Pierre Vassilakos

Hydatidiform mole: two entities

In a continuous series of 811 spontaneous and 1,097 induced abortions, 75 specimens with gross swellings of the chorionic villi were found. On gross morphology, histopatholgy, and karyotype these were classified into two entities: “partial mole” and “complete mole.” A total of 56 moles were “partial” (i.e., normal chorionic villi intermingled with hydropic villi) and associated with a fetus, cord, and/or amniotic membrane. The great majority of partial moles (40/49) presented various chromosomal anomalies, especially triploidy and trisomy 16. None of these cases showed marked trophoblastic hyperplasia or anaplasia and, after at least 1 years follow-up, none had a malignant evolution. A total of 19 moles were “complete,” without fetus, cord, or amniotic membrane. Of the 10 cases in which the karyotype could be established, it was 46,XX normal female. The quality of the material of the nine remaining cases did not permit a cytogenetic evaluation; nevertheless, when a search for sex chromatin was possible (seven cases), it was positive. All 19 cases showed marked trophoblastic hyperplasia and anaplasia; two of them presented distant metastases on follow-up. It is considered that “complete” moles constitute a “high-risk group” for malignant trophoblastic neoplasia.

Direct-to-vial use of the AutoCyte PREP liquid-based preparation for cervical-vaginal specimens in three European laboratories.

OBJECTIVE To compare the AutoCyte PREP direct-to-vial procedure to the conventional Pap smear in two large and similar patient groups compiled from the testing experience of three cytology laboratories in Switzerland and France. STUDY DESIGN Randomly selected, large patient groups were evaluated using either the conventional Pap smear or the AutoCyte PREP direct-to-vial liquid-based preparation. Results were then compared statistically as to disease detection and sample adequacy. RESULTS Specimen adequacy was greatly improved in the group tested with the AutoCyte PREP. PREP also demonstrated a significant reduction in ASCUS and ASCUS:LSIL+ ratios. The three laboratories participating in this review found significantly improved detection of both low and high grade SIL. Routine use of AutoCyte PREP for cervical cytology screening offers substantial improvements in adequacy and disease detection.

Localization of alpha 2, alpha 5 and alpha 6 integrin subunits in human endometrium, decidua and trophoblast

Integrins are heterodimeric glycoproteins acting as membrane receptors for extracellular matrix components. The specificity of these receptors towards one particular matrix glycoprotein depends on the type of alpha and beta subunit combination. Since integrins are involved in the migratory behaviour of cells and since cytotrophoblastic cells are constitutively invasive, we undertook to immunolocalize the alpha 2, alpha 5 and alpha 6 integrin subunits in normal and hydatidiform molar trophoblast, in an implantation site as well as in decidualized and non-decidualized endometrium. alpha 6 positivity was confined to villous cytotrophoblast and was clearly polarized towards the basement membrane. Extravillous cytotrophoblastic cells were alpha 6-negative but became alpha 5-positive. In contrast to normal trophoblast, villous cytotrophoblast from hydatidiform molar tissue was alpha 5-positive. We conclude that the expression of a alpha 5 integrin subunit on cytotrophoblastic cell surfaces is correlated with the appearance of an invasive phenotype. alpha 6 and alpha 2 integrin subunits were both localized on the surface and glandular epithelium of the endometrium and their expression was increased during the secretory phase but became low or undetectable after decidualization. In contrast, alpha 5 subunit positivity was weak in the same epithelial during the first half of the cycle but disappeared after ovulation. Stromal cell alpha 5 positivity was present throughout the cycle but increased dramatically in decidualized endometria. We conclude that the alpha 5 integrin subunit which disappears from the epithelium at the end of the cycle might allow migration of the epithelial cells and repair of the endometrium after menses. We also wonder if alpha 5 positivity is part of a change in the stromal cell phenotype induced by decidualization.

Cytorich liquid-based cervical cytologic test: Screening results in a routine cytopathology service

OBJECTIVE To eliminate the disadvantages and inherent bias of split-sample studies by evaluating the relative performance of monolayers and conventional cervical cytologic smears in a single laboratory through evaluation of two large and similar, randomly derived patient groups from the same geographical and demographically similar population. STUDY DESIGN Two randomly created large patient groups from the same population were evaluated using conventional microscopic screening. One group was tested using the conventional smear. The other was evaluated using only the new liquid-preservative-based CytoRich preparation (AutoCyte, Inc., Elon College, North Carolina, U.S.A.) with the intended direct-tovial cell collection method. Results were then compared statistically as to disease detection and sample adequacy. RESULTS Age comparisons between the two groups demonstrated equivalency. Specimen adequacy was greatly improved in the group tested with the CytoRich monolayer preparation. The monolayer group also demonstrated a significant reduction in ambiguous atypical squamous cells of undetermined significance/atypical glandular cells of undetermined significance diagnoses and a threefold increase in the detection of squamous intraepithelial lesion and cancer. CONCLUSION Routine use of homogeneous monolayer preparations as a total replacement for the conventional smear can be expected to dramatically improve specimen adequacy and sensitivity of the conventional smear alone. Direct-to-vial use of the new monolayer preparation generated significantly better results than those shown in any of the earlier split-sample trials.

