Recommendations for the Diagnosis and Treatment

of HPV Infections of the Female Tract

E.R. Weissenbacher
A. Schneider
L. Gissmann
G. Gross
J. Heinrich
P. Hillemanns
M. Link
K.U. Petry
P. Schneede
 H. Spitzbart

from

Arbeitsgemeinschaft für Infektionen und Infektionsimmunologie in der Gynäkologie und Geburtshilfe der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe 
(AGII der DGGG)

European Society for Infectious Diseases in Obstetrics and Gynaecology
(ESIDOG)

International Infectious Disease Society in Obstetrics and Gynecology - Europe 
(I-IDSOG-EUROPE)

in cooperation with
- Deutsche STD-Gesellschaft (DSTDG)
- Deutsche Gesellschaft für Urologie (DGU)
- AG Zervixpathologie und Kolposkopie einer Sektion der DGGG

Proposed valid date: March 1, 2003
 

I. Natural history
The incidence of detectable HPV infections peaks at an age between 20 and 25 years. The cumulative incidence determined by HPV DNA tests in young women who were observed for a period of several years after their first sexual experience constitutes up to 50% depending on sexual behaviour. Of the HR HPV-positive women, 5-10% develop abnormal cytological findings. The prevalence of detectable HPV infections declines with increasing age. HPV is no longer detectable by molecular biology techniques in 80% of HPV-infected patients after a period of about 12 months. Persistence or progression is observed in only 20%. If an HPV infection in the lower genital tract persists for several years, a precancerous stage (dysplasia, intraepithelial neoplasia) can develop. Nevertheless, less than 1% of persisting HR HPV infections lead to cancer after an interval of an average of 15 years. Because only a few of infected patients develop uterine cancer, other cofactors in addition to HPV are important. In addition to immunosupression, HIV, infection, smoking, and chlamydia infections, genetic factors that do not allow the immune system to suppress or eliminate the HPV infection appear to have considerable importance. There is indirect evidence that a genital HPV infection can persist throughout life and that a latent infection is reactivated in immune weakness (e.g., in HIV infection). 

II. Clinical Manifestation
We find the following clinical pictures in the field of obstetrics and gynecology: 
- Condylomata acuminata in vulvar, vaginal, and vaginal cervix regions, and extragenitally in the anal region; rarely the urethra is affected (1-3%).
- Precancerous stages of the uterine cervix (dysplasia, CIN 1-3) up to cervical cancer.
- Vulvar intraepithelial neoplasia (VIN, bowenoid papulosis, Bowen's disease) up to vulvar carcinoma and verrucous carcinoma (Buschke-Löwenstein).
- Perianal (PAIN) and anal intraepithelial neoplasias (AIN) up to invasive carcinoma.
- Laryngeal papilloma in the newborn and infants.

Condylomata acuminata (CA)
Because of the frequently long incubation period (3 weeks to 8 months), it is generally impossible to determine the exact time of infection. Macroscopically visible condylomata are found in less than 1% of all women.

Condylomata acuminata are diagnosed by examination (vulva, vagina, and cervix) and by palpation (rectum, anus). A speculum examination is always necessary to rule out the presence of vaginal or cervical condylomata. A proctoscopy is indicated for the diagnosis of intra-anal and rectal CA. The use of the colposcope with the topical application of 3-5% acetic acid is an essential adjunct to inspection techniques. Syphilis or HIV infection is to be ruled serologically. Examination of the sexual partner is recommended. Condylomata lata (Syphilis), VIN and anal skin tags should be ruled out by examination, if necessary histologically. This also applies to anal papillae and rectal polyps in case of intra anal-findings.

Condylomata acuminata during pregnancy are associated in very rare cases with the late occurrence of laryngeal papillomas in the child. There is a certain risk for the transmission of HPV to the newborn in primiparas under the age of 20. A compelling indication for a primary caesarean section exists only if the birth canal is blocked by extensive condylomata. The treatment of condylomata during pregnancy is achieved best by TCA, laser vaporization, or cryotherapy. The optimal time is not known; it seems appropriate to perform the treatment outside of the premature birth period: superinfection of the wound surfaces could lead to an ascending infection with subsequent premature labor or rupture of the amniotic membrane.

