Sarah Igidbashian

Self-collected human papillomavirus testing acceptability: comparison of two self-sampling modalities.

BACKGROUND Human papillomavirus (HPV) testing can be used as a primary test for cervical cancer screening. HPV self-sampling has the potential to replace physician/nurse sampling. Our objective was to compare the acceptability of two self-sampling methods among 205 women undergoing an excisional procedure for cervical intraepithelial neoplasia (CIN) at the European Institute of Oncology (IEO). METHODS One hundred eleven patients were given a Hybrid Capture (HC) Cervical Sampler™ (Qiagen, Hilden, Germany), and 94 received a self-lavaging device, the Delphi® Screener (Delphi Bioscience, Scherpenzeel, The Netherlands), both with written instructions. Self-sampling was performed just before the clinician-collected cervical sample. Women responded to questions using 5-point ordinal scales on the general acceptability of self-sampling and the physical comfort, embarrassment, pain, and difficulty experienced. Participants were also asked whether they prefer self-sampling or clinician sampling. RESULTS Both self-sampling methods were generally accepted with a significantly high score (p = 0.005) and significantly lower embarrassment (p = 0.042) in favor of the Delphi Screener. Both self-sampling methods were physically well accepted, not painful, and easy to perform. Most women (n = 117, 68%) preferred the self-sampled compared to the clinician-sampled test, with a significantly higher proportion in the Delphi Screener group (n = 59, 77.6%) compared to those using the HC Sampler (n = 58, 60.4%) (p = 0.021). CONCLUSIONS The present study shows that self-sampling for HPV testing is favorably received by women. A sampling device specifically developed for self-sampling, such as the Delphi Screener, shows the highest degree of satisfaction. A well-accepted HPV sampling method could be especially useful for women who do not take part in cervical screening or in settings where organized screening is not fully implemented.

Distribution of human papillomavirus genotypes in invasive cervical cancer in Italy: a representative, single institution case series.

Despite worldwide human papillomavirus (HPV) types distribution showed constant rates of HPV 16/18 in cervical cancers, regional variations have been consistently documented. Very little data is available on HPV genotype prevalence among Italian women with invasive cervical cancer. This study aims to determine the HPV type distribution in cervical specimens obtained from Italian women diagnosed with invasive cervical cancer and referred to the European Institute of Oncology (IEO). Two hundred-sixty eight cervical specimens were obtained from patients diagnosed with invasive cervical cancer referred to the European Institute of Oncology between 1996 and 2006. Following preparation, all cervical samples were sent to laboratories at the International Agency for Research on Cancer (IARC, Lyon, France) for DNA extraction and HPV typing by the multiplex PCR/APEX assay. The study population was divided into four groups from different macro regions: (i) Milan and surrounding area (n=57, 21.3%), (ii) northern Italy (n=81, 30.2%), (iii) central Italy (n=64, 23.9%) and (iv) southern Italy (n=66, 24.6%). The present study is the first at our knowledge that examines a fair number of Italian cervical cancers, about one tenth of all estimated cervical cancer cases occurring yearly, distributed across the whole country. Two-hundred and fifty-one patients (93.7%) resulted HPV DNA positive; of these 201 patients (80.1%) presented a single infection, whereas 50 women (19.9%) presented multiple infection. One hundred and eighty-nine specimens (75.3%) tested positive for either HPV 16 or HPV 18, whereas 62 (24.7%) resulted positive for other high-risk HPV genotypes only. The proportion of HPV 16/18 positive invasive cervical cancers was similar for all the four geographical Italian areas considered. A statistically significant association with younger age and earlier stage was observed for HPV 16/18 related invasive cervical cancers. The results demonstrate that the proportion of HPV 16/18 cervical cancers is fairly constant in all the areas and covers more than 70% of Italian cervical cancer cases. This observation strengthens the decision to start the vaccination programme in all the Italian regions. In addition, the present study provides new and original data on the genotype related differences of the disease that are worth of further investigation.

