Papillomavirus infection of the uterine cervix

Biopsy site selection during colposcopy and distribution of cervical intraepithelial neoplasia

OBJECTIVE

To determine if sites selected for colposcopic biopsy and histologically proven cervical intraepithelial neoplasia are distributed randomly across the cervix.

MATERIALS AND METHODS

Data were evaluated from all patients who visited the Walter Reed Army Medical Center Colposcopy Clinic during a 20-month period. chi analysis was performed to assess the randomness of distribution of biopsies and cervical intraepithelial neoplasia.

RESULTS

In 303 patients, 479 biopsies were performed. The 11-, 12-, and 1-o'clock positions were selected for 190 of 479 (40%) of biopsies, whereas the 6- and 12-o'clock positions were chosen for 186 of 479 (39%) of biopsies (p < 0.0001). Of 479 specimens, 161 (34%) were diagnosed as low-grade and 57 (12%) were diagnosed as high-grade. The 6-, 11-, and 12-o'clock positions accounted for 32 of 57 (56%) high-grade biopsies (p < 0.0001). The 6- and 12-o'clock positions accounted for 61 of 161 (38%) low-grade biopsies (p < 0.0001).

CONCLUSIONS

Loci selected for biopsy and histologically confirmed cervical intraepithelial neoplasia are not randomly distributed across the cervix. There is a predilection for the locations anterior and posterior to the cervical os.

Human papillomavirus types and cervical squamous intraepithelial lesions that recur after cold-knife conization

The purpose of this study was to analyze the HPV types and histological margins of cervical squamous intraepithelial lesions (SILs) treated by cold-knife conization and to correlate this with recurrent disease. Of 203 cone biopsies done for SILs primarily because the entire lesion could not be visualized at colposcopy, follow-up information was available for 85 cases. Of these 85 cases, biopsy-proven recurrences were documented for 10 (12%) women. In the SILs which recurred after conization, the lesion was noted on the surgical margin in 7/10 (70%) cases. In contrast, SILs that did not recur after cold-knife conization were detected on the surgical margin in only 12% of cases. In 7 of the recurrences, the HPV type detected in the pretreatment SIL was the same as that detected in the SIL that occurred after conization. In the other 3 recurrences, one of either the primary or recurrent SILs was HPV positive and the other corresponding lesion HPV negative. It is concluded that detection of a SIL on the surgical margin is a marker for recurrent disease and that recurrences are often associated with the same HPV type as that noted in the pretreatment SIL.

Correlation of histology and detection of human papillomavirus DNA in vulvar cancers

The purpose of this study was to correlate the histological findings and clinical information for vulvar precancers and cancers with the detection of human papillomavirus (HPV). Forty-five squamous cell lesions (twenty-two high-grade squamous intraepithelial lesions (SILs) and twenty-three invasive cancers) were analyzed for HPV DNA after amplification by the polymerase chain reaction. HPV DNA was noted in 13/22 (59%) high-grade SILs and 7/23 (30%) invasive cancers. For the invasive cancers, HPV DNA was detected in 0/13 that had substantial keratinization compared to 7/10 with minimal keratinization. Adjacent SIL was noted in 6/7 (86%) HPV-positive cancers compared to 1/16 (6%) in the HPV negative group. The mean age of the two groups was equivalent. The rate of metastases (3/7, 43%) for the HPV-positive group was higher than that for the HPV-negative (4/16, 25%) group. We conclude that vulvar cancers, unlike squamous cell carcinoma of the cervix, which is associated with HPV DNA in most cases, can be differentiated into two groups on the basis of histological findings and presence of HPV DNA.

Expression of cytokine receptors and markers of differentiation in human papillomavirus-infected cervical tissues

Human papillomavirus infection of the uterine cervix is associated with a spectrum of benign, premalignant, and malignant epithelial lesions, a process that appears to require the coordinated effects of secondary cellular and environmental events. We have used flow cytometry and immunohistochemistry to examine the expression of the cellular markers for proliferation (interleukin-1, epidermal growth factor receptor, and transferrin receptor) and the markers of cellular differentiation (filaggrin and low-molecular-weight cytokeratin) in normal and human papillomavirus--infected human cervical tissues representing the natural range of human papillomavirus--induced disease. The results were correlated with the histologic grade of disease, human papillomavirus type, cellular deoxyribonucleic acid content, and cell cycle status. Interleukin-1 and transferrin receptor were slightly increased in high-grade dysplasias and in squamous cell carcinomas. Filaggrin expression was found to be inversely related and cytokeratin and epidermal growth factor receptor expression directly related to the degree of neoplasia. These findings indicate that cytokeratin and epidermal growth factor receptor are useful markers of cell proliferation in human papillomavirus--infected tissues and that their expression may directly increase as a result of infection.

