Prevalence and cytologic manifestations of human papilloma virus (HPV) types 6, 11, 16, 18, 31, 33, 35, 42, 43, 44, 45, 51, 52, and 56 among 500 consecutive women

Prevalence of high-risk human papilloma virus in women with high-grade squamous cell intraepithelial lesions in Botswana using Abbott RealTime HPV assay

BACKGROUND

High-risk human papillomavirus (HR-HPV) has been demonstrated to be the necessary cause of cervical carcinoma. High-risk HPV detection has a prognostic significance for the women who are at increased risk of disease progression. HPV genotyping in cervical cancer precursor lesions is crucial for prevention and management of cervical cancer. This study was designed to investigate the distribution of HR-HPV genotypes among a group of patients with high-grade squamous intraepithelial lesions and higher, of the cervix, in Botswana.

MATERIALS AND METHODS

185-archived residual formalin-fixed paraffin-embedded cervical biopsies collected between the years, 2006 and 2008 were studied. These tissues were diagnosed with HSIL (n = 146) and squamous cell carcinoma (n = 39). DNA was extracted using the Abbott m2000 analyser (Abbott Laboratories, Illinois) using reagents provided by the manufacturer. HPV genotyping was done using the Abbott RealTime HR-HPV PCR, which qualitatively detects 14 HR-HPV (reported as HPV 16, 18 & Other HR-HPV).

RESULTS

DNA was successfully extracted from 162/185 (87.6%) tissues as indicated by a positive β-globin test. 132/162 (82%) tested positive for HR-HPV The HPV 16 prevalence was 50% (66/132), HPV 18 at 15.2% (20/132) and other Group 1 HR-HPV plus HPV 66 and 68 had a prevalence of 56.1% (74/132). Other HR-HPV types were common in HSIL than in carcinoma, while HPV 16 was more prevalent in carcinomas than other HR-HPV genotypes.

CONCLUSION

In this study, HPV 16 and other HR-HPV genotypes were commonly associated with HSIL but HPV 18 was uncommon among Botswana women. Our data highlights the need for multivalent HPV vaccines with cross coverage for other high risk HPV other than HPV 16 and 18.

Prevalence of human papillomavirus genotypes in northern Taiwanese women

The prevalence of Human Papillomavirus (HPV) in the general population of northern Taiwan is described. A total of 343 consecutive cervical swabs from women visiting the medical center for routine gynecologic care were included. Cervical cell cytology was examined by the Papanicolaou (Pap) test, and a PCR-based hybridization gene chip analysis was used to identify HPV genotypes. The HPV prevalence in the overall population was 32.4%. When divided into two groups according to cytology, 20.9% of women with normal cytology were HPV positive while 75.3% of women with abnormal cytology were HPV positive. Among positive samples, 68.5% were single type infections while 31.5% harbored multiple HPV types. A total of 32 types of HPV were identified; the leading five were HPV16 (5.8%), HPV58 (5.3%), HPV53 (4.1%), HPV52 (3.8%), and HPV18 (2.3%). Our results constitute baseline data and may provide important implications for future prophylactic programs. The relatively high prevalence of HPV 58, 53, and 52 among northern Taiwanese women has important implications for vaccine development.

Seroepidemiology of human papillomavirus type 11 in the United States: results from the third National Health And Nutrition Examination Survey, 1991--1994

OBJECTIVES

The national seroprevalence of the nononcogenic human papillomavirus (HPV) type 11, one of the types targeted by the quadrivalent HPV vaccine, has not been evaluated in the United States. The objectives of this study were to estimate the national seroprevalence and evaluate predictors of HPV-11 seropositivity.

STUDY DESIGN

We tested serum samples for HPV-11 antibodies and analyzed questionnaire data from the second phase of the National Health and Nutrition Examination Survey III, 1991--1994. Seroprevalence estimates were weighted to represent the US population.

RESULTS

: Overall seroprevalence of HPV-11 infection was 4.7%. Seroprevalence was significantly higher among females (5.7%) than among males (3.6%). Independent predictors of HPV-11 seropositivity included sex, race/ethnicity, lifetime number of sex partners, education, and HPV-16 seropositivity.

CONCLUSION

This study represents the most comprehensive picture of HPV-11 infection in the United States to date, and provides baseline data on the prevalence of HPV-11 before availability of the quadrivalent HPV vaccine.

HPV vaccines: are they the answer?

