HPV-DNA integration into cellular chromatin is usually a necessary event in the pathogenesis of HPV-related cancer; however, the mechanism of integration has not been clearly defined. Breaks must be created in both the host DNA and in the circular viral episome for integration to occur, and studies have shown that viral integration is indeed increased by the induction of DNA double strand breaks. Inflammation generates reactive oxygen species, which in turn have the potential to create such DNA strand breaks. It is plausible that these breaks enable a greater frequency of HPV-DNA integration, and in this way contribute to carcinogenesis. Consistent with this idea, coinfections with certain sexually transmitted diseases cause cervical inflammation, and have also been identified as cofactors in the progression to cervical cancer. This article examines the idea that inflammation facilitates HPV-DNA integration into cellular chromatin through the generation of reactive oxygen species, thereby contributing to carcinogenesis. Keywordsbacterial co-infection; cervical cancer; DNA damage; HPV; inflammation; integration; oropharyngeal cancer; oxidative stress; papillomavirus; viral Human papillomavirusesHuman papillomaviruses (HPVs) are a group of circular, dsDNA viruses that infect epithelial cells [1], and are divided into more than 100 different genotypes based on sequence differences within their L1 gene [2]. Of the 100 genotypes of HPV, at least 30 are sexually transmitted and infect the genital areas of both men and women. A subset of these genotypes causes anogenital warts, which can be either benign or cancerous. Consequently, HPV types are designated 'low risk' or 'high risk' (HR), based on whether they are known to cause benign or cancerous lesions [3]. Virtually all cases of cervical and anogenital cancer are caused by approximately 15 HR genotypes of HPV [4][5][6][7]. Of the HR genotypes, HPV16, HPV18, HPV31 and HPV33 are associated with 90% of all cases of cervical cancer, and HPV DNA is present in more than 90% of premalignant and malignant squamous lesions of the uterine cervix [8,9]. HPV type 16 is the most prevalent type and is associated with more than 50% of all cases of cervical cancers [10,11].Papillomavirus genomes consist of double-stranded circular DNA of approximately 8 kb in size, containing approximately eight open reading frames (ORFs), which are transcribed as polycistronic messages from a single DNA strand. The genome can be divided into three regions: an early region, a late region and a long control region. The early region encodes

High-risk types of human papillomavirus (HPV) are the causative agents of virtually all cases of cervical cancer and a significant proportion of other anogenital cancers, as well as both oral and pharyngeal cancers. The high-risk types encode two viral oncogenes, E6 and E7, which work together to initiate cell transformation. Multiple steps involving the activities and interactions of both viral and cellular proteins are involved in the progression from HPV infection to cell transformation to cancer. The E6 oncoprotein is expressed as several isoforms: a full-length variant referred to as E6 and a few shorter isoforms collectively referred to as E6*. In this study, we found that expression of E6* increased the level of reactive oxygen species (ROS) in both HPVpositive and HPV-negative cells. This increased oxidative stress led to higher levels of DNA damage, as assessed by the comet assay, quantification of 8-oxoguanine, and poly(ADP-ribose) polymerase 1. The observed increase in ROS may be due to a decrease in cellular antioxidant activity, as we found that E6* expression also led to decreased expression of superoxide dismutase isoform 2 and glutathione peroxidase. These studies indicate that E6* may play an important role in virus-induced mutagenesis by increasing oxidative stress and DNA damage. IMPORTANCEOur findings demonstrate for the first time that an HPV gene product, E6*, can increase ROS levels in host cells. This ability may play a significant role both in the viral life cycle and in cancer development, because an increase in oxidative DNA damage may both facilitate HPV genome amplification and increase the probability of HPV16 DNA integration. Integration, in turn, is thought to be an important step in HPV-mediated carcinogenesis.H igh-risk (HR) types of human papillomavirus (HPV) are the causative agents of virtually all cases of cervical cancer as well as a significant percentage of other anogenital and oropharyngeal cancers. In fact, current estimates indicate that HPV infection may be associated with as many as 93% of anal cancers, 63% of oropharyngeal cancers, 40% of penile cancers, 64% of vaginal cancers, and 51% of vulvar cancers (1). HPV infection accounted for approximately 26,700 cases of HPV-related cancers in the United States (2, 3), and it is estimated that 5.2% of all cancers worldwide can be attributed to HPV infection (4). While the incidence of cervical cancer has declined in the last 30 years due to Pap smear screening, the incidence rates of anal, oropharyngeal, and vulvar cancers steadily increased within the same period (1). These numbers underscore the need for ongoing research into the mechanisms behind HPV-related carcinogenesis.The high-risk types of HPV encode two viral oncogenes, E6 and E7, that together serve as the major initiators of cell transformation (5). Multiple steps are involved in the progression from HPV infection to cellular transformation to cancer. Virus-related factors influencing this progression include virus persistence, viral load, and the repr...

