Clinical relevance and implications of HPV-induced neoplasia in different anatomical locations

Elucidating the clonal relationship of esophageal second primary tumors in patients with laryngeal squamous cell carcinoma

Laryngeal cancer ranks as the second most prevalent upper airway malignancy, following Lung cancer. Although some progress has been made in managing laryngeal cancer, the 5-year survival rate is disappointing. The gradual increase in the incidence of second primary tumors (SPTs) plays a crucial role in determining survival outcomes during long-term follow-up, and the esophagus was the most common site with a worse prognosis. In clinical practice, the treatment of esophageal second primary tumors (ESPT) in patients with laryngeal squamous cell carcinoma (LSCC) has always been challenging. For patients with synchronous tumors, several treatment modalities, such as radiotherapy, chemotherapy and potentially curative surgery are necessary but are typically poorly tolerated. Secondary cancer therapy options for metachronous patients are always constrained by index cancer treatment indications. Therefore, understanding the clonal origin of the second primary tumor may be an important issue in the treatment of patients. LSCC cells demonstrate genetic instability because of two distinct aetiologies (human papillomavirus (HPV)-negative and HPV-positive) disease. Various etiologies exhibit distinct oncogenic mechanisms, which subsequently impact the tissue microenvironment. The condition of the tissue microenvironment plays a crucial role in determining the destiny and clonal makeup of mutant cells during the initial stages of tumorigenesis. This review focuses on the genetic advances of LSCC, the current research status of SPT, and the influence of key carcinogenesis of HPV-positive and HPV-negative LSCC on clonal evolution of ESPT cells. The objective is to gain a comprehensive understanding of the molecular basis underlying the clonal origins of SPT, thereby offering novel perspectives for future investigations in this field.

Potential Therapeutic Targets of Formononetin, a Type of Methoxylated Isoflavone, and Its Role in Cancer Therapy through the Modulation of Signal Transduction Pathways

Cancer is one of the main causes of death in all developed and developing countries. Various factors are involved in cancer development and progression, including inflammation and alterations in cellular processes and signaling transduction pathways. Natural compounds have shown health-promoting effects through their antioxidant and anti-inflammatory potential, having an important role in the inhibition of cancer growth. In this regard, formononetin, a type of isoflavone, plays a significant role in disease management through the modulation of inflammation, angiogenesis, cell cycle, and apoptosis. Furthermore, its role in cancer management has been proven through the regulation of different signal transduction pathways, such as the signal transducer and activator of transcription 3 (STAT 3), Phosphatidyl inositol 3 kinase/protein kinase B (PI3K/Akt), and mitogen activating protein kinase (MAPK) signaling pathways. The anticancer potential of formononetin has been reported against various cancer types, such as breast, cervical, head and neck, colon, and ovarian cancers. This review focuses on the role of formononetin in different cancer types through the modulation of various cell signaling pathways. Moreover, synergistic effect with anticancer drugs and methods to improve bioavailability are explained. Thus, detailed studies based on clinical trials are required to explore the potential role of formononetin in cancer prevention and treatment.

Precursors, pathways of carcinogenesis and molecular markers of vulvar squamous cell carcinoma. Literature review

The review analyzes and summarizes the results of the studies on the pathogenesis of  vulvar squamous cell carcinoma and its diagnostic features, reviews precursors and  molecular subtypes of carcinomas. Despite the relatively low incidence of this tumor, over the past few decades, there has been an upward trend in its incidence, including the incidence among young women. According to the latest World Health Organization classification of lower genital tumors from 2020, vulvar squamous cell carcinoma is divided into human papillomavirus (HPV) associated and HPV-independent. While these carcinomas are often morphologically similar, their mechanisms of carcinogenesis, precursors, and clinical outcomes are different. Just the detection of virus DNA in a tumor is not enough to establish HPV status. Meanwhile immunohistochemical detection of the expression of p16 and p53 proteins allows not only to separate two pathogenetic pathways of carcinogenesis, but also to identify its molecular subtypes. The data on the possible use of p16 and p53 expression as the disease prognosis molecular markers have been obtained. Currently, the tactics of treatment and monitoring patients does not depend on the HPV status of carcinoma; however, the results of recent studies suggest that women with HPV positive vulvar cancer have significantly higher survival rates and a lower risk of recurrence. Understanding the mechanisms of carcinogenesis and improving its diagnosis will advance the assessment of the individual risk of the progression of precancerous lesions, as well as the outcome and the occurrence of tumor recurrence. 

Factors Related to HPV Vaccination Intention among MSM in China: A Bayesian Network Model

(1) Background: Men who have sex with men (MSM) are at high risk of human papillomavirus (HPV) infection, and HPV vaccination is the best strategy to prevent HPV infection. Accepting HPV vaccination is an essential factor affecting vaccine promotion among MSM. We aimed to explore the factors related to HPV vaccination intention among MSM and analyze the potential relationship between these factors. (2) Methods: We adopted a nonprobability sampling method to recruit MSM volunteers. Information collection included general demographics, personal behavioral characteristics, knowledge of HPV/vaccine attitudes, and risk threat perception. Bayesian networks (BNs) were used to analyze the data statistically. (3) Results: The BNs showed that perceived HPV risk and attitudes toward vaccine promotion were directly correlated factors, whereas knowledge of HPV/vaccines, a history of HIV testing, and the number of male sexual partners in the past 6 months were indirectly correlated factors. (4) Conclusions: The results of this study illustrate that MSM have a relatively high propensity to receive HPV vaccines. The proposal that strengthening the propagation of HPV and its relevant vaccines, encouraging MSM to undergo regular corresponding tests, and improving their risk perception of HPV infection can be raised to promote HPV vaccination among MSM.

