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Year : 2017  |  Volume : 8  |  Issue : 1  |  Page : 1-4

The role of biomarkers (p16INK4a and Ki-67) in cervical cancer screening: An appraisal

1 Department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Pathology, University of Benin, Benin, Nigeria
3 Department of Histopathology, University of Maiduguri, Maiduguri, Nigeria
4 Department of Human Physiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
5 Department of Obstetrics & Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Web Publication30-Jan-2018

Correspondence Address:
Prof. Saad A Ahmed
Department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/atp.atp_3_17

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Cervical cancer is a common and important public health problem in developing countries. Even though many developed countries have achieved significant successes in reducing invasive cervical cancer burden, the burden in developing countries is still worrisome. Currently, cervical examinations and Papanicolaou (Pap) tests remain the screening method of choice for most women in many parts of Africa. Molecular diagnostic tests for human papillomavirus (HPV) can augment screening for cervical cancer when used in conjunction with the Pap smear. Due to the inherent limitations of morphologic interpretation and borderline cases, the atypical squamous cells (Atypical Squamous Cells of Undetermined Significance [ASCUS] and Atypical Squamous Cells cannot rule out High Grade [ASC-H]) were introduced and this led to significant colposcopic follow-up and/or treatment of these women. p16INK4a is an efficient triage method; the dual staining with Ki-67 was introduced mainly to increase reproducibility and specificity compared with stand-alone p16INK4a staining. Diffuse p16INK4a immunostaining is the hallmark of high-grade squamous intraepithelial lesions regardless of HPV status.

Keywords: Appraisal, cervical cancer screening, immunocytochemistry, Ki-67, p16INK4a, triage

How to cite this article:
Ahmed SA, Obaseki DE, Mayun AA, Mohammed A, Rafindadi AH, Abdul MA. The role of biomarkers (p16INK4a and Ki-67) in cervical cancer screening: An appraisal. Ann Trop Pathol 2017;8:1-4

How to cite this URL:
Ahmed SA, Obaseki DE, Mayun AA, Mohammed A, Rafindadi AH, Abdul MA. The role of biomarkers (p16INK4a and Ki-67) in cervical cancer screening: An appraisal. Ann Trop Pathol [serial online] 2017 [cited 2023 Mar 23];8:1-4. Available from: https://www.atpjournal.org/text.asp?2017/8/1/1/224160

  Introduction Top

Cervical cancer is a common and important public health problem for adult women in developing countries.[1],[2] Many industrialized countries have achieved significant successes in reducing invasive cervical cancer burden over the past six decades and with annual incidence rates between 4 and 14/100,000.[1] In developed countries, an estimated 15,000 new cases of cervical cancer and 5000 deaths occur annually from the disease.[3] These relatively low figures are a far cry from those obtainable in Nigeria where an estimated 250/100,000 cases and 155,000 deaths are recorded annually. Globally, women particularly those living in developing countries suffer higher rates of morbidity and mortality from cervical cancer than previously noted.[3]

Cervical cancer no longer ranks among the top ten cancers in these settings. The low incidence is achieved through substantial healthcare investments for screening programs and diagnostic workup in these countries. On the other hand, cervical cancer is the leading cancer among women in many resource-constrained settings of the developing countries, where incidence and mortality rates are about five to six times higher.[4] Rates are highest in sub-Saharan Africa, South East Asia, and parts of South America, where cervical cancer represents from a sixth up to a fifth of all cancers among women.[1] Cervical cancer is not only the second most common malignancy in adult women but is also the most common malignancy of the female genital tract in Nigeria.[5],[6]

The value of screening for cervical cancer has been proven.[1] Such screening in developed countries has achieved a decrease in incidence and mortality by about 80%.[7] Although screening facilities are available in many parts of developing countries, the incidence of cervical cancer remains very high, and many patients present with late stage disease.[8] Detecting the high-risk human papillomavirus (HR-HPV) DNA is more sensitive test for cervical cancer early detection than Papanicolaou (Pap) cytology. It is used in addition to Pap cytology in certain settings and currently introduced as an alternative for primary screening in many industrialized countries.[9] However, considering the high prevalence of HPV infections particularly in young women, detecting HPV-DNA is a poorly specific test for real cellular alterations and therefore requires additional triage tests for the specific identification of women needing further workup or treatment.[10] To reduce referral rates, unnecessary treatments, and finally costs, new biomarkers (p16INK4a and Ki-67) have been identified and suggested to improve diagnosis of cervical cancer and its precancerous lesions.[11],[12]

