Human papillomavirus testing by hybrid capture appears to be useful in triaging women with a cytologic diagnosis of atypical squamous cells of undetermined significance

Genotyping of 27 human papillomavirus types by using L1 consensus PCR products by a single-hybridization, reverse line blot detection method

Amplification of human papillomavirus (HPV) DNA by L1 consensus primer systems (e.g., MY09/11 or GP5(+)/6(+)) can detect as few as 10 to 100 molecules of HPV targets from a genital sample. However, genotype determination by dot blot hybridization is laborious and requires at least 27 separate hybridizations for substantive HPV-type discrimination. A reverse blot method was developed which employs a biotin-labeled PCR product hybridized to an array of immobilized oligonucleotide probes. By the reverse blot strip analysis, genotype discrimination of multiple HPV types can be accomplished in a single hybridization and wash cycle. Twenty-seven HPV probe mixes, two control probe concentrations, and a single reference line were immobilized to 75- by 6-mm nylon strips. Each individual probe line contained a mixture of two bovine serum albumin-conjugated oligonucleotide probes specific to a unique HPV genotype. The genotype spectrum discriminated on this strip includes the high-risk, or cancer-associated, HPV genotypes 16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 55, 56, 58, 59, 68 (ME180), MM4 (W13B), MM7 (P291), and MM9 (P238A) and the low-risk, or non-cancer-associated, genotypes 6, 11, 40, 42, 53, 54, 57, 66, and MM8 (P155). In addition, two concentrations of beta-globin probes allowed for assessment of individual specimen adequacy following amplification. We have evaluated the performance of the strip method relative to that of a previously reported dot blot format (H. M. Bauer et al., p. 132-152, in C. S. Herrington and J. O. D. McGee (ed.), Diagnostic Molecular Pathology: a Practical Approach, (1992), by testing 328 cervical swab samples collected in Digene specimen transport medium (Digene Diagnostics, Silver Spring, Md.). We show excellent agreement between the two detection formats, with 92% concordance for HPV positivity (kappa = 0.78, P < 0.001). Nearly all of the discrepant HPV-positive samples resulted from weak signals and can be attributed to sampling error from specimens with low concentrations (<1 copy/microliter) of HPV DNA. The primary advantage of the strip-based detection system is the ability to rapidly genotype HPVs present in genital samples with high sensitivity and specificity, minimizing the likelihood of misclassification.

Hybrid capture II, a new sensitive test for human papillomavirus detection. Comparison with hybrid capture I and PCR results in cervical lesions

AIM

To test a new assay for the detection of human papillomavirus (HPV) DNA, hybrid capture II (HC II), compared with the previous commercialized hybrid capture I (HC I) and polymerase chain reaction (PCR) results on cervical scrapes from fresh cone excision biopsy samples.

METHODS

The three methods were used on cervical scrapes from 42 fresh cone excision biopsy samples. There were nine metaplastic and inflammatory lesions, five low grade lesions, and 28 high grade lesions. PCR was performed using the general primers GP5+/GP6+. The viral load of high risk HPV DNA was estimated by the ratio of relative light units to positive control values in the samples.

RESULTS

The sensitivity of HC I for the detection of high grade lesions was 71.4%, while it was 92.8% for HC II and 96.4% for the PCR. Considering only the absence of detectable cervical in situ neoplasia, the specificity was 88.9% for HC I, 66.7% for HC II, and 66.7% for PCR. With HC II, for a ratio of cervical sample to normal control of > 200, the sensitivity for the detection of high grade lesion was only 34.6% with a specificity of 66.7%.

CONCLUSIONS

HPV detection with the HC II assay is more sensitive than the previous HC I and represents a more convenient and easier test than PCR for routine use. Nevertheless the viral load estimated with this test cannot be a reliable predictive indicator of high grade lesions.

Low false-negative rate of PCR analysis for detecting human papillomavirus-related cervical lesions

Although PCR analysis is a sensitive test for detection of human papillomavirus (HPV) in the cervix, the proportion of cases of cervical dysplasia missed, or the false-negative rate, has been unknown. We determined the accuracy of PCR analysis for HPV DNA as a predictor of HPV-related cervical lesions in a cross-sectional study of sexually active women, aged 18 to 50 years, from the University of Michigan Family Medicine HPV study. Of 133 eligible participants, 41 underwent colposcopy because of a positive result for HPV of the cervix by the PCR method and 92 underwent screening colposcopy with biopsy prior to knowing the HPV PCR results. Twenty-four of those screened were subsequently found to also be HPV DNA positive. In those found to be HPV positive, histological studies revealed the presence of condyloma or cervical intraepithelial neoplasia in 16 women (24.6%) and changes suggestive of condyloma in 5 (7.6%). No HPV-negative woman had an abnormal biopsy or cytology report (P = 0. 000001). The false-negative rate (1 - sensitivity) for HPV PCR analysis for detection of the presence of a cervical HPV-related lesion was 0% (95% confidence interval, 0 to 0.047), and the specificity was 60.7%. In summary, PCR analysis for HPV DNA had a very low false-negative rate for predicting HPV-related lesions of the cervix in a community-based population. This supports the validity of using the absence of HPV at the cervix, as determined by PCR testing, as an inclusion criterion for patients in control groups in studies dealing with low-grade cervical lesions.

Does typing of human papillomavirus assist in the triage of women with repeated low-grade, cervical cytologic abnormalities?

OBJECTIVE

To evaluate the ability of testing for high-risk human papillomavirus (HPV) using the hybrid capture technique to detect cervical intraepithelial neoplasia (CIN) in patients with repeated low-grade cervical cytologic abnormalities and an adequate and normal colposcopy.

METHODS

Hybrid capture testing and LEETZ were performed on 166 women with repeated low-grade cervical cytologic abnormalities who were referred for colposcopy which was to be adequate and normal.

RESULTS

A highly significant correlation (P < 0.0001) was found between a positive test for high-risk HPV types and the finding of CIN II,III. In 67 women with atypical squamous cells of undetermined significance on repeated cytologic studies, a positive test for high-risk HPV types had a sensitivity and specificity of 90 and 96.5%, respectively, for detecting CIN II,III. In 99 patients with low-grade squamous intraepithelial lesions found on repeated cytologic study, a positive test for high-risk HPV types identified all patients as having CIN II,III on cone biopsy (sensitivity, 100%), with a specificity of 86.4%. Restriction of tissue sampling to women who were positive for high-risk HPV types would have reduced the number of tissue samplings performed to 20.4%, while identifying 20 of 21 patients with biopsy-confirmed CIN II, III.

