The importance of lymph node ratio for patients with mandibular infiltration of oral squamous cell carcinoma

Clinicopathological analysis of 134 patients with squamous cell carcinoma of the mandibular gingiva

Objective

The accurate assessment of the involvement of mandibular gingival squamous cell carcinoma (SCC) is essential for determining the extent of resection and is also useful for predicting lymph node metastasis and prognosis. The purpose of this study was to investigate the factors for predicting the prognosis.

Study design

We reviewed 134 patients with mandibular gingival SCC treated between 2008 and 2017. The clinical findings, TN stage, relationship between radiographical type and histological pattern, and factors affecting the survival rate were investigated.

Results

The moth-eaten radiographic type was significantly associated with histologically infiltrative pattern. For all 134 cases, the 5-year OS was 89.5 %, and 5-year DSS was 93.9 %. The 5-year DSS was 95.0 % for cN0 and/or pN0 cases and 90.3 % for pN (+) cases, with a significant difference. The significant risk factors for lymph node metastasis were teeth extractions by previous physicians and moth-eaten radiographic type.

Conclusion

The risk factor for poor prognosis was lymph node metastasis. In addition, teeth extractions by previous physicians and moth-eaten radiographic type were the risk factors for lymph node metastasis. It is recommended that these cases be treated considering the possibility of cervical lymph node metastasis.

Effect of segmental versus marginal mandibular resection on local and lymph node recurrences in oral squamous cell carcinoma: is tumorous bone infiltration or location and resulting soft tissue recurrences a long-term problem?

PURPOSE

Oral squamous cell carcinomas (OSCCs) adjacent to the mandible or with clinically suspected bone infiltration are surgically treated either with marginal or segmental resections. This retrospective study compared both resections regarding local recurrence and lymph node recurrence or secondary lymph node metastases.

METHODS

All consecutive primary OSCC cases between January 2007 and December 2015 that underwent mandibular marginal or segmental resection were included. Rates of local and lymph node recurrences or secondary metastases and possible risk factors such as tumor localization according to Urken's classification were recorded.

RESULTS

In total, 180 patients with 85 marginal (group I) and 95 segmental (group II) mandibular resections were analyzed. The local recurrence rates were comparable between the groups (28.2% vs. 27.4%; p = 0.897). Lymph node recurrences or secondary metastases were higher in group I (9.4% (n = 8) vs. 6.2% (n = 6); p = 0.001). Tumor localization appears to affect the outcomes. Significantly fewer local and lymph node recurrences/metastases were found for Urken's classification SB and S calculated by two-proportion z-test (p = 0.014 and 0.056, respectively). Local recurrences mostly emerged from soft tissues, which should be resected more radically than the bones.

CONCLUSION

While bone infiltration appears technically well controllable from an oncologic point of view, local recurrences and lymph node recurrences/metastases remain an issue. Regular clinical aftercare with imaging is crucial to detect recurrences.

Knockdown of Secernin 1 inhibit cell invasion and migration by activating the TGF-β/Smad3 pathway in oral squamous cell carcinomas

Secernin-1 (SCRN1) is a regulator of exocytosis in mast cells. Recently, SCRN1 was reported to be correlated with the prognosis of colorectal cancer and gastric cancer, but its functional effects on oral squamous cell carcinoma (OSCC) remain unclear. Our aim was to explore the expression pattern and the migration and invasion effects of the newly identified SCRN1 in OSCC. Western blotting (WB) was performed to measure SCRN1 expression in human OSCC tissue samples and OSCC cell lines. The effects of SCRN1 on OSCC cell proliferation, invasion and migration were analyzed by cell counting kit-8 and Transwell assays. The expression levels of TGF-β, Smad3 and phosphorylated Smad3 (p-Smad3) were measured by WB. The secretion of matrix metalloproteinase (MMP)-2 and MMP-9 was determined by the enzyme-linked immunosorbent assay. The expression of SCRN1 was significantly elevated in OSCC tissues and cell lines. SCRN1 knockdown reduced the expression of TGF-β and p-Smad3 in OSCC cells. TGF-β stimulation promoted proliferation, invasion and migration and enhanced the expression of p-Smad3 and the secretion of MMP9 in SCRN1-knockdown OSCC cell lines. Our study demonstrated that SCRN1 is upregulated in OSCC. Further analyses demonstrated that SCRN1 promotes the proliferation, invasion and migration of OSCC cells via TGF-β/Smad3 signaling.

Prognostic Involvement of Lymph Node Density in Oral Squamous Cell Carcinoma. A New Predictive Model

PURPOSE

Lymph node density (LND) has been reported to be a significant predictor of survival in oral squamous cell carcinoma (OSCC). The aim of this study was to analyze LND as a prognostic factor in OSCC and create a predictive model that determines the probability of death in these patients.

