Lymph node characteristics and their prognostic significance in oral squamous cell carcinoma

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

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

Prognostic Role of Tumor-Infiltrating Lymphocytes in Oral Squamous Cell Carcinoma

BACKGROUND

In oral squamous cell carcinoma (OSCC), the tumor-node-metastasis (TNM) staging system is a significant factor that influences prognosis and treatment decisions for OSCC patients. Unfortunately, TNM staging does not consistently predict patient prognosis and patients with identical clinicopathological characteristics may have vastly different survival outcomes. Host immunity plays an important role in tumor progression but is not included in the TNM staging system. Tumor-infiltrating lymphocytes (TILs) are part of the host immune response that recognizes tumor cells; and the presence of TILs has emerged as potential candidates for prognostic markers for many types of cancers. The present study aims to determine the association of T cell-specific markers (CD3, CD4, CD8, and FOXP3) with clinicopathological characteristics and survival outcomes in OSCC patients. The prognostic value of CD3, CD4, and CD8 will also be evaluated based on tumor stage.

METHODS

Tissue microarrays were constructed containing 231 OSCC cases and analyzed by immunohistochemical staining for the expression of CD3, CD4, CD8, and FOXP3. The expression scores for each marker were correlated with clinicopathological parameters and survival outcomes. The prognostic impact of CD3, CD4 and CD8 were further analyzed based on tumor stage (early or advanced).

RESULTS

CD3, CD4, and CD8 were found to be significantly associated with both overall survival and progression-free survival using univariate analysis. However, none of these markers were found to independently predict the survival outcomes of OSCC using multivariate analysis. Only conventional factors such as nodal status, tumor differentiation and perineural invasion (PNI) were independent predictors of survival outcomes, with nodal status being the strongest independent predictor. Additionally, low CD4 (but not CD3 or CD8) expression was found to identify early-stage OSCC patients with exceptionally poor prognosis which was similar to that of advanced staged OSCC patients.

CONCLUSIONS

TIL markers such as CD3, CD4, CD8, and FOXP3 can predict the survival outcomes of OSCC patients, but do not serve as independent prognostic markers as found with conventional factors (i.e. nodal status, tumor differentiation and PNI). CD4 expression may assist with risk stratification in early-stage OSCC patients which may influence treatment planning and decision making for early-stage OSCC patients.

Extranodal extension in oral squamous cell carcinoma: clinical and histopathological analysis

OBJECTIVE

Extranodal extension (ENE) is an important prognostic factor in oral squamous cell carcinoma (OSCC). This study aimed to evaluate the clinical significance of stratifying minor or major ENE in OSCC.

STUDY DESIGN

This retrospective cohort study included 75 patients who had undergone neck dissection for OSCC and were classified as pN+. ENE was measured using hematoxylin-eosin-stained specimens and stratified into major (ENEma, >2 mm) and minor (ENEmi, ≤2 mm) by distance. Their association with survival, locoregional relapse, and distant metastases were assessed.

RESULTS

Of 49 patients with pathological ENE, 23 had ENEmi, and 26 had ENEma. The 5-year overall survival (OS) was 38%, 66%, and 76% in the ENEma, ENEmi, and no ENE groups, respectively. Compared with no ENE, ENEma was associated with significantly decreased 5-year cumulative OS and disease-specific survival. ENEma was a risk factor for decreased OS (HR: 2.54, 95% CI: 1.04-6.18, P = .040) in the multivariable Cox regression analysis, and was associated with distant metastasis.

CONCLUSION

In patients with OSCC, ENEma is associated with a significantly poorer prognosis; therefore stratifying ENE is clinically relevant. ENEma may increase the risk of distant metastasis; therefore, new treatment modalities that contribute to distant metastasis control are required.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Identification of PANoptosis-related biomarkers and analysis of prognostic values in head and neck squamous cell carcinoma

PANoptosis plays a crucial role in cancer initiation and progression. However, the roles of PANoptosis-related genes (PARGs) in the prognosis and immune landscape of head and neck squamous cell carcinoma (HNSCC) remain unclear. Integrated bioinformatics analyses based on the data of HNSCC patients in the TCGA database were conducted. We extracted 48 PARGs expression profile and then conducted differentially expressed analysis, following building a Cox model to predict the survival of HNSCC patients. Subsequently, the relationships between the risk score, immune landscape, chemo-, and immune-therapy responses were analyzed, respectively. Moreover, we investigated the prognostic value, and further predicted the pathways influenced by PARGs. Finally, we identified the biological function of crucial PARGs. A total of 18 differentially expressed PARGs were identified in HNSCC, and a Cox model including CASP8, FADD, NLRP1, TNF, and ZBP1 was constructed, which showed that the risk score was associated with the prognosis as well as immune infiltration of HNSCC patients, and the risk score could be regarded as an independent biomarker. Additionally, patients with high-risk score might be an indicator of lymph node metastasis and advanced clinical stage. High-risk scores also contributed to the chemotherapy resistance and immune escape of HNSCC patients. In addition, FADD and ZBP1 played a crucial role in various cancer-related pathways, such as the MAPK, WNT, and MTOR signaling pathways. On the other hand, we suggested that FADD facilitated the progression and 5-fluorouracil (5-FU) resistance of HNSCC cells. A signature based on PANoptosis showed great predictive power for lymph node metastasis and advanced stage, suggesting that the risk score might be an independent prognostic biomarker for HNSCC. Meanwhile, FADD, identified as a prognostic biomarker, may represent an effective therapeutic target for HNSCC.

