Immunopathology of papillomavirus-induced tumors in different tissues

Epidermodysplasia verruciformis: a model for understanding the oncogenicity of human papillomaviruses

The first evidence for the oncogenic potential of human papillomaviruses (HPVs) was obtained through the study of epidermodysplasia verruciformis (EV). This rare skin disease is characterized by disseminated, refractor, pityriasis versicolor-like lesions as well as flat wart-like lesions, and by the development of skin carcinomas in about 30% of the patients. EV is a multifactorial disease involving genetic, immunological and extrinsic (actinic) factors, in addition to infection with specific HPV types. A number of HPVs (at least 15 types) have been characterized in benign EV lesions. HPV DNA sequences are regularly detected in EV carcinomas but, in contrast to benign lesions, the types associated with cancers are usually restricted to HPV-5 and, less frequently, HPV-8, an HPV-5-related type. HPV-5 genomes are usually found as free monomeric or oligomeric DNA molecules in EV carcinomas, and frequently contain deletions. This is in contrast with HPV DNA sequences in genital cancers, which are often integrated into the host DNA. Evidence for the transcription of HPV-5 genomes in primary and metastatic EV carcinomas has recently been obtained. The available data indicate that HPV-5 and some HPV-5-related types have an oncogenic potential and play a role in the malignant transformation of EV lesions. Infection by these HPVs must be considered a major risk factor for the development of cancers in EV patients. EV HPV DNA sequences have only rarely been detected in premalignant or malignant lesions of the skin in the general population. This further stresses the role of genetic, immunological and extrinsic factors in the abnormal susceptibility of EV patients to a set of specific HPV types.

Involvement of canine oral papillomavirus in generalized oral and cutaneous verrucosis in a Chinese Shar Pei dog

Severe papillomatosis developed in the oral cavity and spread throughout the haired skin of the trunk and limbs of an 8-month-old female Chinese Shar Pei dog. The dog had received corticosteroids prior to referral, which was associated with the onset of demodecosis and papillomatosis. Papillomavirus structural antigens were detected in biopsies by immunohistochemistry using a panel of monoclonal and polyclonal antibodies. An 8.2-kilobase papillomavirus-specific DNA molecule was detected in the cutaneous lesions by high stringency Southern blot hybridization using a cloned canine oral papillomavirus DNA probe. Restriction enzyme analysis revealed that the virus in the cutaneous lesions was identical to the canine oral papillomavirus. Discontinuation of the steroids combined with the use of a mitocide, antibiotics, and an autogenous vaccine resolved the demodecosis and papillomatosis. This case report suggests that corticosteroid-induced immunosuppression can expand the tissue tropism of papillomaviruses.

Ribavirin mitigates wart growth in rabbits at early stages of infection with cottontail rabbit papillomavirus

The challenge to develop antiviral agents effective against DNA viruses such as human papillomavirus (HPV) has been dependent on finding an animal model which mimics the human forms of the disease. We have used an existing model system for the purpose of measuring the effect of antiviral drugs on the inhibition of growth of these lesions. This was based upon domestic rabbits which efficiently grow cutaneous papillomas (warts) when infected with cottontail rabbit papillomavirus (CRPV). One agent which had shown significant success in achieving these goals was ribavirin. Ribavirin was administered intradermally shortly prior to infection at multiple sites with CRPV. Following daily injections of this drug for eight weeks, we have shown a dose-dependent response which had markedly reduced the number of warts, the time of first appearance of warts and reduced the tumor mass as compared to placebo-treated control animals. At the highest dose of ribavirin tested, 30 mg/kg/day, compared to controls, the average reduction in the number of warts was 52%, the average time of first appearance of warts was 49% longer, and the average mass of the warts was reduced by 98%. No detectable antibodies to CRPV were observed in any of the animals. The only side effects which were observed was focal alopecia, and a decrease in body growth upon prolonged treatment, both of which were completely reversible. Pharmacokinetic studies established the metabolism of ribavirin over a 24-h period of time. Ribavirin administered beginning 12 or 30 days post-infection, while not reducing the number of warts, slightly retarded the growth of warts as determined by date of first appearance of warts and mass of warts.

