The role of p16(INK4a) immunostaining in the risk assessment of women with LSIL cytology: a prospective pragmatic study

BACKGROUND

The detection of high-grade cervical intraepithelial neoplasia (CIN2 or worse) among patients with low-grade cytology (LSIL) is challenging. The aim of this study was to assess the efficacy of p16(INK4a) in the risk assessment of women with LSIL cytology.

METHODS

Consecutive liquid-based cytology specimens of 95 LSIL smears were selected and stained for p16(INK4a). All patients had colposcopically directed punch biopsies or large loop excision of the transformation zone of the cervix. The endpoint was detection of a biopsy-confirmed CIN2 or worse.

RESULTS

The overall sensitivity and specificity of p16(INK4a) for diagnosis of CIN2+ among LSIL smears were 41% and 86%, respectively. The positive predictive value of the biomarker was 62% and the negative predictive value 72%.

CONCLUSIONS

The study shows that p16(INK4a) has low sensitivity but acceptable specificity for evaluation of LSIL smears harbouring high-grade lesions. The marker needs to be further assessed as an adjunct to other tests in an attempt to improve the triage of LSIL cytology smears.

High-risk human papillomavirus DNA test and p16(INK4a) in the triage of LSIL: a prospective diagnostic study

OBJECTIVE

The detection of high-grade cervical intraepithelial neoplasia (CIN) amongst patients with low-grade cytology (LSIL) is challenging. This study evaluated the role of high-risk HPV (HR-HPV) DNA test and p16(INK4a) immunostaining in identifying women with LSIL cytology at risk of harboring CIN2 or worse (CIN2+) and the role of p16(INK4a) in the triage of a population of HR-HPV positive LSIL.

METHODS

We conducted a prospective study including women with LSIL cytology. Detection of HR-HPV was carried out by means of a polymerase chain reaction based assay. p16(INK4a) immunostaining was performed using the Dako CINtec cytology kit. All patients had colposcopically directed punch biopsies or large loop excision of the transformation zone of the cervix. The endpoint was detection of a biopsy-confirmed CIN2+.

RESULTS

A series of 126 women with LSIL cytology were included. HR-HPV test had sensitivity 75% and specificity 64% for an endpoint of CIN2+. p16(INK4a) had significantly higher specificity of 89% (p=0.0000) but low sensitivity of 42%. The role of p16(INK4a) immunostaining in the triage of LSIL positive for HR-HPV was also evaluated. p16(INK4a) triage had 70% positive predictive value (PPV); however, this was not significantly higher than the PPV (56%) of HR-HPV test alone (p=0.4).

CONCLUSIONS

The results indicate that HR-HPV or p16(INK4a) cannot be used as solitary markers for the assessment of LSIL. The addition of p16(INK4a) immunostaining led to an increase in HR-HPV specificity; however, the biomarker needs to be assessed further to establish its role as an adjunct test in the triage of LSIL.

Clinical management of HPV-related disease of the lower genital tract

Cytology remains the mainstay for cervical screening. The need to achieve effective management, limit complications, and preserve reproductive function led to the popularity of local treatment. Although the cure rates for ablative and excisional methods are similar, the excisional method provides a more reliable histopathological diagnosis. Recent evidence revealed increased perinatal morbidity after treatment that appears to be related to the proportion of cervix removed. The human papillomavirus (HPV) DNA test appears to enhance the detection of disease in primary screening, in the triage of minor cytological abnormalities, and in follow-up. Further research on the clinical application of a scoring system is ongoing. The vaccines are now available and appear to be safe, well tolerated, and highly efficacious in HPV naive women. A synergy of vaccination and screening will be required. Treatment for early cervical cancer is increasingly shifting toward more fertility-sparing surgical techniques. Careful selection of patients is essential.

Pregnancy-associated breast cancer--a review analysis

The aim of the present review was to assess the relationship between pregnancy and/or lactation and breast cancer, the influence of pregnancy on mortality and prognosis of the disease, the consequences of breast cancer to the current pregnancy and also to discuss the future perspective for women's fertility.

MATERIALS AND METHODS

Articles were obtained from Medline (1988 present) using as keywords breast cancer, pregnancy, breastfeeding, lactation, carcinoma and pregnancy.

