Human immunodeficiency virus infection is a major risk factor for detection of human papillomavirus DNA in esophageal brushings

Self-expanding metal stents (SEMS) for patients with advanced esophageal cancer in Malawi: an effective palliative treatment

BACKGROUND AND OBJECTIVES

Esophageal cancer is common in Malawi and most patients are inoperable at time of diagnosis. The aim of this study was to prospectively evaluate palliative treatment with self-expanding metal stents (SEMS) in Malawi, a low-income country with limited medical resources.

METHODS

Data of patients with advanced inoperable esophageal cancer were prospectively collected. Tumor and patient specifics, risk factors, dysphagia scores, complications, and survival were assessed. Follow-up data for 1 year or until death were collected from 118/143 patients (83%) during clinic visits, home visits, or via cell phone.

RESULTS

One hundred forty-three patients were treated with 154 SEMS. Median survival was 210 days (95% CI: 150-262 days). Fourteen of 118 patients with complete follow-up (11.9%) survived more than 1 year with longest documented survival of 406 days. The median dysphagia score improved from 3 at the time of presentation to 0 at the time of death. Early complications occurred in 4.2% (6/143), late complications in 11.9% of patients (14/118). The procedure related mortality was 2.1% (3/143).

CONCLUSIONS

SEMS is an appropriate palliative treatment in a resource-limited environment. For the vast majority of patients a single intervention provides lasting improvement of dysphagia.

[Esophagitis in patients with acquired human immunodeficiency syndrome: an histological and immunohistochemistry study]

BACKGROUND

Almost all patients with acquired immunodeficiency virus syndrome will have gastrointestinal symptoms during the course of their illness. The high prevalence and complications of esophagitis are well documented.

AIM

Graduate esophagitis; identify microorganisms like Candida sp, cytomegalovirus, herpesvirus and mycobacteria; identify by immunohistochemical staining viral agents cytomegalovirus, herpesvirus I, herpesvirus II, Epstein-Barr Virus, human papilloma virus and human immunodeficiency virus; verify how immunohistochemistry changes the profile of esophagitis; verify the association between the histological and endoscopical findings; verify the relevance of the number of fragments studied in the characterization of the histological agents.

METHODS

We studied retrospectively esophageal biopsies in 227 patients with acquired immunodeficiency virus syndrome using hematoxylin and eosin, PAS (periodic acid of Schiff), Groccott and Ziehl-Nielsen stains and immunoperoxidase stains to detect opportunistic agents. Endoscopic aspects were studied.

RESULTS

The non-specific esophagitis grade III, in the inferior third of the esophagus, was the most frequent type. Candida sp was the most frequent agent, followed by viruses cytomegalovirus, herpesvirus and mycobacteria. The presence of plaque and ulceration suggested the diagnosis of esophageal candidiasis and cytomegalovirus esophagitis. Immunohistochemical allowed the characterization of cytomegalovirus and of herpesvirus in those cases where other techniques could not achieve it, furthermore the cytomegalovirus was also found in histological normal cases, making the use of this technique advisable in routine diagnosis. The herpesvirus I was not found isolated but associated to herpesvirus II. We have not found immunoreactivity for the Epstein-Barr virus and the human immunodeficiency virus. The number of fragments does not seem to influence the detection of the etiologic agent.

CONCLUSION

The endoscopic findings of plaques or ulcers are associated with candidiasis or cytomegalovirus esophagitis. Immunohistochemisty improved the diagnosis of viral infections. It is possible to detect cytomegalovirus infections in endoscopic and histologic normal cases.

Association between esophageal squamous cell carcinoma and human papillomavirus detected by Hybrid Capture II assay

From July 1999 to July 2000, 40 patients from the Surgical Oncology and Gastroenterology Departments of Irmandade da Santa Casa de Misericórdia de Porto Alegre were enrolled in a prospective study in order to find the frequency of human papillomavirus DNA (HPV-DNA) in esophageal squamous cell carcinoma. They were compared to 10 normal individuals (controls). Digene Inc. (Digene Corporation, Gaithersburg MD, USA) Hybrid Capture II assay, a chemoluminescent method, was used in both groups. The samples were collected from the tumor group by endoscopic biopsy in 20 cases, and by surgical specimens in the other 20 cases; the control group all underwent endoscopic biopsies. The cut-off point in the analytical assay for HPV-DNA was 1.0 pg/mL. Digene Corp. Hybrid Capture II assay tests HPV-DNA and differentiates high and low-risk for malignization virus groups. Gender, age, location of the tumor in esophagus and degree of differentiation on histology were also analyzed. There was one positive case (1.14 pg/mL), a 2.5% frequency of low-risk HPV-DNA type in the esophageal squamous cell carcinoma group (CI 95%: 0.00-7.34%). This group of patients consisted of 30 male and 10 female individuals, similar to the distribution seen in large series of such patients from the Brazilian population. The mean age was 63 years. Endoscopic samples of 10 patients who underwent endoscopic biopsy procedure for aleatory reasons, with normal looking esophageal mucosa, were tested to detect HPV-DNA, as controls. There was one positive case (1.17 pg/mL) of high-risk HPV-DNA type, resulting in a 10% positive rate. HPV-DNA is rarely found in esophageal squamous cell carcinomas: we found a 2.5% frequency, with confidence interval of 0-7.34%; and this is in the same range of controls (10% frequency, with CI: 9.1-10.9%). Both patients had a viral load quite near the 1.0 pg/mL cut-off point.

