Human papillomavirus and other biomarkers in neck masses of unknown origin and in head and neck cancer

Background. Human papillomavirus (HPV) is, in addition to smoking and alcohol, a risk factor for developing oropharyngeal squamous cell carcinoma (OPSCC), and more specifically tonsillarand base of tongue squamous cell carcinoma (TSCC & BOTSCC respectively). Interestingly, HPV-positive (HPV+) TSCC/BOTSCC has a remarkably better clinical outcome than HPV-negative (HPV-) TSCC/BOTSCC and head and neck cancer in general. However, the role of HPV and other biomarkers in cancer of unknown primary in the head and neck region (HNCUP), i.e. where only a lymph node metastasis and no primary tumour is found, is not well understood. Moreover, the genetic landscape of HPV-positive HNCUP and the prognostic implications of certain mutations in TSCC/BOTSCC has not been studied extensively. Furthermore, using fine-needle aspiration cytology (FNAC) from neck masses for HPV-detection and potentially for predicting an HPV-positive TSCC/BOTSCC as the final diagnosis would be highly clinically useful, but has not been studied prospectively in a cohort consisting of both malignant and benign neck masses. Aims. To investigate HPV DNA and mRNA and other prognostic biomarkers (p16, p53, CD8+ tumour infiltrating lymphocytes (TILs), HLA Class I expression) in HNCUP in relation to clinical outcome. Moreover, to study mutations in HPV+ HNCUP and TSCC/BOTSCC in relation to prognosis and to analyse whether HPV-detection in FNAC from neck masses is reliable and if a finding of HPV could predict an HPV+ TSCC/BOTSCC as the final diagnosis. Results. In Paper I, we show that HPV is a favourable prognostic factor in HNCUP, and in Paper II, we validate this finding in a separate cohort (3-year overall survival 86% vs. 54% for HPV+ and HPVHNCUP respectively, in the combined cohorts). In Paper II, we also demonstrate that HPV mRNA is expressed in the vast majority of HPV DNA+ HNCUP. Moreover, in Paper I we find that high p53-expression correlates to a poor prognosis, and in Paper II that a low number of CD8+ TILs are potentially related to a poor outcome, while HLA Class I expression does not appear to be a prognostic factor in HNCUP. In Paper III, we show that TP53, CDKN2A and PIK3CA are the most commonly mutated genes in HPV+ HNCUP, and that having a mutation in FGFR3 correlated to a poor prognosis in HPV+ TSCC/BOTSCC. In Paper IV, we demonstrate that HPV DNA detection in FNAC from neck masses of unknown origin is reliable and could be used prospectively to predict an HPV+ TSCC/BOTSCC as the final diagnosis. HPV DNA was not found in malignant conditions other than HPV+ TSCC/BOTSCC or in any benign conditions, including branchial cleft cysts. Conclusions. HPV appears to have a similar causative and prognostic role in HNCUP as in TSCC/BOTSCC. Investigation of HPV-status should therefore be part of the diagnostic work-up of an HNCUP. Examination of HPV DNA-status using FNAC is useful in the clinical investigation of patients with neck masses of unknown origins, including patients eventually diagnosed with HNCUP or TSCC/BOTSCC. LIST OF SCIENTIFIC PAPERS INCLUDED IN THE THESIS I. Sivars L, Näsman A, Tertipis N, Vlastos A, Ramqvist T, Dalianis T, MunckWikland E, Nordemar S. Human papillomavirus and p53 expression in cancer of unknown primary in the head and neck region in relation to clinical outcome. Cancer Med. 2014 Apr;3(2):376-84. II. Sivars