Objective: Immunochemical detection of the protein p16INK4a in cervical cytology is used in combination with Ki-67. Cells positive for both proteins are certain to have been transformed by high-risk HPV. p16/Ki-67 immunocytochemistry provides a significant improvement in specificity over cytology and HPV DNA testing. However, p16/Ki-67 immunocytochemistry also has its limitations. Study Design: The research is based on the follow-up of 1,131 patients for whom p16/Ki-67 immunocytochemistry was performed with cytology. Dependencies on the age of patients with LSIL, number of p16/Ki-67-positive cells, and different results during repeated examinations were analyzed. Results: In LSIL, positive p16/Ki-67 is less specific for ≥CIN2/HSIL for patients younger than 30 years compared to patients aged 30 years or older (61.1 vs. 75.7%, p < 0.013). Using a score of 10 p16/Ki-67-marked cells as a positive result instead of 1 led to significantly higher specificity (89.0 vs. 70.2%, p < 0.001). This modified threshold offers better risk assessment in LSIL. In repeated immunocytochemical investigations, 28.4% of the results deviated from the first examination. Conclusion: The abovementioned discrepancies can be interpreted as hints about the molecular biological causes of suboptimal performance of p16/Ki-67. An efficient and reliable application of p16/Ki-67 immunocytochemistry requires knowledge of its methodological limitations.

Alberts B, Johnson A, Lewis J, Raff M, Roberts K, Walter P: Molekularbiologie der Zelle, ed 5. Weinheim, Schäfer U, Wiley-VCH Verlag, Germany, 2011.
Reuschenbach M, Vinokura S, von Knebel Doeberitz M: HPV-associated carcinomas of the female genital tract. Molecular mechanisms of development (in German). Pathologe 2011;32:451-460.
Reuschenbach M, Vinokura S, von Knebel Doeberitz M: Etiology of cervical cancer and its precursors (in German). Onkologe 2012;18:9-19.
McLaughlin-Drubin ME, Crum CP, Munger K: Human papillomavirus E7 oncoprotein induces KDM6A and KDM6B histone demethylase expression and causes epigenetic reprogramming. Proc Natl Acad Sci USA 2011;108:2130-2135.
Trunk MJ, Wentzensen N, von Knebel Doeberitz M: Molecular pathogenesis of cervical cancer (in German). Pathologe 2005;26:283-290.
Schmidt D, Bergeron CH, Denton KJ, et al: p16/Ki-67 Dual-stain cytology in the triage of ASCUS and LSIL Papanicolaou cytology. Cancer Cytopathol 2011;119:158-166.
Fujii T, Saito M, Hasegawa T et al: Performance of p16INK4a/Ki-67 immunocytochemistry for identifying CIN2+ in atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions specimens: a Japanese Gynecologic Oncology Group study. Int J Clin Oncol 2015;20:134-142.
Ikenberg H, Bergeron CH, Schmidt D, et al: Screening for cervical cancer precursors with p16/Ki-67 dual-stained cytology: results of the PALMS study. J Natl Cancer Inst 2013;105:1550-1557
Ordi J, Sagasta A, Munmany M, et al: Usefulness of p16/Ki67 Immunostaining in the triage of women referred to colposcopy. Cancer Cytopathol 2014;35:122-127.
Wentzensen N, Schwartz L, Zuna RE, et al: Performance of p16/Ki-67 immunostaining to detect cervical cancer precursors in a colposcopy referral population. Clin Cancer Res 2012;18:4154-4162.
Ziemke P, Griesser H: Indications for p16-/Ki-67-immuncytochemistry in cervical cytology (in German). Pathologe 2017;38:38-44.
Singh M, Mockler D, Akalin A, et al: Immunocytochemical colocalization of p16(INK4a) and Ki-67 predicts CIN2/3 and AIS/adenocarcinoma: pilot studies. Cancer Cytopathol 2011;120:26-34.
Solares C, Velasco J, Alvarez-Ruiz E, et al: Expression of p16/Ki-67 in ASC-US/LSIL or normal cytology with presence of oncogenic HPV DNA. Anticancer Res 2015;35:6291-6296.
Vrdoljak-Mozetic D, Krasevic M, Versa Ostojic D, et al: HPV16 genotype, p16/Ki-67 dual staining and koilocytic morphology as potential predictors of the clinical outcome for cervical low-grade squamous intraepithelial lesions. Cytopathology 2015;26:10-18.
Ziemke P, Marquardt K, Griesser H: Predictive value of the combined p16INK4a and Ki-67 immunocytochemistry in low-grade squamous intraepithelial lesions. Acta Cytol 2014;58:489-494.
zur Hausen H: Papillomavirus and cancer: from basic studies to clinical application. Nat Rev Cancer 2002;2:342-350.
Scholzen T, Gerdes J: The Ki-67 protein: from the known and the unknown. J Cell Physiol 2000;182:311-322.
Van Oijen MGCT, Medema RH, Slootweg PJ, Rijksen G: Positivity of the proliferation marker Ki-67 in noncycling cells. Am J Clin Pathol 1998;110:24-31.
Bergeron C, Ikenberg H, Sideri M, et al: Prospective evaluation of p16/Ki-67 dual-stained cytology for managing women with abnormal Papanicolaou cytology: PALMS study results. Cancer Cytopathol 2015;123:373-381.
Possati-Resende JC, Fregnani JH, Kerr LM, et al: The accuracy of p16/Ki-67 and HPV test in the detection of CIN2/3 in women diagnosed with ASC-US or LSIL. PLoS One 2015;10:e0134445.
Waldstrøm M, Christensen RK, Ørnskov D: Evaluation of p16INK4a/Ki-67 dual stain in comparison with an mRNA human papillomavirus test on liquid-based cytology samples with low-grad squamous intraepithelial lesion. Cancer Cytopathol 2013;121:136-145.
Koo Y-J, Hahn H-S, Lee I-H, et al: Dual immunostaining of cervical cytology specimens with atypical squamous cells for p16/Ki-67 does not exclude the existence of a high-grade squamous intraepithelial lesion. Virchows Arch 2013;463:689-696.
Uijterwaal MH, Witte BI, van Kemenade FJ, 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;110:1579-1586.
Uijterwaal MH, Polman NJ, Witte BI, et al: Triaging HPV-positive women with normal cytology by p16/Ki-67 dual-stained cytology testing: baseline and longitudinal data. Int J Cancer 2015;136:2361-2368.
Wentzensen N, Fetterman B, Castle PE, et al: p16/Ki-67 dual stain cytology for detection of cervical precancer in HPV-positive women. J Natl Cancer Inst 2015;107:1-8.
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