Human papillomavirus (HPV) assays for testing fine-needle aspiration specimens in patients with head and neck squamous cell carcinoma

Human papillomavirus testing in metastatic squamous cell carcinoma of the neck with unknown primary using PCR on fine-needle aspiration smears: a prospective clinical study

PURPOSE

Squamous cell carcinoma metastasis of the head and neck with unknown primary tumor (CUP) comprises a diagnostic challenge. Human papillomavirus (HPV) testing on cytologic specimens is gaining increasing focus as this may facilitate an early diagnosis of HPV-induced oropharyngeal carcinoma. This study aimed to prospectively assess PCR-based HPV-DNA testing on FNA smears in a clinical setting.

METHODS

Patients referred to a tertiary Head and Neck Cancer Center with suspected CUP were included from November 2016 to November 2018. Scraped cell material from FNA smears was analyzed for HPV-DNA with PCR using general primers (GP5 + /GP6 +) and correlated with the origin and histology of the primary tumor (oropharynx vs. outside oropharynx or benign tumor). The turn-around time reflecting the workflow for HPV-DNA testing by PCR was also calculated.

RESULTS

A total of 93 patients were enrolled in the study. The sensitivity and specificity were 86.7% [95% CI 75.4-94.1%] and 92.0% [95% CI 74.0-99.0%], and the positive and negative predictive values were 96.3% [95% CI 87.3-99.0%] and 74.2% [95% CI 59.9-84.7%], respectively. The turn-around time for HPV testing was a mean four calendar days.

CONCLUSION

HPV-DNA testing on FNA smears can be performed within a reasonable timeframe and can guide for the detection of an HPV-positive oropharyngeal primary tumor in the clinical setting for patients presenting with CUP of the head and neck.

The prognostic role of radiotherapy and radiotherapy target in cervical lymph node metastatic squamous cell carcinoma with unknown primary: a retrospective study

OBJECTIVES

Aim to analyze the effect of radiotherapy for cervical lymph node metastatic carcinoma with unknown primary (CCUP) and compare the survival benefits between Comprehensive radiotherapy and Involved Field radiotherapy.

MATERIALS AND METHODS

The patients diagnosed with CCUP between 2009 and 2019 in our institution were analyzed retrospectively. The categorical variables were tested by χ² test. Kaplan-Meier method was used for survival analysis. Log-rank test and Cox proportional hazards regression were performed with overall survival (OS) and disease-free survival (DFS) as the primary outcome variables.

RESULTS

Of 139 patients, 64.7% (90/139) of them received radiotherapy. Of the 90 patients who underwent radiotherapy, 45.6% (41/90) received Involved Field radiotherapy and the rest 49 patients received Comprehensive radiotherapy. The median follow-up of 139 patients is 69 months. The 1-year, 3-year, and 5-year OS rates are 87%, 62%, and 39%, respectively, and the DFS rates are 73%, 45%, and 29%, respectively. Multivariate analysis of 139 patients with CCUP shows that differentiation grade, N stage, radiotherapy, and the length of the largest lymph node (D_maxLN) are the independent prognostic factors for both OS and DFS. Subgroup analysis of 90 patients who received radiotherapy shows that the Comprehensive radiotherapy group has a better OS (P < 0.001) and DFS (P < 0.001) compared with Involved Field radiotherapy.

CONCLUSION

Radiotherapy is the independent prognostic factor for CCUP. Comprehensive radiotherapy may be superior to Involved Field radiotherapy in survival benefits.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A global epidemic increase of an HPV-induced tonsil and tongue base cancer - potential benefit from a pan-gender use of HPV vaccine

