Detection of human papillomavirus DNA in cytologic specimens derived from esophageal precancer lesions and cancer

Squamous Neoplastic Precursor Lesions of the Esophagus

Clinicopathological and molecular studies have demonstrated that dysplasia is a precancerous and/or neoplastic lesion with malignant potential. Further, it is subclassified into two grades: high-grade and low-grade dysplasia. High-grade dysplasia is a clinically significant lesion requiring resection or ablation. Low-grade dysplasia has a much lower risk of carcinoma; thus, it should be followed by endoscopic surveillance. Because squamous dysplasia may progress to squamous cell carcinoma, periodic endoscopy is useful to detect the lesion in patients with risk factors. Squamous dysplasia is diagnosed histopathologically by evaluating both cytologic and structural changes.

High-Grade Squamous Intraepithelial Lesion of the Gastroesophageal Junction Secondary to High-Risk Human Papillomavirus

OBJECTIVES

Although the role of human papillomavirus (HPV) in the development of some carcinomas (eg, anogenital and oropharyngeal squamous cell carcinomas) is nondebatable, there is still significant controversy regarding the relationship of HPV and esophageal squamous cell carcinomas (SCCs).

METHODS

All cases were sampled at or near the gastroesophageal junctions in patients with reflux and/or known Barrett esophagus and appear to have been initially sampled "incidentally." Patients were all men, aged 56 to 80 years. None had a known history of other HPV-related disease.

RESULTS

We present four cases of high-grade squamous intraepithelial lesion of the gastroesophageal junction secondary to high-risk HPV that have identical histologic features to similar lesions of the anogenital tract.

CONCLUSIONS

Whether such lesions are at risk for developing into invasive SCC remains unclear.

Association of High Risk Human Papillomavirus and Breast cancer: A UK based Study

Infection by human papillomaviruses (HPVs) has been implicated in the aetiology of a variety of cancers. Studies evaluating the presence of HPVs in breast cancer (BC) have generated considerable controversy. To date, most studies have focused on the presence of viral DNA in BC; however there are important gaps in evidencing the role of HPV persistence in the invasiveness of BC. While these studies have been conducted in several countries, none, on the presence and biological activity of high risk (HR) HPV in BC has been done in the UK. Hence, we aimed to investigate these gaps by screening a total of 110 fresh breast tissue specimens from UK patients for the presence of twelve HR-HPV types DNA using PCR and Sanger sequencing. Samples positive for HPV-DNA were screened for viral oncoprotein expression using western blot and dot blot. Data obtained showed the presence of HR-HPVs in 42% of breast tissues of which the viral activity was only confirmed in a number of invasive carcinomas (5/26). This finding, the first to report in the UK, suggests that the selective expression of viral oncoprotein in invasive cases may propose a role for HR-HPVs in the development of some types of BC.

Association between human papillomavirus (HPV) and oesophageal squamous cell carcinoma: a meta-analysis

SUMMARY

The oncogenic potential of human papillomaviruses (HPV) is well known in the context of cervical carcinoma; however, their role in the development of oesophageal squamous cell carcinoma (OSCC) is less clear. We aimed to determine the extent of the association between HPV infection and OSCC. A comprehensive literature search found 132 studies addressing HPV and OSCC in human cases, and a meta-analysis was performed using a random-effects model. There was evidence of an increased risk of OSCC in patients with HPV infection [odds ratio (OR) 2·69, 95% confidence interval (CI) 2·05-3·54]. The prevalence of HPV in OSCC was found to be 24·8%. There was an increased risk associated with HPV-16 infection (OR 2·35, 95% CI 1·73-3·19). Subgroup analyses showed geographical variance, with Asia (OR 2·94, 95% CI 2·16-4·00), and particularly China (OR 2·85, 95% CI 2·05-3·96) being high-risk areas. Our results confirm an increase in HPV infection in OSCC cases.

Prevalence of human papillomavirus infection in esophageal and cervical cancers in the high incidence area for the two diseases from 2007 to 2009 in Linzhou of Henan Province, Northern China

The etiological role of human papillomavirus (HPV) in cervical cancer has been well established. However, it is inconclusive whether HPV plays the same role in esophageal carcinogenesis. In this study, we detected HPV infection in 145 frozen esophageal tissues, including 30 normal epithelium (ENOR), 37 dysplasia (DYS) and 78 invasive squamous cell carcinoma (ESCC), and in 143 frozen cervical tissues composed of 30 normal epithelium (CNOR), 38 intraepithelial neoplasia (CIN) and 75 invasive squamous cell carcinoma (CSCC). The patients and symptom-free subjects enrolled in this study were from a high-incidence area for both ESCC and CSCC, Linzhou City, Northern China, from 2007 to 2009. The HPV infection analysis was conducted by using an HPV GenoArray Test Kit. We found that the high-risk HPV types accounted for more than 90 % of the HPV-positive lesions of esophagus and cervix tissues. The prevalence of high-risk HPV types increased significantly during the progression of both esophageal and cervical carcinogenesis (positive rate in esophageal tissues: 33 % ENOR, 70 % in DYS and 69 % in ESCC; positive rate in cervical tissues: 27 % in CNOR, 82 % in CIN and 88 % in CSCC; P < 0.001, respectively). Infection with the high-risk HPV types increased the risk for both DYS and ESCC by 4-fold (DYS vs. ENOR: OR = 4.73, 95 %CI = 1.68-13.32; ESCC vs. ENOR: OR = 4.50, 95 %CI = 1.83-11.05) and increased the risk for both CIN and CSCC by 12-fold and 20-fold (CIN vs. CNOR: OR = 12.18, 95 %CI = 3.85-38.55; CSCC vs. CNOR: OR = 20.17, 95 %CI = 6.93-58.65), respectively. The prevalence of high-risk types in ESCC patients was lower than that in CSCC patients (P = 0.005) and was significantly associated with the degree of ESCC tumor infiltration (P = 0.001). HPV 16 was the most prevalent subtype in both esophageal and cervical tissues. Single HPV infection increased significantly along with the progression of ESCC and maintained a high level in cervical tissues, regardless of whether they were CNOR or CSCC tissues. Our results showed that infection with HPV, especially the high-risk types, was positively associated with both esophageal and cervical cancers, suggesting that HPV also plays a role in the etiology of ESCC in the high-incidence area.

