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Sznurkowski JJ, Bodnar L, Szylberg Ł, Zołciak-Siwinska A, Dańska-Bidzińska A, Klasa-Mazurkiewicz D, Rychlik A, Kowalik A, Streb J, Bidziński M, Sawicki W. The Polish Society of Gynecological Oncology Guidelines for the Diagnosis and Treatment of Cervical Cancer (v2024.0). J Clin Med 2024; 13:4351. [PMID: 39124620 PMCID: PMC11313441 DOI: 10.3390/jcm13154351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/11/2024] [Accepted: 07/19/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Recent publications underscore the need for updated recommendations addressing less radical surgery for <2 cm tumors, induction chemotherapy, or immunotherapy for locally advanced stages of cervical cancer, as well as for the systemic therapy for recurrent or metastatic cervical cancer. Aim: To summarize the current evidence for the diagnosis, treatment, and follow-up of cervical cancer and provide evidence-based clinical practice recommendations. Methods: Developed according to AGREE II standards, the guidelines classify scientific evidence based on the Agency for Health Technology Assessment and Tariff System criteria. Recommendations are graded by evidence strength and consensus level from the development group. Key Results: (1) Early-Stage Cancer: Stromal invasion and lymphovascular space involvement (LVSI) from pretreatment biopsy identify candidates for surgery, particularly for simple hysterectomy. (2) Surgical Approach: Minimally invasive surgery is not recommended, except for T1A, LVSI-negative tumors, due to a reduction in life expectancy. (3) Locally Advanced Cancer: concurrent chemoradiation (CCRT) followed by brachytherapy (BRT) is the cornerstone treatment. Low-risk patients (fewer than two metastatic nodes or FIGO IB2-II) may consider induction chemotherapy (ICT) followed by CCRT and BRT after 7 days. High-risk patients (two or more metastatic nodes or FIGO IIIA, IIIB, and IVA) benefit from pembrolizumab with CCRT and maintenance therapy. (4) Metastatic, Persistent, and Recurrent Cancer: A PD-L1 status from pretreatment biopsy identifies candidates for Pembrolizumab with available systemic treatment, while triplet therapy (Atezolizumab/Bevacizumab/chemotherapy) becomes a PD-L1-independent option. Conclusions: These evidence-based guidelines aim to improve clinical outcomes through precise treatment strategies based on individual risk factors, predictors, and disease stages.
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Affiliation(s)
- Jacek J. Sznurkowski
- Profesor Sznurkowski Podmiot Leczniczy, ul. Stefana Żeromskiego 23A, 81-246 Gdynia, Poland
| | - Lubomir Bodnar
- Faculty of Medical Sciences and Health Sciences, University of Siedlce, 08-110 Siedlce, Poland;
- Department of Clinical Oncology and Radiotherapy, Siedlce Cancer Center, 08-110 Siedlce, Poland
| | - Łukasz Szylberg
- Department of Tumor Pathology and Pathomorphology, Oncology Centre Prof. Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland;
- Department of Obstetrics, Gynecology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, 85-168 Bydgoszcz, Poland
| | - Agnieszka Zołciak-Siwinska
- Department of Gynecological Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (A.Z.-S.); (A.R.); (M.B.)
| | - Anna Dańska-Bidzińska
- Department of Gynecologic Oncology, Second Clinic of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Dagmara Klasa-Mazurkiewicz
- Department of Obstetrics and Gynecological Oncology, Medical University of Gdańsk, 80-210 Gdańsk, Poland;
| | - Agnieszka Rychlik
- Department of Gynecological Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (A.Z.-S.); (A.R.); (M.B.)
| | - Artur Kowalik
- Department of Molecular Diagnostics, Holy Cross Cancer Center, 25-734 Kielce, Poland;
- Division of Medical Biology, Institute of Biology, Jan Kochanowski University, 25-406 Kielce, Poland
| | - Joanna Streb
- Department of Oncology, Jagiellonian University Medical College, 31-008 Krakow, Poland;
| | - Mariusz Bidziński
- Department of Gynecological Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (A.Z.-S.); (A.R.); (M.B.)
