Incidence of occult cervical metastasis in head and neck carcinomas: development over time

A Deep Learning-Based Detection and Segmentation System for Multimodal Ultrasound Images in the Evaluation of Superficial Lymph Node Metastases

Background/Objectives: Even with today's advancements, cancer still represents a major cause of mortality worldwide. One important aspect of cancer progression that has a big impact on diagnosis, prognosis, and treatment plans is accurate lymph node metastasis evaluation. However, regardless of the imaging method used, this process is challenging and time-consuming. This research aimed to develop and validate an automatic detection and segmentation system for superficial lymph node evaluation based on multimodal ultrasound images, such as traditional B-mode, Doppler, and elastography, using deep learning techniques. Methods: The suggested approach incorporated a Mask R-CNN architecture designed specifically for the detection and segmentation of lymph nodes. The pipeline first involved noise reduction preprocessing, after which morphological and textural feature segmentation and analysis were performed. Vascularity and stiffness parameters were further examined in Doppler and elastography pictures. Metrics, including accuracy, mean average precision (mAP), and dice coefficient, were used to assess the system's performance during training and validation on a carefully selected dataset of annotated ultrasound pictures. Results: During testing, the Mask R-CNN model showed an accuracy of 92.56%, a COCO AP score of 60.7 and a validation score of 64. Furter on, to improve diagnostic capabilities, Doppler and elastography data were added. This allowed for improved performance across several types of ultrasound images and provided thorough insights into the morphology, vascularity, and stiffness of lymph nodes. Conclusions: This paper offers a novel use of deep learning for automated lymph node assessment in ultrasound imaging. This system offers a dependable tool for doctors to evaluate lymph node metastases efficiently by fusing sophisticated segmentation techniques with multimodal image processing. It has the potential to greatly enhance patient outcomes and diagnostic accuracy.

[Nodal metastasis and value of neck dissection in T1/2 oropharyngeal and hypopharyngeal carcinomas]

BACKGROUND

Due to heterogeneous data, the indication for elective neck dissection (END) in patients with squamous cell carcinoma of the hypopharynx and oropharynx (HPSCC and OPSCC) in stages T1/2N0 is somewhat unclear. Therefore, in this multicenter study, we performed detailed analysis of the metastatic behavior of HPSCC and OPSCC.

MATERIAL AND METHODS

The nodal metastatic patterns of 262 HPSCC and OPSCC patients who had undergone surgery was retrospectively investigated. In addition, recurrence-free and overall survival were recorded. Furthermore, a systematic literature review on the topic was completed.

RESULTS

In patients with HPSCC, a discrepancy between clinical and pathologic N status was recorded in 62.1% of patients vs. 52.4% for p16- OPSCC, and 43.6% for p16+ OPSCC. The occult metastasis rate in cT1/2cN0 primary tumors was 38.9% for HPSCC vs. 17.8% (p16- OPSCC) and 11.1% (p16+ OPSCC). Contralateral metastases occurred in 22.2% of cases for HPSCC at stages cT1/2cN0, compared to only 9.1% for p16- OPSCC, and 0% for p16+ OPSCC patients.Patients with p16+ OPSCC had better recurrence-free and overall survival than p16- OPSCC and HPSCC patients. A direct association between patient survival and the extent of neck surgical therapy could not be demonstrated in our patients.

CONCLUSION

Patients with HPSCC are at risk for bilateral neck metastases from stage cT1/2cN0, justifying bilateral END. Patients with T1/2 OPSCC present with occult metastases ipsilaterally in >20% of cases; however, the risk for contralateral occult metastasis is <10%. Hence, in strictly lateralized cT1/2CN0 tumors, omission of contralateral END may be considered.

[Surgical Treatment of Hypopharyngeal Carcinoma, Neck Dissection and Adjuvant Postoperative Therapy of Oropharyngeal and Hypopharyngeal Cancer: Recommendations of the current S3 Guideline - Part II]

