1
|
Klein S, Wuerdemann N, Demers I, Kopp C, Quantius J, Charpentier A, Tolkach Y, Brinker K, Sharma SJ, George J, Hess J, Stögbauer F, Lacko M, Struijlaart M, van den Hout MFCM, Wagner S, Wittekindt C, Langer C, Arens C, Buettner R, Quaas A, Reinhardt HC, Speel EJ, Klussmann JP. Predicting HPV association using deep learning and regular H&E stains allows granular stratification of oropharyngeal cancer patients. NPJ Digit Med 2023; 6:152. [PMID: 37598255 PMCID: PMC10439941 DOI: 10.1038/s41746-023-00901-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 08/10/2023] [Indexed: 08/21/2023] Open
Abstract
Human Papilloma Virus (HPV)-associated oropharyngeal squamous cell cancer (OPSCC) represents an OPSCC subgroup with an overall good prognosis with a rising incidence in Western countries. Multiple lines of evidence suggest that HPV-associated tumors are not a homogeneous tumor entity, underlining the need for accurate prognostic biomarkers. In this retrospective, multi-institutional study involving 906 patients from four centers and one database, we developed a deep learning algorithm (OPSCCnet), to analyze standard H&E stains for the calculation of a patient-level score associated with prognosis, comparing it to combined HPV-DNA and p16-status. When comparing OPSCCnet to HPV-status, the algorithm showed a good overall performance with a mean area under the receiver operator curve (AUROC) = 0.83 (95% CI = 0.77-0.9) for the test cohort (n = 639), which could be increased to AUROC = 0.88 by filtering cases using a fixed threshold on the variance of the probability of the HPV-positive class - a potential surrogate marker of HPV-heterogeneity. OPSCCnet could be used as a screening tool, outperforming gold standard HPV testing (OPSCCnet: five-year survival rate: 96% [95% CI = 90-100%]; HPV testing: five-year survival rate: 80% [95% CI = 71-90%]). This could be confirmed using a multivariate analysis of a three-tier threshold (OPSCCnet: high HR = 0.15 [95% CI = 0.05-0.44], intermediate HR = 0.58 [95% CI = 0.34-0.98] p = 0.043, Cox proportional hazards model, n = 211; HPV testing: HR = 0.29 [95% CI = 0.15-0.54] p < 0.001, Cox proportional hazards model, n = 211). Collectively, our findings indicate that by analyzing standard gigapixel hematoxylin and eosin (H&E) histological whole-slide images, OPSCCnet demonstrated superior performance over p16/HPV-DNA testing in various clinical scenarios, particularly in accurately stratifying these patients.
Collapse
Affiliation(s)
- Sebastian Klein
- Department of Hematology and Stem Cell Transplantation, University Duisburg-Essen, University Hospital Essen, Essen, Germany.
- Institute of Pathology, Medical Faculty, University Hospital Cologne, Cologne, Germany.
| | - Nora Wuerdemann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University Hospital Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Medical Faculty, Cologne, Germany
| | - Imke Demers
- Department of Pathology, GROW - School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Christopher Kopp
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Jennifer Quantius
- Institute of Pathology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Arthur Charpentier
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University Hospital Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Medical Faculty, Cologne, Germany
| | - Yuri Tolkach
- Institute of Pathology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Klaus Brinker
- Hamm-Lippstadt University of Applied Sciences, Hamm, Germany
| | - Shachi Jenny Sharma
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University Hospital Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Medical Faculty, Cologne, Germany
| | - Julie George
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University Hospital Cologne, Cologne, Germany
- Department of Translational Genomics, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Jochen Hess
- Department of Otolaryngology, Head and Neck Surgery, University Hospital Heidelberg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Fabian Stögbauer
- Tissue Bank of the National Center for Tumor Diseases (NCT) Heidelberg, Germany, and Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
- Institute of Pathology, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Martin Lacko
- Department of Otorhinolaryngology and Head and Neck Surgery, GROW-School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marijn Struijlaart
- Department of Otorhinolaryngology and Head and Neck Surgery, GROW-School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mari F C M van den Hout
- Department of Pathology, GROW-School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Steffen Wagner
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Giessen, Giessen, Germany
| | - Claus Wittekindt
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Giessen, Giessen, Germany
- Clinic of Otorhinolaryngology, Head and Neck Surgery, Klinikum Dortmund, University of Witten/Herdecke, Faculty for Health, Department of Human Medicine, Witten, Germany
| | - Christine Langer
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Giessen, Giessen, Germany
| | - Christoph Arens
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Giessen, Giessen, Germany
| | - Reinhard Buettner
- Institute of Pathology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Alexander Quaas
- Institute of Pathology, Medical Faculty, University Hospital Cologne, Cologne, Germany
| | - Hans Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, University Duisburg-Essen, University Hospital Essen, Essen, Germany
- West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Ernst-Jan Speel
- Department of Pathology, GROW - School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jens Peter Klussmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University Hospital Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Medical Faculty, Cologne, Germany
| |
Collapse
|
2
|
Rumianek B, Hillman R, Jeoffreys N, Ghazanfar S, Schifter M, Ajwani S. Prevalence of oral HPV in the adult sample population in Sydney. Aust Dent J 2023; 68:19-25. [PMID: 36281543 DOI: 10.1111/adj.12943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Oropharyngeal squamous cell carcinomas are increasing in incidence. Risk factors include sexual behaviour, high-risk oral HPV infection and poor oral hygiene. We aimed to provide initial information on the prevalence and assess the feasibility of testing in dental settings. METHODS Patients ≥18 years old attending dental clinics in Sydney, Australia, were recruited, oral hygiene assessed, and 10 mL saline oral rinses obtained. Rinses were tested for HBG and HPV by PCR. Participants completed demographic and behavioural questionnaires. RESULTS The mean age was 48 years, of whom 131 (43.6%) were male. HPV genotypes, one each of 16, 66, 51, 35 and 58 in five participants, and 18 and 52 in one participant, were detected in six samples (2.0%), all men. Oral sex was reported by 89 (67.9%) male participants. One participant (4.3%) of the 23 with poor OH had at least one HPV genotype detected. DISCUSSION With dental patients willing to provide rinse samples and disclose potentially sensitive information, we found the hrHPV prevalence of 2%. Given large proportions of the general population attending dental clinics regularly, dentists may be ideally placed to screen for oropharyngeal carcinoma and contribute to the currently limited knowledge of oral HPV prevalence in Australian adults. © 2022 Australian Dental Association.
Collapse
Affiliation(s)
- B Rumianek
- The University of Sydney, Camperdown, Australia
| | - R Hillman
- University of New South Wales, Sydney, Australia
| | - N Jeoffreys
- Westmead Institute for Medical Research, Westmead, Australia
| | - S Ghazanfar
- The University of Sydney, Camperdown, Australia
| | - M Schifter
- The University of Sydney, Camperdown, Australia
| | - S Ajwani
- The University of Sydney, Camperdown, Australia
| |
Collapse
|
3
|
Idel C, Polasky C, Ribbat-Idel J, Loyal K, Perner S, Rades D, Bruchhage KL, Pries R. Increased Abundances of CD16+ Non-Classical Monocytes Accompany with Elevated Monocytic PD-L1 and CD4+ T Cell Disturbances in Oropharyngeal Cancer. Biomedicines 2022; 10:biomedicines10061363. [PMID: 35740384 PMCID: PMC9219638 DOI: 10.3390/biomedicines10061363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Patients with human papilloma virus (HPV)-related oropharyngeal cancer have a better prognosis than nonvirally associated patients, most likely because of better immune responses. Increased infiltration of T lymphocytes into the oropharyngeal tumor tissue has been observed, but the dynamics of circulating lymphocytes and monocytes are not fully understood. The aim of this study was to understand the population dynamics of circulating monocyte subsets in oropharyngeal cancer (OPC) patients with regard to the clinicopathological parameters and accompanying immunological consequences in view of the CD4/CD8 T cell subset composition, and the expression of checkpoint pathway proteins programmed death-1 (PD-1) and programmed death ligand-1 (PD-L1). Materials and Methods: The abundance of circulating monocyte subsets and peripheral blood CD4/CD8 T cells of oropharyngeal cancer patients and their PD-L1 and PD-1 expression levels were analyzed by flow cytometry. Results: The studied oropharyngeal cancer patients revealed heterogeneous individual redistributions of CD14++CD16− (classical), CD14++CD16+ (intermediate), and CD14dim+CD16+ (nonclassical) monocyte subsets compared with healthy donors. These differences in monocyte subset alterations were independent in patients with TNM or HPV status but entailed further immunological consequences. Increased percentages of nonclassical monocytes significantly correlated with increased levels of monocytic PD-L1 expression. We observed significantly decreased levels of CD4+ effector T cells, which were accompanied by increased CD4+ effector memory T cells in OPC patients compared with healthy donors, each having a stronger effect in patients with decreased levels of classical monocytes. Conclusion: We conclude that oropharyngeal cancer, as a malignancy from a lymphoid-tissue-rich anatomical region, has a strong systemic impact on the differentiation and regulation of circulating innate and adaptive immune cells. Further comprehensive investigations are required for the possible future usability of the described immunological alterations as bioliquid parameters for prognosis or therapy response prediction.
Collapse
Affiliation(s)
- Christian Idel
- Department of Otorhinolaryngology, University of Luebeck, 23538 Luebeck, Germany; (C.I.); (C.P.); (K.L.); (K.-L.B.)
| | - Christina Polasky
- Department of Otorhinolaryngology, University of Luebeck, 23538 Luebeck, Germany; (C.I.); (C.P.); (K.L.); (K.-L.B.)
| | - Julika Ribbat-Idel
- Department of Pathology, University of Luebeck, 23538 Luebeck, Germany; (J.R.-I.); (S.P.)
| | - Kristin Loyal
- Department of Otorhinolaryngology, University of Luebeck, 23538 Luebeck, Germany; (C.I.); (C.P.); (K.L.); (K.-L.B.)
| | - Sven Perner
- Department of Pathology, University of Luebeck, 23538 Luebeck, Germany; (J.R.-I.); (S.P.)
| | - Dirk Rades
- Department of Radiation Oncology, University of Luebeck, 23538 Luebeck, Germany;
| | - Karl-Ludwig Bruchhage
- Department of Otorhinolaryngology, University of Luebeck, 23538 Luebeck, Germany; (C.I.); (C.P.); (K.L.); (K.-L.B.)
| | - Ralph Pries
- Department of Otorhinolaryngology, University of Luebeck, 23538 Luebeck, Germany; (C.I.); (C.P.); (K.L.); (K.-L.B.)
- Correspondence: ; Tel.: +49-451-500-42120
| |
Collapse
|
4
|
Straetmans JMJAA, Stuut M, Lacko M, Hoebers F, Speel EJM, Kremer B. Additional parameters to improve the prognostic value of the 8th edition of the UICC classification for human papillomavirus-related oropharyngeal tumors. Head Neck 2022; 44:1799-1815. [PMID: 35579041 PMCID: PMC9544856 DOI: 10.1002/hed.27084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 02/17/2022] [Accepted: 04/27/2022] [Indexed: 12/04/2022] Open
Abstract
Background The prognostic reliability of the UICC's TNM classification (8th edition) for human papillomavirus (HPV)‐positive tonsillar squamous cell carcinomas (TSCCs) compared to the 7th edition was explored, and its improvement by using additional anatomical and nonanatomical parameters. Methods One hundred and ten HPV‐positive and 225 HPV‐negative TSCCs were retrospectively analyzed. Survival was correlated with patient and tumor characteristics (7th and 8th edition UICC TNM classification). Results In HPV‐positive TSCCs, the 8th edition UICC's TNM classification correlated better with prognosis than the 7th edition. Also, smoking status was a stronger prognosticator of survival than UICC staging. Non‐ or former smokers had a 5‐year overall survival of 95.1% regardless of tumor stage. Furthermore, age (>65 years), cN3, and M1 classification were significant prognostic factors. Conclusion The prognostic value of the 8th edition UICC's TNM classification improved significantly when compared to the 7th edition. Nonetheless, further improvement is possible by adding nonanatomical factors (smoking, age >65 year) and separating N0‐N2 from N3.
