The Natural History of Cervical Human Papillomavirus Infections and Cervical Cancer

Microbiota changes: the unseen players in cervical cancer progression

Cervical cancer ranks among the most prevalent cancers globally with high-risk human papillomaviruses implicated in nearly 99% of cases. However, hidden players such as changes in the microbiota are now being examined as potential markers in the progression of this disease. Researchers suggest that changes in the vaginal microbiota might correlate with cervical cancer. This review provides a comprehensive look at the microbiota changes linked with the advancement of cervical cancer. It also scrutinizes the databases from past studies on the microbiota during healthy and cancerous stages, drawing connections between prior findings concerning the role of the microbiota in the progression of cervical cancer. Preliminary findings identify Fusobacterium spp., Peptostreptococcus spp., Campylobacter spp., and Haemophilus spp., as potential biomarkers for cervical cancer progression. Alloscardovia spp., Eubacterium spp., and Mycoplasma spp. were identified as potential biomarkers for HPVs (+), while Methylobacterium spp. may be indicative of HPV (-). However, the study's limitations, including potential biases and methodological constraints, underscore the need for further research to validate these findings and delve deeper into the microbiota's role in HPV development. Despite these limitations, the review provides valuable insights into microbiota trends during cervical cancer progression, offering direction for future research. The review summarizes key findings from previous studies on microbiota during healthy and cancerous stages, as well as other conditions such as CIN, SIL, HPV (+), and HPV (-), indicating a promising area for further investigation. The consistent presence of HPV across all reported cervical abnormalities, along with the identification of distinct bacterial genera between cancerous and control samples, suggests a potential link that merits further exploration. In conclusion, a more profound understanding of the microbial landscape could elucidate the pathogenesis of cervical diseases and inform future strategies for diagnosis, prevention, and treatment.

Association of TLR4 and TLR9 gene polymorphisms with cervical HR-HPV infection status in Chinese Han population

BACKGROUND

Toll-like receptors (TLRs) may be involved in the natural history of human papillomavirus (HPV) infection. In our study, we aimed to investigate the association of TLR4 (rs10116253, rs1927911, rs10759931) and TLR9 (rs187084, rs352140) gene polymorphisms with cervical persistent high-risk HPV (HR-HPV) infection, as well as multiple HR-HPV infections.

METHODS

A total of 269 study subjects were enrolled and grouped by retrospectively analyzing the HR-HPV testing results and other clinical data of 2647 gynecological outpatients from Jingzhou Hospital Affiliated to Yangtze University. We conducted a case-control study to compare the role of TLR4/TLR9 gene polymorphisms between HR-HPV transient and persistent infections, as well as between HR-HPV single and multiple infections. HR-HPV genotypes were detected using Real-time polymerase chain reaction (RT-PCR). PCR-restriction fragment length polymorphism (PCR-RFLP) was used to determine TLR4 and TLR9 gene polymorphisms. Analyses of the different outcome variables (HR-HPV infection status and time for HR-HPV clearance) with respect to TLR4/TLR9 polymorphisms were carried out. Logistic regression analysis was used to determine the association of TLR4/TLR9 genotypes and alleles with HR-HPV infection status. The Kaplan-Meier method with the log-rank test was used to analyze the relationship between TLR4/TLR9 genotypes and the time for HR-HPV clearance.

RESULTS

The mutant genotypes of TLR9 rs187084 and rs352140 were associated with persistent (rs187084: CT and CT+CC; rs352140: CT and CT+TT) and multiple (rs187084: CT and CT+CC; rs352140: CT+TT) (all P < 0.05) HR-HPV infection. However, no association was found between TLR4 polymorphisms and HR-HPV infection status. Kaplan-Meier time to HR-HPV clearance analysis demonstrated that women carrying rs187084 and rs352140 mutant genotypes take longer duration to clear HR-HPV infection compared with wild-type genotype carriers (P1 = 0.012; P2 = 0.031).

CONCLUSION

Our results suggested that TLR9 polymorphisms, but not TLR4, were associated with cervical persistent and multiple HR-HPV infections, which could be useful as a potential predictor of HR-HPV infection status.

