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 intra-observer 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 Fourier-transform 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

Human papillomavirus testing versus repeat cytology for triage of minor cytological cervical lesions

Background: A typical squamous cells of undetermined significance (ASCUS) and low-grade squamous intra-epithelial lesions (LSIL) are minor lesions of the cervical epithelium, detectable by cytological examination of cells collected from the surface of the cervix of a woman. Usually, women with ASCUS and LSIL do not have cervical (pre-) cancer, however a substantial proportion of them do have underlying high-grade cervical intra-epithelial neoplasia (CIN, grade 2 or 3) and so are at increased risk for developing cervical cancer. Therefore, accurate triage of women with ASCUS or LSIL is required to identify those who need further management. This review evaluates two ways to triage women with ASCUS or LSIL: repeating the cytological test, and DNA testing for high-risk types of the human papillomavirus (hrHPV) - the main causal factor of cervical cancer. Objectives Main objective: To compare the accuracy of hrHPV testing with the Hybrid Capture 2 (HC2) assay against that of repeat cytology for detection of underlying cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) or grade 3 or worse (CIN3+) in women with ASCUS or LSIL. For the HC2 assay, a positive result was defined as proposed by the manufacturer. For repeat cytology, different cut-offs were used to define positivity: Atypical squamous cells of undetermined significance or worse (ASCUS+), low-grade squamous intra-epithelial lesions or worse (LSIL+) or high-grade squamous intra-epithelial lesions or worse (HSIL+). Secondary objective: To assess the accuracy of the HC2 assay to detect CIN2+ or CIN3+ in women with ASCUS or LSIL in a larger group of reports of studies that applied hrHPV testing and the reference standard (coloscopy and biopsy), irrespective whether or not repeat cytology was done. Search methods: We made a comprehensive literature search that included the Cochrane Register of Diagnostic Test Accuracy Studies; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (through PubMed), and EMBASE (last search 6 January 2011). Selected journals likely to contain relevant papers were handsearched from 1992 to 2010 (December). We also searched CERVIX, the bibliographic database of the Unit of Cancer Epidemiology at the Scientific Institute of Public Health (Brussels, Belgium) which contains more than 20,000 references on cervical cancer. More recent searches, up to December 2012, targeted reports on the accuracy of triage of ASCUS or LSIL with other HPV DNA assays, or HPV RNA assays and other molecular markers. These searches will be used for new Cochrane reviews as well as for updates of the current review. Selection criteria: Studies eligible for inclusion in the review had to include: women presenting with a cervical cytology result of ASCUS or LSIL, who had undergone both HC2 testing and repeat cytology, or HC2 testing alone, and were subsequently subjected to reference standard verification with colposcopy and colposcopy-directed biopsies for histologic verification. Data collection and analysis: The review authors independently extracted data from the selected studies, and obtained additional data from report authors. Two groups of meta-analyses were performed: group I concerned triage of women with ASCUS, group II concerned women with LSIL. The bivariate model (METADAS-macro in SAS) was used to assess the absolute accuracy of the triage tests in both groups as well as the differences in accuracy between the triage tests. Main results: The pooled sensitivity of HC2 was significantly higher than that of repeat cytology at cut-off ASCUS+ to detect CIN2+ in both triage of ASCUS and LSIL (relative sensitivity of 1.27 (95% CI 1.16 to 1.39; P value < 0.0001) and 1.23 (95% CI 1.06 to 1.4; P value 0.007), respectively. In ASCUS triage, the pooled specificity of the triage methods did not differ significantly from each other (relative specificity: 0.99 (95% CI 0.97 to 1.03; P value 0.98)). However, the specificity of HC2 was substantially, and significantly, lower than that of repeat cytology in the triage of LSIL (relative specificity: 0.66 (95% CI 0.58 to 0.75) P value < 0.0001). Authors' conclusions: HPV-triage with HC2 can be recommended to triage women with ASCUS because it has higher accuracy (significantly higher sensitivity, and similar specificity) than repeat cytology. When triaging women with LSIL, an HC2 test yields a significantly higher sensitivity, but a significantly lower specificity, compared to a repeat cytology. Therefore, practice recommendations for management of women with LSIL should be balanced, taking local circumstances into account

Effect of condom use after CIN treatment on HPV status: a randomised controlled trial

