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Bruno MT, Valenti G, Cavallaro AG, Palermo I, Aiello T, Farina J, Panella MM, Mereu L. Extended Genotyping to Stratify the Risk of CIN2+ in Women with Persistent HPV Infection, Negative Cytology and Type 3 Transformation Zone. Cancers (Basel) 2024; 16:1816. [PMID: 38791895 PMCID: PMC11119326 DOI: 10.3390/cancers16101816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Persistent human papillomavirus (HPV) infection is recognized as a major risk factor for cervical cancer. Women with persistent HPV and negative cytology are at greater risk of CIN2+ than women with negative infection. The diagnosis becomes more complicated when the woman has a type 3 transformation zone at colposcopy. The aim of this study was to determine the prevalence of CIN2+ in women with persistent HPV, negative cytology and TZ3; how to stratify the risk of CIN2+; and what the best diagnostic strategy is, given TZ3. METHODS In a multicenter retrospective cohort study, we enrolled women with negative cytology and TZ3 among the 213 women referred for colposcopy for persistent HPV. The average age of the women was 53 years; in particular, 83% were postmenopausal women. In the presence of a TZ3, the entire transformation zone cannot be explored, making colposcopy and targeted biopsy useless and inadequate, with great risks of underdiagnosis or missed diagnosis. Women with TZ3 underwent diagnostic LEEP to ensure correct diagnoses. RESULTS The study highlighted 19% (16/84) of CIN2+ lesions, a higher frequency of non-HPV 16/18 genotypes (76.2%), and 50% of CIN2+ lesions being due to non-HPV 16/18 genotypes. Furthermore, more than half of the women (80.9%) had normal histopathological results in the LEEP sample. CONCLUSION Women with viral persistence, negative cytology, and TZ3 have a 19% risk of CIN2+; genotyping helps stratify risk, but extensive genotyping is necessary instead of partial genotyping (16/18), referring to a population of women over 50 years old in which the prevalence of genotypes 16,18 decreases and the prevalence of other genotypes increases; diagnostic LEEP is excessive (only 16 cases of CIN2+ out of 48 cases treated), even though 83% of women had viral clearance after LEEP; p16/Ki67 double staining could be a potential risk marker, which would only highlight women at risk of CIN2+ to undergo LEEP. To individualize the diagnostic workup and treatment and minimize the risk of under diagnosis and overtreatment, future studies should explore the use of extended genotyping and new biomarkers for individual risk stratification.
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Affiliation(s)
- Maria Teresa Bruno
- Gynecology and Obstetrics Unit, Department of General Surgery and Medical-Surgical Specialty, Rodolico University Hospital, University of Catania, 95123 Catania, Italy; (A.G.C.); (M.M.P.); (L.M.)
- Multidisciplinary Research Center in Papillomavirus Pathology, Chirmed, University of Catania, 95123 Catania, Italy
| | - Gaetano Valenti
- Humanitas, Gynaecologic Oncology Unit, 95100 Catania, Italy;
| | - Antonino Giovanni Cavallaro
- Gynecology and Obstetrics Unit, Department of General Surgery and Medical-Surgical Specialty, Rodolico University Hospital, University of Catania, 95123 Catania, Italy; (A.G.C.); (M.M.P.); (L.M.)
| | - Ilenia Palermo
- Virology Unit, Rodolico Polyclinic, 95123 Catania, Italy;
| | - Tiziana Aiello
- Gynecology and Obstetrics Unit, Department of General Surgery and Medical-Surgical Specialty, Rodolico University Hospital, University of Catania, 95123 Catania, Italy; (A.G.C.); (M.M.P.); (L.M.)
| | - Jessica Farina
- Section of Anatomic Pathology, Department of Medical Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Marco Marzio Panella
- Gynecology and Obstetrics Unit, Department of General Surgery and Medical-Surgical Specialty, Rodolico University Hospital, University of Catania, 95123 Catania, Italy; (A.G.C.); (M.M.P.); (L.M.)
