HPV-associated epithelial atypia in oral warts in HIV+ patients

Oral Fibroma With HPV-Associated Epithelial Dysplasia

Fibromas are the most common soft tissue lesions of the oral cavity and are generally attributed to trauma. Koilocytic dysplasia refers to human papillomavirus (HPV)–related epithelial cytopathic effect. Koilocytic dysplasia is considered neoplastic. Herein, we report a case of oral fibroma with HPV-induced dysplastic changes of the surface epithelium confirmed by immunohistochemical stains for p16 and p53 as well as HPV in situ hybridization.

Oral lesions associated with human immunodeficiency virus disease

Human immunodeficiency virus (HIV)-associated oral disease among people living with HIV infection includes oral candidiasis, oral hairy leukoplakia, Kaposi sarcoma, oral warts, herpes simplex virus ulcers, major aphthous ulcers or ulcers not otherwise specified, HIV salivary gland disease, and atypical gingival and periodontal diseases. Diagnosis of some oral lesions is based on clinical appearance and behavior, whereas others require biopsy, culture, or imaging for definitive diagnosis. Management strategies including pharmacologic and nonpharmacologic approaches are discussed in this article. Dentists also need to be cognizant of the potential oral side effects of HIV antiretroviral medications.

Common benign oral soft tissue masses

This article reviews some of the more common benign oral soft tissue masses with emphasis on their etiology, epidemiology, clinical presentation, histopathology, and treatment. These lesions include traumatic fibroma, mucocele, warts/papilloma, pyogenic granuloma, peripheral giant cell granuloma, generalized gingival hyperplasia, gingival fibromatosis, lateral periodontal cyst, lipoma, and denture-induced hyperplasia.

Human papillomavirus infections and oral tumors

In the past 20 years, there has been an increasing interest in human papillomaviruses (HPV) because of their potential role in the pathogenesis of malignant tumors. In 1983, we published the first evidence that HPV might be involved in oral squamous cell carcinomas. The identification of morphological similarities between oral and cervical mucosa lead us to this original proposal. In a recent meta-analysis, HPV was indeed confirmed as an independent risk factor for oral carcinoma. To date, totally more than 100 types of HPV have been identified. As in anogenital cancers, HPV type 16 is the most prevalent type in oral carcinomas. The benign oral lesions, associated with HPV infection, include squamous cell papilloma, condyloma acuminatum, verrucca vulgaris and focal epithelial hyperplasia (FEH). Papillomas and condylomas are mostly caused by HPV type 6 or 11, while oral verrucas are associated with the skin types 2 or 4. A family history of FEH has been suggested. The FEH lesions are caused by HPV types 13 and 32, only detected in oral epithelium. In immunocompromised patients, benign HPV-induced lesions are characterized by atypical morphology and the simultaneous detection of multiple HPV types. Oral benign HPV lesions are mostly asymptomatic, and may persist or regress spontaneously.

Proliferation and invasion factors in HIV-associated dysplastic and nondysplastic oral warts and in oral squamous cell carcinoma: an immunohistochemical and RT-PCR evaluation

OBJECTIVE

Oral warts arising in human immunodeficiency virus (HIV) infection occasionally show marked epithelial dysplasia. However, anecdotal evidence suggests that they do not progress to oral squamous cell carcinoma (SCC). Therefore, we evaluated lesions for expression of proteins (tenascin-C, beta6 integrin, and matrix metalloproteinase-1[MMP1]) that have been identified as important in the invasive phase of oral SCC.

STUDY DESIGN

Twenty-two oral dysplastic warts from 22 patients and 5 oral SCCs were stained for human papillomavirus (HPV) antigen, proliferation protein Ki-67, tenascin-C, beta6, and MMP1 by immunohistochemical methods. For comparison, 5 nondysplastic warts each from HIV-positive and HIV-negative patients and 5 normal mucosa specimens were included. Sections were semiquantitatively assessed, and results were compared. Because MMP1 was the lowest or least expressed interface protein, MMP1 mRNA was quantitatively assessed from formalin-fixed paraffin-embedded tissue in selected cases with quantitative reverse transcription-polymerase chain reaction.

