Human papillomavirus DNA after treatment of cervical dysplasia: low prevalence in normal cytologic smears

Patterns of persistent HPV infection after treatment for cervical intraepithelial neoplasia (CIN): A systematic review

A systematic review of the literature was conducted to determine the estimates of and definitions for human papillomavirus (HPV) persistence in women following treatment of cervical intra-epithelial neoplasia (CIN). A total of 45 studies presented data on post-treatment HPV persistence among 6,106 women. Most studies assessed HPV persistence after loop excision (42%), followed by conization (7%), cryotherapy (11%), laser treatment (4%), interferon-alpha, therapeutic vaccination, and photodynamic therapy (2% each) and mixed treatment (38%). Baseline HPV testing was conducted before or at treatment for most studies (96%). Follow-up HPV testing ranged from 1.5 to 80 months after baseline. Median HPV persistence tended to decrease with increasing follow-up time, declining from 27% at 3 months after treatment to 21% at 6 months, 15% at 12 months, and 10% at 24 months. Post-treatment HPV persistence estimates varied widely and were influenced by patient age, HPV-type, detection method, treatment method, and minimum HPV post-treatment testing interval. Loop excision and conization appeared to outperform cryotherapy procedures in terms of their ability to clear HPV infection. This systematic review provides evidence for the substantial heterogeneity in post-treatment HPV DNA testing practices and persistence estimates.

The predictive value of human papillomavirus testing for the outcome of patients conservatively treated for stage IA squamous cell cervical carcinoma

BACKGROUND

Although it is hypothesised that human papillomavirus (HPV) testing may have a role in surveillance of patients conservatively treated for stage IA squamous cell cervical carcinoma, research on this topic has been minimal.

OBJECTIVES

To determine: (1) the changes in HPV test result from treatment onward; (2) the time to viral clearance; and (3) the negative predictive value (NPV) and positive predictive value (PPV) of HPV test result for the detection of CIN2 or worse (CIN2+) during follow-up.

STUDY DESIGN

In a multicentre retrospective follow-up study of a consecutive series (1997-2009) of 91 patients, longitudinal outcome measures were estimated as cumulative probabilities using the Kaplan-Meier method.

RESULTS

For patients testing HPV-positive at the first follow-up visit (n=44), the probability of change to negative rose from 0 to 0.78 between 7 and 21 months after treatment. For HPV-negative patients (n=47), the probability of change to positive rose to 0.13 between 9 and 26 months. After a median follow-up of 50 months (range, 2-80), the NPV for CIN2+ was 1.00. The PPV was 0.60 (95% confidence interval, 0.43-0.77) after 26 months. The median time to detection was 5 months.

CONCLUSIONS

If adequately confirmed, these findings would indicate that HPV testing is capable to identify the patients who have had their lesions fully removed, and would make it possible to focus follow-up efforts on a subset of patients at high risk of residual or progressive disease.

Comparison of two surgical methods for the treatment of CIN: classical LLETZ (large-loop excision of the transformation zone) versus isolated resection of the colposcopic apparent lesion - study protocol for a randomized controlled trial

Background

In compliance with national and international guidelines, non-pregnant women with cervical intraepithelial neoplasia grade 3 should be treated by cervical conization. According to the definition of the large loop excision of the transformation zone (LLETZ) operation, the lesion needs to be resected, including the transformation zone. It is well known from the literature that the cone size directly correlates with the risk of preterm delivery in the course of a future pregnancy. Thus, it would be highly desirable to keep the cone dimension as small as possible while maintaining the same level of oncological safety.

Methods/Design

The aim of this study is to analyze whether resection of the lesion only, without additional excision of the transformation zone, is equally as effective as the classical LLETZ operation regarding oncological outcome. We are performing this prospective, patient-blinded multicenter trial by randomly assigning women who need to undergo a LLETZ operation for cervical intraepithelial neoplasia grade 3 to either of the following two groups at a ratio of 1:1: (1) additional resection of the transformation zone or (2) resection of the lesion only. To evaluate equal oncological outcome, we are performing human papillomavirus (HPV) tests 6 and 12 months postoperatively. The study is designed to consider the lesion-only operation as oncologically not inferior if the rate of HPV high-risk test results is not higher than 5 % compared with the HPV high-risk rate of women undergoing the classical LLETZ operation.

