Extending Human Papillomavirus (HPV) vaccination beyond female adolescents and after treatment for high grade CIN: the Italian HPV Study Group (IHSG) review and position paper.

OBJECTIVE: Human PapillomaVirus (HPV) vaccination has been introduced in recent years in clinical practice as the most effective primary prevention strategy for cervical cancer and HPV-induced lesions, either pre-malignant or benign. Since its introduction, HPV vaccination has been progressively demonstrated as extremely effective in preventing extra-genital and male diseases also; furthermore, non only adolescents but adult subjects have been investigated and reported as positively responding to vaccine immunostimulation. More recently, effectiveness of post-treatment vaccine administration has been preliminarily investigated with very promising results in terms of decreased recurrences. On this basis, we report an Italian-focused picture of the state of the art and take a position in favour of the extension of HPV vaccination to male adolescents, to older age groups and to already treated subjects.

HPV-DNA testing for cervical cancer precursors: from evidence to clinical practice.

The large amount of literature published over the last two decades on human papillomavirus (HPV)-DNA testing has definitely demonstrated the association between high-risk viral genotypes (hrHPV) and cervical cancer. Moreover, hrHPV-DNA testing has shown excellent performance in several clinical applications, from screening settings to the follow-up of treated patients, compared to conventional cytology or colposcopy options. On the other hand, when a huge number of reports are published on the same subject in a relatively short period of time, with many variations in settings, study designs and applications, the result is often confusion and decreased comprehension by readers. In daily office practice, several different situations (in symptomatic or asymptomatic women) can be positively managed by the correct use of hrHPV-DNA testing. Validated hrHPV-DNA testing and, specifically, the HC2® assay, due to its excellent sensitivity and negative predictive value together with optimal reproducibility, currently represent a powerful tool in the clinician's hands to optimally manage several situations related to HPV infection and the potential development of cervical cancer.

Second-line treatment with intravenous gemcitabine and oral etoposide in platinum-resistant advanced ovarian cancer patients: results of a phase II study.

OBJECTIVE: The outcome of advanced ovarian cancer patients has not significantly improved since the introduction of platinum. One of the major reasons for this failure is the lack of an effective second-line treatment. In this phase II trial we tested the combination of gemcitabine and etoposide in 2 different groups of patients. Group 1 consisted of patients showing disease progression or relapse within 6 months of first-line platinum-based chemotherapy. Group 2 comprised heavily pretreated patients showing progression during the last chemotherapy attempt. METHODS: Thirty-four patients were enrolled. Gemcitabine was administered at a dose of 1,000 mg/m(2) on days 1 and 8 and etoposide was administered orally at 100 mg/day on days 8-12 for 6 courses. RESULTS: Eighteen patients (52.9%) had an objective response and the median duration of the response was 10.3 months. Our chemotherapy regimen showed a low toxicity and good patient compliance. In 5 patients the treatment had to be delayed and in only 2 patients it was discontinued. CONCLUSIONS: The combination of gemcitabine and oral etoposide seems to be a safe and effective second-line treatment for platinum-resistant ovarian cancer patients. Additional data on larger series are warranted to better define the activity of this combination regimen.

Cytological analysis of the distension fluid used during diagnostic office hysteroscopies in patients with suspected endometrial pathology.

OBJECTIVE: Evaluation of the feasibility and usefulness of cytological analysis of the distension fluid used during diagnostic office hysteroscopy in patients with suspected endometrial pathology. METHODS: In 243 consecutive patients undergoing diagnostic hysteroscopy for suspected endometrial pathology a few milliliters of the distension medium used for uterine visualization were collected and sent for cytological analysis. Findings of these "endometrial washings" were compared to visual hysteroscopic impression, endometrial biopsy and uterine histology--when available. RESULTS: Endometrial washings were considered adequate in 227 patients (93.4%). In 12 cases (5.3%) atypical cells were detected: all of these presented either atypical complex hyperplasia or endometrial cancer at the final histological evaluation of the uterus. Four of the 16 (25%) patients diagnosed with endometrial cancer or atypical complex hyperplasia at the final histopathological analysis of the uterus had inadequate washings. No patient with cancer or atypical hyperplasia had negative cytology. CONCLUSIONS: Collection and analysis of the distension fluid is feasible and, when positive, has a remarkable value in the diagnosis of endometrial cancer and its precursors.

