Do we need a different staging system for tongue and gingivobuccal complex squamous cell cancers?

Prognostic Heterogeneity Between Oral Tongue and Gingivobuccal Tumours Based on Lymph Node Ratio and Number of Positive Nodes: A Survival Analysis

Introduction

Lymph node ratio (LNR) and number of pathological positive nodes (pN) have shown better prognostic prediction compared to laterality, size and number of nodes (single or multiple). This study evaluates the prognostic significance of LNR and the number of  pathological positive nodes in predicting the outcomes of node positive oral squamous cell carcinoma(OSCC). It attempts to assess the prognostic heterogeneity between oral tongue and gingivobuccal complex tumours based on the lymph node ratio and the number of pathological positive nodes.

Materials and Methods

A retrospective chart review of 498 previously untreated OSCC patients from January 2014 to December 2017 at our tertiary cancer institute was done. Our analysis included 133 oral tongue and 79 gingivobuccal tumours with histopathologically proven lymph node metastasis. The impact of LNR and number of positive nodes on overall survival and disease free survival was studied.

Results

Overall survival rate was found to vary significantly based on LNR (> 0.06) and number of positive nodes (> 2). Overall survival reduced significantly in GBC tumours when LNR was more than 0.06(63.37 vs 32.1, p 0.005) but the same trend was not seen with tongue cancers (55.61 vs 41.9, p 0.98). Both the groups shown no difference in DFS based on LNR. Overall survival reduced significantly in both the groups when >2o pathologically positive nodes were present but disease free survival did not vary significantly in both the groups.

Conclusion

Lymph node ratio (> 0.06) and number of pathological positive nodes (> 2) provide a better prognostic stratification in node positive oral squamous cell carcinoma. Oral tongue and GBC tumours were found to have a differential impact on overall survival rate on the stratification based on LNR.

Association between coca (Erythroxylum coca) chewing habit and oral squamous cell carcinoma: a case-control study from Argentina

OBJECTIVE

Previous isolated reports have hypothesized that chewing coca leaves, a pre-Columbian tradition found in certain regions of South America, may be associated with the development of oral squamous cell carcinoma (OSCC). Coca chewing (CC) is a habit that shares many characteristics with the well-known practice of betel chewing observed in Asia. The aim of this study is to analyze the association between CC and OSCC among patients who attended the Señor del Milagro Hospital in Salta, Argentina.

STUDY DESIGN

A case-control study was conducted from 2013 to 2018. For each case of OSCC, three healthy control patients were included. Odds ratios were calculated to compare demographics, concurrent oral conditions, and other classical risk factors for OSCC.

RESULTS

A total of 62 cases and 180 controls were included, adjusted for sex and age. OSCC was significantly associated with tobacco use (27.4% vs 9.4%, P = .001), CC (62.9% vs 32.2%, P < .001), and poor oral condition (81.1% vs 67.7%, P = .02). In the multivariate analysis, smoking (OR = 2.77, 95% CI 1.23-6.25, P = .0139), CC (OR = 2.98, 95% CI 1.58-5.63, P = .0007), and poor oral condition (OR = 3.1, 95% CI 1.62-5.85, P = .0006) remained independently associated with OSCC development.

CONCLUSIONS

Chewing coca leaves could be considered a risk factor for oral cancer in a subset of Argentinean patients. Further studies are necessary to validate our findings and to elucidate the underlying pathways linking this habit to oral carcinogenesis.

"Survival patterns and prognostic factors of gingivobuccal complex squamous cell cancer: A monocentric retrospective chart audit"

OBJECTIVE

To analyze the impact of clinico-pathological prognostic factors on survival in patients with GBC OSCC. To evaluate the association between various clino-pathological and treatment factors influencing the 3-year and 5-year Overall survival (OS), and Disease specific survival (DSS) in patients with lower GBC OSCC.

PATIENTS & METHODS

An Institutional Ethical Committee (IEC) approved retrospective chart audit was performed. Biopsy proven squamous cell cancer of gingivobuccal complex (GBC OSCC) patients from 2010 to 2019 who were treated primarily with surgery with or without adjuvant therapy having complete clinicopathological and follow up data were included. Survival outcomes including 2-year, 3-year & 5-year OS, and DSS were calculated and analyzed. A multivariate analysis was performed to identify significant predictor for the survival outcomes. A p-value < 0.05 was considered significant.

