Role of human papillomavirus status after conization for high-grade cervical intraepithelial neoplasia

The role of multiple high-risk human papillomavirus infection on the persistence recurrence of high-grade cervical lesions after standard treatment: A systematic review and a meta-analysis

INTRODUCTION

The role of multiple high-risk human papillomavirus (HR-HPV) infections on the occurrence of persistence/recurrence of high-grade squamous intraepithelial lesion (HSIL) after conization/surgery for cervical intraepithelial neoplasia was evaluated.

MATERIAL AND METHODS

A systematic search of Pubmed/Medine, Scopus, Cochrane databases from inception to June 30, 2023 was performed. Three reviewers independently screened the abstracts of the selected studies and extracted data from full-text articles. The data were subsequently tabulated and compared for consistency. The bias associated with each included study was evaluated according to the OSQE method. PROSPERO registration number CRD42023433022.

RESULTS

Out of 1606 records screened, 22 full text articles met the inclusion criteria. A total of 8321 subjects treated (loop electrosurgical excision, laser or surgery) because of HSIL were followed-up and included in the meta-analysis. The pooled prevalence of overall persistence and/or recurrence was 17.6 (95% CI: 12.3-23.5) in multiple and 14.3 (95% CI: 10.1-19.2) in single HR-HPV infections detected shortly before or at surgery. The pooled rate of multiple HR-HPV infections was 25% (95% CI: 20.4-30). The odds ratio of histologically confirmed HSIL persistence and/or recurrence was significantly higher (OR: 1.38, 95% CI:1.08-1.75, p = 0.01, heterogeneity = 39%) among multiple than single HR-HPV infections. Increased risk of HSIL persistence/recurrence was more marked among studies with multiple HR-HPVs prevalence ≥25% (12 studies, N = 3476) (OR: 1.47, 95% CI: 1.18-1.84, heterogeneity = 0%) and in those evaluating true histologically confirmed recurrence after at least 6 months of negative follow-up (9 studies, N = 5073) (OR: 1.67, 95% CI: 1.17-2.37, heterogeneity = 37%). Multiple HR-HPVs infection detected during follow-up visits had no effect on the risk of recurrence although the number of included studies was small (4 studies, N = 1248) (OR: 0.98, 95% CI: 0.68-1.39, heterogeneity = 0%). The risk of bias was rated as high in 10 and low-moderate in 12 studies, respectively. In subgroup analysis, the risk of bias of the included studies (low/moderate vs. high), had a small, although not significant effect on the odds ratios of persistence/recurrence of HSIL (OR: 1.57, 95% CI: 1.23-2 for low-moderate risk of bias and OR: 1.06, 95% CI: 0.65-1.75 for high risk of bias; p-value for subgroup differences = 0.17).

CONCLUSIONS

Multiple HR-HPVs infections at the time of standard treatment of HSIL entail a small but significant increased risk of persistence/recurrence of HSIL and should be taken into account in the follow-up plan.

Optimising follow-up strategy based on cytology and human papillomavirus after fertility-sparing surgery for early stage cervical cancer: a nationwide, population-based, retrospective cohort study

BACKGROUND

The optimal follow-up strategy to detect recurrence after fertility-sparing surgery for early stage cervical cancer is unknown. Tailored surveillance based on individual risks could contribute to improved efficiency and, subsequently, reduce costs in health care. The aim of this study was to establish the predictive value of cervical cytology and high-risk human papillomavirus (HPV) testing to detect recurrent cervical intraepithelial neoplasia grade 2 or worse (CIN2+; including recurrent cervical cancer) after fertility-sparing surgery.

METHODS

In this nationwide, population-based, retrospective cohort study, we used data from the Netherlands Cancer Registry and the Dutch Nationwide Pathology Databank. All patients aged 18-40 years with cervical cancer of any histology who received fertility-sparing surgery (ie, large loop excision of the transformation zone, conisation, or trachelectomy) between Jan 1, 2000, and Dec 31, 2020, were included. Pathology data from diagnosis, treatment, and during follow-up were analysed. The primary and secondary outcomes were the cumulative incidence of recurrent CIN2+ and recurrence-free survival, overall and stratified by results for cytology and high-risk HPV.

