suggest that HPV does not play a role in the development of squamous cell carcinoma of the urinary bladder or urothelial carcinoma with squamous differentiation. p16 expression should not be used as a surrogate marker for evidence of HVP infection in either squamous cell carcinoma of the urinary bladder or urothelial carcinoma with squamous differentiation as neither HVP DNA nor protein is detectable in these neoplasms.

Etiologic role of human papillomavirus infection in bladder carcinoma

BACKGROUND

The authors elucidated an etiologic role of human papillomavirus (HPV) infection in carcinoma of the bladder.

METHODS

One hundred seventeen of 224 patients with bladder carcinoma who were treated between 1997 and 2009 were enrolled in this study. The presence of HPV DNA was tested on frozen carcinoma tissues that were obtained by transurethral resection using a polymerases chain reaction-based method. Localization of HPV was observed on archival tissue specimens by in situ hybridization (ISH) for high-risk HPV DNA. Cyclin-dependent kinase (CDK) inhibitor 2A (inhibits CDK4) (p16-INK4a) and minichromosome maintenance protein-7 (mcm-7)-surrogate markers for high-risk HPV-E7 oncoprotein-and HPV-L1 (capsid) protein expression were evaluated by immunohistochemistry.

RESULTS

HPV types 16, 18, 31, 33, 52, and 58, and an unknown HPV type were detected in 18 of 117 samples (15%) from patients with bladder carcinoma. HPV16 was identified in 6 samples, HPV18 was identified in 4 samples, and HPV33 was identified in 3 samples. All were single HPV type infections. HPV was detected in 38% (12 of 28) of histologic grade 1 bladder carcinomas, 8.5% (6 of 71) of grade 2 bladder carcinomas, and in 0% (0 of 18) of grade 3 bladder carcinomas. Multivariate analysis indicated that younger age (<60 years; odds ratio [OR], 10.9; 95% confidence interval [CI], 2.6-45.3) and grade 1 tumors (OR, 4.5; 95% CI, 1.2-17.0) were associated with HPV infection. ISH analysis indicated that high-risk HPV DNA was localized in the nuclei of tumor cells of all HPV-positive samples. p16-INK4a and mcm-7 were expressed in 94% and 89% of HPV-positive carcinoma cells, respectively. HPV-L1 protein expression, which suggested reproductive HPV infection, was not observed in any carcinoma.

CONCLUSIONS

The current results indicated that high-risk HPV is likely to be a causative agent of some low-grade bladder carcinomas that develop in younger patients.

Vaccination against human papilloma virus (HPV): epidemiological evidence of HPV in non-genital cancers

Recently, the vaccine against human papillomavirus (HPV) was introduced in the national vaccination programmes of several countries worldwide. The established association between HPV and the progression of cervical neoplasia provides evidence of the expected protection of the vaccine against cervical cancer. During the last two decades several studies have also examined the possible involvement of HPV in non-genital cancers and have proposed the presence of HPV in oesophageal, laryngeal, oropharyngeal, lung, urothelial, breast and colon cancers. The possible involvement of HPV in these types of cancer would necessitate the introduction of the vaccine in both boys and girls. However, the role of HPV in the pathogenesis of these types of cancer has yet to be proven. Moreover, the controversial evidence of the possible impact of the vaccination against HPV in the prevention of non-genital cancers needs to be further evaluated. In this review, we present an overview of the existing epidemiological evidence regarding the detection of HPV in non-genital cancers.

Infection: is it a cause of bladder cancer?

This article reviews the literature regarding the possible correlation between infection and occurrence of bladder cancer. The PubMed literature database was searched from inception to January 2008. Keywords of bladder, cancer, parasitic, bacterial, viral and infection, were used. Forty studies were included in the review. Several investigators support the idea that schistosomiasis is aetiologically related to the development of bladder cancer in individuals infected with Schistosoma haematobium. Approximately 70% of those with chronic schistosomiasis who have bladder cancer develop squamous cell rather than transitional cell carcinoma. Several investigators suggest that bacteria may play a role in inducing bladder cancer. Clinically, researchers have linked the development of infection, urinary stones and indwelling catheters with bladder cancer. Nevertheless, to date, no prospective study has examined the association between urinary tract infection and bladder cancer risk. The possibility that infection by human papilloma virus (HPV) is a risk factor contributing to bladder cancer has been investigated but no definite conclusions have been drawn. Thus, the debate remains open as to whether there is any direct link between chronic HPV infection and bladder cancer. Only 15 cases of vesical carcinoma have been reported, to date, in the setting of human immunodeficiency virus (HIV). The rare occurrence of bladder cancer during HIV infection and the lack of correlation with the laboratory markers of HIV disease progression may suggest a trivial association between two unrelated disorders. BK virus is oncogenic in newborn hamsters and can transfer to mammalian cells in vitro, but there is little consistent evidence of a link with human bladder cancer. Studies showed no correlation between herpes simplex virus (HSV) and bladder cancer, but bladder cancer becomes infected with HSV much more easily than non-neoplastic urothelium. In conclusion, with the exception of chronic infection with S. haematobium, the association between the occurrence of bladder cancer and chronic bacterial or viral infections could not be confirmed. Prospective studies with large numbers of patients and controls are required to confirm this issue.

