Human papillomavirus type 16 viral load in relation to HIV infection,cervical neoplasia and cancer in Senegal

Background: The importance of human papillomavirus (HPV) viral load in the pathogenesis of cervical cancer among HIV-infected and HIV-uninfected women has not yet been established. Methods: In this cross-sectional study, HPV-16 viral loads were measured using previously-collected and frozen cervical swab samples from 498 HPV-16 positive Senegalese women (368 HIV-seronegative, 126 HIV-1 and/or HIV-2 seropositive). The real-time polymerase chain reaction assay was used to quantify HPV-16 E7 copy number normalized by human cellular DNA (β-actin), and viral loads were log₁₀ transformed. Associations between HPV-16 viral load, degree of cervical abnormality, and HIV status were assessed using multinomial and linear regression methods. Results: Compared to women with normal cytology, the likelihood of CIN1 (OR_a: 1.21, 95% CI 0.93–1.57), CIN2-3 (OR_a: 2.38, 95% CI 1.72–3.29) and cancer (OR_a: 2.12, 95% CI 1.52–2.96) was found to increase for each 1-unit log₁₀ increase in HPV-16 viral load. Compared to HIV-negative women, HIV-positive women had higher average HPV-16 viral load values (β_a: 0.39, 95% CI 0.03–0.75), even after accounting for degree of cervical abnormality. Conclusion: In our study of women including those with cancer, HPV-16 viral load was associated with a higher likelihood of cervical abnormalities. However, substantial overlaps across categories of disease severity existed. Higher viral load among HIV-infected individuals may indicate that HIV infection influences HPV viral replication factors.     

人乳头状瘤病毒分型及病毒载量与宫颈病变的研究进展

宫颈癌作为目前妇女最常见的恶性肿瘤,新发病例在全球范围内仍处于上升趋势。已有实验证明,HPV感染是宫颈癌发生发展的必要条件。然而不同分型及其病毒载量高低仍会影响诊断率,从而影响病情,使之发展为持续性感染,最终演变为癌前病变或宫颈癌。目前,研究者对于高危型HPV病毒载量与宫颈病变之间是否存在依存关系尚存争议。研究表明,高病毒载量可能成为预测宫颈癌前病变进展的指标,然而对于病理诊断明确的宫颈癌患者而言,病毒载量并不能代表病理分期。本文综述了人乳头状瘤病毒,不同基因分型,病毒载量等因素对于宫颈病变及宫颈癌的相关性的近年研究进展,希望有助于指导临床工作。     

HPV分型及其高危亚型与宫颈病变的关系

目的研究HPV分型及其高危亚型与宫颈病变程度的关系。方法采用HPV基因分型技术对2014年7月至2015年8月在广州中医药大学第一附属医院妇科门诊就诊和体检的3 142例患者进行HPV分型检测,其中327例患者进行宫颈病理检查,分析高危型HPV感染与宫颈病变程度的关系。结果 3 142例受检对象中,21种HPV型别均被检测出,阳性检出者共969例,总检出率为30.80%,其中高危型741例,检出率为23.58%。随着宫颈病变级别的升高,高危型HPV阳性率也相应升高(P0.05),HPV16型感染阳性者宫颈癌发生率最高(P0.05)。高危型HPV阳性者中单一感染和多重感染与宫颈病变程度无关(P0.05)。结论高危型HPV亚型检测在宫颈病变预防和诊治中具有重要意义。     

A retrospective analysis of human papillomavirus (HPV) prevalence and genotype distribution among 25,238 women in Shanghai,China revealed the limitations of current HPV-based screening and HPV vaccine

