Correlation of high-risk human papillomavirus genotypes persistence and risk of residual or recurrent cervical disease after surgical treatment

Methylation testing for the detection of recurrent cervical intraepithelial neoplasia

Women treated for CIN2/3 remain at increased risk of recurrent CIN and cervical cancer, and therefore posttreatment surveillance is recommended. This post hoc analysis evaluates the potential of methylation markers ASCL1/LHX8 and FAM19A4/miR124-2 for posttreatment detection of recurrent CIN2/3. Cervical scrapes taken at 6 and 12 months posttreatment of 364 women treated for CIN2/3 were tested for methylation of ASCL1/LHX8 and FAM19A4/miR124-2 using quantitative multiplex methylation-specific PCR. Performance of the methylation tests were calculated and compared with the performance of HPV and/or cytology. Methylation levels of recurrent CIN were compared between women with a persistent HPV infection, and women with an incident HPV infection or without HPV infection. Recurrent CIN2/3 was detected in 42 women (11.5%), including 28 women with CIN2 and 14 with CIN3. ASCL1/LHX8 tested positive in 13/14 (92.9%) of recurrent CIN3 and 13/27 (48.1%) of recurrent CIN2. FAM19A4/miR124-2 tested positive in 14/14 (100%) of recurrent CIN3 and 10/27 (37.0%) of recurrent CIN2. Combined HPV and/or methylation testing showed similar positivity rates as HPV and/or cytology. The CIN2/3 risk at 12 months posttreatment was 30.8% after a positive ASCL1/LHX8 result at 6 months posttreatment. Methylation levels of CIN2/3 in women with a persistent HPV infection were significantly higher compared with women with an incident or no HPV infection. In conclusion, posttreatment monitoring by methylation analysis of ASCL1/LHX8 and FAM19A4/miR124-2 showed a good performance for the detection of recurrent CIN. DNA methylation testing can help to identify women with recurrent CIN that require re-treatment.

HPV self-sampling in the follow-up of women after treatment of cervical intra-epithelial neoplasia: A prospective study in a high-income country

Current follow-up strategy for women after large loop excision of the transformation zone (LLETZ) for cervical intra-epithelial neoplasia (CIN) is burdened by a low compliance. We evaluated the performance of home-based Human Papillomavirus (HPV) self-sampling (Self-HPV) after treatment for CIN with the aim to assess the (i) feasibility and (ii) follow-up compliance. This study took place at the Geneva University Hospitals between May 2016 and September 2020. Women aged 18 years or older, undergoing LLETZ for a biopsy-proven cervical intraepithelial neoplasia grade 1 or worse (CIN1 + ) were invited to participate. Agreement statistics, interpreted according to the scale of κ values, were calculated for Self-HPV and HPV performed by the physician (Dr-HPV). The samples were analyzed using GeneXpert and Cobas. Sample size was calculated to provide a 10% precision to estimate the kappa coefficient. A total of 127 women were included, with a median age of 35 years (interquartile range 30-41 years). There was a substantial agreement between Self-HPV and Dr-HPV using GeneXpert at 6 and 12 months, with a κ value of 0.63 (95%CI: 0.47-0.79) and 0.66 (95%CI: 0.50-0.82), respectively. Up to 9/10 (90%) women who did not come to their follow-up visit did not send their Self-HPV, either. In the follow-up after LLETZ treatment, home-based self-HPV is feasible, with substantial agreement between the two groups, however, concern remains regarding adherence to Self-HPV performance at home and loss to follow-up. The trial was registered on clinicaltrials.gov with the identifier NCT02780960.

Human Papillomavirus Persistence and Association With Recurrent Cervical Intraepithelial Neoplasia After Cryotherapy vs Loop Electrosurgical Excision Procedure Among HIV-Positive Women: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Persistence of cervical high-risk human papillomavirus (hrHPV) after treatment for cervical intraepithelial neoplasia grade 2 or higher (CIN2+) has not been compared between cryotherapy and loop electrosurgical excision procedure (LEEP) among HIV-positive women.

OBJECTIVE

To evaluate whether cryotherapy or LEEP is more effective at clearing hrHPV and whether persistent hrHPV is associated with CIN2+ recurrence among HIV-positive women.

DESIGN, SETTING, AND PARTICIPANTS

This is a secondary analysis of a randomized clinical trial conducted among women with HIV, hrHPV, and CIN2+ in Nairobi, Kenya. From June 2011 to September 2016, 354 HIV-positive women with CIN2+ disease had hrHPV cervical samples collected before and after treatment with cryotherapy or LEEP. Data were analyzed from September 2018 to January 2021.

INTERVENTIONS

Women were randomized 1:1 to receive cryotherapy or LEEP and were followed up every 6 months for 24 months with hrHPV cervical swab and Papanicolaou test with confirmatory biopsy.

MAIN OUTCOMES AND MEASURES

The main outcomes of this analysis were hrHPV positivity defined as having 1 of 12 hrHPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59) and disease recurrence defined as CIN grade 2 or higher as determined with cervical biopsy.

RESULTS

A total of 354 HIV-positive women with CIN2+ were included in the study; mean (SD) age was 37 (8) years in the cryotherapy arm and 38 (9) years in the LEEP arm. Baseline hrHPV prevalence was 90% (160 of 177) in the cryotherapy arm and 94% (166 of 177) in the LEEP arm (P = .24), and the most common hrHPV types detected were 16 (87 of 326 [27%]), 58 (87 of 326 [27%]), 35 (86 of 326 [26%]), 52 (66 of 326 [20%]), and 18 (56 of 325 [17%]). Over 24 months, clearance of hrHPV was significantly higher among those who underwent LEEP compared with cryotherapy (hazard ratio, 1.40; 95% CI, 1.03-1.90; P = .03). In multivariable analysis, hrHPV type-specific persistence at 12-month follow-up was significantly associated with CIN2+ recurrence from 12 months to 24 months (adjusted hazard ratio, 4.70; 95% CI, 2.47-8.95; P < .001). Performance of hrHPV testing at 12 months for recurrent CIN2+ was 93% sensitivity, 46% specificity, 38% positive predictive value, and 95% negative predictive value.

CONCLUSIONS AND RELEVANCE

In this secondary analysis of a randomized clinical trial, HIV-positive women who received LEEP were more likely to clear hrHPV infection compared with those undergoing cryotherapy, reinforcing the efficacy of LEEP in this population. Persistent hrHPV was significantly associated with recurrent CIN2+, suggesting that LEEP's benefits may be related in part to its ability to clear hrHPV infection. Screening for hrHPV infection after treatment among HIV-positive women may be used to rule out recurrent CIN disease given its high sensitivity and negative predictive value.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01298596.

Human papillomavirus genotyping predicts residual/recurrent disease after local treatment for cervical intraepithelial neoplasia better than viral DNA testing

AIM

Type-specific persistent infection (TSPI) of human papillomavirus (HPV) is reportedly associated with a high risk of residual/recurrent disease after local treatment for cervical intraepithelial neoplasia (CIN). This study aimed to evaluate whether HPV genotyping is more accurate in detecting residual/recurrent disease than HPV DNA testing and identify which HPV genotype can predict a high risk of residual/recurrent disease.

METHODS

We retrospectively reviewed patient outcomes and results of HPV DNA testing and genotyping at 6-12 months after local treatment for CIN2/3 for 439 women. We investigated residual/recurrent disease occurrence according to the TSPI and new infections. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) of the two testing methods for predicting residual/recurrent diseases were also evaluated.

