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[The multicenter registry "oropharyngeal cancer" of the German ENT Study Center - First Results]. Laryngorhinootologie 2024. [PMID: 39168130 DOI: 10.1055/a-2374-2310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
BACKGROUND The number of oropharyngeal squamous cell carcinomas (OPSCC) caused by human papillomavirus (HPV) has increased significantly in recent years. However, no robust data exist on the incidence of HPV-associated OPSCC as well as their treatment in central Europe. AIM OF THE WORK The aim is to establish an epidemiological register of patients with OPSCC in central Europe. MATERIAL AND METHODS To close the evidence gap on p16-positive OPSCC, a prospective multicenter registry on incidence, risk factors and treatment of OPSCC in certified Head and Neck Tumor Centers according to the German Cancer Society was established. Data collection was pseudonymously performed using the web-based Research Electronic Data Capture (REDCap). RESULTS In 2022 and 2023, 1312 patients with OPSCC from 34 centers were included. 720 patients (58.2 %) were p16-positive. The most common locations of p16-positive primary tumors were the tonsil (49.9 %) and the base of the tongue (28.7 %). 63.1 % of p16-positive OPSCC received primary surgical treatment, whereas only 48.0 % of p16-negative tumors received primary surgery. Differences are also evident in the adjuvant therapy: 58 % of p16-negative OPSCC did not receive adjuvant therapy after surgery, compared with 37.1 % of p16-positive OPSCC. CONCLUSION The start of the OPSCC registry study was technically smooth. This registry provides an insight into the current care situation of OPSCC in German-speaking countries and will gain importance through the participation of more centers.
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Balhara N, Yadav R, Ranga S, Ahuja P, Tanwar M. Understanding the HPV associated cancers: A comprehensive review. Mol Biol Rep 2024; 51:743. [PMID: 38874682 DOI: 10.1007/s11033-024-09680-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/27/2024] [Indexed: 06/15/2024]
Abstract
Human papillomavirus (HPV), a common cause of sexually transmitted diseases, may cause warts and lead to various types of cancers, which makes it important to understand the risk factors associated with it. HPV is the leading risk factor and plays a crucial role in the progression of cervical cancer. Viral oncoproteins E6 and E7 play a pivotal role in this process. Beyond cervical cancer, HPV-associated cancers of the mouth and throat are also increasing. HPV can also contribute to other malignancies like penile, vulvar, and vaginal cancers. Emerging evidence links HPV to these cancers. Research on the oncogenic effect of HPV is still ongoing and explorations of screening techniques, vaccination, immunotherapy and targeted therapeutics are all in progress. The present review offers valuable insight into the current understanding of the role of HPV in cancer and its potential implications for treatment and prevention in the future.
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Affiliation(s)
- Nikita Balhara
- Department of Genetics, Maharshi Dayanand University, Rohtak, Haryana, 124001, India
| | - Ritu Yadav
- Department of Genetics, Maharshi Dayanand University, Rohtak, Haryana, 124001, India.
| | - Shalu Ranga
- Department of Genetics, Maharshi Dayanand University, Rohtak, Haryana, 124001, India
| | - Parul Ahuja
- Department of Genetics, Maharshi Dayanand University, Rohtak, Haryana, 124001, India
| | - Mukesh Tanwar
- Department of Genetics, Maharshi Dayanand University, Rohtak, Haryana, 124001, India
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Kumar P, Gupta S, Das BC. Saliva as a potential non-invasive liquid biopsy for early and easy diagnosis/prognosis of head and neck cancer. Transl Oncol 2024; 40:101827. [PMID: 38042138 PMCID: PMC10701368 DOI: 10.1016/j.tranon.2023.101827] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 12/04/2023] Open
Abstract
Head and neck squamous cell carcinomas (HNSCCs) are the most devastating diseases in India and southeast Asia. It is a preventable and curable disease if detected early. Tobacco and alcohol consumption are the two major risk-factors but infection of high-risk HPVs are also associated with development of predominantly oral and oropharyngeal carcinomas. Interestingly, unlike cervical cancer, HPV-induced HNSCCs show good prognosis and better survival in contrast, majority of tobacco-associated HPV-ve HNSCCs are highly aggressive with poor clinical outcome. Biomarker analysis in circulatory body-fluids for early cancer diagnosis, prognosis and treatment monitoring are becoming important in clinical practice. Early diagnosis using non-invasive saliva for oral or other diseases plays an important role in successful treatment and better prognosis. Saliva mirrors the body's state of health as it comes into direct contact with oral lesions and needs no trained manpower to collect, making it a suitable bio-fluid of choice for screening. Saliva can be used to detect not only virus, bacteria and other biomarkers but variety of molecular and genetic markers for an early detection, treatment and monitoring cancer and other diseases. The performance of saliva-based diagnostics are reported to be highly (≥95 %) sensitive and specific indicating the test's ability to correctly identify true positive or negative cases. This review focuses on the potentials of saliva in the early detection of not only HPV or other pathogens but also identification of highly reliable gene mutations, oral-microbiomes, metabolites, salivary cytokines, non-coding RNAs and exosomal miRNAs. It also discusses the importance of saliva as a reliable, cost-effective and an easy alternative to invasive procedures.
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Affiliation(s)
- Prabhat Kumar
- Stem Cell and Cancer Research Lab, Amity Institute of Molecular Medicine & Stem Cell Research (AIMMSCR), Amity University Uttar Pradesh, Sector-125, Noida 201313, India
| | - Shilpi Gupta
- Stem Cell and Cancer Research Lab, Amity Institute of Molecular Medicine & Stem Cell Research (AIMMSCR), Amity University Uttar Pradesh, Sector-125, Noida 201313, India
| | - Bhudev C Das
- Stem Cell and Cancer Research Lab, Amity Institute of Molecular Medicine & Stem Cell Research (AIMMSCR), Amity University Uttar Pradesh, Sector-125, Noida 201313, India.
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Jiang W, Li R, Zhang L, Dou S, Ye L, Shao Z, Wu S, Dong M, Li J, Zhu G. Efficacy and feasibility of Apatinib and S-1 as a novel oral induction therapy in locally advanced head and neck squamous cell carcinoma: an exploratory phase 2 open-label, single-arm trial. Front Oncol 2023; 13:1072538. [PMID: 37251944 PMCID: PMC10213222 DOI: 10.3389/fonc.2023.1072538] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives The current standard nonsurgical treatment for locally advanced head and neck squamous cell cancer (LA-HNSCC) is concomitant chemoradiotherapy (CRT). Neoadjuvant chemotherapy combined with CRT has been explored in HNSCC patients and is an acceptable strategy. However, the occurrence of adverse events (AEs) restricts its application. We conducted a clinical study to explore the efficacy and feasibility of a novel induction therapy with orally administered apatinib and S-1 in LA-HNSCC. Materials and methods This nonrandomized, single-arm, prospective clinical trial included patients with LA-HNSCCs. The eligibility criteria included histologically or cytologically confirmed HNSCC, with at least one radiographically measurable lesion detected by magnetic resonance imaging (MRI) or computerized tomography (CT) scan, age 18-75 years, and a diagnosis of stage III to IVb according to the 7th edition of the American Joint Committee of Cancer (AJCC). Patients received induction therapy with apatinib and S-1 for three cycles (3 weeks/cycle). The primary endpoint of this study was the objective response rate (ORR) to induction therapy. The secondary endpoints included progression-free survival (PFS), overall survival (OS), and AEs during induction treatment. Results From October 2017 to September 2020, 49 patients with LA-HNSCC were screened consecutively and 38 were enrolled. The median age of the patients was 60 years (range, 39-75). Thirty-three patients (86.8%) had stage IV disease according to the AJCC staging system. The ORR after induction therapy was 97.4% (95% confidence interval [CI]: 86.2%-99.9%). the 3-year OS rate was 64.2% (95% CI: 46.0%-78.2%) and 3-year PFS was 57.1% (95% CI: 40.8%-73.6%). The most common AEs during induction therapy were hypertension and hand-foot syndrome, which were manageable. Conclusion Apatinib combined with S-1 as novel induction therapy for LA-HNSCC patients resulted in a higher-than-anticipated ORR and manageable adverse effects. With the associated safety profile and preferable oral administration route, apatinib combined with S-1 is an attractive exploratory induction regimen in outpatient settings. However, this regimen failed to show a survival benefit. Clinical trial registration https://clinicaltrials.gov/show/NCT03267121, identifier NCT03267121.
