Prognostic significance of extracapsular spread in isolated neck recurrences in head and neck squamous cell carcinoma patients

Nodal assessment and extranodal extension in head and neck squamous cell cancer: insights from computed tomography and magnetic resonance imaging

PURPOSE

The aim of the study was to evaluate the concordance between computed tomography (CT)/magnetic resonance imaging (MRI) and histological examination in the evaluation of lymph nodal involvement (N+) and extranodal extension (ENE+) in patients with squamous cell cancer of the head-neck district (HNSCC). The second end point was to evaluate which of the imaging features was more sensitive and specific in establishing N+ and ENE+, and comparing the diagnostic accuracy between CT and MRI.

MATERIAL AND METHODS

58 patients with HNSCC undergoing surgical treatment with lymph node dissection at the Policlinico of Bari were enrolled in this retrospective study. The criteria used for identifying radiological N+ (rN+) included six characteristics; the presence of any two or more criteria out of these six was considered rN+. For each rN+, the radiological extranodal extension (rENE+) was evaluated analyzing three characteristics; rENE was considered positive if any one criterion was present.

RESULTS

Of 167 lymph nodes, 45/167 (27%) had rN+, out of which 20/45 (44%) were rENE+. On pathological examination, 38/45 (84%) nodes were N+ and 11/20 (55%) were ENE+. The agreement between imaging and histology in the evaluation of N was (149/167) 89% with a good concordance (k = 0.7). The agreement between imaging and histology in the evaluation of ENE was (35/45) 78% with a moderate concordance (k = 0.5). Loss of fatty hilum was found to be the most sensitive (84%) imaging finding in N+ evaluation. Capsular irregularity with fat stranding had the highest sensitivity (82%) for the determination of ENE+. Comparing CT and MRI imaging in the evaluation of N+ and ENE+, we found no statistically significant differences (p-value of 0.3 for N+ and p-value of 0.3 for ENE +).

CONCLUSIONS

Imaging has good confidence in detecting rN+ but modest in assessing rENE+. Further research could improve the imaging specificity for the determination of rENE.

Salvage neck dissection for isolated neck recurrences in head and neck tumors: Intra and postoperative complications

BACKGROUND AND OBJECTIVES

The current evidence regarding complications after salvage neck dissection (ND) for isolated regional recurrences (IRRs) in head and neck cancers is poor. The aim of this study is to evaluate the incidence and differences in complication rates of salvage ND after primary surgery, radiotherapy, chemoradiotherapy, or combined treatments.

METHODS

This was a multicentric retrospective study on 64 patients who underwent salvage ND for IRR in three Italian institutes between 2008 and May 2020.

RESULTS

Complications were detected in 7 of the 34 patients (20.8%) and surgeons described difficult dissection in 20 patients (58.82%). Accidental vascular ligations or nervous injury during surgery were never detected. None of the variables analyzed were statistically significant in predicting the risk of complications, disease-free survival, or overall survival.

CONCLUSIONS

IRR represents a rare entity among total relapses. The incidence of complications after salvage ND for IRR is higher than after primary surgery but at an acceptable rate in experienced hands. However, an adequate balance between functional and oncological outcomes is mandatory.

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcome in patients with isolated regional recurrence after primary radiotherapy for head and neck cancer

BACKGROUND

Isolated regional recurrences following head-neck squamous-cell carcinomas (HNSCC) are often accessible for curatively intended salvage treatment. Factors prognostic for outcome were investigated in a large cohort of HNSCC patients.

METHODS

In total, 1811 patients receiving curatively intended radiotherapy from 2007 to 2017 were reviewed and isolated cervical nodal recurrences were identified. Factors associated with survival and second recurrence were investigated using univariate and multivariate analyses.

RESULTS

Isolated regional recurrence was seen in 95/1811 (5.2%) patients. Eighty of 95 patients (84%) received salvage surgery. Two-year survival after isolated regional recurrence was 40%. Overall survival (OS) and time to second recurrence were associated with resection status of the salvage surgery and presence of extranodal spread (ENS), while p16-positive oropharyngeal squamous-cell carcinoma (OPSCC) was associated with better OS.

CONCLUSION

Long-term survival after regional recurrence in HNSCC is possible. p16-positive OPSCC, complete salvage surgery, and lack of ENS are associated with better outcome.

Outcome of Salvage Therapy in Isolated Regional Recurrence in Head and Neck Squamous Cell Carcinoma

OBJECTIVES/HYPOTHESIS

Head and neck squamous cell carcinoma (HNSCC) has a high tendency for regional lymphatic spreading. Nevertheless, isolated regional lymph node recurrences are rare, and only limited data regarding its management are available. The aim of this study was to describe treatment modalities and outcomes, and to identify prognostic factors. Study Design Retrospective cohort study.

METHODS

The records of all patients (n = 498) with tumor persistence or recurrence after curatively intended treatment for HNSCC were retrospectively reviewed. Patients with synchronous secondary tumors at initial presentation, tumor persistence, local or locoregional recurrence, and systemic metastases were excluded.