RESULTS

Twenty of 22 dysplastic warts stained positive for human papillomavirus common antigen, and all warts showed high proliferative fractions similar to SCCs. Tenascin-C and beta6 were variably expressed by the dysplastic warts but were consistently expressed at high levels in the SCCs. MMP1 protein levels were negative or low in 20 of 22 in dysplastic warts, but were elevated in 4 of 5 SCCs. MMP1 mRNA analysis indicated that message was low in 4 dysplastic warts and also suggested that protein translation was incomplete in 3 of the warts.

CONCLUSION

We conclude that invasion-associated proteins are underexpressed in oral dysplastic warts in HIV-positive men. However, until these patients are followed for extended periods, the risk of development of SCC from oral dysplastic warts remains unknown.

Mechanisms of expression of HHV8, EBV and HPV in selected HIV-associated oral lesions

Opportunistic DNA viruses, particularly members of the herpesvirus family, are frequently the aetiological agents of HIV-associated oral lesions. Oral lesions common to the early phase of the AIDS epidemic, including Kaposi's sarcoma (KS), oral aphthous ulceration, AIDS-associated oral lymphoma, and oral hairy leukoplakia (OHL), have been tested for the prevalence of Epstein-Barr virus (EBV) and Kaposi's sarcoma-associated herpesvirus (KSHV). While EBV DNA is detected by PCR in all of these lesions, abundant viral replication can only be detected in OHL. In OHL, a novel state of EBV infection has been discovered with concurrent expression of replicative and transforming proteins, with all of these proteins contributing to the development of the lesion. Activation of signalling pathways and up-regulation of the viral receptor, proliferative and antiapoptotic genes by these proteins induce several of the histological features common to OHL, such as acanthosis and hyperproliferation. In contrast to other permissive herpesvirus infections, expression of EBV transforming proteins within the permissively infected OHL tissue enables epithelial cell survival and may enhance viral replication. Detection of KSHV in these HIV-infected individuals has been localized only to their saliva. Replicative and latent KSHV gene products have been detected in association with the development of oral KS lesions. EBV, but not human cytomegalovirus (HCMV), has been detected by PCR in minor salivary gland biopsies of HIV-associated salivary gland disease. Human papillomaviruses (HPV) are associated with oral warts in HIV-positive individuals; a diagnosis that appears to be increasing in frequency in the era of highly active antiretroviral therapy. To date, there appears to be little increase in the incidence of HPV-associated oral cancer. The mechanisms of interaction between HIV and HPV are not fully understood. Expression of viral gene products is clearly important and necessary for the development of multiple AIDS-associated oral lesions.

Human papilloma virus type 16 E6 gene expression in oral exophytic epithelial lesions as detected by in situ rtPCR

OBJECTIVE

We adopted an in situ reverse transcriptase polymerase chain reaction method of detecting and determining the frequency of early (E6) gene expression of human papilloma virus type 16 at the individual cell level in a sample of oral exophytic lesions with various degrees of epithelial hyperplasia and dysplasia in immunosuppressed and immunocompetent patients.

STUDY DESIGN

The significance of differences between the study groups was determined by Mantel-Haenszel chi-square analysis and calculation of odds ratios, accounting for immunosuppression and degree of dysplasia, respectively.

RESULTS

Grouped together, the lesions of dysplasia (mild to severe) and squamous cell carcinoma were found to be 16 times more likely to express human papilloma virus E6 mRNA than the benign lesions (P = .0013); in the lesions of immunosuppressed patients, human papilloma virus 16 E6 was roughly 10 times more likely to be expressed than in those of the immunocompetent patients (P = .0008, accounting for dysplasia).

CONCLUSIONS

Our data indicate that human papilloma virus 16 E6 gene expression, and perhaps integration of the virus in the host genome, might play a role in the development of oral neoplasia in association with immunosuppression.

Pseudotumour of the tongue caused by herpes simplex virus type 2 in an HIV-1 infected immunosuppressed patient

An HIV-1 infected immunosuppressed patient (CD4+ cell counts: 382 cells/microL; viral load 94,000 copies/mL) with recurrent perianal herpes simplex virus type 2 (HSV-2) infections is described, showing an unusual exophytic tumour resembling a squamous cell carcinoma in the lateral part of the tongue. He also had persistent facial herpes infection, oral candidosis, oral hairy leukoplakia and lymphadenopathy. The presence of HSV-2 was detected by polymerase chain reaction both in smears and in a tissue biopsy taken from the involved tongue area. Treatment with brivudin, a new oral virustatic drug, led to rapid regression of the tumour.

