squamous neoplasia of the uterine cervix: classification,...

Squamous neoplasia of the uterine cervix: classification, biomarkers

and recommendationsJaume Ordi M.D., Ph.D.Professor of Pathology

Department of PathologyHospital Clínic. University of Barcelona

[email protected]

mailto:[email protected]

Conflict of interest/Funding

X None

Company:____________________________

□ Product royalties

□ Paid consultant

□ Research support

Outline1. Squamous intraepithelial lesions (SIL) of the uterine cervix:

a) LAST /WHO 2014 classification and use of biomarkers (p16)

b) Should HSIL/CIN2 and HSIL/CIN3 be considered a single disease?

c) p16 and progression risk of LSIL/CIN1. Other biomarkers of progression

2. Squamous cell carcinoma of the uterine cervix:

a) HPV negative squamous cell carcinomas: do they exist?

b) Value of HPV genotyping, p16 staining. Prognostic implications

LSIL HSIL

TreatmentFollow-up

LAST/WHO 2014 classification

Grade HPV infection Significance Management

Low-grade SIL Transient - Follow-up

High-grade SIL Persistent Pre-cancer Conization

• Two categories:

Use of biomarkers in LAST/WHO 2014• Biomarkers should be used in several circumstances to adequately

classify HPV associated lesions

• p16

• Ki67

• HPV L1

• nm 23

• ISH (HPV)

• TOP2A

• MCM2

• ProEx C (TOP2A+MCM2)

Use of biomarkers in LAST• Biomarkers should be used in several circumstances to adequately

classify HPV associated lesions

• p16

(+)

(-)

LAST recommendations for p161. Differential diagnosis between pre-cancer (HSIL) and mimickers

(immature metaplasia, atrophy, reparative changes, tangential cutting)

p16 and CIN2+ Sensitivity

Klaes (Am J Surg Pathol, 2002) 100%

Hariri (Int J Gynecol Pathol, 2007) 100%

Ordi (Int J Gynecol Pathol, 2009) 99%

Benevolo (Histopathology, 2010) 96%

0.4-0.6 Moderate

Inter-observer agreement. H&E vs p16

Bergeron C, Ordi J, et al. Am J Clin Pathol 2010; 133: 395

0.6-0.8 Substantial

• Kappa 0.58 to 0.73 (CERTAIN study) (Stoler MH, et al. Am J Surg Pathol 2018; 42 1001-9)

LAST recommendations for p16





2. Differential diagnosis between LSIL and HSIL/CIN2

a. Positive staining supports HSIL

b. Negative staining favors LSIL (or a non-HPV-associated lesion)





Benevolo (Histopathology, 2010) 96%

Galgano (Am J Surg Pathol, 2010) 87%

Kong (Am J Surg Pathol, 2007) 82%

Wang (Clin Cancer Res, 2004) 81%

Guo (Am J Clin Pathol, 2011) 79%

LSIL HSIL

Treatment

p16 in CIN2: increasing the threshold

p16 special circumstance (LAST)• Biopsy specimens interpreted as ≤ LSIL/CIN1 at high risk for missed

high grade disease

• Pap smear with HSIL, ASC or AGC result

• HPV16

• Biopsy specimens interpreted as ≤ LSIL/CIN1 at high risk for missed high grade disease

• Pap smear with HSIL, ASC or AGC result

• HPV16

• Any identified p16 positive area must meet H&E morphological criteria for HSIL to be diagnosed as such

p16. HPV+ and negative biopsy

Ordi J, et al. Int J Gynecol Pathol 2009; 28: 90-97

Final biopsy evaluation

p16 N No lesion (n=107)

LSIL/CIN1 (n=13)

HSIL/CIN2-3 (n=13)

p value

Negative 105 103 (98%) 2 (2%) 0 (0%) <0.001

Focal 10 4 (40%) 6 (60%) 0 (0%) <0.001

“Block” staining 24 0 (0%) 5 (21%) 19 (79%) <0.001

• p16 and histological revision in 139 women with negative biopsy and simultaneous positive HPV testing

