Summary
Objective: To assess whether the presence of human papilloma virus (HPV) DNA and/or several genotypes of HPV DNA in primary cervical cancer and cancer free pelvic lymph nodes are correlated with several clinicopathological parameters of well-defined prognostic significance and whether virological parameters are predictors of long-term survival in cancer patients. Patients and methods: 223 cases of cervical cancer patients included in this retrospective study underwent follow-up evaluation. Survival and cause of death were examined for 204 (91.4 %) patients, with a mean follow-up time of 4.4 years. HPV DNA was detected using the high sensitive polymerase chain reaction (PCR) method followed by HPV DNA sequencing for HPV genotyping. These results were correlated with well-defined clinicopathological parameters and survival data. Results: HPV DNA was detected by PCR in 150 of 203 (73.4 %) tissue specimens of cervical cancer patients. DNA sequence analysis revealed the presence of HPV 16 (n = 68, 45.3 %), HPV 18 (n = 49, 32.6 %) and rare HPV types (n = 33, 22.1 %). HPV genotypes correlated significantly with histological tumor types, node status, blood vessel invasion and lymph space involvment. The presence of HPV DNA in cervical cancer as well as the genotype of HPV 16 could also be confirmed as significant prognostic factors in the univariate Cox Regression Analysis (RR 2.856, p < 0.003 resp. RR 3.444, p < 0.0001). The presence of HPV DNA in cancer free pelvic lymph nodes was significantly correlated to the concomitant manifestation of pelvic lymph node metastases (RR 3.1, p < 0.0001). In the multivariate analysis, however, HPV DNA in primary tumor and in negative pelvic lymph nodes failed to be of prognostic relevance. Exclusively, HPV 16 appears to impact independently on the overall survival in cervical cancer patients (RR 3.653, p < 0.002). Conclusion: The detection of HPV 16 genotype may play an important adjunct role in assessing prognosis of cervical cancer patients. The clinical impact of the presence of HPV DNA in primary tumors and cancer free pelvic lymph nodes remains to be investigated in further studies. The exact mechanisms by which HPV influence the prognosis of cervical cancer patients have to be defined.
Humane Papillomavirus (HPV)-DNA in Zervixkarzinomen und tumorfreien pelvinen Lymphknoten - Assoziation mit klinisch-pathologischen Parametern und prognostische Validität
Zusammenfassung
Fragestellung: Ziel dieser retrospektiven Analyse war es, zu prüfen, ob zwischen dem Nachweis von humaner Papillomavirus (HPV)-DNA/verschiedener HPV-Typen in primären Zervixkarzinomen bzw. in tumorfreien pelvinen Lymphknoten und definierten klinisch-pathologischen Prognosefaktoren ein Zusammenhang besteht und ob der HPV-Status von prognostischer Relevanz für das Gesamtüberleben von Zervixkarzinompatientinnen ist. Patientinnen und Methode: Die vorliegende Studie umfaßte insgesamt 223 Patientinnen mit primärem Zervixkarzinom, wobei der klinische Verlauf von 204 Tumorpatientinnen (91,4 %) mit einer mittleren Nachbeobachtungszeit von 4,4 Jahren dokumentiert wurde. Der Nachweis von HPV-DNA erfolgte mittels der hoch sensitiven Polymerasekettenreaktion (PCR) gefolgt von einer HPV-DNA-Sequenzierung für die HPV-Typisierung. Die Ergebnisse wurden mit definierten klinisch-pathologischen Parametern und Gesamtüberlebensdaten korreliert. Ergebnisse: HPV-DNA konnte mittels PCR in Tumorproben von 150 (73,4 %) Zervixkarzinompatientinnen nachgewiesen werden. Mit Hilfe der DNA-Sequenzierung konnten HPV 16 (n = 68; 45,3 %), HPV 18 (n = 49; 32,6 %) und seltenere HPV-Typen (n = 33; 22,1 %) nachgewiesen werden. Dabei korrelierten HPV 16 und HPV 18 siginifikant mit histologischen Tumortypen, Nodalstatus sowie Hämangio- und Lymphangioinvasion. In der univariaten Regressionsanalyse konnte der Nachweis von HPV-DNA bzw. HPV 16 im Primärtumor als prognostisch relevant objektiviert werden (RR 2.556, p < 0,003 bzw. RR 3.444, p < 0,0001). Der Nachweis von HPV-DNA in tumorfreien pelvinen Lymphknoten zeigte eine statistisch signifikante Assoziation mit der gleichzeitigen Manifestaion von pelvinen Lymphknotenmetastasen und einen signifikanten Einfluß auf das Gesamtüberleben in der univariaten Regressionsanalyse (RR3.1, p < 0,0001). In der multivariaten Regressionsanalyse hingegen konnte ausschließlich HPV 16 mit unabhängigen Einfluß auf das Gesamtüberleben von Zervixkarzinompatientinnen ermittelt werden (RR 3.653, p < 0,002). Schlußfolgerung: Der Nachweis von HPV 16 wird als unabhängiger negativer Prognosefaktor identifiziert. Die klinische Relevanz des Nachweises von HPV-DNA in primären Zervixkarzinomen und tumorfreien pelvinen Lymphknoten bleibt abzuwarten. Die genauen Mechanismen mit denen HPV die Prognose von Zervixkarzinompatientinnen beinflußt, bleibt zu definieren.
