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Abstract
Papillomaviruses are one of the oldest viruses known, dating back 330 million years. During this long evolution, human papillomaviruses (HPV) have developed into hijackers of human cellular and immune systems in which they replicate and remain silent. Systematic studies on oral HPV infections and their outcomes are still scarce. Oral HPV infections have been linked to sexual behaviour, but recent evidence supports their horizontal, mouth‐to‐mouth, transmission. Most HPV infections in infants are acquired vertically from the mother during the intrauterine period, during delivery, or later via saliva. The best‐known benign clinical manifestations of HPV infection are oral papilloma/condyloma and focal epithelial hyperplasia. Evidence is emerging which suggests that some oral HPV infections might persist. Persistent HPV infection is mandatory for HPV‐associated malignant transformation. However, progression of HPV‐induced lesions to malignancy requires additional cofactors. In the early 1980s, we provided the first evidence that a subset of oral cancers and other head and neck cancers might be causally linked to HPV infection. This review summarizes current knowledge on the virus itself, its transmission modes, as well as the full spectrum of oral HPV infections – from asymptomatic infections to benign, potentially malignant oral lesions, and squamous cell carcinoma.
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Affiliation(s)
- Stina Syrjänen
- Department of Oral Pathology and Oral Radiology, Institute of Dentistry, Faculty of Medicine, University of Turku, Turku, Finland.,Department of Pathology, Turku University Hospital, Turku, Finland
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Layfield LJ, Esebua M, Schmidt RL. Cytologic separation of branchial cleft cyst from metastatic cystic squamous cell carcinoma: A multivariate analysis of nineteen cytomorphologic features. Diagn Cytopathol 2016; 44:561-7. [PMID: 26956661 DOI: 10.1002/dc.23461] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/04/2016] [Accepted: 02/12/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND The separation of branchial cleft cysts from metastatic cystic squamous cell carcinomas in adults can be clinically and cytologically challenging. Diagnostic accuracy for separation is reported to be as low as 75% prompting some authors to recommend frozen section evaluation of suspected branchial cleft cysts before resection. We evaluated 19 cytologic features to determine which were useful in this distinction. METHODS Thirty-three cases (21 squamous carcinoma and 12 branchial cysts) of histologically confirmed cystic lesions of the lateral neck were graded for the presence or absence of 19 cytologic features by two cytopathologists. The cytologic features were analyzed for agreement between observers and underwent multivariate analysis for correlation with the diagnosis of carcinoma. RESULTS Interobserver agreement was greatest for increased nuclear/cytoplasmic (N/C) ratio, pyknotic nuclei, and irregular nuclear membranes. Recursive partitioning analysis showed increased N/C ratio, small clusters of cells, and irregular nuclear membranes were the best discriminators. CONCLUSION The distinction of branchial cleft cysts from cystic squamous cell carcinoma is cytologically difficult. Both digital image analysis and p16 testing have been suggested as aids in this separation, but analysis of cytologic features remains the main method for diagnosis. In an analysis of 19 cytologic features, we found that high nuclear cytoplasmic ratio, irregular nuclear membranes, and small cell clusters were most helpful in their distinction. Diagn. Cytopathol. 2016;44:561-567. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Lester J Layfield
- Department of Pathology and Anatomical Sciences, University of Missouri, Columbia, Missouri
| | - Magda Esebua
- Department of Pathology and Anatomical Sciences, University of Missouri, Columbia, Missouri
| | - Robert L Schmidt
- Department of Pathology and Laboratory Medicine and ARUP Laboratories, University of Utah, Salt Lake City, Utah
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Banet N, Rooper LM, Maleki Z. Metastatic HPV-related head and neck squamous cell carcinoma to the lung and mediastinal lymph nodes in aspirated cytology material: A diagnostic pitfall. Diagn Cytopathol 2016; 44:206-14. [PMID: 26764038 DOI: 10.1002/dc.23425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 12/10/2015] [Accepted: 12/16/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Although HPV-related head and neck squamous cell carcinoma (HNSCC) has good prognosis, a small proportion of patients develop distant metastases and have worse outcomes. Such metastases can be particularly difficult to diagnose in the lung and mediastinum, where they show extensive morphologic overlap with primary pulmonary neoplasms. This case series discusses metastatic HPV-related HNSCC in lung and mediastinal fine needle aspiration (FNA) cytology. METHODS The cytopathology archives were searched for lung and mediastinal FNA specimens of patients with HNSCC. Specimens were included if either the index FNA or the patient's original HNSCC was positive for HPV by DNA in-situ hybridization (ISH). Ten such cases were identified. Patient demographics and primary tumor details were tabulated from the electronic medical record. All FNA slides and stains were reviewed. RESULTS The ten patients (mean age of 58.2 years) included 4 smokers. Smears from all cases were hypercellular and hyperchromatic, with focal keratinization in 6/10 (60%). Core biopsies and cell blocks showed basaloid morphology with variable amounts of necrosis. All ten FNAs were diffusely positive for p16 (100%) and 7/9 cases stained (77.8%) were positive for HPV DNA ISH. CONCLUSIONS Metastatic HPV-related HNSCC to the lung and mediastinal lymph nodes share the characteristic basaloid, minimally keratinizing morphology seen in Primary HNSCC cytology. Poorly differentiated pulmonary squamous cell carcinoma and neuroendocrine carcinomas are the primary differentials. Although primary lung neoplasms are not HPV-related, p16 positivity can be seen in both squamous cell and small cell lung carcinomas. HPV ISH allows definitive diagnosis of metastatic HPV-related HNSCC.