Discussion

In case that non-inferiority of the “lesion-only” method can be demonstrated, this operation should eventually become standard treatment for all women at childbearing age due to the reduction in risk of preterm delivery.

Trial registration

German Clinical Trials Register (DRKS) Identifier: DRKS00006169. Date of registration: 30 July 2014.

Low frequency of human papillomavirus DNA in breast cancer tissue

Human papillomavirus (HPV) is considered the aetiological agent for cervical cancer. Several reports have addressed a relationship with HPV and breast cancer, as different HPVs have been identified. The purpose of this study was to detect HPV DNA in 67 breast cancer patients and 40 non-malignant disease breast tissues by means of Polymerase Chain Reaction with consensus primers. The frequency of HPV in the cases group were 4.4% (3/67) and no positive samples among the reference group were identified. From the 3 positive samples, HPV types 16, 18 and 33 were identified by restriction patterns and direct sequencing. The high diversity among detection in the related studies shows that population genomic heterogeneity plays an important role in the disease. The low frequency detected in the present study suggests that HPV does not play an important role in breast cancer.

Persistence of human papillomavirus as a predictor for treatment failure after loop electrosurgical excision procedure

We aimed to investigate whether postconization human papillomavirus (HPV) DNA testing can predict treatment failure and improve the accuracy of conventional follow-up in women with high-grade cervical intraepithelial neoplasia (CIN). Between March 2001 and October 2005, 120 patients with confirmed CIN 2 or 3 were treated with loop electrosurgical excision procedure (LEEP) and were enrolled. Six patients were lost to the follow-up. Postconization follow-up was performed at every 3–6 months during the first year and then annually. Specimens were tested for the presence of HPV, using the Hybrid Capture 2 (Digene Co, Gaithersburg, MD) and HPV DNA chip (Mygene Co, Seoul, Korea) test. Persistent HPV infection was defined as persistently (two times or more) positive HPV tests with the same HPV subtype(s) at initial diagnosis. Twenty-two (19.3%) patients showed treatment failure after conization. The only significant risk factor for redevelopment of CIN after conization was persistence of the same HPV subtype (P< 0.0001). And women with recurrent or residual CIN had higher HPV load during the 6-month follow-up postconization. In conclusion, the persistence of the same HPV subtype after LEEP conization was an important predictor of treatment failure. The follow-up protocol after conization of CIN should include both cervical cytology and HPV test, and HPV DNA chip test is needed to detect a persistent HPV infection.

Cervical HPV DNA detection as a predictor of a recurrent SIL diagnosis among untreated women

OBJECTIVES

This study was conducted to test whether patient history of untreated cervical intraepithelial neoplasia (CIN) 1 or low-grade squamous intraepithelial lesions (LGSIL) modifies the interpretation of a positive HPV DNA result with regards to subsequent squamous intraepithelial lesions (SIL).

METHODS

Seventy-three women with recurrent SIL were compared to 105 controls who remain cytologically normal during follow up. Cervical samples collected at enrollment were assayed for HPV DNA in the subject and control groups.

RESULTS

Women with and without a history of LGSIL who tested positive for HPV DNA were at a similarly increased risk of having (recurrent) LGSIL as compared to controls. However, in women with a history of LGSIL, HPV DNA appeared to be less predictive for high-grade squamous intraepithelial lesions (HGSIL) than in women without a history of disease.

CONCLUSIONS

Past history of untreated CIN1 or LGSIL does not modify the predictive value of a positive HPV DNA test for subsequent LGSIL. The observed difference of the predictive value of a positive HPV DNA test for the risk of recurrent HSIL compared to incident HSIL should be pursued.

The impact of high risk human papillomavirus testing in an inner London colposcopy clinic

This is an audit of a new technique to improve the colposcopy service. Samples were tested for high risk HPV DNA using Digene Hybrid Capture II. Sixty-four percent of the sampled women under 30 had detectable high risk HPV DNA, decreasing to 44% in 30--39 year olds and to 27% in women over 40. High risk HPV prevalence increased with severity of cytology, although 22% with normal colposcopy had detectable high risk HPV. Of those women treated for cervical dysplasia, 83% had detectable high risk HPV prior to treatment, compared to only 32% afterwards. The audit has shown that high risk HPV testing has considerable discriminatory value. It has been integrated successfully into the service, particularly to manage low grade cervical abnormalities and to add valuable information following treatment for cervical dysplasia. Results need to be interpreted alongside colposcopy, cytology, and histology, and care must be taken in the interpretation of a single high risk HPV result.