- 18 -

• LAST/WHO2014: HSIL is a single category (May be further qualified with the CIN terminology [CIN2, CIN3])

Klaes et al, Am J SurgPathol 2002 26:1389

Study CIN3 CIN2

Klaes (Am J Surg Pathol 2002) 100% 100%

Ordi (Int J Gynecol Pathol 2009) 100% 99%

• Poor inter-observer reproducibility of CIN2-3 grading

• No differences in terms of biomarker abnormalities (p16)

HSIL a single category: rationale

Spontaneous regression of CIN2

Tainio K, et al. BMJ 2018; 360: K499

del Pino M, et al. ObstetGynecol 2010; 116: 1324-31

Regression of CIN1

Spontaneous regression of CIN2 • Spontaneous regression particularly frequent in women ≤30y: risk of

overtreatment of potentially non-progressive or regressive lesions

• Most investigators in the HPV field, separate HSIL/CIN2 and HSIL/CIN3

Moscicki AB, et al. ObstetGynecol 2010; 116: 1373-80

p16 in LSIL/CIN1

Ordi J, et al. Int J Gynecol Pathol 2009; 28:90-97

p16 immunostaining

Final diagnosis nNegative (n=182)

Focal(n=38)

Block pattern(n=106)

No lesion 161 153 (95%) 8 (5%) 0 (0%)

LSIL/CIN1 85 29 (34%) 29 (35%) 27 (32%)

HSIL/CIN2-3 80 0 (0%) 1 (1%) 79 (99%)

p16 as progression marker in LSIL

Author n Sensitivity Specificity PPV NPV

Hariri (2007) 91 96 37 35 96

del Pino (2009) 138 100 49 18 100

p16 as progression marker in LSIL

Author n Sensitivity Specificity PPV NPV

Hariri (2007) 91 96 37 35 96

del Pino (2009) 138 100 49 18 100

Cortecchia (2013) 610 59 72 18 94

Mills (2015) 524 59 54 15 91

Sagasta (2016) 507 71 56 25 90

Sagasta A, et al. Mod Pathol; 2016; 29: 51-59

- 27 -

Other biomarkers of progression• HPV16 and 18 have

significantly higher risk of progression compared with other HPV types

Rodriguez-Trujillo A, et al. Am J Clin Pathol 2018; 150:432-40

- 28 -

Other biomarkers of progression

del Pino M, et al. Int J Mol Sci; 2019; 20: E2262 Leeman A, et al. In J Cancer 2019; 144: 160-8

CADM1 MAL miR124

• Promoter methylation of tumor suppressor genes (FAM19A4, CADM1, MAL, miR124-2, HPV CpG sites) increases with the severity of the lesion

HPV and cervical carcinoma

de Sanjose S, et al. Lancet Oncol 2010; 11: 1048-56

n= 136

HPV-negative cervical cancer

Rodriguez-Caruchio L, et al. BJOG 2014


Rodriguez-Caruchio L, et al. BJOG 2014

HPV-negative (n=21)

HPV-positive (n=193)

p

Age * 57.7 (15.9) 50.5 (15.3) 0.04Clinical presentation <0.01

Clinical symptoms 20 (95.2) 119 (61.7)Abnormal Pap smear 1 (4.8) 74 (38.2)

Histological type <0.01Squamous cell carcinoma 12 (57.1) 156 (80.8)Adenocarcinoma 6 (28.6) 33 (17.1)Adenosquamous carcinoma 1 (4.8) 3 (1.6)Neuroendocrine carcinoma 2 (9.5) 1 (0.5)


