Radiographic imaging of human papillomavirus related carcinomas of the oropharynx

Identification of clinical and pathologic features associated with extranodal extension in patients with HPV-mediated oropharyngeal squamous cell carcinoma

BACKGROUND

Extranodal extension (ENE) is an important prognostic factor that is not ascertainable prior to surgical resection of involved lymph node(s) or may not be available in patients with prior excisional biopsies.

METHODS

This study involved a retrospective analysis of 900 patients diagnosed with HPV(+)OPSCC and treated with primary surgery at a single tertiary care center. Patient demographics, comorbidities, and pathologic characteristics of disease were collected and analyzed. Pathology reports were reviewed to identify ENE. Univariate and multivariate logistic regression models were used to identify factors associated with odds of ENE.

RESULTS

ENE was identified in 506/900 (56.2 %) patients. On univariate analysis, increased Adult Comorbidity Evaluation - 27 (p = 0.013), pathologic T-stage (p = 0.012), pathologic N-stage (p < 0.001), count of involved nodes (p < 0.001), size of largest involved node (p < 0.001), and perineural invasion (p = 0.001) were found to be positively associated with increased odds of ENE. On multivariate analysis, count of involved nodes (p < 0.001), size of largest involved node (p < 0.001), and perineural invasion (p = 0.021) were positively associated with increased odds of ENE. Although PNI improved the model's predictive performance statistically, its exclusion produced similar results. Both predictive models have been made publicly available (https://rtools.mayo.edu/prime_ene_prediction/).

CONCLUSION

Increased count of involved lymph nodes, size of largest involved lymph node, and presence of perineural invasion in patients with HPV(+)OPSCC are strongly associated with increased odds of ENE. These data suggest that ENE presence can be reliably predicted using the number and size of involved nodes. Such a predictive model could prove a useful tool in informing treatment strategies for HPV(+)OPSCC patients prior to surgical resection of involved lymph node(s) and those without sufficient pathologic ENE data from prior excisional biopsies.

Surgeon-performed intraoperative transoral ultrasound improves the detection of human papillomavirus-positive head and neck cancers of unknown primary

BACKGROUND

Squamous cell carcinomas of unknown primary (SCCUP) are often Human Papillomavirus (HPV)-positive. Due to their small size, extensive surgical workup is required to locate the primary tumors. High-frequency transoral ultrasound (US) may provide improved visualization of these small tumors. Our study aimed to explore whether surgeon-performed intraoperative transoral US for patients with HPV-positiveSCCUP could improve primary tumor detection during panendoscopy.

METHODS

This was a single-center, prospective diagnostic study including patients undergoing panendoscopy under general anesthesia with HPV-positive SCCUP. Preoperative MRIs, PET/CTs, and HPV DNA-testing of lymph node metastases were performed in all patients. Intraoperative transoral US was performed prior to panendoscopy. Frozen section biopsies were performed unblinded to US results, and transoral US-guided biopsies were attempted if initial biopsies were negative. Final histopathology was obtained with palatine- and/or lingual tonsillectomy if frozen section was negative. The main outcome was the primary tumor detection rate with intraoperative transoral US and panendoscopy.

RESULTS

Thirty patients were included: 24 (80 %) were men, and the median age was 60 years [range 35-79 years]. Twenty-nine primary tumors (97 %) were confirmed; 18 (62 %) and 10 (34 %) in the lingual- and palatine tonsils, respectively, and one (3 %) in the posterior oropharynx. Transoral US had a significantly higher sensitivity than panendoscopy to locate the primary tumor (93 % vs 76 %, p = 0.02), and significantly higher than pre-operative PET/CT (62 %, p = 0.002), CT (45 %, p < 0.001), and MRI (28 %, p < 0.001).

CONCLUSIONS

Intraoperative transoral US during panendoscopy is a promising diagnostic tool that may improve the detection of HPV-positive SCCUP.

