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Huang F, He L, Li W, Huang X, Zhang T, Muaibati M, Zhou H, Chen S, Yang W, Yang F, Zhuang L, Hu T. HPV integration: a precise biomarker for detection of residual/recurrent disease after treatment of CIN2-3. Infect Agent Cancer 2024; 19:36. [PMID: 39118158 PMCID: PMC11308599 DOI: 10.1186/s13027-024-00600-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/22/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND This study aimed to investigate whether persistent human papillomavirus integration at the same loci (PHISL) before and after treatment can predict recurrent/residual disease in women with CIN2-3. METHODS A total of 151 CIN2-3 women treated with conization between August 2020 and September 2021 were included. To investigate the precision of HPV integration, we further analyzed HPV integration-positive patients. Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and the Youden index for predicting recurrence/residual disease were calculated. RESULTS Among the 151 enrolled CIN2-3 women, 56 were HPV integration-positive and 95 had HPV integration-negative results. Six (10.7%) experienced recurrence among 56 HPV integration-positive patients, which was more than those in HPV integration-negative patients (one patient, 1.1%). In the 56 HPV integration-positive patients, 12 had positive HPV results after treatment, seven had PHISL, and two had positive cone margin. Among the seven patients who tested with PHISL, six (85.7%) had residual/recurrent disease. PHISL was a prominent predictor of persistent/recurrent disease. The HPV test, the HPV integration test, and PHISL all had a sensitivity of 100% and a NPV of 100% for residual/recurrent disease. PHISL showed better specificity (98.0% vs. 82.0%, p = 0.005) and PPV (85.7% vs. 40.0%, p = 0.001) than the HPV test for predicting recurrence. CONCLUSIONS The HPV-integration-positive CIN2-3 women had much higher relapse rates than HPV-integration-negative CIN2-3 women. The findings indicate that PHISL derived from preoperative and postoperative HPV integration tests may be a precise biomarker for the identification of residual/recurrent CIN 2/3.
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Affiliation(s)
- Fanwei Huang
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Gynecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang He
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Gynecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Li
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Gynecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyuan Huang
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Gynecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Zhang
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Gynecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Munawaer Muaibati
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Gynecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hu Zhou
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Gynecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shimin Chen
- New Technology Platform, Wuhan KDWS Biological Technology Co., Ltd., Wuhan, China
| | - Wenhui Yang
- New Technology Platform, Wuhan KDWS Biological Technology Co., Ltd., Wuhan, China
| | - Fan Yang
- New Technology Platform, Wuhan KDWS Biological Technology Co., Ltd., Wuhan, China
| | - Liang Zhuang
- Cancer Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Ting Hu
- National Clinical Research Centre for Obstetrics and Gynaecology, Cancer Biology Research Centre (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
- Department of Gynecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Recurrence in Cervical High-Grade Squamous Intraepithelial Lesion: The Role of the Excised Endocervical Canal Length-Analysis of 2,427 Patients. J Low Genit Tract Dis 2022; 27:1-6. [PMID: 36205329 DOI: 10.1097/lgt.0000000000000708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to evaluate the influence of the excised canal length on relapse rates of cervical high-grade squamous intraepithelial lesion (HSIL) treated by loop electrosurgical excision procedure and to find a cut-off point, above which lower recurrence rates could be observed, with low probability of compromising future obstetric outcome, and the relationship with other individual factors related to HSIL recurrence. METHOD This was a retrospective cohort study of 2,427 women diagnosed with cervical intraepithelial neoplasia CIN2+ who underwent cervical conization using the high-frequency loop electrosurgical excision procedure surgery technique, to analyze the role of endocervical canal length associated with individual factors in the recurrent disease after CIN2+ treatment and determine a cut-off point for the excised canal length needed to decrease the risk of disease relapse. RESULTS In 2,427 cases, the relapse rate of HSIL treated was 12%. Compromised margins of conization, HIV+, and endocervical canal length were related directly to relapses (p < .001). The cut-off point, by receiver operating characteristic curve, to calculate the endocervical canal length related to relapses was 1.25 cm of canal excised. Canal length of less than 1.25 cm increased the recurrence rate 2.5 times. Compromised margins and HIV+ increased recurrence rates by more than 5 times. CONCLUSION Cervical HSIL recurrence was directly related to the endocervical canal length: excised canal length of 1.25 cm or more decreases recurrence rate; HIV and compromised margins increase the chance of recurrence by more than 5 times.
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Current Updates on Cancer-Causing Types of Human Papillomaviruses (HPVs) in East, Southeast, and South Asia. Cancers (Basel) 2021; 13:cancers13112691. [PMID: 34070706 PMCID: PMC8198295 DOI: 10.3390/cancers13112691] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022] Open
Abstract
Simple Summary Among the over 200 human papillomavirus (HPV) genotypes identified, approximately 15 of them can cause human cancers. In this review, we provided an updated overview of the distribution of cancer-causing HPV genotypes by countries in East, Southeast and South Asia. Besides the standard screening and treatment methods employed in these regions, we unravel HPV detection methods and therapeutics utilised in certain countries that differ from other part of the world. The discrepancies may be partly due to health infrastructure, socio-economy and cultural diversities. Additionally, we highlighted the area lack of study, particularly on the oncogenicity of HPV genotype variants of high prevalence in these regions. Abstract Human papillomavirus (HPV) infection remains one of the most prominent cancer-causing DNA viruses, contributing to approximately 5% of human cancers. While association between HPV and cervical cancers has been well-established, evidence on the attribution of head and neck cancers (HNC) to HPV have been increasing in recent years. Among the cancer-causing HPV genotypes, HPV16 and 18 remain the major contributors to cancers across the globe. Nonetheless, the distribution of HPV genotypes in ethnically, geographically, and socio-economically diverse East, Southeast, and South Asia may differ from other parts of the world. In this review, we garner and provide updated insight into various aspects of HPV reported in recent years (2015–2021) in these regions. We included: (i) the HPV genotypes detected in normal cancers of the uterine cervix and head and neck, as well as the distribution of the HPV genotypes by geography and age groups; (ii) the laboratory diagnostic methods and treatment regimens used within these regions; and (iii) the oncogenic properties of HPV prototypes and their variants contributing to carcinogenesis. More importantly, we also unveil the similarities and discrepancies between these aspects, the areas lacking study, and the challenges faced in HPV studies.
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Kolben TM, Etzel LT, Bergauer F, Hagemann I, Hillemanns P, Repper M, Kaufmann AM, Sotlar K, Kolben T, Helms HJ, Gallwas J, Mahner S, Dannecker C. A randomized trial comparing limited-excision conisation to Large Loop Excision of the Transformation Zone (LLETZ) in cervical dysplasia patients. J Gynecol Oncol 2019; 30:e42. [PMID: 30887760 PMCID: PMC6424847 DOI: 10.3802/jgo.2019.30.e42] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 11/21/2018] [Accepted: 11/28/2018] [Indexed: 11/30/2022] Open
Abstract
Objective To show noninferiority of a limited-excision (resection of the dysplastic lesion only) vs. classical Large Loop Excision of the Transformation Zone (LLETZ). Methods In this prospective, randomized, multicenter trial, women with human papillomavirus (HPV) positive cervical intraepithelial neoplasia grade 3 were randomized into two groups (1:1). Primary outcome was the rate of negative HPV tests after 6 months, secondary outcomes included cone size, complete resection rates as well as cytological and histological results after 6 and 12 months. A sample size of 1,000 was calculated to show noninferiority of the limited-excision compared to the LLETZ group using a noninferiority margin of 5%. Enrollment was stopped after 100 patients due to slow accrual. Results Patients in the limited-excision group did not show a lower number of negative HPV tests (78% [LLETZ]−80% [limited-excision]=−2%; 90% confidence interval=−15%, 12%). The limited-excision resulted in a substantially lower cone size (LLETZ: 1.97 mL vs. limited-excision: 1.02 mL; p<0.001) but higher numbers of involved margins (LLETZ: 8% vs. limited-excision: 20%). Although postoperative cytological results slightly differed, histological results were similar in both groups. One limited-excision patient received immediate re-conisation, whereas one patient in each group was scheduled for re-conisation after 6 months. Conclusion The limited-excision could represent a promising option to reduce the surgical extent of conisations while maintaining oncological safety. The trial was not sufficiently powered to reach statistical significance due to early termination. Nevertheless, the study provides important insights in the feasibility of a limited-excision and could serve as a pilot study for future trials. Trial Registration German Clinical Trials Register Identifier: DRKS00006169
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Affiliation(s)
- Theresa Maria Kolben
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany.
| | - Lea T Etzel
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Florian Bergauer
- Amedes MVZ for Gynecology and Pathology Munich GmbH, Munich, Germany
| | | | - Peter Hillemanns
- Department of Obstetrics and Gynaecology, Hannover Medical School, Hannover, Germany
| | - Monika Repper
- Department of Obstetrics and Gynaecology, Hannover Medical School, Hannover, Germany
| | - Andreas M Kaufmann
- Department for Gynecology, Charité-Universitaetsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Karl Sotlar
- Institute of Pathology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Thomas Kolben
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Hans Joachim Helms
- Department of Medical Statistics, University Medical Center Goettingen, Goettingen, Germany
| | - Julia Gallwas
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Sven Mahner
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Dannecker
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
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Risk of Cervical Dysplasia After Colposcopy Care and Risk-Informed Return to Population-Based Screening: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 42:607-624. [PMID: 31679914 DOI: 10.1016/j.jogc.2019.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/21/2019] [Accepted: 05/30/2019] [Indexed: 11/22/2022]
Abstract
This systematic review examined the risk of cervical dysplasia among women who have undergone a colposcopy episode of care to inform their return to population-based cervical screening. PubMed, Embase, and grey literature were searched between January 2000 and 2018. One reviewer screened citations against pre-defined eligibility criteria. A second reviewer verified 10% and 100% of exclusions at title and abstract and at full-text screening, respectively. One reviewer extracted data and assessed methodological quality of included articles; a second reviewer verified these in full. The primary outcome was incidence of cervical intraepithelial neoplasia grade 2 or greater (CIN2+) subsequent to initial colposcopy evaluation. Secondary outcomes included incidence of CIN2+ after negative follow-up test results and performance of follow-up strategies. Results were synthesized narratively. A total of 48 studies were included. The 1- to 5-year CIN2+ risks after colposcopy evaluation ranged from 2.4% to 16.5% among women treated for CIN2+ and from 0.7% to 16.8% among women untreated for CIN grade 1 or less (≤CIN1). Follow-up strategies included single or repeat cytology, human papillomavirus (HPV) testing, or combined HPV/cytology co-testing at various intervals. After negative follow-up test results, risk varied by follow-up strategy for both groups and by referral cytology severity for untreated women. Performance of follow-up strategies varied among treated women. Among untreated women, co-testing demonstrated greater sensitivity than cytology alone. In conclusion, women treated during colposcopy for CIN2+ and women with ≤CIN1 who were referred to colposcopy for low-grade cytology and who did not receive treatment may be able to return to population-based screening after negative co-testing results. Current evidence does not suggest that women untreated for ≤CIN1 who are referred for high-grade cytology be returned to screening at an average risk interval. The optimal strategy for colposcopy discharge needs ongoing evaluation as implementation of HPV testing evolves.
