Papillomavirus and cervical cancer: a clinical and laboratory study

The causal relation between human papillomavirus and cervical cancer

The causal role of human papillomavirus infections in cervical cancer has been documented beyond reasonable doubt. The association is present in virtually all cervical cancer cases worldwide. It is the right time for medical societies and public health regulators to consider this evidence and to define its preventive and clinical implications. A comprehensive review of key studies and results is presented.

Distinct cytogenetic alterations in squamous intraepithelial lesions of the cervix revealed by laser-assisted microdissection and comparative genomic hybridization

BACKGROUND

It has been established that comparative genomic hybridization (CGH) on Papanicolaou-stained cervical smears can be used to identify chromosomal imbalances.

METHODS

In this study, the authors identified normal and dysplastic squamous epithelial cells cytologically, eliminated surrounding bacteria or leukocytes by a ultraviolet laser microbeam under microscopic control, and scraped out the cell groups of interest by a microdissection system. In 3 cases of squamous intraepithelial lesions (SIL), a total of 9 samples of dysplastic (n = 6) and nontumorous cells (n = 3) were investigated, each of them consisting of 3-40 cells. The DNA was amplified by degenerate oligonucleotide primed PCR (DOP-PCR) and used for CGH.

RESULTS

Analyses of all nontumorous cell groups resulted in fluorescence ratio profiles that showed no deviation from the normal range, confirming that no methodologic artefacts have been produced. The CGH profiles from dysplastic cells, however, showed various chromosomal imbalances affecting six to nine different chromosomes. The most frequent gains in DNA were observed on chromosomes 1p, 2q, 4, and 5, whereas losses were found on chromosomes 6q and 13q.

CONCLUSIONS

The results of this study demonstrate the feasibility and reliability of CGH on microdissected cell samples of routinely processed cervical smears. To the authors' knowledge, this is the first study reporting the use of CGH on cervical routine smears. This approach offers the opportunity to investigate sequence copy number changes in small, morphologically well-defined groups of dysplastic cells. It may, therefore, serve as a cytogenetic screening test for identifying chromosomal aberrations in precancerous lesions that are associated with a high risk for progression to invasive cancer.

Detection of Pneumocystis carinii in induced sputa from immunocompromised patients using a repetitive DNA probe

A hybridization assay for the detection of Pneumocystis carinii was developed using a repetitive DNA fragment of P.c. hominis. The assay was specific as different micro-organisms typically found in the respiratory tract, normal human lung DNA (A 549 cell line) and normal rat lung DNA did not react with the repetitive probe. In a slot blot (SB) hybridization assay, the repetitive probe was able to detect as few as 100 P.c. hominis organisms with no false-positives. The results of the SB hybridization assay were compared with an immunofluorescence (IFA) assay for the detection of P.c. hominis in 84 induced sputum (IS) samples obtained from 52 human immunodeficiency virus (HIV)-seropositive patients, 22 HIV-seronegative patients and 10 healthy individuals. Samples from 24 patients clinically diagnosed with P. carinii pneumonia (PCP) were positive for P.c. hominis by both assays. In addition, the SB assay detected P.c. hominis in 14 patients (10 HIV-positive and four HIV-negative) who were negative by IFA. All 14 samples showed a positive PCR signal for the P.c. hominis dihydrofolate reductase gene, further confirming the presence of P.c. hominis in these specimens. Twelve of these patients had a clinical course highly suggestive of PCP and were either on P. carinii prophylaxis or P. carinii chemotherapy. The other two samples were from HIV-positive patients who had respiratory illness due to causes other than P.c. hominis (disseminated histoplasmosis and fatal Bordetella pneumonia). Detection of P.c. hominis in these samples suggests that these patients may have subclinical colonization by P.c. hominis. Furthermore, P.c. hominis was detected in all 12 sequential IS samples from six AIDS patients who had primary episodes of PCR using the SB assay, while P.c. hominis was detected only in eight samples by IFA (66.6%). All six patients developed recurrent PCP within 6 months from the time the assays were performed, further illustrating the potential of the SB hybridization assay in monitoring PCP recurrence. Thus, the ability of the SB hybridization assay to detect a low parasite load suggests that this assay may become an important supplemental tool, along with current cytological methods, for detecting P.c. hominis in patient populations with lower burdens of the organism and in identifying asymptomatic carriers of the parasite in healthy and immunosuppressed individuals.

