Clinicopathologic risk factors for distant metastases from head and neck squamous cell carcinomas

Distant Metastasis of Tongue Squamous Cell Carcinoma Presenting as Multiple Subdermal and Intramuscular Cysts: A Case Report

The most common sites of distant metastasis (DM) in squamous cell carcinoma (SCC) of the tongue are the lung, bone, and liver; the early identification of metastasis to other sites is difficult. This case report discusses a 48-year-old male initially diagnosed with advanced-stage left tongue SCC, which was treated with wide excision, left radical neck dissection, and adjuvant concurrent chemoradiotherapy. Two months after completing adjuvant therapy, multiple painful nodules without local erythematous changes or warmth were found in the bilateral posterior neck and right medial thigh. Ultrasonography of these nodules revealed a cystic structure. Fine needle aspiration cytology revealed metastatic SCC. The disease progressed despite salvage chemotherapy, and the patient passed away 4 months after the formation of the nodules. Subdermal and intramuscular cysts as the initial presentation of DM have rarely been reported. The identification of unusual cysts, even those outside the head and neck, should raise concern.

Head and Neck Squamous Cell Carcinoma with Distant Metastasis: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Distant metastasis (DM), though uncommon at initial presentation, significantly worsens the prognosis of head and neck squamous cell carcinomas (HNSCCs). This review aimed to investigate the occurrence rates, patterns, and implications of HNSCC DM.

METHODS

A systematic search was performed in Scopus, PubMed and Web of Science.

RESULTS

Out of 7576 identified titles, 35 studies were included, encompassing 28,193 patients. The pooled rate of DM was 10.01%, with significant heterogeneity existing among the studies (I2: 94.13%). The most common metastatic sites were the lungs, bones, and brain (58%, 15%, 4%, respectively). Treatment modalities varied: overall, 20.4% of patients received radiotherapy alone, 7% underwent chemotherapy, and 4.5% received surgical metastasectomies. Combined treatments accounted for 18.3% of patients. However, 41.3% of patients received no treatment for DM. The median overall survival (OS) after DM diagnosis was 10.1 months. Studies highlighted a 36.3% two-year survival rate for patients with oligo-metastases, compared to the 7.4% rate for those with multiple metastases. At the time of DM diagnosis, half of the studied population presented with locoregional failure.

CONCLUSIONS

Advanced imaging techniques and emerging systemic therapies offer hope for improved DM detection and treatment. However, continuous research is essential to develop therapeutic strategies that can enhance survival and improve the quality of life for patients with DM.

Distant metastasis at the time of presentation of head and neck squamous cell carcinoma: a retrospective chart review from a tertiary cancer care centre

OBJECTIVE

To evaluate the rates and patterns of distant metastasis in head and neck SCC at the time of presentation and to study the association between distant metastasis with pre-treatment, clinical, and pathological predictors of outcomes.

METHOD

This is a retrospective study conducted in a tertiary care hospital. All patients with primary head and neck squamous cell carcinoma that had been evaluated at our institute between October 2018 and December 2020 were included in the study. Various clinical data were analysed and pattern of metastasis was studied.

RESULT

Ten per cent (50 cases) of 501 studied patients had distant metastasis. The most common site of distant metastasis was lung. The rate of distant metastasis was high in patients with poorly differentiated cancers. By Kaplan-Meier analysis, the median survival duration after diagnosis of metastasis was four months.

CONCLUSION

The rate of distant metastasis was 10 per cent in the study. Patients with poorly differentiated tumours, locally advanced primary lesions, higher nodal stage, particularly with extra nodal extension, and hypopharyngeal primary, tend to exhibit increased risk for distant metastasis at the time of presentation.

Diagnostic and prognostic nomograms for laryngeal carcinoma patients with lung metastasis: a SEER-based study

PURPOSE

To establish two nomograms to quantify the risk of lung metastasis (LM) in laryngeal carcinoma (LC) and predict the overall survival of LC patients with LM.

METHODS

Totally 9515 LC patients diagnosed histologically from 2000 to 2019 were collected from the Surveillance, Epidemiology, and End Results database. The independent diagnostic factors for LM in LC patients and prognostic factors for LC patients with LM were identified by logistic and Cox regression analysis, respectively. Nomograms were established based on regression coefficients and evaluated by receiver operating characteristic curve, calibration curves, and decision curve analysis.

RESULTS

Patients with supraglottis, higher pathological grade, higher N stage, and distant metastasis (bone, brain, or liver) were more likely to have LM (P < 0.05). Chemotherapy, surgery and radiotherapy were independent factors of the overall survival of LC patients with LM (P < 0.05). The area under curve of diagnostic nomogram were 0.834 and 0.816 in the training and validation cohort respectively. For the prognostic nomogram, the area under curves of 1-, 2-, and 3-years were 0.735, 0.734, and 0.709 in the training cohort and 0.705, 0.803, and 0.809 in the validation cohort. The calibration curves and decision curve analysis indicated good performance of the nomograms.

CONCLUSION

Distant metastasis (bone, brain, or liver) and N stage should be considered for prediction of LM in LC patients. Chemotherapy is the most significant influencing prognostic factor improving the survival of LC patients with LM. Two nomograms may benefit for providing better precautionary measures and treatment decision.

Impact of lymph node ratio and number of lymph node metastases on survival and recurrence in laryngeal squamous cell carcinoma

INTRODUCTION

The aim of this study is to assess the impact of lymph node ratio (LNR) and number of positive lymph nodes (NPLN) on mortality and recurrence rates in patients with laryngeal squamous cell carcinoma.

MATERIALS AND METHODS

We conducted a retrospective multicenter international study involving 24 Otorhinolaryngology-Head and Neck Surgery divisions. Disease-specific survival (DSS) and disease-free survival (DFS) were evaluated as the main outcomes. The curves for DSS and DFS according to NPLN and LNR were analyzed to identify significant variations and establish specific cut-off values.

RESULTS

2507 patients met the inclusion criteria. DSS and DFS were significantly different in the groups of patients stratified according to LNR and NPLN. The 5-year DSS and DFS based on LNR and NPLN demonstrated an improved ability to stratify patients when compared to pN staging.

CONCLUSION

Our data demonstrate the potential prognostic value of NPLN and LNR in laryngeal squamous cell carcinoma.

Spindle Cell Carcinoma of the Head and Neck: Clinical Characteristics and Molecular Signatures

OBJECTIVE/HYPOTHESIS

Spindle cell carcinoma of the head and neck (HNSpCC) is a rare variant of head and neck squamous cell carcinoma (HNSCC). This study evaluated the clinical characteristics and molecular signatures of such tumors.

STUDY DESIGN

Retrospective analysis.

METHODS

Medical records of patients diagnosed with HNSpCC from 1996 to 2018 were reviewed. The clinicopathologic features, treatment modalities, and survival status were carefully recorded. Whole exome sequencing (WES) was performed to evaluate the genetic signatures of HNSpCC.

RESULTS

We found that among all 71 patients included in this study, the majority of them were male, with tumors developing predominantly in the oral cavity. The 1-, 3-, and 5-year disease-specific survival (DSS) rates were 64.6%, 49.5%, and 43.9%, respectively. A high local recurrence (LR) and distant metastasis (DM) rate (47.9%-25.3%, respectively) were observed. A significant proportion (28.2%) of patients with the worst prognosis had history of previous head and neck cancer (HNC) and had been treated with radiotherapy (RT). WES revealed that those post-RT SpCC shared common mutations with their previous HNC (pre-RT SCC), but gained additional genetic traits, such as hypoxia and cell-ECM interaction that were favorable for survival in an irradiated microenvironment. Distinct genetic landscapes in primary and post-RT SpCC were also found.