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Arbyn M, Redman CWE, Verdoodt F, Kyrgiou M, Tzafetas M, Ghaem-Maghami S, Petry KU, Leeson S, Bergeron C, Nieminen P, Gondry J, Reich O, Moss EL. Incomplete excision of cervical precancer as a predictor of treatment failure: a systematic review and meta-analysis. Lancet Oncol 2017; 18:1665-1679. [PMID: 29126708 DOI: 10.1016/s1470-2045(17)30700-3] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/24/2017] [Accepted: 08/29/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Incomplete excision of cervical precancer is associated with therapeutic failure and is therefore considered as a quality indicator of clinical practice. Conversely, the risk of preterm birth is reported to correlate with size of cervical excision and therefore balancing the risk of adequate treatment with iatrogenic harm is challenging. We reviewed the literature with an aim to reveal whether incomplete excision, reflected by presence of precancerous tissue at the section margins, or post-treatment HPV testing are accurate predictors of treatment failure. METHODS We did a systematic review and meta-analysis to assess the risk of therapeutic failure associated with the histological status of the margins of the tissue excised to treat cervical precancer. We estimated the accuracy of the margin status to predict occurrence of residual or recurrent high-grade cervical intraepithelial neoplasia of grade two or worse (CIN2+) and compared it with post-treatment high-risk human papillomavirus (HPV) testing. We searched for published systematic reviews and new references from PubMed-MEDLINE, Embase, and CENTRAL and did also a new search spanning the period Jan 1, 1975, until Feb 1, 2016. Studies were eligible if women underwent treatment by excision of a histologically confirmed CIN2+ lesion, with verification of presence or absence of CIN at the resection margins; were tested by cytology or HPV assay between 3 months and 9 months after treatment; and had subsequent follow-up of at least 18 months post-treatment including histological confirmation of the occurrence of CIN2+. Primary endpoints were the proportion of positive section margins and the occurrence of treatment failure associated with the marginal status, in which treatment failure was defined as occurrence of residual or recurrent CIN2+. Information about positive resection margins and subsequent treatment failure was pooled using procedures for meta-analysis of binomial data and analysed using random-effects models. FINDINGS 97 studies were eligible for inclusion in the meta-analysis and included 44 446 women treated for cervical precancer. The proportion of positive margins was 23·1% (95% CI 20·4-25·9) overall and varied by treatment procedure (ranging from 17·8% [12·9-23·2] for laser conisation to 25·9% [22·3-29·6] for large loop excision of the transformation zone) and increased by the severity of the treated lesion. The overall risk of residual or recurrent CIN2+ was 6·6% (95% CI 4·9-8·4) and was increased with positive compared with negative resection margins (relative risk 4·8, 95% CI 3·2-7·2). The pooled sensitivity and specificity to predict residual or recurrent CIN2+ was 55·8% (95% CI 45·8-65·5) and 84·4% (79·5-88·4), respectively, for the margin status, and 91·0% (82·3-95·5) and 83·8% (77·7-88·7), respectively, for high-risk HPV testing. A negative high-risk HPV test post treatment was associated with a risk of CIN2+ of 0·8%, whereas this risk was 3·7% when margins were free. INTERPRETATION The risk of residual or recurrent CIN2+ is significantly greater with involved margins on excisional treatment; however, high-risk HPV post-treatment predicts treatment failure more accurately than margin status. FUNDING European Federation for Colposcopy and Institut national du Cancer (INCA).
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Affiliation(s)
- Marc Arbyn
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Scientific Institute of Public Health, Brussels, Belgium.
| | | | - Freija Verdoodt
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Maria Kyrgiou
- Division of Reproductive Biology, Department Cancer and Surgery, Imperial College, London, UK
| | - Menelaos Tzafetas
- Division of Reproductive Biology, Department Cancer and Surgery, Imperial College, London, UK
| | - Sadaf Ghaem-Maghami
- Division of Reproductive Biology, Department Cancer and Surgery, Imperial College, London, UK
| | - Karl-Ulrich Petry
- Department of Gynaecology and Obstetrics, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Simon Leeson
- Department of Gynaecology and Obstetrics, Betsi Cadwaladr University Health Board, Bangor, Gwyndd, UK
| | | | - Pekka Nieminen
- Department of Gynaecology and Obstetrics, Helsinki University Hospital, Helsinki, Finland
| | - Jean Gondry
- Service de gynécologie et obstétrique, CHU d'Amiens-Picardie, Amiens, France
| | - Olaf Reich
- Department of Gynaecology and Obstetrics, Medical University of Graz, Graz, Austria
| | - Esther L Moss
- Department of Cancer Studies, University of Leicester, Leicester, UK
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Hoffman SR, Le T, Lockhart A, Sanusi A, Dal Santo L, Davis M, McKinney DA, Brown M, Poole C, Willame C, Smith JS. Patterns of persistent HPV infection after treatment for cervical intraepithelial neoplasia (CIN): A systematic review. Int J Cancer 2017; 141:8-23. [PMID: 28124442 DOI: 10.1002/ijc.30623] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 11/25/2016] [Accepted: 12/13/2016] [Indexed: 01/01/2023]
Abstract
A systematic review of the literature was conducted to determine the estimates of and definitions for human papillomavirus (HPV) persistence in women following treatment of cervical intra-epithelial neoplasia (CIN). A total of 45 studies presented data on post-treatment HPV persistence among 6,106 women. Most studies assessed HPV persistence after loop excision (42%), followed by conization (7%), cryotherapy (11%), laser treatment (4%), interferon-alpha, therapeutic vaccination, and photodynamic therapy (2% each) and mixed treatment (38%). Baseline HPV testing was conducted before or at treatment for most studies (96%). Follow-up HPV testing ranged from 1.5 to 80 months after baseline. Median HPV persistence tended to decrease with increasing follow-up time, declining from 27% at 3 months after treatment to 21% at 6 months, 15% at 12 months, and 10% at 24 months. Post-treatment HPV persistence estimates varied widely and were influenced by patient age, HPV-type, detection method, treatment method, and minimum HPV post-treatment testing interval. Loop excision and conization appeared to outperform cryotherapy procedures in terms of their ability to clear HPV infection. This systematic review provides evidence for the substantial heterogeneity in post-treatment HPV DNA testing practices and persistence estimates.
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Affiliation(s)
- Sarah R Hoffman
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Tam Le
- UNC School of Medicine, Chapel Hill, NC
| | - Alexandre Lockhart
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Ayodeji Sanusi
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Leila Dal Santo
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Meagan Davis
- Department of Health Behavior, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Dana A McKinney
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Meagan Brown
- Department of Health Behavior, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Charles Poole
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Corinne Willame
- Business & Decision Life Science on behalf of GlaxoSmithKline Vaccines, Wavre, Belgium
| | - Jennifer S Smith
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
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Kang WD, Ju UC, Kim SM. A human papillomavirus (HPV)-16 or HPV-18 genotype is a reliable predictor of residual disease in a subsequent hysterectomy following a loop electrosurgical excision procedure for cervical intraepithelial neoplasia 3. J Gynecol Oncol 2015; 27:e2. [PMID: 26463431 PMCID: PMC4695452 DOI: 10.3802/jgo.2016.27.e2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/24/2015] [Accepted: 09/08/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE This study was conducted using the human papillomavirus (HPV) DNA chip test (HDC), in order to determine whether the HPV genotype is a predictor of residual disease in a subsequent hysterectomy following a loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia (CIN) 3. METHODS Between January 2002 and February 2015, a total of 189 patients who underwent a hysterectomy within 6 months of LEEP caused by CIN 3 were included in this study. We analyzed their epidemiological data, pathological parameters, high-risk HPV (HR-HPV) load as measured by the hybrid capture II assay, and HR-HPV genotype as measured by the HDC. A logistic regression model was used to analyze the relationship between covariates and the probability of residual disease in subsequent hysterectomy specimens. RESULTS Of the 189 patients, 92 (48.7%) had residual disease in the hysterectomy specimen, CIN 2 in seven patients, CIN 3 in 79 patients, IA1 cancer in five patients, and IA2 cancer in one patient. Using multivariate analysis, the results were as follows: cone margin positivity (odds ratio [OR], 2.43; 95% CI, 1.18 to 5.29; p<0.05), HPV viral load ≥220 relative light unit (OR, 2.98; 95% CI, 1.38 to 6.43; p<0.01), positive endocervical cytology (OR, 8.97; 95% CI, 3.81 to 21.13; p<0.001), and HPV-16 or HPV-18 positivity (OR, 9.07; 95% CI, 3.86 to 21.30; p<0.001). CONCLUSION The HPV-16 or HPV-18 genotype is a reliable predictive factor of residual disease in a subsequent hysterectomy following a LEEP for CIN 3.
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Affiliation(s)
- Woo Dae Kang
- Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, Korea
| | - U Chul Ju
- Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, Korea
| | - Seok Mo Kim
- Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, Korea.
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Schwarz TM, Kolben T, Gallwas J, Crispin A, Dannecker C. Comparison of two surgical methods for the treatment of CIN: classical LLETZ (large-loop excision of the transformation zone) versus isolated resection of the colposcopic apparent lesion - study protocol for a randomized controlled trial. Trials 2015; 16:225. [PMID: 26002493 PMCID: PMC4443515 DOI: 10.1186/s13063-015-0736-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/01/2015] [Indexed: 11/10/2022] Open
Abstract
Background In compliance with national and international guidelines, non-pregnant women with cervical intraepithelial neoplasia grade 3 should be treated by cervical conization. According to the definition of the large loop excision of the transformation zone (LLETZ) operation, the lesion needs to be resected, including the transformation zone. It is well known from the literature that the cone size directly correlates with the risk of preterm delivery in the course of a future pregnancy. Thus, it would be highly desirable to keep the cone dimension as small as possible while maintaining the same level of oncological safety. Methods/Design The aim of this study is to analyze whether resection of the lesion only, without additional excision of the transformation zone, is equally as effective as the classical LLETZ operation regarding oncological outcome. We are performing this prospective, patient-blinded multicenter trial by randomly assigning women who need to undergo a LLETZ operation for cervical intraepithelial neoplasia grade 3 to either of the following two groups at a ratio of 1:1: (1) additional resection of the transformation zone or (2) resection of the lesion only. To evaluate equal oncological outcome, we are performing human papillomavirus (HPV) tests 6 and 12 months postoperatively. The study is designed to consider the lesion-only operation as oncologically not inferior if the rate of HPV high-risk test results is not higher than 5 % compared with the HPV high-risk rate of women undergoing the classical LLETZ operation. Discussion In case that non-inferiority of the “lesion-only” method can be demonstrated, this operation should eventually become standard treatment for all women at childbearing age due to the reduction in risk of preterm delivery. Trial registration German Clinical Trials Register (DRKS) Identifier: DRKS00006169. Date of registration: 30 July 2014.