Detection of human papillomaviruses in paraffin-embedded condylomata acuminata--comparison of immunohistochemistry, in situ hybridization, and polymerase chain reaction

The polymerase chain reaction (PCR) is used for detection of human papillomavirus (HPV) DNA in paraffin-embedded tissue sections of condylomata acuminata. Incorporation of biotinylated nucleotides during the amplification process allows a highly sensitive, fast, and non-isotopic detection of viral DNA in a subsequent Southern dot blot. In 100% (13 of 13) of histologically confirmed condylomata, HPV-6 or -11 could be detected by polymerase chain reaction. By in situ hybridization 77% (10 of 13) and by immunohistochemistry (IHC) 69% (nine of 13) positive results were obtained. Because HPV genital infection is linked to penile and cervical dysplasia, polymerase chain reaction provides a powerful and highly sensitive tool for epidemiologic studies on sexual transmission of HPV.

Lymphoproliferative response to fusion proteins of human papillomaviruses in patients with cervical intraepithelial neoplasia

The cell-mediated immune response (CMI) to E6 and E4 fusion proteins of human papillomavirus type 16 (HPV-16), E6 fusion protein of HPV-18, and to control proteins similarly produced, was analysed in 29 patients with cervical intraepithelial neoplasia (CIN) and in 15 age-matched laboratory personnel using a lymphocyte proliferation assay (LPA). Compared to controls without any added proteins, a positive response (stimulation index greater than 2.0) to the highly purified E6 control protein was found in only one patient. Positive responses to the E4 control protein which contained beta-galactosidase were noted in three patients and two controls. With control proteins as baseline, the lymphocytes from nine patients (28%) and three laboratory personnel (20%) responded to at least on HPV fusion protein after 7 days in culture. Stimulation indices were low in both groups with a range of 2.06-4.69 and the difference in incidence of positive responses between the groups is not significant. Proliferative responses to HPV-1 and HPV-2 virion antigens were noted in 6/23 (26%) of the patients and 2/15 (18%) of the other group. No correlation between responsiveness and degree of dysplasia or presence of koilocytes was found in the patient group. The relevance of the low proliferative responses is discussed.

Human papilloma virus (HPV) and carcinomas of the head and neck

Increasing evidence for a causal link between human papilloma virus and carcinomas of the cervix has emerged in recent research. This group of species-specific, epitheliotropic viruses has also been associated with tumours of the head and neck, but the individual reports deal only with relatively small sample numbers. In the present review these reports are considered in relation to the methods employed, and it is concluded that HPV is associated with more than 50% of oral and nasal carcinomas, as well as with carcinomas of the larynx and oesophagus. The clinical relevance and strategies for future work are outlined.

Epidermodysplasia verruciformis in a patient with Hodgkin's disease: characterization of a new papillomavirus type and interferon treatment

A new human papillomavirus (HPV) was discovered in disseminated, macular, pityriasis versicolor-like lesions on the skin of the neck, face, scalp, and pubic region of a 42-year-old male suffering from Hodgkin's disease. Histopathology revealed features characteristic of epidermodysplasia verruciformis (ev). In contrast to classical ev, the lesions were almost exclusively seen in previously irradiated and UV-exposed skin areas. Papillomavirus capsid antigen was demonstrated with the genus-specific antiserum and the patient's serum, which had IgM and IgG antibody titers. HPV DNA was isolated from biopsies and cloned into the vector pIC20H. It proved to be related to ev-associated viruses, showing 23% cross-hybridization with DNA of the closest relative HPV14. The new HPV type was named HPV46. The genome was physically mapped and colinearly aligned with HPV8 DNA to establish its gene organization. Interferon treatment of the patient did not significantly change the clinical picture nor was the concentration of viral DNA per lesion affected. However, no virus capsid antigen was detectable after starting treatment.

