Braz. j. . vol.83 número1

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Human

papillomavirus

in

oral

cavity

and

oropharynx

carcinomas

in

the

central

region

of

Brazil

夽

Guilherme

Petito

a,∗

,

Megmar

Aparecida

dos

Santos

Carneiro

b

,

Sílvia

Helena

de

Rabello

Santos

b

_,

_Antonio

_Marcio

_Teodoro

_Cordeiro

_Silva

a

_,

Rita

de

Cassia

Alencar

c

_,

_Antonio

_Paulo

_Gontijo

c

_,

_Vera

_Aparecida

_Saddi

a,c

a_Pontifícia_Universidade_Católica_de_Goiás_{(PUC-Goiás),}_Programa_de_Mestrado_em_Genética,_Goiânia,_GO,_Brazil b_Instituto_de_Patologia_Tropical_e_Saúde_Pública,_Universidade_Federal_de_Goiás_(UFG),_Goiânia,_GO,_Brazil

c_{Associac¸ão}_de_Combate_ao_Câncer_em_Goiás,_Setor_de_Anatomia_Patológica,_Laboratório_de_{Oncogenética}_e_{Radiobiologia,}

Goiânia,GO,Brazil

Received16September2015;accepted10January2016 Availableonline9April2016

KEYWORDS

Papillomaviridae; Papillomaviridae16; Headandneck neoplasm; Epidemiology

Abstract

Introduction:Molecularstudiesaboutcarcinomasoftheoralcavityandoropharynx demon-strate the presence of human papilomavirus genome in these tumors, reinforcing the participationofhumanpapilomavirusinoralcarcinogenesis.

Objectives:Thisstudyaimedtodeterminetheprevalenceofhumanpapilomavirusand geno-typedistributionofHPV16andHPV18inoralcavityandoropharynxcarcinomas,aswellastheir associationwithclinicalcharacteristicsofthetumors.

Methods:Thisisaretrospectivestudy,withclinicaldatacollectedfrom82patients.Human papilomavirusdetectionwasconductedonspecimensoforalcavityandoropharynxcarcinomas includedinparaffinblocks.Patientswereassistedinacancerreferencecenter,inthecentral regionofBrazil,between2005and2007.Polymerasechainreactionwasusedforthedetection andgenotypingofhumanpapilomavirus.

Results:Amongthepatientsevaluated,78%weremale.Theaverageageofthegroupwasabout 58years.Riskfactors,suchassmoking(78%)andalcoholconsumption(70.8%)wererecorded forthegroup.HPVDNAwasdetectedin21cases(25.6%;95%confidenceinterval16.9---36.6) ofwhich33.3%wereHPV16and14.3%wereHPV18.Thepresenceoflymphnodemetastases andregistereddeathswerelessfrequentinhumanpapilomaviruspositivetumors,suggesting abetter prognosisfor thesecases; however,the differences between thegroups were not statisticallysignificant.

夽

Pleasecitethisarticleas:PetitoG,CarneiroMA,SantosSH,SilvaAM,AlencarRC,GontijoAP.Humanpapillomavirusinoralcavityand oropharynxcarcinomasinthecentralregionofBrazil.BrazJOtorhinolaryngol.2017;83:38---44.

∗_{Corresponding}_author.

E-mail:[email protected](G.Petito).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.

http://dx.doi.org/10.1016/j.bjorl.2016.01.004

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Conclusion: Theresultsobtainedinthepresentstudy,withrespecttothepresenceofthe high-riskHPV16andHPV18genotypes,highlighttheimportanceofhumanpapilomavirusvaccination inthecontroloforalcavityandoropharynxcarcinomas.

© 2016 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

PALAVRAS-CHAVE

Papillomaviridae; Papillomaviridae16; Neoplasiadecabec¸a epescoc¸o;

Epidemiologia

Papilomavírushumano(HPV)emcarcinomasdecavidadeoraleorofaringenaregião centraldoBrasil

Resumo

Introdução: Estudosmolecularessobrecarcinomasdacavidadeoraleorofaringedemonstram a presença do genoma do papilomavírus humano (HPV) nesses tumores, o que enfatiza a participaçãodoHPVnacarcinogêneseoral.

Objetivos: EsseEsteestudoteveporobjetivodeterminaraprevalênciadeHPVeadistribuic¸ão genotípica deHPV16eHPV18 noscarcinomasdecavidadeoral eorofaringe,bemcomo sua associac¸ãocomascaracterísticasclínicasdostumores.

