Human papillomavirus-positive tonsillar carcinomas: a different tumor entity?

[Update: Epidemiology and Prevention of Oropharyngeal Cancer]

Due to the association with the causal HPV-16 infection, the oropharyngeal carcinoma spreads into two separate entities depending on HPV-16 positivity. More recent data show a diversified picture of the importance and prevalence of the surrogate parameter p16 (discordance) for a definitive HPV-16 association, which varies worldwide. In the context of prevention options, vaccination is of major and HPV screening of healthy people only of little importance.

The effect of human papillomavirus status on prognosis and local treatment strategies of T1-2N0 oropharyngeal squamous cell cancer

Purpose

To explore the effect of human papillomavirus (HPV) status on prognosis and further investigate whether human papillomavirus (HPV) status has an impact on the local treatment strategies for T1-2N0 oropharyngeal squamous cell cancer (OPSCC) patients.

Methods

Patients diagnosed with T1-2N0 OPSCC between 2010 and 2015 were included from the Surveillance, Epidemiology, and End Results database. Data were analyzed using propensity score matching (PSM), Chi-square test, Kaplan-Meier survival analysis, and Cox multivariable analyses.

Results

A total of 1,004 patients were identified, of whom 595 (59.3%) had HPV-related tumors. Of all the patients, 386 (38.4%) and 618 (61.6%) received definitive radiotherapy and radical surgery, respectively. HPV status had no significant effect on local treatment strategies for early-stage OPSCC (P = 0.817). The 3-year cancer-specific survival (CSS) and overall survival (OS) were 89.6 and 80.1%, respectively. Compared to those with HPV-negative diseases, patients with HPV-positive diseases had better CSS and OS. A total of 222 pairs of patients were completely matched after PSM. The results of multivariate Cox regression analysis showed that patients with HPV-positive disease had significantly better CSS (P = 0.001) and OS (P < 0.001) compared to those with HPV-negative tumors. However, local treatment strategy was not associated with survival outcomes after PSM (CSS, P = 0.771; OS, P = 0.440). The subgroup analysis showed comparable CSS and OS between those treated with radical surgery and definitive radiotherapy regardless of HPV status.

Conclusions

HPV status is an independent prognostic factor for the survival of stage T1-2N0 OPSCC patients. Local treatment strategies had no significant effect on the survival of early-stage OPSCC regardless of HPV status. Patients with early-stage OPSCC should be informed regarding the pros and cons of definitive radiotherapy or radical surgery.

Sexual Behaviour and Human Papillomavirus-Positive Oral Cavity and Oropharyngeal Cancer: An Irish Perspective

Background Characterization of the sexual behaviours and lifestyle factors associated with human papillomavirus (HPV)-positive oral cavity and oropharyngeal squamous cell carcinoma (OPSCC) is crucial to optimal counselling. Our study aims to investigate the relationship between sexual behaviours, lifestyle factors and HPV-positive OPSCC in an Irish population. Methods We performed a case-control study of 60 patients with newly diagnosed HPV-positive and HPV-negative oral cavity and OPSCC. Results Oral sexual activity was more common in the HPV-positive tumour subgroup; however, this association was insignificant on multivariate analysis. No association between age of onset of sexual activity, number of sexual partners or practicing anal sex and HPV-positivity was found. The HPV-positive tumour subgroup had significantly less tobacco use than their HPV-negative counterparts (OR 0.93, 95% CI 0.90-0.97). Conclusion The emergence of HPV-positive OPSCC means head and neck surgeons must adopt new roles as counsellors of sexually transmitted disease, in addition to their previous role of delivering a cancer diagnosis.

Smoking-Induced SLPI Expression Hinders HPV Infections Also in Squamous Cell Carcinomas of the Vulva

In HNSCC, protein- and mRNA-expression of the antileukoproteinase SLPI are significantly inverse correlated with HPV-infection suggesting that elevated expression of SLPI protects against HPV-infections. Moreover, SLPI-expression is up-regulated in HNSCC-patients reporting a smoking habit. Here, we investigate the described correlation in other HPV-driven cancers, namely vulvar squamous cell carcinoma (VSCC). FFPE samples of 99 VSCC were analyzed by PCR for HPV-DNA-expression and by RT-qPCR for SLPI-mRNA-expression. Of 99 VSCC 10 (10.1%) are HPV-positive; 9 were HPV16; 1 HPV18; all were E6/E7 mRNA-positive. 33 of the 99 patients (33.3%) reported a smoking habit; 7 (21.1%) of these were HPV-positive. Of 66 (66.7%) non-smokers 3 (4.5%) were HPV-positive. SLPI-expression was 4.0-fold lower in HPV-positive than HPV-negative patients. Smoking resulted in 2.3-fold higher SLPI expression. The data presented here indicate that SLPI plays a pivotal role in HPV-infection not only in HNSCC but also in VSCC and possibly also in other HPV-driven cancers. This however, needs to be analyzed in future studies. Furthermore these data lead to the hypothesis that the smoking induced SLPI-increase is systemic rather than local, as assumed based on the HNSCC data.

Impact of anatomic origin of primary squamous cell carcinomas of the nasal cavity and ethmoidal sinus on clinical outcome

PURPOSE

Since squamous cell carcinomas (SCCs) of the nasoethmoidal complex are rare and aggressive malignancies, the purpose of this study was to evaluate whether anatomic subsites of SCCs of the nasal cavity and ethmoid sinuses affect clinical outcome.

METHODS

We retrospectively analyzed data from 47 patients with primary SCCs of the nasal cavity and ethmoid sinuses who were treated at the Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, between 1993 and 2018. The impact of anatomic subsites of nasoethmoidal SCCs was evaluated with respect to tumor and nodal classification, disease-free survival (DFS) and disease-specific survival (DSS).

RESULTS

Of the 47 cases, 17 SCCs (36.2%) originated from lateral nasal wall followed by 13 (27.7%) tumors of the edge of naris to mucocutaneous junction, 11 (23.4%) SCCs of the nasal septum, 3 tumors of the nasal floor (6.4%) and 3 SCCs of the ethmoid sinuses (6.4%), respectively. SCCs of the nasal septum were associated with significantly higher rates of neck node metastasis (p = 0.007), which represented a significantly worse prognostic factor for DSS (HR 7.87; p < 0.001). Moreover, advanced tumor stage (HR 5.38; p = 0.014) and tumor origin of nasal septum (HR 4.05; p = 0.025) were also significantly worse prognostic factors for DSS. Fourteen patients (29.8%) developed recurrent disease, including eight local (17.0%), five regional (10.6%) and one distant (2.1%) recurrence. Elective neck dissection (ND) was associated with lower (0 vs. 20.0%) but not significantly different regional and distant DFS (p = 0.075).

