Cervical Cancer Screening in Pregnancy

Cervical cancer: Challenges and prevention strategies: A narrative review

Background and Aims

Human papillomavirus (HPV) infections that continue to exist are the main cause of cervical cancer (CC), two-thirds of CC occurrences worldwide are caused by HPV 16 and HPV 18, and 99.7% of CC tumors are linked to oncogenic HPV infection. To identify challenges of CC and its prevention and treatment modalities.

Methods

This review examined the epidemiology, predisposing factors, genetic factors, clinical assessment methods, current treatment options, and prevention approaches for CC. We had perform a narrative data synthesis rather than a pooled analysis. A thorough literature search in pertinent databases related to CC was done with the inclusion of data that were published in the English language.

Results

Early detection of CC is of utmost importance to detect precancerous lesions at an early stage. Therefore, all responsible agencies concerned with health should make all women aware of the benefits of CC screening and educate the general public. HPV vaccination coverage is very low in resource-limited settings.

Conclusion

To achieve the goal of eliminating CC as a public health problem in 2030, the World Health Organization will pay special attention to increasing HPV vaccination coverage throughout the world. To further improve HPV vaccine acceptability among parents and their children, safety-related aspects of the HPV vaccine should be further investigated through post-marketing surveillance and multicentre randomized clinical trials.

Abnormal Pap smear among pregnant women - Feasibility of opportunistic cervical screening

Objective

The uptake of cervical cancer screening is poor, especially in developing countries. Thus, pregnancy represents a good opportunity to have the test done. The aim of this study is to determine the prevalence of abnormal Pap smear among pregnant women during their antenatal check-ups.

Study design

A prospective study involving five hundred and ninety-six women was recruited over a 1-year duration from 15th January 2018 until 14th January 2019 in a tertiary referral center, in Malaysia. Pap smears were performed on all consented pregnant women using liquid-based cytology and the results were obtained to evaluate the prevalence of abnormal Pap smear during pregnancy. Maternal risk factors associated with abnormal Pap smear were identified and the outcomes of abnormal Pap smear were followed up.

Results

A total of 670 participants were approached and 596 participants agreed to participate, giving a response rate of 89.0 %. Therefore, 587 participants were available for analysis. There were nine unsatisfactory smears (1.5 %). The prevalence of premalignant lesions reported on p % ap smear was 0.8 %. Three respondents had atypical squamous cells of undetermined significance (ASCUS) (0.5 %) and two respondents had low-grade squamous intraepithelial lesions (LSIL) (0.3 %). Almost one-third (30.3 %) of respondents had an infection and 24 (4.1 %) smears were reported as reactive changes associated with inflammation. Respondents between the age of 20-30 years old had a significant association with an abnormal pre-cancerous smear (p = 0.000) as well as nulliparity (p = 0.0.40). There was no significant association between height, weight, BMI, sexual partner, age of first intercourse, smoking habit, history of sexually transmitted disease and history of abnormal Pap smear.

Conclusion

The prevalence of abnormal pre-cancerous smears during pregnancy is low. However, it is desirable to perform cervical screening as it provides an opportunity to no screening at all.

Exploration of shared gene signature with development of pre-eclampsia and cervical cancer

Background: The relationship between pre-eclampsia (PE) and cervical cancer (CC) has drawn more attention recently, while little is known about the shared pathogenesis of CC and PE. In the present research, we aimed to generate the shared gene network as well as the prognostic model to reveal the development of CC and PE.

Methods: The transcription data of CC and PE patients were obtained and enrolled into weighted gene co-expression network (WGCNA) analysis. Disease-specific modules in CC and PE were determined to discover the shared genes. The expression patterns of genes at protein level were examined by HPA database. Further, LASSO penalty regression and Cox analysis were applied to create a prognostic signature based on the shared genes, with survival curves and ROC plots employed to confirm the predictive capacity. To uncover the function roles and pathways involved in signature, gene set enrichment analysis (GSEA) was conducted. Finally, the immune infiltration status in CC was depicted using CIBERSORT algorithms.

Results: WGCNA determined three hub modules between CC and PE. A total of 117 shared genes were obtained for CC and PE and mainly enriched in cell proliferation, regulation of cell development and neuron differentiation. Then, we created a robust prognostic model based on the 10 shared genes by performing stepwise Cox analyses. Our proposed model presented a favorable ability in prognosis forecast and was correlated with the infiltration of immunocytes including B cells, macrophages and T cells. GSEA disclosed that high-risk group was involved in cancer-related pathways.

