HPV and histological status of pelvic lymph node metastases in cervical cancer: a prospective study

Coinfection of HPVs Is Associated with Advanced Stage in Colorectal Cancer Patients from Qatar

High-risk human papillomaviruses (HPVs) are considered risk factors in the origin of several human malignancies, such as breast, cervical, head and neck, as well as colorectal cancers. However, there are no data reported on the HPV status in colorectal cancer in the State of Qatar. Therefore, we herein examined the presence of high-risk HPVs (16, 18, 31, 33, 35, 45, 51, 52, and 59), using polymerase chain reaction (PCR) in a cohort of 100 Qatari colorectal cancer patients, and their association with tumor phenotype. We found that high-risk HPV types 16, 18, 31, 35, 45, 51, 52, and 59 were present in 4, 36, 14, 5, 14, 6, 41, and 17% of our samples, respectively. Overall, 69 (69%) of the 100 samples were HPV positive; among these, 34/100 (34%) were positive for single HPV subtypes, while 35/100 (35%) of the samples were positive for two or more HPV subtypes. No significant association was noted between the presence of HPV and tumor grade, stage, or location. However, the presence of coinfection of HPV subtypes strongly correlated with advanced stage (stage 3 and 4) colorectal cancer, indicating that the copresence of more than one HPV subtype can significantly worsen the prognosis of colorectal cancer. The results from this study imply that coinfection with high-risk HPV subtypes is associated with the development of colorectal cancer in the Qatari population.

Importance of investigating high-risk human papillomavirus in lymph node metastasis of esophageal adenocarcinoma

High-risk human papillomavirus has been suggested as a risk factor for esophageal adenocarcinoma. Tumor human papillomavirus status has been reported to confer a favorable prognosis in esophageal adenocarcinoma. The size of the primary tumor and degree of lymphatic spread determines the prognosis of esophageal carcinomas. Lymph node status has been found to be a predictor of recurrent disease as well as 5-year survival in esophageal malignancies. In human papillomavirus driven cancers, e.g. cervical, anogenital, head and neck cancers, associated lymph nodes with a high viral load suggest metastatic lymph node involvement. Thus, human papillomavirus could potentially be useful as a marker of micro-metastases. To date, there have been no reported studies regarding human papillomavirus involvement in lymph nodes of metastatic esophageal adenocarcinoma. This review highlights the importance of investigating human papillomavirus in lymph node metastasis of esophageal adenocarcinoma based on data derived from other human papillomavirus driven cancers.

Impact of tumor histology on detection of pelvic and para-aortic nodal metastasis with 18F-fluorodeoxyglucose-positron emission tomography in stage IB cervical cancer

OBJECTIVE

¹⁸F-fluorodeoxyglucose-positron emission tomography (FDG-PET) detection of metastatic nodal disease is useful for guiding cervical cancer treatment but the impact of tumor histology is unknown. This study reports the detection of FDG avid pelvic and para-aortic lymph nodes in patients with early stage cervical cancer with squamous carcinoma and adenocarcinoma tumor histology.

METHODS

Patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-2 cervical cancer who underwent pre-surgical FDG-PET between March 1999 and February 2018 were identified in a tertiary academic center database. All patients had radical hysterectomy with pelvic and para-aortic lymph node dissection. Detection of pelvic and para-aortic lymph nodes by FDG-PET versus surgical dissection was compared. FDG-PET sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined and stratified by tumor histology.

RESULTS

We identified 212 patients with early stage cervical cancer (84% FIGO IB1, 16% IB2) who underwent pre-surgical FDG-PET; 137 (65%) patients had squamous carcinoma and 75 (35%) patients had adenocarcinoma. PET/computed tomography was performed in 189 (89%) patients and 23 (11%) had PET only. Surgical dissection revealed positive pelvic and para-aortic lymph nodes in 25% and 3.3% of patients, respectively. For squamous carcinoma, sensitivity, specificity, PPV, and NPV of FDG-PET for pelvic nodal metastasis were 44%, 99%, 95%, and 78%, respectively. For adenocarcinoma, the corresponding results for pelvic nodal metastasis were 25%, 99%, 67%, and 92%, respectively. The overall values for sensitivity, specificity, PPV, and NPV of FDG-PET for para-aortic nodal metastasis were 29%, 99%, 67%, and 98%, respectively.

DISCUSSION

Pelvic nodal metastasis was less likely to be detected by FDG-PET in patients with early stage adenocarcinoma than with squamous carcinoma.

Serum microRNA-205 as a novel biomarker for cervical cancer patients

Objective

Serum microRNAs (miRNAs) are a novel class of diagnostic and prognostic biomarkers for numerous cancers. However, the level and clinical relevance of circulating miR-205 transcripts in human serum of cervical cancer patients are unclear. The purpose of this study was to determine serum miR-205 levels in cervical cancer patients and explore its association with clinicopathological factors and prognosis.