MeSH
C4.588.945.418.948.170 cervix neoplasms
Key words
Cervical cancer - PCR - HPV - prognosis
Schlüsselwörter
Zervixkarzinom - PCR - HPV - Prognose
References
1
Baay M F, Koudstaal J, Hollema H, Duk J M, Burger M P, Quint W, Stolz E, Herbrink P.
Detection of HPV 16 DNA by PCR in histologically cancer free lymph nodes from patients with cervical cancer.
J Clin Pathol.
1997;
50
960-961
2
Baltzer J.
Die Bewertung prognostischer Kriterien bei Karzinomen des Uterus.
Geburtshilfe Frauenheilkd.
1981;
41
663-667
3
Barnes W, Delgado G, Kurman R J, Petrilli E, Smith D, Ahmed S, Lorincz A, Temple G, Jenson A, Lancaster W.
Possible prognostic significance of human papillomavirus type in cervical cancer.
Gynecol Oncol.
1988;
29
267-273
4
Bollen L, Tjong-A-Hung S, Vonk J, van der Velden J, ten Kate F, Kaan F, ter Schegget J.
Human papillomavirus DNA detection in mildly or moderate dysplastic smears: A possible method for selecting patients for colposkopy.
Am J Obstet Gynecol.
1997;
177
548-553
5
Bollen L, Tjong-A-Hung S, van der Velden J, Mol B, ten Kate F, Kaan F, ter Schegget J, Bleker O.
Prediction of recurrent and residual cervical dysplasia by human papillomavirus detection among patients with abnormal cytology.
Gynecol Oncol.
1999;
72
199-201
6
Van Bommel P F J, van Lindert A C M, Kock H C, Leers W H, Neijt J P.
A review of prognostic factors in early stage carcinoma of the cervix (FIGO IB and IIA) and implications for treatment strategy.
Eur J Obstet Gynecol Reprod Biol.
1987;
26
69-84
7
Van Bommel P, van den Brule A, Helmerhorst T, Gallee M, Gaarenstroom K, Walboomers J, Meuer C, Kenemanns P.
HPV DNA presence and HPV genotypes as prognostic factors in low stage squamous cell cervical cancer.
Gynecol Oncol.
1993;
48
333-337
8
Van den Brule A, Claas H, Dumaine M, Melchers W, Helmerhorst T, Quint W, Lindeman J, Meijer C, Walboomers J.
Use of anticontamination primers in the polymerase chain reaction for the detection of human papillomavirus genotypes in cervical scrapes and biopsies.
J Med Vir.
1989;
29
20-27
9
Burger R A, Monk B J, Kurosaki T, Anton-Culver H, Vasilev S A, Berman M L, Wilczynski S P.
Human papillomavirus type18: association with poor prognosis in early stage cervical cancer.
J Natl Cancer Inst.
1996;
88
1361-1368
10
Collins J, Jenkins D, McCance D.
Detection of human papillomavirus DNA sequences by in situ DNA-DNA hybridisation in cervical intraepithelial neoplasia and invasive carcinoma: a retrospective study.
J Clin Pathol.
1988;
41
289-295
11
Czegledy J, Iosif C, Forslund O, Willen R, Hansson B G.
Detection of human papilloma virus DNA in lymph nodes extirpated at radical surgery for cervical cancer is not predictive of recurrence.
J Med Virol.
1998;
54
183-185
12
DeVilliers E, Wagner D, Schneider A, Wesch H, Miklow H, Wahredorf J, Papendiek U, zur Hausen H.
Human papillomavirus infections in women with and without abnormal cervical cytology.
Lancet.
1987;
123
703-705
13
Durst M, Gissman L, Ikenberg H, zur Hausen H.