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Affiliation(s)
- Theresa M Schwarz
- Department of Obstetrics and Gynaecology, Ludwig Maximilian University, Campus Grosshadern, Munich, D-81377, Germany.
| | - Thomas Kolben
- Department of Obstetrics and Gynaecology, Ludwig Maximilian University, Campus Grosshadern, Munich, D-81377, Germany.
| | - Julia Gallwas
- Department of Obstetrics and Gynaecology, Ludwig Maximilian University, Campus Grosshadern, Munich, D-81377, Germany.
| | - Alexander Crispin
- Department of Obstetrics and Gynaecology, Ludwig Maximilian University, Campus Grosshadern, Munich, D-81377, Germany.
| | - Christian Dannecker
- Department of Obstetrics and Gynaecology, Ludwig Maximilian University, Campus Grosshadern, Munich, D-81377, Germany.
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Kong TW, Son JH, Chang SJ, Paek J, Lee Y, Ryu HS. Value of endocervical margin and high-risk human papillomavirus status after conization for high-grade cervical intraepithelial neoplasia, adenocarcinoma in situ, and microinvasive carcinoma of the uterine cervix. Gynecol Oncol 2014; 135:468-73. [DOI: 10.1016/j.ygyno.2014.09.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 09/21/2014] [Accepted: 09/28/2014] [Indexed: 01/11/2023]
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Ryu A, Nam K, Kwak J, Kim J, Jeon S. Early human papillomavirus testing predicts residual/recurrent disease after LEEP. J Gynecol Oncol 2012; 23:217-25. [PMID: 23094124 PMCID: PMC3469856 DOI: 10.3802/jgo.2012.23.4.217] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Revised: 05/11/2012] [Accepted: 05/20/2012] [Indexed: 11/30/2022] Open
Abstract
Objective The purpose of this study was to determine the predictive factors for residual/recurrent disease and to analyze the timing for Pap smears and human papillomavirus (HPV) testing during follow-up after loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia (CIN) 2 or worse. Methods We retrospectively analyzed 183 patients (mean age, 39.3 years) with CIN 2/3 who were treated with LEEP. Post-LEEP follow-up was performed by Pap smear and HPV hybrid capture2 (HC2) testing. The definition of persistent/recurrent disease was biopsy-proven CIN 2 or worse. Results Among 183 patients, punch biopsies were CIN 2 in 31 (16.9%) and CIN 3 in 152 (83.1%). HPV HC2 tests before LEEP were positive in 170 (95.5%) of 178 patients. During follow-up, 12 patients (6.6%) had residual/recurrent CIN 2+. LEEP margin status was a significant predictive factor for persistent/recurrent disease. Other factors such as age, HPV HC2 viral load (≥100 relative light units), and HPV typing (type 16/18 vs. other types) did not predict recurrence. Early HPV HC2 testing at 3 months after LEEP detected all cases of residual/recurrent disease. The sensitivity and negative predictive value of the HPV HC2 test for residual/recurrent disease were both 100% at 3 and 6 months. Conclusion Margin involvement in conization specimens was a significant factor predicting residual/recurrent disease after LEEP. HPV test results at 3 and 6 months after treatment were comparable. Early 3-month follow-up testing after LEEP can offer timely information about residual/recurrent disease and alleviate patient anxiety early about treatment failure.
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Affiliation(s)
- Aeli Ryu
- Department of Obstetrics & Gynecology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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Oliveira PS, Coelho CC, Cerqueira EFSD, Lopes FVF, Fernandes MSA, Monteiro DLM. [Management of high grade squamous intraepithelial lesion of the cervix of adult women]. Rev Col Bras Cir 2011; 38:274-9. [PMID: 21971862 DOI: 10.1590/s0100-69912011000400012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Accepted: 05/05/2010] [Indexed: 11/22/2022] Open
Abstract
Cervical cancer is the second most common cancer among women worldwide, despite having great potential for prevention and cure when early diagnosed and treated, which can reduce the mortality rate among the affected. Since there is no consensus among the therapeutic measures in high grade cervical squamous intraepithelial lesions (HGSIL), we discuss its approach when dealing with adult women who have HGSIL and the follow-up after the adopted procedure. We performed electronic searches of MEDLINE (through PubMed), National Guidelines Clearinghouse, Google Scholar and Lilacs. The guidelines identified were evaluated according to their validity and recommendations. In relation to after-care, the European use cytology every 6 months, the Australians, cytology and colposcopy every 6 months, the Americans advocate the realization of hybrid capture in six to 12 months or cytology every 6 months. The Brazilian Guidelines Project, on its turn, recommends that clinical reassessments and Pap smear should be performed every three or four months during the first two years of follow-up. Studies comparing the method "See and Treat" with the three steps one (histology, colposcopy, biopsy) concluded that the latter is indicated for women ASCUS/LSIL before undergoing the excision of the transformation zone (ETZ), while the "View and Treat" is indicated in women with proven HGSIL in cytology and suggestive in colposcopy, because it presents advantages such as low cost and immediate solution. All the guidelines are unanimous in stating that when facing proven HGSIL, excision of the injury through ablation or conization or ETZ is indicated.
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Dogan NU, Salman MC, Yuce K. The role of HPV DNA testing in the follow-up of cervical intraepithelial neoplasia after loop electrosurgical excision procedure. Arch Gynecol Obstet 2010; 283:871-7. [PMID: 20514490 DOI: 10.1007/s00404-010-1530-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Accepted: 05/18/2010] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To assess human papilloma viruses (HPV) DNA test for detection of recurrences in cervical intraepithelial neoplasia (CIN) patients after loop electrosurgical excision procedure (LEEP). Also effect of LEEP on the clearance of HPV infection was evaluated for CIN 1 lesions. METHODS HPV DNA positive 37 patients (25 CIN 2-3 and 12 CIN 1 cases proven by colposcopic biopsies) were treated with LEEP and followed prospectively with HPV DNA and cytology at third and sixth months. RESULTS There were 11 patients with abnormal cytologic results in third month and 4 in sixth month. HPV DNA positivity rate declined in CIN 1 group between third and sixth month but this did not reach to statistical significance (44 vs. 36%, P = 0.41). There were 3 treatment failures out of 37 patients (8.1%). All these three patients had CIN 3 at the beginning and two of them had positive HPV DNA in two controls. There were no recurrence/treatment failure for CIN 1 patients. Regarding 37 patients, decrease in cytologic abnormality incidence between third and sixth-month control was statistically significant (29.7 vs. 10.9%, P = 0.03). All four patients with cytologic abnormality at the sixth month had HPV persistence. Cytologic abnormality was more prevelant in HPV persistent women (P = 0.01) and also there was no cytologic abnormality in case of HPV DNA negativity. CONCLUSION LEEP does not seem to decrease HPV DNA incidence for CIN 1 at least for 6 months. But HPV DNA used in addition to cytology might help to detect recurrences.
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Lin CT, Yen CF, Shaw SW, Yen TC, Chen YJ, Soong YK, Lai CH. Gene gun administration of therapeutic HPV DNA vaccination restores the efficacy of prolonged defrosted viral based vaccine. Vaccine 2009; 27:7352-8. [DOI: 10.1016/j.vaccine.2009.09.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2009] [Revised: 09/05/2009] [Accepted: 09/13/2009] [Indexed: 01/29/2023]
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Human papillomavirus test after conization in predicting residual disease in subsequent hysterectomy specimens. Obstet Gynecol 2009; 114:87-92. [PMID: 19546763 DOI: 10.1097/aog.0b013e3181ab6dca] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the effectiveness of the human papillomavirus (HPV) test performed after conization in predicting residual disease in patients who subsequently underwent hysterectomy. METHODS A total of 115 patients who underwent hysterectomy after conization caused by cervical intraepithelial neoplasia grade 3 (CIN 3) and microinvasive cervical cancer (IA1 cancer) were included in this prospective study. All patients underwent HPV testing with a liquid hybridization assay immediately before hysterectomy. Differences in sensitivity, specificity, and accuracy between resection margin and the HPV test in predicting residual disease in subsequent hysterectomy samples were estimated using the McNemar exact test. RESULTS Univariable analysis showed that age, parity, menopausal status, glandular extension, and severity of disease were not predictive for residual disease, but positive resection margin and positive HPV tests were significant factors for predicting residual disease. These factors were also significant in a multivariable analysis (positive resection margin 45.5%, odds ratio [OR] 3.09, 95% confidence interval [CI] 1.19-8.03, P=.021; positive HPV test 57.6%, OR 11.05, 95% CI 4.01-30.49, P<.001). With resection margin, the sensitivity, specificity, and accuracy in predicting residual disease were 75%, 53%, and 61%, respectively, whereas, with the HPV test, these values were 85%, 67%, and 73%, respectively (P=.454, .080, and .044, respectively). Of patients with positive resection margins, 79% of HPV-negative patients had no residual disease. Of patients with negative resection margins, no HPV-negative patient had residual disease. CONCLUSION The HPV test after conization was significantly more accurate than resection margin for predicting residual disease. The predictive value of resection margin for predicting residual disease was much improved when used in combination with the HPV test. Use of the HPV test is recommended for identifying patients for subsequent hysterectomy after conization for CIN 3 and IA1 cancer. LEVEL OF EVIDENCE III.
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Kim YT, Lee JM, Hur SY, Cho CH, Kim YT, Kim SC, Kang SB. Clearance of human papillomavirus infection after successful conization in patients with cervical intraepithelial neoplasia. Int J Cancer 2009; 126:1903-1909. [DOI: 10.1002/ijc.24794] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Park JY, Bae J, Lim MC, Lim SY, Lee DO, Kang S, Park SY, Nam BH, Seo SS. Role of high risk-human papilloma virus test in the follow-up of patients who underwent conization of the cervix for cervical intraepithelial neoplasia. J Gynecol Oncol 2009; 20:86-90. [PMID: 19590718 DOI: 10.3802/jgo.2009.20.2.86] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2009] [Revised: 06/19/2009] [Accepted: 06/21/2009] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine whether the presence of high risk-human papilloma virus (HR-HPV) after conization of the cervix was a risk factor for persistence or recurrence of cervical intraepithelial neoplasia (CIN) and whether HR-HPV test could be a guideline for post-therapy surveillance. METHODS The study retrospectively analyzed data from 243 patients who underwent LLETZ or CKC of the cervix due to CIN. RESULTS A positive HR-HPV test result which was performed between 3 and 6 months after procedure was a risk factor for persistent or recurrent cytological (p<0.001, odds ratio [OR]=22.51, 95% confidence interval [CI]=9.74-52.02) and pathological (p<0.001, OR=18.28, 95% CI=5.55-60.20) abnormalities. CONCLUSION HR-HPV positive patients between 3 and 6 months after procedure should undergo frequent and meticulous post-therapy surveillance, while HR-HPV negative patients do not require such high-level surveillance and could undergo routine surveillance.
