E6. Links and References - Biology

E6.  Links and References - Biology

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E6. Links and References


The recognition of a causal relationship between human papillomaviruses and cancer almost 30 years ago led to a rapid expansion of knowledge in the field, resulting in the description of the main mediators of HPV-induced carcinogenesis, the viral proteins E6 and E7. These oncoproteins show a remarkable pleiotropism in binding host-cell proteins, with the tumour suppressor genes p53 and pRb as their major targets. These interactions induce proliferation, immortalization and malignant transformation of infected cells.

The link between HPV and cervical cancer led to the development of molecular methods, often based on the detection of E6 and E7, for screening and diagnosis. Therapeutic vaccines and gene therapy are primarily directed at E6 and E7. Although prophylactic vaccines are available, further understanding of the viral life cycle and the mechanisms underlying HPV-induced oncogenesis is necessary to face the many challenges in the field of HPV and cancer.

Bakker, P. J. M. Aten, J. A. Tukker, C. J., et al. Flow cytometric analysis of experimental parameters for the immunofluorescent labeling of BrdUrd in various tumour cell lines. Histochemistry 91:425–429 1989.

Bennett, D. Cooper, P. J. Hart, I. R. A line of non-tumorigenic mouse melanocytes, syngeneic with the B16 melanoma and requiring a tumour promoter for growth. Int. J. Cancer 39:414–418 1987.

Brüggen, J. Sorg, C. Macher, E. Membrane-associated antigens of human malignant melanoma: serological typing of cell lines using antisera from non-human primates. Cancer Immunol. Immunother. 5:53–68 1978.

Carrel, S. Doré, J. F. Ruiter, D. J., et al. The EORTC melanoma group exchange program: evaluation of a multicenter monoclonal antibody study. Int. J. Cancer 48:836–847 1991.

Chomczynski, P. Sacchi, N. Single-step method of RNA isolation by acid guanidinium thiocyanate-phenol-chloroform extraction. Anal. Biochem. 162:156–159 1987.

Danen, E. H. J. Ten Berge, P. J. M. Van Muyen, G. N. P., et al. Emergence of α5β3 fibronectin- and αvβ3 vitronectin receptor expression in melanocytic tumor progression. Histopathology 24:249–256 1994.

Danen, E. H. J. Van Muyen, G. N. P. Van de Wiel-van Kemenade, E., et al. Regulation of integrin-mediated adhesion to laminin and collagen in human melanocytes and non- and highly metastatic melanoma cells. Int. J. Cancer 54:315–321 1993.

DeCaprio, J. A. Ludlow, J. W. Figge, J., et al. SV40 large tumor antigen forms a specific complex with the product of the retinoblastoma susceptibility gene. Cell 54:275–283 1988.

De Vries, J. E. Keizer, G. D. te Velde, A. A., et al. Characterization of melanoma-associated surface antigens involved in the adhesion and motility of human melanoma cells. Int. J. Cancer 38:465–473 1986.

Eisinger, M. Marko, S. Selective proliferation of normal human melanocytes in vitro in the presence of phorbol ester and cholera toxin. Proc. Natl. Acad. Sci. USA 79:2018–2022 1982.

Evans, A. S. Viral infections of humans: epidemiology and control. New York: Plenum Medical Book Co. 1991:694.

Fidler, I. J. Rationale and methods for the use of nude mice to study the biology and therapy of human cancer metastasis. Cancer Metastasis Rev. 5:29–49 1986.

Fontijn, R. Hop, C. Brinkman, H. J., et al. Maintenance of vascular endothelial cell-specific properties after immortalization with an amphotropic replication-deficient retrovirus containing human papilloma virus. Exp. Cell Res. 216:199–207 1995.

Gadd, S. J. Ashman, L. K. A murine monoclonal antibody specific for a cell surface antigen expressed by a subgroup of human myeloid leukemias. Leuk. Res. 9:1329–1336 1985.

Halaban, R. Alfano, F. D. Selective elimination of fibroblasts from cultures of normal human melanocytes. In Vitro 20:447–450 1984.

Halaban, R. Pomerantz, S. H. Marshall, S., et al. Regulation of tyrosinase in human melanocytes in culture. J. Cell Biol. 97:480–488 1983.

Halbert, C. L. Demers, G. W. Galloway, D. A. The E7 gene of human papillomavirus type 16 is sufficient for immortalization of primary human epithelial cells. J. Virol. 65:473–478 1991.

Ishikoh, A. U. Hayashi, A. Tokimitsu, I., et al. Coordinate modulation of melanogenesis and type I trimer collagen secretion by type I collagen substratum during reversible conversion between melanotic and amelanotic cells on mouse B16 melanoma. J. Biochem. 116:610–614 1994.

Katano, M. Saxton, R. E. Cochran, A. J., et al. Establishment of an ascitic human melanoma cell line that metastasizes to lung and liver in nude mice. J. Cancer Res. Clin. Oncol. 108:197–203 1984.

Le Poole, I. C. Mutis, T. van den Wijngaard, R. M. J. G. J., et al. A novel, antigen-presenting function of melanocytes and its possible relationship to hypopigmentary disorders. J. Immunol. 151:7284–7292 1993.

Le Poole, I. C. van den Wijngaard, R. M. J. G. J. Westerhof, W., et al. Presence or absence of melanocytes in vitiligo lesions. J. Invest. Dermatol. 100:816–822 1993.

Luo, D. Chen, H. Jimbow, K. Cotransfection of genes encoding human tyrosinase and TRP-1 prevents melanocyte death and enhances melanin pigmentation and gene expression of Lamp-1. Exp. Cell Res. 213:231–241 1994.

Miller, A. D. Buttimore, C. Redesign of retrovirus packaging cell lines to avoid recombination leading to helper virus production. Mol. Cell. Biol. 6:2895–2902 1986.

Münger, K. Phelps, W. C. Bubb, V., et al. The E6 and E7 genes of the human papillomavirus type 16 together are necessary and sufficient for transformation of primary human keratinocytes. J. Virol. 63:4417–4421 1989.

Perez-Reyes, N. Halbert, C. L. Smith, P. P., et al. Immortalization of primary human smooth muscle cells. Proc. Natl. Acad. Sci. USA 89:1224–1229 1992.

Seedorf, K. Krämmer, G. Dürst, M., et al. Human papillomavirus type 16 DNA sequence. Virology 145:181–185 1985.

Smit, N. P. M. Le Poole, I. C. van den Wijngaard, R. M. J. G. J., et al. Expression of different immunological markers by cultured human melanocytes. Arch. Dermatol. Res. 285:356–365 1993.

Smotkin, D. Wettstein, F. O. Transcription of human papilloma virus type 16 early genes in a cervical cancer-derived and a cancer-derived cell line and identification of the E7 protein. Proc. Natl. Acad. Sci. USA 83:4680–4684 1986.

Swope, V. B. Medrano, E. E. Smalara, D., et al. Long-term proliferation of human melanocytes is supported by the physiologic mitogens alpha-melanotropin, endothelin-1, and basic fibroblast growth factor. Exp. Cell Res. 217:453–459 1995.

Thomson, T. M. Mattes, M. J. Roux, L., et al. Pigmentation-associated glycoprotein of human melanomas and melanocytes: definition with a mouse monoclonal antibody. J. Invest. Dermatol. 85:169–174 1985.

Tomita, Y. Shibahara, S. Takeda, A., et al. The monoclonal antibodies TMH-1 and TMH-2 specifically bind to a protein encoded at the murine b-locus, not to the authentic tyrosinase at the c-locus. J. Invest. Dermatol. 96:500–504 1991.

