Biomarkers in the Detection and Classification of Cervical and Anal Intraepithelial Neoplasia

This dissertation describes the use of new molecular markers for the detection and classification of cervical and anal intraepithelial neoplasia. We used HPV genotyping, methylation markers of human tumor suppressor genes and HPV E4 immunohistochemistry in the search for an optimal approach for screening and triage. The results contribute to a future with: - A screening for cervical cancer where all tests

Reliable identification of women with CIN3+ using hrHPV genotyping and methylation markers in a cytology-screened referral population.

Cervical screening aims to identify women with high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia 2-3 (HSIL/CIN2-3) or invasive cervical cancer (ICC). Identification of women with severe premalignant lesions or ICC (CIN3+) could ensure their rapid treatment and prevent overtreatment. We investigated high-risk human papillomavirus (hrHPV) detection with genotyping and methylation of FAM19A4/miR124-2 for detection of CIN3+ in 538 women attending colposcopy for abnormal cytology. All women had an additional cytology with hrHPV testing (GP5+/6+-PCR-EIA+), genotyping (HPV16/18, HPV16/18/31/45), and methylation analysis (FAM19A4/miR124-2) and at least one biopsy. CIN3+ detection was studied overall and in women <30 (n = 171) and ≥30 years (n = 367). Positivity for both rather than just one methylation markers increased in CIN3, and all ICC was positive for both. Overall sensitivity and specificity for CIN3+ were, respectively, 90.3% (95%CI 81.3-95.2) and 31.8% (95%CI 27.7-36.1) for hrHPV, 77.8% (95%CI 66.9-85.8) and 69.3% (95%CI 65.0-73.3) for methylation biomarkers and 93.1% (95%CI 84.8-97.0) and 49.4% (95%CI 44.8-53.9) for combined HPV16/18 and/or methylation positivity. For CIN3, hrHPV was found in 90.9% (95%CI 81.6-95.8), methylation positivity in 75.8% (95%CI 64.2-84.5) and HPV16/18 and/or methylation positivity in 92.4% (95%CI 83.5-96.7). In women aged ≥30, the sensitivity of combined HPV16/18 and methylation was increased (98.2%, 95%CI 90.6-99.7) with a specificity of 46.3% (95%CI 40.8-51.9). Combination of HPV16/18 and methylation analysis was very sensitive and offered improved specificity for CIN3+, opening the possibility of rapid treatment for these women and follow-up for women with potentially regressive, less advanced, HSIL/CIN2 lesions

Expression of p16 and HPV E4 on biopsy samples and methylation of FAM19A4 and miR124-2 on cervical cytology samples in the classification of cervical squamous intraepithelial lesions

The decision to treat a cervical squamous intraepithelial lesion (SIL) by loop electrosurgical excision procedure (LEEP) relies heavily on a colposcopy-directed biopsy showing high-grade (H)SIL. Diagnosis is often supported by p16, an immunohistochemical (IHC) biomarker of high-risk (hr)HPV E7 gene activity. Additional potential markers include methylation of tumor suppressor genes FAM19A4/miR124-2 in cervical cytology for advanced transforming HSIL and the IHC marker HPV E4 for productive, potentially regressing lesions. In 318 women referred for colposcopy, we investigated the relationship between staining patterns of p16 and E4 IHC in the worst biopsy, and the relation of these to FAM19A4/miR124-2 methylation status in cytology. E4-positive staining decreased with increasing SIL/CIN grade from 41% in LSIL to 3% in HSIL/CIN3. E4 positivity increased with grade of p16 when p16 expression was limited to the lower two third of the epithelium (r = 0.378), but fell with expression over. Loss of E4 expression in the worst lesion was associated with the methylation of FAM19A4/miR124-2. We also examined whether these biomarkers can predict the histological outcome of the LE

Reliable identification of women with CIN3+ using hrHPV genotyping and methylation markers in a cytology-screened referral population

