Management of clinically negative neck for the patients with head and neck squamous cell carcinomas in the modern era

Development and validation of a machine learning model to predict the risk of lymph node metastasis in early-stage supraglottic laryngeal cancer

Background

Cervical lymph node metastasis (LNM) is a significant factor that leads to a poor prognosis in laryngeal cancer. Early-stage supraglottic laryngeal cancer (SGLC) is prone to LNM. However, research on risk factors for predicting cervical LNM in early-stage SGLC is limited. This study seeks to create and validate a predictive model through the application of machine learning (ML) algorithms.

Methods

The training set and internal validation set data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Data from 78 early-stage SGLC patients were collected from Fujian Provincial Hospital for independent external validation. We identified four variables associated with cervical LNM and developed six ML models based on these variables to predict LNM in early-stage SGLC patients.

Results

In the two cohorts, 167 (47.44%) and 26 (33.33%) patients experienced LNM, respectively. Age, T stage, grade, and tumor size were identified as independent predictors of LNM. All six ML models performed well, and in both internal and independent external validations, the eXtreme Gradient Boosting (XGB) model outperformed the other models, with AUC values of 0.87 and 0.80, respectively. The decision curve analysis demonstrated that the ML models have excellent clinical applicability.

Conclusions

Our study indicates that combining ML algorithms with clinical data can effectively predict LNM in patients diagnosed with early-stage SGLC. This is the first study to apply ML models in predicting LNM in early-stage SGLC patients.

A Proposed Method for Cervical Lymph Node Evaluation in Head and Neck Cancer Patients: A Radiological Study

Objectives

To present a new method to assess the cervical lymph nodes status in head and neck cancer patients.

Methods

Twenty-five oral and maxillofacial cancer patients underwent preoperative CT imaging. The cervical lymph node features on CT scan were examined. Each parameter was given a score, and the total scores in each case was calculated and referred to as metastatic score (MS). Then, patients underwent neck dissection, and all dissected lymph nodes were sent for histopathology.

Results

All cases with MS ≥ 6 were histopathologically positive, and all cases with MS ≤ 3 were histopathologically negative. All cases of nodal sizes > 3 cm were histopathologically positive, 82% of cases of nodal sizes between 2.1 and 3 cm were histopathologically positive, 40% of cases of nodal sizes between 1 and 2 cm were histopathologically positive, and all cases of lymph nodes sizes < 1 cm were histopathologically negative. Seventy-seven percent of cases which had a group of lymph nodes ≥ 3 nodes/region were histopathologically positive, while 79% of cases with rounded nodes were histopathologically positive, and all cases with necrotic lymph nodes were positive for malignancy.

Conclusion

The proposed formula is a good assessment tool for cervical lymph nodes evaluation using helical CT scan in head and neck cancer patients.

Comparison of Survival of Patients With T1 -2 cN0 Oropharyngeal Cancer Treated With or Without Elective Neck Dissection

OBJECTIVES/HYPOTHESIS

This study aimed to examine the prognostic value of elective neck dissection (END) in T_1-2 clinical negative cervical lymph node (cN₀ ) oropharyngeal cancer (OPC) patients.

STUDY DESIGN

An observational retrospective study.

METHODS

This retrospective study included 845 patients diagnosed with T_1-2 cN₀ OPC during 2010-2015 from Surveillance, Epidemiology, and End Results database. Univariable and multivariable Cox regression models were used to evaluate the prognostic roles of END. Furthermore, propensity score matching was used to balance the covariates between the END and observation (OBS) groups, and subgroup analyses were conducted in the matched cohorts. The primary endpoint was overall survival (OS).

RESULTS

Our study showed that END was an independent prognostic factor associated with a better 3-year OS compared with OBS in human papillomavirus (HPV)-positive cohort (adjusted hazard ratio [HR], 0.464; 95% confidence interval [CI], 0.235-0.916; P = .027). However, we found no prognostic value of END in HPV-negative cohort (adjusted HR, 0.837; 95% CI, 0.535-1.310; P = .435). In the subgroup analyses, we found that younger patients (≤65 years old) and patients with nontonsillar tumors in HPV-positive cohort were more likely to benefit from END, while patients with tonsillar tumors in HPV-negative cohort may benefit from END.

