Co-expression patterns of cancer associated fibroblast markers reveal distinct subgroups related to patient survival in oropharyngeal squamous cell carcinoma

Background: The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing in high income countries due to its association with persistent high-risk human papilloma virus (HPV) infection. Recent scientific advances have highlighted the importance of the tumor microenvironment in OPSCC. In this study, including 216 OPSCC patients, we analyze the composition of four established markers of cancer associated fibroblasts (CAFs) in the context of intratumoral CD8 T-cell infiltration.Methods: Immunohistochemical staining for fibroblast activation protein (FAP), platelet-derived growth factor receptor beta (PDGFRb), periostin, alpha smooth muscle actin (α-SMA) and CD8 were analyzed digitally and their association with survival, tumor- and patient characteristics was assessed.Results: Co-expression of CAF markers was frequent but not associated with HPV status. FAPhigh and PDGFRbhigh expression were associated with increased CD8 T-cell infiltration. Low expression of PDGFRb improved patient survival in female patients but not in male patients. We identified PDGFRblow periostinlow α-SMAlow status as an independent predictor of improved survival (hazard ratio 0.377, p = 0.006).Conclusion: These findings elucidate the co-expression of four established CAF markers in OPSCC and underscore their association with T-cell infiltration and patient survival. Future analyses of CAF subgroups in OPSCC may enable the development of individualized therapies

Prognostic implications of p16 and HPV discordance in oropharyngeal cancer (HNCIG-EPIC-OPC): a multicentre, multinational, individual patient data analysis

Background p16(INK4a) (p16) immunohistochemistry is the most widely used biomarker assay for inferring HPV causation in oropharyngeal cancer in clinical and trial settings. However, discordance exists between p16 and HPV DNA or RNA status in some patients with oropharyngeal cancer. We aimed to clearly quantify the extent of discordance, and its prognostic implications. Methods In this multicentre, multinational individual patient data analysis, we did a literature search in PubMed and Cochrane database for systematic reviews and original studies published in English between Jan 1, 1970, and Sept 30, 2022. We included retrospective series and prospective cohorts of consecutively recruited patients previously analysed in individual studies with minimum cohort size of 100 patients with primary squamous cell carcinoma of the oropharynx. Patient inclusion criteria were diagnosis with a primary squamous cell carcinoma of oropharyngeal cancer; data on p16 immunohistochemistry and on HPV testing; information on age, sex, tobacco, and alcohol use; staging by TNM 7th edition; information on treatments received; and data on clinical outcomes and follow-up (date of last follow-up if alive, date of recurrence or metastasis, and date and cause of death). There were no limits on age or performance status. The primary outcomes were the proportion of patients of the overall cohort who showed the different p16 and HPV result combinations, as well as 5-year overall survival and 5-year disease-free survival. Patients with recurrent or metastatic disease or who were treated palliatively were excluded from overall survival and disease-free survival analyses. Multivariable analysis models were used to calculate adjusted hazard ratios (aHR) for different p16 and HPV testing methods for overall survival, adjusted for prespecified confounding factors. Findings Our search returned 13 eligible studies that provided individual data for 13 cohorts of patients with oropharyngeal cancer from the UK, Canada, Denmark, Sweden, France, Germany, the Netherlands, Switzerland, and Spain. 7895 patients with oropharyngeal cancer were assessed for eligibility. 241 were excluded before analysis, and 7654 were eligible for p16 and HPV analysis. 5714 (74middot7%) of 7654 patients were male and 1940 (25middot3%) were female. Ethnicity data were not reported. 3805 patients were p16-positive, 415 (10middot9%) of whom were HPV-negative. This proportion differed significantly by geographical region and was highest in the areas with lowest HPV-attributable fractions (r=-0middot744, p=0middot0035). The proportion of patients with p16+/HPV- oropharyngeal cancer was highest in subsites outside the tonsil and base of tongue (29middot7% vs 9middot0%, p<0middot0001). 5-year overall survival was 81middot1% (95% CI 79middot5-82middot7) for p16+/HPV+, 40middot4% (38middot6-42middot4) for p16-/HPV-, 53middot2% (46middot6-60middot8) for p16-/HPV+, and 54middot7% (49middot2-60middot9) for p16+/HPV-. 5-year disease-free survival was 84middot3% (95% CI 82middot9-85middot7) for p16+/HPV+, 60middot8% (58middot8-62middot9) for p16-/HPV-; 71middot1% (64middot7-78middot2) for p16-/HPV+, and 67middot9% (62middot5-73middot7) for p16+/HPV-. Results were similar across all European sub-regions, but there were insufficient numbers of discordant patients from North America to draw conclusions in this cohort. Interpretation Patients with discordant oropharyngeal cancer (p16-/HPV+ or p16+/HPV-) had a significantly worse prognosis than patients with p16+/HPV+ oropharyngeal cancer, and a significantly better prognosis than patients with p16-/HPV- oropharyngeal cancer. Along with routine p16 immunohistochemistry, HPV testing should be mandated for clinical trials for all patients (or at least following a positive p16 test), and is recommended where HPV status might influence patient care, especially in areas with low HPV-attributable fractions. Copyright (c) 2023 The Author(s). Published by Elsevier Ltd

HPV-induced tumors in the ENT region-The next challenge: are gynecologists also required?