BACKGROUND

The burden of human papillomavirus (HPV)-associated ano-genital disease is significant but the ability to generate HPV virus-like particles by the synthesis and self-assembly in vitro of the major virus coat protein L1 has transformed our prospects for preventing benign and malignant ano-genital disease caused by the common genital HPV types.

SOURCES OF DATA

Peer reviewed journals.

AREAS OF AGREEMENT

Two HPV L1 vaccines have been developed, a quadrivalent HPV 6/11/16/18, and a bivalent HPV 16/18 product. Both vaccines are very immunogenic and well tolerated. They have been shown in the various randomized Control trials to be very effective at preventing infection and premalignant disease related to the vaccine HPV genotypes in women who were DNA negative and sero negative for the vaccine HPV types at base line. The protection against disease generated by the vaccines persists for at least 5 years. HPV vaccines containing HPV 6/11 will reduce the incidence of genital warts by 80-90% in the medium term. The vaccines will reduce but not eliminate the risk of cervical cancer since at the present they only target two of the oncogenic genital types. Cervical cancer screening programmes will remain as important secondary interventions for cervical cancer even in vaccinated populations.

AREAS OF CONTROVERSY

The duration of protection remains unknown but there is evidence of good immune memory, it is possible that protection will be long lasting. The primary target group for cost effective immunization with HPV vaccines are peri-pubertal females. There may be benefit in vaccinating other groups (men, sexually active women of all ages) but the cost effectiveness of these interventions will need to be evaluated. In societies in which organized screening programmes are not available, HPV vaccines are probably the most realistic intervention against HPV-associated disease.

AREAS TIMELY FOR DEVELOPING RESEARCH

Second generation vaccines that offer protection against additional types, are thermostable and delivered by non-injection methods are an important area of investigation.

Atypical parakeratotic spires and HCII HPV results: correlation in liquid-based cervicovaginal cytology specimens interpreted as ASC-US

The 2001 Bethesda System (2nd edition) indicates that parakeratosis with nuclear enlargement, hyperchromasia, irregular contours, and/or three dimensionality should prompt consideration of an interpretation of ASC-US or greater. The authors retrospectively reviewed 812 liquid-based cervicovaginal cytology samples (CVCSs) interpreted as ASC-US during an 11-month period. All slides were studied for the presence or absence of atypical parakeratotic spires (APKSs), a specific form of atypical parakeratosis. Results from corresponding Hybrid Capture II high risk (HR) HPV testing were recorded (blinded). Of 812 women, 28% (230/812) had APKSs and 20% (163/812) had positive HCII assays for HR HPV. Three percent of all reflexed ASC-US vials (26/812) had both APKSs and positive HR HPV assays (sensitivity = 16%, specificity = 69%). APKSs in liquid-based CVCSs interpreted as ASC-US do not independently correlate to a positive reflex test for HR HPV (P < 0.0001). This suggests that APKSs are most often unrelated to underlying HR HPV infection. The finding of APKSs alone in CVCSs does not warrant an interpretation of SIL and should be used only in concert with other findings to label a sample as ASC-US.

Prevalence and typing of human papilloma virus (HPV) among female sex workers and outpatient women in southern Thailand

Background: Thai sex workers (SW) have high rates of sexually transmitted infections (STIs); however, detection and treatment is often complicated by accessibility to sensitive and accurate diagnostic tests. Self-sampling of women combined with molecular amplification techniques could help in accurate diagnosis, treatment and follow-up of such women. Detection of persistent high-risk human papilloma virus (HPV) in such populations could also be beneficial in identifying women who may need more frequent follow-up for cervical cytology screening. The current study aimed to examine the prevalence of HPV in this population and compare this with the lower-risk outpatient women (OPW) in Thailand. Methods: Four hundred and thirty OPW and 524 Thai SW were sampled by a self-administered tampon collection. Cells were extracted from tampons and, subsequently, women underwent routine vaginal examination for detection of other STIs. Detection of HPV was performed by polymerase chain reaction (PCR) using the L1 consensus primers, followed by L1 consensus probe using an in-house PCR-enzyme-linked immunosorbent assay (ELISA). All positive samples were typed using PCR-ELISA and type-specific oligonucleotide probes. Results: Overall, HPV was detected in 20/430 (4.6%) and 120/524 (22.9%) in OPW and SW respectively. Over 98% of samples produced a β-globin signal, indicating adequately collected samples. Human papilloma virus typing probes detected HPV16 or 18 in 14% and 26% of the positive samples from OPW and SW respectively. HPV31, 33, 35 or 39 were detected in 19% and 12% and HPV45, 51 or 52 in 9.5% and 4% of positive OPW and SW patients respectively. Low risk HPV6 or 11 were detected in 1% and 4.9% of OPW and SW respectively. Conclusion: There was a significantly higher HPV prevalence in Thai SW than OPW, with the majority (21%) of positive samples containing the oncogenic HPV16 or 18 DNA. The results indicate that PCR could serve as a rapid and easy method for identification of women who require more frequent screening for cervical cancer.

