The vaccinations against human papilloma virus (HPV) are highly effective in preventing persistent infection. The level of knowledge about HPV and the consequences of an infection with this virus are low in the general population and in patients who suffer from HPV-associated diseases. We aimed to compare the level of knowledge about HPV and about the women’s individual malignant disease between women with and without HPV-associated gynecologic cancer as well as the knowledge about individual malignant diseases.In a pilot study, 51 women with HPV-related cancer  and 60 women with non-HPV associated gynecologic malignancies  were included. They answered a questionnaire including questions about personal medical history, risk factors for cancer development, and HPV.The general level of knowledge of the term “HPV” was low  and it was similar in patients with HPV-related and non-HPV-associated cancer . When asked about their disease, 80% (24/30) of women with ovarian cancer correctly named their diagnosis, followed by women with cervical cancer , endometrial cancer  and vaginal or vulvar cancer .The level of knowledge about HPV and the malignant diseases the patient suffered from was low. This applied even to patients with HPV associated malignancies. Malignancies of the female urogenital tract are among the most common causes of death in women. In addition to adequate medical and surgical treatment, women need detailed information about the risk factors, therapeutic options, including alternatives to standard treatments, as well as possible complications and side effects ,2.Several risk factors for cancer have now been identified. These include age, body mass index (BMI), viral infections, and genetic factors, such as BRCA1 and BRCA2 mutations -6. Both The vaccinations against human papilloma virus (HPV) are highly effective in preventing persistent infection and are well tolerated by patients . The HPVIf a woman is aware of the details of her disease, including information about risk factors, therapeutic options, and consequences, she might find it easier to make her own decisions concerning further treatment options.Moreover, this knowledge might help in coping with the disease. Thus, we consider it a necessity to transmit our knowledge to these patients and make it available to them. In other diseases, it has been shown that an increase in disease-specific knowledge augments medical and surgical treatments by improving quality of life ,14. AlthThe main study objective was to compare the level of knowledge about HPV between women with HPV-associated cancer and women with other gynecologic malignancies. As a second study objective, we aimed to evaluate the level of knowledge about general risk factors that promote cancer development, as well as the level of knowledge about individual malignant diseases.The study was based on the hypothesis that the vast majority of patients who suffer from HPV-associated cancer do not know of the association between HPV and the development of urogenital malignancies. In this pilot study, 51 women with HPV- or possibly HPV-related cancer  and 60 women with non-HPV associated gynecologic malignancies  were included from January 2012 to May 2012. All of these patients were treated at the Department of Obstetrics and Gynecology of the Medical University of Vienna. Only patients who were fluent in written and spoken German were included. To ensure a fast and clean data collection in this pilot study, we aimed to enroll 30 patients per disease type. Due to the low number of patients with vulvar or vaginal cancer, we were unable to enroll 30 women with these types of cancer (n = 21). The ethics committee of the Medical University of Vienna approved the study (IRB number 1202/2011).Patients were asked to participate in the study during the course of their regular follow-up visits at the hospital-based outpatient clinic for gynecologic oncology. After they gave written, informed consent, they had to answer a questionnaire that included questions about personal medical history, risk factors for cancer development, and HPV , and scored as “wrong” if there were two or more mistakes. For removed structures or organs, answers were scored as “correct” if all removed structures had been specified correctly, “partially correct” if there were one or two mistakes, and “wrong” if there were three or more mistakes. The patients had to correctly identify the following risk factors for their individual disease: smoking and infection with HPV for cervical cancer; smoking, infection with HPV, diseases of the skin like lichen sclerosus or vulvar intraepithelial neoplasia for vaginal/vulvar cancer; a family predisposition and a high body mass index for ovarian cancer; and a high body mass index and diabetes for endometrial cancer.Data about patients’ oncologic treatment were reviewed by retrospective chart analysis.Variables are described by frequencies and mean ± standard deviation (SD). Differences in categorical parameters were tested using contingency tables. Metric parameters were analyzed using the Kruskal-Wallis-test. Correlations were tested using Spearman’s rank test. A p-value <0.05 was considered significant. Statistical analysis was performed using SPSS 15.0.1 for Windows .Basic patient characteristics are provided in Table When comparing the knowledge of HPV with the knowledge of the type of disease/the removed structures/the overall treatment , no correlations were found . Moreover, the knowledge of HPV did not differ between the cancer types .When asked about their disease, 80% 24/30) of women with ovarian cancer correctly named their diagnosis, followed by women with cervical cancer , and endometrial cancer 70%, 21/30). Only 42.9% of patients with vaginal or vulvar cancer could identify their illness  . The level of knowledge of the term “HPV” was the same in patients with HPV-related cancer  as in patients with non-HPV-associated neoplasia . Patients with HPV-associated cancer did not know their exact diagnosis significantly more often  and knowledge concerning HPV . There was no significant difference in educational levels between patients with different cancer types (p = 0.763). Answers to questionnaire modules on risk and preventive factors according to the type of disease are provided in Additional file The vast majority of patients reported that doctors had spent enough time with them to answer all their questions. There were no differences in satisfaction about time spent on the individual patient between women with cervical cancer , vaginal/vulvar cancer , ovarian cancer , and endometrial cancer  (p = 0.962). There was no difference in knowledge concerning HPV between patients who were satisfied with the time spent by our physicians on their cases and those who were not (p = 0.144).The diagnosis of a malignant disease is a dramatic life event for most affected people. Despite the fact that malignant diseases affect patients’ quality of life in a substantially negative fashion, women who suffer from malignant diseases of the female genital tract reveal quite a low level of knowledge about their disease and its development.One of the milestones in gynecologic oncology was the identification of HPV as a co-factor in the development of malignant diseases . This fiNevertheless, the general level of knowledge about HPV seems to have increased in the past several years. This was suggested by the results of a systematic review of parental surveys about HPV and/or child HPV-vaccination. The percentage of parents who had heard about HPV rose over time (from 60% in 2005 to 93% in 2009), as did their appreciation for the HPV infection and cervical cancer link (from 70% in 2003 to 91% in 2011) [We carefully evaluated whether our patients were satisfied with the time spent by our physicians on their cases to provide medical information and answer questions. Since this was the case, the low level of knowledge was considerably not attributable to a lack of time spent with patients. Moreover, patient satisfaction and knowledge were not associated with each other. Independent of the underlying malignancy, the vast majority of study participants was satisfied with the amount of time that was spent on their individual care. Nonetheless, our data demonstrate that women with gynecologic malignancies have a low overall knowledge of their disease and of their individual treatment options. Notably, when focusing on whether patients knew their diagnosis, women with vaginal or vulvar cancer were able to give the correct answer less than 50% of the time, compared to 73–80% in the other groups. Our survey revealed similar data when patients were asked about structures that had been removed during surgery. Again, only 47% of patients with vaginal or vulvar cancer knew these details, compared to at least 63% of patients with other malignancies. It is possible that, in general, patients might not be aware of the difference between vagina and vulva, which could explain these results in our study population. This assumption about a lack of anatomical knowledge is supported by the fact that there was no difference between the groups concerning the level of knowledge about the treatment modalities they had received . Rather alarmingly, only 33.3% of our patients with an HPV-associated cancer knew exactly what HPV was. This is a much lower rate than reported by Donder or other authors ,12,21. WThus, our data suggest that patients need even more detailed information about the types of gynaecological cancers and the risk factors and causes of these diseases. The source of information for the patients is an important question. On the one hand it is the duty of national health care providers to supply the patients with information on preventable diseases. On the other hand we must not forget that the face-to-face setting of a patient-physician conversation may be the most effective way to keep patients informed. Nevertheless, recent research suggests that the information itself is important, not the source of information .Moreover, the level of knowledge about risk factors associated with their cancer type was very low. None of the patients was aware of all known risk factors Table . Women wWe consider the fact that we were not able to use a standardized questionnaire about HPV  as a limIn conclusion, cervical cancer is the second most common cancer in women and the leading cause of cancer-related death in many developing countries . ScreeniAll authors declare that they have no political, personal, religious, ideological, academic, and/or intellectual competing interest.Prof. Elmar Joura declares the following conflicts of interest: (i) Research funding by MERCK and GSK; (ii) lecture fees by MERCK, Sanofi Pasteur MSD, GSK, Roche; (iii) Advisory Board fees by MERCK. All other authors declare that they have no commercial interest, financial interest, and/or another relationship with manufacturers of pharmaceuticals, laboratory supplies, and/or medical devices or with commercial providers of medically related services.Study design: All authors. Acquisition of data: SP, AS, AJ. Statistical analysis: MPW, JO. Writing of the manuscript: SP, EJ, AS, JO. Manuscript editing and final approval of the version to be published: All authors.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/14/388/prepubQuestionnaire-subsection.Click here for fileAnswers to questionnaire modules on risk and preventive factors according to the type of disease.Click here for file


