Distribution of HPV infection and tumour markers in cervical intraepithelial neoplasia from cone biopsies of Mozambican women

Human papillomavirus prevalence and genotype distribution among young women and men in Maputo city, Mozambique

OBJECTIVES

Human papillomavirus (HPV) is a well-known cause of cervical cancer, the second most frequent cancer in female African populations. This study aimed at determining the prevalence of HPV infections and the genotype distribution in young adults aged 18-24, in Maputo city, Mozambique, and to assess the suitability of commercially available HPV vaccines.

METHODS

This cross-sectional study was conducted between 2009 and 2011 at a youth clinic in Maputo Central Hospital. Cervical and urethral samples were obtained from 236 women and 176 men, respectively. Demographic and behavioural data were collected using structured questionnaires. HPV genotyping was performed for 35 different high, probably or possibly high-risk and low-risk HPV types using the CLART Human Papillomavirus 2.

RESULTS

HPV prevalence was 168/412 (40.8%; 95% CI 36.0 to 45.5) and was significantly higher in women than in men (63.6%vs10.2%). HPV52 was the most frequent type found in women, followed by HPV35, -16,-53, -58,-6 and -51. In men, HPV51 ranked the highest, followed by HPV6, -11,-52, -59 and -70. HIV infection and sexual debut before 18 years of age were associated with multiple HPV infections (OR 3.03; 95% CI 1.49 to 6.25 and OR 6.03; 95% CI 1.73 to 21.02, respectively). Women had a significantly higher HPV infection prevalence than men (p<0.001). The 9-valent HPV vaccine would cover 36.8% of the high-risk genotypes circulating in women in this study, compared with 26.3% and 15.8% coverage by the bivalent and quadrivalent vaccines, respectively.

CONCLUSION

This study confirmed the high burden of HPV infections in young women in Maputo city, Mozambique. The HPV prevalence was associated with high-risk sexual behaviour. Sex education and sexually transmitted infection prevention interventions should be intensified in Mozambique. Only a proportion of the high-risk HPV genotypes (37%) were covered by currently available vaccines.

Human papillomavirus (HPV) infection: a Mozambique overview

Human Papillomavirus is agent of the most common sexually transmitted disease which is able to infect mucosal and cutaneous membranes of the anogenital region, upper aerodigestive tract, and other head and neck mucosal regions. Although mainly HPV infection can be asymptomatic and transient, it may persist and give rise to various lesions such as warts, condyloma dysplasia and cancers depending on low or high risk type of HPV infection. Moreover, growing recent evidence suggests a role of this virus in male and female fertility. To date no effective prevention, test, treatment and control strategies are provided for people in developing countries despite the reported high incidence of HPV both in women and men. This paper reviews the more recent literature about HPV infection highlighting epidemiology, related pathologies and possible fertility effects of HPV in male and female with particular attention to the Mozambique context.

Correlation of P16 (Ink4a) and CK17 to HPV (16E6+18E6) in Premalignant and Malignant Lesions of Uterine Cervix: A Clinicopathologic Study

BACKGROUND

This research was accomplished to evaluate the IHC expression of p16 (ink4a) and CK17 in low grade cervical intraepithelial lesions (LSIL), high grade cervical intraepithelial lesions (HSIL) and invasive cervical carcinomas and to assess their correlation to HPV (16E6+18E6).

METHODS

The study included (127) formalin-fixed paraffin-embedded cervical biopsies; of which 22 cases were chronic cervicitis, 24 cases were LSIL, 28 cases were HSIL and 53 cases were invasive cervical carcinomas. Sections were immunohistochemically stained for p16 (ink4a), CK17 and HPV (16E6+18E6).

RESULTS

The study established a highly significant increase in IHC of expression of p16 (ink4a), CK17 and HPV (16E6+18E6) from LSIL through HSIL to invasive carcinomas (P-value˂0.001). There was non-significant association between IHC expression of all makers with age of patients; types, grade and stage of cervical carcinomas (P-value˃0.05). HPV (16E6+18E6) revealed a significantly positive correlation with p16 (ink4a) (P-value˂0.05) and a non- significant correlation with CK17 (P-value˃0.05); in LSIL, HSIL and invasive carcinoma cases.

CONCLUSION

p16 (ink4a) expression directly reflects infection with high risk HPV in cervical lesions and can add a significant diagnostic accuracy in the evaluation of CIN. CK 17 is a good marker of malignant transformation, with increasing in its expression according to the severity of cervical lesions; however, it is not related to HPV infection. Both markers are not related to prognostic variables of patients with cervical carcinoma.

Prevalence and risk factors for cancer of the uterine cervix among women living in Kinshasa, the Democratic Republic of the Congo: a cross-sectional study

BACKGROUND

Cancer of the uterine cervix is the leading cause of cancer-related death among women in Sub-Saharan Africa, but information from the Democratic Republic of the Congo (DRC) is scarce. The study objectives were to: 1/ assess prevalence of (pre)cancerous cervical lesions in adult women in Kinshasa, 2/ identify associated socio-demographic and behavioural factors and 3/ describe human papillomavirus (HPV) types in cervical lesions.

