Aetiology, pathogenesis, and pathology of cervical neoplasia

Advancements in the Management of Cervical Intraepithelial Neoplasia: A Comprehensive Review

Cervical intraepithelial neoplasia (CIN) represents a significant precursor to cervical cancer, posing a considerable threat to women's health globally. This comprehensive review examines recent advancements in the management of CIN, encompassing screening, diagnosis, and treatment modalities. The etiology and pathogenesis of CIN are explored alongside an analysis of traditional and emerging screening techniques, including liquid-based cytology and molecular biomarkers. Treatment options, from minimally invasive procedures to immunotherapy approaches, are evaluated for efficacy and potential impact on patient outcomes. Furthermore, this review highlights the implications of these findings for clinical practice, emphasizing the importance of staying abreast of evolving guidelines and integrating innovative strategies into routine care. Recommendations for future research and practice are provided, emphasizing personalized approaches, disparities in access to care, and the exploration of novel therapeutic avenues. By addressing these challenges and opportunities, this review aims to contribute to the ongoing efforts to mitigate the burden of CIN and cervical cancer, ultimately improving women's health outcomes worldwide.

Increase of the T-reg-recruiting chemokine CCL22 expression in a progressive course of cervical dysplasia

PURPOSE

An increasing infiltration of FoxP3-positive T-regs is associated with a higher grade of cervical intraepithelial neoplasia. The T-reg-recruiting chemokine CCL22 is expressed in various tumour entities. Aim of our study was to investigate the role of CCL22 in the progression and regression of cervical intraepithelial neoplasias, especially in patients with intermediate cervical intraepithelial neoplasias (CIN II). Furthermore, our aim was to characterize the CCL22-producing cells and explore the role of innate immunity in the process of cells recruitment.

METHODS

CCL22 expression was analyzed immunohistochemically in 169 patient samples. The immunoreactive score as well as the median numbers of positive cells were calculated in each slide and correlated with the histological CIN grade and FoxP3 expression. Additionally, CD68/CCL22 as well as CD68/PPARγ and CD68/FoxP3 expression were examined by double immunofluorescence. Statistical analysis was performed by SPSS 26.

RESULTS

A significantly higher expression of epithelial CCL22 in CIN II with progression in comparison to CIN II with regression (p = 0.006) could be detected. CCL22 was correlated with FoxP3 (Spearman's Rho: 0.308; p < 0.01). In 88%, CCL22-positive cells were positive for CD68, and 71% of CD68-positive macrophages expressed PPARγ. Colocalization of CD68 and FoxP3 was detected in 12%.

CONCLUSION

We could demonstrate that increased expression of CCL22, mainly produced by macrophages, correlates with elevated potential of malignancy. CCL22 expression could act as a predictor for regression and progression in cervical intraepithelial neoplasia, and it may help in the decision process regarding surgical treatment versus watchful waiting strategy in order to prevent conisation-associated risks. Furthermore, our findings support the potential of CCL22-producing cells as a target for immune therapy in cervical cancer patients.

Personalized approach to manage high-grade squamous intraepithelial lesion

Cervical cancer ranks 4th place among malignant neoplasms in the world in 2020. HPV is the main reason for cervical cancer. The «Gold standard» of cervical screening is an «HPV-testing + PAP-test» co-test. The immune system can clear HPV infection. Pathway of cervical cancer development is investigated, but immunity recognition of HPV is still incompletely studied. Toll-like receptors (TLRs) are membrane receptors on the cell membranes and membrane organelles. TLRs ligands could be bacterial, viral pathogens or toxins. When a ligand binds to TLRs, cytokines production is triggered. Chronic inflammation process down-regulates TLRs expression. This helps develop HPV infection. The current paper demonstrates how photodynamic therapy induces TLRs gene expression. A personal approach to estimating photodynamic therapy by an innate immune response in a clinical case is described. A 43-year-old woman with high-grade squamous intraepithelial lesion and 33rd type of HPV infection turned into a private clinic. The patient had complex check-ups before we defined a treatment strategy. Photodynamic therapy was performed as a non-invasive fertility-preserving treatment. We tested TLRs 2/3/4/8 gene expression before and after photodynamic therapy in 2 hours, one week and 6-month periods. PDT induces TLRs gene expression in a 6-month period. HPV elimination was achieved. The patient has no atypical cells in liquid-based cytology investigation after PDT.

Cervical Pre-cancers: Biopsy and Immunohistochemistry

The existence of precursor lesions for invasive cervical cancer has been recognized for more than 50 years. Our understanding of the pathobiology and behavior of cervical cancer precursors has evolved considerably over the past five decades. Furthermore, the terminology used to classify pre-invasive lesions of the cervix has frequently changed. The realization that human papillomavirus (HPV) infections constitute a morphologic continuum has prompted efforts to include them within a single classification system, specifically the squamous intraepithelial lesions (SILs) which have now been embraced by the surgical pathologists. The reduced number of specific pathological categories has made clinical decision-making more straightforward. The generic criteria for SIL have two important histological parameters: Alterations in the density of superficial epithelial cells and superficial squamous atypia. The flat condyloma or cervical intraepithelial neoplasia (CIN) I is generally associated with intermediate and high-risk HPV types as against the low-risk viruses that cause exophytic/papillary growth patterns of condylomas. The diagnosis of low-grade SIL (LSIL) (flat and exophytic condylomas) requires first excluding benign mimics of LSIL and second to confirm the characteristic cytologic atypia. For high-grade SILs (HSILs), the extent and degree of atypia generally exceed the limits of that described in flat or exophytic condylomas (LSILs). Less maturation, abnormal cell differentiation, loss of cell polarity, and increased mitotic index with abnormal mitotic figures occupying increasing thickness of the epithelium define a lesion as CIN II or CIN III. Atypical immature metaplasia associated with inflammation and atrophy is a challenge in cervical biopsy interpretation. Careful attention to the growth pattern of the epithelium, the distribution of the atypia, nuclear spacing, and the degree of anisokaryosis and the presence of enlarged hyperchromatic nuclei help in differentiating a non-neoplastic from a neoplastic process. This chapter describes in depth the diagnostic difficulties in the interpretation of cervical biopsies. It also provides useful criteria in distinguishing benign mimics from true precancerous lesions and the role of biomarkers such as the p16ink4 and Ki-67 in the differential diagnosis of precursor lesions and the reactive and metaplastic epithelium.

HPV types 16/18 L1 E6 and E7 proteins seropositivity and cervical cancer risk in HIV-positive and HIV-negative black South African women

BACKGROUND

In populations with high rates of human immunodeficiency virus (HIV)-coinfection, the nature of the relationship between human papillomavirus (HPV)-16 and -18 (L1, E6 and E7) antibodies and cervical cancer is still uncertain. We measured the association between seropositivity to HPV (L1, E6 and E7) proteins and cervical cancer among black South African women with and without HIV co-infection.

METHODS

We used questionnaire data and serum collected from consecutively recruited patients with a newly diagnosed cancer from the Johannesburg Cancer Study from 1346 cervical cancer cases and 2532 controls (diagnosed with other non-infection related cancers). Seropositivity to HPV proteins was measured using a multiplex serological assay based on recombinant glutathione S-transferase (GST) fusion proteins. We measured associations between their presence and cervical cancer using unconditional logistic regression models and evaluated the sensitivity and specificity of these HPV biomarkers.

