Prognostic value of the nodal yield in head and neck squamous cell carcinoma: A systematic review

Lymph node yield: Impact on oncologic outcomes in oral cavity cancer

BACKGROUND

Lymph node metastases are associated with poor prognosis in oral cavity squamous cell carcinoma (OCSCC). In other cancers, clinical guidelines on the number of lymph nodes removed during primary surgery, lymph node yield (LNY), exist. Here, we evaluated the prognostic capacity of LNY on regional failure, locoregional recurrence, and disease-free survival (DFS) in patients with OCSCC treated by primary neck surgery.

METHODS

This retrospective cohort study took place at Sunnybrook Health Sciences Centre in Toronto, Canada and involved a chart review of all adult patients with treatment-naive OCSCC undergoing primary neck dissection. For each outcome, we first used the maximally selected rank statistics and an optimism-corrected concordance to identify an optimal threshold of LNY. We then used a multivariable Cox proportional hazards model to assess the association between high LNY (>threshold) and each outcome.

RESULTS

Among the 579 patients with OCSCC receiving primary neck dissection, 61.7% (n = 357) were male with a mean age of 62.9 years (standard deviation: 13.1) at cancer diagnosis. When adjusting for sociodemographic and clinical factors, LNY >15 was significantly associated with improved DFS (adjusted HR [aHR]: 0.73, 95% CI: 0.54-0.98), locoregional recurrence (aHR: 0.68, 95% CI: 0.49-0.95), and regional failure (aHR: 0.61, 95% CI: 0.39-0.93).

CONCLUSIONS

Our study findings suggested high LNY to be a strong independent predictor of various patient-level quality of surgical care metrics. The optimal LNY we found (15) was lower than the conventionally recommended (18), which calls for further research to establish validity in practice.

Do we still need Crile or Hayes Martin approach for cervical lymphadenectomy? A retrospective study of 56 patients with minimal access neck dissection

The concept of neck dissection was introduced by Crile more than a century ago. Since then, multiple modifications have been adopted to ensure the preservation of vital structures. With the new era of minimal access surgery, the incorporation of laparoscopic, endoscopic, and robotic surgery is becoming the new normal. Over the years we have carried out neck dissections using minimal access incisions. Although there is no definitive answer about the average nodal yield required in selective or modified neck dissections, it has been reported that the average nodal yield of more than 18 is associated with better survival rate. In this publication we share the results of our three-year retrospective study of 56 patients who underwent minimal access neck dissection. We look at the nodal yield, assess operating duration, complications, outcome with a three-year follow up from a single unit. Our results demonstrate that minimal access neck dissection should be considered in head and neck lymphadenectomies.

Risk factors for total laryngectomy associated proximal esophageal stricture formation in head and neck cancer patients

BACKGROUND

Development of esophageal strictures is common after the total laryngectomy of head and neck cancer patients. While endoscopic techniques like dilatation by balloon or Salvary bougies are well established, risk factors and pathophysiology for development of refractory strictures are less well understood.

OBJECTIVE

To evaluate risk factors associated with occurrence and recurrence of total-laryngectomy-associated esophageal strictures in head and neck cancer patients.

METHODS

We analyzed retrospectively a cohort of 170 head and neck squamous cell carcinoma patients, who underwent total laryngectomy between 2007 and 2017. The outcome measure was laryngectomy-associated proximal esophageal stricture needing an endoscopic dilatation by using a balloon or Savary dilators.

RESULTS

Of the 170 patients in the cohort, 32 (18.8%) developed strictures. Mean time between surgery and first endoscopic intervention was 24.4 months. Significant predictive factors were age ≥ 65 (p=0.017), nodal status N> 1 (p=0.003), continued alcohol abuse after surgery (p=0.005) and diabetes mellitus (p=0.005). In a subgroup, 17 of 32 patients developed refractory strictures and needed more than three dilatations to relieve dysphagia. Postoperative mean (p=0.016) and maximum (p=0.015) C-reactive protein (CRP) were predictive for refractory strictures.

CONCLUSION

Symptomatic strictures occurred in 18.8% of the cases. Age, nodal status N>1, continued alcohol abuse and diabetes mellitus were predictive factors. For refractory stenosis (>3 dilatations needed) mean and maximum postoperative CRP were predictive. This may indicate that systemic inflammatory response post-surgery is involved in the stricture formation process.

Node Count as a Quality Indicator in Surgically Treated Mucosal Head and Neck Squamous Cell Cancer

INTRODUCTION

A yield of ≥18 nodes from neck dissection has been shown to be associated with improved locoregional recurrence rates and survival. We sought to determine factors associated with lymph node yields below this threshold.

MATERIALS AND METHODS

A retrospective review of patients who underwent neck dissection as part of definitive surgical treatment for mucosal head and neck squamous cell carcinoma (SCC) between January 2015 and December 2018 at an academic tertiary referral center was performed. Patients with a history of prior radiation or neck dissection were excluded.

