|Year : 2013 | Volume
| Issue : 1 | Page : 10-14
Human papilloma virus detection by immunohistochemistry on sinonasal papillomas and nasopharyngeal carcinomas: Report on 26 cases
Carol Dsouza, Mah-e-Jabeen, Pushpalatha K Pai
Department of Pathology, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
|Date of Web Publication||21-Jun-2013|
Pushpalatha K Pai
Department of Pathology, Yenepoya Medical College, Yenepoya University, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Background : Human papilloma virus (particularly HPV 6 and 11) has been documented in 20% to 76% of nasopharyngeal papillomas. HPV is also associated with 25% keratinizing nasopharyngeal squamous cell carcinoma detected by studies using techniques of immunopathology and by modern molecular biology. Objectives: To study the role of human papilloma virus as an etiological agent in sinonasal papillomas and nasopharyngeal carcinomas (NPCs) by immunohistochemistry (IHC). Materials and Methods: A total of 26 cases of neoplasms were studied for HPV antigen. Tumors were classified histopathologically by using Hematoxylin and Eosin-stained slides. Evidence of HPV infection like koilocytic changes and HPV antigens were noted down in all 26 cases. Results: There were 14 sinonasal papillomas, 7 each of fungiform and inverted types and 12 nasopharyngeal carcinomas. All cases of fungiform papillomas had either histological (koilocytes) or immunohisochemical evidence of HPV infection. 85.5% of inverted papillomas had evidence of HPV infection either in the form of koilocytes or in the form of positive immunohistochemistry or both. 50% of nasopharyngeal carcinomas had histological and immunohistochemical (either one or both) evidence of HPV infection. Conclusion: This study, unlike other studies, has found higher rate of HPV detection in both types of Schneiderian papillomas. Not many studies have been carried out on nasopharyngeal carcinomas. We have found evidence of HPV infection in 100% of moderately differentiated squamous cell carcinomas and 33.3% cases of poorly to undifferentiated cases of NPC.
Keywords: Human papilloma virus, immunohistochemistry, nasopharyngeal carcinoma, papilloma
|How to cite this article:|
Dsouza C, Me, Pai PK. Human papilloma virus detection by immunohistochemistry on sinonasal papillomas and nasopharyngeal carcinomas: Report on 26 cases. Arch Med Health Sci 2013;1:10-4
|How to cite this URL:|
Dsouza C, Me, Pai PK. Human papilloma virus detection by immunohistochemistry on sinonasal papillomas and nasopharyngeal carcinomas: Report on 26 cases. Arch Med Health Sci [serial online] 2013 [cited 2020 Jan 25];1:10-4. Available from: http://www.amhsjournal.org/text.asp?2013/1/1/10/113552
| Introduction|| |
Papillomas of nose and paranasal sinuses are called Schneiderian papillomas derived from Schneiderian membrane.  The role of human papilloma virus (HPV) in the development of Schneiderian papillomas (sinonasal papillomas) has been the subject of numerous studies. Many studies have been done in recent years with in situ hybridization or polymerase chain reaction (PCR) techniques demonstrating the presence of human papilloma virus (HPV) in sinonasal papillomas, even if the detection rate varied considerably. The involvement of HPV as a causative agent is suggested by histologic observation of koilocytic change within the squamous epithelium. ,,,,, The association between Epstein-Barr virus (EBV) infection and nasopharyngeal carcinomas of the undifferentiated and non-keratinizing type is well-established. , The role of HPV in the development of nasopharyngeal carcinoma has not been studied much. An attempt is made to detect HPV infection histologically and immunohistochemically in this small study of 26 cases of upper respiratory tract tumors.
