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  Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 52  |  Issue : 3  |  Page : 403-405
 

Predictivity of human papillomavirus positivity in advanced oral cancer


1 Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
3 Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
4 Division of Clinical Research and Biostatistics, Malabar Cancer Centre, Kannur, Kerala, India

Date of Web Publication18-Feb-2016

Correspondence Address:
V M Patil
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.176694

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 » Abstract 

Background And Objective: Human papillomavirus (HPV) is a known prognostic factor world over in patients of carcinoma oropharynx. The role of HPV in oral cancers has not been investigated adequately. We tried to identify standard clinicopathological features in oral cancer, which would predict HPV-positivity. Methods: This was a retrospective analysis of 124 cases of T4 oral cancer patients at our center. HPV-positive was defined in accordance with positive p16 immunohistochemistry done on pretreatment local tumor site biopsy. Age, sex, habits (smoking history and oral tobacco), Eastern Cooperative Oncology Group performance status (ECOG PS), T stage, N stage, grade, and site were selected, for testing of prediction for HPV-positivity. The analysis was performed by R studio version 3.1.1. Two-sample test for equality of proportions with continuity correction was used to identify factors predicting for HPV-positivity. P = 0.05 was considered as significant. Results: Of 124 patients, 16 patients (12.9%) were HPV-positive. The median age of the whole cohort was 43 years (interquartile range 37–52 years) with 15 females (12.1%). All had squamous cell carcinoma (100%). The grade of the tumor was well differentiated in 9 patients (7.2%), moderately differentiated in 98 patients (79.1%), and poorly differentiated in 17 patients (13.7%). The ECOG PS 0 in 19 patients (15.3%), 1 in 104 patients (83.9%), and 2 in 1 patient (0.8%). The subsite of the tumor was buccal mucosa in 74 patients (59.7%), anterior two-third of tongue in 33 patients (26.6%), and others in 17 patients (13.7%). None of the tested factors except the use of oral tobacco were statistically significantly associated with HPV-positivity. History of tobacco usage had a statistical trend toward ability to predict HPV-positivity. The proportion of patients with HPV-positive oral cancer in patients without history usage of oral tobacco was 31.3% while it was 10.2% in patients with previous history of tobacco use (P = 0.03). Conclusion: Standard clinicopathological variables could not predict for HPV-positivity. Negative history of tobacco (smokeless) usage showed statistical trends toward ability to predict HPV-positivity in oral cancer patients.


Keywords: Clinicopathological, human papillomavirus, oral cancers, p16, prediction


How to cite this article:
Kane S, Patil V M, Noronha V, Joshi A, Dhumal S, D’Cruz A, Bhattacharjee A, Prabhash K. Predictivity of human papillomavirus positivity in advanced oral cancer. Indian J Cancer 2015;52:403-5

How to cite this URL:
Kane S, Patil V M, Noronha V, Joshi A, Dhumal S, D’Cruz A, Bhattacharjee A, Prabhash K. Predictivity of human papillomavirus positivity in advanced oral cancer. Indian J Cancer [serial online] 2015 [cited 2019 Jun 26];52:403-5. Available from: http://www.indianjcancer.com/text.asp?2015/52/3/403/176694



 » Introduction Top


Human papillomavirus (HPV) positive head and neck cancers (HNCs) particularly oropharyngeal cancers are now identified as a favorable prognostic subgroup.[1],[2],[3],[4] The proportion of patients with HPV-positive tumors is on rise. The surveillance, epidemiology, and end results database analysis of HNC cases between 1973 and 2003 revealed that HPV-positive HNC cases have increased by 0.8% annually.[5] However, this increment in HPV-positive cases is mainly contributed by oropharyngeal cancers.[2] In recently reported series, 60–70% of oropharyngeal cancers were HPV-positive.[4] However, the corresponding figure in oral cancers was only around 6–20%.[4],[6],[7]

The rate of HPV-positivity decreases as tumor stage increases.[1] In T4 oral cancers, there is a lack of studies based on clinicopathological features, which would predict HPV-positivity. We have analyzed T4 oral cancers for HPV-positivity and have tried to identify clinicopathological features, which would predict for it.


