Severe Cervical Intraepithelial Neoplasia Research Articles

TYPE PROFILE OF HIGH ONCOGENIC RISK HUMAN PAPILLOMAVIRUS IN CLINICAL FORMS OF CERVICAL INFECTION IN RUSSIAN FEDERATION

Abstract Aim: To establish a relationship between the clinical forms of cervical papillomavirus infection and the specific characteristics of high-risk human papillomavirus (HPV) types. The study included 1063 patients aged 16 to 71 years (Me = 33; IQR: 29–38) with active papillomavirus infection and its clinical forms. The patients were stratified into groups based on disease clinical forms during active HPV infection: carriers, mild cervical intraepithelial neoplasia, moderate cervical intraepithelial neoplasia, severe cervical intraepithelial neoplasia, carcinoma in situ, and invasive cervical cancer. Diagnostics was performed using real-time polymerase chain reaction (PCR) with HPV typing (types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68). The results demonstrated that viruses from the alpha-phylogenetic branch are responsible for developing clinical forms of HPV infection. It was found that severe forms of infection, including cervical cancer, was mainly linked to A9 family (HPV16, HPV31, HPV58) viruses, whereas initial disease stages – to A5 and A6 families (HPV51 and HPV66). A particularly significant observation is the transition from A5, A6, and A7 family HPV viruses with relation to HPV16, to the A9 family showing highly related to HPV16. This observation underscores the high significance of HPV16 monoinfection in cervical cancer within the context of the replication theory for HPV16-like viruses. Viral load exhibits a wave-like pattern depending on the clinical form and HPV family, indicating the dynamic nature of the infection process and the potential changes in viral load based on the disease stage and virus type. The study highlights the importance of identifying a specific HPV type in mono- or polyinfection to assess disease clinical form. This can provide significant aid to clinicians for assessing severity of the infection and devising the appropriate management strategy for patients. In conclusion, our findings emphasize a need to take into consideration a HPV type in diagnostics and treatment of cervical papillomavirus infection. This approach will enhance prognostic accuracy and effectiveness of therapeutic interventions aimed at preventing disease progression and cervical cancer development.

Cervical intraepithelial neoplasia and fecundability: a prospective cohort study.

Is cervical intraepithelial neoplasia (CIN) associated with reduced fecundability, defined as the probability of conceiving per menstrual cycle? Overall, we observed no meaningful association between CIN and fecundability, regardless of surgical status, although a recent diagnosis of moderate or severe CIN might be associated with slightly reduced fecundability for 2 years after diagnosis. About 15% of couples experience infertility. Few studies have examined the influence of CIN on fertility, and the results have been inconsistent. No study has investigated the association between fecundability and pathologist-reported CIN diagnoses, particularly with respect to the recency of the specific CIN diagnoses. This prospective cohort study included 9586 women trying to conceive. The women were enrolled from 1 June 2007 to 3 February 2020. Women were invited to complete a baseline questionnaire and bimonthly follow-up questionnaires for up to 12 months or until pregnancy occurred. Data on cervical cytologies and biopsies were retrieved from The National Pathology Registry (DNPR), which holds records of all cervical specimens examined in Denmark. Women were categorized based on their most severe diagnosis of CIN: no lesion, other cervical changes, mild CIN (CIN1), or moderate/severe CIN (CIN2+) with or without surgery. To investigate the association between CIN and fecundability, we computed fecundability ratios (FR) and 95% confidence intervals (CI) using a proportional probabilities regression model. We adjusted for age at study entry, partner age, body mass index, smoking status, timing of intercourse, parity, education, number of sexual partners, and household income. Compared with no lesion, the adjusted FRs (95% CI) for the association between CIN and fecundability were: other cervical lesions, 0.97 (0.91-1.04); CIN1, 1.04 (0.96-1.13); CIN2+ no surgery, 1.00 (0.82-1.22); and CIN2+ with surgery 0.99 (0.89-1.10). The FRs (95% CI) for a recent diagnosis (<2 years) of CIN were 0.98 (0.86-1.11) for other cervical lesions; 1.13 (0.99-1.29) for CIN1; 0.89 (0.62-1.26) for CIN2+ no surgery and 0.91 (0.75-1.10) for CIN2+ with surgery compared with the no lesion group. In the analyses, we adjusted for several covariates related to the women. However, we had little information on the male partners which could lead to unmeasured confounding as fecundability is a couple-based measure of fertility. Furthermore, a CIN diagnosis may not be constant as it may regress or progress spontaneously; therefore, it is possible that we have misclassified some women, especially women categorized as having normal cells or CIN1. Our results contribute important knowledge to women who are concerned about their future fertility after receiving a CIN diagnosis. This study was funded by The Danish Cancer Society (R167-A11036-17-S2). The overall cohorts were funded by the National Institute of Child Health and Human Development (R01-HD086742 and R03-HD094117). The authors report no competing interests. N/A.

