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Article

HPV16 Load Is a Potential Biomarker to Predict Risk of High-Grade Cervical Lesions in High-Risk HPV-Infected Women: A Large Longitudinal French Hospital-Based Cohort Study

by
Antoine Baumann
1,2,
Julie Henriques
3,4,5,
Zohair Selmani
1,4,5,
Aurélia Meurisse
3,4,5,
Quentin Lepiller
1,6,
Dewi Vernerey
3,4,5,
Séverine Valmary-Degano
2,6,
Sophie Paget-Bailly
3,4,5,
Didier Riethmuller
1,6,7,
Rajeev Ramanah
7,
Christiane Mougin
1,4,5 and
Jean-Luc Prétet
1,6,*
1
Papillomavirus National Reference Centre, CHU de Besançon, 25000 Besançon, France
2
Pathology Department, CHU de Besançon, 25000 Besançon, France
3
Methodology and Quality of Life Unit in Oncology, CHU de Besançon, 25000 Besançon, France
4
UMR1098, Host-Graft-Tumor Interactions and Cell and Tissue Engineering, University Bourgogne Franche-Comté, INSERM, 25000 Besançon, France
5
La Fédération Hospitalo-Universitaire Integrated Center for Research in Inflammatory Diseases (FHU Increase), ANR-11-LABX-0021, LabEx LipSTIC, University Bourgogne Franche-Comté, 25000 Besançon, France
6
EA3181, University Bourgogne Franche-Comté, 25000 Besançon, France
7
Gynecology Department, CHU de Besançon, 25000 Besançon, France
*
Author to whom correspondence should be addressed.
Cancers 2021, 13(16), 4149; https://doi.org/10.3390/cancers13164149
Submission received: 15 June 2021 / Revised: 27 July 2021 / Accepted: 4 August 2021 / Published: 18 August 2021
(This article belongs to the Special Issue Cervical Carcinoma)
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Abstract

:

Simple Summary

This study aimed at assessing HPV16 and HPV18 viral loads to predict the development of cervical high-grade lesion. Among 885 women positive for hrHPV and presenting no or mild cytological abnormalities, HPV16 and HPV18 prevalence was 25.9% and 8.4%, respectively. Of those women, 135 developed a high-grade lesion during the follow-up. Considering an HPV16 viral load cut-off set at 3.2 log10 GE/103 cells a subgroup of women at high risk of developing high-grade cervical lesion (HR = 2.67; 95% CI 1.80–3.97 p ≤ 0.0001) has been identified. Moreover, a composite score based on HPV16 load, cytology and hrHPV detection allowed for CIN2+ risk stratification. To conclude, HPV16 load is a relevant biomarker to identify women at high risk for developing precancerous lesions of the cervix.

Abstract

High-risk HPV (hrHPV) testing has been implemented as a primary screening tool for cervical cancer in numerous countries. However, there is still a need for relevant triage strategies to manage hrHPV positive women to avoid excessive referral to colposcopy. The objective of this study was to assess, in women infected by hrHPV and presenting no or mild cytological abnormalities, HPV16 and HPV18 viral loads to predict the development of cervical high-grade lesion. Among 2102 women positive for hrHPV, 885 had no lesion or mild cytological abnormalities at baseline and had at least one follow-up (FU) visit. HPV16 and HPV18 prevalence was 25.9% and 8.4%, respectively. Of those women, 15% developed a high-grade lesion during the FU. An HPV16 viral load cut-off set at 3.2 log10GE/103 cells permitted to identify a subgroup of women at high risk of developing high-grade cervical lesion (HR = 2.67; 95% CI 1.80–3.97; p ≤ 0.0001). No specific HPV18 viral load threshold could have been defined in regard to the present study. In multivariate analysis, HPV16 load (absence/log10GE/103 cells < 3.2 vs. ≥3.2), RLU/PC 239 (1–100 pg/mL vs. >100 pg/mL) and cytology (normal vs abnormal) were independently associated with a significant increased risk of high-grade lesion development and were used to construct the prognostic score. In conclusion, HPV16 load is a relevant biomarker to identify women at high risk for developing cervical precancerous lesions.

1. Introduction

High-risk HPVs (hrHPV) have been recognized as the etiologic agents of cervical cancer [1,2]. However, only persistent infections confer an increased risk of developing precancerous and cancerous lesions [3,4]. Among the twelve HPV genotypes having oncogenic properties, HPV16 is the most at risk, causing cancer of the cervix and at several other sites [5]. In addition, HPV16, HPV18 is the second most prevalent hrHPV in cervical cancer [6,7,8] and both HPV types have been associated with a high ten-year risk of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) [9].
Cervical cancer screening has been based on cytological analysis of cervical smears since the 1950s. Two decades ago, hrHPV testing has been proposed as a potential alternative to repeated cytology or immediate colposcopy for the triage of women with Atypical Squamous Cells of Undetermined Significance (ASC-US) cytology [10]. In the few last years, hrHPV testing has also been introduced in the management protocols of women treated for CIN and it is now considered the standard test of cure after excisional treatment of cervical high-grade lesion [11]. Recently, a Cochrane review demonstrated the superiority of hrHPV testing compared to cytology to detect high-grade lesions [12]. Thus, several countries have changed their screening policies by switching from cytology to primary hrHPV testing [13].
However, the authors of the Cochrane’s review pointed out that relevant triage strategies are needed to manage hrHPV positive women [12]. For instance, reflex cytology is an approach adopted by different countries including France. HPV16 and HPV18 genotyping is another option for stratification of hrHPV positive women. In this line, the ATHENA HPV study showed that the relative risks for CIN3+ in women infected by HPV16 or HPV18 were, respectively, 42.0% and 20.5% compared with hrHPV negative women. Moreover, the relative risk in women infected by non-16 and non-18 hrHPV was only 8%. This is why it has been proposed to refer HPV16/18 positive women with normal cytology to immediate colposcopy [14,15].
Other biomarkers have been assessed to manage hrHPV positive women that include HPV genotyping, p16/Ki67 dual-staining, or methylation status of HPV and some human genes [16,17,18,19,20]. Assessing HPV16/18 viral load (VL) could also represent an attractive option and few longitudinal studies showed that HPV load levels might reflect the natural history of cervical lesions [21,22,23].
In the present study, HPV16 and HPV18 VL were assessed as potential risk factors for the development of high-grade lesions from a large French hospital-based cohort of women infected by hrHPV and presenting without or with equivocal or mildly abnormal cytology.