Background. When the bivalent and the quadrivalent HPV vaccines were marketed they were presented as having comparable efficacy against cervical cancer. Differences between the vaccines are HPV types included and formulation of the adjuvant. Method. A systematic review was conducted to assess the efficacy of the two vaccines against cervical cancer. Outcomes considered were CIN2+, CIN3+, and AIS. Results. Nine reports  were included. At enrolment mean age of women was 20 years, 90% had negative cytology, and 80% were seronegative and/or DNA negative for HPV 16 or 18 (naïve women). In the TVC-naïve, VE against CIN2+ was 58% ; heterogeneity was detected, VE being 65%  for the bivalent and 43%  for the quadrivalent. VE against CIN3+ was 78% ; heterogeneity was substantial, VE being 93%  for the bivalent and 43%  for the quadrivalent. VE in the TVC was much lower. No sufficient data were available on AIS. Conclusions. In naïve girls bivalent vaccine shows higher efficacy, even if the number of events detected is low. In women already infected the benefit of the vaccination seems negligible. In the seventies, Dr. Harald Zur Hausen firstly postulated the link between human papillomaviruses (HPVs) and cervical cancer: studies to develop an anticancer vaccine followed. Approximately 70% of cervical cancers worldwide are associated with two high-risk HPV types 16/18) [6/18 1,  and almoBased on the results of five randomized controlled trials (RCTs) involving 40,000 women –17 two HBoth vaccines contain human papillomavirus L1 self-assembling virus-like particles and are not infectious. Differences between the two vaccines are the number of HPV types included and formulation of the adjuvant  possiblyThree meta-analyses, published when vaccines were marketed, showed comparably high efficacy of the two vaccines against precancerous lesions associated with HPV16/18 , 41, 42.The systematic review was developed based on a prespecified protocol (protocol number FARM8N2ZFL) funded by the Italian Medicines Agency (AIFA) within a program of independent research on drugs . The PRIAs for protocol, primary outcome measures were cervical lesions  associated with any HPV type and cervical lesions exclusively associated with HPV16/18 occurring in three study populations: according to protocol population (ATP), the general population of vaccinated women ) approximating all women regardless of status of HPV infection at vaccination, and a selected population of women seronegative for HPV16/18 and HPV DNA negative for 14 oncogenic HPV types, approximating the group of young adolescent girls targeted in the national immunization campaigns (TVC-naïve). In this paper only data related to cervical lesions associated with any HPV type occurring in the TVC and in the TVC-naïve population are reported, as the other data are not relevant from a public health perspective.Trial identification: we searched the Cochrane Library , MEDLINE (to March 2014), and EMBASE (to March 2014) using keywords and MeSH terms as reported in Annex 1 online, in combination with a highly sensitive filter for identifying RCT . There wTwo reviewers carried out independent assessment of citations retrieved. When more than one publication reported the same trial, the one with a longer follow-up was selected. Reasons for exclusion were recorded. Quality of trials was assessed using the criteria outlined in the Cochrane Handbook  and inclI2 statistics [Two review authors extracted the data independently using a data extraction form. Statistical analyses were carried out using the STATA software version 11. For time to event data the hazard ratio (HR) was used as a measure of association. The results were summarized by using the inverse of variance method and the random effects model. Point estimates as well as their 95% confidence intervals (95% CI) were calculated and represented by the forest plot. Vaccine efficacy (VE) was calculated as VE(%) = (RU − RV)/RU × 100, where RU is the rate of disease in the unvaccinated and RV is the rate in the vaccinated . The equatistics .Geographical areas : the literature suggests that prevalence and circulation of HPV high risk types varies according to geographical areas –51.Vaccine type : data on VE can be influenced by type of vaccine used as differences between the two formulations could be not negligible.The following prespecified subgroup analyses were planned:Study identification and selection process is outlined in The data of the phase III trials included in our meta-analysis have a mean follow-up of 4 years for the bivalent trial  and 3.6 Characteristics of the trials are summarized in Studies were all double blind RCTs, with an adequate sample size. They were all manufacturer-sponsored. Eligible participants were healthy, not pregnant women aged between 15 and 26 years, with 6 or less lifetime sexual partners and no history of abnormal Pap smear at enrolment. Almost 90% of women had normal cytology at study entry. Risk of bias was low in 4 out of 5 trials: generation of the randomization sequence, quality of allocation concealment, completeness of follow-up, and blinding of outcome assessment were adequate. Risk of bias was unclear  in one smaller trial conducted in Japan ; as the Pooling of the data was possible for CIN2+ –28, CIN3CIN2+. The pooled HRs for CIN2+ lesions associated with any type of HPV in the TVC and in the TVC-naïve are reported in I2 test was 68.7% and 66.4% in the TVC and in the TVC-naïve, respectively.CIN3+. The pooled HRs for CIN3+ lesions associated with any type of HPV in the TVC and in the TVC-naïve are reported in I2 test was 86.3% and 90.7% in the TVC and in the TVC-naïve, respectively.AIS. The pooled HR for lesions associated with any type of HPV was 0.31 (95% CI: 0.14–0.70) in the TVC [ the TVC , 27, corI2 suggested low heterogeneity.AIS cases in the TVC-naïve cohort were zero in the vaccine group and ten in the placebo; thus only an approximate estimate of the efficacy was possible. The pooled HR for lesions associated with any type of HPV was 0.01 (95% CI: 0.01–0.22) resulting in a VE of 99%  , 27. ForAlthough formally required by the scientific advisory unit of ECDC in Stockholm, the two manufacturers did not provide single patient data .Five published papers –35 reporSince their introduction into the market, the effectiveness of the two vaccines against cervical cancer, based on first published data –17, has Our systematic review highlights that, for precancerous lesions (CIN), the only available proxy of cervical cancer and heterogeneity among pooled studies is substantial Figures  and 3: tAnother relevant point is that the length of the follow-up in the trials assessed seems insufficient to detect information relevant to the public and to policy-makers: as time interval from HPV infection to cervical cancer development is approximately 20 years, all information gathered in a much shorter period of time is not conclusive. Nevertheless the PATRICIA trial has a planned follow-up of 4 years  and longApart from cervical cancer prevention, quadrivalent vaccine is known to effectively prevent genital warts , 72, wheIn conclusion, we acknowledge that this systematic review has some limitations due to a low number of women with events and a high heterogeneity among trials that suggest caution in the interpretation of results. However, our conclusions are consistent with those from recent immunogenicity head-to-head studies , 39 and Finally, regulatory agencies should encourage the pharmaceutical companies to provide data across trials to assess all relevant outcomes in a comparable way, to reduce uncertainty, and to support health policy-makers that have to choose between alternative options , 78.The supplementary material shows the search strategy that was adapted for each database searched.


HPV-associated ano-genital infections represent the most common sexually-transmitted disease in the general population. The incidence of HPV-associated cancers has been increasing in HIV-infected patients. HPV vaccination may be an approach to reduce the risk of HPV-associated cancers in HIV-infected patients and a combined strategy of screening and vaccination may guarantee an adequate prevention of HPV-associated lesions. Immunogenicity of HPV vaccines in HIV-infected patients is still not adequately evaluated. We analyzed immunogenicity of a quadrivalent HPV vaccine in HIV-infected patients without molecular evidence of vaccine-type HPV infection focusing on HPV-specific cell mediated immunity (CMI).31 ARV-treated HIV-infected adolescents  and 25 sex- and age-matched HIV-seronegative healthy controls were enrolled in the study. HPV-16/18/6/11 VLP vaccine (Gardasil®) was administered 3 times . Immune activation , T-cell patterns and HPV-specific immune responses  were evaluated.HIV-infected individuals showed: 1) no changes in CD4 counts, percentage of CD4 cells and HIV viral load; 2) a significant increase in naїve CD8 T-cells, activated CD8 T-cells and in central memory CD4 and CD8 T-cells; 3) a significant reduction in terminally differentiated CD8 T-cells; 4) a significant increase in unstimulated and in HPV-specific IL2+/CD4+, IFN-γ+/CD4+, IFN-γ+/CD8+ and TNF-α+/CD8+ T-cells; and 5) a significant increase in HPV-specific Perforin- and Granzyme B-secreting CD8 T-cells. Results obtained in HIV-infected patients were comparable to those seen in HC.HPV-16/18/6/11 VLP vaccine induces strong HPV-specific cell-mediated immunity in ARV-treated HIV-infected individuals that are comparable to those observed in HIV-seronegative controls. HPV-specific CMI is likely an important component of the protective effect of this vaccine, data herein indicating that this arm of immunity is not impaired in ARV-treated HIV infected individuals.


