[PPT] - Terminology for cytology NILM: negative for intraepithelial lesion PowerPoint Presentation

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10/19/2018 1

Karen Smith-McCune October 2018

2. Understand the application of HPV testing in

clinical practice

2. Review the FDA-approved tests for HPV

testing and genotyping

3. Apply genotyping information appropriately

to clinical practice

Terminology for cytology

NILM: negative for intraepithelial lesion or

malignancy

ASCUS: atypical squamous cells of undetermined

significance

ASC-H: atypical squamous cells, cannot rule out

high grade

LSIL: low grade squamous intraepithelial lesion
HSIL: high grade squamous intraepithelial lesion
AGC: atypical glandular cells
AIS: adenocarcinoma in situ

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There are over 100 HPV types that can infect

human skin

Approximately 40 HPV types infect the genital

epithelium (cervix, vagina, vulva, anus, perianus)

14 HPV types can cause cancer at those sites-

high risk HPV types (hrHPV)

The other types (for example HPV 6 and 11) do

not cause cancer and testing is not recommended

FDA-approved HPV tests measure 13-14 HPV

types: HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68

Results are reported as positive or a negative
These tests identify specific HPV types: HPV

16, HPV 18 and, for some tests, HPV 45

HPV 16 and 18 are the cause of >70% of

cervical cancers worldwide

HPV 16 and 18 are also more likely to be

associated with presence and/or development

f CIN than the other HPV types

Kjaer et al. Long-term absolute risk of cervical intraepithelial neoplasia grade 3 or worse following human papillomavirus infection: role of persistence. J Natl Cancer Inst 2010;102:1478-88.

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HPV testing

Triage of ASCUS
Co-testing (Pap+HPV) for

screening

HPV testing alone for

screening HPV genotyping

Co-testing, in women with

normal cytology

HPV testing alone for

screening, in women who are hrHPV positive

ASCUS: atypical squamous cells of undetermined

significance= cytology is not normal, but falls short

f a diagnosis of squamous intraepithelial lesion

(SIL)

This is the most common cytological abnormality

(approximately 4% of tests in the U.S.)

Has poor inter- and intra-observer reliability
Rate of underlying CIN2+ is low (less than 10%)
Rate of underlying cancer is extremely low: 0.1-

0.2%

HPV testing can stratify women with ASCUS

into a low risk group (hrHPV test negative) and a higher risk group (hrHPV test positive)

HPV test result Absolute risk of CIN 2+

HRHPV neg 0.75% HRHPV+ 14.0% HPV16+ 31.5% HPV16/18+ 24.4% HPV18+ 4.3% Other HRHPV+ 8.6%

From the ATHENA study, Am J Clin Pathol 2011

Options for management of ASCUS on Pap:

Repeat the Pap in 1 year, perform

colposcopy if ASCUS or worse OR

Perform hrHPV testing:
If hrHPV negative, rescreen in 3 years
If hrHPV+, perform colposcopy

From the American Society of Colposcopy and Cervical Cytology (ASCCP), 2012 Updated Consensus Guidelines for the Management of abnormal Cytology Screening Results and Cancer Precursors: www.asccp.org

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Management does not make use of HPV 16/18 genotyping

Co-test= cytology + HPV testing for screening

in women 30 years and older

Women with negative cytology and negative

hrHPV testing are at very low risk of having or developing CIN 2+: rescreen in 5 years

HPV test results can be used to triage LSIL Paps to

colposcopy (if positive) or follow-up in 1 year (if negative).

GENOTYPING INFORMATION DOES NOT DIRECT

MANAGEMENT

PAP RESULT: LSIL HIGH RISK HPV NEGATIVE PAP RESULT: LSIL HIGH RISK HPV POSITIVE COLPOSCOPY CO-TEST IN 1 YEAR

From the American Society of Colposcopy and Cervical Cytology (ASCCP), 2012 Updated Consensus Guidelines for the Management of abnormal Cytology Screening Results and Cancer Precursors: www.asccp.org

HPV results are not useful in women with

cytology results of ASC-H, HSIL, AGC and AIS. These results warrant referral to colposcopy regardless of HPV status

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PAP RESULT: ASC-H HSIL AGC AIS HIGH-RISK HPV TEST NOT DONE OR HIGH-RISK HPV TEST NEGATIVE OR HIGH RISK HPV TEST POSITIVE COLPOSCOPY

