Are Oral Pain and Otalgia Predictive of Perineural Invasion in Squamous Cell Carcinoma of the Oral Tongue?

The Number of Positive Lymph Nodes Instead of Extranodal Extension and Nodal Diameter is an Independent Predictor of Survival and Treatment Outcome of High-Grade Parotid Gland Carcinoma

BACKGROUND

There is emerging evidence that current 8th edition of the American Joint Committee staging system is not sensitive enough to predict parotid gland carcinoma (PGC) survival outcomes.

PURPOSE

The present study aimed to analyze pathological nodal factors related to survival and treatment outcomes in a cohort of patients surgically treated with PGC.

STUDY DESIGN, SETTING, SAMPLE

We performed a retrospective cohort study of consecutive patients surgically treated with PGC at the authors' institution from January 1993 to December 2018. The inclusion criteria were as follows: confirmed high-grade parotid gland malignancy on histopathology first surgical treatment of the parotid cancer with neck dissection with curative intent at the study clinic; and sufficient data for review. The exclusion criteria were previous treatment in another institution, low-grade carcinomas, cases where neck dissection was not performed, incurable local disease and distant metastases at the time of first diagnosis, and patients lost to follow-up.

PREDICTOR VARIABLE

Predictor variable comprised pathological nodal factors grouped as the number of cervical node metastases, extranodal extension (ENE), largest diameter of nodal metastasis, and involvement of parotid lymph nodes.

MAIN OUTCOME VARIABLES

Outcomes evaluated were overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), locoregional recurrence-free survival, and distant metastasis-free survival (DMFS). OS was calculated from the day of biopsy or definitive surgery to the last known hospital follow-up date or the date of death found in the hospital records or social security data. DSS was calculated from the day of biopsy or definitive surgery until the last known follow-up or death from PGC reported in the patient record. Patients who died from causes other than the disease being studied are not counted in this measurement. Treatment outcome was evaluated through the occurrence of locoregional relapse of the disease or development of distant metastases. RFS was defined as the time from the date of biopsy or definitive surgery to the date of locoregional recurrence free survivalor DMFS reported in the patient record.

COVARIATES

Covariates were composed of a set of heterogeneous variables grouped into the following categories: demographic, pathologic, and clinical.

ANALYSES

Unadjusted and adjusted hazard ratios for each variable were calculated with univariate and multivariable Cox regression. The tatistical significance was defined at a P value of < .05.

RESULTS

The cohort of 112 patients included 62 males (55%) and 50 (45%) females. The mean age of the patients was 60.52 ± 15.22 years. The median follow-up time was 59 months (3-221 months). Adenoid cystic carcinoma was the most common tumor type with the incidence of 45%. Cumulative OS for the 5-and 10-year follow-up period was 75 and 61%, respectively. Locoregional recurrences occurred with 27 patients (24%), distant metastases occurred with 25 patients (22%), and both were diagnosed with 5 patients (6%). The number of metastatic nodes was the most important nodal prognostic factor related to OS (P = .02; HR = 2.67; CI = 0.03-6.35), DSS (P = .011; HR = 2.55; CI = .61-6.83), and DMFS (P = .005; HR = 2.85; CI = 0.12-4.76). The presence of pathological parotid nodes was associated with poorer RFS (P = .015; HR = 3.45; CI = 0.25-6.02).

CONCLUSION AND RELEVANCE

The number of metastatic lymph nodes, instead of ENE and largest nodal diameter, was the contributing factor associated with survival and treatment outcomes of surgically treated patients with high-grade PGC. Since the main function of staging system is to predict outcomes, the significance of ENE and nodal dimension in salivary gland cancer staging system requires further clarification. An important finding in the present study was that the presence of positive parotid lymph nodes was associated to locoregional treatment failure.

Perineural Invasion Is Associated With Function-evoked Pain and Altered Extracellular Matrix in Patients With Head and Neck Squamous Cell Carcinoma