| | - Włodzimierz Sawicki
- Department of Obstetrics and Gynecological Oncology, Medical University of Warsaw, 02-091 Warsaw, Poland;
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Nyman MH, Lillsunde Larsson G, Blomberg K, Schröder A. Older women's perceptions of HPV self-sampling and HPV-sampling performed by a midwife - a phenomenographic study. BMC Public Health 2024; 24:211. [PMID: 38233805 PMCID: PMC10795362 DOI: 10.1186/s12889-024-17723-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 01/10/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Cervical cancer is a global disease and it is well established that cervical cancer is caused by human papillomavirus (HPV). In Sweden self-sampling for HPV is now used as a complement to sampling performed by a midwife. However, there is a lack of knowledge on how older women perceive the self-sampling compared to the sampling performed by a midwife. Therefore, the aim of the study was to describe how women, aged 64 years and older, perceived the process of self-sampling and sampling performed by a midwife for HPV-testing. METHODS Eighteen women were included in a qualitative interview study, and a phenomenographic approach was used for the analysis of the interviews. RESULTS Three descriptive categories emerged: Confidence in sampling, Facilitating participation and Being informed. Within the categories, eight conceptions emerged describing the variation relating to how the women perceived the process of self-sampling and sampling performed by a midwife. CONCLUSIONS Women in this study describe confidence in self-sampling for HPV-testing and that the self-sampling was saving time and money, both for themselves and for society. Information in relation to an HPV-positive test result is of importance and it must be kept in mind that women affected by HPV may feel guilt and shame, which health care professionals should pay attention to. This knowledge can be used in education of health care staff. TRIAL REGISTRATION https://researchweb.org/is/fourol/project/228071 . Reg. no 228,071.
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Affiliation(s)
- Maria Hälleberg Nyman
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Gabriella Lillsunde Larsson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden.
- Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Karin Blomberg
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Agneta Schröder
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Health Science, Faculty of Health, Care and Nursing, Norwegian University of Science and Technology (NTNU), Gjövik, Norway
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Helenius G, Lillsunde-Larsson G, Bergengren L. Molecular triage of cervical screening samples in women 55-59 years of age: a pilot study. Infect Agent Cancer 2023; 18:31. [PMID: 37221548 DOI: 10.1186/s13027-023-00510-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/12/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND With HPV screening the specificity of screening positives has decreased, even with a cytological triage test. Increases in colposcopies and detection of benign or low-grade dysplasia are reported, not least in older women. These results highlight the necessity to find other triage tests in HPV screening strategies, so that women can be more accurately selected for colposcopy, thus minimizing the clinically irrelevant findings. METHODS The study included 55- to 59-year-old women who exited the screening with normal cytology, but later in a follow-up test were positive for the HPV genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68 and had a cervical cone biopsy done. To model a screening situation with hrHPV-positive women, three different triage strategies, namely, cytology, genotyping and methylation, were performed. The study considered the effect of direct referral to colposcopy for HPV genotypes 16, 18, 31, 33, 45, 52 and 58, and methylation for FAM19A4 and hsa-mir124-2 and/or any form of abnormal cytology. RESULTS Seven out of 49 women aged 55-59 years with hrHPV had a cone biopsy with high-grade squamous intraepithelial lesion. No triage method found all cases, and when comparing positive and negative predictive value and false negative rate, cytology showed better results than genotyping and methylation. CONCLUSION This study does not support a switch in triage strategies from cytology to hrHPV genotyping and methylation for women above 55 years of age yet, but demonstrates the need for more evidence on molecular triage strategies.
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Affiliation(s)
- Gisela Helenius
- School of Health Sciences, Örebro University, Örebro, Sweden
| | - Gabriella Lillsunde-Larsson
- School of Health Sciences, Örebro University, Örebro, Sweden
- Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Lovisa Bergengren
- Department of Women's Health, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
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Booth BB, Tranberg M, Gustafson LW, Christiansen AG, Lapirtis H, Krogh LM, Hjorth IMD, Hammer A. Risk of cervical intraepithelial neoplasia grade 2 or worse in women aged ≥ 69 referred to colposcopy due to an HPV-positive screening test. BMC Cancer 2023; 23:405. [PMID: 37142959 PMCID: PMC10161414 DOI: 10.1186/s12885-023-10888-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/26/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Cervical cancer incidence and mortality rates are high in older women in many developed countries, including Denmark. Therefore, Danish women aged 69 and older were invited for one additional human papilloma virus (HPV) based screening test in 2017. Here, we describe the clinical management and detection rate of cervical intraepithelial neoplasia grade 2 or worse (CIN2 +) in screen-positive women referred for colposcopy. METHODS We conducted an observational study in public gynecology departments in Central Denmark Region, Denmark. Women were eligible for enrolment if they were aged 69 + in 2017, HPV positive on a screening test taken between April 20th, 2017, and December 31st, 2017, and had been referred for direct colposcopy. Data on participants' characteristics, colposcopic findings, and histological outcomes were collected from medical records and the Danish Pathology Databank. We estimated the proportion of women with CIN2 + at the first colposcopy visit and at end of follow up including 95% confidence intervals (CIs). RESULTS A total of 191 women were included with a median age of 74 years (IQR: 71-78). Most women (74.9%) did not have a fully visible transformation zone at colposcopy. At the first visit 170 women (89.0%) had a histological sample collected, 34 of whom (20.0%, 95% CI 14.3-26.8%) had CIN2 + diagnosed, 19 had CIN3 + , and two had cervical cancer). During follow-up additional CIN2 + were detected resulting in a total of 42 women (24.4%, 95% CI: 18.2-31.5%) being diagnosed with CIN2 + , 25 with CIN3 + , and three with cervical cancer. When restricting to women with paired histologic results (i.e., biopsies and a loop electrosurgical excision procedure (LEEP) specimen), we found that CIN2 + was missed in 17.9% (95% CI 8.9-30.4%) of biopsies compared to the LEEP. CONCLUSION Our findings suggest a potential risk of underdiagnosis in older postmenopausal women referred to colposcopy. Future studies should explore potential risk-markers for discrimination of women at increased risk of CIN2 + from those at low risk, as this would reduce risk of underdiagnosis and overtreatment.
