Meta-analysis of the accuracy of p16 or p16/Ki-67 immunocytochemistry versus HPV testing for the detection of CIN2+/CIN3+ in triage of women with minor abnormal cytology

BACKGROUND

Women with atypical squamous cells of undetermined significance (ASC-US) can be triaged accurately with a high-risk human papillomavirus (hrHPV) test to identify those who need a referral. However, the triage of low-grade squamous intraepithelial lesion (LSIL) with hrHPV testing has very low specificity. Overexpression of p16, with or without Ki-67, indicates neoplastic transformation of human papillomavirus-infected cervical cells and may more accurately predict underlying cervical intraepithelial neoplasia of grade 3 or worse (CIN3+).

METHODS

A literature search was conducted in 3 bibliographic databases. Studies were selected if they included women with ASC-US or LSIL who were triaged with dual staining (p16/Ki-67) and/or p16 staining and, if available, with a comparator hrHPV test to detect cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) or CIN3+.

RESULTS

Thirty-eight studies were eligible. The sensitivity of p16 staining for CIN3+ was significantly lower than that of hrHPV DNA testing (ratio for ASC-US, 0.87; 95% confidence interval [CI], 0.78-0.97; ratio for LSIL, 0.86; 95% CI, 0.80-0.93). In contrast, the specificity of p16 staining was substantially higher with relative specificities of 1.60 (95% CI, 1.35-1.88) and 2.29 (95% CI, 2.05-2.56) for ASC-US and LSIL respectively. Dual staining was as sensitive as hrHPV DNA testing but was more specific (ratio for ASC-US, 1.65; 95% CI, 1.42-1.92; ratio for LSIL, 2.45; 95% CI, 2.17-2.77).

CONCLUSIONS

This meta-analysis confirms that p16 staining and p16/Ki-67 staining are more specific for CIN2+/CIN3+ than hrHPV DNA testing. Although p16 staining is less sensitive for CIN3+ than hrHPV DNA testing, dual staining has similar sensitivity.

Mitochondrial decay is involved in BaP-induced cervical damage

Benzo[a]pyrene (BaP) is a polycyclic aromatic hydrocarbon and a potent inducer of carcinogenesis. Many studies have reported that the carcinogenic effects of BaP might be due to its intermediate metabolites and to reactive oxygen species (ROS) that cause oxidative damage to the cells. However, the mechanisms of BaP-induced oxidative damage in cervical tissue are still not clear. We studied these mechanisms in female ICR mice treated with BaP either orally or intraperitoneally by measuring (1) several general biomarkers of oxidative stress in serum, (2) mitochondrial function in the cervix, and (3) the morphology of mitochondria in cervical tissue. BaP treatment (1) significantly lowered levels of vitamins A, C, and E and of glutathione; (2) reduced activities of superoxide dismutase, catalase, glutathione peroxidase, and glutathione S-transferases; and (3) significantly increased lipid peroxidation levels. In addition, significant increases in the levels of superoxide anion, hydrogen peroxide, and hydroxyl radical were observed. These results were confirmed by morphological changes in mitochondria and by decreases in membrane potential levels and in succinate dehydrogenase and malate dehydrogenase activities. The changes in these biomarkers and mitochondrial damage were BaP-dose-dependent and eventually induced both cell apoptosis and necrosis in cervical tissue. As mitochondria are the major sites of ROS generation, these findings show that mitochondrial decay greatly contributes to BaP-induced cervical damage.

[The study of expression of apoptosis receptors (CD95+) on the surface of neutrophils from cervical secretion of women with chlamydial infection and the possibility of its correction by magnetic laser radiation]

The present work was designed to study the expression of CD95 antigen (Fas/APO-1) at the surface of neutrophil granulocytes from the cervical secretion. Sixty five female patients with Chlamydia infection available for observation exhibited enhanced CD95+ expression following basic therapy. It was found that combined treatment with the use of magnetic laser radiation normalized the level of CD95+ surface receptors on neutrophils.

[Comparative proteome analysis of human papillomavirus-infected cervical specimens and the difference between the high- and low-risk genotypes of human papillomavirus]

OBJECTIVE

To perform an comparative proteome analysis of human papillomavirus-infected cervical specimens and to investigate different expressions between high- and low-risk genotypes.

METHODS

The cervical specimens were divided into two groups (cervical intraepithelial neoplasia group and condyloma acuminatum group) according to their genotypes. Using comparative proteome technology, high-risk human papillomavirus-infected cervical intraepithelial neoplasia, low-risk human papillomavirus-infected condyloma acuminatum, and normal cervical intraepithelial tissue were compared. The differential expression protein spots were identified by mass spectrometry.

RESULTS

Totally 26 differential spots were selected and analyzed, and 22 peptide mass fingerprints (PMF) maps were obtained by MALDI-TOF-MS. Eighteen proteins were preliminarily identified after searching the NCBInr database. The function information of these 18 proteins mainly involved cell metabolism, signal transduction, cell secretion, cell cytoskeleton construction, cell proliferation, and apoptosis.

CONCLUSION

The proteomic expressions after the cervical infection of high- or low-risk genotype of human papillomavirus are obviously different.

Gastric mucin is expressed in a subset of endocervical tunnel clusters: type A tunnel clusters of gastric phenotype

AIMS

Gastric mucin expression has been demonstrated in a group of endocervical glandular lesions. The aim of this study was to gain further insight into endocervical lesions with a gastric phenotype.

METHODS AND RESULTS

Various types of tunnel clusters (TC) were examined for gastric mucin by alcian blue/periodic acid-Schiff staining and immunohistochemistry for HIK1083. Five of 34 cases of TC expressed gastric mucin defined by PAS dominant neutral mucin and immunopositivity for pyloric gland mucin. Histologically, TC expressing gastric mucin showed lobular arrangements of small to medium-sized glands composed of mucin-rich columnar cells and were classified as Flumann's type A TC. Neither type B TC nor normal endocervical glands expressed PAS dominant neutral mucin and none of them was immunopositive for pyloric gland mucin. Five patients with type A TC of gastric phenotype ranged in age from 33 to 79 years (mean 58 years) and were multiparous. Type A TC of gastric phenotype, ranging from 2 to 4 mm in maximum diameter, were incidental findings in hysterectomy specimens.