- Multidisciplinary Research Center in Papillomavirus Pathology, Chirmed, University of Catania, 95123 Catania, Italy
| | - Liliana Mereu
- Gynecology and Obstetrics Unit, Department of General Surgery and Medical-Surgical Specialty, Rodolico University Hospital, University of Catania, 95123 Catania, Italy; (A.G.C.); (M.M.P.); (L.M.)
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Kuenkel E, Jaeger A, Bohlmann I, Bergauer F, Kuehler-Obbarius C, Prieske K, Maass-Poppenhusen K, Schmalfeldt B, Woelber L. The use of colposcopy for triage in HPV-positive women aged 65 years and older. Arch Gynecol Obstet 2024; 309:1561-1567. [PMID: 38081959 PMCID: PMC10894107 DOI: 10.1007/s00404-023-07281-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/22/2023] [Indexed: 02/25/2024]
Abstract
PURPOSE Persistent high-risk HPV infection is associated with an elevated risk for prevalent CIN II + despite normal cytology (NILM). Our study aims to evaluate the clinical relevance of a persistent high-risk HPV infection without cytologic changes in women aged ≥ 65 and to determine the role of colposcopy for triage in these cases. METHODS 211 patients aged ≥ 65 with persistent HPV infection and normal cytology (NILM) who presented for colposcopy at five certified centers between January 2021 and April 2022 were included in the study. Colposcopic findings, HPV subtypes, when available, histology and p16/Ki67 staining were assessed as well as individual risk factors such as smoking and previous HPV-related surgery. RESULTS 87.7% (185/211) of the included women had a type 3 transformation zone. In 83.4% (176/211), a biopsy was taken [thereof 163 endocervical curettages (ECC)]. In 35/211 women (16.6%), sampling was not possible during colposcopy due to an inaccessible cervix, pain during examination or obliteration of the cervical canal. Out of these, 6 women received a diagnostic excision. CIN II + was detected in 10.6% of all histologies (excisional or biopsy) (20/182). 50% of the women with a CIN II + where HPV 16 positive. Taking only the women diagnosed with CIN III or AIS into account, (n = 12) 75% were HPV 16 positive. Interestingly, 80% of the women with CIN II + had an abnormal cytology when repeatedly taken during colposcopy, vice versa an endocervical lesion was diagnosed in 53% of women with abnormal repeat cytology (27/51). CONCLUSION The prevalence of CIN II + in women is ≥ 65 with persistent hr HPV infection but NILM cytology is similar to that in younger women. However, more than 85% of the women have a type 3 transformation zone. Colposcopy is, therefore, not helpful to diagnose the women who need treatment in this age group.
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Affiliation(s)
- E Kuenkel
- Dysplasia Unit Women's Practice Heussweg, Frauenarztpraxis und Dysplasie-Einheit Heussweg, Heussweg 37, 20255, Hamburg, Germany.