Taxifolin and Lucidin as Potential E6 Protein Inhibitors: p53 Function Re-Establishment and Apoptosis Induction in Cervical Cancer Cells

Simple Summary

Human papillomavirus (HPV)-related cancers continue to be a major medical concern, and there exists an urgent need to improve the current therapeutic approaches by combining strategies or proposing new compounds to offer more specific and less invasive treatments. The aim of this work was to discover potential inhibitors of the E6/E6AP/p53 complex formation. We started this work with an initial in silico approach including molecular docking and molecular dynamics simulations, and these tools allowed us to select potential inhibitors, using E6 protein as a target. In addition, we found that lucidin and taxifolin were able to selectively decrease the viability of HPV-positive cells to re-establish p53 protein levels and to induce apoptosis. These findings represent a promising starting point for the development of anti-HPV drugs.

Abstract

Cervical cancer is the fourth leading cause of death in women worldwide, with 99% of cases associated with a human papillomavirus (HPV) infection. Given that HPV prophylactic vaccines do not exert a therapeutic effect in individuals previously infected, have low coverage of all HPV types, and have poor accessibility in developing countries, it is unlikely that HPV-associated cancers will be eradicated in the coming years. Therefore, there is an emerging need for the development of anti-HPV drugs. Considering HPV E6’s oncogenic role, this protein has been proposed as a relevant target for cancer treatment. In the present work, we employed in silico tools to discover potential E6 inhibitors, as well as biochemical and cellular assays to understand the action of selected compounds in HPV-positive cells (Caski and HeLa) vs. HPV-negative (C33A) and non-carcinogenic (NHEK) cell lines. In fact, by molecular docking and molecular dynamics simulations, we found three phenolic compounds able to dock in the E6AP binding pocket of the E6 protein. In particular, lucidin and taxifolin were able to inhibit E6-mediated p53 degradation, selectively reduce the viability, and induce apoptosis in HPV-positive cells. Altogether, our data can be relevant for discovering promising leads for the development of specific anti-HPV drugs.

The Involvement of Human Papilloma Virus in Gastrointestinal Cancers

Human Papilloma Virus (HPV) is one of the most common sexually transmitted infections worldwide. HPV infection has a strong relationship with the onset of cervix uteri, vagina, penis, anus, and oropharynx, but also tonsils and tongue cancers. Some epidemiological data indicate that except for gynecologic cancers, HPV infection can be one of the risk factors associated with a greater risk of induction and progression of gastrointestinal cancers. Data, however, remain contradictory and definite conclusions cannot be drawn, so far. The following review aims to organize recent evidence and summarize the current state of knowledge regarding the association between HPV infection and gastrointestinal tumors primarily focusing on esophageal, liver, gastric, colorectal, and anal cancers.

Design of a Phase III efficacy, immunogenicity, and safety study of 9-valent human papillomavirus vaccine in prevention of oral persistent infection in men

BACKGROUND

Seven high-risk human papillomavirus (HPV) types (16/18/31/33/45/52/58) covered by the 9-valent HPV (9vHPV) vaccine cause >90% of HPV-related head and neck cancers (HNCs). An ongoing clinical trial (NCT04199689) was designed to evaluate 9vHPV vaccine efficacy against HPV oral persistent infection, a surrogate endpoint for HPV-related HNCs.

METHODS

In this double-blind, placebo-controlled, international trial, men aged 20-45 years (N = 6000) are randomized 1:1 to receive 9vHPV vaccine or placebo on day 1, month 2, and month 6. The primary objective is to demonstrate whether 9vHPV vaccination reduces incidence of HPV16/18/31/33/45/52/58-related 6-month oral persistent infection. Incidence of HPV6/11-related 6-month oral persistent infection will be evaluated as a secondary endpoint. Oral rinse and gargle samples will be collected on day 1, month 7, month 12, and every 6 months thereafter for HPV detection by PCR. Primary analyses will be performed in per-protocol populations. Efficacy in this case-driven study will be analyzed upon accrual of ≥20 primary efficacy endpoint cases. Serum will be collected at day 1 and months 7, 12, 24, 36, and 42; anti-HPV antibody titers will be measured by competitive Luminex immunoassay. Data will be summarized as geometric mean titers and seropositivity rates. Injection-site and systemic adverse events (AEs) will be collected for 15 days post-any vaccination and serious AEs through 6 months after the last vaccination; deaths and vaccine-related serious AEs will be collected throughout the study.

DISCUSSION

This trial is expected to generate important data regarding the potential for 9vHPV vaccine to prevent HPV-related head and neck disease.

Prevalence and genotype specific concordance of oro-genital and anal human papillomavirus infections among sexually active Nigerian women

BACKGROUND

Human papillomavirus (HPV) associated cancers are increasingly reported globally, including in sub-Saharan Africa (SSA). However, with the exception of cervical HPV infection, data from SSA on the epidemiology of oral and genital HPV infections are limited. This study assessed the prevalence and concordance of oro-genital and anal HPV genotype specific infections among women in the general population.

METHODS

We conducted a cross-sectional study in sexually active women aged 18-45 years in Ibadan, Nigeria. After a face-to-face interview and clinical examination, oral, cervical, vulvar, and anal samples were collected from participants and tested by the Anyplex II 28 HPV assay. Descriptive and multivariable analyses were used to report prevalence and risk factors associated with HPV infections.

RESULTS

The prevalence of any vulva, cervical, anal, and oral HPV infections was 68.0% (210/309), 59.7% (182/305), 56.8% (172/303), and 16.1% (14/286), respectively. There was an inverse relationship between age-group and HPV prevalence of HPV in all anatomic sites except for the oral HPV infections. HPV 35 was the most prevalent high-risk HPV genotype in the vulva, cervix and oral cavity. Associated risk factors for HPV infection in each of the anatomic sites were reported. Overall, 10.0% (31/310) women had concordance of any HPV type in the four anatomic sites.

