1
|
Bertelsen VM, Tranberg M, Petersen LK, Booth B, Bor P. Improving diagnostic of cervical dysplasia among postmenopausal women aged ≥50 years using local vaginal oestrogen treatment prior to colposcopy: study protocol for a multicentre randomised controlled trial (the IDEAL study). BMJ Open 2024; 14:e082833. [PMID: 38910002 PMCID: PMC11328618 DOI: 10.1136/bmjopen-2023-082833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/29/2024] [Indexed: 06/25/2024] Open
Abstract
INTRODUCTION Colposcopy is the most important diagnostic tool to detect cervical precancerous lesions and thereby prevention of cervical cancer. Due to age-dependent changes of the cervix, colposcopy is challenging in postmenopausal women, as the majority will have a non-visible transformation zone, resulting in increased risk of missing disease, a diagnostic cone biopsy and prolonged follow-up with repeated colposcopies. This study will be among the first to investigate, if treatment with vaginal oestrogen prior to colposcopy will improve the colposcopy performance, to ensure accurate and timely diagnosis of precancerous cervical lesions among postmenopausal women. METHODS AND ANALYSIS A randomised blinded controlled multicentre study. Enrolment will be performed at gynaecology departments in Central Denmark Region and Region of Southern Denmark. A total of 150 postmenopausal women aged ≥50 years referred for colposcopy due to abnormal cervical screening results will be randomised 1:1 to either pretreatment with vaginal application of Vagifem 30 µg or placebo once a day for 14 days prior to colposcopy. The primary outcome will be to compare the percentage of women in the two groups with a visible transformation zone at colposcopy, and biopsies representative of the transformation zone. Secondary outcomes will be the proportion of detected cervical intraepithelial neoplasia grade 2 or higher in the cervical biopsies; the proportion of diagnostics cone biopsies; the patients' report on possible side effects and compliance to the pretreatment. ETHICS AND DISSEMINATION The study has been approved by the Central Denmark Region Committee on Biomedical Research Ethics (1-10-72-34-22), the Central Denmark Regions' Research Unit (1-16-02-72-22) and The Danish Health Authority (Danish Medicine Agency; 2022015030). The study's EudraCT number is (1-23-456; 2022-000269-42) and it is registered on www. CLINICALTRIALS gov. The local Good Clinical Practice (GCP) unit will supervise and monitor the study closely before, during and after the study period. Findings will be disseminated in peer-reviewed scientific journals and presented in relevant conferences. TRIAL REGISTRATION NUMBER NCT05283421.
Collapse
Affiliation(s)
- Vibe Munk Bertelsen
- Department of Gynecology and Obstetrics, Randers Regional Hospital, Randers, Denmark
- University Research Clinic for Cancer Screening and Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mette Tranberg
- University Research Clinic for Cancer Screening and Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Berit Booth
- Department of Gynecology and Obstetrics, Randers Regional Hospital, Randers, Denmark
- Department of Gynecology and Obstetrics, Odense University, Odense, Denmark
| | - Pinar Bor
- Department of Gynecology and Obstetrics, Aarhus University, Aarhus, Denmark
| |
Collapse
|
2
|
Lindroth Y, Pedersen L, Alssamaray J, Berglund T, Sundqvist A, Borgfeldt C, Forslund O. Cervix cytology samples revealed increased methylation of the human markers FAM19A4/miR124-2 up to 8 years before adenocarcinoma. Acta Obstet Gynecol Scand 2024; 103:378-386. [PMID: 37964497 PMCID: PMC10823397 DOI: 10.1111/aogs.14707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 09/13/2023] [Accepted: 10/13/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION Methylation analysis of the promoter region of tumor-suppressor genes has previously shown high sensitivity for detection of high-grade cervical intraepithelial neoplasia (CIN) and cancer. HPV-testing has a high sensitivity to identify women at risk to develop cancer, and has been implemented in cervical screening programs in several countries. But in most HPV-positive women the infection will clear and they will not develop cancer. Testing for methylation could help to identify women who have potentially progressive cervical disease and need closer follow-up. The goal of the present study was to investigate the potential use of methylation as a triage test of HPV-positive women in the screening program. MATERIAL AND METHODS A collection of liquid-based cytology (LBC) samples from 106 women, collected between 4 months and 8 years before histologically confirmed cervical cancer or CIN3, was analyzed for hypermethylation of the human genes FAM19A4 and miR124-2. RESULTS Methylation was detected in 45% (33/73) of normal LBC samples from women who later developed CIN3+, compared with 10% (3/31) of normal LBC samples from women without subsequent dysplasia (P = 0.0006). Overall, methylation was detected in 39% (14/36), 51% (19/37), 61% (14/23) and 70% (7/10) of LBC samples from women who later developed CIN3, adenocarcinoma in situ (AIS), squamous cell carcinoma (SCC) and adenocarcinoma (ADC), respectively. Positive methylation analysis was not significantly more frequent than abnormal cytology of atypical squamous cells of unclear significance or worse (ASCUS+) in LBC samples collected 4 months to 8 years before SCC or AIS; however, prior to the development of ADC, methylation was observed in 7/10 LBC samples, despite normal cytology. Overall, LBC samples collected before invasive cancer (ADC and SCC) were more frequently positive in the methylation analysis than in cytological analysis of ASCUS+ (P = 0.048). For LBC samples collected more than 2 years before the development of AIS, SCC or ADC, methylation analysis showed a higher positivity rate than cytology did. CONCLUSIONS Testing for methylation of FAM19A4/miR124-2 as a triage for HPV-positive women would be useful to identify women at risk of cancer development, especially adenocarcinoma. Further studies are needed to estimate the cost-effectiveness before introducing methylation testing in the screening program.
Collapse
Affiliation(s)
- Ylva Lindroth
- Department of Laboratory MedicineLund UniversityLundSweden
- Clinical Microbiology, Infection Prevention and Control, Office for Medical ServicesLundSweden
| | - Louise Pedersen
- Clinical Microbiology, Infection Prevention and Control, Office for Medical ServicesLundSweden
| | - Jacob Alssamaray
- Clinical Microbiology, Infection Prevention and Control, Office for Medical ServicesLundSweden
| | - Tim Berglund
- Clinical Microbiology, Infection Prevention and Control, Office for Medical ServicesLundSweden
| | - Avalon Sundqvist
- Department of Obstetrics and GynecologySkåne University Hospital, Lund UniversityLundSweden
| | - Christer Borgfeldt
- Department of Obstetrics and GynecologySkåne University Hospital, Lund UniversityLundSweden
| | - Ola Forslund
- Department of Laboratory MedicineLund UniversityLundSweden
- Clinical Microbiology, Infection Prevention and Control, Office for Medical ServicesLundSweden
| |
Collapse
|
3
|
Jiang Y, Wang C, Zhou S. Artificial intelligence-based risk stratification, accurate diagnosis and treatment prediction in gynecologic oncology. Semin Cancer Biol 2023; 96:82-99. [PMID: 37783319 DOI: 10.1016/j.semcancer.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 08/27/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023]
Abstract
As data-driven science, artificial intelligence (AI) has paved a promising path toward an evolving health system teeming with thrilling opportunities for precision oncology. Notwithstanding the tremendous success of oncological AI in such fields as lung carcinoma, breast tumor and brain malignancy, less attention has been devoted to investigating the influence of AI on gynecologic oncology. Hereby, this review sheds light on the ever-increasing contribution of state-of-the-art AI techniques to the refined risk stratification and whole-course management of patients with gynecologic tumors, in particular, cervical, ovarian and endometrial cancer, centering on information and features extracted from clinical data (electronic health records), cancer imaging including radiological imaging, colposcopic images, cytological and histopathological digital images, and molecular profiling (genomics, transcriptomics, metabolomics and so forth). However, there are still noteworthy challenges beyond performance validation. Thus, this work further describes the limitations and challenges faced in the real-word implementation of AI models, as well as potential solutions to address these issues.