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Affiliation(s)
- Berit B Booth
- Department of Obstetrics and Gynecology, NIDO - Centre for Research and Education, Gødstrup Hospital, Hospitalsparken 15, Herning, 7400, Denmark.
| | - Mette Tranberg
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | - Line W Gustafson
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne G Christiansen
- Department of Obstetrics and Gynecology, NIDO - Centre for Research and Education, Gødstrup Hospital, Hospitalsparken 15, Herning, 7400, Denmark
| | - Helle Lapirtis
- Department of Obstetrics and Gynecology, Randers Regional Hospital, Randers, Denmark
| | - Lisa M Krogh
- Department of Obstetrics and Gynecology, Viborg Regional Hospital, Viborg, Denmark
| | - Ina Marie D Hjorth
- Department of Obstetrics and Gynecology, Horsens Regional Hospital, Horsens, Denmark
| | - Anne Hammer
- Department of Obstetrics and Gynecology, NIDO - Centre for Research and Education, Gødstrup Hospital, Hospitalsparken 15, Herning, 7400, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Gustafson LW, Hammer A, Bennetsen MH, Kristensen C, Majeed H, Petersen LK, Andersen B, Bor P. Cervical intraepithelial neoplasia in women with transformation zone type 3: cervical biopsy versus large loop excision. BJOG 2022; 129:2132-2140. [PMID: 35488417 PMCID: PMC9796102 DOI: 10.1111/1471-0528.17200] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To compare the proportion of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) in cervical biopsies with that in large loop excision of the transformation zone (LLETZ) specimens in women aged ≥45 years with transformation zone type 3 (TZ3). DESIGN Multicentre cross-sectional study. SETTING Three colposcopy clinics in the Central Denmark Region. POPULATION Women aged ≥45 years referred to colposcopy as a result of a positive human papillomavirus (HPV) test and/or abnormal cytology and with TZ3 at colposcopy. METHODS Women had multiple biopsies taken and an LLETZ was performed. MAIN OUTCOME MEASURES Histologically confirmed CIN2+ in biopsies compared with that in LLETZ specimens. RESULTS Of 166 eligible women at colposcopy, 102 women with paired data from biopsies and LLETZ specimens were included for final analysis. The median age was 67.7 years (IQR 62.6-70.4 years), and most were postmenopausal (94.1%) and had undergone HPV-based screening (81.3%). The CIN2+ detection rate was significantly higher in LLETZ specimens than in biopsies (32.4% vs 14.7%, difference 17.7%, 95% CI 6.3-29.0%), resulting in more than half of CIN2+ cases being missed in biopsies (54.5%, 95% CI 36.4-71.9%). The overall agreement between biopsies and LLETZ was 82.4% (95% CI 73.6-89.2%). CONCLUSIONS CIN2+ detection is underestimated in women aged ≥45 years with TZ3 if detection relies on the results of biopsies alone. To reduce the risk of underdiagnosis and overtreatment, future studies should explore the use of new biomarkers for risk stratification to improve discrimination between women at increased risk of CIN2+ who need to undergo LLETZ and women who may undergo follow-up.
