Analysis on influencing factors of viral load in patients with high-risk human papillomavirus

doi:10.21203/rs.3.rs-26821/v1

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Analysis on influencing factors of viral load in patients with high-risk human papillomavirus

https://doi.org/10.21203/rs.3.rs-26821/v1

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published 06 Jan, 2021

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Background

High-risk human papillomavirus (HR-HPV) load is thought to be influenced by many factors, and relationship between viral load and degree of cervical lesion is controversial. This study was to explore possible influencing factors of HR-HPV viral load in uterine cervix.

Methods

605 women who needed colposcopic evaluation for abnormal cervical screening in Affiliated Hospital of Weifang Medical University, China, between November 2017 and September 2018 were enrolled. Cervical specimens were collected from endo- and ectocervix separately using two different cervical brushes. Hybrid Capture II test was used to measure HR-HPV load. Age, histological severity, number of viral types, area and location of cervical lesions were recorded. The correlation between viral load and influencing factors was analysed using univariate and multivariate analysis.

Results

HR-HPV load was positively correlated with age, histological severity, multiple HPV types and area of cervical lesions (P < 0.05). Viral load with combination of endo- and ectocervical sampling was significantly higher than simple endocervical sampling (P < 0.001). Multivariate analysis showed that age, multiple HPV types and area of cervical lesions were independent factors for HR-HPV load with combination of endo- and ectocervical sampling (P < 0.05). However, only age and area of cervical lesions were independent factors for viral load with simple endocervical sampling (P < 0.05). No significant association was found between viral load and lesion severity in multivariate analysis (P > 0.05).

Conclusion

HR-HPV load is influenced by age, histological severity, multiple viral types, area of cervical lesion and sampling methods. Age and area of cervical lesions are independent factors for viral load.

Virology

Human papillomavirus

Viral load

Cervical intraepithelial lesion

Influential factor

Cervical cancer is the second most common gynaecological cancer worldwide. It is well established that almost all precancerous and cancerous lesions of the cervix are caused by persistent oncogenic human papillomavirus (HPV) infection. Therefore, HPV DNA testing was recently recommended as an alternative to cytology-based cervical cancer screening by the American updated screening guidelines [1]. However, it is less specific and has low positive–predictive value, which is incapable of differentiating the transient and persistent infections [2], resulting in excessive management of women with innocuous HPV infections [3]. Therefore, how to best triage HPV-positive women through secondary screening to identify those women with true precancerous lesions remains a pending issue in cervical cancer screening.

Many epidemiologic studies have provided strong and consistent evidences that persistent infection with specific HPV types is responsible for development, maintenance and progression of cervical intraepithelial lesion (SIL) and cervical cancer (CC) [4, 5]. Persistence may depend on certain characteristics such as high viral load as a result of viral replication [5]. However, the relation between HR-HPV viral load and future risk of HSIL or CC is less certain. Many studies have reported that viral load increases with the elevation of disease severity [6, 7], while others have not confirmed such an increased risk of disease progression [8, 9]. Integration of the viral genome is a prerequisite for establishing a causal role in the carcinogenic process [10, 11]. However, arrested squamous maturation in high-grade lesions no longer supports effective HPV-DNA replication and the copy number of HPV-DNA is generally low [11]. On the other hand, low-grade lesions may have thousands of viral copies/cell in upper layers of the cervical mucosa, reflecting high levels of HPV episomal replication or the so called “productive infections” [12]. Furthermore, previously reported influencing factors for HR-HPV viral load include age, lesion size and severity, multiple HPV types and specimen collection methods [12, 14].

Based on the above mentioned, we aim to explore the possible influencing factors of HR-HPV vial load in the uterine cervix and provide the reliable basis for the association of viral load and the severity of cervical lesions.

