Human papillomavirus-associated small cell carcinoma/neuroendocrine carcinoma of the oropharynx: a report of two cases

Neuroendocrine carcinoma of tonsil presented with axillary lymph node metastasis: Management dilemma

ABSTRACT

High-grade neuroendocrine carcinoma (NEC) of the tonsil is rare and has a poor prognosis. The usual presentation is a neck mass with locoregional cervical lymphadenopathy. An axillary lymphadenopathy as a primary presentation of NEC of the tonsils is uncommon and challenging to treat. Tonsil neuroendocrine tumors display aggressive behaviors associated with early recurrence and metastasis after surgical resection. Managing this condition is demanding compared to NECs of gastrointestinal origin since, to date, the management of head-and-neck neuroendocrine tumors is still not well established. We present a 49-year-old female with a rare case of NEC of the tonsil presenting primarily with axillary lymph nodes metastasis. The patient's axillary lymph node was biopsied and revealed a Grade III neuroendocrine tumor. A positron emission tomography (PET) scan was done in searching of a primary lesion and showed a highly metabolic mass of the left tonsil as well as a left axillary lymph node suggestive of metastasis. The patient has been managed with a multimodality approach, with a combination of chemotherapy regimen and surgical resection of the axillary lymph node. Subsequent PET scan evaluation showed a complete response of the primary tumor with residual left axillary lymph node metastasis. NECs of tonsil presented with axillary lymph nodes metastasis is rare and has a poor prognostic outcome. It poses a dilemma with regard to management, as surgical resection of the metastasis is not promising given the possibility of early recurrence.

Human papillomavirus status and prognosis of oropharyngeal high-grade neuroendocrine carcinoma

BACKGROUND

The prognostic impact of human papillomavirus (HPV) infection or smoking on oropharyngeal high-grade neuroendocrine carcinoma (HG-NEC) is not established.

METHODS

Retrospective study with patients with oropharyngeal HG-NEC seen at MD Anderson Cancer Center from 1997 to 2020, and previously reported patients with oropharyngeal HG-NEC and known p16 and HPV status from the literature review. Survival was estimated with the Kaplan-Meier method, and survival differences assessed with the log-rank test and Cox proportional hazards models.

RESULTS

Thirty patients were included; most had a heavy (≥10 pack-years) smoking history (52%), locoregional disease (stage III-IVB; 77%), and p16-positive tumor (92%). HPV was positive in 65% of tested samples (15/23). Of 24 patients treated with curative intent, the objective response rates was 90% (9/10) and 81% (17/21), respectively, for induction chemotherapy and definitive radiotherapy. During follow-up, 54% (13/24) recurred, mostly (11/13) at distant sites. Median overall survival (OS) was 46 months (95% CI, 14.3 - NA). OS was not associated with HPV status (HR 0.73, P = 0.6) or smoking (HR 1.16, P = 0.8). Among 63 patients with known HPV status after the literature review (19 HPV- and 44 HPV + ), HPV status remained unassociated with OS (P = 0.92).

CONCLUSIONS

This is the largest retrospective cohort of oropharyngeal HG-NEC. Distant recurrence rate after curative treatment was high, suggesting that multimodality treatment including systemic therapy may benefit patients with locally advanced disease. HPV infection did not affect survival outcomes, therefore should not lead to therapy de-intensification for this histology.

Systematic review of neuroendocrine carcinomas of the oropharynx

Data describing features and management of oropharyngeal neuroendocrine carcinomas (NEC) remain sparse. A systematic review was performed. Patients were stratified by treatment modality and examined for disease progression and survival outcomes. Ninety-four patients from 50 publications were included. Average age at diagnosis was 59.7 years (range 14-83). 73.4% were male. Most studies did not document HPV status. Forty patients (85.1%) were p16 positive, and 34 (85.0%) were HPV-ISH positive. Overall survival was 75.4% at 1 year, and 40.0% at 2 years. Of patients with locoregional disease, 33.8% developed distant metastasis. 12.5% of patients developed locoregional recurrence. Patients who developed distant metastases had worse overall survival (p = 0.0004). No significant difference was found between treatment modalities. Human papilloma virus may be associated with oropharyngeal NEC. Current treatments provide locoregional control, but distant metastases are common and confer low overall survival.