| Materials and Methods|| |
A total of 26 cases of sinonasal papillomas and nasopharyngeal carcinomas were studied for HPV antigen using cocktail of HPV antibodies (Type 6, 11, 18 -Leica Microsystems). The formalin-fixed tissue biopsies were processed and paraffin blocks were made. 3-5 micrometer sections were cut and stained with hematoxylin and eosin stain. Stained tissue sections were studied under light microscope and were classified into benign (Schneiderian papillomas) and malignant (carcinomas). The papillomas were further classified into fungiform and inverted papillomas and studied for koilocytic changes and for HPV antigens immunohistochemically. The malignant epithelial tumors were classified according to WHO into type 1 - keratinizing squamous cell carcinomas, type 2 - non-keratinizing, and type 3 - undifferentiated carcinomas and studied for koilocytic changes in the non-neoplastic epithelium if any present in the tissue biopsies and for HPV antigens by immunohistochemistry. A koilocyte is a squamous epithelial cell that has undergone a number of structural changes, which occur as a result of infection of the cell by human papilloma virus. Koilocytes may have the following cellular changes: Nuclear enlargement (two to three times normal size), irregularity of the nuclear membrane contour, a darker than normal staining pattern in the nucleus, known as hyperchromasia, and a clear area around the nucleus, known as a perinuclear halo. Collectively, these types of changes are called a cytopathic effect. Various types of cytopathic effect can be seen in many different cell types infected by many different types of HPV viruses. Koilocytes may show mild to severe atypical cellular changes.
| Results|| |
There were 14 sinonasal benign tumors. 7 were fungiform papillomas, and 7 were inverted papillomas [Figure 1]. Out of 7 cases of fungiform papillomas, 6 cases showed koilocytes, 1 was without koilocytes. Those with koilocytes, 3 cases were positive for HPV antigens [Figure 2] and 3 cases were negative for HPV antigens. The one without koilocytic change was positive for HPV antigen. That means all cases of fungiform papillomas, 6 cases with koilocytes and 1 case without koilocyte but positive for HPV antigen, showed evidence of HPV infection. There were 7 cases of inverted papillomas, 6 cases were with koilocytes [Figure 3] with HPV positivity. [Figure 4] One did not show koilocyte as well as HPV antigen. Hence, inverted papillomas were positive for HPV antigen in 85.5% of cases. There were 12 malignant epithelial tumors [Figure 5] where 3 moderately differentiated squamous cell carcinoma cases showed koilocytes in the overlying epithelium with 2 cases positive for HPV antigen. One case with koilocytes in the non-neoplastic epithelium overlying the carcinoma was negative for HPV antigens. That means all 3 cases of keratinizing squamous cell carcinomas of nasopharynx were positive for evidence of HPV infection. Out of the remaining 9 cases of poorly to undifferentiated carcinomas with no normal epithelium in the biopsy, only 3 cases were positive for HPV antigen and other 6 cases were negative. Hence, poorly to undifferentiated nasopharyngeal carcinomas showed 33.3% HPV positivity. On the whole, 50% NPCs showed evidence of HPV infection.
|Figure 2: Inverted papillloma showing koilocytes (vacuolated cells-arrow)-100x|
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| Discussion|| |
Major types of Schneiderian papillomas have many names, reflecting their different microscopic features. They are fungiform papilloma, inverted papilloma, and oncocytic Schneiderian papilloma. Fungiform papillomas and inverted papillomas have often been called transitional cell papillomas.  Papilloma viruses are epitheliotropic viruses that predominantly infect skin and mucous membrane and produce epithelial proliferation at the site of infection. In situ hybridization and polymerase chain reaction (PCR) studies have shown papilloma virus DNA in almost all fungiform papillomas and in minority of inverted papillomas. ,, In a review of literature, Barnes  reported that 38% of inverted papillomas were positive for HPV (in contrast to present study where the positivity was found in 6 cases out of 7). HPV 6/11 has been the type most often detected.  In several of the series, the incidence of possibility was notably higher for the fungiform than for the inverted papillomas, which often show histologic evidence of viral infection in the form of koilocytes, , which is correlating with our results. In the present study, both fungiform papillomas and inverted papillomas had equal incidence, 7 cases of each type. The HPV antigen was detected in 4 cases of fungiform papillomas and koilocytes in 6 cases. But, one case which was positive for HPV antigen did not show koilocytes. This can be explained by the fact that it takes time for the classical koilocyte to develop. 3 cases which were positive for koilocytes but negative for HPV antigen may be caused by different types of HPV. 6 cases of inverted papillomas showed both koilocytic changes and HPV antigen. In one case of inverted papilloma, both HPV antigen and koilocytes were absent. That will rule out HPV as an etiologic agent. This suggests that there must be other co-factors involved in sinonasal papillomas.
