Utilization of human papillomavirus testing for cervical cancer prevention in a university hospital

CIN extension at colposcopy: relation to treatment and blood parameters

OBJECTIVE

To determine the colposcopic lesion size that predicts the presence of residual lesion in patients with cervical intraepithelial neoplasia (CIN) 2/3, to aid gynaecologists in selecting conservative management.

METHODS

Data from 51 patients with low- and high-grade squamous intraepithelial lesions were evaluated. Colposcopic images were captured and lesion areas were calculated. Polymerase chain reaction (PCR) for human papillomavirus was performed. Laboratory parameters were evaluated. Receiver operating characteristic (ROC) curves were used to obtain cut-off values for lesion area. The performance of PCR in the detection of high-grade CIN was assessed. A flowchart was created to compare the costs of related procedures in the Brazilian health system.

RESULTS

For CIN 2/3 treated with excisional surgery, the best cut-off value for lesion area below which no residual lesion was present was 21 019 pixels² (58.87 mm²). The cut-off value that predicted compromised surgical margins was 155 577.65 pixels² (435.75 mm²). Among all patients with CIN, lesion area correlated inversely with neutrophil/lymphocyte ratio (NLR; r = -0.446, P = 0.001), platelet/lymphocyte ratio (PLR; r = -0.438, P = 0.001), and absolute number of leukocytes (r = -0.351, P = 0.011). Conservative clinical management with semi-annual clinical follow-up was found to reduce direct costs to the Brazilian Health System by R $909.82 (US $169.42).

CONCLUSION

CIN reflects systemic alteration, leading to altered NLRs, PLRs, and absolute numbers of leukocytes. Patients with high-grade CIN and colposcopic lesion areas <21 019 pixels² could benefit from conservative management, which would result in cost savings for the Brazilian health system.

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

BACKGROUND

Atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intra-epithelial lesions (LSIL) are minor lesions of the cervical epithelium, detectable by cytological examination of cells collected from the surface of the cervix of a woman.Usually, women with ASCUS and LSIL do not have cervical (pre-) cancer, however a substantial proportion of them do have underlying high-grade cervical intra-epithelial neoplasia (CIN, grade 2 or 3) and so are at increased risk for developing cervical cancer. Therefore, accurate triage of women with ASCUS or LSIL is required to identify those who need further management.This review evaluates two ways to triage women with ASCUS or LSIL: repeating the cytological test, and DNA testing for high-risk types of the human papillomavirus (hrHPV) - the main causal factor of cervical cancer.

OBJECTIVES

Main objective To compare the accuracy of hrHPV testing with the Hybrid Capture 2 (HC2) assay against that of repeat cytology for detection of underlying cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) or grade 3 or worse (CIN3+) in women with ASCUS or LSIL. For the HC2 assay, a positive result was defined as proposed by the manufacturer. For repeat cytology, different cut-offs were used to define positivity: Atypical squamous cells of undetermined significance or worse (ASCUS+), low-grade squamous intra-epithelial lesions or worse (LSIL+) or high-grade squamous intra-epithelial lesions or worse (HSIL+).Secondary objective To assess the accuracy of the HC2 assay to detect CIN2+ or CIN3+ in women with ASCUS or LSIL in a larger group of reports of studies that applied hrHPV testing and the reference standard (coloscopy and biopsy), irrespective whether or not repeat cytology was done.

SEARCH METHODS

We made a comprehensive literature search that included the Cochrane Register of Diagnostic Test Accuracy Studies; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (through PubMed), and EMBASE (last search 6 January 2011). Selected journals likely to contain relevant papers were handsearched from 1992 to 2010 (December). We also searched CERVIX, the bibliographic database of the Unit of Cancer Epidemiology at the Scientific Institute of Public Health (Brussels, Belgium) which contains more than 20,000 references on cervical cancer.More recent searches, up to December 2012, targeted reports on the accuracy of triage of ASCUS or LSIL with other HPV DNA assays, or HPV RNA assays and other molecular markers. These searches will be used for new Cochrane reviews as well as for updates of the current review.

SELECTION CRITERIA

Studies eligible for inclusion in the review had to include: women presenting with a cervical cytology result of ASCUS or LSIL, who had undergone both HC2 testing and repeat cytology, or HC2 testing alone, and were subsequently subjected to reference standard verification with colposcopy and colposcopy-directed biopsies for histologic verification.