Head and neck squamous cell carcinoma (HNSCC) is painful, and perineural invasion (PNI) has been associated with the worst pain. Pain due to HNSCC is diverse and may vary based on clinicopathological factors. This study aims to characterize different pain patterns linked with PNI, its influence on daily functioning, and gain insights into molecular changes and pathways associated with PNI-related pain in HNSCC patients. We conducted a cross-sectional study across 3 medical centers (n = 114), assessing pain phenotypes and their impact on daily functioning using 2 self-reported pain questionnaires, given to patients prior to their cancer surgery. Furthermore, we conducted RNA-seq analysis utilizing the The Cancer Genome Atlas dataset of HNSCC tumor from patients (n = 192) to identify genes relevant to both PNI and pain. Upon adjusting for demographic and clinicopathological variables using linear regression models, we found that PNI independently predicted function-evoked pain according to the University of Calfornia San Francisco Oral Cancer Pain Questionnaire, as well as the worst pain intensity reported in the Brief Pain Inventory. Distinct pain patterns were observed to be associated with daily activities in varying manners. Our molecular analyses revealed significant disruptions in pathways associated with the extracellular matrix structure and organization. The top differentially expressed genes linked to the extracellular matrix are implicated in cancer development, pain, and neurodegenerative diseases. Our data underscore the importance of properly categorizing pain phenotypes in future studies aiming to uncover mechanistic underpinnings of pain. Additionally, we have compiled a list of genes of interest that could serve as targets for both cancer and cancer pain management. PERSPECTIVE: PNI independently predicts function-evoked pain. Different pain phenotypes affect daily activities differently. We identified a list of candidate genes involved in the extracellular matrix structure and function that can be targeted for both cancer and cancer pain control.

Prognostic factors for development of distant metastases in surgically treated high-grade salivary gland carcinomas: results of retrospective single center study with 213 patients

PURPOSE

Distant metastases (DM) are the primary cause of treatment failure and death of patients with salivary gland carcinomas (SGC). The purpose of present study was to evaluate factors predictive on DM development in a cohort of patients with high-grade salivary gland carcinomas.

METHODS

This was a retrospective cohort study of consecutive patients surgically treated with curative intention at the authors' institution from January 1993 to December 2018. Outcomes evaluated were overall survival (OS), disease specific survival (DSS), recurrence free survival (RFS), locoregional recurrence free survival (LRFS) and distant metastasis free survival (DMFS).

RESULTS

A total of 213 patients, 117 males (55%) and 96 females (45%), were included in the study. Parotid gland malignancies accounted for 56% of all cases. Adenoid cystic carcinoma (119 cases; 56%) was the most common tumor type. Cumulative OS for the 5-and 10-year follow-up period was 80% and 58% respectively. DM occurred with 75 patients (35%). The most common locations for DM were lung (55 cases; 73%) and liver (12 cases; 16%). Pathological nodal status, particularly the number of metastatic nodes, was the independent prognostic factor for OS, DSS, RFS and DMFS.

CONCLUSION

Number of metastatic lymph nodes, instead of extranodal extension and largest nodal diameter, was the contributing factor related to DMFS. Since the main function of staging system is to predict outcomes, the significance of extranodal extension and nodal dimension in salivary gland cancer staging system requires further clarification. The elective neck dissection could be considered therapeutic approach for high-grade SGC since occult metastases were detected in 33% of cases.

Advancing Postoperative Pain Management in Oral Cancer Patients: A Systematic Review

The goal of this review is to shed light on the management of orofacial discomfort after a cancer diagnosis in the head and neck region. A search was conducted on PubMed, Scopus, and Web of Science to identify studies on postoperative pain control in oral cancer. The review included open-access research, investigations into pain management, randomized clinical trials, retrospective studies, case-control studies, prospective studies, English-written studies, and full-text publications. Exclusion criteria included animal studies; in vitro studies; off-topic studies; reviews, case reports, letters, or comments; and non-English language. Three reviewers independently accessed databases and assigned a quality rating to the chosen articles. The review explores postoperative pain management in oral cancer patients; highlighting persistent opioid use; the efficacy of adjuvant drugs, such as gabapentin; and a multimodal approach. It emphasizes the need for personalized pain management, recognizing individual pain perception and tailoring interventions. Integrating pharmacological and non-pharmacological strategies is crucial for comprehensive pain management. The review also serves as a guide for future research, emphasizing the need for standardized methodologies and diverse participant populations.

Perineural invasion: A potential driver of cancer-induced pain

Perineural invasion (PNI) is the process through which tumors invade and interact with nerves. The dynamic changes in the nerves caused by PNI may induce disturbing symptoms. PNI-related cancer pain in neuro-rich tumors has attracted much attention because the occurrence of tumor-induced pain is closely related to the invasion of nerves in the tumor microenvironment. PNI-related pain might indicate the occurrence of PNI, guide the improvement of treatment strategies, and predict the unresectability of tumors and the necessity of palliative care. Although many studies have investigated PNI, its relationship with tumor-induced pain and its common mechanisms have not been summarized thoroughly. Therefore, in this review, we evaluated the relationship between PNI and cancer-associated pain. We showed that PNI is a major cause of cancer-related pain and that this pain can predict the occurrence of PNI. We also elucidated the cellular and molecular mechanisms of PNI-induced pain. Finally, we analyzed the possible targets for alleviating PNI-related pain or combined antitumor and pain management. Our findings might provide new perspectives for improving the treatment of patients with malignant tumors.

