Detection of human papillomavirus deoxyribonucleic acid in exfoliated cervicovaginal cells as a predictor of cervical neoplasia in a high-risk population

Specific types of human papillomavirus are currently implicated as etiologic agents of precancerous and cancerous lesions of the cervix. We have previously described the use of cervicovaginal lavage and molecular hybridization to detect human papillomavirus infections of the cervix. We report here the predictive value of this method of human papillomavirus detection to identify women with biopsy proved dysplastic and cancerous lesions of the cervix. One hundred ninety-one women from a city hospital colposcopy clinic underwent concurrent Papanicolaou smear, cervicovaginal lavage, and coloposcopically directed cervical biopsy. Human papillomavirus deoxyribonucleic acid was detected in 114 (59.7%) of these women. Of the positive results, human papillomavirus type 16 accounted for 23.7%, human papillomavirus type 18 for 10.5%, human papillomavirus type six or 11 for 6.2%, related human papillomavirus types for 52.6%, and 7.0% contained more than one type. The distribution of human papillomavirus types was similar in both women younger than 40 years of age and in older women. Eighty-nine of 128 (69.5%) women less than 40 years old with cervical lesions had positive findings of human papillomavirus, and 18 of 29 (62.1%) older women with cervical lesions had positive findings of human papillomavirus. Detection of human papillomavirus types 16 and 18 identified only 35 of 157 (22.3%) women with cervical lesions. The sensitivity of detecting all types of human papillomavirus as a predictor of a biopsy proved lesion (68.0%) was comparable with the sensitivity of cytologic examination alone (74.0%). However, human papillomavirus detection combined with the Papanicolaou smear provided an increased overall sensitivity of 89.3% (p less than 0.01). In fact, women either positive for human papillomavirus or having abnormal cytologic findings were 11.8 times more likely to have a biopsy proved cervical lesion than human papillomavirus-negative women with negative cytologic results (95% confidence interval for odds ratio: 5.3 to 26.6). We conclude that the sensitivity of cytologic examination plus human papillomavirus detection is superior to the use of either cytologic studies or human papillomavirus detection alone in identifying patients with cervical lesions.     

Correlation of cellular atypia and human papillomavirus deoxyribonucleic acid sequences in exfoliated cells of the uterine cervix

Restriction enzyme digestion and Southern blot hybridization were used to analyze deoxyribonucleic acid (DNA) extracted from exfoliated cervical cells for the presence of human papillomavirus sequences and these results were correlated with cytologic findings on Papanicolaou smears. Specimens (N = 204) were obtained from a nonselected population of women undergoing routine cytologic screening and human papillomavirus DNA sequences were detected in 33 (16%) women. Thirteen smears contained atypical squamous cells, ranging from very mild dysplasia to moderate dysplasia; all showed associated morphologic evidence of human papillomavirus infection characterized by koilocytosis, nuclear enlargement, wrinkling, and hyperchromasia, and human papillomavirus DNA was demonstrable in 12 (92%) smears. Of the remaining 191 samples with normal cytology, 21 (11%) also contained human papillomavirus DNA sequences. Reevaluation of the smears from these women resulted in a revision of the cytologic diagnosis to very mild dysplasia in four cases. These data suggest that human papillomavirus infection occurs more frequently than predicted by cytologic screening.     

Evaluation of frequency human papillomavirus infections during pregnancy

OBJECTIVES: The frequency of human papillomavirus (HPV) infection was estimated among pregnant women. MATERIALS AND METHODS: Cervical smears were obtained from 50 patients treated in the Chair and Department of Obstetrics and Perinatology, University Medical School of Lublin. They were investigated for the presence of HPV DNA. For the above purpose Digene Hybrid Capture method was used. RESULTS: HPV DNA was detected in the 4 (8%) of 50 patients. One of them had mixed infection low and high risk types of HPV, the other--high risk types of HPV infections. CONCLUSIONS: 1. HPV DNA was detected in 8% of the patients, in all cases high risk types of HPV was found. 2. The diabetic patients seem to be more vulnerable to HPV infection during pregnancy.     

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.)     

Cervical human papillomavirus deoxyribonucleic acid persists throughout pregnancy and decreases in the postpartum period.