HPV STATUS DOES NOT DIRECT MANAGEMENT

From the American Society of Colposcopy and Cervical Cytology (ASCCP), 2012 Updated Consensus Guidelines for the Management of abnormal Cytology Screening Results and Cancer Precursors: www.asccp.org

Women with normal cytology and hrHPV+ are

at increased risk of CIN 2+ but do not meet the colposcopy threshold

However, women who are positive for HPV

16/18/45 are at even higher risk of CIN 2+

In women with normal cytology and hrHPV

positive, there are 2 options:

Perform HPV genotyping for HPV 16 and 18. If

either is positive, perform colposcopy OR

Repeat the cotest in 1 year. If at that time,

either cytology is abnormal (ASCUS or worse) OR hrHPV is positive, perform colposcopy

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COLPOSCOPY CYTOLOGY NEGATIVE (NILM) HIGH RISK HPV POSITIVE REPEAT COTEST IN ONE YEAR PERFORM HPV 16/18(45) GENOTYPING

From the American Society of Colposcopy and Cervical Cytology (ASCCP), 2012 Updated Consensus Guidelines for the Management of abnormal Cytology Screening Results and Cancer Precursors: www.asccp.org

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The USPSTF recommends screening for

cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (co- testing).

In women who test positive for hrHPV,

perform HPV genotyping

In women positive for HPV 16/18/45, perform

colposcopy

In women negative for HPV 16/18/45, perform

cytology

In women with ASCUS or worse, perform

colposcopy

ASCCO and SGO recommendations, Huh et al, Gynecol Onc Feb 2015

COLPOSCOPY HIGH RISK HPV NEGATIVE RESCREEN IN 5 YEARS HIGH RISK HPV POSITIVE NEGATIVE HPV GENOTYPING POSITIVE CYTOLOGY COLPOSCOPY ASCUS OR WORSE

Hybrid capture 2 was the first HPV test to be

FDA approved in 2003

Approved for triage of ASCUS and for co-

testing

Measures HPV DNA from 13 high risk HPV

types

– HPV 16, 18, 31,33, 35, 39, 45, 51, 52, 58, 59, 68 – Dichotomous result: positive or negative for any

f the 13 types

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FDA approved March 2009
Detects 14 high risk HPV types

– HPV 16, 18, 31,33, 35, 39, 45, 51, 52, 58, 59, 66, 68

A separate assay detects HPV 16 and 18
Approved for triage of ASCUS and for

screening as a co-test with cytology

Cervista results

Component Results

Component Value HPV High-Risk DNA Types with Reflex HPV 16/18 Not detected Comment: Reference range: Not detected

Cervista results Cervista results

Component Results

Component Value HPV High-Risk DNA Types with Reflex HPV 16/18 DETECTED Comment: Reference range: Not detected This test detects the presence of high risk HPV genotypes, but does not identify which individual subtype is present.

Component Results

Component Value HPV DNA, type 16 DETECTED Comment: Reference range: Not detected The Cervista HPV 16/18 test only detects DNA of HPV types 16 and 18. This test does not detect other high-risk HPV types nor does it detect HPV low-risk types. HPV DNA, type 18 Not detected Comment: Reference range: Not detected The Cervista HPV 16/18 test only detects DNA of HPV types 16 and 18. This test does not detect other high-risk HPV types nor does it detect HPV low-risk types. HPV DNA Genotype (Order 246394334) - Reflex for Order 246394333

Cervista results: High Risk HPV DNA Test with Reflex HPV 16/18 Cervista results: High Risk HPV DNA Test with Reflex HPV 16/18

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Component Results

Component Value HPV DNA, type 16 Not detected Comment: Reference range: Not detected The Cervista HPV 16/18 test only detects DNA of HPV types 16 and 18. This test does not detect other high-risk HPV types nor does it detect HPV low-risk types. HPV DNA, type 18 Not detected Comment: Reference range: Not detected The Cervista HPV 16/18 test only detects DNA of HPV types 16 and 18. This test does not detect other high-risk HPV types nor does it detect HPV low-risk types. HPV DNA Genotype (Order 255522575) - Reflex for Order 255522573

