DR. JOSEPH MONSONEGO


- Director of Institut du Col, Paris 
- President of EUROGIN (European Research Organization on Genital Infection and Neoplasia) www.eurogin.com 
- President of the International Foundation WACC (Women Against Cervical Cancer) www.wacc-network.org

There is strong evidence that HPV infection is necessary but not sufficient for the
development of precancerous and cancerous cervical lesions. Today, there are more than
200 known subtypes of HPV, although only a fraction of these have been found to have
oncogenic potential1. Of the 15 types of HPV considered to be high-risk for cervical cancer,
five (16, 18, 33, 31 and 45) are linked to the highest risk, with types 16 and 18 causing 60% of
CIN3 and 70% of cancers. The natural history of the disease must therefore be reconsidered
in its entirety, taking into account high-risk exposure to the most active types of the virus2.

Transmission takes place through sexual contact and, of all the anogenital and oral epidermal
regions, the cervix is the most sensitive and the most vulnerable, probably owing to the
fact that the transformation zone is directly accessible to the virus. During a woman’s life,
the risk of exposure to HPV at least once can reach 70%3. Cervical cancer has an estimated
lifetime risk of between 0.6% and 3%; it should therefore be regarded as the rare result of a
common infection. The types of HPV that are relevant to the anogenital sphere (alpha HPV
group) differ from those predominantly found on the skin (beta and gamma groups).

Peak prevalence of the infection is observed at around 20 to 25 years of age, where it can
reach 30%; prevalence gradually decreases with age and averages an estimated 10-12% in
people over 304. Young women are at a higher risk owing to insufficient preparation of the
immune system, immaturity of the metaplastic epithelium in younger women and increased
exposure to the virus through higher numbers of sexual partners.

Instantaneous infection is transient and short-lived in almost 90% of cases and clears within
18 to 36 months, especially those associated with the less active viruses5. However, 10%
of infections are persistent, more often those found to be associated with the most active
viruses. This clearance of the virus can be attributed to natural immunity, the specific
mechanisms of which have not been fully explained. Nevertheless, natural immunity is not
enough to ensure definitive protection and it is possible to become infected with the same
virus again or with others6. This is due to the fact that HPV infection is not as immunising
as vaccination is effective.

Viral persistence is the most relevant indicator of a lesion: after a persistent infection, the OR of HG
CIN is over 1007 and over 16 for cancer8, while the cumulative risk of CIN3 for a persistent HPV 16
infection lasting more than 10 years is 50%9. A number of factors have been reported as markers
for viral persistence, particularly age, immunodepression, smoking10, chlamydia infection and oral
contraception11. These factors have also been found to be risk markers for cervical cancer.

Nicotine and its carcinogenic metabolites are found in the cervix mucous membrane and smoking has an impact on local immune markers. Oestrogen and progesterone may have an effect on cell proliferation and thus induce susceptibility to DNA damage.

Cervical carcinogenesis always begins as a result of exposure to HPV, particularly to the 5 most active viruses. Viral persistence leads to morphological changes in the cells, some of which, particularly Low Grade lesions (LSIL), may then regress or disappear as natural adaptive immunity is gradually established. High Grade lesions (HSIL) are considered to be high-risk lesions with the potential to progress. Observational data shows that the time in which the persistent virus may lead to cancer after exposure of the cervical transformation zone may be estimated at between 15 and 20 years, although faster progression may have been reported.

The concept of a continuum from LSIL to HSIL is no longer commonly accepted. The specific mechanisms involved in regression and progression, which are most certainly immunological and viral in nature, are still not fully understood. The initial immune response to acute infections is probably mediated by the local innate immune system, and is likely to involve mechanisms such as the activation of toll-like receptors and natural killer cells. Persistent infections probably involve adaptive immune responses, which rely on antigen-presenting cells12. HPV 16 is controlled by both innate immunity and adaptive immunity.

After penetration and persistence of the HPV virus on contact with basal cells, the omnipotent cell receptive to the virus, at the squamocolumnar junction, the virus expresses viral replication and maturation genes (L1 and L2 proteins) in the differentiated epithelium of LSILs, then viral transformation genes (E6 and E7 oncoproteins) in the less and less differentiated epithelium of HSILs13.

These oncoproteins disrupt the cell cycle by interfering with negative cell cycle regulators (p53 and pRB), thus causing the cell to become unstable, the starting point of the transformation. While the virus reaches maturation in LSILs, in HSILs it is in what is known as an episomal state (immature), and is incorporated into the cell genome in cancers13.

