Wen-Ming Cao,Li-Li Yu,Xiu-Rong Wang,Xin-Ling He,Na Yu

1Department of Gynecology,Changle People’s Hospital,Changle 262400,China;2Dezhou Hospital of traditional Chinese Medicine,Dezhou 253000,China;3Shandong Provincial Third Hospital,Jinan 250000,China.

Abstract

Key words: BBT-RF-A self-clotting cutter,Cervix,HR-HPV,Persistent infection

Background

Cervical cancer is the most common gynecologic malignant tumor,with 530,000 new cases worldwide and 132,000 new cases in China every year.Ninety-nine point seven percent of cervical cancer is caused by persistent infection of human papillomavirus,and 70%of cervical cancer is related to types of HPV16 and HPV18 [1].Persistent high risk-HPV (HR-HPV)infection can lead to cervical precancerous lesions and cervical cancer.Timely intervention and treatment to eliminate HR-HPV infection and its persistent infection is very important to prevent cervical tumors.At present,the therapeutic drugs mainly include cytotoxic drugs and immunomodulators.However,the vaginal drug administration period is so long,time-consuming and laborious,and the negative conversion rate is not high,ranging from 31.4% to 48.1%.The radio frequency of BBT-RF-A self-clotting cutter is a sinusoidal alternating current with high frequency,which has no electrolytic effect on tissues and no damage to normal tissues surrounding tumor,and can better avoid complications such as hemorrhage or infection.The thermal effect,photochemical effect and pressure effect of BBT-RF-A are utilized to improve the negative conversion rate of HPV.The low-power radio frequency of self-clotting cutter itself can reduce nerve excitability,has sedative and analgesic effects,and can promote the proliferation of epithelial cells and accelerate cervical repair and healing [2].The operation time is extremely short,with only 5 minutes,safe,painless and no anesthesia needed.It can be completed in the outpatient department,and the cost is low [3].In this paper,the self-clotting cutter radiofrequency treatment of cervical lesions was used to study the negative conversion of HPV after operation,and the relationship between the treatment of cervix by self-clotting cutter radiofrequency and the negative conversion of HR-HPV was discussed.Now,the report is as follows.

Research Objects and Methods

Objects of study

Clinical grouping.One hundred patients diagnosed with persistent cervical HR-HPV infection in Shandong Changle People’s Hospital from April 2019 to February 2020 were selected,which was approved by the Ethics Committee of Changle County People’s Hospital to carry out clinical experiments.Those in the same period were randomly selected by SPSS19.0 software machine according to the ratio of 1: 1,and divided into the treatment group (BBT-RF-A radiofrequency group) and the observation group (recombinant human interferon suppository group) with 50 cases in each group.We aimed to group and monitor people with benign cervical lesions.Patients in both 2 groups underwent thinprep cytologic test (TCT),HPV and colposcopy test,excluding cervical squamous intraepithelial lesions or cervical cancer.Both groups were forbidden to have sex during medication and avoid menstruation.

BBT-RF-A self-clotting cutter treatment group (only self-clotting cutter radio frequency physical therapy):self-clotting cutter radio frequency treatment of cervix,if the patient has cervical erosion,electric ironing will be performed on the cervical erosion surface;if there is cervical polyp,the polyp will be removed by selfcollting cutter and the root is electrocoagulated;if there is cervical cyst,electrocoagulation cyst will be performed;if the appearance of the cervix is hypertrophic and smooth,it will be electrocoagulated superficially on the surface of the cervix for one week.All patients were operated 3-7 days after menstruation,once in total between 5-10 minutes.Taking the bladder lithotomy position of the patient and routinely disinfecting the vulva and vagina.After the speculum exposed the cervix,the cervical forceps clamped the anterior lip of the cervix at 12 o’clock,and slowly rotated the electrocoagulation 360 degrees from 12 o’clock clockwise with the probe of self-clotting cutter.(Self-clotting cutter: gynecologic multifunctional radiofrequency instrument with output power of 50 W and load of 100 Ω,registration certificate number:National Food and Drug Administration approval: No.3250163 of 2003,factory number: 2003B2208,Figure 1).

Interferon observation group: 1 recombinant human interferon suppository was placed in vagina once every other day,9 tablets per month,18 days per month for 6 months.(Recombinant human interferon suppository:trade name anterferon,100,000 international units,example,approval number: National Food and Drug Administration approval No.S20020103,Anhui Anke Bioengineering Co.,Ltd.)