Methods

Serum miR-205 expression was investigated in 60 cervical cancer patients and 60 healthy normal controls by using real-time PCR. Correlations between miR-205 expression and the clinicopathological features and prognosis of cervical cancer patients were then evaluated. Receiver operating characteristic curves were used to evaluate the sensitivity and specificity of serum miR-205.

Results

Serum miR-205 was significantly upregulated in cervical cancer patients compared with healthy donors (p < 0.01), and a high level of miR-205 expression was correlated with poor tumor differentiation (p = 0.009), lymph node metastasis (p = 0.015) and increased tumor stage (p = 0.001). The serum miR-205 level was capable of separating advanced stage from early stage metastatic cervical cancer from non-metastatic samples and poorly differentiated tumors from differentiated tumors with an area under the curve values of 0.74, 0.694 and 0.717, respectively. The expression of miR-205 was also higher in the cervical cancer tissues compared with the para-carcinoma tissues. In addition, Kaplan-Meier survival analysis showed that cervical cancer patients with high miR-205 expression tended to have shorter overall survival. In multivariate Cox regression analysis, miR-205 was identified as an independent prognostic marker.

Conclusions

Serum miR-205, which is upregulated in cervical cancer, represents a predictive biomarker for the prognosis of cervical cancer patients.

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

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

Human papillomavirus DNA presence in pelvic lymph nodes in cervical cancer

INTRODUCTION

This work intends to present a systematic overview of data that have been published so far with regard to methods used for tissue sampling and DNA testing and with regard to the prevalence of human papillomavirus (HPV) DNA in pelvic lymph nodes (LNs) and its prognostic significance.

METHODS

The HPV DNA status of LN in women with cervical cancer is being explored as a potential marker of "occult" metastases. Although the presence of HPV DNA in LN usually correlates with its metastatic involvement, there is always a subgroup of HPV-positive but histologically negative LNs.

RESULTS

The significance of HPV in negative LNs remains uncertain, although several studies have concluded that HPV is a risk factor of recurrence.

CONCLUSIONS

A small group size and a short follow-up are the main limitations for drawing any conclusion concerning prognostic significance of the presence of HPV DNA in LNs.

High-risk human papillomavirus DNA in the primary tumor, sentinel, and nonsentinel pelvic lymph nodes in patients with early-stage cervical cancer: a correlation with histopathology

INTRODUCTION

Metastatic involvement of pelvic lymph nodes is the most important prognostic parameter in early-stage cervical cancer. Still, approximately 15% of patients with negative pelvic nodes experience recurrence, most of them in the pelvis. The presence of human papillomavirus (HPV) DNA in histologically negative pelvic nodes is considered a subclinical metastatic spread.

METHODS

Patients with early-stage cervical cancer referred for surgical treatment were enrolled in the study. Cytobrush technique was used for sample collection from the fresh tissue to avoid any loss of material for histology.

RESULTS

Altogether, 49 patients were enrolled in the study. High-risk (HR) HPV DNA was identified in the tumor in 91.8% patients and in the sentinel node or other pelvic nodes in 49.9% patients. Among the 10 HR HPV genotypes detected, HPV 16 was the most frequently represented in both the tumor and the lymph nodes (66.7% and 71.4%, respectively). All metastatic lymph nodes were HR HPV positive.

CONCLUSIONS

The presence of HR HPV DNA in a sentinel node had a 100% positive predictive value for metastatic involvement of pelvic lymph nodes in our study. This could be considered a sign of an early subclinical metastatic spread; however, the prognostic value has to be evaluated through a longer follow-up.

[Detection of human papilloma virus type 16 in squamous cell carcinoma of colon and its lymph node metastases]

The etiological role of human papilloma virus (HPV) in a number of squamous cell malignant tumours is well known. Squamous cell carcinoma of colon (SCC) is a rare disease with uncertain etiology. Our objective was to detect possible HPV infection in a colon SCC patient. The 94-year-old female patient was operated for an obstructive colon tumour. Histology confirmed SCC. Tumour tissue and the removed lymph nodes were examined with polymerase chain reaction and Southern blot hybridization techniques. From HPV types 16 and 18, which most commonly associated with malignant tumours, the presence of HPV type 16 could be confirmed in the primary tumour and in 4 out of the 9 surrounding lymph nodes (of which 2 were metastatic). HPV-16 infection was detected in a colon cancer patient with SCC histological type in the primary tumour and in surrounding lymph nodes. According to our knowledge, no similar study has been published yet.

Extralesional detection and load of human papillomavirus DNA: a possible marker of preclinical tumor spread in cervical cancer

OBJECTIVE

Because the interaction between viral DNA products and cellular regulatory mechanisms is the first step leading to cancerous transformation, the detection of its presence in histologically negative lymph nodes may represent a very early biological step in cancer spread. The quantitative estimate may represent and an indirect sign of active cellular replication.