CONCLUSION

There was a high prevalence of oro-genital and anal HPV infections among sexually active Nigerian women, with concordance of HPV types in the cervix, vulva, anus and oral cavity. We advocate large longitudinal studies that will involve sampling of multiple anatomic sites and inclusion of other women in the community for better understanding of HPV epidemiology in this region.

In Silico Approaches: A Way to Unveil Novel Therapeutic Drugs for Cervical Cancer Management

Cervical cancer (CC) is the fourth most common pathology in women worldwide and presents a high impact in developing countries due to limited financial resources as well as difficulties in monitoring and access to health services. Human papillomavirus (HPV) is the leading cause of CC, and despite the approval of prophylactic vaccines, there is no effective treatment for patients with pre-existing infections or HPV-induced carcinomas. High-risk (HR) HPV E6 and E7 oncoproteins are considered biomarkers in CC progression. Since the E6 structure was resolved, it has been one of the most studied targets to develop novel and specific therapeutics to treat/manage CC. Therefore, several small molecules (plant-derived or synthetic compounds) have been reported as blockers/inhibitors of E6 oncoprotein action, and computational-aided methods have been of high relevance in their discovery and development. In silico approaches have become a powerful tool for reducing the time and cost of the drug development process. Thus, this review will depict small molecules that are already being explored as HR HPV E6 protein blockers and in silico approaches to the design of novel therapeutics for managing CC. Besides, future perspectives in CC therapy will be briefly discussed.

Reciprocal transactivation of Merkel cell polyomavirus and high-risk human papillomavirus promoter activities and increased expression of their oncoproteins

BACKGROUND

Approximately 15% of human cancers are attributed to viruses. Numerous studies have shown that high-risk human polyomaviruses (HR-HPV) and Merkel cell polyomavirus (MCPyV) are two human tumor viruses associated with anogenetal and oropharyngeal cancers, and with Merkel cell carcinoma, respectively. MCPyV has been found in HR-HPV positive anogenetal and oropharyngeal tumors, suggesting that MCPyV can act as a co-factor in HR-HPV induced oncogenesis. This prompted us to investigate whether the oncoproteins large T-antigen (LT) and small antigen (sT) of MCPyV could affect the transcriptional activity HPV16 and HPV18 and vice versa whether HPV16 and HPV18 E6 and E7 oncoproteins affected the expression of MCPyV LT and sT. Reciprocal stimulation of these viral oncoproteinscould enhance the oncogenic processes triggered by these tumor viruses.

METHODS

Transient co-transfection studies using a luciferase reporter plasmid with the long control region of HPV16 or HPV18, or the early or late promoter of MCPyV and expression plasmids for LT and sT, or E6 and E7, respectively were performed in the HPV-negative cervical cancer cell line C33A, in the keratinocyte cell line HaCaT, and in the oral squamous cell carcinoma cell line HSC-3. Transfections were also performed with deletion mutants of all these promoters and with mutants of all four oncoproteins. Finally, the effect of E6 and E7 on LT and sT expression in the MCPyV-positive Merkel cell carcinoma cell line WaGa and the effect of LT and sT on the expression of E6 and E7 was monitored by Western blotting.

RESULTS

LT and sT stimulated the transcriptional activity of the HPV16 and HPV18 LCR and v.v. E6 and E7 potentiated the MCPyV early and late promoter in all cell lines. Induction by E6 and E7 was p53- and pRb-independent, and transactivation by LT did not require DNA binding, nuclear localization and HSC70/pRb interaction, whereas sT stimulated the HPV16/18 LCR activity in a PP2A- and DnaJ-independent manner.

CONCLUSIONS

These results indicate that the co-infection of MCPyV may act as a co-factor in the initiation and/or progression of HPV-induced cancers.

Multicentre Investigation of Prognostic Factors Incorporating p16 and Tumour Infiltrating Lymphocytes for Anal Cancer After Chemoradiotherapy

AIMS

Anal squamous cell carcinomas (ASCC) are strongly associated with human papillomaviruses. Standard of care is chemoradiotherapy at uniform doses with no treatment stratification. Immunohistochemical staining for p16INK4A (p16), a surrogate for human papillomaviruses, is prognostic for outcomes. We investigated this alongside clinical-pathological factors, including tumour infiltrating lymphocyte (TIL) scores.

MATERIALS AND METHODS

Using an independent, multicentre cohort of 257 ASCC treated with chemoradiotherapy, pretreatment biopsies were stained and scored for p16 and TIL. Kaplan-Meier curves were derived for outcomes (disease-free survival [DFS], overall survival and cancer-specific survival), by stage, p16 and TIL scores and Log-rank tests were carried out to investigate prognostic effect. A multivariate analysis was carried out using Cox regression.

RESULTS

Stage, sex, p16 and TILs were independently prognostic. Hazard ratios for death (overall survival) were 2.51 (95% confidence interval 1.36-4.63) for p16 negative versus p16 positive, 2.17 (1.34-3.5) for T3/4 versus T1/2, 2.42 (1.52-3.8) for males versus females and 3.30 (1.52-7.14) for TIL1 versus TIL3 (all P < 0.05).

CONCLUSIONS

We have refined prognostic factors in ASCC. p16 adds to stratification by stage with respect to DFS in early disease and overall survival/DFS in locally advanced cancers. Our data support the role of the host immune response in mediating outcomes. These factors will be prospectively evaluated in PLATO (ISRCTN88455282).

