HPV-negative Disease Research Articles

Association of human papillomavirus genotype andphylogenic clade with oropharyngeal cancer outcomes.

Human papillomavirus (HPV)+ oropharynx cancer (OPC) has a more favorable prognosis than HPV-negative disease, but the impact of specific HPV genotype and phylogenic clade on patient outcomes is not well understood and has profound implications for treatment de-intensification. The objective of this single-institution cohort study was to investigate the association of HPV genotype (16 vs high-risk non-16) and clade (A9 vs A7) with OPC outcomes. The primary endpoints were overall survival (OS) and event-free survival (EFS) in patients with M0 disease treated with curative intent. The cohort included 598 patients (87% HPV16, 98% A9). Compared to those with HPV16 OPC, individuals with non-HPV16 OPC had a higher age, comorbidity index, and proportion of non-whites, HIV+ patients, T4 tumors, and stage IV disease (AJCC 7th edition). Non-HPV16 genotype was associated with worse OS in univariate (HR = 2.17, 95% CI, 1.24-3.80, P = .0066), but not in multivariate analysis (HRadj = 0.84, 95% CI, 0.43-1.62, P = .5921). A7 clade was associated with worse OS in univariate (HR = 4.42, 95% CI, 1.60-12.30, P = .0041), but not in multivariate analysis (HRadj = 2.39, 95% CI, 0.57-9.99, P = .2325). Neither HPV genotype (HR = 1.60, 95% CI, 0.99-2.60, P = .0566) nor phylogenic clade (HR = 2.47, 95% CI, 0.91-6.72, P = .0761) was associated with EFS. Non-HPV16 genotype and A7 clade were associated with worse OS and trended toward worse EFS in univariate analyses. The survival differences were more pronounced by phylogenic clade than by HPV16 status, suggesting that the former may be a more useful classification for future studies. However, neither HPV16 status nor phylogenic clade was prognostic when adjusting for patient and tumor covariates, raising the question as to whether possible differences in outcomes are related to distinct clinical profiles rather than inherent viral properties.

Survival outcomes in head and neck squamous cell carcinoma of unknown primary: A national cohort study.

To investigate factors influencing survival in head and neck squamous cell carcinoma of unknown primary (HNSCCUP). A retrospective observational cohort study was conducted, over 5 years from January 2015, in UK Head and Neck centres, of consecutive adults undergoing 18F-Fluorodeoxyglucose-PET-CT within 3 months of diagnosis with metastatic cervical squamous cell carcinoma. Patients treated as HNSCCUP underwent survival analysis, stratified by neck dissection and/or radiotherapy to the ipsilateral neck, and by HPV status. Data were received from 57 centres for 965 patients, of whom 482 started treatment for HNSCCUP (65.7% HPV-positive, n = 282/429). Five-year overall survival (OS) for HPV-positive patients was 85.0% (95% CI 78.4-92.3) and 43.5% (95% CI 32.9-57.5) for HPV-negative. HPV-negative status was associated with worse OS, disease-free (DFS), and disease-specific (DSS) survival (all p < .0001 on log-rank test) but not local control (LC) (p = .16). Unilateral HPV-positive disease treated with surgery alone was associated with significantly worse DFS (p < .0001) and LC (p < .0001) compared to radiotherapy alone or combined modalities (5-year DFS: 24.9%, 82.3% and 94.3%; 5-year LC: 41.8%, 98.8% and 98.6%). OS was not significantly different (p = .16). Unilateral HPV-negative disease treated with surgery alone was associated with significantly worse LC (p = .017) (5-year LC: estimate unavailable, 93.3% and 96.6%, respectively). Small numbers with bilateral disease precluded meaningful sub-group analysis. HPV status is associated with variable management and outcomes in HNSCCUP. Unilateral neck disease is treated variably and associated with poorer outcomes when managed with surgery alone. The impact of diagnostic oropharyngeal surgery on primary site emergence, survival and functional outcomes is unestablished.

Sex-Specific Survival and Treatment Delay in Oropharyngeal Squamous Cell Carcinoma.

As the majority of oropharyngeal squamous cell carcinoma (OPSCC) is diagnosed in males, outcomes among females are not well-characterized. We identify sex-specific factors in OPSCC to refine female prognostication. Retrospective cohort. National Cancer Database (NCDB). OPSCC cases from the 2004 to 2019 NCDB were identified. Sociodemographic, clinical, and treatment characteristics (including timing between diagnosis and treatment administration) were compared between sexes. Multivariable Cox proportional hazard regression models were constructed to characterize survival in overall and female-only cohorts. Similar multivariable binomial logistic regression and survival models were constructed to assess odds of treatment delays and their effects on survival, respectively. A total of 192,973 OPSCC patients were identified; 36,695 (19%) were female. Females had more human papillomavirus (HPV) negative, lower clinical T and N stage, and higher comorbidity disease. Females experienced lower survival in HPV negative (hazard ratio, HR = 1.11, P < .001) but not HPV-positive disease. Females were more likely to have any treatment initiated over the median of 28 days (odds ratio, OR = 1.04, P = .014) or delays in adjuvant radiotherapy initiation over 6 weeks (OR = 1.11, P = .032). Treatment delay over 60 days (HR = 1.17, P = .016) and delay in adjuvant therapy initiation (HR = 1.24, P = .02) were associated with worse survival among females. In one of the largest analyses of OPSCC, females had poorer survival than males, specifically in HPV-negative disease, despite presentation with less advanced disease. Notably, delays in any treatment initiation and adjuvant radiotherapy initiation were more likely in HPV-negative women and associated with worse survival, highlighting potential systemic weaknesses contributing to poor prognosis among females.