Note: recombinant human interferon suppository has broad-spectrum antiviral and cell proliferation inhibitory effects,and can improve the immune function of the body.It can enhance the phagocytosis of macrophages,improve the cytotoxicity of lymphocytes to target cells and enhance the function of killer cells of the immune system in vivo.

Observed indexes.(1) The main types of HR-HPV persistent infection include single infection and mixed infection.Further clarifying the most common subtypes of HPV infection in Changle.Studying the main types of HR-HPV persistent infection has guiding value for women in Changle to inject HPV vaccine.(2) Patients in 2 groups were reexamined HPV test at 6 months and 12 months respectively,and the negative conversion rate of HPV-DNA was recorded in the 2 groups.The negative conversion rate of HPV-DNA was calculated at 6 months and 12 months after treatment in the treatment group and the observation group respectively (formula:P = n/N × 100%).(3) At the 12th month after the treatment,patients with abnormal results from TCT,colposcopic and cervical pathological examination before treatment in the treatment group and the observation group were reexamined.The changes of TCT,colposcopy and cervical pathology before and after treatment were compared between the 2 groups.

Inclusion criteria.(1) HPV-DNA examination of cervix showed the same type of HR-HPV infection in patients aged ≥ 23 years old who have sexual life at intervals of 6 months.(2) TCT of the cervix showed no definite diagnostic significance of atypical squamous cell of undetermined significance (ASC-US).(3)Colposcopy showed chronic cervicitis.(4) Cervical biopsy and/or cervical canal curettage were performed in patients with abnormal colposcopy.Pathological diagnosis showed that the lesion was ≤ cervical intraepithelial neoplasia (CIN) I grade.(5) All the subjects voluntarily signed the informed consent form.

Exclusion criteria.(1) Pregnancy or lactation.(2) HRHPV infection was found for 6 months,and anti-HPV drugs,sex hormones or immunoregulatory drugs were used during treatment or follow-up.(3) Those who have pregnancy requirements within 1 year.(4) Acute genital tract infection and genital tract tumor.(5) Not signing the informed consent form,and the compliance is poor.

Research Methods

Strictly following the cervical “three steps”screening process[4].TCT + HPV → colposcopy →cervical multi-point biopsy + pathology.Specifically,liquid-based cytological TCT examination and human papillomavirus HPV detection are the first step of screening;if the screening result is abnormal,patients are enter the second step colposcopy;if colposcopy is abnormal,iodine test and acetic acid white test shall be performed,followed by cervical multi-point biopsy or cervical canal curettage,and pathological test shall be examined (Figure 2).

Cervical TCT.Bladder lithotomy position of patients were selected,the cervix was exposed by speculum,and excessive secretions from the cervical orifice were wiped off with cotton swab.The cell brush was extended into the cervical orifice and cervical canal,and rotated clockwise for 5 cycles.Then taking cell brush out,and pushing the brush head into the sample tube filled with cell preservation solution.Sending it to the pathology department of our hospital for laboratory tests.TCT registration number of our hospital: Luji machinery and device 20140108,Jinan Ruifeng Electronic Technology Co.,Ltd.

HPV virus examination.The sampling method was consistent with that of TCT.The human papillomavirus genotyping type 23 detection kit produced by Yaneng Biochemistry Co.,Ltd.was used for detection by PCR plus reverse hybridization.This kit can detect 23 types of HPV viruses,including 17 high-risk types (16,18,31,33,35,39,45,51,52,53,56,58,59,66,68,73,82) and 6 low-risk types (6,11,42,43,81,83).

The criteria for determining the HR-HPV typing test results are as follows [5]: (1) the positive spots of the test results are clearly visible blue-purple dots;(2)according to the HPV typing distribution map of membrane strips (Figure 3),the positive point matches the certain type of HPV virus;(3) biotin control point,reflecting the reaction between enzyme and color developing solution,should be positive in the detection;internal control (IC) is a quality control template DNA probe,if there are no inhibitory factors in the amplification reaction system,IC points appear;(4) if the 2 control points above are positive and the other points are negative,it should be determined that the HPV typing DNA test result of this kit is negative;if one or more HPV typing points are positive,it means that this type of HPV is positive,and the result is single or mixed HPV infection.