Vaginal micronized progesterone in continuous hormone replacement therapy. A prospective randomized study.

BACKGROUND: In the non-hysterectomized post-menopausal woman undergoing estrogen replacement therapy, the co-administration of a progestogen is mandatory to counteract the estrogenic proliferative effect on the endometrium. Metabolic and tissue effects of the various progestins vary with dosage and route of administration. This study was performed to evaluate the effects of selected progestins on the lipidic profile and endometrial morphology. METHODS: This is a prospective randomised study including 60 post-menopausal women undergoing hormonal replacement therapy (HRT). All patients received transdermic ethinil-estradiol in a continuous schedule. The utilized progestogens were: medroxyprogesterone acetate (MPA) 10 mg p.o. 12 days/month, transdermic nor-ethisterone acetate (NETA) 0.25 mg integrated in the ethinil-estradiol patches for the last two weeks of each cycle, micronized progesterone (MP) 100 mg transvaginally 12 days/month. RESULTS: None of the tested protocols significantly altered the lipidic profile of this group of patients. We noticed different effects on the estrogen stimulated endometrium elicited by the different progestinic regimens. While the cyclic administration of oral MPA or transdermic NETA more frequently resulted in endometrial atrophy, the trans-vaginal administration of MP more often induced (p<0.005 at six-month and p <0.001 after 1 year) a functional-like secretive endometrium. CONCLUSIONS: Micronized progesterone, cyclically administered in the form of a vaginal cream, offers an acceptable and effective alternative for women on continuous HRT wishing to maintain their monthly cycle.

Effects of human papillomavirus-associated cells on human immunodeficiency virus gene expression.

OBJECTIVE: To examine the effects of soluble factors secreted by human papillomavirus (HPV)-associated cells on human immunodeficiency virus (HIV) expression. METHODS: Supernatants collected from cultured cervical biopsies and cervical cancer cell lines, and HPV-immortalized and normal keratinocytes were tested for the ability to induce HIV p24 production in two cell lines that contained latent HIV (the U1 monocytic line and the ACH-2 T cell line). Levels of HIV p24 were measured by enzyme-linked immunosorbent assay (ELISA). Culture supernatants were also assayed for the inflammatory cytokines interleukin 6, tumor necrosis factor, and interleukin 1 beta by ELISA. RESULTS: Supernatants from all epithelial cells tested upregulated HIV p24 expression in the U1 line but not in the ACH-2 cells. Only differentiated normal keratinocytes induced p24 production by ACH-2 cells. Neutralization of the cytokines, particularly interleukin 6, partially reduced the level of HIV-inducing activity in the culture supernatants. Additionally, cervical biopsies from HIV-infected women cultured in vitro also were able to induce HIV in U1 cells but not ACH-2 cells. CONCLUSIONS: Our results suggest that HPV infection of the cervix might influence HIV pathogenesis by inducing the production of immune and inflammatory factors that enhance HIV expression.

Management of the abnormal papanicolaou smear during pregnancy: lessons for quality improvement.