Conclusion: The present project identified the shared genes to uncover the pathogenesis of CC and PE and further proposed and validated a prognostic signature to accurately forecast the clinical outcomes of CC patients.

Maslinic Acid Inhibits Cervical Intraepithelial Neoplasia by Suppressing Interleukin-6 and Enhancing Apoptosis in a Mouse Model

BACKGROUND

Cervical intraepithelial neoplasia (CIN) directly precedes cervical cancer, and elevated proinflammatory cytokine interleukins (IL)-6 is implicated in CIN.

OBJECTIVE

As maslinic acid exhibits anti-IL-6 property, the present study sought to determine the effect of maslinic acid on CIN in vitro and in vivo using cell cultures and mouse CIN models, respectively.

METHODS

The dose-effect of maslinic acid on HeLa cells, a human cervical cancer cell line, was first evaluated, including cytotoxicity, IL-6 secretion, IL-6 receptor (IL-6R) expression, proliferation potential and apoptosis status. A mouse model of CIN was also established, which was then subjected to increasing doses of maslinic acid treatment, followed by assessment of serum IL-6 level, cervical expression of IL-6R, and the proliferation potential and apoptosis of cervical tissues.

RESULTS

Maslinic acid dose-dependently inhibited cell growth and proliferation potential, reduced IL-6 secretion, cervical expression of IL-6R and induced apoptosis of HeLa cells in vitro. In the CIN mouse model, serum IL-6 level and cervical expression of IL-6R were elevated, which could be repressed by maslinic acid administration dose-dependently. Additionally, maslinic acid treatment in the CIN mice could also restore the otherwise increased proliferation potential and reduced apoptosis in the cervical tissues.

CONCLUSION

Maslinic acid exhibits potent anti-IL-6 property in the CIN mouse model, and alleviates the disease-related abnormality in proliferation potential and apoptosis state of the cervical tissue cells, demonstrating its usefulness as a promising agent in treating CIN.

Course of cervical intraepithelial neoplasia diagnosed during pregnancy

PURPOSE

Management of high-grade cervical intraepithelial neoplasia [CIN grade 2 or 3 (CIN2-3)] diagnosed during pregnancy is controversial. Monitoring with colposcopy and cytology every 8-12 weeks is advised by the most current guidelines.

STUDY DESIGN

This study analyzes the course of disease in pregnant women with abnormal cytologies or clinically suspicious cervixes.

RESULTS

In total, 139 pregnant women, at a median age of 31 years (range 19-49), treated at the Colposcopy Unit of the University Medical Center Hamburg-Eppendorf between 2011 and 2017 were identified. During pregnancy, at least one biopsy was performed on 70.5% of patients. In 84.7% of cases, CIN2-3 (CIN2 n = 14 (14.3%), CIN3 n = 69 (70.4%)) was detected, 7.1% (n = 7) of women were diagnosed with CIN1, while no dysplasia was found in 8.2% (n = 8) of cases. No interventions were necessary during pregnancy. Despite explicit invitation, only 72.3% of women with CIN2-3 attended postpartal consultations. While 61.7% showed persistent lesions, 5% were diagnosed with CIN1 and 33.3% with complete remission. During pregnancy, 68.7% of women with prepartal CIN2-3 were tested for HPV infection. Later, 49.1% were followed up postpartally by means of HPV testing and histology. HPV clearance was observed in 36.4% of women with complete histological remission. Postpartum conization was performed on 44.6% of patients with prepartal CIN2-3 diagnosis. CIN2-3 was histologically confirmed in 97.3% cases. Progression from persistent CIN3 to microinvasive carcinoma was observed in a single case.

CONCLUSIONS

High-grade CIN lesions, diagnosed during pregnancy, show a high rate of regression postpartum; whereas, progression to carcinoma is rare. Close and continuous monitoring rarely has any therapeutic consequences. Compliance for postpartal follow-up needs to be improved.

Clinical outcome of high-grade cervical intraepithelial neoplasia during pregnancy: A 10-year experience

OBJECTIVE

To investigate the clinical outcome of high-grade cervical intraepithelial neoplasia (CIN) diagnosed by colposcopy-directed biopsy during pregnancy and to evaluate the risk factors for persistent disease.

