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Sichero L, Ferreira S, López RVM, Mello BP, Costa V, El-Achkar VNR, Carlos R, Ribeiro-Silva A, Pignatari S, Kaminagakura E, Villa LL. Prevalence of human papillomavirus 6 and 11 variants in recurrent respiratory papillomatosis. J Med Virol 2021; 93:3835-3840. [PMID: 32910471 DOI: 10.1002/jmv.26503] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/03/2020] [Accepted: 09/08/2020] [Indexed: 11/11/2022]
Abstract
Human papillomavirus (HPV) types 6 and 11 are the etiological agents of recurrent respiratory papillomatosis (RRP). We examined the prevalence and distribution of HPVs 6 and 11 genetic variants in juvenile onset (JORRP) and adult onset (AORRP) laryngeal papillomas. Cases of JORRP and AORRP were collected, retrospectively. HPV detection and genotyping were accessed by polymerase chain reaction-sequencing in 67 RRP samples. Overall, the most prevalent HPV-6 variants were from B1 (55.8%) and B3 (27.9%) sublineages, whereas among HPV-11 positive samples A2 (62.5%) variants were predominant. A higher prevalence of HPV-6 B1 was observed in JORRP (83.3% B1 and 16.7% B3), compared with AORRP cases (58.3% B1 and 41.7% B3). HPV-11 A2 variants were more prevalent both in JORRP (57.2%) and in AORRP cases (70.0%). Nevertheless, with the exception that HPV-6 B1 were significantly less likely to recur, there was a lack of association between any particular HPVs 6 or 11 variant and clinicopathological features. Our data do not support an association between HPVs 6 and 11 variability and RRP.
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Affiliation(s)
- Laura Sichero
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Silvaneide Ferreira
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Rossana V M López
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Barbara P Mello
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Victor Costa
- Department of Bioscience and Oral Diagnosis, São Paulo State University (UNESP), São Paulo, Brazil
| | - Vivian N R El-Achkar
- Department of Bioscience and Oral Diagnosis, São Paulo State University (UNESP), São Paulo, Brazil
| | - Román Carlos
- Centro Clínico de Cabeza y Cuello, Guatemala City, Guatemala
| | - Alfredo Ribeiro-Silva
- Department of Pathology and Forensic Medicine, Ribeirao Preto Medical School, Universidade de São Paulo, Ribeirao, Preto, Brazil
| | - Shirley Pignatari
- Department of Otorhinolaryngology and Head and Neck Surgery, Sao Paulo Federal University, Sao Paulo, Brazil
| | - Estela Kaminagakura
- Department of Bioscience and Oral Diagnosis, São Paulo State University (UNESP), São Paulo, Brazil
| | - Luisa L Villa
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
- Department of Otorhinolaryngology and Head and Neck Surgery, Sao Paulo Federal University, Sao Paulo, Brazil
- Department of Radiology and Oncology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Allen-Leigh B, Rivera-Rivera L, Yunes-Díaz E, Portillo-Romero AJ, Brown B, León-Maldonado L, Vargas-Guadarrama G, Salmerón J, Lazcano-Ponce EC. Uptake of the HPV vaccine among people with and without HIV, cisgender and transgender women and men who have sex with men and with women at two sexual health clinics in Mexico City. Hum Vaccin Immunother 2019; 16:981-990. [PMID: 31657665 DOI: 10.1080/21645515.2019.1675456] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Our aim was to better understand Human Papillomavirus (HPV) vaccine acceptance among Mexican adults including people with and without HIV, cisgender men who have sex with men (MSM) or with women (MSW), cisgender and transgender women. A computer-assisted, self-administered questionnaire was completed by healthcare users and participants recruited through community organizations, and the first dose of the quadrivalent HPV vaccine was offered at no cost at a large sexual health clinic in Mexico City, from May to December 2018. Socio-demographic characteristics and factors associated with HPV vaccine acceptance were analyzed using logistic regression.The sample of 1915 participants included 1341 cisgender men (70.9%, 1247 MSM and 94 MSW), 396 (20.7%) cisgender women and 178 (9.3%) transwomen; 615 people (32.1%) were HIV positive. Uptake of the HPV vaccine was higher in men and transwomen (91.5% and 87%, respectively) than among cisgender women (81.8%; p < .001). Cisgender women (OR 0.43, 95%CI 0.30-0.61, p < .05) were less likely to accept HPV vaccination than men. Married/partnered people were less likely to accept HPV vaccination compared to those who were single (OR 0.70, 95%CI 0.51-0.97). People living with HIV were not significantly more likely to accept HPV vaccination (OR 1.7; 95%CI 0.86-1.61).HPV vaccine acceptance was high among adult Mexican study participants; it may be higher than among other Mexican adults given most of these individuals are engaged in care. Modifications will be needed in national and international recommendations on HPV vaccination in adults if healthcare personnel are to recommend the vaccine to the population groups studied.