Método: Este é um estudo retrospectivo, com dados clínicos coletadosde 82 pacientes. A detecçãodeHPVfoirealizadaemamostrasdecarcinomasdecavidadeoraleorofaringe incluí-dos emblocosde parafina.Ospacientesforamatendidosem um centrodereferênciapara tratamentodocâncer,naregiãocentraldoBrasil,entre2005e2007.Foiutilizadaareaçãoem cadeiadepolimerase(PCR)paraadetecçãoegenotipagemdoHPV.

Resultados: Entreospacientesavaliados,78%eramhomens.Amédiadeidadedogrupoera de 58 anos. Fatores de risco como o tabagismo (78%) e consumo de álcool (70.,8%) foram registradosparaogrupo.HPVDNAfoidetectadoem21casos(25,6%;ICde95%,16,9----36,6), dosquais33,3%eramHPV16e14,3%eramHPV18.Apresenc¸ademetástasesemlinfonodoseos óbitosregistradosforammenosfrequentesemtumorespositivosparaHPV,sugerindomelhor prognósticoparaessescasos;contudo,asdiferenc¸asentreosgruposnãoforamestatisticamente significantes.

Conclusão:Osresultadosobtidosnopresenteestudo,comrespeitoàpresenc¸adegenótiposde altoriscodeHPV16eHPV18,destacamaimportânciadavacinac¸ãoparaHPVnocontroledos carcinomasdecavidadeoraleorofaringe.

© 2016 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Este é um artigo Open Access sob uma licença CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

Head and neck cancers (HNC), including oral cavity and oropharynx carcinomas, are the sixth most common can-certypesintheworld,withanannualestimateof633,000 newcasesand355,000deaths.1_In_Brazil,_15,290_HNCs_were

expected in 2014, with 11,280 cases in men and 4010 in women.2

Oral andoropharynxcarcinomasaccountfor morethan 80%ofthetotalHNC cases,3 _and_squamous_cell_carcinoma

(SCC)isthemostcommonhistologicaltype,comprisingmore than 90% of the cases. The prognosis of these tumors is mostlypessimistic,withalowfive-yearsurvivalof approxi-mately58%.4,5

Age, gender, and tumor-node-metastasis (TNM) tumor staging,whichincludestheextensionofthetumor,the pres-enceoflymphnodemetastases,anddistantmetastasis,are the main prognostic factors for oral cavity and orophar-ynx carcinomas.6 _In _addition, _histological _grade _and _the

expressionofmolecularmarkers(p16,pRb,andKi-67)allow abetterunderstandingoftumorbehaviorandevolution.6---8

The treatment of SCC of the oral cavity and orophar-ynx is usually accomplished by surgery or radiotherapy, alone or associated, and may also include the use of chemotherapy as an alternative to improve the chances of cure.9 _Studies _suggest _that _for _Human _{papillomavirus}

(HPV)-positiveoral cavityand oropharynxSCC, treatment with surgery and adjuvant radiotherapy is as good as the definitive radiotherapy treatment, with or without chemotherapy.9,10

Smoking and alcohol consumption are considered the mainriskfactorsfororalcavityandoropharynxcancer.9---11

However, with the intensification of campaigns against smoking and alcohol, the role of HPV in oral cavity and oropharynx carcinomas has gained prominence in recent years.11,12_A_growing_number_of_studies_support_the

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HPVis asexually-transmittedinfection;therefore, fac-torssuchasearlyinitiationofsexualactivity,highnumber ofsexpartners,andthepracticeofunprotectedoralsexare includedasriskfactorsforHPVinfectionintheoralcavity andoropharynxmucosa.15 _Growing_incidence_of_oral_cavity

andoropharynx carcinomasassociated with HPV in young peoplehasbeendemonstrated.14---16

TheprevalenceofHPVinoralcavityandoropharynxSCC is the focus of several studies worldwide; HPV16 is con-sidered the most prevalent and relevant genotype in the epidemiologyofthesecarcinomas.13,17---20

Thisstudyaimedtoinvestigatetheprevalenceand geno-typic distribution of HPV16 and HPV18 in oral cavity and oropharynxcarcinomas,aswellastheirpossibleassociation withtheclinicalcharacteristicsofthetumors.

