Use of in situ hybridization for HPV in head and neck tumors: experience from a national reference laboratory

HPV-related head and neck cancers: Pathology and biology

Discovering the key role HPV plays in head and neck carcinogenesis has revolutionized our approach to cancers such as oropharyngeal carcinomas. As the role of HPV expands beyond the oropharynx, there is a pursued need to understand the oncogenic mechanisms of HPV-driven tumorigenesis and their implications. Optimizing HPV detection methods all while acknowledging their limitations will ensure our ability to diagnose HPV-driven neoplasia wherever clinically relevant.

Prevalence of oropharyngeal high-risk human papillomavirus in tumor-free tonsil tissue in adults

PURPOSE

To determine the prevalence of oropharyngeal high-risk human papillomavirus (HPV) in patients undergoing tonsillectomy by detection of high-risk HPV in tonsil tissues using the in situ hybridization (ISH) technique.

MATERIALS AND METHODS

The patients who underwent tonsillectomy between 2014 and 2018 were examined retrospectively. The pediatric cases and patients who underwent tonsillectomy due to malignancy were excluded. The study included 270 adult cases selected by age and gender randomization. The tonsillar tissue of each case was re-examined by the pathology department, and the presence of high-risk HPV was investigated via the ISH technique. Multiple logistic regression models were used for predictions of different factors.

RESULTS

The prevalence of high-risk HPV in the 270 patients (male: 154 [57%]; female: 116 [43%]; mean age: 36.44 ± 12.87 years) was found to be 6.7% (n = 18). The prevalence was found 8.4% in men and 4.3% in women; 8.9% in cases under the age of 40 and 2.9% in cases over the age of 40; and 10.9% in patients who underwent tonsillectomy for infectious indications and 2.3% for non-infectious indications. Multivariate analysis identified that the infectious indications for tonsillectomy were significantly associated with high-risk HPV positivity (OR 5.328; p = 0.009).

CONCLUSIONS

The prevalence of oropharyngeal high-risk HPV was found to be 6.7% and higher in younger people and men. Additionally, the HPV positivity was found to be higher in patients who underwent tonsillectomy for infectious indications. To our knowledge, this is the first study that reports the correlation between recurrent tonsil infections and HPV positivity in tonsil tissue.

Prognostic role of human papilloma virus status in hypopharyngeal squamous cell carcinoma

OBJECTIVE

Although the prognostic role of human papilloma virus (HPV) status in oropharyngeal head and neck squamous cell carcinoma (SCC) is well established, growing evidence shows that there may be a prognostic role for HPV status in hypopharyngeal SCC. The objective of this study was to determine the prognostic role of HPV status in hypopharyngeal SCC.

METHODS

We performed a retrospective, population-based analysis of 1934 adult patients with HNSCC diagnosed between 2010-2016 and treated with a combination of surgery and/or radiotherapy, with or without chemotherapy, and a subset of 641 patients with hypopharyngeal SCC and known HPV status included in the Surveillance, Epidemiology, and End Results (SEER) Head and Neck with HPV Status Database. Patient data were used to determine the adjusted 2-year cancer-specific survival (CSS) and overall survival (OS) for the entire cohort and the specific subgroup of hypopharyngeal cancer patients with known HPV status.

RESULTS

Of the 1934 hypopharynx SCC cases, HPV status was unknown in 1294 (66.9%), and 167 (8.6%) were HPV positive; among hypopharynx cases with known HPV status, 21.6% were HPV positive. In models adjusting for sex, age, race/ethnicity, marital status and stage, patients with HPV-positive hypopharyngeal tumors had improved CSS compared with patients with HPV-negative tumors (CSS: HR: .57, 95% CI = .38 to .86, P = .008; OS: HR: .49, 95% CI = .34 to .71, P = <.001).

CONCLUSION

Our findings in a large cohort of hypopharyngeal SCC with known HPV status and cancer-specific survival support the hypothesis that HPV has a prognostic role in hypopharyngeal cancer. Consideration should be given to increased testing for HPV in hypopharyngeal SCC.

LEVEL OF EVIDENCE

4.