Cause of Death in Patients with Oropharyngeal Carcinoma by Human Papillomavirus Status: Comparative Data Analysis.

The incidence of oropharyngeal squamous cell carcinomas (OPSCC) has increased in recent decades, and human papillomavirus (HPV) infection is the main cause of OPSCC. The data regarding causes of death (CODs) are vitally important in informing follow-up strategies and revising treatment strategies to deal with any possible preventable treatment-related COD. However, limited studies have assessed the competing COD by HPV status in patients with OPSCC. We aimed to analyze the distribution of the competing COD according to HPV status in OPSCC. We retrospectively included stage I-IVB patients with OPSCC from the Surveillance, Epidemiology, and End Results database between 2010 and 2015. The association between HPV status and head and neck cancer-specific mortality (HNCSM), second primary cancer mortality (SPCM), and noncancer-caused mortality (NCCM) were analyzed. The chi-square test, Kaplan-Meier analysis, and Fine and Gray model were used for statistical analysis. We included 5852 patients in this study and 73.2% (n=4283) of them had HPV-related tumors. A total of 1537 (26.3%) patients died, including 789 (51.3%), 333 (21.7%), and 415 (27%) patients who died from head and neck cancer, second cancer, and noncancer causes, respectively. The 5-year HNCSM, SPCM, NCCM, and overall mortality were 14.7%, 6.5%, 7.7%, and 26.4%, respectively. Those with HPV-positive disease had a lower cumulative incidence of HNCSM (subdistribution hazard ratio [sHR] 0.362, 95% CI 0.315-0.417; P<.001), SPCM (sHR 0.400, 95% CI 0.321-0.496; P<.001), and NCCM (sHR 0.460, 95% CI 0.378-0.560; P<.001) than those with HPV-negative disease. The 5-year risk of HNCSM was 26.9% and 10.7% in those with HPV-negative and HPV-positive disease, respectively (P<.001). The 5-year risk of SPCM was 12.4% and 4.6% in those with HPV-negative and HPV-positive disease, respectively (P<.001). The 5-year risk of NCCM of death was 13.7% and 5.8% in those with HPV-negative and HPV-positive disease, respectively (P<.001). Using the Fine and Gray competing-risks model, our results show that those with HPV-negative tumors had a significantly higher risk of HNCSM (P<.001), SPCM (P<.001), and NCCM (P<.001) than those with HPV-negative tumors. HPV-positive OPSCC has a lower NCSM, SPCM, and NCCM as compared to those with HPV-negative OPSCC. HPV positivity is a favorable prognostic factor in the context of overcoming cancer as well as in terms of reducing the risk of other CODs in OPSCC. Our finding supports the need to tailor patient follow-up based on the HPV status of patients with OPSCC.

Risk-adjusted chemoradiation according to human papilloma viral status for anal cancer: a pilot study.

HPV-associated or positive (HPV+) anal cancer patients may have better outcome compared to those with HPV negative (HPV-) disease. We report a planned interim analysis of a prospective registry study that tailors chemoradiation (CRT) for anal cancer according to HPV status. HPV+ patients received de-escalated radiation doses of 45, 50.4 and 55.8 Gy, while HPV- received 50.4, 55.8 and 63 Gy for T1, T2 and T3/T4 disease respectively. Chemotherapy consisted of a single dose of mitomycin-C and oral capecitabine on days of RT. All patients were planned by VMAT following CT, PET/CT and MR simulation. This cohort (n = 24) had a minimum 24-month follow-up. Disease free survival (DFS) and local failure rates (LFR) were compared with 180 patients managed by standard CRT (2 cycles of mitomycin-C and 5-fluorouracil, radiation doses 50.4-63 Gy based on T-category) from 2011-2018. Propensity score comparison was performed using a retrospective to prospective 2 to 1 match based on tumor size and N-category. In the HPV+ cohort (n = 20), there were 2 local failures. Two of 4 HPV- patients failed locally. The 30-month DFS and LFR were 79% and 17% respectively. Similar DFS and LFR were observed in the retrospective (80% and 15% respectively) and matched patients (76% and 16% respectively). No grade ≥3 neutropenia and febrile neutropenia were observed in the registry cohort whereas 19% and 14% respectively were seen in the retrospective patients. De-escalation of CRT for HPV+ anal cancer may result in decreased acute toxicities and similar cancer outcomes compared to standard CRT.

Correlation of CDKN2A genomic alterations with tumor response to palbociclib given before chemoradiation therapy (CRT) to patients with human papillomavirus (HPV)-negative, locally advanced head and neck squamous-cell carcinoma (LA-HNSCC): A single-arm, phase 2 trial.