Фототераностика тяжелых дисплазий и преинвазивного рака шейки матки

Due to the high prevalence of pre-cancerous cervical diseases and cervical cancer, the search, pathogenetic reasoning and evaluation of the efficacy of new approaches to the diagnosis and treatment of these pathologies, including those aimed at fertility preservation, are extremely relevant. Objective. To study the clinical efficacy and safety of phototheranostics as a method of diagnosis and treatment of severe dysplasia and pre-invasive cervical cancer. Patients and methods. An open-label, retrospective-prospective, randomized, comparative, clinical trial involving 94 reproductive-aged patients with morphologically confirmed severe cervical intraepithelial neoplasia (CIN) and pre-invasive cervical cancer was conducted. All patients were divided into two groups: group 1 (comparison) included 49 patients who underwent cervical conization with curettage of the remaining cervical canal; group 2 (study) included 45 patients who underwent phototheranostics: photodynamic therapy (PDT) with simultaneous laser-induced fluorescence excitation. Results. After the first course of phototheranostics, most women in the study group had normal cytological results, which were observed 6, 9, and 12 months after treatment. In these periods, all patients who underwent phototheranostics had a normal colposcopic picture, while in the comparison group, some patients showed signs of cervical lesions. Morphological confirmation of the complete therapeutic effect was considered to be elimination of human papillomavirus (HPV) and normalization of the proliferative activity of the epithelial layer (assessed by the levels of Ki-67 and phosphohistone markers) during phototheranostics. Conclusion. The study demonstrated the high clinical efficacy of phototheranostics in the treatment of CIN and pre-invasive cervical cancer: 85–88% of women achieved the desired therapeutic effect after the first session of phototheranostics, and after the second session, all patients in the study group had complete regression of cervical mucosal lesions. In the study group, higher pregnancy rates and favourable outcomes in patients planning pregnancy confirmed that the use of PDT contributes to fertility preservation in women treated for CIN and pre-invasive cervical cancer, which is associated with the preservation of anatomo-functional characteristics of the cervix when using phototheranostics. Key words: PDT, HPV, photodynamic therapy, fluorescence diagnosis, cervical dysplasia, photosensitizers, pre-invasive cervical cancer, phototheranostics, pregnancy after PDT

Assessing a relation between composition of luminal and tissue microbiota and cervical intraepithelial changes

The incidence of cervical cancer (CC) in Russia remains at a high level and ranks fourth among all cancers. CC is preceded by mild, moderate, and severe cervical intraepithelial neoplasia. Human papillomavirus (HPV) is known to be the main cause for its development being responsible for 99% cancer cases. Despite HPV infection, the oncological process occurs only under certain conditions. There are risk factors that indirectly affect the course and emergence of cervical dysplasia. In recent years, the role of cervico-vaginal microbiome for onset and progression of this pathology has been actively discussed. Many studies evidence that dysbiosis along with cervical intraepithelial dysplasia is associated with increased HPV viral load, additionally allowing to clarify a role of specific microorganisms. Despite the knowledge rapidly accumulating about the nature of vaginal microbiome in cervical precancerous processes, the level of its impact on disease course has not been fully investigated and is of great interest. Identification of microorganisms that affect emergence and progression of this pathology will allow to prevent and apply select approach to treatment of dysbiosis. The aim of our study was to identify a relation between cervical tissue and luminal culturome and severe cervical intraepithelial neoplasia. The study evaluated the microbiota of cervical and cervical canal mucosa biopsy in patients with cervical intraepithelial changes. According to the study results, the Streptococcus genus representatives were significantly more frequent in cervical biopsy specimens in severe dysplasia vs. no cervical intraepithelial changes, whereas cervical canal cultures provided comparable data. Bacteria from the Corynebacterium genus were found in cervical biopsy specimens 3 times more often than in smear from the cervical canal mucous membrane. The microbiota from cervical and cervical canal biopsy specimens differ qualitatively and quantitatively particularly regarding prevalence of Streptococcus spp. representatives being more common in patients with cervical dysplasia. Corynebacterium spp. were detected more often in cervical biopsy specimens than in cervical canal smears. Thus, the method of collecting biological material has a great influence on final results.

