Elective versus therapeutic neck dissection in node-negative oral cancer: Evidence from five randomized controlled trials

Application of CT and MRI images based on artificial intelligence to predict lymph node metastases in patients with oral squamous cell carcinoma: a subgroup meta-analysis

Background

The performance of artificial intelligence (AI) in the prediction of lymph node (LN) metastasis in patients with oral squamous cell carcinoma (OSCC) has not been quantitatively evaluated. The purpose of this study was to conduct a systematic review and meta-analysis of published data on the diagnostic performance of CT and MRI based on AI algorithms for predicting LN metastases in patients with OSCC.

Methods

We searched the Embase, PubMed (Medline), Web of Science, and Cochrane databases for studies on the use of AI in predicting LN metastasis in OSCC. Binary diagnostic accuracy data were extracted to obtain the outcomes of interest, namely, the area under the curve (AUC), sensitivity, and specificity, and compared the diagnostic performance of AI with that of radiologists. Subgroup analyses were performed with regard to different types of AI algorithms and imaging modalities.

Results

Fourteen eligible studies were included in the meta-analysis. The AUC, sensitivity, and specificity of the AI models for the diagnosis of LN metastases were 0.92 (95% CI 0.89-0.94), 0.79 (95% CI 0.72-0.85), and 0.90 (95% CI 0.86-0.93), respectively. Promising diagnostic performance was observed in the subgroup analyses based on algorithm types [machine learning (ML) or deep learning (DL)] and imaging modalities (CT vs. MRI). The pooled diagnostic performance of AI was significantly better than that of experienced radiologists.

Discussion

In conclusion, AI based on CT and MRI imaging has good diagnostic accuracy in predicting LN metastasis in patients with OSCC and thus has the potential for clinical application.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, PROSPERO (No. CRD42024506159).

N0 neck trial: Does intensification of follow-up (Ultrasound + Physical Examination) influence outcomes in early-stage oral cancer?

AIM OF THE STUDY

We previously reported a survival benefit of elective neck dissection (END) over therapeutic neck dissection (TND) in patients with clinically node-negative early-stage oral cancer. We now report the results of the second question in the same study addressing the impact of adding neck ultrasound to physical examination during follow-up on outcomes.

METHODS

Patients with lateralized T1/T2 oral squamous cell carcinoma (SCC) were randomized to END or TND and to follow-up with physical-examination plus neck ultrasound (PE+US) versus physical-examination (PE). The primary endpoint was overall survival (OS).

RESULTS

Between January 2004 and June 2014, 596 patients were enrolled. This is an intention to treat analysis of 592 analysable patients, of whom 295 were allocated to PE+US and 297 to PE with a median follow-up of 77.47 months (interquartile range (IQR) 54.51-126.48). There was no significant difference (unadjusted hazard ratio [HR], 0.92, 95% CI, 0.71-1.20, p = 0.54) in 5-year OS between PE+US (70.8%, 95% CI, 65.51-76.09) and PE (67.3%, 95% CI, 61.81-72.79). Among 131 patients with neck node relapse as the first event, the median time to relapse detection was 4.85 (IQR 2.33-9.60) and 7.62 (IQR 3.22-9.86) months in PE+US and PE arms, respectively. The N stage in the PE+US arm was N1 33.8%, N2a 7.4%, N2b/c 44.1% and N3 14.7% while in PE was N1 28.6%, N2a 9.5%, N2b/c 39.7%, N3 20.6% and unknown 1.6%.

CONCLUSION

Adding neck ultrasound to physical examination during follow-up detects nodal relapses earlier but does not improve overall survival.

Improved recurrence rates and progression-free survival in primarily surgically treated oral squamous cell carcinoma - results from a German tertiary medical center

OBJECTIVES

This study aimed to explore survival and recurrence patterns in patients undergoing primarily surgical treatment for oral squamous cell carcinoma (OSCC) at a high-volume tertiary medical center in Germany.

MATERIALS AND METHODS

The study included 421 patients with primary OSCC who underwent radical tumor resection, neck dissection, and reconstruction with a free flap. Prognostic relevance of clinicopathological characteristics was assessed using Cox proportional-hazards models. Kaplan-Meier method estimated local recurrence-free survival, progression-free survival (PFS), and overall survival (OS), while the log-rank test compared survival outcomes between groups.

RESULTS

Recurrence manifested in 16.63% of the patients (70 patients), encompassing local recurrence in 54 patients (77.14%) and distant metastasis in 24 patients (34.28%). Neck recurrence occurred in only 1 patient (0.24%) on the contralateral side. The majority of recurrences occurred within the initial twelve months following primary tumor surgery (64.29%). Overall, the 5-year OS stood at 58.29%, while the 5-year PFS reached 72.53%. Patients with early recurrence within ≤ 12 months showed the least favorable prognosis (log-rank, all p < 0.001).

CONCLUSIONS

Our findings show a significant decrease in recurrence rates and enhanced PFS at a high-volume tertiary medical center in Germany compared to previous studies. Local recurrence was the primary form observed, with most recurrences happening within the initial twelve months post-surgery. Opting for treatment at a high-volume center and devising therapy plans in interdisciplinary tumor boards may not only enhance OS but also contribute to improved PFS.

CLINICAL RELEVANCE

These findings offer valuable insights for physicians regarding the post-treatment care of patients with OSCC. The results underscore the importance of frequent follow-up appointments, particularly during the initial year, and highlight the critical need for vigilance in monitoring for local recurrence.

The application of radiomics machine learning models based on multimodal MRI with different sequence combinations in predicting cervical lymph node metastasis in oral tongue squamous cell carcinoma patients

BACKGROUND

The purpose of this study was to explore preliminary the performance of radiomics machine learning models based on multimodal MRI to predict the risk of cervical lymph node metastasis (CLNM) for oral tongue squamous cell carcinoma (OTSCC) patients.

METHODS

A total of 400 patients were enrolled in this study and divided into six groups according to the different combinations of MRI sequences. Group I consisted of patients with T1-weighted images (T1WI) and FS-T2WI (fat-suppressed T2-weighted images), group II consisted of patients with T1WI, FS-T2WI, and contrast enhanced MRI (CE-MRI), group III consisted of patients with T1WI, FS-T2WI, and T2-weighted images (T2WI), group IV consisted of patients with T1WI, FS-T2WI, CE-MRI, and T2WI, group V consisted of patients with T1WI, FS-T2WI, T2WI, and apparent diffusion coefficient map (ADC), and group VI consisted of patients with T1WI, FS-T2WI, CE-MRI, T2WI, and ADC. Machine learning models were constructed. The performance of the models was compared in each group.

RESULTS

The machine learning model in group IV including T1WI, FS-T2WI, T2WI, and CE-MRI presented best prediction performance, with AUCs of 0.881 and 0.868 in the two sets. The models with CE-MRI performed better than the models without CE-MRI(I vs. II, III vs. IV, V vs. VI).

CONCLUSIONS

The radiomics machine learning models based on CE-MRI showed great accuracy and stability in predicting the risk of CLNM for OTSCC patients.

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.

Changing trend of oral cancer disease burden in China from 1990 to 2019 and the forecast for the next 20 years

OBJECTIVE

This study aimed to explore the trend of oral cancer (OC) disease burden in China from 1990 to 2019 and predict the disease burden in the next 20 years.

METHODS

OC data collected for 15 years old in China from 1990 to 2019 were obtained from the 2019 Global Burden of Disease Study. Estimated annual percentage changes (EAPCs), with respective 95% CI, were used to assess incidence, mortality, disability-adjusted life-year (DALY), and their trends.

RESULTS

From 1990 to 2019, the age-standardized rate of incidence, mortality, and DALY of OC in China showed an upward trend with EAPCs of 2.33 (95% CI = 2.01-2.63), 1.44 (95% CI = 1.15-1.73), and 1.24 (95% CI = 0.95-1.52), respectively. The main risk factors for OC in China were smoking and alcohol consumption. New cases, deaths, and DALYs due to OC are predicted to increase >1.5 times over the next 20 years.

CONCLUSION

The number of cases, deaths, and DALYs will continue to increase in the next 20 years. Therefore, the control of risk factors, such as tobacco and alcohol consumption, needs to be strengthened to reduce the burden of OC in China.