VIN usual type—from the past to the future

Usual vulvar intraepithelial neoplasia (uVIN) is the most common VIN type, generally related to a human papillomavirus (HPV) infection, predominantly type 16. The incidence of uVIN has been increasing over the last decades, and a bimodal peak is observed at the age of 40–44 and over 55 years. Almost 40% of patients with uVIN have a past, concomitant or future HPV-associated lesion of the lower genital tract. HPV-related malignancies are associated with a persistent HPV infection. The host immune response is of crucial importance in determining clearance or persistence of both HPV infections and HPV-related VIN. About 60% of the patients present with symptoms. Clinical features of uVIN vary in site, number, size, shape, colour, and thickness of lesions. Multicentric disease is often present. Most uVIN lesions are positive at immunohistochemistry to p16ink4a and p14arf, but negative to p53. Irrespective of surgical treatment used, uVIN recurrence rates are high. Positive margins do not predict the development of invasive disease and the need to re-excide the tissue around the scare remains to be demonstrated. Therefore, considering the low progression rate of uVIN and psycosexual sequelae, treatments should be as conservative as possible. Medical treatments available are mainly based on immunotherapy to induce normalisation of immune cell count in uVIN. None are approved by the food and drug administration (FDA) for the treatment of uVIN. If medical treatment is performed, adequate biopsies are required to reduce the risk of unrecognised invasive disease. Some studies suggest that failure to respond to immunotherapy might be related to a local immunosuppressive microenvironment, but knowledge of the uVIN microenvironment is limited. Moreover, our knowledge of the potential mechanisms involved in the escape of HPV-induced lesions from the immune system has many gaps. HPV vaccines have been demonstrated to be effective in preventing uVIN, with 94.9% efficacy in the HPV-naive population, while studies on therapeutic vaccines are limited. The low incidence of VIN requires large multicentre studies to determine the best way to manage affected patients and to investigate the immunological characteristics of the ‘vulvar microenviroment’ which leads to the persistence of HPV.

Tissue genotyping of 37 in situ and invasive cervical cancer with a concomitant negative HC2 HPV DNA Test

Objective The rare occurrence of histology-proven cervical intraepithelial neoplasia grade 3 (CIN 3) or invasive cancer with a negative HC2 result is known. Tissue blocks of 37 cases of histology-diagnosed CIN 3+ with a concomitant negative HC2 test were genotyped to investigate the human papillomavirus (HPV) status within the lesion. Methods We considered 1,976 cervical excision specimens performed with concomitant HC2 test. Of these, 37 histology-confirmed CIN 3+ resulted HC2 negative. Thirty-three paraffin blocks, derived by the cervical excision, could be genotyped for high- (HR) and low-risk (LR) HPV genotypes. Results Detailed histology showed 30 CIN 3, 2 squamous cell invasive carcinomas, and 5 invasive adenocarcinomas. One specimen resulted not amplifiable at the genotyping. Twenty-two cases (68.7%) were positive for HR-HPV types, either in single (n = 17) or multiple HR-HPV infection (n = 5). Most of the HR-HPVs found were 16 or 18. Ten cases (31.3%) were negative for HR-HPV types; 5 of these were positive for probable HR-HPV types, not detectable with HC2 HR-probes, 1 was positive to LR-HPV types, while 1 had HPV-69/71. Three cases were negative for HPV DNA, either high or low risk. Conclusions Of the rare cases of CIN 3+ lesions with concomitant negative HC2 test, 69% are true failures in HR-HPV detection. One third of HC2-negative CIN 3+ is related to the presence of other HPV genotypes not covered by the HC2 panel or to undetectable HPV in the lesion; both these rare occurrences were already described in large cancer series and partially explain the occurrence of HPV-negative CIN 3+.

Sentinel Pap smears in 261 invasive cervical cancer patients in Italy

Although cervical cytology screening has dramatically reduced its incidence, cervical cancer still occurs. The clinical history of 261 cervical cancer patients referred to the European Institute of Oncology between 1996 and 2006 was analysed in depth to better understand the difficulties in the diagnosis and prevention of this neoplasia in Italy. Data concerning anagraphical characteristics, tumour type and stage, Pap smear history, colposcopic and histologic data, treatment outcome were reviewed. Patients who had taken Pap smear in the 3-year time span preceding diagnosis were 199 and 55 (27.7%) of these smears were negative. A negative Pap smear was observed in 62.5% of the women with a cancer at stage IV or III. One hundred and seventy-two patients were symptomatic at diagnosis: 43 (25%) had a negative Pap smear in the 3 years preceding diagnosis while 54 (31.4%) had never done a Pap smear or had one taken more than 3 years before. Eighty-nine women were asymptomatic at the time of diagnosis; 13 patients (14.6%) had a negative Pap smear while 8 had no smear taken in the 3 years preceding diagnosis or no smear at all. The present retrospective investigation indicates that the screening system still has some critical points. Although multiple techniques and approaches have been proposed to improve the general performance of the system, prophylactic vaccination may dramatically limit the failures in an easier, and possibly more cost-effective way. We also stress that history taking and clinical examination are important tools to diagnose cervical cancers. However a clinical diagnosis requires experience, which, with the advent of more efficient screening system and prophylactic vaccination, many of the newer practising gynaecologists might lack.