Statistical analysis of human papillomavirus in a subset of upper aerodigestive tract tumors

Human papilloma virus (HPV) has been detected in some upper aerodigestive tract tumors, but the correlation between HPV and these tumors is not well understood. There is also some controversy regarding this correlation because a large variation in the prevalence of HPV in these tumors has been reported. To discuss the impact of HPV infection on upper aerodigestive tract tumors, this review estimated systematically the prevalence and risk of HPV in upper aerodigestive tract tumors from studies published between 1982 and 2012. In total, 418 articles were selected, which included 273 studies on the head and neck and 145 studies on esophageal squamous cell carcinoma. The overall prevalence of HPV in the 5,467 head and neck squamous cell carcinoma specimens was 36.3%. HPV was detected more frequently in the Americas (40%), than in Asia (38.6%), Europe (32%), or others regions (30.5%). The prevalence of HPV was significantly higher in oropharyngeal (48.5%) than in oral (32.5%), laryngeal (30.7%), and unselected head and neck squamous cell carcinoma (33.3%) (P < 0.001). The pooled prevalence of HPV in the 6,912 esophageal squamous cell carcinoma cases was 38.9% and it was significantly higher in China (44%) versus other regions (31.3%) (P < 0.05). Meta-analysis showed that head and neck and esophageal squamous cell carcinoma are associated with HPV infection (combined OR: 3.58, OR for head and neck and esophageal squamous cell carcinoma: 4.20). These findings suggest that HPV might be linked etiologically to the development of some upper aerodigestive tract tumors.

Squamous dysplasia--the precursor lesion for esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) accounts for 80% of all esophageal cancers worldwide, and esophageal squamous dysplasia (ESD) is the only histopathology that predicts the development of ESCC. The prevalence of ESD parallels rates of invasive ESCC and is typically found in 25% or more of adults above the age of 35 years in populations in north central China, where risk for ESCC is among the highest in the world. Results of chemoprevention and early detection studies to prevent progression of ESD suggest that these approaches, coupled with emerging endoscopic therapies, offer promise for the prevention of esophageal cancer mortality in high-risk populations. Future research on ESD and ESCC should focus on finding additional modifiable risk factors and on identifying biomarkers to incorporate into early detection strategies.

Role of human papillomaviruses in esophageal squamous cell carcinoma

Esophageal cancer (EC) is responsible for almost half a million deaths worldwide annually and has a multifactorial etiology, which may account for its geographical variation in incidence. In the last 30 years the potential of human papillomaviruses (HPV) as oncogenes or co-factors in the tumorigenic process of esophageal squamous cell carcinoma (ESCC) has been widely studied. While the etiology of HPV in cervical and certain other anogenital and aerodigestive cancers has been established, results regarding its role in EC have been largely inconclusive. A causal association can be evaluated only with a case-control study, where normal controls are compared to ESCC cases for the presence of HPV. We reviewed all studies investigating ESCC tissue for HPV DNA and identified 139 that met our inclusion criteria, of which only 22 were case-control studies. Our results support previous findings of higher levels of HPV detection in high-risk ESCC regions than in areas of low risk. In addition, we confirm that the role of HPV in ESCC remains unclear, despite an accumulation of studies on the subject. The variations in investigative technique, study design and sample types tested may account for the lack of consistency in results. There is a need for a meta-analysis of all case-control studies to date, and for large, well-designed case-control studies with adequate power to investigate the association. The potential benefits of prophylactic HPV vaccines could be evaluated if HPV is identified as an etiological factor in EC, highlighting the need for further research in this area.

Geographic origin is a significant determinant of human papillomavirus prevalence in oesophageal squamous cell carcinoma: systematic review and meta-analysis

BACKGROUND

Since the first reports in 1982 suggesting an aetiological role for human papillomavirus (HPV) in a subset of oesophageal squamous cell carcinomas (ESCC), the literature reporting HPV detection in ESCC has expanded rapidly. However no formal meta-analysis of this literature has been published yet. The objective of this study was to perform a systematic review and formal meta-analysis of the literature reporting HPV detection in ESCC.

METHODS

MEDLINE and Current Contents were searched through March 2012. The effect size was calculated as event rates and their 95% confidence interval (95% CI), with homogeneity testing using Cochran's Q and I² statistics. Meta-regression was used to test the impact of study-level covariates (HPV detection method, geographic origin of study) on effect size, and potential publication bias was estimated using funnel plot symmetry (Begg and Mazumdar rank correlation, Egger's regression, and Duval and Tweedie's trim and fill method).

RESULTS

Of the 1177 abstracts found, 152 studies were determined to be eligible for this meta-analysis. These 152 studies covered a total of 10,234 ESCC cases, analysed by different HPV detection methods in different geographic regions. Of these 10,234 cases, 3135 (30.6%) tested HPV-positive, translating to an effect size of 0.372 (95% CI 0.360-0.384; fixed effects model) and 0.290 (95% CI 0.251-0.31; random effects model). When stratified by HPV detection technique, there was a significant heterogeneity between the studies, but importantly, the between-strata summary comparison was not significant (random effects model; p = 0.440). In contrast, there was significant heterogeneity between the studies from the different geographic regions. In the maximum likelihood meta-regression, HPV detection method was not a significant study-level covariate, in contrast to the geographic origin of the study, which had a significant impact (p = 0.00005) on the summary effect size estimates. No evidence for significant publication bias was found in funnel plot symmetry testing. In the sensitivity analysis, all meta-analytic results appeared robust to all (n = 151) one-by-one study removals.

CONCLUSIONS

These meta-analysis results indicate that the reported wide variability in HPV detection rates in ESCC is not due to the HPV detection techniques, but is explained by the geographic origin of the study. These data substantiate the recently elaborated concept that ESCC might have a different aetiology in low-incidence and high-incidence geographic regions, HPV playing an important role only in the latter.

