Clinical applicability of immunotherapy of cervical intraepithelial neoplasia

Immunotherapy for cervical intraepithelial neoplasia (CIN) has not yet reached clinical applicability, but seems sensible and shows promising preliminary results. One of the most promising forms of immunotherapy for CIN may currently be imiquimod, because of its established role in other human papillomavirus (HPV)-induced genital conditions, its promising treatment efficacy in high-grade CIN, and its off-label availability. Although imiquimod cannot yet replace the current gold standard treatment for CIN [i.e., large loop excision of the transformation zone (LLETZ)] in all patients, it may be considered in subgroups of patients; for example, young women who may wish to become pregnant in the future, or patients with recurrent CIN lesions in whom a second LLETZ is to be avoided. Immunotherapy of CIN could be extended to post-treatment vaccination, in order to prevent new HPV infections and disease recurrence.     

宫颈癌及癌前病变组织中Notch1及HPV16 E6/E7表达的研究

目的 探讨Notch1受体和人乳头瘤病毒16感染在宫颈癌前病变和宫颈癌发生发展中的作用。方法 采用免疫组化SP法检测18例宫颈上皮内瘤变（cervical intraepithelial neoplasia,CIN）和35例宫颈癌标本中Notch1受体及HPV16E6/E7蛋白的表达,以34例正常宫颈组织及慢性宫颈炎组织作为对照。比较各组间Notch1及HPV16E6/E7表达的差异,并分析Notch1与HPV16E6/E7表达的关系。结果 Notch1蛋白在细胞胞浆、胞核及胞膜中表达,HPV16E6/E7在细胞核中表达。从对照组到CIN组到宫颈癌组,Notch1及HPV16E6/E7的表达均逐渐增强（P〈0.01）。Notch1的阳性表达与宫颈癌不同分期、分化程度、淋巴结是否转移无关（P〉0.05）。在宫颈癌组中Notch1与HPV16E6/E7的表达均呈正相关性（P〈0.01）。结论 Notch1表达与HPV16E6/E7感染可能与CIN及宫颈癌的发生密切相关,两者在宫颈癌的发病机制中可能协同发挥作用。     

Alterations in human papillomavirus-related biomarkers after treatment of cervical intraepithelial neoplasia

Objective

This study aims to assess the alterations in various HPV-related biomarkers 6 months post-treatment and how these relate to various risk factors and individual characteristics; their role for the prediction of treatment failure was also evaluated.

Material and methods

Design: Prospective observational study.Population: Women planning to undergo treatment for cervical intraepithelial neoplasia.Intervention: A liquid-based cytology sample was taken pre-operatively. This was tested for HPV genotyping, Nucleic Acid Sequence Based Amplification, flow cytometric evaluation and p16 immunostaining. A repeat LBC sample was obtained 6 months post-treatment and was tested for the same biomarkers.Outcomes: The alterations of the biomarkers 6 months post-treatment were recorded. Their relation to individual characteristics and risk factors (age, smoking, sexual history, use of condom, CIN grade, excision margin status, crypt involvement) as well as their role for the prediction of residual/recurrent disease were assessed.Analysis: The accuracy parameters (sensitivity, specificity, positive and negative predictive value and the likelihood ratios) of each biomarker for the prediction of recurrent/residual CIN were calculated.

Results

A total of 190 women were recruited. All biomarkers had significantly higher negativity rates post-treatment compared to pre-treatment ones. Multivariate analysis demonstrated that consistent condom use post-treatment significantly reduces the high-risk HPV positivity rates in comparison to no use (OR = 0.18; 95% CI: 0.09-0.38). Sensitivity and specificity for all high risk HPV DNA testing were 0.5/0.62, respectively; the relevant values for only type 16 or 18 DNA typing were 0.5/0.92, for NASBA 0.5/0.94, for flow 0.5/0.85 and for p16 0.25/0.93.

Conclusion

CIN treatment reduces positivity for all HPV-related biomarkers. Consistent condom use significantly reduces high-risk HPV positivity rates. More cases of treatment failures are required in order to specify whether different combinations of HPV-related biomarkers could enhance the accuracy of follow up, possibly in the form of a Scoring System that could allow tailored post-treatment surveillance.     

