Fernando B. Guijon

The accuracy of colposcopic grading for detection of high-grade cervical intraepithelial neoplasia

Objective. To relate aspects of online colposcopic image assessment to the diagnosis of grades 2 and 3 cervical intraepithelial neoplasia (CIN 2+). Methods: To simulate colposcopic assessment, we obtained digitized cervical images at enrollment after acetic acid application from 919 women referred for equivocal or minor cytologic abnormalities into the ASCUS-LSIL Triage Study. For each, 2 randomly assigned evaluators from a pool of 20 colposcopists assessed images using a standardized tool online. We calculated the accuracy of these assessments for predicting histologic CIN 2+ over the 2 years of study. For validation, a subset of online results was compared with same-day enrollment colposcopic assessments. Results. Identifying any acetowhite lesion in images yielded high sensitivity: 93% of women with CIN 2+ had at least 1 acetowhite lesion. However, 74% of women without CIN 2+ also had acetowhitening, regardless of human papillomavirus status. The sensitivity for CIN 2+ of an online colpophotographic assessment of high-grade disease was 39%. The sensitivity for CIN 2+ of a high-grade diagnosis by Reid Index scoring was 30%, and individual Reid Index component scores had similar levels of sensitivity and specificity. The performance of online assessment was not meaningfully different from that of same-day enrollment colposcopy, suggesting that these approaches have similar utility. Conclusions. Finding acetowhite lesions identifies women with CIN 2+, but using subtler colposcopic characteristics to grade lesions is insensitive. All acetowhite lesions should be assessed with biopsy to maximize sensitivity of colposcopic diagnosis with good specificity.

The association of sexually transmitted diseases with cervical intraepithelial neoplasia: A case-control study

Thirty-three women with histologically confirmed cervical intraepithelial neoplasia (grades I to III, with one case of microinvasive carcinoma) and 54 women without evidence of the disease were prospectively studied to determine the relationship of genital infection to cervical neoplasia. Demographic and sexual data for patients and control subjects were collected, with standardized clinical and colposcopic evaluation by means of predefined diagnostic categories. Cultures from the cervix were examined for herpes simplex virus, cytomegalovirus, Chlamydia trachomatis, and Neisseria gonorrhoeae. Human papilloma virus infection was identified by characteristic changes of koilocytosis in cytologic or histopathologic specimen. Cultures from the vagina were evaluated for Gardnerella vaginalis, Trichomonas vaginalis, Ureaplasma urealyticum, Mycoplasma hominis, Candida albicans, and other yeasts. Separate Gram strains were prepared from endocervical secretions and from vaginal secretions. More lifetime sexual partners, larger area of transformation zone, evidence of human papilloma virus infection, and altered vaginal flora were observed in women with cervical intraepithelial neoplasia. The association of human papilloma virus infection and altered vaginal flora with cervical intraepithelial neoplasia was independent of sexual experience.

Vaginal microbial flora as a cofactor in the pathogenesis of uterine cervical intraepithelial neoplasia

The vaginal microbial flora of 106 women with histopathologically confirmed cervical intraepithelial neoplasia and 79 women without disease, was evaluated for Gardnerella vaginalis, Trichomonas vaginalis, Candida albicans and other yeasts. Flora morphology was assessed by gram staining of secretions. Cervical cultures were examined for Herpes Simplex virus, Cytomegalovirus and Neisseria gonorrhoeae. Chlamydia trachomatis antigens in cervical secretions were detected by enzyme immunoassay. Human Papillomavirus was identified by koilocytosis in cytologic or histopathologic specimens. Human Papillomavirus infection (P < 0.00001), vaginal infection with Mycoplasma hominis (P = 0.012) and abnormal vaginal flora (P = 0.006) were significantly associated with CIN, suggesting that CIN may be promoted by vaginal microorganisms in conjunction with human papillomavirus cervical infection.

Human papillomavirus infection and the size and grade of cervical intraepithelial neoplastic lesions associated with failure of therapy

OBJECTIVE: This investigation was designed to identify specific risk factors associated with treatment failure for cervical intraepithelial neoplasia. METHOD: A cohort of 436 women was assessed for the presence of co‐factors associated with therapy failure. The risk factors included the HP V infection status of the patient, a previous history of genital condyloma and the size of cervical lesions. RESULT: The treatment outcome was not related to the treatment modality (P = 0.058). Thirteen (8.1%) women failed laser therapy while 15 (5.4%) women failed cryotherapy. While treatment failure occurred only in the presence of HP V infection (P = 0.036), failure was not related to infection by a specific genotype. Therapy failure was associated with treatment for CIN II (RR 4.157) and CIN III (RR 2.053) relative to CIN I and treatment of large lesions (P = 0.014). CONCLUSION: The determination of the relative area occupied by cervical lesions may have prognostic value in identifying women who are at risk for treatment failure.

