Bin Yang

Improved sensitivity of vaginal self-collection and high-risk human papillomavirus testing

Self‐collected vaginal specimens tested for high‐risk human papillomavirus (HR‐HPV) have been shown to be less sensitive for the detection of cervical intraepithelial neoplasia or cancer (≥CIN 3) than physician‐collected endocervical specimens. To increase the sensitivity of self‐collected specimens, we studied a self‐sampling device designed to obtain a larger specimen from the upper vagina (POI/NIH self‐sampler) and a more sensitive polymerase chain reaction (PCR)‐based HR‐HPV assay. Women (10,000) were screened with cervical cytology and HR‐HPV testing of vaginal self‐collected and endocervical physician‐collected specimens. Women were randomly assigned to use either a novel self‐collection device (POI/NIH self‐sampler) or conical‐shaped brush (Qiagen). The self‐collected and clinician‐collected specimens were assayed by Cervista (Hologic) and the research only PCR‐based matrix‐assisted laser desorption/ionization time‐of‐flight (MALDI‐TOF). Women with any abnormal screening test underwent colposcopy and biopsy. Women (8,556), mean age of 38.9, had complete data; 1.6% had ≥ CIN 3. For either HR‐HPV assay, the sensitivity was similar for the two self‐collection devices. Tested with Cervista, the sensitivity for ≥CIN 3 of self‐collected specimens was 70.9% and for endocervical specimens was 95.0% (p = 0.0001). Tested with MALDI‐TOF, the sensitivity for ≥CIN 3 of self‐collected specimens was 94.3% and for endocervical specimens was also 94.3% (p = 1.0). A self‐collected sample using a PCR‐based assay with the capability of very high throughput has similar sensitivity as a direct endocervical specimen obtained by a physician. Large population‐based screening “events” in low‐resource settings could be achieved by promoting self‐collection and centralized high‐throughput, low‐cost testing by PCR‐based MALDI‐TOF.

Implementation of tumor testing for lynch syndrome in endometrial cancers at a large academic medical center

OBJECTIVESnLynch syndrome (LS) is a hereditary condition that increases the risk for endometrial and other cancers. Recognizing women at risk for LS based on personal/family history is burdensome and imprecise. Tumor testing using microsatellite instability (MSI) testing and immunohistochemistry (IHC) for mismatch repair protein expression can be an effective strategy for identifying potential LS in patients presenting with colorectal or endometrial cancer. Here we describe our experience implementing a screening program for endometrial cancers.nnnMETHODSnEndometrial cancers diagnosed ≤50 years or those with suspicious personal history or histopathologic features were screened with MSI/IHC, June 2009-June 2011. Criteria were later (July 2011-July 2012) expanded to patients diagnosed <60 years, or at any age with suspicious features, and finally (after August 2012) universal screening was implemented. Screening techniques began with both MSI and IHC for every tumor, and later converted to IHC for two proteins, and MLH1 promoter methylation analysis when indicated. A genetic counselor contacted patients directly to offer genetic counseling appointments.nnnRESULTSnTwo hundred and forty-five endometrial cancers (average age, 57 years) were screened. Sixty-two patients (25%) had abnormal results, and 42 patients were referred for genetic counseling. Of the 42 patients, 34 underwent genetic counseling, 28 pursued genetic testing, and 11 were diagnosed with LS. When age and pathology criteria were used, 27 eligible cases were overlooked for screening and 3 cases of LS were found only because a clinician requested screening.nnnCONCLUSIONSnUniversal screening of endometrial cancers for LS is practical and successfully implemented with collaboration among genetic counselors, gynecologic oncologists, and pathologists.

A Population-Based Clinical Trial Comparing Endocervical High-Risk HPV Testing Using Hybrid Capture 2 and Cervista From the SHENCCAST II Study

