Determination of cervicovaginal microorganisms in women with abnormal cervical cytology: the role of Ureaplasma urealyticum.

OBJECTIVE: To evaluate the existence of an association between cervicovaginal infections and precancerous lesions of the uterine cervix, through determination of prevalent cervicovaginal micro-organisms, alone and in association with human papillomavirus (HPV), in patients with abnormal and normal vaginal cytology. PATIENTS AND METHODS: Patients with abnormal vaginal cytology were divided into three study groups according to cytological findings: ASC-US, L-SIL and H-SIL. All patients underwent colposcopic examination and exoendocervical and vaginal sampling for microbiological and molecular analysis for detection of HPV-DNA, Ureaplasma urealyticum, Chlamydia trachomatis, Trichomonas vaginalis, mycetes and common bacteria. Results were compared with the patient group asymptomatic for cervicovaginal inflammation with negative vaginal cytology and colposcopy. RESULTS: A high association between Ureaplasma urealyticum infection and the grade of cytological cervical lesion (27% for ASC-US, 35% for L-SIL and 45% for H-SIL) was found. Furthermore, 19% of the control group samplings were positive for Ureaplasma urealyticum, significantly less than that observed in the positive cytology groups. An interesting association of HPV with Ureaplasma urealyticum in patients with H-SIL vaginal cytology (83%), much higher than that observed in patients with slightly abnormal or normal vaginal cytology (56% for ASC-US, 49% for L-SIL, 40% for normal cytology) was also identified. In contrast, the association between Papillomavirus and multiple microorganisms seemed to decrease with the level of cellular dysplasia in 30% of controls, 33% of ASC-US, 32% of L-SIL and 17% of H-SIL. CONCLUSION: The presence of a high Ureaplasma urealyticum level seems to be a cofactor of HPV infection, a necessary cause of precancerous lesions of the uterine cervix. The presence of Ureaplasma urealyticum may play a role both in initiating viral cellular anomalies and in viral persistence. It can be hypothesized that these initial processes are helped by a state of cervical inflammation, also supported by multiple microorganisms. It would, thus, be suggested for all patients who present with an abnormal PAP test to undergo a cervicovaginal microbiological examination to detect potentially pathogenic microbes for correct diagnosis and treatment, as well as a more complete follow-up of cervical cytological lesions.

Lactobacilli-mediated control of vaginal cancer through specific reactive oxygen species interaction.

Klebanoff et al. proposed that hydrogen peroxide-producing lactobacilli and peroxidase in the vagina of healthy women might be responsible for the prevention of vaginosis and also might exert an antitumor effect (1). Based on recent evidence on superoxide anion generation by transformed cells (2,3) and on the potential of myeloperoxidase for selective apoptosis induction in transformed cells (4), a model for specific reactive oxygen species interaction during lactobacilli-mediated tumor control in the vagina is presented here. We propose that peroxidase, which converts hydrogen peroxide into hypochlorous acid, is responsible for creating a microbicidal vaginal milieu by maintaining a balanced, non-toxic, steady state level of the microbicides H(2)O(2)and HOCI. In case individual superoxide anion-producing transformed cells eventually appear in the mucosa they will be driven into apoptosis by interaction of HOCI with superoxide anions which leads to the generation of hydroxyl radicals. Hence selective apoptosis induction in transformed cells represents the key element of lactobacilli-mediated antitumor defense. Since papilloma virus infected cells are resistant to this pathway of apoptosis induction, they are plausible candidates for circumvention of lactobacilli-mediated control of oncogenesis.

Colposcopy, colpocytology and the vaginal ecosystem. Oncological, bacteriological and hormonal evaluation in a series of 400 women.

The Authors retrospectively considered colpocytological and colposcopic findings in a series of 400 women, aged 16 to 83 years, presenting for the first time at the Oncological Gynaecology Unit of the Institute of Gynaecology and Obstetrics of Padua University between 1991 and 1992. In addition to oncological evaluation, the bacteriological profile and hormone status of cytological samples were formulated in all cases. The most common oncological finding was a cell morphology within normal limits (67%), followed by reactive and reparative changes (19%) and low-grade squamous intraepithelial lesions (SIL, 12%). Histological findings correlated well with the cytological diagnosis, though low-grade SIL was over-estimated. As for the bacteriological profile, a mixed flora was most frequent (56.7%) followed, especially in fertile age, by Döderlein's bacillus (20%) and vaginosis (15.5%). Colposcopy most frequently revealed ectopia and/or a normal transformation zone (50.7%) and dystrophic mucosa (21%). An abnormal transformation zone was more common among women with a moderate-to-abundant flora. Fifteen male partners were also checked: cellular changes typical of human papilloma virus infection were found in 40% and colposcopic findings compatible with said virus were observed in 26.6% of cases. These results confirm that colpocytology provides a complete and simultaneous evaluation not only of cell morphology, but also of the bacterial population and hormones in the vaginal ecosystem. It is therefore the method of choice in screening for cervical and vaginal neoplasms and an effective means for simultaneously evaluating vaginal flora and hormone status.