The virology of cervical neoplasia: an HPV-associated malignancy

Human papillomaviruses are present in virtually all cervical cancers and cancer precursors. Understanding the epithelial virology of this group of viruses has greatly influenced current concepts of cervical carcinogenesis, has provided a framework for understanding the biologic basis of many diagnostic criteria, and has led to revised classification schemes, diagnostic testing, and modifications in clinical management. This paper briefly reviews virologic concepts supporting the pathogenetic role of these viruses in cervical neoplasia.

HPV infection and number of lifetime sexual partners are strong predictors for 'natural' regression of CIN 2 and 3

The aim of this paper was to evaluate the factors that predict regression of untreated CIN 2 and 3. A total of 93 patients with colposcopic persistent CIN 2 and 3 lesions after biopsy were followed for 6 months. Human papillomavirus (HPV) types were determined by polymerase chain reaction at enrolment. We analysed the biologic and demographic predictors of natural regression using univariate and multivariate methods. The overall regression rate was 52% (48 out of 93), including 58% (22 out of 38) of CIN 2 and 47% (26 out of 55) of CIN 3 lesions (P=0.31 for difference). Human papillomavirus was detected in 84% (78 out of 93) of patients. In univariate analysis, 80% (12 out of 15) of lesions without HPV regressed compared to 46% (36 out of 78) of lesions with HPV infection (P=0.016). Women without HPV and those who had a resolution of HPV had a four-fold higher chance of regression than those with persistent HPV (relative odds=3.5, 95% CI=1.4-8.6). Women with five or fewer lifetime sexual partners had higher rates of regression than women with more than five partners (P=0.003). In multivariate analysis, HPV status and number of sexual partners remained as significant independent predictors of regression. In conclusion, HPV status and number of lifetime sexual partners were strongly predictive of regression of untreated CIN 2 and 3.

Detection of multiple human papillomavirus types in the lower genital tract correlates with cervical dysplasia

Some human papillomavirus (HPV) types, such as HPV 16, are clearly associated with cervical dysplasia; however, the role played by other HPV types occasionally found in dysplasia is less certain. In addition, most methods used to detect HPV in clinical specimens cannot easily distinguish among more than two or three HPV types in a single specimen. Therefore, the significance of infection with multiple HPV types is not known. To address this question, we analyzed cervicovaginal lavage specimens from three cohorts of women for HPV DNA using a PCR/reverse blot assay system that permits the detection and partial quantitation of 26 genital HPV types. As expected, 94.1% of women who had dysplasia (n = 34) and 71.4% of women who had atypical squamous cells of uncertain significance (ASCUS) (n = 21) on cytology had HPV DNA detected compared to 54.5% of age matched women with normal cytology. HPV 16 DNA was detected in 35% of dysplasia patients compared to 9% of cytologic normals (P = 0.0044). Dysplasia patients had a mean of 3.29 (range 0-10) different HPV types detected compared to 1.04 (range 0-7) HPV types among those with normal cytology (P < 0.0001). These data support a possible role for multiple HPV types in the development or progression of cervical dysplasia.

Distribution of HPV 53, HPV 73 and CP8304 in genital epithelial lesions with different grades of dysplasia

To characterize the risk of malignant progression of cervical epithelial lesions associated with human papillomavirus (HPV) types of yet unknown oncogenic potential the prevalences of these HPVs in different cervical epithelial lesions of 809 patients were determined. HPV types 53, 73, and CP8304 were detected in genital specimens of 16, 22, and 12 of the patients, respectively. The ratio of prevalence in high grade dysplastic lesions or cancers and low grade dysplastic lesions or normal specimens was calculated and compared to corresponding values of well known high-risk (HR) and low-risk (LR) HPVs. For HPV 6, 11, 16, 18, 35, and 73 a ratio of 0.1, 0.2, 5.9, 6.5, 2.5, and 2.4, respectively, was calculated. The ratios of HPV53 and CP8304 were less than 1. Moreover, in contrast to HPV73, these viruses have never been detected in cancer specimens. Thus, HPV53 and CP8304 infections are probably not associated with a high risk of carcinogenesis, while HPV73 could be another HR-HPV type.

