Document Type : Original Research


1 Missan Health Directorate, Missan, Iraq

2 Dept. of Pathology and Forensic medicine, College of Medicine, Al-Nahrain University, Baghdad, Iraq


Background: This research was accomplished to evaluate the IHC expression of p16 (ink4a) and CK17 in low grade cervical intraepithelial lesions (LSIL), high grade cervical intraepithelial lesions (HSIL) and invasive cervical carcinomas and to assess their correlation to HPV (16E6+18E6).
Methods: The study included (127) formalin-fixed paraffin-embedded cervical biopsies; of which 22 cases were chronic cervicitis, 24 cases were LSIL, 28 cases were HSIL and 53 cases were invasive cervical carcinomas. Sections were immunohistochemically stained for p16 (ink4a), CK17 and HPV (16E6+18E6).
Results: The study established a highly significant increase in IHC of expression of p16 (ink4a), CK17 and HPV (16E6+18E6) from LSIL through HSIL to invasive carcinomas (P-value˂0.001). There was non-significant association between IHC expression of all makers with age of patients; types, grade and stage of cervical carcinomas (P-value˃0.05). HPV (16E6+18E6) revealed a significantly positive correlation with p16 (ink4a) (P-value˂0.05) and a non- significant correlation with CK17 (P-value˃0.05); in LSIL, HSIL and invasive carcinoma cases.
Conclusion: p16 (ink4a) expression directly reflects infection with high risk HPV in cervical lesions and can add a significant diagnostic accuracy in the evaluation of CIN. CK 17 is a good marker of malignant transformation, with increasing in its expression according to the severity of cervical lesions; however, it is not related to HPV infection. Both markers are not related to prognostic variables of patients with cervical carcinoma.


  1. Madhumati G, Kavita S, Anju M, Uma S, Raj M. Immunohistochemical Expression of Cell Proliferating Nuclear Antigen (PCNA) and p53 Protein in Cervical Cancer. J Obstet Gynaecol India 2012; 62:557-61.
  2. Agorastos T, Miliaras D, Lambropoulos AF, Chrisafi S, Kotsis A, Manthos A, et al. Detection and typing of human papilloma virus DNA in uterine cervices with coexistent grade I and grade III intraepithelial neoplasia: biologic progression or independent lesions? Eur J ObstetGynecolReprod Biol 2005; 121:99-103.
  3. Ellenson LH, Pirog EC. The Female Genital Tract. In: Kumar V, Abbas KA, Fausto N, Aster JC. Robbins and Cotran Pathologic Basis of Disease. 8th ed. Philadelphia, PA: Elsevier Saunders, 2010:pp1018-24.
  4. de Sanjose S, Quint WG, Alemany L, Geraets DT, Klaustermeier JE, Lloveras B, et al. Human papillomavirus genotype attribution in invasive cervical cancer: a retrospective cross-sectional worldwide study. Lancet Oncol 2010; 11:1048-56.
  5. Muñoz N, Bosch FX, de Sanjosé S, Herrero R, Castellsagué X, Shah KV, et al. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med 2003; 348:518-27.
  6. Tsoumpou I, Arbyn M, Kyrgiou M, Wentzensen N, Koliopoulos G, Martin-Hirsch P, et al. p16 (INK4a) immunostaining in cytological and histological specimens from the uterine cervix: a systematic review and meta-analysis. Cancer Treat Rev 2009; 35:210-20.
  7. Rabban JT, Soslow RA, Zaloudek CZ. Diagnostic immunohistochemistry of the female genital tract. In: Dabbs DJ, Ed. Diagnostic Immunohistochemistry. 3rd ed. Churchill Livingstone: Philadelphia2010: pp690-9.
  8. Benevolo M , Mottolese M, Marandino F, Vocaturo G, Sindico R, Piperno G, et al. Immunohistochemical expression of p16 (INK4a) is predictive of HR-HPV infection in cervical low-grade lesions. Mod Pathol 2006;19:384-91
  9. Smedts F , Ramaekers F, Link M, Lauerova L, Troyanovsky S, Schijf C, et al. Detection of keratin subtypes in routinely processed cervical tissue: implications for tumor classification and the study of cervix cancer etiology. Virchows Arch 1994; 425:145-55.
