Neerja Bhatla

Worldwide human papillomavirus genotype attribution in over 2000 cases of intraepithelial and invasive lesions of the vulva

BACKGROUND Human papillomavirus (HPV) contribution in vulvar intraepithelial lesions (VIN) and invasive vulvar cancer (IVC) is not clearly established. This study provides novel data on HPV markers in a large series of VIN and IVC lesions. METHODS Histologically confirmed VIN and IVC from 39 countries were assembled at the Catalan Institute of Oncology (ICO). HPV-DNA detection was done by polymerase chain reaction using SPF-10 broad-spectrum primers and genotyping by reverse hybridisation line probe assay (LiPA25) (version 1). IVC cases were tested for p16(INK4a) by immunohistochemistry (CINtec histology kit, ROCHE). An IVC was considered HPV driven if both HPV-DNA and p16(INK4a) overexpression were observed simultaneously. Data analyses included algorithms allocating multiple infections to calculate type-specific contribution and logistic regression models to estimate adjusted prevalence (AP) and its 95% confidence intervals (CI). RESULTS Of 2296 cases, 587 were VIN and 1709 IVC. HPV-DNA was detected in 86.7% and 28.6% of the cases respectively. Amongst IVC cases, 25.1% were both HPV-DNA and p16(INK4a) positive. IVC cases were largely keratinising squamous cell carcinoma (KSCC) (N=1234). Overall prevalence of HPV related IVC cases was highest in younger women for any histological subtype. SCC with warty or basaloid features (SCC_WB) (N=326) were more likely to be HPV and p16(INK4a) positive (AP=69.5%, CI=63.6-74.8) versus KSCC (AP=11.5%, CI=9.7-13.5). HPV 16 was the commonest type (72.5%) followed by HPV 33 (6.5%) and HPV 18 (4.6%). Enrichment from VIN to IVC was significantly high for HPV 45 (8.5-fold). CONCLUSION Combined data from HPV-DNA and p16(INK4a) testing are likely to represent a closer estimate of the real fraction of IVC induced by HPV. Our results indicate that HPV contribution in invasive vulvar cancer has probably been overestimated. HPV 16 remains the major player worldwide.

Cardiac disease in pregnancy

Objectives: To evaluate the maternal and fetal outcome of pregnancies complicated by cardiac disease in a developing country. Methods: A retrospective analysis was carried out of 207 pregnancies in women with cardiac disease who delivered at ≥28 weeks of gestation from June 1994 through December 2000 at a tertiary care center. Results: Rheumatic heart disease (n=183, 88%) with isolated mitral stenosis (n=71) was the predominant cardiac problem. Septal defects were the most common form of congenital heart disease (n=24). In 28 (13.52%) women, the diagnosis of cardiac disease was made during pregnancy. Cardiac complications were noted in 62 (29.95%) and fetal complications in 42 (20.28%) pregnancies. Patients in NYHA class I/II (n=175, 84.54%) had fewer maternal complications and their babies had a higher birth weight than those in NYHA class III/IV (n=32, 15.45%). Cardiac intervention was performed prior to pregnancy in 111 (60.65%) patients with rheumatic heart disease: PTMC/CMV in 73 and valve replacement (VR) in 38. Maternal and fetal outcome was better in patients with prosthetic valves (n=38) and the majority (97.4%) of them remained in NYHA class I/II. Cardiac intervention was safely carried out during pregnancy in 10 women (PTMC in 7, CMV in l, and VR in 2). One of them developed congestive cardiac failure during labor. None of the newborns of the 41women who had received anticoagulants had any congenital malformation. Conclusions: Rheumatic heart disease was the predominant type. Patients in NYHA class I/II had a better maternal and fetal outcome than those in NYHA class III/IV. Surgical correction of the cardiac lesion prior to pregnancy was associated with better pregnancy outcome. Pregnant women with prosthetic valves tolerated pregnancy well.

A meta-analysis of human papillomavirus type-distribution in women from South Asia: implications for vaccination.

