Oral HPV infection and persistence in patients with head and neck cancer

The molecular characteristics of recurrent/metastatic HPV-positive head and neck squamous cell carcinoma: A systematic review of the literature

OBJECTIVES

About 17% of patients with human papillomavirus (HPV)-positive head and neck squamous cell carcinoma (HNSCC), which is mainly comprised of oropharyngeal SCC (OPSCC), will experience disease recurrence, which is often considered incurable when manifested at a metastatic and/or recurrent stage. We conducted a critical qualitative systematic review. Our objectives were to provide an overview of the molecular landscape of recurrent/metastatic HPV-positive HNSCC as well as novel molecular biomarkers.

DESIGN

A literature review was conducted to identify studies reporting on the molecular characteristics of recurrent/metastatic HPV-positive HNSCC, novel molecular biomarkers and treatment options. The reviews of abstracts, full articles, and revision of the included studies, followed by data extraction and quality assessment were performed by three independent assessors. All primary literature, such as retrospective, prospective, and clinical trials as well as basic research studies were considered, and the final search was conducted at the end of February 2023. The level of evidence was rated using the guidelines published by the Oxford Centre for Evidence-based Medicine and quality was assessed using the Newcastle-Ottawa Scale criteria.

RESULTS AND CONCLUSIONS

The literature search resulted in the identification of 1991 articles. A total of 181 full articles were screened, and 66 articles were included in this analysis. Several studies reported that recurrent/metastatic HPV-positive HNSCC had higher rates of TP53 mutation and were genomically similar to HPV-negative HNSCC. The detection of circulating tumour tissue-modified HPV DNA (ctHPVDNA) as a specific biomarker has shown promising results for monitoring treatment response and recurrence in the subset of HPV-positive HNSCC. In addition, evidence for targeted therapy in recurrent/metastatic HPV-positive HNSCC has emerged, including agents that inhibit overexpressed EGFR. Studies of combination immunotherapy are also underway. Our review outlines the latest evidence on the distinct molecular profiles of recurrent/metastatic HPV-positive HNSCC as well as the clinical potential of ctHPVDNA testing in routine practice. More controlled and longitudinal studies are needed to identify additional molecular targets and to assess the performance and benefits of novel molecular biomarkers in clinical practice.

Human papillomavirus co-infection and survival in oral and oropharyngeal squamous cell carcinoma: A study in 235 Brazilian patients

OBJECTIVES

While unknown for oropharyngeal squamous cell carcinoma (OPSCC) and oral squamous cell carcinoma (OSCC), some studies assessing cervical carcinoma have shown that human papillomavirus (HPV) co-infection can be associated with its prognosis.

METHODS

Through in situ hybridization (HPV and Epstein-Barr virus [EBV] probes) and immunohistochemistry (p16^INK4a, cyclin D1, p53, and Ki-67 antibodies), 126 OPSCC and 109 OSCC samples were assessed.

RESULTS

All patients were EBV-negative. OPSCC (25%) showed a significant association with HPV compared to OSCC (11%). Almost all HPV-associated cases were p16^INK4a-positive. Regarding OPSCC and OSCC, 23 and 7 cases were positive for high-risk HPV (HRHPV) only, 6 and 3 cases for low-risk HPV (LRHPV) only, and 3 and 2 cases for HRHPV/LRHPV, respectively. HPV-associated carcinomas showed a significantly higher proliferative index than HPV-unassociated carcinomas. Both carcinomas showed a similar overall survival rate, which was not affected by the HPV status. However, when comparing HPV-associated subgroups, patients with HRHPV/LRHPV-associated carcinomas showed worse survival.

CONCLUSION

LRHPV-associated and HRHPV/LRHPV-associated cases can also be detected when assessing OSCC and OPSCC. Further studies, especially in populations with a high prevalence of HPV-associated OPSCC, are necessary to understand the clinicopathological behavior of these neoplasm subgroups.

