Interpretation of HPV DNA in situ hybridization in HPV-related head and neck squamous cell carcinoma: an achievable task in cell block and small biopsy material

Advancement in the Oropharyngeal Primary Unknown Cancer Diagnostic and Current Treatments Pathway: A Narrative Review

Objective: The objective of this article is to define a correct diagnostic pathway for oropharyngeal cancer of unknown primary (OPCUP) identification. Background: OPCUP represents one of the most frequent causes of neck metastases onset without the identification of the primary tumor. Therefore, there is a high percentage of late or missing diagnoses, resulting in treatment delay or in a wrong therapeutic process. The up-to-date diagnostic procedures can help us to begin therapies at the right time. Methods: This is a review of the latest articles about diagnostic pathways in the OPCUP. A selection of the references was carried out in PubMed, EMBASE, Cochrane, and CENTRAL electronic databases. Conclusion: The oropharynx represents the most common site of primary unknown head and neck cancer (HNCUP). Recent epidemiologic data reported an increasing incidence of HNCUP related to human papilloma virus positive squamous cell carcinoma. Positron emission tomography combined with computerized tomography scanning or magnetic resonance imaging allows for improving the detection of primary unknown tumors and distant and locoregional metastases. Finally, the introduction of the trans-oral robotic surgical approach has introduced a new role of surgery in the HNCUP diagnosis and treatment. Hence, the new technological improvement allows reaching in most HNCUP patients an early diagnosis, achieving targeted management and better treatment outcomes, as well as decreasing toxicity and the side effects of treatment options.

Head and Neck Cystic Lesions: A Cytology Review of Common and Uncommon Entities

BACKGROUND

Cystic lesions of the head and neck are a diagnostic challenge since they are seen in the clinical presentation of a wide variety of conditions. Herein, common and uncommon entities that present as cystic lesions in the head and neck are reviewed.

SUMMARY

In this study, peer-reviewed articles were selected using the database PubMed, Google, Google Scholar, and Scopus. Emphasis was placed on peer-reviewed articles that discuss the cytomorphology and differential diagnosis of entities that present as cystic lesions of the head and neck. In the anterior neck, both benign and malignant neoplasms can present, including papillary thyroid carcinoma (PTC), thyroid adenomatoid nodule, parathyroid cysts, and thyroglossal cysts. In the lateral neck, branchial cleft cyst, PTC, ectopic thyroid cyst, and squamous cell carcinomas (human papilloma virus and non- human papilloma virus-related) are common. Age over 40 years raises the possibility of malignancy. In the deep neck, mostly benign cystic entities occur such as a pleomorphic adenoma, paraganglioma, schwannoma, branchial cyst, epidermal inclusion cyst, and lymphoepithelial cyst. Lesions with squamous cell features can pose diagnostic dilemmas.

CONCLUSION

Cytologic examination of head and neck cysts can provide valuable information regarding the nature of the cystic lesions. Information about anatomic site and clinical history can assist with the differential diagnoses. Ancillary studies can improve the diagnosis in some cases. Each case should be evaluated very carefully since there are a wide variety of congenital conditions, infectious/inflammatory conditions, benign neoplasms, and primary and secondary malignancies presenting as a cystic mass in the head and neck.

The use of diagnostic patterns for interventional cytopathology during rapid on-site evaluation and final classification

Pathologist-performed fine-needle aspiration, or interventional cytopathology, is a minimally invasive, highly accurate technique for sampling and diagnosing palpable lesions. Utilizing cytomorphologic patterns during rapid onsite evaluation (ROSE) and final classification is one of many strategies that an interventional cytopathologist can employ to simplify the diagnostic approach. Herein, we provide an overview of the salient cytomorphologic patterns encountered in common specimens obtained by the interventional cytopathologist, including major salivary glands, the thyroid gland, and superficial lymph nodes. The topics covered should provide a primer for those interested in utilizing a site-specific, pattern-based approach to cytopathologic evaluation. In summary, cytomorphologic patterns can be used during ROSE to establish adequacy, build a differential diagnosis, and to appropriately triage the specimen for additional investigation, such as microbiology cultures, a liquid-based preparation, a cell block preparation, flow cytometry, chemical analysis, or molecular diagnostic tests. Finally, this approach can be applied at the time of diagnosis to suggest additional ancillary studies, such as immunohistochemistry, and to inform accurate and definitive classification.

Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer: Management in the HPV Era

Background

Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur.

Methods

We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts.

Results

Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy.

Conclusions

New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.

The utility of high-risk human papillomavirus E6/E7 mRNA in situ hybridization in assessing HPV status on cell block

INTRODUCTION

Assessment of human papillomavirus (HPV) status is critical to the treatment and prognosis of patients with oropharyngeal squamous cell carcinoma. Patients often present with enlarged cervical lymph nodes which are amenable to fine needle aspiration (FNA) and cell block creation. The most widely used method for assessing HPV status is the surrogate marker p16. Other HPV specific methods such as high-risk HPV E6/E7 mRNA in situ hybridization (ISH) have been shown to perform as well as p16 and are easier to interpret. Our study evaluates the utility of high-risk HPV mRNA ISH in cell block specimens.

METHODS

Thirty-six cases of metastatic squamous cell carcinoma in cervical neck lymph node FNAs were identified over a 3-year period. All cases had p16 immunohistochemistry (IHC) performed on cell block. HR HPV mRNA ISH was performed on the cell block and compared to the p16 results. Additionally, p16 and HR HPV mRNA ISH status was assessed in those cases with corresponding surgical resections.

