Tidy

2. Adjunctive Colposcopic
Technologies
John Tidy
Professor of Gynaecological Oncology
President BSCCP
Chair,
National Colposcopy Professional Group
Committee,
Research Advisory Committee for Cervical
Screening
Sheffield

3. Disclosures
• Zilico Ltd
– Shareholder, Consultancy, Patent holder
• Qiagen
– Speaker fee
• Roche
– Speaker fee
• Hologic
– Speaker fee
• Sanofi-Pastuer
– Travel and conference fees

4. Why do we need adjuvant
technologies?
• New referral groups
– HPV Triage, ToC, Primary HPV testing
• Post vaccination population
• Minimise overtreatment to avoid adverse
outcomes
• Improve re-assurance when discharging
women to routine screening
• Triage by molecular tests may not be
effective
– CINTEC Plus

5. The Performance of Colposcopy
• Colposcopy has not changed for 90
years
• Understanding performance
• We cannot assess sensitivity and
specificity out side of clinical trials
• We use positive predictive value of a
colposcopic impression of HG-CIN to
confirm HG-CIN on biopsy – as marker of
performance

6. Colposcopy in different
populations
• Positive predictive value (PPV) is
dependent on the prevalence of disease
– More HG-CIN equals better PPV
• If the proportion of women referred have
no disease increases so our
performance will decrease
– HPV primary screening
– Effect of HPV vaccination
• Non HPV16/18 disease is less prevalent

7. Colposcopy in different
populations
• Service review in Sheffield 2292 women with
biopsy data
– Colposcopic impression HG-CIN
– Referred with HG cytology PPV = 93.4%
– Referred with LG cytology PPV = 54.9%
– Referred HPV 16/18 pos/cyto neg PPV = 42.9%
– Referred HPV O pos/cyto neg PPV = 35.0%
• But these data may reflect the performance of our
cytology laboratory

8. Colposcopy in different
populations
• Multiple biopsy study of 690 women
– Colposcopic impression HG-CIN
• HSIL cytology PPV = 60.0%
• LSIL cytology PPV = 32.2%
Wentzensen et al 2015

9. Relationship between disease prevalence and predictive value in a test with 95% sensitivity
and 85% specificity.
Relationship between disease prevalence
and predictive value
Tidy et al
BJOG
2013;120:400-11
Louwers et al
BJOG
2011;118:309-18
van der Marel et al
BJOG
2014;121:1117-26
Sensitivity 74% (63-83%) 52% (42-61%) 62 (55-67%)
Specificity 84% (75-90%) 82% (75-88%) 82% (78-86%)
PPV 78% (68-86%) 70% (60-80%) 73% (67-78%)
NPV 80% (71-87%) 67% (60-75%) 73% (69-78%)
Accuracy 78% 70% 74%
LR+ 4.46 2.13 3.4
HG cyto 43.7% 33.0% 55.4%
HG-CIN 44.4% 46.0% 60.0%

10. Primary HPV Screening
• All women aged 25 - 65
• Commenced April 2013
• 314,244 women underwent primary HPV
testing to Dec 2015
• 651,307 women underwent primary
cytology testing to Dec 2015
• hr-HPV positive rates
– Average 12.7%, range 10.5 – 15.0%
– HPV 16/18 4.0%
– Age 24-29 – 27.6%
– Age 50-64 – 5.5%

11. hr-HPV status at Sheffield
HPV 16
HPV 18
HPV O
Negative
N=88,924
15.0% of the screened population are hr-HPV positive
68.4% of hr-HPV positive women are positive for only HPV O

12. HPV genotypes and CIN2+ -
Sheffield
• 1597 cases of CIN2+ were detected.
• 1008 (63.1%) were associated with
HPV16/18 and multiple infection.
• 589 (36.9%) were HPV O only positive
• 68.4% of the women who are hr-HPV
positive have only HPV O and they
contribute 36.9% of all CIN2+.