 » Methods Top


This was an institutional review board approved retrospective analysis. We maintain a database of HNC patients treated at our center. Randomly 124 T4 oral cancer patients seen at our center between 2012 and 2013 were selected for this analysis.

p16 methodology

p16 immunohistochemistry (IHC) was performed on the pretreatment biopsy of these patients retrospectively. IHC was performed on four micron thick sections with p16INK4 ready to use antibody (Biogenex, CA, USA) with standard protocol. Antigen retrieval was performed by heat induced epitope retrieval method with the help of microwave oven. Slides were placed in microwavable jar with 10 mM sodium citrate buffer (pH 6.0) and were heated with descending units of power that is, first at high power (power 60) for 5 min then at medium power (power 40) for 5 min followed by low power (power 30) for 5 min. Slide jars were removed from the microwave oven and cooled to room temperature. After cooling slides were washed with two changes of Tris buffer saline (pH 7.6) with Tween 20 for 5 min and further IHC was carried out using MACH 2 polymer detection kit. Primary antibody was incubated for 90 min at room temperature followed by polymer solution for 35 min at room temperature. Diaminobenzidine solution was added for 5 min at room temperature and counterstaining was done by using hematoxylin. This was followed by dehydration using increasing grades of alcohol (three changes of 5 min each) and clearing in xylene (three changes of 5 min each). Slides were mounted in DPX.

The nuclear positivity with or without cytoplasmic positivity was considered as positive result for p16 and only cytoplasmic positivity was considered as negative. The IHC result was considered as positive only when nuclear positivity was seen in more than 10% of all the tumor cells. Nuclear positivity in <10% of all the tumor cells was considered to be a negative result. The results were validated by HPV-IST test performed on every 10th p16 positive and 10th p16 negative case of oral cancer.

Factors selected for prediction

We maintain a database of patients undergoing NACT in HNCs. From this database, the details regarding age, gender, habits, Eastern Cooperative Oncology Group performance status (ECOG PS), grade of tumor, clinical N stage, and clinical T stage (T4a or T4b) of the tumor were extracted for the selected cases. These factors were selected on the basis of previous literature showing each of these factors to be linked with HPV-positivity.[2],[8],[9]

Statistical analysis

The analysis was done on R studio version 3.1.2 (R Foundation for Statistical Computing, Vienna, Austria). Descriptive analysis was performed. The Fisher's Exact Test for count data was used to identify factors predicting HPV-positivity. The P ≤ 0.05 was taken as significant.


 » Results Top


Baseline details

The median age of the whole cohort was 43 years (interquartile range 37–52 years). There were 15 females (12.1%) and 109 males (87.9%). One hundred and eight patients (87.1%) had a history of oral tobacco usage while 32 (25.8%) patients had a history of smoking. Seven patients (5.6%) had no history of tobacco usage in any form. The ECOG PS 0 in 19 patients (15.3%), 1 in 104 patients (83.9%), and 2 in 1 patient (0.8%). The subsite of the tumor was buccal mucosa in 74 patients (59.7%), anterior two-third of tongue in 33 patients (26.6%), and others in 17 patients (13.7%). The T stage was T4A in 102 patients (82.3%) and T4b in 22 patients (17.4%). Nodal status was N0 in 22 patients (17.7%), N1 in 25 patients (20.2%), N2 in 72 patients (58.1%), and N3 in 5 patients (4%). All had squamous cell carcinoma (100%). The grade of the tumor was well differentiated in 9 patients (7.2%), moderately differentiated in 98 patients (79.1%), and poorly differentiated in 17 patients (13.7%).

