Prognostic value of lymph node density in buccal squamous cell carcinoma

Association between lymph node ratio and survival outcomes in patients with oral squamous cell carcinoma

BACKGROUND

Recent reports have shown that the Lymph node ratio (LNR) is useful for predicting the prognosis in some cancers, however there are few reports on the usefulness of LNR in predicting the prognosis of oral squamous cell carcinoma (OSCC). The predictive value of LNR for prognosis of OSCC was investigated.

MATERIALS AND METHODS

The study included 152 patients with OSCC and histologically confirmed cervical lymph node metastasis who underwent neck dissection. We analyzed the relationship between LNR and overall survival (OS) and recurrence-free survival (RFS) retrospectively in these cases, with the relationship between prognosis and clinicopathological findings also examined.

RESULTS

Using a receiver operating characteristics curve, the LNR cutoff value was set at 0.095, categorizing 64 and 88 cases into high LNR (≥ 0.095) and low LNR (< 0.095) groups, respectively. Regarding OS and RFS, the prognosis was significantly worse in the high LNR group compared with the low LNR group. In multivariate analysis, sex, postoperative nodal stage, and LNR merged as independent prognostic factors.

CONCLUSION

This study's findings suggest that LNR may represent a prognostic indicator in OSCC with cervical lymph node metastasis.

Node Count as a Quality Indicator in Surgically Treated Mucosal Head and Neck Squamous Cell Cancer

INTRODUCTION

A yield of ≥18 nodes from neck dissection has been shown to be associated with improved locoregional recurrence rates and survival. We sought to determine factors associated with lymph node yields below this threshold.

MATERIALS AND METHODS

A retrospective review of patients who underwent neck dissection as part of definitive surgical treatment for mucosal head and neck squamous cell carcinoma (SCC) between January 2015 and December 2018 at an academic tertiary referral center was performed. Patients with a history of prior radiation or neck dissection were excluded.

RESULTS

There were 412 neck dissections performed in 323 patients. Specimens containing <18 nodes decreased from 16.2% in 2015-2016 to 7.4% of neck dissections in 2017-2018. The proportion of neck dissections removing <3 levels decreased from 9.1% of neck dissections in 2015-2016 to 4.0% in 2017-2018. Multivariable regression analysis demonstrated that dissection of ≥3 levels (OR = 0.2 [0.1-0.4]) and neck dissection in 2017-2018 compared to 2015-2016 (OR = 0.4 [0.2-0.8]) were significantly associated with a lower odds of <18 nodes. Stage, site, race, sex, human papillomavirus status, positive nodes, surgeon volume, and pathologist volume were not associated with neck dissection specimens with <18 nodes, after controlling for all other variables.

CONCLUSIONS

Increased recognition of the importance of node count as a quality indicator, and the extent of neck dissection is associated with increased nodal yield from neck dissection. These data suggest that node count can be used as a quality measure of neck dissection for mucosal SCC.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2160-2165, 2023.

Lymph Node Ratio as a Prognostic Factor in Neck Dissection in Oral Cancer Patients: A Systematic Review and Meta-Analysis

Simple Summary

Lymph node ratio (LNR) is a well-studied prognostic factor in colorectal and breast cancer, and it has been recently evaluated as a clinically relevant biomarker in oral squamous cell carcinoma. LNR represents the ratio of positive lymph nodes extracted in a neck dissection to the total number of nodes harvested (lymph node yield, LNY). Many single-center cohort studies and a few multicenter have assessed the significance of LNR as a prognostic factor in oral cancer. In this systematic review and meta-analysis of 32 studies and 20,994 oral cancer patients, we demonstrate that LNR is an independent prognostic indicator in patients with oral squamous cell carcinoma.

