Féline O Voss

DNA methylation testing for vulvar cancer risk stratification in patients with high-grade vulvar intraepithelial neoplasia: a population-based cohort study

Abstract Background High-grade vulvar intraepithelial neoplasia (VIN) is the precursor of vulvar cancer. The main variants are human papillomavirus (HPV)-associated high-grade squamous intraepithelial lesion (HSIL) and HPV-independent VIN, often clinically referred to as differentiated VIN (dVIN) and associated with vulvar dermatoses, usually lichen sclerosus. Surgical treatment of high-grade VIN often leads to genital deformity, impaired sexual function and reduced quality of life. To optimize clinical management, accurate biomarkers providing information on the cancer risk of high-grade VIN are needed. Objectives To investigate the prognostic value of a three-gene methylation marker panel and other potential risk factors for the risk of progression to cancer in patients with HSIL and dVIN. Methods From a population-based cohort of patients diagnosed with high-grade VIN, patients with a histopathologically confirmed diagnosis of HSIL (n = 578) and dVIN (n = 46) were selected. All lesions were tested by a three-gene methylation panel including the genes ZNF582, SST and miR124-2. The vulvar cancer risk and the prognostic value of methylation status, age, HPV genotype, wild-type vs. mutant p53 immunohistochemistry status and presence of lichen sclerosus were estimated by Kaplan–Meier and Cox regression, respectively. Results Vulvar cancer developed in 26 of 578 patients with HSIL (4.5%) and in 21 of 46 with dVIN (46%) within 5 years. In HSIL, positive methylation status was identified as the only prognostic factor for vulvar cancer development [hazard ratio (HR) 4.87, 95% confidence interval (CI) 1.20–21.45]. The prognostic value of methylation remained present when selecting patients who did not receive radical surgical excision as their primary treatment. In this group, the 5-year cancer risk was 7.7% in methylation-positive HSIL and 1.4% in methylation-negative HSIL (P = 0.008). In dVIN, mutant p53 status was the sole prognostic risk factor for progression to cancer (HR 7.67, 95% CI 1.78–33.08). Conclusions Despite wide CIs, the three-gene methylation test serves as a promising prognostic tool for cancer risk stratification in patients with vulvar HSIL. Patients with methylation-negative HSIL carry a low cancer risk, allowing for more conservative management strategies. This approach may help avoid overtreatment, reducing morbidity and improving quality of life.

DNA Methylation and p53 Immunohistochemistry as Prognostic Biomarkers for Vulvar Lichen Sclerosus

Vulvar lichen sclerosus (LS) is an inflammatory dermatosis that can progress to human papillomavirus (HPV)-independent vulvar intraepithelial neoplasia (HPVi VIN) and vulvar squamous cell carcinoma (VSCC). Although LS has a much lower cancer risk compared with HPVi VIN (5% vs 50%, respectively), its incidence is significantly higher. Therefore, there is a clinical need to identify LS patients with an increased cancer risk. Our objective was to study the value of DNA methylation and p53 immunohistochemistry (IHC) as prognostic biomarkers for progression to cancer in patients with LS. Vulvar tissues from 236 patients were selected, including 75 LS and 68 HPVi VIN, both with and without cancer development, 32 VSCC, and 61 healthy vulvar controls. Samples were subjected to p53 IHC and DNA methylation analysis of a 3-gene marker panel containing ZNF582, SST, and miR124-2. Methylation levels and p53 IHC status (mutant or wild-type) were assessed and compared among all disease categories. Odds ratios were determined to identify whether the biomarkers were associated with progression to cancer in patients with LS. The highest methylation levels were found in HPVi VIN and VSCC, followed by LS and healthy vulvar controls. The largest heterogeneity in methylation levels was observed in LS cases. In fact, the 3-marker panel tested positive in 70% of LS, which progressed to VSCC vs only 17% of LS in patients without cancer development (P = .002). Also, mutant p53 IHC was observed more frequently in LS with progression to VSCC compared with nonprogressive LS cases (42% vs 3%, respectively, P = .001). Multivariable analysis identified a mutant p53 status as the only independent risk factor for cancer development in LS (odds ratio: 34.0, 95% CI: 1.4-807.4). In conclusion, DNA methylation testing and p53 IHC show strong potential as prognostic biomarkers for the identification of LS patients at high risk of progression to cancer.

