Follow-up findings in young females with high-grade squamous intraepithelial lesion papanicolaou test results

Follow-up outcomes in a large cohort of patients with HPV-negative LSIL cervical screening test results

OBJECTIVES

Cervical screening guidelines now recommend repeat cotesting of patients aged 30 years and older having a human papillomavirus (HPV)-negative low-grade squamous intraepithelial lesion (LSIL) in 1 year as preferred management. Only limited follow-up data on patients with HPV-negative LSILs are available from routine US clinical practice settings.

METHODS

In total, 680 patients with Hybrid Capture 2 (Qiagen, Hinden, Germany) high-risk HPV-negative LSIL ThinPrep (Hologic, Marlborough, MA) results were identified. Patients' ages and histopathologic, cytologic, and HPV follow-up results were identified.

RESULTS

Among 680 patients with HPV-negative LSILs, 468 had follow-up within 1 year. During the study period, 14 (3.0%) of 468 had follow-up high-grade squamous intraepithelial lesion (HSIL) and 184 (39.3%) LSIL findings. No diagnoses of cervical carcinoma were documented. There were no significant follow-up differences between age groups. Of the 321 patients who had follow-up HPV testing, 271 (84.4%) had negative and 50 (15.6%) had positive HPV results.

CONCLUSIONS

This is the largest study documenting follow-up results for patients with HPV-negative LSIL results based on prevalent US FDA-approved co-testing methods from one collection vial. These data document that risk for follow-up HSILs in these patients is low and also that no cervical cancers were diagnosed. These findings support recent recommendations for repeat co-testing after 1 year as an appropriate option for patients with HPV-negative LSIL results.

Low-grade squamous intraepithelial lesion/cannot exclude high-grade squamous intraepithelial lesion (LSIL-H) is a unique category of cytologic abnormality associated with distinctive HPV and histopathologic CIN 2+ detection rates

OBJECTIVES

To examine data correlating high-risk human papillomavirus (hrHPV) results in patients with both low-grade squamous intraepithelial lesion (LSIL) and atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H) cytology findings (LSIL-H) with follow-up histopathology.

METHODS

A total of 494 LSIL-H ThinPrep (Hologic, Marlborough, MA) cases with hrHPV testing were identified. Histopathologic follow-up was available in 347 patients.

RESULTS

Among 347 patients with follow-up histopathology after LSIL-H cytology and hrHPV testing, 90.5% tested hrHPV positive. Cervical intraepithelial neoplasia (CIN) 2/3 was diagnosed in 29.4% and CIN 1 in 53.6%. CIN 2/3 was diagnosed in significantly more patients with hrHPV-positive LSIL-H than following hrHPV-negative LSIL-H results. Compared with published institutional data, LSIL-H had significantly lower hrHPV and histopathologic CIN 2/3+ rates (90.5% and 29.4%, with no cervical cancers) than high-grade squamous intraepithelial lesion (HSIL) (95.7% and 70.5%, with 2.4% cervical cancers) but higher rates than LSIL (80.2% and 12.9%) or atypical squamous cells/cannot exclude HSIL (ASC-H) (54.3% and 17.2%). Whereas CIN 2/3 detection rates were similar in HPV-positive LSIL-H and HPV-positive ASC-H, CIN 2/3 findings were more likely with HPV-negative LSIL-H than with HPV-negative ASC-H.

CONCLUSIONS

LSIL-H is a unique category of cytologic abnormality associated with distinctive hrHPV and CIN 2/3+ diagnostic rates.

Cervical screening test results associated with 265 histopathologic diagnoses of cervical glandular neoplasia

OBJECTIVES

To document screening test histories of women with histopathologic cervical glandular neoplasia (CGN) in a large integrated health system using new methods of cervical screening.

METHODS

Cervical screening test results were reviewed for 265 patients with histopathologic diagnoses of CGN, including 168 adenocarcinoma in situ, 80 invasive cervical adenocarcinoma, and 17 invasive cervical adenosquamous carcinoma cases.

RESULTS

Among 222 cases with known triggers of diagnostic studies, 211 (95%) had recent abnormal Papanicolaou (Pap) test results. Glandular cell abnormalities were the most common recent abnormal Pap test finding in 130 (61.6%) of 211; squamous cell abnormalities alone were documented in 81 (38.4%) of 211, reflecting coexisting cervical intraepithelial neoplasia (CIN) in 60% of CGN cases. Among 114 CGN cases with additional Pap tests more than 4 months to 3 years before CGN diagnosis, 70 (61.4%) had only earlier negative Pap test results. Among 72 CGN cases with recent human papillomavirus (HPV) test results, 70 (97.2%) tested HPV positive. Among 29 CGN cases with HPV test results more than 4 months to 3 years before CGN diagnosis, 25 (86.2%) tested HPV positive.