OBJECTIVE: Our goal in this study was to evaluate the management of pregnant patients with abnormal Papanicolaou smears. MATERIALS AND METHODS: We reviewed the records of 292 patients undergoing colposcopy to evaluate abnormal cervical cytology during pregnancy. RESULTS: A total of 32 (11%) of the subjects had Papanicolaou smears demonstrating atypical glandular cells of undetermined significance; 178 (61%) had low-grade squamous intraepithelial lesions; 69 (23.6%) had high-grade squamous intraepithelial lesions; and 2 (1%) had a malignancy. The first colposcopy was performed most commonly during gestational week 24. Colposcopy showed findings consistent with minor changes in 154 cases (53%) and with major changes in 61 (21%). Only 27 patients (9% of the total) underwent a colposcopically directed biopsy, and 51 (83.6%) of the 61 patients with a colposcopic impression of cervical intraepithelial neoplasia grade 2 or greater did not undergo biopsy. Only 24 (26%) of the 91 patients scheduled for follow-up colposcopy during pregnancy complied, and 123 of the 292 patients (42%) returned for follow-up examinations after delivery. Four patients had an invasive cervical carcinoma diagnosed in the 12 months immediately after delivery. Although the first intrapregnancy colposcopy in two of these patients noted findings consistent with cervical intraepithelial neoplasia grade 2 or greater, none of the four underwent biopsy during pregnancy. CONCLUSIONS: Evaluation of cytological abnormalities is frequently suboptimal during pregnancy. The threshold for colposcopically directed biopsy is often modified during pregnancy in a way that may be harmful to the patient. Extra effort is needed to tailor follow-up to the patient's need and to improve patient compliance.

Endogenous versus exogenous IL-10 in postoperative intraperitoneal adhesion formation in a murine model.

BACKGROUND: Modulation of the immune response to peritoneal injury may prevent postoperative adhesion formation. Exogenous interleukin-10 (IL-10) limits postoperative adhesion formation. The objective of the present study is to determine (I) the IL-10 dose most effective at adhesion prevention, (II) the presence of endogenous IL-10 in peritoneal fluid, and (III) the ability of an anti-IL-10 monoclonal antibody to modify postoperative intraperitoneal adhesion formation. MATERIALS AND METHODS: Within parts I, II, and III of the study 8-week-old Swiss Webster mice were randomized to have no surgery or to undergo a standardized adhesion-inducing peritoneal injury. Animals were further randomized to different dosing schedules of IL-10 (10 ng/kg to 100 micrograms/kg; part I), different times of euthanasia and peritoneal lavage after surgery (part II), or intraperitoneal (i.p.) treatment with phosphate-buffered saline vehicle (1 ml), IL-10 (1 microgram/kg), or anti-IL-10 (1 microgram/kg; part III). All i.p. injections were given immediately after surgery and then every 24 hr for a total of four injections. Animals were sacrificed 7 days after surgery and adhesion formation was assessed. RESULTS: Maximal adhesion-limiting effects of exogenons IL-10 were reached at doses of 1 microgram/kg. Mean detectable endogenous IL-10 levels in the peritoneal fluid varied from 145 to 220 pg/ml throughout the postoperative course. There were significant (P < 0.0005) differences in adhesion scores between mice treated with IL-10 (3.39; 95% CI 0.39-6.39) or PBS postoperatively (7.46; 95% CI 5.28-9.64), untreated surgical control animals (5.98; 95% CI 2.55-9.41), or anti-IL-10-treated animals (10.11; 95% CI 8.50-11.72). CONCLUSION: Interleukin 10 is effective at reducing postoperative intraperitoneal adhesion formation. Low levels of endogenous IL-10 are detectable in peritoneal fluid throughout the postoperative course, not correlating with adhesion scores. Anti-IL-10, when administered daily postoperatively in pharmacologic doses, does not appear to significantly increase postoperative adhesion formation. This puts into question if endogenous IL-10 production indeed plays a role in nonadhesiogenic peritoneal healing.

Training cytotechnologists to perform papanicolaou smear screening: development and testing of a third world program.

