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

Human papillomavirus prevalence, genotype distribution, and prognostic factors of vaginal cancer

We aimed to investigate human papillomavirus (HPV) prevalence and genotype distribution and prognostic factors in vaginal cancer (VC). VC patients who received treatment between 1989 and 2020 were retrospectively reviewed. L1 general polymerase chain reaction (PCR) followed by HPV Blot (King Car, I-Lan, Taiwan) and E6 type-specific-PCR were performed for genotyping firstly. P16 and p53 immunohistochemistry staining was performed. Univariate and multivariate analyses identified predictors of clinical outcomes.79 VC patients were eligible for analysis. 73 patients (92.4%) were squamous cell carcinoma (SCC) and 6 (7.6%) as non-SCC. The median follow-up time was 134.3 months (range 0.9-273.4). Among nine initially HPV-negative cases, seven were identified as being positive through HPV16/18/45/52/58 whole-genome amplification followed by Sanger sequencing (WGASS). HPV DNA sequences were detected in 98.6% of SCC and 83.3% of non-SCC, respectively, with HPV16 (49.4%), HPV52 (15.2%) and HPV58 (8.9%) being predominant. Patients with paraaortic lymph node (LN) metastasis had a 5-year cancer-specific survival (CSS) rate of 0%. Multivariate analysis revealed that only p16 and stage were significantly correlated with prognosis. Variables with strong correlations (p16- and HPV-positivity, LN metastasis and stage), were included in models 2-5 alternatively. Stage III/IV (hazard ratio [HR] = 3.64-4.56) and LN metastasis (HR = 2.81-3.44) were significant negative predictors of CSS, whereas p16-positivity (HR = 0.29-0.32) and HPV-positivity (HR = 0.14) were related to better prognosis. In conclusion, 97.5% of VCs were HPV-positive with WGASS. Stage III/IV and LN metastasis were significant negative predictors, whereas p16- and HPV-positivity were significantly associated with better prognosis.

Incidence distributions, risk factors and trends of vaginal cancer: A global population-based study

OBJECTIVE

This study aimed to investigate the incidence, risk factors and trends for vaginal cancer.

DESIGN

Retrospective observational design.

SETTING

Data were collected from multiple sources, including the Global Cancer Observatory, Cancer Incidence in Five Continents Plus, Global Burden of Disease, World Bank and the United Nations.

POPULATION

Individuals diagnosed with vaginal cancer.

METHODS

The study collected data on vaginal cancer from the specified sources. The age-standardised rate (ASR) of vaginal cancer was calculated for different regions and age groups. Multivariable and univariable linear regression analyses were performed to examine the associations between risk factors and the incidence of vaginal cancer. Trend analysis was conducted using joinpoint regression analysis, and the average annual percentage change (AAPC) was calculated to quantify the temporal trend.

MAIN OUTCOME MEASURES

The main outcome measures of the study were the incidence of vaginal cancer, risk factors associated with the disease and the trend of its incidence over time.

RESULTS

There were 17 908 newly reported cases of vaginal cancer (ASR = 0.36, 95% CI 0.30-0.44) in 2020, with the highest ASRs reported in South-Central Asia and Southern Africa. Risk factors associated with a higher incidence of vaginal cancer included a higher prevalence of unsafe sex and human immunodeficiency virus (HIV) infection. The temporal trend showed an overall rising incidence globally, with Iceland (AAPC = 29.56, 95% CI 12.12-49.71), Chile (AAPC = 22.83, 95% CI 13.20-33.27), Bahrain (AAPC = 22.05, 95% CI 10.83-34.40) and the UK (AAPC = 1.40, 95% CI 0.41-2.39) demonstrating the most significant rising trends.

CONCLUSIONS

The significant regional disparities and risk factors associated with vaginal cancer underscore the necessity for targeted interventions and education, particularly in regions with a lower human development index (HDI) and a higher prevalence of human papillomavirus (HPV) infection. The increasing incidence trend emphasises the need for enhanced HPV vaccination rates to prevent the development of vaginal cancer.

The association between body mass index and vulvar and vaginal cancer incidence: findings from a large Norwegian cohort study

BACKGROUND

There is limited evidence of potential associations between body mass index (BMI) and risk of vulvar and vaginal cancer. We explored these associations in a large cohort of Norwegian women.

METHODS

The analytical dataset included 889,441 women aged 16-75 years at baseline in 1963-1975. Multivariable Cox regression analyses were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between BMI and vulvar and vaginal cancer incidence.

RESULTS

During 30.1 million person-years of follow-up, 1748 incident vulvar and 408 incident vaginal cancer cases occurred. The HRs (95% CIs) for vulvar cancer for a BMI of 15- < 18.5, 18.5- < 25, 25- < 30, 30- < 35, ≥ 35 were 0.62 (0.38-1.01), 1.00 (reference), 1.23 (1.10-1.40), 1.43 (1.23-1.66) and 1.72 (1.35-2.20, ptrend < 0.001), and per 5 kg/m2 increment was 1.20 (1.13-1.26). The corresponding HRs (95% CIs) for vaginal cancer were 1.05 (0.52-2.15), 1.00, 0.89 (0.71-1.12), 0.95 (0.68-1.34), and 2.01 (1.29-3.13, ptrend < 0.001), respectively, and per 5 kg/m2 was 1.11 (0.99-1.25). The HR (95% CI) per 5 kg/m2 increase in BMI at ages 16-29 was 1.28 (1.07-1.54, n = 250 cases) for vulvar and 1.53 (1.11-2.11, n = 66 cases) for vaginal cancers. The HR (95% CI) per 5 kg/m2 for early-onset (< 50 years age at diagnosis) vulvar cancer was 0.92 (0.66-1.28, n = 87 cases) and 1.70 (1.05-2.76, n = 21 cases) for vaginal cancer.

CONCLUSION

These results further support the associations between higher BMI and increased risk of vulvar and vaginal cancers, with suggestive stronger associations between BMI in early adulthood for both cancers and for early-onset vaginal cancer. Further studies are needed to elucidate these findings and investigate the underlying mechanisms.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Correlation between gynecological tumors and atherosclerotic diseases

Gynecological cancer is among the leading causes of cancer-related mortality worldwide, with malignancies of the ovary, uterus, fallopian tube, cervix, vagina, and vulva making up 10-18% of all cancers diagnosed in women globally. Gynecological cancer and atherosclerosis are two of the most frequent medical entities that afflict women worldwide; thus the possible correlations between them ought to be explored. Vulvar, cervical, vaginal, endometrial, and ovarian cancers have been found to have common points with atherosclerosis regarding their pathogenesis and predisposing factors. Obesity and metabolic syndrome, HPV infection, vitamin D deficiency, and increased telomere length constitute common ground between these two afflictions, which this article aims to analyze.

Survival rate of vaginal cancer in Asian countries: a systematic review and meta-analysis

Introduction

Vaginal cancer is one of the major causes of mortality in women, which mostly takes place in low- and middle-income countries. Assessing the survival rate of vaginal cancer is essential to investigate the success rate of current treatments and screening tools. This study aims to determine the survival rate of vaginal cancer in Asia.

Methods

This systematic review was carried out using four international databases, including Medline/Pubmed, ProQuest, Scopus, Web of Knowledge, and also Google Scholar. Articles were investigated up to the end of August 2021. The authors utilized the Newcastle-Ottawa Scale to evaluate the quality of the articles. Evaluating the papers for heterogeneity was performed using the Cochrane test and I² statistic. Meta-regression analysis was also applied based on the year of the study.

Results

Three articles (13 records) fulfilled the inclusion criteria. Based on the random model, the overall 5-year survival rate was 74.63%. Also, the rates of survival in relation to the type of treatment including chemotherapy, radiotherapy, or other modalities, were 78.53, 78.44, and 68.54%, respectively. According to meta-regression analysis, no correlation was found between the survival rate and the year of the study.

Conclusion

The vaginal cancer survival rate is lower in Asian countries compared to that of developed countries. Increasing patient survival rates in such countries is crucial by implementing newer diagnostic tools, advanced surgical techniques, and goal-oriented treatments. Early diagnosis in lower stages and educating the populations about risk factors and preventative measures are also necessary for raising the rate of survival.

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

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

Characteristics and survival of primary vaginal malignancy: an analysis of the German nationwide cancer registry data

BACKGROUND

Vaginal neoplasms are rare. To study the survival of patients depending on tumour characteristics and age, the data from the national cancer registries in Germany were analysed.