CONCLUSIONS

This study demonstrates that HNSpCC is a unique entity with more aggressive behavior than conventional HNSCC. HNSpCC arising from a previously irradiated field is a predictor of dismal survival. Both genetic and microenvironmental factors contribute to this highly invasive tumor.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2183-2191, 2023.

A novel nomogram and risk classification system for predicting overall survival in head and neck squamous cell cancer with distant metastasis at initial diagnosis

INTRODUCTION

Head and neck squamous cell carcinoma (HNSCC) is one of the most invasive cancer types globally, and distant metastasis (DM) is associated with a poor prognosis. The objective of this study was designed to construct a novel nomogram and risk classification system to predict overall survival (OS) in HNSCC patients presenting with DM at initial diagnosis.

METHODS

HNSCC patients with initially diagnosed DM between 2010 and 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. Firstly, all patients were randomly assigned to a training cohort and validation cohort (8:2), respectively. The Cox proportional hazards regression model was used to analyze the prognostic factors associated with OS. Then, the nomogram based on the prognostic factors and the predictive ability of the nomogram were assessed by the calibration curves, receiver operating characteristic (ROC) curves and decision curve analysis (DCA). Finally, a risk classification system was established according to the nomogram scores.

RESULTS

A total of 1240 patients initially diagnosed with HNSCC with DM were included, and the 6-, 12- and 18-month OS of HNSCC with DM were 62.7%, 40.8% and 30%, respectively. The independent prognostic factors for HNSCC patients with DM included age, marital status, primary site, T stage, N stage, bone metastasis, brain metastasis, liver metastasis, lung metastasis, surgery, radiotherapy and chemotherapy. Based on the independent prognostic factors, a nomogram was constructed to predict OS in HNSCC patients with DM. The C-index values of the nomogram were 0.713 in the training cohort and 0.674 in the validation cohort, respectively. The calibration curves and DCA also indicated the good predictability of the nomogram. Finally, a risk classification system was built and it revealed a statistically significant difference among the three groups of patients according to the nomogram scores.

CONCLUSIONS

Factors associated with the overall survival of HNSCC patients with DM were found. According to the identified factors, we generated a nomogram and risk classification system to predict the OS of patients with initially diagnosed HNSCC with DM. The prognostic nomogram and risk classification system can help to assess survival time and provide guidance when making treatment decisions for HNSCC patients with DM.

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.

The management of metastatic neck nodes following induction chemotherapy in N2/3 classification hypopharyngeal carcinoma

BACKGROUND

For patients with less chemosensitive neck nodes, poor prognosis after chemoradiotherapy (CRT) could be predicted and neck dissection is needed.

METHODS

Ninety-two N2/3 hypopharyngeal carcinoma patients were retrospectively studied. According to response after induction chemotherapy (ICT), patients were treated with neck dissection followed by concurrent CRT (CCRT) (group 1), surgery plus postoperative CRT (group 2), or CCRT for primary and regional sites (group 3).

RESULTS

Overall survival and disease-free survival rates of group 1 were significantly higher than group 2 (p = 0.038, p = 0.031) and group 3 (both p = 0.018). Regional control rate of group 1 was significantly higher than group 3 (p = 0.041). There were no significant differences between groups 1 and 2 regarding local and regional control (p = 0.746, p = 0.302).

CONCLUSIONS

Neck dissection followed by CCRT is the best choice for patients with responsive primary but nonresponsive nodes.

Prognostic Value of Molecular Intratumor Heterogeneity in Primary Oral Cancer and Its Lymph Node Metastases Assessed by Mass Spectrometry Imaging

Different aspects of intra-tumor heterogeneity (ITH), which are associated with the development of cancer and its response to treatment, have postulated prognostic value. Here we searched for potential association between phenotypic ITH analyzed by mass spectrometry imaging (MSI) and prognosis of head and neck cancer. The study involved tissue specimens resected from 77 patients with locally advanced oral squamous cell carcinoma, including 37 patients where matched samples of primary tumor and synchronous lymph node metastases were analyzed. A 3-year follow-up was available for all patients which enabled their separation into two groups: with no evidence of disease (NED, n = 41) and with progressive disease (PD, n = 36). After on-tissue trypsin digestion, peptide maps of all cancer regions were segmented using an unsupervised approach to reveal their intrinsic heterogeneity. We found that intra-tumor similarity of spectra was higher in the PD group and diversity of clusters identified during image segmentation was higher in the NED group, which indicated a higher level of ITH in patients with more favorable outcomes. Signature of molecular components that correlated with long-term outcomes could be associated with proteins involved in the immune functions. Furthermore, a positive correlation between ITH and histopathological lymphocytic host response was observed. Hence, we proposed that a higher level of ITH revealed by MSI in cancers with a better prognosis could reflect the presence of heterotypic components of tumor microenvironment such as infiltrating immune cells enhancing the response to the treatment.

Oncological Outcomes after Pulmonary Metastasectomy for Head and Neck Squamous-Cell Carcinoma and Adenoid Cystic Carcinoma

INTRODUCTION

Pulmonary metastatic head and neck cancer has a poor prognosis. Pulmonary metastasectomy has been performed but only in carefully selected patients. The aim of this study was to examine the clinical characteristics and oncological follow-up of patients who underwent pulmonary metastasectomy.

METHODS

Data of 54 patients with squamous-cell carcinoma (SCC) or adenoid cystic carcinoma (ACC) who underwent metastasectomy between 2003 and 2019 at two tertiary referral centers were retrospectively reviewed.

RESULTS

The 3-year and 5-year disease-free survival rates after metastasectomy were 49.9% and 39.9% for SCC and 38.9% and 32.4% for ACC, respectively. Univariate analysis revealed that a disease-free interval (DFI) less than 14 months and R1 resection (hazard ratio [HR] [95% confidence interval]: 2.95 [0.77-5.62], 4.64 [0.99-21.65], respectively) were risk factors for recurrence in SCC and that a high T stage (HR: 5.24 [1.22-22.58]) was a risk factor in ACC. In SCC, a DFI less than 14 months and R1 resection (hazard ratio: 6.35 [1.36-29.54], 12.79 [1.53-106.95], respectively) were risk factors in a multivariate analysis.

CONCLUSION

Pulmonary metastasectomy had a fair effect on head and neck SCC and ACC, and the prognosis was better in SCC patients with a DFI greater than 14 months.

Clinical and histopathological risk factors for distant metastasis in head and neck cancer patients

The incidence of distant metastasis (DM) in head and neck squamous cell cancer (HNSCC) is relatively low. Multiple risk factors have been described for development of DM at baseline and after treatment. However, to date, there is no meta-analysis or systematic review investigating the relationships between clinical and histopathological factors and the appearance of DM in HNSCC patients. Among 1,272 eligible articles, 23 met inclusion criteria for qualitative analysis, and 6 for quantitative analysis. The meta-analysis on 5,353 patients showed that hypopharyngeal site, T3-T4 categories, extranodal extension, positive lymph node size > 6 cm, locoregional failure after previous treatment(s) and poor differentiation all significantly increase the risk of DM. According to our results, patients with the above-mentioned clinical and histopathological risk factors should be considered at high risk for DM and therefore submitted to strict pre-treatment assessment and undergo careful post-therapeutic follow-up.

