Characteristics of the Lesions and Risk of Malignant Conversion Associated with the Type of Human Papillomavirus Involved in Epidermodysplasia Verruciformis Gérard Orth, Stefania Jablonska, Maria Jarzabek-Chorzelska, et al. Cancer Res 1979;39:1074-1082.
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[CANCER RESEARCH 39, 1074-1082, March 1979]
0008-5472/79/0039-0000$02.0O
Characteristics of the Lesions and Risk of Malignant Conversion Associated with the Type of Human Papillomavirus Involved in Epidermodysplasia Verruciformis1 Gerard Orth, Stefania Jablonska, Maria Jarzabek-Chorzelska, Slavomir Obalek, Genowefa Rzesa, Michel Favre, and OdIle Croissant Unite de Recherche sur rEtiologie Virale des Cancers Huma!ns, LA 147 CNRS, u 140 INSERM, lnstitut Gustave-Roussy, 94800 villejuIf, France (G. 0., M. F.J; Department of Dermatology, WarsawSchool of Medicine, Warsaw, Poland (S. J., M. J-C., S. 0., G. A.); and unite d'Oncologie virale, Ddpartement de virologie, lnstitut Pasteur, 75015 Paris, France (0. C.J
ABSTRACT
or Bowen's carcinomas), but squamous or basal call carci nomas are also found (9, 11, 15, 25). Many cases occur in Fourteen patients with apidarmodysplasia vermucifommis families, and EV has bean considered as a ganodermatosis, were studied to correlate the type of human papilbomavimus probably transmitted by an autosomal recessive gene (11, (HPV) found in benign lesions to their clinical aspects and 15, 23). Most of the patients thus far investigated showed to the course of the disease; nine patients ware familial abnormal cell-mediated immunity (5, 22). cases, and six had carcinomas. The type of the virus was Flat wart-like EV lesions ware shown to be transmittable determined by the RNA-DNA filter hybridization technique, by auto- or heteroinoculation (10, 11, 14). Typical papibbo using complementary ANA's transcribed from the DNA's of mavirus particles ware regularly found by electron micros the four types of HPV's previously identified, and by immu copy in benign lesions (1, 6, 7, 23, 25, 26, 29). They were nofluorascenca studies, using antisera specific for the four also observed by some authors in in situ carcinomas (3, 25, types of viruses. HPV type 3 was found in seven patients 29) but were never detected in advanced malignant lesions presenting lesions of only the varmuca plana type. These (1 , 3, 8, 9, 25, 27, 29). It was bong thought that the virus cases ware mostly stationary or abortive and showed no found in EV lesions was responsible for all viral skin warts malignant conversion. HPV type 4 was detected in four (19, 24). It is only recently that different types of HPV patients with lesions of different types: vary flat, often showing distinct antiganic properties and only little DNA reddish warts; reddish plaques; and pitymiasis vemsicobor sequence homology were characterized in skin lesions (4, bike pigmented or achmomic plaques. All these patients 17—21) and that tha association of EV with particular types showed cancers. Both types of viruses ware found in two of HPV was demonstrated (20, 21). Of the 4 HPV types patients: HPV type 3 in flat wart-like lesions and, for one characterized in our studies, 2 of them, HPV-3 and HPV-4, patient, in large confluent pigmented plaques and HPV type ware found in EV lesions (20). Furthermore, our previous 4 in reddish
or pitymiasis varsicobom-like plaques.
One of
these patients had early malignant lesions (Bowen's dis ease), and the other had multiple carcinomas. For one patient, the type of virus could not be identified
because of
an insufficient amount of material. These results point to the moleof virus in the pathoganasis of epidammodysplasia vammuciformis,together with genetic and immunological factors. They suggest, in addition, dif fement oncogenic potentials for viruses involved in the disease.
INTRODUCTION EV2 (13) is a mare, lifelong
disease
characterized
by
disseminated skin lesions which usually resemble flat warts but may appear also as reddish plaques or pitymiasis vemsi color-bike pigmented or achromic lesions (for review, sea Aafs. 9, 11, 15, and 25). Malignant transformation of some of the lesions has bean observed in 25 to 30% of the cases; cancers are usually of the Bowan's type (Bowan's disease I
Supported
by
Grant
PR6.