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Affiliation(s)
- Betania Allen-Leigh
- Reproductive Health Division, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Leonor Rivera-Rivera
- Reproductive Health Division, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Elsa Yunes-Díaz
- Center for Population Health Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | | | - Brandon Brown
- School of Medicine, University of California at Riverside, Riverside, California, USA
| | - Leith León-Maldonado
- Cátedra CONACYT-Center for Population Health Research, National Institute of Public Health, Mexico City, Mexico.,Academic Unit in Epidemiological Research. Center for Research in Policies, Population, and Health, School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Galileo Vargas-Guadarrama
- Center for the Prevention and Comprehensive Care of HIV/AIDS in Mexico City, Condesa Clinic, Mexico City, Mexico
| | - Jorge Salmerón
- Academic Unit in Epidemiological Research. Center for Research in Policies, Population, and Health, School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
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Dias MC, Stuqui B, Provazzi PJS, Bittar C, Candido NM, de Matos RPA, Badial RM, do Bonfim CM, Melli PPDS, Quintana SM, Cordeiro JA, Rahal P, Calmon MDF. Analysis of Nucleotide Alterations in the E6 Genomic Region of Human Papillomavirus Types 6 and 11 in Condyloma Acuminatum Samples from Brazil. Adv Virol 2019; 2019:5697573. [PMID: 31186642 PMCID: PMC6521423 DOI: 10.1155/2019/5697573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/27/2019] [Accepted: 03/17/2019] [Indexed: 11/17/2022] Open
Abstract
Condyloma acuminata (CA), or genital warts, are benign proliferative epidermal or mucous lesions that are caused by infection with human papillomavirus (HPV), mainly the low-risk types 6 and 11. HPV variants are defined as viral sequences that share identity in the nucleotide sequence of the L1 gene greater than 98%. Based on this criterion, HPV6 and 11 variant lineages have been studied, and there are ongoing attempts to correlate these genetic variants with different clinical findings of infection. Therefore, the aims of this study were to detect variants and nucleotide alterations present in the E6 regions of HPV types 6 and 11 found in CA samples, to correlate the HPV presence with the clinical-pathological data of the patients, and to determine phylogenetic relationships with variants from other places in the world. The E6 regions of 25 HPV6 samples and 7 HPV11 samples from CA were amplified using PCR with specific primers. The products were ligated to a cloning vector and five colonies of each sample were sequenced to observe the nucleotide alterations. Twelve samples were identified as the HPV6B3 variant, presenting the mutation (guanine) G474A (adenine), and one of them also showed the mutation (thymine) T369G. The other 13 patients were positive for HPV6B1 without nucleotide alterations. In the analysis of the HPV11 samples, all patients showed the mutations T137C and (cytosine) C380T. One patient also presented the nucleotide alteration T410C. None of the mutations found in the 32 analyzed samples resulted in amino acid changes. Patient age, local occurrence, and HIV infection did not show significant association with HPV infection. Besides, the data found in this study did not show a relationship with the geographical region of isolation when compared to other data from different regions of the world. In this way, despite the nucleotide alterations found, it was not possible to observe amino acid changes and variants grouping according to geographical region.