Van Muyen, G. N. P. Cornelissen, L. M. H. A. Jansen, C. F. J., et al. Antigen expression of metastasizing and non-metastasizing human melanoma cells xenografted into nude mice. Clin. Exp. Metastasis 9:259–272 1991.

Van Muijen, G. N. P. Jansen, C. F. J. Cornelissen, L. M. H. A., et al. Establishment and characterization of human melanoma cell line (MV3) which is highly metastatic in nude mice. Int. J. Cancer 48:85–91 1991.

Versteeg, R. Noordermeer, I. A. Krüsse-Wolters, M., et al. C-myc downregulates class I HLA-expression in human melanomas. EMBO J. 7:1023–1029 1988.

Watanabe, S. Kanda, T. Yoshiike, K. Human papillomavirus type 16 transformation of primary human embryonic fibroblasts requires expression of open reading frames E6 and E7. Virology 63:965–969 1989.

Walter, C. Frenk, E. Thermolysin treatment: a new method for dermoepidermal separation. J. Invest. Dermatol. 87:174 1986 (abstr.)

Whittaker, J. R. Changes in melanogenesis during the dedifferentiation of chick retinal pigment cells in cell culture. Dev. Biol. 86:99–127 1963.

Whyte, P. Buchbovich, K. J. Horowitz, J. M., et al. Association between an oncogene and an antioncogene: the adenovirus Ela proteins bind to the retinoblastoma gene product. Nature (Lond.) 334:124–129 1988.

Yavuzer, U. Keenan, E. Lowings, P., et al. The microphtalmia gene product interacts with the retinoblastoma protein in vitro and is a target for deregulation of melanocyte-specific transcription. Oncogene 10:123–134 1995.

Zepter, K. Häffner, A. C. Trefzer, U., et al. Reduced growth factor requirements and accelerated cell-cycle kinetics in adult human melanocytes transformed with SV40 large T antigen. J. Invest. Dermatol. 104:755–762 1995.

E6, or Epic 6, is a variant ruleset for D&D 3.5e invented on the ENWorld forums and “officially” collected in this thread. There is also a PDF version with explicit reference to Dungeons & Dragons scrubbed. And someone did a bit of work porting this to Pathfinder with this “P6 Codex”.

The concept of E6 is superficially similar to the rules of the Epic Level Handbook (hence the name), in that it provides a way for characters to continue growing indefinitely after the “final” level. The similarities end there, however: while the Epic Level Handbook picks up after 20th level, the usual limit for 3.5 and PF, and provides yet more levels to gain, E6 sets 6th level as the final one, and for E6 it actually is final. Instead of gaining more levels beyond 6th, characters instead gain bonus feats as they gain XP above that which is necessary to reach 6th. This allows the game to continue, and characters to continue to grow and evolve, but without gaining additional levels.

The above-linked documents also have rules for the XP thresholds at which characters gain bonus feats, new feats appropriate for such an environment, tweaks to existing feats for such an environment, and so on and so forth. None of these, however, is really core to what makes a game E6—in common usage, any 3.5 and/or PF game that stops levels at 6th and gains bonus feats from then on is an E6 game, whether they use the “official” XP thresholds and tweaks or not.

The official documents do offer useful insight, however, into why a game might want to stop leveling early:

  • Levels 1-5: Gritty fantasy
  • Levels 6-10: Heroic fantasy
  • Levels 11-15: Wuxia
  • Levels 16-20: Superheroes

So E6 was imagined as a way to maintain a heroic fantasy game in 3.5, which it more-or-less does. Ultimately, however, E6 has grown some from its roots (and, in fact, I would argue that “gritty fantasy” really only applies in 3.5 to 1st level, if that, and “heroic fantasy” may well land primarily in the 2nd-6th range). It has been widely recognized that D&D 3.5’s design flaws become more and more significant problems as one increases in level. And, as it turns out, 7th level is something of a cut-off point:

Q: Why 6th level for the cap? Why not 12th, or 20th?

A: My experience in D&D is that at around 6th level the characters are really nicely balanced, both in terms of balance against other classes, and against the CR system. Also, there was an element of setting assumptions each class is strong enough that they're well defined in their role, but not so strong that lower-level characters don't matter to them any more.

The author does not go into detail here, but the primary big new thing at 7th level is the advent of 4th-level spells. Those are a major upgrade from 3rd-level spells, in some very important ways.

Lower-level spells are undoubtedly powerful, but for the most part, they can be handled or mitigated by a lot of characters—characters with good Reflex and Balance can ignore grease, characters with capabilities that benefit fighting blind are much less affected by glitterdust, fly is a relatively short-duration spell, and so on.

This becomes less true with 4th-level spells. Solid fog allows you absolutely no recourse unless you can teleport. Enervation is extremely difficult to defend against (unless you have death ward, which is also 4th-level), and absolutely devastating in effect. Divine power allows a cleric to basically turn into a barbarian on top of his spellcasting. Dimension door and freedom of movement are the beginnings of spellcasters’ “get out of jail free” cards. Polymorph is just basically cheating. And divination, lesser planar ally, and scrying can completely change the nature of game.

And, of course, you might look at that and say “well yeah, 4th-level spells are better than 3rd-level spells that’s how things are supposed to be.” But the real problem is that non-spellcasting classes do not get any such power bump. What 4th-level spells offer are a series of attacks that are exceedingly difficult to defend against without 4th-level spells, as well as a series of defenses that are exceedingly difficult to penetrate without 4th-level spells. The rogue gaining another +1d6 sneak attack damage, the barbarian gaining DR 1/– (the fighter and the ranger getting literally nothing), those are just small incremental improvements, not a whole new league of power the way 4th level spells are.

And it gets worse, much worse, from there.

In short, while the four quartiles suggested by Ryan Dancey exist, they are not accessed equally by all classes. In fact, some classes never graduate to wuxia or superhero kinds of play.

So E6 has become not just an idea for maintaining heroic fantasy, but also a very well-regarded variant for simply improving the overall design quality of the game. Since D&D 3.5’s design problems get worse as levels go up, just stopping is an effective measure for reducing the number of problems you have to deal with.


Some HPV types, such as HPV-5, may establish infections that persist for the lifetime of the individual without ever manifesting any clinical symptoms. HPV types 1 and 2 can cause common warts in some infected individuals. [19] HPV types 6 and 11 can cause genital warts and laryngeal papillomatosis. [1]

Many HPV types are carcinogenic. [20] The table below lists common symptoms of HPV infection and the associated strains of HPV.

  • Highest risk: [21] 16, 18, 31, 45
  • Other high-risk: [21][23] 33, 35, 39, 51, 52, 56, 58, 59
  • Probably high-risk: [23] 26, 53, 66, 68, 73, 82

Warts Edit

Skin infection ("cutaneous" infection) with HPV is very widespread. [24] Skin infections with HPV can cause noncancerous skin growths called warts (verrucae). Warts are caused by a rapid growth of cells on the outer layer of the skin. [25] While cases of warts have been described since the time of ancient Greece, their viral cause was not known until 1907. [18]

Skin warts are most common in childhood and typically appear and regress spontaneously over the course of weeks to months. Recurring skin warts are common. [26] All HPVs are believed to be capable of establishing long-term "latent" infections in small numbers of stem cells present in the skin. Although these latent infections may never be fully eradicated, immunological control is thought to block the appearance of symptoms such as warts. Immunological control is HPV type-specific, meaning an individual may become resistant to one HPV type while remaining susceptible to other types. [ citation needed ]

    are usually found on the hands and feet, but can also occur in other areas, such as the elbows or knees. Common warts have a characteristic cauliflower-like surface and are typically slightly raised above the surrounding skin. Cutaneous HPV types can cause genital warts but are not associated with the development of cancer. are found on the soles of the feet they grow inward, generally causing pain when walking.
  • Subungual or periungual warts form under the fingernail (subungual), around the fingernail, or on the cuticle (periungual). They are more difficult to treat than warts in other locations. [27] are most commonly found on the arms, face, or forehead. Like common warts, flat warts occur most frequently in children and teens. In people with normal immune function, flat warts are not associated with the development of cancer. [28]

Common, flat, and plantar warts are much less likely to spread from person to person.

