Epidemiology of human papillomavirus (HPV) infections and their associations with genital squamous cell cancer. Review article

Vulvar Intraepithelial Neoplasia (VIN) and Condylomata

Human papillomavirus (HPV) infection of the lower genital tract is common and its effects are variable. The majority of infections are transient and the related pathology is self-resolving. Condyloma accuminatum is caused predominantly by HPV 6, 11 and can be managed with medical or surgical therapy. Vulvar intraepithelial neoplasia is a treatable precursor to vulvar cancer with 2 main forms: one related to HPV and the other to chronic vulvar inflammatory conditions. It may be treated medically, surgically, or potentially via the use of therapeutic HPV vaccines. Preventive utilization of a quadrivalent HPV vaccine has the potential to decrease HPV-related lower genital disease burden substantially.

Assessment of the frequency of genetic alterations (LOH/MSI) in patients with intraepithelial cervical lesions with HPV infection: a pilot study

In the present study, we analyzed (1) the type of HPV infection and (2) the frequency of loss of heterozygosity and microsatellite imbalance (LOH/MSI) in normal cytology and cervical intraepithelial neoplasia (CIN1-3). The cytological material included: low-grade squamous intraepithelial lesions (CIN1, n = 11), high-grade lesions (CIN2 and CIN3, n = 13), and cytologically normal cells from non-neoplastic cervical samples (n = 8). HPV genotyping was done using RealLine HPV 16/18 kit. We used 20 microsatellite markers from: 1p31.2, 3p14.3, 3p21.3, 3p22.2, 3p24.2, 3p25.3, 7q32.2, 9p21.3, 11p15.5, 12q23.2, and 16q22.1. LOH/MSI was correlated with clinicopathological parameters. The presence of HPV DNA was revealed in 78.13 % samples, including normal cytology. LOH/MSI was the most frequent for: 3p25.3 (39 %), 3p22.2 (20.83 %), 3p24.2 (20 %), and 3p14.3 (16.67 %). It was demonstrated that D3S1234 (FHIT; 3p14.3), D3S1611 (MLH1; 3p22.2), D3S1583 (RARB; 3p24.2), D3S1317 and D3S3611 (VHL; 3p25.3) could differentiate patients with CIN2/CIN3 versus CIN1, showing significantly higher frequency in CIN2/CIN3. LOH/MSI frequency for other than 3p markers was lower, 10-22.2 %. The simultaneous occurrence of LOH/MSI for several markers (OFAL) was higher in CIN2/CIN3. Significant differences in OFAL were found between samples with versus without HPV infection. In HPV-positive patients, significant differences in OFAL were found between normal cytology, CIN1 and CIN2/CIN3. HPV infection influences the increase in LOH/MSI frequency, especially in tumor suppressor gene loci. Several studied microsatellite markers seem to be useful for CIN grading. Hopefully, the obtained results, if confirmed on larger patient cohort, would allow creating a panel of markers supporting clinical diagnosis in patients with HPV infection.

Reversal of the malignant phenotype of cervical cancer CaSki cells through adeno-associated virus-mediated delivery of HPV16 E7 antisense RNA

Human papillomavirus (HPV) infection is the most important risk factor for the development of cervical cancer. The oncogene E7 from high-risk HPV strains has the ability to immortalize epithelial cells and increase cellular transformation in culture. In this study, we explored the possibility of preventing cervical cancer growth by inhibiting HPV16 E7 expression through gene transfer of an antisense construct. A recombinant adeno-associated virus (rAAV) vector was chosen for the transfer, based on its transfection efficiency, in vivo stability, and lack of detectable pathology. In vitro transfer of an rAAV vector expressing antisense HPV16 E7 (AAV-HPV16E7AS) inhibited cell proliferation, induced apoptosis, reduced cell migration, and restrained in vivo proliferation of HPV16/HPV18-positive cervical cancer CaSki cells. These results indicate that down-regulation of HPV16 E7 with antisense RNA is beneficial in reducing the tumorigenicity of CaSki cells, and rAAV vectors ought to be a new efficient approach for delivering the expression of therapeutic genes.

p53 gene mutation and human papillomavirus (HPV) infection in esophageal carcinoma from three different endemic geographic regions of India

Infection of high-risk human papillomaviruses (HPVs), particularly the HPV types 16 and 18 and mutation or aberrant expression of the p53 tumour suppressor gene, has strongly been implicated in human esophageal carcinoma, which shows a great variation in geographic distribution. Neither the reason(s) for such a variation nor the etiopathogenesis of the disease is clearly understood. The present study has been carried out to determine prevalence of high-risk HPV types 16 and 18 and the p53 gene mutation in patients from three distinctly different endemic geographic regions of India, viz. Kashmir, Dibrugarh, and New Delhi where esophageal cancer is most prevalent. The people from each of these regions differ considerably in their food, drinking, smoking and chewing habits (tobacco and betel nut) and ethnic background. While PCR was employed to detect high-risk HPV types 16 and 18 DNA sequences, PCR-SSCP and direct nucleotide sequencing was used for analysis of p53 mutation. Out of a total of 101 biopsy specimens of carcinoma esophagus analysed, the frequency of HPV was found to be the highest 14/32 (44%) in Dibrugarh followed by 33% (11/33) in Kashmir, but, interestingly, no high-risk HPV could be detected in New Delhi patients who showed the highest frequency (30.6%) of p53 mutation as against only 12.5% in Dibrugarh and 6.1% in Kashmir. The difference in the frequency of p53 mutation between the three regions was statistically highly significant (0.018). Out of a total of 21 nucleotide alterations observed, 12 missense, five frameshift and four were silent changes. The p53 exon 7 appears to be the 'hot-spot' for esophageal cancer as it alone was responsible for more than 76% (13/17) of mutations and more than 95% (20/21) of the patients with p53 mutation were smokers. The results demonstrate differential distribution of HPV infection and p53 mutation in esophageal cancer from different geographic regions of India and this could be due to variation in diet, drinking, and tobacco habit, including ethnic, socio-cultural and genetic variation.

Retrovirus-mediated delivery of HPV16 E7 antisense RNA inhibited tumorigenicity of CaSki cells

OBJECTIVE

In cervical cancer, high-risk human papillomavirus (HPV) genes are expressed solely in cancerous cells and have been proposed to be the most important etiological factors for cervical cancer, thus making them suitable targets for gene therapy. In this study, we aim to inactivate the HPV16 E7 in CaSki cells and test the possibility of reducing the tumorigenicity of these cells.