Difference in clinical presentation and their significance in oral squamous cell carcinoma: A retrospective analysis

BACKGROUND

Oral squamous cell carcinoma (OSCC) remains the most common cancer among Indian men. OSCC involving the tongue and bucco alveolar complex (BAC) behaves differently. Nevertheless, the differences in clinical features and symptoms between the two subsites and their relation to pathology remain largely unexplored.

STUDY DESIGN

The study compared various clinical parameters and pathological factors between tongue cancer patients and patients with BAC cancer.

RESULTS

Among 474 patients, 232 had tongue cancer and 242 had BAC cancer. Except for the ulcer, 30% of patients with OSCC were asymptomatic at presentation. Compared to tongue cancers, lesions confined to BAC present at an advanced stage (P = 0.006). Multivariate analysis showed that dysphagia in tongue cancer (P = 0.020) and external swelling or lesion in BAC cancers (P = 0.002) were significant predictors of an advanced stage of the disease. On histopathology, perineural invasion (PNI) was significantly associated with tongue (P = 0.008) compared to BAC cancers (P = 0.015). Cancers of the tongue with pain and referred otalgia had a significantly higher depth of invasion (DOI), compared to those without pain (DOI - no pain 6.9 mm, pain 9.9 mm, and referred otalgia 11.4 mm).

CONCLUSIONS

Patients with OSCC present late and in an advanced stage of the disease. Among tongue cancers, clinical history of pain was significantly associated with DOI and PNI, the significance of which needs to be prospectively analyzed. Clinical history in OSCC can be used as predicting factor for an advanced pathological stage of the disease. It also had an influence on various pathological characters, which is subsite specific.

Perineural Invasion Is a Significant Indicator of High Malignant Degree and Poor Prognosis in Esophageal Cancer: A Systematic Review and Meta-Analysis

Background

Perineural invasion (PNI) is a malignant metastatic mode of tumors and has been reported in many tumors including esophageal cancer (EC). However, the role of PNI in EC has been reported differently. This systematic review and meta-analysis aims to focus on the role of PNI in EC.

Methods

Eight databases of CNKI, VIP, Wanfang, Scopus, Wiley, ISI, PubMed, and EBSCO are used for literature search. The association of PNI with gender, pathological stages of T and N (pT and pN), lymphovascular invasion (LVI), lymph node metastasis, 5-year overall survival (OS), and 5-year disease-free survival (DFS) was examined in the meta-analysis by Revman5.0 Software. The pooled OR/HR and 95% CI were used to assess the risk and prognostic value.

Results

Sixty-nine published studies were screened for analysis of PNI in EC. The incidence of PNI in esophageal squamous carcinoma (ESCC) and esophageal adenocarcinoma (EAC) was different, but not statistically significant (p > 0.05). The PNI-positive patients had a significantly higher risk of pT stage (OR = 3.85, 95% CI = 2.45–6.05, p < 0.00001), pN stage (OR = 1.86, 95% CI = 1.52–2.28, p < 0.00001), LVI (OR = 2.44, 95% CI = 1.55–3.85, p = 0.0001), and lymph node metastasis (OR = 2.87, 95% CI = 1.56–5.29, p = 0.0007). Furthermore, the cumulative analysis revealed a significant correlation between PNI and poor OS (HR = 1.37, 95% CI = 1.24–1.51, p < 0.0001), as well as poor DFS (HR = 1.55, 95% CI = 1.38–1.74, p < 0.0001).

Conclusion

PNI occurrence is significantly related to tumor stage, LVI, lymph node metastasis, OS, and DFS. These results indicate that PNI can serve as an indicator of high malignant degree and poor prognosis in EC.