CONCLUSION

Anatomic origin of nasal SCC has significant impact on clinical outcome. SCCs of the nasal septum were associated with higher rates of positive neck nodes and worse outcome.

The analysis of human papillomavirus DNA in penile cancer tissue by in situ hybridization

Primary penile cancer is a rare disease. Higher incidence rates occur in underdeveloped countries. Many studies have suggested an association between human papillomavirus (HPV) infection and penile cancer. Although HPV can affect the squamous epithelium of the male genitalia similarly to the female genital tract, the association between penile cancer and HPV remains unclear. In the present study, the HPV gene expression was examined in penile cancer tissue using in situ hybridization (ISH). The present study included 41 cases in which penectomy was performed and 3 cases in which tumor resection was performed to treat pathologically-diagnosed penile cancer at Yokohama City University Medical Center, and its 7 affiliated hospitals between April 1990 and March 2010. The penile cancer tissue was subjected to an ISH analysis, and the clinicopathological features and prognosis were investigated. A total of 5/44 cases (11.4%) showed the expression of high-risk HPV. None of the patients showed the expression of low-risk HPV. The associations between the expression of high-risk HPV, and age, tumor location, tumor size, T stage, pathological differentiation, nuclear grade, Broder's classification, pattern of invasion, Y-K grade, vascular invasion, lymphoid invasion, koilocytosis and lymph-node metastasis were then examined. Patients with a well-differentiated status (P=0.044) and Broder's Grade 1 (P=0.019) showed a significantly lower rate of HPV positivity. The HPV expression was not significantly associated with cancer specific survival (P=0.932). ISH using INFORM HPV III does not detect the HPV genotype, this method is easy to employ and may be useful for the diagnosis of penile cancer tissue, similarly to cervical cancer.

Aetiological heterogeneity of head and neck squamous cell carcinomas: the role of human papillomavirus infections, smoking and alcohol

Tobacco and alcohol consumption are the main risk factors for head and neck squamous cell carcinoma (HNSCC). In addition, human papillomavirus (HPV) infection plays a causal role in oropharyngeal cancer (OPC), a subset of HNSCC. We assessed the independent effects of tobacco, alcohol and HPV infection on OPC risk in the head and neck cancer (HeNCe) Life study, a hospital-based case-control study of HNSCC with frequency-matched controls by age and sex from four Montreal hospitals. Interviewers collected information on socio-demographic and behavioural factors. We tested exfoliated oral cells for HPV DNA by polymerase chain reaction (PCR). We included only OPC cases (n = 188) and controls (n = 427) without missing values for HPV, smoking or alcohol. We examined associations by estimating odds ratios (ORs) and corresponding 95% confidence intervals (CI) using unconditional logistic regression. Smoking (OR = 1.90, 95% CI: 1.04-3.45) and alcohol (OR = 2.74, 95% CI: 1.45-5.15) were associated with an increased risk of OPC independent of HPV status. Positivity for HPV 16 among heavy smokers and heavy alcohol users was associated with a 30.4-fold (95% CI: 8.94-103.26) and 18.6-fold (95% CI: 5.75-60.13) elevation in risk of OPC relative to participants who were HPV negative, respectively. Moreover, the combined effect of heavy smoking and alcohol comsumption with HPV 16 infection substantially increased OPC risk (OR = 48.76, 95% CI: 15.83-150.17) and (OR = 50.60, 95% CI: 15.96-160.40), respectively. Our results support the independent roles of smoking, alcohol and HPV infection in OPC risk and a possible combined effect. Efforts should be made to tackle these major risk factors simultaneously.

Prognostic Impact of AJCC/UICC 8th Edition New Staging Rules in Oropharyngeal Squamous Cell Carcinoma

Introduction

The purpose of this study was to test whether the 8th edition of the AJCC/UICC TNM staging system (UICC) precisely differentiates between stages and reflects disease outcome in human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC).

Patients and methods

OPSCC patients that were diagnosed between 2000 and 2016 were included in this analysis and HPV status was determined by combined DNA and p16 testing. Stratification was done according to 7th and 8th UICC staging rules. Incidence trends of HPV-associated tumorigenesis, 5-year overall survival (OS) according to tumor stages as well as the influence of therapy and prognostic factors toward the outcome were calculated using Kaplan–Meier method and Cox proportional-hazards model.

Results

A significant increase [2000; n = 8/39 (21%)–2015; n = 17/32 (53%); p = 0.002] in HPV-associated OPSCC was seen in the observation period. Together, 150/599 (25.0%) of the patients had HPV-driven OPSCC and 64.7% of curative treatments in all OPSCC patients included upfront surgery of the primary and the neck. 7th edition staging rules led to no discrimination in all respective four UICC stages in HPV OPSCC underlining the need for new staging rules. However, only discrimination between stages I vs. II and III vs. IV was significant in our patients with HPV-OPSCC (94.4 vs. 77.5%; p = 0.031 and 63.9 vs. 25.0%; p = 0.013), and stages II vs. III did not differ in OS rates (p = 0.257), when applying the new staging rules. For HPV-negative OPSCC, significant outcome differences were only seen between UICC stages III vs. IV (57.6 vs. 35.2%; p = 0.012).

Discussion

While the 7th edition of UICC shows invalid discrimination between stages, the 8th edition is more suitable for HPV-associated carcinoma. Due to lack of differentiation between stages II and III further adaption is essential.

Human papillomavirus association is the most important predictor for surgically treated patients with oropharyngeal cancer

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 p16^INK4a 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.

Impact of County-Level Socioeconomic Status on Oropharyngeal Cancer Survival in the United States

Objective To evaluate the impact of county-level socioeconomic status on survival in patients with oropharyngeal cancer in the United States. Study Design Retrospective cohort study via a large population-based cancer database. Methods Data were extracted from the SEER 18 database (Surveillance, Epidemiology, and End Results) of the National Cancer Institute. The study cohort included 18,791 patients diagnosed with oropharyngeal squamous cell carcinoma between 2004 and 2012. Results Patients residing in counties with a low socioeconomic status index had worse overall survival (56.5% vs 63.0%, P < .001) and disease-specific survival (62.7% vs 70.3%, P < .001) than patients residing in counties with a high socioeconomic status index. On multivariable analysis, residing in a county with a low socioeconomic status index was associated with worse overall survival (hazard ratio, 1.21; 95% CI, 1.14-1.29; P < .001) and disease-specific survival (hazard ratio, 1.21; 95% CI, 1.12-1.30; P < .001), after adjusting for race, age, sex, marital status, year of diagnosis, site, American Joint Committee on Cancer stage group, presence of distant metastasis, presence of unresectable tumor, histologic grade, surgical resection of primary site, treatment with neck dissection, and radiation therapy. Conclusion Residing in a county with a low socioeconomic status index is associated with worse survival. Further research is needed to elucidate the mechanism by which socioeconomic status affects survival in oropharyngeal cancer.

