Vacuna frente al virus del papiloma humano y cribado de cáncer de cuello de útero

The HPV vaccine is a primary preventive strategy against cervical cancer. It is highly effective and safe, but its implementation does not preclude the need to maintain a secondary prevention protocol for all vaccinated women.     

Enfermedad de Bowen vulvar. Relación con el virus del papiloma humano

Bowen's disease of the vulva, also called vulvar intraepithelial neoplasia (VIN), is considered a premalignant lesion of the external genitalia. VIN of viral etiology is most often associated with human papillomavirus (HPV) subtypes 16 and 18 and typically occurs in younger premenopausal women. The main risk factor for HPV acquisition is sexual activity. We report the case of a young patient, a carrier of HPV subtype 16, with cervical intraepithelial neoplasia grade 3, who developed severe VIN. Wide local excision of the labia minora was performed. The cosmetic results were satisfactory and the patient has had no relapses after 3 years of follow-up.     

Encuesta sobre el uso en España de la prueba para la determinación del virus del papiloma humano

Objective

To determine knowledge of the Spanish guidelines for cervical cancer screening, and to evaluate the use of tests for the detection of human papilloma virus (HPV) by Spanish gynecologists.

Subjects and methods

The survey focused on gynecologists who were members of the Spanish Society of Gynecology and Obstetrics and the Spanish Association of Cervical Pathology and Colposcopy. One hundred forty-one specialists completed the questionnaire.

Results

Thirty percent of the target population participated. A total of 95.6% were aware of the recommendations and 93.5% routinely used the test for the detection of the HPV (77.7% for cervical cancer screening). The criteria for the use of the test varied considerably among participants. The main reason for not using the technique was its unavailability.

Conclusions

Training and information on the available recommendations for the new screening strategies and, particularly, on the clinical use of HPV determination should be reinforced.     

Cribado de cáncer cervical con citología y test del virus del papiloma humano cada 5 años: una realidad

Objective

To analyze screening for cervical cancer with a combination of cytology and HPV testing in women older than 35 years every 5 years and to determine whether the application of this protocol delays diagnosis of cervical cancer.

Material and methods

Cervical cancer screening strategies have been applied in our hospital since 2005. HPV testing was introduced in 2010 for women older than 35 years. We performed a retrospective study of 500 women attended in our hospital. We studied whether we had correctly applied the strategy and the recommended time interval of the next review. We analyzed cervical cancers diagnosed in our hospital since 2005.

Results

The strategy was correctly applied in 100% of the women. Screening was performed with both cytology and HPV testing in 45.6% and with cytology alone in 23.2%; no screening was performed in 31.2%. The recommended interval until the next review was 5 years in 26% of the patients. The implementation of the strategy did not delay the diagnosis of cancer. Cervical cancer was diagnosed in 27 women since 2005. Only one woman with adenocarcinoma had been correctly screened (before the introduction of HPV testing). In the last 2 years, four microinvasive carcinomas were diagnosed with this strategy.

Conclusions

A combination of cytology and HPV testing can be applied in women older than 35 years and screening intervals can be increased to 5 years in routine clinical practice. This protocol does not delay the diagnosis of cervical cancer and optimizes resources by lengthening the interval between screening tests in healthy women.     

Infección natural y vacunas frente al virus del papiloma humano: papel de los anticuerpos en la protección a largo plazo

The human papilloma virus (HPV) causes limited infection of the cervical epithelium, which results in only limited stimulus of the immune system, meaning that the innate immune response of the host is very limited. Therefore, natural infection provokes very-low levels of antibodies which, in some cases, is not sufficient to prevent new infections, even by the same types of HPV.     

La infección por virus del papiloma humano,una amenaza real para las adolescentes

We performed a study on cervical pathology in adolescents in the Clodomira Acosta Ferrales Obstetrics and Gynecology Hospital between January 2006 and May 2007, in which 340 sexually active adolescents were evaluated.     

