Viruses and cancer of the lower genital tract

Clinical manifestations and natural history of genital human papillomavirus infections

Over the past decade, the ever-increasing volume of evidence implicating HPV types in genital neoplasia has stimulated much research interest into all aspects of the biology of this interesting group of viruses. This research has led to the identification of growing heterogeneity of HPV types. It is not surprising, therefore, that the clinical profile of disease associated with genital HPV types is much broader than previously recognized. Knowledge of this clinical spectrum is mandatory to the understanding of the possible role of specific HPV types in human carcinogenesis.

Herpetic endometritis after pregnancy

A case of endometrial herpex simplex virus infection with severe uterine post-partum bleeding is reported. Histopathologic analysis of curettage samples revealed endometrial necrosis and diffuse herpes-type nuclear inclusions in the glandular epithelial cells. Immunohistochemistry, in situ hybridisation, and electron microscopy confirmed the diagnosis.

Systemic lupus erythematosus: predisposition for uterine cervical dysplasia

A previous retrospective study has found an increased risk of uterine cervical atypia in women with systemic lupus erythematosus (SLE) who have been treated with cytotoxic drugs. Our objective was to prospectively reveal any increased incidence of cervical atypia in SLE patients and to evaluate the relationship to previous chemotherapy. A total of 39 SLE women were prospectively referred for cytologic PAP smears of the uterine cervix. A significantly higher incidence of cervical atypia was found in SLE women (35.9%) compared with non-SLE control groups (< or = 5%; P < 0.01). No significant difference was found between the incidence of atypia in patients previously treated by cytotoxic medications such as cyclophosphamide pulses or methotrexate (4 of 9) compared with SLE women not receiving cytotoxic drugs (10 of 30). Colposcopically directed biopsies revealed three cases of cervical intraepithelial neoplasia (CIN) I-III (23%) among the cases with atypia. We conclude that women with SLE should have regular cytologic cervical smears because of a significantly increased incidence of atypia, regardless of previous cytotoxic therapy.

Applied relaxation training in the treatment of genital herpes

Four individuals with frequent recurrences of genital herpes simplex virus (HSV) were trained in Applied Relaxation (AR). Participants included in the research had been diagnosed with herpes at least 1 year prior to the study, experienced six or more outbreaks annually, and were not taking antiviral medications. The experiment employed a multiple baseline across subjects design. Participants maintained daily diaries of the frequency, duration and severity of herpes activity from baseline until a minimum of 3 months posttreatment. Treatment consisted of 10 individual AR sessions. Pretraining and posttraining frontalis electromyographic activity measures of subjects' ability to relax during rest and to apply the relaxation skill during stressful role plays were obtained. All subjects reported pretreatment to posttreatment reductions in herpes frequency. These changes were statistically significant across all subjects as a group and individually for three of the four subjects. These results suggest that AR is an effective technique for reducing recurrent HSV infection.

Cervical cytopathology. An evaluation of its accuracy based on cytohistologic comparison

BACKGROUND

Although Papanicolaou cytology represents the most effective technique to prevent and detect precancerous conditions of the uterine cervix, its false-negative yield is still a reason of concern among pathologists and gynecologists.

METHODS

Because histologic control is one of the best ways to assess the accuracy of cytology diagnosis, the authors have investigated 1000 women who had cervical smears and tissue sampling obtained during the same colposcopic evaluation between 1987 and 1990.

RESULTS

Out of 1000 cases (average age, 34.6 years; range, 14-80 years), 918 had adequate, 62 had less than optimal, and 10 had unsatisfactory samples. Cytology unsatisfactory and less than optimal cases as well as inadequate histology cases have been disregarded from all calculations. After histologic comparison, confirmed negatives were 622 of 918 (67.8%). Cytologic diagnoses of cervical intra-epithelial neoplasia (CIN) I were 96, of CIN II were 44, of CIN III, inclusive of carcinoma in situ, were 39, and of invasive carcinoma were 2. Atypical cases were 56. The overall sensitivity was 76.3%, with group sensitivity rates increasing directly with CIN grade. Positive predictive value was 80.2%. Specificity was 93.0%, and negative predictive value was 91.3%. False-negatives were 59 of 681 (8.7%), basically due to sampling errors. Among true-positives, there was 1 category discrepancy in 30 cases (mostly undercalled or overcalled CIN II) and 2 category discrepancies in 4 cases.

CONCLUSIONS

Cervical cytology has an overall accuracy close to that reported in studies employing indirect control methods, such as patient follow-up. Higher sensitivity rates emerged for CIN II, CIN III, and cervical carcinoma. Our figures of sensitivity and specificity may represent a useful reference source for future studies dealing with quality control in cervical cytopathology.