  10. Smedts F , Ramaekers F, Troyanovsky S, Pruszczynski M, Robben H, Lane B, et al. Basal-cell keratins in cervical reserve cells and a comparison to their expression in cervical intraepithelial neoplasia. Am J Pathol 1992; 140:601-12.
  11. Yang Y, Sabata B, Monroe R, Chang T, Hsiao L, , Jung S, et al. Digital analysis of IHC images for detecting HPV E6/E7 oncoproteins in CIN2/3 and cervical cancer tissues. The 26thInternation Papillomavirus Conference, Canada, Onco Health 2010: 461.
  12. Agrawal GP, Joshi PS, Agrawal A. Role of HPV-16 in pathogenesis of oral epithelial dysplasia and oral squamous cell carcinoma and correlation of p16INK4A expression in HPV-16 positive cases: an immunohistochemical study. ISRN Pathology. 2013; Article ID 807095, 7 pages.
  13. Chaudhary AK, Pandya S, Singh M, Singh M, Mehrotra R. Identification of high-risk human papillomaviruse (HPV-16 & 18) infection by multiplex PCR (MPX-PCR) and its expression in oral sub mucous fibrosis and oral squamous cell carcinoma. Head Neck Oncol 2013; 5:4.
  14. Shin EA, Lee SR, Lee SY, Kim NH, Ju W, Kim SC. p16INK4a methylation and the correlation to immunohistochemical expression in cervical neoplasia.   J Womens Med 2009; 2: 16-22.
  15. Kitamura R, Toyoshima T, Tanaka H, Kawano S, Kiyosue T, Matsubara R, et al. Association of cytokeratin 17 expression with well differentiation in oral squamous cell carcinoma. J Cancer Res Clin Oncol 2012; 138:1299-310.
  16. Iraqi Cancer Board. Results of Iraqi Cancer Registry, 1976-1985. Ministry of Health (editor), Baghdad, Iraq 1987:18, 35, 59.
  17. Iraqi Cancer Board. Results of Iraqi Cancer Registry, 1995-1997. Ministry of Health (editor), Baghdad, Iraq1999:11-13, 34, 32-39.
  18. Iraqi Cancer Board. Results of Iraqi cancer registry center, 2011. Ministry of Health (editor), Baghdad, Iraq 2014.
  19. Anderson SM. Human papillomavirus and cervical cancer. Clinical Microbiology Newsletter.2002; 24: 113-8.
  20. Thomas MC, Chiang CM. E6 oncoprotein represses p53-dependent gene activation via inhibition of protein acetylation independently of inducing p53 degradation. Mol Cell 2005; 17:251-64.
  21. Kumar A , Zhao Y, Meng G, Zeng M, Srinivasan S, Delmolino LM, et al. Human papillomavirus oncoprotein E6 inactivates the transcriptional co-activator human ADA3. Mol Cell Biol 2002; 22:5801-12.
  22. Al-jewari MMM, Ali SHM, Al-azzawi MKK. Genotyping of human papilloma virus infections and phenotyping of tumor infiltrating lymphocytes in Iraqi patients with uterine cervical neoplasia. Iraqi Postgraduate Medical Journal 2007; 6: 362-73.
  23. Fahad RO, Abdulbaqi S, Hasony HJ. The association of human papillomavirus with cervical neoplasm in Basrah. Basrah Journal of Surgery.2011; 17: 14-21.
  24. Jalilvand S, Shoja Z, Nourijelyani K, Tohidi HR, Hamkar R. Meta-analysis of type-specific human papillomavirus prevalence in Iranian women with normal cytology, precancerous cervical lesions and invasive cervical cancer: Implications for screening and vaccination. J Med Virol 2015; 87:287-95.
  25. Alsbeih G, Ahmed R, Al-Harbi N, Venturina LA, Tulbah A, Balaraj K. Prevalence and genotypes distribution of human papillomavirus in invasive cervical cancer in Saudi Arabia. Gynecol Oncol 2011; 121:522-6.
  26. Al-Badawi IA, Al-Suwaine A, Al-Aker M, Asaad L, Alaidan A, Tulbah A, et al. Detection and genotyping of human papilloma virus in cervical cancer specimens from Saudi patients. Int J Gynecol Cancer 2011; 21:907-10.
