CIN 2 of endocervical and vaginal self

CIN 2 of endocervical and vaginal self

Type–Specific Human Papillomavirus in Endocervical and Vaginal
Self–Collected Specimens; Implications for Vaginal Self–Collection
Robert G. Pretorius MD1, Jerome L. Belinson MD2, You-Lin Qiao MD PhD3, He Wang MD,3 Jennifer Smith PhD,4
Jing Li MD MPH,3 Frank J. Taddeo PhD,5 Shangying Hu MD,3 Raoul J Burchette MPH1
Southern California Permanente Medical Group, 2The Cleveland Clinic Foundation, 3Cancer Institute/Hospital, Chinese Academy of Medical Sciences, 4Univ. North Carolina, 5Merck, Inc.
1
Introduction
To elucidate why vaginal self-collection and high-risk human papillomarvirus (HR-HPV)
testing with Hybrid Capture® (hc2) has a lower sensitivity and specificity for cervical
intraepithelial neoplasia grade 2 or worse (≥CIN 2) [1], we determined the specific HPV
types present in the endocervical and vaginal self–collected specimens in a cohort of
women being screened for cervical cancer.
Methods
Between 5/06 and 4/07, a multi-center, population-based cross-sectional study was
conducted in three rural sites in China to evaluate the association of specific HPV
type with ≥CIN 2. Eligible women were age 16 to 54 years, non-pregnant, had no
history of pelvic radiation, hysterectomy, previous treatment for cervical cancer,
or seropositivity for HIV. Participating women performed vaginal self–collection
(insert conical-shaped brush high into the vagina, rotate three times, and withdraw)
then had practitioner–collected specimens for HPV from the perineum, lower and
upper vagina, and endocervix and cervical specimens for liquid–based cytololgy.
Endocervical and vaginal self–collected specimens were tested for HR-HPV
with hc2. Linear Array® (Roche, Inc.), a PCR-based HPV genotype test, was
performed on the brush specimens obtained from the endocervical, upper
vaginal, lower vaginal, perineal, and vaginal self–collected specimens for women
whose endocervical or vaginal self–collected specimens tested hc2 positive,
on women with ≥CIN 2, and for a 3.4% random sample of the women whose
endocervical and vaginal self–collected specimens tested hc2 negative.
When tested with Linear Array, the 98 women that were HR-HPV by hc2 positive in
the vaginal self–collected specimens and negative in the endocervical specimens,
none of whom had ≥CIN 2 (these 98 women result in the lower specificity of the
vaginal self–collected specimens) have a lower prevalence of HR-HPV (8.2% vs. 49.0%)
in the endocervical specimens and a lower prevalence of LR-HPV (11.2% vs. 32.7%)
in the endocervical specimens. The 65 women that were HR-HPV by hc2 negative
in the vaginal self–collected specimens and positive in the endocervical specimens,
8 of whom had ≥CIN 2 (these 65 women result in the lower sensitivity of the vaginal
self–collected specimens) have a higher prevalence of HR-HPV in the endocervical
specimens (58.5% vs. 40.0%) and a similar prevalence of LR-HPV in the endocervical
specimens (16.9% vs. 27.7%).
Of the 98 women that were HR-HPV by hc2 positive in the vaginal self–collected
specimens but negative in the endocervical specimens, 48 (40.0%) had vaginal self–
collected specimens that were positive for HR-HPV by Linear Array. Forty-one of these
48 women had negative HR-HPV by Linear Array in their endocervical specimen.
These 41 women are a subset of the 59 women with positive HR-HPV by Linear
Array in the vaginal self-test but negative HR-HPV by Linear Array in the endocervical
specimen. None of these 59 women had ≥CIN 2. The mean self–collected specimen
hc2 signal strength, a semiquantitative measure of viral load, for these 59 women
(19.8 RLU/CO) was lower than the mean self–collected specimen signal strength
of the 225 women with HR-HPV by Linear Array in both the self–collected and
endocervical specimens (286.1 pg RLU/CO, p<.001, t-test).
Table 3: Comparison of sensitivity for ≥CIN 2 of endocervical and vaginal selfcollected specimens with HR-HPV testing by hc2 and Linear Array
Women whose endocervical or vaginal self–collected specimens were hc2 positive
or had cervical cytology other than normal or ASC-US underwent colposcopy with
the Preventive Oncology International, Inc. (P.O.I.) five-microbiopsy protocol. [1]
Sensitivity for ≥CIN 2
Results
1
397 of 2,625 participating women had positive HR-HPV by hc2 in endocervical
or vaginal self–collected specimens. Linear Array tests were obtained for these
397, for the single woman with negative HR-HPV by hc2 in endocervical and
vaginal self–collected specimens but with ≥CIN 2, and for a random sample
of 71 of the remaining 2,228 women. Colposcopy and biopsy was performed
on 395 of the 405 eligible women. 47 of 2,625 women had ≥CIN 2.