High- and Intermediate-Risk Human Papillomavirus Infection in Sexually Active Adolescent Females

STUDY OBJECTIVE To determine the prevalence of high- and intermediate-risk type human papillomavirus (HPV) infection and cervical dysplasia in an urban Swiss adolescent population attending the local Adolescent Clinic, using a liquid-based Pap test combined with risk type HPV DNA testing. To determine the prevalence of Chlamydia trachomatis in the same study population. DESIGN Observational study. SETTING The Adolescent Clinic of the Department of Obstetrics and Gynaecology at the University Clinic, Geneva, Switzerland. PARTICIPANTS 134 women between 14 and 20 years of age were enrolled in the study. MAIN OUTCOME MEASURES A standardized patient file on demographic and sexual history information was compiled and completed by physical examination, including a Pap test with adjunct high- and intermediate-risk type HPV DNA detection. RESULTS Of the 134 specimens analyzed for HPV, 115 patients were negative and 19 (14.2%) were positive for HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, or 68. A significant association between HPV infection and having had more than one lifetime sexual partner was found (P <.05). Six (31.6%) of the HPV-positive and three (2.6%) of the HPV-negative specimens had a low-grade squamous intraepithelial lesion (SIL) by cytology. Abnormal Pap test was related to HPV infection (odds ratio, 46.2; 95% confidence interval, 7.4 to 287.4) and, inversely, to age at first sexual intercourse (odds ratio, 0.98; 95% confidence interval,.97 to 1.0). CONCLUSION High- and intermediate-risk type HPV infection is a frequent finding in our study group and is linked to having had more than one lifetime sexual partner. No association was found between HPV infection and other potential risk factors such as patients age, age at first intercourse, frequency of intercourse during the three months prior to the investigation, smoking habits, or alcohol consumption.

Evaluation of estrogen receptors by immunocytochemistry on fine-needle aspiration biopsy specimens from breast tumors

The estrogen receptor (ER) content of 31 surgically removed breast tumors (26 duct carcinomas, one lobular carcinoma, one papillary carcinoma, one colloid carcinoma, one duct carcinoma in situ, and one atypical fibroadenoma) was determined by a commercially available immunocytochemical method (Abbott Laboratories, ER‐ICA) on cytologic material obtained by fine needle aspiration biopsy (FNAB) of surgical specimens. Immunocytochemical staining of cells by a peroxidase‐antiperoxidase technique was evaluated on the basis of the percentage of positive cells and the intensity of staining. An immuno‐staining score for cytologic (IS‐CYTO) and histologic (IS‐HISTO) material was defined and a threshold of positivity determined to facilitate the semi‐quantitation of results and the comparison of cases. The results of immunostaining of cytologic material were compared with the evaluation of ER in corresponding tissue samples as determined by the radioligand binding assay using the dextran‐coated charcoal procedure (ER‐DCC) and by ER‐ICA using cryostat sections of frozen tissue. The sensitivity, specificity, predictive value of a positive test, and test efficiency of ER‐ICA in cytologic material as compared to ER‐DCC was 96%, 83%, 96% and 93%, respectively. The IS‐CYTO was significantly correlated with the IS‐HISTO in corresponding histologic material (r = 0.72, P < 0.001). In conclusion, the combination of ER‐ICA with FNAB represents a useful new technique for the evaluation of ER which may be applied to small primary tumors, tumor recurrences, and metastases.

Cervical cancer screening in developing countries at a crossroad: Emerging technologies and policy choices

Cervical cancer (CC) represents the fourth most common malignancy affecting women all over the world and is the second most common in developing areas. In these areas, the burden from disease remains important because of the difficulty in implementing cytology-based screening programmes. The main obstacles inherent to these countries are poverty and a lack of healthcare infrastructures and trained practitioners. With the availability of new technologies, researchers have attempted to find new strategies that are adapted to low- and middle-income countries (LMIC) to promote early diagnosis of cervical pathology. Current evidence suggests that human papillomavirus (HPV) testing is more effective than cytology for CC screening. Therefore, highly sensitive tests have now been developed for primary screening. Rapid molecular methods for detecting HPV DNA have only recently been commercially available. This constitutes a milestone in CC screening in low-resource settings because it may help overcome the great majority of obstacles inherent to previous screening programmes. Despite several advantages, HPV-based screening has a low positive predictive value for CC, so that HPV-positive women need to be triaged with further testing to determine optimal management. Visual inspection tests, cytology and novel biomarkers are some options. In this review, we provide an overview of current and emerging screening approaches for CC. In particular, we discuss the challenge of implementing an efficient cervical screening adapted to LMIC and the opportunity to introduce primary HPV-based screening with the availability of point-of-care (POC) HPV testing. The most adapted screening strategy to LMIC is still a work in progress, but we have reasons to believe that POC HPV testing makes part of the future strategies in association with a triage test that still needs to be defined.