13. Number of CIN2+ cases following
referral with abnormal cytology -
Sheffield
0
100
200
300
400
500
600
700
800
900
1000
HPV16+/-18+/-O HPV18+/-O HPVO
CIN2+

14. Primary HPV Screening
• 12 month recall
– hr-HPV primary test
– If negative – routine recall
– If positive – reflex cytology
– If cytology positive (any grade) referral to
colposcopy
– If cytology negative but still positive for HPV 16
and or HPV 18 referral to colposcopy
– If cytology negative but still positive for HPV O
repeat hr-HPV test at 12 months

15. Primary HPV Screening
• 24 month recall
– hr-HPV primary test
– If negative – routine recall
– If positive – reflex cytology
– If cytology positive (any grade) referral to
colposcopy
– If cytology negative but still positive for HPV O
referral to colposcopy

16. Primary HPV Screening
• 1076 women seen with persistent hr-HPV
positive / cytology negative
• hr-HPV genotype
– HPV 16 +/- 18+/- O 46%
– HPV 18 +/-O 13%
– HPV O 41%
• Colposcopy
– Normal 72%
– Low grade 11%
– High grade 11%

17. Primary HPV Screening
• 1076 women seen with persistent hr-HPV
positive / cytology negative
• Histology
– Biopsy rate 31%
– CIN2+ 6.5%
• PPV for colposcopic impression of HG-CIN
– 47.4%
• Risk of CIN2+ by hr-HPV genotype
– HPV 16 +/- 18+/- O 1 in 9
– HPV 18 +/-O 1 in 30
– HPV O 1 in 32
• Discharge back to screening
– 87.5%

18. Summary
• The prevalence of disease has the greatest impact
on the performance of colposcopy
• PPV outcome can be ‘gamed’ by colposcopists
– Under calling of HG lesions
• Poor sensitivity of HG Colp impression to detect
HG-CIN
– Biopsy of any grade of lesion because of under
calling of HG Colp Impression
– Failure to discharge patients with no disease
• Changes to screening such as HPV vaccination
and primary HPV screening will increase number
of women referred to colposcopy at low risk of
CIN2+

19. How could new technologies help?
• Increase detection of HG-CIN
– Increased sensitivity
• Improve PPV for S&T and increase number
of cases
– Increased specificity
• Reduce number of biopsies
– Improved accuracy
• Confirmation of a normal colposcopic
examination
– Improved negative predictive value

20. New Technologies in Cervical
Screening and Colposcopy
• LuViva
• DySIS
• ZedScan
• TruScreen
• Gynocular, MobileODT

21. New Technologies in Cervical
Screening and Colposcopy
LuViva Fluorescence + Reflectance
DySIS Photo-optics to quantify
aceto-whiteness
ZedScan Electrical Impedance
Spectroscopy
TruScreen Visible light + Infra Red +
voltage decay

22. TruScreen
• Measures both optical and electrical
changes in the cervix
• Alternative to cervical cytology

23. TruScreen
• Increased sensitivity to detect CIN2+
when combined with cytology
– 93% for cytology + TruScreen
– 70% for TruScreen alone and 69% for
cytology alone
Singer et al 2003

24. LuViva

25. LuViva
• Placed between cytology and colposcopy
• Triage of low grade cytology to colposcopy
– Increased and earlier detection of CIN2+
• Sensitivity to detect CIN2+ 91.3%
• Specificity 38.9%
Twiggs et al 2013

26. DySIS
Video-colposcope
attached to speculum
New versions more
ergonomically friendly
Displays a false colour
to highlight areas to biopsy

27. Red, yellow and white areas indicate intense/long lasting aceto-whitening

28. DySIS performance
ITT
n = 236
Video -
Colposcopy
Dysis + Video-
Colposcopy
Sensitivity (TP) 52% 80% p=0.039
Specificity (TN) 82% 63% p=0.011
PPV 76% 72%
NPV 68% 68%
Accuracy 70% 68%
Positive
likelihood ratio
2.13 2.83
Prevalence of CIN2+ 45.2% Louwers et al BJOG 2011

29. DySIS
• Zaal et al (2012)
– Same study – subgroup analyses
– DySIS increases detection of HPV16 related
CIN
– Abnormal cytology (HG cytology 33%)
– CIN2+ 46%
• Colp - HPV 16 53.0%1 vs non HPV16 61.0%2
• DySIS - HPV 16 97.0%1 vs non HPV16 74.0%2
1Colp vs DySIS p 0.009, 2Colp vs DySIS p=NS

