Presentation is loading. Please wait.

Presentation is loading. Please wait.

INFECTIOUS DISEASE UPDATE A CPMC Regional CME Event - Microbiome and Emerging Infections Saturday October 19, 2013.

Similar presentations


Presentation on theme: "INFECTIOUS DISEASE UPDATE A CPMC Regional CME Event - Microbiome and Emerging Infections Saturday October 19, 2013."— Presentation transcript:

1 INFECTIOUS DISEASE UPDATE A CPMC Regional CME Event - Microbiome and Emerging Infections Saturday October 19, 2013

2 HPV UPDATE: HEAD AND NECK CARCINOMA Gerald Kangelaris, MD San Francisco Otolaryngology

3 No Financial Disclosures

4 HPV IN THE MEDIA

5

6

7 CONCERNED PATIENTS

8 GOALS Describe HPV associated head & neck cancer Understand at-risk population Appreciate disease presentation Describe basics of treatment and outcomes Improve ability to counsel patients!

9 OUTLINE – HPV IN HEAD & NECK CARCINOMA Virology Epidemiology Carcinogenesis Presentation Treatment & Outcomes Future Directions

10 VIROLOGY HPV - dsDNA virus strains isolated - 15 strains high risk Types 16 & 18 Genitals Anus Oropharynx

11 VIROLOGY

12 VIROLOGY

13 VIROLOGY Head & Neck Sites - Palatine tonsil - Tongue base

14 EPIDEMIOLOGY D’Souza G, Kreimer A, et al. Case-Control Study of Human Papillomavirus and Oropharyngeal Cancer. N Eng J Med 2007, 356:

15 EPIDEMIOLOGY Chaturvedi AK, Engels EA, et al. Human Papillomavirus and Rising Oropharyngeal Cancer Incidence in the United States. J Clin Onc (32): Head and Neck Cancers - Overall decreasing - Oropharynx increasing OP Cancer Epidemic - OP HPV (-) 2.0  1.0 per 100,000 - OP HPV (+) 0.8  2.6 per 100,000

16 EPIDEMIOLOGY Typical Head & Neck Cancer Patient

17 EPIDEMIOLOGY HPV Oropharynx Cancer Patient

18 EPIDEMIOLOGY Gillison ML, Broutian T, et al. Prevalence of Oral HPV Infection in the United States, J Am Med Assoc (7): HPV (+) OPSCC as Sexually Transmitted Disease Presence of HPV in Oral Samples Increases With… Being sexually active Early age sexual activity Increasing # oral sex partners Increasing # vaginal & anal sex partners Male No difference if hetero- or homosexual/bisexual

19 EPIDEMIOLOGY Gillison ML, Broutian T, et al. Prevalence of Oral HPV Infection in the United States, J Am Med Assoc (7): HPV (+) OPSCC as Sexually Transmitted Disease Presence of HPV in Oral Samples…

20 EPIDEMIOLOGY D’Souza G, Kreimer A, et al. Case-Control Study of Human Papillomavirus and Oropharyngeal Cancer. N Eng J Med 2007, 356: HPV (+) OPSCC as Sexually Transmitted Disease HPV (+) vs. HPV (-) OPSCC - Lifetime # Oral Sex Partners 0 partnersOR partnersOR partnersOR Lifetime # Vaginal Sex Partners 0-5 partnersOR partnersOR partnersOR 4.2

21 EPIDEMIOLOGY HPV (+) OPSCCHPV (-) OPSCC Younger (<50 years)Older (>60 years) Never / Mild SmokerHeavy Smoker Mild / Mod AlcoholHeavy Alcohol High Sexual ExposureLow Sexual Exposure Higher Socioeconomic StatusLower Socioeconomic Status Increasing IncidenceDecreasing Incidence

22 CARCINOGENESIS HPV DNA - Two capsid proteins, L1 and L2 - Six non-structural proteins Two viral oncoproteins E6 and E7 E6 and E7 increased activity in high-risk HPV strains

23 CARCINOGENESIS E6 - Degradation of tumor suppressor p53 - Prevents apoptosis E7 - Loss of retinoblastoma (Rb) tumor suppressor - Accumulates p16 - Pushes cells from G1  S phase

24 PRESENTATION Palatine or Lingual Tonsil Location

25 PRESENTATION Symptoms - Painful oral lesion - Dysphagia or odynophagia - Bleeding - Asymmetry - Trismus - Otalgia - Hypoesthesia Asymptomatic!

26 PRESENTATION

27 PRESENTATION

28 PRESENTATION Differential Diagnosis - Infectious - Benign lesions - Neoplastic - Inflammatory

29 PRESENTATION

30 PRESENTATION

31 PRESENTATION High Rates Nodal Metastases Often Tumor Undetectable at Primary Site

32 PRESENTATION Consider HPV(+) OPSCC - Neck mass persisting for 4+ weeks, unresponsive to medical therapy Upper jugular chain Firm, discrete, mobile, nontender May be asymptomatic & non-visible at primary site! - Persistent OP sore throat 4+ weeks, unresponsive to medical therapy Tonsillar asymmetry, otalgia - Advanced disease Dysphagia, pharyngeal bleeding, trismus, voice changes

33 PRESENTATION Workup - FNA neck mass US guidance may improve yield in cystic masses - Imaging Contrast enhanced CT / MRI neck CXR - OHNS evaluation Fiberoptic nasopharyngoscopy Exam under anesthesia, biopsies

34 TREATMENT & OUTCOME Treatment Options - Concurrent chemoradiation - Surgery with adjuvant radiation, +/- chemotherapy

35 TREATMENT & OUTCOME Improved survival in HPV (+) OPSCC tumors Ang KK, Harris J, et al. Human Papillomavirus and Survival of Patients with Oropharyngeal Cancer.N Eng J Med (1):24-35.

36 TREATMENT & OUTCOME Improved survival in HPV (+) OPSCC tumors - 53% better overall survival - 74% better disease specific survival - Improvements in progression free survival, disease free survival O’Rorke MA, Ellison MV, et al. Human Papillomavirus Related Head and Neck Cancer Survival: A Systematic Review and Meta-Analysis. Oral Oncology :

37 TREATMENT & OUTCOME Mechanisms for Improved Outcomes - Lack of field cancerization - Increased sensitivity to radiation therapy Degraded wild-type p53, not mutations - Immune response

38 FUTURE DIRECTIONS De-intensification strategies - Lower dose of radiation therapy - Targeted chemotherapeutics - Surgery with de-escalation of adjuvant treatment

39 FUTURE DIRECTIONS Vaccination

40 FUTURE DIRECTIONS Vaccination

41 FUTURE DIRECTIONS Vaccination


Download ppt "INFECTIOUS DISEASE UPDATE A CPMC Regional CME Event - Microbiome and Emerging Infections Saturday October 19, 2013."

Similar presentations


Ads by Google