RESULTS

Among controls, HIV-negative women from rural areas compared to urban had significantly higher HPV seroprevalence, HPV16 E7 (8.6% vs 3.7%) and HPV18 E7 (7.9% vs 2.0%). HPV16 E6 and E7 antibodies were positively associated with cervical cancer in HIV-positive (Adjusted Odds Ratio (AOR) = 33; 95% CI 10-107) and HIV-negative women (AOR = 97; 95% CI 46-203). In HIV-positive women, HPV E6/E7 antibodies had low sensitivity (43.0%) and high specificity (90.6%) for cervical cancer detection. In HIV-negative women, HPV E6/E7 antibodies sensitivity was 70.6% and specificity was 89.7%.

CONCLUSIONS

Our data show that HPV (L1, especially E6 and E7) antibody positivity is associated with cervical cancer in both HIV-positive and HIV-negative women. Nonetheless, being HIV-positive plays an important role in the development of cervical cancer.

The ‘Why and How’ of Cervical Cancers and Genital HPV Infection

Knowing about the virology of human papillomavirus (HPV) including its structure, functions and mechanism of infection, helps in understanding the disease process and morphology of precancerous lesions for cervical cancer. Two types of HPV, low- and high-risk type, adopt different mechanisms of infection which cannot be differentiated on morphological basis. In addition to HPV infection, many other factors such as genetic predisposition, hormonal factors, host immune response, and multiple sexual partners can modify the course and progression of the disease. The viral genome comprises early and late proteins. These early and late genes are expressed in particular course of time after initial infection. Various products of early genes (E1–E7) coordinate for completion of viral life cycle in maturing squamous epithelium by utilizing replication factors and DNA polymerase enzyme of the host cell nucleus. The late genes are mainly concerned with packaging of the viral particles and their release through mature squamous cells. The episomal form of infection seen in the low-risk group of viruses results in productive infection whereas the integrated form seen in high-risk group of viruses is the basis of disruption of host cell growth cycle by inactivating two important tumor suppressor genes p53 and Rb gene by products of E6 and E7 genes. Cervical precancerous lesions and cancer are the resultant effect of the accumulation of mutations. This article discusses the virology of HPV, pathogenesis of HPV infection, and various other factors modifying the disease course.

Role of FoxP3-positive regulatory T-cells in regressive and progressive cervical dysplasia

PURPOSE

Forkhead Box Protein 3 (FoxP3) is known as a key mediator in the immunosuppressive function of regulatory T-cells (Tregs). The aim of our study was to investigate whether FoxP3-positive Tregs have the potential to act as an independent predictor in progression as well as in regression of cervical intraepithelial neoplasia, especially in patients with intermediate cervical intraepithelial neoplasia (CIN II).

METHODS

Nuclear FoxP3 expression was immunohistochemically analysed in 169 patient samples (CIN I, CIN II with regressive course, CIN II with progressive course, CIN III). The median numbers were calculated for each slide and correlated with the histological CIN grade. Statistical analysis was performed by SPSS 26 (Mann-Whitney U test, Spearman's rank correlation).

RESULTS

An increased FoxP3 expression in CIN II with progression could be detected in comparison to CIN II with regression (p = 0.003). Total FoxP3 expression (epithelium and dysplasia-connected stroma) was higher in more advanced CIN grades (p < 0.001 for CIN I vs. CIN II; p = 0.227 for CIN II vs. CIN III). A positive correlation could be detected between FoxP3-positive cells in epithelium and total FoxP3 expression (Spearman's Rho: 0,565; p < 0.01).

CONCLUSION

Expression of FoxP3 could be a helpful predictive factor to assess the risks of CIN II progression. As a prognosticator for regression and progression in cervical intraepithelial lesions it might thereby help in the decision process regarding surgical treatment vs. watchful waiting strategy to prevent conisation-associated risks for patients in child-bearing age. In addition, the findings support the potential of Tregs as a target for immune therapy in cervical cancer patients.

Purple Sweet Potato Phytochemicals: Potential Chemo-preventive and Anticancer Activities

BACKGROUND: Purple sweet potato (PSP; Ipomoea batatas (L.) lam.) is a perennial plant from the morning glory family Convolvulaceae. This plant contains many functional compounds and a high concentration of anthocyanins and phenols, in contrast to other sweet potato plants of different colors. Both in vitro and in vivo studies have shown that parts of PSP have interesting functions in the setting of cancer. AIM: This article is a collective review of the potential properties of PSP in cancer, with an emphasis on its effects in breast, bladder, colorectal, liver, gastric, and cervical cancers.METHODS: Major English research databases, including PubMed, Web of Science, Scopus, and Google Scholar, were searched for studies evaluating the activity of PSP against cancer published ended in Mei 2020. RESULTS: The search yielded 72 articles relevant to this topic. Of note, PSP phytochemicals such anthocyanins and caffeoylquinic acid derivatives act as an antioxidant that scavenges free radicals and regulates the Keap1-Nrf2 signaling pathway, acts as an antimutagenic agent, and has anti-inflammatory activity by inhibiting activation of mitogen-activated protein kinases and the NF-κB pathway as a Chemo-preventive mechanism. Furthermore, PSP can promote apoptosis, cell cycle arrest, inhibit proliferation, cell growth inhibition, and inhibit cancer progression that actions collectively sum as anticancer activity in many cancer cells. The primary target-signaling pathway that is interfered by PSP is the phosphatidylinositol-3-kinase/protein kinase B pathway, which is a very common mutated pathway in cancer cells that regulates many physiologic processes inside the cells. CONCLUSION: As a promising medicinal plant that may serve as a Chemo-preventive and anticancer agent, further research on PSP is required to determine its clinical uses and potential as a food supplement.

Co-infection between genotypes of the human papillomavirus and Chlamydia trachomatis in Mexican women

Not all human papillomavirus (HPV) infections develop into cervical cancer (CC), so it is proposed that other factors may influence this, such as co-infection with Chlamydia trachomatis (CT). To identify the prevalence of co-infection, we included 189 women with suspicion of HPV. Viral typing was performed by carrying out the Roche HP Linear Array test, while CT detection was performed with the COBAS® TaqMan® 48 kit from Roche. Of the 189 women only 184 had an infection with HPV, CT or both: 56.6% were positive for one or several HPV genotypes, and 67.7% for CT. Clinical data showed an association between HPV and CIN I (n = 22; RR = 2.43; 95% CI 1.72-3.43, p < 0.05). CT infection was only associated with cervicitis (n = 40; RR = 1.73; 95% CI 1.34-2.23, p < 0.05). The CT-HPV co-infection rate was 28%. Co-infection revealed an association with CIN I (n = 31, RR= 3.33; 95% CI 2.08-5.34 p < 0.05), CIN III (n = 7; RR = 2.57; 95% CI 1.53-4.31, p < 0.05); and a significant risk of 2.3 (95% CI 1.08-4.90) times higher to develop CC; nevertheless, this risk was not statistically significant. CT/HPV co-infection was associated with the development of a high-grade lesion (CIN III) as well as an important risk for developing CC.

Nonlinear Optics with Near-Infrared Excitation Enable Real-Time Quantitative Diagnosis of Human Cervical Cancers

Histopathologic analysis through biopsy has been one of the most useful methods for the assessment of malignant neoplasms. However, some aspects of the analysis such as invasiveness, evaluation range, and turnaround time from biopsy to report could be improved. Here, we report a novel method for visualizing human cervical tissue three-dimensionally, without biopsy, fixation, or staining, and with sufficient quality for histologic diagnosis. Near-infrared excitation and nonlinear optics were employed to visualize unstained human epithelial tissues of the cervix uteri by constructing images with third-harmonic generation (THG) and second-harmonic generation (SHG). THG images enabled evaluation of nuclear morphology in a quantitative manner with six parameters after image analysis using deep learning. It was also possible to quantitatively assess intraepithelial fibrotic changes based on SHG images and another deep learning analysis. Using each analytical procedure alone, normal and cancerous tissue were classified quantitatively with an AUC ≥0.92. Moreover, a combinatory analysis of THG and SHG images with a machine learning algorithm allowed accurate classification of three-dimensional image files of normal tissue, intraepithelial neoplasia, and invasive carcinoma with a weighted kappa coefficient of 0.86. Our method enables real-time noninvasive diagnosis of cervical lesions, thus constituting a potential tool to dramatically change early detection. SIGNIFICANCE: This study proposes a novel method for diagnosing cancer using nonlinear optics, which enables visualization of histologic features of living tissues without the need for any biopsy or staining dye.