RESULTS

There were 412 neck dissections performed in 323 patients. Specimens containing <18 nodes decreased from 16.2% in 2015-2016 to 7.4% of neck dissections in 2017-2018. The proportion of neck dissections removing <3 levels decreased from 9.1% of neck dissections in 2015-2016 to 4.0% in 2017-2018. Multivariable regression analysis demonstrated that dissection of ≥3 levels (OR = 0.2 [0.1-0.4]) and neck dissection in 2017-2018 compared to 2015-2016 (OR = 0.4 [0.2-0.8]) were significantly associated with a lower odds of <18 nodes. Stage, site, race, sex, human papillomavirus status, positive nodes, surgeon volume, and pathologist volume were not associated with neck dissection specimens with <18 nodes, after controlling for all other variables.

CONCLUSIONS

Increased recognition of the importance of node count as a quality indicator, and the extent of neck dissection is associated with increased nodal yield from neck dissection. These data suggest that node count can be used as a quality measure of neck dissection for mucosal SCC.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2160-2165, 2023.

Prognostic Value of Lymph Node Yield, Lymph Node Density, and pN in Oral Cancer

OBJECTIVES

To investigate thresholds for lymph node yield (LNY), lymph node density (LND), and pN in patients with oral squamous cell carcinoma in relation to previous findings in the literature.

STUDY DESIGN

Retrospective register-based study.

SETTING

Copenhagen Oral Cavity Squamous Cell Carcinoma database.

METHODS

Appropriate thresholds for LNY, LND, and pN were determined by areas under the curve and subsequently subjected to multivariate analysis. Five-year overall survival and 3-year recurrence-free survival were determined by Kaplan-Meier survival curves.

RESULTS

In total, 413 patients diagnosed with oral squamous cell carcinoma were included. In the pN0 cohort, no superior/prognostic LNY cutoff values were detected. In the pN+ cohort, areas under the curve determined thresholds of LNY, LND, and pN to be 21 nodes, 5%, and 3 metastases, respectively. The 5-year overall survival was 52% for patients with LNY ≥21 vs 38% for patients with LNY <21 (hazard ratio [HR], 1.49; 95% CI, 1.05-2.11; P < .05), 60% for patients with LND ≤5% vs 38% for patients with LND >6% (HR, 1.63; 95% CI, 1.03-2.57; P < .05), and 43% for patients with pN <3 vs 26% for patients with pN ≥3 (HR, 1.40; 95% CI, 1.04-2.15; P < .05).

CONCLUSIONS

Increased nodal yield, decreased LND, and decreasing number of pN were associated with significantly improved survival outcomes. LNY might serve as a prognosticator of survival as well as a surgical quality indicator. LND may have implications as a tool in cancer staging and treatment planning.

Prognostic value of the nodal yield in oral squamous cell carcinoma: a systematic review and meta-analysis

OBJECTIVES

To systematically evaluate the prognostic value of the nodal yield in oral squamous cell carcinoma by meta-analysis.

METHODS

The meta-analysis was adherence to PRISMA. We searched MEDLINE, Embase, and Cochrane for studies published up to 20 April 2022. We collected evidences from observational studies regarding nodal yield in oral squamous cell carcinoma, and investigated its prognostic value by the routine methods of meta-analysis.

RESULTS

From seven studies, there was no significant impact of the lymph node yield on overall survival among patients with oral squamous cell carcinoma cases and <18 lymph nodes (hazard ratio (HR) = 1.019, 95% confidence interval (CI) = 0.786-1.320, p = 0.887), with significant heterogeneity (I² = 80%). The pooled result indicated that a > 18-lymph node yield was a favorable prognostic factor (HR = 0.786, 95%CI = 0.646-0.956, p = 0.016; I² = 39%). The lymph node yield was not associated with disease-specific survival (HR = 1.594, 95%CI = 0.996-2.552, p = 0.052; I² = 81%) or disease-free survival (HR = 1.508, 95%CI = 0.924-2.460, p = 0.100; I² = 41%).

CONCLUSION

A lymph node yield of ≥18 lymph nodes might be a favorable prognostic factor for the overall survival of patients with oral squamous cell carcinoma.

Transoral Laser Microsurgery With Neck Dissection Versus Radiotherapy for T2N0 Supraglottic Cancer

OBJECTIVES

To compare overall survival outcomes associated with transoral laser microsurgery (TLM) with neck dissection versus definitive radiotherapy in the management of T2N0 supraglottic squamous cell carcinoma.

METHODS

Data were extracted from the National Cancer Database concerning patients with cT2N0M0 supraglottic cancer treated with either TLM and neck dissection with minimum lymph node yield of 10 or definitive radiotherapy. Predictors of overall survival were assessed via Cox proportional hazards regression.

