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Role of Human Papillomavirus Infection in the Development of Prostate Carcinoma and Benign Prostatic Hyperplasia
Khaled M. Hassanein1,2, Hani Al-Shobaili3, Marwa Salah Mostafa4*, Abdelaziz Al-Saloom5 and Taher Obaid Alshammari6
1Department of Medical Microbiology and Immunology, College of Medicine, Qassim University, KSA.
2Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Egypt.
3Department of Dermatology, College of Medicine, Qassim University, KSA.
4Department of Medical Microbiology and Immunology, Faculty of Medicine, Cairo University, Egypt.
5Department of Pathology, College of Medicine, Qassim University, KSA.
6Al Jouf University, KSA.
Authors’ contributions
This work was carried out in collaboration between all authors. Author KMH designed the study.
Author MSM managed the literature research, performed the statistical analysis and wrote the first draft of the manuscript. Authors KMH, HAS, MSM, AAS and TOA managed the analyses of the study and revised the final manuscript. All authors read and approved the final manuscript.
Article Information
DOI: 10.9734/BMRJ/2016/27283 Editor(s):
(1)Ana Cláudia Coelho, Department of Veterinary Sciences, University of Trás-os-Montes and Alto Douro, Portugal.
Reviewers:
(1)V. Harshini, Sri Devraj Urs University, India.
(2)Tariq Namad, Military Hospital My Ismail Meknes, Morocco.
(3)Volodymyr Chernyshenko, Palladin Institute of Biochemistry NAS of Ukraine, Ukraine.
Complete Peer review History:http://sciencedomain.org/review-history/15263
Received 27th May 2016 Accepted 22nd June 2016 Published 2nd July 2016
ABSTRACT
Aims: Human papillomavirus (HPV) infections are associated with benign and malignant lesions of the female and male anogenital tract. Currently, the possible role of HPV infections in prostate carcinogenesis is a subject of great controversy. The aim of this study is to investigate the role of HPV infections as a risk factor in the development of prostatic carcinoma.
Study Design: Case-control study.
Place and Duration of Study: Department of Medical Microbiology and Immunology and Original Research Article
Department of Dermatology, College of Medicine, Qassim University, between January 2013 and December 2015.
Methodology: Qualitative detection of the HPV DNA was performed in 85 Saudi prostatic carcinoma (PC) male patients. They were compared to 55 patients with benign prostatic hyperplasia (BPH) and 15 normal controls.
Results: The positivity of HPV DNA was significantly higher in patients with PC (25.9%) compared to the control group (0%) (P = .026). The HPV DNA positivity was higher in patients with PC than in BPH patients but with non-significant difference.
Conclusion: The present study reveals that the presence of HPV DNA in the prostatic tissue was associated with a higher incidence of PC. HPV DNA was also associated with a relatively high risk of BPH. Further studies are recommended to disclose the association between HPV infection and BPH.
Keywords: Prostatic carcinoma; benign prostatic hyperplasia; human papilloma virus; high risk HPV serotypes.
ABBREVIATIONS
BPH: Benign prostatic hyperplasia; HPV: Human papillomavirus; PCR: Polymerase chain reaction;
PC: Prostate carcinoma; PSA: Prostatic-specific antigen.
1. INTRODUCTION
The contribution of immune and inflammatory responses to the development of cancer has been well recognized in different human tumors [1]. Human papillomavirus (HPV) infections are associated with benign and malignant lesions of the female and male anogenital tract. Currently, the possible role of HPV infections in prostate carcinogenesis is a subject of great controversy [2]. Mutations in genes associated with the immune defense have been identified in hereditary prostatic carcinoma (PC), indicating that infection and/or inflammation of the prostate may be important mediators for the development of PC [3-5]. The HPV viral oncogenes that encode E6 and E7 proteins are able to induce cell transformation and interact with the signaling capacity of the interferon pathway in a synergistic manner [6].
Moreover, population studies have revealed an increased relative risk for development of PC in men with a prior history of sexually transmitted infections [7]. These findings support the hypothesis that an infectious agent can be a potential cofactor in prostate cancer development [8]. Several studies, carried out in different countries, revealed that the presence of HPV in PC varies from 4.2% to 53%. The types of HPV detected in prostate carcinoma were mostly limited to high-risk HPV types 16, 18, 31 and 33 [9-14]. However, other studies have not reproduced this finding [15,16]. These
inconsistencies in results may be because of several possible reasons for false-positive or false-negative results such as PCR contamination or degradation. In addition, control samples from the target tissue cannot be readily obtained from non-diseased persons [17]. The role of high-risk HPV in prostate carcinogenesis needs to be clarified; especially, since the
availability of HPV vaccines for high-risk HPV subtypes 16 and 18 may provide preventive measures against the development of PC [18].
