Review
Emerging biomarkers and clinical significance of HPV genotyping in prevention and management of cervical cancer

https://doi.org/10.1016/j.micpath.2020.104131Get rights and content

Highlights

  • High rates of cervical cancer deaths in developing countries reflects inaccessibility of health care services and inequity.

  • New technologies and opportunities have led to the rapid evolution in cervical cancer prevention programs.

  • A well personalized intervention strategy to improve the effectiveness of screening and prevention programs is warranted.

Abstract

Cervical cancer is a growing and serious problem world-wide in women, but more acute in developing countries especially in Indian subcontinent. The main causative agent for the disease is Human Papilloma Virus (HPV). The history of the cervical cancer goes back to eighteenth century as the HPV infection is reported since 1800s. Presently, the genetic structure of HPV is well defined. Several screening tests including cytology and visual based screening and high risk HPV testing are available. Also available are various clinical and commercial diagnostic tests. However due to the lack of awareness and population-based screening programs, the morbidity and mortality rate is alarmingly high. There are new emerging biomarkers including E6/E7 mRNA, p16ink4a, markers of aberrant S-phase induction, chromosomal abnormalities and miRNAs along with advanced genotyping methods. These markers have clinical significance and are helpful in disease prevention and management. Further, recent advancement in the field of metagenomics has increased the prospects of identifying newer microbes, viruses hitherto reported thus far in the context of HPV infection. Analysis of HPV cases using modern tools including genotyping using more powerful biomarkers is envisaged to enhance the prospects of early diagnosis, better prognosis, more reliable treatment and eventual management of the disease.

Introduction

Cervical cancer is one of the principal causes of morbidity and mortality among women caused by Human Papilloma Virus (HPV) affecting at least 50% of men and women during their lifetime [1]. The GLOBOCAN database provides a worldwide estimate of mortality and morbidity of cervical cancer in 2012. According to this report, about 5,28,000 newer cases were diagnosed and more than half of them succumbed to it. The global burden of 87% of this disease was observed in less developed countries [2]. In India, cervical cancer is the second most frequent one amongst females. Annually the number of newly diagnosed cases are 1,22,844 and around 67,477 patients die from it. The occurrence of the disease is reported in women aged between 15 and 44 years in India [3], while there is a peak in the diagnosis of cervical cancer between 55 and 59 years [4]. This late diagnosis and increased mortality rate in developing countries is due to the lack of an effective screening program and a high prevalence of HPV [5]. The cervical cancer screening programs cover only 19% of target population in developing countries in comparison to the 63% in developed countries [6].

Previously, Dr. Rous described the progression of papilloma warts into cancer in 1935, while visualization of HPV particles in human warts for the first time was reported in 1949. Cervical cancer gathered interest in the 1970s when Harold zur Hausen discovered, cloned and demonstrated the causative role of HPV in cervical cancer and was awarded Nobel Prize for his remarkable discovery in 2008 [7].

HPV belongs to the Papovaviridae family, a non-enveloped DNA virus measuring 55 nm. The genetic material is enclosed in an icosahedral capsid which contains L1 and L2 capsid proteins. HPV genome is composed of double stranded DNA containing 8000 base pairs that contains a total of 8 genes including early (E) and late (L) genes [8]. The three functional regions in the genome include the upstream non-coding regulatory region or the long control region (LCR). The early region required in the viral replication and oncogenesis consisting of open reading frames (ORF), E1, E2, E4, E5, E6, E7 and finally the late region which encodes the structural proteins L1 and L2 [9]. Fig. 1 shows circular and linear structure of HPV genome [10,11]. Almost a 200 subtypes of HPV have been discovered with more than 30 infecting the genital tract [9] and 11 of them classified as high risk or the oncogenic strains [12]. Type 16 and 18 of the HPV have been mainly associated with cervical cancers [12]. The low risk group HPV causes genital warts or may produce mild dysplasia on the cervix. The HPV 6 and 11 are considered as low risk types. The HPV infection's oncogenic potential rely on the E6 and E7 viral oncogenic activities [13]. The HPV DNA integrates into the host DNA down regulating the E2 protein resulting in over expression of E6 and E7 proteins. These proteins bind and disrupt the functions of p53 and pRB respectively, leading to an increased proliferation of the cells. Proliferating cells are a fertile ground for mutations resulting in oncogenesis [9].

Different screening methods such as cytology (conventional, liquid based, automated pap), visual based screening and high risk HPV testing are presently accessible. Pap test has helped identify many pre-cancerous and cancerous lesions of cervical epithelium and has brought all those under the surveillance umbrella. However, cytological evaluation of cervical cancers have their own limitations which has led to continued research resulting in emergence of varied sophisticated diagnostic tools for cervical cancer. An increase in identification of potential biomarkers in patient studies have been observed in the past decade. Many newer ones are being added to the already existing list of the markers [14].

