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Received: 26 November 2018    Revised: 14 March 2019    Accepted: 29 July 2019    First published online: 8 August 2019

DOI: 10.1002/ijgo.12934

CLINICAL ARTICLE
Gynecology

Cervical intraepithelial neoplasia in women who had

vaccination against HPV

Giorgio Bogani1,* | Maurizio Serati2 | Umberto L. R. Maggiore1 | Antonino Ditto1 | 

Barbara Gardella3 | Simone Ferrero4 | Arsenio Spinillo3 | Fabio Ghezzi2 | 
Francesco Raspagliesi1

1
Gynecologic Oncology, IRCCS National
Cancer Institute, Milan, Italy Abstract
2
Obstetrics and Gynecology, Ospedale di Objective: To investigate the characteristics of women developing cervical intraepithe-
Circolo, Fondazione Macchi, University of
lial neoplasia who had had a vaccination against human papillomavirus (HPV).
Insubria, Varese, Italy
3 Methods: A retrospective cohort study was carried out of women diagnosed with
Obstetrics and Gynecology, IRCCS
Fondazione Policlinico San Matteo, ­moderate or severe cervical dysplasia (CIN2+) in four Italian centers between 2015
University of Pavia, Pavia, Italy
and 2017. All women included had had previous bivalent or quadrivalent vaccination
4
Academic Unit of Obstetrics and
Gynaecology, IRCCS Ospedale Policlinico against HPV.
San Martino, Neurosciences, Rehabilitation, Results: The present study included 43 patients affected by CIN2+. The median age was
Ophthalmology, Genetics, Maternal and
Child Health (DiNOGMI), University of 28 (range, 21–41) years. Ten (23.3%) patients did not have a diagnosis of specific HPV
Genoa, Genoa, Italy type(s) involved: high-­risk HPV was detected in 7 (16.3%) women while HPV testing

*Correspondence
Giorgio Bogani, IRCCS National Cancer
Institute, Milan, Italy.
Email: giorgiobogani@yahoo.it; giorgio.
bogani@istitutotumori.mi.it
was negative in 3 (6.9%) women. Lesions related to HPV16 were found in two patients.
HPV types covered by nonavalent vaccination were diagnosed in 27/33 (81.8%) women.
HPV types not covered by nonavalent vaccination were diagnosed in 6 (18.2%) women.
Co-­infections are most commonly detected in women with HPVs other than those
included in the nonavalent vaccination (P=0.024).
Conclusion: Cervical dysplasia occurring after HPV vaccination is a rare condition.
Theoretically, nonavalent vaccination should improve protection against more than
80% of HPV-­related lesions compared to other vaccines.

KEYWORDS
Cervical dysplasia; HPV; Human papillomavirus; Nonavalent vaccination; Vaccination

1 |  INTRODUCTION infection might cause precancerous and cancerous transformation of

Human papillomavirus (HPV) is the most commonly sexually transmit-
ted disease worldwide. It is estimated that more than 14 000 new
genital infections occur every year.1 HPV includes more than 100
related virus types and has a role in carcinogenesis.2 The International
Agency for Research on Cancer (IARC) working group identified 13
types of HPV classified as high-­risk (HR) viruses. They included: the
alpha-­5 type 51; alpha-­6 types 56 and 66; alpha-­7 types 18, 39, 45,
and 59; and alpha-­9 types 16, 31, 33, 35, 52, and 58.2 Although the
majority of HPV infections resolve spontaneously, persistent HR-­HPV
several types of epithelium.3–5
The introduction of vaccination against HPV aimed to reduce
the prevalence of HPV-­related lesions (i.e. high-­grade lesions, can-
cer, and genital warts (for quadrivalent vaccination)) among women
and men. Since the introduction of quadrivalent (against HPV6, 11,
16, and 18) and bivalent (against HPV16 and 18) vaccines in 2006
and 2007, respectively, the growing body of literature underlined the
effectiveness of these vaccines in reducing the prevalence of HPV
and HPV-­related lesions.6 The beneficial effects of vaccinations have
been seen in vaccinated and even non-­vaccinated individuals due to