High-Grade Neuroendocrine Carcinoma of the Head and Neck: Human Papillomavirus Status and PD-L1 Expression

BACKGROUND

Human papillomavirus (HPV)-related head and neck squamous cell carcinoma represents an important subgroup of head and neck cancer, but HPV occurs also in the less common neuroendocrine carcinomas (NEC). The PD-1/PD-L1 pathway appears to be activated in pulmonary NEC and correlates with a higher mutation burden, but the potential of NEC to respond to checkpoint inhibitors is unknown to a large extent.

OBJECTIVES

To determine the HPV status of NEC of the head and neck region and to investigate the expression of PD-1 and its ligands PD-L1 and PD-L2.

METHODS

Surgical tumor samples from 2006 to 2017 were analyzed. HPV status was determined by p16 immunohistochemistry (IHC) and multiplex PCR. IHC using the Cologne Score was performed for PD-1, PD-L1, and PD-L2.

RESULTS

Seven NEC tumor samples were analyzed, three of them showed HPV type 18. Expression of PD-1 and PD-L1 differed widely and showed no correlation to HPV status. IHC showed an overexpression of PD-L2 in most of the patients.

CONCLUSIONS AND SIGNIFICANCE

A multicentric analysis of NEC is needed to further evaluate the role of HPV as well as immunocheckpoints with regard to inflammatory immune response in genesis and clinical course of this rare tumor entity. Biomarkers for selection of novel treatment regimens, including immunotherapeutic approaches, are warranted.

Human Papillomavirus-Associated Oropharyngeal High-Grade Neuroendocrine Carcinoma in an Adolescent: Case Report and Review of Literature

Oropharyngeal small cell carcinomas (OPSmCC) are rare with only few case reports and case series published in the literature. More recently, an association of these tumors with human papillomavirus (HPV) infection has been detected. However, unlike oropharyngeal squamous cell carcinomas which have a better outcome when associated with HPV, OPSmCC exhibit an aggressive behavior. In this article, we report a case of tonsillar carcinoma arising in a 14-year-old boy that was associated with HPV infection. The tumor exhibited morphologic features of small cell carcinoma with no overt squamous differentiation. Yet, by immunohistochemistry, it showed diffuse and strong co-expression of both squamous and neuroendocrine markers. In addition, we present the clinicopathologic features of all the cases of OPSmCC reported in the literature for which p16 and/or HPV testing have been done.

Poorly differentiated neuroendocrine carcinoma of the head and neck: human papillomavirus tumour status/p16 status and impact on overall survival

AIMS

Poorly differentiated neuroendocrine carcinoma (PDNEC) of the head and neck is a rare high-grade neuroendocrine neoplasm. Human papillomavirus (HPV) status and p16 status are as yet unclear among PDNECs, owing to a lack of statistical analysis. The objective of the present study was therefore to evaluate their potential clinicopathological associations, and their prognostic impact on overall survival in PDNECs of the head and neck, regardless to HPV genotype.

METHODS AND RESULTS

All cases of PDNEC of the head and neck between 1998 and 2019 were identified from the database of the Lyon university hospital pathology department (n = 21); for these cases, p16 immunohistochemistry and HPV in-situ hybridisation were performed. Published cases of PDNEC of the head and neck with assessment of HPV status and p16 status were identified in PubMed (n = 57). Local and published cases were pooled for analysis. HPV positive (HPV+) tumour status was found to be significantly associated with oropharyngeal localisation (P < 0.001) and overexpression of p16 (P < 0.001). Multivariate analysis, adjusted on tumour site, histological subtype, p16 status, HPV status, and source of the case, showed that oropharyngeal localisation [hazard ratio (HR) 3.031, 95% confidence interval (CI) 1.257-7.310] and being a small-cell variant (HR 2.859, 95% CI 1.150-7.109) were significant predictors of worse overall survival; HPV+ tumour status was associated with better overall survival (HR 0.388, 95% CI 0.146-0.995).

CONCLUSIONS

HPV+ tumour status was associated with oropharyngeal PDNECs and with a better prognosis.

Small Cell and Squamous Cell Carcinomas of the Head and Neck: Comparing Incidence and Survival Trends Based on Surveillance, Epidemiology, and End Results (SEER) Data

BACKGROUND

Small cell carcinomas of the head and neck (SmCCHNs) are rare neoplasms with an unfavorable prognosis. Population-based data describing survival and prognostic factors for SmCCHN are limited.