Human papillomavirus infections: epidemiology, pathogenesis, and therapy

BACKGROUND

Human papillomaviruses (HPV) are common human pathogens and are classified into more than 80 different types. These viruses produce benign warts in many cases and aggressive squamous cell carcinomas in other cases.

OBJECTIVE

The goal of this review is to update the reader on the epidemiology, pathogenesis, and therapy of HPV infections. Nonanogenital warts are transmitted by skin-to-skin contact while anogenital warts are usually transmitted sexually. Both types of warts produce much morbidity but rarely undergo malignant transformation. They are commonly treated with surgical or cytodestructive therapy, but immunomodulatory agents, such as imiquimod, have been proven to be very effective in anogenital warts and are being evaluated in nonanogenital warts. Other types of HPV have marked oncogenic potential such that over 99% of all cervical cancers and over 50% of other anogenital cancers are due to infection with oncogenic HPV. Many cofactors, such as cigarette smoking, genetics, and helper viruses, have potential roles in HPV oncogenesis, but their relative contributions are poorly understood. Other control measures for warts and HPV-associated cancers are under study, but the greatest future potential may be from the development of prophylactic and therapeutic vaccines.

CONCLUSIONS

Infection with HPV is very prevalent as are the clinical manifestations of this family of pathogens. Improved therapies for warts (e.g., imiquimod) have recently become available. Vaccines for HPV offer hope for future interventions for warts as well as for prevention of anogenital malignancies.

Usefulness of human papilloma virus testing in the screening of cervical cancer precursor lesions: a retrospective study in 314 cases

OBJECTIVE

To assess the usefulness of human papilloma virus (HPV) typing for predicting pre-malignant and malignant cervical lesions.

STUDY DESIGN

314 women, who underwent colposcopy, biopsies and high and low-risk HPV typing after a confirmed abnormal routine Pap test were studied. HPV-DNAs were typed by using PCR technique.

RESULTS

We found a significant increasing rate of high-risk-HPV by the increasing severity of histology, ranging from 40% in negative cases to 86.9% in those with CIN3 lesions. The positive predictive value of high-risk-HPV ranged from 13.3% in patients with atypical squamous cells of undetermined significance (ASCUS) to 29.4% in those with HSIL. By contrast, negative predictive value was 96% in patients with ASCUS, 97.2% in low-grade squamous intraepithelial lesions (LSIL), and 71.4% in high-grade squamous intraepithelial lesions (HSIL). Sensitivity and specificity for detecting CIN2 or CIN3 was 86.0% and 41.3%, respectively.

CONCLUSIONS

The high negative predictive value of high-risk HPV testing suggests that HPV negativity could be used for predicting the absence of important cervical lesions, and therefore avoiding unnecessary colposcopy in ASCUS and LSIL cases.

Genital human papillomavirus infection in women who have sex with women: a review

Sexual transmission of human papillomavirus between women has been postulated on the basis of reports of abnormal Papanicolaou smears in women who reported no prior sex with men and by studies using amplified deoxyribonucleic acid technology for human papillomavirus detection. To review the current knowledge of the epidemiology of human papillomavirus and the Papanicolaou smear screening practices among women who have sex with women, studies were identified from a search of the MEDLINE database from January 1980-June 1999. Several factors, including prior or concurrent sex with men and sexual behaviors between women, validate the possibility of human papillomavirus infection among women who have sex with women, and data support that human papillomavirus transmission also occurs. Limited data indicate that the frequency of routine Papanicolaou smear screening among women who have sex with women may be suboptimal relative to heterosexual women. Education of women who have sex with women and the providers of their health care should counter any assumptions that sex between women confers no risk of human papillomavirus transmission. Women who have sex with women should receive Papanicolaou smear screening in accord with current guidelines.

Genomic changes and HPV type in cervical carcinoma

To identify chromosomal regions that may include the loci of abnormally expressed cellular genes and may be specifically altered depending on the histological subtype of the tumor, we studied primary cervical carcinoma using CGH and HPV genotyping. Eighty-seven percent of the primary tumors were positive for DNA of a "high-risk" HPV type (e.g., 16 or 18). In the cervical carcinomas, without reference to histologic subtype, overrepresentation of chromosome 3q was the most consistent chromosomal aberration with underrepresentation of chromosome 3p also a frequent finding. Chromosome arms 1q, 5p, 20q, and Xq were overrepresented in many tumors and 3p loss and 5p, 8q, and 16q gain were only associated with squamous cell carcinoma in this series.

