Predicting Response In Cervical Intraepithelial Neoplasia to Topical Imiquimod Treatment

Study Overview
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Brief Summary
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Imiquimod is a good non-invasive treatment option for women with cervical high-grade squamous intraepithelial neoplasia (cHSIL), especially those with a possible (future) pregnancy wish. Complete response to imiquimod occurs in 55-73% of patients, however side-effects of imiquimod are common and can be extensive. Therefore, biomarkers which can predict response to imiquimod therapy are warranted, to increase therapy efficacy and to avoid side effects in patients who will not respond. This prospective, multi-center cohort study aims to validate the potential of immune related biomarkers to predict the clinical response of patients with primary cHSIL to imiquimod, aims to explore the value of these immune biomarkers in recurrent/residual cHSIL to predict treatment responses for imiquimod and aims to explore their potential in spontaneous regression of cHSIL (CIN2).

Detailed Description
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RATIONALE: A persistent high risk Human Papilloma Virus (hrHPV) infection can cause (pre)malignant anogenital lesions of the cervix, vulva or vagina. Cervical high grade squamous intraepithelial lesions (cHSIL) have a malignant potential and require adequate therapy. The natural history of cHSIL is unpredictable:  25% of cHSIL will regress, while 18% will progress to invasive cervical cancer. The standard treatment of histologically confirmed cHSIL is surgical excision by large loop excision of the transformation zone (LLETZ), with potential complications, such as hemorrhage, infection and an increased risk of preterm birth in subsequent pregnancies. Imiquimod cream has been studied as a non-invasive treatment alternative and the recent TOPIC-3 trial for cHSIL a complete response rate of 55% upon imiquimod therapy was reported. Imiquimod is now considered as a standard non-surgical therapy for patients with cHSIL in the Netherlands, especially in those patients with a future pregnancy wish. Side-effects of imiquimod therapy however are common and can be extensive, consisting mostly of local inflammation and burning, but also systemic adverse events such as headache and flu-like symptoms. Therapy adherence is challenging with up to 20% discontinuation of treatment due to the side effects and the 16 week treatment duration. As such, biomarkers which can predict response to imiquimod therapy are warranted, to increase therapy efficacy and to avoid side effects in patients who will not respond. Our previous work shows that clinical response to imiquimod in cHSIL is associated with a coordinated pre-existing type 1 T cell- and inflammatory myeloid cell infiltration and provided the first set of parameters that potentially can function together as a predictive biomarker CIBI (CHSIL Immune Biomarker for Imiquimod). OBJECTIVE: This study aims to validate the potential of immune related biomarkers to predict the clinical response of patients with primary cHSIL to imiquimod and aims to explore the value of these immune biomarkers in recurrent/residual cHSIL to predict treatment responses for imiquimod and aims to explore their potential in spontaneous regression of cHSIL (CIN2). STUDY DESIGN: Multicenter, real-life prospective cohort validation study. STUDY POPULATION: We aim to include 316 women with a primary histological diagnosis of cHSIL, 50 patients with residual/recurrent histological diagnosis of cHSIL treated with imiquimod and 50 patients with cHSIL (e.g. CIN 2) not treated to await potential spontaneous regression according to the real life setting. INTERVENTION: Patients are included in the study if they prefer imiquimod treatment, as standard care, for their cHSIL lesion or choose for expectative management of cHSIL (e.g. CIN2), according to the real-life clinical setting in the Netherlands. Patients are treated by a 16-week regime of imiquimod 5% cream, applied three times a week. Treatment efficacy will be evaluated after 20 weeks, by colposcopy with diagnostic biopsies, and at 6 months after completion of imiquimod therapy with cytology or if indicated histology. At inclusion, at 20 weeks and after 6 months a vaginal swab will be taken to evaluate the vaginal microbiome. Therapy adherence and side effects will be registered. PRIMARY STUDY OBJECTIVES: Confirm the relationship between a complete clinical response to imiquimod and the increased epithelial and stromal infiltration of CD4+ T cells, CD11c+ cells and/or M1-like macrophages as well as the decreased infiltration with FoxP3+ Tregs in primary cHSIL. Validate the association of CIBI to a complete response to imiquimod treatment in primary cHSIL. Determine the sensitivity and specificity of CIBI in patients with primary cHSIL lesions to estimate the predictive value for therapy efficacy upon imiquimod treatment. SECONDARY STUDY OBJECTIVES: Explore the CIBI as a predictive biomarker for therapy efficacy to imiquimod treatment in patients with residual/recurrent cHSIL (rrcHSIL). Explore the CIBI as a predictive biomarker for spontaneous regression of cHSIL (e.g. CIN2). Determine the vaginal microbiome in cHSIL patients treated with imiquimod or not treated to explore the potential interaction of the vaginal microbiome and composition of immune infiltrates in relation to imiquimod treatment and the relation to spontaneous regression. NATURE AND EXTENT OF THE BURDEN AND RISKS ASSOCIATED WITH PARTICIPATION, BENEFIT AND GROUP RELATEDNESS: The burden associated with participation to this study is minimal since patients are included in accordance to real-life selection. If patients prefer imiquimod treatment for the therapy for their cHSIL lesion after consultation with the gynecologist they will be treated following a standard protocol, following the national guideline for cHSIL (CIN, AIS en VAIN.pdf). The burden for patients to participate in the study lies in an extra biopsy taken at colposcopy at 20 weeks and taking vaginal cultures for microbiome analysis. The benefit for the patients lies in extra support via telephonic consultation and close monitoring. For the patients in the observational arm with no treatment, no extra examinations will be performed according to the national guideline for cHSIL, only data and tissue will be used and two vaginal swabs taken. For the study cohort the benefit is limited but if we are able to identify a clinical predictive biomarker for spontaneous regression or imiquimod in cHSIL, this may increase therapy efficacy for future cHSIL patients by patient selection preventing unnecessary imiquimod therapy.

