Clinical implications of human papillomavirus in head and neck cancers

Prevalence and associated survival of high-risk HPV-related adenoid cystic carcinoma of the salivary glands

Adenoid cystic carcinoma (SACC) is a rare malignancy, but a frequent subtype in minor and major salivary glands. The molecular alterations or biomarkers that underlie its development and progression as well as therapy outcomes are poorly characterized. The main study goal was to investigate reliable biomarkers and patient-related factors that may have impact on recurrence and long-term survival of SACC. The prevalence of human papilloma virus (HPV) in SACC was determined by HPV-DNA genotyping and p16 immunostaining. Epithelial growth factor receptor (EGFR), p53 and Ki-67 expression were also evaluated. Twenty-eight (42%) of 67 patients were HPV-DNA positive. Kaplan-Meier analysis indicated that SACC patients with metastases (P=0.03) had a poor overall survival (OS) and a shorter recurrence-free survival (P<0.001). Positive resection margins significantly predicted shorter recurrence-free survival (P=0.01). In the multivariate analysis, non-metastatic disease (P=0.033) and p16 positivity (P=0.005) have shown their prediction value for OS while non-metastatic disease (P=0.002), HPV positivity (P=0.041) and negative resection margin predicted a better recurrence-free survival. The present study documents for the first time the positivity for HPV infection and overexpression of certain markers (p16, Ki-67, EGFR and p53) used in diagnostics in SACC as well as characterizes clinical entities. These factors might be exploited in the future as biomarkers for its prognostic value. Using the clinical and pathological basis for predicting different outcomes could significantly facilitate SACC stratification and potentially directing treatment.

Human Papilloma Virus as a Biomarker for Personalized Head and Neck Cancer Radiotherapy

A dramatic increase in the incidence of HPV-related oropharyngeal cancer has been reported in some parts of the western world over the past 30 years. They constitute a clinically distinct subgroup of cancers in terms of molecular biology, patient characteristics, and treatment outcome. This chapter describes the molecular characteristics, epidemiology, and demographics of the HPV-related head and neck cancers and discuss available methods to detect HPV-related tumours. The impact of HPV-related biomarkers in clinical studies on radiotherapy only, altered fractionation, modulation of hypoxia, and concurrent chemo- or bio-radiotherapy are reviewed as well as the perspectives of de-escalation and immune-modulation are discussed.

Interventions for the treatment of oral and oropharyngeal cancers: targeted therapy and immunotherapy

BACKGROUND

Oral cancers are the sixth most common cancer worldwide, yet the prognosis following a diagnosis of oral cavity or oropharyngeal cancers remains poor, with approximately 50% survival at five years. Despite a sharp increase in research into molecularly targeted therapies and a rapid expansion in the number of clinical trials assessing new targeted therapies, their value for treating oral cancers is unclear. Therefore, it is important to summarise the evidence to determine the efficacy and toxicity of targeted therapies and immunotherapies for the treatment of these cancers.

OBJECTIVES

To assess the effects of molecularly targeted therapies and immunotherapies, in addition to standard therapies, for the treatment of oral cavity or oropharyngeal cancers.

SEARCH METHODS

We searched the following electronic databases: Cochrane Oral Health Group Trials Register (to 3 February 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2015, Issue 1), MEDLINE via Ovid (1946 to 3 February 2015) and EMBASE via Ovid (1980 to 3 February 2015). We searched the US National Institutes of Health Trials Register (clinicaltrials.gov), the World Health Organization Clinical Trials Registry Platform, the American Society of Clinical Oncology conference abstracts and the Radiation Therapy Oncology Group clinical trials protocols for ongoing trials. We placed no restrictions on the language or date of publication.

SELECTION CRITERIA

We included randomised controlled trials where more than 50% of participants had primary tumours of the oral cavity or oropharynx, and which compared targeted therapy or immunotherapy, plus standard therapy, with standard therapy alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where necessary. We combined sufficiently similar studies in meta-analyses using random-effects models when there were at least four studies and fixed-effect models when fewer than four studies. We obtained or calculated a hazard ratio (HR) and 95% confidence interval (CI) for the primary outcomes where possible. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs.

MAIN RESULTS

Twelve trials (2488 participants) satisfied the inclusion criteria. In the included trials, 12% of participants (298 participants) had tumours of the oral cavity and 59% (1468 participants) had oropharyngeal tumours. The remaining 29% had tumours of the larynx or hypopharynx and less than 1% had tumours at other sites.No included trial was at low risk of bias; seven had an unclear risk of bias, and five had a high risk of bias. We grouped trials by intervention type into three main comparisons: standard therapy plus epidermal growth factor receptor monoclonal antibody (EGFR mAb) therapy (follow-up period 24 to 70 months); standard therapy plus tyrosine kinase inhibitors (TKIs) (follow-up period 40 to 60 months) and standard therapy plus immunotherapy (follow-up period 24 to 70 months), all versus standard therapy alone.Moderate quality evidence showed that EGFR mAb therapy may result in 18% fewer deaths when added to standard therapy (HR of mortality 0.82; 95% CI 0.69 to 0.97; 1421 participants, three studies, 67% oropharyngeal tumours, 2% oral cavity tumours).There was also moderate quality evidence that EGFR mAb may result in 32% fewer locoregional failures when added to radiotherapy (RT) (HR 0.68; 95% CI 0.52 to 0.89; 424 participants, one study, 60% oropharyngeal tumours).A subgroup analysis separating studies by type of standard therapy (radiotherapy (RT) or chemoradiotherapy (CRT)) showed some evidence that adding EGFR mAb therapy to RT may result in a 30% reduction in the number of people whose disease progresses (HR 0.70; 95% CI 0.54 to 0.91; 424 participants, one study, 60% oropharyngeal tumours, unclear risk of bias). For the subgroup comparing EGFR mAb plus CRT with CRT alone there was insufficient evidence to determine whether adding EGFR mAb therapy to CRT impacts on progression-free survival (HR 1.08; 95% CI 0.89 to 1.32; 891 participants, one study, 70% oropharyngeal tumours, high risk of bias). The high subgroup heterogeneity meant that we were unable to pool these subgroups.There was evidence that adding cetuximab to standard therapy may result in increased skin toxicity and rash (RR 6.56; 95% CI 5.35 to 8.03; 1311 participants, two studies), but insufficient evidence to determine any difference in skin toxicity and rash in the case of nimotuzumab (RR 1.06; 95% CI 0.85 to 1.31; 92 participants, one study).There was insufficient evidence to determine whether TKIs added to standard therapy impacts on overall survival (HR 0.99; 95% CI 0.62 to 1.57; 271 participants, two studies; very low quality evidence), locoregional control (HR 0.89; 95% CI 0.53 to 1.49; 271 participants, two studies; very low quality evidence), disease-free survival (HR 1.51; 95% CI 0.61 to 3.71; 60 participants, one study; very low quality evidence) or progression-free survival (HR 0.80; 95% CI 0.51 to 1.28; 271 participants, two studies; very low quality evidence). We did find evidence of an increase in skin rash (erlotinib: RR 6.57; 95% CI 3.60 to 12.00; 191 participants, one study; lapatinib: RR 2.02; 95% CI 1.23 to 3.32; 67 participants, one study) and gastrointestinal complaints (lapatinib: RR 15.53; 95% CI 2.18 to 110.55; 67 participants, one study).We found very low quality evidence from one small trial that adding recombinant interleukin (rIL-2) to surgery may increase overall survival (HR 0.52; 95% CI 0.31 to 0.87; 201 participants, 62% oral cavity tumours, 38% oropharyngeal tumours) and there was insufficient evidence to determine whether rIL-2 impacts on adverse effects.