Papillomavirus DNA from cervical carcinoma and its prevalence in cancer biopsy samples from different geographic regions.
Proc Natl Acad Sci USA.
1983;
80
3812-3815
14
Franco E, Bergeron J, Villa L, Arella M, Richardson L, Arseneau J, Stanimir G.
Human papillomavirus DNA in invasive cervical carcinoma and its association with patient survival: a nested case-control study.
Cancer Epidemiol Biomarkers Prev.
1996;
4
271-275
15
Fuchs P G, Girardi F, Pfister H.
Human papillomavirus DNA in normal, metaplastic, preneoplastic and neoplastic epithelia of the cervix uteri.
Int J Cancer.
1988;
41
41-45
16
Fuchs P G, Girardi F, Pfister H.
Human papillomavirus 16 DNA in cervical cancers and in lymph nodes of cervical cancer patients: a diagnostic marker for early metastases.
Int J Cancer.
1989;
43
41-44
17
Garzetti G G, Ciavattini A, Lucarini G, Goteri G, Menso S, DeNictolis M, Romanini C, Biagini G.
The role of human papillomavirus DNAs in cervical carcinoma and risk of lymph node metastasis: association with 72-kilodalton metalloproteinase immunostaining.
Cancer.
1998;
82
889-872
18
Girardi F, Fuchs P, Haas J.
Prognostic importance of human papillomavirus type 16 DNA in cervical cancer.
Cancer.
1992;
69
2502-2504
19 Zur Hausen H, Schneider A. The role of papillomavirus in human anogenital cancer. In: Salzmann NP, Howley PM (Eds). The papovaviridiae: The papillomaviruses. Plenum New York 1987; 2: 1014-1019
20 Hermanek P, Sobin L H. TNM Classification of malignant tumours. Fifth edition, Springer and International Union Against Cancer; New York 1997
21
Higgins G, Davy M, Roder M, Uzelin D, Philips D, Burell C.
Increased age and mortality associated with cervical carcinomas negative for human papillomavirus RNA.
Lancet.
1991;
338
910-913
22
Hording U, Ravn V, Knudsen J, Visfeldt J.
The use of polymerase chain reaction to detect metastatic cancer cells within lymph nodes in stage I cervical carcinoma.
Int J Gynecol Pathol.
1995;
14
339-343
23
Ikenberg H, Teufel G, Schmitt B, Kommoss F, Stanimirovic B, Pfleiderer A.
Human papillomavirus DNA in distant metastases of cervical cancer.
Gynecol Oncol.
1993;
48
56-60
24
Jarell A, Heintz N, Howard P, Collins C, Badger G, Belinson J, Fae N.
Squamous cell carcinoma of the cervix: HPV16 and DNA ploidy as predictors of survival.
Gynecol Oncol.
1992;
46
361-366
25
Kobayashi Y, Yoshinouchi M, Tiangi G, Nakamura K, Hongo A, Kamimura S, Mizutani Y, Kodama J, Miygi Y, Kudo T.
Presence of human papilloma virus DNA in pelvic lymphnodes can predict unexpected reccurrence of cervical cancer patients with histologically negative lymph nodes.
Clin Cancer Res.
1998;
4
979-983
26
Konya J, Veress G, Hernadi Z, Soos G, Czegledy J, Gergely L.
Correlation of human papillomavirus 16 and 18 with prognostic factors in invasive cervical neoplasias.
J Med Virol.
1995;
46
1-6
27
Kristensen G, Karlsen F, Jenkins A, Kaern J, Abeler V, Trope C.
Human papilloma virus has no prognostic significance in cervical carcinoma.
Eur J Cancer.
1996;
32
1349-1353
28
Kurman R, Schiffman M, Lancaster W, Reid R, Jenson B, Temple F, Lorincz A.
Analysis of individual human papillomavirus types in cervical neoplasia: A possible role for type 18 in rapid progression.
Am J Obstet Gynecol.
1988;
159
293-296
29
Lombard I, Vincent-Salomon A, Validire P, Zafrani B, de la Rochefordiere A, Clough K, Favre M, Pouillart P, Sastre-Garau X.
Human papillomavirus genotype as a major determinant of the course of cervical cancer.
J Clin Oncol.
1998;
26
2613-2619
30
Munoz N, Bosch X, Kaldor J M.
Does human papillomavirus cause cervical cancer? The state of the epidemiological evidence.
Br J Cancer.
1988;
57
1-5
31
Münger K, Werness B, Dyson N, Phelps W, Harlow E, Howley P.
Complex formation of human papillomavirus E7 proteins with the retinoblastoma tumor suppressor gene product.