Genital warts Edit

HPV infection of the skin in the genital area is the most common sexually transmitted infection worldwide. [29] Such infections are associated with genital or anal warts (medically known as condylomata acuminata or venereal warts), and these warts are the most easily recognized sign of genital HPV infection. [ citation needed ]

The strains of HPV that can cause genital warts are usually different from those that cause warts on other parts of the body, such as the hands or feet, or even the inner thighs. A wide variety of HPV types can cause genital warts, but types 6 and 11 together account for about 90% of all cases. [30] [31] However, in total more than 40 types of HPV are transmitted through sexual contact and can infect the skin of the anus and genitals. [4] Such infections may cause genital warts, although they may also remain asymptomatic. [ citation needed ]

The great majority of genital HPV infections never cause any overt symptoms and are cleared by the immune system in a matter of months. Moreover, people may transmit the virus to others even if they do not display overt symptoms of infection. Most people acquire genital HPV infections at some point in their lives, and about 10% of women are currently infected. [29] A large increase in the incidence of genital HPV infection occurs at the age when individuals begin to engage in sexual activity. As with cutaneous HPVs, immunity to genital HPV is believed to be specific to a specific strain of HPV. [ citation needed ]

Laryngeal papillomatosis Edit

In addition to genital warts, infection by HPV types 6 and 11 can cause a rare condition known as recurrent laryngeal papillomatosis, in which warts form on the larynx [32] or other areas of the respiratory tract. [33] [34] These warts can recur frequently, may interfere with breathing, and in extremely rare cases can progress to cancer. For these reasons, repeated surgery to remove the warts may be advisable. [33] [35]

Cancer Edit

Virus types Edit

About a dozen HPV types (including types 16, 18, 31, and 45) are called "high-risk" types because persistent infection has been linked to cancer of the oropharynx, [3] larynx, [3] vulva, vagina, cervix, penis, and anus. [37] [38] These cancers all involve sexually transmitted infection of HPV to the stratified epithelial tissue. [1] [2] [36] Individuals infected with both HPV and HIV have an increased risk of developing cervical or anal cancer. [37] HPV type 16 is the strain most likely to cause cancer and is present in about 47% of all cervical cancers, [39] [40] and in many vaginal and vulvar cancers, [41] penile cancers, anal cancers, and cancers of the head and neck. [42]

Case statistics Edit

An estimated 561,200 new cancer cases worldwide (5.2% of all new cancers) were attributable to HPV in 2002, making HPV one of the most important infectious causes of cancer. [36] HPV-associated cancers make up over 5% of total diagnosed cancer cases worldwide, and this incidence is higher in developing countries where it is estimated to cause almost half a million cases each year. [36]

In the United States, about 30,700 cases of cancer due to HPV occur each year. [17]

The number of HPV-associated cancers in the period of 2008–2012 in the US. [17]
Cancer area Average annual number of cases HPV attributable (estimated) HPV 16/18 attributable (estimated)
Cervix 11,771 10,700 7,800
Oropharynx (men) 12,638 9,100 8,000
Oropharynx (women) 3,100 2,000 1,600
Vulva 3,554 2,400 1,700
Anus (women) 3,260 3,000 2,600
Anus (men) 1,750 1,600 1,400
Penis 1,168 700 600
Vagina 802 600 400
Rectum (women) 513 500 400
Rectum (men) 237 200 200
Total 38,793 30,700 24,600

Cancer development Edit

In some infected individuals, their immune systems may fail to control HPV. Lingering infection with high-risk HPV types, such as types 16, 18, 31, and 45, can favor the development of cancer. [43] Co-factors such as cigarette smoke can also enhance the risk of such HPV-related cancers. [44] [45]

HPV is believed to cause cancer by integrating its genome into nuclear DNA. Some of the early genes expressed by HPV, such as E6 and E7, act as oncogenes that promote tumor growth and malignant transformation. [18] HPV genome integration can also cause carcinogenesis by promoting genomic instability associated with alterations in DNA copy number. [46]

E6 produces a protein (also called E6) that binds to and inactivates a protein in the host cell called p53. Normally, p53 acts to prevent cell growth, and promotes cell death in the presence of DNA damage. p53 also upregulates the p21 protein, which blocks the formation of the cyclin D/Cdk4 complex, thereby preventing the phosphorylation of RB, and in turn, halting cell cycle progression by preventing the activation of E2F. In short, p53 is a tumor-suppressor protein that arrests the cell cycle and prevents cell growth and survival when DNA damage occurs. Thus, inactivation of p53 by E6 can promote unregulated cell division, cell growth, and cell survival, characteristics of cancer. [ citation needed ]

E6 also has a close relationship with the cellular protein E6-associated protein (E6-AP), which is involved in the ubiquitin ligase pathway, a system that acts to degrade proteins. E6-AP binds ubiquitin to the p53 protein, thereby flagging it for proteosomal degradation. [ citation needed ]

Squamous cell carcinoma of the skin Edit

Studies have also shown a link between a wide range of HPV types and squamous cell carcinoma of the skin. In such cases, in vitro studies suggest that the E6 protein of the HPV virus may inhibit apoptosis induced by ultraviolet light. [47]

Cervical cancer Edit

Nearly all cases of cervical cancer are associated with HPV infection, with two types, HPV16 and HPV18, present in 70% of cases. [1] [7] [39] [48] [49] [50] In 2012, twelve HPV types were considered carcinogenic for cervical cancer by the International Agency for Research on Cancer: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59. [51] HPV is necessary for cervical cancer to occur. [52] Persistent HPV infection increases the risk for developing cervical carcinoma. Individuals who have an increased incidence of these types of infection are women with HIV/AIDS, who are at a 22-fold increased risk of cervical cancer. [53] [54]

The carcinogenic HPV types in cervical cancer belong to the alphapapillomavirus genus and can be grouped further into HPV clades. [55] The two major carcinogenic HPV clades, alphapapillomavirus-9 (A9) and alphapapillomavirus-7 (A7), contain HPV16 and HPV18, respectively. [56] These two HPV clades were shown to have different effects on tumour molecular characteristics and patient prognosis, with clade A7 being associated with more aggressive pathways and an inferior prognosis. [57]

In 2012, about 528,000 new cases and 266,000 deaths from cervical cancer occurred worldwide. [29] Around 85% of these occurred in the developing world. [1]

Most HPV infections of the cervix are cleared rapidly by the immune system and do not progress to cervical cancer (see below the Clearance subsection in Virology). Because the process of transforming normal cervical cells into cancerous ones is slow, cancer occurs in people having been infected with HPV for a long time, usually over a decade or more (persistent infection). [33] [58] Furthermore, both the HPV infection and cervical cancer drive metabolic modifications that may be correlated with the aberrant regulation of enzymes related to metabolic pathways. [59]

Non-European (NE) HPV16 variants are significantly more carcinogenic than European (E) HPV16 variants. [60]