Diagnostic Accuracy of Combined PET/CT with MRI, 18F-FDG PET/MRI, and 18F-FDG PET/CT in Patients with Oropharyngeal and Hypopharyngeal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

Introduction

The aim of this paper is to compare the diagnostic accuracy of PET/CT, PET/MRI, and the combination of PET/CT and MRI for detecting synchronous cancer and distant metastasis in patients with oropharyngeal and hypopharyngeal squamous cell carcinomas (OHSCC).

Method

A large and growing body of literature has been conducted using the Preferred Reporting Items for Systematic Reviews (PRISMA). The researchers collected all accessible literature existing through Cochrane Library (John Wiley & Sons) electronic databases, Embase (Elsevier), PubMed (U.S. National Library of Medicine), Scopus, and Google Scholar up to June 2020. Analyses were conducted using Stata version 12.0 (StataCorp LP).

Results

A total of nine studies consisting of 1166 patients were included. The pooled sensitivity of combined PET/CT with MRI, 18F-FDG PET/MRI, and 18F-FDG PET/CT was 0.92, 0.80, and 0.79, respectively, and the corresponding specificities were 0.93, 0.91, and 0.88. The overall prevalence of distant metastases and synchronous cancer in patients with oropharyngeal and hypopharyngeal squamous cell carcinomas was 9.2% and 11.8%, respectively, with the esophagus (4.6%) being the most common site of synchronous cancer. The most common sites of distant metastases were lung (3%), bone (1.2%), and distant lymph nodes (1.2%), respectively.

Conclusion

Our study showed an approximately similar diagnostic performance for PET/CT, PET/MRI, and the combination of PET/CT and MRI for metastasis assessment in advanced oropharyngeal and hypopharyngeal squamous cell carcinomas.

Predictive factors for simultaneous distant metastasis in head and neck cancer patients during the diagnostic work-up

INTRODUCTION

The incidence of distant metastasis (DM) in patients affected by head and neck squamous cell carcinoma (HNSCC) is relatively low, and multiple risk factors were described for the development of distant metastasis.

MATERIALS AND METHODS

Retrospective study of patients diagnosed with a HNSCC between July 2016 and July 2020 in a tertiary university hospital.

RESULTS

Five-Hundred and sixty-nine patients meet inclusion criteria. In the univariate analysis we found a statistical correlation in those patients affected by a hypopharyngeal tumour (p = < 0.0001), patients older than 60 years old (p = 0.01), advanced T stage (p = < 0.0001), a proven positive lymph node (p = 0.02), poorly differentiated tumour (p = < 0.0001), patients with 3 or more positive lymph nodes (p = 0.0001), with ECS (p = 0.0001) and a second primary tumour (p = 0.03). However, according to those results from our multivariable analysis, the factor related to an increased or higher chance to detect a DM during the diagnosis work-up were the presence of a hypopharyngeal primary tumor with a hazard ratio (HR) of 1.14, p =  < 0.0001, advanced T stage (T3-T4) with a HR of 1.21, p = 0.001, poorly differentiated tumor with a HR of 1.04, p =  < 0.0001, have proven positive lymph node with a HR of 1.03, p = 0.04, have more than three positive lymph node metastases with a HR of 1.25, p = 0.003, the presence of ECS with a HR of 1.40, p = 0.002, and have a second primary tumor with a HR of 1.05, p = 0.01.

CONCLUSION

According to the present study, factors such as hypopharyngeal tumours, advanced T-stage, poor differentiation grade, have more than three positive lymph nodes, ECS and have a second primary tumour should be considered as high-risk indicators for screening. Based on these results, the authors recommend considered an extensive diagnostic work-up in all patients with a high risk of DM development.

A Unique Presentation of Concurrent Duodenal and Peritoneal Metastasis From Head and Neck Cancer

Metastatic disease to the duodenum or peritoneum from a primary head and neck carcinoma is an extremely rare presentation. We report the case of a 68-year-old male with a history of head and neck squamous cell carcinoma (HNSCC) who presented with worsening nausea, abdominal pain, postprandial vomiting, and early satiety for over two months. Prior to this presentation, he was evaluated for several postauricular lumps, with computerized tomography (CT) scan showing a supraglottic mass and an excisional biopsy of a postauricular nodule confirming metastatic HNSCC. A CT scan of the chest, abdomen, and pelvis during the admission showed worsening lymphadenopathy in the mediastinum and hilar regions, as well as new ascites and peritoneal lesions. Esophagogastroduodenoscopy showed a large erythematous nodular lesion in the second portion of the duodenum occupying approximately one-third of the lumen circumference. Similar to the previously worked up nodule, histology from the duodenal mass biopsies showed metastatic poorly differentiated squamous cell carcinoma that was strongly positive for p63 and p16. Thus, we report the first case of concurrent duodenal and peritoneal metastasis from an HNSCC.

Five- and ten-year survival of squamous cell carcinoma of the head and neck in northern Thailand: a multivariate analysis

Aim:

To report 5- and 10-year overall survival (OS) outcomes of squamous cell carcinoma of the head and neck and identify prognostic factors.

Methods:

Data on 2,095 patients at Maharaj Nakorn Chiang Mai Hospital, Thailand between 2007 and 2014 were analysed using the Kaplan–Meyer method to estimate 5- and 10-year OS rates. Cox proportional hazard regression models were applied to assess the independent prognostic factors of survival.

Results:

8·7% had hypopharyngeal cancer, 19·7% laryngeal, 53·3% oral cavity and 18·3% oropharyngeal. Two-thirds of the patients had locally advanced stage (III–IVB). Five- and ten-year OS rates were 30·1 and 22·8%, respectively.

Conclusions:

Cancer site, stage and age at diagnosis were associated with mortality, highlighting the importance of prevention and early detection.

The Role of Palliative Radiotherapy in the Treatment of Spinal Bone Metastases from Head and Neck Tumors-A Multicenter Analysis of a Rare Event

