Papillomavirus DNA and prognosis in cervical cancer

Tumor size and lymph node status determined by imaging are reliable factors for predicting advanced cervical cancer prognosis

The aim of the present study was to investigate the prognostic role of a number of clinical factors in advanced cervical cancer patients. Patients (n=157) with stage IIA-IIB cervical cancer treated at four Hallym Medical Centers in South Korea (Hallym University Sacred Heart Hospital; Kangnam Sacred Heart Hospital; Chuncheon Sacred Heart Hospital; and Kangdong Sacred Heart Hospital) between 2006 and 2010 were retrospectively enrolled. Univariate analysis identified significant predictive values in the following eight factors: i) Cancer stage (P<0.0001); ii) tumor size (≤4 vs. 4-6 cm, P=0.0147; and ≤4 vs. >6 cm, P<0.0001); iii) serum squamous cell carcinoma antigen level (≤2 vs. >15 ng/ml; P=0.0291); iv) lower third vaginal involvement (P<0.0001); v) hydronephrosis (P=0.0003); vi) bladder/rectum involvement (P=0.0015); vii) pelvic (P=0.0017) or para-aortic (P=0.0019) lymph node (LN) metastasis detected by imaging vs. no metastasis; and viii) pelvic LN metastasis identified by pathological analysis (P=0.0289). Furthermore, multivariate analysis determined that tumor size (≤4 vs. 4-6 cm, P=0.0371; and ≤4 vs. >6 cm, P=0.0024) and pelvic LN metastasis determined by imaging vs. no metastasis (P=0.0499) were independent predictive variables. Therefore, tumor size and pelvic LN metastasis measured by imaging were independent predictive factors for the prognosis of advanced cervical cancer. These factors may provide more clinically significant prognostic information compared with the currently used International Federation of Gynecology and Obstetrics staging system.

Does pretreatment human papillomavirus (HPV) titers predict radiation response and survival outcomes in cancer cervix?—A pilot study

OBJECTIVE

To evaluate if pretreatment HPV titers in cancer cervix could predict radiation response and survival outcomes.

METHODS

Twenty-one patients of cancer cervix were treated by radiotherapy (RT) alone. HPV titers were estimated using DNA Hybrid Capture II test. Loco-regional response at 1 month of RT--complete or partial response (CR and PR respectively) and survival outcomes--local disease-free (LDFS), disease-free (DFS) and overall (OS) survivals were evaluated against pre- and posttreatment HPV titers.

RESULTS

Pretreatment HPV titers ranged from 0.81 to 3966.10 RLU/cut off (mean +/- SD: 1264.39 +/- 1148.22, median: 1129.98). Of the demographic features evaluated, mean HPV titers were significantly different only for patients achieving CR or PR at completion of RT (mean +/- SD for CR vs. PR: 1616.31 +/- 1146.86 vs. 384.57 +/- 538.80, P = 0.022). HPV titers at end of RT ranged from 0.12 to 487.42 RLU/cut off (mean +/- SD: 37.31 +/- 108.60, median: 2.33). Patients with higher pretreatment HPV titers (>1000 RLU/cutoff) had a higher CR (P = 0.022) and better survival compared to those with < or =1000 RLU/cutoff (LDFS, P = 0.004; DFS, P = 0.005; OS, P = 0.012). At completion of RT, those having > or =99.5% fall in HPV had superior survival outcomes than those with <99.5% reduction (LDFS, P = 0.002; DFS, P = 0.002; OS, P = 0.004).

CONCLUSIONS

Higher pretreatment HPV titers (>1000 RLU/cutoff) could be considered as a predictor of radiotherapy response and survival in cancer cervix. A reduction in these titers to 99.5% of their baseline values at end of radiotherapy is also associated with better survival outcomes.

Human papilloma virus (HPV) DNA associated with prognosis of cervical cancer after radiotherapy

PURPOSE

The importance of human papilloma virus (HPV) infection in the outcome of cervical cancer after radiotherapy remains unknown. Our study explored whether the HPV status of tumors is associated with the outcome of radiotherapy in patients with cervical cancer.