Viruses are the causative agents of 10%–15% of human cancers worldwide. The most common outcome for virus-induced reprogramming is genomic instability, including accumulation of mutations, aberrations and DNA damage. Although each virus has its own specific mechanism for promoting carcinogenesis, the majority of DNA oncogenic viruses encode oncogenes that transform infected cells, frequently by targeting p53 and pRB. In addition, integration of viral DNA into the human genome can also play an important role in promoting tumor development for several viruses, including HBV and HPV. Because viral integration requires the breakage of both the viral and the host DNA, the integration rate is believed to be linked to the levels of DNA damage. DNA damage can be caused by both endogenous and exogenous factors, including inflammation induced by either the virus itself or by co-infections with other agents, environmental agents and other factors. Typically, cancer develops years to decades following the initial infection. A better understanding of virus-mediated carcinogenesis, the networking of pathways involved in transformation and the relevant risk factors, particularly in those cases where tumorigenesis proceeds by way of virus integration, will help to suggest prophylactic and therapeutic strategies to reduce the risk of virus-mediated cancer.

PURPOSE:The purpose of this study was to highlight the importance of timely brachytherapy treatment for patients with gynecologic, breast, and prostate malignancies, and provide a framework for brachytherapy clinical practice and management in response to the COVID-19 pandemic. METHODS AND MATERIALS: We review amassing evidence to help guide the management and timing of brachytherapy for gynecologic, breast, and prostate cancers. Where concrete data could not be found, peer-reviewed expert opinion is provided. RESULTS: There may be a significant negative impact on oncologic outcomes for patients with gynecologic malignancies who have a delay in the timely completion of therapy. Delay of prostate or breast cancer treatment may also impact oncologic outcomes. If a treatment delay is expected, endocrine therapy may be an appropriate temporizing measure before delivery of radiation therapy. The use of shorter brachytherapy fractionation schedules will help minimize patient exposure and conserve resources. CONCLUSIONS: Brachytherapy remains a critical treatment for patients and may shorten treatment time and exposure for some. Reduced patient exposure and resource utilization is important during COVID-19. Every effort should be made to ensure timely brachytherapy delivery for patients with gynecologic malignancies, and endocrine therapy may help temporize treatment delays for breast and prostate cancer patients. Physicians should continue to follow developing institutional, state, and federal guidelines/recommendations as challenges in delivering care during COVID-19 will continue to evolve.

Treatment of advanced and relapsed cervical cancer is frequently ineffective, due in large part to chemoresistance. To examine the pathways responsible, we employed the cervical carcinoma-derived SiHa and CaSki cells as cellular models of resistance and sensitivity, respectively, to treatment with chemotherapeutic agents, doxorubicin, and cisplatin. We compared the proteomic profiles of SiHa and CaSki cells and identified pathways with the potential to contribute to the differential response. We then extended these findings by comparing the expression level of genes involved in reactive oxygen species (ROS) metabolism through the use of a RT-PCR array. The analyses demonstrated that the resistant SiHa cells expressed higher levels of antioxidant enzymes. Decreasing or increasing oxidative stress led to protection or sensitization, respectively, in both cell lines, supporting the idea that cellular levels of oxidative stress affect responsiveness to treatment. Interestingly, doxorubicin and cisplatin induced different profiles of ROS, and these differences appear to contribute to the sensitivity to treatment displayed by cervical cancer cells. Overall, our findings demonstrate that cervical cancer cells display variable profiles with respect to their redox-generating and -adaptive systems, and that these different profiles have the potential to contribute to their responses to treatments with chemotherapy.

