Cervical node metastases in squamous cell carcinoma of the upper aerodigestive tract: the significance of extracapsular spread and soft tissue deposits

Standardised definitions and diagnostic criteria for extranodal extension detected on histopathological examination in head and neck cancer: Head and Neck Cancer International Group consensus recommendations

Detection of extranodal extension on histopathology in surgically treated head and neck squamous cell carcinoma indicates poor prognosis. However, there is no consensus on the diagnostic criteria, interpretation, and reporting of histology detected extranodal extension, which has contributed to conflicting evidence in the literature, and likely clinical inconsistency. The Head and Neck Cancer International Group conducted a three-round modified Delphi process with a group of 19 international pathology experts representing 15 national clinical research groups to generate consensus recommendations for histology detected extranodal extension diagnostic criteria. The expert panel strongly agreed on terminology and diagnostic features for histology detected extranodal extension and soft tissue metastasis. Moreover, the panel reached consensus on reporting of histology detected extranodal extension and on nodal sampling. These consensus recommendations, endorsed by 19 organisations representing 34 countries, are a crucial development towards standardised diagnosis and reporting of histology detected extranodal extension, and more accurate data collection and analysis.

Thyroid cartilage infiltration in advanced laryngeal cancer: prognostic implications and predictive modelling

Objective

Detection of laryngeal cartilage invasion is of great importance in staging of laryngeal squamous cell carcinoma (LSCC). The role of prognosticators in locally advanced laryngeal cancer are still widely debated. This study aimed to assess the impact of volume of thyroid cartilage infiltration, as well as other histopathologic variables, on patient survival.

Materials and methods

We retrospectively analysed 74 patients affected by pT4 LSCC and treated with total laryngectomy between 2005 and 2021 at the Department of Otorhinolaryngology - Head and Neck Surgery of the University of Brescia, Italy. We considered as potential prognosticators histological grade, perineural (PNI) and lympho-vascular invasion (LVI), thyroid cartilage infiltration, and pTN staging. Pre-operative CT or MRI were analysed to quantify the volume of cartilage infiltration using 3D Slicer software.

Results

The 1-, 3-, and 5-year disease free survivals (DFS) were 76%, 66%, and 64%, respectively. Using machine learning models, we found that the volume of thyroid cartilage infiltration had high correlation with DFS. Patients with a higher volume (>670 mm3) of infiltration had a worse prognosis compared to those with a lower volume.

Conclusions

Our study confirms the essential role of LVI as prognosticator in advanced LSCC and, more innovatively, highlights the volume of thyroid cartilage infiltration as another promising prognostic factor.

Association between lymph node ratio and survival outcomes in patients with oral squamous cell carcinoma

BACKGROUND

Recent reports have shown that the Lymph node ratio (LNR) is useful for predicting the prognosis in some cancers, however there are few reports on the usefulness of LNR in predicting the prognosis of oral squamous cell carcinoma (OSCC). The predictive value of LNR for prognosis of OSCC was investigated.

MATERIALS AND METHODS

The study included 152 patients with OSCC and histologically confirmed cervical lymph node metastasis who underwent neck dissection. We analyzed the relationship between LNR and overall survival (OS) and recurrence-free survival (RFS) retrospectively in these cases, with the relationship between prognosis and clinicopathological findings also examined.

RESULTS

Using a receiver operating characteristics curve, the LNR cutoff value was set at 0.095, categorizing 64 and 88 cases into high LNR (≥ 0.095) and low LNR (< 0.095) groups, respectively. Regarding OS and RFS, the prognosis was significantly worse in the high LNR group compared with the low LNR group. In multivariate analysis, sex, postoperative nodal stage, and LNR merged as independent prognostic factors.

CONCLUSION

This study's findings suggest that LNR may represent a prognostic indicator in OSCC with cervical lymph node metastasis.

Imaging Characteristics Predictive of Cervical Extranodal Tumor Extension in Patients With Head and Neck Squamous Cell Carcinoma

OBJECTIVES

The aims of the study were to determine the predictive imaging findings of extranodal extension (ENE) in metastatic cervical lymph nodes of head and neck squamous cell carcinoma and to investigate the interobserver agreement among radiologists with different experience levels.

MATERIALS AND METHODS

Patients with cervical lymph node dissection and who had metastatic lymph nodes and preoperative imaging were included. Three radiologists evaluated nodal necrosis, irregular contour, gross invasion, and perinodal fat stranding. They also noted their overall impression regarding the presence of the ENE. Sensitivity, specificity, odds ratios based on logistic regression, and interobserver agreement of ENE status were calculated.

RESULTS

Of 106 lymph nodes (that met inclusion criteria), 31 had radiologically determined ENE. On pathologic examination, 22 of 31 nodes were positive for ENE. The increasing number of metastatic lymph nodes was associated with the presence of the ENE ( P = 0.010). Irregular contour had the highest sensitivity (78.6%) and gross invasion had the highest specificity (96%) for the determination of the ENE. The radiologists' impression regarding the presence of the pathlogical ENE had 39.3% sensitivity and 82% specificity. Metastatic lymph nodes with a perinodal fat stranding and with the longest diameter of greater than 2 cm were found to be strong predictors of the ENE. The gross invasion demonstrated the highest κ value (0.731) among the evaluated imaging criteria.

CONCLUSIONS

In the assessment of ENE, the gross invasion had the highest specificity among imaging features and showed the highest interobserver agreement. Perinodal fat stranding and the longest diameter of greater than 2 cm in a metastatic lymph node were the best predictors of the ENE.

Extracapsular nodal extension and tumor deposits in head and neck squamous cell carcinoma

BACKGROUND

Tumor deposits (TDs) are an infrequently mentioned feature of head and neck squamous cell carcinoma (HNSCC) that are currently grouped under extranodal extension (ENE) in the AJCC 8th edition of HNSCC TNM staging. The prognostic implication of TDs in comparison to ENE remains uncertain.

METHODS

This observational, retrospective, non-randomized study evaluated patients with HNSCC who underwent initial surgical resection, with neck dissection and adjuvant radiotherapy ± chemotherapy. Clinical variables were considered, and statistical analyses were conducted to compare time progression and overall survival (OS) in patients with TDs against those with ENE.