Adolescents' knowledge of human papillomavirus and cervical dysplasia

STUDY OBJECTIVE

This study examined adolescents' knowledge of human papillomavirus (HPV) and cervical dysplasia (CD). Factors associated with knowledge and self-reported change in health-related behaviors were identified.

DESIGN

Interviews were conducted at an average of 2.5 years following the diagnosis of HPV/CD. Medical charts were reviewed.

SETTING

The study was conducted at a university-based adolescent dysplasia clinic.

PARTICIPANTS

Fifty females, ages 15-23 participated in the study: 88% African-American, 12% Caucasian.

RESULTS

On average, participants responded correctly to 86% of the questions regarding HPV/CD. However, the following key points were routinely missed: 52% did not know cigarette smoking increased the risk for cervical cancer; 42% believed that HPV/CD was always symptomatic; and 22% did not know condoms decreased the transmission of HPV. According to participants, their health care provider explained the diagnosis and treatment of HPV/CD using words they understood "some" or "most of the time." Higher academic skills significantly correlated with greater knowledge of HPV/CD. Forty-one percent of participants with a smoking history reportedly increased their smoking since the diagnosis, and only 40% used condoms "most of the time." However, 90% had maintained or increased their frequency of Pap tests.

CONCLUSIONS

Adolescent girls had knowledge of most factors related to HPV/CD, but many did not understand the risks of cigarette smoking and failure to use condoms. To improve understanding and compliance, health care providers should tailor educational strategies to the functional level of adolescents.

Human papillomaviruses and cervical neoplasia: a model for carcinogenesis

Human papillomaviruses are etiologic for cervical cancers and their pathologic precursors. As presented in this review, pathologic, epidemiologic, and molecular data all support a working model that accounts for the pathogenetic role of these viruses in cervical neoplasia. Diagnostic criteria and classification systems are discussed in light of this model. These insights point to a potential change in clinical screening systems for cervical cancer. In addition, vaccine trials for oncogenic HPVs have begun. In the long term, these trials may hold promise as truly specific preventive therapy for this common human cancer.

Human papillomavirus 16 and 18 infection of the uterine cervix in women with different grades of cervical intraepithelial neoplasia (CIN)

OBJECTIVE

To evaluate the frequency of human papillomavirus (HPV) 16 and 18 infection in patients with different grades of cervical intraepithelial neoplasia (CIN).

METHOD

Five-hundred and five patients with CIN, referred for conization, were included in this study. Before conization, cytological material for in situ hybridization was obtained from the uterine cervix to detect the presence of HPV 16 and 18 infection.

RESULT

Among all patients with CIN, 82 (16.2%) were solely HPV 16 and 51 (10.1%) were solely HPV 18 positive. There were 133 patients (26.3%) positive for HPV 16 or HPV 18 and 31 patients (6.1%) were positive for both viral types, giving an overall HPV 16/18 infection rate of 32.4%. There were 15 (55.5%) HPV 16 or HPV 18 positive patients with CIN 1, 45 (33.8%) HPV 16 or HPV 18 positive patients with CIN 2 and 104 (30.2%) HPV 16 or HPV 18 positive patients with CIN 3.

CONCLUSION

In patients with CIN 1, HPV 16 and 18 infection was more frequent than in patients with CIN 2, but the difference was not significant. Patients with CIN 2 were infected slightly more frequently, but not significantly, than patients with CIN 3. On the other hand, patients with CIN 1 were significantly more frequently infected than patients with CIN 3.

Adolescent girls' understanding of Papanicolaou smear results

STUDY OBJECTIVE

Human papillomavirus (HPV) urogenital infections are common in sexually active adolescents. Previous research has indicated that adolescent girls do not reliably report histories of HPV infection. This study examined whether asking an adolescent girl if she had ever had an abnormal Papanicolaou (PAP) smear was a good screening question for evidence of HPV urogenital infection.

DESIGN

The responses to the question about abnormal PAP smears, were compared with their charts for documented abnormal PAP smear, HPV infection, and sexually transmitted infection.

SETTING

An urban, hospital-based adolescent clinic.

PARTICIPANTS

Fifty adolescent girls (mean age, 14.8 years).

MAIN OUTCOME MEASURES

Degree of agreement (kappa statistic).