2. Materials and Methods

2.1. Patients

From January 2009 to September 2017, women attending the Gynecology Clinic of the Besançon’s University Hospital consented to cervical cancer screening with conventional Pap cytology and hrHPV test using the Hybrid Capture 2 (hc2) assay (Qiagen, Courtaboeuf, France). They were followed-up as previously described [24]. Cervical smears positive for hrHPV were further tested for HPV16 and HPV18 VL, the two most prevalent HPV in cervical cancers, using homemade real-time PCRs [25]. Women presenting cervical abnormalities (cytology ≥ LSIL) at the first visit or during the FU were referred for colposcopy and managed according to the French clinical practice guidelines.
The main study endpoint was the histological diagnosis of a high-grade lesion during the FU. In this way, women presenting a high-grade lesion of the cervix (HSIL cytology or CIN2+ histology) at the first visit or with a history of high-grade lesion were excluded from the study. Socio-demographic characteristics, virological, pathological and clinical data were retrieved from medical records.
All samples were stored into a biobank for which a declaration of preparation and storage of human samples for research use has been sent to the Ministère de l’Enseignement Supérieur et de la Recherche (no. DC-2014-2086).

2.2. Cytological and Histological Data

Cytological and histological samples were analyzed at the Pathology Department of the University Hospital of Besançon. The Bethesda System was used for reporting Pap smear results. The WHO 2014 classification was used to describe histological results.

2.3. High-Risk HPV DNA Testing

hrHPV DNA testing was performed from specimen transport medium (STM) using the clinically validated hc2 assay according to the manufacturer’s instructions. This assay detects the most common hrHPV types namely HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68 but does not differentiate HPV types. Presence or absence of hrHPV DNA in the cervical specimens was defined according to the strength in relative light units (RLU) compared to the HPV positive control (PC) harboring 1 pg/mL of HPV16 DNA. Samples were considered positive when the RLU/PC ratio was 1.
All hrHPV positive samples were also tested for HPV16 and HPV18 VL. DNA was extracted from 100 µL of STM with the QIAamp DNA Mini Kit (Qiagen). Simplex real-time PCRs were used to quantify viral load with the LightCycler 480 (Roche Diagnostic, Meylan, France) using 2× Takyon qPCR kit (Kaneka Eurogentec, Seraing, Belgium). Primer and probe sequences are described in the Table S1. Standard curves for viral DNA quantification were made with serial 1:10 dilutions over a range of 7 log concentrations of pBR322 HPV16 or pBR322 HPV18 plasmids. The thermal cycling conditions were a hot start for 3 min at 95 °C followed by 10 min at 95 °C and then 40 cycles of amplification (95 °C for 15 s, 60 °C for 1 min). Albumin gene quantification was used for normalization of VL considering that each cell harbors 2 albumin gene copies. Viral loads were expressed either as HPV16 and HPV18 genome equivalent (GE) per 103 cells or as HPV16 and HPV18 GE per mL of cervical sample. For greater convenience and legibility, the VL values have been log10 transformed.

2.4. Data Analyses

Patients’ characteristics at baseline are shown for the study population. Mean with standard deviation (SD), median with interquartile range (IQR) and frequency with percentage were used to describe continuous and categorical variables, respectively, and compared with Wilcoxon test and Chi-Square test or Fisher test when necessary.
Median and 95% confidence interval (CI) for time-to-event analyses were estimated with the Kaplan–Meier method and compared with the log-rank test. Cox regression models were performed to estimate the hazard ratio (HR) with 95% CI. Association between major characteristics at baseline and time to high-grade lesion progression was assessed in Cox univariate analysis. Variables with p value < 0.1 in univariate analysis were introduced in the multivariate model and a stepwise selection was performed. Hazard proportionality was checked by plotting log-minus-log survival curves and colinearity between variables was assessed. Restricted cubic spline methodology was used to estimate the link between continuous variables and the outcome in order to identify an optimal cut-off of VL for categorization.
To identify populations with different risk of high-grade lesion occurrence, a prognostic score was proposed derived from the multivariable Cox model; for each variable, a weight of 0 was given to the reference modality and the HR rounded to the nearest integer for the other modalities, the sum of the weights giving the final score. Three groups of patients were thus identified namely at low risk (score = 0–1), intermediate risk (score = 2–3) and high risk (score 4–6).
All tests were two-sided and p-values were considered as statistically significant when <0.05. All analyses were performed using SAS version 9.3 (SAS Institute, Cary, NC, USA) and R software version 3.4.3 (R Development Core Team, Vienna, Austria; http://www.r-project.org, accessed on 14 June 2021).

3. Results

3.1. Population

The flow chart of the study is presented in Figure S1. Among the 10,601 women attending the Gynecology Clinic for the first time and co-tested with conventional Pap cytology and hrHPV test, 2102 (19.8%) had a positive hrHPV test with HPV 16/18 VL available. Four hundred eighty-three women with a cervical high-grade lesion at the first visit, 47 women having had a previous history of high-grade lesion and 687 women with no follow-up visit (FU) at the Gynecology Clinic of Besançon’s Hospital were excluded from the analysis. Finally, 885 patients (56.0%) having had ≤LSIL cytology at the first visit and at least one FU visit were referred as to the “study population”. Among them, 135 (15%) developed a high-grade lesion of the cervix during the FU.
The socio-demographic characteristics of the study population are described in Table 1. The mean age was 37 years. The majority of women (60%) had 1–3 children and oral contraception was used by 47% of the population. Thirty two percent of women were current smokers.

