VIRAL ONCOLOGY Basic Science and Clinical Applications pot

VIRAL ONCOLOGY

VIRAL ONCOLOGY
Basic Science and
Clinical Applications
Edited by
Kamel Khalili, PhD
Department of Neuroscience
Center for Neurovirology
Temple University School of Medicine
Kuan-Teh Jeang, MD, PhD
Molecular Virology Section
National Institutes of Health
A JOHN WILEY & SONS, INC., PUBLICATION
Copyright © 2010 by John Wiley & Sons, Inc. All rights reserved
Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientifi c,
Technical, and Medical business with Blackwell Publishing.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey
Published simultaneously in Canada
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as
permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either prior written
permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the
Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax
(978) 750-4470, or on the web at www.copyright.com. Requests to the Publisher for permission should be
addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030,
(201) 748-6011, fax (201) 748-6008, or online at />Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in
preparing this book, they make no representations or warranties with respect to the accuracy or
completeness of the contents of this book and specifi cally disclaim any implied warranties of

merchantability or fi tness for a particular purpose. No warranty may be created or extended by sales
representatives or written sales materials. The advice and strategies contained herein may not be suitable
for your situation. You should consult with a professional where appropriate. Neither the publisher nor
author shall be liable for any loss of profi t or any other commercial damages, including but not limited to
special, incidental, consequential, or other damages.
For general information on our other products and services or for technical support, please contact our
Customer Care Department within the United States at (800) 762-2974, outside the United States at
(317) 572-3993 or fax (317) 572-4002.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may
not be available in electronic formats. For more information about Wiley products, visit our web site at
www.wiley.com.
Library of Congress Cataloging-in-Publication Data
Viral oncology : basic science and clinical applications / edited by Kamel Khalili, Kuan-Teh Jeang.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-470-37991-2 (cloth)
1. Viral carcinogenesis. 2. Oncogenic viruses. I. Khalili, Kamel, 1951– II. Jeang, Kuan-Teh.
[DNLM: 1. Oncogenic Viruses. 2. Neoplasms–etiology. 3. Tumor Virus Infections. QW 166 V8132
2009]
RC268.57.V54 2009
616.99'4019–dc22
2009036491
Printed in the United States of America
10 9 8 7 6 5 4 3 2 1
CONTENTS
Foreword vii
Preface xi
Contributors xiii
1 HUMAN PAPILLOMAVIRUS-ASSOCIATED CANCERS 1
Rachel A. Katzenellenbogen and Denise A. Galloway

2 MOLECULAR EVENTS ASSOCIATED WITH HUMAN
PAPILLOMAVIRUS-INDUCED HUMAN CANCERS 23
Amy Baldwin and Karl Münger
3 THE ROLE OF THE HUMAN PAPILLOMAVIRUS E6
ONCOPROTEIN IN MALIGNANT PROGRESSION 57
Miranda Thomas, David Pim, and Lawrence Banks
4 JC VIRUS ASSOCIATION WITH BRAIN TUMORS: THE ROLE OF
T ANTIGEN AND INSULIN-LIKE GROWTH FACTOR 1 IN DNA
REPAIR FIDELITY 89
Krzysztof Reiss, Kamel Khalili, and Luis Del Valle
5 INVOLVEMENT OF THE POLYOMAVIRUS, JC VIRUS,
IN COLORECTAL CANCER 113
C. Richard Boland, Luigi Ricciardiello, and Ajay Goel
6 POSSIBLE ASSOCIATION OF BK VIRUS WITH
PROSTATE CANCER 129
Michael J. Imperiale and Dweepanita Das
7 ONCOGENIC TRANSFORMATION BY POLYOMAVIRUS LARGE
T ANTIGEN 149
Abhilasha V. Rathi and James M. Pipas
8 SIMIAN VIRUS 40, HUMAN INFECTIONS, AND CANCER:
EMERGING CONCEPTS AND CAUSALITY CONSIDERATIONS 165
Janet S. Butel
v
vi CONTENTS
9 SIMIAN VIRUS 40 AND MESOTHELIOMA 191
Natalya Baranova and Michele Carbone
10 MOLECULAR IMMUNOBIOLOGY OF HEPATITIS B-ASSOCIATED
VIRAL CANCER 211
Timothy M. Block and Anand S. Mehta
11 HEPATITIS B VACCINE AND HEPATOCELLULAR CARCINOMA 225