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Affiliation(s)
- Line Winther Gustafson
- Department of Public Health Programmes, Randers Regional HospitalUniversity Research Clinic for Cancer ScreeningRandersDenmark
- Department of Clinical MedicineAarhus UniversityHerningDenmark
| | - Anne Hammer
- Department of Clinical MedicineAarhus UniversityHerningDenmark
- Department of Obstetrics and GynaecologyGødstrup HospitalHerningDenmark
| | | | | | - Huda Majeed
- Department of Obstetrics and GynaecologyViborg Regional HospitalViborgDenmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and GynaecologyOdense University HospitalOdenseDenmark
- Open Patient data Explorative Network, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Berit Andersen
- Department of Public Health Programmes, Randers Regional HospitalUniversity Research Clinic for Cancer ScreeningRandersDenmark
- Department of Clinical MedicineAarhus UniversityHerningDenmark
| | - Pinar Bor
- Department of Clinical MedicineAarhus UniversityHerningDenmark
- Department of Obstetrics and GynaecologyRanders Regional HospitalRandersDenmark
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Wang Q, He Y, Long F, Li C, Shen Z, Guo D, Zhaxi D, Bumu L, Hua Z, Sun Z, Jiang N, Han X, Li J, Yan K, Bai S, Tao M, Xu X, Xiao Z. Cervical cancer screening in high-altitude areas in China: A large cross-section study of 25,173 women in northern Tibet. Front Oncol 2022; 12:841547. [PMID: 36091127 PMCID: PMC9452642 DOI: 10.3389/fonc.2022.841547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/13/2022] [Indexed: 11/15/2022] Open
Abstract
Background Cervical cancer has become a worldwide concern owing to its high incidence and mortality rates. To date, high-altitude areas of Tibet have not benefited from any large-scale cervical cancer screening programs. Therefore, we initiated a screening program to investigate the prevalence of human papilloma virus (HPV) and HPV genotype distribution to reveal cervical cancer and its precursor which lead to morbidity among women in the city of Nagqu in northern Tib3et. Methods A total of 25,173 women were recruited to undergo HPV genotype tests between June and December 2019. Women infected with HPV 16 and/or 18 underwent colposcopy and histological examination. Women with other high-risk HPV type (hr-HPV) underwent cytological tests to determine whether to conduct further colposcopy and histological examination for diagnosis. HPV prevalence was calculated in the total population and further stratified according to various parameters, such as age group, area location (altitude level), and single or mixed infection status. The HPV genotype distribution was also investigated accordingly. Cervical lesions revealed by further colposcopic findings were also analyzed; high-grade and malignant lesion morbidities were calculated in total and in each county. Most data were collected and analyzed using descriptive and consistency check statistical methods, and a risk factor investigation for HPV infection was performed using logistic regression models. Results The total HPV infection rate among women in Nagqu was 13.42%. Of the 25,173 women in the study, 999 (3.97%) were HPV 16/18 positive, 2,379 (9.45%) were other hr-HPV-positive, and 21,795 (86.58%) were HPV-negative. The five most common HPV genotypes, accounting for more than 60% of all HPV infections in Nagqu people, were HPV 16, 58, 31, 18, and 52. Tibetan women younger than 20 years and older than 60 years were the two age groups with the highest rates of HPV infection, 26.7% and 19.8%, respectively. Among the HPV-positive women, 2,656 (78.33%) were infected with a single strain and 732 (21.67%) were infected with multiple strains (more than two genotypes). HPV prevalence increased in high-altitude areas (positive rate highest in Nyima with an altitude of 5,000 m, 23.9%) and decreased in relatively low-altitude areas (positive rate lowest in Lhari with an altitude of 4,000 m, 6.6%). Multiple analyses showed that age, parity, age at first delivery, and altitude of residence were independent factors facilitating HPV infection in Tibetan women. High-grade and malignant cervical lesions revealed by histological findings were different among living locations, with the highest rates in Xainza, Baingoin, and Nyainrong, these being 2.019%, 1.820%, and 1.116%, respectively, among women in these areas. Conclusion Our survey provides an overall perspective on HPV genotype infection and cervical lesions in women in northern Tibet. The data not only provide useful information for the treatment of cervical lesions but also has great value in terms of the primary and secondary prevention measures that can be taken for women living in these regions. Clinical Trial Registration www.chictr.org.cn, indentifier ChiCTR2000035061.
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Affiliation(s)
- Qimin Wang
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Pathology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yingying He
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Pathology, Dalian Maternal and Child Medical Group, Dalian, China
| | - Fang Long
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Department of Obstetrics and Gynecology, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
| | - Chaoran Li
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Performance and Quality Management Department, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhuowei Shen
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Dongxing Guo
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Department of Obstetrics and Gynecology, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
| | - Duoji Zhaxi
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
| | - Lamu Bumu
- Department of Obstetrics and Gynecology, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
| | - Zhengyu Hua
- Department of Pathology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhigang Sun
- Department of Pathology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Nan Jiang
- Department of Pathology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xu Han
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jing Li
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Keqing Yan
- Department of Pathology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Siqi Bai
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Muhan Tao
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoguang Xu
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Neurosurgery, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhen Xiao
- Institute of High Altitude Medicine, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Department of Obstetrics and Gynecology, People’s Hospital of Nagqu affiliated to Dalian Medical University, Nagqu, China
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Choi MS, Lee YJ, Lee EH, Ji YI, Park MJ. Factors Associated with Cyto-Histological Misinterpretation of Cervical Smear according to Menopausal Status. J Menopausal Med 2022; 28:78-84. [PMID: 36070873 PMCID: PMC9452595 DOI: 10.6118/jmm.22023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/28/2022] [Accepted: 08/16/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES This study aimed to compare histological outcomes between pre-menopausal and post-menopausal women with cervical cytological abnormalities and to investigate the clinical factors affecting the misinterpretation of cytology and histology. METHODS We conducted a retrospective analysis of 599 patients with abnormal cervical cytology who underwent loop electrosurgical excision procedure (LEEP) between January 2010 and May 2019. Baseline characteristics were collected, including age, height, weight, body mass index, gravity, parity, and menopausal status. In total, 477 pre-menopausal women and 122 post-menopausal women were recruited. RESULTS Atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions were cytologically observed in 73.4% (135/184) of the pre-menopausal women, which were high-grade lesions confirmed by LEEP. In post-menopausal patients with cytology results that cannot exclude high-grade squamous intraepithelial lesions (ASC-H) or high-grade squamous intraepithelial lesions (HSIL), 27.0% (24/89) were confirmed to have histologically low-grade lesions. High-risk HPV (hrHPV) prevalence in abnormal cervical smears was 92.2%. Moreover, other hrHPVs had a higher risk of unexpected histological outcomes unrelated to cytologic results. CONCLUSIONS Menopausal status and HPV infection are associated with misinterpretation of cervical cytology and histology. Therefore, the menopausal status of patients should be considered for the management of cervical cytology, and primary co-testing is recommended to identify women at risk of cervical abnormalities.
