State of Art on HPV and genital cancer 4th symposium on virology

State of Art on HPV and genital cancer

1. State of Art on HPV And Genital Cancers   Prof. Thomas Bourlet Service des Agents Infectieux et d’Hygiène, Pôle de Biologie Pathologie CHU de Saint-Etienne GIMAP Team 15 CIRI UMR 5308, U1111 INSERM Université Jean Monnet 23 th november 2023, FSTM , Mohammedia

2. HPV and oncogenesis : perseverance rewarded ! Harald zur Hausen German Cancer Research Center, Heidelberg The Nobel Prize in Physiology or Medicine "for his discovery of human papilloma viruses causing cervical cancer" 2008 1974 2006 Gardasil ® 2007 Cervarix ® 2003 (retired) Attempts to detect virus- specific DNA in human tumors . Nucleic acid hybridizations with complementary RNA of human wart virus zur Hausen H, Meinhof W, Scheiber W, Bornkamm GW Int J Cancer. 1974 May 15;13(5):650-6. 1983 Causal link Diagnosis , prevention , therapy e pidemiology Pathophysiogy F. Barré-Sinoussi L. Montagnier discovery of human immunodeficiency virus

3. State of Art on HPV And Genital Cancers   Pathophysiology Epidemiology Biomarkers Diagnosis

4. Pathophysiology Epidemiology Biomarkers Diagnosis State of Art on HPV And Genital Cancers  

5. HPV and cancers - Infectious agents cause up to 50% of all human cancers - Viruses account for 10–15% of all cases - HPV is linked to nearly 5% of all cancers worldwide - Global burden of HPV-associated cancers in 2020 : Pesut et al, 2021

6. Age-standardized incidence rates of cervical cancer in the world [Source: International Agency Research on Cancer, WHO 2020]

7. Estimated age-standardized mortality rates (World), cervix uteri , females , all ages [Source: International Agency Research on Cancer, WHO 2020]

8. New cases 2020 – the Global Cancer Observatory [ Globocan , IARC, WHO] France Morocco CERVIX UTERI 12 th leading cause of cancer 15 th leading cause of cancer mortality in women 3,379 new cases and 1452 deaths geographical disparities in incidence and mortality highest risk around 45-49

9. Prevalence in males Lancet Glob Health 2023; 11: e1345–62

10. Life-course approach for cervical cancer prevention and control Données CIRC 2018 Rate per 100 000 females - year Incidence Mortality

11. Main risk factor: human papillomavirus 99.7% of cervical cancers contain human papillomavirus DNA In over 70% of invasive cancers, it is HPV 16 or 18 Walboomers J et al., J.Pathol 1999; 189:12-8 Clifford GM, Smith JS, Plummer M, et al. British J.Cancer 2003 ; 88:63-73

12. Risk cofactors  171 meta-analysis from 50 studies In i

13. HPV Vaccines L1, L2: preventive vaccine targets E6, E7: therapeutic vaccine targets (VGX 3100, essai phase 2)  lesions regression  Cervarix ®: protects against HPV 16 and 18  Gardasil 9®: protects against HPV 6, 11, 16, 18, 31, 33, 45, 52 and 58 Recommended for girls and boys aged 11 to 14 with a 2-dose schedule (M0-M6) Make-up vaccination: young women and men aged 15 to 19 with a 3-dose schedule (M0, M2, M6) The 7 HR HPVs included in the nonavalent vaccine are implicated in 90% of cervical cancers

14. Countries which provide and recommend HPV vaccines through routine services [2021] 2022 HPV Vaccination program coverage - first dose: females, 21% - males, 6% - last dose: females , 16% - males, 5%  HPV types linked with cervical, penile, and oral cancers, will be integrated in Morocco’s official vaccination schedule starting October 2022

