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Research Article

The Role of Viruses in Oral Squamous Cell Carcinoma in Young Patients in Khorasan (Northeast of Iran)

Z. Delavarian, A. Pakfetrat, F. Falaki, M. Pazouki and N. Pazouki
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It seems that Oral Squamous Cell Carcinoma (OSCC) in young adults is different from OSCC in older patients especially in risk factors. No significant habits are seen in younger patients. It is claimed that viral infections, especially human papillomavirus, are associated with several human carcinomas, especially oral cancers. The aim of this study was to investigate the presence of viruses in Oral Squamous Cell Carcinoma (OSCC) in young patients (20-40 years old) attending Mashhad Dental Faculty from 1996 to 2009 for the first time in Iranian population. Twenty one formalin-fixed, paraffin-embedded sections of patients under 40 years with clinical diagnosis of OSCC, who had referred to Mashhad Dental Faculty from 1996 and 2009, were evaluated for DNA extraction. All specimens were tested for presence of Human papilloma virus, Epstein-Barr virus, Herpes simplex virus type 1 and Cytomegalovirus virus. From 21 specimens, viruses were detected only in three cases. Two samples were positive for EBV and the third one was co-infected with EBV and HSV-1. All of our specimens were negative for HPV and CMV. We concluded that viruses had no important role in OSCC in our young patients. Further researches are needed to clarify this role and to identify other possible risk factors.

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Z. Delavarian, A. Pakfetrat, F. Falaki, M. Pazouki and N. Pazouki, 2010. The Role of Viruses in Oral Squamous Cell Carcinoma in Young Patients in Khorasan (Northeast of Iran). Journal of Applied Sciences, 10: 981-985.

DOI: 10.3923/jas.2010.981.985



Oral cancer is a significant cause of morbidity and mortality and consistently ranks as one of the top ten cancers worldwide, with broad differences in geographic distribution (Nawroz et al., 1994; Chen et al., 1999). The majority of these cancers are squamous cell carcinoma. More than 274,000 new cases of Oral Squamous Cell Carcinoma (OSCC) are being diagnosed worldwide annually (Parkin et al., 2002). They often develop after the age of 50, with a peak in the sixth decade of life and represent approximately 5% of cancers in men and 2% in women.

The major risk factor of this neoplasm is chronic exposure of oral mucosa to tobacco and alcohol (Nawroz et al., 1994; Chen et al., 1999) but no obvious etiological factors have been identified in young patients with OSCC (Kuriakose et al., 1992).

The first evidences for association of OSCC with infectious agents especially viruses has been proposed nearly two decades ago by some investigators (Scully et al., 2002; Campisi et al., 2007; Andrewsa et al., 2009).

The Human Papilloma Virus (HPV), Epstein-Barr Virus (EBV), Herpes Simplex Virus type 1(HSV1) and Cytomegalovirus (CMV) have been reported as related viruses with OSCC in different studies (Campisi et al., 2007; Andrewsa et al., 2009; Al Moustafaa et al., 2009; Atula et al., 1998; Shillitoe et al., 2009).

The Human Papilloma Virus (HPV) is one of the most common viruses that affect the skin and mucosa. The HPVs are oncogenic DNA viruses with more than 100 different identified subtypes (Harnish et al., 1999). Approximately 38.1% of oral cancers are positive for high-risk HPVs, especially HPV types 16, 18, 31, 33 and 35 (Ragin and Taioli, 2007; Termine et al., 2008).

The EBV is a human herpes virus that infects more than 90% of the human adults. It causes infectious mononucleosis and is closely associated with Burkitt’s Lymphoma (BL), oral carcinomas (especially nasopharyngeal), gastric cancer and some more sporadic malignancies (Harnish et al., 1999). The EBV has been found in 100% of nasopharyngeal carcinomas in Asian countries (Whitney et al., 2002).

The CMV is a human pathogen that spreads mainly by either a sexual or transfusion route. It also may have a role in cervical cancer (Odida and Schmauz, 1996).

By considering the fact that identifiable risk factors of tobacco and alcohol consumption were negative in our young patients, we decided to investigate the correlation of HPV, HSV1, EBV and CMV viruses with OSCC in young adults for the first time in Iran.


The paraffin-embedded biopsies of young patients with oral SCC diagnosed in our department from 1996 to 2010 were extracted from the archive of Oral Pathology Department and were evaluated for DNA extraction using the Qiagen QIAmp tissue extraction kit (Qiagen, Inc., Santa Clarita, CA) and eluted with 100 μL of elution buffer. Extracts were stored at -20°C. DNA integrity and absence of PCR inhibitors were tested by amplification of β-Globin gene (Chan et al., 1996). Only samples with a visible β-Globim gene band in the gel were included in this study. Target DNA was amplified in a 25 μL reaction mixture containing 5 μL DNA sample, 10 X Taq polymerase buffer (20 Mm KCL, 10 Mm Tris-HCL at pH 8.3, 1.5 mM MgCl2, 0.1% Triton-100).