6015 Background: Cell cycle deregulation is ubiquitous in HNSCC. In HPV-negative disease, the most common genomic alteration of cell-cycling included CDKN2A deletions (57%), mutations (27%) or hypermethylation (12%). Selective CDK4/6 inhibition arrested cell cycling and inhibited tumor growth in cell-line and xenograft models of HPV-negative HNSCC, and CDKN2A alterations were predictive of response. An exploratory analysis of a double-blind, randomized, phase 2 trial of patients with HPV-negative recurrent/metastatic HNSCC showed that CDKN2A alterations were associated with better overall survival (OS) with palbociclib and cetuximab vs placebo and cetuximab (median 9.7 vs 4.6 months, HR 0.38). OS was similar between the two arms in patients without CDKN2A alterations. A phase 2 basket trial of patients with CDKN2A-altered head and neck cancers observed that palbociclib resulted in a target lesion decrease in 25% of patients. Collectively, these data warrant further studies to delineate predictive biomarkers of response to selective CDK4/6 inhibitors in HPV-negative HNSCC. Methods: The primary aims of this single-arm, phase 2 trial were to determine the objective response rate (ORR) of HPV-negative, LA-HNSCC to palbociclib, and to correlate responses to somatic CDKN2A alterations. HPV-negative disease was defined as SCC of the larynx, hypopharynx or oral cavity, or SCC of the oropharynx if negative for p16 by IHC and/or high-risk HPV-RNA by ISH. Genome sequencing (FoundationOne CDx/Tempus xT) was performed on tumor tissue obtained before treatment. Patients received palbociclib 125 mg/d orally on days 1-21 of each 28-day cycle. Tumor response was assessed using RECIST 1.1 with CT scans performed pre and post two cycles of palbociclib. Patients then received CRT. A sample size of 24 patients yielded an 80% power if the ORR was ≥38%, using an exact binomial test of one sample proportion comparison with an upper one-sided nominal significance level of 0.05 and null ORR of ≤17%. Results: 24 patients enrolled and completed two cycles of palbociclib: primary site (larynx-15; hypopharynx-4; oropharynx-4, oral cavity-1), clinical stage (III-7; IV-17), and smoking history (yes-23; no-1). The ORR with palbociclib was 41.7%. Best tumor response included: CR (1), PR (9), SD (13), and PD (1). CDKN2A altered disease was identified in 15 patients (62.5%) [mutation: 8, deletion: 7]. Tumor response to palbociclib occurred in 10 of 15 patients (66.7%) with CDKN2A altered disease versus 0 of 9 patients (0%) without CDKN2A altered disease (p=0.002, Fisher’s Exact Test). Conclusions: The primary hypothesis was met: the ORR with palbociclib in HPV-negative, LA-HNSCC was 41.7%. The ORR with palbociclib was significantly higher in CDKN2A altered disease. Clinical trial information: NCT03389477 .

Association of HPV genotype and phylogenic clade with oropharyngeal cancer outcomes.

6058 Background: Human papillomavirus (HPV) is a causative agent of oropharyngeal squamous cell carcinoma (HPVOPC). There are multiple different HPV genotypes based on variations in the nucleotide sequence of the L1 capsid, with HPV16 being most common in HPVOPC (85%). HPV genotypes can be further classified into phylogenic clades, including alpha-9 (A9) and alpha-7 (A7). HPVOPC is associated with a more favorable prognosis than HPV-negative disease, but the impact of specific HPV genotype and phylogenic clade on patient outcomes is not well understood and has profound implications for de-escalation studies in HPVOPC. Methods: A retrospective cohort study was conducted at a large multicenter health system. Patients diagnosed with non-metastatic HPVOPC or unknown primary from 2012-2021 and treated with curative intent were included. Low-risk HPV types (6, 11, etc) and local recurrences were excluded. HPV molecular typing was prospectively performed according to institutional protocol. Cox regressions were used to measure the effect of HPV genotype (16 versus non-16) on overall survival (OS) and event-free survival (EFS). Gender, smoking status, alcohol use, ECOG performance status, T stage, N stage, and subsite (oropharynx versus known primary) were covariates. A secondary survival analysis according to high-risk HPV clade (A9 versus A7) was also performed. Results: The total cohort included 520 patients, the majority of whom were HPV16 (86.9%, n = 452), A9 clade (97.1%, n = 505), oropharynx primary (94.8%, n = 493), male (86.9%, n = 452), white (72.5%, n = 377), non-Hispanic (74.2%, n = 386), non-active smokers (88.3%, n = 459), ECOG 0 (75.6%, n = 393), and N2 stage (65.2%, n = 339). The most common non-16 HPV genotypes were 18 (n = 7), 33 (n = 21), and 35 (n = 29). HPV genotype was not associated with OS (HR = 1.64, 95% CI 0.85-3.16, p= 0.14) or EFS (HR = 1.15, 95% CI 0.64-2.07, p= 0.65). A7 clade was associated with a worse OS compared to A9 in the univariate analysis (HR = 3.43, 95% CI 1.07-10.97, p= 0.04), but not in the multivariate analysis (HR = 1.67, 95% CI 0.45-6.17, p = 0.44). Finally, HPV clade was not associated with EFS (HR = 1.38, 95% CI 0.34-5.60, p= 0.66). Conclusions: While HPV genotype was not associated with survival differences in patients with HPVOPC, HPV A7 clade only predicted worse OS in univariate analysis. Although the total cohort size was large, this analysis was limited by small numbers of subjects with non-16 HPV genotypes and non-A9 clade, which is reflective of the predominance of HPV16 in HPVOPC. Thus, a pooled multicenter collaboration is needed to further address this question. Moreover, future studies should investigate whether outcomes may be related to intratypic HPV16 variants that affect oncoprotein function and/or immunogenicity. Detection of a subgroup of HPVOPC with possible inferior outcomes has important implications for studying treatment de-escalation in HPVOPC.

A proteomic signature associated with prognosis in HPV-related locally advanced oropharyngeal squamous cell carcinoma (LA-OPSCC).