CONCLUSION

A positive hybrid capture test for high-risk HPV types is highly sensitive and specific for detecting CIN II,III in patients with repeated low-grade cervical cytologic abnormalities and an adequate and normal colposcopy and may be used in the triage of these women before performing tissue sampling.

The cost-effectiveness of treating women with a cervical vaginal smear diagnosis of atypical squamous cells of undetermined significance

OBJECTIVE

The purpose was to determine the optimal treatment protocol for women with a cervical vaginal diagnosis of atypical squamous cells of undetermined significance.

STUDY DESIGN

By means of decision analysis, 8 strategies were compared in terms of cost, life expectancy, cost-effectiveness, and the number of cancers and complications from treatment. Data were obtained from the medical literature and the University of Iowa Hospitals and Clinics.

RESULTS

Compared with more aggressive strategies, such as those that use immediate colposcopy, strategies featuring repeated smears were less expensive and carried fewer complications but had lower life expectancies per patient and more cancers. The strategy of repeating a smear annually had a lower cost per patient than did the other strategies, ranging from $112 to $989, and had a similar discounted life expectancy to that of the strategy with the longest discounted life expectancy.

CONCLUSIONS

In most clinical scenarios strategies that used repeated smears were the most cost-effective.

Cervical screening adjuncts: recent advances

In an effort to reduce the false-negative rate of cervical cytologic findings, several new technologies have recently evolved. Automated cytologic testing (PapNet, AutoPap 300 QC) proposes to rescreen negative conventional cytologic findings to identify smears likely to be false negative. Fluid-based monolayers (ThinPrep, CytoRich) propose to reduce the false-negative rates by optimizing the collection and preparation of cells. Human papillomavirus deoxyribonucleic acid testing by Hybrid Capture has been proposed for a variety of screening and triage roles. Visual screening after application of acetic acid is done by cervicography by use of a photographic technique, whereas in speculoscopy the screening is done by direct visualization of the cervix by the primary care provider. Polarprobe uses biophysical parameters and a computer algorithm to give an instantaneous prediction of the likelihood of cervical disease. Each of these techniques, as well as the clinical experience with them, is reviewed. Current and possible future uses are discussed with regard to both clinical usefulness and cost-effectiveness.

Is human papillomavirus testing an effective triage method for detection of high-grade (grade 2 or 3) cervical intraepithelial neoplasia?

OBJECTIVE

Our purpose was to assess the usefulness of the polymerase chain reaction assay for detection of human papillomavirus infection for prognostic value in the triage strategies for high-grade (grade 2 or 3) cervical intraepithelial neoplasia in women referred for colposcopy after abnormal Papanicolaou smears.

STUDY DESIGN

A total of 1007 women referred to a colposcopic clinic providing care for an indigent population were studied. Four hundred fifty-four women were referred after two Papanicolaou smears reported as atypical squamous cells of undetermined significance or low grade-squamous cervical intraepithelial lesion, and 553 were referred after a single smear reported as high-grade squamous intraepithelial lesion. All women had a cervical smear, colposcopy-directed biopsy, and endocervical curettage performed. A sample for human papillomavirus deoxyribonucleic acid detection by polymerase chain reaction was obtained.

RESULTS

High-risk human papillomavirus types were detected in 463 (46%) of 1007 women studied. There was a significant increase of the frequency of high-risk human papillomavirus by the increasing severity of biopsy findings ranging from 32.7% in women without cervical intraepithelial neoplasia on biopsy to 60% in women having grade 2 or 3 on the biopsy specimen. Women having a negative Papanicolaou smear found to have high-risk human papillomavirus deoxyribonucleic acid at the time of colposcopy had a significantly higher rate of grade 2 or 3 cervical intraepithelial neoplasia on the biopsy specimen than did women without high-risk human papillomavirus. There was no such difference observed in women with a cytologic finding of low- or high-grade squamous intraepithelial lesions at the time of colposcopy. The polymerase chain reaction assay appears to be more sensitive than the commercial human papillomavirus profile test. The positive predictive value for grade 2 or 3 cervical intraepithelial neoplasia of both tests was similar (21.7% and 22.8%, respectively).

CONCLUSION

The human papillomavirus is associated with high-grade cervical intraepithelial neoplasia, but the screening for human papillomavirus deoxyribonucleic acid does not have prognostic value in women reported as having atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions on two precolposcopy Papanicolaou smears.

Human papillomavirus detection in cervical intraepithelial neoplasia by the second-generation hybrid capture microplate test, comparing two different cervical specimen collection methods

BACKGROUND

The second generation Hybrid Capture microplate-based human papillomavirus (HPV) test (HC II) was examined to determine its sensitivity for identification of cervical intraepithelial neoplasia (CIN) by two different cervical specimen collection methods.

OBJECTIVES

A cohort of 115 women with a mean age of 34.6 years (SD 9.1), referred to colposcopy with a history of abnormal cytology, was studied to compare HPV prevalence and viral load in low grade CIN vs. high grade CIN.

STUDY DESIGN

Prior to the application of acetic acid, cervical specimens were obtained by either method 1 or 2, as follows: method 1: A cotton-tipped swab was applied to the ectocervix and endocervix for a Papanicolaou (Pap) smear. Next, a special cone-shaped cervical brush was applied to the endocervix, the ectocervix, and to the posterior vaginal vault and suspended in 1.0 ml of transport medium for HPV testing. Method 2: a Pap smear was taken with a cyto standard cylindrical cytology brush from the endocervix, and ectocervix, and the remaining cells were suspended in 3 ml phosphate-buffered saline (PBS) for HPV testing. Next, a Dacron-tipped swab was used to take a specimen from the ectocervix and posterior fornix and suspended in the same PBS solution.

Reflex human papillomavirus deoxyribonucleic acid testing in women with abnormal Papanicolaou smears

OBJECTIVE

The study examined interrelationships between sensitivity and specificity of "reflex human papillomavirus deoxyribonucleic acid testing" from liquid-based cervical cytologic specimens by means of receiver operator characteristics curves.

STUDY DESIGN

A cohort study was performed on 265 women evaluated by colposcopy because of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion found on Papanicolaou smear.