Part II of the S3 guideline report deals with the surgical treatment of hypopharyngeal carcinoma, neck dissection for oropharyngeal and hypopharyngeal carcinomas and adjuvant therapy options. Primary surgical therapy ± adjuvant radio- or radiochemotherapy and primary radio- or radiochemotherapy are established as primary therapies for local-regional hypopharyngeal carcinomas. Direct randomized comparisons of both basic therapeutic procedures were never conducted. Available registry data show a worse prognosis of hypopharyngeal carcinoma compared to oropharyngeal carcinomas in all locoregional tumor stages, regardless of the treatment method. For T1N0-T2N0 squamous cell carcinoma of the hypopharynx, there are no relevant differences in overall survival and locoregional relapse rate between primary surgical and primary non-surgical treatment. Primary surgical therapy ± adjuvant radiotherapy or radiochemotherapy and primary radiotherapy or radiochemotherapy are established as primary therapies for advanced but locoregionally limited hypopharyngeal carcinomas. Neck dissection is an integral part of the primary surgical treatment of oropharyngeal and hypopharyngeal cancer. There are only a few randomized studies on non-surgical organ preservation for advanced hypopharyngeal cancer as an alternative to pharyngolaryngectomy, but these have led to the recommendation of alternative concepts in the new guideline. The indication and implementation of postoperative adjuvant radiotherapy and radiochemotherapy for hypopharyngeal carcinoma do not differ from those for HPV/p16-negative and -positive oropharyngeal carcinoma.

FDG PET-CT for the Detection of Occult Nodal Metastases in Head and Neck Cancer: A Systematic Review and Meta-Analysis

Because of an estimated 20-30% prevalence of occult lymph node (LN) metastases in patients with head and neck squamous cell carcinoma (HNSCC), neck dissection is often proposed, despite its potential morbidity. In this systematic review and meta-analysis, the diagnostic performance of FDG PET-CT in detecting occult LN metastases was evaluated in patients with clinically negative necks (cN0) and in whom histopathology of a neck dissection specimen served as gold standard. Overall, 16 studies out of 2062 screened on PubMed and EMBASE fulfilled the inclusion criteria (n = 1148 patients). Seven of these sixteen studies were split into two or three studies because they contained data that could be processed distinctly in our meta-analysis. For this reason, a total of 25 studies were identified and included in the analysis (n total = 1918 patients). The overall prevalence of metastatic nodes per patient was 22.67%. The pooled sensitivity, specificity, diagnostic odds ratios, and negative predictive value (NPV) were 0.71 (95%CI: 0.66-0.75), 0.90 (95%CI: 0.84-0.93), 20.03 (95%CI: 13.51-29.70), and 0.92 (95%CI: 0.89-0.95), respectively. The main causes of inter-study heterogeneity included different reference standards (evaluation per patient, per neck side, or per neck level). The current meta-analysis showed that FDG PET-CT has a high specificity and NPV for ruling out nodal involvement in cN0 necks, but a limited sensitivity.

Surgical Treatment of Early Glottic Cancer

The incidence of all head and neck malignancies is rising worldwide, with carcinoma of the larynx constituting approximately 1% of all cancers. Early glottic cancer responds quite favorably to surgical intervention due to its early presentation, coupled with the low rate of regional and distant metastases. This article focuses on various approaches to the surgical treatment of early glottic cancer. Details include the clinical and radiological evaluation of laryngeal cancer, the goals of treatment, current surgical options for early disease, approach to surgical resection margins and management of nodal disease, and complications associated with each treatment modality.

Sentinel node identification in laryngeal and pharyngeal carcinoma after flexible endoscopy-guided tracer injection under topical anesthesia: A feasibility study

BACKGROUND

The aim of this study was to investigate the feasibility of flexible endoscopy-guided tracer injection for sentinel lymph node (SLN) identification in patients with laryngeal and pharyngeal carcinoma.

METHODS

Sixteen cT1-4N0-2M0 patients with laryngeal or pharyngeal carcinoma underwent intra- and peritumoral [^99m Tc]Tc-nanocolloid injections after topical anesthesia under endoscopic guidance. SPECT-CT scans were performed at two time points.

RESULTS

Tracer injection and visualization of SLNs was successful in 15/16 (94%) patients. Median number of tracer injections was 1 intratumoral and 3 peritumoral. The median duration of the endoscopic procedure including tracer injection after biopsy taking was 7 min (range 4-16 min). A total of 28 SLNs were identified which were all visualized on the early and late SPECT-CT. Most SLNs were visualized in neck levels II and III.

CONCLUSIONS

Flexible endoscopy-guided tracer injection for SLN identification is a feasible and fast procedure in laryngeal and pharyngeal carcinoma patients.

Exosomal hsa_circRNA_047733 integrated with clinical features for preoperative prediction of lymph node metastasis risk in oral squamous cell carcinoma

BACKGROUND

To evaluate whether exosomal circRNAs could serve as diagnostic biomarkers for the accurate preoperative prediction of lymph node metastasis (LNM) risk in oral squamous cell carcinoma (OSCC) patients.