Colposcopy test.Colposcopy test shall be performed for those with abnormal TCT and HPV typing.Wipe cervical secretions with cotton balls,move the colposcopy objective 10 cm away from the vaginal opening (15-20 cm away from the cervix),aim at the cervical lesion,turn on the light source,and adjust the focal length of the colposcopy objective to make the image clear.First,the shape,color,blood vessels and leukoplakia of cervix were observed with low power microscope.Then acetic acid white test and iodine test were performed.DVIS-C electronic colposcopy digital imaging system,with the model was RH-220 (produced by Xuzhou Ruihua Electronic Technology Development Co.,Ltd.) was used for detection.

Cervical pathology examination.For patients with abnormal results from colposcopic examination,cervical biopsy under colposcopy localization shall be performed,and cervical endometrial curettage shall be performed when necessary.Specimens were sent to the pathology department of our hospital for examination.

Statistical method

SPSS 19.0 statistical software was adopted to analyze the data.Age is expressed as ± s.T test was used for comparison between groups,and rank sum test was used for subtype distribution.Two tests were used to compare the intergroup composition ratio of HPV subtypes,TCT results and colposcopic results before and after treatment,and 2 tests were used to compare the negative conversion rate of HPV between groups after treatment.Inspection standard α = 0.05.

Technical route

Technical route is shown as Figure 4.

Results

Comparison of the situation between the treatment group and the control group before treatment

The minimum age in the treatment group was 31 years old and the maximum was 61 years old,while the minimum age in the observation group was 30 years old and the maximum age was 62 years old.The average age of the treatment group was 41.3 ± 7.65 years old,while that of the observation group was 40.27 ± 8.13 years old.T test showed that there was no significant difference in age between the treatment group and the control group,P＞ 0.05 (Table 1).

The main types of single HR-HPV persistent infection were HPV 16,58 and 52,with 24 cases in the treatment group and 22 cases in the observation group.There were 16 cases infected with other 9 subtypes in the treatment group and 17 cases in the observation group.There were 21 cases of mixed HR-HPV persistent infection,mainly HPV 52 combined with other types of infection.There was no significant difference in subtype distribution between the two groups (P＞ 0.05) (Table 1).

Results of TCT,colposcopic and pathological test before treatment.Before treatment,5 cases in the treatment group and 3 cases in the observation group were ASC-US.Colposcopy showed 12 cases of subclinical papillomavirus infection (SPI) in the treatment group and 14 cases of SPI in the observation group.There were 38 cases of chronic cervicitis in the treatment group and 36 cases of chronic cervicitis in the observation group.Pathological examination showed that 3 cases in the treatment group were chronic cervicitis and the other 2 cases were CIN I grade.In the observation group,2 cases were chronic cervicitis and 1 case was CIN I grade.It is concluded that there was no significant difference in TCT results and colposcopic results between the two groups before treatment (P＞0.05) (Table 1).

Comparison of negative conversion rates of HRHPV persistent infection

The negative conversion rates of HR-HPV were 60.00%and 82.00% in the treatment group and 30.00% and 44.00% in the observation group respectively at the 6th and 12th months after treatment.After treatment,the conversion rate of the 2 groups at the same time point was statistically significant (allP＜ 0.05).The negative conversion rates of HR-HPV at the 12th moth in the treatment group and the observation group were significantly higher than those in the same group at the 6th month after treatment (P＜ 0.05) (Table 2).

Table1 Basic information of patients in 2 groups before treatment (excluding height,weight and BMI index)

Analysis of TCT results of 2 groups of patients before and after treatment

There was no significant difference in TCT results between the 2 groups,as well as the intragroup before and after treatment (P＞ 0.05) (Table 3).

Analysis of colposcopic results of 2 groups of patients before and after treatment

There was no significant difference in colposcopic results between the 2 groups and in the intragroup before and after treatment (P＞ 0.05) (Table 4).After treatment,1 case in the treatment group was diagnosed with ASC-US by colposcopy,but HPV16 type was continuously positive,and cervical biopsy was CIN I grade.After treatment,2 cases in the observation group showed ASC-US by colposcopy,but HPV16 and HPV18 continued to be positive,and cervical biopsy

showed CIN I grade.

