Human Papillomavirus-Associated Oropharynx Cancer (HPV-OPC): Treatment Options

Human papillomavirus, tobacco, and poor oral hygiene can act synergetically, modulate the expression of the nuclear factor kappa B signaling pathway for the development and progression of head and neck cancer in the Pakistani population

BACKGROUND

Head and neck cancers (HNCs) are a heterogeneous group of tumors that progress owing to varied enviromental and genetic risk factors. Viral infections are threatening and adept at altering the expression of cellular transcription factors such as nuclear factor kappa B (NF-κB) and deregulation of other cellular proteins like NF kappa B inhibitor alpha (IκBα). The present study was conducted to detect high-risk genotypes of human papillomavirus (HPV) and protein expression of NF-κB signaling pathway in HNC patients with HPV infection.

METHODS

For HPV detection, genomic DNA from 152 HNC tumors was extracted formalin-fixed paraffin-embedded tissue DNA kit. For genotyping, polymerase chain reaction (PCR) using a general primer, HPV type-specific primers and agarose gel electrophoresis were performed. Immunohistochemistry (IHC) was also performed on 4-μm thick tissue sections using HPV E6 monoclonal antibody. Protein expression analysis of NF-κB signaling pathway including p50, p65, and IκBα was performed using IHC.

RESULTS

PCR analysis showed that 24.3% (37/152) of HNC cases were HPV positive. Among HPV positive, 86.5% (32/37) were tobacco users, while among HPV negative, 66.9% (77/115) were tobacco users. A significant association of HPV positivity and tobacco user was observed by univariate analysis [ P   <  0.01; odds ratio (OR): 0.310, 95% confidence interval (CI): 0.110 to 0.870]. More HPV positive patients were with poor oral hygiene (78.3%) when compared with patients with good oral hygiene (21.6%) [ P  < 0.03, OR: 2.440, 95% CI: 1.650 to 3.600]. The results of the logistic regression analysis showed that age, tobacco use and oral hygiene are significant predictors ( P  < 0.02). PCR and IHC staining results confirmed that HPV16 was predominant among HNC cases (64.8%) when compared with HPV18 (35.2%). Expression of NF-κB proteins (p50, p65, and IκBα inhibitor) were also observed in HPV and non-HPV infected HNC tissues. IHC expression of p50, and p65 showed nuclear staining, while IκBα inhibitor showed cytoplasmic staining. Protein expression in HPV cases was higher as compared to HPV naive cases ( P  < 0.05).

CONCLUSIONS

From the study, it can be established that the use of tobacco, oral hygiene, and HPV infection may be synergistically involved in modulating the expression of NF-κB signaling pathway for the development and progression of HNC in the Pakistani population.

Characteristics and outcomes of young patients with laryngeal cancer: National hospital-based retrospective cohort analysis

BACKGROUND

The relative incidence of laryngeal cancer is rising in young patients, yet their characteristics, risk factors, and outcomes relative to older patients are poorly understood.

METHODS

Retrospective cohort analysis of the National Cancer Database from 2006 to 2015.

RESULTS

Among 25 029 total patients, 923 (3.7%) were young (<45 years old) and 3266 underwent tumor HPV testing. Compared to older patients, a greater proportion of young patients were female (30.3%, 23.3%; p < 0.001) and seen with high-risk HPV-positive tumors (29.9%, 12.4%; p < 0.001). In subset analyses of young patients, females with higher income (≥$38 000) exhibited a decreased risk of overall mortality compared to all other sex-income subcategories (adjusted hazard ratio [aHR]: 0.43, 95% confidence interval [CI]: 0.25-0.72). In subset analyses of patients of all ages with known tumor HPV status, patients with high-risk HPV-positive tumors exhibited a reduced risk of all-cause mortality (aHR: 0.74, 95%CI: 0.60-0.92, p = 0.007).

CONCLUSION

The interdependent associations between age, sex, tumor HPV status, and income on laryngeal cancer outcomes warrant further investigation.

Assessment of the willingness of dentists in the state of Indiana to administer vaccines

BACKGROUND

Human Papillomavirus associated oropharyngeal cancers have been on the rise in the past three decades. Dentists are uniquely positioned to discuss vaccination programs with their patients. The goal of this project was to assess the readiness of dentists in the state of Indiana in being able to administer vaccines.