Evaluating the impact of the degree of extranodal extension on outcomes in locally advanced oral cavity cancer

BACKGROUND

Evaluate whether extranodal extension (ENE) extent impacts outcomes in patients with oral cavity squamous cell carcinoma (OCSCC).

METHODS

From an institutional database, patients with OCSCC and pathologic ENE who received adjuvant treatment were included. Surgical slides were reviewed to confirm ENE extent. Multivariable Cox regression was used to relate patient/treatment characteristics with disease-free survival (DFS) and overall survival (OS). ENE was analyzed as both a dichotomous and continuous variable.

RESULTS

A total of 113 patients were identified. Between major (>2 mm) versus minor ENE (≤2 mm), there was no significant difference in DFS (HR 1.18, 95%CI 0.72-1.92, p = 0.51) or OS (HR 1.17, 95%CI 0.70-1.96, p = 0.55). There was no significant association between ENE as a continuous variable and DFS (HR 0.97 per mm, 95%CI 0.87-1.4, p = 0.96) or OS (HR 0.96 per mm, 95%CI 0.83-1.11, p = 0.58).

CONCLUSION

No significant relationship was seen between ENE extent and DFS or OS in individuals with OCSCC.

Extranodal extension in head and neck squamous cell carcinoma: need for accurate pretherapeutic staging to select optimum treatment and minimize toxicity

PURPOSE OF REVIEW

In 2017, the American Joint Committee on Cancer (AJCC) introduced the inclusion of extracapsular nodal extension (ENE) into the N staging of nonviral head and neck squamous cell carcinoma (HNSCC), while retaining the traditional N classification based on the number and sizes of metastatic nodes. The extent of ENE was further defined as microscopic ENE (ENEmi) and major ENE (ENEma) based on extent of disease beyond the nodal capsule (≤ or > 2 mm). This article reviews the evidence and progress made since these changes were introduced.

RECENT FINDINGS

The 'gold standard' for evaluation ENE is histopathologic examination, the current preferred primary treatment of patients with HNSCC is by radiation-based therapy ± chemotherapy or biotherapy. The current pretreatment staging is by imaging, which needs improved reliability of radiologic rENE assessment with reporting needs to consider both sensitivity and specificity (currently computed tomography images have high-specificity but low-sensitivity). Adjuvant chemotherapy is indicated for patients with ENEma to enhance disease control, whereas for patients with ENEmi, there is a need to assess the benefit of adjuvant chemotherapy. Evidence that the presence of pENE in HPV-positive oropharyngeal carcinoma is an independent prognostic factor and should be considered for inclusion in future AJCC editions has recently emerged.

SUMMARY

There remains a paucity of data on the reliability of imaging in the staging of rENE, more so the for the accurate assessment of ENEmi. Optimistic early results from use of artificial intelligence/deep learning demonstrate progress and may pave the way for better capabilities in tumor staging, treatment outcome prediction, resulting in improved survival outcomes.

The clinical implication and translational research of OSCC differentiation

BACKGROUND

The clinical value and molecular characteristics of tumor differentiation in oral squamous cell carcinoma (OSCC) remain unclear. There is a lack of a related molecular classification prediction system based on pathological images for precision medicine.

METHODS

Integration of epidemiology, genomics, experiments, and deep learning to clarify the clinical value and molecular characteristics, and develop a novel OSCC molecular classification prediction system.

RESULTS

Large-scale epidemiology data (n = 118,817) demonstrated OSCC differentiation was a significant prognosis indicator (p < 0.001), and well-differentiated OSCC was more chemo-resistant than poorly differentiated OSCC. These results were confirmed in the TCGA database and in vitro. Furthermore, we found chemo-resistant related pathways and cell cycle-related pathways were up-regulated in well- and poorly differentiated OSCC, respectively. Based on the characteristics of OSCC differentiation, a molecular grade of OSCC was obtained and combined with pathological images to establish a novel prediction system through deep learning, named ShuffleNetV2-based Molecular Grade of OSCC (SMGO). Importantly, our independent multi-center cohort of OSCC (n = 340) confirmed the high accuracy of SMGO.

CONCLUSIONS

OSCC differentiation was a significant indicator of prognosis and chemotherapy selection. Importantly, SMGO could be an indispensable reference for OSCC differentiation and assist the decision-making of chemotherapy.

Hippo-YAP signaling activation and cross-talk with PI3K in oral cancer: A retrospective cohort study

OBJECTIVES

This study aimed to investigate the clinical and prognostic relevance of the Hippo-YAP transactivators YAP1 and TAZ in oral squamous cell carcinoma, and their possible relationship with PI3K/mTOR pathway activation.

MATERIALS AND METHODS

Immunohistochemical analysis of YAP1, TAZ, PIK3CA (p110α), p-AKT (Ser473), and p-S6 (Ser235) was performed in paraffin-embedded tissue specimens from 165 OSCC patients. Correlations between protein expression and clinical data were further assessed.

RESULTS

YAP1 expression was detected in both cytoplasm and nucleus of tumor cells, whereas TAZ expression was only found in the nucleus. Nuclear YAP1 was significantly associated with tumor size (p = 0.03), neck lymph node metastasis (p = 0.02), TNM stage (p = 0.02), and poor differentiation (p = 0.04). Nuclear TAZ was associated with tobacco (p = 0.03) and alcohol consumption (p = 0.04), and poor tumor differentiation (p = 0.04). There was a positive significant correlation between nuclear and cytoplasmic YAP1, nuclear TAZ, p110α expression, and mTORC1 activation p-S6 (S235). Combined expression of nuclear and cytoplasmic YAP1 was prognostic in both univariate and multivariate analyses. Active nuclear YAP1 was significantly and independently associated with poor disease-specific (p = 0.005, HR = 2.520; 95% CI = 1.319-4.816) and overall survival (p = 0.015, HR = 2.126; 95% CI = 1.155-3.916).

