Angiogenesis in cervical intraepithelial neoplasia and early-staged uterine cervical squamous cell carcinoma: clinical significance.

The objective of this study is to evaluate angiogenesis in cervical intraepithelial neoplasia (CIN), microinvasive squamous cell carcinoma (MIC), and early-staged squamous cell carcinoma (SCC), stage IB-IIA of the cervix. Microvessel density (MVD) was evaluated and correlated with other pathologic prognostic factors and disease outcomes. Four hundred seventy-four cervical specimens were studied. Among these, 100 were designated normal cervix, 30 CIN1, 32 CIN2, 178 CIN3, 74 MIC, and 60 early-staged SCC. MVD per high-power field (x400) of early-staged SCC, MIC, and CIN3 were significantly higher in comparison to CIN2, CIN1, and control subjects (P<0.05). There was no statistically significant difference in MVD between control group, CIN1, and CIN2. In early-staged SCC, no correlation between MVD and pelvic lymph node status, parametrial involvement, depth of stromal invasion, and lymphovascular space invasion was found. Patients with bad outcomes (recurrence or death) showed no statistically different MVD from the ones who had unremarkable clinical courses.

Role of human papillomavirus DNA testing in management of women with atypical squamous cells of undetermined significance.

To find the sensitivity, specificity, and positive and negative predictive values of the high-risk group human papillomavirus (HPV) DNA testing as a triage tool to detect high-grade squamous intraepithelial lesions (HSILs, ie, cervical intraepithelial neoplasia [CIN] 2 or worse) in women with a cytologic smear showing atypical squamous cells of undetermined significance (ASC-US). All new cases with cytologic smears showing ASC-US that presented in King Chulalongkorn Memorial Hospital from January 2003 to November 2003, excluding known cases of HSILs and pregnancies, were enrolled. Cervical cell samplings were done by cervical cytobrush technique and tested for high-risk group HPV with the Hybrid Capture 2 (HC2) test. All participants were examined under a colposcope. Then cervicographs were taken before colposcopic-directed cervical biopsies were done. Of the 90 ASC-US cases enrolled, the pathologic results were normal in 30.0%, squamous metaplasia in 16.7%, CIN 1 in 37.8%, CIN 2 in 1.1%, CIN 3 in 11.1%, and microinvasive cervical carcinoma in 3.3%. The prevalence of HSILs and the prevalence of high-risk HPV detection were 15.6% and 38.9%, respectively. Using pathologic results from cervical biopsy as the gold standard, the HC2 has the sensitivity, specificity, and positive and negative predictive values of 85.7%, 69.7%, 34.3%, and 96.4%, respectively, to detect HSILs. High-risk group HPV detection can be used as an additional triage test to detect HSILs in women having ASC-US with high sensitivity and negative predictive value.

Human papillomavirus DNA in plasma of patients with cervical cancer.

BACKGROUND: Human papillomavirus (HPV) is a crucial etiological factor for cervical cancer (CC) development. From a diagnostic view-point, the consistent presence of HPV in CC allows the viral DNA to be used as a genetic marker. The aims of this study were to evaluate the presence, physical status and clinical significant of HPV DNA in circulation of CC patients. RESULTS: Whereas 6 out of 50 (12%) HPV positive CC patients revealed plasma HPV DNA, it was detected in none of 20 normal controls or 13 HPV negative CC cases. The plasma DNA exhibited an HPV type identical to the HPV in the primary tumors and the DNA from both sources was integrated into host genome. Interestingly, several findings suggested an association between plasma HPV DNA and metastasis. First, three of the HPV DNA positive cases were CC patients with clinical stage IVB or recurrence with distance metastases (P = 0.001, RR = 15.67). Second, the amount of plasma HPV DNA from metastatic patients to be three times more than three other patients without metastases. Finally, the later cases had tendency to develop recurrence distant metastases within one year after complete treatment when compared with other HPV associated CC patients with the same stage but without the present of plasma HPV DNA. CONCLUSIONS: The plasma HPV DNA originated from the CC, was associated with metastasis and could be used as a marker representing the circulating free CC DNA.

p53 status and human papillomavirus infection in Thai women with cervical carcinoma.