CONCLUSION

Type A TC of gastric phenotype could be related to lobular endocervical glandular hyperplasia of gastric phenotype. The pathogenesis of gastric metaplasia in TC remains unclear.

Local Markers for Prediction of Women at Higher Risk of Developing Sequelae to Chlamydia trachomatis Infection

PROBLEM

Chlamydial infections are often associated with various fertility-related disorders. Serological prediction of these has limitations, as they do not differentiate between past and current infections. Thus, we looked for local markers that could predict more precisely women at higher risk of developing severe complications.

METHOD OF STUDY

A total of 320 Chlamydia trachomatis positive women with or without fertility disorders were tested for the prevalence of immunoglobulin A antibodies to synthetic peptides of chlamydial heat-shock protein 60 (cHSP60) and cHSP10 along with cervical interferon-gamma (IFN-gamma) and serum C-reactive protein (CRP) levels.

RESULTS

Positive IFN-gamma level was the single best predictor for fertility disorder [odds ratio (OR) 15.4]. The predictive value of IFN-gamma could be significantly improved only by the addition of CRP test (OR 37.9).

CONCLUSION

Positive IFN-gamma levels in cervical washes along with elevated CRP levels could be used to predict women who are at higher risk of developing fertility disorders.

Mucinous expression in benign and neoplastic glandular lesions of the uterine cervix

CONTEXT

Mucins are glycoproteins produced by both normal and neoplastic glandular epithelial cells including endocervix.

OBJECTIVE

To determine the expression of mucins in uterine cervical glandular lesions and whether mucin expression correlates with the nature and origin of the glandular lesions.

DESIGN

Antibodies to MUC1, MUC2, MUC4, and MUC5AC were applied on 52 cases including 14 endocervical adenocarcinomas (including 4 adenosquamous carcinomas), 9 endometrial carcinomas (8 endometrioid adenocarcinomas and 1 adenosquamous carcinoma), 8 adenocarcinoma in situ (AIS), 2 glandular dysplasias, 6 tubal metaplasias, 10 microglandular hyperplasias, and 3 normal endocervix. The presence of any staining was considered positive.

RESULTS

All benign endocervical epithelia, including tubal metaplasia and microglandular hyperplasia, expressed MUC1, MUC4, and MUC5AC but not MUC2. Almost all endocervical AIS and carcinomas and all endometrial adenocarcinomas expressed MUC1; the exceptions were 2 cases of endocervical adenocarcinoma and 1 case of adenosquamous carcinoma of the endocervix. MUC2 staining was noted in 25%, 40%, and 22% of AIS, endocervical adenocarcinomas, and endometrial adenocarcinomas, respectively. About 38% of AIS, 75% of endocervical adenocarcinomas, and 44% of endometrial adenocarcinomas expressed MUC4. Half of AIS, most of endocervical adenocarcinomas, and 22% of endometrial adenocarcinomas expressed MUC5AC. The difference in MUC4 and MUC5AC expression between benign endocervical lesions and AIS and the difference in MUC5AC expression between endocervical and endometrial neoplasms were statistically significant.

CONCLUSIONS

Mucin expressions differed among benign endocervical lesions and AIS and among endocervical and endometrial malignancies. These results suggest that mucin staining may potentially be helpful in differentiating various uterine cervical glandular lesions.

Intra-uterine fluid collection in postmenopuasal women with cervical stenosis

OBJECTIVES

The aim of the study was to assess the clinical significance of intra-uterine fluid collection in postmenopausal women with cervical stenosis with and without vaginal bleeding.

METHODS

A group of 82 consecutive postmenopausal women with cervical stenosis and sonographically confirmed intra-uterine fluid collection underwent D&C with or without hysteroscopy. Diagnostic hysteroscopy was performed in all patients with an endometrial thickness (ET) was greater than 8mm, or with irregular endometrium at any degree of ET. The patients were divided and evaluated prospectively into two groups according to the presence or absence of postmenopausal bleeding (PMB). Twenty-six women were with PMB and 56 women were asymptomatic.

RESULTS

The groups were similar as far as endometrial thickness and histopathological results were concerned. Atrophic endometrium was found in 69 patients (84%), 23 in the PMB group (89%) and 46 in the other group (82%), proliferative endometrium in 7 (9%) and endometrial polyps were found in 35 patients (43%), 12 in the PMB group (46%) and 23 in the other group (41%). When ET was > or =8 mm, in 93% of the cases an endometrial polyp was found (25 out of 27). No case of endometrial cancer was found. A premalignant condition was diagnosed in one patient with an endometrial polyp in the PMB group. All patients with endometrial thickness of less than 3 mm in ultrasound had atrophic endometrium. The incidence of intrauterine pathology increased with the increasing thickness of endometrium as observed by ultrasound.

CONCLUSIONS

The presence of intra-uterine fluid collection in postmenopausal patients with cervical stenosis seems to be a benign condition. Normal endometrium of less than 3mm observed by ultrasound in postmenopausal women without vaginal bleeding does not necessarily need further surgical investigation.

The many faces of atrophy in gynecologic cytology

As more attention is paid to cervical cancer screening in the postmenopausal population, increased numbers of atrophic specimens will be evaluated in the cytology laboratory. In addition, specimens that have cell patterns that mimic the nonestrogen or partially estrogen-stimulated state occur in a variety of situations, including pregnancy, the postpartum period, and in individuals who are treated with progesterone. A firm understanding of the cellular changes that are within the range of normal in such circumstances is critical to ensure the specificity of interpretation. This article has detailed the conditions under which nonestrogen stimulated patterns occur and addressed the cytologic changes that are noted. Hints to avoid pitfalls have been offered. There is no substitute for a thorough evaluation of each case, and with continued experience and understanding of these principles, the correct interpretations, and, ultimately, correct management of patients, can be optimized.

