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The new techniques in cervix cancer screening are reviewed. Literature relevant to the performance and cost effectiveness of these technologies is reviewed. Literature relevant to cost effectiveness of other techniques used for cervix cancer screening is reviewed. Prospective trials of competing technology are proposed to resolve the question utilizing contemporaneous methods of assessing cost effectiveness.

The AHCPR released its evidence-based report, “Evaluation of Cervical Cytology” in early 1999. This report represents the most comprehensive analysis available to date of Pap smears and new technologies designed to improve cervical cancer screening. Both the ACOG and the AHCPR have released simplified summaries of the results of the evidence report that may lead to misunderstandings of the potential clinical impact of these new technologies. This report reviews the 4 major statements in these summaries and discusses how they are either incorrect based on the full AHCPR report or may be misinterpreted because their ramifications are not fully discussed. New screening technology has the potential to finally bring the sensitivity of a new Pap test to an acceptable level. The increased sensitivity afforded by these new technologies can reduce negative outcomes at reasonable cost-effectiveness ratios and at an equivalent or superior specificity compared to the conventional Pap smear.

Objective: Cervicography was evaluated as a primary screening method for cervical cancer. Study Design: Cervigrams of 8460 women were taken on enrollment into a population-based study of cervical neoplasia. Cervicography results were compared with a referent diagnosis determined by histologic analysis and 3 cytologic tests, and with the performance of conventional cytologic evaluation. Results: Cervicography identified all 11 cancers, whereas cytologic testing missed 1. Cervicography yielded sensitivities for detecting high-grade squamous intraepithelial lesions or cancer of 49.3% overall (specificity, 95.0%), 54.6% in women younger than 50 years of age, and 26.9% in women 50 years of age and older. Cytologic testing yielded sensitivities for detecting high-grade squamous intraepithelial lesions or cancer of 77.2% overall (specificity, 94.2%), 75.5% in women younger than 50 years of age, and 84.6% in women 50 years of age and older. Conclusions: Cytologic testing performed better than cervicography for the detection of high-grade squamous intraepithelial lesions. Cervicography performed marginally better than cytologic testing for the detection of invasive cervical cancer. Cervicography is not recommended for postmenopausal women. (Am J Obstet Gynecol 1999;180:290-8.)

The management of the abnormal smear in pregnancy remains a challenge to the modern colposcopist. Colposcopy in pregnancy is difficult. Anatomic variants can mimic disease. Significant cytologic overall detection of low-grade squamous intraepithelial lesions demands an increased understanding of physiologic variants in pregnancy. Possible recent increases in cervical cancer incidence in younger women requires comprehensive knowledge of warning signs of early invasion. Modern management approaches must temper the need for accurate exclusion of cancer with the risk of overly aggressive interference in patients without disease or with very minor atypia.

Congenital arteriovenous malformations confined to the soft tissues of the pelvis are rare and challenging lesions. Multitudinous embryonic macrocommunication and microcommunication between the arterial and venous systems, with resultant shunting of blood to the low-resistance veins, produce massive venous and tissue engorgement. No well-established guidelines exist concerning their management. Percutaneous arterial embolization and surgery are associated with high recurrence rates. Surgical excision is frequently not possible and can result in massive hemorrhage. Only 52 cases have been reported in the English-language literature, and only two patients were followed for longer than 6 years. This report presents two additional patients with massive pelvic arteriovenous malformations monitored for 9 and 17 years. One patient was initially treated with arterial percutaneous embolization and the other with attempted operative ablation. A review of the literature has allowed us to develop the following management guidelines: Asymptomatic, nonenlarging lesions require no intervention and can be safely followed by clinical and radiologic (ultrasonography, CT scanning) examinations every 6 months. Symptomatic or rapidly enlarging lesions should be treated with preoperative arterial embolization and surgical excision attempted only if the arteriovenous malformation is localized and does not involve adjacent organs. Arterial embolizations may be repeated to provide symptomatic relief of diffuse, large lesions that involve the bladder or bowel. This protocol will avoid unnecessary and frequently life-threatening surgery in the management of pelvic arteriovenous malformations.