Human papillomavirus 8-L1 immune serum: a new diagnostic possibility for Epidermodysplasia verruciformis-specific HPVs

Human papillomavirus (HPV) 8 induces flat macular skin lesions with a high risk of malignant conversion. A 600-bp fragment from the center of the major structural protein gene L1 was cloned into pEX2 to produce a beta-galactosidase-L1 fusion protein. The expressed part of L1 is masked in intact virions and not detected by sera of infected patients. Immunization of guinea pigs with purified fusion protein raised high-titer antisera, which reacted with capsid proteins of HPV8 and closely related viruses in Western blot and indirect immunofluorescence tests. Structural proteins of HPV1, 2, and 3 were not detected, indicating specificity for the subgroup of ev-specific HPVs. The sera present themselves as convenient diagnostic reagents for the demonstration of infections with potentially oncogenic HPVs using routine immunofluorescence procedures.

Humoral and cellular immunity to papillomavirus in patients with cervical dysplasia

The cell-mediated and humoral immune responses to human papillomavirus (HPV) were tested in groups of patients with various degrees of cervical intraepithelial neoplasia (CIN) using a lymphocyte proliferation assay (LPA) as a measure of circulating sensitised T-cells and an enzyme-linked immunosorbent assay (ELISA) for antibodies. Twenty-three of 92 patients (25%) gave stimulation indices (S.I.) greater than two to at least one of the several antigen preparations tested in the LPA. Of 282 patients, 144 (50.1%) showed ELISA indices (E.I.) greater than one to HPV-1 and/or HPV-2 antigens prepared by disruption of purified virions. No correlation was found between positive responses in either test and the presence in cervical biopsies of koilocytes (considered pathognomonic for HPV infections), or between positive responses and the degree of dysplasia observed. Rather, positive antibody and T-cell responses corresponded with a history of past or present skin warts. Although antibody was detected in 42/86 (48.8%) women who thought they had never had warts, only 2/24 (8.3%) with no known history gave a positive S.I. in LPA.

Increased prevalence of human papillomaviruses in the lower genital tract of pregnant women

In order to evaluate the influence of pregnancy on the presence of human papillomavirus (HPV) in the lower female genital tract, cervical smears of 92 pregnant and 96 non-pregnant women, matched by age, were examined for the presence of HPV-DNA by means of Southern blot hybridization. All patients had negative PAP smears. Twenty-six (28%) of the pregnant women and 12 (12.5%) of the non-pregnant women were positive for HPV. HPV 16 accounted for 42% of all positive pregnant cases and only 25% of the positive non-pregnant cases. Smears of pregnant patients contained more than 10 pg viral DNA in 45% of the cases against 20% in the non-pregnant group. HPV 16 showed the most active replication in both groups. This study demonstrates an increased prevalence of HPV (preferentially of HPV 16) and a higher replication rate of viral DNA during pregnancy.

Epidermodysplasia verruciformis: Langerhans cells, immunologic effect of retinoid treatment and cytogenetics

A case study is presented of a 44-year-old negroid male with epidermodysplasia verruciformis (EV), cutaneous carcinomas, and impaired cell-mediated immunity (CMI), infected with human papillomavirus type 8 and 17. Analysis was made of (a) T6+ and HLA-DR+ Langerhans cells (LCs) by immunoperoxidase staining in lesional and clinically normal skin before and during retinoid treatment, (b) the effect of retinoid treatment on CMI in vivo and in vitro, and (c) cytogenetic aspects related to chromosomal instability. The results showed the virtual absence of T6+ and HLA-DR+ LCs in koilocytic areas of epidermis involved with EV. Light-exposed, clinically normal skin also demonstrated microscopic EV lesions largely devoid of T6+ and HLA-DR+ LCs. Retinoid treatment with etretinate (Ro 10-9359) appeared both to increase the CMI response in vitro to T-cell mitogens and to influence the in situ pattern of T6+ and HLA-DR+ LCs. The cytogenetic study did not show evidence of spontaneous or UV-induced chromosomal instability.

