HPV testing in the follow-up after treatment of women with CIN
After detection of human papillomavirus DNA sequences in
genital warts, cervical dysplasia, premalignant lesions, and
cervical cancer specimens in the early 1980s a wealth of
molecular and epidemiological data proved HPV infection as a
necessary event in cervical cancer development. Virtually all
tumour cells in a cervical cancer contain sequences of the
identical HPV type . While in early productive infection the
viral circular DNA genome is extrachomosomally located, it
integrates into the host cell genome at some point during
progression and is then propagated to the resulting tumour cells.
Therefore, most cervical cancers arise as monoclonal tumours.
By integration, most often the E2 gene of the virus is destroyed
leading to a change in gene regulation. While the late virus–
capsidencoding genes are no longer switched on, the oncogenes
E6 and E7 are up-regulated leading to prevention of apoptosis
and enhanced proliferation, respectively. These are key events
that kick start malignant progression, supported by additional
mutations in the uncontrolled proliferating cell. Finally, a
tumour arises that has to be treated by surgery to remove the
malignant cells completely . There is, however, the
possibility that next to such a progressive lesion an area of
ongoing productive infection may be found.
Due to its universality in the cervical cancer tumour cells
HPV can be regarded as a molecular tag. This tag may be used
to monitor completeness of removal of tumour cells, i.e. the
lesion, persistence of infection after surgery, or recurrence of
disease. To this end, several studies have been performed
aiming at detecting HPV after conization or trachelectomy and
to correlate HPV detection with clinical outcome.
HPV detection versus cytology in the follow-up of
treatment of CIN
Following excisional treatment of CIN, 10% of women may
experience recurrent CIN over a period of 4 years. . This may
even lead to cancer in 8 of 1000 women over a period of 8 years
. Therefore, early detection and treatment of recurrent CIN is
important. In order to detect recurrent CIN more accurately,
several investigators have analysed the sensitivity and speci-
ficity of HPV DNA testing by hybrid capture 2 as compared to
follow-up cytology . Arbyn et al. in a recent meta-analysis
have summarized the results of 13 studies and found a higher
sensitivity and comparable specificity for HPV testing in
triaging of ASCUS. For triage of LSIL, HPV testing was less
specific. To detect residual or recurrent disease after treatment
of CIN, HPV testing was more sensitive than follow-up
cytology, again with comparable specificity . Women who
are HPV-positive post surgery have been found to be at higher
risk of treatment failure, while a negative HPV test eliminates
the risk of recurrent disease [7,8]. Altogether, there is sufficient
evidence to recommend HPV testing for triage of women in
surveillance after treatment of CIN . Women treated for
HPV16 should be monitored more intensively because of their
increased risk of post-treatment recurrence .
Prognostic markers would be useful for both pre- and post-
surgery evaluation. More than 80% of all high-grade lesions
regress spontaneously while 12% progress to invasive disease
. Several molecular markers have been investigated for their
potential predictive value for lesion progression or regression.
These markers may be also useful during follow-up after
surgical treatment. Determination of viral load has been shown
to correlate with risk of progression and grade of CIN.
Interestingly, in single-type infections, viral load is higher
than in multiple-type infections [11–13]. Also, the physical
state of HPV genomes correlates with the grade of CIN when an
integrated virus is present in higher-grade CIN .
Gene transcription is to some extent regulated by promoter
long control region is found in most malignant lesions but rarely
in asymptomatic infections and low grade lesions . This
could lead to differential expression of viral proteins like the
capsid protein L1. Lesions without detectable L1 expression are
more likely to progressthan L1-positive cases . Actually, we
observed differential expression of the L1 and E6 proteins
correlating with cytology of LSIL and HSIL, respectively. This
observation is supported by data on the detection of E6/E7 RNA
in ASCUS and LSIL conferring a 70-fold higher risk of
progression to HSIL . Also cellular promoters may be
status of the cellular genes CALCA, DAPK, ESR1 and TIMP3
correlate with lesion progression with higher specificity than
cytology and HPV detection .While pRb inhibition-released
expression of p16INK4ais rather a marker for high-risk HPV
infection, the detection of human telomerase (hTERT) and
topoisomerase IIα correlate with immortalisation and progres-
sion from CINII to CINIII, respectively [19–21].
Gynecologic Oncology 107 (2007) S5–S7
HPV vaccination after excisional therapy
Currently, prophylactic HPV vaccines are being introduced
onto the market, that have shown 100% effectiveness in
preventing persistent HPV infection and development of CIN.