Study population

All clinical samples in this study were organized using the Weifang Cervical Lesions Screening cohorts, Shandong, P.R. China. Detection of the 21 HPV genotypes was performed by HPV GenoArray Test Kit (HybriBio Ltd. China) before enrollment of patients. 605 women who needed colposcopic evaluation for abnormal cervical screening in Affiliated Hospital of Weifang Medical University, China, between November 2017 and September 2018 were enrolled. Inclusion criteria are as follows: 1) Agreement of participation; 2) HR-HPV positive; 3) Indication for colposcopy [15]; 4) No hysterectomy; 5) No pregnancy. Women with cervical lesions not completely visible (unsatisfactory colposcopy) were excluded (Fig. 1). In total, 273 women were eligible in the study. All participants signed an informed consent document before enrolment. Women’s age ranged from 21 to 63 years (38.4 ± 9.0 years). Based on the number of HPV types in primary screening, women were divided into the following two groups: multiple HPV types (at least two or more genotypes of HR-HPV infection) and single HPV type (Only one genotype of HR-HPV infection).

Specimens Collection

At first, one physician (T. T. Wang) who was trained used cytobrush (Digene Cervical Sampler, USA) to collect exfoliated cells of endocervix (an area, which can be covered by cytobrush, bounded below by the ectocervix within a 0.5 cm radius of external os). Then, a different cervical brush (Thinprep ® Cytologic Test Sampler, USA) was used to collect exfoliated cells of ectocervix (an area, cannot be covered by cytobrush, bounded above by ectocervix over a 0.5 cm radius of the external os). Both specimens were separately transferred to specimen preserving medium (formalin), stored at -4 °C and sent to laboratory for viral load testing using the commercially available Hybrid Capture II system (Digene, USA). Based on the anatomical sites of sampling, sampling methods were stratified into two groups: Simple endocervical sampling group, combination of endo- and ectocervical sampling group.

Colposcopic Examination

A standard colposcopic examination was performed by the same professional colposcopist (Y.Z. Liu). Cervical lesions showing aceto-white epithelium and/or atypical vessel changes (mosaic, punctation and tumour vessels) were measured under 15X magnification of colposcopy. Area (cm²) and location (the distance between external os and the below bound of lesions, cm) of lesions was quantified using colposcopy image processor. Based on the location of lesions, women were stratified into two groups: involvement of the area bounded below by the ectocervix within a 0.5 cm radius of the external os(≤0.5), involvement of the area bounded below by ectocervix over a 0.5 cm radius of the external os (> 0.5). For pathology diagnosis, colposcopy with a directed biopsy was performed as indicated and biopsy was evaluated by two pathologists who were blind to colposcopy or clinical information. All cases with disagreement were reanalyzed by another experienced pathologist. Based on colposcopy and pathology, the patients were stratified into three groups: Negative (negative for intraepithelial lesion or malignancy), LSIL (low-grade squamous intraepithelial lesion), HSIL/CC (high-grade squamous intraepithelial lesion and / or cervical cancer).

Detection Of HPV-DNA

HPV genotyping by HybriMax was performed using an HPV GenoArray Test Kit (HybriBio Ltd., China). This assay can determine 21 HPV types, including 14 high-risk HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68), five low-risk HPV types (6, 11, 42, 43, and 44), and two unknown-risk types (53 and CP8304), by the flow-through hybridization technique using HPV DNA amplified by PCR as described before [16].

Hybrid Capture II assay (Digene, USA) was performed on the cervical scrapings collected by the above-mentioned setup. Light measurements were quantified using a luminometer and were expressed by comparing the relative light units (RLU) of clinical samples with a positive control (PC). RLU/PC ratios (RLUs) were calculated as the ratio of the specimen luminescence to the luminescence of the 1.0 pg/ml HPV cut-off standard, which is known to represent a semi-quantitative value for the cumulative viral burden of one or more of the 13 oncogenic HPV genotypes (types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68). An RLU/PC ratio of 1 or higher was considered a positive result as proposed by the manufacturer (equivalent to 1 pg/ml of HPV–DNA).