RESULTS

Eighty-five (19.4%) patients were positive for HPV DNA testing after treatment, of which 74 (87.1%) had TSPI. Residual/recurrent disease was identified in 34 (7.7%) patients, of which 30 were positive for HPV DNA testing and had TSPI of HPV16, 18, 31, 33, 52, and 58 (six HPV genotypes). The sensitivity and NPV of HPV DNA testing and TSPI were equal at 88.2% and 98.9%, respectively. The specificity and PPV of TSPI were higher than those of HPV DNA testing (89.1% vs. 86.4%, 40.5% vs. 35.2%, respectively). Furthermore, the TSPI of the six HPV genotypes further improved specificity (90.6%) and PPV (44.1%) with the same sensitivity and NPV.

CONCLUSION

HPV genotyping is more useful than HPV DNA testing for determining TSPI, especially of the six HPV genotypes.

A Review on Inosine Pranobex Immunotherapy for Cervical HPV-Positive Patients

The purpose of this review was to examine and summarize data for inosine pranobex (IP) immunotherapy in cervical HPV-positive patients. Persistent or recurring cervical human papillomavirus (HPV) infection is a major cause of cervical cancer. Self-clearance and blocking of cervical HPV infection depend on the status of the host immune system. Immunotherapy helps accelerate elimination of the infection. Host immunity is involved in the development of HPV infection. Several mechanisms of interaction between the virus and the immune system have been revealed; however, the mechanisms have not been completely elucidated. A properly functioning immune system impedes HPV progress and helps clear the pathogen from the body. IP has antiviral efficacy because it modulates both cellular and humoral immunities. IP has been on the market since 1971. Nevertheless, it has seldom been administered to treat cervical HPV infections. In this review, Google Scholar, PubMed/MEDLINE, Scopus, Cochrane Library, and Research Gate were searched for the period 1971–2021. Prospective controlled trials, observational and retrospective studies, and meta-analysis and reviews on immunotherapy against HPV cervical infection were explored. Prior studies showed strong clinical efficacy of combined and standalone IP therapy in reversing HPV-induced changes in the cervix, preventing disease progression, and clearing the pathogen. IP treatment enhanced host antiviral activity against HPV, delayed or stopped cervical oncogenesis, and rapidly removed HPV from the body.

High grade cervical intraepithelial neoplasia positive biopsy: the importance of accurate pre-operative workup

BACKGROUND

In cervical cancer screening programs, women with abnormal cytology and confirmation by biopsy are referred for colposcopy for histological evaluation.

METHODS

We characterized the presence and the genotype of HPV by Linear Array HPV genotyping assay in cytological samples collected from about 400 women undergoing conization, with reported high CIN grade after biopsy.

RESULTS

The most prevalent genotype was HPV 16, with an increasing presence depending on the severity of the CIN and with the highest incidence in the 26-35 age range. In the group of younger women (<25) we found the highest percentage of CIN3 (39.3%) and the lowest of CIN1 (17.9%). An increase of CIN1 with increasing age was observed. A different distribution of HPV presence was observed depending on CIN grade (P<0.001): CIN1 HPV negative samples were 46.3%, CIN2: 5.8% and CIN3: 1.4%. Interesting, in the analyzed cohort, we observed the presence of 30% of CIN1. Moreover, within CIN1, 85% of them were associated to negative HPV detection, this observation suggested that the detection of HPV presence may be useful to identify low CIN grade that should be reconsidered for surgical treatment.

CONCLUSIONS

These findings suggest implementing the protocol for the management of women with high risk precancer lesions, with a further HPV test before surgical treatment. The evaluation of HPV presence and genotype before conization might represent a useful tool in reducing or postpone the conization treatment.

Risk factors for type-specific persistence of high-risk human papillomavirus and residual/recurrent cervical intraepithelial neoplasia after surgical treatment

Objective

This study aimed to investigate the clinicopathologic risk factors for type-specific persistence of high-risk human papillomavirus (hrHPV) and residual/recurrent cervical intraepithelial neoplasia (CIN) after surgical treatment.

Methods

Patients with CIN-2/3 who underwent conization or loop electrosurgical excision procedure (LEEP) at Korea University Hospital were enrolled. All patients underwent hrHPV testing and genotyping before conization or LEEP followed by both hrHPV genotyping and cytology. The significance of associations between patient characteristics and persistence of infection were assessed by multivariate logistic regression analyses.

Results

Among 398 women with pathologically confirmed CIN-2/3, 154 (38.7%) patients showed hrHPV persistence after surgical treatment. In multivariate analysis, high preoperative hrHPV load (P<0.05; odds ratio [OR], 2.063), presence of CIN-2 at treatment (P<0.01; OR, 2.732), and multiple hrHPV infections (P<0.001; OR, 4.752) were associated with hrHPV persistence. HPV 53 was the most likely to persist after treatment (24/43, 55.8%). The risk of residual/recurrent CIN-2/3 was higher in persistent infection with HPV 16 than other types (P<0.05). Menopause (P<0.001; OR, 3.969), preoperative and postoperative hrHPV load (P<0.05; OR, 2.430; P<0.05; OR, 5.351), and infection with multiple hrHPV types (P<0.05; OR, 2.345) were significantly related to residual/recurrent CIN following surgical treatment.

Conclusion

HPV load before treatment and infection with multiple hrHPV types were predictors of postoperative hrHPV persistence. HPV 53 was the type most likely to persist, but HPV 16 was the type that was most closely associated with residual/recurrent CIN-2/3.

Human Papillomavirus Genotyping Compared With a Qualitative High-Risk Human Papillomavirus Test After Treatment of High-Grade Cervical Intraepithelial Neoplasia: A Systematic Review

There is moderately high-quality evidence to support the improved clinical utility of human papillomavirus (HPV) genotyping compared with qualitative HPV positivity to follow-up after treatment of high-grade cervical intraepithelial neoplasia.

To systematically examine human papillomavirus (HPV) genotyping compared with qualitative high-risk HPV result during follow-up after treatment of high-grade cervical intraepithelial neoplasia (CIN), for risk estimation of posttreatment high-grade CIN.

[HPV vaccination: not only female adolescents and not only prophylactic. Review and position paper of the Italian HPV Study Group (IHSG)]

HPV vaccination has been introduced in clinical practice in recent years and represents the most effective strategy of primary prevention of cervical carcinoma and of female genital preneoplastic conditions. One of the major issues of the subject is represented by vaccination coverage of the target population. Since its introduction, HPV vaccine efficacy has been progressively demonstrated also towards extragenital HPV-correlated conditions and in males too. Moreover, even subjects of older age groups or subjects who already had HPV infections have been demonstrated to received benefits from vaccination, due to improvements of their immunological response. Recently, vaccine efficacy has also been investigated in terms of adjuvant administration after treatments of preneoplastic or benign conditions of the female lower genital tract caused by HPVs; preliminary results indicate an interesting and promising field of application. On this basis, in this article an analysis of the state of the art has been performed, with specific regard to the Italian scenario and with the focus of future perspectives of implementation of the HPV vaccination policy. From the available evidences, the Italian HPV Study Group recommends the extension of systematic HPV vaccination to males too, to adult subjects and also after conservative treatment of genital HPV correlated conditions.

