Comparison of filter in situ deoxyribonucleic acid hybridization with cytologic, colposcopic, and histopathologic examination for detection of human papillomavirus infection in women with cervical intraepithelial neoplasia

Material from uterine cervical scrapings of 98 women with cervical intraepithelial neoplasia were analyzed by filter in situ hybridization for human papillomavirus infection. Concurrently obtained Papanicolaou smears and colposcopically directed biopsy specimens were also examined for papillomavirus infection. Hybridization was superior to cytologic and colposcopic examinations and was equivalent to histopathologic study for papillomavirus detection. Infection with virus types 6 and/or 11 was associated with milder disease, whereas virus types 16 and/or 18 infection alone or in association with types 6 and/or 11 was associated with more severe disease. Because papillomavirus infection may not be detected by cytologic or colposcopic examination and specific virus types have been documented to be associated with invasive disease, deoxyribonucleic acid hybridization analysis for at least these virus types should be carried out in conjunction with conventional procedures when evaluating women with cervical disease. Filter in situ hybridization is a simple, rapid, noninvasive procedure and has enhanced diagnostic value over conventional procedures by defining infecting virus types.     

The role of human papillomavirus deoxyribonucleic acid assay and repeated cervical cytologic examination in the detection of cervical intraepithelial neoplasia among human immunodeficiency virus-infected women. Cervical Disease Study Group of the American Foundation for AIDS Research Community Based Clinical Trials Network

OBJECTIVES: We sought to measure the characteristics of a quantitative human papillomavirus deoxyribonucleic acid assay and repeated cervical cytologic examination in screening for cervical intraepithelial neoplasia among human immunodeficiency virus-infected women. STUDY DESIGN: Human immunodeficiency virus-infected women with screening CD4+ lymphocyte counts of < or = 500 cells/mm3 (n = 103) were examined by quantitative human papillomavirus deoxyribonucleic acid assay and serial cervical cytologic examination and by colposcopy with biopsy and endocervical curettage during the course of 1 year. RESULTS: Quantitative measures of total human papillomavirus deoxyribonucleic acid and high-risk human papillomavirus deoxyribonucleic acid were strongly associated with any cervical intraepithelial neoplasia (P = .005) and high-grade cervical intraepithelial neoplasia (P = .0006), but they improved the sensitivity and negative predictive value of baseline screening only slightly when combined with cervical cytologic examination. Incident cervical intraepithelial neoplasia occurred frequently (20%) during 1 year of follow-up and was more common among human papillomavirus-infected women. Repeated cytologic examination identified 60% of women with new cervical intraepithelial neoplasia. CONCLUSION: Human immunodeficiency virus-infected women with at least mild immunosuppression have a high incidence of cervical intraepithelial neoplasia, which warrants close follow-up. Those with high baseline human papillomavirus deoxyribonucleic acid levels may be at the highest risk for incident cervical intraepithelial neoplasia.     

The association of sexually transmitted diseases with cervical intraepithelial neoplasia: a case-control study

Thirty-three women with histologically confirmed cervical intraepithelial neoplasia (grades I to III, with one case of microinvasive carcinoma) and 54 women without evidence of the disease were prospectively studied to determine the relationship of genital infection to cervical neoplasia. Demographic and sexual data for patients and control subjects were collected, with standardized clinical and colposcopic evaluation by means of predefined diagnostic categories. Cultures from the cervix were examined for herpes simplex virus, cytomegalovirus, Chlamydia trachomatis, and Neisseria gonorrhoeae. Human papilloma virus infection was identified by characteristic changes of koilocytosis in cytologic or histopathologic specimen. Cultures from the vagina were evaluated for Gardnerella vaginalis, Trichomonas vaginalis, Ureaplasma urealyticum, Mycoplasma hominis, Candida albicans, and other yeasts. Separate Gram strains were prepared from endocervical secretions and from vaginal secretions. More lifetime sexual partners, larger area of transformation zone, evidence of human papilloma virus infection, and altered vaginal flora were observed in women with cervical intraepithelial neoplasia. The association of human papilloma virus infection and altered vaginal flora with cervical intraepithelial neoplasia was independent of sexual experience.     