Table 1: Risk of ≥CIN 2 as a function of vaginal self–collected and
endocervical practitioner–collected HR-HPV testing with hc2.
Endocervical HR-HPV
hc2 positive
Vaginal Self–collected HR-HPV
hc 2positive
Vaginal Self–collected HR-HPV
hc2 negative
38/234 (16.2%)
8/65
(12.3%)
Endocervical HR-HPV
hc2 negative
0/98
(0%)
1/2,228 (0.05%)
The sensitivity for ≥CIN 2 of the endocervical specimen for HR-HPV by hc2
(97.9%, 46/47) exceeds that of the vaginal self–collected specimen for HR-HPV
by hc2 (80.9%, 38/47, p=.008, McNemar test). The specificity for ≥CIN 2 of the
endocervical specimen for HR-HPV by hc2 (90.2%) also exceeds that of the vaginal
self–collected specimen for HR-HPV by hc2 (88.6%, p=.001, McNemar test).
Table 2: Prevalence of HR-HPV and LR-HPV by Linear Array as a function of
self–collected and endocervical practitioner-collected HR-HPV testing with hc2
Linear Array
HPV
Endocervical
HR-HPV hc2
Endocervical HR- Endocervical HR- Endocervical HR- Endocervical HRHPV hc2 neg/
HPV hc2 pos/
HPV hc2 neg /
HPV hc2 pos /
Vaginal selfVaginal selfVaginal selfVaginal selfcollection HR-HPV collection HR-HPV collection HR-HPV collection HR-HPV
hc2 neg (N=71)
hc2 neg (N=65)
hc2 pos (N=98)
hc2 pos (N=234)
HR-HPV
87.2%1
8.2%3
58.5%5
0%7
Endocervix
HR-HPV Vaginal
89.7%1
49.0%3
40.0%5
1.4%7
Self-collection
LR-HPV
20.5%2
11.2%4
16.9%6
2.8%7
Endocervix
LR-HPV Vaginal
36.1%2
32.7%4
27.7%6
2.8%7
Self-collection
1
87.2% vs. 89.7%, p=.29; 220.5% vs. 36.1%, p<.001; 38.2% vs. 49.0%, p<.001;
4
11.2% vs. 32.7%, p<.001; 558.5% vs. 40.0%, p=.012; 616.9% vs. 27.7%, p=.065;
7
0% vs. 1.4% and 2.8% vs. 2.8%, NS (all by McNemar test)
97.9%1,2,3
(46/47)
Vaginal self–
Vaginal self–
Endocervical
HR-HPV Linear collected HR-HPV collected HR-HPV
Linear Array
hc2
Array
100%1
(47/47)
80.9%2
(38/47)
95.7%3
(45/47)
97.9% vs. 100%, p=.1.0; 297.9% vs. 80.9%, p=.008; 397.9% vs. 95.7%, p=1.0
The proportion of type 16 or 18 HPV in women HR-HPV positive by Linear Array in the
endocervical specimens (39.6%, 99/250) did not differ from that in the self–collected
vaginal specimens (38.0%, 108/284, p=.71, Chi-Square).
Among the 38 women with ≥CIN 2 with paired endocervical and vaginal self–collected
specimens that both tested hc2 positive, the mean signal strength of the endocervical
specimens (650.2 RLU/CO) was greater than that of the self–collected specimens
(264.7 RLU/CO, paired t-test, p=.003).
Conclusions
The vaginal self–collection specimen’s lower sensitivity for ≥CIN 2 of HR-HPV testing
by hc2 is secondary to the self-collection specimen obtaining fewer cells. The lower
specificity is secondary to the presence of HR-HPV solely in the vagina which is not
associated with ≥CIN 2 and to a higher prevalence of LR-HPV in the vaginal self–
collection which cross-reacts with hc2 [2]; it is not related to a predilection of type 16
or 18 HPV for the endocervix. One possible explanation for the HR-HPV present solely
in the 59 vaginal self–collected specimens is that incident HPV infections may ascend
from the vulvovaginal area to the cervix [3].
The sensitivity of the vaginal self–collected specimen might be increased to that of
the practitioner-collected endocervical specimen either by changing the collection
device so it is easier for women to obtain a larger specimen or using an HR-HPV assay
with a lower cutpoint (similar to Linear Array). As there is HR-HPV present solely in the
vaginal self-test which is not associated with ≥CIN 2, regardless of the assay used, the
specificity of the vaginal self–collected specimen for HR-HPV will likely remain lower
than that of the endocervical specimen.
In collaboration with the N.I.H. we are evaluating a vaginal self-collecting device with
a smooth sleeve and a larger swab designed to obtain a larger specimen. As it is
difficult to mail liquids, the ideal vaginal self–collection HR-HPV test would not require
a liquid transport medium.
