Clinical performance of human papillomavirus E6 and E7 mRNA testing for high-grade lesions of the cervix (original) (raw)
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Aetiology, pathogenesis, and pathology of cervical neoplasia
Early epidemiological studies of cervical neoplasia suggested a causal relation with sexual activity and human papilloma-viruses (HPVs) have emerged as prime suspects as venerally transmitted carcinogens. HPVs fall into two broad camps: low risk types, associated with cervical condy-lomas and CIN 1; and high risk types (mostly 16 and 18), found in 50-80% of CIN 2 and CIN 3 lesions, and 90% of cancers. This association with cancer is very strong, with odds ratios of > 15 (often much higher) in case-control studies that are methodologically sound. An infrequently detected third group of intermediate risk type HPVs is associated with all grades of CIN and occasionally with cancers. HPVs have also been detected in a wide range of asymptomatic controls, indicating that other events are required for development of neoplasia such as viral persistence and/or altered expression of viral genes, often following integration of the viral genome. This leaves the two major viral oncogenes, E6 and E7, directly coupled to viral enhancers and promoters, allowing their continued expression after integration. High risk HPV E7 proteins bind and inactivate the Rb protein, whereas E6 proteins bind p53 and direct its rapid degradation. A range of putative cofactors has been implicated in progression: HLA type, immunosuppression, sex steroid hormones, and smoking; most of these cofactors appear to influence progression to CIN 3. The natural history includes progression to CIN 3 in 10% of CIN 1 and 20% of CIN 2 cases, whereas at least 12% of CIN 3 cases progress to inva-sive carcinoma. Cervical glandular intra-epithelial neoplasia (CGIN) often co-exists with squamous CIN, and the premalignant potential of high grade CGIN is not in doubt, but the natural history of low grade CGIN remains uncertain. A high proportion of CGIN lesions and adenocarcinomas are HPV positive, and HPV18 has been implicated more in glandular than in squamous lesions. A strong clinical case for the application of HPV typing of cells recovered from cervi-cal scrapes can be made; however, a rigorous cost-benefit analysis of introducing HPV typing into the cervical screening programme is required. Prophylactic and therapeutic HPV vaccines are under development. This article reviews the aetiol-ogy, pathogenesis, and pathology of cervical neoplasia, emphasising the role of HPVs. (J Clin Pathol 1998;51:96-103) It also includes several more recent developments. It is important to emphasise that the cervical screening programme aims to detect women who have an epithelial abnormality that might, if untreated, lead to the development of cervical carcinoma. The screening programme is not designed to detect small or early invasive carcinomas, but no screening system will detect all women at risk and it is inevitable that in a small proportion of smears, evidence of invasive cancer will be found. Cervical smears may also identify non-neoplastic epithelial changes, such as koilocy-tosis and multinucleation, which are believed to be associated with infection by human pap-illomavirus (HPV), which is strongly suspected to play an aetiological role in cervical neopla-sia. Analysis of the eVectiveness of the cervical screening programme and its further development should be based on a clear understanding of the aetiology, pathogenesis, and pathology of cervical neoplasia. Aetiology of cervical neoplasia Early epidemiological studies of cervical neo-plasia suggested a direct causal relation with sexual activity, measured as multiple sexual partners and early onset of sexual activity. 1 2 A further risk factor was exposure to the "high risk man", characterised by a history of promiscuous sexual activity and/or sexual exposure to a partner who develops genital neoplasia. Over the past 20 years the search for venereally transmitted carcinogens has included components of semen and various viruses, including Epstein-Barr virus, cytome-galovirus, and herpes simplex II virus (HSV), but without success. The lack of persistent HSV viral DNA, RNA or protein in most neo-plastic lesions, and the equivocal findings in prospective studies of HSV in cervical cancers do not support a key aetiological role for HSV in cervical cancer. 3 However, HPVs have emerged as prime suspects, being at the scene of the crime carrying the tools to start the job: high risk HPVs are consistently found in over 90% of cervical cancers and they possess transforming viral oncogenes (E6 and E7).