Epidermodysplasia verruciformis. Clinical and light- and electron-microscopic observations during etretinate therapy

Three patients with epidermodysplasia verruciformis (EV) were treated with etretinate for 9-13 months. The patients had lesions characteristic of EV, including flat warts, common genital warts, pityriasis-versicolor-like lesions and malignant changes such as actinic keratosis and Bowenoid cancer in situ. During etretinate treatment, some flattening of the warts was observed in all three patients, and the lesions on the chest and back became less red and scaling. However, none of the lesions disappeared completely, and when the treatment was discontinued, the lesions relapsed. No malignant changes were detected during the period of therapy. Electron microscopy revealed the presence of typical large, clear cells containing viral particles in the upper epidermis. Etretinate therapy induced the same type of fine-structural changes as those seen in keratinization disorders and genodermatoses. The clear cells and virus particles persisted throughout the treatment period. More long-term, controlled studies are necessary to make possible an estimate of the curative and cancer-inhibitory effect of etretinate treatment in patients with EV.

Papillomaviruses: their possible role in oral disease

Papillomaviruses are ubiquitous DNA viruses that are epitheliotropic and produce a range of epithelial neoplasms, both benign and malignant, in animals and man. Human papillomaviruses are associated with a variety of rare and uncommon oral lesions, and there has been increasing suspicion that they may be implicated also in some premalignant and malignant oral lesions.

Immunophenotypes of lymphocytes in prospectively followed up human papillomavirus lesions of the cervix

From 1981 286 women were prospectively followed up for a mean (SD) of 16 (14) months for established infection with human papillomavirus (HPV) with or without coexistent cervical intraepithelial neoplasia (CIN). The in situ immunocompetent cell infiltrates in 263 cervical punch biopsy specimens from these women were phenotypically identified by the avidinbiotin peroxidase complex (ABC) technique using monoclonal antibodies Leu-10, OKT-3, OKT-4, and OKT-8. Leu-10+ B lymphocytes far outnumbered the OKT-3+ T lymphocytes in all types of HPV lesions (flat, inverted, and papillomatous condylomas of the cervix). The ratio of OKT-4+ to OKT-8+ (T helper to T suppressor cells) was slightly reduced in HPV lesions with more severe CIN and correlated positively with the intensity of the immunocompetent cell infiltrate. The ratio of OKT-4+ to OKT-8+ cells was highest in the 47 (28.8%) patients with HPV lesions that regressed during follow up, somewhat lower in the 85 (52.1%) with persistent lesions, and lowest in the 31 (19.1%) with lesions showing clinical progression. The results are discussed in terms of the proposed immune surveillance functions attributed to immunocompetent cells in situ according to the mucosal associated lymphatic tissue (MALT) concept. The conclusion drawn is that a dynamic balance between the immunoregulatory cells and their subtypes is a prerequisite for the proper handling of intracellular infections of the mucosa, including that with HPV.

Molecular cloning and characterization of the genomes of nine newly recognized human papillomavirus types associated with epidermodysplasia verruciformis

The genomes of 11 human papillomaviruses (HPVs) found in benign lesions of eight patients suffering from epidermodysplasia verruciformis were cloned in Escherichia coli after insertion into plasmid pBR322. The study of the sensitivity of the cloned HPV DNAs to 14 restriction endonucleases permitted the construction of physical maps. DNA-DNA hybridization experiments, performed under stringent conditions, showed that these viruses represent nine new types, HPVs 14 (with subtypes a and b), 15, 17 (with subtypes a and b), 19, 20, 21, 22, 23, and 24. These HPVs were divided into three groups based on an absent or very weak cross-hybridization among the genomes of the viruses belonging to different groups.