Factors predicting for human papillomavirus positivity

Sixteen patients were high risk HPV-positive (12.9%, 95% confidence interval [CI] 7.8–20.4%). The factors tested for prediction of HPV-positivity are shown in [Table 1]. History of oral tobacco usage had ability to predict for HPV-positivity. The proportion of patients with HPV-positive oral cancer in patients without history usage of oral tobacco was 31.3% while it was 10.2% in patients with previous history of oral tobacco use (P = 0.03).
Table 1: Factors analyzed for prediction of HPV-positivity

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 » Discussion Top


This study was designed to identify factors, which would help us to predict upfront for HPV-positivity. Unfortunately except lack of history of oral tobacco use, none of the other factors could predict it in our setting. It was an interesting finding that the use of oral tobacco was associated with the high proportion of HPV-negative tumors. The finding seems logical though, both HPV and oral tobacco have been implicated in oral cancer carcinogenesis.[4],[10],[11] High-risk HPV strains (16, 18, 31, 33) are considered as an etiological agent in oral cancer especially in patients without a history of tobacco use or alcohol use.[12]

The pattern of tobacco use in India differs from that prevalent in developed countries. In our previous reports in locally advanced technically unresectable tumors, 69.1% of our patients used tobacco and nearly in 80% of them it was oral tobacco.[13] Similarly in this series, more than 90% of the tobacco habits were contributed by oral tobacco. The quantification of oral tobacco use is difficult as against quantification of smoking. The quantification of oral tobacco should take into account the amount of oral tobacco use per day, the amount of time the tobacco was kept in the mouth and whether the juices were expectorated or swallowed.[14] The oral tobacco use is in India is particularly difficult to quantify as it is available in different quantity (according to the brands), frequently people use various brands and it is also used in unquantifiable forms in tobacco-related preparations (Paan or Khaini). Hence, it is difficult for us to stratify patients according to the quantity of oral tobacco use. However, quantification may further help us to select appropriate cases for HPV testing.

The data regarding clinical profile of HPV-positive cancers from our study is different from that reported in oropharyngeal studies. Commonly HPV-positive oropharyngeal tumors are seen in a young age and the incidence is on a rise in female patients.[2] However, in our study males patients were much more than females and there was no association between age, gender, and HPV-positivity. In series reported HPV-positive, oropharyngeal cancers have small primary, cystic nodal disease, and better ECOG PS.[2],[4],[12],[15] None of these features were seen in our study. As expected we have not taken the whole cohort (all stage inclusive) of oral cancers but a selected cohort of T4 stage disease. Hence, the chance of having node-positive disease in the cohort is high and due to the large disease burden it is unusual for large number patients to have ECOG PS 0. Hence, it seems that the commonly quoted clinicopathological profile of HPV-positive oropharyngeal cancers is unlikely to be seen in T4 HPV-positive oral cancers.

Oral HPV-related data from India has shown variable results.[8],[9],[16] This may be due to small number of patients been enrolled and different techniques used for HPV testing. The different types of method of HPV testing have been compared by Pannone et al. It was suggested that p16 alone may not be a reliable test for HPV testing.[17] Another important factor, which is not controlled in this studies is the proportion of subsites of oral cancers. Oral cancer is a cumulative term used for a collection of tumor subsites in the oral cavity. It is been suggested that cancers arising from oral tongue may have a high proportion of HPV-positivity.[9] Though our data did not confirm this finding. Our study too has its limitations. One important limitation of this study is its retrospective nature and no data regarding sexual habits.

The HPV-positive rate of 12.9% in our setting, in T4 stage oral cancer is surprising. Future studies are to be carried on by us which would help us to decide whether this marker would be clinically useful or not in oral cancers.


 » Conclusion Top


Human papillomavirus positive rate in T4 oral cancers is 12.9% (95% CI 9.0–21.9%). It is seem that oral tobacco users have a high proportion (1/3rd) of HPV-positive tumors. Clinical utility of HPV in oral cavity cancers needs to be explored.