METHODS

A combinative strategy of exosomal circRNAs microarray and qRT-PCR verification was employed to dig LNM-related circRNA signatures. Then, a dynamic nomogram was developed based on candidate circRNAs and preoperative clinical features and the calibration, discrimination, and clinical use of the nomogram were evaluated.

RESULTS

According to the microarray, three circRNAs derived from the tumor were associated with preoperative LNM risk, including hsa_circRNA_047733, hsa_circRNA_024144 and hsa_circRNA_403472. The hsa_circRNA_047733 was further verified to be significantly downregulated in patients with LNM (+) as compared with those with LNM (-) (p = 0.007). Patients with the higher expression of hsa_circRNA_047733 showed a lower risk of LNM (multivariate-adjusted OR = 0.22, 95%CI: 0.06-0.83). The bioinformatics prediction showed that hsa_circRNA_047733 might sponge miR-4464/miR-4748 to regulate RPS21 expression. A dynamic nomogram integrating exosomal hsa_circRNA_047733 with five clinicopathological characteristics (tumor site, leukocyte level, maximum tumor diameter, and LNM reported by MRI and preoperative biopsy differentiation) was developed. The model displayed an excellent discrimination ability (AUC = 0.868, 95%CI: 0.781-0.955) and great calibration. The decision curve revealed a higher net benefit superior to the baseline model at an 80% threshold probability.

CONCLUSION

The data provide preliminary evidence that exosomal hsa_circRNA_047733 might be a novel biomarker for the LNM of OSCC. The hsa_circRNA_047733-based dynamic nomogram could serve as a convenient preoperative assessment tool to predict the risk of LNM for OSCC patients.

Machine Learning Algorithms as a Computer-Assisted Decision Tool for Oral Cancer Prognosis and Management Decisions: A Systematic Review

INTRODUCTION

Despite multiple prognostic indicators described for oral cavity squamous cell carcinoma (OCSCC), its management still continues to be a matter of debate. Machine learning is a subset of artificial intelligence that enables computers to learn from historical data, gather insights, and make predictions about new data using the model learned. Therefore, it can be a potential tool in the field of head and neck cancer.

METHODS

We conducted a systematic review.

RESULTS

A total of 81 manuscripts were revised, and 46 studies met the inclusion criteria. Of these, 38 were excluded for the following reasons: use of a classical statistical method (N = 16), nonspecific for OCSCC (N = 15), and not being related to OCSCC survival (N = 7). In total, 8 studies were included in the final analysis.

CONCLUSIONS

ML has the potential to significantly advance research in the field of OCSCC. Advantages are related to the use and training of ML models because of their capability to continue training continuously when more data become available. Future ML research will allow us to improve and democratize the application of algorithms to improve the prediction of cancer prognosis and its management worldwide.

The Role of Magnetic Resonance Imaging in (Future) Cancer Staging: Note the Nodes

The presence or absence of lymph node metastases is a very important prognostic factor in patients with solid tumors. Current invasive and noninvasive diagnostic methods for N-staging like lymph node dissection, morphologic computed tomography/magnetic resonance imaging (MRI), or positron emission tomography-computed tomography have significant limitations because of technical, biological, or anatomical reasons. Therefore, there is a great clinical need for more precise, reliable, and noninvasive N-staging in patients with solid tumors. Using ultrasmall superparamagnetic particles of ironoxide (USPIO)-enhanced MRI offers noninvasive diagnostic possibilities for N-staging of different types of cancer, including the 4 examples given in this work (head and neck cancer, esophageal cancer, rectal cancer, and prostate cancer). The excellent soft tissue contrast of MRI and an USPIO-based differentiation of metastatic versus nonmetastatic lymph nodes can enable more precise therapy and, therefore, fewer side effects, essentially in cancer patients in oligometastatic disease stage. By discussing 3 important questions in this article, we explain why lymph node staging is so important, why the timing for more accurate N-staging is right, and how it can be done with MRI. We illustrate this with the newest developments in magnetic resonance methodology enabling the use of USPIO-enhanced MRI at ultrahigh magnetic field strength and in moving parts of the body like upper abdomen or mediastinum. For prostate cancer, a comparison with radionuclide tracers connected to prostate specific membrane antigen is made. Under consideration also is the use of MRI for improvement of ex vivo cancer diagnostics. Further scientific and clinical development is needed to assess the accuracy of USPIO-enhanced MRI of detecting small metastatic deposits for different cancer types in different anatomical locations and to broaden the indications for the use of (USPIO-enhanced) MRI in lymph node imaging in clinical practice.