| | - A Jaeger
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Dysplasia Unit at Jerusalem Hospital, Moorkamp 2-6, 20357, Hamburg, Germany
| | - I Bohlmann
- Dysplasia Munich, Nymphenburger Str. 77, 80636, Munich, Germany
| | - F Bergauer
- Dysplasia Munich, Nymphenburger Str. 77, 80636, Munich, Germany
| | - C Kuehler-Obbarius
- Dysplasia Unit Women's Practice Heussweg, Frauenarztpraxis und Dysplasie-Einheit Heussweg, Heussweg 37, 20255, Hamburg, Germany
- Cytologylaboratory Dr. Med. Kühler-Obbarius, Fangdieckstr. 75a, 22547, Hamburg, Germany
| | - K Prieske
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Dysplasia Unit at Jerusalem Hospital, Moorkamp 2-6, 20357, Hamburg, Germany
| | - K Maass-Poppenhusen
- Department of Gynecology, University Hospital Campus Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany
| | - B Schmalfeldt
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - L Woelber
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Dysplasia Unit at Jerusalem Hospital, Moorkamp 2-6, 20357, Hamburg, Germany
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Wittenborn J, Flasshove EM, Kupec T, Najjari L, Stickeler E, Maurer J. A Glimmer of Hope for Patients with a T3 Transformation Zone: miRNAs Are Potential Biomarkers for Cervical Dysplasia. Diagnostics (Basel) 2023; 13:3599. [PMID: 38132183 PMCID: PMC10742976 DOI: 10.3390/diagnostics13243599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND This pilot study assesses the potential use of miRNAs in the triage of colposcopy patients with type 3 (nonvisible) cervical transformation zone (TZ). Type 3 TZ is a constitutional finding associated with many problems and controversies in colposcopy patient management. Here, we present miRNAs as a potential biomarker for the detection of CIN3 in these cases. MATERIALS AND METHODS Cervical mucosa samples (CMS) were collected from patients presenting with T3 transformation zone during routine workup using the Cytobrush. Depending on the histological and cytological result, as well as the result of the routinely performed HPV PCR, patients were divided into three groups: patients with a high-grade intraepithelial lesion (CIN3) and a positive high-risk HPV test (CIN3 group), patients without an intraepithelial lesion and a positive high-risk HPV test (HPV group), and healthy controls (N = no intraepithelial lesion and negative HPV test). The cervical mucus samples included in the study were tested for their expression levels of distinct miRNAs using qPCR. RESULTS All investigated miRNAs were consistently detectable in every sample. The CMSs of histologically graded CIN 3 showed consistently high expression levels of all eight miRNAs, whereas the CMSs from healthy patients (N) show generally lower expression levels. However, CMSs from patients of the HPV group represented a very heterogeneous group. CONCLUSIONS The data presented here can provide a solid basis for future research into a triage test for patients with a T3 transformation zone on the basis of commonly used clinical equipment.
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Affiliation(s)
- Julia Wittenborn
- Department of Obstetrics and Gynecology, University Hospital of the RWTH Aachen, 52074 Aachen, Germany (J.M.)
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Wei B, Li Q, Seery S, Qiao Y, Jiang Y. Endocervical curettage for diagnosing high-grade squamous intraepithelial lesions or worse in women with type 3 transformation zone lesions: a retrospective, observational study. BMC Womens Health 2023; 23:245. [PMID: 37161558 PMCID: PMC10170824 DOI: 10.1186/s12905-023-02297-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/21/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND This study aimed to assess the value of endocervical curettage (ECC) in detecting high-grade squamous intraepithelial lesion or worse (HSIL+) in women with type 3 transformation zone (TZ3) lesions, and to identify the clinical characteristics of patients with TZ3 lesions who benefit most from ECC. METHODS This retrospective, multicenter study included 1,905 women with TZ3 lesions who attended cervical screening in one of seven tertiary hospitals in China between January 2020 and November 2021. All participants had received abnormal results and had been referred to colposcopy. Risk factors were identified through univariate and multifactorial logistic analyses. RESULTS In total, 20.5% (n = 391) of HSIL+ cases with TZ3 lesions had been diagnosed with biopsy and ECC. ECC detected 0.8% (n = 15) HSIL+ cases otherwise missed by biopsy alone. Multivariate analysis identified four factors which influenced detection performance. The probability of detecting HSIL+ with ECC is 2.653 (95% confidence interval [CI] 1.009-6.977) times greater in women aged 40-49 years and 2.545 (95% CI 0.965-6.716) times greater for those aged 50 years and older compared to those younger than 30 years. The probability of ASC-H (atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion) and HSIL cytologies were respectively 2.415 (95% CI 1.213-4.808) and 2.933 (95% CI 1.648-5.220) times higher than for NILM (negative for intraepithelial lesion or malignancy). Women with human papillomavirus 16/18 infections were 2.299 (95% CI 0.942-5.613) times more likely to be HSIL+. Precancerous lesions were 35.884 (95% CI 12.214-105.426) times more likely in women who had high-grade colposcopic impressions compared to those with normal impressions. CONCLUSIONS ECC should be performed for patients with ASC-H or HSIL cytologies, human papillomavirus 16/18 infections, and for those with high-grade colposcopic impressions. This will increase the number of HSIL+ cases identified using biopsy by reducing the number of false negatives.