CONCLUSION

Nuclear YAP1 is an independent predictor of poor survival in oral squamous cell carcinoma.

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

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

Hypoxic tumor-derived exosomal miR-21 induces cancer-associated fibroblast activation to promote head and neck squamous cell carcinoma metastasis

BACKGROUND

Both microRNA-21-5p (miR-21) and the tumor microenvironment, including hypoxia and cancer-associated fibroblasts (CAFs), play a vital role in head and neck squamous cell carcinoma (HNSCC), but whether there is an interaction and the specific regulatory mechanism between them in the process of metastasis is still unclear. In this study, we aimed to elucidate the connection and regulatory mechanism of miR-21, hypoxia, and CAFs in HNSCC metastasis.

METHODS

The underlying mechanisms of HIF1α regulating miR-21 transcription, promoting exosome secretion, CAFs activation, tumor invasion, and lymph node metastasis were determined through quantitative real-time PCR, immunoblotting, transwell, wound healing, immunofluorescence, ChIP, electron microscopy, nanoparticle tracking analysis, dual-luciferase reporter assay, co-culture model and xenografts experiments.

RESULTS

MiR-21 promoted the invasion and metastasis of HNSCC in vitro and in vivo, whereas HIF1α knockdown inhibited these processes. HIF1α upregulated transcription of miR-21 and promoted the release of exosomes from HNSCC cells. Exosomes derived from hypoxic tumor cells were rich in miR-21, which induced NFs activation towards CAFs by targeting YOD1. Knockdown the expression level of miR-21 in CAFs prevented lymph node metastasis in HNSCC.

CONCLUSION

Hypoxic tumor cell-derived exosomal miR-21 might be a therapeutic target to prevent or delay HNSCC invasion and metastasis.

The Role of Contrast-Enhanced Ultrasound in the Differential Diagnosis of Tuberous Vas Deferens Tuberculosis and Metastatic Inguinal Lymph Nodes

PURPOSE

To retrospective analysis and summary the features of tuberous vas deferens tuberculosis (VD TB) and inguinal metastatic lymph nodes (MLN) in routine ultrasound (US) and contrast-enhanced US (CEUS) as well as to assess the utility of CEUS in differentiating between the two diseases.

METHODS

The US and CEUS findings of patients with pathologically confirmed tuberous VD TB (n = 17) and inguinal MLN (n = 28), including the number of lesions, presence of bilateral disease, differences in internal echogenicity, a conglomeration of lesions, and blood flow within the lesions, were retrospectively analyzed.

RESULTS

Routine US showed no significant difference in the number of lesions, nodule size, internal echogenicity, sinus tract, or skin rupture; however, significant differences were observed between the two conditions in the conglomeration of lesions (χ² = 6.455; p = 0.023) and the degree, intensity, and echogenicity pattern on CEUS (χ² = 18.865, 17.455, and 15.074, respectively; p = 0.000 for all).

CONCLUSIONS

CEUS can show the blood supply of the lesion, and judge the physical condition of the lesion better than US. Homogeneous, centripetal, and diffuse enhancement should prompt a diagnosis of inguinal MLN, whereas lesions with heterogeneous and diffuse enhancement on CEUS should be considered as VD TB. CEUS has great diagnostic value in differentiating between tuberous VD TB and inguinal MLN.

Is the N2A Category Still Necessary for Oral Cancer Patients After Extranodal Extension Upgrade?

BACKGROUND

The presence of single-node metastasis (Ns) sometimes could be encountered in patients with oral squamous cell carcinoma (OSCC). The survival outcome for different Ns should be worthy of discussion.

METHODS

Patients diagnosed with OSCC at the National Taiwan University Hospital between January 2007 and December 2018 were reviewed. All patients with Ns were classified into two groups: with and without extranodal extension (ENE).

RESULTS

We analyzed 311 OSCC patients with Ns: 77 (24.76%) with and 234 (75.24%) without ENE. Lymph node (LN) >3 cm was the only significant factor associated with ENE (odds ratio 17.21, p < 0.001). The 5-year, disease-free survival of N₁/N_2A and N_3B patients was 60.5% and 49.4%, respectively (p = 0.04), and the 5-year overall survival was 63.1% and 33.6%, respectively (p = 0.0001). Four fifths of Ns patients with LN >3 cm were upgraded to N_3B category as ENE+. Postoperative radiotherapy (PORT) could provide significant benefit in regional control for Ns patients with (p = 0.03) and without (p = 0.0004) other adverse features. After multivariant Cox analysis, ENE+ was a modest and significant risk factor for disease-free (p = 0.08) and overall survival (p = 0.001). By contrast, the LN>3cm and N_2A category were not significant risk factors for disease-free and overall survival.

CONCLUSIONS

For OSCC patients with Ns, the survival outcome between N_3B category and N₁/N_2A category was significantly different. After ENE+ upgrades (>80%), there were fewer N_2A patients, and these patients became more comparable to N₁ patients. PORT could significantly improve regional control for Ns patients.

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.