RESULTS

At a positive threshold of 0.2 pg/ml (1000 copies of human papillomavirus per test), human papillomavirus deoxyribonucleic acid testing detected 86% of women with cervical intraepithelial neoplasia and 93% of women with high-grade cervical intraepithelial neoplasia with a specificity of 30%. Decreasing the sensitivity of the human papillomavirus test to 1 pg/ml (5000 copies of human papillomavirus per test) improved the specificity of a positive result to 44% but decreased the clinical sensitivity to 78% for cervical intraepithelial neoplasia grade 2 or 3. Relationships between sensitivity and specificity were influenced by patient age and referral diagnosis. For example, limiting the analysis to only women with a referral for atypical squamous cells of undetermined significance found on Papanicolaou smear and a positive human papillomavirus test threshold of 0.5 pg/ml produced a sensitivity of 90% for cervical intraepithelial neoplasia grade 2 or 3 and a test specificity of 55%.

CONCLUSION

Human papillomavirus deoxyribonucleic acid testing of residual cellular material from liquid cytologic specimens appears to be more appropriate for older women (>30 years old) and women with atypical squamous cells of undetermined significance, as opposed to low-grade squamous intraepithelial lesion, on their Papanicolaou smears.

Human papillomavirus (HPV) DNA assay as an adjunct to liquid-based Pap test in the diagnostic triage of women with an abnormal Pap smear

OBJECTIVE

The diagnostic performance and clinical value of the combined use of liquid-based Pap test and human papillomavirus testing were determined in 336 patients with a previous abnormal smear.

METHOD

Subsequent histologic evaluation was used as definitive diagnosis.

RESULT

The combined use of liquid-based Pap test and HPV DNA testing showed higher rates in sensitivity (99.0%), specificity (59.3%), positive predictive value (89.9%) and negative predictive value (94.5%) than either cytology alone (sensitivity 98.8%, specificity 45.7%, positive predictive value 84.7%, negative predictive value 92.6%) or HPV DNA testing alone (sensitivity 84.9%, specificity 67.4%, positive predictive value 88.8%, negative predictive value 59.5%).

CONCLUSION

The study demonstrated that the diagnostic accuracy for cervical cancer and its precursors was improved by using the liquid-based Pap test as a primary diagnostic procedure and HPV assay as an adjunctive test. This information may assist the clinicians in triaging patients with equivocal cytologic cervical atypias.

HPV-16-related proteins as the serologic markers in cervical neoplasia

OBJECTIVE

Recently, a variety of HPV-related proteins have been synthesized and their utility as diagnostic and prognostic markers in cervical cancers needs to be assessed. The ability to generate preparative amounts of HPV-16 L1/L2 VLPs and E6, E7 proteins may have implications for the development of a serologic assay to detect anti-HPV-16 virion immune responses. The purpose of the study is to improve the way of proper management of the cervical cancer by investigating the utility of the recently developed HPV-16 L1/L2 VLPs, HPV-16 E6, E7 proteins as the clinical serologic markers through antibody reactions by comparison with those of SCCA and CEA which have been used as tumor markers for cervical cancer.

METHODS

The serologic responses in Korean women with cervical neoplasia by ELISA using HPV-16 L1/L2 VLPs and radioimmunoprecipitation assay (RIPA) using in vitro translated HPV-16 E6, E7 proteins were investigated. PCR using E6 type-specific primers for HPV-16/18 was used to determine the presence and type of HPV infection (normal controls, 15 cases; preinvasive lesions, 28 cases; invasive cervical cancers, 124 cases).

RESULTS

The sera of 34% (42/124) of cervical cancers were positive for SCCA and the sera of 18% (22/124) of cervical cancers were positive for CEA. The positivity of SCCA was increased with advancing clinical stages, but the antibody levels were not correlated with clinical stage of disease. The sera of 7% (1/15) of normal controls, 39% (11/28) of preinvasive lesions, and 56% (70/124) of patients with cervical cancer were ELISA positive for HPV-16 L1/L2 VLPs (P < 0.05). The sera of 7% (2/28) of preinvasive lesions and 51% (63/124) of cervical cancers were positive for in vitro translated HPV-16 E6 protein (P < 0.05) and the sera of 11% (3/28) of preinvasive lesions and 33% (41/124) of cervical cancers were positive for in vitro translated HPV-16 E7 protein (P < 0.05). The antibody levels to HPV-16 E7 protein were correlated to clinical stage and tumor burden in a significant number of cervical cancers.

CONCLUSIONS

These data suggest that a considerable number of patients with cervical neoplasia generated positive antibody response to L1/L2 VLPs and in vitro translated E6, E7 proteins of HPV-16. These HPV-16-associated proteins might be disease-specific markers which could be useful in an adjunctive diagnostic assay and a seroepidemiologic study of HPV-related cervical neoplasia. In particular, the monitoring of antibody to HPV-16 E7 protein seems to be valuable in the proper management of cervical cancers for specific tumor markers.

Comparative analysis of human papillomavirus detection by hybrid capture assay and routine cytologic screening to detect high-grade cervical lesions

A commercial HPV detection test, Hybrid Capture (HC), designed to detect 14 HPV types divided into high-risk and low-risk groups, has been evaluated. A total of 1064 scrapes from 1028 unselected women attending routine cytologic screening were tested and results were compared with those of classic cytologic screening and cervical biopsies. The reliability of the test was also evaluated on 38 fresh conization samples. HPV DNA was detected in 108 women (10.5%), including 90 infected by a high-risk HPV (8.8%); 25 high-grade lesions were detected histologically, and high-risk HPV was found in 16 of these 25 women (64%), and in 27 (71%) of the 38 conization samples. The overall sensitivity of HC in detecting high-grade SIL on cervical scrapes and conization samples was 71.2%, while its positive predictive value was 17.8%. Classic cytologic screening appeared to be the most sensitive method (84%) for detecting high-grade SIL, with a positive predictive value of 91.3%. The lower sensitivity of HC limits its use for screening high-grade lesions on a large scale, even though it may be useful for reducing cytologically false-negative results. Moreover, the quantitative approach provided by the HC assay for assessment of the viral load cannot clearly distinguish among cases with or without high-grade lesions.

Evaluation of immunoassays for the detection and typing of PCR amplified human papillomavirus DNA

AIMS

To evaluate different hybridisation techniques to detect and type human papillomavirus (HPV) DNAs amplified by consensus primer polymerase chain reaction (PCR) in biopsy and cytological specimens.