CONCLUSIONS

Conservative cytologic screening practices and HPV cotesting can facilitate early diagnoses of CGN.

Should high-risk adolescents have Papanicolaou tests?

BACKGROUND

The current American College of Obstetricians and Gynecologists guidelines state that cervical cancer screening should begin at age 21 years, regardless of sexual or obstetric history. However, previous studies have demonstrated that there is a small but significant subset of high-risk adolescents with extensive sexual and obstetric history who harbor a significant squamous cervical lesion. The objective of the current study was to use histologic and demographic data from adolescents (aged <21 years) who received Papanicolaou (Pap) tests to determine whether they benefited from early cervical cancer screening.

METHODS

Adolescent girls who had Pap tests between 2000 and 2010 were included in the study. Demographic data, including obstetric history, number of sexual partners, age of first coitus, age at first pregnancy, menarche, smoking history, and Chlamydia and syphilis infection, were analyzed for associations with levels of cervical dysplasia.

RESULTS

Of 56,785 adolescent Pap tests, 277 (0.5%) were diagnosed as high-grade squamous HSIL, and 56 of those Pap tests (20%) were from patients who had grade 3 cervical intraepithelial neoplasia (CIN-3) on subsequent biopsy and/or excision. One patient had microinvasive cervical carcinoma identified on loop electrosurgical excision procedure at age 27 years after an HSIL Pap test. Increased parity was associated significantly with higher rates of CIN-3.

CONCLUSIONS

The study findings indicated that current American College of Obstetricians and Gynecologists guidelines to begin Pap testing at age 21 years are appropriate for the majority of adolescents, because the rate of HSIL is very low, and the risk for invasive carcinoma is minimal. Although higher parity was associated with a significantly increased grade of CIN, the conclusions are questionable because of the significant amount of missing demographic data points. That being said, this study should lead to other similar studies to determine any association of higher grade CIN with adolescent sexual and obstetric history.

Follow-up outcomes of a large cohort of low-risk women with negative imaged liquid-based cytology and negative HPV test results

Recently updated cervical screening guidelines have proposed a 5-year screening interval for women aged 30 years and older with "double-negative" Papanicolaou (Pap) and high-risk human papillomavirus (hrHPV) results (DNR); however, published US follow-up data on women with DNR tested with US Food and Drug Administration (FDA) - approved HPV testing are limited to studies from Kaiser Permanente using conventional Pap smear cytology. Between July 2005 and June 2006, 4,112 patients with DNR who were screened with computer-imaged liquid-based cytology (LBC) (ThinPrep) and Hybrid Capture 2 (HC2) hrHPV tests of LBC vial fluid were identified. Cytologic or histopathologic data were available for 3,211 patients who were followed up for a mean 44 months. Among 2,960 patients aged 30 years and older with DNR, follow-up cervical abnormalities of cervical intraepithelial neoplasia (CIN) 3 or more severe (CIN3+) were documented in 5 (0.17%), including 1 endocervical adenocarcinoma. After DNR, CIN+ diagnoses were significantly more likely in women younger than 50 years than in older women. These data are consistent with previously published US and international studies that have consistently documented low rates of histopathologic CIN3+ during years of follow-up after DNR. Large-scale nationwide data are needed to further assess the level of risk of invasive cervical cancer after DNR using different available hrHPV testing methods.

Implementing specificity of HPV-DNA primary screening in a successful organised cervical cancer prevention programme

OBJECTIVE

This two-arm longitudinal study was performed within a regional organized cervical-cancer-prevention program in which HPV-DNA test is used in primary screening. The aim was to analyze the diagnostic performances of p16INK4a/Ki-67 dual-test and E6/E7-mRNA test in identifying CIN2+ lesion among HPV-DNA positive (HPV-DNAve) women triaged for LSIL-or-worse liquid based cytology (LBC).

METHODS

Thirty-six thousand thirty-one women participated to HPV-DNA screening program pilot study. Three thousand six hundred forty-one resulted HPV-DNAve; among these, 43% were LSIL-or-worse (LSIL+). HPV-DNAve/LSIL+ patients were submitted to colposcopy and histological assessment of any visible lesions. Dual-test was performed on 794 residual LBC specimens. In 405 cases, dual-test result was related to histology, considering CIN2+ as endpoint. mRNA test has been carried out retrospectively, on a subset of 173 residual LBC specimens.

