REVIEW ARTICLE
HPV-related Oropharyngeal Carcinoma: A Review of Clinical
and Pathologic Features With Emphasis on Updates in
Clinical and Pathologic Staging
Lisa Buckley, MBBS,* Louise Jackett, MBBS,†‡
Jonathan Clark, MBBS, MD,§∥¶ and Ruta Gupta, MBBS, MD†§
Abstract: There has been a sharp increase in the incidence of the
human papilloma virus–related oropharyngeal squamous cell car-
cinoma, partly due to the increasingly widespread awareness and
recognition of this entity. This review assimilates the recent histo-
pathologic classifications, staging systems, rapidly expanding
research base and developments in management of human papil-
loma virus–related oropharyngeal squamous cell carcinoma and
summarizes their implications for routine diagnostic practice. Dif-
ferential diagnoses and their cytologic appearances are detailed and
the utility of p16 staining and other immunohistochemistry testing is
discussed.
Key Words: human papilloma virus, oropharyngeal squamous cell
carcinoma, pathology, staging, differential diagnoses
(Adv Anat Pathol 2018;25:180–188)
T he increasing incidence of human papilloma virus
(HPV)–related oropharyngeal squamous cell carcinoma
(OPSCC) has triggered a wave of research and analysis of its
histologic appearance, diagnosis, management and out-
comes. HPV-related OPSCC (OPSCC-HPV) has a markedly
different disease profile to HPV-negative squamous cell
carcinoma (SCC), and occurs in younger patients without
traditional risk factors. OPSCC-HPV usually has a good
prognosis despite advanced nodal disease at presentation. It
is included as a specific disease entity in the fourth edition of
the World Health Organization (WHO) Classification of
Head and Neck Tumors,1 and is recognized in a separate
staging chapter in the eighth edition of the American Joint
Commission on Cancer Staging Manual.2
ANATOMY AND HISTOLOGY
OPSCC-HPV predominantly arises in the epithelium-
lined crypts of the lingual or palatine tonsils, but can occur
in any part of the oropharynx. The oropharynx extends
from the soft palate to the hyoid bone (Fig. 1A). This
includes the inferior surface of the soft palate (including the
uvula), the base of tongue (including the lingual tonsils and
vallecula), the lateral pharyngeal wall (including palatine
From the *Liverpool Hospital; †Department of Tissue Pathology and
Diagnostic Oncology, Royal Prince Alfred Hospital; ‡Melanoma
Institute Australia; §Central Clinical School, University of Sydney;
∥Department of Head and Neck Surgery, Chris O’Brien Lifehouse;
and ¶South Western Sydney Clinical School, University of New
South Wales, Sydney, NSW, Austrila.
The authors have no funding or conflicts of interest to disclose.
Reprints: Lisa Buckley, MBBS, PO Box 355, Forestville, NSW 2087,
Australia (e-mail: lisa.buckley15@gmail.com).
All figures can be viewed online in color at www.anatomicpathology.com.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
180 | www.anatomicpathology.com Adv Anat Pathol  Volume 25, Number 3, May 2018
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
tonsils, the tonsillar pillars, and glossotonsillar sulci), and
the posterior pharyngeal wall (Fig. 1B). The oropharynx
drains to upper and midjugular nodes (levels II and III) with
frequent bilateral drainage and may also drain to the retro-
pharyngeal lymph nodes.
The oropharynx is lined by stratified squamous epi-
thelium and the submucosal stroma contains tonsillar-type
lymphoid tissue in most parts. The squamous epithelium
lines the deep invaginating crypts in the tonsillar region and
in these areas the mucosa shows patches of reticulated
sponge-like epithelium. The reticulated epithelium contains
intraepithelial lymphocytes and the basement membrane is
discontinuous. Several lymphatics and small blood vessels
are closely associated with the mucosa (Figs. 2A, B).
The porous nature of the basement membrane of the
reticulated epithelium and the close relationship of the epi-
thelium to the underlying lymphatics in the tonsillar crypts
allows for early nodal metastases without a large invasive
primary tumor.3 Thus, patients frequently present with
advanced nodal disease and a small or unknown primary
tumor. Metastases are often predominantly cystic, and
∼85% of entirely cystic metastatic SCC in the neck nodes are
thought to originate from the oropharynx.4
ETIOLOGY
HPV is a predominantly sexually transmitted, non-
enveloped DNA virus that infects the basal cells of the
epithelium lining the tonsillar crypts, and triggers only a
weak immune response in the tonsillar tissue. The serotype
HPV 16 accounts for 90% of OPSCC-HPV,5 with other
high-risk serotypes being HPV 18, 31, 33, and 35.6 Viral E6
and E7 proteins downregulate p53 and retinoblastoma
proteins (Rb) causing uncontrolled proliferation and inhib-
ition of apoptosis leading to carcinogenesis.7 Degradation of
Rb and p53 proteins by HPV 16 leads to upregulation of
p16INK4a/CDKN2A pathway and thus immunohistochem-
istry (IHC) for p16 can be used as a surrogate marker for
high-risk HPV.