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Affiliation(s)
- Min Seong Choi
- Department of Obstetrics and Gynecology, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Young Jin Lee
- Department of Obstetrics and Gynecology, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Eun Hyun Lee
- Department of Obstetrics and Gynecology, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Yong Il Ji
- Department of Obstetrics and Gynecology, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Min Jeong Park
- Department of Obstetrics and Gynecology, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.
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Bao H, Ma L, Zhao Y, Song B, Di J, Wang L, Gao Y, Ren W, Wang S, Wu J, Wang H. Age-specific effectiveness of primary human papillomavirus screening versus cytology in a cervical cancer screening program: a nationwide cross-sectional study. Cancer Commun (Lond) 2022; 42:191-204. [PMID: 35142100 PMCID: PMC8923126 DOI: 10.1002/cac2.12256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/22/2021] [Accepted: 12/30/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Primary human papillomavirus (HPV) screening is recommended for the detection of cervical intraepithelial neoplasia (CIN) in the general population; however, the triage for HPV-positive women remains a challenge. This study aimed to evaluate the age-specific effectiveness of primary HPV screening versus primary cytology screening for identifying optimal strategies for women of different ages. METHODS The dataset of the prevalence round screening was derived from the National Cervical Cancer Screening Program in China. Primary cervical screening protocols included cytology only, HPV testing with cytology triage, and HPV testing with HPV-16/18 genotyping plus cytology triage. The primary outcomes were age-specific detection rate, colposcopy referral rate and positive predictive value (PPV) for CIN2+. Multivariate Poisson regression was used to evaluate the relative effectiveness of HPV testing and cytology according to age groups. The I2 statistic with a random-effect model was used to test the heterogeneity in relative effectiveness of HPV testing versus cytology between age groups. RESULTS This study included 1,160,981 women. HPV testing with HPV-16/18 genotyping plus cytology triage significantly increased the CIN2+ detection by 36% (rate ratio [RR]: 1.36, 95% confidential interval [CI] 1.21-1.54) for women aged 35-44 years and by 34% (RR: 1.34, 95% CI 1.20-1.51) for women aged 45-54 years compared with cytology only. HPV testing with cytology triage had similar CIN2+ detection rate compared with cytology only. The PPVs were substantially increased for both HPV testing groups. Among women aged 55-64 years old, HPV testing with HPV-16/18 genotyping plus cytology triage increased the colposcopy referral rate by 19% (RR 1.19, 95% CI 1.10-1.29) compared with cytology only, but did not increase the CIN2+ detection (1.09, 0.91-1.30). The effectiveness of HPV testing with cytology triage did not change in older women. The between-age-group heterogeneity in the effectiveness was statistically significant for HPV testing with HPV-16/18 genotyping plus cytology triage versus cytology only. CONCLUSIONS Our results suggested that the effectiveness of primary HPV screening with different triage strategies differed among age groups. HPV testing with HPV-16/18 genotyping plus cytology triage could be used for women aged 35-54 years to detect more lesions, and HPV testing with cytology triage could balance the CIN2+ detection and the number of colposcopies for women aged 55-64 years. Longitudinal data including both prevalence and incidence screening rounds are warranted to assess age-specific triage strategies.