30. DySIS
• Louwers et al (2015)
– Same study – subgroup analyses
– DySIS may increase detection of high grade
CIN post introduction of HPV testing or triage
• Coronado et al (2016)
– Single colposcopist
– 443 women (9.3% CIN2+)
– Sensitivity for CIN2+
• Colp alone 73.2% vs Colp+DySIS 87.8%
– Specificity for CIN2+
• Colp alone 92.3% vs Colp+DySIS 85.6%

31. DySIS
• Roensbo et al (2016)
– Multiple colposcopists
– Up to 5 biopsies including random bx
– 239 women (28.4% CIN2+)
– Sensitivity for CIN2+
• DySIS 32.4%
– Specificity for CIN2+
• DySIS 83%
– DySIS missed 67.6% CIN2+ cases
• Result may reflect, in part, methodology of
study

32. Biological and circuit model for tissue
impedance (EIS)
Extra-cellular
space
Intra-cellular
space
Current input
Measured voltage output
Cell membrane
Current input
Measured voltage output
R
C
S
Can we image the cervical epithelium
with electricity?

33. Structure of cervical epithelium
Basement
membrane Stroma
Surface
epithelium
Normal CIN 1 CIN 2 CIN 3 Invasion
Intermediate
Superficial
Parabasal
Basal
0.4
mm

34. Structure of cervical epithelium
Basement
membrane
Stroma
Surface
epithelium
Normal CIN 1 CIN 2 CIN 3 Invasion
Intermediate
Superficial
Parabasal
Basal
0.4
mm

35. Hierarchical Modelling
Tetrapolar
electrode
array
MACROSCOPIC TISSUE MODEL
Stroma
+I -I
V
V1 V2
I
Z(f)
MUCUS
SUPERFICIAL
INTERMEDIATE
PARABASAL
BASAL
Epithelial layers
CELLULAR MODEL MODELS

36. Finite element derived model
Normal squamous
HG-CIN
Immature
metaplasia
Normal columnar
Walker et al 2003

37. EIS in the detection of CIN
Squamous ― Low grade ― High grade CIN ― Immature metaplasia ― Columnar ―
Modelled Measured
+
Compare modelled data with measured data to
derive a probability that HG-CIN is present or absent

38. Snout LEDs
“Push on – off” single use sensor
Real time on board
data analysis

41. 1
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42. ZedScan – results screens
See and Treat
Biopsy required –
Single point mode

43. 43 March 2010
Commercial in
Confidence
43September 2009 Commercial in Confidence 43July 2009 Commercial in ConfidenceOctober 2008 Commercial in Confidence 43
February 17 Commercial in confidence 43

44. 44 March 2010
Commercial in
Confidence
44September 2009 Commercial in Confidence 44July 2009 Commercial in ConfidenceOctober 2008 Commercial in Confidence 44
February 17 Commercial in confidence 44
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45. ZedScan – results screens
No biopsy required

46. ZedScan – clinical performance
• Service review – 1570 new referrals
– 401 (25.5%) HG cytology
– 836 (53.2%)LG cytology
– 333 (21.0%) hrHPV pos/cyto negative, clinical
referrals
• 504 cases of HG-CIN
– 426 (84.5%) Colp + ZedScan
– 59 (15.5%) ZedScan only

47. ZedScan – clinical performance
• Failure to detect HG-CIN
– Colp 14.1% vs ZedScan 3.8%, p<0.0001
• 50% increase in detection of HG-CIN in
women referred with low grade cytology
• Treatment at first visit including ZedScan
– 68% of all HG referrals
– PPV for CIN2+ 95.2%

48. ZedScan – clinical performance
• Biopsy rate
– 688 underwent bx
– 1.08 bx per patient
– 29 extra cases HG-CIN detected by ZedScan
only directed biopsy
• Glandular neoplasia
– 18 cases, 14 only had HG-CGIN and no HG-
CIN
– 7 had abnormalities on colp + ZedScan
– 2 had abnormalities on colp only
– 5 had abnormalities on ZedScan only