Collapse
Affiliation(s)
- Yuting Jiang
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, West China Second Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan 610041, China; Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Chengdi Wang
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, West China Second Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan 610041, China; Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Shengtao Zhou
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, West China Second Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan 610041, China; Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China.
| |
Collapse
|
4
|
Kultalahti H, Heinävaara S, Sarkeala T, Pankakoski M. Effect of Test History at Ages 50-64 on Later Cervical Cancer Risk: A Population-based Case-control Study. CANCER RESEARCH COMMUNICATIONS 2023; 3:1823-1829. [PMID: 37700796 PMCID: PMC10494786 DOI: 10.1158/2767-9764.crc-23-0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/26/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
As life expectancy increases, the effectiveness of cervical cancer screening programs needs to be reassessed for the older population. We addressed the effect of test history in and outside organized screening at age 50-64 years on later cervical cancer risk. A case-control study was conducted by deriving 229 cases of 65-79 years old women with invasive cervical cancer in 2010-2019 from the Finnish Cancer Registry. Ten controls were matched for each case by birth year and hospital district. The effect of test uptake and abnormal results in 50-64 year olds on cancer risk was investigated using conditional logistic regression and adjusted for self-selection. Test uptake within the 50-64 years age group showed 75% lower odds of cervical cancer [adjusted OR (aOR) = 0.25; 95% confidence interval (95% CI), 0.18-0.35]. Untested women had 4.9 times higher odds than those tested with normal results (aOR = 4.86; 95% CI, 3.42-6.92). Having at least one abnormal test result increased the odds by 2.5 when compared with only normal results but showed lower odds when compared with untested women. The importance of testing is exhibited by the result showing a reduction of odds of cancer to one-fourth for those tested compared with untested. Similarly, receiving abnormal results was protective of cancer compared with having no tests highlighting the importance of proper follow-up. Therefore, screening history should be considered when further developing cervical cancer screening programs with special interest in non-attenders and those receiving abnormal results at older ages. Significance To our knowledge, this is the first study from Finnish data describing the effect of test history on later cervical cancer at older ages. Focusing on the cervical tests taken within the Finnish national screening program and outside it highlights the overall importance of having cervical tests and adds this study into the slowly increasing number of studies considering all cervical testing in Finland.
Collapse
Affiliation(s)
- Henric Kultalahti
- Finnish Cancer Registry, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Sirpa Heinävaara
- Finnish Cancer Registry, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Maiju Pankakoski
- Finnish Cancer Registry, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| |
Collapse
|
5
|
Tranberg M, Petersen LK, Hammer A, Elfström M, Blaakær J, Jørgensen SF, Bennetsen MH, Jensen JS, Andersen B. Value of a catch-up HPV test in women aged 65 and above: A Danish population-based nonrandomized intervention study. PLoS Med 2023; 20:e1004253. [PMID: 37410699 PMCID: PMC10325045 DOI: 10.1371/journal.pmed.1004253] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/31/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND High-risk human papillomavirus (HPV) test is replacing cytology as the primary cervical cancer screening test due to superior sensitivity, but in most countries women ≥65 years have never had an HPV test despite they account for around 50% of cervical cancer deaths. We explored the effect of a catch-up HPV test among 65- to 69-year-old women without previous record of HPV-based screening. METHODS AND FINDINGS This population-based nonrandomized intervention study (quasi-experimental design) included Danish women aged 65 to 69 with no record of cervical cancer screening in the last ≥5.5 years and no HPV-exit test at age 60 to 64 at the time of study inclusion. Eligible women residing in the Central Denmark Region were invited for HPV screening either by attending clinician-based sampling or requesting a vaginal self-sampling kit (intervention group, n = 11,192). Women residing in the remaining four Danish regions received standard care which was the opportunity to have a cervical cytology collected for whatever reason (reference group, n = 33,387). Main outcome measures were detection of cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+) per 1,000 women eligible for the screening offer and the benefit-harm ratio of the intervention and standard practice measured as the number of colposcopies needed to detect one CIN2+ case. The minimum follow-up time was 13 months for all tested women (range: 13 to 25 months). In the intervention group, 6,965 (62.2%) were screened within 12 months from the date of study inclusion and 743 (2.2%) women had a cervical cytology collected in the reference group. The CIN2+ detection was significantly higher in the intervention group (3.9, 95% confidence interval (CI): [2.9, 5.3]; p < 0.001; n = 44/11,192) as compared to the reference group (0.3, 95% CI: [0.2, 0.6]; n = 11/33,387). For the benefit-harm ratio, 11.6 (95% CI: [8.5, 15.8]; p = 0.69; n = 511/44) colposcopies were performed to detect one CIN2+ in the intervention group as compared to 10.1 (95% CI: [5.4, 18.8]; n = 111/11) colposcopies in the reference group. The study design entails a risk of confounding due to the lack of randomization. CONCLUSIONS The higher CIN2+ detection per 1,000 eligible women in the intervention group supports that a catch-up HPV test could potentially improve cervical cancer prevention in older women. This study informs the current scientific debate as to whether women aged 65 and above should be offered a catch-up HPV test if they never had an HPV test. TRIAL REGISTRATION ClinicalTrials.gov NCT04114968.