MATERIALS AND METHODS

Cervical and lymph nodes tissues of 13 cases of invasive cervical cancer were analyzed for human papillomavirus (HPV)-DNA presence and viral load by HPV typing and quantification by real-time polymerase chain reaction.

RESULTS

HPV-DNA was demonstrated in all tissue samples (primary tumor, positive lymph nodes, negative lymph nodes) with the most prevalence of HPV 16 (61.5%) and single-type infection (69.3%), whereas viral load (mean quantity of DNA copies) is statistically different in negative versus positive lymph nodes (p =.005).

CONCLUSIONS

Concordance of viral type and lymph nodes viral load may represent as a useful tool in identifying early metastatic risk of tumor spread.

Human papillomavirus and mutated H-ras oncogene in cervical carcinomas and pathological negative pelvic lymph nodes: a retrospective follow-up

The metastasis status of pelvic lymph nodes (PLNs) seems to be a predictive factor of survival. It was suggested that the presence of HPV DNA and other biological markers in PLN may indicate a sub clinical early metastasis. The aim was to describe the prevalence and distribution patterns of HPV DNA and H-ras mutations in intra operatively obtained cervical tumors and PLN. Thirty-seven cervical tumors and 61 lymph node biopsies from 37 patients with cervical cancer were selected. HPV typing and location were performed by PCR/dot blot and in situ hybridization (ISH) respectively. PCR/RFLP was used to scan for mutations in H-ras. Hundred percent of the cervical cancers and 85% of the PLN were HPV positive; co-infection with more than one type was 27%. HPV 16 was detected alone or co-infecting with other types in 84% of tumors and 46% of PLN; the second most frequent viral type was HPV 18 (tumor: 27%; PLN: 20%). In PLN, HPV was located in nuclei or/and cytoplasm of lymphocytes, macrophages, endothelial, and /or stromal cells. H-ras mutations were identified in 5/24 (21%) of patients with cervical tumors showing poor or moderated differentiation. HPV DNA in histological tumor-free PLN not necessary indicate metastasis, but it may be associated to an active immune reaction. Mutated H-ras is probably involved in cervical carcinogenesis and its detection in tumor and metastasis free PLN may be related to early metastasis or recurrence in at least a subset of poorly differentiated cervical tumors.

Frequency and prognostic significance of HPV DNA in sentinel lymph nodes of patients with cervical cancer

BACKGROUND

It has been suggested that histologically undetectable or 'occult' metastases in the lymphatic system could explain some recurrences. HPV DNA screening by means of the polymerase chain reaction (PCR) has been proposed as a method to detect occult metastases. This study was designed to determine the frequency of HPV DNA detection by PCR in sentinel lymph node (SN), and its relation to the clinical characteristics and outcome of women with cervical cancer.

PATIENTS AND METHODS

The primary cervical tumor and SN were tested for HPV DNA by means of PCR in 59 patients.

RESULTS

Fifteen (25.4%) of the 59 women undergoing the SN procedure had an involved SN. HPV DNA was more frequent in positive SN than in negative SN (P < 0.0001). Seven patients had a recurrence, after a mean delay of 17 months (range: 10-26). One of seven patients with a recurrence had an involved SN. HPV DNA was detected in an SN of one of seven patients with recurrence and nine (19.5%) of 46 patients without recurrence (not significant).

CONCLUSION

In women with cervical cancer, HPV DNA screening of sentinel nodes might help to identify patients at risk of lymph node metastases and recurrence.

HPV status in sentinel nodes might be a prognostic factor in cervical cancer

OBJECTIVE

Although there have been studies that focused on the correlation between the HPV presence of pelvic lymph nodes and pathological metastasis in patients with cervical cancer, the biologic role of HPV DNA in lymph nodes still remains uncertain. We performed this study to investigate the correlation between the sentinel-node HPV status and pelvic lymph node metastasis in patients with cervical cancer. The patients were followed up for 3 years to evaluate the clinical role of HPV in sentinel nodes as a prognostic factor.

METHODS

From August 2001 to July 2003, 57 patients affected by stages IB-IIA cervical cancer had sentinel-node biopsies performed during radical hysterectomy and pelvic and paraaortic lymphadenectomy. Each detected sentinel node was divided into two parts. One part of them was submitted for frozen section examination and the other was submitted for HPV typing by oligonucleotide microarray. After follow-up, we analyzed the outcome of the patients with respect to the influence of sentinel-node HPV.