INCIDENCE
The prevalence of OPSCC-HPV varies in different
countries but in the United States it accounts for ∼65% of all
oropharyngeal cancers,8 with an annual incidence of 2.2 and
7.3 per 100,000 per year for females and males,
respectively.9 There has been a dramatic rise in the incidence
of OPSCC-HPV in the past 25 years with a 225% increase in
the incidence from 1998 to 2004.10 Patients with OPSCC-
HPV present at a younger age, often without a smoking/
tobacco history and with higher functional performance
scores.
Adv Anat Pathol  Volume 25, Number 3, May 2018 HPV-related Oropharyngeal Carcinoma

FIGURE 1. A, Sagittal section of the head showing the anatomic location of the nasopharynx (NP), oropharynx (OP), and hypopharynx
(HP). B, The oropharynx including the vallecula (A), palatine tonsils (B) and lingual tonsil (C). C, A macroscopic transoral robotic surgical
specimen showing an ulcerative lesion involving the right tonsil including the tongue base (A), the glossotonsillar sulcus (B), palatine
tonsil (C), soft palate (D), vallecula (E), and posterior pharyngeal wall (F). Please see this image in color online.

PRESENTATION AND DIAGNOSIS high nucleus to cytoplasm ratio and hyperchromatic

The most common presentation is of a patient in their
fifth or sixth decade with painless neck node enlargement.
Fine-needle aspiration of the node frequently forms the first-
line of investigation. The metastatic deposits are often cystic
containing necrotic tumor cells and debris. Thus sampling
from the peripheral cyst wall and solid component, if any, is
essential to obtain adequate material for diagnosis.11
Cytology
The cytology smears generally show cohesive clusters
and nests of ovoid-shaped and spindle-shaped cells with
nuclei.12 Lymphocytes may be seen closely associated with
the tumor nests. Mitoses, apoptoses and necrotic debris are
present (Figs. 3A, B). Keratinization is usually absent, but
when present is located toward the periphery of the
clusters.2
The cytologic appearance may raise the differential
diagnoses of a nasopharyngeal carcinoma, a HPV-negative
OPSCC or a small cell carcinoma (Figs. 3A, B). Obtaining
material for cellblock to facilitate IHC for p16 and squ-
amous markers such as p40 is often essential for an accurate
diagnosis (Figs. 3C, D). IHC for Epstein-Barr virus (EBV)

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. www.anatomicpathology.com | 181
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
Buckley et al
FIGURE 2. A, Normal tonsillar crypt lined by squamous epithelium.
There are several intraepithelial lymphocytes imparting a reticulated
appearance to the mucosa. Several closely associated vascular
channels are also present (hematoxylin and eosin, ×100). B, A line
drawing demonstrating the crypts extending to a variable depth
and the porous basement membrane allowing easy access to the
lymphovascular structures. Please see this image in color online.
and neuroendocrine markers can help exclude nasophar-
yngeal carcinoma and neuroendocrine carcinoma,
respectively.13 Interpretation of p16 in a cellblock currently
lacks standardized criteria and is discussed later.
Radiology
The primary imaging modality for diagnosis and
evaluation of primary tumor size, invasion and nodal spread
is computed tomography with contrast, although magnetic
resonance is also frequently used as it can provide better
definition of extension into the tongue base and para-
pharyngeal space, as long as there is minimal movement
artifact. Positron emission tomography (PET) is indicated
where there is no obvious primary, and is often used for
staging, however the utility of 18F-fluorodeoxyglucose
182 | www.anatomicpathology.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
Adv Anat Pathol  Volume 25, Number 3, May 2018
(FDG) uptake remains contentious. Benign tonsillar tissue
may yield false-positive results due to hypermetabolism of
the tissue, however evaluation of the asymmetry in the FDG
uptake of contralateral tonsillar tissue may be diagnostically
helpful.14 PET scanning is best performed before the biop-
sies to help guide sampling and reduce false-positive results.
Cystic nodal metastasis may not show FDG avidity with
PET, particularly if the solid component is small, and
tumors may remain clinically undetected when the size is
less than the resolution of the current imaging techniques
(Figs. 3E–H).
Tissue Diagnosis
Biopsy of the primary oropharyngeal lesion is per-
formed if the patient presents with an oropharyngeal mass
without nodal metastasis or to confirm the primary site in
the presence of metastases. A core biopsy from the nodal
metastases may be performed to facilitate definitive diag-
nosis at the time of fine-needle aspiration. Excision biopsy of
a cystic neck mass may be required for diagnosis when the
cytology or core is nondiagnostic and no primary site is
evident.