Foregoing elective neck dissection for elderly patients with oral cavity squamous cell carcinoma

OBJECTIVE

Elective neck dissection (END) improves outcomes among clinically node-negative patients with oral cavity squamous cell carcinoma (OCSCC). However, END is of questionable value, considering the potentially higher comorbidities and operative risks in elderly patients.

METHODS

A retrospective review of all patients older than 65 years of age who were treated for OCSCC at a tertiary care centre between 2005 and 2020 was conducted.

RESULTS

Fifty-three patients underwent primary tumour resection alone, and 71 had simultaneous END. Most primary tumours were located on the mobile tongue. The patients who did not undergo END had a higher mean age (81.2 vs. 75.1 years, P < 0.00001), significantly shorter surgeries, and shorter hospitalizations. Occult cervical metastases were found in 24% of the patients who underwent END. The two groups showed no significant differences in overall survival or recurrence rates. Similar results were shown in a subpopulation analysis of patients older than 75 years.

CONCLUSION

Foregoing END in elderly patients with no clinical evidence of neck metastases did not result in lower survival rates or higher recurrence rates.

Do patients with cN0 oral squamous cell carcinoma benefit from elective neck dissection? A large-scale population-based study

BACKGROUND

The neck management of clinical-nodal negative (cN0) oral squamous cell carcinoma (OSCC) remains controversial. Elective neck dissection (END) and observation are the main strategies, but it is still not clear who could benefit the most from END. The purpose of this study was to clarify the potential clinical factors that affect the therapeutic value of END and to explore the actual characteristics associated with benefit from END.

METHODS

Patients with cN0 OSCC were identified in the SEER database from 2000 to 2019. 5-year Overall survival (OS) and disease-specific survival (DSS) were analyzed using the Kaplan‒Meier method, and the hazard ratios (HRs) for survival were estimated using the Cox regression model. Multiple subgroup analyses of DSS and OS among different factors, comparing END and No END, were performed.

RESULTS

A total of 17,019 patients with cN0 OSCC were included. The basic survival analysis and Cox regression model showed that END increased the probability of 5-year DSS and OS and was an independent prognostic factor. However, among patients who underwent only primary tumor surgery, no significant differences were found between the END and No END groups in 5-year DSS (P = 0. 585) and OS (P = 0.465). Further subgroup analysis showed that primary sites and T stage, but not other factors, might influence the benefit of END. Significant differences were found for T1 (P < 0.001 for OS) and T2 (P = 0.001 for DSS and < 0.001 for OS) tongue squamous cell carcinoma (TSCC) but not for other primary tumor sites.

CONCLUSION

This large-scale retrospective population-based cohort study suggests that not all patients with cN0 OSCC could benefit from END. Patients with cN0 TSCC are recommended to undergo END, especially with early-stage tumors.

Nivolumab for Patients With High-Risk Oral Leukoplakia: A Nonrandomized Controlled Trial

Importance

Proliferative verrucous leukoplakia (PVL) is an aggressive oral precancerous disease characterized by a high risk of transformation to invasive oral squamous cell carcinoma (OSCC), and no therapies have been shown to affect its natural history. A recent study of the PVL immune landscape revealed a cytotoxic T-cell-rich microenvironment, providing strong rationale to investigate immune checkpoint therapy.

Objective

To determine the safety and clinical activity of anti-programmed cell death 1 protein (PD-1) therapy to treat high-risk PVL.

Design, Setting, and Participants

This nonrandomized, open-label, phase 2 clinical trial was conducted from January 2019 to December 2021 at a single academic medical center; median (range) follow-up was 21.1 (5.4-43.6) months. Participants were a population-based sample of patients with PVL (multifocal, contiguous, or a single lesion ≥4 cm with any degree of dysplasia).

Intervention

Patients underwent pretreatment biopsy (1-3 sites) and then received 4 doses of nivolumab (480 mg intravenously) every 28 days, followed by rebiopsy and intraoral photographs at each visit.

Main Outcomes and Measures

The primary end point was the change in composite score (size and degree of dysplasia) from before to after treatment (major response [MR]: >80% decrease in score; partial response: 40%-80% decrease). Secondary analyses included immune-related adverse events, cancer-free survival (CFS), PD-1 ligand 1 (PD-L1) expression, 9p21.3 deletion, and other exploratory immunologic and genomic associations of response.

Results

A total of 33 patients were enrolled (median [range] age, 63 [32-80] years; 18 [55%] were female), including 8 (24%) with previously resected early-stage OSCC. Twelve patients (36%) (95% CI, 20.4%-54.8%) had a response by composite score (3 MRs [9%]), 4 had progressive disease (>10% composite score increase, or cancer). Nine patients (27%) developed OSCC during the trial, with a 2-year CFS of 73% (95% CI, 53%-86%). Two patients (6%) discontinued because of toxic effects; 7 (21%) experienced grade 3 to 4 immune-related adverse events. PD-L1 combined positive scores were not associated with response or CFS. Of 20 whole-exome sequenced patients, all 6 patients who had progression to OSCC after nivolumab treatment exhibited 9p21.3 somatic copy-number loss on pretreatment biopsy, while only 4 of the 14 patients (29%) who did not develop OSCC had 9p21.3 loss.

Conclusions and Relevance

This immune checkpoint therapy precancer nonrandomized clinical trial met its prespecified response end point, suggesting potential clinical activity for nivolumab in high-risk PVL. Findings identified immunogenomic associations to inform future trials in this precancerous disease with unmet medical need that has been difficult to study.

Trial Registration

ClinicalTrials.gov Identifier: NCT03692325.

Regional Nodal Recurence as a Prognostic Factor in Patients Kept on Observation for cT1-T2 Oral Squamous Cell Carcinomas of Tongue: A Meta-Analysis of 11,973 Patients

The surgical management of the clinically node negative neck in T1-T2 early oral tongue squamous cell carcinoma (OTSCC) has been the topic of debate since few decades. As the occult cervical lymph node metastasis is considered to be the primary prognostic factor in early OTSCC, this meta-analysis has been carried out to find the risk of regional nodal recurrence on patients kept under observation than those who have underwent Elective neck dissection (END). The articles were electronically retrieved from Ovid Medline, PubMed, Cochrane and Scholar for comparison of Observation versus END in early OTSCC. The search strategy identified 35 relevant review articles from April 1979 to April 2020 from different search engines. A total of 11,973 patients from 30 retrospective analyses, 4 prospective and 1 randomized control trials were included in this meta-analysis. Overall test revealed (OR: 13.02 95% CI 1.360-17.154) with t test 2.382 and p value 0.023 which is statistically significant and showed that END significantly reduced the risk of regional nodal recurrence. This meta-analysis finds that there is statistically significant relationship when END was performed which reduced the risk of regional nodal recurrence as seen in patients kept on Observation thereby affecting the Overall survival (OS) rate.

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.

Nodal frozen section + elective neck dissection as an alternative to sentinel lymph node biopsy for the management of cT1-2N0 oral squamous cell carcinoma patients: a viability and accuracy study

PURPOSE

Oral Squamous Cell Carcinoma (OSCC) is characterized by a high aggressiveness and a tendency to metastasize. The management of the neck in cT1-2N0 patients c follows three strategies: watchful waiting, elective neck dissection (END) or sentinel lymph node biopsy (SLNB). The aim was to assess the viability of intraoperative frozen sections of the nodes of cT1-2N0 to spot occult metastases as an alternative to SLNB, performing a modified radical neck dissection (MRND) in intraoperatively positive patients.

METHODS

The patients were treated at the Maxillo-Facial Surgery Unit of Policlinico San Marco of Catania between 2020 and 2022. END was performed in all patients, including frozen section examination of at least one clinically suspicious node per level. In case of positivity after frozen section examination, neck dissection was extended to levels IV and V.

RESULTS

All frozen sections were compared with a definitive test after paraffin inclusion. During surgery, 70 END were performed, and 210 nodes were analyzed with frozen sections. Among the 70 END, 52 were negative after frozen Sects. (156 negative nodes), and surgery was ended. Five of the 52 negative ENDs resulted in pN + after paraffin inclusion (9.6%), which underwent postoperative adjuvant treatment. The sensibility of our END + frozen section method was 75%, while the specificity of our test was 94%. The negative predictive value was 90,4%.

