Negative Xpert HPV Test (Cepheid) With Late Amplification Signals: Is There a Clinical Significance? (the PaPCR Study).

Cervical cancer is the fourth most common cancer among women worldwide, with higher prevalence in low-resource countries due to limited access to screening and HPV vaccination. Nucleic acid amplification tests (NAATs) such as Xpert HPV (Cepheid), enable rapid detection of high-risk HPV (HR-HPV) genotypes. However, the clinical significance of weak and late amplification signals (cycle threshold ≥ 38), interpreted as negative, remains unclear. In this study, a comparison with cytological results aimed to assess their significance. Out of 6846 cervical samples analyzed at Brest University Hospital (Jan. 2022-June 2024), 45 showed late amplification and were reported negative by Xpert. These samples were retested using an in-house HPV pangenotypic PCR followed by genotyping (LiPA) and were assessed by cytology. Of the 44 available cytology results, 65.9% were normal, 15.9% showed low-grade squamous intraepithelial lesions (LSIL), and 18.2% were atypical squamous cells of undetermined significance (ASC-US). No high-grade squamous intraepithelial lesions (HSIL) were found at initial cytology. Among the 42 samples available for in-house PCR, 59.5% tested positive for HPV, and 11.9% were confirmed as HR-HPV genotypes (types 52, 56, 35). Additionally, among patients with available HPV history, 73.3% had a previous positive test. In 91% of these cases, the genotype suspected during the late amplification was concordant with the previous infection. During the 1-year follow-up, one patient initially classified as LSIL developed a histologically confirmed HSIL (CIN2) and needed treatment by conization, whereas 3 others were found to have low-grade CIN1 cell lesions. Overall, for 15 out of 45 patients with weak HPV PCR signal and abnormal cytology (33.3%), clinicians chose to recommend a closer 1-year follow-up and not at 5 years as recommended for HPV negative patients. In conclusion, cytological triage and a review of patient history remain crucial to avoid missing at-risk patients, especially in settings where HPV-negative women are re-screened only 5 years later. A multicenter study using Xpert HPV and other automated platforms is recommended to strengthen these findings and further explore potential correlations between viral load and clinical severity.