Changes of cervical pathological examination results after treatment

In the treatment group,5 cases were examined by cervical pathology after treatment,including 4 cases showing chronic cervicitis and 1 case showing CIN I grade.In the observation group,3 cases underwent cervical pathology examination after treatment,including 1 case of chronic cervicitis,1 case of CIN I grade and 1 case of CIN III grade involving glands(Figure 5,6).Among them,the patients with CIN Ⅲgrade involving glands were found to be CIN I grade by cervical pathological examination before drug treatment,and HPV16 type was still positive after drug treatment.After pathological diagnosis of CIN Ⅲ grade,the patients were admitted to gynecological ward for cervical conization,and the postoperative pathological results supported the preoperative diagnosis.It can be seen that BBT-RF-A self-clotting cutter ablation can obviously delay the process of cervical lesions from CIN I grade to CIN II grade and CIN III grade.(Pathological examination results: the number of cases after three-step screening,so the number is small.)(Figure 7,8,Table 5).

Adverse drug reactions

In the treatment group,2 cases complained of lowerabdominal distension discomfort accompanied by vaginal pruritus during the third course of treatment,which was tolerable and did not receive intervention treatment.Gynecological examination and vaginal secretion examination did not indicate abnormalities.The symptoms mentioned above disappeared naturally at the end of the fourth course of treatment.In the observation group,3 cases suffered from slight vaginal pruritus during the second course of treatment,which disappeared after 7 days.There was no abnormality in gynecological examination and vaginal secretion examination.

Table2 Comparison of negative conversion rates of HR-HPV persistent infection between the 2 groups (n,%)

Table3 Comparison of TCT results between the 2 groups after treatment (n,%)

Table4 Comparison of colposcopic results between the 2 groups before and after treatment (n,%)

Table5 Comparison of pathological examination results between the 2 groups before and after treatment (n,number of cases)

Conclusion

Age of persistent cervical HR-HPV infection

Age is an important influencing factor of HPV infection[6].It has been reported that the population aged 20-25 and 35-44 has the largest number of HPV infections [7].Paying attention to cervical screening,health education,disease management,intervention and treatment for the age group with high incidence of HR-HPV persistent infection is of positive significance for reducing the persistent infection rate of HR-HPV and its adverse prognosis [8].

This study showed that the proportion of HR-HPV persistent infection is high in the 32-49 age group.The mainly related factors were analyzed as follows: (1)some women in this age group are still sexually active,and multiple sexual partners and unprotected sexual behaviors increase the chance of cross-infection of HRHPV through sexual routes [9];(2) some individuals cannot eliminate the infected HPV in time due to low immunity,which increases the possibility of persistent HR-HPV infection.The results of this study suggested that attention should be paid to the prevention and treatment of persistent cervical HR-HPV infection among women aged 32-49 in Changle.

Main types of cervical HR-HPV persistent infection

It is now clear that persistent HR-HPV infection is one of the very important pathogenic factors for cervical cancer and its precancerous lesions.Currently,it is believed that persistent HR-HPV infection can be used as the endpoint for evaluating the effectiveness of vaccine preventing cervical cancer [10].Early screening and prevention of HR-HPV persistent infection are of great significance to the prevention of cervical cancer and the blocking of its development.The main types of cervical HPV infection in Chinese women are HPV 16 and HPV 18.

The results of this study suggested that the main types of persistent HR-HPV infection in single cervix are HPV 16,52 and 58,not including HPV 18.Reasons may include: (1) it was related to the difference between transient infection and persistent infection of HR-HPV;(2) it affected by regional and ethnic differences;(3)HPV16 infection was the main infection in high-grade cervical lesions and cervical squamous cell carcinoma,HPV18 infection was the main infection in cervical adenocarcinoma,while cervical adenocarcinoma was rare.

Studying the main types of HR-HPV persistent infection has guiding value for HPV vaccine injection in Changle.The bivalent vaccine (Cervarix)(HPV16/18) and the tetravalent vaccine (Gardasil)(HPV6/11/16/18) currently on the market in China may not be targeted enough to the main types (16/52/58) of HR-HPV persistent infection among women in this region.The 9-valent vaccine Gardasil-9(HPV6/11/16/18/31/33/45/52/58) contains the main types of persistent HR-HPV infection among women in this region.