Transoral Ultrasound in the Outpatient Clinic for the Diagnostic Work-Up of Oropharyngeal Cancer: A Feasibility Study

Magnetic resonance imaging (MRI) is the preferred imaging modality for oropharyngeal cancers (OPCs), but it has difficulties distinguishing between small OPCs and unilateral tonsil hypertrophy. We hypothesized that surgeon-performed transoral ultrasound (US) could be used to accurately detect T-stage OPCs. We performed a single-center prospective diagnostic accuracy study including patients with suspected or biopsy-verified OPCs during outpatient appointments. All patients were offered transoral US and MRI. If transoral US could not be tolerated by the patient, transcervical US was performed. The primary outcome was the diagnostic accuracy of detecting OPCs with US compared to MRI, using histopathology as the reference standard. The secondary outcome was comparing the primary tumor diameters between US and MRI blinded to each other. Out of the 26 patients included in the study, 21 (81%) had OPCs. Transoral US could be performed in 21/21 and 1/5 patients with suspected palatine and lingual tonsil OPCs, respectively. Overall, US diagnostic accuracy was 92%, compared to 81% with MRI (p = 0.37). US and MRI had a high correlation between tumor diameters in the anteroposterior diameter (R = 0.80, p < 0.001), corresponding to the depth axis on US. In conclusion, this small study showed the promise and feasibility of transoral US to improve the initial clinical evaluations of patients with suspected OPCs.

Is 2045 the best we can do? Mitigating the HPV-related oropharyngeal cancer epidemic

INTRODUCTION

Oropharyngeal cancer (OPC) will be among the most common cancers in men by 2045 due to a rapid rise in human papillomavirus (HPV)-related OPC. Those who survive their cancer often suffer life-long treatment effects and early death. HPV vaccination could prevent virtually all HPV-related cancers but is not an effective preventive strategy for those already exposed. Without a dramatic increase in vaccine uptake in the U.S., HPV vaccination will have a negligible effect on OPC incidence through 2045 and no substantial impact until 2060. Additionally, targeted screening for earlier diagnosis may soon be feasible for those inadequately protected by vaccination.

AREAS COVERED

PubMed search for English-language articles related to incidence, screening, and prevention of HPV-related malignancies, focused on OPC in the U.S.

EXPERT OPINION

HPV-related OPC incidence will continue to increase for the foreseeable future with prophylactic vaccination offering no substantial public health impact for decades. Consequently, we must rapidly increase vaccination rates and develop screening methods to identify high-risk individuals. Such individuals would be eligible for potential preventive treatments and screening to diagnose early-stage HPV-related OPC allowing less morbid treatments. These methods will bridge the population into an era of decreasing incidence after vaccination takes effect.

Coexistence of thyroglossal duct cyst and second branchial cleft cyst in a young woman: A case report and literature review

Introduction

Thyroglossal cysts represent 70% of congenital neck anomalies, and second branchial cleft anomalies are the most common anomalies (90%) of the branchial apparatus. However, their coexistence, especially in adults, is very rare.

Presentation of case

A 23-year-old woman presented with a 1-year history of lateral left neck swelling and midline swelling. Imaging and histopathological examination confirmed the diagnosis of a thyroglossal duct cyst and a second branchial cleft cyst. The Sistrunk procedure was performed for surgical excision of the masses.

Discussion

Only three cases of a coexisting thyroglossal duct cyst and branchial cleft have been reported.

Conclusion

When encountering patients, even adults, with neck lesions, clinicians must keep in mind the possibility of a coexistence of a thyroglossal duct and a branchial cleft cyst.

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Thyroglossal cysts represent 70% of congenital neck anomalies.

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Second branchial cleft anomalies are the most common branchial apparatus anomalies.

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Only three cases of coexisting thyroglossal duct and branchial cleft cysts have been reported.

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We present a rare case of a young woman with the two cysts coexisting.

Correlation between radiographic and pathologic lymph node involvement and extranodal extension via CT and PET in HPV-associated oropharyngeal cancer

PURPOSE/OBJECTIVES

Extranodal extension (ENE) and more than 4 pathologically involved lymph nodes (pN2) are critical prognostic factors in HPV-associated oropharyngeal cancer (HPV(+) OPSCC). We analyze a patient cohort with HPV(+) OPSCC to determine the sensitivity and specificity of CT and PET/CT in identifying involvement of more than 4 lymph nodes (rN2) compared to pN2 and radiographic ENE (rENE) compared to pathologic ENE (pENE).