Anal cancer Edit

Studies show a link between HPV infection and anal cancers. Sexually transmitted HPVs are found in a large percentage of anal cancers. [36] Moreover, the risk for anal cancer is 17 to 31 times higher among HIV-positive individuals who were coinfected with high-risk HPV, and 80 times higher for particularly HIV-positive men who have sex with men. [61]

Anal Pap smear screening for anal cancer might benefit some subpopulations of men or women engaging in anal sex. [62] No consensus exists, though, that such screening is beneficial, or who should get an anal Pap smear. [63] [64]

Penile cancer Edit

HPV is associated with approximately 50% of penile cancers. In the United States, penile cancer accounts for about 0.5% of all cancer cases in men. HPV16 is the most commonly associated type detected. The risk of penile cancer increases 2- to 3-fold for individuals who are infected with HIV as well as HPV. [61]

Head and neck cancers Edit

Oral infection with high-risk carcinogenic HPV types (most commonly HPV 16) [17] is associated with an increasing number of head and neck cancers. [65] [49] [66] [67] This association is independent of tobacco and alcohol use. [67] [68] [69]

Sexually transmitted forms of HPV account for about 25% of cancers of the mouth and upper throat (the oropharynx) worldwide, [36] but the local percentage varies widely, from 70% in the United States [70] to 4% in Brazil. [71] Engaging in anal or oral sex with an HPV-infected partner may increase the risk of developing these types of cancers. [66]

In the United States, the number of newly diagnosed, HPV-associated head and neck cancers has surpassed that of cervical cancer cases. [65] The rate of such cancers has increased from an estimated 0.8 cases per 100,000 people in 1988 [72] to 4.5 per 100,000 in 2012, [17] and, as of 2015, the rate has continued to increase. [65] Researchers explain these recent data by an increase in oral sex. This type of cancer is more common in men than in women. [73]

The mutational profile of HPV-positive and HPV-negative head and neck cancer has been reported, further demonstrating that they are fundamentally distinct diseases. [74]

Lung cancer Edit

Some evidence links HPV to benign and malignant tumors of the upper respiratory tract. The International Agency for Research on Cancer has found that people with lung cancer were significantly more likely to have several high-risk forms of HPV antibodies compared to those who did not have lung cancer. [75] Researchers looking for HPV among 1,633 lung cancer patients and 2,729 people without the lung disease found that people with lung cancer had more types of HPV than noncancer patients did, and among lung cancer patients, the chances of having eight types of serious HPV were significantly increased. [76] In addition, expression of HPV structural proteins by immunohistochemistry and in vitro studies suggest HPV presence in bronchial cancer and its precursor lesions. [77] Another study detected HPV in the EBC, bronchial brushing and neoplastic lung tissue of cases, and found a presence of an HPV infection in 16.4% of the subjects affected by nonsmall cell lung cancer, but in none of the controls. [78] The reported average frequencies of HPV in lung cancers were 17% and 15% in Europe and the Americas, respectively, and the mean number of HPV in Asian lung cancer samples was 35.7%, with a considerable heterogeneity between certain countries and regions. [79]

Skin cancer Edit

In very rare cases, HPV may cause epidermodysplasia verruciformis (EV) in individuals with a weakened immune system. The virus, unchecked by the immune system, causes the overproduction of keratin by skin cells, resulting in lesions resembling warts or cutaneous horns which can ultimately transform into skin cancer, but the development is not well understood. [80] [81] The specific types of HPV that are associated with EV are HPV5, HPV8, and HPV14. [81]

Transmission Edit

Sexually transmitted HPV is divided into two categories: low-risk and high-risk. Low-risk HPVs cause warts on or around the genitals. Type 6 and 11 cause 90% of all genital warts and recurrent respiratory papillomatosis that causes benign tumors in the air passages. High-risk HPVs cause cancer and consist of about a dozen identified types. Type 16 and 18 are two that are responsible for causing most of HPV-caused cancers. These high-risk HPVs cause 5% of the cancers in the world. In the United States, high-risk HPVs cause 3% of all cancer cases in women and 2% in men. [82]

Risk factors for persistent genital HPV infections, which increases the risk for developing cancer, include early age of first sexual intercourse, multiple partners, smoking, and immunosuppression. [1] Genital HPV is spread by sustained direct skin-to-skin contact, with vaginal, anal, and oral sex being the most common methods. [4] [37] Occasionally it can spread from a mother to her baby during pregnancy. HPV is difficult to remove via standard hospital disinfection techniques, and may be transmitted in a healthcare setting on re-usable gynecological equipment, such as vaginal ultrasound transducers. [83] The period of communicability is still unknown, but probably at least as long as visible HPV lesions persist. HPV may still be transmitted even after lesions are treated and no longer visible or present. [84]

Perinatal Edit

Although genital HPV types can be transmitted from mother to child during birth, the appearance of genital HPV-related diseases in newborns is rare. However, the lack of appearance does not rule out asymptomatic latent infection, as the virus has proven to be capable of hiding for decades. Perinatal transmission of HPV types 6 and 11 can result in the development of juvenile-onset recurrent respiratory papillomatosis (JORRP). JORRP is very rare, with rates of about 2 cases per 100,000 children in the United States. [33] Although JORRP rates are substantially higher if a woman presents with genital warts at the time of giving birth, the risk of JORRP in such cases is still less than 1%. [ citation needed ]

Genital infections Edit

Genital HPV infections are transmitted primarily by contact with the genitals, anus, or mouth of an infected sexual partner. [85]

Of the 120 known human papilloma viruses, 51 species and three subtypes infect the genital mucosa. [86] Fifteen are classified as high-risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82), three as probable high-risk (26, 53, and 66), and twelve as low-risk (6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81, and 89). [20]

Condoms do not completely protect from the virus because the areas around the genitals including the inner thigh area are not covered, thus exposing these areas to the infected person's skin. [87]

Hands Edit

Studies have shown HPV transmission between hands and genitals of the same person and sexual partners. Hernandez tested the genitals and dominant hand of each person in twenty-five heterosexual couples every other month for an average of seven months. She found two couples where the man's genitals infected the woman's hand with high-risk HPV, two where her hand infected his genitals, one where her genitals infected his hand, two each where he infected his own hand, and she infected her own hand. [88] [89] Hands were not the main source of transmission in these twenty-five couples, but they were significant. [ citation needed ]

Partridge reports men's fingertips became positive for high risk HPV at more than half the rate (26% per two years) as their genitals (48%). [90] Winer reports 14% of fingertip samples from sexually active women were positive. [91]

Non-sexual hand contact seems to have little or no role in HPV transmission. Winer found all fourteen fingertip samples from virgin women negative at the start of her fingertip study. [91] In a separate report on genital HPV infection, 1% of virgin women (1 of 76) with no sexual contact tested positive for HPV, while 10% of virgin women reporting non-penetrative sexual contact were positive (7 of 72). [92]

Shared objects Edit

Sharing of possibly contaminated objects, for example, razors, [84] may transmit HPV. [93] [94] [95] Although possible, transmission by routes other than sexual intercourse is less common for female genital HPV infection. [85] Fingers-genital contact is a possible way of transmission but unlikely to be a significant source. [91] [96]