Official Title
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Predicting Response In Cervical Intraepithelial Neoplasia to Topical Imiquimod Treatment

Conditions
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Cervical High Grade Squamous Intraepithelial Lesion, Cervical Intraepithelial Neoplasia Grade 2/3, CIN 2/3, Cervical Intraepithelial Neoplasia

Intervention / Treatment
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* Drug: Imiquimod
* Diagnostic Test: 3x vaginal swab for microbiome analysis
* Other: Expectative management
* Diagnostic Test: 2x vaginal swab for microbiome analysis


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Primary cHSIL lesions (e.g. CIN3 or CIN 2), histologically confirmed by diagnostic biopsy Nota bene: In case of CIN 2, expectative management must be discussed according to the Dutch national guideline with the patient, if the patient prefers imiquimod therapy the patient can be treated with imiquimod and enrolled in the study, if the patient prefers expectative management they can be enrolled in the observational CIN 2 group. Recurrent or residual cHSIL lesions after initial LLETZ treatment (e.g. CIN2 or CIN3), histologically confirmed by diagnostic biopsy Age of 18 years or older Exclusion Criteria: Concomitant diagnoses of VAIN (vaginal intraepithelial neoplasia e.g. vaginal HSIL) PAP (Papanicolaou) 4 cytology as indication for the baseline colposcopy at study entrance Adenocarcinoma in situ (AIS) diagnosis Previous imiquimod therapy for cHSIL Previous cervical malignancy Current malignant disease Immunodeficiency (including HIV/AIDS and immunosuppressive medication) Pregnancy Legal incapability Insufficient knowledge of the Dutch language