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Affiliation(s)
- Jeong-Yeol Park
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Chen FC, Shaw SW, Cheng PJ, Hsueh S, Lin CT. Diagnosis of human papillomavirus infection by abnormal cervical cytology is highly reproducible after vaginal douching. Taiwan J Obstet Gynecol 2009; 47:412-6. [PMID: 19126507 DOI: 10.1016/s1028-4559(09)60008-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To evaluate whether human papillomavirus (HPV) activity in symptomatic patients with abnormal Papanicolaou smears (minimal abnormal cytology) was affected by a complete vaginal douche, applied to the cervix prior to colposcopic examination. MATERIALS AND METHODS A total of 132 women with abnormal Papanicolaou smears were prospectively registered in this study from 1999 to 2004. Two specimens were collected from each patient; one before and one after the cervix was swabbed with a complete vaginal douche during a colposcopic examination. We compared the HPV detection results before and after douching in the same patients. The samples were analyzed using the Hybrid Capture II assay. RESULTS Before douching, 57.6% (76/132) of the samples were HPV-positive, compared with 58.3% (77/132) of the samples after douching. There was a strong correlation between the cervical HPV detection rates between the before and after douche samples (p<0.001). The kappa statistic was 0.891 for the correlation (positive- positive, negative-negative) and the discrepancy (positive-negative) between the inter-douche rates of HPV activity. A comparison of the HPV assay before and after vaginal douching demonstrated a statistically significant relationship (p<0.001). The sensitivity of the HPV test after douching was higher (97.8%) than that before douching (95.6%). The false-negative rate before douching in women with inflammatory smears was 3% (4/132) and the false-positive rate before douching in women with atypical squamous cells of undetermined significance was 2.1% (3/132). CONCLUSION Our results indicate that self-administration of a vaginal douche is not a reliable method of eradicating HPV infection.
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Affiliation(s)
- Fang-Chun Chen
- Department of Family Medicine, Taipei City Hospital, Ren-Ai Branch, Taipei, Taiwan
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[Importance of human papillomavirus (HPV) screening in the follow-up after CIN2-3 treatment]. ACTA ACUST UNITED AC 2008; 37:329-37. [PMID: 18424016 DOI: 10.1016/j.jgyn.2007.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Revised: 05/15/2007] [Accepted: 12/06/2007] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Cervical intraepithelial neoplasia (CIN) 2 and CIN3 lesions clearly represent precancerous states even if some of them would heal spontaneously. Management is based on surgical excision of part of the uterine cervix because such lesions can potentially progress into carcinomas. In most cases, this treatment leads to the cure of intraepithelial lesions. However, even after such an efficient treatment, theses patients are still at a higher risk of developing an invasive cervical cancer. That is why guidelines recommend a specific follow-up in order to screen for residual disease (incomplete excision) or for recurrences (after a complete excision). The actual problem in the follow-up strategy lies in the screening tools in use - cervical smears and colposcopy - whose sensitivities are low and hence, not quite sufficient when applied to a high risk population. These intraepithelial lesions are due to high risk human papillomaviruses (HPV) and there cannot be any lesion progression without HPV. Consequently, a viral testing would help in identifying a high risk subpopulation of women after cone loop cervical excision. MATERIAL AND METHODS We studied, retrospectively, the contribution of HPV testing (Hybrid Capture 2((R))) in the follow-up after CIN2-3 treatment in 386 cone loop cervical excisions performed at a single centre during 80 months. RESULTS Between three to six months follow-up after surgery, HPV remained present in 22.5% cases. The sensitivity of HPV testing in the screening for residual lesions or for recurrences was 100%, that of cervical smears cytology was 72%, whereas that of the pathological analysis of margins reached only 67%. The negative predictive value of a negative HPV detection associated with a normal cytology was 100%. DISCUSSION Owing to its clinical relevance, HPV testing optimises postoperative follow-up and leads to the rapid and efficient selection of a subgroup, representing less than one upon three patients who are really at risk of an invasive lesion and to wholly reassure the others. Indeed, a negative HPV testing, associated with a normal cervical cytology, obtained after surgery correspond to a negative predictive value of almost 100% and this allows us to increase the time-interval between two screenings and to rapidly place the patient in a routine follow-up.
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Park JY, Lee KH, Dong SM, Kang S, Park SY, Seo SS. The association of pre-conization high-risk HPV load and the persistence of HPV infection and persistence/recurrence of cervical intraepithelial neoplasia after conization. Gynecol Oncol 2008; 108:549-54. [PMID: 18177929 DOI: 10.1016/j.ygyno.2007.11.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 11/08/2007] [Accepted: 11/14/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate whether the pre-conization high-risk human papilloma virus (HR-HPV) load is predictive for the persistence of HR-HPV infection and the persistence/recurrence of cervical intraepithelial neoplasia (CIN) after conization of the cervix. MATERIALS AND METHODS A retrospective review was performed on 236 women who underwent conization due to CIN at the Center for Uterine Cancer, National Cancer Center, Korea, between March 2001 and March 2006. The samples for pre-conization HR-HPV test were obtained at least within 3 weeks before conization. All patients underwent HR-HPV testing and cytology between 3 and 6 months after conization, and subsequent follow-up of 3- to 6-month interval was performed thereafter. The persistence of HR-HPV infection and persistence/recurrence of histologic abnormality after conization were analyzed by age, parity, menopausal status, method of conization, glandular extension, margin status, severity of CIN, and pre-cone HR-HPV load in univariate and multivariate analysis. RESULTS In univariate analysis, high pre-cone HR-HPV load was the only risk factor for the persistence of HR-HPV infection after conization (persistent HR-HPV infection; 19.8% [23/116] of patients with an HR-HPV load > or = 100 RLU/PC vs. 10.0% [12/120] of patients with a load < 100 RLU/PC, P=0.034). Multivariate analysis showed that an HR-HPV load > or = 100 RLU/PC was a risk factor for persistence/recurrence of histological abnormalities after conization (P=0.040, OR=5.748, 95% CI=1.082-30.526). CONCLUSION Patients with a pre-conization HR-HPV load > or = 100 RLU/PC had a higher rate of persistent HR-HPV infection and a higher rate of persistent/recurrent histological abnormalities after conization for CIN compared to patients with a load < 100 RLU/PC.
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Affiliation(s)
- Jeong-Yeol Park
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, 809 Madu1-dong, Ilsan-gu, Goyang-si, Gyeonggi-do, 411-351, Korea
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Prato B, Ghelardi A, Gadducci A, Marchetti I, Di Cristofano C, Di Coscio G, Bevilacqua G, Genazzani AR. Correlation of recurrence rates and times with posttreatment human papillomavirus status in patients treated with loop electrosurgical excision procedure conization for cervical squamous intraepithelial lesions. Int J Gynecol Cancer 2008; 18:90-4. [PMID: 17506849 DOI: 10.1111/j.1525-1438.2007.00965.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim of the present study was to assess recurrence rates and times in patients with squamous intraepithelial lesion (SIL) of the uterine cervix treated with loop electrosurgical excision procedure (LEEP) conization, in order to define categories of patients who have a different risk of recurrence and who need a different surveillance protocol. This study was carried out on 119 consecutive patients who underwent LEEP. All patients were followed up with cervical smear and colposcopy after 3, 6, and 12 months in the first-year posttreatment, and every 6-12 months afterwards. Human papillomavirus (HPV) testing was performed at the time of LEEP and repeated 3-6 months later. The histologic examination of LEEP specimens revealed stage IA1 squamous cell cervical cancer in 4 (3.4%) cases, high-grade SIL in 75 (63%) cases, and low-grade SIL in 40 (33.6%) cases. The four patients with stage IA1 cervical cancer were not included in the further analyses. Disease recurred in none of the 50 patients with negative posttreatment HPV testing, in 4 (9.3%) of the 43 patients with positive posttreatment HPV testing and negative surgical margins, and in 8 (36.4%) of 22 patients with positive posttreatment HPV testing and positive margins. The combined evaluation of surgical margin status and posttreatment HPV testing could allow to subdivide patients treated with LEEP into categories at different risk of recurrence, requiring new tailored surveillance procedures.
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Affiliation(s)
- B Prato
- Department of Procreative Medicine, Division of Gynecology and Obstetrics, University of Pisa, Pisa, Italy.
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Bae JH, Kim CJ, Park TC, Namkoong SE, Park JS. Persistence of human papillomavirus as a predictor for treatment failure after loop electrosurgical excision procedure. Int J Gynecol Cancer 2007; 17:1271-7. [PMID: 17442018 DOI: 10.1111/j.1525-1438.2007.00945.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We aimed to investigate whether postconization human papillomavirus (HPV) DNA testing can predict treatment failure and improve the accuracy of conventional follow-up in women with high-grade cervical intraepithelial neoplasia (CIN). Between March 2001 and October 2005, 120 patients with confirmed CIN 2 or 3 were treated with loop electrosurgical excision procedure (LEEP) and were enrolled. Six patients were lost to the follow-up. Postconization follow-up was performed at every 3–6 months during the first year and then annually. Specimens were tested for the presence of HPV, using the Hybrid Capture 2 (Digene Co, Gaithersburg, MD) and HPV DNA chip (Mygene Co, Seoul, Korea) test. Persistent HPV infection was defined as persistently (two times or more) positive HPV tests with the same HPV subtype(s) at initial diagnosis. Twenty-two (19.3%) patients showed treatment failure after conization. The only significant risk factor for redevelopment of CIN after conization was persistence of the same HPV subtype (P< 0.0001). And women with recurrent or residual CIN had higher HPV load during the 6-month follow-up postconization. In conclusion, the persistence of the same HPV subtype after LEEP conization was an important predictor of treatment failure. The follow-up protocol after conization of CIN should include both cervical cytology and HPV test, and HPV DNA chip test is needed to detect a persistent HPV infection.
