BIO DATA Nama Alamat Riwayat Pendidikan : Riwayat Pekerjaan : Qrganisasi :

Transcription

1 BIO DATA Nama : Dr. dr. Sri Hartini SpPK (K), MARS Alamat : Inst Pat Klin RS Kanker Dharmais Jl. Let Jen. S. Parman Kav 84-86, Slipi Jakarta Barat sri.harijanto@gmail.com Riwayat Pendidikan : Dokter Umum, FKUGM, 1973 Spesialis Pat.Klin : FKUI, 1985 Magister Administrasi RS : Fak. Pasca Sarjana UI, 1999 Doktor FK UGM, 2015 Riwayat Pekerjaan : Peneliti Keselamatan Radiasi & Kedokteran Nuklir BATAN SMF Pat. Klin RS Kanker Dharmais (RSKD) sekarang Ka. Instalasi Patologi KLinik RSKD Direktur Penunjang Medik RSKD Direktur Umum & Operasional RSKD Dosen Program Biomedik Kekhususan Onkologi FKUI di RSKD 2008 sekarang Qrganisasi : PDS. PATKLIN ; Perhimpunan Onkologi Indonesia

2 MOLECULAR HPV : EARLY DETECTION IN CERVICAL CANCER Sri Hartini Dharmais Cancer Hospital

3 HPV classification based on the nucleotide sequence of the capsid protein L1 gene. Burd Clin. Microbiol. Rev. 2016;29:

4 Alpha Papillomaviruses Risk classification HPV types High-risk 16, 18, 31, 33, 35, 39, 45, 51, 52, 56 58, 59, 68, 73, 82 Probable high-risk 26, 53, 66 Low risk 6, 11, 40, 42, 43, 44 Undetermined risk 34, 57, 83 54, 61, 70, 72, 81, CP6108 Journal of Clinical Virology 32s (2005)

5 Global Prevalence of HPV16 and HPV18 1. de Sanjose S, et al. Lancet Oncol 2010; 11: Munoz N, et al. Int J Cancer 2004; 111:

6 PERSISTEN HR-HPV INFECTION Risk Factor for malignancy Head n Neck (cavum oral, tonsil, oro-pharynx,larynx ) Skin Breast Cervical

7 Ten most frequent HPV oncogenic types among women with invasive Cervical cancer by histology in Indonesia ICO HPV Information Centre Institute Catala d Oncologia Version posted on www. hpvcentre. net in February26th,2016

8 Ten most frequent HPV oncogenic types among women with invasive Cervical cancer by histology in Indonesia *No data available. ; No more types than shown were tested or were positive. ICO HPV Information Centre Institute Catala d Oncologia Version posted on in February 26th,2016

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10 Data Dharmais Cancer Hospital % % HR-HPV + in biopsy/ Cervical swab % HPV type in Cervical Ca % % 38.6% 10 0 HPV 16 Normal Ascus NIS 1 NIS 2 NIS 3 Ca Cervix 17.1% HPV 18 HPV 52 HPV % Others

11 Data Dharmais Cancer Hospital HPV HPV 18+ HPV 28+ HPV 45+ HPV HPV 52+ HPV 82+ HPV 16+ dan HPV 16+ dan 28+ HPV 16+ dan 51+ HPV 16+ dan 52+ HPV 16+, 18+, dan 51+ HPV 16+, 18+, 45+, dan 52+ HPV 18+ dan 31+

12 Data Dharmais Cancer Hospital Squamous Ca 4 4 Adenokarsinoma NIS 2/3 P = HPV 16+ HPV 18+ HPV Multi tipe 0

13 British Journal of Cancer 99, , 2008

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16 Infection HPV 16,18 31,45,52 Incubation 1 6 months First lesion Active growth (3 6 months) Immune response Host containment (3 6 months) 7-8 years classically 15 years Seroconversion average time 9 months 75-90% 10-25% Sustained clinical remission 8-30 M 9,8 months DNA-ve Re-infection DNA-ve DNA+ve Persistent or recurrent disease 8,9-14,8 months 4,5 PERSISTENT ONCOGENIC HPV 4 yrs 2,3 Natural history of HR-HPV infection to Cervical Ca High grade lesion 2 yrs Modified from Stanley M. Vaccine 2006;24S1:S1/ (2). Molden T, et al. Int J Cancer.2005: (3) Rozendaal L, etal. Int J Cancer 1996;68:766-9 ( 4).Franco EL, etal. J Infect Dis 1999;180: (5)Munoz N, etal. J Infect Dis 2004;190: Invasive Cancer