RESULTS

Agreement between dual-test and histological diagnosis was 59%. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of cytology-plus-dual-test approach were 62.3%, 76.8%, 63.1% and 84.2%, respectively. Dual-test improved specificity, PPV and NPV of cytological triage Agreement between mRNA testing and histology was 65%. Cytology-plus mRNA testing showing sensitivity, specificity, PPV and NPV reaching 32.1%, 94.9%, 75% and 50%, respectively; implemented specificity and PPV of cytology alone in triaging DNA-ve/LSIL+ patients (p<0.01).

CONCLUSIONS

We provided promising data indicating the important role that p16(INK4)/Ki-67 dual-test, and mostly E6/E7 mRNA test, might have in triaging HPV-DNAve. These approaches would exclude the occurrence of cervical cancer and would avoid overtreatment, at the same time. Further longitudinal analysis has to be considered.

Cytology and human papillomavirus screening test results associated with 2827 histopathologic diagnoses of cervical intraepithelial neoplasia 2/3

CONTEXT

Cervical screening in the United States increasingly involves newer US Food and Drug Administration-approved cytologic methods and adjunctive high-risk human papillomavirus (hrHPV) DNA testing.

OBJECTIVE

To document cervical screening test performance preceding histopathologic cervical intraepithelial neoplasia (CIN) 2/3 diagnoses.

DESIGN

Preceding screening test results with computer-imaged, liquid-based cytology (LBC) and hrHPV results were analyzed for 2827 patients with histopathologic CIN 2/3 diagnoses.

RESULTS

Of 2827 patients with CIN 2/3 diagnoses, 2074 (73.4%) had system LBC findings within 4 months of CIN 2/3 diagnoses: high-grade squamous intraepithelial lesion (n = 862; 41.6%), low-grade squamous intraepithelial lesion (n = 464; 22.4%), atypical squamous cells of undetermined significance (n = 445; 21.5%), atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (n = 288; 13.9%), and atypical glandular cells/adenocarcinoma in situ (n = 15; 0.7%). Of the 2827 patients, 1488 (52.6%) also had earlier system LBC results at more than 4 months to 3 years before CIN 2/3 diagnoses: one or more abnormal LBC results (n = 978; 65.7%), one or more negative LBC results (n = 911; 61.2%), both abnormal and negative LBC (n = 401; 26.9%). Of 807 patients with hrHPV cotest results within 4 months of CIN 2/3 diagnoses, 786 (97.4%) had hrHPV(+) results. Of 454 patients who also had earlier hrHPV results at more than 4 months to 3 years before CIN 2/3 diagnoses: 377 (83.0%) had one or more hrHPV(+) result, 110 (24.2%) had one or more hrHPV(-) result, and 33 (7.3%) had both positive and negative HPV results.

CONCLUSION

Patients with histopathologic CIN 2/3 had recent abnormal LBC results, most often, high-grade squamous intraepithelial lesions. Among cotested patients, 97.4% (786 of 807) tested hrHPV(+). However, a significant number of patients tested during an extended period of several years had earlier negative Papanicolaou or negative HPV test results, suggesting the recent development of some CIN 2/3 lesions and supporting the value of cotesting for enhanced detection of other developing, small, inaccessible, or nondiagnostic precursor lesions.

Follow-up outcomes in a large cohort of patients with human papillomavirus-negative ASC-H cervical screening test results

Limited follow-up data are available on patients with cervical cytology results of atypical squamous cells, cannot exclude a high-grade intraepithelial lesion (ASC-H), who test negative for high-risk human papillomavirus (hrHPV). Between June 2005 and December 2010, 885 patients were identified with ThinPrep results of Hybrid Capture 2 (HC2) hrHPV-negative cervical ASC-H liquid-based cytology and follow-up histopathology or cytology results extending to September 2011. Of the 885 patients with available follow-up results, 549 (62.0%) had at least 1 histopathologic result during the entire follow-up period, whereas 336 (38.0%) had only cytologic follow-up documented. In an average follow-up period of 29 months, 14 (1.6%) of 885 patients with HPV-negative ASC-H results showed evidence of high-grade cervical intraepithelial neoplasia (CIN2/3). No cases of invasive cervical cancer were diagnosed. Four of 14 patients with HPV-negative ASC-H results with follow-up diagnoses of CIN2/3 had a history of earlier CIN2/3 diagnoses before HPV-negative ASC-H results. Follow-up of patients with HPV-negative ASC-H results using methods specified in this study yielded low rates of detectible CIN2/3 and no diagnoses of cervical cancer. Triage of study patients with HPV-negative ASC-H results to routine HPV and cytology cotesting at 1 year was a safe follow-up option.