RESULTS

Seventy-six cT2N0 supraglottic squamous cell carcinoma patients who underwent TLM with neck dissection (+/- adjuvant therapy) versus 991 patients who underwent radiotherapy. TLM was associated with an overall survival benefit (OR = 0.574; 95% CI 0.383-0.860) compared with radiotherapy. There was no difference in survival between TLM patients receiving adjuvant treatment and those receiving definitive radiotherapy.

CONCLUSIONS

An up-front, TLM-based surgical approach to cT2N0 supraglottic cancer may offer an overall survival benefit compared with definitive radiotherapy, and should receive more frequent consideration as a primary approach to this disease process.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:601-606, 2023.

Insight into Classification and Risk Stratification of Head and Neck Squamous Cell Carcinoma in Era of Emerging Biomarkers with Focus on Histopathologic Parameters

Tumor-node-metastasis (TNM) staging system is the cornerstone for treatment planning of head and neck squamous cell carcinoma (HNSCC). Many prognostic biomarkers have been introduced as modifiers to further improve the TNM classification of HNSCC. Here, we provide an overview on the use of the recent prognostic biomarkers, with a focus on histopathologic parameters, in improving the risk stratification of HNSCC and their application in the next generation of HNSCC staging systems.

Prognostic Nomogram for Postoperative Hypopharyngeal Squamous Cell Carcinoma to Assist Decision Making for Adjuvant Chemotherapy

We aimed to investigate the effect of lymph node parameters on postoperative hypopharyngeal squamous cell carcinoma (HSCC) and to establish a nomogram to predict its prognosis and assist in adjuvant chemotherapy decisions. A retrospective analysis of postoperative HSCC in the Surveillance, Epidemiology, and End Results database (2004-2019) was performed. Cutoff points for continuous variables were determined by X-tile software. Univariate and multivariate analyses were performed to identify prognostic factors on overall survival (OS), and these variables were used to construct a nomogram. The nomogram's accuracy was internally validated using concordance index, area under the curve, calibration plot, and decision curve analyses. Furthermore, the value of chemotherapy in each risk subgroup was assessed separately based on individualized scores from the nomogram. In total, 404 patients were eligible for analysis, and the median OS was 39 months. Age, origin, primary site, T stage, number of lymph nodes examined, lymph node ratio, and radiotherapy were identified as prognostic factors for OS and incorporated into the nomogram. In both the training and validation cohorts, favorable performance was exhibited compared with the other stage systems, and patients could be classified into low-, intermediate-, and high-risk subgroups. Chemotherapy significantly improved the OS in the high-risk subgroup, whereas chemotherapy did not confer a survival benefit in the low- or intermediate-risk groups. The lymph node parameter-based nomogram model can better stratify the prognosis of HSCC patients and screen out patients who would benefit from chemotherapy, suggesting that the model could be used as a reference for clinical decision making and to avoid overtreatment.

Prognostic analysis of lymph node ratio of patients with disease recurrence previously submitted to cervical dissection surgery for head and neck cancer

INTRODUCTION

the variable lymph node ratio has recently been studied as a possible influencer in the survival of patients diagnosed with head and neck cancer.

OBJECTIVE

to analyze the correlation between lymph node density and survival of recurred disease patients previously submitted to cervical dissection surgery due to head and neck squamous cell carcinoma.

METHOD

we retrospectively analyzed 71 medical records of patients treated at the Head and Neck Surgery Service of the Pontifícia Universidade Católica de Campinas who had undergone cervical dissection surgery and presented tumor recurrence between 2006 and 2019. Patient and tumor data such as age, gender, skin color, smoking, alcohol consumption, location of the primary tumor, anatomopathological characteristics and lymph node status were correlated with the survival time.

RESULTS

we found a predominance of males and the mean age was 59.5 years. The most frequent primary site was the oral cavity followed by the larynx and oropharynx. The mortality rate was 53.52% and the mean lymph node ratio 0.28. We found influence on survival with statistical significance for the parameters: lymph node ratio, number of dissected and affected lymph nodes, T and N staging, type of treatment proposed (palliative or surgical), presence of compromited margins in the primary tumor and lymph node extravasation.

CONCLUSION

the calculation of lymph node density in patients with recurred disease after cervical dissection surgery by head and neck squamous cell carcinoma should be taken into account during therapeutic planning and prognostic evaluation due to its direct influence on the survival.

Lymph node ratio-dependent prognosis stratification and postoperative radiotherapy utilization in T1-2N1 oral cavity carcinoma

OBJECTIVE

Pathological T1-2N1 oral cavity squamous cell carcinoma (pT1-2N1 OCSCC) is a setting with intermediate prognosis whilst without consensus regarding the utilization of postoperative radiotherapy (PORT). This study aimed to investigate the prognostic value of lymph node ratio (LNR) and to further examine its clinical validity for guiding PORT in pT1-2N1 OCSCC.

