HPV-positive Oropharyngeal Squamous Cell Carcinoma Research Articles

High-risk HPV infection-associated hypermethylated genes in oropharyngeal squamous cell carcinomas

BackgroundHPV-positive oropharyngeal squamous cell carcinomas (OPSCCs) are sensitive to chemo-radiation therapy and have favorable survival outcomes compared with HPV-negative cancers. These tumors are usually not related to tobacco and alcohol exposure. Therefore, diagnosing HPV-positive OPSCCs for the appropriate disease management is crucial, and no suitable markers are available for detecting early malignancies in HPV-infected tissues. In this study, we attempt to find HPV-specific epigenetic biomarkers for OPSCCs.MethodsA total of 127 surgical samples were analyzed for HPV positivity and promoter methylation of a panel of genes. HPV detection was performed by PCR detection of HPV E6 and E7 viral oncoproteins. In addition, promoter methylation of a total of 8 genes (DAPK, FHIT, RASSF1A, TIMP3, AGTR1, CSGALNACT2, GULP1 and VGF) was analyzed by quantitative-methylation specific PCR (QMSP), and their associations with HPV positivity or RB/p16 expressions were evaluated.ResultsAGTR1 and FHIT were frequently methylated in HPV-positive OPSCC samples with a good area under the curve (AUC over 0.70). In addition, these genes' promoter methylation was significantly associated with p16 positive and RB negative cases, which were the characteristics of OPSCC cases with favorable survival outcomes. Either AGTR1 or FHIT methylated cases were significantly associated with HPV-positive cancers with 92.0% sensitivity (P < 0.001). Also, they had significantly better overall survival (P = 0.047) than both unmethylated cases.ConclusionsA combination of AGTR1 and FHIT methylation demonstrated a suitable detection marker of OPSCCs derived from the HPV-infected field, familiar with p16-positive and RB-negative phenotypes.

Impact of Alcohol and Smoking on Outcomes of HPV-Related Oropharyngeal Cancer.

The aim of this study was to evaluate the impact of adverse lifestyle factors on outcomes in patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC). From 2010 to 2019, 150 consecutive non-metastatic OPSCC patients receiving curative treatment in our institution were retrospectively enrolled. HPV positivity was defined as p16 expression ≥75%. The effects of adverse lifestyle factors on overall survival (OS) and disease-free survival (DFS) on OPSCC patients were determined. The median follow-up duration was 3.6 years. Of the 150 OPSCCs, 51 (34%) patients were HPV-positive and 99 (66%) were HPV-negative. The adverse lifestyle exposure rates were 74.7% (n = 112) alcohol use, 57.3% (n = 86) betel grid chewing, and 78% (n = 117) cigarette smoking. Alcohol use strongly interacted with HPV positivity (HR, 6.00; 95% CI, 1.03-35.01), leading to an average 26.1% increased risk of disease relapse in patients with HPV-positive OPSCC. Heavy smoking age ≥30 pack-years was associated with increased risk of death (HR, 2.05; 95% CI, 1.05-4.00) and disease relapse (HR, 1.99; 95% CI, 1.06-3.75) in OPSCC patients. In stratified analyses, the 3-year absolute risk of disease relapse in HPV-positive OPSCC patients reached up to 50% when alcohol use and heavy smoking for ≥30 pack-years were combined. Alcohol acted as a significant treatment-effect modifier for DFS in HPV-positive OPSCC patients, diluting the favorable prognostic effect of HPV positivity. Heavy smoking age ≥30 pack-years was an independent adverse prognostic factor of OS and DFS in OPSCC patients. De-intensification treatment for HPV-related OPSCC may be avoided when these adverse lifestyle factors are present.

Genomic Adjusted Radiation Dose (GARD) Predicts Overall Survival and Outperforms AJCC 8th Edition in Prognostication of HPV-Positive Oropharyngeal Squamous Cell Carcinoma

