Spontaneous regression of low-grade cervical intraepithelial lesions is positively improved by topical bovine colostrum preparations (GINEDIE®). A multicentre, observational, italian pilot study

OBJECTIVES

Human papillomavirus (HPV) is the causal agent of cervical cancer. The great majority of abnormal Pap test results - almost 90% - is referrable to either atypical squamous intraepithelial lesion or CIN1. For these lesions, worldwide agreement exists concerning the high rate - ranging from 40% to 70% - of spontaneous regression over a period of 1-5 years. Host's immune response is a key point influencing the natural history of these conditions. Bovine colostrum is a natural agent positively promoting several immune activities against bacterial and viral agents. The aim of this report was to evaluate the potential positive effect of bovine colostrum-containing vaginal tablets administered to CIN1 diagnosed patients in a prospective trial in regards to spontaneous regression rate.

PATIENTS AND METHODS

A series of 256 consecutive patients with histologically proven CIN1 recruited in a multicentre, observational, Italian study. Patients have been enrolled in a 24-weeks protocol of treatment and re-tested at the end of the study. Rates of regression have been recorded.

RESULTS

Overall regression rate to a negative histology at the end of the 6 month follow up was 75.5%.

CONCLUSIONS

Regression to normal histology was observed in a very high rate of cases in a very short period compared to the natural history of these lesions. CIN1 patients could benefit from bovine colostrum topical administration in terms of significantly shortening the regression time.

Cervical Intraepithelial Neoplasia (CIN) in pregnancy: the state of the art

OBJECTIVES

Cervical cancer is the most commonly diagnosed malignancy in pregnancy and cervical screening should be accordingly performed in this particular situation. Occurrence of a preneoplastic cervical disease in pregnancy has for a long time represented a challenge for the clinician, both in terms of diagnostic accuracy, treatment options and risk of obstetrical complications. For these reasons, lack of uniformity in diagnosis and management is still commonly observed and the need for evidence-based clarifications is strongly required. Consistently with the literature evidences and accordingly with international guidelines, this review aim to overview the most significant aspects of the issue and trace simple and practical indications for an evidence-based correct workout and management of these conditions.

MATERIALS AND METHODS

The most significative and focused-on results from literature as well as recent international guidelines have been considered and summarized in order to clarify the key-points of the topic; epidemiology, pathophysiology, natural history, treatment modalities and procedure-related risks have been approached and discussed.

RESULTS

Risk factors, prevalence and progression rate of cervical intraepithelial neoplasia in pregnancy are comparable to those observed in non-pregnant patients; thus, pregnancy does not have to be considered a condition at higher risk. Cytology, histology and colposcopic patterns must be evaluated by experienced professionals because of pregnancy-induced modifications that can lead to misinterpretations. Each diagnostic step should be directed to exclusion of invasive cervical cancer.

CONCLUSIONS

Once invasive cancer has been excluded through a comprehensive diagnostic workout, treatment of cervical intraepithelial neoplasia can be safely deferred after delivery.

Productive HIV-1 infection of human cervical tissue ex vivo is associated with the secretory phase of the menstrual cycle

Cervical tissue explants (CTEs) from 22 HIV-1 seronegative women were exposed to R5 HIV-1 ex vivo. Eight CTEs were productively infected in terms of HIV-1 p24Gag release in culture supernatants, whereas 14 were not. Nonetheless, both accumulation of HIV-1gag DNA and of p24Gag(+) CD4(+) T cells and macrophages occurred in both productive and, at lower levels, in nonproductive CTEs. Nonproductive CTEs differed from productive CTEs for higher secretion of C-C motif chemokine ligand 3 (CCL3) and CCL5. A post-hoc analysis revealed that all productive CTEs were established from women in their secretory phase of the menstrual cycle, whereas nonproductive CTEs were derived from women either in their secretory (28%) or proliferative (36%) menstrual cycle phases or with an atrophic endometrium (36%). Thus, our results support the epidemiological observation that sexual HIV-1 transmission from males to women as well as from women to men is more efficient during their secretory phase of the menstrual cycle.