OBJECTIVE: Our goal was to determine the persistence of human papillomavirus infection of the cervix in a prospectively evaluated cohort of pregnant women observed from the first trimester until after delivery. STUDY DESIGN: A group of 232 women were enrolled in the first trimester of pregnancy and had cervico-vaginal lavage specimens collected for detection of the deoxyribonucleic acid of human papillomavirus. They underwent sampling again in the third trimester (146 patients available) and at 4 to 12 weeks after delivery (83 patients available). Human papillomavirus deoxyribonucleic acid was detected by means of the Hybrid Capture assay. RESULTS: In the first trimester of pregnancy, 31% of the patients had positive test results for human papillomavirus deoxyribonucleic acid, whereas 35.6% had positive results in the third trimester (P = 1.0). A comparison of first-trimester test results with postpartum results (paired data available from 83 patients) showed a decline from 39.8% positivity to 26.5% (P =.04). Comparing third-trimester results with postpartum results (paired data available from 74 patients) showed a decline from 35.1% to 25. 7% positivity (P =.12). When specimens positive for human papillomavirus were divided between those containing "high cancer risk" types (9 virus types often associated with dysplasia or malignancy) and "low cancer risk" types (5 types usually found in benign lesions), similar trends were seen, although not all comparisons were statistically significant. CONCLUSION: The increased prevalence, during pregnancy, of detectable human papillomavirus deoxyribonucleic acid, which was previously reported (Fife et al, Am J Obstet Gynecol 1996;174:1487-93), persists at a similar level throughout pregnancy but declines in the postpartum period. This observation is most consistent with activation of the virus by the physiologic changes of pregnancy.     

Microsatellite alterations in exfoliated cervical epithelia deoxyribonucleic acid as a marker for high-grade dysplasia

OBJECTIVE: The purpose of this study was to evaluate the feasibility of the use of deoxyribonucleic acid microsatellite alterations in cervical epithelia in the prediction of high-grade dysplasia and to compare it with a strategy based on human papillomavirus testing. STUDY DESIGN: Our prospective study subjects were from a cohort of 498 women with minimally abnormal Papanicolaou test results including atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion who had documented repeated Papanicolaou and human papillomavirus tests. Of these, 52 eligible patients having conizations or hysterectomies as their histologic outcomes were subjected to tests of loss of heterozygosity on a panel of 5 microsatellites (D3S1110, THRB, D3S1228, D6S291, D3S1289) within the deoxyribonucleic acid of exfoliated cervical epithelia. These genetic alterations were analyzed through fluorescence polymerase chain reaction by comparison of allele ratios of exfoliated cells with those of normal control tissue. Predictive values for high-grade cervical dysplasia and cancer between this deoxyribonucleic acid marker and human papillomavirus status were compared. RESULTS: With the use of loss of heterozygosity in at least one locus for predicting high-grade cervical neoplastic lesion, the sensitivity, specificity, positive predictive value, and negative predictive value were 96.7%, 59.1%, 76.3%, and 92.9%, which were superior to those of the human papillomavirus test (80%, 59.1%, 72.7%, and 92.9%). As a triage for atypical squamous cells of undetermined significance, its sensitivity and negative predictive value were up to 100%. CONCLUSION: The promising results on determining microsatellite alteration in dysplastic lesions might imply that it is possible to detect the earliest changes by potential molecular markers with exfoliated cervical epithelial cells.     

Human papillomavirus deoxyribonucleic acid in cervical carcinoma from primary and metastatic sites

Tissue from 13 cervical cancers and pelvic or para-aortic lymph nodes from the same patient were evaluated by deoxyribonucleic acid hybridization with a human papillomavirus type 16 deoxyribonucleic acid probe for the presence of human papillomavirus-related deoxyribonucleic acid sequences. Twelve of the primary malignancies were squamous cancers and one was an adenocarcinoma. Eight of the primary tumors contained human papillomavirus type 16 deoxyribonucleic acid sequences, and five contained viral sequences closely related to human papillomavirus type 16. Histopathologic diagnosis confirmed malignant cells in six of 13 lymph nodes; three of these specimens contained human papillomavirus type 16 sequences while three had human papillomavirus type 16-related sequences. One lymph node that failed to show malignant cells also contained human papillomavirus type 16 deoxyribonucleic acid. The remaining lymph nodes did not contain malignant cells by either histologic examination or deoxyribonucleic acid hybridization. The human papillomavirus deoxyribonucleic acid sequences in the lymph nodes were similar to those in the matched primary cancer in all cases. These data provide further evidence implicating human papillomavirus in the etiology of cervical cancer.     

