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Molecular Diagnostics

The use of biomarkers and HPV genotyping to improve diagnostic accuracy in women with a transformation zone type 3

British Journal of Cancer volume 126, pages 91–99 (2022)Cite this article

Subjects

Abstract

Background

Twenty percent of women referred to colposcopy have a type 3 transformation zone—where colposcopic assessment for high-grade dysplasia (CIN2+) is not possible. This study examines the effectiveness of HPV biomarkers and genotyping in combination with techniques that sample an endocervical TZ.

Methods

A prospective diagnostic accuracy study. Women booked for large-loop excision (LLETZ) with squamous dyskaryosis, high-risk HPV and a TZ3 were recruited. Immediately prior to LLETZ samples were collected for p16/Ki-67 dual-stained cytology, HPV genotyping and H&E, p16- and Ki-67-stained endocervical curettings.

Results

In women with low-grade screening (n = 64), 35.9% had CIN2+; dual-stained cytology had the greatest effect on the PPV of routine screening (76.1% vs 35.9%) and perfectly predicted the absence of CIN2+. In women with a high-grade screening result (n = 37); 75.6% had CIN2+ and dual-stained curettings improved the PPV (96.5 vs 75.6%).

Conclusions

With high-grade screening and a TZ3, LLETZ appears safest as three quarters have CIN2+ . Women with low-grade screening and a TZ3 have a twofold increased risk of CIN2+ when compared to women where the TZ is visible. The use of dual-stained cytology may help identify those women who can be safely offered surveillance and those who require treatment.

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Fig. 1: Flowchart of study recruitment.
Fig. 2: Endocervical curettings with H&E, Ki-67 and p16 immununostains.
Fig. 3: Dual-staining (p16/Ki-67) of the cervical screening cytology samples.

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Data availability

Data supporting the results reported in the paper cannot be found on publicly available databases. Data can be requested on reasonable request from the authors.

References

  1. Bruni L, Diaz M, Castelsague X, Ferrer E, Bosch F, de Sanjose S, et al. Cervical human papillomavirus prevalence in 5 continents: meta-analysis of 1 million women with normal cytological findings. J Infect Dis. 2010;202:1789–99.

    Article  PubMed  Google Scholar 

  2. Kelly RS, Patnick J, Kitchener HC, Moss SM. HPV testing as a triage for borderline or mild dyskaryosis on cervical cytology: results from the Sentinel Sites study. Br J Cancer. 2011;105:983–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Massad LS, Einstein M, Huh W, Katki H, Kinney W, Schiffman M, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Trac Dis. 2013;17:S1–27.

    Article  Google Scholar 

  4. Public Health England. NHS CSP Publication 20. Cervical Screening: programme and colposcopy management. Third Edition (14th March 2016). Cervical screening: programme and colposcopy management - GOV.UK (www.gov.uk). Accessed 26 October 2021.

  5. Castanon A, Landy R, Brocklehurst P, Evans H, Peebles D, Singh N, et al. Risk of preterm delivery with increasing depth of excision for cervical intraepithelial neoplasia in England: nested case-control study. BMJ. 2014;349:g6223.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Baldauf JJ, Dreyfus M, Ritter J, Meyer P, Philippe E. Risk of cervical stenosis after large loop excision or laser conization. Obstet Gynecol. 1996;88:933–8.

    Article  CAS  PubMed  Google Scholar 

  7. Suh-Burgmann EJ, Whall-Strojwas D, Chang Y, Hundley D, Goodman A. Risk factors for cervical stenosis after loop electrocautery excision procedure. Obstet Gynecol. 2000;96:657–60.

    Article  CAS  PubMed  Google Scholar 

  8. Manley KM, Simms B, Platt S, Patel A, Bahl R. Unsatisfactory colposcopy: clinical decision-making in conditions of uncertainty. BMC Med Inform Decis Mak. 2017;17:125.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Manley KM, Wills AK, Crouch N, Lopez Bernal A, Patel A, Current practices in the management of a type 3 transformation zone: results of a UK survey. Abstract. Cardiff: The British Society of Colposcopy and Cervical Pathology Annual Scientific Meeting; 2017.

