Telomerase and human papillomavirus as diagnostic adjuncts for cervical dysplasia and carcinoma

Telomerase and human papillomavirus (HPV) DNA were evaluated as potential markers of high-grade dysplasia in cervical cytological specimens. Cytology specimens were collected from patients at the time of colposcopic evaluation for management of a previous abnormal cytology test result. Telomerase activity was evaluated by the telomeric repeat amplification protocol (TRAP), and HPV DNA was detected by polymerase chain reaction with L1 consensus-sequence primers and filter hybridization genotyping. Telomerase was detected in 8 of 97 (8.2%) cases with normal cytology or benign cellular changes, in 7 of 98 (7.1%) cases of atypical squamous cells of undetermined significance (ASCUS), in 3 of 95 (3.2%) cases of low-grade squamous intraepithelial lesion (LSIL), and in 17 of 48 (35.4%) cases with high-grade squamous intraepithelial lesion (HSIL). High-risk HPVs were detected in 23 of 97 (23.7%) cases with normal/reactive cellular changes (RCC) cytology, in 28 of 98 (28.6%) cases of ASCUS, in 69 of 95 (72.6%) cases of LSIL, and in 35 of 48 (72.9%) cases of HSIL. Telomerase expression did not correlate with the detection of high-risk HPVs in any cytological diagnostic categories. Telomerase and HPV test results of cytological specimens were correlated with the histological diagnoses of concurrent cervical biopsy specimens. Telomerase showed a sensitivity of 29.9% and a specificity of 94.0% for biopsy-confirmed cervical intraepithelial neoplasia (CIN) II/III. In contrast, high-risk HPVs were detected in 70.1% of cases with underlying CIN II/III, with a specificity of 62.5%. A relatively high proportion of normal/RCC or ASCUS cases with telomerase-positive test results had underlying high-grade dysplasia on cervical biopsy. Thus, technical and practical limitations of the TRAP assay in cervical cytology specimens limit the practical application of telomerase as a diagnostic adjunct in cervical cytopathology.     

Assisted primary screening using the automated ThinPrep Imaging System

We report the clinical trial studies for the ThinPrep Imaging System (TIS; Cytyc, Boxborough, MA). Between December 2000 and July 2001, 10,742 ThinPrep specimens were collected at 4 US clinical sites representative of the normal clinical population of the laboratories, including screening patients and referred patients. After nonstudy screening diagnoses were completed, the vials were relabeled and randomized, and study slides were prepared and stained. TIS-trained cytotechnologists and pathologists screened the slides twice, first manually, then TIS-assisted after an appropriate interval. Afterward, 3 independent pathologists performed an adjudication study to determine definitive diagnoses for the nonnegative slides and 5% of the negative slides; the adjudicated diagnoses served as the "gold standard" for subsequent sensitivity and specificity analyses. TIS-assisted screening was statistically more sensitive than manual screening for atypical squamous cells of undetermined significance (ASCUS) or higher (+) and statistically equivalent for low- (LSIL)+ and high-grade squamous intraepithelial lesion (HSIL)+ diagnoses. TIS-assisted screening had equivalent specificity for ASCUS+ and LSIL+ and significantly higher specificity for HSIL+. Average cytologists' daily screening rates doubled with TIS-assisted screening. The sensitivity of the TIS-assisted screening system equals or exceeds the sensitivity of manual primary screening without adversely affecting specificity, and TIS-assisted screening can improve cervical cancer screening productivity. Cost issues require further study.     

Intermediate‐grade squamous intraepithelial lesion may be a valid diagnostic/interpretive category

We undertook this study to assess the characteristics of smears with features intermediate between high‐grade squamous intraepithelial lesion (HSIL) and low‐grade squamous intraepithelial lesion (ISIL). We also wanted to determine how these smears correlate with high risk biopsy diagnosis and to compare this with the biopsy correlation of LSIL and HSIL. Seventy‐four squamous intraepithelial lesion (SIL) smears were identified as intermediate‐grade SIL smears taken at colposcopy in a 1 year period. They were correlated with concurrent colposcopically guided biopsies. Thirty‐five percent of cases with intermediate‐grade SIL smears had a biopsy diagnosis of moderate dysplasia or higher as compared with 12% for LSIL 74% for HSIL. This confirmed our hypothesis that intermediate‐grade SIL smears have a rate of biopsy diagnosis of moderate dysplasia or higher intermediate to that of LSIL and HSIL. Diagn. Cytopathol. 2009. © 2008 Wiley‐Liss, Inc.     