HPV DNA/RNA detection in various oral and oropharyngeal biomaterials identifies active HPV infections also in non-neoplastic tonsils

Previous studies describe a correlation between HPV-positivity and non-smoking in TSCC; p16^INK4A-expression as surrogate-marker for HPV-DNA/RNA-positivity is discussed controversially. In the present study, these parameters are assessed prospectively. HPV-status of sputum and tonsillar-swabs was analyzed to determine their validity as surrogate-marker for tissue-HPV-status. TSCC- (n = 52) and non-neoplastic tonsillar tissue (n = 163) were analyzed. HPV-DNA- and HPV-RNA-status of total sputum, cellular fraction and supernatants, tonsillar-swabs and -tissue was determined by (RT)-PCR. Immunohistochemistry determined p16^INK4A-expression. 23/163 (14.2%) non-neoplastic tonsils were HPV-DNA-positive; five patients (3 HPV16, 2 HPV11) had active HPV-infections (HPV-RNA-positive), in all biomaterials. 140/163 (85.9%) patients were either HPV-DNA-positive or HPV-DNA-negative in all samples. 21/52 (40.4%) TSCC-tonsils were HPV-DNA-positive; 17 patients were HPV-RNA-positive (14 HPV16; 4 HPV18). 40/52 (76.9%) TSCC-patients were congruent in all biomaterials. p16^INK4A-expression alone would have misclassified the HPV-status of 14/52 (26.2%) TSCC-patients. This prospective study confirms the discrepancy between HPV-status and p16^INK4A-expression and the significant correlation between non-smoking and HPV-DNA-positivity. HPV-sputum- and/or swab-results do not consistently match tissue-results, possibly having (detrimental) consequences if those were used to assess tissue-HPV-status. In the 5 patients with active HPV infection in the non-neoplasitic tonsils, tonsillectomy likely prevented subsequent development of TSCC.

Targeted Therapeutic Approaches in Vulvar Squamous Cell Cancer (VSCC): Case Series and Review of the Literature

Therapeutic options in recurrent or metastasized vulvar squamous cell cancer (VSCC) not amenable to radiotherapy or radical surgery are limited. Evidence for the use of targeted therapies is sparse. All patients with VSCC treated at the Gynecological Cancer Center Hamburg-Eppendorf 2013–2019 were retrospectively evaluated for targeted therapeutic approaches. Furthermore, a MEDLINE, EMBASE, Web of Science, Scopus, and OVID database search was performed using the terms: “vulvar cancer” AND “targeted therapy,” “erlotinib,” “EGFR,” “bevacizumab,” “VEGF,” “pembrolizumab,” or “immunotherapy.” Twelve of 291 patients (4.1%) with VSCC received at least one targeted therapy at our institution. Previously, one or more platinum-based chemotherapy was applied to all patients [median 3.5 previous lines (range 2–5)]. In the erlotinib subgroup, two of five patients (40%) achieved stable disease (SD), while two patients (2/5, 40%) experienced partial response (PR). Treatment was given as monotherapy in second/third line for a median of 3.4 months (range 2–6 months). Bevacizumab (n = 9) was given as maintenance therapy after platinum-based first-line chemotherapy (9/9); best response was complete response (CR) (n = 2/9 22.2%). Median duration of treatment was 7 months (range 4–13 months) with two patients still under ongoing treatment. Best response in the pembrolizumab (n = 3) subset was SD (n = 1/3 33%). Treatment was given as monotherapy in second/third line for a median of 3.3 months (range 3–4 months). Nine of 12 patients (75%) experienced treatment-related adverse events (TRAEs), most commonly grade 1/2. Rapidly evolving antibody treatments have proven clinical benefit especially in HPV-driven tumor entities; however, clinical investigations in VSCC are still limited. These reported cases provide evidence for the clinical utility and feasibility while ensuring an acceptable safety profile.

Evaluation of cytopathological screening results and risk factors of women who underwent Papanicolaou test in a maternity school in Fortaleza, Ceará, Brazil

INTRODUCTION

Papanicolaou test (Pap smear) is the standard screening test of pre-neoplastic lesions and cervical cancer. This study aimed to investigate cervical cancer screening results and risk factors such as age, reason for the examination, the epithelia detected in the sample, microbiota and signs of sexually transmitted infection (STIs) of women in a maternity school in Fortaleza, Ceará, Brazil.

METHODS

In this cross-sectional study, data were retrieved of 353 women who underwent Pap smear between April 2016 and January 2017 at the Federal University of Ceará.

RESULTS

Of all Pap smear samples retrieved, 54.1% (191/353) had glandular epithelium and 40.2% (142/353) had metaplastic epithelium. After statistical analyses adjusted for the final model, age ≥51 years (odds ratio = 3.47) and signs of STIs (odds ratio = 4.95) remained as risk factors.

CONCLUSIONS

The diagnosis of high-grade lesions and carcinomas in patients older than 50 years indicates a deficiency in cervical screening. Women with signs and symptoms of STIs and candidiasis sought medical services more frequently than asymptomatic women, and presence of these signs and symptoms contributes to the diagnosis of cervical cancer. We highlight the importance of obtaining a correct smear sampling to allow prompt detection of all preneoplastic lesions; moreover, the implementation of human papillomavirus vaccination and an efficient routine Pap screening are necessary in low-resource settings.