BACKGROUND: Our objective was (1) to develop a training program for teaching cytotechnology students how to perform Papanicolaou (Pap) smear collection, and (2) to compare the Pap smear adequacy rates of trained cytotechnicians to those of physicians screening the same population. METHODS: Cytotechnology students received formal lectures about collection and transport of Pap smears and clinical proctoring of Pap smear collection in at least 20 patients. Ten months after completion of training, a review of screening Pap smears collected by all health care professionals over 1 month was performed. Cytopathology review was performed in a blinded fashion. RESULTS: In November 1994, 1,411 screening Pap smears were performed. Patients were seen randomly by generalists, gynecologists, cytotechnicians, or oncologists with collection rates of 991 (70%), 221 (16%), 100 (7%), and 99 (7%) Pap smears, respectively. Inadequate sampling rates (i.e., less than 70% of the slide surface covered with a cell monolayer, endocervical cells present if uterus was in situ, and fewer than 25% of marker cells obscured by blood or inflammatory cells) were: generalists, 8.8%; gynecologists, 9.9%; cytotechnicians, 9.0%; and oncologists, 58.6%. No significant differences were seen in the inadequacy rates of the first three groups, though the oncologists were more likely to perform inadequate Pap smears (p < .01). CONCLUSIONS: Third World cytotechnicians can be taught the rudimentary aspects of Pap smear collection, with acceptable rates of inadequate sampling similar to their physician colleagues. Oncologist specialists either should be retrained in the proper collection and processing of Pap smears or should be excluded from this primary care activity.

Frequency and cause of aborted laparoscopic-assisted vaginal hysterectomy.

STUDY OBJECTIVE: To evaluate the frequency and cause of aborted laparoscopic-assisted vaginal hysterectomies (LAVH) at two hospitals of a major obstetrics and gynecology training program. DESIGN: Retrospective cohort study. SETTING: A university hospital and a university-affiliated county hospital. PATIENTS: Seventy-eight consecutive women who underwent LAVH at our institutions between June 1992 and February 1995. INTERVENTIONS: Data on age, weight, indications for surgery, obstetric and surgical history, concomitant procedures performed, postoperative diagnosis, perioperative complications, operative time, estimated blood loss, uterine weight, and length of hospital stay were collected from patients' hospital records. Univariate analysis of variance to assess statistical significance was performed when appropriate. MEASUREMENTS AND MAIN RESULTS: Eight (11.1%) of 78 procedures were converted to abdominal hysterectomy. The most frequent reason for conversion (5 cases, 6%) was large uterine size with limited mobility and associated inability to visualize the pelvic sidewall structures adequately. The other three procedures were converted because of massive intraperitoneal adhesions (2) and intraoperative severe bleeding (1). The mean uterine weight of these eight women (575 g, range 387-1030 g) was significantly higher than that of patients undergoing successful LAVH (230 g, range 35-612; p <0.03). CONCLUSIONS: In our limited series of 78 patients, only one LAVH was converted to abdominal hysterectomy because of an intraoperative complication. A conversion rate of 11.1% may be appropriate so as to offer the potential benefits of the laparoscopic-assisted vaginal approach to the largest number of women who would otherwise undergo an abdominal hysterectomy.

Expression of a novel beta 1 integrin in the dysplastic progression of the cervical epithelium.

Epithelial cell interactions with matrices and basal membranes are central for tissue organization, and integrins are a family of adhesion molecules that play a major role in these interactions. We have analyzed the expression of a novel integrin alpha chain, alpha 10.1.2, in the squamous epithelium of the portio vaginalis uteri from patients with cervical intraepithelial neoplasia (CIN) and from control samples without apparent cervical abnormalities. The localization of beta 1 and alpha 6 chains was also investigated, together with the distribution of intraepithelial HLA-DR and CD1c-positive Langerhans cells. In the normal cervical epithelium, all of the integrin chains were detected in the basal cell layer, albeit with a different localization in the apical, lateral, and basal cell surfaces. Langerhans cells were evenly distributed in the deep 2/3 of the squamous epithelium. Expression of alpha 10.1.2 was reduced or absent in all of the CIN 1 specimens in which the other integrin chains were either normal or slightly reduced. CIN 2 was characterized by overexpression of integrins, namely of beta 1 and of alpha 10.1.2 chains which were consistently detected also in suprabasal cell layers. None of the integrin chains was found in CIN3 samples in which Langerhans cells were also absent. Thus, modulation and redistribution of integrins occur in the progression of cervical dysplasia, and lack of integrin expression characterizes high-grade lesions. As in other dysplasias and cancers of squamous epithelia, the localization of alpha 10.1.2 chains provides reliable diagnostic and possibly prognostic criteria.

