Distinct manifestations of human papillomaviruses in the vagina

Clinical Characteristics and Detection Sensitivity of Cervical Cancer Screening in Vaginal Intraepithelial Neoplasia

OBJECTIVE

This study aimed to investigate the characteristics and screening history of vaginal intraepithelial neoplasia (VaIN) or vaginal cancer and compare the sensitivity of cytology and human papillomavirus (HPV) tests on the cervix against vaginal and cervical high-grade squamous intraepithelial lesion or cancer.

METHODS

This study included patients who underwent colposcopy-directed biopsy and were diagnosed with VaIN or vaginal cancer from February 2013 to November 2022. Clinical information was obtained from the medical records of the department. Statistical analysis was performed on SPSS 26.0 (IBM Corp, Armonk, NY) using t test, chi-square, and Fisher exact tests.

RESULTS

A total of 1,166 patients were included in this study. The median age of VaIN2+ patients was 50.5 years, whereas VaIN1 reported a median age of 42.1 years old, p < .001. This study reported that VaIN was significantly and positively correlated with cervical lesions (r = 0.244). The high-risk HPV (hr-HPV) detection rate was 88.2% (858/973) in VaIN and 95.2% in VaIN2+. Human papillomavirus 16 was the most prevalent HPV type in VaIN2+, which accounted for 54.9%, followed by HPV58 (19.5%), HPV52 (15.2%), HPV51 (12.2%), and HPV18 (11.0%). The sensitivity of hr-HPV and cytology tests on the cervix for detecting VaIN2+ was 94.7% and 83.4%, respectively. Both tests were not significantly different from detecting cervical intraepithelial neoplasia 2+.

CONCLUSIONS

Human papillomavirus 16 is the dominant HPV type in vaginal precancer lesions. Cervical cancer screening has similar sensitivity for VaIN2+ as for cervical intraepithelial neoplasia 2+, with hr-HPV testing showing higher sensitivity than cytology.

Cytology and HPV Co-Testing for Detection of Vaginal Intraepithelial Neoplasia: A Retrospective Study

(1) Background: Vaginal intraepithelial neoplasia (VaIN) is a rare premalignant disease caused by persistent human papillomavirus (HPV) infection. Diagnosing VaIN is challenging; abnormal cytology and positive HPV tests are usually the first signs, but published data on their accuracy for detecting it are rare and contradictory. The aim of this study is to compare the results of hrHPV and cytology co-testing with the histological findings of the vagina. (2) Methods: In the certified Dysplasia Unit at Erlangen University Hospital, cytology and HPV samples from the uterine cervix or vaginal wall after hysterectomy were obtained between 2015 and 2023 and correlated with histological findings in biopsies from the vaginal wall. Women without vaginal biopsy findings or concomitant cervical disease were excluded. (3) Results: In all, 279 colposcopies in 209 women were included. The histological results were: benign (n = 86), VaIN I/vLSIL (n = 116), VaIN II/vHSIL (n = 41), VaIN III/vHSIL (n = 33), and carcinoma (n = 3). Accuracy for detecting VaIN was higher in women with previous hysterectomies. Positive HPV testing during colposcopy increased the likelihood for VaIN II/III/vHSIL threefold. The detection rate for VaIN III/vHSIL was 50% after hysterectomy and 36.4% without hysterectomy. (4) Conclusions: Women with risk factors for VaIN, including HPV-16 infection or prior HPV-related disease, need careful work-up of the entire vaginal wall. Hysterectomy for HPV-related disease and a history of cervical intraepithelial neoplasia (CIN) also increased the risk for VaIN II/III/vHSIL.

Human Papillomavirus Infections in Cervical Samples From HIV-Positive Women: Evaluation of the Presence of the Nonavalent HPV Genotypes and Genetic Diversity

Non-nonavalent vaccine (9v) Human papillomavirus (HPV) types have been shown to have high prevalence among HIV-positive women. Here, 1444 cervical samples were tested for HPV DNA positivity. Co-infections of the 9v HPV types with other HPV types were evaluated. The HPV81 L1 and L2 genes were used to investigate the genetic variability of antigenic epitopes. HPV-positive samples were genotyped using the HPVCLART2 assay. The L1 and L2 protein sequences were analyzed using a self-optimized prediction method to predict their secondary structure. Co-occurrence probabilities of the 9v HPV types were calculated. Non9v types represented 49% of the HPV infections; 31.2% of the non9v HPV types were among the low-grade squamous intraepithelial lesion samples, and 27.3% among the high-grade squamous intraepithelial lesion samples, and several genotypes were low risk. The co-occurrence of 9v HPV types with the other genotypes was not correlated with the filogenetic distance. HPV81 showed an amino-acid substitution within the BC loop (N75Q) and the FGb loop (T315N). In the L2 protein, all of the mutations were located outside antigenic sites. The weak cross-protection of the 9v types suggests the relevance of a sustainable and effective screening program, which should be implemented by HPV DNA testing that does not include only high-risk types.

Risk of vaginal cancer among hysterectomised women with cervical intraepithelial neoplasia: a population-based national cohort study

OBJECTIVE

To study the risk of vaginal cancer among hysterectomised women with and without cervical intraepithelial neoplasia (CIN).

DESIGN

Population-based national cohort study.

SETTING AND POPULATION

All Swedish women, 5 million in total, aged 20 and up, 1987-2011 using national registries.

METHODS

The study cohort was subdivided into four exposure groups: hysterectomised with no previous history of CIN3 and without prevalent CIN at hysterectomy; hysterectomised with a history of CIN3/adenocarcinoma in situ (AIS); hysterectomised with prevalent CIN at hysterectomy; non-hysterectomised.

MAIN OUTCOME MEASURE

Vaginal cancer.

RESULTS

We identified 898 incident cases of vaginal cancer. Women with prevalent CIN at hysterectomy and those with a history of CIN3/AIS had incidence rates (IR) of vaginal cancer of 51.3 (95% CI 34.4-76.5) and 17.1 (95% CI 12.5-23.4) per 100 000, respectively. Age-adjusted IR-ratios (IRRs) compared with hysterectomised women with benign cervical history were 21.0 (95% CI 13.4-32.9) and 5.81 (95% CI 4.00-8.43), respectively. IR for non-hysterectomised women was 0.87 (95% CI 0.81-0.93) and IRR was 0.37 (95% CI 0.30-0.46). In hysterectomised women with prevalent CIN, the IR remained high after 15 years of follow up: 65.7 (95% CI 21.2-203.6).

CONCLUSIONS

Our findings suggest that hysterectomised women with prevalent CIN at surgery should be offered surveillance. Hysterectomised women without the studied risk factors have a more than doubled risk of contracting vaginal cancer compared with non-hysterectomised women in the general population. Still, the incidence rate does not justify screening.

TWEETABLE ABSTRACT

High risk of contracting vaginal cancer among hysterectomised women having prevalent CIN at surgery.

