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Sheth SS, Oh JE, Bellone S, Siegel ER, Greenman M, Mutlu L, McNamara B, Pathy S, Clark M, Azodi M, Altwerger G, Andikyan V, Huang G, Ratner E, Kim DJ, Iwasaki A, Levi AW, Buza N, Hui P, Flaherty S, Schwartz PE, Santin AD. Randomized Phase II Trial of Imiquimod with or without 9-Valent HPV Vaccine versus Observation in Patients with High-grade Pre-neoplastic Cervical Lesions (NCT02864147). Clin Cancer Res 2024; 30:1768-1777. [PMID: 38592381 DOI: 10.1158/1078-0432.ccr-23-3639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/31/2024] [Accepted: 03/06/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE We report the results of a randomized phase II trial of imiquimod, a topical immune-response modulator versus imiquimod plus a 9-valent human papillomavirus (HPV) vaccine (9vHPV) versus clinical surveillance in cervical intraepithelial neoplasia (CIN2/3) patients. PATIENTS AND METHODS We randomly allocated 133 patients with untreated CIN2/3 in equal proportions to a 4-month treatment with self-applied vaginal suppositories containing imiquimod (Arm B) or imiquimod plus a 9vHPV (Arm C) versus clinical surveillance (Arm A). The main outcome was efficacy, defined as histologic regression to CIN1 or less. Secondary outcomes were HPV clearance and tolerability. Exploratory objectives included the comparison of cervical CD4/CD8 T-cell infiltration at baseline, mid-study, and posttreatment by flow cytometry among study arms. RESULTS Of the 114 evaluable patients 77% and 23% harbored CIN2 and CIN3, respectively. Regression to CIN1 or less was observed in 95% of patients in the imiquimod group (Arm B) compared with 79% in the control/surveillance (Arm A); P = 0.043 and 84% in the imiquimod+9vHPV group (Arm C; P = 0.384 vs. Arm A). Neither of the treatment-arm differences from Arm A reached the prespecified α = 0.025 significance level. No significant differences were noted in the secondary outcome of rate of HPV clearance. The number of tissue-resident memory CD4/CD8 T cells in cytobrush samples demonstrated a >5-fold increase in Arm B/imiquimod when compared with Arm A/surveillance (P < 0.01). In contrast, there was no significant difference in T-cell responses among participants in Arm C when compared with Arm A. Imiquimod treatment was well tolerated. CONCLUSIONS Although imiquimod induced a higher regression to CIN1 or less and significant increases in CD4/CD8 T cells infiltrating the cervix, it did not meet its prespecified statistical outcome for efficacy. A higher regression rate than expected was observed in the surveillance arm of this prospective trial. Future clinical trials with imiquimod targeting CIN3 patients are warranted.
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Affiliation(s)
- Sangini S Sheth
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Specialties and Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Ji Eun Oh
- Laboratory of Skin and Mucosal Immunology, Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of South Korea
| | - Stefania Bellone
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Eric R Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michelle Greenman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Levent Mutlu
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Blair McNamara
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Shefali Pathy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Specialties and Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Mitchell Clark
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Masoud Azodi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Gary Altwerger
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Vaagn Andikyan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Gloria Huang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Elena Ratner
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Daniel J Kim
- Department of Immunobiology, Yale University, New Haven, Connecticut
- Howard Hughes Medical Institute, Chevy Chase, Maryland
| | - Akiko Iwasaki
- Department of Immunobiology, Yale University, New Haven, Connecticut
- Howard Hughes Medical Institute, Chevy Chase, Maryland
| | - Angelique W Levi
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Natalia Buza
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Pei Hui
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Sean Flaherty
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Specialties and Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Peter E Schwartz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Alessandro D Santin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecologic Oncology, Smilow Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
