Human Papilloma Virus and Head and Neck cancers.

1. HPV and Head and Neck Cancers
Dr Boaz Vincent
CMC, Vellore
27.6.2015

2. Objectives
• Epidemological shift in the etiology of H&N SCC
• HPV - Virology
• Detection of HPV in H&N Cancers
• HPV positive cancers- its prognosis and
treatment .

3. References

4. Head and Neck Cancer
• 6th most common cancer worldwide
• More than 600,000 new diagnoses annually
• > 95% are Squamous cell Carcinomas
• Known risk factors including tobacco, alcohol
and betel nut.

5. The Epidemological Shift
• Reduction in tobacco use in the USA
• In 1965: > 50% of male and 0.25% of female
• In 2006: < 25% of male and 20% of female
• Numbers of head and neck cancer patient should
be decreased ???
Giovino GA et al., Am J Prev Med, 33: s318-s326, 2007

6. Giovino GA et al., Am J
Prev Med, 33: s318-s326,
2007

7. Chaturvedi AK, J Clin Oncol 2008
• ↑ Incidence of tongue and pharynx in the past two
decades
• SEER Data (1973-2001) showed INCREASE annual
incidence of Oropharyngeal squamous cell
carcinomas 0.8% (OPSCC)
Oropharyngeal subsites: Base of tongue ↑1.27%
Tonsillar carcinoma ↑0.6%

8. Among men, OPSCC
significantly increased
in
many developed
countries
e.g. United States,
Canada, UK, Japan,
Netherlands,
Denmark, Australia,
Slovakia, Brazil

9. Professor Harald Zur Hausen
Prince Mahidol Award 2005
Nobel Prize 2008
The First one who demonstrated HPV-DNA
sequences in cervical cancer biopsies and
cervical cancer cell lines.

10. Human Papilloma Virus Virology
• Papovaviridae family
• small DNA-containing virus
▫ double-stranded circular DNA of 7900 base-pairs long
▫ 3 segments:
 Long control
 Early genes
 Late genes
• Non-enveloped virus
• Icosahedral Protein Coat (20-sided)
• Epitheliotropic (infects epithelial cells)

11. Human Papilloma Virus
• >100 types of HPV
• HPV 16, 18, 31, 33
associated with
malignancy

14. VIRAL GENOME
• The HPV genome encodes 8 viral proteins that
regulate the viral life cycle .
• The HPV L1 and L2 genes encode the viral
capsid proteins that encapsulate the viral DNA
and play no known role in carcinogenesis but are
important targets of the immune response to
HPV infection .
• The early viral genes E1 and E2 are important
for viral genome replication and play a role in
transcriptional regulation of other viral genes.

15. • The E4 protein play a role in G2 arrest in HPV-
infected cells .
• The 3 HPV oncogenes E5, E6, and E7 promote
unrestrained cellular proliferation to allow for
viral amplification but also contribute to the
initiation and progression of cancer

16. L2
L1
E6 E7 E1
E2 E5
E4
Oncogenes
Viral
Replication
Assembl
y and
Release
Capsid
proteins
(Zur Hausen, Nat Rev Cancer 2002)
HPV Structure

17. E6
E7 E1
E2
E4
E5 L2
L1
early genes late genes URR*
* URR = upstream regulatory region
HPV Genome Organization

18. Still under investigation
HPV oncproteins: p53 and pRb

19. Clinical Types
• Clinical Types of HPV InfectonHigh Risk Types: found
preferentially in precancerous
and cancerous specimens
including HPV
16,18,31,33,34,35,39,45,51,52,56
,58,59,66,68,70
Low Risk Types: detected in
wart and non-malignant lesion
including HPV 6,11,42,43,44

20. 16 and 18
• 70% of cervical cancer cases are associated
with either HPV-16 or HPV-18 .
• Approximately 50% of penile cancers contain
HPV DNA, mostly HPV-16 .
• Human papillomavirus-16 or HPV-18 is
responsible for 50% of other male and female
anogenital cancers.
• In the oropharynx, HPV-16 accounts for more
than 90% of all HPV associated cancers

21. HPV as Etiology…
• Odds ratio for Oropharyngeal CA in seropositive HPV16 was more than 14
(Mork J, NEJM 2001)
• HPV-associated oropharyngeal carcinoma in the USA = 60-70%
(D’Souza et al NEJM 2007)
(Fakhry C J Nat Can Inst 2008)
(Chaturvedi AK J Clin Oncocol)
• HPV-associated OPSCC in Central Europe and Central America = 10%
(Ribeiro KB , Int J Epidemiol 2011)
• HPV 38-56% in North America, North and West Europe, Australia and Japan
• HPV 13-17% in other parts of the world
(de Martel C , Lancet Oncol 2012)