Abstract

Many studies have evaluated the clinical implications of lymph node ratio (LNR) as a prognostic factor in patients with oral squamous cell carcinoma (OSCC). The main purpose of this systematic review and meta-analysis was to address LNR as a prognosticator in patients with OSCC. A systematic search was conducted in the following databases: PubMed, EMBASE, Google Scholar, OpenGrey, Cochrane library, and ClinicalTrials.gov, and studies between 2009 and 2020 were sought. The pooled relative risk was calculated along with 95% confidence intervals for the following endpoints: overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), distant metastasis-free survival (DMFS), locoregional disease-free survival (LRDFS), local recurrence-free survival (LRFS), and recurrence-free survival (RFS) according to the random-effects model (Der Simonian–Laird approach). Subgroup and meta-regression analyses were performed as well. Finally, 32 cohort studies were eligible, which included 20,994 patients with OSCC. Patients were subdivided into two categories, group YES (studies that included in their analysis only patients with positive lymph nodes) and group NO (studies that did not exclude LNR = 0 patients). In the group YES, patients with high LNR had shorter OS (RR = 1.68, 95% CI: 1.47–1.91), DFS (RR = 1.68, 95% CI: 1.42–1.99), DSS (RR = 1.94, 95% CI: 1.56–2.42), DMFS (RR = 1.83, 95% CI: 1.13–2.96), LRDFS (RR = 1.55, 95% CI: 1.10–2.20), and LRFS (RR = 1.73, 95% CI: 1.41–2.13) compared to patients with low LNR. In the group NO, patients with high LNR in comparison had shorter OS (RR = 2.38, 95% CI: 1.99–2.85), DFS (RR = 2.04, 95% CI: 1.48–2.81), and DSS (RR = 2.90, 95% CI: 2.35–3.57) compared to patients with low LNR. Based on those findings, LNR might be an independent prognostic factor for OS in patients with OSCC and could be incorporated into future classification systems for better risk stratification.

Towards an Improved Pathological Node Classification for Prognostic Stratification of Patients With Oral Cavity Squamous Cell Carcinoma: Results From a Nationwide Registry Study

Background

To assess the prognostic significance of different nodal parameters [i.e., number of pathologically positive nodes, log odds of positive lymph nodes, lymph node ratio (LNR), and extra-nodal extension (ENE)] in Taiwanese patients with oral cavity squamous cell carcinoma (OCSCC), and to devise an optimized pN classification system for predicting survival in OCSCC.

Methods

A total of 4287 Taiwanese patients with first primary OCSCC and nodal metastases were enrolled. Cox proportional hazards regression analysis with the spline method was applied to identify the optimal cut-off values for LNR, log odds of positive lymph nodes, and number of pathologically positive nodes.

Results

On multivariable analysis, we identified a LNR ≥0.078/0.079, the presence of at least three pathologically positive nodes, and ENE as independent prognosticators for 5-year disease-specific survival (DSS) and overall survival (OS) rates. We therefore devised a four-point prognostic scoring system according to the presence or absence of each variable. The 5-year DSS and OS rates of patients with scores of 0−3 were 70%/62%/50%/36% (p &lt;0.0001) and 61%/52%/40%25%, respectively (p &lt;0.0001). On analyzing the AJCC 2017 pN classification, patients with pN3a displayed better survival rates than those with pN2 disease. The 5-year DSS and OS rates of patients with pN1/pN2/pN3a/pN3b disease were 72%/60%/67%/43% (p &lt;0.0001) and 63%/51%/67%/33%, respectively (p &lt;0.0001).

Conclusions

Three nodal parameters (i.e., a LNR ≥0.078/0.079, the presence of at least three pathologically positive nodes, and ENE) assessed in combination provided a better prognostic stratification than the traditional AJCC pN classification.