FACTORS ASSOCIATED WITH PERSISTENCE OF HPV GENITAL INFECTION IN A SMALL COHORT OF ROMANIAN WOMEN

The aim of the study was to assess the role of behavioral factors in persistence of human papillomavirus (HPV) genital infection. Out of a cohort of 605 women included in a study of HPV infection prevalence, 142 HPV positive women (aged 18-57) were retested after a 12-month interval. None of the patients underwent surgical treatment during that period. Selected patients were asked for a second smear for cytologic analysis and HPV genotyping. A questionnaire that included information regarding reproductive health, sexual activity and smoking status was filled-in. After 12 months, 46 of 142 (32.39%) women had persistent HPV infection, with genotypes 16 and 18 found in 27 cases. On the other hand, 17 of 142 (11.97%) women had acquired new infections replacing the baseline genotypes. In our study, smoking (OR=2.320, p=0.0330) and sexual behavior (OR=5.333, p=0.0180 for more than three sexual partners; OR=2.427, p=0.0238 for cases where the partner was involved in another sexual relationship) were associated with viral persistence, while long-term contraception did not yield statistically significant results.

The Clearance of High-Risk Human Papillomavirus is Sooner After Thin Loop Electrosurgical Excision Procedure (t-LEEP)

Purpose/aim of the study: To investigate high-risk human papillomavirus (HPV) infection clearance following thin loop electrosurgical excision procedure (t-LEEP) among patients with cervical benign lesion. Materials and Methods: This retrospective study analyzed clinical data from patients with cervical benign lesion and HPV infection, who had undergone t-LEEP (T-Group), compared with patients with HPV infection undergone no treatment (NT-Group). Both groups attended regular follow-up between January 2008 and January 2012. Kaplan-Meier analysis was used to compare the HPV clearance time. Results: The average clearance time was 7.7 months (M) (95% confidence interval [CI]: 6.5-8.9 M) in T-Group, and 10.4 M (95%CI: 9.4-11.3 M) in NT-Group, with significant difference between groups (p = 0.003). Among patients with low viral load, the HPV clearance times were 7.6 M (95%CI: 6.3-9.0 M) in T-Group and 9.7 M (95%CI: 8.6-10.8 M) in NT-Group (p = 0.042). Among patients with high viral load, the HPV clearance times were 8.0 M (95%CI: 5.3-10.6 M) in T-Group and 11.4 M (95%CI: 9.7-13.1 M) in NT-Group (p = 0.041). The average time of HPV clearance in T-Group was shorter than NT-Group in all age groups, with significant differences in ≤29Y-group (p = 0.008) and 30-39Y-group (p = 0.005). The accumulated clearance rate of HPV infection at sixth month and 12th month were 24.5% and 67.9% in T-Group, 7.8% and 43.1% in NT-Group, with significant differences (p = 0.001 at 6th month, p = 0.032 at 12th month). Conclusions: T-LEEP accelerates the clearance of high-risk HPV infection and make the HPV infection rates dropped rapidly in the first year.

Incomplete excision of cervical precancer as a predictor of treatment failure: a systematic review and meta-analysis

BACKGROUND

Incomplete excision of cervical precancer is associated with therapeutic failure and is therefore considered as a quality indicator of clinical practice. Conversely, the risk of preterm birth is reported to correlate with size of cervical excision and therefore balancing the risk of adequate treatment with iatrogenic harm is challenging. We reviewed the literature with an aim to reveal whether incomplete excision, reflected by presence of precancerous tissue at the section margins, or post-treatment HPV testing are accurate predictors of treatment failure.

METHODS

We did a systematic review and meta-analysis to assess the risk of therapeutic failure associated with the histological status of the margins of the tissue excised to treat cervical precancer. We estimated the accuracy of the margin status to predict occurrence of residual or recurrent high-grade cervical intraepithelial neoplasia of grade two or worse (CIN2+) and compared it with post-treatment high-risk human papillomavirus (HPV) testing. We searched for published systematic reviews and new references from PubMed-MEDLINE, Embase, and CENTRAL and did also a new search spanning the period Jan 1, 1975, until Feb 1, 2016. Studies were eligible if women underwent treatment by excision of a histologically confirmed CIN2+ lesion, with verification of presence or absence of CIN at the resection margins; were tested by cytology or HPV assay between 3 months and 9 months after treatment; and had subsequent follow-up of at least 18 months post-treatment including histological confirmation of the occurrence of CIN2+. Primary endpoints were the proportion of positive section margins and the occurrence of treatment failure associated with the marginal status, in which treatment failure was defined as occurrence of residual or recurrent CIN2+. Information about positive resection margins and subsequent treatment failure was pooled using procedures for meta-analysis of binomial data and analysed using random-effects models.

FINDINGS

97 studies were eligible for inclusion in the meta-analysis and included 44 446 women treated for cervical precancer. The proportion of positive margins was 23·1% (95% CI 20·4-25·9) overall and varied by treatment procedure (ranging from 17·8% [12·9-23·2] for laser conisation to 25·9% [22·3-29·6] for large loop excision of the transformation zone) and increased by the severity of the treated lesion. The overall risk of residual or recurrent CIN2+ was 6·6% (95% CI 4·9-8·4) and was increased with positive compared with negative resection margins (relative risk 4·8, 95% CI 3·2-7·2). The pooled sensitivity and specificity to predict residual or recurrent CIN2+ was 55·8% (95% CI 45·8-65·5) and 84·4% (79·5-88·4), respectively, for the margin status, and 91·0% (82·3-95·5) and 83·8% (77·7-88·7), respectively, for high-risk HPV testing. A negative high-risk HPV test post treatment was associated with a risk of CIN2+ of 0·8%, whereas this risk was 3·7% when margins were free.

INTERPRETATION

The risk of residual or recurrent CIN2+ is significantly greater with involved margins on excisional treatment; however, high-risk HPV post-treatment predicts treatment failure more accurately than margin status.

FUNDING

European Federation for Colposcopy and Institut national du Cancer (INCA).

Cervical cancer screening in women vaccinated against human papillomavirus infection: Recommendations from a consensus conference

In Italy, the cohorts of women who were offered Human papillomavirus (HPV) vaccination in 2007/08 will reach the age (25years) for cervical cancer (CC) screening from 2017. The simultaneous shift from cytology-based screening to HPV test-based screening gives the opportunity for unprecedented reorganisation of CC prevention. The ONS (National Screening Monitoring Centre) Directive and the GISCi (Italian Group for Cervical Screening) identified the consensus conference as the most suitable method for addressing this topic. A summary of consensus recommendations is reported here. The main objective was to define the best screening methods in girls vaccinated against HPV and the knowledge required for defining evidence-based screening strategies. A Jury made recommendations about questions and proposals formulated by a panel of experts representative of Italian scientific societies involved in CC prevention and based on systematic reviews of literature and evidence. The Jury considered changing the screening protocols for girls vaccinated in their twelfth year as appropriate. Tailored screening protocols based on vaccination status could be replaced by "one size fits all" protocols only when a herd immunity effect has been reached. Vaccinated women should start screening at age 30, instead of 25, with HPV test. Furthermore, there is a strong rationale for applying longer intervals for re-screening HPV negative women than the currently recommended 5years, but research is needed to determine the optimal screening time points. For non-vaccinated women and for women vaccinated in their fifteenth year or later, the current protocol should be kept.