OBJECTIVE To determine human papillomavirus (HPV) prevalence and type-distribution in women from South Asia, with and without cervical lesions, in order to estimate the impact of an HPV 16/18 prophylactic vaccine in this region and to assess additional types that should be incorporated in new vaccines. METHODS A meta-analysis was conducted that included studies using polymerase chain reaction to detect HPV-16, -18, -6, -11 and at least one other HPV type, with a minimum of 20 cases in each grade of lesion. Total as well as type-specific prevalence of various HPV types were estimated, stratified by cervical lesion grade, using Stata 9.0 software package. RESULTS Nine studies from India fulfilled the inclusion criteria. A total of 558, 52, 52 and 3061 women, respectively with invasive cervical cancer (ICC), high-grade squamous intraepithelial lesions (HSIL), low-grade squamous intraepithelial lesions (LSIL) and normal cytology/histology were included. Overall HPV prevalence was 94.6%, 86.5%, 65.4% and 12.0% in women with ICC, HSIL, LSIL and normal cytology/histology, respectively. In ICC, HPV-16 was the predominant type (64.8%), followed by HPV-18, -45, -33, -35, -58, -59 and -31. The estimated HPV-16/18 positive fraction was 78.9% in women with ICC (87.7% in North and 77.2% in South India), 61.5% with HSIL, 30.8% with LSIL and 3.9% in women with normal cytology/histology. There was no difference in overall HPV prevalence in cervical cancer between North and South India (P=0.063). However, HPV-16 and -45 appeared to be more prevalent in North India (P=0.018 and 0.013, respectively), while HPV-35 appeared to be more prevalent in South India (P=0.033). CONCLUSION It is estimated that HPV-16/18 vaccines will provide over 75% protection against ICC in South Asia. HPV-45, -33, -35 and -58 account for an additional 20% of cervical cancer in this region. The addition of these additional HPV types in a second-generation vaccine could provide optimal cervical cancer prevention in this region.

Human Papillomavirus Infection and Cervical Cancer Prevention in India, Bangladesh, Sri Lanka and Nepal

Although one-third of the world cervical cancer burden is endured in India, Bangladesh, Nepal and Sri Lanka, there are important gaps in our knowledge of the distribution and determinants of the disease in addition to inadequate investments in screening, diagnosis and treatment in these countries. Prevalence of human papillomavirus (HPV) infection among the general populations varies from 7-14% and the age-specific prevalence across age groups is constant with no clear peak in young women. This observation may be the result of a low clearance rate of incident infections, frequent re-infection/reactivation, limited or no data in target high-risk age groups (teenagers), and sexual behavioural patterns in the population. High-risk HPV types were found in 97% of cervical cancers, and HPV-16 and 18 were found in 80% of cancers in India. Beyond research studies, demonstration projects and provincial efforts in selected districts, there are no serious initiatives to introduce population-based screening by public health authorities in these countries. Cervical cancer is a relatively neglected disease in terms of advocacy, screening and prevention from professional or public health organizations. Cytology, HPV testing and visual screening with acetic acid (VIA) or Lugols iodine (VILI) are known to be accurate and effective methods to detect cervical cancer and could contribute to the reduction of disease in these countries. While HPV vaccination provides hope for the future, several barriers prohibit the introduction of prophylactic vaccines in these countries such as high costs and low public awareness of cervical cancer. Efforts to implement screening based on the research experiences in the region offer the only currently viable means of rapidly reducing the heavy burden of disease.

Immunogenicity and HPV infection after one, two, and three doses of quadrivalent HPV vaccine in girls in India: a multicentre prospective cohort study