METHODS

In a retrospective analysis, data from 2006 to 2015 on disease stage, survival, and factors that might affect prognosis were analysed.

RESULTS

Altogether, out of 4004 datasets, 2194 were deemed adequate to be included in the analysis. Overall survival at 5 years (5YSR) and relative survival (5RSR) were 48.6% (95%CI 45.4-52.1%) and 58.7% (95%CI 55.3-61.2%) for carcinomas, but significantly worse at 20.2% (95%CI 8.3-32.0%) and 24.2% (95%CI 16.4-32.0%) for melanomas and 38.3% (95%CI 23.3-53.5%) and 44.4% (95%CI 31.5-56.8%) for sarcomas. 5YSR and 5RSR correlated significantly with FIGO stages (5YSR: 66.9-10.1%; 5RSR: 81.7-11.9%, p = 0.04). Furthermore, survival depended on the absence of LN metastases (5RSR: 59.1% vs. 38.0%, p < 0.001), and the tumour grading had an influence (5RSR: 83.7-52.1%). We also noted that prognosis was worse for older patients ≥75 years (5RSR:51.2%) than for patients <55 years (62.2%) and 55-74 years of age (61.6%).

CONCLUSION

Unless LN metastases, local advanced tumours and G3 grading are associated with a worse prognosis. Relative survival of older patients decreases, perhaps indicating that treatment compromises have been made.

Which Risk Factors and Colposcopic Patterns Are Predictive for High-Grade VAIN? A Retrospective Analysis

Colposcopic patterns of Vaginal Intraepithelial Neoplasia (VAIN) are not definitively related to histological grade. The aim of the present study was to investigate any correlation between clinical and colposcopic features and the development of high-grade VAIN. Two hundred and fifty-five women diagnosed with VAIN (52 VAIN1, 55 VAIN2 and 148 VAIN3) at the European Institute of Oncology, Milan, Italy, from January 2000 to June 2022, were selected for a retrospective analysis. Multivariate logistic regression was performed to estimate the association of risk factors and colposcopic patterns with VAIN grade. Smoking was associated with the development of VAIN (34.1%, p = 0.01). Most women diagnosed with VAIN3 (45.3%, p = 0.02) had a previous history of hysterectomy for CIN2+. At multivariate analysis, colposcopic grade G2 (OR = 20.4, 95%CI: 6.67−61.4, p < 0.001), papillary lesion (OR = 4.33, 95%CI: 1.79−10.5, p = 0.001) and vascularity (OR = 14.4, 95%CI: 1.86−112, p = 0.01) were significantly associated with a greater risk of VAIN3. The risk of high-grade VAIN should not be underestimated in women with a history of smoking and previous hysterectomy for CIN2+, especially when colposcopic findings reveal vaginal lesions characterized by grade 2, papillary and vascular patterns. Accurate diagnosis is crucial for an optimal personalized management, based on risk factors, colposcopic patterns and histologic grade of VAIN.

Human Papilloma Virus-Infected Cells

Human papillomavirus (HPV) is associated with infection of different tissues, such as the cervix, anus, vagina, penis, vulva, oropharynx, throat, tonsils, back of the tongue, skin, the lungs, among other tissues. HPV infection may or may not be associated with the development of cancer, where HPVs not related to cancer are defined as low-risk HPVs and are associated with papillomatosis disease. In contrast, high-risk HPVs (HR-HPVs) are associated with developing cancers in areas that HR-HPV infects, such as the cervix. In general, infection of HPV target cells is regulated by specific molecules and receptors that induce various conformational changes of HPV capsid proteins, allowing activation of HPV endocytosis mechanisms and the arrival of the HPV genome to the human cell nucleus. After the transcription of the HPV genome, the HPV genome duplicates exponentially to lodge in a new HPV capsid, inducing the process of exocytosis of HPV virions and thus releasing a new HPV viral particle with a high potential of infection. This infection process allows the HPV viral life cycle to conclude and enables the growth of HPV virions. Understanding the entire infection process has been a topic that researchers have studied and developed for decades; however, there are many things to still understand about HPV infection. A thorough understanding of these HPV infection processes will allow new potential treatments for HPV-associated cancer and papillomatosis. This chapter focuses on HPV infection, the process that will enable HPV to complete its HPV life cycle, emphasizing the critical role of different molecules in allowing this infection and its completion during the HPV viral life cycle.

Vulvar Cancer Incidence in the United States and its Relationship to Human Papillomavirus Vaccinations, 2001-2018

The human papillomavirus (HPV) vaccine was indicated for the prevention of vulvovaginal cancers in 2008, but its impact on the incidence of vulvar cancers within the US is unknown. To determine this, we conducted a secondary analysis of 88,942 vulvar cancer cases among women 20+ years old using the US Cancer Statistics 2001-2018 databases. Data were stratified by tumor behavior (in situ or invasive), age (20-44, 45-64, 65+ years old), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic), and US census region (Northeast, South, Midwest, West), and incidence rates and average annual percentage changes (AAPC) were calculated by group. Reversing previous trends, the incidence of vulvar carcinoma in situ significantly decreased between 2001 and 2018 among women from all age groups, races/ethnicities, and regions (combined AAPC,  -4.3; 95% confidence interval (CI), -4.7 to -3.8). The incidence of invasive vulvar squamous cell carcinoma decreased significantly among 20- to 44-year-old women (AAPC, -0.8; 95% CI, -1.3 to -0.3), but significantly increased among those 45 to 64 (AAPC, 2.3; 95% CI, 1.8-2.8) and 65+ years old (AAPC, 1.2; 95% CI, 1.1-1.4). Regardless of tumor behavior, incidence was highest among non-Hispanic Whites and the Midwest region. Overall, the significant declines in vulvar carcinoma in situ among all ages, as well as invasive vulvar cancer among younger women, are encouraging and complement other recent data suggesting HPV vaccinations are already reducing anal and cervical cancer incidence. Over time, further declines in vulvar carcinoma incidence are likely as uptake and completion rates of the HPV vaccine increase in the US.

PREVENTION RELEVANCE

We found evidence that HPV vaccinations likely contributed to a decrease in the incidences of vulvar carcinoma in situ and invasive vulvar carcinoma among 20- to 44-year-old women between 2001 and 2018. Our data add to the growing evidence that HPV vaccinations are reducing the incidence of HPV-related anogenital cancers.

A Comprehensive Discussion in Vaginal Cancer Based on Mechanisms, Treatments, Risk Factors and Prevention

Vaginal cancer is a rare and uncommon disease that is rarely discussed. Although vaginal cancer traditionally occurs in older postmenopausal women, the incidence of high-risk human papillomavirus (HPV)-induced cancers is increasing in younger women. Cervical cancer cells contain high-risk human papillomavirus (HPV) E6 and E7 proteins and inhibiting HPV gene expression leads the cells to stop proliferating and enter senescence. As E6, and E7 protein promoted the carcinogenesis mechanism, and here not only regulate the cellular degradation of P53, and pRb but also enhances the cell proliferation along with E6 protein targets the p53 for breakdown and subsequently promote the apoptotic cell death, and DNA repair inhibition, that is indispensable to the continue the lifecycle of the HPV. As a synchronous or metachronous tumor, vaginal cancer is frequently found in combination with cervical cancer. It is uncertain what causes invasive female vaginal organ cancer. HPV type 16 is the most often isolated HPV type in female vaginal organ cancers. Due to cancer's rarity, case studies have provided the majority of etiologic findings. Many findings demonstrate that ring pessaries, chronic vaginitis, sexual behavior, birth trauma, obesity, vaginal chemical exposure, and viruses are all risk factors. Because of insufficient understanding and disease findings, we are trying to find the disease's mechanism with the available data. We also address different risk factors, therapy at various stages, diagnosis, and management of vaginal cancer in this review.

Extraterrestrial Gynecology: Could Spaceflight Increase the Risk of Developing Cancer in Female Astronauts? An Updated Review

Outer space is an extremely hostile environment for human life, with ionizing radiation from galactic cosmic rays and microgravity posing the most significant hazards to the health of astronauts. Spaceflight has also been shown to have an impact on established cancer hallmarks, possibly increasing carcinogenic risk. Terrestrially, women have a higher incidence of radiation-induced cancers, largely driven by lung, thyroid, breast, and ovarian cancers, and therefore, historically, they have been permitted to spend significantly less time in space than men. In the present review, we focus on the effects of microgravity and radiation on the female reproductive system, particularly gynecological cancer. The aim is to provide a summary of the research that has been carried out related to the risk of gynecological cancer, highlighting what further studies are needed to pave the way for safer exploration class missions, as well as postflight screening and management of women astronauts following long-duration spaceflight.