Patients with abnormal Pap smears underwent repeat Pap smear, colposcopy, biopsy, and human papilloma virus (HPV) typing to identify the presence of CIN and to assess the correlation of HPV type to grade of CIN and behavior of CIN. A total of 334 patients underwent evaluation and typing with Southern blot methodology. Fifty-five percent (185) of the patients demonstrated HPV viral sequences; 98 of the 185 positive patients demonstrated HPV types 16, 18. The presence of HPV sequences was not associated with a higher frequency of positive cytology of CIN II or III. High-grade CIN (II or III) was seen in 17.3, 13.5, 13.8, and 10.7% of patients with HPV 16, 18; 6, 11; 31, 33, 35; or no HPV sequences. Of 52 patients with normal cytology and biopsy revealing less than or equal to CIN I, no patients with types 6, 11, 3/5 patients with 31, 33, 35, 3/15 patients with 16, 18, and 2/23 patients with no HPV sequences progressed to greater than or equal to CIN II. These data do not support a role for HPV typing in predicting the initial histology. Typing may be of some value in monitoring patients with low-grade lesions.

We explored the interaction effects of individual attentional style (high versus low monitoring) and the framing of informational messages on the responses of women undergoing diagnostic follow-up (colposcopy) for precancerous cervical lesions. Prior to the colposcopic procedure, patients (N=76) were randomly assigned to one of three preparatory conditions: (a) Loss-framed message, which emphasized the cost of nonadherence to screening recommendations; (b) Gain-framed message, which emphasized the benefit of adherence; and (c) Neutrally-framed message. It was hypothesized that low monitors (who are more positively biased about their health) would show a more adaptive pattern of response to loss-framed information than high monitors (who are more negatively biased about their health). The results of a series of hierarchical multiple regression analyses were consistent with this prediction. Low monitoring was associated with greater knowledge retention (beta=.61, p.05) and less canceling/rescheduling of follow-up appointments in the loss condition than in the neutral condition (beta=.82, p.002). High monitoring, however, was associated with greater intrusive ideation when information was presented in the loss-oriented frame as compared to the neutral frame (beta=.99, p.01). Knowledge retention and screening adherence were not affected by the framing manipulation. The differences between high versus low monitors as a function of loss or neutral frame suggest an interaction effect, wherein both the type of framing message and the individual's attentional style lead to distinctive cognitive-affective and behavioral patterns. The findings may have clinical implications for the tailoring of health messages to the individual's signature style.

This study reviews 148 patients colposcoped in 1986 in the practice of the principal investigator. An attempt was made to biopsy the cervix, vagina, and vulva of all patients. Of the total of 148 patients, 11 had prior hysterectomies and 6 others had no biopsies. Of the remaining 131 patients, 82 patients (62.6%) had biopsies of all three areas, 35 (26.7%) had two areas biopsied, and 14 (10.7%) had only one area biopsied. Of the group that had three biopsies, 48.8% demonstrated HPV infection involving the cervix, vagina, and vulva synchronously, 24.4% had HPV infection in two of three areas, and 20.7% had HPV documented in only one area. Of the 35 patients who had only two biopsies performed, results were similar—62.9% had both areas involved, and 25.7% had only one of two area involvement. The total number of patients with HPV infections involving two or more sites was 82, 62.6% of the total of 131 patients evaluated and 70.1% of the patients with two or more biopsies performed. This study confi...

During the past decade, much has been learned about the natural history of HPV. Most infections occur early in one's sexual life. The overwhelming majority of infections are cleared by the host immune system and never present as warts or neoplasia. Certain patient behavior such as smoking, frequent sex with many different partners, other STD infections, especially HIV, and immune-suppressive drugs promote HPV expression and cause persistent infection. Persistent HPV infection is very strongly related to neoplasia. In addition to high-risk HPV types, variant subtypes have been identified that interact with the host immune system to subvert host immunity and encourage viral persistence. New treatment programs rely on drugs that modulate the immune system and disrupt viral persistence. There is a real possibility of HPV vaccines in the future, which may protect the unexposed patient.

A case of mullerian adenosarcoma of the uterus with sarcomatous overgrowth is described. The patient was also found to have bilateral polycystic ovaries. This 25 year-old white female presented with irregular vaginal bleeding and was diagnosed as having mullerian adenosarcoma with sarcomatous overgrowth by dilatation, curettage, and biopsy. Total abdominal hysterectomy, bilateral salpingo-oophorectomy with lymph node sampling were performed.