Distribution of high-risk human papillomavirus in women with ASC-US or LSIL in Tunisian women: Place of HPV testing for women triage in Tunisia

The present study aimed to evaluate the distribution of oncogenic HPVs in Tunisian women diagnosed with ASC-US or LSIL in order to highlight the importance of HPV testing in the management of women with minor cytological lesions. The study involved 213 cervical samples from women aged from 18 to 82 years and diagnosed with ASC-US or LSIL. HPV detection and genotyping was performed by nested PCR followed by reverse Line Blotting. HPV DNA was identified in 161 cases (76.3%). Oncogenic HPV genotypes were detected in 53.1% of cases. The most frequent high-risk genotypes in this study were HPV16 (28.8%) followed by: HPV51 (9.6%), HPV18, HPV31 HPV56 (7.1%) and HPV45 (5.1%). Thus, 24 % of studied women were not infected by HPV and about 47% of infections are without oncogenic HPV. These results highlight the value of HPV testing in the decision algorithm of management of minor abnormalities lesions.

Carcinogenesis and Cancer Progression in De Novo Anal Squamous Cell Carcinoma After Organ Transplantation: A Systematic Review

Our aim was to perform a comprehensive literature review on the pathogenesis of squamous anal cancerin patients after solid-organ transplant. Medical databases were consulted until June 1, 2020, for potentially relevant publications.All studies on pathogenesis of de novo anal squamous cell carcinoma in solid-organ transplant recipients were included. Two researchers independently performed study selection, quality assessment, and data extraction and analysis. Twenty-one studies were included.None ofthe selected papers had been solely focused on carcinogenesis. Most ofthe studies identified human papillomavirus infection and immunosuppression to be significantly correlated with the development of de novo anal cancer in adult solid organ transplant recipients. CD4+ T-cell depletion and inactivation oftumor suppressor pathways were mainly implicated. All solid-organ transplant recipients, especially those who were human papillomavirus positive, were shown to be at increased risk for the development of posttransplant anal cancer. Further studies are needed to determine the specific mechanisms of pathogenesis according to different solid-organ transplant populations.

Changes of vaginal microbiota during cervical carcinogenesis in women with human papillomavirus infection

Objective

To evaluate the changes of vaginal microbiota during cervical carcinogenesis in women with high-risk human papillomavirus infection.

Materials and methods

Vaginal microbiota was analyzed using next-generation sequencing in women with normal, cervical intraepithelial neoplasia (CIN), or cervical cancer.

Results

A marked decrease of Lactobacillus crispatus was found in the CIN/cancer groups compared with that in the normal group. The diversity of microorganisms increased in patients with CIN or cervical cancer with HPV infection. Atopobium vaginae (OR 4.33, 95% CI 1.15–16.32), Dialister invisus (OR 4.89, 95% CI 1.20–19.94), Finegoldia magna (OR 6.00, 95% CI 1.08–33.27), Gardnerella vaginalis (OR 7.43, 95% CI 1.78–31.04), Prevotella buccalis (OR 11.00, 95% CI 2.00–60.57), and Prevotella timonensis (OR 6.00, 95% CI 1.46–24.69) were significantly associated with the risk of CIN 2/3 or cervical cancer.

Conclusion

Women with the CIN and cervical cancer showed a high diversity in vaginal microbiota. Depletion of Lactobacillus crispatus and increased abundance of anaerobic bacteria were detected in women with cervical disease.

Outcomes of prior cervical cytology and HR-HPV testing in women subsequently diagnosed with CIN1, CIN2/3, and invasive cervical cancer: a 4-year routine clinical experience after implementation of systematic training and quality control programs

BACKGROUND

In 2013, Jinan KingMed Diagnostics (JKD) first established a systematic cervical cytology training and quality control (QC) program in Shandong Province, China. We compared the efficacy of high-risk human papillomavirus (HR-HPV) detection, cytology, and their combination in routine clinical practice after the implementation of the training and QC program to identify the optimal first-line screening method in this region.

METHODS

The data of patients histologically diagnosed with cervical intraepithelial neoplasia (CIN) 1, CIN2/3, and invasive cervical cancer (ICC) between January 2014 and December 2017 were retrieved from the JKD database. Cytology and/or HR-HPV testing results within 3 months preceding the CIN1 diagnoses and 6 months preceding the CIN2/3 and ICC diagnoses were analyzed.

RESULTS

Prior screening data were available for 1829 CIN1 patients, 2309 CIN2/3 patients, and 680 ICC patients. Cytology alone and HR-HPV testing alone had similar rates of positive results for CIN2/3 (97.2% [854/879] vs. 95.4% [864/906], P = 0.105) and ICC detection (89.1% [205/230] vs. 92.7% [204/220], P = 0.185). Compared with either method alone, co-testing slightly increased the screening sensitivity for CIN2/3 (99.8% [523/524], all P < 0.001) and ICC (99.6% [229/230], all P < 0.001) detection. In the CIN1 group, cervical cytology alone (92.9% [520/560]) was more sensitive than HR-HPV testing alone (79.9% [570/713], P < 0.001), and co-testing (95.3% [530/556]) did not significantly improve the screening sensitivity (P = 0.105).