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Affiliation(s)
- Heling Bao
- Department of Maternal and Child Health, School of Public HealthPeking UniversityBeijing100191P. R. China
| | - Lan Ma
- National Center for Women and Children's HealthChinese Center for Disease Control and PreventionBeijing100081P. R. China
| | - Yanxia Zhao
- National Center for Women and Children's HealthChinese Center for Disease Control and PreventionBeijing100081P. R. China
| | - Bo Song
- National Center for Women and Children's HealthChinese Center for Disease Control and PreventionBeijing100081P. R. China
| | - Jiangli Di
- National Center for Women and Children's HealthChinese Center for Disease Control and PreventionBeijing100081P. R. China
| | - Linhong Wang
- National Center for Chronic and Non‐communicable Disease Control and PreventionChinese Center for Disease Control and PreventionBeijing100050P. R. China
| | - Yanqiu Gao
- Department of Maternal and Child Health, School of Public HealthPeking UniversityBeijing100191P. R. China
| | - Wenhui Ren
- National Center for Women and Children's HealthChinese Center for Disease Control and PreventionBeijing100081P. R. China
| | - Shi Wang
- Department of Maternal and Child Health, School of Public HealthPeking UniversityBeijing100191P. R. China
| | - Jiuling Wu
- National Center for Women and Children's HealthChinese Center for Disease Control and PreventionBeijing100081P. R. China
| | - Hai‐Jun Wang
- Department of Maternal and Child Health, School of Public HealthPeking UniversityBeijing100191P. R. China
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Koc S, Yuksel D, Kayikcioglu F. Colposcopic histopathology results of patients over 50: Is HPV genotyping useful? Curr Probl Cancer 2021; 46:100764. [PMID: 34275530 DOI: 10.1016/j.currproblcancer.2021.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/05/2021] [Accepted: 06/11/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND To determine the rate of high-grade cervical intraepithelial lesion and cancer (HSIL+) diagnosis as a result of colposcopic histopathology in patients aged ≥50 years and to investigate the role of cytology, Human Papillomavirus (HPV) test positivity and HPV genotyping in predicting HSIL+. MATERIAL AND METHOD The study included 1102 patients aged ≥50 as study group and 2723 patients aged <50 as control group who were admitted to our colposcopy unit between January 1, 2015 and December 31, 2019 and underwent colposcopy for the first time. The patients with HSIL+ were compared as Cytology group and HPV group in the study group. To evaluate the impact of genotyping HPV positive group was compared in terms of HSIL+ results in subgroups with HPV16/18 and HPV other types positivity. Patients diagnosed with cancer in the same period were compared in terms of age, stage and histology as screening cancer group and symptomatic cancer groups. RESULTS The rate of cervical cancer in the study group was 2.2% and 1.2 % in the control group. In patients diagnosed with cancer, Federation of Gynecology and Obstetrics stage was ≥ stage IB2 in 57.4% of cases in the symptomatic cancer group and in 18.9% of cases in the screening cancer group. The HPV 16/18 positivity rate in HSIL+ patients were 75.0% and 79.5% in the study and control group, respectively. CONCLUSION Cervical cancer rates were found to be high in the group aged ≥ 50 years. HPV genotyping is as effective in patients ≥50 years of age as in those aged < 50 years. Patients diagnosed as a result of screening are caught in the early stages and therefore with increased general life expectancy, the age at which screening is discontinued should be re-evaluated.
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Affiliation(s)
- Sevgi Koc
- Department of Gynecologic Oncology, University of Health Sciences Turkey, Etlik Zubeyde Hanim Women's Health Education and Research Hospital, Ankara, Turkey.
| | - Dilek Yuksel
- Department of Gynecologic Oncology, University of Health Sciences Turkey, Etlik Zubeyde Hanim Women's Health Education and Research Hospital, Ankara, Turkey
| | - Fulya Kayikcioglu
- Department of Gynecologic Oncology, University of Health Sciences Turkey, Etlik Zubeyde Hanim Women's Health Education and Research Hospital, Ankara, Turkey
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10
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Gustafson LW, Petersen LK, Bor P, Andersen B, Hammer A. Cervical cancer prevention among older women - challenges in screening, diagnostic workup and treatment. Acta Obstet Gynecol Scand 2021; 100:1364-1368. [PMID: 33866548 DOI: 10.1111/aogs.14162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 11/30/2022]
Abstract
Cervical cancer incidence and mortality have declined dramatically after screening for cervical cancer was implemented. Yet, studies have reported high cervical cancer incidence and mortality rates at older age despite low HPV prevalence and incidence of precursor lesions. The underlying reason for these findings remains unclear. However, it is well known that the impact of screening depends not only on the uptake and effectiveness of screening but also on the uptake and effectiveness of diagnostic workup (ie colposcopy), treatment and follow-up. In older women, sensitivity of screening and performance of colposcopy are impaired due to age-dependent changes to the cervix. In this commentary, we aimed to discuss challenges in screening and clinical management of older women, and to identify crucial areas of particular interest for future research.