6055 Background: Although HPV-related LA-OPSCC is associated with better prognosis than HPV-negative disease, ~30% of cases relapse despite curative-intent chemoradiotherapy. New prognostic biomarkers are needed to rationalise curative-intent treatment without compromising efficacy. We aimed to develop a proteomic signature associated with risk of recurrence from diagnostic biopsies of patients with HPV-positive OPSCC. Methods: We analysed 139 formalin fixed paraffin embedded archival core biopsy specimens from 124 patients with HPV-related (p16 IHC positive) T1-4N0-3M0 LA-OPSCC tumours. All patients were treated with definitive chemoradiotherapy at the Princess Alexandra Hospital (Brisbane, Australia) between 2007-2019. The cohort included 50 patients with recurrence less than five years from diagnosis and 74 age/performance-status matched patients with no recurrence. Proteomic analysis was performed utilizing data-independent acquisition mass spectrometry (DIA-MS). A proteomic prognostic signature associated with recurrence free survival (RFS) at five years was the primary endpoint of interest. It was developed using a computational pipeline comprising an initial univariate Cox model step, followed by multiple runs of multivariate Cox models with Least Absolute Shrinkage and Selection Operator (LASSO) regularization, and then a final step of recursive feature selection. Results: A total of 7,597 proteins were quantified and 665 were differentially expressed proteins between tumour and normal adjacent tissues. There were 5,199 proteins remaining in the tumour samples after filtering. RFS was significantly (q-value &lt; 0.05) associated with 252 proteins, whose functions are enriched in adaptive and innate immunity and MAPK6/MAPK4 signalling pathways. A 16-protein signature associated with RFS stratified patients into low, intermediate, or high-risk groups (C-index = 0.885, p &lt; 0.0001). The 16-protein signature outperformed clinico-pathological covariates including age, stage, ECOG and smoking history with the highest area under the receiver operating characteristic curve (AUROC 0.95). Conclusions: DIA-MS-based proteomics on core biopsies can be used to risk stratify HPV-related OPSCC patients. A 16-protein signature associated with RFS was successfully identified as a basis for future studies. Validation of this proteomic prognostic signature in independent cohorts is required and may be used to inform future clinical trials to better tailor upfront therapy.

High-risk human papillomavirus 16/18 associated with improved survival in sinonasal squamous cell carcinoma.

There has been conflicting evidence on the independent prognostic role of human papillomavirus (HPV) status in sinonasal cancer. The objective of this study was to assess whether the survival of patients with sinonasal cancer differs based on various HPV statuses, including HPV-negative, positive for the high-risk HPV-16 and HPV-18 (HPV16/18) subtypes, and positive for other high-risk and low-risk HPV subtypes. In this retrospective cohort study, data from the National Cancer Database were extracted from the years 2010-2017 for patients who had primary sinonasal cancer (N = 12,009). The outcome of interest was overall survival based on HPV tumor status. Study included an analytic cohort of 1070 patients with sinonasal cancer who had confirmed HPV tumor status (732 [68.4%] HPV-negative; 280 [26.2%] HPV16/18-positive; 40 [3.7%] positive for other high-risk HPV; and 18 [1.7%] positive for low-risk HPV). HPV-negative patients had the lowest all-cause survival probability at 5 years postdiagnosis (0.50). After controlling for covariates, HPV16/18-positive patients had a 37% lower mortality hazard than HPV-negative patients (adjusted hazard ratio, 0.63; 95% confidence interval [CI], 0.48-0.82). Patients aged 64-72 years (crude prevalence ratio, 0.66; 95% CI, 0.51-0.86) and 73 years and older (crude prevalence ratio, 0.43; 95% CI, 0.31-0.59) presented with lower rates of HPV16/18-positive sinonasal cancer than those aged 40-54 years. In addition, Hispanic patients had a 2.36 times higher prevalence of non-HPV16/18 sinonasal cancer than non-Hispanic White patients. These data suggest that, for patients with sinonasal cancer, HPV16/18-positive disease may confer a significant survival advantage compared with HPV-negative disease. Other high-risk and low-risk HPV subtypes have survival rates similar to the rates for HPV-negative disease. HPV status might be an important independent prognostic factor in sinonasal cancer that could be used in patient selection and clinical decisions.

Improving head and neck cancer therapies by immunomodulation of the tumour microenvironment.

Targeted immunotherapy has improved patient survival in head and neck squamous cell carcinoma (HNSCC), but less than 20% of patients produce a durable response to these treatments. Thus, new immunotherapies that consider all key players of the complex HNSCC tumour microenvironment (TME) are necessary to further enhance tumour-specific T cell responses in patients. HNSCC is an ideal tumour type in which to evaluate immune and non-immune cell differences because of two distinct TME aetiologies (human papillomavirus (HPV)-positive and HPV-negative disease), multiple anatomic sites for tumour growth, and clear distinctions between patients with locally advanced disease and those with recurrent and/or metastatic disease. Recent technological and scientific advancements have provided a more complete picture of all cellular constituents within this complex TME and have evaluated the interplay of both immune and non-immune cells within HNSCC. Here, we include a comprehensive analysis of the complete ecosystem of the HNSCC TME, performed utilizing data-rich resources such as The Cancer Genome Atlas, and cutting-edge techniques, such as single-cell RNA sequencing, high-dimensional flow cytometry and spatial multispectral imaging, to generate improved treatment strategies for this diverse disease.

Prognostic Role of Porphyromonas gingivalis Gingipain Rgp and Matrix Metalloproteinase 9 in Oropharyngeal Squamous Cell Carcinoma.