Tumor Staging and HPV-Related Oropharyngeal Cancer

The current TNM staging for oropharyngeal cancer (OSCC) was designed empirically for non-HPV-related disease. Emerging evidence suggests it is unsuited for Human papillomavirus (HPV)-related OSCC. Patients with HPV-positive tumors have improved prognosis, despite presenting at advanced stages. These shortcomings of the current staging system have been identified in single- and multi-institutional trials. Patients with HPV related OSCC typically present with advanced N-stages leading to higher stage groupings. A rarity of stages I and II therefore represents the nature of HPV-related OSCC. Concerning prognosis of the patients, N-category and extracapsular spread seem to be of minor importance, whereas advanced T-stages result in unfavourable outcome. Anatomical staging therefore has been implied into different proposals to prognostic risk classifications in HPV-related disease as an additive compound. Prognostic risk groupings are further enhanced by incorporating non-anatomical factors. To summarize, it can be suggested that the current TNM system alone has little prognostic value in HPV-related OSCC.

Periodontal pocket as a potential reservoir of high risk human papilloma virus: A pilot study

Aim:

Human papilloma viruses (HPVs) are small DNA viruses that have been identified in periodontal pocket as well as gingival sulcus. High risk HPVs are also associated with a subset of head and neck carcinomas. HPV detection in periodontium has previously involved DNA detection. This study attempts to: (a) Detect the presence or absence of high risk HPV in marginal periodontiun by identifying E6/E7 messenger RNA (mRNA) in cells from samples obtained by periodontal pocket scraping. (b) Detect the percentage of HPV E6/E7 mRNA in cells of pocket scrapings, which is responsible for producing oncoproteins E6 and E7.

Materials and Methods:

Pocket scrapings from the periodontal pockets of eight subjects with generalized chronic periodontitis were taken the detection of presence or absence of E6, E7 mRNA was performed using in situ hybridization and flow cytometry.

Results:

HPV E6/E7 mRNA was detected in four of the eight samples.

Conclusion:

Presence of high risk human papillomaviruses in periodontal pockets patients of diagnosed with chronic periodontitis, not suffering from head and neck squamous cell carcinoma in the present day could link periodontitis to HPV related squamous cell carcinoma. Prevalence studies are needed detecting the presence of HPV in marginal periodontium as well as prospective studies of HPV positive periodontitis patients are required to explore this possible link.

[Human papillomavirus and squamous cell cancer of the head and neck region : Prognostic, therapeutic and prophylactic implications]

Human papilloma viruses (HPV) are responsible for approximately half of all oropharyngeal squamous cell carcinomas (OPSCC) and incidence rates of HPV-associated OPSCC continue to increase substantially. The defined viral carcinogenesis permits development of specific diagnostic, therapeutic, and prophylactic approaches. Laboratory identification of HPV-associated OPSCC may be achieved by p16(INK4a) immunohistochemistry combined with HPV DNA detection by polymerase chain reaction (PCR) using tumor tissue. Patients with HPV-associated OPSCC have a relatively good prognosis; therefore, the HPV status plays an important role in patient guidance. Due to the relatively favorable prognosis, ongoing studies are evaluating whether less rigorous therapy for HPV-positive patients results in equally good cure rates. The criteria for patient selection are, however, still uncertain. Particularly markers for detection of HPV-positive patients with a high risk of treatment failure are lacking. Besides tumor stage and comorbidities, distinct genomic, epigenetic, and immunologic alterations are prognostically relevant for HPV-associated OPSCC, and might be of predictive value. Furthermore, the characteristic molecular alterations suggest the possibility of novel vigilant and specific therapy approaches. These may be inhibitors of the phosphatidylinositol 3‑kinase (PI3K) pathway, which is frequently activated in HPV-associated OPSCC, and immunotherapeutic methods, e. g., therapeutic vaccination. Although prophylactic HPV vaccinations may also prevent development of HPV-associated OPSCC, foreseeable effects on OPSCC incidence will be low, given the low vaccination rates in Germany. This highlights the fact that interdisciplinary research networks should enhance the necessary activities related to HPV-associated OPSCC.

Incidence of tonsillar cancer in northern Sweden: Impact of human papilloma virus

The incidence rate of tonsillar cancer is increasing worldwide. The current study identifies a parallel increase in the incidence of tonsillar cancer, human papilloma virus (HPV) and p16 expression among a population from northern Sweden, a sparsely populated area, confirming the strong association between p16 and HPV infection in tonsillar tissue. Data from the Swedish Cancer Registry was assessed to identify cases of tonsillar cancer in the northern territorial area of Sweden. HPV DNA was extracted from paraffin embedded diagnostic biopsies and detected by polymerase chain reaction using general primers Gp5+/6+ and CpI/IIG. Expression of p16 was identified by immunochemistry. Patients were grouped into urban or rural residence categories. A total of 214 cases were identified, comprising 155 (72.4%) men and 59 (27.6%) women, and 65 of these patients, who presented between 2000 and 2012, were analyzed. The overall median age for the analyzed patients was 58 years; 48 (74%) were males (median age, 57.5 years) and 17 (26%) were females (median age, 65 years). Of the 65 specimens, 59 (91%) were positive for HPV, and 62 (95%) expressed p16. The incidence of tonsillar cancer in the cohort demonstrated a 2-fold increase between 1990 and 2013; specifically, a 2.7-fold increase was observed in men whilst the female group exhibited only a small increase. These findings demonstrate a strong association between p16 expression and HPV infection in tonsillar malignancies. The incidence of HPV-positive tonsillar cancer has increased in recent years, even in sparsely populated regions, as demonstrated in northern Sweden.

Competing causes of death and medical comorbidities among patients with human papillomavirus-positive vs human papillomavirus-negative oropharyngeal carcinoma and impact on adherence to radiotherapy

IMPORTANCE

Survival of patients with head and neck cancer can be affected by competing causes of mortality, as well as comorbidities that result in radiation treatment interruptions.