Histology of cervical intraepithelial neoplasia and the role of biomarkers

Accurate histological grading of cervical intraepithelial neoplasia (CIN) lesions is important for clinical management of patients, because CIN1 and CIN2 and 3 lesions are treated differently. In general, there tends to be poor inter and intra-observer reproducibility of CIN grade evaluation among pathologists. In particular, the differential diagnosis between immature squamous metaplasia and CIN1 and 2, or between low-grade (CIN1) and high-grade (CIN2 and 3) lesions, tend to be difficult. These difficulties mean that patients tend to be over-treated for CIN lesions, which will naturally regress. Collectively, this highlights the need for alternative approaches and specific biomarkers to aid objective CIN lesion grading, and to identify true high-grade cervical disease. In this review we focus on the aetiology, pathobiology, the natural history of CIN, current issues with diagnosis and classification of CIN and the diagnostic and prognostic utility of specific biomarkers in identifying true cancerous precursor lesions.     

Cryosurgery for the treatment of cervical intraepithelial neoplasia

Cryosurgery was used to treat 208 patients with cervical intraepithelial neoplasia. These patients were referred to our Colposcopy Clinic for investigation of an abnormal Papanicolaou smear. Prior to treatment a colposcopically directed biopsy was taken in all cases. The regrigerant used for cryosurgery was nitrous oxide. Included in the 208 patients were 57 with mild dysplasia, 76 with moderate dysplasia, 44 with severe dysplasia and 31 with carcinoma in situ. The cure rates were 100 per cent for patients with mild dysplasia, 95 per cent for those with moderate dysplasia, 96 per cent for those with severe dysplasia and 91 per cent for those with carcinoma in situ. Cryosurgery is an effective method of treating cervical intraepithelial neoplasia, with cures obtained in 199 of 208 patients in this study.     

Study on the prevalence of human papillomavirus in the anal canal of women with cervical intraepithelial neoplasia grade III

Objective

The objective was to evaluate the prevalence of human papillomavirus (HPV) in the anal canal of women with cervical intraepithelial neoplasia (CIN) grade III.

Study design

Two groups were compared. In group I (study group), 40 women who had undergone cervical biopsy with a histopathological result indicating CIN III were evaluated. Group II (control) consisted of 40 women with normal results from colposcopic examination and colpocytological tests. The women in group I who presented high-grade neoplasia in colpocytological tests underwent collection of material from the uterine cervix and anal canal for investigating HPV DNA using the Hybrid Capture II^® technique. Colposcopy and cervical biopsy were then performed. If CIN III was confirmed, HPV DNA was investigated in the material collected. In group II, colpocytological tests and colposcopy were performed and, if normal, the procedure was similar to that followed for group I, except that no biopsy was performed.

Results

In group I, 39 women (97.5%) were positive for HPV in the uterine cervix and 14 women (35%) in the anal canal. In group II, only four women (10%) had a positive HPV test, for both the uterine cervix and the anal canal.

Conclusions

The prevalence of HPV in the anal canal of the women with CIN III was greater than in the women without CIN III.     

Effectiveness of cryotherapy treatment for cervical intraepithelial neoplasia.

OBJECTIVE: To assess the effectiveness of cryotherapy treatment delivered by general practitioners in primary care settings, as part of a screen-and-treat approach for cervical cancer prevention. METHOD: Women aged between 25 and 49 years residing in San Martin, Peru, who were positive on visual inspection screening were treated, if eligible, with cryotherapy following biopsy. At 12 months post cryotherapy treatment the participants were evaluated for treatment effectiveness and examined by visual inspection and Papanicolaou test and, if positive, referred to a gynecologist for colposcopy and biopsy. RESULTS: Cryotherapy treatment was performed for 1398 women; of these, 531 (38%) had a histology result of cervical intraepithelial neoplasia (CIN). Cryotherapy effectively cured CIN in 418 (88%) women, including 49 (70%) women with a baseline diagnosis of CIN 3. CONCLUSION: Cryotherapy is an effective treatment for cervical precancerous lesions; it can easily be administered by general practitioners in primary care settings following visual inspection screening.     