Distribution of human papillomavirus types in genital lesions from two temporally distinct populations determined by in situ hybridization

We examined 341 paraffin-embedded cervical tissues for human papillomavirus (HPV) DNA by in situ hybridization. The genital lesions examined represented tissue biopsies from two temporally distinct populations (1964 to 1965 and 1988 to 1989). Biotinylated probes to 14 different HPV types were used in our analysis: HPV types 6, 11, 16, 18, 31, 33, 35, 42, 43, 44, 45, 51, 52, and 56. The number of HPV DNA-positive specimens and the distributions of HPV types were similar for these two populations. Human papillomavirus DNA sequences were detected in approximately 50% of the tissues from each time period. Of the low-grade lesions (condyloma/cervical intraepithelial neoplasia 1 [CIN 1]) 52% (1964 to 1965) and 35% (1988 to 1989) were positive for HPV DNA by in situ hybridization. Among the high-grade lesions (CIN 2/CIN 3), 41% (1964 to 1965) and 67% (1988 to 1989) had detectable HPV sequences. Approximately 15% of the tissues with minimal histopathologic changes also contained HPV DNA. Human papillomavirus types 16 and/or 18 were the most common viral types in lesions from both time periods, followed by types 31/33/35; 6/11, 51/52; and 42/43/44, 45/46. Types 16 and/or 18 were strongly associated with high-grade lesions. Five percent of the HPV-positive lesions demonstrated evidence of multiple infections. Our results indicate that HPV DNA sequences can be detected readily by in situ hybridization in archival materials, even those prepared more than 25 years ago. In addition, analysis of HPV type distributions demonstrates that recently isolated HPV types (42, 43, 44, 45, 51, 52, and 56) were equally represented in tissues from both time periods.

Detection of human papillomavirus 16 and 18 DNA in epithelial lesions of the lower genital tract by in situ hybridization and polymerase chain reaction: cervical scrapes are not substitutes for biopsies

Human papillomavirus (HPV) types 16 and 18 in 66 women with histologically documented lesions of the genital tract and 64 control cohorts were investigated. The efficacies of in situ hybridization and polymerase chain reaction (PCR) in detecting HPV 16 and 18 DNA were analyzed. In order to assess the usefulness of replacing biopsies with cervical scrapes, the two samples were compared by PCR. The prevalence rates of HPV infection by PCR were 59.1 and 10.9% in patients and controls, respectively. PCR was three times more sensitive than in situ hybridization (52.6 versus 17.8%). However, the need to improve PCR sensitivity by subsequent dot blot hybridization reduced one of the main advantages of PCR, i.e., expeditious diagnosis. Cervical scrapes were less sensitive than biopsies (13.6 versus 53%), although with four (6.1%) patients with intraepithelial neoplasias, HPV DNA was identified only by means of cervical scraping. We conclude that obtaining biopsy specimens and cervical scraping are complementary sampling procedures.

Clonal p53 mutation in primary cervical cancer: association with human-papillomavirus-negative tumours

Analyses of cancer cell lines and of anal cancers suggest an inverse correlation between infection with human papillomavirus (HPV) and somatic mutation of the p53 tumour-suppressor gene. We have investigated this association in primary cervical tumours. Tumour-tissue samples from 28 women with primary cancer of the cervix were analysed for presence of HPV sequences and for somatic mutations of the p53 gene. Southern blot analysis and the polymerase chain reaction (PCR) showed that 25 of the tumours contained HPV sequences; 20 were HPV16 positive and 5 HPV18 positive. 17 tumours subjected to restriction fragment length polymorphism analysis for the short arm of chromosome 17 showed no evidence of allelic deletion. Sequencing of the entire coding region of the p53 gene by asymmetric PCR detected heterozygous point mutations in only 3 HPV-negative tumours. By contrast, in 21 HPV-positive cancers the p53 sequence was wild-type throughout. Our data indicate that loss of wild-type p53 function is important in the pathology of cervical cancer and that in the absence of an HPV-encoded gene product that mediates loss of p53 function, somatic mutation of the gene is required. This pattern of p53 mutation may partly explain the apparently worse prognosis of HPV-negative cervical cancers.