DATA COLLECTION AND ANALYSIS

The review authors independently extracted data from the selected studies, and obtained additional data from report authors.Two groups of meta-analyses were performed: group I concerned triage of women with ASCUS, group II concerned women with LSIL. The bivariate model (METADAS-macro in SAS) was used to assess the absolute accuracy of the triage tests in both groups as well as the differences in accuracy between the triage tests.

MAIN RESULTS

The pooled sensitivity of HC2 was significantly higher than that of repeat cytology at cut-off ASCUS+ to detect CIN2+ in both triage of ASCUS and LSIL (relative sensitivity of 1.27 (95% CI 1.16 to 1.39; P value < 0.0001) and 1.23 (95% CI 1.06 to 1.4; P value 0.007), respectively. In ASCUS triage, the pooled specificity of the triage methods did not differ significantly from each other (relative specificity: 0.99 (95% CI 0.97 to 1.03; P value 0.98)). However, the specificity of HC2 was substantially, and significantly, lower than that of repeat cytology in the triage of LSIL (relative specificity: 0.66 (95% CI 0.58 to 0.75) P value < 0.0001).

AUTHORS' CONCLUSIONS

HPV-triage with HC2 can be recommended to triage women with ASCUS because it has higher accuracy (significantly higher sensitivity, and similar specificity) than repeat cytology. When triaging women with LSIL, an HC2 test yields a significantly higher sensitivity, but a significantly lower specificity, compared to a repeat cytology. Therefore, practice recommendations for management of women with LSIL should be balanced, taking local circumstances into account.

Prevention of cervical cancer in women with ASCUS in the Brazilian Unified National Health System: cost-effectiveness of the molecular biology method for HPV detection

This study aimed to assess the performance of PCR as a means of detecting HPV 16/18 compared to the single probe-based PCR for detecting high-risk HPV, and evaluate these methods for detecting cervical intraepithelial neoplasia (CIN) in follow-ups for ASCUS testing. It also compares the costs of cytology, PCR methods, colposcopy and biopsy in the Brazilian Unified National Health System. Of the 81 patients with ASCUS, 41 (50.6%) tested positive for HPV 16/18 in PCR testing and 47 (58.02%) tested positive for high-risk HPV with single probe-based PCR testing. The negative predictive value was 93.75% for HPV 16/18 PCR and 100% for single probe-based PCR in cases that progressed to high-grade CIN. The annual costs of patient referral were the following: R$2,144.52 for referral of patients with ASCUS cytology for colposcopy; R$6,307.44 for referral of patients with ASCUS cytology and PCR positive for HPV 16/18 or colposcopy; R$3,691.80 for referral of patients with ASCUS cytology with single probe-based PCR positive for high-risk HPV. Therefore, cost per user can be reduced by performing single probe-based PCR for high-risk HPV on patients with ASCUS.

Evaluation of Cytokines in Endocervical Secretion and Vaginal pH from Women with Bacterial Vaginosis or Human Papillomavirus

Objective. To verify the relationship between vaginal pH and human papillomavirus (HPV) infection and to measure cytokine levels in endocervical secretions of women with bacterial vaginosis (BV) or HPV. Methods. 173 women (16-48 years old) were enrolled and divided into groups: BV, HPV, and controls. Microbiological culture and vaginal pH were measured. HPV detect by PCR, and cytokines by ELISA (IL-2, IL-6, IL-10, IL-12, TNF-α, and IFN-γ cytokines). Results. Of 173 women, 60 were control group (34.7%) and 113 were distributed in HPV (n=36, 20.8%), BV (n=36, 20.8%), vaginitis (n=30, 17.3%) and, BV and HPV-associated groups (n=11, 6.4%). Vaginal pH > 4.5 was related with HPV infection. IL-2 and IL-12 were increased in BV and HPV groups, and IL-6 (only BV group), compared to control group. IL-12 and IFN-γ were higher in HPV than BV group. Conclusion. The increase of vaginal pH was associated with HPV infection; BV and HPV groups had a Th1 cytokines immune response.

