Conservative management of intraepithelial cervical neoplasia.

In a prospective trial cryotherapy was performed in 164 patients with preinvasive cervical neoplasia, most of whom desired future childbearing. Their disease had been evaluated by repeat cytology, colposcopy and colposcopically directed punch biopsies, with endocervical curettage when necessary. This conservative treatment eradicated the disease in 147 (89.6%) of the patients. The remaining 17 underwent complete reinvestigation. The focal residual disease in 12 was successfully treated by conservative means--repeat cryotherapy, focal electrocautery or punch biopsy. The other five required either cone biopsy or hysterectomy because of more extensive lesions.     

DNA changes in progressive cervical intraepithelial neoplasia.

Cervical intra-epithelial neoplasm (CIN) is treated as a progressive lesion, even though most CIN will not progress to invasive cancer if left untreated. This study focussed on DNA-cytometric analysis of cytologic smears of patients who had developed invasive cancer after initial smears showing CIN. The first part of the study aimed at describing the DNA-cytometric changes in these progressive ('malignant') CIN lesions. In the second part a cluster analysis was performed on 'malignant' CIN III lesions and CIN III lesions, with 'unknown' malignant potential. The results indicated that 'malignant' CIN lesions developed high DNA-index (DI) values during malignant transformation, as demonstrated by increasing mean DI values, a high percentage of DNA-aneuploidy and 2.5c Exceeding Rates. Furthermore, a trend-like pattern of texture feature values occurred in 'malignant' CIN lesions with increasing severity. These findings provide objective quantitative confirmation of the evolution of nuclear changes during malignant transformation. Cluster analysis showed that it was possible, using a set of four cytometric features, to subdivide the 'unknown' CIN III lesions into a cluster of lesions with feature values similar to the vast majority of the 'malignant' CIN III lesions, and a second cluster of lesions with feature values dissimilar to 'malignant' CIN III. It is argued that the profile of 'malignant' CIN has become clearer and that the results of this study may serve as a basis for a more objective cytopathologic subdivision of premalignant CIN. It may be justified to follow up patients whose lesions do not yet fit this 'malignant' profile. Not treating the non-progressive lesion group will avoid putting these patients at risk.     

Immunocytochemical staining of cervical smears for the diagnosis of cervical intraepithelial neoplasia

A total of 233 cervical smears were stained by immunocytochemical methods for epithelial membrane antigen (EMA); the findings were compared with those from Papanicolaou-stained smears from the same women. Squamous epithelial cells from normal cervices did not stain, but cells shed from cervices with cervical intraepithelial neoplasia (CIN) did express the EMA marker. Metaplastic cells from normal and abnormal cervices also frequently stained. The results confirm that this marker detects cervical intraepithelial neoplasia in vitro, but its potential use in an automated screening program may be limited by the staining of the metaplastic cells.     

Plasma proteome analysis of cervical intraepithelial neoplasia and cervical squamous cell carcinoma

Although cervical cancer is preventable with early detection, it remains the second most common malignancy among women. An understanding of how proteins change in their expression during a particular diseased state such as cervical cancer will contribute to an understanding of how the disease develops and progresses. Potentially, it may also lead to the ability to predict the occurrence of the disease. With this in mind, we aimed to identify differentially expressed proteins in the plasma of cervical cancer patients. Plasma from control, cervical intraepithelial neoplasia (CIN) grade 3 and squamous cell carcinoma (SCC) stage IV subjects was resolved by two-dimensional gel electrophoresis and the resulting proteome profiles compared. Differentially expressed protein spots were then identified by mass spectrometry. Eighteen proteins were found to be differentially expressed in the plasma of CIN 3 and SCC stage IV samples when compared with that of controls. Competitive ELISA further validated the expression of cytokeratin 19 and tetranectin. Functional analyses of these differentially expressed proteins will provide further insight into their potential role(s) in cervical cancer-specific monitoring and therapeutics.     

