1
|
Mungo C, Kachoria AG, Adoyo E, Zulu G, Goraya SK, Omoto J, Osongo C, Ferrari RM, Rahangdale L. "ARVs is for HIV and cream is for HPV or precancer:" Women's Perceptions and Perceived Acceptability of Self-Administered Topical Therapies for Cervical Precancer Treatment: A Qualitative Study from Kenya. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.11.24304083. [PMID: 38559146 PMCID: PMC10980133 DOI: 10.1101/2024.03.11.24304083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Women in low- and middle-income countries (LMICs) bear a disproportionate burden of global incidence and deaths from cervical cancer, despite being a preventable disease. Prevention efforts in LMICs are hindered in part by lack of access to cervical precancer treatment, due to weak health infrastructure and a lack of adequate human resources to deliver current provider-administered precancer treatments. Innovative strategies are urgently needed to close the cervical precancer treatment gap in LMICs, including the use of self-administered topical therapies for which efficacy evidence is available from high-income settings. We investigated African women's perceptions and perceived acceptability of these therapies for cervical precancer treatment. Methods Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with women ages 25-65 years undergoing cervical cancer screening or precancer treatment in Kisumu, Kenya. The FGDs explored women's experiences with screening and precancer treatment, their acceptability of topical therapies for precancer treatment, and perceived barriers and facilitators to uptake. The FGDs were moderated by local qualitative research assistants, conducted in local languages, transcribed, coded, and analyzed using qualitative description using NVIVO software. Results Twenty-nine women participated, with a mean age of 35.4 years (SD 6.5). All had undergone cervical cancer screening, and 25 (83%) had a history of precancer treatment with ablation or excision. Multiple themes were identified related to women's perceptions of topical therapies. Participants were highly receptive of topical treatments, with many favoring the option of self-administration compared to provider-administration of such therapies. Self-administration of topical therapies was felt to help address challenges associated with current treatment methods, including difficulty in access, pain with procedures, cost, and lack of privacy with pelvic exams. Participants had a preference for topical therapies that are used less frequently compared to those used daily. Conclusions Among Kenyan women with a history of cervical precancer treatment, self-administered topical therapies for precancer are acceptable and have the potential to address barriers, including access, privacy, and cost, that hinder precancer treatment in LMICs. If supported by efficacy studies in LMICs, self-administered topical therapies offer a scalable approach to closing the precancer treatment gap in LMICs. Trial registration Not applicable.
Collapse
Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Aparna Ghosh Kachoria
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | | | - Graham Zulu
- Butler Institute for Families, University of Denver, Denver, CO 80210, USA
| | - Supreet Kaur Goraya
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine, Kisumu, Kenya
| | | | - Renée M. Ferrari
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| |
Collapse
|
2
|
Avitan O, Rafael T, Vreeburg M, Elst L, Bekers EM, Albersen M, Jordanova ES, Brouwer O. Penile intraepithelial neoplasia incidence, clinical classification, microenvironment and implications for imiquimod treatment. BJU Int 2024. [PMID: 39030899 DOI: 10.1111/bju.16473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2024]
Abstract
OBJECTIVES To provide an outline of the existing data on penile intraepithelial neoplasia (PeIN), as well as a narrative review on imiquimod (IQ; a toll-like receptor 7 agonist) treatment and immune microenvironment markers that may predict response to treatment. METHODS A narrative review of the literature from 2000 to the present was conducted on PubMed, and we describe the most relevant data and cross references. RESULTS The incidence of PeIN is increasing. Local therapy with IQ may offer an easy applicable treatment with complete response rates of up to 63% but can be associated with considerable side-effects. There is no conclusive data on the optimal treatment schedule for PeIN, but evaluation of treatment results for other human papillomavirus-related pre-malignancies suggest three times a week for a duration up to 16 weeks. There are no published studies concerning the PeIN immune microenvironment. However, findings from the few studies on penile cancer and pre-cancerous vulvar and cervical lesions imply that specific immune cell subpopulations can serve as future predictors for successful immunomodulation treatments such as IQ. CONCLUSIONS Overall, limited data are available on IQ treatment for PeIN and no published data exists on the PeIN immune microenvironment. Further translational studies are warranted to gain more understanding on the pathophysiology of PeIN and potential predictors of progression and of response to topical treatments.
Collapse
Affiliation(s)
- Ofir Avitan
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Tynisha Rafael
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Manon Vreeburg
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Laura Elst
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Elise M Bekers
- Division of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maarten Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Ekaterina S Jordanova
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Oscar Brouwer
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Diakite I, Martins B, Owusu-Edusei K, Palmer C, Patterson-Lomba O, Gomez-Lievano A, Zion A, Simpson R, Daniels V, Elbasha E. Structured Literature Review to Identify Human Papillomavirus's Natural History Parameters for Dynamic Population Models of Vaccine Impacts. Infect Dis Ther 2024; 13:965-990. [PMID: 38589763 PMCID: PMC11098984 DOI: 10.1007/s40121-024-00952-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
Human papillomavirus (HPV) is a common sexually transmitted virus that can cause cervical cancer and other diseases. Dynamic transmission models (DTMs) have been developed to evaluate the health and economic impacts of HPV vaccination. These models typically include many parameters, such as natural history of the disease, transmission, demographic, behavioral, and screening. To ensure the accuracy of DTM projections, it is important to parameterize them with the best available evidence. This study aimed to identify and synthesize data needed to parametrize DTMs on the natural history of HPV infection and related diseases. Parameters describing data of interest were grouped by their anatomical location (genital warts, recurrent respiratory papillomatosis, and cervical, anal, vaginal, vulvar, head and neck, and penile cancers), and natural history (progression, regression, death, cure, recurrence, detection), and were identified through a systematic literature review (SLR) and complementary targeted literature reviews (TLRs). The extracted data were then synthesized by pooling parameter values across publications, and summarized using the range of values across studies reporting each parameter and the median value from the most relevant study. Data were extracted and synthesized from 223 studies identified in the SLR and TLRs. Parameters frequently reported pertained to cervical cancer outcomes, while data for other anatomical locations were less available. The synthesis of the data provides a large volume of parameter values to inform HPV DTMs, such as annual progression rates from cervical intraepithelial neoplasia (CIN) 1 to CIN 2+ (median of highest quality estimate 0.0836), CIN 2 to CIN 3+ (0.0418), carcinoma in situ (CIS) 2 to local cancer+ (0.0396), and regional to distant cancer (0.0474). Our findings suggest that while there is a large body of evidence on cervical cancer, parameter values featured substantial heterogeneity across studies, and further studies are needed to better parametrize the non-cervical components of HPV DTMs.
Collapse
Affiliation(s)
- Ibrahim Diakite
- Health Economic and Decision Sciences, Merck & Co., Inc., Rahway, NJ, 07065, USA.
- Merck & Co., Inc. Biostatistics and Research Decision Sciences (BARDS), Health Economic and Decision Sciences (HEDS), Vaccines, WP 37A-150 770 Sumneytown Pike, 1st Floor, West Point, PA, 19486, USA.
| | - Bruno Martins
- Analysis Group, Inc, 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA
| | - Kwame Owusu-Edusei
- Health Economic and Decision Sciences, Merck & Co., Inc., Rahway, NJ, 07065, USA
| | - Cody Palmer
- Health Economic and Decision Sciences, Merck & Co., Inc., Rahway, NJ, 07065, USA
| | | | | | - Abigail Zion
- Analysis Group, Inc, 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA
| | - Ryan Simpson
- Analysis Group, Inc, 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA
| | - Vincent Daniels
- Health Economic and Decision Sciences, Merck & Co., Inc., Rahway, NJ, 07065, USA
| | - Elamin Elbasha
- Health Economic and Decision Sciences, Merck & Co., Inc., Rahway, NJ, 07065, USA
| |
Collapse
|
4
|
Hamar B, Teutsch B, Hoffmann E, Hegyi P, Harnos A, Nyirády P, Hunka Z, Ács N, Bánhidy F, Melczer Z. Imiquimod Is Effective in Reducing Cervical Intraepithelial Neoplasia: A Systematic Review and Meta-Analysis. Cancers (Basel) 2024; 16:1610. [PMID: 38672691 PMCID: PMC11048968 DOI: 10.3390/cancers16081610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Topical Imiquimod is an immune response modifier approved for the off-label use of vulvar intraepithelial neoplasia. We conducted this systematic review and meta-analysis to investigate the efficacy and safety of Imiquimod in treating cervical intraepithelial neoplasia (CIN) and human papillomavirus (HPV)-positive patients. METHODS The study was prospectively registered (CRD420222870) and involved a comprehensive systematic search of five medical databases on 10 October 2022. We included articles that assessed the use of Imiquimod in cervical dysplasia and HPV-positive patients. Pooled proportions, risk ratios (RRs), and corresponding 95% confidence intervals (CIs) were calculated using a random effects model to generate summary estimates. Statistical heterogeneity was assessed using I2 tested by the Cochran Q tests. RESULTS Eight articles reported on 398 patients who received Imiquimod out of 672 patients. Among CIN-2-3 patients, we observed a pooled regression rate of 61% (CI: 0.46-0.75; I2: 77%). When compared, Imiquimod was inferior to conization (RR: 0.62; CI: 0.42-0.92; I2: 64%). The HPV clearance rate in women who completed Imiquimod treatment was 60% (CI: 0.31-0.81; I2: 57%). The majority of side effects reported were mild to moderate in severity. CONCLUSIONS Our findings indicate that topical Imiquimod is safe and effective in reducing cervical intraepithelial neoplasia and promoting HPV clearance. However, it was found to be inferior compared to conization. Imiquimod could be considered a potential medication for high-grade CIN patients and should be incorporated into guidelines for treating cervical dysplasia.