Summary Background An increase in worldwide HPV vaccination could be facilitated if fewer than three doses of vaccine are as effective as three doses. We originally aimed to compare the immunogenicity and frequency of persistent infection and cervical precancerous lesions caused by vaccine-targeted HPV after vaccination with two doses of quadrivalent vaccine on days 1 and 180 or later, with three doses on days 1, 60, and 180 or later, in a cluster-randomised trial. Suspension of the recruitment and vaccination due to events unrelated to our study meant that some enrolled girls could not be vaccinated and some vaccinated girls received fewer than the planned number of vaccinations by default. As a result, we re-analysed our data as an observational cohort study. Methods Our study was designed to be done in nine locations (188 clusters) in India. Participants were unmarried girls aged 10–18 years vaccinated in four cohorts: girls who received three doses of vaccine on days 1, 60, and 180 or later, two doses on days 1 and 180 or later, two doses on days 1 and 60 by default, and one dose by default. The primary outcomes were immunogenicity in terms of L1 genotype-specific binding antibody titres, neutralising antibody titres, and antibody avidity after vaccination for the vaccine-targeted HPV types 16, 18, 6, and 11 and incident and persistent infections with these HPVs. Analysis was per actual number of vaccine doses received. This study is registered with ISRCTN, number ISRCTN98283094; and with ClinicalTrials.gov, number NCT00923702. Findings Vaccination of eligible girls was initiated on Sept 1, 2009, and continued until April 8, 2010. Of 21 258 eligible girls identified at 188 clusters, 17 729 girls were recruited from 178 clusters before suspension. 4348 (25%) girls received three doses, 4979 (28%) received two doses on days 1 and 180 or later, 3452 (19%) received two doses at days 1 and 60, and 4950 (28%) received one dose. Immune response in the two-dose HPV vaccine group was non-inferior to the three-dose group (median fluorescence intensity ratio for HPV 16 1·12 [95% CI 1·02–1·23] and for HPV 18 1·04 [0·92–1·19]) at 7 months, but was inferior in the two-dose default (0·33 [0·29–0·38] for HPV 16 and 0·51 [0·43–0·59] for HPV 18) and one-dose default (0·09 [0·08–0·11] for HPV 16 and 0·12 [0·10–0·14] for HPV 18) groups at 18 months. The geometric mean avidity indices after fewer than three doses by design or default were non-inferior to those after three doses of vaccine. Fewer than three doses by design and default induced detectable concentrations of neutralising antibodies to all four vaccine-targeted HPV types, but at much lower concentration after one dose. Cervical samples from 2649 participants were tested and the frequency of incident HPV 16, 18, 6, and 11 infections was similar irrespective of the number of vaccine doses received. The testing of at least two samples from 838 participants showed that there was no persistent HPV 16 or 18 infections in any study group at a median follow-up of 4·7 years (IQR 4·2–5·1). Interpretation Despite the limitations imposed by the suspension of the HPV vaccination, our findings lend support to the WHO recommendation of two doses, at least 6 months apart, for routine vaccination of young girls. The short-term protection afforded by one dose of HPV vaccine against persistent infection with HPV 16, 18, 6, and 11 is similar to that afforded by two or three doses of vaccine and merits further assessment. Funding Bill & Melinda Gates Foundation.

Management and outcome of pregnancies complicated with adnexal masses

Abstract Our purpose was to evaluate the pathologic features and outcome of pregnancies that were complicated with adnexal masses and were managed surgically. A review of patients who had persistent adnexal masses during pregnancy and needed surgical removal of tumours was performed from January 1998 to April 2001. There were 14 cases of persistent adnexal masses identified among 2000 deliveries. There were 13 patients who had surgical interventions: nine (69.2%) had surgery during ongoing pregnancy (at mean gestational age 17±3.7 weeks), two (15.3%) with caesarean section, one (7.6%) after evacuation of missed abortion and one (7.5%) after delivery. Out of 13, ten (76.9%) were benign [mature cystic teratoma, six (46.9%); serous cyst adenoma, two (15.3%); mucinous cyst adenoma, one (7.6%); paratubal cyst, one (7.6%)] and three (23%) were malignant (one immature teratoma, one papillary cyst adenocarcinoma and one krukenberg tumour]. Both patients operated on after 24 weeks had preterm delivery. The worst outcome in the form of PPROM and preterm delivery at 28 weeks occurred in a patient who underwent emergency surgery. The incidence of malignancy was four- to fivefold greater in our series than reported in the literature. Ultrasound was unable to distinguish malignant cases. Pregnancy outcome was poorer if surgical intervention was done after >24 weeks and that, too, was done as emergency surgery.

Can human papillomavirus DNA testing of self-collected vaginal samples compare with physician-collected cervical samples and cytology for cervical cancer screening in developing countries?

