Human papilloma viruses (HPVs) have been acknowledged to be the leading risk factor of cervical intra-epithelial lesion creation (CIN) and cervical cancer development (CxCa), while recently, a vaccine protecting from the most commonly HPV types found in CxCa has been produced and introduced in vaccination schemes across the globe. Many different techniques have been created and utilized in HPV detection and monitoring with a vast amount of them being commercialized and few of them integrated in screening strategies. However, there has been no effort in combining data from all the different techniques and provide efficient patient triaging schemes, since, apart from the obvious increase of patient cost, the amount of data and its interpretation in patient management has been impossible.
TopIntroduction
Human papilloma viruses (HPV) are members of the papillomaviridae family. HPVs are small (7,000-8,500bp) double stranded DNA viruses with no RNA phase in their life cycle that can only be reproduced in keratinocytes. Over 100 different types have been identified and isolated, both in humans and animals (de Villiers, 2004). Around 40 types have been isolated from human cervical specimens and HPVs have been classified, according to their epidemiology in cervical lesions, as low risk and high risk (Dunne, 2007; Muñoz, 2003; Trottier, 2006). Although HPVs have been mostly isolated from cervical samples they have also been identified from samples from the anus, vulva, vagina, skin and even head and neck cancers.
HPVs are small double-stranded DNA viruses encoding ten proteins in total, out of which two (E6 and E7) are considered oncoproteins (Mantovani, 2001; Münger, 2001) and two (L1 and L2) are the structural proteins of the viral capsid. The rest proteins include one helicase (E1), one transcription factor (Ε2), two proteins that induce host proliferation (Ε5) and viral replication (Ε4) and a short protein that is expressed only in few papillomavirus types that may substitute for the E6 open reading frame. E6 has been shown to interact with the p53 tumor suppressor protein leading to its degradation, while E7 inactivates members of the pRB family of tumor suppressor proteins and activates telomerases. Both proteins enhance cell proliferation and down regulate apoptosis.
HPVs proteins are named after the stage of the viral infection cycle; E proteins are early expressed proteins and are responsible for the replication of the virus, while L proteins are late expressed proteins after the virus has replicated. HPVs infect cells of the basal epithelium of the cervix via minor abrasions of the squamous epithelium. At first the virus reproduces as an extra-chromosomal plasmid during cell division and these infections are sub-clinical. Later on and after the expression of viral oncogenes, the virus reproduces by thousands and infection spreads in more cells (activated infection). After a long lasting infection, the virus is proposed to be integrated in the host genome leading to deregulation of gene expression, disruption of tumor suppressor genes and the accumulation of genetic changes that ultimately result in malignant transformation of epithelial cells (Andersson, 2005). A persistent infection by HPV aided by other parameters results in HPV integration in host DNA leading to progression to high grade lesions (Wallin, 1999). Most HPV infections are cleared by the host’s immune system before they progress in the creation of intra-epithelial lesions. Only persistent infection with high risk HPV types has been acknowledged as the most important risk factor for cervical cancer development (Walboomers, 1999).