CONCLUSIONS

After the implementation of a systematic training and QC program, both cytology and HR-HPV testing may be adopted for primary cervical cancer screening in Shandong Province.

An observational study comparing HPV prevalence and type distribution between HPV-vaccinated and -unvaccinated girls after introduction of school-based HPV vaccination in Norway

BACKGROUND

Many countries have initiated school-based human papillomavirus (HPV) vaccination programs. The real-life effectiveness of HPV vaccines has become increasingly evident, especially among girls vaccinated before HPV exposure in countries with high vaccine uptake. In 2009, Norway initiated a school-based HPV vaccination program for 12-year-old girls using the quadrivalent HPV vaccine (Gardasil®), which targets HPV6, 11, 16, and 18. Here, we aim to assess type-specific vaginal and oral HPV prevalence in vaccinated compared with unvaccinated girls in the first birth cohort eligible for school-based vaccination (born in 1997).

METHODS

This observational, cross-sectional study measured the HPV prevalence ratio (PR) between vaccinated and unvaccinated girls in Norway. Facebook advertisement was used to recruit participants and disseminate information about the study. Participants self-sampled vaginal and oral specimens using an Evalyn® Brush and a FLOQSwab™, respectively. Sexual behavior was ascertained through a short questionnaire.

RESULTS

Among the 312 participants, 239 (76.6%) had received at least one dose of HPV vaccine prior to sexual debut. 39.1% of vaginal samples were positive for any HPV type, with similar prevalence among vaccinated and unvaccinated girls (38.5% vs 41.1%, PR: 0.93, 95% confidence interval [CI]: 0.62-1.41). For vaccine-targeted types there was some evidence of lower prevalence in the vaccinated (0.4%) compared to the unvaccinated (6.8%) group (PR: 0.06, 95%CI: 0.01-0.52). This difference remained after adjusting for sexual behavior (PR: 0.04, 95%CI: 0.00-0.42). Only four oral samples were positive for any HPV type, and all of these participants had received at least one dose of HPV vaccine at least 1 year before oral sexual debut.

CONCLUSION

There is evidence of a lower prevalence of vaccine-targeted HPV types in the vagina of vaccinated girls from the first birth cohort eligible for school-based HPV vaccination in Norway; this was not the case when considering all HPV types or types not included in the quadrivalent HPV vaccine.

Evaluation of inter-observer concordance of the Swede score for digital colposcopic images

Objective

To assess inter-observer concordance by training level when applying the Swede score to digital colposcopy images.

Materials and methods

Concordance study assembled in a cross-sectional study. The population consisted of patients referred for colposcopy to a cervical pathology reference center in Bogotá, Colombia, due to abnormal cytology. Convenience sampling was used. Measured variables were age, level of education, marital status, risk factors for cervical cancer such as parity, age of sexual activity initiation and number of sexual contacts, contraceptive method, cytology report and colposcopy result according to the criteria of the Swede score. Concordance was calculated using the weighted kappa (k) index.

Results

The analysis was based on a set of 3 digital colposcopic images of 251patients. For the total score on the scale, low agreement (k = 0.38; 95% CI: 0.26-0.44) was found between two expert gynecologists; low agreement (k = 0.27; IC 95 %: 0.20-0.38) was also shown for a pair of gynecologists with different training levels, while moderate agreement (k = 0.45; 95% CI: 0.34-0.53) was found for the third pair. For individual criteria on the Swede scale, the best agreement was found for "acetowhite reaction" and "lesion size" (k = 0.43; 95% CI: 0.33-0.53).

Conclusions

Inter-observer concordance using the Swede score for digital colposcopic images ranged from low to moderate according to the level of training of the gynecologists.

Previous Papanicolaou and Hybrid Capture 2 human papillomavirus testing results of 5699 women with histologically diagnosed cervical intraepithelial neoplasia 2/3

INTRODUCTION

Cervical cancer remains an important public health problem in Chinese women owing to the lack of a national screening program. The aim of the present study was to evaluate human papillomavirus (HPV) and Papanicolaou (Pap) test results preceding the histologic diagnosis of cervical intraepithelial neoplasia 2/3 (CIN2/3) in China's largest College of American Pathologists-certified clinical laboratory.

MATERIALS AND METHODS

All cases of CIN2/3 histologically diagnosed from January 2011 to August 2016 were retrieved from the pathology department records. The Pap cytology and HPV test results from the 6 months before the CIN2/3 diagnoses were analyzed.

