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Chen Q, Wang SY, Chen Y, Yang M, Li K, Peng ZY, Xu CW, Yao XB, Li HH, Zhao Q, Cao YD, Bai YX, Li X. Novel pretreatment nomograms based on pan-immune-inflammation value for predicting clinical outcome in patients with head and neck squamous cell carcinoma. Front Oncol 2024; 14:1399047. [PMID: 38915366 PMCID: PMC11194608 DOI: 10.3389/fonc.2024.1399047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/20/2024] [Indexed: 06/26/2024] Open
Abstract
Background The prognostic value of an effective biomarker, pan-immune-inflammation value (PIV), for head and neck squamous cell carcinoma (HNSCC) patients after radical surgery or chemoradiotherapy has not been well explored. This study aimed to construct and validate nomograms based on PIV to predict survival outcomes of HNSCC patients. Methods A total of 161 HNSCC patients who underwent radical surgery were enrolled retrospectively for development cohort. The cutoff of PIV was determined using the maximally selected rank statistics method. Multivariable Cox regression and least absolute shrinkage and selection operator (LASSO) regression analyses were performed to develop two nomograms (Model A and Model B) that predict disease-free survival (DFS). The concordance index, receiver operating characteristic curves, calibration curves, and decision curve analysis were used to evaluate the nomograms. A cohort composed of 50 patients who received radiotherapy or chemoradiotherapy (RT/CRT) alone was applied for generality testing of PIV and nomograms. Results Patients with higher PIV (≥123.3) experienced a worse DFS (HR, 5.01; 95% CI, 3.25-7.72; p<0.0001) and overall survival (OS) (HR, 5.23; 95% CI, 3.34-8.18; p<0.0001) compared to patients with lower PIV (<123.3) in the development cohort. Predictors of Model A included age, TNM stage, neutrophil-to-lymphocyte ratio (NLR), and PIV, and that of Model B included TNM stage, lymphocyte-to-monocyte ratio (LMR), and PIV. In comparison with TNM stage alone, the two nomograms demonstrated good calibration and discrimination and showed satisfactory clinical utility in internal validation. The generality testing results showed that higher PIV was also associated with worse survival outcomes in the RT/CRT cohort and the possibility that the two nomograms may have a universal applicability for patients with different treatments. Conclusions The nomograms based on PIV, a simple but useful indicator, can provide prognosis prediction of individual HNSCC patients after radical surgery and may be broadly applicated for patients after RT/CRT alone.
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Affiliation(s)
- Qian Chen
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Shi-Yang Wang
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yue Chen
- Center for Gut Microbiome Research, Med-X Institute Centre, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Ming Yang
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Kai Li
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Zi-Yang Peng
- School of Future Technology, National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Chong-Wen Xu
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Xiao-Bao Yao
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Hong-Hui Li
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Qian Zhao
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yu-Dan Cao
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yan-Xia Bai
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Xiang Li
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
- Center for Gut Microbiome Research, Med-X Institute Centre, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
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Iancu D, Fulga A, Vesa D, Zenovia A, Fulga I, Sarbu MI, Tatu AL. Metastatic patterns and treatment options for head and neck cutaneous squamous cell carcinoma (Review). Mol Clin Oncol 2024; 20:40. [PMID: 38756868 PMCID: PMC11097132 DOI: 10.3892/mco.2024.2739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/14/2024] [Indexed: 05/18/2024] Open
Abstract
According to current predictions, one-fifth of all Americans will develop skin cancer during their lifetime. Cutaneous squamous cell carcinoma (cSCC) most commonly occurs in the head and neck region, which is the area of the body with the highest level of sun exposure. High-risk head and neck cSCC (HNcSCC) is a broad category with numerous high-risk factors that are associated with unfavorable results. In cSCC staging systems, clinical and tumor traits that are likely to result in poor outcomes are identified. Metastasis occurs in ~2.5% of patients with cSCC, most often in the local lymph nodes, and there is some indication that lymph node metastasis has a distinct pattern based on the tumor site. Current findings on tumor molecular targets have suggested the use of systemic treatments, particularly immunotherapy (such as cemiplimab, pembrolizumab and nivolumab), over radiotherapy or chemotherapy for this type of metastasis. However, when used simultaneously with immunotherapy, radiotherapy may be beneficial in the treatment of metastatic HNcSCC by improving the efficacy of immunotherapy. The present review aims to assess the existing literature on metastatic HNcSCC pathways and treatment options, in order to define current and future directions. Notably, there is an urgent need to identify patients who may benefit from local or systemic cancer treatments. The treatment of lymph node metastasis presents a therapeutic challenge and requires comprehensive management.