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Affiliation(s)
- Wen Jiang
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai Center of Head and Neck Oncology Clinical and Translational Science, Shanghai, China
| | - Rongrong Li
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai Center of Head and Neck Oncology Clinical and Translational Science, Shanghai, China
| | - Lin Zhang
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai Center of Head and Neck Oncology Clinical and Translational Science, Shanghai, China
| | - Shengjin Dou
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai Center of Head and Neck Oncology Clinical and Translational Science, Shanghai, China
| | - Lulu Ye
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai Center of Head and Neck Oncology Clinical and Translational Science, Shanghai, China
| | - Ziyang Shao
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai Center of Head and Neck Oncology Clinical and Translational Science, Shanghai, China
| | - Sicheng Wu
- Biostatistics Office of Clinical Research Center, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Minjun Dong
- Department of Radiology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiang Li
- Department of Oral Pathology, Shanghai Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guopei Zhu
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai Center of Head and Neck Oncology Clinical and Translational Science, Shanghai, China
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Flon CHD, Haeggblom L, Holzhauser S, Kostopoulou ON, Zupancic M, Dalianis T, Munck-Wikland E, Marklund L, Näsman A. High Levels of FGF11 Correlate with Poor Survival in Patients with Human Papillomavirus (HPV)-Positive Oropharyngeal Squamous Cell Carcinoma. Cancers (Basel) 2023; 15:cancers15071954. [PMID: 37046615 PMCID: PMC10093012 DOI: 10.3390/cancers15071954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/13/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
Human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) is associated with a favourable prognosis. It has therefore been suggested that treatment should be individualized and separated by HPV status. However, additional prognostic markers are still needed before treatment can be individualized for this patient group. For this purpose, all patients diagnosed with HPV and p16-positive OPSCC in Stockholm 2000-2009, identified as having a partial/nonresponse to treatment and having viable tumour cells in their neck specimen with material available were categorized as cases. These were matched to controls (complete responders), and the differences in the gene expression were analysed. Two separate verification cohorts were identified including patients with HPV- and p16-positive OPSCC, and the data from the case-control study were verified by qPCR and immunohistochemistry (IHC) in the respective cohorts. A separation of gene expression in correlation with survival was observed in the case-control study, and FGF11 expression was identified as significantly differently expressed between the two groups. The prognostic role of FGF11 was validated in the two cohorts on the RNA and protein levels, respectively. Taken together, our findings suggest that FGF11 may indicate a poor prognosis in HPV-positive OPSCC and may serve as a prognostic biomarker.
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Affiliation(s)
- Caroline Haglund de Flon
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden
- Department of Clinical Pathology, CCK R8:02, Karolinska University Hospital, 171 64 Stockholm, Sweden
| | - Linnea Haeggblom
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden
| | - Stefan Holzhauser
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden
| | - Ourania N Kostopoulou
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden
| | - Mark Zupancic
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden
- Medical Unit Head Neck Lung and Skin Cancer, Department of Head and Neck Surgery, Karolinska University Hospital, 171 64 Stockholm, Sweden
| | - Tina Dalianis
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden
- Medical Unit Head Neck Lung and Skin Cancer, Department of Head and Neck Surgery, Karolinska University Hospital, 171 64 Stockholm, Sweden
| | - Eva Munck-Wikland
- Medical Unit Head Neck Lung and Skin Cancer, Department of Head and Neck Surgery, Karolinska University Hospital, 171 64 Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology-CLINTEC Division of Ear, Nose and Throat Diseases, Karolinska Institutet, University Hospital, 171 64 Stockholm, Sweden
| | - Linda Marklund
- Medical Unit Head Neck Lung and Skin Cancer, Department of Head and Neck Surgery, Karolinska University Hospital, 171 64 Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology-CLINTEC Division of Ear, Nose and Throat Diseases, Karolinska Institutet, University Hospital, 171 64 Stockholm, Sweden
- Department of Surgical Sciences, Section of Otolaryngology and Head and Neck Surgery, Uppsala University, 751 05 Uppsala, Sweden
| | - Anders Näsman
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden
- Department of Clinical Pathology, CCK R8:02, Karolinska University Hospital, 171 64 Stockholm, Sweden
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Graessle R, Stromberger C, Beck M, Heiland M, Hofmann VM, Olze H, Dommerich S, Gauger U, Piwonski I, Coordes A. Subgroup Analysis of Overall Survival among Smoking and Non-Smoking Elderly Patients with HNSCC. Cancers (Basel) 2023; 15:cancers15061842. [PMID: 36980728 PMCID: PMC10046679 DOI: 10.3390/cancers15061842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/10/2023] [Accepted: 03/15/2023] [Indexed: 03/22/2023] Open
Abstract
Smoking is a leading cause of head and neck squamous cell carcinoma (HNSCC). However, non-smokers are also affected by HNSCC, and the prognostic factors applicable to older non-smokers with HNSCC are largely unknown. The aim of this study was to determine predictors of overall survival (OS) in patients both with and without a smoking history aged 70 and over at initial diagnosis. Retrospective data of patients aged ≥70 (initial diagnoses 2004–2018) were examined. Evaluated predictors included tumour stage, biological age, health and therapy. A total of 688 patients (520 smokers, 168 non-smokers) were included with a median age of 74. The 5-year OS was 39.6%. Non-smokers had significantly improved OS compared to smokers (52.0% versus 36.0%, p < 0.001). Disease-free survival (DFS) differed significantly between both groups (hazard ratio = 1.3; 95%CI 1.04–1.626). TNM stage and the recommended therapies (curative versus palliative) were comparable. The proportion of p16-positive oropharyngeal carcinomas was significantly higher in non-smokers (76.7% versus 43.8%, p < 0.001). Smokers were significantly more likely to be men (p < 0.001), drinkers (p < 0.001), and have poorer health status (Karnofsky performance status, KPS, p = 0.023). They were also more likely to have additional tumours (p = 0.012) and lower treatment adherence (p = 0.038). Important predictors of OS identified in both groups, were, among others, alcohol abuse, KPS, Charlson comorbidity index, site of primary tumour, UICC stage and treatment received. Elderly non-smokers are also affected by HNSCC, however, both OS and DFS are increased compared to smokers.
