The "new" head and neck cancer patient-young, nonsmoker, nondrinker, and HPV positive: evaluation

Abstract

Objective: The near epidemic rise of the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC) presents the practitioner with a "new" head and neck cancer patient, vastly different from those with the traditional risk factors who formed the basis of most practitioners' training experience. Accordingly, a thorough and disease-specific evaluation process is necessitated. This article will review the evaluation of the HPV-related cancer patient, including a review of the HPV-positive oropharyngeal cancer epidemic from the surgeon's perspective, evaluation of the primary lesion, evaluation of the neck mass, and role of imaging, to provide a framework for addressing the challenging questions patients may ask.

Data sources: Available peer-reviewed literature and practice guidelines.

Review methods: Assessment of selected specific topics by authors solicited from the Head and Neck Surgery and Oncology Committee of the American Academy of Otolaryngology-Head and Neck Surgery Foundation and the American Head and Neck Society.

Conclusions and implications for practice: The dramatic rise in OPSSC related to HPV is characterized by a "new" cancer patient who is younger and lacks traditional risk factors. Today's caregiver must be prepared to appropriately evaluate, counsel, and treat these patients with HPV-positive disease with the expectation that traditional treatment algorithms will evolve to maintain or improve current excellent cure rates while lessening treatment related side effects.

Keywords: human papillomavirus (HPV); management neck mass; oropharyngeal cancer; unknown primary.

Figure 1

Positron emission testing with computed tomography (PET/CT) scan demonstrating normal fluorodeoxyglucose (FDG) activity in the lingual tonsils and Waldeyer’s ring (arrowhead). However, there is increased FDG activity in a positive metastatic lymph node (arrow).

Figure 2

Magnetic resonance imaging scan of a patient with an HPV1 oropharyngeal cancer, demonstrating multiple cystic cervical lymph nodes (arrows).

Figure 3

Computed tomography scan of a patient with an HPV− oropharyngeal cancer, demonstrating bilateral cervical adenopathy with necrotic centers (arrows), in contrast to the cystic lymph nodes seen in Figure 2.

Figure 4

Magnetic resonance imaging scan of a patient with an HPV+ lateral tongue cancer (arrow). Although many HPV+ cancers exhibit exophytic, well-defined borders, in this case the tumor demonstrates infiltrative borders and invasion of intrinsic muscles of the tongue.