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Liu S, Zhang W, Wang W, Zheng J. Topical delivery of drugs in the treatment of high-grade cervical squamous intraepithelial lesions: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024; 296:131-139. [PMID: 38432019 DOI: 10.1016/j.ejogrb.2024.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/01/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE The present study aims to evaluate the efficacy and effect of localized delivery of drugs in the treatment of high-grade squamous intraepithelial lesion (HSIL) based on a meta-analysis. STUDY DESIGN Databases including Cochrane Library, PubMed, Embase, Scopus, CNKI, and Wanfang were searched from their inception till August 2022. Randomized controlled trials (RCTs) that compared the efficacy of drugs and surgery in the treatment of HSIL were collected. A meta-analysis was performed using the software of Review Manager (version 5.4.1). RESULTS Eight RCTs involving 523 patients were included in the meta-analysis. For HSIL, the rate of cervical lesions histological regression was 69.85 % in the surgery group and 59.88 % in the drug group, there was no significant difference between the two groups [OR = 0.45, 95 % CI (0.07, 3.03), P = 0.41]. The histological regression rate of cervical lesions in the placebo group was 37.76 %, and the difference between the drug group and the placebo group was statistically significant [OR = 4.94, 95 % CI (2.65, 9.20), P < 0.00001]. CONCLUSION A total of four drugs were involved in the eight RCTS included in this study, which were imiquimod, 5-fluorouracil (5-FU), cidofovir and interferon. The results showed that although drug administration was effective in the histological regression of HSIL, the efficacy was less than about 10% of surgical treatment. Considering the recurrence of the disease after surgery and the problems of abortion, premature delivery and premature rupture of membranes after cervical conization in reproductive women, drug therapy can be used as a supplement to surgery or conservative treatment to promote the histological regression of cervical lesions in patients with HSIL.
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Affiliation(s)
- Shixuan Liu
- Chenggong Hospital (the 73th Group Military Hospital of People's Liberation Army) Affiliated to Xiamen University, China
| | - Wenlei Zhang
- Chenggong Hospital (the 73th Group Military Hospital of People's Liberation Army) Affiliated to Xiamen University, China
| | - Wenyan Wang
- Chenggong Hospital (the 73th Group Military Hospital of People's Liberation Army) Affiliated to Xiamen University, China
| | - Jianlan Zheng
- Chenggong Hospital (the 73th Group Military Hospital of People's Liberation Army) Affiliated to Xiamen University, China.
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Hamar B, Teutsch B, Hoffmann E, Hegyi P, Harnos A, Nyirády P, Hunka Z, Ács N, Bánhidy F, Melczer Z. Imiquimod Is Effective in Reducing Cervical Intraepithelial Neoplasia: A Systematic Review and Meta-Analysis. Cancers (Basel) 2024; 16:1610. [PMID: 38672691 PMCID: PMC11048968 DOI: 10.3390/cancers16081610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Topical Imiquimod is an immune response modifier approved for the off-label use of vulvar intraepithelial neoplasia. We conducted this systematic review and meta-analysis to investigate the efficacy and safety of Imiquimod in treating cervical intraepithelial neoplasia (CIN) and human papillomavirus (HPV)-positive patients. METHODS The study was prospectively registered (CRD420222870) and involved a comprehensive systematic search of five medical databases on 10 October 2022. We included articles that assessed the use of Imiquimod in cervical dysplasia and HPV-positive patients. Pooled proportions, risk ratios (RRs), and corresponding 95% confidence intervals (CIs) were calculated using a random effects model to generate summary estimates. Statistical heterogeneity was assessed using I2 tested by the Cochran Q tests. RESULTS Eight articles reported on 398 patients who received Imiquimod out of 672 patients. Among CIN-2-3 patients, we observed a pooled regression rate of 61% (CI: 0.46-0.75; I2: 77%). When compared, Imiquimod was inferior to conization (RR: 0.62; CI: 0.42-0.92; I2: 64%). The HPV clearance rate in women who completed Imiquimod treatment was 60% (CI: 0.31-0.81; I2: 57%). The majority of side effects reported were mild to moderate in severity. CONCLUSIONS Our findings indicate that topical Imiquimod is safe and effective in reducing cervical intraepithelial neoplasia and promoting HPV clearance. However, it was found to be inferior compared to conization. Imiquimod could be considered a potential medication for high-grade CIN patients and should be incorporated into guidelines for treating cervical dysplasia.