Only 2 of 125 patients with FIGO stage IB invasive squamous or adenocarcinoma of the cervix 3 cm or less in diameter who underwent exploration for radical hysterectomy, bilateral pelvic lymphadenectomy, and para-aortic node sampling had metastases to the para-aortic nodes. No patient had gross para-aortic nodal involvement, and both patients with microscopic para-aortic nodal metastases had grossly positive pelvic nodal involvement. Para-aortic node sampling in patients with small stage IB cervical cancers undergoing radical hysterectomy may be restricted to patients with suspicious pelvic or para-aortic nodes.

Objective: To compare ThinPrep cytology to conventional cytology in a gynecologic oncology practice in a university hospital laboratory setting.Methods: From March to September 1997, all Papanicolaou smears in the Division of Gynecologic Oncology were collected with a cervical broom device. A conventional cytology slide was prepared. The broom was then immersed in a Preserv-Cyt and processed. As required for ThinPrep cytology. Managed care patients are not included in this analysis. All cytology specimens were evaluated by the same physician (PE). Increased detection of abnormalities was calculated by the formula increased detection=ThinPrep+-conventional+x100%conventional+Results: A total of 172 split samples were available for analysis. Twenty-two patients (12.7%) had LGSIL or worse. Forty-three patients (25%) had ASCUS or worse cytology.Conclusion: ThinPrep cytology demonstrated marginally improved detection of LGSIL or worse. The extremely high rate of cytologic abnormality and high quality cytologic service in our institution may explain the minimal improvement seen.

The use of radioactive colloidal phosphorus 32 (3ZP) in the treatment of epithelial ovarian cancer continues to be controversial. One institution's experience with the use of 32P in 30 patients with epithelial ovarian cancer was reviewed retrospectively. One hundred percent of attempts at placement of 3ZP intra-abdominally were ultimately successful. The complication rate was 11%. Mean clinical (asymptomatic) disease-free survival in patients with stage ill ovarian cancer was as follows: 26 months based on absence of disease at reassessment surgery; 26 months based on microscopic residuum; and 30 months based on minimal «5 mm) residuum. Mean disease-free survival in patients with early-stage (stages IC through IIC) ovarian cancer was 66 months.

THE INCIDENCE of and mortality from cervical cancer in the United States have decreased dramatically over the past 40 years, in part because of early diagnosis and treatment of cervical cancer precursor lesions. The success of cervical cytological screening has served as a model for early diagnosis of other types of cancer. Although numerous studies have shown that lack of cytological screening is a major risk factor for the development of invasive cervical cancer, 1-3 it is important to emphasize that none of the screening, diagnostic, or therapeutic techniques used in medicine are perfect. Accordingly, a few women will develop cervical cancer despite adherence to accepted screening protocols . In addition, problems inherent with sampling, interpretation, and effective clinical follow-up preclude total prevention of cervical cancer. In recent years it has become evident that the cost and morbidity associated with the detection and treatment of low-grade cervical lesions have escalated, probably

The use of DNA probes to examine the type of human papillomavirus (HPV) genome found in penile lesions is described both at a technical level and in a clinical application. At least 40 different types of HPV have been identified, and these types vary not only in their DNA base sequences but also in their clinical manifestations. Although DNA probes currently have a role only in a research setting, this article delineates the possible role of this technology in a clinical setting to detect subclinical intraurethral HPV. (J GYNECOL SURG 5:193, 1989)

The cytologic smears from 100 patients with a diagnosis of cervical condyloma made on colposcopically directed biopsy were reviewed. Smears were obtained at the time of colposcopic examination, before biopsy. In 48 patients, a diagnosis of condyloma could not be made cytologically; 18 patients had negative smears, and in 30, there was evidence of squamous atypia. In the remaining patients, cytologic changes diagnostic of condyloma were present; however, coexisting cervical intraepithelial neoplasia (CIN) was frequently underestimated. It is concluded that cervical cytology is often negative in patients with condyloma. Data regarding the prevalence of human papillomavirus (HPV) infection based on cervical cytology should be accepted with caution.

Since the route of administration of BCG may have an important function in immunotherapy, we investigated intralymphatic administration to direct BCG to the lymph nodes. Multiple injections of high doses of BCG were administered to 6 rhesus monkeys via the dorsal lymphatics of the lower limb. A suppurative lymphadenitis was observed along the lower limb and in the inguinal area in 5 of the 6 monkeys. However, many of the complications reported with other routes of administration were not observed. Granulomatous reactions and histiocytic responses developed in lymph nodes on the injected sides of the pelvis and distant nodes as well as in the liver. The intralymphatic route is the method by which high doses of nonspecific immunostimulants were delivered to regional lymph nodes. The efficacy of this approach remains to be established in tumor-bearing animals and humans.