Previous reports suggest a strong association between human papillomavirus (HPV) and the etiology of laryngeal squamous cell carcinoma (LSCC). However, clinical data regarding the HPV infection rate among LSCC patients remain largely inconsistent.In total, 674 LSCC patients from three major hospitals in Shanghai were enrolled in this study. We determined the patients' HPV infection status using immunohistochemistry and the GenoArray HPV genotyping assay and calculated their long-term survival rate using the Kaplan-Meier method.The total P16-positive rate according to immunostaining results was 7.57% (51/674). None of the P16-negative patients were HPV-positive according to the HPV genotyping test. The rate of HPV infection among patients with LSCC was 4.9% (33/674). HPV infection was more common among nonsmokers (P<0.05), nondrinkers (P<0.05), and patients with supraglottic LSCC (P<0.05). Of the 33 HPV-positive patients, 28 (84.8%) were infected with HPV-16, 2 with HPV-18, 1 with HPV-31, 1 with HPV-33 and 1 with HPV-45. The 3-year overall survival rate and progression-free survival rate were higher in HPV-positive than HPV-negative patients, but the difference was not statistically significant .HPV was not a main causal factor in LSCC carcinogenesis in this Chinese population. HPV infection did not alter patients' overall survival or progression-free survival rates in this study. Cancer of the larynx accounts for >3% of all cancers, making it the sixth most common cancer worldwide The established risk factors for laryngeal squamous cell carcinoma (LSCC) are tobacco and alcohol abuse; however, molecular evidence has supported a role for human papillomavirus (HPV), particularly HPV-16, in the pathogenesis of LSCC Identification of a high viral infection rate for a given cancer may facilitate the use of preventive viral vaccination. Genomic DNA of oncogenic HPV is detected in 72% of patients with OPSCC Viral infection is also an important confounding factor for cancer prognosis. Several reports have suggested HPV-positive HNSCC, notably HNSCC that arises from oropharyngeal sites and integrates HPV-16, has a better prognosis than does HPV-negative HNSCC We therefore conducted the current study, which focused exclusively on LSCC. Our aim was to evaluate the HPV infection rate in Chinese patients with LSCC and assess the prognostic value of HPV-associated LSCC.This was a longitudinal cohort study (started April 2006) of patients with newly diagnosed LSCC in three hospitals: First People's Hospital, Sixth People's Hospital, and Renji Hospital. Patients with a confirmed pathological diagnosis of LSCC were recruited. No patients in our series that had a previous history of HPV related OPSCC and cervical cancer.The study protocol was approved by the Research Ethics Committees of First People's Hospital, Sixth People's Hospital, and Renji Hospital. Written informed consent was obtained from all patients.The demographic data and clinical and pathological characteristics of 674 patients with LSCC were obtained from an electronic medical record system used in each hospital. The TNM staging system was used to classify LSCC in accordance with the American Joint Committee on Cancer classification. Detailed information is provided in Patients' smoking and drinking histories were also available in our electronic medical record system. Patients were classified as smokers or nonsmokers and drinkers or nondrinkers. Smokers were defined as individuals who smoked at least once a week for 1 year One representative formalin-fixed, paraffin-embedded (FFPE) block was retrieved for each case. Histological diagnosis of LSCC was confirmed by a pathologist.Patients were treated according to the National Comprehensive Cancer Network Guidelines. The treatments are illustrated in Patients were followed up every 3 months for the first 3 years, every 6 months for the fourth and fifth years, and every 12 months for the following years. The criteria for determining a disease-free state and identifying disease progression were as follows. Fiberoptic laryngoscopy or electric laryngoscopy and imaging examinations  were performed to evaluate suspicious lesions. When suspicious lesions were observed, biopsies with subsequent pathological examination were obtained to determine if laryngeal recurrence and/or regional lymphatic or distant metastasis had occurred. A progression-free state was defined as the absence of cancer as demonstrated by laryngoscopy and imaging examinations and (if necessary) pathological examination following biopsy. Postoperative complications were not included in the definition of disease, which referred only to the presence, recurrence, or metastasis of cancer.Immunostaining for P16 was performed on representative 4-µm sections cut from FFPE tissue blocks that were obtained before patients received chemotherapy or radiotherapy. P16 immunohistochemistry was carried out using a proprietary kit  on a Roche Autostainer . An LSCC with high P16 expression was used as a positive control. The primary antibody was omitted from negative controls. P16 immunohistochemistry was scored as positive if there was strong and diffuse nuclear and cytoplasmic staining present in >70% of the malignant cells All tissue preparation was conducted in a Class II biological safety cabinet with new sterilized disposable consumables for each specimen to avoid cross-contamination. Sectioning was performed with appropriate precautions to prevent interblock DNA contamination. DNA was extracted from 2- ×10-µm sections of FFPE biopsies using a Qiagen FFPE kit  according to the manufacturer's instructions. We used NanoDrop to measure the concentration and purity of DNA. Resulting DNA preparations were stored at −20°C.The GenoArray test by HybriBio (Chaozhou Hybribio Limited Corporation) is an L1 consensus primer-based PCR assay that is capable of amplifying 21 HPV genotypes, including 13 HR types , 2 probable HR types (types 53 and 66), and 6 LR and unknown-risk types . The assay was performed according to the manufacturer's protocol Multivariate logistic-regression models were used to estimate odds ratios and their associated 95% confidence intervals. Categorical variables were compared using a chi-squared test and Fisher's exact test. Differences were considered significant at P<0.05 in two-tailed tests. Overall survival analyses were based on the duration of time from the end of treatment to death; survivors were censored at their last follow-up. The Kaplan–Meier method was used for survival analysis. Data were analyzed using the SAS 9.3 software.Tumors were classified as HPV-positive if they overexpressed P16 (as shown by immunohistochemisty) and contained HPV DNA (as shown by HPV genotyping) In total, 33 HPV-positive patients were identified using the GenoArray assay, which is capable of amplifying 21 HPV genotypes. Twenty-eight of these 33 patients (84.8%) were infected with HPV-16, 2 (6.1%) with HPV-18, 1 with HPV-31, 1 with HPV-33, and 1 with HPV-45 .For the survival analysis, the mean follow-up was 45.3 months . The overall survival rates at 1, 2, and 3 years after treatment were 89.6%, 77.9%, and 71.0%, respectively. The progression-free survival rates at 1, 2, and 3 years after treatment were 78.1%, 61.1%, and 58.6%, respectively. The overall survival rates at 1, 2, and 3 years for HPV-positive patients were higher than those for HPV-negative patients , but the differences were not statistically significant (P = 0.30). The progression-free rates for HPV-positive patients were also higher than those for HPV-negative patients ; however, the differences were not statistically significant (P = 0.37) .Our study showed all 33 HPV positive cases were P16 immunostaining positive (accounting for 100% P16 sensitivity). We also found 33 cases among 51 P16 positive patients were HPV positive (accounting for 65% P16 specificity). These results are similar to those obtained by Smeets et al. The present study is the first to elucidate the HPV infection rate in patients with LSCC from 3 major hospitals in Shanghai, China. The 4.9% HPV infection rate suggests that HPV is not a main causal factor in LSCC carcinogenesis in this Chinese population, unlike for OPSCC. HPV-16 was a common HPV type (84.8%) in our study as well as in most previous studies on HNSCC A recent meta-analysis The HPV prevalence determined in our study is consistent with the findings of several studies on LSCC from Germany Traditionally, smoking and excessive alcohol consumption have been considered to be the main risk factors for LSCC. Tobacco and HPV infection can cause HNSCC through a similar mechanism, namely by inactivation of host oncosuppressor genes. It is therefore conceivable that in the United States, where smoking has been declining for decades, a substantial fraction of HNSCC attributable to HPV infection is now detected among nonsmokers or former smokers Two recent large-scale exome sequencing projects in patients with HNSCC In conclusion, we found that the HPV infection rate in patients with LSCC was 4.9%, suggesting that HPV is not a main causal factor in LSCC carcinogenesis in this Chinese population. HPV infection did not alter patients' overall survival or disease progression-free survival rates in this study.


Some regional cross-sectional human papillomavirus (HPV) DNA prevalence data show an increase in prevalence in older women, the reasons for which are as yet unknown. A recently published study suggests that the increase may be at least partly due to reactivation of latent HPV in menopausal women.We developed a dynamic mathematical model of HPV-16 transmission to estimate the key consequences of hypothetical HPV-16 reactivation in the Australian heterosexual population. We only consider a worst case scenario with regard to reactivation in the Australian setting when all women who are latently infected reactivate and, wherever feasible, we choose model parameter values which may lead to a more pronounced reactivation. The ongoing National HPV vaccination program covering both women and men is incorporated in the model.We estimate that about 1 in 10 women and men who appear to have cleared HPV-16 infection may be latently infected. The prevalence of HPV-16 in older Australian women will increase by a factor of up to 3.1 between now and 2025 which will be accompanied by an increase by a factor of around 1.9 in older men. However, the long-term impact of the HPV vaccination is not significantly altered by reactivation.If the reactivation hypothesis we consider is substantiated, the public health response should be focused on further improvement of cervical screening coverage for older women. Our study also highlights the urgent need for surveillance of HPV prevalence in older Australians. In general, HPV DNA prevalence peaks in women aged 20–24 and then steadily declines with age. However, in some regions the HPV age-specific prevalence curve has been observed to be U-shaped, i.e., exhibiting an increase in prevalence in older women , whilResults from a recently published study by Gravitt et al. lend plausibility to the hypothesis of HPV reactivation in menopausal women , which mAssuming that the above is indeed valid, we are interested in clarifying if the issue of HPV-16 reactivation should be seen as important for the Australian public health. To address this question, we model HPV-16 transmission in the Australian heterosexual population implementing reactivation of the virus in a manner we consider to be plausible based on our current knowledge. We only consider the worst case scenario, whereby all women at risk of reactivation do reactivate and vaccine efficacy is