Key Molecular Events in Cervical Cancer Development

Cervical cancer is the fourth most common cancer among women. Infection by high-risk human papillomavirus (HPV) is the main aetiology for the development of cervical cancer. Infection by high-risk human papillomavirus (HPV) and the integration of the HPV genome into the host chromosome of cervical epithelial cells are key early events in the neoplastic progression of cervical lesions. The viral oncoproteins, mainly E6 and E7, are responsible for the initial changes in epithelial cells. The viral proteins inactivate two main tumour suppressor proteins, p53, and retinoblastoma (pRb). Inactivation of these host proteins disrupts both the DNA repair mechanisms and apoptosis, leading to rapid cell proliferation. Multiple genes involved in DNA repair, cell proliferation, growth factor activity, angiogenesis, as well as mitogenesis genes become highly expressed in cervical intraepithelial neoplasia (CIN) and cancer. This genomic instability encourages HPV-infected cells to progress towards invasive carcinoma. The key molecular events involved in cervical carcinogenesis will be discussed in this review.

Over Expressed TKTL1, CIP-2A, and B-MYB Proteins in Uterine Cervix Epithelium Scrapings as Potential Risk Predictive Biomarkers in HR-HPV-Infected LSIL/ASCUS Patients

High oncogenic risk human papillomaviruses (HR-HPVs) promote cervical carcinoma development, the fourth most common feminine cancer. A slow oncodevelopmental phase—defined histopathologically as Cervical Intraepithelial Neoplasia (CIN) grades 1–3, or cytologically as Low- or High-grade Squamous Intraepithelial Lesions (LSIL or HSIL)—precedes the malignancy. Cervical carcinoma screenings through HR-HPV genotyping and Pap smears are regularly performed in Western countries. Faulty cytology screening or genotyping or patients' non-compliance with follow-ups can let slip an oncoprogression diagnosis. Novel biomarker tests flanking HR-HPV genotyping and cytology could objectively predict the risk of disease progression thus helping triage LSIL/ASCUS patients. Here, anonymized leftovers of fresh cervical epithelium scrapings from twice (LSIL/ASCUS and HR-HPV DNA)-positive and twice (Pap smear- and HR-HPV DNA)-negative (control) patients in a proteome-preserving solution served to assess the biomarker worth of three cervical carcinoma-related proteins, i.e., B-MYB (or MYBL2), Cancerous Inhibitor of PP2A (CIP-2a), and transketolase-like1 (TKTL1). Leftovers anonymity was strictly kept and storage at −80°C, protein extraction, immunoblotting, and band densitometry were blindly performed. Only after tests completion, the anonymous yet code-corresponding HR-HPV-genotyping and cytology data allowed to assign each sample to the twice-positive or twice-negative group. Descriptive statistics showed that the three proteins levels significantly increased in the twice-positive vs. twice-negative scrapings. Diagnostic ROC curve analysis identified each protein's Optimal Decision Threshold (OTD) showing that TKTL1 and CIP-2a are stronger risk predictive biomarkers (Sensitivity, 0.91–0.93; Specificity, 0.77–0.83) than B-MYB. Logistic Regression coupled with Likelihood-Ratio Tests confirmed that a highly significant relation links increasing TKTL1/CIP-2a/B-MYB protein levels in twice-positive cervical scrapings to the risk of HR-HPV-driven oncoprogression. Finally, a 3 year clinical follow-up showed that 13 patients (50% of total) of the twice-positive group with biomarker values over OTDs compliantly underwent scheduled colposcopy and biopsy. Of these, 11 (i.e., 84.7%) received a positive histological diagnosis, i.e., CIN1 (n = 5; 38.5%) or CIN2/CIN2+ (n = 6; 46,2%). Therefore, TKTL1/CIP-2a/B-MYB protein levels could objectively predict oncoprogression risk in twice (HR-HPV- and Pap smear)-positive women. Further studies will assess the translatability of these findings into clinical settings.

Cervical Cancer and Its Precursors: A Preventative Approach to Screening, Diagnosis, and Management

Cervical cancer affects the cells lining the cervix, most commonly occurring in the cells of the transformation zone. Screening for cervical cancer looks to detect preinvasive disease, allowing for intervention before invasive disease develops. an assessment of individual risk factors, Selection of screening method depends on patient age, her screening history and results, and resources available. Screening has resulted in well-documented declines in cervical cancer incidence and mortality in the United States. Guidelines continue to evolve as new data emerge. Although cervical cancer prevention strategies include interventions directed toward limiting number of sexual partners, condom use, and reduction in cigarette smoking, vaccination represents the most direct targeted strategy.

Costs and cost-effectiveness of LEEP versus cryotherapy for treating cervical dysplasia among HIV-positive women in Johannesburg, South Africa

Background

Cervical cancer incidence is significant in countries, such as South Africa, with high burdens of both HIV and human papillomavirus (HPV). Cervical cancer is largely preventable if dysplasia is diagnosed and treated early, but there is debate regarding the best approaches for screening and treatment, especially for low-resource settings. Currently South Africa provides Pap smears followed by colposcopic biopsy and LEEP if needed in its public health facilities. We estimated the costs and cost-effectiveness of two approaches for treating cervical intraepithelial neoplasia grade 2 or higher (CIN2+) among HIV-infected women, most of whom were taking antiretroviral treatment, at a public HIV treatment facility in Johannesburg, South Africa.

Methods

Method effectiveness was derived from an intention-to-treat analysis of data gathered in a clinical trial completed previously at the study facility. In the trial, women who were diagnosed with CIN2+ and eligible for cryotherapy were randomized to cryotherapy or LEEP. If women were CIN2+ at six months as determined via Pap smear and colposcopic biopsy, all women—regardless of their original treatment assignment—received LEEP. “Cure” was then defined as the absence of disease at 12 months based on Pap smear and colposcopic biopsy. Health service costs were estimated using micro-costing between June 2013 and April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered, and results from an as-treated analysis were considered in sensitivity analysis.

Results

In total, 166 women with CIN2+ were enrolled (86 had LEEP; 80 had cryotherapy). At 12 months, cumulative loss to follow-up was 12.8% (11/86) for the LEEP group and 13.8% (11/80) for cryotherapy. Based on the unadjusted intention-to-treat analysis conducted for this economic evaluation, there was no significant difference in efficacy. At 12 months, 83.8% (95% CI 73.8–91.1) of women with CIN2+ at baseline and randomized to cryotherapy were free of CIN2+ disease. In contrast, 76.7% (95% CI 66.4–85.2) of women assigned to LEEP were free from disease. On average, women initially treated with cryotherapy were less costly per patient randomized at US$ 118.00 (113.91–122.10), and per case “cured” at US$ 140.90 (136.01–145.79). Women in the LEEP group cost US$ 162.56 (157.90–167.22) per patient randomized and US$ 205.59 (199.70–211.49) per case cured. In the as-treated analysis, which was based on trial data, LEEP was more efficacious than cryotherapy; however, the difference was not significant. Cryotherapy remained more cost-effective than LEEP in all sensitivity and scenario analyses.