A study of possible causal relations between squamous cell carcinoma of the penis and carcinoma of the cervix uteri

The authors investigated 26 regular sexual female partners of 24 men with squamous cell carcinoma of the penis. Neoplasms were diagnosed in 6 (23.1%) of the total of 26 women. STDs were found in 6 (23.1%) women. In 2 the cytologic findings on the cervix were classified as PAP III (PAP IIIa-CIN I, PAP IIIb-CIN III). Squamous cell carcinoma of the uterine cervix was found in 2 women (1 case PAP IV-CIN III; 1 case PAP V-suggestive of invasive carcinoma). Endometrial adenoacanthoma, mammary adenocarcinoma, squamous cell carcinoma of the right hand and non-Hodgkin's malignant lymphoma (centroblastic) were found in 1 case each.

The role of human papillomavirus in carcinoma

Human papillomaviruses have long been identified as the cause of common warts and condylomata acuminata. Evidence is now accumulating that human papillomaviruses may be involved in not only benign, but also in malignant neoplasms. They might also be significant in the malignant transformation of cutaneous neoplasms. This review examines the oncogenic potential of human papillomaviruses when they are found in carcinomas in various anatomic areas, including the skin.

Risk of cervical cancer among wives of men with carcinoma of the penis

The relationship between carcinomas of the penis and cervix uteri was analyzed in married couples. The final series comprised 239 patients with squamous cell carcinoma of the penis and their 224 wives. Two wives were found to have squamous cell carcinoma of the cervix uteri. The expected number of cervical cancers within the group of wives was 1.88, the relative risk thus being 1.05 (95% confidence interval 0.13-3.8). The incidence of condylomas has increased during the recent decades, while that of carcinomas of the penis and uterine cervix has decreased. The results of this study did not support the hypothesis that wives of men with penile cancer incur an increased risk of carcinoma of the cervix uteri. Although there is much evidence from a large number of studies that human papilloma virus (HPV) has a role in the aetiology of cervical cancer, our study suggests that HPV associated with genital malignancies has a low infectivity or that these cancers have multifactorial aetiology.

Epidemiology of cancer of the vulva. A case-control study

Few epidemiologic studies have been undertaken to investigate the etiology of cancer of the vulva. To identify risk factors associated with this cancer, a case-control study was conducted in 149 patients with histologically proven vulvar carcinoma and the same number of control patients matched for age, race, marital status, and hospital from five U.S. metropolitan areas. As previously suspected, we found prior histories of leukoplakia of the vulva, inflammation of the vulva or vagina, and urogenital cancer to be significantly associated with vulvar cancer. In addition, we found moderately high odds ratios associated with occupational histories of private household maids and servants, and work in laundry, cleaning, and other garment services. A slightly increased odds ratio was associated with coffee consumption and a dose-response effect was demonstrated. The findings suggest that environmental exposures may play a role in vulvar carcinogenesis.

Prevalence of papillomarvirus infection in colposcopically directed cervical biopsy specimens in 1972 and 1982

A total of 1264 consecutive cervical biopsy specimens obtained at the Parkland Memorial Hospital Dysplasia Clinic during 1972 were reviewed. Histopathologic specimens were assessed with special reference to changes induced by human papillomavirus. In 1972, only 0.7% of biopsy specimens were reported as consistent with human papillomavirus infection. Upon review, however, 36.5% of these specimens were found to demonstrate histologic criteria for the diagnosis of human papillomavirus infection. Approximately half of biopsy specimens reclassified as human papillomavirus were originally interpreted as inflammation; the others were interpreted as cervical intraepithelial neoplasia. Patients with human papillomavirus infection were significantly younger than patients with cervical intraepithelial neoplasia (24.9 versus 30.2 years). These findings were compared with 965 cervical biopsy specimens obtained in 1982. Thirty-four percent of these biopsy specimens revealed human papillomavirus infection. These observations support the concept that human papillomavirus infection of the cervix is not a new entity but a previously unrecognized finding whose prevalence has been relatively stable over a 10-year period.

Preservation of anal function after total excision of the anal mucosa for Bowen's disease

Six women with Bowen's disease of the anogenital area were treated by total excision of the anal mucosa, perianal skin and, in some cases, partial vulvectomy. Two patients had foci of microinvasive squamous carcinoma. Adequate tumor margins were determined by frozen sections. The resulting mucosal and cutaneous defects were grafted with medium split-thickness skin grafts applied to the anal canal and sutured circumferentially to the rectal mucosa. Grafts were held in place by a finger cot inserted in the anal canal and stuffed with cotton balls. Patients were constipated five or six days with codeine. The skin grafts healed per primam. One additional patient was similarly treated for a chronic herpetic ulceration of the anus and healed. Contrary to dire predictions, all patients were able to distinguish between gaseous and solid rectal contents and sphincter function was preserved. In one patient, Bowen's disease has recurred in the grafted perianal skin.