METHODS

OCSCC patients who received surgery between 2010 and 2015 with at least 6 lymph nodes dissection were extracted from the Surveillance, Epidemiology and End Results (SEER) database. Time-dependent receiver operating characteristic (ROC) analysis was used to identify the optimal cutoff of LNR. Multivariable Cox regression analysis was employed to assess the prognostic value of LNR. Impact of PORT was evaluated in respective subgroups stratified by LNR.

RESULTS

A total of 870 OCSCC patients with pT1-2N1 diseases were eligible for analysis. The 5-year overall survival (OS) and disease-specific survival (DSS) was 57.2% and 67.9% respectively. Time-dependent ROC analyses for OS and DSS concordantly revealed 5.5% as the optimal cutoff of LNR. Significantly higher risks of death (HR = 1.610, 95% CI: 1.139-2.276) and disease-specific death (HR = 1.731, 95% CI: 1.101-2.723) were unveiled in patients with LNR > 5.5%. PORT related improvement on OS (5-year rate: 57.6% vs. 47.3%, p = 0.095) and DSS (5-year rate: 71.0% vs. 53.8%, p = 0.030) was only found in LNR > 5.5% subgroup.

CONCLUSIONS

LNR > 5.5% is indicative of inferior outcome in pT1-2N1 OCSCC, warranting the utilization of PORT in this sub-setting.

Análise prognóstica da densidade linfonodal de pacientes recidivados previamente submetidos à cirurgia de esvaziamento cervical por neoplasia de cabeça e pescoço

RESUMO Introdução: recentemente tem-se estudado a variável densidade linfonodal como possível influenciador na sobrevida de pacientes com diagnóstico de câncer de cabeça e pescoço. Objetivo: analisar a relação entre a densidade linfonodal e a sobrevida de pacientes recidivados previamente submetidos a cirurgia de esvaziamento cervical por carcinoma espinocelular de cabeça e pescoço. Método: foram analisados retrospectivamente 71 prontuários pacientes atendidos no Serviço de Cirurgia de Cabeça e Pescoço da Pontifícia Universidade Católica de Campinas que tinham sido submetidos a cirurgia de esvaziamento cervical e apresentaram recidiva tumoral entre os anos de 2006 e 2019. Dados relativos ao paciente e ao tumor tais como: idade, sexo, cor da pele, tabagismo, etilismo, localização do tumor primário, características anatomopatológicas e status linfonodal foram correlacionados ao tempo de sobrevida dos indivíduos. Resultados: encontramos predominância do sexo masculino e a média de idade foi de 59,5 anos. O sítio primário mais frequente foi a cavidade oral seguido da laringe e orofaringe. A taxa de mortalidade foi de 53,52% e a densidade linfonodal média 0,28. Encontramos influência na sobrevida com significância estatística para os parâmetros: densidade linfonodal, número de linfonodos dissecados e acometidos, estadiamento T e N, tipo de tratamento proposto (paliativo ou cirúrgico), presença de margens comprometidas no tumor primário e extravasamento linfonodal. Conclusão: o cálculo da densidade linfonodal em pacientes recidivados após cirurgia de esvaziamento cervical por carcinoma espinocelular de cabeça e pescoço deve ser levado em consideração durante o planejamento terapêutico e na avaliação prognóstica devido à sua direta influencia na sobrevida dos indivíduos.

Limits and potential implementation of the present pN classification for oral squamous cell carcinoma

PURPOSE OF REVIEW

The purpose of this review is to highlight the most important changes in the eighth TNM classification system for oral squamous cell carcinomas compared with the seventh edition with focus on lymph node staging (pN). Nodal involvement is crucial when addressing prediction of survival, and staging must mirror the disease extension. pN classification will be evaluated with respect to lymph node yield (LNY), lymph node density (LND), and a recently proposed classification: pN-N+ reflecting positive regional lymph nodes (metastatic burden) and extra nodal extension.

RECENT FINDINGS

TNM8 was introduced in 2018, and the most noteworthy changes were depth of invasion (DOI) and extranodal extension (ENE). Recent studies indicate, that TNM8-related pN is not superior to TNM7 with respect to predicting survival. LNY and LND are biased with ecological interference fallacy, and currently not recommended in future iterations of TNM. In contrast, the pN-N+ classification has demonstrated improved survival prediction compared with TNM8.

SUMMARY

The recent findings support the inclusion of pN-N+, that is, metastatic burden and extranodal extension in future iterations of TNM.

Standardized Diagnostic Workup and Patient-Centered Decision Making for Surgery and Neck Dissection Followed by Risk-Factor Adapted Adjuvant Therapy Improve Loco-Regional Control in Local Advanced Oral Squamous Cell Carcinoma

Background

Standardized staging procedures and presentation of oral squamous cell carcinoma (OSCC) patients in multidisciplinary tumor boards (MDTB) before treatment and utilization of elective neck dissection (ND) are expected to improve the outcome, especially in local advanced LAOSCC (UICC stages III–IVB). As standardized diagnostics but also increased heterogeneity in treatment applied so far have not been demonstrated to improve outcome in LAOSCC, a retrospective study was initiated.