Papillomavirus detection: demographic and behavioral characteristics influencing the identification of cervical disease

OBJECTIVE: This study was undertaken to assess the association between detection of high-risk types of human papillomavirus and various demographic and behavioral characteristics and to further relate this association to cervical histopathologic findings. STUDY DESIGN: A total of 1007 patients with a Papanicolaou test result reported as high-grade squamous intraepithelial lesion or with 2 results reported as atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion were referred from city and county clinics to a colposcopic clinic. All women had a cervical smear obtained, underwent colposcopically directed biopsy and endocervical curettage, and had a specimen taken for human papillomavirus deoxyribonucleic acid detection by polymerase chain reaction. Demographic information was obtained from each patient. RESULTS: Human papillomavirus deoxyribonucleic acid was identified in 655 (66%) of the specimens. High-risk human papillomavirus types (16, 18, 31, 33, and 35) were detected in 463 (70.7%) of these specimens. The prevalence of evidence of human papillomavirus (koilocytosis) and grade 1 cervical intraepithelial neoplasia in the biopsy specimen decreased significantly with age, whereas the prevalence of grade 2 or 3 cervical intraepithelial neoplasia in the biopsy specimen increased with age. There was a significant age-dependent decreasing trend in detection of high-risk human papillomavirus deoxyribonucleic acid among women who had human papillomavirus-associated changes, grade 1 cervical intraepithelial neoplasia, and grade 2 or 3 cervical intraepithelial neoplasia in the biopsy specimen. The prevalences of high-risk human papillomavirus among patients with grade 1 cervical intraepithelial neoplasia and grade 2 or 3 cervical intraepithelial neoplasia were similar, and both were significantly higher than among women with no evidence of cervical intraepithelial neoplasia or koilocytosis in the biopsy specimen. Risk factors associated with grade 2 or 3 cervical intraepithelial neoplasia were different from those associated with human papillomavirus-associated changes and with grade 1 cervical intraepithelial neoplasia. CONCLUSION: The detection of high-risk human papillomavirus was age-dependent for all histologic categories. Patients with grade 2 or 3 cervical intraepithelial neoplasia had a prevalence of high-risk human papillomavirus that was similar to that among women with grade 1 cervical intraepithelial neoplasia but significantly higher than that among women whose biopsy specimens appeared normal or demonstrated only the presence of human papillomavirus-induced changes (koilocytosis). This suggests that separation of human papillomavirus-associated changes only from grade 1 cervical intraepithelial neoplasia may be of significance in tissue diagnosis.     

Potential hazards of following atypical and low-grade cervical cytology without colposcopy

Objective: To determine the frequency of high-grade cervical intraepithelial neoplasia in patients with atypical and low-grade cervical cytology and to assess the optimal evaluation and follow-up.Methods: Prospective observational study of 367 of 7,651 private patients who had cytologic, virologic, or colposcopic changes suggesting cervical intraepithelial neoplasia or cervical carcinoma. The study was performed to determine the frequency of cervical intraepithelial neoplasia in the various cytologic groups and to assess the effect of testing for human papillomavirus on the sensitivity, specificity, and positive predictive value of these tests.Results: Papanicolaou smears that included all non-negative tests (high- and low-grade squamous intraepithelial lesions and atypical squamous or glandular epithelial cells of undetermined significance) had the maximal sensitivity (89%) for high-grade cervical intraepithelial neoplasia and cancer. The combined cytologic categories of high- and low-grade squamous intraepithelial lesions had a sensitivity of 58%, this was reduced to 24% if only high-grade squamous intraepithelial lesions were considered relevant for additional evaluation. If we had not evaluated the patients with atypical squamous and glandular cells of undetermined significance, we would have missed diagnosing one third of high-grade and one half of low-grade cervical intraepithelial neoplasia. Cervical cytology was false negative in 8% of patients with high-grade and in 14% of those with low-grade cervical intraepithelial neoplasias. High-risk human papillomavirus deoxyribonucleic acid was detected in 40% of women with high-grade and in 24% of those with low-grade grade cervical intraepithelial neoplasias. The positive predictive value of cytology with atypical squamous cells of undetermined significance increased from 5% to 38% for high-grade and from 30 to 85% for high- and low-grade cervical intraepithelial neoplasias in patients with detectable high-risk human papillomavirus deoxyribonucleic acid. Virologic studies produced no significant improvement on these diagnoses in women with high- or low-grade cytology.Conclusions: Because of the poor sensitivity of cytology suggesting high-grade squamous intraepithelial lesions, we recommend that all women with atypical or low-grade cytology be recalled for colposcopy and high-risk human papillomavirus deoxyribonucleic acid testing, if available. Decisions whether to perform a biopsy should be based on the result of colposcopic examination. Performing colposcopy only on those patients who have cytologic high-grade squamous intraepithelial lesions and following those with lower grade cytologic anomalies without colposcopic diagnosis appears inadequate to rule out high-grade cervical intraepithelial neoplasia.     

