The clinician's view: role of human papillomavirus testing in the American Society for Colposcopy and Cervical Pathology Guidelines for the management of abnormal cervical cytology and cervical cancer precursors

Anal intraepithelial neoplasia: review and recommendations for screening and management

Anal cancer is a rare malignancy of the distal gastrointestinal tract, often associated with human papillomavirus, the most common sexually transmitted infection worldwide. Currently available screening methods for anal intraepithelial neoplasia, a precursor for anal cancer, combine anal Papanicolaou cytology and high resolution anoscopy with biopsy of suspicious lesions. Significant barriers to establishing anal cancer screening programmes include the small number of healthcare professionals performing high resolution anoscopy and the lack of data showing that anal cancer screening can reduce morbidity and mortality related to anal carcinoma. Despite several controversies surrounding anal cancer screening, the rising incidence of this disease in some groups supports routine screening programmes in high-risk populations, especially in HIV-positive men who have sex with men.

This review outlines the epidemiology of anal intraepithelial neoplasia and anal cancer and summarizes issues related to the introduction of anal cancer screening programmes.

Near-infrared Raman Microspectroscopy Detects High-risk Human Papillomaviruses

BACKGROUND

Detecting human papillomaviruses (HPVs) infection in cervical cells is an exceedingly important part of the clinical management of cervical dysplasia. Current guidelines in women's health outline the need for both the Papanicolaou test as well as high-risk HPV testing. Testing for HPV is expensive, is time-consuming, and requires experienced technicians.

METHODS

Two sets of near-infrared Raman microspectroscopy experiments were conducted using a Raman confocal microscope system. First, Raman spectra were acquired from four different cell culture lines, two positive for HPV (HeLa, SiHa), one negative for HPV, but malignant (C33A), and one normal, HPV-negative line (NHEK). The three malignant lines were all derived from cervical cells. Second, Raman spectra were acquired from deidentified patient samples that were previously tested for the presence of high-risk HPV.

RESULTS

The spectra from the cell culture lines and the patient samples contained many statistically significant differences. Using sparse multinomial logistic regression to classify the data led to classification accuracies of 89% to 97% for the cell culture samples and 98.5% for the patient samples.

CONCLUSIONS

Raman micro-spectroscopy can be used to detect HPV and differentiate among specific HPV strains. This technique may provide health providers with a new method for quickly testing cell samples for the presence of HPV.

Human Papillomavirus and Pap Smear

High-risk human papillomavirus (HPV) infection and viral persistence is a major risk factor in the development of squamous intraepithelial lesions and invasive carcinoma of the cervix. In the United States, deaths due to squamous cell carcinoma of the cervix have fallen by 75% since the 1960s because of Papanicolaou (Pap) smear screening. However, the traditional Pap had a sensitivity of about 70% for detecting clinically significant precancerous lesions and cancer because of sampling and interpretive errors. The introduction of 2 liquid-based Pap smear collection systems in the 1990s, the use of HPV testing as a triage and co-testing with Pap smear, and the introduction of 2 automated screening devices have had a significant impact on improving the detection of such precancerous lesions. This review provides an analysis of the changes in Pap smear collection, improvements in screening, the evolutionary changes of high-risk HPV testing, reporting terminology of Pap smears, and clinical management guidelines. The future impact of 2 prophylactic HPV vaccines on the incidence of cervical carcinoma is also discussed. This article also discusses alternatives such as primary screening for high-risk HPV testing with visual inspection for cervical cancer detection used in resource-poor settings with a high incidence of cervical cancer.

Human papillomavirus and Papanicolaou tests screening interval recommendations in the United States

OBJECTIVE

Guidelines recommend when the human papillomavirus (HPV) and Papanicolaou tests are used together (HPV co-test) for routine cervical cancer screening, screening intervals can be extended to 3 years. We assessed HPV test practices and Papanicolaou test screening interval recommendations of US providers.

STUDY DESIGN

Using a multistage probability design, we analyzed nationally representative data that were collected in 2006 through the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey.