MATERIALS/METHODS

The dataset consisted of 261 patients enrolled in two prospective clinical trials. All imaging studies were independently reviewed by a blinded neuroradiologist, classifying the presence or absence of rENE and rN2. Secondary analyses included correlations of imaging accuracy and pathologic size of the primary tumor.

RESULTS

CT demonstrated sensitivity of 59%, specificity of 92%, positive predictive value (PPV) of 53%, negative predictive value (NPV) of 94%, and accuracy of 88% for pN2. PET/CT showed similar results. Patients with up to 4 involved lymph nodes (rN0-1) had a 93-94% chance of remaining pN0-1. CT and PET/CT identified an equal number of involved nodes in 81% of patients. CT demonstrated sensitivity of 54%, specificity of 71%, PPV of 72%, NPV of 53%, and accuracy of 62% for pENE. PET/CT showed similar outcomes. Notably, when multiple radiographic criteria were used to identify rENE, PPV increased for both CT (84%) and PET/CT (79%).

CONCLUSION

Patients with rN0-1 had a 93-94% chance of remaining pN0-1, suggesting rN0-1 could effectively stratify patients for clinical trials and treatment de-escalation. While CT and PET/CT were highly correlated, both showed low sensitivity for identifying pENE.

Inclusion of an E7 DNA Amplification Test Improves the Robustness of Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma Diagnosis

Background

The rise in human papillomavirus (HPV) infection rates over the last few decades in the USA has contributed to a significant increase in the overall incidence of patients diagnosed with squamous cell carcinoma of the head and neck. These head and neck carcinomas develop in the oropharynx, with more than 90% of them caused by infection with high-risk HPV type 16. Patients diagnosed with HPV-induced oropharyngeal squamous cell carcinomas (OPSCCs) have a better prognosis and treatment response than those diagnosed with head and neck cancers caused by alcohol consumption and tobacco use. To identify patients with HPV-positive OPSCC, new guidelines recommend positive staining of oropharyngeal tissues for p16 INK4a (p16) by immunohistochemistry (IHC). Herein we discuss the testing algorithm that was adopted to address discrepant results between p16 IHC and a DNA in situ hybridization (ISH) test used routinely to diagnose HPV-positive OPSCC patients.

Methods

A DNA polymerase chain reaction (PCR) test that amplifies HPV16 and HPV18 E7 was developed to aid in the diagnosis of HPV-positive OPSCC in a subset of patients. Specimens from these patients stained positive for p16 by an IHC test, but negative for high-risk HPV by a commercial DNA ISH test. Moreover, these results did not match the histopathological characteristics of the specimens, nor the clinical presentations of the patients.

Results

Of 21 patients’ specimens that were tested for p16 by IHC, 11 specimens showed concordant results with the high-risk HPV 16/18 DNA ISH test. Whereas, in eight p16 IHC positive specimens, HPV viral DNA was not detected by HPV16/18 DNA ISH, and two specimens were not tested by DNA ISH. When these eight p16 IHC positive specimens with discrepant p16 IHC and DNA ISH results were further tested by DNA PCR, six specimens showed concordance with p16 IHC with positive results for HPV16 E7, while two specimens were negative for HPV16 E7 by DNA PCR. All tested specimens were negative for HPV18 E7 by DNA PCR. Thus, the addition of the HPV16 and HPV18 E7 DNA PCR test identified a significant number of false negative test results by the HPV16/18 DNA ISH test and likely several false positive results by p16 IHC.

Conclusions

Inclusion of an HPV16 E7 DNA PCR test improved the robustness of HPV-associated OPSCC diagnosis in patients with discrepant results from p16 IHC staining and a DNA ISH test, and identified patients for proper management with less misclassification.

Discrimination of HPV status using CT texture analysis: tumour heterogeneity in oropharyngeal squamous cell carcinomas

PURPOSE

To evaluate the diagnostic performance of texture analysis for discriminating human papillomavirus (HPV) status in patients with oropharyngeal squamous cell carcinoma (OPSCC) in the primary tumours and metastatic lymph nodes.

