Intralesional Beta-Interferon Treatment of Cervical Intraepithelial Neoplasia Associated with Human Papillomavirus Infection

Aims and backround

Interferons (IFN) have offered considerable advances in the therapy of genital warts even those associated with cervical intraepithelial neoplasia (CIN); intralesional therapy either alone or in combination with other modalities such as cryosurgery and laser surgery provides improved clearing and cure of these often recalcitrant lesions. The purpose of this study was to evaluate the effectiveness of intralesional IFN therapy in patients with CIN associated with human papillomavirus (HPV) infection.

Methods

Beta-IFN was injected intra-perilesionally into the cervix in 41 patients with CIN associated with HPV infection.

Results

The regimen of 3 million international units (IU) injected intralesionally daily in the 1st week and 3 times a week in the 2nd and 3rd weeks for a total of 11 injections and a total dosage of 33 million IU yielded an 80 percent cure rate and may be more advantageous than other treatment options in certain instances. Cytocolposcopic and histologic examination was carried out before and after treatment and 24 lesions were also analyzed for type-specific papillomaviruses using in situ DNA hybridization. CIN disappeared in 33 patients 6 months after the end of therapy. Side effects of intralesional IFN therapy are dose related and for the most part readily tolerated.

Conclusions

Intralesional IFN proved to be effective treatment for CIN associated with HPV infection (cure rate: 80%) and well accepted because hospitalization is not required and no important side effects occur.

High-Grade Cervical Intraepithelial Neoplasia (CIN) in Pregnancy: Clinicotherapeutic Management

An increasing incidence of cervical intraepithelial neoplasia (CIN) among young women has been noticed in recent years. For this reason pregnancy might represent a peculiar opportunity to undergo cytocolposcopic examination for those women who do not take part in a screening program for cervical carcinoma. Diagnosis of CIN during pregnancy poses the question of the management of this disease and particularly of whether it is better to treat the lesion or not during pregnancy. To contribute to the solution of this issue we initiated a study on the management of high-grade CIN in pregnancy.

Material and methods

Five hundred and seventy-one pregnant women underwent cytologic, colposcopic and, when necessary, histologic examination. Those in whom a CIN was discovered in the first four months of gestation underwent laser conization. When the diagnosis of CIN was made after the sixteenth week of gestation, cytocolposcopic monitoring was performed every eighth week during pregnancy and two months after childbirth. Laser conization was performed under colposcopic guidance in the outpatient setting in all cases. All treated patients were submitted to cytologic, colposcopic and, if necessary, histologic examination every third month in the first year after treatment, every sixth month in the second year and yearly from the third year onwards.

Results

In 14 (2.4%) of the 571 examined women a CIN III was discovered, 6 of which associated with a human papilloma virus (HPV) infection. Of these, 8 patients, whose diagnosis was made within the sixteenth week of pregnancy, underwent laser conization. In one case a minor hemorrhage occurred during treatment. Two patients reported minor bleeding up to ten days after treatment. No major hemorrhages or cervical stenosis were observed. Histologic examination of the cones confirmed the preoperative diagnosis based on cervical biopsies and the lesion was entirely removed by conization in all cases. Seven of the 8 patients who underwent laser conization during pregnancy had a spontaneous delivery at term. The remaining patient, who had had a previous cesarean section, was again delivered by cesarean section. All treated patients were cured after the first-year follow-up visit. In 6 patients CIN was diagnosed after the sixteenth week of pregnancy. These women underwent cytocolposcopic examination every eighth week during pregnancy and two months after delivery, when the cervical changes associated with gestation had disappeared. Four of these patients showed persistence of CIN at postpartum follow-up and therefore underwent laser conization. In two patients spontaneous regression of the lesion was observed. In no case did progression to invasive carcinoma occur.

Conclusions

Given the increasing incidence of CIN in young women, the beginning of pregnancy may represent a peculiar opportunity for all pregnant women who do not take part in cervical screening programs to undergo a cytocolposcopic examination. In case of a diagnosis of high-grade CIN within the first 16 weeks of pregnancy, a conservative excisional treatment, which does not expose the pregnancy to any risk, should be carried out in order to confirm the intraepithelial localization of the lesion.

Colposcopic patterns of vaginal intraepithelial neoplasia: a focus on low-grade lesions

OBJECTIVE

The aim of this study was to evaluate the colposcopic patterns observed in women with a histopathological diagnosis of vaginal intraepithelial neoplasia, with a particular interest in analyzing the colposcopic characteristics of low-grade squamous intraepithelial lesions (LSIL).