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Affiliation(s)
- J H Bae
- Department of Obstetrics and Gynecology, Kangnam St Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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Cardoza-Favarato G, Fadare O. High-grade squamous intraepithelial lesion (CIN 2 and 3) excised with negative margins by loop electrosurgical excision procedure: the significance of CIN 1 at the margins of excision. Hum Pathol 2007; 38:781-6. [PMID: 17316761 DOI: 10.1016/j.humpath.2006.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2006] [Revised: 11/07/2006] [Accepted: 11/13/2006] [Indexed: 11/23/2022]
Abstract
The significance of cervical intraepithelial neoplasia grades 2 or 3 (CIN 2-3) at the margin of a loop electrosurgical excision procedure (LEEP) specimen as a predictor of recurrent or persistent disease is relatively controversial. Most studies have found the presence of high-grade dysplasia at the margins in this setting to be an adverse parameter. However, the significance of an isolated finding of CIN 1 at the surgical margins of LEEP specimens has not been rigorously studied. Herein, we evaluate the significance of finding CIN 1 at one or more margins of a LEEP specimen when these margins are negative for CIN 2-3. Consecutive LEEP specimens with a CIN 2-3 diagnosis (and whose margins were negative for the latter) were retrieved, and their slides were reviewed. The cases were classified as to whether CIN 1 was present at the margins. Follow-up cytologic and histologic data were compared between patients with and without CIN 1 at the margin. For patients with multiple follow-up samples, only the most severe abnormality (1 sample per patient) was counted. Seventy-three cases were evaluated, with CIN 1 present at the margin in 59 (81%, group 1) and absent in 14 (19%, group 2). Follow-up cytologic information was available in 60 patients, with a median follow-up of 19 months. The cytologic follow-up of groups 1 and 2 patients were not significantly different regarding the diagnostic frequency of any one of the Bethesda 2001 diagnostic categories (P > .05 for all, Fisher exact and chi(2) tests). Of the 33 patients who received a cervical biopsy and/or endocervical curettage during the follow-up period, 29 belonged to group 1 and 4 to group 2. The distribution of "negative" CIN 1 and CIN 2-3 diagnoses for group 1 were 16 (55%) of 29, 7 (24%) of 29, and 6 (21%) of 29, respectively. Parallel figures for group 2 were 2 (50%) of 4, 2 (50%) of 4, and 0 (0%) of 4, respectively. Although CIN 2-3 was more frequent in group 1, none of the comparisons attained statistical significance. The current study is a small single-institution study, whose findings should not be extrapolated to cold-knife conizations, and need to be confirmed in larger data sets. However, our preliminary analysis suggests that the isolated presence of CIN 1 at the margin of a LEEP specimen, whose margins are otherwise negative, lacks adverse prognostic significance.
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Abstract
The application of high throughput expression profiling and other advanced molecular biology laboratory techniques has revolutionised the management of cancers and is gaining attention in the field of gynaecological cancers. Such new approaches may help to improve our understanding of carcinogenesis and facilitate screening and early detection of gynaecological cancers and their precursors. Individualised prediction of patients' responses to therapy and design of personalised molecular targeted therapy is also possible. The studies of various molecular targets involved in the various signal pathways related to carcinogenesis are particularly relevant to such applications. At the moment, the application of detection and genotyping of human papillomavirus in management of cervical cancer is one of the most well established appliances of molecular targets in gynaecological cancers. Methylation, telomerase and clonality studies are also potentially useful, especially in assisting diagnosis of difficult clinical scenarios. This post-genomic era of clinical medicine will continue to make a significant impact in routine pathology practice. The contribution of pathologists is indispensable in analysis involving tissue microarray. On the other hand, both pathologists and bedside clinicians should be aware of the limitation of these molecular targets. Interpretation must be integrated with clinical and histopathological context to avoid misleading judgement. The importance of quality assurance of all such molecular techniques and their ethical implications cannot be over-emphasised.
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Affiliation(s)
- Annie N Y Cheung
- Department of Pathology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
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Verguts J, Bronselaer B, Donders G, Arbyn M, Van Eldere J, Drijkoningen M, Poppe W. Prediction of recurrence after treatment for high-grade cervical intraepithelial neoplasia: the role of human papillomavirus testing and age at conisation. BJOG 2006; 113:1303-7. [PMID: 16978225 DOI: 10.1111/j.1471-0528.2006.01063.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this study was to examine the accuracy of the presence of high-risk human papillomavirus (HR-HPV) DNA (HR-HPV DNA test) postconisation as prediction of recurrent or residual cervical intraepithelial neoplasia (CIN) after treatment of high-grade cervical intraepithelial lesions (CIN2+) in a prospective study and to compare this with follow-up cytology and the marginal status of the excised tissue. DESIGN Prospective follow-up study. SETTING Unselected women presenting at colposcopy clinic of University Hospital Gasthuisberg, Leuven. POPULATION Seventy-two women treated with conisation for CIN2 or CIN3. METHODS Women were followed by HR-HPV DNA test (Hybrid Capture II test of Digene) every 3 to 6 months. The same vial was used for cytology and the HR-HPV DNA test (SurePath). All women were further followed by colposcopy and cytology for 24 months at 6-month intervals. The outcome of the study was presence of >CIN2, proven with colposcopy-directed biopsy occurring within 24 months after treatment. HR-HPV status was correlated with recurrent or residual CIN2+. MAIN OUTCOME MEASURES Sensitivity, specificity, predictive values and diagnostic odds ratios to predict treatment failure or cure were computed for HR-HPV testing, marginal status and follow-up cytology. HR-HPV status was also correlated with section margins postconisation and with the first cervical smear. RESULTS In 6 of the 72 treated women (8%), residual or recurrent CIN occurred. Women with recurrence were significantly older than women without a recurrence (51.5 +/- 9.6 versus 39.8 +/- 12.2 years, P= 0.007). All six women with recurrence were HR-HPV positive, four had a positive follow-up smear (>or=atypical squamous cells of uncertain significance = ASCUS+) and only two had involved section margins. Among the 66 cured women, 15 were HR-HPV positive, 6 had an abnormal smear and 12 had positive section margins. Sensitivity of cytology, positive section margins and HR-HPV DNA positivity was 66.7, 33.3 and 100% to predict treatment failure. Specificity of the three tests was, respectively, 90.9, 81.8 and 77.3%. Women with HR-HPV DNA at 3 to 6 months showed recurrent or residual CIN in 15% (2/13) if they had normal follow-up Pap smears and in 50% (4/8) if they had abnormal Pap smears. Margin status was not statistically significantly associated with human papillomavirus status. CONCLUSION Persistence or clearance of HR-HPV DNA is an early valid prognostic marker of failure or cure after treatment for CIN2+ and is more accurate than cytology or section margin status at the time of conisation. The absence of HR-HPV DNA has a 100% negative predictive value. Higher age at conisation may be a previously unrecognised risk factor for recurrence.
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Affiliation(s)
- J Verguts
- Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Catholic University Leuven, Leuven, Belgium.
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Alonso I, Torné A, Puig-Tintoré LM, Esteve R, Quinto L, Campo E, Pahisa J, Ordi J. Pre- and post-conization high-risk HPV testing predicts residual/recurrent disease in patients treated for CIN 2–3. Gynecol Oncol 2006; 103:631-6. [PMID: 16780934 DOI: 10.1016/j.ygyno.2006.04.016] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Revised: 04/21/2006] [Accepted: 04/26/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate whether high-risk human papillomavirus (HR-HPV) detection and viral load prior to treatment and status of cone margins can predict residual/recurrent disease as well as the ability of current diagnostic tools to identify residual/recurrent disease during follow-up of high-grade cervical intraepithelial neoplasia (CIN) treated by conization using loop electrosurgical procedure (LEEP). METHODS Two hundred and three women (mean age 38.6 +/- 9.7; range 22-83) with CIN2-3 treated by LEEP conization and confirmed in the surgical specimen, attending follow-up visits were included. Age, HR-HPV detection and viral load determined by HybridCapture 2, and cone margins were evaluated as possible predictors of residual/recurrent disease. Value of single and repeated cytology as well as HR-HPV detection and viral load during follow-up were analyzed as screening tools of recurrence. RESULTS Residual/recurrent disease was demonstrated by colposcopy guided biopsy in 36 patients (17.7%). High HR-HPV load (>1000 RLU) prior to LEEP and positive cone margins were significantly associated with higher risk of recurrence (31.8% vs. 9.4%, P = 0.005; and 36.4% vs. 11.9%, P < 0.001 respectively). HR-HPV detection at 6-12 m after LEEP showed higher sensitivity than a single or repeated cytology (97.2% vs. 83.3% and 94.4% respectively) although it showed less specificity (81.4% vs. 92.2% and 82.6%). The combination of HR-HPV detection and the first cytology during follow-up detected all patients with residual/recurrent disease (sensitivity 100%, negative predictive value 100%) with an acceptable specificity (76.6%). CONCLUSION The inclusion of HR-HPV testing with cytology in follow-up of patients treated for CIN2-3 would allow for fewer post-treatment visits and avoid unnecessary cytologies. High HR-HPV load prior to LEEP or positive margins should be considered as risk factors for developing residual/recurrent disease.
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Affiliation(s)
- Immaculada Alonso
- Department of Obstetrics and Gynecology, IDIBAPS-Hospital Clínic, University of Barcelona School of Medicine, Barcelona, Spain
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Cox JT. Human papillomavirus testing in primary cervical screening and abnormal Papanicolaou management. Obstet Gynecol Surv 2006; 61:S15-25. [PMID: 16729900 DOI: 10.1097/01.ogx.0000221011.01750.25] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Human papillomavirus (HPV) infection is a necessary cause of cervical cancer; HPV testing capitalizes on this fact to maximize the clinical benefits of cervical screening and abnormal Papanicolaou (Pap) test management. HPV tests in combination with Pap tests are 96% to 100% sensitive for detection of cervical intraepithelial neoplasia (CIN) 2/3 and cancer. However, because HPV infection is common in young women and most commonly transient, HPV testing is not recommended as part of primary cervical screening for women younger than 30 years of age. HPV testing is recommended for women of any age for the clarification of atypical cells of undetermined significance (ASC-US) and as an option for follow-up of women with HPV-positive ASC-US, atypical squamous cells "cannot rule out high-grade," or low-grade squamous intraepithelial lesions not found to have CIN 2/3. HPV testing is also recommended as an alternative to colposcopy and/or cytology for follow-up of treated cases. Proper use of HPV testing improves the management of women with cytologic abnormalities. In addition, a negative HPV test in combination with a normal Pap test result in women age 30 and older allows the safe extension of the interval between cervical screenings. Thus, when used properly, HPV testing may reduce morbidity and mortality and do so in a cost-effective manner.