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Affiliation(s)
- Balázs Hamar
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Institute for Translational Medicine, Medical School, University of Pécs, 7621 Pécs, Hungary
| | - Eszter Hoffmann
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Institute for Translational Medicine, Medical School, University of Pécs, 7621 Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, 1088 Budapest, Hungary
| | - Andrea Harnos
- Department of Biostatistics, University of Veterinary Medicine, 1078 Budapest, Hungary;
| | - Péter Nyirády
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
- Department of Urology, Semmelweis University, 1082 Budapest, Hungary
| | - Zsombor Hunka
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
| | - Nándor Ács
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
| | - Ferenc Bánhidy
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
| | - Zsolt Melczer
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.T.); (E.H.); (P.H.); (N.Á.); (F.B.); (Z.M.)
- Department of Obstetrics and Gynecology, Semmelweis University, 1088 Budapest, Hungary; (P.N.); (Z.H.)
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van de Sande AJM, van Baars R, Koeneman MM, Gerestein CG, Kruse AJ, van Esch EMG, de Vos van Steenwijk PJ, Muntinga CLP, Willemsen SP, van Doorn HC, van Kemenade FJ, van Beekhuizen HJ. Topical imiquimod treatment of residual or recurrent cervical intraepithelial neoplasia lesions (TOPIC-2): A randomised controlled trial. BJOG 2024. [PMID: 38556619 DOI: 10.1111/1471-0528.17808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/19/2024] [Accepted: 02/28/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE To investigate the efficacy of imiquimod in women with residual or recurrent cervical intraepithelial neoplasia (rrCIN), compared with large loop excision of the transformation zone (LLETZ). DESIGN Randomised controlled non-inferiority trial. SETTING One academic and one regional hospital in the Netherlands. POPULATION Thirty-five women with rrCIN were included in the study between May 2016 and May 2021. METHODS Women were randomised to receive treatment with 5% imiquimod cream (12.5 mg) intravaginally (three times a week for a duration of 16 weeks) or a LLETZ procedure (standard treatment). MAIN OUTCOME MEASURES The primary outcome was reduction to normal cytology at 6 months after starting treatment. Secondary outcomes were clearance of high-risk human papilloma virus (hr-HPV) in both groups and reduction to ≤CIN1 in the imiquimod group. Side effects were monitored. RESULTS Treatment success was 33% (6/18) in the imiquimod group versus 100% (16/16) in the LLETZ group (P < 0.001), whereas HPV clearance was 22% (4/18) in the imiquimod group versus 88% (14/16) in the LLETZ group (P < 0.001). After the randomisation of 35 women, the futility of treatment with imiquimod was proven and the trial was prematurely finished. In the follow-up period, three patients remained without additional treatment, whereas all other patients underwent LLETZ, conisation or hysterectomy. In the LLETZ group none of the patients received additional treatment during 2 years of follow-up. CONCLUSIONS This is the first randomised controlled trial to show that topical imiquimod has a significantly lower success rate in terms of reduction to normal cytology and hr-HPV clearance, compared with LLETZ, in women with rrCIN. Additionally, imiquimod has numerous side effects and after using imiquimod most women with rrCIN still required additional surgical treatment.