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Affiliation(s)
- Natalie Banet
- Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lisa M Rooper
- Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zahra Maleki
- Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, Maryland
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Canberk S, Longatto-Filho A, Schmitt F. Molecular diagnosis of infectious diseases using cytological specimens. Diagn Cytopathol 2015; 44:156-64. [PMID: 26620694 DOI: 10.1002/dc.23394] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 11/13/2015] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Sule Canberk
- Department of Pathology-Cytopathology, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey
| | - Adhemar Longatto-Filho
- Laboratory of Medical Investigation (LIM) 14, Faculty of Medicine, São Paulo University, FMUSP, São Paulo, Brazil.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga, Portugal.,Molecular Oncology Center, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Fernando Schmitt
- Department of Pathology and Medicine, Laboratoire National De Sante, Dudelange, Luxembourg.,Instituto De Patologia E Imunologia Molecular Da Universidade Do Porto (IPATIMUP) E Faculdade De Medicina Do Porto, Porto, Portugal
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Whang SN, Filippova M, Duerksen-Hughes P. Recent Progress in Therapeutic Treatments and Screening Strategies for the Prevention and Treatment of HPV-Associated Head and Neck Cancer. Viruses 2015; 7:5040-65. [PMID: 26393639 PMCID: PMC4584304 DOI: 10.3390/v7092860] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/17/2015] [Accepted: 08/27/2015] [Indexed: 12/11/2022] Open
Abstract
The rise in human papillomavirus (HPV)-associated head and neck squamous cell carcinoma (HNSCC) has elicited significant interest in the role of high-risk HPV in tumorigenesis. Because patients with HPV-positive HNSCC have better prognoses than do their HPV-negative counterparts, current therapeutic strategies for HPV+ HNSCC are increasingly considered to be overly aggressive, highlighting a need for customized treatment guidelines for this cohort. Additional issues include the unmet need for a reliable screening strategy for HNSCC, as well as the ongoing assessment of the efficacy of prophylactic vaccines for the prevention of HPV infections in the head and neck regions. This review also outlines a number of emerging prospects for therapeutic vaccines, as well as for targeted, molecular-based therapies for HPV-associated head and neck cancers. Overall, the future for developing novel and effective therapeutic agents for HPV-associated head and neck tumors is promising; continued progress is critical in order to meet the challenges posed by the growing epidemic.
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Affiliation(s)
- Sonia N Whang
- Department of Basic Science, Loma Linda University, Loma Linda, CA 92354, USA.
| | - Maria Filippova
- Department of Basic Science, Loma Linda University, Loma Linda, CA 92354, USA.
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Hakima L, Adler E, Prystowsky M, Schiff B, Schlecht N, Fox A, Suhrland M, Khader SN. Hybrid Capture 2 human papillomavirus testing of fine needle aspiration cytology of head and neck squamous cell carcinomas. Diagn Cytopathol 2015; 43:683-7. [DOI: 10.1002/dc.23278] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 01/06/2015] [Accepted: 03/30/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Laleh Hakima
- Department of Pathology; Montefiore Medical Center; Bronx New York
| | - Esther Adler
- Department of Pathology; Montefiore Medical Center; Bronx New York
| | | | - Bradley Schiff
- Department of Otolaryngology; Head & Neck Surgery; Montefiore Medical Center; Bronx New York
| | - Nicolas Schlecht
- Department of Epidemiology and Population Health; Montefiore Medical Center; Bronx New York
| | - Amy Fox
- Department of Pathology; Montefiore Medical Center; Bronx New York
| | - Mark Suhrland
- Department of Pathology; Montefiore Medical Center; Bronx New York
| | - Samer N. Khader
- Department of Pathology; Montefiore Medical Center; Bronx New York
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VanderLaan PA. Molecular markers: Implications for cytopathology and specimen collection. Cancer Cytopathol 2015; 123:454-60. [DOI: 10.1002/cncy.21560] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 04/09/2015] [Accepted: 04/27/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Paul A. VanderLaan
- Department of Pathology; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston Massachusetts
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Westra WH. The pathology of HPV-related head and neck cancer: implications for the diagnostic pathologist. Semin Diagn Pathol 2015; 32:42-53. [PMID: 25804343 DOI: 10.1053/j.semdp.2015.02.023] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A subset of head and neck squamous cell carcinomas are caused by the human papillomavirus (HPV). This HPV-related form of head and neck squamous cell carcinoma (HPV-HNSCC) has captured the attention of the oncology community for its rising incidence, its link to non-traditional risk factors, and its divergent clinical behavior. To diagnose this special form of head and neck squamous cell carcinoma is to provide important prognostic information and, in some instances, redirect clinical therapy. The diagnosis of HPV-HNSCC is aided by a strong appreciation for its characteristic microscopic findings and by an awareness of aberrant features that set apart a growing list of HPV-HNSCC morphologic variants. This review will delineate the microscopic appearance of HPV-HNSCC, spotlight ways in which the misinterpretation of these microscopic features can lead to diagnostic confusion, offer recommendations for appropriate terminology when diagnosing HPV-HNSCC, and provide examples of specific diagnostic scenarios where HPV testing can inform the diagnostic process.