50. ZedScan – international
performance
• 561 women at 8 centres
• Increased sensitivity of ZedScan + colp
– 92.4% vs 84.5%, p<0.01
• Increased detection of CIN2+
– 36 (18.4%) extra cases
• Performance is independent of colposcopy
clinic and cytology practice

51. Utilising ZedScan in a clinical
setting
Tidy et al BJOG 2013

52. Can hr-HPV genotype influence
colposcopic performance?
• Jeronimo 2015 (J Low Gen Tract Dis)
– Screening CIN2+ 1.8%
• HPV 16 76.4% vs non HPV16 43.1%
• Jeronimo 2007 (AJOG)
– Low grade referrals CIN2+ 26.7%
• HPV 16 83.0% vs non HPV16 64.7%

53. Can hr-HPV genotype influence
colposcopic performance?
• Marel et al 2014 (BJOG)
– Abnormal cytology (HG cytology 56.7%)
– CIN2+ 42.6%
• HPV 16 88.0% vs non HPV16 87.0%
• Zaal et al 2012 (BJOG)
– Abnormal cytology (HG cytology 33%)
– CIN2+ 46%
• Colp - HPV 16 53.0%1 vs non HPV16 61.0%2
• DySIS - HPV 16 97.0%1 vs non HPV16 74.0%2
1Colp vs DySIS p 0.009, 2Colp vs DySIS p=NS

54. Does ZedScan increase
detection of HG-CIN irrespective
of hr-HPV genotype?
• ZedScan uses electrical impedance
spectroscopy to detect CIN
• Independent aceto-white change
• Does detection of HG-CIN by ZedScan
affected by hr-HPV genotype?

55. Detection of HG-CIN
• 839 women referred to colposcopy with
known hr-HPV genotype
– 202 HG cytology, 411 LG cytology, 48 F/U
CIN1/2, 4 clinical, 187 hr-HPV pos/cyto neg
– All had an adequate colposcopic examination
(TZ1+2)
• hr-HPV genotype:
– HPV16 – 303 (36.1%)
• 159 single infections; 144 with other types
– HPV18 – 111 (13.2%)
• 54 single infections; 57 with other types
– HPV O – 613 (73.1%)
• 443 without HPV16/18; 170 with HPV16 or 18

56. Colposcopic detection of HG-CIN
by hr-HPV genotype
0
10
20
30
40
50
60
70
80
90
100
HPV16 Non HPV16
CIN2+
p=0.0191 (86.9% vs 79.7%)
N= 611
HG cytology 33.0%
CIN2+ 38.9%

57. ZedScan increases detection of
HG-CIN irrespective of hr-HPV
genotype
0
20
40
60
80
100
120
HPV16 Non HPV16
Colp Impression ZedScan
p<0.0001p=0.0171
n=611HG cytology 33.0%
CIN2+ 38.9%

58. ZedScan increases detection of
HG-CIN irrespective of hr-HPV
genotype in cytology negative
referrals
HPV genotype No CIN2+ Total (%) CIN2+ only detected by
ZedScan (%)
HPV 16 82 12 (14.6%) 2 (20%)
HPV 18 34 3 (8.8%) 2 (200%)
HPV O 71 3 (4.2%) 1 (50%)
Total 187 18 (9.6%) 5 (38.5%)
1p=0.045
1Fisher’s extact test, two tailed

59. Summary
• Colposcopic performance declines as the
prevalence of HG-CIN falls
• Triage by biomarkers may help to enrich the
population referred to colposcopy and reduce
referral rates but as of now are unproven or of
variable performance
• HPV O infections are more frequent than HPV 16
or 18 only infections 67% vs 18.2%
• 33% of CIN2+ are associated with only HPV O
infections

60. Summary
• Adjunctive technologies increase detection of HG-
CIN especially in groups with low prevalence of
HG-CIN
• hr-HPV genotype impacts on colposcopic
performance
– Some technologies, i.e. non aceto-white based,
increase detection of HG-CIN irrespective of hr-HPV
genotype
• More appropriate clinical management
– Increased detection of HG-CIN
– Use of treatment at first visit
– Appropriate discharge at first visit to screening