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Affiliation(s)
- Line W Gustafson
- Department of Public Health Programs, Randers Regional Hospital, Randers, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark.,Open Patient data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Pinar Bor
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Randers Regional Hospital, Randers, Denmark
| | - Berit Andersen
- Department of Public Health Programs, Randers Regional Hospital, Randers, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne Hammer
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Gødstrup Hospital, Gødstrup, Denmark.,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
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11
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Chandrasekhar Srinivasamurthy B, Pulavarthi S, Bhat R, Mathiyazhagan D. Role of Ki-67 and Comparison of Conventional-with Liquid-Based–Cytology in Postmenopausal Women. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2020.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | - Sabita Pulavarthi
- Department of Obstetrics and Gynaecology, Indira Gandhi Medical College and Research Institute, Puducherry, India
| | - Ramachandra.V. Bhat
- Department of Pathology, Indira Gandhi Medical College and Research Institute, Puducherry, India
| | - Dharanya Mathiyazhagan
- Department of Pathology, Indira Gandhi Medical College and Research Institute, Puducherry, India
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12
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Asciutto KC, Borgfeldt C, Forslund O. 14-type HPV mRNA test in triage of HPV DNA-positive postmenopausal women with normal cytology. BMC Cancer 2020; 20:1025. [PMID: 33097006 PMCID: PMC7583187 DOI: 10.1186/s12885-020-07498-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 10/06/2020] [Indexed: 12/22/2022] Open
Abstract
Background During 2013 and 2016 the region of Skåne, Sweden started to analyse human papillomavirus (HPV) and cytology in postmenopausal women 60–65 years of age. Our aim was to evaluate high-risk (HR) HPV mRNA testing for the triage of HPV DNA-positive postmenopausal women with normal cytology. Methods A total of 271 women, 60–65 years of age, underwent liquid-based cytology (LBC) and HPV testing by using the HR-HPV DNA MGP-PCR-Luminex assay. HR-HPV DNA-positive women with normal cytology underwent complimentary HPV mRNA testing (Aptima, Hologic Inc.). Over a period of 49 months (SD 11.0) the women received regular follow-ups at intervals of 12–18 months. Women with abnormal cytology and/or a positive HR-HPV DNA and/or mRNA result at two subsequent visits were scheduled for colposcopy and clinical examination. Results Over the surveillance period, 3.6% (10/271) of the HR-HPV DNA-positive women developed histologically confirmed high-grade squamous intraepithelial lesions (HSILs) or worse. The cumulative incidence rates (CIR) were 29.7% (CI 24.8–30.1) for HSIL or worse among HPV mRNA-positive women at enrolment (39.5% 107/271) and 0% among HPV mRNA-negative women (60.5%, 164/271), (p = 0.002). Conclusions Postmenopausal women with normal cytology testing positive for HR-HPV mRNA are at increased risk for the development of high-grade cervical intraepithelial neoplasia (CIN), in contrast to women with a negative HR-HPV mRNA outcome. The HR-HPV mRNA APTIMA assay detecting 14 HR-HPV types may be a useful triage method among HPV DNA-positive postmenopausal women with normal cytology.
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Affiliation(s)
- Katrin Christine Asciutto
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, SE-22185, Lund, Sweden.
| | - Christer Borgfeldt
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, SE-22185, Lund, Sweden
| | - Ola Forslund
- Department of Laboratory Medicine Region Skåne, Lund University, Lund, Sweden
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13
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Jin J, Yue CY. Analysis of the efficacy of liquid-based cytology combined with HPV genotypes in screening cervical lesions in women of different ages. J LAB MED 2020. [DOI: 10.1515/labmed-2019-0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objectives
To evaluate the value of liquid-based cell examination combined with human papillomavirus (HPV) genotypes in the detection of cervical intraepithelial neoplasia.
Methods
A total of 21,155 patients who had undergone cytology, HPV genotypes and colposcopy-guided biopsy were grouped into three groups. Sensitivity, specificity, positive predictive value, and negative predictive value of the test methods of the three groups were compared.
Results
In the age group of less than 50 years, the sensitivity of HPV genotype testing was significantly higher than that of liquid-based cytology. The specificity of liquid-based cytology was significantly higher in all age groups than that of HPV genotype testing. The positive predictive value of each test index was higher in the age group less than 30 years, and the negative predictive value was higher in the 30–50-year age groups. In different age groups, liquid-based cytology and HPV genotype combined method can improve the sensitivity of detection and negative predictive values.
Conclusions
The HPV test has higher sensitivity and negative predictive value, and the cytology method is relatively specific and less sensitive. The combined method has better sensitivity and negative predictive value.