Head and neck robotic surgery combined with sentinel lymph node biopsy. Fascinating, but feasible?

Robotic approaches and sentinel lymph node (SLN) biopsy are both strategies that evolved driven by the need to reduce impact of head and neck oncological surgery in terms of operative timing, morbidity, hospitalization time, and aesthetic results. A comprehensive review of the scientific literature was performed on PubMed, Embase, ResearchGate, Cochrane, and CENTRAL electronic databases with the aim to discuss the role that these two approaches can play together in the management of head and neck cancers (HNCs) of various sites. Dedicated publications on the combined robotics and SLN biopsy approaches resulted, up to now very limited, while their separated application in non-shared fields is gaining strength. However, the possibility to implement and combine technologies to minimize sequelae of head and neck surgery is an interesting and evolving topic.

Development and validation of a multivariable prediction model for the identification of occult lymph node metastasis in oral squamous cell carcinoma

BACKGROUND

There have been few recent advances in the identification of occult lymph node metastases (OLNM) in oral squamous cell carcinoma (OSCC). This study aimed to develop, compare, and validate several machine learning models to predict OLNM in clinically N0 (cN0) OSCC.

METHODS

The biomarkers CD31 and PROX1 were combined with relevant histological parameters and evaluated on a training cohort (n = 56) using four different state-of-the-art machine learning models. Next, the optimized models were tested on an external validation cohort (n = 112) of early-stage (T1-2 N0) OSCC.

RESULTS

The random forest (RF) model gave the best overall performance (area under the curve = 0.89 [95% CI = 0.8, 0.98]) and accuracy (0.88 [95% CI = 0.8, 0.93]) while maintaining a negative predictive value >95%.

CONCLUSIONS

We provide a new clinical decision algorithm incorporating risk stratification by an RF model that could significantly improve the management of patients with early-stage OSCC.

Soft tissue necrosis in patients treated with transoral robotic surgery and postoperative radiotherapy: preliminary results

OBJECTIVE

Postoperative radiotherapy (PORT) is indicated in almost two-thirds of patients treated with transoral robotic surgery (TORS) for head and neck tumors. The aim of this study was to quantify the toxicity profile of patients treated with PORT after TORS in oropharyngeal and supraglottic laryngeal cancer focusing on soft tissue necrosis (STN).

METHODS

We retrospectively reviewed 28 patients. Acute and late toxicity were examined. Incidence and severity of STN were recorded.

RESULTS

No patient experienced acute grade 3 skin or mucosal toxicity; 1 patient had grade 3 dysphagia. At 12 months, no evaluated patient required enteral nutrition and 2 patients had tracheostomy. STN occurred in 4 (14%) patients: 3 out of 4 (75%) patients with STN had diabetes, whereas 6 out of 13 (25%) patients without STN had diabetes (p = 0.05).

CONCLUSION

We found an acceptable toxicity profile of PORT performed after a TORS procedure. Diabetes mellitus might be a risk factor for STN.

Prediction of Occult Lymph Node Metastasis in Head and Neck Cancer with CD31 Vessel Quantification

Objective

The management of occult lymph node metastasis (LNM) in head and neck squamous cell carcinoma has been a matter of controversy for decades. The vascular density within the tumor microenvironment, as an indicator of ongoing angiogenesis, could constitute an attractive predictor of LNM. The use of the panvascular endothelial antibody CD31 as a marker of occult LNM has never been reported. The aim of this study was to assess the predictive value of CD31 microvascular density for the detection of occult LNM in squamous cell carcinoma of the oral cavity and oropharynx.

Study Design

Case series with chart review.

Setting

Tertiary university hospital.

Subjects and Methods

Intra- and peritumoral microvascular density values were determined in 56 cases of squamous cell carcinoma of the oral cavity (n = 50) and oropharynx (n = 6) with clinically negative necks using the CD31 marker. Statistical associations of CD31 microvascular densities with clinicopathologic data were then established.

Results

Peritumoral CD31 microvascular density was significantly associated with occult LNM in multivariate analysis ( P < .01). Recursive partitioning analysis for this parameter found a cutoff of 19.33, which identified occult LNM with a sensitivity of 91%, a specificity of 65%, a positive predictive value of 40%, a negative predictive value of 97%, and an overall diagnostic accuracy of 71%.