RESULTS

A total of 5699 patients with histologically diagnosed CIN2/3 had previous Pap and/or HPV Hybrid Capture 2 testing results within the previous 6 months. The average age was 39.5 years (range, 16-82 years). Of these patients, 4288 had Pap test findings (average, 1.5 months) available. The results were high-grade squamous intraepithelial lesion in 44.1%, low-grade squamous intraepithelial lesion in 20.0%, atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion, in 16.0%, atypical squamous cells of undetermined significance, in 12.3%, atypical glandular cells in 0.7%, and negative in 6.9%. Of the 5699 patients, 2546 had HPV Hybrid Capture 2 test results (average, 1.4 months) available. Of these, 91.7% had positive results and 8.3% had negative results. Of 1135 patients with both previous Pap and HPV results, 7.1% had negative HPV results and 8.0% had negative Pap results (P = 0.38). Only 21 patients (1.9%) had double negative results.

CONCLUSIONS

The present study has reported the previous results of HPV testing and Pap cytology for patients with high-grade cervical squamous precursor lesions in a population of women in China who had not undergone intensive previous screening. Both high-risk HPV and Pap cytology had similar negative testing rates for these women, although double negative results were less common. These results support the value of combined testing in the detection of cervical cancer precursors.

Influence of intrauterine dispositive in human papillomavirus clearance

INTRODUCTION

An important inverse relation between IUD use and risk of cervical cancer has been proved. Women who used IUD had half the risk of developing cervical cancer. The mechanism how IUD is a protector factor is still unknown. Could be improving the clearance of HPV infection or stopping progression to cancer from preneoplasic lesion. The aim of the study is to check if IUD increases HPV clearance, that is, checking if after 1 year HPV infection disappears in more patients using IUD than those not using it.

STUDY DESIGN

This is a cohort case-control prospective study, carried out in Universitary Hospital La Zarzuela in Madrid, Spain, performed between October 2015 and April 2018. No pregnant women between 25-50 years old, with HPV cervical infection were enrolled. We separated the participants into two groups: an IUD group, with women starting using IUD and non IUD group, with women using any other contraceptive method or none. HPV genotyping of cervical cytology samples were performed initially on enrolment day and one year after.

RESULTS

254 participants were enrolled at the beginning of the study, 85 in the IUD group and 169 in the control group (non IUD). 179 participants completed the study, 54 (31%) in IUD group and 120 participants in non IUD group (69%). 38 women from IUD group cleared HPV infection (69.5%) and 65 women from control group cleared it (54.2%) (p = 0.044). An association in logistic regression was observed in HPV clearance with different factors. Firstly, higher percentage of patients with IUD clear the HPV infection than those in control group significantly associated (OR = 0.698, CI 95%; 0.251-0.998, p = 0.046). Clearance was higher in patients with low-risk HPV infection comparing with high risk HPV (OR = 1.078, CI 95%; 1.126-4.6.281, p = 0.026) and in patients with only one HPV type than those with more than one (OR = 0.194, CI 95%; 0.084-0.403, p < 0.001).

CONCLUSIONS

In Spanish women with HPV infection, the HPV clearance between IUD and non IUD groups show results with statistical significance, patients with IUD have higher clearance rates. There were differences also between suffering one HPV type or more than one, and having low-risk HPV or high-risk HPV infection.

Microbiota dysbiosis is associated with HPV-induced cervical carcinogenesis

Cervical microbial communities serve a crucial role in the persistence and development of oncogenic human papilloma virus (HPV) infections. In the present study, the authors hypothesised that disturbed heterogeneity of microbial flora was associated with HPV-induced carcinogenesis. Swabs of the cervical microbiota were collected from 250 women and the 16S ribosomal DNA was sequenced using a high throughput assay. The swabs of cervical microbiota were grouped according to the community state types (CSTs) as follows: Healthy cervical swabs; swabs taken from low-grade squamous intra-epithelial lesions (LSIL) and swabs taken from high-grade squamous intra-epithelial lesions (HSIL). Analysis of the bacterial classes revealed that the CST cervical swabs of the volunteers were characterised by Lactobacillus crispatus, Lactobacillus iners and Lactobacillus taiwanensis, however, Gardnerella vaginalis and Lactobacillus acidophilus were absent. In the CST of patients with LSIL the predominant type of bacteria was Lactobacillus acidophilus and Lactobacillus iners, however Lactobacillus crispatus was not detected. Swabs from CST women diagnosed with HSIL exhibited abundant Gardnerella vaginalis and Lactobacillus acidophilus, however, lacked Lactobacillus taiwanensis, Lactobacillus iners and Lactobacillus crispatus. The abundance of Lactobacillus acidophilus in swabs from the healthy women was compared with the swabs from the women with LSIL. The results of the present study indicated that the development of HPV-induced cancer is associated with a high diversity of vaginal microbiota, which is involved in the control of viral persistence, and is therefore indicative of disease prognosis.