FINDINGS

1548 patients were identified, of whom 1462 met the inclusion criteria. Of these included patients, 19 568 pathology reports were available. The median age at diagnosis was 31 years (IQR 30-35). After a median follow-up of 6·1 years (IQR 3·3-10·8), recurrent CIN2+ was diagnosed in 128 patients (cumulative incidence 15·0%, 95% CI 11·5-18·2), including 52 patients (cumulative incidence 5·4%, 95% CI 3·7-7·0) with recurrent cervical cancer. The overall 10-year recurrence-free survival for CIN2+ was 89·3% (95% CI 87·4-91·3). By cytology at first follow-up visit within 12 months after fertility-sparing surgery, 10-year recurrence-free survival for CIN2+ was 92·1% (90·2-94·1) in patients with normal cytology, 84·6% (77·4-92·3) in those with low-grade cytology, and 43·1% (26·4-70·2) in those with high-grade cytology. By high-risk HPV status at first follow-up visit within 12 months after surgery, 10-year recurrence-free survival for CIN2+ was 91·1% (85·3-97·3) in patients who were negative for high-risk HPV and 73·6% (58·4-92·8) in those who were positive for high-risk HPV. Cumulative incidence of recurrent CIN2+ within 6 months after any follow-up visit (6-24 months) in patients negative for high-risk HPV with normal or low-grade cytology was 0·0-0·7% and with high-grade cytology was 0·0-33·3%. Cumulative incidence of recurrence in patients positive for high-risk HPV with normal or low-grade cytology were 0·0-15·4% and with high-grade cytology were 50·0-100·0%. None of the patients who were negative for high-risk HPV without high-grade cytology, at 6 months and 12 months, developed recurrence.

INTERPRETATION

Patients who are negative for high-risk HPV with normal or low-grade cytology at 6-24 months after fertility-sparing surgery, could be offered a prolonged follow-up interval of 6 months. This group comprises 80% of all patients receiving fertility-sparing surgery. An interval of 12 months seems to be safe after two consecutive negative tests for high-risk HPV with an absence of high-grade cytology, which accounts for nearly 75% of all patients who receive fertility-sparing surgery.

FUNDING

KWF Dutch Cancer Society.

Persistent HPV infection after conization of cervical intraepithelial neoplasia-- a systematic review and meta-analysis

OBJECTIVE

To systematically evaluate several factors of persistent human papillomavirus (HPV) infection following conization in patients with cervical intraepithelial neoplasia (CIN).

METHODS

PubMed, EMBASE and the Cochrane Library were searched from January 1, 1998 to September 10, 2021. Random-effects models for meta-analyses were used and pooled relative risks with 95% confidence intervals were reported. Literature screening, data extraction, and assessment of the risk of bias in the included studies were conducted independently by two researchers. Data analysis was performed with Stata software, version 12.0.

RESULTS

A total of 28 studies were included in this study. Meta-analysis revealed that surgical margin and residual disease were positively correlated with persistent HPV infection after conization. Compared with patients infected with other types of HPV, CIN patients with HPV 16 had a higher persistent infection rate (OR = 1.967, 95% CI (1.232-3.140), P < 0.05).

CONCLUSIONS

CIN patients who are postmenopausal, have positive surgical margins and residual lesions, and are positive for HPV 16 are prone to persistent HPV infection after conization.

Risk factors analysis of recurrent disease after treatment with a loop electrosurgical excision procedure for high-grade cervical intraepithelial neoplasia

OBJECTIVE

To evaluate the risk factors of recurrent high-grade cervical intraepithelial neoplasia grade 2 or worse (CIN2+) after loop electrosurgical excision procedure (LEEP).

METHODS

This retrospective study included patients with histopathologically confirmed CIN2/3 who underwent LEEP in 2015-2020. Cox regression analysis was used to evaluate the risk factors of recurrence.

RESULTS

Recurrent CIN2+ was found in 268 patients after LEEP (268/4369, recurrence rate, 6.1%). High-risk (hr-) HPV infection (hazard ratio [HR] 12.09, 95% confidence interval [CI] 7.78-18.79), margin status (HR 6.48, 95% CI 4.75-8.84), baseline diagnosis (HR 1.45, 95% CI 1.08-1.95), smoking (HR 3.17, 95% CI 2.27-4.43), and immunosuppression (HR 1.96, 95% CI 1.33-2.91) were significant independent risk factors of recurrence. HPV16 (HR 3.61, 95% CI 2.43-5.37), HPV33 (HR 2.62, 95% CI 1.12-6.12), and HPV52 (HR 1.61, 95% CI 1.02-2.55) infection showed a higher risk of recurrence. High-risk HPV had the highest accuracy (sensitivity 88.5%; negative predictive values 98.7%) in predicting recurrence compared with liquid-based cytology test and margins.