The oral bacteria involved in the development of periodontitis alter the tissue conditions and modify immune responses in a way that may also influence tumor development. We investigated the prevalence of R gingipain (Rgp), a key virulence factor of the oral pathobiont Porphyromonas gingivalis, and the tissue-destructive enzymes matrix metalloproteinase 8 (MMP-8) and 9 (MMP-9) in 202 unselected consecutive oropharyngeal squamous cell carcinoma (OPSCC) samples. We further investigated the relationships between these factors and human papillomavirus (HPV) status, Treponema denticola chymotrypsin-like proteinase (Td-CTLP) immunoexpression, clinical parameters, and patient outcome. Clinicopathological data were derived from university hospital records. Rgp, MMP-8, and MMP-9 immunoexpression was evaluated by immunohistochemistry; the immunohistochemistry of Td-CTLP and HPV has been described earlier for this patient series. Cox regression analysis including death by causes other than OPSCC as a competing risk served to assess sub distribution hazard ratios. In multivariable survival analysis, positive tumoral MMP-9 immunoexpression predicted poor prognosis among all patients [sub distribution hazard ratio (SHR)=2.4; confidence interval (CI)=1.2-4.4, p=0.008], and especially among those with HPV-negative OPSCC (SHR=3.5; CI=1.7-7.3, p=0.001). Positive immunoexpression of Rgp in inflammatory cells was associated with favorable outcome among all patients (SHR=0.5, CI=0.2-0.9, p=0.021) and among those with HPV-negative disease (SHR=0.4, CI=0.2-0.9, p=0.022). Our results suggest that tumoral MMP-9 may be related to poor outcome in OPSCC, especially in HPV-negative disease, while Rgp immunoexpression in inflammatory cells is associated here with better disease-specific survival (DSS).

Risk-Adjusted Chemoradiation according to Human Papilloma Virus Status for Anal Cancer: A Pilot Registry Study

<h3>Purpose/Objective(s)</h3> Radiation with concurrent chemotherapy (CRT) represents standard definitive therapy for anal cancer. CRT protocols result in good local control, but are associated with significant acute and late morbidity. Whether radiation dose escalation beyond 55-60 Gy improves local control remains unknown. Most anal cancers are associated with HPV infection. Patients with HPV positive (+) cancers have better outcomes compared to those with HPV negative (-) disease. HPV+ anal cancer patients may not benefit from standard CRT. <h3>Materials/Methods</h3> Since 2019, we have instituted a REB-approved prospective registry study that tailored CRT for anal cancer according to HPV status in addition to disease stages. Patients with HPV+ T1, T2 and T3/T4 disease received a total dose of 45, 50.4 and 55.8 Gy respectively. Elective nodal radiation dose was 30.6 Gy. For HPV- disease, total doses for T1, T2 and T3/T4 disease were 50.4, 55.8 and 63 Gy respectively, and 36 Gy was given for N0 disease. Concurrent chemotherapy consisted of a single dose of mitomycin C (12 mg/m²) and daily oral capecitabine (825 mg/m² bid) on days of radiation only. Patients were planned following CT, PET/CT and MR simulation. Treatment was delivered using volumetric modulated arc radiotherapy (VMAT) with daily cone beam CT. We report results of an interim analysis, which was planned after the first consecutive cohort of patients had a minimum 18 months of follow-up from CRT. <h3>Results</h3> There were 20 patients with HPV+ (HPV16, 15; HPV18, 1; other HPV types, 3) tumor and 4 were HPV-. All HPV+ tumors demonstrated p16 immunoreactivity. In the HPV+ cohort, there were one T1 (1.6 cm), eleven T2 (2.1-4.8 cm), five T3 (5.1-5.8 cm) and three T4 (4-8.5 cm) lesions. Eight patients (N1a, 4; N1b, 1; N1c, 3) presented with nodal metastases. All HPV+ patients completed protocol RT without RT interruption. Two refused chemotherapy. Grade 2 acute toxicities were observed in all 20 patients and five had grade 3 acute toxicities (skin reactions, pain and anemia). Restaging MRI was done at a median of 170 days (103-204 days) from date of RT. There were two local failures. Both (T4N1c and T2N0) had persistent local disease. Of four patients with HPV- cancer, one (T2N1b) had persistent local disease and one (T2N1c) failed in the iliac nodes; one (T4N0) developed a perforated ischemic sigmoid at 14 months requiring surgery. The local failure rate of 4/24 (16.7%) in this registry study was similar to our historic local failure rate of 28/180 (15.6%) in a retrospective cohort of patients managed by CRT from 2001-2009. These patients were managed using the current RT protocol for HPV- disease but with two cycles of mitomycin C and 5-Fluorouracil. <h3>Conclusion</h3> Treatment de-escalation for HPV+ anal cancer appears safe and may result in similar local control rates compared to standard CRT protocols.

Accuracy of Response Assessment FDG PET-CT Post (Chemo)Radiotherapy in HPV Negative Oropharynx Squamous Cell Carcinoma.

Simple SummaryOropharyngeal squamous cell carcinoma is often treated with (chemo)radiotherapy with curative intent. Human papilloma virus (HPV) is a key risk factor for the development of a majority of oropharynx cancers in many parts of the world. PET-CT is widely used as an accurate method of assessing response following (chemo)radiotherapy and most of the data supporting this is based upon HPV-related disease. Oropharynx squamous cell carcinoma that is not related to human papilloma virus has an inferior prognosis and there is little data regarding the accuracy of response assessment PET-CT after chemoradiotherapy. This study shows that a negative PET-CT after treatment for patients with HPV-negative oropharynx cancer has a high negative predictive value with treatment having been successsful; however if the PET-CT is equivocal there is a significant chance of disease being persistent.Background: Data on the accuracy of response assessment 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) following (chemo)radiotherapy in patients with oropharynx squamous cell carcinoma (OPSCC) is predominantly based on HPV-positive disease. There is a paucity of data for HPV-negative disease, which has a less favourable prognosis. Methods: 96 patients treated with (chemo)radiotherapy for HPV-negative OPSCC with baseline and response assessment FDG PET-CT between 2013–2020, were analysed. PET-CT response was classified as negative, equivocal, or positive based on qualitative reporting. PET-CT response categories were analysed with reference to clinicopathological outcomes. Test characteristics were evaluated, comparing negative results to equivocal and positive results together. Post-test probabilities were calculated separately for positive and equivocal or negative results. Results: Median follow-up was 26 months. The negative predictive value of a negative scan was 93.7 and 93.2%, respectively, for primary tumour and nodal disease. For a negative scan, the post-test probability was 0.06 for primary and 0.07 for nodal disease. The post-test probability of an equivocal scan was 0.51 and 0.72 for primary and lymph node, respectively. The post-test probability of a positive scan approached 1. For patients with/without a negative scan, two-year overall survival and progression-free survival were 83% versus 30% and 79% versus 17% (p < 0.001), respectively. Conclusion: The NPV of a negative response assessment PET-CT in HPV-negative OPSCC is high, supporting a strategy of clinical monitoring. Contrasting with the published literature for HPV-positive OPSCC, an equivocal response scan was associated with a moderate rate of residual disease.