  Risk Factors for Cervical Cancer Top

Known risk factors for cancer of the cervix include persistent infection with HR HPV, early age at first intercourse, and multiple sexual partners. A male consort who in turn has had intercourse with multiple women also confers a significant risk.[13] Other risk factors of cancer of the cervix include cigarette smoking and immune suppression, especially those who have undergone renal transplantation. HIV infection may increase a women's risk for cervical neoplasia. It is claimed that the vast majority of cervical cancers could be prevented if all women were offered and complied with high-quality cytological screening programs.[14]

  Human Papillomavirus in Cervical Cancer Top

HPV is the most prevalent sexually transmitted infection in the world, occurring at some point in up to 75% of sexually active women. Nearly, all cervical cancers (99.7%) are directly linked to previous infection with one or more of the oncogenic types of HPV.[1]

Currently, there are >100 different known HPV genotypes that have been grouped into low-risk and high-risk categories and designated as causing mucosal or cutaneous infections.[15] Warts are generally the result of infection by low-risk types of HPV, including 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81, and CP6108. High-risk types of HPV include 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82. The high-risk strains induce cervical dysplasia and can lead to the development of several types of cancers including cancer of the cervix, vulva, vagina, anus, and penis. The most common of these is HPV-associated cervical cancer.[16] HPV types 16 and 18 are the most prevalent worldwide.[17]

The viral E6 and E7 oncoproteins are necessary for malignant conversion. The abilities of high-risk HPV E6 and E7 proteins to associate with the tumor suppressors p53 and retinoblastoma protein (pRB), respectively, have been suggested as a mechanism by which these viral proteins induce tumors. The E7 proteins encoded by the high-risk type HPVs bind Rb with a much higher affinity compared to those encoded by the low-risk type HPVs. One of the major biochemical functions of Rb is to bind E2F-family transcription factors and repress the expressions of replication enzyme genes.[5] E7 disrupts the interaction between Rb and E2F, resulting in the release of E2F factors in their transcriptionally active forms.[6] This E7-mediated conversion of E2Fs to their activator forms stimulates replication and cell division, which is consistent with the observation that keratinocytes constitutively expressing E7 remain replication competent, even after differentiation.[7] Due to the high prevalence of HPV infections in younger women, HPV testing currently is not recommended for screening women younger than age 30 years.

  Cervical Cancer Screening Top

Pap stain is the gold standard for detecting abnormal cervical epithelial cells, using microscopic analysis of conventional cervical smears or cell suspensions from liquid cytology medium. Currently, cervical examinations and Pap tests remain the screening method of choice for most women in many parts of Africa. Morphological findings from a cytology analysis determine the level of risk for developing cervical malignancy. The efficacy of the Pap test, however, is hampered by high interobserver variability and high false-negative and false-positive rates.[1],[2],[3] This is obviated by repeated screening at frequent intervals thus ensuring a high level of detection and protection. Molecular diagnostic tests for HPV can augment screening for cervical cancer when used in conjunction with the Pap smear.[18]

The cervical cytology is reported using the Bethesda system of classification which established the 2-tiered reporting system for squamous intraepithelial lesions (SILs): low-grade SIL (LSIL) (cervical intraepithelial neoplasia [CIN] I) and high-grade SIL (HSIL) (CIN II and CIN III). This terminology reflected the up-to-date understanding of HPV biology – squamous epithelium is affected by the virus in essentially two ways: either as viral infection or as viral-associated precancer.[19],[20] Due to the inherent limitations of morphologic interpretation and borderline cases, the atypical squamous cells (Atypical Squamous Cells of Undetermined Significance [ASCUS] and Atypical Squamous Cells cannot rule out High Grade [ASC-H]) were introduced and this led to significant colposcopic follow-up and/or treatment of these women.[20],[21]

Role of biomarkers (P16 and Ki67) in the management of abnormal smears

Various immunocytochemical markers have been evaluated with respect to their specificity in staining dysplastic cells either in biopsies or in cytological smears.

Colposcopy is usually done on women with abnormal smears and/or positive HR-HPV test. However, a newer concept of triage using biomarkers p16INK4a and Ki-67 dual immunostaining has been advocated to avoid over referral for colposcopy. P16INK4a is an efficient triage method; the dual staining with Ki-67 was introduced mainly to increase reproducibility and specificity compared with standalone P16INK4a staining.[22] Diffuse p16INK4a immunostaining is the hallmark of HSIL (CIN2 and CIN3), regardless of HPV status.[23]