  27. Dursun P, Ayhan A, Mutlu L, Çağlar M, Haberal A, Güngör T, et al. HPV types in Turkey: multicenter hospital based evaluation of 6388 patients in Turkish gynecologic oncology group centers. Turk Patoloji Derg 2013; 29:210-6.
  28. Kulkarni SS, Kulkarni SS, Vastrad PP, Kulkarni BB, Markande AR, Kadakol GS, et al. Prevalence and distribution of high risk human papillomavirus (HPV) Types 16 and 18 in Carcinoma of cervix, saliva of patients with oral squamous cell carcinoma and in the general population in Karnataka, India. Asian Pac J Cancer Prev 2011; 12:645-8.
  29. Sowjanya AP, Jain M, Poli UR, , Padma S, Das M, Shah KV, BN et al. Prevalence and distribution of high-risk human papilloma virus (HPV) types in invasive squamous cell carcinoma of the cervix and in normal women in Andhra Pradesh, India. BMC Infect Dis 2005; 5: 116.
  30. De Oliveira CM, Fregnani JHTG, Carvalho JP, Longatto-Filho A, Levi JE .Human papilloma virus genotypes distribution in 175 invasive cervical cancer cases from Brazil. BMC Cancer 2013, 13:357.
  31. Vu LT, Bui D, Le HT. Prevalence of cervical infection with HPV type 16 and 18 in Vietnam: implications for vaccine campaign. BMC Cancer 2013, 13:53
  32. Moscicki AB, Schiffman M, Burchell A, Albero G, Giuliano AR, Goodman MT, et al. Updating the natural history of human papillomavirus and anogenital cancers. Vaccine 2012; 30: 24-33.
  33. Bosch FX, Lorincz A, Muñoz N, Meijer CJ, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol 2002; 55:244-65.
  34. Ressler S, Scheiden R, Dreier K, Laich A, Müller-Holzner E, Pircher H, et al. High-risk human papillomavirus E7 oncoprotein detection in cervical squamous cell carcinoma. Clin Cancer Res 2007; 13:7067-72.
  35. Pirog EC, Kleter B, Olgac S, Bobkiewicz P, Lindeman J, Quint WG, et al. Prevalence of human papillomavirus DNA in different histological subtypes of cervical adenocarcinoma. Am J Pathol 2000; 157:1055-62.
  36. Chen S, O'Sullivan H, Tabrizi SN, Fairley CK, Quinn MA, Garland SM. Prevalence and genotyping of HPV in cervical cancer among Australian women. Int J Gynaecol Obstet 1999; 67:163-8.
  37. 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.
  38. SakikoNishio, Takuma Fujii, Hiroshi Nishio, Kaori Kameyama, Miyuki Saito, Takashi Iwata, et al. p16 (ink4a) immunohistochemistry is a promising biomarker to predict the outcome of low grade cervical intraepithelial neoplasia: comparison study with HPV genotyping. J GynecolOnco 2013; 24: 215–221.
  39. Balan R, Simion N, Giuşcă SE, Grigoraş A, Gheucă-Solovăstru L, Gheorghiţă V, et al. Immunohistochemical assessment of p16, COX-2 and EGFR in HPV-positive cervical squamous intraepithelial lesions. Rom J Morphol Embryol. 2011; 52:1187-94.
  40. Wu H, Shi H, Kong L. Relationship of HPVL1 and p16 expression with different cervical lesions. Sci Res Essays 2011; 6: 3724-8.
  41. Yu L, Wang L, Zhong J, Chen S. Diagnostic value of p16 INK4A, Ki-67, and human papillomavirus L1 capsid protein immunochemical staining on cell blocks from residual liquid-based gynecologic cytology specimens. Cancer Cytopathol 2010; 118:47-55.
  42. Volgareva G, Zavalishina L, Andreeva Y, Frank G, Krutikova E, Golovina D, et al. Protein p16 as a marker of dysplastic and neoplastic alterations in cervical epithelial cells. BMC Cancer 2004, 4:58 
  43. Branca M, Ciotti M, Santini D, Di Bonito L, Giorgi C, Benedetto A, et al. P16 (INK4A) expression is related to grade of CIN and high risk human papillomavirus but does not predict virus clearance after conization or disease outcome. Int J Gynecol Pathol 2004; 23:354-65.