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234       Bogani ET AL.
the phenomenon known as “herd protection”.6 The beneficial effects
of HPV vaccines have been observed in young individuals but also in
women aged up to 45 years.6 However, HPV vaccines have reduced,
but not eradicated, the occurrence of HPV-­related lesions.6 In fact,
as previously mentioned, there are many HPV types not covered by
currently available vaccines and some women receiving vaccination
against HPV develop cervical dysplasia even after primary preven-
tion. Recently, the nonavalent vaccination was introduced in order to
improve protection against nine HPV types (6, 11, 16, 18, 31, 33, 45,
52, and 58), thus potentially reducing the prevalence of HPV and HPV-­
related lesions.6
The aim of the present study was to estimate the theoretical
effectiveness of nonavalent vaccination in reducing the prevalence
of cervical dysplasia instead of bivalent and quadrivalent vaccination
against HPV.
2 |  MATERIALS AND METHODS
The present retrospective study involved four Italian centers
in Northern Italy (i.e. Genova, Milano, Pavia, and Varese). The
Institutional Review Board (IRB) of all centers approved this study.
Records of all consecutive women developing high-­grade cervical
intraepithelial neoplasia or more severe cervical lesions (CIN2+),
between 2015 and 2017, after having vaccination against HPV in
the past were retrospectively reviewed. Written informed consent
for the use of personal information for health research was received
from all patients.
The primary aim was to identify HPV type(s) involved in the gen-
esis of CIN2+ among women who had a previous vaccination against
HPV. A secondary aim was to evaluate how the execution of the new
nonavalent vaccine would potentially reduce the prevalence of CIN2+
in this cluster of women. Inclusion criteria were: (1) history of bivalent/
quadrivalent vaccination against HPV; (2) diagnosis of CIN2+; and (3)
execution of HPV testing at the time of diagnosis of CIN2+. Exclusion
criteria were: (1) age under 18 years; (2) withdrawal of consent; (3)
history of invasive genital cancer at diagnosis; (4) pregnancy; and (5)
history of hysterectomy. Demographic details of women—including
data about HPV type(s) detected as well as data on treatment for the
occurrence of CIN2+—were retrospectively reviewed.
According to institutional protocols, women who had had a vac-
cination against HPV had a regular secondary prevention, including
a cervical smear and/or HPV testing on a regular basis. Patients were
evaluated colposcopically in the outpatient clinic when HPV infec-
tion and/or HPV-­related lesions were detected. All gynecological
and colposcopic examinations were performed by a dedicated team
of gynecologic oncologists. Clinical and colposcopic examinations
were performed as previously reported. 7–9
H-­SIL was defined by the
presence of p16 immunohistochemistry. HPV types were considered
10
high-­risk according to the data from the IARC. Data are summarized
using basic descriptive statistics. Statistical analyses were performed
using GraphPad Prism version 6.0 for Mac (GraphPad Software, San
Diego, CA, USA) and IBM-­Microsoft SPSS version 20.0 for Mac (SPSS
Statistics; IBM Corp., Armonk, NY, USA). P<0.05 was considered
­statistically significant.
3 | RESULTS
A total of 43 patients were included. The median age was 28 (range,
21–41) years. Eight (19%), 27 (63%), and 1 (2%) patients had CIN2,
CIN3, and stage IA1 cervical cancer, respectively. In 7 (16%) cases,
the type of cervical dysplasia was classified as H-­SIL. Twelve (28%)
patients had a history of previous HPV infections. Ten (23%) and 2
(5%) patients had previous HPV infection before and after having
the vaccination. Details about HPV type(s) involved in previous HPV
infection were available for five women and included HPV 16/18
(n=4) and HPV 11 (n=1).
Ten (23%) and 28 (65%) women had had bivalent and quadriva-
lent vaccination. Data about type of vaccine used were not available
in 5 (12%) patients. Table 1 shows the baseline characteristics of the
­participants. Figure 1 shows details of the study design.
According to the inclusion criteria, all patients included had HPV test-
ing at the time of cervical dysplasia diagnostic work-­up. The details of
the HPV detected are reported in Table 2. Ten (23%) patients did not have
a diagnosis of the specific HPV type(s) involved: HR-­HPV was detected
in 7 (16%) women while HPV testing was negative in 3 (7%) women.
Two (5%) patients had lesions related to HPV16. Both these patients
reported no prior history of HPV infections but had the vaccination after
becoming sexually active (at 24 and 29 years, respectively). Regarding
women with specific information about HPV types, HPV types covered
by nonavalent vaccination were diagnosed in 27/33 (82%) patients. HPV
types not covered by nonavalet vaccination were diagnosed in 6 (18%)
patients; among those, multiple HPV types infected 5/6 patients. HPV
types included: HPV 51 (n=2); HPV 53 (n=3); HPV 62 (n=1); HPV 66
T A B L E   1   Baseline characteristics.
Characteristics Individuals (n=43)a
Age (y) 28 (21, 41)
Cervical lesion
H-­SIL 7 (16)
CIN 2 8 (19)
CIN 3 27 (63)
Cervical cancer 1 (2)
History of HPV infection(s)
No 31 (72)
Yes 12 (28)
Type of vaccination
Bivalent 10 (23)
Quadrivalent 28 (65)
Unknown 5 (12)
Abbreviations: CIN, cervical intraepithelial neoplasia; HSIL, high-­grade
squamous intraepithelial lesion; HPV, human papillomavirus.
a
Values are given as median (range) or number (percentage).
Bogani ET AL. |
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43 patients with
cervical dysplasia