set at the lower plausible bound. We estimate the proportion of women at risk of reactivation, the impact on HPV-16 prevalence in older women and older men as a result of reinfection of susceptible men within existing partnerships. We also compare the long-term reductions in HPV-16 prevalence due to the ongoing Australian HPV vaccination program produced by the versions of our model with and without reactivation.Our model is briefly described below with a complete description, including justification of assumptions, provided in Additional file a priori the extent to which either should prevail. Susceptible women and men in the model may become infected and then some of them clear the infection completely and become immune, while others enter a latent infected state in which it is assumed that they would not test DNA positive due to viral load falling below the detectable threshold.We developed a dynamic compartmental mathematical model of HPV-16 transmission in the Australian heterosexual population. The model is illustrated schematically in Figure The following key assumptions have been made: • Any woman infected with HPV-16 at least once can potentially become latently infected ;• All women with latent HPV-16 infection reactivate at menopause at constant age-specific rates equal to the rates of onset of menopause;• Latently infected men and women are not infectious;• Men can be latently infected in which case they are not infectious, but they can not reactivate and cannot be reinfected;• The onset of menopause occurs in women aged 45–54 ,14• 70% of all Australian women aged 45 to 54 are assumed to be in the long-term partnerships ; this isWe assume that sexual activity in the Australian heterosexual population increased substantially during the sexual revolution of 1961–1975 and then stabilised at a level close to that described by the ASHR study in 2001–2002. This is a necessary simplification primarily based on public perception and backed by some sparse evidence , and the duration of vaccine induced protection, implemented in the model as reduced susceptibility to reinfection, is assumed to be life-long. Vaccine coverage was fixed at 72% for 12 year old girls , andThe model was calibrated to the HPV-16 age-specific prevalence in non-Indigenous Australian women aged 15–39 as reported in the WHINURS study . These dβmw, and for female-to-male transmission, βwm, inferred by the model are nearly equal . It should be noted, however, that these are usually overestimated by compartmental models [The means and standard deviations of the inferred parameter distributions  obtained through the calibration process are shown in Table l models . The infl models ,29, thoul models . On the l models . The proIn this paper, we present a simple model-based evaluation of the potential impact of reactivation of HPV-16 in Australian menopausal women in terms of changes in HPV-16 prevalence. This is necessary for any further analysis regarding progression to cervical and other cancers in both women and men. We focus on the strongest impact plausible given our current limited understanding of how reactivation may work and because from the public health perspective evaluation of the worst case scenario is essential to assess the scale of hypothetical reactivation issue in principle. The model we set up is adequate for our purposes at this stage, when we effectively aim to outline the magnitude of the effect reactivation brings into a model not accounting for its possibility. While intuition suggests what should generally happen to HPV-16 prevalence in Australia if reactivation occurs , mathematical modelling helps to quantify this. In particular, there is no means to estimate the proportion of latently infected individuals except modelling.Our results suggest that the long-term effect of reactivation will be insignificant as at the post-vaccination equilibrium only 28% of all women will be unvaccinated and so, theoretically, at a risk of reactivation, but according to our estimations only about 1/10 of these may become latently infected. However, we are more interested in the period when older women in the modelled population are largely unvaccinated, which is roughly between now and early the 2030s. We conclude that reactivation has important implications for predicting the impact of vaccination in the short to medium term and for surveillance and screening activities. The fact that from 2013 HPV-16 prevalence in older women is predicted to nearly triple under the reactivation assumption as compared to its pre-reactivation level is a cause for concern. Similarly, the almost 60% increase predicted in older men is of concern, since unlike women who are covered by the National Cervical Screening Program (NCSP) , men areIt is important to mention some limitations of our study. Among the numerous assumptions we have made (see Additional file We do not expect our findings to serve as a basis for any immediate public health decision making. However, we hope that our results will draw the attention of the public health community to the subject of HPV reactivation and serve as motivation to conduct a study focusing on the collection of HPV-16 DNA prevalence data in older Australian women and, if feasible, men. This study would have to be conducted as soon as possible, as after 2025 its relevance in the Australian setting will diminish. Any clinical evidence for or against reactivation would contribute to more efficient detection and prevention of HPV, especially in countries where HPV vaccination programs have not yet reached their full potential.The authors declare that they have no competing interests.DGR coordinated the study and participated in study design, model parameterisation and manuscript preparation. IAK conceived of the study, developed and implemented the models, analysed results and drafted the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/14/312/prepubTechnical Appendix.Click here for file


Human papillomavirus (HPV) is currently considered to be a major etiologic factor, in addition to tobacco and alcohol, for oropharyngeal cancer (OPC) development. HPV positive OPCs are epidemiologically distinct from HPV negative ones, and are characterized by younger age at onset, male predominance, and strong association with sexual behaviors. HPV16 is the most prevalent types in oral cavity cancer (OCC), moreover the prevalence of beta, and gamma HPV types is higher than that of alpha HPV in oral cavity. During the last decade increasing attention has been paid to the presence of human papillomavirus (HPV) in the oral cavity and to its correlation with the development of oropharyngeal squamous cell carcinoma (OPSCC). In fact, recent epidemiological studies have shown a 225% increase in population-level incidence of HPV positive (HPV+) OPSCC between 1984 and 2004 [Papillomavirus, and along with the genus Polyomavirus, they form in the family Papovaviridae. This is a family of epitheliotropic, non-enveloped viruses with a circular double stranded DNA genome. Papillomaviruses are predominantly species specific. In 1933 Shope linked the presence of cottontail rabbit papillomavirus (CRPV) to cutaneous papillomatosis in rabbits, and Peyton Rous studied the conversion of papilloma to squamous cell carcinoma in rabbits. Subsequent studies demonstrated that papillomaviruses infected all reptiles, birds and mammals [taurus) PV type 1 (BPV1), European elk  PV (EEPV), mule, and deer (Odocoileus virginianus or hemonius) PV (DPV), all show their close phylogenetic relationships (for E6 protein function see below).Papillomaviruses (PVs) are members of the genus  mammals . More thepidermodyplasia verruciformis) types. A second group (II) included mainly mucosal HPVs. A third group (III) with HPV2 and HPV57 was found to be associated to the skin, where they cause verruca vulgaris and in oral mucosa. The fourth group (IV) infect both genital and oral mucosa. It can be inferred that during the molecular evolutionary history of PVs, there was a clear division into PV which infected epithelial skin cells and PV which infected mucosal cells. It seems likely that the co-evolution occurred in an anatomic site specific manner  corresponding to HPV1, found in skin warts, and a second group considered to be EV  to 8607 bp , encodes different proteins, depending on the genera considered. All known papillomavirus encode five proteins: E1, E2 and E4, L1 and L2. L1 and L2 are structural, constituting the viral capsid, while E1 and E2 influence the replication cycle and transcription, E4 protein contributes to genome amplification efficiency and it favors high level expression of the viruses. In all papillomaviruses we also found a long control region (LCR) located between L1 and the beginning of the first ORF1 in the early region (E6 in the case of BPV1 and in the most human papillomaviruses). E5, E6, E7 proteins, having a key role in cellular growth regulation, immunosystem control, and in transformation process, are considered oncogenic.In absence of serological classification, HPVs have been classified according to their genotype. The HPV classification is made by analyzing nucleotide difference in a fragment of L1 gene, a gene present in all papillomaviruses. In fact the papillomavirus genome, which ranges from 6953 bp  method, metagenomics approach and new sets of primers able to amplify a larger number of genotypes  the numbAs described above the human papillomaviruses are distributed in five genera. Alpha genus includes mucosal and cutaneous HPV types. The cutaneous alpha types are considered as low risk and the most representative types are HPV2 and HPV 57, which cause common warts, and HPV3 and 10, which are correlated to flat warts ,13. MucoAfter exclusion of nasopharynx, head and neck squamous cell carcinoma (HNCCs) are responsible for approximately 550,000 new cases and 300,000 deaths in the world each year . About tIn general HNSCCs is largely attributed to environmental exposures. Tobacco use and alcohol consumption are the main risk factors. Tobacco represents the cause of 33% of HNCCs cases in North America, Latin America and Europe. Alcohol consumption causes 4% of HNSCCs. Other studies demonstrated that tobacco use and alcohol are related to 42% of HNSCCs deaths in low-income countries and 80% in high income countries . Rates oHowever, significant evidence suggests risk factors other than tobacco and alcohol could be involved in HNCCS development: (1) a small portion 15%–20%) of HNCCs occurs in non-smokers and non-drinkers; (2) the number of HNSCCs has increased even in developed countries where alcohol consumption and smoking have decreased. Oropharyngeal cancer (OPC) incidence has increased over the last 20 years in several countries, including Australia, Canada, Denmark, the Netherlands, Norway, United States, and United Kindom, where a decline in tobacco use has been observed [% of HNCCet al. found HPV to be a risk factor for oral cavity cancer (OCC) and OPC corresponding to 3.7 OR , independent of alcohol and tobacco exposure [versus 6.1%; p < 0.002) [p < 0.01) [Several authors have demonstrated that HPV presence in the oral cavity represents a risk factor for oral cavity or oropharyngeal cancer. Smith exposure . Men witexposure . Gillisoexposure . Another< 0.002) . Tonsill < 0.01) .Studies based on cancer registries show a geographical correlation between the incidence of HNSCCs and cancer of the cervix and the penis. Furthermore, a significantly increased risk of HNSCC was reported subsequent to diagnosis of cervical or anal cancer . HPV infSeveral studies show HPV specificity to tumor cell nuclei, high integration of HPV DNA