METHODS

The full-length HPV16 E7 cDNA was cloned in the pBabe-puro or pWZL-Hygro retrovirus vector in reverse orientation and was stably transfected into CaSki cells by replication-defective retrovirus infection giving rise to CaSki-E7AS and CaSki-E7AS2X cells. Immunoprecipitation/Western analysis and real-time RT-PCR were performed to document the levels of HPV16 E7 gene product. Flow cytometry was performed to study changes in the cell cycle in response to reduced E7 protein. The expression of bcl-2, RB, and E2F-1 was studied using Western blot analysis. Tumorigenicity of CaSki, CaSki-E7AS, and CaSki-E7AS2X cells was assayed with subepidermal tumor growth in nude mice.

RESULTS

We have documented that the delivery of the antisense gene construct resulted in the reduction of HPV16 E7 protein expression and cell proliferation in CaSki cells. Furthermore, we demonstrated that these changes were accompanied by cell cycle arrest, up-regulation of RB, and down-regulation of E2F-1 and bcl-2 proteins. More importantly, dose-dependent transduction of the antisense HPV16E7 construct was able to inhibit and/or retard the tumorigenicity of CaSki cells in vivo.

CONCLUSIONS

Down-regulation of HPV16 E7 with antisense RNA is beneficial in reducing the tumorigenicity of CaSki cells and can potentially be useful for HPV-associated malignancy gene therapy.

Contribution of bovine papillomavirus type 1 E1 protein residue 48 to replication function

The E1 protein of bovine papillomavirus type 1 (BPV-1) is the origin recognition protein and is essential for the initiation of viral DNA replication. We reported previously that there is a conserved motif between residues 25 and 60 of all papillomavirus E1 proteins that resembles a casein kinase II (CKII) phosphorylation site. The corresponding serine in BPV-1, serine-48, is an efficient substrate for CKII in vitro. To examine the functional role of this potential phosphorylation site, three amino acid substitutions were constructed at serine-48. Conversion of serine-48 to a glycine (S48G) resulted in a BPV-1 genome that was unable to replicate and had reduced transformation capacity. The S48G E1 protein also failed to support replication of a BPV-1 origin-containing plasmid when expressed from a heterologous vector rather than the viral genome, indicating a direct replication defect. In contrast, conversion of serine-48 to acidic residues (S48D or S48E), which mimic the charge and structure of phosphoserine, maintained the wild-type replication phenotype. These mutational results are consistent with a replication requirement for a negative charge at serine-48, presumably supplied by in vivo phosphorylation. The mechanistic basis for the negative charge requirement was examined by testing several activities of the S48G mutant E1 protein in vivo using yeast one- and two-hybrid systems. No gross defect was observed for stability, origin binding or interaction with E2 or for E1-E1 interaction, although subtle defects in these activities would not likely be detected. Overall, the results suggest that important phosphoregulatory control of E1 replication function is mediated through the N-terminal region of this protein.

Epidemiological aspects of human papillomavirus infection and cervical cancer in Brazil

OBJECTIVES

A study was conducted to determine the prevalence of HPV infection in cervical lesions of Brazilian women and to search for specific risk factors associated to progression to malignancy.

METHODS

Five hundred and fourteen paraffin-embedded biopsies obtained from female cervical lesions were classified according to the Bethesda System in low grade squamous intraepithelial lesion (LSIL), high grade SIL (HSIL) and squamous cell carcinoma (SCC). Specimens were tested for the presence of human papillomavirus (HPV) types 6/11,16/18 and 31/33/35 DNA using non-isotopic in situ hybridization.

RESULTS

HPV prevalence ranged from 85.6% in LSIL to 55.2% in SCC. Patients were analysed through an 8 year period: 27. 1% of the lesions spontaneously regressed while 43.6% persisted and 29.3% progressed to carcinoma. High risk types were present in 80.5% (Crude OR 13.8, P=0.0003) of the progressive lesions. Possible co-factors have also been evaluated: history of other sexually transmitted diseases, mainly syphilis, showed to be positively related to progression (Adjusted OR 13.0, P=0.0003) while oral contraceptive use and tobacco smoking were not significantly related to it (P>O.1). Association of two or more co-factors also proved to be related to progression.

CONCLUSIONS

Oncogenic HPV types 16 and 18 and history of other concurrent sexually transmitted diseases were found to be significantly associated with progression to cancer. Smoking and the use of oral contraceptives did not show a relation to cancer establishment, but when they were associated a significant co-operative role in progression was demonstrated. Our study indicated that HPV and other risk factors for cancer can act together, corroborating the observation of a poor prognosis for Brazilian women presenting SILs.

Human papillomavirus life cycle: active and latent phases

Productive infection by human papillomaviruses (HPV) is dependent upon the differentiation of the host cell. Following entry into basal epithelial cells, HPV genomes are established as autonomous replicating extrachromosomal elements and a low level of HPV expression occurs. Upon differentiation of infected cells, productive replication and expression of capsid genes is induced resulting in the synthesis of progeny virions. Evidence from immunosuppressed patients as well as individuals with recurring laryngeal papillomatosis suggest that certain HPV types can exist in a latent state. In latently infected cells, HPV DNA may be present but no differentiation-dependent synthesis of virions occurs. The presence of a latent state for HPVs can be a determining factor in the effectiveness of therapeutic methods for treatment of infections.

Vulvar intraepithelial neoplasia and carcinoma

This report describes the classification, clinical profile, etiology, and management of high-grade squamous vulvar intraepithelial-neoplasia (VIN). Recent studies have better defined the progressive potential of high-grade VIN and the relationship of such lesions to squamous vulvar carcinoma. The histologic classification and descriptions have undergone significant refinement over the past decade. The increasing use of more conservative therapeutic approaches to high-grade VIN has demanded greater expertise in clinical evaluation to ensure invasive disease is not missed or undertreated.

Prevalence of human papilloma virus in men attending the infertility clinic

Subclinical human papilloma virus is a potential carcinogen in the male and female genital tract. The sexually active male infertility population represents a high risk group for harbouring this disease. To determine the prevalence of subclinical human papillomavirus in this group, penoscopy was done on 96 male patients visiting the infertility clinic. The feasibility of routine penoscopy as part of the infertility work-up was also investigated. Of the 96 patients 20 had aceto-white lesions on their penises with penoscopy. Thirteen patients (13.5%), 12 proven by biopsy of the aceto-white lesions, and one proven by fluid in situ hybridization on superficial epithelial cells of the distal urethra, were positive for human papillomavirus. Two of the 12 biopsy-positive cases were also proven positive by fluid in situ hybridization. It was concluded that human papillomavirus had a high prevalence amongst asymptomatic male patients attending the infertility clinic and that penoscopy should be included as routine investigation in the work-up of the male infertility patient.