The atypical urothelial cancer patient: management of bladder cancers of non-transitional cell histology and cancers of the ureters and renal pelvis

Non-transitional cell neoplasms of the bladder and upper tract transitional cell carcinomas (ureter and renal pelvis) represent only a small fraction of urothelial carcinomas. Clinicians faced with the rare case are always confronted with management dilemmas complicated by the scarcity of published experience to guide decisions. The current review brings together the best of the limited published data in an attempt to provide some reasonable context to help in the management of these difficult neoplasms.

Nonurothelial cancer of the bladder

In this article, we review available evidence on the treatment of patients with nonurothelial cancer of the bladder. More than 150 published works were reviewed in preparation for this summary. Squamous cell carcinoma and adenocarcinoma are ideally treated with radical cystectomy. High-risk groups for these diseases are defined. Small cell carcinoma should be treated with multimodality therapy, including chemotherapy. Other rarer tumors of the bladder are also discussed.

Análisis estadístico de la influencia del virus del papiloma humano en el desarrollo del carcinoma vesical

INTRODUCTION

The bladder cancer is an important disease by its morbi-mortality and its multifactorialidad. At the moment, between the possible aetiology agents that they have been indicated is the infection by the virus of papilloma human (VPH). The objective study is to analyse, by meta-analysis, the relationship between bladder cancer and infection by human papillomavirus.

MATERIAL AND METHODS

We made a search in the electronic data base MEDLINE of the articles published until September of the 2004 that relate the infection of the VPH to the bladder tumors. Of 414 listed articles, we selected 38 articles.

RESULTS

The articles were classified in two groups, according to they use or non methods based on the detection of the DNA. In articles based on the detection of the DNA, it was that the global proportion from the cases that had contact with the virus, through the detection of the genome was of the 19.4% (95% CI 0.160 to 0.228). Of the total of studies based on the detection of the DNA 8 were selected, to show to a group defined control, in which, the OR was investigated. If we combined the ORs, we obtain an OR estimation of 3.2 (95% CI 1.19 to 8.60) and p = 0.02.

CONCLUSIONS

Most of these studies showed the relation rose at the beginning of the study. Although the majority lacked a group defined control, is possible to analyze the value of the Odds global ratio due to the homogenous behaviour of the studies with defined cases and controls affluent. This demonstrated to association between VPH and the bladder cancer.

Meta-analysis of studies analyzing the relationship between bladder cancer and infection by human papillomavirus

PURPOSE

Studies have been done of the possibility that infection by human papillomavirus is a risk factor contributing to bladder cancer but no definite conclusions have yet been drawn. We performed a meta-analysis of observational studies published until July 2005 to ascertain the degree of association between bladder cancer and human papillomavirus infection.

MATERIALS AND METHODS

The MEDLINE database was searched using the key words bladder cancer and virus. Strict criteria were applied to select studies revealing the prevalence in serum of human papillomavirus infection or its direct detection in patients. A total of 44 articles with these methodological criteria were chosen.

RESULTS

In 39 studies the investigators determined the presence of human papillomavirus DNA, and found a prevalence of between 0% and 100% and significant homogeneity analysis (p <0.001). Pooled estimation of the presence of the infection was 16.0% (95% CI 12.8 to 19.1). Pooled OR estimation was 2.3 (95% CI 1.3 to 4.1) with no significant publication bias. In 7 studies human papillomavirus infection was studied by detecting the antigen or antibodies and a prevalence of between 14% and 60% was found with significant homogeneity analysis (p <0.001). Pooled estimation of the prevalence of infection was 32.4% (95% CI 17.0 to 47.8). Pooled OR estimation was 2.9 (95% CI 1.7 to 5.3).

