1. Transoral Robotic Surgery for Oropharyngeal Carcinoma and HPV Viral Load Marc A. Cohen, MD Research Presentation Faculty Advisors: Dr. Weinstein and Dr. O’Malley Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

2. Goals of Study Determine margins of resection, oncologic outcomes, and functional outcomes following primary Transoral Robotic Surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) Determine prevalence of HPV positivity in OPSCC in patients that undergo TORS Determine prevalence of cervical nodal metastases in OPSCC associated with HPV Assess patient outcomes in reference to HPV status Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

3. Introduction: Head and Neck Cancer There are 500,000 new cases of squamous cell carcinoma of the head and neck per year. 1-3 Overall, 5 year survival is less than 50% 1 More than 7,000 in US die from oral cavity / oropharyngeal cancer per year 4 Oncologic outcomes with oropharyngeal squamous cell carcinoma (OPSCC) are reported along a widely divergent range. Currently, most studies with significant power are investigating various chemoradiation protocols in OPSCC. Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

4. Divergent Outcomes with OPSCC I French cohort of stage III and IV OPSCC treated with xrt vs concomitant chemo/xrt (n=226) 5: Denis, F. et al. J Clin Oncol; 22:69-76 2004

5. Divergent Outcomes with OPSCC II ECOG E2399: phase II chemoradiation trial in resectable AJCC III and IV OPSCC (n=69) 6: Cmelak et al. J Clin Oncol; 25:3971-3977 2007

6. Divergent Outcomes with OPSCC III Brazilian cohort of all stage OPSCC treated with chemoradiation (n=361) 7: Pedruzzi et al. Arch Otolaryngol Head Neck Surg 2008;134:1196-1204.

7. HPV association with HNSCC In past 10 years, there has been evidence supporting an association between high risk human papillomavirus (HPV) serotypes and HNSCC. 8-12 High risk serotypes (16,18,33) are conserved and associated with HNSCC as well as cervical and other carcinomas of the anogenital tract. 9

8. HPV associated HNSCC HPV associated HNSCC comprise a distinct clinical entity and pathogenesis More basaloid features 9 Less p53 mutations 13,14 Younger patients without conventional risk factors 8-10 Lifetime number of sexual partners 15 Better prognosis?

9. Prevalence of HPV Data using all molecular techniques yields an association of approximately 9-26% in all cases of HNSCC with oropharyngeal squamous cell carcinoma being associated with 45-70% 9,16-19 Most common serotypes are HPV 16 (84- 94%), 18 (0-3%), 33 (1-27%) 3,16,19-22 Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

10. Prognosis with HPV status There has long been debate about whether HPV positive lesions are associated with better patient prognosis. 23-29 Recent studies have equated HPV positivity with decreased recurrence rates, longer disease free survival, and overall survival. 23-26 Lack of field cancerization, intact apoptotic mechanisms, better immune response to viral specific antigens, reduced 2nd primary tumors 23,30

11. 30: Fakhry et al. J. Natl Cancer Inst. 2008 100:261-269. ECOG chemoradiation outcomes in OP SCC with HPV status

12. Prognosis with HPV positive OP SCC treated with CRT Worden et al., showed that, “induction chemotherapy followed by chemoradiation is an effective treatment for SCC OP,” especially in those that are HPV positive. The authors suggest CRT should be used in SCC OP that are HPV positive with “alternative treatments” reserved for those that do not respond to induction chemotherapy. 31

13. 31: Worden et al. J Clin Oncol; 26:3138-3146 2008 Worden et al

14. Surgical resection of OP lesions and HPV association 32: Licitra et al. J Clin Oncol; 24:5630-5636 2006

15. Surgical resection of OP lesions and HPV viral load 33: Cohen et al. Acta Otolaryngol 2008;128:583-9.

16. Hypotheses TORS will be oncologically sound as the primary therapy in treatment of select oropharyngeal cancers The prevalence of HPV positivity in OP lesions will be 60-70%. There will be no difference in cervical metastases in HPV positive and HPV negative lesions. Patients with both HPV positive and negative lesions will have favorable prognosis when treated with TORS. Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

17. Research Design This clinical study was a retrospective analysis of a previously completed prospective trial evaluating outcomes of TORS for oropharyngeal squamous cell carcinoma. Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