Methods

Typeofstudyandseries

ThestudywasapprovedbytheResearchEthicsCommittee, underNo.13580613.5.0000.0031/2014.Itwasa retrospec-tive cross-sectional study that used data collected from medical files and analysis of paraffin blocks containing specimensof oral cavityand oropharynxcarcinomas. The selection wasfirst accomplished by analyzing the records of the Pathology Department at the Hospital, and only patientswithhistologicaldiagnosisofSCCoforalcavityand oropharynxwereincluded. Initially312casesofSCC diag-nosedintheperiodfrom2005to2007wereselected.After eliminating duplicates, 174 cases with available clinical recordswereselected. Patientswhoreceived chemother-apy/radiotherapybeforesurgerywereexcluded,resultingin 108cases.Paraffinblocksfrom108caseswerehistologically examined,andspecimenswithexiguousamount oftumors wereexcluded,resultingin82casesthatwereselectedfor DNAextractionandHPVDNAdetection.

DNAextraction

GenomicDNAwaspurifiedfromtumorsamplesfixedin for-malinandincludedinparaffin.Thesamplesweredewaxed inxyleneandwashedinethanolaccordingtostandardized protocol.DNAwasisolatedbyusingthecommercialWizard Kit(Promega). The presence andtheintegrityof theDNA were verifiedby the amplificationof a 99 base pair(BP) fragmentfromglyceraldehyde-3-phosphatedehydrogenase (GAPDH),byusingpolymerasechainreaction(PCR).

HPVDNAdetection

HPV DNA was detected by PCR. The set of primers used wasSPF 1/2(short PCR fragment).The SPF1/2 amplifies afragmentof65pboftheL1regionofHPV genome.This setofprimersallowthedetectionof39highandlow onco-genicrisk HPV: 6, 11, 13, 18,26, 30, 31, 33, 34,35, 39, 40,42,43,44, 45,51,52,53, 54,55,56,58, 59,61,62, 64, 66, 67, 68, 69, 70, 72, MM4, MM7, 73, 74, and MM8. The genotypesdetected bySPF 1/2 are thosethat infect the mucous membrane.13 _PCR _with _SPF _1/2 _primers _was

carriedoutinafinalreactionvolumeof25␮L,adding2␮Lof

purifiedDNA,2.5mM/LMgCl2,2mM/Lofeach deoxyribonu-cleotide(dNTPs),2.5␮M/Lofeacholigonucleotideprimer,

0.25U Taq polymerase (Invitrogen, Brazil) and ultra pure waterinsufficientquantityforthefinalvolume.Cycling con-ditionsincluded:preheatingfor1minat94◦_C,_followed_by

40 cyclesof: 94◦

Cfor 1min, 1min at 45◦

C, and1min at 72◦_C,_with_a_final_extension_of₅_min_at₇₂◦_C._Positive_and

negativecontrolswereusedineachreaction.

GenotypingofHPV16and18

HPV16andHPV18genotypingwasperformedbyPCRforall HPV-positivetumors.Twosetsofprimersthatamplifypart ofE7regionofeachHPVgenomewereemployed.21_For_the

HPV16genome,theampliconpresents108pb,andforHPV18 genome amplification, the ampliconpresents 104pb.PCR withHPV16primerswasperformed inafinalreaction vol-umeof 25␮L, with2␮Lof purifiedDNA,2.5mM/LMgCl2, 2mM/L of each dNTPs, 2.5␮M/L of each oligonucleotide

primer,0.25UTaqpolymerase(Invitrogen,Brazil),andultra purewaterinsufficientquantityforthefinalvolume.Cycling conditionsincluded:preheatingfor1minat94◦_C,_followed

by 40cycles of:94◦_C_for ₁_min, ₁_min _at ₄₅◦_C, _and₁_min

at72◦_C,_with_a_final_extension_of₅_min_at ₇₂◦_C._PCR_with

HPV18primerswasperformedinafinalreactionvolumeof 25␮L,with5␮LofpurifiedDNA,2.5mM/LMgCl2,2mM/Lof eachdNTPs,2.5␮M/Lofeacholigonucleotideprimer,1.25U

Taqpolymerase,(Invitrogen,Brazil)andultrapurewaterin sufficientquantity forthefinalvolume.Cyclingconditions included:preheatfor3minat94◦

C,followedby35cycles of:1minat94◦_C,₁_min_at₅₃◦_C,_and₁_min_at₇₂◦_C,_with_a

finalextensionof3minat72◦_C.