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.

Synergism between HIV and other viruses in the mouth

The HIV family replicate in and are shed from the mouth. Oral sexual practices potentially contribute to the overall extent of HIV transmission, particularly if high-risk practices are not restricted. Herpesviruses and papillomaviruses that appear in the oral cavity can determine oral HIV replication. The mechanisms probably include heterologous transactivation, enhanced expression of HIV receptors and co-receptors in target cells, release of cytokines and chemokines, and production of superantigens. Oral diseases peculiar to, or more common in, the HIV-infected patient further predispose to heightened oral HIV replication and trafficking. Defining the mechanisms by which oral viruses interact with HIV in the co-infected host should permit intervention measures against oral HIV transmission to be more precisely targeted.

AIDS-related malignancies

Cancer remains a significant burden for human immunodeficiency virus (HIV)-infected individuals. Most cancers that are associated with HIV infection are driven by oncogenic viruses, such as Epstein-Barr virus, Kaposi's sarcoma-associated herpesvirus and human papillomavirus. Gaining insight into the epidemiology and mechanisms that underlie AIDS-related cancers has provided us with a better understanding of cancer immunity and viral oncogenesis.

Identification of six putative novel human papillomaviruses (HPV) and characterization of candidate HPV type 87

Six putative novel human papillomavirus (HPV) types were detected by using general primers for a conserved L1 HPV region in patients examined in gynecologic centers. One of the isolates, detected in samples from 4 patients with koilocytic atypia at cervical cytology (3 of whom were also infected with human immunodeficiency virus type 1), was completely sequenced, identified as a new HPV genotype, and designated candidate HPV87 (candHPV87) by the Reference Center for Human Papillomavirus. candHPV87 shows the classic HPV genome organization and the absence of a functional E5 coding region. Phylogenetic analysis documented that the candHPV87 genome clusters within the A3 group of HPVs, together with HPV61, HPV72, HPV83, HPV84 and candHPV86, which have been completely sequenced, and a number of other putative novel genotypes (two of which are described in this work), which have been partially characterized. To address the growth-enhancing potential of candHPV87, the E6 and E7 putative coding regions were cloned and expressed in tissue cultures. The data indicate that both proteins stimulate cell division in tissue cultures more than those of low-risk HPVs, though not as much as those of HPV16. Taken together, the clinical, molecular, and biological data suggest that the novel papillomavirus characterized in the present study is a low- to intermediate-risk HPV.

Oral infections and other manifestations of HIV disease

Oral lesions are important in the clinical spectrum of HIV/AIDS, arousing suspicion of acute seroconversion illness (aphthous ulceration and candidiasis), suggesting HIV infection in the undiagnosed individual (candidiasis, hairy leukoplakia, Kaposi's sarcoma, necrotizing ulcerative gingivitis), indicating clinical disease progression and predicting development of AIDS (candidiasis, hairy leukoplakia), and marking immune suppression in HIV-infected individuals (candidiasis, hairy leukoplakia, necrotizing periodontal disease, Kaposi's sarcoma, long-standing herpes infection, major aphthous ulcers). In addition, oral lesions are included in staging systems for HIV disease progression and as entry criteria or endpoints in clinical trials of antiretroviral drugs. Recognition and management of these oral conditions is important for the health and quality of life of the individual with HIV/AIDS. In keeping with this, the U.S. Department of Health Services Clinical Practice Guideline for Evaluation and Management of Early HIV Infection includes recommendations that an oral examination, emphasizing oral mucosal surfaces, be conducted by the primary care provider at each visit, a dental examination by a dentist should be done at least two times a year, and patients should be informed of the importance of oral care and educated about common HIV-related oral lesions and associated symptoms.