Statistical analysis

All statistical analyses were made by means of the SPSS version 22.0 for Windows. Means, medians, ranges, standard deviations, 95% confidence intervals, standard errors of means were used as descriptive statistics. Viral load was measured as RLU/PC ratios (RLUs) and agrees with previous specifications in the hybrid capture assay. Viral quantification data in RLUs were initially continuous measurements. RLUs were transformed into their logarithm (Log10). An index of Spearman correlation coefficient (r_s) was applied to measure the association between viral load and variables. Multiple linear regression analysis was applied to relate the viral load with variables. The variables included in the model were age, histological severity, number of HPV types, area and location of the cervical lesions. A paired t-test was used to compare viral load with different sampling methods. Two-tailed P values less than 0.05 were considered statistically significant.

1. Correlation of HR-HPV load and age

The age range of the 273 women was 21–63 years (38.4 ± 9.0 years). A significant association between viral load and age was found (r _{s endocervical} = 0.417, P _endocervical =0.001, r _{s endo- and ectocervical} =0.349, P _{endo- and ectocervical} =0.001). A distinct upward trend of viral load paralleled to the increasing age (Table 1).

Table 1

Univariate analysis of factors associated with HR-HPV load
Variables	Parameters	Number of patients (%)	Simple endocervical sampling			Combination of endo- and ectocervical sampling
Variables	Parameters	Number of patients (%)	Mean (SD) of log₁₀ transformed viral load	r _s-value ^a	P-value	Mean (SD) of log₁₀ transformed viral load	r _s-value ^a	P-value
Age (years)	20–29	52(19.0)	0.57(±0.62)	0.417	0.001	0.76(±0.61)	0.349	0.001
	30–39	91(33.3)	0.92(±0.73)			1.11(±0.67)
	40–49	99(36.3)	1.16(±0.78)			1.29(±0.78)
	50–59	25(9.2)	1.41(±0.69)			1.63(±0.72)
	60–69	6(2.2)	2.52(±0.13)			2.56(±0.17)
Severity of lesions	Negative	90(33.0)	0.79(±0.39)	0.371	0.002	0.88(±0.35)	0.424	< 0.001
	LSIL	93(34.1)	0.87(±0.91)			1.03(±0.89)
	HSIL/CC	90(33.0)	1.41(±0.81)			1.66(±0.70)
Multiple HPV types	No	200(73.3)	0.92(±0.71)	0.198	0.060	1.08(±0.65)	0.237	0.024
Multiple HPV types	Yes	73(26.7)	1.29(±0.93)	0.198	0.060	1.48(±0.95)	0.237	0.024
Area of lesions (cm²)	0.0-0.49	174(63.7)	0.95(±0.74)	0.292	0.017	1.04(±0.70)	0.364	< 0.001
	0.5–0.99	46(16.8)	1.03(±0.72)			1.22(±0.69)
	1.0-1.49	24(8.8)	0.93(±0.82)			1.41(±0.75)
	1.5–1.99	6(2.2)	1.64(±0.94)			1.80(± 0.77)
	2.0-2.49	10(3.7)	1.76(±0.86)			1.90(±0.73)
	2.5–2.99	7(2.6)	0.27(±0.14)			0.72(±0.01)
	3.0-3.49	6(2.2)	2.43(±0.41)			2.89(±0.06)
Location of lesions (cm)	≤ 0.5	125(68.3)	1.05(±0.72)	-0.017	0.891	1.21(±0.65)	-0.129	0.222
Location of lesions (cm)	> 0.5	58(31.7)	0.90(±1.01)	-0.017	0.891	1.10(±1.09)	-0.129	0.222
^a Spearman correlation coefficient. SD, standard deviation. Location of lesions, the distance between external os and the below bound of lesions. ≤0.5 cm, involvement of the area bounded below by the exocervix within a 0.5 cm radius of the external os; >0.5 cm, involvement of the area bounded below by exocervix over a 0.5 cm radius of the external os. Multiple HPV types, at least two or more genotypes of HR-HPV infection. Negative, negative for intraepithelial lesion or malignancy; LSIL, low-grade squamous intraepithelial lesion; HSIL/CC, high-grade squamous intraepithelial lesion and / or cervical cancer.