Detection of HPV DNA in archival specimens of cervical cancer using in situ hybridisation and the polymerase chain reaction

An archival survey of 98 cervical cancer specimens dating from the 1920s to the 1980s was undertaken to determine whether changes had occurred in the prevalence of human papilloma-virus (HPV) DNA. HPV DNA was detected in paraffin sections of cancers fixed in 10% formalin by in situ hybridisation (ISH) using HPV 6, 11, 16, and 18 32P-labelled DNA probes under conditions of high stringency; and by the polymerase chain reaction (PCR) using 20-mer oligonucleotide primers to amplify 109 bases of the E6 region of HPV 16. In 30 instances results obtained from Southern blot hybridisations which had been carried out on specimens of fresh tissue from the same cancers collected during the 1980s were available for comparison. The rates of HPV DNA detection in cervical cancers ranged from 83% (by Southern or PCR) and 70% (by ISH) on specimens from the 1980s, to 50% and 63% (by ISH and PCR, respectively) on specimens from the 1920s. HPV 16 was by far the most common type, being identified by Southern or ISH in approximately 92% of HPV DNA-positive specimens. No significant change in the prevalence of HPV DNA, or of HPV types, in cervical cancers was found over the 65 year period examined.

Anal intercourse: a risk factor for anal papillomavirus infection in women?

OBJECTIVE

To determine whether anal intercourse is a risk factor for anal HPV infection in women.

DESIGN

Results derived from clinical examination, anal cytology and HPV DNA hybridisation were correlated with data obtained from a questionnaire administered to the patients at the time of their clinical examination.

SETTING

A sexually transmitted diseases (STD) clinic in Sydney, Australia.

SUBJECTS

31 women attending the clinic for HPV related problems.

METHODS AND RESULTS

A thorough history was elicited from each woman followed by physical examination of the anogenital region. Cervical and anal scrapes were collected for cytology and HPV DNA hybridisation. Of the 15 women who practised anal intercourse, a total of 12 (80%) had either clinical or subclinical HPV infection. Seven had overt anal warts, situated either internally or externally in the anal canal; and further 5 women had evidence of subclinical HPV infection as determined by positive cytological and/or HPV DNA hybridisation results on their anal scrapes. The women who did not have a history of anal intercourse had a lower (7/16, 43%), but not statistically significant, rate of anal HPV infection: five had anal warts and two had subclinical evidence of infection. No correlations were found between anal HPV infection and genital (cervical, vulval or vaginal) HPV infection; nor between the HPV typing patterns of women in either group.

CONCLUSION

The results obtained from these women do not indicate a close relationship between anal intercourse and the presence of detectable anal HPV infection.

Deleterious effects of formalin/acetic acid/alcohol (FAA) fixation on the detection of HPV DNA by in situ hybridization and the polymerase chain reaction

As part of a study of archival cervical cancer specimens (1920s to 1980s) to determine whether changes have occurred in the prevalence of human papillomavirus (HPV) DNAs, investigations were performed on tissues which had been fixed in either 10% buffered formalin (NBF) or formalin-acetic acid-alcohol (FAA). HPV DNA was detected by in situ hybridization (ISH) using HPV 6, 11, 16 and 18 32P-labelled DNA probes under conditions of high stringency; and by the polymerase chain reaction (PCR) using 20-mer oligonucleotide primers to amplify 109 bases of the E6 region of HPV 16. In some instances results obtained from Southern blot hybridizations, which had been carried out on specimens of fresh cancer tissue, were available for comparison. When tissues had been fixed in NBF, HPV DNA sequences were detected in 53% of specimens by ISH and in 72% by PCR. In comparison, the rates of detection of HPV by ISH and PCR in tissues fixed in FAA were 17% and 21% respectively. These results indicate that FAA is clearly inferior to NBF for the preservation of detectable HPV DNA sequences in tissue sections.