Conclusions

For this cost-effectiveness analysis, using an intention-to-treat approach and taking into consideration uncertainty in the clinical and cost outcomes, a strategy involving cryotherapy plus LEEP if needed at six months was dominant to LEEP plus LEEP again at six months if needed for retreatment. However, compared to other studies comparing LEEP and cryotherapy, the efficacy results were low in both treatment groups–possibly due to the HIV-positivity of the participants. Further research is needed, but at present choosing the “right” treatment option may be less important than ensuring access to treatment and providing careful monitoring of treatment outcomes.

Papillary squamous cell carcinoma of the palatine tonsil: a rare cancer of the head and neck

Papillary squamous neoplasms of the upper respiratory tract are rare variants of squamous cell carcinomas. They are characterised by an exophytic, papillary growth and generally have favourable prognosis. The tumour has been described in the upper aerodigestive tract. In this context, most common sites of involvement are the larynx and hypopharynx, and rarely the oral cavity and oropharynx. The limited studies and small number of published cases of papillary squamous cell carcinoma of the palatine tonsil led us to make a complete analysis of this tumour by analysing the clinical, histological, radiological, virological and therapeutic aspects that are not always present in the literature. A case of papillary squamous cell carcinoma of the palatine tonsil is reported. The lesion (T2N0M0) was located into the left palatine tonsil that hung towards the oral cavity. Both HPV 16 DNA and E6/E7 mRNA were detected in the lesion. The clinicopathological profile of the neoplasm is presented and a comprehensive review of recent literature was made by analysing all aspects of interest of this neoplasm.

Cigarette Smoking Promotes Infection of Cervical Cells by High-Risk Human Papillomaviruses, but not Subsequent E7 Oncoprotein Expression

Persistent cervical infection with high-risk human papillomaviruses (hrHPVs) is a necessary, but not sufficient, condition for the development of cervical cancer. Therefore, there are other co-factors facilitating the hrHPV carcinogenic process, one of which is smoking. To assess the effect of smoking on high-risk (hr) HPV DNA positivity and on the expression of HPV E7 oncoprotein, as a surrogate of persistent hrHPV infection, we used data from women recruited for the PIPAVIR project, which examined the role of E7 protein detection in cervical cancer screening. Women were tested for hrHPV DNA, using Multiplex Genotyping (MPG), and E7 protein, using a novel sandwich ELISA method, and gave information on their smoking habits. Among 1473 women, hrHPV prevalence was 19.1%. The odds ratio (OR) for hrHPV positivity of smokers compared to non-smokers was 1.785 (95% confidence intervals (CI): 1.365–2.332, p < 0.001). The ORs for E7 positivity, concerning hrHPV positive women, ranged from 0.720 to 1.360 depending on the E7 detection assay used, but this was not statistically significant. Smoking increases the probability of hrHPV infection, and smoking intensity is positively associated to this increase. Smoking is not related to an increased probability of E7 protein positivity for hrHPV positive women.

Disparities in Cervical Cancer Incidence and Mortality: Can Epigenetics Contribute to Eliminating Disparities?

Screening for uterine cervical intraepithelial neoplasia (CIN) followed by aggressive treatment has reduced invasive cervical cancer (ICC) incidence and mortality. However, ICC cases and carcinoma in situ (CIS) continue to be diagnosed annually in the United States, with minorities bearing the brunt of this burden. Because ICC peak incidence and mortality are 10-15 years earlier than other solid cancers, the number of potential years of life lost to this cancer is substantial. Screening for early signs of CIN is still the mainstay of many cervical cancer control programs. However, the accuracy of existing screening tests remains suboptimal. Changes in epigenetic patterns that occur as a result of human papillomavirus infection contribute to CIN progression to cancer, and can be harnessed to improve existing screening tests. However, this requires a concerted effort to identify the epigenomic landscape that is reliably altered by HPV infection specific to ICC, distinct from transient changes.

mTOR downstream effectors, 4EBP1 and eIF4E, are overexpressed and associated with HPV status in precancerous lesions and carcinomas of the uterine cervix

The present study aims to investigate the expression levels of two critical mammalian target of rapamycin (mTOR) downstream effectors, 4E binding protein 1 (4EBP1) and eukaryotic initiation factor 4E (eIF4E) proteins, in precancerous squamous intraepithelial lesions and cancer of the uterine cervix, and their association with human papilloma virus (HPV) infection status. Uterine cervical biopsies from 73 patients were obtained, including 40 fresh-frozen samples and 42 archival formalin-fixed, paraffin-embedded tissue specimens. Whole protein extracts were analyzed for the expression of 4EBP1 and eIF4E proteins using western blotting. In addition, distribution of 4EBP1 and eIF4E protein expression and 4EBP1 phosphorylation (P-4EBP1) were analyzed by immunohistochemistry in archival tissues and correlated with the degree of dysplasia. The presence of high-risk HPV (HR-HPV) types was assessed by polymerase chain reaction. Using western blot analysis, high expression levels of 4EBP1 and eIF4E were observed in all uterine cervical carcinomas, which significantly correlated with the degree of dysplasia. By immunohistochemistry, overexpression of 4EBP1 and eIF4E was detected in 20 of 21 (95%) and 17 of 21 (81%) samples, respectively, in patients with high-grade dysplasia and carcinomas, compared with 1 of 20 (5%) and 2 of 20 (10%) samples, respectively, in patients with low-grade lesions or normal histology. All 4EBP1-positive cases tested were also positive for P-4EBP1. Furthermore, overexpression of 4EBP1 and eIF4E significantly correlated with the presence of HR-HPV oncogenic types. The present study demonstrated that critical effectors of mTOR signaling, which control protein synthesis initiation, are overexpressed in cervical high-grade dysplasia and cancer, and their levels correlate with oncogenic HPV types. These findings may provide novel targets for investigational therapeutic approaches in patients with cancer of the uterine cervix.

The Human Papillomavirus Vaccine: Current Perspective and Future Role in Prevention and Treatment of Anal Intraepithelial Neoplasia and Anal Cancer

The incidences of human papillomavirus (HPV)-related anal cancer and its precursor lesion, anal intraepithelial neoplasia, are rising in the U.S. and globally. Five-year survival rates with current modalities of treatment for anal cancer are generally favorable for localized and regional disease. For metastatic disease, the relative survival rate is poor. Major contributing factors for the increase in anal cancer incidence include increasing receptive anal intercourse (hetero- and homosexual), increasing HPV infections, and longer life expectancy of treated people who are seropositive for human immunodeficiency virus. Because treatment outcomes with systemic therapy in patients with advanced disease are so poor, prevention may be the best approach for reducing disease burden. The association of a major causative agent with anal cancer provides an excellent opportunity for prevention and treatment. The advent of the HPV vaccine for anal cancer prevention and treatment is a significant milestone and has the potential to greatly impact these cancers. The data regarding potential use of the HPV vaccine in anal cancer prevention and treatment are reviewed.

IMPLICATIONS FOR PRACTICE

The incidences of human papillomavirus (HPV)-related anal cancer and its precursor lesion, anal intraepithelial neoplasia, are on the rise in the U.S. and globally. Based on recent studies, the HPV vaccine is approved for prevention of the infection and development of HPV-related anal cancer. In addition, several small studies have shown that the vaccine may be useful as adjuvant therapy for anal cancer. There is a need for public health strategies aimed at education of both patients and practitioners to improve the use of the vaccine for prevention of HPV-related anal cancer. The development of a therapeutic vaccine is a work in progress.