OPSCC-HPV closely resembles the reticulated epi-
thelium of the tonsillar crypts.15 The tumors tend to show a
solid nodular or nested growth pattern. Islands or ribbons of
tumor cells with central necrosis may also be present. Tumor
cells are typically round-shaped, ovoid-shaped or spindle-
shaped cells with indistinct cell borders, hyperchromatic
nuclei, and minimal cytoplasm (Fig. 4A).16 Maturation and
keratinization are often present, but usually focal. In these
cases, the keratinized cells are often present at the periphery
surrounding clusters of proliferating cells demonstrating an
“inside out” pattern of maturation, distinctly reverse from
that observed in other mucosal SCCs of the head and neck
(Fig. 4B).2 Mitoses and apoptotic bodies are easily
identified.
In some instances, excision specimens of OPSCC-HPV
may show what appears to be carcinoma in situ despite
examination through multiple levels (Fig. 3F). IHC for p16
may be useful for identifying small subtle foci of invasion.
Given the porous nature of the oropharyngeal basement
membrane and proximity of superficial lymphatics, OPSCC-
HPV can metastasize without a histologically obvious
invasive component. The category of carcinoma in situ (Tis)
has been omitted from the eighth edition of the AJCC for
OPSCC-HPV in recognition of this phenomenon.2
The relevance of histopathologic grading of OPSCC-
HPV is unclear. The tumors closely resemble the reticulated
epithelium of the tonsillar crypts and most show an indolent
biological course suggesting that these are well differentiated
neoplasms.12 However this may appear counterintuitive to
pathologists given the presence of large number of mitoses,
apoptoses and necrosis. There is no correlation between the
grade of OPSCC-HPV and survival and the fourth edition
of WHO currently recommends against histopathologic
grading of OPSCC-HPV.1 In light of its relatively favorable
clinical behavior, both the AJCC and WHO also discourage
the description of OPSCC-HPV as “poorly differentiated”
tumors. Before the recognition of HPV oncogenesis, these
tumors were historically described as basaloid in appearance
due to the hyperchromatic “blue” appearance of the nuclei
and the relative lack of cytoplasm. However, with the
development in our understanding of the role of HPV and
the biologic course of OPSCC-HPV, the use of this
terminology is strongly discouraged in both cytology and
Adv Anat Pathol  Volume 25, Number 3, May 2018 HPV-related Oropharyngeal Carcinoma

FIGURE 3. Case example of a 49-year-old male who underwent fine-needle aspiration of an enlarged neck node. A, The cellular smears
show cohesive clusters of nonkeratinizing epithelioid cells with ovoid to spindle-shaped nuclei (Papanicolou stain, ×100). B, The tumor cell
population consists of discohesive cells with ovoid nuclei, nuclear overlapping and molding, and minimal or absent cytoplasm (Papanicolou
stain ×400). C, The tumor cells show strong nuclear staining with p40 (p40 immunostain, cellblock, ×200). D, There is strong nuclear and
cytoplasmic staining with p16 (p16 immunostain, cellblock, ×200). E, Positron emission tomography scan showed mildly increased FDG
uptake in both the right and left tonsils and the patient proceeded to bilateral tonsillectomy and neck dissection. F, One tonsil demonstrates
a 4 mm focus of squamous cell carcinoma involving the tonsillar crypt (arrows, hematoxylin and eosin, ×100). Inset: the tumor shows strong
diffuse staining for p16 (p16 immunostain, ×100). G, Cross-section of the excised neck node showed a cystic center with peripheral solid
regions, typical of metastatic oropharyngeal squamous cell carcinoma (gross photograph). H, The lining epithelium of the cystic metastasis
showed thick atypical nonkeratinizing squamous epithelium (hematoxylin and eosin, ×200). Inset: it is not unusual to see thin squamous
epithelium with relatively bland cytologic features (hematoxylin and eosin, ×200). Please see this image in color online.

histology reports. The term “basaloid” SCC is now reserved
for the HPV-negative SCC that is generally seen in the
larynx or the oral cavity. This latter tumor shows a dis-
tinctive histologic appearance described below and has a
poor prognosis.