Methods

As MDTB was introduced into clinical routine in 2007, 316 LAOSCC patients treated during 1991-2017 in our hospital were stratified into cohort 1 treated before (n=104) and cohort 2 since 2007 (n=212). Clinical characteristics, diagnostic procedures and treatment modality of patients were compared using Chi-square tests and outcome analyzed applying Kaplan-Meier plots and log-rank tests as well as Cox proportional hazard regression. Propensity scores (PS) were used to elucidate predictors for impaired distant metastasis-free survival (DMFS) in PS-matched patients.

Results

Most patient characteristics and treatment modalities applied showed insignificant alteration. Surgical treatment included significantly more often resection of the primary tumor plus neck dissection, tracheostomy and percutaneous endoscopic gastrostomy tube use. Cisplatin-based chemo-radiotherapy was the most frequent. Only insignificant improved disease- (DFS), progression- (PFS) and event-free (EFS) as well as tumor-specific (TSS) and overall survival (OS) were found after 2006 as local (LC) and loco-regional control (LRC) were significantly improved but DMFS significantly impaired. Cox regression applied to PS-matched patients elucidated N3, belonging to cohort 2 and cisplatin-based chemo-radiotherapy as independent predictors for shortened DMFS. The along chemo-radiotherapy increased dexamethasone use in cohort 2 correlates with increased DM.

Conclusions

Despite standardized diagnostic procedures, decision-making considering clear indications and improved therapy algorithms leading to improved LC and LRC, shortened DMFS hypothetically linked to increased dexamethasone use had a detrimental effect on TSS and OS.

Is the addition of extranodal extension and lymph node yield of pN0 to the lymph node ratio useful as a prognostic parameter for patients with oral squamous cell carcinoma?

We investigated the value of the weighted lymph node ratio (WLNR), a new marker in pN0 patients that incorporates the number of metastatic lymph nodes with extranodal extension and the lymph node yield, for the prognosis and postsurgical management of oral squamous cell carcinoma (OSCC). We designed a retrospective study and enrolled patients with OSCC who were treated by neck dissection (ND). The predictor variable was WLNR, and the outcome variable was overall survival (OS). The Cox proportional-hazards model was used to identify independent prognostic factors. In 133 patients with OSCC, the WLNR cut-off value for predicting OS was 0.0363 (area under the curve 0.723, p<0.001). When stratified according to WLNR, there was a significant difference in OS (88.4% for low WLNR and 63.0% for high WLNR, p<0.001). Univariate analyses showed close associations between OS and age, dissection area, postoperative management, extranodal extension, number of positive lymph nodes, pN stage, WLNR, and nodal disease area. Cox multivariate analysis identified the WLNR as an independent predictive factor for OS (HR 3.273, 95% CI 1.227 to 8.731, p=0.018). As a predictive factor, a high WLNR (≥0.0363) in patients with pN0 disease, which included the addition of extranodal extension and lymph node yield to the LNR, was associated with diminished survival.

Defining High-Quality Integrated Head and Neck Cancer Care Through a Composite Outcome Measure: Textbook Outcome

OBJECTIVES/HYPOTHESIS

To further improve the quality of head and neck cancer (HNC) care, we developed a composite measure defined as "textbook outcome" (TO).

METHODS

We analyzed a retrospective cohort of patients after curvative-intent primary surgery, radiotherapy (RT), or chemoradiation (CRT) for HNC between 2015 and 2018 at the Netherlands Cancer Institute. TO was defined as 1) the start of treatment within 30 days, 2a) satisfactory pathologic outcomes, without 30-day postoperative complications, for the surgically treated group, and 2b), for RT and CRT patients, no unexpected or prolonged hospitalization and toxicity after the completion of treatment as planned.

RESULTS

In total, 392 patients with HNC were included. An overall TO was achieved in 9.6% of patients after surgery, 20.6% after RT, and 2.2% after CRT. Two indicators (margins >5 mm and start treatment <30 days) reduced TO radically for both groups.

CONCLUSION

TO can aid the evaluation of the quality of care for HNC patients and guide improvement processes.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

The Prognostic Value of Lymph Node Burden in Oral Cavity Cancer: Systematic Review and Meta-Analysis

OBJECTIVES

Lymph node burden has been proposed to estimate the cumulative adverse effect of nodal metastasis. In this study, a meta-analysis was conducted to evaluate the prognostic value of lymph node burden in oral cavity squamous cell carcinoma.

STUDY DESIGNS

Systemic review and meta-analysis.

METHODS

PubMed, EMBASE and the Cochrane Library as well as manual searches were performed until April 2020. The adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of overall survival, disease-specific survival, and disease-free survival were extracted and pooled.