Loss of p53 function has been implicated in a wide variety of human malignacies. Many studies suggest that in cervical carcinoma p53 function is inactivated either by gene mutation or by complex formation with E6 oncoprotein product of high-risk human papillomavirus (HPV). The aim of this study was to determine the status of HPV infection and p53 gene mutation as well as their correlation in cervical carcinomas. Formalin-fixed paraffin-embedded tissues of 12 cervicitis, 21 cervical intraepithelial neoplasia grade 3 (CIN 3) and 17 squamous cell carcinomas were determined for the presence of HPV using polymerase chain reaction (PCR) amplification and dot blot hybridization. The status of p53 mutations in exons 5-8 was evaluated by polymerase chain reaction single strand conformation polymorphism (PCR-SSCP) and confirmed by direct nucleotide sequencing. HPV infections were detected in all CIN 3 and squamous cell carcinomas (100%). Mutations of p53 were present in 3 of 38 HPV-positive samples: one with an ATG-->TTG transversion (Met-->Leu) in codon 237 of exon 7; and the others with a TGC-->TGG transversion (Cys-->Trp) in codon 242 of exon 7, and a CGT-->CCT transversion (Arg-->Pro) in codon 273 of exon 8, respectively. Our findings show that the frequency of p53 mutation is low in primary cervical carcinoma and that the p53 gene mutation and HPV infection are not mutually exclusive events in the development of cervical cancer. Thus, other genetic events independent of p53 inactivation may also significantly contribute to the carcinogenesis of the uterine cervix.

Uterine histopathologic changes after Cu-Fix intrauterine device insertion.

A study of uterine histopathologic changes after the insertion of the Cu-Fix intrauterine device (IUD) was carried out at the Obstetrics and Gynecology Department, Faculty of Medicine, Chulalongkorn University. Ten patients, who had cold conization for a suspicious Papanicolaou smear, were fitted with the Cu-Fix IUD. All patients were diagnosed as having carcinoma-in-situ of the cervix and were scheduled for hysterectomy at 6 weeks postconization. Preoperative ultrasonography showed the IUD anchoring at the uterine fundus, which corresponded with posthysterectomized findings. At the anchoring site of the nylon knot, which serves as a small retention body in the fundus, slight mononuclear cells infiltration in the myometrium was found in only one patient. However, in the endometrium, there was infiltration of mononuclear cells as well as a few plasma cells during the proliferative phase of the cycle. Evidence of local foreign body reaction was found in all patients. No patient had symptoms or signs of pelvic infection.

PIP: A study conducted at Chulalongkorn University in Bangkok, Thailand, investigated uterine histopathologic changes in 10 women fitted with the Copper (CU)-Fix IUD after cold conization for a suspicious Papanicolaou smear. All 10 women were diagnosed with carcinoma-in-situ of the cervix and underwent hysterectomy 6 weeks after IUD insertion. The findings of preoperative ultrasonography for localization of the IUD were compared with hysterectomized specimens, with emphasis on the anchoring site of the device's nylon knot. Slight mononuclear cell infiltration in the myometrium was observed in only 1 woman; normal findings were seen in the remaining patients. Histopathologic analysis revealed diffuse mononuclear cells as well as plasma cell infiltration during the proliferative phase of the menstrual cycle in all 10 women. This finding showed evidence of foreign body reactions similar to those described after insertion of other types of IUDs. No patient had signs or symptoms of pelvic infection. Overall, these results confirm there is no increased risk of uterine infection when the IUD is fixed in the muscle of the fundus.

Telomerase activity and human papillomavirus in malignant, premalignant and benign cervical lesions.

The purpose of this study was to define a correlation between telomerase activity and human papillomavirus (HPV) in normal control tissue and in benign, premalignant and malignant cervical lesions. Telomerase activity was detectable in 33 out of 34 cases of squamous-cell carcinoma, five out of six cases of microinvasive carcinoma, 8 out of 20 cases and two out of six cases of high- and low-grade squamous intraepithelial lesions (SILs) respectively. The higher frequency of positive telomerase in invasive carcinoma compared with SILs was observed in both HPV-associated and non-associated groups. Whereas 92.6% of HPV-positive and 100% of HPV-negative invasive lesions expressed telomerase, only 50% of HPV-positive and 25% of HPV-negative SILs did. Interestingly, telomerase activity was also detectable in 13 out of 28 cases of benign lesions regardless of the presence of HPV. In conclusion, there may be two roles of telomerase in the cervix. The first one would present in benign lesions; the second is associated with cancer development and activated during the late stage of multistep carcinogenesis in both HPV-positive and -negative groups.

Maternal and neonatal effects of single-dose epidural anesthesia with lidocaine and morphine for cesarean delivery.

Two per cent lidocaine (18-20 ml) with epinephrine 1:200,000 plus 4 mg of morphine was given as a single epidural injection over 3 minutes for elective cesarean section in 60 healthy mothers at term. It provided effective, safe and adequate analgesia in the postoperative period. There was no evidence of neonatal depression related to the epidural morphine as judged by Apgar scores at 1 and 5 minutes and umbilical venous pH at birth. Maternal and umbilical venous levels of morphine were measured and found to be low at birth. However, this study was done only in healthy mothers not in labor and having a term fetus. We do not recommend using this technique in complicated obstetric patients.