[Human papillomavirus testing in cervical cancer screening]

Virtually all cases of cervical cancer are caused by one of the 18 oncogenic types of human papillomavirus (HPV). It is estimated that 80% of all women will be infected by HPV in a lifetime, and the prevalence of HPV is highest among young, sexually active women and declines with increasing age. The risk of developing high-grade squamous intraepithelial lesions depends on the actual HPV type,the duration of infection, and the viral load. Due to the high prevalence of HPV infection, HPV testing in young women is of little value. The high negative predictive value of this test, combined with nor-mal Papanicolaou smear results, almost ensures that the patient is or will be free of a cancer precursor at the time of testing or in the immediate future. Hence, HPV testing combined with cytology is a reasonable approach in elderly women in order to increase the screening interval to 3-5 years. HPV testing is established for triage of borderline cytology findings of atypical squamous cells of undetermined significance if colposcopy is not performed immediately and if HPV-negative women are rescheduled within 12 months. HPV testing 6 months after cone biopsy allows increasing the follow-up interval due to its high negative predictive value. In atypical glandular lesions not otherwise specified, HPV testing may identify patients requiring immediate treatment. In immunocompromised patients with borderline cytology due to persistent HPV infection, HPV test-ing identifies patients with a low risk of cancer precursors not requiring treatment.

Usefulness of human papillomavirus testing in the follow-up of patients with high-grade cervical intraepithelial neoplasia after conization

OBJECTIVE

We aimed to define the adjunctive role of human papillomavirus (HPV) DNA testing in the follow-up of high-grade cervical intraepithelial neoplasia (CIN) after conization.

STUDY DESIGN

We analyzed a consecutive series of 2,154 patients who received conization. Patients who had cone diagnosis of cervical cancer or CIN 1, a hysterectomy within 12 weeks after conization, and no follow-up data were excluded. The remaining 765 patients (monitored by Pap smears, colposcopy with or without high-risk HPV DNA testing) were analyzed.

RESULTS

Of the 765 patients, 279 had CIN at cone margin or endocervix (group A) while 486 were both margin- and endocervix-free (group B). The 3-year cumulative rate of residual/recurrent high-grade CIN was 10.3% (95% CI, 6.9-13.7). HPV follow-up status (P=.015), margin status (P=.001), and follow-up cervical cytology (P<.0001) were significant predictors for residual/recurrent high-grade CIN by multivariate analysis. Four high-grade CINs and 1 microinvasive carcinoma of group A were detected initially by HPV testing, while 48.3% (199/410) of those without recurrent/persistent high-grade CIN still had persistent HPV infection.

CONCLUSION

HPV DNA testing is useful in the follow-up and understanding of the natural history after conization for high-grade CIN.

Value of human papillomavirus testing after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesions

OBJECTIVE

The aim of the study was to evaluate human papillomavirus (HPV) testing during the follow-up of patients after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesion.

METHODS

A prospective study was conducted on 205 patients who underwent conization for high-grade squamous intraepithelial lesion (CIN 2 or 3). Loop electrosurgical excision procedure (LEEP) was used in all cases. High-risk HPV testing was realized by the Hybrid Capture II system before and 3 months after conization.

RESULTS

Of the 205 patients, 193 (94.1%) were positive for the HPV test before conization. Seventy-one were HPV positive after conization (34.6%). The margins were positive in 36.1%. Residual disease was observed in 27 cases (13.2%). Four patients (2%) developed a recurrence after a mean follow-up of 18.1 months (+/-12). There was no correlation between pretreatment HPV testing and the residual disease or recurrence. Patients with positive margins were significantly more likely to have residual disease than those with negative margins (P < 0.0001). Residual disease was more likely to occur when the posttreatment HPV test was positive (P < 10(-7)). All recurrences were observed in patients with a positive posttreatment HPV test (P < 0.05). Residual disease and recurrence were correctly predicted with a sensitivity of 81 and 100%, respectively, and a negative predictive value of 96 and 100%.

CONCLUSION

Posttreatment HPV testing could be useful in the follow-up of patients after conization. In case of negative posttreatment HPV testing, the frequency of follow-up could be reduced, particularly in those patients with free margins.