Collapse
Affiliation(s)
- Jos M J A A Straetmans
- Department of Otorhinolaryngology and Head and Neck Surgery, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Otorhinolaryngology and Head and Neck Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Marijn Stuut
- Department of Otorhinolaryngology and Head and Neck Surgery, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Martin Lacko
- Department of Otorhinolaryngology and Head and Neck Surgery, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Frank Hoebers
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Ernst-Jan M Speel
- Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Bernd Kremer
- Department of Otorhinolaryngology and Head and Neck Surgery, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| |
Collapse
|
5
|
Cheng C, Ou B, Lung F. Developing a Biosensor-Based Immunoassay to Detect HPV E6 Oncoprotein in the Saliva Rinse Fluid of Oral Cancer Patients. J Pers Med 2022; 12:594. [PMID: 35455710 PMCID: PMC9027100 DOI: 10.3390/jpm12040594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 02/04/2023] Open
Abstract
Transmission of Human papillomavirus (HPVs) is faithfully associated with carcinogenesis of oral cavity and oropharyngeal cancers. Therefore, clinical researchers may need to generate customized antibodies for the upcoming ELISA-based analysis to discover rare but valuable biomarkers. The aim of study was to develop and generate a biosensor-based immunoassay for early screening HPV-related oral cancer via saliva rinse fluid analysis. A peptide fragment of high-risk HPV subtype 16/18 protein, E6 protein (HP-1 protein sequence 48–66), was designed and synthesized, followed by the generation of polyclonal antibodies (anti-HP1 IgY) in our university-based laboratories. The titer and specificity of antibodies were determined by enzyme-linked immunosorbent assay (ELISA), and the Surface Plasmon Resonance (SPR) biosensor-based method was developed. Kinetic analyses by SPR confirmed that this designed peptide showed a high affinity with its generated polyclonal antibodies. Saliva fluid samples of thirty oral cancer patients and 13 healthy subjects were analyzed. SPR indicated that 26.8% of oral cancer patients had higher resonance unit (ΔRU) values than normal subjects. In conclusion, we developed a biosensor-based immunoassay to detect HPV E6 oncoprotein in the saliva rinse fluid for early screening and discrimination of HPV-related oral cancer patients.
Collapse
|
6
|
Hampl M, Hillemanns P, Jentschke M. Erweiterte Indikation für die HPV-Impfung: Wer kann profitieren? Geburtshilfe Frauenheilkd 2022. [DOI: 10.1055/a-1378-7098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Monika Hampl
- Universitätsfrauenklinik, Düsseldorf, Deutschland
| | | | | |
Collapse
|
7
|
Camuzi D, Simão TA, Dias F, Ribeiro Pinto LF, Soares-Lima SC. Head and Neck Cancers Are Not Alike When Tarred with the Same Brush: An Epigenetic Perspective from the Cancerization Field to Prognosis. Cancers (Basel) 2021; 13:5630. [PMID: 34830785 DOI: 10.3390/cancers13225630] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/30/2021] [Accepted: 11/02/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary Squamous cell carcinomas affect different head and neck subsites and, although these tumors arise from the same epithelial lining and share risk factors, they differ in terms of clinical behavior and molecular carcinogenesis mechanisms. Differences between HPV-negative and HPV-positive tumors are those most frequently explored, but further data suggest that the molecular heterogeneity observed among head and neck subsites may go beyond HPV infection. In this review, we explore how alterations of DNA methylation and microRNA expression contribute to head and neck squamous cell carcinoma (HNSCC) development and progression. The association of these epigenetic alterations with risk factor exposure, early carcinogenesis steps, transformation risk, and prognosis are described. Finally, we discuss the potential application of the use of epigenetic biomarkers in HNSCC. Abstract Head and neck squamous cell carcinomas (HNSCC) are among the ten most frequent types of cancer worldwide and, despite all efforts, are still diagnosed at late stages and show poor overall survival. Furthermore, HNSCC patients often experience relapses and the development of second primary tumors, as a consequence of the field cancerization process. Therefore, a better comprehension of the molecular mechanisms involved in HNSCC development and progression may enable diagnosis anticipation and provide valuable tools for prediction of prognosis and response to therapy. However, the different biological behavior of these tumors depending on the affected anatomical site and risk factor exposure, as well as the high genetic heterogeneity observed in HNSCC are major obstacles in this pursue. In this context, epigenetic alterations have been shown to be common in HNSCC, to discriminate the tumor anatomical subsites, to be responsive to risk factor exposure, and show promising results in biomarker development. Based on this, this review brings together the current knowledge on alterations of DNA methylation and microRNA expression in HNSCC natural history, focusing on how they contribute to each step of the process and on their applicability as biomarkers of exposure, HNSCC development, progression, and response to therapy.
Collapse
|
8
|
Wojtera M, Barrett JW, Strychowsky JE, Dzioba A, Paradis J, Husein M, Salvadori MI, Nichols AC. The prevalence of human papillomavirus in paediatric tonsils in Southwestern Ontario. J Laryngol Otol 2021;:1-11. [PMID: 34602108 DOI: 10.1017/S0022215121002723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
9
|
Thankappan K, Battoo AJ, Vidhyadharan S, Kudpaje A, Balasubramanian D, Iyer S. Economic evaluations comparing Tran-oral robotic surgery and radiotherapy in oropharyngeal squamous cell carcinoma: A systematic review. Eur J Surg Oncol 2021; 47:2961-2970. [PMID: 34253425 DOI: 10.1016/j.ejso.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/02/2021] [Accepted: 07/05/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Trans-oral robotic surgery (TORS) and primary radiotherapy are the two modalities used to treat early T stage oropharyngeal squamous cell carcinoma(OPSCC). Prior literature including a recent randomized controlled trial have not shown the superiority of one modality over the other. When the modalities have similar outcomes, cost-effectiveness have an important role in deciding on the appropriate treatment. There are economic evaluations comparing the two modality with contradicting conclusions. The purpose of this review is to synthesise the evidence. METHODS This is a systematic review of economic evaluations on the treatment modalities for OPSCC, namely TORS versus radiotherapy. The main outcome measures were the Cost-utility results reported as the effectiveness and costs separately and as part of the Incremental Cost-Effectiveness Ratio. RESULTS Literature search identified five articles reporting cost-utility analysis, eligible for the review. A strategy is considered to be dominant when the effectiveness achieved was more at a lower cost, compared to the comparator. At the willingness to pay (WTP) threshold of 50,000 to 100,000 USD per Quality Adjusted Life-Year (QALY), three studies showed dominance of strategies in the base case analysis (TORS in two and Primary Chemoradiotherapy in one). Two of the articles studied node negative patients, one of them favored TORS. Three articles had node positive patients and two of them favored TORS and one favored chemoradiotherapy in the base case analysis. On sensitivity analysis, adjuvant treatment was found to be the detrimental factor affecting the cost-effectiveness. CONCLUSIONS TORS can be considered a cost-effective strategy in early T stage OPSCC, if the addition of adjuvant therapy involving radiotherapy can be avoided. Literature have shown that around 70% of the early cancers would require adjuvant treatment. This implies the importance of case selection while considering TORS as the initial treatment modality.
Collapse
Affiliation(s)
- Krishnakumar Thankappan
- Department of Head and Neck, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.
| | - Azhar Jan Battoo
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Sivakumar Vidhyadharan
- Department of Head and Neck, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Akshay Kudpaje
- Department of Head and Neck, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Deepak Balasubramanian
- Department of Head and Neck, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Subramania Iyer
- Department of Head and Neck, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| |
Collapse
|
10
|
Bosshart SL, Morand GB, Broglie MA. Frequency and Localization of Second Primary Tumors in Patients with Oropharyngeal Carcinoma-The Influence of the Human Papilloma Virus. Cancers (Basel) 2021; 13:1755. [PMID: 33916999 DOI: 10.3390/cancers13081755] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/25/2021] [Accepted: 04/03/2021] [Indexed: 12/29/2022] Open
Abstract
Simple Summary Human papillomavirus (HPV) infection, smoking, and excessive alcohol consumption have been established as risk factors for the development of oropharyngeal squamous cell carcinoma (OPSCC). While the HPV epidemic has led to an increasing incidence of OPSCC, HPV-negative OPSCC cases associated with smoking and alcohol remain stable. As HPV-positive and -negative OPSCC present two distinct etiological, clinical, and prognostic entities, different treatment and follow-up strategies are being discussed. Still, specific surveillance strategies for HPV-positive OPSCC are lacking, as the risk of second primary tumors (SPT) in the era of HPV-associated OPSCC has not been comprehensively assessed. Our study investigated the frequency and localization of SPT of HPV-positive OPSCC, as well as their prognostic impact. We find that the SPT of HPV-positive OPSCC are less frequent than those of HPV-negative OPSCC, and they are also associated with higher survival rates. The localization of SPT of HPV-positive OPSCC did not differ from the localization of SPT of HPV-negative OPSCC. Abstract Purpose: To investigate the frequency, localization, and survival of second primary tumors (SPT) of oropharyngeal squamous cell carcinoma (OPSCC) depending on human papillomavirus (HPV) status. Methods: We performed a retrospective chart analysis of 107 OPSCC patients treated at the Zurich University Hospital from 2001 to 2010. Rate and localization of SPT after an index OPSCC were stratified according to smoking and HPV infection status. Results: In total, 57/91 (63%) included patients showed an HPV-associated OPSCC. Of these, 37/57 (64.9%) patients with an HPV-positive and 32/34 (94.1%) patients with an HPV-negative OPSCC were smokers. The median age at diagnosis of the SPT was 59.54 years (interquartile range 52.7–65.6). In addition, 8/57 (14%) HPV-positive and 13/34 (38.2%) HPV-negative patients developed SPT. The rate of SPT in patients with HPV-positive index tumors was significantly lower than in patients with HPV-negative OPSCC (p-value 0.01). Smokers showed significantly more SPT in the head and neck area than outside. The development of an SPT led to a significantly lower survival time in HPV-negative patients, while it did not significantly affect the survival time of HPV-positive patients. Conclusions: Patients with HPV-positive index tumors had a significantly lower risk of developing SPT than patients with HPV-negative tumors. If SPT developed, survival was significantly shorter in patients with HPV-negative tumors than with HPV-positive tumors.
Collapse
|
11
|
Quabius ES, Tribius S, Heinrichs A, Haaser D, Kühnel A, Laudien M, Hoppe F, Mlynski R, Ambrosch P, Hoffmann M. HPV DNA/RNA detection in various oral and oropharyngeal biomaterials identifies active HPV infections also in non-neoplastic tonsils. Transl Oncol 2020; 14:101002. [PMID: 33352503 PMCID: PMC7772224 DOI: 10.1016/j.tranon.2020.101002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/14/2022] Open
Abstract
Previous studies describe a correlation between HPV-positivity and non-smoking in TSCC; p16INK4A-expression as surrogate-marker for HPV-DNA/RNA-positivity is discussed controversially. In the present study, these parameters are assessed prospectively. HPV-status of sputum and tonsillar-swabs was analyzed to determine their validity as surrogate-marker for tissue-HPV-status. TSCC- (n = 52) and non-neoplastic tonsillar tissue (n = 163) were analyzed. HPV-DNA- and HPV-RNA-status of total sputum, cellular fraction and supernatants, tonsillar-swabs and -tissue was determined by (RT)-PCR. Immunohistochemistry determined p16INK4A-expression. 23/163 (14.2%) non-neoplastic tonsils were HPV-DNA-positive; five patients (3 HPV16, 2 HPV11) had active HPV-infections (HPV-RNA-positive), in all biomaterials. 140/163 (85.9%) patients were either HPV-DNA-positive or HPV-DNA-negative in all samples. 21/52 (40.4%) TSCC-tonsils were HPV-DNA-positive; 17 patients were HPV-RNA-positive (14 HPV16; 4 HPV18). 40/52 (76.9%) TSCC-patients were congruent in all biomaterials. p16INK4A-expression alone would have misclassified the HPV-status of 14/52 (26.2%) TSCC-patients. This prospective study confirms the discrepancy between HPV-status and p16INK4A-expression and the significant correlation between non-smoking and HPV-DNA-positivity. HPV-sputum- and/or swab-results do not consistently match tissue-results, possibly having (detrimental) consequences if those were used to assess tissue-HPV-status. In the 5 patients with active HPV infection in the non-neoplasitic tonsils, tonsillectomy likely prevented subsequent development of TSCC.