RESULTS

Using a kappa statistic, reported history of an abnormal PAP smear had "fair" agreement with documented dysplasia on PAP smear and "moderate" agreement with documented HPV infection (i.e., either condyloma on PAP smear or genital warts noted on examination). This reported history of an abnormal PAP smear agreed better with documented HPV infection than with documented dysplasia on PAP smear.

CONCLUSIONS

There appears to be considerable confusion among adolescent girls regarding their PAP smear results. Care providers need to be sensitive to this when they are collecting historical information and when they are diagnosing HPV infection or an abnormal PAP smear.

Human papillomavirus testing as triage for atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions: sensitivity, specificity, and cost-effectiveness

OBJECTIVE

Our purpose was to evaluate the cost-effectiveness of the use of a Food and Drug Administration-approved human papillomavirus test in triaging patients with Papanicolaou smears showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion for colposcopy compared with an algorithm that used cytologic follow-up.

STUDY DESIGN

Four hundred sixty-two women referred to our Colposcopy Clinic with a Papanicolaou smear report of atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion underwent repeat Papanicolaou smear, cervical colposcopy, directed cervical biopsy, and endocervical curettage. In addition, human papillomavirus testing by the Food and Drug Administration-approved HPV Profile (Digene Diagnostics, Silver Spring, Md.) test was done. A comparison of sensitivity, specificity, and cost-effectiveness of an algorithm determining the need for colposcopy on the basis of repeat cytologic testing versus an algorithm that incorporated repeat cytologic testing and human papillomavirus screening was done. The cost-effectiveness of both of these triage algorithms was also compared.

RESULTS

As expected, high-risk human papillomavirus deoxyribonucleic acid was detected with greater frequency in relation to increasing severity of cervical intraepithelial neoplasia. In 268 women, the follow-up smear obtained in our clinic was reported as negative. High-risk human papillomavirus types were found in 23.5% of these women. In the human papillomavirus-negative women, 5.9% had grade 2 or 3 cervical intraepithelial neoplasia confirmed on cervical biopsy. In comparison, 20.6% of those with a positive result of the human papillomavirus test had grade 2 or 3 cervical intraepithelial neoplasia on biopsy (p < 0.001). Despite this difference, the sensitivity of a positive result of a high-risk human papillomavirus test in predicting the presence of grade 2 or 3 cervical intraepithelial neoplasia was only 52%. Among the women for whom a follow-up clinic Papanicolaou smear was reported as showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion, there was no difference in the frequency of biopsy-proved grade 2 or 3 cervical intraepithelial neoplasia between those women with a positive human papillomavirus test result and those with a negative test result. Colposcopy would have been recommended for 194 women because of a repeat clinic smear revealing atypical squamous cells of undetermined significance, a low-grade squamous intraepithelial lesion, or a high-grade squamous intraepithelial lesion, and in 21.6% of these grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 63%, specificity 62%). Colposcopy would have been recommended for 180 women because high-risk human papillomavirus or a high-grade squamous intraepithelial lesion was detected at the clinic visit, and in 25% of this group grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 67%, specificity 66%). Sensitivity and specificity were virtually identical for the two algorithms, but the cost of human papillomavirus testing was nearly double that of triage based on repeat cytologic testing alone ($692 vs $1246 per case).

CONCLUSION

The Food and Drug Administration-approved HPV Profile test is not a cost-effective triage for patients referred with Papanicolaou smears reported as showing atypical squamous cells of undetermined significance or low-grade squamous lesions.

Relevance of human papillomavirus screening in management of cervical intraepithelial neoplasia

OBJECTIVE

To evaluate the utility of human papillomavirus detection in identifying women with abnormal Papanicolaou smears who can be safely followed up with cytologic study only, we conducted a study to determine the sensitivity, specificity, and negative and positive predictive values of a Food and Drug Administration-approved human papillomavirus test kit for detection of cervical intraepithelial neoplasia in colposcopically directed biopsy specimens.

STUDY DESIGN

We enrolled women with abnormal Papanicolaou smears referred to a colposcopy clinic serving indigent patients. All 1128 women had a referral Papanicolaou smear, a clinic Papanicolaou smear, and a sample for human papillomavirus deoxyribonucleic acid test; 1075 underwent colposcopically directed biopsies and endocervical curettage. We used the HPV Profile kit for human papillomavirus testing.