Противовирусный препарат аллоферон в лечении пациенток с цервикальными интраэпителиальными неоплазиями: обзорный анализ исследований

Aim: Analysis of the published results of scientific studies evaluating the effect of the antiviral drug alloferon on the reduction of viral load (VL) or the elimination of human papillomavirus (HPV) of high carcinogenic risk both in monotherapy of mild cervical intraepithelial neoplasia (CIN) and in complex treatment of severe CIN, as well as to evaluate the effect of the drug on the dynamics of clinical manifestations of CIN. Key points. Eight published domestic studies of the antiviral drug alloferon in the treatment of CIN of varying severity were analyzed. The selection of relevant publications in the scientific citation database PubMed and Google Scholar was carried out to assess the antiviral and immunomodulatory effect of this drug and a cumulative analysis of the results of the treatment of 646 patients with CIN of varying degrees (361 received alloferon, and 285 were in the control group). The average age is 31 years. VL was calculated per 100,000 human cells: less than 3 lg per 105 cells — low, clinically insignificant concentration: from 3 to 5 lg per 105 cells — average, clinically significant concentration: more than 5 lg per 105 cells — high. The effect of the drug on the dynamics of clinical manifestations of CIN was assessed by the results of a cytological study and/or extended colposcopy. Conclusion. The analysis of studies showed the high efficiency of alloferon against HPV in monotherapy (85%: elimination of HPV — 32%, a significant decrease in VL — 53%). Efficiency in complex therapy (93%: elimination of HPV — 89.7%, reduction in VN — 3.3%). The clinical efficacy of the drug in CIN 1 in monotherapy is 79.9%, and in the complex treatment of CIN 2 — 96.8%. Keywords: human papillomavirus, cervical intraepithelial neoplasia, recurrence, antiviral therapy, immunomodulatory therapy, alloferon.

HPV vaccination following loop electrical excision procedure (LEEP) for cervical intraepithelial neoplasia: A cost-effectiveness analysis (134)

Objectives: Excisional cervical procedures, such as a Cold Knife Cone (CKC) or a loop electrical excision procedure (LEEP), are standard treatments for moderate to severe cervical intraepithelial neoplasia (CIN). Human papillomavirus (HPV) is the causal agent for CIN and can persist or recur; thus, patients can be susceptible to recurrent CIN following excision. Some data suggest that CIN recurrence rates decrease with HPV vaccination after LEEP. Here, we aimed to examine the cost-effectiveness of HPV vaccination following LEEP procedures compared with no vaccination. Methods: We constructed a decision-analytic model (TreeAge Pro 2021) to compare outcomes between patients who underwent LEEP followed by HPV vaccination with those who underwent LEEP without HPV vaccination. Our theoretical cohort contained 250,000 patients, the approximate number of patients who had LEEPs per year in the United States. Our outcomes were costs, quality-adjusted life-years (QALYs), any recurrence, recurrence of CIN 1, recurrence of CIN 2/3, number of pap smears, colposcopy, and second LEEP. We assumed that all individuals with any recurrence underwent a colposcopy and that all individuals who had a recurrence of CIN 2/3 would undergo a second LEEP. Probabilities of recurrence were based on a recently-published meta-analysis. All values were derived from the literature and discounted QALYs at a rate of 3%. Utilities were applied for four years after the initial LEEP procedure. Our cost-effectiveness threshold was $100,000/QALY. Univariate sensitivity analyses were performed to evaluate the robustness of the model. Results: In our one-year theoretical cohort of 250,000 patients who had undergone LEEP, the HPV vaccination strategy was associated with 17,281 fewer recurrences of CIN (8,360 cases of CIN 1 and 8,921 cases of CIN 2/3), 26,203 fewer pap smears (1,025,368 vs 1,051,570), 17,281 fewer colposcopies (20,588 vs 37,869), and 8,921 fewer second LEEP procedures (4,779 vs 13,701) (Table 1). The vaccination strategy was associated with a higher cost of $135 million. However, HPV vaccination was the cost-effective strategy with an incremental cost-effectiveness ratio (ICER) of $29,180.81. In our sensitivity analyses, the HPV vaccination strategy remained cost-effective until the cost of the 3-dose HPV vaccine series reached $1,899.56, or the baseline (non-vaccinated) probability of recurrence was less than 4.8%. Objectives: Excisional cervical procedures, such as a Cold Knife Cone (CKC) or a loop electrical excision procedure (LEEP), are standard treatments for moderate to severe cervical intraepithelial neoplasia (CIN). Human papillomavirus (HPV) is the causal agent for CIN and can persist or recur; thus, patients can be susceptible to recurrent CIN following excision. Some data suggest that CIN recurrence rates decrease with HPV vaccination after LEEP. Here, we aimed to examine the cost-effectiveness of HPV vaccination following LEEP procedures compared with no vaccination. Methods: We constructed a decision-analytic model (TreeAge Pro 2021) to compare outcomes between patients who underwent LEEP followed by HPV vaccination with those who underwent LEEP without HPV vaccination. Our theoretical cohort contained 250,000 patients, the approximate number of patients who had LEEPs per year in the United States. Our outcomes were costs, quality-adjusted life-years (QALYs), any recurrence, recurrence of CIN 1, recurrence of CIN 2/3, number of pap smears, colposcopy, and second LEEP. We assumed that all individuals with any recurrence underwent a colposcopy and that all individuals who had a recurrence of CIN 2/3 would undergo a second LEEP. Probabilities of recurrence were based on a recently-published meta-analysis. All values were derived from the literature and discounted QALYs at a rate of 3%. Utilities were applied for four years after the initial LEEP procedure. Our cost-effectiveness threshold was $100,000/QALY. Univariate sensitivity analyses were performed to evaluate the robustness of the model. Results: In our one-year theoretical cohort of 250,000 patients who had undergone LEEP, the HPV vaccination strategy was associated with 17,281 fewer recurrences of CIN (8,360 cases of CIN 1 and 8,921 cases of CIN 2/3), 26,203 fewer pap smears (1,025,368 vs 1,051,570), 17,281 fewer colposcopies (20,588 vs 37,869), and 8,921 fewer second LEEP procedures (4,779 vs 13,701) (Table 1). The vaccination strategy was associated with a higher cost of $135 million. However, HPV vaccination was the cost-effective strategy with an incremental cost-effectiveness ratio (ICER) of $29,180.81. In our sensitivity analyses, the HPV vaccination strategy remained cost-effective until the cost of the 3-dose HPV vaccine series reached $1,899.56, or the baseline (non-vaccinated) probability of recurrence was less than 4.8%.

