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Importance Human papillomaviruses are now recognized as an etiologic factor in a growing subset of head and neck cancers and have critical prognostic importance that affects therapeutic decision making. There is no universally accepted gold standard for high-risk HPV (hrHPV) assessment in formalin-fixed, paraffin-embedded (FFPE) tissue specimens, nor is there a clear understanding of the frequency or role of hrHPV in sites other than oropharynx. Objective To determine the optimal assessment of hrHPV in FFPE head and neck tumors. Design Assessment of hrHPV by p16 immunohistochemical staining, in situ hybridization (ISH), and PCR-MassArray (PCR-MA), with L1 PGMY-PCR (PGMY-PCR) and sequencing to resolve method discordance, was applied to 338 FFPE oropharyngeal, nasopharyngeal, and oral cavity tumors. Relative sensitivity and specificity were compared to develop a standard optimal test protocol. Setting Large Midwestern referral center. Participants Tissue specimens from 338 head and neck cancer patients treated during the period 2001-2011 in the departments of Otolaryngology, Radiation Oncology and Medical Oncology. Patients with oropharyngeal and oral cancer were consented for IRB approved study through the Head and Neck SPORE. Tissue blocks from nasopharyngeal cancer patients were retrieved from pathology archives under IRB approval for existing tissue and data. Intervention Patients received standard therapy. Main outcomes and measurements Optimal hrHPV identification, detection, and activity in head and neck cancers. Results Using combined PCR-MA with PGMY-PCR and sequencing for conclusive results, we found PCR-MA to have 99.5% sensitivity and 100% specificity, p16 to have 94.2% sensitivity and 85.5% specificity, and ISH to have 82.9% sensitivity and 81% specificity. Among HPV-positive tumors, HPV16 was most frequently detected, but 10 non-HPV16 types accounted for 6-50% of tumors, depending on site. Overall, 86% of oropharynx, 50% of nasopharynx and 26% of oral cavity tumors were positive for hrHPV. Conclusions and relevance PCR-MA has a low DNA (5ng) requirement effective for testing small tissue samples, high throughput, rapid identification of HPV types, with high sensitivity and specificity. PCR-MA together with p16INK4a provided accurate assessment of HPV presence, type, and activity, and was determined to be the best approach for HPV testing in FFPE head and neck tumors.

BACKGROUND Few human papillomavirus (HPV)-positive head and neck squamous cell carcinoma (HNSCC) cell lines exist. We established UM-SCC-104, a new HPV(+) HNSCC cell linefrom a recurrent oral cavity tumor, and characterized it for the presence of cancer stem cells (CSC). METHODS Tumor cells were tested for biomarker expression by immunohistology and the presence of HPV was assessed by several methods. RESULTS UM-SCC-104 has a unique genotype, contains HPV-16 and expresses E6/E7. Inoculation of (Aldehyde Dehydrogenase) ALDH(+) and ALDH(−) cells in an immunocompromised mouse resulted in tumor growth from the ALDH(+) cells after 6 weeks that recapitulated the histology of the primary, while ALDH(−) cells did not produce tumors. CONCLUSIONS UM-SCC-104, a new HPV-16, CSC-containing HNSCC cell line will aid in studying recurrent HPV(+) tumors. The aggressive nature of this tumor is consistent with high uniform expression of EGFR and a functionally significant proportion of ALDH(+) CSC.

Objectives: With the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System, emergency medicine (EM) residency programs will be required to report residents' progress through the EM milestones. The milestones include five progressively advancing skill levels, with Level 1 defining the skill set of a medical school graduate and Level 5, that of an attending physician. The ACGME stresses that multiple forms of assessment should be used to ensure capture of the multifaceted competencies. The objective of this study was to determine the feasibility and results of programmatic assessment of Level 1 milestones using multisource assessments for incoming EM interns in July. Methods:The study population was interns starting in 2012 and 2013. Interns' Level 1 milestone assessment was done with four distinct methods: 1) the postgraduate orientation assessment (POA) by the Graduate Medical Education Office for all incoming interns (this multistation examination covers nine of the EM milestones and includes standardized patient cases, task completion, and computer-based stations); 2) direct observation of patient encounters by core faculty using a milestones-based clinical skills competency checklist; 3) the global monthly assessment at the end of the intern orientation month that was updated to reflect the EM milestones; and 4) faculty assessment during procedural labs. These occurred during the July orientation month that included the POA, clinical shifts, didactic sessions, and procedure labs.Results: In the POA, interns were competent in 48% to 93% of the milestones assessed. Overall, competency was 70% to 80%, with low scores noted in aseptic technique (patient care Milestone 13 [PC13]) and written and verbal hand-off (interpersonal communications skills [ICS]2). In overall communication, 70% of interns demonstrated competency. In excess of 80% demonstrated competency in critical values interpretation (PC3), informed consent (PC9), pain assessment (PC11), and geriatric functional assessment (PC3). On direct observation, almost all Level 1 milestones were achieved (93% to 100%); however, only 78% of interns achieved competency in pharmacotherapy (PC5). On global monthly evaluations, all interns met Level 1 milestones.Conclusions: A multisource assessment of EM milestones is feasible and useful to determine Level 1 milestones achievement for incoming interns. A structured assessment program, used in conjunction with more traditional forms of evaluation such as global monthly evaluations and direct observation, is useful for identifying deficits in new trainees and may be able inform the creation of early intervention programs.ACADEMIC EMERGENCY MEDICINE 2014;21:694-698