Collapse
Affiliation(s)
- Elgar Susanne Quabius
- Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Arnold-Heller-Str. 3, Building 27, D24105 Kiel, Germany.
| | - Silke Tribius
- Hermann-Holthusen-Institute for Radiation Oncology, Asklepios Hospital St. Georg, Hamburg, Germany.
| | - Alessa Heinrichs
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Rostock, Germany.
| | - Dirk Haaser
- Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Arnold-Heller-Str. 3, Building 27, D24105 Kiel, Germany
| | - André Kühnel
- Department of Otorhinolaryngology, Head and Neck Surgery, Asklepios Hospital Harburg, Hamburg, Germany.
| | - Martin Laudien
- Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Arnold-Heller-Str. 3, Building 27, D24105 Kiel, Germany
| | - Florian Hoppe
- Department of Otorhinolaryngology-Head and Neck Surgery, Klinikum Oldenburg, Hoppe, Germany.
| | - Robert Mlynski
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Rostock, Germany.
| | - Petra Ambrosch
- Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Arnold-Heller-Str. 3, Building 27, D24105 Kiel, Germany
| | - Markus Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Arnold-Heller-Str. 3, Building 27, D24105 Kiel, Germany.
| |
Collapse
|
12
|
Laban S, Brand M, Ezić J, Doescher J, Völkel G, Kestler HA, Brunner C, Hoffmann TK. [Tumor biology of oropharyngeal carcinoma]. HNO 2021; 69:249-55. [PMID: 33215226 DOI: 10.1007/s00106-020-00964-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Etiologically, oropharyngeal squamous cell carcinoma (OPSCC) can be divided into OPSCC caused by noxious agents and human papillomavirus (HPV)-driven carcinoma. These types differ with regard to clinical features and prognosis-differences which are rooted in the underlying molecular biology of the tumor. OBJECTIVE The aim of this work is to provide an overview of the molecular biological characteristics of the genetics, epigenetics, and immunology of OPSCC. MATERIALS AND METHODS A literature review was performed on a selection of genetic, epigenetic, and immunological factors characterizing OPSCC. RESULTS The understanding of genetic aberrations and their consequences for cancerogenesis and tumor biology is increasing. Epigenetic phenomena are complementing functional relationships. However, epigenetic mechanisms of gene regulation are complex and much research is still required in this field. Immunological aspects of cancer molecular biology have moved into the focus in light of recent advances in the field of immunotherapy. CONCLUSION The tumor biology of OPSCC is primarily defined by its HPV status. Additionally, HPV-independent genetic, epigenetic, and immunological signatures are being defined. From these advances, rationales for new treatment concepts may evolve.
Collapse
|
13
|
Pakdel F, Farhadi A, Pakdel T, Andishe-Tadbir A, Alavi P, Behzad-Behbahani A, Ashraf MJ. The frequency of high-risk human papillomavirus types, HPV16 lineages, and their relationship with p16 INK4a and NF-κB expression in head and neck squamous cell carcinomas in Southwestern Iran. Braz J Microbiol 2020; 52:195-206. [PMID: 33169334 DOI: 10.1007/s42770-020-00391-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 10/17/2020] [Indexed: 12/14/2022] Open
Abstract
High-risk human papillomaviruses (hr-HPVs) are the key risk factors implicated in the development of a significant proportion of head and neck squamous cell carcinomas (HNSCCs). We aimed to investigate the distribution of hr-HPV types and HPV16 lineages in a sample of patients with HNSCC and the possible association between HPV status and the expression of P16INK4A and NF-κB in Iranian HNSCC patients. We examined 108 formalin-fixed, paraffin-embedded (FFPE) histologically confirmed primary SCC tissue specimens of different head and neck anatomical sites. HPV types and HPV16 lineages were determined by nested PCR and overlapping nested PCR assays, respectively, followed by gene sequencing and phylogenetic analysis. The expression of p16INK4a and NF-κB was evaluated by immunohistochemistry. Twenty-five (23.1%) HNSCC tissue specimens were tested positive for HPV infection. The most prevalent HPV type was HPV-16, followed by HPV18 and HPV11. HPV16 variants belonged to the lineage A and lineage D which were further sorted into sublineages A1, A2, and D2. A significant association between HPV status and p16INK4a immunoreactivity was observed in more than 76% of the HPV-related HNSCCs (P < 0.0001). The overexpression of p16INK4a and cytoplasmic NF-κB was more common in low-grade HNSCC tumors. Our data highlights that HPV16, in particular the A2 sublineage, followed by A1 and D2 sublineages are the major agents associated with HNSCCs in Iran. Based on HPV16 predominance and its lineage distribution pattern, it seems that the prophylactic vaccines developed for cervical cancer prevention could also be applicable for the prevention of HPV-related HNSCCs in our population.
Collapse
Affiliation(s)
- Fatemeh Pakdel
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Oral and Maxillofacial Pathology, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Farhadi
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Tahereh Pakdel
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Azadeh Andishe-Tadbir
- Oral and Dental Disease Research Center, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parnian Alavi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Abbas Behzad-Behbahani
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad J Ashraf
- Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
14
|
Liu J, Zhao H, Zhang Q, Shi Z, Zhang Y, Zhao L, Ren Y, Ou R, Xu Y. Human papillomavirus type 16 E7 oncoprotein-induced upregulation of lysine-specific demethylase 5A promotes cervical cancer progression by regulating the microRNA-424-5p/suppressor of zeste 12 pathway. Exp Cell Res 2020; 396:112277. [PMID: 32918895 DOI: 10.1016/j.yexcr.2020.112277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 12/20/2022]
Abstract
Human papillomavirus (HPV) infection and viral protein expression cause several epigenetic alterations that lead to cervical carcinogenesis. Our previous study identified that upregulated lysine-specific demethylase (KDM) 2 A promotes cervical cancer progression by inhibiting mircoRNA (miR)-132 function. However, the roles of histone methylation modifiers in HPV-related cervical cancer remain unclear. In the present study, changes in the expression of 48 histone methylation modifiers were assessed following knockdown of HPV16 E6/E7 in CaSki cells. The dysregulated expression of KDM5A was identified, and its function in cervical cancer was investigated in vitro and in vivo. E7 oncoprotein-induced upregulation of KDM5A promoted cervical cancer cell proliferation and invasiveness in vitro and in vivo, which was correlated with poor prognosis in patients with cervical cancer. KDM5A was found to physically interact with the promoter region of miR-424-5p, and to suppress its expression by removing the tri- and di-methyl groups from H3K4 at the miR-424-5p locus. Furthermore, miR-424-5p repressed cancer cell proliferation and invasiveness by targeting suppressor of zeste 12 (Suz12). KDM5A upregulation promoted cervical cancer progression by repressing miR-424-5p, which resulted in a decrease in Suz12. Therefore, KDM5A functions as a tumor activator in cervical cancer pathogenesis by binding to the miR-424-5p promoter and inhibiting its tumor-suppressive function. These results indicate a function for KDM5A in cervical cancer progression and suggest its candidacy as a novel prognostic biomarker and target for the clinical management of this malignancy.
Collapse
Affiliation(s)
- Jia Liu
- Department of Plastic and Cosmetic Center, The Affiliated Eye Hospital of Wenzhou Medical University, PR China
| | - Hongqin Zhao
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital of Wenzhou Medical University, PR China
| | - Qian Zhang
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital of Wenzhou Medical University, PR China
| | - Zhengzheng Shi
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital of Wenzhou Medical University, PR China
| | - Yuyang Zhang
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital of Wenzhou Medical University, PR China
| | - Liang Zhao
- Laboratory for Advanced Interdisciplinary Research, Institute of Translational Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Yi Ren
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Rongying Ou
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital of Wenzhou Medical University, PR China.
| | - Yunsheng Xu
- Laboratory for Advanced Interdisciplinary Research, Institute of Translational Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PR China; Department of Dermatovenereology, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, PR China.
| |
Collapse
|
15
|
Innerhofer V, Kofler B, Riechelmann H. High-Risk-HPV-Infektionen im Kopf-Hals-Bereich – Welche Bedeutung hat das Sexualverhalten? Laryngorhinootologie 2020; 99:647-657. [DOI: 10.1055/a-1097-1525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
16
|
Abstract
Update for Diagnosis and Management of HPV-Driven Oropharyngeal Cancer Abstract. In the past decades, an increasing incidence of oropharyngeal squamous cell cancer could be observed. More than twenty years ago, a correlation between a pharyngeal Human papillomavirus high-risk type infection and the development of oropharyngeal cancer has been suspected. Especially younger patients without the former risk factors smoking and alcohol have a higher prevalence for this cancer type. HPV-associated cancer is developing in the lymphatic tissue of the tonsils and the base of the tongue. HPV-driven tumors can be defined as a clinical and morphologic distinct tumor entity with a significantly better prognosis compared to tumors based on smoking and alcohol consumption. They are demonstrating a clearly better treatment response irrespective of the treatment modality. The tumor development is assumed to be comparable to cervical cancer, probably through a step-wise process from dysplasia to invasive cancer. In the pharynx, no HPV-associated precursor lesions have been detected so far. Therefore, Screening program proven to be very successful in the cervix have not could not have been implemented so far. The reduction of HPV-associated tumor burden in the cervix is likely to be compensated by the rising number of HPV-driven oropharyngeal cancer. P16 as a surrogate marker for HPV has been implemented in the 8th edition of the TNM classification for oropharyngeal cancer. A worldwide accepted definition of an HPV-driven tumor is lacking so far. P16 immunhistochemistry or HPV-DNA detection by PCR as single markers have an insufficient sensitivity and specificity. A combination of both markers demonstrates a higher accuracy compared to the gold standard RNA. Antibodies to HPV oncoproteins are reliable diagnostic and prognostic markers that could in the future possibly serve for early tumor detection.
Collapse
|
17
|
Stevenson A, Wakeham K, Pan J, Kavanagh K, Millan D, Bell S, McLellan D, Graham SV, Cuschieri K. Droplet digital PCR quantification suggests that higher viral load correlates with improved survival in HPV-positive oropharyngeal tumours. J Clin Virol 2020; 129:104505. [PMID: 32604039 DOI: 10.1016/j.jcv.2020.104505] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Although HPV-positive oropharyngeal cancer (OPC) patients have improved prognosis compared to HPV negative patients; there remains an HPV-positive group who have poor outcomes. Biomarkers to stratify discrete patient outcomes are thus desirable. Our objective was to analyse viral load (VL) by droplet digital PCR (ddPCR), in HPV-positive patients with OPC on whom clinical outcome data were available. METHODS In a cohort of patients that had previously tested HPV positive via conventional PCR, VL was determined using ddPCR assays for HPV16 L1 and E6 genes. VL was classed as "medium/high" if more than 5.57 copies or 8.68 copies of the HPV 16 L1 or E6 gene were detected respectively. Effect of VL on overall survival and hazard of death & disease progression was performed with adjustments made for sex, age, deprivation, smoking, alcohol consumption and stage. RESULTS L1 VL ranged from 0.0014-304 gene copies per cell with a mean of 30.9; comparatively E6 VL ranged from 0.0012-356 copies per cell with a mean of 37.9. Univariate analysis showed those with a medium/high VL had a lower hazard of death; this was significant for L1 (p = 0.02) but not for E6 (p = 0.67). The ratio of E6 to L1 deviated from n = 1 in most samples but had no influence on clinical outcomes. CONCLUSIONS HPV viral load may be informative for the further stratification of clinical outcomes in HPV positive OPC patients.