26/76
for
Cancer
Research
from
the
Polish
Government and Grants ATP 28.76.60, CRL 76.4.100.1 , ASR 1.005, and 014 from Institut National de Ia Sante et de Ia Recherche Médicale. 2 The
abbreviations
used
are:
EV,
epidermodysplasia
vemruciformis;
HPV,
human papillomavirus; HPV-3, human papillomavirus type 3; HPV-4, human
papillomavirustype 4; HPV-1, humanpapillomavirustype 1; HPV-2,human papillomavirus type 2; cRNA, complementary RNA. Received July 5, 1978; accepted November 15, 1978.
1074
study involving 11 patients (5 of them with cancers) had suggested that the aspect of EV lesions and the probability of malignant transformation could depend on the virus type (20). The aim of the present
studies
is to extend
these
results to 3 additional patients (one with cancers) and to analyze the correlation between the type of the virus, the clinical aspect of the lesions, and the course of the disease.
MATERIALSAND METHODS Sample Collection. Scrapings and biopsies of lesions were collected from patients with EV who ware attending the Department of Dermatology, Warsaw School of Med i cine (Table 1). For virus purification and viral DNA extrac tion, repeated samples from some patients and, for some of them, from various types of lesions were collected in Eagle's minimum essential medium containing antibiotics and ware stored until use at —70°. For immunofluorescenca studies, biopsies ware either processed immediately or frozen in liquid nitrogen 12 to 24 hr after collection in culture medium. Virus PurIfication and Viral DNA Preparation. EV HPV's ware purified from the pooled scrapings of each of the
patients, T. G., J. K., E. D., J. D., and S. M., and HPV-1and HPV-2 were purified from deep plantar warts and hand common warts, respectively, as previously described (18, 20). Viral DNA's were obtained
either by extraction
from the
CANCERRESEARCHVOL. 39
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Role of Virus in EV vinions (20) or by selective extraction
from the lesions (18),
and DNA concentration was determined by electron micros copy as previously described (18). Molecular Hybridization Experiments. DNA's from HPV 1 , HPV-2, J. D. HPV, and J. K. HPV (taken as prototypical HPV-3 and HPV-4, respectively), as well as from T. G. HPV,
were transcribed in vitro into cANA's, using Escharichia coli ANA polymerasa containing a-factor (a gift from S. Saragosti, Institut Pasteur, Paris, France) (18). cRNA-DNA filter hybridization under paraffin (12) was performed as previously reported (18, 20). Immunofluorescence Studies. Direct and indirect immu nofluomascenca tests were performed mainly as described by Bautnar at al. (2). Specific guinea pig antisera ware raised against full particles of HPV-1 (G 121, G 122), HPV-2 (G 206), HPV-3 [using J. D. HPV (G 280) or E. D. HPV (G 281)], and HPV-4 [using S. M. HPV (G 271)] or against empty
particles of HPV-4 [using J. K. HPV (G 251) or S. M. HPV (G 264)]. These sara had been used in previous studies (18, 20), except G 271 , which was obtained under the conditions
described for other EV HPV's (20). Fluomascain-babeled lgG
fractions with a fbuorasceinto protein molar ratio of 2 or 5 were prepared from anti-HPV-1 antiserum as previously described (16) and ware used in direct immunofluorescanca tests at a concentration of 0.5 mg/mI. Anti-HPV-2, anti-HPV 3, and anti-HPV-4 antisera were used in indirect immunoflu
orescance tests at a dilution of 1/80 to 1/320. Tissues embedded in Tissue-Tek II O.C.T. compound medium (Lab Tek Products) ware cut in a cryostat (SLEE, London, Eng land) at —20°. Seven-sm-thick sections were set on gelatin coated slides, fixed for 10 mm at —2@Y' in acetone, and washed for 20 mm in 0.05 M sodium phosphata/0.1 M NaCI (pH 7.2). For direct immunofluomescence tests, sections
were incubated for 30 mm at 37°with fluorescein-labebed anti-HPV-1 bgG. For indirect immunofluorescanca tests, sections ware incubated for 30 mm at 37°with diluted
antisera or preimmune sara and then, after washing, with fluorascein-labebad anti-guinea pig IgG rabbit lgG at a concentration of 0.5 mg/mI (fluorescein to protein molar ratio ranging from 1 to 2.5)(16, 20). Sectionsware mounted in buffered glycerol (pH 8.0), examined, and photographed with an American Optical Company microscope or a Zeiss Photomicroscope II. RESULTS
Morphologyof EV Lesionsas Relatedto the VirusType Characteristics of EV Lesions. The 14 patients studied are presented in Tables 1 and 2. Nine were familial cases, and 6 had cancers. All patients had lesions on the domsaof the hands and on the face, and most of them had lesions on the extremities and the trunk. Patients showed various types of lesions: (a) flat wart-bike lesions, somewhat more elevated on the domsa of the hands (Fig. 1) but in some
patients almost at the skin level and often reddish (Fig. 2); (b) reddish plaques, usually on the trunk (Fig. 3); (c) scaling brownish or achmomic lesions resembling pityriasis vemsi color (Fig. 4); (d) large, pigmented, irregularly shaped confluent plaques (Fig. 5); and (a) common warts intemmin glad with vemrucaplana-type lesions (Fig. 6).