OBJECTIVE

To discern how differences in preexisting medical and psychosocial comorbidities potentially influence adherence to radiation therapy according to human papillomavirus (HPV) status.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis at a comprehensive cancer center of 162 consecutive patients with locally advanced squamous cell carcinoma of the oropharynx treated with primary chemoradiation (n = 95) or primary surgery followed by adjuvant radiation (n = 67). Immunostaining for p16 was used to determine HPV status.

MAIN OUTCOMES AND MEASURES

Difference in alcohol, tobacco, and marijuana use was compared between patients with HPV-positive and HPV-negative tumors, as well as the prevalence of the following comorbidities: diabetes mellitus, chronic obstructive pulmonary disease (COPD), anxiety disorder, and major depression. The number of total missed treatment days was analyzed as both a continuous and categorical variable.

RESULTS

Rates of self-reported heavy alcohol use (47% vs 16%; P = .02) and any marijuana use (47% vs 23%; P = .003) were significantly higher among HPV-negative patients. Fifty-four percent of HPV-positive patients self-identified as never smokers, compared with only 12% of HPV-negative patients (P < .001). HPV-negative patients had more missed treatment days (mean, 2.8 vs 1.7 days; P = .02), as well as an increased rate of at least 5 missed days (24% vs 10%; P = .04), and higher prevalences of COPD (12% vs 7%; P = .37) and anxiety disorder (12% vs 6%; P = .35).

CONCLUSIONS AND RELEVANCE

Pronounced differences exist in lifestyle habits between patients with HPV-negative and HPV-positive oropharyngeal cancer at diagnosis. These differences, as well as those of medical and psychosocial burden, may contribute to observed discrepancies in treatment adherence and need to be considered in outcomes reporting and clinical trial design.

Inaccuracies in oral cavity-pharynx cancer coded as the underlying cause of death on U.S. death certificates, and trends in mortality rates (1999-2010)

OBJECTIVE

To enhance surveillance of mortality from oral cavity-pharynx cancer (OCPC) by considering inaccuracies in the cancer site coded as the underlying cause of death on death certificates vs. cancer site in a population-based cancer registry (as the gold standard).

METHODS

A database was used for 9 population-based cancer registries of the Surveillance, Epidemiology and End Results (SEER) Program, including deaths in 1999-2010 for patients diagnosed in 1973-2010. Numbers of deaths and death rates for OCPC in the SEER population were modified for apparent inaccuracies in the cancer site coded as the underlying cause of death.

RESULTS

For age groups <65 years, deaths from OCPC were underestimated by 22-35% by using unmodified (vs. modified) numbers, but temporal declines in death rates were still evident in the SEER population and were similar to declines using routine mortality data for the entire U.S. population. Deaths were underestimated by about 70-80% using underlying cause for tonsillar cancers, strongly associated with human papillomavirus (HPV) infection, but a lack of decline in death rates was still evident.

CONCLUSION

Routine mortality statistics based on underlying cause of death underestimate OCPC deaths but demonstrate trends in OCPC death rates that require continued surveillance in view of increasing incidence rates for HPV-related OCPC.

[HPV-associated oropharyngeal carcinoma. Status quo and relationship with cancer of unknown primary]

Carcinomas of the oropharynx with association to high-risk types of human papillomavirus (HPV) have been identified as a new tumour entity with favourable prognosis, distinct from classical nicotine- and alcohol-associated carcinoma. They develop through oncogenic transformation of the basal cells of reticulated cryptal epithelium of the palatinal tonsils and the base of the tongue. Positivity for HPV strongly correlates with an atypical, non-keratinizing histological differentiation and cystic transformation of lymph node metastases. Strong immunohistological positivity for p16 reliably detects transcriptionally active infection with high-risk HPV. Hence, p16 staining has been regarded as an effectual diagnostic tool in the appropriate setting. Frequent nodal metastasation as well as considerable size of (cystic) metastases, and frequent small size as well as submucosal location of primary tumours all contribute to frequent initial manifestation of cervical cancer of unknown primary (CUP). In a situation of CUP diagnostic testing for HPV (in negative cases in addition to EBV) is recommended in lymph node metastases, due to the high predictive value for the localization of occult primary carcinomas. Intense clinicopathological cooperation is mandatory for improved detection of small, occult primary carcinomas. The relevance of this new carcinoma entity will increase, as the incidence continues to increase worldwide.

Prevalence and risk factors for oral human papillomavirus infection in 129 women screened for cervical HPV infection

BACKGROUND

Oncogenic human papillomaviruses (HPV) are known to be associated with carcinomas of the uterine cervix. Furthermore, current studies have shown that HPV-infection is also associated with a subtype of oropharyngeal cancers. In general, a sexual transmission of the viruses has been shown by numerous studies in the genital lesions. However, there are unknown factors regarding the prevalence and transmission of HPV in the oropharynx. The aim of this study was to evaluate HPV prevalence in the oropharynx in female participants with and without genital HPV infection. In addition, we analyzed risk factors for an oropharyngeal colonization with HPV in their sexual partners, too.

METHODS

129 Female participants were tested for presence of HPV-DNA by oral lavage, brush cytology of the tonsils and of the cervix. In addition, 15 male partners of these patients were included in the study. HPV-DNA was detected by PCR (polymerase chain reaction) amplification. For HPV-genotyping, PCR products were hybridized with type-specific digoxigenin-labeled oligonucleotide probes and discriminated into 14 high risk (HR) and 6 low risk (LR)-HPV types. The 129 female and 15 male participants were interviewed by a standardized questionnaire for socioeconomic details, drinking, smoking and sexual behaviours.

RESULTS

59 (45.7%) Female participants were negative for a genital HPV-infection. Of these women, 3 (5.1%) showed a positive HPV-PCR result (HR and LR) in the oropharynx. 70 (54.3%) Female participants were positive for a genital HPV infection. In this group, 4 (5.7%) had a positive HPV-detection (HR and LR) in the oral cavity and oropharynx. Female participants with cervical HPV-infection had no higher risk for HPV-detection in the oropharynx (not significant). The analysis of sexual risk factors revealed no specific risk factor for an oral HPV-infection.