Fiber-bundle microendoscopy with sub-diffuse reflectance spectroscopy and intensity mapping for multimodal optical biopsy of stratified epithelium

Early detection of structural or functional changes in dysplastic epithelia may be crucial for improving long-term patient care. Recent work has explored myriad non-invasive or minimally invasive "optical biopsy" techniques for diagnosing early dysplasia, such as high-resolution microendoscopy, a method to resolve sub-cellular features of apical epithelia, as well as broadband sub-diffuse reflectance spectroscopy, a method that evaluates bulk health of a small volume of tissue. We present a multimodal fiber-based microendoscopy technique that combines high-resolution microendoscopy, broadband (450-750 nm) sub-diffuse reflectance spectroscopy (sDRS) at two discrete source-detector separations (374 and 730 μm), and sub-diffuse reflectance intensity mapping (sDRIM) using a 635 nm laser. Spatial resolution, magnification, field-of-view, and sampling frequency were determined. Additionally, the ability of the sDRS modality to extract optical properties over a range of depths is reported. Following this, proof-of-concept experiments were performed on tissue-simulating phantoms made with poly(dimethysiloxane) as a substrate material with cultured MDA-MB-468 cells. Then, all modalities were demonstrated on a human melanocytic nevus from a healthy volunteer and on resected colonic tissue from a murine model. Qualitative in vivo image data is correlated with reduced scattering and absorption coefficients.

Costs and Cost Effectiveness of Three Approaches for Cervical Cancer Screening among HIV-Positive Women in Johannesburg, South Africa

Background

South Africa has high rates of HIV and HPV and high incidence and mortality from cervical cancer. However, cervical cancer is largely preventable when early screening and treatment are available. We estimate the costs and cost-effectiveness of conventional cytology (Pap), visual inspection with acetic acid (VIA) and HPV DNA testing for detecting cases of CIN2+ among HIV-infected women currently taking antiretroviral treatment at a public HIV clinic in Johannesburg, South Africa.

Methods

Method effectiveness was derived from a validation study completed at the clinic. Costs were estimated from the provider perspective using micro-costing between June 2013-April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered. Threshold analysis was used to explore the potential for reducing the cost of HPV DNA testing.

Results

VIA was least costly in both scenarios. In the higher volume scenario, the average cost per procedure was US$ 3.67 for VIA, US$ 8.17 for Pap and US$ 54.34 for HPV DNA. Colposcopic biopsies cost on average US$ 67.71 per procedure. VIA was least sensitive but most cost-effective at US$ 17.05 per true CIN2+ case detected. The cost per case detected for Pap testing was US$ 130.63 using a conventional definition for positive results and US$ 187.52 using a more conservative definition. HPV DNA testing was US$ 320.09 per case detected. Colposcopic biopsy costs largely drove the total and per case costs. A 71% reduction in HPV DNA screening costs would make it competitive with the conservative Pap definition.

Conclusions

Women need access to services which meet their needs and address the burden of cervical dysplasia and cancer in this region. Although most cost-effective, VIA may require more frequent screening due to low sensitivity, an important consideration for an HIV-positive population with increased risk for disease progression.

The human papillomavirus18 E7 protein inhibits CENP-C binding to α-satellite DNA

Human papillomavirus (HPV) infection leads to aneuploidy, a numerical chromosomal aberration that is caused by dysregulation of chromosomal segregation. We previously found that the E7 proteins of high-risk HPVs, but not of low-risk HPVs, could bind to centromere protein-C (CENP-C). In this study, we first found that CENP-C could bind centromere α-satellite DNAs using ChIP analysis and HA-tagged CENP-C/nuc transfected 293T cells. We then investigated if HA-CENP-C/nuc binding to α-satellite DNAs was affected by the E7 proteins of high- or low-risk HPVs. We found that transfection of the FLAG tagged HPV18 E7 inhibited the binding of HA-CENP-C/nuc to α-satellite DNAs. This finding was confirmed in HeLa S3 cells transfected with siRNA targeted to HPV18 E7 expression. We therefore speculate that altered function of kinetochores as a result of inhibition of CENP-C and α-satellite DNAs binding may be associated with the chromosomal abnormalities observed in HPV18-positive cancers.

Human papillomavirus species-specific interaction with the basement membrane-resident non-heparan sulfate receptor

Using a cell culture model where virus is bound to the extracellular matrix (ECM) prior to cell surface binding, we determined that human papillomavirus type 16 (HPV16) utilizes ECM resident laminin (LN) 332 as an attachment receptor for infectious entry. In presence of LN332, soluble heparin can function as ligand activator rather than competitive inhibitor of HPV16 infection. We also show that the ability to use LN332 binding as a productive attachment step for infectious entry is not conserved amongst HPV types. In the alpha genus, species 9 members (HPV16) attach to ECM via LN332, while members of species 7 (HPV18) are completely inhibited by heparin pre-incubation due to an inability to use LN332. Since HPV species 7 and 9 are preferentially associated with adenocarcinoma and squamous cell carcinoma of the cervix, respectively, our data provide first evidence that pre-entry events may contribute to the anatomical-site preference of HPV species.

Viral carcinogenesis: factors inducing DNA damage and virus integration

Viruses are the causative agents of 10%-15% of human cancers worldwide. The most common outcome for virus-induced reprogramming is genomic instability, including accumulation of mutations, aberrations and DNA damage. Although each virus has its own specific mechanism for promoting carcinogenesis, the majority of DNA oncogenic viruses encode oncogenes that transform infected cells, frequently by targeting p53 and pRB. In addition, integration of viral DNA into the human genome can also play an important role in promoting tumor development for several viruses, including HBV and HPV. Because viral integration requires the breakage of both the viral and the host DNA, the integration rate is believed to be linked to the levels of DNA damage. DNA damage can be caused by both endogenous and exogenous factors, including inflammation induced by either the virus itself or by co-infections with other agents, environmental agents and other factors. Typically, cancer develops years to decades following the initial infection. A better understanding of virus-mediated carcinogenesis, the networking of pathways involved in transformation and the relevant risk factors, particularly in those cases where tumorigenesis proceeds by way of virus integration, will help to suggest prophylactic and therapeutic strategies to reduce the risk of virus-mediated cancer.

Is there a gain in chromosome 3q in the pathway to anal cancer?

BACKGROUND

Chromosome 3q gain has been identified in human papillomavirus-infected cervical cancer cells.

OBJECTIVE

We sought to identify the presence of chromosomal 3q gain in anal neoplasia.

DESIGN

This was a retrospective cohort.

SETTINGS

The study was conducted in a group colorectal surgery practice.

PATIENTS

Fifty-two patients with no dysplasia, low-grade dysplasia, high-grade dysplasia, or anal cancer were studied.

INTERVENTIONS

Pairs of biopsy specimens were paraffin embedded and reviewed. One of each slide pair was stained with hematoxylin and eosin and the second processed for fluorescence in situ hybridization. The hybridized set was deparaffinized first and then hybridized with a probe for the chromosome 3q26 region. Then, slides were scanned using an automated fluorescence microscopy system that analyzed defined areas of the tissue to enumerate all of the nuclei for hybridized probe signals to detect chromosome 3q gain.

MAIN OUTCOME MEASURES

We measured for gain in chromosome 3q26.

RESULTS

We identified chromosome 3q gain in 7 (78%) of 9 patients with squamous-cell cancer, 8 (53%) of 15 high-grade dysplasia samples, 0 of 12 low-grade dysplasia samples, and 0 of 16 samples with no dysplasia. The sensitivity for high-grade or invasive neoplasia was 58%, with a specificity of 100%. The positive predictive value of the test was 100% for detecting high-grade dysplasia and/or squamous-cell cancer from no dysplasia, and the negative predictive value of the test was 62%.