Impacto de la vacuna tetravalente frente al virus del papiloma humano (VPH) tipos 6, 11, 16 y 18 en las enfermedades asociadas al VPH en España

Objective

To assess the potential epidemiologic and economic impact of vaccination with the human papillomavirus (HPV) quadrivalent (types 6/11/16/18) vaccine in Spain.

Methods

We used a transmission dynamic model developed for the United Kingdom and applied to Spain by using Spanish-specific epidemiologic and economic data obtained from the literature, databases, and previous epidemiological studies. It was assumed that any vaccination strategy would be implemented in combination with current HPV screening and treatment programs. The strategy of routine vaccination of a cohort of 11-year-old girls was used, alone or in combination with catch-up vaccination in 12-24-year olds.

Results

In the long term, vaccination of girls and young women would reduce the incidence of cervical cancer by 86%, precancerous cervical intraepithelial neoplasia (CIN) II/III lesions by 85%, CIN I by 79% and genital warts by 81% related to HPV 6, 11, 16 and 18. Overall, vaccination would reduce the total cost related to HPV 6, 11, 16 and 18 infections by 83.5%. Catch-up vaccination of 12 to 24-year-old females would save 77% of the costs avoided in the first 10 years of the program. In the first few years of vaccination, most of the cases and costs avoided would be attributable to the prevention of HPV-6- and 11-related diseases.

Conclusions

Implementation of vaccination programs with the HPV quadrivalent vaccine, combined with current screening programs, would significantly reduce the number of cases of cervical cancer, precancerous lesions and genital warts in Spain. Vaccination of girls and women aged 12 to 24 years not included in routine vaccination programs would result in a greater and earlier reduction in the incidence of diseases related to HPV 6, 11, 16 and 18.     

Utilidad de la determinación del virus del papiloma humano en el primer control tras una conización

Objective

To estimate the negative predictive value of human papilloma virus (HPV) status in the first visit at 3 months after conization.

Material and methods

We evaluated the first follow-up visit in 208 patients who underwent conization in Hospital Donostia between January 1, 2003 and December 31, 2006.

Results

The negative predictive value of HPV status at 3 months after conization was 97.99% (95% CI 95.40-100), the positive predictive value was 47.92% (95% CI 32.74-63.09), sensitivity was 88.46% (95% CI 74.26-100) and specificity was 85.38% (95% CI 79.79-90.97).

Conclusions

Negative HPV status 3 months after conization is useful to evaluate cervical disease and could reduce the number of cytological examinations.     

La inmunosupresión es un factor mayor de riesgo en la recidiva de las lesiones del tracto genital inferior asociadas al virus del papiloma humano

Objective

To analyze the characteristics of preneoplastic lesions of the lower genital tract (LGT) and the factors associated with their recurrence.

Material and methods

A total of 376 women treated for some type of intraepithelial neoplasm of the LGT between 1990 and 1999 were studied. The lesions were classified into cervical intraepithelial neoplasms (CIN) and vulvar intraepithelial neoplasms (VIN) and were further classified into high-grade lesions (CIN 2-3 or VIN) and low-grade lesions (CIN 1 or human papillomavirus vulvar atypia [HPV-VA]). Treatment of cervical lesions consisted of CO2 laser and / or loop electrosurgical excision while that of vulvar lesions consisted of cold-knife local excision and / or CO2 laser.

Results

The mean age of women was 32 years. Multicentric disease was found in 57% of CIN lesions and in 87% of vulvar lesions. Ten percent of women in both groups had some type of immunosuppression. High-risk HPV was identified in 25% of patients. With a mean follow-up of 21 months, the overall CIN recurrence was 17% and accumulated recurrence rate at 5 years was 47%. In vulvar lesions, these values were 15% and 54%, respectively. In both groups, more than 90% of recurrences occurred in the first 3 years, and relapse was associated with immunosuppression and high-risk viral genotype. In multivariate analysis, the only independent risk factor was immunosuppression. None of the lesions progressed to invasive cancer.

Conclusions

The most important risk factor predictive of recurrence is immunosuppression. Measures to stimulate immunity could be effective in preventing HPV-related disease.     