Lewis and colleagues have demonstrated that the
presence of multinucleation or anaplasia, defined as the
presence of more than 3 tumor cells with multiple nuclei in
any single high-power (×40) field, or the presence of 3 nuclei
with 5 times the size of a lymphocyte nucleus in any high-
power field, are associated with increased risk of recurrence
in OPSCC-HPV.17 However, further data are needed before
these factors are incorporated into a formal grading system
for OPSCC-HPV.
p16
IHC for p16 overexpression is the most commonly
used, cost effective marker for OPSCC-HPV. It has been
shown to be a robust, reproducible surrogate marker for
HPV-mediated carcinogenesis and when compared with
HPV in situ hybridization (ISH) testing it is simpler,
cheaper, and more readily available.18
Block cytoplasmic and nuclear staining of 2 to 3
+intensity in more than 75% of the tumor cells is essential
for a diagnosis of OPSCC-HPV in histopathologic sections
(Fig. 4C).2 Use of these criteria is essential as normal crypts
and the follicular dendritic network of the tonsils often show
cytoplasmic immunostaining with p16 (Fig. 4C, inset)
Evaluation of p16 expression in a fine-needle aspirate cell-
block is more difficult and is generally hampered by the
paucity of the material available for examination, the loss of
architecture and the degenerative changes of the neoplastic
cells. In these instances a lower threshold of block nuclear
and cytoplasmic staining in 10% to 15% of the cells has been
recommended, however this requires validation.19,20 ISH for
integration of HPV DNA can be performed on the cell-
blocks and is more reliable.20
Ascertaining the presence of HPV as a causative factor
is important in patients who present with neck metastases
with an unknown primary. If the metastasis is in level 2 or 3
lymph node, the carcinoma shows overexpression of p16
and the histology is consistent with an OPSCC-HPV
described above, then the nodal disease should be staged as
for OPSCC-HPV. The staging system for OPSCC-HPV
emphasizes the number of involved nodes, rather than
deposit size or extranodal extension, and is different from
that of the staging system recommended for carcinoma of
unknown primary in the eighth edition of AJCC, which

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. www.anatomicpathology.com | 183
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
Buckley et al Adv Anat Pathol  Volume 25, Number 3, May 2018

FIGURE 4. Typical histologic appearance of human papilloma virus (HPV) related oropharyngeal squamous cell carcinoma and HPV
methods. A, The typical tumor has a lobulated growth pattern and is composed of cells with ovoid to elongated, hyperchromatic nuclei,
and scant amphophilic cytoplasm (hematoxylin and eosin, ×100). B, Focal central necrosis may be seen and keratinization is generally
present at the periphery of lobules (inside out pattern) (hematoxylin and eosin, ×200). C, Typical strong nuclear and cytoplasmic staining
(block positivity) with p16 in oropharyngeal squamous cell carcinoma (p16 immunostain, ×100). Inset: patchy cytoplasmic staining of
background normal squamous cells and follicular dendritic cells by p16 is a normal finding (p16 immunostain, ×100). D, In situ
hybridization for high-risk HPV (types 16,18, 31, 33) shows an integrative pattern with distinct blue speckled staining in tumor cell nuclei
(HPV in situ hybridization, ×400). Please see this image in color online.

184 | www.anatomicpathology.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
Adv Anat Pathol  Volume 25, Number 3, May 2018
takes the number of nodes and the presence of extranodal
extension into account. The methods for establishing HPV-
mediated carcinogenesis is not specified in the eighth edition
of AJCC, however, it is important to note that p16INK4 is a
tumor suppressor and overexpression of p16 may occur in
response to other cell cycle regulators. p16 immunostaining
may also be seen in a subset of other tumors of the head and
neck, including high-risk cutaneous SCC, neuroendocrine
carcinoma, and even melanoma. For tumors outside the
oropharynx, p16 positivity does not appear to correlate with
the indolent biology seen in OPSCC-HPV and therefore
does not carry the same prognostic benefits. Thus, HPV
specific testing may be required if the patient does not fit the
demographic profile for OPSCC-HPV and/or an orophar-
yngeal tumor remains elusive after careful biopsy of the
oropharynx, including bilateral tonsillectomies. HPV spe-
cific tests may also be used where p16 staining returns a
suboptimal result but an oropharyngeal primary tumor is
clinically suspected or known.
DNA ISH is available in some laboratories. It is per-
formed on formalin-fixed paraffin-embedded tissue and viral
DNA sequences are identified in the nuclei of tumor cells
(Fig. 4D). When viral copy numbers are low, staining may
be undetected, however advances in amplification have
improved sensitivity, and concordance between p16 and
DNA ISH results are high.21
RNA ISH is a developing diagnostic test that detects
HPV E6/E7 mRNA. It is technically intensive and has been
shown to have higher sensitivity than DNA ISH. It has not
yet been validated on cytology specimens.21,22
Polymerase chain reaction testing for HPV DNA is a
less frequently used diagnostic tool. It has high sensitivity
but is not routinely used in clinical practice due to the
multiple processing stages and technical expertise required
to achieve reliable and reproducible results.