Molecular HybridizationData. In our previousstudies (20), characterization
of the virus
present
in lesions
of
patients with EV was performed by molecular hybridization without taking into account the clinical types of the lesions. However, results indicated the occurrence of HPV-3 in
Table 1
Patientswith EV― Age at1 Stmalig nantcon var
Cell-me
at onset of PatientsSexAge munity@'Remarks1.
im (ym)Camcinomass'diated
(ym)Age disease (yr)sion
D.2. T.G.M52543++—BmothemofJ.
K.andH.
J.K.F38517+++—3.
H.D.F4611—MothemofE.D.,D.D.,andW.D.4.E.D.F227—5.D.D.F21715+—6. W. D.
disappeared after biopsies
7. R. P.M P.8.A.P.F2510+9. M9
475.5 Early childhood+
NDdWarts
E. I.F184—Fathem
Father of A. with warts on
hands10.
J. D.M43Early case11
childhood37++
long-standing,
flat
+—Nonfamilial
. J. G.M247—Nonfamiliab case12. M. G.M217— case13. 5. M.M22820+ case14.
to
±Nonfamilial
+—Nonfamilial
R.M.M36235+±Nonfamilialcase Cl Characteristics
b
of
@,premalignant
carcinomas; C Depressed
benign
lesions
lesions
of
ama
described
Bowen's
type
+ + + , invasive carcinomas, (— ),
lowered
(± ), om
preserved
in
Table
(carcinoma
2.
in situ)
and
single
carcinoma;
++,
multiple
Bowen's
at various sites. (+
) nonspecific
cell-mediated
immunity,
as
checked
by
in
vitro
methods
and cutaneoustests (5).3 d ND, not done.
MARCH 1979
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1075
G. Orthatal.
EVPatientsExtensionaMorphology
Table 2 of the benign lesions of patients
Characteristics
and distribution
with
of skin lesions@'Activity―HPV
wart type typedFlat Elevated
warts1.
Reddish plaques
Very flat
T.G.++Hands,face thighs+++42.
J. K.++++Hands,
feer
Face, ex-
tmemities++++43. H.D.++Hands,feat,
Pitymiasis vemsi- Pigmented color type plaquesCommon
Trunk
Tmunk,amms,
Whole skin
Trunk, arms
Neck,tmunk, arms,
Tmunk,thighs
Trunk
Trunk,amms,
Faca,ex tmemities
forearms,
legs—34. ED.++AsH.D. AsH.D.+35,
D.D.+++AsH.D.
AsH.D.
thighs++++3,46.
W. D.+Face, hands—37. P.+Hands—Inconclusive8. R. A. P.+Hands Face—39.
E. I.+Hands Face—310. J.D.++++Face,exthighs++++3,411. J.G.+Hands
Legs
tmemities FaceHands,
leg, foot+3,212. Face,
MG.++Hands
thighs, legs++313.
S.M.+++Face,extremities+++414. R.M.+++Face,ex-
tmemities @
a
hands and face; ++,
b Flat
wart-type
Tmunk,ex-
Trunk
Tmunk,extremities++4
Trunk
tmemities
lesions
hands, face, and some at other locations;
are
either
somewhat
elevated
or vary
flat,
+++,
almost
widespread; at the
skin
++++,
level.
generalized.
Reddish
plaques
are
flat
maculam
lesions
(up
to 2 cm). Pitymiasis vemsicobom-typelesions are brownish scaling or achmomic plaques. Pigmented plaques are dark brown, large, confluent, and immegulamly shaped lesions. Common warts are elevated hypemkematoticpapules. C. _ , no
new
lesions
d As determined e The
typical
for
many
years;
in a previous elevated
flat
lesions are clearly distinct
+
study
wart-like
D.,
in
confluent
+ + + + , from
and
lesions
in this
pigmented
a few
new
while
at first
gmadually
HPV-4
was
found in patients showing reddish plaques and/or pityniasis varsicobor-lika lesions together with somewhat flatter and reddish vamrucaplana-typa lesions (Table 2). Molecular
hybridization
data reported
in Table 3 ware
obtained on 3 new patients and on different types of lesions of several patients, using cANA's specific for the 4 types of HPV's, with J. D. and J. K. HPV's as prototypical HPV-3 and HPV-4,
respectively.