Pharmacokinetics and toxicity of antimuscarinic drugs for overactive bladder treatment in females

INTRODUCTION

Antimuscarinics (AMs) are the mainstay of pharmacological treatment of overactive bladder (OAB), a symptom complex defined by the presence of urinary urgency, usually associated with frequency and nocturia, with or without urgency urinary incontinence. The AMs used to treat OAB differ in their pharmacological profiles, which may affect their potential for causing adverse effects (AEs).

AREAS COVERED

The present article aims to review the literature about pharmacokinetics (PK) of the different AMs used in the treatment of OAB. Furthermore, the AEs related to the use of these drugs and their incidence are presented. This systematic review is based on material searched and obtained via Medline, Pubmed and EMBASE up to March 2012 using the search terms "adverse events, pharmacokinetics, tolerability" in combination with "darifenacin, fesoterodine, imidafenacin, oxybutynin, propiverine, solifenacin, tolterodine, and trospium."

EXPERT OPINION

Antimuscarinics are the first-line pharmacological treatment for OAB. Despite the development of new molecules that improve their efficacy/safety profile, there are some drugs that are pharmacokinetically more appropriate to be prescribed in specific populations such as patients with neurological disease or the elderly. Moreover, research should be encouraged in evaluating antimuscarinics in conjunction with other drugs such as estrogens or beta-agonists. The identification of prognostic criteria for pharmacological therapy would be helpful.

HPV-DNA testing for cervical cancer precursors: from evidence to clinical practice

The large amount of literature published over the last two decades on human papillomavirus (HPV)-DNA testing has definitely demonstrated the association between high-risk viral genotypes (hrHPV) and cervical cancer. Moreover, hrHPV-DNA testing has shown excellent performance in several clinical applications, from screening settings to the follow-up of treated patients, compared to conventional cytology or colposcopy options. On the other hand, when a huge number of reports are published on the same subject in a relatively short period of time, with many variations in settings, study designs and applications, the result is often confusion and decreased comprehension by readers. In daily office practice, several different situations (in symptomatic or asymptomatic women) can be positively managed by the correct use of hrHPV-DNA testing. Validated hrHPV-DNA testing and, specifically, the HC2® assay, due to its excellent sensitivity and negative predictive value together with optimal reproducibility, currently represent a powerful tool in the clinician’s hands to optimally manage several situations related to HPV infection and the potential development of cervical cancer.

"Low-grade positivity" of HPV viral load after atypical squamous cells of undetermined significance (ASC-US) cytology identifies women at low-risk for cervical intraepithelial neoplasia grade 2 and 3

The correlation between high-risk HPV-DNA viral load, expressed as relative light units (RLU) values obtained from the Hybrid Capture 2 (HC2) test, and the prevalence of CIN2/CIN3 was investigated and statistically analyzed in 614 ASC-US consecutive cases. Cases were categorized into three groups according to RLU values: "low-grade positivity", "intermediate positivity" and "high-grade positivity", and the prevalence of CIN2/CIN3 was evaluated in the single groups and compared among them. CIN/CIN3 rates demonstrated a significant (p < 0.001) increase with a direct correlation with increasing RLU values: 4.6% (RLU from 1.0 to 10.0), 9.1% (RLU from 11.0 to 100.0) and 32.2% (RLU > 100.0) respectively. The prevalence of CIN2/CIN3 between the group with RLU < 10.0 (4.6%) and the group with RLU > 10 (24.2%) showed statistical significance (p = 0.0002). Increasing hrHPV viral load significantly correlates with increasing prevalence of CIN2/CIN3 in ASC-US cases.

CD4+ T cells against human papillomavirus-18 E7 in patients with high-grade cervical lesions associate with the absence of the virus in the cervix