This retrospective multi-center analysis aimed to assess the clinical response and stabilizing effects of palliative radiotherapy (RT) for spinal bone metastases (SBM) in head and neck cancer (HNC), and to establish potential predictive factors for stability and overall survival (OS). Patients included in this analysis were treated at the University Hospitals of Mainz, Freiburg, and Heidelberg between 2001 and 2019. Clinical information was taken from the medical records. The stability of affected vertebral bodies was assessed according to the validated spine instability neoplastic score (SINS) based on CT-imaging before RT, as well as 3 and 6 months after RT. OS was quantified as the time between the start of palliative RT and death from any cause or last follow-up. Potential predictive factors for stability and OS were analyzed using generalized estimating equations and Cox regression for time-varying covariates to take into account multiple observations per patient. The mean follow-up time of 66 included patients after the first palliative RT was 8.1 months (range 0.3–85.0 months). The majority of patients (70%; n = 46) had squamous cell carcinomas (SCC) originating from the pharynx, larynx and oral cavity, while most of the remaining patients (26%; n = 17) suffered from salivary glands tumors. A total of 95 target volumes including 178 SBM were evaluated that received a total of 81 irradiation series. In patients with more than one metastasis per irradiated region, only the most critical bone metastasis was analyzed according to the SINS system. Prior to RT, pain and neurologic deficits were present in 76% (n = 72) and 22% (n = 21) of irradiated lesions, respectively, and 68% of the irradiated lesions (n = 65) were assessed as unstable or potentially unstable prior to RT. SBM-related pain symptoms and neurologic deficits responded to RT in 63% and 47% of the treated lesions, respectively. Among patients still alive at 3 and 6 months after RT with potentially unstable or unstable SBM, a shift to a better stability class according to the SINS was observed in 20% and 33% of the irradiated SBM, respectively. Pathological fractures of SBM were frequently detected before the start of irradiation (43%; n = 41), but after RT, new fractures or increasing vertebral body sintering within the irradiated region occurred rarely (8%; n = 8). A pathological fracture before RT was negatively associated with stabilization 6 months after RT (OR 0.1, 95% CI 0.02–0.49, p = 0.004), while a Karnofsky performance score (KPS) ≥ 70% was associated positively with a stabilization effect through irradiation (OR 6.09, 95% CI 1.68–22.05, p = 0.006). Mean OS following first palliative RT was 10.7 months, and the KPS (≥70% vs. <70%) was shown to be a strong predictive factor for OS after RT (HR 0.197, 95% CI 0.11–0.35, p < 0.001). There was no significant difference in OS between patients with SCC and non-SCC. Palliative RT in symptomatic SBM of HNC provides sufficient symptom relief in the majority of patients, while only about one third of initially unstable SBM show re-stabilization after RT. Since patients in our multi-center cohort exhibited very limited OS, fractionation schemes should be determined depending on the patients’ performance status.

Predictors for distant metastasis in head and neck cancer, with emphasis on age

PURPOSE

Distant metastasis (DM) in patients with head and neck squamous cell carcinoma (HNSCC) is uncommon, but strongly deteriorates prognosis. Controversy exists regarding age as a predictor for the presence and development of DM. The aim of this study was to investigate age and other predictors for DM in HNSCC patients.

METHODS

From 1413 patients diagnosed with a primary HNSCC between 1999 and 2010 in a tertiary referral centre, patient, disease and pathological characteristics were extracted from patient files. Uni- and multivariable Cox regression analyses were performed to identify risk factors for DM as primary outcome.

RESULTS

DM occurred in 131 (9.3%) patients, of which 27 (1.9%) were diagnosed simultaneously with the primary tumour, 27 (1.9%) were diagnosed synchronous, and 77 (5.4%) were diagnosed metachronous. The most common site of DM was lung (51.1%), followed by bone (19.1%) and liver (11.5%). Multivariable analysis identified male gender (HR = 1.95, 95% CI 1.23-3.10) hypopharyngeal tumours (HR = 3.28, 95% CI 1.75-6.14), advanced T-stage (HR = 1.61, 95% CI 1.09-2.38), poor differentiation grade (HR = 2.49, 95% CI 1.07-5.78), regional lymph node metastasis (HR = 5.35, 95% CI 3.25-8.79) and extranodal extension of regional lymph nodes metastasis (HR = 3.06, 95% CI 1.39-6.72) as independent prognostic factors for the presence or development of DM. No relation with age was found.

CONCLUSION

Age is not related to the presence or development of DM. This study emphasizes the importance of screening for DM, especially in males, patients with hypopharyngeal tumours, advanced T-stage, histopathological poor differentiation grade, regional lymph node metastasis and extranodal extension.

Metastatic disease in head & neck oncology

The head and neck district represents one of the most frequent sites of cancer, and the percentage of metastases is very high in both loco-regional and distant areas. Prognosis refers to several factors: a) stage of disease; b) loco-regional relapses; c) distant metastasis. At diagnosis, distant metastases of head and neck cancers are present in about 10% of cases with an additional 20-30% developing metastases during the course of their disease. Diagnosis of distant metastases is associated with unfavorable prognosis, with a median survival of about 10 months. The aim of the present review is to provide an update on distant metastasis in head and neck oncology. Recent achievements in molecular profiling, interaction between neoplastic tissue and the tumor microenvironment, oligometastatic disease concepts, and the role of immunotherapy have all deeply changed the therapeutic approach and disease control. Firstly, we approach topics such as natural history, epidemiology of distant metastases and relevant pathological and radiological aspects. Focus is then placed on the most relevant clinical aspects; particular attention is reserved to tumours with distant metastasis and positive for EBV and HPV, and the oligometastatic concept. A substantial part of the review is dedicated to different therapeutic approaches. We highlight the role of immunotherapy and the potential effects of innovative technologies. Lastly, we present ethical and clinical perspectives related to frailty in oncological patients and emerging difficulties in sustainable socio-economical governance.

Which Factors Affect the Long-Term Survival of Patients With Oral Squamous Cell Carcinoma With Distant Metastasis?

PURPOSE

The development of distant metastases (DMs) in patients with oral squamous cell carcinoma (OSCC) leads to dismal prospects for survival. The present study aimed to identify the risk factors for DM development and long-term survival.

PATIENTS AND METHODS

The present study was a retrospective cohort study of patients with OSCC at a single institution. The predictor variables were age, gender, lymph node classification, histologic grade, neck dissection, infiltrative growth pattern (INF), vascular/lymphatic invasion, perineural invasion (PI), extranodal extension, local recurrence, nodal metastasis, DMs, interval to the diagnosis of DMs, and surgery for DMs. The primary outcome variables were the 5-year overall survival (OS) and median survival time (MST), which were estimated using the Kaplan-Meier method. Cox hazard models were used to identify the risk factors for DM development.

RESULTS

The cohort included 526 patients; the data from 402 were available for analysis. Of these 402 patients, 37 developed DMs. On multivariate analysis, clinical N1 (cN1)-cN2 (hazard ratio [HR], 3.36), moderate/poor differentiation (HR, 2.51), INFc (HR, 3.27), vascular/lymphatic invasion (HR, 2.95), and PI (HR, 2.17) were independent predictors of DM development. The 5-year OS was 84.6% for the non-DM patients and 9.7% for the DM patients, with a MST of 16.9 months. In those with DMs with cN0, the 5-year OS was 18.2% and the MST was 37.2 months. For those with DMs with cN1-cN2, the 5-year OS was 4.7% and the MST was 12.9 months. In patients with an interval to the DM diagnosis of 10.0 months or longer, the 5-year OS was 20.0% and the MST was 38.6 months. In the patients with an interval to the DM diagnosis of less than 10.0 months, the MST was 11.7 months. The 5-year OS of the patients who had undergone pulmonary metastasectomy was 60.0% and the MST of the nonsurgery group was 16.0 months.

CONCLUSIONS

In the patients with DMs, stage cN0 and a late interval to DM diagnosis were associated with long-term survival. Pulmonary metastasectomy could be worth considering to improve survival.

Comparison of 18F-FDG PET/MRI, MRI, and 18F-FDG PET/CT for the detection of synchronous cancers and distant metastases in patients with oropharyngeal and hypopharyngeal squamous cell carcinoma

PURPOSE

In this prospective study, we sought to compare the clinical utility of fluorodeoxyglucose PET/MRI, MRI, and PET/CT in the detection of synchronous cancers and distant metastases in patients with oropharyngeal and hypopharyngeal squamous cell carcinoma (OHSCC).