AUTHORS' CONCLUSIONS

We found some evidence that adding EGFR mAb to standard therapy may increase overall survival, progression-free survival and locoregional control, while resulting in an increase in skin toxicity for some mAb (cetuximab).There is insufficient evidence to determine whether adding TKIs to standard therapies changes any of our primary outcomes.Very low quality evidence from a single study suggests that rIL-2 combined with surgery may increase overall survival compared with surgery alone.

Tumor Necrosis Factor Inhibition and Head and Neck Cancer Recurrence and Death in Rheumatoid Arthritis

The objective of this retrospective cohort study was to determine the effect of tumor necrosis factor inhibitor (TNFi) therapy on the risk of head and neck cancer (HNC) recurrence or HNC-attributable death in patients with rheumatoid arthritis (RA). RA patients with HNC were assembled from the US national Veterans' Affairs (VA) administrative databases, and diagnoses confirmed and data collected by electronic medical record review. The cohort was divided into those treated with non-biologic disease-modifying anti-rheumatic drugs (nbDMARDs) versus TNF inhibitors (TNFi) after a diagnosis of HNC. Likelihood of a composite endpoint of recurrence or HNC-attributable death was determined by Cox proportional hazards regression. Of 180 patients with RA and HNC, 31 were treated with TNFi and 149 with nbDMARDs after the diagnosis of HNC. Recurrence or HNC-attributable death occurred in 5/31 (16.1%) patients in the TNFi group and 44/149 (29.5%) patients in the nbDMARD group (p = 0.17); it occurred in 2/16 (13%) patients who received TNFi in the year prior to HNC diagnosis but not after. Overall stage at diagnosis (p = 0.03) and stage 4 HNC (HR 2.49 [CI 1.06-5.89]; p = 0.04) were risk factors for recurrence or HNC-attributable death; treatment with radiation or surgery was associated with a lower risk (HR 0.35 [CI 0.17-0.74]; p = 0.01 and HR 0.39 [CI 0.20-0.76]; p = 0.01 respectively). Treatment with TNFi was not a risk factor for recurrence or HNC-attributable death (HR 0.75; CI 0.31-1.85; p = 0.54). We conclude that treatment with TNFi may be safe in patients with RA and HNC, especially as the time interval between HNC treatment and non-recurrence increases. In this study, TNF inhibition was not associated with an increase in recurrence or HNC-attributable death.

Clinical parameters predicting development of pulmonary malignancies in patients treated for head and neck squamous cell carcinoma

BACKGROUND

As the locoregional control rates in head and neck squamous cell carcinoma (HNSCC) have increased, these patients may suffer distant metastasis in a higher proportion of cases. Clinicopathological characteristics allowing prediction of high-risk profile would allow adapting posttreatment surveillance to individual risk.

METHODS

A retrospective review of all patients with HNSCC treated at the Jewish General Hospital, McGill University, Montreal, Quebec, Canada, between 1999 and 2008 was conducted for this study.

RESULTS

The study included 428 patients with a mean follow-up of 65 months (±SEM 1.7). Eighty patients (18.6%) developed pulmonary malignancy during follow-up. In multivariate Cox-regression analysis, locoregional failure and current smoking were associated with higher risk of pulmonary malignancy (p < .001 and p = .008, respectively).

CONCLUSION

Locoregional failure and smoking persistence are predictors of pulmonary malignancy in patients with HNSCC. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1277-E1280, 2016.

NDN and CD1A are novel prognostic methylation markers in patients with head and neck squamous carcinomas

BACKGROUND

HPV-associated HNSCCs have a distinct etiologic mechanism and better prognosis than those with non-HPV associated HNSCCs. However, even within the each group, there is heterogeneity in survival time. Here, we test the hypothesis that specific candidate gene methylation markers (CCNA1, NDN, CD1A, DCC, p16, GADD45A) are associated with tumor recurrence and survival, in a well-characterized, prospective, cohort of 346 HNSCC patients.

METHODS

Kaplan-Meier curves were used to estimate survival time distributions. Multivariable Cox Proportional Hazards models were used to test associations between each methylation marker and OST/RPFT after adjusting for known or identified prognostic factors. Stratified Cox models included an interaction term between HPV and methylation marker to test for differences in the associations of the biomarker with OST or RPFT across HPV status.

RESULTS

Methylation markers were differentially associated with patient characteristics. DNA hypermethylation of NDN and CD1A was found to be significantly associated with overall survival time (OST) in all HNSCC patients (NDN hazard ratio (HR): 2.35, 95% CI: 1.40-3.94; CD1A HR: 1.31, 95% CI: 1.01-1.71). Stratification by HPV status revealed hypermethylation of CD1A was associated with better OST and recurrence/persistence-free time (RPFT) (OST HR: 3.34, 95% CI: 1.88-5.93; RPFT HR: 2.06, 95% CI: 1.21-3.49), while hypomethylation of CCNA1 was associated with increased RPFT in HPV (+) patients only (HR: 0.31, 95% CI: 0.13-0.74).

CONCLUSIONS

This study is the first to describe novel epigenetic alterations associated with survival in an unselected, prospectively collected, consecutive cohort of patients with HNSCC. DNA hypermethylation of NDN and CD1A was found to be significantly associated with increased overall survival time in all HNSCC patients. However, stratification by the important prognostic factor of HPV status revealed the immune marker, CD1A, and the cell cycle regulator, CCNA1 to be associated with prognosis in HPV (+) patients, specifically. Here, we identified novel methylation markers and specific, epigenetic molecular differences associated with HPV status, which warrant further investigation.

Comparing staging by positron emission tomography with contrast-enhanced computed tomography and by pathology in head and neck squamous cell carcinoma

Objective:

This study aimed to evaluate the ability of positron emission tomography with contrast-enhanced computed tomography to correctly stage head and neck squamous cell carcinomas, in comparison with pathological staging.

Methods:

Positron emission tomography computed tomography was used to determine the tumour–node–metastasis classification and overall cancer stage in 85 head and neck squamous cell carcinoma patients who underwent pre-operative imaging using this modality and primary surgery between July 2010 and January 2013. Staging by positron emission tomography computed tomography was retrospectively compared with staging using pathological specimens. Agreement between imaging stage and pathological stage was examined by univariate and multivariate analysis both overall and for each primary tumour site.

Results:

This imaging modality was 87.5 per cent sensitive and 44.8 per cent specific in identifying regional cervical metastases, and had false positive and false negative rates of 18.8 per cent and 8.2 per cent, respectively. The positive predictive and negative predictive values were 75.4 per cent and 65.0 per cent, respectively. Univariate and multivariate analyses revealed a significant agreement between positron emission tomography computed tomography and pathological node classification in older patients and for the oral cavity primary tumour site. There was significant agreement between both methods in the overall classification only for tumours classified as T3 or greater.

Conclusion:

Positron emission tomography computed tomography should be used with caution for the pre-operative staging of head and neck cancers because of its high false positive and false negative rates.

Biologic predictors of serologic responses to HPV in oropharyngeal cancer: The HOTSPOT study

OBJECTIVES

We hypothesized that viral and host factors impact the serologic responses to HPV early antigens in HPV-positive oropharyngeal cancer (HPVOPC).

MATERIALS AND METHODS

We conducted a multicenter study to measure HPV16-specific IgG among patients with HPVOPC, their long-term sexual partners, and healthy volunteers. Risk factor surveys and rinse and gargle specimens were collected. Peripheral blood samples at diagnosis were evaluated for IgG Abs to HPV16 antigens using a programmable ELISA assay. Predictors for HPV16 serologic responses were evaluated using univariate and multivariable linear regression.