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Affiliation(s)
- Raphaela Graessle
- Department of Otorhinolaryngology, Head and Neck Surgery, Campus Virchow Klinikum and Campus Charité Mitte, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Carmen Stromberger
- Department of Radiooncology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Marcus Beck
- Department of Radiooncology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, Campus Virchow Klinikum and Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Veit M. Hofmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Heidi Olze
- Department of Otorhinolaryngology, Head and Neck Surgery, Campus Virchow Klinikum and Campus Charité Mitte, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Steffen Dommerich
- Department of Otorhinolaryngology, Head and Neck Surgery, Campus Virchow Klinikum and Campus Charité Mitte, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Ulrich Gauger
- Private Statistical Consultant, 10437 Berlin, Germany
| | - Iris Piwonski
- Department of Pathology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Annekatrin Coordes
- Department of Otorhinolaryngology, Head and Neck Surgery, Campus Virchow Klinikum and Campus Charité Mitte, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Centre Ruppin Brandenburg, Brandenburg Medical School, 16816 Neuruppin, Germany
- Faculty of Health Sciences Brandenburg, Joint Faculty of the University of Potsdam, Brandenburg University of Technology Cottbus-Senftenberg and Brandenburg Medical School, 14476 Potsdam, Germany
- Correspondence: or ; Tel.: +49-30-450-555-002
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Mehanna H, Taberna M, von Buchwald C, Tous S, Brooks J, Mena M, Morey F, Grønhøj C, Rasmussen JH, Garset-Zamani M, Bruni L, Batis N, Brakenhoff RH, Leemans CR, Baatenburg de Jong RJ, Klussmann JP, Wuerdemann N, Wagner S, Dalianis T, Marklund L, Mirghani H, Schache A, James JA, Huang SH, O'Sullivan B, Nankivell P, Broglie MA, Hoffmann M, Quabius ES, Alemany L, Taberna M, von Buchwald C, Tous S, Huang SH, O'Sullivan B, Garset-Zamani M, Brooks J, Batis N, Fulton-Lieuw T, Nankivell P, Schache A, James JA, Brakenhoff RH, Leemans CR, Heideman DAM, Bloemena E, Nauta I, de Jong RB, Dalianis T, Marklund L, Mirghani H, Wagner S, Wittekindt C, Klussmann JP, Wuerdemann N, Quaas A, Sharma SJ, Maltseva M, Zimmermann P, Hoffmann M, Quabius ES, Däppen MB, Ärztin L, Bruni L, Mena M, Morey F, Alemany L. Prognostic implications of p16 and HPV discordance in oropharyngeal cancer (HNCIG-EPIC-OPC): a multicentre, multinational, individual patient data analysis. Lancet Oncol 2023; 24:239-251. [PMID: 36796393 DOI: 10.1016/s1470-2045(23)00013-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND p16INK4a (p16) immunohistochemistry is the most widely used biomarker assay for inferring HPV causation in oropharyngeal cancer in clinical and trial settings. However, discordance exists between p16 and HPV DNA or RNA status in some patients with oropharyngeal cancer. We aimed to clearly quantify the extent of discordance, and its prognostic implications. METHODS In this multicentre, multinational individual patient data analysis, we did a literature search in PubMed and Cochrane database for systematic reviews and original studies published in English between Jan 1, 1970, and Sept 30, 2022. We included retrospective series and prospective cohorts of consecutively recruited patients previously analysed in individual studies with minimum cohort size of 100 patients with primary squamous cell carcinoma of the oropharynx. Patient inclusion criteria were diagnosis with a primary squamous cell carcinoma of oropharyngeal cancer; data on p16 immunohistochemistry and on HPV testing; information on age, sex, tobacco, and alcohol use; staging by TNM 7th edition; information on treatments received; and data on clinical outcomes and follow-up (date of last follow-up if alive, date of recurrence or metastasis, and date and cause of death). There were no limits on age or performance status. The primary outcomes were the proportion of patients of the overall cohort who showed the different p16 and HPV result combinations, as well as 5-year overall survival and 5-year disease-free survival. Patients with recurrent or metastatic disease or who were treated palliatively were excluded from overall survival and disease-free survival analyses. Multivariable analysis models were used to calculate adjusted hazard ratios (aHR) for different p16 and HPV testing methods for overall survival, adjusted for prespecified confounding factors. FINDINGS Our search returned 13 eligible studies that provided individual data for 13 cohorts of patients with oropharyngeal cancer from the UK, Canada, Denmark, Sweden, France, Germany, the Netherlands, Switzerland, and Spain. 7895 patients with oropharyngeal cancer were assessed for eligibility. 241 were excluded before analysis, and 7654 were eligible for p16 and HPV analysis. 5714 (74·7%) of 7654 patients were male and 1940 (25·3%) were female. Ethnicity data were not reported. 3805 patients were p16-positive, 415 (10·9%) of whom were HPV-negative. This proportion differed significantly by geographical region and was highest in the areas with lowest HPV-attributable fractions (r=-0·744, p=0·0035). The proportion of patients with p16+/HPV- oropharyngeal cancer was highest in subsites outside the tonsil and base of tongue (29·7% vs 9·0%, p<0·0001). 5-year overall survival was 81·1% (95% CI 79·5-82·7) for p16+/HPV+, 40·4% (38·6-42·4) for p16-/HPV-, 53·2% (46·6-60·8) for p16-/HPV+, and 54·7% (49·2-60·9) for p16+/HPV-. 5-year disease-free survival was 84·3% (95% CI 82·9-85·7) for p16+/HPV+, 60·8% (58·8-62·9) for p16-/HPV-; 71·1% (64·7-78·2) for p16-/HPV+, and 67·9% (62·5-73·7) for p16+/HPV-. Results were similar across all European sub-regions, but there were insufficient numbers of discordant patients from North America to draw conclusions in this cohort. INTERPRETATION Patients with discordant oropharyngeal cancer (p16-/HPV+ or p16+/HPV-) had a significantly worse prognosis than patients with p16+/HPV+ oropharyngeal cancer, and a significantly better prognosis than patients with p16-/HPV- oropharyngeal cancer. Along with routine p16 immunohistochemistry, HPV testing should be mandated for clinical trials for all patients (or at least following a positive p16 test), and is recommended where HPV status might influence patient care, especially in areas with low HPV-attributable fractions. FUNDING European Regional Development Fund, Generalitat de Catalunya, National Institute for Health Research (NIHR) UK, Cancer Research UK, Medical Research Council UK, and The Swedish Cancer Foundation and the Stockholm Cancer Society.