RESULTS

Approximately 51% of providers ordered the HPV co-test; however, clinical vignettes found that <15% of providers who ordered the HPV test recommend the next Papanicolaou test in 3 years for women with concurrent normal HPV co-test results and a documented normal screening history.

CONCLUSION

Overall, annual cervical cancer screening continues to be a common recommendation, regardless of whether a screening history has been established or an HPV test has been ordered.

Inverse association between methylation of human papillomavirus type 16 DNA and risk of cervical intraepithelial neoplasia grades 2 or 3

BACKGROUND

The clinical relevance of human papillomavirus type 16 (HPV16) DNA methylation has not been well documented, although its role in modulation of viral transcription is recognized.

METHODS

Study subjects were 211 women attending Planned Parenthood clinics in Western Washington for routine Papanicolaou screening who were HPV16 positive at the screening and/or subsequent colposcopy visit. Methylation of 11 CpG dinucleotides in the 3' end of the long control region of the HPV16 genome was examined by sequencing the cloned polymerase chain reaction products. The association between risk of CIN2/3 and degree of CpG methylation was estimated using a logistic regression model.

RESULTS

CIN2/3 was histologically confirmed in 94 (44.5%) of 211 HPV16 positive women. The likelihood of being diagnosed as CIN2/3 increased significantly with decreasing numbers of methylated CpGs (meCpGs) in the 3' end of the long control region (P(for trend) = 0.003). After adjusting for HPV16 variants, number of HPV16-positive visits, current smoking status and lifetime number of male sex partners, the odds ratio for the association of CIN2/3 with ≥4 meCpGs was 0.31 (95% confidence interval, 0.12-0.79). The proportion of ≥4 meCpGs decreased appreciably as the severity of the cervical lesion increased (P(for trend) = 0.001). The inverse association remained similar when CIN3 was used as the clinical endpoint. Although not statistically significant, the ≥4 meCpGs-related risk reduction was more substantial among current, as compared to noncurrent, smokers.

CONCLUSION

Results suggest that degree of the viral genome methylation is related to the outcome of an HPV16 cervical infection.

Type-specific human papillomavirus detection in cervical smears in Romania

Although Romania has one of the highest incidence of cervical cancer in Europe (30 new cases/100 000 women), little is known about the distribution of the human papillomaviruses (HPV) genotypes in this population. We seek to determine the distribution of HPV genotypes in women with normal and abnormal cervical cytology. We analyzed 460 cervical cytology specimens from women who self-referred to the gynecologic clinic. HPV was detected and genotyped using the commercially available INNOLiPA (INNOGENETICS NV) kit based on the reverse hybridization principle. HPV DNA was detected in 279 cases (60.7%) with a median age of 32.9 years. In HGSIL (High Grade Squamous Intraepithelial Lesion) cytology, the presence of HPV DNA was confirmed in 82.7% of cases. The most frequent high-risk genotype was HPV16, found in 32.6% of HPV-positive samples. The next common high-risk genotypes were HPV18, HPV31 and HPV51. Our findings on the distribution and frequency of the HPV genotypes in Romanian population confirmed the utility of the current available HPV vaccines, HPV16 and 18 being detected in 28.7% of cases in the investigated area.

Clinical significance of cytologic atypical squamous cells of undetermined significance

OBJECTIVE

To analyze the screening status, clinical characteristics, and risk of invasive cervical cancer in women with cytologic atypical squamous cells of undetermined significance (ASC-US) in general populations and to make recommendations for these women.

METHODS

The 95,309 women with initial cytologic ASC-US from the national cervical cancer screening database in Taiwan were divided into unscreened and screened groups based on their previous screening history. Newly diagnosed invasive cervical cancer cases in the follow-up period were retrieved for analysis.

RESULTS

There were 860 cases of invasive cervical cancer during the follow-up period of 556,758 person-years, with an overall incidence rate of 154.5 cases per 100,000 person-years. The incidence was 92.3 and 257.2 cases per 100,000 person-years in the screened and unscreened groups, respectively. Previous screening history was a strong risk predictor of invasive cervical cancer (hazard ratio 2.8, 95% confidence interval 2.4-3.1, P<.001) after adjustments for age, educational status, and hospital setting. Age was also a significant risk factor for developing invasive cervical cancer in the unscreened group but not in the screened group.