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Affiliation(s)
- Bingrui Wei
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Qing Li
- Diagnosis and Treatment for Cervical Lesions Center, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen, 518028, China
| | - Samuel Seery
- Faculty of Health and Medicine, Division of Health Research, Lancaster University, Lancaster, LA1 4YW, UK
| | - Youlin Qiao
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yu Jiang
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Gustafson LW, Hammer A, Bennetsen MH, Kristensen C, Majeed H, Petersen LK, Andersen B, Bor P. Cervical intraepithelial neoplasia in women with transformation zone type 3: cervical biopsy versus large loop excision. BJOG 2022; 129:2132-2140. [PMID: 35488417 PMCID: PMC9796102 DOI: 10.1111/1471-0528.17200] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To compare the proportion of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) in cervical biopsies with that in large loop excision of the transformation zone (LLETZ) specimens in women aged ≥45 years with transformation zone type 3 (TZ3). DESIGN Multicentre cross-sectional study. SETTING Three colposcopy clinics in the Central Denmark Region. POPULATION Women aged ≥45 years referred to colposcopy as a result of a positive human papillomavirus (HPV) test and/or abnormal cytology and with TZ3 at colposcopy. METHODS Women had multiple biopsies taken and an LLETZ was performed. MAIN OUTCOME MEASURES Histologically confirmed CIN2+ in biopsies compared with that in LLETZ specimens. RESULTS Of 166 eligible women at colposcopy, 102 women with paired data from biopsies and LLETZ specimens were included for final analysis. The median age was 67.7 years (IQR 62.6-70.4 years), and most were postmenopausal (94.1%) and had undergone HPV-based screening (81.3%). The CIN2+ detection rate was significantly higher in LLETZ specimens than in biopsies (32.4% vs 14.7%, difference 17.7%, 95% CI 6.3-29.0%), resulting in more than half of CIN2+ cases being missed in biopsies (54.5%, 95% CI 36.4-71.9%). The overall agreement between biopsies and LLETZ was 82.4% (95% CI 73.6-89.2%). CONCLUSIONS CIN2+ detection is underestimated in women aged ≥45 years with TZ3 if detection relies on the results of biopsies alone. To reduce the risk of underdiagnosis and overtreatment, future studies should explore the use of new biomarkers for risk stratification to improve discrimination between women at increased risk of CIN2+ who need to undergo LLETZ and women who may undergo follow-up.
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Affiliation(s)
- Line Winther Gustafson
- Department of Public Health Programmes, Randers Regional HospitalUniversity Research Clinic for Cancer ScreeningRandersDenmark,Department of Clinical MedicineAarhus UniversityHerningDenmark
| | - Anne Hammer
- Department of Clinical MedicineAarhus UniversityHerningDenmark,Department of Obstetrics and GynaecologyGødstrup HospitalHerningDenmark
| | | | | | - Huda Majeed
- Department of Obstetrics and GynaecologyViborg Regional HospitalViborgDenmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and GynaecologyOdense University HospitalOdenseDenmark,Open Patient data Explorative Network, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Berit Andersen
- Department of Public Health Programmes, Randers Regional HospitalUniversity Research Clinic for Cancer ScreeningRandersDenmark,Department of Clinical MedicineAarhus UniversityHerningDenmark
| | - Pinar Bor
- Department of Clinical MedicineAarhus UniversityHerningDenmark,Department of Obstetrics and GynaecologyRanders Regional HospitalRandersDenmark
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Hermansson RS, Olovsson M, Gustavsson I, Gyllensten U, Lindkvist O, Lindberg JH, Lillsunde-Larsson G, Lindström AK. Incidence of oncogenic HPV and HPV-related dysplasia five years after a negative HPV test by self-sampling in elderly women. Infect Agent Cancer 2022; 17:42. [PMID: 35922825 PMCID: PMC9351123 DOI: 10.1186/s13027-022-00453-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 07/26/2022] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Cervical cancer prevention for older women can be challenging since there are no specific guidelines for this group. This study aimed to determine the incidence of oncogenic HPV and