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Affiliation(s)
- Marina Carrara Dias
- Institute of Biosciences, Letters and Exact Sciences of São Paulo State University, São José do Rio Preto, SP, Brazil
| | - Bruna Stuqui
- Institute of Biosciences, Letters and Exact Sciences of São Paulo State University, São José do Rio Preto, SP, Brazil
| | - Paola Jocelan Scarin Provazzi
- Institute of Biosciences, Letters and Exact Sciences of São Paulo State University, São José do Rio Preto, SP, Brazil
| | - Cíntia Bittar
- Institute of Biosciences, Letters and Exact Sciences of São Paulo State University, São José do Rio Preto, SP, Brazil
| | - Natália Maria Candido
- Institute of Biosciences, Letters and Exact Sciences of São Paulo State University, São José do Rio Preto, SP, Brazil
| | - Renata Prandini Adum de Matos
- Institute of Biosciences, Letters and Exact Sciences of São Paulo State University, São José do Rio Preto, SP, Brazil
| | - Rodolfo Miglioli Badial
- Institute of Biosciences, Letters and Exact Sciences of São Paulo State University, São José do Rio Preto, SP, Brazil
| | - Caroline Measso do Bonfim
- Institute of Biosciences, Letters and Exact Sciences of São Paulo State University, São José do Rio Preto, SP, Brazil
| | | | | | | | - Paula Rahal
- Institute of Biosciences, Letters and Exact Sciences of São Paulo State University, São José do Rio Preto, SP, Brazil
| | - Marilia de Freitas Calmon
- Institute of Biosciences, Letters and Exact Sciences of São Paulo State University, São José do Rio Preto, SP, Brazil
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Sichero L, El-Zein M, Ferreira S, Franco EL, Villa LL. Lack of Association between Human Papillomavirus Types 6 and 11 Genetic Variants and Cervical Abnormalities: The Ludwig-McGill Cohort Study. Cancer Epidemiol Biomarkers Prev 2019; 28:1086-1088. [PMID: 30867221 DOI: 10.1158/1055-9965.epi-19-0114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Human papillomavirus (HPV) types 6 and 11 are mainly associated with the development of genital warts and recurrent respiratory papillomatosis. We examined intratypic genetic variability of both viral types with the development of cervical cytologic abnormalities in Brazilian women. METHODS We used PCR sequencing to characterize variants of HPVs 6 and/or 11 in cervical swabs from women in the Ludwig-McGill Cohort Study. We used a binomial generalized estimating equations (GEE) model with logit link to estimate odds ratios (OR) and 95% confidence intervals (CI) for the associations between HPV 6 and 11 variants and cytologic abnormalities. RESULTS B1 and B3 HPV6 and A2 HPV11 variants were the most common isolates identified. Compared with HPV6-negative women, the ORs among women harboring HPV6 B1 or B3 variants were 6.3 (95% CI, 2.3-17.0) and 2.3 (95% CI, 0.6-9.7) for atypical cells of undetermined significance (ASCUS)/low squamous intraepithelial lesions (LSIL), respectively, and 1.7 (95% CI, 0.6-5.1) and 1.2 (95% CI, 0.3-4.7) for ASCUS/LSIL/high squamous intraepithelial lesions (HSIL). Respective ORs were 5.0 (95% CI, 1.7-14.6) and 2.8 (95% CI, 1.0-8.1) upon comparing women with HPV11 A2 variants to HPV11-negative women. All associations disappeared when adjusting for coinfections with high-risk HPV types. CONCLUSIONS Our data do not support an association between low-risk HPVs 6 and 11 genetic variability and cervical abnormalities. IMPACT Risk of cervical cytologic abnormalities is not affected by intratypic polymorphism in HPVs 6 and 11.