Eradicating HPV-Associated Cancer Through Immunization: A Glass Half Full…

The human papillomavirus (HPV) is an important causal agent of premalignant cervical epithelial changes and cervical cancers. These cancers account for ∼5% of all cancers globally and kill more than a quarter million women annually. HPV infections also associate with certain anogenital and oropharyngeal cancers. Events leading to the development of HPV vaccines to prevent associated cancers are described, with a further discussion of goals that must be met to achieve full virus eradication.

Motivos para recusa da vacina contra o Papilomavírus Humano entre adolescentes de 11 a 14 anos no município de Maringá-PR

Introdução: O Ministério da Saúde incluiu a vacina contra o Papilomavírus Humano (HPV) no calendário básico de imunizações em 2014 com a meta vacinar pelo menos 80% das adolescentes entre 11 e 13 anos de idade. Objetivos: Frente à baixa adesão à campanha nacional de vacinação contra o HPV no município de Maringá, PR, em 2014, o presente estudo teve como objetivos: 1) identificar o nível de conhecimento das adolescentes acerca do vírus e da vacina; e 2) descrever os motivos pelos quais elas não se vacinaram. Métodos: Trata-se de um estudo observacional transversal, do tipo inquérito domiciliar com delineamento descritivo, conduzido com 58 adolescentes que não tomaram a 1ª e/ou a 2ª dose da vacina dentro do prazo estipulado pela campanha vacinal de 2014. Para coleta de dados, foi aplicado questionário por meio de entrevistas face a face. Resultados: 86% das adolescentes já ouviram falar do vírus, 74% sabe que sua transmissão é sexual, 49% conhece sua relação com o câncer de colo de útero e 88% já ouviu falar da vacina. A maior parte das meninas entrevistadas não se vacinou por recusa por parte dos pais. Conclusão: Os resultados do presente estudo sugerem que o desconhecimento sobre a infecção pelo HPV e sobre a campanha de vacinação entre as entrevistadas e seus responsáveis, bem como o medo de efeitos colaterais da vacina, como apontado pela população do estudo, interferiram negativamente na tomada de decisão.

[The detection of the human papilloma virus during hyperplastic processes in the nose, ears and throat]

The objective of the present work was to carry out the virological and histological studies of various neoplastic and hyperplastic processes in the nose, ears, and throat with a view to identifying the presence of human papilloma virus and Epstein-Barr virus. The brush biopsies and remote neoplasms obtained from 18 patients (including 2 children and 16 adults) presenting with various ENT diseases and tumours were available for the virological investigation with the use of the polymerase chain reaction (PCR) and a system MY09-MY11 degenerate primers . The histological study of biopsies and remote neoplasms was carried out by means of conventional light microscopy. The virological and histological studies conducted in parallel confirmed the diagnostic significance of morphological changes at the tissue and cellular levels caused by the human papilloma virus.

Human papillomavirus and head and neck carcinomas: focus on evidence in the babel of published data

Human papillomavirus (HPV)-associated squamous cell carcinoma of the oropharynx is a well-defined entity mostly affecting young to middle-aged male non-smokers. It is generally associated with a favourable outcome, and for this reason a less intensive therapeutic approach has been proposed for this subset of patients. The incidence of HPV-associated oropharyngeal cancers is rapidly increasing in most Western countries, but detailed epidemiological data are not available for the Italian population. Furthermore, among other head and neck regions, a smaller proportion of oral high-grade dysplasia and cancers seems to depend on HPV infection, whereas its role in laryngeal cancer is recognised as less relevant. HPV-dependent neoplastic transformation depends on the expression of viral oncogenes in the infected host cell that can only be directly documented through viral oncogene mRNA identification. The consensus on how to classify these patients from clinical and laboratory diagnostic points of view is still limited, with different approaches based on one or more diagnostic techniques including p16 immunostaining, in situ hybridisation and polymerase chain reation (PCR) amplification of viral DNA. The possibility of early diagnosis relying on the identification of HPV infection in oral and oropharyngeal exfoliated cells has so far provided unsatisfactory results, although viral persistence after treatment has been associated with risk of recurrence. Presently, sufficient data are not available to document the natural history and progression from tonsillar HPV infection to oropharyngeal cancer development, and to clearly define the modality of transmission and risk exposure, among which sexual behaviours appear to play a relevant role. The diffusion of HPV vaccination and its administration to both genders will undoubtedly dramatically modify the epidemiology of HPV-related head and neck cancers in the coming years.

