Pitfalls in the diagnosis of cervical intraepithelial neoplasia 1

Bridging the gap in cervical cancer screening for underserved communities: MCED and the promise of future technologies

Cervical cancer screening is a critical public health measure, especially vital for underserved communities where disparities in access and outcomes are pronounced. Despite the life-saving potential of regular screening, numerous barriers-including geographical isolation, cultural and linguistic challenges, and socioeconomic factors-severely hinder accessibility for these populations. Multicancer early detection (MCED) tests emerge as a potentially effective intervention, offering a less invasive, more accessible approach that could transform how screenings are conducted. This paper explores the existing challenges in traditional cervical cancer screening methods, the potential of MCED tests to address these barriers, and the implications of these technologies for global health equity. Through a comprehensive review, we highlight the need for culturally sensitive, tailored interventions and the importance of effectively overcoming logistical and financial difficulties to implement MCED tests. Despite the promise shown by MCED tests, the paper acknowledges significant implementation challenges, including cost, logistical obstacles, and the need for cultural acceptance and validation studies. This study emphasizes the necessity for equitable MCED test implementation strategies, highlighting the potential of these innovative technologies to advance global health equity in cervical cancer prevention.

Utility of p16INK4a expression for the interpretation of uterine cervical biopsies in Kenya

Introduction

histologic interpretation of hematoxylin and eosin-stained cervical biopsies is subject to substantial discordance among pathologists. Immunohistochemical staining for p16INK4a can reduce inter-observer disagreement. We did a cross-sectional study to evaluate the utility of p16INK4a staining in the assessment of cervical biopsies in Nairobi, Kenya.

Methods

hematoxylin and eosin-stained sections from 91 colposcopic biopsies diagnosed as negative for dysplasia or as cervical intraepithelial neoplasia (CIN) grade 1-3 from 2011-2013 in Nairobi, Kenya, were reviewed and immunostained for p16INK4a. Agreement in interpretation of cervical biopsies was compared between primary and consensus review results.

Results

on primary evaluation, 16 cases were negative for squamous dysplasia; 23 were CIN 1; 37 CIN 2; and 15 CIN 3. On consensus review, 32 cases were negative for dysplasia; 19 were CIN 1; 16 CIN 2 and 24 CIN 3. Agreement was moderate between primary and consensus histology review results for the diagnosis of low-grade versus high-grade squamous intraepithelial lesions (Kappa = 0.568). None of the cases negative for dysplasia were positive for p16INK4a expression, but in primary and consensus review results, 17% and 5% cases of CIN 1; 49% and 69% of CIN 2, and 80% and 96% of CIN 3 were p16INK4a positive, respectively.

Conclusion

there was significant variability in the interpretation of cervical biopsies on hematoxylin and eosin between primary and consensus review assessments. 75% of CIN 1 cases that were upgraded to CIN 2 during consensus review expressed p16INK4a. These findings demonstrate the role of p16INK4a in increasing diagnostic accuracy and as a marker of high-grade CIN 2/3.

Novel epigenetic changes in CDKN2A are associated with progression of cervical intraepithelial neoplasia

OBJECTIVE

To conduct a comprehensive mapping of the genomic DNA methylation in CDKN2A, which codes for the p16(INK4A) and p14(ARF) proteins, and 14 of the most promising DNA methylation marker candidates previously reported to be associated with progression of low-grade cervical intraepithelial neoplasia (CIN1) to cervical cancer.

METHODS

We analyzed DNA methylation in 68 HIV-seropositive and negative women with incident CIN1, CIN2, CIN3 and invasive cervical cancer, assaying 120 CpG dinucleotide sites spanning APC, CDH1, CDH13, CDKN2A, CDKN2B, DAPK1, FHIT, GSTP1, HIC1, MGMT, MLH1, RARB, RASSF1, TERT and TIMP3 using the Illumina Infinium array. Validation was performed using high resolution mapping of the target genes with HELP-tagging for 286 CpGs, followed by fine mapping of candidate genes with targeted bisulfite sequencing. We assessed for statistical differences in DNA methylation levels for each CpG loci assayed using univariate and multivariate methods correcting for multiple comparisons.