3.2. Pathological and Virological Characteristics at First, Visit

Equivocal and mildly abnormal cytology were detected in approximately 22% of samples (Table 2). The majority of cytological abnormalities were LSIL (16.5%), while ASC-US represented 5.7% of abnormal smears. Histological results were available for 11% of women and CIN1 was observed in 5.7% of cases.
The median value of RLU/PC given by the hc2 test was 53 (8–319) RLU/PC. Thirty percent of samples presented low (1–10 pg/mL) or middle (11–100 pg/mL) values of RLU/PC and 40% presented high RLU/PC values (>100 pg/mL). The overall HPV16 and HPV18 prevalence was 25.9% and 8.4%, respectively. HPV16 and HPV18 median VL were 3.1 and 3.5 log10GE/103 cells, respectively.
At the end of the follow-up, a prevalence of HPV16 of 46.6% and 21.3% was observed in the subgroup of women with high-grade lesion and in the subgroup of women without high-grade lesion, respectively (p < 0.0001). The prevalence of HPV18 was 8.1% and 8.0% in the subgroup of women with high-grade lesion and in the subgroup of women without high-grade lesion, respectively (p = 0.992).

3.3. Follow-Up and Time to Lesion

The 885 patients included in the analysis had a median of 2 additional visits (from 1 to 11) with cervical samples taken for cytology and HPV testing. The median delay between two visits was 12 months. A high-grade lesion was diagnosed in 135 patients (15%) during the FU and several baseline variables were analyzed using the Cox univariate model (Table 3). Parity (p = 0.44) and immunodepression (p = 0.75) were not associated with a risk to develop a high-grade lesion. A trend for tobacco consumption to be associated with a higher risk for high-grade lesion occurrence was identified (HR 1.4 95% CI 0.99–1.99 p = 0.0582). Using local contraception or being menopausal proved to be protective for the occurrence of high-grade lesion (HR 0.62 95% CI 0.41–0.93 p = 0.0223).
As for cytology results, ASC-US or LSIL smear was significantly associated with a higher risk of high-grade lesion development compared to a Negative for Intraepithelial Lesion and Malignancy (NILM) smear (HR = 2.16; 95% CI 1.54–3.05 p < 10−4).
Furthermore, there was an association between the development of a high-grade lesion and the semi-quantitative hrHPV load determined by the hc2 assay (p < 0.0001). A significant increased risk (HR = 1.98 95% CI 1.41–2.78 p < 10−4) of high-grade lesion outcome was associated with >100 RLU/PC load compared to a 1–100 RLU/PC load. Since the presence of HPV16 DNA (Table 3) in baseline smears was associated with a 2.39 higher risk of high-grade lesion (p < 0.0001; 95% CI 1.70–3.37), the presence of HPV18 did not confer any increased risk.
Not surprisingly, Kaplan–Meier curves showed that the time to high-grade lesion occurrence was shorter in HPV16 positive women compared to those infected by hrHPVs other than HVPV16/18 (Figure 1). In contrast, the time to high-grade lesion occurrence was not different between women infected by HPV18 and women infected by hrHPV other than HPV16/18 (Figure 1).
Then, the prognostic value of the viral load assessed using hc2 assay was addressed in the limited group of HPV16+ cases. As shown in Figure S2, the time to CIN2+ occurrence was shorter in women with >100 RLU/PC load compared to those with a 1–100 RLU/PC load. Such a prognostic value was not observed in the subgroup of HPV18 positive women.
Restricted cubic spline analysis showed linear association for log10 of HPV16 VL in relation to high-grade lesion development. Thus, an HPV16 VL cut-off set at 3.2 log10GE/103 cells permitted to identify a subgroup of HPV16 infected women at high risk of developing high-grade lesion with a HR of 3.09 (95% CI 2.14–4.48 p < 0.0001) (Table 3). Furthermore, the Kaplan–Meier estimate showed that HPV16 DNA load at first visit and lesion free probability were strongly correlated. Thus, women with a HPV16 VL below 3.2 log10GE/103 cells (HPV16 low) had a significantly longer time to high-grade lesion probability compared to women presenting a HPV16 VL > 3.2 log10GE/103 cells (HPV16 high) (Figure 2) (p = 0.0064). No specific HPV18 VL threshold could have been defined to predict the outcome of a CIN2+ (Table 3).
In multivariate analysis, HPV16 load (absence/log10GE/103 cells <3.2 vs ≥3.2), RLU/PC (1–100 pg/mL vs >100 pg/mL) and cytology (normal vs abnormal) were independently associated with a significant increased risk of high-grade lesion development (Table 4) and were used to construct the prognostic score. In a Cox univariate model, scores 2–3 and 4–6 were significantly associated with a higher risk of high-grade lesion outcome with HRs of 2.39 (95% CI 1.61–3.57 p < 10−4) and 4.53 (95% CI 2.92–7.01 p < 10−4), respectively (Table S2, Figure S3).