15. WHO global strategy of elimination of cervical cancer  threshold of less than 4 cases of cervical cancer per 100 000 women per year by the end of 21 st century  90-70-90 targets to be reached by 2030 - 90% of girls fully vaccinated with HPV vaccine by age 15 - 70% of women are screened with a high-performance test by 35, and again by 45 years of age - 90% of women identified with cervical disease receive treatment Guidance and tools on how to prevent and control cervical cancer through vaccination, screening and treatment Benefits of achieving the 90-70-90 targets by 2030 in low- and lower-middle-income countries:  median cervical cancer incidence rate will fall by 42% by 2045, and by 97% by 2120, averting >74 million new cases  median cumulative number of cervical cancer deaths averted - 300 000 by 2030 - >14 million by 2070 - >62 million by 2120 WHO response

16. Epidemiology Biomarkers Diagnosis State of Art on HPV And Genital Cancers   Pathophysiology

17. Genetic diversity and oncogenic risk IARC classification Group 1 , oncogenic (HR): 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 Group 2A , probably oncogenic : 68 Group 2B , possibly oncogenic : 26, 53, 30, 34, 66, 67, 69, 70, 73, 82, 85, 97 Group 3 : not classifiable as oncogenic: 6, 11 https://www.cancer-environnement.fr/ HPV 16 HPV 6 and 11 HPV 18 HPV 2 Danemark ( Bonde et al , 2020) HPV16,18,31,33: highest risk oncogenic with CIN 3 or worse of 31.7% HPV35,45,52,58: medium risk oncogenic with CIN 3 or worse between 14% and 18% HPV39,51,56,59,66,68: large group with limited risks with <10% of CIN 3 or worse National Cancer Institute HPV16: uniquely carcinogenic HPV18 and HPV45: higher risk, especially for CIN and cervical cancer HPV31,33,35,52,58: substantial higher risk HPV39,51,56,59,68: very little risk if precancer not immediately found Main genotypes 2 = common warts 6 and 11 = genital warts 16 and 18 = cervical cancer

18. Natural history of HPV infection clearance persistence progress regression invasion 15% 85% 2 to 6 years 3 to 5 years 5 to 15 years 8% of reinfections HPV infection Precancerous lesions Cervical cancer Normal epithelium Carcinoma Lesion Regression Persistence Progress to higher stage Progress to cancer

19. HPV replication cycle and carcinogenesis Role of E6, E7 viral proteins - Slowing of cell differentiation - Acceleration of cell division - Link between viral replication and cell differentiation/proliferation Pesut et al, 2021 red : E7 green: E4

20. Methylation and non- coding RNAs A vast majority of the human genome is transcribed into RNAs but only 2% are translated into proteins The remaining transcripts  non-coding RNAs Regulatory non-coding RNAs Long non-coding RNAs Circular RNAs Small RNAs: microRNAs, piwi-associated RNA, small nucleolar RNAs and endogenous short-interfering RNA Aberrant expression of lncRNAs , miRNAs, and circRNAs under pathological conditions such as cancer Disruption of the expression profiles of those lncRNAs affects multiple biological processes such as cell proliferation, apoptosis, and migration Superficial Intermediate Basal ↗ hsa-miR-20a-5p, hsa-miR-106b-5p ↓hsa-miR-125b-5p expression  PDL-1 and severity of the lesions Changes of methylation in LCR of HPV 16 HPV- encoded miRNAs

21. Epidemiology Biomarkers State of Art on HPV And Genital Cancers   Pathophysiology Diagnosis

22. Virological diagnosis of HPV infections for cervical cancer prevention https://www.has-sante.fr/upload/docs/application/pdf/2019-09/rapport_hpv_2019-09-09_14-20-44_251.pdf Between the ages of 25 and 29 : two cytological examinations 1 year apart , then 3 years later if the results of the first two are normal

23. Virological diagnosis of HPV infections for cervical cancer prevention  From age 30 to 65 : oncogenic HPV DNA testing for cervical cancer screening every 5 years https://www.has-sante.fr/upload/docs/application/pdf/2019-09/rapport_hpv_2019-09-09_14-20-44_251.pdf