RESULTS

A total of 76 patients were included. The rate of occult additional metastasis in radiologically uninvolved neck compartments during salvage neck dissection was 25%. The salvaged patients showed a 37.5% 5-year recurrence-free survival (RFS). Multivariate analysis revealed initial stage IVA-B (hazard ratio [HR]: 4.16, P < .01), extracapsular spread (HR: 3.71, P = .04), higher involved/total lymph node ratio (HR: 6.79, P < .01), and soft-tissue infiltration (HR: 3.27, P < .01) as independent adverse prognostic factors for RFS. Moreover, univariate data analysis identified recurrent stage rcN2-3; clinical involvement of the neck levels IV, V and/or VI; and smoking as adverse risk factors for RFS.

CONCLUSIONS

This study identifies initial stage IVA-B, extracapsular spread, higher involved/total lymph node ratio, and soft-tissue infiltration as independent adverse prognostic factors for RFS following isolated regional recurrences. The incidence of occult additional metastasis of radiologically uninvolved levels during salvage neck dissections was high (25%). Therefore, superselective or selective neck dissection would not have been the adequate type of salvage surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:67-72, 2021.

A histopathological evaluation and potential prognostic implications of oral squamous cell carcinoma with adverse features

OBJECTIVES

This study aimed to evaluate the adverse clinicopathologic features of oral squamous cell carcinoma (OSCC), including margin status, depth of invasion, lymphovascular invasion, perineural invasion, and extranodal extension that significantly affect survival outcomes.

MATERIALS AND METHODS

This retrospective cross-sectional study included 341 patients with OSCC who underwent therapeutic surgical treatment in Taiwan. The Kaplan-Meier method was used to estimate survival outcomes. A multivariable Cox regression model was used to evaluate the associations of various clinicopathologic features with 5-year overall survival (OS) outcomes in patients with pN0 and pN+ tumors.

RESULTS

Overall, the patients had 5-year OS and progression-free survival rates of 60.0 and 47.9%, respectively. In the pN0 group, the multivariate analysis identified a positive margin (odds ratio [OR] = 16.3, 95% confidence interval [95% CI]: 3.7-72.3; P = 0.001), depth of invasion >5 mm (OR = 2.1, 95% CI: 1.2-3.7; P = 0.012), presence of lymphovascular space invasion (OR = 5.4, 95% CI: 1.3-22.0; P = 0.018), and presence of perineural invasion (OR = 4.3, 95% CI: 1.7-11.1; P = 0.002) as independent and significant prognosticators of OS. In the pN+ group, only the presence of extranodal extension independently predicted OS (OR = 1.7, 95% CI: 1.1-2.7; P = 0.0026).

CONCLUSIONS

When determining survival prognosis for patients with a pN0 status, we recommended including all adverse features. In contrast, extranodal extension was the most important prognostic factor for patients with a pN+ status.

AHNS series: Do you know your guidelines? Guideline recommendations for recurrent and persistent head and neck cancer after primary treatment

Locoregional recurrent/persistent head and neck cancer following primary treatment is a significant challenge as it is usually difficult to treat and has worse outcomes compared to the primary setting. Surgical resection of a local or regional recurrence offers the best chance of cure when feasible. Local recurrence outcomes vary by subsite with laryngeal recurrences having the best prognoses and hypopharynx having the worst. Instances of persistent neck masses following primary nonsurgical treatment can be evaluated with positron emission tomography (PET) with CT (PET-CT) when there is no definitive diagnosis of a recurrence/persistence. Reirradiation with or without chemotherapy can be considered for primary treatment when surgery is not an option, for adjuvant treatment following salvage surgery, or for palliation. Immunotherapy represents a newer class of chemotherapeutic agents. Current guidelines recommend enrollment in clinical trials especially when surgery is not an option as outcomes remain universally poor in the recurrent/persistent setting.

Salvage of recurrence after surgery and adjuvant therapy: A systematic review

PURPOSE

To determine the oncologic and functional outcomes of patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma after initial management with surgery and adjuvant therapy.

DATA SOURCES

Ovid Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov.

REVIEW METHODS

A structured search was performed of the literature to identify studies that included patients undergoing surgical salvage for local, regional, or locoregional recurrent head and neck squamous cell carcinoma without known distant metastases who had been treated with initial surgery and post-operative adjuvant radio- or chemoradiotherapy. Studies were excluded if they did not report at least 1-year survival estimates, included patients who underwent primary non-surgical management, or included those treated with non-surgical salvage therapies or supportive care alone.

RESULTS

The search strategy yielded 3746 abstracts. After applying exclusion and inclusion criteria, 126 full-texts were reviewed and six studies were included with a total of 222 patients. All studies were retrospective in design and included diverse disease subsites and stages. Complications and functional outcomes were inconsistently reported. Five-year survival estimates ranged between 10% and 40% between studies.

CONCLUSIONS

Patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma after initial surgery and adjuvant therapy may have a particularly poor prognosis. Future studies are needed to determine functional and quality of life outcomes in this patient population and to identify specific prognostic factors for re-recurrence and survival.