A variety of human papillomavirus (HPV) types are responsible for the emergence of benign and malignant ear, nose and throat (ENT) tumors, which are sometimes associated with severe courses. In head and neck oncology, the current focus is on the oropharyngeal carcinoma, due to the recognition of HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) as an independent entity and due to the continually increasing incidence. Due to the consistent promotion of the vaccination program, particularly also for boys, the incidence of all benign and the majority of malignant ENT tumors could be greatly reduced in the future. In particular, the sharply increasing incidence curve of HPV-associated OPSCC could be markedly flattened

Reanimation of the Smile with Neuro-Vascular Anastomosed Gracilis Muscle: A Case Series

Background: The aim of our manuscript was to evaluate the time course of clinical and electromyographical (EMG) reinnervation after the reanimation of the smile using a gracilis muscle transplant which is reinnervated with the masseteric nerve. Methods: We present a case series of five patients with a longstanding peripheral facial palsy, who underwent a reanimation of the lower face using a gracilis muscle transplant with masseteric nerve reinnervation from June 2019 to October 2020. Trial-specific follow-up examinations were carried out every three months using clinical assessment and EMG, up to 12 months after the surgery. The grading was carried out using the House-Brackmann scale (HB), the Stennert Index, and a self-designed Likert-like scale for graft reinnervation and smile excursion. Results: The surgery was feasible in all of the patients. The reanimation was performed under general anesthesia in an inpatient setting. Postoperative complications which resulted in prolonged hospitalization occurred in two of the five patients. All of the patients showed a preoperative flaccid facial palsy. The first single reinnervation potentials were detected 3.1 +/- 0.1 months after surgery. After 5.6 (+/- 1.4) months, in three (3/5) patients, clear reinnervation patterns were present. Clinically, the patients obtained symmetry of the face at rest after 5.6 (+/- 1.4) months, and could spontaneously smile without the co-activation of the jaw after an average time of 10.8 (+/- 1.8) months. All of the patients were able to express a spontaneous emotion-stimulated smile after one year. Conclusion: Micro-neurovascular gracilis muscle transfer reinnervated with a masseteric nerve is a sufficient and reliable rehabilitation technique for the lower face, and is performed as a single-stage surgery. The nerve supply via the masseteric nerve allows the very rapid and strong reinnervation of the graft, and results in a spontaneous smile within 10 months

Value of sialendoscopy in German ENT-hospitals in 2016

Objective In 2009 a nationwide survey revealed that only 24 % of the German ENT-hospitals performed sialendoscopy. In 2016 the survey was repeated to reevaluate the actual ranking of sialendoscopy in Germany. Material und Methods Again, the same questionnaire as in 2009 was sent to all German ENT-hospitals. It is a self-developed questionnaire including eleven questions. The results from 2009 and the new results from 2016 were matched with each other. Results The amount of hospitals performing sialendoscopy doubled and the number of interventions tripled. There were various reasons for denying sialendoscopy. Main reason was a lack of patients. No differences were seen in ambulant vs. inpatient interventions and the duration of sialendoscopy. Preoperative ultrasound was performed in all hospitals. Conclusions The survey reveals an increasing number of hospitals performing sialendoscopy and an increasing number of sialendoscopies. Simultaneously, some hospitals alleged a lack of patients. These facts could explain a development of specialized centers for obstructive sialadenitis and sialendoscopy. Meanwhile, further salivary gland diseases are treated with sialendoscopy. The preoperative diagnostic of choice is ultrasound. Sialendoscopy seems to be more and more established in German ENT-hospitals

The 8th edition AJCC/UICC TNM staging for p16-positive oropharyngeal carcinoma: is there space for improvement?

The 8th edition of the AJCC/UICC TNM-staging system for p16[HPV]-positive OPSCC manages to improve prediction of prognosis and will essentially influence choice of therapy in future. Nonetheless, adjustments of the current version are needed. The surrogate marker p16 alone is inadequate for HPV detection, the role of ECS in HPV-positive OPSCC is not fully understood, and the patient's characteristics as well as molecular signatures and genetics have not been taken into consideration yet

Prognostic Impact of AJCC/UICC 8th Edition New Staging Rules in Oropharyngeal Squamous Cell Carcinoma