Prevalence of human papilloma virus in oropharyngeal, tongue and lip squamous cell carcinoma: an experience from the Egyptian National Cancer Institute

Human papilloma virus (HPV) is now a well-known risk factor for head and neck cancer besides smoking and alcohol. Most studies mentioned that patients affected with high-risk HPV cancers have a better outcome, and many clinical trials are trying to prove that such group of patients can receive a different and less aggressive treatment than the HPV-negative group. Although such field has received great interest within different countries and continents, African and Egyptian populations are not yet well studied within the literature. Our aim was to detect the prevalence of HPV in oropharyngeal (OP), lip and tongue squamous cell carcinoma (SSC) and correlate the viral prevalence with different clinicopathologic parameters as well as patients' outcome. HPV detection was done on 99 cases from the lip (29), tongue (38) and oropharynx (32) diagnosed at the Pathology Department of the National Cancer Institute, Cairo University. p16 immunohistochemistry was performed on all cases, followed by HPV DNA in situ hybridization (ISH) for p16-positive cases. The prevalence of HPV in OPSSC was 28% and in lip and tongue cancers lumped together was 37%. There was more than 90% concordance between p16 and HPV DNA ISH results. HPV positivity showed a statistically significant correlation with better disease-free survival (DFS), which was also maintained for OP cases. HPV is highly prevalent in OP and common oral cavity cancers in the Egyptian population. HPV positivity correlated significantly with better DFS, especially in OP cancers.

Comprehensive analysis of HPV infection, EGFR exon 20 mutations and LINE1 hypomethylation as risk factors for malignant transformation of sinonasal-inverted papilloma to squamous cell carcinoma

Different risk factors are suspected to be involved in malignant transformation of sinonasal papillomas and include HPV infection, tobacco smoking, occupational exposure, EGFR/KRAS mutations and DNA methylation alterations. In our study, 25 inverted sinonasal papillomas (ISPs), 5 oncocytic sinonasal papillomas (OSP) and 35 squamous cell carcinomas (SCCs) from 54 patients were genotyped for 10 genes involved in EGFR signalling. HPV-DNA detection was performed by in-situ hybridisation and LINE-1 methylation was quantitatively determined by bisulphite-pyrosequencing. High-risk HPV was observed only in 13% of ISP-associated SCC and in 8% of de novo-SCC patients. EGFR mutations occurred in 72% of ISPs, 30% of ISP-associated SCCs and 17% of de novo-SCCs. At 5-year follow-up, SCC arose in only 30% (6/20) of patients with EGFR-mutated ISPs compared to 76% (13/17) of patients with EGFR-wild-type ISP (p = 0.0044). LINE-1 hypomethylation significantly increased from papilloma/early stage SCC to advanced stage SCC (p = 0.03) and was associated with occupational exposure (p = 0.01) and worse prognosis (p = 0.09). In conclusion, our results suggest that a small subset of these tumours could be related to HPV infection; EGFR mutations characterise those ISPs with a lower risk of developing into SCC; LINE-1 hypomethylation is associated with occupational exposure and could identify more aggressive nasal SCC.

Human papillomavirus infection in patients with laryngeal carcinoma

BACKGROUND

The aim of this study was to determine the HPV positivity rate in patients with laryngeal cancer, and to determine the effect of HPV positivity on survival. An additional aim was to determine if patients with HPV positive laryngeal cancer are more sensitive to chemotherapy and if such sensitivity differs according to chemotherapy protocol.

METHODS

The study included laryngeal specimens obtained from 82 laryngeal cancer patients and 11 laryngeal specimens with normal laryngeal mucosa that were obtained from our hospital's paraffin block archives between 1995 and 2013. HPV was detected via chromogenic in situ hybridization (cISH) and confirmed via genotyping.

RESULTS

HPV was not detected in any of the 82 laryngeal cancer patients' laryngeal specimens, nor in any of the 11 archived laryngeal specimens with normal laryngeal mucosa via cISH. Genotyping confirmed these findings; none of the HPV types studied were detected in any of the specimens. As none of the study samples were HPV positive, it was not possible to compare survival, recurrence, or chemotherapy sensitivity.

CONCLUSIONS

HPV infection is not a leading cause of laryngeal cancer; however, additional research on HPV positivity in patients with laryngeal cancer and its effect on recurrence, survival, and chemotherapy sensitivity is warranted.

Head and Neck Cytopathology: Human Papillomavirus-Positive Carcinomas, Including Diagnostic Updates, Testing Modalities, and Recommendations

Oropharyngeal squamous cell carcinoma caused by transcriptionally active human papillomavirus (HPV) is now well established as a unique form of head and neck cancer. Given the high frequency of metastasis to cervical lymph nodes by HPV-positive oropharyngeal squamous cell carcinomas, fine-needle aspiration (FNA) represents a widely accepted method for the sampling and diagnosis of these cancers. The recently published College of American Pathologists Guideline (2017) provides recommendations for the effective performance and interpretation of high-risk (HR) HPV testing in head and neck squamous cell carcinoma (HNSCC), including testing on FNA samples of metastatic HNSCC to cervical lymph nodes. There is a wide range of options available for HR-HPV testing in cytologic specimens.