RESULTS

116 patients with HPVOPC, 43 partners, and 81 healthy volunteers were enrolled and had baseline sera for analysis. Cases were primarily male (90%), with a median age of 56 years. Abs to E1, E2, E6 or E7 antigens were detected more often in HPVOPC compared with volunteers or partner sera (p<0.0001). HPV16 Abs to at least one early protein (E1, E2, E4, E5, E6, or E7) were detected in the sera of 90.6% of cases, 0% of partners and 7.4% of healthy volunteers. Gender, race, sexual behavior, and viral integration were not associated with antibody response. Younger age and higher oral HPV16 copy number were associated with higher HPV16 E6 and NE2 antibody levels.

CONCLUSIONS

HPV16 seroreactivity is commonly detected among patients with HPVOPC at diagnosis, but not among partners or healthy volunteers. Seroreactivity among cases are correlated with viral load and stage and not with other demographic or behavioral factors. Positive HPV16 serology was strongly associated with HPV 16 oropharyngeal cancer.

Detailed Analysis of Clinicopathologic Factors Demonstrate Distinct Difference in Outcome and Prognostic Factors Between Surgically Treated HPV-Positive and Negative Oropharyngeal Cancer

BACKGROUND

Oropharyngeal cancers (OPC) secondary to human papillomavirus (HPV) infections likely represent a completely different disease compared with conventional head and neck cancers. Our objective was to analyze a surgically treated cohort to determine predictors of outcome in HPV-positive versus HPV-negative patients.

METHODS

HPV positivity was inferred based on p16-immunohistochemistry. Data was available for 201 patients with OPC treated with surgical resection with/without adjuvant radiotherapy between 1985 and 2005. Subsite distribution was: 66 (33 %) tonsil, 46 (23 %) soft palate, and 89 (44 %) tongue base. Patients were classified into low-, intermediate-, and high-risk groups based on p16 status and smoking history. Outcomes stratified by p16 status and risk groups were determined by the Kaplan-Meier method. Factors predictive of outcome were determined by univariate and multivariate analyses.

RESULTS

In this cohort, 30 % had locally advanced disease (pT3/T4) and 71 % had nodal metastasis. The 5-year overall (OS), disease-specific, and recurrence-free survival rates were 60, 76, and 66 %, respectively. There were 22 % low-, 34 % intermediate-, and 44 % high-risk patients. Patients who were p16-positive had better survival compared with p16-negative (OS, 74 vs. 44 %; p < .001). Similarly, low-risk group patients had a better survival compared with intermediate- and high-risk groups (OS, 76, 68, 45 %, respectively, p < .001). Independent predictors of survival in p16-negative patients included margin status, lymphovascular invasion, pN status, and extracapsular spread. In contrast, none of these were predictive in p16-positive patients.

CONCLUSIONS

Surgically treated patients with p16-positive OPC have superior survival compared with p16-negative patients. Outcomes in p16-positive and p16-negative OPC are determined by different prognostic factors supporting the notion that these are very different diseases. These should be incorporated into future clinical trials design.

Randomized trial comparing surgery and adjuvant radiotherapy versus concurrent chemoradiotherapy in patients with advanced, nonmetastatic squamous cell carcinoma of the head and neck: 10-year update and subset analysis

BACKGROUND

The current study was performed to report the long-term results of a trial comparing concurrent chemotherapy and radiotherapy (CCRT) with surgery and adjuvant radiotherapy (RT) in patients with stage III/IV nonmetastatic head and neck squamous cell carcinoma.

METHODS

Patients with stage III/IV resectable head and neck squamous cell carcinoma were randomized to surgery followed by RT or CCRT. The trial was halted prematurely due to poor accrual. Human papillomavirus status was tested on archival material using polymerase chain reaction sequencing.

RESULTS

Of the total of 119 patients, 60 patients were randomized to primary surgery (S arm) and 59 patients were randomized to CCRT (C arm). Human papillomavirus status was tested in 75 patients, and only 3 were found to be positive. The median follow-up for surviving patients was 13 years. Analysis of the entire cohort demonstrated no statistically significant difference in overall survival and disease-specific survival (DSS): 5-year rates were 45% versus 35% for overall survival (P = .262) and 56% versus 46% for DSS (P = .637) for the S arm and C arm, respectively. Analysis by subsites indicated that this difference favoring the S arm was mainly driven by survival data among patients with cancers of the oral cavity and maxillary sinus. For patients with oral cavity cancer, survival was significantly better in those who underwent primary surgery compared with CCRT; the 5-year DSS rate was 68% versus 12% for the S arm and C arm, respectively (P = .038). For patients with cancers of the maxillary sinus, the 5-year DSS rate was 71% for patients on the S arm and 0% for patients on the C arm (P = .05).

CONCLUSIONS

These long-term results demonstrate a significant advantage for primary surgery in patients with cancers of the oral cavity or maxillary sinus, providing strong support for primary surgery as the main modality of treatment for these subsites. In other subsites, CCRT and surgery with adjuvant RT were found to demonstrate similar efficacy for survival in patients with advanced resectable tumors.

Radiotherapy alone or combined with chemotherapy for the treatment of squamous cell carcinoma of the base of the tongue

OBJECTIVES

To evaluate the efficacy of definitive radiotherapy (RT) for the treatment of base of the tongue cancer in a private practice.

METHODS

We retrospectively reviewed the medical records of 48 patients with squamous cell carcinoma of the base of the tongue treated with definitive RT and followed from 0.2 to 15.2 years (median, 2.7 y). Follow-up of living patients ranged from 1.5 to 15.2 years (median, 4.9 y). Two thirds of the patients received twice-daily treatment. The median total dose was 74.4 Gy (range, 65 to 76.8 Gy). The median overall treatment time was 45.5 days (range, 36 to 68 d). There were 3 patients (6%) with clinically positive neck nodes who received a neck dissection. Adjuvant chemotherapy was given to 28 patients (58%) with advanced local-regional disease; 1 patient (4%) received induction chemotherapy and 27 patients (96%) received concomitant chemotherapy. Toxicity was graded according to the Common Terminology Criteria for Adverse Events, v3.0.

RESULTS

Local control rates by T stage at 5 years were as follows: T1 to T2, 91%; T3, 83%; and T4, 12%. The 5-year rates of local-regional control were as follows: I to II 80%; III, 89%; IVA, 59%; and IVB, 42%. The rates of overall survival at 5 years were as follows: I to II, 67%; III, 56%; IVA, 45%; and IVB, 33%. The 5-year rates of cause-specific survival were as follows: I to II, 67%; III, 76%; IVA, 50%; and IVB, 60%. Seven patients (15%) experienced severe late complications.

CONCLUSIONS

Our data reveal that the local-regional control and overall survival rates after definitive RT were comparable with those in the literature. Twice-daily radiation is well tolerated with moderate-late toxicity, which is consistent with the observations of others.

Immune biomarkers of anti-EGFR monoclonal antibody therapy

The tumor antigen (TA)-targeted monoclonal antibodies (mAb) cetuximab and panitumumab target the human epidermal growth factor receptor and have been integrated into treatment regimens for advanced squamous cell carcinoma of the head and neck (SCCHN). The therapeutic efficacy of these mAbs has been found to be enhanced when combined with radiotherapy and chemotherapy. However, clinical trials indicate that these findings are limited to fewer than 20% of treated patients. Therefore, identifying patients who are likely to benefit from these agents is crucial to improving therapeutic strategies. Interestingly, it has been noted that TA-targeted mAbs mediate their effects by contributing to cell-mediated cytotoxicity in addition to inhibition of downstream signaling pathways. Here, we describe the potential immunogenic mechanisms underlying these clinical findings, their role in the varied clinical response and identify the putative biomarkers of antitumor activity. We review potential immunological biomarkers that affect mAb therapy in SCCHN patients, the implications of these findings and how they translate to the clinical scenario, which are critical to improving patient selection and ultimately outcomes for patients undergoing therapy.