Cervical neoplastic lesions are associated with infection by high-risk human papilloma-viruses (HPV). The two genotypes most frequently found in the lesions are HPV-16 and HPV-18 with a prevalence of 50-60% and 15-18%, respectively. The E6 and E7 viral oncoproteins are involved in the transformation process and represent foreign antigens for the host. We previously reported that anti-HPV-18 E6 CD4(+) T cells are present in patients with high-grade HPV-18-expressing cervical lesions but also in 50% of the total consecutive patients tested, independently of the HPV type carried. These results indicated that HPV-18 E6 is immunogenic and suggested that all responsive patients, irrespective of the HPV expressed, had encountered HPV-18 and cleared the infection. Here, we investigated anti-HPV-18 E7 CD4(+) T-cell immunity in a cohort of 23 HPV-18 E6-responsive patients. We found that, although E7-specific CD4(+) T cells were present in all women, a robust T helper type (Th1)/Th2 type response against E7 was associated with HPV-18-negative status, suggesting that indeed these patients might have cleared the virus. In agreement with this hypothesis, we found strong anti-E7 CD4(+) T-cell immunity in 20% of 24 healthy donors without evidence of disease. In contrast, a robust Th1/Th2 type response against E6 but not E7 correlated with a lack of disease relapse and/or infection recurrence but did not discriminate between HPV-18-positive and HPV-18-negative patients. Collectively, our data suggest different roles for anti-HPV-18 E6 and E7 CD4(+) T cells in anti-viral and anti-tumour immunity.

Isolated tubal torsion in pregnancy

Adnexal torsion is an uncommon cause of acute abdomen in pregnancy and isolated fallopian tube twisting accounts for a very small number of these cases. These conditions, either in pregnancy or in non-gestational circumstances, are known to be due to both genital and non-genital causes and, in most cases, predisposing factors can be identified. We reviewed the literature and retrieved only 19 cases of isolated fallopian tube torsion in pregnancy treated surgically from 1936 to today, including one recently published case from our experience. The clinical presentation was lower quadrant abdominal pain in all cases. The right side was involved in 90% of the cases. Tenderness was usually present but peritoneal irritation with guarding or rebound was exceptional. Symptoms were nausea and vomiting, scanty vaginal bleeding and dysuria. Signs suggestive of necrosis such as leucocytosis, increased CRP and mild hyperpyrexia were uncommon. Preoperative ultrasound evaluation was performed in eight patients and in all cases an adnexal cyst was detected on the ipsilateral side of the abdominal pain. The case we recently published was carefully investigated preoperatively by Doppler flow ultrasound techniques which allowed for a precise differential diagnosis with total adnexal torsion. This aspect has never been previously considered. The surgical approach showed acute isolated fallopian tube torsion in all the cases and a predisposing factor was identified in 75% of the patients. Foetal and maternal outcome were always excellent. In cases of acute abdomen in pregnancy, with detailed Doppler flow ultrasound evidence of normal ovaries and of a pelvic cyst, an isolated tubal-paratubal cyst torsion should be considered and appropriate ovary-sparing surgical treatment foreseen.

IFN-gamma produced by human papilloma virus-18 E6-specific CD4+ T cells predicts the clinical outcome after surgery in patients with high-grade cervical lesions

Cervical neoplastic lesions are associated with infection by high-risk human papilloma viruses (HPVs). HPV-16 and HPV-18 are the most common genotypes. It has been proposed that development of HPV-16-positive cervical lesions is associated with impaired CD4(+) T cell immunity against early Ags. The aim of the study was to evaluate whether this impairment also applies to HPV-18. We investigated the presence and the quality of anti-HPV-18 E6 CD4(+) T cell responses in the blood of 37 consecutive patients with high-grade cervical lesions, 25 normal donors, and 20 cord bloods. The immune infiltrate in the cervical lesions was also evaluated. The characteristics of the responses were correlated to the clinical outcome. We found that one or more HPV-18 E6 peptides, containing naturally processed epitopes, were able to induce a response in 40-50% of the patients, depending on the effector function tested. Importantly, these percentages rose to 80-100% when HPV-18-positive patients were considered. HPV-18 E6-specific CD4(+) T cells produced mixed Th1/Th2 responses and statistical analysis of the cytokines produced revealed that the amount of IFN-gamma released could predict infection persistence and/or disease relapse after surgery. Finally, we found that a higher number of infiltrating CD4(+) and T-bet(+) T cells in the lesions correlated with a favorable clinical outcome. Our results strongly suggest a relevant role for CD4(+) T cells in the control of the HPV-18 compared with HPV-16 infections in patients with high-grade cervical lesions and identify an immunologic parameter potentially useful for patients' stratification.