RESULTS

Of the 71 patients included in the study, 50 were diagnosed with ENE (pN2a-ENE in 38 patients and pN3b-ENE in 12), while 21 had TDs ± ENE. The median time to progression was significantly different based on the presence of ENE or TDs (p = .002) and pN2a-ENE/pN3b-ENE or TDs (p = .007). The three-year OS was 55.7% for the entire group, 60.4% in ENE and 38.4% in TDs (p = .021). The OS difference between the pN2a-ENE, pN3b-ENE, and the TDs group was also significant (p = .05). The hazard ratio between ENE and TDs was Exp (B) 4.341 (p = .044).

CONCLUSIONS

TDs in HNSCC are associated with a lower OS than ENE, despite intensified adjuvant therapy. Our results confirm a better prognosis for pN2a-ENE vs. pN3b-ENE, and pN3b-ENE vs. TDs. TDs may serve as an indicator of poor prognosis and require separate TNM classification in HNSCC staging. Larger studies are needed to evaluate TDs impact on treatment strategies and outcomes.

Diagnostic challenges and prognostic implications of extranodal extension in head and neck cancer: a state of the art review and gap analysis

Extranodal extension (ENE) is a pattern of cancer growth from within the lymph node (LN) outward into perinodal tissues, critically defined by disruption and penetration of the tumor through the entire thickness of the LN capsule. The presence of ENE is often associated with an aggressive cancer phenotype in various malignancies including head and neck squamous cell carcinoma (HNSCC). In HNSCC, ENE is associated with increased risk of distant metastasis and lower rates of locoregional control. ENE detected on histopathology (pathologic ENE; pENE) is now incorporated as a risk-stratification factor in human papillomavirus (HPV)-negative HNSCC in the eighth edition of the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) TNM classification. Although ENE was first described almost a century ago, several issues remain unresolved, including lack of consensus on definitions, terminology, and widely accepted assessment criteria and grading systems for both pENE and ENE detected on radiological imaging (imaging-detected ENE; iENE). Moreover, there is conflicting data on the prognostic significance of iENE and pENE, particularly in the context of HPV-associated HNSCC. Herein, we review the existing literature on ENE in HNSCC, highlighting areas of controversy and identifying critical gaps requiring concerted research efforts.

Prognostic significance of soft tissue deposits in head and neck squamous cell carcinoma: a systematic review and meta-analysis

Soft tissue deposits, also known as tumour deposits (TDs), have not been studied well in head and neck squamous cell carcinoma (HNSCC) and are not included in any of the staging systems or treatment guidelines. The aim of this systematic review was to determine the prevalence and prognostic implications of TDs in patients with HNSCC. This systematic review of the literature was conducted following the PRISMA guidelines. The PubMed, Embase, and Scopus electronic databases were searched for relevant studies, from inception to August 2022. Although 14 studies qualified for inclusion, only eight were finally included in the review due to the considerable overlap of patients in several studies. Data from 7127 patients were analysed. The pooled prevalence of TDs was 21% (95% confidence interval (CI) 9-33%). The presence of TDs was adversely associated with overall survival and disease-free survival, with hazard ratios of 2.08 (95% CI 1.60-2.70) and 2.56 (95% CI 1.97-3.32), respectively. TDs are detected in a significant number of patients with HNSCC and adversely affect survival. Longitudinal prospective studies are needed to evaluate the prognostic implications of TDs in HNSCC for their potential role in cancer staging and adjuvant treatment planning.

Extent of Extranodal Extension in Oral Cavity Squamous Cell Carcinoma is Not Independently Associated With Overall or Disease-Free Survival at a 2.0-mm Threshold

PURPOSE

The presence of extranodal extension (ENE) conveys a poor prognosis in oral cavity squamous cell carcinoma (OSCC); however, there is no consensus regarding whether the histopathologic extent of ENE (e-ENE) may be a more discriminating prognostic indicator. The purpose of this study was to assess the impact of minor ENE (<2.0 mm) versus major ENE (≥ 2.0 mm) on overall survival (OS) and disease-free survival (DFS) in OSCC.

MATERIALS AND METHODS

A single-institution, retrospective cohort study was designed using an electronic medical record review. Inclusion criteria included patients with OSCC and cervical node metastasis. All subjects were treated between the years 2009 and 2017 in the Michigan Medicine Department of Oral and Maxillofacial Surgery (Ann Arbor, Michigan). The primary predictor variable was e-ENE, measured as the maximum distance of tumor invasion into extranodal tissue from the outer aspect of the nodal capsule. Primary outcome variables were OS and DFS. Other covariates included demographic data, tumor staging, and histopathologic data. Descriptive statistics were performed. Kaplan-Meier survival plots for OS and DFS were performed. The data were mined for an alternative threshold at which e-ENE may impact survival using Cox proportional hazards models.

RESULTS

One hundred sixty eight subjects were included (91 ENE-negative, 48 minor ENE, and 29 major ENE). Most subjects were male (62%) and the mean age was 62.9 years. Mean follow-up time was 2.97 +/- 2.76 years. There was no statistically significant difference in OS or DFS between minor and major ENE. Five-year OS for minor ENE was 30.4% versus 20.7% for major ENE (P = .28). Five-year DFS for minor ENE was 26.7% versus 18.1% for major ENE (P = .30). Five-year OS and DFS was worse for subjects with ENE-positive disease versus ENE-negative disease (OS: 26.9% vs 63.1%, hazard ratio [HR]: 2.70, 95% confidence interval [CI]: [1.77, 4.10], P < .001; DFS: 23.7% vs 59.7%, HR = 2.55, 95% CI [1.71, 3.79], P < .001). At an alternative threshold of 0.9 mm e-ENE, there was greater DFS in subjects with e-ENE 0.1-0.9 mm versus e-ENE > 0.9 (40.6% vs 18.9%, respectively) (HR = 0.49, 95% CI [0.24, 0.99], P = .047).

CONCLUSION

There was no independent association between survival and e-ENE at a 2.0-mm threshold.

Incidence and prognostic significance of extranodal extension in isolated nodal recurrence of oral squamous cell carcinoma

BACKGROUND

Extranodal extension (ENE) is a crucial prognostic factor of oral squamous cell carcinoma (OSCC). However, the role of ENE in regional recurrence (rENE) remains unclear. The purpose of our study is to assess the salvage outcome according to the presence of rENE in oral cancer patients with isolated nodal recurrence.