METHODS

An 18-question online survey was sent to licensed dentists in the state of Indiana. Mantel-Haenszel chi-square tests, followed by multivariable analyses using ordinal logistic regression were conducted to assess providers' comfort levels and willingness to administer vaccines in both children and adults, by provider characteristics (practice type, location, and years in practice).

RESULTS

A total of 569 completed surveys were included for data analyses. Most dentists (58%) responded positively when asked if they would consider offering vaccinations in their office, if allowed by state legislation. In general, dentists working in academic settings and federally qualified health centers were more agreeable to offering vaccination in their practice. The level of agreement with "Dentists should be allowed to administer HPV, Influenza, Hep A and COVID 19 vaccines" for both children and adults decreased with increased years of practice. More than half of the respondents (55%) agreed that dental providers were competent to administer vaccines and needed no further training.

CONCLUSION

The study results suggest the willingness of dentists in the state of Indiana to offer vaccinations in their practices, if allowed by legislation.

PRACTICAL IMPLICATIONS

Dental providers can be a unique resource to add to workforce for improving vaccination efforts.

HPV status and therapeutic initial strategy impact on survival and oncologic outcomes: 5-year results from the multicentric prospective cohort of oropharyngeal cancers Papillophar

PURPOSE

After the 2 years of follow-up, we aimed to evaluate at 5 years the impact of human papillomavirus (HPV) status, tobacco, and initial treatment approach on progression-free survival (PFS) and overall survival (OS) of patients with oropharyngeal cancer (OPC) in France.

METHODS

Papillophar study was designed as a prospective cohort of 340 OPC patients in 14 French hospitals. HPV-positive status (21.7%) was defined with PCR (positivity for HPV DNA and E6/E7 mRNA). Cox proportional hazard models were used to assess the relationship between PFS, OS, HPV, and other prognostic factors. The combined effect of HPV status with smoking, stage, or initial treatment on PFS was also evaluated.

RESULTS

HPV-pos patients had better PFS than HPV-neg patients (HR = 0.46; 95% CI: 0.29-0.74), and worse for older patients (HR for 5-year age increase = 1.14), UICC stage 4 from the 7th TNM classification compared to stage 1-2 (HR = 2.58; CI: 1.33-5.00), and those having had radiotherapy (HR = 2.07; 95% CI: 1.36-3.16) or induction chemotherapy (HR = 2.11; 95% CI: 1.32-3.38) instead of upfront surgery. HPV-neg patients encountered a larger incidence of loco-regional disease than HPV-pos patients (31.5% and 14.0%, respectively, p = 0.0001). Distant metastases proportion was similar. HPV-neg patients developed more second primary tumor than HPV-pos patients (11.7% vs. 3.3%, p = 0.02).

CONCLUSIONS

5-year follow-up confirms the specifically improved prognosis in HPV-positive patients. The prognosis is nevertheless significantly modified through clinical and therapeutical variations.

NF-κB1 intronic region polymorphisms as risk factor for head and neck cancer in HPV-infected population from Pakistan

BACKGROUND

Head and neck cancer (HNC) developed due to the number of risk factors, including infection of Human Papillomavirus (HPV). The genetic predisposition also plays an important role in deregulating the NF-κB pathway, and certain polymorphisms are reported to affect the pathway genes.

OBJECTIVES

The present study was conducted for the detection of HPV and polymorphisms in the NF-κB1 gene of HNC patients in the Pakistani population.

METHODS

Genomic DNA from HNC tumors samples were extracted using the Exgene SV DNA extraction Kit. Allele-specific PCR and direct sequencing were done for analysis of NF-κB1 SNPs, 94ins/del (rs28362491), rs1598858, and rs4648068.

RESULTS

The genotypes AG (36.2%/ 12%) of rs1598858, and AG (28.3%/ 12%) and GG (28.3%/ 22%) of rs4648068 were associated with significantly (p≤0.05) increased risk of head and neck cancer in studied population. Furthermore, among the HNC cases, genotypes AGrs1598858 (p≤0.014) and GGrs4648068 (p≤0.001) had increased risk of HPV related cancers. Tobacco use (OR-3.158442; [1.140, 8.754]), lymph nodes involvement (OR 4.05128; [1.854, 8.852]), and poorly differentiated tumors (OR 1.997155; [0.940, 4.245]) were positively associated with HPV induced cancers.