2. Correlation Of HR-HPV Load And Histological Severity

Based on colposcopy and pathology, 90 of those women were pathologically negative, 93 were diagnosed with LSIL, 72 with HSIL and 18 with CC. In simple endocervical sampling method, there was a marked increase in log₁₀-transformed viral load (log₁₀RLUs) from the mean value of 0.79(± 0.39) in the pathologically negative group to 0.87(± 0.91) and 1.41(± 0.81) in LSIL and HSIL/CC group, respectively (r _s=0.371, P = 0.002). Similarly, in combination of endo- and ectocervical sampling method, a distinct upward trend of log₁₀-transformed viral load (log₁₀RLUs) was observed from a mean value of 0.88(± 0.35) in the pathologically negative group to 1.03(± 0.89) and 1.66 (± 0.70) in LSIL and HSIL/CC group, respectively (r _s=0.424, P < 0.001) (Table 1).

3. Correlation Of HR-HPV Load And Multiple HPV Types

In this population, 73.3% (200/273) of those women were positive for a single viral type. 26.7% (73/273) were positive for multiple viral types. In simple endocervical sampling method, no significant association between viral load and multiple HPV types was found (r _s=0.198, P = 0.060). In combination of endo- and ectocervical sampling method, multiple HPV types infection group showed significantly higher viral load than single HPV type infection group (r _s=0.237, P = 0.024) (Table 1).

4. Correlation of HR-HPV load and area of cervical lesions

Viral load was significantly associated with area of the cervical lesions (r _{s endocervical} = 0.292, P _endocervical =0.017,

r _{s endo- and ectocervical}=0.364, P _{endo- and ectocervical} <0.001). A distinct upward trend of viral load paralleled to the increasing area of cervical lesions (Table 1).

5. Correlation of HR-HPV viral load and location of cervical lesions

Among the 183 women with a colposcopy-detectable cervical lesions, the distribution of case numbers with lesions involving the area bounded below by the ectocervix within a 0.5 cm radius (≤ 0.5) and bounded below by the ectocervix over a 0.5 cm radius (> 0.5) of the external os was 125 and 58, respectively. No statistical association was identified between viral load and location of the cervical lesions (r _{s endocervical} = -0.017, P _endocervical =0.891, r _{s endo- and ectocervical} = -0.129, P _{endo- and ectocervical} =0.222) (Table 1).

6. Correlation Of HR-HPV Load And Sampling Methods

The value of log₁₀-transformed viral load (log₁₀RLUs) showed statistical difference between simple endocervical sampling and combination of endo- and ectocervical sampling (1.19 ± 0.76 vs. 1.02 ± 0.790). Viral load with combination of endo- and ectocervical sampling was significantly higher than simple endocervical sampling (t = 9.67, P < 0.001) (Table 2).

Table 2

Comparison of HR-HPV load between simple endocervical sampling and combination of endo- and ectocervical sampling
Sampling method	Simple endocervical sampling	Combination of endo- and ectocervical sampling	95% CI	t-value ^b	P-value
Mean(SD) of log₁₀ transformed viral load	1.02 (± 0.79)	1.19 (± 0.76)	0.130–0.197	9.67	< 0.001
^b paired t-test. 95% CI, 95% confidence interval.

7. Multivariate Analysis For Viral Load

All the variables were included which were found to be significant according to univariate analysis in the present study. In simple endocervical sampling, this analysis showed that only age and area of cervical lesions were independent influencing factors for HR-HPV load (P_age =0.001, P _{area of lesions} =0.010). In combination of endo- and ectocervical sampling method, this analysis found that age, multiple HPV types, area of cervical lesions were independent influencing factors for HR-HPV load (P_age =0.004, P _{multiple HPV types} =0.011, P _{area of lesions} <0.001) (Table 3, 4).

Table 3

Multivariate analysis of factors associated with HR-HPV load in simple endocervical sampling
Variables	Unstandardized Coefficients		Standardised Coefficients	t-value ^c	P-value
Variables	β value	SE	β value	t-value ^c	P-value
Age	4.695	1.316	0.376	3.567	0.001
Severity of lesions	9.441	19.213	0.062	0.491	0.625
Area of lesions	46.615	17.525	0.339	2.660	0.010
^c multiple linear regression analysis. SE, standard error.