With
the
conditions
used,
50
to
60%
of
the radioactivity binds to filters when homologous DNA's and cANA's are hybridized, while almost no annealing is observed between hatemobogous prototypical cRNA's and DNA's. Of the 3 new patients, Patient T. G., showing reddish plaques and pityniasis varsicolor-lika lesions, was found to be infected by HPV-4, while Patient M. G., showing only wart-bike lesions, was infected by HPV-3. The limited amount of material from Patient A. P. did not allow conclu sions. A lesser extant of annealing was observed when T. G. and J. K. HPV cANA's ware hybridized
with J. K. and
T. G. DNA's, respectively, as compared to homologous hybridizations, confirming the genetic heterogeneity al ready reported for viruses belonging to type 4 (20). Data further
1076
reported
in Table
3 show
that
viral
to
extensive
spreading
at
the
time
of
studies.
flattened
throughout
the
years.
Although
still
slightly
raised,
the
relatives (Cases 3 to 6).
lesions and, for Patient
plaques,
lesions
study.
observed
from those of the patient's
patients showing only flat wart-type J.
to
(20)
DNA
obtained
from
the
reddish
and
pityniasis
versicobor-like
brownish
plaquespresenton theback of Patient J.D. forsome years (which have been spreading lately) annealed only with HPV 4 cANA. These lesions had not been tasted previously. Two viral DNA preparations obtained from lesions collected from
the lags of this patient (Fig. 5) at a 1-year interval ware both of HPV-3 type, but the most macant showed also some annealing
with HPV-4 cANA, coinciding
with the eruption
of a few reddish and brownish plaques at this location. Clear evidence for infection by HPV-3 and HPV-4 was also found for Patient D. D. , whose wart-like lesions [analogous tothoseof hermother,H. D.,and sister, E. D. (Fig.1)]ama clearly due to HPV-3 and whose reddish plaques [similar to those of her aunt, J. K. (Fig. 3), and uncle, T. G.] are due to HPV-4.
HPV-2
was
detected
in the
typical
common
warts
of
Patient J. G. (Fig. 6), while the viral DNA found in his flat wart-like lesions hybridized only with HPV-3 cRNA. The lesser extant of hybridization observed, as compared to HPV-3
prototypical
DNA,
confirms
previous
results
obtained
for this patient, which showed the genetic heterogeneity of viruses belonging to type 3 (20). However, HPV-4 was found both in flat vamruca plana-typa lesions and in reddish and pityniasis vemsicobor-bike plaques (Fig. 4) of Patient A. M., as
previously found for the different lesions of Patients J. K. CANCER RESEARCH VOL. 39
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Role of Virus in EV Table 3 of HPV present in EV lesions by cRNA-DNA hybridization for17 Filter hybridization under paraffin (12) was performed at 37° withabout hr in 0.3 M NaCI/0.03 M sodium citmata/50% fommamide of[3H]cRNA 50 ng of viral DNA (except A. P. DNA) and 3000 cpm Identification
per filter (specific 20).% activity, 3 to 4 x 10@ cpm/@g)(18, of radioactivity bound on filtemsafter hy bmidization with [3H]RNA's complementary
to
with
anti-HPV-3
antiserum
(Fig.
7, a and b), while
her
reddish plaques gave a positive reaction only with anti-HPV 4 antiserum (Fig. 7, C and d). In addition, results show that, for most patients, no antigen could be detected with the 4
types of antisera in some of the samples tested. Widely variable amounts of viral antigens were also observed in a previous study of numerous common warts of a patient infected with HPV-2 (18).
different DNA'sbHPV-3
MalignantConversionas Relatedto the VIrusType Found
HPV-4(J.D.
T.G.DNA
(J.K.
