TNM 8 staging system beyond p16: Double HPV/p16 status is superior to p16 alone in predicting outcome in oropharyngeal squamous cell carcinoma

Therapeutic options for human papillomavirus-positive tonsil and base of tongue cancer

The incidences of human papillomavirus-positive (HPV+) tonsillar and base tongue squamous cell carcinomas (TSCC and BOTSCC) have increased in recent decades. Notably, HPV+ TSCC and BOTSCC have a significantly better prognosis than their HPV-negative counterparts when treated with current surgical options, radiotherapy, or intensified chemoradiotherapy. However, a cure is not achieved in 20% of patients with HPV+ TSCC/BOTSCC. Meanwhile, cured patients often present with severe chronic side effects. This necessitates novel tailored alternatives, such as targeted therapy, immune checkpoint inhibitors (ICIs), and treatment de-escalation, together with better follow-up. Current precision medicine therefore focuses on detecting predictive and driver cancer genes to better stratify patient treatment, provide those with poor prognostic markers targeted therapy, and select those with favorable markers for de-escalated therapy. Moreover, detecting cell-free HPV DNA (cfHPV DNA) in plasma before and after treatment has been attempted to improve follow-up. In this context, this perspective discusses the significance of optimally defining HPV+ status, which requires HPV DNA and p16INKa overexpression, using prognostic markers, such as high CD8+ T-cell counts and HPV E2 mRNA expression, tumor size, and following cfHPV DNA for patient selection for specific therapies. Clinical trials with ICI with/without chemotherapy, targeted therapy with specific inhibitors-such as phosphoinositide 3-kinase and fibroblast growth factor receptor inhibitors-or immune therapy with various HPV-based vaccines for treating recurrences have yielded promising results.

The epidemiological trends and survival of HPV-related oropharyngeal cancer other than tonsils and base of tongue - a systematic review and meta-analysis

IMPORTANCE

Human papillomavirus (HPV) is a well-established cause of oropharyngeal squamous cell carcinoma (OPSCC) located in the tonsils and base of tongue, but the association with other oropharyngeal subsites (otherOPSCC) remains unclear. This study aimed to examine the worldwide prevalence of HPV in otherOPSCC and its impact on survival utilizing the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

METHODS

The study outcomes and measures were planned at PROSPERO in advance. PubMed was searched from the earliest available record to September 1st, 2023. We included studies reporting otherOPSCC and known HPV-status. Exclusion criteria were (1) studies with ten or less otherOPSCC cases (2) studies with unspecified OPSCC subsite or with unknown primary tumor location (3) review articles, meta-analyses, and case reports (4) studies that focused exclusively on HPV+ or HPV- OPSCC. Two authors independently extracted the data.Risk of bias assessment was done using the ROBINS-E tool. The meta-analysis was conducted utilizing a random-effects model.

RESULTS

A total of 42 studies met the inclusion criteria comprising 20 unique cohorts with a total of 6442 patients (range 11-3776). A meta-analysis showed an overall HPV prevalence of 20% (95% CI 13% 30%). We found no significant differences in the 5-year OS between HPV + otherOPSCC and HPV- otherOPSCC (56% [95% CI 29% 80%] vs 45% [95% CI 41% 49%], p = 0.43).

CONCLUSION

Our study revealed a low HPV prevalence in otherOPSCC (20%). HPV is not a useful prognostic factor in other OPSCCs than palatine tonsils and base of tongue locations.

Prognostic impact of p16 and HPV discordance in cancer of unknown primary: a systematic review and meta-analysis

BACKGROUND

Discordance between human papillomavirus (HPV) and its surrogate marker, p16INK4a (p16), raises concerns about the reliability of p16 as a sole prognostic marker.

OBJECTIVES

To investigate the impact of HPV, p16, and discordant HPV/p16 status on survival in squamous cell carcinoma of unknown primary in the head and neck (SCCUPHN).

MATERIALS AND METHODS

PubMed and EMBASE were searched for relevant studies that used a strict definition of SCCUPHN and reported survival outcomes stratified by HPV/p16 status. A meta-analysis assessed the prevalence and overall survival (OS).

RESULTS

Twelve studies (n = 864) were included. The pooled prevalence rates were: 23% HPV+/p16+ SCCUPHN (95% CI: 14-33%); 50% HPV-/p16- (95% CI: 32-67%); 13% HPV-/p16+ (95% CI: 6-19%); and 6% HPV+/p16- (95% CI: 1-10%). OS hazard ratios were: 0.37 (95% CI: 0.17-0.78) for p16+ vs. p16-, 0.35 (95% CI: 0.19-0.64) for HPV+ vs. HPV-, and 0.24 (95% CI: 0.12-0.50) for HPV+/p16+ vs. HPV-/p16-. Only one study (n = 103) compared survival in the four HPV/p16 subgroups individually.

CONCLUSIONS

HPV and p16 are individual positive prognostic markers in SCCUPHN. Although significant discordance exists, the current literature does not provide sufficient evidence to support risk stratifying SCCUPHN patients into four distinct HPV/p16 subgroups.