Polyhexamethylene biguanide for treatment of external genital warts: a prospective, double-blind, randomized study

Genital human papillomavirus infection is one of the most common sexually transmitted diseases. Polyhexamethylene biguanide is a new agent, that has been demonstrated to have potent in vivo antiviral effects in animal and in human models. The present prospective, double-blind, randomized, placebo (vehicle-controlled) trial evaluated the efficacy and safety of daily patient-applied polyhexamethylene biguanide for up to 16-weeks for the treatment of external genital warts. Wart recurrence was investigated during a 12-week treatment-free follow-up period. In the intent-to-treat analysis, baseline warts cleared from 49 of 94 (52%) patients treated with polyhexamethylene biguanide cream versus and 3 of 95 (4%) placebo patients; the differences between the groups treated with placebo and polyhexamethylene biguanide were significant (P < 0.0001). For subjects who completed the follow-up period, recurrence rates after a complete response were 19% (9 of 48 patients) in the polyhexamethylene biguanide cream group, 17% cream group, and 0% (0 of 3) in the placebo group. There were no systemic reactions, although local skin reactions (generally of mild or moderate severity) were common in the polyhexamethylene biguanide cream group. Local reactions caused two patients to discontinue treatment. The most frequently reported local skin reactions were erythema, excoriation or flaking, and erosion. Patient-applied polyhexamethylene biguanide cream is effective for the treatment of external genital warts and has a favorable safety profile.

Human papillomavirus infection and associated cervical disease in human immunodeficiency virus-infected women: effect of highly active antiretroviral therapy

To determine the effect of highly active antiretroviral therapy (HAART) on high-risk human papillomavirus (HR-HPV) infections and related cervical lesions, the virologic and cytologic markers of HPV infection were prospectively studied in 163 human immunodeficiency virus (HIV)-infected women, including 27 untreated, 62 treated with reverse transcriptase inhibitors, and 74 treated with HAART. A high prevalence of both infections with HR-HPV types (68%) and squamous intraepithelial lesions (SILs; low grade, 20.2%; high grade, 6.2%) was observed. The risks of infection and disease were inversely correlated with CD4 cell counts (P=.015 and P=.022, respectively). During the observation period (mean, 15.4 months; range, 6-24 months), CD4 cell counts increased significantly only in subjects receiving HAART (P<.001). Persistence of HR-HPV infection and progression of SILs were comparable in the 3 groups. These results indicate that, even in the era of HAART, HIV-infected women should be monitored carefully for the emergence of high-grade SILs and cervical cancer.

Human papillomavirus with co-existing vulvar vestibulitis syndrome and vestibular papillomatosis

OBJECTIVE

The role of HPV infection in cases of vulvar papillomatosis and vulvar vestibulitis syndrome is still unclear and data from the literature is controversial. In this study we intended to investigate the prevalence of viral infection, with a multidisciplinary approach, in cases with a co-existence of the two patterns.

METHOD

Sixteen consecutive cases with diagnosis of vulvar vestibulitis syndrome and co-existence of vestibular papillomatosis were enrolled in the study and investigated by the means of vulvar cytology, vulvoscopy, histology, ViraPap and Polymerase Chain Reaction.

RESULT

Cytology, vulvoscopy and histology did not demonstrate suitable accuracy for the diagnosis. Viral DNA identification revealed two (12.50%) positive cases using PCR and one (6.25%) positive case with ViraPap.

CONCLUSION

The results of the present investigation indicate that even in cases of co-existing vulvar papillomatosis and severe vulvar vestibulitis syndrome, the prevalence of HPV infection is too low to be considered causal.

Evaluation of the detection of human papillomavirus genotypes in cervical specimens by hybrid capture as screening for precancerous lesions in HIV-positive women