CONCLUSIONS

Finding a relationship between bladder cancer and human papillomavirus depends on the method used. In the literature examined there are insufficient cases and samples compared to controls and studies rely on a combination of various microbiological techniques in the same patient and sample, making it difficult to draw any definite conclusion.

Noninvasive Squamous Lesions in the Urinary Bladder

Noninvasive squamous lesions are distinctively uncommon in biopsies of the urinary bladder with the exception of nonkeratinizing squamous metaplasia. The clinical significance of these squamous lesions in the bladder remains to be explored. A total of 29 cases of transurethral biopsies and resections of the bladder containing noninvasive squamous lesions (excluding nonkeratinizing metaplasia) were studied from the consult files of one of the authors. These cases included keratinizing squamous metaplasia (5), verrucous squamous hyperplasia (5), squamous papilloma (5), condyloma acuminatum (3), and squamous cell carcinoma in situ (CIS) (11). Immunohistochemistry for epithelial growth factor receptor (EGFR) and in situ hybridization for wide-range human papillomavirus was performed on 23 cases. The follow-up period ranged from 2 months to 3 years with an average of 1.5 years. After the initial diagnoses in biopsies of the bladder, 10 patients received cystectomies, and 7 patients received repeat tissue sampling of the bladder. Of the 5 patients with keratinizing squamous metaplasia, 2 patients had invasive urothelial carcinoma with squamous features in their cystectomy specimens at intervals of 3 and 14 months, respectively, 1 had persistent keratinizing squamous metaplasia on rebiopsy. Of the 5 patients with verrucous squamous hyperplasia, 1 patient had invasive squamous cell carcinoma at cystectomy at an interval of 14 months, 1 had squamous cell CIS on rebiopsy, 1 had persistent verrucous squamous hyperplasia on rebiopsy, and 2 had no evidence of disease at 6 and 24 months. Of the 5 patients with squamous papilloma, 1 patient had low-grade urothelial carcinoma at cystectomy at an interval of 21 months (h/o low-grade urothelial carcinoma preceding papilloma diagnosis), 2 were free of lesions at rebiopsy. Of the 3 patients with condyloma acuminatum, 1 had squamous CIS at cystectomy at an interval of 3 months, 1 had invasive squamous cell carcinoma at 20 months. Of the 11 patients with squamous cell carcinoma in situ (CIS), 3 patients had invasive squamous cell carcinoma at intervals of 2, 3, and 4 months, respectively, 1 had invasive urothelial carcinoma with squamous features in cystectomies at an interval of 12 months, 1 had squamous cell CIS at 10 months, 1 had high-grade urothelial carcinoma (not otherwise specified) at rebiopsy at an interval of 6 months, and 1 had no evidence of disease at 8 months. Among the 9 patients with invasive carcinoma, 4 patients died in the period of 0.5 to 3 years after the diagnoses. Immunohistochemical study with EGFR demonstrated strong signals in 20 cases and no signals in 2 cases. Wide-range human papillomavirus DNA signal was detected in 1 case of condyloma acuminatum and 1 case of squamous cell CIS. Keratinizing squamous metaplasia, verrucous squamous hyperplasia, and condyloma acuminatum in the urinary bladder can be associated with subsequent or concurrent in situ, or invasive squamous carcinoma and should be closely followed. Squamous cell CIS in the urinary bladder is often associated with subsequent or concurrent invasive carcinoma with squamous differentiation. Enhanced expression of EGFR in these bladder squamous lesions suggests that EGFR may represent a logic therapeutic target in those squamous lesions that are difficult to manage clinically.

Cancer risk among patients with condylomata acuminata

Condylomata acuminata have been shown to increase the risk of anogenital cancers. However, previous studies have been of limited sample size and/or short follow-up duration, which prevent precise estimates of long-term excess risk, especially for specific cancer sites. We estimated the risk of specific cancers in a large cohort of hospitalized patients with condylomata acuminata, as recorded in the Swedish Inpatient Register between 1965 and 1999. Altogether, 10,971 patients (1,685 men and 9,286 women) were followed through 1999 for a median of 13 years. The standardized incidence ratio (SIR)--the ratio of the observed number of cancers to the number expected on the basis of the incidence in the Swedish population at large--was used as a measure of relative risk. After excluding the first-year of follow-up, we observed 43 cases of anogenital cancer in women, and 7 cases in men. Risks were elevated for cancers of the vulva (N = 13, SIR = 10.2, 95% confidence interval (CI) = 5.4-17.4), vagina (N = 4, SIR = 12.0, 95% CI = 3.3-30.7) and penis (N = 5, SIR = 21.9, 95% CI = 7.1-51.2). There was a moderate excess risk of cervical cancer in situ (N = 259, SIR = 1.9, 95% CI = 1.7-2.1), but not invasive cervical cancer. Excess risks of esophageal, buccal cavity, nonmelanoma skin, lung and bladder cancers, and Hodgkin and non-Hodgkin lymphoma, were also observed in both men and women. In conclusion, condylomata acuminata are strongly associated with increased risk of cancers of the vulva, vagina, penis and anus, as well as some nonanogenital malignancies, but not invasive cervical cancer.