Mei-Hwei Chang and Ding-Shinn Chen
12 PATHOGENESIS OF ACUTE AND CHRONIC HEPATITIS C VIRUS
INFECTION 243
Mark A. Feitelson, Helena M.G.P.V. Reis, Jingbo Pan, and Bill Sun
13 MOLECULAR MECHANISMS OF HEPATITIS C VIRUS-INDUCED
CELLULAR TRANSFORMATION 267
Donna Sir and Jing-Hsiung James Ou
14 CLINICAL ASPECTS OF HTLV-1-ASSOCIATED CANCER 279
Masao Matsuoka
15 ONCOGENIC POTENTIAL OF THE HTLV-1 TAX PROTEIN 295
Susan J. Marriott
16 HIV-1-ASSOCIATED MALIGNANCY: BASIC AND
CLINICAL ASPECTS 317
Melissa Agsalda and Bruce Shiramizu
17 HIV-RELATED LYMPHOMA 337
Giulia De Falco, Cristiana Bellan, Stefano Lazzi, and Lorenzo Leoncini
18 BIOLOGY AND EPIDEMIOLOGY OF HHV-8 351
Veenu Minhas and Charles Wood
19 THE ROLE OF KSHV IN PATHOGENESIS OF
KAPOSI’S SARCOMA 377
Gary S. Hayward, Donald J. Alcendor, and Ravit Arav-Boger
20 MOLECULAR PATHOBIOLOGY OF EBV INFECTION 409
Joseph S. Pagano
21 EPSTEIN–BARR VIRUS AS A PATHOGEN 425
Wasim A. Dar and Bill Sugden
Index 453
FOREWORD
Cancer, in its several forms, has been and is one of the most common causes of death
and disease in human populations. Primary prevention has been an effective means to
decrease the incidence of several cancers. Programs for smoking cessation have lead

to dramatic drops in cancer of the lung and other cancers and disease. The removal of
carcinogenic toxins (i.e., asbestos) and other measures, such as diet control, have also
had a positive effect. Prevention of cancers with antiviral vaccines has now been
shown; this book will deal with issues related to the viral etiology of cancers and their
prevention and treatment.
There have been signifi cant improvements in treatment in recent decades, particu-
larly of the hematological cancers of the young. However, for many cancers, particu-
larly those with low survival expectations, even very effective treatments may only
prolong life for a short time and the side effects of the treatments can decrease the
enjoyment of life. Early detection and intervention have been effective for some cancers.
The increased survival of patients with cancer of the breast has apparently been due, in
large part, to early detection programs. Surveillance for polyps in the colon and rectum
and their removal have helped decrease the incidence of clinical disease. However,
not all early detection methods are effective. Recent research has questioned the
value of screening for cancer of the prostate using prostate - specifi c antigen (PSA ).
Unnecessary surgery, radiotherapy, and other treatments may cause damage. Overall,
PSA screening and intervention programs may not signifi cantly decrease survival.
Routine chest X - ray screening for the detection of early cancer of the lung was aban-
doned when it did not appear to be of benefi t, although recent improvements in imaging
may increase the value of surveillance.
It is obvious that preventing a disease is more desirable than becoming sick and
then receiving treatment. The recent availability of viral vaccines that prevent cancer
could usher in a new phase of effective cancer control. About 15% or more of human
cancers are considered to be caused by viruses, and a discussion of these is a major
goal of this book. Diseases have several causes, and it is likely that there are other
cancers in which viruses have a role in causation, and where prevention of infection
may favorably alter outcome.
The discovery of hepatitis B virus (HBV) in our laboratory was reported in 1967.
We invented a method for a vaccine in 1969; in 1971 commercial production was being
considered, and in 1975 it was agreed. The etiological association of HBV with primary

cancer of the liver (hepatocellular carcinoma [HCC]) was postulated in 1969 by
Smith and Blumberg and confi rmed in the following years by striking epidemiological
vii
viii FOREWORD
evidence (Beasley in 1981, and others) and laboratory studies. HCC is the third most
common cause of death from cancer in males and the seventh in females. There are
probably about 1 million deaths a year from HCC and other diseases caused by HBV.
Following a convincing fi eld trail of the hepatitis B vaccine by Szmuness and his
colleagues (reported in 1980), the vaccine was approved in the early 1980s for use in
the United States and later elsewhere. By 1990, universal or directed (to the newborn
children of maternal HBV carriers) vaccination programs were in place in a large
percentage of the national members of the World Health Organization and by 2005 in
more than 75% of the nations. Compliance has, in general, been good, with recent
fallback because of antivaccine sentiment in some locations. There has been a dramatic
drop in the prevalence of HBV carriers in the vaccinated populations. On logical
grounds, it would be expected that a fall in HBV prevalence (HBV is said to be the
cause of about 70% of all primary cancers of the liver) would result in a fall in liver
cancer incidence. After the vaccine had been in use for more than a decade, this infer-
ence was confi rmed in a national study in Taiwan (1997) by Chang and colleagues.
They found that the incidence of liver cancer had decreased by about two - thirds in the
vaccinated cohorts. Soon afterward, Mark Kane, then the director of hepatitis programs
at the World Health Organization, noted that vaccine prevention of HCC was one of
the two most important cancer control programs along with smoking cessation projects.
In less than two decades after the approval of the vaccine, it was in use worldwide and
a common and deadly cancer had decreased in incidence.
About 25 years after the introduction of the fi rst cancer prevention vaccine, a
second was approved, and vaccination programs were initiated. In 2008, Harald zur
Hausen was awarded the Nobel Prize in Medicine for identifying strains of the human
papillomavirus (HPV ) as the cause of cancer of the cervix of the uterus, and several
other cancers. Painstakingly, zur Hausen had identifi ed portions of the genomes of