BIBLIOGRAPHY
1. Belinson JL et al. Int J Gynecol Cancer 2003;13(6):819-26.
2. Castle PE et al. J Clin Microbiol 2008;46 (8):2595-2604.
3. Weiner RL et al. Am J Epidemiol 2003;157:218-26.
SUPPORTED BY
Supported by: Preventive Oncology International™;
The Cancer Institute/Hospital, Chinese Academy of Medical Sciences, Beijing, China;
Taussig Cancer Center of The Cleveland Clinic Foundation; and Merck, Inc.
Correspondence:
USA: Robert G. Pretorius, MD; Email: Robert.G.Pretorius@kp.org
China: You-Lin Qiao, MD, PhD; Email: qiaoy@public.bta.net.cn
MultiMedia Communications • 2428 Pretorius • 5/09
Prevalence of Type–Specific Human Papillomavirus (HPV) in the
Endocervix, Upper Vagina, Lower Vagina and Perineum;
Implications For Vaginal Self–Collection
Jerome L. Belinson MD,1 Robert G. Pretorius MD,2 You-Lin Qiao MD PhD,3 He Wang MD,3 Jennifer Smith PhD,4
Jing Li MD MPH,3 Frank J. Taddeo PhD,5 Shangying Hu MD,3 Raoul J Burchette MPH1
The Cleveland Clinic Foundation, 2 Southern California Permanente Medical Group, 3Cancer Institute/Hospital, Chinese Academy of Medical Sciences, 4Univ. North Carolina, 5Merck, Inc.
1
Introduction
When compared with high-risk human papillomarvirus (HR-HPV) testing with
Hybrid Capture® (hc2) of practitioner-collected endocervical specimens,
vaginal self–collected specimens have a lower sensitivity and specificity for
cervical intraepithelial neoplasia grade 2 or worse (≥CIN 2) [1]. The lower
sensitivity of the vaginal self–collected specimens could be secondary to
a lower prevalence of HR-HPV and specifically, type 16 HPV in the vagina
[2]. The lower specificity of the vaginal self–collected specimens could be
secondary to cross-reaction of hc2 with LR-HPV [3], LR-HPV having been
reported to have a higher prevalence in the vagina than in the endocervix
[4]. To further our understanding of vaginal self-collection and HR-HPV
testing, we determined the specific HPV types present in the endocervix,
upper and lower vagina, perineum, and vaginal self–collected specimens in
a cohort of women being screened for cervical cancer.
Methods
Between 5/06 and 4/07, a multi-center, population-based cross-sectional
study was conducted in three rural sites in China to evaluate the association
of specific HPV type with ≥CIN 2. Eligible women were age 16 to 54 years,
non-pregnant, had no history of pelvic radiation, hysterectomy, previous
treatment for cervical cancer, or seropositivity for HIV. Participating women
performed vaginal self-collection (insert conical-shaped brush high into the
vagina, rotate three times, and withdraw) then had practitioner–collected
specimens for HPV from the perineum, lower and upper vagina, and
endocervix and cervical specimens for liquid–based cytololgy.
Endocervical and vaginal self–collected specimens were tested by hc2.
Linear Array® (Roche, Inc.), a PCR-based HPV genotype test, was performed
on the brush specimens obtained from the endocervical, upper vaginal,
lower vaginal, perineal, and vaginal self–collected specimens for women
whose endocervical or vaginal self–collected specimens tested hc2 positive,
on women with ≥CIN 2, and for a 3.4% random sample of the women
whose endocervical and vaginal self–collected specimens were
hc2 negative.
Women whose endocervical or vaginal self–collected specimens were hc2
positive or had cervical cytology other than normal or ASC-US underwent
colposcopy with the Preventive Oncology International, Inc. (P.O.I.) fivemicrobiopsy protocol. [1]
Results
397 of 2,625 participating women had positive HR-HPV by hc2 in
endocervical or vaginal self–collected specimens. Linear Array tests were
obtained for these 397, for the single woman with negative HR-HPV by hc2
in endocervical and vaginal self–collected specimens but with ≥CIN 2, and
for a random sample of 71 of the remaining 2,228 women. Colposcopy
and biopsy was performed on 395 of the 405 eligible women. 47 of 2,625
women had ≥CIN 2.
Table 1: Weighted prevalence of HR-HPV and LR-HPV in five anogenital sites
Endocervix
Upper Vagina
Lower Vagina
Perineum
HR-HPV
9.5%
(250/2625)
14.2%
(371.6/2625)
14.0%
(366.8/2625)
14.8%
(389.5/2625)
Vaginal Selfcollection
12.0%
(315.4/2625)
LR-HPV
5.1%1
(132.8/2625)
12.9%
(338.3/2625)
19.8%1
(520.2/2625)
14.3%
(375.7/2625)
7.6%
(197.8/2625)
Prevalence of LR-HPV in the lower vagina (19.8%1) differed significantly from LR-HPV in endocervix
(5.1%1, p<.0004). Other differences in HPV prevalence were not significant.