Cervista results: High Risk HPV DNA Test with Reflex HPV 16/18 Cervista results: High Risk HPV DNA Test with Reflex HPV 16/18

Approved April 2011
Measures HPV 16, HPV 18 and the other

12 hrHPV types as a group

Approved for triage of ASCUS, for co-

testing, and for primary HPV screening

Component Results

Component Value HPV DNA, Genotype 16 Not detected Comment: Nucleic Acid(DNA) testing by PCR Reference range:Not detected HPV DNA, Genotype 18 Not detected Comment: Reference range: Not detected HPV DNA, High Risk (non 16/18) Not detected Comment: Reference range: Not detected

Component Results

Component Value HPV DNA, Genotype 16 Not detected Comment: Nucleic Acid(DNA) testing by PCR Reference range: Not detected HPV DNA, Genotype 18 Not detected Comment: Reference range: Not detected HPV DNA, High Risk (non 16/18) DETECTED Comment: Reference range: Not detected

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Component Results

Component Value HPV DNA, Genotype 16 DETECTED Comment: Nucleic Acid(DNA) testing by PCR Reference range: Not detected HPV DNA, Genotype 18 Not detected Comment: Reference range: Not detected HPV DNA, High Risk (non 16/18) DETECTED Comment: Reference range: Not detected

Measures intracellular E6/E7 RNA for 14 high risk

HPV types

E6 and E7 gene expression are up-regulated in

CIN lesions. Since the assay measures HPV RNA, it is measuring viral activity rather than just viral presence (DNA), hence this assay has higher specificity than the other HPV tests that measure DNA

A separate assay detects HPV 16 and 18/45
Approved for triage of ASCUS and for co-testing
Approved 2018
Measures HPV 16, HPV 18 and HPV 45

separately, and the other 11 HPV types as a group

Approved for use for triage of ASCUS, co-

testing with cytology, and primary HPV screening

Approved for use with SurePath cytology

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HC2 (Digene) Cervista (Hologic) Cobas (Roche) Aptima (GenProbe) BD Onclarity Detection target HPV DNA HPV DNA HPV DNA HPV E6/E7 RNA HPV DNA # of hrHPV types 13 14 14 14 14 Specimen adequacy control No Yes histone Yes beta-globin No Yes beta-globin Genotyping available No HPV 16 and 18 HPV 16 and 18 HPV 16 and 18/45 HPV 16, 18 and 45 Cytology vial ThinPrep

nly

ThinPrep

nly

ThinPrep or SurePath ThinPrep

nly

SurePath

nly

Approved for primary screening No No Yes No Yes

Clinical Scenario

32 year old G2P1 comes in for co-testing for

cervical cancer screening. She had her last co- test in 2013 and was negative/negative.

Her cytology result is NILM (negative for

intraepithelial neoplasia). HPV testing shows:

Component Results

Component Value HPV DNA, Genotype 16 Not detected Comment: Nucleic Acid(DNA) testing by PCR Reference range:Not detected HPV DNA, Genotype 18 Not detected Comment: Reference range:Not detected HPV DNA, High Risk (non 16/18)Not detected Comment: Reference range: Not detected

Management?

A. Colposcopy
B. Repeat cytology in 1 year
C. Repeat co-test in 1 year
D. Rescreen at the recommended

interval

E. Order genotyping

C

l

p

s

c

p

y R e p e a t c y t

l
g

y i n 1 y e a r R e p e a t c

t

e s t i n 1 y e a r R e s c r e e n a t t h e r e c

m

m . . . O r d e r g e n

t

y p i n g

0% 0% 0% 97% 3%

Clinical Scenario

32 year old G2P1 comes in for co-testing for

cervical cancer screening. She had her last co- test in 2013 and was negative/negative.

Her cytology result is NILM (negative for

intraepithelial neoplasia). HPV testing shows:

Component Value HPV DNA, Genotype 16 Not detected Comment: Nucleic Acid(DNA) testing by PCR Reference range: Not detected HPV DNA, Genotype 18 Not detected Comment: Reference range: Not detected HPV DNA, High Risk (non 16/18) DETECTED Comment: Reference range: Not detected

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Management?