RESULTS

Eleven included studies were published between 2009 and 2019. The cumulative number of patients was 20,607 (range 35-14,554). Extranodal extension was adjusted or evaluated in all of the studies. The meta-analysis indicated that a higher lymph node burden was significantly related to worse overall survival (HR 2.62, 95% CI 2.12-3.25), worse disease-specific survival (HR 3.14, 95% CI 1.85-5.33) and worse disease-free survival (HR 2.30, 95% CI 1.62-3.26). The highest hazard ratio was observed when the cutoff value was 3 for overall survival, 3 for disease-specific survival, and 4 for disease-free survival. The hazard ratio showed an upward trend before the cutoff value of 3 but no significant incremental change when the cutoff exceeded 3.

CONCLUSIONS

In oral squamous cell carcinoma, lymph node burden is an independent prognosticator for survival outcomes. However, more prospective or high-quality studies are required to determine the optimal cutoff.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Prognostic value of the nodal yield in elective neck dissections in patients with head and neck carcinomas

PURPOSE

The objective of this study is to assess the prognostic capacity of the nodal yield in elective neck dissections performed in patients with head and neck squamous cell carcinomas (HNSCC) without clinical or radiological evidence of regional involvement (cN0) at the time of diagnosis.

METHODS

Retrospective study including 647 patients with HNSCC treated with an elective neck dissection.

RESULTS

Patients with < 15 dissected nodes (n = 172, 26.6%) had a 5-year disease-specific survival of 64.9% (95% CI: 57.3-72.5%), while for patients with ≥ 15 dissected nodes (n = 475, 73.4%), it was of 81.9% (95% CI: 78.4-85.4%) (P = 0.0001). The nodal yield category had prognostic capacity on the disease-specific survival in patients with tumors located in the oral cavity (P = 0.001), the oropharynx (P = 0.023) and the hypopharynx (P = 0.034), while for patients with tumors located in the larynx, no significant differences appeared (P = 0.779). Differences in regional recurrence-free survival were also observed based on the nodal yield category in patients with extra-laryngeal tumors (5-year regional recurrence-free survival of 81.0% in patients with < 15 dissected nodes vs 89.0% in patients with ≥ 15 dissected nodes; P = 0.046).

CONCLUSION

The nodal yield in elective neck dissections in patients without evidence of lymph node disease (cN0) had prognostic capacity depending on the location of the primary tumor. For tumors located in the larynx, the number of dissected nodes did not significantly influence the prognosis. For tumors located in the oral cavity, oropharynx or hypopharynx, patients with < 15 dissected nodes had a disease-specific mortality 2.9 times higher than patients with ≥ 15 dissected nodes.

Lymph node yield in treatment naïve cases of head and neck squamous cell carcinoma: en bloc lymphadenectomy versus level-by-level dissection

BACKGROUND

Lymph node yield is an important prognostic factor in head and neck squamous cell carcinoma. Variability in neck dissection sampling techniques has not been studied as a determinant of lymph node yield.

METHODS

This retrospective study used lymph node yield and average nodes per level to compare level-by-level and en bloc neck dissection sampling methods, in primary head and neck squamous cell carcinoma cases operated between March 2017 and February 2020.

RESULTS

From 123 patients, 182 neck dissections were analysed, of which 133 were selective and the rest were comprehensive: 55 had level-by-level sampling and 127 had undergone en bloc dissection. The level-by-level method yielded more nodes in all neck dissections combined (20 vs 17; p = 0.097), but the difference was significant only for the subcohort of selective neck dissection (18.5 vs 15; p = 0.011). However, the gain in average nodes per level achieved by level-by-level sampling was significant in both groups (4.2 vs 3.33 and 4.4 vs 3, respectively; both p < 0.001).

CONCLUSION

Sampling of cervical lymph nodes level-by-level yields more nodes than the en bloc technique. Further studies could verify whether neck dissection sampling technique has any impact on survival rates.

Prognostic capacity of the weighted lymph node ratio in head and neck squamous cell carcinoma patients treated with salvage neck dissection

PURPOSE

The aim of the study was to assess the prognostic capacity of the recently described weighted lymph node ratio (WLNR) in patients with head and neck squamous cell carcinoma (HNSCC) who undergo salvage neck dissection for regional recurrence.

MATERIAL AND METHODS

We retrospectively studied 197 adult patients with head and neck squamous cell carcinoma treated with salvage neck dissection from 1990 to 2017.

RESULTS

The mean value for the WLNR for all patients was 26.2%. We established a classification based on the WLNR values taking 10.8% as the cut-off point. Five-year disease-specific survival for patients with WLNR ≤ 10.8% (n = 89, 45.2%) was 39.9% (IC 95% 29.4-50.4%), and for patients with WLNR ≥ 10.8% (n = 108, 54.8%) it was 20.5% (IC 95% 12.3-28.7%) (p = 0.007). The multivariate analysis showed the WLNR had a significant prognostic capacity.

CONCLUSIONS

As a variable that integrates data related to the number of metastatic nodes with extracapsular spread to the LNR, the WLNR has a prognostic value in the pathological assessment of HNSCC patients with regional recurrence treated with salvage neck dissection.