Current scenario of biomarkers in cervical cancer and oncogenesis by HPV
Jornal Brasileiro de Doenças Sexualmente Transmissíveis, 2019
Cervical cancer (CC) is related to HPV infection and represents the third cause of cancer in women. Annually, more than 500,000 new cases are reported worldwide, with significant death rates. It develops due to genetic and epigenetic alterations that control cell growth and differentiation, and may cause death. These alterations induce uncontrolled cell division and invasion of cervical tissue have severe consequences to women's health (1). CC incidence and mortality drop considerably since the implementation of screening tests and vaccination strategies. Nevertheless, CC continues to have a high incidence, mainly in low-income countries, where these programs do not cover territorial frontiers and there is lack of resources to implement vaccination or screening tests. Oncogenic HPV types reached 25% of cases in Brazil over the last years (2) , and there was no modification on HPV types after four years of the vaccination program, according to Tota et al. (3). Usually, screening tests in Brazil cover women from 25 to 64 years old. According to Teixeira et al. (4) , rates of CC under the age of 25 tend to increase, and women over 64 achieved roughly 20% of CC on research of Brazilian women from two high-income cities. HPV 16 and 18 are the predominant genotypes linked to progression to invasive cancer. HPV uses evasion mechanisms of the immune system in early and late stages of the infection, causing its persistence in cutaneous and mucosal tissues. Its continuous expression of viral proteins E6 and E7 contribute to disease progression (5). Starting lesions are well defined and classified into cervical intraepithelial neoplasm 1, 2, and 3, with grade 3 being the highest level of evolution. Factors such as age, smoking, sexually transmitted disease, long-term oral contraceptive use, and parity are associated to a higher risk of cervical cancer development (6,7). Many CIN 1, 2, and some CIN 3 lesions spontaneously revert. Even though, treatment is still needed, because they have high chances to progress (8) .
Human papillomavirus testing and molecular markers of cervical dysplasia and carcinoma
Cancer, 2007
Cervical cancer is the second most common cancer in women worldwide. Human papillomavirus (HPV) is the etiologic agent for the vast majority of premalignant and malignant lesions, and high-risk HPV types can be detected in almost all cases of cervical dysplasia and carcinoma. HPV testing has been widely adopted for the triage of patients after a cervical cytology screening test (Papanicolaou smear or liquid-based cervical cytology such as ThinPrep or SurePath) interpretation of atypical squamous cells of undetermined significance (ASCUS), and HPV testing is increasingly used for screening in conjunction with cervical cytology. Although cervical cytology is a highly effective screening test for cancer, it has limited specificity for clinically significant lesions in cases with low-grade cytologic abnormalities. Up to a quarter of all patients may have a false-negative result on the basis of cervical cytology testing alone. This review focuses on HPV testing methods and molecular markers and their clinical relevance. HPV testing and surrogate molecular markers of HPV infection (p16 INK4a ) may help identify cases that are associated with underlying high-grade premalignant or malignant lesions and may also reduce aggressive treatment of patients with low-grade lesions.
Cervical carcinoma is one of the major consequences of human papillomavirus (HPV) infections. Although HPV infections of cervix do not always progress to cancer, 90% cases of cervical cancer have been found associated with high risk HPV (hrHPV) infection. Usually, HPV infection is asymptomatic; however, this asymptomatic infection can cause abnormal changes in cervix ultimately leading to cancer development. These changes can be detected by the application of screening tests at regular time intervals. For this purpose, morphological, cytological, and DNA based techniques are available. Nevertheless, abnormal screening tests have only the predictive value for precancerous lesions and thus require further evaluation which is usually done by using diagnostic techniques. So far, colposcopy and histological examination alone were considered as the gold standards for cervical cancer diagnosis. Currently, some tests based on expression level of host cell biomarkers are also being used along with histology for diagnostic purpose. Albeit, these tests have significant specificity and sensitivity values but they are unable to suggest a particular viral genotype involved in infection. Diagnostic methods such as PCR, HPV genotyping assays, microarray, and mRNA based assays are useful to predict the genotypes as well as the quantity of viral load in a host cell. Similarly, these diagnostic procedures have high specificity and sensitivity ranges. However, only few of them are practiced commonly, as approval of these tests as routine diagnostic tests requires clinical validation and cost effectiveness.
Detection and Clinical Management of Cervical Pathology in the Era of HPV
Current Obstetrics and Gynecology Reports, 2014
While infection with high-risk (HR) human papillomavirus (HPV) is central to cervical carcinogenesis, natural history studies show that both low-and high-grade cervical intraepithelial neoplasia (CIN) lesions are very early manifestations of HR-HPV infection. Most high-and low-grade lesions are self limited, and only those HR-HPV infections capable of persisting for decades are at risk of progression. Our new understanding of the natural history of HPV associated lesions has dramatically changed cervical cancer screening, classification and management of cervical lesions. As an increasing proportion of women are vaccinated against those oncogenic-HPVs responsible for most cervical cancers, the positive predictive value of cytology and HPV testing for identification of women at risk for cancer will decrease. New biomarkers, capable of identifying those high-grade lesions which are truly at risk of progression and need treatment, will need to be developed to serve as adjuncts to morphology and patient management.