A. Colposcopy
B. Repeat cytology in 1 year
C. Repeat co-test in 1 year
D. Rescreen at the recommended

interval

E. Order genotyping

C

l

p

s

c

p

y R e p e a t c y t

l
g

y i n 1 y e a r R e p e a t c

t

e s t i n 1 y e a r R e s c r e e n a t t h e r e c

m

m . . . O r d e r g e n

t

y p i n g

13% 9% 4% 9% 66%

Clinical Scenario

32 year old G2P1 comes in for co-testing for

cervical cancer screening. She had her last co- test in 2013 and was negative/negative.

Her Pap result is NILM (negative for

intraepithelial neoplasia). HPV testing shows: Component Results

Component Value Ref Range & Units Status HPV DNA, Genotype 16 Not detected Not detected Final Nucleic Acid(DNA) testing by PCR HPV DNA, Genotype 18 DETECTED Not detected Final HPV DNA, High Risk (non 16/18) Not detected Not detected Final

Management?

A. Colposcopy
B. Repeat cytology in 1 year
C. Repeat co-test in 1 year
D. Rescreen at the recommended

interval

E. Order genotyping

C

l

p

s

c

p

y R e p e a t c y t

l
g

y i n 1 y e a r R e p e a t c

t

e s t i n 1 y e a r R e s c r e e n a t t h e r e c

m

m . . . O r d e r g e n

t

y p i n g

95% 3% 0% 0% 2%

Clinical Scenario

32 year old G2P1 comes in her co-testing for

cervical cancer screening

Her Pap is ASCUS. HPV testing shows:

Component Results

Component Value Ref Range & Units HPV High-Risk DNA Types without Reflex HPV 16/18 Not detected Reference range: Not detected

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Management?

A. Colposcopy
B. Repeat cytology in 1 year
C. Repeat co-test in 1 year
D. Rescreen at the recommended

interval

E. Order genotyping

C

l

p

s

c

p

y R e p e a t c y t

l
g

y i n 1 y e a r R e p e a t c

t

e s t i n 1 y e a r R e s c r e e n a t t h e r e c

m

m . . . O r d e r g e n

t

y p i n g

2% 15% 5% 52% 26%

Clinical Scenario

32 year old G2P1 comes in for co-testing for

cervical cancer screening.

Her cytology result is ASCUS. HPV testing

shows:

Component Results

Component Value HPV High-Risk DNA Types without Reflex HPV 16/18 DETECTED Comment: Reference range: Not detected

Management?

A. Colposcopy
B. Repeat cytology in 1 year
C. Repeat co-test in 1 year
D. Rescreen at the recommended

interval

E. Order genotyping

C

l

p

s

c

p

y R e p e a t c y t

l
g

y i n 1 y e a r R e p e a t c

t

e s t i n 1 y e a r R e s c r e e n a t t h e r e c

m

m . . . O r d e r g e n

t

y p i n g

75% 0% 21% 2% 2%

Clinical Scenario

32 year old G2P1 comes in for cervical cancer

screening.

She has heard about the new

recommendations for HPV testing as a primary screening test for cervical cancer

Your lab uses hybrid capture 2 for HPV testing.

Can you offer her primary HPV screening?

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HC2 (Digene) Cervista (Hologic) Cobas (Roche) Aptima (GenProbe) BD Onclarity Detection target HPV DNA HPV DNA HPV DNA HPV E6/E7 RNA HPV DNA # of hrHPV types 13 14 14 14 14 Specimen adequacy control No Yes histone Yes beta-globin No Yes beta-globin Genotyping available No HPV 16 and 18 HPV 16 and 18 HPV 16 and 18/45 HPV 16, 18 and 45 Cytology vial ThinPrep

nly

ThinPrep

nly

ThinPrep or SurePath ThinPrep

nly

SurePath

nly

Approved for primary screening No No Yes No Yes

Clinical Scenario

32 year old G2P1 comes in for primary HPV

screening

HPV testing shows:

Component Results

Component Value HPV DNA, Genotype 16 Not detected Comment: Nucleic Acid(DNA) testing by PCR Reference range: Not detected HPV DNA, Genotype 18 Not detected Comment: Reference range: Not detected HPV DNA, High Risk (non 16/18) Not detected Comment: Reference range: Not detected

Management?

