Document Type: Original Research


Department of Pathology, Kasturba Medical College, Mangalore, India



Background & Objective:  Cervical cancer is the most common cancer in women worldwide with high mortality, necessitating quicker diagnostic methods. We wish to enhance the existing cervical biopsies of Squamous Intraepithelial Lesions (SIL) using p16 and Ki67 as surrogate markers to assess correlation between its positivity and histological grade of the lesion.
Methods:  Analysis of p16 and Ki67 expression was done on 31 histopathologically diagnosed cases of SILs. Positive expression of p16 was assessed based on a scoring system and compared with histology and cytology. Ki67 expression was studied and the correlation was observed with degree of dysplasia. Twenty cases of chronic cervicitis was assigned to the control group for comparison.
Results:  Cases of HSIL showed greater expression of p16 as compared to LSIL. Sensitivity of p16 for HSIL was higher than that for LSIL. The specificity for HSIL and LSIL was 100%. Ki67 expression correlated well with the degree and level of dysplasia with a significant P-value of 0.002.
Conclusion:  p16 and Ki67 positivity of SILs should point towards further evaluation. The expressions of p16 and Ki67 are useful markers for confirmation of SILs and in predicting HPV infection which can be further confirmed by HPV DNA testing.  


p16 and Ki67 positivity of SILs should point towards further evaluation. The expressions of p16 and Ki67 are useful markers for confirmation of SILs and in predicting HPV infection which can be further confirmed by HPV DNA testing.  