these strains in cancer cervical cancer cells and described the molecular pathogenesis
of the cancer. Cancer of the cervix is the second most common cancer in women;
worldwide, there are about half a million new cases annually and approximately
260,000 deaths.
In 2006, the U.S. Food and Drug Administration approved a vaccine that, based
on a well - designed and well - executed fi eld trial, protected against infection. Vaccination
programs began soon afterward, and these are likely to become more widespread as
the public health community learns more about the strategies for vaccination and the
economics of national and regional vaccination programs.
An additional argument for national vaccination programs is the value of HBV and
HPV vaccines in preventing diseases in addition to cancer. HBV vaccine prevents
disabling and life - shortening acute and chronic hepatitis. HBV is also involved in the
pathogenesis of kidney disease, polyarteritis nodosa, and other diseases that may be
decreased by the use of the vaccine. (HBV infection is associated with cancer of the
pancreas; the signifi cance of these epidemiological observations requires further study.)
HPV is associated with genital warts that can be disabling, as well as with several less
common cancers. The use of the vaccines in large populations can be justifi ed not only
for the prevention of cancer but also for other more common diseases. HBV - and HPV -
related pathologies are among the most common sexually transmitted diseases .
FOREWORD ix
There are about 400 million people who are currently HBV carriers; some of them
are at risk of developing chronic liver disease and HCC. Liaw (2004) and others have
shown that antiviral treatment for relatively long periods can signifi cantly decrease the
risk of disease. This results need to be confi rmed and the treatment modes determined
in detail, including the problem of antiviral resistance with long usage. They hold
promise for the treatment of early cancers with antivirals rather than cancer therapies
that destroy normal cells along with cancer cells.
The widespread use of the vaccines has already and will in the future result in a
dramatic drop in the prevalence of HBV and the strains of HPV affected by the vaccine.
These viruses have affected large proportions of the world ’ s population for many gen-

erations, possibly even before the emergence of Homo sapiens . For HBV, it is known
that there are multiple polymorphic susceptibility loci (SNIPS ) that affect the probabili-
ties that the viral hosts will become carriers or, alternatively, develop protective anti-
body (anti - HBs ). The implication is that there has been a balance, at a population level,
of advantages and disadvantages that have maintained the virus in many populations
at a high level. There are also other microbial agents related to HBV in that they are
affected by the same susceptibility loci. It will be important to monitor the changes in
prevalence of these and other microorganisms in the environment as the vaccines alter
these dynamic relations.
The success of the research on viruses and cancer, and in particular, the major
contributions of the two cancer prevention vaccines, have revived interest in viral
oncology. The publication of this book, the establishment of viral oncology programs
in research centers, and the convening numerous conferences are indications of this
change. These activities could once more bring virus research to the forefront in the
never - ending endeavor to understand how viruses maneuver and negotiate in a complex
environment, including the environment of the human host. It should also give urgency
to a concerted program to develop vaccines and other interventions that will help
prevent additional cancers and decrease their burden on human populations.
Baruch S. Blumberg
Fox Chase Cancer Center
Philadelphia, PA

PREFACE
Oncogenic viruses are the known etiologic agents in 15% – 20% of all human cancers.
Their impact on global health is signifi cant. The fi rst recognition that cancer can be
caused by a virus dates back to observations of Rous sarcoma virus in chickens almost
100 years ago. However, it was not until the 1970s that the mechanistic basis for
retroviral transformation became clearer. That era was marked by the discovery of
many viral oncogenes and counterpart cellular proto - oncogenes. Additionally, insights
into cell growth factors, cell cycle regulation, checkpoints, and their operative protein

factors followed rapidly. Today in 2009, there are six well - established human cancer
viruses (HBV, HCV, HPV, HTLV, EBV, and KSHV ). Besides these six viruses, there
is mounting evidence, as presented in many of the chapters in the book, that illustrate
a strong association of other viruses, most notably human polyomaviruses, including
JCV, BKV, and SV40 , with a variety of human cancers.
This book emerged from a desire to provide an up - to - date survey of human
oncogenic viruses and their pathogenic properties. The 21 chapters in this book bring
together teams of expert authors from all parts of the globe. As the editors, we have
been fortunate to personally witness many pivotal advances during our scientifi c
careers. It is therefore fi tting that we should assemble these fi ndings to share with a
larger audience. Thus, editing this book represents our desire to capture and review
current and past exciting discoveries on human viral oncology for colleagues and
students.
A few important scientifi c concepts that are detailed in the various chapters include
the epidemiology of human viral - induced cancers, cofactors for viral transformation,
the multistepped process of viral transformation, and the common and varying mecha-
nisms used by different types of viruses. Through such mechanistic understanding, we
hope that safer and more effective therapeutics and additional effective cancer virus
vaccines (such as the one developed for HPV) will ensue in the future. The latter subject
areas are not major areas of focus for this volume; however, in future editions, we plan
to expand in these directions.
This book will be of interest to graduate students, medical students, and to anyone
engaged in the study of oncogenic viruses, their molecular biology, evolution, epide-
miology, pathologic potential, and cancer research. It is our hope that this book pro-
vides information that helps better understand the pathogenesis of human cancers,
particularly those that are associated with viruses, and assists in the development of
more customized strategies toward cancer treatment and prevention.
xi
xii PREFACE
An undertaking such as this book could not be accomplished without the combined