BackgroundTo determine the human papillomavirus (HPV) type-specific prevalence and distribution among women with various age and cervical lesions in Shanghai, China. And to evaluate the carcinogenicity of different high-risk HPV (HR-HPV) and the efficacy of HR-HPV testing and HPV vaccine.MethodsThe clinical data from 25,238 participants who received HR-HPV testing (HPV GenoArray test kit, HybriBio Ltd) at the Affiliated Hospital of Tongji University from 2016 to 2019 were reviewed and analyzed using SPSS (version 20.0, Tongji University, China).ResultsThe overall prevalence of HPV was 45.57% in the study population, of which 93.51% were found HR-HPV infection. The three most prevalent HR-HPV genotypes were HPV 52 (22.47%), 16 (16.4%) and 58 (15.93%) among HPV-positive women, and HPV 16 (43.30%), 18 (9.28%) and 58 (7.22%) in women with histologically confirmed cervical cancer (CC). 8.25% of CC were found to be HPV negative. Only 83.51% of CC cases were related to the HPV genotypes covered by nine-valent HPV vaccine. HPV prevalence and genotype distribution varied with age and cervical histology. The odds ratios (OR) of HR-HPV for CC were also different, among which the top three types were HPV 45 [OR= 40.13, 95% confidence intervals (CI) 10.37–155.38], 16 (OR=33.98, 95%CI 15.90–72.60) and 18 (OR=21.11, 95%CI 8.09–55.09). The increase in the types of HPV infection did not increase the risk of CC correspondingly. As the primary cervical screening method, HR-HPV testing showed the high sensitivity (93.97%, 95%CI 92.00–95.49) but low specificity (42.82%, 95%CI 41.81–43.84).ConclusionsOur study provide the comprehensive epidemiological data on HPV prevalence and genotype distribution among Shanghai women with various cervical histology, which can not only serve as a significant reference for clinical practice, but also implicated the need of more effective CC screening methods and HPV vaccine covering more subtypes.     

HPV检测早期筛查宫颈癌的临床意义——附妇科门诊2761例宫颈拭子HPV分析

目的探讨女性HPV DNA检测在宫颈癌防治方面的意义。方法应用DNA杂交技术对2 761例妇科门诊就诊者基因分型检测。结果 2 761例样本中,HPV感染有768例,阳性率27.82%,HPV感染人次972人次。检测高危型HPV（16,18,31,33,35,39,45,51,52,56,58,59,68）813人次,占感染总人次的83.64%;检出低危型HPV（6,11,42,43,44）73人次,占感染总人次7.51%;中国人群常见型HPV（53,66,CP8304）86人次,占感染总人次的8.85%。165例样本中包含了25种亚型的感染。结论 DNA杂交技术检测HPV基因分型,可一次检测多种亚型,有利于对HPV多重感染的诊断和宫颈癌的防治,可作为宫颈癌筛查的手段。     

Detection of human papillomavirus types by the polymerase chain reaction and the differentiation between high-risk and low-risk cervical lesions

By means of a consensus polymerase chain reaction (PCR) method, the prevalence of HPV types was determined in cervical biopsies from 137 women referred to the gynecological outpatient clinic for colposcopy because of an abnormal cervical smear. The prevalence of HPV was 80.3%. There was a statistically highly significant rise in the prevalence of the oncogenic HPV types (16, 18, 31, 33) with increasing severity of cervical intraepithelial neoplasia (CIN I to III), indicating a role for these HPV types in the pathogenesis of cervical cancer. The prevalence of other HPV types decreased significantly with the severity of the lesion, suggesting that these HPV types play a less significant role in this process. These data indicate that HPV typing with PCR may be a valuable tool for distinguishing between highrisk and low-risk cervical lesions. Furthermore, our results suggest that the detection of HPV types by consensus PCR in the cervix of patients with an abnormal smear but without histologically detectable CIN is a useful tool for predicting which of these patiens will eventually develop CIN. Finally, a relatively low percentage (3%) of HPV double infections is reported in this study.     

宫颈不同疾病患者合并HPV感染的病原菌感染状况及免疫功能

目的 调查分析宫颈不同疾病患者合并人乳头瘤病毒（HPV）感染的病原菌感染状况及免疫功能。方法 选择2015年3月至2018年1月在我院就诊的96例宫颈不同疾病患者为研究组,其中宫颈炎组18例,宫颈上皮内瘤变组54例（CINⅠ组15例,CINⅡ组17例,CINⅢ组22例）,宫颈癌组24例;并以同期在我院进行体检的80例健康女性为对照组,检测所有研究对象的HPV感染、阴道菌群情况和宫颈分泌物CD4+、CD8+细胞数。结果 研究组HPV感染率明显高于对照组（P0.05）。宫颈炎组、CINⅠ组、CINⅡ组、CINⅢ组、宫颈癌组CD4+ T细胞表达阳性率呈下降趋势,宫颈癌组与宫颈炎组、CINⅠ组比较差异有统计学意义（P0.05）;CD4+/CD8+<1患者所占比例呈上升趋势,宫颈癌组、CINⅢ组、CINⅡ组与宫颈炎组比较差异有统计学意义（P<0.05）。结论 HPV感染、病原菌感染及免疫功能下降与宫颈病变发生发展密切相关,临床中应给予足够重视并及时进行有效干预。     