  10. Manley KM, Wills AK, Morris GC, Hogg JL, Lopez-Bernal A, Murdoch JB. The impact of HPV cervical screening on negative large loop excision of the transformation zone (LLETZ): a comparative cohort study. Gynecol Oncol. 2016;141:485–91.

    Article  CAS  PubMed  Google Scholar 

  11. Pretorius RG, Zhang W, Belinson JL, Huang M, Wu L, Zhang X, et al. Colposcopically directed biopsy, random cervical biopsy, and endocervical curettage in the diagnosis of cervical intraepithelial neoplasia II or worse. Am J Obstet Gynecol. 2004;191:430–4.

    Article  PubMed  Google Scholar 

  12. Williams DL, Dietrich C, McBroom J. Endocervical curettage when colposcopic examination is satisfactory and normal. Obstet Gynecol. 2000;95:801–3.

    CAS  PubMed  Google Scholar 

  13. Franco EL, Villa LL, Sobrinho JP, Prado JM, Rousseau MC, Desy M, et al. Epidemiology of acquisition and clearance of cervical human papillomavirus infection in women from a high-risk area for cervical cancer. J Infect Dis. 1999;180:1415–23.

    Article  CAS  PubMed  Google Scholar 

  14. Molano M, den Brule A, Plummer M, Weiderpass E, Posso H, Arslan A, et al. Determinants of clearance of human papillomavirus infections in Colombian women with normal cytology: a population-based, 5-year follow-up study. Am J Epidemiol. 2003;158:486–94.

    Article  PubMed  Google Scholar 

  15. Galgano MT, Castle PE, Atkins KA, Brix WK, Nassau SR, Stoler MH. Using biomarkers as objective standards in the diagnosis of cervical biopsies. Am J Surg Pathol. 2010;34:1077–87.

    Article  PubMed  PubMed Central  Google Scholar 

  16. von Knebel Doeberitz M. New markers for cervical dysplasia to visualise the genomic chaos created by aberrant oncogenic papillomavirus infections. Eur J Cancer. 2002;38:2229–42.

    Article  Google Scholar 

  17. Wentzensen N, Schwartz L, Zuna R, Smith K, Mathews C, Gold M, et al. Performance of p16/Ki-67 immunostaining to detect cervical cancer precursors in a colposcopy referral population. Clin Cancer Res. 2012;18:4154–62.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Schmidt D, Bergeron C, Denton K, Ridder R. European CINtec Cytology Study Group). p16/ki-67 dual-stain cytology in the triage of ASCUS and LSIL Papanicolaou cytology: results from the European equivocal or mildly abnormal Papanicolaou cytology study. Cancer Cytopathol. 2011;119:158–66.

  19. Loghavi S, Walts AE, Bose S. CINtec(R) PLUS dual immunostain: a triage tool for cervical pap smears with atypical squamous cells of undetermined significance and low grade squamous intraepithelial lesion. Diagn Cytopathol. 2013;41:582–7.

    Article  PubMed  Google Scholar 

  20. Waldstrom M, Christensen RK, Ornskov D. Evaluation of p16(INK4a)/Ki-67 dual stain in comparison with an mRNA human papillomavirus test on liquid-based cytology samples with low-grade squamous intraepithelial lesion. Cancer Cytopathol. 2013;121:136–45.

    Article  PubMed  Google Scholar 

  21. Kelly RS, Patnick J, Kitchener HC, Moss SM, for the NHSCSP HPV Special Interest Group. HPV testing as a triage for borderline or mild dyskaryosis on cervical cytology: results from the Sentinel Sites Study. Br J Cancer. 2011;105:983–8

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Jordan J, Arbyn M, Martin-Hirsch P, Schenck U, Balduff JJ, da Silva D, et al. European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, part 1. Cytopathology. 2008;19:342–54.