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Affiliation(s)
- William H Westra
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Oncology, The Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Otolaryngology/Head and Neck Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
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The Diagnosis of HPV-Related HNSCC: Recognition of Its Microscopic Appearance and the Use of Ancillary Detection Assays. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/978-81-322-2413-6_5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Roy-Chowdhuri S, Krishnamurthy S. The role of cytology in the era of HPV-related head and neck carcinoma. Semin Diagn Pathol 2014; 32:250-7. [PMID: 25638437 DOI: 10.1053/j.semdp.2014.12.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Sinchita Roy-Chowdhuri
- Department of Pathology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 053, Houston, TX 77030-4095
| | - Savitri Krishnamurthy
- Department of Pathology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 053, Houston, TX 77030-4095.
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Donà MG, Giuliani M, Vocaturo A, Spriano G, Pichi B, Rollo F, Ronchetti L, Covello R, Pescarmona E, Benevolo M. Cytology and human papillomavirus testing on cytobrushing samples from patients with head and neck squamous cell carcinoma. Cancer 2014; 120:3477-84. [PMID: 25043660 DOI: 10.1002/cncr.28909] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 06/11/2014] [Accepted: 06/17/2014] [Indexed: 01/14/2023]
Abstract
BACKGROUND The increasing incidence of human papillomavirus (HPV)-related head and neck squamous cell carcinoma (HNSCC) highlights the need for simple and effective tools to evaluate head and neck lesions and their HPV status. The main objective of the current study was to investigate the association between abnormal cytology and HPV infection, assessed on cytobrushing samples, and histologically confirmed HNSCC. Second, the authors attempted to investigate whether HPV status on cytobrushing samples reflected that of the tumoral tissue. METHODS A total of 164 samples from HNSCC, nonmalignant lesions, or healthy mucosae of the oral cavity and oropharynx were collected by cytobrushing in PreservCyt solution and evaluated by liquid-based cytology and Linear Array HPV genotyping test. All the findings from the cytologic samples were compared with those from the corresponding histologic samples. RESULTS Patients with abnormal cytology had a significantly higher risk of having an HNSCC (odds ratio [OR], 9.18; 95% confidence inteval [95% CI], 3.27-26.49). The association was stronger for oral cancer (OR, 10.86; 95% CI, 2.51-51.06) than oropharyngeal cancer (OR, 8.45; 95% CI, 1.62-49.82). HPV positivity in the oropharyngeal cytobrushing was associated with a nearly 5-fold higher risk of having abnormal cytology (OR, 4.57; 95% CI, 1.57-13.57) as well as histologically proven oropharyngeal cancer (OR, 5.09; 95% CI, 1.09-31.61). Comparing the HPV status on cytologic and corresponding histologic samples from patients with HNSCC, we found that 90.4% of the cases were concordant (kappa, 0.796). CONCLUSIONS Abnormal brushing cytology is strongly associated with a diagnosis of HNSCC, whereas HPV positivity on cytobrushing samples is only associated with oropharyngeal cancer. HPV testing on cytobrushing samples represents a valid option for the assessment of HPV infection in patients with oropharyngeal cancer.