STUDY DESIGN

This retrospective study included pregnant women who were diagnosed with CIN2+ by colposcopy-directed biopsy from January 2005 to December 2014. The clinical characteristics, histopathologic results, and human papillomavirus (HPV) test results were reviewed. The final histopathologic result after delivery was compared with the initial diagnosis to determine disease progression, persistence, or regression.

RESULTS

During the 10-year period, 215 pregnant women were diagnosed with high-grade CIN (75 CIN2, 140 CIN3) by colposcopy-directed biopsy. The mean age of the patients was 30.4 years. A total of 187 patients (87.0%) had high-risk HPV infections, with 76 (35.3%) infections identified as HPV genotype 16 or 18. Excisional procedures for diagnosis and treatment were not performed during pregnancy. The histopathologic results of 160 patients (normal in 43, CIN1 in 10, CIN2 in 15, CIN3 in 89, and invasive cancer in 3) were evaluated during the postpartum period. Multivariate logistic regression analysis was performed, and postpartum high-risk HPV infection (OR 5.09; 95% CI 2.15-12.05; P < 0.001) was identified as a significant independent predictor of CIN2+ persistence.

CONCLUSIONS

Conservative management of CIN2-3 during pregnancy is acceptable. However, persistent high-risk HPV infection is a major risk factor for CIN2+ persistence. Close follow-up with HPV testing, and postpartum colposcopy evaluation are necessary.

Should the Risk of Invasive Cancer in Pregnancy and the Safety of Loop Electrosurgical Excision Procedure During the First 15 Weeks Change Our Practice?

OBJECTIVE

The aim of this article was to describe the outcome of women diagnosed with cervical intraepithelial neoplasia (CIN) grades 2 or 3 in pregnancy either observed or treated by loop electrosurgical excision procedure (LEEP) in the first 15 weeks of gestation.

METHODS

Loop electrosurgical excision procedure during the first 15 gestational weeks compared with observation of CIN2/3. This is a retrospective analysis of a nonrandomized study at tertiary, academic, and referring centers in Israel. Ninety-three pregnant women diagnosed with CIN2/3 between 2006 and 2016 were included in this study. Fifty patients with CIN2/3 on cervical biopsy were conservatively followed-up, and 43 patients have undergone LEEP during the first 15 gestational weeks. Main outcome measures were ultimate diagnosis of invasive cancer or CIN, pregnancy outcome, and complications.

RESULTS

In 5.4% of CIN2/3 during pregnancy, the final diagnosis was invasive cancer. The postpartum results of 50 women who were conservatively observed were as follows: 3 (6.0%) had cervical cancer and undergone radical hysterectomy, 33 (66.6%) had CIN2/3, and 14 (28%) had CIN1 or normal histology. The diagnoses of the 43 patients who have undergone LEEP were invasive cancer in 2 patients (4.6%) but did not undergo hysterectomy, CIN2/3 or adenocarcinoma in situ (AIS) in 38 patients (88.4%), and 3 women (7%) had CIN1 or normal histology. None of them suffered severe bleeding. Thirty-seven women continued their pregnancy, 34 (91.9%) had term deliveries, 2 (5.4%) gave birth at 34 and 36 weeks, and 1 patient had missed abortion (2.7%).

CONCLUSIONS

The LEEP procedure during the first 15 weeks of pregnancy is safe. A total of 5.4% of the women with CIN2/3 during pregnancy were diagnosed with invasive cancer. It is time to reconsider the recommendations about CIN2/3 in early gestation.

Cancer and pregnancy: an overview for obstetricians and gynecologists

A relatively rare occurrence, pregnancy-associated cancer affects approximately 1 in 1000 pregnancies. Optimizing treatment of the cancer and minimizing harm to the fetus are often dependent on the extent of disease, treatment options required, and the impact on the pregnancy as well as the gestational age of pregnancy. When malignancy is diagnosed, the obstetrician-gynecologist plays a key role in the diagnosis, initial evaluation, and coordination of patient care. Furthermore, the obstetrician-gynecologist may be asked to assist in fertility planning for young women with a new diagnosis of cancer and may be responsible for addressing questions about family-planning needs and the safety of future pregnancy. Therefore, the purpose of this article was to provide the obstetrician-gynecologist with a relevant overview of the current literature regarding concurrent pregnancy and cancer diagnoses, management options, including maternal and neonatal outcomes, as well as the future needs of young women diagnosed with cancer who desire fertility preservation.