4. Discussion

In this study, we confirm on a large cohort of women infected by hrHPV and presenting without or with mild abnormalities that HPV16 DNA load may independently predict the development of CIN2+ [21,22,26,27,28,29,30,31]. On the contrary, being infected by HPV 18, did not confer an increased risk of high-grade cervical lesion development compared to other hrHPVs.
In this study, the high incidence of high-grade lesions is consistent with a previous study conducted in our hospital showing that 18.5% of hrHPV infected women with normal cytology or mild cytological abnormalities developed a high-grade lesion [4]. Now considering that hrHPV+ women infected by HPV16/18 with no of mild cervical abnormalities are at risk of cervical lesions, it cannot be excluded that some cases were already present at baseline since no colposcopy was done. As expected, Cox univariate analysis revealed that in this group of hrHPV infected women, an abnormal cytology was a prognostic factor associated with the evolution to high-grade lesions [4,32,33]. In the same line, RLU/PC values >100 increased significantly the risk of developing CIN2+ confirming previous observations and the potential usefulness of hrHPV load as a marker towards pre-cancers [4,34,35,36].
The proportion of HPV16 and HPV18 positive samples among hrHPV positive samples was similar in this cohort to that reported in French or international studies [7,8,37,38]. As expected, at the end of the follow-up the prevalence of HPV16 was higher (almost 2-fold higher) in women presenting a high-grade lesion than in women with no high-grade lesion. This observation confirms that HPV16 infections are at high risk of high-grade lesion development. Even if HPV16 and HPV18 are the most frequently detected genotypes in cervical cancers [6,7], HPV16 but not HPV18 infected women presented an increased risk of CIN2+ development. Numerous studies revealed that HPV18 was not consistently ranked at the second place after HPV16 among the most at-risk genotypes. In this series, the prevalence of HPV18 did not increase notably in CIN2+ cases compared to normal cytology. For instance, in a large series of hrHPV positive women with normal cytology the three years cumulative risk of CIN2+ was the highest for those infected by HPV16 (16.7%), followed by those infected by HPV52 and HPV31 (10.2%) and then by those infected by HPV18 [17]. Numerous other papers, reviewed by Cuzick and Wheeler [39], revealed that HPV31 and HPV33 were associated with a higher risk of CIN2+ lesion than HPV18. They also pointed out that HPV18 was more specifically linked to endocervical adenocarcinoma in situ and adenocarcinoma. Because complete genotyping is not available as a routine test in our hospital, individual genotype risk could not be assessed in the current study. Interestingly, high viral loads (>100 RLU/PC) assessed using the hc2 test add prognostic value in the subgroup of hrHPV positive patients infected by HPV16.
Next, the specific HPV16 VL was investigated as a risk factor enabling prediction to high-grade lesion. Kaplan–Meier curves for CIN2+ lesion-free probability clearly showed that a HPV16 load with a cut-off set at 3.2 log10GE/103 cells was significantly associated with the development of histologically proven high-grade squamous intraepithelial lesion. Very scarce studies addressed the question of a HPV16 load cut-off as a prognostic factor for incident high-grade lesion. Using a normalized HPV16 load, Monnier et al. in our laboratory proposed a cut-off value of 200 GE/103 cells for discriminating women with the highest risk for developing CIN2+ [21]. It is noteworthy that this cut-off is of the same order of magnitude (less than 1 log10 difference), even if the present study design was different. The multivariate analysis confirmed that HPV16 VL was an independent prognosis factor for high-grade lesion outcome as were RLU/PC values and cytology.
To go further, composite scores grouping these three variables were built. As expected, the HRs increased with the scores and reached a maximum for the highest scores. This is in line with recent data showing that a combination of virological parameters (hrHPV load assessed by hc2 and HPV16/18 genotyping), proved to be efficient to screen for prevalent CIN2+ [36].
The present survey conducted on a large cohort of women followed-up for 8 years provides strong evidence that viral load may be a relevant signature to efficiently triage women infected by HPV16 and presenting without or with equivocal or mildly abnormal cytology (ASC-US; LSIL) for the occurrence of high-grade lesion. From a clinical point of view, the present data obtained in the context of switching primary cervical cancer screening from cytology to population-based screening programs with hrHPV testing [13] are of most importance. Indeed, since hrHPV testing is a very sensitive strategy for CIN2+ screening, biomarkers are still needed to better triage women with the highest risk of cervical (pre-) cancer. In this context, measuring HPV16 load should be seriously considered. This may be particularly relevant in hrHPV-positive women with normal cytology that could be referred directly to colposcopy if a high HPV16 load (>3.2 log10GE/103 cells) is measured.
Validation guidelines for specific HPV DNA load quantification are lacking and addressing the relevance of VL for other hrHPVs, notably HPV31, 33 or 52, remains an open question. If home-made HPV load quantification tests are adapted for research use, they may not be sufficiently robust to be used in a routine laboratory. Now, numerous commercial hrHPV screening tests are available that permit partial HPV16/18 identification [40]. Most of these in vitro diagnosis devices, dedicated to qualitative detection of HPV nucleic acids, are based on real-time PCR. It would be interesting to exploit their quantitative potential to assess HPV load directly from the primary sample. Furthermore, investigations are needed to prospectively evaluate the benefit of HPV DNA load in cervical cancer screening program. It is anticipated that such large studies would also help defining the best cut-offs for optimal management of hrHPV positive women with no or mild abnormalities at the cervix level.
The present study is based on virological and pathological data obtained prospectively in a routine medical care setting from patients attending the Gynecology Clinic of the Besançon’s University Hospital. This pragmatic design based on standard operating procedures for cervical cell sampling, sample transportation and laboratory analyses allow us to get close to real-life conditions. It also demonstrates the feasibility of implementing new biological parameters to improve cervical cancer screening. Validated real-time PCR were used for HPV16 and HPV18 DNA quantification [25], a technology that makes it possible to accurately and objectively evaluate VL. It also permits to set-up a clinically relevant cut-off for HPV16 load at 3.2 log10GE/103 cells for patient’s risk stratification. Now, the hospital-based population of women included in this study is probably not representative of the general population. Thus, one should be cautious regarding the generalization of these results and it would be important to reproduce these results in an independent cohort. Furthermore, the impact of multiple infection on VL performance has not been addressed since HPV genotyping is not performed routinely.

5. Conclusions

In the case of hrHPV positivity, triage tests are needed to optimally manage women. In the present study, we confirm the clinical usefulness of HPV16 genotyping and HPV16 VL load to identify women most at risk of cervical high-grade lesion.

Supplementary Materials

The following are available online at https://www.mdpi.com/article/10.3390/cancers13164149/s1, Figure S1: Flow chart for the hrHPV DNA test and HPV16/18 DNA load test performed on the study population, Figure S2: Kaplan–Meier estimates for time from baseline to the development of high grade lesion according to hc2 results in HPV16 positive women, Figure S3: Kaplan–Meier estimates for time from baseline to the development of high grade lesion according to prognostic score, Table S1: Sequences of qPCR primer pairs and probes targeting a polymorphic region of HPV16 and HPV18 E6 genes and the cellular albumin gene, Table S2: Univariate cox model for the association between prognostic groups and high grade lesion occurrence in the study population.

Author Contributions

Conceptualization, C.M. and J.-L.P.; Data curation, A.B. and J.-L.P.; Formal analysis, A.B., Q.L., S.V.-D., C.M. and J.-L.P.; Investigation, Z.S., D.R. and R.R.; Methodology, J.H., A.M., D.V. and S.P.-B.; Supervision, J.-L.P.; Writing—original draft, A.B. and J.-L.P.; Writing—review and editing, J.H., Z.S., Q.L., D.V., S.V.-D., D.R., R.R., C.M. and J.-L.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

All samples were stored into a biobank for which a declaration of preparation and storage of human samples for research use has been sent to the Ministère de l’Enseignement Supérieur et de la Recherche (no. DC-2014-2086).

