AHNS Series: Do you know your guidelines? Review of current knowledge on laryngeal cancer

Evaluation of different methods of transoral minimally invasive surgery for supraglottic laryngeal carcinoma

BACKGROUND AND OBJECTIVES

To analyze oncological and functional results of transoral minimally invasive surgery (TMIS) for supraglottic laryngeal carcinoma (SGLC), and investigate independent prognostic factors.

METHODS

Seventy SGLC patients treated with TMIS were included. The overall survival (OS), recurrence-free survival (RFS), and postoperative functions were analyzed.

RESULTS

Sixty-two patients were early-stage (Tis, T1, and T2) and eight patients were T3. Eleven patients received preoperative induction chemotherapy (IC). Sixty patients received transoral laser microsurgery (TLM), and 10 patients received transoral robotic surgery (TORS). Fifty-eight patients were scored Grade-1 by water swallow test, and 49 patients were scored Grade 0 by grade, roughness, breathiness, asthenia, strain. The 1, 3, and 5 year OS of all were 95.450%, 84.877%, and 78.026%, and RFS were 89.167%, 78.052%, and 75.451% respectively. Kaplan-Meier survival analysis showed N stage and clinical stage were associated with OS, smoking, clinical stage, surgical margins, and Ki-67 index were associated with RFS. There were no significant differences in preoperative IC or direct surgery, TLM, or TORS. Cox analyses showed smoking and surgical margins were independent prognosis factors for RFS.

CONCLUSIONS

The positive margin, Ki-67 index ≥40% and P53(+)&Ki-67 index ≥40% are worse factors affecting recurrence for SGLC patients. Both smoking and surgical margins are independent prognostic factors affecting recurrence.

Primary Total Laryngectomy for Endolaryngeal cT3-4M0 Squamous Cell Carcinoma: A STROBE Analysis

OBJECTIVES

To document 10-year oncologic outcome of primary total laryngectomy (TL) for patients with cT3-4M0 endolaryngeal squamous cell carcinoma (SCC).

STUDY DESIGN

Observational inception cohort of 531 patients with isolated untreated endolaryngeal cT3-4M0 SCC review over 40 years using STROBE guideline. 94% of patients were followed until death or for a minimum of 10 years.

SETTING

Academic tertiary referral care center.

METHODS

All patients underwent primary TL. Prior tracheotomy, induction chemotherapy, thyroid gland resection, level II-IV neck dissection, level VI dissection, and postoperative radiation therapy were associated in 6%, 40%, 43%, 89%, 47%, and 74% of cases, respectively: The main objective was to determine the 10-year actuarial local control estimate. Accessory objectives comprised screening for clinical variables increasing the risk of local recurrence, and analysis of long-term oncologic consequences of local recurrence.

RESULTS

The 10-year actuarial local control estimate was 89.7%. Local recurrence was salvaged in 11% of cases, resulting in 92% overall local control. On multivariate analysis, none of the study variables correlated with local recurrence. Local recurrence resulted in significantly reduced nodal control, distant metastasis control, and survival. Postoperative complications, persistent index SCC, intercurrent disease, and metachronous second primary cancer accounted for respectively 3%, 37%, 33%, and 28% of the 334 deaths noted during the 10 years following TL.

CONCLUSION

The present study underscored the long-term oncologic efficacy of primary TL, the dangers of local recurrence, the key role of local control for survival, and the importance of a long-term oncologic watch policy.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2288-2294, 2024.

Tumor volumes in T3 supraglottic cancers treated with radiotherapy in the modern era: A study of the Canadian Head & Neck Collaborative Research Initiative

PURPOSE

To evaluate the association of primary tumor volume (TV) with overall survival (OS) and disease-free survival (DFS) in T3 N0-3M0 supraglottic cancers treated with intensity-modulated radiotherapy (IMRT).

METHODS

This was a retrospective cohort study involving 239 patients diagnosed with T3 N0-3M0 supraglottic cancers between 2002 and 2018 from seven regional cancer centers in Canada. Clinical data were obtained from the patient records. Supraglottic TV was measured by neuroradiologists on diagnostic imaging. Kaplan-Meier method was used for survival probabilities, and a restricted cubic spline Cox proportional hazards regression analysis was used to analyze TV associations with OS and DFS.

RESULTS

Mean (SD) of participants was 65.2 (9.4) years; 176 (73.6%) participants were male. 90 (38%) were N0, and 151 (64%) received concurrent systemic therapy. Mean TV (SD) was 11.37 (12.11) cm3 . With mean follow up (SD) of 3.28 (2.60) years, 2-year OS was 72.7% (95% CI 66.9%-78.9%) and DFS was 53.6% (47.4%-60.6%). Increasing TV was associated (per cm3 increase) with worse OS (HR, 1.01, 95% CI 1.00-1.02, p < 0.01) and DFS (HR, 1.01, 95% CI 1.00-1.02, p = 0.02).

CONCLUSIONS

Increasing primary tumor volume is associated with worse OS and DFS in T3 supraglottic cancers treated with IMRT, with no clear threshold. The findings suggest that patients with larger tumors and poor baseline laryngeal function may benefit from upfront laryngectomy with adjuvant radiotherapy.