Given the frequency and persistence of human papillomavirus (HPV) infection and associated cytological alterations in HIV-1-positive women, the incidence of uterine cervix neoplasm is likely to increase along with patient survival. More appropriate screening programs, which, in addition to Pap smears (PS), also include tests to detect and type HPV, are needed for the early identification of precancerous cervical lesions. This prospective study involved 168 HIV-positive (group A) and 100 HIV-negative women (group B). Cervicovaginal samples were collected for a PS and HPV DNA search. The detected virus was typed as high-intermediate oncogenic risk HPV (HR-HPV) and low-risk HPV (LR-HPV) using hybrid capture (HC) (Murex-Digene) and in-house PCR tests. The HC-detected prevalence of HPV was 111/168 (66%:HR 75.6%) in group A and 15/100 (15%:HR 42.9%) in group B (P < 0.0001). Polymerase chain reaction (PCR) was positive in 91% and 48%, respectively. No significant difference was observed between drug addicts and heterosexual HIV-1-positive women (P = 0.09). HPV was detected in 94% of the 57 HIV-positive women with cytological alterations. HR-HPV was found in 41/49 women with low-grade and 7/8 with high-grade squamous intraepithelial lesions (LSIL and HSIL, respectively). In women with a negative PS, HPV was detected in 57/111 cases (HR 63%) of group A and in 13/98 of group B (6 cases of HR). Of the 54 group A women who underwent biopsy, histology revealed that 41 had LSIL (18 with negative PS, 19 with LSIL, and 4 with HSIL; HR-HPV in 73% and LR-HPV in 17%), nine had HSIL (5 LSIL and 4 HSIL on cytology; HR-HPV in 89% and LR-HPV in 11%), and four were negative (all cytology negative; 3 HR-HPV and 1 LR-HPV). HR-HPV was more frequent as immunodepression worsened. These results show that cytological evaluation alone underestimated histological alterations in 23/50 women (42.6%), whereas the combination of Pap smear and HPV detection reduced this underestimate to 5%.

Prognostic factors in patients with with locally advanced cervical cancer treated with radical hysterectomy and adjuvant radiotherapy

The purpose of this study was to investigate the presence of risk factors for node metastases and to estimate survival in patients with cervical cancer, stages IB and IIA. In a retrospective study of 103 patients with cervical cancer stages IB and IIA, all treated with radical hysterectomy and adjuvant radiotherapy, we estimated survival curves according to different prognostic parameters. Mean follow-up time was 97 months. A significant difference between clinical pre-operative assessment and histological determination of real extent of the disease was evidenced. Pelvic lymph node metastases (P = 0.0005) significantly correlated with survival. This study shows that only lymph node involvement is an independent prognostic factor. Stage acts through nodal status in its impact on survival. A surgical-pathological staging in early stage cervical cancers is found to be more appropriate to correctly estimate patients' survival and prognosis.

Topical oxatomide: an alternative approach for the treatment of vulvar lichen sclerosus

OBJECTIVE

The treatment of vulvar lichen sclerosus has greatly improved in recent years, with the introduction of new pharmacological approaches and reconsideration of the traditional ones. Oxatomide is a molecule with both antihistamine and inhibiting activities for the inflammatory response, which may have potential use against this disease.

METHODS

We enrolled 22 patients affected by vulvar lichen sclerosus in a double-blind, cross-over, controlled trial. They were administered a 5% oxatomide-based gel formulation and a placebo (petrolatum ointment) topically. At the beginning and the end of the investigation the severity and duration of symptoms, clinical appearance and tolerability were recorded. Statistical analysis of data was performed by Fisher's exact test and the Student-Newman-Keuls test.

RESULTS

The results indicate that both regimens are significantly correlated with vulvar pruritus improvement and that 5% oxatomide gel has better anti-itching effects compared to the placebo. Other symptoms responded poorly to the treatment. The rate of complete-partial regression of pruritus was significantly higher (P < 0.05) in the oxatomide group than in controls, while no significant improvement was obtained neither with oxatomide or with placebo in terms of clinical appearance.

CONCLUSIONS

These results, adequately confirmed, could suggest the introduction of oxatomide, in selected patients, as an alternative for the treatment of vulvar lichen sclerosus.

Vascular endothelial growth factor. Expression in human vulvar neoplastic and nonneoplastic tissues

OBJECTIVE

To investigate the expression of vascular endothelial growth factor (VEGF) in human vulvar neoplastic and nonneoplastic tissues.

STUDY DESIGN

Specimens were collected at the Vulvovaginal Clinic, Department of Obstetrics and Gynecology, University of Milan. Human vulvar neoplastic and nonneoplastic tissues were dissected and frozen immediately at -80 degrees C until RNA extraction. Five micrograms of total RNA from each sample was denatured and transferred to nitrocellulose and nylon membranes for dot blot hybridization with labeled [alpha-32P]dCTP cDNA probe for VEGF.

