The prognostic significance of lymph node involvement in pyriform sinus and supraglottic cancers

Extranodal extension in head and neck squamous cell carcinoma: need for accurate pretherapeutic staging to select optimum treatment and minimize toxicity

PURPOSE OF REVIEW

In 2017, the American Joint Committee on Cancer (AJCC) introduced the inclusion of extracapsular nodal extension (ENE) into the N staging of nonviral head and neck squamous cell carcinoma (HNSCC), while retaining the traditional N classification based on the number and sizes of metastatic nodes. The extent of ENE was further defined as microscopic ENE (ENEmi) and major ENE (ENEma) based on extent of disease beyond the nodal capsule (≤ or > 2 mm). This article reviews the evidence and progress made since these changes were introduced.

RECENT FINDINGS

The 'gold standard' for evaluation ENE is histopathologic examination, the current preferred primary treatment of patients with HNSCC is by radiation-based therapy ± chemotherapy or biotherapy. The current pretreatment staging is by imaging, which needs improved reliability of radiologic rENE assessment with reporting needs to consider both sensitivity and specificity (currently computed tomography images have high-specificity but low-sensitivity). Adjuvant chemotherapy is indicated for patients with ENEma to enhance disease control, whereas for patients with ENEmi, there is a need to assess the benefit of adjuvant chemotherapy. Evidence that the presence of pENE in HPV-positive oropharyngeal carcinoma is an independent prognostic factor and should be considered for inclusion in future AJCC editions has recently emerged.

SUMMARY

There remains a paucity of data on the reliability of imaging in the staging of rENE, more so the for the accurate assessment of ENEmi. Optimistic early results from use of artificial intelligence/deep learning demonstrate progress and may pave the way for better capabilities in tumor staging, treatment outcome prediction, resulting in improved survival outcomes.

A key genomic signature associated with lymphovascular invasion in head and neck squamous cell carcinoma

Background

Lymphovascular invasion (LOI), a key pathological feature of head and neck squamous cell carcinoma (HNSCC), is predictive of poor survival; however, the associated clinical characteristics and underlying molecular mechanisms remain largely unknown.

Methods

We performed weighted gene co-expression network analysis to construct gene co-expression networks and investigate the relationship between key modules and the LOI clinical phenotype. Functional enrichment and KEGG pathway analyses were performed with differentially expressed genes. A protein–protein interaction network was constructed using Cytoscape, and module analysis was performed using MCODE. Prognostic value, expression analysis, and survival analysis were conducted using hub genes; GEPIA and the Human Protein Atlas database were used to determine the mRNA and protein expression levels of hub genes, respectively. Multivariable Cox regression analysis was used to establish a prognostic risk formula and the areas under the receiver operating characteristic curve (AUCs) were used to evaluate prediction efficiency. Finally, potential small molecular agents that could target LOI were identified with DrugBank.

Results

Ten co-expression modules in two key modules (turquoise and pink) associated with LOI were identified. Functional enrichment and KEGG pathway analysis revealed that turquoise and pink modules played significant roles in HNSCC progression. Seven hub genes (CNFN, KIF18B, KIF23, PRC1, CCNA2, DEPDC1, and TTK) in the two modules were identified and validated by survival and expression analyses, and the following prognostic risk formula was established: [risk score = EXP_DEPDC1 * 0.32636 + EXP_CNFN * (− 0.07544)]. The low-risk group showed better overall survival than the high-risk group (P < 0.0001), and the AUCs for 1-, 3-, and 5-year overall survival were 0.582, 0.634, and 0.636, respectively. Eight small molecular agents, namely XL844, AT7519, AT9283, alvocidib, nelarabine, benzamidine, L-glutamine, and zinc, were identified as novel candidates for controlling LOI in HNSCC (P < 0.05).

Conclusions

The two-mRNA signature (CNFN and DEPDC1) could serve as an independent biomarker to predict LOI risk and provide new insights into the mechanisms underlying LOI in HNSCC. In addition, the small molecular agents appear promising for LOI treatment.