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Primary cHSIL<br>Women with a first diagnosis of cHSIL (e.g. CIN 2 or CIN 3) who prefer treatment with imiquimod. | Drug: Imiquimod<br>* Imiquimod 5% will be administered in the evening by either a vaginal applicator or administered on a vaginal tampon for three times a week during 16 weeks. Treatment efficacy will be evaluated after 20 weeks, by colposcopy with diagnostic biopsies, and at 6 months after completion of imiquimod therapy with cytology and if indicated histology.<br>* Other names: Aldara;Diagnostic Test: 3x vaginal swab for microbiome analysis<br>* A vaginal swab will be taken from all patients at inclusion (before start of imiquimod), at colposcopy 20 weeks after start of imiquimod and at 6 months after completion of imiquimod treatment during follow-up appointment.<br>|
| Recurrent/residual cHSIL (rrcHSIL)<br>Women who were treated for cHSIL before, but who have a residual or recurrent lesion and prefer treatment with imiquimod. | Drug: Imiquimod<br>* Imiquimod 5% will be administered in the evening by either a vaginal applicator or administered on a vaginal tampon for three times a week during 16 weeks. Treatment efficacy will be evaluated after 20 weeks, by colposcopy with diagnostic biopsies, and at 6 months after completion of imiquimod therapy with cytology and if indicated histology.<br>* Other names: Aldara;Diagnostic Test: 3x vaginal swab for microbiome analysis<br>* A vaginal swab will be taken from all patients at inclusion (before start of imiquimod), at colposcopy 20 weeks after start of imiquimod and at 6 months after completion of imiquimod treatment during follow-up appointment.<br>|
| CIN 2 observational group<br>Women with primary CIN 2 who prefer expectant management to await the potential of spontaneous regression. | Other: Expectative management<br>* Expectative management of CIN 2 when preferred by the patient. Follow-up 6 months after baseline colposcopy with cytology and if indicated histology.<br>Diagnostic Test: 2x vaginal swab for microbiome analysis<br>* A vaginal swab will be taken from all patients at inclusion and at 6 months after inclusion during follow-up appointment.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Confirm association of 'hot signature' immune infiltrates in cHSIL with complete clinical responses to imiquimod | Confirm the relationship between a complete clinical response to imiquimod and the increased epithelial and stromal infiltration of CD4+ T cells, CD11c+ cells and/or M1-like macrophages as well as the decreased infiltration with FoxP3+ Tregs in primary cHSIL. | Up to 3 years | 
| Validate immune biomarker CIBI for imiquimod for predicting complete response in cHSIL | Defined as the sum of the numbers of either epithelial or stromal CD4+/CD11c+/M1+ cells per square millimeter minus the number of FoxP3+ cells per square millimeter, with a complete response to imiquimod treatment in primary cHSIL. | Up to 3 years | 
| Determine the sensitivity and specificity of the CIBI in cHSIL | Determine the sensitivity and specificity of the CIBI in patients with primary cHSIL lesions to estimate the predictive value for therapy efficacy upon imiquimod treatment. | Up to 3 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Explore the role of CIBI in therapy responses to imiquimod in rrcHSIL | Explore the CIBI as a predictive biomarker for therapy efficacy to imiquimod treatment in patients with residual/recurrent cHSIL (rrcHSIL). | Up to 3 years | 
| Explore the role of CIBI in prediction of spontaneous regression of CIN 2 | Explore the CIBI as a predictive biomarker for spontaneous regression of cHSIL (e.g. CIN2). | Up to 3 years | 
| Determine treatment efficacy upon imiquimod therapy. | Treatment efficacy will be evaluated by determination of clinical responses at 20 weeks and at 6 months by either complete responder (CR), partial responder (PR), non-responder (NR) or progressive disease (PD) assessed by histology from biopsy and/or cytology from papsmear. | During imiquimod treatment, 20 weeks after start of imiquimod and 6 months after completion of imiquimod treatment | 
| Determine therapy adherence upon imiquimod therapy. | Therapy adherence will be evaluated by patient reported use on the calendar by registrating the amount of imiquimod applications per week. | During imiquimod treatment (16 weeks) | 
| Determine reported side effects upon imiquimod therapy. | Reported side effects will be evaluated by documentation of side effects on the calendar. | During imiquimod treatment (16 weeks) | 
| Determine treatment HPV clearance upon imiquimod treatment. | HPV clearance will be tested according to the absence or presence of hrHPV infection according to the local pathology sites via standard operating procedures. | Before start of imiquimod treatment, 20 weeks after start imiquimod treatment, 6 months after completion of imiquimod treatment. | 
| Evaluate maintenance of lesion regression after imiquimod treatment | Determination of recurrent cHSIL or progression to cervical cancer. | 24 months and 5 year follow-up with cytology and histology if necessary | 
| Evaluate time to recurrence or progression of cHSIL. | Determination of time to recurrence or progression of cHSIL. | 24 months and 5 year follow-up with cytology and histology if necessary | 
| Explore and evaluate other potential more specific predictive (immune) biomarkers in cHSIL | For example dedicated gene expression profiles by Nanostring and gene methylation assays. | Up to 3 years | 
| Develop a simplified pathological scoring system | Explorative development of a simplified dual immunohistochemistry protocol to identify the hot signature and exploration of the predictive value of this 'immunoscore' in cHSIL. | Up to 3 years | 
| Validate the CIBI via single immunohistochemistry | Defined as epithelial or stromal cluster of differentiation (CD) 4+/CD11c+/CD68+ cells per square millimeter with a complete response to imiquimod treatment in primary cHSIL. | Up to 3 years | 
| Determine the vaginal microbiome in cHSIL patients | To explore the potential interaction of the vaginal microbiome and composition of immune infiltrates in relation to imiquimod treatment and the relation to spontaneous regression. | Baseline, 20 weeks after start of imiquimod and 6 months after completion of imiquimod treatment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Cervical high-grade squamous intraepithelial lesion (cHSIL), Imiquimod, Tumor immunemicroenvironment, High-risk human papilloma virus (hrHPV), Cervical intraepithelial neoplasia (CIN), Biomarker