Section snippets

HPV DNA integration by FISH

The FISH approach was based on a discrete FISH staining that indicates episomal genomes. The punctuated FISH staining predicts integrated viral genomes [15]. Using FISH technique for human DNA, a viral-human combine structure has been suggested in HPV-positive head and neck carcinomas by observation of a punctuated staining [16]. The viral genome was found to be amplified in huge replication foci in differentiating cervical cancer cell lines retaining HPV episomes [17]. When this amplification

Metagenomics studies of HPV

The study, analysis and interpretation of the association between microbiota and cancer has been transformed in the emerging era of metagenomics. It is a reasonable approach to study culture independent micro-organisms that comprise the structural and functional study and their interactions with the habitat [86]. Different new investigations on the infection caused cancers have reported genomic analysis findings of microorganisms inhabiting in the cancerous tissues [87].

The microbiota of a

Global HPV genotype distribution

Globally, the HPV infection burden that leads to cervical cancer is more in developing countries. The oncogenic properties of the HPV positive genotype is different in every region of the world [103]. Globally, about 5% of all cervical malignancies were found to be comprising high risk HPV45 genotype. It is frequently observed in adenocarcinoma than in squamous cell carcinoma. The 300 samples of pre-determined HPV45 were collected from 36 countries and analyzed. The entire open reading frame of

Genotyping

Different types of primers can be designed which target sequences unique to the HPV and thereby amplifying them resulting in enhanced rate of detection. Type specific primers are used for detection of single genotype, which may be a cumbersome process, therefore, many genotypes may be detected using multiple type-specific reactions [117]. Using consensus primer can prove to be less labor intensive, since they target the group specific regions in the HPV genome like the L1 [118] and E2 [119].

Clinical significance of HPV genotyping

Although, cytology-based screening has resulted in decreasing cervical cancer incidence rates in resource-rich countries [133]; however, requirement of multiple Pap tests for identifying precancerous lesions due to higher rates of false-negative results makes it less cost-effective for masses in resource-poor settings. Therefore, more sensitive techniques than the ones based on cytology are now being utilized for early detection of causative agent of cervical cancer. Randomized clinical trials

Conclusion

Cervical cancer deaths are preventable yet the high rates of mortality in developing countries is reflective of an inaccessibility of health care services and health inequity [2]. Several screening and diagnostic tests are routinely practiced clinically. Disease-specific biomarkers including HPV E6/E7 mRNA, p16ink4a or new methylation analyses may work after HPV DNA test found to be positive as secondary markers. This would differentiate women with pre-cancerous conditions who require urgent

Funding

No funding was received for the study.

Author contributions

Ushma Jaykamal Shah, Mohammad Nasiruddin: Conceptualization, Methodology, Writing-Original draft preparation.

Md. Khurshid Alam Khan, Mohammad Riyaz Akhter, Nidhi Singh, Ali A. Rabaan: Data curation, Writing-Original draft preparation, Visualization.

Sajad Ahmad Dar, Shafiul Haque: Data Curation, Writing- Reviewing and Editing, Supervision.

Declaration of competing interest

None.

References (163)

  • M. Reuschenbach et al.

    Performance of p16INK4a-cytology, HPV mRNA, and HPV DNA testing to identify high grade cervical dysplasia in women with abnormal screening results

    Gynecol. Oncol.

    (2010)
  • S.W. Sorbye et al.

    HPV mRNA test in women with minor cervical lesions: experience of the University Hospital of North Norway

    J. Virol Methods

    (2010)
  • E.A. Burger et al.

    HPV mRNA tests for the detection of cervical intraepithelial neoplasia: a systematic review

    Gynecol. Oncol.

    (2011)
  • W.-T. Wang et al.

    Differentially expressed microRNAs in the serum of cervical squamous cell carcinoma patients before and after surgery

    J. Hematol. Oncol.

    (2014)
  • Y.-N. Zhao et al.

    Circulating MicroRNAs in gynecological malignancies: from detection to prediction

    Exp. Hematol. Oncol.

    (2014)
  • K.U. Petry et al.

    Triaging Pap cytology negative, HPV positive cervical cancer screening results with p16/Ki-67 Dual-stained cytology

    Gynecol. Oncol.

    (2011)
  • W.J. Zeng et al.

    The value of p16ink4a expression by fluorescence in situ hybridization in triage for high risk HPV positive in cervical cancer screening

    Gynecol. Oncol.

    (2011)
  • F. Carozzi et al.

    Use of p16-INK4A overexpression to increase the specificity of human papillomavirus testing: a nested substudy of the NTCC randomised controlled trial

    Lancet Oncol.

    (2008)
  • I. Tsoumpou et al.

    p16INK4a immunostaining in cytological and histological specimens from the uterine cervix: a systematic review and meta-analysis

    Canc. Treat Rev.

    (2009)
  • A.P. Pinto et al.

    Biomarker (ProExTM C, p16INK4A, and MiB-1) distinction of high-grade squamous intraepithelial lesion from its mimics

    Mod. Pathol.

    (2008)
  • A. Hidalgo et al.