Histology correlation with atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL) cytology diagnoses: An argument to ensure ASCUS follow-up that is as aggressive as that for LSIL.

The purpose of the present study was to compare histology outcomes of cytological atypical squamous cells of undetermined significance (ASCUS) to the histology outcomes of cytological low-grade squamous intraepithelial lesion (LSIL). Cases with a cytology diagnosis of ASCUS and LSIL that had correlative histology obtained within 3 mo of the cervico-vaginal smear were accrued from the files of the Cytology and Histology Departments of Mercy Hospital Medical Center (Des Moines, IA). All of the cytology cases were examined by a cytotechnologist, a cytopathologist, and the histopathologist who signed out the biopsy material. The laboratory's benign: ASCUS: LSIL: HSIL + ratio was 94.0%: 3.8%: 1.5%: 0.7% for the time period of this analysis; its ASCUS:SIL proportion was 1.76. Histology correlations to 249 ASCUS cases showed 45 (18%) CIN2s (cervical intraepithelial neoplasm 2) or CIN3s, 134 (54%) CIN1s, and 70 (28%) nonneoplastic biopsies. Ten of 24 (42%) ASCUS cases that showed histological CIN3 and seven of 21 (33%) ASCUS cases that showed histological CIN2 contained atypical immature squamous metaplastic cells, while the remainder showed squamous cells with mature, superficial/intermediate-type cytoplasm. Histology correlations to 576 LSIL cases showed 96 (17%) CIN2s or CIN3s, 397 (69%) CIN1s, and 83 (14%) nonneoplastic biopsies. One hundred forty-six (59%) ASCUS and 424 (74%) LSILs had histological koilocytosis with nuclear atypia (KA); the sole histological finding of KA was seen among 76 (30.5%) ASCUS and 146 (25.3%) LSIL cases. The majority of cytological ASCUS and LSIL cases selected by clinicians for biopsy have histological CIN and a substantial minority show CIN2 and CIN3, which, in the case of ASCUS, is frequently associated with atypical immature squamous metaplastic cells. There is a high prevalence of histological KA among ASCUS and LSIL cases. Diagn. Cytopathol. 21:292-295, 1999.     

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.     

Long-term follow-up of women with atypical squamous cells of undetermined significance (ASCUS)

ASCUS is the most common epithelial abnormality diagnosed in cytology laboratories in the US. Recently, the clinical importance of this diagnosis has been seriously questioned, with some investigators advocating elimination of this diagnostic category. This might be inappropriate if the ASCUS designation does define a population that is at significant risk for the development of dysplasia. Cytology and surgical pathology reports for all patients diagnosed as ASCUS in our laboratory during 1990 were reviewed. Patients with previous dysplasia or carcinoma were excluded from analysis. The pathology reports for the subsequent 9.1 yr were obtained and follow-up data collected. In 1990, 15,860 cervical cytology cases were examined in our laboratory. A diagnosis of ASCUS was made in 1,117 cases (7.0%). After excluding 345 patients with previous dysplasia or human papillomavirus-related diagnoses and 129 patients with no follow-up specimens, 643 study patients remained. Among these, the mean number of subsequent cervical smears was 4.3 (range, 1-18). Subsequent histologic material was available for 134 (20.8%) patients and the mean number of surgical specimens was 1.5 (range, 1-10). Squamous intraepithelial lesion (SIL) or dysplasia was subsequently diagnosed in 197 patients (30.6%). High-grade squamous intraepithelial lesion (HSIL) or at least moderate dysplasia was diagnosed in 64 patients (10.0%). In 21 cases (3.3%) the high-grade dysplasia developed more than 2 yr after the first ASCUS diagnosis. Follow-up disclosed no cases of invasive carcinoma. Among ASCUS patients followed for up to 9 yr, 20% develop only low-grade SIL or mild dysplasia and 10% develop HSIL or moderate or severe dysplasia. ASCUS should be retained as a diagnostic category since it identifies a significant percentage of patients who are at an increased risk for the development of cervical dysplasia.     