The aim of this study is to investigate the role of HPV infections as a risk factor in the development of PC by detection of HPV DNA in prostatic tissue from Saudi male patients who were diagnosed as having PC or BPH.
2. MATERIALS AND METHODS
This study included 140 male patients attending the Department of Dermatology and Urology, Qassim University Polyclinic and King Fahad Specialist Hospital, Kingdom of Saudi Arabia from January 2013 to January 2015. Out of them, 85 patients (63.3±10.5 years old) were diagnosed clinically and histopathologically as prostatic carcinoma (PC), and 55 patients (59.2±10.7 years old) were diagnosed as benign prostatic hyperplasia (BPH). All subjects underwent digital rectal examination by the dermatology consultant and prostatic-specific antigen (PSA) testing. Men with a palpable nodule and/or elevated serum PSA level > 10
ng/ml were selected. In addition, 15 normal individuals (59.6±8.1 years old) were included as a control group. Their PSA serum levels were <
10 ng/ml and no palpable nodules were detected on digital rectal examination. The three study groups were matched for age. The study was approved by the local clinical research committee and performed according to the ethical procedures. A written informed consent was obtained from each participant.
2.1 Detection of Regions E6-E7 of HPV DNA of Medium and High Risk Subtypes
Prostatic tissues were obtained by core needle biopsy guided by trans-rectal ultrasound from all patients and controls. Immediately after removal from the anatomical location, the specimens were placed into sterile disposable plastic containers by the attending surgeon and stored at -80°C until used. DNA was extracted from tissue samples using DNA extraction kit (Operon, Spain). The High Papillomastrip test (Operon, Spain), which is based on the principle of reverse hybridization [19], was used for amplification and qualitative detection of regions E6-E7 of HPV DNA of 19 medium-high risk HPV subtypes according to the manufacturer’s instructions. To each PCR tube, a 38 µl of PCR premix, 5 µl of each primer (medium – high risk), 2 µl of Taq enzyme and 5 µl of DNA were added and mixed.
During PCR, the amplification of an internal control gene (β-globin) also occurs, acting as an indicator of the absence of PCR inhibitors in the amplified DNA samples. Distilled water was included as a negative control. The tubes were placed into the cycler device and DNA was amplified using the following conditions; initial denaturation at 94°C for 5 minutes followed by 40 cycles of 94°C for 1 minute, 58°C for 1 minute and 72°C for 1 minute, followed by final extension at 72°C for 5 minutes. PCR products were hybridized onto the High Papillomastrip containing specific probes. The strip was interpreted with the help of the evaluation chart supplied with the kit.
2.2 Statistical Analysis
Data were analyzed using SPSS version 16.
Values were expressed as mean±SD.
Differences between patients and control groups were assessed by Pearson Chi-Square test.
Results were considered statistically significant at P value ≤ 0.05.
3. RESULTS
The positivity of HPV DNA in prostatic tissue was significantly higher in patients with PC
(22/85, 25.9%) compared to the control group (0/15, 0%) (P = .026). Although PC
patients had higher HPV DNA positivity than the BPH patients (9/55, 16.4%), no significant difference was detected between the
two groups (P = .185). There was no significant difference between BPH patients and the control group (P = .093) (Table 1). The HPV types detected in PC and BPH patients are shown in Table 2.
Interestingly, a higher significant level of PSA was detected in BPH patients with high-risk HPV infection when compared to BPH patients without HPV infection (P = .001). No significant difference was detected between PC patients with and without HPV infection.
Table 1. Detection of human papillomavirus DNA in prostatic tissue from patients with
prostate carcinoma, benign prostatic hyperplasia and the control group
HPV a DNA Total Positive Negative PCb Count
%
22 25.9%
63 74.1%
85 100%
BPHc Count
% 9 16.4%
46 83.6%
55 100%
Control Count
% 0 0%
15 100%
15 100%
a Human papilloma virus, b Prostate carcinoma, c Benign prostatic hyperplasia
Table 2. Human papillomavirus subtypes detected in prostate carcinoma and benign prostatic hyperplasia patients
Total N (%) HPV-33
N (%) HPV-31
N (%) HPV-18
N (%) HPV-16a
N (%)
22 (25.9%) 2 (2.4%)
4 (4.7%) 6 (7%)
10 (11.8%) PCb (N=85)
9 (16.4 %) 1 (1.8%)
1 (1.8%) 3 (5.5%)
4 (7.3 %) BHPc (N= 55)
0 0
0 0
0 Controls (N=15)
a Human papilloma virus, b Prostate carcinoma, c Benign prostatic hyperplasia
4. DISCUSSION
This study showed that PC patients had a significantly higher positivity rate of HPV DNA (25.9%) when compared to the control group (P
= .026), and a higher positivity rate than BPH with a non-significant difference. Furthermore, there was no significant difference in HPV DNA positivity between BPH patients and the controls.