METHODS

A retrospective cohort study was carried out with a cohort of patients who underwent cervical dissection and primary resection of OSCC between 1980 and 2020. The primary predictor variable in this study was LND, which is defined as the number of positive lymph nodes divided by the total number of lymph nodes removed. The cutoff values for prediction of disease-specific survival (DSS) were calculated by receiver operating characteristic curve analysis, which determined the best cutoff value was 0.07. Patients were divided into binary subgroups (low and high risk) using the best cutoff value of LND. The outcome variable was DSS, defined as the duration from the date of diagnosis to death due to OSCC and not due to other causes or secondary tumors. Other variables were type of neck dissection, postsurgical treatment, surgical margin, pathological T category stage, pathological N category (pN) stage, extranodal extension, perineural invasion, bone invasion, and presence of recurrence. A predictive model (score) was generated by selecting variables using a log-rank test and by using the Cox proportional-hazards regression (multivariate analysis).

RESULTS

The sample consisted of 368 patients, 252 (68.5%) male and 116 (31.5%) female patients, with a mean age of 60.3 years. According to the LND cutoff value, there were 289 patients with a low LND (≤0.07) and 79 with a high LND (>0.07). The univariate analysis showed LND as a significant predictor of DSS at 5 years (67.1% in LND ≤ 0.07 vs 32.9% in LND > 0.07; P < .001). The Cox multivariate analysis identified LND (hazard ratio [HR] = 27.2; 95% confidence interval [CI], 3.18-231; P = .002), recurrence (HR = 4.45; 95% CI, 2.3-8.4; P < .001), and type of treatment (HR = 0.52; 95% CI, 0.34-0.81; P < .001) as independent predictive factors for DSS. In the predictive model, the presence of recurrence was the most important factor with 8 points, whereas LND >0.07 contributed only 1 point; however, the 2 categories resulting from this limit were statistically significant.

CONCLUSIONS

Our study demonstrates that LND is an additional prognostic factor in patients with a pN+ disease. In addition, our predictive model could be useful in the therapeutic algorithm of OSCC patients, as it can predict the probability of death in these patients.

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.

Establishment of a prognostic scoring model for regional recurrent nasopharyngeal carcinoma after neck dissection

Objective: The main aim of this study was to establish a scoring model to predict risk of progression and survival in patients with regionally recurrent nasopharyngeal carcinoma (NPC).

Methods: Three hundred and forty-eight patients subjected to neck dissection from 2003 to 2017 were included for study. Clinicopathologic information for each patient was analyzed. Independent prognostic factors were selected using the Cox proportional hazards model and incorporated into the scoring model. Concordance index (C-index) and calibration curves were used to verify discrimination and calibration, respectively and the results validated using bootstrap resampling.

Results: Microscopic positive lymph node > 2 [hazard ratio (HR), 2.19; 95% confidence interval (CI), 1.30–3.68; P = 0.003], extranodal extension (HR, 2.75; 95% CI, 1.69–4.47; P < 0.001), and lower neck involvement (HR, 1.78; 95% CI, 1.04–3.04; P = 0.034) were identified from multivariate analysis as independent factors for overall survival (OS). A qualitative 4-point scale was generated to stratify patients into 4 risk groups for predicting OS and progression-free survival (PFS). The novel scoring model demonstrated enhanced discrimination (C-index = 0.69; 95% CI, 0.62–0.76) relative to the original recurrent tumor-node-metastasis (rTNM) staging system (C-index = 0.56; 95% CI, 0.50–0.62), and was internally validated with a bootstrap-adjusted C-index of 0.70. The calibration curve showed good agreement between predicted probabilities and actual observations.

Conclusions: The scoring system established in this study based on a large regionally recurrent NPC cohort fills a gap regarding assessment of risk and prediction of survival outcomes after neck dissection in this population and could be further applied to identify high-risk patients who may benefit from more aggressive intervention.

Lymph node yield in treatment naïve cases of head and neck squamous cell carcinoma: en bloc lymphadenectomy versus level-by-level dissection

BACKGROUND

Lymph node yield is an important prognostic factor in head and neck squamous cell carcinoma. Variability in neck dissection sampling techniques has not been studied as a determinant of lymph node yield.

METHODS

This retrospective study used lymph node yield and average nodes per level to compare level-by-level and en bloc neck dissection sampling methods, in primary head and neck squamous cell carcinoma cases operated between March 2017 and February 2020.

RESULTS

From 123 patients, 182 neck dissections were analysed, of which 133 were selective and the rest were comprehensive: 55 had level-by-level sampling and 127 had undergone en bloc dissection. The level-by-level method yielded more nodes in all neck dissections combined (20 vs 17; p = 0.097), but the difference was significant only for the subcohort of selective neck dissection (18.5 vs 15; p = 0.011). However, the gain in average nodes per level achieved by level-by-level sampling was significant in both groups (4.2 vs 3.33 and 4.4 vs 3, respectively; both p < 0.001).

