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1 William C. Faquin, MD, PhD Professor of Pathology Harvard Medical School Director of Head and Neck Pathology Massachusetts Eye and Ear Massachusetts General Hospital FNA OF SQUAMOUS CYSTS OF THE HEAD AND NECK: HPV AND MORE Notice of Faculty Disclosures No disclosures. WC Faquin Case History A 40 year old male with a 2.0 cm neck nodule (Level II). No significant past medical history, and an ENT exam was unremarkable. An FNA was performed. 1

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3 Cytologic Diagnosis: Satisfactory for Evaluation Positive for Malignant Cells Metastatic non-keratinizing squamous cell carcinoma Optional ancillary testing on cell block to confirm squamous cell carcinoma: P63, p40, Keratin 5/6 HPV Testing Is Indicated? True False HPV Testing on FNA: Using a sample of the liquid based preparation, Roche cobas 4800 HR-HPV analysis (PCR-based) was performed. Test result: Positive for HPV type 16 3

4 Report Addendum: A. LEFT NECK FNA: HPV TEST Positive for human papillomavirus type 16 by Roche cobas 4800 HR-HPV analysis. Negative for human papillomavirus types 18, and the "Other high risk" probe set (Includes 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68) by Roche cobas 4800 HR-HPV analysis. Clinical correlation is advised. The accuracy and precision of this test has been verified in the Cytopathology laboratory of the Massachusetts General Hospital. This test has not been cleared or approved by the U.S. Food and Drug Administration (FDA). ***Electronically Signed Out By: XXX CT (ASCP) MB*** Clinical Follow-up: The patient was subsequently found to have a PETpositive tonsillar mass A tonsillectomy was performed. The patient was treated with high dose chemo/xrt HPV-Related Squamous Cell Carcinoma of the Tonsil Background to HPV-Positive Head and Neck Cancer 4

5 Two different pathways to HN cancer: tobacco-associated vs. HPV-related HPV Epidemic in HNSCC HPV-Associated Head and Neck Cancer: A Virus-Related Cancer Epidemic Reflex testing for HR-HPV is indicated for certain HN cancers: Diagnosis Prognosis Guide Management Guidelines are needed to establish: When should reflex testing be performed? Which testing method(s) should be used? How should HPV testing be applied to Cytology? THE HPV-HNSCC EPIDEMIC 225% increase in HPV-positive SCC vs 50% decrease in HPV-negative SCC 15 Chaturvedi, SEER data from

6 Incidence of OPSCC in the USA: Has surpassed cervical carcinoma 16 Chaturvedi, SEER data from Worldwide Epidemiology Chaturvedi et al. J Clin Oncol 2013;31: countries in: -Asia, Australia, Europe, North, South, and Central America - Increased incidence of OPC in 9 countries but not in OCC: - Australia, Brazil, Canada, Denmark, Japan, Netherlands, Slovakia, USA, UK - Increase almost exclusively in economically developed countries - Related to sexual behaviors - Findings supported by global studies on HPV in OPSCC tumors Clinical presentation of HPV-positive HNSCC is different than smoking-related cancer This pertains especially to the oropharynx More likely to be younger, male, married, and college educated >3:1-8:1 M:F Typically lack a significant history of tobacco or alcohol abuse. Sexual risk factors for oral or genital HPV exposure. Low T and high N stage tumors. 6

7 Nodal Metastases in HPV-positive OPC 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. Nodal metastases are found at presentation in approx 80-85% of all HPV-positive OPSCC. FNA is a key method used to detect these metastatic cancers. Survival in HPV(+) OPSCC Retrospective analyses of clinical trials suggest that there is a survival benefit in HPV(+) OPSCC. The most comprehensive meta-analysis to date, reports a 53% better overall and 74% better disease-specific survival for HPV(+) OPSCC There is still a subset of patients who have aggressive disease Smokers with HPV+ OPSCC have intermediate to poor prognosis Clinical Trials for HPV-Positive OPSCC Clinical Trials and Treatment: De-Escalation Modified Doses Targeted Therapies Induction Approaches 7

8 Human Papillomavirus Small, non-enveloped, double-stranded DNA viruses that infect squamous (and other) epithelia. Approximately 200 HPV types Classified into two groups. o Mucosal (α) o Cutaneous (β,γ,μ,ν) Classification as low (HPV 6,11) or high risk (HPV16, 18, 51, 53, others) based on risk of malignant progression. HPV16 is the most common type associated with HN Cancer HPV expresses two oncoproteins: E6 and E7 The process of malignant transformation arises from the continued function of the E6 and E7 viral oncoproteins. E6 and E7 target several critical cellular pathways, leading to deregulation of proliferation and evasion of apoptosis. HPV E7 inhibits the retinoblastoma tumor suppressor protein (prb) and targets it for degradation allowing proliferation and resulting in high p16 expression levels. HPV E6 inactivates the p53 tumor suppressor, preventing cell death thru apoptosis. Pathology of HPV-Positive Oropharyngeal Carcinomas 8