into human genome, high HPV viral copy numbers and high level of expression of HPV oncogenes (E6 and E7) in tumors, all of which underscore a casual association of HPV with oropharyngeal cancers ,28,29. Sversus 0.7%, respectively). A similar pattern was found for each HPV type analysed. Men and women had similar prevalence of detectable oral HPV .Despite the established relationship between HPV infection and HNSCC development, only a little data is available in the literature about HPV epidemiology in the oral cavity. A systematic review, which analysed oral HPV infections among healthy individuals took account of data published in 18 articles and related exclusively to alpha-papillomaviruses . The anaversus 25% prevalence respectively). Lifetime oral sex behavior was associated with oral HPV prevalence in HIV-positive (p trend = 0.03), but not in HIV-negative (p = 0.11) people. The association between current CD4T cell count and oral HPV16 was significantly stronger than the association of current CD4 T cell count with all other HPV types (p = 0.02).Recently Gillison evaluated the prevalence of HPV in the oral cavity in people living in the US, checking the presence of 37 alpha-papillomaviruses among 5500 U.S. individuals (age: 14–69 years old). HPV was detected in 6.9% of analysed samples, HR HPV prevalence was 3.7% and LR-HPV represented 3.1% of positive samples; the prevalence of HPV16 was 1% . The risA study carried out in Italy on 166 HIV-positive MSM (men who have sex with men) reported a alpha HPV DNA prevalence of 20.1% at baseline a 21.3% after 6 months follow up: 75% (51/68) of individuals had persistent HPV infection after enrollment. HPV DNA detection was performed with MY09/MY11 and GP5+/GP6+ primers. Persistence rates of 71.4% with HR types and 76.7% in patients infected with LR type were observed. A negative relationship was found between HPV infection and CD4 T cell count . A studyversus 28%, p < 0.001). Among oral HPV infections, 11% were multiple infections, and the main HPV types found in the oral cavity were: HPV55 (4.3%), 83 (4.1%), and 72 (3.8%). The HPV incidence in anal sites was significantly higher respect to the oral site . In this study 38% of both anal and oral HPV infections were persistent (two consecutive HPV positive samples). After 6 months, 63% of anal HPV infections persisted against 46% of oral HPV infections. Age, tobacco use, and nadir CD4 T-cell count a baseline were not associated with anal or oral HPV persistence [Another study carried out at the John Hopkins Hospital in Baltimore  among HIV-positive individuals—153 women (39%), 168 heterosexual men (43%), and 69 MSM (18%)—compared the α-HPV prevalence in oral and anal sites and their persistence. Baseline prevalence was significantly higher in anal sites than in oral sites , the incidence of oral infection was 4.4% and the median duration of oral HPV infection was 6.9 months (95% CI: 6.2–9.3) for all HPV types, 6.3 months (6.0–9.9) for oncogenic HPV, and 7.3 months (6.0-not estimable) for HPV16. Overall oral HPV infection cleared within 1 year, so HPV infection in healthy men seems not to be long lasting [n = 17) HPV multiple infections were observed. No differences were observed in the risk of acquiring any HPV types across age groups (18–73 years old). Other variables  were not significantly associated with oral HPV infection. These results are consistent with another study [In a HIM (HPV infection in men) survey carried out among men living in Mexico, Brazil and USA who were HIV-negative  HPV positivity was 2.4% (95% CI: 1.4–3.45) for all HPV types and HPV16 infection was lower than those reported in other studies: 0.2% (95% CI: 0–0.4).In Pickard’s study, where HPV oral prevalence was analyzed in young people . HPV31, 35, 39, 52, 56, 58, and 59 were the other HRs found in the HIM cohort. HPV55 was the main LR type detected (1.1%). The prevalence of oral HPV increased non-significantly over increasing age categories. Only smoking-related variables were associated with a significant increase in the probability of detecting oral HPV infection .In the HIM study the authors also calculated the HPV prevalence in oral sites . HPV DNAvs. 9.8% respectively). >2 HPV type were found in seven oral samples. HPV16 was the most prevalent HR type , other HR HPV types found were: HPV59 , and HPV51 . HPV42 was the only low risk detected  [In another study performed in Sweden on young people  .Another Finnish study was carried out on pregnant women: 115/398 women acquired a HPV infection over six years of follow-up. HPV16 and HPV multiple infections represented the most frequently caused incidence of oral infections (65% and 12% respectively) and 46% of women cleared their HPV infection within 2 years. HPV58 had the highest clearance frequency (88.9%), while the other HR types have a mean clearance frequency of 33.3%. Mean clearance of HPV16 was 20.7 months, very similar to HPV multiple infection (23.5 months). HPV6 was the main LR detected and showed the longest persistence (mean 4.6 months) with a clearance frequency of 25% [Another recent study in Brazil reported an oral alpha-HPV prevalence of 1.3%. The samples were analysed by PCR for E6 and E7 genes specific for HPV 6, 11, 16, 18, 31, 33, 45, and with a second set of primers MGMY09/11 .On the contrary, a second study carried out in Brazil reported an oral HPV prevalence of 23.2% among 125 healthy individual using MY09/MY11 primers . The difGenera beta, gamma, mu, and nu are considered to be correlated with benign cutaneous lesions and only occasionally have they been found in skin cancers. Some beta types however can be associated with the development of neoplastic disease  .As previously described the beta papillomavirus genus have been divided into five species with related HPV types . Gamma papillomaviruses have been divided into five species  [Cutaneous HPV types represent a risk factor for SCC (skin cell carcinoma) and basal cell carcinoma (BCC), particularly in immunocompromised patients. In general alpha cutaneous HPV types are rarely detected in both SCC and BCC, whereas HPV types belonging to beta1, beta 2, and beta 3 species are the most frequently detected in SCC compared to controls. Among beta 4 species only HPV92 is elevated in SCC in comparison to controls . Only reThe first work which gave information about Beta-papillomavirus and Gamma-papillomavirus prevalence in oral cavity was Bottalico’s paper . The anan = 35) 21 samples (60%) were infected with at least one alpha type, 20 samples (57%) with at least one beta type, and seven samples (20%) with at least one gamma type. There was no statistically significant association between CD4 T cell count and HPV positivity. Among HIV-negative individuals with HPV DNA in oral rinse (n = 117), 29 samples (25%) harbored alpha HPV types, 74% (n = 87) were infected with beta HPV types, and 14 samples (12%) with gamma-HPV types. HPV5 (n = 17) was the most prevalent beta HPV type. In HPV DNA positive cervical specimens (n = 257), 96% were positive for alpha HPV types (n = 248), 2% (n = 6) were positive for beta HPV types, and beta HPV types were detected in nine specimens (4%). Overall eight novel beta HPV types and 12 novel gamma HPV types were identified. Among the beta genus, HPV120 and 124 were most frequently observed, whereas HPV121 and HPV134, belonging to the gamma genus, were each found twice.Among HIV-positive patients with HPV positive oral rinse , 25% of them had HPV multiple infections. Αlpha HR HPV was detected in 12 individuals 23%, and HPV58 and 68 were the most frequently found. Among alpha LR types HPV32 and 42 (8%) were the most common types. In 46% of individuals beta or gamma HPV types were detected: HPV8 was the most frequent beta type and 101/103 were the most commonly found gamma types. All cases with detectable HIV RNA viral load were positive for HPV DNA. Patients on HAART were also most frequently positive for beta or gamma HPV types [versus 43%; p = 0.397). This is the highest prevalence of beta and gamma genus in the oral cavity.The detection of HR and LR alpha-10 types  was elevated among people with a history of genital warts, while individuals with a history of cutaneous warts were more likely to harbour beta or gamma HPV types , which employs the SPF10 primer set, with a Diassay BV assay [n = 246) detection of alpha HPV increased the odds detection of beta cutaneous HPV within the oral region , though cutaneous HPV types were 10 times more common in oral region than mucosal HPV types (21.6%). Unlike the mucosal HPV types, HPV cutaneous infection was not correlated to sexual activity.In another study  oral rinBV assay  and withBV assay . The alpversus 8% mucosal HPV types. Among people with non-malignant lesions, cutaneous HPV prevalence was 51% versus 12.7% mucosal HPV types, whereas in group of samples from oral cancer cutaneous HPV type prevalence was 20.5% versus 21.5% HPV mucosal HPV types. Multiple infections represented 4.6% of all infections, and cutaneous and mucosal co-infection was found only in one sample. Beta HPV types represented 64% out the total HPV types. Moreover no viral transcript RNA was found in any of the positive samples for cutaneous HPV DNA suggesting a non-involvement of cutaneous HPV DNA in tumour development in this anatomical site [Paolini and colleagues, employing MY09/MY11 primers, GP5+/GP6+, CP65/CP70, FAP59/FAP64 primers observed a different prevalence of cutaneous types  in different groups. In healthy individuals group cutaneous HPV types were 25% However, the prevalence of new genotypes in the oral cavity might increase with the introduction of new HPV search methods such as RCA or metagenomics. In a recent paper DNA enrichment by RCA was used and this approach allowed the detection of four new genotypes in the oral rinse of healthy individuals . All fouUnlike HPV in cervical cancers, where the secondary prevention by screening prevention and HPV detection led to a decline in cervical cancer incidence, in oropharyngeal squamous cell carcinoma (OSCC) no associations between HPV presence and cytological abnormalities were found.Fakhry and colleagues carried out a cross sectional population study (PAP1), in which cytology specimens were collected from patients presenting with abnormalities. In a nested case-control study (PAP2) bilateral tonsillar cytology samples were collected at 12 months intervals from HIV-infected individuals. HPV16 infection was not associated with atypical squamous cells of unknown significance (ASCUS), but HPV16 was associated with OSCC among individuals with accessible oropharyngeal lesions  and C/EBP homologous protein (CHOP). USF1 is a basic helix-loop-helix (HLH) transcription factor and regulates genes involved in cellular differentiation. CHOP is involved in the apoptosis regulation process. In HPV-positive OPC a lower level of immunoglubulins, lactotransferrins were observed. Many of the hallmark differences identified by the studies relate to direct action of the viral oncogenes E6 and E7. In addition to E2F1 and EF4 proteins, a higher level of MYC and MAX response protein was found HPV-positive OPC. MAX is a bHLH-LZ protein required for MYC activity and through their association, the MYC/MAX complexes are able to activate the transcription of MYC target genes. It has been shown that higher MYC levels can be detected in the presence of E6. MYC is a key transcriptional factor involved in cell cycle progression, proliferation, metabolism, transformation and apoptosis. In the presence of E6, MYC also induces TERT transcription, through its binding to the TERT promoter proximal E-box ,63.These very promising results are still