BACKGROUND To determine human papillomavirus (HPV) types by polymerase chain reaction (PCR)-reverse line blot assay and examine the concordance between HPV by Hybrid Capture 2 (HC2) and PCR on self-collected vaginal and physician-collected cervical samples and cytology. METHODS This was a cross-sectional study of 546 sexually active women aged > or =30 years with persistent vaginal discharge, intermenstrual or postcoital bleeding or an unhealthy cervix. Participants self-collected vaginal samples (HPV-S) and physicians collected cervical samples for conventional Pap smear and HPV DNA (HPV-P) testing and performed colposcopy, with directed biopsy, if indicated. HPV testing and genotyping was done by HC2 and PCR reverse line blot assay. Concordance between HC2 and PCR results of self- and physician-collected samples was determined using a Kappa statistic (kappa) and Chi-square test. RESULTS Complete data were available for 512 sets with 98% of women providing a satisfactory self-sample. PCR detected oncogenic HPV in 12.3% of self- and 13.0% of physician-collected samples. Overall, there was 93.8% agreement between physician-collected and self-samples (kappa=76.31%, 95% confidence interval [CI]: 64.97-82.29%, p=0.04)-complete concordance in 473 cases (57 positive, 416 negative), partial concordance in seven pairs and discordance in 32 pairs. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of self-sampling for detection of cervical intraepithelial neoplasia (CIN)2+ disease were 82.5%, 93.6%, 52.4% and 98.4%, respectively; for physician-sampling they were 87.5%, 93.2%, 52.2% and 98.9%, respectively; and for cytology they were 77.5%, 87.3%, 34.1% and 97.9%, respectively. Concordance between HC2 and PCR was 90.9% for self-samples (kappa=63.7%, 95% CI: 55.2-72.2%) and 95.3% for physician-collected samples (kappa=80.4%, 95% CI: 71.8-89.0%). CONCLUSIONS Self-HPV sampling compares favourably with physician-sampling and cytology. A rapid, affordable, HPV self-test kit can be used as the primary method of cervical cancer screening in low-resource situations.

Immunogenicity and safety of human papillomavirus‐16/18 AS04‐adjuvanted cervical cancer vaccine in healthy Indian women

Aim:  India has the highest number of annual incident cases and mortality rates for cervical cancer worldwide. This study was conducted to assess the immunogenicity and safety of human papillomavirus (HPV)‐16/18 AS04‐adjuvanted cervical cancer vaccine in healthy Indian women aged 18–35 years old.

Evaluation of cervical screening in rural North India.

To assess the accuracy of cervical screening with visual inspection and cytology testing, and the cure rate of cervical intraepithelial neoplasia (CIN) after treatment, in a rural population in North India.

Human papillomavirus-type distribution in women with and without cervical neoplasia in north India.

Our objective was to determine the human papillomavirus (HPV)-type prevalence in cervical samples in women with and without cervical neoplasia in an opportunistic hospital-based cancer-screening program. A cross-sectional study of 524 women presenting from January 2003 through June 2005 with symptoms of persistent vaginal discharge, intermenstrual bleeding, and postcoital bleeding or detected to have an unhealthy cervix underwent HPV genotyping by consensus polymerase chain reaction and reverse line-blot hybridization assay, conventional Pap smear, and colposcopy, with directed biopsy from all lesions detected. The prevalence rates of HPV infection among women with normal, low-grade cervical neoplasia (CIN 1) and high-grade CIN (>CIN2) were found to be 7.6%, 42.3%, and 87.5%, respectively. Seventeen high-risk and 6 low-risk HPV types were identified by the reverse line-blot assay. Multiple infections were seen in 20% of women. In normal women, the 6 commonest types were HPV-16, HPV-89, HPV-39, HPV-52, HPV-62, and HPV-18, whereas in high-grade disease, these were all high-risk types HPV-16, HPV-18, HPV-33, HPV-39, HPV-35, and HPV-56. HPV-16 was the commonest type in all groups, seen in 49.4% cases overall and in 74.3% of high-grade squamous intraepithelial lesion. It was followed by HPV-18 (7.4%) and HPV-33 and HPV-39 (4.9% each). HPV-89 was the commonest low-risk type (9.9%). HPV-16/18 were associated with 34.3% of normal, 45.4% of low-grade and 65.7% of high-grade lesions. A wide spectrum of HPV types is seen in north Indian women, with the majority being HPV-16 in all grades of histology. A vaccine against HPV-16 and HPV-18 could prevent two thirds of cases of high-grade cervical neoplasia.