Significance of subclassifying high-grade squamous intraepithelial lesions into moderate dysplasia/CIN II versus severe dysplasia/CIN III/CIS in the Bethesda System terminology

Recent revisions of the Bethesda System (TBS III) did not modify the original two-tiered low-grade and high-grade squamous intraepithelial lesion (LSIL/HSIL) terminology and continued to offer the option of subclassifying HSIL into moderate dysplasia/cervical intraepithelial neoplasia (CIN II) and severe dysplasia/CIN III. The purpose of this study is to evaluate the significance of the HSIL moderate dysplasia/CIN II subclassification and the causes of Pap test-biopsy discordance for this subclassification. HSIL/moderate dysplasia/CIN II Pap tests were identified from the University of California Davis Medical Center laboratory file for a 5-yr period (1997-2001) and correlated with follow-up cervical biopsies. Cervical biopsies with CIN II diagnoses were identified from the laboratory file for the same time period, and correlated with their preceding Pap test. Discordant Pap test-biopsy pairs from either group were reviewed by two pathologists for the following causes for discordance: cytologic overcall or undercall, biopsy overcall or undercall, and sampling error or possible lesion regression. During the review period, 161 of 378 total HSIL Pap tests had a HSIL/CIN II result (42%), and 81/161 (50%) had a follow-up cervical biopsy. 38/81 (47%) were concordant, and 43 (53%) were discordant; 39/43 discordant cases had both Pap test and biopsy slides available for review. CIN I was the most common discordant biopsy diagnosis. Sampling error was the most common cause of discordance and was three times more common than the other causes; 536 CIN cervical biopsies with CIN were identified in the laboratory files during this review period, and 108/536 (20%) received a diagnosis of CIN II. Sixty-seven of 108 (62%) had a preceding Pap test result available; 32 of the 67 (48%) had a concordant preceding Pap test with a HSIL/CIN II result, and 35 (52%) were discordant; 32/35 discordant cases had both Pap test and biopsy slides available for review. LSIL was the most common discordant Pap test diagnosis. Sampling error was also the most common cause of discordance, and was also three time more frequent than any other cause for discordance. HSIL/CIN II is a meaningful subclassification in our laboratory. We support the TBS III recommendation for optional subclassification of HSIL and suggest that individual laboratories may wish to monitor use of this subclassification through internal correlation studies.     

Negative loop electrosurgical excision procedure (LEEP) following cervical biopsy diagnosis of high grade squamous intraepithelial lesion

Context: Loop Electrosurgical Excision Procedure (LEEP) is commonly performed after cervical biopsy diagnosis of high grade squamous intraepithelial lesion (HSIL/CIN2 or CIN 3). Histological and immunohistochemical assessments are made to differentiate reactive and metaplastic changes from dysplastic changes. A Human Papillomavirus (HPV) test is used for prognostic assessment after conization. Objective: We retrospectively reviewed cases where the cervical biopsy showed HSIL but the LEEP specimen was negative for high grade dysplasia. Our aim was to determine the cause of miscorrelation. Data: IRB approval was obtained and a search was made of all LEEP specimens received during 2018. We reviewed 25 of 137 LEEP specimens that did not correlate with the diagnosis of HSIL rendered on the cervical biopsy. These were from women between 25 to 54 years. All cases had positive high-risk HPV with 80% being non16/18 subtype. On review, 8/25 had HSIL with the remainder of cases falling short of HSIL diagnosis. Follow up cytology with HPV test after the LEEP procedure was negative in all but one case of LSIL with persistent non-16/18 HPV. Conclusion: The study highlights the diagnostic difficulties of distinguishing HSIL from immature squamous metaplasia. The practical implication is that in cases with non-16/18 high risk HPV which have thin epithelium and fall short of definite morphologic criteria of HSIL, presence of immature squamous metaplasia should be carefully evaluated. The specific role of CK7 and CK17 which highlight squamocolumnar junctional cells and metaplastic cells, respectively, needs to be explored in these cases.     