Depletion of Langerhans cells in human papillomavirus type 16-infected skin is associated with E6-mediated down regulation of E-cadherin

Human papillomavirus type 16 (HPV16) is an oncogenic virus that causes persistent infections in cervical epithelium. The chronic nature of HPV16 infections suggests that this virus actively evades the host immune response. Intraepithelial Langerhans cells (LC) are antigen-presenting cells that are critical in T-cell priming in response to viral infections of the skin. Here we show that HPV16 infection is directly associated with a reduction in the numbers of LC in infected epidermis. Adhesion between keratinocytes (KC) and LC, mediated by E-cadherin, is important in the retention of LC in the skin. Cell surface E-cadherin is reduced on HPV16-infected basal KC, and this is directly associated with the reduction in numbers of LC in infected epidermis. Expression of a single viral early protein, HPV16 E6, in KC reduces levels of cell surface E-cadherin thereby interfering with E-cadherin-mediated adhesion. Through this pathway, E6 expression in HPV16-infected KC may limit presentation of viral antigens by LC to the immune system, thus preventing the initiation of a cell-mediated immune response and promoting survival of the virus.

Oestrogen receptor transcripts associated with cervical human papillomavirus infection

OBJECTIVE

Studies have been inconsistent in establishing sex steroids as a risk factor for human papillomavirus (HPV) infections. This study was designed to determine whether cervical oestrogen receptors (as measured by oestrogen receptor transcripts) at the cervix would be associated with cervical HPV infections.

METHODS

In 175 women, ages 14-44, we tested for the presence of HPV DNA and oestrogen receptors transcripts at the cervix during routine pelvic examinations. All subjects completed a self administered questionnaire regarding sexual and menstrual histories.

RESULTS

40% of the women (n=70) tested positive for HPV at the cervix. Of those women testing positive for HPV, 99% had detectable levels of Oestrogen receptors transcripts (n=69/70). HPV cervical infections were independently associated with presence of Oestrogen receptors transcripts (OR=39.8, CI=4.4, 361.1) and greater numbers of sexual partners (OR=1.1, CI=1.01, 1.18).

CONCLUSION

Women who expressed higher levels of oestrogen receptors transcripts were significantly more likely to have cervical HPV infection. These results demonstrate that Oestrogen receptors may play an important part in cervical HPV infections.

Mucocolpos due to complete transverse septum in middle third of vagina in a 17-year-old girl

A 17-year-old girl had a large abdominopelvic mass (12 x 8cm) extending from vagina, due to the presence of a complete transverse vaginal septum in its middle third which on resection facilitated the drainage and disappearance of the mass finally diagnosed as a case of mucocolpos.

Ceroid granuloma of the uterine cervix

A case of ceroid granuloma of the uterine cervix in a 58-year-old woman is presented, the fourth such case in the literature. It was an incidental finding during a routine pelvic examination and appeared as an exophytic brownish lesion on the anterior wall of the uterine cervix. On histological examination it consisted of sheets of ceroid-rich histiocytes within the superficial cervical stroma. There was no obvious cause for the lesion. Ceroid granulomas of the female genital tract may be related to endometriosis, but the rarity of the cases precludes definite conclusions about the etiology and pathogenesis of this lesion.

MUC4 expression is increased in dysplastic cervical disorders

The female uterine cervix has 2 characteristic populations of epithelial cells: the endocervix is composed by mucus-secreting cells that express several mucin genes, and the exocervix has a typical stratified squamous epithelium and does not express secreted mucins. Among human mucin genes, the MUC4 sequence has a transmembrane domain, and its molecular structure suggests that it has a protective role and also may be implicated in intracellular signalling. The aim of this study is to analyze whether changes in the expression of MUC4 can be detected associated with the squamous dysplastic transformation of exocervical epithelium. MUC4 expression has been analyzed by immunohistochemistry, Western blotting, and in situ hybridization. Using immunohistochemical techniques, MUC4 is found in normal endocervix (n = 11) and is absent or only focally detected in the normal stratified cervical epithelium (n = 18). In samples from squamous metaplasia (n = 9), MUC4 is variably expressed (10% to 50% positive cells), whereas MUC4 is strongly detected in dysplastic cervical epithelia. The greatest number of positive cells is found in samples with moderate and severe dysplasia in which MUC4 is detected in 100% of the analyzed samples (n = 16). These results have been confirmed by Western blotting and by detection of MUC4 transcripts using in situ hybridization. The present data suggest that MUC4 is activated during the process of squamous dysplastic transformation and may be used as a marker for this pathologic process.

Relevance of the rates of PCNA, Ki-67 and p53 expression according to the epithelial compartment in cervical lesions

In order to assess further biological evidence for similarities among the "diagnostic classes" of cervical lesions, which are now a matter of international discussion in the search for a uniform classification, the purpose of this study was to characterize the immunoexpression of cell proliferation markers (proliferating cell nuclear antigen, PCNA and Ki-67) and protein p53. Each marker was individually quantified in basal, intermediate, and superficial epithelial compartments presenting chronic cervicitis (CC) accompanied by the cytopathic effects of infection by human papillomavirus (CCHPV) or not (CC), as well as in cervical intraepithelial neoplasia (CIN) grades I, II, and III. A total of 100 patients were evaluated and the positive nuclei were counted separately, including all extensions of the available epithelium. The percentage of PCNA- and Ki-67-positive cells increased with increasing grade of the cervical lesions, although PCNA immunoreactivity was always greater than the immunoreactivity observed with Ki-67 antigen. The immunoexpression of p53 protein was found to be weak, with no remarkable behavior in any specific "diagnostic class". The differences in cell proliferation markers found herein further emphasize the progressive loss of epithelial layer organization in the course of the development of preneoplastic changes in cervical squamous epithelium. Furthermore, difficulties in morphologically distinguishing "borderline lesions" persist when cell cycle markers are studied, further supporting the suggestion to consider the lesions of CCHPV and CIN I together as only one diagnostic class. Conversely, the different immune profile found between CIN II and III further supports the validity of the subdivision of CIN into three groups.