Persistent lymph nodes after curative chemoradiotherapy for head and neck cancer: imaging predictors of response for decision-making

PURPOSE

To identify response predictors in patients with head and neck squamous cell carcinoma (N + HNSCC) and persistent lymph nodes after curative chemoradiotherapy treatment (CCRT).

MATERIALS AND METHODS

Consecutive patients with N + HNSCC treated with CCRT and persistent lymph nodes at first follow-up between 2015 and 2021 were identified and analyzed. Complete response was defined as the absence of lymph node metastatic involvement in patients with salvage lymphadenectomy or the absence of progression after 1 year of successive follow-ups. Tumour type and location, staging, and human papillomavirus (HPV) status were considered for analysis. The number and size of lymph nodes, type, shape, enhancement and margins on diagnostic and follow-up CT were also analyzed.

RESULTS

The cohort included 46 patients with 134 pathological lymph nodes. Logistic regression models showed the following variables to be significant: performance of salvage lymphadenectomy (OR 0.094, [CI 95% 0.004-0.61], p = 0.037); the type of lymphadenopathy on diagnostic CE-CT (solid vs. cystic) (N1: OR = 4.11, [CI 95% 1.11-17.93], p = 0.042 and N3: OR 6.42, [CI 95% 1.2-42.56], p = 0.036); the change of shape (round to oval) on the follow-up CE-CT (OR 9.76, [CI 95% 1.79-8.57], p = 0.016) and the time in days between CCRT and the first follow-up CE-CT (OR 1.06, [CI 95% 1.004-1.13], p = 0.048).

CONCLUSIONS

In our experience, the presence of solid lymph nodes on pre-treatment CT and the change in shape from round to oval on post-treatment CT are predictors of response to treatment in patients with N + HNSCC persistent lymph nodes after CCRT. Increasing the temporal interval between treatment and follow-up CT should be considered to avoid unnecessary nodal dissections.

Application of anatomy unit resection surgery for lateral basicranial surgical approach in oral squamous carcinoma

BACKGROUND

The basicranial region lacks definite boundaries and includes various anatomical units. We developed a novel concept of the posterior oral anatomical complex (POAC) to identify these anatomical units in the basicranial region. OSCC with POAC involvement is termed posterior oral squamous cell carcinoma (POSCC) with poor prognosis. The principal aim of this study was to evaluate the effect of anatomy unit resection surgery (AUSR) on patients with POSCC.

METHODS

A total of 120 POSCC patients who underwent radical surgical treatment were recruited for this study. These POSCC patients were treated with conventional surgery or AUSR. According to the extent of primary tumor resection in the AUSR group, the lateral basicranial surgical approach can be subdivided into four types: face-lateral approach I, face-lateral approach II, face-median approach or face-median and face-lateral combined approach. Facial nerve function was evaluated according to the House-Brackmann Facial Nerve Grading System.

RESULTS

The overall survival rate was 62.5% and 37.5% in the AURS group and conventional group (hazard ratio: 0.59; p < 0.0001), respectively. The disease-free survival rate was 62.5% and 34.3% in the AURS group and conventional group (hazard ratio: 0.43; p = 0.0008), respectively. The local disease control rate in the AURS group (71.4%) was significantly better than that in the conventional group (34.4%) in present study (p < 0.0001). Compared to the conventional group, all the patients undergoing AURS were classified as T4 stage and presented with more lymph node metastasis (71.4%). A total of 20 patients (face-lateral approach I and face-lateral combined approach) were temporarily disconnected from the temporofacial branch of the facial nerve. Fifteen patients exhibited slight paresis, and five patients presented with moderate or severe paresis. The survival rate of zygomatic arch disconnection was 94.6% (54 of 56 patients).

CONCLUSION

This lateral basicranial surgical approach based on AUSR improves the survival rate and enhances the local control rate while also preserving a good prognosis without damaging the nerve and zygomatic bone. This surgical approach based on AUSR provides a novel and effective surgical treatment to address POSCC with better prognosis, especially for patients without metastatic lymph nodes.

Subcategorization of Perineural Invasion and Its Impact on Survival in Patients with Oral Squamous Cell Carcinoma

BACKGROUND

Perineural invasion (PNI) is  recognized as a poor prognostic factor in oral squamous cell carcinoma (OSCC). However, the prognostic significance of further histologic  subcategorization of PNI is inconclusive. In this study, we determined the prognostic relevance of histologic subcategories of PNI and their correlation with the presence of other clinical and pathological parameters METHODS: This is a retrospective study of 207 homogeneously treated OSCC patients with histologically documented PNI from a single center. Univariate and multivariate survival outcomes, namely, local recurrence-free survival (LRFS), disease-free survival (DFS), and overall survival (OS) of patients with various subcategories of PNI,namely- number of foci, size of the involved nerve, extratumoral or intratumoral extent, and intraneural or perineural location-were determined.

RESULTS

Within the histologic subcategories of PNI, tongue primary and presence of lymph node metastasis correlated significantly with the number of nerves involved with PNI. Larger size of involved nerve correlated with advanced tumor stage. Number of foci, extent, and location of PNI were not prognostically significant except size of the involved nerve which showed an inverse correlation with disease outcome as involvement of larger nerves displayed better outcomes in terms of DFS and LRFS but not of OS on multivariate analysis. Addition of adjuvant chemotherapy to radiotherapy emerged as a significant predictor of improved LRFS, DFS, and OS.

CONCLUSIONS

Histologic subcategorization of PNI did not have prognostic relevance in our study. Involvement of even small nerves was associated with poor prognosis. Addition of chemoradiation was seen to improve prognosis.