CONCLUSION

Given that positive margins present a higher risk, wide excision may be required to avoid residual lesions. More attention should be paid to the correlation between recurrence and hr-HPV genotypes. After treatment for high-grade CIN, HPV-based testing is recommended at 6 months. Timely identification of high-risk factors enables risk stratification, and enables individual management or individual follow-up and recall strategies.

High Prevalence of Non-Vaccinated Oncogenic Human Papillomavirus Genotypes in High-Grade Squamous Intraepithelial Lesions of the Cervix: Thought-Provoking Results of a Detailed HPV Genotype Analysis

Identification of HPV infection is usually performed on cytological specimens, despite the often transient virus types. HPV profile analysis of pathologically confirmed lesions can also be performed on formalin-fixed paraffin-embedded (FFPE) cone samples and should be taken as standard during follow-up. We compared HPV profiles of cytological and FFPE specimens of women diagnosed with HSIL. Archived PAP smears and FFPE cones from 49 patients were processed. For genotyping, the HPV Direct Flow CHIP test was used. All samples were positive. HPV profile agreement of the two sample types was 84.16–100%. Mono-infections occurred in 12.24% and 61.22% in PAP smears and FFPE specimens, respectively; while multi-infections were detected in 87.76% and 38.78%, respectively. The most abundant genotypes were HPVs 16, 31, and 51/33. Of all infections, 56.25% and 64.93% were caused by nonavalent vaccinated type (VT) HPVs; while 50.69% and 38.96% belonged to non-nonavalent VT HPVs, in PAP smears and FFPE specimens, respectively. Our results confirmed the importance of HPV genotyping of FFPE cone samples. We also confirmed a remarkable presence of non-vaccinated HPV types in HSIL cases indicating the importance of vaccine development.

Development of a Nomogram Predicting the Risk of Persistence/Recurrence of Cervical Dysplasia

Background: Cervical dysplasia persistence/recurrence has a great impact on women’s health and quality of life. In this study, we investigated whether a prognostic nomogram may improve risk assessment after primary conization. Methods: This is a retrospective multi-institutional study based on charts of consecutive patients undergoing conization between 1 January 2010 and 31 December 2014. A nomogram assessing the importance of different variables was built. A cohort of patients treated between 1 January 2015 and 30 June 2016 was used to validate the nomogram. Results: A total of 2966 patients undergoing primary conization were analyzed. The median (range) patient age was 40 (18–89) years. At 5-year of follow-up, 6% of patients (175/2966) had developed a persistent/recurrent cervical dysplasia. Median (range) recurrence-free survival was 18 (5–52) months. Diagnosis of CIN3, presence of HR-HPV types, positive endocervical margins, HPV persistence, and the omission of HPV vaccination after conization increased significantly and independently of the risk of developing cervical dysplasia persistence/recurrence. A nomogram weighting the impact of all variables was built with a C-Index of 0.809. A dataset of 549 patients was used to validate the nomogram, with a C-index of 0.809. Conclusions: The present nomogram represents a useful tool for counseling women about their risk of persistence/recurrence after primary conization. HPV vaccination after conization is associated with a reduced risk of CIN2+.

Photodynamic therapy for early-stage cervical cancer treatment

BACKGROUND

The main aim of this article is a retrospective analysis of PDT effectiveness treatment in early-stage cervical cancer.

MATERIAL AND METHODS

28 patients were analyzed retrospectively with PDT treatment of early-stage cervical cancer. A multi-course PDT approach should have been performed for each patient. Patients underwent one PDT session or multi-course PDT approach. It depended on individual reaction and response to therapy after the first session. A multi-course approach was performed in the next two months. Treatment was performed from 2015 to 2020. Relapse-free probability was assessed for these patients by Kaplan Meier estimator in 60 months.

RESULTS

HPV elimination was in 82% of cases in three-month period after PDT (R² = 0.71). Among the analyzed cases, full HPV elimination was detected more than in 90% of cases. Relapse-free probability is 0,8 (CI95%: 0,53-1) in 60 months. Patients had mild (35.7%) and severe (28.6%) leucocyte reactions after PDT in three months.

