Purpose-To prospectively identify markers of response to therapy and outcome in an organsparing trial for advanced oropharyngeal cancer.Patients and Methods-Pretreatment biopsies were examined for expression of epidermal growth factor receptor (EGFR), p16, Bcl-xL, and p53 as well as for p53 mutation. These markers Authors' Disclosures of Potential Conflicts of Interest:Although all authors completed the disclosure declaration, the following author (s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a "U" are those for which no compensation was received; those relationships marked with a "C" were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure were assessed for association with high-risk human papillomavirus (HPV), response to therapy, and survival. Patient variables included smoking history, sex, age, primary site, tumor stage, and nodal status.Results-EGFR expression was inversely associated with response to induction chemotherapy (IC) (P = .01), chemotherapy/radiotherapy (CRT; P = .055), overall survival (OS; P = .001), and diseasespecific survival (DSS; P = .002) and was directly associated with current smoking (P = .04), female sex (P = .053), and lower HPV titer (P = .03). HPV titer was significantly associated with p16 expression (P < .0001); p16 was significantly associated with response to IC (P = .008), CRT (P = . 009), OS (P = .001), and DSS (P = .003). As combined markers, lower HPV titer and high EGFR expression were associated with worse OS (ρ EGFR = 0.008; ρ HPV = 0.03) and DSS (ρ EGFR = 0.01; ρ HPV = 0.016). In 36 of 42 biopsies, p53 was wild-type, and only one HPV-positive tumor had mutant p53. The combination of low p53 and high Bcl-xL expression was associated with poor OS (P = . 005) and DSS (P = .002).Conclusion-Low EGFR and high p16 (or higher HPV titer) expression are markers of good response to organ-sparing therapy and outcome, whereas high EGFR expression, combined low p53/ high Bcl-xL expression, female sex, and smoking are associated with a poor outcome. Smoking cessation and strategies to target EGFR and Bcl-xL are important adjuncts to the treatment of oropharyngeal cancer.

Purpose: The goal of this study was to examine the effect of tobacco use on disease recurrence (local/ regional recurrence, distant metastasis, or second primary) among patients with human papillomavirus (HPV)-positive squamous cell carcinoma of the oropharynx (SCCOP) following a complete response to chemoradiation therapy.Experimental Design: Between 1999 and 2007, 124 patients with advanced SCCOP (86% with stage IV) and adequate tumor tissue for HPV analysis who were enrolled in one of two consecutive University of Michigan treatment protocols were prospectively included in this study. Patients were categorized as never-, former, or current tobacco users. The primary end points were risk of disease recurrence and time to recurrence; secondary end points were disease-specific survival and overall survival.Results: One hundred and two patients (82.3%) had HPV-positive tumors. Over two thirds (68%) of patients with HPV-positive tumors were tobacco users. Among HPV-positive patients, current tobacco users were at significantly higher risk of disease recurrence than never-tobacco users (hazard ratio, 5.2; confidence interval, 1.1-24.4; P = 0.038). Thirty-five percent of HPV-positive ever tobacco users recurred compared with only 6% of HPV-positive never users and 50% of HPV-negative patients. All HPV-negative patients were tobacco users and had significantly shorter times to recurrence (P = 0.002), and had reduced disease-specific survival (P = 0.004) and overall survival (P < 0.001) compared with HPV-positive patients. Compared with HPV-positive never-tobacco users, those with a tobacco history showed a trend for reduced disease-specific survival (P = 0.064) but not overall survival (P = 0.221).Conclusions: Current tobacco users with advanced, HPV-positive SCCOP are at higher risk of disease recurrence compared with never-tobacco users. Clin Cancer Res; 16(4); 1226-35. ©2010 AACR.Head and neck squamous cell carcinoma is the eighth most common malignancy worldwide (1) and represents ∼5% of new cancer diagnoses worldwide annually (2). Over the past three decades, there has been a steady increase in the incidence of tonsil and tongue squamous cell carcinomas (3, 4). Recent evidence has identified high-risk human papillomavirus (HPV), particularly HPV-16, as a causative agent for a subset of head and neck squamous cell carcinomas, accounting for over 50% of squamous cell carcinomas of the oropharynx (SCCOP) in the United States (5-9). HPV-positive SCCOP has a distinct risk factor profile (6) and oncogenic mechanism (10, 11), and likely portends a more favorable prognosis than HPV-negative SCCOP (5,7,(12)(13)(14)(15)(16)(17). Despite its effect on prognosis, tumor HPV status has not yet been used to alter therapeutic management. The most popular current treatment for advanced SCCOP, regardless of HPV status, involves concurrent chemoradiation Authors' Affiliations:

Purpose-To test induction chemotherapy (IC) followed by concurrent chemoradiotherapy (CRT) or surgery/ radiotherapy (RT) for advanced oropharyngeal cancer and to assess the effect of human papilloma virus (HPV) on response and outcome. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTERESTAlthough all authors completed the disclosure declaration, the following author(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a "U" are those for which no compensation was received; those relationships marked with a "C" were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptPatients and Methods-Sixty-six patients (51 male; 15 female) with stage III to IV squamous cell carcinoma of the oropharynx (SCCOP) were treated with one cycle of cisplatin (100 mg/m 2 ) or carboplatin (AUC 6) and with fluorouracil (1,000 mg/m 2 /d for 5 days) to select candidates for CRT. Those achieving a greater than 50% response at the primary tumor received CRT (70 Gy; 35 fractions with concurrent cisplatin 100 mg/m 2 or carboplatin (AUC 6) every 21 days for three cycles). Adjuvant paclitaxel was given to patients who were complete histologic responders. Patients with a response of 50% or less underwent definitive surgery and postoperative radiation. Pretreatment biopsies from 42 patients were tested for high-risk HPV. ; P = .08), and nonsmoking status (P = .037). HPV titer was significantly associated with IC response (P = .001), CRT response (P = .005), OS (P = .007), and DSS (P = .008). ResultsConclusion-Although the numbers in this study are small, IC followed by CRT is an effective treatment for SCCOP, especially in patients with HPV-positive tumors; however, for patients who do not respond to treatment, alternative treatments must be developed.

Human Papillomavirus-16 (HPV-16) associated squamous carcinoma of the oropharynx has a favorable prognosis. Patients with HPV-16 positive cancers have elevated peripheral blood CD8+ T lymphocyte levels that correlate with response to chemotherapy and survival. Tumor infiltrating lymphocyte subpopulations (TIL) were assessed in pretreatment biopsies from a prospective patient cohort to determine if TIL subsets differed by HPV status, clinical factors, patient outcome or correlated with peripheral blood T cell levels. Methods Measured were CD8, CD4, CD68 and Treg (FoxP3) lymphocytes by immunohistochemistry in a tissue microarray created from patients (n=46) with advanced oropharynx cancer. Correlations with peripheral blood levels, HPV status, expression of EGFR, clinical tumor and patient characteristics and outcome were determined. Patients were treated with a single course of neoadjuvant chemotherapy (cisplatin, 5-fluorouracil) followed by either surgery (non-responders) or chemoradiation (cisplatin 100 mg/m2 every 3 weeks × 3; 70 Gy, 2 Gy daily × 7 wks) for responders. Median follow up was 6.6 years. Results HPV-16 positive patients had improved survival (p=0.016). Degree of T cell infiltration did not differ by HPV status but was significantly related to disease specific (DSS) and overall survival (OS). Higher infiltration by CD8, CD4 and FoxP3 subsets was significantly associated with lower T stage and survival. Even after adjusting for HPV status, CD8, FoxP3 and total T cells were significantly associated with DSS (p=0.0236; 0.0040; 0.0197) and OS (p=0.0137; 0.0158; 0.0115, respectively). Less T cell infiltration (p=0.0130) and CD4 cells in particular (p=0.0792) were associated with higher EGFR expression. FoxP3 infiltration correlated significantly and directly with CD4 and CD8 infiltration but not with peripheral blood levels. Conclusions Improved outcomes are associated with increased TILs independent of HPV status and suggest the local immune response to HPV-16 may be related in part to factors such as tumor size, EGFR expression, smoking history, performance status or innate immunity. Assessment of TILs in tissue microarrays is difficult due to small core sample size and variation in tumor representation in tissue cores. Further study of larger numbers of patients and infiltrates in whole tumor sections combined with functional analysis of individual subsets may be necessary to detect differences in local immunity in HPV-16 related cancers.