To Örebro University

OBJECTIVE: With the transition from cytology to human papilloma virus (HPV) testing in cervical cancer screening, it is possible to use self-sampling instead of professionally collected samples. Most studies have included women between 20 and 60 years age. Here we aimed to study postmenopausal women and investigate whether vaginal self-sampling is equally effective as professional sampling for detection of HSIL and the possibility to use a method for molecular triage directly on the screening sample.

METHODS: Postmenopausal women in Örebro county, Sweden, were invited (n = 7835) during 2018-2020 to participate in the study including both professional and self-sampling. In total 2258 women returned both sample types, that were analyzed for HPV followed by triage for cytology, HPV genotyping and methylation and clinical follow-up according to national guidelines.

RESULTS: The prevalence of HPV was 3.4 % in the professionally collected samples and 12.6 % in the self-collected. All women with high-grade squamous intraepithelial lesion (HSIL) were HPV-positive in both professionally and self-collected samples. For self-collected samples, we compared different triage strategies. Cytology was the most efficient strategy. Among the molecular triage methods, the combination of methylation and genotyping was most efficient but resulted in twice as many colposcopy referrals as cytology.

CONCLUSIONS: In conclusion, HPV self-sampling with molecular triage detects HSIL to the same extent as professional screening with cytological triage. The specificity of molecular triage is, however, unacceptably low, and to avoid overtreatment other triage methods following primary self-sampling need to be developed.

Background: Cervical cancer is the most prevalent cancer in Mozambique, with endocervical adenocarcinoma accounting for approximately 5.5% of cases. Knowledge regarding the most prevalent HPV genotypes in endocervical adenocarcinoma is limited, within this setting. This study aimed to investigate human papillomavirus (HPV) prevalence and genotypes within a cohort of endocervical adenocarcinoma patients in the context of Mozambique's recently introduced vaccination programme, considering the country's HIV-endemic setting.

Methods: Forty consecutive cases of endocervical adenocarcinoma diagnosed at Maputo Central Hospital between 2017 and 2018, with limited clinical data available, were included. Human immunodeficiency virus (HIV) status was determined through serological data or in situ hybridisation on histopathological slides. HPV detection was performed using a multi-methodological approach, including Anyplex II, in-house polymerase chain reaction (PCR), and chromogenic and fluorescent in situ hybridisation techniques.

Results: All 40 cases exhibited HPV-dependent morphology. Fourteen of the 40 patients were HIV-positive. No significant differences were observed between the two groups regarding age, stage, or histopathological type. hrHPV16, 18, or 45 were detected in all cases. Notably, multiple hrHPV infections were identified exclusively in HIV-negative cases (10/26, p = 0.0075), with hrHPV18/45 co-infection being the most common (n = 8).

Conclusions: These findings suggest that the newly implemented quadrivalent vaccination programme has the potential to prevent morbidity and mortality from endocervical adenocarcinoma, irrespective of HIV infection status, in Mozambique's HIV-endemic environment.

BACKGROUND AND OBJECTIVE: To improve treatment for patients with penile cancer, there is a need for prognostic and treatment predictive biomarkers. The objective of this study was to examine the expression of checkpoint proteins (programmed cell death ligand 1 [PD-L1], T-cell immunoglobulin and immunoreceptor tyrosine-based inhibitory motif domain [TIGIT], and cluster of differentiation 155 [CD155]) and human papillomavirus (HPV) status in primary tumors of penile cancer patients with indication for perioperative oncological treatment. As a secondary aim, we evaluated the associations between these biomarkers and penile cancer-specific survival.

METHODS: Fifty-two patients who underwent surgical treatment during 2009-2018 were included. HPV status was determined by polymerase chain reaction, and tissue microarray sections from primary tumors were subjected to immunohistochemistry to evaluate the expression of PD-L1, TIGIT, and CD155.