PATIENTS AND METHODS

Medical charts and colposcopy records of women diagnosed with vaginal intraepithelial neoplasia from January 1995 to December 2015, were analyzed in a multicenter retrospective case series. The abnormal colposcopic patterns observed in women with vaginal LSIL and vaginal high-grade SIL (HSIL) were compared. The vascular patterns and micropapillary pattern were considered separately.

RESULTS

Regardless the histopathological grading, in women with vaginal SIL, the grade I abnormal colposcopic findings were more frequent than grade II abnormalities. However, a grade I colposcopy was more commonly observed in women with a biopsy diagnosis of LSIL rather than HSIL (p<0.0001). Similarly, the micropapillary pattern was more frequently observed in women with LSIL (p=0.004), while vascular patterns were observed more frequently in women diagnosed with vaginal HSIL (p<0.0001). In women with grade I colposcopy, the menopausal status and a previous hysterectomy appeared to be associated with the diagnosis of vaginal HSIL.

CONCLUSIONS

Grade I abnormal colposcopic findings were more commonly observed in women with vaginal LSIL, as well as the micropapillary pattern. On the other hand, grade II abnormal colposcopy and the presence of vascular patterns were more frequently observed in women with vaginal HSIL.

High-grade vaginal intraepithelial neoplasia and risk of progression to vaginal cancer: a multicentre study of the Italian Society of Colposcopy and Cervico-Vaginal Pathology (SICPCV)

OBJECTIVE

The aim of this study was to analyse the women with high grade vaginal intraepithelial neoplasia (HG-VaIN), in order to identify a subset of women at higher risk of progression to invasive vaginal cancer.

MATERIALS AND METHODS

The medical records of all the women diagnosed with HG-VaIN, and subsequently treated, from January 1995 to December 2013 were analyzed in a multicentre retrospective case series. The rate of progression to invasive vaginal cancer and the potential risk factors were evaluated.

RESULTS

205 women with biopsy diagnosis of HG-VaIN were considered, with a mean follow up of 57 months (range 4-254 months). 12 cases of progression to vaginal squamocellular cancer were observed (5.8%), with a mean time interval from treatment to progression of 54.6 months (range 4-146 months). The rate of progression was significantly higher in women diagnosed with VaIN3 compared with VaIN2 (15.4% vs. 1.4%, p < 0.0001). Women with HG-VaIN and with previous hysterectomy showed a significantly higher rate of progression to invasive vaginal cancer compared to non-hysterectomised women (16.7% vs. 1.4%, p < 0.0001). A higher risk of progression for women with VaIN3 and for women with previous hysterectomy for cervical HPV-related disease was confirmed by multivariable logistic regression analysis.

CONCLUSIONS

A higher rate of progression to vaginal cancer was reported in women diagnosed with VaIN3 on biopsy and in women with previous hysterectomy for HPV-related cervical disease. These patients should be considered at higher risk, thus a long lasting and accurate follow up is recommended.

Prognostic significance of high-risk HPV persistence after laser CO2 conization for high-grade CIN: a prospective clinical study

PURPOSE OF INVESTIGATION

To estimate the persistence rate of high-risk HPV DNA (HR-HPV DNA) in a population treated totally by laser CO2 conization for high-grade cervical intraepithelial neoplasia (HG-CIN), and to examine if this persistence might be considered an independent risk factor for relapsing disease.

METHODS

All women with a histological diagnosis of HG-CIN and planned for laser CO2 conization from January 2003 to December 2004 were prospectively submitted to a HR-HPV test prior to surgery and at three and six months of follow-up. Women providing written informed consent with 24 months of follow-up were enrolled in the study group. A positive HPV test, involvement of resection margins, age at first intercourse, smoking habits, parity and age at conization > 50 years old were considered as risk factors for relapsing HG-CIN during follow-up, and were univariately and multivariately analyzed to discover any independent influencing factors.

RESULTS

Of HG-CIN 15.4% resulted not to be HPV related nor relapsing. The HPV clearance rate after treatment was 78.8%. Involvement of resection margins and HR-HPV DNA persistence post-treatment resulted as the only two statistically significant risk factors for HG-CIN recurrence (rate 3.8%). HR-HPV DNA persistence in follow-up resulted to be independent from other risk factors at multivariate analysis.

