Management of the clinically N0 neck in early-stage oral squamous cell carcinoma (OSCC). An EACMFS position paper

LRRC59 promotes the progression of oral squamous cell carcinoma by interacting with SRP pathway components and enhancing the secretion of CKAP4-containing exosomes

Background

As a ribosome receptor, LRRC59 was thought to regulate mRNA translation on the ER membrane. Evidence suggests that LRRC59 is overexpressed in a number of human malignancies and is associated with poor prognoses, but its primary biological function in the development of oral squamous cell carcinoma (OSCC) remains obscure.

Objective

The purpose of this study is to investigate at the expression changes and functional role of LRRC59 in OSCC.

Methods

LRRC59 gene expression and correlation with prognosis of OSCC patients were first examined using the data from The Cancer Genome Atlas (TCGA) databases. Following that, a series of functional experiments, including cell counting kit-8, cell cycle analysis, wound healing assays, and transwell assays, were carried out to analyze the biological roles of LRRC59 in tumor cells. Mechanistically, we employed Tandem Affinity Purification-Mass Spectrometry (TAP-MS) approach to isolate and identify protein complexes of LRRC59. Downstream regulatory proteins of LRRC59 were verified through immunoprecipitation and immunofluorescence experiments. Furthermore, we isolated exosomes from OSCC cell supernatant and conducted co-culture experiments to examine the effect of LRRC59 knockdown on OSCC cells.

Results

In samples from OSCC patients, LRRC59 was highly expressed and correlated with poor prognoses. Moreover, the gene sets analysis based on TCGA RNA-seq data indicated that LRRC59 seemed to be strongly related with protein secretory and OSCC migration. Upregulated levels of LRRC59 are more prone to lymph node metastasis in OSCC patients. LRRC59 knockdown impaired the ability of OSCC cell proliferation, migration, and invasion invitro. Mechanistically, our TAP-MS data situate LRRC59 in a functional nexus for mRNA translation regulation via interactions with SRP pathway components, translational initiation factors, CRD-mediated mRNA stabilization factors. More importantly, we found that LRRC59 interacted with cytoskeleton-associated protein 4 (CKAP4) and promoted the formation of CKAP4-containing exosomes. We also revealed that the LRRC59-CKAP4 axis was a crucial regulator of CKAP4-containing exosome secretion in OSCC cells for migration and invasion.

Conclusions

Therefore, based on our findings, LRRC59 may serve as a potential biomarker for OSCC patients, and LRRC59-induced exosome secretion via the CKAP4 axis may serve as a potential therapeutic target for OSCC.

Management of clinically node-negative early-stage oral cancer: network meta-analysis of randomized clinical trials

The best treatments for the clinically node-negative (cN0) neck in early-stage oral squamous cell carcinoma (OSCC) patients are a subject of ongoing debate and there is no consensus. A network meta-analysis (NMA) of randomized clinical trials (RCTs) was conducted to determine the most effective treatment and to rank treatments based on their effectiveness. A systematic search was performed in accordance with the PRISMA guidelines to retrieve RCTs that compared therapeutic neck dissection (TND), sentinel lymph node biopsy (SLNB), and elective neck dissection (END). The outcomes analysed were overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and nodal recurrence. Hazard ratios and risk ratios were calculated by direct meta-analysis and NMA. Ten RCTs with a total of 1858 patients were eligible for inclusion. Direct meta-analysis showed END to be superior to TND and comparable to SLNB. The NMA revealed no statistically significant difference between END and SLNB (very low quality evidence) regarding OS, DSS, DFS, and nodal recurrence. However, END was found to significantly improve OS and DFS, and reduce nodal recurrence when compared to TND (moderate quality evidence). END ranked as probably the top treatment option for maximizing OS and DSS, and reducing nodal recurrence in early-stage OSCC, followed by SLNB and TND. There was very low quality evidence supporting SLNB as non-inferior to END for patients with early-stage OSCC. This NMA yielded favourable results for the use of END (with moderate quality evidence) in early-stage OSCC patients, although excellent results have also been obtained with SLNB. However, data in the literature for SLNB are scarce, as this technique has not yet been formalized in many countries. There is a need to further explore SLNB for early-stage OSCC patients, as well as its value in detecting occult lymph node metastases on the contralateral side. More studies comparing morbidity, quality of life, and costs between the different management strategies for the clinically negative neck in early-stage OSCC patients are needed.

A Study of the Prognostic Factors for Late Cervical Lymph Node Metastasis and Distant Metastasis in Patients with cT1-2N0 Tongue Cancer

Background: Early-stage tongue cancer has a good prognosis in general; however, high-risk patients with late cervical lymph node and distant metastases have a poor prognosis. Elective neck dissection and postoperative chemoradiotherapy are considered for these patients, although no clear criteria have been identified for their evaluation. Methods: This retrospective observational study aimed to determine the predictive factors for late cervical lymph node and distant metastases in 102 patients with cT1-2N0 tongue cancer. The data regarding the demographic characteristics, as well as the depth of invasion, tumor budding, histological grade, and tumor-stromal ratio, among other things, were extracted from medical records. Results: We found that the potential lymph node metastasis rate was 27.5%. The significant clinical predictors of late cervical lymph node metastasis were the tumor thickness and endophytic growth pattern and the significant histopathological factors were poorly and moderately differentiated tumors and ≥3 tumor buds. In addition, the prognostic factors for distant metastasis included ≥4 lymph node metastases, ≥7 tumor budding, and moderate and poor tumor differentiation. Conclusions: The usefulness of tumor budding as a predictor of metastasis for tongue cancer was suggested. The findings of this study can help establish the criteria for evaluating the metastasis risk and prognosis of patients with tongue cancers.