METHODS

A hybrid capture-immunoassay in microtitre wells was performed to detect HPV sequences amplified by PCR and typed by specific oligoprobes. Consensus primers were used to amplify a sequence within the L1 open reading frame, and direct digoxigenin labelling of amplified products was performed during the amplification reaction. The amplified product was separately hybridised with six biotinylated type specific probes (HPV6, 11, 16, 18, 31, and 33); hybrids were then captured into streptavidin coated microtitre wells and detected by a spectrophotometer as an ELISA using antidigoxigenin Fab fragment labelled with peroxidase and a colorimetric substrate. The results were compared with the dot-blot immunoassay used to detect and type PCR amplified HPV DNA sequences. Consensus primers were used to generate the same unlabelled PCR product; digoxigenin labelled type specific probes for HPV6, 11, 16, 18, 31, and 33 were used and hybrids visualised by colorimetric immunoenzymatic reaction. Thirty nine biopsy specimens and 31 cytological samples were tested by the PCR-ELISA and by standard PCR followed by dot-blot hybridisation.

RESULTS

The PCR-ELISA proved to be more sensitive than standard PCR with dot-blot hybridisation typing. All samples positive for HPV-DNA in standard PCR with dot-blot hybridisation method were confirmed positive by the PCR-ELISA assay; however, seven samples were positive only by PCR-ELISA.

CONCLUSIONS

The PCR-ELISA assay, which can be performed in one day, is easily standardised and therefore seems to be a practical, sensitive, and reliable diagnostic tool for the detection and typing of HPV genomes in biopsy and in cytological specimens in the routine diagnostic laboratory.

Efficiency of cytological screening for detection of cervical squamous carcinoma. A study in the county of Uppsala 1991-1994

Squamous carcinoma of the uterine cervix accounts for a considerable mortality among gynecological malignancies, although both the incidence of and mortality from cervical cancer have decreased in the Nordic countries since 1970. The reduction is a result of the cytologic screening program, through which precursor lesions can be detected and removed. Our aim was to determine why women in the county of Uppsala get cervical cancer despite extensive gynecological screening. A retrospective study of all women (43 cases) who developed histologically verified cervical squamous carcinoma in the county of Uppsala during the years 1991 to 1994 was undertaken. A central computer database covering all histopathological and cytological material made it possible to compare each woman's previous smears or lack of smears with her cancer diagnosis. Twenty women (47%, mean age at diagnosis 64.4 years) had not undergone cytological screening. Twenty-three women (53%) had been screened at least once within 6 years before tumor diagnosis. Of these, 11 (mean age 47.5 years) had had normal smears for the last 6 years, 8 (mean age 44.3 years) had shown abnormal cytology for less than one year and 4 (mean age 39.0 years) had shown abnormal cytology for more than one year and up to 6 years before their cervical cancer diagnosis. Women with cervical squamous carcinoma, who are not covered by the gynecological screening program (47%) are at increased risk of developing cervical cancer compared with other women. Consequently the average age of non-screened women developing cancer is considerably higher (64.4 years) than that of women with cancer screened previously (44.9 years). In 26% of the total group of women with cervical squamous carcinoma previous cytology displayed normal features.

Recent advances in thin-layer cytology

In recent years liquid-based cytology has emerged as an alternative to conventional cytopreparatory methods. In particular, the ThinPrep system has found broad acceptance in non-gynecologic cytopreparation. Many laboratories have successfully applied this technique to body fluids (e.g. urine, pleural effusions), brushing samples (e.g. gastrointestinal tract, lung) and fine-needle aspiration. Most comparative studies have shown the ThinPrep system to perform as well as or better than conventional preparations in nongynecologic cytology; plus, the residual cells within the vial can be used for DNA analysis or immunohistochemical and other special studies. Recently, the ThinPrep 2000 system has been approved for use in gynecologic cytology. This approval was based on a large, multicenter clinical study that showed the ThinPrep system to be favored over the conventional Pap smear for the detection of low-grade squamous intraepithelial lesions, or more severe lesions. At screening centers the improved rate of detecting low grade squamous intraepithelial lesions (LSIL) or more severe diagnosis was up to 73%, with an average improvement of 65% as compared to the conventional Pap smears. Also, for specimen adequacy, the ThinPrep method was statistically favored over conventional cytology methods. This multicenter clinical trial demonstrates the ThinPrep 2000 system was more effective than the conventional Pap smear for the detection of atypical cells and cervical cancer and its precursor lesions. In addition, by collecting cells in a liquid-based medium the opportunity is present to improve the Pap test by adjunctive testing for Human Papilloma Virus or other procedures. This creates the opportunity for improved triage and management of patients with cervical abnormalities.

Human papillomavirus testing as triage for atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions: sensitivity, specificity, and cost-effectiveness

OBJECTIVE

Our purpose was to evaluate the cost-effectiveness of the use of a Food and Drug Administration-approved human papillomavirus test in triaging patients with Papanicolaou smears showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion for colposcopy compared with an algorithm that used cytologic follow-up.

STUDY DESIGN

Four hundred sixty-two women referred to our Colposcopy Clinic with a Papanicolaou smear report of atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion underwent repeat Papanicolaou smear, cervical colposcopy, directed cervical biopsy, and endocervical curettage. In addition, human papillomavirus testing by the Food and Drug Administration-approved HPV Profile (Digene Diagnostics, Silver Spring, Md.) test was done. A comparison of sensitivity, specificity, and cost-effectiveness of an algorithm determining the need for colposcopy on the basis of repeat cytologic testing versus an algorithm that incorporated repeat cytologic testing and human papillomavirus screening was done. The cost-effectiveness of both of these triage algorithms was also compared.

RESULTS

As expected, high-risk human papillomavirus deoxyribonucleic acid was detected with greater frequency in relation to increasing severity of cervical intraepithelial neoplasia. In 268 women, the follow-up smear obtained in our clinic was reported as negative. High-risk human papillomavirus types were found in 23.5% of these women. In the human papillomavirus-negative women, 5.9% had grade 2 or 3 cervical intraepithelial neoplasia confirmed on cervical biopsy. In comparison, 20.6% of those with a positive result of the human papillomavirus test had grade 2 or 3 cervical intraepithelial neoplasia on biopsy (p < 0.001). Despite this difference, the sensitivity of a positive result of a high-risk human papillomavirus test in predicting the presence of grade 2 or 3 cervical intraepithelial neoplasia was only 52%. Among the women for whom a follow-up clinic Papanicolaou smear was reported as showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion, there was no difference in the frequency of biopsy-proved grade 2 or 3 cervical intraepithelial neoplasia between those women with a positive human papillomavirus test result and those with a negative test result. Colposcopy would have been recommended for 194 women because of a repeat clinic smear revealing atypical squamous cells of undetermined significance, a low-grade squamous intraepithelial lesion, or a high-grade squamous intraepithelial lesion, and in 21.6% of these grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 63%, specificity 62%). Colposcopy would have been recommended for 180 women because high-risk human papillomavirus or a high-grade squamous intraepithelial lesion was detected at the clinic visit, and in 25% of this group grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 67%, specificity 66%). Sensitivity and specificity were virtually identical for the two algorithms, but the cost of human papillomavirus testing was nearly double that of triage based on repeat cytologic testing alone ($692 vs $1246 per case).