RESULTS

In our discovery sample set, we identified dose dependent differences in DNA methylation with grade of disease in CDKN2A, APC, MGMT, MLH1 and HIC1, whereas single CpG locus differences between CIN2/3 and cancer groups were seen for CDH13, DAPK1 and TERT. Only those CpGs in the gene body of CDKN2A showed a monotonic increase in methylation between persistent CIN1, CIN2, CIN3 and cancers.

CONCLUSION

Our data suggests a novel link between early cervical disease progression and DNA methylation in a region downstream of the CDKN2A transcription start site that may lead to increased p16(INK4A)/p14(ARF) expression prior to development of malignant disease.

Incidence of cervical intraepithelial neoplasia in Estonia

OBJECTIVE

This study aimed to assess the incidence of cervical intraepithelial neoplasia (CIN) by grade (CIN 1, CIN 2, CIN 3) and age in Estonia (a country with less developed cervical cancer screening program and high cervical cancer incidence).

MATERIALS AND METHODS

This descriptive study uses data from a health insurance fund covering the whole country to estimate the incidence of CIN by grade. CIN case definition was based on specific diagnostic procedures (biopsy, pathological diagnosis, and colposcopy) and/or treatment procedures (excision, local destructive therapy, conization, and hysterectomy) with the CIN-specific diagnosis code (International Statistical Classification of Diseases, 10 Revision) reported on health care claims. Age-specific incidence rates were calculated together with the 95% CIs. Main outcome measure includes CIN grade-specific incidence rate per 1,000 women.

RESULTS

The estimates for CIN incidence per 1,000 women range from 0.68 to 2.83 for CIN 1, 0.63 to 1.24 for CIN 2, and 0.13 to 0.53 for CIN 3 for narrow (biopsy/pathological diagnosis based) and broad (any CIN-specific diagnostic procedure/treatment based) case definition criteria, respectively.

CONCLUSIONS

Our estimates for cervical dysplasia disease frequency and age distribution are in line with those from other developed countries. Administrative health care resources (such as health insurance fund data) are a valuable source for health research.

Adjunctive HPV in-situ hybridization (ISH) assay as an aid in the diagnosis of cervical intraepithelial neoplasia in cervical tissue specimens: an analytical and functional characterization

The purpose of this study was to develop and analytically and functionally validate a new human papillomavirus (HPV) in-situ hybridization (ISH) assay and to determine whether the use of this assay combined with hemotoxylin and eosin (H&E) staining could potentially improve the diagnostic accuracy of interpreting cervical intraepithelial neoplasia (CIN) in human cervical tissue specimens. An automated HPV ISH assay was developed using probes that targeted the broad spectrum of HPV genotypes most commonly associated with CIN. In an exploratory study, tissue sections (n=118) were stained with H&E alone and H&E with HPV ISH and evaluated by 6 general surgical pathologists. Results were compared with diagnoses established by expert pathologists on H&E alone. The change in specificity (diagnosis of no-CIN) and sensitivity (diagnosis of CIN) using H&E plus HPV versus H&E alone was determined. The HPV ISH assay detected 21 HPV genotypes and demonstrated no cross-reactivity to Epstein-Barr virus, cytomegalovirus, herpes simplex virus (HSV)-1, HSV-2, or human placental DNA. The assay detected HPV in a range of 1 to 600 copies on CaSki, HeLa, and SiHa xenografts. Use of this assay with H&E staining improved the average diagnostic specificity of the surgical pathologists from 68.5% to 89.9% (P<0.001), with fewer false-positive CIN 1 results (122 vs. 39). The diagnostic sensitivity was similar for assessments made with H&E alone and those made with HPV plus H&E (93.1% vs. 93.6%). In conclusion, a new automated broad-spectrum HPV ISH assay combined with H&E-stained slides contributed to better ascertainment of CIN than H&E staining alone.