HPVHPV-1 on fiItems@' HPV-1 0.8HPV-2
HPV-2
HPV)
HPV)
0.1
0.3
58.0
0.5
0.1
0.3 —0.2
61 .2 —0.1
0.6
0.4
0.3
0.1 0.1 ND
0.9 0.8 ND
44.2 45.3 0.3
0.6 —0.1 —0.1
—0.1
0.1
—0.1
15.4
0.2 0.1
0.1 0.2
42.6 56.4
1.0 8.3
0.1 —0.1
—0.1 0.2
46.0 47.5
0.4 2.4
0.1
—0.2
2.2
28.7
0.1
—0.1
55.9
0.3
1.0HPV-3
0.2
—0.5HPV-4 (J. D. HPV) 28.3T.G.(J. K. HPV)
0.1 0.5
57.5M. G.Face;A' ND―Hands; —A. A —J. P. (hands;A)
0.2 49.0
13.4
D.Back; —Lags;D B, C
—Legs; —D. 0 0.Hands;A —Legs; —Tmunk;B,C A
—J. G.Hands; —Leg;EA
—Palm;E —A.
9.6
—0.2
—0.3 53.4 —0.2 33.4
0.8 1.0
—0.2 1.0
—0.3
0.1
13.5
M.Hands;
in EV Lesions Malignant conversion of lesions was observed only in the 6 patients infected with HPV-4, 2 of them being infected also with HPV-3 (Tables 1, 2, and 5). In Patient 0. 0., infected with both viruses, lesions were of early Bowen's disease type (carcinoma in situ) (Fig. 8) and ware controlled by topical 5-fluorouracil. In other patients, malignant be sions were of Bowen's carcinoma type; they were usually multiple,
mostly
0.3
parts of the body, and
DISCUSSION Our studies indicate that the clinical aspect of the lesions, the course of the disease, and the malignant conversion in EV are rebated to the type of HPV responsible for the infection. Patients infected with HPV-3 alone show flat wart like lesions, a more protracted course of the disease, and no malignant
—Legs;A' A'
on light-exposed
sometimes invasive (Fig. 9); metastases were never ob served.
conversion
(Tables 1 and 2). This includes
abortive and/or stationary familial cases; in one of them, —Back; —0.2 0.2 1.8 20.5 the lesions did not reappear after removal. HPV-4 infection -Tmunk;B,C B, C ND ND 3.4 23.1 results in flatter vemmucaplana-lika lesions, often reddish, —Human ND ND 0.6 11.9 only slightly elevated on the dorsa of the hands, associated 0.5Humanthymus 0.2 0.2 0.6 0.5 liver 0.1 0.1 0.1 1 .5 ND with reddish plaques and pityriasis versicobor-like lesions mostly on the trunk. It was always associated with carcino a Viral DNA's were obtained from vinions extracted from a single plantam wart (HPV-1), pooled common warts of a single patient mas. (HPV-2), limb lesions of patient J. 0. (HPV-3), and whole-body Two patients were found to be infected by both viruses. lesions of Patients J. K. (HPV-4) and T. G. Other viral DNA's were One of them showed all the different types of lesions and selectively extracted from lesions of different sites and momphol ogy: flat wart-like lesions, elevated (A) or very flat (A'); reddish had multiple premalignant or early malignant lesions of plaques (B); pitymiasis vemsicobom-like plaques (C); pigmented Bowan's disease type. It is worth stressing that her mother, plaques (0); and common warts (E). A. P. DNA corresponded to sister, and brother were infected with HPV-3 and showed DNA selectively extracted from very few lesions and showing no no malignant lesions, whereas hemaunt and uncle were viral DNA molecules when checked by electron microscopy. infected with HPV-4 and had multiple cancers. The second b [3H]cRNA's were obtained by in vitro tmanscmiption with E. coli RNA polymerase of pumified Form 1 HPV-1 or HPV-2 DNA molecules and of J. 0., J. K., and T. G. HPV DNA molecules extracted from vimions(18, 20). C ND,
not
done.
and S.M. (20). Immunofluorescence
Studies. The association of distinct
types of HPV with particular cutaneous lesions has been studied by the immunofluorescenca technique, using spa
cific antisera against each of the 4 HPV types. Previous studies have shown that viral capsid antigens are detected in the nuclei of the upper keratinizing cells and in kamatin ized cells of the lesions (18, 20). Aesults reported in Table 4 confirm the data obtained by molecular hybridization axpem imants. This is best illustrated for Patient D. 0. , whose typical flat wart-like lesions gave a positive reaction only
patient
showed,
in addition,
large,
pigmented,
confluent
plaques on the begsdue to HPV-3 and had cancers, includ ing an invasive carcinoma of the forehead. Ha was first considered to be infected only by HPV-3 (20) on the basis of molecular hybridization data obtained with 6 DNA prepama tions from limb lesions including large pigmented plaques until
the
plaques
on
his
back
were
tasted.
