Analysis of risk factors for retropharyngeal lymph node metastasis in carcinoma of the hypopharynx

Distribution of regional lymph lode metastasis in unilateral nasopharyngeal carcinoma and the suggestions for selective prophylactic irradiation with intensity-modulated radiotherapy

PURPOSE

To address the regional lymph node (RLN) distribution and the long-term efficacy in unilateral nasopharyngeal carcinoma (NPC), providing elective irradiation for RLN with intensity-modulated radiotherapy (IMRT).

METHODS

The involvement of clinical data of 136 patients with unilateral NPC, who underwent IMRT from November 2003 to December 2020 were analyzed retrospectively. The therapeutic effect and failure pattern of RLN metastasis were evaluated.

RESULTS

Of 57.1% patients have bilateral RLN metastasis. The rate of contralateral RLNs metastasis is lower than that of ipsilateral RLNs. Contralateral RLN metastasis mainly occurs in level VIIa (39.0%) and II (38.2%). While level IVa is only 0.7%, and none of RLN metastasis was found in level IVb and Va. The median follow-up was 70 months, and the 3-, 5-and 10-year regional recurrence-free survival (RRFS) were 94.1%, 93.1%, and 93.1%, respectively.

CONCLUSION

Routine prophylactic irradiation may not include contralateral lower neck LN and level Va for N0-1 unilateral NPC.

Prevalence and risk factors for retropharyngeal and retro-styloid lymph node metastasis in hypopharyngeal carcinoma

BACKGROUND

We evaluated the prevalence and identified the risk factors for retropharyngeal and retro-styloid lymph node metastasis (LNM) in patients with hypopharyngeal carcinoma (HPC). This was achieved using a combination of magnetic resonance (MR) and [18 F]-fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET)/computed tomography (CT) images.

METHODS

Two board-certified radiation oncologists retrospectively reviewed pretreatment FDG-PET/CT images and contrast-enhanced thin-slice CT and MR images of 155 patients with HPC who underwent radiotherapy. Fisher's exact tests and logistic regression analyses were performed to assess the risk factors for LNM.

RESULTS

Retropharyngeal LNM (RPLNM) was confirmed in 20 (13%) patients. Posterior wall (PW) tumors (odds ratio [OR]: 4.128, 95% confidence interval [CI]: 1.339-12.727; p = 0.014) and bilateral or contralateral cervical LNM (OR: 11.577, 95% CI: 2.135-62.789; p = 0.005) were significantly correlated with RPLNM. The RPLNM was found in 9 (32%) of the 28 patients with PW tumors. Of these 9 patients, 2 (7%) had ipsilateral RPLNM, 3 (11%) had contralateral RPLNM, and 4 (14%) had bilateral RPLNM. The PW tumors were significantly associated with contralateral RPLNM (p < 0.001). Retro-styloid LNM (RSLNM) was confirmed in two (1%) patients, both of whom had ipsilateral RSLNM with lymph nodes (LNs) of ≥ 15 mm in the upper limit of ipsilateral level II. A significant association was found between LNs of ≥ 15 mm in the upper limit of ipsilateral level II and ipsilateral RSLNM (p = 0.001).

CONCLUSIONS

The RPLNM was identified in 13% of patients with HPC. The PW tumors and bilateral or contralateral cervical LNM were risk factors for RPLNM; particularly, PW tumors were a specific risk factor for contralateral RPLNM. Although the RSLNM was rare, LNs of ≥ 15 mm in the upper limit of ipsilateral level II were a risk factor for ipsilateral RSLNM.

A Web-Based Prediction Model for Cancer-Specific Survival of Elderly Patients With Hypopharyngeal Squamous Cell Carcinomas: A Population-Based Study

Background: Hypopharyngeal squamous cell carcinomas (HPSCC) is one of the causes of death in elderly patients, an accurate prediction of survival can effectively improve the prognosis of patients. However, there is no accurate assessment of the survival prognosis of elderly patients with HPSCC. The purpose of this study is to establish a nomogram to predict the cancer-specific survival (CSS) of elderly patients with HPSCC.

Methods: The clinicopathological data of all patients from 2004 to 2018 were downloaded from the SEER database. These patients were randomly divided into a training set (70%) and a validation set (30%). The univariate and multivariate Cox regression analysis confirmed independent risk factors for the prognosis of elderly patients with HPSCC. A new nomogram was constructed to predict 1-, 3-, and 5-year CSS in elderly patients with HPSCC. Then used the consistency index (C-index), the calibration curve, and the area under the receiver operating curve (AUC) to evaluate the accuracy and discrimination of the prediction model. Decision curve analysis (DCA) was used to assess the clinical value of the model.