Infección por Papillomavirus en el hombre. Estado actual

The Virus of the Human Papiloma (HPV), classically he/she has been related with infections of sexual transmission and processes wicked oncologists of the feminine genital apparatus and with less frequency of the masculine one. The new technical diagnostics, based on molecular biology (by means of polymerase chain reaction), they help to a better epidemic approach, an improvement in the I diagnose viral, and a correct therapeutic focus. The object of this work is to revise the current state of the HPV from the points of view etiopathogenics, epidemic, clinical, diagnosis, therapeutic and preservative.

Squamous cell carcinoma of the bladder: pathology, diagnosis and treatment

Squamous cell carcinoma (SCC) can occur in both nonbilharzial and bilharzial bladders; the two subtypes differ in epidemiology, pathogenesis and clinicopathological features. The nonbilharzial type occurs in Western countries and represents < 5% of all vesical tumours; it occurs most often in the seventh decade with a slight male predominance. The principal predisposing factor is prolonged indwelling urethral catheterization in patients with spinal cord injury and the main symptom is haematuria. Patients are usually diagnosed at an advanced stage and most of the tumours are of moderate and high grades. At cystoscopy tumours are predominantly ulcerative and commonly involve the trigone and lateral walls. Although distant metastasis is infrequent (8-10%) the prognosis is grave and most patients die after failure of locoregional control; radical cystectomy provides the best therapy. To avoid nonbilharzial SCC, patients with spinal cord injury should be free of catheterization if possible. The outcome can be improved by early detection with frequent cytology, cystoscopy and biopsy. Bilharzial SCC occurs commonly in the Middle East, South-east Asia and South America where schistosomiasis is endemic. In an Egyptian series SCC represented 59% of 1026 cystectomy specimens. The tumour is diagnosed in the fifth decade, and five times more common in men than women. Bladder carcinogenesis is probably related to bacterial and viral infections, commonly associated with bilharzial infestation rather than the parasite itself. The presentation is often with irritative bladder symptoms and haematuria, and many patients present at an advanced stage, although most tumours are of low and moderate grades. At cystoscopy tumours are predominantly nodular and usually arise from the upper vesical hemisphere. Lymph-node metastasis occurs in approximately 19% and significantly decreases survival; radical cystectomy remains the main treatment, giving a 5-year survival rate of 50%. Early detection improves the therapeutic yield and prevention is possible by combining snail control and mass therapy of the infested rural population by oral antibilharzial drugs.

Urothelial bladder carcinoma and viral infections: different association with human polyomaviruses and papillomaviruses

Bladder cancer is the second most commonly occurring genitourinary cancer in adults. The interaction of different carcinogenic and cocarcinogenic agents are responsible for bladder urothelial carcinoma: alcohol and smoking habits, Schistosoma haematobium infection, exposition to chemicals, analgesic and antineoplastic drugs prolonged use. Recently also viral infections have been associated to this pathology. In this study the correlation between viral infections and bladder carcinoma has been evaluated. A group of 32 patients affected by primary bladder neoplasia has been analysed. A control group of 20 autoptic samples of healthy bladder was analysed. The DNA of the following viruses has been searched by polymerase chain reaction (PCR): Adenovirus, Herpes simplex virus type 1 (HSV-1), Herpes simplex virus type 2 (HSV-2), Human Papillomaviruses (HPV), Polyomaviruses (BKV and JCV). In the examined population the association bladder carcinoma-HPV, found by others, has not been confirmed. The high percentage of human polyomaviruses present in the samples is a statistically significant data (p=0.0087) and allows to presume that BKV and JCV may play a role in the aetiology of bladder tumor. In particular the polyomavirus BK, which is found in significative percentage both in single infection (p=0.0036) and in co-infections with other viral species (p=0.035), may be an important co-factor in the pathogenesis of bladder carcinoma.

