Introduction
An estimated 15–20% of cancers are a consequence of viral infection, such as human papillomaviruses (HPV) in cervical carcinomas and oropharyngeal squamous cell carcinoma (OPSCC) and hepatitis B and C in liver cancers. However, many other known and unknown viruses may trigger carcinogenesis through modification of apoptosis, cell division and differentiation, as well as signaling cascades [
1].
Head and neck squamous cell carcinoma (HNSCC) has a worldwide annual incidence of approximately 600,000 cases [
2]. HPV and EBV are widely known etiological factors for oropharyngeal and nasopharyngeal carcinoma [
1], respectively. In Western countries in the last few decades, the incidence of some HNSCCs has been decreasing, along with a decrease in risk factors such as smoking. Despite this, the incidence of OPSCC has been increasing, likely in conjunction with HPV. However, not all of those infected with high-risk HPV develop squamous cell carcinoma [
3], therefore, it is possible that other viruses act as co-factors. Moreover, oral cavity squamous cell carcinoma (OSCC) incidence has been rising, especially in < 45-year-old individuals and patients without typical risk factors or HPV [
2]. Their etiology needs to be better understood: specifically, whether there is an undiscovered viral component.
Juvenile nasopharyngeal angiofibroma (JNA) is a rare, highly vascular tumor of the nasopharynx, almost exclusively in young males. It is the most common benign nasopharyngeal neoplasm, comprising 0.5% of all head and neck tumors. Despite being histologically benign, it is locally destructive, and can lead to bony remodeling and even intracranial extension [
4]. Its etiology is poorly understood. However, our preliminary results from previous studies have pointed to the possibility of a viral etiology. First, there was upregulation of immunological proteins such as TNF alpha in a higher stage JNA sample [
4]. Additionally, lymphocytes and mast cells, usually present in chronic infection, were seen within two JNA tissue samples, sparking work to look at toll-like receptors (TLR) within JNA samples. The intracellular TLRs 3, 7 and 9, thought to recognize viral nucleic acids, have been found within the JNA tissue [
5]. Therefore, it seemed relevant to investigate a viral etiology for JNA. Furthermore, HPV has been discovered in all samples in a small JNA cohort [
6].
In this study, we aim to investigate the presence of novel viruses in both JNA and OPSCC/OSCC, of which there is little or no documentation in the literature, given a precedent of viral illness’ role in cancer development. The viruses included in this study are 8 human parvoviruses: [parvovirus B19 (B19V), bocaviruses (HBoV) 1–4], bufavirus (BuV), tusavirus (TuV), and cutavirus (CuV); as well as 13 human polyomaviruses (HPyVs): BK, JC, KI, WU, trichodysplasia spinulosa (TS), Merkel cell virus (MC), Malawi (MW), St Louis (STL), New Jersey, and human polyomaviruses 6, 7, 9, 12 and 13.
Discussion
This panel of viruses was selected for varying reasons. Polyomaviruses are known to cause tumors in animals, and to date MCPyV, discovered in 2008, has been detected in 70–80% of Merkel cell carcinomas in humans [
12]. HBoV1-4, belonging to the
Parvoviridae family, are mainly present in respiratory or enteric infections, however, in two studies HBoV1 was found in 20% of colorectal and 18% of lung cancers [
13,
14]. BuV, TuV and CuV are protoparvoviruses discovered in pediatric diarrheal stool samples and CuV was additionally found in skin lesions of cutaneous T-cell lymphoma (CTCL) [
15,
16]. It was later detected in both healthy and malignant skin of CTCL and immunosuppressed organ transplant patients, but not in skin of healthy adults [
10]. Parvoviruses in general are not considered directly oncogenic like the polyomaviruses. However, prolonged antigen stimulation by persistent viruses could induce chronic inflammatory responses that together with other molecular events would lead to cell mutations and cell proliferation. Alternatively, parvoviruses could prefer rapidly dividing cancer cells for their replication and lyse the target cells, thus shrinking or even curing the tumor. It is imperative to study if and how viruses like these affect tumor onset, progression and outcome.
