1/10/2016 HPV-Related Oropharyngeal Carcinoma - “Catch Me If You Can!” James S. Lewis Jr. MD Associate Professor Vanderbilt University Medical Center March 16, 2016 Disclosures I have no financial or other conflicts of interest to report. (just that I think way too much about this topic!) 1 1/10/2016 THE “STORY” HPV “Epidemic” in Oropharyngeal SCC - OPSCC incidence up in most countries, particularly in economically more developed ones: - US, UK, Japan, NorthernHPV + Europe, Brazil, but not Asia or South/Central AmericaOropharynx HPV ‐ only - In US, 225% increase in HPV+ oropharyngeal SCC (1984-2004) - 50% decrease in HPV- over same time period *Chaturvedi et al. J Clin Oncol 2012; 29: 4294. *Chaturvedi et al. J Clin Oncol 2013; 31: 4550. 2 1/10/2016 HPV “Epidemic” in Oropharyngeal SCC By 2020, overall oropharyngeal SCC burden in US predictedHPV + to surpass cervical SCC Already Happened!!! ~13,000 patients with OPSCC in 2012* *Chaturvedi et al. J Clin Oncol 2012; 29: 4294. *Chaturvedi et al. J Clin Oncol 2013; 31: 4550. Transmission of HPV • HPV is sexually transmitted • Increased sex partners and practicing oral sex is associated with: – Prevalent and incident oral high risk HPV detection – Increased rates of HPV-related OPSCC • Oral high risk HPV is 1-10% and usually cleared, but can persist – Increased rates and persistence in men and smokers • Risk of HPV from open mouthed kissing suggested Fakry/D’Souza –Oral Oncol 2013; 49(9): 863‐71 3 1/10/2016 Epidemic!!! Well, at least a modest one, anyway… Typical Patient with HPV-Related Oropharyngeal SCC – Caucasian Insert Head – Male (~95%) Shot of Aging Hollywood – 50-60’s Actor Here… – History of smoking (mostly light or former) – Higher than average sex history, particularly oral sex, many partners 4 1/10/2016 Survival Data by p16/HPV Status The Presence of Transcriptionally- Active HPV in Oropharyngeal SCC is Highly and Independently Predictive of Better Patient Survival (patients have ~2-5 times lower risk for overall and disease specific mortality) 5 1/10/2016 Transcriptionally-active HPV-related OPSCC is a clinically, biologically, morphologically, and molecularly distinct form of head and neck SCC SCC Variant Given the prognostic (and emerging treatment) differences, it is critical for us to diagnose them correctly and communicate the findings clearly in our reports All patients with newly diagnosed oropharyngeal squamous cell carcinoma should get some form of p16 +/- HPV testing 6 1/10/2016 Testing should also be performed on: 1) Tissue (and/or FNA cell blocks) from neck metastases of known oropharyngeal primary 2) Tissue (and/or FNA cell blocks) from neck metastases of unknown primary HPV DNA PCR DNA ISH p16 IHC Nonkeratinizing Morphology HPV E6/E7 mRNA ISH 7 1/10/2016 In the oropharynx, all HPV specific and surrogate marker tests shown to be roughly equivalent prognostic markers… So which one(s) to use and what “approach”? Strategies for p16/HPV Testing in Oropharyngeal SCC: Three “Schools” of Thought: 1) p16 immunohistochemistry alone 2) Morphology-informed strategy: nonkeratinizing SCC with + p16 IHC sufficient; all others also get HPV-specific testing 3) Across the board p16 IHC and HPV-specific testing 8 1/10/2016 Expert Opinions/Recommendations College of American Pathologists Cancer Committee Pharynx: Checklist item for p16 IHC (with suggestions for when to add HPV specific testing) p16 p16 HPV Why p16? Sign here _________ p16 overexpression indicates that the HPV is causing “favorable” signaling in the tumor cells 9 1/10/2016 p16 “The Practical Thing” Reproducible p16 Immunohistochemistry Alone Many caveats! (you should know what these are for your practice) 10 1/10/2016 Caveats for p16 IHC Alone • 1) Only in oropharyngeal carcinomas • 2) Extensive nuclear+cytoplasmic staining cutoff (>70%) for calling positivity • 3) Strict rules on use in neck metastases and CUP – (Level II-III and nonkeratinizing morphology) Which p16 Antibody? Which HPV-Specific Test? • No current data supporting one p16 antibody/clone/platform over another* (*but see USCAP abstract ___) • No current data dictating one HPV-specific test over another, either*. *But HPV RNA ISH probably emerging… 11 1/10/2016 Systematic Literature Review CAP Pathology and Laboratory Quality Center: Human Papillomavirus Testing in Head and Neck Squamous Cell Carcinomas Expert Panel HPV-Related Oropharyngeal Carcinoma = The Bad Guy HPV-Related Oropharyngeal Carcinomas Have Many Morphologies and Presentations = Masquerading as Other Lesions 12 1/10/2016 Pathologists = “Tissue Detectives” A Pathologist’s Job? To Recognize “The Bad Guy” in All His Many Forms and to Call Them Out 13 1/10/2016 Today’s Aim: TeachYou Many of the “Faces” of HPV-Related Oropharyngeal Carcinoma Case #1: 57 year old man with dysphagia and a granular and ill-defined mass in the right base of tongue. 