Factors predicting human papillomavirus clearance in cervical intraepithelial neoplasia lesions treated by conization

OBJECTIVE

The objective was to identify the factors, if any, that may predict long-term results of CIN treatment and HPV clearance/persistence after locally excisional therapy.

METHODS

A series of 252 women with CIN lesions treated by conization were subjected to sequential HPV detection by repeated PCR during the prospective posttreatment follow-up. Factors predicting viral clearance during the follow-up (10.26 months) were elaborated using univariate and multivariate statistical techniques applied on epidemiological, clinical and biological data of the lesions.

RESULTS

Sensitivity of the PAP test in detecting high-grade lesions was 93.9%, and specificity 27.3%. Odds ratio for having CIN 3/Stage IA1 squamous cervical cancer in the cone with HSIL PAP test was 5.69; 77.8 and 22.2% residual disease were found among PCR-positive and -negative cases, respectively. HPV DNA was negative in 74/252 (29.8%) samples at the first PCR. Multivariate logistic regression analysis showed that HPV 16 was an independent explanatory factor for high-grade CIN (P = 0.0001). HPV clearance increased to 63.5% at completion of the follow-up, corresponding to the monthly clearance rate of 5.27%. In Kaplan-Meier analysis, the highly significant (P = 0.0001) predictors of HPV clearance/persistence were age, lesion grade in the biopsy, lesion grade in the cone, volume of the cone, length of active sexual life, and involvement of endocervical margin (P = 0.0013). In chi-square tests, high-risk HPV type (P = 0.001) was such a predictor. In multivariate (Cox) model, the significant independent predictors of HPV clearance were involved endocervical margin (P = 0.001), lesion grade in the cone (P = 0.004), high-grade lesion in the colposcopic biopsy (P = 0.023), age (P = 0.029), and HSIL in PAP smear (P = 0.029).

CONCLUSIONS

These data suggest that posttreatment follow-up should include both the PAP test and HPV detection techniques for early detection of any patients at increased risk for disease recurrence and progression, because of persistent oncogenic HPV types.

Persistent infection with human papillomavirus following the successful treatment of high grade cervical intraepithelial neoplasia

In a need case-control study, we identified women who were successfully treated for CIN 3. Cases had biopsy proven recurrence, whilst controls remained disease free for at least five years. One hundred and seventy-two women were beta-globin positive at diagnostic and at six-month post-treatment smear (90 controls and 82 cases). Thirty-nine cases (47.6%) were HPV16/18 positive at biopsy or follow up smear and 14 (17.1%) of 82 were positive at both. Of the controls, 37 (41.1%) were HPV positive at biopsy or smear with (3.3%) positive at both. The unadjusted OR associated with being HPV positive at both points compared to being HPV negative at both was 8.0 (95% CI 2.13-30.37). The persistence of HPV 16/18 infection following the confirmed eradication of CIN is a highly significant risk factor for recurrence.

Is high-risk human papillomavirus infection associated with cervical intraepithelial neoplasia eliminated after conization by large-loop excision of the transformation zone?

OBJECTIVE

To investigate whether high-risk HPV infection associated with cervical intraepithelial neoplasia (CIN) was successfully eliminated after electrosurgical conization by large-loop excision of the transformation zone (LLETZ).

STUDY DESIGN

142 women, who were admitted for conization of CIN 1-3 were recruited into a prospective follow-up study of HPV infection, including cervical sampling for HPV DNA before, and then 3, 6 and 12 months after surgery. We examined whether there were any differences in the rate of HPV DNA positivity after LLETZ between specific risk groups, such as patients with primary (i.e. before surgical treatment) high-risk HPV infection, CIN of different grades, and positive margins.

RESULTS

We did not detect statistically significant differences between specific risk groups. According to the assay used (hybrid capture II) at the last follow-up visit 94% of primarily infected patients were completely free from infection with high-risk HPV types, while 6% had persisting HPV infection.

CONCLUSIONS

With a detection limit of 5000 genomes/ml HPV DNA the hybrid capture II results revealed, that after electrosurgical removal of CIN in 94% of patients testing positive for high-risk HPV DNA prior to surgery were negative 12 months post-surgery.