The prevalence of VAIN, CIN, and related HPV genotypes in Japanese women with abnormal cytology

Vaginal intraepithelial neoplasia (VAIN) is often found by chance. We investigated the prevalence of VAIN and related human papillomavirus (HPV) types in comparison with cervical intraepithelial neoplasia (CIN). This study enrolled 648 women who were referred to the outpatient clinic of Kanazawa Medical University Hospital for abnormal cytology from January 2009 to January 2019. HPV genotypes were determined using Genosearch-31 + 4, which can detect 35 different HPV types. Colposcopy was performed at the first visit by an experienced gynecological oncologist. Among 611 subjects with squamous cell lesions, 107 (17.5%) VAIN cases were identified, and 67 (11.0%) women had both VAIN and CIN. Ultimately, 72 VAIN1, 15 VAIN2/3, 203 CIN1, 249 CIN2/3, 32 cervical squamous cell carcinomas (SCC), and one vaginal SCC (Vag-SCC) were identified. The prevalences of VAIN1, VAIN2/3, and Vag-SCC were 35.5%, 6.0%, and 3.1% of equivalent cervical lesions, respectively. The VAIN patients were older than the CIN patients (P = .002). About half of the VAIN cases were diagnosed during the follow-up. Multiple HPV infections were found in 42.9% of the VAIN and CIN patients. HPV52, 16, 51, 53, and 56 were the most common types in VAIN, whereas HPV16, 52, 58, 51, and 31 predominated in CIN. HPV18 was rare in VAIN, HPV58 was more common in CIN than in VAIN, and HPV53 and HPV73 were more common in VAIN. In conclusion, VAIN1 was identified more frequently than we expected. Various HPV types were identified in the vagina, which is likely a reservoir for HPV.

Clinical analysis of cervical intraepithelial neoplasia with vaginal intraepithelial neoplasia

The purpose of this prospective cohort study is to evaluate the importance of screening and its diagnostic accuracy compared with the pathological diagnosis of cervical intraepithelial neoplasia (CIN) with vaginal intraepithelial neoplasia (VAIN).The prospective study enrolled 419 patients (pts) and was conducted between February 1, 2015 and January 31, 2016 at Beijing Obstetrics and Gynecology Hospital, Capital Medical University.All enrolled pts underwent multipoint biopsy of cervix and vaginal wall directed by colposcopy. All samples of biopsy underwent pathological examination. Among them, 201 pts (48.0%) were diagnosed with CIN, 218 pts (52.0%) were diagnosed with cervicitis, and 51 pts (12.2%) were diagnosed with VAIN. It was found that the incidence of CIN in pts was 4 times higher than that of VAIN. In all 419 patients enrolled, 218 pts had cervicitis with 13 pts (6.0%) of VAIN. There were 201 pts of CIN with 38 pts (18.9%) of VAIN: including 53 pts of CIN3 with 12 pts (22.6%) of VAIN; 49 pts of CIN2 with 9 pts of VAIN (18.4%), and 99 pts of CIN1 with 17 pts of VAIN (17.2%). The incidence of CIN with VAIN (18.9%) was significantly higher than cervicitis with VAIN (6.0%) (χ = 16.39, P = .00). Our results showed that there was a significant consistency between cervical lesions and vaginal lesions (χ = 135.91, P = .00), which indicated that the increase of CIN grades may be related to an increase of the VAIN grades. Our results also showed the significant (p < .05) increase of CIN and VAIN with age (<40 years Kappa = 0.04; 40-50 years Kappa = 0.11; >50 years Kappa = 0.28).This study showed that cytological test can be used as a routine screening method for cervical lesions and vaginal diseases. If the cytology result shows abnormality, and pathological examination confirms that there is no obvious abnormal cervical disease, colposcopy directed vaginal multipoint biopsy should be conducted to exclude vaginal disease. All patients of CIN should routinely undergo vaginal multipoint biopsy (1/3 upper vagina), especially in patients with high-grade CIN and age older than 50 years.

A Common Clinical Dilemma: Management of Abnormal Vaginal Cytology and Human Papillomavirus Test Results

OBJECTIVE

Vaginal cancer is an uncommon cancer of the lower genital tract, and standardized screening is not recommended. Risk factors for vaginal cancer include a history of other lower genital tract neoplasia or cancer, smoking, immunosuppression, and exposure to diethylstilbestrol in utero. Although cervical cancer screening after total hysterectomy for benign disease is not recommended, many women inappropriately undergo vaginal cytology and/or human papillomavirus (HPV) tests, and clinicians are faced with managing their abnormal results. Our objectives were to review the literature on vaginal cytology and high-risk HPV (hrHPV) testing and to develop guidance for the management of abnormal vaginal screening tests.

MATERIALS AND METHODS

An electronic search of the PubMed database through 2015 was performed. Articles describing vaginal cytology or vaginal hrHPV testing were reviewed, and diagnostic accuracy of these tests when available was noted.

RESULTS

The available literature was too limited to develop evidence-based recommendations for managing abnormal vaginal cytology and hrHPV screening tests. However, the data did show that (1) the risk of vaginal cancer in women after hysterectomy is extremely low, justifying the recommendation against routine screening, and (2) in women for whom surveillance is recommended, e.g., women posttreatment for cervical precancer or cancer, hrHPV testing may be useful in identification of vaginal cancer precursors.

CONCLUSIONS

Vaginal cancer is rare, and asymptomatic low-risk women should not be screened. An algorithm based on expert opinion is proposed for managing women with abnormal vaginal test results.

A common clinical dilemma: Management of abnormal vaginal cytology and human papillomavirus test results

OBJECTIVE

Vaginal cancer is an uncommon cancer of the lower genital tract, and standardized screening is not recommended. Risk factors for vaginal cancer include a history of other lower genital tract neoplasia or cancer, smoking, immunosuppression, and exposure to diethylstilbestrol in utero. Although cervical cancer screening after total hysterectomy for benign disease is not recommended, many women inappropriately undergo vaginal cytology and/or human papillomavirus (hrHPV) tests, and clinicians are faced with managing their abnormal results. Our objective is to review the literature on vaginal cytology and hrHPV testing and to develop guidance for the management of abnormal vaginal screening tests.

METHODS

An electronic search of the PubMed database through 2015 was performed. Articles describing vaginal cytology or vaginal hrHPV testing were reviewed, and diagnostic accuracy of these tests when available was noted.

RESULTS

The available literature was too limited to develop evidence-based recommendations for managing abnormal vaginal cytology and hrHPV screening tests. However, the data did show that 1) the risk of vaginal cancer in women after hysterectomy is extremely low, justifying the recommendation against routine screening, and 2) in women for whom surveillance is recommended, e.g. women post-treatment for cervical precancer or cancer, hrHPV testing may be useful in identification of vaginal cancer precursors.

CONCLUSION

Vaginal cancer is rare, and asymptomatic low-risk women should not be screened. An algorithm based on expert opinion is proposed for managing women with abnormal vaginal test results.

A retrospective study of 152 women with vaginal intraepithelial neoplasia

OBJECTIVE

To analyze the clinical characteristics and treatment of women with vaginal intraepithelial neoplasia (VAIN), as well as HPV prevalence in this population.

METHODS

A retrospective review was undertaken of the medical records of women diagnosed with VAIN at a clinic in Shenyang, China, between January 1, 2009, and December 31, 2012.