RESULTS

Sentinel nodes were identified in all patients. A total of 79 nodes from 57 patients were detected as sentinel nodes. Metastasis in the sentinel nodes were found in 10 patients (17.6%) by frozen section and 11 patients by pathologic examination. The results of sentinel lymph node frozen biopsy were statistically significant for predicting the metastasis of the pelvic lymph nodes (P<0.05), but showed one false-negative case. HPV DNA was detected in the cervical cancer lesions of 55 patients (96.5%) and 80.0% (44/55) of them were found to have HPV DNA in the sentinel nodes as well. HPV DNA was detected in sentinel nodes of 10 patients among 11 patients with lymph node metastasis. Disease recurred in five patients and one of them did not show pelvic lymph node metastasis at surgery. But, all of these patients had HPV in sentinel nodes. The combination of sentinel-node frozen biopsy and HPV typing showed a negative predictive value of 100% in predicting non-metastasis of lymph node and no recurrence of disease.

CONCLUSION

Our results suggested the possibility that sentinel-node HPV typing could play a supportive role to reduce the false-negative rate of the sentinel-node biopsy. All of five patients with recurrence had HPV infection in the sentinel nodes. Absence of HPV in sentinel nodes showed reliable negative predictive value for lymph node metastasis and recurrence. Additional study will be needed to confirm the clinical application of the sentinel-node procedure and to determine whether there is a correlation of HPV status of sentinel nodes to lymph node metastasis and recurrence in cervical cancer patients.

Predictive value of HPV DNA in lymph nodes in surgically treated cervical carcinoma patients--a prospective study

OBJECTIVE

High-risk types of HPV are etiological factors in cervical cancer. Lymph node involvement in cervical cancer patients reduces 5-year survival rates by 25-60%. However, the influence on survival of HPV DNA positivity in histopathologically negative lymph nodes remains unresolved.

METHODS

The study included 116 of 148 patients who underwent Piver type III radical hysterectomy and pelvic lymphadenectomy and who showed HPV DNA positivity in the primary lesion. Lymph node tissues were tested for the presence of HPV DNA, using a PCR technique.

RESULTS

We found the presence of HPV DNA sequences in lymph nodes dissected intraoperatively in 81 (69.83%) cases. In analysis, we compared patients from 3 groups: HPV- and metastatic-negative (LN HPV-M-); HPV-positive metastatic-negative (LN HPV+M-); and metastatic-positive (LN M+). We discovered that survival in groups LN M+ and LN HPV+M- did not differ statistically (p=0.37). However, the survival periods in these two groups differed when compared with LN HPV-M- patients (p<0.001). Using Cox's proportional hazards model, we found that the presence of lymph node HPV DNA, and FIGO stage, and primary lesion volume were independent parameters correlating with survival and mortality risk.

CONCLUSION

We conclude that the presence of HPV DNA in lymph nodes is an early sign of metastasis and should be treated as such in prognostic outlook and planning the therapeutic strategy.

Prophylactic, therapeutic and anti-metastatic effects of an HPV-16mE6Δ/mE7/TBhsp70Δ fusion protein vaccine in an animal model

Human papillomaviruses (HPVs), particularly HPV-16, are not only causally linked to cervical cancers but also play an important role in the development of other cancers. The oncoproteins, E6 and E7, are consistently coexpressed in the majority of HPV-containing carcinomas and their metastatic lesions, and are critical to the induction and maintenance of malignant phenotype, and also can cause tumor metastasis. Therefore, E6 and E7 represent ideal tumor-specific antigens for the development of immunotherapy to prevent and treat HPV-associated cancers and their metastases. The powerful antigenic nature of Mycobacterium tuberculosis heat shock protein 70 (TBhsp70) is emphasized by evidence that mammals are capable of recognizing murine and human multiple B and T cell epitopes in this protein, and therefore allows it to be used as an adjuvant-free carrier to stimulate the immune response to a covalently linked fusion partner. In our present study, we developed a recombinant TBhsp70Delta protein expression vector that permits the production of other protein fused to TBhsp70Delta. A recombinant HPV-16mE6Delta/mE7/TBhsp70Delta fusion protein was expressed and purified, and immunization with the fusion protein in the absence of adjuvant was capable of providing strong protection to C57BL/6 mice against challenge and rechallenge with TC-1 cells, but not HPV negative Lewis lung cancer cells, and induced established TC-1 tumor regression and led to long-term survival. Consistent with the in vivo results, the fusion protein immunization in the absence of adjuvant induced cytolytic T lymphocytes recognized specifically TC-1 tumor cells in vitro. We also demonstrated that immunization with the fusion protein in the absence of adjuvant was effective in both preventing and treating TC-1 metastatic lesions in the lung metastasis model. In particular, immunization with the fusion protein caused regression of established lung metastatic lesions in 50% of immunized animals. This study represents an instance of tumor therapy with a TBhsp70Delta fusion protein and provides the scientific basis for the clinical application of the HPV16mE6Delta/mE7/TBhsp70Delta fusion protein in the treatment of HPV-associated cancers and their metastases.