Invasive cervical cancer following treatment of pre-invasive lesions: A potential theory based on a small case series

Peer reviewe

Expression of HPV-related biomarkers and grade of cervical intraepithelial lesion at treatment

Objectives New human papillomavirus (HPV)-related biomarkers may allow better identification of clinically significant lesions that warrant excision and, conversely, identification of the false positive cases that have been overreported by traditional techniques. The aim of this study was to investigate how the expression of several HPV-related biomarkers correlates to the severity of the lesion at treatment. Design Prospective observational study. Setting University Hospital (2009-2011). Population All women submitted for excisional treatment. Methods A liquid-based cytology sample was obtained before treatment and was tested for HPV typing, mRNA E6 & E7 with NASBA or flow cytometry and p16. All women had histological diagnosis in the form of excisional cone (gold standard). Main outcome measures Correlation of HPV biomarker positivity rates to the grade of the lesion at treatment histology. Results Two hundred women were recruited: 23 were found to have negative histology (11.5%), 79 (39.5%) CIN1, 50 (25.0%) CIN2 and 48 (24.0%) CIN3. All biomarkers (HPV DNA typing, HR HPV, single HPV 16/18, mRNA E6 & E7 expression and p16) revealed an increased linear positivity rate with increasing severity and grade of the lesion (chi-squared test for trend p < 0.05). This was stronger for HPV (all and high-risk) followed by mRNA with NASBA, flow cytometry, HPV 16/18 and ultimately p16 immunostaining. Conclusions The linear correlation between various HPV-related biomarkers and the grade of the lesion suggests that these biomarkers may prove to be useful in the prediction of CIN grade and, as a result, the need for treatment. © 2013 Nordic Federation of Societies of Obstetrics and Gynecology

Classification of cervical cytology for human papilloma virus (HPV) infection using biospectroscopy and variable selection techniques

Cervical cancer is the second most common cancer in women worldwide. We set out to determine whether attenuated total reflection Fourier-transform infrared (ATR-FTIR) spectroscopy combined with principal component analysis-linear discriminant analysis (PCA-LDA) or, variable selection techniques employing successive projection algorithm or genetic algorithm (GA) could classify cervical cytology according to human papilloma virus (HPV) infection [high-risk (hr) vs. low-risk (lr)]. Histopathological categories for squamous intraepithelial lesion (SIL) were segregated into grades (low-grade vs. high-grade) of cervical intraepithelial neoplasia (CIN) expressing different HPV infection (16/18, 31/35 or HPV Others). Risk assessment for HPV infection was investigated using age (≤29 years vs. >30 years) as the distinguishing factor. Liquid-based cytology (LBC) samples (n = 350) were collected and interrogated employing ATR-FTIR spectroscopy. Accuracy test results including sensitivity and specificity were determined. Sensitivity in hrHPV category was high (≈87%) using a GA-LDA model with 28 wavenumbers. Sensitivity and specificity results for >30 years for HPV, using 28 wavenumbers by GA-LDA, were 70% and 67%, respectively. For normal cervical cytology, accuracy results for ≤29 years and >30 years were high (up to 81%) using a GA-LDA model with 27 variables. For the low-grade cervical cytology dataset, 83% specificity for ≤29 years was achieved using a GA-LDA model with 33 wavenumbers. HPV16/18 vs. HPV31/35 vs. HPV Others were segregated with 85% sensitivity employing a GA-LDA model with 33 wavenumbers. We show that ATR-FTIR spectroscopy of cervical cytology combined with variable selection techniques is a powerful tool for HPV classification, which would have important implications for the triaging of patients. © The Royal Society of Chemistry 2014

High-risk human papillomavirus DNA test and p16INK4a in the triage of LSIL: A prospective diagnostic study

Objective. The detection of high-grade cervical intraepithelial neoplasia (CIN) amongst patients with low-grade cytology (LSIL) is challenging. This study evaluated the role of high-risk HPV (HR-HPV) DNA test and p16INK4a immunostaining in identifying women with LSIL cytology at risk of harboring CIN2 or worse (CIN2+) and the role of p16INK4a in the triage of a population of HR-HPV positive LSIL. Methods. We conducted a prospective study including women with LSIL cytology. Detection of HR-HPV was carried out by means of a polymerase chain reaction based assay. p16INK4a immunostaining was performed using the Dako CINtec cytology kit. All patients had colposcopically directed punch biopsies or large loop excision of the transformation zone of the cervix. The endpoint was detection of a biopsy-confirmed CIN2+. Results. A series of 126 women with LSIL cytology were included. HR-HPV test had sensitivity 75% and specificity 64% for an endpoint of CIN2+. p16INK4a had significantly higher specificity of 89% (p = 0.0000) but low sensitivity of 42%. The role of p16INK4a immunostaining in the triage of LSIL positive for HR-HPV was also evaluated. p16INK4a triage had 70% positive predictive value (PPV); however, this was not significantly higher than the PPV (56%) of HR-HPV test alone (p = 0.4). Conclusions. The results indicate that HR-HPV or p16INK4a cannot be used as solitary markers for the assessment of LSIL. The addition of p16INK4a immunostaining led to an increase in HR-HPV specificity; however, the biomarker needs to be assessed further to establish its role as an adjunct test in the triage of LSIL. © 2010 Elsevier Inc

Personalised management of women with cervical abnormalities using a clinical decision support scoring system