Collapse
Affiliation(s)
- Mette Tranberg
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- OPEN, Department of Clinical Medicine, Southern University of Denmark, Odense, Denmark
| | - Anne Hammer
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark
| | - Miriam Elfström
- Center for Cervical Cancer Prevention, Karolinska University Hospital, Stockholm, Sweden
- Regional Cancer Center of Stockholm-Gotland, Stockholm, Sweden
| | - Jan Blaakær
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Susanne Fogh Jørgensen
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | | | - Jørgen Skov Jensen
- Research Unit for Reproductive Microbiology, Statens Serum Institut, Copenhagen, Denmark
| | - Berit Andersen
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
6
|
Wei B, Li Q, Seery S, Qiao Y, Jiang Y. Endocervical curettage for diagnosing high-grade squamous intraepithelial lesions or worse in women with type 3 transformation zone lesions: a retrospective, observational study. BMC Womens Health 2023; 23:245. [PMID: 37161558 PMCID: PMC10170824 DOI: 10.1186/s12905-023-02297-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/21/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND This study aimed to assess the value of endocervical curettage (ECC) in detecting high-grade squamous intraepithelial lesion or worse (HSIL+) in women with type 3 transformation zone (TZ3) lesions, and to identify the clinical characteristics of patients with TZ3 lesions who benefit most from ECC. METHODS This retrospective, multicenter study included 1,905 women with TZ3 lesions who attended cervical screening in one of seven tertiary hospitals in China between January 2020 and November 2021. All participants had received abnormal results and had been referred to colposcopy. Risk factors were identified through univariate and multifactorial logistic analyses. RESULTS In total, 20.5% (n = 391) of HSIL+ cases with TZ3 lesions had been diagnosed with biopsy and ECC. ECC detected 0.8% (n = 15) HSIL+ cases otherwise missed by biopsy alone. Multivariate analysis identified four factors which influenced detection performance. The probability of detecting HSIL+ with ECC is 2.653 (95% confidence interval [CI] 1.009-6.977) times greater in women aged 40-49 years and 2.545 (95% CI 0.965-6.716) times greater for those aged 50 years and older compared to those younger than 30 years. The probability of ASC-H (atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion) and HSIL cytologies were respectively 2.415 (95% CI 1.213-4.808) and 2.933 (95% CI 1.648-5.220) times higher than for NILM (negative for intraepithelial lesion or malignancy). Women with human papillomavirus 16/18 infections were 2.299 (95% CI 0.942-5.613) times more likely to be HSIL+. Precancerous lesions were 35.884 (95% CI 12.214-105.426) times more likely in women who had high-grade colposcopic impressions compared to those with normal impressions. CONCLUSIONS ECC should be performed for patients with ASC-H or HSIL cytologies, human papillomavirus 16/18 infections, and for those with high-grade colposcopic impressions. This will increase the number of HSIL+ cases identified using biopsy by reducing the number of false negatives.
Collapse
Affiliation(s)
- Bingrui Wei
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Qing Li
- Diagnosis and Treatment for Cervical Lesions Center, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen, 518028, China
| | - Samuel Seery
- Faculty of Health and Medicine, Division of Health Research, Lancaster University, Lancaster, LA1 4YW, UK
| | - Youlin Qiao
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yu Jiang
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| |
Collapse
|
7
|
Booth BB, Tranberg M, Gustafson LW, Christiansen AG, Lapirtis H, Krogh LM, Hjorth IMD, Hammer A. Risk of cervical intraepithelial neoplasia grade 2 or worse in women aged ≥ 69 referred to colposcopy due to an HPV-positive screening test. BMC Cancer 2023; 23:405. [PMID: 37142959 PMCID: PMC10161414 DOI: 10.1186/s12885-023-10888-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/26/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Cervical cancer incidence and mortality rates are high in older women in many developed countries, including Denmark. Therefore, Danish women aged 69 and older were invited for one additional human papilloma virus (HPV) based screening test in 2017. Here, we describe the clinical management and detection rate of cervical intraepithelial neoplasia grade 2 or worse (CIN2 +) in screen-positive women referred for colposcopy. METHODS We conducted an observational study in public gynecology departments in Central Denmark Region, Denmark. Women were eligible for enrolment if they were aged 69 + in 2017, HPV positive on a screening test taken between April 20th, 2017, and December 31st, 2017, and had been referred for direct colposcopy. Data on participants' characteristics, colposcopic findings, and histological outcomes were collected from medical records and the Danish Pathology Databank. We estimated the proportion of women with CIN2 + at the first colposcopy visit and at end of follow up including 95% confidence intervals (CIs). RESULTS A total of 191 women were included with a median age of 74 years (IQR: 71-78). Most women (74.9%) did not have a fully visible transformation zone at colposcopy. At the first visit 170 women (89.0%) had a histological sample collected, 34 of whom (20.0%, 95% CI 14.3-26.8%) had CIN2 + diagnosed, 19 had CIN3 + , and two had cervical cancer). During follow-up additional CIN2 + were detected resulting in a total of 42 women (24.4%, 95% CI: 18.2-31.5%) being diagnosed with CIN2 + , 25 with CIN3 + , and three with cervical cancer. When restricting to women with paired histologic results (i.e., biopsies and a loop electrosurgical excision procedure (LEEP) specimen), we found that CIN2 + was missed in 17.9% (95% CI 8.9-30.4%) of biopsies compared to the LEEP. CONCLUSION Our findings suggest a potential risk of underdiagnosis in older postmenopausal women referred to colposcopy. Future studies should explore potential risk-markers for discrimination of women at increased risk of CIN2 + from those at low risk, as this would reduce risk of underdiagnosis and overtreatment.
Collapse
Affiliation(s)
- Berit B Booth
- Department of Obstetrics and Gynecology, NIDO - Centre for Research and Education, Gødstrup Hospital, Hospitalsparken 15, Herning, 7400, Denmark.
| | - Mette Tranberg
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | - Line W Gustafson
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne G Christiansen
- Department of Obstetrics and Gynecology, NIDO - Centre for Research and Education, Gødstrup Hospital, Hospitalsparken 15, Herning, 7400, Denmark
| | - Helle Lapirtis
- Department of Obstetrics and Gynecology, Randers Regional Hospital, Randers, Denmark
| | - Lisa M Krogh
- Department of Obstetrics and Gynecology, Viborg Regional Hospital, Viborg, Denmark
| | - Ina Marie D Hjorth
- Department of Obstetrics and Gynecology, Horsens Regional Hospital, Horsens, Denmark
| | - Anne Hammer
- Department of Obstetrics and Gynecology, NIDO - Centre for Research and Education, Gødstrup Hospital, Hospitalsparken 15, Herning, 7400, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
8
|
E6/E7 mRNA Expression of the Most Prevalent High-Risk HPV Genotypes in Cervical Samples from Serbian Women. Diagnostics (Basel) 2023; 13:diagnostics13050917. [PMID: 36900061 PMCID: PMC10000477 DOI: 10.3390/diagnostics13050917] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/05/2023] Open
Abstract
Cervical cancer caused by persistent infection with HR HPV genotypes is the second leading cause of death in women aged 15 to 44 in Serbia. The expression of the E6 and E7 HPV oncogenes is considered as a promising biomarker in diagnosing high-grade squamous intraepithelial lesions (HSIL). This study aimed to evaluate HPV mRNA and DNA tests, compare the results according to the severity of the lesions, and assess the predictive potential for the diagnosis of HSIL. Cervical specimens were obtained at the Department of Gynecology, Community Health Centre Novi Sad, Serbia, and the Oncology Institute of Vojvodina, Serbia, during 2017-2021. The 365 samples were collected using the ThinPrep Pap test. The cytology slides were evaluated according to the Bethesda 2014 System. Using a real-time PCR test, HPV DNA was detected and genotyped, while the RT-PCR proved the presence of E6 and E7 mRNA. The most common genotypes in Serbian women are HPV 16, 31, 33, and 51. Oncogenic activity was demonstrated in 67% of HPV-positive women. A comparison of the HPV DNA and mRNA tests to assess the progression of cervical intraepithelial lesions indicated that higher specificity (89.1%) and positive predictive value (69.8-78.7%) were expressed by the E6/E7 mRNA test, while higher sensitivity was recorded when using the HPV DNA test (67.6-88%). The results determine the higher probability of detecting HPV infection by 7% provided by the mRNA test. The detected E6/E7 mRNA HR HPVs have a predictive potential in assessing the diagnosis of HSIL. The oncogenic activity of HPV 16 and age were the risk factors with the strongest predictive values for the development of HSIL.