Validation of Regional Lymph Node Excisional Biopsy for Staging Oral and Maxillofacial Malignant Neoplasms in 97 Dogs and 10 Cats (2006-2016)

The objective of this retrospective clinical study was to confirm the validity of excisional biopsy of regional lymphocentrums for staging oral and maxillofacial neoplasms in a population of 97 dogs and 10 cats. Patients diagnosed with oral and maxillofacial malignant neoplasms underwent ipsilateral excisional biopsy of the mandibular, parotid, and medial retropharyngeal lymphocentrums that receive afferent drainage from the oral and maxillofacial region followed by curative intent surgery of the neoplasm. Biopsy specimens and the resected neoplasm were submitted to a commercial pathology laboratory for histopathologic assessment. The incidence of metastasis to one or more regional lymphocentrums was 14.0%. Of the cases with metastatic disease, 26.7% did not involve the mandibular lymphocentrum. Although the incidence of regional lymph node metastasis was less than reported previously, regional lymph node assessment is warranted in cases of oral and maxillofacial neoplasia.

Prognostic significance of soft tissue deposits in laryngeal carcinoma

Introduction

Soft tissue deposits is tumorous islands apart from lymph nodes and occasionally diagnosed in neck dissection specimens. Their importance has begun to be recognized, however, their value has not been investigated in laryngeal cancer as a single tumor site.

Objective

To investigate the prognostic value of soft tissue deposits in patients with laryngeal carcinoma.

Methods

Medical records of 194 patients with laryngeal carcinoma who were treated primarily by surgery and neck dissection were reviewed. Prognostic significance of soft tissue deposits was assessed along with other clinical and pathological findings. Recurrence rates, overall and disease-specific survival rates were examined.

Results

The incidence of soft tissue deposits was found to be 7.2% in laryngeal carcinoma. N stage was more advanced in patients who had soft tissue deposits. Regional recurrence rate was higher and disease specific and overall survivals rates were significantly lower in patients with soft tissue deposits in univariate analysis. However, in multivariate analysis, soft tissue deposits were not found as an independent risk factor.

Conclusion

In laryngeal carcinoma, soft tissue deposits was diagnosed in patients with more advanced neck disease and their significance was lesser than other factors including extranodal extension.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Prevalence of regional and distant metastasis in cats with advanced oral squamous cell carcinoma: 49 cases (2005-2011)

The objective of this study was to evaluate the prevalence of regional and distant metastasis in cats with advanced oral squamous cell carcinoma (SCC) in a retrospective case series. Forty-nine cats with cytologically- or histopathologically-confirmed oral SCC presented to the Matthew J Ryan Veterinary Hospital of the University of Pennsylvania. History, clinical and laboratory results, diagnostic imaging findings and survival times were obtained from the medical records of patients who received diagnostic evaluation for metastasis. The prevalence of metastasis was assessed by means of mandibular lymph node cytology and three-view thoracic radiography. The prevalence of mandibular lymph node metastasis was 31% (15/49). Evidence of possible thoracic metastasis was seen in 10% (5/49) of cases. Of the patients with mandibular lymph node metastasis, 53% (8/15) were maxillary, 27% mandibular (4/15), 13% sublingual (2/15) and 7% caudal pharyngeal (1/15). Pulmonary metastasis was seen in three mandibular, one maxillary and one sublingual mass. Forty-one patients died or were euthanased owing to progression of local disease, and seven patients were lost to follow-up. The prevalence of regional metastasis in this study was more common than most previously reported studies, while the rate of pulmonary metastasis was higher than has previously been published. Although significant conclusions cannot be drawn, control of the primary tumor, regardless of tumor size at diagnosis, appears to be an important factor in improving survival time, and therefore treatment of metastasis may be important in those cases where long-term control of the primary tumor is possible.