Conclusion

Peritumoral CD31 microvascular density in primary squamous cell carcinoma of the oral cavity and oropharynx allows accurate prediction of occult LNM.

Rapid nodal staging of head and neck cancer surgical specimens with flow cytometric analysis

Background:

Detection of metastatic spread of head and neck cancer to cervical lymph nodes is essential for optimal design of therapy. Undetected metastases lead to mortality, which can be prevented by better detection methods.

Methods:

We analysed 41 lymph nodes from 19 patients with oral squamous cell carcinoma (OSCC). Each lymph node was divided in two, one half processed for histopathology and the other half dissociated into single-cell suspension, stained for the carcinoma cell markers cytokeratin 5/8 (CK5/8), epithelial cell adhesion molecule (EpCAM) and epithelial mucin (MUC-1), and analysed with flow cytometry. Flow cytometry data were compared with histopathology performed on serial sections and immunohistochemistry. Six cervical lymph nodes from cancer-free patients were used to establish baseline levels in flow cytometry.

Results:

Flow cytometry analysis (fluorescence-activated cell sorting; FACS) detected all six metastases confirmed by histopathology as well as the histologically negative nodes. Importantly, among nine sentinel lymph nodes, FACS analysis detected <1% malignant cells in four cases, not found in histopathology. Results from flow cytometry analysis can be obtained within 3 h of the time of biopsy.

Conclusions:

We show that flow cytometric analysis of nodal tissue is sensitive and reliable in identifying metastases of OSCC. Flow cytometry is inexpensive and fast, providing a possibility of perioperative diagnostics and immediate treatment planning.

AHNS Series: Do you know your guidelines? Principles of surgery for head and neck cancer: A review of the National Comprehensive Cancer Network guidelines

This article continues a series developed by the American Head and Neck Society's Education Committee entitled "Do you know your guidelines?" It is hoped that these features will increase awareness of and adherence to current best practices in head and neck cancer care. In this installment, the National Comprehensive Cancer Network (NCCN) guidelines for surgical therapy are reviewed. © 2016 Wiley Periodicals, Inc. Head Neck 39: 791-796, 2017.

Correlation between podoplanin expression and extracapsular spread in squamous cell carcinoma of the oral cavity using subjective immunoreactivity scores and semiquantitative image analysis

BACKGROUND

The correlation between podoplanin expression and extracapsular spread in head and neck squamous cell carcinoma (HNSCC) has never been reported. The purpose of this study was to assess the predictive value of podoplanin expression for this parameter.

METHODS

Subjective immunoreactivity scores and semiquantitative image analysis of podoplanin expression were performed in 67 patients with primary oral squamous cell carcinoma and in their corresponding lymph nodes. Neck classification showed 34 cases (51%) of pN0 and 33 cases (49%) of pN+. Correlation between the levels of podoplanin expression and the histopathological data was established.

RESULTS

In lymph nodes, a high level of podoplanin expression correlated with the presence of extracapsular spread by multivariate analysis (p = .03). A strong correlation between subjective and semiquantitative image analysis was observed (r = 0.77; p < .001).

CONCLUSION

A high level of podoplanin expression in lymph node metastases of oral squamous cell carcinoma is independently associated with extracapsular spread. © 2016 Wiley Periodicals, Head Neck 39: 98-108, 2017.

Tumoral Expression of CD44 and HIF1α Predict Stage I Oral Cavity Squamous Cell Carcinoma Outcome

OBJECTIVES/HYPOTHESIS

No biomarkers are used to estimate the prognosis in oral cavity squamous cell carcinoma (OSCC). In our previously published work, we have reported the prognostic value of CD44 and hypoxia inducible factor (HIF)-1α in patients with stage I disease.

STUDY DESIGN

In this study, we tested our previous observations in a larger cohort. We also studied the predictive value of common lymphatic endothelial and vascular endothelial receptor (CLEVER)-1 in this material.

METHODS

CD44, HIF1α, and CLEVER-1 were immunohistochemically analyzed in paraffin-embedded tissue material of stage I OSCC patients treated at three Finnish university hospitals. Microscopy results were correlated with OSCC outcome.

RESULTS

As in our pilot study, the CD44^lowHIF1α^high signature was associated with poorer disease-free survival. Clear correlations between CLEVER-1 expression and clinical outcome were not evident.

CONCLUSION

Our results suggest that immunohistochemistry of CD44 and HIF1α may be useful in identification of patients with poor prognoses. These parameters could be used to select the optimal treatment modalities for stage I OSCC patients.