Evaluación de un nuevo protocolo de cribado de cáncer cervical con citología convencional y test del virus del papiloma humano

Objective

To compare the effectiveness of cervical cancer screening using cytology plus the high risk human papillomavirus (HR-HPV) DNA test in 2011 versus cytology alone in 2010.

Method

Screening was performed in primary care. The target population in the Barbastro sector consisted of 26,936 women (aged 25 to 65 years). The HPV test was performed with hybrid capture (HC2) and the PCR cobas^® system in women between the ages of 30 and 65 years. Women with negative Pap and HPV test results underwent a 5-year recheck as per the latest protocol of Spanish Society of Obstetrics and Gynecology (SEGO, 2010).

Results

A total of 4,770 Pap tests were received in 2010 and 5,241 in 2011 with coverage between 36.8 and 46.8%; 784 HPV tests were carried out in 2010 and 3,560 in 2011, with positive results in 10.58% the first year and in 7.5% the second year. Eighteen new cases of cervical intraepithelial neoplasia grades 2/3 were diagnosed in 2010 and 35 in 2011, along with 3 invasive carcinomas each year (in 2011, 3 microinvasive carcinomas).

Conclusions

The implementation of HPV testing in primary screening for cervical cancer increased the number of pre-invasive lesions detected by 98% in the year of its introduction. Primary Care involvement allows screening for cervical cancer to be performed without additional costs.     

Impacto sanitario y económico de la vacunación frente al cáncer de cérvix y lesiones precursoras en España

Objective

To evaluate the healthcare and economic impact of vaccination against cervical cancer with the HPV 16/18 AS04-adjuvanted vaccine (Cervarix^®) in Spain from the perspective of the national health system.

Material and methods

A health economics model was adapted to the Spanish environment. The model simulated the impact of current vaccination programs on the burden of precancerous lesions and cervical cancer. National epidemiological data and the vaccine efficacy shown in clinical trials were used.

Results

Considering the average vaccination coverage in Spain, the model estimated that vaccination with Cervarix^® would prevent 45,060 cases of atypical squamous cells of undetermined significance (ASCUS), 35,166 cases of low-grade squamous intraepithelial lesions (LSIL), 29,549 cases of high-grade squamous intraepithelial lesions (HSIL) and 1,053 cases of cervical cancer. Thus, vaccination would save 89,271,085 € in direct medical costs.

Conclusions

Vaccination with Cervarix^® in Spain would significantly reduce the number of cases of cervical cancer and precancerous lesions and the associated medical costs.     

Prevalencia de la infección por el virus del papiloma humano en mujeres con citologías anormales del cérvix uterino y factores de riesgo asociados a la infección

Objectives

To determine the prevalence of human papillomavirus (HPV) infection in women with an abnormal pap smear of the uterine cervix and to determine the risk factors associated with HPV infection.

Subjects and methods

Eighty-one women with a cytological result of atypical cells of unknown origin (ASCUS), low-grade squamous intraepithelial lesions (LG-SIL) or high-grade squamous intraepithelial lesions (HG-SIL) were referred for epidemiological questionnaire, HPV detection performed using the Hybrid Capture II^® test, histological study, and analysis of other sexuallytransmitted diseases.

Results

Cytologic study identified 16 women with ASCUS, 44 with LG-SIL and 21 with HG-SIL. The global prevalence of HPV infection was 67.9% (55 patients) and high-risk HPV (HR-HPV) infection was detected in 50 patients (61.8%). The percentages of HR-HPV infection in women with ASCUS, L-SIL and H-SIL were 31.2%, 63.6% and 80.9%, respectively. The number of sexual partners over a woman’s lifetime was significantly associated with HPV infection (χ² for trend: 4.187; p = 0.0407).

Conclusions

Women with ASCUS detected by cytology are those who could most benefit from HR-HPV detection techniques, because of the lower prevalence of the infection. The main risk factor associated with HPV infection was the number of sexual partners over a woman’s lifetime.     