Nasopharyngeal carcinoma - Carcinoma of the nasopharynx is a leading cause of death. ,, Cases showing familial aggregates have been reported.  The accumulated evidence strongly suggest that this tumor results from the combined action of genetic predisposition, environmental factors, and the Epstein - Barr virus. ,, Specifically, it has been proposed that the tumor initiation requires EBV expression, but that the induction of pre-neoplastic events and maintenance of tumor cell phenotype requires critical cellular genes.  The role of HPV and EBV in the development of the conventional type of squamous cell carcinoma of the nose and paranasal sinuses remains to be clarified. DNA from HPV 16 and 18 has been detected using the highly sensitive PCR, in the study in 14% of squamous cell carcinoma of the sinonasal region.  Multiple interactive etiologic factors have been linked to the development of NPC. The most important link to the development of NPC is EBV. ,, Hording et al.  evaluated 38 cases of NPC for the presence of HPV and reported that 4 of 15 keratinizing squamous cell carcinomas (almost 25% of cases) were HPV-positive. But, unlike present study, none of the non-keratinizing or undifferentiated NPC had HPV, and it was concluded that HPV may have a pathogenetic role in some nasopharyngeal keratinizing squamous cell carcinomas but not for the non-keratinizing or undifferentiated types. The present study showed 66.6% of positivity in moderately differentiated (keratinizing) squamous cell carcinomas, and 33.3% of poorly to undifferentiated NPC in the present study were positive for HPV. Mirzamani et al,  found HPV sequence by in situ hybridization in a low percentage of EBV-positive NPCs and opined that significance of this co-existence of EBV and HPV requires further study since their study was confined to 20 cases of NPC. One of the research, it was concluded that HPV can be responsible in a subset of nasopharyngeal carcinomas, and p16 immunohistochemistry is the reliable marker. All HPV-related carcinomas were positive for p16.  In the present study, 3 cases of nasopharyngeal keratinizing squamous cell carcinomas with non-neoplastic epithelium, 2 cases showed koilocytes and HPV antigen and 1 case was negative for HPV antigen even though koilocytes were present. That means, 100% of keratinizing squamous cell carcinomas of nasopharynx did show evidence of HPV infection. The case with koilocytes which was negative for HPV can be explained by the fact that the cocktail of antibodies used in this study does not contain antibodies against all HPV types. It contained only antibodies against HPV type 6, 11, and 18. In 9 cases of nasopharyngeal carcinomas, no normal epithelium was seen in the biopsy. All 9 cases were poorly to undifferentiated carcinomas with HPV antigen present in 3 cases (33.33%). HPV antigen was negative in the remaining 6 cases. On the whole, 41.6% cases of nasopharyngeal carcinomas showed positivity for HPV antigen. In the negative cases of poorly to undifferentiated NPCs, there was no normal epithelium to look for koilocytes, and since limited HPV antigens were tested, it is not possible to say definitely that HPV infection was absent. Even then, 41.6% is a significant percentage, strongly suggesting HPV as one of the etiological agent in NPC.
What can be concluded with this study is HPV infection is an etiological agent in majority of cases of fungiform papillomas (in the present study, 100% of cases), majority of inverted papillomas (85.5% in the present study) and in a significant percentage of NPCs (41.6%).
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]