Human papillomavirus as a form of risk assessment

There is a huge amount of interest in the use of human papillomavirus testing to improve both the sensitivity and specificity of cervical screening. Although oncogenic human papillomavirus subtypes are recognized to be the most important factor in the development of cervical disease, only a minority of such infections results in invasive cancer. Given our current, albeit limited, knowledge of the natural history of human papillomavirus infection and the development of cervical intra-epithelial neoplasia, it may be possible to identify well-defined high-risk groups of women. Such groups may benefit from intensive surveillance, or indeed new developments in immunoprophylaxis, while allowing low-risk women less screening intervention. Known high-risk groups include those with chronic immunosuppression and previous treatment for high-grade cervical intra-epithelial neoplasia. Lowering the upper age limit for cervical screening is already under consideration because of the low incidence of both human papillomavirus infection and cervical intra-epithelial neoplasia in older women, and human papillomavirus testing could rationalize the screening programme.

Primary screening for human papillomavirus infection

As human papillomavirus infection is now known to be a necessary risk factor for at least 95% of cervical cancers, the medical community has a responsibility to assess and evaluate how this knowledge should best be used for the prevention of cervical cancer. Organized screening strategies combining cytological screening with human papillomavirus testing in older age groups could theoretically be more sensitive than current screening programmes in reducing the incidence of cervical cancer. If it is possible safely to extend the screening interval in human papillomavirus-negative women, such programmes could also both be more effective and more cost-efficient. Although some modelling studies have indicated that this could indeed be the case, evidence from clinical trials evaluating the long-term protective effect of primary human papillomavirus screening is still lacking. The key issues on the research agenda for primary human papillomavirus screening are reviewed.

Will New Human Papillomavirus Diagnostics Improve Cervical Cancer Control Efforts?

With the causal link between specific types of human papillomavirus (HPV) and cervical cancer firmly established, efforts have turned to assessing the relative merits of offering HPV testing in screening, triage, and posttreatment management. Many unanswered questions remain, but a growing body of evidence supports a role for HPV testing in cervical cancer prevention programs. Already, clinical centers that serve thousands of women in Europe and the United States have incorporated HPV DNA tests in triage algorithms.

Regular disappearance of the human papillomavirus genome after conization of cervical dysplasia by carbon dioxide laser

OBJECTIVE

We wished to evaluate the effectiveness of treatment of cervical dysplasia by laser conization in relation to persistence of human papillomavirus after treatment.

STUDY DESIGN

Of 203 women referred to colposcopy because of an abnormal Papanicolaou smear, 149 women could be followed up for 3 years. A total of 108 women were treated by carbon dioxide laser excision, 4 women were treated by carbon dioxide laser evaporation, and 37 women were merely followed up. Cervical samples were taken before treatment and at follow-up 3 years later and were analyzed by nested general primer polymerase chain reaction for human papillomavirus deoxyribonucleic acid.

RESULTS

Among women treated by laser conization, 82 (73.2%) had positive results for human papillomavirus deoxyribonucleic acid before treatment. Three women (2.7%) had a positive finding at follow-up, but no woman had the same human papillomavirus type on both occasions. Eighty-eight women had grade 1 to grade 3 cervical intraepithelial neoplasia before treatment, whereas during follow-up only 2 squamous cells atypias were found.

CONCLUSION

The human papillomavirus genome present before treatment was regularly cleared, and there was also no recurrence of dysplasia. The results suggest that human papillomavirus testing is useful for monitoring the efficacy of treatment and that treatment modalities resulting in clearance of human papillomavirus should be favored.

Persistence of human papillomavirus infection after therapeutic conization for CIN 3: is it an alarm for disease recurrence?

OBJECTIVE

The aims of this study were (1) to examine whether HPV DNA is persistently detected in the cervix after therapeutic conization for CIN 3 and (2) to explore whether a patient with persistence of HPV infection is at risk of developing recurrent disease.

METHODS

Of 74 patients referred with CIN 3, 58 who were tested for HPV DNA in the pretreatment cervical lesions were enrolled in the study. After standard therapeutic conization, patients were followed prospectively at the outpatient clinic. Our follow-up protocol was to follow patients without therapeutic intervention as long as they developed no recurrence or recurrence of CIN 1 or 2, while patients who experienced recurrence of CIN 3 were recommended for reconization or hysterectomy. The polymerase chain reaction for detecting HPV DNA was performed using fresh cell samples from the cervix.