preliminary. In fact they have been conducted on a limited number of samples and the predictive power of changes of factors such as MYC/MAX or E2F1, an alteration of this transcript profile, has not yet been established.In another study comparing 50 HPV positive head neck carcinoma to 50 HPV negative HNSCC, the authors identified two differently expressed proteins: prostate stem cell antigen (PSCA), which was upregulated, and eukaryotic elongation factor 1 alpha (EEF1α), which was down regulated in HPV-positive cells .PSCA was discovered 15 years ago and has been found in prostate, bladder, cancer, ovarian and renal carcinomas. To date only one study reported decreased a PSCA expression (100-fold) in HNSCC . EEF1α iFurthermore being that these data refer to a small number of tumor samples and that they have not been confirmed by studies carried out on a substantial number of HPV positive oral samples , they still cannot be used in clinical practice or to decide prevention measures.HPV PCR testing for beta, gamma, mu, and nu papillomaviruses has been developed to detect HPV in human skin and some of these sets of primers have been employed in HPV detection in oral sites ,51. MostTo improve the sensitivity of this PCR system, a nested internal primer pair was introduced to a single FAP59/64 single round system following the “hanging droplet” approach. FAP 6085F and FAP6319 R corresponded to nucleotides 6085-6104 and 6319-6296 of the HPV8 genome, yielding a nested amplicon of 235 bp. The analytical sensitivity of nested PCR is about 10-fold compared to that of single round PCR . MoreoveSKF1 and SKR1 (I Round), SKF2/SKR2 (II Round) primer couples were employed in a nested PCR by Sagasawa to detect the main cutaneous HPVs . It was Berkhout and colleagues used instead a nested PCR to amplify all epidermodyslpasia verruciformis (EV) HPV types. This method consists in of a first-step PCR amplification carried out with CP65 and CP70 primers able to amplify HPV5, 8, 9 12, 14a, 15, 17, 19, 20, 21, 22, 23, 25, 34, 36, 37, 38, 41, 46, 48, 49, and 50. In the second step CP66 and CP69 primers were used in second round PCR. These sets of primers have different capability to amplify different genotypes. The two step PCR succeed in detecting mucosal HPVs, including HPV6, 11, 13, 16, 18, 31, and 33.This method was not able to amplify HPV3, 4, 10, whereas some types including HPV2, 26, 27 were efficiently amplified only by the first round PCR . This auHarwood and colleagues employed degenerate primers in a nested PCR. They employed in a first round a set of primers (F14-B15) for the L1 region as already described by Shamanin . In the et al. [One PCR system is based on amplification of a conserved E1 region, and is able to amplify 25 beta types. The PCR products are employed in a reverse hybridization system (RHA) containing 23 genotypes specific probes, while other probes are used in pattern recognition of genotypes. HPV5, 9, 12, 14, 15, 17, 19, 23, 24, 25, 36, 37, 38, 49, 75, 76, 80, 92, 93, 96, 8, 21, 20, 22, 47 could be identified with this system . The PCRet al. .BGC-PCR/RLB is a method based on HPV PCR followed by reverse-line blotting (BGC-PCR/RLB) able to detect 25 beta-PV, and the analytical sensitivity ranges from 10 copies  to 100 copies (HPV76) .Another typing assay consisting of biotinylated PCR products of the nested FAP method  has beenThe FAP PCR system is very useful in identifying new genotypes, it shows a good sensitivity for almost all types detected, but it loses its sensitivity in HPV multiple infection detection. The other two methods showed a more limited range number of type detection, but they more efficiently identify HPV multiple infections. Concerning alpha HPV detection one suggests other exhaustive reviews ,81.in situ to invasive carcinoma, as demonstrated in cervical cancer, could not be identified in oral-oropharyngeal cancer, so it is difficult to define a prevention measure.The change of epithelial status from normal, cellular atypia, dysplasia, carcinoma A recommendation would be to repeat the HPV DNA test after 6, 12 months, when the HPV DNA test is positive at baseline, especially if a high-risk HPV was found, or if the subject has a cervical or anal dysplasia or if he has immune compromised status. Regarding beta and gamma genotypes, the data about their persistence and correlation with the onset of OPC tumors are lacking. Their high prevalence in oral rinses suggests a high tropism of these HPV types for oral mucosa. Though they are not considered high risk, they can promote benign neoplasia, but only follow-up studies aimed to closely monitor HPV presence in the oral cavity could establish beta-gamma HPVs capacity to influence OPC development.The presence of beta and gamma genotypes in the oral cavity have been weakly investigated. The recent studies by Martin with a metagenomic approach have highlighted the presence of new genotypes of HPV, of which their involvement in the onset of tumors in OPC remains entirely unknown. Of course, the biggest gap is the absence of a system for detection of a larger number of beta and gamma HPV genotypes, including the latest identified and untyped ones. More effort should be applied to improve multiple infection system detection, because this factor (multiple infection) could also promote the persistence of HPV in the oropharynx.et al. [The presence of cutaneous HPV and their influence in OPC is still unclear. Paolini et al.  do not o


The epidemiology of oral human papillomavirus (HPV) infection in men who have sex with men (MSM) differs from anogenital HPV infection. The impact of HPV vaccination has, to date, largely focussed on anogenital outcomes. Vaccination of MSM in the UK has been recommended and, if implemented, baseline estimates of oral HPV prevalence will be useful.We searched Medline, Embase and psycINFO databases for studies reporting prevalence, incidence, and clearance of oral HPV infection in MSM. We performed a random-effects meta-analysis and meta-regression on prevalence estimates and summarised within-study risk factors for oral HPV DNA detection and incidence/clearance rates. We also performed a meta-analysis of the effect of MSM on oral HPV prevalence compared to heterosexual men.26 publications were identified. The pooled prevalence of oral HPV16 from twelve estimates was 3.0% (95%CI 0.5–5.5) in HIV-negative and 4.7% (95%CI 2.1–7.3) in HIV-positive MSM. Median age of study participants explained 38% of heterogeneity (p<0.01) in HPV prevalence estimates . Nine studies compared MSM to heterosexual men and found no difference in oral HPV prevalence (pooled OR 1.07 (95%CI 0.65–1.74)). The clearance rate was higher than incidence within studies. Type-specific concordance between oral and anogenital sites was rare.There was substantial heterogeneity between estimates of oral HPV prevalence in MSM populations that was partly explained by HIV status and median age. Cancers of the oropharynx and tonsil, associated with HPV, have been increasing in recent decades  yet littThe epidemiology of oral HPV infection has recently been reviewed. A systemThe natural history of oral HPV infection is not well understood and while HPV vaccine efficacy against oral HPV infection has been demonstrated  the impaWe performed meta-analyses of (i) the prevalence of oral HPV infection in MSM; and (ii) the association between HPV infection in MSM compared to heterosexual men. Additionally, we reviewed incidence and clearance rates for oral HPV infection; risk factors for prevalence, incidence, and persistence; and concordance between oral and anogenital infection.A systematic review was performed of studies measuring HPV DNA prevalence, incidence and/or persistence in the oral cavity of MSM. We included studies in HIV-negative and HIV-positive populations, published in English, where an MSM-specific estimate was available in ≥ five MSM. We excluded case-control studies and clinical case series  that might introduce additional heterogeneity to prevalence estimates.For oral HPV prevalence estimates, we excluded conference abstracts that were superseded by journal articles and we included baseline estimates from longitudinal studies.We searched databases on 20th October 2015 using the search terms mouth/oral /oropharangeal, HPV/ papillomavirus /papillomaviridae and man/ men /boy$/ adult /male$ /MSM/ "men who have sex with men"/ gay$ /homosexual$ /bisexual$. We searched Medline via PubMed and Medline, Embase and psycINFO using the Ovid platform  using the search strategy in All screening and study selection methods were performed independently by EK and SO and discrepancies were resolved by consensus. Publications were screened by title, then, if not enough detail was available, by review of the abstract, and then the full text. Where data were not stratified by sex and sexual orientation, and both variables were reported in the publication (not a conference abstract), we contacted the corresponding author, via emails , for additional data. If there was no response we excluded the publication. Additional stratified data were obtained from four of the six authors contacted for this purpose.All data extraction was performed by EK . Discrepancies were agreed by consensus. The following data were extracted where available: author name, year of publication, median age and range (years), study location, source of recruitment, HIV status, specimen collection method, and HPV DNA detection/genotyping assay(s). For studies included in the summary HPV prevalence estimation, the following additional data were extracted where available: the number of MSM in the sample and those with any HPV DNA detected, any high risk HPV types (HR-HPV), any low risk HPV types (LR-HPV) and, individually, the number with HPV-16, HPV-18, HPV-6, and HPV-11. For studies including both HIV-positive and -negative MSM, data were extracted separately for each group and treated as separate studies. For studies examining risk factors for oral HPV DNA statistically significant (p<0.05) risk factors in univariate analyses, factors included in multivariate models and factors that were statistically significant in multivariate models were extracted. Finally, for studies included in the meta-analysis of oral HPV prevalence in MSM compared to heterosexual men, the number of MSM and the number of heterosexual men with and without HPV were extracted.We found little variation in the definitions used for HR-HPV and LR-HPV but substantial variation in HPV detection/genotyping assays . DefinitFor studies included in the HPV prevalence estimation and analysis of risk factors for current HPV DNA detection we used the strengthening the reporting of observational studies in epidemiology (STROBE) checklist, for items to be included in reports of observational studies, which examines selection and information bias. A count 2 statistic.HPV DNA prevalence in MSM was determined as the percentage with detectable DNA in the total number of samples that were tested and adequate for PCR. For consistency, we calculated Clopper-Pearson 95% confidence intervals (CI) for each study superseding the published intervals. We did not expect the true population prevalence to be equal in all studies due to heterogeneity in study populations, specimen collection, and testing, so we used random effects meta-analysis to calculate a pooled estimate with 95% confidence interval. We quantified heterogeneity using the Ia priori in a multivariate meta-regression model and other variables significant in univariate analyses. P values were obtained by comparing the multiparameter Wald test statistic to the appropriate F distribution with Knapp-Hartung modification to standard errors.We performed a random effects meta-regression to examine the effect of HIV status, recruitment source , oral specimen collection method , STROBE count, and median age of participants on prevalence of HPV DNA and HR-HPV DNA. We included age and HIV We calculated odds ratios (OR) to represent the effect of male same-sex activity on oral HPV prevalence within each study, and used random-effects meta-analysis to calculate a pooled OR and 95% CI. We examined the funnel plot of the inverse of the standard error and the effect to see whether the ORs across studies were associated with sample size.We standardised estimates of incidence and clearance rates to the same unit (per 1000 person-months), and calculated these rates approximately if they were not presented but sufficient information was reported. For example if median duration of infection was given, in months, we assumed an exponential rate and calculated the rate of clearance as the inverse of median duration of infection multiplied by 1000. We calculated 95% CIs for these rates using the Poisson exact method. Given the heterogeneity introduced by different approximate methods of estimation, we did not perform a meta-analysis on these data.All meta-analyses were conducted using either the metareg, metaprop  or metan2383 articles were identified and 2149 excluded based on information in the title. We excluded a further 93 based on information in the abstract and a further 114 having retrieved the full text . We incl2 = 83% and 84%, respectively). The random-effects pooled prevalence of HR-HPV was 9.1% (95% CI 4.0–14.2%) in HIV-negative MSM and 16.5% (95% CI 8.2–24.8%) in HIV-positive MSM . 