Informed Consent Statement

Patients were informed about the storage and processing of their specimen. Opposition to the use of the specimen was collected.

Data Availability Statement

Data are available upon request to the corresponding author.

Acknowledgments

We thank E. M. de Villiers (DKFZ, Heidelberg, Germany) for kindly providing us with the HPV16 and HPV18 plasmids. The technicians and engineer from the cell and molecular biology laboratory and from the CNR Papillomavirus are gratefully acknowledged for their excellent technical assistance with hrHPV and HPV16/18 testing.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Bosch, F.X.; de Sanjosé, S. Chapter 1: Human papillomavirus and cervical cancer—Burden and assessment of causality. J. Natl. Cancer Inst. Monogr. 2003, 3–13. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  2. Walboomers, J.M.; Jacobs, M.V.; Manos, M.M.; Bosch, F.X.; Kummer, J.A.; Shah, K.V.; Snijders, P.J.; Peto, J.; Meijer, C.J.; Muñoz, N. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J. Pathol. 1999, 189, 12–19. [Google Scholar] [CrossRef]
  3. Wallin, K.L.; Wiklund, F.; Angström, T.; Bergman, F.; Stendahl, U.; Wadell, G.; Hallmans, G.; Dillner, J. Type-specific persistence of human papillomavirus DNA before the development of invasive cervical cancer. N. Engl. J. Med. 1999, 341, 1633–1638. [Google Scholar] [CrossRef]
  4. Dalstein, V.; Riethmuller, D.; Prétet, J.-L.; Le Bail Carval, K.; Sautière, J.-L.; Carbillet, J.-P.; Kantelip, B.; Schaal, J.-P.; Mougin, C. Persistence and load of high-risk HPV are predictors for development of high-grade cervical lesions: A longitudinal French cohort study. Int. J. Cancer 2003, 106, 396–403. [Google Scholar] [CrossRef]
  5. Bouvard, V.; Baan, R.; Straif, K.; Grosse, Y.; Secretan, B.; El Ghissassi, F.; Benbrahim-Tallaa, L.; Guha, N.; Freeman, C.; Galichet, L.; et al. A review of human carcinogens—Part B: Biological agents. Lancet Oncol. 2009, 10, 321–322. [Google Scholar] [CrossRef]
  6. Muñoz, N.; Bosch, F.X.; de Sanjosé, S.; Herrero, R.; Castellsagué, X.; Shah, K.V.; Snijders, P.J.F.; Meijer, C.J.L.M. International agency for research on cancer multicenter cervical cancer study group epidemiologic classification of human papillomavirus types associated with cervical cancer. N. Engl. J. Med. 2003, 348, 518–527. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  7. Guan, P.; Howell-Jones, R.; Li, N.; Bruni, L.; de Sanjosé, S.; Franceschi, S.; Clifford, G.M. Human papillomavirus types in 115,789 HPV-positive women: A meta-analysis from cervical infection to cancer. Int. J. Cancer 2012, 131, 2349–2359. [Google Scholar] [CrossRef] [PubMed]
  8. Prétet, J.-L.; Jacquard, A.-C.; Carcopino, X.; Charlot, J.-F.; Bouhour, D.; Kantelip, B.; Soubeyrand, B.; Leocmach, Y.; Mougin, C.; Riethmuller, D.; et al. Human papillomavirus (HPV) genotype distribution in invasive cervical cancers in France: EDITH study. Int. J. Cancer 2008, 122, 428–432. [Google Scholar] [CrossRef] [PubMed]
  9. Khan, M.J.; Castle, P.E.; Lorincz, A.T.; Wacholder, S.; Sherman, M.; Scott, D.R.; Rush, B.B.; Glass, A.G.; Schiffman, M. The elevated 10-year risk of cervical precancer and cancer in women with human papillomavirus (HPV) type 16 or 18 and the possible utility of type-specific HPV testing in clinical practice. J. Natl. Cancer Inst. 2005, 97, 1072–1079. [Google Scholar] [CrossRef] [PubMed]
  10. ASCUS-LSIL Triage Study (ALTS) Group. Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance. Am. J. Obstet. Gynecol. 2003, 188, 1383–1392. [Google Scholar] [CrossRef]
  11. Ronco, G.; Giorgi Rossi, P. Role of HPV DNA testing in modern gynaecological practice. Best Pract. Res. Clin. Obstet. Gynaecol. 2018, 47, 107–118. [Google Scholar] [CrossRef]
  12. Koliopoulos, G.; Nyaga, V.N.; Santesso, N.; Bryant, A.; Martin-Hirsch, P.P.; Mustafa, R.A.; Schünemann, H.; Paraskevaidis, E.; Arbyn, M. Cytology versus HPV testing for cervical cancer screening in the general population. Cochrane Database Syst. Rev. 2017, 8, CD008587. [Google Scholar] [CrossRef] [PubMed]
  13. Chrysostomou, A.C.; Stylianou, D.C.; Constantinidou, A.; Kostrikis, L.G. Cervical cancer screening programs in Europe: The transition towards HPV vaccination and population-based HPV testing. Viruses 2018, 10, 729. [Google Scholar] [CrossRef] [Green Version]
  14. Cox, J.T.; Castle, P.E.; Behrens, C.M.; Sharma, A.; Wright, T.C.; Cuzick, J. Athena HPV study group comparison of cervical cancer screening strategies incorporating different combinations of cytology, HPV testing, and genotyping for HPV 16/18: Results from the ATHENA HPV study. Am. J. Obstet. Gynecol. 2013, 208, 184.e1–184.e11. [Google Scholar] [CrossRef]
  15. Wright, T.C.; Stoler, M.H.; Sharma, A.; Zhang, G.; Behrens, C.; Wright, T.L. ATHENA (Addressing THE Need for Advanced HPV Diagnostics) study group evaluation of HPV-16 and HPV-18 genotyping for the triage of women with high-risk HPV+ cytology-negative results. Am. J. Clin. Pathol. 2011, 136, 578–586. [Google Scholar] [CrossRef]
  16. Wentzensen, N.; Arbyn, M.; Berkhof, J.; Bower, M.; Canfell, K.; Einstein, M.; Farley, C.; Monsonego, J.; Franceschi, S. Eurogin 2016 Roadmap: How HPV knowledge is changing screening practice. Int. J. Cancer 2017, 140, 2192–2200. [Google Scholar] [CrossRef]
  17. Schiffman, M.; Burk, R.D.; Boyle, S.; Raine-Bennett, T.; Katki, H.A.; Gage, J.C.; Wentzensen, N.; Kornegay, J.R.; Aldrich, C.; Tam, T.; et al. A study of genotyping for management of human papillomavirus-positive, cytology-negative cervical screening results. J. Clin. Microbiol. 2015, 53, 52–59. [Google Scholar] [CrossRef] [Green Version]
  18. Stoler, M.H.; Baker, E.; Boyle, S.; Aslam, S.; Ridder, R.; Huh, W.K.; Wright, T.C. Approaches to triage optimization in HPV primary screening: Extended genotyping and p16/Ki-67 dual-stained cytology-retrospective insights from ATHENA. Int. J. Cancer 2019. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  19. Verhoef, V.M.J.; Bosgraaf, R.P.; van Kemenade, F.J.; Rozendaal, L.; Heideman, D.A.M.; Hesselink, A.T.; Bekkers, R.L.M.; Steenbergen, R.D.M.; Massuger, L.F.A.G.; Melchers, W.J.G.; et al. Triage by methylation-marker testing versus cytology in women who test HPV-positive on self-collected cervicovaginal specimens (PROHTECT-3): A randomised controlled non-inferiority trial. Lancet Oncol. 2014, 15, 315–322. [Google Scholar] [CrossRef]