RESULTS

In 56 of 58 patients (96.6%), HPV DNAs were detected in their primary cervical lesions prior to conization. With regard to the distribution of HPV types, HPV type 16 family (types 16, 31, and 35) was identified in 28 cases (50.0%), type 18 family (types 18, 33 and 58) in 15 (26.8%), and type X in 18 (32.1%). Up to August 1999, all of the 58 patients have been followed with a mean follow-up period of 31.8 months (range: 12 to 73 months). After treatment, HPV DNA was persistently detected in 11 (19.6%) but negative in 45 (80.4%) of 56 HPV DNA-positive patients. HPV DNA was not detected in both HPV DNA-negative patients. Five of 11 persistently HPV DNA-positive patients (45.5%) developed CIN recurrence, while none of 45 persistently HPV DNA-negative patients did. Thus, there was a significant difference between the recurrence rates of these two groups (P < 0.0001). Both patients who were initially HPV DNA-negative developed no recurrence. Accordingly, the overall recurrence following conservative treatment for CIN 3 was 5 of 58 patients (8.6%).

CONCLUSIONS

Patients with persistent HPV infection after conization for CIN 3 should be especially closely followed because they are at increased risk of developing disease recurrence.

Screening for cancer: future potential

Much progress has been made in cancer screening over the past decade, but a great deal more needs to be done if screening is to make a major impact on worldwide cancer mortality. Where fully implemented, cytological screening for cervical precursor lesions has had a major impact on mortality. However, the cost and required infrastructure levels are high, and new approaches are needed if screening is to be effective in the developing world. Testing for the human papillomavirus and automated liquid based cytology offer great promise to improve quality, reduce overall cost and make screening more viable generally. Breast screening has been less successful, although useful mortality benefits have been achieved in women aged over 50 years. Full implementation in countries that can afford it will save lives, but radical new approaches will be needed to conquer breast cancer. Colorectal cancer screening offers the best hope of a major reduction in cancer mortality over the next decade. Less certainty exists about screening for other major cancers such as lung, prostate and ovary, but a range of potential approaches merit investigation.

Short-term follow up of cervical squamous intraepithelial lesions associated with HIV and human papillomavirus infections in Africa

A prospective study in gynaecology clinics was conducted in Abidjan, Côte d'Ivoire, to assess the short-term evolution of squamous intraepithelial lesions (SILs). Of 94 women with a cytological diagnosis of SIL, 38 were infected with HIV. The average follow-up period after the initial smear was 5 months. Detection of human papillomavirus (HPV) by polymerase chain reaction (PCR) was performed at both the time of enrolment and final follow-up smear. There were 39 cases of persistent SILs. HIV-positive women had a higher percentage of persistent SIL (76%) than HIV-negative women (18%, relative risk (RR)=4.3, 95% confidence interval (CI)=2.4, 7.7). SILs were more frequent among women infected with HPV at the time of enrolment or with persistent HPV infection, but these associations disappeared after adjusting for HIV serostatus. Spontaneous regression of SILs commonly occurs in HIV-negative African women. HIV-infected women with cervical dyskaryosis require gynaecology follow-up.

Increased IL-6 and IL-8 levels in cervicovaginal secretions of patients with cervical cancer

OBJECTIVE

Conflicting data exist on IL-6 production by human papillomavirus (HPV) immortalized cell lines and several cervical carcinoma cell lines. However, no information has been reported on the levels of cytokines in cervicovaginal washings in relation to cervical neoplasia. The aim of this study was to investigate whether local production of IL-6 could be found and whether the level of this cytokine was related to the severity of cervical neoplasia. IL-8 was measured to obtain additional information on an inflammatory cytokine with possible epithelial origin.

METHODS

Cervicovaginal washings and sera were obtained from 35 patients with invasive cervical cancer, 62 patients with cervical intraepithelial neoplasia (CIN), and 25 control subjects. IL-6 and IL-8 levels were determined by ELISA. HPV DNA in cervical smears was detected by a HPV-16-specific PCR method and additionally by CPI/IIG PCR. Histological analysis of the inflammatory infiltrate was performed on hematoxylin-eosin-stained tissue sections.

RESULTS

In the patients with cervical cancer, those with CIN, and the controls, the median IL-6 concentration in cervicovaginal washings was 171 pg/ml (interquartile range: 54-780), 22 pg/ml (<2-73), and < 2 pg/ml (<2-<2), respectively. For IL-8, the levels were 2756 pg/ml (1651-7107), 489 pg/ml (248-1158), and 631 pg/ml (346-897), respectively. In most subjects the local levels were much higher than in serum. Local IL-6 and IL-8 levels were significantly higher in patients with cervical carcinoma compared with CIN patients and controls. Likewise, local IL-6 levels were increased in patients with CIN compared with controls. No relation was found between cytokine levels and CIN grade or between cytokine levels and the inflammatory infiltrate scored by histological analysis.