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Affiliation(s)
- Doriana Iancu
- Department of Otorhinolaryngology, ‘Sfantul Andrei’ Emergency Clinical Hospital of Galati, 800578 Galati, Romania
- Clinical Department, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University of Galati, 800010 Galati, Romania
| | - Ana Fulga
- Department of Otorhinolaryngology, ‘Sfantul Andrei’ Emergency Clinical Hospital of Galati, 800578 Galati, Romania
- Clinical Department, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University of Galati, 800010 Galati, Romania
| | - Doina Vesa
- Department of Otorhinolaryngology, ‘Sfantul Andrei’ Emergency Clinical Hospital of Galati, 800578 Galati, Romania
- Clinical Department, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University of Galati, 800010 Galati, Romania
| | - Andrei Zenovia
- Department of Otorhinolaryngology, ‘Cai Ferate’ General Hospital, 800223 Galati, Romania
| | - Iuliu Fulga
- Clinical Department, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University of Galati, 800010 Galati, Romania
- Department of Forensic Medicine, ‘Sfantul Andrei’ Emergency Clinical Hospital of Galati, 800578 Galati, Romania
| | - Mihaela Ionela Sarbu
- Clinical Department, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University of Galati, 800010 Galati, Romania
| | - Alin Laurentiu Tatu
- Clinical Department, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University of Galati, 800010 Galati, Romania
- Department of Dermatology, ‘Sfanta Cuvioasa Parascheva’ Clinical Hospital of Infectious Diseases, 800179 Galati, Romania
- Multidisciplinary Integrative Center for Dermatologic Interface Research, 800179 Galati, Romania
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Fang Q, Yuan J, Zhang X, Dai L, Luo R. Lymph node metastasis in cutaneous squamous cell carcinoma of the head and neck. BMC Cancer 2024; 24:656. [PMID: 38811899 PMCID: PMC11138049 DOI: 10.1186/s12885-024-12384-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/14/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND The study aimed to assess the impact of parotid lymph nodes (LNs) on the prognosis of patients with cutaneous squamous cell carcinomas of the head and neck (HNcSCC), and to develop an alternative LN assessment method to enhance locoregional control (LRC) and overall survival (OS) stratification. METHODS We retrospectively enrolled patients with surgically treated HNcSCC. Primary outcome variables were LRC and OS. The influence of parotid LNs and different LN assessment methods on prognosis was analyzed using Cox models, and comparisons were made using the C-index, Akaike Information Criterion, and Bayesian Information Criterion. RESULTS A total of 126 patients were included. Both intraparotid and periparotid LN statuses significantly linked with prognosis. The presence of extranodal extension (ENE) in cervical LNs, rather than parotid LNs, was predictive of decreased LRC and OS. In the Cox analysis, only N3 of the AJCC N classification, when compared to N0, showed reduced LRC and OS. In comparison to N0P1, only N0P3/N1P1 and N2P2/N2P3 of the O'Brien staging system tended to predict poorer LRC, with no subgroup emerging as an independent predictor for OS. The proposed LN assessment method, based on the number of metastatic LNs and ENE status in cervical LNs, demonstrated superior performance in terms of C-index, Akaike Information Criterion, and Bayesian Information Criterion compared to other systems. CONCLUSION Parotid LNs were significant determinants of prognosis in metastatic HNcSCC. The novel LN assessment method proposed (1-2 vs. 3-4 vs. 5 + or ENE) displayed similar survival stratification to the AJCC N and O'Brien staging systems.
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Affiliation(s)
- Qigen Fang
- Department of Head Neck and Thyroid, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, China.
| | - Junhui Yuan
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, China
| | - Xu Zhang
- Department of Head Neck and Thyroid, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, China
| | - Liyuan Dai
- Department of Head Neck and Thyroid, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, China
| | - Ruihua Luo
- Department of Head Neck and Thyroid, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, China
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Li W, Yu W, Cao H, Zhang A. Number of positive lymph nodes is superior to neck stage of the 8th AJCC in predicting prognosis in parotid mucoepidermoid carcinoma. Head Neck 2023; 45:2613-2618. [PMID: 37594176 DOI: 10.1002/hed.27486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/30/2023] [Accepted: 08/06/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND To clarify the impact of the number of positive lymph nodes (LNs) on the prognosis of parotid mucoepidermoid carcinoma (MEC). METHODS Patients who underwent neck dissection for parotid MEC were retrospectively enrolled. The primary outcome variable was overall survival (OS). Associations between OS and LN factors, including the AJCC N stage, intraparotid LN metastasis, number of positive LNs, LN size, and extranodal extension (ENE), were evaluated using Cox proportional hazard regression analyses. RESULTS A total of 720 patients were included with a mean age of 56 ± 16 years. There was no additional survival compromise until two positive LNs were presented. After adjusting for the number of positive LNs, intraparotid LN metastasis, ENE, and LN size were not related to prognosis. Our proposed N stage based on the number of metastatic LNs (0/1 vs. 2-4 vs. 5+) showed a superior C-index to the AJCC N stage in OS prediction. CONCLUSION Quantitative LN burden was an important determinant of prognosis, and the proposed N stage provided better OS stratification than the AJCC N stage.