<h3>Purpose/Objective(s)</h3> Treatment decision-making in oropharyngeal squamous cell carcinoma (OPSCC) includes clinical stage, HPV status, and smoking history. Despite improvements in staging with separation of HPV positive and negative OPSCC in AJCC 8^th edition (AJCC8), patients are largely treated with a uniform approach, with recent efforts on de-intensification in low-risk patients. We have previously shown, in a pooled analysis, that the genomic adjusted radiation dose (GARD) is predictive of radiation treatment benefit and can be used to guide dose selection. We hypothesize that GARD can be used to predict overall survival (OS) in HPV-positive OPSCC patients treated with radiotherapy (RT). <h3>Materials/Methods</h3> Gene expression profiles were analyzed for 234 formalin-fixed paraffin-embedded samples from HPV-positive OPSCC patients within an international, multi-institutional, prospective/retrospective observational study (Big Data and Models for Personalized Head and Neck Cancer Decision Support (BD2Decide, NCT02832102). GARD, a measure of the biological effect of RT, was calculated for each patient as previously described. In total, 203 patients received definitive treatment (chemoradiation or RT alone), and 31 patients received post-operative RT. Two RT dose fractionations were utilized for definitive cases (70 Gy in 35 fractions or 69.96 Gy in 33 fractions). Median RT dose was 70 Gy (mean 50.88-74) for definitive cases and 66 Gy (range 44-70) for post-operative cases. 29 patients received surgery and adjuvant chemoradiation, 14 received surgery and adjuvant RT, and 19 received RT alone. The median follow up was 46.2 months (95% CI, 41.2 to 50). Cox proportional hazards analyses were performed with GARD as a continuous variable and ROC analyses comparing the performance of GARD with AJCC8. <h3>Results</h3> Despite uniform radiation dose utilization, GARD showed significant heterogeneity (range 30-110), reflecting the underlying genomic differences in the cohort. On multivariate analysis, each unit increase in GARD was associated with an improvement in OS (HR= 0.97, 95% CI 0.94-1.0, p=0.040) compared to AJCC8 (HR=1.96, 95% CI 0.90-4.32, p=0.0952). ROC analysis for GARD at 24 months yielded an AUC of 75.6 (95% CI 61.8-89.4) compared with an AUC of 73.9 (95% CI 56.9-90.9) for AJCC8. GARD ≥64.97 was associated with improved OS (HR=0.29, p=0.005). <h3>Conclusion</h3> In this multi-institutional cohort of patients with HPV-positive OPSCC, GARD predicts OS as a continuous variable and outperforms AJCC8 in prognostication. We propose that GARD, which provides the first opportunity for genomic guided personalization of radiation dose, should be incorporated in the diagnostic workup of HPV-positive OPSCC patients and can be used to guide treatment decision making.

Prognostic impact of extranodal extension (ENE) in surgically managed treatment-naive HPV-positive oropharyngeal squamous cell carcinoma with nodal metastasis

AbstractExtranodal extension (ENE) is a significant prognostic factor for human papilloma virus (HPV)-negative head and neck squamous cell carcinoma and is incorporated into AJCC 8th edition pN stage. It remains controversial whether ENE or the degree of ENE is prognostically relevant in HPV-positive oropharyngeal squamous cell carcinoma (OPSCC). A detailed clinicopathologic review was conducted in a large retrospective cohort of 232 surgically treated patients with HPV-positive OPSCC and nodal metastasis. Fifty-six patients (24%) had nodal metastasis with ENE. The median vertical extent of ENE was 2.9 mm (range 0.2–20.3 mm), and the median horizontal span of ENE was 2.5 mm (range: 0.3–14.0 mm). Comparing with patients without ENE, those with ENE were associated with a higher number of positive lymph nodes, lymphovascular invasion, perineural invasion, adjuvant chemotherapy, larger primary tumor size, and shorter follow up period. Patients with ENE had shortened overall survival (OS), disease specific survival (DSS), disease free survival (DFS), distant metastasis free survival (DMFS), and regional recurrence free survival (RRFS) on univariate survival analysis. The 5-year OS, DSS, and DFS were 95%, 97%, and 90% respectively for the group without ENE, and 64%, 71%, and 65% respectively for the group with ENE. On Multivariate survival analysis, the presence of ENE was an independent adverse prognostic factor for OS, DSS, and DFS. Additionally, major ENE defined as a vertical extent of ≥4 mm or irregular soft tissue deposit independently predicted shortened OS, DSS, and RFS. In conclusion, the presence of ENE, in particular major ENE, is an independent prognostic factor in HPV-positive OPSCC. Therefore, we propose to document the presence and extent of ENE for these tumors. Consideration may be given for AJCC 9th edition to include ENE into pN stage of HPV-positive OPSCC.