METHODS

Oral cancer patients diagnosed with isolated nodal recurrence at the National Taiwan University Hospital between January 2010 and December 2015 were reviewed. All patients were classified into two groups: with and without rENE. The treatment included salvage neck dissection (ND) ± metronomic chemotherapy, salvage ND and radiation (RT)/concurrent chemoradiation (CCRT), Salvage RT/CCRT alone, metronomic chemotherapy, or supportive care.

RESULTS

We analyzed 198 patients, 156 with rENE and 42 without rENE. rENE presented more frequently in patients with initial ENE+ (OR = 3.17, p = 0.04), prior RT+ (OR = 2.96, p = 0.02), initial N2/N3 (OR = 2.76, p = 0.01), and recurrent LN size >1.5 cm (OR = 2.33, p = 0.03). The extent of rENE were also significantly different in these patients. The 2-year disease-free survival for patients with and without rENE were 15.7% and 31.7%, respectively (p = 0.002). The 2-year overall survival for patients with and without rENE were 19.6% and 43.9%, respectively (p = 0.004). For patients without rENE, those received salvage ND had better survival outcome (p < 0.001). By contrast, for patients with rENE, those received salvage RT/CCRT had better survival outcome (p < 0.001).

CONCLUSION

The rENE is frequently present (78.79%) in OSCC patients with isolated nodal recurrence. Individualized treatment modalities based on the presence of rENE should be recommended to achieve better salvage outcomes.

The prognostic significance of tumor deposits in patients with head and neck squamous cell carcinomas

Background

A tumor deposit (TD) is a phenomenon that has not been well studied in head and neck squamous cell carcinoma (HNSCC) but might have prognostic significance. The present study was conducted to explore the presence and the prognostic significance of TDs in patients with HNSCCs.

Methods

Six hundred forty-two pathologically confirmed HNSCC patients with neck dissection samples were enrolled in this retrospective study. Patients were followed up and evaluated every 3 months in the first 3 years after surgery, and every 6 months thereafter by physical examination and computed tomography (CT)/magnetic resonance imaging (MRI) scans. The five-year overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were compared in the TD and non-TD groups using multivariable analyses and propensity score matching (PSM) methodology (1:1).

Results

The 5-year OS, DSS, and RFS rate of all patients was 77.3%, 80.6%, and 71.9%, respectively. In the multivariable analyses, poorer rates of OS (HR =2.345, P<0.001), DSS (HR =2.818, P<0.001), and RFS (HR =2.536, P<0.001) were observed in the TD versus the non-TD group. In the PSM cohort, eighty-one patients who had TDs were paired with 70 patients without TDs. Significantly diminished rates of DSS (P=0.040) and RFS (P=0.004) were found in the TD versus the non-TD group.

Conclusions

In response to sparse reports regarding TDs in HNSCCs, the present study proposes the TD as an independent poor prognostic factor meriting further research because of its association with diminished OS, DSS, and RFS rates.

Diagnostic accuracy of imaging modalities in detection of histopathological extranodal extension: A systematic review and meta-analysis

OBJECTIVE

To present an up to date systematic review and meta-analysis evaluating the diagnostic accuracy of the most used imaging modalities in detection of histopathological extra nodal extension (ENE) in head and neck squamous cell carcinoma.

MATERIALS AND METHODS

Medline, Embase, and Cochrane databases were systematically searched on March 27th 2020. Screening, inclusion, quality assessment, and data extraction were done by two reviewers. Meta-analysis was conducted using the bivariate model approach after pooling the studies according to imaging modality. Heterogeneity was explored by meta-regression. Comparison was done by meta-regression and sub-group analyses.

RESULTS

Out of 476 initial hits, 25 studies were included for analysis. Of these, 14 dealt with CT, nine with PET/CT, four with MRI, two with ultrasound, and none with PET/MRI. Meta-analysis based on a total sample size of 3391 showed that CT had a sensitivity of 76% [67-82%] and specificity of 77% [69-83%], MRI a sensitivity of 72% [64-79%] and specificity of 78% [57-90%], and PET/CT a sensitivity of 80% [76-84%] and specificity of 83% [74-90%] in the ability to predict ENE. No meta-analysis could be done on ultrasound. There were no significant differences between modalities in overall accuracy; however, PET/CT had significantly higher sensitivity than CT and MRI.

CONCLUSION

There was no significant difference in the ability of CT, MRI, and PET/CT to diagnose histopathological ENE, except that PET/CT had a significantly higher sensitivity than CT and MRI.

Histopathological Definitions of Extranodal Extension: A Systematic Review

Extranodal extension (ENE) is a very strong prognostic factor in head and neck squamous cell carcinoma. However, significant variance in reported incidence of ENE suggests discordance in perception of ENE among pathologists. This study aims to map the different definitions of histopathological ENE used in the literature. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. Guided by the research question: "How is histopathological ENE defined?" the databases Medline, Embase, and Cochrane were systematically searched. All retrieved studies were reviewed and qualitatively analyzed. Three categories of existing definitions were formed. The systematic literature search yielded 1786 studies after removal of duplicates. Nine hundred and thirty-four full text articles were assessed for inclusion and 44 unique ENE definitions were identified and categorized 1-3; (1) simple definitions only describing a breach in the capsule (48%), (2) definitions also including a description of the perinodal tissue (43%), and (3) definitions adding a description of a specific reaction in the perinodal structure (9%). No consensus definition of ENE exists, but based on the level of details in the identified definitions, three overall categories of ENE definitions were established.

Update on oral and oropharyngeal cancer staging - International perspectives

Squamous cell carcinoma of the oral cavity and oropharynx have been used synonymously and interchangeably in the world literature in the context of head and neck cancers. As the 21st century progresses, divergence between the two have become more evident, particularly due to evidence related to human papillomavirus-associated oropharyngeal squamous cell carcinoma. As such, the American Joint Committee on Cancer recently published the 8th edition Cancer Staging Manual, serving as a continued global resource to clinicians and researchers. Through changes in staging related to T and N clinical and pathologic classifications, the new system is expected to influence current management guidelines of these cancers that have distinct anatomic and etiopathogenic characteristics. This article aims to review such impactful changes in a time of critical transition of the staging of head and neck cancer and how these changes may affect clinicians and researchers worldwide.