Table 4

Multivariate analysis of factors associated with HR-HPV load in combination of endo- and ectocervical sampling
Variables	Unstandardized Coefficients		Standardised Coefficients	t-value ^c	P-value
Variables	β value	SE	β value	t-value ^c	P-value
Age	4.181	1.399	0.252	2.990	0.004
Severity of lesions	10.878	18.841	0.059	0.577	0.565
Multiple HPV types	72.833	27.984	0.219	2.603	0.011
Area of lesions	96.290	20.641	0.480	4.665	< 0.001
^c multiple linear regression analysis. SE, standard error.

Persistent high-risk human papillomavirus (HR-HPV) infection is the main cause of precancerous and cancerous lesions of cervix [4, 5]. Viral load reflects the number of infected cells and viral copies in individual cells. High viral load has been suggested as a marker of non-transient infection and it has an elevated likelihood of having cells with transforming infections and viral integration into the cellular genome as increasing number of infected cells and/or increasing numbers of viral copies occur in individual cells [5, 17]. However, association between HPV viral load and cervical lesion grade is controversial [6, 8]. There could be undetermined confounding factors [12, 14]. The aim of this study is to explore the possible influencing factors of viral load.

In this study, we observed that age was an independent factor for HR-HPV load and a significantly increasing age correlated with higher viral load. Our result is consistent with one previous study by Hernández-Hernández et al [9]. They divided women into three age groups (< 35, 35–44, 45–70 years), and found that older women presented higher viral load. This may be interpreted by the concept that older women are more likely to experience periods of severe hormonal fluctuations during the menopausal transition. Such hormonal imbalances can result in significant physiologic and immunologic dysregulation, high level of HPV infections cannot achieve spontaneous clearance [13, 18–19].

We found a positive association between the severity of cervical lesions and viral load. However, this association lost significance when other cofactors were considered in multivariate analysis. This study showed high consistency with previous studies using Hybrid Capture II assay detecting a pool of 13 HR-HPV types for a association between the viral burden of HPV and cervical lesions [7, 20–21]. Nonetheless, the present study indicates that histological severity of cervical lesions is not an independent factor for HR-HPV load, and its effect is not obvious when other cofactors are taken into consideration. Association between HPV viral load and cervical lesions is complex [6–8]. High viral load has an elevated likelihood of having cells with transforming infections and viral integration into the cellular genome [17, 22]. Integration of the viral genome is a prerequisite for establishing a causal role in the carcinogenic process [10, 11]. However, integration of viral genome, which disrupts the E1 and E2 genes and leads to increased expression of the E6 and E7 oncoproteins [10], results in viral life cycle terminating and the actual viral DNA copy number being reduced [11]. Observations of viral DNA density in in situ hybridization experiments showed that the extent of lower grade lesion surrounding CIN3 was an important determinant of HPV load, as supposed by Sherman’s study [12]. Dong and colleagues found that viral loads of HPV-16, -31, -33, -52, and − 58 were positively correlated with the cervical lesion grade, whereas those of HPV-18, -45, -56, -59, and other types were not [8]. Hernández-Hernández and colleagues found that there is a strong correlation between viral load of HPV16 and disease severity, whereas HPV18 viral load is in very low level in precancer, but going up sharply in cancer [9]. Therefore, viral load may be mainly influenced by other factors, such as cervical lesion size, individual HPV types.

The prevalence rate of concurrent multiple HPV genotypes infection was reported to be around 20%-25% in several large studies [8, 23], which was nearly consistent with our result (26.7%). The role of multiple infection in carcinogenesis, a synergistic or antagonistic effect, remains to be determined [24, 25], although some studies have considered them to be a risk factor for HPV persistence and for preinvasive and invasive cervical lesions [24]. The data indicated that multiple HPV genotypes infection presented with significantly higher viral load than single HPV genotype infection, but not significantly so in simple endocervical sampling method, probably due to impact of sampling variation on viral load and the relatively small-scale population. This finding indicates that cervical lesions induced by multiple HPV genotypes infection are more likely to be associated with increased viral copies.