efforts of many individuals. We are particularly grateful to the authors who have con-
tributed thoughtfully written chapters, and we are indebted to Thomas H. Moore and
Ian Collins at Wiley, and to Sandy Weiss who has provided us with excellent logistics
and editorial assistance. The publication of this book is also accompanied by the devel-
opment of an annual meeting on human oncogenic viruses organized by the International
Committee on Viral Oncology Research (ICVOR).
Kamel Khalili
Kuan-Teh Jeang
CONTRIBUTORS
Melissa Agsalda, Hawaii Center for AIDS, Departments of Cell & Molecular Biology,
Pediatrics, & Internal Medicine, University of Hawaii, Honolulu, HI
Donald J. Alcendor, Viral Oncology Program, Department of Oncology, Sydney
Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine,
Baltimore, MD
Ravit Arav - Boger, Viral Oncology Program, Department of Oncology, Sydney
Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine,
Baltimore, MD
Amy Baldwin, The Channing Laboratory, Brigham and Women ’ s Hospital and
Department of Medicine, Harvard Medical School, Boston, MA
Lawrence Banks, International Centre for Genetic Engineering and Biotechnology,
Trieste, Italy
Natalya Baranova, Cancer Research Center of the University of Hawaii, Honolulu, HI
Cristiana Bellan, Department of Human Pathology and Oncology, University of
Siena, Siena, Italy
Timothy M. Block, Drexel Institute for Biotechnology and Virology Research, Drexel
University College of Medicine, Doylestown, PA
C. Richard Boland, GI Cancer Research Laboratory, Baylor University Medical
Center, Dallas, TX
Janet S. Butel, Department of Molecular Virology and Microbiology and the Dan L.
Duncan Cancer Center, Baylor College of Medicine, Houston, TX

Michele Carbone, Cancer Research Center of the University of Hawaii, Honolulu, HI
Mei - Hwei Chang, Departments of Pediatrics and Internal Medicine, College of
Medicine, National Taiwan University, Taipei, Taiwan
Ding - Shinn Chen, Departments of Pediatrics and Internal Medicine, College of
Medicine, National Taiwan University, Taipei, Taiwan
Wasim A. Dar, Department of General Surgery, University of Wisconsin - Madison,
Madison, WI
Dweepanita Das, Department of Microbiology and Immunology, and Comprehensive
Cancer Center, University of Michigan Medical School, Ann Arbor, MI
xiii
xiv CONTRIBUTORS
Giulia De Falco, Department of Human Pathology and Oncology, University of Siena,
Siena, Italy
Luis Del Valle, Department of Neuroscience, Center for Neurovirology, Temple
University School of Medicine, Philadelphia, PA
Mark A. Feitelson, Department of Biology, College of Science and Technology,
Temple University, Philadelphia, PA
Denise A. Galloway, Division of Human Biology, Fred Hutchinson Cancer Research
Center, Seattle, WA
Ajay Goel, GI Cancer Research Laboratory, Baylor University Medical Center, Dallas,
TX
Gary S. Hayward, Viral Oncology Program, Department of Oncology, Sydney
Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine,
Baltimore, MD
Michael J. Imperiale, Department of Microbiology and Immunology, and
Comprehensive Cancer Center, University of Michigan Medical School, Ann
Arbor, MI
Rachel A. Katzenellenbogen, Department of Pediatrics, University of Washington,
Seattle, WA, and Division of Human Biology, Fred Hutchinson Cancer Research
Center, Seattle, WA