Delayed lymph node metastases after elective neck dissection in patients with oral and oropharyngeal cancer and pN0 neck

PURPOSE

Patients with surgically treated head and neck cancer and clinical N0 neck with high risk of occult lymph node metastasis undergo elective neck dissection (ND). Late lymph node metastasis may appear in those patients with pN0 neck. The aim of the present study was to analyze the incidence and clinical relevance of late lymph node metastasis in patients with head and neck cancer.

MATERIALS AND METHODS

The clinical data of 61 patients with head and neck cancer who had undergone elective ND with pN0 neck were retrospectively analyzed. Only patients without local failure, second primary, or radiochemotherapy were included in the study.

RESULTS

Late lymph node metastasis could be observed in 4 (6.5%) cases at the margin or outside the initially dissected lymph node levels. In those patients, the primary tumor was localized in the oral cavity (n = 3) or oropharynx (n = 1) and was classified in all cases as T1 or T2. Lymph node metastasis could be found in levels I (n = 2), II (n = 1), and IV (n = 1), respectively.

CONCLUSION

Even in the case of pN0 neck after an elective ND, the appearance of late lymph node metastases must be expected. The low proportion of patients with late lymph node metastases after a selective ND in clinical and histologic N0 does not justify an extended form of neck surgery.

Expression of cathepsin D and E-cadherin in primary laryngeal cancers correlation with neck lymph node involvement

OBJECTIVE

The aim of this study was to investigate the relation between Cathepsin D (Cath-D) and E-Cadherin (E-Cad) expression levels in tumor tissue and neck lymph node metastasis. This attempt should be made to identify new factors that one could be useful in predicting clinical behavior.

STUDY DESIGN

In this study, we investigated rates of dying for E-Cad and Cath-D in paraphin blocks of larynx and neck dissection specimens taken from 56 selected patients. Laryngeal specimens dyed by ECad and Cath-D immunohistochemically. Immunoreactivity classified for E-Cad as positive (75% and above), reduced (25-75%) and negative (below 25%). Immunoreactivity classified for Cath-D:dye absorption rates higher than 50% evaluated positive and absorption rates lower than 50% evaluated negative. We compared the rates of dying for E-Cad and Cath-D groups to with or without neck lymph node metastasis in specimens.

RESULTS

Neck metastasis were found in 41% of patients, in 55.6% of patients, if the E-Cad was negative, 40.6% if it was reduced, 33.3% if it was positive in specimens. The neck metastasis was found in 35.4% of patients with Cath-D expression negative, while 75% of patients was found with Cath-D expression positive.

CONCLUSION

Neck metastasis was found higher in E-Cad reduced group than positive group. Neck node metastasis was significantly higher in Cath-D positive group than Cath-D negative group. Cath-D and E-Cad essays may useful in identifying neck lymph node involvement. Cath-D expression levels are more in this predictive factor than E-Cad levels for possibility of neck lymph node metastasis in LSCC.

Labeling of cervical lymph node levels during neck dissection: from ex vivo to in situ mapping

OBJECTIVES

To analyze the error rate of ex vivo mapping and to evaluate in situ mapping of lymph node (LN) levels during neck dissection (ND) METHODS: We retrospectively reviewed the pathological data on metastatic LN levels in head and neck cancer patients that had ND and ex vivo mapping of LN levels. Among them, we included the data from 43 patients that had a high risk for metastatic nodes based on both the preoperative CT and PET/CT. We compared the metastatic node levels based on the radiological studies and surgical pathology. In addition, we prospectively evaluated the accuracy of in situ mapping (N = 20).

RESULTS

With ex vivo mapping, the discrepancy between the radiological results and the pathological reports was 11.6% (5 out of 43); two side mismatches, two up down mismatches, and one faulty labeling, and in 7.0% (3 out of 43), the adjuvant treatment was redirected. However, in situ mapping of LN levels during ND resulted in no differences between the post-operative pathological and preoperative radiological findings.

CONCLUSION

Ex vivo mapping of LN levels had an error rate of 11.6% in labeling of LN levels. In situ mapping of cervical LN levels during ND provided more accurate results about the status of LN metastasis.