Lymph Node Ratio as a Prognostic Factor in Neck Dissection in Oral Cancer Patients: A Systematic Review and Meta-Analysis

Simple Summary

Lymph node ratio (LNR) is a well-studied prognostic factor in colorectal and breast cancer, and it has been recently evaluated as a clinically relevant biomarker in oral squamous cell carcinoma. LNR represents the ratio of positive lymph nodes extracted in a neck dissection to the total number of nodes harvested (lymph node yield, LNY). Many single-center cohort studies and a few multicenter have assessed the significance of LNR as a prognostic factor in oral cancer. In this systematic review and meta-analysis of 32 studies and 20,994 oral cancer patients, we demonstrate that LNR is an independent prognostic indicator in patients with oral squamous cell carcinoma.

Abstract

Many studies have evaluated the clinical implications of lymph node ratio (LNR) as a prognostic factor in patients with oral squamous cell carcinoma (OSCC). The main purpose of this systematic review and meta-analysis was to address LNR as a prognosticator in patients with OSCC. A systematic search was conducted in the following databases: PubMed, EMBASE, Google Scholar, OpenGrey, Cochrane library, and ClinicalTrials.gov, and studies between 2009 and 2020 were sought. The pooled relative risk was calculated along with 95% confidence intervals for the following endpoints: overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), distant metastasis-free survival (DMFS), locoregional disease-free survival (LRDFS), local recurrence-free survival (LRFS), and recurrence-free survival (RFS) according to the random-effects model (Der Simonian–Laird approach). Subgroup and meta-regression analyses were performed as well. Finally, 32 cohort studies were eligible, which included 20,994 patients with OSCC. Patients were subdivided into two categories, group YES (studies that included in their analysis only patients with positive lymph nodes) and group NO (studies that did not exclude LNR = 0 patients). In the group YES, patients with high LNR had shorter OS (RR = 1.68, 95% CI: 1.47–1.91), DFS (RR = 1.68, 95% CI: 1.42–1.99), DSS (RR = 1.94, 95% CI: 1.56–2.42), DMFS (RR = 1.83, 95% CI: 1.13–2.96), LRDFS (RR = 1.55, 95% CI: 1.10–2.20), and LRFS (RR = 1.73, 95% CI: 1.41–2.13) compared to patients with low LNR. In the group NO, patients with high LNR in comparison had shorter OS (RR = 2.38, 95% CI: 1.99–2.85), DFS (RR = 2.04, 95% CI: 1.48–2.81), and DSS (RR = 2.90, 95% CI: 2.35–3.57) compared to patients with low LNR. Based on those findings, LNR might be an independent prognostic factor for OS in patients with OSCC and could be incorporated into future classification systems for better risk stratification.

Diagnosing cervical lymph node metastasis in oral squamous cell carcinoma based on third-generation dual-source, dual-energy computed tomography

OBJECTIVES

To investigate the potential of dual-energy computed tomography (DECT) parameters in identifying metastatic cervical lymph nodes in oral squamous cell carcinoma (OSCC) patients and to explore the relationships between DECT and pathological features.

METHODS

Clinical and DECT data were collected from patients who underwent radical resection of OSCC and cervical lymph node dissection between November 2019 and June 2021. Microvascular density was assessed using the Weidner counting method. The electron density (ED) and effective atomic number (Z_eff) in non - contrast phase and iodine concentration (IC), normalized IC, slope of the energy spectrum curve (λ_HU), and dual-energy index (DEI) in parenchymal phase were compared between metastatic and non - metastatic lymph nodes. Student's t-test, Pearson's rank correlation, and receiver operating characteristic curves were performed.

RESULTS

The inclusion criteria were met in 399 lymph nodes from 103 patients. Metastatic nodes (n = 158) displayed significantly decreased ED, IC, normalized IC, λ_HU, and DEI values compared with non-metastatic nodes (n = 241) (all p < 0.01). Strong correlations were found between IC (r = 0.776), normalized IC (r = 0.779), λ_HU (r = 0.738), DEI (r = 0.734), and microvascular density. Area under the curve (AUC) for normalized IC performed the highest (0.875) in diagnosing metastatic nodes. When combined with the width of nodes, AUC increased to 0.918.

CONCLUSION

DECT parameters IC, normalized IC, λ_HU, and DEI reflect pathologic changes in lymph nodes to a certain extent, and aid for detection of metastatic cervical lymph nodes from OSCC.

KEY POINTS

• Electron density, iodine concentration, normalized iodine concentration, λ_HU, and dual-energy index values showed significant differences between metastatic and non-metastatic nodes. • Strong correlations were found between iodine concentration, normalized iodine concentration, slope of the spectral Hounsfield unit curve, dual-energy index, and microvascular density. • DECT qualitative parameters reflect the pathologic changes in lymph nodes to a certain extent, and aid for the detection of metastatic cervical lymph nodes from oral squamous cell carcinoma.

Novel pathological predictive factors for extranodal extension in oral squamous cell carcinoma: a retrospective cohort study based on tumor budding, desmoplastic reaction, tumor-infiltrating lymphocytes, and depth of invasion

Background

Extranodal extension (ENE) is a poor prognostic factor for oral squamous cell carcinoma (OSCC). Identifying ENE by clinical and/or radiological examination is difficult, thereby leading to unnecessary neck dissections. Currently, no definitive predictors are available for ENE. Thus, we aimed to determine the histological predictors of ENE by routine histopathological examination using biopsy and surgically resected specimens.