Kamel Khalili, Department of Neuroscience, Center for Neurovirology, Temple
University School of Medicine, Philadelphia, PA
Stefano Lazzi, Department of Human Pathology and Oncology, University of Siena,
Siena, Italy
Lorenzo Leoncini, Department of Human Pathology and Oncology, University of
Siena, Siena, Italy
Susan J. Marriott, Department of Molecular Virology and Microbiology, Baylor
College of Medicine, Houston, TX
Masao Matsuoka, Institute for Virus Research, Kyoto University, Kyoto, Japan
Anand S. Mehta, Department of Microbiology and Immunology, Drexel University
College of Medicine, Doylestown, PA
Veenu Minhas, Nebraska Center for Virology, School of Biological Sciences,
University of Nebraska, Lincoln, NE
Karl M ü nger, The Channing Laboratory, Brigham and Women ’ s Hospital and
Department of Medicine, Harvard Medical School, Boston, MA
Jing - hsiung James Ou, Department of Molecular Microbiology and Immunology,
Keck School of Medicine, University of Southern California, Los Angeles, CA
Joseph S. Pagano, University of North Carolina at Chapel Hill School of Medicine,
Chapel Hill, NC
Jingbo Pan, Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson
University, Philadelphia, PA
CONTRIBUTORS xv
David Pim, International Centre for Genetic Engineering and Biotechnology, Trieste,
Italy
James M. Pipas, Department of Biological Sciences, University of Pittsburgh,
Pittsburgh, PA
Abhilasha V. Rathi, Department of Biological Sciences, University of Pittsburgh,
Pittsburgh, PA
Helena M.G.P.V. Reis, MIT - Portugal Program, Lisbon, Portugal
Krzysztof Reiss, Department of Neuroscience, Center for Neurovirology, Temple

University School of Medicine, Philadelphia, PA
Luigi Ricciardiello, GI Cancer Research Laboratory, Baylor University Medical
Center, Dallas, TX
Bruce Shiramizu, Hawaii Center for AIDS, Departments of Cell & Molecular Biology,
Pediatrics, & Internal Medicine, University of Hawaii, Honolulu, HI
Donna Sir, Department of Molecular Microbiology and Immunology, Keck School of
Medicine, University of Southern California, Los Angeles, CA
Bill Sugden, McArdle Laboratory for Cancer Research, University of Wisconsin -
Madison, Madison, WI
Bill Sun, Department of Biology, College of Science and Technology, Temple
University, Philadelphia, PA
Miranda Thomas, International Centre for Genetic Engineering and Biotechnology,
Trieste, Italy
Charles Wood, Nebraska Center for Virology, School of Biological Sciences,
University of Nebraska, Lincoln, NE

HUMAN PAPILLOMAVIRUS -
ASSOCIATED CANCERS
RACHEL A. KATZENELLENBOGEN
1,2
AND DENISE A. GALLOWAY
2
1
Department of Pediatrics, University of Washington, Seattle, WA
2
Division of Human Biology, Fred Hutchinson Cancer Research Center,
Seattle, WA
1
INTRODUCTION—HUMAN PAPILLOMAVIRUS ( HPV) TYPES AND
HPV LIFE CYCLE

HPV is a small, nonenvelope, double - stranded DNA virus of the Papillomaviridae
family. Different HPVs are defi ned by their genotypes, with more than 100 described
to date. HPV genotypes are clustered into genera (de Villiers et al., 2004 ) based on
genetic relatedness. Within each genus, HPVs are categorized into species based on
distinct genotypes; members of a species have similar biological properties or pheno-
types. Differences of 10% or more in the viral capsid gene (L1) are noted as different
HPV types, differences of 2% – 10% as subtypes, and differences of less than 2% are
variants (Fig. 1.1 ) (de Villiers et al., 2004 ; Doorbar, 2006 ).
The two main genera of HPV are the alpha and beta papillomaviruses, with nearly
90% of typed HPVs falling within these groups (Fig. 1.1 ). Genus alpha papillomavi-
ruses are associated with genital and mucosal infections, although a few infect cutane-
ous epithelium. Genus alpha HPVs are further defi ned as high - risk or low - risk based
on their association with anogenital cancers or benign genital warts, respectively. The
genus beta papillomaviruses are associated with benign skin infections; however, in
immunocompromised patients or patients with epidermodysplasia verruciformis (EV),
Viral Oncology: Basic Science and Clinical Applications. Edited by Kamel Khalili and Kuan-Teh Jeang
Copyright © 2010 John Wiley & Sons, Inc.
1
2 HUMAN PAPILLOMAVIRUS-ASSOCIATED CANCERS
Figure 1.1. HPV cladogram. HPV types are categorized based on their genetic similarities.
The genus alpha papillomaviruses primarily infect mucosal epithelium, and the genus beta
papillomaviruses primarily infect the skin (fi gure from Doorbar, 2006).
a rare genetic disorder caused by mutations in the EVER1 or EVER2 genes (Ramoz
et al., 2002 ; Keresztes et al., 2003 ; Kurima et al., 2003 ), squamous cell carcinomas
(SCC) can develop.
HPV requires actively dividing and differentiating epithelium, typically the basal
layer of stratifi ed squamous epithelium, for its DNA replication, gene expression, and
protein coat production. HPV reaches basal cells through epithelial microabrasions or
at sites where the epithelium transitions from a monolayer to stratifi ed squamous cells,
such as at the cervical transformation zone or the anal verge (Fig. 1.2 ). Although these

