Cervical HPV type-specific pre-vaccination prevalence and age distribution in Croatia.

The main etiological factor of precancerous lesion and invasive cervical cancer are oncogenic human papillomaviruses types (HPVs). The objective of this study was to establish the distribution of the most common HPVs in different cervical lesions and cancer prior to the implementation of organized population-based cervical screening and HPV vaccination in Croatia. In this study, 4,432 cervical specimens, collected through a 16-year period, were tested for the presence of HPV-DNA by polymerase chain reaction (PCR) with three sets of broad-spectrum primers and type-specific primers for most common low-risk (LR) types (HPV-6, 11) and the most common high-risk (HR) types (HPV-16, 18, 31, 33, 45, 52, 58). Additional 35 archival formalin-fixed, paraffin embedded tissue of cervical cancer specimens were analyzed using LiPA25 assay. The highest age-specific HPV-prevalence was in the group 18-24 years, which decreased continuously with age (P<0.0001) regardless of the cytological diagnosis. The prevalence of HR-HPV types significantly increased (P<0.0001) with the severity of cervical lesions. HPV-16 was the most common type found with a prevalence (with or without another HPV-type) of 6.9% in normal cytology, 15.5% in atypical squamous cells of undetermined significance, 14.4% in low-grade squamous intraepithelial lesions, 33.3% in high-grade squamous intraepithelial lesions, and 60.9% in cervical cancer specimens (P<0.0001). This study provides comprehensive and extensive data on the distribution of the most common HPV types among Croatian women, which will enable to predict and to monitor the impact of HPV-vaccination and to design effective screening strategies in Croatia.

Methylated Host Cell Gene Promoters and Human Papillomavirus Type 16 and 18 Predicting Cervical Lesions and Cancer.

Change in the host and/or human papillomavirus (HPV) DNA methylation profile is probably one of the main factors responsible for the malignant progression of cervical lesions to cancer. To investigate those changes we studied 173 cervical samples with different grades of cervical lesion, from normal to cervical cancer. The methylation status of nine cellular gene promoters, CCNA1, CDH1, C13ORF18, DAPK1, HIC1, RARß2, hTERT1, hTERT2 and TWIST1, was investigated by Methylation Specific Polymerase Chain Reaction (MSP). The methylation of HPV18 L1-gene was also investigated by MSP, while the methylated cytosines within four regions, L1, 5'LCR, enhancer, and promoter of the HPV16 genome covering 19 CpG sites were evaluated by bisulfite sequencing. Statistically significant methylation biomarkers distinguishing between cervical precursor lesions from normal cervix were primarily C13ORF18 and secondly CCNA1, and those distinguishing cervical cancer from normal or cervical precursor lesions were CCNA1, C13ORF18, hTERT1, hTERT2 and TWIST1. In addition, the methylation analysis of individual CpG sites of the HPV16 genome in different sample groups, notably the 7455 and 7694 sites, proved to be more important than the overall methylation frequency. The majority of HPV18 positive samples contained both methylated and unmethylated L1 gene, and samples with L1-gene methylated forms alone had better prognosis when correlated with the host cell gene promoters' methylation profiles. In conclusion, both cellular and viral methylation biomarkers should be used for monitoring cervical lesion progression to prevent invasive cervical cancer.

Cytologic follow-up in patients with CIN treated by LLETZ, Cold knife Conization and Semm's cold coagulation.