DIFFERENTIAL DIAGNOSES
A tangential section through a crypt or a hyperplastic
reactive germinal center may mimic an OPSCC-HPV
(Fig. 5A). IHC for cytokeratins and demonstration of block
cytoplasmic and nuclear staining with p16 can be helpful in
excluding germinal centers and cross cut crypts in perma-
nent sections. However, this issue can be particularly
problematic on frozen sections and is further confounded by
the freezing, crush, and cutting artifacts. Careful attention
to architectural and morphologic details can be helpful. The
neoplastic crypts generally tend to be expanded and lobular.
The neoplastic nuclei are larger than those of the adjacent
normal crypts and may also appear elongated to spindle
shaped. Punctate necrosis, if present, is also a useful diag-
nostic feature (Fig. 5B).
HPV-negative OPSCC is a more aggressive disease that
arises in the oropharynx or hypopharynx, is seen in elderly
populations and is associated with tobacco and alcohol use.
HPV-negative OPSCC shows a keratinizing pattern with
epithelioid cells with large amounts of cytoplasm, distinct
cell borders.16 Any OPSCC that is negative for p16 should
automatically be included in this category. Response to
treatment is poor as compared with OPSCC-HPV and nodal
metastases are associated with poor prognosis.
Small cell neuroendocrine carcinomas occur rarely in
the oropharynx but small series have been reported.23
Cytologically and histologically, small cell neuroendocrine
carcinomas can closely resemble OPSCC-HPV with round
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
HPV-related Oropharyngeal Carcinoma
to ovoid hyperchromatic nuclei with minimal cytoplasm.
Nuclear streaking, moulding, apoptosis and necrosis are
frequent. Neuroendocrine markers (synaptophysin, chro-
mogranin, CD 56) are positive and there may be an asso-
ciation with HPV.24 Despite the integration of HPV, these
tumors are highly aggressive and have a poor prognosis with
widespread nodal and metastatic disease and may require
chemotherapy specific for neuroendocrine carcinoma.
Large cell neuroendocrine carcinomas (LCNEC) are
traditionally identified as a lung malignancy, however
examples of oropharyngeal LCNEC have been described.25
The cells have large amounts of cytoplasm and large, round
nuclei with vesicular chromatin or prominent nucleoli.
There may be some differentiation with neuroendocrine
features such as rosette formations, palisading, and orga-
noid nesting (Fig. 5C).26 p16 overexpression can be seen,
and specific HPV testing is required in addition to syn-
aptophysin and p63 testing. Oropharyngeal LCNEC is a
highly aggressive disease, similar to other neuroendocrine
carcinomas, even in the event of p16 or HPV positivity.
Nasopharyngeal carcinomas are nonkeratinizing
tumors driven by EBV. Despite close anatomical proximity,
the presence of EBV in oropharyngeal carcinoma is very
rare and testing for EBV in oropharyngeal disease is
unnecessary. However, HPV has been implicated in some
nasopharyngeal carcinomas, and p16 testing can differ-
entiate or exclude an oropharyngeal primary extending to
the nasopharynx.27
HPV-associated adenosquamous carcinoma of the
oropharynx, or “adenosquamous variant” has been descri-
bed in only small series, and shows significantly improved
outcomes compared with HPV-negative adenocarcinoma.
These tumors have areas of glandular differentiation with
ducts lined by cuboidal or pseudostratified columnar cells.
Occasionally mucin production may be seen. Testing should
occur with both p16 and HPV specific testing.28,29
Basaloid SCC is a highly aggressive tumor that is seen
in the larynx, oral cavity and palate of patients with a
smoking and alcohol history and has a markedly poor
prognosis as compared to OPSCC-HPV. Cribriform nests
and lobules of cells with scanty cytoplasm and angulated
hyperchromatic nuclei are separated by strands of basement
membrane-like hyaline material. Occasional keratin pearls
may be present (Fig. 5D). Tumor necrosis and a high
mitotic rate are seen. Both p16 and specific HPV testing are
negative.
TREATMENT
Contemporary approaches to treatment of orophar-
yngeal carcinoma may be summarized into 2 treatment
modalities, primary radiotherapy or surgery. Given that
most patients will present with nodal metastases, radio-
therapy is usually combined with concurrent chemotherapy.
Surgery may be combined with adjuvant radiotherapy and/
or chemotherapy depending on the histopathology.
Advances in functional outcomes have been well docu-
mented following the introduction of transoral laser
microsurgery and transoral robotic surgery compared with
the more traditional approaches such as mandibulotomy.