DNA-EIA to detect high and low risk HPV genotypes in cervical lesions with E6/E7 primer mediated multiplex PCR

BACKGROUND

Oncogenicity of human papillomavirus (HPV) DNA in premalignant and malignant uterine cervical diseases is mainly induced by E6/E7 open reading frame (ORF). The presence of an oncogenic HPV DNA may be a diagnostic marker for the detection of cytologically negative smears.

AIMS

To evaluate an original polymerase chain reaction enzyme immunoassay (PCR-EIA) for the detection and typing of oncogenic and non-oncogenic HPV types.

METHODS

The test was an original multiplex labelled PCR-EIA for the detection and typing of oncogenic and non-oncogenic HPV using three consensus sequence primers within the oncogenic E6/E7 ORF. One primer was dinitrophenyl (DNP) labelled and the DNP labelled amplimers could be further hybridised with specific biotinylated oligoprobes mixed in only two cocktails: oncogenic (16, 18, 31, 33, 35, 52, and 58) and non-oncogenic (6 and 11) HPV types in only two wells; then biotinylated oligoprobes were deposited in streptavidin-coated microplates. The PCR-EIA was validated on HPV plasmids (types 6, 11, 16, 18, 31, 35, 52, and 58) and used to evaluate cervical scrapes from 181 patients (median age 32 years) at high risk for cervical cancer.

RESULTS

HPV were detected in the cervical scrapes of 88 of 181 patients (48.6%); nine with non-oncogenic HPV (5.0%) and 79 with oncogenic HPV (43.6%) including 29 coinfections with oncogenic and non-oncogenic HPV. The number of oncogenic HPV infections increased with the presence of high grade lesions: 95.8% of the cervical scrapes from patients with high grade lesions contained oncogenic HPV compared with 32.1% of the specimens from patients without any lesions detectable by colposcopy and/or by cytological examination of the cervical smears. Moreover, 60% of cervical scrapes exhibiting low grade lesions contained oncogenic HPV.

CONCLUSIONS

This test is simple, specific, sensitive, safe, fast, reproducible, and easy to use in routine practice. Thus, it is possible to detect simultaneously on a simple cervical scrape, two kinds of HPV--oncogenic and non-oncogenic--in just two microplate wells with non-isotopic oligoprobes.

Human papillomavirus infection and invasive cervical neoplasia: a study of prevalence and morphology

The prevalence of human papillomavirus (HPV) DNA sequences in 45 cervical cancer biopsies was examined with the hot-start polymerase chain reaction (PCR), employing HPV consensus primers from the L1 region. The cases comprised 38 squamous cell carcinomas, three adenosquamous carcinomas, and four adenocarcinomas. PCR products were typed with single-strand conformation polymorphism (SSCP) and the HPV types detected were correlated with tumour type. Forty-three biopsies were HPV-positive, HPV16 being the most prevalent type. HPV18/33/45/58 were also detected, but no low-risk or multiple types. Keratinizing squamous cell carcinoma was invariably associated with HPV16 and adenosquamous carcinoma and adenocarcinoma with HPVs 18/45. Non-keratinizing squamous cell carcinomas harboured all five detected types. Our data corroborate the view that malignant cervical tumours are almost invariably associated with high-risk HPV and that certain malignant cervical tumour phenotypes correlate with specific HPV types.

Importance of peniscopy, oncologic cytology and histopathology in the diagnosis of penile infection by human papillomavirus

INTRODUCTION

Male genital infection by human papillomavirus is of particular importance since it is often asymptomatic. The patient generally presents no clinical lesion. Therefore, men represent an important reservoir of virus, playing a special role in the transmission and perpetuation of the disease.

PATIENTS AND METHODS

In the present prospective clinical trial study, 190 sex partners of women with genital infection by human papillomavirus, associated or not with cervical intraepithelial neoplasia, were investigated. All patients were unaware of or denied the presence of a genital lesion.

RESULTS

Cytologic examination revealed koilocytosis in 9 cases (4.7%) in the urethra and in 3 cases (1.6%) in the corona of the glans and the distal prepuce. Peniscopy with the previous use of 5% acetic acid revealed white lesions in 97.9% of the patients. Toluidine blue stained most of the lesions. At least one fragment revealed koilocytosis in the histopathologic study of 97 cases (51.05%).

CONCLUSION

The three methods complement one another, allowing a more precise diagnosis of the infection in men.

Human papillomavirus and bladder cancer

Bladder cancer remains an important cause of oncological morbidity and mortality in women. Known etiological agents include smoking and exposure to certain industrial chemical compounds, though the origin of the majority of cases remains unknown. Human papillomavirus infection is also common in women and has been closely linked to the development of carcinoma of the cervix. It has been suggested that infection with HPV may also be an important factor in the subsequent development of bladder cancer. A number of studies using various techniques of molecular biology have looked at the relationship between HPV infection and bladder cancer. Although the results are somewhat conflicting, the overall picture would suggest little involvement of HPV in the evolution of bladder cancer, except possibly in a small group of patients who are immunocompromised.

Human papillomavirus infection in progressive and non-progressive cervical intraepithelial neoplasia

Human papillomavirus (HPV) infection is common in cervical intraepithelial neoplasia (CIN) and is widely held to be responsible for its progression to grade 3. This thesis is examined here. Comparison of the level of HPV changes in 133 lesions that had not progressed to that in those from 197 women with histologically proven CIN 3 failed to reveal significant differences in their level of HPV infection on cytology, histology or in situ hybridization. However, in both these groups, some of the cases that did not show HPV positivity on in situ hybridization with probes reacting with the common HPV types did show evidence of HPV DNA using a general primer-mediated polymerase chain reaction. This may indicate low-copy number infections or non-productive infections. Such reactions were more frequent in the women with progressive lesions, and it is probable that they may also have been at greater risk of cervical infection in general. The present findings suggest that a further factor, a cocarcinogen, may be involved in progression to CIN 3, HPV being a common forerunner, providing a proliferative environment and thus favoring such an event.

Clinical role of HPV testing

The subjectivity of morphologic methods contributes to a "swamping" of colposcopic services, excessive costs, overdiagnosis, and overtreatment. HPV DNA testing provides the objectivity required to clarify difficult patient management issues, including follow-up, for low-grade cytologic abnormalities (ASCUS and LSIL), noncorrelating (nonconfirmed) Pap smears, evaluation of nondiagnostic lower genital tract lesions, and cytology and histology laboratory quality assurance. Additionally, favorable preliminary data on HPV testing as a primary screen raise the exciting prospect of potentially lowering costs of cervical cancer-screening programs, while further decreasing the incidence of cervical cancer.

