The Role Of Hpv Technique In Identifying And Triage Patients With Cervical High-grads Squamous Intraepithelial Lesion

Background:With increasing incidence rate,cervical cancer is the most common gynecologic malignant tumor in China and is a major threaten to women's health.Currently,persistent infection of the High risk-human papillomavirus(HR-HPV)has been recognized as the main cause of cervical cancer.High-grade squamous intraepithelial lesions(HSIL)is the precancer pathological change in the long development process of the HR-HPV infections results in progression to cervical cancer.Effective cervical cancer screening programs can reduce the incidence and the mortality of cervical cancer by early detection and treatment of HSIL.Current cervical cancer screening recommendations include cytology,HPV testing,and HPV testing in conjunction with cytology.Cytological tests suffers from low sensitivity and specificity,especially in China.The coincidence rate of cytology reports from different doctors is low,especially in Atypical squamous cells of undetermined significance(ASCUS)which is the most common abnormal diagnosis in cytology-based cervical screening.A large number of ASCUS patients need to be triaged using HPV testing before undergo colposcopic examination.Using HPV testing as the primary screening method,a large number of transient HPV infections are usually diagnosed in the healthy population should be triaged.HPV testing for the primary Screening followed by cytology as triage test,or using cytology combined with HPV testing,a group of hrHPV-positive women with normal cytology will certainly be identified.HR-HPV status not only has a' major impact on management and triage of patients with normal cytology or ASCUS,but also may predict HSIL+ among these women.Colposcopic examination plays an important role in the in identifying patients with HSIL+.In China,although colposcopic examination is cheap and readily available,the sensitivity of colposcopy for detecting HSIL+ is unsatisfactory,especially when cytologic results are normal or ASCUS.Screening HR-HPV-related high-risk factors of HSIL+ can provide reference for colposcopical biopsy and improve the detection rate of HSIL+.This paper is aimed to select a few accessible factors(such as the HPV virus load,HPV genotypes,whether multiple infection of HPV or not,HPV E6E7 mRNA level,etc.)to help identify HSIL+ when cytologic results are normal or ASCUS.So we can find out predict factors for immediate HSIL+.Meanwhile,we analyze the HSIL(P16+/CIN2)among HR-HPV positive women with cytological abnormalities then,compare it with HSIL tested from patients whose cytological test result is LSIL,make a comparison of the LEEP postoperative pathologic reversion rate between the two,and look for possible shunt method,to guide clinical risk stratification,and improve detection rate of HSIL and to avoid excessive treatment.Part 1:Incidence rate of HSIL+ among HR-HPV DNA-Positive Women and Prediction HSIL+ using HPV DNA testingObjectives:1.To investigate the accuracy of colposcopy for detecting HSIL+ in HR-HPV-infected patients with ASCUS cytology and to estimate the prevalence rate of HSIL+ among them.2.To determine whether genotyping and HPV viral load and other possible factors can be useful for identifying immediate HSIL+ in these patients.Methods:1.This study included 620 cases with ASCUS and positive for HR-HPV who underwent colposcopy and punch biopsy within 1 month.2.The accuracy of colposcopy for diagnosing HSIL+ was evaluated through comparison with the biopsy results.HR-HPV status determined by Hybrid Capture 2 or HPV genotyping was analyzed retrospectively as a possible predictor of HSIL+.3.Evaluated sensitivity for the detection of HSIL+ using both the identified high-risk factors and colposcopy.Results:1.26.3%(163/620)of patients got a diagnosis of HSIL+ on punch biopsy;Agreement between colposcopic diagnosis and cervical pathology was matched perfectly in 89.2%of cases(553/620),and the strength of agreement with the k statistic was 0.698(p<0.001),the area under