CONCLUSIONS

Elective neck dissection + intraoperative frozen section could be an alternative to SLNB to spot occult nodal metastases in cT1-2N0 OSCC due to the opportunity to perform a one-step diagnostic/therapeutic procedure.

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.

ALIX promotes cell migration and invasion of head and neck squamous cell carcinoma by regulating the expression of MMP9, MMP14, VEGF-C

OBJECTIVE

The poor survival rate of head and neck squamous cell carcinoma (HNSCC), one of the most prevalent human cancer, is attributed to frequent locoregional recurrence and lymph node metastases. Though it is reported that the expression of ALG-2 interacting protein X (ALIX) closely correlates with the progression of various tumors, its role in HNSCC remains unclear. The present study aims to investigate the role of ALIX in the development of HNSCC.

DESIGN

With immunohistochemical staining, the expression levels of ALIX and series of related functional proteins were compared in normal mucosal (n = 18), HNSCC tissues (n = 54), and metastatic lymph nodes (n = 11). Further, the correlation analysis was performed among the proteins detected. By knocking down ALIX in HNSCC cell lines, the correlation of ALIX with the proteins was verified in vitro. The role of ALIX in proliferation, migration, and invasion of HNSCC cells was further studied by flow cytometry, wounding healing, and transwell assays, respectively.

RESULTS

Higher expression level of ALIX was revealed in HNSCC samples, especially in metastatic lymph nodes, than in normal mucosal tissues. Accordingly, increasing levels of MMP9, MMP14, and VEGF-C were also discovered in metastatic lymph nodes and significantly correlated with the expression of ALIX. In vitro assays demonstrated that the knockdown of ALIX reduced both the transcriptional and protein levels of MMP9, MMP14, and VEGF-C, together with suppressed migration and weakened invasion of HNSCC cell lines.

CONCLUSIONS

ALIX up-regulated the expression of MMP9, MMP14 and VEGF-C, and promoted migration and invasion of HNSCC cells.

Sentinel lymph node biopsy in early oral cancers: are we ready for it yet? Results from a survey among Indian surgeons treating oral cancers

OBJECTIVE

Emerging evidence has shown that sentinel node biopsy (SNB) is an oncologically safe option in patients with early oral cancer compared with elective neck dissection (END). However, its use on a routine basis could be associated with many challenges.

STUDY DESIGN

This online survey was conducted among the Indian surgeons treating patients with oral cancer to understand and comprehend the incidence and patterns of usage of SNB in their practice, their approach toward the use of SNB, and the possible challenges they face or perceive in its routine use in patients with early oral cancer.

RESULTS

We received 352 responses with a response rate of 47.63%. Most of the respondents (82.6%) were managing N-zero necks with END, only 15.1% (n = 53) respondents practiced SNB currently. Most respondents believed that SNB offered the advantage of better shoulder function compared with END (76.4% [n = 269]). The deterrents considered for routine use of SNB in early oral cancer were additional costs (71.9% [n = 253]), the unavailability of necessary expertise and infrastructure (87.2% [n = 307]), SLNB being a more time-consuming treatment (58.8% [n = 207]), a higher false negative rate (74.1% [n = 261]), and the possible need of a second surgery (82.4% [n = 290]).

CONCLUSIONS

Though SNB presently could be considered as an alternative treatment option, there seem to be various issues that need to be addressed before it can be adopted as a standard of care across centers.

Knowledge of Oral Cancer Risk Factors among International Medical and Dental Students at the Lithuanian University of Health Sciences: A Cross-Sectional Study

The aim of this study was to evaluate knowledge of oral cancer risk factors among international dental and medical students at the Lithuanian University of Health Sciences (LSMU). A cross-sectional study was conducted among international medical and dental students at the LSMU in 2018−2019. In total, 253 students participated, for a response rate of 76.2%. An anonymous self-administered English questionnaire, consisting of 18 items, covered background information (gender, faculty and academic study year), and statements about risk factors for oral cancer and attitudes towards the prevention and treatment of oral cancer. The fifteen statements had the following answer options: yes, no and I don’t know. The statistical data analysis was performed using SPSS version 22. Overall, a good, fair and poor knowledge of oral risk factors was reported by 15.02%, 56.92% and 28.06% of the participants, respectively. The mean score for knowledge of oral cancer risk factors was 10.01 (SD = 2.56), which was defined as fair knowledge. Cronbach’s alpha was found to be 0.78 (a good value). Bartlett’s sphericity test and the KMO index were adequate (χ2 = 677.563, p < 0.001; KMO = 0.788). This study demonstrates a lack of knowledge of oral cancer risk factors among international medical and dental students.

Elective Neck Dissection Versus Observation in cT1-T2 Oral Tongue Squamous Cell Carcinoma: A Meta-Analysis of 11,973 Patients

The surgical management of the clinical negative neck node in early oral tongue squamous cell carcinoma (OTSCC) has been the topic of debate since few decades. As the occult cervical lymph node metastasis is considered to be the prime prognostic factor in early OTSCC, this meta-analysis has been carried out to find the risk of regional nodal recurrence, disease specific survival and overall survival rates in outcome of Elective neck dissection (END) versus patients under observation. The articles were electronically retrieved from Ovid Medline, PubMed, Cochrane and Scholar for comparison of END versus Observation in early OTSCC. The search strategy identified 37 relevant review articles from April 1979 to April 2020 from different search engines. A total of 11,973 patients from 32 retrospective analysis, 4 prospective and 1 randomised control trial were included in this meta-analysis. Statistical analysis revealed Overall test (OR: 5.31 95% CI: - 2.132-14.698) with t-test 1.919 and p value 0.113 which is not statistically significant but the readings says that there is always better Disease specific survival with END patients rather than patients kept on observation. Overall test revealed (OR: 13.02 95% CI: 1.360-17.154) with t test 2.382 and p value 0.023 which is statistically significant and showed that End significantly reduced the risk of regional nodal recurrence. Overall test revealed (OR: 7.93 95% CI: - 15.461-4.238) with t test - 1.347 and p value 0.220 which is statistically insignificant and but showed that to some extent Overall survival improves in patient with END than the patients kept on observation. This meta-analysis find that there is statistically significant relationship when Elective neck dissection was performed which reduced the risk of regional nodal recurrence. This analysis didn't statistically find any significance in Disease specific survival and Overall survival with Elective neck dissection patients rather than patients kept on observation but however showed good prognosis when elective neck dissection was performed.

Sentinel node biopsy in node negative early oral cancers: Solution to the conundrum!

Ideal management of the node-negative neck in early oral cancers is a debated issue. Elective neck dissection (END) is recommended in these patients as it offers a survival benefit. However, about 50-70% of patients who do not harbor occult metastasis are overtreated with this approach. Surgery is associated with morbidity, predominantly shoulder dysfunction. Numerous attempts have been made to identify true node-negative patients through imaging and prediction models but none have high diagnostic accuracy to safely spare the neck dissection. The recent publications of 2 large randomized controlled trials comparing the outcomes of sentinel node biopsy (SNB) and END have spurred interest in SNB. Both the trials reported SNB to be an oncologically safe procedure and spared unnecessary neck dissections. The functional outcomes of the trials showed that SNB limits the morbidity compared to END, which albeit evens out at the end of one-year post-surgery. Despite its benefits, SNB has failed to gain widespread acceptability due to various limitations including the need for infrastructure, equipment costs, staff, and multidisciplinary collaboration of nuclear medicine, surgical, and pathology fraternity. The labor-intensive pathology protocol with serial step sectioning and immunohistochemistry poses a challenge to the feasibility at a high-volume center. This perspective discusses these limitations and propose plausible solutions to the conundrum. To make it widely applicable and feasible across the globe efforts should be directed to understand biology better, find novel solutions, and implement the lessons learned over decades from other sites.