Results: A total of 3,172 patients were included in the study, and they were randomly divided into a training set (N = 2,219) and a validation set (N = 953). Univariate and multivariate analysis suggested that age, T stage, N stage, M stage, tumor size, surgery, radiotherapy, chemotherapy, and marriage were independent risk factors for patient prognosis. These nine variables are included in the nomogram to predict the CSS of patients. The C-index for the training set and validation was 0.713 (95% CI, 0.697–0.729) and 0.703 (95% CI, 0.678–0.729), respectively. The AUC results of the training and validation set indicate that this nomogram has good accuracy. The calibration curve indicates that the observed and predicted values are highly consistent. DCA indicated that the nomogram has a better clinical application value than the traditional TNM staging system.

Conclusion: This study identified risk factors for survival in elderly patients with HPSCC. We found that age, T stage, N stage, M stage, tumor size, surgery, radiotherapy, chemotherapy, and marriage are independent prognostic factors. A new nomogram for predicting the CSS of elderly HPSCC patients was established. This model has good clinical application value and can help patients and doctors make clinical decisions.

Radiotherapy for hypopharynx cancers

We present the update of the recommendations of the French society of oncological radiotherapy on radiotherapy for hypopharynx. Intensity-modulated radiotherapy is the gold standard treatment for hypopharynx cancers. Early T1 and T2 tumors could be treated by exclusive radiotherapy or surgery followed by postoperative radiotherapy in case of high recurrence risk. For locally advanced tumours requiring total pharyngolaryngectomy (T2 or T3) or with significant lymph nodes involvement, induction chemotherapy followed by exclusive radiotherapy or concurrent chemoradiotherapy were possible. For T4 tumour, surgery must be proposed. The treatment of lymph nodes is based on initial primary tumour treatment. In non-surgical procedure, for 35 fractions, curative dose is 70Gy (2Gy per fraction) and prophylactic dose are 50 to 56Gy (2Gy per fraction in case of sequential radiotherapy or 1.6Gy in case of integrated simultaneous boost) radiotherapy; for 33 fractions, curative dose is 69.96Gy (2.12Gy per fraction) and prophylactic dose is 52.8Gy (1.6Gy per fraction in integrated simultaneous boost radiotherapy or 54Gy in 1.64Gy per fraction); for 30 fractions, curative dose is 66Gy (2.2Gy per fraction) and prophylactic dose is 54Gy (1.8Gy per fraction in integrated simultaneous boost radiotherapy). Doses over 2Gy per fraction could be done when chemotherapy is not used regarding potential larynx toxicity. Postoperatively, radiotherapy is used in locally advanced cancer with dose levels based on pathologic criteria, 60 to 66Gy for R1 resection and 54 to 60Gy for complete resection in bed tumour; 50 to 66Gy in lymph nodes areas regarding extracapsular spread. Volume delineation were based on guidelines cited in this article.

Different Primary Sites of Hypopharyngeal Cancer Have Different Lymph Node Metastasis Patterns: A Retrospective Analysis From Multi-Center Data

Background

Most hypopharyngeal cancers (HPCs) develop lymph node metastasis (LNM) at initial diagnosis. Understanding the pattern of LNM in HPC could help both surgeons and radiologists make decisions in the management of cervical lymph nodes.

Methods

A total of 244 newly diagnosed HPC patients between January 2010 and December 2018 were recruited from three specialized cancer hospitals in mainland China. All patients received pre-treatment magnetic resonance imaging (MRI), and definitive radiotherapy with or without concurrent chemotherapy. We reassessed the features of the primary tumor (tumor size, primary location, and extent of invasion) and the involvement of lymph nodes at each level. According to the incidence of LNM, these levels were sequenced and sorted into drainage stations. Univariate and multivariate analyses were used to determine the risk factors for bilateral and regional lymph node metastasis.