Computerized colposcopy: results of a pilot study and analysis of its clinical relevance.

OBJECTIVE: To evaluate the clinical usefulness of a computer based system that stores and analyzes high-resolution digital colposcopic images. METHODS: Three hundred patients referred to our institutions for evaluation of abnormal cervical cytology underwent colposcopy with development of digital images. The first 70 patients were used to standardize the system. The images obtained from 188 evaluable patients were analyzed and scored by software according to internationally recognized colposcopic criteria. The results were compared with traditional colposcopic diagnoses and with corresponding histology results using kappa statistics for inter-observer agreement and McNemar test for significance. RESULTS: The exact concordance rate between computer-aided impressions and histology (85.1%, kappa = 0.77) was significantly higher (P < .001) than that observed between traditional colposcopic findings and histology (66%, kappa = 0.40). The computer-assisted colposcopy was much more accurate than traditional colposcopy in diagnosing high-grade lesions (91.2 versus 61.8% of exact concordance, P < .001) as well as normal histology (74.1 versus 34.5%, P < .001), but not significantly different when evaluating low-grade lesions (89.6 versus 86.5%). CONCLUSION: The integration of computer imaging and colposcopy can improve the colposcopic diagnostic accuracy. An inexperienced colposcopist may benefit from computerized support to obtain the most appropriate histologic specimen, and eventually access to distant consultation via modem or through on-line services. An additional advantage is the ability to develop a space-saving permanent record of digitized images readily available to review a patient's cervical history or perform effective programs of quality control in colposcopy.

Reductive surgery and ovarian function in the human--can reductive ovarian surgery in reproductive age negatively influence fertility and age at onset of menopause?

A statistical study was carried out on a cohort of 165 women, menopausal for at least 2 years, who had undergone reductive ovarian surgery in fertile age, against nonoperated controls. The purpose of the study was to examine possible interference caused by surgery on fertility performance and age at which the natural menopause starts. It was found that fertility in the operated women was reduced when compared to the controls, although the difference was not of statistical significance. However, the difference between the two groups in mean age at menopause onset was significant (P < .001). The study sample was divided into two sub-groups according to age at operation (<30/>30) and a significant difference between them was found for age at menopause onset, the under-thirty group starting earlier. In particular, the onset of menopause was even earlier in women who had undergone bilateral wedge biopsy for polycystic ovarian syndrome (PCO). The anatomical state of the ovary at operation was also found to be relevant: ovariectomized women with intrinsic ovarian pathology (cysts, tumors or PCO) started the menopause earlier than those without intrinsic diseases (i.e., ectopic pregnancy), suggesting that such intrinsic pathology may cause a primary depletion of the follicles.

The incidental finding of abnormal cervical histology in postmenopausal patients.

A report is supplied on 216 samples of cervical tissue incidentally found in 684 endometrial specimens collected during hysteroscopic examination of postmenopausal women with uterine bleeding and a recent negative Pap smear. We found 43 (19.9%) specimens including cervical tissue with some histologic sign of pathology. Twenty-five (11.6%) had histologic features suggestive for human papillomavirus (HPV) infection, while 18 (8.3%) had cervical intraepithelial neoplasia (CIN). Of the 18 CIN cases, 9 were CIN I, 6 CIN II and 3 CIN III. Altogether, the prevalence of dysplasia in postmenopausal women with recently referred normal cervical cytology was impressive. A significant number of dysplastic lesions (14 out of 18, 77.7%) did not present any histologic sign of HPV. Also, none of the histologic diagnoses of sub-clinical HPV infection was confirmed by the in situ hybridization. Considering the significant prevalence of high grade lesions (9 CIN II and III, 4.2% of the analysed samples) found in this randomly selected patient population, our data strongly suggest the need for a regular follow-up of the transformation zone in all postmenopausal women. Although in women of postmenopausal age some low grade lesions seem to have only a reactive-reparative significance, a more accurate screening procedure, taking into account the peculiar modifications of the menopausal uterine cervix, is advisable.