Oral Cancer Incidence, Mortality, and Mortality-to-Incidence Ratio Are Associated with Human Development Index in China, 1990–2019

The burden of oral cancer (OC) is closely related to economic development. We aimed to evaluate the burden of OC at different stages of economic development in China in terms of incidence, mortality, and mortality-to-incidence ratio (MIR) from 1990 to 2019. Data on cancer in China from 1990 to 2019 were obtained from the Global Burden of Disease 2019. Based on human development index (HDI), Chinese economic development was divided into three stages: low, medium, and high HDI stages. Mann–Whitney U-test was used to evaluate the differences in age-standardised incidence rates (ASIR), age-standardised mortality rates (ASMR), and MIR at various stages of HDI. Correlation and regression tests were conducted to examine the association amongst ASIR, ASMR, MIR, and HDI in OC. The estimated annual percentage changes (EAPCs) were calculated to assess the trend of ASIR, ASMR, and MIR. Significant differences were observed in terms of ASIR, ASMR, and MIR between groups (P < 0.001). The values of both sexes in the low HDI stage were lower than those of the medium and high HDI stages, except for MIR, in which the low HDI stage was the highest (P < 0.05). ASIR and ASMR of OC in males at the medium HDI stage showed the fastest growth rate with EAPC values of 5.64 (95% confidence interval, 95% CI, 5.20 to 6.08) and 4.42 (95% CI, 4.01 to 4.82), respectively. A strong positive correlation exists between HDI and ASIR (r = 0.96) and ASMR (r = 0.91) in both sexes from 1990 to 2019. During the high HDI stage, the ASIR and ASMR of OC were at a high level, but the ASIR halted the uptrend trend and ASMR showed a decreasing trend. Therefore, the HDI index has been positively correlated with the ASIR and ASMR of OC in China in the past 30 years, but this relationship may not be sustained as the economy develops. The health department should continue to allocate additional resources for the prevention and treatment of OC.

Relationship Between Dietary Fiber and Vitamin C Intake and Oral Cancer

Background

Dietary fiber and vitamin C has been reported to play a possible role in tumorigenesis. However, few studies have estimated their association with oral cancer risk. In this project, we investigated the relationship between dietary fiber and vitamin C and oral cancer risk in adults in Southern China.

Methods

382 patients newly diagnosed with oral cancer were matched to 382 hospital derived controls by frequency matching in age and sex. Pre-diagnostic consumption of dietary fiber and vitamin C intake were measured through food frequency questionnaire. Association between nutrients intake and oral cancer risk were evaluated by logistic regression. OR value and 95% confidence interval was calculated.

Results

Intake of dietary fiber and vitamin C was significantly lower in oral cancer patients (8.15 g/day) than in control participants (8.88 g/day). Increased dietary fiber or vitamin C intake was linked to a decreased incidence of OC after adjustment of age, marital status, residence, BMI, occupation, education, tobacco smoking, alcohol consumption and family history of cancer P_trend< 0.001). Compared with the lowest tertile, the adjusted OR of the top tertile of dietary fiber was 0.47 (95 % CI 0.32, 0.68). While the adjusted OR of the highest tertile was 0.60 (95 % CI 0.42, 0.87) compared with the lowest tertile of vitamin C.

Conclusions

Dietary intake of fiber and vitamin C were lower in oral cancer patients than in control participants. Dietary fiber and vitamin C were inversely related to risk of oral cancer risk.

Comparative study on Classifications of AJCC 8th and 7th in the patients with tongue squamous cell carcinoma

OBJECTIVES

Depth of invasion (DOI) is the most important predictor for lymph node metastasis in early-stage oral cancer. This study aims to investigate the effects of the different classifications of AJCC 7th and 8th on predicting lymph node metastasis and the optimal cutoff point for DOI predicting the lymph node metastasis in patients with tongue squamous cell carcinoma (TSCC).

MATERIALS AND METHODS

We performed a retrospective study in 208 TSCC patients in early T-stage without clinical or radiological signs of lymph node metastasis. Those patients were treated with elective neck dissection (END) between April 2019 and December 2020. And the relation between DOI and lymph node metastasis was analyzed.

RESULTS

Metastases were found in 58 of 208 patients (27.88%). Of those 58 patients, the mean DOI was 8.311 mm compared to 5.425 mm in patients without metastases (P < 0.0001). The receiver operating characteristic curve (ROC-curve) showed an area under the curve of 0.7066 with the most optimal cutoff point on a DOI of 4.050 mm (sensitivity 86.21%, specificity 52%). Linear regression analysis (1 mm≤DOI≤6 mm) revealed that a DOI ≥ 3.211 mm predicated an incidence of occult lymph node metastasis greater than 20%. Regional metastases were found in 12.82% of patients with DOI ≤ 4.0 mm. Within the entire cohort, 60 cases (28.85%) got upgraded with respect to T-stage. No tumor underwent downstaging.

CONCLUSION

The 8th edition provides better lymph node metastasis prediction for TSCC than the 7th. And DOI is a poor predictor for regional metastasis in patients with early T-stage clinically node-negative TSCC. END in patients with early-stage TSCC should be performed in patients with DOI ≥ 3.211 mm.

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.

The neuropeptide calcitonin gene-related peptide links perineural invasion with lymph node metastasis in oral squamous cell carcinoma

Objective

Although perineural invasion (PNI) is well-known to be correlated with and able to predict lymph node metastasis (LNM) in oral squamous cell carcinoma (OSCC), the clinical and molecular correlation between PNI and LNM has not been elucidated, and preoperative biomarkers for LNM prediction in OSCC are urgently needed.

Materials and methods

The correlation between PNI and LNM was retrospectively evaluated using a cohort of 218 patients diagnosed with OSCC. Candidate neuropeptides were screened based on TCGA database and verified via immunohistochemistry and Western blot analyses. ELISA was used to detect calcitonin gene-related peptide (CGRP) in patient plasma. In vitro assays were used to explore the effects of CGRP on OSCC cells.

Results

OSCC patients with PNI had a higher incidence of LNM (69.86% vs. 26.2%, P < 0.0001, n = 218). CGRP expression was upregulated in the PNI niche and in metastatic lymph nodes, and was correlated with poor overall survival of OSCC patients. Preoperative plasma CGRP levels were higher in OSCC patients (n = 70) compared to healthy donors (n = 60) (48.59 vs. 14.58 pg/ml, P < 0.0001), and were correlated with LNM (P < 0.0001) and PNI (P = 0.0002). Preoperative plasma CGRP levels alone yielded an AUC value of 0.8088 to predict LNM, and CGRP levels combined with preoperative T stage reached an AUC value of 0.8590. CGRP promoted proliferation and migration abilities of OSCC cells, which could be antagonized by either pharmacological or genetic blockade of the CGRP receptor.

Conclusions

The neuropeptide CGRP links PNI and LNM in OSCC, and preoperative plasma CGRP levels can be used to predict LNM in OSCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08998-9.

Diagnostic efficacy of combined CT and MRI in detecting nodal metastasis in patients with oral cancer

OBJECTIVE

The objective of this study was to assess the diagnostic efficacy of combined computed tomography (CT) and magnetic resonance imaging (MRI) in detecting metastases of oral cancers to lymph nodes in the neck.

STUDY DESIGN

In total, 105 patients with previously untreated oral squamous cell carcinoma underwent both CT and MRI within 6 weeks before tumor excision and selective neck dissection. The diagnostic efficacy of combined CT and MRI was compared with published data on the efficacy of CT and MRI alone.

RESULTS

The sensitivity, specificity, positive and negative predictive values, and accuracy of diagnosis based on CT and MRI were 80%, 90%, 80%, 90%, and 87%, respectively. These values were similar to or higher than those reported in a meta-analysis for CT or MRI alone. The highest and lowest sensitivities were found for metastatic nodes at levels I (75%) and III (33%). The highest and lowest specificities were discovered for nodes at levels IV (99%) and I (88%).

CONCLUSIONS

Combined CT and MRI may be superior to a single modality alone in detecting metastatic neck nodes. This may have an advantage in both preoperative planning and neck surveillance in superficial oral cancers.