Regional Metastasis in Head and Neck Cutaneous Squamous Cell Carcinoma: An Update on the Significance of Extra-Nodal Extension and Soft Tissue Metastasis

BACKGROUND

Soft tissue metastases (STMs) are reported to predict worse prognosis than extra-nodal extension (ENE) in metastatic head and neck cutaneous squamous cell carcinoma. This study aimed to update the authors' previous analysis of STM in a larger series.

METHODS

The study analyzed 535 cases of consecutive cSCC metastatic to the parotid and/or neck treated by primary surgical resection between 1987 and 2007. A Cox proportional hazard model was used to determine the effect of STM, with adjustment for other relevant prognostic factors. Overall survival (OS) and disease-specific survival (DSS) were the primary end points.

RESULTS

Of the 535 patients, 275 (51.4%) had STM. After adjustment for the effects of age, tumor location, number of metastatic deposits, and adjuvant radiotherapy, both STM (hazard ratio [HR], 1.55; 95% confidence interval [CI], 1.08-2.22; p = 0.018) and ENE (HR, 1.56; 95% CI 1.10-2.22; p = 0.013) were shown to be independent predictors of reduced OS, with similar size of effect.

CONCLUSION

In metastatic cSCC of the head and neck, STM is an independent predictor of reduced survival and has an impact on survival similar to that of ENE.

Combining pretreatment plasma Epstein-Barr virus DNA level and cervical node necrosis improves prognostic stratification in patients with nasopharyngeal carcinoma: A cohort study

This study aimed to evaluate the prognostic value of combining pretreatment Epstein‐Barr virus (EBV) DNA level and cervical node necrosis (CNN) for patients with nasopharyngeal carcinoma (NPC) receiving intensity‐modulated radiotherapy (IMRT). A total of 607 incident nonmetastatic NPC patients treated with IMRT ± chemotherapy were reviewed. Patients were divided into four groups based on EBV DNA level and CNN status. The primary endpoint was progression‐free survival (PFS). Kaplan‐Meier curves with log‐rank test were applied to compare survival outcomes and the Cox proportional model was used to identify independent prognostic factors. Pretreatment EBV DNA level and CNN status were independent prognostic factors. Patients in the low‐level EBV DNA group or non‐CNN group had significantly better 5‐year PFS. Multivariate analyses demonstrated that CNN was an independent prognostic factor for overall survival (OS) (HR = 1.927, 95% CI: 1.129‐3.290, P = .016), PFS (HR = 1.492, 95% CI: 1.005‐2.214, P = .047), distant metastasis‐free survival (DMFS) (HR = 1.661, 95% CI: 1.044‐2.644, P = .032), but not locoregional relapse‐free survival. EBV DNA levels correlated significantly with CNN with a correlation coefficient of .324 (P < .001). Compared with low‐level EBV DNA and non‐CNN grouping, high‐level EBV DNA and CNN grouping had poor PFS. The combined classification was an independent prognostic factor for OS (P < .001), PFS (P = .001), and DMFS (P = .018). Pretreatment plasma EBV DNA level and CNN status both closely correlated with prognosis of NPC patients in the IMRT era. Combined EBV DNA level and CNN status improves risk stratification and prognostic value.

A histopathological evaluation and potential prognostic implications of oral squamous cell carcinoma with adverse features

OBJECTIVES

This study aimed to evaluate the adverse clinicopathologic features of oral squamous cell carcinoma (OSCC), including margin status, depth of invasion, lymphovascular invasion, perineural invasion, and extranodal extension that significantly affect survival outcomes.

MATERIALS AND METHODS

This retrospective cross-sectional study included 341 patients with OSCC who underwent therapeutic surgical treatment in Taiwan. The Kaplan-Meier method was used to estimate survival outcomes. A multivariable Cox regression model was used to evaluate the associations of various clinicopathologic features with 5-year overall survival (OS) outcomes in patients with pN0 and pN+ tumors.

RESULTS

Overall, the patients had 5-year OS and progression-free survival rates of 60.0 and 47.9%, respectively. In the pN0 group, the multivariate analysis identified a positive margin (odds ratio [OR] = 16.3, 95% confidence interval [95% CI]: 3.7-72.3; P = 0.001), depth of invasion >5 mm (OR = 2.1, 95% CI: 1.2-3.7; P = 0.012), presence of lymphovascular space invasion (OR = 5.4, 95% CI: 1.3-22.0; P = 0.018), and presence of perineural invasion (OR = 4.3, 95% CI: 1.7-11.1; P = 0.002) as independent and significant prognosticators of OS. In the pN+ group, only the presence of extranodal extension independently predicted OS (OR = 1.7, 95% CI: 1.1-2.7; P = 0.0026).

CONCLUSIONS

When determining survival prognosis for patients with a pN0 status, we recommended including all adverse features. In contrast, extranodal extension was the most important prognostic factor for patients with a pN+ status.

Clinical effect of postoperative chemoradiotherapy in resected advanced laryngeal squamous cell carcinoma

Laryngeal squamous cell carcinoma (LSCC) is one of the most prevalent types of head and neck malignancies. Advanced LSCC has failed to demonstrate a satisfactory prognosis, despite the progresses in the diagnosis and treatment, and the optimal treatment modality continues to be debated. To evaluate the clinical utility and survival outcomes of adjuvant chemoradiotherapy (CRT) for patients with resected advanced LSCC, a retrospective analysis of 232 patients with LSCC who had undergone total laryngectomy and neck dissection between 2005 and 2010 was conducted. Of the 232 eligible patients, 167 patients (72%) received surgery alone, whereas 65 patients (28%) received surgery + adjuvant CRT. In the overall cohort, the 5- and 10-year overall survival (OS) rates were 55.2 and 48.3%, respectively. Multivariate analysis revealed that the clinical stage was significantly associated with OS. However, the N classification was an independent indicator in disease-free survival and laryngeal cancer-specific survival. In those patients with stage IV disease, patients receiving adjuvant CRT exhibited a markedly improved survival benefit compared with patients receiving surgical treatment only, following propensity score matching of the data (P<0.05). The application of adjuvant CRT confers additional survival benefits in comparison with surgery-only treatment regimens for advanced LSCC. However, additional prospective studies are required.

