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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



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.


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.


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%).


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.


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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.


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



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.

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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).

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