Factors Associated with Lymph Node Count in Mucosal Squamous Cell Carcinoma Neck Dissection

OBJECTIVE/HYPOTHESIS

Decreased lymph node count (LNC) from neck dissection (ND) for mucosal head and neck squamous cell carcinoma (HNSCC) patients is correlated with decreased survival. Advanced age and low BMI due to undernutrition from dysphagia from advanced T-stage tumors are common in patients with HNSCC. We studied the relationship between these two well-described causes for immune dysfunction and LNC in patients undergoing neck dissection.

STUDY DESIGN

We conducted a retrospective review at a single tertiary care institution of patients with HNSCC that underwent neck dissection from 2006 to 2017.

METHODS

Stepwise linear and logistic regression analyses were performed on 247 subjects to identify independent significant factors associated with 1) the LNC per neck level dissected; 2) advanced T-stage. One-way ANOVA was utilized to demonstrate differences between the p16 positive and negative subgroups.

RESULTS

Low BMI (<23 vs. ≥23) (P = .03), extra nodal extension (ENE) (P = .0178), and advanced age (P = .005) were associated with decreased LNC per neck level dissected on multivariable analysis. Higher T-stage (P = .0005) was correlated with low BMI (<23) after controlling for the effects of tobacco, smoking, sex, ECE, and p16 status. p16+ patients, on average had higher BMI, were younger and produced a higher nodal yield (P < .0001, .007, and .035).

CONCLUSIONS

Patient intrinsic factors known to correlate with decreased immune function and worse outcomes, including p16 negative status, advanced age, and low BMI from undernutrition and ENE are associated with low nodal yield in neck dissections. LNC may be a metric for anti-tumor immune function that correlates with prognosis and T-stage.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1516-1521, 2021.

Evaluating compliance with process-related quality metrics and survival in oral cavity squamous cell carcinoma: Multi-institutional oral cavity collaboration study

BACKGROUND

Process-related measures have been proposed as quality metrics in head and neck cancer care. A recent single-institution study identified four key metrics associated with increased survival. This study sought to validate the association of these quality metrics with survival in a multi-institutional cohort.

METHODS

Multicenter retrospective study of patients with oral cavity squamous cell (1/2005-1/2015). Baseline patient and disease characteristics and compliance with quality metrics was evaluated. Association between compliance with quality metrics with overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) was evaluated using Cox proportional hazards models.

RESULTS

Failure to comply with two or more of the quality metrics was associated with worse OS, DFS, and DSS. Adherence to all or all but one of the quality metrics was found to be associated with improved survival.

CONCLUSIONS

Process-related quality metrics are associated with increased survival in patients with oral cavity squamous cell carcinoma in a multi-institutional cohort.

Rational surgical neck management in total laryngectomy for advanced stage laryngeal squamous cell carcinomas

PURPOSE

Controversies exist in regard to surgical neck management in total laryngectomies (TL). International guidelines do not sufficiently discriminate neck sides and sublevels, or minimal neck-dissection nodal yield (NY).

METHODS

Thirty-seven consecutive primary TL cases from 2009 to 2019 were retrospectively analyzed in terms of local tumor growth using a previously established imaging scheme, metastatic neck involvement, and NY impact on survival.

RESULTS

There was no case of level IIB involvement on any side. For type A and B tumor midline involvement, no positive contralateral lymph nodes were found. Craniocaudal tumor extension correlated with contralateral neck involvement (OR: 1.098, p = 0.0493) and showed increased involvement when extending 33 mm (p = 0.0134). Using a bilateral NY of ≥ 24 for 5-year overall survival (OS) and ≥ 26 for 5-year disease-free survival (DFS) gave significantly increased rate advantages of 64 and 56%, respectively (both p < 0.0001).

CONCLUSIONS

This work sheds light on regional metastatic distribution pattern and its influence on TL cases. An NY of n ≥ 26 can be considered a desirable benchmark for bilateral selective neck dissections as it leads to improved OS and DFS. Therefore, an omission of distinct neck levels cannot be promoted at this time.

Weighted lymph node ratio: New tool in the assessment of postoperative staging of the neck dissection in HPV-negative head and neck squamous cell carcinoma patients

BACKGOUND

The objective of this study is to assess a new parameter, the weighted lymph node ratio (WLNR), which incorporates prognostic information regarding the number of metastatic nodes with extracapsular spread and the lymph node yield for pN0 patients to the lymph node ratio.

METHODS

We studied retrospectively 1118 patients with head and neck squamous cell carcinoma (HNSCC) treated with a neck dissection.

RESULTS

We obtained a classification with four categories based on the WLNR values. WLNR classification had a higher prognostic discrimination capacity and a more homogeneous distribution in the number of patients included in each of the categories than the pTNM classification.