Symptoms and factors associated with symptom clusters among older adults with oral and oropharyngeal cancers at diagnosis

OBJECTIVE: Describe differences in pretreatment symptoms and the composition of symptom clusters in older patients with oral and oropharyngeal cancer. METHODS: In this cross-sectional study, quality of life (QoL) assessments for cancer patients (EORCT QLQ-C30 and QLQ-H & N35) were applied to 161 cases of oral and oropharyngeal cancer at the time of enrollment in an outpatient clinic. They were used to evaluate QoL-related symptoms reported by patients, according to their occurrence. To identify symptom clusters, an exploratory factor analysis (EFA) was performed, and the relationships between these clusters and independent variables were assessed with linear regression models. RESULTS: The most prevalent symptoms were pain (52%), worry (48%), and weight loss (44%). Five factors were extracted from the EFA, of which 3 were noteworthy. The dysphagia cluster was common to both cancer sites, although more frequent in oropharyngeal cancer patients, and included symptoms such as difficulty swallowing, pain, and weight loss. The psychological cluster included symptoms related to feeling worried, nervous, and depressed. The asthenia cluster, in addition to being age-related, may represent the advanced stage or progression of the disease. CONCLUSION: The dysphagia cluster loaded the most symptoms and was common to both cancers. In addition to pain (one of the main symptoms of the dysphagia cluster), psychological symptoms were also important in both groups of patients. Adequate and early control of these symptom clusters at diagnosis could favor better management of symptoms during treatment.

The evolving landscape of human papillomavirus-related oropharyngeal squamous cell carcinoma at a single institution in Northern Italy

The increasing incidence of HPV-related oropharyngeal squamous cell carcinoma (OPSCC) observed in several developed countries has not yet been documented in Italy. To investigate changes in the epidemiology of HPV-related OPSCC we reviewed the HPV status of cases evaluated at our centre in northern Italy before and after 2010. The results were correlated with patient age, sex, oropharyngeal subsite (classified as palatine tonsil, tongue base, palatine arch/palate/uvula, posterior oropharyngeal wall, and oropharynx not otherwise specified), AJCC tumour stage, risk factor exposure (smoke, alcohol), disease history (recurrence, metastasis, second tumours), outcome and survival. Positivity for p16 and HR HPV DNA was required to classify HPV-related OPSCC. HPV-related tonsillar OPSCC increased significantly after 2010, while a non-significant reduction of HPV-related extra-tonsillar OPSCC was observed. Non-keratinising morphology was strongly associated with HPV positivity. HPV16 was the most common genotype; the frequency of other high-risk genotype infections decreased after 2010. At multivariate analysis, HPV status showed a significant association with better outcome. We documented an increase of HPV-related OPSCC in our Italian population, synchronous with the increase observed in several Western countries, which in recent years reached a prevalence similar to that reported in central European countries. Our results indicate that HPV infection in head and neck oncology is relevant in Italy and needs to be considered for accurate patient stratification.

Low-Grade Papillary Schneiderian Carcinoma: Report of a Case with Molecular Characterization

In 2015, Lewis et al. first described low-grade papillary Scheneiderian carcinoma (LGPSC) of the sinonasal tract. Their case resembled a sinonasal papilloma clinically and histopathologically; however, invasion and metastasis resulted in the death of the patient despite absence of malignant cytologic features. Additional reports established LGPSC as a distinct entity and characterized its immunohistochemical profile. Diffuse expression of low molecular weight cytokeratins, positivity for p16 and p53 in at least 50% of cells, a high Ki-67 index, and absence of human papillomavirus (HPV)-DNA was observed across all reported cases. We report an additional case of LGPSC and describe the clinical, histologic, and immunohistochemical features. In contrast to sinonasal papillomas, the case was negative for HPV-DNA and showed no mutations in the EGFR and KRAS hotspot regions.

Frequency of human papillomavirus infection in patients with gastrointestinal cancer

INTRODUCTION AND AIM

Cancer is the result of the interaction of genetic and environmental factors. It has recently been related to viral infections, one of which is human papillomavirus. The aim of the present study was to describe the frequency of human papillomavirus infection in patients with digestive system cancers.

