Volume 120 Number 5

after cranial irradiation in two patients with nasopharyngeal carcinoma. .4. L. Ogilvy-Stuart, BM, MRCP(UK) S. M. Shalet, MD, FRCP Christie Hospital National Health Service Trust Manchester M20 9BX, England

REFERENCES 1. Shalet SM, Beardwell CG, Twomey JA, Morris Jones PH, Pearson D. Endocrine function following the treatment of acute leukaemia in childhood. J PED1ATR 1977;90:920-3. 2. Lee KO, Machida T, Beck-Peccoz. Central hypothalamic hypothyroidism with thyrotropin of decreased biological activity: a delayed consequence of cranial irradiation [Abstract 420]. American Endocrine Society, 73rd Annual Meeting, 1991.

Cervicovaginal human papillomavirus infection in adolescents and young adults To the Editor: It was important to read the report of Fisher et al. (J PEDIATR 1991; 119:821-5) confirming that infection with human papillomavirus (HPV) does not spare any socioeconomic classes. I was, however, disturbed by the authors' concluding paragraph: 1. "At present, no treatment is available for girls and women who have an H P V infection." Lesions caused by HPV and identified by eolposcopy can be treated with such therapeutic measures as cryotherapy, electrocautery, laser vaporization, fluorouracil, excisional biopsy, podophyllum resin, trichloroacetic acid, liquid nitrogen, and inteferon alfa. The mode of treatment depends on the location of the infection; treatment of cervical HPV infection with a laser has been reported to yield 90% to 95% cure rates, 80% to 95% for cryotherapy) I recognize that some investigators have raised doubts regarding eradication of HPV by any form of treatment; however, I believe that treatment modalities should be offered to these patients, who potentially have a premalignant state (especially HPV serotypes 16, 18, 31, 33, 35, 39). 2. "It is not clear whether patients with HPV infection should have colposcopy in the absence of specific smear findings." As the authors noted, "a relationship between HPV and cervical neoplastic disease has been established." This relationship is so strong with specific serotypes of HPV that many gynecologists equate them with cervical cancer. Papanicolaou smears miss HPV infections in more than 15% of the cases. Colposcopic examination and directed biopsies frequently unveil the abnormal growth missed by the naked eye. Because of the association of specific HPV serotypes with invasive cervical cancer, I believe that a more aggressive approach is not only warranted but mandated. Papanicolaou smears are a screening tool and in my opinion are insufficient to follow women with any evidence of HPV infection. Colposcopy is a much more sensitive tool for the examination of these women with presumptive cancer.

E d i t o r i a l correspondence


3. I am so concerned about HPV-infected sexually active teenagers and their risk of subsequent cancer that I believe colposcopy may be advisable every other year or even annually. At present, I refer all teenage girls with a documented sexually transmitted disease for colposcopic examination. Michael G. Schaffrinna, MD Director, Adolescent Medicine Service Wright-Patterson USAF Medical Center Dayton, OH 45433

REFERENCES 1. Ferenczy A. Diagnosis and treatment of condyloma. In: Basic and Advanced Colposcopy. Washington, D.C.: American College of Obstetricians and Gynecologists, 1989:47-51. 2. Cripe T. Human papilloma viruses: pediatric perspectives on a family of multifaceted tumorigenic pathogens. Pediatr Infect Dis J 1990;9:836. 3. Nash J, BurkeT, Hoskin W. Biologiccourseofcervicalhuman papillomavirus infection. Obstet Gynecol 1987;69:160-2.

Reply To the Editor." Dr. Schaffrinna has raised several important clinical issues relating to the interpretation and management of cervicovaginal infection with human papillomavirus (HPV) in adolescents and young adults. The detection of H P V by molecular hybridization is not synonymous with detecting a cytologic or histopathologic lesion. As we stated, and stand by, there is at present no treatment for the viral infection itselfJ In fact, although specific lesions are treatable, there is even some debate whether all low-grade squamous intraepithelial lesions (SIL) require ablative therapy (see comment, Obstetrical and Gynecological Survey 1992;47:50-52). Papillomaviruses are classified by genotype with the the of molecular biologic techniques, and not by serotype. The suggestion that all women infected with oncogenic HPVs (e.g., HPV types 16, 18, 31, 33, 35, 39) have a premalignant state and should be treated is unfounded according to current information. 2 This may be analogous to suggesting that because Epstein-Barr virus infection is associated with Burkitt lymphoma, everyone with the infection is in a premalignant state and should be treated. Clinical judgment as to whether a woman needs treatment for a cervical lesion should be based on histologic evidence of SIL and not on whether HPV infection is present. The goal of therapy is to obliterate a cellular growth before it can progress to cancer, not to treat a possible viral infection) The suggestion that an aggressive approach is required in the management of all women infected with certain types of HPV is troublesome. Laser vaporization and electrocautery, to name two procedures, are not benign. Although the current literature supports the notion that HPV-infected women are at a higher risk for the development of cervical lesions, until we know more about the natural history of cervicovaginal HPV infection it is unwarranted to treat such patients aggressively. 2-4 In fact, we performed follow-up HPV evaluations on 51 adolescents from an urban clinic and documented that 19 of 20 initially infected patients did not have the same HPV detected on the follow-up visit (Rosenfeld et al.: unpublished observations). One interpretation of these results

Cervicovaginal human papillomavirus infection in adolescents and young adults.

Volume 120 Number 5 after cranial irradiation in two patients with nasopharyngeal carcinoma. .4. L. Ogilvy-Stuart, BM, MRCP(UK) S. M. Shalet, MD, FRC...
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