BackgroundNo study has investigated whether consistent condom use after treatment of CIN reduces HPV positivity post-operatively and possibly as a result, the risk of treatment failure (TF).Material & Methods:Design: Single-blinded RCT. Period: May 2008 to November 2013. Setting: Colposcopy Clinic - University Hospital of Ioannina, Greece. Inclusion criteria: Women planned to undergo LLETZ for CIN. Intervention: Women randomly allocated to Group A were given recommendation for condom use, whilst women in Group B received routine post-treatment information. An LBC sample was tested for HPV DNA and typing, mRNA E6 & E7 for HR by NASBA & Flow cytometry, p16INK4a and microspectroscopy at time 0 (pre-Tx), 6, 12, 18, 24, 36, 48 and 60 months. A questionnaire to assess compliance was also completed.Outcomes: HPV and other biomarkers status at 6, 12, 18, 24, 36, 48 and 60 months. TFs at 24 months and compliance rates. Analysis: The relative risk (RR) and absolute RR (ARR) were calculated in an ITT analysis. We also assessed the number needed to treat (NNT) and compliance to condom use recommendation, as well as the HPV biomarker’s accuracy parameters (Sensitivity Specificity, PPV, NPV) for detection of TFs, at 24 monthsResultsA total of 204 women were recruited. All of them have completed the 48 and 176 the 60 month follow-up. The positivity for all the tested biomarkers at follow-up was significantly reduced in Group A. In particular, 29.8% of women tested positive for HPV in Group A in comparison to 69.2% in Group B [p75%). Conclusion Post-treatment condom use reduces significantly HPV DNA positivity as well as the positivity of HPV-related biomarkers post-operatively. Significant is also and the reduction on treatment failure rates of either: a. residual disease, b. recurrent disease, and c. possibly the long term invasive cervical cancer. Compliance to consistent condom use after treatment is an issue. However, evidence suggests that condoms effect on HPV status can be clearly drawn even after 3 months usage; so this adjustment could increase compliance rates. To secure and prolong the protective effect of condoms on HPV status in a realistic basis, vaccination for HPV could be suggested at the time of 1st post-operative visit, since women have been used condoms in sexual intercourses and tested negative on the HPV test. Such a post-treatment policy seems to be feasible in everyday colposcopy practice and could be applied as a worldwide guideline.Σκοπός: Μελέτη της συστηματικής επίδρασης της χρήσης προφυλακτικού στη δραστηριότητα του ιού HPV μετά από συντηρητική θεραπεία για CIN.Υλικό και Μέθοδοι:Σχεδιασμός: Τυχαιοποιημένη κλινική δοκιμή.