Evidence of human papillomavirus deoxyribonucleic acid in vulvar squamous papillomatosis.

Squamous papillae of the vulva represent a controversial lesion. Forty-six women with histologically confirmed vulvar squamous papillae and koilocytosis were studied at Chang Gung Memorial Hospital. Vulvar washings were analyzed by the filter in-situ technique using biotin-labeled probes for typing human papillomavirus DNA. Forty of 46 women (87%) were symptomatic. Human papillomavirus (HPV) DNA was detected in 76% (35 of 46) of women, including type 6/11 in 21.7%, type 16/18/31/33 in 45.6%, and both types in 8.6%. Furthermore, intraepithelial neoplasia was found in the epithelium of squamous papillae in two women. This study suggests the potential value of histologic examination and HPV DNA typing in separating anatomic variation from pathologic squamous papillae. We suggest that those squamous papillae with histologic evidence of koilocytosis be designated as squamous papillomatosis.     

Molecular diagnosis of genital human papillomavirus infection: comparison of two methods used to collect exfoliated cervical cells

Human papillomavirus infection is implicated as an etiologic agent in the development of neoplasia and invasive carcinoma of the cervix. To detect human papillomavirus infection of the cervix, cells must be collected and assayed for human papillomavirus-related deoxyribonucleic acid sequences. Gynecologists and other clinical investigators generally use an exocervical spatula scrape and an endocervical swab for cell collection, analogous to Papanicolaou smear collection. However, inadequate cell recovery is common. To overcome this problem, we have developed the cervicovaginal lavage method for human papillomavirus detection. In the present study we compared the cervicovaginal lavage method with the widely used scrape-swab method in 48 women referred for colposcopic examination. After a Papanicolaou test, two samples were obtained from each woman, either with cervicovaginal lavage followed by scrape-swab or with the scrape-swab followed by cervicovaginal lavage. Human papillomavirus types were assessed by restriction analysis and Southern blot hybridization. In 21 women (44%) test results were positive for human papillomavirus with both the scrape-swab and cervicovaginal lavage cell collection methods; in nine women (19%) test results were positive only with the cervicovaginal lavage method; and in 18 women (38%) results were negative for human papillomavirus with both techniques. None of the women had human papillomavirus detected by scrape-swab without also having it detected with cervicovaginal lavage. The human papillomavirus deoxyribonucleic acid types identified were concordant in the 21 women whose infections were detected with both sampling methods, although the second virus type was detected only with cervicovaginal lavage in one woman who had a mixed genital tract infection. We concluded that cervicovaginal lavage is a more sensitive cell collection method than the scrape-swab technique for assessing human papillomavirus infection of the cervix.     

Detection of human papillomavirus types 16, 18 and 33 in exfoliated cervical cells by polymerase chain reaction]

Human papillomavirus (HPV) types 16, 18 and 33 were identified by means of the polymerase chain reaction using exfoliated cells from the uterine cervix in 361 patients. Of 261 patients without cervical lesions, 10(3.8%) patients had HPV DNA whereas 7(70.0%) of 10 patients with invasive cervical carcinomas had HPV DNA. The younger patients' group (29 year-old or less) without cervical lesions had a 6.5% HPV positive rate which was distinctly higher than the older patients' groups. No menopausal patient without cervical lesions had HPV DNA. In the cervical dysplasia group, the HPV DNA positive rate tended to be higher in the older patients. Type 16 was detected more often than types 18 or 33. However, the detectable incidence of type 16 in the follow up group was lower than in the cervical carcinoma groups. The younger patients without cervical lesions had a higher incidence of type 16 than the older patients. The younger patients with cervical neoplastic lesions had a lower incidence of type 16 than the older patients. These results suggest that type 16 has a higher frequency of cervical HPV infections than types 18 and 33. In addition, human papillomavirus is not the only causative factor in cervical carcinomas.     

Detection of human papillomavirus types 16 and 18 in the exfoliated cervical cells using the polymerase chain reaction.

We applied the polymerase chain reaction (PCR) to detect HPV 16 and 18 in cytological samples obtained from the uterine cervices of Japanese women. HPV infection was detected in 17 (25%) of 67 with CIN and 11 (37%) of 30 with cervical carcinoma. It is notable that 11 (16%) of 69 women with normal cervices were infected with either HPV 16 or 18. The polymerase chain reaction is sensitive and useful for epidemiological studies.     