Photodynamic therapy of cervical intraepithelial neoplasia and cervical cancer

Purpose: to study the effectiveness of photodynamic therapy in combination with diathermoelectroconization in the treatment of cervical intraepithelial neoplasia and cervical cancer.Materials and methods. The study included 108 patients aged 33.13 ± 1.18 years. Human papillomavirus was detected in all patients. The study group consisted of 62 patients with cervical diseases. The fi rst subgroup included 28 patients with moderate to severe cervical intraepithelial neoplasia and pT1AN0M0 cervical cancer who underwent diathermoelectroconization and photodynamic therapy. The second subgroup included 34 patients with severe cervical intraepithelial neoplasia who underwent only cervical diathermoelectroconization. The control group included 46 patients with unchanged cervix. To carry out fl uorescent diagnostics and photodynamic therapy, the patients of the fi rst subgroup were intravenously injected with a solution of photosensitizer “Fotoditazin” (“Vetagrand”, Russia) at a dose of 0.8–1.2 mg/kg. Three hours later, using the AFS device (“Polironik”, Russia), fl uorescent diagnostics was performed followed by photodynamic therapy with an ALHT-ELOMED laser (“Elomed”, Russia) in continuous mode. The wavelength was 662 nm, the output power – 3 W, the radiation dose – 200–300 J/cm2 for the cervix and 100–125 J/cm2 – for the cervical canal. All patients underwent complex antiviral therapy.Results. All patients after photodynamic therapy showed complete eradication of human papillomavirus and regression of cervical intraepithelial neoplasia. Morphological studies have shown that the effectiveness of combined treatment of moderate and severe cervical intraepithelial neoplasia, reaching 100 %, was higher than with the use of diathermoelectroconization alone (95 %). There were no recurrences of cervical intraepithelial neoplasia and cervical cancer after combined treatment.Conclusion. Photodynamic therapy of cervical intraepithelial neoplasia and cervical cancer is a highly effective method.

16P The role of IL-8 gene polymorphism (845 T/C) in the development of cervical intraepithelial neoplasia

IL-8 gene polymorphisms are involved in the carcinogenesis of many malignant neoplasms, but their role in the development of cervical cancer (CC) has not been fully elucidated. The aim of the study was to evaluate the relationship between the presence of IL-8 gene polymorphism (845 T/C) and the development of severe cervical intraepithelial neoplasia (CIN) and cervical cancer.

The role of the microbiome and transcriptome in the development and progression of CIN

The article presents a systematic review of the results of modern clinical studies devoted to the problem of the microbiome and transcriptome in women with cervical intraepithelial neoplasia (CIN). Moderate to severe CIN (CIN II – III) can precede the development of cervical cancer (CC) by several years or even decades. Cervical cancer (CC) is an important global health problem. There is a year-on-year increase in the prevalence of CC. Currently, there are many known risk factors that contribute to the development of CIN and cervical cancer. However, the vaginal and cervical microbiome play an important role in the development and progression of CIN and CC, according to some authors. Thus, the timely detection and treatment of cervical intraepithelial lesion-associated genital infections is now especially important. From these point of view, bacterial vaginosis (BV) is considered an acute problem in gynecological practice, which affects the incidence of precancerous conditions of the cervix. The results of the studies have shown the importance of detailed analysis of the vaginal microbial community, which was performed by the method of next generation sequencing (NGS). These studies were conducted using the NGS method based on the analysis of bacterial 16S rRNA genes, which has a high diagnostic accuracy and allows to determine the verity of the microbial landscape. The study of the transcriptome in women with CIN showed a change in many microRNA molecules, which can become markers of the CIN and cervical cancer upon further study. The introduction of the NGS method into the laboratory diagnostics complex will improve the diagnosis and timely prevent the progression of CIN to cervical cancer.The study of the microbiome of the vaginal biotope and cervical canal will allow to identify the groups of patients at high risk for the progression of precancerous lesions of the cervix and cervical cancer. Transcriptome studies have shown changes in many microRNA molecules (SALL4, FOXO1, HBD-1, HBD-2, HBD-3, LL37, psoriasin and IL-8, etc.) in women with CIN and cervical cancer.