Oncogenic human papillomaviruses and ploidy in cervical lesions

AIM

To compare ploidy measurements obtained on tissue sections of selected low and high grade squamous intraepithelial lesions containing oncogenic HPV (types 16, 18 or 33) detected by in situ hybridisation (ISH) or PCR.

METHODS

DNA ploidy was assessed by image cytometry after Feulgen staining of contiguous serial sections of eight lesions exhibiting atypical squamous cells or squamous atypia and 53 low and 63 high grade squamous intraepithelial lesions in which HPV had been detected by ISH or PCR.

RESULTS

Aneuploidy was strongly associated with the presence of oncogenic HPV, being detected in 50% of lesions with squamous atypia and 75.5% of the low and 95.2% of the high grade squamous intraepithelial lesions. The multiploid profile was highly associated with high grade lesions and with the pattern of HPV DNA integration.

CONCLUSIONS

The presence of aneuploidy is strongly suggestive of the presence of oncogenic HPV types. Combining the detection of HPV by ISH and PCR with DNA image cytometry may provide the pathologist and the physician with important prognostic information about low grade lesions, especially when these lesions have a multiploid DNA profile and contain oncogenic HPV.

Analytic sensitivities of hybrid-capture, consensus and type-specific polymerase chain reactions for the detection of human papillomavirus type 16 DNA

Human papillomavirus type 16 (HPV-16) DNA is detected commonly in cervical carcinomas; in this study, we have determined the analytical sensitivities of Hybrid Capture, HPV-consensus PCR, and three HPV-16-specific polymerase chain reactions (PCRs) for the detection of HPV-16 DNA. Samples investigated included a cervical cancer cell line, cervical scrapes from 20 patients attending colposcopy clinics, and buccal swabs from eight immunosuppressed children. HPV-16 E7 and E5-nested PCRs [Cavuslu et al. (1996): Journal of Virological Methods, in press] produced positive signals from samples containing fewer than ten HPV-16 genomes per reaction. HPV-consensus PCR [Manos et al. (1989): Cancer Cells 7:209-214] and HPV-16 PCR using primers of van den Brule et al. [(1990): Journal of Clinical Microbiology 25:2739-2743] were of intermediate sensitivity (i.e., produced positive signals from samples containing 250 and 2,500 HPV-16 genoms/reaction, respectively) and Hybrid Capture could detect just 50,000 HPV-16 genomes/reaction. Highest rates of positivity for cervical samples were detected with HPV-16 E7 or E5-nested PCRs [50% (10 of 20 samples) and 60% (12 of 20 samples) positive, respectively], intermediate rates with HPV-consensus PCR and PCRs using the primers of van den Brule et al. [both 35% (7 of 20 samples)], and lowest rates of positivity [25% (5 of 20 samples)] with Hybrid Capture. None of eight buccal swab samples from immunosuppressed children were positive by Hybrid Capture, yet three (37.5%) were positive by HPV-16 E5-nested PCR. These data indicate that HPV-16 type-specific PCRs should be used for the investigation of specimens that may contain low amounts of HPV-16 DNA.

Human papillomavirus infection and cervical cancer in Brazil: a retrospective study

Two hundred and thirty paraffin-embedded biopsies obtained from female cervical lesions were tested for the presence of human papillomavirus (HPV) types 6/11, 16/18 and 31/33/35 DNA using non-isotopic in situ hybridization. Specimens were classified according to the Bethesda System in low grade squamous intraepithelial lesion (LSIL), high grade SIL (HSIL) and squamous cell carcinoma (SCC). HPV prevalence ranged from 92.5% in LSIL to 68.5% in SCC. Benign types were prevalent in LSILs while oncogenic types infected predominantly HSILs and SCC. HPV infection showed to be age-dependent, but no significant relation to race has been detected. Patients were analyzed through a five-year period: 20.7% of the lesions spontaneously regressed while 48.9% persisted and 30.4% progressed to carcinoma. Patients submitted to treatment showed a 19.4% recurrence rate. High risk types were present in 78.6% (CrudeOR 13.8, P = 0.0003) of the progressive lesions, and in 73.7% of the recurrent SILs (COR 19.3, P = 0.0000001). Possible co-factors have also been evaluated: history of other sexually transmitted diseases showed to be positively related either to progression (Adjusted OR 13.0, P = 0.0002) or to recurrence (AOR 17.2, P = 0.0002) while oral contraceptive use and tobacco smoking were not significantly related to them (P > 0.1). Association of two or more co-factors also proved to be related to both progression and recurrence, indicating that they may interact with HPV infection in order to increase the risk of developing malignant lesions.

Human papillomavirus in oral premalignant lesions

The aetiology of oral premalignant lesions is generally accepted to be multifactorial. Tobacco and alcohol are established as important cofactors in malignant development in the oral cavity, but in addition microorganisms, such as human papillomavirus (HPV), have gained much interest over the past decade. For many years, HPV has been accepted as an important cofactor in the development of cervical cancer, originating from a mucous membrane with similarities to the oral mucosa. 49 patients with oral premalignant lesions and 20 control patients with normal oral mucosa and no history of HPV infection were examined for the presence of HPV by immune histochemical staining using the peroxidase anti-peroxidase technique (PAP), DNA-DNA in situ hybridisation (ISH), and polymerase chain reaction (PCR) analysed by Southern blot hybridisation with an HPV 16 specific probe. The investigations revealed that HPV was found in 62.5% of the verrucous leucoplakias, 50.0% of the erythroplakias, 45.5% of the homogeneous leucoplakias, 33.3% of erythroleucoplakias and in 12.5% of the nodular leucoplakias. An overall HPV detection rate in the examined premalignant lesions was 40.8% and no patients in the control sample were positive. Concerning oral cancer development, it seems likely that HPV may be a cofactor, as 100% of patients who developed oral cancers within 4-12 years were all positive for HPV, one being positive for HPV 16.

Human papillomavirus expression in oral mucosa, premalignant conditions, and squamous cell carcinoma: a retrospective review of the literature

OBJECTIVES

The literature of human papillomavirus detection in normal oral mucosa and oral lesions associated with the dysplastic progression of epithelium was reviewed to help define the role of this virus in the development of oral squamous cell carcinoma.

STUDY DESIGN

All available data from published studies were analyzed by chi-square test for association between the human papillomavirus and age, gender, race, DNA type, location, lesional dysplastic progression, method of detection, tissue preservation, and use of tobacco and alcohol.