Qualification of ASCUS. A comparison of equivocal LSIL and equivocal HSIL cervical cytology in the ASCUS LSIL Triage Study

Cytologic detection of high-grade squamous intraepithelial lesions (HSILs) is critical to cervical cancer prevention. Therefore, identifying "equivocal HSIL" (ASCUS [atypical squamous cells of undetermined significance]-H) may be useful. Accordingly, we compared findings associated with "equivocal low-grade SIL" (ASCUS-L), ASCUS-H, and HSIL using data from the ASCUS LSIL (low-grade squamous intraepithelial lesion) Triage Study. The frequency of oncogenic human papillomavirus (HPV) DNA detection and underlying lesions cervical intraepithelial neoplasia (CIN) 2 or worse or CIN 3 or worse in women with ASCUS-H was intermediate between that of ASCUS-L and HSIL. Oncogenic HPV DNA was associated with 85.6% of ASCUS-H ThinPreps and 69.8% of ASCUS-H smears. Histopathologic lesions CIN 2 or worse were associated with 40.5% of ASCUS-H ThinPreps and 27.2% of ASCUS-H smears (mostly CIN 3). Nevertheless, numerically more lesions CIN 2 or worse were preceded by ASCUS-L than by ASCUS-H because ASCUS-L was more common. ASCUS-H is an uncommon interpretation that derives clinical usefulness from its high positive predictive value for lesions CIN 2 or worse.     

Accuracy and reproducibility of telecytology diagnosis of cervical smears. A tool for quality assurance programs

We randomly selected 50 cervical smears (benign, 14; atypical squamous cells of undetermined significance [ASCUS], 5; low-grade squamous intraepithelial lesion [LSIL], 10; high-grade squamous intraepithelial lesion (HSIL), 12; squamous cell carcinoma, 6; adenocarcinoma, 3) and captured 1,181 digital images (518 MB) at a maximum resolution of 1,600 x 1,200 pixels and transmitted them by e-mail. Diagnosis of glass slides and digital images was done independently in a double-blind manner by 3 pathologists and 3 cytotechnologists, commencing with the diagnosis of digital images followed by diagnosis of glass slides 3 months later. The procedure was repeated after 3 months. Diagnoses were recorded as benign, ASCUS or atypical glandular cells of undetermined significance, LSIL, HSIL, squamous cell carcinoma or adenocarcinoma, and "inadequate for diagnosis." Diagnostic accuracy and interobserver reproducibility were analyzed using an intraclass correlation coefficient (ICC), which revealed good interobserver agreement for the first (0.72) and second (0.64) glass slide diagnoses and the first (0.72) and second (0.60) digital image diagnoses. The kappa values for intraobserver variation between first and second glass slide diagnoses and first and second digital image diagnoses showed moderate to excellent agreement. Digital images are suitable substitutes for glass slides; telecytology can be used as an alternative method for the cytologic diagnosis of cervical smears, particularly in quality assurance programs.     

"ASCUS, rule out HSIL": cytologic features, histologic correlates, and human papillomavirus detection.

Risk factors, cytologic and histopathologic features, and human papillomavirus (HPV) detection associated with 75 cervical smears classified as atypical squamous cells of undetermined significance, rule out high-grade squamous intraepithelial lesion (ASCUS, rule out HSIL) were reviewed. Cases were identified in a pathology panel review of material collected from 1953 women participating in a 5-year prospective study of HPV infection and squamous intraepithelial lesions at Kaiser Permanente, Portland, Oregon, sponsored by the National Cancer Institute. Initial abnormal smears diagnosed as ASCUS, rule out HSIL by one panelist or diagnosed as ASCUS by one pathologist and as HSIL by another were included. The 75 ASCUS, rule out HSIL smears identified were examined again by two pathologists after the study. These cases were compared with cases of ASCUS, not otherwise specified (ASCUS, NOS) and HSIL identified in the same group of 1953 women. Findings in ASCUS, rule out HSIL included tissue fragments (21%); atypical immature metaplasia (17%); atypical mature metaplasia (15%); small atypical cells (9%); and atypical repair (4%). A final patient classification of HSIL, reflecting all available data, was assigned to 11 (24%) of 46 women with ASCUS, rule out HSIL and to 1(1%) of 80 women with ASCUS, NOS in the original review (P < .001). Detection of oncogenic HPV types at diagnosis in ASCUS, rule out HSIL; ASCUS, NOS; and HSIL was similar, but data were unavailable for many subjects. Among women not tested at diagnosis, enrollment testing (1 to 4 years earlier) revealed that HPV detection in women with ASCUS, rule out HSIL was intermediate in frequency between ASCUS, NOS and HSIL. These data suggest that ASCUS, rule out HSIL is a distinct diagnosis from ASCUS, NOS because it is more often associated with an underlying HSIL. Consequently, women with ASCUS, rule out HSIL should be referred for colposcopic examination.     

