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Faisal M, Le NS, Grasl S, Pammer J, Janik S, Heiduschka G, Schratter-Sehn AU, Franz P, Königswieser M, Grasl MC, Erovic BM. Survival Outcome in True Carcinoma of Unknown Primary (tCUP) with p16 + Cervical Metastasis. Int Arch Otorhinolaryngol 2023; 27:e687-e693. [PMID: 37876688 PMCID: PMC10593513 DOI: 10.1055/s-0042-1759575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 08/22/2022] [Indexed: 10/26/2023] Open
Abstract
Introduction Age and lymph node ratio have been attributed as independent predictors for survival and recurrence in carcinoma of unknown primary (CUP). Objective The purpose of this study was to analyze the prognostic value of p16 overexpression for CUP in the absence of true primary (TP). Methods The study involved 43 patients who underwent therapeutic lymph node dissection (LND) from 2000 to 2015 after all the diagnostic work up for CUP. Immunohistochemistry for p16 overexpression was performed. Cox proportional hazard regression analysis was used to analyze the prognostic impact on 5-year overall survival (OS) and recurrence-free survival (RFS). Results The male-to-female ratio was 5.1:1, with a median age of 62 years. The clinicopathological data, except for p16 overexpression, did not differ significantly in terms of 5-year OS and RFS. The Cox regression analysis proposed p16 positivity to be an independent prognosticator of regional recurrence-free survival (RRFS) (hazard ratio [HR] 6.180, p = 0.21). The median time to recurrence and death were 10 and 25 months, respectively. Conclusion Cervical metastasis with p16 overexpression is a significant prognostic factor of improved RFS after surgery in CUP. The prognostic significance of lymph node p16 positivity should be further studied.
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Affiliation(s)
- Muhammad Faisal
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
- Institute of Head and Neck Diseases, Evangelical Hospital, Vienna, Austria
| | - Nguyen-Son Le
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Johannes Pammer
- Department of Clinical Pathology, Medical University of Vienna, Vienna, Austria
| | - Stefan Janik
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Gregor Heiduschka
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Peter Franz
- Department of Otorhinolaryngology, Head and Neck Surgery, Rudolfstiftung Hospital, Vienna, Austria
| | - Meinhard Königswieser
- Department of Otorhinolaryngology, Head and Neck Surgery, Rudolfstiftung Hospital, Vienna, Austria
| | - Matthaeus Ch. Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Boban M. Erovic
- Institute of Head and Neck Diseases, Evangelical Hospital, Vienna, Austria
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Verde-Sánchez L, Capote AL, Sanz-García A, Brabyn P, Rodríguez-Campo FJ, Naval Gías L. Prognostic Involvement of Lymph Node Density in Oral Squamous Cell Carcinoma. A New Predictive Model. J Oral Maxillofac Surg 2023; 81:358-369. [PMID: 36502856 DOI: 10.1016/j.joms.2022.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 10/17/2022] [Accepted: 11/20/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE Lymph node density (LND) has been reported to be a significant predictor of survival in oral squamous cell carcinoma (OSCC). The aim of this study was to analyze LND as a prognostic factor in OSCC and create a predictive model that determines the probability of death in these patients. METHODS A retrospective cohort study was carried out with a cohort of patients who underwent cervical dissection and primary resection of OSCC between 1980 and 2020. The primary predictor variable in this study was LND, which is defined as the number of positive lymph nodes divided by the total number of lymph nodes removed. The cutoff values for prediction of disease-specific survival (DSS) were calculated by receiver operating characteristic curve analysis, which determined the best cutoff value was 0.07. Patients were divided into binary subgroups (low and high risk) using the best cutoff value of LND. The outcome variable was DSS, defined as the duration from the date of diagnosis to death due to OSCC and not due to other causes or secondary tumors. Other variables were type of neck dissection, postsurgical treatment, surgical margin, pathological T category stage, pathological N category (pN) stage, extranodal extension, perineural invasion, bone invasion, and presence of recurrence. A predictive model (score) was generated by selecting variables using a log-rank test and by using the Cox proportional-hazards regression (multivariate analysis). RESULTS The sample consisted of 368 patients, 252 (68.5%) male and 116 (31.5%) female patients, with a mean age of 60.3 years. According to the LND cutoff value, there were 289 patients with a low LND (≤0.07) and 79 with a high LND (>0.07). The univariate analysis showed LND as a significant predictor of DSS at 5 years (67.1% in LND ≤ 0.07 vs 32.9% in LND > 0.07; P < .001). The Cox multivariate analysis identified LND (hazard ratio [HR] = 27.2; 95% confidence interval [CI], 3.18-231; P = .002), recurrence (HR = 4.45; 95% CI, 2.3-8.4; P < .001), and type of treatment (HR = 0.52; 95% CI, 0.34-0.81; P < .001) as independent predictive factors for DSS. In the predictive model, the presence of recurrence was the most important factor with 8 points, whereas LND >0.07 contributed only 1 point; however, the 2 categories resulting from this limit were statistically significant. CONCLUSIONS Our study demonstrates that LND is an additional prognostic factor in patients with a pN+ disease. In addition, our predictive model could be useful in the therapeutic algorithm of OSCC patients, as it can predict the probability of death in these patients.