Collapse
Affiliation(s)
- Balázs Hamar
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Institute for Translational Medicine, Medical School, University of Pécs, 7621 Pécs, Hungary
| | - Eszter Hoffmann
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Institute for Translational Medicine, Medical School, University of Pécs, 7621 Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, 1088 Budapest, Hungary
| | - Andrea Harnos
- Department of Biostatistics, University of Veterinary Medicine, 1078 Budapest, Hungary;
| | - Péter Nyirády
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
- Department of Urology, Semmelweis University, 1082 Budapest, Hungary
| | - Zsombor Hunka
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
| | - Nándor Ács
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
| | - Ferenc Bánhidy
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
| | - Zsolt Melczer
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
| |
Collapse
|
5
|
Mungo C, Adewumi K, Adoyo E, Zulu G, Goraya SK, Ogollah C, Omoto J, Ferrari RM, Rahangdale L. "There is nothing that can prevent me from supporting her:" men's perspectives on their involvement and support of women's use of topical therapy for cervical precancer treatment in Kenya. Front Oncol 2024; 14:1360337. [PMID: 38532929 PMCID: PMC10964769 DOI: 10.3389/fonc.2024.1360337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/16/2024] [Indexed: 03/28/2024] Open
Abstract
Purpose Cervical cancer disproportionately impacts women in low- and middle-income countries (LMICs). The World Health Organization's (WHO) 90/70/90 strategy aims to eliminate cervical cancer by 2030 by increasing HPV vaccination coverage to 90%, screening 70% of eligible women, and effectively treating 90% of those with abnormal results by 2030, potentially preventing 62 million deaths in LMICs. LMICs, however, struggle with limited access to cervical precancer treatment, in part due to a lack of trained professionals and weak health systems. Effective non-surgical, self-administered, which have demonstrated efficacy in high-income countries, could bridge the treatment gap in LMICs and may be more scalable and cost-effective than provider-administered therapies. To inform feasibility studies in LMICs, data are needed on the role of male partners in influencing the acceptability and uptake of self-administered topical therapies, including their support of recommended abstinence and contraception guidelines associated with these therapies. Methods Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with men aged 25 to 65 years in Kenya to explore their perspective and perceived support regarding their female partners using topical self-administered therapies for cervical precancer treatment. The FGDs were moderated by local qualitative research assistants and conducted in local languages, transcribed, coded, and analyzed using qualitative description. Results Thirty-nine male participants meeting the eligibility criteria participated in five FGDs. The mean age of participants was 42.5 years. Most participants, 79.5%, had a female partner with a history of cervical precancer treatment, 5.1% did not, and 15.4% were unsure of their female partner's prior precancer treatment history. The study aimed to assess men's support of their female partners' use of topical therapies for treating cervical precancer. We find that male participants strongly express acceptance and willingness to support their wives or partners in using such therapies, if available. Reported supportive behavior included permitting the use of the therapies and support of maintaining abstinence during the recommended times. Additionally, participants desired male involvement in clinic and community-based education about topical therapies to facilitate widespread support. Conclusion The use of self-administered topical therapies for cervical precancer treatment, if supported by efficacy studies in LMICs, may support achieving the WHO's 2030 goal of 90% treatment access. We find that with adequate education, men express overwhelming support of their female partner's use of topical therapies, including adherence to abstinence and contraception guidelines.
Collapse
Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Konyin Adewumi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Graham Zulu
- University of Denver, Denver, CO, United States
| | - Supreet Kaur Goraya
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine, Kisumu, Kenya
| | - Renée M. Ferrari
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| |
Collapse
|
6
|
Mungo C, Ellis GK, Rop M, Zou Y, Omoto J, Rahangdale L. Perceived acceptability of self-administered topical therapy for cervical precancer treatment among women undergoing cervical cancer screening in Kenya. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.05.24303779. [PMID: 38585806 PMCID: PMC10996722 DOI: 10.1101/2024.03.05.24303779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Purpose Innovative strategies are urgently needed to meet the World Health Organization's 2030 target of treating 90% of women with precancerous cervical lesions, especially in countries most affected by cervical cancer. We assessed the acceptability of self-administered intravaginal therapies for treating cervical precancer in women undergoing cervical cancer screening and precancer treatment in Kenya. Methods We conducted a cross-sectional study among women aged 18 to 65 years undergoing cervical cancer screening or precancer treatment between January and October 2023 in Kisumu County, Kenya. Participants completed a questionnaire about their perceptions and perceived acceptability of self- or provider-administered topical therapies for cervical precancer treatment. Quantitative data were summarized using descriptive statistics. Results A total of 379 questionnaires were completed. The median age of participants was 35 years (IQR 25-62), 62% had a primary education or less, and 71% earned $5 or less daily. All participants had been screened for cervical cancer, and 191 (51%) had received precancer treatment, primarily thermal ablation. Ninety-eight percent of participants were willing to use a self-administered intravaginal therapy for cervical precancer, if available. The majority, 91%, believed their male partner would support their use. Given a choice, 63% preferred self-admiration at home compared to provider-administration of a topical therapy in the clinic, citing time and cost savings. In multivariate analysis, married women were more likely to expect partner support for self-administration than single women. Participants preferred a therapy used less frequently but for a longer duration, compared to daily use therapy with a shorter duration of use. Conclusions Self-administered intravaginal therapies for cervical precancer treatment are highly acceptable among women undergoing screening and precancer treatment in Kenya.
Collapse
Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, North Carolina, USA
| | - Grace K Ellis
- School of Medicine, University of North Carolina Chapel Hill, North Carolina, USA
| | - Mercy Rop
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Yating Zou
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine. Kisumu, Kenya
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, North Carolina, USA
| |
Collapse
|
7
|
Głowienka-Stodolak M, Bagińska-Drabiuk K, Szubert S, Hennig EE, Horala A, Dąbrowska M, Micek M, Ciebiera M, Zeber-Lubecka N. Human Papillomavirus Infections and the Role Played by Cervical and Cervico-Vaginal Microbiota-Evidence from Next-Generation Sequencing Studies. Cancers (Basel) 2024; 16:399. [PMID: 38254888 PMCID: PMC10814012 DOI: 10.3390/cancers16020399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/10/2024] [Accepted: 01/13/2024] [Indexed: 01/24/2024] Open
Abstract
This comprehensive review encompasses studies examining changes in the cervical and cervico-vaginal microbiota (CM and CVM) in relation to human papillomavirus (HPV) using next-generation sequencing (NGS) technology. HPV infection remains a prominent global health concern, with a spectrum of manifestations, from benign lesions to life-threatening cervical cancers. The CM and CVM, a unique collection of microorganisms inhabiting the cervix/vagina, has emerged as a critical player in cervical health. Recent research has indicated that disruptions in the CM and CVM, characterized by a decrease in Lactobacillus and the overgrowth of other bacteria, might increase the risk of HPV persistence and the progression of cervical abnormalities. This alteration in the CM or CVM has been linked to a higher likelihood of HPV infection and cervical dysplasia. NGS technology has revolutionized the study of the cervical microbiome, providing insights into microbial diversity, dynamics, and taxonomic classifications. Bacterial 16S rRNA gene sequencing, has proven invaluable in characterizing the cervical microbiome, shedding light on its role in HPV infections and paving the way for more tailored strategies to combat cervical diseases. NGS-based studies offer personalized insights into an individual's cervical microbiome. This knowledge holds promise for the development of novel diagnostic tools, targeted therapies, and preventive interventions for cervix-related conditions, including cervical cancer.
Collapse
Affiliation(s)
- Maria Głowienka-Stodolak
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781Warsaw, Poland; (M.G.-S.); (K.B.-D.); (E.E.H.); (M.D.)
| | - Katarzyna Bagińska-Drabiuk
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781Warsaw, Poland; (M.G.-S.); (K.B.-D.); (E.E.H.); (M.D.)
| | - Sebastian Szubert
- Division of Gynaecological Oncology, Department of Gynaecology, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (S.S.); (A.H.)
| | - Ewa E. Hennig
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781Warsaw, Poland; (M.G.-S.); (K.B.-D.); (E.E.H.); (M.D.)
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, 02-781 Warsaw, Poland
| | - Agnieszka Horala
- Division of Gynaecological Oncology, Department of Gynaecology, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (S.S.); (A.H.)
| | - Michalina Dąbrowska
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781Warsaw, Poland; (M.G.-S.); (K.B.-D.); (E.E.H.); (M.D.)
| | - Martyna Micek
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, 00-189 Warsaw, Poland; (M.M.); (M.C.)
- Warsaw Institute of Women’s Health, 00-189 Warsaw, Poland
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, 00-189 Warsaw, Poland; (M.M.); (M.C.)
- Warsaw Institute of Women’s Health, 00-189 Warsaw, Poland
| | - Natalia Zeber-Lubecka
- Department of Genetics, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781Warsaw, Poland; (M.G.-S.); (K.B.-D.); (E.E.H.); (M.D.)