Genomic analysis of the first laboratory-mouse papillomavirus

A papillomavirus (PV) that naturally infects laboratory mice will provide an extremely valuable tool for PV research. We describe here the isolation, cloning and molecular analysis of the first novel laboratory-mouse PV, designated MusPV. This agent, recently identified in the tissues from florid and asymmetrical papillomas on the face of nude mice (NMRI-Foxn1(nu)/Foxn1(nu)), was demonstrated to be transmissible to immunocompetent mice (Ingle et al., 2010). The MusPV genome is 7510 bp in length, is organized similarly to those of other PVs and has at least seven ORFs (E1, E2, E4, E6, E7, L1 and L2). Phylogenetic analysis indicates that MusPV belongs to the π genus together with four other rodent PVs (McPV2, MaPV1, MmiPV and RnPV1). Of the rodent PVs, MusPV appears most closely related to Mastomys coucha PV (McPV2), with 65 % genomic homogeneity and 80 % L1 amino acid similarity. Rodent PVs, except for MnPV1, do not contain any identifiable retinoblastoma protein (RB) binding sites. MusPV has one putative RB-binding site on the E6 protein but not on the E7 protein. Non-coding regions (NCRs) of PVs maintain multiple binding sites for transcription factors (TFs). The NCR of MusPV has numerous sites for TF binding, of which at least 13 TFs are common to all PVs in the π genus. MusPV provides a potentially valuable, novel mouse model to study mechanisms of infection, oncology and novel preventive and therapeutic approaches in mice that can be translated to diseases caused by human PVs.

Frequency of human papillomavirus infection in oesophageal squamous cell carcinoma in Iranian patients

Human papillomavirus (HPV) is 1 of the possible aetiological factors in the development of oesophageal squamous cell carcinoma (ESCC). We aimed to study the role of HPV in ESCC. 140 cases of ESCC were analysed for the HPV DNA by polymerase chain reaction (PCR) using GP5+/GP6+ primers for L1 open reading frame (ORF) to amplify a 150 bp segment of HPV L1 ORF. This region was subsequently sequenced to identify the type of HPV. Of the 140 patients enrolled to our study 50.7% were female and 49.3% were male, aged between 20 and 81 y. 33 tumour specimens (23.6%) and 12 (8.6%) non-involved tumour margins were HPV positive. From HPV positive tumour cases 36% were positive in tumour margins. The HPV positive cases were 21.7% male and 25.3% female. There is no correlation between presence and types of HPV with patients' gender and age. The frequency of HPV subtypes in tumoural regions was as follows: HPV-16, 60.6%; HPV-18, 30.3%; HPV-33, 6.1%; and HPV-31, 3%. We found only HPV-16 in tumour margins. Our results are consistent with HPV studies conducted in other high-risk areas for ESCC and provided further evidence to support a causal association of HPV infection with ESCC.

Macaca fascicularis papillomavirus type 1: a non-human primate betapapillomavirus causing rapidly progressive hand and foot papillomatosis

Papillomaviruses (PVs) are a group of small, non-enveloped DNA viruses that cause mucosal or cutaneous neoplasia in a variety of animals. Whilst most papillomas will regress spontaneously, some may persist or undergo malignant transformation. In this study, aggressive, persistent and extensive warts were observed on the hands and feet of a cynomolgus macaque (Macaca fascicularis). The presence of PV in the wart biopsies was identified by immunohistochemistry and PCR amplification of PV DNA. The genomic DNA of this PV was cloned and sequenced, and the PV was designated M. fascicularis papillomavirus type 1 (MfPV-1). Its genome was 7588 bp in length and the organization of its putative open reading frames (E1, E2, E6, E7, L1, L2 and E4) was similar to that of other PVs. MfPV-1 had a short non-coding region (NCR) of 412 bp. Molecular analysis of MfPV-1 genomic DNA classified it into the genus Betapapillomavirus, to which all epidermodysplasia verruciformis (EV)-type PVs belong. Diseases caused by PVs of the genus Betapapillomavirus are usually associated with natural or iatrogenic immunosuppression. The genomic characterization performed in this study showed that MfPV-1 clustered within the genus Betapapillomavirus and also contained EV-type-specific motifs in its NCR. Further characterization of this virus and its host interactions may allow us to develop a non-human primate model for human betapapillomaviruses, a genus populated by human PV types causing EV.

Unique expression of human papilloma virus type 5 and type 16 in esophageal squamous cell carcinoma-a case report

The role of human papilloma virus (HPV) in esophageal cancers from the low-incidence area (Western population) is unclear. We report a case of esophageal squamous papillomatosis associated with underlying esophageal squamous cell carcinoma (OSCC). The esophagectomy specimen confirmed presence of HPV-5 and HPV-16 suggesting a viral etiology. The significance of this dual infection is not known, but it suggests that esophageal papillomatosis is premalignant and should receive regular endoscopic follow-up. This is the first report of both HPV-5 and HPV-16 DNA detected in an esophageal cancer occurring in the Western population.

No association between HPV infection and the neoplastic progression of esophageal squamous cell carcinoma: result from a cross-sectional study in a high-risk region of China

Esophageal cancer is a leading cause of cancer death, especially in developing countries. In high-risk regions, squamous cell carcinoma is the most common type of esophageal cancer, and its etiology remains poorly understood. The purpose of this study was to evaluate the association between human papillomavirus (HPV) infection and esophageal squamous cell carcinoma (ESCC) and related precursor lesions in a high-risk area of China. We conducted a cross-sectional study among adult inhabitants of Linxian, China. All subjects were interviewed about potential risk factors, had the length of their esophagus sampled by a balloon cytology examination and underwent endoscopy with mucosal iodine staining and biopsy of all unstained lesions. A multivalent HPV hybridization probe, Digene Hybrid Capture II (Gaithersburg, MD), which recognizes high-risk types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68, was used to determine the HPV infection status of the cytologic specimens, and the endoscopic biopsies were used to classify each subject's esophageal disease. 740 subjects completed the cytologic and endoscopic exams, and 702 had adequate cytologic and biopsy specimens. Using a cutpoint of > or =3.0 pg/ml of HPV DNA to define a positive test, HPV positivity was identified in 13% (61/475) of subjects without squamous dysplasia, 8% (8/102) with mild dysplasia, 7% (6/83) with moderate dysplasia, 16% (6/38) with severe dysplasia and zero (0/4) with invasive ESCC. Changing the cutpoint defining a positive test did not change the association of HPV infection and dysplasia grade. In this high-risk population, infection of esophageal cells with high-risk HPV types occurs in 13% of asymptomatic adults with no evidence of squamous dysplasia and a similar proportion of individuals with mild, moderate or severe dysplasia. This suggests that HPV infection is not a major risk factor for ESCC in this high-risk Chinese population. Further studies are warranted to determine if infection with this agent is associated with neoplastic progression in a subset of cases.