22. Pathology
• Human papillomavirus infects basal cells in the
stratified squamous epithelium through micro-
abrasions in the epithelial surface.
• HPV receptors- Alpha6 beta 4 integrin, syndecan 1
• Amplification – In endosomes

23. (Syrjänen S, Head and Neck Pathology 2012)

24. Risk Factors
HPV Positive HPV Negative
• No. Oral Sex partners
• Many Vaginal Sex partners
• Younger age of first sexual
contact.
• Ano genital warts
• Consumption of Marijuana
• Consumption of nicotine
• Consumption of Alcohol
• Older Age
• Poor oral hygiene

25. Different Clinical and Biological Features of
HPV-negative and HPV-positive cases
Feature HPV-negative HPV-positive
Age Above 60 years Middle-aged
Risk factors Tobacco +/- alcohol Sexual behaviour
Field cancerization yes Unknown
Predilection site None Oropharynx
T stage Higher T Stage Lower T Stage
Nodal status Lower Higher
TP53 mutations Frequent Infrequent

26. Detection of Human Papilloma Virus
Evidence of functioning
Oncoprotein E7
•DNA In-Situ Hibridization
•PCR assay for viral copies
•mRNA of E6, E7
•p16 Immunohistochemistry
Presence of HPV
DNA

27. HPV Detection
• Polymerase chain reaction
• High sensitivity
• Prone to cross contaminate
• Unable to distinguish episomal vs integrated form
• Best fit for frozen specimen
• Prone to error when analyze in FFPE specimen
• More widely available but not for some pathological lab

28. HPV Detection
• In situ hybridization
• High specificity
• Localize HPV DNA within the
tumor cell nuclei
• Discriminate between
integrated and episomal
infection
• Limited to a few specialist
centers (Syrjänen S, Head and Neck Pathology
2002)

29. Detection of Functional Oncoproteins
• p-16 Immunohistochemistry
(Rushatamukayanunt et al,APJCP 2014)
• Surrogate of functional
downstream effect of Rb gene
inactivation by E7 oncoprotein
• Sensitivity 100%
• Specificity 79%
•Applicable for FFP specimens
Smeets Sj et al, Int J Cancer 2007

31. Why HPV-positive HNC has increased
significantly during the last 20 years?
• Increased awareness of the association of HPV
and HNC
• Improved identification of HPV within tumors
cells .
• A true increase in the prevalence of HPV-
associated cancers (particularly in the head-and-
neck region).

32. • Prevalence of oral HPV infection is 5- to 10-fold
lower than that of genital HPV
• But transmission of both genital and oral high-
risk HPVs is highly correlated with sexual
activity
• The risk of having HPV isolated from the oral
cavity is 8 times greater among sexually
experienced than in sexually inexperienced
individuals

33. Sexual Transmission of HPV H & N cancer
• Methods:
• A hospital-based, case–control study of 100
patients with newly diagnosed oropharyngeal
cancer and 200 control patients without
cancer to evaluate associations between HPV
infection and oropharyngeal cancer
D’Souza et al., 2007

34. • Results:
▫ High life time no of vaginal sex partners (>26) associated
with OPC
 Odds Ratio = 3.1
▫ High life time no of oral sex partners (>6) associated with
OPC
 Odds Ratio = 3.4
▫ OPC significantly associated with HPV-16 infection
 Odds Ratio = 14.6
-HPV-16 DNA detected in 72% of tumors
▫ 64% of pts were were seropositive for E6, E7 or both
Tobacco use increased the association with OPC primarily
among pts without HPV-16.
• Conclusion:
▫ HPV infection is strongly associated with OPC in pts with or
without tobacco abuse
D’Souza et al., 2007

35. Disease course and prognosis..
• On the assumption that HPV-associated H&N
cancer is an entity of its own, clinical studies
have increasingly been published…
• These studies show that patients with HPV-
positive cancers have a much better prognosis.
• The explanation proffered for the survival
advantage is better responsiveness to
radiotherapy and chemotherapy, and thus better
locoregional control.