RESULTS

Human papillomavirus was identified with increasing frequency in normal oral mucosa (13.5%), benign leukoplakia (14.8%), intraepithelial neoplasia (18.5%), squamous carcinoma (26.2%), and verrucous carcinoma (27%). It was detected in oral squamous cell carcinoma significantly (p < 0.005) more often (37.1%; 122 of 329) in studies that used a high sensitivity assay (polymerase chain reaction) than studies that used moderate sensitivity assays (25.2%; 84 of 334) (e.g., Southern blot hybridization) and low sensitivity assays (16.9%; 61 of 362) (e.g., immunohistochemistry, in situ hybridization). Human papillomavirus DNA was detected significantly more often (p < 0.001) in frozen oral squamous cell carcinoma (51.6%; 115 of 223) than paraffin-embedded tissue (21.7%; 136 of 628). High-risk human papillomaviruses (2, 16, 18) were detected in 81.4% of OSCCs that contained the virus compared with low-risk human papillomavirus genotypes (6, 11) in 17.9% of oral squamous cell carcinoma that contained the human papillomavirus (p < 0.001). In studies that analyzed the use of chemical cofactors, the use of tobacco and alcohol (87.3%) was associated more often with oral squamous cell carcinoma than the presence of human papillomavirus (51.3%), however, the difference was not significant.

CONCLUSION

High-risk human papillomavirus genotypes have a significant association with oral squamous cell carcinoma. However, the presence of this virus in a high proportion of oral normal mucosa makes the virus alone a poor prognosticator of progression to malignancy.

Detection of human papillomavirus type 16 in microtitre plate based immuno-enzymatic assays: use to determine E5 gene expression in cervical carcinomas

BACKGROUND

E5-based nested polymerase chain reaction (PCR) assays and a PCR-enzyme immunoassay (EIA) to detect human papillomavirus type 16 (HPV-16) DNA have been developed. These assays were designed to detect small amounts of HPV-16 DNA for epidemiological studies of subclinical infection.

OBJECTIVES

The E5 gene of HPV-16 may be lost in some cell lines derived from cervical carcinomas. The aim of this study was to determine if, and how frequently, E5 gene loss occurs in biopsy samples from patients with cervical lesions.

STUDY DESIGN

Sixteen HPV-16 (E7) DNA positive and five HPV-16 DNA negative cervical lesions (nineteen cervical carcinomas, two cervical intraepithelial neoplasias) were investigated by E5 nested PCR and EIA.

RESULTS

Overall, 15 of the 16 (93.75%) HPV-16 E7 positive samples were positive for HPV-16 E5 DNA: 14 of 16 (87.5%) were positive by E5 PCR and 15 of 16 (93.75%) were positive by E5 PCR, nested PCR and by PCR-EIA. One of 14 HPV-16 (E7) DNA positive cervical carcinomas was negative for E5 DNA in all three assays.

CONCLUSION

Loss of the HPV-16 E5 open reading frame (ORF) is a rare event in HPV-16 positive cervical carcinomas and was detected in just one of 14 (7.1%) cases.

Detection of human papillomavirus type-16 DNA utilising microtitre-plate based amplification reactions and a solid-phase enzyme-immunoassay detection system

The development of a nested polymerase chain reaction (PCR) assay to detect low concentrations of human papillomavirus type-16 (HPV-16) DNA for epidemiological studies is described. The PCR utilises primers located in the E5 open reading frame, has an analytical sensitivity of 4 HPV-16 genomes and does not produce amplicons from other common genital HPVs (types-6, -11, -18, -31 and 33). This assay was carried out in 96-well plates utilising internal primers labelled with dinitrophenol (DNP) and biotin so that amplicons can be captured onto streptavidincoated plates and detected using an alkaline phosphatase-labelled monoclonal antibody to DNP. The assay was effective for detecting HPV-16 DNA in plasmids, cell-lines and, both freshly collected or archival (formalin-fixed/paraffin embedded) clinical specimens. This system is therefore suitable for epidemiological studies to identify individuals infected with HPV-16 DNA in episomal form who may be at increased risk of developing anogenital carcinomas.

Spontaneous evolution of intraepithelial lesions according to the grade and type of the implicated human papillomavirus (HPV)

Because of the fact that any meaningful classification should bear a close relationship to the biological behavior of the lesions, the usefulness of all new classifications of cervical precancer lesions can only be established by well controlled prospective follow-up studies. However, several methodological and conceptual problems are encountered in the natural history studies conducted during the past several decades. While reviewing the available prospective follow-up studies on cervical intraepithelial neoplasia (CIN), Ostör (1993) found 3529 cases of CIN 1, of which 57% showed regression, persistence was found in 32%, progression to CIN III in 11%, and progression to invasive cancer in 1% of cases. The corresponding figures for CIN II were 43%, 35%, 22%, and 5%, respectively. The recognition of the association between human papillomavirus (HPV) and CIN has further complicated the assessment of the natural history of cervical precancer lesions. Results from the early prospective follow-up studies are remarkably consistent, however. Progression from HPV-NCIN (i.e., koilocytosis without CIN) to CIN I or greater was reported for 18 (8%) of 232 women followed by Syrjänen et al. for an average of 25 months, for 26 (8%) of 314 women followed by de Brux et al. (1981) for 15 to 18 months, and for 113 (13%) of 846 women followed for up to six years by Mitchell et al. During a 42-month follow-up period, 10% progression rate was found in 1269 women with HPV-CIN I, and in 17% of 762 women with HPV-CIN II by de Brux et al. (1983). The spontaneous regression rates were 53% and 39% in these cohorts, respectively. This is fully consonant with our experience from an almost 14-year follow-up of 530 women in Kuopio, where the spontaneous regression rate seems to increase in parallel with the extent of the follow-up time, currently being 66.7% for HPV-NCIN and 55.7% for HPV-CIN I. The figures for progression are 6.3% and 14.2%, respectively. It is obvious that the probability of a cervical precancer lesion to progress into an invasive disease increases with the severity of the atypia. Another distinct prognostic factor is HPV type, HPV 16 lesions possessing a significantly higher risk for progression than infections by other HPV types. The follow-up data also indicate, however, that even the high grade lesions may spontaneously regress, which should have important implications in therapy. The continuous problem still remains; these natural history observations only apply to a large series of women but are of little help in predicting the disease outcome in individual women.