The clinical significance of "squamous intraepithelial lesion of indeterminate grade" as a distinct cytologic category

The histologic and/or cytologic follow-up of 127 cases of cervical lesions termed "squamous intraepithelial lesion of indeterminate grade" (SIL) on Papanicolaou (Pap) smears by the 2001 Bethesda System was compared with 150 control cases of low-grade SIL (LSIL), high-grade SIL (HSIL), and atypical squamous cells, cannot exclude HSIL (ASC-H). A follow-up diagnosis of cervical intraepithelial neoplasia (CIN) 2 or higher was identified in 22.8% of SIL cases, which was 2.6 times higher than LSIL, 3 times lower than HSIL, and 1.5 times lower than ASC-H. A follow-up diagnosis of CIN 1 was identified in 31.5% of SIL cases, which was 2 times lower than the LSIL group, 1.5 times higher than the ASC-H cases, and 1.8 times higher than the HSIL group. We found that 22.0% of cases diagnosed as SIL were followed up by Pap smears rather than colposcopy and biopsy, compared with about 1% of LSIL and HSIL cases. Because SIL cases have a significant risk of harboring CIN 2 or greater, we recommend follow-up by colposcopy and biopsy.     

Efficacy of a liquid-based thin layer method for cervical cancer screening in a population with a low incidence of cervical cancer

The performance of the ThinPrep(R) Pap Testtrade mark (TP) (Cytyc Corp., Boxborough, MA) for detection of cervical cancer precursors in a population with a low incidence of disease was evaluated. This prospective trial compared results obtained with TP to those obtained with the standard cytologic smear in women from the general community who were being screened for cervical cancer from January 1, 1995-December 31, 1997 by physicians in private practice (n x 130, 381 conventional examinations and 39,864 TP examinations). In the TP series there was a significant increase in the proportion of "satisfactory" examinations (91.9% TP vs. 72.2% conventional) and positive diagnoses (5.5% TP vs 2.4% conventional, odds ratio x 2.21; 95% confidence interval (CI), 2.08-2.34). The likelihood of detecting a high-grade squamous intraepithelial lesion (HSIL) by TP was significantly greater than in controls (odds ratio x 1.86; 95% CI, 1.68-2.06). Detection of low-grade squamous intraepithelial lesions (LSIL), or atypical squamous cells of undetermined significance (ASCUS), was significantly greater in the TP series than in controls (LSIL odds ratio x 3.41; 95% CI, 3.07-3.79; ASCUS odds ratio x 1.68; 95% CI, 1.56-1.82). A histologic lesion was confirmed in 141 (93%) of the biopsies for HSIL (130 HSIL or greater, 10 LSIL, 1 SIL not otherwise specified). In conclusion, both diagnostic sensitivity and sample adequacy were significantly improved using the ThinPrep(R) Pap test under routine conditions in an outpatient population with a low incidence of cervical cancer.     

Long-term outcome and relative risk in women with atypical squamous cells of undetermined significance.

Few studies have compared long-term follow-up and risk for invasive cancer in women with atypical squamous cells of undetermined significance (ASCUS). We conducted a 6-year review of pathology files for 651 women in whom ASCUS had been diagnosed in 1992. Data collected included patient demographics, follow-up diagnoses, time between follow-up examinations, and procedures performed. At follow-up, high-grade squamous intraepithelial lesions (HSIL) had developed in 9.0% of the women, and invasive cancer in none. Previous cervical history did not affect risk for an HSIL. Although the average time to first follow-up was 6.18 months, in 20.9% of the women the diagnosis of HSIL was not established until after 2.0 years. For individual pathologists, the percentage of HSILs ranged from 0% to 18.8%. Thus women with ASCUS who are followed up regularly are at low risk for development of invasive cancer.     