areas are more accessible to the virus for initial infection, they are poorer sites for viral
production. This makes these anatomical transition areas sites where abnormal and
inadequate viral gene expression, and ultimately HPV genome integration, are likely
to occur. With HPV genome integration, regulatory viral genes may be lost, and
epithelial cells are driven to immortalization, which can progress to cancer.
EPIDEMIOLOGY OF HPV INFECTIONS AND CANCER
Genus Alpha HPV Infection in Women
HPV is the most common sexually transmitted infection (STI). Seventy - fi ve percent of
men and women in the United States have evidence of a current or prior genus alpha
EPIDEMIOLOGY OF HPV INFECTIONS AND CANCER 3
Figure 1.2. HPV life cycle. HPV infects the basal layer of stratifi ed squamous epithelium. E6
and E7 drive continued proliferation as cells differentiate in the suprabasal layers and other
early genes increase HPV gene expression and genome amplifi cation. In the epithelial granu-
lar layers, the late L1 and L2 proteins are expressed, forming infectious virions that are
released through desquamation (fi gure adapted from Doorbar, 2006).
infection by serology, HPV DNA or RNA testing, cervical dysplasia, or genital warts
(Koutsky and Kiviat, 1999 ). High - risk HPV infection has been identifi ed as the key
to cervical intraepithelial neoplasia and cancer (Table 1.1 ) (Durst et al., 1983 ; Koutsky
et al., 1992 ; Munoz et al., 1992, 2003 ; Walboomers et al., 1999 ); however, most
TABLE 1.1. HPV - Associated Cancers
Cancer Type HPV+ (%)
Cervical squamous cell carcinoma
1 – 3
89.3 – 99.7
Cervical adenocarcinoma
1
81.8
Vulvar
1
8 9

Vaginal
1
90.7
Anal
1,4
84 – 93.8
Penile
1,5
40 – 81.8
Head and neck
6
2 5
Oropharynx/tonsil
7,8
43.6 – 72
Note : The majority of anogenital cancers are associated with alpha genus HPV
infections, and a signifi cant subset of head and neck cancers are also associated
with HPV.
1
Carter et al. (2001) .
2
Munoz et al. (2003) .
3
Walboomers et al. (1999) .
4
Frisch et al. (1997) .
5
Gross and Pfi ster (2004) .
6
Gillison et al. (2000) .

7
Schwartz et al. (1998) .
8
D ’ Souza et al. (2007) .
4 HUMAN PAPILLOMAVIRUS-ASSOCIATED CANCERS
high - risk infections do not become cancerous, so high - risk HPV is required but not
suffi cient for cancer progression.
Several natural history studies have been conducted to document the frequency
and length of HPV infection in sexually active female adolescents and adults (Burk
et al., 1996 ; Ho et al., 1998 ; Moscicki et al., 2001 ; Woodman et al., 2001 ; Richardson
et al., 2003 ; Winer et al., 2003, 2005 ). A prospective longitudinal study of female
university students found that with each new lifetime partner, the risk of HPV acquisi-
tion rose: 3% for virginal women, 7% for women with one lifetime partner, 33% for
women with two to four partners, and 53% for women with fi ve or more partners (Burk
et al., 1996 ). Moscicki et al. ’ s (2001) longitudinal study of female adolescents found
that their risk of HPV infection was also directly associated with the number of new
partners as well as evidence of other STIs on exam. Winer et al. ( 2003 ) found that
cumulative incident HPV infections in university women was 32.3% by 24 months,
which is consistent with other studies (Ho et al., 1998 ; Richardson et al., 2003 ; Winer
et al., 2003 ). Woodman et al. (2001) found a cumulative incidence of HPV infection
in 15 - to 19 - year - olds at 44% by 36 months and 60% at 5 years.
In university women, new partners and smoking were risk factors for HPV acquisi-
tion (Winer et al., 2003 ), and the younger a female is at coitarche, the more likely she
is to become infected with HPV (Kahn et al., 2002 ). Several studies have found that
males ’ behaviors impact HPV infection in their female partners. The more lifetime
partners a male has can increase the risk of HPV infection in a female partner; the
briefer the relationship between a male and female can also increase the risk (Burk
et al., 1996 ; Ho et al., 1998 ; Winer et al., 2003 ). So, the behavior of college - aged
women and adolescents, as well as their partners, is an important risk factor for HPV
infection. Young age at sexual debut, multiple partners, short relationships, smoking,