Sociodemographic characteristics and sexual behavior as risk factors for human papillomavirus infection in Saudi Arabia

OBJECTIVES

To determine the prevalence and the sociodemographic characteristics and sexual behavior risk factors for human papillomavirus (HPV) infection in a hospital-based cohort of women in Saudi Arabia.

METHODS

Cervical specimens and questionnaire data were collected from women attending clinics in Riyadh, Saudi Arabia. Cervical specimens were examined for abnormal cytology using a standard Pap test and for the presence of HPV-DNA using PCR and reverse line blot hybridization tests.

RESULTS

Approximately 73% of the 400 women tested were Saudi nationals. Nearly 50% were under 40 years old (range 22-80 years, mean±standard deviation 41.20±10.43 years). Approximately 17% of the women were HPV-positive. The most commonly detected HPV types were HPV-18 (34%) and HPV-16 (19%), with multiple infections detected in 10% of positive specimens. Multivariate analyses revealed that smoking and multiple partners were significant risk factors for HPV infection (p<0.01).

CONCLUSIONS

Because of societal challenges and an unsubstantiated assumption of low HPV prevalence, few studies have examined sociodemographic characteristics or sexual behaviors associated with HPV in Saudi women. However, a high prevalence of HPV infection was found, with smoking and multiple partners as significant risk factors, in this hospital-based cohort of predominantly Saudi women.

[Prevalence of non-vaccinable high risk genotypes of human papillomavirus in the Early Detection of Cervical Cancer Program in Cantabria]

Objetivo

Estimar la prevalencia de infección por genotipos del virus del papiloma humano (VPH) de alto riesgo no vacunables.

Diseño

Estudio descriptivo transversal.

Emplazamiento

Siete centros de salud de Cantabria seleccionados aleatoriamente.

Participantes

Se incluyó a todas las mujeres con una citología vaginal valorable (n = 3.359) entre 2010-2011.

Mediciones principales

Se recogieron diagnóstico citológico, resultado de PCR y método anticonceptivo. Los resultados de las citologías se clasificaron con el sistema Bethesda. Para la tipificación de VPH según el riesgo oncogénico se utilizó la clasificación de Muñoz et al. Se estimaron proporciones y odds ratio (OR) con sus correspondientes intervalos de confianza al 95% (IC95%).

Resultados

La prevalencia de infección por VPH fue del 2,71% (IC95%: 2,15-3,27). La prevalencia de genotipos de VPH de alto riesgo oncogénico fue del 2,26%; (IC95%: 1,75-2,78). El genotipo más frecuente fue el 16 (28,89%). Más de la mitad de las mujeres fueron positivas para algún genotipo de alto riesgo no vacunable: 51 (18,89%) o 58 (13,33%) o 68 (12,22%) o 31 (11,11%). En el 23,33% de las mujeres coexistieron al menos 2 genotipos de alto riesgo no vacunables. Las mujeres más jóvenes (≤ 30 años) tuvieron 2 veces más riesgo de infección por cualquier VPH: OR 2,01; (IC95%: 1,02-3,96); y 2 veces más probabilidad de usar anticonceptivos hormonales frente al preservativo: OR 2,09; (IC95%: 1,64-2,67).

Conclusiones

Atendiendo al alto porcentaje de VPH de alto riesgo oncogénico no vacunable, habría que replantear la estrategia de prevención en la población, que podría tener una falsa sensación de protección.

Visual Inspection of Cervix With Acetic Acid as a Screening Modality for Cervical Cancer

OBJECTIVE

To assess feasibility and suitability of visual inspection of cervix with acetic acid (VIA) in detecting cervical intraepithelial neoplasia (CIN), and compare it with Papanicolaou test.

METHODS

This was a diagnostic accuracy cross-sectional study conducted at an Egyptian teaching hospital, where 784 women were offered Papanicolaou test, VIA, colposcopy, and cervical biopsy.