METHODS

We examined 198 consecutive patients with biopsy-proven OHSCC who agreed to receive chemoradiation. All patients underwent pretreatment PET/MRI and PET/CT on the same day. Patients were followed-up for a minimum of 12 months or until death. The McNemar's test and receiver-operating characteristic (ROC) curves were used to compare sensitivity/specificity and the diagnostic capabilities of PET/MRI, MRI, and PET/CT, respectively.

RESULTS

We identified 55 patients (27.7%) who had synchronous cancers and/or distant metastases (number of involved sites: 83). The results of site-based analysis revealed that the sensitivity of PET/MRI was 15.7% higher than that of MRI (73.5% versus 57.8%, p < 0.001) and 3.6% higher compared with PET/CT (73.5% versus 69.9%, p = 0.083), whereas the sensitivity of PET/CT was 12.1% higher than that of MRI (69.9% versus 57.8%, p = 0.012). On a patient-basis, ROC curve analysis demonstrated that PET/MRI yielded a greater area under curve than MRI (0.930 versus 0.905, p = 0.023). There were no significant differences in terms of diagnostic capability between MRI and PET/CT (0.905 versus 0.917, p = 0.469) and between PET/MRI and PET/CT (0.930 versus 0.917, p = 0.062).

CONCLUSIONS

In our cohort, PET/MRI showed a significantly higher diagnostic capability than MRI and no significant difference compared with PET/CT for the detection of synchronous cancers or distant metastases in patients with OHSCC.

Bone invasion-targeted chemotherapy with a novel anionic platinum complex (3Pt) for oral squamous cell carcinoma

Cisplatin (CDDP) is an important drug for chemotherapy in patients with head and neck squamous cell carcinoma. Nephrotoxicity and lack of an effect on bone invasion are limitations of CDDP. To increase its antitumor effect on bone invasion and reduce toxicity problems, anionic Pt complex (3Pt) has been developed. The present study aimed to characterize the basis of the cytotoxicity of the novel platinum complex 3Pt in comparison with that of CDDP for oral squamous cell carcinoma. The ionic platinum complex was prepared to increase solubility and avoid platinum nephrotoxicity. Furthermore, 3Pt was designed to target bone hydroxyapatite and has germinal bisphosphonate moieties for drug delivery. In vitro antitumor activity was assayed in two oral squamous cell carcinoma cell lines. To investigate the antitumor and nephrotoxic effects of 3Pt, nude mice with OSC-19 were given 3Pt and CDDP. The in vitro growth-inhibitory effect of 3Pt was significantly less than that of CDDP. However, both 3Pt and CDDP showed equivalent antitumor effects in vivo. Mice injected with CDDP developed renal cell apoptosis; however, those injected with 3Pt were almost free of renal cell injury. In addition to similar in vivo antitumor effects, 3Pt decreased the volume of bone resorption compared to that with CDDP in a bone invasion model using OSC-19. In conclusion, considering the potential advantages in terms of noticeable antitumor activity on bone invasion and reduced nephrotoxicity, 3Pt represents a significant improvement in the development of bone-targeting platinum drugs.

Survival analysis of distant metastasis of laryngeal carcinoma: analysis based on SEER database

BACKGROUND

The purpose of this study was to investigate the prognostic factors and the value of surgical treatment of patients with newly diagnosed laryngeal cancer with distant metastasis (DM).

METHODS

The Surveillance, Epidemiology and End Result database (SEER) was used to analyze 446 patients with laryngeal cancer with DM at the time of initial diagnosis from 2010 to 2014.The survival prognosis of patients with DM was performed by using Kaplan-Meier and log-rank test. The prognostic factors and the effect of surgery were analyzed using the Cox regression analysis and R-language data package.

RESULTS

The incidence of DM was 3.21% (446/13865). Lung was the most common distant metastatic site of laryngeal cancer (62.6%), and brain metastases had the worst prognosis in patients at 2 months. T stage and brain metastasis were independent risk factors affecting the survival (P < 0.05). The hazard ratio (HR) of DM in T4 stage was nearly twice than that in T1 stage. Surgical treatment of primary and metastatic tumors can cause better survival for patients. Patients who didn't underwent primary tumor surgery were approximately twice as likely to die from cancer as those who did. The nomogram model was constructed to visually present the 1-, 2- and 3-year survival rates of patients.

CONCLUSIONS

T stage, brain metastasis and surgical treatment are prognostic factors of patients with M1 stage laryngeal cancer. Surgical treatment of primary tumors and metastases can lead to better survival for patients.

TRIAL REGISTRATION

Not applicable.

Biomarkers: paving stones on the road towards the personalized precision medicine for oral squamous cell carcinoma

Traditional therapeutics have encountered a bottleneck caused by diagnosis delay and subjective and unreliable assessment. Biomarkers can overcome this bottleneck and guide us toward personalized precision medicine for oral squamous cell carcinoma. To achieve this, it is important to efficiently and accurately screen out specific biomarkers from among the huge number of molecules. Progress in omics-based high-throughput technology has laid a solid foundation for biomarker discovery. With credible and systemic biomarker models, more precise and personalized diagnosis and assessment would be achieved and patients would be more likely to be cured and have a higher quality of life. However, this is not straightforward owing to the complexity of molecules involved in tumorigenesis. In this context, there is a need to focus on tumor heterogeneity and homogeneity, which are discussed in detail. In this review, we aim to provide an understanding of biomarker discovery and application for precision medicine of oral squamous cell carcinoma, and have a strong belief that biomarker will pave the road toward future precision medicine.

Risk Factors for Distant Metastasis in Patients with Oral Cavity Squamous Cell Carcinoma Undergoing Surgical Treatment

OBJECTIVE

The aim of this study is to investigate the clinical and pathological factors related to distant metastasis in patients with oral cavity squamous cell carcinoma (OCSCC) undergoing surgery.

STUDY DESIGN

A retrospective data review was conducted on patients who underwent primary surgery for OCSCC at the Instituto do Cancer do Estado de São Paulo (ICESP) between 2009 and 2015. Distant metastasis rates were calculated and predictive factors were determined by the Cox proportional-hazards model.

RESULTS

There was a total of 274 patients, including 210 (76.6%) men and 64 (23.4%) women, with a mean age of 59.9 ± 10.9 years. The incidence of distant metastasis was 9.6%, with the lung being the most common site. The mean time interval between surgical treatment and the diagnosis of distant metastasis was 12 months (range 2-40 months). In the multivariate analysis, angiolymphatic invasion (HR = 2,87; p = 0.023), contralateral cervical metastasis (HR = 3.3; p = 0,007), tumor thickness >25 mm (HR = 3.50; p = 0.009), and locoregional recurrence (HR = 6.59; p < 0.0001) were the only independent risk factors for distant metastasis.

CONCLUSION

Patients with OCSCC who have contralateral lymph node metastasis, tumors with a thickness >25 mm, angiolymphatic invasion, or locoregional recurrence after surgical treatment have a greater risk of developing distant metastasis.

The subclonal structure and genomic evolution of oral squamous cell carcinoma revealed by ultra-deep sequencing

Recent studies suggest that head and neck squamous cell carcinomas are very heterogeneous between patients; however the subclonal structure remains unexplored mainly due to studies using only a single biopsy per patient. To deconvolute the clonal structure and describe the genomic cancer evolution, we applied whole-exome sequencing combined with ultra-deep targeted sequencing on oral squamous cell carcinomas (OSCC). From each patient, a set of biopsies was sampled from distinct geographical sites in primary tumor and lymph node metastasis.We demonstrate that the included OSCCs show a high degree of inter-patient heterogeneity but a low degree of intra-tumor heterogeneity. However, some OSCC cancers contain complex subclonal architectures comprising distinct subclones only found in geographically distinct regions of the primary tumors. In several cases we find mutations in the primary tumor that are not present in the lymph node metastasis. We conclude that metastatic potential in our population is acquired early in tumor evolution as evident by the ongoing parallel evolution in several primary tumors.