RESULTS

HR HPV mRNA ISH confirmed the p16 IHC (either positive or negative) in 24 of the 36 cases (66.7%). Six false negative cases were p16 negative/HR HPV mRNA ISH positive. HR HPV mRNA ISH was positive in 75% of the four p16 equivocal cases. Two cases were p16 positive/HR HPV mRNA ISH negative.

CONCLUSIONS

HR HPV mRNA ISH is no more difficult to perform in the IHC lab and is easier to interpret than p16 IHC. HR HPV mRNA ISH is a useful alternative to p16 in cell block specimens.

Diagnostic utility of high-risk human papillomavirus mRNA in situ hybridisation in squamous cell carcinoma of unknown primary in the head and neck and implementing American Society of Clinical Oncology guideline recommendations

INTRODUCTION

The American Society of Clinical Oncology (ASCO)-endorsed College of American Pathologists guideline recommends high-risk human papillomavirus (HPV) testing for metastatic squamous cell carcinoma (SCC) of lymph nodes level II/III of unknown primary. Herein, the performance of HPV-RNA in situ hybridisation (ISH) in detection of HPV-related SCC is evaluated implementing the ASCO guideline recommendations.

METHODS

Eighty head and neck (HN) SCC fine needle aspirations, which utilized HPV-RNA ISH/P16, were evaluated at Johns Hopkins Hospital (2015-2018) to investigate their performance and concordance with histology. The results were compared to a prior study of 59 HNSCCs, which HPV-DNA ISH.

RESULTS

Of the 80 reviewed fine needle aspirations, 65 (50 male, 15 female) were included. The mean age was 63.2 ± 14.0 years. The most common site was neck lymph nodes (47, 72.3%). Fifty-five cases (84.6%) were accompanied by concurrent core biopsy, and 48 cases (59.4%) had surgical follow-ups. HPV-RNA ISH was positive in 44 (67.7%), and P16 was strongly positive in 46 (70.8%). The HPV-RNA ISH/ P16 concordance rate was 92.3% on cytology material. The cytology/surgical concordance rate for HPV-RNA ISH was 88.9% (16/18). There was a discordance between the results in five cases (7.7%; HPV-RNA ISH-/P16+).

CONCLUSION

HPV-RNA ISH is a robust and reliable method for detecting HPV-related HNSCC on cytology material showing concordance rate of 92.3% between HPV-RNA ISH and P16, which is a sensitive but non-specific marker. Compared to HPV-DNA ISH, HPV-RNA ISH reproducibly identifies HPV-related HNSCC with fewer discrepancies between cytology and histology. The findings of this study are in agreement with the ASCO recommendations.

Determination of high-risk HPV status of head and neck squamous cell carcinoma using the Roche cobas HPV test on cytologic specimens and acellular supernatant fluid

BACKGROUND

High-risk human papillomavirus-positive (hrHPV+) oropharyngeal squamous cell carcinomas comprise a subset of head and neck squamous cell carcinomas (HNSCCs) with a distinct biology and prognosis. Commonly, the diagnosis of HNSCC is rendered on fine-needle aspiration (FNA). Because cell blocks may be insufficient for determining HPV status using microscopy-based techniques, the ability of liquid-based assays was examined in the current study.

METHODS

The performance of the Roche cobas 4800 platform was evaluated on the FNA material from the cell pellet and corresponding cell-free supernatant fluid specimens of primary and metastatic HNSCCs. These results were compared with the p16 immunostain result from the histologic material obtained from the same patient. Discrepant cases were adjudicated using hrHPV RNA in situ hybridization.

RESULTS

A total of 41 samples (23 primary tumors and 18 lymph node metastases) were acquired from 34 patients with HNSCC. Primary tumors included the oropharynx (20 samples), oral cavity (13 samples), larynx (3 samples), and skin (3 samples). In 2 cases, a primary tumor could not be identified. Twenty-three samples (56%) were found to be p16 positive by immunohistochemistry. Twenty-two samples were found to be positive on cobas hrHPV testing from both cell pellet and cell-free supernatant fluid. Two cell-free supernatant fluid specimens yielded indeterminate cobas results. At the time additional hrHPV RNA in situ hybridization analysis was performed, one cobas-positive cell pellet was deemed to be a false-positive result. The sensitivity of the cobas assay was 100% for pellet material and cell-free supernatant fluid, with specificities of 94.7% and 100%, respectively.

CONCLUSIONS

cobas hrHPV testing of HNSCC specimens demonstrated high concordance with p16 immunohistochemistry on the corresponding cell block and/or tissue specimen. Using the cell-free supernatant fluid in this platform could provide accurate HPV results while conserving material for cytomorphologic analyses.

Identification of infectious organisms in cytopathology: A review of ancillary diagnostic techniques

Cytology samples obtained from exfoliative sources and fine-needle aspiration (FNA) procedures can all be used to detect microorganisms and/or the associated cytopathologic effects (CPE) caused by an infection. There are many advantages to utilizing cytology samples as an adjunct to routine microbiology laboratory methods. For example, cytology samples can be obtained by non-invasive and minimally invasive techniques, and interpretation is affordable, accurate, and fast. Furthermore, routine cytology stains, including the Papanicolaou (Pap) and the Diff-Quik (DQ) stains, can adequately identify a number of microorganisms. Finally, material obtained by these procedures can also be used for cytologic ancillary testing, microbiology culture, and molecular studies. Currently, there are a variety of ancillary diagnostic techniques that are routinely utilized in the cytopathology laboratory. Additionally, the increasing utilization of molecular-based, diagnostic techniques on fluid specimens, as well as FFPE material, is expanding the role of cytopathology for infectious disease diagnostics. In this review, we provide an overview of the most practical ancillary techniques commonly used to identify microorganisms on cytology specimens.