METHODS

Ninety-five patients with primary tumour and 91 with metastatic lymph nodes with confirmed HPV status, who underwent pretreatment contrast-enhanced CT (CECT), were included as the discovery population. CT texture analysis was performed using commercially available software. Differences between HPV-positive and HPV-negative groups were analysed using the χ² test (or Mann-Whitney U test) and independent t test (or Fisher's exact test). ROC curve analysis was performed to discriminate HPV status according to heterogeneity parameters. Diagnostic accuracy was evaluated in the separate validation population (n = 36) from an outside hospital.

RESULTS

HPV positivity was 52.6% for primary tumours and 56.0% for metastatic lymph nodes. The entropy and standard deviation (SD) values in the HPV-positive group were significantly lower. Entropy using the medium filter was the best discriminator between HPV-positive and HPV-negative primary OPSCCs (AUC, 0.85) and SD without the filter for metastatic lymph nodes (AUC, 0.82). Diagnostic accuracy of entropy for the primary tumour was 80.0% in the discovery group and 75.0% in the validation group. In cases of metastatic lymph node, the accuracy of SD was 79.1% and 78.8%, respectively.

CONCLUSION

Significant differences were found in heterogeneity parameters from texture analysis of pretreatment CECT, according to HPV status. Texture analysis could be used as an adjunctive tool for diagnosis of HPV status in clinical practice.

Expression of human papillomavirus oncoproteins E6 and E7 inhibits invadopodia activity but promotes cell migration in HPV-positive head and neck squamous cell carcinoma cells

Background

The rapid increase in the incidence of head and neck squamous cell carcinoma (HNSCC) is caused by high‐risk human papillomavirus (HPV) infections. The HPV oncogenes E6 and E7 promote carcinogenesis by disrupting signaling pathways that control survival and proliferation. Although these cancers are often diagnosed with metastases, the mechanisms that regulate their dissemination are unknown.

Aims

The aim of this study was to determine whether the HPV‐16 E6 and E7 oncogenes affected the invasive and migratory properties of HNSCC cells which promote their spread and metastasis.

Methods and results

Invasiveness was determined using invadopodia assays which allow for quantitation of extracellular matrix (ECM) degradation by invadopodia which are proteolytic membrane protrusions that facilitate invasion. Using cell lines and genetic manipulations, we found that HPV inhibited invadopodia activity in aggressive cell lines which was mediated by the E6 and E7 oncogenes. Given these findings, we also tested whether HPV caused differences in the migratory ability of HNSCC cells using Transwell assays. In contrast to our invadopodia results, we found no correlation between HPV status and cell migration; however, blocking the expression of the E6 and E7 oncoproteins in a HPV‐positive (HPV⁺) HNSCC cell line resulted in decreased migration.

Conclusions

Our data suggest that the E6 and E7 oncoproteins are negative regulators of invadopodia activity but may promote migration in HPV⁺ HNSCC cells. Despite the need for ECM proteolysis to penetrate most tissues, the unique structure of the head and neck tissues in which these cancers arise may facilitate the spread of migratory cancer cells without significant proteolytic ability.

Comparison between squamous cell carcinoma and inflammatory diseases of the oral and maxillofacial region using gallium-67 scintigraphy with computed tomography and magnetic resonance imaging

Purpose

This study aimed to compare squamous cell carcinoma (SCC) with inflammatory diseases of the oral and maxillofacial region using gallium 67 (⁶⁷Ga) scintigraphy with computed tomography (CT) and magnetic resonance imaging (MRI).

Material and methods

Seventy patients with SCC and 15 patients with inflammatory diseases of the oral and maxillofacial region underwent ⁶⁷Ga scintigraphy with CT and MRI. A comparison between imaging features of ⁶⁷Ga scintigraphy, CT, and MRI and lesions was performed with the Pearson’s chi-squared test.

Results

⁶⁷Ga scintigraphy was positive for 25 of 39 patients with SCC positive on CT and/or MRI (64.1%) and for 13 of 15 patients with inflammatory diseases positive on CT and/or MRI (86.7%). The detection of inflammatory diseases with ⁶⁷Ga scintigraphy was higher than that of SCC (p = 0.104).

Conclusions

This study compared SCC with inflammatory diseases of the oral and maxillofacial region using ⁶⁷Ga scintigraphy with CT and MRI. ⁶⁷Ga scintigraphy is an effective technique for detection of inflammatory diseases of the oral and maxillofacial region.