Cryosurgical treatment of cervical intraepithelial neoplasia (CIN III) in 102 patients

Results of cryosurgical treatment in 102 patients with a histologically confirmed diagnosis of severe dysplasia or carcinoma in situ of the uterine cervix (CIN III) are presented. The colposcopic evaluation performed in all patients required full visualization of the squamocolumnar junction. In 95 of the 102 patients no significant cytological abnormalities were found during the follow-up period, which amounts to a success rate of 93%. In seven patients (7%) treatment was considered to have failed because cervical smears persistently suggested CIN II or III. In five of them this was in all probability due to a residual lesion, since the abnormal smears occurred within 12 weeks after cryosurgery. It is concluded that in selected cases cryosurgery is a safe alternative for conisation in the treatment of CIN III. However, thorough colposcopic expertise is essential for adequate preoperative screening, as is careful selection of patients, and the latter may result in the withholding of cryosurgical therapy from 30% of patients with CIN III.     

Diagnosis of cervical intraepithelial neoplasia and human papillomavirus infection: punch biopsy versus cervical smear

Summary In 102 patients referred to our colposcopy clinic because of one to three Papanicolaou smears indicating cervical intraepithelial neoplasia (CIN) and/or abnormal colposcopy, routine smears and colposcopically directed punch biopsies were taken simultaneously. For detection and typing of human papillomavirus (HPV)-DNA in situ hybridization was performed in all biopsies and in 46 of the cervical smears. In cases of dysplastic lesions the number of HPV 16/18 (40.5%) and 31/33 (42.9%) was markedly higher than HPV 6/11 (16.6%) infection rate. In cases where simultaneous in situ hybridization in biopsy specimen and cervical smears was performed 21.7% showed a HPV negative smear and a positive biopsy, in 6.5% the results were the other way round. In 34.9% of cases with CIN I and 9.5% of cases with CIN II verified by punch biopsy the cytological smear did not indicate dysplasia. Our data show that mild and moderate CIN lesions of the cervix as well as HPV infection are detected more frequently by a combination of cervical smear and colposcopically directed punch biopsy than by cervical smear alone.     

Dynamin 2 expression as a biomarker in grading of cervical intraepithelial neoplasia

Objective

Dynamin 2, which plays a role in endocytosis, is known to be required for HPV infection on host cells. We investigated dynamin 2 as a biomarker in grading of cervical intraepithelial neoplasia (CIN) by comparing with Ki-67 expression and the type of HPV infection (low-risk vs. high-risk).

Study design

We performed immunohistochemical stains of dynamin 2 and Ki-67 on tumor samples of patients with CIN and the type of HPV infection was investigated.

Results

All the patients with reactive changes (n = 7) or normal (n = 4) did not show dynamin 2 expression. There were 33, 14, and 12 cases with CIN I, II, and III, respectively, and there was a negative correlation between the degree of dynamin 2 expression and the severity of CIN lesions with statistical significance (P < 0.001). Negative expression of dynamin 2 was more sensitive for the detection of CIN II/III than high expression (2+) of Ki-67 (96.2% vs. 73.1%, P = 0.041). Among patients in whom HPV infection was detected, the degrees of dynamin 2 expression were not associated with the type of HPV infection (low-risk vs. high-risk). Overall, there was a negative correlation between the expression patterns of Ki-67 and dynamin 2.

Conclusion

We found that dynamin 2 may be a helpful biomarker in grading of CIN lesions and a candidate biomarker for detecting low grade CIN with high sensitivity.     

Human papillomavirus-type persistence patterns predict the clinical outcome of cervical intraepithelial neoplasia