The results of this study are in concordance with Marttinez-Fierro et al. [22] who reported a significantly increased risk of PC in patients positive for HPV DNA, and Zambrano et al. [21]
who detected a high HPV incidence in six out of 12 PC patients using prostatic tissue and urine.
Leiros et al. [14] reported that HPV DNA is detected in 41.5% of carcinoma samples from patients older than 60 years, whereas all 30 hyperplasia samples were negative for HPV DNA. Another study recorded that a subgroup of prostatic tumors (21%) has significantly higher copy numbers of HPV-16 sequences when compared to the control (3%) [13]. Adami et al.
[17] reported a possible association between HPV-33 and prostate cancer but no association of HPV types 16 and 18. Recently, a study by Michopoulou et al. [22] detected HPV DNA in 8/50 (16%) prostate cancer samples and, only 1 was found positive for HPV in the 30 control samples (3.33%). Similarly, Singh et al. [23]
demonstrated HPV DNA in 41% of prostate tumor biopsies; 32% of them were infected with HPV-16 whereas 6% were found to be positive for HPV-18, and 20% in BPH; with only 5% of them were infected with HPV 16. Conversely, several studies reported a non-significant incidence of HPV DNA in prostatic cancer tissue samples [24-28]. Other studies showed that none of the prostate carcinoma tissue samples were positive for HPV DNA [29,30].
Several studies revealed seroepidemiological association between HPV high-risk subtypes and PC; Dillner et al. [31] reported a 2.6-fold increased risk of developing PC associated with HPV-18 and relative association with HPV-16, whereas they did not find an association between HPV-33 and PC risk. On the other hand, Sutcliffe et al. [32] revealed no associations between high-risk HPV types 16, 18 and 31 IgG and the risk for PC.
In concordance to the present study, Aghakhani et al. [2] reported a higher but non-significant difference regarding HPV-DNA presence between PC and BPH specimens, where they detected HPV-DNA in 12.5% PC patients, 76.9%
of them were high-risk HPV, and in 7.7% BPH samples, 62.5% of them were high-risk HPV.
Furthermore, a study by Al-Ahdal et al. [33]
reported that HPV-18 DNA was detected in 30.8% (4/13) of BPH patients, two of them were co-infected with HPV-16.
These discrepancies may be explained by technical differences in the viral detection methods, HPV contamination during the sampling procedure, the use of different primers or procedures such as annealing temperatures.
Primers from the E6 region of the HPV genome is able to amplify episomal and integrated HPV DNA sequences, while those from the frequently used L1 region may not amplify integrated HPV DNA [34]. Moreover, considering that HPV presence is strongly associated with high-risk sexual behavior, including a history of sexually transmitted diseases (STDs), the number of sexual partners, and age of first sexual activities, a comparison of cancers from patients with such sexual activity vs. those who did not engage in high-risk behavior may show a higher incidence of HPV infection [29].
In this study, a higher significant level of PSA was detected in BPH patients with high-risk HPV infection when compared to BPH patients without HPV infection (P = .001) which can be explained by the prostatitis caused by the virus [35]. While no significant difference was detected between PC patients with and without HPV infection. The elevated PSA in all PC patients without correspondence to infection is explained by the malignancy itself.
The relatively high incidence of HPV infection in BPH patients needs to be explained. Although this may be a coincidence, another explanation is to be considered. The prostatitis caused by HPV infection, as indicated by the detection of HPV DNA in the prostatic tissue, may induce hyperplasia. This theory can explain the high incidence of HPV DNA in BPH patients. The significant higher levels of PSA in BPH patients with high-risk HPV infection compared to those without HPV infection may support this theory as HPV infection increases the pathological changes in the prostatic tissue, thus increasing PSA.
5. CONCLUSION
This study shows a significant association of HPV infection in PC patients. These results are added to previous researches to show more
evidence that infection with high-risk oncogenic HPV subtypes is a possible risk factor and may be involved in the etiology of the development of PC where HPV DNA is in an integrated form. It also shows a relatively high incidence of HPV infection in BPH patients. Further studies are needed to disclose the association between HPV infection and BPH.
ACKNOWLEDGEMENTS
We acknowledge the Scientific Research Deanship, Qassim University for funding this study.
COMPETING INTERESTS
Authors have declared that no competing interests exist.
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