There are currently many ongoing trials comparing the
various treatment modalities with a primary focus on
treatment deescalation given the good prognosis of OPSCC-
HPV. Current practices vary between institutions and many
treatment regimes continue to be based on HPV negative
www.anatomicpathology.com | 185
Buckley et al Adv Anat Pathol  Volume 25, Number 3, May 2018

FIGURE 5. Mimics of human papilloma virus–related oropharyngeal squamous cell carcinoma. A, Tangentially sectioned crypts may
resemble oropharyngeal squamous cell carcinoma but are differentiated by epithelial cells with small, uniform nuclei and no lobular
expansion of the crypt (hematoxylin and eosin, ×100). B, Intraoperative frozen section shows normal tonsillar parenchyma with an area of
carcinoma and necrosis (hematoxylin and eosin, ×100). Inset: there is lobular expansion of the crypt with central necrosis, and nuclei are
enlarged and pleomorphic (hematoxylin and eosin, ×200). C, Large cell neuroendocrine carcinoma may show similar nuclear features as
human papilloma virus–related oropharyngeal squamous cell carcinoma; however, focal rosette formation is also present (hematoxylin and
eosin, ×200). D, Basaloid squamous cell carcinoma of the maxilla shows lobules of basaloid cells with minimal cytoplasm and hyperchromatic
nuclei, and an associated desmoplastic stroma (haematoxylin and eosin ×100). Inset: basaloid squamous cell carcinoma shows central areas
of necrosis and basement membrane-like matrix production (hematoxylin and eosin, ×200). Please see this image in color online.

186 | www.anatomicpathology.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
Adv Anat Pathol  Volume 25, Number 3, May 2018
disease. More definitive presented by Mirghani et al30 and
An et al31 and specific trial information may be accessed via
the ClinicalTrials.gov website.32
PROGNOSIS
OPSCC-HPV have a good prognosis and are generally
responsive to treatment. Tobacco or smoking history impacts the
prognosis adversely in OPSCC-HPV. Patients with OPSCC-
HPV and a substantial tobacco history are thought to have an
intermediate prognosis between OPSCC-HPV nonsmoking
patients and HPV-negative OPSCC patients.33
Staging Parameters
The eighth edition of the AJCC cancer staging manual
includes, for the first time, a new staging system for OPSCC-
HPV.2 A synoptic reporting protocol checklist that includes
the latest pTNM updates from the eighth edition AJCC
Staging Manual is available from the College of American
Pathologists.34 Data has been incorporated from multi-
institutional studies to reflect the different clinical pre-
sentation and improved outcome survival.33,35 The AJCC
acknowledges that the current staging system is non-
discriminating due to the unique nature of OPSCC-HPV.
The eighth editions AJCC Staging Manual will officially be
implemented from 1 January 2018. In the meantime, the
latest clinical and scientific information from the eighth
edition Manual may be used to guide patient care.36
The clinical nodal staging system has been proposed based
on the data accrued by multiple American and European
institutions (International Collaboration for Oropharyngeal
Cancer Network for Staging—ICON-S) and includes nearly
2000 OPSCC-HPV cases. It is based on the size of the meta-
static deposit with deposits up to 6 cm being included in stage I,
while this was previously considered stage III or IV.
The pathologic staging is informed by the data from
Washington University School of Medicine including 220
patients treated with transoral robotic surgery and neck dis-
section. The staging system is based on the number of
involved nodes rather than the size of the involved nodes,
presence of extranodal extension or the laterality of the
nodes.2,37 The pathologic staging system has several novel
concepts that reflect the indolent biology of OPSCC-HPV.
For instance, the absence of nodal metastases does not confer
a better prognosis as compared with patients with metastases
to less than 4 lymph nodes. Thus both pN0 and pN1 are
included in stage I.2 Also, unlike the clinical dataset, patients
with nodal deposits larger than 60 mm that are surgically
managed show an unusually good prognosis. Thus the cat-
egory pN3 has not been included in the OPSCC-HPV staging
system. However, it is critical to note that the clinical staging
system has been based on a far larger dataset as compared
with the pathologic staging system.
For a tumor to be classified as OPSCC-HPV in the eighth
edition AJCC Staging Manual, p16 and/or HPV testing is
mandatory (chapter 10, “HPV-mediated (p16+) Oropharyngeal
Cancer”). In cases where HPV status is unknown or cannot be
determined by p16 IHC or HPV-ISH testing, these tumors
should be staged as for p16-negative OPSCCs (chapter 11,
“Oropharynx (p16−) and hypopharynx”).2
The AJCC recommends that the registries collect data
on variables such as tumor location, perineural invasion,
number and size of nodes, presence of extranodal extension,
and smoking history to enable further refinement of the
staging categories in the future.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
HPV-related Oropharyngeal Carcinoma
CONCLUSIONS
The recognition of OPSCC-HPV in AJCC staging
models and evidence for improved outcomes reflects the
epidemiological work that has been the primary focus over
recent years. p16 immunostaining should be performed on
all OPSCCs as well as the diagnostic material obtained from
cystic nodal metastases with nonkeratinizing SCC to facili-
tate the detection of OPSCC-HPV. OPSCC-HPV may
metastasize without a histologically identifiable invasive
component and should not be termed as poorly differ-
entiated or “basaloid” carcinomas in light of their indolent
behavior. The research focus is now toward the evaluation
of treatment approaches and the deescalation of multi-
modality treatments.