Prognostic significance of soft tissue deposits in laryngeal carcinoma

Introduction

Soft tissue deposits is tumorous islands apart from lymph nodes and occasionally diagnosed in neck dissection specimens. Their importance has begun to be recognized, however, their value has not been investigated in laryngeal cancer as a single tumor site.

Objective

To investigate the prognostic value of soft tissue deposits in patients with laryngeal carcinoma.

Methods

Medical records of 194 patients with laryngeal carcinoma who were treated primarily by surgery and neck dissection were reviewed. Prognostic significance of soft tissue deposits was assessed along with other clinical and pathological findings. Recurrence rates, overall and disease-specific survival rates were examined.

Results

The incidence of soft tissue deposits was found to be 7.2% in laryngeal carcinoma. N stage was more advanced in patients who had soft tissue deposits. Regional recurrence rate was higher and disease specific and overall survivals rates were significantly lower in patients with soft tissue deposits in univariate analysis. However, in multivariate analysis, soft tissue deposits were not found as an independent risk factor.

Conclusion

In laryngeal carcinoma, soft tissue deposits was diagnosed in patients with more advanced neck disease and their significance was lesser than other factors including extranodal extension.

Pituitary tumor-transforming 1 expression in laryngeal cancer and its association with prognosis

The purpose of the present study was to investigate the association between the expression of pituitary tumor-transforming 1 (PTTG1) and the expression of matrix metalloproteinase (MMP)-2 and MMP-9 in laryngeal carcinoma tissues, and to elucidate the association between PTTG1 expression and the prognosis of patients with laryngeal cancer. Immunohistochemical staining was used to detect PTTG1 expression in laryngeal cancer and normal tumor-adjacent laryngeal tissues. Western blotting was used to determine the levels of PTTG1 and MMP-2 and -9 in laryngeal carcinoma tissues and to assess their correlation. In addition, the associations between PTTG1 expression and the clinical parameters of laryngeal cancer and patient survival were determined. The immunohistochemistry results revealed that the positive expression rates of PTTG1, MMP-2 and MMP-9 in the laryngeal cancer tissues were significantly higher than those in the carcinoma-adjacent normal laryngeal tissues (all P<0.05). In addition, expression levels of PTTG1, MMP-2 and MMP-9 were significantly associated with lymph node metastasis, histological grade and clinical stage (P<0.05). Furthermore, the levels of PTTG1 were positively correlated with the levels of MMP-2 and MMP-9 in laryngeal cancer tissues (P<0.05). In summary, the expression levels of PTTG1, MMP-2 and MMP-9 are closely associated with the biological behaviors of laryngeal cancer tissues, showing that they serve important roles in the occurrence and development of laryngeal cancer, and may be useful as biological indicators of laryngeal tissue invasion, metastasis and patient prognosis.

Small size of metastatic lymph nodes with extracapsular spread greatly impacts treatment outcomes in oral squamous cell carcinoma patients

Extracapsular spread (ECS) of metastatic lymph nodes from oral carcinoma is the most significant prognostic predictor of a poor treatment outcome. However, only a few reports on prognostic factors in ECS-positive cases have been investigated. To address this problem, a detailed examination of ECS pathology was conducted to determine the prognostic factors of oral squamous cell carcinoma (OSCC) with ECS of metastatic lymph nodes. This study involved 63 OSCC patients with at least one pathologically metastatic node with ECS. Among the 229 metastatic lymph nodes, 149 exhibited ECS. Univariate analysis revealed that a poor outcome and recurrence were significantly associated with the number of ECS-positive nodes, density of ECS, and the minor axis of the smallest ECS-positive node. However, multivariate analysis identified only small size of ECS-positive nodes as a significant and independent factor predicting recurrence and a poor outcome. Thus, small size of ECS-positive nodes is the most important prognostic indicator for OSCC with ECS in metastatic lymph nodes. The classification of ECS status using the minor axis of ECS-positive nodes may be useful for further prediction of a poorer prognosis in OSCC cases. Standardization of ECS diagnosis and multicenter prospective studies will be required to confirm and refine these findings.

Sentinel node necrosis is a negative prognostic factor in patients with nasopharyngeal carcinoma: a magnetic resonance imaging study of 252 patients

PURPOSE

We explored the patterns of sentinel node metastasis and investigated the prognostic value of sentinel node necrosis (snn) in patients with nasopharyngeal carcinoma (npc), based on magnetic resonance imaging (mri).

METHODS

This retrospective study enrolled 252 patients at our institution who had metastatic lymph nodes from biopsy-confirmed npc and who were treated with definitive radiation therapy, with or without chemotherapy. All participants underwent mri before treatment, and the resulting images were reviewed to evaluate lymph node status. The patients were divided into snn and non-snn groups. Overall survival (os), tumour-free survival (tfs), regional relapse-free survival (rrfs), and distant metastasis-free survival (dmfs) were calculated by the Kaplan-Meier method, and differences were compared using the log-rank test. Factors predictive of outcome were determined by univariate and multivariate analysis.

RESULTS

Of the 252 patients, 189 (75%) had retropharyngeal lymph node metastasis, and 189 (75%) had level iia or iib lymph node necrosis. The incidence of snn was 43.4% (91 of 210 patients with lymph node metastasis or necrosis, or both). After a median follow-up of 54 months, the 5-year rates of os, tfs, rrfs, and dmfs in the snn and non-snn groups were, respectively, 79.4% and 95.3%, 73.5% and 93.3%, 80.4% and 96.6%, and 75.5% and 95.3% (all p < 0.01). Age greater than 40 years, snn, T stage, and N stage were significant independent negative prognostic factors for os, tfs, rrfs, and dmfs.

CONCLUSIONS

Metastatic retropharyngeal lymph nodes and necrotic level ii nodes both seem to act as sentinels. Sentinel node necrosis is an negative prognostic factor in patients with npc. Patients with snn have a worse prognosis.