RESULTS

Unfortunately, delays in diagnosis and treatment are common during pregnancy and the prognosis is thus worsened. Nulliparity, early menarche and late age at first pregnancy are associated with increased risk for breast cancer. Breastfeeding confers a protective effect on risk of breast cancer, which appears to be related to the duration of breastfeeding. In cases of advanced metastatic disease during the first 14 to 15 weeks of pregnancy when chemotherapy is necessary for prompt treatment, termination of pregnancy may be proposed, particularly if the patient is ER-positive. Modified radical mastectomy is probably the procedure most frequently used today. In general chemotherapy should be delayed until after 14 to 15 weeks of gestation and radiation should be reserved until post delivery. Several authorities generally advise that future pregnancy should be delayed for at least two years after breast cancer treatment.

CONCLUSION

Breast cancer has an equivalent prognosis in pregnant and non pregnant patients when matched by age and stage at diagnosis. Women are invariably best treated by multidisciplinary teams.

Awareness of human papillomavirus infection, testing and vaccination in midwives and midwifery students in Greece

Midwives play an important role in the implementation of cervical cancer screening. We assessed the knowledge of human papillomavirus (HPV) infection and of its relationship with cervical cancer in 107 midwives and 29 graduating midwifery students. The majority of midwives (78.5%) were aware that a viral infection causes cervical cancer, whereas only 48.3% of the students knew this (p = 0.003). Only one midwife (0.9%) was not aware of HPV infection compared with 10.3% of the students (p = 0.029). Midwives were also more knowledgeable of the relationship between HPV infection and cervical cancer and of the availability of a vaccine against HPV infection (p = 0.005 and p < 0.0001, respectively). In conclusion, Greek midwives have a satisfactory level of knowledge about cervical cancer and HPV infection, in contrast to midwifery students. It is important to better educate midwifery students in order to facilitate the incorporation of HPV testing and vaccination in clinical practice.

Conjunctiva is an estrogen-sensitive epithelium

BACKGROUND

To investigate whether the conjunctival epithelium shows cyclical maturation changes during the ovarian cycle and to study the cytological appearance of the conjunctiva in postmenopausal and pregnant women.

PATIENTS

Fifteen menstruating women with ovulatory cycles, ten postmenopausal women, and twelve pregnant women in the second or the third trimester of their pregnancy.

INTERVENTIONS

Conjunctival and vaginal smears were taken on a near-daily basis.

MAIN OUTCOME MEASURES

The percentage of the parabasal, the intermediate and the superficial cells (Maturation Index) in each specimen was determined.

RESULTS

In the conjunctival smears of the menstruating women cyclical maturation changes were noted. These changes were parallel to those of the vaginal smears, but to a minor degree. No cyclical changes were found in either the postmenopausal women or in the pregnant women, showing an extreme shift to the left in the Maturation Index.

CONCLUSION

Conjunctiva appears to be a relatively estrogen-sensitive epithelium.

Epidemiology of human papillomavirus infection in Greek asymptomatic women

In an attempt to estimate the prevalence of human papilloma virus (HPV) positivity among asymptomatic, cytologically normal Greek women, and the possible associations between HPV infection and other demographic, sexual, behavioural and sociological parameters, we undertook an epidemiological study of 226 clinically normal women from an outpatient gynaecological clinic in Northern Greece. The polymerase chain reaction was used for detection of HPV DNA and dot blot hybridization analysis for HPV typing (only for the high-risk types 16 and 18). Eighty-two of the 226 women examined (36.3%) were positive for HPV DNA, 6.6% (15/226) were positive for HPV-16 DNA and only 1.3% (3/226) were positive for HPV-18 DNA. From all epidemiological correlates, age and residence showed a negative correlation with risk of HPV infection, whereas use of contraceptive intrauterine device, class II or III result of the last Papanicolaou cytological examination, history of painful inflammatory disease of inner genitals and frequent washing of the genital area, particularly during the menstrual period, were positively correlated with increased risk of HPV infection. No association was found between HPV DNA positivity and other well-known risk factors for cervical cancer, confirming the observations of other authors that sexual behaviour, a significant risk factor for cervical cancer, is not inevitably correlated with risk of HPV infection.