Usefulness of fluorescence visualization-guided surgery for early-stage tongue squamous cell carcinoma compared to iodine vital staining

Clinical Experience with Autofluorescence Guided Oral Squamous Cell Carcinoma Surgery

In our study, the effect of the use of autofluorescence (Visually Enhanced Lesion Scope-VELscope) on increasing the success rate of surgical treatment in oral squamous carcinoma (OSCC) was investigated. Our hypothesis was tested on a group of 122 patients suffering from OSCC, randomized into a study and a control group enrolled in our study after meeting the inclusion criteria. The preoperative checkup via VELscope, accompanied by the marking of the range of a loss of fluorescence in the study group, was performed before the surgery. We developed a unique mucosal tattoo marking technique for this purpose. The histopathological results after surgical treatment, i.e., the margin status, were then compared. In the study group, we achieved pathological free margin (pFM) in 55 patients, pathological close margin (pCM) in 6 cases, and we encountered no cases of pathological positive margin (pPM) in the mucosal layer. In comparison, the control group results revealed pPM in 7 cases, pCM in 14 cases, and pFM in 40 of all cases in the mucosal layer. This study demonstrated that preoperative autofluorescence assessment of the mucosal surroundings of OSCC increased the ability to achieve pFM resection 4.8 times in terms of lateral margins.

Combination of fluorescence visualization and iodine solution-guided surgery for local control of early tongue cancer

The control of enclosed oral epithelial dysplasia is important for the control of oral cancer. Fluorescence visualization and iodine solution are able to detect oral epithelial dysplasia and surrounding oral cancer. The purpose of this study was to clarify the effectiveness of combining fluorescence visualization and iodine solution-guided surgery for early tongue cancer. Participants comprised 264 patients with primary early tongue cancer who underwent surgery. The surgical margin was set at 10 mm outside the clinical tumour, and 5 mm outside the area of fluorescence visualization loss, and 5mm outside the iodine unstained area. The 5-year disease-free survival rate was 87.1% vs 76.1% (P = 0.016) and the 5-year local control rate was 98.6% vs 93.0% (P = 0.008) for combination-guided surgery when compared to conventional surgery. Positive margin rates were 0% for cancer, and 6.5% and 0% for low- and high-grade dysplasia, respectively, with combination-guided surgery (P = 0.257). Multivariate analysis revealed that combination-guided surgery (odds ratio 0.140, 95% confidence interval 0.045-0.437; P < 0.001) and intraoperative frozen section examination (odds ratio 0.302; 95% confidence interval 0.115-0.791; P = 0.015) were significantly associated with local control. The combination of fluorescence visualization and iodine solution are effective in selecting surgical margins for early tongue cancer.

Prediction of Prognosis of Tongue Squamous Cell Carcinoma Based on Clinical MR Imaging Data Modeling

Objective: Tongue squamous cell carcinoma (TSCC) is one of the most common and poor prognosis head and neck tumors. The purpose of this study is to establish a model for predicting TSCC prognosis based on clinical and MR radiomics data and to develop a nomogram. Methods: A retrospective analysis was performed on the clinical and imaging data of 211 patients with pathologically confirmed TSCC who underwent radical surgery at xx hospital from February 2011 to January 2020. Patients were divided into a study group (recurrence, metastasis, and death, n = 76) and a control group (normal survival, n = 135) according to 1 to 6 years of follow-up. A training set and a test set were established based on a ratio of 7:3 and a time point. In the training set, 3 prediction models (clinical data model, imaging model, and combined model) were established based on the MR radiomics score (Radscore) combined with clinical features. The predictive performance of these models was compared using the Delong curve, and the clinical net benefit of the model was tested using the decision curve. Then, the external validation of the model was performed in the test set, and a nomogram for predicting TSCC prognosis was developed. Results: Univariate analysis confirmed that betel nut consumption, spicy hot pot or pickled food, unclean oral sex, drug use, platelet/lymphocyte ratio (PLR), neutrophil/lymphocyte ratio (NLR), depth of invasion (DOI), low differentiation, clinical stage, and Radscore were factors that affected TSCC prognosis (P < .05). In the test set, the combined model based on these factors had the highest predictive performance for TSCC prognosis (area under curve (AUC) AUC: 0.870, 95% CI [0.761-0.942]), which was significantly higher than the clinical model (AUC: 0.730, 95% CI [0.602-0.835], P = .033) and imaging model (AUC: 0.765, 95% CI [0.640-0.863], P = .074). The decision curve also confirmed the higher clinical net benefit of the combined model, and these results were validated in the test set. The nomogram developed based on the combined model received good evaluation in clinical application. Conclusion: MR-LASSO extracted texture parameters can help improve the performance of TSCC prognosis models. The combined model and nomogram provide support for postoperative clinical treatment management of TSCC.

