A quadrivalent vaccine for human papillomavirus

Cervical cancer is responsible for at least 13,500 deaths a year in the European Union and more than 30 times that worldwide. DNA from a group of human papillomaviruses (HPVs) is found in virtually all cervical carcinoma cells, and these so-called high-risk HPV types are acknowledged to be a necessary cause of this disease. Vaccines that target these HPV types have the potential to dramatically reduce the incidence of cervical carcinoma. Low-risk HPV types cause genital warts, a common sexually transmitted disease, and vaccines that target these HPV types and the high-risk HPV types, are therefore particularly attractive. This review will focus on the potential of a new HPV vaccine that appears to offer protection against the most prevalent high- and low-risk HPV types and their associated diseases.

Nursing care and treatment of the patient with human papillomavirus

Human papillomavirus is a common and highly contagious virus that causes genital warts, which are not only unsightly, but the treatment may also be complex and the results of such treatment variable. For the patient this may result in physical and psychological trauma. Over 100 genotypes of the virus have been identified and a number of these can result in benign tumours of the skin and mucosa. Others however, are associated with intraepithelial neoplaisa of the vulva, cervix, penis and anus and squamous cell carcinoma. The nurse can provide the patient with the physical and psychological support the patient needs only if he/she has insight and understanding regarding the infection, its natural history, the diagnosis and subsequent management. Care should be provided in a non-judgmental manner, with respect and empathy.

New developments in the management of STDs

To assist clinicians in preventing and treating STDs, the CDC recently published new guidelines that not only emphasize treatment, but also prevention strategies and diagnostic recommendations.

An armamentarium of wart treatments

Patients and clinicians experience the frustration of cutaneous viral warts caused by infection with the human papilloma virus (HPV).Warts appear in various forms on different sites of the body and include common warts (verruca vulgaris), plane or flat warts, myrmecia, plantar warts, coalesced mosaic warts, filiform warts, periungual warts, anogenital warts (venereal or condyloma acuminata), oral warts and respiratory papillomas. Cervical infection with HPV is now known to cause cervical cancer if untreated. A review of the medical literature reveals a huge armamentarium of wart monotherapies and combination therapies. Official evidence-based guidelines exist for the treatment of warts, but very few of the reported treatments have been tested by rigorous blinded, randomized controlled trials.Therefore, official recommendations do not often include treatments with reportedly high success rates, but they should not be ignored when considering treatment options. It is the purpose of this review to provide a comprehensive overview of the wart treatment literature to expand awareness of the options available to practitioners faced with patients presenting with problematic warts.

Prevalence of perianal intraepithelial neoplasia in HIV-infected patients referred for high-resolution anoscopy

PURPOSE

This study was designed to describe perianal disease in a cohort of HIV-infected patients referred for high-resolution anoscopy.

METHODS

A retrospective chart review was performed on 52 HIV-infected patients referred for high-resolution anoscopy from 2001 to 2005. All patients underwent anal canal and perianal high-resolution anoscopy in the office with biopsy of suspicious areas. Patients with high-grade intraepithelial perianal lesions underwent multiple biopsies under general anesthesia in the operating room to rule out malignancy.

RESULTS

Of the 52 patients, 19 (37 percent) had perianal abnormalities noted on high-resolution anoscopy and underwent punch biopsy. The mean duration of known HIV infection in these 19 patients (15 males) was 10.6 years, with 17 on highly active antiretroviral therapy for the last 3-month period. Mean CD4 count was 371 cells/microl. Office perianal biopsies diagnosed two patients with invasive squamous-cell carcinoma and nine with high-grade squamous intraepithelial lesion. Seven of the nine patients with perianal high-grade squamous intraepithelial lesion on office biopsy were submitted to multiple biopsies under general anesthesia. One of these seven had an occult perianal squamous-cell carcinoma.

CONCLUSIONS

Perianal disease was common in this group of HIV-infected patients; 11 patients (21 percent of total) were diagnosed with squamous-cell carcinoma or high-grade squamous intraepithelial lesion. Because only 19 patients had clinically suspicious perianal lesions biopsied, this may be an underestimate. Our data suggest that anal canal neoplasia often is accompanied by perianal disease and illustrates the need for biopsy of any suspicious perianal lesions.