The 2.5 U of Taq polymerase Roche (Roche Holding Ltd), 200 pmol of each primer, 2.5 mM of dNTP. Thermal cycles were performed in an ABI (Applied Biosciences, Foster City, California, United States) thermal cycler. The PCR Primers, their respective base sequences, size of amplified bands and optimum annealing temperature are shown in Table 1, in all samples; sterile water was used as a substitute for DNA and served as a negative control. The PCR products were analyzed by running a 2% agarose electrophoretic gel containing ethidium bromide (0.5 g mL-1) and visualized under ultraviolet illumination.


From 158 cases of OSCC diagnosed in our center between 1996 and 2010, 21 cases were presented in patients younger than 40 years of age. Our patients were between 20 and 38 years of age with a mean age of 30 years. Fifty seven percent of our patients were male and the most common site of involvement was lateral border of the tongue.

The DNA was extracted from all of our samples. Viruses were detected in 3 cases by PCR analysis. Two cases were positive for EBV (one strongly positive and one weakly positive) and the third one was co-infected with EBV and HSV-1 (Fig. 1). The age of these patients were 33, 24 and 31 years, respectively. All of our specimens were negative for HPV and CMV. Both EBV positive cases were female and their location was the tongue, the only HSV positive case was located in Maxillary alveolar ridge and the patient was female (Table 2).

Questions regarding possible risk factors associated with carcinomas in younger individuals still remain to be answered. The significance of major risk factors (alcohol consumption and tobacco use) among young patients is still controversial (Al-Sharif et al., 2009).

The HPV is the most widely studied virus in oral cancer researches but its role in oral cancer is controversial. The prevalence of HPV in oral carcinomas ranges from 0 to 87% in different studies (Bouda et al., 2000). Many investigators found HPV DNA in oral leukoplakias and oral malignant lesions which indicate the possible role of this virus in malignant transforming of oral epithelium especially in non-smoker patients (Reddout et al., 2007).

Sisk et al. (2000) found no significant difference in the rates of HPV positivity between young (less than 50) and old (more than 50) patients with oral cancer, but in another study a higher proportion of young patients with Head and Neck SCC and HPV positive compared with HPV negative patients was noticed (Gillison et al., 2008).

Table 1: PCR primers, annealing temperature and product length

Fig. 1: Representative gels showing PCR amplification. PCR primers used: β-Globin, lane 1: EBV, lane 2: HSV-1, lane 3: NC is water (template negative) control

Table 2: Clinical data of the selected Oral SCC patients
M: Male, F: Female

Similar to the study of Siebers et al. (2008), we could not find any relation between HPV and oral cancer in present study.

In a multicentre study by International Agency for Research on Cancer HR-HPV DNA was detected only in 3.9% of the biopsy specimens of the oral cavity, whereas, in a large population-based review study conducted by Kreimer et al. (2005). This prevalence was 23.5% in SCC of the oral cavity (Herrero et al., 2003; Kreimer et al., 2005).

This inconsistency may be related to the different sensitivity of the applied methods and to epidemiologic factors of the examined groups (Bouda et al., 2000). For further determination of the relationship between HPV and OSCC, further studies are needed (Siebers et al., 2008).

This investigation also showed that no significant association exists between HSV-1 and OSCC in young people.

It was compatible with the study of Parker et al. that showed HSV didn't increase the risk of OSCC in the absence of other risk factors (Parker et al., 2006).

Parker suggested that patients diagnosed with head and neck cancer who reported oro-genital contact were more likely to be HSV-1 and HSV-2 sero-positive compared with those who did not (Parker et al., 2006).

Murrah et al. (1996) indicated that HSV-1 and smokeless tobacco may have synergic effect in oral carcinogenesis but none of our patients used these products.

However in present study, only one case was positive for this virus, which is not statistically significant and it seems that HSV is not an etiologic factor in young people with OSCC in our area.

The EBV latent gene products have intrinsic activating characteristics (Altmann et al., 2006) thereby contribute to growth transformation of some oral epithelial cells especially nasopharyngeal cells. This reflects EBV’s contributions to viral oncogenesis.

Schneider et al. demonstrate that some subtypes of HPV and EBV play important roles in human oral cancers (Schneider et al., 2008). Higa et al. (2002) found EBV infection in a large population with oral squamous cell carcinoma in Okinawa.

The EBV was the most common detected virus in our patients (three out of 21 cases). Two samples were weakly positive and one case was strongly positive. All three cases were female. The site of tumor sin two cases was tongue. In the third case maxillary alveolar ridge was involved and it was weakly positive for EBV and strongly positive for HVS-1. Duration of lesions was between 3 weeks to 2 months.