Cervical cancer: cytological cervical screening in Iceland and implications of HPV vaccines

K. Sigurdsson
Cervical cancer: cytological cervical screening in Iceland and implications of HPV vaccines This paper reviews the Icelandic experience regarding the age‐specific effectiveness, optimal targeted age range and intervals in cervical cancer screening and the screening implications of the HPV16/18 vaccines. The background material is based on data from a screening programme with centralized records dating back to 1964, as well as from population‐based studies on the distribution of oncogenic HPV types in cancer and histologically verified CIN2‐3 lesions and from the Icelandic arm of the Future II trial with Gardasil^®. The findings confirm significant increased rates in the screened population of CIN2‐3, stage IA (microinvasive) cancer since 1979, mainly in the age group 20–34 years. These lesions start to accumulate within 3 years of a normal smear. Studies on the distribution of HPV types indicate that the marketed vaccines could lower the incidence of cancer and CIN2‐3 by about 67% and 53%, respectively, after taking into account reported cross‐protection. About 65% of women below 25 years of age had lesions related to the non‐vaccine types and after the last normal smear these cases accumulated at the same frequency as cases with vaccine‐included types. Cases with combined vaccine and non‐vaccine types accumulated at a slower rate. We conclude that screening should continue to start at age 20 years, with invitations at 2‐year intervals up to age 39 years and thereafter at 4‐year intervals up to age 65–69 years. Current data support the conclusion that the optimal age for catch‐up HPV vaccination should be considered in the context of sexual practices and the data do not support changes in the lower age limit or screening intervals for the vaccinated women.     

Potential impact of a 9-valent HPV vaccine in HPV-related cervical disease in 4 emerging countries (Brazil,Mexico, India and China)

BackgroundWe estimated the potential impact of an investigational 9-valent human papillomavirus (HPV) vaccine (HPVs 6/11/16/18/31/33/45/52/58) in HPV-related cervical disease in Brazil, Mexico, India and China, to help to formulate recommendations on cervical cancer prevention and control.MethodsEstimations for invasive cervical cancer (ICC) were based on an international study including 1356 HPV-positive cases for the four countries altogether, and estimations for precancerous cervical lesions were extracted from a published meta-analysis including 6 025 HPV-positive women from the four mentioned countries. Globocan 2012 and 2012 World Population Prospects were used to estimate current and future projections of new ICC cases.ResultsCombined proportions of the 9 HPV types in ICC were 88.6% (95%CI: 85.2–91.3) in Brazil, 85.7% (82.3–88.8) in Mexico, 92.2% (87.9–95.3) in India and 97.3% (93.9–99.1) in China. The additional HPV 31/33/45/52/58 proportions were 18.8% (15.3–22.7) in Brazil, 17.6% (14.2–21.2) in Mexico, 11.3% (7.5–16.1) in India and 11.9% (7.5–17.2) in China. HPV6 and 11 single types were not identified in any of the samples.Proportion of the individual 7 high risk HPV types included in the vaccine varied by cytological and histological grades of HPV-positive precancerous cervical lesions. HPV 16 was the dominant type in all lesions, with contributions in low grade lesions ranging from 16.6%(14.3–19.2) in Mexico to 39.8% (30.0–50.2) in India, and contributions in high grade lesions ranging from 43.8% (36.3–51.4) in Mexico to 64.1% (60.6–67.5) in Brazil. After HPV 16, variations in other majors HPV types were observed by country, with an under representation of HPV 18 and 45 compared to ICC.ConclusionThe addition of HPVs 31/33/45/52/58 to HPV types included in current vaccines could increase the ICC preventable fraction in a range of 12 to 19% across the four countries, accounting the 9-types altogether 90% of ICC cases. Assuming the same degree of efficacy of current vaccines, the implementation of the 9-valent HPV vaccine in Brazil, Mexico, India and China would substantially impact on the reduction of the world cervical cancer burden.     