Management of the clinically negative neck (N0) of supraglottic laryngeal carcinoma: a systematic review

AIM

The most effective therapeutic approach for patients with supraglottic laryngeal carcinoma (SGLC) and clinically negative neck (cN0) remains a subject of much debate. The purpose of this systematic review was to answer the following question: among patients with SGLC and cN0 neck, are the survival and occurrence of neck metastases significantly different between patients that received neck dissection and those that had another therapeutic treatment (radiotherapy, combined therapy, 'wait and see' policy)?

MATERIALS AND METHODS

An electronic literature search was performed in MEDLINE, EMBASE, Cochrane Library and CENTRAL databases, followed by extensive hand-searching for the identification of relevant studies. The following inclusion criteria were established: the study should (a) include a comparison of neck dissection with one of the other therapeutic procedures for cN0 of SGLC; (b) report the therapy for the initial supraglottic cancer; and (c) use time-to-event analysis of its results. Six studies were eventually identified and systematically reviewed.

RESULTS

All studies included in the systematic review were retrospective (n=792 patients). The survival (overall, disease-specific and neck disease-free) and the site of neck recurrence of the patients with N0 supraglottic cancer were not significantly different between patients in the neck dissection treatment group and those of the rest of the therapeutic strategies examined (neck radiotherapy, combined therapy and 'wait and see' policy).

CONCLUSIONS

The present systematic review highlights the need for further well-designed prospective studies that will provide more reliable answers to the debatable issue of the management of cN0 of SGLC. Currently, based on the best available evidence, it seems that neck dissection is not superior to radiotherapy or combined therapy or a 'wait and see' policy in terms of survival and control of neck disease.

Prognostic factors for hypopharyngeal cancer: a univariate and multivariate study of 142 cases

CONCLUSIONS

Reduction of distant metastases is essential for better survival. Effective adjuvant chemotherapy should be developed for patients with advanced primary disease (T>2) as well as for patients with advanced nodal status (N>0 or PLN>2).

OBJECTIVES

The aim of this study was to identify prognostic factors for hypopharyngeal cancer.

PATIENTS AND METHODS

In all, 142 previously untreated patients were analyzed retrospectively; 75% of the cases were stage III or IV. Surgical resection was administered as primary treatment to 116 of the patients (82%), while 26 patients (18%) underwent primary radiotherapy.

RESULTS

The cause-specific 5-year actuarial survival was 46.3%. Distant metastases were the most frequent (23%) cause of failure, followed by local recurrence (15%), and regional recurrence (13%). Cox's regression analysis showed that the significant factors affecting cause-specific survival were N classification, T classification, number of pathological lymph node metastases (PLN), lymphatic invasion, and positive surgical margin. Similarly, T classification and PLN affected distant metastases.

Clinical relevance of ceramide metabolism in the pathogenesis of human head and neck squamous cell carcinoma (HNSCC): attenuation of C(18)-ceramide in HNSCC tumors correlates with lymphovascular invasion and nodal metastasis

It has been documented previously that defects in the generation of C(18)-ceramide, a product of ceramide synthase 1 (CerS1), also known as longevity assurance gene 1 (hLASS1), play important roles in the pathogenesis and/or progression of HNSCC. However, whether altered levels of ceramide generation in HNSCC tumors have any clinical relevance remains unknown. In this study, the levels of endogenous ceramides were measured in tumor tissues of 45 HNSCC patients as compared to their normal tissues using high-pressure liquid chromatography/mass spectrometry (LC/MS), and then possible link between ceramide levels and the clinical parameters of HNSCC were examined. The data showed that the levels of C(16)-, C(24)-, C(24:1)-ceramides were significantly elevated in the majority of tumor tissues compared to their normal tissues, while the levels of only C(18)-ceramide were significantly decreased in HNSCC tumors, especially in tumor tissues of male patients. Importantly, it was also shown here that decreased C(18)-ceramide levels in HNSCC tumor tissues were significantly associated with the higher incidences of lymphovascular invasion, and pathologic nodal metastasis. Importantly, attenuation of C(18)-ceramide was also positively linked to the higher overall stages of the primary HNSCC tumors. Therefore, these data suggest, for the first time, that the defects in the generation/accumulation of C(18)-ceramide might have important clinical roles in HNSCC, especially in lymphovascular invasion and nodal disease.