RESULTS

Histopathologically confirmed CIN 2/3 was noted in 26 cases (3.3%) and cervical cancer in 3 cases (0.4%). Twenty-seven (93.1%) of these 29 cases of CIN 2+, including one invasive cancer, were suggested by VIA. The test sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to detect CIN 2+ were 93.1%, 90.6%, 26.6%, and 99.7%, respectively. Positive likelihood ratio (LR +) and negative likelihood ratio (LR-) for VIA were 9.90 (95% confidence interval [CI], 7.77-12.62) and 0.08 (95% CI, 0.02-0.29), respectively. Twenty-six cases (89.7%) of CIN 2+ were suggested by Papanicolaou test, whereas all 3 cancers were missed by this test. Papanicolaou test sensitivity, specificity, PPV, and NPV to detect CIN 2+ were 89.7%, 99.1%, 78.8%, and 99.6%, respectively. Positive likelihood ratio and LR- for the Papanicolaou test were 96.7 (95% CI, 45.78-204.23) and 0.10 (95% CI, 0.04-0.3), respectively. Colposcopy suggested 28 cases (96.6%) of CIN 2+, including 2 cancers. Colposcopy sensitivity, specificity, PPV, and NPV to detect CIN 2+ were 96.6%, 99.2%, 82.4%, and 99.9%, respectively.

CONCLUSION

Visual inspection of the cervix with acetic acid is a feasible and suitable screening test for cervical cancer in under-resourced settings in developing countries. Its performance is comparable to the Papanicolaou test.

HPV and Cervical Dysplasia in Adolescents: A Progressive March Toward Prevention

Cervical cancer caused by infection with the human papillomavirus is the second most common malignancy among women worldwide. Over the course of the past century our understanding of the virus and the disease has expanded exponentially through landmark studies and pioneers of academic medicine. It has all led to the current evidence-based guidelines for prevention of cervical dysplasia and invasive carcinoma in adolescent females that will significantly lessen morbidity and mortality and may eradicate the disease completely. Unfortunately, the greatest challenge to this may be overcoming common misunderstandings and other barriers to compliance with these guidelines among practitioners, patients, and the general public.

An unusual cause of pulmonary nodules in the emergency department

We report a 51-year-old woman who presented to the emergency department with left-sided pleuritic chest pain 2 weeks after subtotal hysterectomy and bilateral salpingo-oophorectomy for a leiomyomatous uterus. Computed tomography scan of the chest revealed bilateral pulmonary nodules. Biopsy showed cytologically bland spindle cells without overt malignant features. Immunohistochemistry confirmed smooth muscle phenotype, in keeping with a clinicopathologic diagnosis of benign metastasizing leiomyoma (BML). BML does not frequently come to the attention of the emergency physician because it is rare and usually asymptomatic. When symptomatic, its clinical presentation depends on the site(s) of metastasis, number, and size of the smooth muscle tumors. Emergent presentations of BML are reviewed.

Clinical characteristics of women diagnosed with carcinoma who tested positive for cervical and anal high-risk human papillomavirus DNA and E6 RNA

High-risk human papillomavirus (hrHPV) is an essential cause of cervical carcinoma and is also strongly related to anal cancer development. The hrHPV E6 oncoprotein plays a major role in carcinogenesis. We aimed to evaluate the frequency of hrHPV DNA and E6 oncoprotein in the anuses of women with cervical carcinoma. We analyzed 117 women with cervical cancer and 103 controls for hrHPV and the E6 oncogene. Positive test results for a cervical carcinoma included 66.7 % with hrHPV-16 and 7.7 % with hrHPV-18. One case tested positive for both HPV variants (0.9 %). The samples from the anal canal were positive for HPV-16 in 59.8 % of the cases. Simultaneous presence of HPV in the cervix and anal canal was found in 53.8 % of the cases. Regarding expression of E6 RNA, positivity for HPV-16 in the anal canal was found in 21.2 % of the cases, positivity for HPV-16 in the cervix was found in 75.0 %, and positivity for HPV-18 in the cervix was found in 1.9 %. E6 expression in both the cervix and anal canal was found in 19.2 % of the cases. In the controls, 1 % tested positive for HPV-16 and 0 % for HPV-18. Anal samples from the controls showed a hrHPV frequency of 4.9 % (only HPV16). The presence of hrHPV in the anal canal of women with cervical cancer was detected at a high frequency. We also detected E6 RNA expression in the anal canal of women with cervical cancer, suggesting that these women are at risk for anal hrHPV infection.

The role of acquired immunity in the spread of human papillomavirus (HPV): explorations with a microsimulation model

Background

Knowledge of the natural history of human papillomavirus (HPV), in particular the role of immunity, is crucial in estimating the (cost-) effectiveness of HPV vaccination and cervical cancer screening strategies, because naturally acquired immunity after clearing an infection may already protect part of the risk population against new HPV infections.