Association of Pretreatment Circulating Tumor Tissue–Modified Viral HPV DNA With Clinicopathologic Factors in HPV-Positive Oropharyngeal Cancer

Circulating tumor tissue-modified viral (TTMV) human papillomavirus (HPV) DNA is a dynamic, clinically relevant biomarker for HPV-positive oropharyngeal squamous cell carcinoma. Reasons for its wide pretreatment interpatient variability are not well understood. To characterize clinicopathologic factors associated with TTMV HPV DNA. This cross-sectional study included patients evaluated for HPV-positive oropharyngeal squamous cell carcinoma at Dana-Farber Cancer Institute in Boston, Massachusetts, between December 2019 and January 2022 and who were undergoing curative-intent treatment. Clinicopathologic characteristics including demographic variables, tumor and nodal staging, HPV genotype, and imaging findings. Pretreatment circulating TTMV HPV DNA from 5 genotypes (16, 18, 31, 33, and 35) assessed using a commercially available digital droplet polymerase chain reaction-based assay, considered as either detectable/undetectable or a continuous score (fragments/mL). Among 110 included patients, 96 were men (87%) and 104 were White (95%), with a mean (SD) age of 62.2 (9.4) years. Circulating TTMV HPV DNA was detected in 98 patients (89%), with a median (IQR) score of 315 (47-2686) fragments/mL (range, 0-60 061 fragments/mL). Most detectable TTMV HPV DNA was genotype 16 (n = 86 [88%]), while 12 patients (12%) harbored other genotypes. Circulating TTMV HPV DNA detection was most strongly associated with clinical N stage. Although few patients had clinical stage N0 disease, only 4 of these 11 patients (36%) had detectable DNA compared with 94 of 99 patients (95%) with clinical stage N1 to N3 disease (proportion difference, 59%; 95% CI, 30%-87%). Among patients with undetectable TTMV HPV DNA, more than half (7 of 12 [58%]) had clinical stage N0 disease. The TTMV HPV DNA prevalence and score increased with progressively higher clinical nodal stage, diameter of largest lymph node, and higher nodal maximum standardized uptake value on positron emission tomography/computed tomography. In multivariable analysis, clinical nodal stage and nodal maximum standardized uptake value were each strongly associated with TTMV HPV DNA score. Among 27 surgically treated patients, more patients with than without lymphovascular invasion had detectable TTMV HPV DNA (12 of 12 [100%] vs 9 of 15 [60%]). In this cross-sectional study, circulating TTMV HPV DNA was statistically significantly associated with nodal disease at HPV-positive OPSCC diagnosis. The few patients with undetectable levels had predominantly clinical stage N0 disease, suggesting assay sensitivity for diagnostic purposes may be lower among patients without cervical lymphadenopathy. Mechanisms underlying this association, and the use of this biomarker for surveillance of patients with undetectable baseline values, warrant further investigation.

An interpretable machine learning prognostic system for risk stratification in oropharyngeal cancer

BackgroundThe optimal management of oropharyngeal squamous cell carcinoma (OPSCC) includes both surgical and non-surgical, that is, (chemo)radiotherapy treatment options and their combinations. These approaches carry a risk of specific treatment-related side effects. HPV-positive OPSCC has been reported to be more sensitive to (chemo)radiotherapy-based treatment modalities. Objectives: This study aims to demonstrate how machine learning can aid in classifying OPSCC patients into risk groups (low-chance or high-chance) for overall survival. We examined the input variables using permutation feature importance. Furthermore, we provided explanations and interpretations using the Local Interpretable Model Agnostic Explanations (LIME) and SHapley Additive Explanation (SHAP) frameworks. Methods: The machine learning model for 3164 OPSCC patients was built using data obtained from the Surveillance, Epidemiology, and End Results (SEER) program database. A total of five variants of tree-based machine learning algorithms (voting ensemble, light GBM, XGBoost, Random Forest, and Extreme Random Trees) were used to divide the patients into risk groups. The developed model with the best predictive performance was temporally validated with a different cohort. Results: The voting ensemble machine learning algorithm showed an accuracy of 88.3%, Mathews’ correlation coefficient of 0.72, and weighted area under curve of 0.93, when temporally validated. Human papillomavirus (HPV) status, age of the patients, T stage, marital status, N stage, and the treatment modality (surgery with postoperative radiotherapy) were found to have the most significant effects on the ability of the machine learning model to predict overall survival. Similarly, for the individual patients with SHAP framework, HPV status, gender, and treatment modality (surgery with postoperative radiotherapy) were the input features that improved the model’s prediction. Conclusion: The proposed stratification of OPSCC patients into risk groups by machine learning techniques can provide accurate predictions and thus aid clinicians in administering early and personalized interventions. Clinicians could utilize the predicted risk with the explanations offered by the SHAP and LIME frameworks to understand previously undetected relationships between prognostic variables to make informed clinical decisions and effective interventions.