Survival in an era of organ preservation: an update on laryngeal cancer in Ireland

BACKGROUND

Laryngeal cancer epidemiology has changed in recent years, with falling incidence observed internationally. Organ preservation therapies have revolutionised management, though some patients may be unsuitable and survival was noted to fall in the 2000s. This study examines trends in laryngeal cancer in Ireland.

METHODS

A retrospective cohort study of National Cancer Registry of Ireland data from 1994 to 2014.

RESULTS

From a cohort of 2651, glottic disease was most common (62%, n = 1646). Incidence rose to 3.43 cases/100,000/year for 2010-2014. 5-year disease-specific survival (DSS) was 60.6% and did not change significantly over time. Overall survival (OS) for T3 disease managed with primary radiotherapy was similar to primary surgery (HR 0.98, p = 0.9). DSS for T3 disease improved with primary radiotherapy (HR 0.72, p = 0.045).

CONCLUSION

Incidence of laryngeal cancer in Ireland rose despite international trends, while survival changed little. Radiotherapy improves DSS for T3 disease but does not improve OS, possibly secondary to poor organ function post-radiotherapy.

Laryngeal cancer treatment decision making: A conjoint analysis of general public attitudes and priorities

Objective

Patients with advanced laryngeal cancer are typically presented with divergent treatment options, namely chemoradiation versus total laryngectomy. This study aims to understand general perspectives of the factors involved in this decision-making process.

Methods

Surveys were constructed using specialized conjoint analysis software. Seven attributes integral to the decision-making process for advanced laryngeal cancer treatment were included.

Results

Three hundred one healthy adult volunteers completed the decision-making program. The relative impact of each treatment attribute on decision making across all participants was scored with an average importance score (standard deviation) as follows: Lifespan 22.2% (±8.5), Voicing 21.4% (±5.9), Swallowing 19.1% (±7.3), Cancer Cure 14.9% (±6.2), Mode of Breathing 11.0% (±3.7), Self-Image 6.7% (±2.9), and Treatment Type 4.8% (±3.0).

Conclusions

General public opinion ranked lifespan, voicing, and swallowing aspects as similarly important, and all were ranked more important than probability of cure. These data demonstrate a variety of priorities among participants and the need for tailored discussions when determining treatment choice for advanced laryngeal cancer.

Level of Evidence

Level 4.

Identification of Ferroptosis-Related Genes in Laryngeal Carcinoma Using an Integrated Bioinformatics Approach

Amaç: Hücre içi demir birikimi ve lipid peroksidasyonu ile karakterize edilen ferroptoz, tümör baskılanmasında önemli rol oynayabilen yeni tanımlanmış bir hücre ölüm şeklidir. Larengeal skuamöz hücreli karsinom (LSHK) ve ferroptozis arasındaki ilişki hakkında yapılan çalışmalar sınırlıdır. Bu çalışmanın amacı, LSHK' nin tanı, tedavisinde ve ferroptozis ile ilgili belirteçleri in siliko yöntemleri kullanarak saptamaktır.Yöntem: Ferroptoz ile ilgili genler, FerrDb veri tabanından elde edildi. The Cancer Genome Atlas (TCGA) veri setlerinden LSHK hastalarının mRNA ekspresyon verileri ve ferroptoz ile ilgili bazı genleri taramak için kullanıldı. LSHK ile ilgili GSE143224 ve GSE84957 mikrodizi veri setleri GEO veri tabanından elde edilmiştir. Tüm veri setleri kullanılarak ferroptoz ve LSHK ile ilişkili genleri elde etmek için örtüşen veriler kullanılmıştır. LSHK grubu ve normal kontroller arasındaki diferansiyel olarak eksprese edilen genler (DEG'ler) ve ferroptoz ile ilgili DEG'ler, biyoinformatik yöntemler kullanılarak analiz edildi. Daha sonra STRING ve Cytoscape yazılımları kullanılarak Gene Ontology (GO), KEGG ve protein-protein etkileşimi (PPE) ağı analizleri gerçekleştirilmiştir.Bulgular: Ferroptoz ile ilgili 259 gen, FerrDb veri tabanından alındı ve ferroptoz DEG'lerini tanımlamak için bunları TCGA-HNSC (523 örnek), GSE143224 (25 örnek) ve GSE84957 (18 örnek) ile analizleri yapıldı. Analiz sonrasında 13 adet yukarı regüle edilmiş (NOX4, BID, ABCC1, TNFAIP3, PANX1, SLC1A4, SLC3A2, FTL, TFRC, AURKA, HSF1, PML, CA9; p&lt;0.05) ve 3 adet aşağı regüle edilmiş gen (CHAC1, LPIN1, MUC1; p&lt;0.05) saptanmıştır. GO, KEGG ve PPE analizleri ile elde edilen hücresel stres, inflamasyon, oksidatif stres ve karsinogenez süreçlerine benzer sonuçlar (p&lt;0.05) ile bu genlerin LSHK' nin ilerlemesinde rol oynayabileceğini göstermektedir.Sonuç: Sonuç olarak, bu çalışmada LSHK'de ferroptoz ile yakından ilişkili olan ve LSHK hastalarını sağlıklı kontrollerden ayırt edebilen 16 potansiyel gen saptanmıştır. Çalışmamız, LSHK’nin moleküler mekanizmasını ve terapötik hedeflerini keşfetmek için daha geniş bir fikir sağlayabilir.