MATERIALS AND METHODS

A prospective, multicenter, observational study was conducted on patients with gastrointestinal cancer at 2public healthcare institutes in Veracruz. Two tumor samples were taken, one for histologic study and the other for DNA determination of human papillomavirus and its genotypes. Anthropometric variables, risk factors, sexual habits, tumor location, and histologic type of the cancer were analyzed. Absolute and relative frequencies were determined using the SPSS version 24.0 program.

RESULTS

Fifty-three patients were studied. They had gastrointestinal cancer located in: the colon (62.26%), stomach (18.87%), esophagus (7.55%), rectum (7.55%), and small bowel (3.77%). Human papillomavirus was identified in 11.32% of the patients, 66.7% of which corresponded to squamous cell carcinoma and 33.3% to adenocarcinoma. Only genotype 18 was identified. Mean patient age was 61.8±15.2 years, 56.60% of the patients were men, and 43.40% were women. A total of 15.8% of the patients had a family history of cancer and 31.6% had a personal history of the disease, 38.6% were tobacco smokers, and 61.4% consumed alcohol. Regarding sex, 5.3% of the patients said they were homosexual, 3.5% were bisexual, 29.8% engaged in oral sex, and 24.6% in anal sex.

CONCLUSIONS

Our study showed that human papillomavirus infection was a risk factor for the development of gastrointestinal cancer, especially of squamous cell origin.

The role of human papillomavirus in p16-positive oral cancers

BACKGROUND

The aim of this study was to identify the presence and frequency of human papillomavirus (HPV) nucleic acid in p16-positive oral squamous cell carcinomas (OSCCs), to assess whether the virus was transcriptionally active and to assess the utility of p16 overexpression as a surrogate marker for HPV in OSCC.

METHODS

Forty-six OSCC patients treated between 2007 and 2011 with available formalin-fixed paraffin-embedded (FFPE) specimens were included. Twenty-three patients were positive for p16 by immunohistochemistry (IHC) and these were matched with 23 patients with p16-negative tumours. Laser capture microdissection of the FFPE OSCC tissues was undertaken to isolate invasive tumour tissue. DNA was extracted and tested for high-risk HPV types using a PCR-ELISA method based on the L1 SPF10 consensus primers, and a real-time PCR method targeting HPV-16 and HPV-18 E6 region. Genotyping of HPV-positive cases was performed using a reverse line blot hybridization assay (Inno-LiPA). RNAScope^® (a chromogenic RNA in situ hybridization assay) was utilized to detect E6/E7 mRNA of known high-risk HPV types for detection of transcriptionally active virus.

RESULTS

HPV DNA was found in 3 OSCC cases, all of which were p16 IHC-positive. Two cases were genotyped as HPV-16 and one as HPV-33. Only one of the HPV-16 cases was confirmed to harbour transcriptionally active virus via HPV RNA ISH.

CONCLUSION

We have shown that the presence of transcriptionally active HPV rarely occurs in OSCC and that p16 is not an appropriate surrogate marker for HPV in OSCC cases. We propose that non-viral mechanisms are responsible for the majority of IHC p16 overexpression in OSCC.

Prevalence of HPV Infection in Racial-Ethnic Subgroups of Head and Neck Cancer Patients

The landscape of HPV infection in racial/ethnic subgroups of head and neck cancer (HNC) patients has not been evaluated carefully. In this study, a meta-analysis examined the prevalence of HPV in HNC patients of African ancestry. Additionally, a pooled analysis of subject-level data was also performed to investigate HPV prevalence and patterns of p16 (CDNK2A) expression amongst different racial groups. Eighteen publications (N = 798 Black HNC patients) were examined in the meta-analysis, and the pooled analysis included 29 datasets comprised of 3,129 HNC patients of diverse racial/ethnic background. The meta-analysis revealed that the prevalence of HPV16 was higher among Blacks with oropharyngeal cancer than Blacks with non-oropharyngeal cancer. However, there was great heterogeneity observed among studies (Q test P<0.0001). In the pooled analysis, after adjusting for each study, year of diagnosis, age, gender and smoking status, the prevalence of HPV16/18 in oropharyngeal cancer patients was highest in Whites (61.1%), followed by 58.0% in Blacks and 25.2% in Asians (P<0.0001). There was no statistically significant difference in HPV16/18 prevalence in non-oropharyngeal cancer by race (P=0.682). With regard to the pattern of HPV16/18 status and p16 expression, White patients had the highest proportion of HPV16/18+/p16+ oropharyngeal cancer (52.3%), while Asians and Blacks had significantly lower proportions (23.0% and 22.6%, respectively) [P <0.0001]. Our findings suggest that the pattern of HPV16/18 status and p16 expression in oropharyngeal cancer appears to differ by race and this may contribute to survival disparities.

