Pretreatment pain predicts perineural invasion in oral squamous cell carcinoma: A prospective study

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

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

Tumor Neurobiology in the Pathogenesis and Therapy of Head and Neck Cancer

The neurobiology of tumors has attracted considerable interest from clinicians and scientists and has become a multidisciplinary area of research. Neural components not only interact with tumor cells but also influence other elements within the TME, such as immune cells and vascular components, forming a polygonal relationship to synergistically facilitate tumor growth and progression. This review comprehensively summarizes the current state of the knowledge on nerve-tumor crosstalk in head and neck cancer and discusses the potential underlying mechanisms. Several mechanisms facilitating nerve-tumor crosstalk are covered, such as perineural invasion, axonogenesis, neurogenesis, neural reprogramming, and transdifferentiation, and the reciprocal interactions between the nervous and immune systems in the TME are also discussed in this review. Further understanding of the nerve-tumor crosstalk in the TME of head and neck cancer may provide new nerve-targeted treatment options and help improve clinical outcomes for patients.

Perineural Invasion Is a Significant Prognostic Factor in Oral Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

(1) Objectives: This systematic review and meta-analysis aimed to summarize current evidence regarding the prognostic role of perineural invasion (PNI) in patients with oral squamous cell carcinoma (OSCC). (2) Methods: We searched Cochrane Central, ProQuest, PubMed, Scopus, Science Direct, and Web of Science, using relevant keywords to identify eligible articles. Two independent reviewers conducted two-stage screening, data extraction, and quality assessment. The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) criteria. All analyses were performed using comprehensive meta-analysis (CMA; version 3.3.070) software. (3) Results: The study included 101 published articles encompassing 26,062 patients. The pooled analyses showed that PNI was associated with significantly worse overall survival (OS; HR = 1.45, 95% CI: 1.32-1.58; p < 0.001), worse disease-specific survival (DSS; HR = 1.87, 95% CI: 1.65-2.12; p < 0.001), and worse disease-free survival (DFS; HR = 1.87, 95% CI: 1.65-2.12; p < 0.001). Similarly, both local recurrence-free survival (LRFS) and regional recurrence-free survival (RRFS) were worse in patients with PNI (HR = 2.31, 95% CI: 1.72-3.10, p < 0.001; and HR = 2.04, 95% CI: 1.51-2.74, p < 0.001), respectively. The random-effect estimate of three studies demonstrated that the presence of PNI was associated with worse failure-free survival (FFS; HR = 2.59, 95% CI: 1.12-5.98, p < 0.001). (4) Conclusions: The current evidence suggests that PNI can be used as an independent predictor of the prognosis for patients with OSCC. The presence of PNI was associated with worse OS, DFS, DSS, FFS, and with recurrence. Asian patients and patients with extra-tumoral or peripheral PNI invasion were associated with worse prognosis.

Perineural invasion: A potential driver of cancer-induced pain

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

Pretreatment pain predicts perineural invasion in patients with head and neck squamous cell carcinoma

OBJECTIVES

Perineural invasion (PNI) in head and neck cancer (HNC) is a distinct pathological feature used to indicate aggressive tumor behavior and drive treatment strategies. Our study examined the prevalence and predictors of PNI in HNC patients stratified by tumor site.

STUDY DESIGN AND METHODS

A retrospective analysis of head and neck squamous cell carcinoma (HNSCC) patients who underwent surgical resection at the University of Pittsburgh Medical Center between 2015 and 2018 was performed. Pretreatment pain was assessed at least 1 week before surgery using the Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N). Demographics, clinical characteristics, and concomitant medications were obtained from medical records. Patients with cancers at the oropharynx and non-oropharynx (i.e., cancer at oral cavity, mandible, larynx) sites were separately analyzed. Tumor blocks were obtained from 10 patients for histological evaluation of intertumoral nerve presence.

RESULTS

A total of 292 patients (202 males, median age = 60.94 ± 11.06) were assessed. Pain and PNI were significantly associated with higher T stage (p < 0.001) and tumor site (p < 0.001); patients with non-oropharynx tumors reported more pain and had a higher incidence of PNI compared to oropharynx tumors. However, multivariable analysis identified pain as a significant variable uniquely associated with PNI for both tumor sites. Evaluation of nerve presence in tumor tissue showed 5-fold higher nerve density in T2 oral cavity tumors compared to oropharyngeal tumors.

