title: Challenges in establishing the diagnosis of human papillomavirus-related oropharyngeal carcinoma.
abstract: To describe initial presentations and idiosyncrasies in establishing the diagnosis for human papillomavirus-related (HPV(+) ) compared to HPV-unrelated (HPV(-) ) oropharyngeal carcinoma (OPC).
  
  
  
  A single institution retrospective series derived from an institutional prospectively compiled database supplemented by chart review.
  
  
  
  We reviewed consecutive OPC patients referred to an academic tertiary cancer center from 2009 to 2011. HPV status was evaluated by p16 staining. Signs/symptoms and procedures to establish diagnosis were recorded independently by two abstractors blinded to the HPV status during data retrieval. Initial presentations (signs/symptoms), interval, and the procedures to establish the diagnosis were compared between HPV(+) and HPV(-) OPC.
  
  
  
  The most common initial presentation was an asymptomatic nodal mass for HPV(+) patients (n = 208; 69% vs. 29%, P < .001) in contrast to dysphagia/odynophagia for HPV(-) (n = 96; 34% vs. 63%, P < .001). Protracted interval (>12 months) from onset of signs/symptoms to diagnosis was observed in 18 (9%) HPV(+) versus three (3%) HPV(-) patients (P = .058). More HPV(+) patients required repeated (≥2) biopsy procedures (56% vs. 10%, P < .001). Misattribution to other disease occurred in eight (4%) HPV(+) patients (seven were mistaken as having a "branchial cleft cyst" when there were cystic lymph nodes and one as having a "lymphoma") compared to none in HPV(-) .
  
  
  
  About two-thirds of HPV(+) patients present with an asymptomatic neck mass and often require multiple biopsy procedures to establish the diagnosis. Idiosyncrasies in appreciating the diagnostic setting (cystic lymph node, misattribution to other entities, or submucosal location of the tumor) or patient-related factors could delay the diagnosis of HPV(+) OPC.
  
  
  
  4 Laryngoscope, 126:2270-2275, 2016.
authors.affiliation: Department of Radiation Therapy, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Michelle
authors.initials: M
authors.lastname: Truong Lam
authors.affiliation: Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.|Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Brian
authors.initials: B
authors.lastname: O'Sullivan
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Patrick
authors.initials: P
authors.lastname: Gullane
authors.affiliation: Department of Radiation Therapy, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada. shaohui.huang@rmp.uhn.on.ca.|Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada. shaohui.huang@rmp.uhn.on.ca.
authors.forename: Shao Hui
authors.initials: SH
authors.lastname: Huang
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D002277:Carcinoma / Q000175:diagnosis* / Q000821:virology; D016208:Databases, Factual; D057210:Delayed Diagnosis; D003951:Diagnostic Errors; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009333:Neck / Q000473:pathology / Q000601:surgery / Q000821:virology; D009959:Oropharyngeal Neoplasms / Q000175:diagnosis* / Q000821:virology; D027383:Papillomaviridae; D030361:Papillomavirus Infections / Q000150:complications* / Q000821:virology; D011446:Prospective Studies; D012189:Retrospective Studies; D063189:Symptom Assessment / Q000379:methods*
keywords: Oropharyngeal carcinoma; clinical presentation; diagnosis; human papillomavirus