Evaluation of p16INK4a immunostaining for the detection of high-grade changes in cervical cytology

Since its introduction in Australia in 2007, the human papillomavirus (HPV) vaccine has led to a markedly lower prevalence of vaccine targeted HPV genotype infections as well as HPV disease including genital warts and histologically confirmed high-grade (HG) cervical abnormalities. To increase the ability to identify abnormal cells in lower prevalence, adjunct markers can be incorporated to improve the sensitivity and specificity of cytology test. One such marker is p16(p16), which is detectable in cells expressing the E7 oncogene encoded by high-risk HPVs (HR-HPV). In this study, the sensitivity and specificity of p16 immunostaining in detection of underlying HG lesions was evaluated in a cohort of 454 women undergoing surgical treatment for biopsy proven cervical dysplasia. Overall, p16 positive cells were detected in 321 (71%) of cytology preparations evaluated. Comparison of p16 staining on cytological preparations to histology diagnosis available on 212 patients, showed 26 (54%), 41 (78%) and 80 (90%) of cytology preparations to be p16 positive in women with CIN1, CIN2 and CIN3, respectively (p < 0.005). HPV16 and 18 were the most prevalent genotypes in HG lesions and were highly correlated with p16 staining. p16 staining provides an additional marker which can assist in better detecting underlying HG lesion in cytology smears with low disease prevalence.

Distribution of Human Papillomavirus Genotypes in Iranian Women According to the Severity of the Cervical Lesion

BACKGROUND

Persistent infection with high-risk human papillomavirus (HPV) has been recognized as a major cause of cervical cancer. Distribution of HPV genotypes may differ according to the geographic region and the severity of the cervical lesion. Determining HPV genotypes' specific distribution is useful for HPV surveillance and control programs. However, little is known about the distribution of HPV genotypes in Iranian women.

OBJECTIVES

The aim of this study was to determine the distribution of HPV genotypes in Iranian women with different grades of cervical lesions.

PATIENTS AND METHODS

From 2011 to 2013, a total of 436 Iranian women with convenience sampling strategy were included in this cross-sectional study. In detail, 287 women negative for intraepithelial lesion or malignancy, 32 with atypical squamous cells of undetermined significance (ASCUS), 50 with low-grade squamous intraepithelial lesion (LSIL), 44 with high-grade squamous intraepithelial lesion (HSIL), and 23 with cervical cancer were evaluated in this investigation. HPV genotypes were determined by INNO-LiPA HPV Genotyping Extra assay.

RESULTS

In total, HPV infection was detected in 45.4% of the cases. The most common high-risk HPV (HR-HPV) genotype was HPV-16 (32.8%), followed by HPV-53 (9.1%). Within low-risk (LR-HPV) genotypes HPV-6 (22.2%) and HPV-44 (6.1%) were the most prevalent. HPV-16 was the predominant genotype in cases with cervical cancer (56.5%), ASCUS (34.4%), and HSIL (34.1%). HPV-6 was the most common genotype in normal cases (9.1%) and LSIL patients (18%). The prevalence of HPV positivity was significantly higher in cases with high-grade lesions (≥ HSIL) (64.2%) than in normal/LSIL (37.3%) (P = 0.033). The rate of HR-HPV infection was significantly higher in ≥ HSIL cases (61.2%) than normal/LSIL (27.9%) (P = 0.003).

CONCLUSIONS

This study describes robust information on the distribution of HPV genotypes among Iranian women with and without cervical lesions. The present data may be of importance for designing future public health strategies, including HPV vaccination programs.

HPV testing in the context of post-treatment follow up (test of cure)

BACKGROUND

Women treated for cervical lesions are at higher risk of subsequent disease compared to the general population. Consequently, post treatment surveillance strategies are required to ensure the success of treatment, so called "test of cure". The high sensitivity and negative predictive value of HPV assays can enhance post-treatment strategies.

OBJECTIVES

To provide an overview of the current data on test of cure strategies with a particular focus on HPV testing and to identify knowledge gaps and areas for further research.

RESULTS

HPV testing is sensitive for the detection of residual or recurrent disease post treatment for CIN2+ and is more sensitive than cytology alone. Co-testing increases sensitivity, marginally and there is a lack of consensus regarding the efficiency and safety to release negative women. Most test of cure studies have applied HPV DNA tests and post treatment positivity rates vary widely depending on assay and potentially, treatment type.

CONCLUSIONS

Globally, an increasing number of test of cure algorithms now incorporate HPV testing although there is heterogeneity of practice with respect to assay, number of post treatment tests, testing intervals, follow up time. While type specific persistence identified through genotyping may identify those at greater risk of disease there is no consensus as to how this may be applied, clinically. Data on HPV testing in women treated for glandular lesions would be welcome as would the performance of different HPV assays and associated biomarkers in this context.

[Primary cervical cancer screening]

Cervico-uterine cancer screening with cytology decrease incidence by more than 50%. The cause of this cancer is the human papilloma virus high risk, and requires a sensitive test to provide sufficient sensitivity and specificity for early detection and greater interval period when the results are negative. The test of the human papilloma virus high risk, is effective and safe because of its excellent sensitivity, negative predictive value and optimal reproducibility, especially when combined with liquid-based cytology or biomarkers with viral load, with higher sensitivity and specificity, by reducing false positives for the detection of cervical intraepithelial neoplasia grade 2 or greater injury, with excellent clinical benefits to cervical cancer screening and related infection of human papilloma virus diseases, is currently the best test for early detection infection of human papillomavirus and the risk of carcinogenesis.

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

BACKGROUND

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Performance of HPV DNA testing in the follow-up after treatment of high-grade cervical lesions, adenocarcinoma in situ (AIS) and microinvasive carcinoma

Background

Over the last two decades it has become clear that distinct types of human papillomavirus (HPV), the so-called high-risk types (hrHPV), are the major cause of cervical cancer. The hrHPV-DNA testing has shown excellent performance in several clinical applications from screening to the follow-up of conservatively treated patients.

Methods

We conducted a systematic review of the recent literature on the performance of HPV DNA testing in follow-up after treatment of high-grade cervical lesions, adenocarcinoma in situ, and microinvasive carcinoma compared to Pap smear cytology.

Results

Observational studies have demonstrated that the high risk hrHPV-DNA test is significantly more sensitive (95%) compared to follow-up cytology(70%) in detecting post-treatment squamous intraepithelial high-grade lesions. Moreover, in patients treated conservatively for cervical adenocarcinoma in situ, the hrHPV-DNA test is the most significant independent predictor of recurrent disease or progression to invasive cancer, and the combination of viral DNA testing and cytology reaches 90% sensitivity in detecting persistent lesions at the first follow-up visit and 100% at the second follow-up visit. The cause of microinvasive squamous cervical carcinoma is increasingly treated with conservative therapies in order to preserve fertility, and an effective strategy allowing early detection of residual or progressive disease has become more and more important in post-treatment follow-up. Primary results seem to indicate that the median time for viral clearance is relatively longer compared with patients treated for CIN and suggest a prolonged surveillance for these patients. However, the potential clinical value of HPV-DNA testing in this clinical setting needs to be confirmed by further observations.

Conclusions

The excellent sensitivity, negative predictive value, and optimal reproducibility of the hrHPV DNA testing, currently is considered a powerful tool in the clinicians’ hands to better manage post-treatment follow-up either in cervical squamous lesion or in situ adenocarcinoma.