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, 02-781 Warsaw, Poland
| |
Collapse
|
8
|
van de Sande AJM, Kengsakul M, Koeneman MM, Jozwiak M, Gerestein CG, Kruse AJ, van Esch EMG, de Vos van Steenwijk PJ, Muntinga CLP, Bramer WM, van Doorn HC, van Kemenade FJ, van Beekhuizen HJ. The efficacy of topical imiquimod in high-grade cervical intraepithelial neoplasia: A systematic review and meta-analysis. Int J Gynaecol Obstet 2024; 164:66-74. [PMID: 37350560 DOI: 10.1002/ijgo.14953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/29/2023] [Accepted: 06/04/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE A major side effect of cervical excision for high-grade cervical intraepithelial neoplasia (CIN) is premature birth. A non-invasive treatment for reproductive age women is warranted. The aim of the present study was to determine the efficacy of topical imiquimod in the treatment of high-grade CIN, defined as a regression to ≤CIN 1, and to determine the clearance rate of high-risk human papillomavirus (hr-HPV), compared with surgical treatment and placebo. METHODS Databases were searched for articles from their inception to February 2023.The study protocol number was INPLASY2022110046. Original studies reporting the efficacy of topical imiquimod in CIN 2, CIN 3 or persistent hr-HPV infections were included. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist. RESULTS Five studies were included (n = 463). Histological regression to ≤CIN 1 was 55% in imiquimod versus 29% in placebo, and 93% in surgical treatment. Imiquimod-treated women had a greater odds of histological regression to ≤CIN 1 than placebo (odds ratio [OR] 4.17, 95% confidence interval [CI] 2.03-8.54). In comparison to imiquimod, surgical treatment had an OR of 14.81(95% CI 6.59-33.27) for histological regression to ≤CIN 1. The hr-HPV clearance rate was 53.4% after imiquimod and 66% after surgical treatment (95% CI 0.62-23.77). CONCLUSIONS The histological regression rate is highest for surgical treatment followed by imiquimod treatment and placebo.
Collapse
Affiliation(s)
- A J M van de Sande
- Department of Gynecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M Kengsakul
- Department of Gynecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Panyananthaphikkhu Chonprathan Medical Center, Department of Obstetrics and Gynecology, Srinakharinwirot University, Nonthaburi, Thailand
| | - M M Koeneman
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M Jozwiak
- Department of Gynecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C G Gerestein
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - A J Kruse
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Obstetrics and Gynecology, Isala Clinics, Zwolle, The Netherlands
| | - E M G van Esch
- Department of Obstetrics and Gynecology, Catharina Cancer Institute, Catharina Hospital, Eindhoven, The Netherlands
| | - P J de Vos van Steenwijk
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - C L P Muntinga
- Department of Obstetrics and Gynecology, Catharina Cancer Institute, Catharina Hospital, Eindhoven, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - W M Bramer
- Medical Library, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - H C van Doorn
- Department of Gynecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - F J van Kemenade
- Department of Pathology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - H J van Beekhuizen
- Department of Gynecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
9
|
Mungo C, Adewumi K, Adoyo E, Zulu G, Goraya SK, Ogollah C, Omoto J, Ferrari RM, Rahangdale L. "There is nothing that can prevent me from supporting her:" Men's perspectives on their involvement and support of women's use of topical therapy for cervical precancer treatment in Kenya. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.22.23300455. [PMID: 38234805 PMCID: PMC10793535 DOI: 10.1101/2023.12.22.23300455] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Purpose Cervical cancer disproportionately impacts women in low- and middle-income countries (LMICs). The World Health Organization's (WHO) 90/70/90 strategy aims to eliminate cervical cancer by 2030 by increasing HPV vaccination coverage to 90%, screening 70% of eligible women, and effectively treating 90% of those with abnormal results by 2030, potentially preventing 62 million deaths in LMICs. LMICs, however, struggle with limited access to cervical precancer treatment, in part due to a lack of trained professionals and weak health systems. Effective non-surgical, self-administered, which have demonstrated efficacy in high-income countries, could bridge the treatment gap in LMICs and may be more scalable and cost-effective than provider-administered therapies. To inform feasibility studies in LMICs, data are needed on the role of male partners in influencing the acceptability and uptake of self-administered topical therapies, including their support of recommended abstinence and contraception guidelines associated with these therapies. Methods Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with men aged 25 to 65 years in Kenya to explore their perspective and perceived support regarding their female partners using topical self-administered therapies for cervical precancer treatment. The FGDs were moderated by local qualitative research assistants and conducted in local languages, transcribed, coded, and analyzed using qualitative description. Results Male participants in the FGDs strongly expressed acceptance and willingness to support their wives or partners in using topical therapies for cervical precancer treatment, if available. Reported supportive behavior included permitting the use of the therapies and support of maintaining abstinence during the recommended times. Additionally, participants desired male involvement in clinic and community-based education about topical therapies to facilitate widespread support. Conclusion The use of self-administered topical therapies for cervical precancer treatment, if supported by efficacy studies in LMICs, may support achieving the WHO's 2030 goal of 90% treatment access. We find that with adequate education, men express overwhelming support of their female partner's use of topical therapies, including adherence to abstinence and contraception guidelines.
Collapse
Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Konyin Adewumi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | | | | | - Supreet Kaur Goraya
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | | | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine, Kisumu, Kenya
| | - Renée M. Ferrari
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| |
Collapse
|
10
|
Desravines N, Hsu CH, Mohnot S, Sahasrabuddhe V, House M, Sauter E, O’Connor S, Bauman JE, Chow HHS, Rahangdale L. Feasibility of 5-fluorouracil and imiquimod for the topical treatment of cervical intraepithelial neoplasias (CIN) 2/3. Int J Gynaecol Obstet 2023; 163:862-867. [PMID: 37431689 PMCID: PMC10782812 DOI: 10.1002/ijgo.14983] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/06/2023] [Accepted: 06/16/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVES To determine the feasibility (as measured by tolerability and safety) and efficacy of topical 5-fluorouracil (5-FU) and imiquimod for the treatment of cervical intraepithelial neoplasia (CIN) 2/3. METHODS This pilot prospective study was conducted in women aged 18-45 years with p16+ CIN 2/3. Participants underwent an 8-week alternating regimen of self-applied 5% 5-FU on weeks 1, 3, 5, and 7 and physician-applied imiquimod on weeks 2, 4, 6, and 8. Adverse events (AEs) were collected by symptom diary and clinical exam. Feasibility was measured by tolerability and safety (AEs) of the study intervention. Tolerability was assessed as the number of participants able to apply 50% or more of the treatment doses. The safety outcome was calculated as the number of participants who experienced "specified AEs" defined as possibly, probably, or definitely related grade 2 or worse AE or grade 1 genital AEs (blisters, ulcerations, or pustules) lasting more than 5 days. The efficacy of the intervention was determined by histology and high-risk human papillomavirus (hrHPV) testing was done after treatment. RESULTS The median age of the 13 participants was 27 ± 2.9 years. Eleven (84.61%) participants applied 50% or more of the treatment. All participants reported grade 1 AEs; 6 (46.15%) reported grade 2 AEs; and 0 reported grade 3/4 AEs. Three (23.08%) participants had specified AEs. Histologic regression to normal or CIN 1 among those completing 50% or more of the treatment doses was observed in 10 (90.91%) participants, and 7 (63.63%) tested negative for hr-HPV at the end of the study. CONCLUSIONS Topical treatment for CIN 2/3 with 5-FU/imiquimod is feasible, with preliminary evidence of efficacy. Topical therapies need further investigation as adjuncts or alternatives to surgical therapy for CIN 2/3.
Collapse
Affiliation(s)
- Nerlyne Desravines
- Johns Hopkins School of Medicine, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | | | | | - Vikrant Sahasrabuddhe
- Breast and Gynecologic Cancer Research Group, Division of Cancer Prevention, Bethesda, MD, USA
| | - Margaret House
- Breast and Gynecologic Cancer Research Group, Division of Cancer Prevention, Bethesda, MD, USA
| | - Edward Sauter
- Breast and Gynecologic Cancer Research Group, Division of Cancer Prevention, Bethesda, MD, USA
| | - Siobhan O’Connor
- University of North Carolina Department of Pathology and Laboratory Medicine, Chapel Hill, NC, USA
| | | | | | - Lisa Rahangdale
- University of North Carolina Department of Obstetrics and Gynecology, Chapel Hill, NC, USA
| |
Collapse
|
11
|
Borella F, Gallio N, Mangherini L, Cassoni P, Bertero L, Benedetto C, Preti M. Recent advances in treating female genital human papillomavirus related neoplasms with topical imiquimod. J Med Virol 2023; 95:e29238. [PMID: 38009696 DOI: 10.1002/jmv.29238] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/28/2023] [Accepted: 11/04/2023] [Indexed: 11/29/2023]
Abstract
Human papillomavirus (HPV) encompasses a group of viruses that infect the skin and mucous membranes. In the presence of certain factors, persistent infection with high-risk HPVs can trigger a process of neoplastic transformation. Imiquimod is a topical agent that acts as a Toll-like receptor 7/8 agonist, stimulating the innate and adaptive immune system to exert antitumor and antiviral effects. It has been approved for the treatment of various skin conditions, however, its efficacy and safety in the management of HPV-related-neoplasms of the lower genital tract, such as vulvar, vaginal, and cervical neoplasia, are still under investigation. This review summarizes the current evidence on the use of imiquimod for the treatment of HPV-induced lesions of the female lower genital tract, focusing on its indications, mechanisms of action, outcomes, and predictors of response.