Patología del tracto genital inferior asociada al virus del papiloma humano en mujeres españolas

Objective

To assess the frequency of lower genital tract lesions associated with human papillomavirus (HPV) infection in Spanish women attended in routine gynecology practice.

Material y methods

We performed an observational, retrospective, cross-sectional, multicenter study in which participating gynecologists collected information on women attended in the previous 6 months with a diagnosis of intraepithelial neoplasia of the cervix (CIN), vagina (VaIN), vulva (VIN), adenocarcinoma in situ (AIS) and/or genital warts.

Results

The study population consisted of 5,665 women (median age 32 years) attended by 385 gynecologists, with a total of 6,200 diagnoses (de novo 82.5%).The majority of diagnoses were CIN (71.6%), followed by genital warts (20.8%), AIS (3.6%), VIN (2.0%) and VaIN (1.9%). In patients with CIN and VaIN, the most frequently diagnosed lesions were grade 1. Independently of the grade of the lesion, most patients with a diagnosis of CIN were aged 30 to 44 years (90% were under 45 years). Most of the women with VaIN grade 1 (71%), AIS (77.2%) or genital warts (96%) were also younger than 45 years. In contrast, most of the diagnoses of VaIN grades 2 and 3 corresponded to women older than 45 years. There were no differences in the frequency of diagnosis of VIN among age groups.

Conclusions

Among lower genital tract lesions associated with HPV infection, the most frequent diagnoses made by Spanish gynecologists were CIN and genital warts (representing approximately 70% and 20% of all cases, respectively). Most of the burden of disease was found among women aged between 30 and 44 years (CIN, any grade, AIS and VaIN grade 1). Genital warts mainly occurred in women younger than 30 years, while VIN and VaIN grade 2 and 3 lesions were more frequently diagnosed in women older than 60 years of age.     

Epidemiología de las lesiones precancerosas y verrugas genitales asociadas a infección por virus del papiloma humano en España

Objective

The objective of this study was to estimate the number of cytologies and diagnoses of cervical intraepithelial neoplasia (CIN) and genital warts performed annually in Spain.

Material and methods

Two cross-sectional studies based on retrospective data were conducted among a sample of gynaecologists, urologists and dermatologists in 6 Autonomous Regions considered to be representative of the Spanish population. Study data were extrapolated to the general population, taking into account the age and sex distribution of the Spanish population.

Results

Based on the study results, the estimated number of cases of genital warts that occur annually in Spain was 56,400. It was, also, estimated that 7.6 million cytologies were performed annually in Spain and that 40,530, 26,243 and 28,423 women are annually diagnosed with CIN 1, CIN 2 and CIN 3, respectively.

Conclusions

Lesions related to human papilloma virus (HPV) infection cause substancial morbidity burden in Spain.     

Hospitalizaciones por cáncer de cuello de útero en la Comunidad de Madrid, 1999-2002

Objective

The aim of this study was to assess the frequency and characteristics of cervical cancer hospitalizations in the Autonomous Region of Madrid, and to estimate the resource consumption and costs related to hospital treatment of the disease.

Methods

A retrospective study was conducted by using information of the cervical cancer patients hospitalized in the Autonomous Region of Madrid from the national surveillance system for hospital data, Conjunto Mínimo Básico de Datos. Data on resource consumption for costs analysis was collected from clinical records of women admitted to Hospital Universitario 12 de Octubre of Madrid with cervical cancer.

Results

During the study period (1999-2002) an annual average of 667 hospitalizations with cervical cancer in the Autonomous Region of Madrid hospitals were reported. Hospitalization rate were 30.7 per 100,000 women ≥ 20 years of age and the average number of hospitalizations per patient was 2.2. A total of 126 deaths among hospitalized women were reported during the study period (average annual number of 32 deaths). The mean cost per patient of the hospital treatment was estimated in 5.247 €.

Conclusion

Each year more approximately 700 cervical cancer cases are notified in the Autonomous Region of Madrid hospitals. These represent an annual expenditure for the health care system of about 3,5 millions €.     