LncRNA HOXA-AS2 Promotes Oral Squamous Cell Proliferation, Migration, and Invasion via Upregulating EZH2 as an Oncogene

Oral squamous cell carcinoma (OSCC) is one of the most common types of cancer worldwide. Accumulating evidence has shown that long noncoding RNAs (lncRNAs) serve important roles in the development of OSCC. The purpose of this study was to investigate the biological function and underlying regulatory mechanism of lncRNA homeobox A cluster antisense RNA2 (HOXA-AS2) in OSCC. RT-qPCR was performed to analyze the HOXA-AS2 expressions in human immortalized oral epithelial cell (HIOEC) line, human OSCC cell lines, and plasma. The expression of HOXA-AS2 and enhancer of zeste 2 polycomb repressive complex 2 subunit (EZH2) in Tca-8113 cells were knocked down or overexpressed by transfection with shRNA-HOXA-AS2 or pcDNA-EZH2, respectively. The interaction between HOXA-AS2 and EZH2 was validated by RNA immunoprecipitation assay. In addition, cell proliferation was assessed by CCK-8 and EdU assays. Cell cycle distribution was analyzed by flow cytometry. Cell migration and invasion were detected using wound healing and Transwell assays, respectively. Apoptosis was detected by TUNEL staining. The protein expression levels of cell cycle and apoptosis-related proteins were measured by western blot analysis. Compared with HIOEC cells, HOXA-AS2 expression in OSCC cells was upregulated. HOXA-AS2 knockdown significantly inhibited Tca-8113 cell proliferation, blocked the cell cycle by arresting cells in the G0/G1 phase, promoted apoptosis, and suppressed migration and invasion. In addition, HOXA-AS2 was predicted to directly target EZH2 and positively regulate EZH2 expression. EZH2 overexpression could reverse the inhibitory effect of HOXA-AS2 knockdown on the proliferation, migration, and invasion of Tca-8113 cells. In summary, the findings suggested that HOXA-AS2 may inhibit cell proliferation, invasion, and migration, induce cell cycle arrest in the G0/G1 phase, and increase cell apoptosis by targeting EZH2. The research indicated that HOXA-AS2/EZH2 axis may play a key role in the development of OSCC.

Assessment of squamous cell carcinoma of the floor of the mouth with magnetic resonance imaging

PURPOSE

We aimed to use magnetic resonance imaging (MRI) to determine the relationship between the pathological depth of invasion (DOI), undetectability, and tumor thickness of squamous cell carcinoma of the floor of the mouth.

MATERIALS AND METHODS

We retrospectively evaluated the relationship between pathological DOI and MRI detectability, as well as the relationship between pathological DOI and tumor thickness on coronal fat-suppressed contrast-enhanced T1-weighted imaging or coronal T2-weighted imaging.

RESULTS

We analyzed 30 patients with squamous cell carcinoma of the floor of the mouth; MRI revealed that the pathological DOI of the 11 undetectable lesions (median 2 mm) was smaller than that of the 19 detectable lesions (median 14 mm) (p < 0.001), and the cut-off value was 3 mm (sensitivity, 0.84; specificity, 0.91; area under the curve, 0.89). Tumor thickness on coronal fat-suppressed contrast-enhanced T1-weighted imaging was assessed in all 19 detectable lesions; however, tumor thickness on coronal T2-weighted imaging could not be assessed in eight cases. Tumor thickness on coronal fat-suppressed contrast-enhanced T1-weighted imaging was found to be significantly associated with the pathological DOI.

CONCLUSIONS

Undetectability on MRI indicates superficial lesions with a pathological DOI value that is less than 3 mm. In detectable lesions, tumor thickness on coronal fat-suppressed contrast-enhanced T1-weighted imaging is associated with pathological DOI.

Elective node dissection versus observation for management of patients with early-stage cT1/T2N0 tongue carcinoma: A systematic review and meta-analysis of prospective studies

OBJECTIVE

To carry out a meta-analysis of prospective literature comparing the clinical efficacy of elective neck dissection (END) vs observation (OBS) in patients with early-stage cT1/T2N0 tongue carcinoma.

DESIGN/SETTING/PARTICIPANTS/OUTCOME MEASURES

We systematically reviewed four databases from inception to 30-October-2020. We considered all studies meeting the following PICOS conditions: (a) Patients: early-stage cT1/T2N0 tongue carcinoma, (b) Intervention: END, (c) Comparator: OBS, (d) Outcomes: local tongue recurrence, cervical nodal recurrence, disease-specific survival (DSS) rate, and disease-free survival (DFS) rate and (e) Study design: prospective reports. We pooled dichotomous data as relative risks (RRs) with 95% confidence intervals (CIs).

RESULTS

Four studies (one case-control study and three randomised controlled trials) met our inclusion criteria. There were 448 eligible patients (225 and 223 patients were treated with END and OBS, respectively). END significantly correlated with improved DSS rate (RR = 1.15, 95% CI: 1.04-1.27, P = .007). Nonetheless, there were no significant differences between END and OBS groups regarding the rates of local tongue recurrence (RR = 1.23, 95% CI: 0.50-3.03, P = .65), cervical nodal recurrence (RR = 0.45, 95% CI: 0.16-1.27, P = .13) and DFS rate (RR = 1.08, 95% CI: 0.91-1.27, P = .38). Pooled analysis for cervical nodal recurrence was heterogeneous, and sensitivity analysis revealed a significantly lower cervical nodal recurrence rate in favour of END group (RR = 0.30, 95% CI: 0.13-0.67, P = .004).

CONCLUSION

END correlated with a significant decrease in cervical nodal recurrence and improved DSS rate. END might be superior to OBS in patients with early-stage cT1/T2N0 tongue cancer.

Research on neck dissection for oral squamous-cell carcinoma: a bibliometric analysis

Neck dissection for oral squamous-cell carcinoma (OSCC) is a clinically controversial issue and has therefore been the subject of abundant research. However, no one has performed a bibliometric study on this topic to date. The aim of this study was to assess the development of research on neck dissection for OSCC in terms of the historical evolution, current hotspots and future directions, particularly including research trends and frontiers from 2010 to 2019. Literature records related to research on neck dissection for OSCC were retrieved from the Web of Science Core Collection (WoSCC). CiteSpace was used as a tool to perform a bibliometric analysis of this topic. The survey included 2 096 papers. “Otorhinolaryngology” was the most popular research area. The most active institutions and countries were Memorial Sloan Kettering Cancer Center and the USA, respectively. Shah J.P. was the most cited author. Among the six identified “core journals”, Head & Neck ranked first. The top three trending keywords were ‘invasion’, ‘upper aerodigestive’ and ‘negative neck’. ‘D’Cruz AK (2015)’ was the most cited and the strongest burst reference in the last decade. The study evaluated the effect on survival of elective versus therapeutic neck dissection in patients with lateralized early-stage OSCC. The depth of invasion and the management of N0 OSCC were research frontiers in this field. The present study provides a comprehensive bibliometric analysis of research on neck dissection for OSCC, which will assist investigators in exploring potential research directions.

The impact of sentinel lymph node biopsy on the quality of life in patients with oral cavity squamous cell carcinoma

INTRODUCTION

Sentinel lymph node biopsy is a proven method for staging the neck in patients with early oral cavity squamous cell carcinoma because it results in less comorbidity than the traditional method of selective neck dissection, with the same oncological results. However, the real effect of that method on the quality of life of such patients remains unknown.

OBJECTIVE

The present study aimed to evaluate the quality of life of patients with oral cavity squamous cell carcinoma T1/T2N0 submitted to sentinel lymph node biopsy compared to those that received selective neck dissection.

METHODS

Cross-sectional study including 24 patients, after a 36 month follow-up, 15 of them submitted to the sentinel lymph node biopsy and 9 to selective neck dissection. All patients answered the University of Washington quality of life questionnaire.

RESULTS

The evaluation of the questionnaires showed a late worsening of the domains appearance (p=0.035) and chewing (p=0.041), as well as a decrease of about 10% of general quality of life (p=0.025) in patients undergoing selective neck dissection ​​in comparison to those undergoing sentinel lymph node biopsy.

CONCLUSION

Patients with early-stage oral cavity squamous cell carcinoma undergoing sentinel lymph node biopsy presented better late results of general quality of life, mainly regarding appearance and chewing, when compared to patients submitted to selective neck dissection.

