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Aumento de espesor de la capa basal, que ocupa el 30% de la altura del epitelio, con mantenimiento de una basal integra. O SlideShare utiliza cookies para otimizar a funcionalidade e o desempenho do site, assim como para apresentar publicidade mais relevante aos nossos usuarios. Basal cells in the cervical epithelium rest on the basement membrane, which is supported by the dermis.
Nell’ambito delle infezioni ginecologiche, quelle da virus del papilloma (HPV) rivestono particolare importanza, per l’aumentata frequenza (incremento del 700% negli anni 60-80), per i loro stretti rapporti con i tumori del basso tratto della sfera genitale femminile, per la multifocalita delle lesioni genitali indotte, per la latenza subclinica e infine per le modalita di contagio.
Gli HPV sono virus nudi (senza pericapside), possiedono un capside icosaedrico con un diametro attorno a 50 nm, formato da 72 capsomeri che possono essere pentameri o esameri. Il DNA di HPV codifica per proteine precoci (early, nomenclate con la lettera E seguita da un numero) e tardive (late, nomenclate con la lettera L seguita da un numero) (15). La proteina E2 partecipa alla trascrizione del promoter di E6, attiva E1 e possiede capacita transattivatrice.
La proteina E4 e espressa nelle fasi tardive dell’infezione ed e molto importante nella maturazione e proliferazione virale. La proteina E5 blocca l’esposizione dei complessi di istocompatibilita di tipo I e II, evitando la risposta cellulare T mediata. La proteina E7 si lega alla proteina del retinoblastoma (Rb), impedendo il blocco del ciclo cellulare.
In virtu delle loro proprieta leganti ed inattivanti gli oncosoppressori come p53 e Rb, le proteine codificate dal genoma virale promuovono un’intensa replicazione cellulare che esita verso la formazione di papillomi, condilomi, iperplasia epiteliale focale, verruche e carcinomi. Una volta che l’HPV e entrato dentro la cellula fa sintetizzare alla cellula infettata due proteine chiamate E6 e E7, che si legano e inibiscono le proteine oncosoppressive RB e p53.
L’oncoproteina E7 e una piccola proteina idrosolubile costituita soltanto da 98 amminoacidi, scarsamente immunogenica. La capacita oncogena del virus e inoltre condizionata dalla risposta immunitaria dell’ospite che da sola puo indurre guarigione spontanea senza alcuna terapia. E inoltre importante ricordare che anche le donne che hanno lo stesso partner da anni devono sottoporsi a controlli per la prevenzione del tumore del collo dell’utero. I ceppi di HPV ad alto rischio 16 e 18 che provocano il cancro della cervice, non si manifestano invece attraverso i condilomi, ma con modificazioni displasiche che possono evolvere in cancro  a livello della mucosa vaginale e della portio. Il grado di precisione diagnostica nell’esame citologico cervico-vaginale non e sufficiente per individuare tutti i casi di infezione (percentuale di falsi negativi non eliminabile del tutto).  E’ sempre opportuno, soprattutto in caso di ASCUS o LSIL,  associare alla citologia la colposcopia e il controllo bioptico mirato delle lesioni sospette. Sebbene LSIL (comprendente infezione da HPV, displasi lieve, CIN1) sembra essere un’espressione benigna dell’infezione da papillomavirus, i fattori di rischio per lo sviluppo di questa lesione squamosa, sembrano essere distinti da quelli associati all’infezione da HPV, il che suggerisce che lo sviluppo della LSIL non corrisponda ad una semplice infezione da papillomavirus. Recenti studi, effettuati su donne adulte, hanno dimostrato che una percentuale compresa tra il 20% ed il 40%  per cento di queste LSIL, potevano evolvere verso lesioni di alto grado (HSIL termine in cui sono compresi displasia moderata e grave, CIS, CIN2, Cin3, Carcinoma in situ), con solo il 50-60% di regressione spontanea in relazione al grado di immunocompetenza individuale (19). Recidive: La frequenza delle recidive e strettamente connessa con lo stato immunitario delle pazienti. Science, Technology and Medicine open access publisher.Publish, read and share novel research. Por encima de esta capa, las celulas muestran anisonucleosis y vacuolizacion citoplasmatica (koilocitos).