Finally,
HPV-2
was detected in typical common warts intermingled with elevated vammucaplana-lika lesions due to HPV-3 in one patient. This virus has bean shown to be preferentially associated with common warts (18, 19), so its possible role in the few cases described as EV and showing hypertrophic typical common warts (15, 28) should be considered. In conclusion, this study shows that the morphological aspects of lesions and the type of HPV associated with them may be of prognostic significance. It further reinforces our
MARCH 1979
Downloaded from cancerres.aacrjournals.org on June 3, 2013. © 1979 American Association for Cancer Research.
1077
G. Orthetal. Table 4 of the virus present in different EV lesions by immunofluorescence
techniquesViral Characterization
capsid antigens were detected in frozen 7-j.@m-thick sections of lesions by a direct immunofluomescence technique with fluomescein-labeled anti-HPV-1 guinea pig lgG or by an indirect immunofluorescence technique with anti-HPV-2, anti-HPV-3, and anti-HPV-4 guinea pig antisera and fluomescein-labebed anti-guinea pig IgG rabbit lgG
under conditions described in “Materials and Methods.―HPV in:Flat
type
wart-type tested1 Patients―
Elevated
Very flat
. T. G.
2. J. K. 3. 4. 5. 6. 8. 9. 10.
lesions
H.D. E. D. D. D. W.D. A.P. El. J. D.
Reddish plaques
Pitymiasis ver sicolom-type lesions
HPV-4 (1/5)
HPV-4 (1/2)'@
HPV-4 (3/5)
HPV-4(1/4)
HPV-4(2/3)
HPV-4(4/5)
HPV-3(2/2) HPV-3 (4/5) HPV-3 (7/10) (0/2) HPV-3(1/2) HPV-3(1/3)
HPV-3(1/2) HPV-3 (1/1) HPV-3 (2/3)
HPV-4 (5/6)
HPV-3 (6/16)
HPV-4 (5/5)
11 . J. G.
HPV-3 (7/15)
12. MG.
HPV-3(5/6)
Pigmented plaques: HPV-3 (2/4) Common
13. S. M.
HPV-4 (4/4)
HPV-4 (1/1)
14. R. M.
HPV-4 (2/2)
HPV-4 (1/3)
a No sample available for Patient R. P. (Case 7). b Numbers in parentheses, numbem of positive lesions
Table5 Carcinomasin patients withV as related to the virus typeVirus
HPV-42/2 for Patient
warts: HPV-2 (3/4)
HPV-4 (2/3)
versus
number
of lesions
tested.
ously or through interaction with environmental factors, such as actinic radiations. Nevertheless, although mobecu lamhybridization and immunofluomascanca evidence for the persistence and the expression of the viral genoma in EV carcinomas must be obtained, our data strongly suggest that HPV-4 is associated somehow with malignant progmas
conversionHPV-30/7HPV-44/4HPV-3, typeMalignant
a HPV type was not determined
HPV-4 (1/1)
Other types of lesions
A. P. His lesions weme
analogous to those of his daughter, A. P., who was infected by HPV-3.
sion and, thus, that one HPV, at least, has an oncoganic potential. Note Added in Proof
previous conclusions on the importance of the virus in the pathoganasis of EV, together with other factors (20). Ga netic
factors
are known
to play a major
role in this disease,
and compilation of literature data on the genetics of EV supports transmission by an autosomal recessive gene (15). Nine of the 14 patients
of this study ware familial
3 S.
Obalek,
W.
in preparation.
1078
Glinski,
M.
Haftek,
and
S.
Jablonska.
Comparative
proposed. While the designation of HPV-1, HPv-2, and HPv-3 remains unmodified, HPv-4 should now be designated HPv-5 (Coggin, J. H., Jr., and
zur Hausen,H. Meetingreport: workshopon papillomavirusesand cancer. Cancer Res. 39: 545-546, 1979).
cases.
Three of them belonged to a family of 6 siblings with no evidence of EV in the parents (Patients 1 to 3) (Table 1) (5). Three families among the 4 studied showed EV in 2 succas sive generations, without evidence of consanguinity (Pa tiants 3 to 9). These rates are unexpected in the hypothesis of a rare autosomal recessive disease. Immunological fac tons appear to be important as wall (5, 22); cell-mediated immunity was abnormal in all the patients of this study except those showing abortive or regressive evolution of the disease (Table 1) (5).3 Our data, especially those on familial cases, indicate that the type of infecting HPV determines the clinical aspects of the lesions and bead to a consideration of the robe of the virus in their malignant conversion. It cannot be excluded, however, that a particular genetic constitution may have 2 distinct consequences: a higher susceptibility to HPV-4 infection, resulting in lifelong, widespread, benign skin lesions, and a higher risk for skin cancer, either spontana on cell-mediated
Since this manuscript was submitted, a classification of human papillo
mavirusesbased on the chronological order of their identification was
studies
immunity in patients with various types of warts, manuscript
ACKNOWLEDGMENTS We thank Peter Sheldrick and Franç,oiseBreitburd for fruitful discussion and critical reading of the manuscript; Nicole Jibard and Dominique Fortin for careful assistance; and Daniel Cany and AyszamdWierczak for preparation of the illustrations.