  20. Kelly, H.; Benavente, Y.; Pavon, M.A.; De Sanjose, S.; Mayaud, P.; Lorincz, A.T. Performance of DNA methylation assays for detection of high-grade cervical intraepithelial neoplasia (CIN2+): A systematic review and meta-analysis. Br. J. Cancer 2019, 121, 954–965. [Google Scholar] [CrossRef]
  21. Monnier-Benoit, S.; Dalstein, V.; Riethmuller, D.; Lalaoui, N.; Mougin, C.; Prétet, J.L. Dynamics of HPV16 DNA load reflect the natural history of cervical HPV-associated lesions. J. Clin. Virol. 2006, 35, 270–277. [Google Scholar] [CrossRef]
  22. van Duin, M.; Snijders, P.J.F.; Schrijnemakers, H.F.J.; Voorhorst, F.J.; Rozendaal, L.; Nobbenhuis, M.A.E.; van den Brule, A.J.C.; Verheijen, R.H.M.; Helmerhorst, T.J.; Meijer, C.J.L.M. Human papillomavirus 16 load in normal and abnormal cervical scrapes: An indicator of CIN II/III and viral clearance. Int. J. Cancer 2002, 98, 590–595. [Google Scholar] [CrossRef] [PubMed]
  23. Moberg, M.; Gustavsson, I.; Wilander, E.; Gyllensten, U. High viral loads of human papillomavirus predict risk of invasive cervical carcinoma. Br. J. Cancer 2005, 92, 891–894. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  24. Dalstein, V.; Riethmuller, D.; Sautière, J.L.; Prétet, J.L.; Kantelip, B.; Schaal, J.P.; Mougin, C. Detection of cervical precancer and cancer in a hospital population; Benefits of testing for human papillomavirus. Eur. J. Cancer Oxf. Engl. 1990 2004, 40, 1225–1232. [Google Scholar] [CrossRef]
  25. Jacquin, E.; Saunier, M.; Mauny, F.; Schwarz, E.; Mougin, C.; Prétet, J.-L. Real-time duplex PCR for simultaneous HPV 16 and HPV 18 DNA quantitation. J. Virol. Methods 2013, 193, 498–502. [Google Scholar] [CrossRef] [PubMed]
  26. Xi, L.F.; Hughes, J.P.; Castle, P.E.; Edelstein, Z.R.; Wang, C.; Galloway, D.A.; Koutsky, L.A.; Kiviat, N.B.; Schiffman, M. Viral load in the natural history of human papillomavirus type 16 infection: A nested case-control study. J. Infect. Dis. 2011, 203, 1425–1433. [Google Scholar] [CrossRef] [Green Version]
  27. Carcopino, X.; Henry, M.; Mancini, J.; Giusiano, S.; Boubli, L.; Olive, D.; Tamalet, C. Significance of HPV 16 and 18 viral load quantitation in women referred for colposcopy. J. Med. Virol. 2012, 84, 306–313. [Google Scholar] [CrossRef]
  28. Carcopino, X.; Henry, M.; Mancini, J.; Giusiano, S.; Boubli, L.; Olive, D.; Tamalet, C. Two years outcome of women infected with high risk HPV having normal colposcopy following low-grade or equivocal cytological abnormalities: Are HPV16 and 18 viral load clinically useful predictive markers? J. Med. Virol. 2012, 84, 964–972. [Google Scholar] [CrossRef]
  29. Josefsson, A.M.; Magnusson, P.K.; Ylitalo, N.; Sørensen, P.; Qwarforth-Tubbin, P.; Andersen, P.K.; Melbye, M.; Adami, H.O.; Gyllensten, U.B. Viral load of human papilloma virus 16 as a determinant for development of cervical carcinoma in situ: A nested case-control study. Lancet Lond. Engl. 2000, 355, 2189–2193. [Google Scholar] [CrossRef]
  30. Depuydt, C.E.; Thys, S.; Beert, J.; Jonckheere, J.; Salembier, G.; Bogers, J.J. Linear viral load increase of a single HPV-type in women with multiple HPV infections predicts progression to cervical cancer. Int. J. Cancer 2016, 139, 2021–2032. [Google Scholar] [CrossRef]
  31. Depuydt, C.E.; Criel, A.M.; Benoy, I.H.; Arbyn, M.; Vereecken, A.J.; Bogers, J.J. Changes in type-specific human papillomavirus load predict progression to cervical cancer. J. Cell. Mol. Med. 2012, 16, 3096–3104. [Google Scholar] [CrossRef] [PubMed]
  32. Schlecht, N.F.; Platt, R.W.; Duarte-Franco, E.; Costa, M.C.; Sobrinho, J.P.; Prado, J.C.M.; Ferenczy, A.; Rohan, T.E.; Villa, L.L.; Franco, E.L. Human papillomavirus infection and time to progression and regression of cervical intraepithelial neoplasia. J. Natl. Cancer Inst. 2003, 95, 1336–1343. [Google Scholar] [CrossRef] [Green Version]
  33. Moscicki, A.B.; Hills, N.; Shiboski, S.; Powell, K.; Jay, N.; Hanson, E.; Miller, S.; Clayton, L.; Farhat, S.; Broering, J.; et al. Risks for incident human papillomavirus infection and low-grade squamous intraepithelial lesion development in young females. JAMA 2001, 285, 2995–3002. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  34. Gravitt, P.E.; Burk, R.D.; Lorincz, A.; Herrero, R.; Hildesheim, A.; Sherman, M.E.; Bratti, M.C.; Rodriguez, A.C.; Helzlsouer, K.J.; Schiffman, M. A comparison between real-time polymerase chain reaction and hybrid capture 2 for human papillomavirus DNA quantitation. Cancer Epidemiol. Biomark. Prev. Publ. 2003, 12, 477–484. [Google Scholar]
  35. Origoni, M.; Carminati, G.; Rolla, S.; Clementi, M.; Sideri, M.; Sandri, M.T.; Candiani, M. Human papillomavirus viral load expressed as relative light units (RLU) correlates with the presence and grade of preneoplastic lesions of the uterine cervix in atypical squamous cells of undetermined significance (ASCUS) cytology. Eur. J. Clin. Microbiol. Infect. Dis. 2012, 31, 2401–2406. [Google Scholar] [CrossRef]
  36. Luo, H.; Du, H.; Belinson, J.L.; Wu, R. Evaluation of alternately combining HPV viral load and 16/18 genotyping in secondary screening algorithms. PLoS ONE 2019, 14, e0220200. [Google Scholar] [CrossRef]
  37. Heard, I.; Tondeur, L.; Arowas, L.; Falguières, M.; Demazoin, M.-C.; Favre, M. Human papillomavirus types distribution in organised cervical cancer screening in France. PLoS ONE 2013, 8, e79372. [Google Scholar] [CrossRef]
  38. Lagos, M.; Van De Wyngard, V.; Poggi, H.; Cook, P.; Viviani, P.; Barriga, M.I.; Pruyas, M.; Ferreccio, C. HPV16/18 genotyping for the triage of HPV positive women in primary cervical cancer screening in Chile. Infect. Agent. Cancer 2015, 10, 43. [Google Scholar] [CrossRef] [Green Version]
  39. Cuzick, J.; Wheeler, C. Need for expanded HPV genotyping for cervical screening. Papillomavirus Res. Amst. Neth. 2016, 2, 112–115. [Google Scholar] [CrossRef] [Green Version]