Quantitative deoxyribonucleic acid analysis of patients with mild cervical atypia: a potentially malignant lesion?

Quantitative deoxyribonucleic acid (DNA) analysis of cervical biopsy material from 32 women with cytologic, colposcopic, and histologic evidence of mild cervical atypia consistent with cervical intraepithelial neoplasia I, reactive atypia, or human papillomavirus infection was carried out using flow cytometry and Feulgen microspectrophotometry. Evidence of aneuploidy, ie, neoplastic transformation, was demonstrated in all cases of cervical intraepithelial neoplasia I and 68% of cases with human papillomavirus-induced atypia. These results support the growing impression that human papillomavirus-induced cervical atypia should be regarded as a true precursor of cervical neoplasia, and emphasize the necessity to refer patients with mild atypia for definitive diagnosis and management.     

Temporal associations of human papillomavirus infection with cervical cytologic abnormalities

The relationship between infection with different human papillomavirus types and cervical intraepithelial neoplasia was studied in a group of 398 women seen in a private gynecology practice in Washington, D.C. Each woman was assessed for human papillomavirus infection by Southern blot hybridization analysis of cervical cells obtained by swab. The human papillomavirus results were correlated with the results of Papanicolaou smears taken the same day and with data abstracted from medical records regarding past cervical disease. Subjects with normal cytologic findings at the time of human papillomavirus testing were followed up for an average of 2 to 3 years with additional Papanicolaou smears. At the time of human papillomavirus testing, 58% (19/33) of women with cervical intraepithelial neoplasia had detectable human papillomavirus deoxyribonucleic acid in contrast to 10% (28/289) of women with normal cytologic findings (p less than 0.001). This association persisted after statistical adjustment for age and current use of oral contraceptives, a factor that appeared to increase the detection of human papillomavirus. Among women with no current cytologic evidence of neoplasia, human papillomavirus detection was more likely in those with a history of past genital neoplasia (p = 0.05). In the follow-up study, 15% (3 of 20) of cytologically normal women who were human papillomavirus-positive at baseline subsequently exhibited cervical cells suggestive of cervical intraepithelial neoplasia compared with only 5% (9 of 195) of human papillomavirus-negative women. However, this difference reflected recurrent and not incident neoplasia.     

Factors associated with an increased risk of prevalent and incident grade III cervical intraepithelial neoplasia and invasive cervical cancer among women with Papanicolaou tests classified as grades I or II cervical intraepithelial neoplasia.