Nutritional characterization of patients with oropharyngeal cancers: impact of human papillomavirus status

BACKGROUND

Oropharyngeal squamous cell carcinoma (OPSCC) of human papillomavirus (HPV)-positive status is increasing relative to HPV-negative disease. Nutritional features of OPSCC patients according to HPV status is unclear.

SUBJECTS/METHODS

Canadian and Spanish patients with OPSCC were assessed for body mass index (BMI), weight loss grade (WLG), and computed tomography-defined skeletal muscle index (SMI). Chi-square, t-test, Mann-Whitney-U, Kruskal-Wallis tests were conducted to compare HPV positive and negative groups. Overall survival (OS) was assessed by univariable Kaplan-Meier and Cox proportional hazard methods.

RESULTS

No differences in BMI, WLG, SMI, and adipose tissue index between the 308 (Canada) and 134 (Spain) patients according to HPV status; hence cohorts were pooled (n = 442). HPV-positive patients (n = 317) were overweight/obese (72.8%), had WLG of 0/1 (59.6%) and high SMI (83.4%) while HPV-negative patients were normal/underweight (61.5%), had high WLG 3/4 (50.8%), and moderate/severe SMI depletion (46.9%) (p < 0.003). These overall differences notwithstanding, there was crossover i.e. 35% of HPV-positive patients had high WLG and/or moderate/severe muscle depletion and 29% of HPV-negative patients had minimal weight loss and high SMI. HPV-negative patients had a higher risk of mortality (HR 3.78, 95% CI 2.70-5.29, P < 0.001) and this difference was retained after multivariable adjustment for WLG, SMI, age, disease stage, and planned treatment (HR 3.30, 95% CI 2.17-5.02, P < 0.001).

CONCLUSION

Nutrition features of patients with OPSCC did not differ between Canada and Spain. Distinctive nutrition features exist in patients according to HPV status. The high heterogeneity of individual nutritional profiles invites an individualized approach to nutrition care.

Evolution of testing for the diagnosis of human papillomavirus (HPV) status in head and neck squamous cell carcinoma: Where from and where to?

Human papillomavirus (HPV) is causally associated with head and neck squamous cell carcinomas with the strongest association in the oropharynx. HPV-associated oropharyngeal carcinomas have a different pathogenesis with distinct clinical features and better prognosis than HPV-negative oropharyngeal carcinomas which impacts staging and prognosis. It is, therefore, of clinical significance to accurately determine the HPV status, particularly in oropharyngeal carcinomas. In this review, the different test methods that are used for characterizing HPV status in head and neck squamous cell carcinomas, both conventional methods (p16 immunohistochemistry, HPV DNA in-situ hybridization, HPV DNA PCR, HPV E6/E7 mRNA RT-PCR, HPV RNA in-situ hybridization) as well as emerging novel approaches (HPV circulating tumour DNA, HPV16 E6 antibodies, oral HPV DNA/mRNA PCR), are discussed. Currently, a combined testing approach is favoured, using a sequential strategy of screening with p16 immunohistochemistry and confirming with HPV DNA PCR. HPV RNA in-situ hybridization could potentially serve as a single test owing to its good sensitivity and specificity. The use of liquid biopsies is gaining momentum with HPV circulating tumour DNA as the frontrunner in demonstrating promising clinical utility for early detection in HPV-associated oropharyngeal carcinomas. HPV16 E6 antibodies and oral HPV DNA PCR has potential utility as adjunct tests to aid diagnosis. In this rapidly evolving HPV testing landscape, we as clinicians and laboratorians must evolve and advocate for access to cost-effective accurate HPV testing globally.

Prognostic and predictive value of pathohistological features in gastric cancer and identification of SLITRK4 as a potential biomarker for gastric cancer

The aim of this study was to develop a quantitative feature-based model from histopathologic images to assess the prognosis of patients with gastric cancer. Whole slide image (WSI) images of H&E-stained histologic specimens of gastric cancer patients from The Cancer Genome Atlas were included and randomly assigned to training and test groups in a 7:3 ratio. A systematic preprocessing approach was employed as well as a non-overlapping segmentation method that combined patch-level prediction with a multi-instance learning approach to integrate features across the slide images. Subjects were categorized into high- or low-risk groups based on the median risk score derived from the model, and the significance of this stratification was assessed using a log-rank test. In addition, combining transcriptomic data from patients and data from other large cohort studies, we further searched for genes associated with pathological features and their prognostic value. A total of 165 gastric cancer patients were included for model training, and a total of 26 features were integrated through multi-instance learning, with each process generating 11 probabilistic features and 2 predictive labeling features. We applied a 10-fold Lasso-Cox regression model to achieve dimensionality reduction of these features. The predictive accuracy of the model was verified using Kaplan-Meyer (KM) curves for stratification with a consistency index of 0.741 for the training set and 0.585 for the test set. Deep learning-based resultant supervised pathohistological features have the potential for superior prognostic stratification of gastric cancer patients, transforming image pixels into an effective and labor-saving tool to optimize the clinical management of gastric cancer patients. Also, SLITRK4 was identified as a prognostic marker for gastric cancer.