The Role of Human Papillomavirus in Head and Neck Cancer
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APMIS 118: 510–519 Ó 2010 The Authors Journal Compilation Ó 2010 APMIS DOI 10.1111/j.1600-0463.2010.02624.x The role of human papillomavirus in head and neck cancer CHRISTEL BRAEMER LAJER and CHRISTIAN VON BUCHWALD Department of Oto-rhino-laryngology, Head and Neck Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark Lajer CB, von Buchwald C. The role of human papillomavirus in head and neck cancer. APMIS 2010; 118: 510–519. Over the last 20 years, there has been increasing awareness of a subset of squamous cell carcinomas of the head and neck (HNSCC), i.e. HPV-positive HNSCC. These cancers seem to differ somewhat from HPV-negative HNSCC. Patients with HPV-positive HNSCC tend to be younger and have a lower intake of tobacco and alcohol. Distinct molecular profiles separate them from HPV-negative cancers and show similarities with HPV-positive cervical SCC. There is evidence that HPV-positive HNSCC is a sexually transmitted disease. Patients with HPV-positive HNSCC are often diagnosed at a late stage with large cystic lymph nodes in the neck. HPV-positive HNSCC show an affinity for the oropharynx, especially the tonsils and the base of the tongue, and tend to show low differentiation histopathologi- cally. There is a better prognosis regardless of the treatment regimen for HPV-positive HNSCC com- pared with HPV-negative HNSCC, and this seems to be related to the immune system. Whether the new vaccines for HPV will protect not only against cervical cancer but also against HPV-positive HNSCC remains unknown. Key words: Human papillomavirus; head and neck cancer; tonsil; immune system; prognosis. C.B. Lajer, Department of Oto-rhino-laryngology, Head and Neck Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark. e-mail: christel.lajer@rh. regionh.dk Approximately 1100 persons in Denmark are future we may have to look at these two types of diagnosed with squamous cell carcinomas of cancers separately, both from a scientific, diag- the head and neck (HNSCC) each year. More nostic, epidemiological and clinical point of than 21 000 patients within the European view but also with regard to treatment. Union die from cancer of the oral cavity and This paper provides a review of recent data pharynx each year (1). Alcohol and tobacco linking HPV to HNSCC and the distinct molec- are disposing factors for developing this type ular and clinical features of HPV-positive of cancer, but HPV also is now known to HNSCC. be associated with head and neck cancer, espe- The involvement of human papillomavirus cially SCC of the oropharynx (tonsils and (HPV) in head and neck carcinogenesis was first base of the tongue). There are indications that suggested by Syrjanen in 1983 (3–5). Prior to the prevalence of HPV-induced head and neck this, from 1974 to 1977, zur Hausen suggested cancers is increasing, while the prevalence of that cervical cancer may arise from the same tobacco- and alcohol-induced cancers is declin- virus as is found in condylomata acuminate, i.e. ing (2). HPV (6–8). Today it is well established that the HPV-positive HNSCC appears to be distinct infection with specific types of HPV can cause from HPV-negative HNSCC with regard to a cervical cancer. More than 95% of cervical can- number of different characteristics, and in the cer biopsies contain high-risk HPV genomes (9). Vaccination against HPV allows us to state Invited review that essential precursor lesions of this cancer 510 THE ROLE OF HUMAN PAPILLOMAVIRUS IN HEAD AND NECK CANCER type are effectively prevented (10, 11). High-risk The function of E7 is also discussed in Chow, HPV infection has also been associated with Broker and Steinberg (14) and Pim and Banks anogenital carcinomas including cervical, anal, (15). E7 binds and destabilizes the tumour vulvar and penile cancers, and more recently suppressor retinoblastoma protein (pRb), pre- breast cancer (12). venting it from binding to the E2F transcription Since Syrjanen’s first proposal regarding the factor and thereby promoting cell cycle progres- involvement of HPV in head and neck cancer, sion. This functional inactivation of pRb results several other studies have demonstrated HPV in in a reciprocal overexpression of p16 tumour oral cavity, pharyngeal and laryngeal SCC. The suppressor protein p16INK4A. The HPV-posi- incidence varies considerably depending on the tive tonsillar SCC share a disruption of the pRb population studied, location of the tumours and pathway as a common biological marker. By the methods used for identification. immunohistochemistry (IHC), most HPV-posi- The HPV types (most often HPV 16 and occa- tive HNSCC show p16 overexpression. In non- sionally HPV18) identified in HPV-positive ton- HPV-related HNSCC, continuous tobacco and sillar SCC are similar to those found in cervical alcohol exposure can lead to mutational loss of cancers. the TP16 