CONCLUSION

A correlation between cervical and oral colonization by HPV could not be demonstrated in our small cohort. Our limited data suggest that sexual transmission of HPV from the cervix uteri to the oropharynx is a rare and unlikely event.

p16 expression in carcinoma of unknown primary: diagnostic indicator and prognostic marker

BACKGROUND

Carcinoma of unknown primary (CUP) of the neck are heterogeneous tumors in their clinical and biological characteristics, and a preoperative prognostic marker is desirable to optimize staging and therapy and to improve outcome and survival. For CUP syndrome, no optimized diagnostic and treatment strategy or biomarker have yet been determined.

METHODS

Forty-seven patients presenting with CUP syndrome were analyzed after thorough standard diagnostic staging procedures. All patients were surgically treated with tonsillectomy, neck dissection of the diseased neck, as well as adjuvant chemoradiation. The tissue of lymph node metastases (and, if found, of the primary tumor) was analyzed regarding expression of p16, epidermal growth factor receptor (EGFR), and presence of human papillomavirus (HPV) DNA.

RESULTS

In 39% of all cases (20 of 47), the primary cancer was found during diagnostic workup. If HPV DNA was detected in the neck lymph node metastasis, the primary cancer was significantly more frequently found in the oropharynx (p = .002). Patients with a p16-positive tumor had a significantly higher 5-year overall survival (OS; 33% vs 69%; p = .045, disease-free survival [DSF] 77% vs 89%; p = not significant [NS]). Patients with p16-positive neck metastasis and no detectable primary cancer had a better prognosis. Expression of EGFR in this series did not have a significant effect on prognosis.

CONCLUSION

In patients presenting with CUP syndrome, p16 immunohistochemistry can serve to locate the primary cancer in the oropharynx. It is a positive prognostic indicator in patients with those heterogeneous cancers.

Prognostic impact of human papillomavirus status, survivin, and epidermal growth factor receptor expression on survival in patients treated with radiochemotherapy for very advanced nonresectable oropharyngeal cancer

BACKGROUND

The influence of human papillomavirus (HPV) status on survival for patients with very advanced inoperable oropharyngeal SCC treated with radiochemotherapy (RCT) was studied.

METHODS

Patients received either 69.2 Gy with concomitant boost (ccb) or 70 Gy conventionally fractionated (cf), weekly paclitaxel 40 mg/m(2), and carboplatin area under the concentration-time curve (AUC) 1. Tumor was analyzed for the presence of high-risk HPV-DNA using polymerase chain reaction (PCR) and direct DNA sequencing. p16-expression, survivin, and epidermal growth factor receptor (EGFR) expression were evaluated by immunohistochemistry and influence on survival was calculated.

RESULTS

Of 52 patients, 25.0% were HPV positive and 75.0% HPV negative. The 2-year progression-free survival (PFS) was 70.1% for p16-positive patients and 37.1% for p16-negative patients (p = .005). The 3-year overall survival (OS) rate was 43.9% for all patients and did not significantly differ between the groups. Neither survivin nor EGFR expression influenced PFS or OS significantly.

CONCLUSIONS

HPV status influences PFS in patients with advanced, nonresectable tumor stages but not OS. Additional risk factors seem to have a stronger influence on survival than HPV status.

Cancer of unknown primary originating from oropharyngeal carcinomas are strongly correlated to HPV positivity

Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OSCC) has been identified as a distinct entity within squamous cell carcinoma of the head and neck. It is associated with special characteristics and is preponderantly restricted to palatial tonsils and base of tongue. These primary locations have for long been associated with the clinical situation of cancer of unknown primary (CUP). In order to investigate the putative relationship between CUP and HPV, we investigated 26 patients who initially presented as CUP and were finally diagnosed with carcinomas of these two locations. Twenty-one cases proved to be positive for high-risk HPV. Primary carcinomas were small and frequently presented in a submucosal location. HPV-positive carcinomas, presented more often in women, showed atypical basaloid differentiation and correlated to cystic lymph node metastases. This study demonstrates an over-representation of HPV-associated OSCC in patients who were initially diagnosed with CUP. This finding indicates a strong relationship between HPV-association and CUP in OSCC. The frequent manifestation as CUP is presumably caused by the unusual predisposition for small size and submucosal location combined with early lymphatic metastization. In order not to miss clinically occult carcinomas, consequent interdisciplinary cooperation in combination with meticulous histological workup is mandatory.

Biopsy vs. brushing: comparison of two sampling methods for the detection of HPV-DNA in squamous cell carcinoma of the oral cavity

BACKGROUND

HR HPV infection was proposed as aetiological factor of oral squamous cell carcinomas (OSCC). HPV frequency in OSCC is highly variable, due to the discrepancy in oral sampling procedures, HPV testing methods and inclusion criteria regarding tumour site (strictly oral cavity vs. nearby structures). Our aim was to compare HPV DNA frequency and type-specific distribution in paired cytological and histological samples of SCC strictly located in oral cavity. The correlation between HPV detection rate by each method of sampling and demographical, behavioural and clinical-pathological variables was also examined.

PATIENTS AND METHODS

HPV DNA was detected in brushed cells and formalin-fixed paraffin-embedded biopsies obtained from 83 consecutive unselected immunocompetent adults with OSCC. HPV DNA detection was performed in all samples by nPCR followed by direct DNA sequencing and the assay INNO-LiPA HPV Genotyping. Univariate and multivariate statistics were used, including Cohen κ index to evaluate agreement between two methods and association between HPV infection and demographical, behavioural and clinical-pathological variables for each method of sampling (p<0.05 statistically significant).

RESULTS

HPV DNA was detected in 15.7% (13/83) of brushings and 12.1% (10/83) of biopsies (p>0.05). High risk HPV 51, 16 and 39 were genotypes more frequently detected, especially among biopsies; no concordance between two methods was found (Cohen κ index=0.04, p=0.34).

CONCLUSION

A fraction of OSCC could be linked to HR HPV infection in the Mediterranean area. Although without a statistical significance, biopsy specimen demonstrated more accurate for HR HPV detection than brushing in OSCC.

Interaction between Chronic Inflammation and Oral HPV Infection in the Etiology of Head and Neck Cancers

Incidences of oral tongue, base of the tongue, and tonsil cancers have been increasing steadily in many parts of the world in spite of declining rates of tobacco use over the last four decades. A better understanding of the etiology, interactions between risk factors, and new approaches to prevention and treatment are necessary to change this course. This paper will present evidence supporting a potential role of chronic inflammation in the etiologies of oral human papillomavirus infection and head and neck squamous cell carcinoma, and it will discuss the implications for prevention and treatment.

A 20-year retrospective study of tonsil cancer incidence and survival trends in South East England: 1987-2006

BACKGROUND

There has been an increasing incidence of tonsil cancer worldwide. Documenting these changes is crucial to cancer prevention and control measures, resource allocation and understanding disease aetiology.