Our objective was to directly compare the accuracy of the high-risk human papillomavirus (HPV) assays, Hybrid Capture 2 (hc2; Qiagen, Gaithersburg, MD) and Cervista (Hologic, Bedford, MA), in diagnosing cervical intraepithelial neoplasia (CIN) 3 or worse (cancer). A population-based, cross-sectional study (The Shenzhen Cervical Cancer Screening Trial II) was conducted in Guangdong Province in China. Three high-risk HPV assays, self and direct cervical sampling and cytology, were studied. Abnormal results on any of 6 study tests (33%) resulted in referral to colposcopy. At colposcopy, every patient had at least 5 cervical biopsy specimens obtained. For 8,556 women between the ages of 25 and 59 years (mean, 38.9 years), the rate for CIN 3 or worse was 1.6% (141/8,556). The sensitivity (confidence interval) values for CIN 3 or worse were 97.9% (94.0%-99.6%) and 95.1% (90.0%-98.0%) for hc2 and Cervista, respectively (P > .05). The specificity (confidence interval) values were 87.8% (87.1%-88.5%) and 90.3% (89.6%-90.9%), respectively (P < .05). Differences in accuracy in diagnosing CIN 3 or worse with the hc2 and Cervista tests are minor and result from the decisions made in selecting the cut points.

False negative colposcopy is associated with thinner cervical intraepithelial neoplasia 2 and 3

OBJECTIVEnTo assess whether thinner lesion epithelium or lower nuclear density contribute to false negative colposcopy for dysplasia, we determined epithelial thickness and nuclear density and correlated this with the accuracy of colposcopic impression for cervical quadrants with biopsies of normal, CIN 1, CIN 2 and CIN 3.nnnMETHODSnThe thickness and nuclear density of squamous epithelium of 261 selected cervical biopsies (CIN 2/CIN 3, N=144; Normal/CIN 1, N=117) from the Shanxi Province Cervical Cancer Screening Study (where a colposcopic impression and biopsy were obtained in each cervical quadrant) were measured. Average epithelial thickness was defined as the thinnest area plus the thickest area divided by two. Average nuclear density was defined as the number of nuclei in a 2,500 microm(2) grid at the junction of the superficial and intermediate zones plus that at the junction of the intermediate and parabasal zones divided by two. Differences in means were measured by Wilcoxon Rank-Sum Test. Trends among means were measured by a generalized linear mixed model.nnnRESULTSnMean average epithelial thickness for 33 biopsies of CIN 2/CIN 3 from cervical quadrants with colposcopic impression of normal (184 microm) was less than that of 111 biopsies of CIN 2/CIN 3 from quadrants with colposcopic impressions of low, high, or cancer (321 microm, p<.001). CIN 2/CIN 3 had higher mean average nuclear density (p<.001) and was thinner than normal/CIN 1 (p<.001).nnnCONCLUSIONnThe inability of expert colposcopists to visualize some CIN 2/CIN 3 is associated with thinner epithelium.

Development and validation of a new HPV genotyping assay based on next-generation sequencing.

OBJECTIVESnWe developed a new human papillomavirus (HPV) genotyping assay based on multiplex polymerase chain reaction and next-generation sequencing (NGS) methods for large-scale cervical cancer screening.nnnMETHODSnWe first trained the assay on 1,170 self-collected samples, balancing the cutoff points for high-risk types. Then using 4,262 separate self-collected specimens, we compared concordance, sensitivity, and specificity for cervical intraepithelial neoplasia type 2 (CIN2) or higher and CIN type 3 (CIN3) or higher of the HPV sequencing assay with that of Hybrid Capture 2 (HC2) direct samples and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry assay self-samples.nnnRESULTSnAll assays had a good agreement. The sensitivity for CIN2 or higher and CIN3 or higher of the self-sampling specimens tested with the sequencing assay run on both MiSeq and Ion Torrent Personal Genome Machine sequencer was similar to that of direct-sampling specimens tested with HC2 (P > .05), but the specificity of the sequencing assay for CIN2 or higher and CIN3 or higher was significantly higher than that of HC2 (P < .01).nnnCONCLUSIONSnThis population-based study has demonstrated the applicability of a new NGS high-risk HPV assay for primary cervical cancer screening based on self-collection.