CONCLUSION

The Food and Drug Administration-approved HPV Profile test is not a cost-effective triage for patients referred with Papanicolaou smears reported as showing atypical squamous cells of undetermined significance or low-grade squamous lesions.

Human papillomavirus deoxyribonucleic acid detection in mildly or moderately dysplastic smears: a possible method for selecting patients for colposcopy

OBJECTIVE

Current screening protocols for cervical cancer dictate that patients with smears read as mild or moderate dysplasia of the uterine cervix undergo colposcopy, although approximately half these women do not prove to have high-grade squamous intraepithelial lesions. The aim of this study was to determine whether human papillomavirus testing is capable of discriminating between high- and low-grade squamous intraepithelial lesions so as to be useful in reducing the number of colposcopic examinations.

STUDY DESIGN

We tested 190 consecutive patients with smears read as mild or moderate dysplasia for the presence of human papillomavirus deoxyribonucleic acid by use of two different polymerase chain reactions with the consensus primer pairs CPI/IIG and MY09/11. Typing was carried out by direct sequence analysis of the CPI/IIG amplimers. The MY09/11 amplimers were detected in enzyme-linked immunosorbent assay format with the SHARP (Solution Hybridization Assay for PCR Products) Signal System with two probe mixtures (A and B) to detect nononcogenic and oncogenic human papillomavirus types. The human papillomavirus test results were compared with the histologic diagnosis, which was regarded as the reference standard.

RESULTS

Fifty-six of the 190 patients had high-grade squamous intraepithelial lesions. The sensitivity was 96% for the CPI/IIG test and 95% for the MY09/11 polymerase chain reaction plus SHARP Signal System when probe B only was used. The specificity was 33% for the CPI/IIG test and 40% for the MY09/11 polymerase chain reaction plus SHARP Signal System when probe B was used.

CONCLUSION

A negative CPI/IIG or SHARP Signal System probe B test can select, respectively, 44 or 54 of the 134 patients without high-grade squamous intraepithelial lesions. The use of these human papillomavirus tests as a secondary triage in patients with smears that were read as mild or moderate dysplasia could prevent those patients from undergoing unnecessary colposcopy. However, respectively, 2 or 3 of the 56 patients who have high-grade squamous intraepithelial lesions would be missed by human papillomavirus testing.

Comparison of the hybrid capture tube test and PCR for detection of human papillomavirus DNA in cervical specimens

The strong association of human papillomavirus (HPV) and cervical cancer makes it important to study HPV detection methods that may play a role in cervical cancer screening. We compared two DNA methods that are commonly used for HPV research in the United States: the MY09/MY11 L1 consensus primer PCR-based test and the first-generation Hybrid Capture tube method (HCT). Laboratory assays by each method were performed with 596 cervicovaginal specimens collected from participants in a large cohort study conducted in Portland, Oreg. Included were 499 specimens from women whose cytology was normal and 97 specimens from women with squamous intraepithelial lesions (SILs). The overall HPV DNA positivity for known types was 22.5% by PCR compared to 13.6% by HCT. When the analysis was restricted to the 14 HPV types detectable by both methods, the sensitivity of HCT, with PCR used as the standard for HPV status, was higher for specimens from women with concurrent SILs (81.0%) than for specimens from women with normal cytology (46.7%). Among specimens testing positive by both methods, 97.2% of the time the two methods agreed on whether specimens were positive for cancer-associated HPV types. Both of these HPV test methods provide information that supplements the information provided by the Pap smear. The PCR method has higher analytic sensitivity than HCT in detecting HPV, but HCT may be helpful in identifying women with concurrent SILs.

The future of HPV testing in clinical laboratories and applied virology research

BACKGROUND

Human papillomaviruses (HPV) are now considered etiologic agents of cancer of the uterine cervix. Adjunctive diagnostic procedures for the detection of HPV infection could increase the sensitivity of primary and secondary screening of cervical cancer. HPV testing could also improve the specificity of screening programs resulting in avoidance of overtreatment and saving of costs for confirmatory procedures.

OBJECTIVES

To review the rationale of HPV testing in genital diseases and the potential applications of HPV DNA detection methods for clinical and epidemiological purposes.

RESULTS

Progression of HPV infection is associated with the persistence of HPV infection, involvement of high-risk HPV types, high HPV viral load in specimens, integration of viral DNA and possibly the presence of cofactors. The design of HPV diagnostic tests will need to take into account these parameters of disease progression. HPV DNA detection techniques based on signal-amplification are standardized, commercially available and detect several high-risk HPV types. They increase the sensitivity of screening for high-grade and low-grade lesions. Although they may yield false-negative results in the presence of significant HPV-related disease, new test formats could resolve this weakness. Amplification techniques are ideal instruments for epidemiologic purposes since they minimize misclassification of HPV infection status and allow for the detection of low viral burden infections. They are currently not readily applicable to diagnostic laboratories.

CONCLUSIONS

Before recommending HPV testing, prospective trials of untreated LSIL with HPV testing as well as the determination of the efficacy and cost-effectiveness of novel HPV tests, need to be completed.

Detection of human papillomavirus type 16 early-gene transcription by reverse transcription-PCR is associated with abnormal cervical cytology

Human papillomavirus type 16 (HPV-16) is associated with abnormal Papanicolou smears, indicative of cervical intraepithelial neoplasia. HPV-16 is the most common genital HPV and is found in up to 40% of young women with normal cervical cytology. In order to investigate whether transcriptionally active HPV-16 infection is associated with abnormal cervical smears, a reverse transcription-nested PCR assay with primers from the E5 open reading frame was developed to detect all HPV-16 early-region mRNA (E-mRNA) transcripts. It was used to study HPV-16-infected women with normal and abnormal cervical cytologies to obtain evidence of active infection. Among HPV-16 DNA-positive women, HPV-16 E-mRNA was detected in 15 of 37 (40.5%) women with abnormal cervical cytology but in only 4 of 35 (11.4%) women with normal cytology (P = 0.007). Thus, HPV-16 E-mRNA transcription is associated with abnormal cervical smears and may have value as a prognostic marker of progressive disease.