Πληθυσμός: Γυναίκες στις οποίες αποφασίστηκε αφαιρετική μέθοδος θεραπείας (LLETZ) για CIN. Μεθοδολογία: Αμέσως πριν την θεραπεία όλες οι γυναίκες τυχαιοποιήθηκαν σε δύο groups. Στο group Α εκτός από τις μετεγχειρητικές πληροφορίες ρουτίνας δινόταν αυστηρή σύσταση για χρήση προφυλακτικού για το πρώτο μετεγχειρητικό εξάμηνο, ενώ στο group B δινόταν μόνο μετεγχειρητικές πληροφορίες ρουτίνας. Επιπλέον, πριν την επέμβαση σε όλες τις γυναίκες γινόταν δειγματοληψία τραχηλικού επιχρίσματος κυτταρολογίας υγρής φάσης (Thin Prep Pap Smear), το οποίο αποστελλόταν για μοριακή ανάλυση HPV-δεικτών (ανίχνευση και τυποποίηση HPV DNA, HPV E6 & E7 mRNA με τη τεχνική NASBA και κυτταρομετρίας ροής καθώς και ανίχνευση έκφρασης της p16INK4a). Στις μετεγχειρητικές επισκέψεις (6ος, 12ος, 18ος, 24ος, 36ος, 48ος και 60ος μήνας) πραγματοποιούνταν επαναληπτική κολποσκόπηση και δειγματοληψία Thin Prep Pap Smear και οι γυναίκες συμπλήρωναν ερωτηματολόγιο σχετικό με την συμμόρφωσή τους στη χρήση προφυλακτικού.Ανάλυση: Η ανάλυση των αποτελεσμάτων έγινε με βάση την αρχική τυχαιοποίηση των γυναικών στα δύο groups. Υπολογίστηκαν ο relative risk (RR) και absolute RR (ARR) στην Intention To Treat analysis καθώς επίσης το number needed to treat (NNT) όπως επίσης και η συμμόρφωση των γυναικών στη σύστασή για χρήση προφυλακτικού. Έγινε επίσης υπολογισμός των παραμέτρων αξιοπιστίας στην ανίχνευση των θεραπευτικών αποτυχιών για κάθε HPV-σχετιζόμενο βιοδείκτη ξεχωριστά [Sensitivity (S), Specificity (Sp), Positive (PPV) and Negative Predictive Value (NPV)].Αποτελέσματα: Στη μελέτη συμπεριλήφθησαν 204 γυναίκες, 98 στο group Α και 104 στο group B. Τα αποτελέσματα έδειξαν στατιστικά σημαντική μείωση της θετικότητας στην πλειονότητα των HPV-δεικτών στο group A (p75%).Συμπεράσματα: Η χρήση προφυλακτικού μετά από θεραπεία για CIN φαίνεται να αυξάνει στατιστικά σημαντικά την αρνητικοποίηση του HPV και να μειώνει εξίσου σημαντικά τον κίνδυνο θεραπευτικής αποτυχίας. Η συμμόρφωση του πληθυσμού στη συστηματική χρήση προφυλακτικού την πρώιμη μετεγχειρητική περίοδο, είναι χαμηλή και μειώνεται σημαντικά με την πάροδο του χρόνου από τη στιγμή της θεραπείας. Βασιζόμενοι στην παραδοχή ότι η χρήση προφυλακτικού στο γενικό πληθυσμό (χωρίς θεραπεία για CIN), εμφανίζει ευεργετικά αποτελέσματα όσον αφορά την HPV κάθαρση και την υποστροφή των αλλοιώσεων από τους 3 πρώτους μήνες, θα μπορούσαμε να αναμένουμε σημαντική μείωση της HPV θετικότητας και στις γυναίκες μετά από θεραπεία για CIN, και αυτή η προσαρμογή θα μπορούσε να αυξήσει τα ποσοστά συμμόρφωσης. Η μετεγχειρητική διαχείριση γυναικών μετά από θεραπεία για CIN ακολουθώντας τον προτεινόμενο άξονα: θεραπεία για CIN – αυστηρή χρήση προφυλακτικού για χρονικό διάστημα 6 μηνών - HPV DNA test στην πρώτη μετεγχειρητική επίσκεψη και επί αρνητικού αποτελέσματος αυτού την εφαρμογή εμβολιασμού, με στόχο την απόλυτη προστασία αυτών των γυναικών έναντι σε νέες λοιμώξεις από τον ιό, θα μπορούσε να αποτελέσει παγκόσμια κατευθυντήρια οδηγία για όλες τις γυναίκες που υποβλήθηκαν σε θεραπεία για CIN