Nicolas I, et al. Mod Pathol 2019; 32: 1189-96

Case Age Histological type p16 p53 FIGO1 64 SCC, non-keratinizing - nm IIIB2 57 SCC, sarcomatoid - nm IVA3 83 SCC, non-keratinizing - abn IIIB4 69 Neuroendocrine carcinoma - abn IVB5 85 SCC, non-keratinizing - nm IIIA6 51 Neuroendocrine carcinoma - nm IIIB7 49 ADC, mucinous - abn IIIB8 41 ADC, mucinous - abn IIB9 61 SCC, keratinizing - abn IIB10 53 SCC, non-keratinizing + abn IIIB11 54 ADC, mucinous + abn IIIB12 36 Adenosquamous carcinoma + nm IIB13 82 ADC, mucinous + abn IIIB14 38 SCC, non-keratinizing + abn IB115 53 SCC, non-keratinizing + abn IIIB16 32 ADC, mucinous + abn IB117 64 SCC, non-keratinizing + abn IIB18 40 SCC, non-keratinizing + abn IIIB19 66 ADC, mucinous + nm IVB20 54 SCC, non-keratinizing + abn IIB21 80 SCC, non-keratinizing + abn IVA


HPV-negative (n=21)

HPV-positive (n=193)

p

Tumor size* 54.7 (22.4) 36.8 (21.2) <0.01FIGO staging <0.01

Early (IA-IB1) 2 (9.5) 83 (43.0)Advanced (IB2-IV) 19 (90.5) 110 (57.0)

Lymph node metastasis 14 (66.7) 69 (35.8) <0.01



HPV-negative CC: survival


p=0.01 p=0.01

HPV-negative squamous CC: survival


HPVHPV

p=0.04p=0.01

HPV-negative CC: overall survival

Univariable Cox model Multivariable Cox model

HR 95% CI p HR CI 95% p

Non SCC histology 0.7 0.3-1.5 0.35 - - -

Negative HPV status 2.5 1.2-5.1 0.01 0.9 0.4-2.3 0.44

p16 negative 3.5 1.6-7.4 <0.01 1.9 0.8-5.1 0.14

Advanced FIGO stage 43.7 6.0-316.5 <0.01 23.8 3.1-177.6 <0.01

Lymph node metastasis 7.1 3.7-13.7 <0.01 3.2 1.7-6.0 <0.01


Disease-free survival HPV-negative CC

Li P et al. Oncotarget 2017; 8: 66352-9

Overall survival HPV-negative CC

Li P et al. Oncotarget 2017; 8: 66352-9

HPV genotypes in cervical cancer

Nicolas I, et al. Mod Pathol 2019; in press

HPV16 and/or 18 (n=156)

Other HPV types(n=38)

p

Age * 49 (15) 57 (17) <0.01

Histological type 0.01

Squamous cell carcinoma 119 (76) 38 (100)

Adenocarcinoma 33 (21) - -

Adenosquamous carcinoma 3 (2) - -

Neuroendocrine carcinoma 1 (1) - -

FIGO 2009 staging 0.22

Early (IA-IB1) 62 (40) 11 (29)

Advanced (IB2-IV) 94 (60) 27 (71)

Relapse 31 (20) 11 (29) 0.22

Lymph node metastasis 55 (35) 15 (40) 0.62

HPV genotypes and survival


p16 p16 p16


p16 negativity in HPV + CC: survival

“Take home” messages (SIL)• p16 is a useful tool in the differential diagnosis between HSIL/CIN2+

and the mimics of pre-cancer and may help in identifying occult HSIL lesions in women at high risk for missed high grade disease

• CIN2 and CIN3 have probably a different behavior. The separation between HSIL/CIN2 and HSIL/CIN3 should be recommended

• p16 has little (or no) value as a marker of progression of LSIL/CIN1. Other biomarkers are promising, but have a limited utility in biopsy specimens

“Take home” messages (SCC)• A low percentage of SCCs arise via HPV-independent pathway. Many

of them are of conventional non-keratinizing type. These tumors may have impaired prognosis

• A negative p16 staining in patients with HPV-positive tumors may be a prognostic marker associated with a poor overall survival

squamous neoplasia of the uterine cervix: classification,...

Documents