Human papillomavirus prevalence in invasive laryngeal cancer in the United States

Purpose

Human papillomavirus (HPV) is a major risk factor for specific cancers of the head and neck, particularly malignancies of the tonsil and base of the tongue. However, the role of HPV in the development of laryngeal cancer has not been definitively established. We conducted a population-based, cancer registry study to evaluate and characterize the genotype-specific prevalence of HPV in invasive laryngeal cancer cases diagnosed in the U.S.

Methods

The presence of genotype-specific HPV DNA was evaluated using the Linear Array HPV Genotyping Test and the INNO-LiPA HPV Genotyping Assay in formalin-fixed paraffin embedded tissue from 148 invasive laryngeal cancer cases diagnosed in 1993–2004 within the catchment area of three U.S. SEER cancer registries.

Results

HPV DNA was detected in 31 of 148 (21%) invasive laryngeal cancers. Thirteen different genotypes were detected. Overall, HPV 16 and HPV 33 were the most commonly detected types. HPV was detected in 33% (9/27) of women compared with 18% (22/121) of men (p = 0.08). After adjustment for age and year of diagnosis, female patients were more likely to have HPV-positive laryngeal tumors compared to males (adjusted OR 2.84, 95% CI 1.07–7.51). Viral genotype differences were also observed between the sexes. While HPV 16 and 18 constituted half of HPV-positive cases occurring in men, among women, only 1 was HPV 16 positive and none were positive for HPV 18. Overall 5-year survival did not vary by HPV status.

Conclusions

HPV may be involved in the development of a subset of laryngeal cancers and its role may be more predominant in women compared to men.

Surveillance of human papilloma virus using reference laboratory data for the purpose of evaluating vaccine impact

Nationwide positivity rates of high-risk human papillomavirus for the United States before and since the introduction of a Human Papillomavirus (HPV) vaccine in 2006 would provide insight into the population impact of HPV vaccination. Data for high-risk HPV testing results from January 1, 2004 to June 1, 2013 at a national reference laboratory were retrospectively analyzed to produce 757,761 patient records of women between the ages of 14 and 59. Generalized linear models and finite mixture models were utilized to eliminate sources of bias and establish a population undergoing standard gynecological screening. Unadjusted positivity rates for high-risk HPV were 27.2% for all age groups combined. Highest rates occurred in women aged 14 to 19. While the positivity rates decreased for all age groups from 2004 to 2013, the higher age categories showed less downward trend following vaccine introduction, and the two age categories 20 to 24 and 25 to 29 showed a significantly different downward trend between pre- and post-vaccine time periods (-0.1% per year to -1.5% per year, and 0.4% per year to -1.5% per year, respectively). All other age groups had rates of change that became less negative, indicating a slower rate of decline.

HPV16 DNA status is a strong prognosticator of loco-regional control after postoperative radiochemotherapy of locally advanced oropharyngeal carcinoma: results from a multicentre explorative study of the German Cancer Consortium Radiation Oncology Group (DKTK-ROG)

OBJECTIVE

To investigate the impact of HPV status in patients with locally advanced head and neck squamous cell carcinoma (HNSCC), who received surgery and cisplatin-based postoperative radiochemotherapy.

MATERIALS AND METHODS

For 221 patients with locally advanced squamous cell carcinoma of the hypopharynx, oropharynx or oral cavity treated at the 8 partner sites of the German Cancer Consortium, the impact of HPV DNA, p16 overexpression and p53 expression on outcome were retrospectively analysed. The primary endpoint was loco-regional tumour control; secondary endpoints were distant metastases and overall survival.

RESULTS

In the total patient population, univariate analyses revealed a significant impact of HPV16 DNA positivity, p16 overexpression, p53 positivity and tumour site on loco-regional tumour control. Multivariate analysis stratified for tumour site showed that positive HPV 16 DNA status correlated with loco-regional tumour control in patients with oropharyngeal carcinoma (p=0.02) but not in the oral cavity carcinoma group. Multivariate evaluation of the secondary endpoints in the total population revealed a significant association of HPV16 DNA positivity with overall survival (p<0.01) but not with distant metastases.

CONCLUSIONS

HPV16 DNA status appears to be a strong prognosticator of loco-regional tumour control after postoperative cisplatin-based radiochemotherapy of locally advanced oropharyngeal carcinoma and is now being explored in a prospective validation trial.

Human papillomavirus and overall survival after progression of oropharyngeal squamous cell carcinoma

PURPOSE

Risk of cancer progression is reduced for patients with human papillomavirus (HPV) -positive oropharynx cancer (OPC) relative to HPV-negative OPC, but it is unknown whether risk of death after progression is similarly reduced.

PATIENTS AND METHODS

Patients with stage III-IV OPC enrolled onto Radiation Therapy Oncology Group trials 0129 or RTOG 0522 who had known tumor p16 status plus local, regional, and/or distant progression after receiving platinum-based chemoradiotherapy were eligible for a retrospective analysis of the association between tumor p16 status and overall survival (OS) after disease progression. Rates were estimated by Kaplan-Meier method and compared by log-rank; hazard ratios (HRs) were estimated by Cox models. Tests and models were stratified by treatment protocol.

RESULTS

A total of 181 patients with p16-positive (n = 105) or p16-negative (n = 76) OPC were included in the analysis. Patterns of failure and median time to progression (8.2 v 7.3 months; P = .67) were similar for patients with p16-positive and p16-negative tumors. After a median follow-up period of 4.0 years after disease progression, patients with p16-positive OPC had significantly improved survival rates compared with p16-negative patients (2-year OS, 54.6% v 27.6%; median, 2.6 v 0.8 years; P < .001). p16-positive tumor status (HR, 0.48; 95% CI, 0.31 to 0.74) and receipt of salvage surgery (HR, 0.48; 95% CI; 0.27 to 0.84) reduced risk of death after disease progression whereas distant versus locoregional progression (HR, 1.99; 95% CI, 1.28 to 3.09) increased risk, after adjustment for tumor stage and cigarette pack-years at enrollment.

CONCLUSION

Tumor HPV status is a strong and independent predictor of OS after disease progression and should be a stratification factor for clinical trials for patients with recurrent or metastatic OPC.

Clinical and scientific impact of human papillomavirus on head and neck cancer

Head and neck cancer (HNC) arises from the skull base to the clavicles and is the fifth most common cancer in the world by incidence. Historically, in the developed world HNC was associated with tobacco use and alcohol consumption, and the combination of the two produced a synergistic increase in risk. However, beginning in 1983, investigators have found a significant and growing proportion of HNC patients with human papillomavirus-positive (HPV) tumors who neither drank nor used tobacco. Since that time, there has been increased interest in the molecular biology of HPV-positive HNC. Multiple studies now show that HPV has shifted the epidemiological landscape and prognosis of head and neck squamous cell carcinoma (HNSCC). These studies provide strong evidence for improved survival outcomes in patients with HPV-positive HNSCC compared to those with HPV-negative HNSCC. In many reports, HPV status is the strongest predictor of locoregional control, disease specific survival and overall survival. In response to these findings, there has been significant interest in the best management of HPV-positive disease. Discussions within major cooperative groups consider new trials designed to maintain the current strong survival outcomes while reducing the long-term treatment-related toxicities. This review will highlight the epidemiological, clinical and molecular discoveries surrounding HPV-related HNSCC over the recent decades and we conclude by suggesting how these findings may guide future treatment approaches.