OBJECTIVE: Women with Papanicolaou tests classified as cervical intraepithelial neoplasia grade I or II are treated conservatively in many countries. However, these women are at an increased risk of having underlying prevalent and incident grade III cervical intraepithelial neoplasia and invasive cancer. This study was undertaken to identify factors that could predict these clinically important disease states. STUDY DESIGN: Five hundred women with Papanicolaou tests classified as persistent grade I or II cervical intraepithelial neoplasia underwent a repeat test, human papillomavirus testing with Hybrid Capture assay (Digene, Silver Spring, Md) and polymerase chain reaction, and colposcopy with histologic assessment. One hundred fifty-seven women with histologically proven grade I or II cervical intraepithelial neoplasia were monitored conservatively for a minimum of 9 months to assess predictors of incident grade III cervical intraepithelial neoplasia. RESULTS: One hundred fifty-one women with prevalent grade III cervical intraepithelial neoplasia and 5 women with prevalent invasive cancer were identified at the first colposcopy. A repeated Papanicolaou test classified as higher than grade II cervical intraepithelial neoplasia and detection of oncogenic human papillomavirus types were significant predictors of underlying grade III cervical intraepithelial neoplasia and cancer in the multivariate analysis. Seventeen of 157 women (10.8%) with grade I or II cervical intraepithelial neoplasia progressed to grade III cervical intraepithelial neoplasia. Age >30 years and detection of oncogenic human papillomavirus were significantly correlated with progression in the multivariate analysis. No progression was observed in women who were negative for human papillomavirus. CONCLUSION: The high rate of underlying prevalent grade III cervical intraepithelial neoplasia and cancer found in our study (31.2%) indicates that conservative management of women with persistent grade I or II cervical intraepithelial neoplasia should be discouraged. Colposcopy with histologic assessment should be recommended as the standard of care. However, for women with histologically proven grade I or II cervical intraepithelial neoplasia, subsequent conservative management was safe in our study for those who were negative for human papillomavirus by type-specific polymerase chain reaction.     

Colposcopy is superior to cytology for the detection of early genital human papillomavirus infection

Of 2232 women with no cytologic evidence of intraepithelial neoplasia, 250 (11.2%) were positive for human papillomavirus deoxyribonucleic acid (DNA) by filter in situ hybridization. In 150 of those human papillomavirus-positive patients, an adequate colposcopic examination of the cervix was possible; human papillomavirus infection was diagnosed in 104 women (70%). Cervical cytology showed evidence of human papillomavirus infection in only 23 patients (15%). The following colposcopic features were most common: acetowhite epithelium (29%), punctuation (18%), acetowhite spikes (17%), and mosaicism (9%). Colposcopy was essentially normal in 27%. In 64 hysterectomized patients, vaginal colposcopy showed evidence of human papillomavirus infection in 38 women (59%). Vaginal cytology showed signs of human papillomavirus infection in only 9% (N = 6). Acetowhite spikes were seen in 52%, acetowhite epithelium in 5%, punctuation in 3%, and normal findings in 40%. Histologic examination of 25 biopsy specimens (cervical, N = 15; vaginal, N = 10) showed mainly a lack of glycogenation, acanthosis, and elongation of rete pegs. Koilocytosis and dyskeratosis were seen only in a few cases as rare foci, hence the negative cytology. We conclude that colposcopy is far more sensitive than cytology for the detection of cervical and vaginal human papillomavirus infection.     

Is human papillomavirus testing an effective triage method for detection of high-grade (grade 2 or 3) cervical intraepithelial neoplasia?

OBJECTIVE: Our purpose was to assess the usefulness of the polymerase chain reaction assay for detection of human papillomavirus infection for prognostic value in the triage strategies for high-grade (grade 2 or 3) cervical intraepithelial neoplasia in women referred for colposcopy after abnormal Papanicolaou smears. STUDY DESIGN: A total of 1007 women referred to a colposcopic clinic providing care for an indigent population were studied. Four hundred fifty-four women were referred after two Papanicolaou smears reported as atypical squamous cells of undetermined significance or low grade-squamous cervical intraepithelial lesion, and 553 were referred after a single smear reported as high-grade squamous intraepithelial lesion. All women had a cervical smear, colposcopy-directed biopsy, and endocervical curettage performed. A sample for human papillomavirus deoxyribonucleic acid detection by polymerase chain reaction was obtained. RESULTS: High-risk human papillomavirus types were detected in 463 (46%) of 1007 women studied. There was a significant increase of the frequency of high-risk human papillomavirus by the increasing severity of biopsy findings ranging from 32.7% in women without cervical intraepithelial neoplasia on biopsy to 60% in women having grade 2 or 3 on the biopsy specimen. Women having a negative Papanicolaou smear found to have high-risk human papillomavirus deoxyribonucleic acid at the time of colposcopy had a significantly higher rate of grade 2 or 3 cervical intraepithelial neoplasia on the biopsy specimen than did women without high-risk human papillomavirus. There was no such difference observed in women with a cytologic finding of low- or high-grade squamous intraepithelial lesions at the time of colposcopy. The polymerase chain reaction assay appears to be more sensitive than the commercial human papillomavirus profile test. The positive predictive value for grade 2 or 3 cervical intraepithelial neoplasia of both tests was similar (21.7% and 22.8%, respectively). CONCLUSION: The human papillomavirus is associated with high-grade cervical intraepithelial neoplasia, but the screening for human papillomavirus deoxyribonucleic acid does not have prognostic value in women reported as having atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions on two precolposcopy Papanicolaou smears. (Am J Obstet Gynecol 1998;178:1235-44.)     