METHODS

Data were obtained from the U.S. National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database for 1973-2013. Patient and tumor-related characteristics for SmCCHN were compared with those for squamous cell carcinoma of the head and neck (SCCHN). Survival was compared by constructing Kaplan-Meier curves and Cox proportional hazard models with and without propensity score matching.

RESULTS

The data set included 609 SmCCHN and 227,943 SCCHN cases. Both histological subtypes were more common in men than women and more common in white patients. SmCCHN was most likely to originate in the larynx, glottis and hypopharynx, or salivary glands and to present with more advanced stage and grade. SCCHN was most likely to originate in the oral cavity and was found infrequently in the salivary glands. Overall 5- and 10-year survival estimates were 27% and 18% for SmCCHN and 46% and 31% for SCCHN, respectively. In multivariable survival analyses adjusting for age, sex, race, marital status, year of diagnosis, stage, grade, and receipt of radiation, the hazard ratio (HR) comparing SmCCHN with SCCHN was 1.53 with a 95% confidence interval (CI) from 1.39 to 1.68. Average 5-year survival varied widely between the histologic types when comparing tumor sites: 14.5% for SmCCHN versus 48.9% for SCCHN in the oropharynx. In propensity score matched analyses, the corresponding HR was 1.27 (95% CI, 1.15-1.40).

CONCLUSION

Compared with SCCHN, SmCCHN carries a worse survival and is more likely to present with more advanced stage.

IMPLICATIONS FOR PRACTICE

Small cell carcinoma of the head and neck (SmCCHN) is a rare subtype of head and neck cancer. In this Surveillance, Epidemiology, and End Results (SEER) data analysis, the characteristics and survival of SmCCHN are compared with those of the common squamous cell carcinoma of the head and neck. Results show that SmCCHN carries a worse prognosis and tends to present at a more advanced stage; SmCCHN also is ten times more likely to originate from the salivary glands. These findings may have implications for clinical practice, as location of the tumor may strongly associate with the pathologic diagnosis. If a SmCCHN is diagnosed, a disseminated disease is likely; hence vigilance in staging procedures is indicated.

A Rare Case of Human Papillomavirus-associated High-grade Neuroendocrine Carcinoma of the Hypopharynx

We present a case of primary small cell carcinoma of the hypopharynx (SCCH), with a rare association with human papillomavirus (HPV). A comparison is made to 11 previously known, well-documented cases of SCCH with a review of the literature concerning SCCH. Our patient's age of 23 years is the lowest among all previously reported cases, with an age range of 35-75. HPV association with SCCH is a rare new entity and eight HPV subtypes were identified in our case by ribonucleic acid (RNA) in-situ hybridization. The important common features among the previously reported 11 cases and our case include: (a) piriform sinus of the hypopharynx as the primary site in all cases, (b) a majority of patients presented with dysphagia and a neck mass, and (c) most patients had locoregional involvement at the time of presentation as opposed to distant metastasis. HPV-associated SCCH is extremely rare, with potentially aggressive clinical behavior, and needs much more research to further elucidate both the diagnostic and therapeutic approaches.

Cytopathologic characteristics of HPV-related small cell carcinoma of the oropharynx

BACKGROUND

Human papillomavirus (HPV)-related squamous cell carcinoma (SqCC) of the oropharynx is an epidemiologically and clinically distinct form of SqCC that is associated with an improved prognosis. However, HPV-related small cell carcinoma of the oropharynx is a rare and newly described variant that is associated with aggressive clinical behavior and poor outcomes. To date, fewer than 2 dozen reports of this entity exist in the literature, and there is no discussion of cytopathologic features. This article reports 6 cases and discusses the salient cytomorphologic findings, ancillary studies, and challenges when this entity is encountered.

METHODS

Anatomic pathology archives were searched to identify patients with a diagnosis of HPV-related small cell carcinoma of the oropharynx. Medical records were reviewed to document the following: age, sex, smoking status, other relevant clinical history, primary location, treatment, and clinical outcome. Both p16 and high-risk HPV in situ hybridization (ISH) studies were positive in at least 1 specimen from each patient. The pathologic diagnoses, cytomorphologic characteristics, immunocytochemical stains, and HPV ISH studies were reviewed and recorded for all available cases.