The immune microenvironment of HPV-positive and HPV-negative oropharyngeal squamous cell carcinoma: a multiparametric quantitative and spatial analysis unveils a rationale to target treatment-naïve tumors with immune checkpoint inhibitors

BackgroundImmune checkpoint inhibitors (ICI) are approved for treatment of recurrent or metastatic oropharyngeal head and neck squamous cell carcinoma in the first- and second-line settings. However, only 15–20% of patients benefit from this treatment, a feature increasingly ascribed to the peculiar characteristics of the tumor immune microenvironment (TIME).MethodsImmune-related gene expression profiling (GEP) and multiplex immunofluorescence (mIF) including spatial proximity analysis, were used to characterize the TIME of 39 treatment-naïve oropharyngeal squamous cell carcinomas (OPSCC) and the corresponding lymph node metastases. GEP and mIF results were correlated with disease-free survival (DFS).HPV-positive tumors disclosed a stronger activation of several immune signalling pathways, as well as a higher expression of genes related to total tumor-infiltrating lymphocytes, CD8 T cells, cytotoxic cells and exhausted CD8 cells, than HPV-negative patients. Accordingly, mIF revealed that HPV-positive lesions were heavily infiltrated as compared to HPV-negative counterparts, with a higher density of T cells and checkpoint molecules. CD8+ T cells appeared in closer proximity to tumor cells, CD163+ macrophages and FoxP3+ cells in HPV-positive primary tumors, and related metastases. In HPV-positive lesions, PD-L1 expression was increased as compared to HPV-negative samples, and PD-L1+ tumor cells and macrophages were closer to PD-1+ cytotoxic T lymphocytes. Considering the whole cohort, a positive correlation was observed between DFS and higher levels of activating immune signatures and T cell responses, higher density of PD-1+ T cells and their closer proximity to tumor cells or PD-L1+ macrophages. HPV-positive patients with higher infiltration of T cells and macrophages had a longer DFS, while CD163+ macrophages had a negative role in prognosis of HPV-negative patients.ConclusionsOur results suggest that checkpoint expression may reflect an ongoing antitumor immune response. Thus, these observations provide the rationale for the incorporation of ICI in the loco-regional therapy strategies for patients with heavily infiltrated treatment-naïve OPSCC, and for the combination of ICI with tumor-specific T cell response inducers or TAM modulators for the “cold” OPSCC counterparts.

The role of HPV CMV and EBV latent viruses of the development of Oropharyngeal squamous cell carcinoma (OPSCC)

Background:In recent years, a dynamic increase in the incidence of oropharyngeal squamous cell carcinoma (OPSCC) has been observed, especially in highly developed countries. As in the case of anal and genital cancers, a significant proportion of OPSCC (about 60%) is due to sexually acquired HPV infection, and the increase in OPSCC is attributed to changes in sexual behavior in Western countries. EBV and CMV viruses are also characterized by carcinogenesis, but the literature data on their participation in the development of neoplasms of the middle throat are still very limited.Objective:The aim of this article is to review the latest scientific reports on the impact of infections with latent viruses (HPV, EBV, CMV) on the oncogenesis process in the middle pharynx and to summarize the prophylactic options using the available multivalent vaccines against HPV infections.Conclusions:HPV-positive oropharyngeal squamous cell carcinoma of the middle pharynx is a significant clinical problem due to the increase in the number of cases, especially in young people, who lack classic risk factors, such as exposure to tobacco and alcohol. HPV-dependent neoplasms are characterized by a better prognosis and less invasive oncological therapy (radiotherapy and chemotherapy). Of central importance in the prevention of HPV-positive OPSCC in both women and men is prophylaxis with multivalent vaccination. Due to the lack of sufficient data on the participation of EBV and CMV viruses in the development of OPSCC, as well as the lack of prophylaxis, intensive research in this area is necessary.

Current perspectives on recurrent HPV-mediated oropharyngeal cancer.

In the recent years, the prevalence of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) has increased significantly. Currently, nearly 80-90% of all oropharynx tumors are HPV-positive. In addition, it is now recognized that HPV-positive tumor status is associated with good prognosis and improved response to chemoradiation. However, within this setting, there are still patients with HPV-positive OPSCC who will experience recurrence. With the increasing incidence of HPV-mediated OPSCC, recurrent HPV disease is also becoming more prevalent and there is an increasing need to understand the unique presentation and treatment of recurrent HPV-mediated disease. In this review, we will discuss epidemiology of recurrent HPV-positive OPSCC, role of surgical salvage, re-irradiation, and the role of upcoming novel treatments and immunotherapy. Historically, recurrent oropharyngeal disease has been associated with poor prognosis and high morbidity. However, recent advances have transformed the landscape for salvage treatment of HPV-mediated OPSCC. Liquid biomarkers offer potential for early detection of recurrence, robotic techniques may reduce morbidity of surgical salvage, improvements in re-irradiation approaches reduce toxicities, and novel immune based therapies on the horizon are offering promising results. These advances combined with the improved prognosis of HPV-positive disease offer to transform our approach to recurrent disease of the oropharynx.