Intraepithelial Neoplasias
Intraepithelial neoplasias of the vulva (VIN) are generally slightly raised and multicentric. Similar changes in the vagina (VAIN) are rare, but can be easily missed (3,5% Acetic acid, Schiller's iodine test).
Intraepithelial neoplasias of the vagina and of the cervix can be localized precisely only by a colposcopic examination.

Documentation:
Drawings, photographs, videos, computer presentations
(also see the guidelines of the AG-CPC of the DGGG)

III. Diagnostic Procedures
Cytology
Cytology is not a suitable method for detecting HPV. Koilocytes and dyskeratocytes are specific markers only for a florid infection, whereas the majority of HPV infections cannot be detected by this technique. The accuracy of cytology in HPV infection alone is given today as only 15%. 

Colposcopy
Native, green filter, acetic acid, iodine
(also see the guidelines of the AG-CPC of the DGGG)

HPV Detection in the Laboratory
The techniques for HPV detection differ in their sensitivity. The laboratory's experience is very critical for reliable results (particularly with PCR techniques).
The classic methods of viral diagnosis such as electron microscopy, cell cultures, and certain immunological methods are not suitable for HPV detection. HPV cannot be cultured in cell cultures. The established method for viral detection as a matter of routine is the hybridization of nucleic acids:
- hybrid capture microplate assay (HC II)
- polymerase chain reaction = PCR

The FDA-approved hybrid capture II test (Digene, USA) detects even 1 pg of HPV DNA/mL; its sensitivity and specificity are almost comparable to PCR.  The advantages of this method are the relatively simple handling and good reproducibility of results, which make this test the best standardized HPV detection method. Identification of the exact HPV type is not possible, but only "low-risk" (6, 11, 42, 43, 44) and "high-risk" (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) HPV genotype groups are detected.

In PCR, amplification of the viral DNA occurs first. A sensitivity exceeding that of the hybrid capture can be achieved in appropriately specialized laboratories. Nevertheless, variations in findings among the various laboratories are considerable in some cases. HPV DNA detection by PCR at a facility specializing in this technique is the method of choice for numerous scientific studies.

Indications for the HPV Test
The clinical use of the HPV test has been evaluated thus far for the following indications:
1. cancer screening in addition to cytology,
2. inconclusive cytological findings for triage (borderline/ equivocal Pap results),
3. mild and moderate precancerous stages to predict regression, persistence, or pro-
    gression,
4. following conization for dysplasia.

Re 1. The HPV test can be potentially used for primary screening in addition or as an alternative to the cytology smear. The HR HPV test is more sensitive than the cytological examination but less specific. A negative finding with HR HPV indicates that the presence of a serious precancerous stage or a carcinoma is extremely unlikely. The benefit of the HPV test for screening must still be evaluated using a cost-benefit analysis. 

Re 2: The question studied most often with the HPV test is the triage of women with minor changes (Pap class IIW or IIK, ASCUS, AGUS, and CIN 1). Although the majority of women with these cytological diagnoses have normal findings or lesions with a high regression potential in the histological evaluation (CIN 1), CIN 2 or CIN 3 can be detected histologically in 5-20% of all women with these cytological diagnoses. The value of the HPV test for the triage of women with (Pap class IIW or IIK) for CIN 2/3 appears to be superior to repeating the cytological examination in all previous studies. A positive cost-benefit effect must be demonstrated in this indication as well for the health care system.

Re 3: Up to 70% of mild dysplasia or CIN 1 regresses over a period of 5 years. A recurring negative finding in HR HPV by PCR shows that the resultant precancerous stage will regress with a high likelihood.

Re 4: About 10-15% of all women experience persistence or recurrence after removal of CIN. The incidence of invasive cervical cancer in women in whom CIN 3 was treated by conization is 1 per 1000 per year. All studies conducted thus far agree that in persistent or recurrent CIN the high-risk HPV DNA test is superior to the cytological examination.

