Lymph node ratio predicts survival in hypopharyngeal cancer with positive lymph node metastasis

Number of positive lymph nodes and lymph node ratio predict recurrence and survival in hypopharyngeal cancer based on SEER database and validation of real-world data

PURPOSE

This study investigated the impacts of the number of positive lymph nodes (NPLN) and lymph node ratio (LN ratio) for patients with hypopharyngeal squamous cell carcinoma (HPSCC) based on SEER database, which were validated in the real-world data of China.

METHODS

A total of 520 patients from SEER database were analyzed. Then 195 patients with pathologically stage III or IV HPSCC in our center were retrospectively studied.

RESULTS

In the SEER database, NPLN ≥ 3 was found in 36.9% of patients. Multivariate analysis revealed that LN ratio ≥ 0.138 was significant with poorer overall survival (OS) (hazard ratio [HR] = 1.525, p = 0.001) and cancer-specific survival (CSS) (HR = 1.697, p < 0.001), so was the NPLN ≥ 3 (HR = 1.388, p = 0.013; HR = 1.479, p = 0.008). Patients with NPLN ≥ 3 were found in 103 (52.8%) in our center. Multivariate analysis confirmed a significant association regarding OS (p = 0.005) or CSS (p = 0.003) between patients with LN ratio ≥ 0.138 or not. In addition, disease recurrence rate differed significantly between the patients with NPLN ≥ 3 (27.2%) and NPLN < 3 (14.1%, p = 0.026). Moreover, postoperative chemoradiotherapy (CCRT) was significantly associated with better prognosis in patients with NPLN ≥ 3.

CONCLUSION

In the SEER database, NPLN ≥ 3 and LN ratio ≥ 0.138 were independent poor prognostic factors for patients with HPSCC. Whereas identifying worldwide cut-off values for LN ratio is difficult and surgeon-dependent. In our cohort, adjuvant CCRT was beneficial for OS in patients with NPLN ≥ 3.

A Survival Nomogram Containing Lymph Node Ratio for Hypopharyngeal Carcinoma Patients After Neck Dissection

OBJECTIVE

The purpose of our study is to establish a survival nomogram based on lymph node ratio (LNR) in hypopharyngeal carcinoma.

STUDY DESIGN

Retrospective cohort study.

SETTING

Hypopharyngeal squamous cell carcinoma (HPSCC) is prone to regional metastasis. Emerging evidence has shown that LNR is a promising prognostic factor in HPSCC.

METHODS

From January 2004 to January 2018, 411 HPSCC patients who underwent neck dissection at our institution were retrospectively studied. The enrolled patients were divided into training and validation cohorts at a ratio of 7:3. A survival nomogram was finally built based on factors screened from multivariate analysis using the bidirectional stepwise method.

RESULTS

LNR was superior to other nodal classifications for survival prediction and was used to establish the R classification. A nomogram was developed using R classification (p < .001), pT classification (p < .001), tumor invasive depth (p < .001), and internal jugular vein adhesion (p = .001). The C-indexes were 0.712 and 0.703 in the training and validation dataset. The 36- and 60-month AUCs were 0.767 and 0.766 in the training dataset and 0.713 and 0.757 in the validation dataset, respectively. The calibration curves showed relatively good agreement between the predicted and actual probability.

CONCLUSION

Based on the LNR, we developed a survival nomogram for HPSCC after neck dissection, which will be a practical tool to discriminate patients with different survival risks.