Counseling the patient with potentially HPV-related newly diagnosed head and neck cancer

The recent emergence of a clinically distinct subset of head and neck cancers (HNC) caused by infection with the human papillomavirus (HPV) necessitates critical reevaluation of the existing counseling paradigm for patients with newly diagnosed HNC. Herein we propose a structural framework for patient counseling in which HPV testing is incorporated and the impact of HPV-status is discussed in the context of multiple medical and psychosocial domains. We strive to maintain a balance between making recommendations based on the best available scientific evidence and acknowledgment of uncertainty for both patients and providers. We anticipate that both the standard-of-care diagnostic workup and treatment, and counseling guidelines for these patients will change rapidly in the years ahead, as data from ongoing and planned prospective clinical trials become available.

[Human papilloma virus in head and neck cancer]

Head and neck cancer is frequently associated with alcohol and tobacco consumption but there is an increasing incidence of oropharyngeal carcinoma associated with oncogenic type-16 human papillomavirus (HPV). The clinical profile of these patients is distinct from that of other patients, with an earlier onset, 1/1 male to female sex ratio, cystic cervical nodes. Detection of intratumoral viral DNA is essential to confirm the role of HPV. According to several reports, the prognosis in terms of survival and locoregional control is better in HPV-positive oropharyngeal carcinoma than in HPV-negative oropharyngeal carcinoma or associated with tobacco consumption. The future lies in vaccination of women against cervical cancer but vaccination of boys will be certainly necessary.

PCR based detection of HPV 16 and 18 genotypes in normal oral mucosa of tobacco users and non-users

There is increasing evidence of a causal association between human papillomavirus (HPV) and oral squamous cell carcinoma (OSCC). Several studies have shown that HPV is associated with increased risk of oral cancer independent of exposure to tobacco and alcohol. The association is valid for HPVs 16 and 18, which generally are considered high risk types, because they have been detected in oral dysplastic lesions and cancers. We determined the baseline prevalence of HPVs 16 and 18 in normal oral mucosa of individuals with and without tobacco habit. PCR was used for DNA collected by oral smears to detect HPV 16/18 DNA in normal oral mucosa of 60 healthy individuals who were assigned to two groups of 30 subjects each. One group had a tobacco habit, the other did not. The tobacco user group comprised individuals who were tobacco chewers only. Sixty-five percent of individuals were positive for HPV 16/18 DNA, but HPV 16/18 positivity was less in individuals with tobacco habit than in those without tobacco habit. No significant association was found between the presence of HPVs and gender, age or duration of chewing habit, or between groups with and without a tobacco habit. We propose that HPVs16 and 18 commonly are present in normal oral mucosa and emphasize the importance of distinguishing clinical, subclinical and latent HPV infections when investigating HPVs and OSCC.

Human Papillomavirus (HPV) - structure, epidemiology and pathogenesis

The number of cancers is constantly increasing. An important role in the etiology of many of them is played by the viral factor, by oncogenic viruses, such as the Human Papillomavirus. The article shows current epidemiological situation and describes the structure of the virus and modes of transmission. It also explains the role of HPV infection in cancer with particular emphasis on oropharynx and head and neck cancer. Summarizing, HPV infection plays an important role in carcinogenesis of the oropharynx tumors. The presence of viral genetic material in the tumor may influence prognosis and treatment method choices.

Squamous cell carcinoma of the tonsil managed by conventional surgery and postoperative radiation

BACKGROUND

The purpose of this study was to report the long-term outcome of patients with squamous cell cancer (SCC) of the tonsil managed by surgery followed by postoperative radiotherapy (PORT).

METHODS

Eighty-eight patients treated between 1985 and 2005 were analyzed. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were determined by the Kaplan-Meier method. Factors predictive of outcome were determined by univariate and multivariate analysis.

RESULTS

Forty-eight percent of patients had T3 to T4 disease and 75% had a positive neck. Five-year OS, DSS, and RFS were 66%, 82%, and 80%, respectively. The status of the neck was not predictive of outcome (DSS 80% for N0 vs 82% for N+; p = .97). Lymphovascular invasion was an independent predictor of OS, DSS, and RFS on multivariate analysis.

CONCLUSION

Lymphovascular invasion but not pathological stage of the neck is an independent predictor of outcome in patients with tonsillar SCC.

Quality of life, shoulder range of motion, and spinal accessory nerve status in 5-year survivors of head and neck cancer

OBJECTIVE

To determine the association of neck dissection and radiation treatment for head and neck cancer (HNC) with subsequent shoulder range of motion (ROM) and quality of life (QOL) in 5-year survivors.

DESIGN

A cross-sectional convenience sample.

SETTING

Otolaryngology clinics at tertiary care hospital and Veterans Affairs medical center.

PATIENTS

Five-year, disease-free survivors of HNC.

METHODS

Demographic and cancer treatment information was collected, including type of neck dissection (none, spinal accessory "nerve sparing," and "nerve sacrificing") and radiation. QOL questionnaires were administered, and shoulder ROM was measured.

MAIN OUTCOME MEASUREMENTS

University of Washington Quality of Life (UWQOL), Functional Assessment of Cancer Therapy (FACT) Head and Neck, and Performance Status Scale for Head and Neck. Shoulder ROM measurements included abduction, adduction, flexion, extension, internal and external rotation.

RESULTS

One hundred and five survivors completed QOL surveys; 85 survivors underwent additional shoulder ROM evaluations. The nerve sacrifice group exhibited significantly poorer scores for UWQOL measures of disfigurement, level of activity, recreation and/or entertainment, speech and shoulder disability, and willingness to eat in public, FACT functional well-being, and FACT Head and Neck (P < .05). Shoulder ROM for flexion and abduction was poorest in the nerve sacrifice group (P < .05). Radiation was associated with significantly worse UWQOL swallowing (P < .05), but no other differences were found for QOL or ROM measurements. Decreased QOL scores were associated with decreased shoulder flexion and abduction (P < .05). Survivors with decreased shoulder abduction had significantly (P < .05) worse scores in disfigurement, recreation and/or entertainment, employment, shoulder disability, and FACT emotional well-being.

CONCLUSIONS

Sparing the spinal accessory nerve during neck dissection is associated with significantly less long-term shoulder disability in 5-year survivors of HNC. QOL measures demonstrated the highest level of function in the no dissection group, an intermediate level of functioning with nerve sparing, and poorest function when the nerve is sacrificed. Decreased shoulder flexion and abduction is associated with reduced QOL in long-term survivors of HNC.

Identification of human papillomavirus status specific biomarker in head and neck cancer

BACKGROUND

In an attempt to improve the prognosis of patients with head and neck cancer, it could be necessary to identify biomarkers in homogeneous subgroups of patients with head and neck cancer.

METHODS

We explored the necessity of human papillomavirus (HPV) status-specific biomarkers in patients with head and neck cancer and identified an HPV status-specific gene set. The identified gene set was validated with the external microarray datasets. For this purpose, we used 4 microarray datasets obtained from a public database. One dataset was used for identifying the HPV status specific gene set, and the other datasets were used for validation.