Statisticalanalysis

Allthepatients’dataweretranscribedtoMicrosoftExcel® spreadsheets. Clinical and histological data of the group, aswellasthepresenceofHPVgenome,HPV16,andHPV18 genotypeswereanalyzedbyusingFisher’sexacttestandthe chi-squaredtest.Valuesofp≤0.05wereconsidered

statis-ticallysignificant.Positiveandnegativecontrolswereused ineachreaction.

Results

Clinicalandhistologicalcharacteristics:agroupof82cases of SCC of oral cavity and oropharynx were selected and evaluatedwithrespecttoclinical andhistological charac-teristics (Table 1). Among the patients, 78% were male. Mostofthepatients(54.9%)wereintheagegroupunder59 yearsand62.2%weremarried.Riskfactors,suchas smok-ing (78%)and alcohol consumption (70.8%)were recorded forthemajority ofthegroup.Dataassociatedwithsexual behaviorandorientation,suchasthenumberofsexual part-ners,ageatsexualactivityonset,andpracticeoforalsex werenotreportedinthemedicalfiles.

HPVdetectionandgenotyping:HPVDNAwasdetectedin 21cases(25.6%;95%confidenceinterval(CI)16.9---36.6),of which 33.3% were HPV16 and 14.3% were HPV18. Table 2

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Table1 Analysis of theclinical and histological charac-teristics of the patients with oral cavity and oropharynx carcinomas.

Variable Allcases(n=82)

n %

Gender

Female 18 22.0

Male 64 78.0

Ageatdiagnosis

Average 58

---≤59 45 54.9

≥60 37 45.1

Maritalstatus

Single 15 18.2

Married 51 62.2

Other 16 19.6

Smoking

Yes 64 78.0

No 18 22.0

Alcoholconsumption

Yes 58 70.8

No 24 22.0

Tumorlocation

Oralcavity 39 47.6

Oropharynx 43 52.4

Staging

I/II 14 17.1

III/IV 68 82.9

Tumorsize

T1andT2 35 42.7

T3andT4 47 57.2

Lymphnodemetastasis

Yes 42 51.2

No 40 48.8

Distantmetastases

Yes 01 1.2

No 81 98.8

Histologicalgrade

Low 13 15.8

Moderate/high 69 84.2

Registereddeath

Yes 28 34.1

No 54 65.9

negativecases.Amongthe21HPV-positivesamples,47.4% were located in the oral cavity and 52.6% in oropharynx. Considering the clinical staging for HPV-positive tumors, 4.8%werein stagesI/II, while95.2% wereinstages III/IV. Lymph node metastases were detected in 42.9% of HPV-positivecasesandin57.4%ofHPV-negativecases(p=0.08). DistantmetastaseswerenotdetectedinHPV-positivecases, while one distant metastasis was described in the HPV-negativecases(p=0.46).Withrespecttohistologicalgrade, 85.7%ofHPV-positivecasesshowedmoderatetohighgrade

of differentiation. A greater number of deaths were reg-istered in the HPV-negative group (39.3%) compared to theHPV-positivegroup(19.1%),thoughthisdifferencewas notstatisticallysignificant (p=0.11).With respecttoHPV genotyping, seven samples (33.3%) were HPV16 positive, while threesamples (14.3%) wereHPV18 positive. Signifi-cant differences between HPV16 and HPV18 tumorswere notdetectedinthisstudy.

Discussion

Inthis study analyzing 82 casesof SCCof oral cavity and oropharynxdiagnosed ina cancer referencecenter inthe centralregionofBrazil.HPVDNAwasdetectedin21cases (25.6%),ofwhich33.3%wereHPV16and14.3%wereHPV18. Theseresultssupportthehypothesisthatasubgroupoforal cavityandoropharynxcarcinomasis HPVrelated.12---18

Sig-nificantchangesintheepidemiologyofmucosalSCCsofthe headandneck,withanincreasingnumberofcasesrelated toHPV,havebeen demonstratedinthelastdecade.1---22 _In

additiontotobaccoandalcoholconsumption,HPVappears asan importantrisk factor fororal cavityand oropharynx SCCdevelopment.TheprevalenceofHPVDNAin oropharyn-gealcancer(OC)variesindifferentstudies,andupto84% ofcaseshavebeenassociatedtoHPVinfection.19

Theassociation betweenHPVinfectionwithoralcavity andoropharynxSCCemphasizestheimportanceof introduc-ing specific molecular tests into oral cancer prevention practices,inordertoevaluatethepresenceofthevirusand thepossibilityof expanding anti-HPV vaccine in the male population.23,24