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Affiliation(s)
- Laura Verde-Sánchez
- Resident, Oral and Maxillofacial Surgery Department, University Hospital ''La Princesa", Madrid, Spain.
| | - Ana-Laura Capote
- Consultant, Oral and Maxillofacial Surgery Department, University Hospital ''La Princesa", Madrid, Spain
| | - Ancor Sanz-García
- Research Associate, Data Analysis Unit, University Hospital ''La Princesa", Madrid, Spain
| | - Philip Brabyn
- Consultant, Oral and Maxillofacial Surgery Department, University Hospital ''La Princesa", Madrid, Spain
| | | | - Luis Naval Gías
- Department Head, Oral and Maxillofacial Surgery Department, University Hospital ''La Princesa", Madrid, Spain
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Zhang Y, Yu J, Zhu H. Risk factors for cervical lymph node metastasis of head and neck squamous cell carcinoma: A retrospective population-based study. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e484-e488. [PMID: 35526829 DOI: 10.1016/j.jormas.2022.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Head and neck squamous cell carcinoma (HNSCC) is characterized by high frequency of early cervical lymph node metastases (LNMs), resulting in poor survival of patients. However, cervical LNMs are difficult to detect, which makes the decision-making of which patients should undergo neck dissection surgery challenging for surgeons. This study aimed to analyze the clinicopathological risk factors associated with cervical LNM and determine the indications for neck dissection in HNSCC patients. METHODS The medical records of patients diagnosed with HNSCC who were treated at our hospital between January 2010 and June 2020 were retrospectively reviewed. A database of their clinicopathological data, including sex, age at diagnosis, primary tumor regions, tumor size, and grade, was constructed. The associations of these clinicopathological features with cervical LNM were analyzed using univariate and multivariate logistic regression analyses. The TCGA database were used to externally validate the risk factors. RESULTS Overall, 531 patients with HNSCC were included; 38.6% had confirmed pathological cervical LNM. Univariate and multivariate analyses identified that tumor size and grade were independent risk factors associated with LNM (odds ratio = 1.338, 95% CI: 1.015-1.767, p < 0.05; odds ratio = 1.936, 95% CI: 1.46-2.587, p < 0.0001, respectively). The significant positive associations of tumor size and grade with LNM were externally validated in the TCGA datasets. CONCLUSIONS HNSCC patients with large tumor size or poor tumor differentiation degree were at high risk of lymph node metastasis and were recommended to undergo neck dissection.
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Affiliation(s)
- Yamin Zhang
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou, Zhejiang, China; Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jing Yu
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou, Zhejiang, China; Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Huiyong Zhu
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou, Zhejiang, China.
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Faisal M, Dhanani R, Ullah S, Bakar MA, Irfan N, Malik KI, Loya A, Boban EM, Hussain R, Jamshed A. Prognostic outcomes of treatment naïve oral tongue squamous cell carcinoma (OTSCC): a comprehensive analysis of 14 years. Eur Arch Otorhinolaryngol 2020; 278:3045-3053. [PMID: 33236214 DOI: 10.1007/s00405-020-06482-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/07/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To analyze the factors predicting survival outcomes in treatment naïve oral tongue squamous cell carcinoma (OTSCC). MATERIALS AND METHODS A comprehensive review of 531 oral tongue carcinoma patients treated with upfront surgery followed by adjuvant radiotherapy or chemoradiotherapy was conducted from 2004-2018. RESULTS The mean age of presentation was 53 years (11-86) with a male to female ratio of 1.3:1. The associated risk factors were smoking (21%), betel nut (16%), naswar (9%) and alcohol (1%). Most of the cases were either well (45.1%) or moderately (46.2%) differentiated. Surgery was performed in 164 patients alone while 368 were treated with surgery in combination with adjuvant modalities. Overall (OS) and disease free survival (DFS) were 66 and 71%, respectively, with a median follow up of 2.5 years. Cox regression analysis showed nodal positivity, increased depth of invasion (DOI) and higher lymph node ratio (LNR) as significant prognosticators impacting OS and DSS. CONCLUSION Nodal volume, DOI and LNR are the most consistent predictors of poor outcome in OTSCC. Nodal positivity, depth of invasion > 5 mm and lymph node ratio > 0.04 adversely affect OS and DSS.