Indications for Colposcopy
Any woman with suspected HPV infection (e.g., condylomata acuminata) should undergo a colposcopy regardless of the test procedure, positive cytology smear, and/or diagnosis of intraepithelial neoplasia of the lower genital tract.
The colposcopic examination is recommended with the selective removal of tissue when necessary.

Since the false-negative cytological smears (up to 20%) are caused by sampling errors in the majority of the cases, colposkopy of the dysplastic lesion is recommended. Patients with abusual cytology require colposcopic assessment (Munich Nomenclature II).
 

Indications for Further Diagnostic Procedures
The partner of a woman with genital warts should be examined clinically and treated appropriately if visible warts or HPV-associated lesions are found (e.g., clarification of PAIN). In recurrent CIN, VIN, VAIN, or PIN, examination of the partner is also recommended.
Further diagnostic procedures are strongly advised to rule out other sexually transmitted infections.

(also see the guidelines of the AGII of the DGGG)

VI. Treatment
Current Guidelines for VIN

VIN 1 and VIN 2 Surface destruction (laser vaporization) under colposcopic control after prior 
   histological clarification

VIN 3   Surgical excision in healthy tissue, 
Extensive areas: laser vaporization after histological exclusion of an invasive lesion,
   skinning vulvectomy, simple vulvectomy
 

Current Guidelines for CIN
1. Surface Destruction:
 Method:  CO2 laser, guided colposcopically with micromanipulator 
 Indications:  -benign findings (e.g., papilloma), CIN 1or CIN 2 with ectocervical 
   location, 
   completely visible, after prior biopsy, cooperative patient
   -CIN 2-3 (HGSIL) individually performed by experts only with 
multiple biopsies
 

2. Treatment by Resection:
 HF surgery loop conization (loop excision, large-loop-excision of the transformation 
zone, LLETZ)
 Indication:  persistent CIN 2-3 (HGSIL)

 Conization (therapeutic conization is based on the histology of the biopsy material)
 Method:  loop or laser conization, scalpel
 Indications:  -CIN 2 (endocervical), CIN 3, adenocarcinoma in situ 
   -Persistent CIN 1 and CIN 2 with endocervical extension

(also see the guidelines of the AG-CPC of the DGGG)

Treatment of the Partner
A specific positive effect on the risk of infection or reinfection by condom use has not been proven in HPV-associated diseases. Until other STIs are ruled out or treated, the use of condoms should be recommended.

Evidence-based, Recommended Treatment Procedures (for anogenital warts)
Evidence-based stages (I to IV) and value of the recommendations (A to C) correspond internationally to the quality assurance in conventional literature evaluations (also see Appendix)
 

Medically prescribed self-treatment Podophyllotoxin (0.15% cream, 0.5% solution);  (Ib, A) Imiquimod cream (5% cream); (Ib, A) (Interferon beta gel (0.1 million IU/g) adjuvant)

Medically preformed treatment Trichloroacetic acid Cryotherapy Electrosurgery (Ib, A) / laser (IIb, B) Scissors excision / curettage

Medically Prescribed Self-treatment
Podophyllotoxin 0.5% solution, Podophyllotoxin 0.15% cream
Podophyllotoxin 0.5% solution is applied to the genital warts by the patient using a cotton swab, and podophyllotoxin 0.15% cream with the finger twice daily for 3 days. This is followed by a 4-day pause. The treatment is repeated for a maximum of four cycles. Maximum treatable wart surface area: 10 cm2, maximum daily dose: 0.5 mL.
Podophyllotoxin 0.15% cream has been approved for the treatment of external genital warts in men and women. Podophyllotoxin 0.5% solution has been approved for men only.

Imiquimod % Cream (Aldara®)
Imiquimod is the first "topical" immunostimulant on the market. Topical therapy of genital warts three times a week at night up to a maximum of 16 weeks. It is recommended that the treated area be washed off with water 6 to 10 hours later. If the primary response to treatment in studies was successful, imiquimod revealed very low recurrence rates (16%) over the subsequent course of the disease. 