Collapse
Affiliation(s)
- Fulvio Borella
- Obstetrics and Gynecology Unit 1, Sant' Anna Hospital, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Niccolò Gallio
- Obstetrics and Gynecology Unit 2, Sant' Anna Hospital, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Luca Mangherini
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Chiara Benedetto
- Obstetrics and Gynecology Unit 1, Sant' Anna Hospital, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Mario Preti
- Obstetrics and Gynecology Unit 1, Sant' Anna Hospital, Department of Surgical Sciences, University of Turin, Turin, Italy
| |
Collapse
|
12
|
Inayama Y, Takamatsu S, Hamanishi J, Mizuno K, Horinouchi N, Yamanoi K, Taki M, Murakami R, Yamaguchi K, Kosaka K, Efthimiou O, Kawakami K, Furukawa TA, Mandai M. Imiquimod for Cervical and Vaginal Intraepithelial Neoplasia: A Systematic Review and Meta-analysis. Obstet Gynecol 2023; 142:307-318. [PMID: 37411024 DOI: 10.1097/aog.0000000000005256] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/04/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To evaluate the treatment efficacy and the risk of adverse events of imiquimod for cervical intraepithelial neoplasia (CIN) and vaginal intraepithelial neoplasia (VAIN), compared with placebo or no intervention. DATA SOURCES We searched Cochrane, PubMed, ISRCTN registry, ClinicalTrials.gov , and the World Health Organization International Clinical Trials Registry Platform up to November 23, 2022. METHODS OF STUDY SELECTION We included randomized controlled trials and prospective nonrandomized studies with control arms that investigated the efficacy of imiquimod for histologically confirmed CIN or VAIN. The primary outcomes were histologic regression of the disease (primary efficacy outcome) and treatment discontinuation due to side effects (primary safety outcome). We estimated pooled odds ratios (ORs) of imiquimod, compared with placebo or no intervention. We also conducted a meta-analysis of the proportions of patients with adverse events in the imiquimod arms. TABULATION, INTEGRATION, AND RESULTS Four studies contributed to the pooled OR for the primary efficacy outcome. An additional four studies were available for meta-analyses of proportions in the imiquimod arm. Imiquimod was associated with increased probability of regression (pooled OR 4.05, 95% CI 2.08-7.89). Pooled OR for CIN in the three studies was 4.27 (95% CI 2.11-8.66); results of one study were available for VAIN (OR, 2.67, 95% CI 0.36-19.71). Pooled probability for primary safety outcome in the imiquimod arm was 0.07 (95% CI 0.03-0.14). The pooled probabilities (95% CI) of secondary outcomes were 0.51 (0.20-0.81) for fever, 0.53 (0.31-0.73) for arthralgia or myalgia, 0.31 (0.18-0.47) for abdominal pain, 0.28 (0.09-0.61) for abnormal vaginal discharge or genital bleeding, 0.48 (0.16-0.82) for vulvovaginal pain, and 0.02 (0.01-0.06) for vaginal ulceration. CONCLUSION Imiquimod was found to be effective for CIN, whereas data on VAIN were limited. Although local and systemic complications are common, treatment discontinuation is infrequent. Thus, imiquimod is potentially an alternative therapy to surgery for CIN. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022377982.
Collapse
Affiliation(s)
- Yoshihide Inayama
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Shiro Takamatsu
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Junzo Hamanishi
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Kayoko Mizuno
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Noboru Horinouchi
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Koji Yamanoi
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Mana Taki
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Ryusuke Murakami
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Ken Yamaguchi
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Kenzo Kosaka
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Orestis Efthimiou
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Koji Kawakami
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Toshiaki A Furukawa
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Masaki Mandai
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| |
Collapse
|
13
|
Kesic V, Carcopino X, Preti M, Vieira-Baptista P, Bevilacqua F, Bornstein J, Chargari C, Cruickshank M, Erzeneoglu E, Gallio N, Gultekin M, Heller D, Joura E, Kyrgiou M, Madić T, Planchamp F, Regauer S, Reich O, Esat Temiz B, Woelber L, Zodzika J, Stockdale C. The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) consensus statement on the management of vaginal intraepithelial neoplasia. Int J Gynecol Cancer 2023; 33:446-461. [PMID: 36958755 PMCID: PMC10086489 DOI: 10.1136/ijgc-2022-004213] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/19/2023] [Indexed: 03/25/2023] Open
Abstract
The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vaginal intraepithelial neoplasia (VaIN). The management of VaIN varies according to the grade of the lesion: VaIN 1 (low grade vaginal squamous intraepithelial lesions (SIL)) can be subjected to follow-up, while VaIN 2-3 (high-grade vaginal SIL) should be treated. Treatment needs individualization according to the patient's characteristics, disease extension and previous therapeutic procedures. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Total vaginectomy is used only in highly selected cases of extensive and persistent disease. Carbon dioxide (CO2) laser may be used as both an ablation method and an excisional one. Reported cure rates after laser excision and laser ablation are similar. Topical agents are useful for persistent, multifocal lesions or for patients who cannot undergo surgical treatment. Imiquimod was associated with the lowest recurrence rate, highest human papillomavirus (HPV) clearance, and can be considered the best topical approach. Trichloroacetic acid and 5-fluorouracil are historical options and should be discouraged. For VaIN after hysterectomy for cervical intraepithelial neoplasia (CIN) 3, laser vaporization and topical agents are not the best options, since they cannot reach epithelium buried in the vaginal scar. In these cases surgical options are preferable. Brachytherapy has a high overall success rate but due to late side effects should be reserved for poor surgical candidates, having multifocal disease, and with failed prior treatments. VaIN tends to recur and ensuring patient adherence to close follow-up visits is of the utmost importance. The first evaluation should be performed at 6 months with cytology and an HPV test during 2 years and annually thereafter. The implementation of vaccination against HPV infection is expected to contribute to the prevention of VaIN and thus cancer of the vagina. The effects of treatment can have an impact on quality of life and result in psychological and psychosexual issues which should be addressed. Patients with VaIN need clear and up-to-date information on a range of treatment options including risks and benefits, as well as the need for follow-up and the risk of recurrence.
Collapse
Affiliation(s)
- Vesna Kesic
- Medical Faculty, University of Belgrade, Clinic of Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, 13397, Marseille, France
| | - Mario Preti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Pedro Vieira-Baptista
- Lower Genital Tract Unit Centro Hospitalar de São João, Porto, Portugal
- Hospital Lusiadas, Porto, Portugal
| | | | - Jacob Bornstein
- Galilee Medical Center and Azrieli Faculty of Medicine, Bar-Ilan, Israel
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Maggie Cruickshank
- Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - Emre Erzeneoglu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Niccolò Gallio
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Debra Heller
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Elmar Joura
- Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Maria Kyrgiou
- Surgery and Cancer - West London Gynecological Cancer Center, IRDB, Department of Gut, Metabolism & Reproduction-Surgery & Cancer, Imperial College London, London, UK
- Imperial Healthcare NHS Trust, Queen Charlotte's & Chelsea Hospital West London Gynaecological Cancer Centre, London, UK
| | - Tatjana Madić
- Clinic for Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Sigrid Regauer
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Olaf Reich
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Bilal Esat Temiz
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Linn Woelber
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
- Dysplasia Center Hamburg; Jerusalem Hospital Hamburg, Hamburg, Germany
| | - Jana Zodzika
- Department of Obstetrics and Gynaecology Rīga Stradiņš University, Riga, Latvia
| | - Colleen Stockdale
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
14
|
Kesic V, Carcopino X, Preti M, Vieira-Baptista P, Bevilacqua F, Bornstein J, Chargari C, Cruickshank M, Erzeneoglu E, Gallio N, Gultekin M, Heller D, Joura E, Kyrgiou M, Madić T, Planchamp F, Regauer S, Reich O, Esat Temiz B, Woelber L, Zodzika J, Stockdale C. The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) Consensus Statement on the Management of Vaginal Intraepithelial Neoplasia. J Low Genit Tract Dis 2023; 27:131-145. [PMID: 36951985 PMCID: PMC10026974 DOI: 10.1097/lgt.0000000000000732] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
ABSTRACT The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vaginal intraepithelial neoplasia (VaIN). The management of VaIN varies according to the grade of the lesion: VaIN 1 (low grade vaginal squamous intraepithelial lesions (SIL)) can be subjected to follow-up, while VaIN 2-3 (high-grade vaginal SIL) should be treated. Treatment needs individualization according to the patient's characteristics, disease extension and previous therapeutic procedures. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Total vaginectomy is used only in highly selected cases of extensive and persistent disease. Carbon dioxide (CO2) laser may be used as both an ablation method and an excisional one. Reported cure rates after laser excision and laser ablation are similar. Topical agents are useful for persistent, multifocal lesions or for patients who cannot undergo surgical treatment. Imiquimod was associated with the lowest recurrence rate, highest human papillomavirus (HPV) clearance, and can be considered the best topical approach. Trichloroacetic acid and 5-fluorouracil are historical options and should be discouraged. For VaIN after hysterectomy for cervical intraepithelial neoplasia (CIN) 3, laser vaporization and topical agents are not the best options, since they cannot reach epithelium buried in the vaginal scar. In these cases surgical options are preferable. Brachytherapy has a high overall success rate but due to late side effects should be reserved for poor surgical candidates, having multifocal disease, and with failed prior treatments. VaIN tends to recur and ensuring patient adherence to close follow-up visits is of the utmost importance. The first evaluation should be performed at 6 months with cytology and an HPV test during 2 years and annually thereafter. The implementation of vaccination against HPV infection is expected to contribute to the prevention of VaIN and thus cancer of the vagina. The effects of treatment can have an impact on quality of life and result in psychological and psychosexual issues which should be addressed. Patients with VaIN need clear and up-to-date information on a range of treatment options including risks and benefits, as well as the need for follow-up and the risk of recurrence.