Proteases and HPV-Induced Carcinogenesis

Simple Summary

Human papillomavirus (HPV) infection is a sexually transmitted disease with high prevalence worldwide. Although most HPV infections do not lead to cancer, some HPV types are correlated with the majority of cervical cancers, and with some anogenital and oropharyngeal cancers. Moreover, enzymes known as proteases play an essential role in the pathogenic process in HPV-induced carcinogenesis. This review highlights the role of proteases and recent epidemiological data regarding HPV-dependent carcinogenesis.

Abstract

Persistent infection with Human papillomavirus (HPV) is the main etiologic factor for pre-malignant and malignant cervical lesions. Moreover, HPV is also associated with oropharynx and other anogenital carcinomas. Cancer-causing HPV viruses classified as group 1 carcinogens include 12 HPV types, with HPV 16 and 18 being the most prevalent. High-risk HPVs express two oncoproteins, E6 and E7, the products of which are responsible for the inhibition of p53 and pRB proteins, respectively, in human keratinocytes and cellular immortalization. p53 and pRB are pleiotropic proteins that regulate the activity of several signaling pathways and gene expression. Among the important factors that are augmented in HPV-mediated carcinogenesis, proteases not only control processes involved in cellular carcinogenesis but also control the microenvironment. For instance, genetic polymorphisms of matrix metalloproteinase 1 (MMP-1) are associated with carcinoma invasiveness. Similarly, the serine protease inhibitors hepatocyte growth factor activator inhibitor-1 (HAI-1) and -2 (HAI-2) have been identified as prognostic markers for HPV-dependent cervical carcinomas. This review highlights the most crucial mechanisms involved in HPV-dependent carcinogenesis, and includes a section on the proteolytic cascades that are important for the progression of this disease and their impact on patient health, treatment, and survival.

Human Papillomaviruses as Infectious Agents in Gynecological Cancers. Oncogenic Properties of Viral Proteins

Human papillomaviruses (HPVs), which belong to the Papillomaviridae family, constitute a group of small nonenveloped double-stranded DNA viruses. HPV has a small genome that only encodes a few proteins, and it is also responsible for 5% of all human cancers, including cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancers. HPV types may be classified as high- and low-risk genotypes (HR-HPVs and LR-HPVs, respectively) according to their oncogenic potential. HR-HPV 16 and 18 are the most common types worldwide and are the primary types that are responsible for most HPV-related cancers. The activity of the viral E6 and E7 oncoproteins, which interfere with critical cell cycle points such as suppressive tumor protein p53 (p53) and retinoblastoma protein (pRB), is the major contributor to HPV-induced neoplastic initiation and progression of carcinogenesis. In addition, the E5 protein might also play a significant role in tumorigenesis. The role of HPV in the pathogenesis of gynecological cancers is still not fully understood, which indicates a wide spectrum of potential research areas. This review focuses on HPV biology, the distribution of HPVs in gynecological cancers, the properties of viral oncoproteins, and the molecular mechanisms of carcinogenesis.

Trends in Incidence and Mortality of Gynecological and Breast Cancers in Poland (1980-2018)

BACKGROUND

This study aimed to analyze and determine the incidence and mortality trends in gynecological and breast cancers (BCs) in Poland. The gynecological cancers assessed were cervical cancer (CC), corpus uteri cancer (CUC), ovarian cancer (OC), vaginal cancer (VAC), and vulvar cancer (VUC).

PATIENTS AND METHODS

Data concerning the incidence and mortality for the period of 1980-2018 were obtained from the Polish National Cancer Registry (PNCR). Joinpoint regression analysis was performed to identify trends, which were described using the annual percentage change (APC) and the average annual percent change (AAPC).

RESULTS

Statistically significant increases were observed in BC incidence (AAPC: 2.3; CI: 1.8 to 2.9; p<0.05), CUC incidence (AAPC: 2.3; CI: 1.9 to 2.7; p<0.05), CUC mortality (AAPC: 0.4; CI: 0.1 to 0.7; p<0.05) and VUC mortality (AAPC: 1.16, CI: 0.1 to 2.2; p<0.05). VAC mortality decreased (AAPC: -3.5, CI: -5.0 to -2.0; p<0.05), as did CC incidence and mortality (AAPC: -2.1, CI: -2.3 to -1.8; p<0.05, AAPC: -2.0, CI: -2.2 to -1.8; p<0.05, respectively). Between 1980 and 1993, OC incidence initially increased and then stabilized (AAPC: 0.9; CI: 0.7 to 1.1; p<0.05). After 2007, OC mortality decreased (AAPC: 0.0; CI: -0.2 to 0.2; p=0.8). Trends in VUC and VAC incidence and BC mortality were not statistically significant.

CONCLUSION

The results of this study showed a significant increase in OC, CUC, and BC incidence, and a decrease in the incidence of CC and VAC. The VUC trends were stable. Mortality trends for BC initially fluctuated and, since 2010, has begun to increase. Throughout the observed period, mortality due to VUC and CUC increased, whereas decreased among patients with CC. OC mortality was stable, but not significant. Furthermore, the study showed a correlation between age group and rate of incidence and mortality of each assessed cancer.

Essentiality of Trace Elements in Pregnancy, Fertility, and Gynecologic Cancers-A State-of-the-Art Review

Gynecological neoplasms pose a serious threat to women's health. It is estimated that in 2020, there were nearly 1.3 million new cases worldwide, from which almost 50% ended in death. The most commonly diagnosed are cervical and endometrial cancers; when it comes to infertility, it affects ~48.5 million couples worldwide and the number is continually rising. Ageing of the population, environmental factors such as dietary habits, environmental pollutants and increasing prevalence of risk factors may affect the reproductive potential in women. Therefore, in order to identify potential risk factors for these issues, attention has been drawn to trace elements. Trace mineral imbalances can be caused by a variety of causes, starting with hereditary diseases, finishing with an incorrect diet or exposure to polluted air or water. In this review, we aimed to summarize the current knowledge regarding trace elements imbalances in the case of gynecologic cancers as well as female fertility and during pregnancy.

Rare case of chemotherapy-refractory metastatic vaginal squamous cell carcinoma with complete response to concurrent pembrolizumab and radiotherapy- case report and literature review

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Metastatic vaginal cancer, rare cancer with limited treatment options.

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Pembrolizumab and radiotherapy led to complete response in a patient with metastatic vaginal cancer.

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Wall-eyed bilateral internuclear ophthalmoplegia, a new immune related adverse event.

Primary vaginal cancer is a rare malignancy with a lack of international guidelines and supporting clinical trial evidence to guide decision making. Historical results have shown poor outcomes with chemotherapy for stage IVB vaginal squamous cell carcinoma (SCC). The evolving role of checkpoint inhibitors in rare gynaecological cancers prompted us to investigate the role of pembrolizumab in this setting. The efficacy of pembrolizumab in vaginal SCC has never been investigated in any clinical trial. There is established data to support the use of concurrent chemoradiotherapy in gynaecological cancers, however, the data for concurrent use of immunotherapy and radiotherapy is still lacking but is the subject of several clinical trials. We herein present the first reported case of chemotherapy refractory vaginal SCC with complete response to pembrolizumab and concurrent pelvic radiotherapy. We also present wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) as a rare but new immune related adverse event.

Screening History in Vaginal Precancer and Cancer: A Retrospective Study of 2131 Cases in China

Purpose

To examine the screening history of vaginal intraepithelial neoplasia (VaIN) and vaginal cancer.

Patients and Methods

We included women with histologically confirmed VaIN or vaginal cancer by colposcopy-directed biopsy between 1 January 2019 and 31 December 2019. The results of cytology, hrHPV, colposcopic examination and history of hysterectomy were retrospectively analysed.