Collapse
|
9
|
Wang J, Jing G, Huang W, Xin L, Du J, Cai X, Xu Y, Lu X, Chen W. Rapid In Situ Hydrogel LAMP for On-Site Large-Scale Parallel Single-Cell HPV Detection. Anal Chem 2022; 94:18083-18091. [PMID: 36517452 DOI: 10.1021/acs.analchem.2c04701] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Rapid human papillomavirus (HPV) screening is urgently needed for preventing and early diagnosis of cervical cancer in rural areas. To date, no HPV nucleic acid test (NAT) can be implemented within a single patient visit starting from clinical samples. Here, we develop a hydrogel loop-mediated isothermal amplification (LAMP) method in a fashion of large-scale parallel (about 1000 cells) in situ HPV DNA detection in clinical cervical exfoliated cells at the single-cell level. It can be used with a hotplate and smartphone to obtain HPV NAT results in less than 30 min, which is especially suitable for the on-site scenario. We apply this rapid HPV NAT on 40 clinical cervical exfoliated cell samples and compare the results to a clinical gold standard quantitative polymerase chain reaction (qPCR) method [area under curve (AUC), 1.00]. Meanwhile, our assay can provide HPV infection information for large-scale parallel single clinical cervical exfoliated cells, which cannot be received from traditional NAT methods. Our findings suggest the potential of in situ hydrogel LAMP as a powerful tool for clinical HPV screening and fundamental research.
Collapse
Affiliation(s)
- Jidong Wang
- Medical Research Center, Huazhong University of Science and Technology Union Shenzhen Hospital, The 6th Affiliated Hospital, Shenzhen University Health Science Center, Shenzhen 518052, P. R. China
| | - Gaoxing Jing
- School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
| | - Wenxuan Huang
- School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
| | - Luhua Xin
- School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
| | - Jihui Du
- Medical Research Center, Huazhong University of Science and Technology Union Shenzhen Hospital, The 6th Affiliated Hospital, Shenzhen University Health Science Center, Shenzhen 518052, P. R. China
| | - Xiaoqing Cai
- School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
| | - Ying Xu
- School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
| | - Xi Lu
- School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
| | - Wenwen Chen
- School of Biomedical Engineering, Shenzhen University Health Science Center, Shenzhen 518060, P. R. China
| |
Collapse
|
10
|
Gustafson LW, Hammer A, Bennetsen MH, Kristensen C, Majeed H, Petersen LK, Andersen B, Bor P. Cervical intraepithelial neoplasia in women with transformation zone type 3: cervical biopsy versus large loop excision. BJOG 2022; 129:2132-2140. [PMID: 35488417 PMCID: PMC9796102 DOI: 10.1111/1471-0528.17200] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To compare the proportion of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) in cervical biopsies with that in large loop excision of the transformation zone (LLETZ) specimens in women aged ≥45 years with transformation zone type 3 (TZ3). DESIGN Multicentre cross-sectional study. SETTING Three colposcopy clinics in the Central Denmark Region. POPULATION Women aged ≥45 years referred to colposcopy as a result of a positive human papillomavirus (HPV) test and/or abnormal cytology and with TZ3 at colposcopy. METHODS Women had multiple biopsies taken and an LLETZ was performed. MAIN OUTCOME MEASURES Histologically confirmed CIN2+ in biopsies compared with that in LLETZ specimens. RESULTS Of 166 eligible women at colposcopy, 102 women with paired data from biopsies and LLETZ specimens were included for final analysis. The median age was 67.7 years (IQR 62.6-70.4 years), and most were postmenopausal (94.1%) and had undergone HPV-based screening (81.3%). The CIN2+ detection rate was significantly higher in LLETZ specimens than in biopsies (32.4% vs 14.7%, difference 17.7%, 95% CI 6.3-29.0%), resulting in more than half of CIN2+ cases being missed in biopsies (54.5%, 95% CI 36.4-71.9%). The overall agreement between biopsies and LLETZ was 82.4% (95% CI 73.6-89.2%). CONCLUSIONS CIN2+ detection is underestimated in women aged ≥45 years with TZ3 if detection relies on the results of biopsies alone. To reduce the risk of underdiagnosis and overtreatment, future studies should explore the use of new biomarkers for risk stratification to improve discrimination between women at increased risk of CIN2+ who need to undergo LLETZ and women who may undergo follow-up.
Collapse
Affiliation(s)
- Line Winther Gustafson
- Department of Public Health Programmes, Randers Regional HospitalUniversity Research Clinic for Cancer ScreeningRandersDenmark
- Department of Clinical MedicineAarhus UniversityHerningDenmark
| | - Anne Hammer
- Department of Clinical MedicineAarhus UniversityHerningDenmark
- Department of Obstetrics and GynaecologyGødstrup HospitalHerningDenmark
| | | | | | - Huda Majeed
- Department of Obstetrics and GynaecologyViborg Regional HospitalViborgDenmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and GynaecologyOdense University HospitalOdenseDenmark
- Open Patient data Explorative Network, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Berit Andersen
- Department of Public Health Programmes, Randers Regional HospitalUniversity Research Clinic for Cancer ScreeningRandersDenmark
- Department of Clinical MedicineAarhus UniversityHerningDenmark
| | - Pinar Bor
- Department of Clinical MedicineAarhus UniversityHerningDenmark
- Department of Obstetrics and GynaecologyRanders Regional HospitalRandersDenmark
| |
Collapse
|
11
|
Wang Q, He Y, Long F, Li C, Shen Z, Guo D, Zhaxi D, Bumu L, Hua Z, Sun Z, Jiang N, Han X, Li J, Yan K, Bai S, Tao M, Xu X, Xiao Z. Cervical cancer screening in high-altitude areas in China: A large cross-section study of 25,173 women in northern Tibet. Front Oncol 2022; 12:841547. [PMID: 36091127 PMCID: PMC9452642 DOI: 10.3389/fonc.2022.841547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/13/2022] [Indexed: 11/15/2022] Open
Abstract
Background Cervical cancer has become a worldwide concern owing to its high incidence and mortality rates. To date, high-altitude areas of Tibet have not benefited from any large-scale cervical cancer screening programs. Therefore, we initiated a screening program to investigate the prevalence of human papilloma virus (HPV) and HPV genotype distribution to reveal cervical cancer and its precursor which lead to morbidity among women in the city of Nagqu in northern Tib3et. Methods A total of 25,173 women were recruited to undergo HPV genotype tests between June and December 2019. Women infected with HPV 16 and/or 18 underwent colposcopy and histological examination. Women with other high-risk HPV type (hr-HPV) underwent cytological tests to determine whether to conduct further colposcopy and histological examination for diagnosis. HPV prevalence was calculated in the total population and further stratified according to various parameters, such as age group, area location (altitude level), and single or mixed infection status. The HPV genotype distribution was also investigated accordingly. Cervical lesions revealed by further colposcopic findings were also analyzed; high-grade and malignant lesion morbidities were calculated in total and in each county. Most data were collected and analyzed using descriptive and consistency check statistical methods, and a risk factor investigation for HPV infection was performed using logistic regression models. Results The total HPV infection rate among women in Nagqu was 13.42%. Of the 25,173 women in the study, 999 (3.97%) were HPV 16/18 positive, 2,379 (9.45%) were other hr-HPV-positive, and 21,795 (86.58%) were HPV-negative. The five most common HPV genotypes, accounting for more than 60% of all HPV infections in Nagqu people, were HPV 16, 58, 31, 18, and 52. Tibetan women younger than 20 years and older than 60 years were the two age groups with the highest rates of HPV infection, 26.7% and 19.8%, respectively. Among the HPV-positive women, 2,656 (78.33%) were infected with a single strain and 732 (21.67%) were infected with multiple strains (more than two genotypes). HPV prevalence increased in high-altitude areas (positive rate highest in Nyima with an altitude of 5,000 m, 23.9%) and decreased in relatively low-altitude areas (positive rate lowest in Lhari with an altitude of 4,000 m, 6.6%). Multiple analyses showed that age, parity, age at first delivery, and altitude of residence were independent factors facilitating HPV infection in Tibetan women. High-grade and malignant cervical lesions revealed by histological findings were different among living locations, with the highest rates in Xainza, Baingoin, and Nyainrong, these being 2.019%, 1.820%, and 1.116%, respectively, among women in these areas. Conclusion Our survey provides an overall perspective on HPV genotype infection and cervical lesions in women in northern Tibet. The data not only provide useful information for the treatment of cervical lesions but also has great value in terms of the primary and secondary prevention measures that can be taken for women living in these regions. Clinical Trial Registration www.chictr.org.cn, indentifier ChiCTR2000035061.