An expression profile for diagnosis of lymph node metastases from primary head and neck squamous cell carcinomas

Metastasis is the process by which cancers spread to distinct sites in the body. It is the principal cause of death in individuals suffering from cancer. For some types of cancer, early detection of metastasis at lymph nodes close to the site of the primary tumor is pivotal for appropriate treatment. Because it can be difficult to detect lymph node metastases reliably, many individuals currently receive inappropriate treatment. We show here that DNA microarray gene-expression profiling can detect lymph node metastases for primary head and neck squamous cell carcinomas that arise in the oral cavity and oropharynx. The predictor, established with an 82-tumor training set, outperforms current clinical diagnosis when independently validated. The 102 predictor genes offer unique insights into the processes underlying metastasis. The results show that the metastatic state can be deciphered from the primary tumor gene-expression pattern and that treatment can be substantially improved.

Cervical node metastases in squamous cell carcinoma of the upper aerodigestive tract: the significance of extracapsular spread and soft tissue deposits

BACKGROUND

Literature regarding the prognostic significance of extracapsular spread and soft tissue deposits in cervical lymph node metastases of squamous cell carcinoma of the upper aerodigestive tract shows variable results.

METHODS

We analyzed 215 prospectively collected neck dissections from 155 patients with upper aerodigestive tract squamous cell carcinoma to assess the prevalence of extracapsular spread and soft tissue deposits and to assess their effect on survival.

RESULTS

Both extracapsular spread and soft tissue deposits significantly reduced survival (actuarial and recurrence free) compared with pN0 necks (p <.001) and pN+ve necks without extracapsular spread (p <.0025). There was no statistically significant difference between pN+ve necks without soft tissue deposits or extracapsular spread compared with those with pN0 necks (p =.24). Multivariate analysis revealed comparable results.

CONCLUSIONS

Microscopic and macroscopic extracapsular spread and soft tissue deposits are of prognostic significance for survival and recurrence-free survival in patients with upper aerodigestive tract squamous cell carcinoma.

Cervical metastases in upper aerodigestive tract squamous cell carcinoma: histopathologic analysis and reporting

BACKGROUND

Accurate histopathologic assessment of neck dissections is of paramount importance. Retrospective analyses of the distribution of lymph node metastases have formed the rationale for elective neck dissection. However, standard techniques for examination of neck dissection specimens may have difficulty in correctly recognizing node levels and may also miss micrometastases, microscopic extracapsular spread, and soft tissue deposits.

METHODS

Two hundred thirty-seven neck dissections were performed in 173 patients with squamous cell carcinoma of the upper aerodigestive tract between August 1995 and November 2000. The neck dissections were separated into node levels peroperatively, sectioned at 6 microm thickness, and stained with hematoxylin and eosin.

RESULTS

Eleven thousand three hundred forty-nine lymph nodes were identified and examined. The mean yield per neck dissection was 50.4 (range, 12-131); 21.4% had extracapsular spread, 11.0% had soft tissue deposits, and 13.3% had both. A third of the metastatic nodes were 3 mm or less in diameter.

CONCLUSIONS

The accurate pathologic staging of the neck in patients with upper aerodigestive tract squamous cell cancer is important for providing prognostic information and optimizing the treatment plan for the patient. Accurate staging also allows the changing patterns of disease to be monitored and allows equitable comparison of patients in clinical trials and among surgical units.

Delayed regional metastases, distant metastases, and second primary malignancies in squamous cell carcinomas of the larynx and hypopharynx

OBJECTIVE

To determine the impact of delayed regional metastases, distant metastases, and second primary tumors on the therapeutic outcomes in squamous cell carcinomas of the larynx and hypopharynx.

STUDY DESIGN

Chart review and statistical analysis.