KEY FINDINGS AND LIMITATIONS: PD-L1, TIGIT, and CD155 were expressed widely. Specifically, 75% of patients had PD-L1-positive tumors, 80% had TIGIT-positive tumors, and 98% had CD155-positive tumors. Additionally, 47% of patients had HPV-positive tumors. Patients with HPV-positive tumors had better survival than those with HPV-negative tumors. Patients with indication for perioperative oncological therapy who received such treatment and whose tumors exhibited low PD-L1 expression demonstrated better survival than those with higher PD-L1 expression levels. The main limitations of this study include the small number of patients, retrospective design, and use of tissue microarrays rather than whole tissue sections.

CONCLUSIONS AND CLINICAL IMPLICATIONS: We found high expressions of the investigated checkpoint proteins, suggesting an immunosuppressed tumor microenvironment in patients with advanced penile cancer. These findings imply that checkpoint proteins could serve as prognostic and treatment predictive biomarkers. Patients with HPV-positive tumors had better prognosis.

PATIENT SUMMARY: In this report, we investigated tumor tissue from patients with penile cancer and identified a high prevalence of proteins that play an important role in the immune system's defense against cancer. The findings suggest that these proteins can be important in understanding and developing treatments for patients with lymph node metastasized penile cancer.

Background and aim: Evaluate the diagnostic performance of automated, quantitative bilirubin measurement, modified to extend its lower measurement ranges, in cerebrospinal fluid (CSF) using the Siemens analyzer Advia XPT. Results were compared with the gold standard spectrophotometry for diagnosis of subarachnoid haemorrhage (SAH).

Method: Eighty clinical samples were analyzed on an Advia XPT, and results were compared to spectrophotometric results using the Agilent Cary 100 bio system. Method performance at low concentrations were evaluated using diluted control material and patient plasma and CSF samples. ROC curve analysis determined a suitable cutoff.

Result: Evaluation of low-concentration performance, below 2 mu mol/L on Advia XPT, showed a measurement bias of-1.0 %, and a linear regression equation of y = 0.843x + 0.0351 (R2 of 0.975), describing the relationship between measured and expected concentrations of diluted samples. The coefficient of variation, (CV), was 2.92 % at 0.598 mu mol/L and 26.6 % at 0.161 mu mol/L. Using the outcome of the analysis on Agilent Cary 100 as reference, sensitivity was 100 % and specificity 96 %, employing a cutoff of 0.41 mu mol/L.

Conclusion: Quantitative measurement of bilirubin in CSF using the bilirubin oxidase method on the automated Advia XPT platform perform well, with the analysis of low concentrations of bilirubin displaying a high precision and a high concordance with the results of spectrophotometry. These preliminary findings are indicative of the merits of quantitative measurement, that warrants further study of its diagnostic potential as an alternative to the more cumbersome spectrophotometry for diagnosing SAH.

BACKGROUND: Since 2022, self-sampling has been recommended in Sweden's cervical screening program. Despite still being used primarily for long-term non-attendees, its expected increase in use raises interest in molecular triage methods applicable to self-collected samples. Postmenopausal women face screening challenges due to physiological changes, making this group particularly relevant for evaluating alternative strategies. This study models the cost-effectiveness of different sampling and triage methods in identifying histological high-grade squamous intraepithelial lesions (HSIL) in women aged 60-69 years.

METHODS: Using real-world data, this study compares the cost-effectiveness of currently implemented strategy based on professional HPV sampling and combination triage with genotyping and cytology, with modelled strategies based on self-sampling and various molecular triage. The comparison evaluates healthcare resource use and the number of identified histological HSIL cases. The analysis focuses on a single screening cycle, re-testing of invalid samples or screening-positive/triage-negative women are not addressed.

RESULTS: Screening with molecular triage either leads to decreases in effect, i.e. fewer histological HSIL identified, or significant cost increases due to higher rate of HPV-positive screening samples and higher number of colposcopy follow-ups.

CONCLUSIONS: Molecular triage, whether used with self-sampling or professional sampling, does not appear cost-effective for identifying HSIL in this age group compared to the current screening strategy.