HPV-Positive and -Negative Cervical Cancers Are Immunologically Distinct.

Although infection with human papillomavirus (HPV) is associated with nearly all cervical cancers (CC), a small proportion are HPV-negative. Recently, it has become clear that HPV-negative CC represent a distinct disease phenotype compared to HPV-positive disease and exhibit increased mortality. In addition, variations between different HPV types associated with CC have been linked to altered molecular pathology and prognosis. We compared the immune microenvironments of CC caused by HPV α9 species (HPV16-like), HPV α7 species (HPV18-like) and HPV-negative disease. HPV-negative CC appeared distinct from other subtypes, with greatly reduced levels of lymphocyte infiltration compared to either HPV α9 or α7 CC. Besides reduced levels of markers indicative of B, T, and NK lymphocytes, the expression of T-cell effector molecules, activation/exhaustion markers, and T-cell receptor diversity were also significantly lower in HPV-negative CC. Interestingly, HPV-negative CC expressed much higher levels of potential neoantigens than HPV-positive CC. These results identify profound differences between the immune landscape of HPV-positive and HPV-negative CC as well as modest differences between HPV α9 and α7 CC. These differences may contribute to altered patient outcomes between HPV-negative and HPV-positive CC and potentially between CC associated with different HPV types.

The Role of Human Chorionic Gonadotropin Beta (hCGβ) in HPV-Positive and HPV-Negative Oropharyngeal Squamous Cell Carcinoma.

Simple SummaryOropharyngeal squamous cell carcinoma (OPSCC) is often associated with human papillomavirus (HPV). The management of OPSCC remains a challenge, and HPV-negative disease is commonly associated with impaired survival. Novel insights into diagnostics and treatment modalities are warranted to improve disease outcome. Various potential biomarkers affecting prognosis in OPSCC have been distinguished. Our aim was to study the role of the free β-subunit of human chorionic gonadotropin hormone in HPV-negative and HPV-positive OPSCC.Background: This study was carried out to observe the upregulation of the free β-subunit of human chorionic gonadotropin (hCGβ) and its prognostic significance in human papillomavirus (HPV)-positive and HPV-negative oropharyngeal squamous cell carcinoma (OPSCC). Materials and methods: A total of 90 patients with OPSCC treated with curative intent at the Helsinki University Hospital (HUS), Helsinki, Finland, during 2012–2016 were included. Serum samples were collected prospectively, and their hCGβ concentrations (S-hCGβ) were determined by an immunofluorometric assay. The expression of hCGβ in tumor tissues was defined by immunohistochemistry (IHC). HPV determination was performed by combining p16-INK4 IHC and HPV DNA PCR genotyping. Overall survival (OS) and disease-specific survival (DSS) were used as survival endpoints. Results: S-hCGβ positivity correlated with poor OS in the whole patient cohort (p < 0.001) and in patients with HPV-negative OPSCC (p < 0.001). A significant correlation was seen between S-hCGβ and poor DSS in the whole cohort (p < 0.001) and in patients with HPV-negative OPSCC (p = 0.007). In a multivariable analysis, S-hCGβ was associated with poor DSS. Of the clinical characteristics, higher cancer stage and grade were associated with S-hCGβ positivity. No statistically significant correlation with tissue positivity of hCGβ was seen in these analyses. Conclusion: S-hCGβ may be a potential independent factor indicating poor prognosis, notably in HPV-negative OPSCC.

Development and Validation of a Decision Analytical Model for Posttreatment Surveillance for Patients With Oropharyngeal Carcinoma

Clinical practice regarding posttreatment radiologic surveillance for patients with oropharyngeal carcinoma (OPC) is neither adapted to individual patient risk nor fully evidence based. To construct a microsimulation model for posttreatment OPC progression and use it to optimize surveillance strategies while accounting for both tumor stage and human papillomavirus (HPV) status. In this decision analytical modeling study, a Markov model of 3-year posttreatment patient trajectories was created. The training data source was the American College of Surgeon's National Cancer Database from 2010 to 2015. The external validation data set was the 2016 International Collaboration on Oropharyngeal Cancer Network for Staging (ICON-S) study. Training data comprised 2159 patients with OPC treated with primary radiotherapy who had known HPV status and disease staging information. Patients with American Joint Committee on Cancer, 7th edition stage III to IVB disease and those with clinical metastases during the time of primary treatment were included. Data were analyzed from August 1 to October 31, 2020. Main outcomes included disease stage and HPV status, specific disease transition probabilities, and latency of surveillance regimens, defined as time between recurrence incidence and disease discovery. Training data consisted of 2159 total patients (1708 men [79.1%]; median age, 59.6 years [range, 40-90 years]; 401 with stage III disease, 1415 with stage IVA disease, and 343 with stage IVB disease). Cohorts predominantly had HPV-negative disease (1606 [74.4%]). With model-optimized regimens, recurrent disease was discovered a mean of 0.6 months (95% CI, 0.5-0.8 months) earlier than with a standard surveillance regimen based on current clinical guidelines. Recurrent disease was discovered using the optimized regimens without significant reduction in sensitivity. Compared with strategies based on reimbursement guidelines, the model-optimized regimens found disease a mean of 1.8 months (95% CI, 1.3-2.3 months) earlier. Optimized, risk-stratified surveillance regimens consistently outperformed nonoptimized strategies. These gains were obtained without requiring any additional imaging studies. This approach to risk-stratified surveillance optimization is generalizable to a broad range of tumor types and risk factors.