CONCLUSION

Sampling of cervical lymph nodes level-by-level yields more nodes than the en bloc technique. Further studies could verify whether neck dissection sampling technique has any impact on survival rates.

Squamous cell carcinoma of the mandible - Patterns of metastasis and disease recurrence in dependence of localization and therapy

INTRODUCTION

Oral squamous cell carcinomas exhibit distinct patterns of disease progression, depending on their localisation. This study aimed to evaluate clinicopathological data in patients with tumors of the mandibular alveolar process, to facilitate risk assessment and therapy planning.

MATERIALS AND METHODS

A retrospective cohort study was designed including patients with squamous cell carcinoma of the mandibular gingiva. Clinical and pathological data were collected to determine the rate of cervical metastases and clinical outcomes depending on tumor stage, localization (anterior, intermediate and posterior) and the extent of tumor resection.

RESULTS

120 patients were included in the analysis. Rate of metastases was 42.6%. Tumors of the anterior part of the mandible exhibited significantly higher rates of bilateral metastases (anterior: 85.7%, intermediate: 15.8%, posterior: 4%, p < 0.001) and local recurrence (anterior: 25%, intermediate: 16.3%, posterior: 5.5%, p = 0.03) compared to posterior malignancies.

CONCLUSION

Tumors of the anterior segment of the mandible are characterized by high rates of metastases and local recurrence. Therefore, we propose radical segmental resection and bilateral neck dissection in those patients.

The prognostic significance of the lymph node ratio in oral cancer differs for anatomical subsites

The aim of this study was to validate the prognostic significance of the lymph node ratio (LNR) in patients suffering from oral squamous cell carcinoma in regard to different anatomical subsites. A cohort of 430 patients was investigated to determine the rates of primary metastasis and local and regional disease recurrence. Correlation analysis of the LNR with relevant clinical and pathological parameters was performed. Receiver operating characteristic (ROC) curve analysis was conducted to evaluate the prognostic impact for different subsites. Significantly differing rates of primary metastasis and loco-regional disease recurrence were found for cancer of different anatomical subsites of the head and neck. Furthermore, ROC curve analysis suggested that LNR has prognostic relevance in subsets of cancer (tongue, P< 0.001; alveolar process, P= 0.04; maxilla, P= 0.03; buccal mucosa, P= 0.02). The LNR of cancer located in the soft palate (P= 0.6) and floor of the mouth (P= 0.11) showed little or no association with the clinical outcome. There is the need for a more sensitive consideration of the LNR as a factor in the assessment of risk and the treatment decision, as the anatomical subsite plays a crucial role in its impact on the clinical outcome.

Mandibular Invasion by Oral Squamous Cell Carcinoma: Clinicopathologic Features of 74 Cases

OBJECTIVES

(1) For patients with oral squamous cell carcinoma (OSCC) and mandibular invasion, to determine whether prior radiation to the head and neck region (PXRTHN) affects the density of osteoblasts, osteoclasts, or fibroblasts along the tumor interface invading the mandible and whether this is significantly associated with overall survival. (2) To identify clinicopathologic features that are associated with overall survival.

STUDY DESIGN

Case series with chart review.

SETTING

University of Missouri hospital.

SUBJECTS AND METHODS

Retrospective review of 74 cases with pathologically confirmed mandible invasion by OSCC and surgical treatment between January 1, 2005, and December 31, 2015. A board-certified anatomic pathologist reviewed the slides from all mandibulectomy cases.

RESULTS

The mean density of osteoclasts was 2.0 per linear mm among the patients with PXRTHN and 7.1 among those without PXRTHN ( P < .001). Positive soft tissue frozen section margin was significantly associated with overall survival on univariate analysis ( P < .001; hazard ratio [HR], 0.34; 95% CI, 0.19-0.62) and multivariate analysis ( P = .026; HR, 0.41; 95% CI, 0.19-0.90). Maximum tumor dimension was significantly associated with overall survival on univariate analysis ( P = .021; HR, 1.19; 95% CI, 1.03-1.38) and multivariate analysis ( P = .002; HR, 1.49; 95% CI, 1.16-1.93). Osteoclast, osteoblast, and fibroblast density were not associated with overall survival.

CONCLUSIONS

(1) Osteoclast density along the tumor front is significantly lower among patients with PXRTHN. Stromal cell density was not associated with overall survival. (2) Positive soft tissue frozen section margin and maximum tumor dimension are significantly associated with overall survival among patients with mandibular invasion by OSCC.