Diagnostic performance of HPV E6/E7 mRNA testing towards HPV‐DNA testing and p16/Ki67 immunostaining as a biomarker of high‐risk HPV recurrence in Greek women surgically treated for their cervical lesions

To evaluate the diagnostic performance of E6/E7 HPV-mRNA overexpression towards HPV-DNA testing and p16/Ki67 immunocytochemistry in a post-op population to verify if this biomarker can be effectively used as indicator of successful cervical intraepithelial neoplasia (CIN) treatment. Our study retrospectively analyzed 197 patients of our Colposcopy Clinic between January 2013 and September 2020 coming with an abnormal Pap smear suggestive for colposcopy, and after a series of follow-ups including liquid-based cytology (LBC) and punch-biopsy sampling, there were surgically treated. LBC was used for cytology and molecular analysis of the three HPV-related biomarkers. Six months after treatment, 93% of the HPV-mRNA-positive women became negative while this applied to only 80.2% of the HPV-DNA-positive women. HPV persistence was 6.9% at 6-12 months after treatment. The comparison among cytology, colposcopy, HPV-DNA test, and HPV-mRNA test after treatment revealed that the last one is the only with a strong correlation with actual severity (histology during treatment) (ρ=0.345, p=0.006) implying that clinical cases with more severe CIN may have higher chances of unsuccessful treatment. HPV-mRNA test had higher sensitivity (100%), specificity (96.88%), and positive predictive value (45.45%) for CIN2+ recurrent lesions when compared with HPV-DNA testing (80%, 82.81%, 10.81% respectively) and p16/Ki67 immunocytochemistry (80%, 95.83%, 33.33% respectively) while their negative predictive values were similar. E6/E7 mRNA detection has higher diagnostic values for the prediction of treatment failure compared with HPV-DNA testing and p16/Ki67 immunocytochemistry, and as an outcome could be used as predictive indicator of CIN-treatment status.

Comparison of Punch Biopsy and Loop Biopsy for the Management of Severe Cervical Intraepithelial Neoplasia (CIN).

The study was undertaken for comparing the colposcopy directed punch versus loop excision biopsy technique in order to get the most précised sample for study as well as comparing the complications associated with them. The prospective clinical study was conducted on 50 women of age group 20-80years. Women who were found to have a Reid colposcopic index of high grade disease, low grade disease or invasive disease recognized as the patients needed biopsy. They were randomly divided into either the punch biopsy forceps group (PB group) or the round loop electrode group (LE group). The quality of tissue of the LE group was found significantly better than the tissue quality of PB group based on the size, site and tissue damaged measures. Both the groups were found to have the same cytology report as well as colposcopic diagnosis and histology reports. Mild degree of bleeding has been reported as a frequent complication in LEEP and punch biopsy. The VAS pain score associated in each procedure was found to be 2.4 and 2.8, respectively, in both groups with no significant difference. The present study has concluded that the quality of tissue from the LEEP biopsy electrode was better than the punch biopsy forceps with no difference in the pain score, and it could be suggested that use of the round loop electrode in CDB provides good quality tissue to evaluate the histology.

Vaginal delivery of mucus-penetrating organic nanoparticles for photothermal therapy against cervical intraepithelial neoplasia in mice

Photosensitizer-based photothermal therapy (PTT) may be a good choice for the treatment of severe cervical intraepithelial neoplasia (CIN) compared with conventional thermal ablation.