RESULTS

Of the 152 records reviewed, 69 (45.4%) women had low-grade VAIN (VAIN1) and 83 (54.6%) had high-grade VAIN (VAIN2/3). Among 110 patients with an available HPV status, 97 (88.2%) were positive. The predominant HPV types were HPV16, HPV33, HPV81, HPV53, HPV18, HPV58, and HPV66. Previous hysterectomy was documented in 60 (39.5%) patients. Additionally, 80 (52.6%) patients had no history of dysplasia of the lower genital tract. Of patients with VAIN1, 50 (72.5%) were treated by observation only, 31 (62.0%) of whom regressed spontaneously. Of 66 patients with VAIN2, 38 (57.6%) underwent treatment, 14 (36.8%) of whom experienced recurrence or progression. Of 17 patients with VAIN3, 13 (76.5%) underwent treatment, 5 (38.5%) of whom experienced recurrence or progression.

CONCLUSION

Evaluation of the entire vagina by colposcopy is warranted in each patient with abnormal cervical screening results. The predominant HPV genotypes among patients with VAIN could be used to establish diagnosis program and develop an HPV vaccine.

Abnormal Pap Smear and Diagnosis of High-Grade Vaginal Intraepithelial Neoplasia: A Retrospective Cohort Study

The aim of this study was to analyze the correlation between the first diagnosis of high-grade Vaginal Intraepithelial Neoplasia (HG-VaIN: VaIN 2-VaIN 3) and the cytological abnormalities on the referral pap smear.All the women with histological diagnosis of HG-VaIN consecutively referred to the Gynecological Oncology Unit of the Aviano National Cancer Institute (Aviano, Italy) from January 1991 to April 2014 and with a pap smear performed in the 3 months before the diagnosis were considered, and an observational cohort study was performed.A total of 87 women with diagnosis of HG-VaIN were identified. Major cytological abnormalities (HSIL and ASC-H) on the referral pap smear were significantly more frequent than lesser abnormalities (ASC-US and LSIL) in postmenopausal women (64.9% vs 36.7%, P = 0.02) and in women with a previous diagnosis of HPV-related cervical preinvasive or invasive lesions (70.5% vs 39.5%, P = 0.01). Diagnosis of VaIN 3 was preceded by major cytological abnormalities in most of the cases (72.7% vs 27.3%, P < 0.001).The diagnosis of HG-VaIN can be preceded by different abnormalities on referral pap smear. Major abnormalities are usually reported in postmenopausal women and in women with previous cervical HPV-related disease. However, ASC-US or LSIL do not exclude HG-VaIN, especially VaIN2. An accurate examination of the whole vaginal walls (or vaginal vault) must be performed in all the women who underwent colposcopy for an abnormal pap smear, and a biopsy of all suspicious areas is mandatory.

Site of infections associated with human papillomavirus

INTRODUCTION

Human papillomavirus (HPV) is the most clinically common sexually transmitted infection due to its carcinogenic power and the high number of lesions that it causes at different sites of the human body.

MATERIAL AND METHODS

Genital tract organs are the most common sites where the virus can be found, but by increasing the sensitivity of diagnostic technique, it is possible to identify viral presence in different regions of the body such as the stomach, the lung, and the urinary tract. These findings break with the traditional HPV skin/genital tropic profile and demonstrate that the virus is capable of infecting a wide variety of cells, tissues, and organs or can, at least, survive in these areas. The widespread presence of the HPV in the human body, often in latent form, led us to consider the hypothesis that HPV latency may be associated with no disease.

CONCLUSION

This observation raises further questions about the possibility of the virus not causing disease in specific sites of the human body, but rather, behaving like a commensal/opportunistic microorganism.

Surveillance for recurrent cancers and vaginal epithelial lesions in patients with invasive cervical cancer after hysterectomy: are vaginal cytology and high-risk human papillomavirus testing useful?

OBJECTIVES

To examine whether women who have had a hysterectomy for cervical cancer may be at an increased risk of vaginal epithelial lesions.

METHODS

We studied 147 patients with invasive cervical carcinoma (76 squamous cell carcinomas [SCCs], 60 adenocarcinomas [ADCs], and 11 adenosquamous cell carcinomas) who were treated by hysterectomy and had vaginal pathologic follow-up for a mean period of 43.3 months.

RESULTS

Of the patients, 15.0% (22/147) developed vaginal intraepithelial neoplasia (VAIN) or recurrence after hysterectomy, including two recurrent carcinomas and eight high-grade VAINs. More important, these high-grade VAINs or recurrent carcinomas were detected only in patients with cervical SCC within the first two years after hysterectomy but not in patients with cervical ADC. Eleven (23.4%) of 47 patients had at least one positive high-risk human papillomavirus (hrHPV) testing result during the follow-up period, and VAIN was detected in 54.5% (6/11) of patients with an hrHPV-positive result compared with 16.7% (6/36) with an hrHPV-negative result.

CONCLUSIONS

Our results indicate that women with cervical cancer are at an increased risk of VAIN besides recurrence, and women with cervical SCC are more prone to high-grade VAIN/recurrence, especially within the first two years after hysterectomy. The significantly increased detection rate of VAINs/recurrence in the hrHPV-positive group suggests vaginal cytology and HPV cotesting might be the preferred method for surveillance in these women.

A contemporary analysis of epidemiology and management of vaginal intraepithelial neoplasia

OBJECTIVE

The purpose of this study was to review a large cohort of patients with vaginal intraepithelial neoplasia (VAIN) and to analyze the epidemiology and outcomes with various treatment modalities.

STUDY DESIGN

A retrospective chart review was performed that encompassed patients who were treated for VAIN at a single center from 1990-2007. Demographics, disease characteristics, referring cytology, and histologic information were recorded. Primary outcome was recurrence or progression to carcinoma. Statistical analyses were performed with statistical software.

RESULTS

One hundred sixty-three women were included in the study: median age, 50 years (range, 21-84 years); white, 87%; current or previous smokers, 35%. At the time of diagnosis, 23% of the women had VAIN1; 37% of the women had VAIN2, and 35% of the women had VAIN3. Referral Papanicolaou smear results of high-grade squamous intraepithelial lesion or atypical glandular cells revealed VAIN2 or VAIN3 in 89% of cases (P = .0019) vs 53% of cases with low-grade squamous intraepithelial lesion. The median follow-up period was 18 months (range, 1-194 months). VAIN1 was observed in 70% of cases; 71% of patients who were treated for VAIN1 had recurrence or progression. VAIN2 was treated in 77% of patients; 53% of those who were treated had recurrence or progression. VAIN3 was treated in 94% of cases; 31% of them had recurrence or progression. Risk of recurrence was not correlated to VAIN type (P = .3). Six carcinomas were discovered in patients with VAIN2 and VAIN3. Median time to progression was 17 months for VAIN1, 11 months for VAIN2, and 11 months for VAIN3 (P = .036).

CONCLUSION

Despite the subtype, VAIN often recurs but does so more quickly with higher grade dysplasia.