Human papillomavirus infection in Egyptian esophageal carcinoma: correlation with p53, p21, mdm2, C-erbB2 and impact on survival

The etiological role of human papillomavirus (HPV) in esophageal carcinoma (EC) in relation to p53, mdm2, p21(waf), c-erbB2 and the overall survival (OS) rate was investigated. Tumor and normal tissues from 50 EC were evaluated by polymerase chain reaction and InnoLiPA for HPV. Single strand conformation polymorphism/sequencing were used to detect p53 gene mutations. Immunohistochemistry was performed to determine p53, mdm2, p21(waf)and c-erbB2 expression. Human papillomavirus was detected in 54% of tumors and in 24% of normal tissues. p53, mdm2 and c-erbB2 overexpression was detected in 68%, 70% and 60% of tumors and in 14%, 16% and 10% of normal samples, whereas loss of p21(waf) was evident in 64% of tumors. p53 mutations were detected in 20% of cases. Exon 8 and 5 showed the highest mutation rate (40% each), followed by exons 6 and 7 (10% each). There was a significant correlation between HPV and p53, mdm2, c-erbB2 overexpression. The OS was significantly associated with overexpression of p53 and loss of p21(waf). Human papillomavirus infection is frequent in Egyptian EC. Both p53-dependent and p53-independent pathways seem to be involved in HPV-associated EC. mdm2 and c-erbB2 are possible targets for HPV in the p53-independent pathway. However, only advanced stage and aberrant expression of p53 and p21(waf) are independent prognostic markers.

HPV infections and oesophageal cancer

The first reports suggesting an involvement of human papillomavirus (HPV) in the development of both benign and malignant squamous cell tumours of the oesophagus date back to 1982. Since then, a substantial amount of literature has accumulated on this subject, summarised in this review. To date, 239 oesophageal squamous cell papillomas have been analysed in 29 separate studies using different HPV detection methods, with HPV being detected in 51 (21.3%) cases. Many more squamous cell carcinomas have been analysed: of the 1485 squamous cell carcinomas analysed by in situ hybridisation, 22.9% were positive for HPV DNA, as were 15.2% of the 2020 cases tested by the polymerase chain reaction. In addition, evidence derived from large scale serological studies, animal experiments, and in vitro studies is discussed in the light of the highly variable geographical incidence rates of oesophageal carcinoma worldwide. It may be that the (multifactorial) aetiology of oesophageal cancer differs greatly between those geographical areas with a low risk and those with a high risk for this disease. Oncogenic HPV types seem to play an important causal role, particularly in high risk areas.

HPV infections and oesophageal cancer

The first reports suggesting an involvement of human papillomavirus (HPV) in the development of both benign and malignant squamous cell tumours of the oesophagus date back to 1982. Since then, a substantial amount of literature has accumulated on this subject, summarised in this review. To date, 239 oesophageal squamous cell papillomas have been analysed in 29 separate studies using different HPV detection methods, with HPV being detected in 51 (21.3%) cases. Many more squamous cell carcinomas have been analysed: of the 1485 squamous cell carcinomas analysed by in situ hybridisation, 22.9% were positive for HPV DNA, as were 15.2% of the 2020 cases tested by the polymerase chain reaction. In addition, evidence derived from large scale serological studies, animal experiments, and in vitro studies is discussed in the light of the highly variable geographical incidence rates of oesophageal carcinoma worldwide. It may be that the (multifactorial) aetiology of oesophageal cancer differs greatly between those geographical areas with a low risk and those with a high risk for this disease. Oncogenic HPV types seem to play an important causal role, particularly in high risk areas.

Human papillomavirus involvement in esophageal carcinogenesis in the high-incidence area of China. A study of 700 cases by screening and type-specific in situ hybridization

BACKGROUND

Human papillomavirus (HPV) DNA has been identified in esophageal precancerous lesions and carcinomas. However, there are marked variations in the prevalence of HPV infection reported in different studies. Most previous studies on HPV and esophageal carcinomas have been based on a limited number of biopsy samples studied by different HPV detection methods with highly variable sensitivity and specificity, making systematic studies of larger series clearly warranted.

METHODS

A series of 1876 surgical specimens (primary tumor, adjacent epithelium, regional lymph nodes, resection margins) from 700 patients surgically resected for an invasive squamous cell carcinoma of the esophagus in the high-incidence area of China was analyzed for the presence of HPV DNA with screening in situ hybridization (ISH) using biotinylated HPV DNA probes and followed by type-specific ISH for HPV 6, 11, 16, 18, 30, and 53.

RESULTS

Of the 700 esophageal carcinomas, 118 (16.9%) were shown to contain HPV DNA sequences by screening ISH. Positive signals were most frequent in the cancer cells (16.6%), more rare in the surrounding hyperplastic and dysplastic epithelia (5.6%), and infrequently present in the resection margins (0.2%). HPV signals were also detected in cancer cells in 6.9% of the lymph node metastases. HPV types 6, 11, 16, 18, and 30 account for 39.8% of the HPV-positive lesions, of which the high-risk types HPV 16 and 18 were present in 27.1% (32 of 118). Notably, 60.2% of the HPV-positive lesions contained DNA sequences other than HPV types 6, 11, 16, 18, 30, and 53.

CONCLUSIONS

This study reports the largest series of esophageal cancers ever analyzed for the presence of HPV DNA. Our results confirm the presence of common mucosal HPV types in esophageal carcinomas but also suggest the involvement of other (novel?) HPV types that are unusually detected in genital cancers in a significant proportion of these lesions. The results further indicate that HVP has an etiologic role in esophageal carcinogenesis, at least in the high-incidence area of northern China.

