Looking Human Papilloma Virus
Looking Human Papilloma Virus
Urdinola Jaime MD
Medical Association Andes CS AK 9116 20 326 Bogotá DC Colombia
Phone 571/215 23 00
e-mail: jaimeurdinolamd@gmail.com - jurdinol@uniandes.edu.co
blogger: http://www.urdinola.blogspot.com/ www.urdinolamenopausia2.blogspot.com
Symposium / Luncheon on Women's Health and Menopause
Medical Association de los Andes - Board Room - Wednesday, March 26, 2008
Introduction
prevention programs for cervical cancer, initiated since the early sixties in the United States (U.S.) have been based until now on cervical-vaginal cytology (CCV). Although these programs have reduced cervical cancer incidence in many industrialized countries between 20 and 90%, the limited sensitivity of cervical cytology - range from 30 to 87% 1 - makes the maintenance of these programs is difficult and expensive 2.
The latest figure known in Colombia uterine cancer mortality (without discrimination if the cervix or body) is that of 2126 cases in 2005 3.
test DNA (deoxyribonucleic acid) to locate and identify HPV
Since 2007 is available to gynecologists in Colombia a test for finding the high-risk types of human papilloma virus (HPV), through hybrid capture technique (CH2-HPV). With the arrival of this review, which is considered slightly more sensitive and less specific - only in women under 30 years - the CCV, the question arises whether in the coming years will witness the change in the pursuit of cervical cancer only through this technique. Now is expected to be used initially by a combination of CCV and CH2-HPV, but as more data are known to search large studies of cervical cancer, is likely to become clear that the LCC will provide little advantage over the use of CH2-HPV in a unique way. Therefore, to the future, CH2-HPV would be used for search and CCV reserved as a step to determine which HPV-positive women require additional colposcopy for follow up.
For purposes of the last decade before the present century much progress was achieved in understanding the pathogenesis of cervical cancer. Today we know invasive cervical cancer that is caused by infection with one or more of approximately 15 high-risk HPV or oncogenic, which can be detected specifically with the 2 nd test. generation of molecular type, which can overcome the limitations of the search by CCV.
This could provide greater protection for women against cervical cancer, although it would be desirable and necessary that the cost is lower in the future. The molecular test most widely used today in clinical specimens is evidence of hybridization in solution called Hybrid Capture 2 (hc2).
The company produces, initially called Digene Diagnostics, Gaithersburg, MD U.S. Identifies high-risk HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68 in a test designed to "pool". Has been approved by the FDA (Federal Drug Administration Food and USA) and widely applied in Europe. Its sensitivity shown in European studies of 97-98%, almost double that of the CCV and its specificity is between 93-95% 2.4. When using the CH2-HPV and CCV together, the negative predictive value is extremely high, 99.9% in most studies. This means that the risk of having a neoplasm intracervical (NIC) Type 2 + was not observed in women in whom cervical cancer has sought both tests is very low, approximately 1 in 1000. The lower sensitivity in young women under 30 years is due to the high prevalence of HPV seen in late adolescents and young women, because of multiple partners present in the years following the initiation of sexual activity with the consequent development of sequential infections with different types of HPV. However, it is known today that most of these infections are transient. As the years go by women tend to have fewer sexual exposures and thus less new HPV infections, which causes the decline of HPV prevalence in women over 30 years.
Given the high negative predictive value associated with the two tests when both are negative, it was recommended that in this case is not necessary to revisit the women until 3 years after 5. This would save considerable resources of a costly for society and the state in the search or screening for cervical cancer.
daily clinical management problems - ASCUS and monitoring after treatment
One of the biggest problems when CH2 is used as driving-HPV positive women with HPV-negative CCV 5. The available studies show that the risk is less than 2% in the next 2 years for CIN 2 +, which is a low risk and are similar to those with negative CCV but not knowing the status of HPV, compared with those with ASC -US 6 (atypical squamous cells of undetermined Significance = atypical squamous cells of undetermined significance), the risk is between 5 and 17% in the latter case.
guidelines published in 2007 7, based on the low risk, recommended that in case of positive HPV CH2-negative CCV is not appropriate to have a colposcopy immediately, but to repeat both tests at 6-12 months. The CH2-HPV identified that half of patients with ASC-US were negative for malignancy.
A meta-analysis in the Netherlands and based on 9 prospective studies 8 CH2-HPV recommended for the control and subsequent monitoring of CIN 3. The negative predictive value obtained for recurrent disease / residual after treatment was 98% higher than the state of the resection margins, 93%, although these values \u200b\u200bbecome higher when combined with the CCV, 99% in both cases. Authors recommend control women with CIN 3, at 6 months with both tests. In case of positivity of one of the 2 tests, colposcopy should be done to these women. However, in 70% of women, according to their findings, both tests are negative at 6 months, making it possible to omit them control at 12 months. Recommended anyway dual control at 24 months, the risk of reinfection with high-risk HPV. If both tests come back negative in this time, you may refer them to the program routine screening.