Reader performance in the ultrasonographic evaluation of oropharyngeal carcinoma

OBJECTIVE

To examine reader performance in evaluating oropharyngeal anatomy on ultrasonography.

MATERIALS AND METHODS

Ultrasound images of the oropharynx comprising normal and malignant anatomic variants were organized into slideshows. Slideshows were administered to 6 readers blinded to participant tumor status and with varying experience reading oropharyngeal sonograms. A training slideshow oriented readers to images of the oropharynx with and without malignant lesions. Readers then evaluated images in a test slideshow for tumor presence and marked orthogonal long and short dimensions of the tumor. Results were analyzed for accuracy, sensitivity, specificity, inter-reader agreement, and measurement error relative to prospectively-identified reference measurements.

RESULTS

Eighty-seven percent of base of tongue (BOT) sonograms were identified correctly by a majority of readers. In identifying BOT tumors, median accuracy, sensitivity, specificity, and Fleiss's kappa were 79%, 73%, 85%, and 0.51, respectively. Median measurement error in the long and short axes for BOT tumors was -2.6% (range: -40% to 29%) and -2.6% (range: -56% to 156%), respectively. Eighty-four percent of palatine tonsil sonograms were identified correctly by a majority of readers. In identifying tonsil tumors, median accuracy, sensitivity, specificity, and Fleiss's kappa were 77%, 74%, 78%, and 0.41, respectively. Median measurement error in the long and short axes for tonsil tumors was 3.8% (range: -45% to 32%) and -6.5% (range: -83% to 42%), respectively.

CONCLUSIONS

Overall, US has clinically useful sensitivity for identification of oropharyngeal carcinoma among readers of diverse clinical backgrounds and experience. US may be useful for the evaluation of features such as tumor dimensions.

Unusually rapid development of a lateral neck mass: Diagnosis and treatment of a branchial cleft cyst. A case report

Introduction

Branchial cleft cysts are benign lesions caused by anomalous development of the branchial cleft. Cases that arise in the lateral neck region are often misdiagnosed, resulting initially in inappropriate management.

Case presentation

We describe a 32-year-old woman with a swelling on the right side of her neck and no pain during palpation or neck motion.

Discussion

The patient was evaluated using fine-needle aspiration cytology (FNAC), ultrasound, and magnetic resonance imaging (MRI) scans. The MRI showed a right-sided cervical mass with hyperintense content, well-defined margins, and no evidence of infiltration into surrounding structures, while FNAC found a yellow, pus-like fluid, keratinised anuclear cells, squamous epithelium, and a matrix of amorphous debris.

Conclusion

Based on the images and the patient's symptoms, a surgical intervention was performed.

The true malignancy rate in 135 patients with preoperative diagnosis of a lateral neck cyst

Objective

In this study, the true malignancy rate in 135 patients with a preoperative tentative diagnosis of a lateral neck cyst (LNC) was assessed. Furthermore, the sensitivity and specificity of fine needle aspiration of suspected LNC were evaluated and the diagnostic delay was analyzed.

Study Design

This study was retrospective in design and included all patients who had undergone surgery for a suspected LNC in four secondary hospitals in the eastern regions of Denmark during the period of 2009 to 2012.

Methods

One hundred thirty‐five patients were identified and included by means of a search strategy for NOMECO surgical procedure codes KENB40A+B in the electronic surgical booking systems. Because the procedure codes also include median neck cysts and fistulas, the latter were excluded manually.

Results

Of the 135 patients preoperatively diagnosed with LNC, a malignant postoperative histopathological diagnosis was revealed in 19 patients (14.4%). Of these, three individuals were between 35 to 40 years of age. In 17 cases, preoperative fine‐needle aspiration biopsy showed benign cytology, whereas histopathology postoperatively proved to be malignant. This renders a sensitivity of 88.8% and a specificity of 60.0% for fine needle aspiration biopsy with regard to LNC diagnostics.

Conclusion

This study suggests that, for patients older than 35 years, a cystic lateral neck mass should be considered potentially malignant; by contrast, LNC is a diagnosis of exclusion. Any delay in treatment should be avoided until final histopathological diagnosis has been obtained. Arguably, all patients older than 35 years with a cystic lesion laterally on the neck should be included in the fast‐track cancer referral program.