Microbiota and HPV

The microbiota plays an important role in human health. It has been reported that an imbalance in the microbiota may be involved in colon cancer and atopic dermatitis. The vaginal microbiota is made up of a large variety of Lactobacilli, the balance and diversity of which can have an effect on the local immune state and vice versa14.

Figure 1.

Figure 2.
Adapted from Mitra et al. Microbiome (2016).

In vitro studies show that certain Lactobacilli (Lactobacillus spp) exert cytotoxic effects on cervical tumour cells15. This indicates that cervical cells, the microbiota and its metabolites are likely to interact15.

There is substantial evidence to suggest that HPV is affected by the vaginal microbiota (VM). In meta-analyses of most cross-sectional studies, the presence of bacterial vaginosis (BV) was linked to higher rates of HPV infection (12 studies: odds ratio [OR]): 1.43, CI 95%: 1.11-1.84)16. Lactobacilli-depleted microbiota could contribute to HPV persistence.

Other work indicates that HPV persistence is more likely in people with an altered microbiota. One study showed that women exhibiting HPV persistence had a BV prevalence of 11% compared to only 5% in women who had cleared their HPV17. In addition, King et al.18 found that women with bacterial vaginosis exhibited a delayed viral clearance (adjusted hazard ratio 5 0.84, 95% CI: 0.72, 0.97).

One of the first studies aimed at examining the link between the vaginal microbiota (VM) and HPV was conducted in Korea and used cervico-vaginal samples collected from 912 women19. Out of 78 women 68 were analysed, 23 of whom were HPV-positive and 45 of whom were HPV-negative. An analysis of 45 premenopausal women with or without an HPV infection showed that certain bacteria (Fusobacteria, particularly Sneathia spp) could be used as microbiological markers for HPV infection. The HPV-positive women exhibited greater microbiota diversity and a lower proportion of Lactobacillus spp than the HPV-negative women.

Other data show that the microbiota plays an important role in modulating the immune system of the female genital tract20.


A number of questions must be answered as part of the work in progress:


- Does the microbiota observed during the immature squamous metaplasia in young women explain why HPV infection is more likely at a young age?


- Do risk factors for HPV persistence (smoking, immunodepression, oral contraception) have a negative influence on the microbiota by helping to advance the carcinogenesis process?

 

- Is the age-related difference in prevalence of HPV, HSIL and cervical cancer a result of the
changes in microbiota diversity with age?


- Do HPV-induced variations in the microbiota trigger oncogenic changes at the time of
carcinogenesis?

- conclusion -

In conclusion, the vaginal microbiota appears to play a role in the acquisition and persistence of HPV and in the development and progression of CIN. There is a need for further studies to prove that these outcomes are influenced by the composition and modified diversity of the microbiota 15.


These data may provide opportunities to develop novel therapeutic agents that aim to restore or preserve the vaginal microbiota, such as specific prebiotics (bioselective substrate for the growth of beneficial Lactobacillus, to the detriment of pathogens)21,22, in order to prevent HPV infection and, in infected women, limit the risk of precancerous lesions.

DR. JAVIER CORTÉS BORDOY
- Senior Consultant in Gynecology Oncologic.
- Private practice.
- Palma de Mallorca
- EUROGIN 2015 President.
- Ex-president of the Spanish Association of Cervical Pathology and Colposcopy.

The aim of this report is to evaluate the usefulness of the product Papilocare ®, with moisturizing and regenerative properties of the vaginal mucosa, to re-epithelize micro-injuries that may exist in the vaginal mucosa and get thereby hindering the integration of human papillomavirus (HPV) and prevent potential infection.

- Presence of the human papillomavirus (HPV) -

In the CLEOPATRE1 study, we found that in Spain the average rate of HPV in women between 18 and 65 years
old was 14%, shown a stable curve at the level of 30% in the age group 18-30 years, and a fast decrease to
another level maintained around 10% for 30 to 35 year old.


Consequently, it can be said that in the first third of life in Spain, the presence of HPV in cervical mucus is very
common. For more and more well-understood reasons (type of HPV, host immunity, among others)
generally, there is a clearance of this viral presence, except for a group of women in which it has not
taken place. A group that can be labeled as chronic carriers of the HPV. This is a situation that we consider of
high risk for the initial development of precancerous lesions of the cervix, which leads to a high percentage,
of invasive cervical cancer 2.