Caesarean Scar Pregnancy: A Case Report and a Literature Review

Background and Objectives: Caesarean scar pregnancy (CSP) refers to placental implantation on or in the scar of a previous caesarean section and represents a potentially life-threatening condition. CSP is considered a diagnostic challenge in obstetrics, with the diagnosis relying mainly on transvaginal ultrasound (TVS) and the management depending upon case presentation and available healthcare infrastructures. Case Presentation: We present a case of 34-year-old G3P2 with a history of two-previous caesarean sections referred to the outpatient gynaecology clinic of our Department at the 7th week (7/40) of gestation with abnormal early pregnancy TVS findings, illustrating the gestational sac attached to the caesarean scar and a foetal pole with evidence of foetal cardiac activity. We discuss the outcome of an alternative combined medical and surgical approach we followed as well as an updated review of the current literature. Conclusions: The ideal management of CSP requires tertiary centers, equipment availability and experienced healthcare professionals capable of dealing with any possible complication, as well as individualized treatment based on each case presentation

Urine HPV in the Context of Genital and Cervical Cancer Screening—An Update of Current Literature

Within the previous decades, following the widespread implementation of HPV-related biomarkers and computerization in liquid-based cytology, screening for lower genital tract malignancies has been optimized in several parts of the world. Many organized anogenital cancer prevention systems have reached a point at which efficacy is more a matter of population coverage and less of available infrastructures. Meanwhile, self-sampling modalities in which biologic material (vaginal secretions, urine, etc.) is obtained by the individual and not the clinician and subsequently undergoes examination for HPV biomarkers enjoy appreciating acceptance. Bygone the initial skepticism that vaginal or urine HPV represents “passenger” transient infections, extensive scientific work has been conducted to optimize high-risk HPV (hrHPV) detection from this “novel” biologic material. Nowadays, several state-of-the-art meta-analyses have illustrated that self-sampling techniques involving urine self-sampling represent a feasible alternative strategy with potentially enhanced population coverage possessing excellent performance and sensitivity. Recently published scientific work focusing on urine HPV was reviewed, and after a critical appraisal, the following points should be considered in the clinical application of hrHPV urine measurements; (i) use of first-void urine (FVU) and purpose-designed collection devices; (ii) using a preservation medium to avoid human/HPV DNA degradation during extraction and storage; (iii) using polymerase chain reaction (PCR) based assays, ideally with genotyping capabilities; (iv) processing of a sufficient volume of whole urine; and (v) the use of an analytically sensitive HPV test/recovery of cell-free HPV DNA in addition to cell-associated DNA

Identification of women for referral to colposcopy by neural networks: A preliminary study based on LBC and molecular biomarkers

Objective of this study is to investigate the potential of the learning vector quantizer neural network (LVQ-NN) classifier on various diagnostic variables used in the modern cytopathology laboratory and to build an algorithm that may facilitate the classification of individual cases. From all women included in the study, a liquid-based cytology sample was obtained; this was tested via HPV DNA test, E6/E7 HPV mRNA test, and p16 immunostaining. The data were classified by the LVQ-NN into two groups: CIN-2 or worse and CIN-1 or less. Half of the cases were used to train the LVQ-NN; the remaining cases (test set) were used for validation. Out of the 1258 cases, cytology identified correctly 72.90% of the CIN-2 or worst cases and 97.37% of the CIN-1 or less cases, with overall accuracy 94.36%. The application of the LVQ-NN on the test set allowed correct classification for 84.62% of the cases with CIN-2 or worse and 97.64% of the cases with CIN-1 or less, with overall accuracy of 96.03%. The use of the LVQ-NN with cytology and the proposed biomarkers improves significantly the correct classification of cervical precancerous lesions and/or cancer and may facilitate diagnosis and patient management

Ascites in the Puerperium in the Context of a Woman with Turner Syndrome Who Conceived through Assisted Reproductive Technology

The case is about a young female who delivered twins by caesarean section (CS). On the 4th postoperative day, she presented with ascites which was resistant to empirical antibiotic and diuretic treatment. The woman was affected by Turner syndrome (TS); she had a medical background of chronic use of hormonal medication since puberty and conceived through ART- (assisted reproduction techniques-) IVF-oocyte donation. It is important to exhibit high suspicion for clot formation in the hepatic vasculature during the puerperium, especially in the case of history of chronic hormone treatment. Ascites albumin gradient and Doppler values lead to the diagnosis of thrombosis and the administration of high doses of anticoagulants is considered to be fundamental

The influence of sexual behavior and demographic characteristics in the expression of HPV-related biomarkers in a colposcopy population of reproductive age greek women

Despite the significant scientific evolution in primary and secondary cervical cancer prevention in the battle started by George Papanicolaou in the previous century, global cervical cancer mortality rates remain disappointing. The widespread implementation of HPV-related molecular markers has paved the way to tremendous developments in cervical cancer screening, with the transition from cytological approach to the more accurate and cost-effective HPV testing modalities. However, the academic audience and different health systems have not yet adopted a universal approach in screening strategies, and even artificial intelligence modalities have been utilized from the multidisciplinary scientific armamentarium. Combination algorithms, scoring systems as well as artificial intelligent models have been so far proposed for cervical screening and management. The impact of sexual lifestyle inherently possesses a key role in the prevalence of HPV-related biomarkers. This study aimed to investigate any possible influence of sexual behavior and demographic characteristics in the expression of HPV-related biomarkers in a colposcopy population from October 2016 to June 2017, and corroborated the determining role of age at fist intercourse; the older the age, the lower the probability for DNA positivity. Multivariate analysis illustrated additionally that a number of sexual partners exceeding 4.2 was crucial, with women with ≤5 partners being approximately four times less likely to harbor a positive HPV DNA test (p &lt; 0.0001). Similarly, a reported partner change during the last year before HPV DNA assessment contributed to 2.5 times higher odds for DNA positivity (p = 0.0006). From this perspective, the further development and validation of scoring systems quantifying lifestyle factors that could reflect cervical precancer risk seems paramount. © 2021 by the authors. Licensee MDPI, Basel, Switzerland