Human Papillomavirus Testing in Head and Neck Carcinomas: Guideline From the College of American Pathologists

Context Human papillomavirus (HPV) is a major cause of oropharyngeal squamous cell carcinomas, and HPV (and/or surrogate marker p16) status has emerged as a prognostic marker that significantly impacts clinical management. There is no current consensus on when to test oropharyngeal squamous cell carcinomas for HPV/p16 or on which tests to choose. Objective To develop evidence-based recommendations for the testing, application, interpretation, and reporting of HPV and surrogate marker tests in head and neck carcinomas. Design The College of American Pathologists convened a panel of experts in head and neck and molecular pathology, as well as surgical, medical, and radiation oncology, to develop recommendations. A systematic review of the literature was conducted to address 6 key questions. Final recommendations were derived from strength of evidence, open comment period feedback, and expert panel consensus. Results The major recommendations include (1) testing newly diagnosed oropharyngeal squamous cell carcinoma patients for high-risk HPV, either from the primary tumor or from cervical nodal metastases, using p16 immunohistochemistry with a 70% nuclear and cytoplasmic staining cutoff, and (2) not routinely testing nonsquamous oropharyngeal carcinomas or nonoropharyngeal carcinomas for HPV. Pathologists are to report tumors as HPV positive or p16 positive. Guidelines are provided for testing cytologic samples and handling of locoregional and distant recurrence specimens. Conclusions Based on the systematic review and on expert panel consensus, high-risk HPV testing is recommended for all new oropharyngeal squamous cell carcinoma patients, but not routinely recommended for other head and neck carcinomas.

Current and future techniques for human papilloma virus (HPV) testing in oropharyngeal squamous cell carcinoma

Despite a reduction in smoking and alcohol consumption, the incidence of oropharyngeal squamous cell carcinoma (OPSCC) is rising. This is attributed to human papilloma virus (HPV) infection and screening for HPV is now recommended in all cases of OPSCC. Despite a variety of clinically available tests and new non-invasive test strategies there is no consensus on which technique is best. This review reports on current techniques for HPV detection in OPSCC and the clinical applicability of emerging techniques. Literature searches of Medline, Embase and clinicaltrials.gov using the search terms 'head and neck neoplasms', 'squamous cell carcinoma' and 'HPV testing' were performed. 45 studies were identified and included. p16 immunohistochemistry (IHC), HPV DNA in situ hybridization (ISH) and HPV polymerase chain reaction (PCR) are the commonest tests to determine HPV status. p16 IHC and HPV DNA PCR are highly sensitive whilst HPV DNA ISH is more specific, these techniques conventionally utilize surgical biopsies. New tests using PCR to screen fine needle aspirates, saliva, brush cytology and serum for HPV are promising but have variable sensitivity and specificity. These non-invasive samples avoid the morbidity of surgical biopsies and need for tissue blocks; their clinical role in screening and surveillance remains largely untested. Further work is needed to validate these tests and define their role.

The prognostic role of sex, race, and human papillomavirus in oropharyngeal and nonoropharyngeal head and neck squamous cell cancer

BACKGROUND

Human papillomavirus (HPV) is a well-established prognostic marker for oropharyngeal squamous cell cancer (OPSCC). Because of the limited numbers of women and nonwhites in studies to date, sex and racial/ethnic differences in prognosis have not been well explored. In this study, survival differences were explored by the tumor HPV status among 1) patients with OPSCCs by sex and race and 2) patients with nonoropharyngeal (non-OP) head and neck squamous cell cancers (HNSCCs).

METHODS

This retrospective, multi-institution study included OPSCCs and non-OP HNSCCs of the oral cavity, larynx, and nasopharynx diagnosed from 1995 to 2012. Race/ethnicity was categorized as white non-Hispanic, black non-Hispanic, Asian non-Hispanic, and Hispanic of any race. Tumors were centrally tested for p16 overexpression and the presence of HPV by HPV16 DNA and high-risk HPV E6/E7 messenger RNA in situ hybridization. Kaplan-Meier and Cox proportional hazards models were used to evaluate overall survival (OS).

RESULTS

The study population included 239 patients with OPSCC and 621 patients with non-OP HNSCC with a median follow-up time of 3.5 years. After adjustments for the tumor HPV status, age, current tobacco use, and stage, the risk of death was lower for women versus men with OPSCC (adjusted hazard ratio, 0.55; P = .04). The results were similar with p16. In contrast, for non-OP HNSCCs, HPV positivity, p16 positivity, and sex were not associated with OS.

CONCLUSIONS

For OPSCC, there are differences in survival by sex, even after the tumor HPV status has been taken into account. For non-OP HNSCC, the HPV status and the p16 status are not of prognostic significance. Cancer 2017;123:1566-1575. © 2017 American Cancer Society.