Sentinel lymph node biopsy versus elective neck dissection in management of the clinically negative (cN0) neck in patients with oral squamous cell carcinoma: A systematic review and meta-analysis

Oral squamous cell carcinoma (OSCC) is the most prevalent type of head and neck cancer, and lymph node metastasis is a crucial prognostic factor that has a direct correlation with the survival rate. The standard procedure for managing clinically negative (cN0) neck in OSCC patients is elective neck dissection (END), but it can lead to various complications that affect the patient's quality of life. Therefore, medical professionals are exploring the use of the sentinel lymph node biopsy (SLNB) to manage cN0 neck in OSCC patients. The aim of this systematic review and meta-analysis was to compare the overall survival (OS) and disease-free survival (DFS) of patients undergoing SLNB and END in the surgical management of early cN0 neck in OSCC patients. To conduct this study, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to report the systematic reviews. The study included all comparative clinical studies, including randomized clinical trials (RCTs), clinical perspective studies, and retrospective studies that compared END to SLNB for early cN0 neck in OSCC patients. The hazard ratio (HR) and risk ratio (RR) with 95% confidence interval (CI) were calculated using comprehensive meta-analysis. The primary outcome variables were OS, DFS, and disease-specific survival (DSS). The secondary outcome variable was the nodal recurrence rate without local or distant metastasis. The GRADE system was used to assess the evidence's certainty. The meta-analysis included 12 clinical studies, comprising three RCTs and seven non-RCTs. The results showed no statistically significant difference between END and SLNB concerning OS (HR = 0.993, CI: 0.814 to 1.211, P = 0.947, low-quality evidence), DFS (HR = 0.705, CI: 0.408 to 1.29, P = 0.21, low-quality evidence), and nodal recurrence (RR = 1.028, CI: 0.969 to 1.090, P = 0.907, low-quality evidence). Additionally, SLNB was non-inferior to END regarding DSS (RR = 1.028, CI: 0.969 to 1.090, P = 0.907, low-quality evidence). In conclusion, this research affirms the safety and precision of SLNB as a means to stage cN0 OSCC patients, with outcomes that are comparable to END in terms of survival and nodal recurrence. Nevertheless, it's crucial to acknowledge that the quality of evidence in this study was relatively low. Therefore, additional RCTs comparing END to SLNB are warranted to validate these results and offer more robust guidance for managing cN0 OSCC patients.

Surgical Management of the Neck in Oral Cavity Squamous Cell Carcinoma

Oral cavity cancer remains a significant cause of morbidity and mortality globally, with a poor prognosis once the disease has metastasized to cervical lymph nodes. The anatomy of lymphatic drainage in the neck gives us a roadmap to follow when assessing for metastasis, although the predictive factors are still not well understood. The mainstay of treatment continues to be neck dissection. However, there is much debate on the management of the clinically negative neck. The necessity of elective neck dissection has been questioned in recent years, with other options such as sentinel lymph node biopsy gaining popularity. This review will explore the aspects of surgical management of the neck in oral cavity cancer and highlights the further research that needs to be done.

Effect of Prognostic Factors of Postoperative Radiotherapy in Oral Squamous Cell Carcinoma: A SEER-Based Study

Objective: The treatment of oral squamous cell carcinoma (OSCC) is dominated by surgery and radiochemotherapy, but its prognosis is still unsatisfactory, with around five tenths of 5-year survival. This study aimed to assess the prognosis of OSCC patients treated with surgery with and without postoperative radiotherapy. Study Design: Retrospective study. Methods: The clinicopathological information and follow-up datasets on patients with OSCC (T1-4 and/or N+) registered from 2010 to 2015 were downloaded from the Surveillance, Epidemiology, and End Results database. Totally 7231 enrolled subjects were divided into a case group (surgery alone, n = 4167) and a control group (surgery combined with postoperative radiotherapy, n = 3064). One-to-one matching was performed by propensity score matching to make the baseline data comparable between the 2 subgroups. Multivariate Cox regression analysis was used to calculate hazard ratios (HR) of various clinicopathological features. The Kaplan-Meier method and log-rank test were used to plot the survival curves. Results: The majority of patients in case group were tumor stage I (n = 2569, 61.7%), whereas most patients in control group were stages III to IV (n = 2360, 77.1%). In the case group, the 1-, 3-, and 5-year overall survival (OS; 76%, 59.5%, 53.7%) were significantly lower than those of the control group (85.1%, 64.1%, 55.8%; P < .0001). Similarly, the 1-, 3-, and 5-year cancer-specific survival (CSS) of the case group (80.2%, 66.6%, 63.3%) were significantly lower than those of the control group (87.2%, 69.3%, 63.9%, respectively; P < .0001). Cox multivariate analysis indicated that age, differentiation, clinical stage, and tumor-node-metastasis stage affected the prognosis of OSCC patients, while postoperative radiotherapy was a protective factor (OS: HR = 0.649, P < .001; CSS: HR = 0.702, P < .001). Conclusions: Postoperative radiation was an independent protective factor, hence, the combination of surgery plus radiotherapy is more beneficial for the survival of patients with OSCC, particularly for advanced cases.

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.

Oral squamous cell carcinoma - do we always need elective neck dissection? evaluation of clinicopathological factors of greatest prognostic significance: a cross-sectional observational study

The aim of the study was to find clinical and pathological factors with the greatest prognostic significance in patients with OSCC. The analysis included 125 patients grouped according to the tumor primary site (TPS): the floor of the mouth (FOM), tongue (TC) and retromolar triangle (RMT). Grading (G), tumor size (pT), nodal metastases (NM), local recurrence (LR), nodal recurrence (NR), perineural invasion (PNI), lymphovascular invasion (LVI), extranodal extension (pENE), and nodal yield (NY) were evaluated in each group.

Results

With regard to TPS, FOM appeared to be the most metastatic. However, the recurrence rate was similar to TC tumors, which were characterized by higher G than those in other locations. When analyzing G, the highest percentage of LR (40.5%) and NM (34.5%) was observed among patients with G2. As G increased, so did the number of pENE G1 - 7.4%; G2 - 31%; G3 - 35.7%; LVI: G1 - 25.9%; G2 - 50%; G3 - 57.1%; PNI: G1 - 29.6%; G2 - 47.6%; G3 - 92.9%; NR G1 - 14.8%; G2 - 32.1%; G3 - 21.4%. Grading did not affect the type of growth and did not directly affect the occurrence of NR. pT and DOI increased the frequency of NM but we did not observe any effect of pT and DOI on LR, PNI, and LVI. NY in the study group did not increase the risk of NR.