Level of Evidence

2b.

Visualization of the Oropharynx With Transcervical Ultrasound

OBJECTIVE

The purposes of this article are to illustrate the sonographic appearance of the oropharynx and to discuss the potential role of ultrasound in evaluation of the oropharynx.

CONCLUSION

Ultrasound is not currently used in the standard clinical evaluation of the oropharynx, but it is a promising imaging modality for evaluating the base of the tongue and the palatine tonsils. Ultrasound is comparable and complementary to CT and MRI, which have recognized limitations.

Characteristics and Limitations of FDG PET/CT for Imaging of Squamous Cell Carcinoma of the Head and Neck: A Comprehensive Review of Anatomy, Metastatic Pathways, and Image Findings

OBJECTIVE

This image-based article illustrates the anatomic regions of squamous cell carcinomas of the head and neck and describes the metastatic pathways in and TNM staging for each region. Both the role and limitations of FDG PET/CT in imaging such cancers are discussed, and cases exemplifying these issues are reported. Also included is a discussion of the use of FDG PET/CT to monitor the response of squamous cell carcinomas of the head and neck to therapy, in addition to a brief comparison of PET/CT with such traditional imaging modalities as CT, MRI, and ultrasound.

CONCLUSION

Understanding the characteristics of squamous cell carcinoma of the head and neck, as imaged by FDG PET/CT, is crucial for determining treatment strategy, because it helps to avoid incorrect staging and also provides an accurate assessment of treatment response.

Correlation of PET-CT nodal SUVmax with p16 positivity in oropharyngeal squamous cell carcinoma

Background

The incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) has been rising in recent years. Given the clinical impact of HPV/p16 positivity in OPSCC, identifying surrogate markers of this disease early in the diagnostic work-up of these patients could improve patient care.

Methods

Demographic, pathologic, staging and PET-CT data from patients diagnosed with OPSCC from 2009–2014 were obtained from a prospectively collected provincial cancer registry. Tumor HPV/p16 status was correlated to the maximum standard uptake value (SUVmax) of the primary tumor and cervical nodes. Comparisons of means and multinomial regression models were used to determine associations between p16 status and SUVmax. A diagnostic odds ratio was calculated using a cut off value for predicting HPV/p16 positivity based on nodal SUVmax.

Results

PET-CT and HPV/p16 data was obtained for 65 patients treated surgically for OPSCC. Significantly higher nodal SUVmax was associated with HPV/p16 positive nodes (SUVmax 10.8 vs 7.9). No significant differences were seen between HPV/p16 positive vs negative primary tumor SUVmax (10.3 vs 13.7). In combination with other clinical parameters, higher nodal SUVmax was highly correlated with HPV/p16 positivity.

Conclusion

Elevated nodal SUVmax is a significant predictor of HPV/p16 positive disease.

The "new" head and neck cancer patient-young, nonsmoker, nondrinker, and HPV positive: evaluation

OBJECTIVE

The near epidemic rise of the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC) presents the practitioner with a "new" head and neck cancer patient, vastly different from those with the traditional risk factors who formed the basis of most practitioners' training experience. Accordingly, a thorough and disease-specific evaluation process is necessitated. This article will review the evaluation of the HPV-related cancer patient, including a review of the HPV-positive oropharyngeal cancer epidemic from the surgeon's perspective, evaluation of the primary lesion, evaluation of the neck mass, and role of imaging, to provide a framework for addressing the challenging questions patients may ask.

DATA SOURCES

Available peer-reviewed literature and practice guidelines.

REVIEW METHODS

Assessment of selected specific topics by authors solicited from the Head and Neck Surgery and Oncology Committee of the American Academy of Otolaryngology-Head and Neck Surgery Foundation and the American Head and Neck Society.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The dramatic rise in OPSSC related to HPV is characterized by a "new" cancer patient who is younger and lacks traditional risk factors. Today's caregiver must be prepared to appropriately evaluate, counsel, and treat these patients with HPV-positive disease with the expectation that traditional treatment algorithms will evolve to maintain or improve current excellent cure rates while lessening treatment related side effects.