Utility of P16 expression and Ki‐67 proliferation index in ASCUS and ASC‐H pap tests

Current cervical screening uses a combination of cytology and high‐risk human papillomavirus (HR‐HPV) analysis in cases of atypical squamous cells of undetermined significance (ASCUS) and atypical squamous cells cannot exclude high‐grade intraepithelial lesion (ASC‐H). These diagnoses are subject to interobserver variability and HR‐HPV analysis can be limited by sampling inadequacy. This study correlates immunoexpression of P16 and Ki‐67 in residual cervicovaginal material against cytology category and HR‐HPV status. Eighteen pap tests were selected: 8 ASCUS, 4 ASC‐H, and 6 controls (2 LSIL and 4 HSIL). Digene Hybrid Capture II test was used to detect HR‐HPV. The cytospins were stained for P16/Ki‐67. Pap tests, P16, Ki‐67, HR‐HPV result and available biopsies were correlated. P16 expression correlated with HR‐HPV status in 15/17 cases. Discordant cases (1 ASCUS and 1 ASC‐H) were +P16/–HR‐HPV. Ki‐67 correlated with HR‐HPV in 8/15 cases. Discordant cases were +HR‐HPV/– Ki‐67 (HSIL, LSIL, and ASC‐H one each), and –HR‐HPV/+Ki‐67 (3 ASCUS, 1 LSIL, 1 ASC‐H). Two cases were + P16/+ Ki‐67/– HR‐HPV. None were ‐ P16/– Ki‐67/+ HR‐HPV. Histologic follow‐up in 13 cases varied from benign to CIN III. Two cases of +P16/ – Ki‐67/– HR‐HPV had benign cervical biopcies. Although a small sample size, our findings show a utility for adjunct P16/ Ki‐67 in addition to HR‐HPV testing in cases of squamous atypia when HR‐HPVs are non‐detected due to low DNA copies, or missed lesions in cervical biopsies. Diagn. Cytopathol. 2014;42:576–581. © 2013 Wiley Periodicals, Inc.     

Prevalence of human papillomavirus genotypes in cytologic abnormalities from unvaccinated women living in north-western Spain

Cervical cancer and its precursors low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL) are associated with infection by human papillomavirus (HPV), in particular HPV 16 and 18. The distribution of the HPV genotype varies with the severity of cervical disease, age and the geographic location of the patients. We report the results of a population study carried out in a region of north-western (NW) Spain aimed at determining the prevalence of single and multiple infections by 35 types of HPV using low-density microarrays for 113 cases with negative for intraepithelial lesions or malignancies; 588 with atypical squamous cells of undetermined significance (ASCUS)/LSIL; 183 with HSIL; and seven cases of squamous cell carcinomas. Of the 891 patients analysed, 50.2% had single infections and 49.8% had multiple HPV infections. In women aged below 30 years, there was a predominance of multiple infections (p = 0.027). ASCUS/LSIL was associated with multiple and HSIL with single infections (p = 0.025). We observed significant increases in the percentage of infections due to a high-risk (HR) type of HPV when the severity of the cytological lesion increased (p = 0.001). No relationship was found between greater aggressiveness in the cytological diagnosis and a higher number of HPV types involved in multiple infections. The five most frequent genotypes were HPV 16 (26.3%), 53 (18.2%), 51 (17.3%), 6 (14.8%) and 66 (13.1%). The prevalence of HPV 16, 33 and 58 increased significantly from ACUS/LSIL to HSIL and the prevalence of HPV 51, 53 and 66 decreased. HPV 16 was the only genotype that showed a significant increase in prevalence when the severity of the cytological disease increased in single infections (p = 0.0001). The implementation of bivalent prophylactic vaccination could potentially lead to prevention in 32% of the population included in the study - in at least a quarter of patients with ACUS/LSIL (26.7%), and in half of HSIL (50.2%).     

Clinicopathological Implications of Human Papilloma Virus (HPV) L1 Capsid Protein Immunoreactivity in HPV16-Positive Cervical Cytology