Pretreatment C-Reactive Protein/Albumin Ratio is Associated With Poor Survival in Patients With 2018 FIGO Stage IB-IIA HPV-Positive Cervical Cancer.

Objectives: The present study aimed to identify the predictive value of inflammatory indexes stratified according to human papillomavirus (HPV) infection status in women with FIGO 2018 stage IB∼IIA cervical cancer. We also explored the influences of HPV infection status on the survival of cervical cancer patients. Methods: We collected data for 583 women with stage IB∼IIA cervical cancer in Sun Yat-sen University Cancer Center between 2009 and 2017. The t-test, chi-squared (χ2) test and Fisher’s exact test were applied to compare the differences of inflammatory indexes and clinicopathological features between HPV-positive and HPV-negative groups. Univariate and multivariate analyses were used to identify clinicopathological factors that were associated with the prognosis of cervical cancer patients. Results: There were no differences in overall survival (OS) and progression-free survival (PFS) between HPV-positive and HPV-negative groups. In HPV-positive group, the maximum tumor size, neoadjuvant chemotherapy and the body mass index (BMI) correlated significantly with C-reactive protein/albumin ratio (CAR). The maximum tumor size and the prognostic nutritional index (PNI) correlated significantly with the platelet-lymphocyte ratio (PLR). The maximum tumor size, neoadjuvant chemotherapy and PLR correlated significantly with PNI. Univariate and multivariate analyses showed that the depth of tumor invasion (HR: 3.651, 95% CI: 1.464–9.103, p = 0.005; HR: 2.478, 95% CI: 1.218–5.043, p = 0.012) and CAR (HR: 5.201, 95% CI: 2.080–13.004, p < 0.0001; HR: 2.769, 95% CI: 1.406–5.455, p = 0.003) were independent predictors of poor OS and PFS. PNI was an independent protective factor of OS (HR: 0.341, 95% CI: 0.156–0.745, p = 0.007). PLR was an independent factor of PFS (HR: 1.991, 95% CI: 1.018–3.894, p = 0.044). In HPV-negative group, BMI correlated significantly with CAR. Only depth of invasion (HR: 9.192, 95% CI: 1.016–83.173, p = 0.048) was the independent predictor of poor OS, and no inflammation indexes were independent predictors of prognosis. Conclusion: In patients with HPV-positive cervical cancer, depth of invasion, PNI and CAR are independent factors of OS, and depth of invasion, PLR and CAR are independent factors for PFS. For patients with HPV-negative disease, no inflammation indexes had predictive value for prognosis. The predictive value of inflammation indexes on prognosis is more significant in patients with HPV-positive cervical cancer. Stratification of HPV infection status promotes a more precise clinical application of inflammation indexes, thus improving their accuracy and feasibility.

Prognostic impact of matted lymphadenopathy in patients with oropharyngeal squamous cell carcinoma treated with definitive chemoradiotherapy

ObjectiveTo determine whether cervical matted lymphadenopathy (ML) is associated with outcomes in patients with oropharyngeal squamous cell carcinoma (OPSCC) treated with definitive chemoradiotherapy (CRT). Materials and MethodsOPSCC patients treated at our institution with CRT were included (n = 417). ML was defined by three adjacent nodes without an intervening fat plane. Patients were stratified into favorable OPSCC (p16 + with ≤ 10 pack-years smoking history) or unfavorable OPSCC (p16- and/or > 10 pack years). Primary outcomes were overall survival (OS) and progression-free survival (PFS) and the cumulative incidences of regional recurrence (RR) and distant metastasis (DM). ResultsThe median follow-up time for the surviving cohort was 49.9 months. In favorable OPSCC (n = 220), there were no significant associations between ML and any outcome. In unfavorable OPSCC (n = 197), ML had a significant negative impact on OS and PFS, with 3-year OS for patients without and with matted nodes at 74% and 56% (HR, 1.61, 95% CI 1.01–2.58). On multivariable Cox regression, patients with ML experienced significantly worsened OS (HR 1.65, 95% CI 1.03–2.65) and PFS (HR 1.94, 95% CI 1.28–2.93). The cumulative incidence of DM was also higher with ML (31% vs. 9%, adjusted HR 3.3, 95% CI 1.71–6.48). ConclusionML carries no prognostic importance in patients with favorable OPSCC. However, ML portends significantly worse outcomes in individuals with HPV-negative disease or a significant smoking history. Thus, ML may help risk-stratify this latter population for treatment intensification, but does not seem to be a contraindication for treatment de-escalation in the former.

3p Arm Loss and Survival in Head and Neck Cancer: An Analysis of TCGA Dataset.