Clinical Value Screening, Prognostic Significance, and Key Gene Identification of TrkB in Laryngeal Carcinoma

Purpose

Using human gene chip expression profiling technology to screen out downstream genes related to TrkB regulation in laryngeal cancer cells.

Methods

Using the Hep-2 TrkB shRNA cell line, divide it into an experimental group (shNTRK2) and a control group (PLKO1), and use the human gene expression microarray to screen out the differential genes. Then, select 10 upregulated genes and 10 downregulated genes from the differential genes, and use RT-PCR to verify whether the screening results of human gene expression microarray profiles are reliable. Use GO, KEGG, and miRNA enrichment analyses, PPI network diagram, etc., to analyze the differential genes and further screen out the key genes.

Results

A total of 318 differential genes (87 upregulated genes and 231 downregulated genes) were screened in laryngeal cancer cells. Use RT-PCR for the 10 upregulated differential genes (DMKN, FHL1, FOXN4, GGNBP1, HOXB9, ABCB1, TNFAI, RGS2, LINC01133, and FGG) and 10 downregulated differential genes (CHI3L1, FMOD, IGFBP1, IRF5, SPARC, NPAS4, TRPS1, TRAP, COL8A1, and DNER), and the results are consistent with the chip results, confirming the accuracy of the chip results; GO analysis results show that the downstream differential genes (DEGs) regulated by TrkB are mainly involved in biological processes such as retinol metabolic process, diterpenoid metabolic process, and regulation of cell-substrate adhesion. DEGs mainly affect cytoskeletal protein binding, serotonin-activated cation-selective channel activity, and sphingosine molecular functions. DEGs are mainly enriched in the cell periphery, secretory granule, cytoplasmic membrane-bounded vesicle lumen, blood microparticle, and other molecular components. The results of disease enrichment analysis show that the downstream differential genes regulated by TrkB are mainly involved in atypical hemolytic uremic syndrome, hematologic disease, meningococcal disease, lung cancer, susceptibility, asthma, and other diseases. The PPI network diagram results showed 7 hub genes, and then, we used GO analysis and KEGG enrichment analysis to see the biological process, cell component, molecular functions, and biological pathways.

Conclusion

Gene chip technology was used to screen out the differential genes of TrkB epigenetic modification in the Hep-2 cell line, and seven key genes (ALDH1A1, SDR16C5, PIK3R1, PLCG2, IL2RG, PIK3CD, and SPARC) were further screened using bioinformatics technology.

Marital status and survival in laryngeal squamous cell carcinoma patients: a multinomial propensity scores matched study

OBJECTIVE

To explore the correlation between the marital status and prognosis of patients with laryngeal squamous cell carcinoma (LSCC).

STUDY DESIGN

MPSM was adopted to minimize the maximum standardized average difference of the covariates among the four groups with different marital status.

SETTING

Multinomial propensity scores matching (MPSM) based on data from the surveillance, epidemiology, and end results (SEER) database.

METHODS

The Kaplan-Meier method and log-rank test were used to compare the survival outcomes of these groups with different marital status.

RESULTS

Totally, 16,981 LSCC patients (median [IQR] age 62 [55-69] years; 829 [76.41%] males) from 2004 to 2016 were included in this study. Among them, 9112 (53.66%) were married, 2708 (15.95%) divorced or separated, 1709 (10.06%) widowed, and 3452 (20.33%) single. After MPSM, the weights make the characteristics of four groups with different marital status sufficient balance. The Kaplan-Meier method and log-rank test showed widowed patients may lead to the highest mortality rate while married patients have a higher survival rate than the other three groups. Single and divorced or separated patients had no significant difference in the survival rate. In addition, multivariate analysis by controlling for confounding factors showed that in male, well-differentiated, and early stage patients, compared with married, unmarried was an independent risk factor for CSS (P < 0.05).

CONCLUSION

Marital status showed a significant association with the survival status of LSCC patients. Importantly, the outcome of married patients was better, while widowed patients tended to have worse prognosis.

Neutrophils Promote Larynx Squamous Cell Carcinoma Progression via Activating the IL-17/JAK/STAT3 Pathway

Laryngeal squamous cell carcinoma (LSCC) is the main type of laryngeal cancer with poor prognosis. Incidence of LSCC increases every year, posing a great threat to human health. The underlying mechanism needs further study. Neutrophils are the most prevalent type of immune cells, which play vital roles in crosstalk between the microenvironment and cancer cells. In our study, we aim to figure out the complex regulation between neutrophils and LSCC. Our experiments showed that LSCC cells could promote the activation and mobility of neutrophils. And, in return, neutrophils enhanced the proliferation, migration, and invasion of LSCC. The subsequent results showed that IL-17 was highly expressed in neutrophil conditioned medium. Block of IL-17 could effectively inhibit the progression of LSCC induced by neutrophils. What is more, the results showed that IL-17 activated the JAK/STAT3 pathway in LSCC. Inhibition of the JAK/STAT3 pathway could significantly block neutrophil-induced LSCC progression. Our research reveals the complex interaction between neutrophils and LSCC cells, providing new ideas for the treatment of LSCC.