Multiplex HPV RNA in situ hybridization/p16 immunohistochemistry: a novel approach to detect papillomavirus in HPV-related cancers. A novel multiplex ISH/IHC assay to detect HPV

BACKGROUND

High-risk human papillomavirus (HR-HPV) is notoriously associated with tumor progression in a broad spectrum of malignancies. Detection of HR-HPV is clinically important in the management of HPV-related carcinomas, particularly in cervical cancer and oropharyngeal squamous cell carcinoma (OPSCC). Several methods for HPV detection are currently available including Polymerase chain reaction (PCR)-based techniques, DNA in situ hybridization (ISH), RNA ISH, and p16 immunohistochemistry (IHC). Currently, the guidelines for HPV detection in cervical carcinoma are available, while no clear consensus has not yet been reached on the gold standard for HPV testing in OPSCC. Multimodality testing could help to reliably identify patients with transcriptionally active high-risk HPV-positive.

METHODS

We propose a multiplex approach carrying out HPV RNA ISH and p16 IHC on the same slide to detect simultaneously HPV E6/E7 transcripts and p16INK4a overexpression. We tested this assay in two different series one of the cervical cancers with p16-positive, as control, and the other of oropharyngeal squamous cell carcinomas with blind p16 status.

RESULTS

The multiplex HPV RNA ISH /p16 IHC results in the series both of the cervical cancers and the oral-oropharyngeal cancers were fully concordant with the previous results achieved through the classic p16 IHC and HPV RNA scope carried out on two different slides.

CONCLUSIONS

Our results suggesting several advantages of this technical approach, namely an easy interpretation fully in the light field, the feasibility in formalin-fixed paraffin-embedded tissue sections, complete automation and a potential wide spreadable for routine testing in several clinical laboratories.

Insertional oncogenesis by HPV70 revealed by multiple genomic analyses in a clinically HPV-negative cervical cancer

Cervical carcinogenesis, the second leading cause of cancer death in women worldwide, is caused by multiple types of human papillomaviruses (HPVs). To investigate a possible role for HPV in a cervical carcinoma that was HPV-negative by PCR testing, we performed HPV DNA hybridization capture plus massively parallel sequencing. This detected a subgenomic, URR-E6-E7-E1 segment of HPV70 DNA, a type not generally associated with cervical cancer, inserted in an intron of the B-cell lymphoma/leukemia 11B (BCL11B) gene in the human genome. Long range DNA sequencing confirmed the virus and flanking BCL11B DNA structures including both insertion junctions. Global transcriptomic analysis detected multiple, alternatively spliced, HPV70-BCL11B, fusion transcripts with fused open reading frames. The insertion and fusion transcripts were present in an intraepithelial precursor phase of tumorigenesis. These results suggest oncogenicity of HPV70, identify novel BCL11B variants with potential oncogenic implications, and underscore the advantages of thorough genomic analyses to elucidate insights into HPV-associated tumorigenesis.

The impact of p16ink4a positivity in invasive vulvar cancer on disease-free and disease-specific survival, a retrospective study

Purpose

To evaluate HPV and p16^ink4a status as prognostic factors in patients with invasive vulvar cancer.

Methods

Retrospective analysis of disease-free (DFS) and disease-specific survival (DSS) of patients with invasive vulvar cancer at a single tertiary care center. Histology, HPV and p16^ink4a status were evaluated in the context of a global multicenter trial. Logistic regression models were performed to identify the impact of p16^ink4a positivity.

Results

135 patients were included in the analysis. 32 (23.7%) showed a p16^ink4a expression of over 25%. Disease-free and disease-specific survival was longer in p16^ink4a positive patients (23 vs. 10 months, p = 0.004, respectively, 29 vs. 21 months, p = 0.016). In multivariate analysis, p16^ink4a positivity was an independent parameter for DFS (p = 0.025, HR: 2.120 (1.100–4.085)), but not for DSS (p = 0.926, HR: 1.029 (0.558–1.901), in contrast to age and tumor stage.

Conclusions

Age and tumor stage negatively affect survival. However, disease-free survival is significantly longer in patients with p16^ink4a positive invasive vulvar cancer.

Overexpression of p16INK4a Serves as Prognostic Marker in Squamous Cell Vulvar Cancer Patients Treated With Radiotherapy Irrespective of HPV-Status

Purpose: We aimed to evaluate the impact of HPV-driven carcinogenesis on outcome in vulvar squamous cell carcinoma patients (VSCC) treated with radiotherapy.

Methods and Materials: Analysis of clinical, pathological, and treatment data, HPV DNA-detection and -genotyping as well as p16^INK4a immunohistochemistry were performed in 75 VSCC patients. Kaplan–Meier-method was used to estimate locoregional control (LC), Progression-free survival (PFS), and Overall Survival (OS). Univariate survival time comparisons were performed using the log-rank-test. Chi-square/Fisher exact test was used to assess correlations between HPV DNA and p16^INK4a data, pathological, clinical, and treatment characteristics.

Results: 23/75 (30.67%) of all women had locoregional relapse, 7/75 (9.3%) systemic recurrence, and 35/75 (46.67%) died after a median follow-up of 26.4 months. 21.3% of the tumors were HPV DNA-positive, mostly (93.75%) for the high-risk (HR) HPV type 16. 25.3% showed p16^INK4a-overexpression. 17.3% showed concomitant HPV DNA- and p16^INK4a-positivity (cHPPVC). Patients with p16^INK4a-overexpression, irrespective of the HPV DNA status, showed significantly better PFS (5-year-PFS 69.3 vs. 39.2%, p = 0.045), LC (5-year-LC 86.7 vs. 56.7%, p = 0.033) and a strong trend for better OS (5-year-OS 75.6 vs. 43.9%, p = 0.077). Patients with cHPPVC showed a trend for better PFS (5-year-PFS 72.7 vs. 41.3%, p = 0.082) and OS (5-year-OS 81.1 vs. 45.7%, p = 0.084) but no significant benefit for LC.