The overexpression of the cyclin-dependent kinase inhibitor p16INK4a (p16) in cervical dysplasia has been shown to be associated with the transforming activity of the E7 oncoprotein of high-risk HPV types, and it is a surrogate marker of the E7-mediated inactivation of the tumor-suppressor function of the pRb. In replicating cells, the transcription factor E2F is regulated by phosphorylation of RB. Rb phosphorylation is normally mediated by cyclin-dependent kinases (CDK4, CDK6) that are controlled by several kinase inhibitors (INKs). Aberrant expression of E7 in basal cells disrupts binding of pRB to E2F that is counteracted by massive expression of p16INK4a, an important CDK inhibitor. Since E7-dependent E2F release is not mediated by phosphorylation of Rb, the counter-regulatory p16 INK4a expression has no effect on the activated cell cycle. Nondysplastic epithelia infected with LR- or HR-HPV do not diffusely stain for p16INK4a. In sharp contrast to this expression pattern of p16INK4a in resting cells with aberrant differentiation, the pathological expression in HPV transformed cells is indicated by a very strong diffuse staining pattern in the replicating cells of the basal and parabasal cell layer. Basically, all cervical carcinomas, CIN3 lesions, as well as the majority of CIN2 lesions are diffusely positive in immunohistochemistry.

Proliferation-associated antigens such as Ki-67 are related to DNA replication and specifically highlight cells with active DNA replication.[16],[17],[18],[19],[20],[21] Since HPV infection leads to increased epithelial cell proliferation in infected tissues, increased Ki-67 staining can be an indicator of HPV infection. In normal human cervical squamous mucosa, expression of Ki-67 is limited to the proliferating basal and parabasal cells. In dysplasia and carcinoma, however, expression extends above the basal one-third of the epithelium and the number of positive cells increase, with a significant positive correlation between ascending grade of SIL and labeling index.

Normally, the p16 protein triggers cell cycle arrest in the course of cellular differentiation processes and is rarely observed simultaneously with Ki-67. However, in transforming HPV infections, p16 is strongly overexpressed in proliferating cells. Observing dual expression, therefore, suggests HPV-induced deregulation of the cell cycle and may be used as an indicator for the presence of high-grade lesions.[24]

The workup of the primary test result (i.e., the triage) can be the second of application for novel biomarkers. Currently, HPV testing is recommended as one option to triage ASC-US cytology.[25] Biomarkers used in triage should be specifically associated with disease progression. Some novel biomarkers such as p16INK4a and Ki-67 have been evaluated in comparison with HPV testing and other markers.[26] In a multicenter study in China, it was found that the p16/Ki-67 positivity increased with histologic severity, and the sensitivity and specificity of p16/Ki-67 to detect CIN2+ in the entire population were 90.9% and 79.5%, respectively. In women with ASC-US and LSIL, sensitivity and specificity for detection of CIN2+ were 87.5% and 66.4%, respectively. Therefore, p16/Ki-67 dual-stained cytology provided a high sensitivity and moderate specificity to detect underlying cervical precancer and cancers in various settings and might be considered as an efficient screening tool in screening.[27]