18. Patient Inclusion At least 18 years old Presented with therapeutic approaches for a new squamous cell carcinoma of the oropharynx evaluated on prior endoscopy and with pre-operative computed tomography (CT) and/or magnetic resonance (MR) Lesions that were anatomically amenable to transoral robotic surgery Signed a written informed consent. Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

19. Tumor related contraindications Unresectability of the tumor or involved lymph nodes Invasion of the mandible Bilateral posterior pharyngeal wall involvement (greater than 50%) Carotid artery involvement Tumor fixation to the prevertebral fascia. Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

20. Additional intervention Staged cervical lymphadenectomy was offered to all patients. Adjuvant therapy with radiation and/or chemotherapy as indicated Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

21. Clinical Patient Data Under IRB approved protocol, patient charts were evaluated with respect to gender, age, stage, margins of OP resection, incidence of pN+ in the neck, post operative radiation, swallowing function, and status of disease at follow up. This was done in a blinded fashion, prior to obtaining HPV data. Statistical analysis was performed using SPSS 16.0. Nonparametric statistics were performed using Pearson’s Chi Square and Fisher’s Exact Test (2- sided). Kaplan-Meier analysis was performed for survival with differences assessed by the Log-Rank method.

22. Obtaining HPV data In an arrangement with SensiGen, LLC, (Ann Arbor, Michigan) a biotechnology company focused on molecular diagnosis, we sent paraffin slides of oropharyngeal squamous cell carcinoma specimens for testing using real-time PCR technology. This company has performed HPV assays for other institutions. Identification of the presence of any of the following HPV genotypes: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 73 (for the 16-plex version) in attomoles. Measurement of the level of betaglobin DNA present, in attomoles.

23. Results: Patient Information The first 78 patients with oropharyngeal squamous cell carcinoma assessed 58 patients with minimum 18 months follow up 31 patients with HPV evaluation (no minimum follow up) Mean follow up 21 months (2-41) HPV assessed in 31 patients 71% HPV positive, 95% of these HPV-16% Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

24. Patient Characteristics 18 month follow (n=58) HPV- (n=9)HPV+ (n=22) Mean Age57.455.458.6 Females4 (7%)01 (5%) Follow up25 (18-41)23 (3-36)21 (2-39) Site (tonsil, BOT) 27(47%), 26(45%)4(44%), 3(33%)9(41%), 12(55%) N+ in at- risk necks 44/56 (79%)6/8 (75%)17/23 (74%) ECS20/53 (38%)3/8 (38%)7/22 (32%) AJCC (I-IV) 7(12%), 4(7%), 23(40%), 24(41%) 2(22%), 0, 2(22%), 5(55%) 1(5%), 0, 12(55%), 9(41%)

25. Oncologic Characteristics following TORS 18 month cohort (n=58) HPV- (n=9)HPV+ (n=22) Final margins (close/positive) 5(9%), 0(0%)1(11%), 0(0%)0 (0%), 0 (0%) Local Recurrence1 (2%)01 (5%) Neck Recurrence1 (2%)1 (11%)0 (0%) Distant Metastases4 (7%)0 (0%)1 (5%) Overall survival at 1 and 2-year 55/58 (95%), 33/41 (81%) 7/7 (100%), 5/6 (83%) 21/22 (95%), 11/14 (79%) Disease specific survival 1 and 2-yr 55/56 (98%), 33/36 (92%) 7/7 (100%), 5/5 (100%) 21/21 (100%), 11/12 (92%)

26. 58 patients with 18 months follow up overall survival

27. Comparison of overall survival Worden, F. P. et al. J Clin Oncol; 26:3138-3146 2008

28. 58 patients with 18 month follow up disease-specific survival

29. Comparison of disease-specific survival 31: Worden et al. J Clin Oncol; 26:3138-3146 2008

30. Overall survival with respect to post operative adjuvant regimen P=0.585 (log rank)

31. Overall survival with respect to HPV status P=0.87 (log rank)

32. Comparison of outcomes related to HPV status 30: Fakhry et al. J. Natl Cancer Inst. 2008 100:261-269.31: Worden et al. J Clin Oncol; 26:3138-3146 2008

33. Swallowing function There is a wide range of cited percentage of people after chemoradiation requiring gastrostomy tube. This is cited from 3% to approximately 50%. 5,34,35 Ang et al cited the long term need for gastrostomy tubes in 30% of those with OPSCC treated with chemoradiation. 34 Shiley et al cited the need for gastrostomy tube in 48% of those with OPSCC treated with chemoradiation. 35 In our cohort 91% (50/55) of at risk patients had the gastrostomy tube removed.