Is vestibular papillomatosis associated with human papillomavirus?

The origin and clinical significance of vestibular papillae were evaluated by comparing histological features with the presence of human papillomavirus (HPV) types 6/11 and 16/18, as revealed by Southern blot DNA hybridization. Twenty women with vestibular papillomatosis underwent clinical evaluation and follow-up. When available, male partners were also examined. Histological changes suggestive of HPV infection were present in all the 20 specimens. Sixteen cases (80%) contained DNA sequences homologous to the viral probes. In particular, 12 cases (60%) reacted with the HPV 16/18 probe. Follow-up for more than 18 months revealed no variation in the distribution and appearance of vestibular papillae. No male partner showed signs of HPV lesions. The study shows that HPV 16 is frequently associated with vestibular papillae but does not support a productive infection. Therefore the most appropriate management of these patients should be evaluated clinically in each individual case.

The increased frequency of cervical dysplasia-neoplasia in women infected with the human immunodeficiency virus is related to the degree of immunosuppression

Cytologic and histologic investigations of the uterine cervix and studies of the lymphocyte functions were performed in human immunodeficiency virus-infected and human immunodeficiency virus antibody-negative women to study possible linkages between human papillomavirus-induced dysplasia and degree of human immunodeficiency virus-induced immunosuppression. Cytologic smears of the uterine cervix of 111 human immunodeficiency virus-infected women were compared with findings in 76 female intravenous drug users negative for human immunodeficiency virus antibodies and in a group of 526 women of the outpatient population of the hospital. Cervical dysplasia-neoplasia (including five cases of invasive carcinoma) was seen in 41% of the human immunodeficiency virus-infected patients. In human immunodeficiency virus-negative intravenous drug users dysplasia-neoplasia was seen in 9%, and in the sample from outpatients in 4%, including two cases of invasive carcinoma (p less than 0.01). Cytologic features that were attributable to infection with human papillomavirus were observed in human immunodeficiency virus-infected women four times more often than in the sample from the outpatient population (p less than 0.01). Frequency and severity of dysplasia appear to increase with diminishing numbers of CD4+ helper/inducer T lymphocytes and correlated significantly (p less than 0.01) with a loss of blastogenic response to phytohemagglutinin, pokeweed mitogen, and tetanus toxoid. These results suggest an increased risk for the development of dysplasia of the uterine cervix in women with human immunodeficiency virus infection, which is related to the degree of immunosuppression.

In situ hybridization analysis of human papillomavirus DNA segregation patterns in lesions of the female genital tract

Various histologic features may be used to divide human papillomavirus (HPV)-related lesions of the genital tract into two groups: condylomata and "low-grade" or grade 1 cervical intraepithelial neoplasias (CIN 1) versus "high-grade" or grade 2 and 3 intraepithelial neoplasias. Using in situ hybridization analysis we correlated HPV DNA type with histologic features in 350 biopsies of lesions from the cervix, vulva, and perianal region. HPV DNA was most commonly found in vulvar and perianal condylomata (39/46, 85%), whereas the rate in CIN 1 lesions was 72% (86/120). The rates were 53% (40/76) and 57% (12/21) in CIN 2/3 and vulvar intraepithelial neoplasm (VIN) grades 2 and 3, respectively. The HPV type in all but 2 of the 39 perianal and vulvar condylomata which contained HPV was 6/11. Despite their similar histologic features, the HPV type in only 23 of 86 (27%) CIN 1 cases with detectable HPV was 6/11 compared to 31 of 86 (36%) which contained HPV 16-related DNA and 32 of 86 (37%) which contained HPV 31,-33, or -35-related DNA. The viral DNA in the majority of CIN 2/3 lesions and all of the VIN 2/3 lesions was HPV-16 related; no CIN 2/3 or VIN 2/3 lesion had HPV 6/11-related DNA. It is concluded that although cutaneous genital tract condylomata are highly associated with HPVs of low oncogenic potential (types 6 and 11), these HPV types are not as frequent as the oncogenic HPVs (16, 31, 33, and 35) in CIN 1 lesions. Further, HPV 6/11 appears to be very rarely associated with CIN 2/3 or VIN 2/3 lesions.