CONCLUSIONS

We found that patients with HPV-positive T_1-2 cN₀ OPC could benefit from END in terms of OS, especially younger patients and those with nontonsillar tumors. Patients with HPV-negative T_1-2 cN₀ OPC could not benefit from END in terms of OS, while those with tonsillar tumors may benefit from END.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Paradoxical Roles of Desmosomal Components in Head and Neck Cancer

Desmosomes are intercellular adhesion complexes involved in various aspects of epithelial pathophysiology, including tissue homeostasis, morphogenesis, and disease development. Recent studies have reported that the abnormal expression of various desmosomal components correlates with tumor progression and poor survival. In addition, desmosomes have been shown to act as a signaling platform to regulate the proliferation, invasion, migration, morphogenesis, and apoptosis of cancer cells. The occurrence and progression of head and neck cancer (HNC) is accompanied by abnormal expression of desmosomal components and loss of desmosome structure. However, the role of desmosomal components in the progression of HNC remains controversial. This review aims to provide an overview of recent developments showing the paradoxical roles of desmosomal components in tumor suppression and promotion. It offers valuable insights for HNC diagnosis and therapeutics development.

The limited role of elective neck dissection in patients with cN0 salivary gland carcinoma

PURPOSE

To evaluate whether elective neck dissection (END) was beneficial for cN0 patients with salivary gland carcinoma.

MATERIALS AND METHODS

The rates of regional failure-free survival and disease-free survival were calculated using Kaplan-Meier methods and Cox models. The risk factors for occult lymph node metastasis (OLNM) in cN0 patients undergoing END was analyzed using logistic regression. A nomogram was formulated to calculate the estimated probability of OLNM.

RESULTS

Neck dissection was performed in 84 patients (43.3%). OLNM was detected in eight of the patients who underwent END. During the follow-up period, regional recurrences involving cervical lymph nodes were found in 10 patients. Cox model analysis revealed that neck dissection was not related to regional failure-free survival and disease-free survival. Logistic regression analysis revealed that older age, neural symptoms, and positive adjacent lymph nodes were associated with OLNM. A nomogram comprising age, neural symptoms, and adjacent lymph nodes was developed to predict the risk of OLNM.

CONCLUSION

The incidence of OLNM was low in cN0 patients after detailed preoperative evaluations. There was no strong evidence supporting END as a conventional therapy in cN0 patients with salivary cancers. Our nomogram is a simple and practical instrument for strengthening the prediction of OLNM.

Clinicopathological significance of miR-26, miR-107, miR-125b, and miR-203 in head and neck carcinomas

OBJECTIVES

MicroRNAs play a role in the development and progression of head and neck squamous cell carcinomas (HNSCC). Our aim was to study the expression of miR-26, miR-107, miR-125b, and miR-203 in primary HNSCC with and without lymph node metastasis and their clinicopathological significance.

MATERIALS AND METHODS

The expression of microRNAs in primary HNSCC with lymph node metastasis (n = 16) and their matched lymph node, as well as primary tumors without metastasis (n = 16), were determined by quantitative RT-PCR and analyzed with clinicopathological features and survival.

RESULTS

The expression levels of miR-26 (p < .05) and miR-125b (p < .01) were higher in metastatic primary HNSCC, while levels of miR-203 (p < .01) were lower. The expression of the microRNAs was associated with clinicopathological features, including miR-26 high expression and N stage (p = .04), poor differentiation (p = .005) and recurrence (p = .007), miR-125b high expression and N stage (p = .0005) and death (p = .02), and low levels of miR-203 and N stage (p = .04). The high expression of miR-26 was associated with shortened disease-free survival, and high miR-125b expression was an independent risk factor for poor disease-specific survival.

CONCLUSIONS

These findings suggest that miR-26 and miR-125b may be associated with the progression and metastasis of HNSCC and that miR-203 is associated with a more favorable prognosis.

A prospective randomised trial of LigaSure Small Jaw® versus conventional neck dissection in head and neck cancer patients

OBJECTIVES

We compared the differences between LigaSure Small Jaw®-assisted and conventional neck dissection in patients with head and neck cancer.

DESIGN

Prospective randomised study.

SETTING

Tertiary referral hospital.

PARTICIPANTS

Patients scheduled to undergo neck dissection due to head and neck cancer were eligible for this study. The study group was treated using the LigaSure vessel sealing system (Small Jaw®; Covidien, Colorado, USA) for dissection and hemostasis throughout the whole procedures (ClinicalTrials.gov number: NCT02597582).