Extensively keratinized squamous intraepithelial lesions of the cervix are difficult to grade

We tested the hypothesis that extensively keratinized squamous intraepithelial lesions (SILs) are difficult to grade precisely by identifying 100 Papanicolaou smears with a keratinizing SIL that had been originally judged difficult to grade. Of these, 65 were confirmed as low-grade SIL (LSIL) or high-grade SIL (HSIL) on subsequent biopsy. The 65 smears were reviewed independently by 3 cytopathologists who graded each case as LSIL or HSIL (by Bethesda System criteria). The accuracy of the grade was determined by the subsequent biopsy results; accuracy was compared with that of a historic control group of SILs with biopsy follow-up. In the study group, biopsies showed LSIL in 41 cases and HSIL in 24. The mean accuracy for a smear diagnosis of LSIL was 60% for the study group and 92% for the control group. For a smear diagnosis of HSIL, the accuracy was 60% for the study group and 95% for the control group. The overall kappa value for the study group confirmed poor interobserver agreement. Some keratinizing SILs are difficult if not impossible to grade precisely using standard criteria. For such lesions, the diagnosis "SIL, grade cannot be determined due to extensive keratinization" is justified.

Observations of high iron diamine-alcian blue stain in uterine cervical glandular lesions

We studied epithelial glycoproteins in uterine cervical lesions, including glandular lesions, and investigated whether a more accurate diagnosis could be obtained using high iron diamine-alcian blue (HID-AB) stain and immunostaining with carcinoembryonic antigen (CEA). In addition, we examined the usefulness of preoperative diagnosis using biopsy specimens stained with HID-AB and CEA. Normal endocervical glands showed a predominance of sulfomucin, while adenocarcinoma predominantly showed sialomucin. CEA was highly detected in adenocarcinoma, but not in normal endocervix or in glandular dysplasia, suggesting that this stain has high specificity. The staining patterns of biopsy specimens and hysterectomy specimens were similar. Therefore HID-AB stain and CEA stain may be useful as a supplementary means of diagnosing uterine cervical lesions.

Overriding of cyclin-dependent kinase inhibitors by high and low risk human papillomavirus types: evidence for an in vivo role in cervical lesions

High risk types of human papillomavirus (HPV) are agents in the aetiology of cervical carcinoma. The products of two early genes, E6 and E7, appear to be the principal transforming proteins. Studies of various monolayer cell culture systems have shown that the E7 oncoprotein of human papillomavirus type 16 is able to neutralize or bypass the inhibitory effect of the cell cycle-dependent kinase (CDK) inhibitors (CKIs) p21WAF1/CIP1 and p27KIP1. To understand whether the p21WAF1/CIP1 or p27KIP1 neutralization also plays a role in vivo, we performed studies on clinical specimens. Forty-five cervical biopsies, including HPV-negative mucosa, HPV 16-positive preinvasive (low and high grade lesions) and invasive neoplasia as well as HPV 6-positive condyloma acuminatum were analysed by single and double immunohistology. We examined the positive cell cycle regulator cyclin A and the universal cell cycle marker Ki67 as well as the negative cell cycle regulators p21WAF1/CIP1 and p27KIP1. Here, we show that in a significant fraction of cells the G1 block can be overcome despite high levels of CKIs in HPV lesions. This phenomenon, which was more evident for p21WAF1/CIP1 than for p27KIP1 was most marked in low grade lesions and in condylomata acuminata, in which a high viral productivity is expected. These results indicate that the overriding of CKI inactivation by viral oncoproteins appears to be a conserved property between low and high risk HPV types. We conclude that the CKI neutralization by HPVs is likely to be required for viral DNA replication rather than for malignant transformation of the host cell.

Cervical condylomas show higher proliferation than do inflamed or metaplastic cervical squamous epithelium

Changes of condyloma are sometimes difficult to distinguish from changes seen with inflammation or with squamous metaplasia (SM) in the uterine cervix. Cervical condylomas show increased proliferative activity, so we sought to discover whether this increased activity is more than that seen in SM or with inflammation. Mitotic activity per 10 high power fields was measured in 22 cases with SM, 22 cases with exocervix only, 26 cases with inflammation, and 34 cases with condylomas. The percentage of basal cells staining for MIB-1 was compared between 27 cases with condyloma, 11 cases each with SM and inflammation, and 13 cases with exocervix. Mitotic activity was significantly increased in cervical condylomas (7.6 +/- 6.6, mean +/- standard deviation) compared with SM (1.4 +/- 1.4, P < .0001), inflamed epithelium (1.6 +/- 1.4, P < .0001), and exocervix (1.4 +/- 1.5, P < .0001). More than 15% of basal cells stained for MIB-1 in 18 of the 27 condylomas, 1 of 11 cases with SM, 1 of 11 cases with inflammation, and none of the 13 cases with exocervix (P = .003, .003, and .0006 respectively). Expression of MIB-1 in the surface half of the epithelium was seen in 18 (66%) of the 27 cases with condyloma but in none of the 24 controls (P < .00001). MIB-1 in the surface half of the epithelium and/or in more than 15% of the basal cells was seen in 24 (90%) of the 27 condyloma cases and 1 (4%) of the 24 control cases (P < .00001). A finding of 6 or more mitoses per 10 high power fields, expression of MIB-1 in the surface half of the epithelium, and more than 15% of basal cells staining for MIB-1 should support a diagnosis of condyloma over metaplastic or inflammatory changes.