  40. Poljak, M.; Oštrbenk Valenčak, A.; Gimpelj Domjanič, G.; Xu, L.; Arbyn, M. Commercially available molecular tests for human papillomaviruses: A global overview. Clin. Microbiol. Infect. Off. 2020. [Google Scholar] [CrossRef]
Cancers 13 04149 g001 550
Figure 1. Kaplan-Meier estimates for time from baseline to the development of CIN2+ according to HPV16/HPV18 status (up), HPV16 (middle) and HPV18 (down) status vs other hrHPV. LCI: 95% Lower Confidence Interval; 95% UCI: Upper Confidence Interval. NA: Not available; HPV: Human Papillomavirus.
Figure 1. Kaplan-Meier estimates for time from baseline to the development of CIN2+ according to HPV16/HPV18 status (up), HPV16 (middle) and HPV18 (down) status vs other hrHPV. LCI: 95% Lower Confidence Interval; 95% UCI: Upper Confidence Interval. NA: Not available; HPV: Human Papillomavirus.
Cancers 13 04149 g001
Cancers 13 04149 g002 550
Figure 2. Kaplan-Meier estimates for time from baseline to the development of CIN2+ according to HPV16 viral load (log10GE/103 cells). LCI: 95% Lower Confidence Interval; UCI: 95% Upper Confidence Interval. NA: Not available; HPV: Human Papillomavirus.
Figure 2. Kaplan-Meier estimates for time from baseline to the development of CIN2+ according to HPV16 viral load (log10GE/103 cells). LCI: 95% Lower Confidence Interval; UCI: 95% Upper Confidence Interval. NA: Not available; HPV: Human Papillomavirus.
Cancers 13 04149 g002
Table
Table 1. Socio-demographic characteristics of the study population.
Table 1. Socio-demographic characteristics of the study population.
CharacteristicsStudy Population (n = 885) n (%)
Age (year)
Mean ± SD37.4 ± 11.7
Median (q1–q3)34.5 (28.5–44.5)
Parity
0260 (35.0)
1191 (25.7)
2–3260 (35.0)
>333 (4.4)
NA141
Contraception
Oral contraception381 (47.7)
Local contraception138 (17.3)
Intra-uterine device155 (19.4)
Menopause124 (15.5)
NA87
Immunocompromised
Transplantation21 (15.8)
HIV infection 34 (25.6)
Haemopathy and cancer33 (24.8)
Auto-immune disease44 (33.1)
Chronic renal failure1 (0.7)
NA752
Tobacco smoking history
Current smoker284 (32.1)
Never / Ex-smoker601 (67.9)
Sexually Transmitted Infection
HIV *34 (47.2)
Chlamydia24 (33.33)
HSV216 (22.2)
Syphilis2 (2.8)
HBV2 (2.8)
NA813
SD: Standard deviation; NA: Not available; HIV: Human immunodeficiency virus; HSV2: Herpes simplex virus 2; HBV: Hepatitis B virus; * including co-infection cases as HIV+Chlamydia or HIV+Syphilis.
Table
Table 2. Cytology, Histology, hrHPV, HPV16 and HPV18 DNA loads.
Table 2. Cytology, Histology, hrHPV, HPV16 and HPV18 DNA loads.
VariablesStudy Population (n = 885) n (%)
Cytology
Unsatisfactory66 (7.5)
NILM621 (70.3)
ASC-US51 (5.7)
LSIL146 (16.5)
NA1
Histology
Normal45 (5.9)
CIN150 (5.7)
NA790 (89.3)
hc2
Mean RLU/PC (pg/mL) ± SD326 ± 597
Median RLU/PC (pg/mL) (q1–q3)53 (8–319)
hc2 RLU/PC distribution
1–10 pg/mL262 (29.6)
11–100 pg/mL267 (30.2)
>100 pg/mL356 (40.2)
HPV16
Negative660 (74.9)
Positive*221 (25.9)
Mean (Log10GE/103 cells) ± SD3.1 ± 1.3
Median (q1–q3) (Log10GE/103 cells)3.2 (2.1–4)
Mean (Log10GE/mL) ± SD7.1 ± 7.9
Median (q1–q3) (Log10GE/mL)5.8 (5–6.6)
NA
HPV18
Negative789 (92)
Positive *69 (8.4)
Mean (Log10 GE/103 cells) ± SD3.5 ± 1.5
Median (q1–q3) (Log10GE/ 103 cells)3.6 (2.7–4.6)
Mean (Log10GE/ mL) ± SD6.2 ± 1.4
Median (q1–q3) (Log10GE/mL)6.2 (4.3–7.1)
NA27
* including women for whom HPV16 or HPV18 viral loads were below the limit of quantification; ASC-US: Atypical Squamous Cells of Undetermined Significance; CIN: Cervical Intraepithelial Neoplasia; GE: Genome equivalent; hc2: Hybrid Capture 2; LSIL: Low-grade Squamous Intraepithelial Lesion; NA: Not Available; NILM: Negative for Intraepithelial Lesion or malignancy; RLU/PC: Relative Light Unit/Positive Control; SD: Standard Deviation
Table
Table 3. Univariate Cox regression for time from baseline to the development of CIN2+ in the studied population with follow-up.
Table 3. Univariate Cox regression for time from baseline to the development of CIN2+ in the studied population with follow-up.
Variablesn (Events) aHR95% CIp-Value
Parity
0260 (44)1-0.44
1191 (32)0.870.55–1.37-
2–3258 (45)0.860.63–1.45-
>333 (2)0.320.08–1.33-
Contraception
Yes b536 (95)1-0.0223
No c262 (30)0.620.41–0.93-
Immunodepression
No737 (112)1-0.75
Yes145 (23)0.930.59–1.46-
Tobacco smoking
No598 (85)1-0.0582
Yes284 (50)1.40.99–1.99-
Cytology
Normal621 (76)1-<0.0001
Abnormal263 (58)2.161.54–3.05-
Hc2
1–100 pg/mL529 (61)1 <0.0001
>100 pg/mL356 (74)1.981.41–2.78-
HPV16
Absence660 (71)1-<0.0001
Presence221 (62)2.391.70–3.37-
HPV16 load
Absence and Log10 HPV16 GE/103 cells < 3.2780 (91)1 <0.0001
Log10 HPV16 GE/103 cells ≥ 3.2101 (42)3.092.14–4.48-
HPV18
Absence789 (114)1-0.83
Presence69 (10)1.70.56–2.05-
Log10 HPV18 GE/103 cells
<5.259 (7) 1-0.0968
≥5.210 (3)3.190.81–12.51-
a number of subject (number of CIN2+); b Oral contraception and intra-uterine device; c Local contraception and menopause; HR: hazard ratio; CI: confidence interval.
Table
Table 4. Multivariate Cox regression for time from baseline to the development of high-grade lesion in the studied population with follow-up.
Table 4. Multivariate Cox regression for time from baseline to the development of high-grade lesion in the studied population with follow-up.
Variablesn (Events)HR95% CIp-ValueWeight
-880 (132)----
Hc2
1–100 pg/mL527 (60)1-0.050
>100 pg/mL353 (72)1.441.00–2.08-1
Cytology
Normal618 (75)1-<0.00010
Abnormal262 (57)2.021.43–2.87-2
HPV16
Absence and Log10 HPV16 GE/103 cells < 3.2780 (91)1-<0.00010
Log10 HPV16 GE/103 cells ≥ 3.2100 (41)2.671.80–3.97-3
HR: hazard ratio; CI: confidence interval.
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Baumann, A.; Henriques, J.; Selmani, Z.; Meurisse, A.; Lepiller, Q.; Vernerey, D.; Valmary-Degano, S.; Paget-Bailly, S.; Riethmuller, D.; Ramanah, R.; et al. HPV16 Load Is a Potential Biomarker to Predict Risk of High-Grade Cervical Lesions in High-Risk HPV-Infected Women: A Large Longitudinal French Hospital-Based Cohort Study. Cancers 2021, 13, 4149. https://doi.org/10.3390/cancers13164149