Mean nuclear volume in cervical intraepithelial neoplasia and carcinoma

OBJECTIVE: To correlate three-dimensional nuclear size (mean nuclear volume) estimated by the stereologic intercept methodfor objective classification of cervical intraepithelial neoplasia (CIN) and carcinoma. STUDY DESIGN: In this retrospective study a total number of 29 CIN cases (8 cases of CIN 1, 10 cases of CIN 2 and 11 cases of CIN 3) and 10 cervical squamous cell carcinoma cases were selected. Mean nuclear volume (MNV) of all cases was measured with an image cytometer (Leica, Cambridge, England) using Quantimet 600 software (Leica). Nuclear point resection method was adopted to measure nuclear volume. Mean intercepted diameter of at least 50 nuclei was measured randomly. MNV was correlated with the histologic grade and diagnosis. RESULTS: MNV of CIN 1, 2, 3 and carcinoma cases was 291.72, 403.33, 711.45 and 893 microm3, respectively. ANOVA test results showed that MNV of CIN 1 and 2 was significantly lower than that of CIN 3 and invasive carcinoma (P < .000). MNV of CIN 3 was also significantly lower than that of carcinoma cases (P <.05). CONCLUSION: The findings suggest that estimates of MNV on conventional histopathology slides provide objective and useful criteria for relatively subjective histopathologic grading.     

Clinical and pathological heterogeneity of cervical intraepithelial neoplasia grade 3

Objective

Cervical intraepithelial neoplasia grade 3 (CIN3), the immediate cervical cancer precursor, is a target of cervical cancer prevention. However, less than half of CIN3s will progress to cancer. Routine treatment of all CIN3s and the majority of CIN2s may lead to overtreatment of many lesions that would not progress. To improve our understanding of CIN3 natural history, we performed a detailed characterization of CIN3 heterogeneity in a large referral population in the US.

Methods

We examined 309 CIN3 cases in the SUCCEED, a large population-based study of women with abnormal cervical cancer screening results. Histology information for 12 individual loop electrosurgical excision procedure (LEEP) segments was evaluated for each woman. We performed case-case comparisons of CIN3s to analyze determinants of heterogeneity and screening test performance.

Results

CIN3 cases varied substantially by size (1–10 LEEP segments) and by presentation with concomitant CIN2 and CIN1. All grades of CINs were equally distributed over the cervical surface. In half of the women, CIN3 lesions were found as multiple distinct lesions on the cervix. Women with large and solitary CIN3 lesions were more likely to be older, have longer sexual activity span, and have fewer multiple high risk HPV infections. Screening frequency, but not HPV16 positivity, was an important predictor of CIN3 size. Large CIN3 lesions were also characterized by high-grade clinical test results.

Conclusions

We demonstrate substantial heterogeneity in clinical and pathological presentation of CIN3 in a US population. Time since sexual debut and participation in screening were predictors of CIN3 size. We did not observe a preferential site of CIN3 on the cervical surface that could serve as a target for cervical biopsy. Cervical cancer screening procedures were more likely to detect larger CIN3s, suggesting that CIN3s detected by multiple independent diagnostic tests may represent cases with increased risk of invasion.     

Flow cytometric classification of biopsy specimens from cervical intraepithelial neoplasia

The distribution of single-cell DNA content was investigated in biopsy specimens from the human cervix of 121 women suspected of having intraepithelial neoplasia. Comparison of the results of the histopathological examination with the ploidy level showed that all normal specimens were diploid. Thus, no false-positive results occurred. Most of the specimens classified as mild and moderate dysplasia were diploid as well. Aneuploid cell populations occurred in 78% of the lesions classified as severe dysplasia and carcinoma in situ. The ploidy level distribution permitted a natural division of the aneuploid cell populations into two groups with DNA indices either above or below 1.5. The importance of the aneuploidy in carcinogenesis is discussed.     

Risk of cervical intraepithelial neoplasia in women with glomerulonephritis.

