Immaculada Alonso

Does human papillomavirus infection imply a different prognosis in vulvar squamous cell carcinoma

BACKGROUND Two independent pathways in the development of vulvar squamous cell carcinoma (VSCC) have been described, one related to and the other independent of high-risk human papillomavirus (HR-HPV). The aim of our study was to evaluate whether the HPV status has a prognostic significance or can predict response to radiotherapy. METHODS All VSCC diagnosed from 1995 to 2009 were retrospectively evaluated (n=98). HPV infection was detected by amplification of HPV DNA by PCR using SPF-10 primers and typed by the INNO-LIPA HPV research assay. p16(INK4a) expression was determined by immunohistochemistry. Disease-free and overall survival (DFS and OS) were estimated by Kaplan-Meier analysis with the log-rank test and a multivariate Cox proportional hazards model. RESULTS HR-HPV DNA was detected in 19.4% of patients. HPV16 was the most prevalent genotype (73.7% of cases). p16(INK4a) stained 100% HPV-positive and 1.3% HPV-negative tumors (p<.001). No differences were found between HPV-positive and -negative tumors in terms of either DFS (39.8% vs. 49.8% at 5 years; p=.831), or OS (67.2% vs. 71.4% at 5 years; p=.791). No differences in survival were observed between HPV-positive and -negative patients requiring radiotherapy (hazard ratio [HR] 1.04, 95% confidence interval [CI] .45 to 2.41). FIGO stages III-IV (p=.002), lymph node metastasis (p=.030), size ≥ 20 mm (p=.023), invasion depth (p=.020) and ulceration (p=.032) were associated with increased mortality but in multivariated only lymph node metastasis retained the association (HR 13.28, 95% CI 1.19 to 148.61). CONCLUSIONS HPV-positive and -negative VSCCs have a similar prognosis. Radiotherapy does not increase survival in HPV-positive women.

Value of p16INK4a as a marker of progression/regression in cervical intraepithelial neoplasia grade 1

OBJECTIVE The objective of this study was to evaluate the usefulness of p16(INK4a) staining to classify cervical intraepithelial neoplasia grade 1 according to its progression/regression risk. STUDY DESIGN Patients with a histologic diagnosis of cervical intraepithelial neoplasia grade 1 were prospectively recruited (n = 138). Simultaneous detection of high-risk human papillomaviruses and p16(INK4a) evaluation were performed. Follow-up was conducted every 6 months by cytology and colposcopy and annually by high-risk human papillomavirus testing, for at least 12 months (mean, 29.0). Progression was defined as a histologic diagnosis of cervical intraepithelial neoplasia grades 2-3, regression as a negative cytology and high-risk human papillomaviruses, and persistence as a cytologic result of low-grade squamous intraepithelial lesions and/or a positive test for high-risk human papillomaviruses. RESULTS Progression was observed in 14 women (10.1%), 66 (47.6%) regressed, and 58 (42.0%) had a persistent disease. p16(INK4a) was positive in 77 (55.8%) initial biopsy specimens. Progression to cervical intraepithelial neoplasia grades 2-3 was identified in 14 of 77 (18.2%) women with positive and none of 61 (0.00%) women with negative p16(INK4a) immunostaining (P < .001). CONCLUSION p16(INK4a) negative cervical intraepithelial neoplasia grade 1 lesions rarely progress and may benefit from a less intensive follow-up.

p16INK4a Immunostaining Identifies Occult CIN Lesions in HPV-positive Women

To evaluate whether p16INK4a staining could help to recognize underestimated cervical intraepithelial neoplasia (CIN) in women positive for high-risk human papillomavirus (HR-HPV) with negative biopsy. Out of 1,259 women undergoing a histologic study and a simultaneous HR-HPV detection using the Hybrid Capture 2 test, we selected all patients testing positive for HR-HPV and having a negative biopsy (n=139), as well as all women testing negative for HR-HPV with a biopsy of either CIN 1 (26 cases) or CIN 2 to 3 (11 cases). Of the remaining 1,083 women, we randomly selected for the purpose of controls, 50 cases negative for HR-HPV with negative biopsy and 100 cases positive for HR-HPV and with biopsy of CIN (50 CIN 1, 50 CIN 2–3). In all cases, immunohistochemical staining for p16INK4a and a second evaluation of the initial biopsy was carried out. Thirty-four out of 139 biopsies (24.5%) testing positive for HR-HPV but having a negative biopsy were positive for p16INK4a. Thirty of these cases (21.6%) were classified as harboring a CIN (11 CIN 1, 19 CIN 2/3) after reevaluation. Both the number of cases reclassified as CIN of any grade, or as CIN 2/3, were significantly higher for cases with HR-HPV load above 100 relative light unit (P<0.005). Particular attention should be paid to biopsies from patients having positive Hybrid Capture 2. The risk of harboring undetected CIN of any type or CIN 2/3 is significantly higher for patients with high HR-HPV load. Immunostaining with p16INK4a should be considered as a highly desirable addition to the histologic evaluation of cervical biopsy specimens in HR-HPV–positive women.