Papillary immature metaplasia (immature condyloma) of the cervix: a clinicopathologic analysis and comparison with papillary squamous carcinoma

Papillary immature metaplasia (PIM) is a variant of human papillomavirus (HPV) 6 or 11 infection. PIM resembles an immature metaplasia but has filiform papillae, variable cytological atypia, and, frequently, extension into the endocervical canal. Because the unusual morphology and presentation of PIM may cause confusion between this and other benign and malignant papillary neoplasms, we conducted a clinicopathologic analysis of PIM and compared expression of Ki-67 between PIM, condyloma, and papillary carcinoma. Data on patient age, duration of the lesions, and procedures, including cone biopsy, were obtained. The distribution and intensity of staining for Ki-67 in the epithelium was recorded and compared with both condyloma and papillary carcinoma. HPV typing was performed by polymerase chain reaction (PCR) and restriction fragment length pleomorphism analysis (RFLP). Ten of 13 PIMs were HPV 6/11 positive. Three cases contained areas closely resembling condyloma. Eleven cone biopsies were performed on nine cases. Three were found to have a coexisting high-grade squamous intraepithelial lesion that was either HPV 6/11 negative or contained another HPV type. All PIMs displayed variable staining for Ki-67 with a low index of staining in the mid and upper epithelial layers. In contrast, areas of condyloma had significantly stronger staining in areas with viral cytopathic effect (koilocytosis). Six papillary carcinomas were analyzed and displayed moderate to diffuse staining, including staining of the superficial cell nuclei. PIM is a distinct pathological subset of cervical condyloma that frequently is managed by cone biopsy and may persist. The marked reduction in Ki-67 staining in superficial cell layers distinguishes PIM from some condylomata and most HSILs and papillary carcinomas. Immunostaining thus may be helpful in distinguishing PIM from papillary carcinoma, although the differentiation of the two is best made on morphological grounds.

Concentrations of carotenoids, tocopherols, and retinol in paired plasma and cervical tissue of patients with cervical cancer, precancer, and noncancerous diseases

Paired blood (collected after an overnight fast) and cervical tissue (cancerous, precancerous, and noncancerous) samples were obtained from 87 patients (age, 21-86 years) who had a hysterectomy or biopsy due to cervical cancer, precancer (cervical intraepithelial neoplasia I, II, and III), or noncancerous diseases. The samples were analyzed using high-performance liquid chromatography for 10 micronutrients (lutein, zeaxanthin, beta-cryptoxanthin, lycopene, alpha-carotene, beta-carotene, cis-beta-carotene, alpha-tocopherol, gamma-tocopherol, and retinol). The results indicated that: (a) among the three patient groups, the mean plasma concentrations of all micronutrients except gamma-tocopherol were lowest in the cancer patients; however, the mean tissue concentrations of the two tocopherols and certain carotenoids were highest in the cancerous tissue; and (b) among the 10 micronutrients, only the concentrations of beta-carotene and cis-beta-carotene were lower in both the plasma and tissue of cancer and precancer patients than in those of noncancer controls. These results suggest that: (a) not all of the micronutrient concentrations in plasma reflect the micronutrient concentrations in cervical tissue; thus, in some cases, it may be necessary to measure the tissue micronutrient concentrations to define the role of the micronutrients in cervical carcinogenesis; and (b) maintaining an adequate plasma and tissue concentration of beta-carotene may be necessary for the prevention of cervical cancer and precancer.

Comparison of topoisomerase II alpha and MIB-1 expression in uterine cervical squamous lesions

The aim of this study was to assess the role of MIB-1 in the classification of cervical squamous lesions and to compare it with a novel proliferation marker, topoisomerase II alpha (TP II alpha). We classified 46 archival uterine cervical cases into 6 groups: normal (n = 3); human papillomavirus (n = 15); mild (n = 10), moderate (n = 7), and severe (n = 6) cervical intra-epithelial neoplasia; and invasive carcinoma (n = 5). The formalin-fixed, paraffin-embedded tissue sections were stained with monoclonal antibodies to Ki-67 (MIB-1) and TP II alpha with a standard streptavidin immunohistochemical technique, with antigen retrieval to assess enzyme presence. The results were based on nuclear staining and percentage of positivity. We found that the mean percentage of positive nuclei increased from normal through increasing grades of dysplasia to its maximal level in invasive carcinoma. The level of positive nuclei in the epithelium also generally increased from basal to full thickness with progression of the lesions. The correlation between the percentage of nuclei positive for both antibodies with the use of linear regression was close, with an r value of 0.85. Our conclusions were that MIB-1 is an adjunct in the classification of squamous lesions of the uterine cervix and that TP II alpha is a useful proliferation marker in this setting.

Assessment of estrogen receptor distribution in human endometrium by direct immunofluorescence

OBJECTIVE

To use a direct immunofluorescence technique employing a fluorescein labeled anti-idiotypic antibody that recognizes the estrogen receptor (ER) order to assess the distribution of ER in the uteri of normal women throughout the normal menstrual cycle and of a woman exposed prenatally to diethylstilbestrol (DES).

SUBJECTS

Included in the study were 25 women aged between 35 and 50 years and an amenorrheic patient diagnosed as "DES Syndrome".

LOCALIZATION

Localization of ER expression in frozen sections of uterine tissue was achieved by direct immunofluorescence using a fluorescein labeled anti-idiotypic antibody that interacts with ER.

RESULTS

Analysis of the immunofluorescence staining indicated that in the normal human endometrium the intensity of ER staining varied according to the phase of the cycle as well as according to the cell type. On the other hand, endometrial ER evaluation of the patient with DES syndrome showed minimal expression of ER and after treatment with conjugated estrogens, endometrial biopsy revealed a significant increase in ER expression.

CONCLUSIONS

These findings indicate that the fluorescein labeled anti-idiotypic antibody can be used to detect ER in normal and pathological human endometrium and to monitor changes in ER expression in the endometrium during hormonal therapy.

Immunohistochemical localization of filaggrin in benign, premalignant and malignant cervical tissue

Epithelial distribution of filaggrin, a histidine-rich protein related to squamous terminal differentiation, was investigated in 87 cervical biopsies using an avidin-biotin-peroxidase technique with a monoclonal anti-human filaggrin antibody (AKH1). Normal squamous cervical epithelium exhibited a positive homogeneous immunoperoxidase stain in the upper parabasal, intermediate and superficial cell layers. Similar findings were obtained in cervical condylomas, although full-thickness staining was observed in 35.7% of the cases (P < 0.001). Filaggrin expression in CIN was inversely related to the severity of the lesion (P < 0.001). An irregular staining pattern was present in most high-grade CIN. Filaggrin expression was closely connected to the degree of tumour differentiation (P < 0.05) in squamous cell carcinomas of the cervix. Abnormal filaggrin stainings identified a premalignant/malignant cervical squamous lesion with a positive predictive value of 92.3%. Non-squamous epithelia showed lack of filaggrin expression. Filaggrin may therefore be considered a marker of squamous differentiation in both the normal and pathological human uterine cervix.