Ameloblastoma in young persons: a clinicopathologic analysis and etiologic investigation

Ameloblastoma, an odontogenic tumor of ectodermal origin, has been reported to arise, on rare occasions, in a primordial or dentigerous cyst of a young person. Numerous authors have suggested differing nomenclatures for these ameloblastomas (e.g., mural, unicystic, monocystic, intracystic, cystogenic, cystic, plexiform unicystic) and have sought to describe and classify the clinical and histopathologic features. These tumors have been characterized as a distinct variant exhibiting less aggressive behavior and a lower rate of recurrence than conventional ameloblastoma. Furthermore, various etiologic factors have been proposed for these cystic ameloblastomas, including (1) nonspecific irritational factors such as extraction, caries, trauma, infection, inflammation, or tooth eruption; (2) nutritional deficit disorders, and (3) viral infection. The files of the combined accessioned cases of Emory University's and Temple University's oral pathology laboratories were searched and a review of the literature was performed. Thirty-eight cases of mandibular ameloblastoma (37 intraosseous, 1 peripheral) in persons 19-year-old and younger were found from a combined total of 311 accessioned cases of ameloblastoma (12.2%). The average age at diagnosis was 10.4 years for the 18 males and 20 females. Of the 33 cases in which race was stated, 19 (57.6%) were white and 14 (42.4%) were black. In the 28 cases in which a clinical diagnosis was offered, fifteen (53.6%) were thought to be dentigerous cysts. Ten cases from patients less than 19 years old were investigated by means of an immunohistochemical staining technique for the detection of human papilloma virus (HPV) genus-specific structural antigen in formalin-fixed, paraffin-embedded tissue. Three of the ten cases (cases 31, 37 and 38) were positive for HPV capsid antigen, whereas none of ten randomly selected ameloblastomas in adults was positive. A discussion of the clinical and histopathologic comparative findings, with emphasis on treatment results and possible HPV etiology, is included. The preliminary nature of finding HPV in the tumor cells is stressed, with recommendation for further verification and typing with the more sensitive in situ hybridization technique.

Occult human papillomavirus infection of the uterine cervix in postmenopausal women

Occult infection is assumed when human papillomavirus is detected in the absence of unequivocal cytologic or histologic changes. In this study occult human papillomavirus infection in postmenopausal women was examined to determine if the histologic findings with such infections were indeed nondiagnostic and to compare the rate of occult human papillomavirus infection in this group with that in a younger age group. In five of 43 cases (12%) sequences homologous to human papillomavirus deoxyribonucleic acid were detected in biopsy specimens from the cervices of hysterectomy specimens of postmenopausal women who had no history of abnormal Papanicolaou smears or genital tract neoplasms. This rate was not significantly different from that found in a premenopausal group of women (8%, n = 60) studied concurrently. Except for one case in which human papillomavirus type 11 was detected, the human papillomavirus types in the occult infections were distinct from those commonly associated with the genital tract. The histologic features of human papillomavirus infection were not found in the human papillomavirus-positive cases, except for one case of cervical intraepithelial neoplasia. The similar rates of occult infection in the two age groups suggests that about 10% of women over a wide range of ages may be infected by human papillomavirus but have no clinical or pathologic evidence of the infection.