Conclusion

Tumor primary sites within the FOM, TC, and pT classification are the factors that increase the risk of NM and LR. However, apart from the primary site predisposing to the occurrence of NM, the histological structure of the tumor turned out to be the most important feature affecting the patient's prognosis. The number of cases of pENE+, LVI+, PNI+, NM+, and NR+ increased with the increase in G. Although the pT, DOI increased the frequency of NM, we did not observe the effect of the pT and DOI on LR, PNI and LVI. Thus, even in the case of a small tumor of the FOM and TC with at least G2, elective neck dissection should be performed each time.

Comparable Accuracy of Quantitative and Visual Analyses of [18F]FDG PET/CT for the Detection of Lymph Node Metastases from Head and Neck Squamous Cell Carcinoma

BACKGROUND

In head and neck squamous cell carcinoma (HNSCC), [18F]FDG PET/CT is recommended for detecting recurrent disease and in the initial staging for evaluating distant metastases, but its use in detecting cervical lymph metastases remains unclear. The aim of this study is to evaluate and compare the diagnostic accuracy of [8F]FDG-PET/CT using visual and semi-quantitative analyses for detecting the nodal involvement in HNSCC.

METHODS

We analyzed consecutive patients who underwent a preoperative [18F]FDG-PET/CT and neck dissection for HNSCC at our tertiary hospital. A blinded evaluation of the [18F]FDG uptake in each neck level was performed using a semi-quantitative approach (SUVmax and SUVR) and a visual grading system (uptake superior to the internal jugular vein for grade 1 and superior to the liver for grade 2). Analyses were compared to the histological results.

RESULTS

In our 211 patients, analyses demonstrated similar diagnostic accuracy using a semi-quantitative approach or a visual grading system. Regarding the visual grading system, [18F]FDG-PET/CT detected nodal metastases with a specificity of 83% for lymph nodes classified as grade 1 and 98% for those classified as grade 2. The sensitivity was moderate, ranging from 60 to 63%.

CONCLUSIONS

[18F]FDG PET/CT has a high specificity for detecting lymph node metastases in HNSCC and therefore must be considered in the nodal clinical staging.

Salivary microbiome profiles of oral cancer patients analyzed before and after treatment

BACKGROUND

Treating oral squamous cell carcinoma (OSCC) introduces new ecological environments in the oral cavity. This is expected to cause changes in the oral microbiome. The purpose of this study was to gain new information on the salivary microbiome of OSCC patients in order to improve the aftercare of OSCC patients. The aims of this study were to investigate possible changes in the salivary microbiome profiles of OSCC patients before and after cancer treatment and to compare these changes with the profiles of healthy controls.

PATIENTS AND METHODS

Paraffin-stimulated whole saliva samples were collected, and the salivary flow rate was measured from 99 OSCC patients prior to surgical resection of the tumor and other adjuvant therapy. After treatment, 28 OSCC patients were re-examined with a mean follow-up time of 48 months. In addition, 101 healthy controls were examined and sampled. After DNA extraction and purification, the V4 hypervariable region of the 16S rRNA gene was amplified and sequenced using Illumina MiSeq. The merged read pairs were denoised using UNOISE3, mapped to zero-radius operational taxonomic units (zOTUs), and the representative zOTU sequences were assigned a taxonomy using HOMD. Descriptive statistics were used to study the differences in the microbial profiles of OSCC patients before and after treatment and in comparison to healthy controls.

RESULTS

At baseline, the OSCC patients showed a higher relative abundance of zOTUs classified as Streptococcus anginosus, Abiotrophia defectiva, and Fusobacterium nucleatum. The microbial profiles differed significantly between OSCC patients and healthy controls (F = 5.9, p < 0.001). Alpha diversity of the salivary microbiome of OSCC patients was decreased at the follow-up, and the microbial profiles differed significantly from the pre-treatment (p < 0.001) and from that of healthy controls (p < 0.001).

CONCLUSIONS

OSCC patients' salivary microbiome profile had a higher abundance of potentially pathogenic bacteria compared to healthy controls. Treatment of the OSCC caused a significant decrease in alpha diversity and increase in variability of the salivary microbiome, which was still evident after several years of follow-up. OSCC patients may benefit from preventive measures, such as the use of pre- or probiotics, salivary substitutes, or dietary counseling. Video Abstract.

Radiomics-Based Analysis in the Prediction of Occult Lymph Node Metastases in Patients with Oral Cancer: A Systematic Review

BACKGROUND

Tumor extension and metastatic cervical lymph nodes' (LNs) number and dimensions are major prognostic factors in patients with oral squamous cell carcinoma (OSCC). Radiomics-based models are being integrated into clinical practice in the prediction of LN status prior to surgery in order to optimize the treatment, yet their value is still debated.

METHODS

A systematic review of the literature was conducted according to the PRISMA guideline. Baseline study characteristics, and methodological items were extracted and summarized.

RESULTS

A total of 10 retrospective studies were included into the present study, each of them exploiting a single imaging modality. Data from a cohort of 1489 patients were analyzed: the highest AUC value was 99.5%, ACC ranges from 68% to 97.5%, and sensibility and specificity were over 0.65 and 0.70, respectively.

CONCLUSION

Radiomics may be a noninvasive tool to predict occult LN metastases (LNM) in OSCC patients prior to treatment; further prospective studies are warranted to create a reproducible and reliable method for the detection of LNM in OSCC.