Topical Adjuvant Interferon beta Gel Therapy After Removal of Anogenital Warts
Topical therapy after removal of external anogenital warts with electrocautery or laser consists of five applications of Interferon beta gel (0.1 million IU/g of gel) per day for the period of 4 weeks. Maximum treatable wart area < 10 cm2.
The self-treatment with the indicated medications is generally to be recommended in new lesions with limited keratosis. Treatment failure in the case of keratotic lesions and, because of insufficient penetration depth of the substances, local recurrences are to be expected more frequently. The substances have been approved thus far only for the external genitalia.
Podophyllotoxin, imiquimod, and interferon beta are contraindicated during pregnancy and are not approved for the mucous membranes or for patients with immunosuppression. 

Medically Performed Treatments
Trichloroacetic acid (up to 85%)
The application of trichloroacetic acid leads to cell necrosis. Trichloroacetic acid is applied to the warts by the physician with an applicator. Very good results are achieved in small, non-keratotic condylomata acuminata in areas of mucous membranes. Treatment is repeated at weekly intervals.
Disadvantage: burning and pain
Advantage:  healing with no scar formation. Safe to use during pregnancy. Used only in very small amounts. Neutralization with sodium bicarbonate is necessary in the case of overdosage. The surrounding epithelium can be covered with a fatty ointment if necessary.

Cryotherapy
Use of cold with liquid nitrogen in an open procedure (spraying or cotton swab) or as contact cryotherapy (closed procedure - cryoprobe with CO2, N2O, N2). Treatment is repeated weekly or every 2 weeks.
Advantage:   low cost, simple procedure, hardly any long-term complications
Disadvantage:  initial local complications, recurrences are frequent (up to 75%)

Surgical Methods
Removal by means of scissors excision or sharp spoon, curettage, electrocautery, or CO2 Laser / Nd-YAG laser. Surgical methods can be used as the primary treatment. Local anesthesia is always necessary. Treatment with electrocautery or laser is indicated in extensive and recurrent, primarily patchy warts. 
Advantage:   immediate treatment effect
Disadvantage:  Smoke formation by the CO2 laser and electrocautery treatment. This could be a safety problem because of possible infectious viral particles in the smoke (detection of viral DNA). Special face masks and protective glasses must be worn, and smoke removed by suction. 

Recommended Treatments for Genital Warts with a Special Localization
Anal canal
Cryotherapy with liquid nitrogen, trichloroacetic acid (only with small condylomata acuminata), or surgical methods (CO2-/Nd-YAG laser or electrocautery).

Vagina
Cryotherapy (liquid nitrogen only, cryoprobe is contraindicated), trichloroacetic acid, or surgical procedure (CO2 laser or electrocautery).

Uterine cervix
CO2 laser

(in regard to the Urethra see guidelines of the DGU)

V. Vaccination
Both the important role of human pathogenic papillomaviruses in the etiology of cancer and the infection-associated morbidity in women patients indicate that the search for suitable prophylactic and therapeutic vaccines is appropriate. DNA-free virus particles (VLP), which have already been tested in animal experiments, have been developed for immunoprophylaxis. Because VLPs have a highly specific activity, various HPV types must be included in an effective prophylaxis. Vaccines that stimulate the immune system to reject HPV-positive cells can be used for the treatment of existing lesions. Because this reaction is probably type-specific as well, an HPV diagnostic procedure in the lesion to be treated is necessary (by a PCR-based method). At present, various vaccines are in preclinical or clinical development; it will take several years for the first HPV vaccine to reach the market, however.
 