Detection of oncogenic HPV DNA by a consensus polymerase chain reaction method in genital carcinomas in twenty women in Barbados.

Paraffinized tissue from Barbadian women with histologically proven genital carcinoma was subjected to a consensus polymerase chain reaction method. Nineteen patients had cervical and one, vaginal carcinoma. The histological types were 17 squamous cell carcinoma, 2 adenocarcinoma and 1 adenosquamous carcinoma. HPV DNA was detected in 18/20 (90%). HPV DNA type 16 in 13 (65%), type 33 and type 45 in 1 (5%) each and 3 (15%) could not be typed. HPV DNA, type 16, was detected in one (50%) of the two cases of adenocarcinoma and 12/17 (71%) cases of squamous cell carcinoma. DNA HPV, type 33, and type 45 were each detected in 1/17 (6%) cases of squamous cell carcinoma. No HPV DNA, type 18, was detected.

Detection of oncogenic HPV DNA by a consensus polymerase chain reaction method in genital carcinomas in twenty women in Barbados

Paraffinized tissue from Barbadian women with histologically proven gential carcinoma was subjected to a consensus polymerase chain reaction method. Nineteen patients had cervical and one, vaginal carcinoma. The histological types were 17 squamous cell carcinoma, 2 adenocarcinoma and 1 adenosquamous carcinoma. HPVDNA was detected in 18/20 (90 percent). HPVDNA type 16 in 13 (65 percent), type 33 and type 45 in 1 (5 percent) each and 3 (15 percent) could not be typed. HPVDNA, type 16, was detected in one (50 percent) of the two cases of adenocarcinoma and 12/17 (71 percent) cases of squamous cell carcinoma. DNAHPV, type 33, and type 45 were each detected in 1/17 (6 percent) cases of squamous cell carcinoma. No HPVDNA, type 18, was detected (AU)

Detection of oncogenic HPV DNA by a consensus polymerase chain reaction method in genital carcinomas in twenty women in Barbados

Paraffinized tissue from Barbadian women with histologically proven gential carcinoma was subjected to a censensus polymerase chain reaction method. Nineteen patients had cervical and one, vaginal carcinoma. The histological types were 17 squamous cell carcinoma, 2 adenocarcinoma and 1 adenosquamous carcinoma. HPVDNA was detected in 18/20 (90 per cent ). HPVDNA type 16 in 13 (65 per cent ), type 33 and type 45 in 1 (5 per cent ) each and 3 (15 per cent ) could not be typed. HPVDNA, type 16, was detected in one (50 per cent ) of the two cases of adenocarcinoma and 12/17 (71 per cent ) cases of squamous cell carcinoma. DNAHPV, type 33, and type 45 were each detected in 1/17 (6 per cent ) cases of squamous cell carcinoma. No HPVDNA, type 18, was detected.

Localization of p53 protein and human papillomavirus in anogenital squamous lesions: immunohistochemical and in situ hybridization studies in benign, dysplastic, and malignant epithelia.

p53 Protein is a 53-kd nuclear phosphoprotein believed to play an important role in controlling proliferation of neoplastic and normal cells. This "natural tumor suppressor" can be rendered ineffective (or oncogenic) by mutations in the p53 gene or by interactions with proteins synthesized by DNA-transforming viruses, including specific subtypes of human papillomavirus (HPV). We describe the localization of p53 protein in association with HPV in paraffin sections of a spectrum of benign, dysplastic, and malignant anogenital squamous epithelia using immunohistochemical and in situ hybridization techniques. p53 Was detected in 81% of the 48 cases studied. Immunoreactivity for p53 was seen in 83% of the benign and low-grade squamous intraepithelial lesions (SILs), in 73% of the high-grade SILs, and in 86% of the infiltrating squamous carcinomas. In high-grade SILs p53 staining was frequently observed in individual nuclei at various levels of the abnormal epithelium and in the basal layer of the adjacent epithelium, while in squamous metaplasia and low-grade SILs immunostaining for p53 was limited to the basal layer of the epithelium. p53 Was detected in a slightly higher percentage of HPV-positive than HPV-negative epithelia as determined by in situ hybridization. No correlation was observed between p53 immunoreactivity and HPV subtypes. p53 Protein and HPV were detected in anal lesions from a small group of human immunodeficiency virus-positive individuals. Antibodies currently available mainly demonstrate mutant forms of p53 protein that are associated with longer half-lives than the wild-type protein, but demonstration of p53 protein overexpression is not necessarily indicative of malignancy.