J Virol.
1989;
61
1061-1066
32
Park J, Chee Y, Namkoong S, Han S, Kim T, Lee H, Kim S.
Human pillomavirus detection in cervical carcinoma tissue and paraaortic lymph nodes by the polymerase chain reaction.
Gynecol Oncol.
1994;
53
344-351
33
Park J S, Rhyu K S, Kim C J, Kim H S, Han K T, Ahn H K, Kim SJ, Namkoong S E.
Presence of oncogenic HPV DNAs in cervical carcinoma tissues and pelvic lymph nodes associating with proliferating cell nuclear antigen expression.
Gynecol Oncol.
1996;
60
410-423
34
Polka R, Czegledy J.
HPV- and node status in cervical cancer long-term results.
Eur J Obstet Gynecol Reprod Biol.
1997;
71
169-172
35
Riou G, Favre M, Jeannel D, Bourhis J, Le Doussal V, Orth G.
Association between poor prognosis in early stage invasive cervical carcinomas and non-detection of HPV DNA.
Lancet.
1990;
335
1171-1174
36
Rose B, Thompson C, Cossart Y, Elliot P, Tattersall M.
Papillomavirus DNA and prognosis in cervical cancer.
Lancet.
1991;
337
489
37
Rose B, Thompson C, Chantrill L A, Tattersall M H, Cossart Y E.
Prevalence and distribution of human papillomavirus type DNA in pelvic lymph nodes of patients with cervical cancer and in women with no history of cervical abnormality.
Int J Cancer.
1992;
52
225-228
38
Sapy T, Hernadi Z, Konya Y, Lukacsko L.
Poor clinical outcome in early stage cervical cancer with human papillomavirus -18 positive lymph nodes.
Eur J Obstet Gynecol Reprod Biol.
2000;
90
93-95
39
Schneider A, Kirchhoff T, Meinhardt G, Gissman L.
Repeated evaluation of human papillomavirus 16 status in cervical swabs of young women with a history of normal Papanicolaou smears.
Obstet Gynecol.
1992;
79
683-688
40
Smits H, Tjong-A-Hung S, Vonk J, van der Velden J, ten Kate F, Kaan F, ter Schegget J.
Intermethod variation in detection of human papillomavirus DNA in cervical smears.
J Clin Mirobiol.
1995;
33
2631-2636
41
Szarka K, Veress G, Juhasz A, Konya J, Sapy T, Soos G, Hernadi Z, Gergely L.
Integration status of virus DNA and p53 codon 72 polymorphism in human papillomavirus type 16 positive cervical cancers.
Anticancer Res.
2000;
20
2161-2167
42
Vavra N, Kucera H, Eppel W, Barrada M, Salzer H, Schemper M, Sevelda P.
Prognosefaktoren des radikal operierten Zervixkarzinoms im Stadium Ib.
Geburtshilfe Frauenheilkd.
1992;
52
157-160
43
Viladiu P, Bosch X, Castellsague X, Munoz N, Escriba J M, Hamsikova E, Hofmannova V, Guerro E, Izquierdo A, Navarro C, Moreo P, Izarzugaza I, Ascunce N, Gili M, Munoz M, Tafur L, Shah K, Vonka V.
Human papillomavirus DNA and antibodies to human papillomaviruses 16E2, L2 and E7 peptides as predictors of survival in patients with squamous cell cervical cancer.
J Clin Oncol.
1997;
2
610-619
44 WHO .Histological typing of female genital tract tumours. International Histological Classification of Tumours. 2nd edn. Scully et al. 1994
45
Wright T C, Richart R M.
Role of human papillomavirus in the pathogenesis of genital tract warts and cancer.
Gynecol Oncol.
1990;
37
151-164
46
Yang Y, Shen J, Tate J, Wang K, Su T, Wang K, Jeng C, Chen H, Chiang S, Crum C.
Cervical Cancer in young women in Taiwan: prognosis is independent of papillomavirus or tumor cell type.
Gynecol Oncol.
1997;
64
59-63
47
Zitz J, McLachlin C, Tate J, Mutter G, Crum C.
Analysis if isotope-labeled PCR-amplified HPV DNA by RFLP provides optimal sensitivity and contamination detection.
Mod Pathol.
1994;
7
407-411
Henryk PilchMD
Section of Gynecopathology Department of Obstetrics and Gynecology Medical Center Mainz University of Mainz
Langenbeckstr. 1
D-55101 Mainz
Phone: Tel.: 61 31/1 70
Email: E-mail: HPilch3920@aol.com