Safety evaluation of nonoxynol-9 gel in women at low risk of HIV infection.

OBJECTIVE: To determine the safety of a vaginal microbicide, COL-1492, containing 52.5 mg nonoxynol-9, applied once daily for 14 days among healthy volunteers. METHODS: A randomized, double-blind controlled trial with three arms, COL-1492 gel versus placebo gel versus no-treatment controls, was conducted. Outcomes of interest were reported genital symptoms, incidence of gynaecological signs, and incidence of genital lesions revealed by colposcopy. Participants were enrolled in four centres (Belgium, The Netherlands, and two in Thailand). RESULTS: A total of 534 women participated in the study: 179 used COL-1492, 178 used placebo, and 177 were no-treatment controls. Study visits were scheduled 1 week prior to enrollment (day -7), day 0 (enrollment), day 8 and day 14. The most frequently reported genital symptom was vaginal discharge in both the COL-1492 and placebo groups. This appeared to be related to leakage of the product out of the vagina. The incidence of lesions associated with epithelial disruption (ulcers and abrasions) was very low (< 2%) and there was no statistically significant difference between the three groups. Of the lesions observed by colposcopy that did not involve epithelial disruption, petechial haemorrhage was the most frequently detected, with an incidence of 20.1, 9.0 and 7.3% in the COL-1492, placebo and control groups, respectively. COL-1492 users had a higher incidence of erythema (8.4 versus 2% in the other groups). CONCLUSION: COL-1492 showed minimal toxicity when applied once daily. A Phase III trial to assess the product's effectiveness in HIV prevention is currently ongoing.

13-cis-retinoic acid and interferon-alpha 2a therapy in locally advanced squamous cell carcinoma of the cervix: p53 alteration, proliferating cell nuclear antigen expression and angiogenesis response.

OBJECTIVE: To evaluate prognostic importance of p53, PCNA and vascularization alteration in patients with locally advanced cervical squamous cell carcinoma (SCC) after combination therapy with 13-cis-retinoic acid (13cRA) and interferon-alpha 2a (IFN-alpha 2a). METHODS: 13cRA and IFN-alpha 2a were administered to patients with locally advanced cervical SCC. Formalin fixed, paraffin embedded tissues sections obtained at pre- and post-therapy, respectively, were stained immunohistochemically with anti-p53, anti-PCNA and anti CD31. RESULTS: p53 alteration was demonstrated in 5/10 patients and 3/10 patients pre- and post-therapy, respectively. There was no correlation between p53 alteration and prognosis. After therapy, two patients with complete response had lower PCNA expression whereas the non-responders demonstrated the opposite result. The vascularization showed a correlation with PCNA and prognosis. In the response group, patients had lower microvessel count while the metastatic group exhibited higher count. CONCLUSIONS: The present study suggests that p53 alteration is neither related to the prognosis of cervical SCC nor is it influenced by the combination therapy while PCNA expression and vascularization might be constitute potential markers for tumorigenesis, prognosis and responsiveness to this novel regimen.

Detection and typing of human papillomavirus in cervical intraepithelial neoplasia grade III in Thai women.

Infection of human papillomaviruses (HPVs) has been shown to play an important role in the development of cervical cancer from precancerous lesions known as cervical intraepithelial neoplasia (CIN-I, CIN-II and CIN-III). In Thailand, cervical cancer is the most common cancer in women. Fifty tissue samples diagnosed as CIN-III and 50 tissues of normal histopathologic appearance as controls were examined for the presence of HPV-DNA and HPV typing using PCR and dot hybridization (DH) methods. All specimens used in this study were formalin-fixed paraffin embedded tissues. HPV-DNA was detected in 74% (37/50) of CIN-III and 6% (3/50) of the control group giving a crude odd ratio of 44.58 (95% confidence interval of 15.2-130). Among the CIN-III group, the most prevalent type was HPV-16; 48.65% (18/37) followed by HPV-18; 16.2% (6/37) and HPV-33; 10.8% (4/37). Mixed infection was identified in 4 specimens, ie HPV-6/16, HPV-16/18, HPV-16/33, and HPV-16/18/33. Twelve samples were untyped. In the control group, only one sample (33.3%) was detected to contain HPV-6 DNA and the remaining ones were untyped. Our results revealed infection with HPV, especially HPV-16 and HPV-18, to be strongly associated with CIN-III in Thai women.

Detection and typing of human papillomavirus in cervical cancer in the Thai.