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Affiliation(s)
- Hisham Mehanna
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomics Sciences, University of Birmingham, Birmingham, UK.
| | - Miren Taberna
- Department of Medical Oncology, Catalan Institute of Oncology (ICO), Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO), Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Christian von Buchwald
- Department of Otolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Sara Tous
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO), Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Epidemiology and Public Health, Centro de Investigación Biomédica en Red: Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Jill Brooks
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomics Sciences, University of Birmingham, Birmingham, UK
| | - Marisa Mena
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO), Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Epidemiology and Public Health, Centro de Investigación Biomédica en Red: Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Francisca Morey
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO), Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Christian Grønhøj
- Department of Otolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Jacob Høygaard Rasmussen
- Department of Otolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Martin Garset-Zamani
- Department of Otolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Laia Bruni
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO), Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Epidemiology and Public Health, Centro de Investigación Biomédica en Red: Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Nikolaos Batis
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO), Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ruud H Brakenhoff
- Otolaryngology-head and neck surgery, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Netherlands
| | - C René Leemans
- Otolaryngology-head and neck surgery, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Netherlands
| | | | - Jens Peter Klussmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Nora Wuerdemann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Steffen Wagner
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Giessen, Giessen, Germany
| | - Tina Dalianis
- Department of Oncology-Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - Linda Marklund
- Department of Clinical Science, Intervention and Technology, Department of Oto-Rhinolaryngology, Head and Neck Surgery, Karolinska University Hospital, Stockholm, Sweden; Medical Unit Head and Neck, Lung and Skin Cancer, Karolinska University Hospital, Stockholm, Sweden; Department of Surgical Sciences, Section of Otolaryngology and Head and Neck Surgery, Uppsala University, Uppsala, Sweden
| | - Haïtham Mirghani
- Department of Head and Neck Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Andrew Schache
- Liverpool Head & Neck Centre, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Jaqueline A James
- Precision Medicine Centre of Excellence, Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, Northern Ireland, UK; Regional Molecular Diagnostic Service, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Shao Hui Huang
- Department of Radiation Oncology/Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Brian O'Sullivan
- Department of Radiation Oncology/Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Paul Nankivell
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomics Sciences, University of Birmingham, Birmingham, UK
| | - Martina A Broglie
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Markus Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Elgar Susanne Quabius
- Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Laia Alemany
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO), Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Epidemiology and Public Health, Centro de Investigación Biomédica en Red: Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
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8
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Leiendecker L, Neumann T, Jung PS, Cronin SM, Steinacker TL, Schleiffer A, Schutzbier M, Mechtler K, Kervarrec T, Laurent E, Bachiri K, Coyaud E, Murali R, Busam KJ, Itzinger-Monshi B, Kirnbauer R, Cerroni L, Calonje E, Rütten A, Stubenrauch F, Griewank KG, Wiesner T, Obenauf AC. Human Papillomavirus 42 Drives Digital Papillary Adenocarcinoma and Elicits a Germ Cell-like Program Conserved in HPV-Positive Cancers. Cancer Discov 2023; 13:70-84. [PMID: 36213965 PMCID: PMC9827110 DOI: 10.1158/2159-8290.cd-22-0489] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/24/2022] [Accepted: 10/04/2022] [Indexed: 01/13/2023]
Abstract
The skin is exposed to viral pathogens, but whether they contribute to the oncogenesis of skin cancers has not been systematically explored. Here we investigated 19 skin tumor types by analyzing off-target reads from commonly available next-generation sequencing data for viral pathogens. We identified human papillomavirus 42 (HPV42) in 96% (n = 45/47) of digital papillary adenocarcinoma (DPA), an aggressive cancer occurring on the fingers and toes. We show that HPV42, so far considered a nononcogenic, "low-risk" HPV, recapitulates the molecular hallmarks of oncogenic, "high-risk" HPVs. Using machine learning, we find that HPV-driven transformation elicits a germ cell-like transcriptional program conserved throughout all HPV-driven cancers (DPA, cervical carcinoma, and head and neck cancer). We further show that this germ cell-like transcriptional program, even when reduced to the top two genes (CDKN2A and SYCP2), serves as a fingerprint of oncogenic HPVs with implications for early detection, diagnosis, and therapy of all HPV-driven cancers. SIGNIFICANCE We identify HPV42 as a uniform driver of DPA and add a new member to the short list of tumorigenic viruses in humans. We discover that all oncogenic HPVs evoke a germ cell-like transcriptional program with important implications for detecting, diagnosing, and treating all HPV-driven cancers. See related commentary by Starrett et al., p. 17. This article is highlighted in the In This Issue feature, p. 1.
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Affiliation(s)
- Lukas Leiendecker
- Research Institute of Molecular Pathology (IMP), Vienna BioCenter (VBC), Vienna, Austria
- Vienna BioCenter PhD Program, Doctoral School of the University at Vienna and Medical University of Vienna, Vienna BioCenter (VBC), Vienna, Austria
| | - Tobias Neumann
- Research Institute of Molecular Pathology (IMP), Vienna BioCenter (VBC), Vienna, Austria
- Vienna BioCenter PhD Program, Doctoral School of the University at Vienna and Medical University of Vienna, Vienna BioCenter (VBC), Vienna, Austria
- Quantro Therapeutics, Vienna, Austria
| | - Pauline S. Jung
- Research Institute of Molecular Pathology (IMP), Vienna BioCenter (VBC), Vienna, Austria
- Vienna BioCenter PhD Program, Doctoral School of the University at Vienna and Medical University of Vienna, Vienna BioCenter (VBC), Vienna, Austria
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Shona M. Cronin
- Research Institute of Molecular Pathology (IMP), Vienna BioCenter (VBC), Vienna, Austria
- Vienna BioCenter PhD Program, Doctoral School of the University at Vienna and Medical University of Vienna, Vienna BioCenter (VBC), Vienna, Austria
| | - Thomas L. Steinacker
- Institute of Molecular Biotechnology (IMBA), Vienna BioCenter (VBC), Vienna, Austria
| | - Alexander Schleiffer
- Research Institute of Molecular Pathology (IMP), Vienna BioCenter (VBC), Vienna, Austria
| | - Michael Schutzbier
- Research Institute of Molecular Pathology (IMP), Vienna BioCenter (VBC), Vienna, Austria
- Institute of Molecular Biotechnology (IMBA), Vienna BioCenter (VBC), Vienna, Austria
- The Gregor Mendel Institute of Molecular Plant Biology of the Austrian Academy of Sciences (GMI), Vienna BioCenter (VBC), Vienna, Austria
| | - Karl Mechtler
- Research Institute of Molecular Pathology (IMP), Vienna BioCenter (VBC), Vienna, Austria
- Institute of Molecular Biotechnology (IMBA), Vienna BioCenter (VBC), Vienna, Austria
- The Gregor Mendel Institute of Molecular Plant Biology of the Austrian Academy of Sciences (GMI), Vienna BioCenter (VBC), Vienna, Austria
| | - Thibault Kervarrec