Methods

This retrospective study included 186 surgically resected OSCC and 83 matched biopsy specimens. Clinical features associated with the tumor microenvironment, including desmoplastic reaction (DR), tumor budding (TB), and tumor-infiltrating lymphocytes (TILs), were evaluated using hematoxylin and eosin-stained primary OSCC and neck dissection specimens. These histological features were divided into two groups: DR-immature (DR-I) and DR-mature (DR-M); TB-high (TB-H) and TB-low (TB-L); and TILs-low (TILs-L) and TILs-high (TILs-H). Clinical depth of invasion (cDOI) and pathological DOI (pDOI) were adapted for biopsies and resections, respectively; DOI was evaluated as DOI > 10 mm and DOI ≤ 10 mm. The clinicopathological relationships between these histopathological features and ENE and the independent risk factors for ENE were analyzed. The histological predictors of ENE were evaluated.

Results

The histological status of DR, TILs, and TB present in biopsy and resection specimens showed high accuracy with that of ENE. DR-I, TILs-L, and TB-H were significantly associated with lymph node metastasis, cDOI, and pDOI. Bivariate and multivariate analyses revealed that TB-H and pDOI > 10 mm in resections were independent factors for the presence of ENE (ENE +). The combination of TB-H/pDOI > 10 mm in resection specimens showed high specificity (91%) and accuracy (83%) regarding ENE + . Although there proved to be no independent factors in biopsies, DR-I and TILs-L were significantly associated with ENE + (p < 0.001). The combination of DR-I/TILs-L/cDOI > 10 mm in biopsies exhibited high sensitivity and specificity with ENE + (70% and 77%, respectively, p < 0.001). These histological predictors could detect even minor ENE (< 2 mm).

Conclusions

The tumor microenvironment status in primary OSCC was significantly associated with that of ENE, and TB-H was an independent risk factor for ENE. The histological status of DR-I/TILs-L/cDOI > 10 mm in biopsy specimens and TB-H/pDOI > 10 mm in resection specimens is a useful predictor of ENE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09393-8.

Value of contrast-enhanced ultrasound in predicting early lymph-node metastasis in oral cancer

OBJECTIVES

To explore the value of contrast-enhanced ultrasound (CEUS) in predicting early lymph node metastasis in clinically node-negative oral cancer patients.

METHODS

We recruited 42 patients (a total of 70 lymph nodes) with clinically node-negative oral cancer in the study. All of them received both conventional ultrasound (B-mode and power Doppler) and CEUS before operation and then they were taken for pathological examination to analyze the diagnostic accuracy. And their CEUS data were analyzed qualitatively and quantitatively.

RESULTS

The sensitivity and specificity of CEUS in the diagnosis of cervical lymph node metastasis of oral cancer were 82.7 and 82.9%, respectively. The accuracy of conventional ultrasound was only 67.1% while that of CEUS was up to 82.9%. The area under the cure (AUC) of CEUS in detecting lymph node metastasis was 0.828, which was higher than the 0.614 by conventional ultrasound, with statistically significant differences observed (p < 0.05). Most of the metastatic lymph nodes were characterized by inhomogeneous enhancement and the peak intensity (PI) of the metastatic group was lower than that of the non-metastatic group (p < 0.05).

CONCLUSIONS

Compared with conventional ultrasound, CEUS may have higher clinical value for predicting early lymph node metastasis in clinically node-negative oral cancer patients. And quantitative parameters obtained from CEUS may provide valuable information in the diagnosis of cervical lymph node metastasis.

Tumor-Infiltrating CD4+ Central Memory T Cells Correlated with Favorable Prognosis in Oral Squamous Cell Carcinoma

OBJECTIVE

Oral squamous cell carcinoma (OSCC) is the most frequent oral malignancy with a poor prognosis, in which tumor-infiltrating immune cells may play a critical role. Therefore, our study aims to screen potential immune cells and immune-related genes for predicting OSCC prognosis.

METHODS

A total of 310 OSCC patients with full transcriptional data and clinical characteristics were extracted from the TCGA database. Then, we obtained their abundance of tumor-infiltrating immune cells on TIMER 2.0 and analyzed them using xCell method. Univariate and multivariate Cox regressions were applied successively to identify the immune cells associated with overall survival of OSCC patients. Furthermore, we screened the prognostic genes that related to the identified immune cells and validated their expressions by immunohistochemistry.

RESULTS

CD4+ central memory T (TCM) cell was recognized as the sole independent immune cell correlated with OSCC prognosis (p = 0.0085). A novel nomogram based on CD4+ TCM cell abundance was established for predicting the prognosis of OSCC patients, with calibration plots showing good performance for 1-, 3-, 5-year overall survival. Thirty-four related prognostic genes were screened according to the differential abundance of CD4+ TCM cell infiltration. In immunohistochemistry analysis, DEFB1 showed a significant positive relationship with the density of CD4+ TCM cells (p = 0.0075).

CONCLUSION

CD4+ central memory T cell was proposed as an independent prognostic biomarker for OSCC patients. DEFB1 might positively regulate the abundance of tumor-infiltrating CD4+ TCM cells, thus improving OSCC prognosis. Our findings may provide a new insight into better prognosis prediction and precise medicine for OSCC.

A combined postoperative nomogram for survival prediction in clear cell renal carcinoma

PURPOSE

To investigate and validate the prognostic value of nomogram models for predicting disease-free survival (DFS) and overall survival (OS) in patients with clear cell renal cell carcinoma (ccRCC).