Increased frequency of genital human papillomavirus infection in human immunodeficiency virus-seropositive Taiwanese women.

BACKGROUND AND PURPOSE: Human papillomavirus (HPV) infection is associated with increased incidence and severity of HPV-related cervical dysplasia and cervical cancer in women with human immunodeficiency virus (HIV) infection. This study examined the incidence of genital HPV infection in HIV-infected Taiwanese women and its relationship with cervical neoplasia. METHODS: This hospital-based, case-control study enrolled 31 consecutive HIV-seropositive women and 124 age-matched women who were free from HIV infection. Polymerase chain reaction (PCR) was used to distinguish high-risk (types 16, 18, 31, 33, 52 and 58) and low-risk HPV (types 6 and 11). The occurrence of genital HPV infection was compared between women with and without HIV infection. In addition, CD4 lymphocyte counts were determined by flow cytometry and Papanicolaou test was done in women with HIV infection. RESULTS: HPV and Papanicolaou test were done soon after the diagnosis of HIV infection. HIV seropositive women had a significantly greater high-risk HPV infection rate (48.4%; 15/31) than women without HIV infection (20.2%; 25/124; odds ratio, 3.71; p = 0.001). However, the prevalence of cervical intraepithelial neoplasia was similar between women with and without HIV infection. The CD4 lymphocyte counts in HIV-seropositive women were similar between those with and without genital HPV infection. CONCLUSIONS: The risk of genital HPV infection was significantly increased in HIV-infected women. Due to the association between high-risk HPV infection and the development of cervical dysplasia and cervical cancer, regular follow-up of Papanicolaou test is necessary in these women.     

Human papillomavirus deoxyribonucleic acid testing in developed countries

Cervical cancer has been largely eliminated in developed countries with the implementation of cytology-based screening programmes that depend on a call-recall system, followed by colposcopy and biopsy, treatment of precancerous lesions and follow up. With the discovery that persistent infection with high-risk human papillomavirus types is necessary for the development of cervical cancer, several tests for human papillomavirus deoxyribonucleic acid have been developed that can identify women at risk. Human papillomavirus deoxyribonucleic acid testing is more sensitive and only slightly less specific than cytology for detecting cervical intraepithelial neoplasia. It is also more reproducible, with the potential for self-sampling. Human papillomavirus genotyping, messenger RNA analysis and other biomarkers can help to further stratify this group and diminish referrals to colposcopy. Initially, human papillomavirus testing was used as an adjunct to cytology for triage of borderline cases, but evidence has shown its superiority as a screening method and in the follow up of women treated for cervical intraepithelial neoplasia.     

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.     

Effect of the menstrual cycle on detection and typing of human papillomavirus in uterine cervical cells

We observe fluctuations in human papillomavirus detection and variation in genotyping between sequential cervical cell specimens analyzed by filter in situ hybridization. Furthermore, specimen adequacy for analysis varies. To determine whether these phenomena are correlated with menstrual cycle stage at the time of sampling, we analyzed cervical cell specimens from women with cervical intraepithelial neoplasia. Specimens were categorized on the basis of a 28-day menstrual cycle and were analyzed by hybridization to combined probes for virus types 6 and 11 or types 16 and 18. Specimen adequacy was determined by hybridization to a human Alu I repetitive deoxyribonucleic acid probe. Analysis of data with chi 2 revealed that fluctuations in virus detection and type variation are unrelated to menstrual cycle stage. Specimen adequacy is stage-dependent for women who take oral contraceptives. Whereas specimens can be collected at any time other than the first week of the menstrual cycle, accurate determination of infection status requires multiple assessments.     

The value of human papillomavirus detection in primary cervical cancer screening

Human papillomavirus (HPV) is present in the vast majority of high-grade gynecological abnormalities (high-grade squamous intraepithelial lesions and worse) and, therefore, HPV detection has a very high negative predictive value. Nevertheless, introduction of HPV detection into primary screening would result in large numbers of false positives: HPV positive women with normal cytology. The prevalence of HPV in women with cytologically normal smears is age-dependent as has been shown extensively. We hypothesize that women at the age of 50, who are HPV negative and have a cytologically normal smear might be encouraged to refrain from further screening. The data available from the literature on HPV prevalence in elderly women is presented. Data of cohort studies of elderly women with and without HPV infection as well as health-economical analyses to investigate the cost-effectiveness of the proposed hypothesis are still lacking.