ROC curve was 0.822(95%CI:0.777-0.867).The PPV of a positive colposcopic impression was 88.7%,and the NPV of a negative colposcopic impression was 89.5%.However,the sensitivity of colposcopic impression was low(110/163,67.5%)compared with specificity(443/457,96.9%),and there were 3.1%false-positive and 32.5%false-negative results.2.The correlation between increased RLU/CO of HPV DNA testing and worse diagnosis was not significant(ROC = 0.542,p>0.05),but at cut-offs of 50 RLU/CO and 100 RLU/CO,HSIL+ and high virus load were correlated(p = 0.024 and 0.044,respectively).3.HSIL + outcome rates showed a progressive increase from Class 1(1 RLU/CO?HC2<10 RLU/CO)(14.25%)to Class 5(200RLU/CO?HC2<500 RLU/CO)(41.67%),but the rate decreased when virus load>500 RLU/CO.With the exception of Classes 1-2,all HSIL+outcome rates were>20%.4.HSIL+ risk was significantly higher in patients with HPV16 infection(52.3%)than in patients with HPV infection other than HPV16(17.9%,p<0.001).5.If high virus load(at cut-off 50 RLU/CO)was considered a diagnostic standard of HSIL+ when colposcopic impression was negative,sensitivity was improved from 74.2%(66/89)to 81.0%(72/89),(p=0.023).If positive colposcopic impression and HPV16 infection status were considered predictors,the sensitivity of HSIL+ diagnosis was improved from 60.0%(45/75)to 74.7%(56/75),but the difference was not statistically significant(p=0.262).Conclusions:1.Using the 2011 international colposcopy terminology,the overall accuracy of colposcopy is high.Colposcopy has a high specificity for detecting HSIL+ but a low sensitivity.2.HR-HPV genotyping or virus load is relevant to the detection of HSIL+among HPV-infected patients with ASCUS cytology.3.During colposcopy examination,biopsies considering HPV-16 infection or virus load ? 50 RLU/CO may be helpful for increasing the HSIL+ detection rate.Part 2:Incidence rate of HSIL+ among HC2-positive/NILM Women and prediction HSIL+ using HPV DNA testingObjectives:1.To investigate the accuracy of colposcopy for detecting HSIL+ in HC2-positive/NILM patients and to estimate the prevalence rate of HSIL+ among them.2.To determine whether genotyping,viral load,HPV E6/E7mRNA and other possible factors can be useful for identifying immediate HSIL+ in these patients.3.To evaluate the value of HPV genotype test and HPV E6/E7mRNA test in triage of these patients.Methods:1.HC2-positive/NILM women were randomly divided into 2 groups,group 1 performed HPV genotype test,group 2 performed HPVmRNA E6E7 test.All of them underwent colposcopy and punch biopsy within 1 month,the accuracy of colposcopy was evaluated.2.HR-HPV status determined by Hybrid Capture 2,HPV genotyping or HPVmRNA E6E7 level was analysed as a possible predictor of HSIL+.3.Evaluated sensitivity for the detection of HSIL+ using both the identified high-risk factors and colposcopy.4.T.he efficiency of HPVmRNA E6E7 test and HPV genotyping on identification of the immediate HSIL+ among HC2-positive/NILM patients was compared.Results:1.18.30%(71/388)of patients got a diagnosis of HSIL+ on punch biopsy;Agreement between colposcopic diagnosis and cervical pathology was matched perfectly in 86.1%(291/338)of cases,and the strength of agreement with the k statistic was 0.486(P<0.001).The clinically relevant portion of the area under the curve was 0.732(95%CI:0.657-0.807).The PPV of a positive colposcopic impression was 62.9%,and the NPV of a negative colposcopic impression was 88.4%.However,the sensitivity of colposcopic impression was low(54.9%)compared with specificity(91.4%),and there were 8.6%false-positive and 45.1%false-negative results.2.The age,the number of HR-HPV genotype were not correlated with HSIL+,while the clinical features associated with cervical lesions were correlated with HSIL+(p=0.028).3.The correlation between increased RLU/CO of HPV DNA testing and worse diagnosis was not significant(ROC = 0.511,p>0.05),but at cut-offs of 10 RLU/CO,50 RLU/CO or 100 RLU/CO,incidence of HSIL+ and HPV virus load were correlated(p= 0.018,p = 0.038 and p=0.049,respectively).3.HSIL + outcome