METHODS AND MATERIALS

A total of 84 patients with cervical cancer (6 Stage I, 10 Stage II, 49 Stage III, and 19 Stage IV) who underwent definitive radiotherapy between January 1995 and June 2000 were included in this study. Tumor samples were obtained from all patients by punch biopsy before radiotherapy. The presence of HPV and its type were analyzed by polymerase chain reaction (PCR) based assay using the consensus primers for E6 and L1 regions. Actuarial methods were used to calculate overall survival and disease-free survival.

RESULTS

A total of 42 patients (50%) had cancer recurrence after radiotherapy. HPV-positive tumors were found in 76.2% (64 cases) of patients. HPV-negative patients survived for significantly shorter time periods compared to the HPV-positive patients in the overall survival (p = 0.007) and the disease-free survival (p = 0.005). According to multivariate analysis, HPV status is a significant predictor of both overall (p = 0.02) and disease-free survival time (p = 0.005).

CONCLUSION

The results of this study suggest that HPV-negative patients with cervical carcinoma have a significantly poorer prognosis after radiotherapy, and HPV status may be used as a marker to optimize the treatment of patients with this type of cancer.

The presence of HPV DNA in cervical cancer: correlation with clinico-pathologic parameters and prognostic significance: 10 years experience at the Department of Obstetrics and Gynecology of the Mainz University

The objective of this study was to assess whether the presence of human papillomavirus (HPV) DNA and/or several genotypes of HPV DNA in cervical cancer are correlated with several clinicopathologic parameters of well-defined prognostic significance and whether virologic parameters are predictors of long-term survival in cancer patients. Two hundred twenty three cases of cervical cancer patients included in this retrospective study underwent follow-up evaluation. Survival and cause of death were examined for 204 (91.4%) patients, with a mean follow-up time of 4.4 years. HPV DNA was detected using the highly sensitive polymerase chain reaction (PCR) method followed by HPV DNA sequencing for HPV genotyping. These results were correlated with well-defined clinicopathologic parameters and survival data. HPV DNA was detected by PCR in 150 of 193 (73.4%) tissue specimens of cervical cancer patients. DNA sequence analysis revealed the presence of HPV 16 (n = 68, 45.3%), HPV 18 (n = 49, 32.6%) and rare HPV types (n = 33, 22.1%). HPV genotypes correlated significantly with histologic tumor types, node status, tumor oxygenation, blood vessel invasion, and lymph space involvement. The presence of HPV DNA in cervical cancer as well as the genotype of HPV 16 could also be confirmed as significant prognostic factors in the univariate Cox regression analysis (RR 2.856, P < 0.003 resp. RR 3.444, P < 0.0001). In the multivariate analysis, however, HPV DNA status failed to be of prognostic relevance. Exclusively HPV 16 appears to have an independent impact on the overall survival in cervical patients (RR 3.653, P < 0.002). We conclude that the detection of HPV 16 genotype may play an important adjunct role in assessing prognosis of cervical cancer patients. The clinical impact of the presence of HPV DNA in primary tumors of uterine cervix remains to be investigated in further studies, and the exact mechanisms by which HPV influences the prognosis of cervical cancer patients have to be defined.

Favorable clinical outcome of cervical cancers infected with human papilloma virus type 58 and related types