Conclusions: Patients with cHPPVC, indicating an etiological relevance of HPV in the respective tumors, showed a better, albeit not significant, prognosis. The sole detection of p16^INK4a-overexpression is a prognostic factor for survival in vulvar cancer and indicates better prognosis after radiotherapy, independent of detection of HPV DNA. p16^INK4a should be used as surrogate marker for HPV-driven carcinogenesis in vulvar cancer with caution.

Evaluation of human papillomavirus DNA detection-guided aminolaevulinic acid-mediated photodynamic therapy for the treatment of condyloma acuminata

BACKGROUND

Aminolaevulinic acid-mediated photodynamic therapy (ALA-PDT) is used to treat condyloma acuminata (CA), yielding a high clearance rate and low recurrence rate. Consecutive human papillomavirus (HPV) DNA detection can be used to dynamically monitor the therapeutic efficiency of PDT. Here, we evaluated the efficacy of ALA-PDT in the context of different HPV infection states.

METHODS

One hundred thirty-eight patients with HPV infection and visible anogenital warts were enrolled. Microwave or radiofrequency was used to remove visible lesions before PDT. HPV DNA detection was performed using real-time polymerase chain reaction before each PDT session and at follow-up. Treatment was halted after the patient showed two negative results for HPV DNA detection in a row.

RESULTS

Of the 138 patients enrolled in the study, 72 completed treatment. Multisite HPV-infected patients required more sessions of PDT than did single-site infected patients to reach the endpoint of treatment. Compared with patients with only external CA, individuals with internal CA required more sessions to eliminate HPV infection. The total number of PDT sessions performed in the multitype HPV-infected group was significantly higher than that in the single-type infected group. Patients with non-high-risk (HR)-HPV infection required fewer PDT sessions than did those with HR-HPV infection by the end of treatment. Sixty-nine patients were followed-up for at least 6 months, only 2.9% of whom showed recurrence.

CONCLUSIONS

Combined ALA-PDT and HPV DNA detection was an effective strategy for the treatment of CA. Patients with multisite and multitype HPV infection required more PDT sessions to eliminate the virus.

Increasing Incidence rates of Oropharyngeal Squamous Cell Carcinoma in Germany and Significance of Disease Burden Attributed to Human Papillomavirus

Increasing incidences of head and neck cancers and rising proportions of these associated with human papillomavirus (HPV), especially in the oropharynx, have been reported in international studies. So far, the trends and contribution of HPV to the number of newly diagnosed cases of oropharyngeal squamous cell carcinomas (OPSCC) in Germany are uncertain. We investigated HPV association and incidence rates in a cohort of consecutively included patients with OPSCC in Giessen 2000-2017, and compared our results with regional (Giessen and the federal state of Hesse), national (Germany), and international (United States) databases. Regional data show a significant increase in the overall incidence rates of oropharyngeal cancers and in the incidence of HPV-associated cancers of the subsites tonsils and oropharynx, whereas other oropharyngeal subsites show no significant change. Analysis of national databases shows a significant incidence increase in Germany and in the United States. The rise in incidence is predominantly attributable to male patients in the US population, whereas in Germany rising OPSCC incidence is more associated with females. There is a significant elevation of OPSCC incidence rates in Germany, which corresponds to the recognized incidence increase of HPV-related oropharyngeal cancers based on experimental data from consecutively included patients of our cohort. Our investigation shows different patterns of this increase in Germany and in the United States, which demonstrates spatial heterogeneity and the need for population-based investigations regarding the role of HPV in oropharyngeal cancer.

Human Papillomavirus Infection in Female Sex Workers: A Case Control Study

Background

To determine the association of infection with human papillomavirus (HPV) and the occupation of female sex worker; and the correlation of infection with HPV with sociodemographic, clinical and behavioral characteristics of female sex workers.

Methods

We performed a case-control study of 217 female sex workers and 354 women without sex work in Durango City, Mexico. We determined the prevalence of infection with HPV in cervical samples of women using polymerase chain reaction, and HPV genotypes were determined using line probe assay. Bivariate and multivariate analyses were used to assess the association between the characteristics of women and infection.

Results

Twelve (5.5%) of the 217 sex workers, and 10 (2.8%) of the 354 control women were positive for HPV DNA (age-adjusted OR = 1.51; 95% CI: 0.62 - 3.68; P = 0.36). Six (50.0%) of the 12 HPV DNA positive sex workers had infections with high-risk genotypes (16, 31, 33, 35, 51, 58). Seven (70%) of the 10 HPV DNA positive control women had infections with high-risk genotypes (16, 18, 56, 58, and 66). The frequency of high risk genotypes in the control women was equal with that found in the female sex workers (P = 0.41). Logistic regression analysis showed that the variable alcohol consumption was associated with HPV infection (OR = 4.0; 95% CI: 1.0 - 16.0; P = 0.04).

Conclusions

No association between HPV infection and female sex work was found in our setting. High risk HPV genotypes were prevalent among the women studied. Results can be used for the design of preventive measures against HPV infection.

Human oncoviruses: Mucocutaneous manifestations, pathogenesis, therapeutics, and prevention: Papillomaviruses and Merkel cell polyomavirus

In 1964, the first human oncovirus, Epstein-Barr virus, was identified in Burkitt lymphoma cells. Since then, 6 other human oncoviruses have been identified: human papillomavirus, Merkel cell polyomavirus, hepatitis B and C viruses, human T-cell lymphotropic virus-1, and human herpesvirus-8. These viruses are causally linked to 12% of all cancers, many of which have mucocutaneous manifestations. In addition, oncoviruses are associated with multiple benign mucocutaneous diseases. Research regarding the pathogenic mechanisms of oncoviruses and virus-specific treatment and prevention is rapidly evolving. Preventative vaccines for human papillomavirus and hepatitis B virus are already available. This review discusses the mucocutaneous manifestations, pathogenesis, diagnosis, treatment, and prevention of oncovirus-related diseases. The first article in this continuing medical education series focuses on diseases associated with human papillomavirus and Merkel cell polyomavirus, while the second article in the series focuses on diseases associated with hepatitis B and C viruses, human T-cell lymphotropic virus-1, human herpesvirus-8, and Epstein-Barr virus.