Human papillomavirus (HPV) is thought to access the basal cells through micro-abrasions in the cervical epithelium.
Ciascun capsomero da origine a una protuberanza che ha una forma simile a una stella a cinque punte con un canale al centro. E in grado di legarsi alle proteine citoscheletriche, provocando la deformazione delle cellule infettate (coilocitosi). La proteina E5 inibisce inoltre l’apoptosi e altera i segnali promossi dal legame di EGF e di PDGF con i rispettivi recettori. Secondo MC Ardle  l’HPV, riducendo la densita delle cellule di Langherans epiteliali, puo diminuire la sorveglianza immunitaria locale e avere cosi un effetto promotore nello sviluppo del cancro cervicale. Sebbene i profilattici forniscano una certa protezione, non proteggono sempre dalla trasmissione di infezioni perche non coprono tutte le zone genitali. Tuttavia, una piccola  percentuale di donne non elimina il virus e corre pertanto un maggior rischio di sviluppare anomalie del collo dell’utero. Generalmente, i segni piu comuni dell’infezione sono le verruche (verruche comuni, verruche plantari, verruche genitali) da riferire ad infezioni da parte di HPV a basso rischio (6 e 11). Il virus va ricercato sulle cellule raccolte con un normale striscio vaginale e della portio come per pap-test o meglio thin-prep. La percentuale di recidive nella popolazione trattata per lesioni da HPV e di circa il 20%, tale percentuale sale al 65% se valutiamo un gruppo di pazienti immunocompromesse.
Si pratica esame penescopico e  prelievo solo sulle zone di lesione piu significative; Molte volte le lesioni si mettono in evidenza solo dopo trattamento con ac. Histologically, CIN grading is based upon the proportion of the surface epithelium composed of undifferentiated cells characteristic of the basal layer. L1 and histological sectionsAs already mentioned earlier colposcopically guided punch biopsies are taken during the follow up of women with abnormal Pap smears as step 2 of the 3 step strategy of cervical cancer prevention.Negri and colleagues [27] pointed out in their study that the possibility of predicting the behavior of low-grade cervical lesions could be of high value in clinical practice, potentially allowing an individualized management of cervical lesions depending on their progression risk. Not using p16, but a type-specific HPV-DNA Chip, it was possible for the first time to correlate the HPV type with the regression of the L1 positive CIN1 lesions.
Following infection, the early HPV genes E1, E2, E4, E5, E6 and E7 are expressed and the viral DNA replicates from episomal DNA (purple nuclei). Il capside contiene un genoma costituito da DNA circolare a doppio filamento lungo 8 Kb che codifica per otto geni precoci (early, da E1 a E8) e due geni tardivi (Late, L1 e L2).


E impossibile determinare esattamente quando si abbia contratto un’infezione da HPV o da quanto tempo se ne sia affetti. Un’infezione da HPV persistente puo provocare alterazioni cellulari che, se non curate, possono evolvere in un tumore della cervice uterina.
Le verruche a localizzazione genitale vengono definite condilomi e possono riscontrarsi sui genitali esterni, sulla mucosa vaginale, anale e perineale. L1 negative dysplastic lesions as proof of a non-productive, but deregulated life cycle6.2. Cervical cancer and HPVCervical cancer is still the 2nd most common cancer in women worldwide, and especially women in developing countries are suffering from the disease [1].If detected at an early stage Cervical Cancer is preventable. In 2010 and 2011 two Korean studies reported that the prognostic significance of the L1 detection with Cytoactiv for the clinical outcome of early dysplastic lesions can be confirmed for East Asian women as well.Lee et al [25] confirmed 2011 in a prospective trial of 318 women the benefit for Cytoactiv for the management of HPV high risk positive LSIL women.