Concurrent HPV infection in oral and genital mucosa

Screening for human papillomavirus (HPV) types was performed by a PCR-based assay on 29 women (mean age 34.0 years, range 21-48 years). HPV-DNA was demonstrated in 16 women (55.2%), with a detection rate of 37.9% in the oral cavity and 34.5% in the genital tract. HPV-16 was the most prevalent genotype (53.8%), followed by HPV-6, which was present in 34.6% of the positive samples. Other types were more rarely detected. Five subjects showed concurrent genital tract and oral cavity infections but HPV type-specific concordance was detected in only 3 patients. Multiple HPV infections were found in 9 of the 26 positive samples, where HPV-6 appeared frequently associated with the other types. These data confirm the occurrence of mixed HPV infections and the wide diffusion of different types of HPV in the genital mucosa and in the oral cavity; they also stress the need to utilize diagnostic methods with a wide typing capacity.

HIV-related oral disease

Few people with HIV infection fall to experience oral lesions during the course of their disease. Oral mucosal and salivary gland manifestations include several that were not seen before the AIDS epidemic, while others are more severe in this population. Oral lesions reflect HIV status and the stage of immunosuppression, are important elements in HIV staging and classification schemes, raise pertinent questions about mucosal aspect of immunosuppression, and provide therapeutic challenges. Their pervasive nature and biological significance emphasise the importance of a careful oral examination as part of the general clinical evaluation.

Novel HPV types present in oral papillomatous lesions from patients with HIV infection

Patients infected with the human immunodeficiency virus (HIV) often develop multiple papillomatous lesions of the oral cavity. In the present study, a total of 67 biopsies from benign oral lesions were analyzed for the presence of human papillomavirus (HPV) DNA using Southern-blot hybridization in combination with a polymerase chain reaction designed to detect all known HPV types, as well as unidentified types. These samples, collected at random from a high-risk population, were subsequently divided into 57 biopsies originating from patients with confirmed HIV infection and 10 biopsies from patients with unknown HIV status. Each sample was amplified with 7 different combinations of degenerate primers. All amplified products were sequenced. HPV DNA sequences were detected in 67% (45/67) of the samples. HPV 7 (19%) and HPV 32 (28%) were the predominant HPV types. HPV 32 was present in 2/4 fibromas tested. Two new HPV types, HPV 72 and HPV 73, were identified in oral warts with atypia. The complete genomes of these viruses were cloned and sequenced. Other HPV types detected were HPV 2a, HPV 6b, HPV 13, HPV 16, HPV 18, HPV 55, HPV 59 and HPV 69.

Intraoral squamous cell carcinoma in human immunodeficiency virus infection. A clinicopathologic study

The purpose of this study was to characterize the clinical and histological features of intraoral squamous cell carcinoma in men who were seropositive for the human immunodeficiency virus and to evaluate viral cofactors (human papillomavirus, herpes simplex virus, Epstein-Barr virus), proliferative index (proliferating cell nuclear antigen), a factor associated with invasion (cathepsin D), and mutated tumor suppressor gene and proto-oncogene products (mutated p53, c-erbB-2). Four men who were seropositive for the human immunodeficiency virus and had acquired immunodeficiency syndrome presented with painful oral lesions of variable duration. Oral cancer risk factors included heavy tobacco use (four of four), heavy alcohol use (three of four), and previous radiotherapy (one of four). The lesions consisted of ulcers (two of four), a fungating mass (one of four), and papillary erythroplakia (one of four). Incisional biopsy specimens were obtained. High-stringency in situ hybridization was performed with DNA probes to the human papillomavirus (types 6/11; 16/18; 31/33/35) and Epstein-Barr virus: Immunocytochemical studies for the herpes simplex virus, proliferating cell nuclear antigen, cathepsin D, mutated p53, and c-erbB-2 were performed. Two lesions were moderately differentiated squamous cell carcinoma, one lesion was a basaloid squamous cell carcinoma, and one was carcinoma in situ. Stage of disease at diagnosis was II (one of four), III (two of four), and IV (one of four). Three cases were positive for the human papillomavirus, one case was positive for Epstein-Barr virus, and three cases were positive for the herpes simplex virus. C-erbB-2 was focally positive in one case, and mutated p53 was positive in a separate case.(ABSTRACT TRUNCATED AT 250 WORDS)