REFERENCES 1. Aaronson, C. M., and Lutzner, M. A. Epidermodysplasia verruciformis
and epidermoidcarcinoma.Electronmicroscopicobservations.J. Am. Med.Assoc.,201:775-777,1967. 2. Beutner, E. H., Chorzelski, T. P., Bean, S. F., and Jordon, A. E. Immunopathology of the skin: labeled antibody studies. pp. 147-197. Stroudsburg: Dowden, Hutchinson, and Ross Inc., 1973.
3, Delescluse,C., Pruniêras, M., Regnier,M., Moreno,G., andArouete.J. Epidermodysplasia verruciformis. I. Electron microscope autoradiogra phy and tissue culture studies. Arch. Dermatol. Forsch. , 242: 202-215, 1972. 4. Gissmann, L. , Pfister, H., and Zur Hausen, H. Human papilloma viruses (HPv). Characterization of four different isolates. Virology, 76: 569—580, 1977.
5, Glinski, W., Jablonska,S., Langner,A., Obalek, S., Haftek, M., and Proniewska,M. Cell-mediatedimmunity in epidermodysplasiaverruci formis. Dermatologica, 153: 218-227, 1976.
6. Grupper,C., PruniCras,M., Delescluse,C., Arouete,J., and Garelly,E. Epidermodysplasie
verruciforme:
etude ultrastructurale
et autoradi
CANCERRESEARCHVOL. 39
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Role of Virus in EV ographique. Ann. Dermatol. Syphiligr., 98: 33—47, 1971. 7. Jablonska, S., Biczysko, W., Jakubowicz, K., and Dabrowski, J. On the viral etiology of epidermodysplasla verruciformis Lewandowsky-Lutz. Electron microscope studies. Dermatologica, 137: 113—125, 1968. 8. Jablonska, S., Biczysko, W., Jakubowicz, K., and Dabrowski, J. The ultrastructure of transitional states to Bowen's disease and invasive Bowen's carcinoma in epidermodysplasia verruciformis. Dermatologica, 140: 186-194, 1970. 9. Jablonska, S., Dabrowski, J., and Jakubowicz, K. Epidermodysplasia vermuciformis as a model in studies on the role of papovaviruses in oncogenesis. Cancer Res., 32: 583-589, 1972. 10. Jablonska, S., Fabjanska, L., and Fommas,I. On the viral aetiology of epidermodysplasia verruciformis. Demmatologica, 132: 369-385, 1966. 11. Jablonska, S., Maciejewski, W., Dabrowski, J., and Langner, A. Epider modysplasia vermuciformis. In: M. Pruniémas (ed), Biomedical Aspects of Human Wart Virus Infection. pp. 113-135. Lyon: Fondation Mérieux, 1976. 12. Kourilsky, P.. Mercereau, 0., Gros, D., and Tremblay, G. Hybridization on filters with competitor DNA in the liquid phase in a standard and a microassay. Biochimie (Paris), 56: 1215—1221 , 1974.
human papillomavirus that causes skin warts. J. Virol., 24: 108—120,
1977. 19. Orth, G.. Jablonska, S., Breitburd, F., Favre. N., and Croissant, 0. The human papillomaviruses. Bull. Cancer (Paris), 65: 151-164, 1978. 20. Orth, G., Jablonska, S., Favre, M., Croissant, 0., Jarzabek-Chorzelska. M. , and Rzesa, G. Characterization of two types of human papillomavi ruses in lesions of epidermodysplasia
verrucifommis. Proc. Natl. Aced.