Management of cervical premalignant lesions starts with abnormal Pap smear. Regular screening of asymptomatic women (the Pap smear) allows us to diagnose and treat preinvasive lesions before they progress to cervical cancer. There is a wide variety of ablative and destructive methods used in treatment of cervical premalignant lesions. In this study we have compared follow-up cytology results in patient groups treated by LLETZ (Large Loop Excision of the Transformation Zone), Cold Knife Conization (CKC) and Semm's cold coagulation (Electrocoagulation, ECG) according to CIN on target biopsy specimen, and definite therapeutic approach according to patient age, parity and lesion grading. The aim was to evaluate therapeutic success in all three patient groups on the basis of control cytology findings. Normal cytology findings after treatment were recorded in 43 women in LLETZ group (88%), 22 women in CKC group (73%) and in 22 women from the Semm's cold coagulation group (73%). The importance of the use of diagnostic and therapeutic guidelines and regular follow up is emphasized, bearing in mind primarily the young female population with severe preinvasive lesions of uterine cervix. Treating cervical preinvasive lesions offers an excellent opportunity to prevent the occurrence of cervical cancer in the large majority of women with abnormal cervical smears.

[Diagnostic-therapeutic guidelines for men whose partners have HPV genital infection]. / Dijagnosticko-terapijski postupnik za muskarce kojih partnerice imaju HPV-genitalnu infekciju.

Human papilloma virus infection is the most frequent sexually transmitted disease. HPV infections are connected with different diseases such as benign warts, condylomata acuminata, malignant cervical, vulvar, vaginal, penile and anal carcinoma. Peniscopy with HPV detection is a specific diagnostic method for diagnosis of subclinical HPV genital infection in asymptomatic men. Taking the samples for HPV detection from asymptomatic men with curette is more qualitative way of getting enough samples then taking swab with wooden stick or (tongue) depressor. Early diagnosis and treatment of HPV infections in men is of potential benefit because their eradication can reduce the viral reservoir and as the result of that the incidence of CIN, carcinoma in situ and invasive cervical carcinoma can be reduced. For the correct diagnosis and for choosing the adequate therapeutical technique, we suggest diagnostic-therapeutic guidelines for HPV genital infection in men.

Identification of human papillomavirus type 16 integration sites in high-grade precancerous cervical lesions.

OBJECTIVES: Infection with oncogenic human papillomaviruses (HPV) is a prerequisite for the development of cervical cancer. In many cases of cervical cancer and all cervical cancer derived cell lines oncogenic HPV DNA is found to be integrated, indicating the importance of integration in disease development. In this study, 176 HPV 16 positive precancerous cervical lesions were analyzed for the physical state of viral genome to determine the sites of integration into a host cell DNA and to evaluate the incidence of the integration in different stages of cervical lesions. METHODS: The detection of integrated papillomavirus sequences (DIPS) method in combination with the amplification by polymerase chain reaction (PCR) of E1/E2 region was used to identify the physical state of HPV 16 genome. The site of integration within a host cell genome was determined by sequencing of unusual sized DIPS amplicons. RESULTS: The combined results of DIPS and E1/E2 PCR revealed the integration of HPV 16 DNA in 7.4% samples. The integration was found only in high grade cervical lesions indicating that it is a late event in disease progression. Sequencing of 11 DIPS amplicons revealed HPV DNA from 6 samples (54.5%) to be integrated in cellular genes (VMP1, PVRL1, CHERP, CEACAM5, AHR, MRF-2) and also 6 (54.5%) within the common fragile sites (CFS). CONCLUSIONS: Although, the HPV integration is known to be a random event, this study indicates that HPV 16 integrates more than by chance within or close to CFSs. As most of the genes affected by HPV 16 integration can be linked with some aspects of tumor formation, this indicates that the site of HPV DNA integration might play a role in the rate and the nature of tumor development.

Diagnostic approach for precancerous and early invasive cancerous lesions of the uterine cervix.