Human papillomavirus and head and neck carcinomas: focus on evidence in the babel of published data

Human papillomavirus (HPV)-associated squamous cell carcinoma of the oropharynx is a well-defined entity mostly affecting young to middle-aged male non-smokers. It is generally associated with a favourable outcome, and for this reason a less intensive therapeutic approach has been proposed for this subset of patients. The incidence of HPV-associated oropharyngeal cancers is rapidly increasing in most Western countries, but detailed epidemiological data are not available for the Italian population. Furthermore, among other head and neck regions, a smaller proportion of oral high-grade dysplasia and cancers seems to depend on HPV infection, whereas its role in laryngeal cancer is recognised as less relevant. HPV-dependent neoplastic transformation depends on the expression of viral oncogenes in the infected host cell that can only be directly documented through viral oncogene mRNA identification. The consensus on how to classify these patients from clinical and laboratory diagnostic points of view is still limited, with different approaches based on one or more diagnostic techniques including p16 immunostaining, in situ hybridisation and polymerase chain reation (PCR) amplification of viral DNA. The possibility of early diagnosis relying on the identification of HPV infection in oral and oropharyngeal exfoliated cells has so far provided unsatisfactory results, although viral persistence after treatment has been associated with risk of recurrence. Presently, sufficient data are not available to document the natural history and progression from tonsillar HPV infection to oropharyngeal cancer development, and to clearly define the modality of transmission and risk exposure, among which sexual behaviours appear to play a relevant role. The diffusion of HPV vaccination and its administration to both genders will undoubtedly dramatically modify the epidemiology of HPV-related head and neck cancers in the coming years.

Low prevalence of HPV-driven head and neck squamous cell carcinoma in North-East Italy

Objectives

To investigate the frequency of Human papillomavirus (HPV)-driven head and neck squamous cell carcinoma (HNSCC) among patients living in North-East Italy, by assessing HPV-DNA positivity in all tumors and additional markers whenever possible.

Material and methods

HPV types, viral load, viral RNA, HPV16/18 E6 protein and p16^INK4a and pRb expression were determined in primary tumor tissues from 247 HNSCC patients. Tumor-specific HPV seropositivity was analyzed in 102 patients.

Results

Tumor HPV-DNA prevalence was 8.5% overall (21/247) and 27% in oropharynx (17/63). HPV16 accounted for 95% of all HPV types found. Among HPV-DNA+ tumors, type-concordant HPV E6^*I RNA prevalence was 79%. HPV DNA+ RNA+ tumors showed high viral load, up-regulated p16^INK4a, down-regulated pRb and presence of HPV16 E6 protein. Eight cases showed tumor-specific HPV seropositivity, all type-concordant with the tumor. Tumors were defined as HPV-driven when positive for HPV-DNA plus 2 additional HPV transformation-related markers.

Conclusion

Relative prevalence of HPV-driven tumors (14 HPV16, 1 HPV58) was 6% overall and 20% among oropharyngeal cancers. In the oropharynx the HPV-driven group showed a trend for better survival versus the HPV-negative group.

The relative prevalence of HPV-driven oropharyngeal cancer is low in North-East Italy as compared to Western and Northern Europe.

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HPV DNA alone is not sufficient to demonstrate causality in HNSCC.

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Additional transformation markers are needed to correctly identify HPV-driven tumors.

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HPV prevalence in HNSCC shows large geographical variation, even within Europe.

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Few small studies investigated the relative prevalence of HPV in HNSCC in Italy.

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In North-East Italy 6% of HNSCC and 20% of OPSCC are HPV-driven.