Langerhans cells in human papillomavirus (HPV) lesions of the uterine cervix identified by the monoclonal antibody OKT-6

The local inflammatory cell infiltrates in 263 cervical punch biopsies of the women followed-up since 1981 (16 +/- 14 months, mean +/- S.D.) for an established human papillomavirus (HPV) lesion with or without concomitant cervical intraepithelial neoplasia (CIN) were analysed for occurrence of Langerhans cells, defined by the monoclonal antibody OKT-6 using the avidin-biotin peroxidase complex (ABC) technique. OKT-6+ cells remained at the constant low level (1.5-1.9% of the inflammatory cells) in the different types of HPV lesions (flat, inverted or papillomatous condylomas), their percentages (range 0.8-2.1% of the cells) being slightly affected by the grade of HPV-associated CIN, however, (P less than 0.05 between HPV-CIN I and HPV-CIS). Although cervical HPV lesions characteristically are a disease of young females, the relative levels of in situ Langerhans cells did not show any age-dependence. Furthermore, the intensity of the inflammatory cell infiltrate did not correlate with the relative levels of OKT-6+ cells in the biopsies. Practically identical (1.6%) levels of OKT-6+ cells were found in the first biopsies of the HPV lesions shown to regress during the follow-up period (28.8% of cases), when compared with those (1.7%) in the lesions persisted (52.1% of cases) or progressed (19.1% of lesions). The results are discussed in terms of the proposed immune surveillance function against viral infections, attributed to Langerhans cells in the SALT/MALT concept.(ABSTRACT TRUNCATED AT 250 WORDS)

Human papilloma virus (HPV) antigens and local immunologic reactivity in oral squamous cell tumors and hyperplasias

A series of 191 oral mucosal tumors including those with suspected HPV (Human Papilloma Virus) etiology; squamous cell papilloma (SQP), condyloma acuminatum (CA), focal epithelial hyperplasia (FEH), as well as those regarded as unrelated to HPV; fibrous hyperplasia (FH), papillary hyperplasia (PH), and true fibroma (TF), were analyzed for HPV structural proteins (by indirect immunoperoxidase IP-PAP technique), for the presence of epithelial dysplasia, and for the cellular composition (B and T lymphocytes, mononuclear phagocytes, (MPS cells] of their local inflammatory cell infiltrates using ANAE-(acid alpha-naphthyl acetate esterase) stain. HPV structural proteins were disclosed in 85% of FEH, in 75% of CA, and in 41% of SQP. These three lesions significantly differed from PH and FH with regard to the intensity and cellular composition of the local infiltrates, being most intense and B cell predominated in the latter two. Mild dysplasia was found in 20% of both CA and SQP lesions, the former also showing moderate dysplasia in 12% of cases. The HPV antigen positivity was negatively correlated with dysplasia in CA and SQP, the intensity of the infiltrate showing positive association with dysplasia. The results are discussed in terms of HPV etiology of CA, SQP and FEH, of the host immunologic reactivity against these lesions, as well as of the possible role of HPV in human squamous cell carcinogenesis.

The treatment of resistant warts with intralesional bleomycin: a controlled clinical trial

A controlled double-blind trial was carried out on fifty-nine matched pairs of hand warts in a group of twenty-four patients, with proven resistance to treatment, to study the effectiveness of the intralesional injection of 0.1% solution of bleomycin sulphate in normal saline, compared with a normal saline placebo injected into the paired warts in the same patient. We found that 87.5% of patients showed a more favourable response to bleomycin (P less than 0.001); 76% of the fifty-nine warts treated with bleomycin were cured by one to three injections of up to 0.2 ml of solution. Subsequently 75% of thirty-two patients with resistant hand warts and 66% of fifteen patients with mosaic plantar warts were cured of all their warts. No patient received more than 4 mg of bleomycin. No toxicity was experienced. Local pain was on the whole well tolerated. This form of treatment for resistant warts is reliable, safe and acceptable to patients.

