Late recurrence of Human Papilloma Virus positive oropharyngeal cancer with very poor prognosis: a caveat in the move to de-escalation


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Helen Joyce1,Hannah Crane2,Fawzia Tahir1,Keith Hunter2,Bernadette Foran1
1Sheffield Teaching Hospitals,2University of Sheffield

Abstract

Background

There is an increased incidence of oropharyngeal carcinoma (OPC) globally secondary to Human Papilloma Virus (HPV) infection. In OPC, HPV is a strong, independent prognostic factor in improved survival. However, we have a cohort of HPV+ OPC patients with poor clinical outcomes.

Method

In Sheffield between 2011-2016, 23 HPV+ OPC patients were identified with poorer than expected outcomes. Demographic and treatment data were gathered for this cohort.

Results

The patients were predominantly men (20/23:87%) between 45-77 years of age. 22 patients were staged as 4a (TNM version 7) and 1 was metastatic at presentation. Excluding the metastatic patient, over half received induction chemotherapy (12/22:55%). The majority received radical chemo-radiotherapy (19/22:86%). Recurrence post treatment occurred between 5-58 months, (median = 14 months). In 10 patients, recurrence was within 12 months, in 12 patients, over 12 months. Site of primary disease or delivery of induction chemotherapy did not influence timing of recurrence. Current smokers were more likely to recur early (<12 months) compared to non-smokers. The most frequent sites of disease recurrence were lung (n=10), bone (n=9), liver (n=6) or within the oropharynx (n=11). In early recurrence, local disease was most prevalent. In later recurrences, bone and lung metastases were most frequently seen. 18/23 (78%) patients died from their disease with a mean time from disease recurrence to death of 9.4 months

Conclusion

A sub-population of HPV+ OPC patients develop unsalvageable disease recurrence despite an expected favourable prognosis. The reasons for this are currently unknown. Further investigation is needed, especially as TNM 8 would have down-staged all the identified patients to stage II or III disease, irrespective of smoking status and in view of the desire within the H&N community to de-intensify radical treatment in HPV+ OPC. There are implications on the length and intensity of follow-up of this patient group.