CONCLUSION

Women with cytologic ASC-US, especially those without a previous Pap test or older women, were more likely to develop invasive cervical cancer and should be followed up aggressively.

LEVEL OF EVIDENCE

II.

Cervical dysplasia among women over 35 years of age

OBJECTIVE

The objective of the study was to review the cytologic and histopathologic features among women 35 years of age or older with cervical dysplasia.

STUDY DESIGN

Patients presenting between 2001 and 2005 were included. Patients were labeled as pre- (PRE) or postmenopausal (POST) based on age younger than or 50 years old or older. Statistics were performed using SAS 8.0.

RESULTS

Three hundred fifty-nine patients were identified: 270 PRE and 89 POST. PRE and POST patients had similar referral cytology with atypical cells of undetermined significance (ASC)/low-grade squamous intraepithelial lesion (LSIL) in 60% and 65% and high-grade squamous intraepithelial lesion (HSIL) in 35% and 27%, respectively. Among patients with ASC/LSIL, POST had significantly more cervical intraepithelial neoplasia (CIN) 3 (41% vs 29%; P = .027) as well as more malignancies (17 vs 0%; P = .002). Among patients referred for loop electrical excisional procedure secondary to HSIL cytology not explained by colposcopy, CIN 2 or greater was identified more often in POST (71 vs 32%; P = .03).

CONCLUSION

Our data demonstrate a high proportion of severe cervical dysplasia in age groups traditionally thought to have less risk than younger patients.

Linear array genotyping and hybrid capture II assay in detecting human papillomavirus genotypes in women referred for colposcopy due to abnormal Papanicolaou smear

Summary:

The main objective of this study was to assess the feasibility of human papillomavirus (HPV) genotyping in women referred for colposcopy due to abnormal Papanicolaou (Pap) smear. A series of 248 women referred for colposcopy due to an abnormal Pap smear were analysed with the Roche Linear Array HPV genotyping test detecting 37 most frequent HPV types, and compared with hybrid capture II (HCII) assay for oncogenic (high-risk [HR] HPV) types as well as for p16INK4a expression using immunocytochemistry. All tests were performed in cervical samples collected in PreservCyt® liquid media for liquid-based cytology (ThinPrep), and colposcopic biopsy and/or loop electro excision procedure cone biopsy was used as the gold standard. HPV16 was the single most frequent genotype (29/258; 11.7%), followed by HPV51 (4.4%), HPV66 (3.6%), HPV42, 52 and 56 (3.2% for all). Linear array genotyping test significantly predicts both abnormal colposcopy (odds ratio [OR] = 9.0; 3.12-25.93), high-grade squamous intraepithelial lesions (OR = 9.6; 1.26-74.17) and cervical intraepithelial neoplasia (CIN) 3+ (OR = 29.3; 3.95-218.06). In detecting CIN3, linear array was equivalent (97.6%) to colposcopy in sensitivity (SE), both being superior to HCII (92.7%). Concordance between linear array and HCII was moderate (Cohen's kappa κ = 0.547; 95% confidence interval [CI]: 0.435-659). Specificity (SP) and positive predictive value (PPV) of linear array were significantly improved, if only HPV16 genotype was considered. Performance in the best balance is obtained, when linear array and colposcopy are combined, giving 82.9% SE, 93.9% SP, 73.9% PPV and 96.3% negative predictive value (NPV) as predictor of CIN3+ (OR 74.5; 95% CI: 27.36-202.72). In conclusion, linear array for HR-HPV is a highly sensitive test (97.6%) with high NPV (98.9%) in detecting CIN3+ lesions. HPV16 genotyping alone significantly improves SP and PPV of this test in management of women with abnormal cytology.