Hilfrich and Hariri [28] have discribed first, the prognostic relevance of HPV L1 capsid protein detection on paraffin embedded histological sections, initially reported on routinely performed Papanicolaou stained cervical smears and on liquid based cytology (LBC) [18], [19] (see Figure 9). In the upper layers of epithelium (the midzone and superficial zone) the viral genome is replicated further, and the late genes L1 and L2, and E4 are expressed.
Queste lesioni si manifestano come piccole escrescenze, a volte disposte a grappolo, dalla forma che ricorda quella di un cavolfiore (condilomi acuminati). Gli uomini con infezione sub-clinica rappresentano un serbatoio di riserva per reinfezioni successive alla terapia.
L1 detection allows to identify the different progressive potentials of transient HPV infection (red) and precancer (yellow). In almost all places around the world the traditional Pap smear is used as primary screening tool and even from being far away to be a perfect test, the benefits of Papanicolaou based cervical cancer screening programs in reducing morbidity and mortality are well accepted. Le proteine precoci servono a modificare il metabolismo della cellula infettata per metterlo al servizio dell’HPV, mentre le tardive sono le proteine strutturali, che associandosi tra loro formano la struttura icosaedrica del capside virale. In altri casi le lesioni sono piatte (condilomi piani) e tendono a sovrapporsi (9-11). La maggior parte delle lesioni causate da HPV sono asintomatiche, ma in alcuni casi, le verruche possono provocare fastidio, prurito o disagio. About 50 years after Papanicolaou has started his initial work, Meisels & Fortin published in 1976 a report in which they showed that the “halo cell” in pap smears, was a koilocyte - the pathognomic cell of an HPV infection [2] and that low grade or mild dysplasia of the cervix had the histological features of a papillomavirus infection [3].
Of the more than 120 HPV subtypes known today, the anogenital ones are further divided into low risk (LR-HPV) and currently at least 15 high risk types (HR-HPV; HPV 16, 18, 45, 31, 33, 52, 58 are most frequent). The high progression rate of HPV-L1 negative mild and moderate dysplasia emphasizes the precancerous nature of these lesions.
Negri and colleagues [27] included in their approach 38 conization specimens with coexisting cervical intraepithelial neoplasia grade 1 (CIN1) and 3 (CIN3) (group A) and 28 punch biopsies from women with CIN1 and proven spontaneous regression in the follow-up (group B). HPV positive (p16 positive) but L1 negative lesions are high risk lesions whereas on the other hand HPV negative (p16 negative) and L1 negative lesions are ?no risk? lesion or as Negri mentioned could be classified as ?no evidence of CIN?. An unknown number of high-risk HPV infections progress to high-grade cervical intraepithelial neoplasia (HGCIN).
While the former are only in rare cases cancerogenic, HR-HPV are detected virtually regularly in high-grade intraepithelial neoplasias and invasive cervical cancers, of which more than 70% are HPV 16 and HPV 18 [5]. As a clinical recommendation they suggested that a close follow-up with colposcopy and histological evaluation and removal of these lesions should be considered. Figure 9.L1+ CIN2Not surprisingly mixing and not differentiating the L1 negative ?high risk? and the L1 negative ?no risk? entities have to result in ?disappointing? results because remission and progression of the lesions are observed equally.
The progression of untreated lesions to microinvasive and invasive cancer is associated with the integration of the HPV genome into the host chromosomes (red nuclei), with associated loss or disruption of E2, and subsequent upregulation of E6 and E7 oncogene expression. The negative predictive value of the highly sensitive DNA determination of HR-HPV in the cervical smear cell material is with more than 99% very high, i.e. The low malignant potential of HPV-L1 positive cases, however, indicates transient HPV infection, justifying a watch and wait strategy with cytological follow-up thus preventing overtreatment especially for women in their reproductive age. On the other hand the use as primary screening tool for cervical cancer is limited because the positive predictive value of a HPV DNA test is low. As expressed in different phases of cervical carcinogenesis, the authors expected that p16 and L1 are potentially promising markers of progression risk of LSIL.