Collapse
Affiliation(s)
- A Stevenson
- Centre for Virus Research, Institute of Infection Immunity and Inflammation, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | | | - J Pan
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - K Kavanagh
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - D Millan
- Department of Pathology, The Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - S Bell
- Department of Pathology, The Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - D McLellan
- Department of Pathology, The Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - S V Graham
- Centre for Virus Research, Institute of Infection Immunity and Inflammation, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - K Cuschieri
- Scottish HPV Reference Laboratory, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK.
| |
Collapse
|
18
|
Manucha V, Patel T, Grunes D, Akhtar I. Threshold for interpretation of p16 immunostaining in fine-needle aspirate specimens of metastatic oropharyngeal squamous cell carcinoma. J Am Soc Cytopathol 2020; 9:177-84. [PMID: 32115376 DOI: 10.1016/j.jasc.2020.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (HPV-OPSCC) has been recognized to have an excellent response to treatment and has a distinct pathologic staging. For this reason, HPV testing is recommended in cytology specimens of metastatic OPSCC, although the guidelines for testing are not clearly defined. The aim of the current study was to establish a threshold for interpretation of p16 in aspirates from metastatic OPSCC. MATERIALS AND METHODS Cases diagnosed as metastatic SCC by cytology in neck lymph nodes with concurrent p16 on cytology and on paired surgical specimen or an in situ hybridization (ISH) for HPV were included in the study. Stain intensity and percentage positive cells for p16 was compared with p16 on paired surgical pathology specimens and/or ISH RNA for HPV on cytology specimens. RESULTS Of the 52 cases diagnosed as metastatic SCC on neck aspirates, paired surgical pathology specimens and/or ISH HPV was available in 17 cases. A p16 expression in ≥10%-15% cells resulted in a sensitivity and negative predictive value of 66% and 37%, respectively. However, when even minimal expression in tumor fragments is considered positive, the negative predictive value increases to 100%. CONCLUSIONS We recommend that even minimal nuclear expression for p16 in viable tumor fragments must be considered as positive in cytology specimens. Expression limited to only background single tumor cells or in a necrotic specimen must be interpreted with caution.
Collapse
|
19
|
Abstract
The human papillomavirus (HPV) family includes more than 170 different types of virus that infect stratified epithelium. High-risk HPV is well established as the primary cause of cervical cancer, but in recent years, a clear role for this virus in other malignancies is also emerging. Indeed, HPV plays a pathogenic role in a subset of head and neck cancers-mostly cancers of the oropharynx-with distinct epidemiological, clinical and molecular characteristics compared with head and neck cancers not caused by HPV. This review summarises our current understanding of HPV in these cancers, specifically detailing HPV infection in head and neck cancers within different racial/ethnic subpopulations, and the differences in various aspects of these diseases between women and men. Finally, we provide an outlook for this disease, in terms of clinical management, and consider the issues of 'diagnostic biomarkers' and targeted therapies.
Collapse
Affiliation(s)
- Maria Elisa Sabatini
- Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, IFOM-IEO Campus, Via Adamello 16, 20139, Milan, Italy
| | - Susanna Chiocca
- Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, IFOM-IEO Campus, Via Adamello 16, 20139, Milan, Italy.
| |
Collapse
|
20
|
Holstead R, Rasul R, Golden A, Kamdar D, Ghaly M, Teckie S, Frank D, Fantasia J, Seetharamu N. Identifying patterns of failure and secondary primary malignancies in HPV-related oropharyngeal squamous cell carcinomas. Future Oncol 2020; 16:199-207. [PMID: 31967480 DOI: 10.2217/fon-2019-0673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Aim: To compare patterns and rates of recurrence in patients with oropharyngeal squamous cell carcinoma by human papilloma virus (HPV) status. Patients & methods: Retrospective chart review of 155 patients diagnosed with oropharyngeal squamous cell carcinoma between 2012 and 2014 at a single center. Results: Two-year recurrence-free survival was higher in patients with HPV-positive tumors compared with negative (85.2% [standard error = 0.03] versus 59.3% [standard error = 0.09]; p < .001) with the former proportionally less likely to have locoregional recurrence. HPV-positive patients had proportionally higher incidence of second primary malignancies outside of head, neck and lung compared with HPV-negative (74.2 vs 37.5%; p = 0.09). Conclusion: The differences in failure by HPV status indicates a need for modified surveillance guidelines. The differences in second primary malignancies patterns are interesting, warranting further evaluation in larger studies.
Collapse
Affiliation(s)
- Ryan Holstead
- Department of Medicine, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, NY USA, 11030
| | - Rehana Rasul
- Department of Medicine, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, NY USA, 11030
| | - Anne Golden
- Department of Medicine, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, NY USA, 11030
| | - Dev Kamdar
- Departement of Otolaryngology, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, NY USA, 11040
| | - Maged Ghaly
- Department of Radiation Medicine, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, NY USA, 11042
| | - Sewit Teckie
- Department of Radiation Medicine, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, NY USA, 11042
| | - Douglas Frank
- Departement of Otolaryngology, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, NY USA, 11040
| | - John Fantasia
- Department of Dental Medicine, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, NY USA, 11040
| | - Nagashree Seetharamu
- Department of Medicine, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, NY USA, 11030
| |
Collapse
|
21
|
Abstract
BACKGROUND The incidence of HPV-associated squamous cell carcinoma of the head and neck region (HNSCC) has increased dramatically in recent years. Despite a similar localization (oropharyngeal squamous cell epithelia) to smoking- and alcohol-associated cancers, HPV-associated carcinomas are considered to represent a distinct entity. Reasons for the different therapeutic responses of the two tumor entities are not yet fully understood. METHODS AND OBJECTIVE This review investigates the importance of tumor-infiltrating lymphocytes in HPV+ and HPV- HNSCC by means of articles and publications concerning the tumor micromilieu, effects on prognosis, and patients' therapeutic responses. RESULTS HNSCC patients with a positive HPV status and increased frequencies of CD8+ T cells (CD, cluster of differentiation) demonstrated an improved therapeutic response and improved outcomes. Decreased expression of the EGF (epidermal growth factor) receptor correlates with increased TH1 cytokine secretion by CD4+ T cells, which, in their role as T helper cells, can activate macrophages, dendritic cells, and cytotoxic T cells, amongst others. Regulatory T cells (Treg) execute an immune-suppressive effect in the tumor micromilieu through different metabolic and signaling pathways (IL[interleukin]‑4, IL-10, TGF‑β ["transforming growth factor‑β"]). CONCLUSION The importance of the adaptive immune response for treatment response and patients' prognosis has been supported by different investigations. Understanding the immunological processes in the tumor environment plays an important role for the development of new treatment approaches.
Collapse
|
22
|
Sarkar B, Ullah MA, Araf Y. A systematic and reverse vaccinology approach to design novel subunit vaccines against Dengue virus type-1 (DENV-1) and human Papillomavirus-16 (HPV-16). Informatics in Medicine Unlocked 2020. [DOI: 10.1016/j.imu.2020.100343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
|
23
|
Wagner S, Reder H, Sharma SJ, Würdemann N, Wittekindt C, Klußmann JP. [HPV-associated oropharyngeal cancer-incidence, trends, diagnosis, and treatment]. Urologe A 2018; 57:1457-63. [PMID: 30421134 DOI: 10.1007/s00120-018-0810-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A rising incidence of oropharyngeal squamous cell carcinoma (OPSCC) is reported by many countries worldwide and OPSCC associated with human papillomavirus (HPV) has been recently defined as a new class of head and neck cancers. Besides tobacco and alcohol consumption, HPV is an accepted risk and prognostic factor for OPSCC. Although the incidence increase of HPV-associated OPSCC is convincing, cancer registry studies and studies based on cohorts often have drawbacks regarding data linkage to comparable experimental data, comparable anatomical definitions or HPV diagnostics. Patients with HPV-associated OPSCC have remarkably better prognosis and the tumors differ from HPV-negative OPSCC with respect to molecular and genetic aspects. Nevertheless, choice of therapy is independent of HPV, and rather is subject to the individual patient's condition, local preference and anatomic characteristics. New concepts emerge in immune-checkpoint oncology, which might be a valuable add-on to established concepts. Also, treatment de-escalation (e.g., by reduction of radiation dosage) might be suitable for patients with certain risk profiles. Prophylactic vaccination can contribute to reducing HPV-induced disease, likewise OPSCC. Prerequisite is a high rate of vaccination, which is currently not sufficient in Germany. Because of currently low vaccination rates and the rather long time between initial infection and HPV-induced carcinogenesis, reduction of incidence increase or prevalence of HPV-associated OPSCC is not expected in the near future.
Collapse
|
24
|
Abstract
Since their discovery as the etiologic agents of cervical cancer in the mid-1970s, human papillomaviruses (HPVs) have been linked with a growing number of epithelial-derived tumors, including head and neck squamous cell carcinomas. HPV demonstrates a particular predilection for causing tumors of the oropharynx, with the majority of cases involving infection with high-oncogenic risk HPV-16. People living with HIV are at increased risk of infection with HPV- and HPV-related oral complications even with adequate control of their HIV infection with antiretroviral therapy. In this chapter, we discuss the molecular mechanisms that underlie HPV-mediated oncogenesis in the oropharynx. We also describe the progress that has been made in understanding the epidemiology of oral HPV infection and the determinants of oral HPV-related pathology. Finally, we examine what can be done to treat and prevent oral HPV infection, benign lesions, and cancer, particularly in the context of the HIV-positive patient.
Collapse
|
25
|
Tang KD, Kenny L, Frazer IH, Punyadeera C. High‐risk human papillomavirus detection in oropharyngeal cancers: Comparison of saliva sampling methods. Head Neck 2018; 41:1484-1489. [DOI: 10.1002/hed.25578] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 09/04/2018] [Accepted: 12/05/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Kai Dun Tang
- The School of Biomedical Sciences, Institute of Health and Biomedical InnovationQueensland University of Technology Kelvin Grove Queensland Australia
- The Translational Research Institute Brisbane Queensland Australia
| | - Liz Kenny
- School of MedicineUniversity of Queensland Brisbane Queensland Australia
- Royal Brisbane and Women's Hospital Brisbane Queensland Australia
- Central Integrated Regional Cancer ServiceQueensland Health Brisbane Queensland Australia
| | - Ian H. Frazer
- Faculty of Medicine, Translational Research InstituteThe University of Queensland Brisbane Queensland Australia
| | - Chamindie Punyadeera
- The School of Biomedical Sciences, Institute of Health and Biomedical InnovationQueensland University of Technology Kelvin Grove Queensland Australia
- The Translational Research Institute Brisbane Queensland Australia
| |
Collapse
|
26
|
Mazurek AM, Rutkowski T, Śnietura M, Pigłowski W, Suwiński R, Składowski K. Detection of circulating HPV16 DNA as a biomarker in the blood of patients with human papillomavirus-positive oropharyngeal squamous cell carcinoma. Head Neck 2018; 41:632-641. [PMID: 30566259 DOI: 10.1002/hed.25368] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 04/13/2018] [Accepted: 05/21/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Development of biomarker analysis using the circulating cell-free DNA (cfDNA) methodology is a challenge for noninvasive cancer diagnosis. In this study, a comparison between the plasma and tumor tissue HPV16 DNA viral loads (VLs) has been presented. METHODS Real-time polymerase chain reaction was performed for quantitating of HPV16 DNA in the plasma and tumor samples of patients with oropharyngeal cancer. RESULTS Among the tissues, HPV16-positive patients with oropharyngeal squamous cell carcinoma, nonsmoking patients, displayed significantly higher HPV16 DNA VLs in their tissue. No smoking and advanced N disease were the most important predictors for cHPV16 DNA (circulating HPV16 DNA) detection. The cHPV16-positive women displayed significantly higher VLs in their tumor tissues compared to the men, although without notable impact on the blood detection. CONCLUSIONS Many factors were responsible for human papillomavirus DNA circulation in blood. As a result of the small size of the analyzed group, some observed discrepancies need to be proven on a larger cohort.
