Clinical follow-up of women infected with human papillomavirus-16, either alone or with other human papillomavirus types: identification of different risk groups.

OBJECTIVES: Evaluation of the clinical impact of multiple infections of the cervix by human papillomavirus, including human papillomavirus-16, compared with single human papillomavirus-16 infection. STUDY DESIGN: One hundred sixty-nine women were classified in 3 categories depending on their human papillomavirus profile: human papillomavirus-16 only, human papillomavirus-16 and low-risk type(s), and human papillomavirus-16 and other high-risk type(s). Cervical brush samples were analyzed for human papillomavirus DNA by polymerase chain reaction and reverse line blot hybridization. All women were evaluated with colposcopy during 24 months or more. Management was according to the Bethesda recommendations. RESULTS: Women infected with human papillomavirus-16 and other high-risk human papillomavirus type(s) presented more progression or no change in the grade of dysplasia, compared with women of the other groups (relative risk [RR], 1.39; 95% confidence interval [CI], 1.07-1.82; P = .02 at 6 months; RR, 2.10; 95% CI, 1.46-3.02; P < .001 at 12 months; RR, 1.82; 95% CI, 1.21-2.72; P = .004 at 24 months). CONCLUSION: Coinfection of women with human papillomavirus-16 and other high-risk human papillomavirus type(s) increases the risk of unfavorable evolution.

Intraoperative lymphatic mapping and sentinel node biopsy using hysteroscopy in patients with endometrial cancer.

OBJECTIVE: The purpose of the study was to assess the feasibility of intraoperative sentinel node (SN) detection using injection of patent blue dye and radioactive tracer beneath the tumor of patients with endometrial carcinoma. METHODS: Hysteroscopy was used for injection of 2 ml of patent-V blue, followed by 20-50 MBq technetium-99 m-labelled nanocolloids into the subendometrial layer underlying the tumor of 60 patients with endometrial cancer. Then SN biopsy, pelvic and paraaortic lymphadenectomy, hysterectomy and bilateral salpingo-oophorectomy were carried out through laparotomy or laparoscopy. RESULTS: Sixty patients aged 43 years to 87 years (median age 65 years) were enrolled in this study. Sentinel nodes were identified in 49 of 60 patients (82%). The mean number of SN retrieved was 3.7 per patient (range, 1 to 8). Sixteen patients (33%) had SN in both pelvic and paraaortic areas. No patient had SN only at the paraaortic level. Metastatic disease was found in 9 patients (15%). In 8 of them at least one SN was positive. CONCLUSION: Intraoperative sentinel node detection is feasible in patients with endometrial carcinoma using hysteroscopy for injection of blue dye and technetium-99 m beneath the tumor. This technique may actually enhance the chances of detecting metastatic disease, while reducing the extent of the surgery.

[Bulking agents and their place in the treatment of urinary stress incontinence]. / Les produits injectables et leur place dans le traitement de l'incontinence urinaire d'effort.

Bulking agents are used in the treatment of urinary stress incontinence associated with intrinsic sphincter deficiency. Bovine collagen remains the gold standard despite problems such as allergic reaction and absorption of the injected material. Several new products are being evaluated or used clinically to try and overcome problems linked with bovine collagen. The aim of this paper is to review the bulking agents available and to put in prospect use of these products with the recent progress made in the treatment of urinary stress incontinence. The gold standard treatment for intrinsic sphincter deficiency is suburethral autologous or synthetic suburethral slings. Bulking agents are indicated for multi-operated patients with urinary stress incontinence and intrinsic sphincter deficiency. Bladder neck hypermobility is not a contraindication.

Immune responses induced by lower airway mucosal immunisation with a human papillomavirus type 16 virus-like particle vaccine.

Cervical cancer results from cervical infection by human papillomaviruses (HPV), especially HPV16. Previous studies have shown that intramuscular vaccination of women with an HPV16 virus-like particle (VLP) vaccine induced a strong IgG response and protected against genital HPV16 infection. However, an alternative route of administration that avoids parenteral injection while inducing mucosal immunity might facilitate vaccine implementation in some settings, and partially overcome the substantial variation in HPV16 antibodies at the cervix seen in ovulating women. In this study, women were vaccinated with escalating doses of HPV16L1 VLPs via nasal nebulisation, bronchial aerosolisation, or a combination of intramuscular and aerosol vaccination. The alternative routes of vaccination were well tolerated and many of the volunteers who received aerosol vaccinations exhibited serum antibody titers that were comparable to those induced by intramuscular vaccination. A mucosal immune response was induced by aerosol vaccination as demonstrated by the induction of anti-HPV16 VLP IgA secreting cells in PBMC and SIgA in secretions. Our data suggest that aerosol administration of HPV VLPs may represent a potential alternative to parenteral injection.