Blood Edit

Though it has traditionally been assumed that HPV is not transmissible via blood—as it is thought to only infect cutaneous and mucosal tissues—recent studies have called this notion into question. Historically, HPV DNA has been detected in the blood of cervical cancer patients. [97] In 2005, a group reported that, in frozen blood samples of 57 sexually naive pediatric patients who had vertical or transfusion-acquired HIV infection, 8 (14.0%) of these samples also tested positive for HPV-16. [98] This seems to indicate that it may be possible for HPV to be transmitted via blood transfusion. However, as non-sexual transmission of HPV by other means is not uncommon, this could not be definitively proven. In 2009, a group tested Australian Red Cross blood samples from 180 healthy male donors for HPV, and subsequently found DNA of one or more strains of the virus in 15 (8.3%) of the samples. [99] However, it is important to note that detecting the presence of HPV DNA in blood is not the same as detecting the virus itself in blood, and whether or not the virus itself can or does reside in blood in infected individuals is still unknown. As such, it remains to be determined whether HPV can or cannot be transmitted via blood. [97] This is of concern, as blood donations are not currently screened for HPV, and at least some organizations such as the American Red Cross and other Red Cross societies do not presently appear to disallow HPV-positive individuals from donating blood. [100]

Surgery Edit

Hospital transmission of HPV, especially to surgical staff, has been documented. Surgeons, including urologists and/or anyone in the room, is subject to HPV infection by inhalation of noxious viral particles during electrocautery or laser ablation of a condyloma (wart). [101] There has been a case report of a laser surgeon who developed extensive laryngeal papillomatosis after providing laser ablation to patients with anogenital condylomata. [101]

Virology Edit

HPV infection is limited to the basal cells of stratified epithelium, the only tissue in which they replicate. [103] The virus cannot bind to live tissue instead, it infects epithelial tissues through micro-abrasions or other epithelial trauma that exposes segments of the basement membrane. [103] The infectious process is slow, taking 12–24 hours for initiation of transcription. It is believed that involved antibodies play a major neutralizing role while the virions still reside on the basement membrane and cell surfaces. [103]

HPV lesions are thought to arise from the proliferation of infected basal keratinocytes. Infection typically occurs when basal cells in the host are exposed to the infectious virus through a disturbed epithelial barrier as would occur during sexual intercourse or after minor skin abrasions. HPV infections have not been shown to be cytolytic rather, viral particles are released as a result of degeneration of desquamating cells. HPV can survive for many months and at low temperatures without a host therefore, an individual with plantar warts can spread the virus by walking barefoot. [31]

HPV is a small double-stranded circular DNA virus with a genome of approximately 8000 base pairs. [37] [104] The HPV life cycle strictly follows the differentiation program of the host keratinocyte. It is thought that the HPV virion infects epithelial tissues through micro-abrasions, whereby the virion associates with putative receptors such as alpha integrins, laminins, and annexin A2 [105] leading to entry of the virions into basal epithelial cells through clathrin-mediated endocytosis and/or caveolin-mediated endocytosis depending on the type of HPV. [106] At this point, the viral genome is transported to the nucleus by unknown mechanisms and establishes itself at a copy number of 10-200 viral genomes per cell. A sophisticated transcriptional cascade then occurs as the host keratinocyte begins to divide and become increasingly differentiated in the upper layers of the epithelium. [ citation needed ]

The phylogeny of the various strains of HPV generally reflects the migration patterns of Homo sapiens and suggests that HPV may have diversified along with the human population. Studies suggest that HPV evolved along five major branches that reflect the ethnicity of human hosts, and diversified along with the human population. [107] Researchers have identified two major variants of HPV16, European (HPV16-E), and Non-European (HPV16-NE). [108]

E6/E7 proteins Edit

The two primary oncoproteins of high risk HPV types are E6 and E7. The “E” designation indicates that these two proteins are early proteins (expressed early in the HPV life cycle), while the "L" designation indicates that they are late proteins (late expression). [49] The HPV genome is composed of six early (E1, E2, E4, E5, E6, and E7) open reading frames (ORF), two late (L1 and L2) ORFs, and a non-coding long control region (LCR). [110] After the host cell is infected viral early promoter is activated and a polycistronic primary RNA containing all six early ORFs is transcribed. This polycistronic RNA then undergoes active RNA splicing to generate multiple isoforms of mRNAs. [111] One of the spliced isoform RNAs, E6*I, serves as an E7 mRNA to translate E7 protein. [112] However, viral early transcription subjects to viral E2 regulation and high E2 levels repress the transcription. HPV genomes integrate into host genome by disruption of E2 ORF, preventing E2 repression on E6 and E7. Thus, viral genome integration into host DNA genome increases E6 and E7 expression to promote cellular proliferation and the chance of malignancy. The degree to which E6 and E7 are expressed is correlated with the type of cervical lesion that can ultimately develop. [104]

The E6/E7 proteins inactivate two tumor suppressor proteins, p53 (inactivated by E6) and pRb (inactivated by E7). [113] The viral oncogenes E6 and E7 [114] are thought to modify the cell cycle so as to retain the differentiating host keratinocyte in a state that is favourable to the amplification of viral genome replication and consequent late gene expression. E6 in association with host E6-associated protein, which has ubiquitin ligase activity, acts to ubiquitinate p53, leading to its proteosomal degradation. E7 (in oncogenic HPVs) acts as the primary transforming protein. E7 competes for retinoblastoma protein (pRb) binding, freeing the transcription factor E2F to transactivate its targets, thus pushing the cell cycle forward. All HPV can induce transient proliferation, but only strains 16 and 18 can immortalize cell lines in vitro. It has also been shown that HPV 16 and 18 cannot immortalize primary rat cells alone there needs to be activation of the ras oncogene. In the upper layers of the host epithelium, the late genes L1 and L2 are transcribed/translated and serve as structural proteins that encapsidate the amplified viral genomes. Once the genome is encapsidated, the capsid appears to undergo a redox-dependent assembly/maturation event, which is tied to a natural redox gradient that spans both suprabasal and cornified epithelial tissue layers. This assembly/maturation event stabilizes virions, and increases their specific infectivity. [115] Virions can then be sloughed off in the dead squames of the host epithelium and the viral lifecycle continues. [116] A 2010 study has found that E6 and E7 are involved in beta-catenin nuclear accumulation and activation of Wnt signaling in HPV-induced cancers. [117]

Latency period Edit

Once an HPV virion invades a cell, an active infection occurs, and the virus can be transmitted. Several months to years may elapse before squamous intraepithelial lesions (SIL) develop and can be clinically detected. The time from active infection to clinically detectable disease may make it difficult for epidemiologists to establish which partner was the source of infection. [101]

Clearance Edit

Most HPV infections are cleared up by most people without medical action or consequences. The table provides data for high-risk types (i.e. the types found in cancers). [ citation needed ]

Clearance rates of high risk types of HPV [118]
Months after initial positive test 8 months 12 months 18 months
% of men tested negative 70% 80% 100%

Clearing an infection does not always create immunity if there is a new or continuing source of infection. Hernandez' 2005-6 study of 25 couples reports "A number of instances indicated apparent reinfection [from partner] after viral clearance." [88]

Over 170 types of HPV have been identified, and they are designated by numbers. [8] [113] They may be divided into "low-risk" and "high-risk" types. Low-risk types cause warts and high-risk types can cause lesions or cancer. [120] [121]

Cervical testing Edit

Guidelines from the American Cancer Society recommend different screening strategies for cervical cancer based on a woman's age, screening history, risk factors and choice of tests. [122] Because of the link between HPV and cervical cancer, the ACS currently recommends early detection of cervical cancer in average-risk asymptomatic adults primarily with cervical cytology by Pap smear, regardless of HPV vaccination status. Women aged 30–65 should preferably be tested every 5 years with both the HPV test and the Pap test. In other age groups, a Pap test alone can suffice unless they have been diagnosed with atypical squamous cells of undetermined significance (ASC-US). [123] Co-testing with a Pap test and HPV test is recommended because it decreases the rate of false-negatives. According to the National Cancer Institute, "The most common test detects DNA from several high-risk HPV types, but it cannot identify the types that are present. Another test is specific for DNA from HPV types 16 and 18, the two types that cause most HPV-associated cancers. A third test can detect DNA from several high-risk HPV types and can indicate whether HPV-16 or HPV-18 is present. A fourth test detects RNA from the most common high-risk HPV types. These tests can detect HPV infections before cell abnormalities are evident. [ citation needed ]