METHODS

In this retrospective study, 223 patients (age 54.38 ± 10.93 years) with pathologically confirmed ccRCC who underwent resection and lymph node dissection between March 2010 and September 2018 were investigated. All patients were randomly divided into training (n = 155) and validation (n = 68) cohorts. Radiomics features were extracted from computed tomography (CT) images in the unenhanced, corticomedullary, and nephrographic phases. Radiomic score was calculated and combined with clinicopathological factors for model construction and nomogram development. Clinicopathological factors and imaging features were collected at initial diagnosis. Univariate and multivariate Cox proportional hazards regression analyses were used to evaluate the relationship between the radiomics signature and prognosis outcomes.

RESULTS

There were four prognostic factors for predicting DFS and five factors for predicting OS in our nomogram model (P < 0.05). The radiomics signature correlated independently with DFS (hazard ratio = 27; P < 0.001) and OS (hazard ratio = 25; P < 0.001). The nomogram showed excellent performance (C-index = 0.825) for predicting DFS. The combined nomogram also showed the highest C-index for OS (C-index = 0.943), which was verified in the validation dataset.

CONCLUSION

The combined nomogram model based on radiomics, clinicopathological factors, and preoperative CT features can accurately perform prognosis and survival analysis and can potentially be used for preoperative non-invasive survival prediction in ccRCC patients.

Determinants of prognosis in patients with oral squamous cell carcinoma metastasizing to a single cervical lymph node

OBJECTIVES

Metastasis in a single lymph node without adverse tumour factors and perineural invasion has been assigned to a lower risk category by the ASCO recommendations of 2019. We analyzed patients with a single positive node with a view to identifying high risk features and their impact on prognosis within this subgroup.

MATERIALS AND METHODS

The study retrospectively analyzed 707 patients with OSCC. Descriptive statistics were used to compare distribution of clinicopathologic risk features between 323 N0 and 121 single node positive (N_s) patients. The N_s group was further analyzed for the impact of clinicopathologic factors on disease free (DFS) and overall survival (OS) using univariate and multivariate models.

RESULTS

The N_s group exhibited greater depth of invasion compared to the N0 group and significantly higher proportion of lymphovascular invasion (LVI), perineural invasion (PNI) and poorly differentiated tumors. Within the N_s group, primary tumor localised to the gingivobuccal subsite (HR 2.55, 1.18-5.52 95%CI, p = 0.02) and PNI (HR 2.55, 1.14-5.62, 95%CI p = 0.02) exhibited poor DFS. PNI also contributed to poor OS (HR 2.86, 1.27-6.47 95%CI, p = 0.01). Uninvolved margins (HR 0.46, 0.22-0.96 95%CI, p = 0.04) and chemoradiation (HR 0.18,0.05-0.68 95% CI, p = 0.01) improved OS.

CONCLUSION

Significant differences are noted in the prevalence of pathologic risk factors between the single node positive and node negative groups. Within the single node positive group, tumour factors like the gingivobuccal subsite, PNI and margin positivity impacted survival. Among nodal factors, deposit size of 12 mm or more and presence of ENE are pointers to poor prognosis. These patients would benefit from adjuvant treatment.

Extranodal Extension in Bilateral Cervical Metastases: A predictor of Undesirable Survival Outcomes despite Aggressive Salvage Treatment in Oral Cancer Patients

Objectives: Despite the inclusion of extranodal extension (ENE) in the recent staging system, the presence of ENE alone is not sufficient to depict all clinical situations, as ENE is frequently found in multiple nodes. Thus, the purpose of this study was to evaluate the surgery-based treatment outcomes and clinicopathological features of oral cavity squamous cell carcinoma (OCSCC) patients with ENE found in bilateral multiple cervical metastases.

Materials and methods: A retrospective single-institutional study of OCSCC patients with bilateral ENE nodes was performed from January 2011 to December 2018. OCSCC patients of different admission statuses (with primary lesions (PL), recurrent lesions (RL) and isolated neck metastases (INM)) were included for subgroup comparisons. All patients received surgical treatment with/without adjuvant therapies and had complete follow-up data. Disease-free survival (DFS) was regarded as the main outcome. Time-to-relapse data were also collected for comparison.

Results: A total of 128 patients were included, of whom 97 (75.8%) were male. The mean follow-up period reached 15 months. Among the patients, 85 (66.4%) were treated for PLs, followed by 26 (20.3%) treated for RLs after failed prior therapy and 17 (13.3%) treated for INMs (concurrent or sequential). The DFS rate was merely 35.2%. Treatment-related factors such as surgical margin (p=0.003), postoperative adjuvant therapy (p=0.014) and perioperative complications (p=0.036) were significantly associated with patient outcomes. In addition, oral lesion-related variables such as oral subsites (p=0.037), T classification (p=0.026) and skull base involvement (p=0.040) were indicators of a worse prognosis. For bilateral ENE features, ENE subclassification (p=0.036), maximum size of ENE nodes (p=0.039) and arterial nodal encasement (p=0.025) tended to predict the surgery-based treatment outcomes of these patients.

Conclusions: Bilateral cervical metastases with ENE features, though uncommon, are a serious regional burden, and these patients have lower-than-expected treatment outcomes, especially those with RLs or INMs. A fairly large number of OCSCC patients with advanced oral lesions gain little benefit from intensified salvage surgical treatment. Such treatment should instead be offered to select patients with smaller bilateral ENE nodes (<3 cm) and those with lower ENE subclassifications and no arterial nodal encasement.