Vaginal cells of smokers are more resistant to human papillomavirus infection than that of non-smokers

To evaluate effect of HPV and smoking on DNA double-strand breaks in vaginal samples, vaginal specimens collected from participants (n=76) were classified based on HPV and smoking status, and DNA double-strand breaks measured using comet assay. Mean tail length (31.2±18.7μm) and tail moment (2.4±2.8 arbitrary units) for HPV-positive patients were lower (p<0.001) compared with HPV-negative patients (61.7±22.6μm; 8.7±4.9AU). Never-smokers were found to have a higher level (p<0.001) of double-strand breaks (57.7±24.5μm, 7.5±5.5AU) compared with ever smokers (35.3±21.9μm; 3.4±3.7AU). Among HPV infected patients, never-smokers have more double-strand breaks compared to smokers (p<0.001) which correlated with age (p<0.001). Highly differentiated vaginal epithelium may be resistant to DNA damage associated with HPV infection and smoking, which may be attributed to adoptive survival mechanisms of vaginal epithelium.

Management of precancerous lesions prior to conception and during pregnancy: a narrative review of the literature

Special considerations aiming at preserving reproductive function have to be implemented when treating young patients with precancerous lesions of the lower genital tract. These high-grade lesions may progress into invasive cancer if left untreated. Currently, there are limited data on the impact of vulvar and vaginal precancerous lesions on fertility and its management during pregnancy. However, management and outcomes for cervical lesions have been extensively reported. The main approach for vulvar and vaginal lesions are maintaining anatomical function and cosmetics; whereas, treatment options for cervical precancerous lesions range from observation, cryotherapy or the more aggressive conisation. Gestational age is the most important factor in determining expectant management or surgical intervention. This narrative review draws attention to the relevant aspects of precancerous lesions of the lower genital tract, the potential effects and management prior to conception and during pregnancy.

A simplified classification for describing colposcopic vaginal patterns

OBJECTIVE

This study aimed to highlight that colposcopic vaginal patterns are not specific, unlike cervical colposcopic patterns, and to provide a simpler classification of vaginal colposcopic patterns.

MATERIALS AND METHODS

A total of 223 patients who underwent colposcopy with Schiller test were assessed (hierarchical log-linear model) retrospectively.

RESULTS

The greatest predictability for histologically confirmed warts and cancers is represented by colposcopic patterns of wart and cancer. Lugol-negative area is strongly predictive of koilocytosis, even if it is found in other vaginal lesions. Thickened epithelium seems to better predict a severe vaginal lesion, whereas thin white epithelium better suggests a mild vaginal lesion. Colposcopic patterns were simplified as follows: Lugol-negative area, white epithelia (thin white epithelium and white thickened epithelium), vascular lesions (regular and irregular mosaicisms and punctations), wart, and cancer. Thus, koilocytosis is predicted by the Lugol-negative area, whereas white epithelia patterns and vascular patterns are not specific, suggesting overall vaginal intraepithelial neoplasias. Wart and cancer patterns are pathognomonic for histologically confirmed warts and cancers.

CONCLUSIONS

Vaginal colposcopy poorly predicts the severity of vaginal lesions. By including each type of white epithelium within a new category called "white epithelia patterns" and each type of vascular pattern within a new category called "vascular patterns," it is possible to simplify vaginal colposcopy without compromising its accuracy.

[HPV-associated alterations of the vulva and vagina. Morphology and molecular pathology]

Non-neoplastic HPV-induced alterations of the vulva and vagina are frequent. The traditional three-tier grading system of vulvar intraepithelial neoplasia (VIN) will be replaced by the definition of usual and simplex type of VIN. The usual type is characterized by a strong association to high-risk HPV infections, the occurrence at younger age and multifocality, mostly associated with non-keratinizing squamous cell carcinoma. The differentiated (or simplex) type is rare and shows an association to older age and p53 alterations and is typically diagnosed co-incidentally with keratinizing squamous cell carcinoma. Vaginal intraepithelial neoplasia (VAIN) is still graded into VAIN 1-3 where VAIN 1 and 2 are mostly associated with low-risk HPV infections and a high spontaneous regression rate whereas VAIN 3 represents a high-risk HPV-associated lesion with capable progression into (micro-)invasive carcinoma. The differential diagnosis between a non-neoplastic condylomatous lesion and VIN common type and VAIN may be aided by p16 immunohistochemistry. The HPV-associated invasive vulvo-vaginal cancers are verrucous carcinoma (low-risk HPV) and the high-risk HPV-induced (non-keratinizing) squamous cell carcinoma (NOS), the condylomatous (warty) carcinoma and the very rare vaginal squamo-transitional carcinoma.

Aggressive Clinical Course of Primary Invasive Vaginal Carcinoma Associated with Type 61 HPV: A Case Report

Primary invasive vaginal cancer is one of the rarest malignant processes in the female genital tract. The etiology has not been identified, but the strongest association is with HPV infection and subtypes 16 and 18 have the highest oncogenic potential. We present the case of a young woman diagnosed with metastatic squamous cell carcinoma of the vagina associated with HPV type 61, a non-oncogenic HPV type. We report the propensity of a primary vaginal neoplasm to spread to lymphatic vessels early and the unresponsive aggressive behavior to multimodal therapy.

Posthysterectomy cytology screening: indications and clinical implications

OBJECTIVE

To review the results of patients who were referred for posthysterectomy of abnormal cytology based on screening indications.

MATERIALS AND METHODS

We performed a retrospective review of 64 patients who have been referred for posthysterectomy vaginal colposcopy to the gynecologic oncology service. Patients' demographics, clinical features, reason for screening, and final diagnosis were recorded. Patients were divided into 2 groups based on posthysterectomy screening guidelines. Group A was considered to have undergone unnecessary screening based on national guidelines, and group B had risk factors that appropriately called for continued surveillance. The number of colposcopic examinations and the incidence of neoplasia were recorded for each group.

RESULTS

The mean age of the patients was 65 years (range = 35-95 y). Group A included 22 patients with history of abnormal cytology posthysterectomy for benign disease. Of the 22 abnormal cytology results, 21 were low-grade squamous intraepithelial lesion (n = 14) or atypical squamous cells of undetermined significance (n = 7) with 1 high-grade squamous intraepithelial lesion. After referral and colposcopy of this group, no neoplasia was found. Group B included 42 total patients. Of these 42 patients, 20 (48%) had a history of cervical intraepithelial neoplasia, 12 (28%) had a history of vaginal intraepithelial neoplasia, 6 (14%) had history of cervical cancer, 2 (5%) had history of diethylstilbestrol exposure, and 2 (5%) had a history of radiation therapy. In group B, 8 (9%) and 1 (2%) of the patients had vaginal intraepithelial neoplasia 2/3 and squamous cell carcinoma, respectively.

CONCLUSIONS

Current national guidelines are appropriate. Adherence to these guidelines will decrease intervention and not affect the detection of vaginal neoplasia. Patients with risk factors for lower genital tract neoplasia warrant continued screening after hysterectomy.