In 2007, human papillomavirus (HPV) type 16 was finally recognized as a risk factor, besides smoking and alcohol, for oropharyngeal squamous cell carcinoma (OPSCC), including tonsillar squamous cell carcinoma (TSCC), by the International Agency for Research against Cancer. Just before, in 2006, the Food and Drug Administration had approved Gardasil, the first vaccine against HPV16, 18, 6 and 11, for preventive vaccination women against cervical cancer. Concurrently, some Western countries, where smoking was decreasing, disclosed an epidemic increase in the incidence of OPSCC, especially of TSCC and base of tongue cancer (BOTSCC), together accounting for 80-90% of all OPSCCs, and mainly affecting men. The epidemic was later revealed to be due to a rise in HPV-positive cases, and scientists in the field suggested HPV vaccination also of boys. Globally, there are roughly 96 000 incident OPSCC cases/year of which 20-24% are caused by HPV, thereby accounting for around 22 000 OPSCC cases annually. Of these cases, 80-90% are due to HPV16 infection and would be prevented with the presently registered HPV vaccines. In Western countries, such as Sweden (with almost 400 TSCC and BOTSCC cases per year) and the United States, HPV prevalence in OPSCC is higher and around 70%. HPV vaccination of girls has been initiated in many countries, and the vaccines have been efficient and their side effects limited. HPV vaccination of boys has, however, been the exception, but should definitely not be delayed any further. It would benefit both girls and boys directly, and result in better and more robust herd immunity. Today, we have the possibility to eliminate several high-risk HPV types in the younger generations and avoid more than 600 000 cancer cases annually worldwide, and this possibility should be embraced by offering global pan-gender HPV vaccination.

The incidence of malignancy in clinically benign cystic lesions of the lateral neck: our experience and proposed diagnostic algorithm

AIM

Solitary cystic masses of the lateral neck in an adult patient can pose a diagnostic dilemma. Malignancy must be ruled out since metastases arising from H&N cancers may mimic the presentation of benign cystic masses. Only a small number of studies have investigated the diagnostic management and malignancy rate of clinically benign solitary cervical cystic lesions. There are no established guidelines for the diagnostic evaluation.

METHODS

Retrospective review of the clinical, cytological, radiological, and pathological records of all adult patients (> 18 years) operated on for second branchial cleft cysts (BrCC) between 1/2008-2010/2016. Patients with apparent primary H&N malignancy, history of H&N cancer or irradiation, preoperative fine needle aspiration (FNA) of highly suggestive or confirmed malignancy, missing pertinent data, or age less than 18 years were excluded from analysis.

RESULTS

28 patients were diagnosed as having BrCC. The diagnosis was based on clinical findings, FNA cytology, and typical sonographic features. The histologic analysis determined an overall rate of malignancy of 10.7% (3/28): two patients had metastatic papillary thyroid carcinoma, and one patient had metastatic tonsillar squamous cell carcinoma. Purely cystic features on pre-operative ultrasound was the only significant predictor for true BrCC on final histology (p = .02).

CONCLUSIONS

Occult malignancy is not rare among adult patients presenting with a solitary cystic mass of the lateral neck. A diagnostic algorithm is proposed. Further studies are needed to establish the appropriate workup and management of an adult patient presenting with a solitary cystic mass of the lateral neck.

Validation study of HPV DNA detection from stained FNA smears by polymerase chain reaction: Improving the diagnostic workup of patients with a tumor on the neck

BACKGROUND

Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) often presents with cystic cervical metastasis and a small primary tumor localized in the palatine tonsils or base of the tongue, which is diagnostically challenging. Testing for HPV DNA in fine-needle aspiration (FNA) smears from metastases may facilitate a targeted diagnostic workup for identifying the primary tumor. This study was designed to assess the ability to detect HPV DNA in FNA smears with polymerase chain reaction (PCR).

METHODS

May-Grünvald-Giemsa (MGG)-stained FNA smears from metastases and corresponding surgical specimens were collected from 71 patients with known HPV-positive OPSCC, 12 patients with oral squamous cell carcinoma (OSCC), 20 patients with branchial cleft cysts, and 20 patients with Warthin tumors. Thirty-eight patients with OPSCC and 7 patients with OSCC had FNA smears available from metastases and also surgical specimens from the primary tumor and the metastases. The scraped cell material from FNA smears and corresponding surgical specimens were analyzed for HPV DNA by PCR. p16 immunohistochemistry was performed on surgical specimens from the carcinomas.

RESULTS

HPV DNA was detected in 68 of the 71 FNA smears from OPSCC metastases. All corresponding surgical specimens from primary tumors (n = 71) and metastases (n = 38) were p16- and HPV DNA-positive. All the surgical specimens and corresponding FNA smears from OSCCs, Warthin tumors, and branchial cleft cysts were HPV DNA-negative. The sensitivity and specificity were 94.7% and 100%, respectively.