Prevalence of prescribing topical corticosteroids to patients with lichen sclerosus following surgery for vulvar cancer: a survey among gynaecologic oncologists in The Netherlands

Vulvar lichen sclerosus (LS) is a chronic inflammatory dermatosis which can progress to precursor lesion differentiated vulvar intraepithelial neoplasia (dVIN) and vulvar squamous cell carcinoma (VSCC). The risk of developing recurrent vulvar cancer following LS-associated VSCC is high. Evidence suggests that treatment of LS with topical corticosteroids (TCS) can prevent progression to dVIN, VSCC and recurrences. However, current guidelines do not give any recommendation on the management of LS following surgery for VSCC. The aim of this study was to conduct a survey among all registered gynaecologic oncologists (GOs) in the Netherlands to evaluate the current management of LS patients without a history of VSCC (LS An online survey was distributed to all registered GOs in the Netherlands. Primary outcome measures were the frequency, type and duration of TCS treatment prescribed for LS Forty-four GOs completed the survey, resulting in a response rate of 75%. TCS were prescribed more often to patients with LS The majority of GOs who participated in our study endorse the utilisation of long-term ultra-potent TCS therapy in both patients with LS

Clinical validation of methylation biomarkers for optimal detection of high‐grade vulvar intraepithelial neoplasia

Abstract The precursor lesions of vulvar squamous cell carcinoma (VSCC) include human papillomavirus (HPV)‐associated and HPV‐independent squamous neoplasia with a varying cancer risk. Our study aimed to validate the accuracy of previously identified DNA methylation markers for detection of such high‐grade vulvar intraepithelial neoplasia (VIN). A large clinical series of 751 vulvar lesions, originally diagnosed as high‐grade VIN, were reassessed and categorized into HPV‐associated or HPV‐independent vulvar disease categories. Together with 113 healthy vulvar controls, all samples were tested for 12 methylation markers with quantitative multiplex methylation‐specific PCR (qMSP). Performance of individual markers and selection of an optimal marker panel for detection of high‐grade VIN was determined by logistic regression analysis. SST was the best‐performing individual marker (AUC 0.90), detecting 80% of high‐grade VIN cases, with excellent detection of HPV‐independent VIN (95%), known to have the highest cancer risk. Merely 2% of controls tested methylation positive for SST . Selection of a marker panel, including ZNF582 , SST and miR124‐2 , resulted in a comparably high accuracy for detection of high‐grade VIN (AUC 0.89). In conclusion, we clinically validated the accuracy of 12 DNA methylation markers for detection of high‐grade VIN. SST , as a sole marker or in a panel, provides an optimal diagnostic tool to distinguish high‐grade VIN in need of treatment, particularly HPV‐independent VIN, from low‐grade or reactive vulvar lesions. These findings warrant further prognostic validation of methylation biomarkers for cancer risk stratification of patients with VIN.

DNA methylation and copy number alterations in the progression of HPV‐associated high‐grade vulvar intraepithelial lesion

AbstractHuman papillomavirus (HPV)‐associated high‐grade vulvar intraepithelial lesion (HSIL) is a precursor of vulvar squamous cell carcinoma (VSCC). Because of the 8% cancer risk, many vulvar HSIL patients undergo aggressive and mutilating treatments. Characterizing HSIL by their progression risk can help individualize treatment strategies. Accordingly, copy number alterations (CNAs) and DNA methylation have been identified as biomarkers for cancer risk stratification of HSIL. Here, we assessed their potential correlation, and relation to HPV16 (sub)lineages and progression to vulvar cancer. Eighty‐two vulvar formalin‐fixed paraffin‐embedded (FFPE) samples, including controls, HSIL, HSIL adjacent to VSCC and VSCC, with previously determined DNA methylation profiles, were analysed for CNAs using mFAST‐SeqS. Genome‐wide z‐scores were calculated to determine overall aneuploidy (aneuploidy scores), and compared to the methylation levels and status of marker panel ZNF582/SST/miR124‐2. For 52 HPV16‐positive cases, HPV (sub)lineages were determined by Sanger sequencing. HPV16 lineage A was predominant (86.4%), followed equally by lineages B, C, and D. Frequent chromosomal alterations included chr1pq, chr3q, chr9q gains, and chr2q, chr4q losses. Median aneuploidy scores increased across disease categories, from 0 in controls, to 3 in HSIL, 16 in HSIL adjacent to VSCC and 29 in VSCC. A positive relationship between aneuploidy scores and DNA methylation levels was found (ρ = 0.61, Spearman's rank correlation test). Aneuploidy scores were significantly higher in methylation‐positive samples (p < .001). In conclusion, we showed that DNA methylation and CNAs both rise with increasing severity of disease, indicating their prognostic value for cancer risk stratification of HSIL, while no relation to HPV16 (sub)lineages was found.