Immunohistochemical localization of syndecan-1 in normal and pathological human uterine cervix

Expression of syndecan-1, a cell surface proteoglycan that binds growth factors and extracellular matrix components, was studied in normal and pathological human uterine cervix using immunohistochemical methods. Normal cervical squamous epithelium showed positive staining for syndecan-1 in all cell layers, except the basal cell layer, whereas endocervical columnar epithelium stained weakly. In non-neoplastic reactive lesions, metaplastic squamous cells were positive for syndecan-1, whereas columnar cells showed weak or negative staining. In cervical condylomas, cells showing koilocytotic atypia were positive for syndecan-1. The progression of cervical intraepithelial neoplasia (CIN) grade I to grade III was associated with reduced syndecan-1 expression and localization of syndecan-1 to more superficial cell layers. In squamous cell carcinomas (SCCs), syndecan-1 expression correlated with histological differentiation, being absent from most poorly differentiated tumours. The results suggest that loss of syndecan-1 from atypical cells is an early event during cervical carcinogenesis and show a close association of syndecan-1 expression with preserved epithelial morphology and differentiation.

Cytokeratin expression and acetowhite change in cervical epithelium

AIM

To investigate the distribution of cytokeratins 10, 13, 14 and 19 in biopsy specimens taken from acetowhite and non-acetowhite areas of the cervix.

METHOD

Cervical biopsy specimens were taken from both acetowhite and non-acetowhite areas from 44 patients who presented with abnormal cervical cytology. The specimens were snap frozen in liquid nitrogen and multiple sections taken from each specimen. Staining was performed for cytokeratins 10, 13, 14, 19 and NADPH diaphorase enzyme. The areas of each section positive for the various markers were measured.

RESULTS

Cytokeratin 10 positive cells were greatly increased in number in acetowhite biopsy specimens compared with non-acetowhite samples (45.1% v 2.8%; p < 0.0001). Cytokeratin 19 was also increased, but to a lesser extent (17.8% v 5.5%; p < 0.0001). In contrast, the almost universal expression of cytokeratin 13 was reduced in acetowhite biopsy specimens (86.2% v 96.9%; p < 0.0001). Cytokeratin 14 was found diffusely in the basal region of the stratified squamous epithelium and was marginally more apparent in the acetowhite biopsy specimens (p = 0.04).

CONCLUSION

It is suggested that the presence of cytokeratin 10 may be an essential requirement for the formation of acetowhite change in association with the cellular swelling caused by acetic acid.

Unusual endocervical lesions with endocrine cells

Four cases of unusual lesions of endocervix are presented. They were all incidental findings, showing no obvious infiltrative and metastatic properties to attest their malignant nature. Two lesions were entirely confined to the endocervical mucosa. The main characteristics of these proliferative processes thus were an abnormal architecture with branched or small glands, a hypermucinous benign-appearing epithelium of endocervical type, and stromal smooth-muscle. In contrast with normal endocervical mucosa, all lesions contained prominent and variegated endocrine cells. These 4 cases were quite comparable to 3 other observations previously reported. This homogeneous group of endocervical lesions does not correspond to a well-defined type of endocervical neoplasia. It shares morphological analogies with adenoma malignum. The relationship with adenoma malignum as well as with some other gynaecological neoplasms is discussed. The recognition of these small-sized and highly differentiated lesions is largely facilitated by the use of the Grimelius reaction to detect argyrophilic cells.

Enhanced tenascin expression in cervical and vulvar koilocytotic lesions

Tenascin is an extracellular matrix glycoprotein that is widely expressed during embryogenesis. In adults, it is restricted to select sites, including certain epithelial-stromal interfaces, but is notably enhanced in active inflammatory-reactive processes and in the stroma of many neoplasms. The authors immunostained with the monoclonal antibody (MAb) 100EB2 cryosections of vulvar and cervical biopsies displaying convincing koilocytosis with variable degrees of hyperplasia-dysplasia; in situ carcinomas were included. The presence of human papillomaviruses (HPV) 6, 11, 16, 18, 31, or 33 was confirmed by in situ hybridization in a subset of cases. Findings were compared with normal controls. The study was extended with the MAb 143DB7 that reacted with tenascin in paraffin sections. In normal samples, tenascin immunoreaction appeared as a delicate, continuous rim, in the immediate vicinity of the laminin staining; in parakeratotic areas, the rim was thicker. In foci of hyperplastic-dysplastic epithelium with or without koilocytosis, a distinct increase in tenascin staining was noted; enhanced tenascin often paralleled increasing hyperplasia and dysplasia. In most cervical and vulvar carcinomas in situ, the reactions were intense and extended deeply and raggedly into the underlying stroma. Tenascin was selectively enhanced in the endocervical stroma around inflammed or metaplastic glands. The authors conclude that tenascin is increased in HPV infection associated with epithelial proliferation. Enhancement was most consistently strong and extensive in in situ carcinomas, suggesting a correlation with active phases of epithelial growth and stromal remodeling.

Patterns of keratin 19 expression in normal, metaplastic, condylomatous, atrophic, dysplastic, and malignant cervical squamous epithelium

Keratin 19 (K-19) expression has been strongly correlated with dysplasia in oral epithelium. Expression of K-19 was evaluated by immunoperoxidase staining in formalin-fixed normal ectocervical tissue, normal endocervical tissue, cervical dysplasia, squamous metaplasia, atrophic epithelium, cervical condylomas, and invasive carcinoma to determine if a correlation of K-19 expression with dysplasia was present in the cervical epithelium. Uniform expression of K-19 was seen in endocervical epithelium and in the basal layer of normal ectocervical epithelium in all areas where these epithelia were present. Cervical dysplasia without associated condylomatous changes showed increased expression of K-19 in suprabasal epithelium, corresponding to the level of immature cells. Squamous metaplasia was characterized by scattered cells with increased staining (patch-quilt pattern). There was considerable overlap in the patterns of K-19 expression in dysplastic and metaplastic epithelium. Thus K-19 staining pattern could not be used as a distinctive marker for dysplasia in the cervical epithelium. Atrophic epithelium showed a characteristic uniform but low-level expression of K-19 in suprabasal areas. This pattern may be of diagnostic use in differentiating atrophic lesions from dysplasia. Condylomas showed focal loss of K-19 in the basal layer, suggesting induction of premature differentiation in the basal layer by human papillomavirus infection. Invasive carcinomas showed variable patterns. K-19 is a marker of immature cervical squamous epithelium, with generally distinctive but sometimes overlapping patterns of expression in various diagnostic categories.