Such virus-like particle-based vaccines consist exclusively of
the late capsid protein L1. L1, however, is not consistently
expressed in HPV-infected cells and obviously not at all in
transformed cells, as has been discussed above. In addition, the
protective principle is the induction of virus-neutralising
antibodies that will not be effective against intracellular HPV
antigens. Induction of T cells that rather have a therapeutic
capacity is only sparsely investigated and not demonstrated in
vaccineesuptodate. Therefore,these vaccineswillprobablynot
it has been shown that natural HPV infection induces only a
weak humoral immunity with low antibody titers that do not
In addition, vaccination with the prophylactic vaccines will
protect from additional HPV types that a patient has not had
before, including related types to HPV 16 and 18 . It may
therefore be beneficial to vaccinate patients after surgery to
protect them from reinfection (by their partners). Even in the
case of persistent infection after surgery, as discussed above, the
induced immunity will not prolong infection or enhance
progression as shown in the phase III vaccination studies with
volunteers already infected by HPV . In conclusion,
vaccination of patients after surgery with prophylactic L1
vaccines has some benefits and no disadvantages.
More advantageous would be a HPV vaccine with
therapeutic effectiveness that could be used in an adjuvant
setting after surgical removal of the lesion. Several approaches
are under investigation like synthetic peptides and recombinant
protein (e.g. Hsp-E7 fusion, L1-E7 CVLP) viral vaccines (e.g.
MVA-E2, MVA-E7) or DNA vaccines (e.g. Zyc101a Mini-
genes, HPV16E7SH) . All of those are under pre-clinical or
early clinical investigation. Some have produced promising
results but are not yet available for clinical use. Despite highly
successful prophylactic vaccines, there will be an ongoing
demand for therapeutic vaccines due to women already infected
to date and the oncogenic HPV types not yet included in the
In conclusion, conservative therapyand follow-up in patients
with CIN has to be newly defined. HPV DNA detection is more
sensitive than cytology following surgical therapy and specific
markers describing progressive potential of CIN are on the
horizon. While therapeutic vaccination has generated promising
results in early disease trials, the value of prophylactic
vaccination in post therapy settings is unclear.
Conflict of interest statement
We declare that we have no conflict of interest.
necessary cause of invasive cervical cancer worldwide. J Pathol 1999;189:
 zur Hausen H. Papillomaviruses and cancer: from basic studies to clinical
application. Nat Rev Cancer 2002;2:342–50.
 Flannelly G, Langhan H, Jandial L, Mana E, Campbell M, Kitchener H. A
study of treatment failures following large loop excision of the trans-
formation zone for the treatment of cervical intraepithelial neoplasia. Br J
Obstet Gynaecol Jun 1997;104(6):718–22.
 Soutter WP, de Barros Lopes A, Fletcher A, Monaghan JM, Duncan ID,
Paraskevaidis E, et al. Invasive cervical cancer after conservative therapy
for cervical intraepithelial neoplasia. Lancet Apr 5 1997;349(9057):
women treated for high-grade CIN: an update of pooled evidence. Gynecol
Oncol Dec 2005;99(3 Suppl 1):S7–S11 [Accepted 2005 Sep 9].
 Arbyn M, Sasieni P, Meijer CJ, Clavel C, Koliopoulos G, Dillner J.
Chapter 9: Clinical applications of HPV testing: a summary of meta-
analyses. Vaccine Aug 21 2006;24(Suppl 3):S78–89.
 Hernadi Z, Szoke K, Sapy T, Krasznai ZT, Soos G, Veress G, et al. Role of
human papillomavirus (HPV) testing in the follow-up of patients after
treatment for cervical precancerous lesions. Eur J Obstet Gynecol Reprod
Biol Feb 1 2005;118(2):229–34.
Kitchener HC.Humanpapillomavirustestingandtheoutcomeof treatment
for cervical intraepithelial neoplasia. Obstet Gynecol Nov 2001;98(5 Pt 1):
 Murat Gök, Coupé Veerle MH, Berkhof Johannes, Verheijen René HM,
risk of recurrence after treatment for CIN. Gynecol Oncol Feb 2007;104(2):
273–5 [Accepted 2006 Dec 8].
 Ostor AG. Natural history of cervical intraepithelial neoplasia: a critical
review. Int J Gynecol Pathol Apr 1993;12(2):186–92 [Review].