High prevalence of human papillomaviruses in the normal oral cavity of adults

Human papillomavirus (HPV) infection in the normal oral cavity was studied by the sensitive polymerase chain reaction (PCR) using primers for the L1 region of human papillomavirus DNA and high fidelity amplification system. Cells were scraped from the oral mucosae of 7 (mean age; 42 years) and 30 (mean age; 32 years) volunteers with and without skin warts, respectively. Human papillomavirus DNA was detected in 30/37 (81.1%) specimens and their copy numbers per cell were 10(-1) to 10(-4) (mean, 10(-3)). The human papillomavirus types determined by PCR-based sequencing analysis were HPV-18 (26/30; 86.7%), -61 (18/30; 60%), -59 (7/30; 23.3%), -16 (2/30; 6.7%), -6 (1/30; 3.3%) and an unknown type (HPV-X71) (1/30; 3.3%). Multiple human papillomavirus types were present in 17/30 (56.7%) specimens. HPV-6 was detected in 2 of 7 skin warts and differed from the human papillomavirus types of the corresponding oral specimens. These data suggest that human papillomavirus infection in the oral mucosa occurs much more frequently than previously considered.

Squamous cell papillomatosis of esophagus following placement of a self-expanding metal stent

The esophageal self-expanding metal stent has gained widespread acceptance for the management of tracheoesophageal fistulas and the palliative management of malignant esophageal strictures. The complications associated with its use can be classified as either immediate or delayed. The most frequent delayed complications include tumor ingrowth, stent migration, reflux of gastric contents, bleeding, and perforation. This case report illustrates an otherwise unrecognized delayed complication of a self-expanding metal stent. Near complete ingrowth of the stent by squamous mucosal hyperplasia occurred within six weeks of the metal stent's placement. This finding supports the hypothesis that mucosal injury and regeneration underlies the etiology of esophageal squamous cell papilloma formation.

Esophageal papillomatosis from human papilloma virus proven by polymerase chain reaction

Human papilloma viruses (HPVs) are known to infect the genitourinary tract, the skin, the anal canal, and the upper respiratory tract. Esophageal papillomas and especially HPV-induced squamous papillomas of the esophagus are rare. The authors report a case of extensive HPV-induced esophageal polyposis, which was probably sexually transmitted. The 53-year-old female patient presented with chronic diarrhea and had occult blood in the stool. She underwent esophagogastroduodenoscopy, at which time multiple esophageal polyps were observed and biopsy specimens obtained. Histologic evaluation was consistent with benign papillomas. Polymerase chain reaction and DNA hybridization of the biopsied tissue specimens confirmed the diagnosis of HPV infection. Because of our observation and because of HPV's relationship to cervical and esophageal cancer, further evaluation of HPV as the cause of esophageal papillomatosis and as a risk factor for esophageal cancer is warranted.

Human papillomavirus and oesophageal squamous cell carcinoma in the UK

Human papillomavirus (HPV) has previously been identified in up to 67% of squamous cell carcinomas of the oesophagus. In particular, HPV types of 16 and 18 are believed to play an important role in neoplastic transformation, by means of their oncoproteins E6 and E7. Most of these studies, however, pertain to areas of high incidence of squamous cell carcinoma of the oesophagus (the Far East and South Africa). It is not known if HPV plays any role in the development of oesophageal squamous cell carcinoma in the UK, where the tumour is relatively uncommon. The polymerase chain reaction was used to examine frozen tissue from 22 oesophageal squamous cell carcinomas for the presence of specific DNA sequences from oncogenic strains of HPV. PCR products were further analysed by Southern blot hybridization. No HPV sequences were detected in any tumours. These results suggest that these types of HPV are not associated with oesophageal squamous cell carcinoma in this country. It is unlikely, therefore, that HPV plays a significant role in the pathogenesis of squamous cell carcinoma of the oesophagus in the UK.

Presence of human papillomavirus in esophageal squamous cell carcinomas of Hong Kong Chinese and its relationship with p53 gene mutation

There is no scientific study that has investigated the association between human papilloma virus (HPV) and p53 mutation in Hong Kong Chinese patients with esophageal cancers. The aim of this survey is to evaluate in details the prevalence and relationship of HPV and p53 mutation in these patients with esophageal squamous cell carcinomas. Fresh tissues from the resected specimens of 70 Chinese patients (59 men, 11 women) with primary esophageal squamous cell carcinomas (20 well-differentiated, 36 moderately differentiated, and 14 poorly differentiated squamous cell carcinomas) were tested for the presence of HPV and p53 mutation using the polymerase chain reaction (PCR), single-strand conformational polymorphism (SSCP) analysis, and DNA sequencing. No HPV type 18 was detected, whereas HPV type 16 was identified in 8.6% (6 of 75) of the cases. p53 mutation was found in 44% (31 of 70) of the tumors. The mean ages of HPV-positive and HPV-negative groups of patients were 55 and 64 years, respectively (P = .046, t-test). There was no correlation between the prevalence of HPV and p53 mutation in these tumors. The presence of HPV and p53 also had no relation to the sex of the patients or to the grade of the carcinomas. It is concluded that the overall low prevalence of HPV in esophageal carcinomas may suggest that the virus may not play an important role in the pathogenesis of these tumors in Hong Kong Chinese patients. Also, p53 mutation and integrated HPV DNA are not mutually exclusive in esophageal cancer.

Risk factors for squamous cell carcinoma of the oesophagus

Cancer of the oesophagus has great diversity in geographical distribution and incidence. The rate of oesophageal cancer has been increasing in some areas and the reasons for this are not clear. This review outlines fascinating epidemiological aspects and the risk factor for squamous cell carcinoma of the oesophagus. While in the Western world the effects of alcohol and tobacco are substantial preconditions, worldwide other factors, such as diet, nutritional deficiencies, environmental exposure and infectious agents (especially papillomavirus and fungi), play a significant role. Chronic irritation of the oesophagus appears to participate in the process of carcinogenesis, particularly in patients with thermal and/or mechanical injury, achalasia, oesophageal diverticulum, chronic lye stricture, radiation therapy, injection sclerotherapy and gastric resection before the appearance of oesophageal tumour. The association of Plummer-Vinson syndrome, coeliac disease, tylosis and scleroderma with oesophageal cancer has also been reviewed.