CONCLUSIONS

There is local production of IL-6 and IL-8 in cervicovaginal secretions, and the production of IL-6 was related to the severity of cervical neoplasia.

Screening for cancer: future potential

Much progress has been made in cancer screening over the past decade, but a great deal more needs to be done if screening is to make a major impact on worldwide cancer mortality. Where fully implemented, cytological screening for cervical precursor lesions has had a major impact on mortality. However, the cost and required infrastructure levels are high, and new approaches are needed if screening is to be effective in the developing world. Testing for the human papillomavirus and automated liquid based cytology offer great promise to improve quality, reduce overall cost and make screening more viable generally. Breast screening has been less successful, although useful mortality benefits have been achieved in women aged over 50 years. Full implementation in countries that can afford it will save lives, but radical new approaches will be needed to conquer breast cancer. Colorectal cancer screening offers the best hope of a major reduction in cancer mortality over the next decade. Less certainty exists about screening for other major cancers such as lung, prostate and ovary, but a range of potential approaches merit investigation.

Prediction of recurrent and residual cervical dysplasia by human papillomavirus detection among patients with abnormal cytology

To determine the discriminative capacity of human papillomavirus (HPV) DNA testing for recurrent and residual cervical dysplasia, 43 patients with abnormal cytology after treatment for cervical dysplasia were tested for the presence of HPV DNA by PCR. An endocervical curettage was performed in all patients for histological examination. Sixteen of the 43 patients showed moderate or severe dysplasia. The HPV test was positive in all 16 patients with recurrent or residual dysplasia and negative in 12 of the 27 patients without dysplasia. The sensitivity and specificity of the HPV test were 100 and 44%, respectively. The likelihood ratio of a positive HPV test was 1.8, whereas a negative HPV test had a likelihood ratio of 0.12. Testing for the presence of HPV has the potential to select patients without recurrent or residual cervical dysplasia who have an abnormal cytological smear. This may have clinical implications, since unnecessary diagnostic conizations may be avoided in patients with abnormal cytology after treatment for cervical dysplasia and a negative HPV test.

Clearance of cervical human papillomavirus infection by treatment for cervical dysplasia

OBJECTIVES

The aim of this study was to investigate the prevalence of human papillomavirus (HPV) after treatment for cervical dysplasia.

STUDY DESIGN

The presence of HPV was investigated in cervical scrapes of 91 patients, before and after treatment, using consensus primers in the polymerase chain reaction.

RESULTS

Before treatment for cervical dysplasia, 89 of 91 patients (98%) were HPV-positive compared with 28 of 91 patients (31%) after treatment. The HPV type present before treatment was found in the scrapes of only 9 of 89 patients (10%). Detection of HPV after treatment was associated with human immunodeficiency virus infection and incomplete conization.

CONCLUSION

The HPV type present before treatment was frequently cleared by treatment for cervical dysplasia.

Human papillomavirus analysis as a prognostic marker following conization of the cervix uteri

Cervical intraepithelial neoplasia grade 3 (CIN 3) is treated surgically. Follow-up of these patients is important to ensure successful treatment. The present study was undertaken to determine whether human papillomavirus (HPV) testing can be used to discriminate patients who will have recurrences from those who will not. It is composed of 26 patients who presented with recurrences of CIN and 22 patients who remained disease-free after treatment. DNA was extracted from paraffin-embedded cone biopsies of incident CIN 3, their corresponding follow-up Pap smears taken 3 months postoperatively, and their secondary cone biopsies of the recurrent lesions. The extracted DNA were then analyzed by PCR for the presence of HPV. The posttreatment cervical smears in the recurrent group had a (25/26) 96% HPV prevalence, while HPV DNA was not detectable in any of the 22 patients in the control group. The HPV types in both the initial and recurrent lesions correlated very well. This suggest that most recurrences are likely to be due to persisting lesions or subclinical HPV infections that had not been completely removed. Cytology alone was not sufficiently sensitive to discriminate the patients at risk for recurrences. It appears that HPV testing can be useful to monitor the therapeutic result.