CONCLUSION

The article demonstrates new treatment results of CC and detected a five-year period relapse-free probability after PDT. Only correct protocol using PDT for invasive cervical cancer provides high effectiveness and relapse-free survival.

Risk factors associated with the persistence of human papillomavirus after cervical excision in patients with high-grade squamous intra-epithelial neoplasia

OBJECTIVE

To evaluate risk factors associated with the persistence of human papillomavirus (HPV) after cervical excision in patients with high-grade squamous intra-epithelial neoplasia (HSIL).

METHODS

A retrospective cohort study enrolled 550 patients who underwent cervical excision for HSIL between January 2015 and January 2018. The effects of various factors were assessed using univariate and multi-variate analyses.

RESULTS

The mean age of patients was 42.6 [standard deviation (SD) 8.7, range 22-64] years, and the mean duration of follow-up was 29.0 (SD 4.8, range 24-36) months. Persistent HPV infection after cone excision was detected in 78 (14.2%) patients. Univariate logistic regression analysis revealed that advanced age (>35 years), menopausal status, HPV type (HPV16/18), abnormal vaginal micro-ecological morphology, type of excision (loop electrosurgical excision procedure) and positive margin were closely associated with the persistence of HPV. Multi-variate analysis indicated that menopausal status [odds ratio (OR) 4.708, 95% confidence interval (CI) 2.770-8.001; p < 0.001], abnormal vaginal micro-ecological morphology (OR 2.320, 95% CI 1.372-3.922; p = 0.002) and positive margin (OR 3.346, 95% CI 1.261-8.876; p = 0.015) were significant risk factors for the persistence of HPV after treatment. Furthermore, infection with HPV16/18 increased the risk of persistent infection, and a higher rate of HPV persistence was found in patients who were infected with HPV18 (OR 1.020, 95% CI 0.415-2.505) or co-infected with HPV16/18 (OR 2.064, 95% CI 0.272-2.041) compared with HPV16.

CONCLUSION

Persistent HPV infection after surgical treatment for HSIL is considered to be strictly related to the recurrence and progression of disease. Patients who are at increased risk of HPV persistence should receive intensive follow-up after surgery, especially in the first year.

Risk factors associated with HPV persistence after conization in high-grade squamous intraepithelial lesion

OBJECTIVE

Persistence of HPV infection in patients with high-grade squamous intraepithelial lesion (HSIL) undergoing cervical excision is considered strongly associated with the recurrence and progression of cervical dysplasia. This study aims to review potential risk factors for persistence of HPV infection in patients with HSIL, thus optimizing the postoperative monitoring program and clinical treatment.

METHODS

Through literature review, published data about estimated prognostic risk factors for persistence of HPV infection in patients with HSIL after conization within two decades were searched and analyzed, and their references were manually reviewed as well.

RESULTS

Women with persistence of HPV infection after cervical excision were at an extremely high risk of disease recurrence and progression to cervical cancer. Some clinicopathological and even physiological elements involving viral, organic human body and treatment factors, such as human papillomavirus (HPV) 16, high viral load, age older than 50 years and positive surgical margin were of prognostic significance in persistent HPV infection in patients with HSIL, yet some of which still remained controversial.

CONCLUSIONS

Monitoring prognostic factors in women with persistence of HPV infection who have underwent cervical excision for HSIL are of great significance, especially the follow-up within 2 years postoperatively, which significantly improves the clinical outcome.

Acquired epidermodysplasia verruciformis or generalized verrucosis? A clinical and virological comparative study

Few articles have described the difference between epidermodysplasia verruciformis (EV) and generalized verrucosis (GV). This study aimed to analyze the clinical findings and virology of the two diseases. The study enrolled patients diagnosed with EV and GV by clinical and histopathological findings. The demographic information, clinical manifestation, treatment, and therapeutic outcome were analyzed. All of the biopsy specimens of enrolled patients were sent for β-human papillomavirus (HPV) DNA detection. A total of 13 cases were included in the present study, including five EV cases and eight GV cases. Legs and feet were significantly affected in GV cases (p = 0.035). All acquired EV cases had immunocompromised conditions, while only three GV cases could be identified as having an immunocompromised history. All EV cases were detected with β-HPV infection, especially HPV5, but none of the GV cases were found to be infected with β-HPV. The therapeutic response was refractory and often relapsed after discontinuation of treatment in both groups.