Objectives To develop a clinical decision support scoring system (DSSS) based on artificial neural networks (ANN) for personalised management of women with cervical abnormalities. Methods We recruited women with cervical abnormalities and healthy controls that attended for opportunistic screening between 2006 and 2014 in 3 University Hospitals. We prospectively collected detailed patient characteristics, the colposcopic impression and performed a series of biomarkers using a liquid-based cytology sample. These included HPV DNA typing, E6&E7 mRNA by NASBA or flow cytometry and p16INK4a immunostaining. We used ANNs to combine the cytology and biomarker results and develop a clinical DSSS with the aim to improve the diagnostic accuracy of tests and quantify the individual's risk for different histological diagnoses. We used histology as the gold standard. Results We analysed data from 2267 women that had complete or partial dataset of clinical and molecular data during their initial or followup visits (N = 3565). Accuracy parameters (sensitivity, specificity, positive and negative predictive values) were assessed for the cytological result and/or HPV status and for the DSSS. The ANN predicted with higher accuracy the chances of high-grade (CIN2 +), low grade (HPV/CIN1) and normal histology than cytology with or without HPV test. The sensitivity for prediction of CIN2 or worse was 93.0%, specificity 99.2% with high positive (93.3%) and negative (99.2%) predictive values. Conclusions The DSSS based on an ANN of multilayer perceptron (MLP) type, can predict with the highest accuracy the histological diagnosis in women with abnormalities at cytology when compared with the use of tests alone. A user-friendly software based on this technology could be used to guide clinician decision making towards a more personalised care. © 2016 Elsevier Inc

Molecular epidemiology of HPV infection using a clinical array methodology in 2952 women in Greece

The molecular epidemiology of human papillomavirus (HPV) infection in a sample of Greek women (n=2952, mean age 42.2±13.3years) was examined. HPV prevalence was 50.7% (95% confidence interval, 48.8-52.6). The most frequent HPV types were HPV 53, 51 and 66 (10.2%, 9.4% and 9.3%, respectively). HPV positivity was associated with age, age of sexual debut, number of sexual partners and duration of sexual relationship, while marriage or multiparity protected against infection (all p<0.001). Follow-up of this cohort will assist in predicting the effect of vaccination with the new HPV vaccines on future screening with HPV-based tests for cervical cancer. © 2011 European Society of Clinical Microbiology and Infectious Diseases

Multicentric assessment of cervical HPV infection co-factors in a large cohort of Greek women

Purpose of Investigation: Despite the general principle that persistent high risk human papillomavirus (hr-HPV) infection may progressively cause cervical cancer (CxCa), demographic aspects may still identify groups at high risk for HPV infection and consequently for precancerous lesions. The role of demographic parameters on cervical status, the diagnostic accuracy of cytology, HPV genotyping, and their possible combinations, were investigated in this study. Materials and Methods: 11,072 women from diverse locations across Greece participated in the study. Liquid Based Cytologic (LBC) assessment was followed, when necessary, by HPV-genotyping and histologic confirmation. Demographic characteristics were also assessed. Results: Life style parameters such as age, number of sexual partners, condom use, parity and marital status, education level, and combination of smoking/condom use, were significant factors for CIN2+ lesions (p < 0.05). For LSIL+ detection, cytology had maximum sensitivity: 96.90%, HPV-typing: 72.55% and co-testing: 98.97%, for HSIL+ detection: 98.49%, 92.22%, and 99.55% respectively. Conclusions: There are notable relationships between lifestyle, demographic details, and cervical status. Despite the differences in sensitivity and specificity levels, co-testing might offer some marginal improvement in the detection of particular pre-cancerous conditions. ©2020 Mnimatidis et al

Histology verification demonstrates that biospectroscopy analysis of cervical cytology identifies underlying disease more accurately than conventional screening: Removing the confounder of discordance

Background: Subjective visual assessment of cervical cytology is flawed, and this can manifest itself by inter- and intraobserver variability resulting ultimately in the degree of discordance in the grading categorisation of samples in screening vs. representative histology. Biospectroscopy methods have been suggested as sensor-based tools that can deliver objective assessments of cytology. However, studies to date have been apparently flawed by a corresponding lack of diagnostic efficiency when samples have previously been classed using cytology screening. This raises the question as to whether categorisation of cervical cytology based on imperfect conventional screening reduces the diagnostic accuracy of biospectroscopy approaches; are these latter methods more accurate and diagnose underlying disease? The purpose of this study was to compare the objective accuracy of infrared (IR) spectroscopy of cervical cytology samples using conventional cytology vs. histology-based categorisation. Methods: Within a typical clinical setting, a total of n = 322 liquid-based cytology samples were collected immediately before biopsy. Of these, it was possible to acquire subsequent histology for n = 154. Cytology samples were categorised according to conventional screening methods and subsequently interrogated employing attenuated total reflection Fouriertransform IR (ATR-FTIR) spectroscopy. IR spectra were pre-processed and analysed using linear discriminant analysis. Dunn's test was applied to identify the differences in spectra. Within the diagnostic categories, histology allowed us to determine the comparative efficiency of conventional screening vs. biospectroscopy to correctly identify either true atypia or underlying disease. Results: Conventional cytology-based screening results in poor sensitivity and specificity. IR spectra derived from cervical cytology do not appear to discriminate in a diagnostic fashion when categories were based on conventional screening. Scores plots of IR spectra exhibit marked crossover of spectral points between different cytological categories. Although, significant differences between spectral bands in different categories are noted, crossover samples point to the potential for poor specificity and hampers the development of biospectroscopy as a diagnostic tool. However, when histology-based categories are used to conduct analyses, the scores plot of IR spectra exhibit markedly better segregation. Conclusions: Histology demonstrates that ATR-FTIR spectroscopy of liquid-based cytology identifies the presence of underlying atypia or disease missed in conventional cytology screening. This study points to an urgent need for a future biospectroscopy study where categories are based on such histology. It will allow for the validation of this approach as a screening tool. © 2014 Gajjar et al