Insurance Status Effect on Laryngeal Cancer Survival: A Population Based Study

OBJECTIVE

To analyze insurance status effect on overall survival (OS) and disease-specific survival (DSS) in laryngeal cancer.

STUDY DESIGN

Cross-sectional population analysis.

SETTING

Surveillance, Epidemiology, and End Results (SEER) database.

PARTICIPANTS

Laryngeal cancer patients from 2007 to 2016.

MAIN OUTCOME MEASURES

Kaplan-Meier method with log-rank statistic analyzed OS and DSS by insurance status. Multivariable cox proportional hazard modeling generated survival prognostic factors.

RESULTS

Of 19 667 laryngeal cancer cases, initial disease presentation was stage I: 7770 patients (39.5%), stage II: 3337 patients (17.0%), stage III: 3289 patients (16.7%), and stage IV: 5226 patients (26.6%). Patients had non-Medicaid insurance (15 523, 78.9%), had Medicaid (3306, 16.8%), or were uninsured (891, 4.5%). Mean and median OS for insured, Medicaid, and uninsured patients were 60.5, 49.6, and 56.6 and 74.0, 40.0, and 65.0 months, respectively. Following multivariable analysis, OS for insured, Medicaid, and uninsured patients was stage I: 87.9, 82.8, and 88.4 (P < .001), stage II: 79.1, 75.1, and 78.3 (P = .12), stage III: 68.7, 66.1, and 72.1 (P = .11), and stage IV: 57.1, 51.7, and 50.3 (P < .001) months. DSS mean survival times were 77.0, 65.8, and 67.7 months (P < .001) for insured, Medicaid, and uninsured patients. Age (HR: 1.02/year, P < .001) and black (HR: 1.15, P = .001) compared to white race predicted worse survival. Compared to insured status, Medicaid insurance carried a death hazard ratio of 1.40 (P < .001) and uninsured status had a death hazard ratio of 1.40 (P < .001).

CONCLUSION

Insured laryngeal cancer patients had prolonged OS and DSS compared to Medicaid and uninsured patients. Medicaid patients had equivalent survival outcomes to uninsured patients.

LEVEL OF EVIDENCE

2c.

[Robotics in otorhinolaryngology, head and neck surgery]

In many surgical specialities, e.g., visceral surgery or urology, the use of robotic assistance is widely regarded as standard for many interventions. By contrast, in European otorhinolaryngology, robotic-assisted surgery (RAS) is rarely conducted. This is because currently available robotic systems are not adequately adapted to the restricted space and partially difficult access to surgical fields in the head and neck area. Furthermore, RAS is associated with high costs at present. In some Anglo-American regions, robot-assisted surgery is already used regularly for different indications, particularly in transoral surgery of oropharyngeal tumors. Several feasibility studies demonstrate multiple fields of application for RAS in head and neck surgery. For standard use, the robotic systems and surgical instruments need to be reduced in size and adapted to application in the head and neck area.

Knockdown of long non-coding RNA RP11-297P16.3 inhibits the migration and invasion of laryngeal squamous carcinoma cells

PURPOSE

Laryngeal cancer has a poor prognosis when progressing to an advanced stage with limited treatment options. Therefore, understanding the underlying mechanisms is important to identify novel treatment targets. Long non-coding RNAs (lncRNAs) have been shown to play oncogenic roles in cancer, including in laryngeal cancer. We previously discovered that the lncRNA RP11-297P16.3 is overexpressed in laryngeal squamous cell carcinoma (LSCC) based on RNA-sequencing data. Therefore, the aim of the present study was to investigate the effects of knockdown of RP11-297P16.3 on the migration and invasion of LSCC cells, and the significance of these effects.

METHODS

Six methods were employed to assess the function of RP11-297P16.3 including gene silencing, RT-PCR, the 5-Ethynyl-20-deoxyuridine (EdU) staining assay, Scratch wound-healing assay, transwell assay, and Western blot.

RESULTS

The results show that the expression of RP11-297P16.3 in the si-lncRNA group was significantly decreased compared with those in the BC (blank control) and NC (negative control) groups. Moreover, knockdown of RP11-297P16.3 significantly inhibited the migration and invasion of LSCC cells but had no effect on cell proliferation. The protein expression of N-cadherin and vimentin was notably decreased after RP11-297P16.3 knockdown; whereas, the protein expression of cadherin was significantly increased CONCLUSION: These results suggested that RP11-297P16.3 may inhibit the migration and invasion of LSCC cells by regulating the epithelial-mesenchymal transition process, suggesting that RP11-297P16.3 is a potential new target for treating LSCC.

A dynamic prognostic nomogram to predict the benefit from surgical treatment modality for patients with laryngeal squamous cell carcinoma

BACKGROUND

Although nonsurgical treatment strategy is increasingly adopted in patients with locoregionally advanced laryngeal squamous cell carcinoma (LSCC), survival disparities were reported between surgical treatment modality and organ preservation protocols, highlighting the great importance for accurate patients' selection.