Improved efficiency of a Salmonella-based vaccine against human papillomavirus type 16 virus-like particles achieved by using a codon-optimized version of L1.

Cervical cancer results from cervical infection by human papillomaviruses (HPVs), especially HPV16. An effective vaccine against these HPVs is expected to have a dramatic impact on the incidence of this cancer and its precursor lesions. The leading candidate, a subunit prophylactic HPV virus-like particle (VLP) vaccine, can protect women from HPV infection. An alternative improved vaccine that avoids parenteral injection, that is efficient with a single dose, and that induces mucosal immunity might greatly facilitate vaccine implementation in different settings. In this study, we have constructed a new generation of recombinant Salmonella organisms that assemble HPV16 VLPs and induce high titers of neutralizing antibodies in mice after a single nasal or oral immunization with live bacteria. This was achieved through the expression of a HPV16 L1 capsid gene whose codon usage was optimized to fit with the most frequently used codons in Salmonella. Interestingly, the high immunogenicity of the new recombinant bacteria did not correlate with an increased expression of L1 VLPs but with a greater stability of the L1-expressing plasmid in vitro and in vivo in absence of antibiotic selection. Anti-HPV16 humoral and neutralizing responses were also observed with different Salmonella enterica serovar Typhimurium strains whose attenuating deletions have already been shown to be safe after oral vaccination of humans. Thus, our findings are a promising improvement toward a vaccine strain that could be tested in human volunteers.

Immunogenicity against human papillomavirus type 16 virus-like particles is strongly enhanced by the PhoPc phenotype in Salmonella enterica serovar Typhimurium.

Recombinant Salmonella strains have been widely used to deliver heterologous antigens and induce immune responses in vaccinated animals and humans. It remains to be established, however, how these bacteria mount an immune response; this has prevented the rational design of vaccines. Here we report for the first time that a particular genetic program, PhoPc, is necessary for recombinant Salmonella strains to induce an antibody response to a heterologous antigen, the human papillomaviruses type 16 (HPV16) virus-like particle (VLP). The PhoPc phenotype results from a point mutation in phoQ, the gene encoding the sensor component of a two-component regulatory system (PhoP-PhoQ) that controls the expression of a number of virulence factors in Salmonellae. To demonstrate that immunogenicity of the viral antigen expressed by the bacterial vector was dependent on the PhoPc phenotype, we have expressed the phoQ mutant gene (phoQ24) in two differently attenuated Salmonella enterica serovar Typhimurium strains. Our data show extrachromosomal phoQ24 to be dominant over the chromosomal copy of the phoQ gene, conferring the PhoPc phenotype on the recipient strains. In addition, activation of PhoPQ-regulated genes by the plasmid-encoded PhoQ24 did not alter bacterial survival and conferred immunogenicity to the HPV16 VLP expressed in the two S. enterica serovar Typhimurium backgrounds, inducing the production of HPV-specific antibodies in mice. This strongly suggests that at least one of the PhoP-regulated genes is necessary for mounting an efficient antibody response to HPV16 VLP. This finding sets the stage for further development of a Salmonella-based vaccine against HPV infection and cervical cancer.

Specific antibody levels at the cervix during the menstrual cycle of women vaccinated with human papillomavirus 16 virus-like particles.