    Article  CAS  PubMed  Google Scholar 

  23. Stillson T, Knight AL, Elswick RK Jr. The effectiveness and safety of two cervical cytologic techniques during pregnancy. J Fam Pr. 1997;45:159–63.

    CAS  Google Scholar 

  24. Royal College of Obstetricians and Gynaecologists. Induction of Labour at Term in Older Mothers: Scientific Impact Paper No. 34. 2013. www.rcog.org.uk/en/guidelines-research-services/guidelines/sip34/. Accessed 27 October 2021.

  25. Public Health England. Cervical screening: primary HPV screening implementation. Appendix 2: Cervical Screening Colposcopy Management Recommendation Algorithms. 2019. Available from: https://www.gov.uk/government/publications/cervical-screening-primary-hpv-screening-implementation#history. Accessed 27 November 2020.

  26. Eisenberger D, Hernandez E, Tener T, Atkinson BF. Order of endocervical and ectocervical cytologic sampling and the quality of the Papanicolaou smear. Obstet Gynecol. 1997;90:755–8.

    Article  CAS  PubMed  Google Scholar 

  27. Zhao C, Austin RM. Human papillomavirus DNA detection in ThinPrep Pap test vials is independent of cytologic sampling of the transformation zone. Gynecol Oncol. 2007;107:231–5.

    Article  CAS  PubMed  Google Scholar 

  28. Denton KJ, Herbert A, Turnbull LS, Waddell C, Desai MS, Rana DN, et al. The revised BSCC terminology for abnormal cervical cytology. Cytopathology. 2008;19:137–57.

    Article  CAS  PubMed  Google Scholar 

  29. Lesnikova I, Lidang M, Hamilton-Dutoit S, Koch J. p16 as a diagnostic marker of cervical neoplasia: a tissue microarray study of 796 archival specimens. Diagnostic Pathol. 2009;4:22–28.

    Article  Google Scholar 

  30. Van Niekerk D, Guillaud M, Matisic J, Benedet J, Freeberg JA, Follen M, et al. p16 and MIB1 improve the sensitivity and specificity of the diagnosis of high grade squamous intraepithelial lesions: methodological issues in a report of 447 biopsies with consensus diagnosis and HPV HCII testing. Gynecol Oncol. 2007;107:S233–40.

    Article  PubMed  Google Scholar 

  31. NHS CSP Cervical Screening Programme, England. Statistics for 2019-20. Published 26th November 2020. England: Cervical Screening Programme, 2019-20. www.digital.nhs.uk/data-and-information/publications/statistical/cervical-screening-annual/england---2019-20. Accessed 17 May 2021.

  32. Cancer Research UK. Cervical Cancer Incidence Statistics. Cervical cancer|Cancer Research UK. www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer/incidence. Accessed 18 May 2021.

  33. Mercer CH, Tanton C, Prah P, Erens B, Sonnenberg P. Clifton Soazig. Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). Lancet. 2013;382:1781–94.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Nakamura Y, Matsumoto K, Satoh T, Nishide K, Nozue A, Shimabukuro K, et al. HPV genotyping for triage of women with abnormal cervical cancer screening results: a multicenter prospective study. Int J Clin Oncol. 2015;20:974–81.

    Article  PubMed  Google Scholar 

  35. Khan M, Castle P, Lorincz A, Wacholder S, Sherman M, Scott D, et al. The elevated 10-year risk of cervical precancer and cancer in women with human papillomavirus (HPV) type 16 or 18 and the possible utility of type-specific HPV testing in clinical practice. J Natl Cancer Inst. 2005;97:1072–9.

    Article  PubMed  Google Scholar 

  36. Peralta R, Vargas-de-Leon C, Cabrera A, Miramontes P. Dynamics of high-risk nonvaccine human papillomavirus types after actual vaccination scheme. Comput Math Methods Med. 2014;542923:1–8.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Hellsten C, Sjostrom K, Lindqvist PG. A prospective Swedish cohort study on psychosocial factors influencing anxiety in women referred for colposcopy. BJOG. 2007;114:32–8.