Smoking-Induced SLPI Expression Hinders HPV Infections Also in Squamous Cell Carcinomas of the Vulva

In HNSCC, protein- and mRNA-expression of the antileukoproteinase SLPI are significantly inverse correlated with HPV-infection suggesting that elevated expression of SLPI protects against HPV-infections. Moreover, SLPI-expression is up-regulated in HNSCC-patients reporting a smoking habit. Here, we investigate the described correlation in other HPV-driven cancers, namely vulvar squamous cell carcinoma (VSCC). FFPE samples of 99 VSCC were analyzed by PCR for HPV-DNA-expression and by RT-qPCR for SLPI-mRNA-expression. Of 99 VSCC 10 (10.1%) are HPV-positive; 9 were HPV16; 1 HPV18; all were E6/E7 mRNA-positive. 33 of the 99 patients (33.3%) reported a smoking habit; 7 (21.1%) of these were HPV-positive. Of 66 (66.7%) non-smokers 3 (4.5%) were HPV-positive. SLPI-expression was 4.0-fold lower in HPV-positive than HPV-negative patients. Smoking resulted in 2.3-fold higher SLPI expression. The data presented here indicate that SLPI plays a pivotal role in HPV-infection not only in HNSCC but also in VSCC and possibly also in other HPV-driven cancers. This however, needs to be analyzed in future studies. Furthermore these data lead to the hypothesis that the smoking induced SLPI-increase is systemic rather than local, as assumed based on the HNSCC data.

Association of HIV status with infection by multiple HPV types

OBJECTIVES

To identify the clinical and demographic characteristics of HIV-positive and HIV-negative women infected by multiple HPV types.

METHODS

1399 women participated in the study (240 HIV-positive and 1159 HIV-negative women). Samples were provided for Pap tests and for HPV detection and typing by PCR. Data were collected on HPV infection, frequency of multiple infection, and HPV type distribution. Odds ratios were reported from logistic regression models.

RESULTS

Compared with HIV-negative women, HIV-positive women had higher frequencies of cervical abnormality (30% vs. 20.8%), higher HPV prevalence (68.3% vs. 51.3%) and were more commonly infected with multiple HPV types (78.7% vs. 44.3%). HPV-16 was the most common type detected in the study population, with other types showing variable associations with HIV status. Positive associations were observed between infection by multiple HPV types and HIV status, cervical abnormality and having had more than three pregnancies. The odds of multiple infection by HPV types were higher in HIV-positive women who used an intrauterine device, who had a history of abortions and who had HIV viral loads >100 000 copies/ml, whilst the odds were lower in women with >500 CD4 cells/mm³ .

CONCLUSIONS

HIV immunosuppression favours infection by multiple high-risk HPV types, mainly in women affected by low-grade squamous intraepithelial lesions. Antiretroviral therapy had no effect on infection by multiple HPV types. Risk factors related to progressive damage to the cervix were positively associated with infection by multiple HPV types in women living with HIV.

Alkyl-imino sugars inhibit the pro-oncogenic ion channel function of human papillomavirus (HPV) E5

Despite the availability of prophylactic vaccines the burden of human papillomavirus (HPV) associated malignancy remains high and there is a need to develop additional therapeutic strategies to complement vaccination. We have previously shown that the poorly characterised E5 oncoprotein forms a virus-coded ion channel or viroporin that was sensitive to the amantadine derivative rimantadine. We now demonstrate that alkylated imino sugars, which have antiviral activity against a number of viruses, inhibit E5 channel activity in vitro. Using molecular modelling we predict that imino sugars intercalate between E5 protomers to prevent channel oligomerisation. We explored the ability of these viroporin inhibitors to block E5-mediated activation of mitogenic signalling in keratinocytes. Treatment with either rimantadine or imino sugars prevented ERK-MAPK phosphorylation and reduced cyclin B1 expression in cells expressing E5 from a number of high-risk HPV types. Moreover, viroporin inhibitors also reduced ERK-MAPK activation and cyclin B1 expression in differentiating primary human keratinocytes containing high-risk HPV18. These observations provide evidence of a key role for E5 viroporin function during the HPV life cycle. Viroporin inhibitors could be utilised for stratified treatment of HPV associated tumours prior to virus integration, or as true antiviral therapies to eliminate virus prior to malignant transformation.

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Imino sugars inhibit the viroporin activity of the E5 oncoprotein.

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Imino sugars likely interact at E5 protomer interfaces within a channel to prevent oligomerisation.

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Imino sugars and adamantanes block mitogenic signalling mediated by E5 from a range of high-risk HPV types.

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Viroporin inhibitors reduce mitogenic signalling in differentiating primary keratinocytes containing high-risk HPV18.

Risk of Human Papillomavirus Infection in Cancer-Prone Individuals: What We Know

Human papillomavirus (HPV) infections cause a significant proportion of cancers worldwide, predominantly squamous cell carcinomas (SCC) of the mucosas and skin. High-risk HPV types are associated with SCCs of the anogenital and oropharyngeal tract. HPV oncogene activities and the biology of SCCs have been intensely studied in laboratory models and humans. What remains largely unknown are host tissue and immune-related factors that determine an individual's susceptibility to infection and/or carcinogenesis. Such susceptibility factors could serve to identify those at greatest risk and spark individually tailored HPV and SCC prevention efforts. Fanconi anemia (FA) is an inherited DNA repair disorder that is in part characterized by extreme susceptibility to SCCs. An increased prevalence of HPV has been reported in affected individuals, and molecular and functional connections between FA, SCC, and HPV were established in laboratory models. However, the presence of HPV in some human FA tumors is controversial, and the extent of the etiological connections remains to be established. Herein, we discuss cellular, immunological, and phenotypic features of FA, placed into the context of HPV pathogenesis. The goal is to highlight this orphan disease as a unique model system to uncover host genetic and molecular HPV features, as well as SCC susceptibility factors.