Our current data showed a distinct upward trend of viral load paralleled to the increasing area of cervical lesions both in univariate analysis and multivariate analysis. This result corroborates previous studies which have reported that more severe lesions tended to be larger and to harbor more HPV viral copies [26, 28]. Our finding suggests that the area of cervical lesions is an independent factor determining viral load. Some studies have shown that viral load is strongly affected by HPV copies in individual cells [29]. Our finding indicates that viral load is strongly affected by the number of infected cells, which increases in parallel with the increasing area of squamous intraepithelial lesions. However, to explore the association between HPV viral load and cervical lesion grade, some studies normalized viral load by using human cells to adjust the absolute viral load (expressed by copies/10,000 cells, etc.) to lessen the impact of the variation of sample volume [30]. This may lead to ignoring the effect of the number of infected cells on viral load.

HPV viral load estimated from cervical scrapings can be easily affected by sampling [14]. The radius of cytobrush, such as Digene cervical sampler, which is commonly used in HPV test is 0.5 cm. It is limited to collect specimens in the area of the external os within a 0.5 cm radius. When cervical lesions extend to the area of the external os over a 0.5 cm radius, it cannot fully reach, resulting in inadequate cells which would underestimate actual viral load. Therefore, to evaluate the impact of sampling methods on viral load, we compared the currently used simple endocervical sampling with a new method of combination of endo- and ectocervical sampling. We found that viral load with combination of endo- and ectocervical sampling was significantly higher than simple endocervical sampling. However, there was no significant difference in viral load between the lesion located in the area of the external os within and over a 0.5 cm radius. This may be explained by a possible biased selection of participants in our study, in that only a minor proportion of the enrolled women with cervical lesions involved the area of the external os over a 0.5 cm radius.

High-risk human papillomavirus (HR-HPV) load is influenced by age, histological severity, multiple viral types, area of cervical lesion and sampling methods. Age and area of cervical lesions are independent factors for viral load. Comprehensive sampling is needed especially when the cervical lesion was located far from cervical os.

To our knowledge, we firstly demonstrate that age and area of cervical lesions are independent factors determining viral load, which may contribute valuable data for future discussions related to the potential application of viral load measurement. Nevertheless, several limitations also need to be addressed. Firstly, the number of women with cervical lesions involved the area of the external os over a 0.5 cm radius is too limited to draw a definitive conclusion for the effect of location of the cervical lesions on viral load and specimen collection methods. Besides, clinical data collected in one institution limit our statistical power to draw definitive conclusions for population worldwide. Finally, other potential confounders, such as sampling physicians, individual HPV types, may influence viral load. Further intensive clinical setup and laboratory investigations are therefore needed.

LSIL: Low-grade squamous intraepithelial lesion; HSIL: High-grade squamous intraepithelial lesion; CC: Cervical cancer; HR-HPV: High-risk-Human papillomavirus; HCII: Hybrid capture II; TCT: Thinprep cytological test; HPV-DNA: Human papillomavirus deoxyribonucleic acid; ASC-US: Atypical squamous cell of undetermined significance; RLU: relative light units; PC: positive control

Conflict of Interest

The authors declare that they have no competing interests.

Acknowledgement

The authors would also like to thank Dr. Hongqing, Liu and Mrs. Antong, Fan (Department of Epidemiology and Health statistics, Weifang Medical University, Weifang, China) for data analysis and interpretation.

Availability of data and materials

The data used to support the findings of this study are mainly included within the article, and the underlying data are available from the corresponding author upon request.

Funding

This study was supported by a grant from the National Natural Science Fund of China (No. 81572559) and Scientific Research Foundation of the Weifang Medical University (2017BSQD43).