17 A. Uninfected Epithelium Feedback Cyclin/cdk P P prb prb E2F prb B. High Risk HPV INfection prb E7 No Feedback Upregulation of Genes necessary for S-phase progression P16 MCM PCNA Ki67 P14 ARF Cyclin E Transactivation Regulated MDM E2F Basal Layer Regulation of p53 levels E2F Basal + Parabasal Layer degradation p53 Upregulation of p53 Transactivation Inactivation of MDM High p21 Low E7 P16 MCM PCNA Ki67 P14 ARF Cyclin E Upregulation of Genes necessary for S-phase progression Low p21 High E7 p53 E7 p21 cdk Cyclin P21, E7 and cyclin E form a complex. Cyclin E/cdk inactive and present at high levels CELL CYCLE PROGRESSION STALLED E7 Cyclin p21 cdk p21 + E7 form a complex p21 inactivated. Cyclin E/cdk active and present at low levels S-PHASE PROGRESSION Clinical Science Clin. Sci. (2006) 110,

18 Feller L, Wood NH, Khammissa RA, Lemmer J - Head Face Med (2010)

19 Characteristics of HPV test technologies

20 Characteristics of HPV test technologies

21 Characteristics of HPV test technologies

22 NON PCR HPV DETECTION : SIGNAL AMPLIFICATION 1. Release and denature DNA 4. React captured hybrids with multiple Ab conjugates 2. Hybridize RNA probe with target DNA 3. Capture RNA:DNA hybrids onto a solid phase Qualitative in vitro test, detect amplified chemiluminecent Amplification of signal DNA by HC technology 5. Detect amplified Detects 13 high risk anogenital HPV genotypes:16, 18, 31, 33, 35, 39, chemiluminescent 45, 51, 52, 56, 58, 59 and 68 signal First in the market Very manual, Hands on time, Time to result, No internal controls

23 PCR HPV DETECTION : TARGET AMPLIFICATION Qualitatif invitro test Discrimination of 37 genotypes 37 anogenital types: (6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 45, 51, 52, 53, 54, 55, 56, 58, 59, 61 62, 64, 66, 67, 68, 69, 70, 71, 72, 73, 81, 82, 83, 84, IS39, and CP6180) Discrimination of high risk versus low risk genotypes Suited for detection of multiple infections & epidemiology studies Low and high beta-globin reference lines assess cellular adequacy, extraction and amplification for each individually processed specimen

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25 Reference Line LINEAR ARRAY HPV Genotyping Test Result Interpretation HPV Strip Reference Guide Reference Line GT 18 GT 18 GT 31 GT 16 Numerical order of genotypes GT 45 Low Globin Control High Globin High High globin control Low globin control High Globin Control

26 Hasil HPV Genotyping : HPV 16, 18, 42, 52/33/35/58, 58

27 Real Time PCR : three HPV results in a single test Clinical Design HR Contr. Ch1 Ch2 Ch3 Ch4 Pooled result for 12 HPV genotypes Responsible for ~30% of cervical cancers Individual result for HPV16 Most aggresive genotype Individual result for HPV18 HPV18+ disease often missed by cytology Most common in ADC, the most aggressive form of cervical cancer Multi colour, single tube Test

28 CLINICAL APPLICATION Identification of oncogenic HPV types Primary cervical cancer screening Different relative risk of cervical cancer according to HPV types Essential to investigate the efficiency of the vaccines Confirm the unclear cervical cytology result Decrease the use of colposcopy

29 Choi YJ, Park JS Clinical significance of HPV genotyping J Gynecol Oncol Mar; 27(2):e21

30 Main characteristics of cervical cancer screening in Indonesia HPVDNA testing is being introduced as an adjunct to cytology screening (co testing) or as the primary screening test to be followed by a secondary, more specific test, such as cytology (in private sector).

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32 Principles for screening programs Wilson, Jungner WHO Chronicle Geneva. 22(11):473. Public Health Papers, #

33 Principles for screening programs Principle Test is accurate and reliable ATHENA Results: Variability of Cervical Cytology Wright, et al. IntJ Cancer (8): *To detect CIN2 ATHENA : Addressing THE Need for Advanced HPV Diagnostics A prospective study of >47,000 women Atypical Squamous Cells of Undetermined Significance.

34 Principles for screening programs Principle Test is sensitive Sensitivity of Cervical Cytology (for CIN2) Whitlock et al. Ann Intern Med. 2011; 155: , W214 5.

35 Principles for screening programs Principle Test is specific Specificity of Cervical Cytology (for CIN2) Whitlock et al. Ann Intern Med. 2011; 155: , W214 5.