Collapse
Affiliation(s)
- Qimin Wang
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Pathology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yingying He
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Pathology, Dalian Maternal and Child Medical Group, Dalian, China
| | - Fang Long
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Department of Obstetrics and Gynecology, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
| | - Chaoran Li
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Performance and Quality Management Department, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhuowei Shen
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Dongxing Guo
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Department of Obstetrics and Gynecology, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
| | - Duoji Zhaxi
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
| | - Lamu Bumu
- Department of Obstetrics and Gynecology, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
| | - Zhengyu Hua
- Department of Pathology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhigang Sun
- Department of Pathology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Nan Jiang
- Department of Pathology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xu Han
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jing Li
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Keqing Yan
- Department of Pathology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Siqi Bai
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Muhan Tao
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoguang Xu
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Neurosurgery, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhen Xiao
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Department of Obstetrics and Gynecology, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
| |
Collapse
|
12
|
Jørgensen SF, Andersen B, Petersen LK, Rebolj M, Njor SH. Adherence to follow-up after the exit cervical cancer screening test at age 60-64: A nationwide register-based study. Cancer Med 2022; 11:224-237. [PMID: 34766466 PMCID: PMC8704149 DOI: 10.1002/cam4.4420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/14/2021] [Accepted: 10/24/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND In Denmark, human papillomavirus (HPV) testing has replaced cytology in primary cervical cancer screening for women aged 60-64; at this age, women are invited for the last (exit) screening test within the national organized program. AIM We investigated the adherence of these women to the recommended follow-up after a non-negative (positive or inadequate) HPV test and the overall resource use during that follow-up. MATERIALS & METHODS We included all 2926 women aged 60-64 years with nonnegative HPV screening tests between March 2012 and December 2016. All relevant follow-up tests and procedures were retrieved until the end of 2020 from the highly complete Danish administrative health registers, and the data were linked at the individual level. We determined the extent to which the adherence patterns followed the national recommendations for follow-up and estimated the total numbers of tests and diagnostic procedures utilized during the entire process. RESULTS In total, only 26% of women had follow-up in accordance with the recommendations; 4% had no follow-up, 46% had insufficient follow-up, and 24% had more follow-up than recommended. We estimated that 17% of women remained in follow-up for longer than 4 years. The average numbers of diagnostic tests and procedures used after positive HPV screening were higher than expected, even among women who had insufficient follow-up, that is, those who received less invasive procedures than recommended, or experienced delays in receiving those procedures. CONCLUSION To conclude, we found that the patterns of follow-up of women with nonnegative primary HPV screening tests at 60-64 often diverged from the recommendations. Addressing these inconsistencies in follow-up by providing evidence for optimal clinical management should help improve the quality of screening programs and secure an equal and reliable follow-up care service for all women.
Collapse
Affiliation(s)
- Susanne F. Jørgensen
- University Research Clinic for Cancer ScreeningDepartment of Public Health ProgrammesRanders Regional HospitalRandersDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Berit Andersen
- University Research Clinic for Cancer ScreeningDepartment of Public Health ProgrammesRanders Regional HospitalRandersDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Lone Kjeld Petersen
- Department of Gynaecology and ObstetricsOdense University HospitalOdenseDenmark
- Open Patient Data Explorative Network (OPEN)University of Southern DenmarkOdenseDenmark
| | - Matejka Rebolj
- Cancer Prevention GroupSchool of Cancer & Pharmaceutical SciencesFaculty of Life Sciences & MedicineKing's College LondonLondonUK
| | - Sisse H. Njor
- University Research Clinic for Cancer ScreeningDepartment of Public Health ProgrammesRanders Regional HospitalRandersDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| |
Collapse
|
13
|
Qin Y, Li Q, Ke X, Zhang Y, Shen X, Wang W, Shi Q, Li C. Clearance of HR-HPV within one year after focused ultrasound or loop electrosurgical excision procedure in patients with HSIL under 30. Int J Hyperthermia 2021; 39:15-21. [PMID: 34937489 DOI: 10.1080/02656736.2021.2010817] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To compare the clearance rate of high-risk human papillomavirus (HR-HPV) in patients with a high-grade squamous intraepithelial lesion (HSIL) 12 months after focused ultrasound (FUS) or loop electrosurgical excision procedure (LEEP), and analyze the influencing factors. METHODS A retrospective cohort was established in HSIL patients with HR-HPV infection treated with FUS or LEEP from 2015 to 2019. The cohort consisted of 321 patients under 30 years of age, of which 119 patients received FUS and 202 patients received LEEP. The Cox regression model was used to identify the influencing factors for HR-HPV clearance. Kaplan-Meier method was applied to estimate the efficacy of FUS and LEEP in HR-HPV clearance, and the log-rank test was used to compare the efficacy difference between FUS and LEEP. RESULTS Multivariate Cox regression analysis showed that both FUS and LEEP were independent influencing factors for HR-HPV clearance. HR-HPV cleared faster in the FUS group than in the LEEP group [the median time to HR-HPV clearance: 6 months in the FUS group (95% CI: 5.492-6.508) and 6 months in the LEEP group (95% CI: 5.734-6.266), p = 0.021]. The HR-HPV clearance rates at 6 and 12 months were 54.6% and 94.1% respectively in the FUS group, and 50.5% and 79. 2%, respectively in the LEEP group (p = 0.001 at 6 months, p = 0.000 at 12 months). CONCLUSIONS For HPV-positive HSIL patients under 30, FUS had a better HR-HPV clearance effect than LEEP 1 year after treatment. FUS may be a viable modality for the treatment of young HSIL patients.