and TP53 genes. These early neoplas- tic events are seen in up to 80% of HNSCC and cause uncontrolled cellular growth (16). The METHODS – SEARCH STRATEGY expression of p53 and bcl-2 is not associated with HPV-positive oral cavity SCC (17) and A systematic review of the literature was con- mutations in TP53 are rarely seen in HPV-posi- ducted using the NIH PubMed search engine tive tumours compared with HPV-negative and the following Mesh words: papillomavirus, tumours (18, 19). There seems to be an inverse and head and neck neoplasms. Furthermore, a relationship between epidermal growth factor search was made using the words HPV in ‘All receptor expression and HPV status (20, 21). Fields’ and ⁄ or head and neck cancers in ‘All Genetic signatures of HPV-positive oropha- Fields’. Only studies published in English have ryngeal SCC have been shown to be different been considered, especially those within the last from those of HPV-negative oropharyngeal 10 years. SCC, and, in addition, distinct chromosomal alterations were of prognostic significance, reflecting a possible difference in tumour develop- MOLECULAR FACTORS ment and progression (22). Parallel to this, gene expression profiles show a different pattern in HPV-positive HNSCC seem to have a different HPV-positive oropharyngeal cancers compared molecular profile compared with that of HPV- with HPV-negative oropharyngeal cancers (23). negative HNSCC. In addition, HPV-positive Pyeon et al. carried out genome-wide expres- HNSCC share some similarities with cervical sion profiling comparing HPV-positive and carcinomas. HPV-negative HNSCC with cervical cancers The HPV genome is comprised of three (24). This revealed that HPV-positive HNSCC major regions: the long control region, the and cervical cancers differed in their patterns of early (E1-8) genes and the late (L1-2) genes. gene expression but shared many changes when High-risk oncogenic subtypes HPV-16, 18, 31, compared with HPV-negative HNSCC. Nota- 33 and 35 have been shown to be capable of bly, HPV-positive HNSCC and cervical cancers transforming oral epithelial cells through the were upregulated in their expression of a distinct viral oncoproteins E6 and E7 (13). The func- and larger subset of cell cycle genes compared tion of E6 is discussed in Chow, Broker and with HPV-negative HNSCC. Moreover, HPV- Steinberg (14) and Pim and Banks (15). The positive cancers overexpressed testis-specific virally encoded E6 binds to a cellular ubiqu- genes that are normally expressed only in itin ⁄ protein ligase, E6–AP, and simultaneously meiotic cells. Many, although not all, of the to the tumour suppressor protein p53, resulting hallmark differences between HPV-positive in ubiquitination of p53 and its subsequent HNSCC and HPV-negative HNSCC were a proteolytic degradation. direct consequence of HPV and, in particular, Ó 2010 The Authors Journal Compilation Ó 2010 APMIS 511 LAJER & VON BUCHWALD the viral E6 and E7 oncogenes. This included a period with comprehensive materials or remark- novel association of HPV oncogenes with testis- able HPV prevalence are included. specific gene expression (24). Many different assays for HPV detection are To summarize, at the molecular level, HPV- available, each with its own analytical sensitiv- positive HNSCC differ from HPV-negative ity. There are the PCR-based assay systems, HNSCC and similarities exist between HPV-posi- often linked to a specific genotyping system. tive HNSCC and HPV-positive cervical SCC. Amplicor35 and SPF1036, as well as various type-specific PCR methods, are very sensitive systems, whereas GP5+ ⁄ GP6+-PCR37 and THE INFLUENCE OF TUMOUR PGMY38 are somewhat less sensitive in detect- LOCATION AND METHODS USED FOR ing HPV (29). In addition, there are methods HPV PREVALENCE ANALYSIS based on DNA hybridization with specifically labelled RNA probes ISH that can be applied to A serious problem in HPV research is that there detect HPV on histological sections (30). In a is no consensus as to how to identify HNSCC recently published study by Shi et al., the prog- caused by HPV. This may undermine the true nostic value of HPV16 E6 mRNA was com- importance of HPV for HNSCC patients. There pared with that found using ISH and p16 are many assay variables that differ between immunostaining in human oropharyngeal SCC studies, making it difficult to compare various (31). HPV16 E6 mRNA was positive in 73 studies and to generalize from the results. (66%) of 111 samples; ISH was positive in 62 of The frequencies of HPV-positive tumours in 106 samples (58%), with 86% concordance. p16 HNSCC show considerable variation in pub- was overexpressed in 72 samples (65%), and lished studies. Some studies report frequencies strongly associated with HPV16 status by either of 0% (25, 26) in oral and laryngeal carcinomas, method. Classification of HPV positivity by whereas others report up to 93% in oropharyn- HPV16 E6 mRNA, HPV16 ISH or p16 IHC geal carcinomas (2).