Future According to the studies that have clearly shown that women infected with HPV 16 and 18 are at higher risk to develop a NIC 2 +, as other women infected by other high-risk HPV, are expected in the future the application of tests to identify the genotype of HPV 16, 33, 45 or 31, which are the 5 most common types found in cervical cancer.
The purpose of the search and cervical cancer screening is to reduce but not eliminate the risk of cervical cancer among the population subjected to screening or screening. Having a test such as CH2-HPV is to have available a molecular technique, which for reasons of sensitivity can make the CCV into obsolescence in the future.
important thing for the views expressed in this symposium, is to note that when new technology is introduced into daily clinical use, are present confusion unless you know what to do with the knowledge acquired for the benefit of patients. This technique is part of the concept of better define the risk in the detection of CIN 3, although treatable, to control the following query to determine how often and how intense must be measures in the monitoring or treatment patients. The previous model of the LCC and the associated additional colposcopy histology of biopsy obtained is a static model of false certainty, if not precisely the risk projected into the future and appropriate clinical response. Also, over time their use can save huge financial resources which are currently unavailable.
Representative Clinical Cases
A-grade squamous intraepithelial lesion low grade in the VCB, followed by a colposcopy directed biopsy, which showed a CIN 1
B-ASC-US in the CCV with CH2-HPV positive, why was colposcopy, during which no abnormalities were found
Some clinicians might consider treatment of histologically confirmed CIN 1 in the case A. But in fact both women, cases A and B have the same risk of 10 to 15% for the detection of CIN 3 / cancer in the next 2 years
C-Young woman under 30 who recently started their sexual life presents CH2-HPV positive, but its routine use is not recommended because the positive predictive value real and the risk is low, because with or without detectable lesions in the CCV, has a high probability that if you have an injury, this return spontaneously
Highlights
● The CCV has limited sensitivity in detecting cervical cancer in Colombia
● You will have modern DNA testing to identify high-risk HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68
● This test allows to accurately identify women at risk for cervical cancer clarify the diagnosis and management of those who have ASC-US, and control those treated for CIN 3
● Its proper use will save financial resources to the program based on CCV
References
1 - Nanda K, McCrory DC, Myers ER, Bastian LA, Hasselblad V, Hickey JD, Matchar DB. Accuracy of the Papanicolaou test in screening for and follow-up of cervical cytologic Abnormalities: a systematic review. Ann Intern Med . 2000;132:810-9.
2- Wright TC. Cervical cancer screening in the 21st Century: Is it time to retire the PAP Smear ? Clin Obstet Gynecol. 2007; 50:313-23.
3- “Fuente: Departamento Administrativo Nacional de EstadÃstica: http://www.dane.gov.co/ ”.
4- Castle PE, Sideri M, Jeronimo J, Solomon D, Schiffman M. Risk assessment to guide the prevention of cervical cancer. Am J Obstet Gynecol. 2007; 197:356.e1-6.
5- Khan MJ, Castle PE, Lorincz AT,et al. The elevated 10-year risk of cervical pre-cancer and cancer in women with human papillomavirus ( HPV ) type 16 or 18 and the possible utility of type-specific HPV testing in clinical practice. J Natl Cancer Inst. 2005; 97: 1072 -1079.
6-. Sherman ME, Schiffman M, Cox JT. Effects of age and human papilloma viral load on colposcpy triage: Data from the randomized atypical squamous cells of undetermined significance / low- grade squamous intraepithelial lesion triage study (ALTS). J Natl Cancer Inst. 2002; 94: 102-7.
7- Wright TC, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D, and for the 2 006 ASCCP-Sponsored Consensus Conference. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. Am J Obstet Gynecol 2007; 197:346-55
8- Zielinski GD, Bais AG, Helmerhorst THJ, Verheijen RHM, of Schipper FA, Snijders PJF, Voorhorst FJ, van Kemenade FJ, Rozendaal L, Meijer CJLM. HPV testing and monitoring of Women after Treatment of CIN 3: Review of the literature and meta-analysis. Obstet Gynecol Surv. 2004, 59:543-53.
If you have any comments, questions or concerns, you can "click" on comments and sending your message.
Or if you prefer, you can send your comments, questions or concerns e-mail jaimeurdinolamd@gmail.com
0 comments:
Post a Comment