Inthepresentstudy,54.9%ofthepatientswereyounger than59years.Severalstudiesdescribetheagerangeofthe patients withcarcinoma of oral cavity and oropharynx as similartothevaluedescribedinthepresentstudy.25,26_In_a

studyconductedinItaly,themedianagewas65.6years.18

Theaccumulationofexposuretovariousriskfactors,such as lifelong smoking and alcoholism, contributes to the higherprevalenceofthesetumorsinmoreadvancedages.6

Studies demonstrated that HPV-associated HNC, including oropharyngealandoralcavitySCCs,haverecentlyrisen dra-maticallyin men under 50 years old.27 _In _a _period _of ₂₀

years,the relative prevalence of HPV-positive oropharyn-gealsquamouscancercell(OSCC)wentfromlessthan20% tomorethan70%intheUnitedStatesandsomeEuropean countries.28---30_In_the_HPV-positive_patients_evaluated_in_the

presentseries,66.7%ofthecaseswereundertheaverage age (59 years). Most cases of carcinoma of the oral cav-ityandoropharynxwereobservedinmales(78.0).Various authorshavepreviouslyreportedthisinformation;however, indifferentcountriesofEurope,anincreasingtendencyin theincidenceoforopharynxcarcinomashasbeennoticedin females.9---29

Smokingandalcohol consumption aredescribed asthe main risk factors for carcinomas of the oral cavity and oropharynx.11---31 _The_present_study_confirmed_the_high

fre-quencyofsmokers(78.0%)andalcohol drinkers(70.8%)in thegroup.Althoughnotfullyconsideredasaprognostic fac-tor,carcinomasoftheoralcavityandoropharynxassociated withsmokingandalcoholismtend tobemoreaggressive.1

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Table2 AnalysisoftheclinicalandhistologicalcharacteristicsofthepatientswithHPV-positiveandHPV-negativeoralcavity andoropharynxcarcinomas.

Variable HPV(−)(n=61) HPV(+)(n=21) pa

n % n %

Gender

Female 15 24.6 03 14.3 0.38

Male 46 75.4 18 85.7

Ageatdiagnosis

Average 60 --- 53 --- 0.31

≤59 31 50.8 14 66.7

≥60 30 49.2 07 33.3

Tumorlocation

Oralcavity 29 47.5 10 47.4 1.00

Oropharynx 32 54.5 11 52.6

Staging

IandII 13 21.3 1 4.8 0.10

IIIandIV 48 78.7 20 95.2

Tumorsize

T1andT2 26 42.6 09 33.3 1.00

T3andT4 35 57.4 12 66.7

Lymphnodemetastasis

Yes 35 57.4 07 42.9 0.08

No 26 42.6 14 57.1

Remotemetastases

Yes 01 1.6 00 0.00 0.46

No 60 98.4 21 100.0

Gradeofdifferentiation

Low 10 16.4 03 14.3 1.00

Moderate,high 51 83.6 18 85.7

Registereddeaths

Yes 24 39.3 04 19.1 0.11

No 37 60.6 17 80.9

Treatment

Surgeryonly 24 39.5 03 14.3 0.32

Surgery+radiotherapy 14 22.9 08 38.1

Radiotherapy+chemotherapy 09 14.7 03 14.3

Other 14 22.9 07 33.3

HPVtype

HPV16 --- --- 07 33.3

---HPV18 --- --- 03 14.3

Other --- --- 11 42.4

a_All_p_-values_were_calculated_with_Fischer’s_exact_test.

phenomenonknownasfieldcancerization,whichis charac-terizedbymolecularchangesinthereservecells,leadingto theformationofepithelialfieldchanges.26_This_field

under-goesexpansionandextendsoverthesurfaceofthemucous membrane,increasingthepossibilityofformationofanew carcinoma.32,33

Theprofileofpatientswithcarcinomaoftheoralcavity and oropharynx associated with HPV tends to be charac-terizedby agroupof youngerpatients, agedless than60 years,non-smokersorlightsmokers,non-drinkers,andwith

morepromiscuoussexualbehavior;however,thesedataare controversial.34,35 _One_important_limitation_of _the_present

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In the present study, the average age for HPV-positive patientswaslower,53years,comparedtotheHPV-negative group,60years.AstudyconductedinColombiaconfirmed a lower average age for HPV-positive patients with oral cavityandoropharynxcarcinomas.12_Significant_associations

betweenthepresenceofHPVandtheabsenceofhabitslike smokingandalcohol consumptionwere notnoticedin the presentstudy,corroboratingwithvariousstudies.6---18