Epidemiology and natural history of human papillomavirus infections in the female genital tract

Human papillomavirus (HPV) is the most common newly diagnosed sexually transmitted infection in the United States. Although the majority of sexually active adults will be infected with HPV at least once in their lives, it is sexually active women less than 25 years of age who consistently have the highest rates of infection. Besides youth and gender, common risk factors for HPV infection and clinical sequelae of infection include high number of sexual partners and coinfection with Chlamydia trachomatis or herpes simplex virus. Most HPV infections are cleared by the immune system and do not result in clinical complications. Clinical sequelae in cases of low-risk HPV infection consist of genital warts, and clinical manifestations of high-risk HPV infection include abnormal Pap test results, low-grade squamous intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL), and cervical cancer. LSIL, HSIL, and cervical cancer carry significant morbidity and/or mortality; genital warts and abnormal Pap test results are often significant sources of psychosocial distress. Currently, there are neither effective means of preventing HPV transmission nor cures for clinical manifestations: infection can only be prevented via complete sexual abstinence, while treatment for clinical sequelae such as genital warts and cytologic abnormalities consists of removing the problematic cells and watching for recurrence; this method consumes significant health care resources and is costly. New prophylactic HPV vaccines promise to dramatically reduce the incidence of HPV infection, genital warts, and cytologic abnormalities.

Adolescent cervical dysplasia: histologic evaluation, treatment, and outcomes

OBJECTIVE

The purpose of this study was to evaluate histologic findings and outcomes among adolescents with cervical dysplasia.

STUDY DESIGN

Patient charts (2001-2005) were reviewed. Prevalence of cervical intraepithelial neoplasia (CIN) grades 2 and 3 and progression and regression were recorded.

RESULTS

Five hundred one patients were identified. On biopsy, 324 patients (65%) had CIN 1 or less, and 177 patients (35%) had CIN > or = 2. Twenty-nine percent of the patients with CIN 2 opted for conservative treatment vs excision. Over 18 months, the condition of 65% of the patients regressed; the condition of 20% of the patients was stable, and the condition of 5% of the patients progressed without cancer. Of the patients who underwent excision (follow-up median, 26 months), 84% experienced regression of their condition; the condition of 11% was persistent, and 5% progressed with no cancer.

CONCLUSION

CIN > or = 2 is present in 35% of our cohort. Most had CIN 2, and most experienced regression. Our observation supports continued vigilance in the evaluation of adolescents but suggests that less intervention for CIN 2 may be acceptable.

Human papillomavirus testing in primary cervical screening and abnormal Papanicolaou management

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.

Screening for gynaecological cancers

BACKGROUND

The role of screening in gynaecological cancers is under evaluation. With mass screening proven effective in significantly reducing cervical cancer mortality, there is an interest in developing other screening methods to detect gynaecological malignancies early. This review covers advances in cervical cancer screening, strategies being investigated in ovarian cancer screening and the lack of justification in screening for endometrial, vulval and vaginal cancers.

METHODS

A Medline based literature search was performed for articles relating to screening for different gynaecological malignancies. Additional original papers cited in those identified by the initial search were also reviewed.

RESULTS

Advances in cervical cancer screening include liquid-based cytology and HPV testing. Results of ongoing trials are awaited before these can be fully implemented. The results of the two large, multicentre, randomised controlled trials being conducted in the United Kingdom and United States (UKCTOCS and PLCO study, respectively) to assess impact of screening on ovarian cancer mortality will shed some light on the need to implement screening for ovarian cancer in the general population. Novel markers, serum proteomic profiles and Doppler are some of the other technologies being explored. Currently, screening for endometrial cancer is not advocated as most women present with symptoms in early disease with good survival outcomes. Vulval and vaginal cancers are too rare to justify mass screening.

CONCLUSION

Methods to screen for various gynaecological malignancies need further evaluation before implementation in the general population. Results of large multicentred trials are awaited. Presently, screening for endometrial, vaginal and vulval cancers is not justified.