RESULTS

The identified gene set for distinguishing head and neck cancer from head and neck normal, did not accurately discriminate the HPV specific patients with head and neck cancer from the head and neck normal group. Also, it was demonstrated that some HPV-positive (HPV+) head and neck cancer-specific genes may not be significant in HPV-negative (HPV-) head and neck cancer patients. The identified HPV specific gene sets showed good performance in validation datasets. The HPV+ head and neck cancer-specific gene set included various metabolism-related pathways, and the HPV- head and neck cancer-specific gene set included several pathways; fibroblast, collagen degradation, actin-binding, and actin cytoskeleton.

CONCLUSION

The identification of HPV status-specific significant gene set was necessary. It is expected that HPV status-specific biomarkers can be helpful in deciding therapeutic methods for patients with head and neck cancer, after biological validation and large prospective trials.

Estimate of the impact of FDG-avidity on the dose required for head and neck radiotherapy local control

Background and purpose

Although FDG-avid tumors are recognized as a potential target for dose escalation, there is no clear basis for selecting a boost dose to counter this apparent radioresistance. Using a novel analysis method, based on the new concept of an outcome-equivalent dose, we estimate the extra dose required to equalize local control between FDG-avid and non-avid head and neck tumors.

Materials and methods

Based on a literature review, five reports of head and neck cancer (423 patients in total), along with an internal validation dataset from our institution (135 oropharynx patients), were used in this analysis. To compensate for the heterogeneity among multi-institutional patient cohorts and corresponding treatment techniques, local control data of the cohorts were fit to a single dose–response curve with a clinically representative steepness (γ₅₀ = 2), thereby defining an ‘outcome-equivalent dose’ (OED) for each institutional cohort. Separate dose–response curves were then determined for the FDG-avid and FDG-non-avid patient cohorts, and the ratio of TD₅₀ (tumor dose required for 50% of control) values between the high- and low-FDG-uptake groups (TD_50,high/TD_50,low) was estimated, resulting in an estimated metabolic dose-modifying factor (mDMF) due to FDG-avidity.

Results

For individual datasets, the estimated mDMFs were found to be in the range of 1.07–1.62, decreasing if the assumed slope (γ₅₀) increased. Weighted logistic regression for the six datasets resulted in a mDMF of 1.19 [95% CI: 1.04–1.34] for a γ₅₀ value of 2, which translates to a needed dose increase of about 1.5 Gy per unit increase in the maximum standardized uptake value (SUV_m) of FDG-PET [95% CI: 0.3–2.7]. Assumptions of lower or higher γ₅₀ values (1.5 or 2.5) resulted in slightly different mDMFs: 1.26 or 1.15, respectively. A validation analysis with seven additional datasets, based on relaxed criteria, was consistent with the estimated mDMF.

Conclusions

We introduced a novel outcome-equivalent dose analysis method to estimate the dose– response modifying effect of FDG uptake variation. To reach equal response rates, FDG-avid tumors are likely to require 10% to 30% more dose than FDG-non-avid tumors. These estimates provide a rational starting point for selecting IMRT boosts for FDG-avid tumors. However, independent tests and refinements of the estimated dose-modifying effect, using high-quality prospective clinical trial data, are needed.

Human papillomavirus 16 detected in nasopharyngeal carcinomas in white Americans but not in endemic Southern Chinese patients

BACKGROUND

We evaluated the relationship of human papillomavirus (HPV) and Epstein-Barr virus (EBV) with race in endemic and nonendemic cohorts of patients with nasopharyngeal carcinoma (NPC), and with smoking status in the nonendemic cohort.

METHODS

Tissue microarrays (TMAs) were constructed using samples from 86 patients treated in southern China and 108 patients from Stanford, California. TMAs were stained with p16, HPV in situ hybridization (ISH), and EBV ISH. Polymerase chain reaction (PCR) was used to confirm EBV(-) cases and HPV status in p16(+) cases. Survival data was available for the Stanford cohort only.

RESULTS

No HPV(+) cases were detected in the Chinese cohort. In the Stanford cohort, 5 of 11 EBV(-) cases harbored HPV-16, 10 of 10 occurred in whites, and 8 of 11 were smokers. Patients with EBV(-) NPC also showed a trend toward worse survival.

CONCLUSION

EBV(-) NPC shows an association with the presence of HPV, white race, and smoking. In contrast, EBV(-) NPC shows no association with HPV in the endemic cohort.

Treatment outcomes and prognostic factors, including human papillomavirus, for sinonasal undifferentiated carcinoma: a retrospective review

BACKGROUND

Sinonasal undifferentiated carcinoma (SNUC) is a high-grade, aggressive neoplasm. Low incidence and poor outcomes make identification of prognostic factors and treatment standardization difficult. Similarly, little is known regarding the association of human papillomavirus (HPV) with SNUC.

METHODS

A retrospective review was conducted. Extracted information included treatment received, tumor recurrence, patient survival, p16 expression, and HPV status. The Kaplan-Meier method was used to estimate overall survival (OS) and disease-free survival (DFS). Survival trends were compared using the log-rank test.

RESULTS

Nineteen patients received multimodality treatment for SNUC. Five-year OS and DFS rates were 45.2% and 50.7%, respectively, with no significant difference between treatment types. Tumors from 11 patients were p16-positive and 9 of these were also HPV-positive. Kaplan-Meier analysis demonstrated improved survival.

CONCLUSION

Our series demonstrates a higher prevalence of HPV in SNUC than previously reported. HPV-positive SNUCs may benefit from improved survival and should be investigated further in future studies.

Paxillin promotes tumor progression and predicts survival and relapse in oral cavity squamous cell carcinoma by microRNA-218 targeting

High-risk human papillomavirus (HPV) 16-infected oral cavity squamous cell carcinoma (OCSCC) differs significantly from non-HPV-infected OCSCC. However, the molecular pathogenesis of HPV-infected OCSCC remains unclear. Paxillin (PXN) has been reported to promote lung tumor progression by miR-218 targeting. In addition, expression of miR-218 has been shown to be reduced by HPV16 E6 in cervical cancer. We thus asked whether PXN can promote tumor progression by E6-reduced miR-218 in OCSCC, especially in HPV-infected OCSCC. Mechanistic studies demonstrated that PXN expression increased markedly upon E6-mediated reductions in miR-218, resulting in increased colony formation and invasion capabilities in HPV-infected OCSCC cells. Among tumor specimens, HPV16/18 infection was negatively associated with miR-218 expression and positively associated with PXN expression. Kaplan-Meier and Cox regression models demonstrated that patients with low-miR-218 tumors or high-PXN tumors exhibited shorter overall survival (OS) and relapse-free survival (RFS) than those with high-miR-218 tumors or low-PXN tumors. Interestingly, HPV-infected patients with low-miR-218, high-PXN tumors and both combinations exhibited the worst OS and RFS compared with patients in their counterparts. These observations in patients were consistent with the findings from the cell model. Therefore, we suggest that PXN might be targeted to suppress tumor progression and consequently to improve outcomes in OCSCC, especially in HPV-infected OCSCC.

Combination of anti-HER3 antibody MM-121/SAR256212 and cetuximab inhibits tumor growth in preclinical models of head and neck squamous cell carcinoma

The EGFR monoclonal antibody cetuximab is the only approved targeted agent for treating head and neck squamous cell carcinoma (HNSCC). Yet resistance to cetuximab has hindered its activity in this disease. Intrinsic or compensatory HER3 signaling may contribute to cetuximab resistance. To investigate the therapeutic benefit of combining MM-121/SAR256212, an anti-HER3 monoclonal antibody, with cetuximab in HNSCC, we initially screened 12 HNSCC cell lines for total and phosphorylated levels of the four HER receptors. We also investigated the combination of MM-121 with cetuximab in preclinical models of HNSCC. Our results revealed that HER3 is widely expressed and activated in HNSCC cell lines. MM-121 strongly inhibited phosphorylation of HER3 and AKT. When combined with cetuximab, MM-121 exerted a more potent antitumor activity through simultaneously inhibiting the activation of HER3 and EGFR and consequently the downstream PI3K/AKT and ERK pathways in vitro. Both high and low doses of MM-121 in combination with cetuximab significantly suppressed tumor growth in xenograft models and inhibited activations of HER3, EGFR, AKT, and ERK in vivo. Our work is the first report on this new combination in HNSCC and supports the concept that HER3 inhibition may play an important role in future therapy of HNSCC. Our results open the door for further mechanistic studies to better understand the role of HER3 in resistance to EGFR inhibitors in HNSCC.