Comparing prognostic utility between the 8th edition of TNM staging system and the lymph node ratio for oral squamous cell carcinoma

BACKGROUND

Lymph node metastasis in oral squamous cell carcinoma (OSCC) is associated with poor prognosis. The 8th edition of TNM has implemented new nodal staging criteria. We assess the prognostic utility of the lymph node ratio (LNR) and compare it to that of pN in the TNM 8th edition.

METHODS

One hundred and forty-two patients with OSCC were retrospectively studied. Nodal staging was performed using the TMN 8th edition and the prognostic value of the LNR in terms of overall survival (OS) and disease-free survival (DFS) was evaluated.

RESULTS

Fifty-seven patients were eligible for inclusion. The LNR was independently prognostic of OS (p = 0.02). Instead N classification was not significantly predictive of OS (p = 0.10). High LNRs resulted in decreases in OS of approximately 40% within 6 months after surgery.

CONCLUSIONS

The LNR identifies patients with poor outcomes better than N classification. The lack of reliable LNR cutoffs compromises its utility in clinical practice.

Arecoline induces epithelial-mesenchymal transformation and promotes metastasis of oral cancer by SAA1 expression

Arecoline, the main alkaloid of areca nut, is well known for its role in inducing submucosal fibrosis and oral squamous cell carcinoma (OSCC), however the mechanism remains unclear. The aim of this study was to establish an arecoline‐induced epithelial‐mesenchymal transformation (EMT) model of OSCC cells and to investigate the underlying mechanisms. CAL33 and UM2 cells were induced with arecoline to establish an EMT cell model and perform RNA‐sequence screening. Luminex multiplex cytokine assays, western blot, and RT‐qPCR were used to investigate the EMT mechanism. Arecoline at a concentration of 160 μg/ml was used to induce EMT in OSCC cells, which was confirmed using morphological analysis, transwell assays, and EMT marker detection. RNA‐sequence screening and Luminex multiplex cytokine assays showed that many inflammatory cytokines (such as serum amyloid A1 [SAA1], interleukin [IL]‐6, IL‐36G, chemokine [CCL]2, and CCL20) were significantly altered during arecoline‐induced EMT. Of these cytokines, SAA1 was the most highly upregulated. SAA1 overexpression induced EMT and promoted the migration and invasion of CAL33 cells, while SAA1 knockdown attenuated arecoline‐induced EMT. Moreover, arecoline enhanced cervical lymph node metastasis in an orthotopic xenograft model of the tongue established using BALB/c nude mice. Our findings revealed that arecoline induced EMT and enhanced the metastatic capability of OSCC by the regulation of inflammatory cytokine secretion, especially that of SAA1. Our study provides a basis for understanding the mechanism of OSCC metastasis and suggests possible therapeutic targets to prevent the occurrence and development of OSCC associated with areca nut chewing.

Assessment Criteria and Clinical Implications of Extranodal Extension in Head and Neck Cancer

Tumor breaching the capsule of a lymph node is termed extranodal extension (ENE). It reflects aggressiveness of a tumor, creates anatomic challenges for disease clearance, and increases the risk of distant metastasis. Extranodal extension can be assessed on a pathology specimen, by radiology studies, and by clinical examination. Presence of ENE in a pathology specimen has long been considered a high-risk feature of disease progression and would ordinarily benefit from the addition of chemotherapy to adjuvant radiotherapy. Although the eighth edition of the Union for International Cancer Control/American Joint Committee on Cancer stage classification dichotomizes pathologic ENE according to its presence or absence, emerging evidence suggests that the extent of a pathologic ENE may provide additional value for risk stratification to guide adjuvant therapy. Recent data suggest that the prognostic importance of pathologic ENE is also applicable for HPV-associated head and neck squamous cell carcinoma. In addition, compelling data demonstrate that indisputable radiologic ENE is a powerful risk stratification tool to identify patients at high risk for treatment failure, especially distant metastasis, applicable for both HPV-positive and HPV-negative head and neck squamous cell carcinoma. However, the definition and taxonomy of radiologic ENE requires standardization. The goal of this review is to clarify the contemporary understanding of the prognostic implications of ENE in head and neck squamous cell carcinoma, present the nuances of what is presently known and unknown, and elucidate how to classify ENE pathologically and radiologically with an understanding of the strengths and weaknesses of each approach. Finally, with the development of several risk stratification methods, the relative role of ENE and other prognostic schema will be explored.

FGF8 induces epithelial-mesenchymal transition and promotes metastasis in oral squamous cell carcinoma

Oral squamous cell carcinoma (OSCC) is one of the most common cancers worldwide, and with 354 864 new cases each year. Cancer metastasis, recurrence, and drug resistance are the main causes to cripples and deaths of OSCC patients. As potent growth factors, fibroblast growth factors (FGFs) are frequently susceptible to being hijacked by cancer cells. In this study, we show that FGF8 is upregulated in OSCC tissues and high FGF8 expression is related with a set of clinicopathologic parameters, including age, drinking, and survival time. FGF8 treatment enhances the invasive capability of OSCC cells. Lentivirus-based FGF8 expression promotes OSCC metastasis in a mouse lung metastasis model. Further, mechanistic study demonstrates that FGF8 induces epithelial-mesenchymal transition (EMT) in OSCC cells. These results highlight a pro-metastatic function of FGF8, and underscore the role of FGF8 in OSCC development.