Universal Collection Medium (UCM)® is as suitable as the Standard Transport Medium (STM)® for Hybrid Capture II® (HC-2) assay

BACKGROUND

Collection of cervical-vaginal material in liquid media enables simultaneous evaluation of both oncologic cytology and molecular tests for the detection of Human papillomavirus (HPV), Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). Universal Collection Medium (UCM) has been developed to fulfill this objective.

OBJECTIVES

To compare Hybrid Capture II (HC-2) to diagnose HPV, NG and CT in specimens collected in UCM and in the current Digene Standard Transport Medium (STM).

STUDY DESIGN

The study was cross-sectional. Three collections of endocervical and ectocervical material were performed in each of 893 women referred for colposcopy in the following order: (1) to prepare a conventional Pap smear slide using the accompanying brush of the STM kit and with Ayre spatula; (2) for HC-2 test and liquid-based cytology using a 1 ml UCM vial as transport medium; material was collected with another similar brush; (3) for HC-2 test using a 1 ml STM vial as transport medium; material was collected with the same brush that we used in the procedure no. (1) (conventional Pap smear). HC-2 results from samples taken from STM and UCM media were compared by using simple linear regression analysis and Kappa statistic.

RESULTS AND CONCLUSIONS

HC-2 results from the two media were highly correlated: high-risk HPV (kappa=0.92; r(2)=0.92), low-risk HPV (kappa=0.85; r(2)=0.86) and NG/CT (kappa=0.96; r(2)=0.81). Despite being obtained from a second specimen, the UCM HC-2 results were equivalent to those obtained with the standard medium STM and the UCM medium.

Human papillomavirus testing improves the accuracy of colposcopy in detection of cervical intraepithelial neoplasia

To assess the performance of human papillomavirus (HPV) testing and colposcopy in detection of cervical pathology. A series of 389 women referred for colposcopy due to an abnormal Pap smear had cervical swabs analyzed for oncogenic (high-risk [HR]) HPV types using Hybrid Capture II (HC2) assay. Loop electrical excision procedure cone biopsy (88%) or colposcopic biopsy (11%) was used as the gold standard. Of the atypical squamous cells of undetermined significance (ASCUS) smears, 48% were positive for HR HPV, as compared to 76.3% of low-grade squamous intraepithelial lesions (LSIL) smears. HR HPV was detected in 66.7% and 90% of patients with cervical intraepithelial neoplasia (CIN) 1 and CIN2 (or higher), respectively. The sensitivity of the Pap smear using an ASCUS threshold in detecting high-grade CIN was 94.5% (95% confidence intervals (CI): 91-97%) and that of colposcopy 98.5% (95% CI: 95-99%). The respective specificities were 30% (95% CI: 17-28%) and 35.6% (CI: 29-42%). HC2 test had comparable sensitivity, 90% (95% CI: 85-93%), but higher specificity, 54.3% (95% CI: 47-61%). Combining HC2 test with Pap increased specificity, 66.7% and 41.3% for ASCUS and LSIL cutoff, respectively. The minor-abnormality threshold together with HC2 increased specificity of colposcopy with no changes in sensitivity. High viral load (>100 relative light unit/positive control) was associated with significant disease. HPV DNA testing improves the accuracy of colposcopy in the detection of high-grade CIN in women with ASCUS or LSIL smears.

Screening for Cervical Cancer in High-Risk Populations: DNA Pap Test or Hybrid Capture II Test Alone?