Ceroid granuloma of the uterine cervix

An excision biopsy was taken from a 59-year-old woman with a small dark-brown lesion on the anterior lip of the cervix. The histology revealed an ulcerated surface epithelium with a band-like infiltrate of pigment containing macrophages in the subepithelial zone. Histochemical examination of the specimen revealed that the pigment was ceroid. This is, to the best of our knowledge, the first case report of ceroid granuloma of the uterine cervix.

Immunolocalization of cystatin A in neoplastic, virus and inflammatory lesions of the uterine cervix

Cystatin A was immunohistochemically demonstrated in the normal squamous epithelium of the uterine cervix, particularly in the parabasal and superficial cell layers whereas it was absent or scanty in the basal cells and in areas with parakeratosis. Cystatin A was also found in neoplastic lesions (dysplasia, carcinoma in situ and squamous cell carcinoma), but less abundant than in normal squamous epithelium. The immunoreaction in intraepithelial neoplasia was closely related to the degree of morphological maturation of the squamous cells with more abundant cystatin A in low grade dysplasia and less in high grade dysplasia and carcinoma in situ. In squamous cell carcinoma, cystatin A was often abundant in highly differentiated areas and almost absent in poorly differentiated ones. Cystatin A was found in the squamous epithelium in herpes and in condylomatous lesions. It was also found in the cytoplasm of neutrophils, but not in lymphocytes and plasma cells. In unspecific cervicitis, cystatin A was found extracytoplasmatically as small vesicles in the epithelial-stromal junction. The implications of cystatin A in neoplastic, virus, and inflammatory processes are discussed.

Patterns of Keratin Subsets in Normal and Abnormal Uterine Cervical Tissues An Immunohistochemical Study

We investigated the use of three monoclonal antikeratin antibodies on routinely formalin-fixed and paraffin-embedded punch and cone biopsies of the normal human uterine cervix and its metaplastic and premalignant lesions. Monoclonal antibodies used were AE8, which is specific for keratin 13; 34BE12, which reacts with keratins of the stratified squamous epithelium; and CAM5.2, which is specific for keratin 8. All these antibodies performed well in routinely processed surgical pathology material. AE8 antibody stained the suprabasal layer of the normal squamous epithelium. Squamous metaplasia and dysplasia were stained in 50% of the cases. Normal suprabasal distribution of the keratin 13, however, was lost in all positive dysplasia cases. CAM5.2 reacted with normal columnar cells in all cases, and squamous metaplasia was focally positive in 20% of the cases. Dysplasia showed a positive reaction in 30% to 40% of the cases. The 34BE12 antibody was reacting with the full thickness of the squamous epithelium. Squamous metaplasia and dysplasia were positive in 80% of the cases. In addition, 34BE12 stained reserve cell hyperplasia, making it a useful marker for this condition. Our results demonstrate that keratin immunohistochemistry with the above-listed antibodies gives pathogenetically interesting information on cervical lesions.

Ultrastructural visualization of human papillomavirus DNA in verrucous and precancerous squamous lesions

Human papillomavirus (HPV) DNA was ultrastructurally localized by the non-isotopic in situ hybridization technique in formalin-fixed, paraffin-embedded specimens of verruca vulgaris of the skin, condyloma acuminatum of the penis and severe dysplasia of the uterine cervix. Biotinylated DNA probe cocktails were employed for the visualization of HPV-DNA, types 6 and 11 (HPV 6/11) and types 16 and 18 (HPV 16/18). The papillomavirus genus-specific antigen was also visualized by pre-embedding immunoelectron microscopy using rabbit antiserum. In verruca vulgaris, HPV antigen-positive 50-60 nm-particles of mature viral size were observed in the nuclei of the granular cells and parakeratotic cells with perinuclear haloes, whereas HPV 6/11 and HPV 16/18 DNA were negative. In condyloma acuminatum, the nuclei were positive for the HPV antigen and HPV 6/11 DNA, but were negative for HPV 16/18 DNA. More cells were labeled for the viral DNA than for the viral antigen. The ultrastructural observation indicated the presence of the naked (plasmid) viral DNA as fine particles sized 15-20 nm. In the dysplastic cervical mucosa, dot-like positivity of HPV 16/18 DNA was recognized. The HPV antigen and HPV 6/11 DNA were undetectable. HPV 16/18 DNA was localized in part of the nuclear chromatin. This pattern of localization may suggest integration of the viral DNA into the host cell DNA.

Distribution of involucrin in normal and pathological human uterine cervix

A study was undertaken to determine the potential value of involucrin immunostaining, a protein synthesized by mature squamous epithelial cells, in distinguishing benign from neoplastic lesions in cervical pathology. A total of 146 cervical biopsies were analyzed using an indirect immunoperoxidase method and polyclonal antibody. A suprabasal homogeneous cytoplasmic staining pattern was consistently observed in normal squamous cervical epithelium. In contrast, 43.7% of cervical condylomas showed involucrin at all levels of the epithelium including the basal layer. Variable patterns were seen in cervical intraepithelial neoplasia (CIN), with 46% of full-thickness stainings, although no significant difference was obtained among the different grades of CIN lesions. Distribution of involucrin was correlated (P less than 0.05) with the degree of tumor differentiation in squamous cell carcinomas, being absent in 71.4% of poorly differentiated carcinomas and focally present in 75% of well-differentiated carcinoma. Lesions of endocervical origin, either benign or malignant, were entirely negative for involucrin. It is concluded that involucrin seems unable to establish a reliable differential diagnosis between benign and neoplastic conditions in cervical pathology, and should therefore be considered only a specific marker of squamous differentiation in both normal and pathological human uterine cervix.

