Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, México.
Centro de Investigación en Políticas, Población y Salud, Universidad Nacional Autónoma, Ciudad de México, México.
Clin Epigenetics. 2019 Oct 12;11(1):140. doi: 10.1186/s13148-019-0743-9.
Vigilant management of women with high-risk human papillomavirus (hrHPV) is necessary in cancer screening programs. To this end, we evaluated the performance of S5 (targeting DNA methylation in HPV16, HPV18, HPV31, HPV33, and human gene EPB41L3) to predict cervical intraepithelial neoplasia grade 2 or higher (CIN2+) in a sample of hrHPV-infected women referred to colposcopy in the FRIDA Study, a large screening trial in Mexico. A nested case-control sample with women referred to colposcopy either by atypical squamous cells of undetermined significance or higher (ASCUS+) in cytology and/or positive for HPV types 16 or 18 was tested by S5. Seventy-nine cases of CIN2+ were age-matched to 237 controls without a diagnosis of CIN2+ (<CIN2). DNA from exfoliated cervical cells was bisulfite converted and PCR amplified for S5 targets, and methylation was quantified at specific cytosines by pyrosequencing.
The S5 classifier separated women with CIN2+ from <CIN2 with a highly significant area under the curve (AUC) of 0.75 (95% CI 0.69-0.82), while AUC for CIN3+ was 0.81 (95% CI 0.74-0.89). To optimize sensitivity and specificity for Mexico, an alternative S5 cutoff of 3.7 was implemented to account for overall higher methylation seen in our already triaged women. All three invasive cancers were detected by methylation or HPV16/18 but none by cytology. Sensitivity of S5 for CIN2+ was 62% (95% CI 50.4-72.7%), specificity was 73% (95% CI 66.9-78.5%), and adjusted PPV was 15.1% (95% CI 12.0-18.3%). In contrast, the crude sensitivity of HPV16/18 detection and cytology were 63.3% (95% CI 51.7-73.9%) and 57.0% (95% CI 45.3-68.1%) respectively; specificity was 29.1% (95% CI 23.4-35.3%) and 62.4% (95% CI 55.9-68.6%) respectively, while adjusted PPV was 6.4% (95% CI 4.9-8.1%) and 10.5% (95% CI 8.0-13.1%), respectively. Methylation testing could reduce colposcopy referrals by 30 to 50% with virtually no loss of sensitivity for CIN2+ and CIN3+.
S5 testing on hrHPV-positive women significantly increased diagnostic information compared to triage by HPV16/18 plus cytology and appears to have clinical utility as an additional test to substantially lessen burdens on colposcopy.
The FRIDA Study is registered in ClinicalTrials.gov , number NCT02510027.
在癌症筛查计划中，对高危型人乳头瘤病毒（hrHPV）感染的女性进行警惕性管理是必要的。为此，我们评估了 S5（针对 HPV16、HPV18、HPV31、HPV33 和人类基因 EPB41L3 的 DNA 甲基化）在 FRIDA 研究中 hrHPV 感染女性中预测宫颈上皮内瘤变 2 级或更高（CIN2+）的性能，这是一项在墨西哥进行的大型筛查试验。通过 S5 检测细胞涂片 ASCUS+或更高水平（意义不明的不典型鳞状细胞）和 HPV16 或 18 阳性的女性，构建了一个巢式病例对照样本。79 例 CIN2+病例与 237 例无 CIN2+（<CIN2）诊断的对照者年龄匹配。从宫颈脱落细胞中提取 DNA，进行亚硫酸氢盐转化和 S5 靶标 PCR 扩增，通过焦磷酸测序定量特定胞嘧啶的甲基化。
S5 分类器以具有高度显著性的曲线下面积（AUC）0.75（95%CI 0.69-0.82）将 CIN2+女性与<CIN2 女性区分开来，而 CIN3+的 AUC 为 0.81（95%CI 0.74-0.89）。为了优化墨西哥的灵敏度和特异性，实施了替代的 S5 截断值 3.7，以考虑到我们已经分诊的女性中总体较高的甲基化水平。所有三种浸润性癌症均通过甲基化或 HPV16/18 检测到，但均未通过细胞学检测到。S5 检测 CIN2+的灵敏度为 62%（95%CI 50.4-72.7%），特异性为 73%（95%CI 66.9-78.5%），调整后的阳性预测值为 15.1%（95%CI 12.0-18.3%）。相比之下，HPV16/18 检测和细胞学的粗灵敏度分别为 63.3%（95%CI 51.7-73.9%）和 57.0%（95%CI 45.3-68.1%），特异性分别为 29.1%（95%CI 23.4-35.3%）和 62.4%（95%CI 55.9-68.6%），而调整后的阳性预测值分别为 6.4%（95%CI 4.9-8.1%）和 10.5%（95%CI 8.0-13.1%）。对 hrHPV 阳性女性进行 S5 检测可将阴道镜检查转诊减少 30%至 50%，而对 CIN2+和 CIN3+的灵敏度几乎没有损失。
与 HPV16/18 加细胞学联合筛查相比，S5 检测对 hrHPV 阳性女性的诊断信息量有显著提高，并且似乎具有临床应用价值，可作为减少阴道镜检查负担的附加检测方法。
FRIDA 研究在 ClinicalTrials.gov 注册，编号为 NCT02510027。