Simple SummaryLoss of the 3p chromosome arm has previously been reported to be a predictor of poorer outcome in head and neck cancer regardless of human papillomavirus (HPV) infection. However, a useful measurement of 3p arm loss remains unclear, as well as its associations with survival and mutations in head and neck cancers. We found that HPV-negative tumors almost universally had close to all or no genes deleted on the 3p arm. 3p arm loss was not associated with survival regardless of HPV infection. HPV-negative tumors with 3p arm loss also had arm-level gene copy number changes in other chromosomes across the genome. Their extracellular environments had decreased immune cell activity and oxygen depletion. Abundances of two proteins were decreased and two micro-RNAs were increased, and these changes were associated with survival. Our findings suggest that 3p arm loss may not predict survival, but produces distinct biological characteristics in HPV-negative tumors.Loss of the 3p chromosome arm has previously been reported to be a biomarker of poorer outcome in both human papillomavirus (HPV)-positive and HPV-negative head and neck cancer. However, the precise operational measurement of 3p arm loss is unclear and the mutational profile associated with the event has not been thoroughly characterized. We downloaded the clinical, single nucleotide variation (SNV), copy number aberration (CNA), RNA sequencing, and reverse phase protein assay (RPPA) data from The Cancer Genome Atlas (TCGA) and The Cancer Proteome Atlas HNSCC cohorts. Survival data and hypoxia scores were downloaded from published studies. In addition, we report the inclusion of an independent Memorial Sloan Kettering cohort. We assessed the frequency of loci deletions across the 3p arm separately in HPV-positive and -negative disease. We found that deletions on chromosome 3p were almost exclusively an all or none event in the HPV-negative cohort; patients either had <1% or >97% of the arm deleted. 3p arm loss, defined as >97% deletion in HPV-positive patients and >50% in HPV-negative patients, had no impact on survival (p > 0.05). However, HPV-negative tumors with 3p arm loss presented at a higher N-category and overall stage and developed more distant metastases (p < 0.05). They were enriched for SNVs in TP53, and depleted for point mutations in CASP8, HRAS, HLA-A, HUWE1, HLA-B, and COL22A1 (false discovery rate, FDR < 0.05). 3p arm loss was associated with CNAs across the whole genome (FDR < 0.1), and pathway analysis revealed low lymphoid–non-lymphoid cell interactions and cytokine signaling (FDR < 0.1). In the tumor microenvironment, 3p arm lost tumors had low immune cell infiltration (FDR < 0.1) and elevated hypoxia (FDR < 0.1). 3p arm lost tumors had lower abundance of proteins phospho-HER3 and ANXA1, and higher abundance of miRNAs hsa-miR-548k and hsa-miR-421, which were all associated with survival. There were no molecular differences by 3p arm status in HPV-positive patients, at least at our statistical power level. 3p arm loss is largely an all or none phenomenon in HPV-negative disease and does not predict poorer survival from the time of diagnosis in TCGA cohort. However, it produces tumors with distinct molecular characteristics and may represent a clinically useful biomarker to guide treatment decisions for HPV-negative patients.

Prognostic Impact of Matted Lymphadenopathy in Oropharynx Cancer Treated With Chemoradiotherapy

<h3>Purpose/Objective(s)</h3> Identifying prognostic factors beyond p16 status and smoking history in patients with oropharyngeal squamous cell carcinoma (OPC) is an area of active research. Prior data have suggested that the relatively straightforward radiologic finding of matted lymphadenopathy (ML) was strongly associated with disease-specific survival after chemoradiotherapy (CRT), but these results have not been validated in larger datasets. In this analysis, we evaluated the impact of ML on oncologic outcomes in a large cohort of patients treated with CRT for OPC. We hypothesized that ML would be associated with poorer outcomes as measured by rates of regional recurrence, distant metastasis and overall survival. <h3>Materials/Methods</h3> All OPC patients treated with definitive CRT at our institution between 2005 and 2018 were eligible for this retrospective analysis. ML was defined by three adjacent nodes without an intervening fat plane. Each subject scan was evaluated manually for these characteristics. Patients were stratified into favorable OPC (p16-positive with ≤ 10 pack-years smoking history) or unfavorable OPC (p16-negative or 10+ pack-years). Overall survival (OS) and progression-free survival (PFS) were determined using Kaplan-Meier statistics, and Cox regression was performed for multivariable adjustment. The cumulative incidences of distant metastasis (DM) and regional recurrence (RR) were calculated with death as a competing risk. <h3>Results</h3> A total of 417 patients (220 favorable, 197 unfavorable) were included, with a median follow-up time for surviving patients of 49.9 months. For patients with favorable OPC, there were no associations between ML and OS, PFS, RR, or DM. In contrast, the presence of ML was significantly and independently associated with worsened OS in patients with unfavorable OPC; the 3-year OS without and with ML was 74% vs. 56% (<i>P</i> = 0.05). On multivariable regression, only ML (HR 1.65, 95% CI 1.03-2.65) and active smoking were significantly related to OS. Similarly, 3-year PFS was 67% vs 44% without vs. with ML (<i>P</i> < 0.01), and ML retained significance for decreased PFS on multivariable analysis (HR 1.94, 95% CI 1.28-2.93). Finally, ML predicted increased rates of DM on both univariable and multivariable analysis (31% with vs. 9% without, HR 3.3, 95% CI 1.71-6.48, <i>P</i> < 0.01) for patients with unfavorable OPC. <h3>Conclusion</h3> Matted lymphadenopathy carried no meaningful prognostic impact in patients with favorable oropharyngeal squamous cell carcinoma, arguing ML should not be a contraindication for treatment de-escalation. However, for patients with either a significant smoking history or HPV-negative disease, ML was associated with a markedly adverse outcome. This population of OPC may be particularly well-suited for treatment intensification.