Risk factors for squamous cell carcinoma of the oesophagus

Cancer of the oesophagus has great diversity in geographical distribution and incidence. The rate of oesophageal cancer has been increasing in some areas and the reasons for this are not clear. This review outlines fascinating epidemiological aspects and the risk factor for squamous cell carcinoma of the oesophagus. While in the Western world the effects of alcohol and tobacco are substantial preconditions, worldwide other factors, such as diet, nutritional deficiencies, environmental exposure and infectious agents (especially papillomavirus and fungi), play a significant role. Chronic irritation of the oesophagus appears to participate in the process of carcinogenesis, particularly in patients with thermal and/or mechanical injury, achalasia, oesophageal diverticulum, chronic lye stricture, radiation therapy, injection sclerotherapy and gastric resection before the appearance of oesophageal tumour. The association of Plummer-Vinson syndrome, coeliac disease, tylosis and scleroderma with oesophageal cancer has also been reviewed.

Type 73 human papillomavirus in esophageal squamous cell carcinoma: a novel association

BACKGROUND

Human papillomaviruses (HPVs) commonly cause proliferative lesions of squamous epithelia, and infection with certain HPV types carries a high risk of malignant transformation, especially in the uterine cervix but also at other sites, including the esophagus. We used molecular techniques to detect and type HPV in an in situ squamous cell carcinoma in the esophagus of a 39-year old woman.

METHODS

DNA was extracted from paraffin sections of the esophageal lesion and of the uterine cervix (which was removed several years earlier), and analyzed for HPV by polymerase chain reaction (PCR). Primers complementary to highly conserved regions of the open reading frame of most genital HPVs were used to amplify a approximately 450 base pair product that contained both conserved and divergent regions. The PCR products were hybridized with probes specific for HPV-6, HPV-11, HPV-16, and HPV-18, and with a consensus probe. A conspicuous band in the esophageal sample failed to hybridize with any of the probes. The amplimer was subcloned and sequenced. The sequence was compared with other known HPVs.

RESULTS

The intraepithelial neoplasia in the patient's cervical cone biopsy contained HPV-16. The esophageal lesion contained HPV that did not hybridize with probes for types 6, 11, 16, or 18, but exhibited 98.3% homology with HPV-73.

CONCLUSIONS

Squamous cell carcinoma in situ of the esophagus may be associated with infection by HPV-73.

Absence of human papillomavirus DNA detected by polymerase chain reaction in French patients with esophageal carcinoma

BACKGROUND & AIMS

Recent studies have suggested that esophageal human papillomavirus infection could be a risk factor for esophageal squamous cell carcinoma. The aim of this study was to evaluate the prevalence of human papillomavirus DNA sequences in the esophagus of French patients with esophageal squamous cell carcinoma.

METHODS

Multiplex polymerase chain reactions with consensus primers directed to the L1 gene or specific primers for human papillomavirus types 6, 11, 16, 18, 31, and 33 directed to E6 gene (40 cycles followed by restriction mapping of the amplified products) were used to determine the presence of human papillomavirus DNA sequences in esophageal squamous cell carcinoma (n = 75), normal adjacent mucosa (n = 49), and metastatic lymphadenopathies (n = 5). As an internal control, a target located in the embryonic myosin heavy-chain gene was used in each reaction.

RESULTS

Human papillomavirus DNA sequences could not be detected in any of the tumoral samples, the normal adjacent mucosa, or the metastatic lymphadenopathies.

CONCLUSIONS

Human papillomavirus seems not to be implicated in esophageal carcinogenesis, at least in French patients, because the viral genomes are not associated with esophageal squamous cell carcinomas.

High prevalence of human papillomavirus in squamous cell carcinoma and matched normal esophageal mucosa: assessment by polymerase chain reaction

BACKGROUND

Studies using DNA technology have reported the presence of human papillomavirus (HPV) DNA in esophageal carcinomas, suggesting that it could play a role in the pathogenesis of this tumor. In the present study, in addition to DNA from neoplasms, normal mucosa was screened for viral DNA, assuming that this would increase HPV detection substantially.

METHODS

Seventeen patients with esophageal carcinoma and 10 control subjects were studied. In 8 of the patients, normal mucosa was also available. Polymerase chain reaction (PCR) was performed using primers for the E6 region of HPV-16 and HPV-18. Koilocytosis, a commonly accepted histopathologic marker of viral infection, was studied, and results were correlated with PCR findings.

RESULTS

DNA from neoplastic lesions was positive for HPV-16 and HPV-18 in 8 of 16 (50%) and in 3 of 16 (18.8%), respectively. When tumor tissue and normal mucosa were available, PCR results were 3 of 8 (37.5%), 5 of 8 (62.5%), and 8 of 8 (100%) for HPV-16, in tumor, normal mucosa, and both. For HPV-18, results were 0 of 8 (0%), 5 of 8 (62.5%), and 5 of 8 (62.5%), respectively. In comparison with tumor samples, positivity in normal mucosa was increased for HPV-18 and for both viral genotypes (P = 0.01). No amplification was obtained in the control group. Koilocytosis was present in 33% of the cases.

CONCLUSIONS

These results suggested a high prevalence of HPV in esophageal carcinoma. The detection rate is significantly higher in normal mucosa specimens, suggesting that infection probably antedates tumor development. Koilocytosis was substantially less sensitive than PCR.

Morphological analysis of gastro-esophageal diseases by molecular cell techniques

The molecular cell sciences have had a great impact in the analysis of the genetic and epigenetic events of esophageal and gastric tumorigenesis. In other regions of the alimentary tract such as the colon, the serial identification of the molecular events in the corresponding morphological lesions is perhaps most advanced. This is, in part, due to the relative ease of the histological characterisation of the premalignant lesions. In this regard the analysis of morphological and molecular adaptation in the alimentary tract is inextricable. This review aims, therefore, to judiciously assess the relative applications of contemporary techniques in investigative histopathology.