Extracapsular spread in head and neck squamous cell carcinoma: A systematic review and meta-analysis

Extracapsular spread (ECS) is one of the most important prognostic factors in head and neck squamous cell carcinoma (HNSCC). However, despite its major clinical relevance, there are still a number of important remaining issues regarding this condition. Indeed, standardized diagnostic and grading criteria of ECS are still lacking. The imaging modality of choice for its diagnosis is a matter of debate. Current research looking at the identification of specific biomarkers is ongoing. Recent findings demonstrate a direct correlation between the level of extension of ECS and a poor prognosis. Accumulating data show that ECS does not carry the same adverse features in human papilloma virus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC). New treatment strategies based on these factors are currently considered to investigate the possibility of diminishing the toxicity of chemo-radiotherapy while maintaining similar outcomes. The goal of this article was to provide a systematic review of the literature covering all the issues related to ECS. As an additional component of the review, meta-analyses were performed on relevant aspects of ECS for which previous quantitative data were outdated or not available. The results of these meta-analyses confirm the negative impact of ECS on loco-regional recurrence and distant metastasis. They also demonstrate the absence of a negative impact of ECS in HPV-positive OPSCC.

Clinical Significance of miR-149 in the Survival of Patients with Laryngeal Squamous Cell Carcinoma

MicroRNAs (miRNAs) play critical roles in the progression of laryngeal cancer (LC). In this study, we aimed to investigate whether miR-149 is associated with the prognosis of patients with LC. A total of 97 laryngeal squamous cell carcinoma patients who underwent tumor resection were included in our follow-up study. In vitro studies was performed in cancer cell line Hep-2 to explore the antitumor role of miR-149 in LC. We found that the expression of miR-149 was significantly lower in tumor tissues, compared with vocal cord polyp tissues (P < 0.05). Kaplan-Meier analysis revealed that miR-149 expression status is significantly associated with survival duration (log rank test, P < 0.05), and multivariate Cox regression analysis revealed that patients with low miR-149 expression had shorter survival times compared with patients with high miR-149 expression. In vitro studies revealed that the exogenous expression of miRNA-149 inhibits the proliferation of human Hep-2 cells and induces cell apoptosis. Our study suggests that miR-149 expression in laryngeal squamous cell carcinoma tissues is critically associated with the prognosis of patients, and the ectopic expression of miR-149 in Hep-2 cells inhibits proliferation and cell cycle progression.

Lymph Node Density in Node-Positive Laryngeal Carcinoma: Analysis of Prognostic Value for Survival

OBJECTIVE

We investigated the value of lymph node density (LND) as a predictor of survival in patients with laryngeal squamous cell carcinoma (SCC) and positive neck node (pN+) after laryngectomy.

STUDY DESIGN

Case series with chart review.

SETTING

Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey.

SUBJECTS AND METHODS

We reviewed the records of 289 patients with newly diagnosed primary laryngeal carcinomas who underwent partial or total laryngectomy and combined neck dissection at a tertiary referral center between June 2006 and December 2014. Patients with pN+ laryngeal SCC (n = 101) were included in the study. Overall survival (OS) and disease-free survival (DFS) were used to evaluate the prognostic significance of LND.

RESULTS

In 101 patients with pN+ laryngeal SCC, LND ≥0.09 and number of metastatic lymph nodes >4 were significantly associated with OS and DFS but not the overall tumor, node, and metastasis stage. Forward stepwise Cox regression analysis revealed that LND ≥0.09 was the only independent predictor of both DFS and OS. Furthermore, the odds ratio of LND ≥0.09 was 10 times higher in patients with regional recurrence when compared patients without regional recurrence.

CONCLUSIONS

LND was the only independent prognostic predictor of OS and DFS in patients with pN+ laryngeal SCC. Moreover, patients with LND ≥0.09 were significantly associated with high risk of regional recurrence. Thus, patients with LND ≥0.09 are at high risk of regional recurrence and death and may be considered for adjuvant chemoradiation.

Influence of extracapsular nodal spread extent on prognosis of oral squamous cell carcinoma

BACKGROUND

An objective definition of clinically relevant extracapsular nodal spread (ECS) in head and neck squamous cell carcinoma (SCC) is unavailable.

METHODS

Pathologic review of 245 pathologically positive oral cavity SCC neck dissection specimens was performed. The presence/absence of ECS, its extent (in millimeters), and multiple nodal and primary tumor risk factors were related to disease-specific survival (DSS) at a follow-up of 73 months.

RESULTS

ECS was detected in 109 patients (44%). DSS was significantly better for patients without ECS than patients with ECS. Time-dependent receiver operator curve (ROC) analysis identified a prognostic cutoff for ECS extent at 1.7 mm. In multivariate analyses, DSS was significantly lower for patients with major ECS compared with patients with minor ECS, but not significantly different between patients with minor ECS and patients without ECS.

CONCLUSION

ECS is clinically relevant in oral cavity SCC when it has extended more than 1.7 mm beyond the nodal capsule. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1192-E1199, 2016.

Tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers: a critical appraisal

Objective:

The tumour–node–metastasis staging system has a dynamic structure that is continuously being updated as scientific data develops. This review discusses some suggested revisions on tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers.

Methods:

The seventh edition of The American Joint Committee on Cancer Staging Manual was reviewed and important issues that could be considered for revision were identified and discussed.

Results:

According to our assessment of the oncological outcomes of previous studies, the following factors should be considered for revision: anterior commissure involvement and subglottic extension in laryngeal cancers; underlying bone involvement in hard palate and upper alveolar ridge cancers; tumour thickness in oral cancers; and extracapsular spread and carotid artery involvement in neck metastases.

Conclusion:

Sufficient data on the prognostic importance of these issues have been reported. Suggested revisions in line with current knowledge on the clinical behaviour of upper aerodigestive tract cancers would improve the relevancy of staging.

Prognostic Value of Cervical Nodal Necrosis in Nasopharyngeal Carcinoma: Analysis of 1800 Patients with Positive Cervical Nodal Metastasis at MR Imaging

PURPOSE

To evaluate the prognostic value of cervical nodal necrosis (CNN) in patients with nasopharyngeal carcinoma (NPC) with magnetic resonance (MR) imaging.