The physician population delivering obstetric care in Philadelphia between 1950 and 1970 was contacted to ascertain their use of diethylstilbesterol (DES) during pregnancy. Of the 31.8% of the physicians who responded to the questionnaire, 71.8% used DES during pregnancy and 12.7% desired assistance in review of their records. During the 6 years from the initial survey, 830 young women exposed to DES in utero were periodically screened for cervicovaginal abnormalities and clear cell adenocarcinoma. Of these 830 patients 61.7% were found to have cervicovaginal abnormalities, and 65.9% of the patients showed either adenosis or evidence of the prior existence of vaginal adenosis. Eight patients were treated for clear cell adenocarcinoma. Two cases were detected while asymptomatic. Seven of the patients are living with no evidence of cancer, and two of these have survived over 5 years.A project, designed to locate the population at risk to diethylstilbestrol (DES) exposure in utero in the greater Philadelphia area from 1950-1970, was implemented by contacting area physicians who might have used the drug in their practices on pregnant women. 216 (31.8%) physicians responded to the questionaire; 155 (71.8%) responded that they had used DES. During the 6 years from initial survey, 830 young women exposed to DES in utero were periodically screened for cervicovaginal abnormalities and clear cell adenocarcinoma. Gross structural cervicovaginal abnormalities were found in 512 (61.7%) of the individuals evaluated. In 38 patients, vaginal adenosis existing alone was documented. In another 279 patients, metaplasia alone was noted in the vagina, and in another 230 patients, both metaplasia and adenosis coexisting in varying degrees were found. Thus, 547 (65.9%) showed either adenosis or evidence of the prior existence of vaginal adenosis. 8 patients with clear cell adenocarcinoma of the vagina or cervix were seen; each individual was born during the decade of the 1950s. 2 cases were detected while asymptomatic; 7 of the patients are living with no evidence of cancer, and 2 of these have survived over 5 years. These results showed a much lower incidence of significant dysplastic squamous changes (1.1%) than that of earlier reports, emphasizing the subjective element of earlier, more alarming reports.

Human papillomaviruses (HPVs) have been implicated in the development of a number of human malignancies, but direct tests of their involvement have not been possible. We describe a system in which human skin from various sites was infected with HPV type 11 (HPV-11) extracted from vulvar condylomata and was grafted beneath the renal capsule of athymic mice. Most of the skin grafts so treated underwent morphological transformation, resulting in the development of condylomata identical to those which occur spontaneously in patients. Foreskins responded with the most vigorous proliferative response to HPV-11. The lesions produced the characteristic intranuclear group-specific antigen of papillomaviruses. Both dot blot and Southern blot analysis of DNA from the lesions revealed the presence of HPV-11 DNA in the transformed grafts. These results demonstrate the first laboratory system for the study of the interaction of human skin with an HPV. The method may be useful in understanding the mechanisms of HPV transformation and replication and is free of the ethical restraints which have impeded study. This system will allow the direct study of factors which permit neoplastic progression of HPV-induced cutaneous lesions in human tissues.

To determine the incidence of penile condyloma in a group of high-risk men, we carried out colposcopy and biopsy of suspicious lesions in 51 men. All men were partners of women with condyloma. Of these men, 45 were found to have histologic evidence of condyloma, and only eight of these had grossly visible disease.The frequency of penile condyloma in the male partners of women referred for evaluation of abnormal Papanicolaou smears from April-October 1984 at Pennsylvania Hospital was prospectively evaluated. All 51 men examined had elevated white penile lesions colposcopically consistent with a diagnosis of condyloma. Histologic evidence of condyloma was found in 45 of these men. The findings in men with suspicious lesions that were not condyloma included chronic inflammation, dilated sweat duct, lichen nitidus, verruca vulgaris, and penile skin tag. Only 8 of the 45 confirmed lesions were identifiable with the naked eye; the remainder required magnification and acetic acid for visualization. Cytologic evidence of abnormal epithelium was detected in 13 men. The mean age at 1st coitus among those men with penile condyloma was 17.5 years; the mean number of sexual partners was 14.7. In men, treatment of condyloma encompasses YAG laser, 5-fluorouracil cream, carbon dioxide laser, and podophyllin. In women, management is dependent on whether atypical mitotic figures are present or absent; in the former cases, carbon dioxide laser is appropriate, while in the latter cases, cryotherapy or topical 5-fluorouracil cream is recommended.