E6/E7 mRNA testing for human papilloma virus-induced high-grade cervical intraepithelial disease (CIN2/CIN3): a promising perspective

Since the introduction of biomolecular testing for the identification of high-risk human papillomavirus DNA (hrHPV-DNA) in cervical cancer preventive strategies, many interesting aspects have emerged in this field; firstly, HPV-DNA testing has been demonstrated to have better sensitivity than conventional cytology in several settings: screening, triage of ASC-US and in follow-up after treatment. Despite this, some limitations of these new technologies have also been underlined: the major issue is the low specificity of the tests, which cannot discriminate between regressive and progressive infections. Thus, recent research has moved the attention towards novel markers of progression that could more precisely detect cases at real risk of cancer development. In view of the fact that progression to cancer is dependable of the E6/E7 proteins integration and transforming action, the overexpression of E6/E7 transcripts has been seen as a valuable marker of this risk. This review aims to summarise the literature data on this topic and to provide a clear view of the emerging perspectives.

Risk factors for high-risk and multi-type Human Papillomavirus infections among women in Ho Chi Minh City, Vietnam: a cross-sectional study

Background

Concurrent infection with multiple types of Human Papillomavirus (HPV) is associated with an increased risk of cervical cancer; yet, little is known about risk factors for concurrent HPV infection in Vietnam. This study investigated the prevalence of and risk factors for high-risk-type HPV and multi-type HPV infections among women in Ho Chi Minh City, Vietnam.

Methods

Data were collected from a population-based survey of 1,550 women (mean age = 42.4; SD = 9.5), using a multi-stage sampling process. Socio-demographic and behavioral variables were obtained by self-report. HPV genotypes in cervical specimens were identified using PCR protocols.

Results

The prevalence of any high-risk HPV infection was 9.0%, and of multi-type HPV infection was 1.9%. In the HPV+ subsample, the percentage of high-risk HPV was 84% and of multi-type HPV was 20%. All multi-type HPV infections were high-risk-type. Lifetime smoking and older age of first sex were significantly associated with any high-risk and multi-type HPV infections. Regular condom use was inversely associated with high-risk and multi-type HPV infection.

Conclusions

Risk factors for high-risk and multi-type HPV infections were similar. Further research and intervention are needed to reduce HPV infections in order to prevent HPV-related cancers.

Follow-up strategies after treatment (large loop excision of the transformation zone (LLETZ)) for cervical intraepithelial neoplasia (CIN): Impact of human papillomavirus (HPV) test

BACKGROUND

Development of cancer of the cervix is a multi-step process as before cervical cancer develops, cervical cells undergo changes and become abnormal. These abnormalities are called cervical intraepithelial neoplasia (CIN) and are associated with increased risk of subsequent invasive cancer of the cervix. Oncogenic high-risk human papillomavirus (hrHPV), the causative agent of cervical cancer and its precursor lesions, is present in up to one-third of women following large loop excision of the transformation zone (LLETZ) treatment and is associated with increased risk of residual disease and disease recurrence. HPV testing may serve as a surveillance tool for identifying women at higher risk of recurrence. High-risk human papillomavirus testing will enable us to identify women at increased risk of residual or recurrent CIN and therefore will allow us to offer closer surveillance and early treatment, when indicated.

OBJECTIVES

• To evaluate the effectiveness and safety of hrHPV testing after large loop excision of the transformation zone (LLETZ) treatment• To determine optimal follow-up management strategies following LLETZ treatment according to hrHPV status

SEARCH METHODS

We searched the Cochrane Gynacological Cancer Review Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed and PsycINFO up to August 2013. We searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies, and we contacted experts in the field.

SELECTION CRITERIA

We searched for randomised control trials (RCTs) that compared follow-up management strategies following LLETZ treatment for CIN.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. No trials were found; therefore no data were analysed.

MAIN RESULTS

The search identified 813 references on MEDLINE, 418 on EMBASE, 22 on CINAHL, 666 on PubMed, 291 on PsycINFO and 145 on CENTRAL. When all references were imported into EndNote and duplications were removed, 1348 references remained. Initial screening of titles and abstracts of these references revealed that 42 references were potentially eligible for this review. After reading the full-text versions, we identified no relevant trials comparing hrHPV and cytology testing versus cytology testing alone for detecting residual or recurrent disease during follow-up to LLETZ treatment of adult women with CIN.We found no evidence on the effects of hrHPV and cytology testing on residual or recurrent CIN2 or higher lesions, anxiety and psychosexual morbidity outcomes in women undergoing colposcopy and treatment for CIN.

AUTHORS' CONCLUSIONS

We found no evidence from RCTs to inform decisions about the best surveillance strategy for women following treatment for CIN. A prognostic systematic review is needed to investigate the risk of developing recurrent cervical intraepithelial neoplasia 2+ (CIN2+) in women with a positive hrHPV test after large loop excision of the transformation zone (LLETZ) treatment.

A whole-population profile of HPV testing as a test of cure for high-grade cervical dysplasia in NSW, Australia

Introduction

Few population-based studies have been conducted on the efficacy of human papilloma virus (HPV) testing as a test of cure for high grade cervical dysplasia.

Methods

A cohort of women (n = 11,521) with high grade (CIN2+) cervical dysplasia diagnosed during 2006–2010, who also had accompanying HPV testing (n = 19,434 HPV tests), was analyzed with respect to National Health and Medical Research Council (NHMRC) follow-up guidelines. Cure rates, and number of follow-up tests and times to reach a cure were estimated.

Results

In the ≥2-years following high grade dysplasia, 53% of women had a single follow-up HPV test, 33% had two, and 14% had three or more HPV follow-up tests. 75% of women with follow-up HPV and cytology testing according to NHMRC guidelines were cured (2,210 from 2,948). Cure rates were lowest in those aged <30 (71%) and highest in women aged 30–49 (80%). Of those cured, 68% attained cure by the second HPV test, 21% by the third, and 11% at the fourth or later HPV test. The median time to cure was 1,097 days. In non-cured women, 56% of test results originated from all-negative cytology with positive HPV, compared with 9% from all-negative HPV results.

Conclusions

Cure rates in women with follow-up testing according to NHMRC guidelines are high. Further studies are needed of the high proportion of women with negative cytology classed as not cured due to HPV positivity, and of the high proportion of women with high grade dysplasia who had one follow-up HPV test only.

Oral HPV infection and persistence in patients with head and neck cancer

OBJECTIVE

To investigate the presence and persistence of human papillomavirus (HPV) infection in the oral mucosa of patients with head and neck squamous cell carcinoma (HNSCC), and its correlation with prognosis.

STUDY DESIGN

HPV infection was characterized in tumors and pre and posttreatment oral scrapings in 51 patients with HNSCC and matched controls using the SPF10 LiPA Extra assay. p16INK4A immunostain and in situ hybridization for high-risk HPV genotypes recognized transcriptionally active infection in tumor samples. The risk of infection was compared in patients and controls. The association of pretreatment HPV status with recurrence and survival and with posttreatment HPV persistence was assessed.

RESULTS

Oral HPV infection risk was significantly higher in patients with HNSCC than in controls (P < .001). Oral HPV infection was associated with infection in the first posttreatment scrapings (P = .015), but did not affect recurrence or prognosis.

CONCLUSION

Oral HPV infection is frequent in patients with HNSCC and has no prognostic implications, suggesting that posttreatment polymerase chain reaction monitoring on oral cells is not effective to monitor patient recurrence risk.

Clearance of human papillomavirus in women treated for cervical dysplasia

OBJECTIVE

To estimate human papillomavirus (HPV) clearance of women with cervical abnormalities after treatment.

METHODS

Women attending dysplasia clinics between 2001 and 2007 with a new diagnosis of high-grade dysplasia or persistent low-grade dysplasia requiring treatment by excision or laser ablation were invited to participate. Cervical cytology, histology of biopsies collected at colposcopy, and HPV DNA detection and genotyping of 37 HPV genotypes on specimens collected at treatment and subsequent routine visits were examined. A log-rank test was used to compare the survival distribution between groups.