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Affiliation(s)
- Muhammad Faisal
- Department of Head and Neck Surgery, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan.
| | - Rahim Dhanani
- Department of Head and Neck Surgery, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Sami Ullah
- Department of Head and Neck Surgery, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Muhammad Abu Bakar
- Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Nabia Irfan
- Department of Radiation Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Kashif Iqbal Malik
- Department of Head and Neck Surgery, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Asif Loya
- Department of Pathology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Erovic M Boban
- Department of Head and Neck Surgery, Evangelisches Krankenhaus, Vienna, Austria
| | - Raza Hussain
- Department of Head and Neck Surgery, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Arif Jamshed
- Department of Radiation Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
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León X, Neumann E, Gutierrez A, García J, Quer M, López M. Prognostic Capacity of the Lymph Node Ratio in Squamous Cell Carcinomas of the Head and Neck. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2020. [DOI: 10.1016/j.otoeng.2019.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Lymph node ratio as a predictor for outcome in oral squamous cell carcinoma: a multicenter population-based cohort study. Clin Oral Investig 2020; 25:1705-1713. [PMID: 32754787 PMCID: PMC7966215 DOI: 10.1007/s00784-020-03471-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Abstract
Objectives Recently, multiple studies addressed the importance of lymph node ratio (LNR) in specifying patients’ risk of disease recurrence in various malignancies. The present study examines the prognostic significance of LNR in predicting outcome of oral squamous cell carcinoma (OSCC) patients after surgical treatment with curative intent. Methods Here, we describe a retrospective population-based cohort with 717 patients previously diagnosed with OSCC. Histopathologically verified lymph node metastasis was diagnosed in 290 patients. Among these patients, we evaluated the impact of LNR on overall survival (OAS) and recurrence-free survival (RFS) in uni- as well as multivariate analysis. Results A median cutoff (0.055) in LNR was found to significantly predict outcome in OSCC patients. Five-year OAS was 54.1% in patients with a low LNR, whereas a high LNR was associated with a 5-year OAS of 33.3% (p < 0.001). Similar results were detected for RFS with a 5-year survival rate of 49.8% (LNR low) and 30.3% (LNR high) (p = 0.002). Results were confirmed in multivariate Cox regression which substantiated the importance of LNR in predicting survival in OSCC patients. Conclusions LNR was shown to be an independent prognostic factor for outcome of OSCC in a population-based cohort in uni- as well as multivariate analysis. Hereby, a LNR ≥ 0.055 predicted a shorter OAS and RFS in our cohort. Clinical relevance Besides established histopathological factors, LNR can be used as a reliable predictor of outcome in OSCC and might therefore be further applied in evaluating adjuvant treatment after resection in curative intention.
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León X, Neumann E, Gutierrez A, García J, Quer M, López M. Prognostic capacity of the lymph node ratio in squamous cell carcinomas of the head and neck. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2020; 71:265-274. [PMID: 32473713 DOI: 10.1016/j.otorri.2020.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/26/2019] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES Lymph node density or lymph node ratio (LNR), defined as the quotient between the total number of positive lymph nodes and the total number of dissected lymph nodes, has demonstrated a prognostic capacity in several tumour models, including patients with head and neck squamous cell carcinomas (HNSCC). The aim of the present study is to analyse the prognostic value of LNR in a wide cohort of patients with HNSCC. METHODS We carried out a retrospective study of a cohort of 1,311 patients with HNSCC treated with unilateral or bilateral neck dissections. Of the patients included in the study, 55.0% had lymph node metastases (pN+). We proceeded to calculate the value of the LNR, and its categorization through a recursive partition analysis considering specific survival as the dependent variable. RESULTS Three categories were defined according to the value of the LNR with a cut-off point at the values < of .025 and .118. The 5-year specific survival for patients with an LNR less than .025 (n=654, 49.8%) was 87.2%, for patients with a LNR .025-.118 (n=394, 30.1%) it was 51.6%, and for patients with a LNR greater than .188 (n=263, 20.1%) it was 27.3% (P=.0001). According to the results of a multivariate analysis, the LNR significantly related to specific survival. CONCLUSION The LNR can be a prognostic variable to be considered in the pathological staging of the lymph nodes.