Prognostic significance of clinical and 18 F-FDG PET/CT parameters for post-distant metastasis survival in head and neck squamous cell carcinoma patients

INTRODUCTION

Distant metastasis (M1) to vital organs remains a major cause of death in patients with head and neck squamous cell carcinomas (HNSCC). Clinically the survival periods vary in individual M1 HNSCC patients and a prognostic indicator has not been fully studied. Here, we evaluated the prognostic factors for survival including ¹⁸ F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) parameters in M1 HNSCC patients.

METHODS

The study included 108 patients with newly diagnosed M1 HNSCC (68 during clinical courses, 40 at presentation) who underwent FDG PET/CT. Maximum standardized uptake value (SUVmax) of metastatic tumors was measured by FDG PET/CT. Associations of primary tumor or metastatic tumor variables with overall survival were assessed with Cox regression models.

RESULTS

Multivariate analyses demonstrated that nasopharynx primary and incomplete response of loco-regional disease to treatment were significant prognostic factors. In addition, adverse prognostic factors included short distant metastasis-free period (<10 months), high number (≥5), and high PET SUVmax (≥6.3) of metastatic lesions. The patients with at least one of these adverse features had a median survival <14 months.

CONCLUSION

PET SUVmax of the metastatic tumors in M1 HNSCC patients can be a good predictor for survival. J. Surg. Oncol. 2016;114:888-894. © 2016 2016 Wiley Periodicals, Inc.

Predictors of Distant Metastasis after Radical Surgery Followed by Postoperative Radiotherapy with or without Chemotherapy for Oropharyngeal Cancer

Purpose

We investigated the prognostic factors for distant metastasis (DM) in patients with locally advanced oropharyngeal cancer (OPC) treated with surgery and adjuvant radiotherapy with or without concurrent chemotherapy.

Materials and Methods

Eighty-five patients treated between January 1995 and August 2014 were evaluated retrospectively. Data regarding the pathological tumour and nodal status, human papillomavirus (HPV) status, treatment characteristics, and pretreatment maximum standardized uptake value (SUVmax) of 18-fluoro-2-deoxyglucose positron emission tomography–computed tomography scan (¹⁸F-FDG PET-CT) were evaluated, and their influence on DM and survival outcomes were analyzed.

Results

Median follow-up period was 48.0 months. Recurrence was observed in 20 patients, including locoregional recurrence and DM. DM was observed in 13 patients. A multivariate analysis confirmed that the presence of lymphovascular invasion (p=0.031), lower neck lymph node (LN) involvement (p=0.006), SUVmax ≥ 9.7 (p=0.014), and tumour size ≥ 3 cm (p=0.037) significantly affected DM. HPV status was not associated with DM. Perineural invasion (p=0.048), lower neck LNinvolvement (p=0.008), SUVmax ≥ 9.7 (p=0.019), and tumour size ≥ 3 cm (p=0.033) were also significant factors for the DM-free survival rate.

Conclusion

Lower neck LN involvement, high SUVmax in pretreatment ¹⁸F-FDG PET-CT, and large tumour size were predictive factors for DM in patients of OPC.

Expression of IL-1α correlates with distant metastasis in patients with head and neck squamous cell carcinoma

The presence of IL-1 in human cancers is associated with aggressive tumor biology but its prognostic value is unknown. We studied whether IL-1α expression is a prognostic marker of distant metastasis in patients with head and neck squamous cell carcinoma (HNSCC). IL-1α mRNA and protein levels were determined in tumor samples and cancer cell lines using RT-PCR and ELISA. The effects of constitutive IL-1α expression by tumor lines were characterized. IL-1α mRNA and protein secretion were higher in tumor samples from patients who later developed distant metastasis than in patients who did not. By using distant metastasis as a dependent variable, patients were classified into two categories of IL-1α transcript-levels. The high-IL-1α group had a significantly lower five-year distant metastasis-free survival than the low-IL-1α group [70.0% (CI 95%: 55.9-84.1%) vs 94.7% (CI 95%:90.2-99.2%)]. When IL-1α transcript-levels were combined with clinical factors related to tumor metastasis, the predictive power of the model increased significantly. Additionally, transcript levels of IL-1α correlated significantly with those of the IL-1 family genes and genes related to the metastatic process. IL-1 treatment of microvascular endothelial cells increased adhesion of HNSCC cells but no differences were found based on constitutive IL-1α expression by tumor cells. Nevertheless, IL-1α produced by tumor cells effectively increased their transmigration across the endothelium. We found a significant relationship between IL-1α expression and development of distant metastasis in HNSCC patients. IL-1α expression could help to define a subset of patients at high risk of distant metastasis who could benefit from adjuvant treatment.

Relation between the level of lymph node metastasis and survival in locally advanced head and neck squamous cell carcinoma

BACKGROUND

The current head and neck squamous cell carcinoma (HNSCC) staging system may not capture the full prognostic implications of regional lymph node involvement. This study investigated the impact of the level of lymph node metastasis (LNM) on survival.

METHODS

The Surveillance, Epidemiology, and End Results registry was queried for oral cavity (OC), oropharynx (OP), larynx (LAR), and hypopharynx (HP) HNSCC. A multivariate Cox proportional hazards model was used to evaluate whether the level of LNM was an independent prognostic factor. Site-specific recursive-partitioning analysis was performed to classify patients into different risk groups.

RESULTS

In all, 14,499 patients, including OC (n = 2463), OP (n = 8567), LAR (n = 2332), and HP patients (n = 1137), were analyzed. Both the American Joint Committee on Cancer (AJCC) N classification and the level of LNM showed significant effects on overall survival (OS) in patients with OC, OP, or LAR HNSCC but not in patients with HP HNSCC. In patients with N2 disease, the AJCC subclassification (N2a, N2b, or N2c) was significantly associated with the OS of patients with OP and LAR HNSCC but not with the OS of patients with OC or HP HNSCC, whereas the level of LNM (primary, secondary, or tertiary) was significantly associated with the OS of patients with OC, OP, and LAR HNSCC but not HP HNSCC. With recursive-partitioning analysis, a simple, primary site-specific prognostic tool integrating the AJCC T and N classifications and the level of LNM was designed, and it could be easily used by health care providers in clinic.

CONCLUSIONS

The level of LNM is an independent prognostic factor for patients with locally advanced HNSCC and could add to the prognostic value of AJCC T and N classifications in patients with locally advanced HNSCC.

Risk factors associated with distant metastasis in patients with oral squamous cell carcinoma

OBJECTIVE

The purpose of this study was to retrospectively evaluate the incidence of distant metastasis (DM) after curative surgical treatment and assess the multivariate relationships among various risk factors for DM in patients with oral squamous cell carcinoma (OSCC).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

The medical records of all patients with OSCC without DM who underwent curative surgery with or without postoperative adjuvant chemoradiation between January 2001 and February 2014 at our institution were retrospectively reviewed. There were a total of 451 patients, including 271 men and 180 women, with a mean age of 65.9 ± 13.5 years.