RESULTS

Six patients with 11 cytopathology specimens of HPV-related small cell carcinoma of the oropharynx were identified. The mean age was 61.3 years, and all patients died with widely metastatic disease (mean, 23 months; range, 12-48 months). Mixed small cell carcinoma and SqCC components were present in half of the cases.

CONCLUSIONS

The identification of a small cell component can be reliably performed with cytology preparations and is crucial because this (and not the HPV status) determines the prognosis.

The First Report of Small Cell Cancer of the Uvula Presenting With Ectopic Adrenocorticotropic Hormone Syndrome

Small cell carcinoma (SmCC) of the head and neck is a rare occurrence. We herein present a case of a 62-year-old female who was diagnosed with small cell cancer of the uvula. The patient developed increased body swelling, elevated blood pressure, persistent hypokalemia and new onset diabetes mellitus. Further workup confirmed a diagnosis of Cushing's syndrome secondary to ectopic adrenocorticotropic hormone (ACTH) production. To our knowledge, this is only the second case of SmCC of the uvula described in literature, and the first associated with any paraneoplastic syndrome. By reporting this case, we aim to characterize the tumor clinical course and highlight the aggressive nature of its growth.

Differential expression of neuroendocrine markers, TTF-1, p53, and Ki-67 in cervical and pulmonary small cell carcinoma

Small cell carcinoma (SCC) is a highly malignant neuroendocrine tumor that may occur in many anatomic sites of the body.In this study, we compared the different expression of neuroendocrine markers, thyroid transcription factor 1 (TTF-1), p53, and Ki-67 in 23 cases of cervical SCC and 56 cases of pulmonary SCC using immunohistochemistry.Our study showed that cervical SCC had a younger onset age than pulmonary counterpart. Although both had the similar morphological features, different immunohistochemical expression panel was observed in this study. As neuroendocrine tumors, SCC of cervix and lung had similar immunoreactive staining for CD56 and chromogranin A, but the expression of the synaptophysin in cervical SCC was significantly higher than that in pulmonary SCC (P = .007). The TTF-1 expression of pulmonary SCC illustrating diffuse and strong positivity in tumor cell nuclei was significantly higher than that of the cervical SCC (P = .003). There was only 1 case showing p53 protein over-expression in the 23 cases of cervical SCC, and p53 over-expression was observed in 42.9% of pulmonary SCC (P = .001). Only 9 cases of cervical SCC showed ≥80% of the Ki-67 proliferation index, while it was found in 94.6% of pulmonary SCC (P < .001).The different immunohistochemical expressions of these 2 kinds of SCCs may be related with their pathogenetic mechanism, and these differences may be helpful in the identification of the origins of the metastatic SCC with unknown primary site.

Human Papillomavirus-Related Neuroendocrine Carcinomas of the Head and Neck

Human papillomavirus (HPV)-related head and neck carcinoma (HNC) represents an important subgroup of head and neck cancer that is characterized by a consistent microscopic appearance and a favorable prognosis. A growing experience with HPV testing, however, has uncovered variants that deviate from the prototypic HPV-HNC with respect to morphology. While these HPV-HNCs may deviate morphologically from the prototype, they do not appear to stray far from the favorable clinical outcome assigned to HPV-positive status. In effect, HPV positivity trumps traditional prognostic features predicated on morphology such as tumor grade and histologic subtype when it comes to predicting clinical behavior. For the diagnostic pathologist, the pedestrian task of tumor grading and subtyping would seem to be of little prognostic or therapeutic relevance when it comes to HPV-HNC. Recognition and documentation of neuroendocrine differentiation is a most notable exception. Forms of HPV-HNC have now been reported that morphologically resemble small cell carcinoma (SCC) and large cell neuroendocrine carcinoma (LCNEC) of other sites, and that immunohistochemically exhibit neuroendocrine differentiation. Despite the presence of HPV, these SCCs and LCNECs share the same aggressive clinical behavior of their counterparts in the lung and other sites where the high grade neuroendocrine phenotype is associated with early distant spread and poor overall survival. Consequently, the high grade neuroendocrine phenotype should be regarded as an aggressive form of HPV-HNC where tumor morphology displaces HPV positivity as the most important prognostic feature.