"Theoretically, the HPV DNA and RNA tests could be used to identify HPV infections in cells taken from any part of the body. However, the tests are approved by the FDA for only two indications: for follow-up testing of women who seem to have abnormal Pap test results and for cervical cancer screening in combination with a Pap test among women over age 30." [124]

Mouth testing Edit

Guidelines for oropharyngeal cancer screening by the Preventive Services Task Force and American Dental Association in the U.S. suggest conventional visual examination, but because some parts of the oropharynx are hard to see, this cancer is often only detected in later stages. [61]

The diagnosis of oropharyngeal cancer occurs by biopsy of exfoliated cells or tissues. The National Comprehensive Cancer Network and College of American Pathologists recommend testing for HPV in oropharyngeal cancer. [61] However, while testing is recommended, there is no specific type of test used to detect HPV from oral tumors that is currently recommended by the FDA in the United States. Because HPV type 16 is the most common type found in oropharyngeal cancer, p16 immunohistochemistry is one test option used to determine if HPV is present, [125] which can help determine course of treatment since tumors that are negative for p16 have better outcomes. Another option that has emerged as a reliable option is HPV DNA in situ hybridization (ISH) which allows for visualization of the HPV. [61]

Testing men Edit

There is not a wide range of tests available even though HPV is common most studies of HPV used tools and custom analysis not available to the general public. [126] [ needs update ] Clinicians often depend on the vaccine among young people and high clearance rates (see Clearance subsection in Virology) to create a low risk of disease and mortality, and treat the cancers when they appear. Others believe that reducing HPV infection in more men and women, even when it has no symptoms, is important (herd immunity) to prevent more cancers rather than just treating them. [127] [128] [ needs update ] Where tests are used, negative test results show safety from transmission, and positive test results show where shielding (condoms, gloves) is needed to prevent transmission until the infection clears. [129]

Studies have tested for and found HPV in men, including high-risk types (i.e. the types found in cancers), on fingers, mouth, saliva, anus, urethra, urine, semen, blood, scrotum and penis. [126]

The Qiagen/Digene kit mentioned in the previous section was used successfully off label to test the penis, scrotum and anus [130] of men in long-term relationships with women who were positive for high-risk HPV. 60% of them were found to carry the virus, primarily on the penis. [130] [ needs update ] Other studies used cytobrushes and custom analysis. [131] [132] [ needs update ]

In one study researchers sampled subjects' urethra, scrotum and penis. [131] [132] [ needs update ] Samples taken from the urethra added less than 1% to the HPV rate. Studies like this led Giuliano to recommend sampling the glans, shaft and crease between them, along with the scrotum, since sampling the urethra or anus added very little to the diagnosis. [90] Dunne recommends the glans, shaft, their crease, and the foreskin. [126]

In one study the subjects were asked not to wash their genitals for 12 hours before sampling, including the urethra as well as the scrotum and the penis. [131] Other studies are silent on washing - a particular gap in studies of the hands. [ citation needed ]

One small study used wet cytobrushes, rather than wet the skin. [132] It found a higher proportion of men to be HPV-positive when the skin was rubbed with a 600 grit emery paper before being swabbed with the brush, rather than swabbed with no preparation. It's unclear whether the emery paper collected the virions or simply loosened them for the swab to collect.

Studies have found self-collection (with emery paper and Dacron swabs) as effective as collection done by a clinician, and sometimes more so, since patients were more willing than a clinician to scrape vigorously. [133] [ needs update ] [134] Women had similar success in self-sampling using tampons, swabs, cytobrushes and lavage. [135] [ needs update ]

Several studies used cytobrushes to sample fingertips and under fingernails, without wetting the area or the brush. [91] [96] [136] [ needs update ]

Other studies analyzed urine, semen, and blood and found varying amounts of HPV, [126] but there is not a publicly available test for those yet.

Other testing Edit

Although it is possible to test for HPV DNA in other kinds of infections, [126] there are no FDA-approved tests for general screening in the United States [137] or tests approved by the Canadian government, [138] since the testing is inconclusive and considered medically unnecessary. [139]

Genital warts are the only visible sign of low-risk genital HPV and can be identified with a visual check. These visible growths, however, are the result of non-carcinogenic HPV types. Five percent acetic acid (vinegar) is used to identify both warts and squamous intraepithelial neoplasia (SIL) lesions with limited success [ citation needed ] by causing abnormal tissue to appear white, but most doctors have found this technique helpful only in moist areas, such as the female genital tract. [ citation needed ] At this time, HPV tests for males are used only in research. [ citation needed ]

Research into testing for HPV by antibody presence has been done. The approach is looking for an immune response in blood, which would contain antibodies for HPV if the patient is HPV positive. [140] [141] [142] [143] The reliability of such tests has not been proven, as there has not been a FDA approved product as of August 2018 [144] testing by blood would be a less invasive test for screening purposes.

The HPV vaccines can prevent the most common types of infection. [4] To be effective they must be used before an infection occurs and are therefore recommended between the ages of nine and thirteen. Cervical cancer screening, such as with the Papanicolaou test (pap) or looking at the cervix after using acetic acid, can detect early cancer or abnormal cells that may develop into cancer. This allows for early treatment which results in better outcomes. [1] Screening has reduced both the number and deaths from cervical cancer in the developed world. [15] Warts can be removed by freezing. [5]

Vaccines Edit

Three vaccines are available to prevent infection by some HPV types: Gardasil, Gardasil 9 and Cervarix all three protect against initial infection with HPV types 16 and 18, which cause most of the HPV-associated cancer cases. Gardasil also protects against HPV types 6 and 11, which cause 90% of genital warts. Gardasil is a recombinant quadrivalent vaccine, whereas Cervarix is bivalent, and is prepared from virus-like particles (VLP) of the L1 capsid protein. Gardasil 9 is nonavalent, it has the potential to prevent about 90% of cervical, vulvar, vaginal, and anal cancers. It can protect for HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 the latter five cause up to 20% of cervical cancers which were not previously covered. [145]

The vaccines provide little benefit to women already infected with HPV types 16 and 18. [146] For this reason, the vaccine is recommended primarily for those women not yet having been exposed to HPV during sex. The World Health Organization position paper on HPV vaccination clearly outlines appropriate, cost-effective strategies for using HPV vaccine in public sector programs. [147]

There is high-certainty evidence that HPV vaccines protect against precancerous cervical lesions in young women, particularly those vaccinated aged 15 to 26. [148] HPV vaccines do not increase the risk of serious adverse events. [148] Longer follow-up is needed to monitor the impact of HPV vaccines on cervical cancer. [148]

The CDC recommends the vaccines be delivered in two shots at an interval of least 6 months for those aged 11–12, and three doses for those 13 and older. [149] In most countries, they are funded only for female use, but are approved for male use in many countries, and funded for teenage boys in Australia. The vaccine does not have any therapeutic effect on existing HPV infections or cervical lesions. [150] In 2010, 49% of teenage girls in the US got the HPV vaccine. [ citation needed ]

Following studies suggesting that the vaccine is more effective in younger girls [151] than in older teenagers, the United Kingdom, Switzerland, Mexico, the Netherlands and Quebec began offering the vaccine in a two-dose schedule for girls aged under 15 in 2014. [ citation needed ]

