Determinants of Circulating Tumor HPV DNA in Surgically Treated Oropharyngeal Cancer

Introduction

Human papillomavirus (HPV)-mediated oropharyngeal squamous cell carcinoma (OPSCC) represents a distinct disease entity. Circulating tumor DNA (ctDNA), specifically tumor tissue-modified viral HPV DNA (ctHPVDNA), has emerged as a promising biomarker for monitoring disease status. Understanding the factors influencing its presence and levels is crucial for clinical application.

Study Objective

This research aimed to identify the clinicopathologic variables associated with detectable ctHPVDNA levels both before and after surgery in patients with HPV-mediated OPSCC undergoing primary surgical treatment.

Methods

Design and Participants

A retrospective review and cohort study was conducted at a tertiary academic medical center. It included 104 patients diagnosed with HPV-mediated OPSCC who received upfront surgical intervention between September 2021 and April 2025. Data analysis occurred from September 2025 to December 2025.

Variables Assessed

Researchers examined numerous clinicopathologic factors: demographic characteristics, pathologic Tumor (T) and Nodal (N) stage, overall American Joint Committee on Cancer (AJCC) 8th edition stage, tumor size, surgical margin status, pathologic extranodal extension (pENE), and the presence of lymphovascular invasion (LVI) and perineural invasion (PNI).

Outcome Measures

Preoperative ctHPVDNA levels were analyzed using multivariable negative binomial regression to identify associated factors. The presence of detectable ctHPVDNA after surgery was evaluated using logistic regression.

Results

Patient Characteristics

The cohort comprised 104 patients (mean age 59 ± 10 years; 81% male, 19% female; 97% White, 3% Black). Preoperative ctHPVDNA measurements were available for all 104 patients, while both pre- and postoperative assessments were available for 74 patients.

Preoperative ctHPVDNA Factors

The mean preoperative ctHPVDNA level was 2786 ± 9714 copies/mL. Multivariable analysis revealed that a higher estimated Glomerular Filtration Rate (eGFR; Rate Ratio [RR] = 1.05, 95% CI: 1.01–1.09) and a higher pathologic N stage (RR = 12.30, 95% CI: 2.65–57.5) were independently associated with significantly higher preoperative ctHPVDNA levels. Conversely, the presence of Perineural Invasion (PNI; RR = 0.23, 95% CI: 0.07–0.83) and pathologic Extranodal Extension (pENE; RR = 0.11, 95% CI: 0.04–0.28) were associated with significantly lower preoperative ctHPVDNA levels.

Postoperative ctHPVDNA Detection

Detectable ctHPVDNA after surgery was found in 15 out of 74 patients (20.2%). Factors associated with detectable postoperative ctHPVDNA included: having more than 4 positive lymph nodes (Odds Ratio [OR] = 4.86, 95% CI: 1.39–19.49), higher preoperative ctHPVDNA levels (OR = 1.17 per unit increase, 95% CI: 1.04–1.36), PNI (OR = 2.95, 95% CI: 0.51–15.51), and pENE (OR = 3.38, 95% CI: 0.84–13.29).

Recurrence Outcomes

Recurrence developed in 3 out of the 15 patients (20.0%) with detectable postoperative ctHPVDNA, compared to 8 out of 59 patients (13.6%) with undetectable postoperative ctHPVDNA. Notably, among the patients with undetectable ctHPVDNA after surgery, 4 locoregional recurrences occurred specifically in individuals who declined the recommended adjuvant therapy following guidelines.

Conclusions and Relevance

This cohort study provides significant insights into the biological and clinical factors that influence both the shedding of ctHPVDNA into circulation and its subsequent clearance following surgery. Key modulators include renal function (eGFR), the extent of nodal disease (N stage), and aggressive tumor features like PNI and pENE. The presence of detectable ctHPVDNA after surgery was linked to several high-risk pathologic features and was associated with a higher recurrence rate, highlighting its potential as a biomarker for residual disease and risk stratification. These findings offer valuable guidance for the future integration of ctHPVDNA testing into biomarker-driven clinical trials and treatment decision-making for patients with HPV-mediated OPSCC.

Citation

Birkenbeuel JL, Noel C, Baliga S, Gogineni E, Blakaj DM, Bonomi M, Miller LE, Ozer E, Agrawal A, VanKoevering KK, Kang SY, Seim NB, Old MO, Rocco JW, Haring CT. Determinants of Circulating Tumor HPV DNA in Surgically Treated Oropharyngeal Cancer. JAMA Otolaryngol Head Neck Surg. 2026 Apr 2. PMID: 41926134. URL: https://pubmed.ncbi.nlm.nih.gov/41926134/