Results

A total of 26,432 colposcopies were performed during the study period, among which 2131 women (1835 [86.1%] with VaIN 1; 268 [12.6%] with VaIN 2/3; and 28 [1.3%] with vaginal cancer) were retrospectively studied. hrHPV test positivity was significantly higher than that of cytology for VaIN 1 (84.4% vs 67.3%; P < 0.001) and VaIN 2/3 (92.0% vs 79.9%; P < 0.001) but not for vaginal cancer (84.6% vs 78.6%; P = 0.73). Additionally, the concordance rates for colposcopic impression were 79.5%, 54.5%, and 92.8% for VaIN1, VaIN2/3, and vaginal cancer, respectively. All 372 patients had a history of hysterectomy, and 81.0% (282/348) of indications were related to cervical precancer and cancer. Although cytology test positivity was significantly higher in patients with hysterectomy than in patients without hysterectomy (76.2% vs 67.5%; P < 0.001), cytology combined with hrHPV can help to detect more than 95% of VaIN and vaginal cancer cases in both groups (96.2% for patients with hysterectomy and 96.5% for patients without hysterectomy).

Conclusion

VaIN and vaginal cancer are not rare diseases. Although cytology was sensitive (67.5%-76.2%) for detecting vaginal lesions regardless of hysterectomy, cytology combined with hrHPV improves detection accuracy up to 95% in both groups.

Current update on vaginal malignancies

Primary vaginal cancers are rare and account for 1-3% of all gynecologic malignancies. There are several histological subtypes that affect a wide range of the population. Imaging plays an important role in the diagnosis, staging, and treatment planning of vaginal cancers. This article reviews the relevant anatomy, clinical findings, imaging characteristics, and recent advances in the management of vaginal malignancies.

Twenty years' experience of primary vaginal cancer treatment at one cancer centre: does residence status matter?

Objectives

To study the long-term results of the treatment of patients with vaginal cancer and to examine whether there are any differences in diagnostic and survival rates between urban and rural patients.

Methods

The data of 70 patients with primary vaginal cancer treated at NN Alexandrov National Cancer Centre of Belarus from 2000 to 2019 were included. The median age was 64 years (range = 56–75). Morphology in 91.4% (64/70) of the cases was squamous cell cancer, in 7.1% (5/70) it was adenocarcinoma and in 1.4% (1/70) it was adenosquamous carcinoma. In total, there were 31 patients from urban and 39 from rural areas. The groups were comparable in age (61 versus 67, p = 0.104), morphology (p = 0.188) and distribution of stages: stage I in 7 and 10 patients (22.6% and 25.6%, respectively; p = 0.999), stage II in 14 and 16 patients (45.1% and 41.0%, respectively; p = 0.810), stage III in 6 and 6 patients (19.4% and 15.4%, respectively; p = 0.754) and stage IV in 4 and 7 patients (12.9% and 18.0%, respectively; p = 0.744).

Results

The median follow-up time was 33 months (range = 1–220). A total of 42 women died: 28 from progression of vaginal cancer and 14 from other diseases. Overall survival (OS) was 31.9 ± 6.8%, median survival was 41 months (95% CI = 0.0–105.3). Disease-specific survival (DSS) for the entire group was 54.5 ± 6.8%; median was not reached. The overall survival rate of urban women was 44.8 ± 10.6% and for rural it was 22.5 ± 8.2% (p = 0.142); DSS was 57.6 ± 10.5% and 53.0 ± 8.4% (p = 0.448), respectively.

Conclusion

DSS rate was 54.0 ± 6.8% and the OS rate did not exceed 31.9 ± 6.8%. Rural residence was not associated with late stage at diagnosis or receipt of treatment.

Image-Guided Adaptive Brachytherapy (IGABT) for Primary Vaginal Cancer: Results of the International Multicenter RetroEMBRAVE Cohort Study

PURPOSE

This study assessed outcomes following the nowadays standing treatment for primary vaginal cancer with radio(chemo)therapy and image-guided adaptive brachytherapy (IGABT) in a multicenter patient cohort.

METHODS

Patients treated with computer tomography (CT)-MRI-assisted-based IGABT were included. Retrospective data collection included patient, tumor and treatment characteristics. Late morbidity was assessed by using the CTCAE 3.0 scale.

RESULTS

Five European centers included 148 consecutive patients, with a median age of 63 years. At a median follow-up of 29 months (IQR 25-57), two- and five-year local control were 86% and 83%; disease-free survival (DFS) was 73% and 66%, and overall survival (OS) was 79% and 68%, respectively. Crude incidences of ≥ grade-three urogenital, gastro-intestinal and vaginal morbidity was 8%, 3% and 8%, respectively. Lymph node metastasis was an independent prognostic factor for disease-free survival (DFS). Univariate analysis showed improved local control in patients with T2-T4 tumors if >80 Gy EQD2α/β10 was delivered to the clinical target volume (CTV) at the time of brachytherapy.

CONCLUSIONS

In this large retrospective multicenter study, IGABT for primary vaginal cancer resulted in a high local control with acceptable morbidity. These results compared favorably with two-dimensional (2D) radiograph-based brachytherapy and illustrate that IGABT plays an important role in the treatment of vaginal cancer.

Pembrolizumab in vaginal and vulvar squamous cell carcinoma: a case series from a phase II basket trial

Vaginal and vulvar squamous cell carcinoma (SCC) are rare tumors that can be challenging to treat in the recurrent or metastatic setting. We present a case series of patients with vaginal or vulvar SCC who were treated with single-agent pembrolizumab as part of a phase II basket clinical trial to evaluate efficacy and safety. Two cases of recurrent and metastatic vaginal SCC, with multiple prior lines of systemic chemotherapy and radiation, received pembrolizumab. One patient had significant reduction (81%) in target tumor lesions prior to treatment discontinuation at cycle 10 following confirmed progression of disease with new metastatic lesions (stable disease by irRECIST criteria). In contrast, the other patient with vaginal SCC discontinued treatment after cycle 3 due to disease progression. Both patients had PD-L1 positive vaginal tumors and tolerated treatment well. One case of recurrent vulvar SCC with multiple surgical resections and prior progression on systemic carboplatin had a 30% reduction in her target tumor lesions following pembrolizumab treatment with a PD-L1 positive tumor. Treatment was discontinued for grade 3 mucositis after cycle 5. Pembrolizumab may provide some clinical benefit to some patients with vaginal or vulvar SCC and is overall safe to utilize in this population. Future studies are needed to evaluate the efficacy of pembrolizumab in these rare tumor types and to identify predictive biomarkers of response.

Management options for vaginal intraepithelial neoplasia

BACKGROUND

Vaginal intraepithelial neoplasia (VaIN) is a rare disease of the lower genital tract, strongly associated with HPV infection, which may progress to vaginal carcinoma.

PURPOSE

The aim of this review is to summarise current treatment options, evaluate their efficacy and make provide recommendations on the optimal management of the disease.

MATERIALS AND METHODS

A comprehensive search of the literature was performed using the PubMed database for articles referring to the treatment of VaIN. We restricted our search only in articles written in English with publication dates within the last 10 years.

RESULTS

Surgical approach included local excision, CO₂ laser ablation, CO₂ laser skinning colpectomy and laparoscopic upper vaginectomy. Medical management was based on intravaginally administered topical agents such as 5% imiquimod cream, 5-fluorouracil cream and topical oestrogens. Intracavitary radiation therapy was reported in two forms: Low-dose rate (LDR) brachytherapy and high-dose rate (HDR) brachytherapy. All treatment options were well tolerated, with satisfactory cure rates and acceptable recurrence rates.

CONCLUSION

The choice of treatment depends upon many factors. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Topical agents are useful for persistent, multifocal lesions or for women that cannot undergo surgical treatment. Brachytherapy is associated with high morbidity rates and should be reserved for women who have multifocal disease, are poor surgical candidates and/or have failed other treatments. CO₂ laser ablation achieves minimal scarring and sexual dysfunction; however, invasive disease should be ruled out with biopsies before the initiation of the treatment.

Types and viral load of human papillomavirus, and vaginal microbiota in vaginal intraepithelial neoplasia: a cross-sectional study

Background

Human papilloma virus (HPV) infection is an important risk factor for vaginal intraepithelial neoplasia (VAIN). Recent studies have suggested that the microbiome may play a potential role in cervicovaginal diseases. This study aimed to explore the characteristics of the types and viral load of HPV in VAIN, as well as the association between vaginal microbiota and VAIN.

Methods

A total of 176 women, either with VAIN, or without VAIN but with HPV infection were enrolled in the study. Among them, 109 HPV positive cases were qualified for viral load assay. The vaginal microbiota of 122 HPV positive women, who were matched by severity of cervical lesions and menopause status, was determined by 16S ribosomal RNA (16S rRNA) sequencing.