Dysregulation of FOXD2-AS1 promotes cell proliferation and migration and predicts poor prognosis in oral squamous cell carcinoma: a study based on TCGA data

FOXD2 adjacent opposite strand RNA 1 (FOXD2-AS1) plays an important role in the pathogenesis of some cancers. However, its functional role in oral squamous cell carcinoma (OSCC) remains largely unknown. In this study, we conducted expressional and functional analyses of FOXD2-AS1 using data from the Cancer Genome Atlas (TCGA) and in vitro OSCC assays. FOXD2-AS1 dysregulation was remarkably associated with radiation therapy, anatomic location, high histologic grade, and lymphovascular invasion (P < 0.05). A nomogram based on FOXD2-AS1 expression was constructed for use as a diagnostic indicator for OSCC patients, and multivariate cox regression analysis showed that FOXD2-AS1 expression was an independent prognostic factor for OSCC patients. KEGG, gene set enrichment analysis, and immune infiltration evaluations indicated that FOXD2-AS1 was involved in tumor progression via epithelial-to-mesenchymal transition and cell cycle regulation and was negatively associated with mast cell, DCs, iDCs, and B cells. FOXD2-AS1 silencing suppressed the proliferation and migration of Cal27 cells. Our findings showed that an aberrantly high FOXD2-AS1 expression predicts poor prognosis in OSCC; FOXD2-AS1 may act as an oncogenic protein by regulating cell proliferation and migration and may suppress adaptive immunity by modulating the number and function of antigen-presenting cells.

Predictive Value of Occult Metastasis and Survival Significance of Metabolic Tumor Volume Determined by PET-CT in cT1-2N0 Squamous Cell Carcinoma of the Tongue

Objectives

Our goal was to analyze the possibility of using metabolic tumor volume (MTV) to predict occult cervical metastasis and survival in cT1-2N0 squamous cell carcinoma (SCC) of the tongue.

Methods

Data on the primary tumor MTV and cervical node status as determined by the maximum standardized uptake value were retrieved. The sensitivity and specificity in predicting occult metastasis were calculated with a fourfold table. Associations between occult metastasis and clinicopathological variables were evaluated by univariate and multivariate analyses. The main study endpoints were locoregional control (LRC) and disease-specific survival (DSS).

Results

A total of 24 (20.3%) of 118 patients had occult metastasis. An MTV cutoff value of 4.3 cm³ showed a sensitivity of 50.0% and a specificity of 76.6% in predicting occult metastasis. The sensitivity and specificity of PET-CT in predicting occult metastasis in cT1 tumors were 66.6 and 89.8%, respectively, with values of 83.3 and 67.3%, respectively, when combined with the MTV. The sensitivity and specificity of PET-CT in predicting occult metastasis in cT2 tumors were 72.2 and 82.2%, respectively, with values of 88.9 and 57.8%, respectively, when combined with the MTV. Patients with MTV ≥4.3 cm³ had a higher occult metastasis rate than patients with MTV <4.3 cm³. The 5-year LRC and DSS rates were 86 and 94%, respectively, in patients with MTV <4.3 cm³ and 54 and 72%, respectively, in patients with MTV ≥4.3 cm³. Both differences were found to be significant in univariate and multivariate analyses.

Conclusions

MTV ≥4.3 cm³ was associated with an increased probability of occult metastasis and lower LRC and DSS rates in early-stage SCC of the tongue.

Impact of histological Oral Tongue Cancer margins on locoregional recurrence: A multi-centre retrospective analysis

OBJECTIVES

To assess the effect of the histological margins (HM) upon locoregional failure (LRF) and overall survival (OS) for oral tongue squamous cell carcinoma (OTSCC).

MATERIALS AND METHODS

We undertook a retrospective review of 258 patients, across two institutions, treated for OTSCC between 2007 and 2016. A Cox-proportional hazards model was used to compare the relative hazard ratio of HM to the accepted standard of 5 mm margins for LRF and OS.

RESULTS

The median follow up period was 4.8 years. The 5 year OS and freedom from LRF were 69% and 75% respectively. The Cox-proportional hazards model adjusted for age, DOI and LVI showed increasing risk of mortality and LRF with decreasing HM widths of <5 mm.

CONCLUSION

HM >5 mm were associated with a risk reduction of both LRF and mortality in OTSCC. This study supports >5 mm HM being the oncologic goal of surgery.

Sex determining region Y-box 2 is a prognostic factor for head and neck squamous cell carcinoma: Evidence from 11 published investigations

Objective

The aim of this study was to review the published literature and investigate whether sex determining region Y-box 2 (SOX2) is a prognostic factor in head and neck squamous cell carcinoma (HNSCC) by conduct a meta-analysis.

Materials and Methods

Trials were identified from the major electronic databases (MEDLINE, EMBASE, and Cochrane Library) using the key words "HNSCC" and "SOX2." The overall survival (OS), disease-specific survival (DPS), and disease-free survival (DFS) were the primary outcome measures.

Results

We identified 371 articles, 9 articles 11 studies with a total number of 1334 cases were eligible for inclusion of this meta-analysis. The results showed that OS (DPS) in low-expression group was higher than that in high-expression group. However, the difference between the two groups was not significant (hazard ratio [HR] = 1.30, 95% confidence interval [95% CI] = [0.88, 1.91]; P = 0.18), and there was great statistical heterogeneity (I² = 66%, P = 0.002). After subgroup analysis, the HR for OS of the patients with reduced expression of SOX2 was 1.34 (95% CI = [1.04, 1.74], P = 0.03), and the heterogeneity became acceptable (I² = 32%, P = 0.16). The HR for DFS of the patients with reduced expression of SOX2 was 1.39 (95% CI = [1.00, 1.93]; P = 0.05).

Conclusion

The findings of this meta-analysis are indicative of that high SOX2 expression is a negative prognostic factor of HNSCC and exhibit both worse OS and DFS. However, the small sample size available for this systematic review limited the power of this quantitative meta-analysis. It may therefore be too early to place complete confidence in these results.

Variability in Recommendations for Cervical Lymph Node Pathology for Staging of Canine Oral Neoplasia: A Survey Study

There is no clear guideline regarding the indication for routine lymph node extirpation and pathologic evaluation during staging of canine oral tumors, despite a relatively high reported nodal metastatic rate for select tumor types. It is particularly unclear if clinicians recommend removal of lymph nodes only when there is confirmation of metastasis, defined as the N+ neck, or if elective neck dissection (END) is routinely recommended to confirm the true pathologic metastatic status of lymph nodes in the clinical N0 neck (no evidence of metastasis on clinical staging with diagnostic imaging or cytology). When clinicians are recommending END as a staging tool to confirm nodal status, there is also ambiguity regarding the surgical extent for subsequent histopathologic evaluation. The objective of this cross-sectional survey study was to determine the current recommendations given by practicing specialists regarding lymph node removal for dogs with oral tumors. Overall, 87 responses were obtained from 49 private practices (56%) and 38 academic institutions (44%). Respondents identified as oncologists (44%, N = 38), soft tissue surgeons (40%, N = 35), and dentists (16%, N = 14). Regardless of tumor type and stage, extirpation and histopathology were most commonly recommended in the clinical N+ neck only. The recommendation to routinely perform END in the N0 neck was significantly associated with tumor type. Bilateral removal of the mandibular and retropharyngeal lymph nodes was recommended more often for oral malignant melanoma (OMM) than for oral squamous cell carcinoma (OSCC; p ≤ 0.0039) or for oral fibrosarcoma (OFSA; p ≤ 0.0007). The likelihood of recommending END increased with increasing tumor size. Academic clinicians were significantly (p < 0.01) more likely to recommend END compared to private practitioners for canine T1-T3 OMM, T3 OSCC, T2 OFSA, and MCT. This study highlights the variability in recommendations for lymph node pathology for dogs with oral tumors. While tumor type and size influenced the decision to pursue END, it was not routinely recommended, even for tumor types with a known propensity for metastasis. Prospective studies are warranted to determine the potential diagnostic and therapeutic value of END in the N0 neck in veterinary patients such that a consensus approach can be made.