Trends in oral cavity, pharyngeal, oesophageal and gastric cancer mortality rates in Spain, 1952-2006: an age-period-cohort analysis

BACKGROUND

Although oral cavity, pharyngeal, oesophageal and gastric cancers share some risk factors, no comparative analysis of mortality rate trends in these illnesses has been undertaken in Spain. This study aimed to evaluate the independent effects of age, death period and birth cohort on the mortality rates of these tumours.

METHODS

Specific and age-adjusted mortality rates by tumour and sex were analysed. Age-period-cohort log-linear models were fitted separately for each tumour and sex, and segmented regression models were used to detect changes in period- and cohort-effect curvatures.

RESULTS

Among men, the period-effect curvatures for oral cavity/pharyngeal and oesophageal cancers displayed a mortality trend that rose until 1995 and then declined. Among women, oral cavity/pharyngeal cancer mortality increased throughout the study period whereas oesophageal cancer mortality decreased after 1970. Stomach cancer mortality decreased in both sexes from 1965 onwards. Lastly, the cohort-effect curvature showed a certain degree of similarity for all three tumours in both sexes, which was greater among oral cavity, pharyngeal and oesophageal cancers, with a change point in evidence, after which risk of death increased in cohorts born from the 1910-1920s onwards and decreased among the 1950-1960 cohorts and successive generations. This latter feature was likewise observed for stomach cancer.

CONCLUSIONS

While the similarities of the cohort effects in oral cavity/pharyngeal, oesophageal and gastric tumours support the implication of shared risk factors, the more marked changes in cohort-effect curvature for oral cavity/pharyngeal and oesophageal cancer could be due to the greater influence of some risk factors in their aetiology, such as smoking and alcohol consumption. The increase in oral cavity/pharyngeal cancer mortality in women deserves further study.

High-risk human papillomavirus is transcriptionally active in a subset of sinonasal squamous cell carcinomas

It has been reported that high-risk human papillomavirus (HPV) is a causative agent of a subgroup of oropharyngeal carcinomas. In these tumors, the presence of the transcriptionally active HPV has been proved through the identification of HPV E6 or E7 messenger RNA (mRNA) transcripts. The aim of the study was to assess the HPV-active transcription in a series of sinonasal carcinomas, in correlation with the HPV DNA identification and the p16 immunohistochemistry. Seventy patients with squamous cell carcinomas of the sinonasal tract were included in the survey. The main clinicopathological characteristics were recorded. All tumors were investigated for HPV through the HPV DNA detection by PCR, using the SPF10 primers and by in situ hybridization, using the high-risk GenPoint probe (Dako, Glostrup, Denmark). HPV16 E7 mRNA transcripts detection was performed by RT-PCR in 27 cases. The immunostaining for p16 was performed in all cases. Fourteen carcinomas (20%) were positive for high-risk HPV by PCR: 13 HPV16 and one HPV35. In situ hybridization showed a dotted nuclear positivity in all these cases. HPV16 E7 mRNA was detected in seven tumors harboring HPV16; in the remaining HPV-positive cases, RNA did not reach the quality for analysis. Strong, diffuse positivity for p16 was observed only in the HPV-positive cases. The 14 HPV-positive squamous cell carcinomas were non-keratinizing or scarcely keratinizing tumors. No significant differences were found in terms of gender, age, or staging at diagnosis between HPV-positive and HPV-negative tumors. However, differences in disease-free survival and overall survival between both groups of patients were significant (P=0.004 and P=0.028, respectively). In conclusion, we have shown that HPV is the etiological agent of a subset of sinonasal carcinomas demonstrating the transcriptionally active HPV in these tumors. Immunostaining for p16 can be used as a surrogate marker to identify these tumors.

High-risk human papillomavirus detection in oropharyngeal, nasopharyngeal, and oral cavity cancers: comparison of multiple methods

IMPORTANCE

Human papillomaviruses are now recognized as an etiologic factor in a growing subset of head and neck cancers and have critical prognostic importance that affects therapeutic decision making. There is no universally accepted gold standard for high-risk HPV (hrHPV) assessment in formalin-fixed, paraffin-embedded (FFPE) tissue specimens, nor is there a clear understanding of the frequency or role of hrHPV in sites other than oropharynx.

OBJECTIVE

To determine the optimal assessment of hrHPV in FFPE head and neck tumor tissue specimens.

DESIGN, SETTING, PARTICIPANTS

In the setting of a large Midwestern referral center, assessment of hrHPV by p16 immunohistochemical staining, in situ hybridization, and polymerase chain reaction (PCR)-MassArray (PCR-MA), with L1 PGMY-PCR and sequencing to resolve method discordance, was conducted for 338 FFPE oropharyngeal, nasopharyngeal, and oral cavity tumor tissue specimens. Relative sensitivity and specificity were compared to develop a standard optimal test protocol. Tissue specimens were collected from 338 patients with head and neck cancer treated during the period 2001 through 2011 in the departments of Otolaryngology, Radiation Oncology, and Medical Oncology.

INTERVENTION

Patients received standard therapy.

MAIN OUTCOMES AND MEASURES

Optimal hrHPV identification, detection, and activity in head and neck cancers.

RESULTS

Using combined PCR-MA with L1 PGMY-PCR and sequencing for conclusive results, we found PCR-MA to have 99.5% sensitivity and 100% specificity, p16 to have 94.2% sensitivity and 85.5% specificity, and in situ hybridization to have 82.9% sensitivity and 81.0% specificity. Among HPV-positive tumors, HPV16 was most frequently detected, but 10 non-HPV16 types accounted for 6% to 50% of tumors, depending on the site. Overall, 86% of oropharynx, 50% of nasopharynx, and 26% of oral cavity tumors were positive for hrHPV.

CONCLUSIONS AND RELEVANCE

PCR-MA has a low DNA (5 ng) requirement effective for testing small tissue samples; high throughput; and rapid identification of HPV types, with high sensitivity and specificity. PCR-MA together with p16INK4a provided accurate assessment of HPV presence, type, and activity and was determined to be the best approach for HPV testing in FFPE head and neck tumor tissue specimens.

Correlation between human papillomavirus and p16 overexpression in oropharyngeal tumours: a systematic review

Background:

A significant proportion of squamous cell carcinomas of the oropharynx (OP-SCC) are related to human papillomavirus (HPV) infection and p16 overexpression. This subgroup proves better prognosis and survival but no evidence exists on the correlation between HPV and p16 overexpression based on diagnostic measures and definition of p16 overexpression. We evaluated means of p16 and HPV diagnostics, and quantified overexpression of p16 in HPV-positive and -negative OP-SCCs by mode of immunohistochemical staining of carcinoma cells.

Methods:

PubMed, Embase, and the Cochrane Library were searched from 1980 until October 2012. We applied the following inclusion criteria: a minimum of 20 cases of site-specific OP-SCCs, and HPV and p16 results present. Studies were categorised into three groups based on their definition of p16 overexpression: verbal definition, nuclear and cytoplasmatic staining between 5 and 69%, and ⩾70% staining.