Chapter 4: Burden and management of non-cancerous HPV-related conditions: HPV-6/11 disease

Human Papillomavirus (HPV)-6 and -11 are the causative agents of ano-genital warts (GWs) and recurrent respiratory papillomatosis (RRP). They are low-risk HPV types that are uncommonly found in malignant lesions. GWs are an extremely prevalent sexually transmitted disease, whereas RRP is a rare disease that can be life threatening and requires multiple surgical procedures. GWs and RRP cause substantial healthcare costs. A quadrivalent HPV-6/11/16/18 vaccine (Merck/SPMSD) has shown essentially 100% protection against GWs in women in early studies. Cost-effectiveness analyses are needed to assess the benefits of the HPV-6/11 virus-like particle (VLP) components of the quadrivalent vaccine in population-based vaccination programmes.

Genital warts in children: what do they mean?

Human papillomaviruses (HPVs) are a diverse family of viruses, of which 30-40 genotypes specifically infect the genital tract. Genital HPVs are largely transmitted sexually, with most infections being asymptomatic and transient. In contrast, persistent infection with oncogenic genotypes in a minority is a strong risk factor, for subsequent development of high grade dysplasia, the precursor lesion to cervical neoplasia, which generally occurs after a long latency period. It is unknown whether there is a disease correlate in children chronically infected with oncogenic HPVs. Low risk HPV genotypes 6 and 11 are the primary cause of condylomata acuminata, although in children non-genital genotypes are also found in a proportion, with the mode of transmission being either perinatal, horizontal, or sexual. The finding of asymptomatic HPV DNA in children, and correlation with live virus, infectivity, or disease is unclear. Long term follow up for children with anogenital warts is recommended, although there are no longitudinal studies available to clarify whether they are at risk of developing carcinoma in young adulthood.

Recombined DNA vaccines encoding calreticulin linked to HPV6bE7 enhance immune response and inhibit angiogenic activity in B16 melanoma mouse model expressing HPV 6bE7 antigen

Calreticulin (CRT) has been reported to have an effect of upregulating MHC class I presentation as well as inhibiting angiogenesis in vitro and in vivo. Combination of dual mechanisms of enhanced immunogenicity of human papillomavirus (HPV) 6bE7 antigen and antiangiogenesis may be introduced in the strategy of vaccines against condyloma acuminatum (CA) resulting from HPV infection. Therefore, we constructed DNA vaccines by employing different lengths of CRT chimerically linked to a model antigen HPV6bE7 and investigated the immunological and antiangiogenic effects of these vaccines in a B16 melanoma model that express HPV6bE7 antigen. Our results showed that vaccination with CRT180/HPV6bE7 or CRT120/HPV6bE7 enhanced the presence of CD8(+) T cells and TCRgammadelta T cells in vivo, increased the specific lysis activity against E7-expressing cells and secretion levels of IL-2 and IFN-gamma by activating T cells in vitro significantly. Moreover, recombined CRT180 or CRT120 with HPV6bE7 vaccines could elicit a more efficient E7-specific immune response than HPV6bE7 alone. The similarity of immunological enhancement of CRT180/HPV6bE7 and CRT120/HPV6bE7 implies that the immunologically active region mainly exist in fragment 1-120 aa. Furthermore, CRT180/HPV6bE7 and CRT180 displayed remarkable superiority over CRT120/HPV6bE7 in vivo angiogenesis assay, suggesting that the antiangiogenic activity of CRT resides in a domain between aa 120 and 180. Vaccination with CRT180/HPV6bE7 generated the best protective effect of delaying tumor formation and reduction of tumor size in tumor growth inhibition experiment among all DNA constructs. Therefore, CRT180/HPV6bE7 vaccine may enhance the immunological response to HPV6bE7 and inhibit angiogenesis. This construct may be useful in preventing HPV-associated dermatosis and may be developed as a promising strategy to control CA.