Results

The top 5 types of HPV-associated vaginal lesions were HPV16 (24.2%), HPV52 (24.2%), HPV53 (16.1%), HPV58 (14.5%) and HPV66 (14.5%). The viral load of HPV types 16, 52, and 58 appeared higher in separate vaginal lesions than in histopathologically normal cases (P=0.026, 0.002, and 0.013, respectively). The vaginal microbiota of HPV-positive patients with VAIN did not exhibit a large change in diversity. Vaginal microbiota of VAIN was characterized by an increased abundance of Atopobium, Gardnerella, Allobaculum and Clostridium, as well as decreased abundance of Finegoldia, Actinobaculum and Blautia. A higher level of Enterococcus and some specific Clostridium spp. might be associated with an elevated risk of VAIN2/3.

Conclusions

A higher level of viral load of HPV16, 52, and 58 may indicate VAIN. The composition of vaginal microbiota changes during the progression of VAIN and specific bacteria such as Atopobium, Gardnerella, Allobaculum, Enterococcus and Clostridium, may help to promote its development.

Genes Regulated by HPV 16 E6 and High Expression of NFX1-123 in Cervical Cancers

Purpose

High-risk human papillomaviruses (HR HPV) cause cervical cancer, and in these cancers, HPV type 16 is the most common HR type. The HR viral oncogenes E6 and E7 partner with cellular proteins to drive cancer and modulate immune pathways; previously, we demonstrated in keratinocytes that HPV 16 E6 and high expression of the endogenous host protein partner NFX1-123 led to the increased expression of multiple genes, including Notch1, secretory leukocyte peptidase inhibitor (SLPI), and retinoic acid early transcript 1G (RAET1G). The present study was conducted to determine if NFX1-123 was highly expressed in cervical cancer and if genes increased by NFX1-123 and 16E6 in keratinocytes were also increased in cervical cancers.

Materials and Methods

The Cancer Genome Atlas (TCGA) database and The Human Protein Atlas database were used to compare relative mRNA and protein gene expression, respectively, in the normal cervix and cervical cancers. Formalin-fixed paraffin-embedded (FFPE) normal cervix and HPV 16 positive cervical cancer samples were analyzed for relative protein expression by immunohistochemical staining. Protein expression of a subset of regulated genes was quantified by Western blot of HPV positive and negative cell lines.

Results

Immunohistochemical staining of HPV 16 positive cervical dysplasias and cancers revealed high NFX1-123, Ki67, and Notch1 expression. NFX1 and NFX1L1 mRNA levels were increased in cervical cancers compared to normal cervix in the TCGA database. Fourteen genes previously identified as upregulated in keratinocytes with 16E6 and overexpressed NFX1-123 also had high mRNA expression and selected genes had high protein expression in cervical cancers and cell lines.

Conclusion

In cervical cancer, NFX1-123 is highly expressed, and 16E6 and NFX1-123 together alter the expression of a wide set of genes. The involvement of these genes in cell proliferation, differentiation, invasion, and metastasis provides further insight into potential ways that HR HPVs promote cancer initiation and maintenance.

The Use of Both Therapeutic and Prophylactic Vaccines in the Therapy of Papillomavirus Disease

Human papillomavirus (HPV) is the most common sexually transmitted virus. The high-risk HPV types (i.e., HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59) are considered to be the main etiological agents of genital tract cancers, such as cervical, vulvar, vaginal, penile, and anal cancers, and of a subset of head and neck cancers. Three prophylactic HPV vaccines are available that are bivalent (vs. HPV16, 18), tetravalent (vs. HPV6, 11, 16, 18), and non-avalent (vs. HPV6, 11, 16, 18, 31, 33,45, 52, 58). All of these vaccines are based on recombinant DNA technology, and they are prepared from the purified L1 protein that self-assembles to form the HPV type-specific empty shells (i.e., virus-like particles). These vaccines are highly immunogenic and induce specific antibodies. Therapeutic vaccines differ from prophylactic vaccines, as they are designed to generate cell-mediated immunity against transformed cells, rather than neutralizing antibodies. Among the HPV proteins, the E6 and E7 oncoproteins are considered almost ideal as targets for immunotherapy of cervical cancer, as they are essential for the onset and evolution of malignancy and are constitutively expressed in both premalignant and invasive lesions. Several strategies have been investigated for HPV therapeutic vaccines designed to enhance CD4⁺ and CD8⁺ T-cell responses, including genetic vaccines (i.e., DNA/ RNA/virus/ bacterial), and protein-based, peptide-based or dendritic-cell-based vaccines. However, no vaccine has yet been licensed for therapeutic use. Several studies have suggested that administration of prophylactic vaccines immediately after surgical treatment of CIN2 cervical lesions can be considered as an adjuvant to prevent reactivation or reinfection, and other studies have described the relevance of prophylactic vaccines in the management of genital warts. This review summarizes the leading features of therapeutic vaccines, which mainly target the early oncoproteins E6 and E7, and prophylactic vaccines, which are based on the L1 capsid protein. Through an analysis of the specific immunogenic properties of these two types of vaccines, we discuss why and how prophylactic vaccines can be effective in the treatment of HPV-related lesions and relapse.

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

OBJECTIVE

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

DESIGN

Population-based national cohort study.

SETTING AND POPULATION

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

METHODS

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

MAIN OUTCOME MEASURE

Vaginal cancer.

RESULTS

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

CONCLUSIONS

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

TWEETABLE ABSTRACT

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

Prognostic Significance of P16 Expression and P53 Expression in Primary Vaginal Cancer

To evaluate the correlation between p16 expression and clinical outcomes in patients with primary vaginal cancer treated with definitive radiotherapy. P16 immunohistochemical was performed on 25 patient samples and recorded from pathology reports in 7 patients. P53 immunohistochemical was performed on 3 p16-negative samples. Baseline characteristics were compared using the Fisher exact test. Outcomes were compared using log-rank tests, and cox proportional hazards models. Survival and recurrence analysis was performed with the Kaplan-Meier method and cumulative incidence estimates. P16 expression was positive in 29 patients and negative in 3 patients. Two of the p16-negative tumors showed positive expression of p53. The median overall survival, progression-free survival and 2-yr cumulative incidence of recurrence were 66 mo [95% confidence interval (CI), 31-96], 34 mo (95% CI, 21-86), and 19% (95% CI, 7%-34%), respectively. P16-positive tumors had higher median overall survival and progression-free survival compared with p16-negative tumors (82 vs. 31 mo, P=0.02 and 35 vs 16 mo, P=0.04, respectively). The 2-yr cumulative incidence of recurrence was 14% for p16-positive tumors compared with 67% for p16-negative tumors (P=0.07). On univariable analysis, p16-negative status, age older than 65, and advanced stage were associated with inferior overall survival. P16 negativity is an independent predictor of inferior overall survival. P16-positive vaginal cancers have a better prognosis and decreased incidence of recurrence compared with p16-negative tumors. These prognostic findings associated with p16-negative vaginal cancers will need to be confirmed in larger patient cohorts.

Safety and efficacy of human papillomavirus vaccination for people living with HIV: A systematic review and meta-analysis

The current evidence regarding the safety and immunogenicity of human papillomavirus (HPV) vaccinations for people living with HIV (PLWH) is unclear. We searched PubMed, Embase, Cochrane Library and Web of Science databases from inception to 23 November 2018. The pooled proportion, relative risk (RR) and the standardized mean difference (SMD) with 95% confidence intervals (CIs) were calculated. Twenty-four studies consisting of 7507 participants were identified. The pooled proportion of adverse events in HIV-infected vaccinees was 60% and the antibody seroconversion rates in HPV-6, -11, -16, -18 subtypes were all above 90%. When compared with the placebo groups, the risk of adverse events was not different except for the injection site reactions (RR: 2.63, 95% CI: 1.72–4.01, p < 0.001), and the level of CD4 was relatively lower (SMD: −0.17, 95% CI: −0.29 to −0.04, p = 0.01) in the HIV-positive vaccinees groups. When compared with HIV-negative vaccinees, the risk of adverse events was not different, but the pooled RR and SMD indicated that antibody seroconversion and geometric mean titer for HPV-18 in HIV-positive groups was lower (RR: 0.91, 95% CI: 0.87–0.95, p < 0.001; SMD: −0.43, 95% CI: −0.62 to −0.24, p < 0.001). The study proves that HPV vaccine is safe and efficacious for PLWH and has important implications for international guidelines and strategies for HPV vaccination.