Collapse
Affiliation(s)
- Agnieszka M Mazurek
- Center for Translational Research and Molecular Biology of Cancer, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Tomasz Rutkowski
- I Radiotherapy and Chemotherapy Clinic, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Mirosław Śnietura
- Tumor Pathology Department, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Wojciech Pigłowski
- Tumor Pathology Department, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Rafał Suwiński
- II Radiotherapy and Chemotherapy Clinic, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Krzysztof Składowski
- I Radiotherapy and Chemotherapy Clinic, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland
| |
Collapse
|
27
|
Koch EM, Fazel A, Hoffmann M. Cystic masses of the lateral neck – Proposition of an algorithm for increased treatment efficiency. J Craniomaxillofac Surg 2018; 46:1664-1668. [DOI: 10.1016/j.jcms.2018.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/16/2018] [Accepted: 06/05/2018] [Indexed: 12/23/2022] Open
|
28
|
Hufbauer M, Maltseva M, Meinrath J, Lechner A, Beutner D, Huebbers CU, Akgül B. HPV16 increases the number of migratory cancer stem cells and modulates their miRNA expression profile in oropharyngeal cancer. Int J Cancer 2018; 143:1426-1439. [PMID: 29663357 DOI: 10.1002/ijc.31538] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/08/2018] [Accepted: 04/04/2018] [Indexed: 12/22/2022]
Abstract
Human papillomavirus type 16 (HPV16) is a major risk for development of oropharyngeal squamous-cell-carcinoma (OPSCC). Although HPV+ OPSCC metastasize faster than HPV- tumors, they have a better prognosis. The molecular and cellular alterations underlying this pathobiology of HPV+ OPSCC remain elusive. In this study, we examined whether expression of HPV16-E6E7 targets the number of migratory and stationary cancer stem cells (CSC). Furthermore, we wanted to elucidate if aberrantly expressed miRNAs in migratory CSC may be responsible for progression of OPSCCs and whether they may serve as potential novel biomarkers for increased potential of metastasis. Our studies revealed that HPV16-E6E7 expression leads to an increase in the number of stationary (CD44high /EpCAMhigh ) stem cells in primary keratinocyte cultures. Most importantly, expression of E6E7 in the cell line H357 increased the migratory (CD44high /EpCAMlow ) CSC pool. This increase in migratory CSCs could also be confirmed in HPV+ OPSCC. Differentially expressed miRNAs from HPV16-E6E7 positive CD44high /EpCAMlow CSCs were validated by RT-qPCR and in situ hybridization on HPV16+ OPSCCs. These experiments led to the identification of miR-3194-5p, which is upregulated in primary HPV16+ OPSCC and matched metastasis. MiR-1281 was also found to be highly expressed in HPV+ and HPV- metastasis. As inhibition of this miRNA led to a markedly reduction of CD44high /EpCAMlow cells, it may prove to be a promising drug target. Taken together, our findings highlight the capability of HPV16 to modify the phenotype of infected stem cells and that miR-1281 and miR3194-5p may represent promising targets to block metastatic spread of OPSCC.
Collapse
Affiliation(s)
- Martin Hufbauer
- Institute of Virology, University of Cologne, Cologne, Germany
| | - Margaret Maltseva
- Institute of Virology, University of Cologne, Cologne, Germany.,Department of Otorhinolaryngology, Head and Neck Surgery, University of Cologne, Cologne, Germany
| | | | - Axel Lechner
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Cologne, Cologne, Germany.,Cologne Interventional Immunology, Department of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Dirk Beutner
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Cologne, Cologne, Germany
| | - Christian U Huebbers
- Jean-Uhrmacher-Institute for Otorhinolaryngological Research, University of Cologne, Cologne, Germany
| | - Baki Akgül
- Institute of Virology, University of Cologne, Cologne, Germany
| |
Collapse
|
29
|
Abstract
Head and neck cancer is the sixth most common cancer with over 500000 annually reported incident cases worldwide. Besides major risk factors tobacco and alcohol, oropharyngeal squamous cell carcinomas (OSCC) show increased association with human papillomavirus (HPV). HPV-associated and HPV-negative OSCC are 2 different entities regarding biological characteristics, therapeutic response, and patient prognosis. In HPV OSCC, viral oncoprotein activity, as well as genetic (mutations and chromosomal aberrations) and epigenetic alterations plays a key role during carcinogenesis. Based on improved treatment response, the introduction of therapy de-intensification and targeted therapy is discussed for patients with HPV OSCC. A promising targeted therapy concept is immunotherapy. The use of checkpoint inhibitors (e.g. anti-PD1) is currently investigated. By means of liquid biopsies, biomarkers such as viral DNA or tumor mutations in the will soon be available for disease monitoring, as well as detection of treatment failure. By now, primary prophylaxis of HPV OSCC can be achieved by vaccination of girls and boys.
Collapse
Affiliation(s)
- Claus Wittekindt
- Klinik für HNO-Heilkunde, Kopf-/Halschirurgie, Plastische Operationen, Universitätsklinikum Gießen und Marburg GmbH, Standort Gießen
| | - Steffen Wagner
- Klinik für HNO-Heilkunde, Kopf-/Halschirurgie, Plastische Operationen, Universitätsklinikum Gießen und Marburg GmbH, Standort Gießen
| | - Shachi Jenny Sharma
- Klinik für HNO-Heilkunde, Kopf-/Halschirurgie, Plastische Operationen, Universitätsklinikum Gießen und Marburg GmbH, Standort Gießen
| | - Nora Würdemann
- Klinik für HNO-Heilkunde, Kopf-/Halschirurgie, Plastische Operationen, Universitätsklinikum Gießen und Marburg GmbH, Standort Gießen
| | - Jennifer Knuth
- Klinik für HNO-Heilkunde, Kopf-/Halschirurgie, Plastische Operationen, Universitätsklinikum Gießen und Marburg GmbH, Standort Gießen
| | - Henrike Reder
- Klinik für HNO-Heilkunde, Kopf-/Halschirurgie, Plastische Operationen, Universitätsklinikum Gießen und Marburg GmbH, Standort Gießen
| | - Jens Peter Klußmann
- Klinik für HNO-Heilkunde, Kopf-/Halschirurgie, Plastische Operationen, Universitätsklinikum Gießen und Marburg GmbH, Standort Gießen
| |
Collapse
|
30
|
Daher T, Tur MK, Brobeil A, Etschmann B, Witte B, Engenhart-Cabillic R, Krombach G, Blau W, Grimminger F, Seeger W, Klussmann JP, Bräuninger A, Gattenlöhner S. Combined human papillomavirus typing and TP53 mutation analysis in distinguishing second primary tumors from lung metastases in patients with head and neck squamous cell carcinoma. Head Neck 2018. [PMID: 29522268 DOI: 10.1002/hed.25041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND In head and neck squamous cell carcinoma (HNSCC), the occurrence of concurrent lung malignancies poses a significant diagnostic challenge because metastatic HNSCC is difficult to discern from second primary lung squamous cell carcinoma (SCC). However, this differentiation is crucial because the recommended treatments for metastatic HNSCC and second primary lung SCC differ profoundly. METHODS We analyzed the origin of lung tumors in 32 patients with HNSCC using human papillomavirus (HPV) typing and targeted next generation sequencing of all coding exons of tumor protein 53 (TP53). RESULTS Lung tumors were clearly identified as HNSCC metastases or second primary tumors in 29 patients, thus revealing that 16 patients had received incorrect diagnoses based on clinical and morphological data alone. CONCLUSION The HPV typing and mutation analysis of all TP53 coding exons is a valuable diagnostic tool in patients with HNSCC and concurrent lung SCC, which can help to ensure that patients receive the most suitable treatment.
Collapse
Affiliation(s)
- Tamas Daher
- Institute of Pathology, University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| | - Mehmet Kemal Tur
- Institute of Pathology, University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| | - Alexander Brobeil
- Institute of Pathology, University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| | - Benjamin Etschmann
- Institute of Pathology, University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| | - Biruta Witte
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | | | - Gabriele Krombach
- Department of Diagnostic and Interventional Radiology, University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| | - Wolfgang Blau
- Department of Internal Medicine V, University Hospital Giessen, Giessen, Germany
| | - Friedrich Grimminger
- Department of Internal Medicine V, University Hospital Giessen, Giessen, Germany
| | - Werner Seeger
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Jens Peter Klussmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| | - Andreas Bräuninger
- Institute of Pathology, University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| | - Stefan Gattenlöhner
- Institute of Pathology, University Hospital Giessen, Justus-Liebig-University Giessen, Giessen, Germany
| |
Collapse
|
31
|
Abstract
Approximately 18% of all human cancers have a viral etiology, and human papillomavirus (HPV) has been identified as one of the most prevalent viruses that plays causative role in nearly all cervical cancers and, in addition, in subset of head and neck, anal, penile and vulvar cancers. The recent introduction of next generation sequencing (NGS) and other omics approaches have resulted in comprehensive knowledge on the pathogenesis of HPV-driven tumors. Specifically, these approaches have provided detailed information on genomic HPV integration sites, disrupted genes and pathways, and common and distinct genetic and epigenetic alterations in different human HPV-associated cancers. This review focuses on HPV integration sites, its concomitantly disrupted genes and pathways and its functional consequences in both cervical and head and neck cancers. Integration of NGS data with other omics and clinical data is crucial to better understand the pathophysiology of each individual malignancy and, based on this, to select targets and to design effective personalized treatment options.
Collapse
Affiliation(s)
- Musaffe Tuna
- Department of Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Lebanon
| | - Christopher I Amos
- Department of Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Lebanon
| |
Collapse
|
32
|
Wojtera M, Paradis J, Husein M, Nichols AC, Barrett JW, Salvadori MI, Strychowsky JE. The prevalence of human papillomavirus in pediatric tonsils: a systematic review of the literature. J Otolaryngol Head Neck Surg 2018; 47:8. [PMID: 29378664 PMCID: PMC5789580 DOI: 10.1186/s40463-018-0255-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 01/17/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND HPV-related head and neck cancer rates have been increasing in recent years, with the tonsils being the most commonly affected site. However, the current rate of HPV infection in the pediatric population remains poorly defined. The objective of this study was to systematically review and evaluate the prevalence and distribution of HPV in the tonsils of pediatric patients undergoing routine tonsillectomy. METHODS AND RESULTS The literature was searched using PubMed, EMBASE, Scopus, CINAHL, Cochrane Library, and ProQuest Dissertations & Theses Global databases (inception to December 2017) by two independent review authors. Inclusion criteria included articles which evaluated the prevalence of HPV in a pediatric cohort without known warts or recurrent respiratory papillomatosis, those which used tonsil biopsy specimens for analysis, and those with six or more subjects and clear outcomes reported. Eleven studies met the inclusion criteria. Using the Oxford Clinical Evidence-based Medicine (OCEBM) guidelines, two reviewers appraised the level of evidence of each study, extracted data, and resolved discrepancies by consensus. The systematic review identified 11 articles (n = 2520). Seven studies detected HPV in the subject population, with prevalence values ranging from 0 to 21%. The level of evidence for all included studies was OCEBM Level 3. CONCLUSIONS HPV may be present in pediatric tonsillectomy specimens; however, the largest included study demonstrated a prevalence of 0%. Future testing should be performed using methods with high sensitivities and specificities, such as reverse transcript real-time PCR or digital droplet PCR.
Collapse
Affiliation(s)
- Monika Wojtera
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, N6A 5C1, ON, Canada
| | - Josee Paradis
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, N6A 5C1, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery, Victoria Hospital B3-400, 800 Commissioners Rd E, London, N6A 5W9, ON, Canada
| | - Murad Husein
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, N6A 5C1, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery, Victoria Hospital B3-400, 800 Commissioners Rd E, London, N6A 5W9, ON, Canada
| | - Anthony C Nichols
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, N6A 5C1, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery, Victoria Hospital B3-400, 800 Commissioners Rd E, London, N6A 5W9, ON, Canada
| | - John W Barrett
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, N6A 5C1, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery, Victoria Hospital B3-400, 800 Commissioners Rd E, London, N6A 5W9, ON, Canada
| | - Marina I Salvadori
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, N6A 5C1, ON, Canada.,Department of Paediatrics, Children's Hospital at London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
| | - Julie E Strychowsky
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, N6A 5C1, ON, Canada. .,Department of Otolaryngology-Head and Neck Surgery, Victoria Hospital B3-400, 800 Commissioners Rd E, London, N6A 5W9, ON, Canada.
| |
Collapse
|
33
|
Abstract
Although several studies have reported that oropharyngeal infection with HPV may predispose to tumorigenesis, little is known about the etiological factors of salivary gland tumors and the presence of HPV We studied 9 parotid lesions for HPV infection including an oncocytoma, an acinic cell carcinoma, a high-grade adenocarcinoma, a low-grade polymorphous adenocarcinoma, a Warthin's tumor and 2 pleomorphic adenomas, a lymphoepithelial cyst and a lipoma of the parotid gland. DNA was extracted from formalin-fixed and paraffin-embedded tissue sections. Solution PCR for HPV detection was performed using the GP5+/GP6+ primers, while HPV typing was carried out by multiplex PCR for HPV6, 11, 16, 18, and 33; positive samples were recorfirmed by PCR with specific primers for each type. Quantitative real-time PCR for the high-risk HPV genotypes 16, 18, 31, 33, 35, 52, 58 and 67 was also performed to quantitate the viral load. Finally, in situ PCR was employed with HPV16-specific primers by direct-detection method. Seven of the 9 parotid lesions were HPV positive while 6 of these 7 had been infected by HPV16 and/or HPV18 oncogenic types. High viral load of high-risk genotypes of HPV was found in the oncocytoma, in one of the pleomorphic adenomas, and in the Warthin's tumor. Finally, in situ PCR indicated that HPV16 amplification occurred in the salivary gland tumors. This is the first time that high-risk HPV genotypes are detected in these histological types of parotid lesions, suggesting the possible involvement of the virus in the disease.