OBJECTIVE--To investigate the occurrence of cervical intraepithelial neoplasia in women with glomerulonephritis and its possible association with immunosuppressive treatment. DESIGN--Retrospective study of cytological or histological specimens from women presenting with glomerulonephritis and a group of case and age matched controls. SETTING--University department of pathology, Norway. PATIENTS--81 women presenting with glomerulonephritis from 1981 to 1988, from whom gynaecological cytological or histological specimens were available. A group of 162 case and age matched controls. MAIN OUTCOME MEASURES--Age when glomerulonephritis of cervical intraepithelial neoplasia was diagnosed, type and characteristics of kidney lesion, stage of cervical intraepithelial neoplasia and presence of human papillomavirus, use of immunosuppressive treatment. RESULTS--Cervical intraepithelial neoplasia was more common in women with glomerulonephritis than in their controls (16/81 (20%) v 7/162 (4%), p less than 0.001) and was more advanced in those with glomerulonephritis than in the controls (9/81 (11%) of the study group had grade III cervical intraepithelial neoplasia compared with 1/162 (1%) of the controls). The increased occurrence of cervical lesions was independent of the use of immunosuppressive treatment, but the individual lesions tended to be more advanced when it was used (four of the seven cervical lesions in women with glomerulonephritis who had received immunosuppressive treatment were carcinoma in situ). Of the nine cervical lesions tested, seven were virus associated. CONCLUSION--Women with glomerulonephritis should have regular cervical smears, irrespective of their use of immunosuppressive treatment.     

Inflammatory atypia and the false-negative smear in cervical intraepithelial neoplasia

The effectiveness of cervical cytologic screening is compromised by the increasingly recognized prevalence of false-negative smears. Our previous studies suggested that some false-negative cytologies can be accounted for by smears showing cervical intraepithelial neoplasia (CIN) reported as inflammatory atypia; we found that at least 4% of 5,752 consecutive smears had been underreported in this manner. In the present study, that data was reanalyzed to derive 95% confidence limits for the number of CIN smears reported as inflammatory atypia. Using several differing estimates of cytologic screening sensitivity, it is speculated that, under certain testable assumptions, colposcopy of patients with cytologic diagnoses of inflammatory atypia may be one cost-effective approach to finding CIN cases missed by screening. If confirmed, these findings imply that laboratory quality assurance efforts, traditionally directed to the most serious cytologic diagnoses, should also focus in part on nondysplastic atypia.     

Tissue microarrays for testing molecular biomarkers of cervical intraepithelial neoplasia: feasibility study

OBJECTIVE: To test the possibility of creating tissue microarrays of pre-malignant lesions of the cervix. STUDY DESIGN Paraffin-embedded blocks of 240 cervical tissue specimens were sampled. Lesions from benign squamous and glandular epithelium through various grades of cervical intraepithelial neoplasia (CIN) to frank carcinoma of squamous and glandular origin were cored with a 0.6-mm needle and arrayed in 4 tissue blocks. Sections of these blocks were stained with hematoxylineosin (H-E) and evaluated as to adequacy of tissue cores, representativity of the material and correspondence to the original diagnosis. Immunohistochemical staining with p16 and a novel marker C4.8(4/2/#1) was performed. RESULTS: In > 80% of cases sufficient material from the lesion could be obtained. No or inadequate material was seen in 6% of cases. The core sample did not correspond to the original diagnosis in 12% of cases. The reason was mainly a discrepancy in the grade of the CIN. Discrepancies in diagnoses occurred in only premalignant lesions. Immunohistochemical staining could reliably be performed and evaluated on all tissue cores. CONCLUSION: Tissue microarrays of cervical intraepithelial lesions are technically feasible and can be created reliably. The key to success is a careful and repeated comparison of the tissue block with the corresponding H-E section. Tissue microarrays of preinvasive cervical lesions may allow high throughput analysis of emerging molecular biomarkers in cervical carcinogenesis.     

Diagnosis and treatment of cervical intraepithelial neoplasia in general practice.

OBJECTIVE--To audit the first five years of a colposcopy and treatment service for cervical dysplasia established within a general practice. DESIGN--A cervical smear register was established to determine which women were "at risk" of dysplasia. The results of colposcopy and treatment of dysplasia were analysed. SETTING--A large rural general practice with community hospital facilities in mid-Wales. PATIENTS--4437 Women at risk in a total practice population of 14,100. INTERVENTIONS--Colposcopy of women with dyskaryotic smear results, persistent inflammatory smear results, or vulval warts. Treatment of women with proved dysplasia by electrodiathermy of the cervix or cone biopsy. RESULTS--138 Women with dysplasia were diagnosed over five years: 36 mild, 97 moderate or severe, and five with microinvasion. Despite a 78% smear rate of at risk women over five years, nine invasive cancers still occurred. CONCLUSIONS--The results of treatment are acceptable. Cervical dysplasia has become very common, the risk of a dysplasia in women aged 20-39 who had smear tests being one in 14 over five years.     