Collapse
Affiliation(s)
- Vesna Kesic
- Medical Faculty, University of Belgrade, Clinic of Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, 13397, Marseille, France
| | - Mario Preti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Pedro Vieira-Baptista
- Lower Genital Tract Unit Centro Hospitalar de São João, Porto, Portugal
- Hospital Lusiadas, Porto, Portugal
| | | | - Jacob Bornstein
- Galilee Medical Center and Azrieli Faculty of Medicine, Bar-Ilan, Israel
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Maggie Cruickshank
- Aberdeen Centre for Women’s Health Research, University of Aberdeen, Aberdeen, United Kingdom
| | - Emre Erzeneoglu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Niccolò Gallio
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Elmar Joura
- Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Maria Kyrgiou
- Surgery and Cancer - West London Gynecological Cancer Center, IRDB, Department of Gut, Metabolism & Reproduction-Surgery & Cancer, Imperial College London, London, United Kingdom
- Imperial Healthcare NHS Trust, Queen Charlotte's & Chelsea Hospital West London Gynaecological Cancer Centre, London, United Kingdom
| | - Tatjana Madić
- Clinic for Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Sigrid Regauer
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Olaf Reich
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Bilal Esat Temiz
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
| | - Linn Woelber
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
- Dysplasia Center Hamburg; Jerusalem Hospital Hamburg, Hamburg, Germany
| | - Jana Zodzika
- Department of Obstetrics and Gynaecology Rīga Stradiņ,š University, Riga, Latvia
| | - Colleen Stockdale
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, IA
| |
Collapse
|
15
|
Muntinga CLP, de Vos van Steenwijk PJ, Bekkers RLM, van Esch EMG. Importance of the Immune Microenvironment in the Spontaneous Regression of Cervical Squamous Intraepithelial Lesions (cSIL) and Implications for Immunotherapy. J Clin Med 2022; 11:jcm11051432. [PMID: 35268523 PMCID: PMC8910829 DOI: 10.3390/jcm11051432] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 12/10/2022] Open
Abstract
Cervical high-grade squamous intraepithelial lesions (cHSILs) develop as a result of a persistent high-risk human papilloma virus (hrHPV) infection. The natural course of cHSIL is hard to predict, depending on a multitude of viral, clinical, and immunological factors. Local immunity is pivotal in the pathogenesis, spontaneous regression, and progression of cervical dysplasia; however, the underlying mechanisms are unknown. The aim of this review is to outline the changes in the immune microenvironment in spontaneous regression, persistence, and responses to (immuno)therapy. In lesion persistence and progression, the immune microenvironment of cHSIL is characterized by a lack of intraepithelial CD3+, CD4+, and CD8+ T cell infiltrates and Langerhans cells compared to the normal epithelium and by an increased number of CD25+FoxP3+ regulatory T cells (Tregs) and CD163+ M2 macrophages. Spontaneous regression is characterized by low numbers of Tregs, more intraepithelial CD8+ T cells, and a high CD4+/CD25+ T cell ratio. A ‘hot’ immune microenvironment appears to be essential for spontaneous regression of cHSIL. Moreover, immunotherapy, such as imiquimod and therapeutic HPV vaccination, may enhance a preexisting pro-inflammatory immune environment contributing to lesion regression. The preexisting immune composition may reflect the potential for lesion regression, leading to a possible immune biomarker for immunotherapy in cHSILs.
Collapse
Affiliation(s)
- Caroline L. P. Muntinga
- Department of Gynecology and Obstetrics, Catharina Ziekenhuis Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands; (C.L.P.M.); (R.L.M.B.)
- GROW—School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands;
| | - Peggy J. de Vos van Steenwijk
- GROW—School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands;
- Department of Gynecology and Obstetrics, Maastricht Universitair Medisch Centrum, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Ruud L. M. Bekkers
- Department of Gynecology and Obstetrics, Catharina Ziekenhuis Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands; (C.L.P.M.); (R.L.M.B.)
- GROW—School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands;
| | - Edith M. G. van Esch
- Department of Gynecology and Obstetrics, Catharina Ziekenhuis Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands; (C.L.P.M.); (R.L.M.B.)
- Correspondence: ; Tel.: +31-402-399-111
| |
Collapse
|
16
|
Dyavar SR, Singh R, Emani R, Pawar GP, Chaudhari VD, Podany AT, Avedissian SN, Fletcher CV, Salunke DB. Role of toll-like receptor 7/8 pathways in regulation of interferon response and inflammatory mediators during SARS-CoV2 infection and potential therapeutic options. Biomed Pharmacother 2021; 141:111794. [PMID: 34153851 PMCID: PMC8189763 DOI: 10.1016/j.biopha.2021.111794] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/17/2022] Open
Abstract
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) is the causative agent of Corona Virus Disease 2019 (COVID-19). Lower production of type I and III interferons and higher levels of inflammatory mediators upon SARS-CoV2 infection contribute to COVID-19 pathogenesis. Optimal interferon production and controlled inflammation are essential to limit COVID-19 pathogenesis. However, the aggravated inflammatory response observed in COVID-19 patients causes severe damage to the host and frequently advances to acute respiratory distress syndrome (ARDS). Toll-like receptor 7 and 8 (TLR7/8) signaling pathways play a central role in regulating induction of interferons (IFNs) and inflammatory mediators in dendritic cells. Controlled inflammation is possible through regulation of TLR mediated response without influencing interferon production to reduce COVID-19 pathogenesis. This review focuses on inflammatory mediators that contribute to pathogenic effects and the role of TLR pathways in the induction of interferon and inflammatory mediators and their contribution to COVID-19 pathogenesis. We conclude that potential TLR7/8 agonists inducing antiviral interferon response and controlling inflammation are important therapeutic options to effectively eliminate SARS-CoV2 induced pathogenesis. Ongoing and future studies may provide additional evidence on their safety and efficacy to treat COVID-19 pathogenesis.
Collapse
Affiliation(s)
- Shetty Ravi Dyavar
- University of Nebraska Medical Center (UNMC) Center for Drug Discovery, UNMC, Omaha, NE 68198, USA.
| | - Rahul Singh
- Department of Chemistry and Centre of Advanced Studies in Chemistry, Panjab University, Chandigarh 160014, India
| | - Rohini Emani
- Buck Institute for Research on Ageing, Novato, CA, USA
| | - Ganesh P Pawar
- Division of Medicinal Chemistry, CSIR-Institute of Microbiology Technology Chandigarh, Sector-39A, Chandigarh,160036, India
| | - Vinod D Chaudhari
- Division of Medicinal Chemistry, CSIR-Institute of Microbiology Technology Chandigarh, Sector-39A, Chandigarh,160036, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - Anthony T Podany
- University of Nebraska Medical Center (UNMC) Center for Drug Discovery, UNMC, Omaha, NE 68198, USA
| | - Sean N Avedissian
- University of Nebraska Medical Center (UNMC) Center for Drug Discovery, UNMC, Omaha, NE 68198, USA
| | - Courtney V Fletcher
- University of Nebraska Medical Center (UNMC) Center for Drug Discovery, UNMC, Omaha, NE 68198, USA
| | - Deepak B Salunke
- Department of Chemistry and Centre of Advanced Studies in Chemistry, Panjab University, Chandigarh 160014, India; National Interdisciplinary Centre of Vaccine, Immunotherapeutics and Antimicrobials, Panjab University, Chandigarh, 160014, India.
| |
Collapse
|
17
|
Topical Imiquimod for the Treatment of High-Grade Squamous Intraepithelial Lesions of the Cervix: A Randomized Controlled Trial. Obstet Gynecol 2021; 137:1043-1053. [PMID: 33957649 PMCID: PMC8132915 DOI: 10.1097/aog.0000000000004384] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/04/2021] [Indexed: 12/03/2022]
Abstract
Weekly topical treatment with imiquimod is effective in promoting regression of cervical high-grade squamous intraepithelial lesions. OBJECTIVE: To evaluate the histologic response rate of high-grade squamous intraepithelial lesions (HSIL) of the cervix after topical application of 5% imiquimod cream. METHODS: In this phase II trial, women with cervical HSIL (cervical intraepithelial neoplasia [CIN] 2–3) were randomly assigned to 250 mg of 5% imiquimod cream applied to the cervix weekly for 12 weeks, followed by loop electrosurgical excision procedure (LEEP) without preceding treatment. The sample size was calculated based on the HSIL regression rates previously reported by Grimm et al. The primary outcome was rate of histologic regression (to CIN 1 or less) in LEEP specimens. Prespecified secondary endpoints included surgical margin status and adverse events. Outcomes were stratified by human papillomavirus type and lesion grade (CIN 2 or CIN 3). Results were reported according to per protocol (PP) and intention-to-treat (ITT) analyses. RESULTS: Ninety women were enrolled: 49 in the experimental group and 41 in the control group. In the PP population, histologic regression was observed in 23 of 38 participants (61%) in the experimental group compared with 9 of 40 (23%) in the control group (P=.001). Surgical margins were negative for HSIL in 36 of 38 participants (95%) in the experimental group and 28 of 40 (70%) in the control group (P=.004). In the ITT population, rates of histologic regression also were significantly higher in the experimental group. Rates of adverse events in the experimental group were 74% (28/38) in the PP population and 78% (35/45) in the ITT population. Adverse events were mild, with abdominal pain being the most common. Three patients in the experimental group had grade 2 adverse events, including vaginal ulcer, vaginal pruritus with local edema, and moderate pelvic pain. CONCLUSION: Weekly topical treatment with imiquimod is effective in promoting regression of cervical HSIL. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03233412.