Methods

We used STDSIM, an established stochastic microsimulation model, quantified to the Netherlands. We explored different assumptions regarding the natural history of HPV-16 and HPV-18, and estimated the transmission probabilities and durations of acquired immunity necessary to reproduce age-specific prevalence.

Results

A model without acquired immunity cannot reproduce the age-specific patterns of HPV. Also, it is necessary to assume a high degree of individual variation in the duration of infection and acquired immunity. According to the model estimates, on average 20% of women are immune for HPV-16 and 15% for HPV-18. After an HPV-16 infection, 50% are immune for less than 1 year, whereas 20% exceed 30 years. For HPV-18, up to 12% of the individuals are immune for less than 1 year, and about 50% over 30 years. Almost half of all women will never acquire HPV-16 or HPV-18.

Conclusions

Acquired immunity likely plays a major role in HPV epidemiology, but its duration shows substantial variation. Combined with the lifetime risk, this explains to a large extent why many women will never develop cervical cancer.

Assessment of high-risk human papillomavirus infections using clinician- and self-collected cervical sampling methods in rural women from far western Nepal

Introduction

Nepal has one of the highest cervical cancer rates in South Asia. Only a few studies in populations from urban areas have investigated type specific distribution of human papillomavirus (HPV) in Nepali women. Data on high-risk HPV (HR-HPV) types are not currently available for rural populations in Nepal. We aimed to assess the distribution of HR- HPV among rural Nepali women while assessing self-collected and clinician-collected cervico-vaginal specimens as sample collection methods for HPV screening.

Methods

Study participants were recruited during a health camp conducted by Nepal Fertility Care Center in Achham District of rural far western Nepal. Women of reproductive age completed a socio-demographic and clinical questionnaire, and provided two specimens; one cervical-vaginal specimen using a self-collection method and another cervical specimen collected by health camp auxiliary nurse midwives during a pelvic examination. All samples were tested for 14 different HR-HPV mRNA and also specific for HPV16/18/45 mRNA.

Results

Of 261 women with both clinician- and self-collected cervical samples, 25 tested positive for HR-HPV, resulting in an overall HR-HPV prevalence of 9.6% (95% confidence Interval [CI]: 6.3–13.8). The overall Kappa value assessing agreement between clinician- and self-collected tests was 0.62 (95% CI: 0.43–0.81), indicating a “good” level of agreement. Abnormal cytology was reported for 8 women. One woman identified with squamous cell carcinoma (SCC), and 7 women with high grade squamous intraepithelial lesions (HSIL). Seven of the 8 women tested positive for HR-HPV (87.5%) in clinician-collected samples and 6 in self-collected samples (75.0%).

Conclusion

This is the first study to assess HR-HPV among rural Nepali women. Self-collected sampling methods should be the subject of additional research in Nepal for screening HR-HPV, associated with pre-cancer lesions and cancer, in women in rural areas with limited access to health services.

Influence of the tryptophan-indole-IFNγ axis on human genital Chlamydia trachomatis infection: role of vaginal co-infections

The natural history of genital Chlamydia trachomatis infections can vary widely; infections can spontaneously resolve but can also last from months to years, potentially progressing to cause significant pathology. The host and bacterial factors underlying this wide variation are not completely understood, but emphasize the bacterium's capacity to evade/adapt to the genital immune response, and/or exploit local environmental conditions to survive this immune response. IFNγ is considered to be a primary host protective cytokine against endocervical C.trachomatis infections. IFNγ acts by inducing the host enzyme indoleamine 2,3-dioxgenase, which catabolizes tryptophan, thereby depriving the bacterium of this essential amino acid. In vitro studies have revealed that tryptophan deprivation causes Chlamydia to enter a viable but non-infectious growth pattern that is termed a persistent growth form, characterized by a unique morphology and gene expression pattern. Provision of tryptophan can reactivate the bacterium to the normal developmental cycle. There is a significant difference in the capacity of ocular and genital C. trachomatis serovars to counter tryptophan deprivation. The latter uniquely encode a functional tryptophan synthase to synthesize tryptophan via indole salvage, should indole be available in the infection microenvironment. In vitro studies have confirmed the capacity of indole to mitigate the effects of IFNγ; it has been suggested that a perturbed vaginal microbiome may provide a source of indole in vivo. Consistent with this hypothesis, the microbiome associated with bacterial vaginosis includes species that encode a tryptophanase to produce indole. In this review, we discuss the natural history of genital chlamydial infections, morphological and molecular changes imposed by IFNγ on Chlamydia, and finally, the microenvironmental conditions associated with vaginal co-infections that can ameliorate the effects of IFNγ on C. trachomatis.