Predictive Value of Class III D Cytological Diagnosis (Munich II, Low and Moderate Dysplasia) and Additional High-risk HPV Testing

The validity of cytological diagnostic procedures for the detection of pre- and early cervical cancer stages is limited due to biological conditions, the uncertainty of cell sampling, and the subjective nature of microscopic assessment. Particularly in class III D cases (Munich II) this can lead to a stigmatization of patients and uncertainty with regard to further clinical follow-up and therapy. Prior to carrying out additional investigations such as high-risk HPV testing or the examination of biomarkers, the positive predictive values of patients with a class III D cytological diagnosis need to be assessed in routine practice. To this end, all relevant data from patients from our practice classed as class III D (pap smears) between 2002 and 2008 (n = 1190; 38.2 % histological diagnosis = therapeutic endpoint) and their current HPV status were recorded. Cytology, histology, persistence, age and follow-up were recorded. The database was used for comparative statistical analysis. Overall, the positive predictive value of conventional pap smear for CIN 2+ was calculated to be 32.3 % (mean follow-up: 39.7 months). The following values were calculated for high-risk HPV testing: sensitivity 94.8 %, specificity 39 %, positive predictive value 42.8 %, negative predictive value 94 %. The additional information obtained from high-risk HPV testing resulted in a significantly better positive predictive value only in patients older than 40 years. However, there was no evidence for an individual risk stratification approach which would reduce uncertainty in the management of III D patients.

Review: Optical Micrometer Resolution Scanning for Non-invasive Grading of Precancer in the Human Uterine Cervix

Management of cervical precancer is archetypal for other cancer prevention programmes but has to consider diagnostic and logistic challenges. Numerous optical tools are emerging for non-destructive near real-time early diagnosis of precancerous lesions of the cervix. Non-destructive, real-time imaging modalities have reached pre-commercial status, but high resolution mapping tools are not yet introduced in clinical settings. The NCBI PubMed web page was searched using the keywords ‘CIN diagnosis’ and the combinations of ‘cervix {confocal, optical coherence tomography, ftir, infrared, Raman, vibrational, spectroscopy}’. Suitable titles were identified and their relevant references followed. Challenges in precancer management are discussed. The following tools capable of non-destructive high resolution mapping in a clinical environment were selected: confocal microscopy, optical coherence tomography, IR spectroscopy, and Raman spectroscopy. Findings on the clinical performance of these techniques are put into context in order to assist the reader in judging the likely performance of these methods as diagnostic tools. Rationale for carrying out research under the prospect of the HPV vaccine is given.

The utility of p16(Ink4a) in discriminating between cervical intraepithelial neoplasia 1 and nonneoplastic equivocal lesions of the cervix

CONTEXT

The protein p16(Ink4a) is overexpressed in cervical lesions associated with high-risk human papillomavirus (HPV) subtypes 16 and 18, but not in low-risk HPV subtypes 6 and 11 or non-HPV-associated cervical lesions.

OBJECTIVE

To determine whether p16(Ink4a) expression in equivocal cervical lesions helps distinguish atypical non-HPV changes from HPV-related changes.

DESIGN

One hundred ninety-one cervical lesions, including 81 cervical intraepithelial neoplasia 1, 52 squamous metaplasia, 33 cellular features suggestive of HPV-related change, 9 reserve cell hyperplasia, 4 microglandular hyperplasia, and 12 inflammatory cervicitis, were randomly selected from archival cervical biopsy specimens. All 191 samples were studied with p16(Ink4a) (JC8 monoclonal antibody). Reactivity for p16(Ink4a) was scored on a 3-tier system as follows: negative, 0% to 5% cells reactive; focal/scattered positive, greater than 5% and less than or equal to 80% cells reactive; diffuse positive, greater than 80% cells reactive. Reactivity was based on normal/reactive cervical specimens where anti-p16 antibody was negative/weakly expressed in non-cervical epithelial cells. Cervical intraepithelial neoplasia 1 lesions not reactive for p16(Ink4a) were investigated for the presence of high-risk HPV by real-time polymerase chain reaction.

RESULTS

No p16(Ink4a) reactivity was detected in the cervical lesions associated with atypical non-HPV change. Eleven of the cervical intraepithelial neoplasia 1 lesions showed focal/scattered reactivity expression for p16(Ink4a), and 19 of the CIN 1 lesions had diffuse reactivity. Fifty of 51 of the CIN 1 lesions negative for p16(Ink4a) were real-time polymerase chain reaction negative for the presence of high-risk HPV; 1 was real-time polymerase chain reaction positive for high-risk HPV.

CONCLUSIONS

The data support the routine use of p16(Ink4a) immunohistochemical evaluation of cervical biopsy specimens for better discrimination of non-HPV-associated lesions from HPV-related lesions.