Present study suggests that infection with EBV may have a role in the development of OSCC in young patients in our area although our samples were not enough to make a definite conclusion.

Recently, Yang et al. (2004). concluded that CMV might not have direct oncogenic effect but might enhance the possibility of oncogenesis or infect cancer tissues opportunistically.

The result of our study about CMV and also HSV-1 was in concordance with the research of Yang et al. (2004) although, we had different results for HPV and EBV. Actually, we couldn't find any report about the relation of CMV and oral cancer and our study also confirmed it.

We concluded that tobacco and alcohol consumption had no role in OSCC in young patients. Among viral infections we could only find a possible role of EBV in the development of OSCC in patients under 40 years old in northeast of Iran. Further researches are needed to clarify this role and to identify other possible risk factors.


The authors would like to extend their appreciation to the vice chancellor for research, MUMS (Mashhad University of Medical Sciences) for the financial support.

1:  Al-Moustafaa, A., D. Chend, L. Ghabreaub and N. Akilb, 2009. Association between human papillomavirus and Epstein-Barr virus infections in human oral carcinogenesis. Med. Hypoth., 73: 184-186.
CrossRef  |  

2:  Al-Sharif, M.J., W.A. Jiang, S. He, Y. Zhao, Z. Shan and X. Chen, 2009. Gingival squamous cell carcinoma in young patients: Report of a case and review of the literature. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endodol., 107: 696-700.
CrossRef  |  

3:  Altmann, M., D. Pich, R. Ruiss, J. Wang, B. Sugden and W. Hammerschmidt, 2006. Transcriptional activation by EBV nuclear antigen 1 is essential for the expression of EBV`s transforming genes. Proc. Natl. Acad. Sci. USA., 103: 14188-14193.
Direct Link  |  

4:  Andrewsa, E., W.T. Seamanc and J. Webster-Cyriaque, 2009. Oropharyngeal carcinoma in non-smokers and non-drinkers: A role for HPV. Oral Oncol., 45: 486-491.
Direct Link  |  

5:  Atula, T., R. Grenman, P. Klemi and S. Syrjanen, 1998. Human papillomavirus, Epstein-Barr virus, human herpesvirus 8 and human cytomegalovirus involvement in salivary gland tumours. Oral Oncol., 34: 391-395.
Direct Link  |  

6:  Bouda, M., V.G. Gorgoulis, N.G. Kastrinakis, A. Giannoudis, E. Tsoli and D. Danassi-Afentaki, 2000. High risk HPV types are frequently detected in potentially malignant and malignant oral lesions, but not in normal. Oral Mucosa Mod. Pathol., 13: 644-653.
Direct Link  |  

7:  Campisi, G., V. Panzarella, M. Giuliani, C. Lajolo, O. Di Fede, S. Falaschini, 2007. Human papillomavirus: Its identikit and controversial role in oral oncogenesis, premalignant and malignant lesions (Review). Int. J. Oncol., 30: 813-823.
Direct Link  |  

8:  Chan, M.K., K.M. Lau, Y. Tsui, F.W. Wong and D.P. Huang, 1996. Human papillomavirus infection in Hong Kong Chinese women with normal and abnormal cervix-detection by polymerase chain reaction method on cervical scrapes. Gynecol. Oncol., 60: 217-223.
CrossRef  |  

9:  Chen, Y.K., H.C. Huang, L.M. Lin and C.C. Lin, 1999. Primary oral squamous cell carcinoma: An analysis of 703 cases in Southern Taiwan. Oral Oncol., 35: 173-179.
CrossRef  |  

10:  Gillison, M.L., G. D'Souza, W. Westra, E. Sugar, W. Xiao, S. Begum and R. Viscidi, 2008. Distinct risk factor profiles for human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck cancers. J. Natl. Cancer Inst., 100: 407-420.
CrossRef  |  Direct Link  |  

11:  Harnish, D.G., L.K. Belland, E.E. Scheid and T.E. Rohan, 1999. Evaluation of human papillomavirus-consensus primers for HPV detection by the polymerase chain reaction. Mol. Cell. Probes, 13: 9-21.
CrossRef  |  

12:  Herrero, R., X. Castellsague, M. Pawlita, J. Lissowska and F. Kee et al., 2003. Human papillomavirus and oral cancer: The International Agency for research on cancer multicenter study. J. Natl. Cancer Inst., 95: 1772-1783.
CrossRef  |  PubMed  |  Direct Link  |  

13:  Higa, M., T. Kinjo, K. Kamiyama, T. Iwamasa, T. Hamada and K. Iyama, 2002. Epstein-Barr Virus (EBV) subtype in EBV related oral squamous cell carcinoma in Okinawa, a subtropical island in southern Japan, compared with Kitakyushu and Kumamoto in mainland Japan. J. Clin. Pathol., 55: 414-423.
Direct Link  |  