Detection of human papillomavirus DNA in genital lesions by using a modified commercially available in situ hybridization assay

A modified, commercially available DNA-DNA in situ hybridization test that uses biotinylated probes for the identification of human papillomavirus (HPV) DNA types 6/11, 16/18, and 31/33/35 was evaluated. HPV DNA was detected in 314 of 787 (40%) histologically abnormal genital biopsy specimens by using the ViraType in situ assay (Life Technologies, Gaithersburg, Md.), in which the hybridization time was increased from 2 to 16 h. Ninety percent of positive condyloma acuminata specimens contained HPV type 6/11 DNA. The prevalences of HPV DNA for cervical intraepithelial neoplasia I, II, and III lesions by this in situ hybridization test were 42, 54, and 55%, respectively. The combined prevalence of HPV type 16/18 and 31/33/35 DNAs increased with the severity of the lesion, while the prevalence of type 6/11 DNA decreased. HPV type 6/11 DNA was found only in 1 of 16 (6%) positive cervical intraepithelial neoplasia III specimens. HPV type 16/18 and 31/33/35 DNA was detected in 11 of 16 (69%) and 4 of 16 (25%) in situ hybridization-positive cervical intraepithelial neoplasia III specimens, respectively. Thus, the observation that certain "higher-risk" HPV genotypes are associated with upper-grade cervical precancer lesions was confirmed by this commercial hybridization system. In general, the assay was found to be well suited for use in the clinical laboratory. The ViraType in situ procedure modified for a longer hybridization time may be helpful in identifying lesions containing higher-risk HPV strains.

Manifestations of anogenital HPV infection in the male partners of women with anogenital warts and/or abnormal cervical smears

The prevalence and manifestations of anogenital human papillomavirus (HPV) infection in 154 men, all of whom were the sexual partners of women with either overt anogenital warts or cervical HPV-related abnormalities, were assessed using clinical, histopathological and molecular criteria. Detailed examination of the anogenital region using a colposcope was supplemented by the use of 5% acetic acid to detect possible foci of subclinical HPV infection. Biopsies of warts and aceto-white lesions were examined histopathologically and by HPV DNA hybridization using radiolabelled HPV 6/11 and 16/18 DNA probes. More than two-thirds of the men had clinical indications of genital HPV infection: 37% had apparent macroscopic warts, almost invariably in combination with aceto-white lesions; while 34% had aceto-white lesions only. The overwhelming majority of these lesions (92%) were located on the penis only. However, only 49% of the macroscopic and 29% of the aceto-white lesions showed histological features consistent with a conclusive diagnosis of HPV infection; while the corresponding figures for HPV DNA positivity were 72% and 56% respectively. Current HPV infection was strongly associated with a past history of anogenital warts, but there was little or no correlation between the manifestations of HPV infection in the male and female sexual partners.

In-situ hybridization using biotinylated DNA probes to human papillomavirus in adenocarcinoma-in-situ and endocervical glandular dysplasia of the uterine cervix

In-situ hybridization using biotinylated probes to human papillomavirus (HPV) DNA was performed on formalin fixed paraffin embedded tissue in 30 patients with histologically confirmed adenocarcinoma-in-situ (AIS). Thirteen of the 30 cases contained areas of endocervical glandular dysplasia (EGD) admixed with AIS. Twenty one patients showed positive staining of the AIS nuclei for HPV DNA. Ten cases (33%) were positive for HPV 16 DNA and 11 cases (37%) were positive for HPV 18 DNA. No case showed synchronous expression of HPV 16 and 18 DNA. All cases of AIS were negative for HPV 6b and 11 DNA. Four cases of EGD were positive for HPV 18 DNA and 2 cases were positive for HPV 16 DNA. Four of 6 cases of intestinal dysplasia/AIS were positive for HPV 18 DNA. Associated squamous abnormalities (HPV +/- CIN +/- SCC) were noted in 15 cases. Of these, 7 showed positive staining for HPV DNA in the squamous lesion. Moreover, 5 of these were positive in both the AIS and squamous lesion. In-situ hybridization using biotinylated DNA probes is a sensitive and safe technique readily adaptable to routine histopathology.

Factors associated with clinical and sub-clinical anal human papillomavirus infection in homosexual men

OBJECTIVES

(I) to determine the relative sensitivities of clinical examination, cytology and HPV DNA hybridisation for the detection of anal human papillomavirus infection; and (ii) to examine various factors which may influence presentation of anal human papillomavirus infection in homosexual men.