RESULTS

183 patients with primary OSCC were identified out of which 83 patients comprised of OSCC of lower GBC. Age (p < 0.001), tumor grade (p = 0.009), pN status (p = 0.002), PNI (p < 0.001), lymph node metastasis (p = 0.002), treatment given (p = 0.02) and adjuvant therapy (p = 0.02) were found as a significant prognostic factor in univariate analysis.

CONCLUSION

The OS & DSS of the patients with lower GBC SCC is 78.3%. The 2-year, 3-year, and 5-year OS of the study population was reported to be 95.2%, 87.9%, and 78.8% respectively. PNI & lymph node metastasis were significant prognostic factor for OS with an adjusted hazard ratio 4.91 and 7.75 respectively.

Invasion of the bucco-mandibular space by oral squamous cell carcinoma: histopathological analysis of invasion pattern

Background

This study aimed to determine the patterns of invasion of oral squamous cell carcinoma (OSCC) into the bucco-mandibular space (BMS) using detailed histopathological analysis and to assess clinical outcomes.

Methods

Patients with OSCC who underwent segmental mandibulectomy or hemi-mandibulectomy combined with resection of the BMS between 2012 and 2021 were included. The invasions of the BMS were classified into three patterns. Pattern A was defined as a horizontal invasion, Pattern B as a vertical invasion, and Pattern C as an expansive invasion.

Results

In total, 109 patients were reviewed. Of these 109 patients, the primary tumor affected the lower gingiva in 78 patients, the buccal mucosa in 18 patients, and was a primary intraosseous carcinoma of the mandible in 13 patients. Invasion of the BMS was significantly associated with a higher pathological T stage, positive/close margins, and lower disease-free survival (DFS) rates. The DFS rates were 86.7% and 66.0% in the BMS non-invasion and invasion groups, respectively. The DFS rates for each type of invasion were 82.1% for Pattern A, 67.4% for Pattern B, and 48.0% for Pattern C (P=0.277).

Conclusion

Patients with BMS invasion have a poorer prognosis than those without invasion of the BMS. Therefore, adjuvant therapy is necessary, especially in Patterns B and C. Evaluation of preoperative BMS invasion patterns is important for predicting the prognosis of OSCC.

Clinicopathological Difference Between Gingivobuccal and Oral Tongue Cancers: A Cross-Sectional Observational Study from a Tertiary Healthcare Centre in Northern India

Gingivobuccal and oral tongue squamous cell carcinomas are commonly considered together as a single clinical entity for staging and treatment purposes. Though there is data suggesting a significant difference between SCC of various oral cavity subsites, very few studies have compared clinicopathological characteristics between the tongue and gingivobuccal primaries. We retrospectively analysed 225 patients with biopsy-proven gingivobuccal (GB) and oral tongue (OT) SCC operated between April 1, 2018 and April 30, 2021 in All India Institute of Medical Sciences, Rishikesh, India to compare their clinicopathological characteristics. Demographic, clinical and histopathological data were collected from electronic medical records. An independent sample t-test was used to compare means and Pearson chi-square test or Fisher exact test was applied to compare the distribution of categorical variables. A relative male preponderance (12:1 vs. 5:1, p = 0.036) and increased smokeless tobacco consumption (82% Vs. 69%, p = 0.003) was seen in GB-SCC. Significantly higher proportion of patients with OT-SCC presented with early primaries (T1/T2) (54.1% vs. 24.8%, p < 0.001). Similarly, a higher proportion of GB-SCC patients presented with palpable neck nodes (cN +) (81% Vs. 67%, p = 0.02). Due to early primary tumours at presentation, stage I/II disease was also significantly higher in cases of OT-SCC (36.5% Vs.13.7%, p < 0.001). No difference was noticed in age at presentation, neck node status, and other clinicopathological parameters. GB-SCC has a higher male preponderance than OT-SCC due to relatively higher consumption of smokeless tobacco in males. Oral tongue cancers presented at an earlier stage than gingivobuccal malignancies. No difference in neck node status, however, suggests a relatively aggressive disease behaviour and early regional metastasis in tongue cancers. Follow up data regarding recurrence and survival is required to further characterise the differences between these two common OSCC subsites.