METHODS

A retrospective tumor registry analysis was made of patients with squamous cell carcinomas of the larynx and hypopharynx who were treated with curative intent in the Department of Otolaryngology-Head and Neck Surgery and the Radiation Oncology Center of the Washington University School of Medicine (St. Louis, MO) between January 1971 and December 1991 and developed delayed regional metastases (2 y after treatment), distant metastases, and second primary malignancies.

RESULTS

In 2550 patients, the mean age (59.8 y), sex (8.5 male patients and 1 female patient), and tumor differentiation did not affect the incidence of delayed distant, regional, or second primary malignancies. The overall incidence of delayed regional metastases was 12.4% (317/2550 patients); distant metastases, 8.5% (217/2550); and second primary tumors, 8.9% (228/2550), with a 5-year disease-specific survival of 41%, 6.4%, and 35%, respectively. Second primary malignancies were not statistically related to the origin of the primary tumor, tumor staging, or delayed regional and distant metastases (P =.98). Delayed regional metastases and distant metastases were related to advanced primary disease (T4 stage), lymph node metastases (node positive [N+]), tumor location (hypopharynx), and locoregional tumor recurrence (P < or =.028). Advanced regional metastases at initial diagnosis (N2 and N3 disease) increased the incidence of delayed and distant metastases threefold (P =.017). These two metastatic parameters were significantly greater in hypopharyngeal tumors than in laryngeal tumors (P =.037). The incidences of delayed regional metastases by anatomical location of the primary tumor were as follows: glottic, 4.4%; supraglottic, 16%; subglottic, 11.5%; aryepiglottic fold, 21.9%; pyriform sinus, 31.1%; and posterior hypopharyngeal wall, 18.5%. The incidences of distant metastases were as follows: glottic, 4%; supraglottic, 3.7%; subglottic, 14%; aryepiglottic fold, 16%; pyriform fossa, 17.2%; and posterior hypopharyngeal wall, 17.6%. Seventeen hypopharyngeal tumors (2%) presented with M1 disease. Delayed regional metastases to the ipsilateral treated neck had a significantly worse survival prognosis than delayed metastases to the contralateral nontreated neck (P =.001).

CONCLUSIONS

Conclusions are as follows: 1) The incidence of second primary tumors is independent from the primary tumor staging and distant and delayed regional metastases. The highest incidence occurred in patient groups with the highest disease-free survival rates (P =.0378). 2) Highest incidence of delayed and distant metastases occurred in hypopharyngeal tumors and was three times greater than in laryngeal cancers (P =.028). 3) Salvage therapeutic rates were poor for delayed metastases to the ipsilateral treated nodes and distant metastases as compared with contralateral neck metastases and second primary tumors (P =.001). 4) Delayed and distant lymph node metastases were significantly higher in advanced primary disease (T4 stage), locoregional recurrences, and regional disease (N2 and N3) (P =.028) in both the larynx and hypopharynx. 5) The higher incidence of delayed and distant metastatic disease was related to more advanced initial tumor presentation in hypopharyngeal cancer as compared with laryngeal cancer (P =.039). 6) Incidence of distant metastases was greatest between 1.5 and 6 years after initial treatment with a mean incidence being less than or equal to 3.2 years.

Does pathologic node status affect local control in patients with carcinoma of the head and neck treated with radical surgery and postoperative radiotherapy?

PURPOSE

To evaluate the effect of pathologic lymph node status and nodal stage on local control at the primary site in patients with advanced squamous cell carcinomas of the head and neck, treated with radical surgery and postoperative irradiation.

METHODS AND MATERIALS

Fifty-seven patients with advanced squamous cell carcinomas of the oral cavity, oropharynx, hypopharynx, larynx, and supraglottic larynx were analyzed. All patients underwent resection of the primary lesion, neck dissection, and postoperative radiotherapy. Minimum follow-up was 2 years. The median dose to the primary tumor bed was 60.4 Gray (range 39.7-72.0). Besides pathologic nodal status (pN0 vs. pN+) and nodal stage, the following factors were analyzed for their impact on local control: age, gender, T stage, tumor grade, resection margins, interval from surgery to irradiation, dose to the primary site, and overall treatment time.