Collapse
Affiliation(s)
- Yi Qin
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Qing Li
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Xunyu Ke
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Yan Zhang
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Xiaoling Shen
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Wenping Wang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Qiuling Shi
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Chengzhi Li
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| |
Collapse
|
14
|
Gustafson LW, Petersen LK, Bor P, Andersen B, Hammer A. Cervical cancer prevention among older women - challenges in screening, diagnostic workup and treatment. Acta Obstet Gynecol Scand 2021; 100:1364-1368. [PMID: 33866548 DOI: 10.1111/aogs.14162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 11/30/2022]
Abstract
Cervical cancer incidence and mortality have declined dramatically after screening for cervical cancer was implemented. Yet, studies have reported high cervical cancer incidence and mortality rates at older age despite low HPV prevalence and incidence of precursor lesions. The underlying reason for these findings remains unclear. However, it is well known that the impact of screening depends not only on the uptake and effectiveness of screening but also on the uptake and effectiveness of diagnostic workup (ie colposcopy), treatment and follow-up. In older women, sensitivity of screening and performance of colposcopy are impaired due to age-dependent changes to the cervix. In this commentary, we aimed to discuss challenges in screening and clinical management of older women, and to identify crucial areas of particular interest for future research.
Collapse
Affiliation(s)
- Line W Gustafson
- Department of Public Health Programs, Randers Regional Hospital, Randers, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark.,Open Patient data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Pinar Bor
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Randers Regional Hospital, Randers, Denmark
| | - Berit Andersen
- Department of Public Health Programs, Randers Regional Hospital, Randers, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne Hammer
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Gødstrup Hospital, Gødstrup, Denmark.,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
15
|
Bonde J, Bottari F, Iacobone AD, Cocuzza CE, Sandri MT, Bogliatto F, Khan KS, Ejegod DM, Gary DS, Andrews JC. Human Papillomavirus Same Genotype Persistence and Risk: A Systematic Review. J Low Genit Tract Dis 2021; 25:27-37. [PMID: 33105450 PMCID: PMC7748037 DOI: 10.1097/lgt.0000000000000573] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to examine whether high-grade cervical intraepithelial neoplasia (CIN) was more closely associated with human papillomavirus (HPV) same-genotype persistence (SGTP) versus clearance of prior infection with a subsequent infection by a new genotype (genotype switch [GS]), clearance of HPV infection, or acquisition of a new HPV infection after a negative infection status, during a follow-up testing subsequent to abnormal screening results. MATERIALS AND METHODS MEDLINE, Cochrane Library, Health Technology Assessment, and clinicaltrials.gov were searched from January 2000 to July 2019 for prospective controlled trials and observational studies of women and retrospective studies using HPV assays with extended- or full-genotype reporting. The primary outcome was high-grade CIN after at least 2 rounds of testing. Overall quality of evidence for the risk estimate outcomes was assessed. Of the 830 identified abstracts, 66 full-text articles were reviewed, and 7 studies were included in the synthesis. The study protocol was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42018091093). RESULTS Continued HPV-positive women falls in 2 equally large groups: SGTP and GS. Sensitivity, positive predictive value, and positive likelihood ratio of SGTP were significantly higher than for GS. Human papillomavirus genotypes may be ranked into 3 tiers (immediate colposcopy, follow-up testing, return to routine screening), according to associated risk of persistence for high-grade CIN and to prevailing clinical action thresholds. CONCLUSIONS There is moderately high-quality evidence to support the clinical utility of SGTP to improve risk discrimination for high-grade CIN compared with qualitative HPV testing without genotype-specific information.
Collapse
Affiliation(s)
- Jesper Bonde
- Molecular Pathology Laboratory, Department of Pathology, Copenhagen University Hospital, Hvidovre, Denmark
| | - Fabio Bottari
- Division of Laboratory Medicine, European Institute of Oncology IRCCS, Milan, Italy
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Anna D. Iacobone
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Maria-Teresa Sandri
- Division of Laboratory Medicine, Humanitas Clinical and Research Center IRCCS, Milan, Italy
| | | | - Khalid S. Khan
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
| | - Ditte M. Ejegod
- Molecular Pathology Laboratory, Department of Pathology, Copenhagen University Hospital, Hvidovre, Denmark
| | - Devin S. Gary
- Becton, Dickinson and Company, BD Life Sciences – Diagnostic Systems, Sparks, MD
| | - Jeffrey C. Andrews
- Becton, Dickinson and Company, BD Life Sciences – Diagnostic Systems, Sparks, MD
| |
Collapse
|
16
|
Xu XQ, Rezhake R, Hu SY, Chen F, Zhang X, Pan QJ, Zhang WH, Ma JF, Qiao YL, Zhao FH, Cruickshank M. Effect of Sequential Rounds of Cervical Cancer Screening on Management of HPV-positive Women: A 15-year Population-based Cohort Study from China. Cancer Prev Res (Phila) 2020; 14:363-372. [PMID: 33303694 DOI: 10.1158/1940-6207.capr-20-0456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/09/2020] [Accepted: 12/03/2020] [Indexed: 11/16/2022]
Abstract
Women are anticipated to go through more than two rounds of cervical screening in their lifetime. Human papillomavirus (HPV) testing is increasingly used as the primary cervical cancer screening test. However, triage strategies for HPV-positive women were usually evaluated at baseline screening. We assessed the effect of sequential rounds of cervical screening on several algorithms for HPV triage. A total of 1,997 women ages 35-45 years were enrolled in 1999 in Shanxi, P.R. China and followed up three times at approximately 5-year intervals. Cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+) prevalence by prior HPV results and performance of 12 triage algorithms with cytology, genotyping, and prior HPV were examined among 229 HPV-positive women at the fourth round. CIN2+ prevalence varied from 56.5% (95% confidence interval, 36.8%-74.4%) following 15 years HPV persistence to 3.5% (1.2%-9.9%) with an incident HPV within 15 years. Triage with cytology (with threshold of atypical squamous cells of undetermined significance) yielded positive predictive value (PPV) of 21.4% (13.8%-29.0%), entailing immediate colposcopic referral, and negative predictive value (NPV) of 97.4% (94.6%-100%), permitting retesting at short intervals. Triage with genotyping (16/18/31/33/45/52/58) or prior HPV results showed comparable performance with cytology. Among 11 triage algorithms with similar NPV to cytology, triage with prior HPV results and reflex genotyping (16/18) achieved highest PPV of 28.9% (18.8%-39.1%) and lowest colposcopy referral of 33.2% (27.4%-39.5%). HPV persistence across rounds is an effective risk stratifier in HPV-positive women. Mainstream cytology and genotyping, with or without consideration of prior HPV results, remain effective for HPV triage at fourth round. PREVENTION RELEVANCE: The study highlights the sustained effectiveness of mainstream HPV triage methods, such as cytology and genotyping, after sequential rounds of cervical screening. It also suggests that use of HPV persistence across rounds can improve management of HPV-positive women in cervical cancer screening.