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Affiliation(s)
- Anna J M van de Sande
- Department of Gynaecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Romy van Baars
- Department of Gynaecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Margot M Koeneman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Cornelis G Gerestein
- Division of Imaging and Oncology, Department of Gynaecological Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Arnold-Jan Kruse
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of Obstetrics and Gynaecology, Isala Clinics, Zwolle, the Netherlands
| | - Edith M G van Esch
- Department of Obstetrics and Gynaecology, Catharina Cancer Institute, Catharina Hospital, Eindhoven, the Netherlands
| | - Peggy J de Vos van Steenwijk
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Caroline L P Muntinga
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Sten P Willemsen
- Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Helena C van Doorn
- Department of Gynaecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | | | - Helene J van Beekhuizen
- Department of Gynaecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Cokan A, da Silva NCH, Kavalar R, But I, Pakiž M, Andrade de Oliveira S, dos Santos Gomes FO, da Silva RS, Peixoto CA, Lucena-Silva N. Modulation of sHLA-G, PD-1, and PD-L1 Expression in Cervical Lesions Following Imiquimod Treatment and Its Association with Treatment Success. Cancers (Basel) 2024; 16:1272. [PMID: 38610950 PMCID: PMC11010979 DOI: 10.3390/cancers16071272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/05/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024] Open
Abstract
(1) Background: Cervical intraepithelial neoplasia (CIN) is a precancerous condition linked to human papillomavirus (HPV) infection, often necessitating surgical interventions carrying the risk of subsequent preterm births. This study explores the potential of imiquimod (IMQ), as a non-invasive alternative treatment. The focus is on understanding IMQ impact on immune checkpoint molecules, particularly PD-1, PD-L1, and sHLA-G, which play pivotal roles in shaping immune responses and cancer progression. (2) Methods: Forty-three patients diagnosed with a high-risk squamous intraepithelial lesion (HSIL, p16-positive) self-applied 5% IMQ encapsulated in sachets containing 250 g of cream into the vaginal cavity three times a week for 16 weeks. The impact of IMQ therapy on cervical lesion regression was assessed through immunohistochemistry (IHC), examining changes in sHLA-G, PD-L1, and PD-1 levels. The antiviral activity of IMQ was evaluated through HPV-E7 immunofluorescence. Ethical considerations were adhered to, and the research methods were based on a previously approved clinical trial (clinicaltrials.gov Identifier: NCT04859361). (3) Results: IMQ treatment demonstrated efficacy, leading to lesion regression. sHLA-G levels in CIN before starting IMQ application were associated with unsuccessful treatment (p = 0.0036). IMQ did not significantly alter the expression of PD-1. We observed a decrease in PD-L1 levels in those who were successfully treated (p = 0.0509) and a reduction in HPV burden. (4) Conclusions: IMQ exhibits promise as a non-invasive treatment for CIN, emphasising its potential to modulate the immune microenvironment. Baseline sHLA-G levels emerge as potential predictors of treatment response. Understanding the nuanced dynamics of immune checkpoints sheds light on IMQ mechanism of action. Further exploration is warranted to decipher the intricate mechanisms underlying IMQ treatment in the context of cervical lesions.
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Affiliation(s)
- Andrej Cokan
- Department for Gynaecological and Breast Oncology, University Medical Centre Maribor, 2000 Maribor, Slovenia;
| | - Neila Caroline Henrique da Silva
- Laboratório de Imunogenética, do Departamento de Imunologia, Instituto Aggeu Magalhães-Fiocruz, Campus da UFPE, Recife 50740-465, Brazil; (N.C.H.d.S.); (S.A.d.O.); (N.L.-S.)
| | - Rajko Kavalar
- Department for Pathology, University Medical Centre Maribor, 2000 Maribor, Slovenia;
| | - Igor But
- Department for General Gynaecology and Gynaecological Urology, University Medical Centre Maribor, 2000 Maribor, Slovenia;
| | - Maja Pakiž
- Department for Gynaecological and Breast Oncology, University Medical Centre Maribor, 2000 Maribor, Slovenia;
| | - Sheilla Andrade de Oliveira
- Laboratório de Imunogenética, do Departamento de Imunologia, Instituto Aggeu Magalhães-Fiocruz, Campus da UFPE, Recife 50740-465, Brazil; (N.C.H.d.S.); (S.A.d.O.); (N.L.-S.)
| | - Fabiana Oliveira dos Santos Gomes
- Laboratório de Ultraestrutura, do Departamento de Entomologia, Instituto Aggeu Magalhães-Fiocruz, Campus da UFPE, Recife 50740-465, Brazil; (F.O.d.S.G.); (R.S.d.S.); (C.A.P.)
| | - Rodrigo Soares da Silva
- Laboratório de Ultraestrutura, do Departamento de Entomologia, Instituto Aggeu Magalhães-Fiocruz, Campus da UFPE, Recife 50740-465, Brazil; (F.O.d.S.G.); (R.S.d.S.); (C.A.P.)
| | - Christina Alves Peixoto
- Laboratório de Ultraestrutura, do Departamento de Entomologia, Instituto Aggeu Magalhães-Fiocruz, Campus da UFPE, Recife 50740-465, Brazil; (F.O.d.S.G.); (R.S.d.S.); (C.A.P.)
| | - Norma Lucena-Silva
- Laboratório de Imunogenética, do Departamento de Imunologia, Instituto Aggeu Magalhães-Fiocruz, Campus da UFPE, Recife 50740-465, Brazil; (N.C.H.d.S.); (S.A.d.O.); (N.L.-S.)