CONCLUSIONS

Although able to reach a low recurrence rate of HG-CIN, laser CO2 conization does not remove HPV infection completely from the cervix with a case of persistence in every five treated patients. In our experience this persistence in itself represents an independent risk factor for developing relapsing disease and constitutes the basis to introduce HPV testing even in the follow-up of patients treated for HG-CIN by laser CO2 conization.

Feasibility and outcome of laser CO2conization performed within the 18th week of gestation

The purpose of this study is to evaluate the feasibility, safety, and potential therapeutic benefit of laser CO2conization of the cervix forin situand minimally invasive carcinoma diagnosed during pregnancy. Twenty-six pregnant patients with biopsy-proven carcinomain situ/cervical intraepithelial neoplasia III but colposcopically suspicious for invasion underwent laser CO2conization during the 18th week of gestation in an outpatient setting under local anesthesia. No major intraoperative or postoperative complications occurred, and cervical cerclage was not required in any case. Two cases (7.7%) of occult FIGO stage IA1 minimally invasive cervical cancers with free surgical margins were diagnosed. Both patients delivered vaginally at term and were free of disease at postpartum follow-up. Median length of gestation was 39.1 weeks with a median birth weight of 3450 g. All 1-min Apgar scores were 8 or greater. Twenty patients (76.9%) delivered vaginally, while six patients underwent cesarean section for indications not related to the prior conization. After a mean postpartum follow-up of 18 months (range 3–42), 92.3% of patients continued to have both cytologic and colposcopic evaluations negative for persistent or recurrent disease. Two cases of persistent intraepithelial disease were successfully managed by reconization. In summary, our data suggest that laser CO2conization performed within the 18th week of gestation is safe for both the patient and the fetus, provides reliable histologic diagnosis, and can be curative. Further studies are required to confirm the favorable risk–benefit ratio of laser CO2conization in the management of non-reassuring cervical lesions observed in the first half of pregnancy.

[Cervical myomectomy by laser CO2. Report of two cases]

Cervical localization of uterine fibroids is an uncommon event and vaginal surgery by cold knife is the current therapeutic approach. Two patients with cervical fibroids underwent laser CO2 excision under colposcopic guidance, using local anesthesia and in outpatient setting. The absence of intra- and post-surgical complications and the successful therapeutical results prove that laser CO2 surgery could be an alternative treatment in selected cases.

[Cervical cytologic reports of ASCUS and LSIL. Cyto-histological correlation and implication for management]

BACKGROUND

The purpose of this retrospective study is to evaluate the appropriate management of ASCUS and LSIL pap smears by correlating the histological findings obtained by punch biopsy or excised specimens.

METHODS

The study group included 584 women with abnormal pap smear: 358 with ASCUS and 226 with LSIL cytological abnormalities. All patients underwent colposcopy and, if necessary, directed-punch biopsy. In case of biopsy-proven dysplasia a destructive or excisional treatment was performed, as indicated.

RESULTS

The prevalence of HPV-CIN histological lesions in ASCUS patients was 36.3% and in LSIL patients was 67.7%. High grade CIN was observed in 15.7 and 20.8% respectively. In one ASCUS patients an invasive lesion was diagnosed on punch biopsy and two LSIL patients showed stromal invasion on the final histopathologic report on excised specimens.

CONCLUSIONS

Patients with ASCUS or LSIL pap smear exhibit a wide spectrum of histological findings ranging from no pathologic abnormality to frequent high grade CIN and invasive carcinoma in rare cases. Because of the histological assessment by directed-punch biopsy and its therapeutical indications, colposcopic examination is recommended for all women with a cytologic diagnosis of ASCUS and LSIL.

[Cervical intraepithelial neoplasia (CIN) and human papillomavirus (HPV) infection]