[Detection of HPV-DNA in the various uterocervical lesions by in situ hybridization]

We detected HPV (Human Papilloma Virus) -DNA in various uterocervical lesions by in situ hybridization using biotinylated DNA probes. In cases positive for HPV, the nuclei of the epithelial cells was purple to blackish purple. In 2 of 6 cases of chronic cervicitis, HPV-DNA was detected in the outer layer of the squamous epithelium. Eleven of 19 with mild dysplasia (57.9%) showed a positive reaction in the upper one-third of the epidermis in a mainly consisting of koilocytotic cells. All 6 patients with moderate dysplasia had positive cells among the koilocytotic cells and atypical cells in the middle layer. Five of 11 patients with severe dysplasia had scattered positive cells. Two of them had atypical condylomatoid lesions. Eight of 32 patients with squamous cell carcinoma were positive for HPV-DNA, but there was no consistent distribution pattern of the positive cells.

Cytokeratin expression in cervical epithelium: an immunohistological study of normal, wart virus-infected and neoplastic tissue

In this study using a panel of anticytokeratin antibodies and an indirect immunoperoxidase method, we examined cervical squamous epithelia including mature stratified epithelium, immature squamous metaplasia, CIN 1, 2 and 3, wart virus infection and squamous carcinoma. Changes from the normal patterns of staining were inconsistently seen in CIN 1 and 2, but in CIN 3 the changes were more marked, and consisted of a loss of stratification of the staining pattern and a patchy reduction in staining. Invasive carcinomas showed a similar staining pattern to CIN 3 lesions.

Correlation of histology with human papillomavirus DNA detection in the female genital tract

Genital condyloma and intraepithelial neoplasia secondary to Human Papillomavirus (HPV) infection are characterized by perinuclear halos and marked nuclear atypia (koilocytotic atypia) on cytologic and histologic examination. However, at times the histologic findings, including the degree of nuclear atypia, may be suggestive but not absolutely diagnostic of an HPV related neoplasm. HPV DNA sequences were detected in 63 and 56% of colposcopically visible vaginal and cervical lesions, respectively, that were diagnosed as condyloma or intraepithelial neoplasia. HPV DNA sequences were detected in 14 and 47% of vaginal and cervical lesions, respectively, that did not fulfill the histologic criteria of condyloma or intraepithelial neoplasia (i.e., "nondiagnostic"). When examining cervices from patients with no visible lesion and no recent history of an abnormal pap smear, 5.5% had detectable HPV DNA sequences. The histologic findings in this group were equivalent to the virus-negative cases and similar to the "nondiagnostic" cervical lesions. These findings suggest that the detection rate of HPV DNA in "nondiagnostic" tissues is dependent on the site and presence or absence of a visible lesion. The rate is similar in cervical lesions regardless of the histologic findings whereas it is less in vaginal lesions when the histologic criteria of condyloma or intraepithelial neoplasia are not detected.

Estrogen receptor distribution in the normal and pathologically changed human cervix uteri: an immunohistochemical study with use of monoclonal anti-ER antibody

Normal and pathologically changed structures of human cervix uteri were examined for estrogen receptor (ER) content using monoclonal antiestrophilin antibody (H 222 SP gamma) and the peroxidase-antiperoxidase method (PAP). The study was performed on fresh-frozen cervical specimens from 30 women; the staining was evaluated semiquantitatively. The ER expression in cervical mucosa was generally strong and comparable to the ER expression by proliferating endometria. The only exception was the endocervical stroma, which showed distinctly weaker specific staining than other cervical structures. This might account for ER concentration gradients observed in biochemical studies. The ER content in endocervical glands varied in different cases and in different areas of the same specimen, but no correlation to the functional activity of the genital tract or to the morphology of the glands could be found. The squamous epithelium of the portio vaginalis contained relatively large amounts of ER in the basal, parabasal, and intermediate layers. The superficial layer was ER-negative. The only factor we observed that strongly influenced the ER content in cervical mucosa was a local inflammatory process. Our results suggest that the synthesis of ER in cervical epithelium can be influenced by underlying stroma.

Spontaneous resolution of cervical warty atypia: the relevance of clinical and nuclear DNA features: a prospective study

A selected group of 51 patients with histological features of cervical warty atypia was observed for 1 year. Initial features were compared with a cohort of 50 patients with CIN. Twenty-four patients showed resolution of the warty atypia, in 19 it remained unchanged, and in eight patients CIN or microinvasive disease was present on repeat biopsy. The DNA patterns obtained by tissue imprint of the initial biopsies and subsequent integrated densitometry, using a Vickers M85 scanning densitometer, showed that warty atypias could be objectively distinguished from CIN, but that the method could not predict the group of warty atypias that would resolve. There was no clinical feature or group of features which allowed a means of predicting the outcome of such lesions.

Epidemiology and aetiology of cancer of the uterine cervix including the detection of carcinogenic N-nitrosamines in the human vaginal vault

Cancer of the uterine cervix occurs with high frequency in black females of several populations of Southern Africa. It accounts for 40-50% of all cancers in Black females in the Johannesburg area and for over 40% of those in women in the rural lowveld area of the Transvaal. The aetiology of this cancer has several distinct features, almost all of which concern some or other aspect of coitus. Age at first coitus and at first marriage, and promiscuity, are very strongly associated with the development of the disease, and age, race, religion, culture, socio-economic status, extent of genital hygiene and venereal disease also play a major role. In spite of current belief, circumcision of the male partner is at best weakly associated with the development of the disease, and so are menstruation, coital habits and pregnancy. Certain aetiological features are selectively discussed; these include Herpesvirus type II, 'rogue' spermatozoa and the recent isolation of a group of potent carcinogens, the nitrosamines, in infected discharge samples taken from the vaginal vault of patients attending gynaecological clinics.