Hpv-negative Vulvar Intraepithelial Neoplasia (vin) With Basaloid Histologic Pattern: An Unrecognized Variant of Simplex (differentiated) Vin

Vulvar intraepithelial neoplasia (VIN) is classified into 2 clinicopathologic subtypes, classic, related to human papillomavirus (HPV) infection and affecting relatively young women, and simplex (differentiated), negative for HPV and affecting elderly women. Histologically, classic VIN may be basaloid and characterized by a replacement of the whole epidermis by a homogeneous population of small, “undifferentiated” keratinocytes, which are diffusely positive for p16INK4a and negative for p53. Simplex VIN is characterized by atypia of the basal layer with high degree of cellular differentiation and shows negative staining for p16INK4a and frequent positivity for p53. Simplex VIN is frequently associated with squamous cell hyperplasia and lichen sclerosus. From a series of 110 invasive squamous cell carcinomas of the vulva negative for HPV by highly sensitive polymerase chain reaction, 51 had VIN lesions located at least 1 cm away from the tumor. In 4 (7.8%) cases, the VIN had basaloid histologic features. All cases showed obvious architectural disorganization with a homogeneous population of basaloid, undifferentiated keratinocytes with scanty cytoplasm replacing the whole epidermis. Immunohistochemically, all cases were negative for p16INK4a and strongly positive for p53 with suprabasilar extension of positive cells. All patients were postmenopausal (median age 61.0 y; range, 45-76). Squamous cell hyperplasia was identified in 1 case and lichen sclerosus in 1 case. The invasive squamous cell carcinoma was of keratinizing type in 3 cases and basaloid in 1 case. In conclusion, simplex, HPV-negative VIN may occasionally have basaloid morphology. Immunostaining for p16INK4a and p53 protein may be helpful in the identification of these lesions and the differential diagnosis with classic, HPV-positive basaloid VIN.

Human papillomavirus as a favorable prognostic biomarker in squamous cell carcinomas of the vagina

OBJECTIVE Recent evidence has confirmed two independent pathways in the development of vaginal squamous cell carcinoma (VaSCC): one related to and the other independent of human papillomavirus (HPV). The aim of our study was to evaluate whether HPV status has prognostic significance in this neoplasm. METHODS All confirmed primary VaSCCs diagnosed and treated from 1995 to 2009 in two institutions were retrospectively evaluated (n=57). HPV infection was detected by PCR using SPF-10 primers and typed with the INNO-LIPA HPV assay and p16(INK4a) expression by immunohistochemistry. Disease-free and overall survival (DFS and OS) were analyzed by Kaplan-Meier analysis with the log-rank test and a multivariate Cox proportional hazards model. RESULTS HR-HPV DNA was detected in 70.2% patients. HPV16 was the most prevalent genotype (67.5% of cases). p16(INK4a) was positive in 97.5% HPV-positive and 17.6% HPV-negative tumors (p<.001). FIGO stage was associated with DFS (p=.042) and OS (p=.008). HPV-positive tumors showed better DFS (p=.042) and OS (p=.035) than HPV-negative tumors. Multivariate analysis confirmed better DFS and OS of HPV-positive patients independent of age and stage. This reduced risk of progression and mortality in HPV-positive patients was limited to women with FIGO stages I and II tumors (HR=0.26; 95% CI 0.10-0.69; p=0.006). CONCLUSIONS HPV-positive early stage (FIGO I and II) VaSCCs have a better prognosis than early HPV-negative tumors. HPV detection and/or p16(INK4a) immunostaining can be easily implemented in routine pathology and should be considered as valuable prognostic biomarkers in the study of patients with VaSCC.

The impact of human papillomavirus genotype on colposcopic appearance: a cross‐sectional analysis

To study colposcopic performance in diagnosing high‐grade cervical intraepithelial neoplasia or cervical cancer (CIN2+ and CIN3+) using colposcopic characteristics and high‐risk human papillomavirus (hrHPV) genotyping.