Lymph Node Ratio in Head and Neck Cancer with Submental Flap Reconstruction

This study aimed to investigate the relationship between the lymph node ratio (LNR) and survival results of patients with head and neck squamous cell carcinoma (HNSCC) reconstructed by a submental artery flap (SMAF) to limit tumor size. This study retrospectively recruited 49 patients with HNSCC who underwent both primary resection and neck dissection with SMAF reconstruction. The LNR was the ratio of the number of metastatic lymph nodes to the sum number of examined lymph nodes. A LNR of 0.04 was the best cut-off value for HNSCC-specific death on receiver operating curve analysis. Patients with LNRs > 0.04 were univariately related to cancer-specific, disease-free, distant metastasis-free, and locoregional recurrence-free survival than those with LNRs ≤ 0.04 by log-rank test. In a Cox’s proportional hazards model with hazard ratio (HR) and 95% confidence interval (CI) adjusting for pathological stage, extranodal extension and or surgical margins, the LNR (>0.04/≤0.04) predicted multivariate shorter cancer-specific (HR = 9.24, 95% CI = 1.49−176), disease-free (HR = 3.44, 95% CI = 1.23−10.3), and distant metastasis-free (HR = 9.76, 95% CI = 1.57−187) survival. In conclusion, LNR for patients of HNSCC with SMAF reconstruction for limited tumor size was a prognostic factor for survival outcomes.

RBM24 Mediates Lymph Node Metastasis and Epithelial-Mesenchymal Transition in Human Hypopharyngeal Squamous Cell Carcinoma by Regulating Twist1

Objective

Despite the target RNA regulatory action of RBM24 (RNA Binding Motif 24), a protein implicated in multiple carcinomas, its role in HSCC remains unclear. Our study probed to understand the effect of RBM24 on HSCC.

Materials and Methods

A combination of qRT-PCR, IHC, and western blot was employed to assess the HSCC tissue level of RBM24. The colony formation and CCK-8 assays were performed to estimate cellular proliferative potential, whereas the transwell assay was conducted to examine invasive and metastatic potential. The FaDu cell motility was assessed via the scratch-wound assay and EMT (epithelial-mesenchymal transition) by adopting qRT-PCR in conjunction with western blot and IF (immunofluorescence). The in-vivo effect of RBM24 on HSCC was investigated through modeling metastasis to the popliteal LNs (lymph nodes).

Results

Among HSCC patients showing metastasis to LNs, prominent RBM24 downregulation was noted, with an intrinsic association between low RBM24 level and poor outcome. Knocking down RBM24 promoted cell multiplication, migration, and infiltration, while overexpression led to the opposite effects and inhibited the EMT. RBM24's suppressive action against the FaDu cell mobility and invasion was reversed by Twist1 overexpression. RBM24's suppressive actions against the tumor evolution and LN metastasis in HSCC in-vivo were also validated.

Conclusion

As a carcinoma inhibitor gene, RBM24 regulates Twist1 to achieve LN metastasis and EMT suppression in HSCC.

Lymph node ratio as a predictor for minor salivary gland cancer in head and neck

Background

We investigate whether pathological continuous variables of lymph nodes were related with survival results of carcinomas of minor salivary gland carcinoma in head and neck.

Methods

Forty-four cases with minor salivary gland carcinoma who underwent both primary resection and neck dissection were retrospectively enrolled. The pathological continuous variables were evaluated by the number of positive lymph nodes, lymph node ratio, and log odds of positive lymph nodes. Receiver operating curve analysis was used for the cut-off values of the carcinoma-specific death. Log-rank test and Cox’s proportional hazards model were used for uni−/multi-variate survival analyses adjusting for pathological stage, respectively.

Results

Lymph node ratio = 0.05 as well as log odds of positive lymph nodes = − 2.73 predicted the carcinoma-specific death. Both lymph node ratio and log odds of positive lymph nodes were significantly related with survival outcomes by the univariate analysis. Lymph node ratio ≥ 0.05 was associated with shorter disease-specific (hazard ratio = 7.90, 95% confidence interval = 1.54–57.1), disease-free (hazard ratio = 4.15, 95% confidence interval = 1.48–11.2) and overall (hazard ratio = 4.84, 95% confidence interval = 1.05–24.8) survival in the multivariate analysis.

Conclusion

A higher lymph node ratio of minor salivary gland carcinoma is a predictor of shorter survival results.

Tumor dimension-dependent microscopic extensions of hypopharyngeal cancer: Therapeutic implications for larynx-preserving hypopharyngectomy

INTRODUCTION

Hypopharyngeal cancer (HPC) is well characterized by the early submucosal spread of cancer cells into adjacent subsites of the hypopharynx and deep tissues, advocating a wide extent of treatment. However, the microscopic extensions (ME) from gross tumors, according to the primary tumor dimensions, has not been reported in detail.