RESULTS

Of the 1,649 women eligible at treatment (baseline), 1,207 (73%) were included in the analysis; 96% (n=1,159) had three or more posttreatment visits. At baseline and the subsequent three follow-up visits, the prevalence of women with HPV DNA detected was 84%, 53% (on average, 6.3 months after baseline), 44% (on average, 15.7 months after baseline), and 45% (on average, 24.3 months after baseline). The median time to HPV clearance was approximately 6 months for either HPV 16 (n=387) or HPV 18 (n=96), irrespective of concurrent detection of other types. On average, HPV 16 or HPV 18 types cleared faster than other types (P<.001). This association remained significant after adjustment for age, preoperative histology, number of preoperative histology results, and treatment type.

CONCLUSION

Clearance times of HPV 16 and HPV 18 infections were similar to each another but shorter than other HPV types.

LEVEL OF EVIDENCE

III.

Polymerase chain reaction and deoxyribonucleic acid-sequencing based study on distribution of human papillomavirus 16/18 among histopathological types of cervical intra-epithelial neoplasia and primary invasive cervical carcinoma: A scenario in North Bengal, India

Introduction:

Human papillomavirus (HPV) types 16/18 are reportedly most common in cervical cancer (CaCx) with geographical variation of genotypes. HPV16 predominates both in squamous cell carcinoma (SCC) and adenocarcinoma in India, contrary to reported global predominance of HPV18 in the latter. Our study was aimed to determine the occurrence of HPV16/18 among histopathological types of cervical intra-epithelial neoplasia (CIN) and invasive CaCx from North Bengal, India and to identify any major deviation from the known Indian scenario of distribution of HPV16/18 genotypes in cases of SCC and adenocarcinoma.

Materials and Methods:

This was a retrospective, cross-sectional, case-only type of study, in which 40 cases were histopathologically diagnosed as CIN/CaCx, on which polymerase chain reaction (PCR), deoxyribonucleic acid (DNA)-sequencing and bioinformatics by basic search local alignment tool were performed for HPV-genotyping.

Statistical Analysis:

The distribution of HPV genotypes among cases of SCC and adenocarcinoma was compared by Fisher's exact-test.

Results:

HPV was detected in 97.5% (39/40) cases. HPV16-infected cases (32/39; 82.05%) predominated over HPV18-infected ones (7/39; 17.95%). However, HPV18-only infection was significantly (P = 0.0045, one-sided Fisher's exact test) more among adenocarcinoma (3/4; 75%) than SCC (2/26; 7.69%) contrary to HPV16-only infection (SCC = 24/26, 92.31%; adenocarcinoma = 1/4; 25%) whereas both CIN3 cases were HPV16-positive.

Conclusion:

Predominance of HPV18 over HPV16 in cases of adenocarcinoma in this region was contrasting to that of earlier Indian studies suggesting research on HPV18 related cervical carcinogenesis. PCR and DNA-sequencing could prove to be highly effective tools in HPV detection and genotyping. The study reported HPV16/18 infection in almost 98% of the cases, the knowledge about which might prove useful in future population based studies on HPV genotyping and designing of appropriate HPV-vaccines for this region.

The incidence of human papillomavirus infection following treatment for cervical neoplasia: a systematic review

OBJECTIVE

To systematically review the published literature in order to estimate the incidence and describe the variability of human papillomavirus (HPV) infection in women following treatment for cervical neoplasia.

METHODS

Several scientific literature databases (e.g. PubMed, ISI Web of Science) were searched through January 31, 2012. Eligible articles provided data on (i) baseline HPV infection status within 6 months prior to or at time of treatment (pre-treatment); and (ii) HPV test results for women's first visit after treatment occurring within 36 months (post-treatment). We abstracted and summarized the post-treatment incidence of newly detected HPV genotypes that were not present at pre-treatment, overall and stratified by study and other population characteristics.

RESULTS

A total of 25 studies were included, reporting post-treatment HPV incidence in nearly 2000 women. Mean patient age ranged from 31 to 43 years (median 36). Most studies used cervical exfoliated cell specimens to test for HPV DNA (n=20; 80%), using polymerase chain reaction (n=21; 84%). Cervical neoplasia treatment included loop electrical excision procedure (n=11; 44%); laser conization (n=2; 8%); laser ablation, surgical conization, cryotherapy, alpha-interferon (n=1; 4% each); or multiple treatment regimens (n=8; 32%). Follow-up times post-treatment ranged from 1.5 to 36 months (median 6). More than half of studies (n=17; 68%) estimated the incidence of any HPV type following treatment, while 7 (28%) focused specifically on high-risk (HR) HPV. HPV incidence after treatment varied widely, ranging from 0 to 47% (interquartile range: 0%-15%) in up to 3 years of follow-up after treatment. Lower HPV incidence was observed among studies that included relatively younger women, used laser conization, focused on HR-HPV rather than overall HPV infection, and had a lower proportion of recurrent cervical disease.

CONCLUSIONS

These modest summary incidence estimates from the published literature can guide clinicians, epidemiologists and health economists in developing best practices for post-treatment cervical cancer prevention.

High HPV-51 prevalence in invasive cervical cancers: results of a pre-immunization survey in North Sardinia, Italy

Background

Human Papilloma virus (HPV) is recognized as the etiological agent of benign and malignant ano-genital lesions. The most prevalent genotypes associated with cervical carcinoma are HPV-16 and -18 worldwide. However, recent studies have emphasized the role of other genotypes, such as HPV-51, in the pathogenesis of cervical dysplasia. The aim of the study was to estimate the burden of HPV-51 infection in invasive cervical malignant lesions in Northern Sardinia, Italy.

Methods/Principal Findings

An observational, retrospective, prevalence, mono-center study was carried out to evaluate the presence of HPV genotypes in tissues biopsies of cervical lesions (CIN-1, CIN-2, CIN-3 and invasive carcinoma) gathered from 1996 to 2009. Biological samples were collected from women admitted consecutively to a tertiary university hospital situated in Sassari, Italy. Molecular methods were used to identify 28 oncogenic HPV types. A total of 155 formalin-fixed and paraffin-embedded cervical tissue samples were analyzed. Approximately half of the cervical lesions were classified as invasive carcinoma. HPV-DNA was detected in 71% of the samples, with a higher frequency (100%) in those categorized as invasive neoplasia. Mono- or co-infections were demonstrated in 45.8% and 25.8% of the cervical samples, respectively. Overall, the most prevalent HPV types were -16 (49%) and -51 (19.4%), with an increased frequency of detection associated with the severity of the cervical lesions.

Conclusions/Significance

This survey highlights for the first time the relevant role of HPV-51 infection in the pathogenesis of invasive cervical cancer prior to the introduction of a vaccination program. Although a selection bias could have influenced the results, other recent studies have described the impact of HPV-51. This remarkable epidemiological element should be carefully evaluated, particularly in the view of opting for preventive vaccines, whose cross-protection patterns determine their efficacy in protecting against infection from HPV types that are not included in the vaccine itself.