European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, part 1

The current paper presents the first part of Chapter 6 of the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. It provides guidance on how to manage women with abnormal cervical cytology. Throughout this article the Bethesda system is used for cervical cytology terminology, as the European guidelines have recommended that all systems should at least be translated into that terminology while cervical intraepithelial neoplasia (CIN) is used for histological biopsies (Cytopathology 2007; 18 :213–9). A woman with a high‐grade cytological lesion, a repeated low‐grade lesion or with an equivocal cytology result and a positive human papillomavirus (HPV) test should be referred for colposcopy. The role of the colposcopist is to identify the source of the abnormal cells and to make an informed decision as to whether or not any treatment is required. If a patient requires treatment the colposcopist will decide which is the most appropriate method of treatment for each individual woman. The colposcopist should also organize appropriate follow‐up for each woman seen. Reflex testing for high‐risk HPV types of women with atypical squamous cells (ASC) of undetermined significance with referral for colposcopy of women who test positive is a first option. Repeat cytology is a second possibility. Direct referral to a gynaecologist should be restricted to special circumstances. Follow‐up of low‐grade squamous intraepithelial lesion is more difficult because currently there is no evidence to support any method of management as being optimal; repeat cytology and colposcopy are options, but HPV testing is not sufficiently selective, unless for older women. Women with high‐grade squamous intraepithelial lesion (HSIL) or atypical squamous cells, cannot exclude HSIL (ASC‐H) should be referred without triage. Women with glandular lesions require particular attention. In a subsequent issue of Cytopathology, the second part of Chapter 6 will be presented, with recommendations for management and treatment of histologically confirmed intraepithelial neoplasia and guidance for follow‐up of special cases such as women who are pregnant, postmenopausal or immunocompromised.     

Comparison of culture, enzyme immunoassay and nucleic acid sandwich hybridization in detecting Chlamydia trachomatis in genital tract infections

Abstract Culture, enzyme immunoassay (Chlamydiazyme™) and nucleic acid sandwich hybridization were compared in detecting Chlamydia trachomatis in uncomplicated genital tract infections. Urethral and cervical specimens were collected from 100 males and 100 females attending a sexually transmitted disease clinic. Chlamydial culture was performed under optimal conditions (duplicate inoculation within the day specimen was collected, culture in vials, monoclonal antibody staining of inclusions, blind passage for negative samples). Here the sensitivity of culture exceeded that of the rapid methods. The sensitivity of a chlamydial antigen detection method (Chlamydiazyme™) was 68% in male and 86% in female specimens, when compared with culture, and the specificity was 100% and 97%, respectively. Acinetobacter calcoace9icus present in clinical specimens did not interfere with Chlamydiazyme™. The sensitivity of the nucleic acid sandwich hybridization was 53% of that of the culture, and specificity 100%. By comparing the three methods it was apparent that the rapid methods did not reveal chlamydial infections not detectable by culture. Thus, if performed carefully, culture is the most sensitive diagnostic method in acute genital infections due to C. trachomatis .     

Primary HPV testing: a proposal for co‐testing in initial rounds of screening to optimise sensitivity of cervical cancer screening

As explained by Kitchener in a previous issue of Cytopathology (2015; 26 :4‐6), primary human papillomavirus (HPV) testing is likely to be introduced in the UK for all women aged 25–64 years following pilot site studies already in place. This will be necessary when the prevalence of cervical cancer and its precursors declines when vaccination takes effect but there is a risk in abandoning cytology as a primary test: a risk that would be most apparent in the present unvaccinated population in which the prevalence of cervical cancer and its precursors is exceptionally high. HPV testing is more sensitive than cytology but has a significant false‐negative rate that could be detrimental to a successful screening programme if introduced without cytology backup. Accurate cytology would be needed for triage and could be compromised if HPV‐negative tests were excluded from examination. This article proposes a compromise: cytology and HPV co‐testing for the first two screening tests to optimise the sensitivity of the test as a whole. Registrations of invasive and in situ carcinoma of the uterine cervix in England indicate that the prevalence of the disease is highest in young women in the early rounds of screening. Calculations of the likely impact on the workload of this proposal have been based on a service evaluation of 295 cytology tests received at St Thomas’ Hospital, which suggests that the volume of cytology tests would be reduced by approximately 60% compared with 80% for primary HPV testing alone. This proposal should be debated openly before irrevocable changes are made to a skilled workforce.     