- Department of Pathology, University Hospital Center of Tours, University of Tours, Tours, France
| | - Estelle Laurent
- PRISM INSERM U1192, Université de Lille, Villeneuve d'Ascq, France
| | - Kamel Bachiri
- PRISM INSERM U1192, Université de Lille, Villeneuve d'Ascq, France
| | - Etienne Coyaud
- PRISM INSERM U1192, Université de Lille, Villeneuve d'Ascq, France
| | - Rajmohan Murali
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Klaus J. Busam
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Reinhard Kirnbauer
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Lorenzo Cerroni
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Eduardo Calonje
- Department of Dermatopathology, St John's Institute of Dermatology, St Thomas’ Hospital, London, United Kingdom
| | - Arno Rütten
- Dermatopathology Friedrichshafen, Friedrichshafen, Germany
| | - Frank Stubenrauch
- University Hospital Tuebingen, Institute for Medical Virology and Epidemiology of Viral Diseases, Tuebingen, Germany
| | - Klaus G. Griewank
- Department of Dermatology, University Hospital Essen, University of Duisburg, German Cancer Consortium (DKTK), Partner Site, Essen, Germany
| | - Thomas Wiesner
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Anna C. Obenauf
- Research Institute of Molecular Pathology (IMP), Vienna BioCenter (VBC), Vienna, Austria
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9
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Ramberg IMS. Human papillomavirus-related neoplasia of the ocular adnexa. Acta Ophthalmol 2022; 100 Suppl 272:3-33. [PMID: 36203222 PMCID: PMC9827891 DOI: 10.1111/aos.15244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/21/2022] [Indexed: 01/12/2023]
Abstract
Human papillomaviruses (HPV) are involved in approximately 5% of solid cancers worldwide. The mucosotropic genotypes infect the stratified epithelium of various locations, where persistent infection may lead to invasive carcinomas. While the causative role of HPV in certain anogenital and head and neck carcinomas is well established, the role of HPV in carcinomas arising in the mucosal membranes of the ocular adnexal tissue (the lacrimal drainage system and the conjunctiva) has been a topic of great uncertainty. Therefore, we conducted a series of studies to assess the correlation between HPV and carcinomas arising in the mucosa of the ocular adnexal tissue and characterize the clinical, histopathological, and genomic features of the tumors in the context of HPV status in a Danish nationwide cohort. We collected clinical and histopathological data and tumor specimens from patients with carcinomas of the conjunctiva and the lacrimal drainage system, and their potential precursors, identified in Danish nationwide registries. The HPV status of the tumors was determined by the combined use of HPV DNA polymerase chain reaction (PCR), HPV E6/E7 mRNA in-situ hybridization, and p16 immunohistochemistry. The genomic profile was investigated by high-throughput DNA sequencing targeting 523 cancer-relevant genes. The literature to date on carcinomas of the lacrimal drainage system and the conjunctiva was summarized. In the Danish cohort, 67% of all carcinomas of the lacrimal drainage system and 21% of all conjunctival carcinomas were HPV-positive. HPV16 was the most frequently implicated genotype. A full-thickness expression of the viral oncogenes E6 and E7 was evident in almost all HPV DNA-positive cases. The HPV-positive carcinomas of the conjunctiva and the lacrimal drainage system shared histopathological and genomic features distinct from their HPV-negative counterparts. The HPV-positive carcinomas were characterized by a non-keratinizing morphology, p16 overexpression, high transcriptional activity of HPV E6/E7, and frequent pathogenic variants in the PI3K-AKT signaling cascade. In contrast, the HPV-negative carcinomas were characterized by a keratinizing morphology, lack of p16 and E6/E7 expression, and frequent somatic pathogenic variants in TP53, CDKN2A, and RB1. Among the patients with conjunctival tumors, HPV positivity was associated with a younger age at diagnosis and a higher risk of recurrence. In conclusion, the results support an etiological role of HPV in a subset of conjunctival and LDS carcinomas and their precursor lesions. Our investigations have shown that the HPV-positive carcinomas of the ocular adnexa share genomic and phenotypic characteristics with HPV-positive carcinomas of other anatomical locations. Therefore, these patients may be eligible for inclusion in future basket trials and future treatment regimens tailored to the more frequently occurring HPV-positive carcinomas of other locations. Future research will further elucidate the diagnostic, prognostic, and predictive role of HPV in these carcinomas.
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10
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Landin D, Näsman A, Jara SJ, Hammarstedt-Nordenvall L, Munck-Wikland E, Dalianis T, Marklund L. Post-Treatment Neck Dissection of Tonsillar and Base of Tongue Squamous Cell Carcinoma in the Era of PET-CT, HPV, and p16. Viruses 2022; 14:v14081693. [PMID: 36016315 PMCID: PMC9413897 DOI: 10.3390/v14081693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/25/2022] Open
Abstract
Human-papillomavirus (HPV)-positive tonsillar and base of tongue carcinomas (TSCC/BOTSCC) are rising in incidence and treatments with radiotherapy, chemoradiotherapy (RT/CRT), and neck dissections (NDs) have several side effects. Therefore, an improved selection of patients needing salvage NDs would be beneficial. We examined the prevalence and localisations of viable tumour cells in neck lymph nodes in patients post-RT/CRT, identified by fluorodeoxyglucose positron-emission tomography with computer-tomography (FDG PET-CT), with a focus on HPV-associated tumours. Patients with 217 TSCC/BOTSCC with tumours assessed for HPV-DNA and p16INK4a undergoing FDG PET-CT 12 weeks after treatment and/or an ND were included. The FDG PET-CT data were compared with the findings in the pathology report after the ND. In total, 36/217 (17%) patients were selected for an ND due to positive findings in post-treatment FDG PET-CT. Of these, 35/36 were HPV-associated, 10/36 (28%) had viable tumour cells in the pathology reports of the neck specimen, and 8/10 (80%) were consistent with the FDG PET-CT findings, while 2/36 (5%) were missed by FDG PET-CT. We conclude that FDG PET-CT 12 weeks after RT/CRT is useful, but not completely reliable for finding all the metastases of HPV-associated TSCC/BOTSCC. Nonetheless, our data indicate that an ND could be more selectively guided by FDG PET-CT.
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Affiliation(s)
- David Landin
- Department of Clinical Science, Intervention and Technology, Department of Oto-Rhinolaryngology, Head and Neck Surgery, Karolinska University Hospital, Karolinska Institute, 17164 Stockholm, Sweden; (D.L.); (L.H.-N.); (E.M.-W.)
- Medical Unit Head Neck, Lung and Skin Cancer, Karolinska University Hospital, 17164 Stockholm, Sweden
| | - Anders Näsman
- Department of Oncology, Pathology, Karolinska Institute, 17164 Stockholm, Sweden;
- Department of Clinical Pathology, Karolinska University Hospital, 17164 Stockholm, Sweden
| | - Sara Jonmarker Jara
- Department of Neuroradiology, Karolinska University Hospital, 17164 Stockholm, Sweden;
| | - Lalle Hammarstedt-Nordenvall
- Department of Clinical Science, Intervention and Technology, Department of Oto-Rhinolaryngology, Head and Neck Surgery, Karolinska University Hospital, Karolinska Institute, 17164 Stockholm, Sweden; (D.L.); (L.H.-N.); (E.M.-W.)
- Medical Unit Head Neck, Lung and Skin Cancer, Karolinska University Hospital, 17164 Stockholm, Sweden
| | - Eva Munck-Wikland
- Department of Clinical Science, Intervention and Technology, Department of Oto-Rhinolaryngology, Head and Neck Surgery, Karolinska University Hospital, Karolinska Institute, 17164 Stockholm, Sweden; (D.L.); (L.H.-N.); (E.M.-W.)
- Medical Unit Head Neck, Lung and Skin Cancer, Karolinska University Hospital, 17164 Stockholm, Sweden
| | - Tina Dalianis
- Department of Oncology, Pathology, Karolinska Institute, 17164 Stockholm, Sweden;
- Correspondence: (T.D.); (L.M.)
| | - Linda Marklund
- Department of Clinical Science, Intervention and Technology, Department of Oto-Rhinolaryngology, Head and Neck Surgery, Karolinska University Hospital, Karolinska Institute, 17164 Stockholm, Sweden; (D.L.); (L.H.-N.); (E.M.-W.)