Collapse
|
18
|
Imiquimod for vaginal intraepithelial neoplasia 2-3: A systematic review and meta-analysis. Gynecol Oncol 2020; 160:140-147. [PMID: 33010966 DOI: 10.1016/j.ygyno.2020.09.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 09/15/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The treatment strategy for vaginal intraepithelial neoplasia (VaIN) 2-3 has not been established. This study aimed to investigate the efficacy of imiquimod in VaIN 2-3. METHODS Electronic databases (PubMed, EMBASE, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials) were searched from their inception until October 2019 and articles reporting imiquimod treatment for VaIN 2-3 were extracted. Additionally, the clinical records of women with VaIN 2-3 who had been treated with imiquimod in Shizuoka General Hospital from January 2016 to May 2020 were investigated. The data from the systematic search and the data from our hospital were analyzed, and a pooled complete response (CR) rate and response rate of imiquimod treatment for VaIN 2-3 were estimated. As a subgroup analysis, the CR rates and response rates were compared between women with and without a history of hysterectomy, and the rate ratio was calculated. RESULTS Five articles described 28 women with VaIN 2-3 who underwent imiquimod treatment, and nine women with VaIN 2-3 were treated with imiquimod in our hospital. The discontinuation of the treatment was required in only one patient of the reported cases. The pooled CR rate and response rate of imiquimod, regardless of a history of hysterectomy, was 0.76 (95% CI, 0.59-0.87) and 0.89 (95% CI, 0.71-0.97), respectively. In the subgroup analysis, the CR rate in patients with hysterectomy was 0.98 (95% CI, 0.11-1.0) and in those without hysterectomy was 0.60 (95% CI, 0.30-0.84), and the rate ratio was 0.83 (95% CI, 0.48-1.19). The pooled response rates with and without a history of hysterectomy were not estimated, and the rate ratio was 0.83 (95% CI, 0.54-1.09). CONCLUSION Imiquimod can be an effective treatment for vaginal intraepithelial neoplasia 2-3.
Collapse
|
19
|
Desravines N, Miele K, Carlson R, Chibwesha C, Rahangdale L. Topical therapies for the treatment of cervical intraepithelial neoplasia (CIN) 2-3: A narrative review. Gynecol Oncol Rep 2020; 33:100608. [PMID: 32685652 PMCID: PMC7356206 DOI: 10.1016/j.gore.2020.100608] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/23/2020] [Accepted: 06/27/2020] [Indexed: 12/18/2022] Open
Abstract
CIN management is currently surveillance or surgical therapy. This review describes current research on medical therapies. Imiquimod is the most studied with evidence of safety and efficacy. 5-Fluorouracil has also shown promise with two clinical trials showing efficacy as adjuvant and primary treatment. Antivirals therapies have produced mixed results with cidofovir showing the most potential. The data remains weak regarding hormonal, herbal and alternative therapies rending it difficult to draw conclusions.
Current management of Cervical Intraepithelial Neoplasia (CIN), caused by high-risk human papillomavirus (hr-HPV), is based on surveillance and surgical therapy. Procedures carry potential risks such as preterm birth, and access remains limited throughout the world. However, there are no medical therapies recommended to promote the clearance of hr-HPV infection or CIN. Ultimately, even if less efficacious than excision procedures, medical therapies have the potential to decrease cervical cancer by eliminating barriers to treatment, such as access to treatment, or serving as an adjunct to surgical treatment in both high- and low-resource settings. This review describes current research on topical therapies with the potential for self-application for the treatment of HPV or CIN. Therapies included are immune-modulators, anti-proliferative medications, antivirals, hormones, and herbal/alternative therapies. Randomized trials of immune-modulating (imiquimod), anti-proliferative (5-fluorouracil), and anti-viral (cidofovir) therapies have had the most promising results. However, no option has sufficient clinical trial evidence to be recommended as treatment for CIN 2–3 and surgery remains the standard of care. The research described in this review serves as a guide for the development of future trials in the burgeoning arena of topical therapies for CIN 2–3.
Collapse
Affiliation(s)
- Nerlyne Desravines
- University of North Carolina School of Medicine, Department of Obstetrics and Gynecology, Chapel Hill, NC, USA
| | - Kate Miele
- University of North Carolina School of Medicine, Department of Obstetrics and Gynecology, Chapel Hill, NC, USA
| | - Rebecca Carlson
- University of North Carolina Health Sciences Library, Chapel Hill, NC, USA
| | - Carla Chibwesha
- University of North Carolina School of Medicine, Department of Obstetrics and Gynecology, Chapel Hill, NC, USA.,South Africa University of the Witwatersrand, Clinical HIV Research Unit, Department of Internal Medicine, Johannesburg-Braamfontein, Gauteng, ZA, South Africa
| | - Lisa Rahangdale
- University of North Carolina School of Medicine, Department of Obstetrics and Gynecology, Chapel Hill, NC, USA.,University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| |
Collapse
|
20
|
Wouters T, Hendriks N, Koeneman M, Kruse AJ, van de Sande A, van Beekhuizen HJ, Gerestein KG, Bekkers RLM, Piek JMJ. Systemic adverse events in imiquimod use for cervical intraepithelial neoplasia - A case series. Case Rep Womens Health 2019; 21:e00105. [PMID: 30906696 PMCID: PMC6411488 DOI: 10.1016/j.crwh.2019.e00105] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 01/25/2023] Open
Abstract
Treatment for cervical intraepithelial neoplasia (CIN) often consists of an excisional procedure. However, less invasive treatment methods have been explored, such as topical treatment with imiquimod cream. Imiquimod has been proven to be effective in the regression of vulvar intraepithelial neoplasia (VIN) and vaginal intraepithelial neoplasia (VAIN). Previous studies have investigated the effect of imiquimod in CIN and showed well tolerated adverse effects. During a current study in the Netherlands, a number of adverse events have occurred. This case series presents a selection of these. Gynaecologists should be aware of the possible adverse effects of topical treatment with imiquimod cream. Cervical intraepithelial neoplasia (CIN) is usually treated with an excisional procedure. A less invasive treatment method has been investigated: imiquimod cream. During a study in the Netherlands, a number of adverse events have occurred. Adverse effects were presented in this case series. Gynaecologists should be aware of the possible adverse effects.
Collapse
Affiliation(s)
- Tirza Wouters
- Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven, the Netherlands
| | - Natasja Hendriks
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Margot Koeneman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Arnold-Jan Kruse
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Anna van de Sande
- Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Heleen J van Beekhuizen
- Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Kees G Gerestein
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ruud L M Bekkers
- Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven, the Netherlands
| | - Jurgen M J Piek
- Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven, the Netherlands
| |
Collapse
|
21
|
Dadar M, Chakraborty S, Dhama K, Prasad M, Khandia R, Hassan S, Munjal A, Tiwari R, Karthik K, Kumar D, Iqbal HMN, Chaicumpa W. Advances in Designing and Developing Vaccines, Drugs and Therapeutic Approaches to Counter Human Papilloma Virus. Front Immunol 2018; 9:2478. [PMID: 30483247 PMCID: PMC6240620 DOI: 10.3389/fimmu.2018.02478] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/08/2018] [Indexed: 02/05/2023] Open
Abstract
Human papillomavirus (HPV) is a viral infection with skin-to-skin based transmission mode. HPV annually caused over 500,000 cancer cases including cervical, anogenital and oropharyngeal cancer among others. HPV vaccination has become a public-health concern, worldwide, to prevent the cases of HPV infections including precancerous lesions, cervical cancers, and genital warts especially in adolescent female and male population by launching national programs with international alliances. Currently, available prophylactic and therapeutic vaccines are expensive to be used in developing countries for vaccination programs. The recent progress in immunotherapy, biotechnology, recombinant DNA technology and molecular biology along with alternative and complementary medicinal systems have paved novel ways and valuable opportunities to design and develop effective prophylactic and therapeutic vaccines, drugs and treatment approach to counter HPV effectively. Exploration and more researches on such advances could result in the gradual reduction in the incidences of HPV cases across the world. The present review presents a current global scenario and futuristic prospects of the advanced prophylactic and therapeutic approaches against HPV along with recent patents coverage of the progress and advances in drugs, vaccines and therapeutic regimens to effectively combat HPV infections and its cancerous conditions.
Collapse
Affiliation(s)
- Maryam Dadar
- Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization, Karaj, Iran
| | - Sandip Chakraborty
- Department of Veterinary Microbiology, College of Veterinary Sciences and Animal Husbandry, West Tripura, India
| | - Kuldeep Dhama
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Minakshi Prasad
- Department of Animal Biotechnology, LLR University of Veterinary and Animal Sciences, Hisar, India
| | - Rekha Khandia
- Department of Genetics, Barkatullah University, Bhopal, India
| | - Sameer Hassan
- Department of Biomedical Informatics, National Institute for Research in Tuberculosis, Indian Council of Medical Research, Chennai, India
| | - Ashok Munjal
- Department of Genetics, Barkatullah University, Bhopal, India
| | - Ruchi Tiwari
- Department of Veterinary Microbiology and Immunology, College of Veterinary Sciences, U P Pt. Deen Dayal Upadhayay Pashu Chikitsa Vigyan Vishwavidyalay Evum Go-Anusandhan Sansthan, Mathura, India
| | - Kumaragurubaran Karthik
- Central University Laboratory, Tamil Nadu Veterinary and Animal Sciences University, Chennai, India
| | - Deepak Kumar
- Division of Veterinary Biotechnology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Hafiz M. N. Iqbal
- Tecnologico de Monterrey, School of Engineering and Sciences, Monterrey, Mexico
| | - Wanpen Chaicumpa
- Department of Parasitology, Center of Research Excellence on Therapeutic Proteins and Antibody Engineering, Faculty of Medicine SIriraj Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
22
|
Efficacy of 5% imiquimod for the treatment of Vaginal intraepithelial neoplasia-A systematic review of the literature and a meta-analysis. Eur J Obstet Gynecol Reprod Biol 2017; 218:129-136. [PMID: 28985547 DOI: 10.1016/j.ejogrb.2017.09.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/21/2017] [Accepted: 09/22/2017] [Indexed: 11/20/2022]
Abstract
Vaginal intraepithelial neoplasia (VaIN) is an uncommon disease associated with HPV and is considered to be a precursor of vaginal carcinoma. To date, treatment recommendations vary with no universally accepted standard of care as best treatment modality. Nevertheless, 5% imiquimod appears to be a promising, alternative, non-invasive treatment option. To ascertain the efficacy of 5% imiquimod for the treatment of this rare condition, we conducted a systematic review and meta-analysis of the proportion of women who received 5% imiquimod with their complete response, HPV clearance and recurrence rates. A literature search was carried out throughout the PubMed, EMBASE, ClinicalTrials.gov and Cochrane Databases for relevant studies. We computed the summary proportions for complete response, HPV clearance and non-recurrence following administration of 5% imiquimod by random effects meta-analysis. Six articles reporting on 94 patients were included. The summary proportions of women with complete response and HPV clearance were 76.5% (95% CI 59.4-98.5) and 52.5% (95% CI 29.5-93.6) respectively. The summary proportion of women with non-recurrence appeared high (94.3% (95% CI 67.1-132)), yet not significant. Use of 5% imiquimod for the treatment of VaIN is associated with relatively high response rate, satisfactory HPV clearance, whilst the risk for VaIN recurrence appears low.
