A case of advanced gynecologic pelvic tumors showing the diagnostic utility of HPV analysis

Three cases of women with HPV-related squamous cell carcinoma of unknown primary in the pelvis and retroperitoneum: A case series

Background

Carcinoma of unknown primary (CUP) of the pelvis is a challenging entity for the oncologist. The role of human papilloma virus (HPV)/p16 in carcinogenesis and prognosis is more established in the head and neck than in the pelvis. In the case of an HPV positive occult primary of the pelvis the radiation therapy target coverage is not well established.

Case reports

Case#1: A 69-year-old female with a left retroperitoneal and pelvic mass was treated with chemoradiation to a dose of 45 Gy in 25 fractions to elective lymph node regions and simultaneous boost to FDG-avid lymph nodes to 55 Gy in 25 fractions. A post-treatment PET-CT showed complete response of disease now 7 months post treatment. Case#2: A 58-year-old female with a large left retroperitoneal pelvic mass was treated post-operatively with chemoradiation to 45 Gy in 25 fractions with a pelvic boost to 54 Gy. She is clinically and radiographically with no evidence of disease at 4 years. Case#3: A 47-year-old female with left sided retroperitoneal pelvic mass that declined therapy. She ultimately died of progressive disease at 1 year after diagnosis.

Conclusion

Cisplatin based chemoradiation is effective for treating HPV/p16 + pelvic squamous cell cancers of unknown primary as long as the mass, regional lymph nodes and high risk pelvic primary sites are adequately covered.

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Adds 3 cases of pelvic squamous cell carcinoma of unknown primary

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Similarities between pelvic and head and neck squamous cell of unknown primary

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Radiation to highest risk sites of primary disease important

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Prognosis not as bad as previously shown with aggressive chemoradiation

The presence of human papillomavirus or p16 in six cases of retroperitoneal carcinoma

OBJECTIVE

To describe six cases of unknown primary carcinoma of the retroperitoneum that were positive for human papillomavirus (HPV), a surrogate molecular marker for high-risk HPV (p16), or both.

METHODS

Using the MD Anderson pathology database, females with confirmed HPV or p16 expression within retroperitoneal carcinomas of unknown primary were identified. Clinical data were collected by retrospective chart review. One pathologist reviewed all histology. Individuals with known primary were excluded. Data regarding individual demographics, presentation, Pap test history, pathology, HPV and p16 positivity, and outcome were analyzed using descriptive statistics.

RESULTS

Six individuals were identified. The median age of the individuals was 43.5 years (range 27-54). Three malignancies (50%) were squamous and three (50%) were undifferentiated. Median follow-up was 12 months (range 6-48 months). Two of the six (33%) individuals had remote histories (more than 10 years) of abnormal Pap test results. All had normal gynecologic examination and Pap test results at diagnosis. Four tumors were HPV-positive (66%) and six were p16-positive (100%). All samples that were HPV-positive were also p16-positive. All individuals underwent treatment with chemotherapy, radiation, or both. One individual underwent initial attempt at resection that was unsuccessful. Two individuals are without evidence of disease, two have had progression of disease, and two have died of their disease.

CONCLUSION

Pelvic masses of unknown primary may be HPV-related despite normal cervical examinations.

LEVEL OF EVIDENCE

III.

Absence of dysplasia in the excised cervix by a loop electrosurgical excision procedure in the treatment of cervical intraepithelial neoplasia

OBJECTIVE

Absence of dysplasia in the excised specimen following loop electrosurgical excision procedure (LEEP) for treatment of cervical intraepithelial neoplasia (CIN) 2/3 is an occasional finding of uncertain clinical significance. We evaluated several factors including age, liquid-based Pap (LBP) test, human papillomavirus (HPV) load before treatment, and HPV typing as predictors for absence of dysplasia. Absence of dysplasia in LEEP specimens was analyzed in terms of factors for recurrent disease after LEEP conization

METHODS

In total, 192 women (mean age, 39.3+/-8.4 years; range, 24 to 70 years) with biopsy-proven CIN 2/3 were treated by LEEP conization. Age, LBP test, histological grade, HPV load, and HPV DNA typing were evaluated as possible predictors of the absence of residual dysplasia or recurrent disease.

RESULTS

Of the LEEP specimens, 34 (17.7%) showed no dysplasia in preoperative biopsies from patients with proven CIN 2/3. Low HPV load (<100 relative light units [RLU]) was significantly related to the absence of dysplasia in LEEP specimens, using logistic regression. Margin involvement and high HPV load (>/=400 RLU) were significant factors for recurrence.

CONCLUSION

Absence of dysplasia in LEEP specimens occurred in 17.7% of our specimens. Prediction of the absence of dysplasia in LEEP specimens was associated with low HPV load. Residual/recurrent disease after LEEP was associated with a positive resection margin and high viral load, and was not associated with absence of dysplasia in LEEP specimens. Even if there is no dysplasia in conization specimens, close follow-up for residual/recurrent disease is needed.