A population-based five-year follow-up study of cervical human papillomavirus infection

OBJECTIVE: The purpose of this study was to determine the long-term tendency for cervical human papillomavirus infections to persist in the general population. STUDY DESIGN: From 500 women who participated in a 1991 population-based survey, 90 healthy women with normal results of cytologic examination (women with human papillomavirus deoxyribonucleic acid detected and age-matched control women without human papillomavirus deoxyribonucleic acid detected) were interviewed and examined 5 years later colposcopically, cytologically, and with human papillomavirus serologic testing and human papillomavirus deoxyribonucleic acid testing by polymerase chain reaction with 2 different consensus primer pairs (MY09 and MY11 and GP5(+) and GP6(+)), type-specific polymerase chain reaction, and deoxyribonucleic acid sequencing. RESULTS: The 5-year human papillomavirus clearance rate was 92%. Only human papillomavirus type 16 infections persisted. Colposcopic impression of grade 2 cervical intraepithelial neoplasia was associated with persistent human papillomavirus 16 infection (P <.03). Human papillomavirus detection was associated with sexual history. Human papillomavirus type was the only determinant of human papillomavirus persistence. CONCLUSION: The high clearance rates in a population-based setting with a 5-year follow-up period imply that inclusion of human papillomavirus deoxyribonucleic acid testing in population-based cervical screening programs should target persistent infection.     

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 comparision 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 women 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 evident 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. (Am J Obstet Gynecol 1997;177:930-6.)     

The prevalence of HPV16DNA in normal and pathological cervical scrapes using the polymerase chain reaction.

Human papillomavirus (HPV) has been implicated in the development of cervical cancer. Newly developed molecular techniques have facilitated HPV identification and typing of cervical lesions. Several studies have suggested a strong correlation between HPV16 and intraepithelial cervical neoplasia. However, there is no agreement on this point since HPV16 is detected also in normal cervical tissue. We have amplified the L1 region of HPV16 DNA using the polymerase chain reaction (PCR) technique and analyzed the HPV16 prevalence in cytological scrapes of 201 Italian sexually active patients. One hundred twenty-four of these women had normal cytologic and colposcopic examination, while seventy-seven women had normal or abnormal cytology and a cervical lesion detectable by colposcopy. Within this latter group, 25 of 77 women (32.4%) were positive for HPV16 DNA, compared to 11 of 124 samples (8.87%) from women with normal cytology and colposcopy. The present results confirm the high efficiency of the PCR technique in detecting HPV16 DNA from cervical scrapes and suggest that this analysis should become a method of choice in clinical studies.     

A population-based study of human papillomavirus deoxyribonucleic acid testing for predicting cervical intraepithelial neoplasia

Objective: Our purpose was to determine the predictive values of primary or secondary screening for cervical human papillomavirus infection for cytologic detection of cervical intraepithelial neoplasia. Study Design: Most of the 254 women referred for colposcopy in Västerbotten County in Sweden during October 1993 through December 1995 and 320 age-matched women from the general population were screened for human papillomavirus deoxyribonucleic acid by nested general-primer polymerase chain reaction. Results: Ninety-six percent of women with high-grade cervical intraepithelial neoplasia had human papillomavirus, compared with 4% of women with normal findings (odds ratio 606; 95% confidence interval 137 to 5607). Thirty-seven percent of referred women and 48% of referred women >39 years old had mostly minor cytologic abnormalities with no human papillomavirus. The human papillomavirus–associated positive predictive value for cervical intraepithelial neoplasia was 76% in the colposcopy group and 11% in the general population, whereas the negative predictive value was >97% in both populations. Conclusion: Testing for human papillomavirus deoxyribonucleic acid seems diagnostically useful among women referred for colposcopy. (Am J Obstet Gynecol 1998;179:1497-502.)     