Human Papillomaviruses and Genital Disease

Human papillomavirus (HPV) infection is causally related to several benign and malignant diseases of the anogenital tract. In this article the authors detail the epidemiology, methods of transmission and risk factors, pathogenesis, and oncogenesis of HPV, and describe clinical manifestations and current treatments. Special attention is given to condyloma acuminatum and non-cervical anogenital intraepithelial neoplasia. The authors conclude with the latest information on prophylactic vaccine development and prospects for future control of HPV-related disease.

Genital warts: current and future management options

Genital warts are a cosmetic nuisance. They are caused by low-risk human papillomavirus types, have no oncogenic potential and are not linked to cervical cancer. However, they often cause significant psychological morbidity. Treatments are aimed at eradicating the unsightly lesions and stimulating the immune system to generate clearance and prevent recurrence. Commonly used physical treatment methods include cryotherapy, trichloroacetic acid, laser, and electrocautery. However, many patients respond extremely well to home therapies with either podophyllotoxin or imiquimod. Patients prefer the comfort and dignity of home treatment, and this should be the first-line of treatment for the majority of patients. A routine screen for sexually transmitted infections is appropriate in most cases. Detailed explanation and reassurance are of paramount importance in reducing the psychological distress associated with this unpleasant genital condition.

Cervical cancer and low-risk HPV; a case report

A case of cervical cancer in a 32-year-old woman with a genotype 6 HPV genital infection that developed from a cervical low-grade SIL after a LLETZ procedure two years before is presented. This case obliges us to reconsider both the benign nature of low-grade lesions and the potentially good prognosis of low-risk HPV infection.

Randomized Controlled Trial of an Adjuvanted Human Papillomavirus (HPV) Type 6 L2E7 Vaccine: Infection of External Anogenital Warts with Multiple HPV Types and Failure of Therapeutic Vaccination

BACKGROUND

Cellular immunity is involved in spontaneous clearance of anogenital warts caused, most typically, by human papillomavirus (HPV) type 6 or 11, supporting the concept of therapeutic vaccination. A therapeutic vaccine composed of HPV-6 L2E7 fusion protein and AS02A adjuvant was evaluated in conjunction with conventional therapies in subjects with anogenital warts.

METHODS

A total of 457 subjects with anogenital warts were screened, of which 320 with HPV-6 and/or HPV-11 infection were enrolled into 2 double-blind, placebo-controlled substudies. Three doses of vaccine or placebo were administered along with either ablative therapy or podophyllotoxin.

RESULTS

Although a positive trend toward clearance was seen in patients infected with only HPV-6, in neither substudy did the vaccine significantly increase the efficacy of conventional therapies, despite induction of adequate immune responses. Extensive HPV typing by polymerase chain reaction demonstrated that a majority of screened subjects (73.7%) were infected with HPV-6 and/or HPV-11 and that a large proportion (40.1%) were infected with multiple HPV types. HPV types that put subjects at high risk of development of cervical cancer were detected in 39.8% of subjects.

CONCLUSIONS

Infection with multiple HPV types, including high-risk types, is common in anogenital wart disease. Therapeutic vaccination failed to increase the efficacy of conventional therapies.

Squamous cell carcinoma arising in a giant condyloma acuminatum (Buschke-Lowenstein tumour)

Giant condyloma acuminatum (GCA) is a tumour that primarily affects the genital and perianal areas. Despite the histologically benign appearance, it behaves in a malignant fashion, destroying adjacent tissues, and is regarded as an entity intermediate between an ordinary condyloma acuminatum and squamous cell carcinoma. Primary anorectal lesions account for only a small number of GCA cases and, as with squamous cell carcinoma, the human papilloma virus is the causative agent. The hallmark of GCA is the high rate of local recurrence and transformation into squamous cell carcinoma. We describe a case of GCA complicated by malignant transformation, where locoregional control was achieved with combined chemoradiotherapy.