Many studies have shown a strong correlation between CIN and HPV infection. Molecular biology has allowed identification of types of HPV which seem to be connected, more frequently than others, to dysplastic lesions. Physical state of HPV-genome seems to play an important role in the development of cervical cancer. In this study the HPV-genome has been searched in tissue specimens obtained from 34 women affected by CIN II and III. All patients underwent laser conization. Immediately before treatment, colposcopically directed biopsies of the cervical lesion and of the areas with no colposcopically apparent disease were taken and on these samples, HPV-DNA has been searched, isolated and analysed for HPV types and physical state. Histologic examination on cones showed 6 cases of CIN II (3 with HPV), 24 cases of CIN III (14 with HPV), 1 microinvasive carcinoma and 3 with no residual lesion. Southern blot analysis detected HPV-DNA in 4 cases of CIN II (16.7%) and in 20 cases of CIN III (70.6%). In 50% of CIN II and 85% of CIN III HPV 16 DNA has been found and in the remaining 50% of CIN II and 15% of CIN III HPV 31 DNA has been detected. All CIN II and 14 cases of CIN III showed episomal HPV-DNA. Integrated HPV-DNA has been found in 3 cases of CIN III and the other 3 cases of CIN III showed both integrated and episomal HPV-genome. Integrated form has been noticed only for HPV 16 type. In no case of colposcopically normal tissue has HPV-DNA been found. These data seem to confirm the strong correlation between HPV 16 type, which often has integrated form, and CIN III strengthening the hypothesis of its potential oncogenic action.

[Cervical intraepithelial neoplasia and genital condylomatosis in HIV-positive patients. Clinical aspects and management]

In this study prevalence of cervical intraepithelial neoplasia (CIN) and genital condylomatosis in HIV-positive women and the possible relation between HIV and HPV infection and CIN have been analyzed. 66 seropositive women underwent cytological, colposcopic and, when necessary, histologic examination and the results have been compared with those obtained from 150 HIV-seronegative controls. HIV-positive patients were divided in two groups, depending on number of CD4+/mm3, < 400 or > = 400, to evaluate the relation between immunity and HPV infection and/or CIN. 35 seropositive and 136 seronegative patients affected by genital condylomatosis and/or CIN I were submitted to laser CO2 vaporization and the results of the treatment have been compared. All cases of CIN II and III underwent laser CO2 conization. Among HIV-seropositive patients the prevalence of genital condylomatosis appeared to be 87.9% and among the seronegative controls 18% (p < 0.001). Multilocated condylomatosis represented 58.7% of genital condylomatosis among seropositive women and 11.1% among the seronegative patients. In HIV-seropositive group the prevalence of genital condylomatosis was of 95.2% among women with CD4+ < 400 and of 75% among those with CD4+ > = 400 (p > 0.01). 13 patients (19.7%) of the 66 seropositive women and 12 of the 150 (8%) seronegative had a cervical intraepithelial neoplasia. A CIN III was diagnosed in 9 seropositive patients (13.6%) and in 5 seronegative (3.3%). Among the HIV-seropositive women who underwent laser vaporization for genital condylomatosis a cure-rate of 34.5% was found; among seronegative women who underwent the same treatment the cure-rate was of 79.4%. Those patients who underwent laser conization resulted all cured at first check. In the group of HIV-seropositive women a higher prevalence (p < 0.001) of genital condylomatosis, particularly multilocated localization, has been found than in HIV-seronegative patients. An increased prevalence of CIN has also been found among HIV-seropositive women. Genital condylomatosis in seropositive patients resulted extremely difficult to treat with laser vaporization in contrast with the 100% success in laser conization for high-grade CIN.

[Radiosurgical excision in the treatment of cervical intraepithelial neoplasia]

39 patients affected by CIN had undergone radio surgical excision. This non-traumatic method employs 3.8 MHz radio waves are employed to cut and/or coagulate. The radio surgical excision was carried out by a loop electrode, or microneedle, according to the colposcopic, histologic and microcolpohysteroscopic characteristics of the cervical lesion. In fact 14 patients, among whom 11 affected by CIN I and 4 by CIN II with a total visibility of squamous columnar junction and not extended lesion of the cervical canal, had undergone radio surgical excision through various dimensions loop according to the size of the tissue to be excised. Whereas 10 CIN II patients who had not entirely visible squamous columnar junction or large cervical canal lesion, and 14 CIN III patients underwent to radiosurgical conization through a subtle and extensible tungsten thread according to the size of the tissue to be excised. In the 100% of the both groups the recovery was confirmed after three and six months. Inno cases cervical canal stenosis was observed and the squamous columnar junction resulted well visible. In both groups no thermal damages on the excised tissue, which could create difficulties on the histological diagnosis, were observed. Therefore, this method resulted an easy and cheap technique to be executed in surgery with excellent results under the therapeutic and economical aspect.