Applicability of autofluorescence and fluorescent probes in the trans-surgical of oral carcinomas: A systematic review

Oral cancer represents an important health problem, as it is the sixth most common type of cancer in the world and is associated with high rates of morbidity and mortality. The treatment considered the gold standard for this type of tumor is surgical resection with negative margins, with a distance of at least 5 mm from the tumor. This procedure is strongly associated with local control and disease-specific survival, however, in many cases, large amounts of healthy tissue are removed, resulting in surgical defects, compromising various functions and directly affecting the individual's quality of life. From this perspective, this systematic review aimed to evaluate the use of autofluorescence and fluorescent probes as potential adjuvant techniques to facilitate the delineation of surgical margins for oral cancers. A comprehensive search was performed in Pubmed, Scopus, Web of Science, LIVIVO, Embase, ProQuest Open Access Dissertations & Theses, Open Access Theses and Dissertations, and DART Europe databases, where 1948 articles were found. After the different stages of critical evaluation, 15 articles were selected, eligible for the inclusion criteria. Of these, 7 articles used autofluorescence, 7 used fluorescent probes and 1 article used both methods. As for autofluorescence, the most used device was the VELScope, and indocyanine green was the most used probe. Compared to histopathology, autofluorescence did not obtain significant and/or superiors results. In contrast to fluorescent probes that, most articles showed a good performance of margins during surgical resection, making them a promising alternative. However, it is still necessary to carry out the analysis of more articles, with more significant samples and sensitivity and specificity data to qualify the results.

Evaluation of Oral Mucosal Lesions Using the IllumiScan® Fluorescence Visualisation Device: Distinguishing Squamous Cell Carcinoma

We evaluated whether fluorescence intensity (FI) and its coefficient of variation (CV) can be used to diagnose squamous cell carcinoma (SCC) through IllumiScan®, an oral mucosa fluorescence visualisation (FV) device. Overall, 190 patients with oral mucosal lesions (OMLs; SCC, 59; non-SCC OMLs, 131) and 49 patients with normal oral mucosa (NOM) were enrolled between January 2019 and March 2021. The FI of the images was analysed using image analysis software. After establishing regions of interest for SCC, non-SCC, and NOM, the average FI, standard deviation (SD), and CV were compared. There was a significant difference in the average FI for all pairs of comparisons. The SD was not significantly different between the SCC and NOM groups (p = 0.07). The CV differed significantly for NOM (p < 0.001) and non-SCC groups (p < 0.001) relative to the SCC group but was not different between NOM and non-SCC groups (p = 0.15). Univariate analysis of SCC and non-SCC groups showed significant differences for all factors, except age. However, multivariate analysis showed a significant intergroup difference only in the CV (p = 0.038). Therefore, analysing the CV in FV images of OML may be useful for the diagnosis of oral cancer.

In Vivo Imaging-Based Techniques for Early Diagnosis of Oral Potentially Malignant Disorders-Systematic Review and Meta-Analysis

Objectives: Oral potentially malignant disorders (OPMDs) are lesions that may undergo malignant transformation to oral cancer. The early diagnosis and surveillance of OPMDs reduce the morbidity and mortality of patients. Diagnostic techniques based on medical images analysis have been developed to diagnose clinical conditions. This systematic review and meta-analysis aimed to evaluate the efficacy of imaging-based techniques compared to the gold standard of histopathology to assess their ability to correctly identify the presence of OPMDs. Design: Literature searches of free text and MeSH terms were performed using MedLine (PubMed), Scopus, Google Scholar, and the Cochrane Library (from 2000 to 30 June 2020). The keywords used in the search strategy were: (“oral screening devices” or “autofluorescence” or “chemiluminescence” or “optical imaging” or “imaging technique”) and (“oral dysplasia” or “oral malignant lesions” or “oral precancerosis”). Results: The search strategy identified 1282 potential articles. After analyzing the results and applying the eligibility criteria, the remaining 43 papers were included in the qualitative synthesis, and 34 of these were included in the meta-analysis. Conclusions: None of the analyzed techniques based on assessing oral images can replace the biopsy. Further studies are needed to explore the role of techniques-based imaging analysis to identify an early noninvasive screening method.