LIMITATIONS

This study was limited by its small sample size and retrospective design.

CONCLUSIONS

Chromosome 3q gain represents an important shared pathway to tumorigenesis in cervical and anal neoplasia. Multiple potential diagnostic roles exist for this easily performed test in the evaluation of anal neoplasia.

Knowledge, attitude and practice of the pap smear as a screening procedure among nurses in a tertiary hospital in north eastern India

BACKGROUND

Cancer of the uterine cervix is one of the most common cancers among women worldwide. Industrialized countries have dramatically reduced the incidence of mortality from cervical carcinoma in the last 50 years through aggressive screening programs utilizing pelvic examinations and Papanicolaou (Pap) smears but it still remains a major problem in the developing world.

OBJECTIVES

This study was performed to determine knowledge, attitude and practice of Pap smear as a screening procedure among nurses in a tertiary hospital in north eastern India.

MATERIAL AND METHODS

This cross sectional study was carried out with a questionnaire survey covering the socio demographic factors, knowledge, attitude and practices about Pap smear screening among 224 nurses in Regional Institute of Medical Sciences, Imphal, Manipur, India during December 2011.

RESULTS

Two hundred and twenty one participants (98.6%) had heard about cervical carcinoma but 18.3% lacked adequate knowledge regarding risk factors. Knowledge about the Pap smear was adequate in 88.8% of the respondents. Out of these, only 11.6% had Pap smear at least once previously. The most common reasons for non-participation in screening were lack of any symptoms (58.4%), lack of counselling (42.8%), physician does not request (29.9%) and fear of vaginal examination (20.5%).

CONCLUSION

Although knowledge of Pap smear as a screening procedure for cervical cancer is high, practice is still low. The nurses who should be responsible for opportunistic screening of women they care for are not keen on getting screened themselves. If we can improve the practice of Pap smear screening in such experts, they should be able to readily provide appropriate and accurate information and motivate the general population to join screening programs.

Impact of HPV immunization on the detection of cervical disease

Human papillomavirus (HPV) is the primary cause of cervical cancer and genital warts. The development of HPV vaccines has been a major advance in the prevention of these diseases. Recent studies have shown promising early effects of HPV immunization programs on cervical abnormalities and genital warts, with evidence of herd immunity against genital warts also emerging in Australia. Further studies are required to not only continue monitoring the effect of the HPV immunization on the incidence of these diseases, but also to establish the effect the immunization will have on cervical screening programs and the performance of colposcopy.

Concomitant high-grade prostatic intraepithelial neoplasia is associated with good prognosis factors and oncologic outcome after radical prostatectomy

OBJECTIVES

To assess correlations between concomitant high-grade prostatic intraepithelial neoplasia (HGPIN), pathological features and oncologic outcomes after radical prostatectomy (RP).

MATERIAL AND METHODS

We prospectively collected a single-institution database of 2,351 patients who underwent RP between 1998 and 2011.

RESULTS

1,272 (54.1%) patients had HGPIN on specimens. The mean follow-up was 28 months. Presence of HGPIN was significantly associated with a favorable preoperative risk status and with pathological factors of poor prognosis in RP specimens. Patients without HGPIN had a worse biochemical recurrence-free survival compared with those with HGPIN in RP specimen (log-rank test: p = 0.015). The 3-year RFS rate was 73.9% for the HGPIN group versus 67.2%. The absence of HGPIN was also significantly correlated with the use of androgen deprivation treatment during the follow-up (p < 0.001). In Cox multivariate analysis, taking into account the other prognostic pathological factors, HGPIN was not an independent predictive factor for PSA failure (p = 0.868).

CONCLUSION

HGPIN is associated with factors of good prognosis but fails to show independent significance when classical pathological prognostic factors are taken into account.

The role of human papillomavirus in nongenital cancers

Human papillomavirus (HPV), one of the most common sexually transmitted diseases worldwide, has an established role in the pathogenesis of genital malignancies such as cervical cancer. The virus has also been implicated in the oncogenesis of nongenital cancers including head and neck malignancies (specifically oropharyngeal cancers) as well as anal cancer. There is less clarity regarding its role in lung and esophageal cancers. Worldwide, the incidence and prevalence of HPV-associated oropharyngeal cancer has been increasing over time. These patients have improved outcomes compared with those with HPV-negative oropharyngeal cancers, and there is continued interest in designing treatments specifically for this HPV-positive subgroup. Clinicians continue to gain an understanding of HPV in anal cancers and the risk factors associated with infection and progression to malignancy. This has potential implications for the eventual screening of high-risk groups. While HPV vaccination is currently approved for the prevention of cervical cancer, it also has potential in the prevention of all HPV-associated malignancies. In this review, current understanding of the role of HPV in nongenital cancers is discussed, as well as future implications for treatment and prevention.

HLA-DP genetic variation, proxies for early life immune modulation and childhood acute lymphoblastic leukemia risk

The human leukocyte antigen (HLA) genes are candidate genetic susceptibility loci for childhood acute lymphoblastic leukemia (ALL). We examined the effect of HLA-DP genetic variation on risk and evaluated its potential interaction with 4 proxies for early immune modulation, including measures of infectious exposures in infancy (presence of older siblings, daycare attendance, ear infections) and breastfeeding. A total of 585 ALL cases and 848 controls were genotyped at the HLA-DPA1 and DPB1 loci. Because of potential heterogeneity in effect by race/ethnicity, we included only non-Hispanic white (47%) and Hispanic (53%) children and considered these 2 groups separately in the analysis. Logistic regression analyses showed an increased risk of ALL associated with HLA-DPB1*01:01 (odds ratio [OR] = 1.43, 95% CI, 1.01-2.04) with no heterogeneity by Hispanic ethnicity (P = .969). Analyses of DPB1 supertypes showed a marked childhood ALL association with DP1, particularly for high-hyperdiploid ALL (OR = 1.83; 95% CI, 1.20-2.78). Evidence of interaction was found between DP1 and older sibling (P = .036), and between DP1 and breastfeeding (P = .094), with both showing statistically significant DP1 associations within the lower exposure categories only. These findings support an immune mechanism in the etiology of childhood ALL involving the HLA-DPB1 gene in the context of an insufficiently modulated immune system.

The PxDLLCxE sequence in conserved region 2 of human papilloma virus 18 protein E7 is required for E7 binding to centromere protein C

High-risk human papillomaviruses (HPVs) are etiologically linked to human cervical and oral cancers. HPV infection leads to aneuploidy, a numerical chromosomal aberration caused by dysregulation of chromosomal segregation. We found that high-risk HPV18 and HPV58 E7 proteins bind to centromere protein C (CENP-C), a component of the kinetochore that is essential for proper chromosomal segregation. Low-risk HPV4, HPV6, and HPV11 E7s do not bind to CENP-C. The PxDLLCxE sequence in conserved region 2 (CR2) of HPV18 E7 is required for E7 binding to CENP-C. Our results indicate that differences in the ability of high- and low-risk HPV E7s to bind to CENP-C reflect the different oncogenic potentials of high- and low-risk type HPVs.

Lipoprotein lipase is frequently overexpressed or translocated in cervical squamous cell carcinoma and promotes invasiveness through the non-catalytic C terminus

Background:

We studied the biological significance of genes involved in a novel t(8;12)(p21.3;p13.31) reciprocal translocation identified in cervical squamous cell carcinoma (SCC) cells.

Methods:

The rearranged genes were identified by breakpoint mapping, long-range PCR and sequencing. We investigated gene expression in vivo using reverse-transcription PCR and tissue microarrays, and studied the phenotypic consequences of forced gene overexpression.