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Affiliation(s)
- Wenlu Li
- Department of Oral Maxillofacial Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wenli Yu
- Department of Oral Maxillofacial Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haifei Cao
- Department of Oral Maxillofacial Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aolin Zhang
- Department of Oral Maxillofacial Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Li CX, He Q, Wang ZY, Fang C, Gong ZC, Zhao HR, Ling B. Risk assessment of venous thromboembolism in head and neck cancer patients and its establishment of a prediction model. Head Neck 2023; 45:2515-2524. [PMID: 37548087 DOI: 10.1002/hed.27475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/21/2023] [Indexed: 08/08/2023] Open
Abstract
IMPORTANCE Venous thromboembolism (VTE) is closely relevant to head and neck cancer (HNC) prognosis, but little data exist on the risk prediction of VTE in patients with HNC. OBJECTIVE To study the risk factors regarding VTE in HNC patients and construct a nomogram model for its prediction. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional retrospective study was implemented to comparatively analyze 220 HNC patients from January 2018 to December 2021. The Lasso algorithm was used to optimize the selection of variables. A nomogram model for predicting HNC-associated VTE was established using multivariate logistic regression analysis. Internal validation of the model was performed by bootstrap resampling (1000 times). Calibration plot and decision curve analysis (DCA) were applied to evaluate the calibration capability of the prediction model. MAIN OUTCOME AND MEASURE The demographics, medical history, blood biochemical indicators, and modalities of treatment were included for analysis. RESULTS The incidence of HNC-associated VTE was 2.8% (55/1967) in authors' affiliation. Five variables of risk factors, including surgery, radiochemotherapy, D-dimer, aspartate transaminase, and globulin, were screened and selected as predictors by Lasso algorithm. A prediction model that incorporated these independent predictors was developed and presented as the nomogram. The model showed good discrimination with a C-index of 0.972 (95% CI: 0.934-0.997), and had an area under the receiver operating characteristic curve value of 0.981 (p < 0.001, 95% CI: 0.964-0.998). The calibration curve displayed good agreement of the predicted probability with the actual observed probability for HNC-associated VTE. The DCA plot showed that the application of this nomogram was associated with net benefit gains in clinical practice. CONCLUSIONS AND RELEVANCE The high-performance nomogram model developed in this study may help early diagnose the risk of VTE in HNC patients and to guide individualized decision-making on thromboprophylaxis.
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Affiliation(s)
- Chen-Xi Li
- Department of Oral and Maxillofacial Oncology & Surgery, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology Xinjiang Medical University, Urumqi, China
- Stomatological Research Institute of Xinjiang Uygur Autonomous Region, Urumqi, China
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, School of Stomatology, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qi He
- Department of Oral and Maxillofacial Oncology & Surgery, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology Xinjiang Medical University, Urumqi, China
| | - Zheng-Ye Wang
- Department of Preventive Medicine, College of Public Health, Xinjiang Medical University, Urumqi, China
| | - Chang Fang
- Department of Oral and Maxillofacial Oncology & Surgery, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology Xinjiang Medical University, Urumqi, China
| | - Zhong-Cheng Gong
- Department of Oral and Maxillofacial Oncology & Surgery, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology Xinjiang Medical University, Urumqi, China
- Stomatological Research Institute of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Hua-Rong Zhao
- The First Ward of Oncological Department, Cancer Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Bin Ling
- Department of Oral and Maxillofacial Oncology & Surgery, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology Xinjiang Medical University, Urumqi, China
- Stomatological Research Institute of Xinjiang Uygur Autonomous Region, Urumqi, China
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Desai N, Divatia MK, Jadhav A, Wagh A. Aggressive Cutaneous Squamous Cell Carcinoma of the Head and Neck: A Review. Curr Oncol 2023; 30:6634-6647. [PMID: 37504347 PMCID: PMC10378287 DOI: 10.3390/curroncol30070487] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/27/2023] [Accepted: 07/09/2023] [Indexed: 07/29/2023] Open
Abstract
Non-melanoma skin cancer of the head and neck (NMSCHN) is one of the most common malignancies worldwide, and its incidence is growing at a significant rate. It has been found to be aggressive in its spread and has the capacity to metastasize to regional lymph nodes. Cutaneous squamous cell carcinoma (cSCC) has a considerably high mortality rate. It has remarkable characteristics: diameter >2 cm, depth >5 mm, high recurrence, perineural invasion, and locoregional metastases. Aggressive cSCC lesions most commonly metastasize to the parotid gland. Also, immunocompromised patients have a higher risk of developing this aggressive cancer along with the worst prognostic outcomes. It is very important to discuss and assess the risk factors, prognostic factors, and outcomes of patients with cSCC, which will give clinicians future directives for making modifications to their treatment plans. The successful treatment of aggressive cSCC of the head and neck includes early detection and diagnosis, surgery alone or adjuvant chemotherapy, and radiotherapy as required. Multimodal therapy options should be considered by clinicians for better outcomes of aggressive cSCC of the head and neck.