24. New recommendations for screening and treatment to prevent cervical cancer [WHO 2021]

25. Validation for screening precancerous and cancerous cervical lesions by clinical studies -VALGENT protocol [Meijer et al. Int J Cancer 2009] List based on meta-analysis by Arbyn et al. [CMI, 2021] French recommendations: ( i ) detect high-risk HPV and (ii) include an internal cellularity control, particularly in the case of self-sampling Clinical sensitivity or diagnostic sensitivity: probability that a test will give a positive result (presence of an HPV) in the presence of a high-grade lesion Sensitivity and specificity must be at least 90% and 98% versus the reference test (Hybrid Capture 2) Detection of viral DNA or viral mRNA E6/ E7 (viral oncoproteins ) Must detect all 13 HR HPV groups 1+2A ( detection of group 2B not recommended ) - signal amplification ( liquid -phase hybridization ): not recommended for auto- samples - DNA amplification (PCR) - mRNA of E6/E7 by isothermal amplification (TMA), = not recommended for auto- samples HPV detection kits

26. Cytological & histological features Cytology Histology CIN classification (cervical intraepithelial neoplasia ) squamous lesions CIN 1 ( mild dysplasia ) CIN 2 ( moderate dysplasia ) CIN 3 ( severe dysplasia and carcinoma in situ ) WHO classification precursor lesions to squamous cell carcinomas low -grade squamous intraepithelial lesions high-grade squamous intraepithelial lesions adenocarcinoma precursor lesions adenocarcinoma in situ koilocytes Bethesda classification Squamous cells ASC-US: atypical squamous cells of undetermined significance ASC-H: atypical squamous cells for which a high-grade lesion cannot be excluded LSIL: low -grade squamous intraepithelial lesion HSIL: high-grade suqamous intraepithelial lesion Squamous cell carcinoma Glandular cells Atypical cells : endocervical, endometrial or glandular Atypical cells : endocervical or glandular ; favor neoplatic Adenocarcinoma in situ: endocervical Adenocarcinoma : endocervical, endometrial , extrauterine junction area

27. Alternatives to cervical smear  Insufficient screening coverage Deployment of self- testing Not suitable for cytology Several devices available on the market ( swab , cervico-vaginal lavage, cyto-brush ) PCR tests validated for self- sampling with cell control Urine sample Accumulation of mucus and cellular debris from the genital tract in the labia minora and around the urethral opening Discharge carried away by the flow of urine during micturition

28. Urine as an alternative to Pap smear Diagnostic performance of the HPV urine test Heterogeneous Variable from one study to another (various populations and HPV prevalence) Lack of standardization of used protocols (sampling, volume, fraction tested, PCR assay…) Bober et al., 2021 Evaluation of first-void urine for primary screening of cervical cancer Prevalence of HPV infection In 1 st void urine = 12.5% (95% CI: 5.5 -26.1) In smears = 10% (95% CI: 4.0-23.10) Good agreement between the two samples : Cohen's Kappa (k) = 0.63 (95% CI: 0.3-1.00) Se and Sp of the Anyplex ™ II kit on urine 1st jet versus PCV:

29. Epidemiology Biomarkers Diagnosis State of Art on HPV And Genital Cancers   Pathophysiology

30. Serology : no diagnostic value; prognostic value in oropharyngeal cancers (anti-E6 antibodies )? Triage markers under study (predictive of progression to cancer) - Viral load - p16/Ki-67 expression p16 overexpressed, involved in cell mitosis: marker for expression of viral oncoprotein E7 liaison E7  Ki67, cellular proliferation marker Biomarkers predictive of progression to cancer - Viral and cellular methylation markers FAM19A4 miR124-2

31. Biomarkers predictive of progression to cancer < 5 years of HPV infection Low methylation level FAM19A4/miR124-2 Low risk of short- term cervical cancer > 5 years of HPV infection High methylation level FAM19A4/miR124-2 High risk of short- term cervical cancer Steenbergen et al. Nat Rev Cancer 2014 De Strooper et al. Cancer Prev Res 2014 Van Zummeren , Modern Pathol 2018  Triage strategy : m ethylation of CADM1, MAL, MIR-124-2, FAM19A4, POU4F3, EPB41L3, PAX1, SOX1, and L1/L2 from HPV16 [Kelly et al., 2019] and… Transcriptome (Single- cell technology ) Suppressing Long Non- Coding RNAs Oncogenic Long Non- Coding RNAs Exosomes