OBJECTIVE

To analyse the changing epidemiology of tonsil cancer in South East England over a 20-year period between 1987 and 2006.

DESIGN

A retrospective, quantitative study using secondary anonymised data obtained from the Thames Cancer Registry, London. Data were analysed using spss v.17 and survival analyses with Kaplan-Meier and Cox regression.

SETTING

This study was conducted in South East of England comprising London, Kent, Surrey and Sussex counties with an average population of 12 million. This population increased from 10.7 to 11.8 million (a 10% increase) between 1987 and 2006.

PARTICIPANTS

All patients with tonsil cancer in South East England registered with the Thames Cancer Registry (ICD-10 code C09) between 1987 and 2006. A total of 1794 patients' data were analysed. Ethical Considerations: Ethical approval was granted by the Kent Research Ethics Committee.

MAIN OUTCOME MEASURES

Data were analysed for demographic trends including gender, age at diagnosis, yearly incidence and survival.

RESULTS

Tonsil cancer incidence has increased significantly from 0.60 to 1.45 per 100,000 in the 20 years (P < 0.001). This increase is mainly amongst men and age groups 40-59 years with a significant reduction in age at diagnosis by 2 years from 61.6 years in the first decade to 59.6 years in the second decade (P < 0.001). Survival was worse in men, older age groups and in the presence of synchronous tumours (P < 0.001). There has been a statistically significant increase in median survival times from tonsil cancer by about 3 years from 2.7 years in the first decade to 5.7 years in the second decade of this study (P < 0.001).

CONCLUSIONS

Tonsil cancer incidence has increased in the 20 years of this study in South East England, especially amongst men and age groups 40-59 years. There has also been significant reduction in the mean age at diagnosis and an increase in median survival times for tonsil cancer. Further studies are needed to explain these trends.

Human papillomavirus in head and neck tumors: epidemiological, molecular and clinical aspects

High-risk types of human papillomaviruses (HR HPV) play an important role in the etiology of a group of head and neck squamous cell cancers (HNSCC). This review is focused on epidemiological, molecular, and clinical aspects of HPV infection in head and neck cancer. High risk HPV DNA is being detected in a very different proportion of HNSCC with the highest prevalence in oropharynx. Patients with HPV-associated tumors are characterized by moderate tobacco and alcohol consumption. Some aspects of sexual behavior may represent a risk factor. Recently, it has been shown that HPV infection is spreading and the rising prevalence of HPV-positive tumors can probably be attributed to this epidemic. On molecular level the viral oncoproteins E6 and E7 were shown to be involved in oncogenesis. HPV-positive cancers have better prognosis and HPV status should be considered in clinical decision-making. The rising proportion of HPV-positive tumors underlines the importance of HPV vaccination also for the prevention of HNSCC.

p16(INK4a) overexpression predicts translational active human papillomavirus infection in tonsillar cancer

The causal role of human papillomaviruses (HPV) in squamous cell carcinogenesis of tonsillar cancers (TSCC) depends on the activity of the viral oncoproteins E6 and E7, leading to inactivation of the cellular tumor suppressor p53 and the retinoblastoma gene product pRb. Because of the negative feedback mechanisms, the pRb inactivation causes an increase of the inhibitor of the cyclin-dependent kinases p16(INK4a). In 39 TSCC specimens, genotyping based on the amplification of HPV DNA was carried out using PCR by applying HPV type-specific oligonucleotides. Subsequently, amplicons were hybridised with fluorescence-labeled complementary probes using the Southern blot technology. For HPV E6/E7 mRNA expression, Northern hybridization and RT-PCR were performed, and for p16(INK4a) detection, immunohistochemistry was performed. With 21/39 (53%) HPV-positives, the detection rate is within the range that can be expected in TSCC. The E6/E7 oncogene mRNA was detectable in 11 cases, 10 of which showed positive signals after p16(INK4a) staining. Albeit the small study group was investigated, the correlation of the HPV DNA status with the p16(INK4a) expression was of statistical significance (p = 0.02). Kaplan-Meier estimations revealed better survival outcome for patients with HPV-positive tumors with detectable E6/E7 mRNA and p16(INK4a) overexpression (p = 0.02, median observation time 29 months). As mRNA expression tests are not routinely available in many clinical diagnostic laboratories, and based on the high correlation of p16(INK4a) staining with HPV E6/E7 mRNA expression, in conclusion we suggest for a deeper exploration for the use of p16(INK4a) as a surrogate marker with the potential to impact the standard of care of HPV DNA-positive head and neck carcinomas.

Update of prognostic and predictive biomarkers in oropharyngeal squamous cell carcinoma: a review

Oropharyngeal squamous cell carcinomas (OSCC) constitute about 5% of all cancers in the western world and the incidence and mortality rates of this tumor have shown little improvement over the last 30 years. Molecular targeted therapy, a promising strategy for the treatment of OSCC and other cancers, requires the understanding of specific molecular events of carcinogenesis and the different pathological, partly interrelated pathways. Extended knowledge of the prognostic or predictive value of molecular biomarkers in oropharyngeal cancer is necessary to allow a better characterization and classification of the tumor, improve the appraisal of clinical outcome and help to specify individual multimodal therapy with increased efficiency. This work affords an updated summary regarding recent data about tissue biomarkers in patients with OSCC, based on the six essential hallmarks of cancer described by Hanahan and Weinberg (Cell 100(1):57-70, 2000) providing the characterization of a malignant cell.

HPV status in head and neck tumors

HPV infection has been associated with head and neck carcinoma (HNSCC). In the present study, a tumor collective from Middle Germany was analyzed using two HPV-detection methods, i.e., PCR followed by agarose gel electrophoresis and microarray chip hybridization. In addition, the predictive value of tumor morphology was assessed. In total, 76 HNSCCs from 52 patients were examined, including 23 pairs of primaries and corresponding metastases. The highest rate of positive tumors was observed in the tonsils, with 76% of the patients and 81% of tumor samples being positive for high-risk HPV. DNA chip analysis detected significantly more HPV-positive cases than did agarose gel electrophoresis. Except for one HPV-33-positive case, all others tumors harbored HPV 16. There was a good concordance between the HPV status of the primary tumor and its corresponding metastasis (21/23 cases, 91%). In two cases, HPV was found only in the primary tumor but not in the metastasis. Our results clearly confirmed the high prevalence of HR-HPV in tonsillar carcinomas with a rate that was even 20% higher than those reported in the literature. Morphology is a valuable indicator for an HPV association that needs to be confirmed by molecular tests.