    Human papilloma virus status and chromosomal imbalances in primary cervical carcinomas and tumour cell lines

    Eur. J. Canc.

    (2000)
  • Y.C. Yang et al.

    Frequent gain of copy number on the long arm of chromosome 3 in human cervical adenocarcinoma

    Canc. Genet. Cytogenet.

    (2001)
  • J. Jiang et al.

    Detection of TERC amplification in cervical epithelial cells for the diagnosis of high-grade cervical lesions and invasive cancer: a multicenter study in China

    J. Mol. Diagn.

    (2010)
  • K. Heselmeyer-Haddad et al.

    Genomic amplification of the human telomerase gene (TERC) in Pap smears predicts the development of cervical cancer

    Am. J. Pathol.

    (2005)
  • G.R. Jalali et al.

    Amplification of the chromosome 3q26 region shows high negative predictive value for nonmalignant transformation of LSIL cytologic finding

    Am. J. Obstet. Gynecol.

    (2010)
  • M.A. Fitzpatrick et al.

    Identification of chromosomal alterations important in the development of cervical intraepithelial neoplasia and invasive carcinoma using alignment of DNA microarray data

    Gynecol. Oncol.

    (2006)
  • J. Banerjee et al.

    Metagenomics: a new horizon in cancer research

    Meta Gene

    (2015)
  • M.S. Mancuso et al.

    Midtrimester bacterial vaginosis and cervical length in women at risk for preterm birth

    Am. J. Obstet. Gynecol.

    (2011)
  • D.H. Martin

    The microbiota of the vagina and its influence on women's health and disease

    Am. J. Med. Sci.

    (2012)
  • H. Johansson et al.

    Metagenomic sequencing of “HPV-negative” condylomas detects novel putative HPV types

    Virology

    (2013)
  • Centers for Disease Control and Prevention (CDC)

    Genital HPV infection – CDC fact sheet

    CDC Fact Sheets

    (2014)
  • WHO

    Cervical Cancer Estimated Incidence, Mortality and Prevalence Worldwide in 2012. IARC, 150 Cours Albert Thomas, 69372 Lyon CEDEX 08, France

    (2012)
  • HPV Information Centre

    India: Human Papillomavirus and Related Diseases, Summary Report 2017. ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre) 2017

    (2017)
  • A. Sreedevi et al.

    Epidemiology of cervical cancer with special focus on India

    Int. J. Wom. Health

    (2015)
  • R. Sankaranarayanan

    Effective screening programmes for cervical cancer in low-and middle-income developing countries

    Bull. World Health Organ.

    (2001)
  • E. Gakidou et al.

    Coverage of cervical cancer screening in 57 countries: low average levels and large inequalities

    PLoS Med.

    (2008)
  • N.M. Nour

    Cervical cancer: a preventable death

    Rev. Obstet. Gynecol.

    (2009)
  • E.M. Burd

    Human papillomavirus and cervical cancer

    Clin. Microbiol. Rev.

    (2003)
  • C. Kroupis et al.

    Human papilloma virus (HPV) molecular diagnostics

    Clin. Chem. Lab. Med.

    (2011)
  • H.B. Krebs et al.

    Human papillomavirus infection and genital tract cancer

    Glob. Libr. Women’s Med.

    (2008)
  • N. Muñoz et al.

    Epidemiologic classification of human papillomavirus types associated with cervical cancer

    N. Engl. J. Med.

    (2003)
  • J. Ferlay et al.

    Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008

    Int. J. Canc.

    (2010)
  • V.V. Sahasrabuddhe et al.

    Human papillomavirus and cervical cancer: biomarkers for improved prevention efforts

    Future Microbiol.

    (2011)
  • B. Samama et al.

    HPV DNA detection by in situ hybridization with catalyzed signal amplification on thin-layer cervical smears

    J. Histochem. Cytochem.

    (2002)
  • M. Parfenov et al.

    Characterization of HPV and host genome interactions in primary head and neck cancers

    Proc. Natl. Acad. Sci. U.S.A.

    (2014)
  • N. Sakakibara et al.

    Brd4 is displaced from HPV replication factories as they expand and amplify viral DNA

    PLoS Pathog.

    (2013)
  • M.R. Evans et al.

    An oral keratinocyte life cycle model identifies novel host genome regulation by human papillomavirus 16 relevant to HPV positive head and neck cancer

    Oncotarget

    (2017)
  • R.G. Ursu et al.

    Detection of hpv 16 and hpv 18 viral loads by real time pcr in women with cervical dysplasia

    Analele Ştiinţ. Ale Univ. Alexandru Ioan Cuza din Iași Sect. II A Genet. Biol. Mol.

    (2011)
  • M. Esteller

    Epigenetics in cancer. - main article

    N. Engl. J. Med.

    (2008)
  • Integrated genomic and molecular characterization of cervical cancer

    Nature

    (2017)
  • Cited by (11)

    View all citing articles on Scopus
    1

    These authors contributed equally.

    View full text