BACKGROUND: In early-phase trials, a human papillomavirus 16 (HPV16) virus-like particle (VLP) vaccine has been shown to be well tolerated, immunogenic, and protective against HPV16 in women, most of whom were taking oral contraceptives. Previous studies have not determined whether HPV immunization results in specific antibody levels in the human genital tract or whether these levels might vary during contraceptive or ovulatory cycles. Therefore, we determined the levels of total and specific antibodies in the cervical secretions of women who had been immunized with HPV16 VLPs and examined the influence of the menstrual cycle and oral contraceptive use on these levels. METHODS: Two groups of women were immunized, seven who were taking oral contraceptives and 11 who were ovulating. After seroconversion, serum and cervical secretions were collected twice weekly for 5 weeks. Total immunoglobulins (IgG and IgA) and vaccine-specific IgGs were determined by enzyme-linked immunosorbent assay. Nonparametric statistical analyses were used to determine the statistical significance of differences in IgG levels between groups, and correlations between serum- and cervical-specific IgG levels were determined by the Spearman correlation coefficient. RESULTS: All participants developed detectable titers of anti-HPV16 VLP IgGs in their cervical secretions after immunization. The cervical titers of specific IgG and total IgGs and IgAs among participants in the contraceptive group were relatively constant throughout the contraceptive cycle. In contrast, the cervical titers of specific IgG and total IgGs and IgAs among participants in the ovulatory group varied during the menstrual cycle, being highest during the proliferative phase, decreasing approximately ninefold around ovulation, and increasing approximately threefold during the luteal phase. Serum- and cervical-specific IgG levels were correlated (r =.86) in women in the contraceptive group but not in women in the ovulatory group (r =.27). CONCLUSIONS: The relatively high titer of anti-HPV16 antibodies at the cervix is promising in terms of vaccine efficacy; however, the decrease in antibody titer around ovulation raises the possibility that the HPV16 VLP vaccine might be less effective during the peri-ovulatory phase.

[Quality assurance in organized screening of breast cancer]. / L'assurance de qualité en dépistage organise du cancer du sein.

Quality assurance is an essential process which should be applied for any organised breast cancer screening program since mammography it the only test available for an early diagnosis. It should also assess the quality of diagnostic and treatment processes in order to ascertain that the quality of the screening program would not be altered by the procedures which take place after the screening. Quality assurance must be applied to each component of the screening process: equipment, radiographers (technicians) as well as radiologists. It is a multidisciplinary approach following a well defined protocol, which should be supervised by a coordination unit, the Breast Cancer Screening Foundation in Canton of Vaud. Performances of the Vaud program show clearly at what extend multiple reading method improves the quality of screening. It seems that there is no inconvenient to involve radiologists who wish to participate without any selection to the reading process provided that there is in place a team of 2nd and 3rd readers who benefit of an appropriate training and experience.

[Network for sentinel lymph node research in breast cancer]. / Un réseau pour la recherche du ganglion sentinelle du cancer du sein.

AIMS: The goals of this paper were to determine the accuracy of the sentinel node in predicting axillary nodal status and to evaluate the feasibility of incorporating sentinel node biopsy into a general practice. METHODS: Between June 1999 and February 2003, 304 patients with clinically T0-T2[< 3 cm] M0 breast cancer underwent sentinel node biopsy. Both lymphoscintigraphy and blue dye were used to guide this biopsy. The procedure was followed by a complete axillary dissection in the first patients and when the sentinel node was positive. Sentinel nodes were evaluated using serial levels of hematoxylin eosin staining, and cytokeratin immunohistochemistry. RESULTS: The overall sentinel node detection rate was 99% (301 of 304 patients). The accuracy of the identification in operating room was 98% (296 of 301 patients). The sentinel node was involved in 75 patients (25%): metastases (38 patients), micrometastases (32 patients) and isolated tumor cells (5 patients). The false negative rate was 0% and the negative predictive value 100%. CONCLUSION: Our results support that the sentinel node biopsy is an accurate predictor of axillary nodal status in patients with early breast cancer and implementing a network greatly facilitates its' discovery.

Trachea, lung, and tracheobronchial lymph nodes are the major sites where antigen-presenting cells are detected after nasal vaccination of mice with human papillomavirus type 16 virus-like particles.

Vaccination by the nasal route has been successfully used for the induction of immune responses. Either the nasal-associated lymphoid tissue (NALT), the bronchus-associated lymphoid tissue, or lung dendritic cells have been mainly involved. Following nasal vaccination of mice with human papillomavirus type 16 (HPV16) virus-like-particles (VLPs), we have previously shown that interaction of the antigen with the lower respiratory tract was necessary to induce high titers of neutralizing antibodies in genital secretions. However, following a parenteral priming, nasal vaccination with HPV16 VLPs did not require interaction with the lung to induce a mucosal immune response. To evaluate the contribution of the upper and lower respiratory tissues and associated lymph nodes (LN) in the induction of humoral responses against HPV16 VLPs after nasal vaccination, we localized the immune inductive sites and identified the antigen-presenting cells involved using a specific CD4(+) T-cell hybridoma. Our results show that the trachea, the lung, and the tracheobronchial LN were the major sites responsible for the induction of the immune response against HPV16 VLP, while the NALT only played a minor role. Altogether, our data suggest that vaccination strategies aiming to induce efficient immune responses against HPV16 VLP in the female genital tract should target the lower respiratory tract.