Collapse
|
23
|
Treatment of Cervical Intraepithelial Neoplasia: Patients Preferences for Surgery or Immunotherapy with Imiquimod. J Immunother 2017; 40:148-153. [PMID: 28221188 DOI: 10.1097/cji.0000000000000158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Imiquimod has been studied as a noninvasive pharmacological treatment alternative to large loop excision of the transformation zone (LLETZ) for high-grade cervical intraepithelial neoplasia (CIN), to prevent long-term obstetric complications from surgical treatment. This study aims to investigate womens' preferences for treatment of high-grade CIN with imiquimod or LLETZ. A labeled discrete choice experiment was conducted among 100 women with abnormal cervical cytology in 5 hospitals in the Netherlands between March 2014 and December 2015. Participants were asked to choose between imiquimod treatment or standard surgical treatment in 9 separate scenarios, based on the following treatment characteristics: treatment success rate, rate of side effects, risk of premature birth in subsequent pregnancies, and risk of subfertility after treatment. The levels of these characteristics differed for the imiquimod alternatives. Women assigned a positive utility to LLETZ compared with imiquimod. When making a choice for imiquimod, women preferred a higher treatment success rate and a lower risk of premature birth, infertility and side effects. The choice for imiquimod treatment was also influenced by the intention of a future pregnancy. Subgroup analyses revealed that a lower efficacy regarding imiquimod might be more acceptable for women who desired a future pregnancy compared with women who did not desire a future pregnancy. Women with a future pregnancy wish may prefer treatment of high-grade CIN with imiquimod cream over LLETZ, if the risk of subfertility and premature birth is low.
Collapse
|
24
|
Randomised trial on treatment of vaginal intraepithelial neoplasia-Imiquimod, laser vaporisation and expectant management. Int J Cancer 2016; 139:2353-8. [DOI: 10.1002/ijc.30275] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/01/2016] [Indexed: 11/07/2022]
|
25
|
Abstract
Persistent human papillomavirus (HPV) is the primary etiologic agent of cervical cancer and causes a significant number of vulvar, penile, anal and oropharyngeal cancers. The development of highly effective HPV therapeutic vaccines is a reasonable goal given the recent advances in basic and applied immunology. A number of vaccine strategies designed to induce systemic T cell responses have been tested in clinical trials against high grade cervical or vulvar high grade neoplasia and cancers, but with limited success. In line with the emerging trend to focus more on the epithelial context of HPV infection and premalignant disease, it might be advantageous to develop vaccination strategies that promote trafficking of HPV-specific T cells into lesions and overcome the local immunosuppressive environment. The development of more biologically relevant animal models would improve the preclinical evaluation of therapeutic vaccine candidates. Finally, persistent infection and low grade lesions may prove to be easier targets for therapeutic vaccines, and these vaccines would likely be commercially viable in high income countries and valuable components in screen and treat programs in low resource settings.
Collapse
Affiliation(s)
- Nicolas Çuburu
- a Laboratory of Cellular Oncology , Center for Cancer Research, National Cancer Institute, NIH , Bethesda , MD , USA
| | - John T Schiller
- a Laboratory of Cellular Oncology , Center for Cancer Research, National Cancer Institute, NIH , Bethesda , MD , USA
| |
Collapse
|
26
|
Koeneman MM, Kruse AJ, Kooreman LFS, Zur Hausen A, Hopman AHN, Sep SJS, Van Gorp T, Slangen BFM, van Beekhuizen HJ, van de Sande M, Gerestein CG, Nijman HW, Kruitwagen RFPM. TOPical Imiquimod treatment of high-grade Cervical intraepithelial neoplasia (TOPIC trial): study protocol for a randomized controlled trial. BMC Cancer 2016; 16:132. [PMID: 26897518 PMCID: PMC4761416 DOI: 10.1186/s12885-016-2187-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 02/16/2016] [Indexed: 11/10/2022] Open
Abstract
Background Cervical intraepithelial neoplasia (CIN) is the premalignant condition of cervical cancer. Whereas not all high grade CIN lesions progress to cervical cancer, the natural history and risk of progression of individual lesions remain unpredictable. Therefore, high-grade CIN is currently treated by surgical excision: large loop excision of the transformation zone (LLETZ). This procedure has potential complications, such as acute haemorrhage, prolonged bleeding, infection and preterm birth in subsequent pregnancies. These complications could be prevented by development of a non-invasive treatment modality, such as topical imiquimod treatment. The primary study objective is to investigate the efficacy of topical imiquimod 5 % cream for the treatment of high-grade CIN and to develop a biomarker profile to predict clinical response to imiquimod treatment. Secondary study objectives are to assess treatment side-effects, disease recurrence and quality of life during and after different treatment modalities. Methods/design The study design is a randomized controlled trial. One hundred forty women with a histological diagnosis of high-grade CIN (CIN 2–3) will be randomized into two arms: imiquimod treatment during 16 weeks (experimental arm) or immediate LLETZ (standard care arm). Treatment efficacy will be evaluated by colposcopy with diagnostic biopsies at 20 weeks for the experimental arm. Successful imiquimod treatment is defined as regression to CIN 1 or less, successful LLETZ treatment is defined as PAP 1 after 6 months. Disease recurrence will be evaluated by cytology at 6, 12 and 24 months after treatment. Side-effects will be evaluated using a standardized report form. Quality of life will be evaluated using validated questionnaires at baseline, 20 weeks and 1 year after treatment. Biomarkers, reflecting both host and viral factors in the pathophysiology of CIN, will be tested at baseline with the aim of developing a predictive biomarker profile for the clinical response to imiquimod treatment. Discussion Treatment of high-grade CIN lesions with imiquimod in a selected patient population may diminish complications as a result of surgical intervention. More knowledge on treatment efficacy, side effects and long-term recurrence rates after treatment is necessary. Trial registration EU Clinical Trials Register EU-CTR2013-001260-34. Registered 18 March 2013. Medical Ethical Committee approval number: NL44336.068.13 (Medical Ethical Committee Maastricht University Hospital, University of Maastricht). Affiliation: Maastricht University Hospital. Registration number ClinicalTrials.gov: NCT02329171.
Collapse
Affiliation(s)
- M M Koeneman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands. .,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - A J Kruse
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - L F S Kooreman
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A Zur Hausen
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A H N Hopman
- GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Molecular Cell Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S J S Sep
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - T Van Gorp
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - B F M Slangen
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - H J van Beekhuizen
- Department of Obstetrics and Gynaecology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M van de Sande
- Department of Obstetrics and Gynaecology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - C G Gerestein
- Department of Obstetrics and Gynaecology, Meander Medical Center, Amersfoort, The Netherlands
| | - H W Nijman
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, Groningen, The Netherlands
| | - R F P M Kruitwagen
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
27
|
Koeneman M, Kruitwagen R, Kruse AJ. Clinical applicability of immunotherapy of cervical intraepithelial neoplasia. World J Obstet Gynecol 2016; 5:1-4. [DOI: 10.5317/wjog.v5.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/10/2015] [Accepted: 11/11/2015] [Indexed: 02/05/2023] Open
Abstract
Immunotherapy for cervical intraepithelial neoplasia (CIN) has not yet reached clinical applicability, but seems sensible and shows promising preliminary results. One of the most promising forms of immunotherapy for CIN may currently be imiquimod, because of its established role in other human papillomavirus (HPV)-induced genital conditions, its promising treatment efficacy in high-grade CIN, and its off-label availability. Although imiquimod cannot yet replace the current gold standard treatment for CIN [i.e., large loop excision of the transformation zone (LLETZ)] in all patients, it may be considered in subgroups of patients; for example, young women who may wish to become pregnant in the future, or patients with recurrent CIN lesions in whom a second LLETZ is to be avoided. Immunotherapy of CIN could be extended to post-treatment vaccination, in order to prevent new HPV infections and disease recurrence.