Current Updates on Cancer-Causing Types of Human Papillomaviruses (HPVs) in East, Southeast, and South Asia

Simple Summary

Among the over 200 human papillomavirus (HPV) genotypes identified, approximately 15 of them can cause human cancers. In this review, we provided an updated overview of the distribution of cancer-causing HPV genotypes by countries in East, Southeast and South Asia. Besides the standard screening and treatment methods employed in these regions, we unravel HPV detection methods and therapeutics utilised in certain countries that differ from other part of the world. The discrepancies may be partly due to health infrastructure, socio-economy and cultural diversities. Additionally, we highlighted the area lack of study, particularly on the oncogenicity of HPV genotype variants of high prevalence in these regions.

Abstract

Human papillomavirus (HPV) infection remains one of the most prominent cancer-causing DNA viruses, contributing to approximately 5% of human cancers. While association between HPV and cervical cancers has been well-established, evidence on the attribution of head and neck cancers (HNC) to HPV have been increasing in recent years. Among the cancer-causing HPV genotypes, HPV16 and 18 remain the major contributors to cancers across the globe. Nonetheless, the distribution of HPV genotypes in ethnically, geographically, and socio-economically diverse East, Southeast, and South Asia may differ from other parts of the world. In this review, we garner and provide updated insight into various aspects of HPV reported in recent years (2015–2021) in these regions. We included: (i) the HPV genotypes detected in normal cancers of the uterine cervix and head and neck, as well as the distribution of the HPV genotypes by geography and age groups; (ii) the laboratory diagnostic methods and treatment regimens used within these regions; and (iii) the oncogenic properties of HPV prototypes and their variants contributing to carcinogenesis. More importantly, we also unveil the similarities and discrepancies between these aspects, the areas lacking study, and the challenges faced in HPV studies.

Role of human papillomavirus status after conization for high-grade cervical intraepithelial neoplasia

Human papillomavirus (HPV) is the well‐established etiologic factor for cervical neoplasia. Cervical conization constitutes an effective treatment for high‐grade cervical intraepithelial neoplasia (HG‐CIN). We conducted an observational study for long‐term outcomes and HPV genotype changes after conization for HG‐CIN. Between 2008 and 2014, patients with newly diagnosed HG‐CIN before conization (surveillance new [SN] group) and those who had undergone conization without hysterectomy (surveillance previous [SP] group) were enrolled. HPV testing and Pap smear were performed periodically for the SN and SP (collectively S) groups. All other patients receiving conization for HG‐CIN during the study period were identified from our hospital database. Those eligible but not enrolled into our study were assigned to the non‐surveillance (non‐S) group. For the S group (n = 493), the median follow‐up period was 74.3 months. Eighty‐four cases had recurrent CIN Grade 2 or worse (CIN2+) (5‐year cumulative rate: 14.8%), of which six had invasive cancer. Among the 84 patients, 65 (77.4%) exhibited type‐specific persistence in the paired HPV results, whereas only 7 (8.3%) harbored new HPV types that belonged to the 9‐valent vaccine types. Among the 7397 non‐S patients, 789 demonstrated recurrent CIN2+, of which 57 had invasive cancer. The stages distribution of those progressed to invasive cancer in the non‐S group were more advanced than the S group (P = .033). Active surveillance might reduce the severity of those progressed to cancer. Because a majority of the patients with recurrent CIN2+ had persistent type‐specific HPV infections, effective therapeutic vaccines are an unmet medical need.

What's new?

High‐grade cervical intraepithelial neoplasia (HG‐CIN), a cervical carcinoma precursor, frequently is caused by high‐risk human papillomavirus (hr‐HPV) infection. HG‐CIN can be treated by cervical conization, though the procedure does not eradicate hr‐HPV, potentially enabling CIN recurrence. Here, in Taiwanese patients, investigation of HPV genotype changes in relation to HG‐CIN status after conization shows that 77.4 percent of patients with recurrent CIN 2 grade or worse (CIN2+) after conization had persistent type‐specific HPV infections. Vaccination against the remaining high‐risk HPVs prevented recurrent CIN2+ in only 8.3 percent of patients, revealing an unmet need for effective therapeutic vaccines.