Imaging-based navigation technologies in head and neck surgery

PURPOSE OF REVIEW

Image guided navigation has had significant impact in head and neck surgery, and has been most prolific in endonasal surgeries. Although conventional image guidance involves static computed tomography (CT) images attained in the preoperative setting, the continual evolution of surgical navigation technologies is fast expanding to incorporate both real-time data and bioinformation that allows for improved precision in surgical guidance. With the rapid advances in technologies, this article allows for a timely review of the current and developing techniques in surgical navigation for head and neck surgery.

RECENT FINDINGS

Current advances for cross-sectional-based image-guided surgery include fusion of CT with other imaging modalities (e.g., magnetic resonance imaging and positron emission tomography) as well as the uptake in intraoperative real-time 'on the table' imaging (e.g., cone-beam CT). These advances, together with the integration of virtual/augmented reality, enable potential enhancements in surgical navigation. In addition to the advances in radiological imaging, the development of optical modalities such as fluorescence and spectroscopy techniques further allows the assimilation of biological data to improve navigation particularly for head and neck surgery.

SUMMARY

The steady development of radiological and optical imaging techniques shows great promise in changing the paradigm of head and neck surgery.

Succinate Pathway in Head and Neck Squamous Cell Carcinoma: Potential as a Diagnostic and Prognostic Marker

Simple Summary

Emerging evidence points to succinate as an important oncometabolite in cancer development; however, the contribution of the succinate-SUCNR1 axis to cancer progression remains unclear. Head and neck squamous cell carcinoma (HNSCC) is associated with disease and treatment-related morbidity so there is an urgent need for innovation in treatment and diagnosis practices. Our aim was to evaluate the potential of the succinate-related pathway as a diagnostic and prognostic biomarker in HNSCC. The circulating succinate levels are increased in HNSCC, being a potential noninvasive biomarker for HNSCC diagnosis. Moreover, the succinate receptor (SUCNR1) and genes related to succinate metabolism, which are predominantly expressed in the tumoral mucosa as compared with healthy tissue, are positively associated with plasma succinate. Remarkably, we found that SUCNR1 and SDHA expression levels predict prognosis.

Abstract

Head and neck squamous cell carcinoma (HNSCC) is characterized by high rates of mortality and treatment-related morbidity, underscoring the urgent need for innovative and safe treatment strategies and diagnosis practices. Mitochondrial dysfunction is a hallmark of cancer and can lead to the accumulation of tricarboxylic acid cycle intermediates, such as succinate, which function as oncometabolites. In addition to its role in cancer development through epigenetic events, succinate is an extracellular signal transducer that modulates immune response, angiogenesis and cell invasion by activating its cognate receptor SUCNR1. Here, we explored the potential value of the circulating succinate and related genes in HNSCC diagnosis and prognosis. We determined the succinate levels in the serum of 66 pathologically confirmed, untreated patients with HNSCC and 20 healthy controls. We also surveyed the expression of the genes related to succinate metabolism and signaling in tumoral and nontumoral adjacent tissue and in normal mucosa from 50 patients. Finally, we performed immunohistochemical analysis of SUCNR1 in mucosal samples. The results showed that the circulating levels of succinate were higher in patients with HNSCC than in the healthy controls. Additionally, the expression of SUCNR1, HIF-1α, succinate dehydrogenase (SDH) A, and SDHB was higher in the tumor tissue than in the matched normal mucosa. Consistent with this, immunohistochemical analysis revealed an increase in SUCNR1 protein expression in tumoral and nontumoral adjacent tissue. High SUCNR1 and SDHA expression levels were associated with poor locoregional control, and the locoregional recurrence-free survival rate was significantly lower in patients with high SUCNR1 and SDHA expression than in their peers with lower levels (77.1% [95% CI: 48.9–100.0] vs. 16.7% [95% CI: 0.0–44.4], p = 0.018). Thus, the circulating succinate levels are elevated in HNSCC and high SUCNR1/SDHA expression predicts poor locoregional disease-free survival, identifying this oncometabolite as a potentially valuable noninvasive biomarker for HNSCC diagnosis and prognosis.