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Affiliation(s)
- Xavier León
- Servicio de Otorrinolaringología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España; Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, España.
| | - Eduard Neumann
- Servicio de Otorrinolaringología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España
| | - Alfons Gutierrez
- Servicio de Otorrinolaringología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España
| | - Jacinto García
- Servicio de Otorrinolaringología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España
| | - Miquel Quer
- Servicio de Otorrinolaringología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España
| | - Montserrat López
- Servicio de Otorrinolaringología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España
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Yeung DCM, Yeung Z, Wong EWY, Vlantis AC, Chan JYK. Neck lymph node status on survival of regionally recurrent or persistent nasopharyngeal carcinoma. Sci Rep 2020; 10:5622. [PMID: 32221400 PMCID: PMC7101328 DOI: 10.1038/s41598-020-62625-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/17/2020] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to evaluate the impact of lymph node status from neck dissection pathological specimens on the survival for isolated regional nodal recurrence or persistence after primary treatment of nasopharyngeal carcinoma. Through a retrospective cohort study performed in an academic tertiary referral hospital in Hong Kong. Forty-six patients who underwent a salvage neck dissection between June 2001 and January 2013 for isolated regionally recurrent or persistent nasopharyngeal carcinoma was performed. Informed consent was waived for this retrospective study by The Joint CUHK-NTEC CREC. In the study forty-six patients had a salvage neck dissection for nodal failure with a mean age of 53 and 74% (34) were male. With a mean follow-up of 45.3 months, Overall survival, disease specific survival, loco-regional recurrence free survival, and regional recurrence free survival were 56.5%, 73.9%, 87.0%, and 91.3% respectively. For both univariate and multivariate analysis, patients with a number of positive lymph nodes more than 5 and a lymph node density more than 20% were significantly associated with poorer overall survival. Extracapsular spread and pathological cervical lymph node staging did not have an association with poorer survival. In conclusion, an absolute number of positive lymph nodes more than five and a lymph node density more than 20% were potentially useful prognostic factors affecting survival following a neck dissection for regional residual or recurrent nasopharyngeal carcinoma.
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Affiliation(s)
- David C M Yeung
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong, Kong SAR, China
| | - Zenon Yeung
- Department of Ear Nose & Throat, United Christian Hospital, Affiliated Teaching Unit of the Chinese University of Hong Kong, Kwun Tong, Hong Kong SAR, China
| | - Eddy W Y Wong
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong, Kong SAR, China
| | - Alexander C Vlantis
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong, Kong SAR, China
| | - Jason Y K Chan
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong, Kong SAR, China.
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Amit M, Tam S, Boonsripitayanon M, Cabanillas ME, Busaidy NL, Grubbs EG, Lai SY, Gross ND, Sturgis EM, Zafereo ME. Association of Lymph Node Density With Survival of Patients With Papillary Thyroid Cancer. JAMA Otolaryngol Head Neck Surg 2019; 144:108-114. [PMID: 29192312 DOI: 10.1001/jamaoto.2017.2416] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Importance Lymph node metastases are common in papillary thyroid cancer (PTC), yet the impact of nodal metastases on survival remains unclear. Lymph node density (LND) is the ratio between the number of positive lymph nodes excised and the total number of excised lymph nodes. Lymph node density has been suggested as a prognostic factor in many types of cancer. Objective To evaluate the prognostic role of LND in PTC. Design, Setting, and Participants This cohort study reviewed medical records of patients with PTC who were treated at the University of Texas MD Anderson Cancer Center between January 1, 2000, and December 31, 2015. Survival and recurrence outcomes were calculated by using the Kaplan-Meier method. Significant variables on univariate analysis were subjected to a Cox proportional hazards regression multivariate model. Main Outcomes and Measures Primary study outcome was disease-specific survival (DSS); other measurements included overall survival (OS). Results The study cohort included data for 2542 patients (1801 [71%] male; median age, 48 years [range, 18-97 years]) with a median follow-up of 55 months (range, 4-192 months). The 10-year disease-specific survival rate was 98% for patients with LND of 0.19 or less, compared with 90% for those with LND greater than 0.19 (effect size, 8%; 95% CI, 4%-15%). The 10-year overall survival was 87% for patients with LND of 0.19 or less, compared with 79% for patients with LND greater than 0.19 (effect size, 8%; 95% CI, 3%-15%). Multivariable analysis revealed that LND greater than 0.19 was independently associated with an adverse DSS (hazard ratio [HR], 4.11; 95% CI, 2.11-8.97) and OS (HR, 1.96; 95% CI, 1.24-4.11). Subgroup analysis of patients with 18 or more lymph nodes analyzed revealed that LND greater than 0.19 remained a significant marker for DSS (HR, 2.94; 95% CI, 1.36-9.81) and OS (HR, 2.26; 95% CI, 1.12-5.34). Incorporating LND into the current American Joint Committee on Cancer staging system successfully stratified risk groups compared with the traditional TNM staging system. Conclusions and Relevance This single-institute study demonstrates the reproducibility of LND as a predictor of outcomes in PTC. Lymph node density can potentially assist in identifying patients with poorer survival who may benefit from more aggressive adjuvant therapy.