CONCLUSION

The WLNR improved the predictive capacity of the eighth edition of the pTNM classification and it can be a useful tool in the assessment of the postoperative staging of the neck dissections in HNSCC patients.

Triaging algorithm for head & neck oncology follow-up patients in COVID-19 climate

The current climate is one of uncertainty and immeasurable tragedy for people afflicted by the pandemic of SARS-CoV-2 virus infection. As professionals, we have a duty of care towards all patients especially the vulnerable and those suffering with life-threatening illnesses such as oral cancer. We present a safe & objective triaging method for afflicted with this disease in the prevailing morbid situation.

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Objective method.

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Safe triaging system.

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Risk assessment in COVID-19 climate.

Impact of Radiotherapy on Neck Dissection Nodal Count in Patients With Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

Our study aimed to review the impact of preoperative radiotherapy (RT) and other factors on the lymph node count of neck dissection (ND) specimens from patients with head and neck cancer (HNC). A retrospective study was conducted on all patients with head and neck cancers who had undergone NDs in Singapore General Hospital between 1992 and 2013.

STUDY DESIGN

Retrospective study.

METHODS

Patients were categorized into two groups: patients treated with RT with or without chemotherapy before ND and patients who had undergone ND surgery without previous history of RT. The primary endpoint for this study would be the lymph node count from ND.

RESULTS

The study cohort consists of 1,024 NDs on 829 patients. There were 597 (58.3%) radical/modified radical NDs involving levels I-V. Within this group, 75 (12.6%) NDs had preoperative RT. Preoperative RT and age were found to significantly reduce nodal yield in both univariate and multivariate analysis in the radical/modified radical ND subgroup. In our multivariate analysis, preoperative RT was shown to decrease the nodal yield by 7.464 (P = .0002, 95% confidence interval [CI]: -11.35 to -3.58). Advanced age independently decreases nodal yield, even after accounting for the effect of RT (P = .0002, 95% CI: -0.27 to -0.08). In addition, preoperative RT has a more pronounced effect in reducing lymph node count in the older age group.

CONCLUSIONS

Preoperative RT and advanced age are independent and synergistic factors that reduce nodal count from NDs in patients with head and neck cancers.

LEVEL OF EVIDENCE

4 Laryngoscope, 130: 1947-1953, 2020.

Lymph node yield and lymph node ratio in oral cavity and oropharyngeal carcinoma: Preliminary results from a prospective, multicenter, international cohort

OBJECTIVES

Recently, Lymph Node Yield (LNY) and Lymph Node Ratio (LNR) have emerged as prognostic indicators in head and neck cancer. However, there is a lack of data regarding the LNY and LNR values in the specific neck levels dissected and regarding the factors that influence these values.

MATERIALS AND METHODS

Preliminary results of the NCT03534778 trial are reported. LNY and LNR values were estimated for 100 patients with oral or oropharynx carcinoma, from November 1, 2018 to September 30, 2019.

RESULTS

Overall, the mean number of lymph nodes retrieved was 34.4 (95% confidence interval [CI] 31.6-37.3). LNY means and CI per single neck level were as follows: level I 5.5 lymph nodes harvested (95% CI 3.5-7.5), level II 15.4 (95% CI 10.6-20.2), level III 8.0 (95% CI 4.6-11.3), level IV 6.3 (95% CI 3.4-9.15), level V 6.3 (95% CI 3.6-9.0). cN+ patients had a higher number of lymph nodes retrieved, odds ratio (OR) 1.2 (95% CI 1.05-1.36). Smokers had less lymph nodes harvested, OR 0.78 (95% CI, 0.71-0.87). Mean LNR was 0.063 (95% CI 0.047-0.078). A multiple regression analysis showed that anatomic site, pN, smoking status and LNY statistically significantly predicted the LNR (p < 0.05) CONCLUSIONS: The LNY and LNR values are influenced by various demographic and pathological characteristics of the patient, such as the number of dissected levels, primary site, cN positivity, and smoking status.

Prognostic value of the nodal yield in head and neck squamous cell carcinoma: A systematic review

Objective

Literature analysis on the prognostic factor of the nodal yield (NY) in neck dissections (NDs), which in general surgical oncology is a strong prognosticator and quality‐of‐care marker.

Methods

We performed a systematic review of all PubMed and Embase publications until June 30, 2018 screening for data on NY as prognosticator and overall survival (OS) as outcome in patients with head and neck squamous cell carcinoma (HNSCC). Risk for bias was asserted by application of the Quality In Prognosis Studies tool.

Results

Of the 823 screened publications, 15 were included in this analysis. Five out of seven that compared NY ≥18 vs <18 as prognosticator, showed significantly improved survival if NY ≥18. Six studies used other cutoffs and three reported improved survival with each additionally harvested lymph node.

Conclusion

Increased NY in ND specimen for HNSCC, most commonly described as ≥18 lymph nodes, is associated with improved OS and could be used as a prognosticator and quality‐of‐care marker.