British journal of cancer, 2000
Human papillomavirus (HPV) testing has been suggested for primary screening of cervical cancer. Prediction of future high-grade cervical lesions is crucial for effectiveness and cost. We performed a case control study in a retrospective cohort of women with at least two cervical smears, all but the last one being negative, from the organized cervical screening programme in Florence, Italy. We searched for high-risk HPV in all previous, archival, smears from cases (new histologically confirmed cervical intraepithelial neoplasia (CIN) grade II or worse) and in one previous smear from each control (last smear cytologically normal, matched by age and interval (latency) from last smear). We applied polymerase chain reaction (PCR), and the b-globin gene was used as a DNA preservation marker. High-risk HPV was identified in 71/92 (77.17%) previous smears from 79 cases and 17/332 controls (5.12%). The odds ratio (OR) was 63.76 (95% CI 30.57-132.96). Among cases the proportion of HPV-positiv...
Cancer Research, 1999
Cervical cancer emerges from cervical intraepithelial neoplasia (CIN) induced by high-risk HPV (HR-HPV) infections. However, the vast majority of CIN lesions regresses spontaneously, and only a few lesions persist or progress to invasive carcinoma. On the basis of morphological criteria, it is not possible to differentiate high-grade lesions that will regress or persist from those that inevitably will progress to invasive cancers. In most cervical carcinomas, human papillomavirus (HPV) genomes are integrated into host cell chromosomes and transcribed into mRNAs encompassing viral and cellular sequences. In contrast, in early preneoplastic lesions, HPV genomes persist as episomes, and derived transcripts contain exclusively viral sequences. Thus, detection of HPV transcripts derived from integrated HPV genomes may specifically indicate both CIN lesions at high risk for progression as well as invasive cervical cancers. Here, we established a protocol for the amplification of papillomavirus oncogene transcripts (APOT) from cervical specimens that allows us to distinguish episome-from integrate-derived HPV mR-NAs. Cervical swab and biopsy samples from 549 patients attending outpatient clinics for cervical dysplasia were screened for the presence of HPV DNA, and 155 samples that were positive for either HPV type 16 (n ؍ 143) or 18 (n ؍ 12) were subjected to the APOT assay. In samples derived from normal cervical epithelia (n ؍ 19) or low-grade cervical lesions (CIN I, n ؍ 10), no integrate-derived HPV transcripts were found. In contrast, in 1 (5%) of 22 samples derived from CIN II lesions, in 10 (16%) of 64 samples from patients with CIN III lesions, and in 35 (88%) of 40 samples from patients with cervical cancer, integrate-derived HPV transcripts were detected. Thus, detection of integrate-derived HPV transcripts in cervical swabs or biopsy specimens by the APOT assay points to advanced dysplasia or invasive cervical cancer.
Determination of malignant potential of cervical intraepithelial neoplasia
Tumor Biology, 2015
Basic diagnostic procedures in cervical cancer screening are able to set the diagnosis but they do not provide any information about the biological nature and behavior of lesions. The causal link of HPV infection and cervical cancer and discoveries of complex interactions between host and HPV genome opened new possibilities in molecular diagnostics. HPV DNA analysis, determination of viral load, detection of E6 and E7 mRNA transcripts, identifying of methylation profiles, genomic changes, miRNAs, and telomerase activity should be the right choice for exact diagnostics and prediction of behavior of premalignant lesions of the cervix. These findings set a completely new light not only in diagnostic but also in management and treatment of cervical dysplasia and cervical cancer.
Detection of HPV-induced Cervical (Pre) Neoplastic Lesions
Applied Immunohistochemistry & Molecular Morphology, 2008
The aim of this study was to evaluate the usefulness of a panel of biomarkers in the characterization of human papillomavirus (HPV)-induced cervical lesions. Management of these lesions depends on their histologic confirmation. Misinterpretation especially for benign mimics results in a significant diagnostic disagreement. For these reasons, a continuous effort is still needed to discover surrogate markers, which could support the final diagnosis. Archival biopsies of normal ectocervical and endocervical tissues, squamous metaplasia, cervical intraepithelial neoplasia (CIN), squamous cell carcinoma, adenocarcinoma in situ, and adenocarcinoma were retrieved to perform a tissue microarray (TMA). A panel of markers was tested on the TMA obtained slides by in situ hybridization (HPV DNA) and immunohistochemistry (p16, involucrin, Ki-67, and HPV L1 proteins). The sensitivity to detect high-risk HPV DNA increased with lesion's severity. In situ hybridization signals suggesting integrated viral physical status predominated in CIN II/III, squamous cell carcinoma, and glandular (pre) neoplastic lesions. The p16 and Ki-67 protein expression increased from CIN I to CIN III and to infiltrative lesions. Involucrin positivity was better appreciated in well-differentiated diagnostic entities (ectocervix, mature metaplasia, and CIN I). HPV L1 antibody detected the viral capsid protein in a low proportion of CIN I and II. In conclusion, using a panel of cervical biomarkers improves the final reporting of various HPV-induced epithelial lesions. Carefully constructed TMA with single spots of 1-mm diameter are powerful tools, which have a high reliability in representing full tissue sections.