METHODS

A cross-sectional study was conducted in Kinshasa. Between 2006 and 2013, four groups of women were recruited. The first two groups were included at HIV screening centres. Group 1 consisted of HIV-positive and group 2 of HIV-negative women. Group 3 was included in large hospitals and group 4 in primary health centres. Pap smears were studied by monolayer technique (Bethesda classification). Low- or high-grade squamous intraepithelial lesions or carcinoma were classified as LSIL+. HPV types were determined by INNO-LiPA®. Bivariate and multivariable analyses (logistic regression and generalised estimating equations (GEE)) were used to assess associations between explanatory variables and LSIL+.

RESULTS

LSIL+ lesions were found in 76 out of 1018 participants. The prevalence was 31.3 % in group 1 (n = 131 HIV-positive women), 3.9 % in group 2 (n = 128 HIV-negative women), 3.9 % in group 3 (n = 539) and 4.1 % in group 4 (n = 220). The following variables were included in the GEE model but did not reach statistical significance: history of abortion, ≥3 sexual partners and use of chemical products for vaginal care. In groups 3 and 4 where this information was available, the use of plants for vaginal care was associated with LSIL+ (adjusted OR 2.70 (95 % confidence interval 1.04 - 7.01). The most common HPV types among HIV-positive women with ASCUS+ cytology (ASCUS or worse) were HPV68 (12 out of 50 samples tested), HPV35 (12/50), HPV52 (12/50) and HPV16 (10/50). Among women with negative/unknown HIV status, the most common types were HPV52 (10/40), HPV35, (6/40) and HPV18 (5/40).

CONCLUSION

LSIL+ lesions are frequent among women in Kinshasa. The use of plants for vaginal care deserves attention as a possible risk factor for LSIL+. In this setting, HPV16 is not the most frequent genotype in samples of LSIL+ lesions.

Trends in cancer incidence in Maputo, Mozambique, 1991-2008

Background

Very limited information is available regarding the incidence of cancer in sub-Saharan Africa. We analyzed changes in cancer patterns from 1991 to 2008 in Maputo (Mozambique).

Methods

We calculated the rates of incidence of different cancer sites by sex in the 5-year age-group of the population of Maputo city as well as age-standardized rates (ASRs) and average annual percentage changes (AAPC).

Results

Over the 18-year study period a total of 12,674 cases of cancer (56.9% females) were registered with an overall increase in the risk of cancer in both sexes. In males, the most common cancers were those of the prostate, Kaposi sarcoma (KS) and the liver. Prostate cancer showed the most dramatic increase over the whole study period (AAPC +11.3%; 95% CI: 9.7–13.0), with an ASR of 61.7 per 10⁵ in 2003–2008. In females, the most frequent cancers were of the uterine cervix, the breast and KS, with the former increasing along the whole study period (AAPC + 4.7%; 95% CI: 3.4–6) with an ASR of 62.0 per 10⁵ in 2003–2008 as well as breast cancer (AAPC +6.5%; 95%CI: 4.3–8.7).

Conclusions

Overall, the risk of cancer rose in both sexes during the study period, particularly among cancers associated with westernization of lifestyles (prostate, breast), combined with increasingly rising incidences or limited changes in cancers associated with infection and poverty (uterine cervix, liver). Moreover, the burden of AIDS-associated cancers has shown a marked increase.

Implementation of cervical cancer screening using visual inspection with acetic acid in rural Mozambique: successes and challenges using HIV care and treatment programme investments in Zambézia Province

BACKGROUND

In order to maximize the benefits of HIV care and treatment investments in sub-Saharan Africa, programs can broaden to target other diseases amenable to screening and efficient management. We nested cervical cancer screening into family planning clinics at select sites also receiving PEPFAR support for antiretroviral therapy (ART) rollout. This was done using visual inspection with acetic acid (VIA) by maternal child health nurses. We report on achievements and obstacles in the first year of the program in rural Mozambique.

METHODS

VIA was taught to clinic nurses and hospital physicians, with a regular clinical feedback loop for quality evaluation and retraining. Cryotherapy using carbon dioxide as the refrigerant was provided at clinics; loop electrosurgical excision procedure (LEEP) and surgery were provided at the provincial hospital for serious cases. No pathology services were available.

RESULTS

Nurses screened 4651 women using VIA in Zambézia Province in year one of the program, more than double the Ministry of Health service target. VIA was judged positive for squamous intraepithelial lesions in 8% (n=380) of the women (9% if age ≥ 30 years (n=3154) and 7% if age <30 years (n=1497); p=0.02). Of the 380 VIA-positive women, 4% (n=16) had lesions (0.3% of 4651 total screened) requiring referral to Quelimane Provincial Hospital. Fourteen (88%) of these 16 women were seen at the hospital, but records were inadequate to judge outcomes. Of women screened, 2714 (58%) either had knowledge of their HIV status prior to VIA or were subsequently sent for HIV testing, of which 583 (21%) were HIV positive.