and presence of other STIs all put teenagers and young women at risk for HPV.
The transition from a documented HPV infection to a low - grade squamous intraep-
ithelial lesion (LGSIL) Pap smear is directly associated with a persistent infection as
well as daily cigarette smoking in women (Moscicki et al., 2001 ). In a study of univer-
sity women who had an HPV infection, nearly half of them developed cervical squa-
mous intraepithelial lesions (SILs) and more than a quarter developed vaginal SILs
within 36 months of their infection (Winer et al., 2005 ). These SILs regressed within
4.7 – 5.5 months on average (Winer et al., 2005 ).
LGSIL in adolescents also typically regress: 91% within 3 years (Moscicki et al.,
2004 ). Women typically require a referral for colposcopy with the diagnosis of LGSIL;
however, as adolescents and young women up to 21 years old have a greater likelihood
of clearance of their HPV infection and regression of clinical disease, management of
atypical cells of undetermined signifi cance (ASCUS) and LGSIL Pap smears has been
modifi ed accordingly ( ) (Wright
et al., 2007 ). In contrast, older women are less able to clear infections and are more
likely to have abnormal Pap smears, including high - grade squamous intraepithelial
lesions (HGSIL) (Herrero et al., 2000 ; Castle et al., 2005 ), perhaps due to their
relatively poor immune response to HPV infections (Garcia - Pineres et al., 2006 ).
Since the implementation of Pap smears for all sexually active women in the United
States, rates of cervical cancer have fallen three - quarters since the 1950s. Within the
EPIDEMIOLOGY OF HPV INFECTIONS AND CANCER 5
past 30 years, cervical cancer incidence has decreased from 14.2 per 100,000 in 1973
to nearly 3 per 100,000 in 1998, with a goal of 2 per 100,000 in Healthy People 2010
( ). However in the United
States, women are still diagnosed with cervical cancer and die from this disease. In
2003, 11,820 women were diagnosed with cervical cancer and 3919 women died from
it (U.S. Cancer Statistics Working Group, 2006 ). This makes understanding the infec-
tion and progression of disease critical to continued diagnosis and treatment.
More than 95% of cervical cancers contain high - risk HPV DNA, and HPV is also
present in the majority of vulvar and vaginal cancers (Table 1.1 ) (Walboomers et al.,

1999 ; Carter et al., 2001 ; Munoz et al., 2003 ). As the anal verge is similar to the cervix
in transitioning from stratifi ed squamous epithelium to columnar cells, HPV can also
infect these cells and is associated with anal cancer in women. The rate of female
anal cancer is increasing, likely representing a change in women ’ s sexual behaviors
(Frisch et al., 1993, 1999 ).
Genus Alpha HPV Infection in Men
HPV infection in men has been less well studied. HPV has been detected in 42% – 80%
of penile cancers (Table 1.1 ) (Gross and Pfi ster, 2004 ; Daling et al., 2005 ), the rate of
which may refl ect a greater diffi culty of sampling for HPV from the penis, or the overlap
of two distinct cancer types, one due to high - risk HPV infection and one not (Bleeker
et al., 2006 ; Micali et al., 2006 ; Partridge and Koutsky, 2006 ). When compared with
women, men have a less good antibody response to infection, which may be due to
lower viral load or faster clearance of infection (Partridge and Koutsky, 2006 ). It has
been shown that circumcision is protective against HPV acquisition in men (Hernandez
et al., 2008 ), as well as cervical cancer in their wives (Castellsague et al., 2002 ); when
circumcised, the amount of columnar epithelium on the glans of the penis is reduced,
making it more diffi cult for HPV to infect.
Like in women, anal cancer in men is associated with HPV infection and is increas-
ing in incidence (Table 1.1 ) (Frisch et al., 1993, 1997, 1999 ; Daling et al., 2004 ). Unlike
women, men who have sex with men have a high (over 50%) and persistent HPV
infection rate regardless of age (Chin - Hong et al., 2004 ), as well as a high and persistent
level of abnormal anal cytology (Chin - Hong et al., 2005 ). The high level of infection
and abnormal cytology put men who have sex with men at greater risk for anal cancer
when compared with women and cervical HPV infections.
Patients who are human immunodefi ciency virus (HIV) positive or have acquired
immune defi ciency syndrome (AIDS) are at increased risk for abnormal cytology on anal
cytology (Palefsky et al., 1998 ; Frisch et al., 2000 ; Sobhani et al., 2004 ). Although regular
screening for men who have sex with men has not been universally recommended, studies
have shown screening programs for anal cytology similar to cervical Pap smears to be
reliable and potentially helpful (Cranston et al., 2004 ; Mathews et al., 2004 ).