Mechanistic and Technical Challenges in Studying the Human Microbiome and Cancer Epidemiology

This article reviews the significance of the microbiome in cancer epidemiology, mechanistic and technical challenges in the field, and characterization of the microbiome in different tumor types to identify biomarkers of risk, progression, and prognosis. Publications on the microbiome and cancer epidemiology were reviewed to analyze sample collection and processing, microbiome taxa characterization by 16S ribosomal RNA sequencing, and microbiome metabolite characterization (metabotyping) by nuclear magnetic resonance and mass spectrometry. The analysis identified methodology types, research design, sample types, and issues in integrating data from different platforms. Aerodigestive cancer epidemiology studies conducted by different groups demonstrated the significance of microbiome information in developing approaches to improve health. Challenges exist in sample preparation and processing (eg, standardization of methods for collection and analysis). These challenges relate to technology, data integration from "omics" studies, inherent bias in primer selection during 16S ribosomal RNA sequencing, the need for large consortia with well-characterized biospecimens, cause and effect issues, resilience of microbiota to exposure events (requires longitudinal studies), and expanding studies for fungal and viral diversity (most studies used bacterial 16S ribosomal RNA sequencing for microbiota characterization). Despite these challenges, microbiome and cancer epidemiology studies are significant and may facilitate cancer risk assessment, diagnosis, and prognosis. In the future, clinical trials likely will use microbiota modifications to improve the efficacy of existing treatments.

Identification of transcriptionally active HPV infection in formalin-fixed, paraffin-embedded biopsies of oropharyngeal carcinoma

Human papillomavirus (HPV) oncogenic activity is the result of viral oncogene E6 and E7 expression in infected cells. Oncogene expression analysis is, however, not part of the routine diagnostic evaluation of HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) since it requires fresh tumor tissue. We compared the diagnostic accuracy of several methods commonly employed for HPV characterization in OPSCC with the results of the newly available HPV E6/E7 mRNA in situ hybridization (ISH) on formalin-fixed, paraffin-embedded biopsy samples, in order to establish if the latter should be introduced in the diagnostic routine to increase accuracy when fresh tissue is not available. p16 immunostain, DNA ISH for high-risk HPV genotypes, SPF LiPA amplification and genotyping, and HPV16 E6 amplification were performed on 41 consecutive OPSCC samples. Twenty (48.7%) cases were positive by mRNA ISH; sensitivity and specificity were 100% and 90% for p16, 90% and 100% for DNA ISH, 70% and 76% for SPF10 LiPA, 90% and 76% for E6 amplification. A diagnostic algorithm considering p16 immunostain as first step followed by either high-risk HPV DNA ISH or HPV16 E6 amplification in p16-positive cases correctly characterized 90% of mRNA-positive and all mRNA-negative cases; combining the 3 tests correctly identified all cases. While no stand-alone test was sufficiently accurate for classifying HPV-associated OPSCC, the high sensitivity and specificity of the established combination of p16 immunostain, DNA ISH, and HPV16 DNA amplification suggests that the introduction of labour- and cost-intensive mRNA ISH, is not necessary in the diagnostic routine of oropharyngeal tumors.

Distribution of 37 human papillomavirus types in parotid gland tumor tissues

Human papillomavirus (HPV) infection has been shown to be associated with human tumorigenesis. The aim of the present study was to demonstrate the association between HPV infection and parotid gland tumors. Paraffin-embedded tissue sections from 59 cases of parotid gland tumors and 20 normal oral mucosa were subjected to DNA extraction and flow-through hybridization and gene chip technology to detect infection of 37 HPV types. The HPV-positive rate was 57.6% in parotid gland tumor paraffin-embedded tissue specimens, whereas, the normal control group was negative for HPV. The HPV-positive rate was 59.6% in parotid gland benign tumor tissues and 42.9% in parotid malignant tissues. HPV infection in parotid gland tumors was dominated by the high-risk subtypes (80.7%), which mainly consisted of HPV 16, 18 and 52 (61.4%). In addition, parotid gland tumor tissues were found to be infected by multiple or single types of HPV, but were predominantly infected by mixed HPV types. In this study, we found that the occurrence of parotid gland tumor is correlated with HPV infection.