Upfront transoral robotic surgery (TORS) versus intensity-modulated radiation therapy (IMRT) in HPV-positive oropharyngeal cancer: real-world data from a tertiary comprehensive cancer centre.

SUMMARYObjectiveThis study aims to provide real-world data on oncologic and functional outcomes of the most modern surgical and non-surgical treatments of locally advanced HPV-positive oropharyngeal cancer.MethodsWe reviewed data on patients treated for stage III and IV HPV-positive oropharyngeal squamous cell carcinoma with either endoscopic surgery (Transoral Robotic Surgery, TORS; Transoral Laser Microsurgery, TLM – group A) or intensity-modulated radiotherapy (IMRT – group B). The minimum follow-up required was 6 months. Survival outcomes and toxicities of treatments were evaluated.Results30 patients in group A and 66 in group B were eligible for the analysis. 28% of patients in group A underwent a unimodal treatment, while 42% needed trimodal treatment. 90% of patients in group B underwent concurrent chemoradiation. We found no statistically significant difference in survival outcomes (group A: overall survival 97%, progression-free survival 83%; group B: OS 98%, PFS 86%) or toxicities between groups.ConclusionsBoth transoral surgery and IMRT provide excellent outcomes in HPV-positive oropharyngeal cancer. Because of the good prognosis, treatments need to be refined to reduce toxicities while preserving oncologic soundness.

Therapeutic Vaccines for HPV-Associated Oropharyngeal and Cervical Cancer: The Next De-Intensification Strategy?

The rise in human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) has prompted a quest for further understanding of the role of high-risk HPV in tumor initiation and progression. Patients with HPV-positive OPSCC (HPV+ OPSCC) have better prognoses than their HPV-negative counterparts; however, current therapeutic strategies for HPV+ OPSCC are overly aggressive and leave patients with life-long sequalae and poor quality of life. This highlights a need for customized treatment. Several clinical trials of treatment de-intensification to reduce acute and late toxicity without compromising efficacy have been conducted. This article reviews the differences and similarities in the pathogenesis and progression of HPV-related OPSCC compared to cervical cancer, with emphasis on the role of prophylactic and therapeutic vaccines as a potential de-intensification treatment strategy. Overall, the future development of novel and effective therapeutic agents for HPV-associated head and neck tumors promises to meet the challenges posed by this growing epidemic.

The clinical value of oral robotic surgery in the treatment of oropharyngeal squamous cell carcinoma

Objective: To explore the therapeutic effects of transoral robotic surgery (TORS) and traditional surgical modes in oropharyngeal squamous cell carcinoma (OPSCC). Methods: The clinicopathological data of patients with oropharyngeal squamous cell carcinoma treated at Sun Yat-sen University Cancer Center from 2010 to 2018 were retrospectively analyzed. 135 cases were treated with traditional surgery (non-TORS group), while 52 cases were treated with TORS (TORS group). The prognosis of the two groups of patients were analyzed by Kaplan-Meier method and Log rank test, the influencing factors were analyzed by Cox regression model. Results: The 2-year overall survival (OS, 94.2%) and 2-year progression-free survival (PFS, 93.8%) of patients in the TORS group were better than those in the non-TORS group (71.4% and 71.4%, respectively, P<0.05). The 2-year OS (93.3%) and 2-year PFS (92.8%) of TORS group patients in T1-2 stage were better than those of non-TORS group (73.1% and 72.8%, respectively, P<0.05). The 2-year OS (95.8%) and 2-year PFS (95.2%) of patients with stage Ⅰ to Ⅱ in the TORS group were not significantly different from those in the non-TORS group (84.1% and 83.9%, respectively, P>0.05). The 2-year OS (92.9%) and 2-year PFS rate (92.7%) of patients with stage Ⅲ to Ⅳ in the TORS group were better than those in the non-TORS group (64.7% and 63.9%, respectively, P<0.05). The 2-year OS (94.4%) of HPV-positive patients in the TORS group was not significantly different from that in the non-TORS group (83.3%, P=0.222). The 2-year OS of HPV-negative patients in the TORS group (94.1%) was significantly different from that in the non-TORS group (43.7%, P<0.001). HPV status was an independent prognostic factor (P=0.008). Conclusions: TORS has a better prognosis in the treatment of oropharyngeal squamous cell carcinoma compared with the traditional treatment methods. The patients with T1-T2 can achieve better survival benefits after TORS treatment. The HPV-positive OPSCC patients has a better prognosis than that of HPV-negative OPSCC patients, and regardless of HPV status, OPSCC patients in the TORS group could obtain a better survival prognosis.