RESULTS

The 3-year actuarial local control rate was 78%. When all patients were analyzed, nodal status (pN0 vs. pN+) did not affect control at the primary site (71% vs. 82%, p = 0.42). Nodal stage (pN0-N2a va. pN2b-N2c) was also not a significant factor for local control (74% vs. 82%, p = 0.57). When only patients with negative margins were analyzed, nodal status again did not impact on local control (79% vs. 90% for pN0 vs. pN+, p = 0.39). On univariate analysis, only tumor grade, margin status, and elapsed days were significant factors for local control. Local control was 85% for patients with negative margins vs. 60% for those with positive margins (p = 0.016). For patients with moderately and poorly differentiated tumors, local control was 86% as compared to 50% for patients with well-differentiated tumors (p = 0.007). When radiotherapy was completed within 50 days, local control was 93% as opposed to 63% for > 50 days (p = 0.016). On multivariate analysis, only margin status (p = 0.002) and tumor grade (p = 0.007) remained significant.

CONCLUSION

We conclude that neither the presence of pathologically positive nodes nor nodal stage is a prognostically significant factor for local control in patients who have undergone radical surgery and postoperative radiotherapy for advanced squamous cell carcinomas of the head and neck. We do not recommend a change in treatment philosophy, such as an increase in dose to the primary site, based on the pathologic status of the neck.

The treatment of node negative squamous cell carcinoma of the postcricoid region

This study includes 155 patients with T1-4N0 carcinoma of the postcricoid region seen between 1963 and 1993. Sixty-seven were treated by primary surgery, 50 by primary irradiation therapy, 36 were unsuitable for curative treatment and two patients were lost to follow-up. Reasons for deciding against curative therapy were: advanced age, poor general condition and advanced disease at the primary site. This study included only those patients who had no neck node metastases at presentation. Patients receiving surgery tended to be in better general physical condition and tended to have more advanced disease than those treated by irradiation in this series. The tumour-specific five-year survival rate for those treated by surgery was 43 percent (95 percent confidence interval (CI) 23-60 percent). For those patients treated by irradiation the five-year survival rate was 48 percent (95 percent CI 27-66 percent) and for those receiving no treatment the median survival rate was three months (95 percent CI two-six months). The observed survival for the surgery group was only 18 percent and for the radiotherapy group 25 percent at five years. Multiple logistic regression showed no significant difference in proportions of host and tumour factors between the group receiving radiotherapy and the group receiving surgery. Recurrence at the primary site and the appearance of neck node metastases were not predicted by any host or tumour factor. Twenty-one patients out of 67 receiving primary surgery had recurrence at the primary site compared with 26 patients out of 50 receiving primary irradiation.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrence at the primary site in head and neck cancer and the significance of neck lymph node metastases as a prognostic factor

BACKGROUND

Biologic aggressiveness of head and neck carcinoma is reflected in its capability to metastasize to regional lymph nodes and its propensity to recur after treatment.

METHODS

The authors report on 244 patients treated at the Department of Otolaryngology-Head and Neck Surgery of the Free University Hospital, Amsterdam, The Netherlands, with excision of primary tumor with incontinuity neck dissection with or without postoperative radiation therapy between January 1973 and July 1986. All patients had surgical margins free of tumor.

RESULTS

The overall recurrence rate was 12.3%. Stages T3-4 and the presence of more than three positive nodes on histopathologic examination were associated with a 16.2% and 26.2% incidence in recurrence at the primary site, respectively. No prognostic influence arose from primary tumor localization, three or fewer positive nodes, extranodal spread, and postoperative radiation therapy.

CONCLUSIONS

Patients with T3-4 disease and those with more than three positive lymph nodes may benefit from novel adjuvant treatment modalities.