Previous vaccination
against HPV

Quadrivalent
Bivalent vaccination Unknown vaccination
vaccination
n=10 n=5
n=28

F I G U R E   1   Study design. Abbreviation: HPV, human papilloma virus.

(n=3); HPV 81 (n=1); and HPV 89 (n=2). Data about co-­infections are
4 | DISCUSSION
listed in Table 3. There was no difference in terms of prevalence of HPV
types not covered by nonavalent vaccination compared to patients who
The present study investigated the prevalence of HPV types
had had bivalent or quadrivalent vaccination (P=0.99). Similarly, the type
involved in the genesis of cervical dysplasia in women who had a
of vaccine did not have an impact on the risk of developing further co-­
previous vaccination against HPV, suggesting a number of note-
infections (P=0.682). Interestingly, co-­infections are most commonly
worthy findings. First, although rare, cervical dysplasia may even
detected in women with HPV types other than those included in the
nonavalent vaccinations (P=0.024, Fisher exact test). T A B L E   3   Details about HPV types involved and co-­infections.

Characteristics Individuals (n=43)a

T A B L E   2   Type(s) of HPV detected.
HPV type(s) involved
Characteristics Individuals (n=43)a HPV 16 2 (5)
HPV DNA testing 43 (100) HPV 31 7 (16)
Positive 40 (93) HPV 33 3 (7)
Negative 3 (7) HPV 45 2 (5)
HPV type(s) involved HPV 51 2 (5)
HPV 16 2 (5) HPV 52 8 (19)
HPV 18 0 HPV 53 3 (7)
High-­risk HPV (not specified) 7 (16) HPV 58 5 (12)
Other HPV type(s) covered by nonavalent 27 (16) HPV 62 1 (2)
vaccinesb HPV 66 3 (7)
Other HPV type(s) not covered by 6 (7) HPV 81 1 (2)
nonavalent vaccinesb
HPV 89 2 (5)
Abbreviation: HPV, human papillomavirus.
a None 3 (7)
Values are given as number (percentage).
b
Other HPV type(s) covered by nonavalent vaccine included HPV 31, 33, Abbreviation: HPV, human papillomavirus.
a
45, 52, and 58. Values are given as number (percentage).
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236       Bogani ET AL.
occur in women who have had the vaccination against HPV, thus
underlining the need to have an adequate screening program for
women having the vaccination. Second, theoretically, the adoption
of the nonavalent vaccine, instead of the quadrivalent and bivalent
vaccines, would reduce the risk of developing cervical dysplasia by
more than 80%. Third, it was observed that the HPV types not cov-
ered by the nonavalent vaccination included HPV 52, HPV 53, HPV
66, and HPV 89, highlighting the need to include these HPV types
in future vaccines.
Randomized controlled trials testing the safety and the efficacy
of vaccines against HPV reported that the risk of developing cervi-
cal dysplasia in women is low.11–13 However, secondary prevention
(through the adoption of effective screening programs) represents the
most effective method to minimize morbidity and mortality related to
cervical cancer. Although primary prevention (i.e. vaccination) is effec-
tive in reducing the rate of HPV-­related disease, secondary prevention
should not be omitted, even in women who have been vaccinated. In
fact, WHO underlined that the implementation of the HPV vaccina-
tion should not divert funds from screening programs, thus underlin-
ing the importance of secondary prevention.2
Canfell et al.12 reported interesting data regarding the value of var-
ious screening methods in women receiving a vaccination against HPV.
Beyond the data regarding the effectiveness of liquid-­based cytology,
they reported a rate of low-­grade and high-­grade cervical dysplasia
of approximately less than 1% and 6%, respectively, in an extensively
HPV-­vaccinated population.12