RESULTS

Of these patients, 30 (6.7%) developed DM. During the follow-up period, the 5-year overall survival rate was 76.2%. Sites of DM comprised the lungs (80.0%), skin (13.3%), liver (10.0%), bone (6.7%), and brain (3.3%). We found the T classification and N classification as well as the histologic grade to be significant risk factors associated with the development of DM in the univariate analysis only (P = .003), whereas locoregional failure (odds ratio [OR], 4.03), multiple lymph node metastases (more than 4 positive nodes; OR, 3.32) and positive extracapsular spread (OR, 3.06) were identified to be significant risk factors associated with the development of DM in the multivariate analysis.

CONCLUSION

We demonstrated multivariate relationships among various risk factors for DM in OSCC patients. Clinicians should consider these risk factors and pay special attention to detecting DM early during the postoperative management of OSCC patients with these risk factors.

Contemporary therapeutic management of locally advanced hypopharyngeal cancer: oncologic and functional outcomes - a report on 100 cases

CONCLUSION

A significant proportion of patients with locally advanced hypopharyngeal cancer could not be managed by larynx-sparing therapy. T4 stage is one of the main predictive factors of oncologic and functional outcomes.

OBJECTIVES

To analyze the therapeutic management of patients with locally advanced hypopharyngeal cancer in clinical practice and to report oncologic and functional outcomes.

METHODS

This was a retrospective study of all patients treated for a locally advanced hypopharyngeal squamous cell carcinoma between 2001 and 2012 at our institution.

RESULTS

A total of 100 patients were included in this study. Induction chemotherapy (CT) followed by radiotherapy (RT) ± CT, primary RT + CT, and primary total pharyngolaryngectomy (TPL) comprised the initial therapeutic management for 54, 24, and 20 patients, respectively. Two patients received only supportive care. Overall survival (OS) and cause-specific survival (SS) were 50% and 60% at 3 years, respectively. In the group of patients referred for induction CT, the 3-year OS and SS were 58% and 70%, respectively. In multivariate analysis, T stage (p = 0.05) and ASA score (p = 0.02) were significant predictive factors of OS. T4 tumor stage had a pejorative impact on swallowing function after therapy (p = 0.006). The rate of patients alive, disease-free, and with a functional larynx at 2 years was 23%.

[Long-term results and cause of failure analysis in larynx cancer patients irradiated conventionally and with accelerated fractionation schedules in 1995-1998]

The clinical material consists of 217 patients with squamous cell carcinoma in supraglottic and glottic larynx in clinical stage T1-3N0M0 irradiated radically in Warsaw Oncology Centre in 1995-1998. All patients were treated with Co-60, according to two schedules of fractionation, with maintenance of the consistent therapeutic protocol. The same team of doctors worked on the treatment of patients and on the follow-up as well. The clinical material is a part of a three-phased clinical trial KBN 0295. In the course of observation, the progression of cancer was not observed in 157 patients, among whom, 66% were treated conventionally and 79% with accelerated fractionation method. 60 cases of loco-regional recurrences were noted, among which 55 were regional. The majority of failure cases was observed until the 30(th) of the month after the radiotherapy ended. In conventional fractionation treatment, recurrences in T1 were 8/31 (26%), in T2 22/59 (37%) and in T3 8/20 (40%). In patients treated with AF, recurrences were T1 5/39 (13%), T2 15/55 (27%) and T3 2/13 (15%) respectively. The percentage of primary site tumour recurrences for each localization and kind of treatment was analysed. In CF 28/78 (37%) of glottic tumour recurrences and 10/34 (29%) of supraglottic tumour, recurrences were observed. In AF, 12/71 (17%) and 10/36 (28%) were observed respectively. In 48 cases salvage surgery was used, and 12 patients were not qualified because of tumour massive progression or because they refused to have a surgery. Among 34 cases (16%) of the second primary tumour or distant methastases, 25 were observed with glottic cancer, among which 23 were observed in early stages, and 9 cases with supraglottic cancer, among which, 6 showed early stage of tumour. In only 3 cases out of all the patients, distant methastases were confirmed in histopatology examination. The main cause of failure in larynx cancer patients in stage T1 is that 3N0M0 are local recurrences. Second primary or distant methastases constitute 16% of the patients in this paper.

Prognostic value of level IV metastases from head and neck squamous cell carcinoma

BACKGROUND

The purpose of this study was to evaluate the prognostic value of level IV metastases in head and neck squamous cell carcinoma (HNSCC).

METHODS

The clinical and histopathological data of 111 patients with HNSCC with pN+ neck who underwent a primary tumor resection with unilateral or bilateral neck dissection were analyzed.

RESULTS

Level IV metastases were histopathologically proven in 33 patients (29.7%). Pulmonary metastases were observed in 12 of 33 patients (36.4%) with level IV metastases, and in 13 of 78 patients (16.7%) without level IV metastases (p = .04). Multivariate analyzes revealed a significant association between level IV metastases and pulmonary metastases (p = .038). However, an influence on overall (p = .65) or disease-free survival (p = .66) was not observed.

CONCLUSION

Level IV metastases seem to be a predictive factor for pulmonary metastases but not for overall and disease-free survival in patients with HNSCC.

Long-term survival after distant metastasis in patients with oropharyngeal cancer

OBJECTIVES

For patients with oropharyngeal squamous cell carcinoma (OPSCC), especially for those with HPV-positive tumors, locoregional control is excellent. Distant metastasis, however, remains a substantial problem. The purpose of our study was to evaluate outcomes and predictors of survival after distant metastasis in OPSCC.

MATERIALS AND METHODS

Between June 2002 and January 2011, 25 OPSCC patients treated with curative intent subsequently developed distant metastasis. The primary end-points evaluated were time-to-distant metastasis and overall survival after development of distant metastasis. Predictors of outcome were evaluated with median regression analysis or Cox regression. Best subset models were chosen to minimize the Bayesian Information Criterion (BIC). A prognostic index for survival after distant failure was created based on the selected model.

RESULTS

Median time-to-distant metastasis after completion of radiation was 7.9 months (range, 1.6-25.4). Median overall survival from distant metastasis was 18.3 months (95% CI, 14.3-39.8). The overall survival rates at 1- and 2-year after development of distant metastasis were 72.0% (95% confidence interval [CI], 53.4-89.6) and 40.8% (95% CI, 20.6-61.0), respectively. In multivariate analysis, Karnofsky Performance Status score (KPS) > or = 80 (p=0.01, hazard ratio [HR] 0.15, 95% CI, 0.04-0.52) and limited, single-organ disease (p=0.003, HR 0.13, 95% CI 0.03-0.61) predicted for increased survival from distant metastasis. Patients with both limited disease and good KPS formed the most favorable risk group with a 2-year survival of 100%. Two patients with human papilloma virus (HPV)-positive tumors were alive without any evidence of disease at 64.6 and 60.4 months, respectively, after aggressive local treatment of solitary metastasis.

CONCLUSION

For OPSCC patients with limited, single-organ disease and good KPS, long-term survival can be achieved.