Non Melanoma Skin Cancer Pathogenesis Overview

(1) Background: Non-melanoma skin cancer is the most frequently diagnosed cancer in humans. The process of skin carcinogenesis is still not fully understood. However, several studies have been conducted to better explain the mechanisms that lead to malignancy; (2) Methods: We reviewed the more recent literature about the pathogenesis of non-melanoma skin cancer focusing on basal cell carcinomas, squamous cell carcinoma and actinic keratosis; (3) Results: Several papers reported genetic and molecular alterations leading to non-melanoma skin cancer. Plenty of risk factors are involved in non-melanoma skin cancer pathogenesis, including genetic and molecular alterations, immunosuppression, and ultraviolet radiation; (4) Conclusion: Although skin carcinogenesis is still not fully understood, several papers demonstrated that genetic and molecular alterations are involved in this process. In addition, plenty of non-melanoma skin cancer risk factors are now known, allowing for an effective prevention of non-melanoma skin cancer development. Compared to other papers on the same topic, our review focused on molecular and genetic factors and analyzed in detail several factors involved in non-melanoma skin cancer.

Perceived cervical cancer risk among women treated for high-grade cervical intraepithelial neoplasia: The importance of specific knowledge

Objective

Women with high-grade cervical intraepithelial neoplasia (CIN) are at increased risk for developing cervical cancer. We examine how women with high-grade CIN perceive their own risk, and about pertinent knowledge concerning human high-risk papillomavirus (HPV), CIN and cervical cancer.

Methods

All patients who underwent first-time treatment of high-grade CIN (grade 2+) were followed-up at 6-months at the Karolinska University Hospital, Stockholm, Sweden and were invited to participate in the present study. This included completion of a questionnaire examining sociodemographic characteristics, self-perceived risk of cervical cancer without regular gynecologic follow-up, and 14 queries about HPV, CIN and cervical cancer knowledge, inter alia.

Results

The participation rate was 96.6%, with 479 women enrolled in this study. Over 75% were age 40 or younger, over half had completed university education. Most were married or co-living with their partner and were gainfully employed. On a scale scored from 10 (highest self-perceived risk of cervical cancer without regular gynecologic follow-up) to 1 (lowest self-perceived risk), 64% rated their risk ≥ 7; almost 30% viewed their risk ≤ 6 and 7.5% did not rate their risk. A Specific Knowledge Scale with six of the queries explained 58.3% of the total variance. Nearly 30% of the women answered four or fewer of the six queries correctly. The Specific Knowledge Scale predicted self-perceived cervical cancer risk (Odds ratio = 11.3, 95% Confidence Interval 5.6 − 22.6) after adjusting for age, income and education. Most of the women with low self-perceived cervical cancer risk did not rate their HPV-related knowledge as good. However, 32 predominantly university-educated women, with low self-perceived cervical cancer risk, considered their HPV-related knowledge good.

Conclusion

It is vital to effectively convey accurate information about these patients’ cervical cancer risk, needed preventive and follow-up measures, together with the relevant specific knowledge, for these women at increased risk for developing cervical cancer. Tailored programming to address these knowledge gaps is needed.

Viral Oncology: Molecular Biology and Pathogenesis

Oncoviruses are implicated in approximately 12% of all human cancers. A large number of the world's population harbors at least one of these oncoviruses, but only a small proportion of these individuals go on to develop cancer. The interplay between host and viral factors is a complex process that works together to create a microenvironment conducive to oncogenesis. In this review, the molecular biology and oncogenic pathways of established human oncoviruses will be discussed. Currently, there are seven recognized human oncoviruses, which include Epstein-Barr Virus (EBV), Human Papillomavirus (HPV), Hepatitis B and C viruses (HBV and HCV), Human T-cell lymphotropic virus-1 (HTLV-1), Human Herpesvirus-8 (HHV-8), and Merkel Cell Polyomavirus (MCPyV). Available and emerging therapies for these oncoviruses will be mentioned.

Somatic Host Cell Alterations in HPV Carcinogenesis

High-risk human papilloma virus (HPV) infections cause cancers in different organ sites, most commonly cervical and head and neck cancers. While carcinogenesis is initiated by two viral oncoproteins, E6 and E7, increasing evidence shows the importance of specific somatic events in host cells for malignant transformation. HPV-driven cancers share characteristic somatic changes, including apolipoprotein B mRNA editing catalytic polypeptide-like (APOBEC)-driven mutations and genomic instability leading to copy number variations and large chromosomal rearrangements. HPV-associated cancers have recurrent somatic mutations in phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) and phosphatase and tensin homolog (PTEN), human leukocyte antigen A and B (HLA-A and HLA-B)-A/B, and the transforming growth factor beta (TGFβ) pathway, and rarely have mutations in the tumor protein p53 (TP53) and RB transcriptional corepressor 1 (RB1) tumor suppressor genes. There are some variations by tumor site, such as NOTCH1 mutations which are primarily found in head and neck cancers. Understanding the somatic events following HPV infection and persistence can aid the development of early detection biomarkers, particularly when mutations in precancers are characterized. Somatic mutations may also influence prognosis and treatment decisions.