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.

Generative adversarial neural networks augment marker and pathway analysis of treatment resistant HPV+ head and neck squamous cell carcinoma.

e18059 Background: Biological behaviors of cancers are extremely complex and governed via nonlinear interplay of thousands of genes. This complexity has become a major hurdle to generating mechanistic conclusions in rare clinical scenarios, such as treatment resistant HPV+ head and neck squamous cell carcinoma, when observations are limited. Recently, data augmentation algorithms have served to increase the number and diversity of training observations while preserving the underlying structure and nonlinear relationships of data features. Deep learning techniques such as generative adversarial neural networks (GANs) have shown promise as robust tools for data augmentation of nonimage data. This study aims to evaluate the utility of employing separate GANs to highlight gene expression differences between treatment sensitive (TS) vs treatment resistant (TR) HPV+ head and neck squamous cell carcinoma. Methods: We performed RNAseq on 17 patients with HPV-positive oropharyngeal squamous cell carcinoma (OPSCC). We defined TR patients as those with locally advanced OPSCC at presentation, who rapidly recurred following receipt of standard of care therapy (n = 11). In most cases, patients failed to respond to salvage therapies and rapidly died. In contrast, we defined TS patients as those with locally advanced OPSCC at presentation, who received standard of care therapy, and were followed for 5 years without any evidence of recurrence (n = 6). These two cohorts were used to train two separate GANs, which synthesized 500 robust synthetic samples of each phenotype for downstream analysis. Results: Analysis of 17 samples yielded less than 100 differentially expressed (DE) genes passing FDR cutoffs, inhibiting pathway enrichment analysis (PAE). DE testing between synthetic samples yielded 1196 DE genes. Validating our deep learning approach, these genes belong to coherent pathways as determined by PAE. Namely, the VEGFA-VEGFR2 pathway was strongly enriched in the TR population (p = 1.5 x 10-4). Further, the NKT cell signature (p = 3.0x10-62), and the gene library of T-cell receptor induction of apoptosis (p = 5.4 x 10-9), was enriched in the TS population. Lastly, to validate the experimental method, DE testing on GAN augmented cohorts of renal papillary vs renal clear cell samples from The Cancer Genome Atlas, trained on 10 samples per condition, reliably predicted DE genes when comparing the full cohort of renal papillary n = 534 vs renal clear cell n = 295 samples, with an accuracy of 93% and F1 score of 88%. Conclusions: To our knowledge this is the first study to utilize separate GANs to augment structural gene expression changes occurring in rare clinical scenarios such as treatment resistant HPV+ OPSCC. Utilizing this method uncovers changes in angiogenesis and T-cell function between treatment sensitive and resistant HPV+ OPSCC.

The role of concomitant chemoradiotherapy versus radiation alone in T1-3N0 HPV-positive and HPV-negative oropharyngeal squamous cell carcinoma

ObjectiveTo evaluate the role of curative intent concurrent chemoradiation (CCRT) vs radiation (RT) alone for T1-T3N0 HPV-positive and HPV-negative oropharyngeal squamous cell cancer (OPSCC). MethodsThe NCDB was queried for patients diagnosed between 2010 and 2017 with cT1-3N0M0 OPSCC treated with definitive RT or CCRT. Univariable analysis (UVA) and multivariable analysis (MVA) Cox regression analysis was performed with OS as the endpoint. Propensity score matching (PSM) 1:1 was performed. Interaction test to assess heterogeneity of treatment effect. ResultsA total of 2830 patients were queried. On MVA, CCRT was associated with improved OS for T3N0 tumors (HR 0.49; 95% CI 0.39–0.63) but not for T1N0 (HR 1.43; 95% CI 0.99–2.07) and T2N0 (HR 0.92; 95% CI 0.75–1.13). For T3 patients, CCRT improved OS for HPV-negative (HR 0.43; 95% CI 0.31–0.59) and HPV-positive tumors (HR 0.39; 95% CI 0.25–0.61). After PSM, CCRT was not statistically different to RT for patients with T1-2N0 HPV-negative tumors (HR 1.10; 95% CI 0.85–1.43; p = 0.48) and T1-2N0 HPV-positive tumors (HR 1.15; 95% CI 0.79–1.68; p = 0.45). After PSM, CCRT improved OS compared to RT alone for patients with T3N0 HPV-negative (HR 0.43; 95% CI 0.31–0.59; p < 0.01) and HPV-positive tumors (HR 0.39; 95 %CI 0.25–0.61; p < 0.01). ConclusionsCCRT is associated with improved OS in HPV-positive and HPV-negative T3N0 OPSCC. RT alone vs. CCRT demonstrated similar OS for T1-T2N0 OPSCC for both HPV negative and HPV positive tumors.