Authors’ contributions

YZL designed the study. TTW, XRL and YZL designed and performed the experiments. XRL verified and analyzed the data, and wrote the manuscript. YZL and YZZ edited the manuscript. All authors read and approved the final manuscript.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Ethics approval is not applicable. Informed consent was obtained from each participant. Not applicable

Huh WK, Ault KA, Chelmow D, Davey DD, Goulart RA, Garcia FA, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstetrics and gynecology. 2015;125:330-337.
Zhao X, Wu Q, Wang X, Fu Y, Zhang X, Tian X, et al. The performance of human papillomavirus DNA detection with type 16/18 genotyping by hybrid capture in primary test of cervical cancer screening: a cross-sectional study in 10, 669 Chinese women. Clin Microbiol Infect. 2018;24(12):1322-1327.
Torres-Ibarra L, Lazcano-Ponce E, Franco EL, Cuzick J, Hernández-Ávila M, Lorincz A, et al. Triage strategies in cervical cancer detection in Mexico: methods of the FRIDA Study. Salud pública de México. 2016;58:197-210.
Kjaer SK, van den Brule AJ, Paull G, Svare EI, Sherman ME, Thomsen BL, et al. Type specific persistence of high risk human papillomavirus (HPV) as indicator of high grade cervical squamous intraepithelial lesions in young women: population based prospective follow up study. BMJ. 2002;325:572.
Dalstein V, Riethmuller D, Prétet JL, Le Bail Carval K, Sautière JL, Carbillet JP, et al. Persistence and load of high-risk HPV are predictors for development of high-grade cervical lesions: a longitudinal French cohort study. International journal of cancer. 2003;106:396-403.
Dong L, Wang MZ, Zhao XL, Feng RM, Hu SY, Zhang Q, et al. Human papillomavirus viral load as a useful triage tool for non-16/18 high-risk human papillomavirus positive women: A prospective screening cohort study. Gynecologic oncology. 2018;148:103-110.
Luo H, Belinson JL, Du H, Liu Z, Zhang L, Wang C, et al. Evaluation of viral load as a triage strategy with primary high-risk human papillomavirus cervical cancer screening. J Low Genit Tract Dis. 2017;21:12-16
Dong B, Sun P, Ruan G, Huang W, Mao X, Kang Y, et al. Type-specific high-risk human papillomavirus viral load as a viable triage indicator for high-grade squamous intraepithelial lesion: a nested case- control study. Cancer management and research. 2018;10:4839-4851.
Hernández-Hernández DM, Ornelas-Bernal L, Guido-Jiménez M, Apresa-Garcia T, Alvarado-Cabrero I, Salcedo-Vargas M, et al. Association between high-risk human papillomavirus DNA load and precursor lesions of cervical cancer in Mexican women. Gynecologic oncology. 2003;90:310-317.
Jeon S. Integration of human papillomavirus type 16 DNA into the human genome leads to increased stability of E6 and E7 mRNAs: implications for cervical carcinogenesis. Proc Natl Acad Sci U S A. 1995;92:1654-1658.
Ganguly N, Parihar SP. Human papillomavirus E6 and E7 oncoproteins as risk factors for tumorigenesis. J. Biosci. 2009;34:113-123.
Sherman ME, Wang SS, Wheeler CM, Rich L, Gravitt PE, Tarone R, et al. Determinants of human papillomavirus load among women with histological cervical intraepithelial neoplasia 3: dominant impact of surrounding low-grade lesions. Cancer Epidemiol Biomarkers Prev. 2003;12:1038-1044.
Li W, Meng Y, Wang Y, Cheng X, Wang C, Xiao S, et al. Association of age and viral factors with high-risk HPV persistence: A retrospective follow-up study. Gynecologiconcology. 2019;154:345-353.
Deng T, Feng Y, Zheng J, Huang Q, Liu J. Low initial human papillomavirus viral load may indicate worse prognosis in patients with cervical carcinoma treated with surgery. Journal of gynecologic oncology. 2015;26:111-117.
Massad LS, Einstein MH, Huh WK, Katki HA, Kinney WK, Schiffman M, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstetrics and gynecology. 2013;121:829-846.
Tao P, Zheng W, Wang Y. Sensitive HPV genotyping based on the flow-through hybridization and gene chip. J Biomed Biotechnol. 2012;2012:938780.
Peitsaro P, Johansson B, Syrjanen S. Integrated human papillomavirus type 16 is frequently found in cervical cancer precursors as demonstrated by a novel quantitative real-time PCR technique. J. Clin. Microbiol. 2002;40:886-891.
Althoff KN, Paul P, Burke AE, Viscidi R, Sangaramoorthy M, Gravitt PE. Correlates of cervicovaginal human papillomavirus detection in perimenopausal women. J Womens Health (Larchmt). 2009;18:1341-1346.
Ho GY, Burk RD, Klein S, Kadish AS, Chang CJ, Palan P, et al. Persistent genital human papillomavirus infection as a risk factor for persistent cervical dysplasia. J Natl Cancer Inst. 1995; 87:1365-1371.
Lowe B, O'Neil D, Loeffert D, Nazarenko I. Distribution of Human papillomavirus load in clinical specimens. J Virol Methods. 2011;173(1):150-152.
Wu Y, Chen Y, Li L, Yu G, Zhang Y, He Y. Associations of high-risk HPV types and viral load with cervical cancer in China. J Clin Virol. 2006;35(3):264-269.