METHODS

We included patients who underwent upfront curative surgery, and retrospectively reviewed pathology specimens from 45 HPC cases. The distance of the MEs, defined as tumor infiltration beyond the gross tumor border on the submucosal and deep sides, was measured. We analyzed potential correlations between MEs and various physical tumor factors.

RESULTS

A rough linear correlation between the submucosal ME and the maximal diameter of tumors was found (p < .001, r²  = 0.225). Deep MEs did not correlate with tumor physical factors. However, the MEs differed significantly by the T status (p = .033 and .015 in submucosal and deep sides). In T1-2 tumors, the submucosal MEs were less than 0.5 cm, whereas those of T3-4 tumors were 1.5-2.0 cm.

CONCLUSION

In HPC, local MEs beyond the gross tumor border correlated with primary tumor T status. Our findings support that the surgical safety margin for HPC can be adjusted according to tumor dimension.

Prognostic Value of Lymph Node Density in Patients With T3 and T4 Pyriform Sinus Carcinoma

Background/Aim:

Lymph node density is a parameter used to more accurately predict tumor recurrence and patient survival. However, its association with surgical outcome in pyriform sinus carcinoma remains unclear. The purpose of this study was to assess the prognostic value of lymph node density in advanced pyriform sinus carcinoma.

Patients and Methods:

A total of 87 patients with pyriform sinus carcinoma treated between 2008 and 2015 were enrolled. Then, 5-year overall survival, 5-year disease-specific survival, 5-year disease-free survival, and 5-year regional recurrence-free survival were utilized to assess the prognostic significance of lymph node density.

Results:

With a median follow-up period of 31.8 months, 5-year overall survival, disease-specific survival, disease-free survival, and regional recurrence-free survival were 37.9%, 46.0%, 41.4%, and 54.0%, respectively. Univariate analysis revealed that lymph node density ≥ 0.093 was a significant predictor of poor 5-year overall survival (P = .005), disease-specific survival (P = .008), disease-free survival (P = .0013), and regional recurrence-free survival (P = .003). Furthermore, multivariate analysis demonstrated that lymph node density was negatively associated with adverse 5-year overall survival (hazard ratio = 1.62, 95% CI: 1.15-2.29, P = .006), disease-specific survival (hazard ratio = 1.86, 95% CI: 1.24-2.80, P = .003), disease-free survival (hazard ratio = 0.45, 95% CI: 0.24-0.85, P = .014), and regional recurrence-free survival (hazard ratio = 2.97, 95% CI: 1.43-6.17, P = .004).

Conclusion:

Taken together, these results reveal that lymph node density is a powerful prognostic factor for patients with T3 and T4 pyriform sinus carcinoma, and the median lymph node density cutoff values ≥ 0.093 are associated with a greater risk of recurrence and poorer survival.

Prognostic capacity of the lymph node ratio in squamous cell carcinomas of the head and neck

INTRODUCTION AND OBJECTIVES

Lymph node density or lymph node ratio (LNR), defined as the quotient between the total number of positive lymph nodes and the total number of dissected lymph nodes, has demonstrated a prognostic capacity in several tumour models, including patients with head and neck squamous cell carcinomas (HNSCC). The aim of the present study is to analyse the prognostic value of LNR in a wide cohort of patients with HNSCC.

METHODS

We carried out a retrospective study of a cohort of 1,311 patients with HNSCC treated with unilateral or bilateral neck dissections. Of the patients included in the study, 55.0% had lymph node metastases (pN+). We proceeded to calculate the value of the LNR, and its categorization through a recursive partition analysis considering specific survival as the dependent variable.

RESULTS

Three categories were defined according to the value of the LNR with a cut-off point at the values < of .025 and .118. The 5-year specific survival for patients with an LNR less than .025 (n=654, 49.8%) was 87.2%, for patients with a LNR .025-.118 (n=394, 30.1%) it was 51.6%, and for patients with a LNR greater than .188 (n=263, 20.1%) it was 27.3% (P=.0001). According to the results of a multivariate analysis, the LNR significantly related to specific survival.