This study was designed to evaluate whether Hybrid Capture II (HC2) test alone refer women to colposcopy as appropriately as DNA Papanicolaou (Pap) test, in the context of a high-risk group of women using the recently validated DNACitoliq LBC system. Women with suspected cervical disease were included in this cross-sectional study at a tertiary center in São Paulo, Brazil, for further workup. All women had cervical material collected for LBC and HC2 for high-risk human papillomavirus (hrHPV)-DNA test. Irrespective of cytology and HC2 results, colposcopy, and cervical biopsy when applicable, was systematically performed. All tests were performed blindly. Sensitivity, specificity, positive and negative predictive values, and overall accuracy of both methods were computed in relation to histology. A total of 1,080 women were included: 36.4% (393/1080) had ACUS+, 10.2% (110/1080) were high-grade squamous intraepithelial lesions (HSIL) or cancer. Mean age was 33.5 years. All women underwent colposcopy, and cervical biopsies were performed in 38.4% (415/1080): 33% (137/415) of the biopsies were negative, 14.4% (155/415) were low-grade squamous intraepithelial lesions (LSIL), 10.7% (116/415) were HSIL, and 0.6% (7/415) were cancer. HC2 sensitivity to diagnose biopsy-proven HSIL was 100%. Because all HSIL cases had a positive HC2 test, sensitivity could not be improved by adding LBC. Specificity and positive and negative predictive values of DNA Pap were not significantly different from HC2 test alone when considering LSIL+ histology as "gold standard" and HSIL+ histology. As a screening strategy for women with high-risk for cervical cancer, DNA Pap test does not seem to add substantially to HC2 alone in terms of appropriately referring to colposcopy.

A comparison of four screening methods for cervical neoplasia

OBJECTIVE

To evaluate the sensitivity and accuracy of 4 screening methods for cervical neoplasia.

METHODS

Cervical samples from 450 women were evaluated for human papillomavirus DNA with a second-generation hybridization assay. Visual inspection, colposcopy, and liquid-based cytology were also performed for 273 of these women. The sensitivity, specificity, efficiency, positive predictive value (PPV), negative predictive value (NPV), Youden index, and kappa value of the different screening methods were compared.

RESULTS

Liquid-based cytology was superior in specificity (98.63%) and PPV (92.86%) to visual inspection and colposcopy, while human papillomavirus DNA testing was superior in sensitivity (88.89%) and NPV (97.10%) to visual inspection and colposcopy. The best concordance with histologic findings was achieved by using both liquid-based cytology and viral DNA hybridization.

CONCLUSION

Visual inspection and colposcopy should not be used when screening for early stage cervical lesions. The DNA hybridization assay is the best choice in primary screening, if available. Screening should begin at the age of 20 years.

Diagnosis and management of oncogenic cervical human papillomavirus infection

Cervical HPV infection should be managed less as a typical STI and more as a strong risk factor predisposing to cervical cancer development. HPV infection is undeniably transmitted predominately through sexual contact.However, the fact that more than 80% of women followed over time will acquire at least one HR-HPV infection reflects the ubiquitous nature of the infection and the ease of transmission. Although the behavioral profiles typically associated with an increased risk for STI (including lifetime partner number, age at first intercourse, and so forth) will certainly lead to an increased risk for HPV detection, there is a high absolute prevalence of HPV even among women who have few lifetime sex partners. It could be argued that to counsel patients for an HPV infection as an STI would be counterproductive, as short of absolute abstinence, the prevention of infection is difficult and treatment options, short of excisional procedures for neoplasia, are limited. The real promise held in this area is the availability of an apparently highly effective prophylactic HPV vaccine, targeting at least HPV 16, 18, 6, and 11[33,34]. This vaccine cocktail, if it achieved 100% coverage, could theoretically prevent 50% to 70% of invasive cervical cancers and most genital warts. Vaccination will be required among women before initiation of sexual contact, presumably among girls 10 to 13 years of age. Many programmatic issues remain regarding the implementation of HPV vaccine programs, including the marketing of the vaccine as STI or cancer prevention,as reviewed in detail by Gravitt and Shah [72]. Even in the era of potentially effective vaccines, screening for cervical cancer is likely to remain a priority in cervical cancer prevention programs for at least several decades. Vaccine trials have proven high short-term efficacy; however, these effects were clearly type-specific and antibody titers gradually decrease postvaccination. It is unclear whether the protection will remain over an individual's lifetime without vaccine booster, and oncogenic HPV infections not targeted by vaccination will continue to contribute to risk for development of cervical intraepithelial neoplasia and cancer. Therefore, although the public health success of HPV vaccination is undoubtedly promising, the role of cervical cancer screening as a secondary prevention effort should not be trivialized. In fact, the nature of screening programs should continue to be reevaluated in the context of effective but limited spectrum vaccines.