HPV-Based Screening, Triage, Treatment, and Followup Strategies in the Management of Cervical Intraepithelial Neoplasia

Cervical cancer is the second most common cause of death from cancer in women worldwide, and the development of new diagnostic, prognostic, and treatment strategies merits special attention. Many efforts have been made to design new drugs and develop immunotherapy and gene therapy strategies to treat cervical cancer. HPV genotyping has potentially valuable applications in triage of low-grade abnormal cervical cytology, assessment of prognosis and followup of cervical intraepithelial neoplasia, and in treatment strategies for invasive cervical cancer. It is known that during the development of cervical cancer associated with HPV infection, a cascade of abnormal events is induced, including disruption of cellular cycle control, alteration of gene expression, and deregulation of microRNA expression. Thus, the identification and subsequent functional evaluation of host proteins associated with HPV E6 and E7 oncoproteins may provide useful information in understanding cervical carcinogenesis, identifying cervical cancer molecular markers, and developing specific targeting strategies against tumor cells. Therefore, in this paper, we discuss the main diagnostic methods, management strategies, and followup of HPV-associated cervical lesions and review clinical trials applying gene therapy strategies against the development of cervical cancer.

Emerging human papillomavirus vaccines

INTRODUCTION

Identification of human papillomavirus (HPV) as the etiologic factor of cervical, anogenital, and a subset of head and neck cancers has stimulated the development of preventive and therapeutic HPV vaccines to control HPV-associated malignancies. Excitement has been generated by the commercialization of two preventive L1-based vaccines, which use HPV virus-like particles (VLPs) to generate capsid-specific neutralizing antibodies. However, factors such as high cost and requirement for cold chain have prevented widespread implementation where they are needed most.

AREAS COVERED

Next generation preventive HPV vaccine candidates have focused on cost-effective stable alternatives and generating broader protection via targeting multivalent L1 VLPs, L2 capsid protein, and chimeric L1/L2 VLPs. Therapeutic HPV vaccine candidates have focused on enhancing T cell-mediated killing of HPV-transformed tumor cells, which constitutively express HPV-encoded proteins, E6 and E7. Several therapeutic HPV vaccines are in clinical trials.

EXPERT OPINION

Although progress is being made, cost remains an issue inhibiting the use of preventive HPV vaccines in countries that carry the majority of the cervical cancer burden. In addition, progression of therapeutic HPV vaccines through clinical trials may require combination strategies employing different therapeutic modalities. As research in the development of HPV vaccines continues, we may generate effective strategies to control HPV-associated malignancies.

Risk factors for cervical intraepithelial neoplasia recurrence after conization: a 10-year study

OBJECTIVE

To evaluate the risk factors potentially involved in the development of cervical intraepithelial neoplasia (CIN) recurrence after cervical conization in a long-term follow-up period.

STUDY DESIGN

Consecutive patients with histologically proven CIN who had undergone either cold knife conization or a loop electrosurgical excision procedure were enrolled and scheduled for serial follow-up examinations over a 10-year period. Data were stored in a digital database. Multivariate analysis was performed to identify factors for recurrence.

RESULTS

Between January 1999 and December 2009, 282 patients fulfilled the inclusion criteria and were included in the final statistical analysis. After a median follow-up of 26.7 months (range 6-100), 64 (22.7%) women developed histologically confirmed recurrence. The 2-year recurrence-free survival was 83.7% and 66.7% for women with negative and positive margins, respectively (p=0.008). The 5-year recurrence-free survival was 75.4% and 50.3% for patients with negative and positive margins, respectively (p=0.0004). Positive surgical margin was the most important independent predictor of recurrence [HR 2.5 (95%CI 1.5-4.5), p=0.0007; Wald 11.338]. After multinomial logistic regression the indication for conization based on persistent CIN1 was the only independent predictor for negative margin [OR 0.3 (95%CI 0.1-0.7), p=0.008].

CONCLUSIONS

Our study demonstrated that the surgical margin status represents the most important predictor for CIN recurrence after conization. After excisional therapy, close follow-up is mandatory for the early detection of recurrent disease. The identification of risk factors for recurrence may guide clinical decision-making on expectant management versus re-intervention.

HPV-DNA testing for cervical cancer precursors: from evidence to clinical practice

The large amount of literature published over the last two decades on human papillomavirus (HPV)-DNA testing has definitely demonstrated the association between high-risk viral genotypes (hrHPV) and cervical cancer. Moreover, hrHPV-DNA testing has shown excellent performance in several clinical applications, from screening settings to the follow-up of treated patients, compared to conventional cytology or colposcopy options. On the other hand, when a huge number of reports are published on the same subject in a relatively short period of time, with many variations in settings, study designs and applications, the result is often confusion and decreased comprehension by readers. In daily office practice, several different situations (in symptomatic or asymptomatic women) can be positively managed by the correct use of hrHPV-DNA testing. Validated hrHPV-DNA testing and, specifically, the HC2® assay, due to its excellent sensitivity and negative predictive value together with optimal reproducibility, currently represent a powerful tool in the clinician’s hands to optimally manage several situations related to HPV infection and the potential development of cervical cancer.

Prevalence and type distribution of human papillomavirus infection in women from North Sardinia, Italy

Background

Human papillomavirus (HPV) has been associated with several disorders of the genital tract, skin and oropharynx. The aims of our study were to evaluate the prevalence of HPV infection in women between 15 and 54 years of age in North Sardinia, Italy, to identify the prevalence of High Risk - Human papillomaviruses (HR-HPV) genotypes and to establish a correlation between molecular and cytological results.

Methods

From 2007 to 2009 we consecutively enrolled women aged 15-54 years admitted to public and private outpatient settings. All the participants filled in a questionnaire about the socio-cultural state, sexual activity and awareness about HPV. 323 cervical specimens were tested for HPV-DNA and HPV genotypes with INNO-LiPA HPV Genotyping CE Amp kit. Samples showing positivity to some HPV genotypes were re-tested using "in house" quantitative Real-Time PCR assays.

Results

Overall HPV-DNA positivity was detected in 35.9% of the women. The prevalence of HR-HPV infection among HPV positive samples was 93.1% with a specific prevalence of HPV 16, 51, 31, 53 and 18 of 54.3%, 37.9%, 10.3%, 6.9% and 5.2%, respectively. Co-infection with any HPV, HR-HPV, LR-HPV and HR/LR-HPV type was 18.3%, 14.9%, 0.9% and 2.5%, respectively; HPV 16/51 co-infection was detected in 64.6% of the HR-HPV co-infection group. The most frequent HPV-genotypes detected were 16 (32.5%) and 51 (22.7%). Among the 57 patients harboring mono-infection the most prevalent HPV genotypes were 16 (38.6%) and 31(10.5%). A multivariate analysis identified a statistical significant association between HPV infection and age and between HPV infection and previous sexual transmitted diseases. A statistically significant association between cytological cervical lesions and generic HPV exposure was identified.

Conclusions

To our knowledge, this is the first survey evaluating the prevalence of HPV infection in Northern Sardinia and drawing attention to the unusual high proportion of genotype HPV 51. Given the recent implementation of a widespread immunization program with vaccines not containing HPV 51, it has been relevant to prove the high prevalence of this HPV genotype from the start of the vaccination campaign, in order to avoid in the future attributing to the vaccination program a possible selection effect (HPV replacement).

[The role of human papillomavirus typization and cytology in early detection of relapse of cervical intraepithelial neoplasia]

BACKGROUND/AIM

Female patients who underwent ceratin treatment forms of cervical intraepithelial neoplasia (CIN) are at five times greater risk for disease relapse in comparison to the rest of female population. The aim of the study was to investigate validity of human papillomavirus (HPV) typization and cytology in detection of relapse. METHODS; The prospective clinical investigation included 35 patients with relapse and 30 ones without it after adequate treatment of cervical intraepithelial neoplasia. HPV typization using PCR methods and cytological test (conventional Pap smear) were performed in all the patients. Validation of tests applied was performed by determining their sensitivity, specificity, and positive and negative predictive value.