CONCLUSION

The LNR can be a prognostic variable to be considered in the pathological staging of the lymph nodes.

Prognostic value of lymph node ratio in laryngeal and hypopharyngeal squamous cell carcinoma: a systematic review and meta-analysis

Background

Several recent studies have indicated that the lymph node ratio (LNR) is an independent prognostic factor for laryngeal and hypopharyngeal squamous cell carcinoma (LHSCC). The purpose of this paper is to assess the prognostic value of LNR and explore appropriate cutoff values by conducting a systematic review and meta-analysis.

Methods

Pubmed, Embase (via Ovid), and Cochrane library were systematically searched for studies on the prognostic value of LNR in LHSCC up to October 31, 2019. Then, Literature review, data extraction, and quality assessment of eligible studies were performed by two independent reviewers back-to-back. Lastly, Stata 14.0 software was hired to conduct a meta-analysis.

Results

A total of 445 articles were retrieved, and 13 studies published in English between 2013 and 2019 were included after the title/abstract and full-text screening. Among the 13 studies contributed to 4197 patients, seven studies were about hypopharyngeal squamous cell carcinoma (HPSCC), four studies about laryngeal squamous cell carcinoma (LSCC), and the remaining two studies about LHSCC. The meta-analysis results showed that shorter overall survival (OS) (HR 1.49; 95%CI: 1.18 to 1.88), disease-specific survival (DSS) (HR 1.66; 95%CI: 1.32 to 2.07) and disease-free survival (DFS) (HR 2.04; 95%CI: 1.54 to 2.71) were significantly correlated with a higher LNR in a random-effect model. The cutoff values of eligible studies were varied from 0.03 to 0.14, and the lowest significant LNR was 0.044.

Conclusion

LNR is a valuable prognostic factor in the survival of LHSCC and may be used to improve the tumor staging systems, which, however, requires the solid support of more high-quality studies.

Definitive chemoradiotherapy in patients with squamous cell cancers of the head and neck - results from an unselected cohort of the clinical cooperation group "Personalized Radiotherapy in Head and Neck Cancer"

BACKGROUND

Definitive chemoradiotherapy (dCRT) is a standard treatment for patients with locally advanced head and neck cancer. There is a clinical need for a stratification of this prognostically heterogeneous group of tumors in order to optimize treatment of individual patients. We retrospectively reviewed all patients with head and neck squamous cell carcinoma (HNSCC) of the oral cavity, oropharynx, hypopharynx, or larynx, treated with dCRT from 09/2008 until 03/2016 at the Department of Radiation Oncology, LMU Munich. Here we report the clinical results of the cohort which represent the basis for biomarker discovery and molecular genetic research within the framework of a clinical cooperation group.

METHODS

Patient data were collected and analyzed for outcome and treatment failures with regard to previously described and established risk factors.

RESULTS

We identified 184 patients with a median follow-up of 65 months and a median age of 64 years. Patients received dCRT with a median dose of 70 Gy and simultaneous chemotherapy in 90.2% of cases, mostly mitomycin C / 5-FU in concordance with the ARO 95-06 trial. The actuarial 3-year overall survival (OS), local, locoregional and distant failure rates were 42.7, 29.8, 34.0 and 23.4%, respectively. Human papillomavirus-associated oropharynx cancer (HPVOPC) and smaller gross tumor volume were associated with significantly improved locoregional tumor control rate, disease-free survival (DFS) and OS in multivariate analysis. Additionally, lower hemoglobin levels were significantly associated with impaired DFS und OS in univariate analysis. The extent of lymph node involvement was associated with distant failure, DFS and OS. Moreover, 92 patients (50%) of our cohort have been treated in concordance with the ARO 95-06 study, corroborating the results of this study.

CONCLUSION

Our cohort is a large unselected monocentric cohort of HNSCC patients treated with dCRT. Tumor control rates and survival rates compare favorably with the results of previously published reports. The clinical data, together with the available tumor samples from biopsies, will allow translational research based on molecular genetic analyses.