- Medical Unit Head Neck, Lung and Skin Cancer, Karolinska University Hospital, 17164 Stockholm, Sweden
- Department of Surgical Sciences, Section of Otolaryngology and Head and Neck Surgery, Uppsala University, 75105 Uppsala, Sweden
- Correspondence: (T.D.); (L.M.)
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11
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De-Escalating Strategies in HPV-Associated Head and Neck Squamous Cell Carcinoma. Viruses 2021; 13:v13091787. [PMID: 34578368 PMCID: PMC8473011 DOI: 10.3390/v13091787] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/02/2021] [Accepted: 09/06/2021] [Indexed: 12/22/2022] Open
Abstract
HPV-related head and neck squamous cell carcinoma (HNSCC) has emerged as a diverse clinical and biological disease entity, mainly in young patients with oropharyngeal tumors who are nonsmokers and nondrinkers. Indeed, during the past few years, the pendulum has shifted towards a new epidemiological reality, the “HPV pandemic”, where the majority of oropharyngeal squamous cell carcinomas (OPSCCs) are attributed to HPV. The oncogenic potential of the virus is associated to its capacity of integrating oncogenes E6 and E7 into the host cell, leading to the inactivation of several tumor suppressor genes, such as Rb. HPV status can affect prognosis in OPSCC, but its role as a predictive biomarker remains to be elucidated. Given the favorable prognosis associated with HPV-positive disease, the concept of de-escalation treatment strategies has been developed with the primary intent being the reduction of treatment-related long-term toxicities. In this review, we aim to depict current data regarding treatment de-escalation in HPV-associated OPSCC and discuss ongoing clinical trials.
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12
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Brennan S, Baird AM, O’Regan E, Sheils O. The Role of Human Papilloma Virus in Dictating Outcomes in Head and Neck Squamous Cell Carcinoma. Front Mol Biosci 2021; 8:677900. [PMID: 34250016 PMCID: PMC8262095 DOI: 10.3389/fmolb.2021.677900] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/10/2021] [Indexed: 12/29/2022] Open
Abstract
The Human Papilloma Virus (HPV) is an oncogenic virus which is associated with the development of head and neck squamous cell carcinoma (HNSCC), predominantly within the oropharynx. Approximately 25% of oropharyngeal squamous cell carcinoma (OPSCC) cases worldwide are attributable to HPV infection, with an estimated 65% in the United States. Transmission is via exposure during sexual contact, with distinctive anatomical features of the tonsils providing this organ with a predilection for infection by HPV. No premalignant lesion is identifiable on clinical examination, thus no comparative histological features to denote the stages of carcinogenesis for HPV driven HNSCC are identifiable. This is in contrast to HPV-driven cervical carcinoma, making screening a challenge for the head and neck region. However, HPV proffers a favorable prognosis in the head and neck region, with better overall survival rates in contrast to its HPV negative counterparts. This has resulted in extensive research into de-intensifying therapies aiming to minimize the morbidity induced by standard concurrent chemo-radiotherapy without compromising efficacy. Despite the favorable prognosis, cases of recurrence and/or metastasis of HPV positive HNSCC do occur, and are linked with poor outcomes. HPV 16 is the most frequent genotype identified in HNSCC, yet there is limited research to date studying the impact of other HPV genotype with respect to overall survival. A similar situation pertains to genetic aberrations associated in those with HPV positive HNSCC who recur, with only four published studies to date. Somatic mutations in TSC2, BRIP1, NBN, TACC3, NFE2l2, STK11, HRAS, PIK3R1, TP63, and FAT1 have been identified in recurrent HPV positive OPSCC. Finding alternative therapeutic strategies for this young cohort may depend on upfront identification of HPV genotypes and mutations which are linked with worse outcomes, thus ensuring appropriate stratification of treatment regimens.
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Affiliation(s)
- Shane Brennan
- School of Medicine, Faculty of Health Sciences, Trinity College, Dublin, Ireland
| | - Anne-Marie Baird
- School of Medicine, Faculty of Health Sciences, Trinity College, Dublin, Ireland
| | - Esther O’Regan
- Department of Histopathology, St. James’s Hospital, Dublin, Ireland
| | - Orla Sheils
- School of Medicine, Faculty of Health Sciences, Trinity College, Dublin, Ireland
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13
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Hoffmann M, Quabius ES. Relevance of Human Papillomaviruses in Head and Neck Cancer-What Remains in 2021 from a Clinician's Point of View? Viruses 2021; 13:v13061173. [PMID: 34207440 PMCID: PMC8235461 DOI: 10.3390/v13061173] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 12/12/2022] Open
Abstract
Human papillomaviruses (HPV) cause a subset of head and neck cancers (HNSCC). HPV16 predominantly signs responsible for approximately 10% of all HNSCC and over 50% of tonsillar (T)SCCs. Prevalence rates depend on several factors, such as the geographical region where patients live, possibly due to different social and sexual habits. Smoking plays an important role, with non-smoking patients being mostly HPV-positive and smokers being mostly HPV-negative. This is of unparalleled clinical relevance, as the outcome of (non-smoking) HPV-positive patients is significantly better, albeit with standard and not with de-escalated therapies. The results of the first prospective de-escalation studies have dampened hopes that similar superior survival can be achieved with de-escalated therapy. In this context, it is important to note that the inclusion of p16INK4A (a surrogate marker for HPV-positivity) in the 8th TMN-classification has only prognostic, not therapeutic, intent. To avoid misclassification, highest precision in determining HPV-status is of utmost importance. Whenever possible, PCR-based methods, still referred to as the "gold standard”, should be used. New diagnostic antibodies represent some hope, e.g., to detect primaries and recurrences early. Prophylactic HPV vaccination should lead to a decline in HPV-driven HNSCC as well. This review discusses the above aspects in detail.