No positive cases were found in the group of SCC, thus indicating that L1 capsid protein expression tends to decline with increasing severity of the lesions. Besides the original WHO classification [7], The Bethesda System (TBS) [8] is internationally accepted, while the Munich Nomenclature II is being recommended in Germany [9].
Based on Ostors meta-analysis it’s common sense that treatment isn’t warranted for early dysplastic lesions as for atypical squamous cells of undetermined significance (ASCUS) and mild dysplasia (LSIL) since only 10% of the mild dysplastic lesions will progress to CIN3+ [10].
A cytological follow up with colposcopic evaluation is recommended for these women and if necessary directed biopsies of abnormal-looking cervical tissue for diagnosis are taken. L1 negative dysplastic lesions as proof of a non-productive, but deregulated life cycleAs already described a tight communication between the virus and the host cell is of critical importance for the viral life cycle. The cervical histopathologic diagnoses of these samples are graded according to the cervical intraepithelial neoplasia (CIN) system as normal, CIN1, CIN2, CIN3, and cervical cancer [11].
So far diagnosis of CIN2 or worse is the clinical threshold leading to ablative or excisional therapy in the United States and Europe.In the meantime a discussion started if moderate dysplasias, the cytological CIN2 equivalent, should be called low grade or high grade lesion.
As long as the L1 capsid protein can be detected within the nucleus of dysplastic cells the virus was successful in this ?walk on the edge?. Ostor reported that only 20% of the moderate dysplasitic lesions progressed to CIN3+, typically a threshhold that should not warrant invasive procedures. Despite of all viral activities the cells are still in the condition to allow the normal, productive life cycle of the Human Papilloma Viruses.


L1 capsid protein negative dysplasias, however, are due to this virally induced cellular deregulation processes no longer capable to produce virions.
Therefore more specific tools like prognostic markers would be of great value, allowing an individualized management of cervical lesions depending on their risk profil.
A shift from a productive HPV infection towards a non-productive or precancerous lesion has occurred. The reasons for this event are multifarious since the differentiation dependent expression of L1 is controlled at multiple levels.
HPV L1 detection as prognostic marker for early dysplastic lesionsOver the last couples of years cytological samples as well as colposcopically guided punch biospsies, have been used to determine if Cytoactiv HPV L1 detection is able to predict the clinical outcome of HPV high risk positive early dysplastic lesions.Moderate dysplastic lesions, being part of HSIL, have been investigated as well since the Munich nomenclature II, in contrast to TBS, groups moderate dysplastic lesions, together with mild dysplasias, in the category IIID, with recommendation for cytological follow up and colposcopy. This different risk assesement offered the unique possibility to follow up these women with moderate dysplasias as well.
The HPV L1 capsid protein and the viral life cycleL1 or the major capsid protein is one of eight known HPV specific proteins (E1, E2, E4, E5, E6, E7, L1 and L2). Loss of L1 due to integration of the HPV genomeIntegration of the viral DNA is considered to be of critical importance for the progression from CIN to cancer, since the frequency of HPV-16 viral integration increase in parallel with the severity of cervical lesions. It is produced within the cytoplasm and translocated into the nucleus, clearly visible by strong nuclear immunochemical staining reaction in intermediate and superficial squamous epithelial cells.
During the integration process of the HPV genome into the host chromosome a linearization of the ring – shaped, episomal viral DNA is required. It’s easy to imagine, that this non directed event is regularly associated with a deregulation of the strictly controlled episomal DNA.