To determine whether the status of human-papillomavirus (HPV) infection affects the clinical outcome of cervical carcinoma (CC), HPV genotype was prospectively determined in 94 consecutive CC cases subsequently followed for a median duration of 37.5 months. With a consensus PCR-RFLP method of HPV genotyping, 81 (86.2%) cancers were positive for HPV DNA. They were classified, according to the phylogenic similarities, into HPV-16-related (type 16, n = 45; type 31, n = 2), HPV-58-related (type 58, n = 17; type 33, n = 3; type 52, n = 2) and HPV-18-related (type 18, n = 8; type 68, n = 1) groups, and analyzed in relation to clinical outcome. The following results were observed: (i) Type-58-related HPVs were more prevalent in the old age (older than the median age of 52) group than in the young age group (41% vs. 14.6%, p = 0.045); (ii) 63% (5/8) of patients with advanced stages (III and IV) were HPV-negative, a figure much higher than that (9.3%, 8/84) of patients with early stages (stage I and II) (p = 0.002); (iii) the occurrence of adenocarcinoma or adenosquamous carcinoma was higher in the HPV-18-related group (50%) than in the HPV-16-related (33.3%) or the HPV-58-related (16.7%) groups (p = 0.024); (iv) the status of lymph-node metastasis and tumor grade did not correlate with HPV status; (v) 5-year survival rates were 90.2%, 80% and 74% for HPV-58-, HPV-16- and HPV-18-related groups, respectively (p = 0.03, after adjustment for tumor stage); (vi) in comparison with the HPV-16-related group, the relative risk of death in the HPV-58- and the HPV-18-related groups were 0.32 [95% CI, 0.07-1.49] and 1.87 [0.36-14.9] respectively. HPV genotype appears to affect the clinical behavior and outcome of cervical cancer. HPV-58-related types are prevalent in the older population, and appear to confer a favorable prognosis. Int. J. Cancer (Pred. Oncol.) 84:553-557, 1999.

Identification of human papillomavirus types 16 and 18 deoxyribonucleic acid sequences in bulky cervical cancer after chemotherapy

OBJECTIVE

The objectives of this study were to evaluate the effect of chemotherapy on the continual presence of human papillomavirus deoxyribonucleic acid sequences in bulky cervical cancer tissues and the relationship between the presence of human papillomavirus and the response of these patients to chemotherapy.

STUDY DESIGN

Multiple tissue sections obtained from 33 patients with bulky cervical cancer both before and after chemotherapy were analyzed for the presence of human papillomavirus types 16 and 18 by deoxyribonucleic acid amplification.

RESULTS

The cytotoxic effects of chemotherapy did not significantly alter the continual presence of human papillomavirus deoxyribonucleic acid sequences in these tissues (p = 0.8048). The presence of human papillomavirus type 16 deoxyribonucleic acid in tumors treated with neoadjuvant chemotherapy was significantly associated with favorable tumor response compared with type 18-positive patients and type 16/18-negative patients (94.7% vs 42.9%, p = 0.0059 and 94.7% vs 44.4%, p = 0.0004, respectively). Additionally, patients with type 18 deoxyribonucleic acid had a significantly higher risk of recurrence than did type 16-positive patients (p = 0.0123).

CONCLUSIONS

These results seem to suggest that the presence of human papillomavirus deoxyribonucleic acid sequences may serve as a marker to predict the response of bulky cervical cancer to chemotherapy and may be useful in reassessing neoadjuvant treatment for those patients who are free of human papillomavirus or those with type 18 deoxyribonucleic acid.

Cervical cancer survival in a high risk urban population

BACKGROUND

Cervical cancer remains an important public health problem, particularly for the urban minority population. To the authors' knowledge, determinants of cervical cancer survival have not been studied in this high risk population.

METHODS

This study included all 158 women diagnosed and treated for invasive cervical cancer from January 1, 1986, through December 31, 1992, at the Grady Memorial Hospital and Clinics (Atlanta, GA). Medical records were abstracted to determine age at diagnosis, race, International Federation of Gynecology and Obstetrics (FIGO) clinical stage, treatment, and survival. Pathologic material was reviewed to confirm the diagnosis.

RESULTS

Most patients (80%) were African American, and the stage distribution was similar for African American and white patients. Sixty-six (42%) had FIGO Stage I disease; 50%, Stage II or III; and 8%, Stage IV. Four-year actuarial survival differed significantly according to clinical stage (Ia = 94%, Ib = 79%, II = 39%, III = 26%, IV = 0%). Overall survival was lower for patients with glandular carcinomas than for those with squamous cell carcinomas (26% vs. 55%, P = 0.09). This difference was almost entirely due to increased mortality in patients with Stage Ib adenocarcinomas (53% vs. 88% for squamous cell carcinoma, Stage Ib, P = 0.03).

CONCLUSIONS

The major prognostic markers for cervical cancer survival in this high risk patient population were clinical stage and histology, factors identical to those identified for other populations.