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Baloch Z, Bubendorf L, Bedrossian CWM. There is more than meet the eyes in head and neck cytopathology. Diagn Cytopathol 2014; 42:1-4. [PMID: 24376170 DOI: 10.1002/dc.23089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Lastra RR, Pramick MR, Nakashima MO, Weinstein GS, Montone KT, Livolsi VA, Baloch ZW. Adequacy of fine-needle aspiration specimens for human papillomavirus infection molecular testing in head and neck squamous cell carcinoma. Cytojournal 2013; 10:21. [PMID: 24403949 PMCID: PMC3869969 DOI: 10.4103/1742-6413.120789] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/01/2013] [Indexed: 11/24/2022] Open
Abstract
Background: Head and neck squamous cell carcinoma is often associated with human papillomavirus (HPV) infection. Positive HPV status has been associated with increased response to treatment and improved prognosis in terms of recurrence-free and overall survival. In certain instances, diagnosis is performed through fine-needle aspiration of lymph nodes with metastatic carcinoma, often demonstrating extensive tumor necrosis. We evaluated the effect of tumor necrosis on deoxyribonucleic acid (DNA) adequacy for HPV molecular testing. Materials and Methods: Retrospective review of the pathology files at our institution identified cases of squamous cell carcinoma (SCC) diagnosed by fine-needle aspiration (FNA) on which HPV DNA molecular testing was performed. The cases were classified according to percent tumor necrosis into three categories (<10% necrosis, 10-70% necrosis and >70% necrosis) and the percentage of cases with adequate HPV DNA for molecular testing in each of the categories was compared. When available, p16 immunohistochemistry performed on the cases was compared with HPV status by molecular testing. Results: A total of 70 cases from 67 patients were included in the study. Adequate DNA for molecular HPV testing was obtained from samples of 47 cases (67%) while samples from 23 cases (33%) were inadequate for molecular testing. Of the adequate samples, 36 (77%) were positive and 11 (23%) were negative for high-risk HPV. Adequate DNA for testing was obtained in 22 out of 33 cases showing no necrosis (67%), 10 out of 16 cases showing partial necrosis (63%) and in 13 out of 17 cases showing extensive necrosis (76%). Conclusion: Our study found that HPV molecular testing is not influenced by percent tumor necrosis or method by which FNA was performed. We believe that a portion of the FNA specimen obtained from head and neck lesions diagnosed as SCC during the rapid on-site evaluation should be sent for HPV DNA testing, independent of the amount of tumor necrosis, thus guaranteeing availability of specimen for HPV testing.
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Affiliation(s)
- Ricardo R Lastra
- Address: Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle R Pramick
- Address: Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Megan O Nakashima
- Department of Clinical Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gregory S Weinstein
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen T Montone
- Address: Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Virginia A Livolsi
- Address: Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zubair W Baloch
- Address: Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Tao K, Yang J, Yang H, Guo ZH, Hu YM, Tan ZY, Zhang F, Duan JL. Comparative study of the cervista and hybrid capture 2 methods in detecting high-risk human papillomavirus in cervical lesions. Diagn Cytopathol 2013; 42:213-7. [PMID: 23904341 DOI: 10.1002/dc.23025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 03/30/2013] [Accepted: 06/03/2013] [Indexed: 11/09/2022]
Abstract
High-risk human papillomavirus (HR HPV) testing is important for the follow-up of patients with cytological abnormalities. This study was undertaken to compare the clinical value of the Cervista and hybrid capture 2 (HC2) tests for detection of HR HPV in cervical lesions. Overall 439 cervical specimens with abnormal cytology and 22 normal cervical specimens were subjected to the Cervista and HC2 tests. HPV positivity and its predictive value for high-grade cervical lesions were assessed. The Cervista and HC2 tests showed comparable HR HPV detection rates in women with all cytological and histological diagnoses, with a positive and negative percent agreement of 90.8% and 64.5%, respectively. The two methods had a same sensitivity of 90% in detecting CIN II or greater cervical lesions, while the specificity for the Cervista test and HC2 assay was 47% and 43%, respectively. The positive rate for the Cervista assay probe set A9 increased with the histological severity, ranging from 25.0% in normal specimens to 69.5% in high-grade lesions. In conclusion, the clinical performance for the Cervista test is as excellent as the HC2 test in detecting HR HPV and predicting high-grade cervical lesions.
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Affiliation(s)
- Kun Tao
- Department of Pathology, Shanghai Changning District Central Hospital, Shanghai, China
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Holmes BJ, Westra WH. The expanding role of cytopathology in the diagnosis of HPV-related squamous cell carcinoma of the head and neck. Diagn Cytopathol 2013; 42:85-93. [DOI: 10.1002/dc.23014] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 04/04/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Brittany J. Holmes
- Department of Pathology; the Johns Hopkins Medical Institutions; Baltimore Maryland
| | - William H. Westra
- Department of Pathology; the Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Oncology; the Johns Hopkins Medical Institutions; Baltimore Maryland
- Department of Otolaryngology/Head and Neck Surgery; the Johns Hopkins Medical Institutions; Baltimore Maryland
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