Human papillomavirus in vaginal intraepithelial neoplasia

There are limited data on the prevalence and distribution of human papillomavirus (HPV) genotypes in vaginal intraepithelial neoplasia (VAIN). We sought to clarify this issue in a series of 450 VAIN cases with a confirmed diagnosis between 1990 and 2006. HPV genotyping was performed using paraffin-embedded specimens and polymerase chain reaction (PCR)-based methods. Multiple HPV types were validated by E6 type-specific PCR and direct sequencing. The HPV genotypes of the vaginal and cervical neoplasms were compared for those with incident VAIN and a history of previous/concomitant cervical neoplasms. Ki-67 was performed for supporting diagnosis of VAIN. Of these 450 VAIN cases (median age, 59 years; range, 19-93), two with missing paraffin blocks and 54 with poor DNA quality were excluded. HPV was detected in 273/394 (69.3%) VAIN, and multiple infections were found in 17.9% of HPV-positive samples. The leading types were HPV16 (35.5%), HPV58 (9.9%), HPV52 (9.9%), HPV39 (8.4%), HPV33 (7.3%) and HPV53 (7.0%). Among the 156 cases with a history of previous cervical neoplasia, 29.0% had concordant HPV genotypes, while synchronous VAIN samples (n = 49) were more likely to harbor concordant genotypes (58.7%) with the concomitant cervical neoplasm (p = 0.0003). Whether those HPV types in the incident VAIN lesions had existed in the vaginal epithelium at the time of the previous cervical neoplasia or a new acquisition needs to be clarified in prospective follow-up studies.

The utility of the human papillomavirus DNA load for the diagnosis and prediction of persistent vaginal intraepithelial neoplasia

OBJECTIVE

We evaluated the human papillomavirus (HPV) DNA load for the diagnosis and prediction of persistent vaginal intraepithelial neoplasia (VAIN).

METHODS

A retrospective review of the medical records of patients with a pathological diagnosis of VAIN was performed. Eligible women (N=48) were followed for cytology and HPV DNA test, and colposcopic biopsies were taken at 3- to 6-month intervals. Thirty-seven patients were followed for more than 6 months; their HPV DNA test results were compared to the cytology results for the prediction of disease prognosis.

RESULTS

The degree of VAIN was more severe in patients with a high initial HPV DNA load (p=0.009). Patients with VAIN 2 and VAIN 3 were older than those with VAIN 1 (p=0.005 and 0.008, respectively). In 26 out of 37 patients (70.3%), the VAIN resolved. The other patients had persistent lesions with no progression to invasive vaginal carcinoma. The last follow-up HPV DNA load was significantly higher in the group with persistent VAIN compared to the group with resolved VAIN (p<0.0001). Negative cytology was observed in 25 out of 26 patients in the VAIN resolved group and in nine out of 11 patients in the VAIN persistent group (p=0.205).

CONCLUSION

These results suggest that the HPV DNA test, especially for viral load, was more effective for the diagnosis and prediction of persistent VAIN than cytology.

HPV DNA detection and genotyping in 21 cases of primary invasive squamous cell carcinoma of the vagina

Primary invasive squamous cell carcinoma of the vagina is rare, and the role of human papilloma virus in its pathogenesis remains unclear. The aims of our study were to determine the distribution of human papilloma virus genotypes in 21 cases of primary invasive squamous cell carcinoma of the vagina and to correlate human papilloma virus genotype with histological subtypes. Patients' clinical records were reviewed for demographic data and the stage of the disease. Tumors (n=21) were classified according to the World Health Organization criteria. Human papilloma virus genotyping (INNO-LiPA HPV Genotyping) was performed in the whole series, and statistical analysis was performed with Fisher's Exact Test and with Student's t-test. The patients' age ranged from 36 to 88 (mean 65) years. Six cases were keratinizing squamous cell carcinoma, and 15 cases were non-keratinizing squamous cell carcinoma (seven non-keratinizing not otherwise specified, three basaloid, and five warty types). The median age of patients with keratinizing squamous cell carcinoma was 73.8 years and that of non-keratinizing squamous cell carcinoma patients was 61.5 years (P=0.08). Human papilloma virus DNA was detected in 17 cases (81%): 13 non-keratinizing squamous cell carcinoma (87%) and four keratinizing squamous cell carcinoma (67%) (P=0.31). The human papilloma virus genotypes identified were: 6, 11, 16, 18, 31, 33, 35, 40, and 58, with human papilloma virus 16 DNA the most prevalent (33%). Invasive squamous cell carcinoma of the vagina is frequently associated with human papilloma virus infection, and human papilloma virus 16 is the most common genotype. Although without statistical significance, keratinizing squamous cell carcinoma is more frequent in older patients, whereas non-keratinizing squamous cell carcinoma more frequently affects younger women. All studied histological subtypes are strongly associated with human papilloma virus infection.

Smoking increases the risk of high-grade vaginal intraepithelial neoplasia in women with oncogenic human papillomavirus

OBJECTIVES

In a large retrospective study, the association of smoking with human papillomavirus (HPV) genotype and vaginal intraepithelial neoplasia (VAIN) grade was analyzed.

METHODS

A SNOMED search was performed for vaginal biopsy or resection specimens diagnosed as VAIN over an 11-year period. The diagnosis of VAIN grade was confirmed by histological review. HPV genotype was determined by GP5+/6+ PCR and dot blot hybridization with type-specific oligonucleotide probes. Smoking history was obtained by chart review. Statistical analysis was performed using the chi-square test.

RESULTS

We identified specimens from 111 patients (age range 15-84); 64% (n=71) were diagnosed with high-grade VAIN (HGVAIN) and 36% (n=40) with low-grade VAIN (LGVAIN). High-risk (HR) HPV genotypes were identified in 83% of specimens (n=92), other types in 17% (n=19). Twenty-one different HPV genotypes were detected in total. Smoking history was available for 81% (n=90). Forty-one percent (n=37) had a positive smoking history. There was no significant difference in infection with HR vs. other types (p=0.92) among smokers when compared to non-smokers. In patients with HR HPV genotypes, smokers were at an increased risk for HGVAIN lesions when compared to patients who had never smoked (83% vs. 59%, p=0.02).

CONCLUSIONS

These data indicate an increased risk for HGVAIN in HR HPV positive women who smoke compared to HR HPV positive non-smokers.

Vulvo-vaginal cancers: risks, evaluation, prevention and early detection

Vulvar and vaginal cancers are rare and account for approximately 7% of cancers of the female reproductive tract. Vulvar and vaginal neoplasia share similar risk factors: human papillomavirus infection, previous cervical intraepithelial neoplasia or cervical cancer, current smoking, sexual factors, and immunosuppression. Several treatment options are available for patients with documented histologic high-grade intraepithelial vulvar or vaginal neoplasia, including excision, laser vaporization, and 5-fluorouracil. After treatment, lifetime follow-up with cytology and colposcopy is recommended. With the widespread use of the human papillomavirus vaccine, one half to two thirds of vulvar and vaginal cancers may be prevented. Patient education regarding reduction of risk factors for progression and close surveillance of at-risk individuals may prevent the progression to invasive disease.

Pitfalls in the epidemiologic classification of human papillomavirus types associated with cervical cancer using polymerase chain reaction: driver and passenger

Cervical cancer is a common malignancy in women worldwide, and it has now been established that the human papillomavirus (HPV) is both necessary and causal for these lesions. HPV itself is both ubiquitous and markedly heterogeneous but can nevertheless be classified as either a high-risk type or a low-risk type based upon its frequency of detection in cervical cancer. Given that the association between HPV and cervical cancer is causal, the classification of this virus has been strengthened by large-scale epidemiologic studies and is widely accepted across many disciplines. It is evident, however, that cervical cancer is frequently associated with multiple HPV types. Therefore, it is crucial to distinguish causal types of HPV (drivers) from noncausal types (passengers) in cervical lesions. In this review, we highlight the current pitfalls of using polymerase chain reaction methods instead of Southern blot hybridization for detecting HPV and discuss the distinction between driver and passenger HPVs with regard to the viral type, the length of the viral genome, and the levels of viral DNA associated with cervical cancer. Finally, we newly propose three categories of HPV instead of two risk groups, based on similarities between viral genes.