Premalignant cervical lesions are characterized by dihydrofolate reductase gene amplification and c-Myc overexpression: possible biomarkers.

Objective. The c-Myc oncoprotein deregulation is associated with overall genomic instability and locus-specific genomic instability involving the dihydrofolate reductase (DHFR) locus. This study analyzes c-Myc protein levels and the stability of the DHFR gene in cervical tissue biopsies. Materials and Methods. The stability of the DHFR gene was examined by fluorescence in situ hybridization (FISH). c-Myc protein levels were evaluated using quantitative fluorescent immunohistochemistry. Forty-four cervical tissue biopsies were analyzed and included 33 preinvasive cervical lesions identified by histology, 14 samples were cervical intraepithelial neoplasia (CIN) 1; 7 were CIN 2; and 12 were CIN 3. Eleven biopsies had negative histology. Results and Conclusion. c-Myc protein levels were elevated in CIN 1, 2, and 3 (p = .02) biopsies. Concomitantly, DHFR gene amplification was detected in CIN 1, 2, and 3 (p = .0001). The degrees of DHFR gene amplification and of c-Myc protein levels were a measure of the progressive degree of the lesion.

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.

A Comparative Analysis of Gene Expression Patterns and Cell Phenotypes between Cervical and Peripheral Blood Mononuclear Cells

Studies of the immunological environment in the female genital tract (FGT) are critical for the development of vaccines or microbicides to halt the spread of sexually transmitted infections. Challenges arise due to the difficulties of sampling from this site, and the majority of studies have been conducted utilising peripheral blood mononuclear cells. Identifying functional differences between immune cells of the FGT and peripheral blood would aid in our understanding of mucosal immunology. We compared the gene expression profile of mononuclear cells at these two sites. Messenger RNA expression analysis was performed using gene expression arrays on matched cervical mononuclear cells and peripheral blood mononuclear cells. Further cellular phenotyping was done by 10 colour flow cytometry. Of the 22,185 genes expressed by these samples, 5345 genes were significantly differentially expressed between the cell populations. Most differences can be explained by significantly lower levels of T and B cells and higher levels of macrophages and dendritic cells in the FGT compared with peripheral blood. Several immunologically relevant pathways such as apoptosis and innate immune signalling, and a variety of cytokines and cytokine receptors were differentially expressed. This study highlights the importance of the unique immunological environment of the FGT and identifies important differences between systemic and mucosal immune compartments.

Laboratory diagnosis of latent human papillomavirus infection.

The etiologic association of human papillomavirus (HPV) with uterine cervical cancer has prompted the need for improved laboratory diagnosis of this virus. The application of conventional hybridization technology, including filter in situ hybridization (FISH) and Southern-blot analysis, has revealed that the detection and typing of the virus is inconsistent between sequential specimens from the same individual. To determine whether the polymerase chain reaction (PCR) can be used to provide a more accurate assessment of infection status, two exfoliated cervical cell specimens obtained sequentially from a cohort of 30 women without clinical evidence of cervical abnormalities were analyzed in parallel by FISH and PCR at 6-month intervals. Neither of the procedures provided consistent findings with two sequential specimens suggesting that multiple analyses are necessary to assess infection accurately. However, PCR was less subjective in interpretation and demonstrated greater specificity than did FISH. With the increased sensitivity inherent to PCR, our findings indicated that PCR is more likely to identify latent HPV infection with a single specimen.

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

human papillomavirus (HPV) infection is a disease of the entire female lower genital tract. Colposcopic examinations and biopsies of the cervix and vulva were performed on all patients. Two hundred two women had cervical disease, of whom 164 (81%) also had vulvar disease. The percentage was the same regardless of the severity of the cervical disease. One hundred ninety-four of the patients had vulvar disease and of these, 164 (85%) also had cervical disease. Twenty-nine of 37 women (78%) with overt vulvar condylomata had cervical disease; 15 of these presented without a Papanicolaou smear, and 13 had cervical disease. We conclude that HPV infection of the female lower genital tract is a multicentric disease. All patients with evidence of HPV infection should undergo colposcopic evaluation of the entire lower genital tract. The significance that this will have on future attempts to cure this infection needs to be studied.

Mucometra: A rare complication of cryosurgery

In a series of 400 patients treated for cervical intraepithelial neoplasia, 3 developed a clinical picture 6 days after the procedure that consisted of lower abdominal pain and uterine cramps. Examination revealed a closed os; on probing of the cervix, a large amount of mucus (approximately 60 ml) under tension was drained, after which there was almost immediate relief of the symptoms.