Application of transoral robotic surgery in treatment of oropharyngeal squamous cell carcinoma

Objective: To evaluate the therapeutic and prognostic outcomes of transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OSCC). Methods: A retrospective study of 99 OSCC patients treated with TORS in Department of Head and Neck Surgery, Sun Yat-sen University Cancer Center between April 2017 and May 2021 was conducted. There were 84 males and 15 females, with an age range of 35-85 years. Patients' clinical characteristics, including clinical staging, HPV infection status, perioperative management and postoperative adjuvant treatment, were recorded. The overall survival (OS) and progression-free survival (PFS) were analyzed. The survival outcomes were analyzed with Kaplan-Meier method and Log-rank test. Results: The hospital stay of OSCC patients with TORS was (5.3±2.9) days and the average time of postoperative nasal feeding tube indwelling was (15.2±10.8) days. Among the 99 patients, 21 (21.2%) received tracheotomy and the average time of tracheotomy tube indwelling was (11.9±11.4) days. The two-year OS and PFS in patients with follow-up over two years were 94.0% and 87.7%, respectively and the three-year OS and PFS of patients with follow-up over three years were 94.0% and 78.9%, respectively. The two-year OS and PFS were respectively 97.4% and 88.9%, for patients with stages I-II and 86.8% and 88.9% for patients with stages III-IV. HPV-negative and HPV-positive patients had respectively two-year OS (100.0% vs. 91.5%) and PFS (88.9% vs. 87.2%). There was no significantly statistical difference in survival between patients with and without adjuvant radiotherapy after TORS (82.6% vs. 90.5%, HR=0.52, 95%CI: 0.12-2.23, P=0.400). Conclusions: TORS is more suitable for the treatment of patients with early (Ⅰ-Ⅱ) or HPV-positive oropharyngeal squamous cell carcinoma, and the recovery after TORS treatment is good.

Sex-Related Differences in Outcomes for Oropharyngeal Squamous Cell Carcinoma by HPV Status.

Background Overall survival for HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) has differed by sex, but little is known regarding cancer-specific outcomes. We assessed the independent association of sex with cancer-specific survival in patients with HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Methods We identified 14,183 patients from the Surveillance, Epidemiology, and End Results (SEER) program with OPSCC and tumor HPV status. We used Kaplan–Meier methods to compare overall survival (OS) and OPSCC-specific survival (HNCSS) by patient sex and by tumor HPV status. We then separately fit multivariable survival and competing risk models evaluating the association of sex on these outcomes by tumor HPV status and stratified by the use of guideline-concordant OPSCC treatment. Results A total of 10,210 persons with HPV-positive tumors (72.0%) and 3,973 with HPV-negative tumors (28.0%) were identified. A larger proportion of women had HPV-negative tumors (24.0%) versus HPV-positive tumors (13.2%; p < 0.001). Women with HPV-positive tumors were less likely to receive guideline-concordant treatment compared to men. In unadjusted survival analyses, women did not differ in OS or HNCSS compared to men for HPV-positive tumors but had worse OS and HNCSS for HPV-negative tumors. After adjustment, men and women with HPV-positive OPSCC did not differ in OS or HNCSS. However, women with HPV-negative tumors faced worse overall survival (hazard ratio (HR) 1.15, 95% CI 1.02–1.29) that persisted even after stratifying for stage-appropriate treatment (HR 1.28, 95% CI 1.11–1.47). Conclusions Women with HPV-positive OPSCC had similar survival outcomes compared to men, but those with HPV-negative tumors have worse overall and cancer-specific survival.