Invasive cervical cancer is second most common female cancer worldwide with about 493,000 new cases per year. About 273,000 women die from cervical cancer each year, 85% of which take place in developing countries. Cervical cancer has a slow progress, from pre-invasive cervical intraepithelial neoplasia (CIN) to invasive phases, meaning that the disease can be diagnosed while in the phase of pre-invasive lesion, and treated successfully thanks to the regular screening of asymptomatic women (the Pap smear). The authors review new possibilities of early detection of cervical cancer with emphasis on colposcopy. The role of colposcopy is discussed among possibilities of early diagnosis. The authors discuss additional diagnostic procedures for preinvasive lesions of the uterine cervix like DNA cytometry, (flow cytometry). This method can point to dysplasia which can progress to severe stages, such as HSIL (High grade Squamous Intraepithelial Lesion). If the level of chromosomal disturbance is higher (aneuploidy), it is more probable that HSIL will develop. Laser screening of cells extracted with modern cytologic screening LBC (Liquid Base Cytology) enables us to automatically measure ploidy (chromosome regularity, or irregularity) and PCR provides analysis of HPV types. These methods are recommended for a routine check-up of borderline cervical lesions in order to anticipate ones likely to regress or progress.

Report on the 2007 International Workshop on Human Papillomaviruses and Consensus Recommendations for Cervical Cancer Prevention.

National and international experts in cervical cancer prevention met at the International Workshop on Human Papillomaviruses and Consensus Recommendations for Cervical Cancer Prevention to review the current evidence and assess the potential for improvement in cervical cancer prevention and to develop plans for implementation of cervical cancer prevention programmes in Croatia. Key recommendations were developed and adopted during the course of the meeting. The process of bringing national experts together with internationally recognized experts in an open forum for the development of consensus recommendations could serve as a model for other countries seeking to implement or improve cervical cancer prevention programmes.

Chloasma--the mask of pregnancy.

Chloasma is a required hypermelanosis of sun-exposed areas occurred during pregnancy and it can affect 50-70% of pregnant women. It presents as symmetric hyperpigmented macules, which can confluent or punctuate. The most common locations are the cheeks, the upper lip, the chin and the forehead. The exact mechanism by which pregnancy affects the process of melanogenesis is unknown. Estrogen, progesterone, and melanocyte-stimulating hormone (MSH) levels are normally increased during the third trimester of pregnancy. However, nulliparous patients with chloasma have no increased levels of estrogen or MSH. In addition, the occurrence of melasma with estrogen- and progesterone-containing oral contraceptive pills has been reported. The observation that postmenopausal woman who are given progesterone develop melasma, while those who are given only estrogen do not, implicates progesterone as playing a critical role in the development of melasma. UV-B, UV-A, and visible light are all capable of stimulating melanogenesis. The condition is self-limited; however spontaneous resolution is time-consuming and may take months to resolve normal pigmentation. Therefore, it is worthwhile to prevent the onset of chloasma, by strict photoprotection. Prudent measures to avoid sun exposure include hats and other forms of shade combined with the application of a broad-spectrum sunscreen at least daily. Sunscreens containing physical blockers, such as titanium dioxide and zinc oxide, are preferred over chemical blockers because of their broader protection. Chloasma can be difficult to treat. Quick fixes with destructive modalities (eg, cryotherapy, medium-depth chemical peels, lasers) yield unpredictable results and are associated with a number of potential adverse effects. The mainstay of treatment remains topical depigmenting agents. Hydroquinone (HQ) is most commonly used.

History of colposcopy: a brief biography of Hinselmann.