MATERIALS AND METHODS

This was an institutional review board-approved retrospective study of 1800 patients with newly diagnosed stage T1, 4N1, 3M0 NPC who were treated with definitive radiation therapy, with or without chemotherapy, between January 2007 and December 2009; the requirement to obtain informed consent was waived. MR images were reviewed to assess lymph node status, and patients were divided into CNN and non-CNN groups. The overall survival, disease-free survival, regional relapse-free survival (RRFS), and distant metastasis-free survival (DMFS) were calculated with the Kaplan-Meier method, and differences were compared by using the log-rank test.

RESULTS

The incidence of CNN was 44.0% (792 of 1800). After the median follow-up period of 53 months, the 5-year overall survival, disease-free survival, RRFS, and DMFS rates of the CNN and non-CNN groups were 78.8% and 91.8%, 78.2% and 91.2%, 78.6% and 91.8%, and 78.4% and 91.6%, respectively (for all rates, P < .001). The distant metastasis rate was 18.7% (148 of 792) for the CNN group versus 4.6% (46 of 1008) for the non-CNN group (P < .01). Subgroup analysis revealed similar survival outcomes between stage N1 disease with CNN and stage N2 disease without CNN, stage N2 disease with CNN, and stage N3 disease regardless of CNN. CNN, T stage, N stage, age older than 44 years, and male sex were significant independent negative prognostic factors for overall survival, disease-free survival, RRFS, and DMFS.

CONCLUSION

CNN is an independent negative prognostic factor in patients with NPC, and it may be appropriate to investigate whether N stage should be upgraded by one level in patients with CNN.

Lymph node density as an independent predictor of cancer-specific mortality in patients with lymph node-positive laryngeal squamous cell carcinoma after laryngectomy

BACKGROUND

We examined the prognostic value of lymph node density in predicting cancer-specific mortality (CSM) for patients with lymph nodes positive (pN+) laryngeal squamous cell carcinoma (SCC) after laryngectomy.

METHODS

The records of 156 patients with laryngeal SCC who initially underwent curative resection of the primary tumor combined with neck dissection were reviewed.

RESULTS

The 5-year cumulative incidence of CSM was 20.4%. N classification and extralaryngeal spread (ELS) were independent variables for CSM in all patients. Univariate analyses in 71 pN+ patients showed that ELS, number of positive lymph nodes >4, and lymph node density >0.044 were significantly associated with increased CSM, whereas pN classification was not (p = .218). On multivariate analysis, lymph node density ≥0.044 remained an independent predictor of CSM (p = .001).

CONCLUSION

Among the pN+ patients with laryngeal SCC, no pN classification but lymph node density was noted to have an independent impact on CSM.

Prognostic significance of epithelial-mesenchymal transition of extracapsular spread tumors in lymph node metastases of head and neck cancer

BACKGROUND AND PURPOSE

The extracapsular spread (ECS) of lymph node metastasis (LNM) reflects tumor aggressiveness and is associated with poor survival and risk of distant metastasis. In this study, we aimed to explore the prognostic significance of epithelial-mesenchymal transition (EMT) of ECS tumors in LNM of head and neck cancers.

METHODS

We collected LNM samples from head and neck cancer patients (follow-up >2 years) and made 20 ECS(-): ECS(+) pairs (1:2) of LNM (N = 60), matched by the primary sites and by T and N classifications. Immunostaining of cytokeratin, E-cadherin, vimentin, and CD31 were performed and quantified to determine the epithelial-mesenchymal transition percent (EMT%), defined as vimentin(+)/cytokeratin(+) area of ECS. Univariate and multivariable analyses of clinic-pathologic factors, including EMT% of ECS, were conducted to identify the significant prognosticators. In addition, the anatomical relationship between CD31 vessels and ECS tumors was analyzed.

RESULTS

Rather than the presence of ECS in LNM, higher EMT% (>50 %) of ECS strongly correlated with the worse overall and disease-free survival and had more frequent recurrence and distant dissemination in their clinical courses. ECS tumors intermingled closely with Ki-67(-) CD31(+) non-proliferating perinodal blood vessels. Particularly, vimentin(+) ECS areas exhibited a higher density of CD31(+) perinodal vessels than did vimentin(-) ECS.

CONCLUSION

High EMT scores of ECS tumors in LNM predict an unfavorable prognosis and systemic dissemination more accurately than the simple presence of ECS in LNM in head and neck cancer patients.

Retrospective analysis of prognostic factors in 205 patients with laryngeal squamous cell carcinoma who underwent surgical treatment

Objectives

To investigate the most important factors affecting the prognosis of the patients with squamous cell carcinoma (SCC) of the larynx.

Methods

Based on the clinical and follow-up data, 205 patients with SCC of the larynx receiving total laryngectomy, partial laryngectomy, or CO₂ laser surgery in GuangDong General Hospital were retrospectively analyzed. A survival analysis was performed by the Kaplan-Meier method and a multivariable analysis of prognostic factors was carried out using the Cox proportional hazard model.

Results

Subtypes of carcinoma included 69.8% glottic and 30.2% supraglottic. Most patients were in N0 stage (77.6%), and 22.4% patients were in N1∼N3 stage. Over half of the patients were in T1∼T2 stage (55.1%), 20.0% in T3, and 24.9% in T4. Mean follow-up duration was 49.2 months. The survival rates 1, 2, and 3 years after the surgery were 99.0%, 91.7%, and 81.5%, respectively. The survival rate for those patients with clinical stage IV was significantly lower than for those with clinical stage I and II (p<0.001 and p = 0.013, respectively). The disease-free progression rates 1, 2, and 3 years after the surgery were 83.9%, 74.6%, and 71.2%, respectively. Futhermore, those patients with a Charlson score of 1 to 2 and ≥3 had higher risk of mortality than those with a Charlson score of 0 (hazard ratios of 1.8 and 2.41 p = 0.042 and p = 0.008). Multivariable analysis revealed that clinical stage, surgical margin, and comorbidity were significantly associated with both mortality and disease-free progression.

Conclusion

The surgical resection margin, clinical stage, and comorbidity were independent factors affecting the laryngeal cancer prognosis. The survival rates were lower for patients with advanced laryngeal cancer, positive surgical margins, or severe comorbidity, suggesting the importance of early diagnosis, early treatment, negative surgical margins, and conditions of comorbidity.

