**3. Other types of tumors**

Next, we will describe other tumoral clinical processes that have been associated with HPV infection. It is important to highlight that the majority of people infected with HPV do not present symptomatology or health-problems related to the infection. In 90% of the cases, the immune system naturally eliminates the virus within two years. However, sometimes HPV infections become chronic, and they can be associated with other lesions or tumors aside from the previously described pathology. These lesions and tumors include warty lesions in the oral

loss, anesthesia or trismus. Clinically, the tumor manifests in exophytic, ulcerative or warty forms (Figure 17). It is important to completely explore the entire oral cavity and to obtain a biopsy of the lesion when it is accessible, or a puncture-aspiration with a fine needle when biopsy is difficult. The neck must be carefully explored to detect adenopathies, and a radiologic

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The importance of HPV in oropharyngeal carcinoma patients is increasing. It is important to determine the presence or absence of this virus in patients who present epidermoid carcinoma in the oropharynx or who have cervical adenopathy of uncertain origin to obtain information

or endoscopic study should be performed to establish tumoral extension.

**Figure 17.** Squamous cell carcinoma of the lip: exophytic, ulcerative, warty tumor of the lower lip.

Sexual abuse should also be suspected in diseased children older than 5 years.

Recurrent respiratory papillomatosis (RRP) is characterized by warty lesions produced by HPV infection of the airways. These lesions can obstruct the airways or cause dysphonia, among other symptoms. Two clinical variants are recognized depending on the patient's age at onset: the juvenile (before 5 years) and the adult form (after 40 years). The juvenile variant is more frequent and severe than the adult form. HPV 6 and 11 are the types most frequently involved in this clinical picture [73]. HPV 11 produces a more severe clinical picture than the other viral variants do, and HPV 11 infection more frequently requires tracheostomy. The transmission mechanisms of the infection are not always clear, but sexual transmission should be considered in adults, and mother-to-child transmission should be considered in the juvenile RRP variant. In this regard, some risk factors associated with this variant have been confirmed. These risk factors include a mother younger than 20 years, vaginal delivery and being firstborn.

**3.2. Recurrent respiratory papillomatosis and lung cancer**

on the patient's therapeutic attitude, prognosis and survival [72].

**Figure 16.** Excrescent ulcerated lesions in cervix clinically compatible with carcinoma

cavity and pharynx (recurrent respiratory papillomatosis [RRP]) and rare but serious cancers such as those of the bladder, lung and oropharynx (the posterior area of the throat, including the base of the tongue and the tonsils).

#### **3.1. Oral and cervical cancer**

Eighty-five percent of oral cavity cancers are epidermoid (we will be referring primarily to this type), and their incidence increases progressively with age. HPV 16/18 are the types most frequently associated with oral and cervical cancer, especially in the oropharynx and tonsils [69, 70]. The principal lesions associated with HPV infection in the oral cavity are oral papil‐ lomatosis (associated with HPV 6 and 11), focal epithelial hyperplasia (HPV 13 and 32) and erythroplasia (HPV 16).

Causal factors strongly associated with oral and cervical cancer are tobacco and alcoholic beverage consumption. Therefore, investigations to determine the possible etiological role of HPV will need to consider these factors. Several studies that controlled for age, gender, smoking, tobacco chewing and drinking have not observed significant differences among these factors for HPV detection in tumoral tissue, with the exception of smoking. That is, HPV DNA was less likely to be found in the biopsy samples of ex-smokers and smokers than those of people who had never smoked. In comparison, patients with more than a single sexual partner had a higher possibility of HPV DNA detection than those who had a single lifetime sexual partner. Similar observations were obtained when comparing oral sex practitioners versus nonpractitioners. These associations were similar for oral cavity and oropharynx cancer [71].

The clinical manifestations of patients with epidermoid carcinoma are very diverse and depend on the location and size of the lesions. Leukoplakia and erythroplasia are premalignant lesions over which neoplastic lesions can develop. The most common initial presentation is a painful ulcer. Pain appears precociously in lesions that affect the base of the mouth or the gums; however, it is delayed in other locations, such as the base of the tongue. Dysphagia occurs with lesions that affect the oropharynx or that alter the mobility of the tongue. Hemorrhage usually occurs in ulcerated lesions. Other associated symptoms include dysphonia, tooth mobility or loss, anesthesia or trismus. Clinically, the tumor manifests in exophytic, ulcerative or warty forms (Figure 17). It is important to completely explore the entire oral cavity and to obtain a biopsy of the lesion when it is accessible, or a puncture-aspiration with a fine needle when biopsy is difficult. The neck must be carefully explored to detect adenopathies, and a radiologic or endoscopic study should be performed to establish tumoral extension.

The importance of HPV in oropharyngeal carcinoma patients is increasing. It is important to determine the presence or absence of this virus in patients who present epidermoid carcinoma in the oropharynx or who have cervical adenopathy of uncertain origin to obtain information on the patient's therapeutic attitude, prognosis and survival [72].

**Figure 17.** Squamous cell carcinoma of the lip: exophytic, ulcerative, warty tumor of the lower lip.