MAIN OUTCOMES MEASURES

Operation duration, perioperative blood loss, postoperative drainage amount and postoperative pain status.

RESULTS

The study group consisted of 21 patients, while the control group had 20 patients. The operation duration was shorter (97.1 versus 116.3 min, P = 0.022) and the average amount of injected analgesics was lower (8.8 versus 17.7 ampules, P = 0.037) in the study group.

CONCLUSIONS

The assistance of the LigaSure Small Jaw® during functional neck dissection shortened the operation duration and decreased the amount of injected analgesics needed.

Neck dissection in relation with disease-free, disease-specific, and overall survival of patients with squamous cell cancer of the oral cavity

PURPOSE

The aims of this study were to assess the accuracy of the presurgical TNM staging of patients with oral squamous cell carcinoma who underwent neck dissection, to explore the relation between the site of the primary tumor and the histopathologically determined neck metastasis, and to perform survival analysis in relation to the histopathologic neck status.

PATIENTS AND METHODS

A retrospective chart review with prospective follow-up of oral squamous cell carcinoma patients who underwent neck dissection was performed. Presurgical clinical neck status (cN) and postsurgical histopathologic neck status (pN) were recorded. Sensitivity, specificity, and likelihood ratios were calculated. Kaplan-Meier survival analysis was performed.

RESULTS

The patients clinically staged as cN+ have more than 2-fold odds of having a pN+ neck. Those staged as cN0 have 4 times less odds of a pN+ neck. The mean follow-up was 45.8 months. The median overall survival was 27 months (41 mo in the patients with pN0 and 19.5 mo in the patients with pN+). For the patients with pN0, the 1-year overall survival probability was 95%, falling to 90% at 2 years and 81.8% at 5 years. In the patients with pN+, the 1-year overall survival probability was 72.2%, falling to 44.4% at 2 years and 26.7% at 5 years. Disease-specific and disease-free survival exhibited similar trends.

CONCLUSIONS

No means of presurgical assessment either clinical or imaging was sufficiently sensitive and specific enough to predict the metastatic status of the neck. An approximately 50% decrease in the 5-year overall survival rate may be expected when regional metastasis is confirmed.

The impact of tissue glue in wound healing of head and neck patients undergoing neck dissection

We investigated the impact of fibrin glue on postoperative drainage amount and duration in head and neck cancer patients who underwent neck dissection. This study was a prospective randomized controlled trial. Patients who were scheduled to undergo neck dissection due to head and neck cancer were eligible for this study. After receiving a detailed explanation, all patients signed an informed consent form before enrollment. Patients were then randomly assigned to the study group (fibrin glue) or control group. In the study group, 2 ml of fibrin glue (Tissucol(®); Duploject, Baxter AG) was applied on the surface of the surgical wound before closure. Basic demographic data along with tumor-related features, operation-related variables, postoperative drainage amount/duration, postoperative pain, and analgesic usage were collected and analyzed. A total of 15 patients were included in the final analyses, with eight patients in the study group and seven patients in the control group. No significant differences were found between the two groups in age, gender, primary site, clinical N stage, neck dissection levels, perioperative bleeding, postoperative drainage amount/duration, hospitalization duration, and postoperative pain status. The application of 2 ml fibrin glue by the method described herein did not reduce the postoperative drainage amount/duration nor the postoperative pain status in patients who underwent neck dissection.

Incidence and outcome for patients with occult lymph node involvement in T1 and T2 oral squamous cell carcinoma: a prospective study

BACKGROUND

The evidence base to inform the decision making process in patients with early stage oral cancer and a clinical and radiological N0 neck remains insufficient to answer the question when it is safe to "watch and wait" and when to proceed with a selective neck dissection.

METHODS

A total of 327 consecutive cases of histopathologically staged T1-2, N0-1 and M0, but clinically N0, squamous cell carcinoma of the tongue were prospectively analysed. Univariate and multivariate analyses were used for statistical analysis and are represented as Kaplan-Meier analyses or Cox proportional hazard regression analysis.