OBJECTIVES: To consider all the historical reasons for the slow growth of colposcopy through a brief biography of Hinselmann. The history of colposcopy is beginning in March 1924. In the first experiments, colposcopic examination was almost impossible to perform because of the distance from the focus, that was no more than 80 mm. Hinselmann tried to solve this problem by pulling out the uterine cervix. The examined part is anemised by this procedure, which can prejudice the final result and a small amount of blood might leak as well. Beside that, a patient can feel pain if the portio is held by a thin forceps. The colposcopy, established in Germany, had spread throughout slowly its motherland, probably thanks to the many mistakes caused by Hinselmann himself: a technique proposed and almost exclusively intended for early discovery of cervical carcinoma;very authoritative imposition of terms, especially histological, which caused resistance by hystopathologists possibly induced by the fear of loosing their prestige who considered them too complex;his stubbornness in considering leukoplakia as precancerous lesion imposed him a lot of opponents;until the 1950's there had not yet been any adequate didactic material at the disposal of numerous gynaecologists;Hinselmann's temper, described by Wespi as a mixture of innocence and missionary eagerness, had not prepared him for dialogue and compromise. CONCLUSION: It might seem surprising that colposcopy, accurate in detecting all benign lesions and initial atypical transformations, and perfectly capable of pointing safe biopsy in cases of suspicious lesions, did not develop as it should have a method whose function is of great importance in the prevention and treatment of CIN. Despite the role and the importance of cytology in the realization of the population programme of cervical cancer detection, the colposcopy allows the precise diagnosis among women with abnormal pap smears.

Antropologic factors in prediction of ovary cancer.

The aim of the study was to determine a combination of anthropometric variables that would enable better differentiation between benign and malignant ovarian masses. Prospective study has been performed in a two year period in which 208 women with ovarian lesions were analyzed and correlated with histopathologic surgical findings. We examined the relation between self-reported anthropometric and other variables (height, weight, body mass index--BMI, parity, marital status, education, age, rural versus urban residence, menopausal status) and incidence of ovarian cancer. Age, parity, marital status and menopausal status individually showed statistical significance.

Limitations of colposcopy in early invasive cervical cancer detection.

Colposcopy is a key element in the diagnostic chain required to reduce cervical cancer mortality but it has limitations in the diagnosis of malignant disease. In the Republic of Croatia the Croatian Society for Colposcopy and Cervical Pathology started constructing guidelines for early detection, therapy and follow-up of patients with early invasive cervical cancer in order to achieve the best possible results in diagnosis, therapy and follow-up. From 2001 to 2006 Croatian society for colposcopy and cervical pathology organised six courses "Role of colposcopy in early diagnosis and prevention of premalignant lesions of the uterine cervix" in cooperation with Medical faculty, University of Zagreb and the Croatian medical chamber. Leading presentations were focused on the epidemiology of cervical cancer, cytologic, colposcopic and pathohistologic classification, HPV testing and role of male partner. After the theoretical part, a series of colposcopic pictures were presented as a practical part of the course where attendees participated in colposcopic images description and estimation of what could be the underlying pathological process. Such, courses are needed for continued medical education and quality practice of colposcopy.

Preoperative serum levels of c-erbB-2 do not seem to be useful in management of patients with rectal cancer.

BACKGROUND AND AIM: Soluble c-erbB-2 oncoprotein has been proven as a useful marker in the management of breast cancer patients, but its value in diagnostics and follow-up of colorectal cancer patients remains controversial. The aim of this study was to evaluate the usefulness of serum c-erbB-2 monitoring in diagnostics and prediction of disease outcome in rectal cancer patients. MATERIALS AND METHODS: Serum samples from 88 patients with rectal adenocarcinoma before surgery and from 41 healthy controls were tested for the presence of c-erbB-2 oncoprotein by ELISA, and the patients were followed up for at least 5 years after the surgery. RESULTS: Preoperative serum c-erbB-2 levels were significantly higher in stage IV patients than in healthy controls (P<0.001) and did not show correlation with preoperative CEA levels. Elevated preoperative serum c-erbB-2 levels showed relatively high specificity (88%) and low sensitivity (44%) in the diagnosis of rectal cancer. Elevated preoperative oncoprotein levels were predictive neither for overall survival nor for development of local recurrence/distant metastases. CONCLUSION: Although preoperative serum c-erbB-2 levels were significantly higher in rectal cancer patients than in healthy controls, the soluble c-erbB-2 does not seem to be useful in the diagnosis of rectal cancer due to its low sensitivity. Preoperative serum levels of this oncoprotein were predictive neither for overall survival nor for local recurrence/distant metastases in rectal cancer patients.