Symptomatic genital papillomavirus infection in a community. Incidence and clinical picture

BACKGROUND

Incidence of condyloma acuminatum is not well known. Descriptive data are usually based on selected groups of patients. This study aims at giving incidence of the clinically defined disease in a well-defined area, thought to be representative for Sweden outside the capital city.

METHODS

Data from people with condyloma acuminatum seeking medical attention were collected during a two-year period, 1989-90, in a middle-sized urban area in Sweden. A person with symptoms and a clinical picture consistent with condyloma was considered a case.

RESULTS

Overall incidence was 2.4 per 1000. The highest age specific incidence occurred in the age group 20-24 years, 12 per 1,000. Women 15-19 years old had an incidence of 14 per 1,000. The total female to male ratio was 1.3.

CONCLUSIONS

Women more often than men had a mixture of exo- and endophytic condylomata. Condyloma as another and complementary indicator of changing sexual behavior deserves further interest.

Transmission of genital human papillomavirus infections is unlikely through the floor and seats of humid dwellings in countries of high-level hygiene

To evaluate the transmission of genital human papillomavirus (HPV) through the floor and seats of humid dwellings, samples were collected with a toothbrush from the floor and seat surfaces of humid dwellings; showers, saunas and dressing rooms. The survey included 3 bathing resorts, 1 indoor swimming pool, 2 schools and 2 private homes. Polymerase chain reaction (PCR) was used to amplify the human beta-globin gene and HPV DNA. The results for HPV DNA amplification were confirmed by Southern blot hybridization under low stringency using a probe mixture of HPV types 6, 16, 18 and 31. beta-globin could be amplified only from 3 sample taken from a dressing room of and indoor public swimming pool. No HPV DNA-positive samples were found. These results indicate that transmission of genital HPV infection via floor or seat surfaces in the above dwellings in general or family use is highly unlikely.

Perinatal infection and persistence of human papillomavirus types 16 and 18 in infants

Perinatal transmission of genital human papillomaviruses (HPVs), including HPV-16 and -18 which are associated with anogenital carcinomas have been described previously [Pakarian et al. (1994): British Journal of Obstetrics and Gynaecology 101:514-517; Kaye et al. (1994) Journal of Medical Virology 44:415-421]. A study was undertaken to investigate whether HPV-16 and -18 DNA in infants contaminated at delivery persists until they are 6 months of age. Of 61 pregnant women recruited, 42 (68.8%) were HPV-16 and 13 (21.3%) were HPV-18 DNA positive. At 24 hr there were transmission rates from HPV DNA positive mothers to their infants of about 73% (HPV-16: 69%; HPV-18: 76.9%). Ten mothers who were both HPV-16 and -18 DNA positive produced six (60%) infants who were also doubly positive at 24 hr. HPV DNA persisted to 6 weeks in 79.5% (HPV-16: 84%; HPV-18: 75%) of those infants who were positive at birth. At 6 months of age, persistent HPV-16 DNA was detected in 83.3% of cases, but HPV-18 DNA persistence at this time was 20%. To extend these observations over a greater age range of children HPV-16 L1 and L2 proteins were expressed in insect cells via recombinant baculoviruses and sera from 229 children were examined to determine at what age IgM antibodies to HPV were acquired. There was a bimodal distribution of IgM seropositivity which peaked between 2 and 5 and 13 and 16 years of age, suggesting that two distinct modes of transmission may occur. The observation that infection with high cancer risk genital HPVs may occur in early life and persist is of considerable importance for HPV vaccine strategies.

Congenital papillomas and papillomatoses associated with the human papilloma virus (HPV)-report on 5 cases

The authors present a study of five cases of vulvar congenital papillomas and papillomatoses in stillborns and neonates dead upon birth. The studied material was collected from five necropsies. The histopathological evaluation showed hyperkeratosis, acanthosis, papillomatosis, perinuclear haloes, and nuclear abnormalities. In three of the cases, the electron microscopy identified nuclear and cytoplasmatic viral particles ranging from 40 to 60 nm in size, compatible with HPV. The immunohistochemical study of those lesions showed nuclear and cytoplasmatic positivity. The authors concluded that the presence of viral particles suggestive of HPV added to the immunopositivity indicated the possibility of viral infection.

Human papillomavirus (HPV) in vulvar dysplasia and carcinoma in situ

Surgical specimens from 62 patients with vulvar dysplasia and carcinoma in situ were morphologically investigated. Lesions were classified according to WHO (mild, moderate, severe dysplasia and carcinoma in situ) and according to Toki et al. (1991) (warty, basaloid, combined warty/basaloid or basaloid/warty types or mixed (warty, basaloid and simple) forms). Following the WHO classification, moderate dysplasia was shown in 4 cases, severe dysplasia in 47 and carcinoma in situ in 11 cases. Pure warty type was shown in 2 cases (both biopsy specimens). One case revealed pure simple dysplasia whereas no case of pure basaloid type was found. Various combinations of warty and basaloid types were shown in 52 cases and mixed forms in 7 cases. The results indicate that pure forms of warty and basaloid types probably do not exist. HPV DNA was detected by PCR in 51/58 cases (88%) (45 with HPV type 16 and 6 with HPV type 33) evenly distributed in all age groups and in all types of lesions (WHO and Toki et al. 1991). By ISH HPV was detected in 24/62 cases (39%) (21 with HPV type 16/18 and 3 with HPV type 31/33), nearly always in warty areas. All these cases were positive for the same virus type by PCR. No case revealed more than one type of HPV. HPV type 6, 11, 18, and 31 were not detected by PCR. The results indicate a correlation between HPV type 16 and 33 and dysplasia/carcinoma in situ in the vulva.

Epidemiology of cervical intraepithelial neoplasia: the role of human papillomavirus