A. Perform colposcopy
B. Order cytology
C. Repeat test in 1 year
D. Rescreen at the recommended

interval

E. Order genotyping

P e r f

r

m c

l

p

s

c

p

y O r d e r c y t

l
g

y R e p e a t t e s t i n 1 y e a r R e s c r e e n a t t h e r e c

m

m . . . O r d e r g e n

t

y p i n g

0% 2% 2% 96% 0%

Clinical Scenario

32 year old G2P1 comes in for primary HPV

screening

HPV testing shows:

Component Results

Component Value HPV DNA, Genotype 16 DETECTED Comment: Nucleic Acid(DNA) testing by PCR Reference range: Not detected HPV DNA, Genotype 18 Not detected Comment: Reference range: Not detected HPV DNA, High Risk (non 16/18) Not detected Comment: Reference range: Not detected

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Management?

A. Perform colposcopy
B. Order cytology
C. Repeat test in 1 year
D. Rescreen at the recommended

interval

E. Order genotyping

P e r f

r

m c

l

p

s

c

p

y O r d e r c y t

l
g

y R e p e a t t e s t i n 1 y e a r R e s c r e e n a t t h e r e c

m

m . . . O r d e r g e n

t

y p i n g

86% 10% 2% 0% 2%

Clinical Scenario

32 year old G2P1 comes in for primary HPV

screening

HPV testing shows:

Component Results

Component Value HPV DNA, Genotype 16 Not detected Comment: Nucleic Acid(DNA) testing by PCR Reference range: Not detected HPV DNA, Genotype 18 Not detected Comment: Reference range: Not detected HPV DNA, High Risk (non 16/18) DETECTED Comment: Reference range: Not detected

Management?

A. Perform colposcopy
B. Order cytology
C. Repeat test in 1 year
D. Rescreen at the recommended

interval

E. Order genotyping

P e r f

r

m c

l

p

s

c

p

y O r d e r c y t

l
g

y R e p e a t t e s t i n 1 y e a r R e s c r e e n a t t h e r e c

m

m . . . O r d e r g e n

t

y p i n g

17% 64% 0% 0% 19%

Management

You order cytology, and it comes back ASCUS
What will you do next?

– Perform colposcopy – Repeat test in 1 year – Rescreen at the recommended interval

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Clinical Scenario

32 year old G2P1 comes in for co-testing for

cervical cancer screening.

Her cytology result is ASC-H. HPV testing

shows:

Component Results

Component Value HPV High-Risk DNA Types without Reflex HPV 16/18 Not detected Comment: Reference range: Not detected This test detects the presence of high risk HPV genotypes, but does not identify which individual subtype is present.

Management?

A. Perform colposcopy
B. Order cytology
C. Repeat test in 1 year
D. Rescreen at the recommended

interval

E. Order genotyping

P e r f

r

m c

l

p

s

c

p

y O r d e r c y t

l
g

y R e p e a t t e s t i n 1 y e a r R e s c r e e n a t t h e r e c

m

m . . . O r d e r g e n

t

y p i n g

98% 0% 0% 0% 2%

Clinical Scenario

32 year old G2P1 comes in for co-testing for

cervical cancer screening.

Her cytology result is AGC-NOS (atypical

glandular cells- not otherwise specified. HPV testing shows: Component Results

Component Value Ref Range & Units HPV High-Risk DNA Types without Reflex HPV 16/18 Not detected Reference range: Not detected

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Management?

Perform colposcopy
Order cytology
Repeat test in 1 year
Rescreen at the recommended interval
Order HPV genotyping

62

HPV test result Absolute risk of CIN 2+

HRHPV neg 0.8% HRHPV+ 6.1% HPV16+ 13.6% HPV16+/HPV18+ 11.4% HPV18+ 7.0% Other 12 HRHPV+ 4.6%

From the ATHENA study, Am J Clin Pathol 2011

Kjaer et al. Long-term absolute risk of cervical intraepithelial neoplasia grade 3 or worse following human papillomavirus infection: role of persistence. J Natl Cancer Inst 2010;102:1478-88.

Cervista results: High Risk HPV DNA Test without Reflex HPV 16/18 Cervista results: High Risk HPV DNA Test without Reflex HPV 16/18

Component Results

Component Value HPV High-Risk DNA Types without Reflex HPV 16/18 Not detected Reference range: Not detected