Determinants of prognosis in patients with oral squamous cell carcinoma metastasizing to a single cervical lymph node

OBJECTIVES

Metastasis in a single lymph node without adverse tumour factors and perineural invasion has been assigned to a lower risk category by the ASCO recommendations of 2019. We analyzed patients with a single positive node with a view to identifying high risk features and their impact on prognosis within this subgroup.

MATERIALS AND METHODS

The study retrospectively analyzed 707 patients with OSCC. Descriptive statistics were used to compare distribution of clinicopathologic risk features between 323 N0 and 121 single node positive (N_s) patients. The N_s group was further analyzed for the impact of clinicopathologic factors on disease free (DFS) and overall survival (OS) using univariate and multivariate models.

RESULTS

The N_s group exhibited greater depth of invasion compared to the N0 group and significantly higher proportion of lymphovascular invasion (LVI), perineural invasion (PNI) and poorly differentiated tumors. Within the N_s group, primary tumor localised to the gingivobuccal subsite (HR 2.55, 1.18-5.52 95%CI, p = 0.02) and PNI (HR 2.55, 1.14-5.62, 95%CI p = 0.02) exhibited poor DFS. PNI also contributed to poor OS (HR 2.86, 1.27-6.47 95%CI, p = 0.01). Uninvolved margins (HR 0.46, 0.22-0.96 95%CI, p = 0.04) and chemoradiation (HR 0.18,0.05-0.68 95% CI, p = 0.01) improved OS.

CONCLUSION

Significant differences are noted in the prevalence of pathologic risk factors between the single node positive and node negative groups. Within the single node positive group, tumour factors like the gingivobuccal subsite, PNI and margin positivity impacted survival. Among nodal factors, deposit size of 12 mm or more and presence of ENE are pointers to poor prognosis. These patients would benefit from adjuvant treatment.

Postoperative Concurrent Chemoradiotherapy Versus Radiotherapy Alone for Advanced Oral Cavity Cancer in the Era of Modern Radiation Techniques

Background/Purpose

Surgery followed by postoperative radiotherapy (RT) has been considered the standard treatment for oral cavity squamous cell carcinoma (OCSCC) of advanced stages or with adverse prognostic factors. In this study, we compared the outcomes in patients with OCSCC who received postoperative concurrent chemoradiotherapy (CCRT) or postoperative RT alone using modern RT techniques.

Methods

A total of 275 patients with OCSCC treated between 2002 and 2018 were retrospectively analyzed. Adverse prognostic factor was defined as extranodal extension (ENE), microscopically involved surgical margin, involvement of ≥2 lymph nodes, perineural disease, and/or lymphovascular invasion (LVI). In total, 148 patients (54%) received CCRT and 127 patients (46%) received RT alone. More patients in the CCRT group had N3 disease and stage IVB disease (46.6% vs. 10.2%, p<0.001), ENE (56.1% vs. 15.7%, p<0.001), LVI (28.4% vs. 13.4%, p=0.033).

Results

With a median follow-up of 40 (range, 5–203) months, there were no significant differences in the 5-year overall survival (OS) and PFS between treatment groups. In the subgroup analysis according to high risk, the concurrent use of chemotherapy showed significantly improved OS in patients with ENE (HR 0.39, p=0.003).

Conclusion

Our retrospective study showed that postoperative CCRT group had comparable survival outcomes to those in the RT alone group for advanced OCSCC in the era of modern RT techniques and indicated that concurrent chemotherapy should be administered to patients with ENE. Prospective randomized studies for confirmation are needed.

Perineural and lymphovascular invasion in squamous cell carcinoma of the tongue

BACKGROUND

Perineural invasion (PNI) and lymphovascular invasion (LVI) may be adverse prognostic indicators in squamous cell carcinoma (SCC) of the tongue.

METHODS

The percentages of histological PNI and LVI were determined in 335 patients with tongue SCC. Sixty tumours originally reported as negative for these features were tested to determine how many more were positive with "immunohistochemical enhancement."