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6
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Wang DY, Cui YY, Zhang WW, Fan MS, Qiu KX, Yan L. Effect of different interventions on the treatment of high-risk human papillomavirus infection: a systematic review and network meta-analysis. Front Med (Lausanne) 2024; 11:1274568. [PMID: 38420364 PMCID: PMC10899477 DOI: 10.3389/fmed.2024.1274568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/24/2024] [Indexed: 03/02/2024] Open
Abstract
Background Persistent infection with high-risk human papillomavirus (HR-HPV) can lead to cervical intraepithelial neoplasia and cancer. At present, there is no medication that specifically targets HR-HPV infection. Objective This study aimed to evaluate the effectiveness of different interventions in promoting HR-HPV regression using a MeSH meta-analysis method. Methods A search for randomized controlled trials (RCTs) reporting different interventions for the treatment of HR-HPV infection included PubMed, Web of Science, Embase and Cochrane Library from the inception of the databases to March 8, 2023. Two researchers independently screened the articles, extracted data, and evaluated the quality. The literature that met the inclusion criteria was selected, the quality and risk of bias of the included studies were assessed according to the Cochrane 5.1 manual, and NMA was performed using Stata 16.0. The area under the cumulative ranking probability graph (SUCRA) represented the probability that each treatment would be the best intervention. Results Nine studies involving 961 patients and 7 treatment options were included in the analysis. The results of the network meta-analysis indicated the following rank order in terms of promoting HR-HPV conversion: Anti-HPV biological dressing > vaginal gel > imiquimod > REBACIN® > interferon > probiotics > observation/placebo > Polyphenon E. Conclusion Anti-HPV biological dressing treatment was found to be significantly effective in promoting HR-HPV conversion. However, further validation of the findings is necessary due to the limited number and quality of studies included in the analysis. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023413917.
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Affiliation(s)
- Dong-Yue Wang
- Department of Gynecology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
- Key Laboratory of Laparoscopic Technology, department of Gynecology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Ying-Ying Cui
- Key Laboratory of Laparoscopic Technology, department of Gynecology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Wei-Wei Zhang
- Department of Gynecology, Tengzhou Maternal and Child Health Hospital, Tengzhou, China
| | - Meng-Si Fan
- School of Public Health, Weifang Medical University, Weifang, China
| | - Ke-Xin Qiu
- School of Public Health, Weifang Medical University, Weifang, China
| | - Li Yan
- Key Laboratory of Laparoscopic Technology, department of Gynecology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
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van de Sande AJM, Kengsakul M, Koeneman MM, Jozwiak M, Gerestein CG, Kruse AJ, van Esch EMG, de Vos van Steenwijk PJ, Muntinga CLP, Bramer WM, van Doorn HC, van Kemenade FJ, van Beekhuizen HJ. The efficacy of topical imiquimod in high-grade cervical intraepithelial neoplasia: A systematic review and meta-analysis. Int J Gynaecol Obstet 2024; 164:66-74. [PMID: 37350560 DOI: 10.1002/ijgo.14953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/29/2023] [Accepted: 06/04/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE A major side effect of cervical excision for high-grade cervical intraepithelial neoplasia (CIN) is premature birth. A non-invasive treatment for reproductive age women is warranted. The aim of the present study was to determine the efficacy of topical imiquimod in the treatment of high-grade CIN, defined as a regression to ≤CIN 1, and to determine the clearance rate of high-risk human papillomavirus (hr-HPV), compared with surgical treatment and placebo. METHODS Databases were searched for articles from their inception to February 2023.The study protocol number was INPLASY2022110046. Original studies reporting the efficacy of topical imiquimod in CIN 2, CIN 3 or persistent hr-HPV infections were included. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist. RESULTS Five studies were included (n = 463). Histological regression to ≤CIN 1 was 55% in imiquimod versus 29% in placebo, and 93% in surgical treatment. Imiquimod-treated women had a greater odds of histological regression to ≤CIN 1 than placebo (odds ratio [OR] 4.17, 95% confidence interval [CI] 2.03-8.54). In comparison to imiquimod, surgical treatment had an OR of 14.81(95% CI 6.59-33.27) for histological regression to ≤CIN 1. The hr-HPV clearance rate was 53.4% after imiquimod and 66% after surgical treatment (95% CI 0.62-23.77). CONCLUSIONS The histological regression rate is highest for surgical treatment followed by imiquimod treatment and placebo.