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Affiliation(s)
- J Thomas Cox
- University of California, Santa Barbara, CA, USA
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Tachezy R, Mikysková I, Ludvíková V, Rob L, Kucera T, Slavík V, Beková A, Robová H, Pluta M, Hamsíková E. Longitudinal study of patients after surgical treatment for cervical lesions: detection of HPV DNA and prevalence of HPV-specific antibodies. Eur J Clin Microbiol Infect Dis 2006; 25:492-500. [PMID: 16896828 DOI: 10.1007/s10096-006-0172-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The principal aims of this study were to test whether persistence of human papillomavirus (HPV) DNA is predictive of recurrent disease in women after surgical treatment for cervical lesions, to distinguish between persistent and newly acquired HPV infection, and to observe the effect of surgical treatment on levels of HPV-specific antibodies. A group of 198 patients surgically treated for low-grade and high-grade squamous intraepithelial lesions and 35 age-matched controls were monitored for 18 months at 6-month intervals. The presence of HPV DNA in cervical smears was detected by means of consensus polymerase chain reaction, and serum levels of HPV-specific antibodies to HPV types 16, 18, 31, 33, and 45 were measured. In ten patients positive for HPV type 16 in consecutive samples, the HPV 16 variants were identified using a polymerase chain reaction specific for the long control region. Data regarding demographics, risk factors for cervical cancer, and risks related to HPV exposure were collected through a patient questionnaire. Subjects persistently positive for HPV DNA were more likely to present with cytological and/or colposcopical abnormalities. A higher reactivity to HPV-specific antibodies was observed in these women at the 18-month follow-up visit. All ten patients with HPV 16 infection detected in consecutive samples showed persistence of either the same prototype or the same variant during the follow-up period. Risky sexual behavior and smoking were more common in patients than in controls. Persistent HPV infection as demonstrated by both HPV DNA detection and antibody detection appears to be a risk factor for the recurrence of pathological findings in women after surgery. An individually based approach to surgical treatment is an important factor in the outcome of disease at follow-up.
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Affiliation(s)
- R Tachezy
- Department of Experimental Virology, Institute of Hematology and Blood Transfusion, U Nemocnice 1, 12820 Prague 2, Czech Republic.
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Lin CT, Chang TC, Shaw SW, Cheng PJ, Huang CT, Chao A, Soong YK, Lai CH. Maintenance of CD8 effector T cells by CD4 helper T cells eradicates growing tumors and promotes long-term tumor immunity. Vaccine 2006; 24:6199-207. [PMID: 16824651 DOI: 10.1016/j.vaccine.2006.05.108] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2005] [Revised: 05/26/2006] [Accepted: 05/29/2006] [Indexed: 10/24/2022]
Abstract
Human papillomavirus, particularly type 16 (HPV-16), is present in more than 99% of cervical cancers, and oncogenic HPV infection is one of the most important etiologies. It is now clear that CD4(+) T cells play an important role in controlling HPV-associated lesions because immunocompromised patients have a higher frequency of HPV-associated lesions. In the current study, we characterized the significance of CD4(+) T cells in the generation of E7-specific CD8(+) T cell immune responses in mice vaccinated with SINrep5-E7/HSP70 and boosted with vac-E7/HSP70. In addition, we characterized the contribution of CD4(+) T cells to the long-term antitumor effects. We found that vaccination with CD4 depletion significantly reduced the number of E7-specific CD8(+) T cells in mice. Furthermore, CD4(+) T cells are important for the long-term anti-tumor effects generated by vaccination with SINrep5-E7/HSP70 and booster with vac-E7/HSP70. Thus, CD4 T cells clearly have an important role in successful tumor immunity and maintenance of long-term tumor antigen-specific memory responses in vaccinated mice with established tumors.
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Affiliation(s)
- Cheng-Tao Lin
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Shin Street, Kweishan, Taoyuan, Taiwan.
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Huang SL, Chao A, Hsueh S, Chao FY, Huang CC, Yang JE, Lin CY, Yan CC, Chou HH, Huang KG, Huang HJ, Wu TI, Tseng MJ, Qiu JT, Lin CT, Chang TC, Lai CH. Comparison between the Hybrid Capture II Test and an SPF1/GP6+ PCR-based assay for detection of human papillomavirus DNA in cervical swab samples. J Clin Microbiol 2006; 44:1733-9. [PMID: 16672400 PMCID: PMC1479179 DOI: 10.1128/jcm.44.5.1733-1739.2006] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We compared the efficacy of human papillomavirus (HPV) DNA detection between a PCR-based genechip (Easychip HPV Blot [hereafter referred to as HPV Blot]; King Car, Taiwan) method and Hybrid Capture II (HCII; Digene, Gaithersburg, MD) in women with previous normal (n = 146) or abnormal (> or =atypical squamous cells of undetermined significance [ASCUS] [n = 208]) cytology. A total of 354 cervical swab samples were collected for HPV DNA assay by both HCII and SPF1/GP6+ PCR followed by HPV Blot tests. Colposcopy-directed biopsy was performed if clinically indicated. Of the 354 samples, HPV-positive rates by these two methods (HCII and HPV Blot) were 12.6% and 18.2% in 143 normal samples, 36.2% and 45.7% in 105 ASCUS samples, 57.4% and 57.4% in 94 low-grade squamous intraepithelial lesion samples, and 83.3% and 75.0% in 12 high-grade squamous intraepithelial lesion samples, respectively. The concordance of HPV Blot and HCII was 80.8% (286/354), and the agreement between the methods (kappa value, 0.68) was substantial. Discrepancies were further investigated by at least one of the following three methods: direct sequencing, type-specific PCR, and HPV Blot genotyping of cervical biopsy tissue. In the 15 HCII-positive samples, HPV Blot detected only non-HCII HPV genotypes; results of further verification methods were consistent with the latter test in the 15 samples. Of the 20 samples with HCII-negative and HPV Blot-positive results, 18 were found to contain the 13 HCII high-risk genotypes by verification methods. In only 16.7% (3/18) of the HCII-positive but HPV Blot-negative samples, further studies detected the 13 HCII genotypes. We conclude that HPV Blot seemed comparable to HCII for detection of HPV DNA in cervical swab samples.
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Affiliation(s)
- Shang-Lang Huang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Aschkenazi-Steinberg SO, Spitzer BJ, Spitzer M. The role treatment for cervical intraepithelial neoplasia plays in the disappearance of human papilloma virus. J Low Genit Tract Dis 2005; 9:19-22. [PMID: 15870517 DOI: 10.1097/00128360-200501000-00005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To explore the role played by excision of the transformation zone in women diagnosed with cervical intraepithelial neoplasia (CIN) in the disappearance of human papillomavirus (HPV). MATERIAL AND METHODS In a retrospective, cohort study, women with CIN who were treated by loop electrosurgical excision procedure of the transformation zone were compared with another group of women with CIN who were managed expectantly. The decision to treat or manage expectantly was made by one of the authors on clinical grounds. All patients were evaluated with cervical cytologic analysis, pathologic examination of excised tissue, and HPV DNA testing, which was considered positive when high-risk HPV types were detected. Among women treated with loop electrosurgical excision procedure, the median lag time was calculated from diagnosis of CIN to treatment. The median time for conversion from HPV-positive to HPV-negative status in both groups was compared, as well as the 1- and 2-year cure rates (defined as converting to HPV-negative status) in the treated and untreated groups. RESULTS In the treated group, 12% had CIN 1, 83% had CIN 2,3, 2% had cancer, and 3% had normal pathologic results. In the untreated group, 82% had CIN 1, 16% had CIN 2,3, and 2% had normal pathologic results (p < 0.0001). The lag time from the initial diagnosis of CIN to treatment was less than 1 month. The median follow-up time was 7 months (range, 1-121 months) in the treated group and 13 months (range, 1-70 months) in the untreated group. The 1-year rates of conversion to HPV-negative status, defined as the cure rates in the treated and untreated groups, were 65% (+/- 6%) and 23% (+/- 7%), respectively, and the 2-year cure rates in the treated and untreated groups were 90% (+/- 4%) and 56% (+/- 11%), respectively (p < 0.0001). Median time to conversion to a negative HPV status was 7.7 months for the treated patients compared with 19.4 months in the untreated patients (p < 0.0001). CONCLUSIONS Women treated by loop electrosurgical excision procedure are more likely convert to HPV-negative status at 1 and 2 years and do so significantly sooner than those managed expectantly.
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[Guideline for managing suspect and positive cytologic smears of the uterine cervix (revised form, version 2.4)]. ACTA ACUST UNITED AC 2005; 45:44-55. [PMID: 15655885 DOI: 10.1159/000081716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Fonseca-Moutinho JA, Cruz E, Carvalho L, Prazeres HJM, de Lacerda MMP, da Silva DP, Mota F, de Oliveira CF. Estrogen receptor, progesterone receptor, and bcl-2 are markers with prognostic significance in CIN III. Int J Gynecol Cancer 2004; 14:911-20. [PMID: 15361203 DOI: 10.1111/j.1048-891x.2004.14529.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
There are no known biological markers or technologies to predict the natural history of an individual CIN III. The probability of progression is considered greater with the persistence of high-risk human papillomavirus (HPV) infection and age. p53 polymorphism has been associated with cervical carcinogenesis. Hormone-induced cervical cancer is mediated by estrogen receptor (ER) and progesterone receptor (PR). In cervical cancer, increased bcl-2 and Bax immunoreactivity is generally associated with a better prognosis. The purpose of this study was to evaluate the value of HPV 16 and HPV 18 typing and p53 codon polymorphism genotyping by polymerase chain reaction and ER, PR, bcl-2, and Bax expression by immunohistochemistry in predicting the CIN III clinical behavior of CIN III lesions. We studied the expression of these prognostic factors in the CIN III adjacent to squamous cell microinvasive carcinomas of the cervix (MIC) from 29 patients with FIGO stage IA1 cervical cancer and in 25 patients with CIN III and no documented focus of invasion. In the MIC group, only the CIN III was considered at least 2 mm away from the microinvasive complex. The ER, PR, bcl-2, and Bax immunoreactivity was scored as positive (>10% staining cells) and negative (<10% staining cells). No significant difference was observed between MIC and CIN III group concerning HPV infection and p53 polymorphism. The ER, PR, bcl-2, and Bax immunohistochemical expression was stronger and more frequent in the CIN III group. After multivariable analysis, coexpression of ER, PR, and bcl-2 was the only independent factor in defining low risk of progression for CIN III. Our study suggests that coexpression of ER, PR, and bcl-2 may be a useful tool in identifying the CIN III lesions with low risk of progression to cervical cancer.
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Nagai Y, Toma T, Moromizato H, Maehama T, Asato T, Kariya KI, Kanazawa K. Persistence of human papillomavirus infection as a predictor for recurrence in carcinoma of the cervix after radiotherapy. Am J Obstet Gynecol 2004; 191:1907-13. [PMID: 15592271 DOI: 10.1016/j.ajog.2004.06.088] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study was undertaken to examine a possible correlation between clearance or persistence of human papillomavirus (HPV) infection and radiation response in carcinoma of the cervix. STUDY DESIGN We reviewed 97 patients with HPV-positive cervical squamous cell carcinoma (International Federation of Gynecology and Obstetrics [FIGO] stage IB-IVA) treated with radiotherapy. Examination of HPV DNA was performed by the polymerase chain reaction-based assay. RESULTS Cervical HPV DNA cleared in 42 patients (43.3%) and persisted in 55 patients (56.7%) at the end of irradiation. All of 42 HPV-cleared patients (100.0%) and 50 of 55 HPV-persistent patients (90.9%) had complete response. Of 92 patients with complete response, 20 (21.7%) had local recurrence develop. The recurrence rate was significantly higher in HPV-persisted patients (34.0%) than in HPV-cleared patients (7.1%) ( P = .0016). Univariate analysis demonstrated the significant differences for both 5-year local disease-free survival (LDFS) and overall survival (OAS) between HPV-cleared and HPV-persisted groups. Multivariate analysis showed that persistence of HPV DNA was the most powerful independent predictor for LDFS and OAS compared with other prognostic factors, such as FIGO stage or node swelling. CONCLUSION In HPV-positive cervical carcinoma, persistence of HPV DNA in the cervix at the end of irradiation was highly predictive of LDFS and OAS.