Sexual behaviour of women with human papillomavirus (HPV) lesions of the uterine cervix

To analyse the epidemiological aspects contributing to the transmission of human papillomavirus (HPV) lesions (flat, inverted, and papillomatous condylomas) of the uterine cervix, we recorded the sexual behaviour of 146 women who consecutively attended the department of obstetrics and gynaecology of Kuopio University Central Hospital with a cervical HPV lesion (with or without concomitant cervical intraepithelial neoplasia (CIN]. Similar data were collected from an age matched group of women with no signs of gynaecological infection. The sexual habits of the women infected with HPV differed from those of healthy controls in most aspects studied, including an earlier onset of sexual activity (p less than 0.05), lower number of deliveries (p less than 0.05), less regular use of contraceptive measures (p less than 0.05), and use of the condom instead of intrauterine contraceptive device (IUCD) (p less than 0.0001). They also differed from controls in giving histories of more frequent episodes of: CIN (p less than 0.005), abnormal Pap (Papanicolaou) smears (p less than 0.0001), sexually transmitted disease (STD) (p less than 0.05), and genital warts (p less than 0.001). Furthermore, they had more multiple sexual partnerships (both past and current) than the controls (p less than 0.0001 and 0.005 respectively), they had not established permanent partnerships as often as the controls (p less than 0.001), and they had a higher frequency of casual relationships (p less than 0.0001). In addition, their own and their partners' sexual hygiene was poorer than in the control subjects (p less than 0.05 and 0.001 respectively). The results show the dramatic influence of sexual behaviour on the transmission of cervical HPV lesions, which are known to be intimately associated with CIN in many cases.

Clinical observations, virologic studies, and treatment trials in patients with epidermodysplasia verruciformis, a disease induced by specific human papillomaviruses

We have studied 11 patients with the papillomavirus-induced disease epidermodysplasia verruciformis (EV). Clinical diagnostic features are widespread, long-lasting, pityriasis versicolor-like macules and flat, wart-like papules, both usually occurring in early childhood, with the subsequent development in the third decade of multiple skin cancers of the Bowenoid in situ and squamous cell types, primarily in sun-exposed skin. Virologic studies using the methods of immunofluorescence microscopy, restriction endonuclease analysis, and DNA blot hybridization have shown benign lesions to be associated with one or several types of the human papillomaviruses (HPVs) specifically associated with EV (at least 15 types recognized on the basis of sequence homology studies of molecularly cloned genomes). Skin cancers in these patients were associated with the genomes of either HPV-5, HPV-8 or HPV-14, suggesting that these three viruses are potentially oncogenic. A genetic factor appears to play a role in the pathogenesis of EV, since 5 of our patients were children of consanguineous parents and 2 had siblings also suffering with EV, suggesting a recessive inheritance pattern. Treatment of 4 EV patients with an oral retinoid resulted in partial temporary improvement of benign lesions, and the treatment of 2 patients with intralesional interferon injections into multiple Bowenoid cancers in situ has resulted in the disappearance of these lesions. Finally, EV serves as a model for studying the interplay of oncogenic viruses, genetic and immunologic factors, and sunlight in the production of skin cancer in humans.

The relation between the type of immunoreactive cells found in human papillomavirus (HPV) lesions of the uterine cervix and the subsequent behaviour of these lesions

Human papillomavirus (HPV) lesions in the skin are rejected by immunological mechanisms, but very little is known about such mechanisms in HPV lesions of the uterine cervix. We studied the mononuclear cell infiltrates in cervical biopsies from 65 women with an HPV lesion (flat, inverted or papillomatous condyloma) who were followed for at least twelve months. We examined cryostat sections using the ANAE (acid alpha-naphthylacetate esterase) technique to demonstrate B cell, T cells, and mononuclear phagocytes (MPs), and monoclonal antibodies (OKT3, OKT4, OKT6, and OKT8) for the T cell subsets. The percentages of B-, T-, and MPs in HPV lesions with concomitant cervical intraepithelial neoplasia (CIN) were similar to those lesions without CIN. Similarly, no significant differences in cell type percentages were found in HPV lesions which regressed (n = 24), remained stationary (n = 24) or progressed (n = 3) during the follow-up period. The ratio OKT4+/OKT8+ (T helper/T suppressor, cytotoxic) cells was 1.44 and 0.81 in HPV lesions with CIN and those without CIN respectively (p less than 0.025). No statistically significant differences in that ratio were found between the lesions which remained stationary, regressed or progressed. The tendency to progress was directly related to the degree of CIN associated with HPV.