To determine the incidence of penile condyloma in a group of high risk males, we have performed magnified penile surface scanning and biopsy of suspicious lesions in 51 men. All men were partners of women with proven condyloma. Of these men, 45 were found to have histologic evidence of condyloma, only 8 of which were grossly visible.

The etiology and treatment of condyloma caused by the human papilloma virus (HPV) and the association of HPV with cervical dysplasia and/or carcinoma is a major issue in current gynecologic literature. This study examined results of carbon dioxide (CO 2 ) laser treatment of 127 high-risk males with biopsy-proved subclinical HPV infections found by magnified penile surface scanning (MPSS At a mean follow-up of four months a 66 per cent recurrence rate of microscopic condyloma was encountered. A discussion of the causes of such a high recurrence rate is given, with conclusions on this and prior condyloma treatment series.

Eighty-five patients underwent a surgical staging procedure during a 2-year period. Fifty-eight of these patients were evaluated in relation to the histologic grade of their squamous carcinoma of the cervix. An increased incidence of extrapelvic lymph node metastasis is associated with poorly differentiated tumors and with parametrial extension of the primary tumor regardless of histologic grade. Surgical staging is suggested for patients with parametrial extension of their tumor or for patients with poorly differentiated tumors.

Exfoliated cells of the uterine cervix obtained from women during pregnancy and at the time of their first postpartum examination were used to monitor the prevalence of human papillomavirus infections in this population and to study the natural fluctuations in viral expression. When deoxyribonucleic acid hybridization analysis alone was used to monitor the presence of human papillomavirus infection, 20.9% of our study population had results that were positive for human papillomavirus deoxyribonucleic acid during their first-trimester examinations. A dramatic increase in the percentage of women with positive results for human papillomavirus deoxyribonucleic acid was observed at the time of the patients' third-trimester examinations (46%). The overall increase in human papillomavirus-positive patients was a combination of a small number of patients who had positive results on their first examination and negative results on their second examination, and a larger number of patients who had negative results on their first-trimester examination and positive results for human papillomavirus deoxyribonucleic acid in the exfoliated cervical cells at the time of their third-trimester examination. The total percentage of patients with positive results for human papillomavirus deoxyribonucleic acid in their cervical cells at one or both assay points during pregnancy was 52.5%. Samples obtained at the postpartum examination demonstrated a dramatic decrease in the number of samples positive for human papillomavirus deoxyribonucleic acid (17.5%). This result was a combination of a large decrease in human papillomavirus-positive patients coupled with a small increase in detectable levels of human papillomavirus deoxyribonucleic acid in cervical samples from patients who had negative results on their previous examination. This study demonstrates a very high level of detectable human papillomavirus deoxyribonucleic acid in exfoliated cervical cells obtained during pregnancy and shows that the detectable levels of human papillomavirus deoxyribonucleic acid fluctuate during pregnancy.

Thirty-six patients with primary ovarian carcinoma who had 42 second-look procedures performed are reported. Twenty-three patients had no tumor found at the second-look celiotomy and were given no further treatment. Thirteen patients had tumor at the second-look procedure and were continued on therapy. Six patients have died with disease and all had a positive second-look celiotomy. Two patients have died with leukemia but with no evidence of ovarian cancer, one after a negative second-look and the other a negative third-look. No patient with a negative second-look celiotomy has died with disease. A correlation with respect to the findings at the second-look was found with respect to the stage of disease and the amount of residual tumor at the initial surgery. The use of the second-look celiotomy in patients with disease in the early stages and in patients treated with irradiation is discussed, along with the utilization of the laparoscopy.

Of 120 patients with FIGO stage IIA-IVB squamous cell carcinoma of the cervix treated with standard radiotherapeutic techniques, 41 (34.2%) relapsed with hematogenous or serosal metastases. Development of such metastases was individually associated with patient age less than or equal to 55, bilateral bulky parametrial extension, and histologically positive paraaortic nodes. Poor histologic differentiation exerted significant negative influence only in patients age less than or equal to 55. Neither surgical staging nor vascular injury predisposed to hematogenous dissemination. Radiotherapy techniques differed only in increased time to completion, from 84 to 100 days in clinical IIB and IIIB patients developing metastases. Local or regional pelvic recurrences, although associated with an increase in hematogenous or serosal metastases, were not accompanied by concomitant relapse in extrapelvic nodes. Twenty-six of 41 metastases were limited to single organ systems, with pulmonary sites most common (43.9%). A direct (non-nodal) route of hematogenous dissemination of 31% was documented within clinical stages IIA and IIB. One hundred percent concordance between bilateral bulky parametrial involvement and positive pretreatment paraaortic nodes occurred in clinical stage IIIB and IVA patients with metastatic relapse. Our data from the period 1976-1985 do not substantially differ from earlier reports on the incidence or distribution of hematogenous or serosal metastases, despite our implementation of contemporary local/regional radiotherapy prescriptions. The potential for hematogenous and serosal metastases in high-risk patients with advanced squamous cervical carcinoma merits consideration of alternative treatment protocols and precise definition of the role of pretreatment surgical staging procedures.