Advances in Head and Neck Cancer Pain

Head and neck cancer (HNC) affects over 890,000 people annually worldwide and has a mortality rate of 50%. Aside from poor survival, HNC pain impairs eating, drinking, and talking in patients, severely reducing quality of life. Different pain phenotype in patients (allodynia, hyperalgesia, and spontaneous pain) results from a combination of anatomical, histopathological, and molecular differences between cancers. Poor pathologic features (e.g., perineural invasion, lymph node metastasis) are associated with increased pain. The use of syngeneic/immunocompetent animal models, as well as a new mouse model of perineural invasion, provides novel insights into the pathobiology of HNC pain. Glial and immune modulation of the tumor microenvironment affect not only cancer progression but also pain signaling. For example, Schwann cells promote cancer cell proliferation, migration, and secretion of nociceptive mediators, whereas neutrophils are implicated in sex differences in pain in animal models of HNC. Emerging evidence supports the existence of a functional loop of cross-activation between the tumor microenvironment and peripheral nerves, mediated by a molecular exchange of bioactive contents (pronociceptive and protumorigenic) via paracrine and autocrine signaling. Brain-derived neurotrophic factor, tumor necrosis factor α, legumain, cathepsin S, and A disintegrin and metalloprotease 17 expressed in the HNC microenvironment have recently been shown to promote HNC pain, further highlighting the importance of proinflammatory cytokines, neurotrophic factors, and proteases in mediating HNC-associated pain. Pronociceptive mediators, together with nerve injury, cause nociceptor hypersensitivity. Oncogenic, pronociceptive mediators packaged in cancer cell-derived exosomes also induce nociception in mice. In addition to increased production of pronociceptive mediators, HNC is accompanied by a dampened endogenous antinociception system (e.g., downregulation of resolvins and µ-opioid receptor expression). Resolvin treatment or gene delivery of µ-opioid receptors provides pain relief in preclinical HNC models. Collectively, recent studies suggest that pain and HNC progression share converging mechanisms that can be targeted for cancer treatment and pain management.

Are Throat Pain and Otalgia Predictive of Perineural Invasion in Squamous Cell Carcinoma of the Oropharynx?

PURPOSE

Head and neck cancer is often associated with pain and perineural invasion (PNI). The purpose of this study was to determine the association of pain complaints and the microscopic identification of PNI in patients with oropharyngeal squamous cell carcinoma (OPSCC).

PATIENTS AND METHODS

A retrospective cohort study was performed including patients diagnosed with OPSCC from 2010 to 2019. Patients diagnosed and operated on with curative intent at 2 institutions were included. The primary predictor variable was pain (measured as no pain, ear pain, throat pain, or simultaneous pain). Other variables were patient demographics, p16 status, and TNM staging. The primary outcome variable was the histologic presence of PNI. Chi-square analysis was performed to test for any significant associations between pain, T stage, overall stage, and p16 status in relation to PNI outcome. Multivariate logistic regression analysis was used to control for cancer staging variables when testing the association between pain and PNI.

RESULTS

The final sample was composed of 157 subjects of whom 126 were men. The mean age was 59.7 years. Seventy-seven (49.0%) presented with no pain, while 35 (22.3%), 39 (24.8%), and 6 (3.8%) presented with both throat/ear pain, throat pain only, and ear pain only, respectively. Patients with simultaneous pain had 3.41 times higher odds of PNI compared to the no pain group (P = .02), although only pathologic T stage 4 and a diagnosis on the base of the tongue were independent postoperative predictors of PNI (P < .05).

CONCLUSIONS

Our study demonstrates that otalgia is a preoperative predictor of PNI in OPSCC and also demonstrates a trend of increasing pain complaints with PNI.

Peripheral nerve injury and sensitization underlie pain associated with oral cancer perineural invasion

Cancer invading into nerves, termed perineural invasion (PNI), is associated with pain. Here, we show that oral cancer patients with PNI report greater spontaneous pain and mechanical allodynia compared with patients without PNI, suggesting that unique mechanisms drive PNI-induced pain. We studied the impact of PNI on peripheral nerve physiology and anatomy using a murine sciatic nerve PNI model. Mice with PNI exhibited spontaneous nociception and mechanical allodynia. Perineural invasion induced afterdischarge in A high-threshold mechanoreceptors (HTMRs), mechanical sensitization (ie, decreased mechanical thresholds) in both A and C HTMRs, and mechanical desensitization in low-threshold mechanoreceptors. Perineural invasion resulted in nerve damage, including axon loss, myelin damage, and axon degeneration. Electrophysiological evidence of nerve injury included decreased conduction velocity, and increased percentage of both mechanically insensitive and electrically unexcitable neurons. We conclude that PNI-induced pain is driven by nerve injury and peripheral sensitization in HTMRs.

Incidence of pain complaints in oropharyngeal squamous cell carcinoma

OBJECTIVE

The purpose of this study was to determine the prevalence of throat pain and otalgia as presenting symptoms in patients with oropharyngeal squamous cell carcinoma (OPSCC) stratified by the cancer being their first or recurrent/second primary head and neck cancer (fHNC or rsHNC).