The current status of immunotherapy for cervical cancer

BackgroundImmunotherapy has been proven effective in several tumours, hence diverse immune checkpoint inhibitors are currently licensed for the treatment of melanoma, kidney cancer, lung cancer and most recently, tumours with microsatellite instability. There is much enthusiasm for investigating this approach in gynaecological cancers and the possibility that immunotherapy might become part of the therapeutic landscape for gynaecological malignancies.Cervical cancer is the fourth most frequent cancer in women worldwide and represents 7.9% of all female cancers with a higher burden of the disease and mortality in low- and middle-income countries. Cervical cancer is largely a preventable disease, since the introduction of screening tests, the recognition of the human papillomavirus (HPV) as an etiological agent, and the subsequent development of primary prophylaxis against high risk HPV subtypes. Treatment for relapsed/advanced disease has improved over the last 5 years, since the introduction of antiangiogenic therapy. However, despite advances, the median overall survival for advanced cervical cancer is 16.8 months and the 5-year overall survival for all stages is 68%. There is a need to improve outcomes and immunotherapy could offer this possibility. Clinical trials aim to understand the best timing for immunotherapy, either in the adjuvant setting or recurrent disease and whether immunotherapy, alone or in combination with other agents, improves outcomes.     

Comparison between the polymerase chain reaction and slot blot hybridization for the detection of HPV sequences in cervical scrapes

Sixty-four women presenting with a single mildly abnormal smear were investigated for infection with human papillomavirus (HPV) type 16 using both slot blot hybridization and polymerase chain reaction (PCR) amplification. PCR was nearly three times more sensitive for the detection of HPV 16 DNA than slot blot hybridization. HPV 16 was not significantly associated with a risk of progression to CIN if PCR was used to screen for infection. Women who smoked were at significantly greater risk of progression to CIN than non-smokers.     

高级别宫颈上皮内瘤变术后转归与阴道微生态的相关性研究

目的 研究高危型人乳头瘤病毒(HRHPV)持续感染的高级别宫颈上皮内瘤变(CIN)女性行宫颈锥切术后HPV病毒感染转归与阴道微生态的相关性。 方法 选取2015年12月至2018年12月我院342例行宫颈锥切术的CINⅡ以上患者(术前HRHPV检测均为阳性)为研究对象,根据术后1年随访HRHPV感染转归分为持续阳性组58例,阴性组284例,对比两组研究对象术后1年阴道微生态检测的情况。 结果 持续阳性组在菌群密集度、菌群多样性及优势菌构成上与阴性组差异存在统计学意义(χ2=13.711、37.120、25.312,P=0.001、0.05)。 结论 HRHPV的持续感染与阴道微生态平衡关系密切,在高级别CIN患者术后应注意纠正阴道微生态平衡,增强宫颈的局部免疫有利于宫颈癌的防治。     

Genetic diversity and phylogenetic analysis of HPV 16 & 18 variants isolated from cervical specimens of women in Saudi Arabia