Collapse
|
28
|
Hampson L, Maranga IO, Masinde MS, Oliver AW, Batman G, He X, Desai M, Okemwa PM, Stringfellow H, Martin-Hirsch P, Mwaniki AM, Gichangi P, Hampson IN. A Single-Arm, Proof-Of-Concept Trial of Lopimune (Lopinavir/Ritonavir) as a Treatment for HPV-Related Pre-Invasive Cervical Disease. PLoS One 2016; 11:e0147917. [PMID: 26824902 PMCID: PMC4732739 DOI: 10.1371/journal.pone.0147917] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 01/02/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cervical cancer is the most common female malignancy in the developing nations and the third most common cancer in women globally. An effective, inexpensive and self-applied topical treatment would be an ideal solution for treatment of screen-detected, pre-invasive cervical disease in low resource settings. METHODS Between 01/03/2013 and 01/08/2013, women attending Kenyatta National Hospital's Family Planning and Gynaecology Outpatients clinics were tested for HIV, HPV (Cervista®) and liquid based cervical cytology (LBC-ThinPrep®). HIV negative women diagnosed as high-risk HPV positive with high grade squamous intraepithelial lesions (HSIL) were examined by colposcopy and given a 2 week course of 1 capsule of Lopimune (CIPLA) twice daily, to be self-applied as a vaginal pessary. Colposcopy, HPV testing and LBC were repeated at 4 and 12 weeks post-start of treatment with a final punch biopsy at 3 months for histology. Primary outcome measures were acceptability of treatment with efficacy as a secondary consideration. RESULTS A total of 23 women with HSIL were treated with Lopimune during which time no adverse reactions were reported. A maximum concentration of 10 ng/ml of lopinavir was detected in patient plasma 1 week after starting treatment. HPV was no longer detected in 12/23 (52.2%, 95%CI: 30.6-73.2%). Post-treatment cytology at 12 weeks on women with HSIL, showed 14/22 (63.6%, 95%CI: 40.6-82.8%) had no dysplasia and 4/22 (18.2%, 95%CI: 9.9-65.1%) were now low grade demonstrating a combined positive response in 81.8% of women of which 77.8% was confirmed by histology. These data are supported by colposcopic images, which show regression of cervical lesions. CONCLUSIONS These results demonstrate the potential of Lopimune as a self-applied therapy for HPV infection and related cervical lesions. Since there were no serious adverse events or detectable post-treatment morbidity, this study indicates that further trials are clearly justified to define optimal regimes and the overall benefit of this therapy. TRIAL REGISTRATION ISRCTN Registry 48776874.
Collapse
Affiliation(s)
- Lynne Hampson
- University of Manchester Viral Oncology Laboratories, Institute of Cancer Sciences, Research Floor 5, St Mary’s Hospital, Oxford Road, Manchester M13 9WL, United Kingdom
| | - Innocent O. Maranga
- Kenyatta National Hospital, Department of Reproductive Health, PO Box 20723–00202, Nairobi, Kenya
- University of Nairobi, College of Health Sciences, Departments of Gynaecology and Pathology, PO Box 19676–00202, Nairobi, Kenya
| | - Millicent S. Masinde
- University of Nairobi, College of Health Sciences, Departments of Gynaecology and Pathology, PO Box 19676–00202, Nairobi, Kenya
| | - Anthony W. Oliver
- University of Manchester Viral Oncology Laboratories, Institute of Cancer Sciences, Research Floor 5, St Mary’s Hospital, Oxford Road, Manchester M13 9WL, United Kingdom
| | - Gavin Batman
- University of Manchester Viral Oncology Laboratories, Institute of Cancer Sciences, Research Floor 5, St Mary’s Hospital, Oxford Road, Manchester M13 9WL, United Kingdom
| | - Xiaotong He
- University of Manchester Viral Oncology Laboratories, Institute of Cancer Sciences, Research Floor 5, St Mary’s Hospital, Oxford Road, Manchester M13 9WL, United Kingdom
| | - Minaxi Desai
- Cytology Laboratories, PO Box 208, Clinical Sciences Building 2, Central Manchester University Hospital NHS Trust, Oxford Rd, Manchester M13 9WW, United Kingdom
| | - Parmenas M. Okemwa
- University of Nairobi, College of Health Sciences, Departments of Gynaecology and Pathology, PO Box 19676–00202, Nairobi, Kenya
| | - Helen Stringfellow
- Department of Pathology, Royal Preston Hospital, Sharoe Green Lane, Fulwood, Preston, PR2 9HT, United Kingdom
| | - Pierre Martin-Hirsch
- Department of Obstetrics & Gynaecology, Royal Preston Hospital, Sharoe Green Lane, Fulwood, Preston, PR2 9HT, United Kingdom
| | - Alex M. Mwaniki
- University of Nairobi, College of Health Sciences, Departments of Gynaecology and Pathology, PO Box 19676–00202, Nairobi, Kenya
| | - Peter Gichangi
- University of Nairobi, College of Health Sciences, Departments of Gynaecology and Pathology, PO Box 19676–00202, Nairobi, Kenya
| | - Ian N. Hampson
- University of Manchester Viral Oncology Laboratories, Institute of Cancer Sciences, Research Floor 5, St Mary’s Hospital, Oxford Road, Manchester M13 9WL, United Kingdom
- * E-mail:
| |
Collapse
|
29
|
Physicians’ Awareness, Attitudes, and Experiences Regarding Imiquimod Treatment of Vaginal and Cervical Intraepithelial Neoplasia. J Low Genit Tract Dis 2016; 20:75-9. [DOI: 10.1097/lgt.0000000000000158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
30
|
Hampson L, Martin-Hirsch P, Hampson IN. An overview of early investigational drugs for the treatment of human papilloma virus infection and associated dysplasia. Expert Opin Investig Drugs 2015; 24:1529-37. [PMID: 26457651 DOI: 10.1517/13543784.2015.1099628] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION High-risk HPV (HR-HPV) related invasive cervical cancer (ICC) causes >270,000 deaths per annum world-wide with over 85% of these occurring in low-resource countries. Ablative and excisional treatment modalities are restricted for use with high-grade pre-cancerous cervical disease with HPV infection and low-grade dysplasia mostly managed by a watch-and-wait policy. AREAS COVERED Various pharmacological approaches have been investigated as non-destructive alternatives for the treatment of HR-HPV infection and associated dysplasia. These are discussed dealing with efficacy, ease-of-use (physician or self-applied), systemic or locally applied, side-effects, cost and risks. The main focus is the perceived impact on current clinical practice of a self-applied, effective and safe pharmacological anti-HPV treatment. EXPERT OPINION Current prophylactic HPV vaccines are expensive, HPV type restricted and have little effect in already infected women. Therapeutic vaccines are under development but are also HPV type-restricted. At present, the developed nations use national cytology screening and surgical procedures to treat only women identified with HPV-related high-grade dysplastic disease. However, since HPV testing is rapidly replacing cytology as the test-of-choice, a suitable topically-applied and low-cost antiviral treatment could be an ideal solution for treatment of HPV infection per se with test-of-cure carried out by repeat HPV testing. Cytology would only then be necessary for women who remained HPV positive. Although of significant benefit in the developed countries, combining such a treatment with self-sampled HPV testing could revolutionise the management of this disease in the developing world which lack both the infrastructure and resources to establish national cytology screening programs.
Collapse
Affiliation(s)
- Lynne Hampson
- a Viral Oncology Laboratories, Research Floor, St Mary's Hospital , University of Manchester , Manchester M13 9WL , UK
| | - Pierre Martin-Hirsch
- b Department of Obstetrics and Gynaecology , Royal Preston Hospital , Preston PR2 9HT , UK
| | - Ian N Hampson
- a Viral Oncology Laboratories, Research Floor, St Mary's Hospital , University of Manchester , Manchester M13 9WL , UK
| |
Collapse
|
31
|
de Witte CJ, van de Sande AJM, van Beekhuizen HJ, Koeneman MM, Kruse AJ, Gerestein CG. Imiquimod in cervical, vaginal and vulvar intraepithelial neoplasia: a review. Gynecol Oncol 2015; 139:377-84. [PMID: 26335596 DOI: 10.1016/j.ygyno.2015.08.018] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 08/17/2015] [Accepted: 08/24/2015] [Indexed: 01/22/2023]
Abstract
Human papillomavirus (HPV) infection is in the vast majority of patients accountable for the development of vulvar, cervical and vaginal intraepithelial neoplasia (VIN, CIN, VAIN); precursors of vulvar, cervical and vaginal cancers. The currently preferred treatment modality for high grade VIN, CIN and VAIN is surgical excision. Nevertheless surgical treatment is associated with adverse pregnancy outcomes and recurrence is not uncommon. The aim of this review is to present evidence on the efficacy, safety and tolerability of imiquimod (an immune response modifier) in HPV-related VIN, CIN and VAIN. A search for papers on the use of imiquimod in VIN, CIN and VAIN was performed in the MEDLINE, EMBASE and Cochrane library databases. Data was extracted and reviewed. Twenty-one articles met the inclusion criteria and were analyzed; 16 on VIN, 3 on CIN and 2 on VAIN. Complete response rates in VIN ranged from 5 to 88%. Although minor adverse effects were frequently reported, treatment with imiquimod was well tolerated in most patients. Studies on imiquimod treatment of CIN and VAIN are limited and lack uniformly defined endpoints. The available evidence however, shows encouraging effect. Complete response rates for CIN 2-3 and VAIN 1-3 ranged from 67 to 75% and 57 to 86% respectively. More randomized controlled trials on the use of imiquimod in CIN, VAIN and VIN with extended follow-up are necessary to determine the attributive therapeutic value in these patients.
Collapse
Affiliation(s)
- C J de Witte
- Universal Medical Center Utrecht, The Netherlands
| | - A J M van de Sande
- Erasmus MC Cancer Institute, Department of Gynaecology, Rotterdam, The Netherlands
| | - H J van Beekhuizen
- Erasmus MC Cancer Institute, Department of Gynaecology, Rotterdam, The Netherlands
| | - M M Koeneman
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A J Kruse
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | |
Collapse
|