Prognostic significance of lymph node ratio in patients with squamous cell carcinoma of the floor of the mouth

The lymph node ratio (LNR) has been proposed as an independent prognostic factor for survival in patients with oral squamous cell carcinoma (OSCC). However, little attention has been paid to its role in the specific subsite of the floor of the mouth (FOM). The purpose of this study was to evaluate the prognostic significance of the LNR in patients with FOM SCC. A retrospective analysis of 92 patients with FOM SCC who were treated with primary curative resection and neck dissection was conducted. Overall survival (OS) and disease-free survival (DFS) were used to evaluate the prognostic significance of the LNR. Both of these parameters were significantly worse (P < 0.001) in patients with neck metastases. The mean LNR was 0.145 in patients with positive lymph nodes. A LNR <0.145 was predictive of longer DFS, while the receiver operating characteristic curve analysis demonstrated that a LNR ≥0.175 indicated a significantly lower OS. This study confirms that metastatic cervical lymph nodes correlate with an adverse prognosis in patients with FOM SCC, and specifically, a LNR ≥0.145 is predictive. Therefore, the LNR in patients with FOM SCC may be a predictor of survival in these patients.

Comparing prognostic utility between the 8th edition of TNM staging system and the lymph node ratio for oral squamous cell carcinoma

BACKGROUND

Lymph node metastasis in oral squamous cell carcinoma (OSCC) is associated with poor prognosis. The 8th edition of TNM has implemented new nodal staging criteria. We assess the prognostic utility of the lymph node ratio (LNR) and compare it to that of pN in the TNM 8th edition.

METHODS

One hundred and forty-two patients with OSCC were retrospectively studied. Nodal staging was performed using the TMN 8th edition and the prognostic value of the LNR in terms of overall survival (OS) and disease-free survival (DFS) was evaluated.

RESULTS

Fifty-seven patients were eligible for inclusion. The LNR was independently prognostic of OS (p = 0.02). Instead N classification was not significantly predictive of OS (p = 0.10). High LNRs resulted in decreases in OS of approximately 40% within 6 months after surgery.

CONCLUSIONS

The LNR identifies patients with poor outcomes better than N classification. The lack of reliable LNR cutoffs compromises its utility in clinical practice.

The role of the histones H3K9ac, H3K9me3, HP1γ, and H3K36me3 in oral squamous cell carcinoma loco-regional metastasis and relapse

Molecular markers with unequivocal significance in predicting cervical lymph node metastasis of oral squamous cell carcinoma (OSCC) has not yet been identified. Histones are DNA-binding proteins that can regulate gene expression, and some studies have shown that such proteins are implicated with tumor development and progression. This study aimed to investigate the expression of some histone modifications in OSCC and their roles in cervical lymph node metastasis. To address this goal, H3K9ac, H3K9me3, HP1γ, and H3K36me3 expression levels were investigated immunohistochemically in a retrospective metastatic and non-metastatic OSCC samples. We analyzed the association between these markers with clinical-pathological data and survival rates. Hyperacetylation of H3K9ac was associated with cervical lymph node metastasis and local relapse. High expression levels of H3K9m3 were related to age and symptomatology. Furthermore, it was also found a statistically significant association between high HP1γ-expressing tumors and tumor size. However, no markers were associated with reduced overall survival rate. Our results suggest that covalent histone modifications contribute to OSCC behavior, and H3K9ac may play a critical role in OSCC-derived cervical lymph node metastasis.

Elective neck dissection versus wait-and-see policy in cT1N0 buccal squamous cell carcinoma

Background

Our goal was to clarify the comparison between elective neck dissection (END) and the wait-and-see policy in neck management for cT1N0 buccal squamous cell carcinoma (SCC).

Methods

This was a retrospective comparison of 175 prospectively enrolled patients with cT1N0 buccal SCC. The patients were divided into two groups based on the nonrandomized management of the neck: 125 patients received END, and 50 patients were exposed to the wait-and-see policy. The main study endpoints were locoregional control (LRC) and disease-specific survival (DSS). Patients were asked to complete the shoulder domain in the University of Washington quality of life questionnaire, version 4, 1 year postoperatively.