Direct skin involvement of cervical lymph node metastasis from mucosal squamous cell carcinoma of the head and neck

INTRODUCTION

Direct skin involvement of nodal metastasis from mucosal head and neck squamous cell carcinoma has traditionally been considered a poor prognostic indicator.

METHODS

This retrospective review identified eight patients (five with mucosal upper aerodigestive and three with occult primary squamous cell carcinoma) who presented between 2000 and 2007 with direct skin involvement of nodal metastasis.

RESULTS

Five patients were treated with extended radical and three with extended modified radical neck dissection. Closure was achieved directly (four cases), with local (two) or pedicled (two) flaps. Surgery was always followed by radiotherapy (pan-mucosal or to the primary site). The five-year recurrence-free and disease-specific survival rates were 100 per cent.

CONCLUSION

It is exceptionally rare to encounter direct skin involvement of metastatic lymph nodes from mucosal head and neck squamous cell carcinoma without evidence of involvement of other anatomical structures. Surgical intervention is possible and combined modality treatment with curative intent is essential, as most patients can have a favourable outcome.

Prognostic biological features in neck dissection specimens

The superior prognostic value offered by routine histopathological staging of neck dissections, as compared to clinical staging using palpation and modern imaging techniques, is well established in the literature concerning the management of squamous cell carcinoma of the head and neck. In this review, we discuss the definitions and criteria used in standardised routine histopathological reporting and explore additional potential nodal prognostic features. In addition, we critically appraise the value of immunohistochemistry, histochemistry, molecular and other non-morphological techniques and suggest tumour and host features that merit further investigations.

Extracapsular extension is a poor predictor of disease recurrence in surgically treated oropharyngeal squamous cell carcinoma

Extracapsular extension in squamous cell carcinoma nodal metastases usually predicts worse outcome. However, there are no standard histologic grading criteria for extracapsular extension, and there have been few studies on oropharyngeal squamous cell carcinoma alone. We studied the extent of extracapsular extension utilizing a novel grading system and correlated grades with outcomes while controlling for p16 status. A cohort of surgically treated oropharyngeal squamous cell carcinoma cases were reviewed and metastases graded as 0 (within substance of node), 1 (filling subcapsular sinus with thickened capsule/pseudocapsule, but no irregular peripheral extension), 2 (≤1 mm beyond capsule), 3 (>1 mm beyond capsule), or 4 (no residual nodal tissue or architecture; 'soft tissue metastasis'). There were 101 cases, for which p16 was positive in 90 (89%). Extracapsular extension grades did not correlate with nodal size (P=0.28) or p16 status (P=0.8). In follow up, 10 patients (10%) had disease recurrence with only 3 of 64 (5%) grade 0-3 cases and 7 of 37 (19%) with grade 4 recurring (P=0.04). Grade 4 extracapsular extension was associated with poorer survival (P<0.01). However, grade 4 extracapsular extension correlated with higher T-stage (P=0.02), and in multivariate analysis, was not significantly associated with poorer overall (P=0.14) disease-free (P=0.2), or disease-specific survival (P=0.09). The impact of extracapsular extension in nodal metastases is limited in oropharyngeal squamous cell carcinoma. Only extracapsular extension grade 4 associates with poorer outcomes, but not independently of T-stage and other variables.

Lymph node central necrosis on computed tomography as predictor of extracapsular spread in metastatic head and neck squamous cell carcinoma: pilot study

OBJECTIVE

This study aimed (1) to investigate the relationship between the presence of lymph node central necrosis, viewed on pre-operative computed tomography imaging, and the occurrence of histopathologically determined metastatic lymph node extracapsular spread and (2) to determine whether a larger scale study would be valuable.

MATERIALS AND METHODS

Pre-operative computed tomography scans, surgical records and post-operative histopathological analysis results were reviewed for 19 consecutive neck dissections performed in 17 patients with head and neck squamous cell carcinoma.

RESULTS

A total of 20/26 (77 per cent) lymph nodes with central necrosis had extracapsular spread on histopathological analysis. Twenty of 21 (95 per cent) lymph nodes with extracapsular spread had central necrosis on pre-operative computed tomography. Thirty-four of 40 (85 per cent) lymph nodes without extracapsular spread had no evidence of central necrosis on computed tomography. Only three of 12 (25 per cent) patients with lymph node central necrosis identified on pre-operative computed tomography were found to have actual necrosis on final histopathological analysis.

CONCLUSIONS

Lymph node central necrosis viewed on pre-operative computed tomography scans is a useful indicator of metastatic lymph node extracapsular spread, with a sensitivity of 95 per cent, a specificity of 85 per cent, a positive predictive value of 69 per cent and a negative predictive value of 98 per cent. Lymph node diameter is not a sensitive indicator of extracapsular spread.

Impact of difference in the definition of extranodal spread on the outcome of node-positive patients with gastric cancer

PURPOSE

Previous studies have reported that extranodal spread is a prognostic factor in patients with several solid cancers. However, the definition of extranodal spread varies with the reporting investigator and has not been standardized yet. Therefore, we selected several widely used definitions from previous reports and comparatively assessed the clinicopathologic significance of these definitions.

METHODS

Extranodal spread in the 103 node-positive patients who had received curative resections for gastric cancer was classified into two groups, viz., (a) capsule rupture, where cancer cells infiltrated into the perinodal fatty tissue beyond the capsule of the involved lymph node, and (b) no capsule rupture, where nests of cancer cells were detected demonstrable in adjacent tissues around the metastatic lymph node without rupture of the capsule.

RESULTS

Sixty-five (63.1%) of the 103 patients showed extranodal spread. Of the 65 patients, 50 patients showed the capsule rupture type and 15 showed the no capsule rupture type of extranodal spread. The 5-year survival rate was significantly poorer in the capsule rupture group as compared with that in the no capsule rupture group and extranodal spread-negative group (P < 0.05 and P < 0.01, respectively). In regard to the mode of recurrence, the rate of peritoneal recurrence was significantly higher in the capsule rupture group (P < 0.01).

CONCLUSIONS

In the assessment of patients with extranodal spread, it is considered important to classify the patients based on the status of extranodal spread into the capsule rupture group and no capsule rupture group.