Human Papillomavirus HPV types in Cervical Cancer in

Human Papillomavirus (HPV) types in Cervical Cancer in Jordan Maher Sughayer M. D Full Member and Chairman, Pathology Dept. King Hussein Cancer Center Amman, Jordan An-Najah University, Faculty of Medicine Conference, Oct. 10, 2009

Introduction • Genital HPV is the most common STD in the United States* & probably in the world • 6. 2 million people are newly infected/year in the US alone. • About 100 HPV types are identified of which 40 infect the genital regions. • Low-risk types (6, 11): LSIL, genital warts. • High-risk types: HSIL, cervical cancer. *Markowitz; MMWR 23/3/07

High-Risk Types • Include types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 73, and 82 : cause invasive cervical cancer, LSIL, HSIL and other anogenital cancers. • Found in 99. 7% of ca cervix. • HR HPV is necessary but not sufficient for ca cervix.

Cervical Cancer • The 2 nd most common cancer in women worldwide. • 493, 000 new cases diagnosed annually. • Causing 274, 000 deaths each year: 80% of which in the developing world. • The largest single cause of years of life lost to cancer in the developing world. Agosti, NEJM, 356, 2007

Incidence Rates and Proportions caused by types 16/18 Agosti, NEJM. 356, May 10, 2007

Cervical Cancer in Jordan • In 2003 Jordan Cancer Registry: 1735 cases of cancer in women. • Cervical cancer cases: 41, not among the ten most common cancers in women. • In contrast breast cancer cases: 551. • HPV types: unknown.

Worldwide HPV Types in Cervical Cancer: The Impact of the Vaccine • Several meta-analyses published on HPV types from all over the world (Munoz, Clifford and finally Smith, 2007) to predict the impact of the new HPV vaccines. • And to study regional variation for possible future modification. • Smith’s meta-analysis: Int. J. Cancer, 2007

Meta-analysis Findings: Minor Regional Differences • In 14, 595 cases: HPV 16 most common, 18 second and 16/18: 74 -77% in North America, Europe, Australia and 65 -70% in the rest of the world. • The next most common types: 31, 33, 35, 45, 52 and 58, in all continents but not in the same order • 58 and 52 more important in Asia, 56 in Europe.

Number of Cases of Cervical Cancer with Available HPV Typing Smith, Int. J. Cancer, 2007

Multiple Infections with High-Risk HPV Types in Invasive Cervical Cancer • Cuschieri (J Clin Pthol 2004): 40% of HSIL cases have multiple HR HPV types. • Lai (Int J Cancer 2007): 18% of scc cases have multiple infections. • Gargiulo (Virus Res. 2007): 49% have multiple infections. • The effect of multiple infections on progression to cancer is not clear.

HPV Typing in Cervical Cancer in Jordan • Objective: To determine HPV types involved in invasive cervical cancer in Jordan. This is necessary to establish a base line and to check for any regional differences in HPV types in Jordan “in case a vaccine is to be considered? ”

Methods • The archives of the Pathology department were searched for cases of ICC. • Cases with available paraffin blocks were used for the study. • DNA was extracted using a commercially available kit (Extra DNA Tissue kit, Sacace Biotechnologies, Italy).

Methods • Adequacy and integrity of extracted DNA were assessed (spectrophotometry and PCR for GAPDH gene). • Multiplex PCR using a commercially available kit (HPV High Risk Typing, Sacace Biotechnologies, Italy). • 4 mixes (types 16, 31, 33, 35), (18, 39, 45, 59), (52, 56, 58, 66) and for some cases (6, 11).

• Electrophoresis and band identification using DNA ladder. Results were invalidated if internal control (B-globin gene) was absent.

Results • 48 cases with paraffin blocks were identified. • One adenocarcinoma, one adenosquamous, 46 sq. cell ca. • Age: range 37 -80. median age group: 44 -49 years.

Age Distribution

HPV Type Distribution • Successful DNA extraction was achieved in 41 cases. • 7 cases failed to produce adequate DNA. The reasons: old blocks, poorly processed/fixed tissue samples (referral material), small consumed biopsies.

HPV TYPE DISTRIBUTION HPV Type Number % 16 28 68. 3 18 10 24. 4 39 4 9. 8 56 4 9. 8 45 3 7. 3 52 3 7. 3 33 2 4. 9 31 1 2. 4 35 1 2. 4 58 1 2. 4 59 1 2. 4 66 0 0 11 0 0

HPV Type Prevalence %

• Types 16/18 found in 75. 6% of cases. • Multiple infections (2 or 3 types) were found in 14 cases representing 34% of all cases.

Conclusions • Types 16/18 are the most common types in cervical cancer in Jordan and are responsible for 75% of cases. • Other types (39, 56, 45, 52, 33, 31, 35, 58, 59) are responsible for 25%. • The relative importance of non 16/18 types is slightly different from reported studies: 39 and 56 appear more important than other minor types But…

• The number of cases (non 16/18) is small and more studies are needed. • Multiple infections are common similar to previously reported studies.

Thank You • • • Tasnim Dayeh Suzan Oraibi Mai Abu-Taha Mohamad Abdel-Hadi Lian Otay