The frequency of human papillomavirus detection in postmenopausal women on hormone replacement therapy

Postmenopausal women enrolled in the Iowa portion of the postmenopausal estrogen/progestin interventions randomized clinical trial (n = 105) during 1989-1991 were studied for (i) the prevalence of human papillomavirus (HPV) in this older age population (ages 45-64), and (ii) the association between hormone replacement therapies (HRTs) and changes in detection of HPV over a 2-year time period. HPV is causative in most cervical and some other genital cancers and in the presence of steroid hormones has been shown to increase neoplastic transformation by HPV in vitro. Using PCR to detect HPV DNA, the overall frequency of the virus regardless of time period was 50.3% (n = 53) with a baseline (BL) frequency of 38.1% and the second year follow-up (FU) of 22.9%. The oncogenic types HPV-16 (75.5%) and HPV-31 (20.8%) were the most commonly reported. All those with persistently detected infection (10.5%), defined as HPV+ at both BL and FU, were identified with HPV-16 or -18. Between these two time periods there were no significant differences in HPV frequency between the placebo and combined HRT groups (BL-/FU+, 21% vs 18%; BL+/FU-, 71% vs 80%). While the study is based on a small sample, the findings suggest that short-term use of HRTs is not associated with an increased risk of HPV detection, but assessment of effects from long-term use is needed. The data also indicate that the frequency of HPV found in older women is higher than previously suspected but that short-term changes in HPV detected in this age group are unrelated to the development of precancerous cervical lesions.

Diagnosis of human papillomavirus genital tract infection

Although visible anogenital lesions are present in some persons infected with human papillomavirus (HPV), the majority of individuals with HPV genital tract infection do not have clinically apparent disease. Conventional viral detection assays, including serologic assays and growth in cell culture, are not available for the diagnosis and tracking of HPV infection. Papanicolaou tests are a valuable screening tool, but they miss a large proportion of HPV-infected persons. Accordingly, HPV DNA detection assays have become a key research tool in the detection of HPV infection, particularly in asymptomatic individuals. Several types of HPV DNA tests are now available, including Southern blots, dot blots, in situ hybridization, polymerase chain reaction, and solution hybridization (Hybrid Capture assay). Of these, the polymerase chain reaction assay is the most sensitive, whereas dot blots and solution hybridization are the least labor intensive. HPV DNA detection assays are not routinely used in screening patients, in part because the clinical relevance of asymptomatic infection is unclear. Nevertheless, these tests may be beneficial in confirming differential diagnoses and in providing prognostic information, particularly with respect to the HPV type involved.

A sensitive, type-specific, fluorogenic probe assay for detection of human papillomavirus DNA

A simple method for the detection of a number of human papillomavirus (HPV) genotypes associated with cervical cancer has been developed. The assay exploits the 5'-->3' exonucleolytic activity of Taq DNA polymerase to increase the signal from fluorescent dyes by releasing them from genotype-specific probes during PCR. The probes are oligonucleotides with a 5' reporter dye (6-carboxyfluorescein), a quencher dye (6-carboxy-tetramethyl-rhodamine), and a phosphate-blocked 3' end. In the intact probe, the proximity of the reporter and the quencher results in suppression of reporter fluorescence by Förster-type energy transfer (V. T. Förster. Ann. Phys. 2:55-75, 1948). If the probe is bound downstream of either primer during PCR, the 5'-->3' exonucleolytic activity of Taq polymerase degrades it, allowing the reporter to diffuse away from the quencher, which results in an increase in reporter fluorescence. The increased fluorescence is directly related to the amount of target DNA and can be detected with an automated fluorometer. Probes for the L1 region of the cervical-cancer-associated HPV types 16, 18, 31, 33, and 35 were synthesized and the assays were optimized. The most sensitive assay can detect as few as two copies of HPV DNA in human cervical specimens.

A general primer GP5+/GP6(+)-mediated PCR-enzyme immunoassay method for rapid detection of 14 high-risk and 6 low-risk human papillomavirus genotypes in cervical scrapings

Two cocktails of digoxigenin-labeled human papillomavirus (HPV) type-specific oligonucleotide probes and an enzyme immunoassay (EIA) were used as a basis to developed a group-specific detection method for 14 high-risk (types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68) and 6 low-risk (types 6, 11, 40, 42, 43, and 44) HPVs, following a general primer GP5+/bioGP6(+)-mediated PCR. The sensitivity of this high-risk/low-risk (HR/LR) HPV PCR-EIA ranged from 10 to 200 HPV copies, depending on the HPV type. Comparison of HR/LR HPV PCR-EIA with radioactive Southern blot hybridization using a general probe on the same PCR products derived from 417 cytomorphologically abnormal cervical scrapings resulted in an overall agreement of 96% between the two methods. Complete concordance between group-specific HR/LR detection and individual typing results for both single and multiple infections indicate the strong specificity of this HR/LR HPV PCR-EIA. Multiple infections could be predicted by comparing PCR-EIA optical density values of the cocktail probes with one of the individual oligonucleotide probes. This novel HR/LR PCR-EIA allows accurate and rapid identification of high-risk and low-risk HPV types in cervical scrapings and will facilitate HPV detection in HPV mass-screening programs.

Ki-67 antigen staining as an adjunct to identifying cervical intraepithelial neoplasia

The purpose of the work was to determine the feasibility and predictive value of Ki-67 immunostaining of cervical cytology and the detection of cervical dysplasia. Air-dried cervical smears were stained with MIB-1 antibody to identify the Ki-67 antigen. Nuclear decoration in abnormal squamous nuclei determined immunoreactivity. One hundred twenty-four nonpregnant patients underwent colposcopy and directed biopsies for abnormal cytology. Sensitivity (0.89), specificity (0.65), positive predictive value (0.60), and negative predictive value (0.91) were found for Ki-67 immunostaining in detection of high-grade cervical intraepithelial neoplasia (CIN) in 124 patients and positive Ki-67 staining was a significant predictor of high-grade CIN in both univariate (odds ratio 15.5 (95% CI 5.5-43.8) and multivariable (odds ratio 21.5 (95% CI 5.0-92.0) analysis. In 101 patients with ASCUS and LGSIL, Ki-67 immunostaining demonstrated the following in detection of high-grade CIN: sensitivity (0.96), specificity (0.67), positive predictive value (0.49), and negative predictive value (0.98). Ki-67 immunostaining of cervical cytology is a predictor of significant cervical pathology with high sensitivity and negative predictive value. Ki-67 immunostaining of cervical cytology may represent a new and cost-effective triage tool for patients with minor abnormalities on cytology.