Immunohistochemical markers of distant metastasis in laryngeal and hypopharyngeal squamous cell carcinomas

Metastasis remains a major cause of mortality in head and neck squamous cell carcinoma (HNSCC). Current clinicopathological features have shown limited predictability for the risk of distant metastasis in individual patients, and therefore more accurate and reliable markers are needed. The aim of this study was to investigate the ability of various molecular markers present in primary tumors to predict the risk of developing distant metastasis. Restrictive clinical criteria were applied for patient selection in order to carry out a case-control study with comparable clinical features on a group-wide basis and a similar risk of metastasis. All patients were surgically treated (with postoperative radiotherapy when appropriate) and classified as stage IV disease. Immunohistochemical analysis was performed for a panel of proteins known to participate in cellular processes relevant to metastatic dissemination (E-cadherin, annexin A2, cortactin, FAK, EGFR, p53, and p-AKT). Results showed that the loss of E-cadherin expression was significantly correlated with the risk of distant metastasis (P = 0.002; log-rank test), while the loss of annexin A2 expression was nearly statistically significant (P = 0.06). None of the other protein markers assessed were associated with the development of distant metastasis. Therefore, according to our data the loss of epithelial adhesion seems to play a central role in the development of metastasis in HNSCC, and more importantly, immunohistochemical assessment of key proteins involved in cell adhesion regulation, such as E-cadherin could represent a useful tool to evaluate easily and routinely the metastatic potential of these carcinomas.

Causes of death of patients with laryngeal cancer

Despite remarkable advances in the care of patients with laryngeal cancer over the past several decades, including a growing awareness of therapeutic complications and attention to quality of life, little is known about the causes of mortality in this population. In addition to the laryngeal malignancy itself, acute and late or chronic treatment-associated causes, second primary cancers, intercurrent disease and psychosocial factors are all responsible for patient morbidity and mortality. We examine the current literature related to the causes of death in patients with laryngeal cancer, in the hope of guiding future interventions to improve the longevity and quality of life of individuals with this cancer.

Distant Metastases and Survival Prediction in Head and Neck Squamous Cell Carcinoma

Objective

This study was designed to identify the risk factors associated with distant metastases (DM) and survival outcomes in patients with head and neck squamous cell carcinoma (HNSCC).

Study Design

Database analysis plus chart review.

Setting

Tertiary care academic medical center.

Subjects and Methods

Four hundred four eligible patients were involved who were treated with a minimum 2-year follow-up from January 2005 through August 2009. Confirmation of DM was performed by histopathology or follow-up imaging. Univariate and multivariate analyses were used for factors predictive of DM. The survival of patients was calculated by the Kaplan-Meier method.

Results

Thirty-six of the 404 eligible patients (8.9%) developed DM, most frequently in the lungs (80.6%). Univariate analyses revealed that T and N classifications, lymphovascular invasion and perineural invasion of the primary tumor, and locoregional recurrences were each significantly associated with the development of DM ( P < .05). Multivariate analyses showed that T and N classifications and locoregional recurrences were independent predictors of DM ( P < .05). The overall 1- and 2-year survival rates of the 36 patients with DMs were 40.6% and 13.5%, respectively. Metastases to more than 1 organ negatively affected patient survival ( P < .001).

Conclusion

Patients with advanced tumors, nodal involvement, or locoregional recurrences may require more frequent surveillance for the development of DMs.

Clinicopathologic analysis and predictive factors for distant metastases in patients with head and neck squamous cell carcinomas

BACKGROUND

The recognition of patients at high risk for the development of distant metastasis (DM) is required to recognize a subset of patients who may benefit from systemic therapy.

METHODS

In a retrospective analysis of patients treated between 1995 and 2006, 443 patients with surgically treated primary head and neck squamous cell carcinoma were included. The frequency and clinicopathologic risk factors for DM were evaluated.

RESULTS

A total of 60 patients (13.5%) developed DM. In a univariate analysis, tumor site (pharynx), pN classification (pN2-N3), differentiation grade (poorly differentiated), disease stage (stage IV), number (3 or more nodes), and site (bilateral nodes) of nodal metastasis were found to be significantly associated with the risk of DM. In a multivariate analysis, the only significant risk factors were the differentiation grade and the number and site of nodal metastasis.

CONCLUSIONS

Patients with pharyngeal poorly differentiated tumors, with multiple or bilateral nodal metastases, are at greater risk of DM and should be considered for systemic therapy.

Dynamic contrast-enhanced magnetic resonance imaging as a predictor of outcome in head-and-neck squamous cell carcinoma patients with nodal metastases

PURPOSE

Dynamic contrast-enhanced MRI (DCE-MRI) can provide information regarding tumor perfusion and permeability and has shown prognostic value in certain tumors types. The goal of this study was to assess the prognostic value of pretreatment DCE-MRI in head and neck squamous cell carcinoma (HNSCC) patients with nodal disease undergoing chemoradiation therapy or surgery.

METHODS AND MATERIALS

Seventy-four patients with histologically proven squamous cell carcinoma and neck nodal metastases were eligible for the study. Pretreatment DCE-MRI was performed on a 1.5T MRI. Clinical follow-up was a minimum of 12 months. DCE-MRI data were analyzed using the Tofts model. DCE-MRI parameters were related to treatment outcome (progression-free survival [PFS] and overall survival [OS]). Patients were grouped as no evidence of disease (NED), alive with disease (AWD), dead with disease (DOD), or dead of other causes (DOC). Prognostic significance was assessed using the log-rank test for single variables and Cox proportional hazards regression for combinations of variables.

RESULTS

At last clinical follow-up, for Stage III, all 12 patients were NED. For Stage IV, 43 patients were NED, 4 were AWD, 11 were DOD, and 4 were DOC. K(trans) is volume transfer constant. In a stepwise Cox regression, skewness of K(trans) (volume transfer constant) was the strongest predictor for Stage IV patients (PFS and OS: p <0.001).

CONCLUSION

Our study shows that skewness of K(trans) was the strongest predictor of PFS and OS in Stage IV HNSCC patients with nodal disease. This study suggests an important role for pretreatment DCE-MRI parameter K(trans) as a predictor of outcome in these patients.

Adenosquamous carcinoma of the head and neck: relationship to human papillomavirus and review of the literature

Adenosquamous carcinoma (ADSC) of the head and neck is an aggressive variant of squamous cell carcinoma (SCC). Certain variants of head and neck SCC are human papillomavirus (HPV)-related and have better prognosis. The relationship of HPV to head and neck ADSC has not been investigated. We searched our files for the term "adenosquamous" and head and neck subsites and found cases from 1998 to 2009. The requisite histologic criteria were the presence of SCC combined with distinct gland formation and/or intracellular mucin. DNA in situ hybridization for high-risk HPV, RNA in situ hybridization for high risk HPV E6 and E7 transcripts, and immunohistochemistry for p16 and p53 were performed. The existing literature on ADSC was also reviewed. Of the 18 cases, eight were from the larynx and hypopharynx, four from the oral cavity, three from the oropharynx, and three from the nasal cavity. Three cases (16%) showed both high risk HPV E6 and E7 and p16 expression, one from the nasal cavity and two from the oropharynx. Both oropharyngeal carcinoma patients were alive and disease free at 34 and 103 months, respectively. ADSCs of the head and neck are a heterogeneous group of tumors. A small minority of cases harbor HPV and most of these, particularly those occurring at sites with known high prevalence of HPV, show active viral transcription with detectable E6 and E7 and overexpression of p16. The HPV-related oropharyngeal cases, though rare, appear to do very well clinically, while the remaining cohort of ADSC patients do quite poorly. Head and neck ADSC appears to be a mixed variant that can be further classified according to its HPV status.