A new multiparameter assay to assess HPV 16/18, viral load and physical status together with gain of telomerase genes in HPV-related cancers

Oncogenic human papillomavirus (HPV) is the most important risk factor for cancer of the uterine cervix and a subgroup of head and neck cancers. Viral load has been associated with persistence of infection, whereas integration of HPV into the host cell genome is associated with transition to invasive disease. Viral integration is frequently correlated with loss of viral E2 and gain of the telomerase-related genes TERC and TERT. The objective of this study was to develop a rapid and sensitive multiplex ligation-dependent probe amplification (MLPA) assay for the simultaneous analysis of viral load, integration and copy number gain of TERC and TERT in HPV16/18-associated lesions. The performance of the assay was tested for HPV vs. human gene copy number ratios ranging from 0.1 to 100 and for percentages of integration ranging from 0 to 100%. The model systems used include plasmid mixtures and the HPV-positive cell lines SiHa, HeLa and CaSki described to contain a range of 2-600 viral copies per cell. In samples with low-viral load, viral integration can be reliably determined when more than 30% of the virus is integrated. Gain of the telomerase-related genes in the cell lines as determined by our MLPA assay was in accordance with data reported in the literature. Our study demonstrates that within a single MLPA-reaction viral type, load, integration and gain of TERC and TERT can be reliably determined, which will improve risk assessment for patients suspected for HPV infection.

Value of p16(INK4a) as a marker of progression/regression in cervical intraepithelial neoplasia grade 1

OBJECTIVE

The objective of this study was to evaluate the usefulness of p16(INK4a) staining to classify cervical intraepithelial neoplasia grade 1 according to its progression/regression risk.

STUDY DESIGN

Patients with a histologic diagnosis of cervical intraepithelial neoplasia grade 1 were prospectively recruited (n = 138). Simultaneous detection of high-risk human papillomaviruses and p16(INK4a) evaluation were performed. Follow-up was conducted every 6 months by cytology and colposcopy and annually by high-risk human papillomavirus testing, for at least 12 months (mean, 29.0). Progression was defined as a histologic diagnosis of cervical intraepithelial neoplasia grades 2-3, regression as a negative cytology and high-risk human papillomaviruses, and persistence as a cytologic result of low-grade squamous intraepithelial lesions and/or a positive test for high-risk human papillomaviruses.

RESULTS

Progression was observed in 14 women (10.1%), 66 (47.6%) regressed, and 58 (42.0%) had a persistent disease. p16(INK4a) was positive in 77 (55.8%) initial biopsy specimens. Progression to cervical intraepithelial neoplasia grades 2-3 was identified in 14 of 77 (18.2%) women with positive and none of 61 (0.00%) women with negative p16(INK4a) immunostaining (P < .001).

CONCLUSION

p16(INK4a) negative cervical intraepithelial neoplasia grade 1 lesions rarely progress and may benefit from a less intensive follow-up.

The incidence and risk of developing a second primary esophageal cancer in patients with oral and pharyngeal carcinoma: a population-based study in Taiwan over a 25 year period

BACKGROUND

The incidence of oral and pharyngeal (including oral cavity, oropharynx and hypopharynx) carcinoma increases rapidly in Asia and South Pacific because of betel quid chewing. Thus far, large-scale epidemiological studies are not available yet to stratify these patients by their risks of developing a second primary cancer in the digestive tract including esophagus, stomach, colon, and rectum.

METHODS

A population-based study was conducted using the database from the Taiwan National Cancer Registry for the period 1979-2003. We quantified standardized incidence ratios (SIRs) and cumulative incidence of second primary cancers among 33,787 patients with initial diagnoses of oral and pharyngeal carcinoma.

RESULTS

Among these four digestive tract organs, the esophagus was the only site of second cancer with excess risk in patients with oral and pharyngeal carcinoma. The incidence and risk of developing a second primary esophageal cancer differed by the site of the primary index tumor, most frequently seen in hypopharyngeal cancer (71/4,218 = 1.68%, SIR = 22.76, 95% CI 17.77-28.70), followed by oropharyngeal cancer (30/3,403 = 0.88%, SIR = 14.29, 95% CI 9.64-20.39) and the least in oral cavity cancer (99/26,166 = 0.38%, SIR = 5.57, 95% CI 4.53-6.78). In addition, the risk was extraordinarily high for patients with a follow-up interval

CONCLUSION

The present study represents the first population-based study in Asia attempting to stratify the patients of oral and pharyngeal carcinoma by their risk of developing a second esophageal cancer. It helps identify patients at high risk and tailor the application of intense follow-up surveillance to the estimated risk in each individual case.

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MESH Headings

• Adult
• Aged
• Aged, 80 and over
• Carcinoma, Squamous Cell/epidemiology
• Esophageal Neoplasms/epidemiology
• Female
• Follow-Up Studies
• Humans
• Incidence
• Male
• Middle Aged
• Mouth Neoplasms/epidemiology
• Neoplasms, Second Primary/epidemiology
• Pharyngeal Neoplasms/epidemiology
• Population Groups/statistics & numerical data
• Registries/statistics & numerical data
• Risk Factors
• Taiwan/epidemiology
• Young Adult

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Affiliation(s)

Kuan-Der Lee Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Chang-Hsien Lu Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Ping-Tsung Chen Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Chunghuang Hubert Chan Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Jen-Tsun Lin Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Cih-En Huang Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China
Chih-Cheng Chen Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Min-Chi Chen Department of Public Health and Biostatistics Consulting Center, School of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China

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Human papillomavirus (HPV) type 18 induces extended growth in primary human cervical, tonsillar, or foreskin keratinocytes more effectively than other high-risk mucosal HPVs

Mucosal high-risk (HR) human papillomaviruses (HPVs) that cause cervical and other anogenital cancers also are found in approximately 25% of head and neck carcinomas (HNCs), especially those arising in the oropharynx and the tonsils. While many HR HPV types are common in anogenital cancer, over 90% of HPV-positive HNCs harbor HPV type 16 (HPV-16). Using a quantitative colony-forming assay, we compared the ability of full-length mucosal HPV genomes, i.e., the low-risk HPV-11 and HR HPV-16, -18, and -31, to persist in and alter the growth of primary human keratinocytes from the foreskin, cervix, and tonsils. The HR HPV types led to the formation of growing keratinocyte colonies in culture independent of the site of epithelial origin. However, HPV-18 induced colony growth in all keratinocytes >4-fold more effectively than HPV-16 or HPV-31 and >20-fold more efficiently than HPV-11 or controls. HPV-11-transfected or control colonies failed to expand beyond 32 to 36 population doublings postexplantation. In contrast, individual HR HPV-transfected clones exhibited no apparent slowdown of growth or "crisis," and many maintained HPV plasmid persistence beyond 60 population doublings. Keratinocyte clones harboring extrachromosomal HR HPV genomes had shorter population doubling times and formed dysplastic stratified epithelia in organotypic raft cultures, mirroring the pathological features of higher-grade intraepithelial lesions, yet did not exhibit chromosomal instability. We conclude that, in culture, the HR HPV type, rather than the site of epithelial origin of the cells, determines the efficacy of inducing continued growth of individual keratinocytes, with HPV-18 being the most aggressive mucosal HR HPV type tested.