rates showed a progressive increase from 7.69%of Class 1(1 RLU/CO<HC2<10 RLU/CO)to 33.8%of Class 5(200 RLU/CO<HC2<500 RLU/CO),but the rate decreased when virus load>500 RLU/CO.4.HPV16 was positive in 42.94%(70/163)of patients.The HPV16 positive rate of HSIL+ group(58.1%)was higher than that of LSIL-group(39.4%)(P=0.059),while the positive rate of other subtypes was not significantly different between the two groups.There was no statistically significant difference in the incidence rate between the single type HR-HPV infected group and the multi-type HR-HPV infected group(P=1.044).5.E6/E7 mRNA was positive in 66.28%(116/175)patients,The positive rate and test value of HPV E6/E7mRNA in HSIL+ group was significantly higher than that in LSIL-group(P=0.000).An optimal cut-off value(?802.12 copies/ml)was determined using the ROC curve to predict HSIL+.5.If HPV 16 infection was considered a diagnostic standard of HSIL+ when colposcopic impression was negative,sensitivity was improved to 80.6%(25/31),the difference was statistically significant(p=0.030).If positive colposcopic impression and HPV E6E7 mRNA?802.12 copies/ml were considered predictors,the sensitivity of HSIL+diagnosis was improved to 70.0%(28/40),this difference was not statistically significant.(p=0.166).7.Using 802.12 copies/ml as the cutoff value,the sensitivity of E6/E7 mRNA was higher than HPV 16 typing for predicting HSIL +(75.0%vs 58.1%),with statistical difference(p=0.012),while there was no statistical difference performance parameters were found in their specificity(62.2%vs60.6%)(p=0.786).The positive predictive values of E6/E7 mRNA>802.12 copies/ml on HSIL+ was 36.25%(29/80),and HPV16 positive on HSIL+ was 25.71%(18/70).Negative predictive values were 88.62%and 86.02%,respectively;there was no statistically significant differences.Conclusions:1.Using the 2011 international colposcopy terminology,the overall accuracy of colposcopy is high.Colposcopy has a high specificity for detecting HSIL+ but a low sensitivity.2.Among HC2-positive/NILM women,when HC2<500 RLU/CO,viral load was correlated with detection of HSIL+.3.HSIL+ is associated with HPV16 infection,but may not be associated with multiple HPV infection.4.The detection of HPV E6/E7mRNA by b-DNA technology assist to identification of HSIL+ in patients with HC2+/NILM,and the cutoff value of HPV E6/E7mRNA is 802.12 copies/ml.5.During colposcopy examination,biopsies considering HPV-16 infection or E6/E7 mRNA ? 802.12 copies/ml may be helpful for increasing the detection rate of HSIL+.6.In the detection of HSIL+,HPV mRNA ? 802.12 copies/ml was more sensitive than HPV16-positive,while there was no statistical difference performance parameters were found in their specificity.HPV E6/E7mRNA may be a potential triage for HC2-positive/NILM patients.Part 3 Predictors of discrepancies between biopsy and subsequent LEEP specimens P16+/CIN2.Objective:To analysis the rate of in patients with biopsy-confirmed P16+/CIN2 and to find possible predictors.Methods:1.Refer women who had abnormal results in outpatient gynecological screening using liquid-based cytology combined with HR-HPV testing to colposcopy-guided biopsies.The patients who had biopsy-confirmed CIN2 and showed p16 positivity were subsequently received LEEP treatment.Try to recognize the possible predictors of pathologic discrepancy such as age,HPV status,preoperative fluid cytology and colposcopy.2.Testing for HPV E6/E7 mRNA was performed before LEEP treatment.According to the test results,the patients were divided into two groups:<802.12 copies/ml group and>802.12 copies/ml group,and compare the postoperative pathological degradation rate of the two groups.Results:1.The postoperative pathological degradation rate was related to HPV 16 infestation.2.The HPV mRNA E6E7>802.12 copies/ml before LEEP treatment predicted a lower pathological degradation rate.Conclusions:P16+/CIN2 patients with NILM,ASCUS,or LSIL have a high rate of pathologic discrepancy.HPVmRNA E6E7 might be of value to select those women in need of immediate referral for LEEP treatment.