HPV‐mRNA and HPV‐DNA detection in samples taken up to seven years before severe dysplasia of cervix uteri

Randomized clinical trials using human papillomavirus (HPV) DNA testing have found increased protection against cervical cancer and HPV-based screening is globally recommended for women ≥30 years of age. HPV-mRNA is a promising alternative target for cervical screening tests, but assessing equivalence requires longitudinal evaluation over at least the length of a screening interval. Our aim is to analyze the longitudinal sensitivity of HPV-mRNA and HPV-DNA in cervical samples taken up to 7 years before severe cervical intraepithelial neoplasia or worse (CIN3+). From a population-based cohort of 95,023 women in Sweden, cervical samples were frozen at -80°C between May 2007 and January 2012. Registry linkages identified that 1,204 of these women had CIN3+ 4 months to 7 years after enrolment. Baseline samples were analyzed for HPV-mRNA (Aptima, Hologic) and for HPV-DNA (Cobas 4800, Roche) and results from both tests obtained for 1,172 women. For both women <30 and ≥ 30 years, HPV-mRNA had similar sensitivity for CIN3+ as HPV-DNA (p = 0.0217 and p = 0.0123 in noninferiority testing for at least 90% relative sensitivity, respectively). Among women ≥30 years, the longitudinal sensitivities for CIN3+ occurring 5-7 years later were comparable [76.3% (95% CI: 65.8%-84.3%) and 82.5% (95% CI: 72.6%-89.4%)] as were the longitudinal negative predictive values for absence of CIN3+ [99.97% (95% CI: 99.95-99.98) and 99.98% (95% CI: 99.96-99.99)], for the HPV-mRNA and HPV-DNA test. In conclusion, HPV-mRNA testing has similar longitudinal sensitivity as HPV-DNA, implying that HPV-mRNA testing can safely be used for cervical screening.

TOPical Imiquimod treatment of residual or recurrent cervical intraepithelial neoplasia (TOPIC-2 trial): a study protocol for a randomized controlled trial

BackgroundCervical dysplasia (cervical intraepithelial neoplasia (CIN)) is caused by Human Papillomavirus (HPV) and is most common in women of reproductive age. Current treatment of moderate to severe CIN is surgical. This procedure has potential complications, such as haemorrhage, infection and preterm birth in subsequent pregnancies. Moreover, 15% of women treated for high grade CIN develop residual/recurrent CIN or cervical cancer after surgical excision. Finally, 75–100% of patients with a residual and recurrent CIN 2–3 lesion are still HPV positive. They could possibly benefit from an alternative medical treatment, which aims to eliminate HPV.The primary study objective is to evaluate the effectivity of imiquimod 5% cream compared to treatment with Large Loop Excision of the Transformation Zone (LLETZ) for recurrent/residual CIN.Methods/designThis study is a multicentre, non-inferiority randomized single blinded study. The study population consists of female patients with histological proven residual/recurrent CIN after previous surgical treatment. Four hundred thirty-three patients will be included in the Netherlands. The first 35 patients will be included in a pilot study to prove non-futility.Included patients will be randomized to receive either 5% imiquimod cream or LLETZ treatment. Imiquimod will be inserted three times a week intravaginally for a period of 16 weeks using a vaginal applicator. Ten weeks after the end of imiquimod treatment a biopsy will be taken for treatment response. In case of progressive or stable disease a LLETZ will be performed. At 12 and 24 months after the start of treatment cytology will be taken for follow up. The LLETZ group will be treated according to the current guidelines. Throughout the study, HPV typing and quality of life will be tested.DiscussionRepeated LLETZ in women with residual/recurrent CIN lesions has complications. We would like to possibly offer alternative treatment in a selected group to avoid these risks. Moreover, we monitor treatment efficacy, side effects and long-term recurrence rates.Trial registrationMedical Ethical Committee approval number: NL 53792.078.15. Affiliation: Erasmus Medical Center.Registration number ClinicalTrials.gov: NCT02669459, date of registration: 27th January 2016.

Association of HPV infection and pathological grading of cervical premalignant lesions

Objective To investigate the classification of human papilloma virus(HPV) infection in different pathological grading of cervical intraepithelial neoplasia. Methods 150 cases with cervical premalignant lesions were prospectively collected, 50 cases in each mild(CINⅠ), moderate(CINⅡ ) and severe(CINⅢ) cervical intraepithelial neoplasia group. HPV infection type of the three groups were detected and analyzed. And the association between different cervical intraepithelial neoplasia multiple HPV infection was analyzed as well. Results CINⅠ, Ⅱ and Ⅲ patients with HPV16 infection were 7, 18 and 21 cases, respectively; the patients with HPV18 infection were 6 cases, 14 cases, and 15 cases, respectively; the patients with HPV58 infection were 5 cases, 13 cases and 15 cases, respectively; the patients with multiple HPV infection were 3 cases, 23 cases and 29 cases, respectively.All the above differences were statistically significant(χ2=10.222, 6.140 and 6.527, all P<0.05). Conclusion High risk HPV16, 18 and 58 are the risk factors of moderate and severe CIN, which may lead to the occurrence of cervical cancer in women. Key words: Cervical intraepithelial neoplasia; Precancerous conditions; Human papilloma virus; Infection