OBJECTIVE: To improve human papilloma virus (HPV) screening, more effective triage methods for HPV-positive samples need development and validation. Cytology, the most common triage method today, is subjective and can only be applied to professionally collected samples. Methylation status has been shown to be informative, as genes are highly methylated in HPV-induced cervical dysplasia and cancer. This study aimed to assess whether triaging HPV-positive samples using molecular methods, such as methylation and genotyping for high-risk HPV types, could be as effective as cytology in cervical screening.

METHODS: A retrospective biobank study was conducted on HPV-positive samples collected in 2017-2018, analyzing FAM19A4/MiR-124-2 hypermethylation and HPV genotyping for types 16, 18, 31, 33, 45, 52, and/or 59, comparing these results to cytology triage for detecting histologically confirmed high-grade squamous intraepithelial lesions (HSIL) and cancer.

RESULTS: Results from 1915 positive screening samples were analyzed, including 1052 follow-up biopsies with 402 HSIL or cancer cases. Genotyping showed slightly higher sensitivity than cytology but lower specificity, while methylation had higher specificity but much lower sensitivity. Cytology's positive predictive value (PPV) was 36%, with lower PPVs for the molecular methods. Combining molecular methods increased the PPV but significantly reduced sensitivity.

CONCLUSIONS: Based on these findings with molecular methods reducing sensitivity, we do not recommend adopting the molecular triage methods evaluated in this study in the Swedish setting. The trade-off between sensitivity and specificity does not support a change from the current cytology-based triage approach.

Inguinal lymph node surgery is a standard treatment for penile cancer patients with intermediate or high risk for lymph node metastasis (LNM) according to European Association of Urology (EAU) risk grading. We are proposing a more objective histological prognostic grading system for inguinal LNM in these patients. We assessed worst pattern of invasion, lymphocytic host response, lymphovascular invasion, and perineural invasion in a population-based cohort of 306 penile cancer patients. Patients were classified into low, intermediate, and high risk for inguinal LNM. There was a significant association both between risk groups and pT stage (p < 0.001) and between risk groups and LNM. Univariate logistic regression showed 25.43 times higher odds of LNM for patients in the intermediate risk group compared with the low risk group (odds ratio (OR) 25.43; 95% confidence interval (CI): 5.94-108.97) and a 177.13 times higher odds in the high risk group compared to the low risk group (OR 177.13; 95% CI: 40.09-782.51). When comparing our histological risk grading with the EAU grading, we found a higher sensitivity, of 51.28% (95% CI: 45.68-56.88) versus 37.09% (95% CI: 31.68-42.50), as well as a higher area under the curve (0.86; 95% CI: 0.81-0.89; versus 0.65; 95% CI: 0.58-0.71) with our grading system. While our grading classified 111 patients as low risk, only 31 were considered low risk for LNM according to the EAU risk classification. The new histological risk grading system shows a higher sensitivity and includes a higher number of patients in the low risk group in whom lymph node surgery could be avoided, reducing morbidity and costs.