METHODS AND RESULTS

112 unselected homosexual men attending a Sydney STD clinic for routine screening underwent a complete anogenital and physical examination, during which blood samples (for haematological, serological and immunological investigations), rectal swabs (for culture of anal pathogens) and anal scrapes of the dentate line (for cytology and HPV DNA hybridisation) were collected. Papanicolaou-stained anal smears were examined for cytological abnormalities, including those indicative of HPV infection or anal intraepithelial neoplasia (AIN). HPV DNA was detected by high stringency dot hybridisations using radiolabelled HPV 6, 11, 16 and 18 DNA probes. Visible anal condylomata, situated either externally or in the anal canal, were present in 26% of these men; 46% had cytological evidence of HPV infection, and 19% of the smears showed evidence of mild to moderate dysplastic changes (AIN I-II). Detectable HPV DNA was present in 40% of the anal scrapes. By combining these results, a total of 73 men (65%) were found to have at least one of the indicators of HPV infection. These data, together with that relating to HIV antibody, immune status and past or present infection with other STDs, was correlated with information obtained from a questionnaire administered to the patients at the time of their clinical examination.

CONCLUSIONS

In this study cytology was found to be slightly more sensitive than HPV DNA dot hybridisation for the detection of HPV infection in the anal canal, providing the full range of HPV-associated cytological changes were accepted as a basis for diagnosis. Clinical anal lesions were more likely to be detected in young men, men who had symptomatic HIV infection and those with a history of past anal wart infection. The latter group also had a higher incidence of cytologically apparent HPV infection in their anal smears. There was a significant association between the detection of HPV 16/18 and the presence of anal dysplasia, but there were no significant correlations between HPV infection or anal dysplasia and HIV antibody, immune function status, sexual practices or history of other STDs.

Automated polymerase chain reaction for papillomavirus screening of cervicovaginal lavages: comparison with dot-blot hybridization in a sexually transmitted diseases clinic population

The aim of the present study was to compare the recently developed polymerase chain reaction (PCR) technique with conventional dot-blot DNA hybridization for human papillomavirus (HPV) detection. Cells were collected by cervicovaginal lavage from a study group of 109 women attending a sexually transmitted diseases clinic. Using a machine that we developed for alternation of temperature cycles, HPV was detected in 51% of patients by PCR. By dot-blot hybridization, 44% of the patients were positive. Concordance of combined positive and negative results between PCR and dot blot was 69%. The greater sensitivity of PCR may have accounted for 19% of specimens that were PCR positive but dot-blot negative. Unexpectedly, however, 12% of specimens were dot-blot positive but negative by PCR, and several specimens were discordant for type of HPV. Both HPV DNA tests agreed with cytology in 41% of women, and in 33% cytology was negative in the face of positive PCR and dot blot. Concordance of cytology with just PCR was 59%, and only with dot blot was 56%. Cervicography agreed with both HPV DNA tests in 41% of patients, with PCR alone in 55%, and with dot blot alone in 58%. Biopsy results did not reveal a strong correlation between histopathological criteria of HPV infection and detection of HPV DNA by either PCR or dot-blot hybridization. Thus the present study has shown that PCR is a slightly more sensitive indicator of HPV infection than dot-blot hybridization. Agreement of HPV DNA results with conventional screening tests was not strong, an observation consistent with many comparative studies by others. In conclusion, PCR is slightly more sensitive than DNA hybridization for detection of HPV, it can be used in conjunction with specimen collection by gentle lavage of the cervicovaginal epithelium, and the possibility remains that it may prove suitable as a screening test.

Uterine cervical punch biopsy specimens can be analyzed by 1H MRS

Biopsy specimens of the uterine cervix, including colposcopically directed punch biopsy specimens of females with atypical Papanicolaou smear tests, are suitable for analysis by magnetic resonance (MR) spectroscopy. A narrow lined lipid MR spectrum, characteristic of malignant tissue, is obtained from a 6-mm3 biopsy specimen of histologically confirmed squamous carcinoma of the cervix. In contrast, specimens containing inflammatory cells generate a broad component only centered at 1.3 ppm with a T2 relaxation value of less than 350 ms. Most biopsy specimens which contain dysplastic cells or evidence of human papilloma virus (HPV) infection have a discernible lipid spectrum similar to that of the malignant tissue specimen. Long T2 relaxation values found in malignant tissue specimens at 1.3 and 1.2 ppm are observed in some but not all of the biopsies which show evidence of HPV infection. The suitability of small tissue samples, such as punch biopsy specimens, for study by MR illustrates the sensitivity of this technique and its potential as an aid to histopathological discrimination between the various precursor states of cervical cancer.