Human papillomavirus infection of the epididymis and ductus deferens: an evaluation by nested polymerase chain reaction

CONTEXT

Human papillomaviruses (HPVs) play an important role in the etiology of squamous cell carcinoma of the uterine cervix. The possible role of the male urogenital tract as a reservoir of HPV infection is not fully understood. We inferred from our previous observation of HPV-31 in epididymal tissue in a case of chronic epididymitis that HPV might be commonly present in cases of epididymitis caused by sexually transmitted pathogens.

OBJECTIVE

To assess the presence of HPV in the epididymis and ductus deferens in nontuberculous epididymitis.

DESIGN

Epididymal samples obtained from 17 patients and epididymal and ductus deferens samples from 5 patients surgically treated for nontuberculous epididymitis were analyzed by nested polymerase chain reaction for the presence of HPV DNA. In positive samples, the HPV type was determined by DNA sequencing.

SETTING

Tertiary-care academic hospital and national reference laboratory for papillomaviruses.

RESULTS

Low-risk HPV type 6 and high-risk HPV types 16, 33, 35, 55, and 73 were detected in 7 patients (31%). Neither koilocytes nor dysplastic changes were found in the epididymis and ductus deferens.

CONCLUSION

Low-risk and high-risk HPV types were detected in the epididymis and ductus deferens of patients with nontuberculous epididymitis. The infection was not accompanied by koilocytic atypia or dysplasia. Our findings support the hypothesis that the male urogenital tract serves as a reservoir of HPV infection.

Chapter 9: Role of mucosal human papillomavirus in nongenital cancers

Established associations between human papillomavirus (HPV) and lower genital tract cancers provide a framework from which to evaluate a possible pathogenic role for the virus in cancers at nongenital sites. Proposed associations must fit coherently within the context of our current knowledge of the epidemiology and biology of HPV. In this article, insights obtained from studies of the etiologic link between mucosal-type HPV infection and four specific human cancers are described briefly. Specific characteristics, shared among cancers caused by HPV, are then used by extrapolation to discuss possible associations between certain other nongenital cancers and mucosal HPV infections in a manner intended to supplement, and in no way to supplant, the classic Hill criteria for causal inference.

Risk for tumor and other disease transmission by transplantation: a population-based study of unrecognized malignancies and other diseases in organ donors

BACKGROUND

Organ donation may involve the risk of transmittal of unwanted host factors such as infections and malignancy. These may be concealed in the emergent donation process. It may be unavoidable if first observed in a donor postmortem. A number of reports on transferred cancers have been published, but quantification of the risk has never been reliably performed. We report here the first population-based analysis of unrecognized malignancies and other diseases in cadaveric or living-related donors and the possible consequences for the recipients.

METHODS

We compiled a cohort of all organ donors through 27 years (1969-1996) in one single kidney transplant center covering a population on one million people. This cohort was linked to the Danish Cancer Registry, the Danish National Hospital Register, and the Danish Register of Causes of Death by means of the unique personal identification number, and all cancers, diagnosis from hospital admissions, and causes of death were identified. Follow-up was to the end of 1996.

RESULTS

A total of 626 donors (491 cadaveric and 135 living-related donors) was included in the study. Ten carcinoma in situ or dysplasia cervix uteri (by definition nonmalignant), and 13 malignant tumors (5 of these were detected in living-related donors after donation) were detected by linkage to the cancer registry. All together, 17 recipients received organs from donors with carcinoma in situ or dysplasia cervix uteri and 20 from donors with malignancies. Two recipients from organ donors with carcinoma in situ or dysplasia of the cervix uteri and two recipients from donors with malignancies had a cancer detected; however, these were likely unrelated. One died 1 year after transplantation from a melanoma transmitted from the donor. Two cadaveric donors had previous admissions for glomerulonephritis, five for pyelonephritis, five for nephrolithiasis or ureterolithiasis, four for cystitis, and one for hydronephrosis.

CONCLUSION

Despite all efforts to secure a safe organ for transplantation, transmission of donor malignancy and other diseases nevertheless can happen, as is recorded many times in the literature. We have quantified the risk using the population-based cancer registry and found a risk of 8 in 626 (1.3%) for having a donor with undetected malignancy and a risk of 1 in 626 (0.2%) for transmitting a cancer. The risk for getting some transmitted glomerulonephritis is 2 in 626 (0.3%). None of the donors with cerebral malignancies transmitted any tumors to the recipients. Compared with the benefits of organ transplantation, these risks are small; however, if time allows, a search for additional medical information from registries could further minimize the risk of transmission of malignancies or other diseases. However, this requires updated, accurate, and accessible registries and legislation that allows access to personal data and transmission of such data across administrative borders.