CONCLUSIONS

Our study finds that PNI is associated with pretreatment pain and tumor stage. These data support the need for additional research into the impact of tumor location when investigating targeted therapies of tumor regression.

Autoimmunity, cancer and COVID-19 abnormally activate wound healing pathways: critical role of inflammation

Recent evidence indicates that targeting IL-6 provides broad therapeutic approaches to several diseases. In patients with cancer, autoimmune diseases, severe respiratory infections [e.g. coronavirus disease 2019 (COVID-19)] and wound healing, IL-6 plays a critical role in modulating the systemic and local microenvironment. Elevated serum levels of IL-6 interfere with the systemic immune response and are associated with disease progression and prognosis. As already noted, monoclonal antibodies blocking either IL-6 or binding of IL-6 to receptors have been used/tested successfully in the treatment of rheumatoid arthritis, many cancer types, and COVID-19. Therefore, in the present review, we compare the impact of IL-6 and anti-IL-6 therapy to demonstrate common (pathological) features of the studied diseases such as formation of granulation tissue with the presence of myofibroblasts and deposition of new extracellular matrix. We also discuss abnormal activation of other wound-healing-related pathways that have been implicated in autoimmune disorders, cancer or COVID-19.

Advances in Head and Neck Cancer Pain

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

Preoperative Evaluation of Perineural Invasion in Cervical Cancer: Development and Independent Validation of a Novel Predictive Nomogram

BACKGROUND

Perineural invasion (PNI) is associated with a poor prognosis for cervical cancer and influences surgical strategies. However, a preoperative evaluation that can determine PNI in cervical cancer patients is lacking.

METHODS

After 1:1 propensity score matching, 162 cervical cancer patients with PNI and 162 cervical cancer patients without PNI were included in the training set. Forty-nine eligible patients were enrolled in the validation set. The PNI-positive and PNI-negative groups were compared. Multivariate logistic regression was performed to build the PNI prediction nomogram.

RESULTS

Age [odds ratio (OR), 1.028; 95% confidence interval (CI), 0.999-1.058], adenocarcinoma (OR, 1.169; 95% CI, 0.675-2.028), tumor size (OR, 1.216; 95% CI, 0.927-1.607), neoadjuvant chemotherapy (OR, 0.544; 95% CI, 0.269-1.083), lymph node enlargement (OR, 1.953; 95% CI, 1.086-3.550), deep stromal invasion (OR, 1.639; 95% CI, 0.977-2.742), and full-layer invasion (OR, 5.119; 95% CI, 2.788-9.799) were integrated in the PNI prediction nomogram based on multivariate logistic regression. The PNI prediction nomogram exhibited satisfactory performance, with areas under the curve of 0.763 (95% CI, 0.712-0.815) for the training set and 0.860 (95% CI, 0.758-0.961) for the validation set. Moreover, after reviewing the pathological slides of patients in the validation set, four patients initially diagnosed as PNI-negative were recognized as PNI-positive. All these four patients with false-negative PNI were correctly predicted to be PNI-positive (predicted p > 0.5) by the nomogram, which improved the PNI detection rate.

CONCLUSION

The nomogram has potential to assist clinicians when evaluating the PNI status, reduce misdiagnosis, and optimize surgical strategies for patients with cervical cancer.

Modified Head and Neck Swallow Scale: Using EORTC-QLQ-H&N35 to Predict Overall Survival

OBJECTIVES/HYPOTHESIS

Dysphagia is a treatment-related complication of head and neck cancer (HNCA). We demonstrate the predictive value of a modified head and neck swallow scale (m-HNSW) adapted from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35 (EORTC-QLQ-H&N35).

STUDY DESIGN

Retrospective Cohort Study.

METHODS

Retrospective, single-center cohort study utilizing a prospectively collected database of HNCA patients in a high-volume tertiary referral center. 736 HNCA patients more than 2 years from completion of treatment were identified. EORTC-QLQ-H&N35 data collected from at least one of three defined episodes of care were used. The m-HNSW uses three questions to form a 9-point dysphagia scale. A Cox proportional hazards model was used to determine the effect of the m-HNSW while controlling for demographics, tumor staging, site, and treatment.