Purpose Advances in radiotherapy have improved tumor control and reduced toxicity in the management of nasopharyngeal carcinoma (NPC). Local failure remains a problem for some patients with advanced primary tumors, and toxicities are significant given the large treatment volume and tumor proximity to critical structures, even with modern photon-based radiotherapy. Proton therapy has unique dosimetric advantages, and recent technological advances now allow delivery of intensity-modulated proton therapy (IMPT), which can potentially improve the therapeutic ratio in NPC. We report our 2-year clinical outcomes with IMPT for NPC. Materials and Methods We retrospectively reviewed treatment records of patients with NPC treated with IMPT at our center. Demographics, dosimetry, tumor response, local regional control (LRC), distant metastasis, overall survival, and acute and late toxicity outcomes were reviewed. Analyses were performed with descriptive statistics and Kaplan-Meier method. Toxicity was graded per Common Terminology Criteria for Adverse Events (version 4.0). Results Twenty-six patients were treated from 2015 to 2020. Median age was 48 years (range, 19–73 years), 62% (n = 16) had T3-T4 disease, 92% (n = 24) were node positive, 92% (n = 24) had stage III-IV disease, and 69% (n = 18) had positive results for Epstein-Barr virus. Dose-painted pencil-beam IMPT was used. Most patients (85%; 22 of 26) were treated with 70 Gy(RBE) in 33 fractions once daily; 4 (15%) underwent hyperfractionated accelerated treatment twice daily. All received concurrent cisplatin chemotherapy; 7 (27%) also received induction chemotherapy. All patients (100%) completed the planned radiotherapy, and no acute or late grade 4 or 5 toxicities were observed. At median follow-up of 25 months (range, 4-60), there were 2 local regional failures (8%) and 3 distant metastases (12%). The Kaplan-Meier 2-year LRC, freedom from distant metastasis, and overall survival were 92%, 87%, and 85% respectively. Conclusion IMPT is feasible in locally advanced NPC with early outcomes demonstrating excellent LRC and favorable toxicity profile. Our data add to the growing body of evidence supporting the clinical use of IMPT for NPC.

PURPOSE: Brachytherapy is an irreplaceable component of gynecologic cancer treatment. Resident training has declined, and procedural exposure is variable. We evaluated whether simulationbased gynecologic brachytherapy training among radiation oncology residents could improve knowledge, confidence, and interest. METHODS AND MATERIALS: Before a brachytherapy workshop, radiation oncology residents without prior gynecologic brachytherapy experience completed a survey on brachytherapy knowledge, procedural confidence, plan evaluation, and quality/safety. Residents then participated in a gynecologic brachytherapy workshop. Lectures covered brachytherapy imaging and physics principles/quality assurance, followed by hands-on and individualized feedback regarding applicator selection and placement, target segmentation, and physics quality assurance. Afterward, preworkshop questions were recollected. Descriptive statistics and Fisher's exact tests were used for data analysis. RESULTS: After the workshop, resident responses regarding the learning environment and baseline knowledge questions improved overall. There was a 30% improvement in favorable responses to the learning environment statement ''My residency has a formal process/curriculum to teach brachytherapy'' and for baseline knowledge the greatest improvement was seen for ''I am familiar with the anatomy and placement of the applicators in relation to the anatomy''. ''Lack of didactic or procedural training exposure'' was identified as the main reason for declining brachytherapy use. Initially, 1/8 residents correctly completed the knowledge questions, and after the workshop, 6/7 ( p ! 0.001) residents correctly completed the questions. CONCLUSIONS: Domain-specific knowledge, procedural confidence, and brachytherapy interest improved after a gynecologic brachytherapy workshop. Integrated didactic and simulation-based brachytherapy training may serve as a valuable learning tool to augment resident knowledge, introduce practical skills, and spark resident interest in brachytherapy. Published by Elsevier Inc. on behalf of American Brachytherapy Society.

High-risk types of human papillomavirus (HPV) cause nearly all cases of cervical cancer. The E6 oncoprotein is produced as a full-length variant (E6) as well as several shorter isoforms (E6*). E6* inhibits certain oncogenic activities of E6, suggesting that it might play an anti-oncogenic role in vivo. To test this, we created E6*-expressing SiHa (HPV+) and C33A (HPV−) cells, then examined the ability of both the parental and E6*-expressing cells to form tumors in nude mice. We found that over-expression of E6* indeed decreased the growth of tumors derived from both SiHa and C33A cells, with the reduction greatest in tumors derived from E6*-expressing SiHa cells. These findings point to multiple anti-oncogenic characteristics of E6*, some of which likely involve down-regulation of the full-length isoform, and others that are independent of HPV. These data represent the first demonstration of biologically-relevant E6* activities distinct from those of the full-length isoform in vivo.