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Affiliation(s)
- Yutaka Nagai
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of the Ryukyus, 207 Uehara Nishihara-Machi, Nakagami-Gun, Okinawa 903-0215, Japan.
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Aschkenazi-Steinberg SO, Spitzer BJ, Spitzer M, Lesser M. The Clinical Usefulness of Human Papillomavirus Testing in the Follow-up of Women after Treatment for Cervical Intraepithelial Neoplasia. J Low Genit Tract Dis 2004; 8:304-7. [PMID: 15874877 DOI: 10.1097/00128360-200410000-00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the effectiveness of human papillomavirus (HPV) testing and cervical cytologic analysis in monitoring patients after treatment for cervical intraepithelial neoplasia. MATERIALS AND METHODS A retrospective study comparing cytologic analysis and HPV testing using the follow-up protocol recommended by the American Society for Colposcopy and Cervical Pathology Consensus Conference. Sixty-one patients were seen for a total of 193 follow-up patient visits. In 120 visits, both cytologic and HPV results were available. Specificity, sensitivity, positive and negative predictive values, and the rate of referral to colposcopy were calculated. RESULTS In 68 visits, both HPV and cytologic results were negative, and in 19, both were positive. In 21 visits, cytologic results were positive and HPV results were negative, and in 12 visits, cytologic results were negative and HPV results were positive. The specificity of cytologic analysis and HPV testing was 68.3% and 75.8%, respectively (p = .16). The positive predictive value for cytologic analysis and HPV testing was 6.5% and 7.5%, respectively, and the negative predictive value was 100% and 98.9%, respectively. Had either test been used alone, cytologic analysis would have referred 40 patients to colposcopy and HPV testing would have referred 31 patients. Had both been used in combination, 52 patients would have required colposcopy with no significant improvement in the amount of disease detected. CONCLUSIONS Both cytologic analysis and HPV testing are equally effective in monitoring patients after treatment for cervical intraepithelial neoplasia. The simultaneous use of cytologic analysis and HPV testing significantly increased colposcopy referrals without increasing the amount of disease detected.
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Abstract
UNLABELLED Recurrences of cervical intraepithelial neoplasia (CIN) as well as invasive cervical carcinoma have been reported to arise following ablative or excisional treatment for cervical intraepithelial neoplasia. This review utilizes MEDLINE and National Library of Medicine's PubMed review of the various screening tools used in follow-up protocols for women treated by loop excision for CIN. Cervical cytology, colposcopy, endocervical curettage and HPV typing have been advocated for use as tools for follow up. Involvement of the surgical margins and the presence of HPV-DNA are associated with higher risks of recurrence and should be taken into consideration. The psychological impact of undergoing colposcopy may affect compliance with follow-up visits and should be dealt with appropriately. LEARNING OBJECTIVES After completion of this article, the reader should be able to list the various tools that can be used for the surveillance of patients after treatment for CIN, to compare the advantages and disadvantages of each surveillance method, and summarize methods to improve compliance with follow-up.
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Affiliation(s)
- Jacob Bornstein
- Colposcopy unit, Department of Obstetrics and Gynecology, Western Galilee Hospital, Nahariya, Israel.
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Sarian LO, Derchain SFM, Andrade LAA, Tambascia J, Morais SS, Syrjänen KJ. HPV DNA test and Pap smear in detection of residual and recurrent disease following loop electrosurgical excision procedure of high-grade cervical intraepithelial neoplasia. Gynecol Oncol 2004; 94:181-6. [PMID: 15262139 DOI: 10.1016/j.ygyno.2004.03.036] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE We compared the performance of cervical cytology and HPV DNA test in detection of residual or recurrent disease following the treatment of cervical intraepithelial neoplasia (CIN) 2/3 with loop electrosurgical excision procedure (LEEP). SUBJECTS AND METHODS A series of 107 women subjected to LEEP due to histologically confirmed CIN 2/3 between March 2001 and December 2002 were followed-up biannually until January 2004. Follow-up visits consisted of interview and gynecological examination including cervical cytology, hybrid capture II (HCII), and colposcopy. Patients presenting with abnormal colposcopy or high-grade squamous intraepithelial lesion (HSIL) smear were subjected to new excision procedure, and presence of histologically confirmed CIN 2/3 or higher was considered as residual or recurrent disease. Performance indicators were calculated for cytology and HCII assay in detecting residual or recurrent disease. RESULTS Eleven (10.2%) women showed residual or recurrent disease during the follow-up. Considering HCII and Pap smear as stand-alone tests, both techniques showed similar sensitivity, detecting 100% of CIN 2/3 at the first follow-up visit. At the second follow-up visit, Pap smear showed better specificity and positive predictive value (PPV) than HCII, and both tests had fairly the same high negative predictive value (NPV) and sensitivity. The combined positive HCII and abnormal cytology had the same sensitivity as each of the tests alone, but specificity and PPV were significantly higher than those of single tests. When only one of the tests was positive, the sensitivity and the NPV of the combination remained the same, but its specificity and PPV were lower than that of the combined two positive tests and that of the individual test, at both follow-up visits. CONCLUSIONS Both tests performed well in detecting residual or recurrent disease after LEEP and combination of the tests did not increase sensitivity of the single tests.
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Affiliation(s)
- Luís Otávio Sarian
- Obstetrics and Gynecology Department, Universidade Estadual de Campinas, UNICAMP, Campinas, São Paulo 13083-370, Brazil
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Zielinski GD, Bais AG, Helmerhorst TJ, Verheijen RHM, de Schipper FA, Snijders PJF, Voorhorst FJ, van Kemenade FJ, Rozendaal L, Meijer CJLM. HPV Testing and Monitoring of Women After Treatment of CIN 3: Review of the Literature and Meta-analysis. Obstet Gynecol Surv 2004; 59:543-53. [PMID: 15199273 DOI: 10.1097/00006254-200407000-00024] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
According to the current guidelines in most western countries, women treated for cervical intraepithelial neoplasia grade 3 (CIN 3) are followed for at least 2 years after treatment by cytology.High-risk human papillomavirus (hrHPV) infections are necessary for the development and maintenance of CIN 3. HrHPV testing could be used to improve monitoring of women treated for CIN 3. This has prompted numerous studies for the implementation of hrHPV testing in monitoring of women treated for CIN 3. Included in this review are 20 studies, published between 1996 and 2003, comparing hrHPV testing with either resection margins or cervical cytology to predict recurrent/residual disease, and 11 of them could be used in a meta-analysis. In the meta-analysis of the 11 studies, the negative predictive value (NPV) for recurrent/residual disease of hrHPV testing was 98% (95% CI 97-99%), that of resection margins 91% (95% CI 87-94%), and that of cervical cytology 93% (95% CI 90-95%). When hrHPV testing was performed in conjunction with cytology, the sensitivity was 96% (95% CI 89-99%), specificity was 81% (95% CI 77-84%), the associated positive predictive value (PPV) was 46% (95% CI 38-54%), and the NPV was 99% (95% CI 98-100%). Combined hrHPV and cytology testing yielded the best test characteristics. We propose to include hrHPV testing in conjunction with cytology for monitoring women treated for CIN 3. Some follow-up visits for women testing negative for both hrHPV and cytology can be skipped. In western countries, this could mean that for women double negative at 6 months, retesting at 12 months should be skipped while keeping the 24-month follow-up visit.
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Affiliation(s)
- G D Zielinski
- The Department of Pathology, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
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Fehr MK, Welti S. [Human papillomavirus testing in cervical cancer screening]. ACTA ACUST UNITED AC 2004; 44:131-7. [PMID: 15211058 DOI: 10.1159/000077858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Virtually all cases of cervical cancer are caused by one of the 18 oncogenic types of human papillomavirus (HPV). It is estimated that 80% of all women will be infected by HPV in a lifetime, and the prevalence of HPV is highest among young, sexually active women and declines with increasing age. The risk of developing high-grade squamous intraepithelial lesions depends on the actual HPV type,the duration of infection, and the viral load. Due to the high prevalence of HPV infection, HPV testing in young women is of little value. The high negative predictive value of this test, combined with nor-mal Papanicolaou smear results, almost ensures that the patient is or will be free of a cancer precursor at the time of testing or in the immediate future. Hence, HPV testing combined with cytology is a reasonable approach in elderly women in order to increase the screening interval to 3-5 years. HPV testing is established for triage of borderline cytology findings of atypical squamous cells of undetermined significance if colposcopy is not performed immediately and if HPV-negative women are rescheduled within 12 months. HPV testing 6 months after cone biopsy allows increasing the follow-up interval due to its high negative predictive value. In atypical glandular lesions not otherwise specified, HPV testing may identify patients requiring immediate treatment. In immunocompromised patients with borderline cytology due to persistent HPV infection, HPV test-ing identifies patients with a low risk of cancer precursors not requiring treatment.
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Affiliation(s)
- Mathias K Fehr
- Klinik für Gynäkologie, Departement Frauenheilkunde, Universitätsspital Zürich, Zürich, Schweiz.
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Chao A, Lin CT, Hsueh S, Chou HH, Chang TC, Chen MY, Lai CH. Usefulness of human papillomavirus testing in the follow-up of patients with high-grade cervical intraepithelial neoplasia after conization. Am J Obstet Gynecol 2004; 190:1046-51. [PMID: 15118639 DOI: 10.1016/j.ajog.2003.09.054] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We aimed to define the adjunctive role of human papillomavirus (HPV) DNA testing in the follow-up of high-grade cervical intraepithelial neoplasia (CIN) after conization. STUDY DESIGN We analyzed a consecutive series of 2,154 patients who received conization. Patients who had cone diagnosis of cervical cancer or CIN 1, a hysterectomy within 12 weeks after conization, and no follow-up data were excluded. The remaining 765 patients (monitored by Pap smears, colposcopy with or without high-risk HPV DNA testing) were analyzed. RESULTS Of the 765 patients, 279 had CIN at cone margin or endocervix (group A) while 486 were both margin- and endocervix-free (group B). The 3-year cumulative rate of residual/recurrent high-grade CIN was 10.3% (95% CI, 6.9-13.7). HPV follow-up status (P=.015), margin status (P=.001), and follow-up cervical cytology (P<.0001) were significant predictors for residual/recurrent high-grade CIN by multivariate analysis. Four high-grade CINs and 1 microinvasive carcinoma of group A were detected initially by HPV testing, while 48.3% (199/410) of those without recurrent/persistent high-grade CIN still had persistent HPV infection. CONCLUSION HPV DNA testing is useful in the follow-up and understanding of the natural history after conization for high-grade CIN.