2 = 97% and 96%, respectively) and of any of the quadrivalent vaccine types HPV6/11/16/18 was 2.8% (95% CI 1.7–3.8%) in HIV-negative MSM and 5.9% (95% CI 0.8–11.0%).For oral HPV DNA prevalence, we included 19 studies. Estimates of HPV DNA prevalence were available from six studies that included 1329 HIV-negative MSM,–22 11 st2 = 3%, p = 0.30), mode of sample collection , and STROBE count  were not significant contributors to the heterogeneity of any HPV prevalence estimates  and by median age of study participants  or HPV16 prevalence . In multivariate analyses, median age remained a significant contributor to the heterogeneity of any HPV prevalence, after adjusting for HIV status , mode of specimen collection  or STROBE count . However recruitment source, especially recruiting from a community setting compared to an HIV clinic, was a significant contributor to heterogeneity .The number of included studies was too low (<10 per stratum) to perform meta-regression in estimates from HIV-negative MSM or for HR-HPV and HPV16 estimates in HIV-positive MSM. In HIV-positive MSM there were 11 estimates of any HPV prevalence with high heterogeneity , smoking , and number of sex partners  as risk factors. These were similar to the risk factors identified in studies that had, in addition to MSM, heterosexual male participants [We analysed 12 studies that examined risk factors for oral HPV DNA detection and stated the number of MSM in the population . With thh HR-HPV, all studh HR-HPV,,19 identicipants ,32,39,40icipants ,26,39.2 = 51.7%, heterogeneity p = 0.04. There was little difference in effect size in the four studies in HIV-positive populations compared to the five with unknown HIV status and no studies in HIV-negative populations presented appropriate data to examine this effect. Excluding estimates from studies with a high risk of bias reduced the heterogeneity (I2) to 38.4% (heterogeneity p = 0.15) and gave a pooled OR of 1.05 . There were too few studies to formally test for small study bias.Our meta-analysis showed no evidence that MSM were at higher risk of oral HPV DNA detection compared to heterosexual men . We inclWe examined HPV DNA incidence and clearance rates in six longitudinal studies . There wDefinitions of cleared HPV infection differed by study (single undetectable following a detectable or two consecutive undetectable following a detectable). In some studies only incident infections were ‘at risk’ for clearance, and clearance rate was reported in various ways, eg median duration of infection, percentage with persistent infection at six months, and number of incident infections clearing in 1000 person-months. However, clearance rate (range: 12-900/1000 person-months) was generally higher than acquisition rate.Risk factors for oral HPV acquisition and persistence are described, but were not formally examined, due to the low number of longitudinal studies. In MSM overall in the Dutch H2M study and the US-based MACS cohort of MSM, HIV infection increased the risk of oral HPV acquisition–43. AddiFor HIV-positive MSM in the MACS cohort risk factors were declining CD4+ T cell count, younger age and increasing number of lifetime oral sex partners, and in the H2M cohort, these were increasing number of recent oral sex partners, recent tobacco smoking and cannabis use. On the oIn populations that included both MSM and non-MSM , HIVIn MSM, oral HPV persistence was associated with increased time since HIV diagnosis ,44 but net al. found that 2/191 (1%) had HPV-16 detected in the anal brushing, penile swab, and oral brushing.[Four studies ,24,35,45brushing.et al. found that 65/458 (14%) MSM had concurrent oral and anal HPV infection and 30/457 (7%) had concurrent oral and penile.[et al. showed that penile HPV infection was related to oral HPV infection  and that two or three site  concordance of any HPV was 48%.[et al, found 2/50 HIV-positive MSM had detectable HPV, but of different types, simultaneously in anal and coronal sulcus samples.[Concurrent HPV detection, without details of HPV type, at oral and anogenital sites in MSM was presented in two studies.,25 Videl was 48%. Blas et  samples. A furthe samples.,33,39The analysis of data from 26 publications has provided estimates of epidemiological parameters concerning oral HPV infection in MSM. These include prevalence, risk factors, and incidence and clearance rates. Substantial heterogeneity was identified between HPV prevalence estimates and subgroup analyses were performed by HIV status.We showed a statistically significant contribution of HIV status to heterogeneity in oral HPV prevalence (of any type) across studies and the pooled estimate from this meta-analysis for HIV-negative MSM  was half that for HIV-positive MSM . Furthermore, HIV status was consistently found to be a risk factor for oral HPV infection in cross-sectional studies –20,32 anWe found a positive correlation between median age of study participants and prevalence which partly explained heterogeneity between study estimates. This association may be modified by HIV status since it was not found for prevalence estimates from HIV-positive populations. No within-study associations between age and oral HPV were found in studies of HIV-positive MSM, but four studies including HIV-negative MSM did find a statistically significant association with age –20,32  and HIV-positive (73.5%) MSM wereanal HPV.Oral HPV prevalence estimates in MSM from this meta-analysis were three to six times higher than the pooled estimate in all men (5%) from a previous systematic review  but theret al, whatever the current prevalence, if there is no effective natural immunity and all other factors remain unchanged, the rates would equilibrate at a prevalence of 23% .[Clearance rates were greater than incidence in all five longitudinal studies. The clearance rate applies only to MSM infected with HPV (10–30% of the MSM population) and incidence on the susceptible portion  so that, all other things equal, in the total population the number of new infections will eventually equal the number of cleared infections and the prevalence will stabilise. For example, using rates from Videla ulation).The strengths of this study include the high inter-rater agreement in study selection and data extraction and the exploration of reasons for heterogeneity in prevalence estimates including risk of bias. Yet there remain several limitations. We were not able to fully explain the extreme heterogeneity between prevalence estimates so pooled estimates should be used with caution. We needed to use approximation methods to estimate incidence and clearance rates and standardise them across studies; this, undoubtedly, introduced uncertainty into the estimates and so precluded meta-analysis. Although not designed for measuring risk of bias in meta-analyses, we used the STROBE checklist, which was not ideal for assessing the quality of study designs. We were unable to include data from four potentially eligible studies.–53Considerable uncertainty remains in determining the public health implications of oral HPV DNA detection in MSM as it is not clear what proportion of infections will lead to cancer. However, these findings are important for our understanding of oral HPV epidemiology in terms of transmission, incidence, and persistence.S1 Fig(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOC)Click here for additional data file.


Cervical cancer is one of the most common female cancers and is caused by human papillomavirus (HPV). Viral infection leads to cell cycle deregulation by inactivating p53 and retinoblastoma protein by viral oncoproteins E6 and E7, respectively. Then, nuclear proteins such as DNA topoisomerase type IIa (TOP2A) and Ki-67 show increased expression because of increased cell division. These molecules are used as biomarkers for immunohistochemistry analysis of cervical tissue.In this cross-sectional study, we recruited 110 women receiving regular gynecological surveillance at public health centers in Olinda – PE, Brazil. Cervicovaginal cells were collected to determine the presence of cytological abnormalities and HPV infection. Pap smear slides were used to evaluate the expression of TOP2A and Ki-67 using immunocytochemistry techniques.