34. Conclusions TORS appears to be oncologically sound, with adequate margins of resection as well as satisfactory preliminary overall and disease specific survival. 1 and 2 year oncologic data is equal to or superior to the most recent chemoradiation data. On preliminary assessment, negative HPV status does not appear to be a negative prognostic factor as seen in prior publications. Swallowing function without gastrostomy tube is preserved in more than 90% of patients.

35. Future directions With the cohort created, we can follow out for long term survival data. We are awaiting quantitative data, with which we can further analyze patient outcomes. We can compare outcome data for patients undergoing surgical resection with those undergoing primary chemo/xrt. We can compare function of the those undergoing surgical resection with those undergoing chemo/xrt.

36. 1.Parkin DM, Pisani P, Ferlay J. Global cancer statistics. CA Cancer J Clin 1999; 49:33-64. 2.Parkin DM, Bray F, Ferlay J, Pisaniet P. Estimating the world cancer burden: Globocan 2000. Int J Cancer 2001;94:153-6. 3. Herrero R, Castellsague X, Pawlita M, et al. Human papillomavirus and oral cancer: the International Agency for Research on Cancer multicenter study. J Natl Cancer Inst 2003;95:1772-83. 4. Carvalho AL, Nishimito IN, Califano JA, Kowalski LP. Trends in incidence and prognosis for head and neck cancer in the united states: a site-specific analysis of the SEER database. Int J Cancer 2005;114:806-16. 5.Denis F, Garaud P, Bardet E, et al. Final results of the 94-01 French Head and Neck Oncology and Radiotherapy Group randomized tiral comparing radiotherapy alone with concomitant radiochemotherapy in advanced-stage oropharynx carcinoma. J Clin Oncol 2004;22:69-76. 6. Cmelak AJ, Sigui L, Goldwasser MA, et al. Phase II trial of chemoradiation for organ preservation in resectable stage III or IV squamous cell carcinomas of the larynx or oropharynx: results of Eastern Cooperative Oncology Group Study E2399. J Clin Oncol 2007;25:3971-7. 7.Pedruzzi PA, Kowalski LP, Nishimito IN, et al. Analysis of prognostic factors in patients with oropharyngeal squamous cell carcinoma treated with radiotherapy alone or in combination with systemic chemotherapy. Arch Otolaryngol Head Neck Surg 2008;134:1196-204. 8.Koch WM, Lango M, Sewell D, et al. Head and neck cancer in nonsmokers: a distinct clinical and molecular entity. Laryngoscope 1999;109:1544-51. 9. Gillison ML, Koch WM, Capone RB, et al. Evidence for a causal association between human papillomavirus and a subset of head and neck cancers. J Natl Cancer Inst 2000;92:709-20. 10. van Houten VM, Snijders PJ, van den Brekel MW, et al. Biological evidence that human papillomaviruses are etiologically involved in a subgroup of head and neck squamous cell carcinomas. Int J Cancer 2001;93:232-5. 11.El-Mofty SK, Lu DW. Prevalence of human papillomavirus type 16 DNA in squamous cell carcinoma of the palatine tonsil, and not the oral cavity, in young patients: a distinct clinicopathologic and molecular disease entity. Am J Surg Pathol 2003;27:1463-70. 12.Franceschi S, Munoz N, Snijders PJ. How strong and how wide is the link between HPV and oropharyngeal cancer? Lancet 2000;356:871-2. 13. Blons H, Laurent-Puig P. TP53 and head and neck neoplasms. Hum Mutat 2003; 21:252-7. 14.Westra WH, Taube JM, Poeta ML, et al. Inverse relationship between human papillomavirus-16 infection and disruptive p53 gene mutations in squamous cell carcinoma of the head and neck. Clin Cancer Res 2008;14:366-9. 15.Furniss CS, McClean MD, Smith JF, et al. Human papillomavirus 16 and head and neck squamous cell carcinoma. Int J Cancer 2007;120:2386-92. 16.Gillison ML, Koch WM, Shah KV. Human papillomavirus in head and neck squamous cell carcinoma: are some head and neck cancers a sexually transmitted disease? Curr Opin Oncol 1999;11:191-9. 17.Gillison ML, Shah KV. Human papillomavirus-associated head and neck squamous cell carcinoma: mounting evidence for an etiologic role for human papillomavirus in a subset of head and neck cancers. Curr Opin Oncol 2001;13:183-8. 18.Mork J, Lie AK, Glattre E, et al. Human papillomavirus infection as a risk factor for squamous-cell carcinoma of the head and neck. N Engl J Med 2001;344:1125-31. References