Collapse
Affiliation(s)
- D. Vageli
- Department of Pathology, Medical School, University of Thessaly, Larissa
| | - G. Sourvinos
- Department of Virology, Faculty of Medicine, University of Crete, Heraklion, Crete - Greece
| | - M. Ioannou
- Department of Pathology, Medical School, University of Thessaly, Larissa
| | - G.K. Koukoulis
- Department of Pathology, Medical School, University of Thessaly, Larissa
| | - D.A. Spandidos
- Department of Virology, Faculty of Medicine, University of Crete, Heraklion, Crete - Greece
| |
Collapse
|
34
|
Huang WB, Chan JYW, Liu DL. Human papillomavirus and World Health Organization type III nasopharyngeal carcinoma: Multicenter study from an endemic area in Southern China. Cancer 2017; 124:530-536. [PMID: 29072774 DOI: 10.1002/cncr.31031] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND The current study was conducted to study the incidence of human papillomavirus (HPV)-associated nasopharyngeal carcinoma (NPC) in Southern China and the corresponding treatment outcome. METHODS A retrospective chart review with a level of evidence of 4 was performed. RESULTS Between 2000 and 2015, a total of 1328 patients with NPC were treated in 3 study institutes in Hong Kong and Foshan City in Guangdong Province, China. All tumors were undifferentiated, nonkeratinizing carcinoma, of which 91.9% were positive for the Epstein-Barr virus (EBV+) and 7.7% were positive for HPV/p16 (HPV+). Although coinfection with both viruses occurred only in 8 patients (0.6%), 94 patients had tumors that were EBV negative (EBV-) and HPV+. All patients were treated with intensity-modulated radiotherapy alone for American Joint Committee on Cancer stage I and II disease, and concurrent chemoradiotherapy for stage III and IV disease. With a median follow-up of 72.8 months, the authors found that the local recurrence rate was significantly lower for patients with tumors that were EBV-/HPV+ compared with patients with tumors that were EBV+/HPV- (6.4% vs 13.8%; P = .03). Similar trends were observed for the 5-year disease-free survival rate (89.8% vs 70.8%; P =.03) and 5-year overall survival rate (86% vs 72%; P =.03). CONCLUSIONS In regions that are endemic for NPC, the prevalence of EBV and HPV coinfection in patients with NPC is extremely low. Conversely, patients with EBV-/HPV+ NPC demonstrate significantly better local tumor control and survival after radiotherapy. Cancer 2018;124:530-6. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Wen Bo Huang
- Department of Head and Neck Surgery, Southern Medical University, Zhujiang Hospital, Guangzhou, China
| | - Jimmy Yu Wai Chan
- Division of Head and Neck Surgery, Department of Surgery, University of Hong Kong Li Ka Shing Faculty of Medicine, Queen Mary Hospital, Hong Kong
| | - Da Lie Liu
- Department of Head and Neck Surgery, Southern Medical University, Zhujiang Hospital, Guangzhou, China
| |
Collapse
|
35
|
Sharma SJ, Wittekindt C, Knuth J, Steiner D, Wuerdemann N, Laur M, Kroll T, Wagner S, Klussmann JP. Intraindividual homogeneity of 18 F-FDG PET/CT parameters in HPV-positive OPSCC. Oral Oncol 2017; 73:166-71. [DOI: 10.1016/j.oraloncology.2017.08.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/08/2017] [Accepted: 08/30/2017] [Indexed: 11/21/2022]
|
36
|
Lin FPY, Pokorny A, Teng C, Epstein RJ. TEPAPA: a novel in silico feature learning pipeline for mining prognostic and associative factors from text-based electronic medical records. Sci Rep 2017; 7:6918. [PMID: 28761061 PMCID: PMC5537364 DOI: 10.1038/s41598-017-07111-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 06/21/2017] [Indexed: 12/13/2022] Open
Abstract
Vast amounts of clinically relevant text-based variables lie undiscovered and unexploited in electronic medical records (EMR). To exploit this untapped resource, and thus facilitate the discovery of informative covariates from unstructured clinical narratives, we have built a novel computational pipeline termed Text-based Exploratory Pattern Analyser for Prognosticator and Associator discovery (TEPAPA). This pipeline combines semantic-free natural language processing (NLP), regular expression induction, and statistical association testing to identify conserved text patterns associated with outcome variables of clinical interest. When we applied TEPAPA to a cohort of head and neck squamous cell carcinoma patients, plausible concepts known to be correlated with human papilloma virus (HPV) status were identified from the EMR text, including site of primary disease, tumour stage, pathologic characteristics, and treatment modalities. Similarly, correlates of other variables (including gender, nodal status, recurrent disease, smoking and alcohol status) were also reliably recovered. Using highly-associated patterns as covariates, a patient's HPV status was classifiable using a bootstrap analysis with a mean area under the ROC curve of 0.861, suggesting its predictive utility in supporting EMR-based phenotyping tasks. These data support using this integrative approach to efficiently identify disease-associated factors from unstructured EMR narratives, and thus to efficiently generate testable hypotheses.
Collapse
Affiliation(s)
- Frank Po-Yen Lin
- Department of Oncology, St Vincent's Hospital & The Kinghorn Cancer Centre, Darlinghurst, NSW, Australia.
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.
| | - Adrian Pokorny
- Department of Oncology, St Vincent's Hospital & The Kinghorn Cancer Centre, Darlinghurst, NSW, Australia
| | - Christina Teng
- Department of Medical Oncology, Liverpool Hospital, Liverpool, Sydney, NSW, Australia
| | - Richard J Epstein
- Department of Oncology, St Vincent's Hospital & The Kinghorn Cancer Centre, Darlinghurst, NSW, Australia
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| |
Collapse
|
37
|
Wagner S, Wittekindt C, Sharma SJ, Wuerdemann N, Jüttner T, Reuschenbach M, Prigge ES, von Knebel Doeberitz M, Gattenlöhner S, Burkhardt E, Pons-Kühnemann J, Klussmann JP. Human papillomavirus association is the most important predictor for surgically treated patients with oropharyngeal cancer. Br J Cancer 2017; 116:1604-11. [PMID: 28472822 DOI: 10.1038/bjc.2017.132] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/12/2017] [Accepted: 04/12/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Upfront surgery is a valuable treatment option for oropharyngeal squamous cell carcinoma (OPSCC) and risk stratification is emerging for treatment de-escalation in human papillomavirus (HPV)-related OPSCC. Available prognostic models are either based on selected, mainly non-surgically treated cohorts. Therefore, we investigated unselected OPSCC treated with predominantly upfront surgery. METHODS All patients diagnosed with OPSCC and treated with curative intent between 2000 and 2009 (n=359) were included. HPV association was determined by HPV-DNA detection and p16INK4a immunohistochemistry. Predictors with significant impact on overall survival (OS) in univariate analysis were included in recursive partitioning analysis. RESULTS Risk models generated from non-surgically treated patients showed low discrimination in our cohort. A new model developed for unselected patients predominantly treated with upfront surgery separates low-, intermediate- and high-risk patients with significant differences in 5-year OS (86%, 53% and 19%, P<0.001, respectively). HPV status is the most important parameter followed by T-stage in HPV-related and performance status in HPV-negative OPSCC. HPV status and ECOG remained important parameters in risk models for patients treated with or without surgery. CONCLUSIONS Regardless of treatment strategies, HPV status is the strongest predictor of survival in unselected OPSCC patients. The proposed risk models are suitable to discriminate risk groups in unselected OPSCC patients treated with upfront surgery, which has substantial impact for design and interpretation of de-escalation trials.
Collapse
|
38
|
Holzinger D, Wichmann G, Baboci L, Michel A, Höfler D, Wiesenfarth M, Schroeder L, Boscolo‐Rizzo P, Herold‐Mende C, Dyckhoff G, Boehm A, Del Mistro A, Bosch FX, Dietz A, Pawlita M, Waterboer T. Sensitivity and specificity of antibodies against HPV16 E6 and other early proteins for the detection of HPV16‐driven oropharyngeal squamous cell carcinoma. Int J Cancer 2017; 140:2748-2757. [DOI: 10.1002/ijc.30697] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 02/21/2017] [Accepted: 02/27/2017] [Indexed: 01/12/2023]
Affiliation(s)
- Dana Holzinger
- Division of Molecular Diagnostics of Oncogenic Infections, Infection, Inflammation and Cancer ProgramGerman Cancer Research Center (DKFZ)Heidelberg Germany
| | - Gunnar Wichmann
- Department of OtorhinolaryngologyUniversity Hospital LeipzigLeipzig Germany
| | - Lorena Baboci
- Division of Molecular Diagnostics of Oncogenic Infections, Infection, Inflammation and Cancer ProgramGerman Cancer Research Center (DKFZ)Heidelberg Germany
- Department of Oncology and Surgical SciencesUniversity of PaduaPadua Italy
| | - Angelika Michel
- Division of Molecular Diagnostics of Oncogenic Infections, Infection, Inflammation and Cancer ProgramGerman Cancer Research Center (DKFZ)Heidelberg Germany
| | - Daniela Höfler
- Division of Molecular Diagnostics of Oncogenic Infections, Infection, Inflammation and Cancer ProgramGerman Cancer Research Center (DKFZ)Heidelberg Germany
| | - Manuel Wiesenfarth
- Division of BiostatisticsGerman Cancer Research CenterHeidelberg Germany
| | - Lea Schroeder
- Division of Molecular Diagnostics of Oncogenic Infections, Infection, Inflammation and Cancer ProgramGerman Cancer Research Center (DKFZ)Heidelberg Germany
| | - Paolo Boscolo‐Rizzo
- Department of NeurosciencesENT Clinic and Regional Center for Head and Neck Cancer, University of PaduaTreviso Italy
| | - Christel Herold‐Mende
- Department of Otorhinolaryngology, Head and Neck SurgeryHeidelberg UniversityHeidelberg Germany
- Department of Neurosurgery, Division of Experimental NeurosurgeryHeidelberg UniversityHeidelberg Germany
| | - Gerhard Dyckhoff
- Department of Otorhinolaryngology, Head and Neck SurgeryHeidelberg UniversityHeidelberg Germany
| | - Andreas Boehm
- Department of OtorhinolaryngologyUniversity Hospital LeipzigLeipzig Germany
| | - Annarosa Del Mistro
- Department of Immunology and Molecular OncologyIRCCS Veneto Institute of Oncology (IOV)Padua Italy
| | - Franz X. Bosch
- Department of Otorhinolaryngology, Head and Neck SurgeryHeidelberg UniversityHeidelberg Germany
| | - Andreas Dietz
- Department of OtorhinolaryngologyUniversity Hospital LeipzigLeipzig Germany
| | - Michael Pawlita
- Division of Molecular Diagnostics of Oncogenic Infections, Infection, Inflammation and Cancer ProgramGerman Cancer Research Center (DKFZ)Heidelberg Germany
| | - Tim Waterboer
- Division of Molecular Diagnostics of Oncogenic Infections, Infection, Inflammation and Cancer ProgramGerman Cancer Research Center (DKFZ)Heidelberg Germany
| |
Collapse
|
39
|
Thongsuksai P, Pruegsanusak K, Boonyaphiphat P. Prognostic significance of p16, p53, Bcl-2, and Bax in oral and oropharyngeal squamous cell carcinoma. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.0802.287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background: The proteins p16, p53, Bcl-2, and Bax are important cell cycle and apoptotic regulators involved in carcinogenesis and found to have prognostic significance in various cancers. However, the data for squamous cell carcinoma of oral cavity (OSCC) and of oropharynx (OPSCC) are conflicting.