Cervical cancer screening recommendations have not changed for females who receive HPV vaccine. It remains a recommendation that women continue cervical screening, such as Pap smear testing, even after receiving the vaccine, since it does not prevent all types of cervical cancer. [150] [152]

Both men and women are carriers of HPV. [153] The Gardasil vaccine also protects men against anal cancers and warts and genital warts. [154]

Duration of both vaccines' efficacy has been observed since they were first developed, and is expected to be longlasting. [155]

In December 2014, the FDA approved a nine-valent Gardasil-based vaccine, Gardasil 9, to protect against infection with the four strains of HPV covered by the first generation of Gardasil as well as five other strains responsible for 20% of cervical cancers (HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58). [156]

Condoms Edit

The Centers for Disease Control and Prevention says that male "condom use may reduce the risk for genital human papillomavirus (HPV) infection" but provides a lesser degree of protection compared with other sexual transmitted diseases "because HPV also may be transmitted by exposure to areas (e.g., infected skin or mucosal surfaces) that are not covered or protected by the condom." [157]

Disinfection Edit

The virus is unusually hardy, and is immune to most common disinfectants. It is the first virus ever shown to be resistant to inactivation by glutaraldehyde, which is among the most common strong disinfectants used in hospitals. [158] Diluted sodium hypochlorite bleach is effective, [158] but cannot be used on some types of re-usable equipment, such as ultrasound transducers. [83] As a result of these difficulties, there is developing concern about the possibility of transmitting the virus on healthcare equipment, particularly reusable gynecological equipment that cannot be autoclaved. [159] [160] For such equipment, some health authorities encourage use of UV disinfection [161] or a non-hypochlorite "oxidizing‐based high‐level disinfectant [bleach] with label claims for non‐enveloped viruses", [162] such as a strong hydrogen peroxide solution [163] [161] or chlorine dioxide wipes. [161] Such disinfection methods are expected to be relatively effective against HPV. [ citation needed ]

There is currently no specific treatment for HPV infection. [164] [165] [166] However, the viral infection is usually cleared to undetectable levels by the immune system. [167] According to the Centers for Disease Control and Prevention, the body's immune system clears HPV naturally within two years for 90% of cases (see Clearance subsection in Virology for more detail). [164] However, experts do not agree on whether the virus is completely eliminated or reduced to undetectable levels, and it is difficult to know when it is contagious. [168] [ needs update ]

Follow up care is usually recommended and practiced by many health clinics. [169] Follow-up is sometimes not successful because a portion of those treated do not return to be evaluated. In addition to the normal methods of phone calls and mail, text messaging and email can improve the number of people who return for care. [170] As of 2015 it is unclear the best method of follow up following treatment of cervical intraepithelial neoplasia. [171]

Globally, 12% of women are positive for HPV DNA, with rates varying by age and country. [172] The highest rates of HPV are in younger women, with a rate of 24% in women under 25 years. [173] Rates decline in older age groups in Europe and the Americas, but less so in Africa and Asia. The rates are highest in Sub-Saharan Africa (24%) and Eastern Europe (21%) and lowest in North America (5%) and Western Asia (2%). [172]

The most common types of HPV worldwide are HPV16 (3.2%), HPV18 (1.4%), HPV52 (0.9%), HPV31 (0.8%), and HPV58 (0.7%). High-risk types of HPV are also distributed unevenly, with HPV16 having a rate around 13% in Africa and 30% in West and Central Asia. [173]

Like many diseases, HPV disproportionately affects low-income and resource-poor countries. The higher rates of HPV in Sub-Saharan Africa, for example, may be related to high exposure to human immunodeficiency virus (HIV) in the region. Other factors that impact the global spread of disease are sexual behaviors including age of sexual debut, number of sexual partners, and ease of access to barrier contraception, all of which vary globally. [172] [174]

United States Edit

HPV prevalence among women by age, including 20 low-risk types and 23 high-risk types [175]
Age (years) Prevalence (%)
14 to 19 24.5%
20 to 24 44.8%
25 to 29 27.4%
30 to 39 27.5%
40 to 49 25.2%
50 to 59 19.6%
14 to 59 26.8%

HPV is estimated to be the most common sexually transmitted infection in the United States. [175] Most sexually active men and women will probably acquire genital HPV infection at some point in their lives. [39] The American Social Health Association estimates that about 75–80% of sexually active Americans will be infected with HPV at some point in their lifetime. [176] [177] By the age of 50 more than 80% of American women will have contracted at least one strain of genital HPV. [175] [178] It was estimated that, in the year 2000, there were approximately 6.2 million new HPV infections among Americans aged 15–44 of these, an estimated 74% occurred to people between ages of 15 and 24. [179] Of the STDs studied, genital HPV was the most commonly acquired. [179] In the United States, it is estimated that 10% of the population has an active HPV infection, 4% has an infection that has caused cytological abnormalities, and an additional 1% has an infection causing genital warts. [180]

Estimates of HPV prevalence vary from 14% to more than 90%. [181] One reason for the difference is that some studies report women who currently have a detectable infection, while other studies report women who have ever had a detectable infection. [182] [183] Another cause of discrepancy is the difference in strains that were tested for. [ citation needed ]

One study found that, during 2003–2004, at any given time, 26.8% of women aged 14 to 59 were infected with at least one type of HPV. This was higher than previous estimates 15.2% were infected with one or more of the high-risk types that can cause cancer. [175] [184]

The prevalence for high-risk and low-risk types is roughly similar over time. [175]

Human papillomavirus is not included among the diseases that are typically reportable to the CDC as of 2011. [185] [186]

Ireland Edit

On average 538 cases of HPV-associated cancers were diagnosed per year in Ireland during the period 2010 to 2014. [187] Cervical cancer was the most frequent HPV-associated cancer with on average 292 cases per year (74% of the female total, and 54% of the overall total of HPV-associated cancers). [187] A study of 996 cervical cytology samples in an Irish urban female, opportunistically screened population, found an overall HPV prevalence of 19.8%, HPV 16 at 20% and HPV 18 at 12% were the commonest high-risk types detected. In Europe, types 16 and 18 are responsible for over 70% of cervical cancers. [188] Overall rates of HPV-associated invasive cancers may be increasing. Between 1994 and 2014, there was a 2% increase in the rate of HPV-associated invasive cancers per year for both sexes in Ireland. [187]

As HPV is known to be associated with ano-genital warts, these are notifiable to the Health Protection Surveillance Centre (HPSC). Genital warts are the second most common STI in Ireland. [189] There were 1,281 cases of ano-genital warts notified in 2017, which was a decrease on the 2016 figure of 1,593. [190] The highest age-specific rate for both male and female was in the 25-29 year old age range, 53% of cases were among males. [190]

Sri Lanka Edit

In Sri Lanka, the prevalence of HPV is 15.5% regardless of their cytological abnormalities. [191]

In 1972, the association of the human papillomaviruses with skin cancer in epidermodysplasia verruciformis was proposed by Stefania Jabłońska in Poland. In 1978, Jabłońska and Gerard Orth at the Pasteur Institute discovered HPV-5 in skin cancer. [192] In 1976 Harald zur Hausen published the hypothesis that human papilloma virus plays an important role in the cause of cervical cancer. In 1983 and 1984 zur Hausen and his collaborators identified HPV16 and HPV18 in cervical cancer. [193]

The HeLa cell line contains extra DNA in its genome that originated from HPV type 18. [194]

The Ludwig-McGill HPV Cohort is one of the world's largest longitudinal studies of the natural history of human papillomavirus (HPV) infection and cervical cancer risk. It was established in 1993 by Ludwig Cancer Research and McGill University in Montreal, Canada. [ citation needed ]