HPV-related dysplasia in elderly women 5 years after being HPV negative. METHODS Invited women participated five years earlier in a study where self-sampling for HPV testing was applied, at this time, they were all HPV negative. The women were now, five years later invited to perform self-sampling for HPV testing. Women with a positive result performed a repeat HPV test. Those with a positive repeat HPV test were examined by colposcopy, biopsy and cytology. RESULTS Of the 804 invited women, 634 (76.9%) agreed to participate in the study and a self-sampling kit was sent to them. Of these, 99.6% (632/634) sent a sample to the HPV laboratory. The participation rate in each age group was 93.3% at age 65, 74.0% at age 70, 80.7% at age 75 and 64.6% at age 80. Overall 18 women (2.8%, 95% CI 3.2 to 6.0) were HPV positive in the first test and 8 (1.3%, 95% CI 0.6 to 2.6) in the second test. Sampling for the second test was done on average 5.4 months after the first test. Fifty per cent (4/8) of the women with a positive repeat test had dysplasia in histology. CONCLUSION The incidence of HPV in previously HPV-negative elderly women was low. Among women who were HPV positive in a repeat test, there was a high prevalence of low grade dysplasia.
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Affiliation(s)
- Ruth S Hermansson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden. .,Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Matts Olovsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Inger Gustavsson
- Department of Immunology, Genetics, and Pathology, Uppsala University, Uppsala, Sweden
| | - Ulf Gyllensten
- Department of Immunology, Genetics, and Pathology, Uppsala University, Uppsala, Sweden
| | - Olga Lindkvist
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | - Gabriella Lillsunde-Larsson
- Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,School of Health Sciences, Örebro University, Örebro, Sweden
| | - Annika K Lindström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Lannér L, Lindström AK. Incidence of HPV and HPV related dysplasia in elderly women in Sweden. PLoS One 2020; 15:e0229758. [PMID: 32196503 PMCID: PMC7083300 DOI: 10.1371/journal.pone.0229758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 02/14/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND About one-third of the cervical cancer cases in Sweden occur in women over the age of 60. The primary aim of this study was to analyze the incidence of HPV, and HPV related dysplasia, in elderly women who had an HPV negative test at the age of 60 years or older. METHODS From October 2004 to June 2019, 1784 women aged 60-90 years were sampled for an HPV test when attending an outpatient gynecology clinic. Of these women, 827 HPV-negative women had two or more HPV tests at intervals of three months to eleven years (mean 3.2 years). The women with positive results had a repeat HPV test and cytology after 2.5 months on average. Those with a positive repeat HPV test were examined by colposcopy and biopsy. FINDINGS The overall prevalence of HPV was 5.4%, (95%CI 4.4-6.6, 96/1784). The incidence of HPV in the 827 women, who were HPV negative in their first test, was 2.4% (95%CI 1.5-3.8, n = 20). At the repeat test 1.2% remained positive (95%CI 0.6-2.3, n = 10). HPV-related dysplasia diagnosed by histology was found in 1.2% (95%CI 0.6-2.3, n = 10) of the 827 women. CIN2+ was found in 0.5% (95%CI 0.2-1.3, n = 4). In the repeat HPV test 52.6% 10/19) were HPV positive. The time between an HPV negative test and an HPV positive test and CIN2+ was on average 45.5 months (range 10-85 months). The positive predictive value (PPV) for CIN2+ was 20.0% in the first positive HPV test and 40.0% in the repeat HPV test. The women with CIN2+ had normal cytology. No cancer or glandular dysplasia was detected. INTERPRETATION In this study older HPV-negative women were at risk of becoming HPV positive. Among the women who were HPV positive in a repeat test, there was a high risk of dysplasia.
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Affiliation(s)
- Lars Lannér
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Annika Kristina Lindström
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Clinical Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- * E-mail:
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