RESULTS

In 61 patients (18.65%) lymph node involvement was found in the histopathological processing. The mean survival of all patients was 73.3 ± 48.6 months. The 2-year and 5-year overall survival rates of all patients were 87.5% and 68.4%, respectively. The 2-year and 5-year survival rates for stage N0 were 89.1% and 70.7% compared to 83.3% and 62.9% in N1 situations. The 2-year and 5-year survival rates for stage T1 were 87.9% and 73.6% compared to 87.2% and 65.3% in stage T2, respectively. The time to recurrence in stage N0 was 35.1 ± 30.5 months compared to 25.63 ± 24.6 months in cases with N1 disease. Stage T1 was associated with a time to recurrence of 38.1 ± 33.9 months compared with 27.2 ± 22.7 months in patients classified T2.Variables found to be strongly associated with survival in the univariate analysis included older age, higher tumour and N stage, and grading. Age, tumour stage (p = 0.011, 95% CI, 1.09 to 2.0), nodal stage (p = 0.038, 95% CI, 1.02 to 2.07), and recurrence were independently and significantly associated with survival in the multivariate analysis.

CONCLUSIONS

This confirms a high overall disease free survival for patients with T1 and N0 treated with single modality surgery and in common with the literature confirms the poor impact on prognosis of the N positive neck.

Elective neck dissection vs observation in transorally treated early head and neck carcinomas with cN0 neck

CONCLUSION

This study showed that elective neck dissection (ND) resulted in reduced regional recurrences in a selected group of surgically treated patients with pT1-2 carcinomas but did not show any benefit for disease-specific survival (DSS). Furthermore, the importance of pN classification was also verified for this patient group.

OBJECTIVES

The aim of this study was to determine whether the use of elective ND in patients with early head and neck carcinomas and cN0 neck that have undergone a transoral removal of the primary tumor can reduce the incidence of regional recurrence and improve survival.

METHODS

Between 1980 and 2010, 224 patients that underwent transoral resection of a pT1-2 carcinoma and had a cN0 neck were included in the study; 101 patients received an elective ND and 123 did not.

RESULTS

The group that underwent elective ND showed a tendency toward better regional control (RC) (96.0% vs 90.3%, p = 0.07) but similar DSS (85.7% vs 85.4%, p = 0.984). Cases with pN0 classification had a better overall survival (74.6% vs 46.9%, p = 0.07), DSS (88.4% vs 53.6%, p = 0.44), and RC (98.6% vs 62.5%, p < 0.001) compared with pN+ patients.

Novel diagnostic modalities for assessment of the clinically node-negative neck in oral squamous-cell carcinoma

Oral squamous-cell carcinomas arise in mucosal linings of the oral cavity and frequently metastasise to regional lymph nodes in the neck. The presence of nodal metastases is a determinant of prognosis and clinical management. The neck is staged by palpation and imaging, but accuracy of these techniques to detect small metastases is low. In general, 30-40% of patients will have occult nodal disease and will develop clinically detectable lymph-node metastases when the neck is left untreated. The choice at present is either elective treatment or careful observation followed by treatment of the neck in patients who develop manifest metastases. These unsatisfying therapeutic options have been the subject of debate for decades. Recent developments in staging of the neck, including expression profiling and sentinel lymph-node biopsy, will allow more personalised management of the neck.

Nodal recurrence of sinonasal cancer: does the risk of cervical relapse justify a prophylactic neck treatment?

BACKGROUND

Sinonasal cancers are rare and no high-level evidence exists to determine their optimal management. Prophylactic neck treatment issue remains controversial. The aim of this study was to analyze the pattern of neck failure and to identify any prognostic factors that may influence neck control.

METHODS

A retrospective review of 155 consecutive patients treated for sinonasal malignancy, without prophylactic neck treatment, between 1995 and 2005 at tertiary cancer center was performed. Demographic, clinical, morphological and pathological parameters were correlated with oncologic outcomes.

RESULTS

Eight out of 155 patients (5%) presented initially with neck node metastasis. Complete remission was obtained for 133 patients after treatment completion. During follow up, 16 out of 133 patients (12%) were affected with regional recurrence. Neck failure occurred in 8 out of 51 patients with local failure and in 8 out of 82 patients locally controlled. Isolated nodal failure was observed in 5 patients initially cN0 out of 133 (3.8%) representing 7.3% of all recurrences and 3 of them underwent successful salvage therapy. None of the tested factors were significantly associated with neck control (p>0.05). Lymph node at diagnosis time was significantly and independently associated with poor survival (p=0.0012).