Cáncer cervical uterino en el área sanitaria III de Asturias: eficacia del cribado oportunista

Objective

To investigate the number of invasive cervical carcinomas detected in our hospital over a 10-year period (1996-2005), to study the mean age at diagnosis of squamous cell carcinomas, adenocarcinomas, and the relation of cervical screening in its diagnosis. Establish the mean number of negative smears in women without cervical human papilloma virus (HPV) infection.

Material and methods

Data on all diagnoses of cervical cancer, the presence of smear tests prior to biopsy, and the interval between the two procedures were gathered. The Mann-Whitney test was applied. The mean number of negative cytologies without evidence of HPV infection during the period studied was established.

Results

Between 1996 and 2005, 67 cervical carcinomas (49 squamous cell carcinomas and 18 adenocarcinomas) were diagnosed. In 40% cytology had never been performed. The mean age at diagnosis was 59 years for squamous cell carcinoma and was 49 years for adenocarcinoma. The mean number of negative cytologies per healthy woman was 3.59.

Conclusions

Opportunistic screening for cervical cancer, the most common form of screening in Spain, is not accessible to many women with cervical carcinoma and wastes substantial healthcare resources on performing unneccessary cytologies in healthy women.     

Tumores malignos ginecológicos sincrónicos. Casuística del Hospital de Manacor

Objective

To alert clinicians to the possibility of synchronous tumors in patients with gynecological cancer. An important tool in diagnosis is the family history. We describe several familial syndromes involving the development of synchronous gynecological tumors.

Subjects and methods

We studied all cases of synchronous gynecological tumors in the Manacor Hospital from 1997 to 2006.

Results

Synchronous gynecologic tumors represented 0.83% of all gynecological neoplasms treated in our center in the period studied.

Conclusions

This kind of tumor is uncommon but should be considered by clinicians, especially in women with a familial history of cancer or in those with certain genetic syndromes. Examination aimed at excluding the presence of synchronous tumors is recommended.     

Laparoscopia frente a laparotomía para el tratamiento quirúrgico del cáncer de endometrio

Objective

To compare overall survival and disease-specific survival for endometrial cancer with the laparoscopic and laparotomy approaches.

Subjects and methods

We performed a retrospective cohort study that included 235 patients with a diagnosis of endometrial carcinoma who were surgically treated between 2001 and 2010 either by the laparoscopic approach (104 patients) or by laparotomy (131 patients) in our hospital.

Results

Overall survival, disease-specific survival and the disease-free interval were similar in the two groups. In the laparoscopic group, disease-free survival was 85.5% and survival was 80.2%, while in the laparotomy group, disease-free survival was 77.9% and survival was 82.3%, with no statistically significant differences. In the laparoscopy group, operating time was longer and hospital stay was shorter. Except for organ injury, surgical and postoperative complications were similar.

Conclusions

There were no differences in survival or the disease-free interval between the laparoscopy and laparotomy groups. Considering the risks of surgery, laparoscopy is a good alternative to traditional surgery.     

Valoración ecográfica del endometrio en pacientes tratadas con tamoxifeno

Objective

To measure endometrial thickness and characterize ultrasonographic endometrial images induced by tamoxifen, as well as to determine changes in ultrasonographic patterns throughout treatment.

Patients and methods

We analyzed 278 patients with breast cancer between 1995 and 2000 under adjuvant therapy with tamoxifen for 5 years. Annual ultrasonographic examination was performed. Endometrial thickness and the morphological endometrial patterns in stored ultrasonographic images were retrospectively analyzed.

Results

Endometrial thickness significantly increased during treatment from a mean of 7.84 mm in the first year to 16.67 mm in the fifth year. Five endometrial patterns were found on ultrasonography in patients receiving tamoxifen: linear, heterogeneous-hyperechoic, homogeneoushyperechoic, endometrial polyp, and suspicious for malignancy. The homogeneous-hyperechoic pattern predominated in the first year and the heterogeneous-hyperechoic pattern in the fifth year.

Conclusions

Tamoxifen increases endometrial thickness in the course of treatment and induces five ultrasonographic patterns which change year-by-year.