Retroconversion of immature to mature tissues in metastases from an immature ovarian teratoma following chemotherapy is an uncommon phenomenon. We report a case of this entity to highlight the changes in the internal architecture of hepatic metastases as seen on CT.

Carcinoma of the human uterine cervix has been associated with several infectious agents including papillomavirus. Papillomavirus group-specific antigen (GSA) and viral particles have been demonstrated in human condylomata acuminata (CA) and flat warts of the uterine cervix. Cell alterations consisting of nuclear enlargement, hyperchromasia, irregularity, binucleation and cytoplasmic clearing (koilocytosis) are often interpreted as mild to moderate dysplasia. Present evidence that human papillomavirus (HPV) is responsible for the development of these lesions relies on the association of GSA and virus particles in the affected tissue, fulfilling the first two of Koch's postulates. Direct proof of an aetiological relationship, however, requires induction of the CA change in normal, human uterine cervix after exposure to papillomavirus. Infecting human subjects with HPV is ethically unacceptable and no satisfactory alternative systems have been defined. Also, human cell cultures do not support growth or transformation by HPV. Here we report the first demonstration of the morphological transformation of human tissues with a human papillomavirus under controlled, experimental conditions. 'Transformation' is used here in its literal sense to refer to a heritable morphological alteration in the appearance of the cells. The use of this term does not indicate that the changes described are neoplastic, but they are identical to the dysplastic changes found in biopsies of uterine cervical CA. Our results demonstrate the direct involvement of CA virus in dysplastic change of human cervical tissue and indicate that the experimental system described may be useful in elucidating the contribution of human papillomaviruses to the pathogenesis of human cervical cancer.

The average postoperative stay for 45 patients undergoing radical vulvectomy with femoral and inguinal lymphadenectomy was 37 days. Five patients were treated with oral zinc sulfate for at least 7 days prior to surgery. The incidence of wound infection was decreased, and the average postoperative stay was reduced to 18 days.

Previously we demonstrated a 68 per cent recurrence rate for subclinical penile human papillomavirus infections found by magnified penile surface scanning and treated with the carbon dioxide laser. In this report it is shown that the addition of a regimen of adjuvant topical 5-fluorouracil does not lower the recurrence rate. This knowledge combined with the evidence for a subclinical urethral reservoir of human papillomavirus implies that any strictly topical therapy will fail at 4 months of followup and that improved systemic therapy may be needed.

We attempted to investigate mechanisms, in addition to sexual contact, by which human papillomaviruses associated with anogenital tract lesions could be transmitted. Samples of exfoliated cervical cells were obtained from 45 pregnant women and were assayed by Southern blot hybridization analysis for the presence of human papillomavirus nucleic acids. Twenty-five of the 45 women had cells positive for human papillomavirus deoxyribonucleic acid. A neonatal nasopharyngeal aspirate was obtained at term and analyzed for the presence of human papillomavirus deoxyribonucleic acid. We documented the presence of human papillomavirus deoxyribonucleic acid in the oral pharyngeal cavity of the neonates in 15 of 45 nasopharyngeal samples analyzed. Amniotic fluid was obtained from 13 patients when their membranes were artificially ruptured. These samples were assayed for the presence of human papillomavirus deoxyribonucleic acid; two of the 13 amniotic fluid samples contained human papillomavirus deoxyribonucleic acid. The detection of human papillomavirus deoxyribonucleic acid in the oral cavity of neonates is indicative of a perinatal mechanism of viral transmission. The detection of human papillomavirus deoxyribonucleic acid in the amniotic fluid may suggest an in utero mechanism of transmission. However, problems encountered in collecting the amniotic fluid samples preclude us from definitive interpretation of these data.