The "new" head and neck cancer patient-young, nonsmoker, nondrinker, and HPV positive: evaluation

OBJECTIVE

The near epidemic rise of the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC) presents the practitioner with a "new" head and neck cancer patient, vastly different from those with the traditional risk factors who formed the basis of most practitioners' training experience. Accordingly, a thorough and disease-specific evaluation process is necessitated. This article will review the evaluation of the HPV-related cancer patient, including a review of the HPV-positive oropharyngeal cancer epidemic from the surgeon's perspective, evaluation of the primary lesion, evaluation of the neck mass, and role of imaging, to provide a framework for addressing the challenging questions patients may ask.

DATA SOURCES

Available peer-reviewed literature and practice guidelines.

REVIEW METHODS

Assessment of selected specific topics by authors solicited from the Head and Neck Surgery and Oncology Committee of the American Academy of Otolaryngology-Head and Neck Surgery Foundation and the American Head and Neck Society.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The dramatic rise in OPSSC related to HPV is characterized by a "new" cancer patient who is younger and lacks traditional risk factors. Today's caregiver must be prepared to appropriately evaluate, counsel, and treat these patients with HPV-positive disease with the expectation that traditional treatment algorithms will evolve to maintain or improve current excellent cure rates while lessening treatment related side effects.

Epidemiology of HPV-associated oropharyngeal cancer

Squamous cell carcinoma of the oropharynx is increasing in incidence in epidemic proportion. This site specific increase in incidence is due to an increase in human papillomavirus (HPV)-related squamous cell carcinoma, while the incidence of tobacco related squamous cell carcinoma is decreasing. In particular, the incidence of HPV-related oropharyngeal squamous cell carcinoma (OPSCC) is increased among middle aged white men, and sexual behavior is a risk factor. HPV-related oropharyngeal squamous cell carcinoma represents a growing etiologically distinct subset of head and neck cancers with unique epidemiological, clinical, and molecular characteristics that differ from those of HPV-unassociated cancers. In this review, we discuss the epidemiology of HPV-related OPSCC, the prevalence of oral/oropharyngeal HPV infection, and efforts aimed at reducing the incidence of HPV-related OPSCC.

Human papillomavirus-related oropharyngeal cancer: HPV and p16 status in the recurrent versus parent tumor

BACKGROUND

Although typically associated with a favorable prognosis, a minority of human papillomavirus (HPV)-related (+) oropharyngeal cancers recur after chemoradiation. We postulated that a minor HPV-negative tumor subfraction may be responsible for recurrences of HPV+ oropharyngeal cancer.

METHODS

Paired untreated primary and recurrent tumor specimens were identified for 37 patients with oropharyngeal cancer who received definitive chemoradiotherapy at our institution. Concordance in HPV/p16 expression between primary and recurrent tumors was assessed.

RESULTS

Among 31 patients with HPV+/p16+ primary tumors, 30 (97%) retained evidence of both HPV and p16 expression at recurrence (27 HPV+/p16+; 3 HPV+/p16-partial). One (3%) initially HPV+/p16+ patient developed an HPV-negative/p16-negative lung squamous cell carcinoma (SCC), representing either a discordant oropharyngeal cancer metastasis or second primary tumor.

CONCLUSION

HPV-related oropharyngeal cancers retain HPV+/p16+ expression at recurrence. Our results fail to provide evidence that a minor HPV-negative tumor subfraction is responsible for biologically aggressive behavior of HPV+ oropharyngeal cancer that recurs after chemoradiation.

Transcervical ultrasonography is feasible to visualize and evaluate base of tongue cancers

Background

Base of tongue (BOT) is a difficult subsite to examine clinically and radiographically. Yet, anatomic delineation of the primary tumor site, its extension to adjacent sites or across midline, and endophytic vs. exophytic extent are important characteristics for staging and treatment planning. We hypothesized that ultrasound could be used to visualize and describe BOT tumors.

Methods

Transcervical ultrasound was performed using a standardized protocol in cases and controls. Cases had suspected or confirmed BOT malignancy. Controls were healthy individuals without known malignancy.