Malignancies associated with pregnancy: an analysis of 21 clinical cases

AIM

This study aimed at investigating the clinical characteristics of malignancies associated with pregnancy and to provide information for the development of suitable strategies of treating maternal malignancies.

METHODS

We conducted a retrospective analysis of 21 pregnant women with cancer who were admitted to our hospital between 2006 and 2012. The patients' clinical characteristics, treatment during pregnancy and postpartum, and pregnancy outcome were recorded.

RESULTS

There were 21 cases of malignancies associated with pregnancy, including 6 cases of cervical cancer, 6 cases of breast cancer, 3 cases of liver cancer, 2 cases of ovarian cancer, 2 cases of thyroid cancer, 1 case of nasopharyngeal carcinoma, and 1 case of malignant brain tumor. Of the 21 patients, 15 patients continued their pregnancies (9 of these patients received cancer treatment), whereas the other 6 terminated pregnancy. The modes of delivery included cesarean section (12 cases) and vaginal delivery (3 cases), which resulted in 17 newborns, 12 of them with preterm birth (12/17, 70.6 %). The gestational age was from 30 weeks + 5 days to 39 weeks. No neonatal malformations were found.

CONCLUSIONS

The management of malignancies associated with pregnancy is a challenge for doctors and patients. It should be based on histological subtype, disease stage, gestational age, obstetrics complications, and patient's preference regarding continuing the pregnancy.

Cervical cancer screening in pregnancy

Cervical cancer is the most commonly diagnosed malignancy during pregnancy with an incidence of 1.5 to 12 per 100,000 pregnancies. In the United States between 2% and 7% of all pregnant women will have an abnormal Pap test. The management of these abnormal results during pregnancy can present a challenge to the practitioner. This article reviews recently published guidelines and current evidence for evaluation and management of abnormal cervical cytology and cervical cancer in pregnancy.

Development of biomarker panel to predict, prevent and create treatments tailored to the persons with human papillomavirus-induced cervical precancerous lesions

Introduction

Human papillomavirus (HPV) induce many cancer conditions and cause cervical cancer, second in frequency of malignant disease in women.

The aim was to develop biomarker panel for HPV-induced cervical precancerous diseases in patients infected with herpes simplex virus (HSV).

Material and methods

The study involved 71 women with cervical precancerous diseases (mean age 26 ± 5 years) revealed by colposcopic, cytomorphological, and ultrasound signs which were assessed according to the following: first group, 44 patients infected with HPV; second group, 27 HPV-negative patients; and third group, 30 healthy patients (controls). In cervical specimen, we identified HPV DNA of different oncogenic risk types by polymerase chain reaction (PCR). Enzyme-linked immunosorbent assay (ELISA) kits (JSC SPC ‘DiaprofMed’) were used for detecting antibodies to HSV1 and/or HSV2 and for determining the avidity index. The production of pro-inflammatory cytokines, interferon-γ (IFN-γ), IFN-α, TNF-α, and interleukin-1β (IL-1β), and anti-inflammatory cytokines, IL-4, IL-10, and transforming growth factor-β1 (TGF-β1), were studied by ELISA.

Results

In HPV-induced cervix precancerous diseases, we identified low-avidity IgG antibodies to HSV serum of 20 patients; in the serum of 17 patients, we identified average-avidity antibodies, and high-avidity antibodies were found in 2 patients only. In 14 HPV-negative patients, we found low-avidity IgG antibodies to HSV; in 10 patients, medium avidity. Patients with low-avidity IgG antibodies to herpes virus showed high and medium oncogenic risk HPV types and a decrease of IFN-γ compared to patients with medium-avidity IgG antibodies. Production of IFN-γ was suppressed also in HPV-negative patients with cervical precancers, but we found low- and medium-avidity IgG antibodies to herpes virus. In patients with low-avidity antibodies, we observed increased level of IL-10. Level of IFN-α, IL-1β, IL-2, and IL-4 did not change in patients of all groups, but TGF-β1 increased.

Conclusions

In HPV-positive patients, those with low-avidity IgG antibodies to HSV had immunosuppression, confirmed by increased TGF-β1 and violation of IFN-γ production. Therefore, in pro- and anti-inflammatory cytokines and IgG antibodies to HSV, their avidity is an important diagnostic biomarker of HPV-induced precancerous cervical diseases. Low-avidity IgG antibodies may be an indication for treatment with immunomodulators and antiviral drugs.