    Article  CAS  PubMed  Google Scholar 

  38. Bonevski B, Sanson-Fisher R, Girgis A, Perkins J. Women’s experiences of having a colposcopic examination: self-reported satisfaction with care, perceived needs and consequences. J Obstet Gynecol. 1998;18:462–70.

    Article  CAS  Google Scholar 

  39. Gray NM, Sharp L, Cotton SC, Masson LF, Little J, Walker LG, et al. Psychological effects of a low-grade abnormal cervical smear test result: anxiety and associated factors. Br J Cancer. 2006;94:1253–62.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Manley KM, Wills AK, Villeneuve N, Hunt K, Patel A, Glew S. Comparison of the Cervex-Brush alone to Cytobrush plus Cervex-Brush for detection of cervical dysplasia in women with a transformation zone type 3. Cytopathol. 2019;30:157–63.

    Article  Google Scholar 

  41. Bergeron C, Ikenberg H, Sideri M, Denton K, Bogers J, Schmidt D, et al. Prospective evaluation of p16/Ki-67 dual-stained cytology for managing women with abnormal Papanicolaou cytology: PALMS study results. Cancer Cytopathol. 2015;123:373–81.

    Article  CAS  PubMed  Google Scholar 

  42. Boonstra H, Aalders JG, Koudstaal J, Oosterhuis JW, Janssens J. Minimum extension and appropriate topographic position of tissue destruction for treatment of cervical intraepithelial neoplasia. Obstet Gynecol. 1990;75:227–31.

    CAS  PubMed  Google Scholar 

  43. Mangham LJ, Petrou S, Doyle LW, Draper ES, Marlow N. The cost of preterm birth throughout childhood in England and Wales. Pediatrics. 2009;123:e312–27.

    Article  PubMed  Google Scholar 

  44. Davey DD, Cox JT, Austin RM, Birdsong G, Colgan TJ, Howell LP, et al. Cervical cytology specimen adequacy: patient management guidelines and optimizing specimen collection. J Low Genit Trac Dis. 2008;12:71–81.

    Article  Google Scholar 

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Acknowledgements

The authors would like to thank all the women who participated in the study and donated their samples and data for research. The research group would also like to thank Professor Henry Kitchener, Dr. Alex Sargent, Professor David Cahill, Dr. Naomi Crouch, Mrs. Yvonne Higgins, Miss. Karen Shaw and the Colposcopy Administration Department at University Hospitals Bristol for their advice and support during the running of this study.

Funding

The study was funded by the David Telling Charitable Trust and the Above & Beyond Charity Bristol; they did not have a role in the design or conduct of the study.

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Authors and Affiliations

  1. University Hospitals Bristol NHS Foundation Trust, Bristol, UK

    Kristyn Manley & Amit Patel

  2. University of Bristol, Bristol, UK

    Kristyn Manley, Susan Glew, Andres López-Bernal & Andrew Wills

  3. Department of Pathology, North Bristol Trust, Bristol, UK

    Joya Pawade, Katherine Hunt, Nichole Villeneuve, Samantha Thompson & Helen Hoskins

  4. Department of Pathology, Royal United Hospitals Bath, Bristol, UK

    Pinias Mukonoweshuro

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Contributions

Study concept and design: KM, AW, JP, SG, AP. Acquisition, processing and reporting of samples: KM, JP, KH, NV, PM, HH, ST. Analysis and interpretation of the data: KM and AW. Drafting of the manuscript: KM. Critical revision of the manuscript: KM, AW, SG, AP, PM, JP, NV, AL-B.

Corresponding author

Correspondence to Kristyn Manley.

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Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles as outlined in the Declaration of Helsinki. Ethical approval was granted by NRES Committee South West—Frenchay on May 25, 2014, (ref OG/SW/0028). All patients provided written informed consent.

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Not applicable.

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The authors declare no competing interests.

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Manley, K., Patel, A., Pawade, J. et al. The use of biomarkers and HPV genotyping to improve diagnostic accuracy in women with a transformation zone type 3. Br J Cancer 126, 91–99 (2022). https://doi.org/10.1038/s41416-021-01539-y

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