Results:

We identified 39 studies with available outcome data (n=3926): 22 studies (n=1980) used PCR, 6 studies (n=688) used ISH, and 11 studies (n=1258) used both PCR and ISH for HPV diagnostics. The methods showed similar HPV-positive results. Overall, 52.5% of the cases (n=2062) were HPV positive. As to p16 overexpression, 17 studies (n=1684) used a minimum of 5–69% staining, and 7 studies (n=764) used ⩾70% staining. Fifteen studies (n=1478) referred to a verbal definition. Studies showed high heterogeneity in diagnostics of HPV and definition of p16. The correlation between HPV positivity and p16 overexpression proved best numerically in the group applying ⩾70% staining for p16 overexpression. The group with verbal definitions had a significantly lower false-positive rate, but along with the group applying 5–69% staining showed a worse sensitivity compared with ⩾70% staining.

Conclusions:

There are substantial differences in how studies diagnose HPV and define p16 overexpression. Numerically, p16 staining is better to predict the presence of HPV (i.e. larger sensitivity), when the cutoff is set at ⩾70% of cytoplasmatic and nuclear staining.

Selective intra-arterial infusion of rAd-p53 with chemotherapy for advanced oral cancer: a randomized clinical trial

BACKGROUND

In this study, a combination of recombinant adenoviral p53 (rAd-p53) gene therapy and intra-arterial delivery of chemotherapeutic agents for treatment of oral squamous cell carcinoma was evaluated.

METHODS

In total, 99 patients with stage III or IV oral carcinoma who had refused or were ineligible for surgery were enrolled in a randomized, placebo-controlled, double-blind, phase III clinical trial. They were randomly assigned to group I (n = 35; intra-arterial infusion of rAd-p53 plus chemotherapy), group II (n = 33; intra-arterial infusion of rAd-p53 plus placebo chemotherapy), or group III (n = 31; intra-arterial infusion of placebo rAd-p53 plus chemotherapy).

RESULTS

The median length of follow-up was 36 months (range, 3 to 86 months). During follow-up, 16 patients in group I, 20 in group II, and 22 in group III died. Group I (48.5%) had a higher complete response rate than groups II (16.7%) and III (17.2%) (P = 0.006). The rate of non-responders in group I was significantly lower than that in groups II and III (P < 0.020). A log-rank test for survival rate indicated that group I had a significantly higher survival rate than group III (P = 0.019). The survival rate of patients with stage III but not stage IV oral cancer was significantly higher in group I than in group III (P = 0.015, P = 0.200, respectively). The survival rate of patients with stage IV did not differ significantly among the three groups. Or the 99 patients, 63 patients experienced adverse events of either transient flu-like symptoms or bone marrow suppression, while 13 patients had both these conditions together. No replication-deficient virus was detected in patient serum, urine, or sputum. rAd-p53 treatment increased Bax expression in the primary tumor of 80% of patients, as shown by immunohistochemical staining.

CONCLUSIONS

Intra-arterial infusion of combined rAd-p53 and chemotherapy significantly increased the survival rate of patients with stage III but not stage IV oral cancer, compared with intra-arterial chemotherapy. Intra-arterial infusion of combined rAd-p53 and chemotherapy may represent a promising alternative treatment for oral squamous cell carcinoma.

TRIAL REGISTRATION

ChiCTR-TRC-09000392 (Date of registration: 2009-05-18).

p16INK4a impairs homologous recombination-mediated DNA repair in human papillomavirus-positive head and neck tumors

The p16INK4a protein is a principal cyclin-dependent kinase inhibitor that decelerates the cell cycle. Abnormally high levels of p16INK4a are commonly observed in human papillomavirus (HPV)-positive head and neck squamous cell carcinomas (HNSCC). We and others found that p16INK4a overexpression is associated with improved therapy response and survival of patients with HNSCC treated with radiotherapy. However, the functional role of p16INK4a in HNSCC remains unexplored. Our results implicate p16INK4a in regulation of homologous recombination-mediated DNA damage response independently from its role in control of the cell cycle. We found that expression of p16INK4a dramatically affects radiation sensitivity of HNSCC cells. p16INK4a overexpression impairs the recruitment of RAD51 to the site of DNA damage in HPV-positive cells by downregulating of cyclin D1 protein expression. Consistent with the in vitro findings, immunostaining of HNSCC patient samples revealed that high levels p16INK4a expression significantly correlated with decreased cyclin D1 expression. In summary, these findings reveal an unexpected function of p16INK4a in homologous recombination-mediated DNA repair response and imply p16INK4a status as an independent marker to predict response of patients with HNSCC to radiotherapy.

Clinicopathologic features of oral squamous cell carcinoma: do they vary in different age groups?

PURPOSE

To analyze clinicopathologic parameters of oral squamous cell carcinoma (OSCC) in different age groups. We hypothesized that clinical and pathologic parameters of OSCCs will vary in different age groups.

MATERIALS AND METHODS

A retrospective cohort study was performed. All patients who were treated for a primary manifestation of OSCC at a single institution from 2001 to 2012 were reviewed and allocated to predefined age groups (predictor variable) as follows: young (≤40 years), middle-aged (40-80 years), and very elderly (≥80 years). The following outcome variables were recorded: demographic parameters, classic risk factors, tumor location and size, neck node involvement, histopathologic and therapeutic details, and association with human papillomavirus (HPV). The descriptive statistics were computed. Parametric and nonparametric tests were used for additional analysis. The significance level was set at P < .05.

RESULTS

We reviewed 739 patients and identified 11 (1.4%) young (mean age 34.2 ± 2.8 years) and 17 (2.3%) very elderly patients (mean age 83.1 ± 1.2 years). The predilection site for OSCC was the oral tongue (63%) in young patients, the floor of the mouth (52%) in middle-aged patients, and the alveolar process (60%) in very elderly patients. One patient in the young group (9%) and 8 patients in the very elderly group (47%) had been exposed to risk factors; however, all of the examined middle-aged patients had had such exposure. The association of OSCC with HPV was distributed equally among the age groups. No age-related differences in the histopathologic parameters of OSCC were found.

CONCLUSIONS

The features of OSCC that vary at different ages are the anatomic predilection site and the association with classic risk factors. HPV was not an age-related independent risk factor for OSCC development in the present study.

Combined modality treatment of laryngeal squamous cell carcinoma

Squamous cell carcinoma of the larynx is a major public health concern; it causes substantial morbidity and mortality, and arises chiefly as a result of tobacco and alcohol consumption. Early stage disease is best treated with radiation or surgery alone, but for patients with more locally advanced squamous cell carcinoma of the larynx, combined modality treatment has been shown to benefit selected patients, particularly when cisplatin-based chemotherapy and concurrent radiation therapy are employed, with or without altered fractionated radiation therapy. Substantial laryngectomy-associated quality-of-life decrements can be avoided in selected, potentially resectable patients with organ-sparing approaches, without sacrificing survival. Recently, trials have addressed the role of targeted systemic agents to the epidermal growth factor receptor, and other targets are under investigation. The addition of induction chemotherapy to concurrent chemoradiotherapy is a promising treatment strategy that warrants further evaluation, but has not yet emerged as a standard of care; the toxicity of such regimens must be balanced with the potential benefits on a case-by-case basis, and functional outcomes are often quite variable. Treatment planning, management and follow-up are complex, and thus should ideally be performed in a comprehensive, multidisciplinary fashion, in a center accustomed to a high volume of such cases. Future research directions are described herein.