STUDY DESIGN

A retrospective analysis of patients operated on for OPSCC was performed. The primary predictor variable was HNC instance (fHNC/rsHNC) with outcome variables of throat pain and/or otalgia. Chi-square analysis was performed to test for significant associations between HNC instance and pain variables. Unadjusted odds ratios were calculated.

RESULTS

Eighty-nine patients met the inclusion criteria. Patients with OPSCC as an rsHNC had 4.67 times higher odds of throat pain (95% confidence interval [CI], 1.45-15.06) than those with OPSCC as an fHNC and had 20.22 times higher odds of simultaneous throat pain and otalgia (95% CI, 4.76-85.97) than those presenting with an fHNC. Current smoking status and human papillomavirus (HPV)-negative disease were also significantly predictive of rsHNC. HPV-negative disease was also predictive of pain.

CONCLUSIONS

In addition to the known associations of smoking and HPV status on recurrence and pain, there is a statistically significant association between cancer instance and pain in patients presenting with newly diagnosed, operable OPSCC.

miRNA-200a Regulating Proliferation, Migration, and Infiltration of Tongue Squamous Cell Carcinoma Cells by Targeting DEK Proto-Oncogene

Tongue squamous cell carcinoma (TSCC) is the most frequently occurring oral cancer and is characterized by high proliferation and metastasis rates. Incomplete understanding of the pathogenesis of TSCC coupled with frequent tongue movement increases the difficulty of therapy. Additionally, TSCC is prone to recurrence and metastasis after treatment. Thus, exploring mechanisms of proliferation, migration, and infiltration of TSCC cancer cells is essential for reducing morbidity and mortality. Transfection of miRNA-200a mimics into SCC15 cells showed that miRNA-200a expression decreased significantly, and DEK expression significantly increased. Transfection of miRNA-200a mimics (miRNA-200a group), negative control mimics (miRNA-NC group), empty vector (miRNA-200a + pcDNA3.1 group), and miRNA-200a mimics and DEK overexpression vector (miRNA-200a + DEK group) into SCC15 cells respectively indicates that overexpression of miRNA-200a substantially inhibits SCC15 cell proliferation, infiltration and migration, decreases PCNA and Vimentin expression, and promotes E-cadherin expression. miRNA-200a + DEK transfection induced greater cell proliferation, infiltration and migration, much higher PCNA and Vimentin expression, and significantly lower E-cadherin expression. Luciferase reporter gene detection of overexpressed DEK or DEK expression after inhibiting miRNA-200a expression indicated a targeting association between miRNA-200a and DEK. miRNA-200a inhibits proliferation, infiltration and migration ability of TSCC by targeting DEK and may represent a novel means for clinical intervention in TSCC. miRNA-200a inhibits proliferation, invasion, and migration of TSCC by targeting DEK.

Is Perineural Invasion a Reasonable Indicator for Neck Dissection in cT1N0M0 Squamous Cell Carcinoma of the Oral Cavity?

PURPOSE

Perineural invasion (PNI) is considered an adverse histological feature in oral squamous cell carcinoma (OSCC). Controversy exists regarding elective neck dissection (END) in cT1N0M0 OSCC with PNI as the only risk factor. The purpose of this study was to evaluate PNI as an indicator for END, as well as its utility when combined with the depth of invasion (DOI) as a second indicator.

PATIENTS AND METHODS

cT1N0M0 (AJCC8) OSCC patients treated from August 1998 to July 2017 in the Department of Oral and Maxillofacial Surgery, University of Michigan (MI), and Beijing Stomatological Hospital, Capital Medical University (BSH) were reviewed. Data from these sites included both prospectively captured data housed in a database and retrospective data.

RESULTS

283 cT1N0M0 OSCC patients were analyzed. The tongue was the most common subsite (56.2%). Ninety-nine (99) patients received END and 184 neck observation. PNI was found in only 8 patients (2.83%) all in the tongue or inferior gingiva. END was performed in 7 of the PNI patients. The mean depth of invasion for tumors with PNI was 3.97 mm, compared to 2.54 mm in tumors without PNI. PNI was statistically correlated with nodal disease (pN+) and extranodal extension (ENE+). After using DOI as a primary indicator for END, no additional PNI patients benefited from END. In addition, only 2 patients had PNI identified preoperatively both with 5 mm DOI, and therefore, already indicated for END on the basis of DOI status.

CONCLUSIONS

PNI status is statistically correlated with pN+ and ENE + pathology in cT1N0M0 OSCC. After using DOI as a primary indicator for END, PNI status had no added value in decision making. Even surgeons who do not use DOI will find very limited value in PNI status with less than 1% preoperative prevalence (0.71%) in this patient population.