- Email: [email protected]
Comment on “Human papillomavirus in the oral mucosa of women with genital human papillomavirus lesions” [Eur. J. Obstet. Gynecol. Reprod. Biol. 126 (2006) 104–106]
European Journal of Obstetrics & Gynecology and Reproductive Biology 130 (2007) 142–143 www.elsevier.com/locate/ejogrb
LETTERS TO THE EDITOR—COMMENT Comment on ‘‘Human papillomavirus in the oral mucosa of women with genital human papillomavirus lesions’’ [Eur. J. Obstet. Gynecol. Reprod. Biol. 126 (2006) 104–106] Dear Editors, Giraldo et al. [1] investigated the prevalence of oral HPV in women with and without HPV genital lesions. They detected oral HPV in 26 out of 70 (37.1%) women with HPV genital lesions (study group) versus 3 out of 70 (4.3%) women without HPV genital lesions (control group) and concluded that patients with HPV genital infection are more likely to have HPV in their oral mucosa. Taking into account the current knowledge on HPV infection, we think it opportune to underline some uncertainties with regard to this paper, mainly related to the methods used for the diagnosis of HPV lesions and infection. Regarding the genital region, the authors verified supposed ‘‘HPV lesions’’ by means of histopathological examination, but they never reported any description of lesions and, above all, they did not report any pathognomonic sign of HPV infection (i.e. koilocytosis). Additionally, they performed ‘‘routine oncological, cytological and colposcopic examinations on all participants to exclude the possibility of subclinical HPV lesions in the control group’’, but it is well known that HPV DNA can be present in silent form at the inoculation site without any cytological and colposcopic changes [2]. In accordance with the recent data in the literature, diagnosis of HPV infection should be based mainly on molecular biology techniques (i.e. HC2, PCR), which are able to detect HPV genomic sequences in infected epithelial cells [2]. Although cytological, colposcopic and histopathological examinations are useful to identify the possible virus-related alterations, they have a mediocre sensibility and are insufficient to verify both clinical and, above all, subclinical HPV infections [2–3]. With regard to HPV DNA detection in the oral cavity, it is known that, since it has weak viral productivity, a highly sensitive PCR system is required to obtain reliable information on HPV presence in oral samples with a low copy number of viral DNA. With this aim in mind, the more sensitive nested PCR assay with MY09/MY11 and inner GP5+/GP6+ primers could be the technique of choice [4]. On the contrary, Giraldo et al. used MY-PCR, that is not a
very sensitive assay, since its limit is 100–200 HPV DNA copy; furthermore, they provided scant information on the MY-PCR protocol used. In particular, they did not indicate whether they had used Taq polymerase or TaqGold polymerase, since the latter is able to identify more highrisk HPV types than the former. Finally, the cycling parameters of amplification used to control possible contamination were not described. Moreover, in relation to oral sampling, Giraldo et al. reported to have sampled oral cells by scraping only the hard palate and cheeks with Dacron swabs. The majority of authors use a cytobrush to collect epithelial cells and underline the importance of full mouth oral scraping for the accuracy of HPV detection. A negative correlation between HPV frequency and keratinisation of the scraping site has recently been noted: HPV prevalence was reduced in keratinised sites (14.5%) compared with non-keratinised sites (34.4%; p = 0.007) [4]. Hence, the scraping of as many oral mucosal sites as possible (e.g. cheeks, alveolar mucosa, border of the tongue and hard palate) is considered the best method of sampling. On the basis of these considerations, the results of Giraldo et al. are difficult to compare with the literature. In our opinion, Giraldo et al. do not show the limits of their findings and their statement that females with HPV genital infection are at a higher risk of having an oral HPV infection is not adequately supported. Finally, it is not clear why Giraldo et al. never cited one of their previous papers published in the same journal [5] in which they reported the same study population and data on HPV frequencies.
References [1] Giraldo P, Gonc¸alves AKS, Pereira SA, Barros-Mazon S, Gondo ML, Witkin SS. Human papillomavirus in the oral mucosa of women with genital human papillomavirus lesions. Eur J Obstet Gynecol Reprod Biol 2006;126:104–6. [2] Brink AA, Snijders PJ, Meijer CJ, Berkhof J, Verheijen RH. HPV testing in cervical screening. Best Pract Res Clin Obstet Gynaecol 2006;20(2):253–665. [3] Adams AL, Eltoum I, Roberson J, Chen J, Connolly K, Chhieng DC. Negative colposcopic biopsy after positive human papilloma virus (HPV) DNA testing: false-positive HPV results or false-negative histologic findings? Am J Clin Pathol 2006;125(3):413–8. [4] Giovannelli L, Campisi G, Colella G, Capra G, Di Liberto C, Caleca MP, et al. Brushing of oral mucosa for diagnosis of HPV infection in
0301-2115/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.