According to the results of this study,the 9-valent vaccine Gardasil may have greater preventive value for cervical cancer in women in Changle,but the vaccination age of the 9-valent vaccine is 16-26 years old,women aged 32-49 years old cannot be injected with the 9-valent vaccine and can only choose bivalent and tetravalent vaccines.Therefore,regular screening,early detection of HR-HPV persistent infection and early diagnosis of cervical precancerous lesions are issues extensively concerned by gynecologists and even government departments.It is a good policy for the country to benefit the people with free screening of the two-cancer for women aged 35-65 who have sexual life in Changle every year.However,the two-cancer screening only examines cervical two-cancer,which has certain limitations and does not include women before the age of 35.We suggest that women in Changle should be vaccinated with HPV vaccine before having sex.Women who have sex should be examined for TCT and HPV every year.If the results are negative for 3 consecutive years,it can be tested for 2-3 years instead.

Discussion

HPV is a kind of spherical unenveloped doublestranded DNA virus.So far,more than 100 different types of human papillomavirus have been found,54 of which can infect reproductive tract mucosa.According to the relationship between HPV and cancer,HPV infecting anus and genitals can be divided into low risk types (often appearing in benign lesions,such as HPV6 and HPV11),moderate risk types (existing in moderate and severe atypical hyperplasia foci) and high risk types(in severe atypical hyperplasia and cancer foci,for example,HPV16 and HPV18 types can be detected in most cervical cancers,some anal canal cancers,penile cancers and vaginal cancers).Ninety-nine point seven percent of cervical cancer is caused by persistent infection with human papillomavirus,and 70% of cervical cancer is related to HPV16 and 18 types [11].

There are 132,000 new cases of cervical cancer in China every year,and more than 33,000 people die of cervical cancer every year in China.Cervical cancer is the result of high load and continuous infection of human papillomavirus.It is developed from untreated precancerous lesions.HR-HPV infection is a necessary condition for cervical cancer,with a clear causal relationship between them.This discovery won the 2008 Nobel Prize in Medicine and Physiology (German scientist Harald zur Hausen).However,persistent HRHPV infection is most likely to cause cervical cancer.If the HR-HPV virus infection turns negative within one year,the probability of cervical cancer is low.HPV is only a necessary condition for cervical cancer,not a sufficient condition [12].Because the occurrence of any infectious disease is the result of a game between pathogens and human defense systems.

Young age of first sex,frequent sexual intercourse,multiple sexual partners,sexually transmitted diseases,multiple births,herpes simplex virus infection,smoking,alcohol abuse,et al.are all the causes of cervical cancer [13].However,since it is clear that HPV is a necessary condition,these factors discovered by people have become indirect causes or synergistic effects,which only increase the risk of infection or reduce the immune function against HPV,thus increasing the risk of morbidity.

The self-clotting cutter has no bright blade and is not a scalpel in the traditional sense.Self-clotting cutter is a system and a specialized technology that simulates the application of space rocket guidance technology in the medical field.BBT-RF-A self-clotting cutter,also known as radiofrequency minimally invasive selfclotting cutter,is a minimally invasive treatment technology that does not harm cervix and does not affect fertility.BBT-RF-A self-clotting cutter has strong radiofrequency penetration to human tissues,with high thermal efficiency and simple operation technology.The radiofrequency bands (medium wave,short wave and ultrashort wave) emitted by the therapeutic instrument has no adverse effect on human body and has remarkable therapeutic effect.BBT-RF-A self-clotting cutter has good therapeutic effect on cervical cyst,cervical erosion,cervical polyp,cervical hypertrophy,et al.BBT-RF-A radiofrequency is a kind of sinusoidal alternating current with very high frequency,which appears in the form of full wave and has no electrolytic effect on tissues.It does not harm the cervix or affect fertility.Radiofrequency treatment of cervix selfclotting cutter uses thermal effect,photochemical effect and pressure effect of self-clotting cutter to improve HPV negative conversion rate.The self-clotting cutter used in the treatment group of this study has antiinflammatory effect,which can improve the circulation of blood and lymph,absorb and dissipate pathological metabolites,and promote inflammation to subside.Low-power radiofrequency itself can reduce nerve excitability,which not only has sedative and analgesic effects,but also can promote the proliferation of epithelial cells and accelerate cervical repair and healing.The recombinant human interferon suppository used in the observation group can combine with interferon receptor to inhibit replication and transcription of virus nucleic acid,and can enhance the specific cytotoxic effect of lymphocytes and phagocytes on target cells by regulating immune function,thus eliminating virus.