References
1. Livengood Ch, Hoyme UB. IDSOG Task Team Report: Management of Genital Human Papillomavirus (HPV) Infection.  2000.
2. Krogh,G von, Lacey CfN, Gross, G, Barasso R, Schneider A. European course on HPV associated pathology: guidelines for primary care physicians for the diagnosis and management of anogenital warts. Sexual transmitted Infections 2000; 76: 162 - 168.
3. Schneede P, Hofstetter A. Diagnostic Procedures and Treatment of Genital Diseases Caused by Human Papillomaviruses (HPV).  Guidelines of the German Society for Urology 2001.
4. Guidelines for the Clinical Picture of Condylomata in the Anorectal Region. Guidelines of the German Dermatological Society 2000.
5. Condylomata acuminata and other HPV-associated Clinical Pictures of the Genitalia and Urethra. Guidelines of the German STD Society 2000.
6. Prevention of Genital HPV Infection and Sequelae: Report of an external consultants' Meeting. CDC Division of STD Prevention 12/1999
7. Schneider A, Hoyer H, Dürst M. Importance of the Detection of Human Papillomaviruses (HPV) in Screening. Deutsches Ärzteblatt 2001.
8. Diagnostic and Therapeutic Standards in Intraepithelial Neoplasia and Early Invasive Carcinomas of the Female Genital Tract. AG-CPC of the DGGG 2000.
9. Solomon D, Schiffmann M, Tarone R (for the ALTS Group). Comparison of three management strategies for patients with a typical squamous cells of undetermined significance: Baseline results from a randomized trial. J Nat Cancer Inst February 21, 2001;  93/4: 293-299.
10. Harro CD et al. Safety and Immunogenicity trial in adult volunteers of a human papillomavirus 16 L1 virus-like particle vaccine. J Nat Cancer Inst February 21, 2001; 93/4: 284-292.
11. Schneider A, Wagner D. Infections of Women with Genital Human Papillomavirus. Dt Ärztebl 1993; 90: 
     730-732.
12. Schneider A., Wagner D. Recommendations for the Diagnosis and Treatment of HPV Infections and Precancerous States of the Lower Genital Tract. Frauenarzt 1994; 35: 1057-1065.
13. Schneider A. Sponsoring group "Papillomavirus Infections in Man and Animals." Approach in a Pathological Cervical Smear. Frauenarzt 1995; 36: 704-707.
14. Thaler C. personal communication
 

Appendix
Evidence Evaluation (stages I-IV) and Grading (A-C) of Treatment Recommendations of Relevance to the Guidelines:

Literature sources with evidence degree A and evidence evaluation stage Ib were used for the guidelines, i.e., evidence based on controlled, randomized studies. Meta-analysis-controlled, randomized studies (degree A, stage Ia) were not available. The evaluation of laser therapy was possible only based on studies of evidence stage IIa (degree B), i.e., expertly designed scientific studies with no randomization. Expertly designed quasi-experimental studies (IIb, B), nonexperimental descriptive studies (comparison studies, correlation studies, and case studies) (degree B, stage III), and expert opinions (degree C, stage IV) were basically not considered.
 

Abbreviations
AG-CPC Arbeitsgemeinschaft Zervixpathologie und Zytologie der DGGG [Study Group on Cervical Pathology and Cytology of the DGGG]
AGII Arbeitsgemeinschaft Infektiologie und Infektionsimmunologie der DGGG [Study Group on Infectology and Infectious Immunology of the DGGG]
AIN  Anal intraepithelial neoplasia
AGUS  Atypical glandular cells of undetermined significance
ASCUS Atypical squamous cells of undetermined significance
CIN  Cervical intraepithelial neoplasia
DGGG  Deutsche Gesellschaft für Gynäkologie und Geburtshilfe [German Society for Obstetrics and Gynecology]
DNA  Desoxyribonucleic acid
HC II  Hybrid capture II
HPV  Human papillomavirus
HR HPV High-risk HPV
HGSIL  High-grade squamous intraepithelial lesion
LLETZ Large-loop-excision of the transformation zone
LR HPV Low-risk HPV
LGSIL  Low-grade squamous intraepithelial lesion
PCR  Polymerase chain reaction
PIN  Penile intraepithelial neoplasia
TCA  Trichloroacetic acid
VAIN  Vaginal intraepithelial neoplasia
VIN  Vulvar intraepithelial neoplasia
VLP  Virus-like particles