METHOD

This secondary analysis used data from the Surveillance, Epidemiology, and End Results database between 2010 and 2015 with follow-up data up to 2018. We developed and validated a dynamic prognostic nomogram for overall survival (OS) in 4237 patients with LSCC and subgroup of 2087 patients with locoregionally advanced laryngeal squamous cell carcinoma (LALSCC). Based on the total risk score derived from the dynamic nomogram, two well-matched risk groups (i.e., low- and high-risk) were created via X-tile software and 1-to-1 propensity score matching (PSM); surgical treatment modality was compared with nonsurgical one in each risk group.

RESULTS

A more accurate and convenient dynamic prognostic nomogram based on age, marital status, T category, N category, M category, tumor size, and tumor differentiation was developed and validated, of which the predictive performance was superior to that of TNM staging system. For high-risk LALSCC selected by the dynamic nomogram, after 1-to-1 PSM, significantly improved OS was observed in patients with receiving surgical treatment compared to those receipt of nonsurgical management (restricted mean survival time at 36-month: 26.6 vs 22.7, p < 0.001; restricted mean survival time at 60-month: 36.7 vs 31.0, p = 0.003).

CONCLUSION

We establish and validate a more accurate and convenient dynamic prognostic nomogram for patients with LSCC, which may predict the benefit from surgical treatment modality for patients with high-risk LALSCC.

Apolipoprotein M inhibits proliferation and migration of larynx carcinoma cells

Prior studies have shown that apolipoprotein M (APOM) is involved in the development of some cancers. Here we investigated the effects of APOM on larynx cancer (LC). 20 patients with vocal cord polyps and 18 patients with LC were included in this study. The protein and mRNA levels of the samples were analysed using the Wes-ProteinSimple system (or traditional Western blot) and PCR technology, respectively. APOM protein level in cancer tissues was lower than that in paracarcinomatous (P = 0.0003) and polyp tissues (P < 0.0001). APOM overexpression significantly inhibited TU686 cell proliferation (P < 0.0001) and migration (P < 0.01), and increased expression of vitamin D receptor (VDR, P < 0.0001) as well as nuclear factor erythroid 2-like 3 (NFE2L3, P = 0.0215). In addition, matrix metalloproteinase-10 (MMP-10) mRNA level was significantly reduced in the APOM overexpression group (P = 0.0077). However, Western blot analysis showed that APOM overexpression did not change VDR, NFE2L3 and MMP-10 protein levels (P > 0.05). In summary, APOM inhibits the proliferation and migration of LC cells, but may not be related to VDR, NFE2L3 and MMP-10, which needs further study.

Occult Lymph Node Metastasis in Early-Stage Glottic Cancer in the National Cancer Database

OBJECTIVES

Early-stage glottic cancer (cT1-T2 cN0) may be treated by primary surgery or radiation. Elective treatment of the neck in clinically N0 disease is usually not performed due to low rates of regional lymph node metastasis. This study examines the role of elective neck dissection (END) and rate of occult nodal metastasis in cT1-T2 cN0 glottic cancer treated with primary surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

The National Cancer Database was used to identify patients treated for early-stage glottic cancer. Demographic variables, disease characteristics, and overall survival were compared between the subgroups of patients who did and did not receive END. Factors predictive of occult lymph node metastasis were also identified using a multivariate logistic regression model.

RESULTS

Thirty-eight percent of the 991 patients in this cohort underwent END. Younger age, treatment at an academic facility, advanced T-stage, and higher tumor grade were associated with receiving END. Sixteen percent of the 372 patients undergoing END had occult nodal metastasis. Higher tumor histopathologic grade was associated with occult metastasis (P = .004). While undergoing END did not affect significantly survival, those with occult metastasis had poorer survival (P < .001).

CONCLUSIONS

END should be considered in cT1-T2 N0 glottic cancers with poorly differentiated or undifferentiated tumor histopathology. While END itself may not improve overall survival, identification of occult nodal metastasis is an important finding for prognostication.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 131:E1139-E1146, 2021.

Lymphoscintigraphy for Sentinel Node Mapping in Head and Neck Cancer

The aim of this comprehensive review is to describe and analyze the role of the sentinel node mapping in head and neck cancers. For this purpose, head and neck neoplasms have been categorized in cutaneous malignancies and neoplasms of the upper aerodigestive tract. A concise description of lymphatic drainage will be the "prelude" for each section, as well as the description of the injection techniques, when specific. Concisely, the attention has been focused on detection rate of the sentinel node by lymphoscintigraphy for each cancer, and for those patients in which the sentinel lymph node has been identified, true-positives rates, false-negative rates, and overall accuracy has been pointed out. Overall, in cutaneous neoplasms of the head and neck, the detection rate is higher than 90%, however the false-negative rate is still an issue, in particular in melanoma, inducing the need for newer developments. In fact, new tracers and techniques are already available, while prospective multicenter trials exploring the outcome impact are needed in the near future. For the upper aerodigestive tract and in particular oral cavity and oropharynx, sentinel lymph node identification by lymphoscintigraphy allows avoiding unnecessary neck dissection and/or node irradiation. Even in this case, the main limit remains the risk of false-negative rates. While, for patients affected by laryngeal and hypopharyngeal cancers the data seem very limited and, although the feasibility has been demonstrated, performances of this lymphoscintigraphy still need to be confirmed by multicenter studies.