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Affiliation(s)
- Moran Amit
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Samantha Tam
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Mongkol Boonsripitayanon
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Maria E Cabanillas
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston
| | - Naifa L Busaidy
- Division of Internal Medicine, Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston
| | - Elizabeth Gardner Grubbs
- Division of Surgery, Department of Endocrine Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Stephen Y Lai
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Neil D Gross
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Erich M Sturgis
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
| | - Mark E Zafereo
- Division of Surgery, Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston
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Rempel V, Safi A, Drebber U, Nickenig H, Neugebauer J, Zöller J, Kreppel M. The prognostic relevance of lymph node ratio in patients with oral squamous cell carcinoma treated with neoadjuvant therapy regimen and radical surgery. J Craniomaxillofac Surg 2018; 46:1659-1663. [DOI: 10.1016/j.jcms.2018.05.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/03/2018] [Accepted: 05/31/2018] [Indexed: 10/14/2022] Open
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Sano D, Yabuki K, Takahashi H, Arai Y, Chiba Y, Tanabe T, Nishimura G, Oridate N. Lymph node ratio as a prognostic factor for survival in patients with head and neck squamous cell carcinoma. Auris Nasus Larynx 2018; 45:846-853. [DOI: 10.1016/j.anl.2017.11.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/10/2017] [Accepted: 11/21/2017] [Indexed: 12/19/2022]
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Cheraghlou S, Otremba M, Kuo Yu P, Agogo GO, Hersey D, Judson BL. Prognostic Value of Lymph Node Yield and Density in Head and Neck Malignancies. Otolaryngol Head Neck Surg 2018; 158:1016-1023. [DOI: 10.1177/0194599818756830] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective Studies have suggested that the lymph node yield and lymph node density from selective or elective neck dissections are predictive of patient outcomes and may be used for patient counseling, treatment planning, or quality measurement. Our objective was to systematically review the literature and conduct a meta-analysis of studies that investigated the prognostic significance of lymph node yield and/or lymph node density after neck dissection for patients with head and neck cancer. Data Sources The Ovid/Medline, Ovid/Embase, and NLM PubMed databases were systematically searched on January 23, 2017, for articles published between January 1, 1946, and January 23, 2017. Review Methods We reviewed English-language original research that included survival analysis of patients undergoing neck dissection for a head and neck malignancy stratified by lymph node yield and/or lymph node density. Study data were extracted by 2 independent researchers (S.C. and M.O.). We utilized the DerSimonian and Laird random effects model to account for heterogeneity of studies. Results Our search yielded 350 nonduplicate articles, with 23 studies included in the final synthesis. Pooled results demonstrated that increased lymph node yield was associated with a significant improvement in survival (hazard ratio, 0.833; 95% CI, 0.790-0.879). Additionally, we found that increased lymph node density was associated with poorer survival (hazard ratio, 1.916; 95% CI, 1.637-2.241). Conclusions Increased nodal yield portends improved outcomes and may be a valuable quality indicator for neck dissections, while increased lymph node density is associated with diminished survival and may be used for postsurgical counseling and planning for adjuvant therapy.