Main Subjects

  1. Bruni L, Barrionuevo-Rosas L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, Bosch FX, De Sanjosé S. ICO information centre on HPV and cancer (HPV information centre). Human papillomavirus and related diseases in the world. Summary Report. 2015 Mar;4(08).
  2. Sreedevi A, Javed R, Dinesh A. Epidemiology of cervical cancer with special focus on India. Int J Womens Health. 2015;7:405-14. [DOI:10.2147/IJWH.S50001] [PMID] [PMCID]
  3. Musa J, Achenbach CJ, O'Dwyer LC, et al. Effect of cervical cancer education and provider recommendation for screening on screening rates: A systematic review and meta-analysis [published correction appears in PLoS One. 2017 Dec 29;12 (12 ):e0190661]. PLoS One. 2017;12(9):e0183924. [DOI:10.1371/journal.pone.0183924] [PMID] [PMCID]
  4. Khazaei S, Izadi B, Mirbahari SG, Madani SH, Malek Khosravi Sh, Emami Alagha M, Sajadimajd S. Comparison Between Two Detection Methods for HPV16, HPV18 and P16Ink4a Biomarkers in Diagnosis of Abnormal Cervical Cytology. Asian Pac J Cancer Prev. 2016 Dec 1;17(12):5223-7.
  5. Solomon D, Nayar R. The Bethesda System for Reporting Cervical Cytology. Nayar R, Wilbur DC, editors. Cham: Springer International Publishing; 2015. 342.
  6. Genovés J, Alameda F, Mancebo G, Solé JM, Bellosillo B, Lloveras B, et al. Human papillomavirus detection and p16INK4a expression in cervical lesions: A comparative study. Hum Pathol. 2014;45(4):826-33. [DOI:10.1016/j.humpath.2013.10.035] [PMID]
  7. Galgano MT, Castle PE, Atkins KA, Brix WK, Nassau SR, Stoler MH. Using biomarkers as objective standards in the diagnosis of cervical biopsies. Am J Surg Pathol. 2010;34(8):1077-87. [DOI:10.1097/PAS.0b013e3181e8b2c4] [PMID] [PMCID]
  8. van Baars R, Griffin H, Wu Z, et al. Investigating Diagnostic Problems of CIN1 and CIN2 Associated With High-risk HPV by Combining the Novel Molecular Biomarker PanHPVE4 With P16INK4a. Am J Surg Pathol. 2015;39(11):1518-28. [DOI:10.1097/PAS.0000000000000498] [PMID] [PMCID]
  9. de Freitas AC, Coimbra EC, Leitão MDCG. Molecular targets of HPV oncoproteins: Potential biomarkers for cervical carcinogenesis. Biochim Biophys Acta. 2014;1845(2):91-103. [DOI:10.1016/j.bbcan.2013.12.004] [PMID]
  10. Wentzensen N, von Knebel Doeberitz M. Biomarkers in cervical cancer screening. Dis Markers. 2007;23(4):315-30. [DOI:10.1155/2007/678793] [PMID] [PMCID]
  11. Rk M, Su V, Sk M, Nagger S, Shrivastava K, Mishra RK, et al. The use of molecular markers ( Ki67 & p53 ) in premalignant and malignant cervical neoplasms. Trop J Pathol Microbiol. 2016;2(1):3-8. [DOI:10.17511/jopm.2016.i01.02]
  12. Alshenawy HAS. Evaluation of p16, human papillomavirus capsid protein L1 and Ki-67 in cervical intraepithelial lesions: Potential utility in diagnosis and prognosis. Pathol Res Pract. 2014;210(12):916-21. [DOI:10.1016/j.prp.2014.07.007] [PMID]
  13. Volgareva G, Zavalishina L, Andreeva Y, et al. Protein p16 as a marker of dysplastic and neoplastic alterations in cervical epithelial cells. BMC Cancer. 2004;4:58. [DOI:10.1186/1471-2407-4-58] [PMID] [PMCID]
  14. Krishnappa P, Mohamad IB, Lin YJ, Barua A. Expression of P16 in high-risk human papillomavirus related lesions of the uterine cervix in a government hospital, Malaysia. Diagn Pathol. 2014;9:202. [DOI:10.1186/s13000-014-0202-z] [PMID] [PMCID]
  15. Sangwaiya A, Gill M, Bairwa S, Chaudhry M, Sen R, Prakash Kataria S. Utility of P16/INK4a and Ki-67 in Preneoplasticand Neoplastic Lesions of Cervix. Iran J Pathol. 2018;13(3):308-16.
  16. Lee H, Lee H, Cho YK. Cytokeratin7 and cytokeratin19 expression in high grade cervical intraepithelial neoplasm and squamous cell carcinoma and their possible association in cervical carcinogenesis [published correction appears in Diagn Pathol. 2017 May 22;12 (1):40]. Diagn Pathol. 2017;12(1):18. [DOI:10.1186/s13000-017-0609-4] [PMID] [PMCID]
  17. Kong J, Li Y, Liu S, et al. High expression of ezrin predicts poor prognosis in uterine cervical cancer. BMC Cancer. 2013;13:520. Published 2013 Nov 4. doi:10.1186/1471-2407-13-520. [DOI:10.1186/1471-2407-13-520] [PMID] [PMCID]
  18. Zhang W, Ou J, Lei F, et al. C14ORF166 overexpression is associated with pelvic lymph node metastasis and poor prognosis in uterine cervical cancer. Tumour Biol. 2016;37(1):369-379. [DOI:10.1007/s13277-015-3806-3] [PMID] [PMCID]
  19. Lim S, Lee MJ, Cho I, Hong R, Lim SC. Efficacy of p16 and Ki-67 immunostaining in the detection of squamous intraepithelial lesions in a high-risk HPV group. Oncol Lett. 2016;11(2):1447-52. [DOI:10.3892/ol.2015.4071] [PMID] [PMCID]
  20. Vinyuvat S, Karalak A, Suthipintawong C, Kleebkaow P, Trivijitsilp P, Triratanachat S, et al. Interobserver Reproducibility in Determining p16 Overexpression in Cervical Lesions : Use of a Combined Scoring Method. Asian Pac J Cancer Prev. 2008;9:653-7.
  21. Schwarz JK, Lewis JS, Pfeifer J, Huettner P, Grigsby P. Prognostic Significance of p16 Expression in Advanced Cervical Cancer Treated With Definitive Radiotherapy. Int J Radiat Oncol. 2012 ;84(1):153-7. [DOI:10.1016/j.ijrobp.2011.11.032] [PMID]
  22. Srivastava S. P16INK4A and MIB-1: An immunohistochemical expression in preneoplasia and neoplasia of the cervix. Indian J Pathol Microbiol. 2010;53(3):524. [DOI:10.4103/0377-4929.68301] [PMID]
  23. Hebbar A, Murthy V. Role of p16/INK4a and Ki-67 as specific biomarkers for cervical intraepithelial neoplasia: An institutional study. J Lab Physicians. 2017;9(2):104. [DOI:10.4103/0974-2727.199630] [PMID] [PMCID]
  24. Galgano MT, Castle PE, Atkins K a, Brix WK, Nassau SR, Stoler MH. Using Biomarkers as Objective Standards in the Diagnosis of Cervical Biopsies. Am J Surg Pathol. 2010 ;34(8):1077-87. [DOI:10.1097/PAS.0b013e3181e8b2c4] [PMID] [PMCID]
  25. Eleutério Jr J, Lima T, Cunha M, Cavalcante D, Silva A. Immunohistochemical Expression of the Tumor Suppressor Protein p16INK4a in Cervical Adenocarcinoma. Rev Bras Ginecol e Obs / RBGO Gynecol Obstet. 2017;39(01):21-5. [DOI:10.1055/s-0037-1598042] [PMID]
  26. Kanthiya K, Khunnarong J, Tangjitgamol S, Puripat N, Tanvanich S. Expression of the p16 and Ki67 in cervical squamous intraepithelial lesions and cancer. Asian Pacific J Cancer Prev. 2016;17(7):3201-6.
  27. Eleutério Jr J, Giraldo PC, Gonçalves AK, Cavalcante DIM, Ferreira FVDA, Mesquita SM, et al. Prognostic markers of high-grade squamous intraepithelial lesions: the role of p16 INK4a and high-risk human papillomavirus. Acta Obstet Gynecol Scand. 2007 ;86(1):94-8. [DOI:10.1080/00016340601089727] [PMID]
  28. Eleutério J, Cavalcante D, Linhares I, Pompeu M., Giraldo P. The utility of p16 INK4a and Ki-67 to identify high-grade squamous intraepithelial lesion in adolescents and young women. Indian J Pathol Microbiol. 2012;55(3):339. [DOI:10.4103/0377-4929.101740] [PMID]
  29. Xing Y, Wang C, Wu J. Expression of geminin, p16, and Ki67 in cervical intraepithelial neoplasm and normal tissues. Medicine (Baltimore). 2017 ;96(26):e7302. [DOI:10.1097/MD.0000000000007302] [PMID] [PMCID]
  30. Leite P, Tafuri L, Costa M, Lima M, Simões R, Leite PM de O, et al. Evaluation of the p16 and Ki-67 Biomarkers as Predictors of the Recurrence of Premalignant Cervical Cancer Lesions after LEEP Conization. Rev Bras Ginecol e Obs / RBGO Gynecol Obstet. 2017;39(06):288-93. [DOI:10.1055/s-0037-1598643] [PMID]