Genus Alpha HPVs and Head and Neck Cancers
Head and neck cancers are associated with genus alpha HPV infections (Table 1.1 ),
although this is a weaker correlation than with anogenital cancers (Fakhry and Gillison,
6 HUMAN PAPILLOMAVIRUS-ASSOCIATED CANCERS
2006 ). Also, although tobacco and alcohol use are risk factors for non - HPV - associated
head and neck cancers, this is not true in HPV - associated head and neck cancers
(Fakhry and Gillison, 2006 ; D ’ Souza et al., 2007 ; Gillison et al., 2008 ). HPV appears
to be important, specifi cally in oropharyngeal cancers, such as the tonsils and the base
of the tongue. The tonsils mimic the cervix and the anal verge as sites of metaplastic
epithelium, making them an appropriate site for HPV infection. Studies have shown
patients with anogenital cancers have a two - and - a - half - to fourfold increased risk of
tonsillar cancer, and their partners are at increased risk of tonsillar cancer or cancer of
the tongue (Frisch and Biggar, 1999 ; Hemminki et al., 2000 ).
A case - control study of patients with oropharyngeal cancer showed sexual behavior
as a primary risk factor; a high lifetime number of vaginal - sex partners or oral - sex
partners was associated with cancer (3.1 and 3.4 odds ratio, respectively) (D ’ Souza
et al., 2007 ). Oral infection with high - risk HPV types were strongly associated with
oropharyngeal cancer (12.3 odds ratio) (D ’ Souza et al., 2007 ). Again, understanding
sexual behaviors is critical for predicting changes in oral cancer epidemiology, just as
seen in anal cancer incidence.
Genus Beta HPVs and Skin Cancer
Nonmelanoma skin cancer is the most common cancer in the United States, with more
than 1 million cases diagnosed annually ( />skin ). Nonmelanoma SCC accounts for 20% – 30% of skin cancers, and SCC has been
associated with genus beta HPV infection on sun - exposed skin. This cancer rate is even
higher among two clusters of patients: organ transplant patients who are on immuno-
suppressive therapy and EV patients. Patients with EV develop lifelong warty lesions,
25% of which convert to SCC in sun - exposed areas (Orth et al., 1978, 1979 ; Ostrow
et al., 1982 ; Orth, 2006 ). Genus beta HPVs are ubiquitously found in skin and hair
follicle samples (Orth, 2006 ) and typically lead to benign lesions. However, the increas-
ing number of transplant patients makes this infection a concern for future patients.

The mechanism of genus beta HPVs leading to cancer is different than genus alpha
HPVs and cancers, and it is the focus of ongoing research.
HPV EARLY AND LATE GENE EXPRESSION
The mechanism by which HPV binds to and enters basal epithelial cells is not known
entirely, although both binding to laminin 5 and glycosaminoglycans are likely impor-
tant (Joyce et al., 1999 ; Selinka et al., 2002 ; Culp et al., 2006 ). Once the virus infects
cells, the HPV coat is removed and the HPV genome enters the nucleus. All HPV
genomes have at least two promoters named early and late for their timed expression
during the viral life cycle (Fig. 1.3 ). The E6 and E7 genes (designated E for early) are
expressed from the early promoter (p97), and the E1, E2, E4, and E5 genes are expressed
from the late promoter (p670) (Fig. 1.2 ) but utilize the early polyadenylation site. The
early open reading frames drive viral DNA replication and expression, as well as
dysregulate the normal epithelial cell cycle for the benefi t of HPV viral production.
HPV EARLY AND LATE GENE EXPRESSION 7
Figure 1.3. HPV genome. HPV is a double -stranded DNA virus with early (E) and late (genes)
designated for their expression during the HPV life cycle . LCR =long control region.
The E2 protein has several critical roles in HPV genome expression and replication.
It is expressed early in the viral life cycle and is found in basal and suprabasal layers
of stratifi ed squamous epithelium infected by HPV. E2 binds as a dimer to DNA and
recognizes the palindromic motif AACCg(N
4
)cGGTT in the noncoding region of the
HPV genome 5 ′ of the early promoter (Hines et al., 1998 ; Masterson et al., 1998 ;
Stubenrauch et al., 1998 ; Dell et al., 2003 ). E2 recruits the HPV viral helicase E1 to
the viral origin and increases the DNA - binding affi nity to the noncoding region
(Masterson et al., 1998 ; Sun et al., 1998 ; Conger et al., 1999 ; Titolo et al., 2003 ). Both
E1 and E2 together utilize cellular machinery for DNA replication and transcription
(Masterson et al., 1998 ; Conger et al., 1999 ; Muller et al., 2002 ; Clower et al., 2006a,b ).
Although E2 is a transcriptional activator at low concentrations, high levels of E2
repress expression of E6 and E7 from the late promoter (Steger and Corbach, 1997 ;

Francis et al., 2000 ). Finally, E2 also functions to segregate the HPV genome as cells
divide by tethering the genome to cellular chromosomes during mitosis (You et al.,
2004 ; McPhillips et al., 2005, 2006 ; Oliveira et al., 2006 ).
The E4 protein is found in the suprabasal and granular layers of stratifi ed squamous
epithelium. Without a functional E4 protein, HPV episomal DNA cannot amplify from
their initial 50 – 100 copies per cell to the several thousands normally seen (Wilson
et al., 2005 ).
E5 protein has effects on both cellular transformation and viral genome amplifi ca-
tion. Although HPV E5 has little effect on monolayer undifferentiated keratinocytes in
vitro , E5 does increase the number of suprabasal cells dividing in organotypic cultures
grown to mimic stratifi ed squamous epithelium (Genther et al., 2003 ). Additionally, in
differentiated keratinocytes, E5 induces HPV genome amplifi cation. HPV 16E5 can
cause epithelial hyperplasia, abnormal cellular differentiation, and skin tumors when
expressed in mice. This effect occurs through the epidermal growth factor receptor,
although this may not be consistent across all HPV types (Fehrmann et al., 2003 ;
Genther et al., 2005 ).