Results:

The rearrangement involved lipoprotein lipase (LPL) and peroxisome biogenesis factor-5 (PEX5). Whereas LPL–PEX5 was expressed at low levels and contained a premature stop codon, PEX5–LPL was highly expressed and encoded a full-length chimeric protein (including the majority of the LPL coding region). Consistent with these findings, PEX5 was constitutively expressed in normal cervical squamous cells, whereas LPL expression was negligible. The LPL gene was rearranged in 1 out of 151 cervical SCCs, whereas wild-type LPL overexpression was common, being detected in 10 out of 28 tissue samples and 4 out of 10 cell lines. Forced overexpression of wild-type LPL and PEX5–LPL fusion transcripts resulted in increased invasiveness in cervical SCC cells, attributable to the C-terminal non-catalytic domain of LPL, which was retained in the fusion transcripts.

Conclusion:

This is the first demonstration of an expressed fusion gene in cervical SCC. Overexpressed wild-type or translocated LPL is a candidate for targeted therapy.

Near-infrared Raman Microspectroscopy Detects High-risk Human Papillomaviruses

BACKGROUND

Detecting human papillomaviruses (HPVs) infection in cervical cells is an exceedingly important part of the clinical management of cervical dysplasia. Current guidelines in women's health outline the need for both the Papanicolaou test as well as high-risk HPV testing. Testing for HPV is expensive, is time-consuming, and requires experienced technicians.

METHODS

Two sets of near-infrared Raman microspectroscopy experiments were conducted using a Raman confocal microscope system. First, Raman spectra were acquired from four different cell culture lines, two positive for HPV (HeLa, SiHa), one negative for HPV, but malignant (C33A), and one normal, HPV-negative line (NHEK). The three malignant lines were all derived from cervical cells. Second, Raman spectra were acquired from deidentified patient samples that were previously tested for the presence of high-risk HPV.

RESULTS

The spectra from the cell culture lines and the patient samples contained many statistically significant differences. Using sparse multinomial logistic regression to classify the data led to classification accuracies of 89% to 97% for the cell culture samples and 98.5% for the patient samples.

CONCLUSIONS

Raman micro-spectroscopy can be used to detect HPV and differentiate among specific HPV strains. This technique may provide health providers with a new method for quickly testing cell samples for the presence of HPV.

Metastatic endocervical adenocarcinoma in a western lowland gorilla (Gorilla g. gorilla): no evidence of virus-induced carcinogenesis

BACKGROUND

Cervical Cancer is the second most common cancer among women. Nevertheless, similar tumours have only been rarely described in Great Apes. This report characterizes the pathological and molecular features of a metastatic endocervical adenocarcinoma in a Western lowland gorilla (Gorilla g. gorilla).

METHODS

Necropsy and histopathology was performed to identify the cause of the disease in an cachectic 50-year-old western lowland gorilla. Immunohistochemistry for Ki67, oestrogen receptor alpha and ERBB2 was performed to characterize the tumor. In addition, Pan-herpesvirus and Pan-papillomavirus PCR were used to identify a possible viral cause.

RESULTS

The endoccervical carcinoma showed a severe metastatic spread to the lung, brain and bone and was herpesvirus and papillomavirus-negative. Most tumor cells were ERBB2-positive, 15% of tumor cells were Ki67-positive and only few tumor cells had oestrogen receptor alpha expression.

CONCLUSIONS

Histopathologically and immunohistochemically, the tumour had striking similarities to human endocervicial adenocarcinomas of the common type. However, PCR analysis failed to identify herpes- or papillomaviral DNA in the tumor at the time of necropsy, thus leaving the question for cause of the disease open.

Diagnostic efficacy of backscattering intensity measurements in optical coherence tomography of cervical intraepithelial dysplasia

BACKGROUND AND OBJECTIVES

The aim of this study was to determine the diagnostic efficacy of backscattering intensity measurements in optical coherence tomography in identifying different grades of cervical intraepithelial dysplasia.

STUDY DESIGN/MATERIALS AND METHODS

OCT images were taken from 153 unsuspicious and suspicious areas of 30 fresh conisation and hysterectomy specimens, evaluated by two blinded investigators using a six-grade classification (normal, inflammation, CIN1, CIN2, CIN3, squamous carcinoma) and later compared to the corresponding histology. Differences between judgments based on either the histology or the OCT images were investigated employing Correspondence Analysis (CA). Further, we explored the extent as to which backscattering intensity profiles of OCT images contained the essential information required for a reliable and valid diagnosis, using Linear Discriminant Analysis (LDA).

RESULTS

The CA of histology- and OCT-based judgments suggests that the diagnostic process may be characterized in terms of two stochastically independent underlying ("latent") variables, the first of them reflecting the definiteness with which CIN classes are identified, the second reflecting a bias towards diagnosing inflammation on the side of the OCT-based judgments. This finding is supported by the results of LDAs, where histology and OCT categorizations differ in particular with respect to the positions of inflammation and CIN1. Possibly, a second canonical variable has to be assumed accounting for the evaluation of carcinoma.

CONCLUSIONS

The systematic differences between histology-based and OCT-based diagnoses suggest that the use of available information is influenced by perceptual and/or cognitive biases. Apart from this it seems that the profiles appear to provide a remarkably large amount of information determining the main course of the diagnostic process.

Co-expression of metalloproteinases 11 and 12 in cervical scrapes cells from cervical precursor lesions

The metalloproteinases (MMP) 11 and 12 have been shown to be expressed in cervical cancer (CC). In order to extend our previous results, these MMPs were evaluated in cervical precursor lesions. One hundred seventeen cervical scrapes: thirty-six normal, thirty-six low grade squamous lesions (LSIL), thirty-six high grade (HSIL), nine CC; and, also ninety-nine paraffin-embedded cervical lesions: fifteen normal cervices, thirty eight LSIL, sixteen HSIL, and five CC were collected. The samples were analyzed for relative expression by real time RT-PCR or immunohistochemistry assay. We were able to identify a relative increased expression of MMP11 in 75% and 78% from LSIL and HSIL samples, respectively. While MMP12 expression was 64% and 75% in LSIL and HSIL, respectively. Positive samples for MMP11 expression were also positive for MMP12 expression and also increased according to illness progression. In the tissues, MMP11 or MMP12 expression was observed in the cytoplasm of the neoplastic cells, while in the normal epithelium was absent. The reaction was always stronger for MMP12 than MMP11. MMP11 expression was present in 77% and 66% of LSIL and HSIL, while MMP12 expression was 73% and 68%. There was a relationship between MMP11 or MMP12 expression and HPV infection. Our data are showing a relationship between diagnostic of precursor lesions and the MMP11 and 12 expressions, suggesting that their expression could be an early event in the neoplastic lesions of the cervix and could have clinical significance.

Cervical cytology and histopathologic abnormalities in women living with AIDS in São Paulo, Brazil

BACKGROUND

Women living with HIV/AIDS present with a higher prevalence of human papillomavirus (HPV) infection, higher rates of squamous intraepithelial lesions, and are more susceptible to invasive cervical carcinoma progression.

OBJECTIVE

We assessed the frequency of precursory cervical lesions of cancer and its risk factors for women living with HIV/AIDS.

METHODS

Sociodemographic, clinical, behavioral, and laboratory data were collected from medical records from 2008 to 2009 and analyzed using forward stepwise logistic regression.