BACKGROUND: Persistent infection with high-risk (HR) human papillomavirus (HPV) genotypes is required for the development of cervical carcinoma, and integration of HPV testing into cervical screening programs is under investigation. For the clinical value of HPV testing to be fully established, genotyping studies are needed to identify HR HPV persistence in samples of known cytology and histology, and to determine the relationship with clinical outcome. To date, methods for genotyping have been research-based, and subject to variation. The availability of the Roche prototype line blot assay (LBA) offers a PCR-based, reproducible genotyping method, with a 37-type target spectrum and many potential applications. METHODS: We applied the LBA to determine persistence of HR HPV in 54 women with low-grade histology. Median interval between genotyping was 12.5 months (range 5-48). RESULTS: All 15 lesions that progressed to CIN3 (PD) were associated with HR HPV persistence. Regression of lesions (REM) was observed in 31 HPV+ women, of whom nine had clearance of existing HPV infections, with one patient then acquiring additional types. Eight HPV+ patients had no change in lesions observed (NC). Persistence of HPV type 16 was more common in the PD group (60%), compared with the REM group (27%) and the NC group (38%). CONCLUSION: Our results show that the LBA is a useful tool to identify HPV persistence patterns under anonymized conditions, with potential for research and clinical studies.     

Importance of surgical margins in conization for cervical intraepithelial neoplasia grade III

We conducted a retrospective study on 201 conizations for CIN III done over the last 14 years. Of these, 53 (26.4%) had involvement of the margins, 114 (56.7%) had margins free of neoplasia, and 34 (16.9%) were not evaluated. Of the 53 cases with margin involvement, 28 (52.8%) had complementary surgery and 25 (47.2%) cytological follow-up. Residual CIN was identified in the surgical specimen in 15 cases (53.6%) and microinvasion was present in 2 cases (7.1%). Of the 114 patients with margins free of neoplasia in the cone, 12 had a hysterectomy during follow-up for CIN III diagnosed by cytology and biopsy. Seven of these 12 patients (58.3%) had CIN in the surgical specimen and none had microinvasive cancer. Received: August 1998 / Accepted: 3 May 1999     

阴道上皮内瘤变与宫颈上皮内瘤变的相关性及其诊治的初步研究

目的 探讨阴道上皮内瘤变(VAIN)与宫颈上皮内瘤变(CIN)的相关性及其诊断和治疗.方法 回顾性分析35例VAIN患者的临床表现、阴道脱落细胞学、人乳头状瘤病毒(HPV)感染以及治疗方法等资料.结果患者平均年龄43.9岁.VMN Ⅰ、VAIN Ⅱ和VMNⅢ分别占52%(18/35)、34%(12/35)和14%(5/35).VAINⅢ在年龄≤40岁者和>40岁者中分别为8%(1/13)和18%(4/22).69%(24/35)有CIN病史,17%(6/35)有宫颈癌病史.CIN Ⅰ、CIN Ⅱ～Ⅲ和宫颈癌中分别有3/9、53%(8/15)和4/6发生VAINⅡ～Ⅲ.87%(13/15)的VMN Ⅰ患者高危型HPV-DNA阳性,VAIN Ⅱ和VAINⅢ中的阳性率均为100%.97%(33/34)液基薄片检测提示细胞学检查结果异常.86%(30/35)病变位于阴道上1/3.19例患者进行了治疗,其中手术切除占74%(14/19),局部用药占16%(3/19),腔内放疗占11%(2/19).9例随访者VMN病变均出现逆转.结论 VMN 临床特点与CIN相似,CIN诊断和治疗的原则也可适用于VAIN.     

Prediction of persistence or recurrence after conization for cervical intraepithelial neoplasia III

OBJECTIVE: To estimate the predictive factors for persistent/recurrent disease before and after conization for cervical intraepithelial neoplasia III. METHODS: Patients who received conization due to histologic diagnosis of cervical intraepithelial neoplasia III from 1998 to 2000 and who had at least one cytologic/histologic follow-up within one year of conization (n = 449) were enrolled in our study. All available demographic and pathologic parameters were analyzed. RESULTS: We performed multivariable logistic regression analysis to identify predictive factors for cervical intraepithelial neoplasia III persistence/recurrence. Age (greater than 50 years) was the only preoperative predictor and had an odds ratio equaling 3.070 (95% confidence interval [CI] 1.421-6.630, P = .004). Post-cone endocervical curettage was found to be the most statistically significant factor for predicting persistent disease (odds ratio 7.940, 95% CI 3.428-18.390, P < .001). Positive endocervical curettage was associated with 65.5% (36/55) of persistent disease, whereas negative endocervical curettage was associated with only 7.6% (26/342). Positive endocervical resection margins and multiple-quadrant disease also had predictive values with odds ratios equaling 2.972 (95% CI 1.401-6.281, P = .004) and 2.180 (95% CI 1.014-4.689, P = .046), respectively. The positive predictive values for age (> 50 years), positive endocervical curettage, positive endocervical resection margin, and multiple quadrant disease were 31.7%, 65.5%, 40.0%, and 21.9%, respectively. CONCLUSION: We found that age is the only preoperative predictive factor. Pathologic parameters, including endocervical curettage, endocervical resection margins, and multiple-quadrant disease are the only postoperative predictive factors for cervical intraepithelial neoplasia persistence or recurrence found in our study. These factors should be considered in patient management before and after therapeutic conization for cervical intraepithelial neoplasia III. LEVEL OF EVIDENCE: II-3.     