CONCLUSION

Isolated neck relapse, when local control is achieved, is rare and salvage treatment is effective. Routine prophylactic neck treatment has little interest. However, this approach could be profitable to few selected patients, who remain to be defined. Further investigations are needed.

Validation of a gene expression signature for assessment of lymph node metastasis in oral squamous cell carcinoma

PURPOSE

Current assessment of lymph node metastasis in patients with head and neck squamous cell carcinoma is not accurate enough to prevent overtreatment. The aim of this study was validation of a gene expression signature for distinguishing metastasizing (N+) from nonmetastasizing (N0) squamous cell carcinoma of the oral cavity (OSCC) and oropharynx (OPSCC) in a large multicenter cohort, using a diagnostic DNA microarray in a Clinical Laboratory Improvement Amendments/International Organization for Standardization-approved laboratory.

METHODS

A multigene signature, previously reported as predictive for the presence of lymph node metastases in OSCC and OPSCC, was first re-evaluated and trained on 94 samples using generic, whole-genome, DNA microarrays. Signature genes were then transferred to a dedicated diagnostic microarray using the same technology platform. Additional samples (n=222) were collected from all head and neck oncologic centers in the Netherlands and analyzed with the diagnostic microarray. Human papillomavirus status was determined by real-time quantitative polymerase chain reaction.

RESULTS

The negative predictive value (NPV) of the diagnostic signature on the entire validation cohort (n=222) was 72%. The signature performed well on the most relevant subset of early-stage (cT1-T2N0) OSCC (n=101), with an NPV of 89%.

CONCLUSION

Combining current clinical assessment with the expression signature would decrease the rate of undetected nodal metastases from 28% to 11% in early-stage OSCC. This should be sufficient to enable clinicians to refrain from elective neck treatment. A new clinical decision model that incorporates the expression signature is therefore proposed for testing in a prospective study, which could substantially improve treatment for this group of patients.

DSG3 as a biomarker for the ultrasensitive detection of occult lymph node metastasis in oral cancer using nanostructured immunoarrays

OBJECTIVES

The diagnosis of cervical lymph node metastasis in head and neck squamous cell carcinoma (HNSCC) patients constitutes an essential requirement for clinical staging and treatment selection. However, clinical assessment by physical examination and different imaging modalities, as well as by histological examination of routine lymph node cryosections can miss micrometastases, while false positives may lead to unnecessary elective lymph node neck resections. Here, we explored the feasibility of developing a sensitive assay system for desmoglein 3 (DSG3) as a predictive biomarker for lymph node metastasis in HNSCC.

MATERIALS AND METHODS

DSG3 expression was determined in multiple general cancer- and HNSCC-tissue microarrays (TMAs), in negative and positive HNSCC metastatic cervical lymph nodes, and in a variety of HNSCC and control cell lines. A nanostructured immunoarray system was developed for the ultrasensitive detection of DSG3 in lymph node tissue lysates.

RESULTS

We demonstrate that DSG3 is highly expressed in all HNSCC lesions and their metastatic cervical lymph nodes, but absent in non-invaded lymph nodes. We show that DSG3 can be rapidly detected with high sensitivity using a simple microfluidic immunoarray platform, even in human tissue sections including very few HNSCC invading cells, hence distinguishing between positive and negative lymph nodes.

CONCLUSION

We provide a proof of principle supporting that ultrasensitive nanostructured assay systems for DSG3 can be exploited to detect micrometastatic HNSCC lesions in lymph nodes, which can improve the diagnosis and guide in the selection of appropriate therapeutic intervention modalities for HNSCC patients.

Recent advances in oral oncology 2008; squamous cell carcinoma imaging, treatment, prognostication and treatment outcomes

This paper provides a synopsis of the main papers on diagnosis, imaging, treatment, prognostication and treatment outcomes in patients with oral and oropharyngeal squamous cell carcinoma (OSCC) and head and neck SCC (HNSCC) published in 2008 in Oral Oncology - an international interdisciplinary journal which publishes high quality original research, clinical trials and review articles, and all other scientific articles relating to the aetiopathogenesis, epidemiology, prevention, clinical features, diagnosis, treatment and management of patients with neoplasms in the head and neck, and orofacial disease in patients with malignant disease.