Previous research detecting viruses within JNA have studied HPV, human herpesvirus-8 (HHV-8) and EBV: in a small sampling of 6 patients, all were positive for HPV [
6], and in another study, all 15 JNA tissue samples were negative for HHV-8 and EBV [
17]. Our results are the first published on B19V, HBoV1-4, BuV, TuV, CuV, and 13 HPyVs within JNA samples, showing negative findings in all patients except one, whose JNA was positive for MCPyV DNA, a known oncogenic virus found in the majority of Merkel cell carcinomas [
12]. This is the first documented case of MCPyV DNA within JNA tissue. However, the MCPyV is a relatively ubiquitous virus, with a seroprevalence in adults of 50–95%. The majority of adults further shed MCPyV from their skin [
12]. Thus, this finding in the oldest patient of the cohort could be a reflection of his previous encounter with the virus. Although exceedingly rarely, Merkel cell carcinomas have been reported within the nasal vestibule [
18]; therefore, it is conceivable that MCPyV may also be present in the sinonasal passages.
In one recent HNSCC study, viral signatures were detected from 100 OSCC/OPSCC samples [
19]. HPV 16 was found in 98% of the OSCC/OPSCCs but not in controls, and reo-, herpes-, pox-, orthomyxo-, retro- and polyomaviruses were found with a hybridization signal level 2–3 logs higher than in the controls, all showing statistically significant differences. The presence of EBV in this study was statistically associated with OSCC [
20].
A recent study of HPyV DNA detection in 82 HNSCC samples by Poluschkin et al. revealed HPyV positivity in 52% (83% of 29 OSCCs and 0% of 23 OPSCC) [
21]. In OSCC, JCPyV was present in 59%, SVPyV in 21% and BKPyV in 3% of the samples. Interestingly, in 86.2% of JCPyV-positive HNSCC samples, there was HPV co-infection. In our study, one out of eight OPSCC samples was positive for HPyV (MCPyV), and both OSCC samples were negative for HPyV. The discrepancy between this study and our study, both on Finnish patients, could be due to local variance, as the patient cohorts were from different regions, small sample size, or perhaps due to different methods used in the detection of the viruses.
Parvovirus B19 can persist lifelong in human body tissues [
22]. Of the patients with B19V DNA-positive tumor samples, all harboring genotype 1 were under 60 years of age, whereas those with genotype 2 were over 60 years of age, correlating with the fact that B19V genotype 2 widely circulated around 50 years ago, but then disappeared from circulation around 1970 [
23]. One patient was found to harbor, in both healthy and cancerous tissue, DNA of B19V genotype 3, which is extremely rare in Finland—indeed, this patient had travelled from Bulgaria. Hitherto, only two subjects have been found positive for genotype 3 in this region, and they were soldiers from the Soviet army killed during World War II [
24]. In the current study, B19V DNA was present in 11/18 samples of 7/10 patients, however, in three of the patients the cancer tissue was negative for B19V while the paired healthy tissue was positive. The role of B19V existing in the control tissues more than the cancer tissues of the same patients is unclear at this point.
For the recently discovered boca-, bufa-, tusa-, and cutaviruses, this is the first study of their presence in OSCC/OPSCC, however, CuV has been detected in skin lesions of CTCL, melanoma, basal cell and squamous cell carcinomas [
10,
16,
25].
In conclusion, PCRs for B19V and the emerging parvoviruses HBoV1-4, BuV, TuV, and CuV, as well as for 12 of 13 HPyVs were negative in the studied JNA samples, whereas MCPyV was detected in one. This was the first report of MCPyV DNA being found in JNA. The OSCC/OPSCC samples were DNA positive only for MCPyV in one patient, and B19V DNA in 11/18 samples in 70% of the patients, however, the significance of this viral presence remains unclear.
Acknowledgements
Open access funding provided by University of Helsinki including Helsinki University Central Hospital. This work was supported by the Helsinki University Hospital Research and Education Fund, The Sigrid Jusélius Foundation, the Life and Health Medical Association, the Finnish-Norwegian Foundation for Medicine, the Emil Aaltonen Research Foundation, the Jane and Aatos Erkko Foundation, The Medical Society of Finland (FLS), the China Scholarship Council, and the Doctoral Programme in Biomedicine, University of Helsinki.