Can we detect cervical human papillomavirus (HPV) infection by cytomorphology alone? Diagnostic value of non-classic cytological signs of HPV effect in minimally abnormal Pap tests

OBJECTIVE

Our aim was to assess the validity of non-classical cytological signs in minimally abnormal cervical smears for the prediction of HPV infection.

METHODS

164 ThinPrep monolayers were re-screened for mild nuclear changes, disorders of keratinisation, abortive koilocytes and 'measles cells', as well as degenerative changes. HPV DNA was detected by GP5+/6+ and MY09/MY11 consensus primer PCR assays.

RESULTS

Seventy six of 164 cases (46.3%) had HPV positivity by PCR. All cytomorphological features studied were significantly associated with the presence of HPV. Mild nuclear changes had 100% sensitivity and 100% negative predictive value for HPV infection.

CONCLUSIONS

Our results indicate that non-classic cytomorphological signs can improve the sensitivity of cytology for detecting HPV. Minimally abnormal Pap smears lacking mild nuclear changes (16%) in the present study--do not require further molecular HPV testing.

Assessment of human papillomavirus mRNA detection over time in cervical specimens collected in liquid based cytology medium

Little is known about the stability of human papillomavirus (HPV) RNA within cervical samples collected in liquid based cytology (LBC) preservation media. We addressed this by analysing patient LBC specimens for the presence of HPV RNA over a prospective time course. LBC samples in PreservCyt were obtained from seven women referred to colposcopy due to a cytological diagnosis of moderate or severe dyskaryosis. Aliquots were removed and subject to RNA extraction at, 6h (base-line), 4, 7 and 14 days, post-collection. HPV mRNA was detected using the PreTect HPV Proofer, which detects HPV 16, 18, 31, 33 and 45 E6/E7 transcripts and human small ribonucleoprotein U1A mRNA as a sample control. HPV DNA genotyping was also performed at base-line to assess the range of types in our group. In addition to assessment of viral RNA, overall integrity of the cellular RNA extract was analysed by the RNA 6000 pico assay. Control human RNA was amplified successfully in all seven samples at each time point. Five of the seven women were HPV positive for E6/E7 viral transcripts at base-line and positivity was maintained in all five up to 14 days. Although the pattern of cellular RNA profiles generated from the samples was variable, results indicated that this extract could be amenable to gene expression profiling and that degradation did not increase as a result of storage time. It is concluded that HPV RNA in routinely collected LBC specimens in PreservCyt can be detected for at least 14 days from sample collection.

The predictive value of p16(INK4a) and hybrid capture 2 human papillomavirus testing for high-grade cervical intraepithelial neoplasia

We performed p16(INK4a) immunocytochemical analysis and Hybrid Capture 2 (HC2; Digene, Gaithersburg, MD) high-risk HPV testing on 210 abnormal SurePath (TriPath Imaging, Burlington, NC) Papanicolaou specimens diagnosed as low-grade squamous intraepithelial lesion (LSIL) or high grade squamous intraepithelial lesion (HSIL). The results were compared with 121 follow-up biopsy specimens. p16(INK4a) was positive in 57.9% of women with LSIL compared with 97.1% of women with HSIL. In contrast, HC2 testing was positive in 85.0% of women with LSIL and 86.4% of women with HSIL. The differences in the positive rates for16(INK4a) between LSIL and HSIL was significant (P < .001), whereas, for HC2, it was not (P = .264). In patients who had cervical biopsies following a cytologic diagnosis of LSIL, the positive predictive value (PPV) of p16(INK4a) for a biopsy of cervical intraepithelial neoplasia grade 2 or 3 (CIN2/3; 33.3%) was significantly higher than the PPV of HC2 results (21.2%) (P < .001). Using liquid-based cytology specimens, p16(INK4a) immunocytochemical analysis has a higher PPV than reflex HC2 HPV testing for identifying CIN2/3 among patients with LSIL and might be useful for selecting patients with LSIL for colposcopy.