A study of abnormal cervical cytology in pregnant women

During the 4-year routing study of smears in 2,919 pregnant women, 33 cases of abnormalities of the uterine cervix were detected (1.13%). The patients were followed with uterine cervical cytology and colposcopy, and in case of need, sometimes punch biopsies were performed. As a result of the cytologies, 33 cases with abnormalities were detected. There were 26 cases classified as class IIIa and 7 cases were class IIIb. All cases underwent colposcopy. For the 17 cases that showed lesions by colposcopy, punch biopsies were performed. The results of histologic examination were wide: 5 chronic cervicitis, 1 condyloma, 1 mild dysplasia, 3 moderate dysplasia, 3 severe dysplasia, 3 carcinoma in situ, and 1 microinvasive carcinoma. Only two cases were treated during pregnancy, condyloma underwent Laser vaporization and microinvasive carcinoma underwent Loop electrosurgical excision procedure (LEEP) conization. Other cases were conservative treatment during pregnancy. Excluding one case for persistence smear class IIIa of histology condyloma, all the other cases with regression of dysplasia and carcinoma in situ with treatment after delivery. We conclude that lesions up to carcinoma in situ do not require intervention during pregnancy but microinvasive carcinoma is suspected, diagnostic LEEP conization is necessary, even during pregnancy.

Therapy for genital human papillomavirus-related disease

Genital human papillomavirus (HPV) infection is very common, and often sub-clinical and usually resolves without any treatment. Genital warts are caused by HPV 6/11 infection and are one of the commonest clinically recognised disease manifestations of genital HPV. Subjects with genital warts usually perceive them as cosmetically disfiguring, often leading to adverse psychological symptoms, and most subjects with genital warts will present requesting treatment. A wide variety of treatments are available including both provider- and patient-applied therapies. Various individual subject and disease factors mediate appropriate therapy choice. Some of the treatments that are used for genital warts can also be used for some cases of intraepithelial neoplasia caused by high-oncogenic risk HPVs occurring at vulval, anal or penile sites. Specific treatment considerations apply to genital warts in pregnancy and laryngeal papillomatosis and these are also discussed.

Primary care of patients with sexually transmitted diseases or genitourinary symptoms in Hong Kong

OBJECTIVES

To determine the adequacy of care received from general practitioners by patients with sexually transmitted diseases or genitourinary symptoms.

DESIGN

Prospective study.

SETTING

Hong Kong.

PARTICIPANTS

Diagnoses and drug data obtained from logbooks submitted by doctors studying for the Diploma in Family Medicine and candidates for Fellowship examinations between 1999 and 2002.

MAIN OUTCOME MEASURES

Diagnosis or symptom of a sexually transmitted disease and prescribed treatment.

RESULTS

Sexually transmitted diseases and genitourinary symptoms accounted for 1.1% of the workload of these community doctors in Hong Kong. The majority of patients were young adult males. The overall standard of treatment was inadequate: both multi-pharmacy and inappropriate treatment was common; in up to 30% of cases, doctors ignored local or international guidelines.

CONCLUSION

Primary care doctors play an important role in the diagnosis and management of sexually transmitted diseases or genitourinary symptoms in Hong Kong. A high index of suspicion should be maintained and continuing education made available if doctors are to provide an equally high standard of care.

[The relation of local immune status to efficacy of immunotherapy in patients with condyloma acuminatum]

OBJECTIVE

To study the local immune status and its relation to immunotherapy in patients with condyloma acuminatum.

METHODS

Clinical efficacy of 5% imiquimod cream in treating 30 patients with condyloma acuminatum was observed. The expressions of Human Leukocyte Antigen (HLA)-DR, CD1a, CD16 and Intercellular Adhesion Molecule (ICAM)-1 were detected by immunohistochemistry in lesions of these patients before treatment.

RESULTS

The imiquimod cream was found to be efficacious in 20 cases after 8 weeks' treatment. Before treatment, the expressions of HLA-DR, CD1a, CD16 and ICAM-1 in the lesions of responders were significantly higher than those in the lesions of nonresponders (P<0.05).

CONCLUSION

Higher expressions of HLA-DR, CD1a, CD16 and ICAM-1 suggested that immunotherapy might have efficacy in treating condyloma acuminatum.