Performance of self-sampled HPV test in comparison with liquid based cytology

OBJECTIVE Strong evidences shows that HPV testing is more sensitive than cytology in detecting high-grade CIN. HPV test can be performed on samples collected by women themselves by means of self-sampling devices. This study compares the results of self-sampled HPV tests with the results of liquid based cytology (LBC). STUDY DESIGN Seven hundred women scheduled for cervical cytology self-collected a cervicovaginal sample for HPV testing and then underwent a clinician-collected LBC at the European Institute of Oncology. The HPV and LBC results were compared with the McNemar test. RESULTS All HSIL (N=5) resulted hrHPV positive. LBC resulted LSIL or worse in 38 (5.4%) women (out of 700). Self-sampled HPV was positive in 96 women (13.7%). A LSIL or worse LBC result was found in 15 (2.5%) patients, out of the 604 hrHPV negative women and in 23 (24%) patients, out of the 96 hrHPV positive women. Positive cytology after a self-sampled HPV positive result had an Odds Ratio of 12.4 (95% CI: 5.8-26.6). CONCLUSION Self-collected HPV testing identifies a group of women at high risk of positive LBC and high grade SIL.

HPV-based screening for prevention of invasive cervical cancer

1294 www.thelancet.com Vol 383 April 12, 2014 The landmark follow-up study by Guglielmo Ronco and colleagues clearly demonstrates that high grade cervical intraepithelial neoplasia (CIN) is an excellent surrogate marker for invasive cervical cancer, strengthening the findings of the initial screening studies conducted in the four European countries (Sweden [Swedescreen], the Netherlands [POBASCAM], England [ARTISTIC], and Italy [NTCC]). Non-believers now lose another argument often used against prophylactic HPV vaccination programmes. Furthermore, the pooled analysis proves again that HPV testing is superior to regular cytologic screening, as has been repeatedly proven in multiple trials over the years. However, it is disappointing that even with HPV screening so many women still developed cervical cancer in both groups, especially the 19 patients diagnosed during the long-term follow-up raise concern. The rates in the Italian NTCC trial were much lower than in the other three trials. Can this be explained by a more stringent triage, a more careful follow-up of test-positive women, or because of other reasons? We feel the authors should really provide a more thorough analysis of all such breakthrough cases, including compliance issues, demographics, history, stage, proportion of adenocarcinomas, just to name a few potential key variables. While there is evidence that HPV testing is the best screening test, it appears that further improvement is needed. We must identify the best triage, including colposcopy and follow-up protocols to ensure that women who comply do not develop cervical cancer. Another important point is the fact that in some countries the fi rst cohorts of HPV-vaccinated women are already in their thirties thus entering the number of invasive cervical cancers detected in the human papillomavirus (HPV)-based screening group was slightly lower than in the cytologybased screening group only at the fi rst screening round. This result suggests that HPV testing is not as eff ective as cytology in early detection of invasive cervical cancers; and this is plausible from both epidemiological and biological points of view. In western countries the incidence of invasive cervical cancers is very low; after the fi rst round of screening, clearance of cervical intraepithelial neoplasia grade 3 (CIN3) following HPV testing is high, and the effi cacy of early detection of invasive cancer by cytology is masked. The lesser sensitivity of HPV testing for invasive cervical cancers could be explained because invasive cervical cancers are shedding cells with major molecular rearrangement and the viral DNA load could be in some instances under the sensitivity of the test. Ronco and colleagues’ study infers two different roles for cytology and HPVbased testing: the fi rst is best directed for the identifi cation of precursors, the second is best for early diagnosis of cervical cancer and to a lesser extent to CIN3 detection. These two diff erent performances should be acknowledged to choose cytology or HPV-based testing on the basis of disease prevalence and screening aims, cancer prevention, or early cancer diagnosis.