The evidence implicating specific HPV types in the aetiology of cervical cancer is now strong enough to establish a causative role. HPV infection of the cervix affects the developing immature metaplastic cells of the transformation zone. Cervical neoplasia can be viewed as the interaction of high risk papillomavirus and immature metaplastic epithelium. Once maturity is reached, there is minimal risk of subsequent development of cervical squamous neoplasia. Exposure to HPV is an extremely common event, especially in young sexually active women. Yet, despite frequent HPV exposure at that phase of life in which the cervical transformation zone is at its most vulnerable, established expressed disease is relatively uncommon. Most studies in which the natural history of CIN is not altered by cervical biopsy reveal a progression rate from low to high grade CIN of less than one third. Where viral type is taken into account, however, the progression rate from normal but high risk HPV-infected cervical epithelium to CIN 2 or 3 is higher. Despite this, most cervical abnormalities will not transform into invasive cancer, even if left untreated. The variance between the high rate of HPV infection, the intermediate rate of CIN and the relatively low rate of cervical cancer establishes a stepwise gradient of disease of increasing severity with decreasing prevalence. In an immunocompetent host, HPV infection alone does not appear to be sufficient to induce the step from high grade CIN to invasion. Epidemiological studies indicating that HPV infection with oncogenic viral types is far more common than cervical neoplasia suggest the necessity of cofactors in cervical carcinogenesis. The long time-lag between initial infection and eventual malignant conversion suggests that random events may be necessary for such conversion, and the spontaneous regression of many primary lesions suggests that most patients are not exposed to these random events. Potential cofactors include cigarette smoking, hormonal effects of oral contraceptives and pregnancy, dietary deficiencies, immunosuppression and chronic inflammation. In those women who develop cervical cancer, malignant progression is rarely rapid, more commonly taking many years or decades. Malignant progression has been documented in patients who presented initially with only low grade HPV-induced atypia. On the other hand, progression may be a misnomer, as 'apparent' progression may really represent adjacent 'de novo' development of higher grade CIN. Although most cervical cancers contain high risk HPV types, up to 15% of such cancers test negative for HPV, raising the possibility that a few, usually more aggressive, cervical cancers may arise from from a non-viral source.(ABSTRACT TRUNCATED AT 400 WORDS)

Response to podophyllotoxin treatment of genital warts in relation to HIV-1 infection among patients in Dar es Salaam, Tanzania

Forty-two Tanzanian patients with genital warts were treated with 0.5% podophyllotoxin solution (Wartec) for 3 days. Thirteen patients (30.9%) were cured and a further 7 patients (16.7%) had more than 50% of lesions cleared at 6 weeks, while 19 patients were resistant to treatment. Three patients had a recurrence of lesions after an initial response. Thirty-three patients were tested for serological evidence of infection with human immunodeficiency virus (HIV) and 15 (45.5%) patients were shown to be HIV-1 antibody positive. The response to treatment was analysed in relation to HIV antibody status. The cure rate was significantly higher in HIV seronegative patients (8/18 = 44.4%) compared to HIV seropositive patients (1/15 = 6.7%) (P = 0.018). We conclude that podophyllotoxin treatment provides a useful non-hospital based treatment for genital warts, but HIV infection appears to contribute to the failure of treatment for genital warts.

Detection of human papillomavirus in cervical scrapings by in situ hybridization and the polymerase chain reaction in relation to cytology

A gynaecological out-patient population consisting of 200 patients aged 19-43 years (mean age 34.2 years) was screened for the presence of human papillomavirus (HPV) by the polymerase chain reaction and in situ hybridization on cervical scrapings. A novel method was applied for the detection of HPV in cervical cells by embedding them in a paraffin block before in situ hybridization was performed. This technique resulted in well preserved cytological morphology, easy performance and economy of probes. In eight of the 200 patients (4%), human papillomavirus DNA was revealed by the polymerase chain reaction. Subtyping revealed the presence of HPV serotype 16 DNA in three of these patients. In one patient HPV serotype 18 DNA was also present. The in situ hybridization assay was able to detect all those cases with a specific HPV serotype infection.

Papillomavirus-associated balanoposthitis

OBJECTIVE

To assess whether there might be an association between genital papillomavirus infection (GPVI) and balanoposthitis.

DESIGN

Retrospective HPV DNA examination of biopsy specimens from 23 men suffering from balanoposthitis and exhibiting acetowhite lesions that were penoscopically and histologically concurrent with HPV infection.

SETTING

The STD clinics at Karolinska Hospital and South Hospital, Stockholm, Sweden.

PARTICIPANTS

Randomly selected men attending with long-lasting and/or recurrent penile symptoms and exhibiting a clinical picture of balanoposthitis, who revealed a penoscopical and histopathological picture of epidermal lesions that were concordant with accepted criteria for typical or conspicuous GPVI. Asymptomatic controls were selected retrospectively on the basis of identical penoscopy and histology criteria.

RESULTS

A history of previous condylomata was obtained in eight (35%) of 23 men. At penoscopic evaluation tiny condylomatous lesions were observed in five (22%) patients. The in situ hybridisation (ISH) assay using specific probes for the HPV types 6/11, 16/18, 31/33 and 42 was positive in 13/23 (56%) of the patient samples, but in only 26% of the 19 control samples. In patient biopsies the oncogenic HPV types 16/18 and/or 31/33 were found in 7/13 samples, whereas HPV 6/11 and/or 42 were present in another six cases. PCR performed on the ten ISH negative patient biopsies, were negative in all cases.

CONCLUSION

Symptoms included redness, itching, burning, tenderness, dyspareunia, fissuring and in two cases penile oedema and inguinal adenopathy. All patients fulfilled penoscopical and histopathological criteria for HPV infection. We demonstrate some tentative evidence that HPV might be associated with long-lasting balanoposthitis, although our data still are circumstantial for a causative association. The results also elucidate the diversity in clinical presentation of GPVI.

Umbilical warts: a new entity?

Two cases of umbilical warts are described. The occurrence of these lesions was not previously known. In both cases there was a history of long-standing genital warts.

Fast solid support detection of human papillomavirus in in vitro amplified DNA using a DNP-anti DNP monoclonal antibody couple

In some anogenital lesions the detection of certain types of human papilloma virus, especially oncogenic types, is of interest. In a first step during a prospective study, we compared two methods for the detection of human papillomavirus (HPV) DNA in clinical samples: Southern blotting followed by hybridization with a cloned radioactive genomic probe and a classical polymerase chain reaction (PCR) followed by hybridization with a 32P-labelled oligonucleotide probe. 118 biopsies and swabs were examined for HPV 6/11, 16, 18 and 33, 67 positive reactions were found by both methods, 5 positives only by PCR and 2 positives only by Southern blot for unidentified HPV. Patients with anogenital condylomas, dysplasias and carcinomas or asymptomatic patients were studied. Most high grade (II and III) dysplasias were associated with HPV 16 and HPV 18. Condylomata lesions and low grade dysplasia (grade I) were associated mostly with HPV 6/11, mixed type of HPV, less frequently with HPV 16 or HPV 18. As a second step a nested PCR coupled to solid support detection method was used as described by Sauvaigo et al. (1990) Nucleic Acids Res. 18, 3175-3183) to study a panel of 30 previously qualified different HPV DNA extracts. In this procedure the second round of PCR amplification involves biotinylated and dinitrophenylated labelled primers allowing the capture of PCR amplified HPV DNA sequences on streptavidin coated tubes and its revelation. We describe an improvement of HPV DNA detection by means of single-step immunoenzymatic revelation involving anti-DNP monoclonal antibodies conjugated to horseradish peroxidase enzyme. A perfect correlation with the previous results was obtained. This solid support method allows a faster and easier HPV typing compared to methods using membrane transfer.