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Affiliation(s)
- Laura Sichero
- Center for Translational Investigation in Oncology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil.
| | - Mariam El-Zein
- Division of Cancer Epidemiology, McGill University, Montreal, Canada
| | - Silvaneide Ferreira
- Center for Translational Investigation in Oncology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Eduardo L Franco
- Division of Cancer Epidemiology, McGill University, Montreal, Canada
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Sichero L, Giuliano AR, Villa LL. Human Papillomavirus and Genital Disease in Men: What We Have Learned from the HIM Study. Acta Cytol 2019; 63:109-117. [PMID: 30799416 DOI: 10.1159/000493737] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 01/01/2023]
Abstract
It is currently recognized that in addition to the major impact of human papillomavirus (HPV) infection in females, HPV causes considerable disease in men at the genitals, anal canal, and oropharynx. Specifically, genital HPV infections may progress to genital warts and penile carcinoma. Although studies concerning the natural history of HPV infections and associated neoplasias have mainly focused on women, during the last 2 decades considerable attention has been given in further understanding these infections in men. The HIM (HPV infection in men) Study, the only prospective multicenter study of male HPV natural history, consisted of a large prospective international cohort study in which men from Brazil, the United States, and Mexico were enrolled. The design and protocols of this study allowed unraveling crucial information regarding the relationship between HPV infection and clinical consequences in men, and associated risk factors at each of the anatomic sites where HPV is known to cause cancer in men.
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Affiliation(s)
- Laura Sichero
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Anna R Giuliano
- Center for Immunization and Infection Research in Cancer, and the Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Luisa Lina Villa
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil,
- Department of Radiology and Oncology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil,
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Yao Y, Yan Z, Dai S, Li C, Yang L, Liu S, Zhang X, Shi L, Yao Y. Human Papillomavirus Type 16 E1 Mutations Associated with Cervical Cancer in a Han Chinese Population. Int J Med Sci 2019; 16:1042-1049. [PMID: 31341418 PMCID: PMC6643129 DOI: 10.7150/ijms.34279] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/30/2019] [Indexed: 12/20/2022] Open
Abstract
Human papillomavirus type 16 (HPV16) is a high-risk HPV type and a potent carcinogen. HPV E1 is one of the most highly conserved proteins and it plays a central role in initiating HPV DNA replication. In current study, we enrolled 161 HPV16-positive cervical cancer patients (case group) and 171 HPV16-positive asymptomatic individuals (control group) in a study to analyse the association between HPV16 E1 genetic mutations and cervical cancer. The samples of case group were cervical cancer tissues and the samples of control group were cervical exfoliated cells. Three variants (A4, A1-A3 and D3) were found in the case group, 68.3% of the HPV16 E1 sequences belonged to the A4 (As) sub-lineage, 29.2% belonged to the A1-A3 (EUR) sub-lineage, and 2.5% belonged to the D3 (AA1) sub-lineage. Two variants (A4 and A1-A3) occurred in the control group. The A4 (As) sub-lineage was predominant in this group as well (66.1%), followed by the A1-A3 (EUR) sub-lineage (33.9%), but the D3 (AA1) sub-lineage was not found in the control group. The distribution of the HPV16 variants between the case and control groups was significantly different (P<0.05). When the distribution of the HPV16 E1 gene mutations was compared, the distribution of twenty-seven mutations was significantly different between the case and control groups (P<0.05), and twenty-two mutations occurred only in the D3 (AA1) sub-lineage, two were found only in the A4 (As) sub-lineage, one was found in the A1-A3 (EUR) sub-lineage, two was found in both the A4 (As) and A1-A3 (EUR) sub-lineages. In the sub-lineage analysis, the differences in the T933A (A23A), T1014G (D50E) and G2160A (R432R) mutations were statistically significant between the case and control groups for the A4 (As) sub-lineage (P<0.05), and the differences in the T2232C (F456F), G2337A (M491I) and A2547G (P561P) mutations were statistically significant between the case and control groups for the A1-A3 (EUR) sub-lineage (P<0.05). In the current study, we describe specific mutations in the HPV16 E1 gene associated with cervical cancer, and our study will provide a good reference for further functional studies of the relationship between cervical cancer carcinogenesis and HPV genes.