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Affiliation(s)
- A J M van de Sande
- Department of Gynecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M Kengsakul
- Department of Gynecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Panyananthaphikkhu Chonprathan Medical Center, Department of Obstetrics and Gynecology, Srinakharinwirot University, Nonthaburi, Thailand
| | - M M Koeneman
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M Jozwiak
- Department of Gynecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C G Gerestein
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - A J Kruse
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Obstetrics and Gynecology, Isala Clinics, Zwolle, The Netherlands
| | - E M G van Esch
- Department of Obstetrics and Gynecology, Catharina Cancer Institute, Catharina Hospital, Eindhoven, The Netherlands
| | - P J de Vos van Steenwijk
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - C L P Muntinga
- Department of Obstetrics and Gynecology, Catharina Cancer Institute, Catharina Hospital, Eindhoven, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - W M Bramer
- Medical Library, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - H C van Doorn
- Department of Gynecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - F J van Kemenade
- Department of Pathology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - H J van Beekhuizen
- Department of Gynecological Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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8
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Borella F, Gallio N, Mangherini L, Cassoni P, Bertero L, Benedetto C, Preti M. Recent advances in treating female genital human papillomavirus related neoplasms with topical imiquimod. J Med Virol 2023; 95:e29238. [PMID: 38009696 DOI: 10.1002/jmv.29238] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/28/2023] [Accepted: 11/04/2023] [Indexed: 11/29/2023]
Abstract
Human papillomavirus (HPV) encompasses a group of viruses that infect the skin and mucous membranes. In the presence of certain factors, persistent infection with high-risk HPVs can trigger a process of neoplastic transformation. Imiquimod is a topical agent that acts as a Toll-like receptor 7/8 agonist, stimulating the innate and adaptive immune system to exert antitumor and antiviral effects. It has been approved for the treatment of various skin conditions, however, its efficacy and safety in the management of HPV-related-neoplasms of the lower genital tract, such as vulvar, vaginal, and cervical neoplasia, are still under investigation. This review summarizes the current evidence on the use of imiquimod for the treatment of HPV-induced lesions of the female lower genital tract, focusing on its indications, mechanisms of action, outcomes, and predictors of response.
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Affiliation(s)
- Fulvio Borella
- Obstetrics and Gynecology Unit 1, Sant' Anna Hospital, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Niccolò Gallio
- Obstetrics and Gynecology Unit 2, Sant' Anna Hospital, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Luca Mangherini
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Chiara Benedetto
- Obstetrics and Gynecology Unit 1, Sant' Anna Hospital, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Mario Preti
- Obstetrics and Gynecology Unit 1, Sant' Anna Hospital, Department of Surgical Sciences, University of Turin, Turin, Italy
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9
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Inayama Y, Takamatsu S, Hamanishi J, Mizuno K, Horinouchi N, Yamanoi K, Taki M, Murakami R, Yamaguchi K, Kosaka K, Efthimiou O, Kawakami K, Furukawa TA, Mandai M. Imiquimod for Cervical and Vaginal Intraepithelial Neoplasia: A Systematic Review and Meta-analysis. Obstet Gynecol 2023; 142:307-318. [PMID: 37411024 DOI: 10.1097/aog.0000000000005256] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/04/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To evaluate the treatment efficacy and the risk of adverse events of imiquimod for cervical intraepithelial neoplasia (CIN) and vaginal intraepithelial neoplasia (VAIN), compared with placebo or no intervention. DATA SOURCES We searched Cochrane, PubMed, ISRCTN registry, ClinicalTrials.gov , and the World Health Organization International Clinical Trials Registry Platform up to November 23, 2022. METHODS OF STUDY SELECTION We included randomized controlled trials and prospective nonrandomized studies with control arms that investigated the efficacy of imiquimod for histologically confirmed CIN or VAIN. The primary outcomes were histologic regression of the disease (primary efficacy outcome) and treatment