Detection of human papillomavirus DNA in esophageal squamous cell carcinomas by the polymerase chain reaction using general consensus primers

We studied 40 formalin-fixed, paraffin-embedded esophageal squamous cell carcinomas from a high risk region for this tumor for the presence of human papillomavirus (HPV) DNA by the polymerase chain reaction (PCR). We used two general consensus primers from a highly conserved E1 region of HPV types 6, 11, 16, and 18. Human papillomavirus DNA was detected in 60% (24 of 40) of the cases without relation to the tumor grade. Two lymph node metastases had the same HPV types as the primary tumor. Human papillomavirus types were determined in the 24 HPV-positive cases by Southern blot analysis of amplified DNA. Human papillomavirus type 6 was detected in 50% (12 of 24) of the cases, HPV type 16 in 8% (two of 24), and HPV types 6 and 16 in 17% (four of 24); in 25% (six of 24) of the cases the type was unknown. Human papillomavirus types 11 and 18 were not detected. Esophageal mucosa adjacent to the tumor was studied for morphological changes of HPV effect in 27 cases. Adjacent esophageal mucosa in 16 HPV-positive tumors showed statistically significant (P < .05) koilocytosis in six cases. Papillomatosis was the next most frequent finding in four cases. This study supports the role of HPV in the causation of esophageal squamous cell carcinomas, especially in high risk regions for this tumor.

Squamous cell papillomas of the esophagus: a study of 23 lesions for human papillomavirus by in situ hybridization and the polymerase chain reaction

This study assessed squamous cell papillomas of the human esophagus for the presence of human papillomavirus (HPV) and correlated the results with histological features. Twenty-three lesions obtained by endoscopic biopsy from 17 patients were studied, first by in situ hybridization (ISH) for HPV types 6-11, 16-18, 18, and 31-33-51, and second by the polymerase chain reaction (PCR) with amplification of multiple HPV types and demonstration of amplified product by ethidium bromide staining and Southern blot hybridization for HPV types 6-11, 16, and 18 in each case. Evidence of HPV DNA was found in only one lesion, which showed HPV type 6-11 by ISH and HPV positivity by Southern blotting of the amplified product after the PCR. This case exhibited histological features suggestive of HPV infection, although no morphological changes specific to the lesion were identified. The remaining 22 lesions, including those from cases in which multiple papillomas were present, were negative for HPV. The results show that HPV DNA is frequently not detectable in esophageal squamous cell papillomas, even when highly sensitive techniques are used. These findings are consistent with the hypothesis that other pathogenetic mechanisms, such as mucosal injury and repair, are important in the etiology of these lesions.

Esophageal infections: risk factors, presentation, diagnosis, and treatment

Infections of the esophagus are unusual in the general population and strongly imply immunodeficiency, although immunocompetent individuals are not exempt. HIV infection is predominant among risk factors for infectious esophagitis. For all immunocompromised patients, the most frequently identified esophageal pathogens are Candida, CMV, and HSV. Peculiar to HIV-infected patients are idiopathic esophageal ulcers as well as unusual bacteria and parasites. Patterns of presentation differ with each infecting organism, and clinical features should be used as a guide in achieving a correct diagnosis. For example, a patient with AIDS presenting with esophageal symptoms and thrush, along with abdominal pain, nausea, vomiting, and fever, is unlikely to resolve all symptoms with empiric antifungal therapy alone. Parsimony of diagnosis does not hold among immunodeficient patients in whom concurrent infections are common. Accurate and timely diagnoses are essential as effective treatments are available for particular etiologies. Finally, among immunocompromised patients, all esophageal symptoms are not necessarily due to an infection, and possible diagnoses of pill esophagitis, acid-peptic injury, or structural and functional abnormalities should not be overlooked.

Screening for human papillomavirus infections in esophageal squamous cell carcinomas by in situ hybridization

BACKGROUND

Infections with specific types of human papillomavirus (HPV) have been closely linked with human squamous cell carcinomas, those of the anogenital tract in particular. Increasing number of reports also suggest that HPV infection could be a risk factor for esophageal cancer. However, most of the previous studies on HPV involvement in esophageal carcinomas have included only small numbers of biopsy specimens, thus necessitating additional studies based on extensive series of esophageal samples.

METHODS

A series of 776 biopsy specimens derived from 363 patients who had undergone esophagectomy for squamous cell carcinoma in the high-incidence area of China were analyzed for the presence of HPV DNA by screening and specific typing in situ hybridization with biotinylated HPV DNA probes.

RESULTS

Under low-stringency conditions, 85 (23.4%) tumors were demonstrated to contain HPV DNA: Positive signals were found on the nuclei of cancer cells in 71 (19.6%), in the surrounding epithelial cells with hyperplastic or dysplastic changes in 13 (3.6%), in the cancer cells and the surrounding epithelial cells in 10 (2.8%), and in the resected margins in 1 (0.3%). Thirty-four (40%) of the 85 HPV-positive tumors were shown to contain at least one type of HPV 6, 11, 16, 18, or 30 DNA sequences. HPV 16 was the type found most frequently, occurring in 18.8% of the 85 HPV-positive specimens. In addition to the primary tumors, HPV DNA sequences were found in 12.3% (7 of 57) of the lymph node metastases.

CONCLUSION

The results confirm the previously reported HPV involvement in esophageal squamous cell lesions and implicate HPV as a potential etiologic agent in the multifactorial pathogenesis of esophageal carcinoma.

Infectious agents in the etiology of esophageal cancer

Extensive epidemiological and experimental studies have suggested that some chemical agents, nutritional deficiencies, and physical factors are associated with the development of esophageal cancer (EC). Recent evidence also suggests an etiologic role of certain microorganisms in esophageal carcinogenesis either by producing carcinogens or promotors or by acting directly on the host cells. The mutagenic and carcinogenic effects of several fungi and bacteria isolated from the grains and foodstuffs in high-risk areas have been shown by in vitro and in vivo studies. Certain viruses, e.g., human papillomavirus, herpes simplex virus, cytomegalovirus, and Epstein-Barr virus, have been implicated in the pathogenesis of a variety of human cancers, and all of them are known to produce tumors in animals and cell transformation in vitro. These viruses also have been shown to infect the esophageal epithelium. Therefore, although many of the key issues of their mechanisms of action are unclear as yet, they should be considered potential etiologic agents of EC. The present review summarizes the data available on the etiology of EC, emphasizing the current evidence implicating an etiologic role of microorganisms in the pathogenesis of this malignancy.