[The value of hybridization-in-situ technique in the diagnosis of condyloma acuminatum].

By using 35S-dCTP labelled HPV16 probe, the HPV DNA sequence in 32 cases of condyloma acuminatum and suspicious condyloma acuminatum of vulva and vagina as well as 18 cases of papillomas at different anatomical sites were detected. The results showed that the HPV DNA sequences were positive in all 25 cases of condyloma acuminata which were typical both clinically and pathologically and in 6/7 of the suspicious cases; whereas in only 1/18 of the papillomas at various sites were they positive. Thus, nucleic acid hybridization-in-situ technique combined with histopathology seemed to be of great value for the diagnosis and differential diagnosis of condyloma acuminatum.

Detection and typing of human papillomavirus infection affecting the cervix, vagina and vulva. Comparison of DNA hybridization with cytological, colposcopic and histological examinations.

The sensitivity of human papillomavirus (HPV) detection was compared by colposcopy, histology and DNA hybridization among 304 women with abnormal Papanicolaou (Pap) smear. Colposcopically directed biopsies revealed HPV infection in 71% of cases, DNA hybridization in 35%, and both together in 78%. DNA hybridization detected HPV in 24% of the 84 benign cases with no histological signs of HPV, in 32% of the 133 condylomas verified by biopsies and in 51% of the 85 cases with intraepithelial neoplasia, 95% of which presented histological signs of HPV. The pattern of occurrence of different HPV-types resembled findings in earlier reports. HPV infection is common with abnormal Pap smears and it can be identified relatively reliably by means of cytology, colposcopy and histology. DNA hybridization serves as a complementary technique which may reveal the oncological potential of the virus.

Second genital primary squamous neoplasms in vulvar carcinoma: viral and histopathologic correlates.

OBJECTIVE: To determine whether vulvar squamous cell carcinomas associated with certain morphologic features and/or human papillomavirus (HPV) nucleic acids were more likely to be associated with other genital primary squamous neoplasms. METHODS: We surveyed 169 invasive squamous cell carcinomas of the vulva and correlated associated vulvar intraepithelial neoplasia (VIN), invasive growth patterns resembling VIN (intraepithelial-like or basaloid), and the presence of HPV nucleic acids by in situ hybridization with a history of a second primary squamous neoplasm of the genital tract. RESULTS: Twenty-two patients (13%) had a history of a second primary. An intraepithelial growth pattern or an associated VIN correlated significantly with HPV, at P = .0005 and P = .007, respectively, and with a second primary, at P = .077 and P = .009, respectively. When HPV-positive, the same histologic variables correlated with a second primary at P = .099 and P = .25, respectively. Compared with cases lacking both these histologic features and HPV, they correlated with multifocal disease at P = .01 and P = .003. CONCLUSIONS: The findings of HPV nucleic acids, tumor growth patterns, and associated VIN are interrelated and confer risk of other genital primary neoplasms in women with vulvar carcinoma. This supports the concept that subsets of vulvar carcinoma may be distinguished not only by morphology and HPV DNA, but also by a distinctly different risk of a second genital primary neoplasm.

Small cell neuroendocrine carcinoma of the vagina.

A 65-year-old woman with a history of recurrent vaginal intraepithelial neoplasia was found to have small cell carcinoma (SCC). Exfoliative cytology was instrumental in the discovery of each episode of vaginal neoplasia. Thorough examination of the patient established the tumor as being primary to the vagina, and immunohistochemistry confirmed it to be a neuroendocrine SCC. Eleven patients with neuroendocrine SCC of the vagina have been reported previously. Morphologic characteristics and histogenesis are discussed within the context of the embryology and natural history of extrapulmonary-genital SCC. They have been classified in the amine precursor uptake and decarboxylation family of neoplasms. Originally, a neuroectodermal origin was proposed, but derivation now is thought to be from multipotential epithelial stem cells of the genital tract. Neuroendocrine SCC tends to be an aggressive neoplasm with a propensity for early spread. Long-term survival for patients with vaginal SCC has not been documented. Therapeutic decisions regarding SCC from this site have been based on information gained from the treatment of these tumors elsewhere. Combined modality therapy using initial surgery and adjuvant treatment, including systemic chemotherapy and local exposure to radiation, has produced an apparent complete response in our patient.