Risk factors for cervical intraepithelial neoplasia recurrence after conization: a 10-year study

Objective

To evaluate the risk factors potentially involved in the development of cervical intraepithelial neoplasia (CIN) recurrence after cervical conization in a long-term follow-up period.

Study design

Consecutive patients with histologically proven CIN who had undergone either cold knife conization or a loop electrosurgical excision procedure were enrolled and scheduled for serial follow-up examinations over a 10-year period. Data were stored in a digital database. Multivariate analysis was performed to identify factors for recurrence.

Results

Between January 1999 and December 2009, 282 patients fulfilled the inclusion criteria and were included in the final statistical analysis. After a median follow-up of 26.7 months (range 6–100), 64 (22.7%) women developed histologically confirmed recurrence. The 2-year recurrence-free survival was 83.7% and 66.7% for women with negative and positive margins, respectively (p = 0.008). The 5-year recurrence-free survival was 75.4% and 50.3% for patients with negative and positive margins, respectively (p = 0.0004). Positive surgical margin was the most important independent predictor of recurrence [HR 2.5 (95%CI 1.5–4.5), p = 0.0007; Wald 11.338]. After multinomial logistic regression the indication for conization based on persistent CIN1 was the only independent predictor for negative margin [OR 0.3 (95%CI 0.1–0.7), p = 0.008].

Conclusions

Our study demonstrated that the surgical margin status represents the most important predictor for CIN recurrence after conization. After excisional therapy, close follow-up is mandatory for the early detection of recurrent disease. The identification of risk factors for recurrence may guide clinical decision-making on expectant management versus re-intervention.     

HPV testing as an adjunct to cytology in the follow up of women treated for cervical intraepithelial neoplasia

Objective  To evaluate human papillomavirus (HPV) testing in combination with cytology in the follow up of treated women.
Design  A prospective study.
Setting  Three UK centres: Manchester, Aberdeen and London.
Population or sample  Women treated for cervical intraepithelial neoplasia (CIN).
Methods  Women were recruited at 6 months of follow up, and cytology and HPV testing was carried out at 6 and 12 months. If either or both results were positive, colposcopy and if appropriate, a biopsy and retreatment was performed. At 24 months, cytology alone was performed.
Main outcome measures  Cytology and histology at 6, 12 and 24 months.
Results  Nine hundred and seventeen women were recruited at 6 months of follow up, with 778 (85%) and 707 (77.1%) being recruited at 12 and 24 months, respectively. At recruitment, 700 women had had high-grade CIN (grades 2 or 3) and 217 had CIN1. At 6 months, 14.6% were HPV positive and 10.7% had non-negative cytology. Of those with negative cytology, 9% were HPV positive. Of the 744 women who were cytology negative/HPV negative at baseline, 3 women with CIN2, 1 with CIN3, 1 with cancer and 1 with vaginal intraepithelial neoplasia (VAIN)1 were identified at 24 months. Nine of 10 cases of CIN3/cervical glandular intraepithelial neoplasia (CGIN) occurred in HPV-positive women. At 23 months, cancer was identified in a woman treated for CGIN with clear resection margins, who had been cytology negative/HPV negative at both 6 and 12 months.
Conclusions  Women who are cytology negative and HPV negative at 6 months after treatment for CIN can safely be returned to 3-year recall.