RESULTS

Using data from 3, 6, 12 months from treatment, we analyzed a subset that included 328 patients. Three months after the completion of therapy, the m-HNSW score had a significant association with 1 (HR = 1.24, P = .0005) and 5 year survival (HR = 1.19, P = .0002) after accounting for body mass index. Six (HR = 1.14, P = .014) and 12 month (hazard ratio (HR) = 1.33, P < .0001) scores post completion of therapy predict 5-year survival. An increase of the m-HNSW score by 1 point was associated with an increase in death by 24%, and 19% at 1 and 5 years following therapy.

CONCLUSIONS

The m-HNSW is a simple assessment of dysphagia using previously validated EORTC-QLC-H&N35 data that when taken at 3, 6, and 12 months after completion of therapy is predictive of overall survival.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

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

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

Incidence of pain complaints in oropharyngeal squamous cell carcinoma

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Calcitonin gene-related peptide: A promising bridge between cancer development and cancer-associated pain in oral squamous cell carcinoma

Nerves have been widely demonstrated to exert major effects in tumor-associated microenvironments. Due to the characteristic innervation of the oral cavity and the fact that cancer-associated pain is a distinct feature of oral squamous cell carcinoma (OSCC), the sensory nerves may dominate in the OSCC-nerve microenvironment. As the most abundant neuropeptide in the trigeminal ganglion, the calcitonin gene-related peptide (CGRP) exerts a dual effect on cancer development and cancer-associated pain in various types of cancer. The present review explored the potential molecular mechanisms of the roles of CGRP in cancer development and cancer-associated pain, suggesting that CGRP may be a promising therapeutic target for OSCC.

Perineural invasion in oral squamous cell carcinoma: Incidence, prognostic impact and molecular insight

BACKGROUND

The objective of this study was to characterise the incidence and prognostic correlation of perineural invasion (PNI) in oral squamous cell carcinoma and determine whether nerve growth factor and its receptor tyrosine Kinase A expression could be used as biological markers for PNI.

METHODS

A retrospective review of pathology reports of 430 patients with oral squamous cell carcinoma who were treated from 1992 to 2014 in Tayside, Scotland, was carried out. The expression of nerve growth factor and tyrosine kinase A was assessed with immunohistochemistry in 132 tissue sections of oral squamous cell carcinoma.

RESULTS

Perineural invasion was identified in 17.4% of oral squamous cell carcinomas. High expression of nerve growth factor and tyrosine kinase A was seen in 84% and 92% of oral squamous cell carcinoma, respectively. Tumours with PNI expressed nerve growth factor and tyrosine kinase A with a greater frequency than tumours without PNI. PNI and high expression of nerve growth factor were significantly associated with pain. PNI was significantly associated with stage IV tumours and poor disease-specific survival.

CONCLUSIONS

A higher level of expression of nerve growth factor and tyrosine kinase A may predict PNI and therefore may be considered as biological markers for PNI in oral squamous cell carcinoma. PNI and nerve growth factor overexpression may contribute to the pain generation in oral cancer patients. PNI and nerve growth factor expression can predict the aggressiveness and prognosis of oral squamous cell carcinoma patients.

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

PURPOSE

Tongue cancer is often associated with pain and perineural invasion. The purpose of the present study was to determine the association between tongue pain and otalgia and the microscopic identification of perineural invasion (PNI) in patients with squamous cell carcinoma of the tongue (SCCOT).

PATIENTS AND METHODS

A retrospective cohort study was performed of patients with a diagnosis of SCCOT from January 2013 through June 2019. Patients without a history of head and neck cancer, who had SCCOT diagnosed and treated surgically by a single surgeon, were included in the present study. The primary predictor variables were tongue pain and otalgia (presence vs absence of both). Other variables included patient demographic data and TNM stage. The primary outcome variable was the histologic presence of PNI. A χ² analysis was performed to test for any significant associations between pain, T stage, and overall stage in relation to PNI outcome. Multivariate logistic regression analysis was used to control for cancer staging variables when testing the association between pain and PNI.

RESULTS

The sample included 128 subjects, of whom 76 were men. Their mean age was 60 years. Most patients (n = 97; 75.8%) complained of tongue pain and a few (n = 50; 39.1%) complained of otalgia. The patients with otalgia had a 3.15 times greater odds of PNI when controlling for T stage (P = .016) and 3.68 times greater odds of PNI when controlling for overall stage (P = .007). Increasing T stage and overall stage-with the exception of stage II-were also significantly associated with PNI (P ≤ .05).