Prognostic significance of extranodal extension in oral cavity squamous cell carcinoma with occult neck metastases

A grade of extranodal extension (ENE) may advance risk stratification related to survival in patients with metastatic oral cavity squamous cell carcinoma (OCSCC). Pathological examination of 174 OCSCC patients who were primarily surgically treated with tumour resection and elective neck dissection was performed. Data of ENE presence, its extent (in millimetres), patients and tumour characteristics were statistically analysed with respect to disease-free survival (DFS) and overall survival (OS). Ninety patients (51.7%) were identified with occult nodal disease, with 41 patients (23.6%) presenting with ENE. Receiver operating characteristics (ROC) curve analysis set the threshold at 1.9 mm as an optimal ENE cut-off regarding both DFS and OS. Patients were divided by extent into minor ENE (≤1.9 mm) and major ENE (>1.9 mm) subgroups. The subgroup with minor ENE had significantly higher DFS and OS rates compared with major ENE. ENE cut-off threshold at 1.9 mm discriminates low and high-risk subgroups of patients with occult OCSCC in terms of DFS and OS.

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

Metastasis of oral squamous cell carcinoma (OSCC) to the cervical lymph nodes has a significant impact on prognosis. Accurate staging of the neck is important in order to deliver appropriate treatment for locoregional control of the disease and for prognosis. The management of the neck in early, low volume disease (clinically T₁/T₂ oral cavity tumours) has long been debated. The risk of occult nodal involvement in cT₁/T₂ OSCC is estimated around 20-30%. We describe the natural evolutionary history of OSCC and its patterns of spread and metastasis to the local lymphatic basins. We discuss most published literature and studies on management of the clinically negative neck (cN₀). Particular focus is given to prospective randomized trials comparing the outcomes of upfront elective neck dissection against the observational stance, and we summarize the results of the sentinel node biopsy studies. The paper discusses the significance of the primary tumour histological characteristics and specifically the tumour's depth of invasion (DOI) and its impact on predicting nodal metastasis. The DOI has been incorporated in the TNM staging highlighting its significance in aiding the treatment decision making and this is reflected in world-wide oncological guidelines. The critical analysis of all available literature amalgamates the existing evidence in early OSCC and provides recommendations in the management of the clinically N₀ neck.

Lingual Lymph Node Metastasis in cT1-2N0 Tongue Squamous Cell Carcinoma: Is It an Indicator for Elective Neck Dissection

Objective: Accurate predictors for occult metastasis in cT1-2N0 tongue squamous cell carcinoma (SCC) remains scarce, the main goal in current study was to evaluate whether there is significant association between lingual lymph node (LLN) metastasis and occult lymph node metastasis as well as whether there is prognostic value of LLN metastasis in early stage tongue SCC.

Methods: Patients with surgically treated primary cT1-2N0 tongue SCC were prospectively enrolled from January 2010 to December 2018. LLNs were dissected independently for pathologic analysis. The main study endpoints were locoregional control survival (LRC) and disease-specific survival (DSS). The Chi-square test and multivariate regression analysis were used to assess the predictors for occult metastasis. The Kaplan-Meier approach and Cox model were used to analyze the potential prognostic factors.

Results: A total of 317 patients were enrolled for analysis. Eighty-eight patients had occult metastasis with a prevalence of 27.8%. LLNs presented in 89 patients, in which 43 patients had LLN metastasis. In the 43 patients with positive LLNs, 20 patients had occult metastasis, in 274 patients with negative LLNs or no LLNs, 68 patients had occult metastasis, the difference was significant (p = 0.012). Further multivariate regression analysis confirmed the independence of LLN metastasis in predicting the occult metastasis. In patients without LLNs, the 5-year LRC rate was 79%, in patients with negative LLNs, the 5-year LRC rate was 78%, in patients with positive LLNs, the 5-year LRC rate was 62%, the difference was significant (p = 0.024). In patients without LLNs, the 5-year DSS rate was 84%, in patients with negative LLNs, the 5-year DSS rate was 74%, in patients with positive LLNs, the 5-year DSS rate was 51%, the difference was significant (p < 0.001), further Cox model confirmed the independence of LLN metastasis in affecting the LRC and DSS.

Conclusions: LLN metastasis is significantly associated with occult neck lymph node metastasis, and decrease the LRC and DSS in early stage tongue SCC.

Genomics and precision surgery for head and neck squamous cell carcinoma

The identification of the biological determinants that shape the response of tumors to medical therapies offers perspectives for better patient stratification and therapeutic targeting. Here, we discuss how genomics could help to improve the surgical treatment of head and neck squamous cell carcinoma (HNSCC). We examine the potential use of genomic analyses for: i) refining and standardizing the indications for surgery, ii) the choice of surgical procedure, and iii) the follow-up of patients with resected tumors. We highlight the studies that used genomics to explore the contribution of tumor biology to the outcome of surgery. We discuss the important developments that are challenging current surgical practice in HNSCC, such as neoadjuvant immunotherapy and the analysis of circulating DNA. Genomic analyses provide practical tools that could help improve the pathological diagnosis and staging of HNSCC, and increase the appreciation of the importance of tumor biology in the outcome of surgery. Identification of biomarkers will likely contribute to a move toward precision surgery of HNSCC, i.e. the personalization of surgical practice based on tumor biology.

Global and regional burdens of oral cancer from 1990 to 2017: Results from the global burden of disease study

Background

Data on the incidence, mortality, and other burden of oral cancer as well as their secular trends are necessary to provide policy‐makers with the information needed to allocate resources appropriately. The purpose of this study was to use the Global Burden of Disease (GBD) 2017 results to estimate the incidence, mortality, and disability‐adjusted life years (DALYs) for oral cancer from 1990 to 2017.

Methods

We collected detailed data on oral cancer from 1990 to 2017 from the GBD 2017. The global incidence, mortality, and DALYs attributable to oral cancer as well as the corresponding age‐standardized rates (ASRs) were calculated. The estimated annual percentage changes in the ASRs of incidence (ASRI) and mortality (ASRM) and age‐standardized DALYs of oral cancer were also calculated according to regions and countries to quantify the secular trends in these rates.

Results

We tracked the incidence, mortality, and DALYs of oral cancer in 195 countries/territories over 28 years. Globally, the incidence, mortality, and DALYs of oral cancer increased by about 1.0‐fold from 1990 to 2017. The ASRI of oral cancer showed a similar trend, increasing from 4.41 to 4.84 per 100,000 person‐years during the study period. The ASRM remained approximately stable at about 2.4 per 100,000 from 1990 to 2017, as did the age‐standardized DALYs, at about 64.0 per 100,000 person‐years. ASRI was highest in Pakistan (27.03/100,000, 95% CI = 22.13‐32.75/100,000), followed by Taiwan China, and lowest in Iraq (0.96/100,000, 95% CI = 0.86‐1.06/100,000). ASRM was highest in Pakistan (16.85/100,000, 95% CI = 13.92‐20.17/100,000) and lowest in Kuwait (0.51/100,000, 95% CI = 0.45‐0.58/100,000).

Conclusions

The ASRI of oral cancer has increased slightly worldwide, while the ASRM and age‐standardized DALY have remained stable. However, these characteristics vary between countries, suggesting that current prevention strategies should be reoriented, and much more targeted and specific strategies should be established in some countries to forestall the increase in oral cancer.

Differential expression of matrix metalloproteinases and miRNAs in the metastasis of oral squamous cell carcinoma

BACKGROUND

Our study aimed to reveal the regulatory mechanisms of miRNAs and matrix metalloproteinases (MMPs) in oral squamous cell carcinoma (OSCC).

METHODS

The mRNA and miRNA expression profiles of six metastatic tumour samples, six nonmetastatic tumour samples, and six normal tissue samples were used for microarray analysis. Moreover, the important genes and miRNAs were validated by published profiles in Oncomine and by qRT-PCR.

RESULTS

MMP7, MMP13, and MMP10 were upregulated, and MMP12 and MMP9 were downregulated in metastatic tumours compared with nonmetastatic tumours. MMP7 was regulated by miR-4697-5p and miR-7109-5p. MMP7 and MMP13 were upregulated in OSCC samples compared with normal samples in Oncomine. Moreover, qRT-PCR revealed that the expression of miR-7109-5p and miR-34b was decreased in metastatic tumours compared with nonmetastatic tumours.

CONCLUSIONS

Our study suggested that miR-7109-5p and miR-34b might play important roles in the metastasis of OSCC by regulating MMP7 and MMP13 expression, respectively.