Letters to the Editor—Comment / European Journal of Obstetrics & Gynecology and Reproductive Biology 130 (2007) 142–143 patients with potentially malignant and malignant oral lesions. Mol Diagn Ther 2006;10(1):49–55. [5] Gonc¸alves AKS, Giraldo P, Barros-Mazon S, Gondo ML, Amaral RL, Jacyntho C. Secretory immunoglobulin A in saliva of women with oral and genital HPV infection. Eur J Obstet Gynecol Reprod Biol 2006;124:227–31.
Giuseppina Campisi* Vera Panzarella Nicoletta Termine Departments of Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy Lucia Giovannelli Departments of Microbiology, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy *Corresponding author. Tel.: +39 091 655 2221; fax: +39 091 655 2236 E-mail address: [email protected] (G. Campisi) 7 July 2006
resources and personnel. We would like to point out that our methods were clearly stated for the reader to assess and, within the limits of our protocol, the analysis and conclusions accurately and logically reflected our observations. We live in the real world and all investigators must acknowledge their scientific limitations. Nevertheless, it would be a fatal mistake for scientific progress to confine the reporting of experimental observations to the very few topof-the-line laboratories in the wealthiest countries. The number of critical scientific advances made by individuals and research teams under less than ideal conditions are far too numerous to mention. It is our hope that our manuscript will increase interest in this area and foster additional experimentation on HPV physiology and infectology. The letter by Campisi et al. suggests that we did well in this regard.
Reference [1] Giraldo P, Gonc¸alves AKS, Pereira SA, Barros-Mazon S, Gondo ML, Witkin SS. Human papillomavirus in the oral mucosa of women with genital human papillomavirus lesions. Eur J Obstet Gynecol Reprod Biol 2006;126:104–6.
Paulo Giraldo* A.K.S. Gonc¸alvez S.A. Pereira S. Barros-Mazon M.L. Gondo S.S. Witkin University of Campinas, Campinas, Sao Paulo, Brazil
doi:10.1016/j.ejogrb.2006.08.020
Response to comment on ‘‘Human papillomavirus in the oral mucosa of women with genital human papillomavirus lesions’’ [Eur J Obstet Gynecol Reprod Biol 2006;126:104–6] Dear Editors, We appreciate the interest of Campisi et al. in our recent manuscript on human Papillomavirus (HPV) in the oral mucosal in women with genital HPV lesions [1]. We certainly agree that it is sometimes possible to utilize alternative high powered techniques of increased sensitivity in performing laboratory experiments, especially if the analyses were undertaken in a setting with unlimited
143
*Corresponding author. Tel.: +55 19 32942292; fax: +55 19 37889302 E-mail address: [email protected] 21 July 2006 doi:10.1016/j.ejogrb.2006.08.021
LETTERS TO THE EDITOR—COMMENT Comment on ‘‘Human papillomavirus in the oral mucosa of women with genital human papillomavirus lesions’’ [Eur. J. Obstet. Gynecol. Reprod. Biol. 126 (2006) 104–106] Dear Editors, Giraldo et al. [1] investigated the prevalence of oral HPV in women with and without HPV genital lesions. They detected oral HPV in 26 out of 70 (37.1%) women with HPV genital lesions (study group) versus 3 out of 70 (4.3%) women without HPV genital lesions (control group) and concluded that patients with HPV genital infection are more likely to have HPV in their oral mucosa. Taking into account the current knowledge on HPV infection, we think it opportune to underline some uncertainties with regard to this paper, mainly related to the methods used for the diagnosis of HPV lesions and infection. Regarding the genital region, the authors verified supposed ‘‘HPV lesions’’ by means of histopathological examination, but they never reported any description of lesions and, above all, they did not report any pathognomonic sign of HPV infection (i.e. koilocytosis). Additionally, they performed ‘‘routine oncological, cytological and colposcopic examinations on all participants to exclude the possibility of subclinical HPV lesions in the control group’’, but it is well known that HPV DNA can be present in silent form at the inoculation site without any cytological and colposcopic changes [2]. In accordance with the recent data in the literature, diagnosis of HPV infection should be based mainly on molecular biology techniques (i.e. HC2, PCR), which are able to detect HPV genomic sequences in infected epithelial cells [2]. Although cytological, colposcopic and histopathological examinations are useful to identify the possible virus-related alterations, they have a mediocre sensibility and are insufficient to verify both clinical and, above all, subclinical HPV infections [2–3]. With regard to HPV DNA detection in the oral cavity, it is known that, since it has weak viral productivity, a highly sensitive PCR system is required to obtain reliable information on HPV presence in oral samples with a low copy number of viral DNA. With this aim in mind, the more sensitive nested PCR assay with MY09/MY11 and inner GP5+/GP6+ primers could be the technique of choice [4]. On the contrary, Giraldo et al. used MY-PCR, that is not a
very sensitive assay, since its limit is 100–200 HPV DNA copy; furthermore, they provided scant information on the MY-PCR protocol used. In particular, they did not indicate whether they had used Taq polymerase or TaqGold polymerase, since the latter is able to identify more highrisk HPV types than the former. Finally, the cycling parameters of amplification used to control possible contamination were not described. Moreover, in relation to oral sampling, Giraldo et al. reported to have sampled oral cells by scraping only the hard palate and cheeks with Dacron swabs. The majority of authors use a cytobrush to collect epithelial cells and underline the importance of full mouth oral scraping for the accuracy of HPV detection. A negative correlation between HPV frequency and keratinisation of the scraping site has recently been noted: HPV prevalence was reduced in keratinised sites (14.5%) compared with non-keratinised sites (34.4%; p = 0.007) [4]. Hence, the scraping of as many oral mucosal sites as possible (e.g. cheeks, alveolar mucosa, border of the tongue and hard palate) is considered the best method of sampling. On the basis of these considerations, the results of Giraldo et al. are difficult to compare with the literature. In our opinion, Giraldo et al. do not show the limits of their findings and their statement that females with HPV genital infection are at a higher risk of having an oral HPV infection is not adequately supported. Finally, it is not clear why Giraldo et al. never cited one of their previous papers published in the same journal [5] in which they reported the same study population and data on HPV frequencies.