Transcription of the E6 and E7 genes of human papillomavirus type 6 in anogenital condylomata is restricted to undifferentiated cell layers of the epithelium.

The E6 and E7 genes of human genital papillomaviruses (HPVs) appear to transform cells by different mechanisms. They seem to act synergistically but are not equally important when tested under diverse experimental conditions. We were therefore tempted to investigate the E6- and E7-specific transcription pattern in HPV6-infected condylomas separately, by in situ hybridization. Recent studies have identified three promoters within the E6-E7 region of HPV6 and HPV11 by applying S1, exonuclease VII, and cDNA analyses. On the basis of these data, we cloned subgenomic fragments of HPV6 into plasmid pBS to obtain riboprobes that differentiated between transcripts starting upstream of the E6 and E7 open reading frames, respectively. These different species of mRNAs were analyzed in serial thin sections of eight HPV6-positive anogenital condylomas. The E6 probe (nucleotides 7862 to 241) led to weak signals within the basal layer. In three cases, rather strong signals were confined to a few basal cells. The E7 probe (nucleotides 242 to 534) gave rise to a more pronounced labeling of all cells within the two to three lowest epidermal layers. In situ hybridization with a riboprobe for human c-fos revealed an expression pattern similar to that observed with the E7 probe. In contrast to the preferential expression of the transforming E6 and E7 genes in the lower epithelium, the major transcriptional activity of the virus was detected in the middle and upper third by probes colinear with the 3' moiety of the early region.

Differences in the integration pattern and episomal forms of human papillomavirus type 16 DNA found within an invasive cervical neoplasm and its metastasis.

Human papillomavirus (HPV) type 16 DNA was found in three separate neoplastic lesions within a female patient. The physical state of the viral DNA in each lesion was determined by two-dimensional agarose gel electrophoresis. The primary cervical tumor contained large amounts of several distinct episomal forms as well as integrated HPV DNA. Metastatic tumor tissue found in the vagina had greatly reduced levels of episomal DNA and a viral DNA integration pattern that was different from that of the primary tumor. The vulvar carcinoma in situ had what appears to be free and integrated forms of viral DNA. The results show that although metastatic tissue retained HPV DNA, further rearrangements of the integrated viral DNA pattern found in the primary tumor may occur with a dramatic decrease of episomal forms during malignant progression.

Cigarette smoking and the risk of anogenital cancer.

The association between cigarette smoking and cervical cancer has been demonstrated in numerous prior studies. As part of population-based case-control studies of cancers of the vulva, vagina, cervix, anus, and penis in relation to infection with human papillomavirus, conducted in western Washington State and the province of British Columbia from the mid 1980s until the present time, the authors have collected detailed information on smoking history. The proportion of subjects who were current smokers of cigarettes ranged from slightly over 40% among incident cases of vaginal and cervical cancer to 60% among cases of vulvar and anal cancer. In contrast, only about 25% of controls were current smokers. The adjusted odds ratios (OR) associated with current smoking were substantially elevated (OR = 1.9-14.6) for all cancer sites except cancer of the vagina (OR = 1.3). The risks tended to increase in proportion to the number of cigarettes smoked. For most cancer sites, the odds ratios associated with former smoking were substantially less than those associated with current smoking and diminished with increasing time since cessation of smoking. The authors' data and those of other investigators suggest that cigarette smoking plays a role in the etiology of anogenital cancers and that smoking has a late-stage or promotional effect.

Implication of human papillomavirus in postirradiation dysplasia.

The presence of human papillomavirus (HPV) DNA and association of condylomata acuminata (CA) in the biopsy tissues of postirradiation dysplasia (PRD) of the cervix and/or vagina from 17 patients who previously had radiation therapy for malignancies of the uterine cervix, vagina, and endometrium were evaluated with DNA in situ hybridization. Eight of 17 patients (47.1%) had HPV DNA identified in the lesions of postirradiation dysplasia (PRD). Five of eight cases (62.5%) contained HPV DNA of more than one type. Type 16 HPV DNA (HPV-16) was the most frequently identified type. Several PRD lesions also contained HPV-6, HPV-18, HPV-31, and/or HPV-33 DNA. Eleven patients (64.7%) showed CA in the vicinity of PRD. In two cases, different types of HPV were found in the lesions of PRD and contiguous CA. The frequency of the cases containing HPV DNA, the types of HPV, and the distribution pattern of silver grains in the preparations of in situ hybridization over the nuclei of cells of PRD were very similar to those found in naturally occurring dysplasia. Based on these findings, persistent or repeat HPV infection was the most likely etiologic factor of PRD, which might be facilitated by immunosuppression due to pelvic irradiation.