Transition from Hybrid Capture 2 to Cobas 4800 in Hpv detection: sensitivity and specificity for Cin2+ in two time periods

Abstract Background: High-risk (HR) Human Papilloma Virus (HPV) Tests for HPV detection differ in sensitivity and specificity. In this study, we evaluated the sensitivity and specificity of the HC2 HR HPV Test and the Cobas 4800 HPV Test in consecutive cervical samples collected from a referral population with a high prevalence of disease, using CIN2+ histology as clinical outcome. Methods: Ten thousand two-hundred and thirteen consecutive cervical samples were assayed for HR-HPV in the Laboratory Medicine Division of IEO: 5140 from January 2012 to June 2013 with HC2 and 5073 from July 2013 to December 2014 with the Cobas HPV Test. These two assays differ in terms of target genes and testing methods. Results: The test positivity rates for HC2 and Cobas 4800 were 29.5% (1515/5135, 95% CI 28.3–30.8%) and 23.9% (1212/5069, 95% CI 22.7–25.1%), respectively. The detection rates of CIN2+ in the two time periods were 2.8% (145/5140, 95% CI 2.4–3.3%) and 1.6% (79/5073, 95% CI 1.2–1.9%), respectively. The sensitivity for CIN2+ for HC2 and Cobas 4800 was 95.2% (138/145, 95% CI 91.7–98.7%) and 93.7% (74/79, 95% CI 88.3–99.0%), respectively. The specificity for CIN2+ for HC2 and Cobas 4800 was 72.4% (3613/4990, 95% CI 71.2–73.6%) and 77.2% (3852/4990, 95% CI 76.0–78.4%), respectively. There were 23 cases of cancer in each of the two time periods. HC2 detected 100% (23/23). Cobas 4800 detected 82.6% (19/23). Conclusions: The detection rate of CIN2+ was higher in the first period than in the second period. There was no significant difference in sensitivity of HC2 and Cobas 4800 in women with CIN2+. The specificity of CIN2+ using Cobas 4800 in the second period was higher than HC2 in the first period, probably due to the lower prevalence of CIN2+ in the second period.

Prevalence and Risk Factors of Human Papillomavirus Infection in 18-Year-Old Women: Baseline Report of a Prospective Study on Human Papillomavirus Vaccine

Objectives Little is known about the epidemiology of human papillomavirus (HPV) in Italy before the age of 25. At the European Institute of Oncology, a prospective observational study on cervical HPV infection in 18-year-old women undergoing quadrivalent HPV vaccination is ongoing. Methods At the first visit before vaccination, all the young women answered an epidemiological questionnaire, and then, the presence of high-risk HPV (hrHPV) was tested. Samples positive for hrHPV were genotyped. Liquid-based cytology was done only to women declaring not to be virgins. Any positivity at cytology or HPV testing was completed with colposcopy and eventually biopsies. Results Seven hundred and thirty women were enrolled. Two hundred sixty-six women were virgins; 7 (2.6%) of these resulted positive to hrHPV: 1 had HPV16 and CP6108, whereas the other 6 resulted negative at genotyping. Of the 464 nonvirgins, 61 (13.1%) were HPV positive: 19 had HPV16, 4 were positive to HPV18 with other hrHPVs, 25 to other hrHPVs, 7 to low-risk HPV, whereas 13 resulted negative at genotyping. HPV positivity was significantly associated to both smoking and having more than 3 partners. Cervical cytology was negative in 433 cases (93.3%), ASC-US in 10 cases (2.2%), low-grade squamous intraepithelial lesion in 20 cases (4.3%), and ASC-H in 1 case (0.2%). No CIN2+ was identified. Conclusions Overall, we found a low positivity to HPV in this population; however, the rate of HPV positivity was significantly related to smoking and sexual life. The cytology result low-grade squamous intraepithelial lesion was more frequent than in the screening population, whereas no CIN2+ was identified, confirming the indication to avoid screening at this age.

HPV self-sampling in CIN2+ detection: sensitivity and specificity of different RLU cut-off of HC2 in specimens from 786 women

Aims Mortality for cervical cancer varies between the different regions of the world, with high rates in low-income countries where screening programmes are not present and organised. However, increasing screening coverage is still a priority in all countries: one way to do that is to base screening on self-sampled screening. The success of a self-sampling screening strategy depends on capacity to recruit unscreened women, on the performance and acceptability of the device and on the clinical performance of the high-risk human papillomavirus (HPV) test. Methods This study based on 786 enrolled women investigates the best cut-off value of Hybrid Capture 2 HPV test (HC2) for self-sampled specimens in terms of sensitivity and specificity. Results In this population, we found that the sensitivity and the specificity for cervical intraepithelial neoplasia grade 2 or more detection of HC2 performed on self-sampled specimens were 82.5% and 82.8%, respectively considering the relative light units (RLU) cut-off value of 1. Increasing the cut-off value the sensitivity decreases and the specificity raises and the best area under the curve for the RLU cut-off value is 1. Conclusions Our results confirm that the cut-off value of 1 suggested by Qiagen for PreservCyt specimen is the best cut-off value also for self-sampled specimens.