One hundred formalin-fixed paraffin embedded tissues with histopathologic diagnosed invasive cervical cancer (squamous cell carcinoma) were examined for the presence of HPV-DNA by polymerase chain reaction (PCR) using L1-consensus primers. The results indicated that 82 out of 100 (82%) samples were positive for HPV-DNA. Among the positive samples, 50 samples (61%) were typed by dot hybridization technique (DH). HPV-16 was the dominant type (42.68%), followed by HPV-18 (20.73%) and HPV-33 (3.66%). There were double infection of HPV-16 and 18 in 5 (6.1%) samples. None of HPV-6 and 11 were detected in this study. This finding suggests that HPV infection is an important etiologic factor for the development of cervical cancer especially the infection with high risk types, i.e., HPV-16 and 18.

Use of nonoxynol-9 and reduction in rate of gonococcal and chlamydial cervical infections.

The spermicide nonoxynol-9 (N-9) has been used as a contraceptive for over 30 years, but the use of a vaginal spermicide and condoms for the prevention of sexually transmitted infections has not been examined in randomised studies. We report a single-blind randomised field trial to assess the effect of N-9 film on the rate of gonococcal and chlamydial cervical infection in women at high risk of these diseases. 343 women were randomly assigned to use either condoms and N-9 (186 women) or condoms and a placebo (157). Compliance with condom use was much the same in the two groups. Overall, N-9 reduced the rate of cervical infection by 25% (rate ratio [RR] 0.75, 95% confidence interval [Cl] 0.5-1.1); in women who used N-9 for more than 75% of their coital acts the infection rate was reduced by 40% (RR 95% Cl 0.3-1.0). The rate of yeast vulvovaginitis or genital ulcers was not higher in N-9 users than in placebo users, but the rate of symptomatic irritation was increased by 70% (RR 95% Cl 1.1-2.6) among N-9 users. Condom use was more protective against cervical infection than N-9 use. The rate of infection was 50% (RR 95% Cl 0.3-0.7) lower with 75% than with 0-50% condom compliance. The use of a vaginal N-9 spermicide with condoms whenever possible seems to be a better strategy than the use of condoms only for prevention of gonococcal and chlamydial cervical infection.

Male sexual behavior as risk factor in cervical cancer.

Risk factors of male sexual behavior for squamous cell carcinoma of the uterine cervix were studied in Thai women at Chulalongkorn Hospital, Bangkok, Thailand, using an unmatched case-control design. A total of 93 case husbands and 169 control husbands were recruited in the study. Case husbands are prone to have more sexual partners than the control and have an age of first sexual intercourse earlier than the controls. More husbands of cases than of controls had history of prostitute visits in their life with the odds ratio of 9.42. Prostitute visit is a main risk factor, irrespective of whether the husband had a history of sexually transmitted diseases or not. Condom use in sexual intercourse with prostitutes seemed to have a protective effect for their wives in decreasing risk of cervical cancer. This study supports the infectious and venerally transmitted character of cervical cancer and indicates that the other measure of preventing and controlling cervical cancer in women is to educate and prevent men from having high risk sexual behavior.

The effects of frequent nonoxynol-9 use on the vaginal and cervical mucosa.

The authors conducted a single-dose phase I local toxicity study of the effects of frequent insertion of nonoxynol-9 (N-9) on the lower genital tract to determine whether a phase II dose-ranging study is warranted. Fourteen women used 150 mg of N-9 cumulatively four times a day for 14 days. Epithelial disruption of the cervix and vagina, the main outcome of interest, occurred in 43% (95% CI, 18-71%) of women on this high-frequency use schedule. None of the women experienced symptoms that prompted them to discontinue the study. This preliminary study indicates that a phase II study to examine the local toxicity of different use schedules is needed to provide further safety information about the use of N-9.

PIP: A Phase I type clinical trial was conducted to study the local toxic effects of nonoxynol-9 (N-9) on the vaginal and cervical mucosa of women, to see whether a Phase II trial is needed, since women may use the spermicide frequently to prevent sexually transmitted diseases. 14 women inserted suppositories containing 150 mg N-9 every hour for 4 doses for 14 days. They were checked before the trail and for 2 or 3 weeks, with pelvic exam, smears for trichomonas and monilia, and colposcopy. 5 women inserted placebos to blind the trial. 43$ of the subjects had physical findings including sloughing of the cervical epithelium in 4, cervical erythema in 4, cervical bleeding in 1, vaginal erythema in 3, vaginal sloughing and bleeding in 1, vaginal dryness in 3, dryness in 2 and itching in 2. The cervical sloughing did not cross the transformation zone. 1 woman had edema and bleeding of the cervix resembling severe strawberry cervix. All symptoms resolved in 1 week. No effects were seen on the vulva, perineum or anus. The dose and frequency of use of N-9 in this trail are larger than women would normally be expected to use, but the data do justify a Phase II study.