RESULTS

Of 486 women with low-grade squamous intraepithelial lesions on Papanicolaou smear, 35.4% had high-risk human papillomavirus deoxyribonucleic acid detected, and of 592 with high-grade lesions, 44.4% had high-risk human papillomavirus detected. Among 527 women with biopsy specimens showing cervical intraepithelial neoplasia and in 267 with cervical intraepithelial neoplasia grades 2 or 3, 38.7% and 56.2% had high-risk human papillomavirus deoxyribonucleic acid detected. However, the sensitivity of human papillomavirus deoxyribonucleic acid detection to identify biopsy-confirmed cervical intraepithelial neoplasia grades 2 or 3 was 55.7%, and the positive predictive value of the test was only 34.9%.

CONCLUSION

Human papillomavirus appears to be causally associated with cervical cancer but human papillomavirus screening does not appear to be of value to identify women with abnormal Papanicolaou smears who can be safely followed up with cytologic study alone.

Clinical role of HPV testing

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

Natural history of cervical neoplasia: overview and update

Current cervical cancer control strategies and specifically, the screening and treatment policies that have been used during the past 30 years, are based on an understanding of the natural history of cervical neoplasia that does not take into account the important role of human papillomavirus in cervical cancer pathogenesis. This survey presents a review of new data on the causes of cervical cancer and the role of human papillomavirus and recommends the integration of these data. Incorporation of new information on the role of human papillomavirus as the causative agent of most cervical cancers will allow the design of more efficient and more cost-effective strategies for cervical cancer control.

Human papillomavirus infection and therapy with interferon

The studies summarized have shown that therapy of condylomata acuminata with interferon is effective. The route of administration does not appear to influence the results; the intralesional, intramuscular, and subcutaneous routes were effective. Additional research is required to determine whether the natural interferon or recombinant product is superior. The appropriate administration schedule may also not have been attained.

Epidemiology of cervical intraepithelial neoplasia: the role of human papillomavirus

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

Influence of age and human papillomavirus-infection on reliability of cervical cytopathology

The aim of the present study was to evaluate the effect of age and human papillomavirus (HPV) infection associated cellular changes on the predictive value of cervical cytology. In a group of 671 women with Papanicolaou smears suggesting low grade squamous intraepithelial lesion (LSIL), a high grade squamous intraepithelial lesion (HSIL) or invasive cervical cancer, cervical cytology was correlated with the histological finding. Predictive values were calculated and related to severity of the lesion, age and HPV associated changes. The predictive values of Papanicolaou (cervical) smears suggesting LSIL, HSIL and invasive carcinoma were 40%, 86%, and 78%, respectively. A poor predictive value of smears suggesting LSIL was found among older women. HPV associated changes were diagnosed in 80% of women < or = 25 years of age, 66% in the age group 26 to 35 years, 51% in the age group 36 to 45 years and 38% in women aged > or = 46 years (P = 0.03). The presence of HPV associated cellular changes led to a significantly higher number of overdiagnoses (9% with HPV infection compared to 4% without HPV infection) and HPV negative cases were more frequently associated with underdiagnosis (15% without HPV infection compared to 8% with HPV infection, P = 0.0011). This result remained significant after adjustment for age (P = 0.004). Cellular changes associated with HPV infection most frequently occurred in young women. HPV infection should therefore be acknowledged as source of overdiagnosis in the cytological evaluation of SIL especially in young women.

Regional distribution and incidence of human papillomavirus infections among heterosexual men and women with multiple sexual partners: a prospective study

OBJECTIVE

To assess prevalence, incidence and potential risk factors of human papillomavirus (HPV) infection among heterosexual men and women with multiple partners and to identify niches of HPV-infection.

DESIGN

A prospective study of heterosexual men and women with multiple partners attending an STD clinic as participants in a study on HIV from May 1988 until January 1991. Routine STD examination and physical examination using colposcopy were performed, interviews with standardised questionnaires were administered. Specimens for HPV DNA detection by polymerase chain reaction were collected from multiple sites of the genital, anorectal and oral regions. In women cervical cytology was performed.

SETTING

The STD Clinic of the Municipal Health Service of Amsterdam.

PARTICIPANTS

162 women and 85 men entered the study, 110 women and 48 men were followed up.