Diagnostic efficacy of real-time optical coherence tomography in the management of preinvasive and invasive neoplasia of the uterine cervix

Objective: Determine the sensitivity and specificity of optical coherence tomography (OCT) as an adjunct to colposcopy in the detection of cervical intraepithelial neoplasia (CIN) grade 2 or higher in a real-time clinical evaluation. Background: Optical coherence tomography (OCT) uses infrared light similar to ultrasound pulse-echo imaging. Image resolution is optimal in the 1-to-3-mm range. This study is the third in our series of OCT investigations and our first real-time clinical trial. The study was conducted at the Peking University Shenzhen Hospital, Shenzhen, China. Methods: Nonpregnant women 18 years or older with abnormal cervical cytologic findings or a positive high-risk human papillomavirus test result were recruited. Women were assessed; and diagnoses, recorded by cervical quadrant first with colposcopy, followed by colposcopic directed OCT. A biopsy of the abnormal areas was performed. In normal quadrants, biopsy specimens were obtained at the 2-, 4-, 8-, and 10-oclock positions at the squamocolumnar junction depending on the quadrant. An endocervical curettage was also done. Individual OCT diagnoses were paired with colposcopic impressions and biopsy specimens to assess its role as a paired secondary screen. Data were analyzed using generalized estimating equations to control for correlation within a woman. Results: One thousand two hundred thirty-seven paired diagnoses from 299 women were analyzed. Median age was 36 years. Ninety-six women (8%) had a diagnosis of CIN 2 or higher. Evaluation by quadrant showed that the sensitivity for CIN 2 or higher decreased by adding OCT to colposcopy, but the specificity increased from 83% to 93%. Conclusions: We continue to try to improve sensitivity by improving the near-infrared light source, decreasing the scan time to 8 frames per second, and using a larger diameter (5 mm) fiberoptic probe with a newly designed application specific probe sheath.

Study of the diagnostic efficacy of real-time optical coherence tomography as an adjunct to unaided visual inspection with acetic acid for the diagnosis of preinvasive and invasive neoplasia of the uterine cervix.

Objectives: To determine the sensitivity and specificity of optical coherence tomography (OCT) as an adjunct to unaided visual inspection using acetic acid (VIA) in the detection of cervical intraepithelial neoplasia 2 (CIN 2) in a real-time clinical evaluation. Background: This clinical study was a prospective cross-sectional comparative trial that screened 1000 patients (aged 30-50 years) in a low-resource setting. Women with abnormal cervical cytology or positive human papillomavirus (HPV) tests were referred for further evaluation including VIA, OCT imaging, colposcopy, and cervical biopsies. Methods: The VIA diagnoses were coded by quadrant. The OCT was then performed in all VIA-positive areas and at the squamocolumnar junction in all 4 quadrants. All patients were colposcoped; assessed by quadrant with biopsies at 2, 4, 8, and 10 oclock; all abnormal areas were biopsied; and endocervical curettage was performed. Data were analyzed using generalized estimating equations and logistic regression. Results: Of the 1000 patients, 175 (17.5%) were HPV positive, 93 (9.3%) had abnormal cervical cytology greater than or equal to atypical squamous cells of undetermined significance, and 211 (21.1%) were either HPV positive or had abnormal cytology. The VIA, OCT, colposcopy, and biopsies were completed on 183 (86.7%) of 211 women. For VIA alone, the sensitivity and specificity in detecting lesions greater than or equal to CIN 2 was 43% and 96%. With the addition of OCT, the sensitivity increases to 62% with a specificity of 80%. Conclusions: With the addition of OCT, the sensitivity of VIA increased in all analyses for the detection of greater than or equal to CIN II, with a loss in specificity. We hope that the potential of this technology will be realized when a computer algorithm is generated to aid in image interpretation.

A New PCR-Based Mass Spectrometry System for High-Risk HPV, Part II Clinical Trial

This was a population-based clinical trial of a polymerase chain reaction-based multiplex high-risk human papillomavirus (HR-HPV) assay using mass spectrometry (MassARRAY [Sequenom, San Diego, CA] matrix-assisted laser desorption/ionization time-of-flight mass spectrometry system [MALDI-TOF]). Participants were 10,000 women between the ages of 25 and 59 years in Guangdong Province, China (SHENCCAST II Study). All women collected a self-sample (tested with Cervista [Hologic, Marlborough, MA] and MALDI-TOF) followed by a clinician-collected cervical sample (for cytology, Hybrid Capture 2 [HC2; Qiagen, Gaithersburg, MD], Cervista, and MALDI-TOF). Patients with any abnormal result were asked to return for colposcopy and biopsies. This analysis included the data for 8,556 women. The sensitivity values for cervical intraepithelial neoplasia (CIN) 3 or worse for a direct cervical sample were 97.9%, 95.1%, and 94.3 for HC2, Cervista, and MALDI-TOF, respectively (P > .05). The sensitivity for CIN 3 or worse for a self-collected sample tested with MALDI-TOF was also 94.3%, which was similar to a clinician-obtained endocervical sample assayed with the 3 HR-HPV assays. MALDI-TOF combined with a self-collected sample provides a highly sensitive, high-throughput, low-cost-per-case assay for mass screening.