The medical literature is devoid of information regarding type-­
specific HPV involved in the risk of developing cervical dysplasia
in women who had received vaccines against HPV. This “real-­world
experience” suggested that potentially more than 8 out of 10 cases
of cervical dysplasia could be avoided with the adoption of a nona-
valent vaccine. Our study group7 investigated trends in prevalence
of HPV types involved in the genesis of HPV-­related lesion in a
cohort of more than 13 000 women undergoing HPV testing during
an 18-­year study period. It was observed that the proportion of
HPV 16 and 18 infections decreased dramatically over the study
period (P<0.001 for trend). The proportion of patients with genital
dysplasia who had infections with HPV types not covered by the
bivalent and quadrivalent vaccines increased over time (P<0.001
for trend). If considering the HPV types not covered by the nona-
valent vaccine, the most common HPV infection among the entire
cohort was HPV 53, followed by HPV 51 and HPV 66. Other HPV
types had a limited prevalence (<2.5%).7 Similarly, in this multi-­
institutional study, HPV 53 and HPV 66 are two of the main HPV
types involved in the genesis of cervical dysplasia that are not
potentially covered by the nonavalent vaccine.7 Interestingly, it was
observed that women with HPV types not covered by the nonava-
lent vaccine are more likely to have co-­infections than women with
more oncogenic HPV types.
The inherit biases related to the small sample size and the retro-
spective study design are the main weaknesses of the present study.
However, although the sample size is relatively small, this condition
is relatively rare, thus making it difficult to collect a larger study
population. Moreover, this is the first study evaluating the role of var-
ious HPV types in a real-­world setting, including data from four differ-
ent centers. In addition, three other points deserve to be discussed:
(1) The treatment of p16-­negative CIN2 lesions. According to the
LAST group (Lower Anogenital Squamous Terminology) p16 staining
is useful in discriminating between low-­grade or high-­grade lesions.
p16-­negative CIN2 could be downgraded to low-­grade lesions.14,15 (2)
Data regarding the type of HPV vaccine performed are missing in 12%
of patients; this point limits the value of the present study. (3) Further
studies to evaluate the costs/benefits of developing new plurivalent
vaccines versus less widely potent vaccines are needed.
In conclusion, our data support the use of nonavalent vaccina-
tions against HPV in women having primary prevention. The occur-
rence of cervical dysplasia after the vaccination is a rare event. It was
observed that most HPVs involved in the genesis of cervical dyspla-
sia would be covered by the nonavalent vaccination. Theoretically,
compared with bivalent and quadrivalent vaccinations, the adoption
of a nonavalent vaccination would reduce the prevalence of cervi-
cal dysplasia by approximately 80%. Further prospective studies are
needed to estimate the trends in HPV types not covered by cur-
rently available vaccinations, in order to increase protection against
cervical cancer.
AU T HO R CO NT R I B U T I O NS
GB and FR were responsible for conception of the study data analysis
and manuscript writing. MS, ULRM, AD, BG, and AS were responsible
for data collection and revising the manuscript. SF was responsible for
data collection and manuscript writing. FR contributed to the inter-
pretation of data and revising of the manuscript.
CO NFL I C TS O F I NT ER ES T
The authors have no conflicts of interest.
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