Human papillomavirus infection and cervical neoplasia: new perspectives.

This review addresses several problems associated with human papillomavirus (HPV) infection of the cervix and lower female genital tract. These include the definition of HPV infection and its distinction from HPV-associated neoplasia, the distinction of HPV infection from reactive epithelial changes induced by other infections, and the transmission of HPV infection via the male partner. The available evidence indicates that there are two distinct intraepithelial processes in the cervix associated with HPV. One is the classical condyloma and its counterpart in immature epithelium, atypical immature metaplasia. The other is intraepithelial neoplasia, which, like classical infection, may be mature [cervical intraepithelial neoplasia (CIN) with koilocytosis] or immature (high grade CIN or carcinoma in situ). Molecular hybridization studies indicate that HPVs 6 and 11 are most commonly detected in the former, whereas HPVs 16 and 18 DNA are most common in the latter and in invasive cancer. From the clinical standpoint the most important distinction is between HPV-related disease (condyloma or CIN) and reactive changes associated with other pathogens, such as Chlamydia. The former should be removed from the cervix, whereas the latter should be treated medically or followed. It is stressed that therapy should not hinge upon the histological distinction of HPV infection from neoplasia and that all lesions should be removed, by conservative means if possible. This is underscored by the fact that a high proportion of CIN lesions contain areas identical to condyloma and that lesions with deep endocervical canal involvement, including those with features suggesting condyloma, should be treated by cone biopsy to exclude the presence of invasive cancer. Histological classifications for nonneoplastic, HPV-infected, and neoplastic epithelium are proposed. The management of the male partner is still unsettled. However, a large proportion of male partners of these patients have penile lesions and should be included in diagnostic and therapeutic protocols of women with genital HPV infections or neoplasms.