Prognostic value of lymph node density for major salivary gland carcinoma without clinical lymph node metastasis

BACKGROUND AND OBJECTIVE

This study aimed to investigate whether lymph node density (LND) was correlated with overall survival (OS) in major salivary gland carcinoma without clinical lymph node metastasis.

METHODS

Sixty patients who were diagnosed with major salivary gland carcinoma without clinical lymph node metastasis were enrolled. Of these, 50 patients underwent neck dissection. LND was defined as the ratio of the number of positive lymph nodes to the total number of resected lymph nodes.

RESULTS

An LND of ≥0.1 was significantly associated with a short OS (p < 0.05). Multivariate analysis with adjustment for pathological N classification and positive surgical margin showed that an LND of ≥0.1 is a predictor of OS.

CONCLUSION

Results demonstrated that lymph node density functions as a predictor of outcomes for major salivary gland carcinoma without clinical lymph node metastasis.

Prognostic significance of lymph node yield and lymph node ratio in patients affected by squamous cell carcinoma of the oral cavity and oropharynx: Study protocol for a prospective, multicenter, observational study

Background

Lymph node involvement is a fundamental prognostic factor in head and neck squamous cell carcinoma (SCC). Lymph node yield (LNY), which is the number of lymph nodes retrieved after neck dissection, and lymph node ratio (LNR), which is the ratio of positive lymph nodes out of the total removed, are measurable indicators that may have the potential to be used as prognostic factors. The present study is designed to define the exact role of LNY and LNR regarding the overall and specific survival of patients affected by oral cavity and oropharyngeal SCC. It has been registered on clinicaltrials.gov database (NCT03534778).

Methods

This is a multicenter study involving tertiary care referral centers in Europe and North America. Patients affected by oral cavity, HPV+ and HPV- oropharyngeal SCC undergoing neck dissection will be consecutively enrolled and followed-up for up to 5 years. Patients and disease characteristic will be properly recorded and centrally analyzed. The primary end-point is to define reliable cut off-values for LNY and LNR which may serve as prognosticators of survival. This will be achieved through the use of ROC curves. Secondary outcomes will be the Overall survival (OS), Disease Specific Survival (DSS), and Progression Free Survival Hazard Ratios (HR) at 2-, 3- and 5 years, which will be evaluated through the Kaplan-Meier method and the difference in survival attested by the log-rank test. Univariate and multivariate analysis will be performed to understand the association of various outcomes with LNY and LNR.

The Prognostic Significance of Lymph Node Ratio and Log Odds Ratio in Laryngeal Squamous Cell Carcinoma

Objective

To investigate whether lymph node ratio (LNR) and log odds ratio (LODDS) have prognostic significance for overall survival (OS) and disease-free survival (DFS) in patients with laryngeal squamous cell cancer (LSCC) treated with curative intent.

Study Design

Case-control study.

Setting

University hospital.

Subjects and Methods

Records of 229 patients with LSCC who underwent surgery with a curative intent with or without adjuvant treatment from 2000 to 2014 were reviewed. The clinicopathological parameters LNR and LODDS were analyzed; univariate and multivariate analysis was performed to evaluate the prognosis of each for OS and DFS.

Results

The 5-year OS was 81.7% for LNR ≤0.233 and 47.1% for LNR >0.233, and the 5-year OS was 79.6% for LODDS ≤–0.1 and 51.8% for LODDS >–0.1, respectively. In the univariate analysis, the independent variables were subsites, pT stage (pT1 and pT2 vs pT3 and pT4), pN, pTNM, alcohol consumption, and LNR and LODDS (P < .05). By multivariate analysis, we determined that subsites, pT stage, alcohol consumption, LNR, and LODDS were independent prognostic predictors of survival (P < .05). Univariate and multivariate models identified that both LNR and LODDS were significant prognostic factors for survival. However, the hazard ratio (HR) for LNR >0.233 vs ≤0.233 was 8.95 (95% confidence interval [CI], 3.18-25.16; P < .001) in OS, and the HR was 11.37 (95% CI, 4.02-32.15; P < .001) in DFS. The risk of LNR was noticeably greater than other factors.