Penile verrucous carcinoma

Eleven patients with verrucous carcinoma of the penis are presented. The age range was from 41 to 80 years with a mean of 59 years. The pathological features of these tumours are described and the aetiology of penile verrucous carcinoma is discussed.

Morphological and immunohistochemical evidence of human papilloma virus (HPV) involvement in the dysplastic lesions of the uterine cervix

A series of 110 biopsies of the uterine cervix containing dysplastic and/or in situ changes were assessed morphologiccally with reference to presence or absence of the coexistent condylomatous lesions, and using the immunoperoxidase-PAP technique to disclose the HPV (human papilloma virus) antigens in the cells. Morphologically, 79 biopsies contained condylomatous (CO) lesions (63 flat, 12 inverted and 4 papillomatous ones), and 31 were non-condylomatous (NCO) dysplasias/in situ carcinomas. The mean age of the CO group was more than 10 years less than that of NCO women (P less than 0.0001). Of the papillomatous COs, 75% were associated with mild or moderate dysplasia only, whereas 42% of the inverted ones contained an associated in situ carcinoma. Most of the flat lesions were found in very young women (10-39 years of age). HPV antigens were demonstrated in all papillomatous lesions (100%), in 83% of the inverted ones, and in 67% of the flat COs. In generally, the frequency of the HPV-positive cases decreased when epithelial atypia increased. None of the NCO lesions showed HPV positive cells. The results support earlier morphological findings on the frequent association of cervical condylomas and epithelial dysplasias, as well as those on the HPV as the etiologic agent of the former. The role of HPV as a possible etiologic agent of the cervical squamous cell neoplasia deserves further attention.

Multicentric carcinoma of the female lower genital tract

The clinical history and treatment of 17 patients with multicentric primary carcinomas of the cervix and vulva is presented. There is a significant association between vulval intraepithelial neoplasia and cervical neoplasia. The concept of multicentricity in relation to invasive and intraepithelial neoplasia of the cervix and vulva is critically reviewed.

Immunoperoxidase demonstration of human papilloma virus (HPV) in dysplastic lesions of the uterine cervix

Routinely processed sections of 47 unselected cervical dysplasias and in situ carcinomas (both condylomatous, CO, and noncondylomatous, NCO) were subjected to staining with indirect immunoperoxidase-PAP technique using anti-human papilloma virus (anti-HPV) immune serum to demonstrate HPV antigens in these lesions. Anti-HPV was raised in guinea pigs immunized with highly purified virions from a pool of human skin wart tissues. Positive reactivity for HPV (brown intranuclear precipitates) was disclosed in 72% of the CO dysplasias and in only one case (5.6%) of the NCO group. The frequency of HPV-positive lesions was inversely related to the degree of epithelial dysplasia, being consistent with the disappearance of ultrastructurally detectable virus particles in lesions turned malignant. HPV-containing cells were characteristic koilocytes or dyskeratotic superficial cells. The present technique provides definite evidence for the HPV etiology of the flat, inverted, and papillomatous condylomas, and seems to offer an advantage as a diagnostic tool of these lesions. When applied to malignant tumors in the near future, the method will undoubtedly bring more light on the suggested role of HPV in the etiology of human squamous cell carcinomas of the uterine cervix and other sites as well.

Intraepithelial squamous lesions of the vulva: biologic and histologic criteria for the distinction of condylomas from vulvar intraepithelial neoplasia

We reviewed 65 intraepithelial lesions of the vulva and distal vagina and compared the presence of koilocytosis, abnormal mitoses, and parabasal or basal nuclear enlargement with DNA microspectrophotometric distribution patterns and the presence of human papillomavirus antigen as determined by immunoperoxidase. Abnormal mitoses and cytologically atypical nuclear enlargement were specific predictors of aneuploidy and were reliable for distinguishing vulvar intraepithelial neoplasia (VIN) from condylomas. Koilocytosis was present in 100% of condylomas and 71% of aneuploid (VIN) lesions, but there were qualitative and quantitative differences in the distribution of koilocytic cells in the two classes of lesions. On the basis of these findings, criteria for distinguishing between VIN and condyloma are proposed.