IntroductionThe purpose of this study was to test whether the 8th edition of the AJCC/UICC TNM staging system (UICC) precisely differentiates between stages and reflects disease outcome in human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC).Patients and methodsOPSCC patients that were diagnosed between 2000 and 2016 were included in this analysis and HPV status was determined by combined DNA and p16 testing. Stratification was done according to 7th and 8th UICC staging rules. Incidence trends of HPV-associated tumorigenesis, 5-year overall survival (OS) according to tumor stages as well as the influence of therapy and prognostic factors toward the outcome were calculated using Kaplan–Meier method and Cox proportional-hazards model.ResultsA significant increase [2000; n = 8/39 (21%)–2015; n = 17/32 (53%); p = 0.002] in HPV-associated OPSCC was seen in the observation period. Together, 150/599 (25.0%) of the patients had HPV-driven OPSCC and 64.7% of curative treatments in all OPSCC patients included upfront surgery of the primary and the neck. 7th edition staging rules led to no discrimination in all respective four UICC stages in HPV OPSCC underlining the need for new staging rules. However, only discrimination between stages I vs. II and III vs. IV was significant in our patients with HPV-OPSCC (94.4 vs. 77.5%; p = 0.031 and 63.9 vs. 25.0%; p = 0.013), and stages II vs. III did not differ in OS rates (p = 0.257), when applying the new staging rules. For HPV-negative OPSCC, significant outcome differences were only seen between UICC stages III vs. IV (57.6 vs. 35.2%; p = 0.012).DiscussionWhile the 7th edition of UICC shows invalid discrimination between stages, the 8th edition is more suitable for HPV-associated carcinoma. Due to lack of differentiation between stages II and III further adaption is essential

Awareness of Human Papillomavirus (HPV) and HPV Vaccination amongst the General Population in Germany: Lack of Awareness and Need for Action

Introduction: The oncogenic human papillomaviruses (HPV) types 16 and 18 contribute to more than 73% cases of all HPV-related cancers and commonly affect the anogenital and head and neck region, with rapidly rising incidence rates of HPV-related oropharyngeal squamous cell carcinomas (OPSCC). HPV vaccination has the potential to decrease the burden of HPV-related disease, but vaccination rates remain low in many countries. We investigated the level of awareness of HPV, and HPV-OPSCC in particular, in a representative sample of the German population. Materials and Methods: As part of an online, population-based survey, an electronic questionnaire was administered to a representative sample of 1,095 adult individuals with a specific emphasis on awareness of HPV, transmission, and indicator symptoms of oropharyngeal cancer. Statistical analysis of levels of awareness and relation of these to age, gender, and socioeconomic background were conducted using the IBM SPSS Statistics Version 25.0. Results: 699/1,095 (63.8%) subjects had never heard of HPV. Of the subjects with awareness for HPV, 210 knew that HPV could be transmitted during sex (58.3%) and 138 recognized HPV as a risk factor for OPSCC (14.2%), unrelated to gender (p = 0.357), educational status (p = 0.581), or family status (p = 0.719). 416 subjects knew that a preventive vaccine against HPV existed (44.9%). Women were significantly more aware of HPV (34.2% vs. 22.8%, p < 0.001) and the vaccination (56.4% vs. 32.7%, p < 0.001) as were men. Younger individuals (age group 25-34) were significantly more aware of HPV (p < 0.001), likely as they were offered and/or had received the HPV vaccination. There was no regional variation of HPV awareness within the German state (p = 0.051). Conclusion: Here we demonstrate a significant lack of awareness of HPV and HPV vaccination in a representative sample of the German population. Levels of awareness of the link of HPV and oropharyngeal cancer are particularly low, bearing in mind that this cancer is commonly affecting men and incidence rates are rapidly rising in many European countries and the USA. Awareness programs and further education are required to tackle the low awareness rates and increase the uptake of the vaccination program not only in Germany, but also worldwide. (c) 2022 The Author(s). Published by S. Karger AG, Base

Evaluation of p16(INK4a)expression as a single marker to select patients with HPV-driven oropharyngeal cancers for treatment de-escalation

Background A remarkably better prognosis is associated with oropharyngeal squamous cell carcinomas (OPSCC) driven by human papillomaviruses (HPV) compared with HPV-negative OPSCC. Consequently, de-escalation of standard treatment has been suggested. Due to modest specificity rates, debates are ongoing, whether p16(INK4a), a surrogate marker for HPV-driven OPSCC, is sufficient to correctly identify those tumours and avoid substantial HPV misattribution and thus undertreatment of patients by de-escalation. Robust data estimating the proportion of potentially undertreated patients are missing. Methods We assessed a large-scale cohort of consecutively included OPSCC diagnosed between 2000 and 2017 for HPV-DNA, HPV genotypes, p16(INK4a)expression and multiple tumour- and patient-related risk factors, and investigated their impact on patients' survival in comprehensive uni- and multivariate analyses. Results Aetiological relevance of HPV (p16(INK4a)- and high-risk HPV-DNA-positivity) was detected in 27.1% (n = 192) of OPSCC, with HPV(16)being the most abundant HPV type (94.6%). In 5.5% patients (n = 39), p16(INK4a)overexpression but no HPV-DNA was detected. Principal component and survival analyses revealed that 60.6% of these p16(INK4a)-positive OPSCC lacking HPV-DNA did not resemble HPV16-driven but HPV-negative OPSCC regarding risk-factor profile and overall survival. Notably, this group represented 10.6% of all p16(INK4a)-overexpressing OPSCC. Conclusions p16(INK4a)as a single marker appears insufficient to indicate OPSCC patients suitable for treatment de-escalation