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Affiliation(s)
- Shayan Cheraghlou
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael Otremba
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Center, New Haven, Connecticut, USA
| | - Phoebe Kuo Yu
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - George O. Agogo
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Denise Hersey
- Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, Connecticut, USA
| | - Benjamin L. Judson
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Center, New Haven, Connecticut, USA
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Talmi YP, Takes RP, Alon EE, Nixon IJ, López F, de Bree R, Rodrigo JP, Shaha AR, Halmos GB, Rinaldo A, Ferlito A. Prognostic value of lymph node ratio in head and neck squamous cell carcinoma. Head Neck 2018; 40:1082-1090. [PMID: 29394461 DOI: 10.1002/hed.25080] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 07/10/2017] [Accepted: 12/06/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Lymph node ratio (LNR) is increasingly reported as a potential prognostic tool. The purpose of this review was to analyze the available literature on the prognostic significance of LNR in head and neck squamous cell carcinoma (HNSCC). METHODS A PubMed internet search was performed and articles meeting selection criteria were reviewed. RESULTS Twenty-eight studies were identified in the literature dealing with the prognostic value of LNR. The published results are variable with a range of cutoff values of LNR associated with prognosis (overall survival [OS] and/or disease-specific survival [DSS]) between 0.02 and 0.20, with an average of 0.09. CONCLUSION The LNR is reported to be of value in assessing prognosis in the patients with HNSCC. Although it is easy to calculate and could be considered in the staging of these patients, the currently available evidence in the literature does not yet provide a solid base for implementation.
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Affiliation(s)
- Yoav P Talmi
- Department of Otolaryngology - Head and Neck Surgery, the Chaim Sheba Medical Center, Tel Hashomer, Israel and the Sackler School of Medicine, Tel Aviv University, Israel
| | - Robert P Takes
- Department of Otolaryngology - Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eran E Alon
- Department of Otolaryngology - Head and Neck Surgery, the Chaim Sheba Medical Center, Tel Hashomer, Israel and the Sackler School of Medicine, Tel Aviv University, Israel
| | - Iain J Nixon
- Ear, Nose, and Throat Department, NHS Lothian, Lauriston Building, Lauriston Place, Edinburgh, UK
| | - Fernando López
- Department of Otolaryngology, Hospital Universitario Central de Asturias, and Instituto Universitario de Oncología del Principado de Asturias, University of Oviedo, Oviedo, Spain.,Head and Neck Oncology Unit, Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain
| | - Remco de Bree
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Juan P Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias, and Instituto Universitario de Oncología del Principado de Asturias, University of Oviedo, Oviedo, Spain.,Head and Neck Oncology Unit, Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain
| | - Ashok R Shaha
- Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gyorgy B Halmos
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Groningen University Medical Center Groningen, Groningen, The Netherlands
| | | | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group
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14
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Majercakova K, Valero C, López M, García J, Farré N, Quer M, León X. Postoperative staging of the neck dissection using extracapsular spread and lymph node ratio as prognostic factors in HPV-negative head and neck squamous cell carcinoma patients. Oral Oncol 2018; 77:37-42. [DOI: 10.1016/j.oraloncology.2017.12.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 11/08/2017] [Accepted: 12/15/2017] [Indexed: 11/16/2022]
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15
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Chow TL, Kwan WWY, Fung SC, Ho LI. Prognostic value of lymph node density in buccal squamous cell carcinoma. Am J Otolaryngol 2017; 38:529-532. [PMID: 28554580 DOI: 10.1016/j.amjoto.2017.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/21/2017] [Accepted: 05/05/2017] [Indexed: 12/13/2022]
Abstract
PURPOSE Lymph node density(LND) has been shown to be a better prognosticator than conventional nodal classification to predict prognosis for squamous cell carcinoma(SCC) of the oral cavity. However, studies focusing on subsites of oral cancer are meager. The role of LND for buccal SCC was evaluated in this study. METHODS A total of 39 patients with buccal SCC primarily treated surgically with neck dissection were identified. LND was defined as the number of positive nodes over the number of nodal yield. The cut-off of LND was ≤0.07 or >0.07. Patient demographic data and clincopathologic parameters were described. Survival was expressed by Kaplan-Meier method and correlation with survival is analyzed with log-rank test. IBM SPSS Statistics version 22 was used for data computation. RESULTS The median follow-up was 79.0months and median nodes removed was 23 (range 8-93). Positive nodal involvement was found in 19(48.7%) patients. The 5-year and 10-year OS were 67.4% and 42.5% whilst for DSS were 69.2% and 65.5%, respectively. When pT-, pN-, LND-classification and AJCC stage were analyzed for the whole series, only pN- (p=0.006) and LND-classification (p=0.002) were significant factors for OS, while pT-, pN-, LND-classification and AJCC stage were all significant factors for DSS. When only cases with positive nodal spread were considered, the pN-classification (pN1 vs pN2) was not a significant risk factor for either OS (p=0.075, HR 3.10(CI 0.89-10.76)) and DSS (p=0.074, HR 3.58(CI 0.88-14.56)). By contrast, LND-classification (≤0.07 vs >0.07) remained a significant predictor for OS (p=0.03, HR 3.95(CI 1.15-13.63)), but not for the DSS (p=0.112, HR 2.92(CI 0.78-10.99)). CONCLUSION The prognostic value of LND on buccal SCC is supported in this study. The results also suggest that LND is better than the conventional pN-classification to predict OS. Further studies on LND with big sample size for buccal SCC or other subsites of OSCC are worthwhile.
