Improving Risk Stratification for Cervical Intraepithelial Neoplasia Grade II: A Prospective Cohort Study on Combined HPV DNA and E6/E7 mRNA Testing to Predict Histologic Progression

Background: The management of cervical intraepithelial neoplasia grade II (CIN II) is challenging due to its unpredictable natural history. Although high-risk human papillomavirus (HR-HPV) DNA testing is highly sensitive, it lacks specificity in predicting which lesions will progress. Detection of E6/E7 oncogene mRNA reflects viral oncogenic activity. This study aimed to prospectively evaluate and compare the performance of HR-HPV DNA testing, E6/E7 mRNA testing, and their combination in predicting the histologic progression of CIN II lesions, using repeat histopathology as the gold standard. Methods: A prospective cohort study was conducted involving 150 women with biopsy-confirmed CIN II. Baseline cervical samples were collected for HR-HPV DNA detection (using a validated PCR-based assay) and E6/E7 mRNA detection (using a proprietary nucleic acid amplification test). All participants were followed for 12 months, with the primary endpoint defined as histologic progression to CIN III or worse (CIN III+), confirmed by colposcopic-directed biopsy or conization. The predictive efficacies of the tests, alone and in combination, were assessed using sensitivity, specificity, and Receiver Operating Characteristic (ROC) curve analysis. Results: After 12 months, histologic progression was confirmed in 16 patients (10.7%). The sensitivities for predicting progression were similar for HPV DNA (0.905) and E6/E7 mRNA (0.857) testing. However, E6/E7 mRNA showed higher specificity (0.792) than HPV DNA (0.701) (AUC: 0.861 vs. 0.827). The combined testing strategy (defined as positivity for both assays) demonstrated the highest predictive accuracy, achieving a specificity of 0.917 while maintaining a sensitivity of 0.857. The area under the ROC curve for the combined model was 0.912 (95% CI: 0.854 - 0.952), which was significantly superior to that of HPV DNA testing alone (P < 0.05). Conclusion: For women with biopsy-confirmed CIN II, a combined testing strategy for HPV DNA and E6/E7 mRNA significantly improves the prediction of histologic progression by markedly increasing specificity. This approach offers a powerful tool for precise risk stratification, potentially reducing overtreatment while ensuring timely intervention for high-risk individuals.