References [1] Giraldo P, Gonc¸alves AKS, Pereira SA, Barros-Mazon S, Gondo ML, Witkin SS. Human papillomavirus in the oral mucosa of women with genital human papillomavirus lesions. Eur J Obstet Gynecol Reprod Biol 2006;126:104–6. [2] Brink AA, Snijders PJ, Meijer CJ, Berkhof J, Verheijen RH. HPV testing in cervical screening. Best Pract Res Clin Obstet Gynaecol 2006;20(2):253–665. [3] Adams AL, Eltoum I, Roberson J, Chen J, Connolly K, Chhieng DC. Negative colposcopic biopsy after positive human papilloma virus (HPV) DNA testing: false-positive HPV results or false-negative histologic findings? Am J Clin Pathol 2006;125(3):413–8. [4] Giovannelli L, Campisi G, Colella G, Capra G, Di Liberto C, Caleca MP, et al. Brushing of oral mucosa for diagnosis of HPV infection in
0301-2115/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.
Letters to the Editor—Comment / European Journal of Obstetrics & Gynecology and Reproductive Biology 130 (2007) 142–143 patients with potentially malignant and malignant oral lesions. Mol Diagn Ther 2006;10(1):49–55. [5] Gonc¸alves AKS, Giraldo P, Barros-Mazon S, Gondo ML, Amaral RL, Jacyntho C. Secretory immunoglobulin A in saliva of women with oral and genital HPV infection. Eur J Obstet Gynecol Reprod Biol 2006;124:227–31.
Giuseppina Campisi* Vera Panzarella Nicoletta Termine Departments of Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy Lucia Giovannelli Departments of Microbiology, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy *Corresponding author. Tel.: +39 091 655 2221; fax: +39 091 655 2236 E-mail address: [email protected] (G. Campisi) 7 July 2006
resources and personnel. We would like to point out that our methods were clearly stated for the reader to assess and, within the limits of our protocol, the analysis and conclusions accurately and logically reflected our observations. We live in the real world and all investigators must acknowledge their scientific limitations. Nevertheless, it would be a fatal mistake for scientific progress to confine the reporting of experimental observations to the very few topof-the-line laboratories in the wealthiest countries. The number of critical scientific advances made by individuals and research teams under less than ideal conditions are far too numerous to mention. It is our hope that our manuscript will increase interest in this area and foster additional experimentation on HPV physiology and infectology. The letter by Campisi et al. suggests that we did well in this regard.
Reference [1] Giraldo P, Gonc¸alves AKS, Pereira SA, Barros-Mazon S, Gondo ML, Witkin SS. Human papillomavirus in the oral mucosa of women with genital human papillomavirus lesions. Eur J Obstet Gynecol Reprod Biol 2006;126:104–6.
Paulo Giraldo* A.K.S. Gonc¸alvez S.A. Pereira S. Barros-Mazon M.L. Gondo S.S. Witkin University of Campinas, Campinas, Sao Paulo, Brazil
doi:10.1016/j.ejogrb.2006.08.020
Response to comment on ‘‘Human papillomavirus in the oral mucosa of women with genital human papillomavirus lesions’’ [Eur J Obstet Gynecol Reprod Biol 2006;126:104–6] Dear Editors, We appreciate the interest of Campisi et al. in our recent manuscript on human Papillomavirus (HPV) in the oral mucosal in women with genital HPV lesions [1]. We certainly agree that it is sometimes possible to utilize alternative high powered techniques of increased sensitivity in performing laboratory experiments, especially if the analyses were undertaken in a setting with unlimited
143
*Corresponding author. Tel.: +55 19 32942292; fax: +55 19 37889302 E-mail address: [email protected] 21 July 2006 doi:10.1016/j.ejogrb.2006.08.021