LEVEL OF EVIDENCE

2b.

Sentinel lymph node biopsy in oral and oropharyngeal squamous cell carcinoma: current status and unresolved challenges

Because imaging with ultrasound, computed tomography, magnetic resonance imaging or positron emission tomography is unreliable for preoperative lymph node staging of early-stage oral and oropharyngeal squamous cell carcinoma (OSCC), elective neck dissection has been typically performed. The targeted sampling of sentinel lymph nodes (SLN) identified by lymphoscintigraphy and detected by gamma probe has become an effective alternative for the selection of patients for regional nodal resection. With careful consideration to technique, high SLN detection rates have been reported. Advanced techniques including intraoperative handheld gamma camera imaging and freehand single photon emission computed tomography (SPECT) are expected to increase surgical confidence in these procedures. This review gives an update on SLN biopsy in patients with OSCC including clinical standards and controversial aspects.

Neck observation is appropriate in T1-2, cN0 oral squamous cell carcinoma without perineural invasion or lymphovascular invasion

OBJECTIVES

Management of cN0 neck, elective neck dissection (END) or observation, remains controversial for T1-2 oral squamous cell carcinoma (OSCC). To allow for the safe observation of cN0 neck, it is mandatory to define predictors with high negative predictive value (NPV) for cervical lymph node (LN) status.

MATERIALS AND METHODS

Pathologic re-evaluation was performed in tumors of 253 consecutive patients with T1-2, cN0 OSCC. The predictive roles of pathologic parameters for cervical LN status in guiding neck management were investigated.

RESULTS

Cervical LN metastasis (LN+) occurred at a similar rate between observation and END groups (20.8% vs. 22.2%, p=0.807), indicating poor discriminatory value for cervical LN status by clinical judgment. Compared with T classification, tumor thickness and differentiation, PNI/LVI (perineural invasion/lymphovascular invasion) demonstrated the highest NPV (85.5%). Hypothetically using PNI/LVI status to guide neck management, a dramatic reduction in overtreatment rate could be achieved (54.2% to 20.2%), with a minimal increase in undertreatment rate (6.3% to 9.9%). In patients without PNI or LVI (PNI/LVI-), the ultimate neck control rate (96.9% vs. 96.3%, p=1.000) and 5-year disease-specific survival rate (91.1% vs. 92.8%, p=0.863) were equivalent between observation and END. However, a significantly higher incidence of neck recurrence was found with observation (16.9% vs. 6.5%, p=0.031), with 93.8% occurring within one year and 73.3% being successfully salvaged.

CONCLUSION

Observation under close follow-up for the first year is appropriate in T1-2, cN0 OSCC without PNI or LVI, for the achievement of equivalent ultimate neck control and 5-year disease-specific survival rates compared with END.

Primary surgical therapy for locally limited oral tongue cancer

Objectives. The aim of this study was to assess the efficacy of primary surgical treatment in the management of locally limited oral tongue carcinoma. Methods. A retrospective evaluation was carried out for all patients treated with primary surgery for pT1-pT2 oral tongue carcinomas at a tertiary referral center between 1980 and 2005. All cases were assessed for disease-specific survival and local control rates in relation to T classification, N classification, infiltration depth of the primary tumor, and decision making on neck management and adjuvant therapy. The cases were additionally evaluated for the incidence of major complications and tracheotomies. Results. 263 cases were assessed. The 5-year disease-specific survival rate was 75.2%. Positive neck disease was shown to be a significant negative prognostic factor. The occult metastasis rate was 20.2%. Conclusions. Primary surgical treatment is a very effective modality against T1-T2 oral tongue carcinoma, and a low rate of complications can be anticipated.

Squamous cell carcinoma of the oral cavity and circulating tumour cells

Due to a lack of substantial improvement in the outcome of patients suffering from oral squamous cell carcinoma (OSCC) during the past decades, current staging methods need to be revised. This disease is associated with poor survival rates despite considerable advances in diagnosis and treatment. The early detection of metastases is an important indicator of survival, prognosis and relapse. Therefore, a better understanding of the mechanisms underlying metastasis is crucial. Exploring alternative measures apart from common procedures is needed to identify new prognostic markers. Similar to previous findings predominantly for other solid tumours, recently published studies demonstrate that circulating tumour cells (CTCs) and disseminated tumour cells (DTCs) might serve as prognostic markers and could supplement routine staging in OSCC. Thus, the detection of CTCs/DTCs is a promising tool to determine the individual need for therapeutic intervention. Encouraging results and new approaches point to the future use of targeted therapies for OSCC, an exceedingly heterogeneous subgroup of head and neck cancer. This review focuses on summarising technologies currently used to detect CTCs/DTCs. The translational relevance for OSCC is highlighted. The inherent challenges in detecting CTCs/DTCs will be emphasised.