Weighted prevalence of HPV was calculated by multiplying the prevalence
of HPV in the randomly chosen 71 of 2,228 women with negative HR-HPV
by hc2 in the endocervical and vaginal self–collected specimens by a factor
of 2,228/71=31.38.
Table 2: Sensitivity for ≥CIN 2 of HR-HPV by hc2 and HR-HPV by
Linear Array for five anogenital sites
Anogenital Site
1
Sensitivity for ≥CIN 2 of
HR-HPV by hc2
Endocervix
97.9%
(46/47)1,2,3,4
Upper Vagina
91.5%
Lower vagina
Sensitivity for ≥CIN 2 of
HR-HPV by Linear Array
100.0%
(47/47)4
(43/47)
97.9%
(46/47)
85.1%
(40/47)1
95.7%
(45/47)
Perineum
46.8%
(22/47)2
91.5%
(43/47)
Vaginal self-collection
80.9%
(38/47)3,5
95.7%
(45/47)5
97.9% vs. 85.1%, p=.03; 297.5% vs. 46.8%, p<.001; 397.9% vs. 80.9%, p=.008;
4
97.9% vs. 100%, p=1.0; 595.7% vs. 80.9%, p=.02. Other comparisons of
sensitivity were not significant. (all McNemar tests)
The sensitivity for ≥CIN 2 of HR-HPV testing with hc2 in the endocervix
(97.9%) is similar to that of HR-HPV testing with hc2 in the upper
vagina (91.5%), but higher than that of HR-HPV testing with hc2
in the lower vagina (85.1%), perineum (46.8%), or vaginal self–
collected specimens (80.9%). With Linear Array testing for HR-HPV,
the sensitivities for ≥CIN 2 of the five anogenital sites are similar.
Table 3: Mean signal strength (RLU/CO) as measured by hc2 in 34 women
with ≥CIN 2 that have positive HR-HPV by hc2 in the endocervical,
upper and lower vaginal, and vaginal self–collected specimens
Endocervix
Mean RLU/CO
1
688.21,2,3
Upper Vagina
Lower Vagina
118.01,4
51.22,4
Vaginal Selfcollection
273.53
688.2 vs. 118.0, p<.001; 2688.2 vs. 51.1, p<.001; 3688.2 vs. 273.5 p=.004; 4118.0 vs. 51.2,
p=.015 (all paired t-test with two degrees of freedom)
The signal strength as measured by hc2 in the endocervical specimens
exceeds that in the vaginal specimens. The signal strength in the upper
vaginal specimens exceeds that in the lower vaginal specimens.
None of the women with positive Linear Array tests for HRHPV in the upper vagina (N=65), lower vagina (N=66), perineum
(N=52), or vaginal self–collected specimens (N=59) but negative
Linear Array tests for HR-HPV in the endocervix had ≥CIN 2.
Conclusions
The lower sensitivity of the vaginal self–collected specimens with HR-HPV
testing by hc2 is related to their lower HR-HPV viral loads. If hc2 is the test
for HR-HPV, obtaining a larger specimen from the upper vagina should
result in a higher sensitivity for ≥CIN 2. We, in collaboration with the N.I.H.,
are evaluating a vaginal self-collecting device with a smooth sleeve and a
larger swab that helps women obtain a larger specimen from the upper
vagina. An alternative way to increase the sensitivity of the vaginal selfcollection is to use a more sensitive HR-HPV assay (similar to Linear Array).
The lower specificity of the vaginal self–collected specimens with HR-HPV
testing by hc2 is secondary to HR-HPV present solely in the vagina and
perineum that is not associated with ≥CIN 2 and to cross-reaction of LRHPV found in excess in the vagina.
BIBLIOGRAPHY
1.
2.
3.
4.
Belinson JL et al. Int J Gynecol Cancer 2003;13(6):819-26.
Baldwin S et al. Gynecol Oncol 2005;97:612-7
Castle PE et al. J Clin Microbiol 2008;46(8)2595-2604
Castle PE et al. J Infec Dis 2004;190:458-67
SUPPORTED BY
Supported by: Preventive Oncology International™;
The Cancer Institute/Hospital, Chinese Academy of Medical Sciences, Beijing, China;
Taussig Cancer Center of The Cleveland Clinic Foundation; and Merck, Inc.
Correspondence:
USA: Jerome L. Belinson, MD; Email: jlb@poiinc.org
China: You-Lin Qiao, MD, PhD; Email: qiaoy@public.bta.net.cn
MultiMedia Communications • 2428 Pretorius • 5/09