  Conclusion Top

In addition to primary and triage screening markers, biomarkers could be used for a risk assessment of detected lesions, to stratify intermediate lesions, to predict progression, and to monitor recurrences after treatment. A very interesting field for biomarkers could be the assessment of LSIL and borderline lesions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sahasrabuddhe VV, Luhn P, Wentzensen N. Human papillomavirus and cervical cancer: Biomarkers for improved prevention efforts. Future Microbiol 2011;6:1083-98.  Back to cited text no. 1
Omran OM, AlSheeha M. Human papilloma virus early proteins E6 (HPV16/18-E6) and the cell cycle marker P16 (INK4a) are useful prognostic markers in uterine cervical carcinomas in Qassim region – Saudi Arabia. Pathol Oncol Res 2015;21:157-66.  Back to cited text no. 2
Pisani P, Parkin DM, Bray F, Ferlay J. Estimates of the worldwide mortality from 25 cancers in 1990. Int J Cancer 1999;83:18-29.  Back to cited text no. 3
Bouvard V, Baan R, Straif K, Grosse Y, Secretan B, El Ghissassi F, et al. A review of human carcinogens – Part B: Biological agents. Lancet Oncol 2009;10:321-2.  Back to cited text no. 4
Mohammed A, Ahmed SA, Oluwole OP, Avidime S. Malignant tumours of the female genital tract in Zaria, Nigeria: Analysis of 513 cases. Ann Afr Med 2006;5:93-6.  Back to cited text no. 5
Ahmed SA, Ayuba HU, Maiangwa A, Vakkai VI, Dashe DR, Joel R, et al. Prevalence of squamous intraepithelial lesions of the cervix in Jalingo. Afr J Cell Pathol 2013;1:19-22.  Back to cited text no. 6
Avidime S, Ahmed SA, Oguntayo A, Abu TO, Ndako JA. Pattern of cervical dysplasia among women of reproductive age in Zaria, Northern Nigeria. J Med Trop 2014;16:52-5.  Back to cited text no. 7
  [Full text]  
Ferley J, Bray F, Pisani P, Parkin DM. Globocan 2000: Cancer Incidence, Mortality and Prevalence Worldwide. Lyon: IARC Press; 2001.  Back to cited text no. 8
Schiffman M, Wentzensen N, Wacholder S, Kinney W, Gage JC, Castle PE, et al. Human papillomavirus testing in the prevention of cervical cancer. J Natl Cancer Inst 2011;103:368-83.  Back to cited text no. 9
Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, et al. American cancer society, American Society for colposcopy and cervical pathology, and American Society for clinical pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol 2012;137:516-42.  Back to cited text no. 10
McLaughlin-Drubin ME, Crum CP, Münger K. Human papillomavirus E7 oncoprotein induces KDM6A and KDM6B histone demethylase expression and causes epigenetic reprogramming. Proc Natl Acad Sci U S A 2011;108:2130-5.  Back to cited text no. 11
Reuschenbach M, von Knebel Doeberitz M. Diagnostic tests for the detection of human papillomavirus-associated cervical lesions. Curr Pharm Des 2013;19:1358-70.  Back to cited text no. 12
Arevian M, Noureddine S, Kabakian T. A survey of knowledge, attitude, and practice of cervical screening among Lebanese/Armenian women. Nurs Outlook 1997;45:16-22.  Back to cited text no. 13
Bakheit NM, Haroon AI. The knowledge, attitude and practice of Pap smear among local school teachers in the Sharjah district. Middle East J Fam Med 2004;4:19-24.  Back to cited text no. 14
de Villiers EM, Fauquet C, Broker TR, Bernard HU, zur Hausen H. Classification of papillomaviruses. Virology 2004;324:17-27.  Back to cited text no. 15
Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999;189:12-9.  Back to cited text no. 16
Manga MM, Fowotade A, Abdullahi YM, El-Nafaty AU, Adamu DB, Pindiga HU, et al. Epidemiological patterns of cervical human papillomavirus infection among women presenting for cervical cancer screening in North-Eastern Nigeria. Infect Agent Cancer 2015;10:39.  Back to cited text no. 17
Molijn A, Kleter B, Quint W, van Doorn LJ. Molecular diagnosis of human papillomavirus (HPV) infections. J Clin Virol 2005;32 Suppl 1:S43-51.  Back to cited text no. 18
The 1988 Bethesda system for reporting cervical/vaginal cytological diagnoses. National Cancer Institute Workshop. JAMA 1989;262:931-4.  Back to cited text no. 19
Nayar R, Wilbur DC. The pap test and Bethesda 2014. "The reports of my demise have been greatly exaggerated." (after a quotation from mark twain). Acta Cytol 2015;59:121-32.  Back to cited text no. 20
Solomon D. Foreword. In: Nayar R, Wilbur DC, editors. The Bethesda System for Reporting Cervical Cytology: Definitions, Criteria, and Explanatory Notes. 3rd ed. New York: Springer; 2015.  Back to cited text no. 21
Allia E, Ronco G, Coccia A, Luparia P, Macrì L, Fiorito C, et al. Interpretation of p16(INK4a)/Ki-67 dual immunostaining for the triage of human papillomavirus-positive women by experts and nonexperts in cervical cytology. Cancer Cytopathol 2015;123:212-8.  Back to cited text no. 22
Zhang G, Yang B, Abdul-Karim FW. P16 immunohistochemistry is useful in confirming high-grade squamous intraepithelial lesions (HSIL) in women with negative HPV testing. Int J Gynecol Pathol 2015;34:180-6.  Back to cited text no. 23
Uijterwaal MH, Witte BI, Van Kemenade FJ, Rijkaart D, Ridder R, Berkhof J, et al. Triaging borderline/mild dyskaryotic pap cytology with p16/Ki-67 dual-stained cytology testing: Cross-sectional and longitudinal outcome study. Br J Cancer 2014;110:1579-86.  Back to cited text no. 24
Wentzensen N, von Knebel Doeberitz M. Biomarkers in cervical cancer screening. Dis Markers 2007;23:315-30.  Back to cited text no. 25
Wright TC Jr., Cox JT, Massad LS, Twiggs LB, Wilkinson EJ; ASCCP-Sponsored Consensus Conference, et al. 2001 consensus guidelines for the management of women with cervical cytological abnormalities. JAMA 2002;287:2120-9.  Back to cited text no. 26
Yu LL, Chen W, Lei XQ, Qin Y, Wu ZN, Pan QJ, et al. Evaluation of p16/Ki-67 dual staining in detection of cervical precancer and cancers: A multicenter study in china. Oncotarget 2016;7:21181-9.  Back to cited text no. 27

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