Conclusions

LNR and LODDS were both prognostic factors for OS and DFS. However, LNR was confirmed as a more reliable indicator for evaluating the prognosis, and it can be used to increase the prognostic value of the traditional TNM classification of LSCC.

Lymph node density in papillary thyroid carcinoma is a prognostic factor after adjusting for pathological stage

We investigated the possible association between the lymph node density and survival outcomes in differentiated papillary thyroid carcinoma, and examined whether the lymph node density was a predictor in a multivariate analysis adjusted for the pathological stage in the eighth edition of the Union for International Cancer Control Tumor-Node Metastasis Classification of Malignant Tumors. A total of 543 patients with papillary thyroid carcinoma were enrolled. We performed restaging according to the eighth edition. The lymph node density was the ratio between number of positive lymph nodes and total number of excised lymph nodes. A log-rank test and Cox's proportional hazards model were used for univariate and multivariate analysis with adjustment for the pathological stage in the eighth edition, respectively. In both the univariate and multivariate analyses of 150 patients with pN1bM0, the presence of a lymph node density of ≥ 0.3 with pN1b was significantly associated with shorter disease-specific survival. In both the univariate and multivariate analyses of all 543 patients, a lymph node density of ≥ 0.3 with pN1b were also significantly associated with shorter overall and disease-specific survival. In conclusion, these results suggest that the lymph node density can be used as a predictor for the survival outcomes after adjustment for the pathological stage in the eighth edition.

Prognostic Value of Lymph Node Yield and Density in Head and Neck Malignancies

Objective

Studies have suggested that the lymph node yield and lymph node density from selective or elective neck dissections are predictive of patient outcomes and may be used for patient counseling, treatment planning, or quality measurement. Our objective was to systematically review the literature and conduct a meta-analysis of studies that investigated the prognostic significance of lymph node yield and/or lymph node density after neck dissection for patients with head and neck cancer.

Data Sources

The Ovid/Medline, Ovid/Embase, and NLM PubMed databases were systematically searched on January 23, 2017, for articles published between January 1, 1946, and January 23, 2017.

Review Methods

We reviewed English-language original research that included survival analysis of patients undergoing neck dissection for a head and neck malignancy stratified by lymph node yield and/or lymph node density. Study data were extracted by 2 independent researchers (S.C. and M.O.). We utilized the DerSimonian and Laird random effects model to account for heterogeneity of studies.

Results

Our search yielded 350 nonduplicate articles, with 23 studies included in the final synthesis. Pooled results demonstrated that increased lymph node yield was associated with a significant improvement in survival (hazard ratio, 0.833; 95% CI, 0.790-0.879). Additionally, we found that increased lymph node density was associated with poorer survival (hazard ratio, 1.916; 95% CI, 1.637-2.241).

Conclusions

Increased nodal yield portends improved outcomes and may be a valuable quality indicator for neck dissections, while increased lymph node density is associated with diminished survival and may be used for postsurgical counseling and planning for adjuvant therapy.

Prognostic value of lymph node ratio in head and neck squamous cell carcinoma

BACKGROUND

Lymph node ratio (LNR) is increasingly reported as a potential prognostic tool. The purpose of this review was to analyze the available literature on the prognostic significance of LNR in head and neck squamous cell carcinoma (HNSCC).

METHODS

A PubMed internet search was performed and articles meeting selection criteria were reviewed.

RESULTS

Twenty-eight studies were identified in the literature dealing with the prognostic value of LNR. The published results are variable with a range of cutoff values of LNR associated with prognosis (overall survival [OS] and/or disease-specific survival [DSS]) between 0.02 and 0.20, with an average of 0.09.

CONCLUSION

The LNR is reported to be of value in assessing prognosis in the patients with HNSCC. Although it is easy to calculate and could be considered in the staging of these patients, the currently available evidence in the literature does not yet provide a solid base for implementation.