Human papillomavirus in exophytic condylomatous lesions on different female genital regions.

Clinically diagnosed exophytic condylomatous lesions on the vulva (20 cases), vagina (5 cases), and cervix (9 cases) were examined pathologically, and human papillomavirus (HPV) types present in those lesions were identified by Southern blot hybridization analysis. All vulvar and vaginal lesions showed typical histopathological features of classical condylomata, and HPV 6 and 11 were found in 15 vulvar and 3 vaginal lesions and in 5 vulvar and 2 vaginal lesions, respectively. In 5 cervical lesions with typical condylomatous changes, HPV 6 or 11 was also detected; however, HPV 16 was found in 2 cases of cervical lesion surrounded by prominent intraepithelial neoplasia, and HPV 31 was found in 2 cases of slightly elevated lesion with intraepithelial neoplasia. These observations suggest that HPV 6 and 11 have the potency to induce the specific pathological changes, condylomatous, in any regions of the female lower genital tract.

Anogenital papillomavirus infection and neoplasia in immunodeficient women: an update.

People with deficient cell-mediated immunity have an increased susceptibility to viral infections and certain cancers, particularly non-Hodgkin's lymphomas and cancers of the skin and anogenital region. These are linked to viral origins. Anogenital neoplasms in immunodeficient patients show a strong association with HPV infection; often occur at relatively young ages; involve multifocal locations; and tend to persist, recur, and progress rapidly, despite standard therapy. Because standard therapy of anogenital HPV lesions and neoplasia is often not effective in immunodeficient patients (and others with an anogenital neoplastic syndrome), special treatment is required. 5-Fluorouracil chemosurgery, followed by maintenance 5-fluorouracil therapy, is often effective and provides field suppression against recurrent HPV infection and neoplasia, with minimal damage to affected organs. After removal of all detectable HPV and neoplastic lesions, immunodeficient patients require close surveillance of the entire anogenital tract. Immunodeficient patients are an in vivo human laboratory in which to study the natural history of HPV and its oncogenic effects on the anogenital tract. The theory of HPV oncogenesis is supported by the evidence gathered from these patients.

Human T-cell leukemia virus type I infection as an oncogenic and prognostic risk factor in cervical and vaginal carcinoma.

The seroprevalence of human T-cell leukemia virus type I (HTLV-I) antibody in 6701 healthy females and 226 women with gynecologic malignancies, all living in an adult T-cell leukemia-endemic area in southwestern Japan, was investigated to determine whether HTLV-I infection was a risk factor influencing oncogenesis and prognosis. The seroprevalences in cervical carcinoma patients younger than 59 years and in vaginal carcinoma patients of all ages were significantly higher than in age-matched healthy controls. The ratios of observed to expected HTLV-I seroprevalence in patients younger than 59 with cervical carcinoma and in vaginal carcinoma patients were 2.92 and 7.36, respectively. Among the patients with cervical carcinoma or vaginal carcinoma, the tumor recurrence rate in HTLV-I carriers was significantly higher than that in HTLV-I seronegative patients. Our results suggest that HTLV-I infection may be oncogenic and may affect the prognosis in some patients with cervical or vaginal carcinoma.

[Genital HPV infection, relation between vulvar and cervico-vaginal localization]. / Infezione da HPV genitale, rapporto tra localizzazione vulvare e cervico-vaginale.

The Authors studied 37 women affected by vulvar condylomatosis. Thirty-four presented features of florid or microflorid condylomatosis, three were affected by flat condylomatosis, Papillomavirus (HPV) infection of the cervico-vaginal tract was present in 25 women. No vulvar cellular atypia was found in the 37 cases with HPV lesions, while in 6 cases there were also cervical dysplasia (CIN 1-CIN 2). Nineteen out of 23 patients with disseminated revealed a vaginal flogosis mostly by yeats, detected by microbiological examinations. The evidence of disseminated florid or microflorid lesions associated with the virus infection, both located at the cervico-vaginal tract, support the ipothesis of virus types with higher virulence, a greater ubiquitary trophysm and a greater oncogenic risk, as supported also by other Authors.