Diagnostic accuracy of E-cadherin for malignanteffusions: a systematic review and meta-analysis

BACKGROUND

The differential diagnosis of malignant effusion remains a clinical challenge. We aim to summarise all relevant literature studies in order to determine the overall clinical value of E-cadherin in the diagnosis of malignant effusion by meta-analysis.

METHODS

PubMed, the Cochrane Library Database, Medline (Ovid), Web of Science, CNKI, WANFANG and WEIPU databases are thoroughly searched up to 15 March2018. The calculated pooled sensitivity, specificity, likelihood ratio (LR), diagnostic OR(DOR) and the summary receiver operating characteristic (SROC) curve were plotted.

RESULTS

A total of 15 studies were included in the analysis. The sensitivity and specificity of E-cadherin in the diagnosis of malignant effusion were determined to be high, with a sensitivity of 0.83(95%CI0.79 to 0.87) and a specificity of 0.96(95%CI0.90 to 0.98). The positive LR was determined to be 21.10(95%CI 8.54 to 52.11), the negative LR was determined to be 0.17(95% CI 0.14 to 0.22) and the DOR was determined to be 121.34(95%CI 49.11 to 299.80). The SROC curve exhibited a high overall diagnostic, with the area under the curve measured to be 0.91(95% CI 0.89 to 0.93). Subgroup analysis showed the method (cell blocks or smears), sample size (≥100 or<100), geographical location (Asia, Europe or USA) and impact factor of each article (≥3 or<3) were not the sources of overall heterogeneity.

CONCLUSION

E-cadherin exhibits very good diagnostic accuracy for the diagnosis for malignant effusion; thus, it can be helpful in the process of clinical decisions.

Nationwide randomised trial evaluating elective neck dissection for early stage oral cancer (SEND study) with meta-analysis and concurrent real-world cohort

BACKGROUND

Guidelines remain unclear over whether patients with early stage oral cancer without overt neck disease benefit from upfront elective neck dissection (END), particularly those with the smallest tumours.

METHODS

We conducted a randomised trial of patients with stage T1/T2 N0 disease, who had their mouth tumour resected either with or without END. Data were also collected from a concurrent cohort of patients who had their preferred surgery. Endpoints included overall survival (OS) and disease-free survival (DFS). We conducted a meta-analysis of all six randomised trials.

RESULTS

Two hundred fifty randomised and 346 observational cohort patients were studied (27 hospitals). Occult neck disease was found in 19.1% (T1) and 34.7% (T2) patients respectively. Five-year intention-to-treat hazard ratios (HR) were: OS HR = 0.71 (p = 0.18), and DFS HR = 0.66 (p = 0.04). Corresponding per-protocol results were: OS HR = 0.59 (p = 0.054), and DFS HR = 0.56 (p = 0.007). END was effective for small tumours. END patients experienced more facial/neck nerve damage; QoL was largely unaffected. The observational cohort supported the randomised findings. The meta-analysis produced HR OS 0.64 and DFS 0.54 (p < 0.001).

CONCLUSION

SEND and the cumulative evidence show that within a generalisable setting oral cancer patients who have an upfront END have a lower risk of death/recurrence, even with small tumours.

CLINICAL TRIAL REGISTRATION

NIHR UK Clinical Research Network database ID number: UKCRN 2069 (registered on 17/02/2006), ISCRTN number: 65018995, ClinicalTrials.gov Identifier: NCT00571883.

Elective Neck Dissection Versus Observation in Early-Stage (cT1/T2N0) Oral Squamous Cell Carcinoma

Objectives

Whether to perform elective neck dissection (END) or apply the observation (OBS) policy in patients with early‐stage oral squamous cell carcinoma (OSCC) without clinical evidence of cervical lymph node metastasis (cT1/T2N0) remains uncertain. The two most recent meta‐analyses include many studies published before the widespread availability of CT scanning in the 1990s. With the rapid advancement in imaging studies since 1990, the early clinical detection of cervical node metastasis has become more reliable without the need for END or pathological staging. Thus, we conducted a systematic review and meta‐analysis of studies comparing survival outcomes between END and OBS in patients with cT1/T2N0 OSCC.

Methods

We performed a systematic search of MEDLINE, PubMed, and Scopus for retrospective and prospective studies published between January 1, 1990, and January 1, 2018, comparing clinical outcomes between END and OBS in patients with cT1/T2N0 OSCC. Information on population characteristics, study design, overall survival (OS), disease‐specific survival (DSS), and disease‐free survival (DFS) was extracted and estimated. Effect measures for outcomes were hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

Thirteen retrospective and two prospective randomized studies (3,158 patients) met the inclusion criteria. Compared to OBS, END failed to significantly improve OS (HR, 1.02; 95% CI, 0.95–1.09; P = .77; fixed‐effects model), DSS (HR, 1.07; CI, 1.02–1.13; P = .31; fixed‐effects model), and DFS (HR, 0.86; CI, 0.72–1.01; P = .12; random‐effects model).

Conclusions

Our findings indicate that in patients with cT1T2N0 OSCC, the OBS policy can yield markedly similar OS, DSS, and DFS to those resulting from END.

Level of Evidence

2

Can pattern and depth of invasion predict lymph node relapse and prognosis in tongue squamous cell carcinoma

Background

Tongue squamous cell carcinoma (TSCC) is a special type of oral cancer. Cervical lymph node relapse may occur in a large percentage of TSCC patients, which usually indicates poor prognosis. In this cohort study, we focused on the predictive value of the pathological features on cervical lymph node relapse and TSCC prognosis (disease free survival).

Methods

One hundred forty-one TSCC patients staged as T_1–2N₀ were enrolled and categorized. Subjects were followed-up for 60 months. Univariate analysis was performed with Chi-square test for cervical lymph node relapse and Kaplan-Meier survival analysis and log rank P value for patient prognosis; multivariate analysis was also utilized with Cox regression.

Results

In univariate analysis, trabes growth pattern, depth of invasion greater than 4 mm, poor pathological differentiation and neurovascular invasion were considered as risk factors for cervical lymph node relapse and poor prognosis. In multivariate analysis, only patients with trabes growth pattern in the invasive front or depth of invasion larger than 4 mm had a higher risk of metastasis. Elder age group and trabes growth pattern of invasive front were considered as predictors of poor prognosis. Bad habits of smoking and alcohol consumption were related to the higher risk of metastasis.

Conclusion

Trabes growth pattern of invasive front was a potent risk factor for TSCC cervical lymph node relapse and indicated poor prognosis. Preventive therapy including selective neck dissection was thus suggested for certain patients.

Trial registration

Not applicable.

Tantum verde mouthwash for tonsillectomy: A prospective, double-blind, randomized control trial

OBJECTIVES

Post-tonsillectomy pain control is still considered a challenge. Topical agents would seem to be an ideal, safe option. Our objective was to compare the efficacy of mouthwash preparation with anti-inflammatory, anesthetic, and analgesic properties (Tantum Verde^®, 0.15% benzydamine hydrochloride) with that of placebo in improving post-tonsillectomy morbidity.

METHODS

A prospective, double blind, randomized clinical trial was performed. Patients older than 12-years-of-age who underwent tonsillectomy were recruited. Participants were randomized into 2 groups to receive either 0.15% benzydamine hydrochloride (TV) mouthwash solution (study arm) or a placebo solution. They were instructed to gargle the intervention they received 3 times a day for 7 days following surgery. Primary outcomes were intensity and duration of post-operative pain (using VAS visual analogue score) during a 2-week follow-up period. Secondary outcomes were pain medication demand, readmission, incidence of post-operative bleeding, hospital stay duration, and time to resume normal solid diet.

RESULTS

Thirty-nine patients completed the study, of whom 23 received TV and 16 received placebo. The mean age was 23.1 years. There was no significant difference between the groups in the primary or secondary outcomes.

CONCLUSIONS

The data suggest that topical treatment with TV mouthwash solution was not found to be superior to placebo in the management of post-tonsillectomy pain, bleeding, and return to a regular solid diet. Further research studies should be designed to investigate the ideal treatment for reducing post-tonsillectomy morbidity.

CLINICAL TRIAL REGISTRATION

NIH identifier: NCT02190762; IRB NHR002814.