Screening test results associated with cancer diagnoses in 287 women with cervical squamous cell carcinoma

CONTEXT

The limitations of newer cervical screening tests are still being studied.

OBJECTIVE

To investigate those limitations, we conducted a retrospective review of 287 cases of cervical squamous cell carcinoma (SCC).

DESIGN

A search through 5 years of records identified 287 women with cervical SCC diagnoses. Clinical history, histopathology, and liquid-based cytology (ThinPrep) and Hybrid Capture 2 (HC2) high-risk human papillomavirus (HPV) results were documented. Polymerase chain reaction HPV tests were performed on SCC tissues with prior negative HC2 results.

RESULTS

Of 287 women, 156 (54.4%) had abnormal cytology results, and 75 (26.1%) had abnormal clinical findings triggering tissue diagnoses of SCC. Among 156 patients with abnormal Papanicolaou (Pap) test results, more-seriously abnormal Pap test results were reported in 142 women (91.1%). Among 31 women with Pap and HC2 HPV cotesting within 1 year of SCC diagnoses, 28 (90%) were Pap⁺/HPV⁺, 2 (15.5%) were Pap⁺/HPV⁻, and 1 (3%) was Pap⁻/HPV⁻. Two of 3 women with negative HC2 results before SCC diagnosis had abnormal Pap results; 1 had negative Pap reports with questionable lesional cells mimicking atrophy. In all 3 cases of SCC with negative HC2 results, HPV-18 was detected; in 2 cases (66%), HPV-16 was also detected.

CONCLUSIONS

Although abnormal cytology preceded most SCC diagnoses, about one-third of patients were referred for diagnostic testing because of clinical suspicion alone. Among 31 SCC cases with liquid-based cytology and high-risk HPV cotest results less than 1 year before SCC diagnoses, 2 patients (6.5%) had Pap⁺/HPV⁻ results, and 1 patient (3.2%) had Pap⁻/HPV⁻ results. Polymerase chain reaction detected high-risk HPV DNA in tumor tissues of 3 SCC cases with recent HC2⁻ results.

Intracellular Human Papillomavirus E6, E7 mRNA Quantification Predicts CIN 2+ in Cervical Biopsies Better Than Papanicolaou Screening for Women Regardless of Age

Context.—Cervical cancer screening in women younger than 30 years relies on cervical cytology because of the poor performance of human papillomavirus (HPV) DNA testing in this age group.

Objectives.—To determine the performance of in-cell HPV E6, E7 mRNA quantification (HPV OncoTect) for the detection of high-grade cervical intraepithelial neoplasia in women younger than 30 years.

Design.—We analyzed 3133 cytology specimens from a screening population of women aged 19–75 years investigate HPV OncoTect as a triage/secondary screening test for atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL) cytology in women younger than 30 years. Test results were compared to histology in 246 cases.

Results.—The sensitivity of E6, E7 mRNA was 89% for CIN 2+ and 100% for CIN 3+ lesions in women 30 years and older. In women younger than 30 years, the sensitivity of E6, E7 mRNA for CIN 2+ lesions was 88% for CIN 2+ and 92% for CIN 3+ lesions. Abnormal cytology (≥ASCUS) exhibited a sensitivity of 89% for CIN 2+ and 100% for CIN 3+ in women 30 years and older and 96% sensitivity for CIN 2+ and 93% sensitivity for CIN 3+ in women younger than 30. The specificity of E6, E7 mRNA was &gt;80% for CIN 2+ and CIN 3+ in both groups of women compared to a specificity of abnormal cytology of &lt;10% for CIN 2+ and CIN 3+ in both groups.

Conclusions.—HPV OncoTect demonstrates a performance that would be effective for ASCUS/LSIL triage in women including those younger than 30 years.

[Precursor lesions: epidemiology--is there enough evidence?]

Exact knowledge of the incidence and prevalence of precursor lesions of malignant diseases would be of great value for the precise evaluation of their potential clinical-pathological progression and therefore for planning and intervention in individual cases and also for planning and evaluation of prevention and early detection strategies. Concerning these high expectations it is surprising that precise data on incidence, prevalence and the exact risk for progression are lacking. Sources of data (cancer registries, specific registries for precursor lesions, early detection programs and specific designed studies) are analyzed concerning their validity and reliability. Imprecise and redundant terminology represents a crucial reason for the lack of data availability.