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Affiliation(s)
- Markus Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, Christian-Albrechts-University Kiel, D24105 Kiel, Germany;
- Quincke-Forschungszentrum (QFZ), Medical Faculty, Christian-Albrechts-University Kiel, D24105 Kiel, Germany
- Correspondence: ; Tel.: +49-431-500-21701; Fax: +49-431-500-19028
| | - Elgar Susanne Quabius
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, Christian-Albrechts-University Kiel, D24105 Kiel, Germany;
- Quincke-Forschungszentrum (QFZ), Medical Faculty, Christian-Albrechts-University Kiel, D24105 Kiel, Germany
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14
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Wendt M, Hammarstedt-Nordenvall L, Zupancic M, Friesland S, Landin D, Munck-Wikland E, Dalianis T, Näsman A, Marklund L. Long-Term Survival and Recurrence in Oropharyngeal Squamous Cell Carcinoma in Relation to Subsites, HPV, and p16-Status. Cancers (Basel) 2021; 13:cancers13112553. [PMID: 34070952 PMCID: PMC8196945 DOI: 10.3390/cancers13112553] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 12/29/2022] Open
Abstract
Simple Summary Long-term survival in patients with oropharyngeal cancer is sparsely studied, but atypical recurrences in human papillomavirus-positive (HPV+) oropharyngeal cancer have been indicated. Furthermore, while the role of HPV is well established in tonsillar and base of tongue cancer, the dominant oropharyngeal subsites, its role in the minor oropharyngeal sites (the oropharyngeal walls, the uvula, and the soft palate) is not fully elucidated. The aim of this retrospective study was therefore to assess long-term outcome in relation to oropharyngeal sub-sites and HPV/p16 status. We confirm the prognostic role of p16+ in tonsillar and base of tongue cancer, but not the other sites. We find that combined HPV/p16-status gives better prognostic information than p16 alone. Lastly, we show that p16− cancer has more locoregional and late recurrences compared to p16+ cancer. Consequently, only combined HPV/p16 positivity in patients with tonsillar and tongue base cancer should be used in future treatment de-escalation trials. Abstract Long-term survival data in relation to sub-sites, human papillomavirus (HPV), and p16INK4a (p16) for patients with oropharyngeal squamous cell carcinoma (OPSCC) is still sparse. Furthermore, reports have indicated atypical and late recurrences for patients with HPV and p16 positive OPSCC. Therefore, we assessed long-term survival and recurrence in relation to oropharyngeal subsite and HPV/p16 status. A total of 529 patients with OPSCC, diagnosed in the period 2000–2010, with known HPVDNA and p16-status, were included. HPV/p16 status and sub-sites were correlated to disease-free and overall survival (DFS and OS respectively). The overexpression of p16 (p16+) is associated with significantly better long-term OS and DFS in tonsillar and base of tongue carcinomas (TSCC/BOTSCC), but not in patients with other OPSCC. Patients with HPVDNA+/p16+ TSCC/BOTSCC presented better OS and DFS compared to those with HPVDNA−/p16− tumors, while those with HPVDNA−/p16+ cancer had an intermediate survival. Late recurrences were rare, and significantly more frequent in patients with p16− tumors, while the prognosis after relapse was poor independent of HPVDNA+/−/p16+/− status. In conclusion, patients with p16+ OPSCC do not have more late recurrences than p16−, and a clear prognostic value of p16+ was only observed in TSCC/BOTSCC. Finally, the combination of HPVDNA and p16 provided superior prognostic information compared to p16 alone in TSCC/BOTSCC.
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Affiliation(s)
- Malin Wendt
- Department of Clinical Science, Intervention and Technology—CLINTEC Division of Ear, Nose and Throat Diseases, Karolinska Institutet, Karolinska University Hospital, 171 64 Stockholm, Sweden; (L.H.-N.); (D.L.); (E.M.-W.); (L.M.)
- Correspondence:
| | - Lalle Hammarstedt-Nordenvall
- Department of Clinical Science, Intervention and Technology—CLINTEC Division of Ear, Nose and Throat Diseases, Karolinska Institutet, Karolinska University Hospital, 171 64 Stockholm, Sweden; (L.H.-N.); (D.L.); (E.M.-W.); (L.M.)
- Medical Unit Head Neck, Lung and Skin Cancer, Karolinska University Hospital, 171 76 Stockholm, Sweden; (M.Z.); (S.F.); (T.D.)
| | - Mark Zupancic
- Medical Unit Head Neck, Lung and Skin Cancer, Karolinska University Hospital, 171 76 Stockholm, Sweden; (M.Z.); (S.F.); (T.D.)
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden;
| | - Signe Friesland
- Medical Unit Head Neck, Lung and Skin Cancer, Karolinska University Hospital, 171 76 Stockholm, Sweden; (M.Z.); (S.F.); (T.D.)
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden;
| | - David Landin
- Department of Clinical Science, Intervention and Technology—CLINTEC Division of Ear, Nose and Throat Diseases, Karolinska Institutet, Karolinska University Hospital, 171 64 Stockholm, Sweden; (L.H.-N.); (D.L.); (E.M.-W.); (L.M.)
| | - Eva Munck-Wikland
- Department of Clinical Science, Intervention and Technology—CLINTEC Division of Ear, Nose and Throat Diseases, Karolinska Institutet, Karolinska University Hospital, 171 64 Stockholm, Sweden; (L.H.-N.); (D.L.); (E.M.-W.); (L.M.)
- Medical Unit Head Neck, Lung and Skin Cancer, Karolinska University Hospital, 171 76 Stockholm, Sweden; (M.Z.); (S.F.); (T.D.)
| | - Tina Dalianis
- Medical Unit Head Neck, Lung and Skin Cancer, Karolinska University Hospital, 171 76 Stockholm, Sweden; (M.Z.); (S.F.); (T.D.)
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden;
| | - Anders Näsman
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden;
- Department of Clinical Pathology, CCK R8:02, Karolinska University Hospital, 171 64 Stockholm, Sweden
| | - Linda Marklund
- Department of Clinical Science, Intervention and Technology—CLINTEC Division of Ear, Nose and Throat Diseases, Karolinska Institutet, Karolinska University Hospital, 171 64 Stockholm, Sweden; (L.H.-N.); (D.L.); (E.M.-W.); (L.M.)
- Medical Unit Head Neck, Lung and Skin Cancer, Karolinska University Hospital, 171 76 Stockholm, Sweden; (M.Z.); (S.F.); (T.D.)
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Näsman A, Holzhauser S, Kostopoulou ON, Zupancic M, Ährlund-Richter A, Du J, Dalianis T. Prognostic Markers and Driver Genes and Options for Targeted Therapy in Human-Papillomavirus-Positive Tonsillar and Base-of-Tongue Squamous Cell Carcinoma. Viruses 2021; 13:v13050910. [PMID: 34069114 PMCID: PMC8156012 DOI: 10.3390/v13050910] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/12/2022] Open
Abstract
The incidence of Human-papillomavirus-positive (HPV+) tonsillar and base-of-tongue squamous cell carcinoma (TSCC and BOTSCC, respectively) is increasing epidemically, but they have better prognosis than equivalent HPV-negative (HPV−) cancers, with roughly 80% vs. 50% 3-year disease-free survival, respectively. The majority of HPV+ TSCC and BOTSCC patients therefore most likely do not require the intensified chemoradiotherapy given today to head and neck cancer patients and would with de-escalated therapy avoid several severe side effects. Moreover, for those with poor prognosis, survival has not improved, so better-tailored alternatives are urgently needed. In line with refined personalized medicine, recent studies have focused on identifying predictive markers and driver cancer genes useful for better stratifying patient treatment as well as for targeted therapy. This review presents some of these endeavors and briefly describes some recent experimental progress and some clinical trials with targeted therapy.
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Affiliation(s)
- Anders Näsman
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.N.); (S.H.); (O.N.K.); (M.Z.); (A.Ä.-R.)
| | - Stefan Holzhauser
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.N.); (S.H.); (O.N.K.); (M.Z.); (A.Ä.-R.)
| | - Ourania N. Kostopoulou
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.N.); (S.H.); (O.N.K.); (M.Z.); (A.Ä.-R.)
| | - Mark Zupancic
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.N.); (S.H.); (O.N.K.); (M.Z.); (A.Ä.-R.)
| | - Andreas Ährlund-Richter
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.N.); (S.H.); (O.N.K.); (M.Z.); (A.Ä.-R.)
| | - Juan Du
- Department of Microbiology, Tumor Biology and Cellular Biology, Karolinska Institutet, Biomedicum, 171 77 Stockholm, Sweden;
| | - Tina Dalianis
- Department of Oncology-Pathology, Karolinska Institutet, Bioclinicum J6:20, Karolinska University Hospital, 171 64 Stockholm, Sweden; (A.N.); (S.H.); (O.N.K.); (M.Z.); (A.Ä.-R.)