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Affiliation(s)
- Tam-Lin Chow
- Division of Head and Neck Surgery, Department of Surgery, United Christian Hospital, Hong Kong, China.
| | - Wilson W Y Kwan
- Division of Head and Neck Surgery, Department of Surgery, United Christian Hospital, Hong Kong, China
| | - Siu-Chung Fung
- Division of Head and Neck Surgery, Department of Surgery, United Christian Hospital, Hong Kong, China
| | - Lai-In Ho
- Division of Head and Neck Surgery, Department of Surgery, United Christian Hospital, Hong Kong, China
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16
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Wu CN, Chuang HC, Lin YT, Fang FM, Li SH, Chien CY. Prognosis of neutrophil-to-lymphocyte ratio in clinical early-stage tongue (cT1/T2N0) cancer. Onco Targets Ther 2017; 10:3917-3924. [PMID: 28831266 PMCID: PMC5552147 DOI: 10.2147/ott.s140800] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Inflammation plays a role in the development of cancer. This study aims to analyze the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) and other clinicopathological determinants in early-stage (cT1/T2N0) tongue cancer. MATERIALS AND METHODS A total of 262 patients were selected from our institute's cancer database between 2004 and 2011. Optimal cutoff value of NLR and lymph node density (LND) were determined statistically using receiver operating characteristic curve analysis for survival prediction. The 5-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) rates were estimated using the Kaplan-Meier method. RESULTS The results showed that, in this cohort, the optimal cutoff value of NLR was 2.95 and for LND, it was 0.031. Patients with NLR ≥2.95 correlated significantly with positive N classification (P=0.011), T2 classification (P=0.007), positive perineural invasion (P<0.001), and a tumor thickness of >5 mm (P=0.005). The 5-year OS among patients with NLR <2.95 was much higher than that in patients with NLR ≥2.95 (P<0.001). Similarly, the 5-year DSS among patients with NLR <2.95 was much higher than that in patients with NLR ≥2.95 (P=0.002). The 5-year DFS among patients with NLR <2.95 was much higher than that in patients with NLR ≥2.95 (P=0.004). The 5-year OS, DSS, and DFS were significantly reduced among patients with LND >0.031 compared to those with LND <0.031, respectively. In multivariate analysis, NLR, LND, and tumor thickness were independent prognostic factors for OS. CONCLUSION Pretreatment NLR ≥2.95 is significantly correlated with a larger tumor, positive neck lymph node metastasis, and positive perineural invasion. Importantly, it indicates reduced survival rate. Therefore, if the NLR ≥2.95 in early-stage (cT1/T2N0) tongue cancer is noted preoperatively, it reveals more invasive tumor behavior clinically. Then, aggressive treatments, including elective neck dissection, become necessary.
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Affiliation(s)
- Ching-Nung Wu
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hui-Ching Chuang
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Kaohsiung Chang Gung Head and Neck Oncology Group, Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yu-Tsai Lin
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Kaohsiung Chang Gung Head and Neck Oncology Group, Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Fu-Min Fang
- Kaohsiung Chang Gung Head and Neck Oncology Group, Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shau-Hsuan Li
- Kaohsiung Chang Gung Head and Neck Oncology Group, Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Yen Chien
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Kaohsiung Chang Gung Head and Neck Oncology Group, Cancer Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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17
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de Ridder M., Marres C, Smeele L, van den Brekel M, Hauptmann M, Balm A, van Velthuysen M. A critical evaluation of lymph node ratio in head and neck cancer. Virchows Arch 2016; 469:635-641. [DOI: 10.1007/s00428-016-2015-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/13/2016] [Accepted: 08/30/2016] [Indexed: 10/21/2022]
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18
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Lieng H, Gebski VJ, Morgan GJ, Veness MJ. Important prognostic significance of lymph node density in patients with node positive oral tongue cancer. ANZ J Surg 2016; 86:681-6. [DOI: 10.1111/ans.13512] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 01/26/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Hester Lieng
- Head and Neck Cancer Service, Crown Princess Mary Cancer Centre; Westmead Hospital, The University of Sydney; Sydney New South Wales Australia
| | - Val J. Gebski
- Head and Neck Cancer Service, Crown Princess Mary Cancer Centre; Westmead Hospital, The University of Sydney; Sydney New South Wales Australia
- NHMRC Clinical Trials Centre; The University of Sydney; Sydney New South Wales Australia
| | - Gary J. Morgan