Predictors of absence of cervical intraepithelial neoplasia in the conization specimen

OBJECTIVE Over 10% of women who undergo conization for cervical intraepithelial neoplasia (CIN) show no lesion in the surgical specimen. We aimed to determine whether these patients can be identified before conization using clinical, virological and/or cyto-histological characteristics, to avoid unnecessary treatment. METHODS Of 687 women with CIN treated by conization in the Hospital Clinic of Barcelona between 2008 and 2011, all patients (n=110, 16%) showing no lesion in the surgical specimen were included as the study group. The control group included a series of randomly selected women with CIN in the cone specimen (n=220). Pre-conization clinical characteristics as well as high-risk human papillomavirus (hr-HPV) status determined by Hybrid Capture 2 were analyzed as possible predictors of absence of lesion. RESULTS A negative pre-conization hr-HPV test or a low viral load (<10 relative light units) significantly increased the probability of absence of CIN in the conization specimen (75.0%, and 52% respectively) compared with patients with a high viral load (26.7%, p<0.001). This association was confirmed in the multivariate analysis (p<0.001). The risk of developing persistent/recurrent disease after treatment was significantly lower in patients with negative hr-HPV test or a low viral load (16.1% CIN1, 0% CIN2-3), than in patients with a high viral load (27.6% CIN1, 4.1% CIN2-3, p=0.031). CONCLUSION Women with negative pre-conization hr-HPV test results or a low viral load have a high probability of having no lesion in the conization specimen. These patients should be excluded from immediate surgical excision and considered for follow-up.

Colposcopy Prediction of Progression in Human Papillomavirus Infections With Minor Cervical Lesions

OBJECTIVES: To evaluate the risk of progression to cervical intraepithelial neoplasia (CIN) grade 2 or 3 in women with positive human papillomavirus (HPV) testing and low-grade (low-grade squamous intraepithelial lesions), borderline (atypical squamous cells of undetermined significance), or no cervical lesions, and to determine the accuracy of initial colposcopy to predict progression. METHODS: Women with HPV infection and low-grade squamous intraepithelial lesions, atypical squamous cells, or normal cytology were recruited and grouped according to cytologic or histologic diagnosis. Exclusion criteria were histologic CIN 2 or 3, previous cervical cancer and HPV infection, cervical disease, or treatment for CIN 2 or 3 in the past 3 years. Four-hundred sixty-five women were included and monitored by cytology, Hybrid Capture-2 test, and colposcopy every 6 months. Colposcopy results were described as normal, with minor or major changes, and lesion size was recorded in quadrants. RESULTS: Forty-three women (9.3%) had progression to CIN 2 or 3. No significant differences were found in rate of progression between women with low-grade squamous intraepithelial lesions, atypical squamous cells, or negative results (8.2%, 13.4%, and 9.8%, respectively; P=.679). Neither colposcopy pattern (P=.284) nor lesion size (P=.170) at recruitment provided any information on the risk of progression. History of cervical lesion and worsening of the colposcopy pattern during follow-up were associated with progression (P<.001). CONCLUSION: Initial colposcopy findings do not provide relevant information on the risk of progression in HPV-positive women with minor or no cervical lesions. These women have a similar risk of progression and should benefit from the same follow-up strategies. LEVEL OF EVIDENCE: II

Clinical role of cervical cancer vaccination: When and whom to vaccinate?

The recent development of two highly effective vaccines against persistent infection by the 2 most important types of human papillomavirus (HPV) (16 and 18) and against high grade premalignant lesions (CIN2+) has opened a new scenario for the primary prevention of cervical cancer. The optimum target population for vaccination should be individually defined taking the following into account: 1) the efficacy of the vaccine, 2) the epidemiological context and 3) the vaccination programs available in each country. To achieve the maximum preventive benefits, the vaccine should be administered before the initiation of sexual relations. So, the HPV vaccine should be integrated in the school vaccination programs of adolescents together with other vaccines. The vaccination of sexually active women may considerably increase the speed with which results in the fight against this disease will be achieved. Developed countries will probably consider the vaccination of these women, although vaccination strategies and the efforts to reach this population will be conditioned by the resources of each country and by the estimations of the cost-efficacy relationship in each situation. Women with a previous history of premalignant cervical disease or with an abnormal screening test should not be excluded from the potential benefits which the vaccine may provide. There is no contraindication for the administration of the vaccine in immunosupressed women. However, it is still unknown under what specific circumstances of immunosuppression the immunogenicity of the vaccine may be affected and there are currently ongoing studies for an answer to this question.

Intraoperative post‐conisation human papillomavirus testing for early detection of treatment failure in patients with cervical intraepithelial neoplasia: a pilot study

To evaluate the feasibility and utility of intraoperative post‐conisation human papillomavirus (IOP‐HPV) testing and cytology to detect treatment failure in patients with cervical intraepithelial neoplasia grades 2–3 (CIN2–3).