Collapse
Affiliation(s)
- Xiao-Qian Xu
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Remila Rezhake
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Shang-Ying Hu
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Feng Chen
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Xun Zhang
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Qin-Jing Pan
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Wen-Hua Zhang
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Jun-Fei Ma
- Xiangyuan Maternal and Child Health Care and Family Planning Service Center, Changzhi, Shanxi, P.R. China
| | - You-Lin Qiao
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Fang-Hui Zhao
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China.
| | - Margaret Cruickshank
- Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| |
Collapse
|
17
|
Tranberg M, Petersen LK, Elfström KM, Hammer A, Blaakær J, Bennetsen MH, Jensen JS, Andersen B. Expanding the upper age limit for cervical cancer screening: a protocol for a nationwide non-randomised intervention study. BMJ Open 2020; 10:e039636. [PMID: 33154056 PMCID: PMC7646343 DOI: 10.1136/bmjopen-2020-039636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Cervical cancer screening ceases between the ages of 60 and 65 in most countries. Yet, a relatively high proportion of cervical cancers are diagnosed in women above the screening age. This study will evaluate if screening of women aged 65-69 years may result in increased detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) compared with women not invited to screening. Invited women may choose between general practitioner (GP)-based screening or cervico-vaginal self-sampling. Furthermore, the study will assess if self-sampling is superior to GP-based screening in reaching long-term unscreened women. METHODS AND ANALYSIS This population-based non-randomised intervention study will include 10 000 women aged 65-69 years, with no record of a cervical cytology sample or screening invitation in the 5 years before inclusion. Women who have opted-out of the screening programme or have a record of hysterectomy or cervical amputation are excluded. Women residing in the Central Denmark Region (CDR) are allocated to the intervention group, while women residing in the remaining four Danish regions are allocated to the reference group. The intervention group is invited for human papillomavirus-based screening by attending routine screening at the GP or by requesting a self-sampling kit. The reference group receives standard care which is the opportunity to have a cervical cytology sample obtained at the GP or by a gynaecologist. The study started in April 2019 and will run over the next 4.5 years. The primary outcome will be the proportion of CIN2+ detected in the intervention and reference groups. In the intervention group, the proportion of long-term unscreened women attending GP-based screening or self-sampling will be compared. ETHICS AND DISSEMINATION The study has been submitted to the Ethical Committee in the CDR which deemed that the study was not notifiable to the Committee and informed consent is therefore not required. The study is approved by the Danish Data Protection Regulation and the Danish Patient Safety Authority. Results will be disseminated in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04114968.
Collapse
Affiliation(s)
- Mette Tranberg
- Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- OPEN, Department of Clinical Medicine, University of Southern Denmark, Odense, Denmark
| | - Klara Miriam Elfström
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Regional Cancer Center of Stockholm-Gotland, Stockholm, Sweden
| | - Anne Hammer
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Regionshospitalet Herning, Herning, Denmark
| | - Jan Blaakær
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- OPEN, Department of Clinical Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Jørgen Skov Jensen
- Research Unit for Reproductive Microbiology, Statens Serum Institut, Copenhagen, Denmark
| | - Berit Andersen
- Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
18
|
Asciutto KC, Borgfeldt C, Forslund O. 14-type HPV mRNA test in triage of HPV DNA-positive postmenopausal women with normal cytology. BMC Cancer 2020; 20:1025. [PMID: 33097006 PMCID: PMC7583187 DOI: 10.1186/s12885-020-07498-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 10/06/2020] [Indexed: 12/22/2022] Open
Abstract
Background During 2013 and 2016 the region of Skåne, Sweden started to analyse human papillomavirus (HPV) and cytology in postmenopausal women 60–65 years of age. Our aim was to evaluate high-risk (HR) HPV mRNA testing for the triage of HPV DNA-positive postmenopausal women with normal cytology. Methods A total of 271 women, 60–65 years of age, underwent liquid-based cytology (LBC) and HPV testing by using the HR-HPV DNA MGP-PCR-Luminex assay. HR-HPV DNA-positive women with normal cytology underwent complimentary HPV mRNA testing (Aptima, Hologic Inc.). Over a period of 49 months (SD 11.0) the women received regular follow-ups at intervals of 12–18 months. Women with abnormal cytology and/or a positive HR-HPV DNA and/or mRNA result at two subsequent visits were scheduled for colposcopy and clinical examination. Results Over the surveillance period, 3.6% (10/271) of the HR-HPV DNA-positive women developed histologically confirmed high-grade squamous intraepithelial lesions (HSILs) or worse. The cumulative incidence rates (CIR) were 29.7% (CI 24.8–30.1) for HSIL or worse among HPV mRNA-positive women at enrolment (39.5% 107/271) and 0% among HPV mRNA-negative women (60.5%, 164/271), (p = 0.002). Conclusions Postmenopausal women with normal cytology testing positive for HR-HPV mRNA are at increased risk for the development of high-grade cervical intraepithelial neoplasia (CIN), in contrast to women with a negative HR-HPV mRNA outcome. The HR-HPV mRNA APTIMA assay detecting 14 HR-HPV types may be a useful triage method among HPV DNA-positive postmenopausal women with normal cytology.
Collapse
Affiliation(s)
- Katrin Christine Asciutto
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, SE-22185, Lund, Sweden.