The prognosisoforalcavityandoropharynxcarcinomas isuncertain anddifficult topredict.4_The _{identification}_of

factorsthatmayhelpchoosingthebesttreatment, predict-ingtheevolutionofthetumoraswellaspatient’ssurvival, is of evident clinical importance.HPV-positive oral cavity and oropharynx SCC seem to present a better prognosis when treated with surgery and adjuvant radiotherapy or radiationtherapywithorwithoutfinalchemotherapy.10

Lim-itationsondatacollectioninthepresentstudypreventeda survivalanalysisassociatedwiththetherapyused.A system-aticreviewhighlightstheimportanceofevaluatingpatients with HPV-related oropharyngeal carcinomas, in order to predict thebesttherapy,sincethesevirus-associated car-cinomasshowdistinct molecularcharacteristics compared toHPV-negativeones.9_However,_currently,_only_a_few

stud-ies describe a direct association between treatment, the presenceoftheHPVgenome,andsurvival.9,10

A better prognosis for HPV-positive oral cavity and oropharynxcarcinomashasbeendescribedinafewstudies, includingwell-differentiatedtumors,withlessriskoflymph node metastasisanddistant metastasis.9---36 _In _the_present

study, these characteristics were observed; however, the differencebetweenthegroupswasnotsignificant.Distant metastaseswere notdescribed inthe HPV-positive group, although only onecase of HPV-negativetumorspresented withdistantmetastases.Concerningthepresenceoflymph nodemetastasis,alowerrateoflymphnodemetastasiswas observedintheHPV-positivetumors(42.9%vs.57.4%), sug-gestingabetterprognosisforthesetumors;however,such differenceswerenotstatisticallysignificant.

HPV16 and HPV18 are described as the most preva-lent genotypes in oral cavity and oropharynxcarcinomas, and their association with these carcinomas seems to be relevant.14_In_the_present_study,_of_the₂₁_HPV-positive

sam-ples,HPV16wasdescribedin33.3%andHPV18in14.3%of thetumors.TodescribetheprevalenceofHPV16and18in oralcavityandoropharynxcarcinomasisimportantinorder topredicttheimpactofvaccinationonthesetumors,since bothgenotypesarethemaintargetsforthebivalent(16/18) andquadrivalentvaccines(11/16/18/6).15---27_In_the_present

study,nosignificant differences were described regarding thestaginganddeathofthepatientswhencomparingHPV16 and18positiveandnegativecases.

Recentreportshighlightthatvaccinationcampaignsare an efficientsolutionforthe controlofthe HPV-associated carcinomas.15---37_Regarding_this_connection_and_considering

the highprevalence of HPV in oral cavity andoropharynx carcinomas in males, it is extremely important that this campaignmightalsobeextendedtothemalegroup.

Inthepresent study,thepresenceofHPVwasdetected in 25.6% of the cases, including types 16 and 18, lead-ingtotheconclusion thatHPV isalso associatedwiththe developmentoforalcavityandoropharyngealcarcinomas. This studypresented an importantlimitationwithrespect

to clinical and behavioral data of the patients. In the medicalfiles,suchdatawerescarce,includingsexual behav-ior,oral hygiene, historyof sexually transmitteddiseases, andpatientfollow-up,amongothers.Thesedifficultiesare inherenttoretrospectivestudies,sincetheresearchersrely onlyontheinformationpresentinmedicalrecordsthatcan oftenbelost,incomplete,orunclear.20---30

Theauthorssuggestaprospectivestudy,withmore effi-cientdatacollectionandpatientfollow-up,allowingamore accurateandcompletesurvey,withalargernumberofcases fromdifferentoncologycentersinthecountry,inorderto improvetheknowledgeofHPVcarcinogenesisinoralcavity andoropharynxcarcinomas.

Conclusions

This study confirms the higher prevalence of HPV DNA in oralcavityandoropharynxcarcinomas,especiallyinmales (78%),withanaverageageof58years,andahighfrequency ofsmokersandalcoholdrinkers.

TheprevalenceofHPVDNAgenomeinthesamples ana-lyzedwas25.6%,andamongthepositivecases,33.3%were HPV16and14.3%wereHPV18,highlightingtheassociationof high-riskHPVinoralcavityandoropharynxcarcinogenesis.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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