9 Role of HR-HPV in Head and Neck Cancer at Various Sites Association between HR-HPV and cancer at various HN sites: Oropharynx: 80-90% Sinonasal Cavity: 20-25% Oral Cavity: 3-6% Larynx: <5% Other HN sites: e.g. Periocular, Nasopharynx Role of HR-HPV in HN Cancer The oropharynx is the only HN site where there is strong evidence-based information linking HPV-positivity and improved outcome. OROPHARYNGEAL CARCINOMA AND HPV Palatine Tonsils Base of Tongue 9

10 Oropharynx at Risk for HPV Palatine tonsils and base of tongue (lingual tonsil) -/+ -/+ OROPHARYNGEAL CARCINOMA Keratinizing SCC Specialized Crypt Epithelium HPV in Oropharyngeal SCC Non-keratinizing or partially keratinizing Basaloid appearance 90-95% are due to HPV type 16 Small subset due to HPV 18 and other HR- HPV types (31, 33, 53 etc) 10

11 HPV-Positive Non-Keratinizing SCC of the Oropharynx Subepithelial Cancer Lobular growth but invasive HPV-Positive Non-Keratinizing SCC of the Oropharynx 32 How does this apply to FNA? 11

12 HPV-Positive Oropharyngeal SCC: Often first detected and diagnosed by FNA! Nodal metastases occur in approx 80-85% of all HPV-positive OPSCC Ancillary Markers for SCC If you are not sure if it is squamous, use IHC on a cell block. SCC is positive for: p63, p40, keratin 5/6, Ki-67 FNA of HPV+ Oropharyngeal SCC: Basaloid Features 12

13 FNA of HPV-Positive Oropharyngeal SCC 37 FNA Pitfall: Many HPV+ SCC Metastases are Cystic 38 Resemblance of HPV- Related SCC to crypt lymphoepithelium Benign SCC 13

14 HPV in Oropharyngeal SCC Should not be considered poorly differentiated do NOT grade. Distinct from basaloid SCC Preferred terms: HPV-positive or p16- positive SCC Role of HR-HPV in HN Cancer The oropharynx is the only HN site where HPV-positivity is linked to improved outcome. HPV in Oral Cavity SCC Ukpo et al. Histopathol 2012; 60:982. Lopes et al. Oral Oncol 2011; 47: 698. Bishop et al. Am J Surg Pathol 2012; 36:1874. HR-HPV DNA in 5-50% (average 33%) DNA PCR and ISH testing No survival benefit for patients with HPV DNA Transcriptionally-active HPV uncommon (3-5%) No clear association with morphology or patient outcome Same is true for the larynx and hypopharynx 14

15 FNA of Nasopharyngeal Carcinoma: Usually EBV (EBER) Positive Nasopharyngeal Carcinoma: Non-Keratinizing Type HPV in Nasopharyngeal SCC Lo et al. Laryngoscope 2010; 120 S4: S185 Maxwell et al. Head Neck 2010; 32: 562 Robinson et al. Inf Agents Cancer 2013; 8: 30 WHO Nonkeratinizing Type Strongly related to EBV HPV+: Transcriptionally-active HPV found in some EBVcases 7% of all NPC; 39% of EBV- cases No mixed EBV/HPV infections p16 correlates with HPV+/EBV- Worse prognosis than EBV+ cases 15

16 Should we do reflex testing for HR- HPV in HN SCC??? YES!!! Why Should We Test for HR-HPV in HNSCC? Improved prognosis among many patients Identify primary site of metastatic SCC (CUP) Distinguish metastatic SCC from branchial cleft cyst or other benign HN cysts Distinguish HPV- from EBV-related carcinomas Determine patient eligibility for clinical trials/de-escalation therapy Head and Neck Squamous Cell Carcinoma When should testing for HR-HPV be performed, and which tests should be used? 16

17 The CAP EBG HPV Testing Committee was Formed to Address These Questions CAP EBG HPV Testing Committee CAP EBG HPV Testing Committee 14 Draft Recommendations for HPV Testing in Head and Neck Cancer 51 17

18 Draft Recommendations for HPV Testing in Head and Neck Cancer General Overview: The tumors of all patients presenting with oropharyngeal SCC should be tested for HR-HPV Neck nodal tissue from all patients with metastatic SCC of unknown primary should be tested for HR- HPV Staining with p16 can be used as the sole initial screening method but confirmatory testing may be necessary in selected cases HPV Testing of FNA specimens is recommended Methods for determining HR-HPV status in HNSCC IHC for p16 Reduced specificity, esp outside OP PCR for HPV DNA High sensitivity but low specificity ISH for HPV DNA High specificity; reduced sensitivity at low viral load RT-PCR E6/E7 mrna Needs fresh frozen tissue ISH for HPV RNA Reduced sensitivity at low viral load IHC for E6/E7 Low sensitivity/poor performance Cytology Test Platforms Validation studies needed; automated OROPHARYNGEAL CARCINOMA AND HPV: Common algorithm was p16 IHC followed by confirmation with ISH or PCR using HPV 16 HR Cocktail P16 IHC ISH HPV16 Cocktail Must be nuclear & cytoplasmic in >70% of tumor cells Highly sensitive but low specificity outside of oropharynx May be very focal nuclear staining Low sensitivity but high specificity 18