Results

100% of BOT tumors were visualized. On ultrasound BOT tumors were hypoechoic (90.9%) with irregular margins (95.5%). Ultrasound could be used to characterize adjacent site involvement, midline extent, and endophytic extent, and visualize the lingual artery. No tumors were suspected for controls.

Conclusions

Ultrasonography can be used to transcervically visualize BOT tumors and provides clinically relevant characteristics that may not otherwise be appreciable.

The clinical impact of HPV tumor status upon head and neck squamous cell carcinomas

Human papillomavirus (HPV) is etiologically responsible for a distinct subset of head and neck squamous cell cancers (HNSCCs). HPV-positive HNSCCs (HPV-HNSCCs) most commonly arise from the oropharynx and are responsible for the increasing incidence of oropharyngeal SCC (OSCC) in the United States (US) and abroad. HPV-positive OSCC (HPV-OSCC) has a unique demographic and risk factor profile and tumor biology. HPV-OSCC patients tend to be white, younger, and have a higher cumulative exposure to sexual behaviors as compared with HPV-negative OSCC patients. HPV-positive tumor status also significantly improves survival, and is indeed the single strongest prognostic factor for OSCC. The mechanisms that underlie the improved prognosis conferred by HPV-positive disease are unknown. The purpose of this review is to describe the clinical impact of HPV status in HNSCC, particularly in OSCC, both in terms of the unique clinic-demographic profile and prognostic implications.

Use of quantitative diffusion-weighted magnetic resonance imaging to predict human papilloma virus status in patients with oropharyngeal squamous cell carcinoma

Although identification of human papilloma virus (HPV) status in oropharyngeal squamous cell carcinoma (OPSCC) is essential in predicting treatment response, no imaging modality can currently determine whether a tumor is HPV-related. In this retrospective study, 26 patients with OPSCC confined to the lateral wall or the base of tongue underwent neck magnetic resonance imaging, using T1-, T2- and diffusion-weighted imaging (DWI). Apparent diffusion coefficients (ADCs) in a region of interest covering the largest available primary tumor area of OPSCC on a single slice of the ADC map were calculated using two b values (0 and 1,000 s/mm(2)). Mean and minimum ADCs were compared with HPV status, using p16 immunohistochemistry as a surrogate marker for HPV infection. Mean and minimum ADCs for HPV(+) OPSCC were significantly lower than those for HPV(-) OPSCC. A cut-off value of mean ADC for HPV(+) OPSCC of 1.027 × 10(-3) mm(2)/s yielded sensitivity and specificity of 83.33 and 78.57%, respectively. In conclusion, the present study indicates that ADC could be used to predict HPV status in patients with OPSCC.

New insights into human papillomavirus-associated head and neck squamous cell carcinoma

Human papillomavirus (HPV)-associated head and neck squamous cell carcinoma (HNSCC) is an entity with peculiar clinical and molecular characteristics, which mainly arises from the reticulated epithelium lining the crypts of the palatine tonsils and the base of the tongue. The only head and neck site with a definite etiological association between persistent high-risk (HR) HPV infection and development of SCC is the oropharynx. HPV-positive malignancies represent 5-20% of all HNSCCs and 40-90% of those arising from the oropharynx, with widely variable rates depending on the geographic area, population, relative prevalence of environment-related SCC and detection assay. HPV-16 is by far the most common HR HPV genotype detected in oropharyngeal SCC (OPSCC), and the only definitely carcinogenic genotype for the head and neck region. Patients with HPV-induced OPSCC are more likely to be middle-aged white men, non-smokers, non-drinkers or mild to moderate drinkers, with higher socioeconomic status and better performance status than subjects with HPV-unrelated SCC. HPV-induced HNSCCs are often described as non-keratinizing, poorly differentiated or basaloid carcinomas, and are diagnosed in earlier T-category with a trend for a more advanced N-category, with cystic degeneration, than the HPV-unrelated carcinomas. HPV positivity is associated with better response to treatment and modality-independent survival benefit. Treatment selection in HPV-related oropharyngeal carcinoma is becoming a critical issue, and although there is no evidence from randomized, controlled trials to support a treatment de-escalation in HPV-positive SCC, some investigators argue that intensive combined modality strategies may represent an overtreatment.