14:  Kreimer, A.R., G.M. Clifford, P. Boyle and S. Franceschi, 2005. Human papillomavirus types in head and neck squamous cell carcinomas worldwide: A systematic review. Cancer Epidemiol. Biomarkers Prev., 14: 467-475.
Direct Link  |  

15:  Kuriakose, M., M. Sankaranarayanan, M.K. Nair, T. Cherian, A.W. Sugar, C. Scully and S.S. Prime, 1992. Comparison of oral squamous cell carcinoma in younger and older patients in India. Eur. J. Cancer B Oral Oncol., 28B: 113-120.
Direct Link  |  

16:  Murrah, V.A., E.P. Gilcrist and M.P. Moyer, 1996. Attenuation of the natural course of herpes simplex virus infection in human oral epithelial cell cultures by smokeless tobacco extracts suggests the possibility of a synergistic mechanism for carcinogenesis. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endodontol., 81: 63-69.
CrossRef  |  

17:  Nawroz, H., P. Van der Riet, R.H. Hruban, W. Koch, J.M. Ruppert and D. Sidransky, 1994. Allelotype of head and neck squamous cell carcinoma. Cancer Res., 54: 1152-1155.
Direct Link  |  

18:  Odida, M. and R. Schmauz, 1996. Cervical cancer and cytomegalovirus. East Afr. Med. J., 73: 810-812.
Direct Link  |  

19:  Parker, T.M., E.M. Smith, J.M. Ritchie, T.H. Haugen, V. Vonka, L.P. Turekd and E. Hamsikova, 2006. Head and neck cancer associated with herpes simplex virus 1 and 2 and other risk factors. Oral Oncol., 42: 288-296.
CrossRef  |  

20:  Parkin, D.M., F. Bray, J. Ferlay and P. Pisani, 2005. Global cancer statistics, 2002. CA: Cancer J. Clin., 55: 74-108.
CrossRef  |  PubMed  |  Direct Link  |  

21:  Ragin, C.C. and E. Taioli, 2007. Survival of squamous cell carcinoma of the head and neck in relation to human papillomavirus infection: Review and meta-analysis. Int. J. Cancer, 121: 1813-1820.
Direct Link  |  

22:  Scully, C., 2002. Oral squamous cell carcinoma; from a hypothesis about a virus, to concern about possible sexual transmission. Oral Oncol., 38: 227-234.
Direct Link  |  

23:  Reddout, N., T. Christensen, A. Bunnell, D. Jensen, D. Johnson, S. O`Malley and K. Kingsley, 2007. High risk HPV types 18 and 16 are potent modulators of oral squamous cell carcinoma phenotypes in vitro. Infectious Agents Cancer, 2: 21-21.
Direct Link  |  

24:  Shillitoe, E.J., 2009. The role of viruses in squamous cell carcinoma of the oropharyngeal mucosa. Oral Oncol., 45: 351-355.
CrossRef  |  

25:  Siebers, T.J.H., M.A.W. Merkx, P.J. Slootweg, W.J.G. Melchers, P. van Cleef and P.C.M. de Wilde, 2008. No high-risk HPV detected in SCC of the oral tongue in the absolute absence of tobacco and alcohol-a case study of seven patients. Oral Maxillofacial Surg., 12: 185-188.
Direct Link  |  

26:  Sisk, E.A., C.R. Bradford, A. Jacob, C.H. Yian and K.M. Staton et al., 2000. Human papilloma virus infection in young versus old patients with squamous cell carcinoma of the head and neck. Head Neck, 22: 649-657.
Direct Link  |  

27:  Termine, N., V. Panzarella, S. Falaschini, A. Russo, D. Matranga and L.L. Muzio, 2008. HPV in oral squamous cell carcinoma vs head and neck squamous cell carcinoma biopsies: A meta-analysis (1988-2007). Ann. Oncol., 19: 1681-1690.
Direct Link  |  

28:  Whitney, B.M., A.T. Chan, A.B. Rickinson, S.P. Lee, C.K. Lin and P.J. Johnson, 2002. Frequency of Epstein-Barr virus-specific cytotoxic T lymphocytes in the blood of Southern Chinese blood donors and nasopharyngeal carcinoma patients. J. Med. Virol., 67: 359-363.
Direct Link  |  

29:  Yang, Y.Y., L.W. Koh, J.H. Tsai, C.H. Tsai, E.F. Wong, S.J. Lin and C.C. Yang, 2004. Correlation of viral factors with cervical cancer in Taiwan. J. Microbiol. Immunol. Infect., 37: 282-287.
Direct Link  |  

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