Outcome and prognostic factors in T4a oropharyngeal carcinoma, including the role of HPV infection

Background. The prognosis of patients with advanced oropharyngeal carcinoma (OPSCC) is generally poor. The aim of this study is to investigate the different therapeutic approaches and identify prognostic factors associated with a worse outcome for patients treated for T4a OPSCC, in order to improve treatment selection for the individual. Methods. A retrospective study was conducted on 426 patients with T4a OPC treated between 1980 and 2010. Eleven prognostic factors including treatment modality, lymph node staging, and p16 status as a surrogate marker for human papillomavirus (HPV) infection were analyzed. Results. Univariate analysis showed a significant difference in DSS between N0 and N+ (57.1% versus 26.9%, P < 0.001), primary surgical and primary nonsurgical treatment (52.7% versus 31.4%, P < 0.001), and perinodal invasion (51.7% versus 19.9%, P = 0.011). P16-negative patients tended towards a worse DSS than p16-positive patients (40.2% versus 64.6%, P = 0.126) but responded better to primary surgery than to nonsurgical treatment (71.4% versus 34.0%, P = 0.113). Multivariate analysis identified the N category as an independent prognostic factor for survival. Conclusion. The survival of p16-negative patients was worse than p16-positive patients, although they seem to respond better to primary surgery. The strongest independent prognostic factor for T4a carcinomas proved to be the presence of lymph node metastases.

Lymph node ratio is of limited value for the decision-making process in the treatment of patients with laryngeal cancer

The lymph node ratio (LNR) combines two types of information--about the extent of neck dissection and about the extent of the pathological examination of the specimen--and thus represents an interesting variable for risk assessment in patients with head and neck cancer. This retrospective study with data from January 1, 1980, to December 31, 2010, evaluates the utility of the LNR as a potential prognostic predictor in patients with laryngeal squamous cell carcinoma (LSCC). A total of 202 consecutive patients with regionally metastasized LSCC who underwent primary surgery with or without adjuvant treatment were included. The mean follow-up period was 4.4 years. The LNR was calculated as the ratio of positive nodes to the total number of nodes removed during neck dissection. Multivariate analysis was carried out. Peak values as averaged clusters of individual LNRs were registered at three points (LNR 0.05, 0.07, and 0.09). LNR 0.09 was a significant prognostic parameter in the Cox regression model (P = 0.007). Patients with an LNR > 0.09 had a hazard ratio of 2.065 for a disease-specific survival event in comparison with LNR < 0.09. The most accurate LNR for LSCC is expected to be located in the range of 0.08-0.1. The LNR seems to be of limited value for the decision-making process in the treatment of patients with LSCC, in comparison with other locations. Prospective trials will be required in order to allow evidence-based recommendations for treatment decisions based on the LNR.

Epidemiology and survival of HPV-related tonsillar carcinoma

The aim of this study was to determine the proportion of human papilloma virus (HPV)-positive cases in tonsillar carcinomas and investigate its development over the last decade. Further aim was to show the oncologic results in accord to HPV status and various treatment modalities. A retrospective study was conducted between 2000 and 2012 and included 275 patients treated for tonsillar carcinoma. P16 immunohistochemistry was used as a surrogate marker for HPV-associated carcinogenesis. A total of 101 (36.7%) patients proved to be p16 positive and 174 p16 negative. 80.2% of the p16-positive cases presented with T1-2 tumor. Of the early-stage patients, 79% of the p16-positive and 52.3% of the p16-negative presented with lymph node metastases. The percentage of p16-positive patients increased from 23.2% in the period 2005–2007 to 58.6% in the period 2010–2012 in the whole population and from 30.9% to 76.9% in T1-2 carcinomas. Early T-category p16-positive carcinomas had significantly better disease-specific survival (92.4% vs. 75.5%, P = 0.007) and overall survival (OS, 79.6% vs. 54.3%, P < 0.001) compared to p16-negative tumors. This study showed an increase in the percentage of p16-positive patients in tonsillar carcinoma from 23.2% in the years between 2005 and 2007 to 58.6% between 2010 and 2012. The majority (80.2%) of p16-positive patients presented with early T-category tumor but most of these (79.0%) had also lymph node metastases. Nevertheless, p16-positive patients had excellent oncologic results after surgery and adjuvant radiotherapy and could be considered for de-escalation of treatment.