Human papillomavirus self-sampling in Cameroon: women's uncertainties over the reliability of the method are barriers to acceptance.

Objective The study aimed to assess acceptability and preference for self-collected human papillomavirus tests (self-HPV) compared with traditional physician-sampled Pap tests (physician sampling) in a low-resource country. Materials and Methods Women were recruited through a cervical cancer screening campaign conducted in Cameroon. Written and oral instructions were given to carry out an unsupervised self-HPV, followed by a physician-collected cervical sample for HPV testing and cytology. Subsequently the women were asked to answer a questionnaire. Results A total of 243 women were prospectively enrolled in this study. Median age of participants was 39 years (range = 25–65 years). Acceptability score was higher for self-HPV (p < .001) compared with physician sampling. Preference was lower for self-HPV than physician sampling (29% vs 62%; p < .001). Most participants thought that physician sampling was more reliable than self-HPV (59% vs 1%; p < .001). Women who preferred physician sampling were significantly more likely to have low knowledge about cervical cancer and a low educational level. Conclusions Although most of the women were more comfortable and less embarrassed with the self-HPV, they did not trust the method and did prefer physician sampling. The study underlines the need not only to educate women about HPV, cervical cancer, and its prevention but also to reassure them about the accuracy of self-HPV.

Randomized comparison of vaginal self-sampling by standard vs. dry swabs for Human papillomavirus testing

BackgroundTo evaluate if human papillomavirus (HPV) self-sampling (Self-HPV) using a dry vaginal swab is a valid alternative for HPV testing.MethodsWomen attending colposcopy clinic were recruited to collect two consecutive Self-HPV samples: a Self-HPV using a dry swab (S-DRY) and a Self-HPV using a standard wet transport medium (S-WET). These samples were analyzed for HPV using real time PCR (Roche Cobas). Participants were randomized to determine the order of the tests. Questionnaires assessing preferences and acceptability for both tests were conducted. Subsequently, women were invited for colposcopic examination; a physician collected a cervical sample (physician-sampling) with a broom-type device and placed it into a liquid-based cytology medium. Specimens were then processed for the production of cytology slides and a Hybrid Capture HPV DNA test (Qiagen) was performed from the residual liquid. Biopsies were performed if indicated. Unweighted kappa statistics (к) and McNemar tests were used to measure the agreement among the sampling methods.ResultsA total of 120 women were randomized. Overall HPV prevalence was 68.7% (95% Confidence Interval (CI) 59.3–77.2) by S-WET, 54.4% (95% CI 44.8–63.9) by S-DRY and 53.8% (95% CI 43.8–63.7) by HC. Among paired samples (S-WET and S-DRY), the overall agreement was good (85.7%; 95% CI 77.8–91.6) and the κ was substantial (0.70; 95% CI 0.57-0.70). The proportion of positive type-specific HPV agreement was also good (77.3%; 95% CI 68.2-84.9). No differences in sensitivity for cervical intraepithelial neoplasia grade one (CIN1) or worse between the two Self-HPV tests were observed. Women reported the two Self-HPV tests as highly acceptable.ConclusionSelf-HPV using dry swab transfer does not appear to compromise specimen integrity. Further study in a large screening population is needed.Trial registrationClinicalTrials.gov: NCT01316120

Is It Time to Introduce HPV Self-Sampling for Primary Cervical Cancer Screening?

Regular Papanicolaou (Pap) testing has been the backbone of the most successful cancer reduction program in the public health system. However, it is not perfect. In high-income countries, more than half of the women who are diagnosed with cervical cancer had never had a Pap test or were infrequently screened (1). In the United Kingdom, recent studies have suggested a decline in the routine screening program participation to below its target rate of 80%, particularly among women aged 25–29 years (2). Factors that may discourage women from going for regular screening are lack of time, discomfort, inconvenience, cultural objections, and poor socioeconomic status. In low-resource regions, additional barriers include lack of knowledge and lack of accessible or appropriate screening facilities as well as the prohibitively high cost of screening. Offering a simple, inexpensive, and convenient self-test that respects individual privacy may improve the participation of women who might be otherwise reluctant to undergo screening and those who live in areas with poor access to health care. In the last few years, we have learned that self-collected vaginal specimens from women who have received appropriate instruction produce human papillomavirus (HPV) test results similar to cervical specimens collected by health-care professionals (3). This congruence has supported the concept of introducing HPV selfsampling (Self-HPV) as an alternative means for cervical cancer screening. However, screening is a complex process, and the introduction of a new screening scenario should be carefully evaluated. Fundamental issues that must be addressed regarding the future of Self-HPV as a primary screening method are 1) whether the performance for the detection of cervical intraepithelial neoplasia (CIN) grade 2–3 and cervical cancer (CIN2+) by Self-HPV is (at least) equal or superior to that of the Pap test, 2) whether screening participation rate with Self-HPV will be sufficiently high, and 3) whether comparable results would be obtained outside a research setting.