Prevalence of abnormal cervical cytology and its relation with age and parity

This screening study was carried out in Gynae Unit II, Sir Ganga Ram Hospital, Lahore. The aim of study was to find out prevalence of abnormal pap smears and its correlation to age &amp; parity so that we can formulate a policy to screen at risk population with Utilization of minimum resources in our setup. Role of Pap smear in detection of cervical pre-malignant &amp; malignant lesions can not be over emphasized. The Cervical smears of 310 women have been evaluated. The frequency of mild to severe cervical intraepithelial neoplasia was found to be 8% while smear positive for malignant cells was in 0.9% of cases. This study reveals 41-60 years of age and Para three and above a high risk group for Cervical Intraepithelial Neoplasia (CIN) and cytology positive for malignant cells. In view of the expenditure involved and technical constraints in mass screening, an approach of selective screening of high risk population could be an effective strategy for control of carcinoma of cervix in developing countries like ours. 524-5+7+F Bushra Zahid-Department of Obstetrics &amp; Gynaecology, Sir Ganga Ram Hospital/Fatima Jinnah Medical College, Lahore Nuzhat Khawaja-Department of Obstetrics &amp; Gynaecology, Sir Ganga Ram Hospital/Fatima Jinnah Medical College, Lahore+np_khawaja@hotmail.com Rakhshanda Tayyeb-Department of Obstetrics &amp; Gynaecology, Sir Ganga Ram Hospital/Fatima Jinnah Medical College, Lahore

Risk of head-and-neck cancer following a diagnosis of severe cervical intraepithelial neoplasia: a nationwide population-based cohort study in Denmark

ObjectiveWomen with a history of cervical intraepithelial neoplasia grade 3 including adenocarcinoma in situ (CIN3/AIS) may be more prone to develop cancers of the ano-genital region and head-and-neck cancers. The current literature is, however, limited. MethodsWe established a nationwide cohort of approximately 2,500,000 Danish women born in 1918–1990. By linking the cohort to population-based health registries, we obtained information on CIN3/AIS, cancer, migration, death, education, and smoking. Cox proportional hazards models were used to estimate hazard ratios (HRs) and confidence intervals (CIs) for the association between CIN3/AIS and risk of head-and-neck squamous cell carcinoma (HNSCC). HRs were presented for any HNSCC and for four subgroups categorized by their anticipated degree of association with human papillomavirus (HPV). ResultsA history of CIN3/AIS was significantly associated with an increased overall relative risk of HNSCC after adjustment for year of birth, attained age, and length of education. The risk was especially high for sites anticipated to be strongly associated with HPV (e.g. base of tongue, tonsils) (HR, 2.49; 95% CI, 1.84–3.36). Lower risks were found for sites anticipated to be not or weakly associated with HPV (e.g. nasal cavity, middle ear, sinuses) (HR, 1.29; 95% CI, 0.61–2.76). ConclusionWomen with a history of CIN3/AIS have a significantly higher risk of HNSCC than women without such a history. The increased relative risk persisted for at least 20years after the CIN3/AIS diagnosis. Women with CIN3/AIS may be more susceptible to the consequences of HPV and/or may have higher risk behavior, such as smoking.

Application of HPV E6/E7 mRNA detection in screening of moderately severe cervical intraepithelial neoplasia

Objective This study aimed to explore the clinical value of human papilloma virus (HPV) E6/E7 mRNA tests in identifying precancerous lesions of the uterine cervix- cervical intraepithelial neoplasia 2 or more CIN2+ (CINⅡand CINⅢ). Methods This study is a cross-sectional survey design, between December 2011 to December 2013.The specimens were collected from the First People's Hospital of Huizhou and the Third People's Hospital of Huizhou in Department of Obstetrics and Gynecology outpatient and inpatient of cervical disease suspected patients, with thin-prep cytologic test (TCT) and histopathological results as reference, detected 345 patients of exfoliated cervical epithelial cells by using the branched DNA (b-DNA) technology to evaluate the application value of high risk HPV E6 / E7mRNA in the clinical diagnosis of CIN.Using spss 19.0 software for data analysis. Results (1)Compared with TCT, the positive rate of E6/E7 mRNA in 325 samples were grading by cytology as follows: no intraepithelial lesion cells (NILM) 21.1% (40/190), atypical squamous cells (ASC) 38.5% (15/39 ), low-grade squamous intraepithelial lesions (LSIL) 76.9% (30/39), atypical squamous cells can not exclude high-grade intraepithelial lesions (ASC-H) (8/10), high-grade squamous intraepithelial lesions (HSIL) 72.3% (34/47), TCT grades and HPV E6/E7 mRNA positive rate showed linear association (χ2=67.654, P<0.01; r=0.497, P<0.01); and with HPV E6/E7 mRNA copy number was also relevant (r=0.511, P<0.01). (2) Compared with pathological results, the positive rate of E6/E7 mRNA in 164 women samples were grading by pathology as follows: with NILM was 27.8%(10/36), with CIN Ⅰ was 65.9%(29/44), with CIN Ⅱ was 80.6%(54/67), and with CINⅢ was 82.4%(14/17), pathological grades and HPV E6/E7 mRNA positive rate showed a linear correlation (χ2= 26.426, P<0.01; r=0.438, P<0.01); and the number of copies correlated with the increase of pathological grades too(r=0.543, P<0.01). (3) Screening effectiveness analysis results showed, the sensitivity of HPV E6 / E7mRNA was 84.6% while TCT was 47.7%. The sensitivity and specificity were 40.0% and 91.1% respectively when HPV E6/E7 mRNA and TCT processed as sequential detection test. The CIN2 + (CIN Ⅱ and CIN Ⅲ) best diagnostic critical point of 890.26 copies/ml, was established using receiver operating characteristic (ROC) curve. The sensitivity and specificity were 58.5% and 93.7%, respectively. Conclusions The sensitivity of HPV E6/E7 mRNA test is better than TCT, the specificity is high in HPV E6/E7 mRNA and TCT processed as sequential detection test. Using the optimal cut-off value of ROC curve to detect CIN2+ has high sensitivity and specificity, so the detection of HPV E6/E7 mRNA may have some clinical value in screening and risk assessment of precancerous lesions of the uterine cervix.(Chin J Lab Med, 2015, 38: 532-536) Key words: Cervical intraepithelial neoplasia; Papillomaviridae; Oncogene proteins, viral; Papillomavirus E7 proteins