Results

The cohort consisted of 195 piriform sinus cancers (PSC), 47 posterior wall cancers (PWC), and 2 post-cricoid cancers (PCC). A total of 176 patients (72.1%) presented with MRI-detectable LNMs. The overall LNM rates for level II-VI and retropharyngeal lymph nodes (RPLNs) were 59.0%, 52.9%, 14.3%, 1.6%, 2.9%, and 16.4%, respectively. Based on the prevalence of LNM at each level, we hypothesize that the lymphatic drainage of PSC was carried out in sequence along three stations: Level II and III (61.0% and 55.4%), Level IV and RPLN (15.9% and 11.3%), and Level V and VI (1.5% and 3.1%). For PWCs, lymphatic drainage is carried out at two stations: Level II, III, and RPLN (48.9%, 40.4%, and 34.0%) and Level IV-VI (6.4%, 0%, and 2.1%). According to univariate and multivariate analyses, posterior wall invasion was significantly correlated with bilateral LNM (P = 0.030, HR = 2.853 95%CI, 1.110-7.338) and RPLN metastasis (P = 0.017, HR = 2.880 95%CI, 1.209-6.862). However, pyriform sinus invasion was less likely to present with bilateral LNM (P = 0.027, HR = 0.311, 95%CI, 0.111-0.875) and RPLN metastasis (P = 0.028, HR = 0.346, 95%CI, 0.134-0.891).

Conclusions and Relevance

The primary tumor site and extent of invasion are related to the pattern of lymph node metastasis. That is, the metastasis would drainage station by station along different directions.

Retropharyngeal Lymph Node Metastasis Diagnosed by Magnetic Resonance Imaging in Hypopharyngeal Carcinoma: A Retrospective Analysis From Chinese Multi-Center Data

Background

To assess the prevalence, risk factors and prognostic significance of retropharyngeal lymph node (RPLN) metastasis diagnosed by magnetic resonance imaging (MRI) in patients with hypopharyngeal squamous cell carcinoma (HPSCC).

Methods

259 patients from three cancer institutions in China from Jan 2010 to Dec 2018 were analyzed, retrospectively. All the patients had been given pre-treatment magnetic resonance imaging (MRI) of head and neck and were then treated with definitive radiotherapy with or without chemotherapy. Pretreatment diagnostic MRIs were reviewed by a dedicated head and neck radiologist, for the presence or absence of radiographically positive RPLN, cervical LN and tumor invasion.Demographic variables were analysed by descriptive statistics using SPSS 20.0. Predictors of the presence of RPLN and its prognostic significance were examined.

Results

RPLN metastasis was discovered in 44 patients (17%). Logistic analysis showed that posterior pharyngeal wall (PPW) primary tumor; PPW invasion; N2-3; multiple cervical lymph node (LN) involvement (>2 LNs) were associated with RPLN metastasis, with metastasis rates 37%, 30%, 31% and 33% respectively. Patients with RPLN metastasis had a significantly reduced 5-year overall survival (OS) and disease-free survival (DFS) compared to the non-RPLN metastasis group (OS 28% vs. 48%, p=0.001; DFS 25% vs. 41%, p=0.040).

Conclusions

RPLN metastasis was not uncommon in HPSCC patients. Risk factors were: PPW primary tumor, PPW invasion and cervical LN status. RPLN metastasis is a poor prognosticator for survival.

Verification of the Efficacy of New Diagnostic Criteria for Retropharyngeal Nodes in a Cohort of Nasopharyngeal Carcinoma Patients

Purpose: A multistage approach to diagnose lateral retropharyngeal nodes (LRPNs) of nasopharyngeal carcinoma (NPC) had been proposed and warranted for validation. Methods: Between 2012 and 2017, the patients with newly diagnosed NPC were enrolled. The responsive nodes or those that progressed during follow-up were positive. The criteria for the multistage approach delimited LRPNs with a minimal axial diameter (MIAD) ≥ 6.1 mm were assessed as positive and if the mean standard uptake value ≥ 2.6, or if the maximal coronal diameter ≥ 25 mm and maximal axial diameter ≥ 8 mm with nodes MIAD < 6.1 mm were also considered as positive. The outcomes were compared with the MIAD cutoff value ≥ 6 mm (traditional method). A chi-squared test was used to compare two areas under the curve of the receiver operating characteristic curves. Results: A total of 67 eligible NPC cases and 155 LRPNs (72 positive and 83 negative) were analyzed. The accuracy, specificity, and sensitivity of the traditional method were 0.91, 0.93, and 0.89, respectively. The values for the multistage approach all reached 0.94. The area under the curve was significantly greater for the multistage approach compared with the traditional method (p = 0.023). Conclusion: The results support the advantage of the multistage approach.