  44. Bahnassy AA, Zekri AR, Saleh M, Lotayef M, Moneir M, Shawki O. The possible role of cell cycle regulators in multistep process of HPV-associated cervical carcinoma. BMC Clin Pathol 2007; 7:4.
  45. Ishikawa M, Fujii T, Saito M, Nindl I, Ono A, Kubushiro K, et al. Overexpression of p16 INK4a as an indicator for human papillomavirus oncogenic activity in cervical squamous neoplasia. Int J Gynecol Cancer 2006; 16:347-53.
  46. Lili C, Guoqing Y, Haiwei W, Yan C. Expression of HPV16/18, P16, CK17, Ki67 in cervical squamous epithelial lesions. Cancer Res Clin 2015; 27: 113-116.
  47. Wu J, Li X, Zhu W, Liu X. Detection and pathological value of papillomavirus DNA and p16INK4A and p53 protein expression in cervical intraepithelial neoplasia. Oncol Lett 2014; 7: 738–744.
  48. Guo M, Baruch AC, Silva EG, Jan YJ, Lin E, Sneige N, et al. Efficacy of p16 and ProExCimmunostaining in the detection of high-grade cervical intraepithelial neoplasia and cervical carcinoma. Am J Clin Pathol 2011; 135:212-20.
  49. Benevolo M, Mottolese M, Marandino F, Vocaturo G, Sindico R, Piperno G, et al. Immunohistochemical expression of p16 (INK4a) is predictive of HR-HPV infection in cervical low-grade lesions. Mod Pathol 2006; 19:384-91.
  50. Kalof A, Cooper K. p16INK4a immunoexpression: surrogate marker of high-risk HPV and high-grade cervical intraepithelial neoplasia. AdvAnat Pathol 2006; 13:190-4.
  51. Leversha MA, Fielding P, Watson S, Gosney JR, Field JK. Expression of p53, pRB, and p16 in lung tumors: a validation study on tissue microarrays. J Pathol 2003; 200:610-9.
  52. Mäkitie AA, MacMillan C, Ho J, Shi W, Lee A, O'Sullivan B, et al. Loss of p16 expression has prognostic significance in human nasopharyngeal carcinoma. Clin Cancer Res 2003; 9:2177-84.
  53. Klaes R, Benner A, Friedrich T, Ridder R, Herrington S, Jenkins D, et al. p16INK4a immunohistochemistry improves interobserver agreement in the diagnosis of cervical intraepithelial neoplasia. Am J Surg Pathol 2002; 26:1389-99.
  54. Klaes R, Friedrich T, Spitkovsky D, Ridder R, Rudy W, Petry U, et al. Overexpression of p16 (INK4A) as a specific marker for dysplastic and neoplastic epithelial cells of the cervix uteri. Int J Cancer 2001; 92:276-84.
  55. Ikeda K, Tate G, Suzuki T, Mitsuya T. Coordinate expression of cytokeratin 8 and cytokeratin 17 immunohistochemical staining in cervical intraepithelial neoplasia and cervical squamous cell carcinoma: an immunohistochemical analysis and review of the literature. Gynecol Oncol 2008; 108:598-602.
  56. Carrilho C, Alberto M, Buane L, David L. Keratins 8, 10, 13, and 17 are useful markers in the diagnosis of human cervix carcinomas. Hum Pathol. 2004; 35:546-51.
  57. Martens JE, Arends J, Van der Linden PJ, De Boer BA, Helmerhorst TJ. Cytokeratin 17 and p63 are markers of the HPV target cell, the cervical stem cell Anticancer Res. 2004; 24:771-5.
  58. Maddox P, Sasieni P, Szarewski A, Anderson M, Hanby A. Differential expression of keratins 10, 17, and 19 in normal cervical epithelium, cervical intraepithelial neoplasia, and cervical carcinoma. J Clin Pathol 1999; 52:41-6.
  59. Carrilho C, Cirnes L, Alberto M, Buane L, Mendes N, David L. Distribution of HPV infection and tumor markers in cervical intraepithelial neoplasia from cone biopsies of Mozambican women. J Clin Pathol 2005; 58:61-8.