<p>This section provides any useful information about the protein, mostly biological knowledge.<p><a href='/help/function_section' target='_top'>More. </a></p> Function i

Plays a major role in the induction and maintenance of cellular transformation. Acts mainly as an oncoprotein by stimulating the destruction of many host cell key regulatory proteins. E6 associates with host UBE3A/E6-AP ubiquitin-protein ligase, and inactivates tumor suppressors TP53 and TP73 by targeting them to the 26S proteasome for degradation. In turn, DNA damage and chromosomal instabilities increase and lead to cell proliferation and cancer development. The complex E6/E6AP targets several other substrates to degradation via the proteasome including host DLG1 or NFX1, a repressor of human telomerase reverse transcriptase (hTERT). The resulting increased expression of hTERT prevents the shortening of telomere length leading to cell immortalization. Other cellular targets including BAK1, Fas-associated death domain-containing protein (FADD) and procaspase 8, are degraded by E6/E6AP causing inhibition of apoptosis. E6 also inhibits immune response by interacting with host IRF3 and TYK2. These interactions prevent IRF3 transcriptional activities and inhibit TYK2-mediated JAK-STAT activation by interferon alpha resulting in inhibition of the interferon signaling pathway.

<p>Manual validated information which has been generated by the UniProtKB automatic annotation system.</p> <p><a href="/manual/evidences#ECO:0000255">More. </a></p> Manual assertion according to rules i

<p>Manually curated information for which there is published experimental evidence.</p> <p><a href="/manual/evidences#ECO:0000269">More. </a></p> Manual assertion based on experiment in i

HPV16 E6 promotes cervical cancer cell migration and invasion by downregulation of NHERF1

Correspondence to: Junqi He, Department of Biochemistry and Molecular Biology, Capital Medical University, No.10 Xitoutiao, You An Men Wai, Beijing 100069, People's Republic of China, E-mail: [email protected] Tel.: 86-10-8395-0513Search for more papers by this author

Department of Biochemistry and Molecular Biology, Beijing Key Laboratory for Tumor Invasion and Metastasis, Capital Medical University, Beijing, People's Republic of China

Q.W. and R.S. contributed equally to this workSearch for more papers by this author

Department of Biochemistry and Molecular Biology, Beijing Key Laboratory for Tumor Invasion and Metastasis, Capital Medical University, Beijing, People's Republic of China

Q.W. and R.S. contributed equally to this workSearch for more papers by this author

Department of Biochemistry and Molecular Biology, Beijing Key Laboratory for Tumor Invasion and Metastasis, Capital Medical University, Beijing, People's Republic of China

Department of Biochemistry and Molecular Biology, Beijing Key Laboratory for Tumor Invasion and Metastasis, Capital Medical University, Beijing, People's Republic of China

Core Facilities Center, Capital Medical University, Beijing, People's Republic of China

Department of Biochemistry and Molecular Biology, Beijing Key Laboratory for Tumor Invasion and Metastasis, Capital Medical University, Beijing, People's Republic of China

Department of Interventional Radiology, First Hospital of Shanxi Medical University, Taiyuan, People's Republic of China

Department of Biochemistry and Molecular Biology, Beijing Key Laboratory for Tumor Invasion and Metastasis, Capital Medical University, Beijing, People's Republic of China

Correspondence to: Junqi He, Department of Biochemistry and Molecular Biology, Capital Medical University, No.10 Xitoutiao, You An Men Wai, Beijing 100069, People's Republic of China, E-mail: [email protected] Tel.: 86-10-8395-0513Search for more papers by this author


HPV16 is the predominant type of HPV causing invasive cervical cancer. However, the underlying molecular mechanism of the unparalleled carcinogenic power of HPV16 compared to other types of high-risk (HR)-HPV including HPV18 remains elusive. The PDZ binding motif (PBM) of high-risk HPV E6 plays an important role in neoplasia and progression of cervical cancer. HPV16 E6 rather than HPV18 E6, interacted with NHERF1 by its PBM region, and induced degradation of NHERF1. NHERF1 retarded the assembly of cytoskeleton by downregulation of ACTN4, thereby inhibited the migration and invasion of cervical cancer cells in both cell and mouse model. HPV16 E6 was confirmed to enhance actin polymerization with increased ACTN4 level by downregulation of NHERF1, and result in enhanced migration and invasion of cervical cancer cells. GSEA analysis of cervical cancer specimens also showed that HPV16 E6 rather than HPV18 E6, was significantly associated with actin cytoskeleton assembly. That downregulation of NHERF1 by HPV16 E6 promoted cytoskeleton assembly and cell invasion, was an important cause in cervical cancer carcinogenesis. These findings provided the differential mechanism between HPV16 E6 and HPV18 E6 in the development and progression of cervical cancer, which may partially explain the differences of carcinogenic power between these two types of HR-HPVs.

Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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The E6 and E7 proteins in human papillomavirus 16 (HPV 16) are the main oncogenes in the occurrence of lung cancer. In recent studies, we found that E6 and E7 downregulated the expression of LKB1 in lung cancer cells. However, it is still unclear how E6 and E7 regulate LKB1 in lung cancer cells.


Double directional genetic manipulation and nuclear plasma separation technology were performed to explore the molecular mechanism of E6 and E7 inhibiting the antitumor activity of LKB1 in well-established lung cancer cell lines.


E6 but not E7 significantly downregulated the expression of tumor suppressor KIF7 at protein level, and the inhibition of KIF7 further reduced the expression of LKB1 both in the nuclei and in the cytoplasm, whereas reduced the expression of p-LKB1 in the cytoplasm only. This suggested that HPV 16 E6 but not E7 downregulates the antitumor activity of LKB1 by downregulating the expression of p-LKB1 in the cytoplasm only.


Here, we demonstrated for the first time that E6 but not E7 inhibits the antitumor activity of LKB1 in lung cancer cells by downregulating the expression of KIF7. Our findings provide new evidence to support the important role of KIF7 in the pathogenesis of lung cancer and suggests new therapeutic targets.


Human papillomaviruses (HPVs) comprise a diverse group, and have different epithelial tropisms and life-cycle strategies. Many HPVs are classified as low-risk, as they are only very rarely associated with neoplasia or cancer in the general population. These HPVs typically cause inapparent/inconspicuous infections, or benign papillomas, which can persist for months or years, but which are eventually resolved by the host's immune system. Low-risk HPVs are difficult to manage in immunosuppressed people and in individuals with genetic predispositions, and can give rise to papillomatosis, and in rare instances, to cancer. The high-risk HPV types are, by contrast, a cause of several important human cancers, including almost all cases of cervical cancer, a large proportion of other anogenital cancers and a growing number of head and neck tumours. The high-risk HPV types constitute a subset of the genus Alphapapillomavirus that are prevalent in the general population, and in most individuals cause only inconspicuous oral and genital lesions. Cancer progression is associated with persistent high-risk HPV infection and with deregulated viral gene expression, which leads to excessive cell proliferation, deficient DNA repair, and the accumulation of genetic damage in the infected cell. Although their life-cycle organisation is broadly similar to that of the low-risk HPV types, the two groups differ significantly in their capacity to drive cell cycle entry and cell proliferation in the basal/parabasal cell layers. This is thought to be linked, at least in part, to different abilities of the high- and low-risk E6 proteins to modulate the activity of p53 and PDZ-domain proteins, and the differential ability of the E7 proteins to target the several different members of the retinoblastoma protein family.

This article forms part of a special supplement entitled “Comprehensive Control of HPV Infections and Related Diseases” Vaccine Volume 30, Supplement 5, 2012.

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