RESULTS

At entry of the study 37 (23%) women and 24 (28%) men were found positive for HPV DNA at any site. Only in one woman was oral presence of HPV DNA found during follow-up. Abnormal cervical cytology was observed in four women. In multivariate analysis, diagnosis of condylomata [odds ratio (OR) 5.61, 95% confidence interval (CI) 1.86 to 16.90)], reporting genital dermatological abnormalities (OR 3.72, 95% CI 1.38 to 9.99) and age (OR per year 0.93, 95% CI 0.88 to 0.99) predicted independently the presence of HPV DNA in women at entry of the study. In women 59 of the 99 (60%) HPV infections were observed in the genital region and 40% in the anorectal region: in men these figures were 65% and 35%, respectively. The incidence of HPV infection was 47.1 and 50.5 per 100 person-years for women and men respectively. At least 20/99 (20%) infections in women were intermediate or long persistent and only 3/48 (6%) HPV infections in men (P = 0.03). No risk factor for persistency could be determined, either in women or in men.

CONCLUSIONS

HPV infection was found to be a multicentric genital and/or anorectal event both in women and men. The oral presence of HPV DNA was detected only once in one of the participants. In women persistent HPV infection was more common than in men. Independent predictors for presence of HPV DNA in women were diagnosis of condylomata acuminata, reporting genital dermatologic abnormalities and age. Incidence of HPV infection in women turned out to be 47.1 infections per 100 person-years and for men 50.5 per 100 person-years.

Pathogenesis of genital HPV infection

Clinical, subclinical, and latent human papillomavirus (HPV) infections are distinguished from HPV-associated neoplasia. Besides HPV additional cofactors are necessary to transform HPV infected tissue to intraepithelial or invasive neoplasia. Risk factors for the presence of HPV are high number of sexual partners, early cohabitarche, young age at first delivery, suppression and alteration of immune status, young age and hormonal influences. While the fact of a high number of sexual partners exclusively increases the risk of HPV infection, it is not known whether the other factors lead to either an increased risk for HPV infection and/or to HPV-associated neoplasia. Subclinical and latent genital HPV infections are highly prevalent. The prevalence rate depends on the sensitivity of the HPV detection system used, on age and sexual activity of the population screened, and on the number of subsequent examinations performed for each subject. Sexual transmission is the main pathway for genital HPV's, however, vertical, peripartal, and oral transmission are also possible. Seroreactivity against genital HPV may be due to an active infection or the result of contact with HPV earlier in life. Antibodies against the HPV 16 E7 protein indicate an increased risk for cervical cancer. Compared with humoral response cellular immune response is probably more important for regression of genital HPV infection: impaired cellular response is characterized by depletion of T helper/inducer cells and/or Langerhans cells and impaired function of natural killer cells and/or the infected keratinocyte. In condylomata replication and transcription of viral nucleic acids and antigen production coincide with cellular differentiation. However, the interaction between HPV and the keratinocyte on a molecular level in subclinical and latent disease is not well understood. Regression or persistence of subclinical and latent genital HPV infections as observed in longitudinal investigations show a constant come-and-go of HPV presence. Subclinical or latent cervical infections with high-risk HPV types (such as HPV 16 and 18) have an increased risk for the development of HPV-associated neoplasia.

A cohort study of the risk of cervical intraepithelial neoplasia grade 2 or 3 in relation to papillomavirus infection

BACKGROUND

Human papillomavirus (HPV) has been associated with cervical intraepithelial neoplasia, but the temporal relation between the infection and the neoplasia remains unclear, as does the relative importance of the specific type of HPV, other sexually transmitted diseases, and other risk factors.

METHODS

We studied prospectively a cohort of 241 women who presented for evaluation of sexually transmitted disease and had negative cervical cytologic tests. The women were followed every four months with cytologic and colposcopic examinations of the uterine cervix and tests for HPV DNA and other sexually transmitted diseases.

RESULTS

Cervical intraepithelial neoplasia grade 2 or 3 was confirmed by biopsy in 28 women. On the basis of survival analysis, the cumulative incidence of cervical intraepithelial neoplasia at two years was 28 percent among women with a positive test for HPV and 3 percent among those without detectable HPV DNA: The risk was highest among those with HPV type 16 or 18 infection (adjusted relative risk as compared with that in women without HPV infection, 11; 95 percent confidence interval, 4.6 to 26; attributable risk, 52 percent). All 24 cases of cervical intraepithelial neoplasia grade 2 or 3 among HPV-positive women were detected within 24 months after the first positive test for HPV. After adjustment for the presence of HPV infection, the development of cervical intraepithelial neoplasia was also associated with younger age at first intercourse, the presence of serum antibodies to Chlamydia trachomatis, the presence of serum antibodies to cytomegalovirus, and cervical infection with Neisseria gonorrhoeae.

CONCLUSIONS

Cervical intraepithelial neoplasia is a common and apparently early manifestation of cervical infection by HPV, particularly types 16 and 18.