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Affiliation(s)
- Ashley Wysong
- From the Department of Dermatology, University of Nebraska Medical Center, Omaha
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Hurrell MJL, Low TH(H, Ebrahimi A, Veness M, Ashford B, Porceddu S, Clark JR. Evolution of Head and Neck Cutaneous Squamous Cell Carcinoma Nodal Staging—An Australian Perspective. Cancers (Basel) 2022; 14:cancers14205101. [PMID: 36291884 PMCID: PMC9600647 DOI: 10.3390/cancers14205101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/11/2022] [Accepted: 10/15/2022] [Indexed: 11/18/2022] Open
Abstract
Simple Summary Australia has the highest incidence of cutaneous squamous cell carcinoma of the head and neck (HNcSCC) in the world. Although the majority of HNcSCCs are cured by simple surgical excision, those that spread to lymph nodes require aggressive and debilitating surgery in conjunction with radiation therapy, with a significant risk of treatment failure and subsequent loss of life. Cancer staging is critical to guide prognosis, treatment (to maximise disease control and minimise morbidity), and for research. Australian institutions have been at the forefront of prognostication for HNcSCC with lymph node spread. Despite this, the search for a well performing staging system is ongoing. This review chronologically explores and summarises the Australian contribution to date and highlights the ongoing challenges. Abstract Cutaneous squamous cell carcinoma of the head and neck (HNcSCC) is one of the commonest malignancies. When patients present with regional metastatic disease, treatment escalation results in considerable morbidity and survival is markedly reduced. Owing to the high incidence, Australian institutions have been at the forefront of advocating for reliable, accurate, and clinically useful staging systems that recognise the distinct biological characteristics of HNcSCC. As a result, an extensive body of literature has been produced over the past two decades, which has defined critical prognostic factors, critiqued existing staging systems, and proposed alternative staging models. Notwithstanding, a suitable staging system has proved elusive. The goal of cancer staging is to group patients according to cancer characteristics for which survival differs between groups (distinctiveness), consistently decreases with increasing stage (monotonicity), and is similar within a group (homogeneity). Despite implementing major changes based on published data, the latest edition of the American Joint Committee on Cancer (AJCC) staging manual fails to satisfy these fundamental requirements. This review chronologically explores and summarises the Australian contribution to prognostication and nodal staging of HNcSCC and highlights the ongoing challenges.
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Affiliation(s)
- Michael J. L. Hurrell
- Department of Head and Neck Surgery, Chris O’Brien Lifehouse, Sydney, NSW 2050, Australia
- Correspondence:
| | - Tsu-Hui (Hubert) Low
- Department of Head and Neck Surgery, Chris O’Brien Lifehouse, Sydney, NSW 2050, Australia
- Department of Otolaryngology—Head & Neck Surgery, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW 2109, Australia
- Sydney Medical School, Faculty of Medicine and Health Sciences, University of Sydney, Sydney, NSW 2006, Australia
| | - Ardalan Ebrahimi
- Medical School, College of Health and Medicine, Australian National University, Canberra, ACT 2601, Australia
| | - Michael Veness
- Westmead Hospital, University of Sydney, Westmead, NSW 2006, Australia
| | - Bruce Ashford
- School of Medicine, University of Wollongong, Wollongong, NSW 2522, Australia
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2500, Australia
- Illawarra Shoalhaven Local Health District, Wollongong, NSW 2502, Australia
| | - Sandro Porceddu
- Radiation Oncology, University of Queensland, St Lucia, QLD 4072, Australia
- Princess Alexandra Hospital, Brisbane, QLD 4102, Australia
| | - Jonathan R. Clark
- Department of Head and Neck Surgery, Chris O’Brien Lifehouse, Sydney, NSW 2050, Australia
- Sydney Medical School, Faculty of Medicine and Health Sciences, University of Sydney, Sydney, NSW 2006, Australia
- Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, NSW 2050, Australia
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Bradley PJ. Parotid lymph nodes in primary malignant salivary neoplasms. Curr Opin Otolaryngol Head Neck Surg 2021; 30:99-106. [DOI: 10.1097/moo.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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