- Correspondence:
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16
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Zupancic M, Haeggblom L, Landin D, Marklund L, Dalianis T, Näsman A. Psoriasin expression is associated with survival in patients with human papillomavirus-positive base of tongue squamous cell carcinoma. Oncol Lett 2021; 21:277. [PMID: 33732353 PMCID: PMC7905654 DOI: 10.3892/ol.2021.12538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/25/2021] [Indexed: 12/23/2022] Open
Abstract
Patients with human papillomavirus-positive (HPV+) base of tongue squamous cell carcinomas (BOTSCC) have an improved survival compared with patients with HPV-negative BOTSCC and it has been suggested that treatment should be tailored. Before individualized treatment can be introduced, additional prognostic markers are required. A prognostic role of psoriasin has previously been demonstrated outside BOTSCC. Therefore, the present study aimed to examine psoriasin in BOTSCC, with focus on HPV+ BOTSCC, in relation to prognosis. A total of 72 BOTSCC samples were stained for psoriasin by immunohistochemistry, and the association between expression and clinical outcomes was analyzed. Patients with low psoriasin expression exhibited significantly improved overall survival (OS; P=0.001) and disease-free survival (DFS; P=0.007), which also was observed in patients with HPV+ BOTSCC (OS, P<0.001; DFS, P=0.02). Furthermore, psoriasin was a significant prognostic factor in univariable and multivariable analyses. In conclusion, psoriasin could be used as a prognostic marker in HPV+ BOTSCC.
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Affiliation(s)
- Mark Zupancic
- Department of Oncology-Pathology, Karolinska Institutet, 171 64 Stockholm, Sweden
| | - Linnea Haeggblom
- Department of Oncology-Pathology, Karolinska Institutet, 171 64 Stockholm, Sweden
| | - David Landin
- Division of Ear, Nose and Throat Diseases, Department of Clinical Science, Intervention and Technology - CLINTEC, Karolinska Institutet, 171 64 Stockholm, Sweden
| | - Linda Marklund
- Division of Ear, Nose and Throat Diseases, Department of Clinical Science, Intervention and Technology - CLINTEC, Karolinska Institutet, 171 64 Stockholm, Sweden
| | - Tina Dalianis
- Department of Oncology-Pathology, Karolinska Institutet, 171 64 Stockholm, Sweden
| | - Anders Näsman
- Department of Oncology-Pathology, Karolinska Institutet, 171 64 Stockholm, Sweden.,Department of Clinical Pathology, Karolinska University Hospital, 171 77 Stockholm, Sweden
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17
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Pilar A, Yu E, Su J, O'Sullivan B, Bartlett E, Waldron JN, Ringash J, Spreafico A, Hansen AR, de Almeida J, Bayley A, Bratman SV, Cho J, Giuliani M, Hope A, Hosni A, Kim J, Tong L, Xu W, Huang SH. Prognostic value of clinical and radiologic extranodal extension and their role in the 8th edition TNM cN classification for HPV-negative oropharyngeal carcinoma. Oral Oncol 2021; 114:105167. [PMID: 33508706 DOI: 10.1016/j.oraloncology.2020.105167] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/26/2020] [Accepted: 12/24/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND/OBJECTIVES We evaluate the performance between the TNM-8 versus TNM-7 cN-classification and explore the relative prognostic contribution of radiologic extranodal extension (rENE) for HPV-negative oropharyngeal cancer (HPV-OPC). MATERIALS/METHODS All HPV- OPC treated with IMRT between 2005 and 2016 were included. cENE was defined as unambiguous "fixation" of a neck mass or "skin involvement" on clinical examination. rENE was recorded by re-reviewing pre-treatment CT/MR. Disease-free survival (DFS) stratified by cENE or rENE were compared. Multivariable analyses (MVA) calculated the adjusted hazard ratio (aHR) for the separate cENE and rENE attributes and their combination. A refined cN-category incorporating both cENE and rENE parameters was proposed. The performance of the revision was compared to TNM-8 and TNM-7. RESULTS Of 361 HPV- OPC, 97 were cN0 and 264 were cN+ with 48 cENE+ and 72 rENE+ respectively. Median follow-up was 5.4 years. The 3-year DFS was lower in cENE+ vs cENE-negative (cENE-) (23% vs 45%; aHR = 1.68, p = 0.008) and rENE+ vs rENE-negative (rENE-) patients (29% vs 45%; aHR = 1.44, p = 0.037). The cENE+/rENE+ subset had the worse DFS vs cENE-/rENE+ or cENE-/rENE- (24%/37%/46%, p = 0.005). We propose a refined cN-category wherein any cENE-/rENE+ case is reclassified one N-stratum higher while any cENE+ case remains cN3b. The stage schema with the refined N-categorization outperformed TNM-8, and both outperformed TNM-7. CONCLUSIONS cENE and rENE are both prognostic but the cENE+/rENE+ subset has the worst outcome. The TNM-8 cN-categories improves outcome prediction compared to the TNM-7. Incorporation of rENE into TNM-8 cN-categories may further augment performance.
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Affiliation(s)
- Avinash Pilar
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada
| | - Eugene Yu
- Department of Neuroradiology and Head and Neck Imaging, Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Jie Su
- Department of Biostatistics, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Brian O'Sullivan
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada; Department of Otolaryngology-Head & Neck Surgery, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Eric Bartlett
- Department of Neuroradiology and Head and Neck Imaging, Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - John N Waldron
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada; Department of Otolaryngology-Head & Neck Surgery, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Jolie Ringash
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada; Department of Otolaryngology-Head & Neck Surgery, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Anna Spreafico
- Division of Medical Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Aaron R Hansen
- Division of Medical Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - John de Almeida
- Department of Otolaryngology-Head & Neck Surgery, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Andrew Bayley
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Scott V Bratman
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - John Cho
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Meredith Giuliani
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Andrew Hope
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Ali Hosni
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - John Kim
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Li Tong
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Wei Xu
- Department of Biostatistics, The Princess Margaret Cancer Centre/University of Toronto, Canada.
| | - Shao Hui Huang
- Department of Radiation Oncology, The Princess Margaret Cancer Centre/University of Toronto, Canada; Department of Otolaryngology-Head & Neck Surgery, The Princess Margaret Cancer Centre/University of Toronto, Canada.
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18
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Grégoire V, Hamoir M. "Are some green apples less green than others?". Eur J Cancer 2020; 139:201-203. [PMID: 32981824 DOI: 10.1016/j.ejca.2020.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Vincent Grégoire
- Department of Radiation Oncology, Centre Leon Bérard, Lyon, France
| | - Marc Hamoir
- Department of Head & Neck Surgery St Luc University Hospital and King Albert II Cancer Institute; Institut de Recherche Expérimentale et Clinique (IREC), UCLouvain, Brussels, Belgium.
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