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Find a doctor at The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center or Johns Hopkins Community Physicians. About a week after her annual pelvic exam, 22-year-old Julie* woke up to an unwelcome voicemail from her gynecologista€™s office. The USPSTF recommends that women over 30 undergo routine HPV testing, along with their pap smear, every five years.
Marc Arbyn, an epidemiologist at the Scientific Institute of Public Health in Belgium, agrees.
In spite of the USPSTF recommendations, some doctors choose to perform HPV tests on women under 30. For older women, however, HPV testing can be an efficient tool for determining how to proceed when a pap smear turns up abnormal cells, according to a 2013 review coauthored by Dr. HPV tests are sensitive to cellular abnormalities, but they are less adept at determining the severity of the abnormality, and often return false positives, according to the USPSTF. Despite her youth, Julie was referred for a colposcopy after her pap smear and HPV test revealed abnormal cells. The procedure is invasive, expensive and anxiety-provoking, Cuzick says, a€?So the intent is to focus that on women who actually really need it.a€? The price of a colposcopy can vary, but with additional fees, it usually comes to about $750. Similar to a routine pelvic exam, the patient lies on a table with feet in stirrups, and the doctor inserts a speculum into the vagina and swabs the cervix with vinegar, which turns the abnormal patches white. For patients who dona€™t have a biopsy during their colposcopy, or for patients whose biopsy reveals low-grade abnormalities, a€?you would basically monitor them,a€? says Cuzick. If the biopsy reveals a€?high gradea€? lesions that could be precursors to cancer, however, then the woman will need a larger surgery to have the abnormality cut out. During a loop excision, the doctor uses a low-voltage electrified wire to cut out the abnormal tissue while the patient is under anesthesia. In a cone biopsy, the doctor uses a knife to make a cone-shaped cut and remove the abnormal cells.A  Cone biopsies are slightly more expensive than loop excisions, costing about $1,500, and result in more negative side effects.
Because of these risks, many surgeons hesitate to perform such procedures on women under age 25 unless the cells are at an advanced stage of abnormality, Arbyn says. All comments are moderated, your comment will not appear on the site until it has been approved.
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Learn about the connection between human papilloma virus (HPV), abnormal Pap smears, the immune.
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About 80 percent of people will contract HPV after becoming sexually active, according to the Cleveland Clinic, and about 20 million people have it at any given time. Most people never realize they are infected because the virus generally doesna€™t cause any immediate health problems.
Preventive Services Task Force, women over 21 should have a pap smear (also called cytology) every three years to screen for cervical cancer. Young women with positive HPV tests often dona€™t require any further action other than continued observation, but the test can be distressing, and frequently leads to recommendations for further procedures that can increase the patienta€™s medical expenses and require time off from work, Arbyn says. As a result, colposcopies are over-prescribed a€” particularly for women under 30 who have received an HPV test. Although a quarter of a million women have colposcopies each year, Cuzick says, only 20 percent of them have significant cervical abnormalities. He suggests that patients wait about one year before their next test to see if the abnormalities have disappeared.
Depending on the country, only about 10 to 20 percent of women with positive HPV tests go on to have a more involved procedure, usually either a cone biopsy or a loop excision.
In addition to vaginal bleeding and risk of premature birth, they can cause cervical scarring, which can lead to painful periods and fertility issues. He advised her to schedule a pap smear every six months for up to three years so they could continue to monitor her cervix.
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. Despite its prevalence, there is no cure for HPV, and the lack of clarity about treatment options leaves many women feeling anxious after receiving their diagnosis.
Some types of HPV can cause cells in the cervix to become abnormal, however, eventually leading to cancer. If the cells swabbed from the cervix during the pap smear appear abnormal, there are several ways for the doctor to proceed a€” some order a follow up pap smear, some schedule a biopsy to get a closer look at the cells, and others perform an HPV test, examining the cellsA on a molecular level for DNA from the cancer-causing virus.
Cuzick believes that performing HPV tests on younger women, particularly those under age 25, is unnecessary.
If an HPV test comes back negative for precancerous cells, the American Cancer Society suggests that the woman return to routine screening. Stephanie Blank, an obstetrician and gynecologist at NYU Langone Medical Center, says the speculum is a€?uncomfortable,a€? but that the biopsy amounts to a a€?quick pinch,a€? though there can be irregular bleeding afterwards.


She describes a a€?slight pinchinga€? when the doctor biopsied the cells, but says her recovery time only lasted through the car ride home.
Julie was relieved, but also skeptical about her experience after that initial positive test. 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).
But while practically every woman will be exposed to HPV at some point in her life, cervical cancer is relatively rare, affecting only about 5 percent of women worldwide, says Jack Cuzick, a cancer researcher at Queen Mary, University of London. While young women tend to have more cellular abnormalities, he says, most of their infections disappear within six months. But if the abnormality persists for a year or longer, or if the test comes back positive for a potentially cancer-causingA strain of HPV, the gynecologist will conduct a procedure known as a colposcopy to assess the likelihood that the abnormalities will progress to cervical cancer.
But while loop excisions are highly effective for preventing the recurrence of abnormal cells, they can result in pregnancy complications later on, according to a 2005 study. The vaccines Gardasil and Cervarix consist of three shots over six months, and can protect against cervical cancer; both cost approximately $130.
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.
The CDC recommends that boys and girls receive their vaccinations before becoming sexually active, though people can still be vaccinated until their early twenties. 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]. The lab may test your Pap smear specimen for HPV.LSIL ~ Low-grade squamous intraepithelial lesionThis diagnosis means there are early changes in the size and shape of the cells. 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?. 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. These lesions, in women with intact immune systems, often resolve without intervention within 18 to 24 months. 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.
If it is your first abnormal Pap smear, your doctor will likely recommend a colposcopy (link to above).HSIL ~ High-grade squamous intraepithelial lesionThis diagnosis means the cells appear very different from normal cells. 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. These precancerous lesions are more severe than with LSIL, but involve cells on the surface of the cervix.
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 diagnosis is usually made by a biopsy or endocervical curettage (a gentle scraping of the cervical opening). 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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