The Pattern of Cervical Lymph Node Metastasis and Risk Factors of Retropharyngeal Lymph Node Metastasis Based on Magnetic Resonance Imaging in Different Sites of Hypopharyngeal Carcinoma

Background

This study was to determine the patterns of regional lymph node (LN) spread and the risk factors of retropharyngeal lymph node (RPLN) metastasis based on magnetic resonance imaging (MRI) in hypopharyngeal squamous carcinoma (HPC) to improve clinical target volume (CTV) delineation.

Methods

A cohort of 326 consecutive patients of HPC in a single institute were retrospectively reviewed. All patients underwent MRI prior to initial treatment, and the diagnosis based on MRI of the LN metastasis was confirmed by all radiation oncologists in the head and neck group during twice weekly chat rounds. Statistical analysis of data was using chi-square test and multivariant logistic regression model in SPSS 22.0 software.

Results

The LN metastasis rate of all patients in this cohort was 90.5% (295/326). Level IIa/b and level III were the most frequently involved regions followed by level IV and retropharyngeal region. Skip metastasis only occurred in 6.4% (19/295). Univariate and multivariate analysis demonstrated that primary tumor subsites were located in the posterior pharyngeal wall (P=0.002), bilateral cervical LN metastasis (P=0.020), larger volume of primary gross target (GTVp, P=0.003), and larger volume of LN gross target (GTVnd, P=0.023) were significantly associated with RPLN metastasis.

Conclusion

The regional LN spread of HPC follows an ordered pattern as level II is the most frequently involved area followed by level III, level IV, and RPLN. RPLN metastasis is more likely to occur in patients with primary site of posterior pharyngeal wall, large tumor burden, or bilateral neck LN metastasis. Therefore, it is highly recommended that the RPLN should be included into CTV for patients who have these risk factors.

Patterns of regional lymph node failure of locally advanced hypopharyngeal squamous cell carcinoma after first-line treatment with surgery and/or intensity-modulated radiotherapy

Background

To identify the spatial patterns of regional lymph node failure of locally advanced hypopharyngeal squamous cell carcinoma (SCC) after first-line treatment with surgery and/or intensity-modulated radiotherapy (IMRT).

Methods

We retrospectively obtained the clinicopathological characters of 123 hypopharyngeal SCC patients, and investigated the patterns of regional lymph node failure. Univariate and multivariate logistic regression were used to determine the risk factors of regional lymph node failure.

Results

Forty patients (32.5% of total patients) were suffered regional lymph node failure. In these patients, the ipsilateral neck level II nodal failure account for 55.0% (22/40) followed by level III 30.0% (12/40), level VIb 15.0% (6/40), level VII 15.0% (6/40), and level IV 5.0% (2/40). In addition, 17.5% (7/40) patients suffered contralateral neck level II nodal failure and 7.5% (3/40) patients suffered level III nodal failure. The common failure levels were the II (7/46, 15.2%), III (4/46, 8.7%), VIb (4/46, 8.7%), and VII (5/46, 10.9%) for treatment by surgery. The lymph node recurrence and persistent disease at levels II (19/77, 24.7%) and III (10/77, 13.0%) remained the major cause of failure following curative intent of IMRT. The postoperative radiation significantly decreased the risk of regional lymph node failure (OR = 0.082, 95% CI: 0.007–1.000, P = 0.049); and the radiologic extranodal extension significantly increased the risk of regional lymph node failure (OR = 11.07, 95% CI: 2.870–42.69, P < 0.001).

Conclusions

Whatever the treatment modality, the lymph node failure at level II and III was the most popular pattern for hypopharyngeal SCC. Moreover, for patients who underwent surgery, the nodal failure at level VIb and VII was frequent. Thus, postoperative radiation of level VIb and VII may give rise to benefit to locally advanced hypopharyngeal SCC patients.

Management of retropharyngeal lymph node metastasis in oral cancer

OBJECTIVES

Retropharyngeal lymph node (RPLN) metastasis is extremely rare, and prognosis is significantly poor in oral cancer. We retrospectively examined the management of RPLN metastases in oral cancer.

MATERIALS AND METHODS

A total of 1247 patients with oral cancer were treated at our department from January 2002 and December 2016. Among these patients, 374 (30%) had histologically positive lymph node metastases. Of these, 15 patients (1.2%) were diagnosed with RPLN metastases. We evaluated the diagnostic period, size, recurrence pattern, laterality, treatment, and therapeutic outcomes. The Kaplan-Meier method was used to determine overall survival (OS) among the RPLN metastasis group, cervical lymph node (CLN) metastases group, and treatment methods group for RPLN metastases.