Human papillomavirus deoxyribonucleic acid as a prognostic indicator in early-stage cervical cancer: a possible role for type 18

OBJECTIVE

Our purpose was to determine the prognostic significance of human papillomavirus deoxyribonucleic acid in cervical cancers.

STUDY DESIGN

The polymerase chain reaction was used to detect human papillomavirus deoxyribonucleic acid types 6, 11, 16, 18, 31, 33, 52, or 58 in tumors from 148 patients (equal numbers of whom were disease free or had relapses) surgically treated for stage IB or IIA cancers in a major Australian hospital. Cox regression modeling was used to assess the effect of human papillomavirus status on tumor recurrence, taking into account patient age, clinical stage, histologic node status, and type of tumor.

RESULTS

Seventy of 74 (95%) of the recurring tumors and 62 of 74 (84%) of the nonrecurring tumors were human papillomavirus deoxyribonucleic acid positive. The rates of positivity of types 16 and 18 were 64% versus 31% in the recurrers and 65% versus 14% in the nonrecurrers. Human papillomavirus type 18 positivity was associated with a greater risk of recurrence than was type 16 positivity (hazard ratio 1.8; p = 0.03). Clinical stage, nodal metastasis, and young age (< or = 35 years) also had adverse effects on relapse (hazard ratio for each approximately 2).

CONCLUSION

Human papillomavirus type 18 positivity is a risk factor for tumor recurrence in surgically treated cervical cancer.

Lymph node metastases, cell type, age, HPV status and type, neoadjuvant chemotherapy and treatment failures in cervical cancer

Conflicting evidence on the prognostic influence of some of the clinical and histopathological variables in cervical cancer of the HPV status and type and chemotherapeutic response prompted a number of reviews from nearly 40 years experience in a tertiary referral centre. The collation and analyses of these data with those from recent literature allow some proposals to be made. The disease is more prevalent in the young women in whom, in many centers, the mortality is also higher; the latter may be related to the reported increase in both small cell types and adeno and adenosquamous carcinoma--a finding more marked in the young. Lymph node metastases, related to increasing grade, size, stage and lymph space invasion, are unequivocally associated with a worse prognosis. Resolution of the exact nature of the intimate association of this disease with the human papilloma virus remains to be resolved as does the influence on prognosis of the tumor HPV status and that of the different oncogenic types. Reports on the efficiency of neoadjuvant platinum based combination chemotherapy are generally promising but vary considerably depending on the regimen used. Its value will not be determined without properly conducted large randomized studies.

Human papillomavirus DNA in cervical carcinoma--correlation with clinical data and influence on prognosis

Human papillomavirus (HPV) is a main factor in cervical carcinogenesis. However, data on the correlation of HPV with clinical features and the prognosis of cervical carcinoma remain controversial. The HPV status (positivity, type, copy number) in unfixed tissue specimens of 205 primary invasive cervical carcinomas was determined by Southern blot hybridization. A correlation with comprehensive clinical and histopathologic data and long-time survival was evaluated. HPV DNA was detected in 73% of the cases; 83% of the HPV-positive tumors contained HPV 16. HPV 16 was predominant among squamous-cell carcinomas (SCC) (p = 0.05). HPV 16 copy number was higher in keratinizing tumors (p < 0.05), and elevated levels of the SCC antigen were more common in patients positive for HPV 16 (p < 0.03). No association was found between the HPV status and 8 other clinical and histopathologic variables. Multivariate analysis after a median follow-up of 73 months demonstrated longer survival for patients with lower clinical stage (p = 0.001) and keratinizing SCC (p = 0.005). Women with HPV-negative tumors had a higher risk of death (RR 1.51; p = 0.07). HPV analysis does not clearly define biologically distinct sub-sets of cervical carcinoma. This underlines the importance of additional factors in cervical carcinogenesis.