DJ-1 Oncogene as a Potential Diagnostic and Prognostic Biomarker for Head and Neck Cancer

Background Current methods used to diagnose and prognosticate oropharyngeal cancer have contributed to unfavorable patient survival rates that have not significantly improved for the last several decades. Precision medicine oncology relies on molecular diagnostics and biomarkers to supplement existing methods of detecting and prognosticating cancers. This study evaluated the expression of DJ-1, an oncogene that is implicated in the pathogenesis of oral squamous cell carcinoma (OSCC), the most common type of head and neck cancer, to determine its utility as a diagnostic and prognostic biomarker. Methodology Immunohistochemistry (IHC) was performed on 13 normal oral mucosa tissue samples and 143 OSCC tissue samples of varying histopathological grades. Computer-assisted image analysis was performed using the Aperio ImageScope software from Leica Biosystems (Buffalo Grove, IL), which utilizes an algorithm of positive pixel counting for the quantification of immunoreactivity and the percentage of positive cell staining, generating a histo-score (H-score). The comparisons of the average H-scores of the different groups were made using a two-tailed T-test with P ≤ 0.05 set as the level of significance. Results The study found a significant increase in DJ-1 expression in oral squamous cell carcinoma tissue samples in comparison to the normal oral mucosa tissue samples. Additionally, the study documented a significant upregulation in DJ-1 expression in the OSCC tissue samples with high histopathological grades compared to the OSCC tissue samples with low histopathological grades. Conclusions DJ-1 expression patterns were able to reliably differentiate between oral squamous cell carcinoma and the normal counterpart tissues of the oral mucosa, thereby highlighting its role as a potential diagnostic biomarker. Moreover, DJ-1 expression significantly correlates with the OSCC histological grade, which serves as an indicator of the differentiation status and a predictor of the biological behavior of malignant neoplasms, adding to DJ-1's potential utility as a prognostic biomarker for this common type of head and neck cancer.

Evaluation of sarcopenia and sarcopenic obesity in patients affected by oral squamous cell carcinoma: A retrospective single-center study

This retrospective single-center study aimed to evaluate the relevance of sarcopenia and sarcopenic obesity as negative prognostic factors in patients with oral squamous cell carcinoma (OSCC). The study was performed on patients who underwent oral squamous cell carcinoma resection surgery. Patients' demographic and clinical variables were collected at diagnosis (sex, age, height, weight, comorbidities, smoke and alcohol consumption, HPV positivity, TNM-stage) and corrected for known prognostic factors (age, body mass index, TNM-stage). The Skeletal Muscle Mass (SMM) and the Cross-Sectional Area (CSA) on pre-treatment CT scans and Body Mass Index (BMI) were measured to assess sarcopenia and sarcopenic obesity correlated to overall survival (OS). Chi-square statistics were used to analyze the differences between the frequencies of each categorical variable with the presence or absence of sarcopenia and sarcopenic obesity. The cumulative overall survival was calculated by the Kaplan-Meier method, and the differences between curves were evaluated by the log-rank test. A Cox proportional hazard regression model was used for univariate and multivariate analysis of the overall survival. Within the limitations of the study, in this sample, sarcopenia did not seem to cause a statistically significant reduction in the overall survival in patients with oral squamous cell carcinoma (Log Rank χ2 = 3.67, p = 0.055; HR 0.996, 95% CI 0.732-1.354, p = 0.979), however, sarcopenic obesity showed a meaningful negative prognostic impact on it (Log Rank χ2 = 5.71, p = 0.017; HR 0.985, 95% CI 0.424-2.286, p = 0.972). Within the limitations of the study it seems that sarcopenic obesity, age, BMI, and TNM-stage are more relevant negative prognostic factors, influencing overall survival in surgically treated OSCC, than sarcopenia.

Characterization of DJ-1, PTEN, and p-Akt as Prognostic Biomarkers in the Progression of Oral Squamous Cell Carcinoma

Objective Oral cancer has a five-year survival rate of 68%, and the methods used to assess it still rely heavily on morphology. Protein biomarkers can potentially increase the predictive power of histopathological evaluation. This study aims to examine the expression of three closely linked proteins implicated in the pathogenesis of oral squamous cell carcinoma (OSCC); protein deglycase (DJ-1), an oncogene, phosphatase, and tensin homolog (PTEN), a tumor suppressor gene, and phosphorylated protein kinase B (p-Akt), the activated form of a vital serine/threonine kinase, which is involved in the oncogenesis of several human malignancies, throughout the tumor progression steps to establish their potential as prognostic biomarkers. Study design Western blot analysis was carried out using four different cell lines representing the successive steps of OSCC progression, including normal oral keratinocytes, dysplastic oral keratinocytes, locally invasive OSCC, and metastatic OSCC.  Results DJ-1 expression was found to be upregulated gradually throughout the successive steps of OSCC progression from normal to dysplastic to locally invasive to metastatic OSCC. PTEN expression showed an overall opposite trend. Interestingly, a significant downregulation of p-Akt was seen in the locally invasive OSCC cells, although it was followed by a significant increase in p-Akt expression in the metastatic OSCC cell line, which is consistent with the role of p-Akt in the motility and migration of cancer cells. Conclusion This study documented trends in expression patterns of three important signaling molecules, DJ-1, PTEN, and p-Akt, in normal, premalignant, and malignant oral keratinocytes. The oncogenic DJ-1 and tumor suppressor PTEN were expressed in a manner consistent with their respective roles in tumorigenesis, while p-Akt only showed a significant upregulation in the metastatic OSCC cells. Overall, all three proteins exhibited unique trends throughout the progressive stages of OSCC tumor progression, thereby adding to their potential utility as prognostic biomarkers for oral cancer patients.

Influence of Site, Size, Depth of Invasion and Histologic Grading on the Occurrence of Cervical Level IIb Metastasis and Extranodal Extension in Clinically N0 Neck of Patients with OSCC: A Single Center Retrospective Analysis

Background

Depth of Invasion ≥ 4 mm, T stage and primary site with more than 20% chances for occult metastasis are currently the accepted indications for elective neck dissection. Nodal metastasis decreases survival by 50%. ENE further reduces the prognosis. Dissection of level IIb lymph nodes in clinically N0 neck does not improve survival.

Methods

A total of 320 patients were evaluated. Binary and multiple logistic regression and chi-square test were used for data analysis. ROC curve with Youden's J index was used to set up a cutoff value for DOI. The predictor variables were site, size, grading and depth of invasion of primary tumor. Incidence of level IIb metastasis and ENE were the outcomes.

Results

The study revealed a significant association and risk stratification between primary tumor characteristics with the occurrence of ENE. The cutoff value for DOI predicting ENE was 12.5 mm. Tumors of the oral tongue were an independent risk factor for level IIb metastasis.