Objective: We sought to determine if expression of p16, p53, Bcl-2, and Bax expression are associated with 5-year overall survival (OS) of patients with OSCC and OPSCC.
Methods: One-hundred thirty-seven cases of OSCC and 140 cases of OPSCC diagnosed from January 2002 to December 2004 at Songklanagrind Hospital, Songkhla, Thailand, were analyzed using a Cox proportional hazards model for 5-year OS in relation to immunohistochemical detection of Bcl-2, Bax, p53, and p16 proteins.
Results: The frequencies of p16, p53, Bcl-2, and Bax expression in OSCC were 13%, 45%, 4%, and 66%, and in OPSCC were 18%, 53%, 22%, and 75%, respectively. In univariate analysis, clinical variables including T stage, N stage and treatment were significantly associated with survival. In multivariate Cox regression, Bax overexpression was significantly associated with poor survival both in OSCC (HR 1.77, 95% CI 1.04-3.01) and in OPSCC (HR 2.21, 95% CI 1.00-4.85). We found no significant association of p16, Bcl-2, and p53 expression with survival.
Conclusion: The expression pattern of p16, p53, Bcl-2, and Bax are similar in OSCC and OPSCC. Only Bax expression has prognostic significance for both tumor sites.
Collapse
Affiliation(s)
- Paramee Thongsuksai
- MD, Department of Pathology, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Kowit Pruegsanusak
- Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Pleumjit Boonyaphiphat
- Department of Pathology, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| |
Collapse
|
40
|
Geltzeiler M, Clayburgh D, Gleysteen J, Gross ND, Hamilton B, Andersen P, Brickman D. Predictors of extracapsular extension in HPV-associated oropharyngeal cancer treated surgically. Oral Oncol 2017; 65:89-93. [DOI: 10.1016/j.oraloncology.2016.12.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 12/21/2016] [Accepted: 12/26/2016] [Indexed: 12/27/2022]
|
41
|
Geltzeiler M, Doerfler S, Turner M, Albergotti WG, Kubik M, Kim S, Ferris R, Duvvuri U. Transoral robotic surgery for management of cervical unknown primary squamous cell carcinoma: Updates on efficacy, surgical technique and margin status. Oral Oncol 2017; 66:9-13. [PMID: 28249654 DOI: 10.1016/j.oraloncology.2016.12.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 12/27/2016] [Accepted: 12/29/2016] [Indexed: 10/20/2022]
Abstract
IMPORTANCE Management of cervical unknown primary squamous cell carcinoma (CUP) has evolved with the introduction of transoral robotic surgery (TORS). OBJECTIVES 1. To describe the efficacy of TORS lingual and palatine tonsillectomy in identifying the primary site of malignancy. 2. To explore how the extent of surgery affects diagnostic yield. 3. To report margin status of TORS resections. DESIGN, SETTING AND PARTICIPANTS A retrospective, single-center cohort study utilizing a prospectively collected database of CUP patients in a high-volume tertiary referral center. Patient underwent operative laryngoscopy plus TORS as clinically indicated. MAIN OUTCOMES AND MEASURES Primary end point was successful identification of the primary. The extent of surgery and margin status were also examined. RESULTS From 2010-2016, 64 patients with CUP were treated. The primary tumor was found in 51 patients (80%). Fourteen patients (22%) were identified with operative laryngoscopy alone. Fifty patients underwent TORS lingual tonsillectomy ± palatine tonsillectomy with 37 primary tumors identified (74%). The primary was located in the lingual tonsil in 32 patients (86%) and palatine tonsil in 5 patients (10%, p<0.001). Negative margins were achieved in 19 patients (51%). The deep margin was the most commonly positive margin (47%, p=0.049). CONCLUSION AND RELEVANCE Operative laryngoscopy with TORS is efficacious, localizing the primary in 80% of patients. If a margin was positive, it was most commonly the deep margin. This study provides valuable information that can help standardize surgical technique, further increasing the diagnostic yield and decreasing the negative margin rate of TORS for CUP.
Collapse
Affiliation(s)
- Mathew Geltzeiler
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sean Doerfler
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Meghan Turner
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William Greer Albergotti
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Kubik
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Seungwon Kim
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert Ferris
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Umamaheswar Duvvuri
- UPMC Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| |
Collapse
|
42
|
Herberhold S, Hellmich M, Panning M, Bartok E, Silling S, Akgül B, Wieland U. Human polyomavirus and human papillomavirus prevalence and viral load in non-malignant tonsillar tissue and tonsillar carcinoma. Med Microbiol Immunol 2016; 206:93-103. [PMID: 27832373 DOI: 10.1007/s00430-016-0486-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 10/31/2016] [Indexed: 12/21/2022]
Abstract
Human papillomaviruses (HPVs) are an acknowledged cause of a subset of oropharyngeal cancers, especially of tonsillar cancer. Similar to HPV, some human polyomaviruses (HPyVs), such as Merkel cell polyomavirus (MCPyV), have an oncogenic potential. Recently, several novel HPyVs have been discovered. The aim of our study was to determine viral DNA prevalence and viral DNA load of 13 different HPyVs in benign and malignant tonsillar tissue and to compare the data with those found for HPV. A total of 78 biopsies of palatine tonsils with a histologic diagnosis of non-malignant disease (chronic tonsillitis, tonsillar hyperplasia, n = 40) or tonsillar squamous cell carcinoma (n = 38) were included in the study. HPyV DNA prevalence and viral load were determined by virus-specific quantitative real-time PCRs. JCPyV (1/40, 2.5%) and WUPyV (3/40, 7.5%) were only found in non-malignant tonsillar tissue. HPyV7 and HPyV10 were only detected in one (2.6%) and seven (18.4%) of the 38 cancer biopsies, respectively. Both MCPyV (8/38, 21.1 vs. 4/40, 10.0%) and HPyV6 (2/38, 5.3 vs. 1/40, 2.5%) were found more frequently in cancer samples than in non-malignant tissue, but the differences were not significant. BKPyV, KIPyV, TSPyV, HPyV9, STLPyV, HPyV12 and NJPyV were not discovered in any of the samples. HPyV loads found in HPyV DNA-positive biopsies were very low with no difference between non-malignant and malignant samples (median load <0.0001 HPyV DNA copies per beta-globin gene copy, respectively). In contrast to HPyV, high-risk HPV types (HPV16/HPV18) were found significantly more frequently in tonsillar cancers than in non-malignant tonsillar tissue (17/38, 44.7 vs. 2/40, 5.0%, p < 0.001). Furthermore, high-risk HPV DNA loads were significantly higher in the cancer compared to the non-malignant samples (median load 11.861 vs. 7 × 10-6 HPV DNA copies per beta-globin gene copy, p = 0.012). While both HPV and HPyV may persist in tonsillar tissue, our data on HPyV DNA prevalence and load do not support a role of HPyV in tonsillar carcinogenesis, neither alone nor as co-infecting agents of HPV.
Collapse
Affiliation(s)
- Stephan Herberhold
- ENT Department, Head and Neck Surgery, University of Bonn, Bonn, Germany.,ENT Department, Johanniter-Kliniken Bonn, Bonn, Germany
| | - Martin Hellmich
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Marcus Panning
- Institute for Virology, Medical Center - University of Freiburg, Freiburg, Germany
| | - Eva Bartok
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn, Bonn, Germany
| | - Steffi Silling
- Institute of Virology, National Reference Center for Papilloma- and Polyomaviruses, University of Cologne, Fürst-Pückler-Str. 56, 50935, Cologne, Germany
| | - Baki Akgül
- Institute of Virology, National Reference Center for Papilloma- and Polyomaviruses, University of Cologne, Fürst-Pückler-Str. 56, 50935, Cologne, Germany.
| | - Ulrike Wieland
- Institute of Virology, National Reference Center for Papilloma- and Polyomaviruses, University of Cologne, Fürst-Pückler-Str. 56, 50935, Cologne, Germany
| |
Collapse
|
43
|
Wang Z, Xia RH, Ye DX, Li J. Human Papillomavirus 16 Infection and TP53 Mutation: Two Distinct Pathogeneses for Oropharyngeal Squamous Cell Carcinoma in an Eastern Chinese Population. PLoS One 2016; 11:e0164491. [PMID: 27749915 PMCID: PMC5066983 DOI: 10.1371/journal.pone.0164491] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 09/26/2016] [Indexed: 12/16/2022] Open
Abstract
Objectives To investigate the clinicopathological characteristics, human papillomavirus (HPV) infection, p53 expression, and TP53 mutations in oropharyngeal squamous cell carcinoma (OPSCC) and determine their utility as prognostic predictors in a primarily eastern Chinese population. Methods The HPV infection status was tested via p16INK4A immunohistochemistry and validated using PCR, reverse blot hybridization and in situ hybridization (ISH) in 188 OPSCC samples. p53 expression levels and TP53 gene mutations were assessed through immunohistochemistry and sequencing, respectively. Clinicopathological characteristics and follow-up information were collected. Overall survival was estimated using the Log-rank test. Results Overall, 22 of the 188 OPSCC samples were associated with HPV infection. HPV16 was identified in all 22 samples, whereas no samples were positive for HPV18. All 22 HPV-associated OPSCC samples were p53 negative and lacked TP53 mutations. HPV16 positivity, female patients, non-smokers, and patients with histological grade I and stage N0 diseases showed better overall survival (p = 0.009, 0.003, 0.048, 0.009, and 0.004, respectively). No significant differences in overall survival between smoking and non-smoking patients were observed in the HPV-associated OPSCC group. Patients without mutations in TP53 exons 5–8 had better prognoses (p = 0.031) among the 43 sequenced specimens. Multivariate analysis indicated that HPV16 infection status (p = 0.011), histological grade (p = 0.017), and N stage (p = 0.019) were independent prognostic factors for patients with OPSCC. Conclusions Distinct from the situation in Europe and America, for the patients with OPSCC in this study, HPV16 infection was relatively low, although it was still the most important independent prognostic predictor for the disease. In addition to the high smoking and drinking rate in this population, HPV16 infection and TP53 dysfunction appear to be two distinct pathogens for OPSCC patients in the eastern Chinese population.
Collapse
Affiliation(s)
- Zhen Wang
- Department of Oral Pathology, ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, P. R. China
| | - Rong-Hui Xia
- Department of Oral Pathology, ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, P. R. China
| | - Dong-Xia Ye
- Department of Oral Maxillofacial Surgery, ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, P. R. China
| | - Jiang Li
- Department of Oral Pathology, ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, P. R. China
- * E-mail:
| |
Collapse
|
44
|
Wagner S, Würdemann N, Hübbers C, Reuschenbach M, Prigge ES, Wichmann G, Hess J, Dietz A, Dürst M, Tinhofer I, von Knebel-Döberitz M, Wittekindt C, Klussmann JP. [HPV-associated head and neck cancer : mutational signature and genomic aberrations]. HNO 2015; 63:758-67. [PMID: 26507715 DOI: 10.1007/s00106-015-0074-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
A significantly increasing proportion of oropharyngeal head and neck carcinomas (OSCC) in North America and Europe are associated with human papillomavirus (HPV) infections. HPV-related OSCC is regarded as a distinct tumor type with regard to its cellular, biologic, and clinical characteristics. Patients with HPV-related OSCC have significantly better local control, but higher rates of regional lymph node and distant metastases as compared to patients with HPV-negative OSCC. Classical molecular genetic investigations demonstrated specific chromosomal aberration signatures in HPV-related OSCC, and recent developments in next generation sequencing (NGS) technology have rendered possible the sequencing of entire genomes, and thus detection of specific mutations, in just a few days. Initial data from The Cancer Genome Atlas (TCGA) project obtained by using genome-wide high throughput methods have confirmed that HPV-related OSCC contain fewer, albeit more specific mutations than HPV-negative tumors. Additionally, these data revealed the presence of specific-potentially therapeutically targetable-activating driver mutations in subgroups of HPV-positive OSCC, some of which have a prognostic impact. Specific targeted NGS technologies provide new possibilities for identification of diagnostic, prognostic, and predictive biomarkers and the development of personalized cancer treatment. Patients with HPV-positive tumors are likely to profit from these developments in the future, since the genetic alterations are relatively homogenous and frequently lead to signal pathway activation. There is an urgent need for network research activities to carry out the necessary basic research in prospective cohort studies.