ACKNOWLEDGMENT
The authors wish to thank Candice Wise for graphic
design assistance.
REFERENCES
1. El-Naggar AK, Chan CJ, Grandis JR, et al. WHO Classi-
fication of Head and Neck Tumours WHO/IARC Classification
of Tumours, Volume 9, 4th ed. IARC: Lyon; 2017.
2. Amin MB, Edge S, Greene F, et al. AJCC Cancer Staging
Manual, 8th ed. Springer: Switzerland; 2017.
3. Howard JD, Chung CH. Biology of human papillomavirus–related
oropharyngeal cancer. Semin Radiat Oncol. 2012;22:187–193.
4. An Y, Park HS, Kelly JR, et al. The prognostic value of
extranodal extension in human papillomavirus-associated
oropharyngeal squamous cell carcinoma. Cancer. 2017;123:
2762–2772.
5. Steinau M, Saraiya M, Goodman MT, et al. Human papilloma-
virus prevalence in oropharyngeal cancer before vaccine introduc-
tion, United States. Emerg infect Dis. 2014;20:822–828.
6. Bishop JA, Lewis JS Jr, Rocco JW, et al. HPV-related
squamous cell carcinoma of the head and neck: an update on
testing in routine pathology practice. Semin Diagn Pathol.
2015;32:344–351.
7. Havre PA, Yuan J, Hedrick L, et al. p53 inactivation by
HPV16 E6 results in increased mutagenesis in human cells.
Cancer Res. 1995;55:4420–4424.
8. Stein AP, Saha S, Kraninger JL, et al. Prevalence of human
papillomavirus in oropharyngeal cancer: a systematic review.
Cancer J. 2015;21:138–146.
9. Chaturvedi AK, Anderson WF, Lortet-Tieulent J, et al.
Worldwide trends in incidence rates for oral cavity and
oropharyngeal cancers. J Clin Oncol. 2013;31:4550–4559.
10. Chaturvedi AK, Engels EA, Pfeiffer RM, et al. Human
papillomavirus and rising oropharyngeal cancer incidence in
the United States. J Clin Oncol. 2011;29:4294–4301.
11. Roy-Chowdhuri S, Krishnamurthy S. The role of cytology in
the era of HPV-related head and neck carcinoma. Semin Diagn
Pathol. 2015;32:250–257.
12. El-Mofty SK. Histopathologic risk factors in oral and
oropharyngeal squamous cell carcinoma variants: an update
with special reference to HPV-related carcinomas. Med Oral
Patol Oral Cir Bucal. 2014;19:e377–e385.
13. Krane JF. Role of cytology in the diagnosis and management of
HPV-associated head and neck carcinoma. Acta Cytol. 2013;57:
117–126.
14. Davison JM, Ozonoff A, Imsande HM, et al. Squamous cell
carcinoma of the palatine tonsils: FDG standardized uptake
value ratio as a biomarker to differentiate tonsillar carcinoma
from physiologic uptake. Radiology. 2010;255:578–585.
15. Isayeva TX, Ragin J, Dai C, et al. The protective effect of p16
(INK4a) in oral cavity carcinomas: p16(Ink4A) dampens tumor
invasion-integrated analysis of expression and kinomics path-
ways. Mod Pathol. 2015;28:631–653.
www.anatomicpathology.com | 187
Buckley et al
16. Chernock RD, El-Mofty SK, Thorstad WL, et al. HPV-related
nonkeratinizing squamous cell carcinoma of the oropharynx:
utility of microscopic features in predicting patient outcome.
Head Neck Pathol. 2009;3:186–194.
17. Lewis JSJ, Scantlebury JB, Luo J, et al. Tumor cell anaplasia
and multinucleation are predictors of disease recurrence in
oropharyngeal squamous cell carcinoma, including among just
the human papillomavirus-related cancers. Am J Surg Pathol.
2012;36:1036–1046.
18. El-Naggar AK, Westra WH. p16 expression as a surrogate marker
for HPV-related oropharyngeal carcinoma: a guide for interpretative
relevance and consistency. Head Neck. 2012;34:459–461.