Discussion

Size of primary tumor, DOI, tumors of the mandibular alveolus and poor grading are independent risk factors for ENE. Isolated metastasis to level IIb rarely occurs in the absence of concomitant level IIa metastasis. Size, DOI and grading were significantly associated with level IIb metastasis. However, only tumors of the oral tongue were independent risk factor.

Nodal Disease and Survival in Oral Cancer: Is Occult Metastasis a Burden Factor Compared to Preoperatively Nodal Positive Neck?

The impact of neck involvement and occult metastasis (OM) in patients with oral squamous cell carcinoma (OSCC) favors an elective neck dissection. However, there are barely any existing data on survival for patients with OM compared with patients with positive lymph nodes detected preoperatively. This study aims to compare survival curves of patients suffering from lymph nodal metastases in a preoperatively N+ neck with those suffering from OM. In addition, clinical characteristics of the primary tumor were analyzed to predict occult nodal disease. This retrospective cohort study includes patients with an OSCC treated surgically with R0 resection with or without adjuvant chemoradiotherapy between 2010 and 2016. Minimum follow-up was 60 months. Kaplan–Meier analysis was used to compare the survival between patients with and without occult metastases and patients with N+ neck to those with occult metastases. Logistic regression was used to detect potential risk factors for occult metastases. The patient cohort consisted of 226 patients. Occult metastases occurred in 16 of 226 patients. In 53 of 226 patients, neck lymph nodes were described as suspect on CT imaging but had a pN0 neck. Higher tumor grading increased the chance of occurrence of occult metastasis 2.7-fold (OR = 2.68, 95% CI: 1.07–6.7). After 12, 24, 48 and 60 months, 82.3%, 73.8%, 69% and 67% of the N0 patients, respectively, were progression free. In the group with OM occurrence, for the same periods 66.6%, 50%, 33.3% and 33.3% of the patients, respectively, were free of disease. For the same periods, respectively, 81%, 63%, 47% and 43% of the patients in the N+ group but without OM remained disease free. The predictors for progression-free survival were a positive N status (HR = 1.44, 95% CI: 1.08–1.93) and the occurrence of OM (HR = 2.33, 95% CI: 1.17–4.64). The presence of occult metastasis could lead to decreased survival and could be a burdening factor requiring treatment escalation and a more aggressive follow-up than nodal disease detected in the preoperative diagnostic imaging.

Efficacy of different sentinel lymph node biopsy protocols in oral squamous cell carcinoma: Systematic review and meta-analysis

The sentinel node biopsy (SNB) is highly protocolized in other cancers, however, this is not the case for oral squamous cell carcinoma patients, hence our objective was to evaluate the different protocols published. A specific study protocol was designed and subsequently registered on PROSPERO (Ref. CRD42021279217). Twenty‐three articles were included in the meta‐analysis. The grouped sensitivity of the SNB was 82% (95% CI: 0.74–0.88), and the grouped specificity was 100% (95% CI: 0.99–1.00). The use of other radiotracers other than pre‐operative lopamidol showed higher values of sensitivity of 82.80% (95% CI: 76.90%–87.50%; p < 0.001). The use of the blue dye stain showed higher sensitivity values of 85.60% (95% CI: 71.90%–93.20%), compared to sensitivity values of 77.50% when it was not used (95% CI: 69.10%–84.20%) (p < 0.001). Diagnostic rates are variable and they were significantly better when 99mTc was used in all its variations and accompanied by the blue dye staining.

A validated predictive model for risk of nodal metastasis in node negative oral squamous cell carcinoma of the buccal mucosa and tongue

BACKGROUND

Lymph node metastasis in oral squamous cell carcinoma (OSCC) is influenced by clinical and histopathological variables. The aim of this study was to develop a simple model to predict nodal metastasis of OSCC in clinically negative necks (cN0).

METHODS

Data from patients who underwent surgery for treatment of OSCC of the tongue or buccal mucosa with neck dissection were used for model development and validation.

RESULTS

Nodal metastasis was significantly associated with gender, age, tumor size, site, pattern of invasion and depth of invasion on univariate analysis. All the five variables except age were retained at the variable selection step of the model development and were used in the final model because it was not significant at 0.10 significance level after adjusting for other variables. Regression coefficients of the model were used to estimate risks of nodal metastases for each combination of clinicopathological characteristics. A 10-fold cross-validation was used to assess the model. The average of the resultant 10 AUCs (along with its 95% confidence interval estimated using bootstrap) was used as the overall validated measure of the model. A risk chart was produced using probability of nodal metastasis predicted by the model for each combination of five characteristics. The model's ability to identify patients with nodal metastases as assessed by the area under the ROC curve (AUC) was 0.752.

CONCLUSION

The model based on established clinicopathological variables has been internally validated on a large cohort of patients and offers practicability for use in OSCCs of the tongue and buccal mucosa.

Neck Management in cT1N0 Tongue Squamous Cell Carcinoma as Determined by Sonographic Depth of Invasion

Objectives

To compare the oncologic outcomes in patients with cT1N0 tongue squamous cell carcinoma (SCC) who underwent different neck management strategies stratified by sonographic depth of invasion (DOI).

Methods

The included patients were retrospectively enrolled, and divided into two groups: observation (OBS) and elective neck dissection (END). The regional control (RC) and disease-specific survival (DSS) rates were compared and stratified by sonographic DOI.

Results

The mean sonographic and pathologic DOIs were 3.8 and 3.7 mm, respectively; the two DOIs were significantly correlated (Spearman correlation coefficient 0.974. p <0.001). In patients with sonographic DOI <4.0 mm, the 5-year RC rates were 73 and 89% in the OBS and END groups, respectively, and were not significantly different. However, in patients with sonographic DOI ≥4.0 mm, the 5-year RC rate was significantly different between the OBS (57%) and END (80%) groups (p = 0.031). In patients with sonographic DOI <4.0 mm, the 5-year DSS rates were 79 and 89% in OBS and END groups, respectively, and were not significantly different. However, in patients with sonographic DOI ≥4.0 mm, the 5-year DSS rate was significantly different between the OBS (67%) and END (86%) groups (p = 0.033).