CONCLUSIONS

The detection of HPV DNA in MGG-stained FNA smears by PCR is a valid method that could be implemented in routine clinical practice. Cancer Cytopathol 2016;124:820-7. © 2016 American Cancer Society.

Performance of a Branch Chain RNA In Situ Hybridization Assay for the Detection of High-risk Human Papillomavirus in Head and Neck Squamous Cell Carcinoma

High-risk human papillomavirus (HR-HPV) is a major etiologic agent in a subset of head and neck squamous cell carcinomas (HNSCCs), and its recognition has prognostic and predictive implications. The availability of a sensitive and specific test to assess HR-HPV status is limited. We evaluate an RNA in situ hybridization (ISH) method using branch chain technology to detect HR-HPV and compare its results with DNA ISH, p16 immunohistochemistry, and polymerase chain reaction (PCR). Tissue sections from 54 patients were stained with a manual RNA ISH assay (ViewRNA), which detects 14 HR-HPV types, an automated DNA ISH assay, and p16 immunohistochemistry. Most cases (83%, n=45) were also tested on an automated platform for 14 HR-HPV types and 1 limited to HPV 16/18. PCR was performed in all cases and was successful in 93% (n=50). The RNA ISH assay produced results in 96% of the cases with strong signals and was easily interpreted. HR-HPV was detected in more cases (63%, n=34) by RNA ISH than by DNA ISH (39%, n=21). Compared with PCR, both ISH platforms were 94% specific. RNA ISH was more sensitive (91%) than DNA ISH (65%), and RNA ISH correlated more strongly with p16 immunostaining. HPV 16 represented 89% of HR-HPV detected. The cocktail HPV 16/18 platform was concordant with the pooled HR-HPV assay in all expected cases. The automated assay demonstrated high concordance (96%) with the manual version, showed decreased background, and should allow for easy implementation into the workflow of the diagnostic pathology laboratory.

Molecular diagnosis of infectious diseases using cytological specimens

Pathologists have an important role in the diagnosis of infectious disease (ID). In many cases, a definitive diagnosis can be made using cytopathology alone. However, several ancillary techniques can be used on cytological material to reach a specific diagnosis by identifying the causative agent and consequently defining the management of the patient. This review aims to present the effectiveness of the application of molecular studies on cytological material to diagnose IDs and discuss the advantages and disadvantages of the various molecular techniques according to the type of cytological specimen and the infectious agents.

The role of cytology in the era of HPV-related head and neck carcinoma

Enlarged neck lymph nodes are very often subject to fine needle aspiration biopsy to detect metastatic disease in patients with suspected or proven squamous cell carcinoma in head and neck region. Cytology specimens of metastatic carcinoma in such patients are routinely evaluated for human papilloma virus (HPV) to identify patients with HPV-related head and neck squamous cell carcinoma. Different types of cytology specimens including smears, cytospins, cell blocks and aspirated material in the rinse can all be used for different types of HPV testing such as immunohistochemistry for p16, HPV-in situ hybridization, and HPV-Polymerase chain reaction. There is currently no consensus regarding the testing of high-risk HPV in cytology specimens. The establishment of standardized HPV testing of cytology specimens is of utmost importance and is eagerly awaited.

Detection of human papillomavirus (HPV) in clinical samples: evolving methods and strategies for the accurate determination of HPV status of head and neck carcinomas

Much recent attention has highlighted a subset of head and neck squamous cell carcinomas (HNSCCs) related to human papillomavirus (HPV) that has an epidemiologic, demographic, molecular and clinical profile which is distinct from non-HPV-related HNSCC. The clinical significance of detecting HPV in a HNSCC has resulted in a growing expectation for HPV testing of HNSCCs. Although the growing demand for routine testing is understandable and appropriate, it has impelled an undisciplined approach that has been largely unsystematic. The current state of the art has now arrived at a point where a better understanding of HPV-related tumorigenesis and a growing experience with HPV testing can now move wide scale, indiscriminant and non-standardized testing towards a more directed, clinically relevant and standardized approach. This review will address the current state of HPV detection; and will focus on why HPV testing is important, when HPV testing is appropriate, and how to test for the presence of HPV in various clinical samples. As no single test has been universally accepted as a best method, this review will consider the strengths and weaknesses of some of the more commonly used assays, and will emphasize some emerging techniques that may improve the efficiency of HPV testing of clinical samples including cytologic specimens.