Citologia da cúpula vaginal com suspeita de lesão intraepitelial de grau indeterminado

No presente artigo é relatado um caso de uma paciente de 42 anos, diagnosticada em 2011 com Adenocarcinoma in situ e displasia grave do epitélio de revestimento pavimentoso, que foi tratada por traquelectomia. Em Novembro de 2013, a paciente realizou uma citologia da cúpula vaginal, onde se observaram achados citológicos compatíveis com lesão intraepitelial de baixo grau mas também a presença de células que favorecem o diagnóstico de lesão intraepitelial de alto grau. Não sendo possível classificar a lesão intraepitelial como sendo claramente baixo ou alto grau, atribuiu-se a interpretação de lesão intraepitelial de grau indeterminado. Para confirmação e esclarecimento do diagnóstico foi efetuada biopsia com resultado de displasia grave do epitélio de revestimento pavimentoso vaginal sem evidência de invasão do estroma. Por fim foi indicada a pesquisa e tipificação de vírus do papiloma humano, com resultado positivo para o tipo 16. Diagnósticos citológicos de lesão intraepitelial de grau indeterminado apresentam um follow-up histológico estatisticamente diferente das lesões intraepiteliais de alto e baixo grau, e estão na sua maioria associadas a infeção por vírus do papiloma humano de alto risco. Os achados citológicos do presente estudo apoiam a necessidade de se estabelecer esta lesão como categoria de diagnóstico no Sistema de Bethesda, com um follow-up definido.

Molecular transitions from papillomavirus infection to cervical precancer and cancer: Role of stromal estrogen receptor signaling

To study the multistep process of cervical cancer development, we analyzed 128 frozen cervical samples spanning normalcy, increasingly severe cervical intraepithelial neoplasia (CIN1- CIN3), and cervical cancer (CxCa) from multiple perspectives, revealing a cascade of progressive changes. Compared with normal tissue, expression of many DNA replication/repair and cell proliferation genes was increased in CIN1/CIN2 lesions and further sustained in CIN3, consistent with high-risk human papillomavirus (HPV)-induced tumor suppressor inactivation. The CIN3-to-CxCa transition showed metabolic shifts, including decreased expression of mitochondrial electron transport complex components and ribosomal protein genes. Significantly, despite clinical, epidemiological, and animal model results linking estrogen and estrogen receptor alpha (ERα) to CxCa, ERα expression declined >15-fold from normalcy to cancer, showing the strongest inverse correlation of any gene with the increasing expression of p16, a marker for HPV-linked cancers. This drop in ERα in CIN and tumor cells was confirmed at the protein level. However, ERα expression in stromal cells continued throughout CxCa development. Our further studies localized stromal ERα to FSP1+, CD34+, SMA- precursor fibrocytes adjacent to normal and precancerous CIN epithelium, and FSP1-, CD34-, SMA+ activated fibroblasts in CxCas. Moreover, rank correlations with ERα mRNA identified IL-8, CXCL12, CXCL14, their receptors, and other angiogenesis and immune cell infiltration and inflammatory factors as candidates for ERα-induced stroma-tumor signaling pathways. The results indicate that estrogen signaling in cervical cancer has dramatic differences from ERα+ breast cancers, and imply that estrogen signaling increasingly proceeds indirectly through ERα in tumor-associated stromal fibroblasts.