14 1/10/2016 Reverse Maturation 15 1/10/2016 Retraction Artifact Brisk Mitotic Activity 16 1/10/2016 p16 Positive Diagnosis: Oropharynx, base of tongue, biopsy: - p16 Positive (or HPV-Related) Squamous Cell Carcinoma, NonkeratinizingType with Maturation 17 1/10/2016 Is this tumor: Well-Differentiated Moderately-Differentiated Poorly-Differentiated Differentiation Not Applicable Answer: Differentiation Not Applicable 18 1/10/2016 Morphology in Oropharyngeal Squamous Cell Carcinoma 19 1/10/2016 20 1/10/2016 “Reverse Keratinizing Areas Maturation” Nonkeratinizing Areas Clefting/Retraction 21 1/10/2016 20‐25% 20‐25% 50‐60% Keratinizing Nonkeratinizing Nonkeratinizing w/Maturation (100% maturing (>10 but <100% (<10% maturing squamous maturing squamous squamous differentiation) differentiation) differentiation) 22 1/10/2016 Nonkeratinizing Morphology and HPV • Four Years of Clinical Practice –Washington University – 435 OPSCC Cases • Nonkeratinizing (NK) SCC = 53% of total cases • 99.1% were p16 positive (226/228) • Combine surrogate markers: • All 48 NKSCC that were “audited” for HPV mRNA (by RTPCR and RNA ISH) were positive (100%) Dibe‐Gondim et al, USCAP Meeting Abstract ‐ 2015 Strictly defined nonkeratinizing SCC (minimal maturing squamous differentiation) is almost implicitly related to transcriptionally-active high risk HPV Chernock. Head Neck Pathol 2009; 3: 186. Lewis Jr. Histopathol 2012; 60: 427. 23 1/10/2016 College of American Pathologists Cancer Committee Pharynx: Protocol for the Examination of Specimens From Patients With Carcinomas of the Pharynx 2013 Modification: p16 IHC sufficient alone for “nonkeratinizing or predominantly nonkeratinizing oropharyngeal SCC” 24 1/10/2016 “Grading” of Oropharyngeal Squamous Cell Carcinoma Literature Descriptions “Patients with HPV positive tumors had a higher prevalence of high grade lesions” “The HPV positive cases were more likely to be poorly differentiated than those that were negative” 25 1/10/2016 Morphology in Oroph SCC • Turns out that “poorly differentiated/high grade” tumors actually have much better prognosis – Nonkeratinizing, partially keratinizing, lymphoepithelial, and basaloid tumors consistently related to transcriptionally-active high risk HPV – Genetically less complex and better treatment response – Paradoxical – and not at all what is clinically conveyed by the terms Let’s come back to the crypts… Nonkeratinizing SCC 26 1/10/2016 *Avoid terms about grading and/or differentiation for p16/HPV positive tumors Fight that urge!!! Now Something Even More Confusing!!! 27 1/10/2016 Nonkeratinizing SCC with Multinucleation Nonkeratinizing SCC with maturation and nuclear anaplasia 28 1/10/2016 Nonkeratinizing SCC with multinucleation and anaplasia Nonkeratinizing SCC with Nuclear Anaplasia p16 29 1/10/2016 p16 Positive Patients vs p16 Negative p16 positive & A/MN negative p16 positive & A/MN positive p16 negative Overall Survival (years) Lewis Jr. et al. Am J Surg Pathol 2012; 36: 1036 Anaplasia and Multinucleation: Only one study to date Only surgically-resected patients Pathologist reproducibility in classification? 30 1/10/2016 Case #1 p16 Positive/HPV-Related OPSCC Mimicking a Poorly Differentiated Tumor Case #2: 42 year old man with a large neck mass. On clinical examination, he has a subtle irregularity of the left tonsil. 31 1/10/2016 p16 Copyright © 2013 by ASCP 63 Diagnosis? 32 1/10/2016 Concept of Tonsillar ‘Crypt Dysplasia’ • Theoretical as precursor lesion • Electron microscopy studies of normal tonsil – “reticulated” crypt epithelium Normal Tonsillar Crypts Copyright © 2013 by ASCP 66 33 1/10/2016 C Normal Tonsillar Crypts L E Capillaries within reticulated crypt epithelium Discontinuous Basement C Membrane E Perry ME. J Anat 1994; 185: 111 What percentage of patients with HPV-related oropharyngeal SCC have nodal metastases at presentation? 20% 35% 50% 80% 95% 34 1/10/2016 Answer: 80% Nodal metastases are present at presentation in ~80 to 85%+ of all HPV-related oropharyngeal squamous cell carcinomas Ang et al. NEJM 2010; 363: 24. Jordan et al. Am J Surg Pathol 2012; 36: 945. Lewis Jr. et al. Am J Surg Pathol 2010: 1044:38. 35 1/10/2016 Tonsillar Crypt Epithelium a Poor Barrier to the Spread of Carcinoma NKSCC Along Tonsillar Crypts Mimicking In Situ Only 36 1/10/2016 Overtly invasive foci also lacking stromal reaction “The tissue doesn’t lie…but it may try to deceive you!” Louis “Pepper” Dehner, MD Washington University in St. Louis http://news.wustl.edu/news/Pages/13804.aspx 37 1/10/2016 Recommended Diagnosis p16 positive (or HPV-related) squamous cell carcinoma, nonkeratinizing type* *No morphologic difference from clearly metastasis-capable tumor *Caveats • Tonsillar