Human papillomavirus as an independent risk factor of invasive cervical and endometrial carcinomas in Jordan

BACKGROUND

Endometrial and cervical carcinomas are the most common gynecologic malignancies in Western world and many countries. The human papillomavirus (HPV) high-risk genotypes are associated with cervical carcinoma (CC). Chlamydia trachomatis (C. trachomatis), the most common sexually transmitted bacterial infection worldwide, considered a cofactor for HPV infection and CC. Information on HPV infection rate and type distribution among Jordanian women having CC is currently limited and unavailable among those with endometrial carcinoma. Therefore, the present study aimed to provide an updated estimate on HPV infection rate and its high-risk genotypes' distribution among Jordanian women by comparing data from invasive cervical carcinoma (ICC) to normal cervical tissues. Similarly, assessment of HPV infection rate was extended to the endometrial tissues. C. trachomatis infection was investigated as well to explore its possibility as HPV cofactor for induction of such carcinomas.

METHODS

Total DNA was extracted from 144 formaldehyde-fixed paraffin-embedded cervical and endometrial tissue, equally divided between age-matched control and carcinoma cases. Polymerase chain reaction (PCR) was used for general detection of HPV-DNA, high risk HPV-16 and 18 genotypes and C. trachomatis DNA using specific primers.

RESULTS

HPV infection was detected in 91.7% and 61.1% of cervical cancer patients and controls, respectively. Likewise, it was higher among cases (47.2%) than controls (13.8%) in endometrial biopsies. Significantly higher HPV infection rates were found among ICC and endometrial control biopsies of women >50 years. Out of 33 HPV positive ICC cases, single HPV-16 infections were detected in 69.7% compared to HPV-18 (15.2%), while HPV-16/18 co-infections were only found in three (9%) samples. C. trachomatis was not detected in all studied groups.

CONCLUSION

The present study has successfully provided an updated estimate on HPV infection rate among Jordanian women with and without ICC and endometrial carcinoma. In addition, a lack of co-infection was observed between HPV and C. trachomatis in both cancer types.

Clinical performance of the HPV DNA Array genotyping assay in detection of CIN2+ lesions with BS GP5+/6+ MPG Luminex tested cervical samples

Human papillomavirus (HPV) detection is used for screening of cervical cancer and genotype-specific persistence has shown to be mandatory for dysplasia development. Aim of this study was to evaluate the clinical performance of HPV DNA Array for cervical intraepithelial neoplasia 2+ (CIN2+)  lesion detection. HPV DNA Array is a polymerase chain reaction-based assay that targets E1 sequences of 29 HPV types (6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 44, 45, 51, 52, 53, 54, 56, 58, 59, 66, 67, 68, 69, 70, 73, 82, 85, and 97). The clinical evaluation was performed against the reference assay, BS-GP5+/6+ multiplex genotyping (MPG)-Luminex, with 600 cervical smear samples of a referral population. HPV DNA Array detected CIN2+  lesions with a sensitivity of 90.2%, identical to that of MPG-Luminex. Detection of CIN3+  lesions was with a sensitivity of 90.3%, as compared with 88.7% of MPG-Luminex. It demonstrated very good agreement for HPV detection, irrespective of type, of 91.5% (κ  =  0.832). HPV DNA Array is a simple and robust assay, with a short protocol of 4 hours hands-on time and automated readout by ELISpot AiDot software. It permits testing of up to 96 samples in one run and may be considered for use in organized screening programs and low resource settings.

Lower Genital Tract Precancer and Cancer in Hematopoietic Cell Transplant Survivors and the Role of HPV: A Systematic Review and Future Perspectives

Female recipients of hematopoietic cell transplant (HCT) may develop lower genital tract (LGT) dysplasia or new malignancies. A comprehensive systematic review to delineate the occurrence and risk factors for post-HCT LGT precancer and cancer in women was conducted via electronic search of the Cochrane Library, PubMed, Embase, Wiley Online Library, from 1990 to 2018. All studies on the risk, presentation, or incidence of LGT (cervix, vulva, vagina) precancer or cancer post-HCT were included. Reviews, case reports, meta-analysis, book chapters, and studies without the relevant clinical outcomes were excluded. Post-HCT incidence and risk factors for developing LGT precancer or cancer were assessed and determined. Twenty-two out of the original 344 studies met the selection criteria. The risk of LGT cancers in allo-HCT recipients was found to be significantly higher than in the general population, with the standardized incidence ratios of 1.5–48 for cervical cancer and from 19 to 287 for dysplasia. Our review portrays an increased risk of premalignant and malignant neoplasms of female LGT, which have an incompletely described epidemiology and outcomes. Similar to other immunocompromised states, HCT recipients require specific cervical screening guidelines and can greatly benefit from HPV vaccinations. However, there is a lack of prospective data regarding optimum cervical screening in HCT recipients and limited programs offer HPV vaccinations worldwide.

MRI for Radiation Therapy Planning in Human Papillomavirus-associated Gynecologic Cancers

Locally advanced human papillomavirus (HPV)-associated gynecologic cancers, including cervical, vaginal, and vulvar cancers, are treated primarily with radiation therapy (RT). Cervical cancer remains a leading cause of cancer death among women worldwide. The superior soft-tissue resolution of MRI compared with other imaging modalities makes it an ideal modality for RT planning, execution, and follow-up of these malignancies. This superiority has been corroborated in the literature when comparing MRI-based RT planning to radiography-based conventional treatment planning approaches. In 2005, the Groupe Européen de Curiethérapie and the European Society for Radiation Therapy and Oncology guidelines underscored the central role of MRI for successful implementation of three-dimensional image-based cervical cancer brachytherapy. The delineation of both gross tumor volume and clinical tumor volume for brachytherapy is performed at the time of each brachytherapy application, on the basis of the findings depicted on anatomic MR images. Contemporary knowledge concerning the role of MRI for RT planning in HPV-associated gynecologic cancers warrants an understanding of the epidemiology and clinical manifestations of these cancers, as well as knowledge of MRI protocol for cancer staging, selection of RT candidates, brachytherapy implant assessment, posttreatment surveillance, and delineation of treatment-related complications. Technical requirements, patient preparation, and image acquisition protocols are detailed in this review, and imaging-based treatment protocols are summarized. Knowledge of these fundamental concepts enables the radiologist to play an important role in diagnosis, staging, and posttreatment follow-up, helping to guide radiation oncologists and other clinicians in the management of these malignancies.^©RSNA, 2019.

Risk of cervical and vaginal dysplasia after surgery for vulvar intraepithelial neoplasia or cancer: A 6 year follow-up study

OBJECTIVES

To estimate the frequency of abnormal surveillance cytology leading to high-grade dysplasia after surgical management for high-grade vulvar intraepithelial neoplasia (VIN) and vulvar cancer and to determine whether prior hysterectomy reduces this risk.

METHODS

Women who underwent surgery for high-grade VIN or vulvar cancer between 2006 and 2014 were identified retrospectively. Patients who underwent prior hysterectomy for any indication were included. Univariate and multivariate logistic regression analyses were used to identify clinical correlates of abnormal cytology after surgical treatment for VIN and vulvar cancer.

RESULTS

During a median follow-up for 72 months, 302 women underwent surveillance with cytologic screening after vulvar surgery including 99 (33%) women with prior hysterectomy. 75 (25%) women had abnormal cytology results. Of those, 47 (63%) were low-grade and 28 (37%) were high-grade, including 2 (3%) cases of invasive cancer. The rates of high-grade vaginal intraepithelial neoplasia (VAIN), cervical intraepithelial neoplasia (CIN), or cancer were not significantly different despite prior hysterectomy (9% VAIN 2+, 7% CIN 2+). Multivariate analysis showed that correlates of high-grade cytology following treatment for VIN or vulvar cancer included non-white race [odds radio (OR) 3.6, 95% confidence interval (CI) 1.7-7.8], prior abnormal cytology (OR 3.5, 95% CI 1.6-7.6), and immunodeficiency (OR 3.4, 95% CI 1.3-8.8). Prior hysterectomy did not significantly decrease risk of high-grade cytology (OR 0.87, 95% CI 0.5-1.6).

CONCLUSIONS

Women treated surgically for VIN/vulvar cancer have an 8% risk of at least high-grade dysplasia from surveillance screening and prior hysterectomy does not mitigate the risk. Extrapolating from current guidelines, we recommend surveillance cytology screening at least 6-12 months after treatment.