L, Landin D, Grün N, Vlastos A, Marklund L, Nordemar S, Ramqvist T, Munck-Wikland E, Näsman A, Dalianis T. Validation of human papillomavirus as a favourable prognostic marker and analysis of CD8+ tumour-infiltrating lymphocytes and other biomarkers in cancer of unknown primary in the head and neck region. Anticancer Res. 2017 Feb;37(2):665673. III. Bersani C, Sivars L, Haeggblom L, DiLorenzo S, Mints M, Ährlund-Richter A, Tertipis N, Munck-Wikland E, Näsman A, Ramqvist T, Dalianis T. Targeted sequencing of tonsillar and base of tongue cancer and human papillomavirus positive unknown primary of the head and neck reveals prognostic effects of mutated FGFR3. Oncotarget. 2017 May 23;8(21):35339-35350. IV. Sivars L*, Landin D*, Haeggblom L, Tertipis N, Grün N, Bersani C, Marklund L, Ghaderi M, Näsman A, Ramqvist T, Nordfors C*, MunckWikland E*, Tani E*, Dalianis T*. Human papillomavirus DNA detection in fine-needle aspirates as indicator of human papillomavirus-positive oropharyngeal squamous cell carcinoma: A prospective study. Head Neck. 2017 Mar;39(3):419-426. *Contributed equally RELATED PUBLICATIONS, NOT INCLUDED IN THE THESIS I. Nordfors C, Grün N, Tertipis N, Ährlund-Richter A, Haeggblom L, Sivars L, Du J, Nyberg T, Marklund L, Munck-Wikland E, Näsman A, Ramqvist T, Dalianis T. CD8+ and CD4+ tumour infiltrating lymphocytes in relation to human papillomavirus status and clinical outcome in tonsillar and base of tongue squamous cell carcinoma. Eur J Cancer. 2013 Jul;49(11):2522-30. II. Nordfors C, Grün N, Haeggblom L, Tertipis N, Sivars L, Mattebo M, Larsson M, Häggström-Nordin E, Tydén T, Ramqvist T, Dalianis T. Oral human papillomavirus prevalence in high school students of one municipality in Sweden. Scand J Infect Dis. 2013 Nov;45(11):878-81. III. Sivars L, Tertipis N, Näsman A, Ramqvist T, Dalianis T (2014) A simple approach for determining presence of HPV DNA from slides previously stained for P16ink4a. J Cytol Histol S4:014. IV. Tertipis N, Hammar U, Näsman A, Vlastos A, Nordfors C, Grün N, Ährlund-Richter A, Sivars L, Haeggblom L, Marklund L, Hammarstedt-Nordenvall L, Chaturvedi AK, Munck-Wikland E, Ramqvist T, Bottai M, Dalianis T. A model for predicting clinical outcome in patients with human papillomavirus-positive tonsillar and base of tongue cancer. Eur J Cancer. 2015 Aug;51(12):1580-7. V. Sivars L, Tani E, Näsman A, Ramqvist T, Munck-Wikland E, Dalianis T. Human papillomavirus as a diagnostic and prognostic tool in cancer of unknown primary in the head and Neck region. Anticancer Res. 2016 Feb;36(2):487-93. (Review) VI. Sivars L, Bersani C, Grün N, Ramqvist T, Munck-Wikland E, Von Buchwald C, Dalianis T. Human papillomavirus is a favourable prognostic factor in cancer of unknown primary in the head and neck region and in hypopharyngeal cancer. Mol Clin Oncol. 2016 Dec;5(6):671-674. (Review) VII. Bersani C, Mints M, Tertipis N, Haeggblom L, Sivars L, ÄhrlundRichter A, Vlastos A, Nordfors N, Grün N, Munck-Wikland E, Näsman A, Ramqvist T, Dalianis T. A model using four concomitant biomarkers for predicting outcome in patients with human papillomavirus positive tonsillar and base of tongue squamous cell carcinoma. Oral Oncol. 2017 May;68:53-59 VIII. Sivars L, Landin D, Rizzo M, Haeggblom L, Bersani C, MunckWikland E, Dalianis T, Näsman A, Marklund L. Presence of Human papillomavirus (HPV) in branchial cleft cysts – a way to distinguish branchial cleft cysts from cystic metastases? (Submitted)