AMA Style

Baumann A, Henriques J, Selmani Z, Meurisse A, Lepiller Q, Vernerey D, Valmary-Degano S, Paget-Bailly S, Riethmuller D, Ramanah R, et al. HPV16 Load Is a Potential Biomarker to Predict Risk of High-Grade Cervical Lesions in High-Risk HPV-Infected Women: A Large Longitudinal French Hospital-Based Cohort Study. Cancers. 2021; 13(16):4149. https://doi.org/10.3390/cancers13164149

Chicago/Turabian Style

Baumann, Antoine, Julie Henriques, Zohair Selmani, Aurélia Meurisse, Quentin Lepiller, Dewi Vernerey, Séverine Valmary-Degano, Sophie Paget-Bailly, Didier Riethmuller, Rajeev Ramanah, and et al. 2021. "HPV16 Load Is a Potential Biomarker to Predict Risk of High-Grade Cervical Lesions in High-Risk HPV-Infected Women: A Large Longitudinal French Hospital-Based Cohort Study" Cancers 13, no. 16: 4149. https://doi.org/10.3390/cancers13164149

APA Style

Baumann, A., Henriques, J., Selmani, Z., Meurisse, A., Lepiller, Q., Vernerey, D., Valmary-Degano, S., Paget-Bailly, S., Riethmuller, D., Ramanah, R., Mougin, C., & Prétet, J. -L. (2021). HPV16 Load Is a Potential Biomarker to Predict Risk of High-Grade Cervical Lesions in High-Risk HPV-Infected Women: A Large Longitudinal French Hospital-Based Cohort Study. Cancers, 13(16), 4149. https://doi.org/10.3390/cancers13164149

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