Brotherton JML, Tabrizi SN, Phillips S, Pyman J, Cornall AM, Lambie N, et al. Looking beyond human papillomavirus (HPV) genotype 16 and 18: defining HPV genotype distribution in cervical cancers in Australia prior to vaccination. Int J Cancer. 2017;141:1576-1584.
Wang S, Wei H, Wang N, Zhang S, Zhang Y, Ruan Q, et al. The prevalence and role of human papillomavirus genotypes in primary cervical screening in the northeast of China. BMC Cancer. 2012;12:160.
Sasagawa T, Basha W, Yamazaki H, Inoue M. High-risk and multiple human papillomavirus infections associated with cervical abnormalities in Japanese women. Cancer Epidemiology Biomarkers & Prevention. 2001; 10:45–52.
Chaturvedi AK, Myers L, Hammons AF, Clark RA, Dunlap K, Kissinger PJ, et al. Prevalence and clustering patterns of human papillomavirus genotypes in multiple infections. Cancer Epidemiology Biomarkers & Prevention. 2005;14:2439–2445.
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 the uterine cervix. Gynecol Oncol. 2001;83(1):95-99.
Crum CP, Nagai N, Levine RU. In situ hybridization analysis of HPV 16 DNA sequences in early cervical neoplasia. Am J Pathol. 1986;123(1):174-182.
Schneider A, Oltersdorf T, Schneider V. Distribution pattern of human papilloma virus 16 genome in cervical neoplasia by molecular in situ hybridization of tissue sections. Int J. Cancer. 1987;9(6):717-721.
Garner-Hamrick PA, and Fisher C. HPV episomal number closely correlates with cell size in keratinocyte monolayer cultures. Virology. 2002;301(2):334-341.
Segondy M, Ngou J, Kelly H, Omar T, Goumbri-Lompo O, Doutre S, et al. Diagnostic value of human papillomavirus (HPV) 16 and HPV 18 viral loads for the detection of high-grade cervical intraepithelial neoplasia (CIN2+) in a cohort of African women living with HIV. J Clin Virol. 2018;100:9979–9983.

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Analysis on influencing factors of viral load in patients with high-risk human papillomavirus

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Materials And Methods

Study population

Specimens Collection

Colposcopic Examination

Detection Of HPV-DNA

Statistical analysis

Results

1. Correlation of HR-HPV load and age

2. Correlation Of HR-HPV Load And Histological Severity

3. Correlation Of HR-HPV Load And Multiple HPV Types

6. Correlation Of HR-HPV Load And Sampling Methods

7. Multivariate Analysis For Viral Load

Discussion

Conclusion

Abbreviations

Declarations

References

Status:

Journal Publication

Version 1