Sci.U.S.A.,75:1537-1541.1978. 21. Pass, F., Reissig, M., Shah, K. V.. Eisinger, M., and Orth, G. Identifica tion of an immunologically distinct papillomavirus from lesions of epidermodysplasia verruciformis. J. NatI. Cancer Inst., 59: 1107-1112,
1977. 22. Prawer, 5. E., Pass, F., Vance, J. C., Greenberg, L. J., Yunis. E. J.. and Zelickson, A. S. Depressed immune function in epidemmodysplasia verrucifommis. Arch. Demmatol., 113: 495—499, 1977. 23. Rajagopalan, K., Bahru, J., Loo, D. S. C., Tay, C. H., Chin, K. N., and Tan. K. K. Familial epidemmodysplasiavemruciformisof Lewandowsky and Lutz. Arch. Dermatol., 105: 73-78. 1972. 24. Rowson, K. E. K., and Mahy, B. W. J. Human papova (wart) virus.
Bacteriol.Rev.,31: 110-131,1967. 13. Lewandowsky,F.,and Lutz.W. EmFalleinerbishernicht beschriebenen 25. Aueda, L. A., and Rodriguez, G. Verrugas humanas per virus papova. Hauterkrankung (Epidermodysplasia vermucifommis).Arch. Dermatol. Sy
philol., 141:193-203,1922. 14. Lutz, W. A propos de l'epidermodysplasie verrucifomme. Dermatologica,
92: 30-42,1946.
15. Lutzner, M. A. Epidermodysplasia verrucifommis: an autosomal recessive disease characterized by viral warts and skin cancer. A model for viral oncogenesis. Bull. Cancer (Paris), 65: 169-182, 1978. 16. Orth, G., Breitburd, F., and Favre, M. Evidence for antigenic determi nants shamed by the structural polypeptides of (Shops) rabbit papillo
mavirus and human papillomavirus type 1. Virology, in press, 1978.
17. Orth, G., Breitburd, F., Favre,M., and Croissant,0. Papillomaviruses: possible role in human cancer. In: H. H. Hiatt, J. D. Watson, and J. A. Winsten (ads.), Origins of Human Cancer, pp. 1043-1068. Cold Spring Harbor: Cold Spring Harbor Laboratory, 1977. 18. Orth, G., Favre, M., and Croissant, 0. Characterization of a new type of
Correlacion clinica, histologica y ultraestructural. Med. Cutanea Ibero LatinoAmericana,2: 113-136, 1976. 26. Ruiter, M., and Van Mullem, P. J. Demonstration by electron microscopy
of an lntmanuclearvirus In epidermodysplaslaverrucifommis.J. Invest. Dermatol., 47: 247-252, 1966. 27. Ruiter, M., and Van Mullem, P. J. Behavior of virus in malignant degeneration of skin lesion in epidemmodysplasia verrucifommis. J. In
vest.Dermatol., 54:324-331 , 1970.
28. Van Der Meer, J. B. Epidermodysplasiavemruclformls.Report of a case
from Utmecht.In: M. Prunléras (ed), BiomedicalAspectsof HumanWart Virus Infection, pp. 137-143. Lyon: Fondation Mérleux,1976. 29. Yabe, Y., and Sadakane, H. The virus of epidermodysplasla verruclfor mis: electron microscopic and fluorescent antibody studies. J. Invest. Dermatol., 65: 324-330, 1975.
Fig. 1. Typical flat wart-like lesions. Dorsum of the hand of Patient E. D. Fig. 2. Very flat, reddish, wart-type lesions. Dorsum of the hand of Patient S. M. Fig. 3. ReddIsh plaques with some brown and achromic lesions resembling pityriasisversicolor. Chest of Patient J. K. Fig. 4. Achromic plaques resembling pltyriasls versicolor lesions together with a few reddish and brown-reddish small plaques. Back of Patient R. M. Fig. 5. Large, pigmented (dark brown). Irregularly shaped, confluent plaques. Leg of Patient J. D. Fig. 6. Common warts (arrows) together with elevated flat wart-like lesions. Hand of Patient J. G. Fig. 7. DetectIon of viral antigens In the superficial layers of different lesions of Patient D. D. by the indirect immunofluorescence test. Adjacent frozen sections of a flat wart-like lesion (a and b) and of a reddish plw@ue(c and d) were incubated with antl-HPV-3 antiserum (G 290) at a 1/160 dIlution (a and c) or with antl-HPV-4 antiserum (G 251) at a 1/160 dilutIon (b and d) and, after washing, with fluorescein-labeled anti-guinea pig lgG rabbit globulins. x 260. Fig. 8. Multiple lesions of Bowen's disease type (carcinomain situ) intermingled with flat wart-like lesions. Forehead of Patient D. D. Fig. 9. InvasIve carcinoma. Forehead of Patient J. K.
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