Background: The objective of this study was to investigate the expression of human papilloma virus (HPV) L1 capsid protein in abnormal cervical cytology with HPV16 infection and analyze its association with cervical histopathology in Korean women.Material and Methods: We performed immunocytochemistry for HPV L1 in 475 abnormal cervical cytology samples from patients with HPV16 infections using the Cytoactiv^® HPV L1 screening set. We investigated the expression of HPV L1 in cervical cytology samples and compared it with the results of histopathological examination of surgical specimens.Results: Of a total of 475 cases, 188 (39.6%) were immunocytochemically positive and 287 (60.4%) negative for HPV L1. The immunocytochemical expression rates of HPV L1 in atypical squamous cells of unknown significance (ASCUS), low-grade squamous intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL), and cancer were 21.8%, 59.7%, 19.1%, and 0.0%, respectively. LSIL exhibited the highest rate of HPV L1 positivity. Of a total of 475 cases, the multiple-type HPV infection rate, including HPV16, in HPV L1-negative cytology samples was 27.5%, which was significantly higher than that in HPV L1-positive cytology samples (p = 0.037). The absence of HPV L1 expression in ASCUS and LSIL was significantly associated with high-grade (≥cervical intraepithelial neoplasia [CIN] 2) than low-grade (≤CIN1) histopathology diagnoses (p < 0.05), but was not significantly different between HPV16 single and multiple-type HPV infections (p > 0.05). On the other hand, among 188 HPV L1-positive cases, 30.6% of multiple-type HPV infections showed high-grade histopathology diagnoses (≥CIN3), significantly higher than the percentage of HPV16 single infections (8.6%) (p = 0.0004)Conclusions: Our study demonstrates that the expression of HPV L1 is low in advanced dysplasia. Furthermore, the absence of HPV L1 in HPV16-positive low-grade cytology (i.e., ASCUS and LSIL) is strongly associated with high-grade histopathology diagnoses. The multiplicity of HPV infections may have an important role in high-grade histopathology diagnoses (≥CIN3) in HPV L1-positive cases.     

Findings to date from the ASCUS-LSIL Triage Study (ALTS)

Controversy exists in the United States regarding the proper evaluation and management of low-grade squamous intraepithelial lesion (LSIL) and equivocal (atypical squamous cells of undetermined significance [ASCUS, now ASC-US]) cervical cytologic interpretations. To address this issue, the National Cancer Institute initiated the ASCUS-LSIL Triage Study (ALTS). ALTS is a multicenter, randomized clinical trial designed to evaluate 3 alternative methods of management, namely, immediate colposcopy, cytologic follow-up, and triage by human papillomavirus (HPV) DNA testing. This article summarizes the major findings of ALTS that have been published to date. Patients with ASCUS (n = 3488) or LSIL (n = 1572) were randomly assigned to research arms between November 1996 and December 1998, and were monitored for 2 years. The disease outcome was histologic cervical intraepithelial neoplasia (CIN) 3/cancer. The prevalence of oncogenic HPV was too high to permit effective triage of LSIL using HPV DNA testing by Hybrid Capture 2. However, for the women referred with a cytologic interpretation of ASCUS, HPV triage proved useful, with sensitivity equivalent to immediate colposcopy and a halving of colposcopic referrals. Among older women with ASCUS, HPV testing remained sensitive for detecting CIN 3 and cancer, but the referral percentage was dramatically lower compared to younger women. ALTS yielded insight into the performance of cytology and histopathology; experienced pathologists differed significantly in their interpretations of cervical abnormalities, especially histologic CIN 1 and cytologic ASCUS. Nonetheless, it was possible to distinguish a relatively uncommon type of ASCUS, equivocal for high-grade squamous intraepithelial lesion, that has a high positive predictive value for identifying women with underlying high-grade CIN. Many additional analyses are underway.     

The role of human papillomavirus in cyto-histological practice: distribution and prevalenceof hig-risk strains (16, 18, 31, 33, and 35) in intraepithelial lesions and neoplasia of the uterine cervix

INTRODUCTION: Many studies have already shown the association of persistent infection of human high risk papillomavirus (HPV) with the development of pre-invasive and invasive cervical disease. MATERIALS AND METHODS: We evaluated the use of high risk HPV testing in a study of about 1908 women, aged 29-78, who attending, from 1996 to 1998, the Sant'Anna Hospital in Turin for routine, second level smears and histopathological diagnosis. We considered all cervical lesions: ASCUS, LSIL, HSIL, squamous and adeno invasive cancers. HPV testing was performed by polymerase chain reaction (PCR) using L1 consensus primers which can detect almost all infections (high and low risk types). The most important high risk HPV types (16, 18, 31, 33 and 35) were tested using specific primers. RESULTS: The prevalence of high risk HPV was: ASCUS 42.2%, LSIL 39%, HSIL 73.5%, squamous invasive cancers 98.3% and adeno 100%. In addition HPV 16 is the most represented type in all lesions: ASCUS 40%, LSIL 62%, HSIL 71.2% squamous invasive cancers 73.3% and adeno 50.6%. In addition we study the mean age of cervical cancer onset compared with the different high risk HPV types. We found that HPV 18 related cancer occurs in younger women (mean age 41 years; range 39-42). CONCLUSIONS: The addition of high risk HPV testing to cytology may improve early identification of women at risk for cervical cancer.