CINtec PLUS and the Pap smear - britishcytology.org.uk

HARVARD MEDICAL SCHOOL

MASSACHUSETTS GENERAL PHYSICIANS ORGANIZATION

CINtec PLUS and the

Pap smear:

a co-testing alternative

Rosemary Tambouret MD



p16/Ki67 (CINtec

PLUS) and the Pap

smear

Rosemary Tambouret MD



CINtec PLUS dual stain: p16 and Ki67

• p16 is anti-proliferative marker

• cell cycle regulator by inhibition of CDK4/ CDK6 leading to cell cycle arrest in epithelial cells undergoing cellular differentiation.

• In response to transforming hrHPV, levels of p16 rise; p16 over expression is considered to be a surrogate marker for transforming hrHPV infection

• Ki67 is a marker of cycling cells



CINtec PLUS

p16 in normal squamous cells: no staining or brown cytoplasmic staining and no red stain of Ki67as the cell is in G0 Clone E6H4

Ki67 nuclear stain if normal cell is cycling but no p16 staining is identified Clone 274-11 AC3

Dual staining for p16 and Ki67 correlates with cell cycle dysregulation and with the presence of high risk HPV in women at risk for HSIL (independent of morphology)



Screening for cervical cancer

• Single test: Pap, hrHPV

• Single test with triage:

• Pap -> hrHPV

• hrHPV -> Pap or genotyping

• hrHPV-> CINtec PLUS or other tests

• Co-testing:

• Pap and hrHPV

• Pap and CINtec PLUS



Studies evaluating use of dual p16/Ki67 stain

in cervical cancer screening

• Co-testing with cytology and hrHPV • Ikenberg H et al. J Natl Cancer Inst 2013;105:1550-7

• Cytology negative, hrHPV positive • Petry KU et al. Gynecol Oncol 2011; 121:505-9

• Wentzensen N et al JNCI 2015:107: (12)

• Abnormal cytology, hrHPV positive • Schmidt D et al. Cancer Cytopathol 2011;119:158-66

• Uijterwaal MH et al BJCancer 2014; 110:1579-86

• Bergeron C et al Cancer Cytopathol 2015;123:373-81

• Wentzensen N et al J Natl Cancer Inst 2015;107 (12)



Screening for cervical cancer precursors with

p16/Ki67 dual-stained cytology: PALMS

• 25,577 women >18 years at 196 centers

• Screening with hrHPV (HC2), cytology (CS,

TP or SP), dual stain

• 21,909 all negative (86%)

• Positive tests

• 5.4% dual stain

• 5.2% cytology ASC-US+

• 10.7% HC2

Ikenberg H et al. J Natl Cancer Inst 2013;105:1550-7



Screening for cervical cancer precursors with

p16/Ki67 dual-stained cytology: PALMS

• Colposcopy done following any positive

test except in women <30 years old with

only HPV positive

• Cervical biopsies taken as clinically

indicated

• When no biopsy taken, the patient was

considered to have no clinical disease

Ikenberg H et al. J Natl Cancer Inst 2013;105:1550-7



PALMS: Test results



Sensitivity, specificity, predictive value



PALMS: Diagnostic performance for CIN2+



PALMS: Conclusions

• Because 3 tests applied to all women, can tease out “Pap-dual stain co-testing” results

• hrHPV testing is most sensitive test, suggesting may be used as primary screen

• Dual stain has higher sensitivity than Pap but nearly equivalent specificity

• Confirmed that hrHPV prevalence too high in women <= 30 years



PALMS: Dual stain triage for abnormal cytology Bergeron C et al Cancer Cytopathol 2015;123:373-81

• Large prospective study, >1100 women with ASCUS/LSIL

cytology

• ASCUS triage: DS sensitivity near or same as HPV, but

specificity higher for DS

• Women < 30 with ASCUS would have almost 50% less

referral to colposcopy

• LSIL triage: HPV more sensitive than DS but much less

specific;

• referral rates for DS slightly >50% and risk CIN3+ <2% in

DS neg group

• Results in LSIL group vary by cytology method



PALMS: Dual stain triage for abnormal cytology Bergeron C et al Cancer Cytopathol 2015;123:373-81



Triage cytology negative hrHPV positive

results with dual stain Petry KU et al. Gynecol Oncol 2011;121:505-9

• Prospective Pap (TP)/HPV (HC2) co-testing

trial 2007-8 of women >= 30 years

• In subgroup of 425 women negative TP/pos HC2, the dual stain was used

• Usual follow up for this group is by HPV and/or Pap in 6-12 months

• 147 colposcopy results (1/3 of cohort), biopsy in 132, 64 no follow-up visit



Triage cytology negative hrHPV positive

results with dual stain Petry KU et al. Gynecol Oncol 2011;121:505-9

• 108 samples dual stain positive with 34 CIN2+

• 317 samples dual stain negative with 3 CIN2+

• Sensitivity of dual stain for CIN2+ 91.9%

• Specificity of dual stain for CIN2+ 82.1%

• Conclusion: Use of dual stain to triage Pap negative/HPV positive women will identify >90% of underlying CIN2+



p16/Ki67 dual stain cytology for detection of

precancer in HPV-positive women Wentzensen N et al JNCI 2015;107 (12)

• Prospective trial of HPV/cytology co-testing begun 2003 in women >=30 yrs

• Evaluated performance of dual stain in all HPV positive women and in a cohort of HPV positive/cytology negative women

• Samples collected over 3 months in 2012, dual stain on HPV pos samples from 1509 women



p16/Ki67 dual stain cytology for detection of precancer in

HPV-positive women Wentzensen N et al JNCI 2015;107 (12)

• ASCUS 383 (25.4%)

• LSIL 319 (21.1%)

• ASC-H 36 ( 2.4%)

• HSIL 49 ( 3.3%)

DS positivity increased with lesion severity

All women with cancer were DS positive



Performance of DS compared to ASCUS+

Wentzensen N et al JNCI 2015;107 (12)



Test performance of dual p16/Ki67 stain in HPV-

positive/cytology-negative women




Risk of cervical precancer for DS results

in relation to clinical mgt thresholds



p16/Ki67 dual stain cytology for detection of precancer in HPV-positive women: Conclusions

• DS had lower positivity and higher

sensitivity and specificity than cytology at

ASCUS threshold despite better than most

cytology screening performance at KPNC

• Using established risk thresholds to

HPV+/cyto-

• DS+ surpassed the colposcopy risk level

• DS- was below risk level for one year f/u




European Equivocal of Mildly Abnormal Pap

Cytology Study (EEMAPS) and dual stain Schmidt D et al Cancer Cytopathol 2011;119:158-66

• Dual stain on TP from prior retrospective study using p16

• ASCUS and LSIL 5 European cytology labs

• HPV testing by HC2

• Biopsy within 6 months into 2 categories

• Disease = CIN2+

• No disease = CIN1 or negative for dysplasia

• Cases enriched for CIN2+



EEMAPS and dual stain results ASCUS

DS identifies about same proportion of HSIL as HPV testing

but reduces number of women referred to colposcopy, most evident

in group of women aged 18-29



EEMAPS LSIL Pap and dual stain results

DS in LSIL has about the same sensitivity for CIN2+ but with

a much higher specificity, DS could be used to triage LSIL



p16/Ki67 dual stain in screening for

cervical cancer

• Mounting evidence for a role in

• Triage of ASCUS and LSIL

• Triage of co-testing results: cytology

negative/hrHPV positive

• Triage of primary hrHPV test positive women

• Future developments

• Cost analysis

• Automation

CINtec PLUS and the Pap smear - britishcytology.org.uk

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