Hybrid capture 2 viral load and the 2-year cumulative risk of cervical intraepithelial neoplasia grade 3 or cancer

OBJECTIVE: The purpose of this study was to determine the clinical value of a semiquantitative measure of human papillomavirus viral load by the hybrid capture 2 assay for stratification of the risk of histologic cervical intraepithelial neoplasia grade 3 or carcinoma. STUDY DESIGN: The Atypical Cells of Unknown Significance and Low-Grade Squamous Intraepithelial Lesions Triage Study was a randomized clinical trial of 5060 women with 2 years of follow-up to evaluate treatment strategies for women with equivocal or mildly abnormal cervical cytologic condition. The usefulness of the continuous hybrid capture 2 output relative light units/positive controls that were above the positive threshold (1.0 relative light units/positive controls), which was a surrogate for human papillomavirus viral load, for distinguishing between hybrid capture 2 positive women who were diagnosed with cervical intraepithelial neoplasia grade 3 or carcinoma during the study from those who were not diagnosed with cervical intraepithelial neoplasia grade 3 or carcinoma was examined with the use of receiver-operator characteristic analyses. RESULTS: Relative light units/positive controls values did not further discriminate between hybrid capture 2 positive women with cervical intraepithelial neoplasia grade 3 or carcinoma from those with less than cervical intraepithelial neoplasia grade 3 or carcinoma. The use of a cervical intraepithelial neoplasia grade 2 or more severe or carcinoma case definition did not alter our findings. CONCLUSION: Among women with atypical cells of unknown significance or low-grade squamous intraepithelial lesion cervical cytologic findings, the hybrid capture 2 viral load measurement did not improve the detection of 2-year cumulative cases of cervical intraepithelial neoplasia grade 3 or carcinoma significantly.     

Vaginal microbial flora as a cofactor in the pathogenesis of uterine cervical intraepithelial neoplasia.

The vaginal microbial flora of 106 women with histopathologically confirmed cervical intraepithelial neoplasia and 79 women without disease, was evaluated for Gardnerella vaginalis, Trichomonas vaginalis, Candida albicans and other yeasts. Flora morphology was assessed by gram staining of secretions. Cervical cultures were examined for Herpes Simplex virus, Cytomegalovirus and Neisseria gonorrhoeae. Chlamydia trachomatis antigens in cervical secretions were detected by enzyme immunoassay. Human Papillomavirus was identified by koilocytosis in cytologic or histopathologic specimens. Human Papillomavirus infection (P less than 0.00001), vaginal infection with Mycoplasma hominis (P = 0.012) and abnormal vaginal flora (P = 0.006) were significantly associated with CIN, suggesting that CIN may be promoted by vaginal microorganisms in conjunction with human papillomavirus cervical infection.     

Specific serologic response to genital human papillomavirus types in patients with vulvar precancerous and cancerous lesions