Laryngeal Lesion Classification Based on Vascular Patterns in Contact Endoscopy and Narrow Band Imaging: Manual Versus Automatic Approach

Longitudinal and perpendicular changes in the vocal fold’s blood vessels are associated with the development of benign and malignant laryngeal lesions. The combination of Contact Endoscopy (CE) and Narrow Band Imaging (NBI) can provide intraoperative real-time visualization of the vascular changes in the laryngeal mucosa. However, the visual evaluation of vascular patterns in CE-NBI images is challenging and highly depends on the clinicians’ experience. The current study aims to evaluate and compare the performance of a manual and an automatic approach for laryngeal lesion’s classification based on vascular patterns in CE-NBI images. In the manual approach, six observers visually evaluated a series of CE+NBI images that belong to a patient and then classified the patient as benign or malignant. For the automatic classification, an algorithm based on characterizing the level of the vessel’s disorder in combination with four supervised classifiers was used to classify CE-NBI images. The results showed that the manual approach’s subjective evaluation could be reduced by using a computer-based approach. Moreover, the automatic approach showed the potential to work as an assistant system in case of disagreements among clinicians and to reduce the manual approach’s misclassification issue.

Erchen decoction plus huiyanzhuyu decoction inhibits the cell cycle, migration and invasion and induces the apoptosis of laryngeal squamous cell carcinoma cells

ETHNOPHARMACOLOGICAL RELEVANCE

Laryngeal carcinoma (LC) is one of the most common malignant head and neck cancers with high incidence and mortality rates. Erchen decoction plus Huiyanzhuyu decoction (EHD) is commonly used for treating LC patients and produces beneficial results. However, the mechanisms underlying the effects of EHD remain unclear.

AIM OF THE STUDY

The present study aimed to analyse the anticancer effects of EHD on the LC cell cycle, apoptosis, migration and invasion in vitro and to explore the underlying biological mechanisms.

MATERIALS AND METHODS

TU212 and Hep-2 cells were used. The antitumour effects of EHD were detected by CCK8, microscopy, flow cytometry, EdU incorporation, Hoechst 33342 staining, wound-healing, and transwell assays to assess viability, morphology, apoptosis, cell cycle, migration and invasion, respectively. Furthermore, STAT3 and related proteins were evaluated in laryngeal squamous cell carcinoma (LSCC) cells by Western blot (WB) analysis.

RESULTS

EHD treatment significantly decreased STAT3 and p-STAT3 protein expression levels in LSCC cells. EHD blocked the cell cycle at the G0/G1 phase and induced LSCC apoptosis. Moreover, the viability, migration, and invasion of LSCC cells were markedly inhibited by EHD. In addition, the expression of the cell cycle-related proteins cyclin D1 and cyclin B1 was downregulated in LSCC cells, but P27 expression was increased after EHD treatment. Regarding apoptosis-related proteins, EHD also reduced Bcl-2 expression but upregulated Bax and caspase-3 expression in LSCC cells. In the migration- and invasion-related protein analyses, EHD downregulated MMP-9 expression and upregulated E-cadherin expression.

CONCLUSIONS

These results suggest that EHD has an anticancer effect in LSCC. EHD treatment induces apoptosis and inhibits the cell cycle, migration and invasion of LSCC cells, but further work is warranted to address the mechanisms.

Erchen Plus Huiyanzhuyu Decoction Inhibits the Growth of Laryngeal Carcinoma in a Mouse Model of Phlegm-Coagulation-Blood-Stasis Syndrome via the STAT3/Cyclin D1 Pathway

Erchen plus Huiyanzhuyu decoction (EHD), a Chinese herbal medicine (CHM) formula that consists of Erchen decoction and Huiyanzhuyu decoction, has achieved satisfactory results in the clinic. The main function of EHD is to remove phlegm and blood stasis, and EHD is suitable for phlegm-coagulation-blood-stasis (PCBS) syndrome in laryngeal cancer (LC). In this study, a xenograft mouse model of LC with PCBS syndrome was constructed by feeding a high-fat diet, swimming in ice water, and subcutaneously injecting epinephrine hydrochloride for 2 weeks. Based on the successful Chinese medicine syndrome model, Hep2-luciferase-GFP cells were injected subcutaneously under the armpit of the right upper limb in mice to form tumours. A mouse model of LC with PCBS syndrome was established via heterotopic transplantation. Then, the mice received intragastric administration of different concentrations of EHD daily, and cisplatin (DDP) was intraperitoneally injected every week for 21 days. Tumour fluorescence in mice was measured with a living animal imager on days 7, 14, 21, and 28 during treatment. The results of this experiment confirmed that a mouse model of Chinese medicine syndrome was successfully constructed. Moreover, EHD slowed the growth of xenograft tumours in nude mice; decreased the expression levels of STAT3, p-STAT3, and cyclin D1; and upregulated the expression level of P27. In brief, EHD inhibited laryngeal tumour growth in a xenograft mouse model of PCBS syndrome and regulated the STAT3/cyclin D1 signalling pathway. This study was the first to construct a Chinese medicine xenograft mouse model of LC with PCBS syndrome; in addition, this study clarified that EHD regulated the STAT3/cyclin D1 signalling pathway to inhibit the growth of LC and that EHD may be a promising novel therapeutic compound for the treatment of patients with LC.