CONCLUSION

It was the first comprehensive study from Pakistan, to evaluate the polymorphic variants of NF-κB1. Genotypes AGrs4648068, GGrs4648068, and AGrs1598858 of NF-κB1 gene are associated with increased risk of head and neck cancers in the Pakistani population. It can be concluded that HPV infection, lymph nodes and tobacco use can act synergetic to each other and add up in modulating HNC when present together with intronic SNPs of NF-κB1 gene.

Upfront surgery or definitive radiotherapy for patients with p16-negative oropharyngeal squamous cell carcinoma. A GETTEC multicentric study

INTRODUCTION

Therapeutic management of oropharyngeal squamous cell carcinomas (OPSCC) is still debated. Since the role of HPV was demonstrated, few studies have focused on HPV-negative OPSCC. The aim of our study was to assess the impact of therapeutic strategy (surgical vs. non-surgical) on oncologic outcomes in patients with HPV-negative OPSCC.

MATERIAL AND METHOD

All p16-negative OPSCCs treated from 2009 to 2014 in 7 tertiary-care centers were included in this retrospective study and were classified according to the therapeutic strategy: surgical strategy (surgery ± adjuvant radiotherapy and chemotherapy) vs. non-surgical strategy (definitive radiotherapy ± chemotherapy). Patients not eligible for surgery (unresectable tumor, poor general-health status) were excluded. Univariate, multivariate and propensity score matching analyses were performed to compare overall (OS), disease-specific (DSS) and recurrence-free survival (RFS).

RESULTS

Four hundred seventy-four (474) patients were included in the study (surgical group: 196; non-surgical group: 278). Five-year OS, DSS and RFS were 76.5, 81.3 and 61.3%, respectively, in the surgical group and 49.9, 61.8 and 43.4%, respectively, in the non-surgical group. The favorable impact of primary surgical treatment on oncologic outcomes was statistically significant after multivariate analysis. This effect was more marked for locally-advanced than for early-stage tumors. Propensity score matching analysis confirmed the prognostic impact of primary surgical treatment for RFS.

CONCLUSION

Therapeutic strategy is an independent prognostic factor in patients with p16-negative OPSCC and primary surgical treatment is associated with improved OS, DSS and RFS. These results suggest that surgical strategy is a reliable option for advanced stage OPSCC.

Base of tongue cancer-is it tongue cancer located at the base of the tongue, or is it a type of lingual tonsil cancer? The perspective from a genomic analysis

The aim of this study was to determine whether base of tongue (BOT) cancer is tongue cancer located at the base of the tongue or lingual tonsil cancer originating from tonsil tissue. This was a retrospective study using data from The Cancer Genome Atlas (TCGA). The genomic patterns of three primary cancers (BOT, oral tongue, and tonsil) were compared to determine their similarities and differences. Gene expression data (n=193; 26 BOT, 125 oral tongue, and 42 tonsil cases), copy number alteration data (n=142; 19 BOT, 96 oral tongue, and 27 tonsil cases), and somatic mutation data (n=187; 25 BOT, 122 oral tongue, and 40 tonsil cases) were analyzed using the t-test, heatmap analysis, and OncoPrint, respectively. Clinical information for the three tumour groups was included in the analyses. When using multiplatform analysis, BOT cancer showed nearly the same genomic pattern as tonsil cancer, but not oral tongue cancer. The χ² test and survival analysis revealed that BOT cancer had the same clinical and survival patterns as tonsil cancer. In conclusion, BOT cancer showed a genomic pattern similar to that of tonsil cancer, but different to that of oral tongue cancer. Further prospective studies are warranted before the results of this study can be applied in a clinical setting.