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Affiliation(s)
- Angel Chao
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and University, Linkou Medical Center, Taoyuan, Taiwan
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Paraskevaidis E, Arbyn M, Sotiriadis A, Diakomanolis E, Martin-Hirsch P, Koliopoulos G, Makrydimas G, Tofoski J, Roukos DH. The role of HPV DNA testing in the follow-up period after treatment for CIN: a systematic review of the literature. Cancer Treat Rev 2004; 30:205-11. [PMID: 15023438 DOI: 10.1016/j.ctrv.2003.07.008] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is an emerging interest concerning the role HPV DNA testing in the follow-up period after conservative treatment for cervical intraepithelial neoplasia. METHODS A MEDLINE and EMBASE search was done (1985 to March 2002), using the keywords HPV/HPV DNA, together with CIN, follow-up, recurrence and LLETZ. References of retrieved articles were also screened. Selection criteria were original published English-language reports of prospective or retrospective studies, including women with an initial diagnosis of cervical intraepithelial neoplasia, who received conservative surgical treatment and were followed with HPV DNA testing in addition to cytology, colposcopy and/or biopsy); the latter methods were used for verification of residual or recurrent disease. RESULTS There is a marked heterogeneity in the design, population, intervention and follow-up policy across different studies. The sensitivity of HPV DNA testing in detecting treatment failures was quite good in most studies, reaching 100% in four of them, whereas the specificity of the test differed across the studies, ranging from 44% to 95%. Among women in whom the treatment was considered to be successful, 84.2% had a negative postoperative HPV DNA test and 15.8% a positive one. The corresponding rates for cases with treatment failures were 17.2% and 82.8%, respectively. CONCLUSIONS It seems that a positive HPV test, even in the presence of normal cytology, may pick up early and accurately a treatment failure. Cytology and colposcopy may still be needed in order to rule out false positive and false negative results. MINI-ABSTRACT A systematic review of studies concerning HPV DNA testing in the follow-up period after conservative treatment for cervical intraepithelial neoplasia indicates that a positive HPV test, even in the presence of normal cytology, may pick up early and accurately a treatment failure. Cytology and colposcopy may still be needed in order to rule out false positive and false negative results.
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Zielinski GD, Rozendaal L, Voorhorst FJ, Berkhof J, Snijders PJF, Risse EJK, Runsink AP, de Schipper FA, Meijer CJLM. HPV testing can reduce the number of follow-up visits in women treated for cervical intraepithelial neoplasia grade 3. Gynecol Oncol 2003; 91:67-73. [PMID: 14529664 DOI: 10.1016/s0090-8258(03)00415-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE We evaluated high-risk human papillomavirus (HPV) testing by Hybrid Capture II (HC II) in addition to cytology to predict recurrent/residual cervical intraepithelial neoplasia (CIN) 2/3 and cervical cancer in women treated for CIN 3. METHODS Follow-up study of 108 women with histologically confirmed CIN 3. RESULTS Pretreatment, in 96% (104/108) of the smears high-risk HPV DNA was present. Posttreatment, 71% (77/108) of the women had normal cytology and negative HC II test and none developed recurrent/residual disease during a median follow-up of 28.8 months with a range of 2.4-64.8 months. One of the 12% (13/108) of women with normal cytology and positive HC II test was diagnosed with cervical adenocarcinoma. One of the 7% (8/108) of women with abnormal cytology (borderline dyskaryosis or worse) and negative HC II test was diagnosed with CIN 2. Three of the 9% (10/108) of women with abnormal cytology and a positive HC II test were diagnosed with CIN 2/3. These results show an increased risk for recurrent/residual CIN 2/3 and cervical carcinoma when at least one posttreatment test is positive. The highest relative risk (72.9, 95% CI 25-210) was present in women with both tests positive. CONCLUSIONS HPV testing with Hybrid Capture II in conjunction with cytology can be used as a tool to select women with an increased risk for recurrent/residual CIN 2/3 and cervical cancer. The standard policy in The Netherlands is cytology at 6, 12, and 24 months posttreatment. However, for women with both normal cytology and negative HC II test at 6 months the chance to develop recurrent/residual CIN 2/3 and cervical carcinoma is so low that retesting at 12 months can be omitted.
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Affiliation(s)
- G Denise Zielinski
- Department of Pathology, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
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Houfflin Debarge V, Collinet P, Vinatier D, Ego A, Dewilde A, Boman F, Leroy JL. Value of human papillomavirus testing after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesions. Gynecol Oncol 2003; 90:587-92. [PMID: 13678729 DOI: 10.1016/s0090-8258(03)00372-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate human papillomavirus (HPV) testing during the follow-up of patients after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesion. METHODS A prospective study was conducted on 205 patients who underwent conization for high-grade squamous intraepithelial lesion (CIN 2 or 3). Loop electrosurgical excision procedure (LEEP) was used in all cases. High-risk HPV testing was realized by the Hybrid Capture II system before and 3 months after conization. RESULTS Of the 205 patients, 193 (94.1%) were positive for the HPV test before conization. Seventy-one were HPV positive after conization (34.6%). The margins were positive in 36.1%. Residual disease was observed in 27 cases (13.2%). Four patients (2%) developed a recurrence after a mean follow-up of 18.1 months (+/-12). There was no correlation between pretreatment HPV testing and the residual disease or recurrence. Patients with positive margins were significantly more likely to have residual disease than those with negative margins (P < 0.0001). Residual disease was more likely to occur when the posttreatment HPV test was positive (P < 10(-7)). All recurrences were observed in patients with a positive posttreatment HPV test (P < 0.05). Residual disease and recurrence were correctly predicted with a sensitivity of 81 and 100%, respectively, and a negative predictive value of 96 and 100%. CONCLUSION Posttreatment HPV testing could be useful in the follow-up of patients after conization. In case of negative posttreatment HPV testing, the frequency of follow-up could be reduced, particularly in those patients with free margins.
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Affiliation(s)
- V Houfflin Debarge
- Clinique de Gynécologie, Obstétrique et Néonatologie, Hôpital Jeanne de Flandre, CHRU Lille 59037, France
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Lörincz AT, Richart RM. Human papillomavirus DNA testing as an adjunct to cytology in cervical screening programs. Arch Pathol Lab Med 2003; 127:959-68. [PMID: 12873167 DOI: 10.5858/2003-127-959-hpdtaa] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Our objective was to review current large studies of human papillomavirus (HPV) DNA testing as an adjunct to the Papanicolaou test for cervical cancer screening programs. We analyzed 10 large screening studies that used the Hybrid Capture 2 test and 3 studies that used the polymerase chain reaction test in a manner that enabled reliable estimates of accuracy for detecting or predicting high-grade cervical intraepithelial neoplasia (CIN). Most studies allowed comparison of HPV DNA and Papanicolaou testing and estimates of the performance of Papanicolaou and HPV DNA as combined tests. The studies were selected on the basis of a sufficient number of cases of high-grade CIN and cancer to provide meaningful statistical values. Investigators had to demonstrate the ability to generate reasonably reliable Hybrid Capture 2 or polymerase chain reaction data that were either minimally biased by nature of study design or that permitted analytical techniques for addressing issues of study bias to be applied. Studies had to provide data for the calculation of test sensitivity, specificity, predictive values, odds ratios, relative risks, confidence intervals, and other relevant measures. Final data were abstracted directly from published articles or estimated from descriptive statistics presented in the articles. In some studies, new analyses were performed from raw data supplied by the principal investigators. We concluded that HPV DNA testing was a more sensitive indicator for prevalent high-grade CIN than either conventional or liquid cytology. A combination of HPV DNA and Papanicolaou testing had almost 100% sensitivity and negative predictive value. The specificity of the combined tests was slightly lower than the specificity of the Papanicolaou test alone, but this decrease could potentially be offset by greater protection from neoplastic progression and cost savings available from extended screening intervals. One "double-negative" HPV DNA and Papanicolaou test indicated better prognostic assurance against risk of future CIN 3 than 3 subsequent negative conventional Papanicolaou tests and may safely allow 3-year screening intervals for such low-risk women.
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Abstract
Risk management efforts in the cytology laboratory must address the gap between what can be achieved with medical history's most effective cancer screening test, the Papanicolaou (Pap) test, and even higher entrenched public expectations. Data from the Atypical Squamous Cells of Undetermined Significance (ASCUS)/Low-Grade Squamous Intraepithelial Lesion Triage Study (ALTS) now provide level I clinical evidence from a large, randomized, controlled, multicenter clinical trial that reflex human papillomavirus (HPV) DNA testing of ASCUS cases is generally the preferred method for initial assessment of the most prevalent category of abnormal Pap interpretation. The proposed combination of HPV DNA testing with cytologic Pap testing, the DNA Pap test, further shows the potential to nearly eliminate false-negative screening results, based on sensitivity and negative predictive values reported in available studies. Human papillomavirus DNA testing also appears to represent a significant enhancement for detection of endocervical adenocarcinomas, which are difficult to detect and prevent. Human papillomavirus DNA testing, when used in conjunction with cervical cytology, can significantly reduce risk to both the patient and the laboratory.
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Affiliation(s)
- R Marshall Austin
- Coastal Pathology Laboratories and The Medical University of South Carolina, Charleston 29407, USA.
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Abstract
An understanding of the natural history of HPV-induced precancer and cancer, and of the immune response to HPV and to these lesions, has significantly changed the management of lower genital tract neoplasia. New management guidelines incorporate this understanding, providing a more rational approach to diagnosis and treatment. Understanding that low-grade HPV-induced lesions are not true cervical cancer precursor has fostered expectant management of women with these lesions; however, management approaches are still hampered by the inability to better predict who is at risk for high-grade intraepithelial neoplasia and cancer and who is not; this is particularly problematic in the expectant management of CIN 1. In addition, the decision whether or not to treat these low-grade lesions may depend on a number of complex factors that take into account the woman's preferences and reliability for follow-up, as well as a host of issues related to costs and the reliability of the original diagnosis and the tests used for follow-up. Management options for high-grade cervical cancer precursor lesions are much more definitive, because the option of expectant management is given except in pregnancy and for adolescents with CIN 2. New markers that better predict which women with high-risk HPV are at highest risk for subsequent development of a true cervical cancer precursor lesion appear to be on the horizon and may make the management of low-grade lesions as clear as present guide lines for their high-grade cousins. Until that time, understanding all the issues involved in expectant and in active management of cervical HPV-induced lesions will help provide women with the best care possible.
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Affiliation(s)
- J Thomas Cox
- Gynecology Clinic. Health Services, University of California, Santa Barbara, CA 93110, USA.
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Affiliation(s)
- Jack Cuzick
- Department of Mathematics, Statistics and Epidemiology, Cancer Research UK, 61 Lincoln's Inn Fields, London, UK.
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