RESULTS

Medical records of 631 women were reviewed; mean age at AIDS diagnosis was 34 years old (interquartile range = 29-40 years old), 32% were <16 years old at first sexual intercourse; 61% had ≤5 sexual partners during life; 43% had been living with AIDS for ≥9 years; 47% reported previous sexually transmitted infections; 44% presented with HPV infection; and 10% presented with high squamous intraepithelial lesions. Presenting high squamous intraepithelial lesions was significantly associated with home district Human Development Index, age at AIDS diagnosis (>40 years old), time of AIDS diagnosis (>8 years), CD4 cell count <350/mm, and HPV infection.

CONCLUSIONS

Frequent squamous intraepithelial neoplasia in these women shows the importance of gynecologic examinations in routine care and follow-up required by those who present with cervical lesions.

Knowledge of cervical cancer and screening practices of nurses at a regional hospital in Tanzania

BACKGROUND

Cervical cancer, the most common cancer among women in Tanzania is strongly linked to Human Papilloma Virus. Precancerous lesions can be detected by Papanicolau smear screening. Nurses, being the largest group of health workers, have an important role in promotion of cervical cancer screening.

OBJECTIVES

To determine nurses' awareness of cervical cancer and their own screening practices at a hospital in Tanzania.

METHODS

A descriptive cross sectional study using questionnaires on 137 nurses. Data analysis was made by descriptive statistics and chi square tests.

RESULTS

Less than half of the nurses had adequate knowledge regarding cervical cancer. There was a significant association between knowledge levels of causes of cervical cancer and transmission of HPV and age. Knowledge was more adequate among the young nurses (p = 0.027) and knowledge differed significantly between cadres. Registered nurses had more adequate knowledge than enrolled nurses (p = 0.006). The majority did not know screening intervals and a few were aware of HPV vaccine. Most nurses (84.6%) had never had a Pap smear examination.

CONCLUSION

These results reflect a need for continuing medical education, creation of cervical cancer prevention policies and strategies at all levels of the health sector.

Identification and validation of genes involved in cervical tumourigenesis

Background

Cervical cancer is the most common cancer among Indian women. This cancer has well defined pre-cancerous stages and evolves over 10-15 years or more. This study was undertaken to identify differentially expressed genes between normal, dysplastic and invasive cervical cancer.

Materials and methods

A total of 28 invasive cervical cancers, 4 CIN3/CIS, 4 CIN1/CIN2 and 5 Normal cervix samples were studied. We have used microarray technique followed by validation of the significant genes by relative quantitation using Taqman Low Density Array Real Time PCR. Immunohistochemistry was used to study the protein expression of MMP3, UBE2C and p16 in normal, dysplasia and cancers of the cervix. The effect of a dominant negative UBE2C on the growth of the SiHa cells was assessed using a MTT assay.

Results

Our study, for the first time, has identified 20 genes to be up-regulated and 14 down-regulated in cervical cancers and 5 up-regulated in CIN3. In addition, 26 genes identified by other studies, as to playing a role in cervical cancer, were also confirmed in our study. UBE2C, CCNB1, CCNB2, PLOD2, NUP210, MELK, CDC20 genes were overexpressed in tumours and in CIN3/CIS relative to both Normal and CIN1/CIN2, suggesting that they could have a role to play in the early phase of tumorigenesis. IL8, INDO, ISG15, ISG20, AGRN, DTXL, MMP1, MMP3, CCL18, TOP2A AND STAT1 were found to be upregulated in tumours. Using Immunohistochemistry, we showed over-expression of MMP3, UBE2C and p16 in cancers compared to normal cervical epithelium and varying grades of dysplasia. A dominant negative UBE2C was found to produce growth inhibition in SiHa cells, which over-expresses UBE2C 4 fold more than HEK293 cells.

Conclusions

Several novel genes were found to be differentially expressed in cervical cancer. MMP3, UBE2C and p16 protein overexpression in cervical cancers was confirmed by immunohistochemistry. These will need to be validated further in a larger series of samples. UBE2C could be evaluated further to assess its potential as a therapeutic target in cervical cancer.

TP53 genetic polymorphisms and environmental risk factors associated with cervical carcinogenesis in a cohort of Brazilian women with cervical lesions

The purpose of this study was to determine the prevalence of TP53 polymorphism at codon 72 and its association with environmental risk factors in a sample of women in Rio de Janeiro, Brazil. A cross-sectional study was conducted with 304 women with histological diagnoses of negative, precancerous, and cancerous lesions between October 2004 and May 2006. Antecedents of exposure to environmental risk factors were ascertained through an interview-administered questionnaire, and whenever indicated, colposcopy tests and lesion excisions were performed. Genomic DNA was extracted from leukocytes of peripheral blood subjects, and genotyping of TP53 polymorphism was conducted using polymerase chain reaction and restriction fragment-length polymorphism methods. Crude and adjusted odds ratios (OR) and their 95% confidence intervals (CI) were ascertained for selected risk factors and allelic groups among control, low-grade squamous intraepithelial lesion (LSIL), and high-grade squamous intraepithelial lesion (HSIL)/cancer strata, using logistic regression analysis. The TP53 polymorphism distribution in this population was 64 (21.1%) Arg/Arg, 55 (18.1%) Pro/Pro, and 185 (60.9%) Arg/Pro. Women who were heterozygous (Arg/Pro) showed an independent risk for cervical HSIL/cancer (adjusted OR: 1.92, 95%CI: 1.03-1.59, controlled for age, ethnicity, and age at menarche) compared to Pro/Pro genotypic women. Age at sexual onset up to 16 yr old (adjusted OR: 1.97, 95%CI: 1.18-3.3), lifelong 3-4 sexual partners (adjusted OR: 2.38, 95%CI: 1.32-4.28), current smoking (adjusted OR: 2.32, 95%CI: 1.31-4.13), and smoking more than 10 yr (adjusted OR: 2.52, 95%CI: 1.042-6.09) were found to be independent risk factors for cervical HSIL/cancer. Women possessing the Arg/Pro genotype presented a higher risk for HSIL/cancer development compared to Pro/Pro genotypic women in the sample studied after control for selected confounders. Early sexual onset, multiple sexual partners, and current and past tobacco smoking were independent risk factors for HSIL/cancer development.

A 7 gene expression score predicts for radiation response in cancer cervix

BACKGROUND

Cervical cancer is the most common cancer among Indian women. The current recommendations are to treat the stage IIB, IIIA, IIIB and IVA with radical radiotherapy and weekly cisplatin based chemotherapy. However, Radiotherapy alone can help cure more than 60% of stage IIB and up to 40% of stage IIIB patients.

METHODS

Archival RNA samples from 15 patients who had achieved complete remission and stayed disease free for more than 36 months (No Evidence of Disease or NED group) and 10 patients who had failed radical radiotherapy (Failed group) were included in the study. The RNA were amplified, labelled and hybridized to Stanford microarray chips and analyzed using BRB Array Tools software and Significance Analysis of Microarray (SAM) analysis. 20 genes were selected for further validation using Relative Quantitation (RQ) Taqman assay in a Taqman Low-Density Array (TLDA) format. The RQ value was calculated, using each of the NED sample once as a calibrator. A scoring system was developed based on the RQ value for the genes.

RESULTS

Using a seven gene based scoring system, it was possible to distinguish between the tumours which were likely to respond to the radiotherapy and those likely to fail. The mean score +/- 2 SE (standard error of mean) was used and at a cut-off score of greater than 5.60, the sensitivity, specificity, Positive predictive value (PPV) and Negative predictive value (NPV) were 0.64, 1.0, 1.0, 0.67, respectively, for the low risk group.

CONCLUSION

We have identified a 7 gene signature which could help identify patients with cervical cancer who can be treated with radiotherapy alone. However, this needs to be validated in a larger patient population.