Conclusions

Sonographic DOI was notably correlated with pathologic DOI. Moreover, there was a significant survival difference between the OBS and END groups in cT1N0 tongue SCC patients with sonographic DOI ≥4.0 mm but not in those with sonographic DOI <4.0 mm. Our study provides a useful method to aid decision-making in the clinical setting for this patient group.

Systematic review and meta-analysis of randomized controlled trials comparing elective neck dissection versus sentinel lymph node biopsy in early-stage clinically node-negative oral and/or oropharyngeal squamous cell carcinoma: Evidence-base for practice and implications for research

PURPOSE

Management of clinically node-negative (N0) neck in early-stage (T1-T2) oral and/or oropharyngeal squamous cell carcinoma (OOSCC) has been controversial. The purpose of this systematic review and meta-analysis was to compare sentinel lymph node biopsy (SLNB) with elective neck dissection (END) in early-stage OOSCC.

METHODS

Studies comparing SLNB versus END in early-stage clinically node-negative OOSCC were identified using validated search strategy. To be considered eligible, trials had to include patients with early-stage, clinically node-negative OOSCC who had been randomly assigned to either SLNB or END. Primary outcome of interest was overall survival (OS), while secondary outcomes included isolated neck nodal recurrence (NNR), loco-regional recurrence (LRR), and neck-shoulder function. Outcome data was pooled using random-effects model and reported as hazard ratio (HR) or risk ratio (RR) with 95% confidence interval (CI). Any p-value < 0.05 was considered statistically significant.

RESULTS

A total of 608 patients from three trials comparing SLNB versus END in early-stage clinically node-negative OOSCC were included. The pooled HR of death for SLNB versus END was 1.18 (95% CI: 0.79-1.78, p = 0.41) which was not statistically significant. The rates of isolated NNR (pooled RR = 1.11, 95% CI: 0.69-1.80, p = 0.66) and LRR (pooled RR = 1.18, 95% CI: 0.81-1.72, p = 0.39) were also similar. Pooled analysis of the neck-shoulder function significantly favoured SLNB arm (pooled RR = 1.21, 95% CI: 1.12-1.32, p < 0.00001).

CONCLUSION

There is low-certainty evidence that SLNB is oncologically non-inferior to END and is associated with potentially lesser functional morbidity making it an emerging alternative standard of care in patients with early-stage clinically node-negative OOSCC.

Development and Validation of Prognostic Models for Oral Squamous Cell Carcinoma: A Systematic Review and Appraisal of the Literature

(1) Background: An accurate prediction of cancer survival is very important for counseling, treatment planning, follow-up, and postoperative risk assessment in patients with Oral Squamous Cell Carcinoma (OSCC). There has been an increased interest in the development of clinical prognostic models and nomograms which are their graphic representation. The study aimed to revise the prognostic performance of clinical-pathological prognostic models with internal validation for OSCC. (2) Methods: This systematic review was performed according to the Cochrane Handbook for Diagnostic Test Accuracy Reviews chapter on searching, the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, and the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS). (3) Results: Six studies evaluating overall survival in patients with OSCC were identified. All studies performed internal validation, while only four models were externally validated. (4) Conclusions: Based on the results of this systematic review, it is possible to state that it is necessary to carry out internal validation and shrinkage to correct overfitting and provide an adequate performance for optimism. Moreover, calibration, discrimination and nonlinearity of continuous predictors should always be examined. To reduce the risk of bias the study design used should be prospective and imputation techniques should always be applied to handle missing data. In addition, the complete equation of the prognostic model must be reported to allow updating, external validation in a new context and the subsequent evaluation of the impact on health outcomes and on the cost-effectiveness of care.

Effect of elective neck dissection versus sentinel lymph node biopsy on shoulder morbidity and health-related quality of life in patients with oral cavity cancer: A longitudinal comparative cohort study

OBJECTIVE

To research the difference in shoulder morbidity and health-related quality of life between patients with cT_1-2N0 oral cavity squamous cell carcinoma that undergo either elective neck dissection (END) or a sentinel lymph node biopsy (SLNB) based approach of the neck.

MATERIALS AND METHODS

A longitudinal study with measurements before surgery, 6 weeks, 6 months, and 12 months after surgery. Shoulder morbidity were determined with measurements of active range of motion of the shoulder and patient-reported outcomes for shoulder morbidity (SDQ, SPADI) and health-related quality of life (HR-QoL) (EQ5D, EORTC-QLQ-HN35). Linear mixed model analyses were used to analyze differences over time between patients that had END, SLNB or SLNB followed by complementing neck dissection.

RESULTS

We included 69 patients. Thirty-three patients were treated with END. Twenty-seven patients had SLNB without complementing neck dissection (SLNB), and nine were diagnosed lymph node positive followed by completion neck dissection (SLNB + ND). Ipsilateral shoulder abduction (P = .031) and forward flexion (P = .039) were significantly better for the SLNB group at 6 weeks post-intervention compared to the END and SLNB + ND group. No significant differences for shoulder morbidity, or health-related quality of life were found at 6 weeks, 6 months, and 12 months between the three groups.

CONCLUSION

With oncologic equivalence for the END and SLNB as strategies for the cN₀ neck already demonstrated, and the SLNB being more cost-effective, our demonstrated benefit in short-term shoulder function strengthens the choice for the SLNB as a preferred treatment strategy.

Pretreatment Blood Markers in the Prediction of Occult Neck Metastasis: A 10-Year Retrospective Study

Introduction

The purpose of this study was to clarify the role of inflammatory blood markers in the management of early-stage (T1-T2) oral squamous cell carcinoma (OSCC) of the tongue in patients with a clinically negative neck. 

Materials and methods

We undertook a retrospective chart review of 102 patients with early-stage OSCC of the tongue, subjected to tumor resection and elective neck dissection. Based on postsurgical histopathological examination results, we divided our cohort into pN+ and pN0 groups. Afterwards, we analyzed the role of pretreatment inflammatory blood markers in predicting occult neck metastasis. We also evaluated neutrophil-lymphocyte ratio (NLR) association with the depth of invasion (DOI) of the primary tumor.