Vulvar intraepithelial neoplasia: correlation of nuclear DNA content and the presence of a human papilloma virus (HPV) structural antigen

Immunoperoxidase localization of a human papilloma virus structural antigen (HPV) was attempted in 68 intraepithelial lesions of the vulva, 39 of which were analyzed for nuclear DNA content by microspectrophotometry. Overall, 5.9% (4/68) stained positive for HPV. Ninety percent (35/39) of the cases tested were aneuploid, and, of these, 2.8% (1/35) stained positive for HPV. In contrast, 50% (2/4) of the polyploid lesions were positive. Hence DNA microspectrophotometry and immunoperoxidase localization of HPV are useful coparameters for distinguishing wart virus infection (condylomata) from vulvar intraepithelial neoplasia. HPV is detected infrequently within aneuploid lesions, in keeping with the concept that epithelial maturation is required for virion assembly. Whether the HPV genome exists in a nonreplicative state within the aneuploid cell population is unknown.

High-risk factors in gynecologic cancer

Cervical cancer retains its character as a venereal disease associated with infections and multiple sexual partners, but poverty also is important. Precise incidence figures for cervical and endometrial cancer are almost nonexistent because in areas with precise case counts there is rarely accurate knowledge of hysterectomy prevalence. For endometrial cancer little recent attention has been paid to any risk factor except exogenous estrogen. It is now suggested that a low pregnancy rate is a cause, not a consequence, of ovarian pathology leading to cancer. Some progress has been made in separating the epidemiologies of various kinds of ovarian and uterine cancer. A few clues are available regarding the epidemiology of fallopian tube cancers and vaginal cancers other than those produced by maternal stilbestrol. Vulvar cancer becomes common only after the age of 75 and so has been neglected epidemiologically.

Increased incidence of cervical atypia in women with systemic lupus erythematosus treated with chemotherapy

In a retrospective study we found that 19 of 80 women with systemic lupus erythematosus had atypical cervical smears as compared to only 9 of 80 age-matched women without the disease. This increased incidence occurred mainly among women receiving cytotoxic drugs. Cervical atypia in women with lupus was not morphologically different from cervical atypia in general. Possible mechanisms responsible for the increased incidence are discussed. It is concluded that women with lupus who receive chemotherapy should have cervical smears taken regularly.

Demonstration of papilloma virus particles in cervical and vaginal scrape material: a report of 10 cases

The finding of virus particles by transmission electron microscopy (TEM) in fixed cervical and vaginal scrape material and their identification as papilloma viruses by negative staining is described. The colposcopic, cytological, and histological appearances in a group of 10 patients in whom virus particles were seen are discussed and the possibly considered of an association between papilloma virus infection and the development of cervical intraepithelial neoplasia (CIN) and multifocal intraepithelial neoplasia of the female lower genital tract.

Carcinoma in situ of the vulva: a continuing challenge

The epidemiologic data, clinical features, associated diseases, and histologic characteristics present in 50 cases of carcinoma in situ of the vulva are analyzed. A comparison of follow-up results obtained with various treatment methods is presented. With primary surgery the recurrence rate is dependent on the presence or absence of tumor at the surgical margins. Deoxyribonucleic acid patterns, determined by microspectrophotometry, were aneuploid in 92% of the cases studied. Five patients (10%) with aneuploid lesions, observed without therapy, experienced spontaneous regression of tumor and replacement of abnormal areas by euploid epithelium.

Condylomatous epithelial changes in the uterine cervix and their relationship to cervical carcinogenesis

Two hundred twenty-six (226) women with histologically verified dysplastic or neoplastic epithelial lesions in the uterine cervix were assessed for the presence (CO-series) or absence (N-CO-series) of the three newly established types of condylomatous lesions. Both the CO-series and the N-CO-series comprised 113 patients. Histologic changes fulfilling the previously outlined criteria of the (a) flat, (b) inverted and (c) papillomatous condylomas were found in association with all degrees of epithelial atypia, from mild dysplasia to frankly invasive carcinoma. The flat type was most common, comprising 69% of all condylomas. The inverted and papillomatous types were relatively rare, with frequencies of 18.6% and 12.4%, respectively. The mean age of the patients in the CO-series was 30.9 years, that of the N-CO-series patients was 39.3 years (p less than 0.0001). The causal relationship between the cervical condylomas and cervical carcinoma is discussed. The conclusion is drawn that this possibility needs to be seriously considered when searching for a venereally transmitted agent as an etiologic factor of cervical carcinoma.

Effect of immunization on the development of latent ganglionic infection in mice challenged intravaginally with herpes simplex virus types 1 and 2

Immunization of BALB/c mice with virulent and avirulent strains of HSV-1 resulted in high levels of neutralizing antibody and protected against both the lethal effect of the virus and the development of a latent ganglionic infection when animals were challenged by the intravaginal route. In animals immunized with avirulent strain of HSV-2 and challenged with a high virulent strain of HSV-2, substantial protection against death was observed despite low levels of neutralizing antibody. Nineteen per cent of the survivors, however, developed a latent ganglionic infection. Relatively little protection was observed in mice immunized with HSV-1 and challenged with HSV-2.