Comparison of PCR and hybrid capture methods for detection of human papillomavirus in injection drug-using women at high risk of human immunodeficiency virus infection

We compared Hybrid Capture, a new technique for detection of human papillomaviruses (HPV), with a PCR assay based on L1 consensus primers. By both methods, the HPV prevalence was higher in human immunodeficiency virus (HIV)-positive women than in HIV-negative women. PCR had a higher sensitivity (0.89 versus 0.48) but lower specificity (0.43 versus 0.93) for detection of Pap smear abnormalities, compared to Hybrid Capture. The higher intensity of hybridization signal by PCR was related to higher estimates of viral load by Hybrid Capture.

Relevance of human papillomavirus screening in management of cervical intraepithelial neoplasia

OBJECTIVE

To evaluate the utility of human papillomavirus detection in identifying women with abnormal Papanicolaou smears who can be safely followed up with cytologic study only, we conducted a study to determine the sensitivity, specificity, and negative and positive predictive values of a Food and Drug Administration-approved human papillomavirus test kit for detection of cervical intraepithelial neoplasia in colposcopically directed biopsy specimens.

STUDY DESIGN

We enrolled women with abnormal Papanicolaou smears referred to a colposcopy clinic serving indigent patients. All 1128 women had a referral Papanicolaou smear, a clinic Papanicolaou smear, and a sample for human papillomavirus deoxyribonucleic acid test; 1075 underwent colposcopically directed biopsies and endocervical curettage. We used the HPV Profile kit for human papillomavirus testing.

RESULTS

Of 486 women with low-grade squamous intraepithelial lesions on Papanicolaou smear, 35.4% had high-risk human papillomavirus deoxyribonucleic acid detected, and of 592 with high-grade lesions, 44.4% had high-risk human papillomavirus detected. Among 527 women with biopsy specimens showing cervical intraepithelial neoplasia and in 267 with cervical intraepithelial neoplasia grades 2 or 3, 38.7% and 56.2% had high-risk human papillomavirus deoxyribonucleic acid detected. However, the sensitivity of human papillomavirus deoxyribonucleic acid detection to identify biopsy-confirmed cervical intraepithelial neoplasia grades 2 or 3 was 55.7%, and the positive predictive value of the test was only 34.9%.

CONCLUSION

Human papillomavirus appears to be causally associated with cervical cancer but human papillomavirus screening does not appear to be of value to identify women with abnormal Papanicolaou smears who can be safely followed up with cytologic study alone.

Human papillomaviruses and cervical cancer

Molecular and epidemiological studies conducted over the last 20 years led to the recognition of certain types of human papillomavirus (HPV) as the etiological agents of cervical cancer, a very common neoplasia, particularly in developing countries. More than 70 HPVs have been described, including both cutaneous and mucosal types. About half of the known HPVs, and an even higher number of variants, have been isolated from genital mucosas. The association of certain types primarily with normal tissues and benign lesions, as opposed to cancer-associated types, has led to the concept of low and high oncogenic risk HPVs, respectively. The latter express oncogenic proteins that interfere with cell growth control functions. As a consequence of the continuous expression of these viral genomes, chromosome instability may occur, leading to fully transformed cells. Studies indicate that persistence of high-risk HPVs may determine progression to more severe stages of cervical disease, while the majority of HPV infections are transient and do not seem to be important in cervical carcinogenesis. The risk for disease progression seems also to be associated with viral burden. Prospective epidemiological studies will contribute to the knowledge of the natural history of HPV infections and provide information on the determinants of viral persistence. Data derived from these studies may define the clinical utility of HPV testing and its use in cervical cancer prevention programs.

Prospects for automated cytology

Rescreening of Pap smears using automated devices offers the ability to re-examine Paps initially interpreted as within normal limits and to use cell-sorting technology to increase the detection of missed abnormal smears. Only recently has the development of high-resolution imaging techniques and advances in computer sciences and cell classifiers enabled investigators to achieve sensitivity and specificity levels in automated screening and quality control devices.

Tissue effects and host response. The key to the rational triage of cervical neoplasia

Genital HPV infections are associated with a spectrum of lesions ranging from benign condylomata to invasive cancer and its precursor lesions. The transformation zone of the cervix is the most frequent target of the high-risk HPV types. Depending on the nomenclature used, cancer precursors are subdivided on the basis of their morphologic presentation into dysplasias (mild, moderate, and severe); cervical intraepithelial neoplasias (CIN I, II, and III); or low-grade and high-grade squamous intraepithelial lesions (LGSILs and HGSILs). The HGSILs (i.e., moderate and severe dysplasias, CIN II and III lesions) are recognized universally as cancer precursors. The LGSILs (i.e., very mild dysplasia and mild dysplasias, condylomata and CIN I lesions), have shown that one of the most important denominators of their cancer potential is the presence of intermediate and particularly high-risk HPV types. HPV typing provides the most rational basis for selecting women with LGSILs to be colposcoped and treated or given follow-up treatment with Pap smears. Until the clinical significance of HPV typing is known, management decisions may be based on an individual's risk factors such as age, compliance, past history of abnormal Pap smears, sexual habits, and access to adequate cytologic diagnosis.

Screening and epidemiological trends in cervical cancer

The developed or less developed countries where basic conditions for the screening of cervical cancer are quite different in terms of essential factors such as accuracy of cytology, cost effectiveness and development of new methods of diagnosis. Considering these factors the screening program made by annual Pap smear with adjunctive cervicography and HPV DNA test in the women aged from 20 to 69 years may have universal validity.

Hybrid Capture method for detection of human papillomavirus DNA in clinical specimens: a tool for clinical management of equivocal Pap smears and for population screening

High- and intermediate-risk types of human papillomavirus (HPV) in concert with cofactors are responsible for over 90% of cervical cancers world-wide. While the Pap smear is a valuable cancer prevention tool, its subjective nature leaves it error prone. As a result, HPV DNA testing appears to be a needed adjunct to the Pap smear. Hybrid Capture is a simple DNA test with high specificity and sensitivity which appears useful for clinical management of equivocal Pap tests and shows promise for mass screening.

Clinical role of HPV testing

The subjectivity of morphologic methods contributes to a "swamping" of colposcopic services, excessive costs, overdiagnosis, and overtreatment. HPV DNA testing provides the objectivity required to clarify difficult patient management issues, including follow-up, for low-grade cytologic abnormalities (ASCUS and LSIL), noncorrelating (nonconfirmed) Pap smears, evaluation of nondiagnostic lower genital tract lesions, and cytology and histology laboratory quality assurance. Additionally, favorable preliminary data on HPV testing as a primary screen raise the exciting prospect of potentially lowering costs of cervical cancer-screening programs, while further decreasing the incidence of cervical cancer.