RESULTS

More severe degrees of CIN relapse occur significantly more often in patients which remain HPV positive despite of the treatment. The patients which remain positive on HPV type 18 or, on both HPV types 18 and 16, have more often CIN relapses of more severe degree in relation to those just positive on HPV type 16. HPV typization has higher predictive value for diagnosis of the rezidual disease in older patients. Sensitivity of HPV typization for diagnosis all CIN relapse degrees is 68.57%, for more severe degrees (HSIL and MIC) 90.47%, specificity is 93.33%, while positive and negative predictive values are 90.47% and 93.53%, respectively. Sensitivity of cytology for diagnosis of more severe CIN relapses is 80.95%. HPV typization used along with cytology ofters the highest sensitivity (95.23%).

CONCLUSION

Both tests, HPV typization and Pap smear, offer satisfactory sensitivity and high specificity in detection of relapse, parcticularly those with more severe degree. The highest sensitivity in detection of CIN relapse is obtained by using both tests.

Role of HPV testing in the follow-up of women treated for cervical dysplasia

PURPOSE

The aim of study was to investigate factors predicting persistence or relapse of disease after cervical conisation for high-grade squamous intraepithelial lesions (CIN 2 or 3).

METHODS

The study involved 78 women with high-grade squamous intraepithelial lesions, conservatively treated with loop electroexcision procedure for cervical conisation and subsequent with CO(2) laser-vaporisation of the cervical bed. Histological specimens were totally included and examined by an experienced pathologist. To evaluate the efficacy of treatment, the patients were examined with colposcopy and Pap smear 4 months after surgery and with PCR to search for and genotyping of HPV, 10 months after treatment.

RESULTS

During the post-treatment follow-up, the cytologic examination showed persistent/relapsing disease in six patients (7.6%). In only 1 case, the deep margin of the cone was considered positive for CIN (16%).Ten months after treatment, viral typing revealed the persistence of high-risk HPV in all of these patients. Conversely, the viral follow-up of the other 72 patients without persisting/relapsing disease after treatment disclosed low-risk HPV genotypes in 6 cases, high-risk HPV in 2 cases (2.7%), whereas 7 cases had positive margins for CIN (9.7%). The risk of persistence and relapse of CIN in the group with positive margins was not statistically significant (P = 0.87), whereas it was in the group with HR-HPV positive (P = 0.000048).

CONCLUSION

HPV testing is the most sensitive mean of identifying persistence or relapse early and is therefore capable of optimising follow-up after the treatment of high-grade CIN.

Residual and recurrent disease rates following LEEP treatment in high-grade cervical intraepithelial lesions

INTRODUCTION

Loop electrosurgical excision procedure (LEEP) is a basic procedure in the conization performed on patients with CIN II/III. After excisional therapy, close follow up is essential for the earlier detection of residual and recurrent disease. The value of PAP-smear and HPV-DNA tests for investigation of residual and recurrent disease in patients diagnosed with high-grade intraepithelial lesion after LEEP treatment was purposed.

MATERIALS AND METHODS

42 patients were included in the study for whom epithelial cell anomalies were detected at PAP-smear screening. HPV-DNA test, colposcopy, cervical biopsy and endocervical curettage and then LEEP procedures were performed. The patients were followed with HPV DNA and PAP-smear tests in terms of recurrence and residual disease at 3-month intervals.

RESULTS

HPV-DNA examination revealed that 36 patients (85.7%) were positive for high-risk HPV-DNA before treatment. Histopathological evaluation of LEEP materials revealed the presence of CIN I in 4 and CIN II/III in 38 patients. Surgical margin was positive in five patients. No sign of invasive cervical neoplasia was detected. The high-risk HPV DNA's persistence was observed in 11 (30.6%) of the 36 patients of whom HPV-DNA positivity had been detected before the treatment. HSIL was detected in four patients using PAP-smear on the third month examination. Positive LEEP surgical margins were found to be positively correlated both with HPV-DNA positivity detected during the follow-up examination and with the presence of residual disease in the follow-up PAP smear.

CONCLUSION

LEEP is a basic procedure in the conization performed on patients with CIN II/III. In spite of high recurrence and residual disease rates, this kind of patients requires close monitoring. Follow-up with HPV and PAP-smear tests after LEEP treatment is of great importance in the detection of residual or recurrent disease.

High-throughput two-step LNA real time PCR assay for the quantitative detection and genotyping of HPV prognostic-risk groups

BACKGROUND

Human papillomavirus (HPV) infection is a necessary event in the development of cervical carcinoma. High risk (HR) HPV genotypes, however, may progress differentially from low grade lesions to malignancy.

OBJECTIVES

The necessity to genotype and quantify HPV-DNA in cervical screening programs, in the follow up post-surgical treatments and in monitoring the effectiveness of HPV vaccination programs, requires access to economical, high-throughput and flexible molecular technologies.

STUDY DESIGN

A high-throughput two-step LNA real time PCR assay was developed consisting of real time PCR reactions with fluorescent Locked Nucleic Acid (LNA) probes. The first step permits classification into three prognostic-risk groups of nine HR HPV genotypes (16, 18, 31, 33, 35, 45, 52, 56 and 58) most frequently found associated with cervical lesions in Europe. The second step allows us to genotype/quantify the HPV-DNA only when clinical, epidemiological or prophylactic aims exist.

RESULTS

The specificity, repeatability, detection and quantitation limit, and linearity of the assay were evaluated and appear to be in agreement with guidelines for the validation of analytical procedures. The overall genotype concordance on cervical samples between our assay and INNOLiPA test was 94% (k 0.83) indicating good agreement.

CONCLUSIONS

The two-step PCR assay can give much information relative to the predictive value of different HR HPV types and can quantify the genotype-specific viral load. In particular, its ability to detect and quantify nine HR HPV genotypes can help provide more efficient and successful patient care and may be useful for the monitoring of the efficacy of HPV vaccines.

Modified general primer PCR system for sensitive detection of multiple types of oncogenic human papillomavirus

Human papillomavirus (HPV) infection is a necessary cause of cervical cancer and cervical dysplasia. Accurate and sensitive genotyping of multiple oncogenic HPVs is essential for a multitude of both clinical and research uses. We developed a modified general primer (MGP) PCR system with five forward and five reverse consensus primers. The MGP system was compared to the classical HPV general primer system GP5+/6+ using a proficiency panel with HPV plasmid dilutions as well as cervical samples from 592 women with low-grade cytological abnormalities. The reference method (GP5+/6+) had the desirable high sensitivity (five copies/PCR) for five oncogenic HPV types (HPV type 16 [HPV-16], HPV-18, HPV-56, HPV-59, and HPV-66). The MGP system was able to detect all 14 oncogenic HPV types at five copies/PCR. In the clinical samples, the MGP system detected a significantly higher proportion of women with more than two concomitant HPV infections than did the GP5+/6+ system (102/592 women compared to 42/592 women). MGP detected a significantly greater number of infections with HPV-16, -18, -31, -33, -35, -39, -42, -43, -45, -51, -52, -56, -58, and -70 than did GP5+/6+. In summary, the MGP system primers allow a more sensitive amplification of most of the HPV types that are established as oncogenic and had an improved ability to detect multiple concomitant HPV infections.