 Sun CA, Lai HC, Chang CC, Neih S, Yu CP, Chu TY. The significance of
human papillomavirus viral load in prediction of histologic severity and
size of squamous intraepithelial lesions of uterine cervix. Gynecol Oncol
 van Duin M, Snijders PJ, Schrijnemakers HF, Voorhorst FJ, Rozendaal L,
Nobbenhuis MA, et al. Human papillomavirus 16 load in normal and
abnormalcervical scrapes: an indicatorof CINII/IIIand viral clearance. Int J
Cancer Apr 1 2002;98(4):590–5.
 Flores R, Papenfuss M, Klimecki WT, Giuliano AR. Cross-sectional
analysisof oncogenicHPV viralloadandcervical intraepithelial neoplasia.
Int J Cancer 2006;118(5):1187–93.
 Klaes R, Woerner SM, Ridder R, et al. Detection of high-risk cervical
intraepithelial neoplasia and cervical cancer by amplification of transcripts
derived from integrated papillomavirus oncogenes. Cancer Res
 Kalantari M, Calleja-Macias IE, Tewari D, Hagmar B, Lie K, Barrera-
Saldana HA, et al. Conserved methylation patterns of human papilloma-
virus type 16 DNA in asymptomatic infection and cervical neoplasia.
J Virol Dec 2004;78(23): 12762–72.
 Griesser H, Sander H, Hilfrich R, Moser B, Schenck U. Correlation of
immuno-chemical detection of HPV L1 capsid protein in pap smears with
regression of high-risk HPV positive mild/moderate CIN. Anal Quant
Cytol Histol 2004;26(5):241–5.
 Molden T, Nygard JF, Kraus I, Karlsen F, Nygard M, Skare GB, et al.
Predicting CIN2+ when detecting HPV mRNA and DNA by PreTect HPV-
proofer and consensus PCR: a 2-year follow-up of women with ASCUS or
LSIL Pap smear. Int J Cancer 2005;10;114(6):973–6.
 Wisman GB, Nijhuis ER, Hoque MO, Reesink-Peters N, Koning AJ,
Volders HH, et al. Assessment of gene promoter hypermethylation for
detection of cervical neoplasia. Int J Cancer Oct 15 2006;119(8):
 Jarboe Elke A, Liaw Kai-Li, Thompson L Chesney, Heinz David E,
Baker Paige L, McGregor Jamie A, et al. Analysis of telomerase as a
diagnostic biomarker of cervical CIN and carcinoma. Oncogene 2002;21
 Branca M, Giorgi C, Ciotti M, Santini D, Di Bonito L, Costa S, et al.
Over-expression of topoisomerase IIalpha is related to the grade of
cervical intraepithelial neoplasia (CIN) and high-risk human papilloma-
virus (HPV), but does not predict prognosis in cervical cancer or HPV
clearance after cone treatment. Int J Gynecol Pathol Oct 2006;25(4):
 Murphy N, Ring M, Heffron CCBB, King B, Killalea AG, Hughes C,
et al. p16INK4A, CDC6, and MCM5: predictive biomarkers in cervical
preinvasive neoplasia and cervical cancer. J Clin Pathol 2005;58:
 Viscidi RP, Schiffman M, Hildesheim A, et al. Seroreactivity to human
papillomavirus (HPV) types 16, 18, or 31 and risk of subsequent HPV
infection: results from a population-based study in Costa Rica. Cancer
Epidemiol Biomark Prev 2004;13:324–7.
 Harper DM, Franco EL, Wheeler CM, et al. Sustained efficacy up to
4.5 years of a bivalent L1 virus-like particle vaccine against human
papillomavirus types 16 and 18: follow-up from a randomised control trial.
 US Food and Drug Administration. Product Approval Information-
Licensing Action: Quadrivalent Human Papillomavirus (Types 6, 11, 16,
18) Recombinant Vaccine. Available at: http://www.fda.gov/cber/products/
hpvmer060806.htm. Accessed October 26, 2006.
and prevention of cervical cancer. Curr Opin Oncol 2004;16:485–91.
Helmut von Keyserling
Andreas M. Kaufmann
Department of Gynecologic Oncology,
Charité Universitätsmedizin Berlin,
Campus Mitte und Benjamin Franklin, Germany
Hindenburgdamm 30, 12200 Berlin
E- mail address: achim .schneider@ charite.de.
⁎Corresponding author. Fax: +49 30 8445 4477.
6 July 2007