19. Jalaly JB, Lewis JS Jr, Collins BT, et al. Correlation of p16
immunohistochemistry in FNA biopsies with corresponding
tissue specimens in HPV-related squamous cell carcinomas of
the oropharynx. Cancer Cytopathol. 2015;123:723–731.
20. Xu B, Ghossein R, Lane J, et al. The utility of p16 immunostaining
in fine needle aspiration in p16-positive head and neck squamous cell
carcinoma. Hum Pathol. 2016;54:193–200.
21. Bernadt CT, Collins BT. Fine-needle aspiration biopsy of HPV-
related squamous cell carcinoma of the head and neck: current
ancillary testing methods for determining HPV status. Diagn
Cytopathol. 2017;45:221–229.
22. Rooper LM, Gandhi M, Bishop JA, et al. RNA in-situ
hybridization is a practical and effective method for determin-
ing HPV status of oropharyngeal squamous cell carcinoma
including discordant cases that are p16 positive by immuno-
histochemistry but HPV negative by DNA in-situ hybrid-
ization. Oral Oncol. 2016;55:11–16.
23. Bates T, McQueen A, Iqbal MS, et al. Small cell neuro-
endocrine carcinoma of the oropharynx harbouring oncogenic
HPV-infection. Head Neck Pathol. 2014;8:127–131.
24. Bishop JA, Westra WH. Human papillomavirus-related small cell
carcinoma of the oropharynx. Am J Surg Pathol. 2011;35:1679–1684.
25. Thompson ED, Stelow EB, Mills SE, et al. Large cell neuro-
endocrine carcinoma of the head and neck: a clinicopathologic
series of 10 cases with an emphasis on HPV status. Am J Surg
Pathol. 2016;40:471–478.
26. Fisseler-Eckhoff A, Demes M. Neuroendocrine tumors of the
lung. Cancers. 2012;4:777–798.
27. Stenmark MH, McHugh JB, Schipper M, et al. Nonendemic
HPV-positive nasopharyngeal carcinoma: association with poor
prognosis. Int J Radiat Oncol Biol Phys. 2014;88:580–588.
188 | www.anatomicpathology.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
Adv Anat Pathol  Volume 25, Number 3, May 2018
28. Masand RP, El-Mofty SK, Ma X-J, et al. Adenosquamous
carcinoma of the head and neck: relationship to human
papillomavirus and review of the literature. Head Neck Pathol.
2011;5:108–116.
29. Mehrad M, Trinkaus K, Lewis JS. Adenosquamous carcinoma
of the head and neck: a case-control study with conventional
squamous cell carcinoma. HeadNeck Pathol. 2016;10:486–493.
30. Mirghani H, Amen F, Blanchard P, et al. Treatment de-
escalation in HPV-positive oropharyngeal carcinoma: ongoing
trials, critical issues and perspectives. Int J Cancer. 2015;136:
1494–1503.
31. An Y, Holsinger FC, Husain ZA. De-intensification of
adjuvant therapy in human papillomavirus-associated orophar-
yngeal cancer. Cancers Head Neck. 2016;1:18.
32. US National Institutes of Health. ClinicalTrials.gov. 2017.
Available at: https://clinicaltrialsgov/ct2/home. Accessed July
22, 2017.
33. O’Sullivan B, Huang SH, Su J, et al. Development and
validation of a staging system for HPV-related oropharyngeal
cancer by the International Collaboration on Oropharyngeal
cancer Network for Staging (ICON-S): a multicentre cohort
study. Lancet Oncol. 2016;17:440–451.
34. Seethala RR, B M, Carlson DL, et al. Protocol for the
examination of specimens from patients with cancers of the
pharynx, version Pharynx 4.0.0.0 [Internet] 2017. Available
at: http://www.cap.org/web/home/protocols-and-guidelines/cancer-
reporting-tools/cancer-protocol-templates?_afrLoop=84215875836
193#!%40%40%3F_afrLoop%3D84215875836193%26_adf.ctrl-
state%J;3Dc2l8kxgrz_43. Accessed June 31, 2017
35. Huang SH, Xu W, Waldron J, et al. Refining American Joint
Committee on Cancer/Union for International Cancer Control
TNM Stage and Prognostic Groups for human papillomavirus-
related oropharyngeal carcinomas. J Clin Oncol. 2015;33:
836–845.
36. American Joint Committee on Cancer. Implementation of
AJCC 8th edition cancer staging system. 2017. Available at:
https://cancerstagingorg/About/news/Pages/Implementation-of-
AJCC-8th-Edition-Cancer-Staging-Systemaspx. Accessed July
31, 2017.
37. Lydiatt WM, Patel SG, O’Sullivan B, et al. Head and neck
cancers—major changes in the American Joint Committee on
cancer eighth edition cancer staging manual. CA Cancer J Clin.
2017;67:122–137.