RESULTS

PNI was found in 141 (42.1%) and LVI in 51 (15.2%) patients. 79.4% of the 141 patients who had PNI and 72.6% of the 51 with LVI had a T3 or T4 tumour. Lymph node metastasis was identified in 145 (51.2%) of the 280 patients who had undergone neck dissection; 58.2% of the 141 patients with PNI and 80.4% of the 51 patients with LVI had lymph node metastasis. There was a highly statistically significant correlation between PNI with increasing pT (P < .00001) and pN (P < .0001) stage, and a statistically significant correlation between LVI and pT stage (P < .001), the association of LVI with pN status could not be reliably tested statistically. Immunohistochemistry for S100 identified five further cases of PNI, but review of the original H&E showed the feature was present in four and had been missed at original reporting. CD31 identified three further possible cases of LVI and D2-40 none. The endothelium of some vascular channels was positive for both CD31 and D2-40 and cross-reactivity with other cells compromised interpretation.

CONCLUSIONS

Histological identification of PNI and LVI per se remains of uncertain prognostic significance. "Immunohistochemical enhancement" offered little benefit.

Safety and Feasibility of PARP1/2 Imaging with 18F-PARPi in Patients with Head and Neck Cancer

PURPOSE

We performed a first-in-human clinical trial. The aim of this study was to determine safety and feasibility of PET imaging with ¹⁸F-PARPi in patients with head and neck cancer.

PATIENTS AND METHODS

Eleven patients with newly diagnosed or recurrent oral and oropharyngeal cancer were injected with ¹⁸F-PARPi (331 ± 42 MBq), and dynamic PET/CT imaging was performed between 0 and 25 minutes postinjection. Static PET/CT scans were obtained at 30, 60, and 120 minutes postinjection. Blood samples for tracer concentration and metabolite analysis were collected. Blood pressure, ECG, oxygen levels, clinical chemistry, and complete blood count were obtained before and after tracer administration.

RESULTS

¹⁸F-PARPi was well-tolerated by all patients without any safety concerns. Of the 11 patients included in the analysis, ¹⁸F-PARPi had focal uptake in all primary lesions (n = 10, SUV_max = 2.8 ± 1.2) and all ¹⁸F-FDG-positive lymph nodes (n = 34). ¹⁸F-PARPi uptake was seen in ¹⁸F-FDG-negative lymph nodes of 3 patients (n = 6). Focal uptake of tracer in primary and metastatic lesions was corroborated by CT alone or in combination with ¹⁸F-FDG. The overall effective dose with ¹⁸F-PARPi PET was 3.9 mSv - 5.2 mSv, contrast was high [SUV_max(lesion)/SUV_max(trapezius muscle) = 4.5] and less variable than ¹⁸F-FDG when compared with the genioglossus muscle (1.3 vs. 6.0, P = 0.001).

CONCLUSIONS

Imaging of head and neck cancer with ¹⁸F-PARPi is feasible and safe. ¹⁸F-PARPi detects primary and metastatic lesions, and retention in tumors is longer than in healthy tissues.

Survival outcomes after treatment of cancer of the oral cavity (1985-2015)

OBJECTIVES

To present treatment results of oral squamous cell carcinoma (OSCC) at a tertiary cancer care center from 1985 to 2015.

MATERIALS AND METHODS

A total of 2082 patients were eligible for this study. Main outcomes measured were overall survival (OS) and disease specific survival (DSS). Prognostic variables were identified with bivariate analyses using Kaplan-Meier curves and log-rank testing for comparison. A p-value < 0.05 was considered statistically significant and significant factors were entered into multivariate analysis. Median age was 62 years (16-100), 56% were men, 66% reported a history of tobacco use and 71% of alcohol consumption. The most common subsite was tongue (51%). Seventy-three percent of patients had cT1-2 and 71% had clinically negative necks (cN0). Surgery alone was performed in 1348 patients (65%), adjuvant postoperative radiotherapy in 608 patients (29%) and postoperative chemoradiation in 126 patients (6%). Neck dissection was performed in 920 patients with cN0, and in 585 patients with a clinically involved neck. The median follow-up was 37.6 months (range 1-382).

RESULTS

The 5-year OS and DSS were 64.4% and 79.3%, respectively. Age, comorbidities, margin status, vascular invasion, perineural invasion, AJCC 8th edition pT, and pN were independent prognostic factors of OS (p < 0.05). History of alcohol consumption, margin status, vascular invasion, perineural invasion, pT, and pN were independent prognostic factors of DSS (p < 0.05).

CONCLUSION

pN stage is the most powerful and consistent predictor of outcome in patients with OSCC treated with primary surgery and appropriate adjuvant therapy.