Prediction of persistent vaginal intraepithelial neoplasia in previously hysterectomized women by high-risk HPV DNA detection

AIM

To estimate the incidence and latency of Vaginal Intraepithelial Neoplasia (VAIN) in women previously hysterectomized for benign/malign pathology and to evaluate the role of high risk HPVs in the prediction of persistent or recurrent disease.

SUBJECTS AND METHODS

830 women with prior hysterectomy for benign/malign pathologies followed by cytological scraping and vaginal colposcopy. Forty-four patients presented VAIN lesions confirmed by histopathological diagnosis. HPV DNA test was performed at the time of diagnosis. Patients were treated by Laser CO(2) vaporization and underwent follow-up by cytology, colposcopy for a mean period of 3 years. HPV DNA test was performed at 6 months after treatment and every years. Persistent or relapsed disease was confirmed by histopathology.

RESULTS

Incidence of VAIN in women hysterectomized for benign pathologies did not differ significantly from the malign group. VAIN degree was more severe in the hysterectomized patients with cervical malignancy and subsequently radiated respect to non-radiated patients. The HPV DNA test at 6 months after VAIN treatment showed fifteen positive cases: twelve HPV 16 (80%) and three HPV 18 (20%). In five cases HPV DNA test was positive with a persistent negative cytological smear during the years. Positivity to high-risk HPV (either 16 or 18) was significantly higher in the patients with relapse to VAIN (10/44, p<0.002).

CONCLUSIONS

We suggest to include HPV DNA test in addition to cytology in the follow-up of patients previously treated for VAIN, in order to predict VAIN persistence or progression in vaginal carcinoma before cytology becomes abnormal.

Detection of human papillomavirus type 34 in Bowen's disease on the pubic area

We describe an 86-year-old man with Bowen's disease on the pubic area. The lesion was clinically a black-brownish keratotic nodule resembling seborrheic keratosis. Histopathological findings showed those of Bowen's disease and harboured human papillomavirus type 34 DNA. Genital, but not skin, human papillomaviruses are responsible for Bowen's disease on the skin.

Touchdown General Primer (GP5+/GP6+) PCR and optimized sample DNA concentration support the sensitive detection of human papillomavirus

Background

The GP5+/GP6+ PCR assay is a well-established HPV detection technique. This study has examined the effects of incorporating 'hot start' and 'touchdown' steps into the protocol. In addition, dTTP was substituted with dUTP to permit contamination control measures against carry-over PCR product.

Methods

Firstly, HPV-16 was amplified from SiHa cell DNA (0.1 ng–100 ng) diluted in a background of C-33A DNA (100 ng-2 μg). Secondly, the detection of small quantities (15ag-1.5pg) of HPV recombinant plasmids (types 16, 31, 33, 45, 51, 52, and 56) diluted in C-33A DNA was investigated. Thirdly, clinical sample DNA extracts (cervical smears, formalin-fixed vaginal lesions and breast tumors) were tested for HPV. Six different PCR protocols were assessed. HPV was detected by gel electrophoresis, and by Southern and dot blot hybridization.

Results

HPV detection sensitivity was dependent on the total amount of DNA in a PCR. Touchdown protocols supported HPV-16 detection from 1 ng or 0.5 ng SiHa cell DNA in a background of 2 μg or 1 μg C-33A DNA respectively, and from 0.1 ng of SiHa cell DNA (~28 copies HPV-16) in 500 ng or 100 ng background DNA. Under standard GP5+/GP6+ annealing conditions, HPV-16 went undetected when the DNA content of a PCR was 2 μg or 1 μg, and with 500 ng C-33A DNA the sensitivity limit was 1 ng SiHa cell DNA. HPV recombinant plasmids were each detected with high (albeit varying) sensitivity by a touchdown protocol. HPV-31 was better amplified under standard annealing conditions (1.5fg in 100 ng background DNA) than by a touchdown approach (15fg detection limit). HPV-52 was not amplified by the standard protocol at the dilutions tested. Seventeen different HPV types were demonstrated in 47/65 (72%) abnormal cytology samples recorded as HPV negative by standard GP5+/GP6+ conditions. Twenty-one different HPV types were recorded in 111/114 (97%) vaginal lesions. Multiple infections were also detectable using a touchdown approach. Of 26 breast tumors, 5 (19%) tested HPV positive by the standard assay and 15/26 (58%) using a touchdown protocol.

Conclusion

Touchdown modification of the GP5+/GP6+ PCR assay enables the detection of HPV undetected under regular assay conditions. The use of standardized DNA quantities in a PCR rather than standard sample volumes containing arbitrary amounts of DNA is supported. A touchdown approach may be beneficial as an analytical test for the re-evaluation of (apparently) HPV negative abnormal cervical cytological or histological samples, and for investigating the association of HPV with disease conditions at diverse organ sites. The clinical utility of a touchdown approach for HPV detection requires further investigation as increased assay analytical sensitivity may not necessarily equate with improved clinical sensitivity or specificity.

Other Gynecologic Cancers: endometrial, ovarian, vulvar and vaginal cancers

HEALTH ISSUE: In Canada, cancers of the endometrium, ovaries, vulva, vagina, placenta and adnexa account for 11% of all malignant neoplasms in women and 81% of all genital cancers. Although the incidence and mortality from vulvar and vaginal cancers are very low, endometrium and ovarian cancer are important public health problems. KEY FINDINGS: In Canada, there has been no appreciable improvement in survival for women with advanced endometrial (EC) or ovarian cancer (OC) over the past 30 years. The prognosis of EC is good for most patients because diagnosis is made at early stages. However, survival of OC is poor; more than 70% of cases are diagnosed at late stages. Up to 10% of OCs is linked to familial aggregation. Cancers of the vulva and of the vagina are very rare. The survival experience for women with the latter is worse than for those with the former. Both share many risk factors with cervical cancer and the recent developments in the study of HPV infection should be applicable to these diseases as well. Of particular interest will be the advent of vaccines for the primary prevention of HPV infection. DATA GAPS AND RECOMMENDATIONS: At present, the best available means to diagnose gynecologic malignancies is a detailed clinical examination, considering the totality of information on potential and proven risk factors, such as age, reproductive health, sexual practices, use unopposed estrogens or of oral contraceptives or tubal ligation, obesity, diet, smoking, and the familial clustering of some of these cancers.

Low prevalence of HPV infection and its natural history in normal oral mucosa among volunteers on Miyako Island, Japan

OBJECTIVE

To investigate the prevalence of human papillomavirus (HPV) infection in normal oral mucosa, and to observe the natural history in the oral cavity in oral swab samples collected from healthy volunteers on Miyako Island, Okinawa, Japan.