Cervical screening aims to identify women with high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia 2-3 (HSIL/CIN2-3) or invasive cervical cancer (ICC). Identification of women with severe premalignant lesions or ICC (CIN3+) could ensure their rapid treatment and prevent overtreatment. We investigated high-risk human papillomavirus (hrHPV) detection with genotyping and methylation of FAM19A4/miR124-2 for detection of CIN3+ in 538 women attending colposcopy for abnormal cytology. All women had an additional cytology with hrHPV testing (GP5+/6+-PCR-EIA+), genotyping (HPV16/18, HPV16/18/31/45), and methylation analysis (FAM19A4/miR124-2) and at least one biopsy. CIN3+ detection was studied overall and in women <30 (n = 171) and ≥30 years (n = 367). Positivity for both rather than just one methylation markers increased in CIN3, and all ICC was positive for both. Overall sensitivity and specificity for CIN3+ were, respectively, 90.3% (95%CI 81.3–95.2) and 31.8% (95%CI 27.7–36.1) for hrHPV, 77.8% (95%CI 66.9–85.8) and 69.3% (95%CI 65.0–73.3) for methylation biomarkers and 93.1% (95%CI 84.8–97.0) and 49.4% (95%CI 44.8–53.9) for combined HPV16/18 and/or methylation positivity. For CIN3, hrHPV was found in 90.9% (95%CI 81.6–95.8), methylation positivity in 75.8% (95%CI 64.2–84.5) and HPV16/18 and/or methylation positivity in 92.4% (95%CI 83.5–96.7). In women aged ≥30, the sensitivity of combined HPV16/18 and methylation was increased (98.2%, 95%CI 90.6–99.7) with a specificity of 46.3% (95%CI 40.8–51.9). Combination of HPV16/18 and methylation analysis was very sensitive and offered improved specificity for CIN3+, opening the possibility of rapid treatment for these women and follow-up for women with potentially regressive, less advanced, HSIL/CIN2 lesions

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Assessment and care for non-medical risk factors in current antenatal health care

Objective: this study aims to identify current practice in risk assessment, current antenatal policy and referral possibilities for non-medical risk factors (lifestyle and social risk factors), and to explore the satisfaction among obstetric caregivers in their collaboration with non-obstetrical caregivers. Design: cross-sectional study Setting: Dutch antenatal care system Participants: community midwives from 139 midwifery practices and gynaecologists, hospital-based midwives, and trainees in obstetrics from 38 hospitals. Measurements and findings: results were analysed with chi(2) tests and unpaired t-tests. Caregivers universally screened upon lifestyle risk factors (e.g. smoking or drug use), whereas the screening for social risk factors (e.g. social support) was highly variable. As national guidelines are absent, local protocols were reported to be used for screening on non medical risk factors in more than 40%. Caregivers stated multidisciplinary protocols to be a prerequisite for assessment of non medical risk factors. Only 22% of the caregivers used predefined criteria to define when patients should be discussed multidisciplinary. Conclusion: despite their relevance, non medical risk factors remain an underexposed topic in antenatal risk factor screening in both the community and hospital based care setting. Implications for practice Structural antenatal risk assessment for non medical risk factors with subsequent consultation opportunities is advocated, preferably based on a multidisciplinary guideline. (C) 2015 Elsevier Ltd. All rights reserved

Assessment and care for non-medical risk factors in current antenatal health care

Objective: this study aims to identify current practice in risk assessment, current antenatal policy and referral possibilities for non-medical risk factors (lifestyle and social risk factors), and to explore the satisfaction among obstetric caregivers in their collaboration with non-obstetrical caregivers. Design: cross-sectional study. Setting: Dutch antenatal care system. Participants: community midwives from 139 midwifery practices and gynaecologists, hospital-based midwives, and trainees in obstetrics from 38 hospitals. Measurements and findings: results were analysed with χ2 tests and unpaired t-tests. Caregivers universally screened upon lifestyle risk factors (e.g. smoking or drug use), whereas the screening for social risk factors (e.g. social support) was highly variable. As national guidelines are absent, local protocols were reported to be used for screening on non-medical risk factors in more than 40%. Caregivers stated multidisciplinary protocols to be a prerequisite for assessment of non-medical risk factors. Only 22% of the caregivers used predefined criteria to define when patients should be discussed multidisciplinary. Conclusion: despite their relevance, non-medical risk factors remain an underexposed topic in antenatal risk factor screening in both the community and hospital-based care setting. Implications for practice Structural antenatal risk assessment for non-medical risk factors with subsequent consultation opportunities is advocated, preferably based on a multidisciplinary guideline