CONCLUSIONS

Our study has demonstrated a statistically significant association between preoperative otalgia and PNI in a consecutive group of patients presenting with newly diagnosed SCCOT.

Reciprocal interactions between cancer and Schwann cells contribute to oral cancer progression and pain

Pain associated with oral squamous cell carcinoma (oral SCC) decreases quality of life and survival. The interaction between cancer and the peripheral nerves is known to initiate and amplify pain and contribute to carcinogenesis. Schwann cells envelop peripheral nerves and are activated in response to neuronal damage. The contributions of Schwann cells to oral SCC progression and pain are unknown. Using a non-contact co-culture model, we demonstrate that Schwann cells (RSC-96) and oral SCC cells (HSC-3) reciprocally interact to promote proliferation, migration, and invasion. Schwann cell-oral SCC interaction leads to increased production of adenosine, which stimulates cell proliferation and migration of both cell types. The adenosine receptor A2B (ADORA2B) is expressed on RSC-96 cells. We show that supernatant from the RSC-96 cells co-cultured with HSC-3 cells induces increased mechanical hypersensitivity in mice compared to supernatant from control RSC-96 cells. Treatment with the ADORA2B antagonist PSB603 significantly inhibits co-culture interactions - proliferation and migration, and co-culture supernatant induced mechanical hypersensitivity. RSC-96 cells co-cultured with HSC-3 cells secrete increased amounts of the pronociceptive mediator, interleukin-6 (IL-6), which can be reduced by adding PSB603 into the co-culture. Our data support a reciprocal interaction between oral SCC and Schwann cells mediated by adenosine with potential to promote oral SCC progression and pain via increased secretion of IL-6.

Brain metastasis from squamous cell carcinoma of the head and neck: a review of the literature in the genomic era

Squamous cell carcinoma of the head and neck (HNSCC) affects nearly 500,000 individuals globally each year. With the rise of human papillomavirus (HPV) in the general population, clinicians are seeing a concomitant rise in HPV-related HNSCC. Notably, a hallmark of HPV-related HNSCC is a predilection for unique biological and clinical features, which portend a tendency for hematogenous metastasis to distant locations, such as the brain. Despite the classic belief that HNSCC is restricted to local spread via passive lymphatic drainage, brain metastases (BMs) are a rare complication that occurs in less than 1% of all HNSCC cases. Time between initial diagnosis of HNSCC and BM development can vary considerably. Some patients experience more than a decade of disease-free survival, whereas others present with definitive neurological symptoms that precede primary tumor detection. The authors systematically review the current literature on HNSCC BMs and discuss the current understanding of the effect of HPV status on the risk of developing BMs in the modern genomic era.

miRNAs: Important Targets for Oral Cancer Pain Research

Pain is a symptom shared by an incredible number of diseases. It is also one of the primary conditions that prompt individuals to seek medical treatment. Head and neck squamous cell carcinoma (HNSCC) corresponds to a heterogeneous disease that may arise from many distinct structures of a large, highly complex, and intricate region. HNSCC affects a great number of patients worldwide and is directly associated with chronic pain, which is especially prominent during the advanced stages of oral squamous cell carcinoma (OSCC), an anatomical and clinical subtype that corresponds to the great majority oral cancers. Although the cellular and molecular bases of oral cancer pain have not been fully established yet, the results of recent studies suggest that different epigenetic mechanisms may contribute to this process. For instance, there is strong scientific evidence that microRNAs (miRNAs), small RNA molecules that do not encode proteins, might act by regulating the mechanisms underlying cancer-related pain. Among the miRNAs that could possibly interfere in pain-signaling pathways, miR-125b, miR-181, and miR-339 emerge as some of the most promising candidates. In fact, such molecules apparently contribute to inflammatory pain. Moreover, these molecules possibly influence the activity of endogenous pain control systems (e.g., opioidergic and serotonergic systems), which could ultimately result in peripheral and central sensitization, central nervous system (CNS) phenomena innately associated with chronic pain. This review paper focuses on the current scientific knowledge regarding the involvement of miRNAs in cancer pain, with special attention dedicated to OSCC-related pain.