STUDY DESIGN

The prevalence of HPV infection in oral buccal mucosa cell scrapes collected between 2000 and 2002 from a cohort of 668 healthy volunteers was determined. HPV DNA was detected by consensus polymerase chain reaction (PCR) using MY09/MY11 primers followed by direct cycle sequencing. Just over 2 years later the HPV-positive participants were reevaluated.

RESULTS

Of the 668 subjects, 662 samples were analyzed for HPV. HPV DNA was detected in 4 (0.6%) specimens. HPV type 16 (HPV16), HPV53, and HPV71, mucosal types, and HPV12, a cutaneous type, were all identified by direct sequencing. In the follow-up survey, the HPV71- and HPV12-positive participants again tested positive, while HPV DNA was not detected in the HPV16- and HPV53-positive participants.

CONCLUSION

The results of this study among healthy individuals from Miyako Island suggest that oral HPV infection is uncommon. In this cohort, HPV71 and HPV12 were persistent, while HPV16 and HPV53 were transient in normal oral mucosa.

Human papillomavirus genomes in squamous cell carcinomas of the uterine cervix

The association between invasive cervical carcinoma and human papillomavirus (HPV) has now been established beyond doubt, but this is not necessarily a direct-and-effect association. To assess the causality of HPV, we analyzed HPV genomes in squamous cell carcinomas (SCCs) [corrected] of the uterine cervix by both blot hybridization and PCR. Genital HPV sequences were found in 231 (79%) of 294 SCCs by blot hybridization with more than five copies of entire HPV genomes identified in some cases including HPV 16 (92 cases), HPV 58 (32 cases), and HPV 52 (24 cases). By PCR-direct sequence analysis in 250 of 294 SCCs, genital HPV sequences were found in 240 samples (96%). The partial L1 sequences of HPV 16 were identified in 123 cases, and those of HPVs 18 and 31 were found in 24 and 20 cases, respectively. In addition, multiple HPV types were identified in 29 (12%) of 250 SCCs, and the HPV copy number, detected by PCR only, was less than 0.05. Marked discrepancies were therefore evident between the two analytical techniques. In this report, we discuss the causality of HPV for SCC with regard to the length of the viral genome, the amount of viral DNA, and multiple HPVs in single SCCs.

Therapeutic vaccination for the treatment of mucosotropic human papillomavirus-associated disease

There is a high prevalence of diseases caused by human papillomavirus (HPV) infection. Unfortunately, current treatments are inadequate. However, because there is evidence to support a role for the immune system in host defence against this virus, an immunotherapeutic approach is warranted. The existing immunotherapies are not completely effective, nor are they durable. In addition, natural history studies associated with spontaneous regression have provided little guidance to the design of successful interventions. This state of knowledge has encouraged efforts towards the development of novel immunotherapeutic strategies. Successful preclinical studies of therapeutic vaccine candidates have led to clinical studies for a variety of HPV-associated indications, such as anogenital warts and cervical and anal intraepithelial neoplasia. Immunisation approaches such as adjuvanted peptides, virus-like particles and fusion constructs are discussed. Specifically, chimaeric molecules comprised of mycobacterial heat-shock proteins (Hsps) and HPV16 E7 appear promising.

Vaginal dysplastic lesions in women with hysterectomy and receiving radiotherapy are linked to high-risk human papillomavirus

Patients undergoing radiotherapy for advanced cervical and endometrial cancer bear a considerable risk of developing vaginal preneoplastic lesions. Radiotherapy itself has been considered to have a role in the pathogenesis of vaginal dysplasia, although human papillomavirus (HPV) involvement has also been suggested. A series of 88 patients who underwent hysterectomy and were irradiated for gynecological cancer, including 43 with postradiation vaginal dysplasia at colposcopy and 45 without vaginal lesions, were included in this study. Detection and genotyping of HPV DNA in vaginal scraping were carried out by a PCR-based method and compared with colposcopic and cytological findings and with other clinical and laboratory data. Forty-two (97.7%) colposcopy-positive subjects and 6 (13.3%) colposcopically-negative patients were PCR-positive for high-risk HPV DNA (P < 0.000001). Twenty-two out of the 43 patients with colposcopic lesions showed an abnormal Papanicolau (PAP) test. Cytologic examination was negative in all colposcopically negative women. Type 16 HPV DNA was more frequent in patients with high-grade squamous intraepithelial lesions and in patients treated with external radiotherapy, whereas other types of high-risk HPV were more common in patients with low-grade lesions and in those treated with brachytherapy. When considering colposcopy as the standard for diagnosing vaginal dysplasia, HPV DNA testing was more sensitive than the PAP test. However, the specificity of the PAP test was higher with no false-positive case. In conclusion, vaginal preneoplastic changes in women post-hysterectomy and receiving radiotherapy for cervical, endometrial, and vaginal cancer represent an HPV-related nosologic entity. Whereas colposcopic examination can detect these preneoplastic lesions, HPV genotyping is a sensitive, inexpensive, and noninvasive method that may complement colposcopy and the PAP test.

A population-based study of squamous cell vaginal cancer: HPV and cofactors

BACKGROUND

Little is known about the etiology of in situ or invasive squamous cell cancer of the vagina. It is thought that some vaginal cancers may have the same etiology as cervical cancer. It is also not known whether in situ and invasive vaginal cancer share the same etiologic factors. We conducted a study to evaluate risk factors for in situ and invasive vaginal cancer and their potential relationship to prior exposure to human papillomaviruses (HPV).

METHODS

A population-based case-control study included 156 women with squamous cell in situ or invasive vaginal cancer diagnosed between January 1981 and June 1998 and 2041 control women identified through random-digit dialing in western Washington state. Cases and controls were interviewed in person and provided blood samples; archival tumor tissue was retrieved for cases. Blood samples were tested for antibodies to HPV, and tumor tissue was tested for HPV DNA.

RESULTS

Women with vaginal cancer were more likely to have five or more lifetime sexual partners (OR = 3.1, 95% CI 1.9 to 4.9), to have an early age at first intercourse (<17 years OR = 2.0, 95% CI 1.2 to 3.5), and to be current smokers at diagnosis (OR = 2.1, 95% CI 1.4 to 3.1) than control women. Approximately 30% of all cases had been treated for a prior anogenital tumor, most often of the cervix. Prior hysterectomy was a risk factor only among women who had no history of prior anogenital cancer (OR = 3.9 95% CI 2.5 to 6.1). Antibodies to HPV16 L1 were strongly related to risk of vaginal cancer (OR = 4.3, 95% CI 3.0 to 6.2). We detected HPV DNA in tumor blocks from over 80% of the patients with in situ and 60% of the patients with invasive cancers.

CONCLUSIONS

In situ and invasive vaginal neoplasia have many of the same risk factors as cervical cancer, including a strong relationship to HPV infection. Women who have been treated for a prior anogenital cancer, particularly of the cervix, have a high relative risk, although low absolute risk, of being diagnosed with vaginal cancer.