Outcome analysis of 4 years' follow-up of patients referred for colposcopy with one smear showing mild dyskaryosis

OBJECTIVE

To assess the 4-year outcome of patients after one smear showing mild dyskaryosis with respect to smear regression rate, prevalence of cervical intraepithelial neoplasia (CIN) and the effect of age.

METHODS

Retrospective analysis of patients diagnosed with initial mildly dyskaryotic smear during the year 2000 with a follow-up period of 48 months. These women had not had any previous abnormal smears.

SETTINGS

Cytopathology Department and Colposcopy Unit, King's College Hospital, London, UK.

RESULTS

We identified 524 patients of whom 375 patients with complete follow-up data are included. The age range was 19-67 years with a median of 29 years. There were 207 patients aged 35 years or less (55%). At 6 months, 258 smears were performed and 47.8% of them were negative (95% CI: 41.6-54.0%). The total number of negative follow-up smears in the first year was 198 out of a total of 397 smears performed (50%). This proportion has significantly increased between 1 and 4 years' follow-up to 67.5% (RR: 1.24; 95% CI: 1.14-1.35). Over the 4-year period, 791 smears were performed and 477 were negative (60.3%; 95% CI: 56.9-63.7%). Of the 477 negative smears there were only 61 smears (12.8%; 95% CI: 10-16%), in 54 patients (14%; 95% CI: 11-18%) that reverted back to low-grade cytological abnormality. In only one case the repeat smear showed high-grade abnormality after initial negative follow-up; however, on biopsy, histology showed CIN I. Out of the 375 patients, 70 required treatment with excisional biopsy (19%; 95% CI: 15.0-22.9%). Histology confirmed high-grade CIN in only 41 cases giving a prevalence of 11% (95% CI: 8.1-14.5%). There were no cases of microinvasive or invasive cancer detected. Age (< or =35 years versus >35 years) did not significantly affect either cytological or histological outcome.

CONCLUSION

Sixty per cent of follow-up smears after initial mild dyskaryosis subsequently became negative; of them 87.2% remained negative over the 4 year follow-up. Treatment was only required in 19% of patients, with 11% prevalence of high-grade CIN. Age did not affect the outcome. These results are reassuring and indicate that colposcopic referral may not be necessary after only one mildly dyskaryotic smear.

Agreement between the AMPLICOR Human Papillomavirus Test and the Hybrid Capture 2 assay in detection of high-risk human papillomavirus and diagnosis of biopsy-confirmed high-grade cervical disease

The AMPLICOR HPV test (AMP) and the Hybrid Capture 2 assay (HC2) detect 13 high-risk human papillomavirus (HR-HPV) types. Evaluation of comparative performance with clinical samples is needed to allow informed implementation of AMP into clinical practice. AMP was used (i) to assess the prevalence of HR-HPV in 1,032 samples of known cytology, HC2 status, and/or confirmed histology; (ii) to determine agreement between AMP and HC2; (iii) to evaluate the clinical sensitivity and specificity for detecting HR-HPV; and (iv) to detect the presence of biopsy-confirmed high-grade cervical intraepithelial neoplasia. The prevalence of HR-HPV was 39.3% and 45.6% by AMP and HC2, respectively. Overall agreement was 89.2% (kappa value, 0.78). Of 509 HR-HPV-negative specimens by HC2, 488 (95.9%) were AMP negative. Of 427 HR-HPV-positive specimens by HC2, 347 (81.2%) were AMP positive. In comparing the ability to detect high-grade squamous intraepithelial lesions (HSIL), the two tests were positive for all HSIL samples. Both tests performed similarly on CIN2+ samples (clinical sensitivities were 96.7% and 97.8%, respectively, for AMP and HC2). The clinical specificities of AMP and HC2 were comparable (54.9% versus 51.6%; P=0.18). Genotyping of 20 HC2-negative/AMP-positive cases using alternative technologies revealed target HR genotypes in 63.1% of cases and low-risk types in 15.7% of cases, while 21% of cases were negative. In conclusion, AMP provides a viable alternative to HC2, with good agreement for samples with high-grade cytology and similar sensitivity in detecting CIN2+ lesions.