discontinuation due to side effects (primary safety outcome). We estimated pooled odds ratios (ORs) of imiquimod, compared with placebo or no intervention. We also conducted a meta-analysis of the proportions of patients with adverse events in the imiquimod arms. TABULATION, INTEGRATION, AND RESULTS Four studies contributed to the pooled OR for the primary efficacy outcome. An additional four studies were available for meta-analyses of proportions in the imiquimod arm. Imiquimod was associated with increased probability of regression (pooled OR 4.05, 95% CI 2.08-7.89). Pooled OR for CIN in the three studies was 4.27 (95% CI 2.11-8.66); results of one study were available for VAIN (OR, 2.67, 95% CI 0.36-19.71). Pooled probability for primary safety outcome in the imiquimod arm was 0.07 (95% CI 0.03-0.14). The pooled probabilities (95% CI) of secondary outcomes were 0.51 (0.20-0.81) for fever, 0.53 (0.31-0.73) for arthralgia or myalgia, 0.31 (0.18-0.47) for abdominal pain, 0.28 (0.09-0.61) for abnormal vaginal discharge or genital bleeding, 0.48 (0.16-0.82) for vulvovaginal pain, and 0.02 (0.01-0.06) for vaginal ulceration. CONCLUSION Imiquimod was found to be effective for CIN, whereas data on VAIN were limited. Although local and systemic complications are common, treatment discontinuation is infrequent. Thus, imiquimod is potentially an alternative therapy to surgery for CIN. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022377982.
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Affiliation(s)
- Yoshihide Inayama
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Shiro Takamatsu
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Junzo Hamanishi
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Kayoko Mizuno
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Noboru Horinouchi
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Koji Yamanoi
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Mana Taki
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Ryusuke Murakami
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Ken Yamaguchi
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Kenzo Kosaka
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Orestis Efthimiou
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Koji Kawakami
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Toshiaki A Furukawa
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
| | - Masaki Mandai
- From the Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, and the Department of Pharmacoepidemiology and the Department of Health Promotion and Human Behavior, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, the Department of General Medicine, Oita University Faculty of Medicine, Oita, and the Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan; and the Institute of Primary Health Care (BIHAM) and the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Each author has confirmed compliance with the journal's requirements for authorship
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10
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Schwameis R, Ganhoer-Schimboeck J, Hadjari VL, Hefler L, Bergmeister B, Küssel T, Gittler G, Steindl-Schoenhuber T, Grimm C. TRICIN: A Phase II Trial on the Efficacy of Topical TRIchloroacetic Acid in Patients with Cervical Intraepithelial Neoplasia. Cancers (Basel) 2022; 14:5991. [PMID: 36497473 PMCID: PMC9740961 DOI: 10.3390/cancers14235991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/07/2022] Open
Abstract
Data on non-surgical treatment approaching persistent cervical intraepithelial neoplasia (CIN) are scarce. Retrospective analysis suggest high efficacy of topical treatment with trichloroacetic acid (TCA). This prospective phase II study set out to investigate the efficacy of a single application of 85% TCA in the treatment of CIN I/II. Patients with CIN I/II were treated a single time with 85% TCA. After three and six months colposcopic, histologic, and HPV evaluation was performed. The primary endpoint was treatment efficacy defined as complete histologic remission six months after treatment. The secondary endpoint was HPV clearance six months after treatment. A total of 102 patients with CIN I/II were included into this trial. Complete histologic remission rates were 75.5% and 78.4% three and six months after TCA treatment, respectively. Clearance rates of HPV 16, 18 and other high risk types were 76.5%, 91.7%, 68.7% after six months, respectively. Side effects of TCA were mild and lasted usually less than 30 min. This is the first prospective trial reporting high histologic complete remission rates in patients with CIN I/II after a single 85% TCA treatment. In the future, TCA may represent an effective and feasible non-surgical treatment approach for CIN.