Diagnostic evaluation of sentinel lymph node biopsy in early head and neck squamous cell carcinoma: a meta-analysis

BACKGROUND

The purpose of this study was to evaluate the efficacy of sentinel lymph node biopsy (SLNB) in early head and neck squamous cell carcinoma (HNSCC).

METHODS

The PubMed database was searched for studies published before October 31, 2012. Pooled values for the sentinel lymph node identification rate, sensitivity, false-negative rate, negative predictive value, and accuracy were calculated.

RESULTS

A total of 16 studies (987 patients) was included. The pooled identification rate, sensitivity, false-negative rate, negative predictive value, and accuracy were 95.2%, 86.3%, 13.7%, 94.2%, and 95.0%, respectively. The subgroup with high methodological quality showed a mean identification rate of 95.4% for SLNB validation trials and 94.2% for SLNB alone trials, and mean sensitivity of 91.0% for SLNB validation trials and 84.2% for SLNB alone trials.

CONCLUSION

The SLNB procedure has shown a high sensitivity rate, but the pooled sensitivity and false-negative rate were worse in SLNB alone trials than in SLNB validation trials.

Freehand SPECT for sentinel lymph node detection in patients with head and neck cancer: first experiences

CONCLUSION

Feasibility of intraoperative 3D imaging with freehand (fh) SPECT for sentinel lymph node (SLN) biopsy in head and neck cancer (HNC) could be demonstrated. Controlled clinical studies are needed to evaluate its accuracy and impact on patient morbidity.

OBJECTIVES

The clinical N0 neck in HNC needs improvement in management to sufficiently detect occult neck disease but to spare patients from potential morbidity by elective neck dissection. The SLN concept has potential to accurately stage the neck with low morbidity.

METHODS

fhSPECT is a 3D tomographic imaging modality with a gamma probe system combined with an infrared optical tracking system. Five patients with HNC and clinical N0 neck were recruited. Scanning for SLN using fhSPECT was performed before excision and selective neck dissection and specimens were analyzed histopathologically.

RESULTS

Preoperatively, a total of nine SLNs were located in five patients with fhSPECT. SLNs in three patients were positive for metastatic disease; in two patients the SLNs were tumor-free. No residual radioactivity was found in the neck in any of the patients after extirpation of SLNs. fhSPECT acquisitions took 2.6 ± 0.4 min. No metastatic lymph nodes were detected in any other node harvested during subsequent selective neck dissection in any patients.

[Current treatment strategies for papillary thyroid microcarcinoma]

The increase in the incidence of thyroid cancer is accompanied by a mortality rate that is stable or perhaps even slightly decreasing. This phenomenon is due to the increased frequency of papillary microcarcinomas (thyroid tumors with a diameter of less than 1 cm), which is presumably attributable to the improved diagnosis enabled by high resolution ultrasound and fine needle aspiration cytology. The American and European Thyroid Associations have recently published new guidelines for the diagnosis and therapy of differentiated thyroid tumors. These guidelines are aimed at minimizing the diagnostic and therapeutic procedures without reducing their effectiveness. This goal is particularly important for papillary thyroid microcarcinoma patients, who have an excellent prognosis and almost normal life expectancy. This article summarizes the history of thyroid surgery and introduces papillary thyroid microcarcinoma--an important topic in modern thyroid oncology. Current methods for diagnosis, treatment and follow-up care of this disease are discussed.

Planned neck dissection following radiation treatment for head and neck malignancy

Introduction. Optimal therapy for patients with metastatic neck disease remains controversial. Neck dissection following radiotherapy has traditionally been used to improve locoregional control. Methods. A retrospective review of 28 patients with node-positive head and neck malignancy treated with planned neck dissection following radiotherapy between January 2002 and December 2005 was performed to assess treatment outcomes. Results. Median interval to neck dissection was 9.6 weeks with a median number of 21 + 9 lymph nodes per specimen. Ten of 31 (32%) neck dissection specimens demonstrated evidence of residual carcinoma. Overall survival at two years was 85%; five-year overall survival was 65%. Concurrent chemotherapy did not impact the presence of residual neck disease. Conclusion. Based on the frequency of residual malignancy in the neck of patients treated with primary radiotherapy, a planned, postradiotherapy neck dissection should be strongly advocated for all patients with advanced-stage neck disease.