Human papillomavirus involvement in esophageal precancerous lesions and squamous cell carcinomas as evidenced by microscopy and different DNA techniques

A series of 71 surgically resected esophageal squamous cell carcinomas, including 51 cases of formalin-fixed samples and 20 cases of fresh biopsy specimens derived from the high-incidence area of esophageal cancer in China, were systematically analyzed for the presence of human papillomavirus (HPV) infections by light microscopy, electron microscopy (TEM), in situ DNA hybridization, Southern blot hybridization, and polymerase chain reaction (PCR) techniques. On light microscopy, HPV-suggestive lesions were found in a total of 49.0% (25 of 51) of the specimens, including the flat type (22 of 51) and, less frequently, an inverted one (2 of 51). Of the 51 formalin-fixed, paraffin-embedded specimens, 43.1% (22 of 51) contained HPV DNA sequences by in situ hybridization. Of the positive cases, HPV 6 was present in three (5.9%), HPV 11 in three (5.9%), HPV 16 in eight (15.7%), HPV 18 in six (11.8%), double infections with HPV 11/18 in one (2.0%), and HPV 16/18 in one. In most cases the HPV-positive signals were localized in the hyperplastic and/or dysplastic epithelium adjacent to invasive carcinomas. In two specimens, however, HPV DNA sequences were found in the frankly invasive lesions, one being HPV 6 and the other HPV 18. On TEM, HPV-like particles located in the nuclei of koilocytotic cells were demonstrated in two of the five specimens previously shown to be HPV-positive by in situ hybridization. By means of the PCR technique, all specimens positive for HPV by in situ hybridization also contained amplified HPV sequences. Moreover, three additional samples negative by in situ hybridization were found to contain HPV 11 DNA sequences. Of the 20 DNA samples extracted from the fresh carcinoma samples (containing some surrounding tissues as well) 9 were shown to contain HPV DNA sequences by Southern blot hybridization under low-stringency conditions. Of these, eight samples remained positive when hybridized with the probe cocktail of HPV 11, 16, 18, and 30 DNA under high-stringency conditions. HPV DNA sequences in these carcinoma specimens appeared to be present mainly in an integrated form. The present results confirm the HPV involvement in esophageal squamous cell lesions and suggest that HPV infection might be an important etiologic factor in the pathogenesis of esophageal cancer, most probably acting synergistically with other carcinogenic factors.

Squamous papilloma of the esophagus associated with the human papillomavirus

Squamous cell papilloma of the esophagus is a rare lesion involving less than 60 case reports worldwide. These lesions are generally asymptomatic but may at times grow and spread rapidly. One fatality, a result of massive dissemination, has been reported. Until recently, human papillomavirus had not been identified in association with esophageal papillomas. A second case, to the authors' knowledge, of esophageal papillomas associated with human papillomavirus is reported. The virus has been previously shown to be associated with abnormal squamous epithelium in and adjacent to esophageal carcinoma. The virus was identified from biopsy specimens obtained at endoscopy using DNA in situ hybridization techniques. The strain of human papillomavirus identified is similar to those found in the oropharynx and genital tract, raising the possibility of sexual transmission. This case also differs from the previous case report involving the human papillomavirus because of the patient's benign clinical course. Our case serves to highlight differences that are perhaps unique to the human papillomavirus. Multiple papillomas found in a proximal location within the esophagus seem to favor involvement of the human papillomavirus. Isolated lesions located distally appear more characteristic of chronic gastroesophageal reflux as an etiology. The syndrome of squamous cell papillomas involving the esophagus is reviewed in the article.

Verrucous carcinoma of the leg positive for human papillomavirus DNA 11 and 18: a case report

Human papillomavirus (HPV) types 6 and/or 11 have been associated with benign lesions, while types 16, 18, 31, and 33 are prevalent in malignant lesions. This case report describes the findings in a verrucous carcinoma of the leg, which was examined for HPV types 11, 16, and 18 by in situ DNA hybridization. The lesion gave positive results for HPV subtypes 11 and 18, a combination that, to our knowledge, has not been previously reported in this neoplasm.

Human papillomavirus (HPV) infections and their associations with oral disease

More than 65 distinct types of human papillomavirus (HPV) have been identified to date. Several of the HPV types have been proposed as etiologic agents of squamous cell carcinoma. In the oral cavity, HPVs have been found associated with several benign squamous cell proliferations. Evidence from histology and DNA hybridization studies suggests that HPV is also involved in oral carcinogenesis. It is apparent, however, that substantial amount of confusion exists in the diagnosis of oral HPV infections. The keratotic, papillary lesions in the oral cavity are usually small and easily overlooked. The gross appearance of these viral lesions is not distinct enough to be readily diagnosed by the clinicians. Degenerative changes found on oral mucosa frequently simulate koilocytosis. Thus, caution should be exercised to avoid overdiagnosis of HPV infection in the oral cavity. The present review summarizes the current evidence available on HPV infections in general and on oral HPV infections in particular. The diagnostic techniques available as well as the problems encountered in the distinction of these lesions are also discussed in short.

Esophageal squamous cell papillomas. Failure to detect human papillomavirus DNA by in situ hybridization and polymerase chain reaction

Squamous cell papilloma of the esophagus has been regarded as a distinct rarity. After having reviewed the files of the Gastrointestinal Endoscopy Unit of our hospital we found 14 patients diagnosed as having an esophageal papilloma on endoscopy of about 18,000 patients during the period 1985-90. On histologic examination of the biopsy specimens 12 cases showed histologic characteristics typical of a squamous cell papilloma (SQP), 1 was a fibroid polyp, and another showed epithelial dysplasia without the features typical of SQP. To assess the role of human papillomavirus (HPV) recently implicated in the etiology of this tumor, we analyzed all specimens for the presence of HPV types 6, 11, 16, and 18 DNA by in situ DNA hybridization (ISH) and polymerase chain reaction (PCR). No viral DNA was found by either ISH or PCR in any of these lesions. The significance of these findings is discussed in relation to the previous evidence presented on HPV involvement in the development of esophageal squamous cell papillomas and in esophageal carcinogenesis.