37. 19.Klussmann JP, Weissenborn SJ, Wieland U, et al. Prevalence, distribution, and viral load of human papillomavirus 16 DNA in tonsillar carcinomas. Cancer 2001; 92:2875- 84. 20.Koskinen WJ, Chen RW, Leivo I, et al. Prevalence and physical status of human papillomavirus in squamous cell carcinomas of the head and neck. Int J Cancer 2003;107:401-6. 21.Syrjanen S. HPV infections and tonsillar carcinoma. J Clin Pathol 2004; 57:449-55. 22.Smith EM, Ritchie JM, Summersgill KF, et al. Age, sexual behavior and human papillomavirus infection in oral cavity and oropharyngeal cancers. Int J Cancer 2004;108:766-72. 23.Gillison ML, Koch WM, Capone RB, et al. Evidence for a causal association between human papillomavirus and a subset of head and neck cancer. J Natl Cancer Inst 2000;92:709-720 24.Schwartz SR, Yueh B, McDougall JK, et al. Human papillomavirus infection and survival in oral squamous cell cancer: a population-based study. Otolaryngol Head Neck Surg 2001;125:1-9. 25. Weinberger PM, Yu Z, Haffty BG, et al. Molecular classification identifies a subset of human papillomaviruses--associated oropharyngeal cancers with favorable prognosis. J Clin Oncol 2006;24:736-47. 26.Ragin CC, Taioli E. Survival of squamous cell carcinoma of the head and neck in relation to human papilomavirus infection: review and meta-analysis. Int J Cancer 2007;121:1813-20. 27. Gillison ML. Human papillomavirus-associated head and neck cancer is a distinct epidemiologic, clinical, and molecular entity. Semin Oncol 2004;31:744 28. Clayman GL, Stewart MG, Weber RS, et al. Human papillomavirus in laryngeal and hypopharyngeal carcinomas. Relationship to survival. Arch Otololaryngol Head Neck Surg 1994;120:743-748. 29. Snijders PJ, Scholes AG, Hart CA, et al. Prevalence of mucosotropic human papillomaviruses in squamous-cell carcinoma of the head and neck. Int J Cancer 1996;66:464-9. 30.Fakhry C, Westra WH, Li S, et al. Improved survival of patients with human papillomavirus-positive head and neck squamous cell carcinoma in a prospective clinical trial. J Natl Cancer Inst 2008;100:261-9. 31. Worden FP, Kumar B, Lee SJ, et al. Chemoselection as a strategy for organ preservation in advanced oropharynx cancer: response and survival positively associated with HPV16 copy number. J Clin Onol 2008;26:3138-46. 32.Licitra L, Perrone F, Bossi P, et al. High-risk human papillomavirus affects prognosis affects prognosis in patients with surgically treated oropharyngeal squamous cell carcinoma. J Clin Oncol 2006;24:5630-36. 33.Cohen MA, Basha SR, Reichenbach DK, et al. Increased viral load correlates with improved survival in HPV-16-associated tonsil carcinoma patients. Acta Otolaryngol 2008;128:583-9. 34.Ang KK, Harris H, Garden AS, et al. Concomitant boost radiation plus concurrent cisplatin for advanced head and neck carcinomas: radiation therapy oncology group phase II trial 99-14. J Clin Oncol 2005;23:3008-15. 35.Shiley SG, Hargunani CA, Skoner JM, et al. Swallowing function after chemoradiation for advanced stage oropharyngeal cancer. Otolaryngol Head Neck SUrg 2006;134: References II

38. Thank you Dr. Weinstein Dr. O’Malley TORS research team Department of Otorhinolaryngology: Head and Neck Surgery Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870