NFX1-123 is highly expressed in cervical cancer and increases growth and telomerase activity in HPV 16E6 expressing cells

A significant contributor to women's cancer mortality worldwide is cervical cancer, which is caused by high-risk human papillomavirus (HR HPV). The two viral oncoproteins of HR HPV, E6 and E7, partner with host cell proteins to target oncogenic proteins and pathways. Previously, we have shown HR HPV type 16 E6 (16E6) interacts with the host protein NFX1-123 to target telomerase and cellular immortalization, requiring NFX1-123 to fully upregulate telomerase activity. We now report that NFX1-123 is highly expressed in primary cervical cancers. In vitro, cells expressing 16E6 and overexpressing NFX1-123 have extended active growth, decreased senescence marker staining, and more rapid cell cycling compared to 16E6 expressing cells with endogenous amounts of NFX1-123. These findings were associated with increased telomerase activity and augmented expression of its catalytic subunit, hTERT. In complement, HPV 16 positive cervical cancer cell lines with knocked down NFX1-123 had slowed growth and reduced hTERT over time. In cells that express HR HPV E6, greater expression of NFX1-123 can modify active cellular growth and augment hTERT expression and telomerase activity over time, potentially supporting the initiation and progression of HPV-associated cancers.

Human papillomavirus and p16 in squamous cell carcinoma and intraepithelial neoplasia of the vagina

We estimated the overall and type-specific prevalence of human papillomavirus (HPV) and p16 overexpression in vaginal cancer and vaginal intraepithelial neoplasia (VaIN). We conducted a systematic search of PubMed, Embase and Cochrane Library to identify studies published between 1986 and 2017 using PCR-based or Hybrid Capture 2 tests to evaluate the presence of HPV DNA and/or using any method to detect p16 overexpression in VaIN, vaginal squamous cell carcinoma (VaSCC), or other types of vaginal cancer. Applying a random effects model, we estimated the pooled prevalence of HPV and p16 overexpression along with 95% confidence intervals (CIs). The I² statistic was used to assess heterogeneity. We included 26 studies, reporting HPV prevalence and six studies evaluating p16 overexpression. The pooled HPV prevalences in VaSCC (n = 593) and VaIN (n = 1,374) were 66.7% (95% CI = 54.7-77.8) and 85.2% (95% CI = 78.2-91.0), respectively. Substantial inter-study heterogeneity was observed, and analyses stratified on geographic region, type of tissue, HPV detection method or PCR primer type did not fully explain the observed heterogeneity. The most predominant HPV type among the HPV positive VaSCC and VaIN cases was HPV16, followed by HPV33, and HPV45 (in VaIN) and HPV18, and HPV33 (in VaSCC). In pooled analyses, 89.9% (95% CI = 81.7-94.6) of HPV positive and 38.9% (95% CI = 0.9-90.0) of HPV negative vaginal cancers were positive for p16 overexpression. Our findings suggest that vaccination against HPV might prevent a substantial proportion of vaginal neoplasia and highlight the need for further studies of the possible clinical value of p16 testing in these patients.

A report of human papilloma virus-16 associated vaginal carcinoma after thirty-two years of successful radiation therapy for cervical cancer

Once the recommended 5-year recurrence-free follow-up is achieved for cervical cancers regular annual pelvic examination is mandatory. The main aim of presenting this short report is to emphasize the difficulties in the collection and interpretation of cytology samples from stenosed cervix or vault after pelvic irradiation. Radiotherapy can induce changes in the cellular morphology which may persist for many years. A 64-year old post-menopausal lady who had received radiation therapy 32 years back for cervical carcinoma stage IIb presented to the Gynecology outpatient department with vaginal spotting. Even though the patient was under regular follow-up for the initial 2 years, she was lost to further follow-ups. The patient was symptom-free except for one episode of spotting in August 2016 and the histopathological examination of the vault smear had ruled out malignancy. However, 1 month later she again presented with spotting and pelvic examination revealed a warty growth at the lateral vaginal wall. The tissue excision biopsy was tested positive for HPV-16 DNA and the histopathology confirmed vaginal squamous cell carcinoma. The association of human papilloma virus (HPV) in cervical cancers was well established and these patients manifest a higher risk of HPV-induced vaginal cancers. HPV DNA testing during follow-up may facilitate early recognition of HPV-related lower genital tract cancers.

The Role of MicroRNAs in the Metastatic Process of High-Risk HPV-Induced Cancers

High-risk human papillomavirus (HPV)-driven cancers represent a major health concern worldwide. Despite the constant effort to develop and promote vaccination against HPVs, there is still a high percentage of non-vaccinated population. Furthermore, secondary prevention programs are not ubiquitous worldwide and not widely followed. Metastatic disease is the cause of the great majority of cancer-associated deaths, making it essential to determine its underlying mechanisms and to identify actionable anti-metastatic targets. Within certain types of cancer (e.g., head and neck), HPV-positive tumors show different dissemination patterns when compared with their HPV-negative counterparts, implicating HPV-related factors in the metastatic process. Among the many groups of biomolecules dysregulated by HPV, microRNAs have recently emerged as key regulators of carcinogenesis, able to control complex processes like cancer metastization. In this review, we present recent data on the role of microRNAs in the metastization of HPV-related cancers and on their possible clinical relevance as biomarkers of metastatic disease and/or as therapeutic targets.

HPV vaccination and the effects on rates of HPV-related cancers

Globally, human papillomavirus (HPV) infection is one of the most common sexually transmitted infection. HPV is linked to at least five malignancies including vulvar, vaginal, anal penile, oropharyngeal, and cervical cancer. Three HPV vaccines are currently available: bivalent (HPV 16,18), quadrivalent (HPV 6,11,16,18), and nonavalent (6,11,16,18,31,33,45,52,58) targeting between 2 and 7 oncogenic HPV serotypes. This review highlights the currently epidemiologic burden of HPV-related cancers, efficacy of current HPV vaccines, and speculates about the benefits of widespread HPV vaccination. At present, all three vaccines are effective in reducing cervical disease and anogenital dysplasia in industry sponsored clinical trials and in limited study of clinical effectiveness. Models predict elimination of HPV infection with global vaccination rates of 80% and benefits in reducing malignancy at 20% global coverage. Large population-based clinical efficacy studies of these vaccines will be necessary to assess the true impact of vaccination. HPV vaccines provide a promising primary approach to preventing malignancy and barriers to vaccine access must be addressed to meet vaccination goals.

Correlation between systemic lupus erythematosus and malignancies: a cross-sectional population-based study

Autoimmune conditions reflect dysregulation of the immune system; this may be of clinical significance in the development of several malignancies. Previous studies show an association between systemic lupus erythematosus (SLE) and the development of malignancies; however, their investigations into the development of specific malignancies are inconsistent, and their external validity may be questionable. The main objective of this study is to investigate the association between the presence of SLE and various malignancies, in a large-scale population-based study. Data for this study was collected from Clalit Health Services, the largest state-mandated health service organization in Israel. All adult members diagnosed with SLE were included (n = 5018) and their age and sex-matched controls (n = 25,090), creating a cross-sectional population-based study. Medical records of all subjects were analyzed for documentation of malignancies. Logistic regression models were built separately for each malignant condition, controlling for age, gender, BMI, smoking, and socioeconomic status. Diagnosis of malignancy (of any type) was more prevalent in the SLE population (odds ratio [OR] 3.35, 95% confidence interval [CI] 3.02-3.72). SLE diagnosis was also found to be independently associated with higher proportions of non-Hodgkin lymphoma (OR 3.02, 95% CI 2.72-3.33), Hodgkin lymphoma (OR 2.43, 95% CI 1.88-2.99), multiple myeloma (OR 2.57, 95% CI 1.85-3.28), cervix uteri malignancies (OR 1.65, 95% CI 1.10-2.20), and genital organ malignancies (OR 2.32, 95% CI 1.42-3.22), after adjustment for confounding variables. The presence of an SLE diagnosis was found to be independently associated with higher proportions of malignancies, particularly hematologic malignancies. These findings should be considered while treating SLE patients, and possibly supplement their screening routine.

Effect of HPV vaccination and cervical cancer screening in England by ethnicity: a modelling study

BACKGROUND

Health equality is increasingly being considered alongside overall health gain when assessing public health interventions. However, the trade-off between the direct effects of vaccination and herd immunity could lead to unintuitive consequences for the distribution of disease burden within a population. We used a transmission dynamic model of human papillomavirus (HPV) to investigate the effect of ethnic disparities in vaccine and cervical screening uptake on inequality in disease incidence in England.