Local expression of interferon-alpha and interferon receptors in cervical intraepithelial neoplasia

Purpose  

The present study evaluated mRNA expression of interferon-alpha (IFN-α), IFN-α receptor subunits (IFNAR-1 and IFNAR-2) and an IFN-stimulated gene encoding the enzyme 2′,5′-oligoadenylate synthetase (2′5′OAS) in biopsies on patients with varying grades of cervical intraepithelial neoplasia (CIN I, II and III).     

Genome-wide methylation profiling identifies hypermethylated biomarkers in high-grade cervical intraepithelial neoplasia

Epigenetic modifications, such as aberrant DNA promoter methylation, are frequently observed in cervical cancer. Identification of hypermethylated regions allowing discrimination between normal cervical epithelium and high-grade cervical intraepithelial neoplasia (CIN2/3), or worse, may improve current cervical cancer population-based screening programs. In this study, the DNA methylome of high-grade CIN lesions was studied using genome-wide DNA methylation screening to identify potential biomarkers for early diagnosis of cervical neoplasia. Methylated DNA Immunoprecipitation (MeDIP) combined with DNA microarray was used to compare DNA methylation profiles of epithelial cells derived from high-grade CIN lesions with normal cervical epithelium. Hypermethylated differentially methylated regions (DMRs) were identified. Validation of nine selected DMRs using BSP and MSP in cervical tissue revealed methylation in 63.2–94.7% high-grade CIN and in 59.3–100% cervical carcinomas. QMSP for the two most significant high-grade CIN-specific methylation markers was conducted exploring test performance in a large series of cervical scrapings. Frequency and relative level of methylation were significantly different between normal and cancer samples. Clinical validation of both markers in cervical scrapings from patients with an abnormal cervical smear confirmed that frequency and relative level of methylation were related with increasing severity of the underlying CIN lesion and that ROC analysis was discriminative. These markers represent the COL25A1 and KATNAL2 and their observed increased methylation upon progression could intimate the regulatory role in carcinogenesis. In conclusion, our newly identified hypermethylated DMRs represent specific DNA methylation patterns in high-grade CIN lesions and are candidate biomarkers for early detection.     

Validating polymerase chain reaction for detecting HPV in cervical intraepithelial neoplasia

OBJECTIVE: To validate polymerase chain reaction (PCR) analysis for detecting HPV in Mexican women with cervical intraepithelial neoplasia, grade 2 and 3 (CIN 2/3) versus histologic evidence. STUDY DESIGN: A diagnostic test study was carried out. A sample of 25 selected women who were diagnosed by histology as having CIN 2/3 was analyzed. Biopsies were examined for HPV infection using light microscopy. The histologic criteria used for HPV infection included koilocytosis, dyskeratosis cells, bi/multinucleation, and parakeratosis. PCR was performed on each sample using commercial probes (MY09 and MY11), and then HPV typing was carried out by restriction fragment length polymorphism analyses. RESULTS: PCR revealed that 88% (22/25) of the women were HPV positive (19 high risk and 3 low risk). In contrast, histology revealed that 28% (7/25) of the women were HPV positive. The number of women infected with HPV was 3.14 times (88/28) more frequently detected with PCR procedure than with the histology. Using PCR as the gold standard, 4 values (true positive, false positive, false negative and true negative) were obtained (7, 0, 15 and 3), and histology had a sensitivity, specificity, and positive and negative predictive values of .32, 1.00, 1.00 and .17, respectively. There was a correlation between low-risk and high-risk for PCR (chi 2 with Yates correction = 6.32, P = .012). CONCLUSION: PCR is a powerful tool for the early detection of HPV infection and is independent of histologic criteria.