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Joshua D. Hornig, M.D., FRCS(C) Director, Microvascular Surgery & Functional Outcomes Medical University of South Carolina
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HPV Positive and HPV Negative Oropharyngeal Carcinomas
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The rate of oropharyngeal carcinoma is rapidly increasing in North America in the last several decades. This increase seems to be secondary to the increased rate of HPV related orophayrngeal carcinomas and not due to a change in smoking or drinking prevalence.
Interestingly, the clinical presentation between HPV positive and HPV negative oropharyngeal cancers are strikingly different and can lead to a delay in diagnosis if the proper vigilance is not kept. This short article will compare and contrast the typical HPV positive and HPV negative clinical presentation to assist you in providing timely care for these patients.
The typical epidemiological profile of HPV-negative cancer is in the 7th decade of life, male pre-dominance (3:1 male: female ratio), strong association with tobacco and alcohol use, moderate association with poor oral hygiene, and a diet low in fruit and vegetable consumption. In contrast, HPV-positive cancer patients are characterized by a younger age of onset (6th decade of life), male predominance (3:1 male: female ration), strong associations with sexual behaviors, strong association with marijuana use and inconsistent association with tobacco and alcohol use.
HPV positive oropharyngeal cancer patients typically present at a more advanced clinical stage. However, their T stage is usually lower and they are increasingly likely to have nodal metastasis to the cervical lymph node groups compared to HPV-negative oropharyngeal cancers. Interestingly, there are also differences in histological features. HPV-positive cancers have distinct histological features, such as moderate/poor tumor differentiation and non-keratinizing or basaloid pathology.
One of the most striking differences is in the type of lymphadenopathy that develops. While in the majority of cases the HPV-positive and HPV-negative tumors are indistinguishable from each other, there are is much higher preponderance of cystic lymph nodes in patients with HPV-positive cancers. Interestingly, often the FNA of these cystic lesions can be misinterpreted by the cytopathologist as containing benign looking squamous cells. This is particularly important for the Head & Neck Surgeon as this will lead to an erroneous diagnosis of a branchial cleft cyst. The surgeon must remain hyper vigilant in these cases and ensure a thorough upper aerodigestive examination to rule out a primary. Often once the erroneously diagnosed branchial cleft cyst is removed, then the true diagnosis of squamous cell carcinoma is finally discovered.
Clinical Pearl: HPV positive carcinoma will often present with a cystic neck mass that can be misdiagnosed as a benign branchial cleft cyst.
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Table 1: Clinical Comparison of HPV-positive and HPV-negative Oropharyngeal carcinomas
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HPV -
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HPV +
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Age
| 7th decade |
6th decade
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M:F ratio
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3:1
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3:1
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Tobacco Use
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Strong
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Variable
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Alcohol Use
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Strong
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Variable
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Marijuana Use
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Negligible
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Strong
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Oral Hygiene
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Poor
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Unknown
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Fruit/Vegetable Intake
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Poor
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Unknown
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Sexual Activity
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Negligible
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Strong
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Joshua D. Hornig , M.D., FRCS(C)
Associate Professor; Director, Microvascular Surgery & Functional Outcomes
Medical University of South Carolina
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About Dr. Hornig...
Joshua D. Hornig , M.D., FRCS(C)
- Associate Professor
- Director, Microvascular Surgery & Functional Outcomes
M.D.: University of Alberta
Residency: University of Alberta
Fellowship: Medical University of SC
Special interests: Endoscopic thyroid and parathyroid surgery, Robotic thyroid and oral surgery, Facial plastic surgery, Head and neck tumors
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