High risk does not mean absolute certainty. It can be deduced, from the estimated cervical precancerous
lesions and documented invasive cervical cancer rates, that only a limited proportion of women with HPV
will eventually - if unchecked - develop cervical lesions 3. Why?

- Pathogenesis of HPV infection -

Above other basic considerations related to the biology of the process, the answer to this question has
recently been added to our knowledge. Although it is very simple: keep in mind HPV in cervical or anal mucus
does not stricktly mean to be infected by HPV.


Being infected represents a step further to the viral presence, it means that the HPV has been integrated into
the cervical epithelium and has colonized cells.


For this reason, there is growing evidence of the usefulness of techniques that measure viral mRNA and
expression of their oncogenes E6 and E7, because this expression is a marker of the integration of the virus
into the cell genome and, consequently, the first step in the oncogenic process is made.


The cervix has a very unstable histological structure, with the permanent confrontation of two epithelia,
polystratified vaginal squamous and endocervical cylindrical glandular (Figure 1). Below this glandular
epithelium, the cell line is composed of «reserve» cells. These retain the ability to grow and differentiate
more often into mature forms of squamous epithelium or glandular epithelium.


This process has been called metaplasia and creates a more or less extensive area identified as «transformation
zone»5 in the cervix (Figure 1).


This is a normal process in sexually active women, increasing in users of hormonal contraception, IUDs
or had children.

 

The HPV needs to integrate cells in mitotic activity. The reserve cells in metaplasic re-epithelization
process fulfill this condition and therefore are ideal targets for anchoring HPV.


Consequently, well epithelized cervix with squamous epithelium, with limited extension or nonexistent
areas of transformation would provide little suitable enviroment for inclusive colonization - and therefore
oncogenic potential – for HPV.

PAPILOCARE®:

POTENTIAL PREVENTIVE STRATEGY

We have consistent evidence that the vaginal gel Papilocare® significantly improves re-epithelization of the cervix (95% of cases)7. We hypothesize that, through this implementation, this gel could limit, if not prevent, HPV integration, by reducing the epithelial conflict area with intense cellular activity that represents the perfect target for HPV integration. If the cervix is well epithelized, the possibility of HPV viral anchor with oncogenicity potential decreases significantly. This offers a new preventive strategy; easy to use, without appreciable side effects 7 for primary prevention of dependent HPV lesions

CONCLUSION

Taking into account the above and understanding that the research should be continued, the "barrier effect" produced by Papilocare® allows contemplating the possibility of using it in patients with alterations of cervical epithelization to hinder the integration of HPV and prevent infection.

REFERENCIAS

1. Castellsagué X, Iftner T, Roura E, Vidart JA, Kjaer SK, Bosch FX et al. Prevalence and genotype distribution of human papillomavirus infection of the cervix in Spain: the CLEOPATRE study. J Med Virol. 2012;84:947-56.

2.  Moscicki AB, Schiffman M, Burchell A, Albero G, Giuliano AR, Goodman MT et al. Updating the natural history of human papillomavirus and anogenital cancers. Vaccine. 2012; 30Suppl 5:F24-33.

 

3. Torné A, del Pino M, Cusidó M, Alameda F, Andia D, Castellsagué X et al. Guía de Cribado del Cáncer de Cuello de Útero en España, 2014. Prog Obstet Ginecol 2014; 57(Supl. 1):1-53.

 

4. Reid JL, Wright TC Jr, Stoler MH, Cuzick J, Castle PE, Dockter J. et al. Human Papillomavirus Oncogenic mRNA Testing for Cervical Cancer Screening: Baseline and Longitudinal Results From the CLEAR Study. Am J Clin Pathol. 2015; 144:473-83.

 

5. Curso de Colposcopia de la Asociación Española de Patología Cervical y Colposcopia. Disponible en http://www.aepcc.org/ Acceso: 07/09/15.

 

6. Egawa N, Egawa K, Griffin H and Doorbar J. Human Papillomaviruses: Epithelial Tropisms and the Development of Neoplasia. Viruses. 2015; 7:3863-90.

 

7. Palacios S.: Pilot study to evaluate the effect of a Coriolus versicolor based vaginal gel on the epithelialization of the cervix lesions. Poster. 30th International Papillomavirus Conference. Septiembre 17-21, 2015. Lisboa. Portugal.