Concurrent Cetuximab-based bioradiotherapy versus Cisplatin-based Chemoradiotherapy in the Definitive Management of Favourable Biology Human Papillomavirus-associated Oropharyngeal Squamous Cell Carcinoma: Systematic Review and Meta-analysis

Replacing cisplatin with cetuximab concurrently during radiotherapy has been one of the strategies of treatment de-escalation in human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC). However, until recently, there were limited data on the efficacy and safety of such an approach. A systematic search of the literature was carried out to identify prospective randomised controlled trials comparing definitive cisplatin-based chemoradiotherapy (CT-RT) versus cetuximab-based bioradiotherapy (BRT) in HPV-positive OPSCC. Overall survival and locoregional control were primary outcomes of interest; rates of acute and late toxicities (≥grade 3) were secondary end points. Outcome data were aggregated using a random-effects model as per Cochrane methodology including risk of bias assessment and expressed as hazard ratio or risk ratio as appropriate with respective 95% confidence intervals. Data from five randomised controlled trials involving 1560 patients with HPV-positive OPSCC were aggregated in the meta-analysis. Cetuximab-based BRT was associated with a significantly increased risk of death (hazard ratio = 2.83, 95% confidence interval 1.22–6.57; P = 0.02) and locoregional relapse (hazard ratio = 2.78, 95% confidence interval 1.77–4.39; P < 0.0001) compared with cisplatin-based CT-RT. Cisplatin was associated with higher rates of acute ≥grade 3 toxicity in terms of acute kidney injury, dry mouth, febrile neutropenia, hearing impairment, nausea and vomiting, whereas dermatitis and acneiform rash were more common with cetuximab. There were no significant differences in overall rates of late ≥grade 3 toxicity (risk ratio = 0.63, 95% confidence interval = 0.36–1.10; P = 0.10). In conclusion, there is moderate-certainty evidence that cetuximab-based BRT leads to inferior efficacy outcomes compared with cisplatin-based CT-RT in the definitive curative-intent management of HPV-associated OPSCC.

Emerging Trends in the Pathological Research of Human Papillomavirus-positive Oropharyngeal Squamous Cell Carcinoma.

Oropharyngeal squamous cell carcinomas (OPSCCs) have shown an alarming rate of increase in incidence over the past several decades, markedly in men. In the United States, transcriptionally-active human papillomavirus (HPV), particularly HPV 16, has become the highest contributive agent of OPSCCs, affecting approximately 16,000 people a year. Compared to patients with HPV-negative OPSCCs, patients with HPV-positive OPSCCs exhibit better health responses to chemoradiotherapy and an overall increase in long-term survival. Despite promising treatment options, many OPSCCs are discovered at an advanced stage, and ~20% of cases will recur after definitive treatment. Therefore, extensive research is ongoing to identify new targets for precision treatment and to stratify tumor prognosis. The aim of this review is to capture the most updated research on HPV-positive OPSCCs, emphasizing their relevance as potential new targets for precision medicine and survival prognosis.

What is the predictive value of OroGrams to estimate survival rates of HPV-positive oropharyngeal squamous cell carcinoma?

Design Retrospective cohort study.Cohort selection OroGrams is a nomogram designed to better predict survival patterns in patients with oropharyngeal squamous cell carcinoma (OPSCC) by incorporation of both HPV-DNA and p16 status. The aim of this study was to evaluate the external validity of OroGrams in a Scottish population. The study population was noted to have a higher smoking status than the four European cohorts among which Orograms was originally developed and established.Data analysis Retrospective analysis was undertaken of health records and death certificates of patients with OPSCC in Glasgow, Scotland between 2012 and 2017. Required baseline characteristics were compared to the original study cohorts to assess comparability. OroGrams was implemented to produce Kaplan Meier curves for overall and progression-free survival at one, three and five years. Brier scores were produced to compare these to the actual observed outcomes.Results Compared to the UK study group, significantly more of the Scottish cohort presented at a later stage (p <0.001), were smokers (p = 0.002), and were both HPV-DNA and p16-negative. More patients received surgery or radiotherapy alone and less received a combination of both with chemotherapy. Low Brier scores indicated good predictive ability of OroGrams in the Scottish group at one, three and five years that was most accurate for overall survival. This accuracy was similar to the UK cohort at one and three years, but less so at five-year follow-up. Outcome predictions were significantly better for HPV-positive versus negative cases at all time points.Conclusions OroGrams showed good prognostic accuracy for this Scottish cohort with significantly higher smoking, and HPV-DNA and p16-negative status, compared to the original UK study population. There were, however, limitations at longer follow-up periods and individual variation which limits its clinical application. Incorporation and weighting of smoking status and other comorbidities in future nomograms is recommended to enhance outcome understanding and better inform treatment planning.