19 Is there a role for HR-HPV testing in FNA specimens? HR-HPV in FNAs of HNSCC Cell blocks can be used Caveats for p16 and cell blocks: P16 alone restricted to certain conditions for FNA of CUP Criteria for percentage of stained cells less defined (Jalaly et al, 2015) Branchial cleft cysts can be p16 positive FNA of cervical nodes with met HNSCC; Usually non-keratinizing cytology P16-pos NK SCC P16-neg keratinizing SCC Contributed by Dr. Mary Schwartz 19

20 Caution: p16-positive Branchial Cleft Cyst HR-HPV in FNAs of HNSCC Liquid-phase testing: Advantages over cell block (FFPE) Objective result with clear-cut scoring Can be automated Several have already been validated:» Hybrid Capture II» CervistaTM HPV HR» CervistaTM HPV 16/18» Roche cobas HPV test» APTIMA HPV Assay Clinical Information: A 63 year old male with prior history of OP SCC and cervical LN metastasis presents 4 years later with a 1.5 cm left upper lobe lung nodule. FNA performed. Operative procedure: Lung wedge biopsy 20

21 FNA of Metastatic HPV+ OP SCC to Cervical Lymph Node FNA of Lung Mass HPV Testing Is Indicated True False 21

22 HPV Testing by PCR: Using a sample of the FNA, Roche cobas 4800 HR-HPV analysis (PCR-based) was performed. Test result: Positive for HPV type 16 Histologic Diagnosis: Metastatic HPV-positive OP SCC to lung LUNG WEDGE RESECTION 66 22

23 LUNG WEDGE RESECTION 67 P16 IHC on Lung Wedge Resection 68 HPV Testing For Selected Cases of Metastatic Disease **Caution is warranted when using HPV testing outside of the oropharynx or Level II-III lymph nodes **In selected cases, HPV testing can be useful for diagnostic purposes of metastatic disease to distant sites 23

24 Differential Diagnosis of Squamous Cysts of the Head and Neck Squamous Cysts of Head and Neck: Epidermal inclusion cyst Branchial cleft cyst Dermoid cyst PMX Thyroglossal duct cyst Pilomatrixoma Cystic squamous cell carcinoma FNA of Cystic Squamous Lesions of the Head and Neck FNA of any cystic squamous lesion of the neck in a patient over 35 years old should be evaluated with caution! Demonstration of HR-HPV can confirm the dx of SCC and identify the primary site as the oropharynx. Testing for EBV can also be useful in some cases to identify a CUP as nasopharyngeal carcinoma. Recurring Problem in the FNA Evaluation of Head and Neck Squamous Cysts: Branchial cleft cyst vs. Well differentiated squamous cell carcinoma 24

25 Branchial Cleft Cyst Usually present in young adults Anterolateral neck along SCM muscle near bifurcation of carotid artery 1 st, 2 nd, and 3rd branchial cleft derivatives, but most are from the 2 nd branchial cleft Non-tender fluctuant mass Can have squamous or respiratory epithelium Branchial Cleft Cyst Cytologic Features: Intermediate and superficial squamous cells Anucleate squames Keratin debris Scant lymphocytes and histiocytes If inflamed, keratinization and variable atypia Branchial Cleft Cyst: Mostly Anucleate Cells 25

26 Branchial Cleft Cyst: Bland Pyknotic and Anucleate Cells Pap Stain Diff-Quik Stain Inflamed Branchial Cleft Cyst: Cytologic atypia How do we distinguish this from well differentiated squamous cell carcinoma? 26

27 Squamous Cell Carcinoma: Mild to Severe Atypia Squamous Cell Carcinoma: Moderate Nuclear Pleomorphism Squamous Cell Carcinoma: High N/C Ratio Cells 27

28 Branchial Cleft Cyst vs. WD SCC? Branchial Cleft Cyst Squamous Cell Carcinoma Well Differentiated Squamous Cell Carcinoma Immunohistochemical Markers for Branchial Cleft Cyst vs Cystic WD SCC P53 positivity favors SCC P16 positivity is NOT useful GLUT-1 positivity favors SCC GLUT-1 SCC Branchial Cleft Cyst 28

29 SUMMARY: General Exercise caution with FNA of cystic squamous lesions: Obtain an adequate sample Aspirate any residual solid mass Beware especially in middle-age to older individuals Use ancillary markers and testing for HR-HPV and EBER SUMMARY: HPV HPV-positive HNSCC represents a distinct disease from traditional smoking-related HNSCC. Patients are typically male, younger, non-drinkers and non-smokers with risk factors associated with sexual exposure to the HPV virus. FNA will often detect the cancers as CUP in cervical LNs Reflex testing for HR-HPV is needed for cytologic specimens Many testing options including p16, PCR-based, ISH Thank You! 29