| | - Christer Borgfeldt
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, SE-22185, Lund, Sweden
| | - Ola Forslund
- Department of Laboratory Medicine Region Skåne, Lund University, Lund, Sweden
| |
Collapse
|
19
|
Bogani G, DI Donato V, Sopracordevole F, Ciavattini A, Ghelardi A, Lopez S, Simoncini T, Plotti F, Casarin J, Serati M, Pinelli C, Valenti G, Bergamini A, Gardella B, Dell'acqua A, Monti E, Vercellini P, Fischetti M, D'Ippolito G, Aguzzoli L, Mandato VD, Carunchio P, Carlinfante G, Giannella L, Scaffa C, Falcone F, Borghi C, Ditto A, Malzoni M, Giannini A, Salerno MG, Liberale V, Contino B, Donfrancesco C, Desiato M, Perrone AM, Dondi G, De Iaco P, Leone Roberti Maggiore U, Signorelli M, Chiappa V, Ferrero S, Sarpietro G, Matarazzo MG, Cianci A, Bosio S, Ruisi S, Guerrisi R, Brusadelli C, Mosca L, Tinelli R, DE Vincenzo R, Zannoni GF, Ferrandina G, Petrillo M, Dessole S, Angioli R, Greggi S, Spinillo A, Ghezzi F, Colacurci N, Muzii L, Benedetti Panici P, Scambia G, Raspagliesi F. Recurrence rate after loop electrosurgical excision procedure (LEEP) and laser Conization: A 5-year follow-up study. Gynecol Oncol 2020; 159:636-641. [PMID: 32893030 DOI: 10.1016/j.ygyno.2020.08.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/21/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Conization aims to remove pre-neoplastic lesions of the uterine cervix. Several techniques for conization have been compared, but evidence regarding the most effective therapeutic option is scant. Here, we aimed to compare the recurrence rate following laser conization and loop electrosurgical excision procedure (LEEP) in patients with high-grade cervical dysplasia (HSIL/CIN2+). METHODS This is a retrospective multi-institutional study. Medical records of consecutive patients with HSIL/CIN2+ undergoing conization between 2010 and 2014 were retrieved. A propensity-score matching (PSM) was applied in order to reduce allocation bias. The risk of developing recurrence was estimated using Kaplan-Meir and Cox hazard models. RESULTS Overall, 2966 patients had conization over the study period, including 567 (20%) and 2399 (80%) patients having laser conization and LEEP, respectively. Looking at predictors of recurrence, diagnosis of CIN3 (HR:3.80 (95%CI:2.01,7.21); p < 0.001) and HPV persistence (HR:1.81 (95%CI:1.11,2.96); p < 0.001) correlated with an increased risk of recurrence. After applying a PSM we selected 500 patients undergoing laser conization and 1000 undergoing LEEP. Patients undergoing LEEP were at higher risk of having positive surgical margins in comparison to patients undergoing laser conization (11.2% vs. 4.2%). The risk of having persistence of HPV was similar between the two groups (15.0% vs. 11.6%;p = 0.256). Five-year recurrence rate was 8.1% and 4% after LEEP and laser conization, respectively (p = 0.023). HPV persistence was the only factor associated with [5-]year recurrence after both laser conization (p = 0.003) and LEEP (p = 0.001). CONCLUSIONS HPV persistence is the only factor associated with an increased risk of recurrence after either laser conization or LEEP. Owing to the lack of data regarding obstetrical outcomes, we are not able to assess the best therapeutic option for women with cervical dysplasia.
Collapse
Affiliation(s)
- Giorgio Bogani
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via G Venezian 1, Milano, 20133, MI, Italy.
| | - Violante DI Donato
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy
| | - Francesco Sopracordevole
- Gynecological Oncology Unit, Centro di Riferimento Oncologico - National Cancer Institute, Via F. Gallini 2, 33081, Aviano, Italy
| | - Andrea Ciavattini
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy
| | - Alessandro Ghelardi
- Azienda Usl Toscana Nord-Ovest, UOC Ostetricia e Ginecologia, Ospedale Apuane, Massa, Italy
| | - Salvatore Lopez
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via G Venezian 1, Milano, 20133, MI, Italy
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | | | - Jvan Casarin
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy
| | - Maurizio Serati
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy
| | - Ciro Pinelli
- Ospedale di circolo Fondazione Macchi, Varese, Italy
| | - Gaetano Valenti
- Gynecological Oncology Unit, Centro di Riferimento Oncologico - National Cancer Institute, Via F. Gallini 2, 33081, Aviano, Italy
| | - Alice Bergamini
- Department of Obstetrics and Gynecology, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Barbara Gardella
- IRCCS S. Matteo Foundation, Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Andrea Dell'acqua
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ermelinda Monti
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Margherita Fischetti
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy
| | - Giovanni D'Ippolito
- Division of Obstetrics and Gynecology, Cesare Magati Hospital, Scandiano, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
| | - Lorenzo Aguzzoli
- Division of Obstetrics and Gynecology, Cesare Magati Hospital, Scandiano, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
| | - Vincenzo D Mandato
- Division of Obstetrics and Gynecology, Cesare Magati Hospital, Scandiano, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
| | - Paola Carunchio
- Division of Obstetrics and Gynecology, Cesare Magati Hospital, Scandiano, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
| | - Gabriele Carlinfante
- Division of Obstetrics and Gynecology, Cesare Magati Hospital, Scandiano, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
| | - Luca Giannella
- Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy
| | - Cono Scaffa
- Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Francesca Falcone
- Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Chiara Borghi
- Department of Obstetrics and Gynecology, S. Anna University Hospital, Ferrara, Italy
| | - Antonino Ditto
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via G Venezian 1, Milano, 20133, MI, Italy
| | - Mario Malzoni
- Endoscopica Malzoni, Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy
| | - Andrea Giannini
- Department of Woman's and Child's Health, Obstetrics and Gynecological Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - Maria Giovanna Salerno
- Department of Woman's and Child's Health, Obstetrics and Gynecological Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - Viola Liberale
- Department of Obstetrics and Gynecology, Ospedale Maria Vittoria, Torino, Italy
| | - Biagio Contino
- Department of Obstetrics and Gynecology, Ospedale Maria Vittoria, Torino, Italy
| | - Cristina Donfrancesco
- Department of Obstetrics and Gynecology, Azienda ASL, Frosinone, Ospedale S Trinità di Sora, Sora, Iatly
| | - Michele Desiato
- Department of Obstetrics and Gynecology, Azienda ASL, Frosinone, Ospedale S Trinità di Sora, Sora, Iatly
| | - Anna Myriam Perrone
- Gynecologic Oncology Unit, Sant'Orsola-Malpighi Hospital, 40138, Bologna, Italy
| | - Giulia Dondi
- Gynecologic Oncology Unit, Sant'Orsola-Malpighi Hospital, 40138, Bologna, Italy
| | - Pierandrea De Iaco
- Gynecologic Oncology Unit, Sant'Orsola-Malpighi Hospital, 40138, Bologna, Italy
| | - Umberto Leone Roberti Maggiore
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via G Venezian 1, Milano, 20133, MI, Italy
| | - Mauro Signorelli
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via G Venezian 1, Milano, 20133, MI, Italy
| | - Valentina Chiappa
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via G Venezian 1, Milano, 20133, MI, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy.; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Italy
| | - Giuseppe Sarpietro
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124, Catania, Italy
| | - Maria G Matarazzo
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124, Catania, Italy
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124, Catania, Italy
| | - Sara Bosio
- San Paolo Hospital, Università degli Studi di Milano, 20142, Milan, Italy
| | - Simona Ruisi
- San Paolo Hospital, Università degli Studi di Milano, 20142, Milan, Italy
| | | | | | - Lavinia Mosca
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Raffaele Tinelli
- Department of Obstetrics and Gynecology, "Valle d'Itria" Hospital, Martina Franca, via San Francesco da Paola, 74015, Taranto, Italy
| | - Rosa DE Vincenzo
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Gian Franco Zannoni
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Gabriella Ferrandina
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Marco Petrillo
- Gynecologic and Obstetric Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Salvatore Dessole
- Gynecologic and Obstetric Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | | | - Stefano Greggi
- Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Arsenio Spinillo
- IRCCS S. Matteo Foundation, Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy; Ospedale di circolo Fondazione Macchi, Varese, Italy
| | - Nicola Colacurci
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Ludovico Muzii
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy
| | | | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Francesco Raspagliesi
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via G Venezian 1, Milano, 20133, MI, Italy
| |
Collapse
|