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Affiliation(s)
- Richard Schwameis
- Department of General Gynecology and Gynecologic Oncology, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, 1080 Vienna, Austria
| | - Julia Ganhoer-Schimboeck
- Department of Obstetrics and Gynecology, Konventhospital Barmherzige Brueder and Ordensklinikum Linz, 4010 Linz, Austria
| | - Victoria Laudia Hadjari
- Department of Obstetrics and Gynecology, Konventhospital Barmherzige Brueder and Ordensklinikum Linz, 4010 Linz, Austria
| | - Lukas Hefler
- Department of Obstetrics and Gynecology, Konventhospital Barmherzige Brueder and Ordensklinikum Linz, 4010 Linz, Austria
- Karl Landsteiner Institut Fuer Gynaekologische Chirurgie und Onkologie, 4020 Linz, Austria
| | - Birgit Bergmeister
- Department of Obstetrics and Gynecology, Konventhospital Barmherzige Brueder and Ordensklinikum Linz, 4010 Linz, Austria
| | - Tatjana Küssel
- Department of Obstetrics and Gynecology, Konventhospital Barmherzige Brueder and Ordensklinikum Linz, 4010 Linz, Austria
| | - Gunda Gittler
- Barmherzige Brueder Linz, Hospital Pharmacy, 4020 Linz, Austria
| | | | - Christoph Grimm
- Department of General Gynecology and Gynecologic Oncology, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, 1080 Vienna, Austria
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11
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Muntinga CLP, de Vos van Steenwijk PJ, Bekkers RLM, van Esch EMG. Importance of the Immune Microenvironment in the Spontaneous Regression of Cervical Squamous Intraepithelial Lesions (cSIL) and Implications for Immunotherapy. J Clin Med 2022; 11:jcm11051432. [PMID: 35268523 PMCID: PMC8910829 DOI: 10.3390/jcm11051432] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 12/10/2022] Open
Abstract
Cervical high-grade squamous intraepithelial lesions (cHSILs) develop as a result of a persistent high-risk human papilloma virus (hrHPV) infection. The natural course of cHSIL is hard to predict, depending on a multitude of viral, clinical, and immunological factors. Local immunity is pivotal in the pathogenesis, spontaneous regression, and progression of cervical dysplasia; however, the underlying mechanisms are unknown. The aim of this review is to outline the changes in the immune microenvironment in spontaneous regression, persistence, and responses to (immuno)therapy. In lesion persistence and progression, the immune microenvironment of cHSIL is characterized by a lack of intraepithelial CD3+, CD4+, and CD8+ T cell infiltrates and Langerhans cells compared to the normal epithelium and by an increased number of CD25+FoxP3+ regulatory T cells (Tregs) and CD163+ M2 macrophages. Spontaneous regression is characterized by low numbers of Tregs, more intraepithelial CD8+ T cells, and a high CD4+/CD25+ T cell ratio. A ‘hot’ immune microenvironment appears to be essential for spontaneous regression of cHSIL. Moreover, immunotherapy, such as imiquimod and therapeutic HPV vaccination, may enhance a preexisting pro-inflammatory immune environment contributing to lesion regression. The preexisting immune composition may reflect the potential for lesion regression, leading to a possible immune biomarker for immunotherapy in cHSILs.
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Affiliation(s)
- Caroline L. P. Muntinga
- Department of Gynecology and Obstetrics, Catharina Ziekenhuis Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands; (C.L.P.M.); (R.L.M.B.)
- GROW—School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands;
| | - Peggy J. de Vos van Steenwijk
- GROW—School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands;
- Department of Gynecology and Obstetrics, Maastricht Universitair Medisch Centrum, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Ruud L. M. Bekkers
- Department of Gynecology and Obstetrics, Catharina Ziekenhuis Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands; (C.L.P.M.); (R.L.M.B.)
- GROW—School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands;
| | - Edith M. G. van Esch
- Department of Gynecology and Obstetrics, Catharina Ziekenhuis Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands; (C.L.P.M.); (R.L.M.B.)
- Correspondence: ; Tel.: +31-402-399-111
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