Evaluating the effects of smoking on the voice and subjective voice problems using a meta-analysis approach

The objectives of this study were to identify the effects of smoking on the voice of smokers and present the baseline data for establishing the basis for preventing voice disorders. This study was evaluated using a meta-analysis from studies published between Jan 1, 2000, and Nov 15, 2018. As a result, the final meta-analysis was conducted using nine papers. The standard mean difference was analyzed after dividing the effects of smoking on voice into the pitch (F0), sound quality (jitter, shimmer, and noise to harmonic ratio; NHR), Maximum Phonation Time (MPT), and subjective voice problem. The results showed that there was a significant difference in F0 and MPT. On the other hand, the jitter, shimmer, NHR, and Voice Handicap Index (VHI) had different mean effect size but they were not significantly different. The analysis by sub-function of VHI results showed that the mean effect size was significantly different only in VHI-P (Physical). This study evaluated the effects of smoking on voice using meta-analysis. It was confirmed that smoking had significant and moderate effects on the F0 of voice, MPT, VHI, and physical functions. It is necessary for future meta-analysis studies to conduct randomized controlled experiments or longitudinal studies to confirm the effect sizes of variables.

PRPH2 Activates Hippo Signalling and Suppresses the Invasion and Anoikis Inhibition of Laryngeal Cancer

Introduction

Laryngeal cancer is the most common head and neck cancer worldwide. It is urgent to identify the mechanisms underlying laryngeal cancer pathogenesis. In the present study, we investigated the biological functions of Peripherin 2 (PRPH2) in laryngeal cancer and uncovered the molecular mechanism underlying this disease.

Methods

Laryngeal cancer tissues were used to analyze the expression of PRPH2. In vitro transwell matrigel invasion assay and annexin V anoikis assay in laryngeal cancer cells were conducted to investigate PRPH2 related biological functions. Quantitative real-time PCR and Western blotting were performed to investigate the expression and mechanism of PRPH2 in laryngeal cancer.

Results

We found that the expression of PRPH2 was significantly downregulated in laryngeal cancer tissues. Overexpression of PRPH2 suppressed the invasion and anoikis inhibition of laryngeal cancer cells. Furthermore, PRPH2 overexpression increased the phosphorylation of YAP and LATS1 and decreased the activities of Rho GTPases, while PRPH2 knockdown had opposite effects. Inhibitors of the Hippo pathway abrogated PRPH2 knockdown-induced laryngeal cancer cell invasion and anoikis inhibition.

Discussion

These results suggested that PRPH2 suppresses laryngeal cancer cell invasion and anoikis inhibition by activating Hippo signalling. PRPH2 may serve as a potential therapeutic target for laryngeal cancer in the future.

Real-World Outcomes and Prognostic Factors in Patients Receiving Nivolumab Therapy for Recurrent or Metastatic Head and Neck Carcinoma

Recently, a global phase III study demonstrated that nivolumab markedly improved patient outcomes in recurrent or metastatic head and neck carcinoma (RMHNC). However, the efficacy of nivolumab in patients who are ineligible for clinical trials is unknown. We investigated nivolumab efficacy in real-world patients and prognostic factors associated with the response to nivolumab. This study was conducted at 11 institutes associated with Kyoto University and its Affiliated Hospitals-Head and Neck Oncology Group. In total, 93 patients with RMHNC who received nivolumab between May 2017 and May 2018 were retrospectively reviewed. Objective response rate (ORR), overall survival, and progression-free survival (PFS) were evaluated. Univariate and multivariate analyses were performed to identify prognostic factors. The ORRs in patients with squamous cell carcinoma (SCC) and non-SCC were 21.8% and 0%, respectively. In patients with SCC and non-SCC, the 1-year PFS rates were 28.7% and 8.9%, respectively. The hazard ratio (HR) for risk of PFS events (SCC versus non-SCC) was 2.28 (95% confidence interval: 1.21–4.1; log-rank p = 0.007). Univariate and multivariate analyses revealed radiotherapy history, platinum-refractory carcinoma, and treatment-related adverse events (TRAEs) as important prognostic factors associated with PFS in patients with SCC. In a real-world setting, non-SCC and platinum-refractory carcinoma were associated with a poorer prognosis, and a history of radiotherapy to the primary tumor, and the occurrence of TRAEs were associated with a better prognosis. These findings could be useful for clinicians and patients when selecting a treatment strategy.

Pretreatment Level of Red Cell Distribution Width as a Prognostic Indicator for Survival in a Large Cohort Study of Male Laryngeal Squamous Carcinoma

Objective: High levels of red cell distribution width (RDW) may be associated with adverse outcomes in patients with cancer. The purpose of the present study was to investigate the prognostic impact of pretreatment RDW levels on overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS) in a large cohort of male laryngeal squamous cell cancer (LSCC) patients.

Methods: A total of 809 LSCC patients who were treated between 2007 and 2011 at the Eye & ENT Hospital of Fudan University were enrolled and evaluated retrospectively. OS, CSS, and DFS were analyzed using the Kaplan–Meier method. To evaluate the prognostic significance of RDW levels, univariate, and multivariate Cox analyses were applied.