The capsid is composed of 72 L1 pentamers, linked to each other by disulfide bonds, and associated with the minor capsid protein L2, which encapsulates the viral DNA to build new infectious viral particles that are released in the upper epithelial layer.
But for the background that many of the HPV-associated cancers do not even carry any integrated viral genome [31], [33] additional mechanisms have to exist to block L1 expression. The virus genome then separately lies outside the chromosomal DNA of the host cell as a ring-shaped, episomal DNA molecule.These initial steps are not associated with cellular changes that can be detected by morphological methods. This individually variably long so called latent or silent virus infection can only be detected with molecular biological methods. Loss of L1 in precancerous lesions with an episomal HPV genomeControl of gene expression by epigenetic modification of distinct DNA sequences is a fundamental biological process, which affects for example embryonic development, cellular differentiation and others.One important mechanism, affecting the chromatin conformation, is the methylation of DNA, specifically at cystidine-guanidine (CpG) dinucleotides. The signals to leave the latent virus infection and to initiate the productive or permissive phase of the viral life cycle, leading to a L1 synthesis, are not identified yet. Once differentiation of the immature squamous epithelial host cells begins, the viral DNA starts to replicate to high copy numbers. Alterations were observed particularly in the control region, and the L1 and L2 gene in high grade precancer and invasive cancer. In the further course and dependent on the host cell differentiation the late proteins are synthesized, and encapsidates the viral DNA. These observations lead to the suggestion that the lack of expression of these genes may be attributed at least in part to increasing methylation of the respective parts of the viral genomes. Thus, mature, infectious viruses emerge, which are released from the perishing superficial squamous epithelia [16].
Within the scope of this productive phase, morphological epithelial changes mostly occur after several weeks or months post infection, which allow the cytological diagnosis of dysplasia in the smear. The typical morphological changes like nuclear enlargement, multinucleosis, changes in the chromatin structure and cytoplasm composition as well as koilocytes or ?halo cells? have already been described by Papanicolaou.Upon termination of the productive phase, the viral life cycle from primary infection to the release of the virus is completed without any malignant neoplasia having occurred (Figure 1). In addition E2 expression seems to be strictly linked to the differentiation process from normal to malignant cells, indirectly affecting L1 expression as well. Study resultsA particular methodical advantage of the L1 capsid protein detection is that the protein is synthesized in the cells of the superficial layer of the epithelium that are easy to obtain by taking a smear (see Figure 2).The typical L1 staining is a strong, homogenous nuclear stain (Figure 3-7), in contrast to other markers, leading to a very good interobserver reproducibility. One major problem was the well known high frequency of point mutations leading to a loss of the relevant epitopes, and false negative results as a viral strategy to escape immune recognition. This high variability is in clear contrast to the stability of epitopes recognized by antibodies detecting cellular proteins, like p16 or ki67. During the product development of Cytoactiv it was possible to increase the sensitivity significantly by extensive selection processes generating an optimized antibody detecting a specific epitope.Nevertheless there were a small number of cases where it was impossible to detect the L1 capsid protein. During a follow up time of 23 month they showed that the HPV high risk associated mild to moderate dysplastic squamous lesions without immunochemically detectable HPV L1 capsid protein progressed significantly more likely to CIN3+ (76,4%) than the L1 positive cases (23,6%).Similar results were reported by Rauber et al. They reported that none of the L1 positive patients showed a progression towards cervical cancer and on the other hand all progredient cases were found to be L1 negative.
The ThinPrep Imager allows the automated evaluation of the L1 stained slides, to speed up the reading process [22]. The benefit of computer based automatisation can be extended to conventional Pap smears and SurePath slides as well if choosing BD?s focal point system.The first prospective randomized study was published in 2009 by Griesser and colleagues [23].
The study included 211 HPV High risk-positive mild and moderate dysplasias (LSIL and HSIL) with a follow-up of the patients up to 48 months.



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