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Affiliation(s)
- Jun Jin
- Department of Pathology , Fudan University Affiliated Obstetrics and Gynecology Hospital , Shanghai , P.R. China
| | - Chao-Yan Yue
- Department of Laboratory Medicine , Fudan University Affiliated Obstetrics and Gynecology Hospital , Shanghai , P.R. China
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14
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Rezhake R, Chen F, Hu S, Zhao X, Zhang X, Cao J, Qiao Y, Zhao F, Arbyn M. Triage options to manage high‐risk human papillomavirus
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positive women: A population‐based cross‐sectional study from rural China. Int J Cancer 2020; 147:2053-2064. [PMID: 32249409 DOI: 10.1002/ijc.33001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/12/2020] [Accepted: 03/24/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Remila Rezhake
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Feng Chen
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Shang‐Ying Hu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Xue‐Lian Zhao
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Xun Zhang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Jian Cao
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Shenzhen China
| | - You‐Lin Qiao
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Fang‐Hui Zhao
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Marc Arbyn
- Unit of Cancer Epidemiology Belgian Cancer Centre Sciensano, Brussels Belgium
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15
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Prevalence of HPV and pathological changes among women 70 years of age, 10 years after exclusion from the Swedish cervical cancer screening program. Cancer Causes Control 2020; 31:377-381. [PMID: 32076907 DOI: 10.1007/s10552-020-01278-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Örebro County introduced an updated screening program 2016 with primary HPV test for women over 30 years and prolonged screening, increasing the cut-off age from 56-60 to 64-70. The aim of this study was to investigate the prevalence of HPV genotypes and their correlation to histological changes in women, 10 years after exclusion from the screening program, due to an eventual implementation of a catch-up program including all women aged 60-70. METHODS All women in Örebro County, born 1,946 (n = 1,968), were invited to a liquid-based cell sample with primary HPV screening. Samples were analyzed for hrHPV mRNA and positive samples were genotyped. hrHPV positive women were offered to do a conization. RESULTS Out of 809 participants, 31 (3.8%) were hrHPV positive, of these 22 did a conization. Histologically, 5/22 (23%) had LSIL and 5/22 (23%) had HSIL. Normal histology was found in 12/22 (55%). The most prevalent genotypes were HPV 16, 33, 52, 56, and 68. Of the women with HSIL, one case of cervical cancer was confirmed in a recone biopsy after 4 months. CONCLUSION The study showed considerable prevalence of hrHPV and histologically confirmed LSIL/HSIL. These data led to catch-up screening for women between 60 and 70 years when overlapping two screening strategies.
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16
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Zhao J, Zhan Q, Guo J, Liu M, Ruan Y, Zhu T, Han L, Li F. Phylogeny and polymorphism in the E6 and E7 of human papillomavirus: alpha-9 (HPV16, 31, 33, 52, 58), alpha-5 (HPV51), alpha-6 (HPV53, 66), alpha-7 (HPV18, 39, 59, 68) and alpha-10 (HPV6, 44) in women from Shanghai. Infect Agent Cancer 2019; 14:38. [PMID: 31832087 PMCID: PMC6873513 DOI: 10.1186/s13027-019-0250-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/21/2019] [Indexed: 12/13/2022] Open
Abstract
Background Persistent infection with human papillomaviruses (HPVs) has been associated with cervical intraepithelial neoplasia (CIN) and cervical cancer. However, why only a fraction of HPV cases progress to cancer is still unclear. Methods We focused on the heterogeneity, classification, evolution and dispersal of variants for 14 common HPV types in 262 HPV-positive patients with cervical lesions. The E6 and E7 genes of HPV were sequenced and compared with the HPV reference for sequence analysis. Phylogenetic trees were constructed using the neighbour-joining tree method with MEGA 7.0. Results In this study, 233 E6 and 212 E7 sequences were successfully amplified by PCR, and these sequences were divided into 5 species groups: alpha-9 (HPV16, 31, 33, 52, 58), alpha-5 (HPV51), alpha-6 (HPV53, 66), alpha-7 (HPV18, 39, 59, 68) and alpha-10 (HPV6, 44). The incidence of high-grade squamous intraepithelial lesion (HSIL) in patients infected with alpha-9 HPV was significantly increased compared with other groups (P < 0.0001), especially HPV16 (P < 0.0001). Strikingly, E7 had significantly fewer nonsynonymous variants in the HSIL compared to <HSIL groups (P = 3.17× 10- 4). The A388C (K93 N) variation in HPV58 E6 can significantly reduce the risk of HSIL (P = 0.015). However, T7220G (D32E) variation in HPV16 E6 and A7689G (N29S) in HPV16 E7 increased the incidence of HSIL compared to the <HSIL group (P = 0.036 and 0.022). Conclusions Strict conservation of E7 is important for HPV carcinogenicity, especially N29 of HPV16. The findings in this work provide preventative/therapeutic interventions for HPV infections and CIN.
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Affiliation(s)
- Junwei Zhao
- 1Department of Obstetrics and Gynecology, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, Shanghai, 200120 People's Republic of China
| | - Qin Zhan
- 2Department of Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 201204 China
| | - Junhan Guo
- 1Department of Obstetrics and Gynecology, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, Shanghai, 200120 People's Republic of China
| | - Min Liu
- 1Department of Obstetrics and Gynecology, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, Shanghai, 200120 People's Republic of China
| | - Yetian Ruan
- 1Department of Obstetrics and Gynecology, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, Shanghai, 200120 People's Republic of China
| | - Tailin Zhu
- 3School of Physics HH Wills Physics Laboratory, University of Bristol, Bristol, UK
| | - Lingfei Han
- 2Department of Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 201204 China
| | - Fang Li
- 1Department of Obstetrics and Gynecology, East Hospital, Tongji University School of Medicine, 150 Jimo Rd, Shanghai, 200120 People's Republic of China
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