METHODS

We developed an individual-based model of HPV transmission and disease, parameterising it with the latest data for sexual behaviour (from National Survey of Sexual Attitudes and Lifestyles [Natsal-3]) and vaccine and screening uptake by ethnicity (from Public Health England [PHE]) and fitting it to data for HPV prevalence (from ARTISTIC, PHE, Natsal-3) and HPV-related disease incidence (from National Cancer Registry [ONS]). The outcome of interest was the age-adjusted incidence of HPV-related cancer (both cervical and non-cervical) in all women in England in view of differences and changes in vaccination and screening uptake by ethnicity in England, over time. We also studied three potential public health interventions aimed at reducing inequality in HPV-related disease incidence: increasing uptake in black and Asian females to match that in whites for vaccination; cervical screening in women who turn 25 in 2018 or later; and cervical screening in all ages.

FINDINGS

In the pre-vaccination era, before 2008, women from ethnic minorities in England reported a disproportionate share of cervical disease. Our model suggests that Asian women were 1·7 times (95% credibility interval [CI] 1·1-2·7) more likely to be diagnosed with cervical cancer than white women (22·8 vs 13·4 cases per 100 000 women). Because HPV vaccination uptake is lower in ethnic minorities, we predict an initial widening of this gap, with cervical cancer incidence in Asian women up to 2·5 times higher (95% CI 1·3-4·8) than in white women 20 years after vaccine introduction (corresponding to an additional 10·8 [95% CI 10·1-11·5] cases every year). In time, we predict that herd immunity benefits will diffuse from the larger white sub-population and the disparity will narrow. Increased cervical screening uptake in vaccinated women from ethnic minorities would lead to rapid improvement in equality with parity in incidence after 20 years of HPV vaccination.

INTERPRETATION

Our study suggests that the introduction of HPV vaccination in England will initially widen a pre-existing disparity in the incidence of HPV-related cancer by ethnicity, partly due to herd immunity disproportionately benefiting subgroups with high vaccination rates. Although in time this induced disparity will narrow, increasing cervical screening uptake in girls from ethnic minorities should be encouraged to eliminate the inequality in cervical cancer incidence in the medium term. We recommend that dynamic effects should be considered when estimating the effect of public health programmes on equality.

FUNDING

Cancer Research UK.

Alterations in oral bacterial communities are associated with risk factors for oral and oropharyngeal cancer

Oral squamous cell carcinomas are a major cause of morbidity and mortality, and tobacco usage, alcohol consumption, and poor oral hygiene are established risk factors. To date, no large-scale case-control studies have considered the effects of these risk factors on the composition of the oral microbiome, nor microbial community associations with oral cancer. We compared the composition, diversity, and function of the oral microbiomes of 121 oral cancer patients to 242 age- and gender-matched controls using a metagenomic multivariate analysis pipeline. Significant shifts in composition and function of the oral microbiome were observed with poor oral hygiene, tobacco smoking, and oral cancer. Specifically, we observed dramatically altered community composition and function after tooth loss, with smaller alterations in current tobacco smokers, increased production of antioxidants in individuals with periodontitis, and significantly decreased glutamate metabolism metal transport in oral cancer patients. Although the alterations in the oral microbiome of oral cancer patients were significant, they were of substantially lower effect size relative to microbiome shifts after tooth loss. Alterations following tooth loss, itself a major risk factor for oral cancer, are likely a result of severe ecological disruption due to habitat loss but may also contribute to the development of the disease.

Vitamin D and VDR in Gynecological Cancers-A Systematic Review

In recent years, a vast amount of studies have centered on the role of vitamin D in the pathogenesis of certain types of cancers such as breast, colorectal and lung cancer. Increasing evidence suggests that vitamin D and its receptor play a crucial role in the development of gynecological cancers. In this review, we systematically analyzed the effect of vitamin D and the vitamin D receptor on endometrial, ovarian, cervical, vulvar and vaginal cancer. Our literature research shows that vitamin D levels and vitamin-D-related pathways affect the risk of gynecological cancers. Numerous ecological studies give evidence on the inverse relationship between UVB exposure and gynecological cancer risk. However, epidemiologic research is still inconclusive for endometrial and ovarian cancer and insufficient for rarer types of gynecological cancers. The vitamin D receptor (VDR) is upregulated in all gynecological cancers, indicating its influence on cancer etiology. The VDR polymorphism FokI (rs2228570) seems to increase the risk of ovarian cancer. Other nuclear receptors, such as the RXR, also influence gynecological cancers. Although there is limited knowledge on the role of the VDR/RXR on the survival of endometrial, cervical, vulvar or vaginal cancer patients, some studies showed that both receptors influence survival. Therefore, we suggest that further studies should focus on the vitamin D- and its hetero dimer receptor RXR in gynecological cancers.

Effects of neoadjuvant chemotherapy on patients with primary vaginal squamous cell carcinoma

Vaginal cancer is a rare gynecological malignancy, mainly treated by radiotherapy and surgery. However, the effect of neoadjuvant chemotherapy on patients with vaginal cancer has not been extensively evaluated. The aim of the present study was to assess the feasibility and efficacy of irinotecan and cisplatin in the management of patients with vaginal squamous cell cancer (SCC). Two patients with International Federation of Obstetrics and Gynecology (FIGO) stage I and one patient with FIGO stage II vaginal SCC were treated with irinotecan (240 mg) and cisplatin (100 mg) every 3-4 weeks. The effect of chemotherapy after 2-4 courses was assessed and the next step of treatment was determined according to the outcome. In the present study, all 3 patients had complete remission after 2-4 courses of chemotherapy. In case 1, the patient received a total of 6 courses of chemotherapy and had no recurrence after 45 months of follow-up. In case 2, the patient received 4 courses of chemotherapy and partial vaginal resection, and had no recurrence after 48 months of follow-up. In case 3, the patient underwent laparoscopic radical surgery and peritoneal vaginoplasty after 2 courses of chemotherapy, and no residual tumors were identified in the resected tissues on postoperative pathological examination. Effective neoadjuvant chemotherapy may decrease the size of the tumor, induce tumor regression, or even achieve pathologically-confirmed complete tumor eradication. Thus, neoadjuvant chemotherapy with irinotecan combined with cisplatin is a feasible treatment for patients with early-stage vaginal SCC. In the present study, all the patients achieved good therapeutic results following chemotherapy.

Descriptive epidemiological study of vaginal cancer using data from the Osaka Japan population-based cancer registry: Long-term analysis from a clinical viewpoint

Vaginal cancer is such a rare tumor that epidemiological and clinical information for it is based mainly on studies of small numbers of cases. The aim of the present study was to perform a descriptive epidemiological analysis of vaginal cancer using a significantly larger population-based dataset from the Japanese Osaka Cancer Registry.The age-standardized incidence of vaginal cancer per 1,000,000 persons, from 1976 to 2010, was calculated and examined for trends. Relative-survival analysis was applied to estimate a more up-to-date 10-year period calculation, using data from recently followed-up patients. The conditional 5-year survival of patients who survived for 0 to 5 years after diagnosis was calculated.A total of 481 cases of vaginal cancer were registered in Osaka during the 35-year period from 1976 to 2010. The age-adjusted incidence rate has significantly and consistently decreased over this time [annual percent change (APC) = -1.29, 95% confidence interval (95% CI): -0.3 ∼ -2.2]; however, due to significant population aging, the raw incidence of vaginal cancer appeared to have been increasing. The 10-year relative survival of patients with surgery-based treatments was comparable to that of radiation-based treatments, implying that surgery and radiotherapy provide similar therapeutic benefits (P = .98). The 10-year relative survival was not significantly different during the period of 1976 to 2000 compared with the period of 2001 to 2008, although there has been, in the latter period, a tendency for improvement of long-term survival, especially for survival longer than 5 years. The longer the time after diagnosis, the higher the conditional 5-year relative-survival at 0 to 4 years after diagnosis.The age-adjusted incidence of vaginal cancer has decreased since 1976. Regrettably, the 10-year survival rate did not similarly improve, and it remained stable during the period from 2001 to 2008, compared with the period from 1976 to 2000, indicating that significant work remains to be done to develop more effective vaginal cancer treatments.