Results: Higher pretreatment RDW levels were significantly associated with high death events, red blood cell count, hemoglobin, radiotherapy, operation therapy, and advanced tumor stage (p < 0.05). From the univariate analysis, we observed that the higher (13.2–13.5%) and the highest (>13.5%) quartiles of RDW level were consistent factors for poor OS, CSS, and DFS in LSCC patients. In the multivariate analysis, after adjusting for confounding factors, the higher and highest quartiles of RDW levels were identified as independent prognostic factors in male LSCC patients.

Conclusion: Higher pretreatment RDW levels were demonstrated to be associated with poor clinical outcome in male LSCC patients and might be novel markers for patient stratification in LSCC management.

Signature microRNAs and long noncoding RNAs in laryngeal cancer recurrence identified using a competing endogenous RNA network

The aim of the present study was to identify novel microRNA (miRNA) or long noncoding RNA (lncRNA) signatures of laryngeal cancer recurrence and to investigate the regulatory mechanisms associated with this malignancy. Datasets of recurrent and nonrecurrent laryngeal cancer samples were downloaded from The Cancer Genome Atlas (TCGA) and the Gene Expression Omnibus database (GSE27020 and GSE25727) to examine differentially expressed miRNAs (DE-miRs), lncRNAs (DE-lncRs) and mRNAs (DEGs). miRNA-mRNA and lncRNA-miRNA networks were constructed by investigating the associations among these RNAs in various databases. Subsequently, the interactions identified were combined into a competing endogenous RNA (ceRNA) regulatory network. Feature genes in the miRNA-mRNA network were identified via topological analysis and a recursive feature elimination algorithm. A support vector machine (SVM) classifier was established using the betweenness centrality values in the miRNA-mRNA network, consisting of 32 optimal feature-coding genes. The classification effect was tested using two validation datasets. Furthermore, coding genes in the ceRNA network were examined via pathway enrichment analyses. In total, 21 DE-lncRs, 507 DEGs and 55 DE-miRs were selected. The SVM classifier exhibited an accuracy of 94.05% (79/84) for sample classification prediction in the TCGA dataset, and 92.66 and 91.07% in the two validation datasets. The ceRNA regulatory network comprised 203 nodes, corresponding to mRNAs, miRNAs and lncRNAs, and 346 lines, corresponding to the interactions among RNAs. In particular, the interactions with the highest scores were HLA complex group 4 (HCG4)-miR-33b, HOX transcript antisense RNA (HOTAIR)-miR-1-MAGE family member A2 (MAGEA2), EMX2 opposite strand/antisense RNA (EMX2OS)-miR-124-calcitonin related polypeptide α (CALCA) and EMX2OS-miR-124-γ-aminobutyric acid type A receptor γ2 subunit (GABRG2). Gene enrichment analysis of the genes in the ceRNA network identified that 11 pathway terms and 16 molecular function terms were significantly enriched. The SVM classifier based on 32 feature coding genes exhibited high accuracy in the classification of laryngeal cancer samples. miR-1, miR-33b, miR-124, HOTAIR, HCG4 and EMX2OS may be novel biomarkers of recurrent laryngeal cancer, and HCG4-miR-33b, HOTAIR-miR-1-MAGEA2 and EMX2OS-miR-124-CALCA/GABRG2 may be associated with the molecular mechanisms regulating recurrent laryngeal cancer.

A Critical Reappraisal of Primary and Recurrent Advanced Laryngeal Cancer Staging

Objectives:

Laryngeal squamous cell carcinoma (LSCC) can involve different anatomic subunits with peculiar surgical and prognostic implications. Despite conflicting outcomes for the same stage of disease, the current staging system considers different lesions in a single cluster. The aim of this study was to critically discuss clinical and pathologic staging of primary and recurrent advanced LSCC in order to define current staging pitfalls that impede a precise and tailored treatment strategy.

Methods:

Thirty patients who underwent total laryngectomy in the past 3 years for primary and recurrent advanced squamous cell LSCC were analyzed, comparing endoscopic, imaging, and pathologic findings. Involvement of the different laryngeal subunits, vocal-fold motility, and spreading pattern of the tumor were blindly analyzed. The diagnostic accuracy and differences between clinicoradiologic and pathologic findings were studied with standard statistical analysis.

Results:

Discordant staging was performed in 10% of patients, and thyroid and arytenoid cartilage were the major diagnostic pitfalls. Microscopic arytenoid involvement was significantly more present in case of vocal-fold fixation ( P = .028). Upstaging was influenced by paraglottic and pre-epiglottic space cancer involvement, posterior commissure, subglottic region, arytenoid cartilage, and penetration of thyroid cartilage; on the contrary, involvement of the inner cortex or extralaryngeal spread tended to be down-staged. Radiation-failed tumors less frequently involved the posterior third of the paraglottic space ( P = .022) and showed a significantly worse pattern of invasion ( P < .001).

Conclusions:

Even with the most recent technologies, 1 in 10 patients with advanced LSCC in this case series was differently staged on clinical examination, with cartilage involvement representing the main diagnostic pitfall.