Vulvar cancer is a rare gynaecological disease that can be caused by infection with human papillomavirus (HPV). The mutational frequencies and landscape for HPV-associated and HPV-independent vulvar tumor development are supposedly two distinctly different pathways and more detailed knowledge on target biological mechanisms for individualized future treatments is needed. The study included formalin-fixed paraffin-embedded (FFPE) samples from 32 cancer patients (16 HPV-negative and 16 HPV-associated), treated in Örebro, Sweden from 1988 to 2008. The Oncomine™ Comprehensive Assay v3 was used to detect variants across 161 different tumor relevant genes. Data analysis included quality assessment followed by variant analysis of DNA with the Oncomine Comprehensive v3 workflow and with a custom filter using the VarSome Clinical software. The RNA-analysis was performed with the Oncomine Comprehensive v3 workflow. Totally, 94% of DNA libraries and 81% of RNA libraries were of adequate quality for further downstream analysis. With the Oncomine™ filter chain there was an increased number of variants in the HPV-negative group (2.5 variants) compared to the HPV-associated group (1.5 variants). Using custom filter and the Varsome Clinical software; additional single nucleotide variants (SNV) were detected where the vast majority were classified as likely benign/benign. HPV-negative tumors had a larger fraction of variants of unknown significance (VUS), and likely pathogenic/pathogenic compared to the HPV-associated tumours. The top 10 frequently mutated genes in HPV-indepentent tumors were TP53, POLE, PTCH1, BRCA2, CREBBP, NOTCH2, ARID1A, CDKN2A, MSH2, and NOTCH1. Three fusion genes were detected; TBL1XR1(1)::PIK3CA(2) (n = 2) and NF1(5)::PSMD11(2) (n = 1). Copy number variations (CNV) were more common in HPV-associated tumors (n = 13/16, 81%) compared to HPV-negative tumors (n = 9/14, 64%). The most frequent CNV was found in the cMYC gene, followed by CDK2 (n = 5) and CDK4 (n = 4). The main outcome of this study show that vulvar cancer harbour genetic variations of different types and specifically, HPV-independent tumours are molecularly very heterogeneous and harboured more SNVs while HPV-associated tumors more frequently presented with gene amplifications. The PI3K/AKT/mTOR1 pathway was affected in both the groups as well as the cell cycle regulation pathway. Similarly, the DNA repair gene POLE was found mutated in both vulvar cancer groups.

Objective: The aim of this study was to investigate if there is a lack of professionals in the Nordic countries as well as the prognosis for the future in relation to educational output. In addition, the study aimed to investigate the Nordic professional’s point of view on how to make the profession attractive, what career opportunities that are needed and what role the BLS should have in the future healthcare setting.

Materials and methods: Data for each country were provided from reports. Professionals present at the NML congress 2023 were invited to discuss questions related to the lack of BLS. Answers were collected, summarized, and grouped in themes.

Results: Three of four Nordic countries report current and future challenges in BLS workforce and a substantial amount of BLS in the Nordic countries are 50 years or older. Despite efforts where admissions to the universities have increased, the amount of examinates has not increased proportionally. Professionals identifies a need for making the profession more attractive highlighting career opportunities, professional visibility, salary increase, and task-shifting.

Discussion: We have identified several threats to the sustention of BLS in healthcare today and in the future in the Nordic countries. This includes high retirement numbers, drift towards working in the private sector, as well as low salaries and lack of career opportunities. In this study, the profession has provided useful insights on how to make the profession more attractive including increased visibility, provide career paths, and distinguish what the BLS competence is and can be in the future.

Conclusion: We have identified several future arenas for the profession that can attract students to educations, keep professionals in healthcare, and secure high quality in diagnostics. To succeed, we need stronger linkage between the profession itself, educational institutions, healthcare employers, and professional organizations.

BACKGROUND: The aim of this study was to examine the natural course of HPV infection in women of 60 years and older who were HPV positive at inclusion, and any association between HPV positivity in historical samples and dysplasia outcome. METHODS: Eighty-nine women aged 60-82 years, who tested positive for HPV between 2012 and 2016 were included. Sampling for cytology and/or histology was also performed. HPV genotyping was carried out on archived material back to 1999.

RESULTS: Of the 89 HPV-positive women 16 had HSIL, 34 had LSIL and 39 were benign at inclusion. Of the women with HSIL, 50.0% had the same HPV type in the archive samples, 12.5% had another type, and 37.5% were HPV negative. Among the 34 women with LSIL, 47.1% had the same HPV type in archive samples, 5.8% had another type, and 47.1% were HPV negative. Of the 39 women without dysplasia at inclusion, 25.6% had the same HPV type in archive samples, 5.1% had another HPV type and 69.2% were HPV negative.

CONCLUSION: Surprisingly few of the elderly women thus seem to have a history with the same or any HPV infection the years before being diagnosed with an HPV infection and dysplasia. The significance of an HPV infection for dysplasia development in elderly women is still not fully understood.