37. HPV VACCINE
• Prophylactic vaccine composed of HPV-16 viral
capsid proteins
• Prevents persistent HPV-16 infection
• Prevents development of cervical dysplasia
• NO DATA yet on oral HPV infection
• Canine and hamster work promising

38. HPV VACCINE – In H&N Cancer???
• HPV-16 is responsible for only 50-60% of
cervical cancers
• In HPV + oropharyngeal cancer, HPV-16
subtype is present in 94% of these cancers
• The HPV vaccine should be even more
effective in head and neck cancer

39. BY 2020….
• The annual number of HPV-positive OPSCCs
(approximately 8,700 patients) will surpass the
annual number of cervical cancers
(approximately 7,700 patients) with the majority
occurring among men (approximately 7,400).
• By 2030, OPSCC will likely constitute a majority
(47%) of all head and neck cancers.
• Chaturvedi A K et al. JCO 2011

40. HPV Vaccine
• Gardasil
▫ HPV Quadravalent Recombinant Vaccine
▫ HPV 6, 11, 16, 18
• Approved by FDA for girls in 2006
• Approved by FDA for boys for prevention of
genital warts in October 2009
• Cervarix (bivalent HPV 16, 18)
• Approved by FDA in 2009

41. VACCINE MOA
• They each make use of virus-like particles
composed of the major capsid protein L1 of the
targeted HPV subtypes.
• Immune-system surveillance for HPV-L1 results
in acquired immunity. Both vaccines prevent
infection with HPV-16 and HPV-18

42. Can we use this after development of
cancer?
• Vaccines after the development of cancer is
unlikely to provide clinical benefit, because
expression of the capsid proteins is usually lost
during transformation

43. De-intensified Therapy for
HPV-Positive HNC Patients

44. HPV-positive Oro pharyngeal
Carcinoma has better prognosis
Better
Survival
Long-term morbidity associated
with current treatment will be
longer lasting
De-escalating
Treatment
Regimens

45. • Deintensification trials can be divided into 2
camps:
1. Deintensification of local therapy via use
alternative chemotherapy, reduced dose
radiation, or surgery
2. Use of induction therapy to identify good-
responding patients for subsequent dose
reduction.

46. Role of induction chemotherapy
• Use of induction therapy will deliver successful
cytotoxic therapy to micrometaststic disease at
the earliest time point, thus improving distant
disease control without compromising
local/regional control.

47. ECOG 1308
• Eastern Cooperative Oncology Group 1308
phase 2 trial used induction chemotherapy to
select patients for radiation dose modification
(from 66-70 Gy to 54 Gy) according to whether
they achieved a complete response to induction
therapy. Results from this study are currently
pending.

48. RTOG 1016
• Accrual is nearly completed in RTOG 1016, a
phase 3 trial randomizing HPV-positive HNC
patients to cisplatin versus cetuximab given
concurrent with 70 Gy radiation.
• This study hopes to definitively answer the
question of whether cetuximab, with its
favorable toxicity profile, can be safely
substituted for cisplatin in patients with HPV-
positive HNC.

49. • University of Michigan and the University of
North Carolina (UNC) are pursuing phase 2 trials
investigating dose deintensification without
induction therapy .
• Using either cetuximab plus standard-dose
radiation or cisplatin plus reduced-dose radiation.
• Experimental treatment is less toxic than
standard-of-care.
• Although still preliminary, the UNC trial has
shown promising results in HPV-positive patients
treated with reduced-dose radiation (60 Gy), less
toxic weekly cisplatin (30 mg/m2

50. Ongoing trials

51. WHY HPV +ve patients do well??

52. • It has been hypothesized that the immune
system plays a more important role in clearance
of HPV-positive cancers owing to the expression
of viral proteins within HPV-positive HNC.
• Finally, radiation can induce loss of CD47 (a
cell-surface marker that plays a role in
identification of self) expression in HPV-positive
cell lines, providing a potential explanation for
the proposed interaction between the immune
system and radiation therapy.

53. Conclusions
1. HPV has a strong association with
oropharyngeal SCC (particularly tonsil)
2. HPV has weaker associations with oral and
laryngeal cancer
3. Pts with HPV +ve oropharynx tumors:
▫ Present at a relatively younger age
▫ Do not have excessive tobacco use
▫ Appear to have better survival

54. Conclusions
4. HPV Vaccine shown to have high efficacy in
preventing cervical cancer related to HPV-16
and 18.
5. Screening of patients (esp. tonsillar ca.) for
HPV may improve treatment protocols and
provide important prognostic information.

55. Remember…
• HPV positive H&N Cancers …
• Are clinically distinct from HPV-negative cancers.
• Are molecularly distinct from HPV-negative cancers.
• Have risk factor profiles that are distinct from HPV-negative cancers.
• Have a better prognosis that HPV-negative cancers.
• Are increasing in incidence while HPV-negative cancers are
decreasing.

56. Future
• In much the same way we differentiate ER
positive from ER-negative breast cancer, one day
soon we may use significantly different
treatments for patients with HPV-positive as
compared with HPV-negative HNC.
• Within the next few years, we will likely use
tumor HPV status not only to aid in prognostic
discussions with patients but also to aid in the
selection of treatment approaches

57. Thank You…..