Results

Ten of the patients undergoing END developed recurrence, and the 5-year LRC rate was 92%. Five patients undergoing the wait-and-see policy developed recurrence, and the 5-year LRC rate was 90%. The difference was not significant (p = 0.668). There were 6 deaths in patients undergoing END, and the 5-year DSS rate was 94%. There were 3 deaths in patients undergoing the wait-and-see policy, and the 5-year DSS rate was 94%; the difference was not significant (p = 0.777). The mean shoulder scores of patients undergoing END and the wait-and-see policy were 93.9 and 100, respectively, and the difference was not significant (p = 0.284).

Conclusion

Elective neck dissection does not carry a survival benefit compared to the wait-and-see policy, and it is not suggested for patients with cT1N0 buccal SCC.

High-risk lymph node ratio predicts worse prognosis in patients with locally advanced oral cancer

Background

To investigate the prognostic value of lymph node ratio (LNR), as well as the correlation with docetaxel, cisplatin, and 5‐FU (TPF) induction chemotherapy, in patients with locally advanced oral squamous cell carcinoma (OSCC).

Methods

Two‐hundred and forty‐five patients from a phase 3 trial involving TPF induction chemotherapy in stage III/IVA OSCC patients (NCT01542931) were enrolled in this study between 2008 and 2010. The clinical and pathological data were collected and analyzed. The cutoff value for LNR was calculated on the receiver operating characteristic (ROC) curve. Univariate and multivariate Cox regression models, and Kaplan‐Meier method were used for survival analysis.

Results

According to the ROC curve, the cutoff value for LNR was 7.6%. With a median follow‐up period of 80 months, the OSCC patients with high‐risk LNR (> 7.6%), or positive extranodal extension (ENE) had significantly worse clinical outcomes than patients with low‐risk LNR (≤7.6%) or negative ENE. Multivariate analysis on pathological covariates showed that only high‐risk LNR was an independent negative predictive factor for survival (P < .05). The cutoff value of LNR of 7.6% was also verified with the similar results using an open TCGA database, high‐risk LNR indicating worse overall survival (P < .001) and disease‐free survival (P < .001).

Conclusion

Oral squamous cell carcinoma patients with high‐risk LNR have a worse clinical outcome than patients with low‐risk LNR. High‐risk LNR is an independent negative predictive factor for clinical outcome in patients with locally advanced OSCC.

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.

The prognostic value of lymph node ratio in survival of head-and-neck squamous cell carcinoma

BACKGROUND

Head-and-neck squamous cell carcinoma (HNSCC) is the sixth most prevalent type of cancers in the world. Due to its relatively high rate of recurrence, the prognosis of patients is poor and the survival rate is low; therefore, identifying the prognostic factors is considered necessary for better treatment.

MATERIALS AND METHODS

This historical cohort study was conducted on 201 patients diagnosed with aerodigestive SCC who underwent surgery and lymph node dissection. We determined the prognostic value of lymph node ratio (LNR) on overall survival (OS), disease-free survival (DFS), and locoregional failure-free survival (LFFS). We noticed an association between LNR and survival by Kaplan-Meier analysis. Hazard ratio (HR) of LNR was determined by Cox's regression model.

RESULTS

Two hundred and one patients entered this study after their medical histories were evaluated. The mean of lymph node count and LNR was 14.30 (±9.50) and 0.12 (±0.23), respectively. Eighty patients (39.80%) experienced recurrence of SCC. Five-year OS, DFS, and LFFS were 32%, 21%, and 64%, respectively. The median of OS was 40.70 months and 30.11 months in patients with LNR of ≤0.06 and >0.06, respectively (P < 0.01). The LNR >0.06 was found to be a significant prognostic factor for lower OS of patients with HNSCC (HR = 2.11 [1.10, 4.40]; P = 0.04). DFS was not significantly different among patients with LNR ≤0.06 and patients with LNR >0.06 (P = 0.9). However, LFFS was slightly different among two groups (HR = 2.04 [0.90-4.80]; P < 0.1).

CONCLUSION

We recommend more intensive adjuvant therapies such as chemotherapy with radiotherapy and short interval follow-up for patients with LNR >0.06. Further investigations with larger sample sizes are recommended.