36 33% Up to Cervical cancer cases are found in women with Normal pap smear

37 Limitations of cytology 1. Castle PE, et al. Lancet Oncol2011; 12: plus supplementary tables. 2. Wright TC et al. Int. J. Cancer 2014; 134: Herzog TJ & Monk BJ. Am J ObstetGynecol2007; 197:

38 HPV Test Sensitivity in Cervical cancer screening Cervical cancer screening is not the same as HIV screening Kinney, et. al., Am J Clin Pathol 2010;134:

39 Requirements of HPV tests 1. The candidate test should have a clinical sensitivity for CIN2 not less than 90% in women of at least 30 years 2. A clinical specificity for CIN2 of the candidate test not less than 98% in women of at least 30 years of age. 3. Should display intra-laboratory reproducibility and inter-laboratory agreement with a lower confidence Meijer, et. al., Int. J. Cancer: 124, bound not less than 87% (2009) ACS/ASCCP/ASCP Guidelines: the sensitivity of HPV testing for CIN3+ and CIN2+ should be greater than or equal to 90%... Saslow et. al., CA CANCER J CLIN 2012;62:

40 Risk of CIN3+ After Negative Screening Test & European follow-up studies; 24,295 women Months of Follow-up Dillner et al. BMJ 2009;377

41 Risk of CIN3+ After Negative Screening Test ATHENA study : women > 25 yrs Months of Follow-up cobas HPV Test Package Insert

42 Co-testing HPV Screening Algorythme NILM : Negative for Intraepithelial Lesion or Malignancy

43 Limitations of Cotesting Cotesting is inefficient It requires two screening tests every time a women screened Cotesting isn t logical It combines a relatively insensitive test with a highly sensitive test Cotesting is complicated -It incorporates cytology as part of the initial screen and cytology-based screening has become incredibly complicated over the last decade

44 HPV primary screening trials Results from European trials Ronco et al. Lancet pub online, 2013.

45 Primary HPV Screening Algorythme SGO & ACCP Interim Guidance NILM : Negative for Intraepithelial Lesion or Malignancy Huh W et al. Gyn. Oncol. 2015

46 HPV Primary Screening SGO & ASCCP Interim Guidance Because of equivalent or superior effectiveness, primary hrhpv screening can be considered an alternative to current US cytologybased cervical cancer screening methods. Cytology alone and cotesting remain the screening options specifically recommended in major guidelines Based on limited data, triage of hrhpv-positive women using a combination of genotyping for HPV 16 &18 and reflex cytology for women positive for the 12 other hrhpv genotypes appears to be a reasonable approach to managing hrhpv-positive women Society of Gynecologic Oncology, American Society for Colposcopy and Cervical Pathology, American College of Obstetricians and Gynecologists, American Cancer Society, American Society of Cytopathology, College of American Pathologists, and the American Society for Clinical Pathology Huh W et al. Gyn. Oncol. 2015

47 HPV Primary Screening SGO & ASCCP Interim Guidance Re-screening after a negative primary hrhpv screen should occur no sooner than every 3 yrs. Primary hrhpv screening should not be initiated before 25 years of age. They note that primary hrhpv screening at age yrs may lead to increased CIN3 detection but impact of increased number of colposcopies, etc needs further investigation. Huh W et al. Gyn. Oncol. 2015

48 HPV GENOTYPING : SELF COLLECTING SAMPLES an option to reduce costs and increase patient participation in HPV screening programs. Results using self-and clinician-collected samples showed equivalent HPV genotype distributions and prevalence Feasible and well accepted, and showed sensitivity and specificity comparable to those achieved using cliniciancollected samples. Self-testing detected precancerous cervical lesions even earlier than cytology. Home-based HPV testing is a good alternative not only for people residing in developed countries, but also for people living in developing Choi YJ, Park JS J Gynecol Oncol Mar;27(2):e21

49 Therapeutic vaccine using HPV 16- specifc CD8+ T-lymphocyte responses that stimulates the expansion of CD8α+ lymphoid dentritic cells and facilitated the expression of HPV antigen through the MHC I pathway. Choi YJ, Park JS J Gynecol Oncol Mar;27(2):e21

50 TAKE HOME MESSAGES Cervical cancer is caused by 14 "high-risk" types of HPV Indonesia : Common type hr-hpv : 16, 18, 45, 51/52 hr HPV detection : RT-PCR with internal control more sensitive than non PCR method Utilization of hrhpv testing for screening : identifies BOTH women with disease today and women at risk for developing disease in the future HPV 16/18 stratification is important & has high medical value Screening Cervical Cancer : Cytology alone is not sufficient Co testing HPV- DNA & Trial Primary HPV-DNA Future application : Self sampling & Therapeutic vaccine