Human papillomavirus DNA and p53 status in stage IB bulky cervical cancer

We used the polymerase chain reaction (PCR) to study the presence and typing of human papillomavirus (HPV) DNA, and PCR/single-strand confirmation polymorphism to survey the mutations of the p53 gene in exons 5-9 in 26 bulky stage IB cervical cancers. The HPV DNA was present in 20 out of the 21 (95%) squamous-cell carcinoma tissues, including 13 cases of HPV-16, 0 case of HPV-18, and 7 cases of other HPV types. In the other 5 adenocarcinoma tissues, 3 had HPV type-18 DNA and 2 had no detectable HPV DNA. The distribution of HPV DNA in bulky tumors was not statistically different from that in the other 228 squamous-cell carcinomas and 23 adenocarcinomas of smaller size operated upon during the same period. Out of the 26 patients, 9 (35%) had lymph node metastasis at the time of operation. During the follow-up period ranging from 19 to 48 months, 9 patients had recurrence and 7 of them died of disease. The distribution of HPV types was not related to the prognosis in these patients. There were no p53 mutations detected in all the 26 samples. Thus, HPV type and the status of p53 could not serve as additional prognostic factors in stage IB bulky cervical cancers.

Prognostic significance of polymerase chain reaction detected human papillomavirus of tumors and lymph nodes in surgically treated stage IB cervical cancer

This study describes the prognostic role of polymerase chain reaction detected human papillomavirus (HPV) in Stage IB cervical cancer patients treated with radical hysterectomy and pelvic and paraaortic node dissection. All tumors were confined to the cervix and all margins and nodes were disease free. Twenty-one patients were analyzed: 6 patients recurred within 20 months of initial therapy, while 15 had no evidence of disease with a minimum follow-up of 36 months. Polymerase chain reaction (PCR) was performed on paraffin-block tissue of the hysterectomy specimen cervical tumor and lymph nodes. Oligonucleotide probes for HPV types 6, 11, 16, 18, 31, 33, and 35 were used with consensus primers for uncharacterized HPV types created from an L1 constant region. Control tissues were run with each tumor sample to assure against contamination. HPV type confirmation was performed using diagnostic restriction sites. HPV was detected in all cervical tumors. Recurring tumors were infected with multiple types of HPV in all 6 tumors versus only 5 of 15 nonrecurring tumors being multiply infected (P = 0.023). No tumor had HPV 6 or 11, and the incidence of HPV 16, 31, 33, and 35 was not significantly different for recurrent versus nonrecurrent groups. HPV 18 was found in 5 of 6 recurring cancers versus 1 of 15 nonrecurring tumors (P = 0.0029). PCR typing of the histologically negative nodes that had been obtained at radical hysterectomy was done in all 6 recurring patients and in 6 nonrecurring patients. The recurrent patients had a significantly higher incidence of lymph nodes positive for HPV DNA (71%) than the nonrecurring patients (35%) (P = 0.0047). These observations suggest that HPV 18 cervical cancer patients, those with infections of multiple types, and those with HPV DNA in histologically negative lymph nodes may be at increased risk for recurrence.

Papillomaviruses and human oncogenesis

During the past year, significant advances have been made in understanding the functions of the oncoproteins, E6 and E7, of human papillomaviruses that are associated with malignant genital tumors. In addition, important new information is now available on the responses of both the keratinocyte and of the individual following papillomavirus infection.

Increased age and mortality associated with cervical carcinomas negative for human papillomavirus RNA

Attempts to relate presence and type of human papillomavirus in cervical carcinoma with prognosis have yielded conflicting results. To further investigate this relation, the association between survival of cervical cancer patients after diagnosis and the presence of human papillomavirus (HPV) RNA within the tumour was assessed retrospectively. Formalin-fixed biopsy specimens from 212 patients with cervical carcinoma who had been followed for up to 6 years were tested by in-situ hybridisation with 125I-labelled riboprobes. HPV-RNA-positive women were 11.9 years younger than HPV-negative women at diagnosis (p less than 0.001). Case-fatality rates from cervical cancer rose with absence of HPV RNA, age at diagnosis, or FIGO stage. Multivariate analysis confirmed that absence of detectable HPV RNA and advanced FIGO stage were independent risk factors. No differences in survival between HPV types 16, 18, 31, or 33 were seen. These observations suggest that cervical carcinoma patients fall into two groups--a younger, HPV-RNA-positive group, with a better prognosis, and an older, HPV-RNA-negative group with poorer prognosis. Treatment regimens for the two groups may need to differ.