High-Grade Cervical Intraepithelial Neoplasia Detected by Colposcopy-Directed or Random Biopsy Relative to Age, Cytology, Human Papillomavirus 16, and Lesion Size

Objective The aim of the study was to determine whether p16 positive/cervical intraepithelial neoplasia (CIN) 2, 3, and cancer (p16 + CIN 2/3+) detected by colposcopy-directed or random biopsy differ by age, referral cytology, human papillomavirus (HPV) 16, and lesion size. Materials and Methods Data from the Shenzhen Cervical Cancer Screening Trial II where, at colposcopy, women who had directed and random cervical biopsies were reviewed to find women with CIN 2, 3, or cancer; 227 such women identified had their paraffin-embedded tissue blocks recut, reviewed, and then immune stained for p16. Data were analyzed by &khgr;2, Fisher exact test, and linear regression. Results After histopathologic review and p16 staining of CIN 2, 175 women were diagnosed with p16 + CIN 2/3+. When compared with those diagnosed by colposcopy-directed biopsy (n = 138), those diagnosed by random biopsy (n = 37) were more likely to have Cytology-Lo (cytology of negative, atypical squamous cells of undetermined significance, or low-grade squamous intraepithelial lesion; p = .07), less likely to have HPV 16 (p = .041), more likely to be 51 years or older (p = .022), and more likely to have 1 quadrant lesions (p < .001). Logistic regression analysis showed p16 + CIN 2/3+ diagnosed by random biopsy was predicted by 1 quadrant lesions (p < .0001) and age of 51 years or older (p = .03) but not by Cytology-Lo (p = .71) nor HPV 16 (p = .26). Conclusions Women with p16 + CIN 2/3+ diagnosed by random biopsy are older and less likely to have HPV 16; hence, CIN diagnosed by random biopsy may not be as virulent as CIN diagnosed by colposcopy-directed biopsy. Regardless, we advise that CIN diagnosed by random biopsy be viewed like CIN diagnosed by colposcopy-directed biopsy.

Outcome of neoadjuvant chemotherapy in BRCA1/2 mutation positive women with advanced-stage Müllerian cancer

OBJECTIVESnTo investigate whether patients with germline BRCA1/2 mutations who received neoadjuvant chemotherapy (NAC) for advanced-stage Müllerian cancer (MC) have an improved outcome compared to patients who did not undergo genetic testing.nnnMETHODSnThree hundred and two patients who received NAC for stage III-IV MC were identified from a multi-institutional study involving Cleveland Clinic and Brigham and Womens Hospital for 2000-2014 and 2010-2014 respectively. Patients were divided into 3 cohorts: patients with germline BRCA1/2 mutations (BRCA_mut+; N=30), patients with no genetic testing (BRCA_mut_unk; N=166) and patients with negative genetic testing (BRCA_mut-, N=106).nnnRESULTSnThere were no differences in the clinical characteristics and rates of complete cytoreduction and bowel resection between the three groups. BRCA_mut+ had longer PFS compared to BRCA_mut_unk and BRCA_mut- (19.1 vs. 15.1 vs. 15.7months respectively. However, this difference was not statistically significant (p=0.48). Patients with BRCA2 mutation had non-significant trend toward longer PFS compared to patients with unknown BRCA or BRCA1 mutation (20.2 vs. 15.1 vs. 14.8months respectively, p=0.58). BRCA_mut+ and BRCA_mut- had longer overall survivals (OS) compared to BRCA_mut_unk patients (50.5 vs. 54.1 vs. 36.5months respectively, p=0.009). In multivariable analyses, controlling for age, stage and complete cytoreduction, BRCA_mut_unk was associated with worse PFS (HR 1.44, 95% CI 1.01-2.05, p=0.045) and OS (HR 2.67, 95% CI 1.33-5.36, p=0.006).nnnCONCLUSIONSnPatients with germline BRCA mutations had improved outcomes with NAC compared to patients with unknown BRCA status. These outcomes were more favorable compared to the outcome of NAC in prior studies.