Human papillomavirus (HPV) are well known to be associated with the development of cervical cancer. HPV16 and HPV 18 are known as high-risk types and reported to be predominantly associated with cervical cancer. The prevalence and genetic diversity of HPV have been well documented globally but, in the Kingdom of Saudi Arabia, data on HPV genetic diversity are lacking. In this study, we have analyzed the genetic diversity of both HPV16 and HPV18 based on their L1 gene sequence because L1 gene is a major capsid protein gene and has been utilized to develop a prophylactic vaccine. In January 2011–2012, a total of forty samples from cervical specimens of women in Saudi Arabia were collected. The association of HPV16, HPV18 was detected by polymerase chain reaction, sequenced and submitted to GenBank. The sequences identity matrix and the phylogenetic relationship were analyzed with selected HPVs. The highest sequence identity (99.5%) for HPV16 and (99.3%) for HPV was observed with selected HPVs. The phylogenetic analysis results showed that HPVs from Saudi Arabia formed a closed cluster with African, Asian, East Asian as well as American HPVs distributed into multiple linages from various geographical locations. The results provided the valuable information about genetic diversity, but there is an urgent need to generate full genome sequence information which will provide a clearer picture of the genetic diversity and evolution of HPVs in Saudi Arabia. In conclusion, the generated data will be highly beneficial for developing molecular diagnostic tools, analyzing and correlating the epidemiological data to determine the risk of cervical cancer and finally to develop a vaccine for Saudi Arabian population.     

The ideal strategy for cervical cancer screening in Japan: Result from the Fukui Cervical Cancer Screening Study

Introduction

The aims of the Fukui Cervical Cancer Screening (FCCS) study are to determine the frequency of women with high‐risk HPV (hrHPV), whether HPV16 or HPV18 (HPV16/18), in the Japanese cancer screening population for the first time and to identify the best strategy for cervical cancer screening in Japan.

Methods

This study enrolled 7584 women aged ≥25 years who were undergoing routine screening. All women underwent LBC and cobas HPV tests. Women with abnormal cytology, whether hrHPV positive or negative; women with hrHPV positivity with either normal or abnormal cytology; and women randomly selected from women with normal cytology and negative hrHPV negative were referred for colposcopy.

Results

The prevalences of hrHPV positivity and HPV16/18 positivity were 6.8% and 1.7%, respectively. The baseline data from the FCCS study showed that the combination of HPV tests and cytology was more sensitive than cytology with respect to the detection of intraepithelial neoplasia grade 2 or worse. However, the specificity (94.1%) of the co‐testing strategy that required all women with abnormal cytology or hrHPV positivity to be referred for colposcopy was much lower than that (97.8%) of cytology. The sensitivity and specificity of the co‐testing strategy that required only women with abnormal cytology or HPV16/18 positivity to undergo colposcopy were 85.5% and 97.0%, respectively.

Conclusion

The baseline data from the FCCS study suggest that a cervical cancer screening strategy in which only women with abnormal cytology or HPV16/18 positivity undergo colposcopy offers a more balanced sensitivity and specificity than other strategies.     

高危型人乳头瘤病毒感染与宫颈癌中miR-218表达的关系

目的观察高危型人乳头瘤病毒(HPV)感染与宫颈癌中miR-218表达的关系。方法收集2015年6月至2018年12月我院手术切除的宫颈癌组织并检测高危型HPV感染情况和miR-218表达量。培养HPV16阳性的SiHa细胞株并进行分组,阴性对照(NC)组转染NC模拟物、miR-218组转染miR-218模拟物,检测两组细胞凋亡率、B淋巴细胞瘤-2基因(Bcl-2)、Bcl-2相关x蛋白(Bax)、Bcl-2相互作用细胞死亡介导因子(Bim)、含半胱氨酸的天冬氨酸蛋白水解酶(Caspase)-9、Caspase-3的mRNA表达量及凋亡通路分子c-Jun氨基末端激酶(JNK)、c-Jun基因(c-Jun)、磷脂酰肌醇3-激酶(PI3K)、蛋白激酶B(AKT)、哺乳动物雷帕霉素靶蛋白(mTOR)的蛋白表达量。结果高危型HPV阳性的宫颈癌组织中miR-218表达量减少。转染24 h后,miR-218组细胞凋亡率、细胞中Bax、Bim、Caspase-9、Caspase-3的mRNA表达量及JNK、c-Jun的蛋白表达量均明显高于NC组,而细胞中Bcl-2的mRNA表达量及PI3K、AKT、mTOR的蛋白表达量均低于NC组,差异均有统计学意义(均P<0.05)。结论miR-218在高危型HPV感染的宫颈癌组织中表达减少。增加miR-218的表达能够促进HPV感染宫颈癌细胞的凋亡。该调控作用与JNK/c-Jun通路的激活及PI3K/AKT/mTOR通路的抑制有关。