+ infection (83/110) and 29.1 % showed cellular abnormalities (32/110). Two atypical cells of undetermined significance, one low-grade squamous intraepithelial lesion, and one high-grade squamous intraepithelial lesion samples showed no HPV-DNA. TOP2A was positive in 71.9 % of samples, while Ki-67 was positive in 81.2 %. Immunocytochemistry results were positive in 4 of 5 atypical cells of undetermined significance samples. In HPV-DNA+ samples with cytological abnormalities, immunocytochemistry results were positive 96.4 % of samples . Among the samples infected with HR-HPV, TOP2A+ was effective in 71 % samples, while and Ki-67+ was 77.4 %. Ki-67 and TOP2A were positive for all samples infected with HPV6, HPV11, and HPV18. Ki-67 was also positive for all HPV16 samples, except for one negative sample in cytopathology analysis.Of the 110 women, 75.4 % showed HPV-DNATOP2A and Ki-67 antibodies may be used in combination for cervical cancer screening in immunocytochemistry assays. Worldwide, cervical cancer is the third most common female cancer. In 2012, 527,624 cases were reported. This number is expected to increase by 6.23 % in 2015, reaching to 560,505 cases [The viral oncoproteins E6, E7, and E5 deregulate the cell cycle and structure [TOP2A is responsible for enzymatic uncoupling during the replication of DNA strands, playing a significant role in S-phase regulation. TOP2A is overexpressed during the progression from cervical intraepithelial neoplasia 2 (CIN2)-CIN3 to cervical cancer, and thus it is considered to be a late marker of cervical carcinogenesis , 8. The Ki-67 is a nuclear and nucleolar protein expressed during all phases of the cell cycle, except for the G0 phase . Ki-67 eThe aim of this study was to determine the feasibility of using immunocytochemistry for TOP2A and Ki-67 on cytopathology slides to improve the accuracy of cervical cancer screening.This cross-sectional study included women under surveillance at public health centers in Brazil. Samples consisted of 110 patients aged 13–71 years from 3 familial health units located in Olinda-PE. During regular gynecological inspection, all patients underwent Pap testing and HPV-DNA investigation. Exclusion criteria were: HIV infection, pregnancy and post-partum, history of transplant, history of partial or complete uterus removal, and immunocompromised patients. This study was approved by institutional ethical committee Health Sciences Center Federal University of Pernambuco, Brazil (Code No.275/08) and conducted according to the guidelines of the Declaration of Helsinki (1964).Cervical samples were harvested from the ectocervix and endocervix using a spatula and cytobrush , respectively. Collected cells were transferred to a glass slide, identified, and then fixed in absolute ethanol  until sample preparation for cytopathology and immunocytochemistry analysis at Pathology Sector – LIKA/UFPE. The residual cells in the cytobrush were stored in phosphate-buffered saline (PBS), pH 7.0  at −20 °C before HPV identification and genotyping at Molecular Prospection Sector – LIKA/UFPE. For analysis, patients were divided into four groups according to Pap test and HPV-DNA identification: (1) women with cervical abnormalities and HPV-DNA positive; (2) women with cervical abnormalities and HPV-negative; (3) women with normal cytology and HPV-DNA positive; and (4) women with normal cytology and HPV-negative (control group).All samples underwent Papanicolaou staining  and wereTotal DNA extraction was performed using the Wizard Genomic DNA Purification Kit  following the manufacturer’s instructions. Eluted DNA was stored at −20 °C until HPV-DNA identification. Conventional PCR was performed in a Verity® Thermal Cycler  using two consensus primers: GP5+/GP6+  or MY09/Cervical samples assumed as positive for HPV-DNA or presenting cytological abnormalities were evaluated using the PapilloCheck® Test Kit , according to the manufacturer’s instructions. This chip-based assay identifies 18 HPV genotypes classified as high-risk (HR) or probable HR-HPV  and 6 low-risk (LR) HPV . The test cannot distinguish between HPV-55 and HPV-44 because of a cross-reaction, and the manufacturer instructions do not differentiate HR-HPV from probable HR-HPV. Slide scanning was performed using a Greiner Bio-One CheckScanner™. Data analysis was performed using CheckReport™ Software. Since PapilloCheck® requires highly pure and concentrated DNA (400–800 ng input), all samples that did not fulfill the criteria were excluded from the study.+; TOP2A+; Ki-67+/TOP2A+ (positive for both markers); and Ki-67+ and/or TOP2A+ (positive for at least one marker on the same slide), designated as ICC+. Two independent cytopathologists (A.L.P. and N.T.P.F) assessed all slides in a double-blinded manner; contradictory findings resolved through discussion.Immunocytochemistry (ICC) was performed on the Pap smear slides by removing coverslips in xylene and rehydrating the samples in decreasing concentration of ethyl alcohol . To testp < 0.05. The concordance between Ki-67 and TOP2A results were analyzed using Kappa statistics (κ) with 95 % CI in BioEstat software (Version 5.3).Statistical analysis was performed using Prism software v6.0 . The association between groups according to cytopathology, immunocytochemistry, and PCR results were performed by Chi-square test or Fischer exact test with 95 % confidence intervals (95 % CI) and odds ratio (OR). Statistics were significant when p = 0.0013; OR = 4.779). The youngest patient to report tubal ligation was 26 years, she used no other contraceptive method, had her first pregnancy at 19 years, and had 5 children. Smoking habits and alcohol consumption were reported by 34.5 and 54.5 % of patients, respectively.Among the 110 patients, the median age was 30 years, 77.8 % declared household incomes up to two minimum wages, and 95.4 % had no more than a high school education level (Table + infection (83/110) and 29.1 % showed cellular abnormalities (32/110). Twenty-eight samples were positive for both tests, cytopathology, and HPV-DNA (87.5 %). Two ASC-US, one LSIL, and one HSIL sample showed no HPV-DNA .In samples with cytological abnormalities, TOP2A was positive in 71.9 % of the samples, while Ki-67 was positive in 81.2 % of the samples. Comparison of the two markers showed that TOP2A was more efficient for HSIL, as expected for a prognosis cancer biomarker. Ki-67 was more effective for detecting ASC-US and LSIL, as it indicates cellular proliferation. The positive rate of TOP2A and Ki-67 increases when cervical lesion severity increases. The concordance between TOP2A and Ki-67 results was 78.2 %  and TOP2A (OR = 4.56). The concordance between the cytopathology and ICC test was 70 % .When evaluated as a single test, the positive rate for ICC+. TOP2A+ and Ki-67+ were observed in 36 and 27 % of samples, respectively. ICC+ results were observed in 39.7 % of samples (31/78). Twenty-seven samples (49.1 %) were HPV-DNA+ and ICC-negative. Only four samples (7.3 %) were HPV-negative and ICC+.The samples categorized as NILM corresponded to 70.9 % (78/110). Among these samples, 70.5 % (55/78) were HPV-DNA+ samples with cytological abnormalities, the ICC+ result was 96.4 % . In the HPV-negative group, the overall ICC+ rate was 33.3 %, identifying 3 of 4 HPV-negative samples. The overall ICC+ result in HPV-DNA+ samples was 64 %, with similar positivity between both markers.Table + samples.Samples infected with HPV-DNA or showing cytological abnormalities were selected for genotyping. A total of 83 samples were considered for genotyping, but seven samples were excluded because of low quality, including three ASC-US and one LSIL. Therefore, 76 samples were evaluated for HPV genotypes, including 28 samples with cytological abnormalities and 74 HPV-DNAHPV genotypes were identified in 34 samples (43.6 %), of which 31 (91.2 %) were infected with the HR-HPV genotypes. Nine patients were infected with HPV16 and three patients were infected with HPV18  showed negative results for the Papillocheck test, including one HSIL (ICC+), two LSIL samples, and one ASC-US (HPV-DNA+ and ICC+). Genotyping tests failed in 15 samples, including two LSIL (ICC+). Of the 37 NILM samples evaluated, 13 samples were infected with HR-HPV and one sample was infected with LR-HPV.Among the samples infected with HR-HPV, we found 71 % TOP2A+ test in samples with cytological abnormalities. TOP2A was more effective for HSIL samples, while Ki-67 was more effective for ASC-US and LSIL. A combination of markers is necessary for cervical cancer screening systems when the concordance between markers shows only moderate agreement. TOP2A and Ki-67 were also useful for identifying samples infected with HR-HPV, an important result the potential of these markers for commercial application.Our findings showed a high positive rate for the ICCHPV-DNA tests exhibit high sensitivity but low specificity and generally cannot distinguish clinically relevant lesions from transient infections . Thus, cApplication of the Ki-67 marker has been investigated in cervical cytology using classic Pap smears as a diagnostic adjunct for reducing the need for tissue biopsies , 20–22. TOP2A and Ki-67 were previously tested together for immunohistochemistry in carcinoma and high-grade cervical neoplasia (CIN2/3), revealing no relationship between stained nuclei counting and survival . However+ samples indicates a low risk of cervical lesion development in these patients, although HPV is present.In our study, using both markers enabled identification of cellular abnormalities in four of five ASC-US samples, corroborating the results of previous studies focused on atypical squamous cell cytology , 27, 31.+ lesions and was associated with HR-HPV infection and an increasing grade of cervical lesions [+ and Ki-67+ showed higher positive rates in samples infected with HR-HPV compared to in biopsied paraffin blocks analyzed for HPV16, 18, and 31 [The association of p16/Ki-67 staining increased sensitivity and specificity for identifying women at high-risk for developing high-grade precancerous disease in a group of HPV-positive patients with negative liquid-based Pap cytology . Singh e lesions . In our , and 31 .This is the first study investigating a combination of TOP2A and Ki-67 as markers for ICC in HR-HPV infection. The present study has some limitations, including the relatively small number of selected cases and the use of material collected during routine gynecological inspection of women under surveillance at public health centers in Brazil.TOP2A and Ki-67 may be a useful antibody combination for cervical cancer screening in health services currently using only conventional cytology. Further analyses are required before considering these markers for clinical follow-up in immunohistochemistry. Their performance must also be compared with those of commercial assays.


Cervical cancer is the third most gynecological cancer and one of the common causes of cancer death in women in Iran and the other developing countries. Human Papilloma Virus (HPV) is a known Risk factor in cervical cancer, but according to HPV deference types, the high risk and low risks differ.We evaluate the most common high risk and low risk HPV type in 180 females with an atypical squamous cells of undetermined significance (ASCUS) results in pap smear in Gynecological Oncology Clinic in Shahid Sadoughi Hospital in Yazd, Iran within 2012 to 2014.HPV typing was done with polymerase chain reaction (PCR) method. The data obtained were recorded in a questionnaire and analyzed by SPSS software.More common low risk HPV type in ASCUS patients was type 6 (63.6%) and then type 11 (36.4%). Type 16 was the most common high risk HPV type.HPV DNA typing for better management of women With ASCUS is important and this study showed HPV type 16 is the most prevalent type in ASCUS patients. It seems the living region is important in HPV type distribution and Quadri-valant Vaccine can prevent cervical cancer in Iran because the most common low risk HPV is type6 and 11, and HPV 16 is the most common high risk HPV. Cervical cancer is the fourth most common cancer in women and near 7.5% deathfrom cancer in females is due to cervical cancer worldwide -2.Risk factors such as early age marriage, poor sexual hygiene, using hormonal contraceptives, sex working and… are important in cervical cancer incidence . In pastDe Villiers EM explained more than 118 types of HPV that near the 40 types can infect the genital mucosa  and then type 11 (36.4%).Type 16 as the more common high risk HPV type was in 79.3% of patient and then respectively were Type 31 (8.6%), 45 (6.9%), 18 (3.4%) and 59 (1.7%) (Table p=0.095) (Table After biopsy there was no association between biopsy result and HPV typing (5) Table .HPV infection is an Important risk factor for cervical cancer as is seen in 99% of CC patients , 15, 16.Our cases came from the group were referred to a gynecologist because of the previous ASCUS result in PaP smear.Studies have shown, type 16 is common, more than 60% in CC. In other steps, type 18, 45 and 31 respectively, are 10-15%, 7% and 3% of HPV infection in CC patients , 18.Clifford GM, the prevalence of HPV 16 in ASCUS patients was 31% that in our study was 25.5%. Consistent with other studies, HPV type16 is the most common type in our specimens  Vaccine can decrease cervical cancer -18. This