Results

We found a significant association of NLR (p=0.001) and monocyte-lymphocyte ratio (p=0.011) with neck status on univariate analysis. Multivariate analysis showed that only NLR (p=0.02) was an independent risk factor for occult metastasis among inflammatory blood markers. Receiver Operating Characteristic curve analysis and Younden’s Index determined the NLR value of 2.96 as the most adequate cut-off value for neck status prediction. NLR values of pretreatment workup also had a significant association with the DOI of the primary tumor (p=0.018).

Conclusion

Our study supports the role of pretreatment NLR in predicting occult neck metastasis in early-stage OSCC of the tongue. It also sheds some light over the potential of NLR as a predictor of the primary tumor’s DOI.

Sentinel lymph node biopsy versus elective neck dissection in squamous cell carcinoma of the oral cavity with a clinically N0 neck: Systematic review and meta-analysis of prospective studies

Sentinel lymph node biopsy (SLNB) is an emerging strategy for managing early-stage oral squamous cell carcinoma (SCC) with a clinically N0 (cN0) neck. However, the role of SLNB in this scenario is debatable. Herein, relevant literature was systematically reviewed, and a meta-analysis was performed to evaluate the potential dividends of SLNB compared to elective neck dissection (END) for these patients. The meta-analysis, including six prospective studies, showed comparable results of the two management strategies in terms of regional recurrence (risk ratio [RR] = 0.99; 95% confidence interval [CI], 0.58-1.70), 5-year disease-free survival (RR = 0.99; 95% CI, 0.87-1.11), and 5-year overall survival (RR = 1.01; 95% CI, 0.90-1.13). Fewer adverse events occurred in the SLNB arm than in the END arm (RR = 0.12; 95% CI, 0.02-0.70). Overall, SLNB results in as favorable an oncologic prognosis for patients with cN0 oral SCC as END, while significantly lessening side effects and unnecessary surgeries.

Sentinel Lymph Node Biopsy in Early Stages of Oral Squamous Cell Carcinoma Using the Receptor-Targeted Radiotracer 99mTc-Tilmanocept

Neck management in patients with early-stage, clinically node-negative oral squamous cell carcinoma (OSCC) remains a matter of discussion. Sentinel lymph node biopsy (SLNB) represents a treatment alternative to avoid elective neck dissection (END) in this cohort and different protocols and tracers exist. Here we present the clinical outcome of SLNB using ^99mTc-tilmanocept in a two-day protocol in patients suffering from early-stage OSCC. A total of 13 patients (males: 6; females: 7; mean age: 65.7 years, ranging from 47 to 89 years) were included in this study. Most of the patients suffered from an OSCC of the floor of mouth (n = 6), followed by tongue (n = 5) and upper alveolar crest/hard palate (n = 2). Sentinel lymph nodes (SLNs) were successfully identified in all cases (range: 1–7). The average length of hospital stay was 4.7 days (range: 3–8 days) and mean duration of surgical intervention was 121 min (range: 74–233 min). One patient who suffered from an OSCC of the tongue was sentinel lymph node positive (SLN+). The mean follow-up for all sentinel lymph node negative (SLN-) patients (n = 12) was 20.3 months (range: 10–28 months). No local or nodal recurrences were observed within the observation period. In our patient cohort, SLNB using ^99mTc-tilmanocept in a two-day protocol proved to be a reliable and safe staging method for patients suffering from early-stage, clinically node-negative OSCC. These results and their possible superiority to colloid tracers have to be confirmed in a prospective randomized controlled study.

Diagnostic accuracy of magnetic resonance imaging in detecting depth of invasion of tongue cancers

The recent eighth edition of the American Joint Committee on Cancer (AJCC) staging system has introduced depth of invasion (DOI) as one of its important components. DOI is also important for deciding neck management in superficial tongue cancers. Magnetic resonance imaging (MRI) is mainly used to assess DOI, and in this study we have evaluated the efficacy of MRI to detect it. This is a retrospective study consisting of 60 treatment-naïve tongue cancer patients operated on between July 2017 and June 2019. Patients underwent MR imaging on an Optima MR450W 1.5T unit, and MRI was reported by two experienced ead and eck adiologistss. Postoperative histological DOI was considered the gold standard. The correlation coefficient was derived for postoperative DOI and MRI-detected DOI. A subgroup analysis of superficial tongue cancer was also done. The mean MRI DOI was 13.7 mm and the mean histological DOI 12.45 mm. The shrinkage factor was 0.6 mm. Pearson's correlation coefficient was 0.80 (p=<0.001) for Radiologist 1 and 0.85 (p=<0.001) for Radiologist 2. The interobserver variation was low, with a correlation coefficient between the two radiologists of 0.965 (p=<0.001). For superficial tongue cancers there was moderate correlation for MRI and histologically-detected DOI with a kappa value of 0.681 (p=0.03). As per the ROC curve, the cut-off value for MRI DOI to predict nodal metastasis was 4.6 mm. MRI has high reliability to predict the DOI of tongue cancers. The interobserver variation was low. The diagnostic accuracy in cases of superficial tongue cancer was moderate.

To map or not to map the cN0 neck: Impact of sentinel lymph node biopsy in canine head and neck tumours

Tumour stage is a prognostic indicator for canine malignant head and neck tumours (MHNT). However, consensus is lacking on nodal staging in the absence of clinically apparent nodal disease (cN0 neck). This prospective observational study aims to determine the diagnostic accuracy of radiopharmaceutical and blue dye for sentinel lymph node biopsy (SLNB), to assess the correspondence between sentinel lymph node (SLN) and clinically expected regional lymph node (RLN) and the impact on staging of the procedure in dogs with MHNT and cN0 neck. Twenty-three dogs with MHNT and cN0 neck underwent tumour excision and SLNB guided by preoperative lymphoscintigraphy and intraoperative gamma-probe and blue dye. Diagnostic performances and detection rate were calculated. Correspondence between SLN and RLN, number of nodes excised, histopathological status of the SLN and complications related to the procedure were recorded. The mapping technique identified at least one SLN in 19/23 dogs, with a detection rate of 83%. The SLN did not correspond to the RLN in 52% of dogs. Multiple nodes were removed in 61% of dogs. At histopathology, eight (42%) dogs had SLN+, of which four differed from the RLN. Only minor self-limiting complications occurred in five (22%) dogs. Radiopharmaceutical and blue dye guidance is accurate (sensitivity 88.9%; specificity 100%) for SLNB in dogs with MHNT and cN0 and allowed the extirpation of unpredictable and/or multiple SLN with minimal morbidity. Incorporation of SLNB in the management of MHNT is desirable to correctly stage the cN0 neck, owing the unpredictability of the lymphatic drainage.