OBJECTIVE: Antibodies to human papillomavirus are indicative for previous human papillomavirus exposure. Human papillomavirus antibody reactivities to vulvar precancerous lesions were reported poorly, and the role of human papillomavirus in some of these lesions is still unclear. STUDY DESIGN: In a direct enzyme-linked immunosorbent assay, serum samples from 126 healthy control subjects, 97 women with lichen sclerosus with or without squamous hyperplasia, 78 women with vulvar intraepithelial neoplasia, and 16 women with verrucous carcinoma were examined for immunoglobulin G and A antibodies to L1 virus-like particles of genital human papillomavirus types 6, 11, 16, 18, and 31, cutaneous human papillomavirus type 8, bovine papilloma virus, and cottontail rabbit papilloma virus. RESULTS: In lichen sclerosus/squamous hyperplasia with atypia immunoglobulin G and A, antibody positivity rates to high-risk human papillomavirus virus-like particle types 16, 18, and 31 were significantly higher than in the control group and the lichen sclerosus/squamous hyperplasia group without atypia. In patients with vulvar intraepithelial neoplasia I, increased immunoglobulin G antibody prevalences with both high-risk and low-risk human papillomavirus-virus-like particles were detected; whereas in patients with vulvar intraepithelial neoplasia II/III, this was observed only with the human papillomavirus types 16, 18, and 31. When only reactivities with 2 genital human papillomavirus types were compared, percentages of positives to only 1 of these 2 types ranged between 43% and 82%, with regard to all respective positives. CONCLUSION: Our data support the role of high-risk human papillomavirus types, mainly human papillomavirus-16, in the pathogenesis of different vulvar lesions with atypia. Serologically, there are no indications that lichen sclerosus/squamous hyperplasia without atypia is associated with human papillomavirus, but high-risk human papillomavirus in lichen sclerosus/squamous hyperplasia with atypia could play a role in carcinogenesis. High antibody specificity was clearly demonstrated among 5 genital, 1 cutaneous human, and 2 animal papillomavirus types.     

Human papillomavirus in women with vulvar intraepithelial neoplasia III

Untreated cases of vulvar intraepithelial neoplasia (VIN) III may progress to invasive vulvar carcinoma. Tissues from 29 New Zealand women with VIN III were examined for the presence of human papillomavirus (HPV) types 6, 11, 16 and 18 by in situ hybridization and polymerase chain reaction. HPV 16, the only HPV type detected in the lesions, was identified in about half the cases. HPV-positive women were younger than HPV-negative women, and their lesions displayed koilocytosis more often. In four of five cases in which there was a progression to invasive cancer, HPV 16 was detected in both the VIN III and invasive cancer tissue.     

Abnormal Papanicolaou smears. Comparison of cytology, colposcopy and cervical swab DNA hybridization.

Cervical swab sampling for DNA hybridization was performed on 89 women attending a colposcopy clinic. In situ hybridization studies for human papillomavirus (HPV) types 6/11, 16/18 and 31/33/35 were performed on the specimens. Biopsy specimens were obtained from 65 patients. The cytologic, colposcopic and histologic results were classified into five groups and assigned a score of 0-5, depending upon the diagnosis. An increasing score correlated positively with the presence of HPV, especially types 16/18 and 31/33/35. A comparison was made of the sensitivity, specificity, and positive and negative predictive values for the standard method of colposcopic evaluation versus the standard method combined with DNA cervical swab sampling. No significant changes in the parameters were found when the DNA cervical swab was added.     

Analysis of individual human papillomavirus types in cervical neoplasia: a possible role for type 18 in rapid progression

Histologic and molecular analyses of 214 cervical biopsy specimens were performed to test the hypothesis that certain individual human papillomavirus types that are usually grouped together are differentially distributed in various grades of cervical intraepithelial neoplasia and invasive squamous carcinoma. Specifically, types 16 and 18, which are commonly grouped together, were analyzed separately and compared. Biopsies obtained from three different geographic sites in the United States and Brazil were analyzed by Southern blot hybridization and correlated with the histologic diagnosis from the same tissue sample. There was a highly significant correlation between papillomavirus type and histologic grade comparing all grades of cervical intraepithelial neoplasia with invasive cancer (p less than 0.001). Of particular interest was the striking deficit of type 18 in intraepithelial neoplasia (3%) as compared with invasive carcinoma (22%; p less than 0.001). In contrast, there was no significant difference in the distribution of type 16 in intraepithelial neoplasia (37%) as compared with invasive carcinoma (41%). The deficit of type 18 in intraepithelial neoplasia compared with invasive carcinoma could represent a rapid transit time through the precursor stage. Human papillomavirus type 18 may therefore play a role in the development of rapidly progressive cervical cancer.