 
 » References Top

1.
Ang KK, Harris J, Wheeler R, Weber R, Rosenthal DI, Nguyen-Tân PF, et al. Human papillomavirus and survival of patients with oropharyngeal cancer. N Engl J Med 2010;363:24-35.  Back to cited text no. 1
    
2.
Friedman JM, Stavas MJ, Cmelak AJ. Clinical and scientific impact of human papillomavirus on head and neck cancer. World J Clin Oncol 2014;5:781-91.  Back to cited text no. 2
    
3.
Dayyani F, Etzel CJ, Liu M, Ho CH, Lippman SM, Tsao AS. Meta-analysis of the impact of human papillomavirus (HPV) on cancer risk and overall survival in head and neck squamous cell carcinomas (HNSCC). Head Neck Oncol 2010;2:15.  Back to cited text no. 3
    
4.
Benson E, Li R, Eisele D, Fakhry C. The clinical impact of HPV tumor status upon head and neck squamous cell carcinomas. Oral Oncol 2014;50:565-74.  Back to cited text no. 4
    
5.
Chaturvedi AK, Engels EA, Anderson WF, Gillison ML. Incidence trends for human papillomavirus-related and-unrelated oral squamous cell carcinomas in the United States. J Clin Oncol 2008;26:612-9.  Back to cited text no. 5
    
6.
Lingen MW, Xiao W, Schmitt A, Jiang B, Pickard R, Kreinbrink P, et al. Low etiologic fraction for high-risk human papillomavirus in oral cavity squamous cell carcinomas. Oral Oncol 2013;49:1-8.  Back to cited text no. 6
    
7.
Isayeva T, Li Y, Maswahu D, Brandwein-Gensler M. Human papillomavirus in non-oropharyngeal head and neck cancers: A systematic literature review. Head Neck Pathol 2012;6 Suppl 1:S104-20.  Back to cited text no. 7
    
8.
Bahl A, Kumar P, Dar L, Mohanti BK, Sharma A, Thakar A, et al. Prevalence and trends of human papillomavirus in oropharyngeal cancer in a predominantly north Indian population. Head Neck 2014;36:505-10.  Back to cited text no. 8
    
9.
Barwad A, Sood S, Gupta N, Rajwanshi A, Panda N, Srinivasan R. Human papilloma virus associated head and neck cancer: A PCR based study. Diagn Cytopathol 2012;40:893-7.  Back to cited text no. 9
    
10.
Balaram P, Nalinakumari KR, Abraham E, Balan A, Hareendran NK, Bernard HU, et al. Human papillomaviruses in 91 oral cancers from Indian betel quid chewers – high prevalence and multiplicity of infections. Int J Cancer 1995;61:450-4.  Back to cited text no. 10
    
11.
D'Costa J, Saranath D, Dedhia P, Sanghvi V, Mehta AR. Detection of HPV-16 genome in human oral cancers and potentially malignant lesions from India. Oral Oncol 1998;34:413-20.  Back to cited text no. 11
    
12.
Hennessey PT, Westra WH, Califano JA. Human papillomavirus and head and neck squamous cell carcinoma: Recent evidence and clinical implications. J Dent Res 2009;88:300-6.  Back to cited text no. 12
    
13.
Epidemiology of Oral Cancers Referred for NACT, the Demographics, Clinical Profile, and Organ Functions. 2013 ASCO Annual Meeting. Abstracts Meeting Library. Available from: http://www.meetinglibrary.asco.org/content/116116-132. [Last cited on 2015 Jan 25].  Back to cited text no. 13
    
14.
Al-Ibrahim MS, Gross JY. Tobacco use. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. Boston: Butterworths; 2011.  Back to cited text no. 14
    
15.
Auluck A, Hislop G, Bajdik C, Poh C, Zhang L, Rosin M. Trends in oropharyngeal and oral cavity cancer incidence of human papillomavirus (HPV)-related and HPV-unrelated sites in a multicultural population: The British Columbia experience. Cancer 2010;116:2635-44.  Back to cited text no. 15
    
16.
Patra J, Dikshit R, Bhatia M, Ramasundarahettige C, Jha P. HPV-avertable cancer risks in India: A pooled analysis of 9 observational studies. Int J Cancer 2015;136:491-2.  Back to cited text no. 16
    
17.
Pannone G, Rodolico V, Santoro A, Lo Muzio L, Franco R, Botti G, et al. Evaluation of a combined triple method to detect causative HPV in oral and oropharyngeal squamous cell carcinomas: P16 Immunohistochemistry, Consensus PCR HPV-DNA, and in situ Hybridization. Infect Agent Cancer 2012;7:4.  Back to cited text no. 17
    



 
 
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