Oncogenic human papillomaviruses and ploidy in cervical lesions

AIM

To compare ploidy measurements obtained on tissue sections of selected low and high grade squamous intraepithelial lesions containing oncogenic HPV (types 16, 18 or 33) detected by in situ hybridisation (ISH) or PCR.

METHODS

DNA ploidy was assessed by image cytometry after Feulgen staining of contiguous serial sections of eight lesions exhibiting atypical squamous cells or squamous atypia and 53 low and 63 high grade squamous intraepithelial lesions in which HPV had been detected by ISH or PCR.

RESULTS

Aneuploidy was strongly associated with the presence of oncogenic HPV, being detected in 50% of lesions with squamous atypia and 75.5% of the low and 95.2% of the high grade squamous intraepithelial lesions. The multiploid profile was highly associated with high grade lesions and with the pattern of HPV DNA integration.

CONCLUSIONS

The presence of aneuploidy is strongly suggestive of the presence of oncogenic HPV types. Combining the detection of HPV by ISH and PCR with DNA image cytometry may provide the pathologist and the physician with important prognostic information about low grade lesions, especially when these lesions have a multiploid DNA profile and contain oncogenic HPV.

Atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion: diagnostic criteria and management

Since institution of the Bethesda system for reporting cervical and vaginal smears, there has been an increase in the number of smears reported to demonstrate atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions. The cytologic changes associated with a smear reported to have these cells are discussed. It is apparent that the interpretation of the cellular changes defined as atypical squamous cells of undetermined significance are not clear and that there is a significant variation among cytopathologists as to the cytologic changes that should be incorporated under this classification. Data are presented on the frequency of this diagnosis in our laboratory and of the follow-up findings observed in a subgroup of patients whose smears were reported to demonstrated atypical squamous cells of undetermined significance. The cytologic and histopathologic changes observed with smears reported as demonstrating findings compatible with a low-grade squamous intraepithelial lesion are also discussed. A follow-up algorithm for the management of such patients is presented.

Diagnostic performance of Hybrid Capture human papillomavirus deoxyribonucleic acid assay combined with liquid-based cytologic study

OBJECTIVE

Our purpose was to determine the diagnostic performance of human papillomavirus deoxyribonucleic acid testing when performed on liquid-based (Thin-prep) cytologic samples.

STUDY DESIGN

Thin-prep cytologic study, human papillomavirus deoxyribonucleic acid assay with probes for high oncogenic risk human papillomavirus types (16, 18, 31, 33, 35, 45, 51, 52, and 56), and cervical biopsies on women referred to colposcopy for an abnormal Papanicolaou smear were performed.

RESULTS

Of the 364 patients, 186 (51.6%) had a low-grade squamous intraepithelial lesion or worse by histologic diagnosis. Human papillomavirus deoxyribonucleic acid quantitation was correlated with a histologic diagnosis of squamous intraepithelial lesion (p < 0.0001) and the morphologic severity (p < 0.01). The combination of Thin-prep cytologic study and human papillomavirus deoxyribonucleic acid testing correctly identified 87.7% of histologic low-grade lesions and 95.1% of the women with high grade lesions and invasive cancer (p < 0.01).

CONCLUSIONS

A liquid-based cytologic system provides adequate material for concomitant human papillomavirus testing. Addition of human papillomavirus testing to Thin-prep cytologic study provides significant gains in diagnostic accuracy over either cytologic study or human papillomavirus deoxyribonucleic acid testing alone.

HPV testing in patients with low grade cervical cytological abnormalities: a follow up study

AIM

To assess the diagnostic performance of human papillomavirus (HPV) analysis in predicting cervical intraepithelial neoplasia (CIN) grades 2 and 3 in patients with persistent low grade cervical cytological abnormalities.

METHODS

Cervical smears from 167 women referred for colposcopy with persistent borderline, wart virus or mildly dyskaryotic changes on cervical screening were analysed by Papanicolaou staining, non-isotopic in situ hybridisation and generic and type specific polymerase chain reaction (PCR) amplification of HPV sequences. Follow up was by cytological and, where appropriate, histological analysis.

RESULTS

CIN grade 2 or 3 was identified in 46 patients after a median follow up of 27 months. HPV positivity by both techniques was associated with high grade CIN and with age less than 30 years (median age 33 years). Non-isotopic in situ hybridisation was more predictive but less sensitive than either generic or type specific PCR, but prediction was greater using either molecular technique in women over 30 years of age.

CONCLUSIONS

Although the degree of prediction found is of only limited clinical value, the strong association of HPV positivity with both high grade CIN and patient age suggests that further studies of HPV testing in this patient group are warranted.

Screening for cervical intraepithelial neoplasia grade 2/3: validity of cytologic study, cervicography, and human papillomavirus detection

OBJECTIVE

A commercial test for human papillomavirus detection (hybrid capture assay) was examined for its potential value to augment the sensitivity of cytologic study or cervicography for screening for cervical intraepithelial neoplasia grade 2/3.

STUDY DESIGN

In a cohort of 967 women with a mean age of 37.1 years who underwent routine cytologic screening, cytologic examination, cervicography, and testing for high-risk human papillomavirus by the hybrid capture assay were compared for their ability to detect cervical intraepithelial neoplasia grade 2/3. Cervical punch biopsy specimens were taken in 20.5% (198/967) patients because they had an atypical or positive cervigram or abnormal cytologic results in the primary screening smears. The data were analyzed by two-tailed chi(2) and Fisher's exact test.

RESULTS

Thirty-eight patients were diagnosed with cervical intraepithelial neoplasia grade 2/3 (prevalence 3.9%) by histologic study. Cytologic study identified 29%, cervicography 45%, and testing for high-risk human papillomavirus 50% of cervical intraepithelial neoplasia grade 2/3. When combined, detection of high-risk human papillomavirus or cervicography augmented sensitivity of cytologic study to 58% (p = 0.01) with positive predictive values of 23% and 17%, respectively. Results of the different techniques should be interpreted in relationship to each other and not as absolute values because collection of specimens for cytologic study was done with cotton swabs, which may be suboptimal for screening but is general practice in Germany.

CONCLUSIONS

Screening for cervical intraepithelial neoplasia grade 2/3 can significantly be improved by human papillomavirus testing with the hybrid capture assay.