CCR7-CCL21 axis promotes the cervical lymph node metastasis of tongue squamous cell carcinoma by up-regulating MUC1

This study aims at investigating the potential role of MUC1 in CCR7-CCL21 axis-induced metastasis of tongue squamous cell carcinoma (TSCC). TSCC patients were selected for epidemiologic trends. The expression of CCR7 and MUC1 was detected via immunohistochemistry. SCC15 and CAL27 cells were induced by CCL21 and specific antibody to CCR7. Gene and protein expression was detected using qRT-PCR and western blotting. Migration and invasion capacities of TSCC cells were determined using wound healing and Transwell invasion assays. The male:female ratio of 78 patients was 1.6:1. Metastasis rate of cervical lymph nodes (CLNs) was 42.3%. CLN metastasis significantly correlated with T staging (P = 0.026), clinical staging (P = 0.024), and depth of invasion (DOI, P = 0.001). DOI significantly influenced CLN metastasis (P = 0.033, OR = 10.919) of TSCC, as did CCR7 (P = 0.041) and MUC1 (P = 0.026). The consistency of CCR7 and MUC1 expression was fairly good (Kappa = 0.683, P < 0.001). Reduced survival was significantly associated with higher expression of CCR7 (P = 0.039) and MUC1 (P = 0.030). CCL21 up-regulated MUC1 in SCC15 cells, which was inhibited when CCR7 was blocked. MUC1 positively correlated with TSCC cell migration and invasion. CCR7-CCL21 axis might promote CLN metastasis of TSCC by up-regulating MUC1. CCR7 and MUC1 show promise as potential biomarkers for TSCC treatment.

Contribution of Genomics to the Surgical Management and Study of Oral Cancer

Background

Oral squamous cell carcinoma (OSCC) is the most frequent type of tumor arising from the oral cavity. Surgery is the cornerstone of the treatment of these cancers. Tumor biology has long been overlooked as an important contributor to the outcome of surgical procedures, but recent studies are challenging this concept. Molecular analyses of tumor DNA or RNA provide a rich source of information about the biology of OSCC.

Methods

We searched for relevant articles using PubMed. We examined in particular the prospect of applying molecular methods for minimally invasive exploration of OSCC biology.

Results

We examined five potential applications of genomics to the surgical management and study of OSCC: i) assessing oral potentially malignant lesions; ii) tumor staging prior to surgery; iii) predicting postoperative risk in locally advanced tumors; iv) measuring minimal residual disease and optimizing the longitudinal monitoring of OSCC; and v) predicting the efficacy of medical treatment.

Conclusions

Genomic information can be harnessed in order to identify new biomarkers that could improve the staging, choice of therapy and management of OSCC. The identification of new biomarkers is awaited for better personalization of the surgical treatment of OSCC.

How is neck dissection performed in Oral and Maxillofacial Surgery? Results of a representative nationwide survey among university and non-university hospitals in Germany

Introduction

Neck dissection (ND) is a surgical procedure addressing cervical lymph nodes and metastases in patients with oral squamous cell carcinoma (OSCC). The aim of this study was to analyze clinical decisions regarding indications and variations of ND in Oral and Maxillofacial Surgery (OMFS) in Germany.

Material and methods

A nationwide survey of the German Association of Oral and Maxillofacial Surgery was performed using dynamic online questionnaires including 38 questions. Data about oncological centers, case numbers, and staging procedures were collected. Relevant aspects, such as inclusion of level IIb and levels IV and V to ND, uni- vs. bilateral ND, and the influence of extra-nodal extension (ENE) of metastases on extension of ND were evaluated.

Results

Eighty-four OMFS of university and non-university hospitals participated in the study (responding rate 21.4%). Sixty-six (78.57%) stated to work at certified cancer centers and 53.57% of the hospitals treated between 50 and 100 OSCC cases per year. CT and/or MRI of the head and neck was performed in most of the staging procedures. Level IIb was included by 71 (93.42%) of the participants in selective ND. Levels IV and V were included by 53 (69.74%) in node-positive neck. In solitary ipsilateral metastases (ENE−), 49 participants (62.82%) stated to perform exclusively an ipsilateral ND and 40 (51.95%) stated to perform only an ipsilateral ND in ENE+.

Conclusion

This study demonstrated a high rate of certified cancer centers in Germany showing differences regarding staging procedures, indications, and extension of ND, especially in increasingly complex cases.

Clinical relevance

Clinical decisions regarding ND are dependent on case-individual aspects and must be decided individually.

Pentapartite fractionation of particles in oral fluids by differential centrifugation

Oral fluids (OFs) contain small extracellular vesicles (sEVs or exosomes) that carry disease-associated diagnostic molecules. However, cells generate extracellular vesicles (EVs) other than sEVs, so the EV population is quite heterogeneous. Furthermore, molecules not packaged in EVs can also serve as diagnostic markers. For these reasons, developing a complete picture of particulate matter in the oral cavity is important before focusing on specific subtypes of EVs. Here, we used differential centrifugation to fractionate human OFs from healthy volunteers and patients with oral squamous cell carcinoma into 5 fractions, and we characterized the particles, nucleic acids, and proteins in each fraction. Canonical exosome markers, including CD63, CD9, CD133, and HSP70, were found in all fractions, whereas CD81 and AQP5 were enriched in the 160K fraction, with non-negligible amounts in the 2K fraction. The 2K fraction also contained its characteristic markers that included short derivatives of EGFR and E-cadherin, as well as an autophagosome marker, LC3, and large multi-layered vesicles were observed by electronic microscopy. Most of the DNA and RNA was recovered from the 0.3K and 2K fractions, with some in the 160K fraction. These results can provide guideline information for development of purpose-designed OF-based diagnostic systems.