- Head and Neck Cancer Service, Crown Princess Mary Cancer Centre; Westmead Hospital, The University of Sydney; Sydney New South Wales Australia
| | - Michael J. Veness
- Head and Neck Cancer Service, Crown Princess Mary Cancer Centre; Westmead Hospital, The University of Sydney; Sydney New South Wales Australia
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19
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SUZUKI HIDENORI, HANAI NOBUHIRO, HIRAKAWA HITOSHI, NISHIKAWA DAISUKE, HASEGAWA YASUHISA. Lymph node density is a prognostic factor in patients with major salivary gland carcinoma. Oncol Lett 2015; 10:3523-3528. [PMID: 26788162 PMCID: PMC4665639 DOI: 10.3892/ol.2015.3814] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 09/18/2015] [Indexed: 11/06/2022] Open
Abstract
Lymph node density (LND) has been reported to be a significant predictor of survival in patients with oral and other carcinomas exhibiting positive lymph nodes. The present study investigated whether the LND is associated with overall survival in subjects with major salivary gland carcinoma. A total of 78 patients newly diagnosed with major salivary gland carcinoma underwent primary tumor resection and neck dissection without preoperative treatment. Of these 78 patients, 32 with pathologically positive lymph nodes were enrolled in the present study. The LND was calculated as the ratio of the number of positive lymph nodes to the number of total lymph nodes. The survival rate was analyzed according to the Kaplan-Meier method. A univariate survival analysis was performed using the log-rank test, and a multivariate survival analysis was performed using the Cox proportional hazards model. An LND of ≥0.38 was found to significantly correlate with a shorter overall survival time in univariate analysis (P=0.017). In multivariate survival analysis, after adjusting for anatomical location (parotid gland/others), an LND of ≥0.38 was identified to be associated with a significantly shorter overall survival time. These results suggest that the LND functions as a prognostic factor in cases of major salivary gland carcinoma.
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Affiliation(s)
- HIDENORI SUZUKI
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - NOBUHIRO HANAI
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - HITOSHI HIRAKAWA
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - DAISUKE NISHIKAWA
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - YASUHISA HASEGAWA
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
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20
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Hong HR, Roh JL, Cho KJ, Choi SH, Nam SY, Kim SY. Prognostic value of lymph node density in high-grade salivary gland cancers. J Surg Oncol 2015; 111:784-9. [DOI: 10.1002/jso.23874] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 11/26/2014] [Indexed: 02/01/2023]
Affiliation(s)
- Hye Ran Hong
- Departments of Otolaryngology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Republic of Korea
| | - Jong-Lyel Roh
- Departments of Otolaryngology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Republic of Korea
| | - Kyung-Ja Cho
- Departments of Pathology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Republic of Korea
| | - Seung-Ho Choi
- Departments of Otolaryngology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Republic of Korea
| | - Soon Yuhl Nam
- Departments of Otolaryngology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Republic of Korea
| | - Sang Yoon Kim
- Departments of Otolaryngology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Republic of Korea
- Departments of Biomedical Research Institute; Korea Institute of Science and Technology; Seoul Republic of Korea
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21
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Chen YL, Wang CY, Wu CC, Lee MS, Hung SK, Chen WC, Hsu CY, Hsu CW, Huang CY, Su YC, Lee CC. Prognostic influences of lymph node ratio in major cancers of Taiwan: a longitudinal study from a single cancer center. J Cancer Res Clin Oncol 2014; 141:333-43. [DOI: 10.1007/s00432-014-1810-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 08/03/2014] [Indexed: 01/29/2023]
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22
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Künzel J, Mantsopoulos K, Psychogios G, Grundtner P, Koch M, Iro H. Lymph node ratio as a valuable additional predictor of outcome in selected patients with oral cavity cancer. Oral Surg Oral Med Oral Pathol Oral Radiol 2014; 117:677-84. [DOI: 10.1016/j.oooo.2014.02.032] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 02/22/2014] [Accepted: 02/28/2014] [Indexed: 11/27/2022]
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23
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Shum JW, Dierks EJ. Evaluation and Staging of the Neck in Patients with Malignant Disease. Oral Maxillofac Surg Clin North Am 2014; 26:209-21. [DOI: 10.1016/j.coms.2014.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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