The human papillomavirus replication cycle, and its links to cancer progression: a comprehensive review

HPVs (human papillomaviruses) infect epithelial cells and their replication cycle is intimately linked to epithelial differentiation. There are over 200 different HPV genotypes identified to date and each displays a strict tissue specificity for infection. HPV infection can result in a range of benign lesions, for example verrucas on the feet, common warts on the hands, or genital warts. HPV infects dividing basal epithelial cells where its dsDNA episomal genome enters the nuclei. Upon basal cell division, an infected daughter cell begins the process of keratinocyte differentiation that triggers a tightly orchestrated pattern of viral gene expression to accomplish a productive infection. A subset of mucosal-infective HPVs, the so-called ‘high risk’ (HR) HPVs, cause cervical disease, categorized as low or high grade. Most individuals will experience transient HR-HPV infection during their lifetime but these infections will not progress to clinically significant cervical disease or cancer because the immune system eventually recognizes and clears the virus. Cancer progression is due to persistent infection with an HR-HPV. HR-HPV infection is the cause of >99.7% cervical cancers in women, and a subset of oropharyngeal cancers, predominantly in men. HPV16 (HR-HPV genotype 16) is the most prevalent worldwide and the major cause of HPV-associated cancers. At the molecular level, cancer progression is due to increased expression of the viral oncoproteins E6 and E7, which activate the cell cycle, inhibit apoptosis, and allow accumulation of DNA damage. This review aims to describe the productive life cycle of HPV and discuss the roles of the viral proteins in HPV replication. Routes to viral persistence and cancer progression are also discussed.

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

OBJECTIVES/HYPOTHESIS

To evaluate the long-term disease control, survival, and complications after definitive radiotherapy (RT) alone or combined with adjuvant chemotherapy with or without planned neck dissection for base of tongue squamous cell carcinoma (SCC).

STUDY DESIGN

We retrospectively reviewed the medical records of 467 patients treated at the University of Florida with definitive RT alone or combined with adjuvant chemotherapy between 1964 and 2011 for base of tongue SCC.

METHODS

Median follow-up was 5.6 years. Median total dose to the primary site was 74.4 Gy. Eighty-seven patients (19%) were treated with once-daily fractionation, and 380 (81%) received altered fractionation schedules. Intensity-modulated RT was used in 128 patients (27%). Chemotherapy was administered to 173 (37%) patients. Planned neck dissection after RT was performed in 226 patients (48%). Data regarding p16 pathway activation were available for 25 patients.

RESULTS

At 5 years, the local, local-regional, and regional control rates were 85.5%, 80.0%, and 90.0%, respectively. The 5-year overall, cause-specific, and distant metastasis-free survival rates were 59.1%, 71.5%, and 84.1%, respectively. Sixty-four patients (14%) developed one or more severe late complications. Fifty patients (11%) required late gastrostomy tube placement.

CONCLUSIONS

This study supports the continued use of RT alone or combined with adjuvant chemotherapy for patients with base of tongue SCC, as this treatment yields high rates of cause-specific survival and disease control, with a relatively low rate of late complications.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1589-1594, 2017.

Human Papilloma Virus in Oral Cavity Cancer and Relation to Change in Quality of Life Following Treatment-a Pilot Study from Northern India

Human papilloma virus (HPV)-associated head and neck cancer (HNC) has generated significant amount of research interest in recent times with focus shifted to oral cavity squamous cell cancer (OCSCC) after oropharyngeal cancer. Due to high incidence of OCSCC and anecdotal reports on association of HPV infection from northern region of India, this study was conceived to investigate HPV infection and establish its association with lifestyle habits such as tobacco, alcohol consumption, oro-genital sex, number of sexual contacts, and change in quality of life posttreatment. A total of 43 primary OCSCC biopsy specimens were collected. These samples were analyzed for HPV DNA genotyping which was done by using 13 high-risk HPV real-time PCR kits. Quality of life was assessed using University of Washington questionnaire for HNC patients, which was administered pretreatment and 3-months posttreatment. HPV presence was confirmed in only three patients (7.0 %). HPV positivity did not find any statistical correlation with age, gender, residence, addiction habit, stage, tumor size, nodal status, tumor grade, and number of sexual contacts. There was no significant (p > 0.05) difference in the average percent change in QOL parameters from pretreatment to posttreatment when correlated with HPV status.