The human DNA tumor viruses: human papilloma virus and Epstein-Barr virus

HPV and EBV are common infectious agents that persist after primary infection in a latent state with occasional shedding of virus. Therefore, one of the fundamental questions in the etiology of those cancers that are linked to infection with such ubiquitous viruses is why cancer develops in a few people when many are infected. Because only a small subset of infected people will develop specific cancers, it has been suggested that the presence of the viral genomes in the malignancies merely indicates a persistent or latent infection. However, if the viral infection was not an etiologic factor in the development of the specific cancers, then one would predict that the proportion of cancers that contained the viral genome would reflect the proportion of infected people and that the same cancers could develop in uninfected people. The sporadic detection from nonendemic areas of Burkitt's lymphoma without EBV initially suggested that EBV infection was not etiologic. However, the rate of incidence of BL in infected populations of children is disproportionately greater than the very low incidence in uninfected children, which suggests that EBV infection is an important contributing factor. Moreover, the development of EBV-induced lymphomas in the immunocompromised and the consistent detection of EBV in specific epithelial malignancies such as NPC suggest that EBV infection is essential in the induction of specific cancers. Similarly, the consistent detection of particular HPV types in certain types of cancer suggests that HPV is also an etiologic factor. There are several strikingly similar aspects of infection with HPV and EBV. In latent infection, both of the viral genomes persist as an extrachromosomal episome with an origin of replication that is activated by binding to a virally encoded polypeptide. The state of viral infection appears to be linked with the state of cellular differentiation such that latent infections are activated into a replicative state as the cells differentiate. Moreover, elevated levels of expression of the putative transforming genes are linked to transformation. However, perhaps most importantly, the malignancies are clonal with regard to the viral infection; HPV-associated malignancies have unique integrative events and EBV-associated malignancies have clonal episomal forms. This reveals that the specific cancers are clonal cellular proliferations that developed after viral infection. In vitro, the initially polyclonal cell lines produced by EBV infection rapidly evolve to oligoclonality or monoclonality. This could be due to a slightly faster rate of growth such that the progeny of one clone rapidly predominate.(ABSTRACT TRUNCATED AT 400 WORDS)

Correlation of histology with human papillomavirus DNA detection in the female genital tract

Genital condyloma and intraepithelial neoplasia secondary to Human Papillomavirus (HPV) infection are characterized by perinuclear halos and marked nuclear atypia (koilocytotic atypia) on cytologic and histologic examination. However, at times the histologic findings, including the degree of nuclear atypia, may be suggestive but not absolutely diagnostic of an HPV related neoplasm. HPV DNA sequences were detected in 63 and 56% of colposcopically visible vaginal and cervical lesions, respectively, that were diagnosed as condyloma or intraepithelial neoplasia. HPV DNA sequences were detected in 14 and 47% of vaginal and cervical lesions, respectively, that did not fulfill the histologic criteria of condyloma or intraepithelial neoplasia (i.e., "nondiagnostic"). When examining cervices from patients with no visible lesion and no recent history of an abnormal pap smear, 5.5% had detectable HPV DNA sequences. The histologic findings in this group were equivalent to the virus-negative cases and similar to the "nondiagnostic" cervical lesions. These findings suggest that the detection rate of HPV DNA in "nondiagnostic" tissues is dependent on the site and presence or absence of a visible lesion. The rate is similar in cervical lesions regardless of the histologic findings whereas it is less in vaginal lesions when the histologic criteria of condyloma or intraepithelial neoplasia are not detected.

Isolation of a novel human papillomavirus (type 51) from a cervical condyloma

We cloned the DNA from a novel human papillomavirus (HPV) present in a cervical condyloma. When DNA from this isolate was hybridized at high stringency with HPV types 1 through 50 (HPV-1 through HPV-50), it showed weak homology with HPV-6 and -16 and stronger homology with HPV-26. A detailed restriction endonuclease map was prepared which showed marked differences from the maps for other HPVs that have been isolated from the female genital tract. Reassociation kinetic analysis revealed that HPV-26 and this new isolate were less than 10% homologous; hence, the new isolate is a novel strain of HPV. The approximate positions of the open reading frames of the new strain were surmised by hybridization with probes derived from individual open reading frames of HPV-16. In an analysis of 175 genital biopsies from patients with abnormal Papanicolaou smears, sequences hybridizing under highly stringent conditions to probes from this novel HPV type were found in 4.2, 6.1, and 2.4% of biopsies containing normal squamous epithelium, condylomata, and intraepithelial neoplasia, respectively. In addition, sequences homologous to probes from this novel isolate were detected in one of five cervical carcinomas examined.