RESULTS

One patient had RPLN involvement at the initial treatment, and RPLN involvement in other patients was found subsequently. The mean duration in confirming RPLN metastases was 228 days (range, 50-867 days). Surgical therapy was performed in 5 patients, chemoradiotherapy in 7 patients, and best supported care (BSC) in 3 patients. The cumulative 5-year OS rate for the RPLN metastasis group (n = 15) was 38.1%, compared with the rate of 71.3% for the CLN group (n = 359). Regarding the therapeutic approach for RPLN metastases, OS rates were 80.0% (n = 5) in the surgical therapy group, 28.6% (n = 7) in the chemoradiotherapy group, and 0% (n = 3) in the BSC group.

CONCLUSION

Early detection and surgical treatment of RPLN metastases are associated with increased survival rate in oral cancer.

Clinical value of ultrasonic imaging in diagnosis of hypopharyngeal cancer with cervical lymph node metastasis

Clinical value of ultrasonic imaging in diagnosis of hypopharyngeal cancer with cervical lymph node metastasis was investigated. Eighty-nine patients who were diagnosed with hypopharyngeal cancer in Qilu Hospital of Shandong University (Qingdao) from January 2014 to June 2016 were retrospectively analyzed. Sixty-eight patients were diagnosed with hypopharyngeal cancer with cervical lymph node metastasis by pathological sections. Twenty-one patients did not have cervical lymph node metastasis. All the patients were diagnosed by palpation and ultrasound. The lymph node ultrasound images were quantified by computer, and the long/short diameter ratio, the maximum systolic velocity, blood flow resistance of the metastatic and non-metastatic patients were compared. The diagnostic efficacy of palpation and ultrasound was analyzed in the diagnosis of hypopharyngeal cancer with cervical lymph node metastasis. A correlation analysis was carried out between the image features of ultrasound and lymph node metastasis. The long/short diameter ratio, maximum systolic velocity and resistance index of patients with lymph node metastasis were significantly higher than those without lymph node metastasis, with a significant difference (P<0.05). Forty-one patients were diagnosed with lymph node metastasis by palpation, fifty-nine patients were diagnosed with lymph node metastasis by ultrasound. The sensitivity and diagnostic coincidence rate of ultrasound in diagnosis of hypopharyngeal cancer with cervical lymph node metastasis were significantly higher than those of palpation (P<0.05). Statistically significant differences were observed in lymph node internal echo types, medullary echo characteristics, envelope definition, and blood flow distribution characteristics between the metastasis group and the non-metastasis group (P<0.05). Lymph node internal echo was heterogeneous. There was no medulla, and the disordered blood flow in the lymph node predicted lymph node metastasis. Preoperative ultrasound has a high diagnostic value in diagnosis of hypopharyngeal cancer with cervical lymph node metastasis. The diagnostic results of preoperative ultrasound can be used as a reference for the diagnosis and treatment of hypopharyngeal cancer with cervical lymph node metastasis.

Impact of retropharyngeal lymph node dissection in the surgical treatment of hypopharyngeal cancer

OBJECTIVES

To evaluate the impact of retropharyngeal lymph node (RPLN) dissection in the surgical treatment of hypopharyngeal cancer.

METHODS

Between 2007 and 2016, 98 previously untreated patients with pathological diagnosed hypopharyngeal squamous cell carcinoma underwent total pharyngolaryngectomy and bilateral neck dissection at Kobe University Hospital. Bilateral dissection of RPLN was simultaneously performed in all patients. Pharynx was reconstructed with free jejunal transfer in 94 patients and primarily closed in 4 patients. Postoperative chemoradiotherapy was performed in patients with high risk factors including metastasis to RPLN, multiple lymph node metastasis, extranodal invasion, and/or positive/close surgical margins.

RESULTS

The median follow-up period was 25 months ranging from 1 to 105 months. RPLN adenopathy was preoperatively identified in 9 patients in FDG-positron emission tomography. All of them had pathologically diagnosed RPLN metastases, which had been controlled in all patients during the observation periods. Among the other 89 patients, 7 patients had RPLN metastasis. The 2-year overall survival rates of the patients with and without RPLN metastasis were 65.7% and 69.8% (P = .61), respectively.

CONCLUSIONS

In the present study, patients with RPLN metastasis showed equally favorable oncological outcome compared with patients without RPLN metastasis. At least, ipsilateral RPLN dissection should be considered in the surgical treatment of advanced hypopharyngeal cancer and multiple neck lymph node metastasis regardless of primary subsite.