Atypical squamous cells of undetermined significance: Bethesda classification and association with Human Papillomavirus

Introduction. To analyze patients with atypical squamous cells of undetermined significance (ASCUS) through a cytology review and the presence of microbiological agents, with consideration of colposcopy and semiannual tracking. Methods. 103 women with ASCUS were reviewed and reclassified: normal/inflammatory, ASCUS, low-grade squamous intraepithelial lesion (LSIL), or high-grade squamous intraepithelial lesion (HSIL). If ASCUS confirmed, it was subclassified in reactive or neoplastic ASCUS, ASC-US, or ASC-H; and Regione Emilia Romagna Screening Protocol. Patients underwent a colposcopic examination, and test for Candida sp., bacterial vaginosis, Trichomonas vaginalis, and human papillomavirus (HPV) were performed. Results. Upon review, ASCUS was diagnosis in 70/103 (67.9%), being 38 (54.2%) reactive ASCUS and 32 (45.71%) neoplastic ASCUS; 62 (88.5%) ASC-US and 8 (11.41%) ASC-H. ASCUS (Regione Protocol), respectively 1-5: 15 (21.4%), 19 (27.1%), 3 (27.1%), 16 (22.8%), and 1 (1.4%). A higher number of cases of cervical intraepithelial neoplasia (CIN) II/III in the biopsies of patients with ASC-H compared to ASC-US (P = .0021). High-risk HPV test and presence of CIN II/III are more frequent in ASC-H than ASC-US (P = .031). Conclusions. ASC-H is associated with clinically significant disease. High-risk HPV-positive status in the triage for colposcopy of patients with ASC-US is associated with increased of CIN.

Prevalence of human papillomavirus infection in women attending a gynecology/oncology clinic in Qatar

Aim: Human papillomavirus (HPV) detection is very important for the evaluation of prevention strategies in cervical cancer and other HPV-related diseases. This study aimed to assess the prevalence of high-risk HPV infection in a cohort of Qatari residents, and correlate this with cytology and potential risk factors. Method: The study utilized cervical cytology and HPV DNA testing methods, high-risk screen real-time PCR, to detect high-risk HPV genotype infections in a sample of Qatar’s female population. A series of 95 women attending the Gynecology/Oncology Clinic at Hamad Medical Corporation between August 2007 and May 2008 were enrolled in the study. Cervical smears isolated from patients were subjected to real-time PCR to confirm the presence of HPV DNA. The smears were characterized as atypical squamous cells of undetermined significance (ASCUS); low-grade squamous intraepithelial lesions (LGSIL) and high-grade squamous intraepithelial lesions (HGSIL). As a secondary outcome, risk factors for HPV infection were also assessed. However, the samples were not case-controlled for these. Results: A total of 28 women had normal smears and 65 had abnormal smears. Among the 65 women in the study population with abnormal smears, 33 had ASCUS (18 of them were HPV DNA positive), 21 had LGSIL (18 were HPV DNA positive), eight had HGSIL (four were HPV DNA positive) and the remaining three had squamous cell carcinoma (two were HPV DNA positive). Conclusion: The overall prevalence of high-risk HPV in our study population (n = 95) was 64%. The relatively high prevalence of HPV 52, 56 and 16 among the study group has important implications in vaccine prophylaxis in Qatar.

Human papillomavirus infection is principally found with cervical intra-epithelial neoplasia-III in Toluca, State of Mexico

INTRODUCTION

To describe the prevalence of human papillomavirus infection (HPV) in cases of cervical intra-epithelial neoplasia (CIN), micro-invasive carcinoma and invasive carcinoma in Toluca, State of Mexico.

MATERIALS AND METHODS

Cross-sectional study analysing slides with the diagnosis of CIN I to invasive carcinoma for one year and reporting the presence of HPV; also identifying these cervical-uterine cancer stages noted during one semester in the registery of histopathological studies, at the Department of Pathology, General Regional Hospital 220, Instituto Mexicano del Seguro Social (IMSS).

RESULTS

In one year, from a total of 5755 studies, 731 (13%) were of cervical-uterine cancer, 112 (16%) of these were positive for some stage of cervical cancer and 46.43% had HPV infection. In one semester, 2918 histopathological studies were done, 341 (11.68%) of these were cervix uterine biopsies, colposcopies and hysterectomies. 62 women (18.18%) diagnosed with CIN II-III, carcinoma in situ (CIS), micro-invasive carcinoma or invasive carcinoma and finding HPV infection in 51.92% of total cases.

CONCLUSIONS

The prevalence of HPV was higher than that reported in developed world and CIN II-III are the most common stages in Toluca, State of Mexico.