CE: Human Papillomavirus-Related Oropharyngeal Cancer: A Review of Nursing Considerations

: The overall incidence of head and neck cancer-which includes laryngeal, hypopharyngeal, nasal cavity, paranasal sinus, nasopharyngeal, oral, oropharyngeal, and salivary gland cancers-has declined in the United States over the past 30 years with the concomitant reduction in tobacco use. Over that same period, however, the worldwide incidence of oropharyngeal cancer has escalated significantly, most notably among men and women under age 60 who live in developed countries. This epidemic rise in oropharyngeal cancer is largely attributed to certain genotypes of the human papillomavirus (HPV). In the United States, HPV prevalence in oropharyngeal tumors increased dramatically, from roughly 16% between 1984 and 1989 to nearly 73% between 2000 and 2004, and the annual incidence of HPV-positive oropharyngeal cancer is expected to surpass that of HPV-related cervical cancer by 2020.This article provides an overview of head and neck cancer-its incidence, risk factors, treatment, and posttreatment sequelae-with a focus on HPV-related oropharyngeal cancer. Unlike other forms of head and neck cancer, HPV-related oropharyngeal cancer tends to affect younger patients with few or none of the traditional risk factors and has a distinctive presentation, histology, and natural course. In order to provide appropriate patient education and to help these patients monitor and manage late and long-term treatment effects, it is important for nurses to be aware of this disease and its treatment, and of the unique survivorship issues that arise for affected patients.

Alcohol and Tobacco Increases Risk of High Risk HPV Infection in Head and Neck Cancer Patients: Study from North-East Region of India

BACKGROUND

Human papilloma virus (HPV) associated Head and Neck Cancers (HNCs) have generated significant amount of research interest in recent times. Due to high incidence of HNCs and lack of sufficient data on high-risk HPV (hr-HPV) infection from North -East region of India, this study was conceived to investigate hr-HPV infection, its types and its association with life style habits such as tobacco, alcohol consumption etc.

METHODS

A total of one hundred and six primary HNC tumor biopsy specimens were collected. These samples were analyzed for hr-HPV DNA (13 HPV types) using hybrid capture 2 (HC2) assay and genotyping was done by E6 nested multiplex PCR (NMPCR).

RESULTS

The presence of hr-HPV was confirmed in 31.13% (n = 33) and 24.52% (n = 26) of the HNC patients by nested multiplex PCR (NMPCR) and HC2 assay respectively. Among hr-HPV positive cases, out of thirteen hr- HPV types analyzed, only two prevalent genotypes, HPV-16 (81.81%) followed by HPV-18 (18.18%) were found. Significant association was observed between hr-HPV infection with alcohol consumption (p <0.001) and tobacco chewing (p = 0.02) in HNC cases. Compared to HPV-18 infection the HPV-16 was found to be significantly associated with tobacco chewing (p = 0.02) habit.

CONCLUSIONS

Our study demonstrated that tobacco chewing and alcohol consumption may act as risk factors for hr-HPV infection in HNCs from the North-East region of India. This was the first study from North-East India which also assessed the clinical applicability of HC2 assay in HNC patient specimens. We suggest that alcohol, tobacco and hr- HPV infection act synergistically or complement each other in the process of HNC development and progression in the present study population.

Targeted Therapy in Oropharyngeal Squamous Cell Carcinoma: The Implications of HPV for Therapy

Oropharyngeal cancers caused by human papillomaviruses (HPV) have a different epidemiology, prognosis, genetic mutational landscape, response to treatment, and outcome when compared to HPV-negative cancers. In this review, a summary of our current understanding of HPV in head and neck cancer and the important advances that have shown HPV to be an etiological agent are discussed. HPV-positive and HPV-negative tumors are compared discussing clinicopathological factors, prognosis, outcome following treatment, and the molecular and genetic differences. Currently, the standard of care for oropharyngeal cancer is both surgery and post-operative radiotherapy with or without cisplatin or concurrent chemo-radiotherapy. The latter is used more often, especially in cancers of tonsil and base of tongue. However, there is increased interest in trying to de-intensify treatment and in the development of new treatments to target the underlying different molecular pathways of HPV-positive cancers. The current clinical trials involving surgery, chemotherapy, and radiation therapy are discussed. The new targeted treatments are also summarized. Although there is currently is no evidence from prospective studies to support a change in the treatment algorithm, the treatment options for patients with HPV-positive disease are likely to change in the future.