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Affiliation(s)
- Yueting Yao
- Institute of Medical Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Kunming 650118, Yunnan, China
| | - Zhiling Yan
- Department of Gynaecologic Oncology, The 3rd Affiliated Hospital of Kunming Medical University, Kunming 650118, China
| | - Shuying Dai
- School of Basic Medical Science, Kunming Medical University, Kunming 650500, China
| | - Chuanyin Li
- Institute of Medical Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Kunming 650118, Yunnan, China
| | - Longyu Yang
- Institute of Medical Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Kunming 650118, Yunnan, China
| | - Shuyuan Liu
- Institute of Medical Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Kunming 650118, Yunnan, China
| | - Xinwen Zhang
- Institute of Medical Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Kunming 650118, Yunnan, China
| | - Li Shi
- Institute of Medical Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Kunming 650118, Yunnan, China
| | - Yufeng Yao
- Institute of Medical Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Kunming 650118, Yunnan, China
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Abstract
Human papillomavirus infection is associated with the development of malignant and benign neoplasms. Approximately 40 viral types can infect the anogenital mucosa and are categorized into high- and low-risk oncogenic human papillomavirus, depending on their association with the development of cervical carcinoma. High-risk human papillomavirus 16 and 18 are detected in 55% and 15% of all invasive cervical squamous cell carcinomas worldwide, respectively. Low-risk human papillomavirus 6 and 11 are responsible for 90% of genital warts and are also associated with the development of recurrent respiratory papillomatosis. Human papillomavirus preferentially infects mitotic active cells of the basal layer from both mucosal and cutaneous epithelium through microabrasions. The viral life cycle synchronizes with the epithelial differentiation program, which may be due, in part, to the binding of differentially expressed cellular transcription factors to the long control region throughout the various epithelial layers. This review aimed to summarize the current knowledge regarding the mechanisms by which viral gene expression is regulated and the influence of human papillomavirus heterogeneity upon this phenomenon. A better understanding of the regulatory mechanisms may elucidate the particularities of human papillomavirus-associated pathogenesis and may provide new tools for antiviral therapy.
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Affiliation(s)
- Aline Lopes Ribeiro
- Centro de Pesquisa Translacional em Oncologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Amanda Schiersner Caodaglio
- Centro de Pesquisa Translacional em Oncologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Laura Sichero
- Centro de Pesquisa Translacional em Oncologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Combes JD, Franceschi S. Human papillomavirus genome variants and head and neck cancers: a perspective. Infect Agent Cancer 2018; 13:13. [PMID: 29643933 PMCID: PMC5891965 DOI: 10.1186/s13027-018-0185-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 03/27/2018] [Indexed: 12/22/2022] Open
Abstract
Human papillomaviruses (HPV) cause infections that are responsible for diverse clinical manifestations from benign conditions to invasive cancer. As different HPV types are associated with variable pathogenic potential, minor genetic variations within a given high-risk HPV type might also be associated with distinct oncogenic capacities, through variable ability of persistence or risk of progression to precancer/cancer. Most recent HPV variant studies in the cervix using latest sequencing technology confirmed that minor changes in the HPV genome can have a major influence on carcinogenesis and have revealed key data that help better understand the carcinogenicity of HPV at a molecular level. Here we review the limited number of studies on HPV genome variants in head and neck cancers (HNC) and discuss their implications for cancer research in the light of accumulated knowledge for the cervix. Challenges in transposing HPV variant studies from the lower anogenital to the upper aerodigestive tract are also discussed, highlighting the main gaps of knowledge in the field of HPV-induced HNC. Specifically in the head and neck region, the lack of characterisation of precancerous lesions and the difficulty in sampling normal tissue will challenge the development of accurate studies. Although there is so far no indication that HPV variant research in HNC could directly translate into clinical application, such research is expected to be useful to disentangle unanswered questions in the pathogenesis of HNC. Yet, history of HPV variant research suggests that, to be successful, studies will require large international collaborative efforts.
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Affiliation(s)
- Jean-Damien Combes
- International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Cedex 08 Lyon, France
| | - Silvia Franceschi
- Cancer Epidemiology Unit, CRO Aviano National Cancer Institute IRCCS, Via Franco Gallini 2, 33081 Aviano, PN Italy
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