Changes in HPV infection in patients with anogenital warts and their partners

OBJECTIVES--To investigate the relationship between clinical findings and the detection of human papillomavirus (HPV) DNA in a range of anatomical sites in patients with and without anogenital warts. SUBJECTS--Men and women with a clinical diagnosis of anogenital warts, or a current partner with anogenital warts. SETTING--A department of genitourinary medicine in central London. METHODS--The anogenital areas of the patients were thoroughly examined using a colposcope before and after application of acetic acid. Different types of specimens were taken from a variety of anatomical sites. Superficial skin sampling was performed by the application of slides covered with "Superglue" (SG) to clinically normal and abnormal areas of anogenital skin. The presence of human cells in the SG samples was confirmed by detection of the beta-globin gene using the polymerase chain reaction (PCR). HPV DNA was extracted from the specimens and amplified by using consensus primers with the PCR. HPV types 6, 11, 16, 18, 31 and 33 were identified by Southern blotting followed by hybridisation. RESULTS--In women, HPV DNA was detected in 83% of wart biopsies, 29% of cervical biopsies, 36% of cervical scrapes, 25% of urethral loop specimens, 37% of vaginal washes and 33% of rectal swab specimens. In men, HPV DNA was detected in 67% of wart biopsies, 37% of urethral loop specimens and 12% of rectal swab specimens. Of the SG samples containing the beta-globin gene, 49% from women and 50% from men contained HPV DNA. HPV DNA was not detected in buccal scrapes and serum samples from women or men. Of all specimens with detectable HPV DNA, there was evidence of a single HPV type in 41%, multiple types in 48% and undetermined types in 11%. Samples taken from different sites of a patient tended to have HPV types in common. Sexual partners, however, did not consistently have HPV types in common. CONCLUSIONS--HPV DNA was distributed widely in the anogenital area, in warts, acetowhite areas and clinically normal skin. The SG technique was well tolerated by patients and produced results consistent with other findings. Sampling from a single site of the genitalia on one occasion may significantly underestimate the infection rate with HPV. Multifocal infection of the anogenital area with HPV should be taken into consideration when interpreting epidemiological studies and management strategies.

Patients with various types of human papillomavirus: covariation and diagnostic relevance of cytological findings in Papanicolaou smears

Human papillomavirus (HPV) infection in the genital tract is associated with a number of cytological changes which are accepted as standard criteria for a cytological diagnosis. We evaluated the covariation and diagnostic accuracy of these criteria in 210 patients, i.e. 150 cases who were positive for HPV types 6, 11, 16, 18, 31, 33 or 35, and 60 cases who were HPV-negative by simultaneous Southern blot analysis. This was done by re-examining cervical smears obtained at the same time, without knowing the results of the Southern blot analysis, for the presence of koilocytosis, dyskeratosis-parakeratosis, nuclear smudging, hyperchromasia, binucleation, multinucleation, karyorrhexis and macrocytosis. We found that all these cytological changes correlated with the presence of an HPV infection. However, analysis of variance showed that koilocytosis, dyskeratosis-parakeratosis and karyorrhexis were of particular diagnostic value, while the other features provided little or no additional information. By omitting these features and making the diagnosis when two out of three of the key criteria, i.e. koilocytosis, dyskeratosis-parakeratosis and karyorrhexis were present, we diagnosed HPV infection with a specificity of 100% in 36% of the 150 cases, which were positive by Southern blot analysis. The various HPV types produced different morphological patterns which may reflect differences in action on the host cell. In the individual patient, however, such differences in cytology do not provide a sound basis for distinguishing between viral types.

Detection of human papillomavirus infection by non-isotopic in situ hybridisation in condylomatous and CIN lesions

AIMS

To study the value of non-isotopic in situ hybridisation (NISH) in detecting human papillomavirus (HPV) infection in female genital lesions positive for the virus by conventional histology but negative by filter DNA hybridisation.

METHODS

Forty three cases, which showed the histological hallmarks of the HPV infection but produced negative results in filter dot blot hybridisation tests (Vira Pap and Vira Type kits), were identified in the course of an investigation of 304 vaginal, vulvar, and cervical samples from 267 patients. These cases were studied by NISH for the presence of HPV infection.

RESULTS

In 28 (65%) of the cases NISH gave a positive hybridisation signal. In 26 cases (96%) the signal was diffuse, and in two (4%) punctate or diffuse, representing episomal and episomal or integrated HPV DNA, respectively. In most cases only a few HPV positive cells were discernible.

CONCLUSION

NISH is a more sensitive technique than dot blot hybridisation, detecting HPV infection in most cases which show histological HPV atypia but which remain negative in filter DNA hybridisation. Thus NISH is useful as an additional technique to verify the presence of HPV in lesions which remain negative in filter hybridisation tests.

Human papillomavirus DNA in urine samples compared with that in simultaneously collected urethra and cervix samples

A polymerase chain reaction was used to evaluate the occurrence of human papillomavirus (HPV) DNA in urine samples compared with that in urethra and cervix samples simultaneously collected with brushes. Of 138 presumably healthy military conscripts, 12 (8%) had HPV DNA-positive urethra samples and 8 (5%) had HPV DNA-positive urine samples. Both the urine and urethra cell samples of five men were positive, with identical types found in the paired specimens. Seven had HPV DNA-positive urethra samples only, and three had HPV DNA-positive urine samples only. Five of 7 urethra samples from males and 11 of 12 urethra samples from females, who were among patients consulting a clinic for adolescents, were positive for HPV DNA. Among those patients whose urethras were positive for HPV DNA, the corresponding urine samples of 3 of the 5 men and all the 11 women were also positive, with one or two HPV types being in common within the paired samples. Among female patients referred to a colposcopy clinic, 49% (241 of 489) of the cervical cell samples and 38% (187 of 489) of the urine specimens were found to be HPV DNA positive. Of the patients whose cervixes were positive for HPV DNA, 65% (158 of 241) of the simultaneously collected urine samples were also positive for HPV DNA. On the other hand, 84% (158 of 187) of the patients with HPV DNA in their urine also had HPV DNA in their cervical samples. Although not all individuals with genital HPV infections could be identified as HPV positive by analysis of urine samples, at least in epidemiological surveys in which invasive samples are difficult to obtain, such as from children, analysis of urine could be an alternative means of identifying HPV DNA.