[Vulval vestibular papillomatosis: anatomo-clinical study]

Vestibular papillomatosis of the vulva is only by some authors considered as a viral lesion, and its origin is controversial. A study of 44 women with vestibular papillomatosis was undertaken, and in all the cases biopsies of vulvar skin were taken. We did not reveal any presence of koilocytotic change suggestive of viral infection, and no human papillomavirus sequences were detected by DNA probe technique. These results suggest that this vestibular papillomatosis of the vulva can be considered as an anatomical variant of the vestibular mucosa. Only in case of viral over-infection, ablative treatment is justified.

[Human papillomavirus infections in the lower genital tract of women]

Viral infections of the lower female genital tract have gained increasing clinical, epidemiological and cyto-histopathological relevance in the last few years. From January 1981 to December 1990, 14,090 patients who referred to the center of cervical-vaginal-vulvar physiopathology of the Ob/Gyn Institute (University of Florence), underwent a cytologic, colposcopic and, if necessary, histologic examination. Patients were divided in two groups: the first group consisting of 8635 women and relating to the period 1981-1986, the second group consisting of 5455 patients and relating to the period 1987-1990. This division in groups was necessary because vulvoscopy (after 3-5% acetic acid application) was performed as a routine examination starting in 1987, so that the former period could not be considered homogeneous to the latter for vulvar results. About genital condylomatosis were made some observations: localization, morphology and the different prevalence in the various age groups verifying the statistic reliability using chi 2 test. Finally the association of intraepithelial neoplasias to HPV infection was related to the age of patients, localization and morphology of condylomatous lesions. In the first group 466 patients (5.4%) were affected by genital condylomatosis, 1041 patients (19.1%) were affected in the second group. The yearly prevalence of HPV infection increased during the decade of observation changing from 1.9% of 1981 to 21% of 1990. The prevalence of condylomatous lesions reduces significantly as the age increases (p < 0.0001) showing a maximum of prevalence under twenty-five years of age. Genital condylomatosis is localized in most cases (76%) in a single seat of the lower genital tract and cervical localization is the most commonly involved (43.13% in the first group; 42.65 in the second). Sporadic is the vaginal localization as the sole one. The vulvoperineal seat, after the cervical, is the most frequently involved (1st group: 29.82%; 2nd group: 31.03%). It seems that HPV infection assumes different morphologies according to its localization, generally flat on the cervix and florid at vulvo-vaginal level.(ABSTRACT TRUNCATED AT 400 WORDS)

[Treatment of female genital condylomatosis with intramuscular beta interferon]

Intramuscular injections of beta-interferon were used to treat a first group of 64 outpatients with clinically diagnosed genital condylomata at single doses of 3 x 10(6) IU for 10 consecutive days. A second group of 30 patients affected by HPV genital infection has been treated with placebo intramuscular injections. Patients were checked at 3, 6 and 12 months after therapy and twice during a one year follow-up after the disappearance of the warts. In the first group 29 patients (45.3%) were cured after 3 months, another 6 after 6 months and 1 patient after one year. In the second group only 3 (10%) patients were cured after 3 months, while in 2 cases (6.7%) lesions disappeared after 6 months (p value less than 0.001). Therapy was most effective on flat lesions in the cervical area. Follow-up of the patients with complete regression of lesions showed three recurrences of condylomatous lesion.

[Viral infections and neoplasms of the uterine cervix]

Since the last century, epidemiological studies of cervical carcinoma have shown a close link with sexual activity and in particular with promiscuity starting at an early age. Aetiological research has therefore concentrated on identifying sexually transmitted pathogens. In recent years studies have focused on the apparently significant role of HSV and particularly HPV in the aetiopathogenesis of this tumour. After the first cytohistological findings the HPV-cervical cancer link has been confirmed by electron microscopy, immunohistochemical studies and hybridisation of viral DNA. The identification of different HPV types presenting varying degrees of oncogenic risk offers the prospect of reaching a reliable prognosis on the basis of the particular virus identified in the lesion. The hypothesis that the virus has a decisive influence on the biology of th tumour is also intriguing: findings on the incidence and course of cervical cancer in the youngest women seems to suggest tha HPV may be a fundamental tumour growth factor.

[Use of topical methisoprinol (Viruxan) in female genital condylomatosis]

Medical therapy of genital condylomatosis seems to be the most rational strategy, since this pathology is characterised by highly frequent recurrences after destructive physical therapy alone. Successful therapy of female genital condylomatosis with methisoprinol (Viruxan), administered as ointment and/or vaginal ovules is reported. The drug proved to be efficient both in curing this viral infection and preventing its recurrences.