Diagnosis and management of vulvar and vaginal intraepithelial neoplasia

Vulvar intraepithelial neoplasia and VAIN present unique challenges to the practicing gynecologist. VIN may produce distressing symptoms and undergo malignant conversion. A high index of suspicion and liberal use of biopsy are required to make the diagnosis. The approach to therapy for VIN has been reviewed. Treatment should be tailored to each individual patient and may include a period of expectant observation. Variations and combinations are used whenever necessary to preserve normal function and anatomy. Frequent surveillance is a must because recurrence rates are high, especially with multifocal disease in young women. Although VAIN accounts for less than 0.5% of lower genital tract neoplasia, the frequency of its detection is increasing, especially in younger patients. These lesions are most commonly found in the upper third of the vagina and are often multifocal in nature. The close proximity of the upper vagina to the rectum, bladder, and ureters makes treatment difficult. The occult invasion rate may be as high as 28%, and a wide variety of therapies are available. As is true for VIN, recurrence is not uncommon.

Mucinous adenocarcinoma arising in a neovagina using the sigmoid colon thirty years after operation: a case report

BACKGROUND

Because of a relative rarity of the cases with an artificial vagina, the incidence of a case with malignant disease arising in the neovagina is extremely rare. A case of adenocarcinoma arising from a neovagina is presented with a review of the literature.

CASE

A neovagina was constructed using the sigmoid colon at the age of 23 for congenital agenesis of the vagina, Rokitansky-Küster-Hauser syndrome. Subsequently, the patient had regular sexual intercourse for about 20 years. At the age of 53, she came to our outpatient clinic with a complaint of vaginal bleeding, and adenocarcinoma was found at the anterior wall of the neovagina adjoining the introitus. Total resection of the neovagina and adjuvant radiotherapy was performed. The pathological diagnosis was mucinous adenocarcinoma.

CONCLUSIONS

In view of relatively low incidence of mucinous carcinoma arising in the sigmoid colon along with the ectopic localization, this case may have implications for the understanding of pathogenesis of sigmoid colon cancer.

Relationships between 80 human papillomavirus genotypes and different grades of cervical intraepithelial neoplasia: association and causality

To clarify the causal relationship between human papillomavirus (HPV) and cervical intraepithelial neoplasia (CIN), we analyzed 386 unfixed biopsy specimens by blot hybridization at Tm -40 degrees C, targeting 38 skin and 42 genital HPVs. By the recognition of PstI, BanI, and MspI cleavage patterns, single genital, but no skin's HPVs were identified with more than 10 copies per cell in 354 CIN (88 CIN I, 94 CIN II, and 172 CIN III). HPVs 40, 42, 43, 54, 62, or 71 was found in 10 CIN I, while HPVs 18, 30, 39, 51, 56, 59, 66, 68, 69, or 82 was found in 35 CIN I, 20 CIN II, or 8 CIN III. On the other hand, HPVs 16, 31, 33, 35, 52, 58, or 67 was identified in 43 CIN I, 74 CIN II, or 164 CIN III. The results are strongly indicative that most genital HPVs have potency to induce CIN I; however, HPV 16 and its closely related types are able to efficiently induce CIN III. We discuss the definition of causal HPV for CIN with regard to viral prevalence and viral load.

Human papillomavirus type 58 in Bowen's disease of the elbow

Human papillomavirus (HPV) can be detected in skin lesions of Bowen's disease, particularly on the fingers, and its genotype is associated with mucosal/genital types of HPV. We report herein an 85-year-old woman who had HPV-associated Bowen's disease on her elbow. HPV-58 DNA was detected in the lesion by polymerase chain reaction with restriction fragment length polymorphism and by Southern blot hybridization. In situ hybridization revealed numerous hybrid cells in the nuclei of the upper epidermis and stratum corneum of Bowen's disease. A high-risk type of mucosal HPV-58 DNA is associated with Bowen's disease in this case, suggesting that HPV-related Bowen's disease is not always restricted to genital or finger lesions.

Distinctive distribution of human papillomavirus type 16 and type 20 DNA in the tonsillar and the skin carcinomas of a patient with epidermodysplasia verruciformis

BACKGROUND

Epidermodysplasia verruciformis (EV) is a rare skin disease characterized by disseminated pityriasis versicolor-like or flat wart-like lesions and by the development of skin carcinomas. It is well established that specific cutaneous human papillomaviruses (EV-HPVs) are associated with both benign and malignant skin lesions in EV patients. However, little is known of the relationship between HPV and the mucosal lesions of EV patients.

OBJECTIVES

To detect and identify HPV types associated with skin and mucosal lesions of an EV patient.

PATIENT/METHODS

We investigated the skin carcinoma and the coexisting tonsillar carcinoma of a 41-year-old man with EV. Histopathologically, both lesions were squamous cell carcinomas. We analysed these two lesions by immunohistochemistry, in situ hybridization, and by molecular virology.

RESULTS

Neither skin nor tonsillar lesions exhibited positivity for HPV capsid antigen by immunohistochemistry. By Southern blot hybridization, however, the skin carcinoma harboured 'EV-specific' HPV20 DNA, while the tonsillar carcinoma harboured 'genital' HPV16 DNA. In addition, in situ hybridization localized the respective viral DNA in the corresponding lesion.

CONCLUSIONS

The results indicate that EV-HPV could be responsible for the development of the skin carcinoma, but not the mucosal carcinoma in this patient.

Development of squamous cell carcinoma by two high-risk human papillomaviruses (HPVs), a novel HPV-67 and HPV-31 from bowenoid papulosis

We report a patient with bowenoid papulosis (BP) involving two high-risk human papillomaviruses (HPVs) and the development of invasive squamous cell carcinoma (SCC). Our patient showed verrucous lesions on the penis, perianal area and groin that had been noted over the previous 8 years and had recurred after all therapeutic approaches. The perianal and left inguinal lesions revealed invasive SCC on histology. HPV-31 and HPV-67 sequences were detected by polymerase chain reaction from BP lesions of the perianal area and the shaft of the penis. HPV-31 has already been reported in BP as a high-risk HPV for the development of SCC, but HPV-67 is a novel one that has never been reported in BP. As HPV-67 has sequence homology to HPV-52 and HPV-58, it belongs to the family of HPV-16, a high-risk HPV group. Thus our patient showed two high-risk HPVs, i.e. HPV-31 and the novel HPV-67, which may be directly involved in the development of SCC.

Molecular cloning and nucleotide sequence analysis of a novel human papillomavirus (Type 82) associated with vaginal intraepithelial neoplasia

The genome of a novel human papillomavirus (HPV-82) was cloned from a vaginal intraepithelial neoplasia grade I. In our series of 291 biopsy specimens, HPV-82 was identified in one case each of cervical intraepithelial neoplasia grade II and grade III by blot hybridization. The histological localization of HPV-82 DNA in the three lesions was confirmed by in situ hybridization. The results indicated that HPV-82 is an etiologic agent for vaginal and cervical intraepithelial neoplasia. By nucleotide sequence similarity of L1 open reading frame (ORF), HPV-82 was closely related to HPV-26, -51, and -69. To know the precise relationship between the HPVs, we determined the complete sequence of HPV-82, as well as that of HPV-69. Sequencing revealed that the four HPVs had no initiation codon in the E5 ORF and had extensive nucleotide sequence similarities in all ORFs. In addition, they exhibited unique frame position patterns for ORFs, different from those of the other genital HPVs.