Collapse
|
45
|
Andratschke M, Hagedorn H, Nerlich AG. [HPV infection in oral, pharyngeal and laryngeal papillomas]. HNO 2016; 63:768-72. [PMID: 26507714 DOI: 10.1007/s00106-015-0079-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND HPV infections play a major role in the pathogenesis of squamous cell carcinomas of the head and neck. Regarding benign papillomas, the role of HPV is still uncertain. MATERIALS AND METHODS To clarify this issue, 100 exophytic papillomas of the oral cavity, pharynx and larynx were subjected to histopathological and molecular pathological examination. Excision biopsies were taken from 62 male and 38 female patients with an age range of 18 to 87 years. Biopsies were tested for p16 expression by immunohistochemistry and analyzed for HPV subtypes 6/11 (low-risk), 16/18 and 31/33/53 (high-risk) by chromogenic in situ hybridization. RESULTS HPV infections were verified molecularly in 34 % of biopsies; in all cases with the low-risk HPV subtypes 6/11. Only one case showed infection with both 6/11 and 31/33/53 subtypes, but not subtype 16/18; whereas expression of p16 was found in 67 %. The rate of positive molecular verification of HPV infection (in situ hybridization) was highest in the laryngeal lesions with 61.1 %, followed by the oral cavity with 52.9 %, and lowest in pharyngeal lesions (21.5 %). Recurrent papillomas were seen in 18 cases (18 %), of which 14 were molecularly positive for HPV (in situ hybridization). A correlation between inflammatory infiltration and HPV infection could be verified in 82 %. CONCLUSION Our data demonstrate an important role of HPV infection for the development of benign papillomas of the head and neck region. Furthermore, there is a positive correlation between HPV infection and recurrent papillomas. Therefore, a molecular morphological HPV analysis of papillomas could provide important prognostic data.
Collapse
Affiliation(s)
- M Andratschke
- Abteilung für Hals-, Nasen- und Ohrenheilkunde, Helios Amper-Klinikum Dachau, Krankenhausstrasse 15, 85221, Dachau, Deutschland.,Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - H Hagedorn
- Abteilung für Hals-, Nasen- und Ohrenheilkunde, Helios Amper-Klinikum Dachau, Krankenhausstrasse 15, 85221, Dachau, Deutschland
| | - A G Nerlich
- Institut für Pathologie, Klinikum München Bogenhausen, Englschalkingerstrasse 77, 81925, München, Deutschland.
| |
Collapse
|
46
|
Shigeishi H, Sugiyama M. Risk Factors for Oral Human Papillomavirus Infection in Healthy Individuals: A Systematic Review and Meta-Analysis. J Clin Med Res 2016; 8:721-9. [PMID: 27635177 PMCID: PMC5012241 DOI: 10.14740/jocmr2545w] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Oral human papillomavirus (HPV) infection is associated with oral cancer development. However, few epidemiologic investigations have focused on oral HPV prevalence in healthy individuals. The objective of this study was to provide updated information regarding oral HPV prevalence in patients without oral cancer worldwide. METHODS We systematically reviewed 29 studies reporting the prevalence of oral HPV infection that included 22,756 subjects (10,124 males, 12,623 females, and nine unknown gender; age range 2 - 89 years) and were published from January 2012 to June 2015. RESULTS The prevalence of overall HPV, low-risk type HPV, high-risk type HPV, and HPV16 in the reported cases was 5.5%, 2.2%, 2.7%, and 1.0%, respectively. The prevalence of overall HPV was considerably higher in males who had sex with males (12.2%) as compared to heterosexual males (4.7%) and females (2.9%). A meta-analysis was performed to elucidate significant risk factors for oral HPV infection, which revealed a significant statistical association for oral sex and smoking with oral HPV infection (odds ratio (OR): 1.90, 95% confidence interval (CI): 1.51 - 2.39, P < 0.0001; OR: 2.13, 95% CI: 1.32 - 3.43, P = 0.002). CONCLUSIONS Our findings suggest that sexual behavior and smoking are importantly related to oral HPV infection in healthy individuals.
Collapse
Affiliation(s)
- Hideo Shigeishi
- Department of Oral and Maxillofacial Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Masaru Sugiyama
- Department of Public Oral Health, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| |
Collapse
|
47
|
Hettmann A, Demcsák A, Decsi G, Bach Á, Pálinkó D, Rovó L, Nagy K, Takács M, Minarovits J. Infectious Agents Associated with Head and Neck Carcinomas. Adv Exp Med Biol 2016; 897:63-80. [PMID: 26563307 DOI: 10.1007/5584_2015_5005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In addition to traditional risk factors such as smoking habits and alcohol consumption, certain microbes also play an important role in the generation of head and neck carcinomas. Infection with high-risk human papillomavirus types is strongly associated with the development of oropharyngeal carcinoma, and Epstein-Barr virus appears to be indispensable for the development of non-keratinizing squamous cell carcinoma of the nasopharynx. Other viruses including torque teno virus and hepatitis C virus may act as co-carcinogens, increasing the risk of malignant transformation. A shift in the composition of the oral microbiome was associated with the development of oral squamous cell carcinoma, although the causal or casual role of oral bacteria remains to be clarified. Conversion of ethanol to acetaldehyde, a mutagenic compound, by members of the oral microflora as well as by fungi including Candida albicans and others is a potential mechanism that may increase oral cancer risk. In addition, distinct Candida spp. also produce NBMA (N-nitrosobenzylmethylamine), a potent carcinogen. Inflammatory processes elicited by microbes may also facilitate tumorigenesis in the head and neck region.
Collapse
Affiliation(s)
- Andrea Hettmann
- Division of Virology, National Center for Epidemiology, Albert F. ut 2-6, H-1097, Budapest, Hungary
| | - Anett Demcsák
- Faculty of Dentistry, Department of Oral Biology and Experimental Dental Research, University of Szeged, Szeged, Hungary
| | - Gábor Decsi
- Department of Oral Surgery, University of Szeged, Tisza Lajos krt. 64, H-6720, Szeged, Hungary
| | - Ádám Bach
- Faculty of Medicine, Department of Oto-Rhino-Laryngology and Head-Neck Surgery, University of Szeged, Tisza L. krt. 111, H-6725, Szeged, Hungary
| | - Dóra Pálinkó
- Faculty of Medicine, Department of Oto-Rhino-Laryngology and Head-Neck Surgery, University of Szeged, Tisza L. krt. 111, H-6725, Szeged, Hungary
| | - László Rovó
- Faculty of Medicine, Department of Oto-Rhino-Laryngology and Head-Neck Surgery, University of Szeged, Tisza L. krt. 111, H-6725, Szeged, Hungary
| | - Katalin Nagy
- Department of Oral Surgery, University of Szeged, Tisza Lajos krt. 64, H-6720, Szeged, Hungary
| | - Mária Takács
- Division of Virology, National Center for Epidemiology, Albert F. ut 2-6, H-1097, Budapest, Hungary
| | - Janos Minarovits
- Faculty of Dentistry, Department of Oral Biology and Experimental Dental Research, University of Szeged, Szeged, Hungary.
| |
Collapse
|
48
|
Prigge ES, von Knebel Doeberitz M, Reuschenbach M. Clinical relevance and implications of HPV-induced neoplasia in different anatomical locations. Mutat Res Rev Mutat Res 2016; 772:51-66. [PMID: 28528690 DOI: 10.1016/j.mrrev.2016.06.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/11/2016] [Accepted: 06/20/2016] [Indexed: 01/26/2023]
Abstract
Human papillomaviruses (HPV) are widespread DNA viruses that can infect epithelial cells of the skin and mucosa. Most HPV infections remain clinically unapparent and clear spontaneously. In few cases, however, HPV infections persist and can cause benign and malignant neoplasms at different anatomic locations. Malignant HPV-induced neoplasms are caused by distinct types of HPV (oncogenic or high-risk (HR) HPV types) and present in the anogenital (anus, penis, uterine cervix, vagina and vulva) and head and neck (particularly oropharynx) region. In the anogenital region defined precancerous stages precede invasive cancer. In the head and neck region there is clear evidence only for the invasive stage of HPV-induced neoplasia. In early infection stages the HPV oncogenes (E6/E7) are under tight control in the basal and parabasal cell layers. In more advanced precancerous stages increased expression of the HPV oncogenes E6 and E7 occurs (transforming infection) that may result in transformation of these cells. The defined carcinogenesis in the anogenital tract enables cancer early detection, particularly at the uterine cervix where cytologic and molecular tests contribute to early diagnosis and treatment at a non-invasive stage. Up to now, the treatment of HPV-related precancerous stages (high-grade intraepithelial neoplasia) and cancer is not specifically targeting molecular characteristics of the virus. This article reviews the current state and new developments in epidemiology, prevention, diagnosis and treatment of HPV-associated neoplasia in various anatomic locations.
Collapse
Affiliation(s)
- Elena Sophie Prigge
- Department of Applied Tumor Biology, Institute of Pathology, University of Heidelberg, and Clinical Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Magnus von Knebel Doeberitz
- Department of Applied Tumor Biology, Institute of Pathology, University of Heidelberg, and Clinical Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Miriam Reuschenbach
- Department of Applied Tumor Biology, Institute of Pathology, University of Heidelberg, and Clinical Cooperation Unit Applied Tumor Biology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| |
Collapse
|
49
|
Vivenza D, Lo Nigro C, Denaro N, Fortunato M, Monteverde M, Tonissi F, Lattanzio L, Astesana V, Gloghini A, Volpi CC, Russi E, Merlano MC. E1 detection as prognosticator in human papillomavirus-positive head and neck cancers. Int J Biol Markers 2016; 31:0. [PMID: 27040135 DOI: 10.5301/jbm.5000193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE HPV-related locally advanced head and neck cancers (LA-HNCs) show a good prognosis. This study aimed to investigate the HPV prevalence in LA-HNCs and compare the prognostic value of E1, E6 and L1 genomic viral fragments and p16, individually and in combination, in order to find the best prognosticator in terms of overall survival (OS) and progression-free survival (PFS). PATIENTS AND METHODS HPV16 was searched in 255 LA-HNC formalin-fixed paraffin-embedded tumor tissues, 89 oropharyngeal cancers (OPCs), and 166 non-OPCs by DNA-PCR with 3 primer pairs. p16 was analyzed by immunohistochemistry in 235 patients. RESULTS The prevalence of positive samples decreased constantly from E6 to L1 and E1 in both OPCs and non-OPCs. Each LA-HNC patient highlighted variable positivity for each fragment. OPCs showed a higher prevalence of positive samples compared to non-OPCs.Positive coexistence of all the fragments was more common in OPCs (31.5%) than non-OPCs (4.2%), and E1 detection was always associated with E6 and L1. E1-positive OPCs showed improved OS (p = 0.012) and PFS (p = 0.036), while L1- or E6-positive ones did not. p16-positive patients were more prevalent in the OPC (29.8%) than the non-OPC group (7.3%) (p<0.0001) and its prognostic value was not superior to that of E1. However, the multivariate Cox analysis which included E1, L1, E6 status and p16 expression did not show a significant p value. CONCLUSIONS Though HPV16 positivity measured by DNA-PCR was higher for L1 and E6, they performed weakly as prognosticators; E1 might become a strong prognostic marker for OS and PFS in OPCs.
Collapse
|
50
|
Ozretić L, Wagner S, Huebbers C, Gattenlöhner S, Klussmann J, Beutner D, Zander T, Buettner R, Quaas A. FGFR1 amplification and co-overexpression of c-MYC in oropharyngeal squamous cell carcinoma. Oral Oncol 2016; 54:e7-9. [DOI: 10.1016/j.oraloncology.2015.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 12/19/2015] [Accepted: 12/21/2015] [Indexed: 01/09/2023]
|