Proteomic analysis of human papillomavirus-related oral squamous cell carcinoma: identification of thioredoxin and epidermal-fatty acid binding protein as upregulated protein markers in microdissected tumor tissue

Human papillomavirus (HPV) infection has been identified as an etiologic agent for a subset of oral squamous cell carcinoma (OSCC) with increasing incidence. HPV DNA-positivity may confer better prognosis but the related oncogenic mechanisms are unknown. For the identification of HPV relevant proteins, we analyzed microdissected cells from HPV DNA-positive (n = 17) and HPV DNA-negative (n = 7) OSCC tissue samples. We identified 18 proteins from tumor tissues by peptide fingerprint mapping and SELDI MS that were separated using 2-DE. Among a number of signals that were detected as significantly different in the protein profiling analysis, we identified thioredoxin (TRX) and epidermal-fatty acid binding protein as upregulated in HPV related tumor tissue. This study, investigating for the first time proteomic changes in microdissected HPV infected tumor tissue, provides an indication on the oncogenic potential of viruses.

[Human papillomavirus and cancer of the oropharynx. Molecular interaction and clinical implications]

One-third of the cases of oropharyngeal squamous cell carcinoma (OSCC) contain oncogenic human papillomavirus (HR-HPV). Epidemiologic and molecular evidence underlines the causal role of HR-HPV in these tumors, which can be defined as HPV-related OSCC. These tumors differ from chemical/toxin-induced OSCC in several biological aspects, including specific molecular and genetic alterations. This leads to a characteristic clinical profile of HPV-related OSCC. Sexual risk factors play a role; however, the knowledge about natural infection and the rate of persistence of HR-HPV in the oropharynx is marginal. It is shown that the distinct biological behavior of the HPV-related subset of oropharyngeal tumors results in a more favorable prognosis. This might be the result of a better response to chemotherapy and radiotherapy. However, further studies are needed to show whether it will be possible to reliably select patients for individualized therapy depended on the HPV status of their tumors. Therefore, we think it will be mandatory to consider and stratify HPV status in the design of prospective clinical trials in the future.

Effect of HPV-associated p16INK4A expression on response to radiotherapy and survival in squamous cell carcinoma of the head and neck

PURPOSE

A subset of head and neck cancers is associated with the human papillomavirus (HPV). Viral infection is closely correlated with expression of p16(INK4A) in these tumors. We evaluated p16(INK4A) as a prognostic marker of treatment response and survival in a well-defined and prospectively collected cohort of patients treated solely with conventional radiotherapy in the Danish Head and Neck Cancer Group (DAHANCA) 5 trial.

PATIENTS AND METHODS

Immunohistochemical expression of p16(INK4A) was analyzed in pretreatment paraffin-embedded tumor blocks from 156 patients treated with conventional primary radiotherapy alone. The influence of p16(INK4A) status on locoregional tumor control, disease-specific survival, and overall survival after radiotherapy was evaluated.

RESULTS

p16(INK4A) positivity was found in 35 tumors (22%). Tumor-positivity for p16(INK4A) was significantly correlated with improved locoregional tumor control (5-year actuarial values 58% v 28%; P = .0005), improved disease-specific survival (72% v 34%; P = .0006), and improved overall survival (62% v 26%; P = .0003). In multivariate analysis, p16(INK4A) remained a strong independent prognostic factor for locoregional failure (hazard ratio [HR], 0.35; 95% CI, 0.19 to 0.64), disease-specific death (HR, 0.36; 95% CI, 0.20 to 0.64), and overall death (HR, 0.44; 95% CI, 0.28 to 0.68).

CONCLUSION

Expression of p16(INK4A) has a major impact on treatment response and survival in patients with head and neck cancer treated with conventional radiotherapy.

Genetic signatures of HPV-related and unrelated oropharyngeal carcinoma and their prognostic implications

PURPOSE

Patients with human papillomavirus (HPV)-containing oropharyngeal squamous cell carcinomas (OSCC) have a better prognosis than patients with HPV-negative OSCC. This may be attributed to different genetic pathways promoting cancer.

EXPERIMENTAL DESIGN

We used comparative genomic hybridization to identify critical genetic changes in 60 selected OSCC, 28 of which were associated with HPV-16 as determined by HPV-specific PCR and fluorescence in situ hybridization analysis and positive p16(INK4A) immunostaining. The results were correlated with HPV status and clinical data from patients.

RESULTS

Two thirds of OSCC harbored gain at 3q26.3-qter irrespective of HPV status. In HPV-negative tumors this alteration was associated with advanced tumor stage (P=0.013). In comparison with HPV-related OSCC, the HPV-negative tumors harbored: (a) a higher number of chromosomal alterations and amplifications (P=0.03 and 0.039, respectively); (b) significantly more losses at 3p, 5q, 9p, 15q, and 18q, and gains/amplifications at 11q13 (P=0.002, 0.03; <0.001, 0.02, 0.004, and 0.001, respectively); and (c) less often 16q losses and Xp gains (P=0.02 and 0.03). Survival analysis revealed a significantly better disease-free survival for HPV-related OSCC (P=0.02), whereas chromosome amplification was an unfavorable prognostic indicator for disease-free and overall survival (P=0.01 and 0.05, respectively). Interestingly, 16q loss, predominantly identified in HPV-related OSCC, was a strong indicator of favorable outcome (overall survival, P=0.008; disease-free survival, P=0.01) and none of these patients had a tumor recurrence.

CONCLUSIONS

Genetic signatures of HPV-related and HPV-unrelated OSCC are different and most likely underlie differences in tumor development and progression. In addition, distinct chromosomal alterations have prognostic significance.