Oncolytic activity of NK cells against SW-756 squamous cervical carcinoma cell line: role of interferons alpha and gamma and CD54 adhesion molecule in oncolysis.

We investigated the sensitivity of a cervical tumor cell line SW-756 to lysis by peripheral blood mononuclear cells (MNC), natural killer (NK) cells, and major histocompatibility complex (MHC)-nonrestricted (MHC-NR) T cells from cervical cancer patients and normal donors. We found that SW-756 was resistant to lysis mediated by naive (unstimulated) MNC and MHC-NR T cells, but sensitive to lysis by naive NK cells. However, the cytotoxic function of MNC could be activated with interleukin-2 (IL-2) and interferon (IFN) alpha or gamma. Although IFNs were effective in enhancement of effector cell cytotoxicity and inhibited proliferation of cervical tumor cells, they also exerted an adverse effect on cytotoxicity; specifically, pretreatment of SW-756 cells with IFNs significantly decreased their susceptibility to lysis by effector cells. Analysis of surface phenotype of SW-756 cells after treatment with IFNs showed up-regulation of expression of HLA class I determinants, the phenomenon that may be responsible for decreased sensitivity of this tumor to MHC-NR NK cells. The studies on the involvement of CD54 adhesion molecule in cytotoxic functions indicated that expression of this molecule on effector cells (but not on target cells) was important for cytotoxicity against SW-756 tumor cells. The therapeutic implication of these studies for patients with cervical cancer is discussed.

Folinic acid in the treatment of human male infertility.

OBJECTIVE: To investigate the clinical and histologic effects of folinic acid in the treatment of round cell idiopathic syndrome. DESIGN: Sixty-five males of infertile couples have been treated with folinic acid alone (15 mg one time per day) for a 3-month period. Various sperm parameters (spermatozoa number and motility, round cell number) have been evaluated before and after the therapy. Moreover, to investigate the histologic patterns of the testis induced by the administration of folinic acid, an experimental animal model has been designed on rats previously treated with chemotherapy drugs. RESULTS: All the investigated human seminal parameters presented significant variations after the treatment. An improvement in spermatozoa number and motility and a decrease in round cell number have constantly been noticed; the significance of the changes was particularly impressive in those men whose partners became pregnant later on. A consistent improvement in the histologic structure of the rat tubular epithelium was also detected. CONCLUSION: Folinic acid appears to be a valuable approach for the treatment of round cell idiopathic syndrome.

Effect of new investigational drug taxol on oncolytic activity and stimulation of human lymphocytes.

Taxol is a new antineoplastic agent active in the treatment of drug-refractory ovarian and metastatic breast neoplasms. Extensive investigations have been concerned with the effect of taxol on a variety of tumor cells, but there is virtually no information about its effect on human lymphocytes. Since lymphocytes, especially natural killer (NK) cells, have been recognized to play an important role in the body's defense against tumors, we studied the effect of taxol on the cytotoxicity of naive (unstimulated) peripheral blood mononuclear cells (MNCs) and NK cells as well as on these cells' activation and growth in interleukin-2 (IL-2) cultures. We found that taxol impaired the cytotoxicity of naive MNC and NK cells against the NK-sensitive cell line K-562 and against an ovarian cancer cell line, OV-2774, in a concentration-dependent fashion. The highest impairment was observed after incubation of the effector cells with 10 micrograms/ml taxol. In addition, taxol also interfered with the induction of lymphokine-activated cytotoxicity and with lymphocyte growth in IL-2 cultures. However, IL-2 preactivated NK cells displayed substantial levels of cytotoxicity even after taxol treatment. These findings, which indicate that treatment with taxol should follow rather than precede immunotherapeutic intervention, may be important in planning combined chemo- and immunotherapy strategies for cancer patients.