CONCLUSIONS

Screening and clinical services were successfully provided on a large scale for the first time ever in these rural clinics. However, health manpower shortages, equipment problems, poor paper record systems and a limited ability to follow-up patients inhibited the quality of the cervical cancer screening services. Using prior HIV investments, chronic disease screening and management for cervical cancer is feasible even in severely resource-constrained rural Africa.

Acceptability of cervical cancer screening in rural Mozambique

In Zambézia province, Mozambique, cervical cancer (CC) screening was introduced to rural communities in 2010. Our study sought to determine whether women would accept screening via pelvic examination and visual inspection with acetic acid (VIA) at two clinical sites near the onset of a new CC screening program. A cross-sectional descriptive study of 101 women was undertaken in two rural communities in north-central Mozambique. We assessed a woman's willingness to be screened, knowledge about CC symptoms and treatment, and her recommendations for best methods to deliver information to other women. After the interview, we offered CC screening. Fully 86% of women accepted VIA screening when it was offered, but uptake was 100% at one clinic and only 68% at another. The cause of CC was thought to be associated with promiscuous activity (49%) and curses placed on the woman (42%). All women in one rural Mozambique clinic and two-thirds at a second clinic underwent CC screening. Knowledge about CC screening was significantly associated with uptake, suggesting educational campaigns need to be undertaken. However, educators need to be cautious about linking screening with high-risk behaviors, as women who understood the link trended toward refusing screening.

Vaccine-related HPV genotypes in women with and without cervical cancer in Mozambique: burden and potential for prevention

Knowledge about the burden of Human Papillomavirus (HPV) infections in Sub-Saharan Africa is very limited. We collected cervical samples from 262 women from the general population and 241 tumor samples from women with invasive cervical cancer in Mozambique and tested them for HPV genotyping by the SPF(10)-LiPA(25) PCR system. Among the 195 women without cervical abnormalities by cytology HPV prevalence was 75.9%. In this group of women, the most frequently identified HPV types among HPV-positive women were in descending order of frequency: HPV51 (23.6%), HPV35 (19.6%), HPV18 (14.2%), HPV31 (13.5%) and HPV52 (12.8%). In women with cervical cancer HPV DNA detection was 100%. The type-specific distribution of the most frequent types in descending order of frequency was: HPV16 (47.0%), HPV18 (31.3%), HPV51 (14.8%), HPV52 (14.3%), HPV45 (12.6%), HPV35 (10.4%), HPV33 (4.8%) and HPV31 (2.6%). HPVs 16/18 and HPVs 16/18/31/45 were detected in 71.7% and 80.9% of cervical cancer tissue, respectively. While HPVs 51 and 35 were the two most common types in cytologically normal women in Mozambique, HPVs 16 and 18 remained the two most frequently identified types in cervical cancer. The introduction of an efficacious HPV 16/18 vaccine could potentially prevent the occurrence of 72% of cervical cancer cases and up to 81% of the cases if full cross-protection against HPVs 31 and 45 is assumed.

Coordinate expression of cytokeratin 8 and cytokeratin 17 immunohistochemical staining in cervical intraepithelial neoplasia and cervical squamous cell carcinoma: an immunohistochemical analysis and review of the literature

OBJECTIVE

Several Cytokeratin (CK) isoforms have been analyzed in cervical intraepithelial lesions. However, previously reported numbers of specimens have been too low to evaluate any correlation between CK and CIN.

METHODS

We examined the immunohistochemical staining of p16, CK8, and CK17 in 134 cervical tissues obtained by punch biopsy and graded as follows: CIN I (n=39), CIN II (n=31), CIN III (n=43), SCC (n=21).

RESULTS

p16 staining was identified in 74.4% of CIN I, 93.6% of CIN II, 97.7% of CIN III, and 100% of SCC cases. CK8 and CK17 staining were identified in 12.8% and 33.3% of CIN I, 22.6% and 58.1% of CIN II, 62.8% and 81.4% of CIN III, and 71.4% and 95.2% of SCC cases, respectively. Interestingly, positivity for CK8 and CK17 correlated with increasing lesion grade of the intraepithelial lesions and also correlated with p16 staining (p16, p=0.0008; CK8, p<0.0001, and CK17, p<0.0001), and a coordinate expression profile of CK8[+]/CK17[+] correlates with increasing CIN grade and carcinoma (likewise, a coordinate expression profile of CK8[-]/CK17[-] correlates with decreasing CIN grade and absence of carcinoma), but expression of just CK8 (CK8[+]/CK17[-]) or just CK17 (CK8[-]/CK17[+]) does not correlate with increasing CIN grade and carcinoma.

CONCLUSIONS

Results of the present study showed that p16, CK8, and CK17 immunostaining differed according to the degree of cervical intraepithelial lesions and SCC, and surprisingly, that staining was significantly correlated with increasing lesion grade of CIN and SCC.