RESULTS

Messenger RNA encoding VEGF was detected in all tissues studied. VEGF mRNA was highly expressed in vulvar epithelial neoplasia (VIN) associated with human papillomavirus infection and minimally expressed in invasive squamous cells carcinoma of the vulva. Nonneoplastic lesions, such as chronic inflammation, lichen sclerosus, lichen planus, squamous hyperplasia and squamous papilloma, were also assessed, and none had a significant difference in VEGF mRNA expression.

CONCLUSION

The prominence of VEGF mRNA levels in particular cases of VIN demonstrated that VEGF may be involved in promoting a new vascular network as a basic condition for the progression or at least self-maintenance of those lesions.

Surgical staging of invasive squamous cell carcinoma of the vulva. Analysis of treatment and survival

The records of patients treated for vulvar carcinoma at the University of Milan from January 1967 through December 1991 have been studied retrospectively, making an analysis of the results of surgical staging in terms of prognosis, morbidity and long-term survival. All cases have been reevaluated and restaged according to the 1988 FIGO classification of vulvar cancer, considering 196 cases of primary invasive vulvar squamous carcinoma. Surgical treatments have been divided according to radicality. Ninety-five per cent of patients underwent radical vulvectomy with different degrees of lymphadenectomy. Surgical mortality rate amounted to 2%. Surgical staging has not been related to increased early or late morbidity. Overall recurrence rate amounted to 19.9% without significant differences among FIGO stages. Five-year survivals amounted to 100%, 86.2%, 59.4%, 29.8%, and 20% for stages I, II, III, IVA and IVB respectively. Accurate surgical staging of vulvar carcinoma enables a precise prognosis and does not increase morbidity.

Topical testosterone in the treatment of vulvar lichen sclerosus

OBJECTIVES

Comparison between 2% testosterone propionate and petrolatum ointment in the treatment of vulvar lichen sclerosus in a randomized, double-blind, controlled clinical study.

METHODS

Fifty-eight consecutive patients with histologically confirmed vulvar lichen sclerosus were enrolled. They underwent a 1-year period of topical treatment with either medication, with clinical evaluations of symptoms and gross appearance at 2-month intervals, followed by histological evaluation at the end of the treatment period. Statistical analysis was performed according to the chi-squared test and the Student-Newman-Keuls test.

RESULTS

A substantial improvement in symptoms was achieved in 20 (66.6%) patients in the testosterone group and in 21 (75%) patients in the placebo group. No statistical differences were observed between the two groups. Gross changes were observed in a few cases and no case demonstrated histologic modifications.

CONCLUSIONS

Petrolatum ointment is as effective as 2% testosterone in the treatment of vulvar lichen sclerosus.

Determinants of invasive vulvar cancer risk: an Italian case-control study

Risk factors for vulvar cancer have been evaluated in a case-control study conducted between 1987 and 1990 in northern Italy on 73 women with histologically confirmed invasive vulvar cancer and 572 control subjects in hospital for acute nongynecological, nonneoplastic non-hormone-related conditions. The risk of vulvar cancer was inversely related to education level: with reference to women reporting less than 7 years of schooling, the relative risk estimates were 0.6 and 0.4, respectively, in those reporting 7 to 11 and 12 or more years of schooling (chi 2(1) trend = 4.91 P = 0.03). No relationship emerged between number of births and spontaneous or induced abortions. Parous women reporting late first birth tended to be at lower risk (relative risk = 0.5, 95% confidence interval 0.3 to 1.1 for < 25 vs > or = 25 years at first birth), but there was no evidence of the risk to decrease with increasing age at first birth. The risk of vulvar cancer increased with body mass index, but the trend in risk was not significant after taking into account potential confounders in the multivariate analysis. No association emerged with indicators of sexual habits, menstrual history, and smoking. The risk of the disease was lower in women reporting Pap smears during their life and diminished with increasing number of cervical smears and decreasing recency of last Pap: compared to women reporting no Pap screening, it was 0.5 in those who reported one smear and 0.3 in those with two or more.