Control of neck nodes in squamous cell carcinoma of the head and neck by radiotherapy: prognostic factors

313 patients with cervical metastases from a squamous carcinoma of the head and neck treated with radiotherapy, were studied by means of a multivariant analysis in order to determine the prognostic factors for cure. These were: lymph node response to irradiation (P = 0.0000), size of node (P = 0.0000), radiotherapy dose (P = 0.0037), condition of the primary (controlled vs non-controlled) (P = 0.0015), recurrent cervical metastases post-surgery (P = 0.0286).

Prognostic factors for survival and tumor control in cervical lymph node metastases from head and neck cancer. A multivariate study of 492 cases

A multivariate analysis was carried out in 492 patients with metastatic neck disease from squamous cell carcinoma to determine the influence of clinical and therapeutic factors on survival, local and regional control, and distant metastases. After radiation treatment with radical intent, recurrence at the primary site was the most frequent site of treatment failure (20% of cases), followed by distant metastases (14% of the cases), whereas isolated neck recurrences occurred in only 7% of the patients. The most significant factors influencing survival were primary tumor site, node fixation, N-stage, T-stage, and number of lymphatic chains. The most significant factors influencing local control were primary site, T-stage, and node fixation. Significant factors influencing regional control were radiation therapy volume, primary tumor site, node fixation, and node location (upper and lower neck). Significant factors influencing distant control were N-stage, number of nodes, and number of involved lymphatic chains.

Does neck stage influence local control in squamous cell carcinomas of the head and neck?

Recently, reports have suggested that the probability of local control of head and neck cancers treated with radiotherapy alone is inversely related to the extent of neck node disease at presentation. This has led some to conclude that primary lesions in patients with neck node metastases should be treated more aggressively than lesions of the same T stage in patients presenting with a clinically negative neck. We reviewed the records of 607 patients with squamous cell carcinoma of the head and neck to determine the relationship between the extent of neck node disease at diagnosis and the probability of tumor control at the primary site. All patients were treated with continuous-course irradiation alone to the primary site and have a minimum follow-up of 2 years. Mucosal sites analyzed included the oropharynx (soft palate, tonsillar region, base of tongue), hypopharynx (pharyngeal wall, pyriform sinus), and supraglottic larynx. Patients with simultaneous primary lesions were excluded from the analysis. Parameters tested included T stage, N stage, and fractionation (once daily or twice daily). For statistical analyses, N stage was grouped as N0, N1, N2A-N3A, and N2B-N3B. Local control was analyzed using a multivariate analysis, the forward stepwise long-rank test of association of covariates. Multivariate analyses revealed that the following parameters significantly influenced local control: oropharynx, T stage only (p = .0010); hypopharynx, T stage (p = .001) and twice-daily fractionation (p = .0031); and supraglottic larynx, T stage only (p = .0002). No significant correlation was found between neck stage and primary tumor control on univariate or multivariate analyses. Our data do not support the conclusion that primary lesions are controlled less often in patients with clinically positive neck nodes.

Cancer of the supraglottic larynx with neck node metastasis treated by radiation therapy only. The revised 1987 UICC classification system as prognostic indicator

In 1987, a thoroughly renewed TNM classification was published; the revision was a conjunct effort of the International Union Against Cancer (UICC) and American Joint Committee on Cancer (AJCC). With respect to the former UICC classification, a major change was introduced regarding the regional lymph node subcategories in head and neck cancer; that is compared to the 1978 edition the subjective subcategory of fixation was eliminated and size of the lymph node has become of paramount importance. To see whether the 1987 UICC classification system is indeed more predictive and discriminatory than the 1978 edition, we have analysed patients with supraglottic cancer with clinically detectable lymph node metastasis (T1-4, N+). All patients treated between 1965 and 1980 by radiation therapy only were staged according to both editions of the UICC classification system. From these data we conclude that the prognosis of patients with lymph nodal involvement indeed worsens from N1 to N3 when classified according to the 1987 edition; in contrast, no difference is seen between the N1, N2 or N3 subcategories when staged according to the 1978 classification rules.