Tumor thickness as a predictor of cervical lymph node metastasis in squamous cell carcinoma of the lower lip

Contribution of Open Mouth Technique in 18F-FDG PET/CT Imaging in Patients with Malignant Lip Neoplasm

Objectives:

¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) plays an important role in evaluating head and neck cancers. However, localization and size evaluation in this region can be rough due to the multitude of the anatomic structures and physiologic uptakes. The aim of this study was to evaluate malignant lip lesions with the contribution of open mouth (OM) imaging technique at PET/CT.

Methods:

Fifty-six patients with malignant lip neoplasm underwent ¹⁸F-FDG PET/CT imaging. Each patient was imaged twice as whole-body PET/CT with routine closed mouth (CM) position; and OM head and neck image, standardized with a special device. Lesion maximum standard uptake value (SUV_max), localization, size, and involvement of lymph nodes were evaluated.

Results:

Lesion localization was correctly detected in 100% of the OM images. Lesion size in PET/CT was compared with clinical, radiological (magnetic resonance imaging and CT) and/or histopathological results and the size measurement was coherent at 47.1% and 95.6% for CM and OM images, respectively. It was observed that OM acquisition did not contribute additionally in detecting regional lymph node metastasis. Forty-one PET/CT scans with CT artifacts due to dental amalgams were evaluated and 46.3% dimensional and 53.7% localization errors were detected in the CM position. There was no statistically significant difference between OM and CM SUV_max (p>0.05).

Conclusion:

We concluded that additional OM head and neck imaging is useful and necessary to accurately determine the localization and size of the tumor, thus enhancing the value of PET/CT in staging, treatment response assessment, and restaging of patients with malignant lip cancer with or without dental amalgam

Retrospective analysis of outcome and toxicity after postoperative radiotherapy in patients with squamous cell carcinoma of the lip

Background:

Carcinomas of the lips are a relatively common malignancy of the head and neck region, accounting for roughly one quarter of all oral cavity cancers. Compared to other oral cancer sites, this location has a favorable prognosis, with 5-year survival rates between 85% and 95%. This study summarizes our institutional experience in utilizing postoperative radiation for patients with squamous cell carcinoma of the upper and/or lower lip following incomplete surgical resection or positive lymph node involvement with extracapsular extension.

Methods:

We retrospectively reviewed the medical records of all patients at the University Hospital of Heidelberg between 2005 and 2018 treated with postoperative radiotherapy of the upper and lower lip. Nineteen patients were identified with a median age at diagnosis of 67 years (range, 41–95 years), with 58% male and 42% female patients. Fourteen patients (73.7%) underwent neck dissection, with 5 (35.7%) found to have extracapsular extension (ECE) and positive resection margin (R1/2), 2 (14.3%) only ECE, and 7 (50.0%) with only R1/2. All patients received a median cumulative dose of 66.0 Gy (range, 60.0–70.0 Gy) in a median of 2.0 Gy per fraction (range, 1.8–2.2 Gy).

Results:

Median follow-up was 5.2 years. The median progression-free survival (PFS) was 3.9 years (range, 0.2–12.4 years), local disease-free survival (LDFS) was 4 years (range, 1–12 years) and overall survival (OS) was 5.2 years (range, 0.2–12.4 years). The 5-year Kaplan-Meier estimates for OS, PFS, and LDFS were 61.4%, 85.7%, and 100.0%, respectively. At last follow-up, 13 patients (68.4%) were still alive. Although no patient developed locoregional relapse, two patients developed distant relapse at a median of 15 months after radiotherapy. There was a statistically significant improvement in OS in patients treated with higher radiotherapy doses (>60.0 Gy, p = 0.044) compared to lower radiotherapy doses. PFS was significantly improved among patients who had N0 disease, with a negative resection margin, without ECE, and who were treated with intensity-modulated radiotherapy to doses >60.0 Gy. No grade 3/4 toxicity was detected; the most common grade 1/2 toxicities included dermatitis (n = 11, 57.9%), oral mucositis (n = 8, 42.1%), and dysphagia (n = 8, 42.1%).

Conclusion:

Our results demonstrate excellent local control and OS with acceptable toxicity when utilizing postoperative radiotherapy in patients with squamous cell carcinoma of the upper and lower lip, despite unfavorable characteristics (advanced T or N stage and/or ECE).

A model to predict nodal metastasis in patients with oral squamous cell carcinoma

Difficulty in precise decision making on necessity of surgery is a major problem when managing oral squamous cell carcinomas (OSCCs) with clinically negative neck. Therefore, use of clinical and histopathological parameters in combination would be important to improve patient management. The main objective is to develop a model that predicts the presence of nodal metastasis in patients with OSCC.623 patients faced neck dissections with buccal mucosal or tongue squamous cell carcinoma (SCC) were selected from patients’ records. Demographic data, clinical information, nodal status, Depth of invasion (DOI) and pattern of invasion (POI) were recorded. The parameters which showed a significant association with nodal metastasis were used to develop a multivariable predictive model (PM). Univariate logistic regression was used to estimate the strengths of those associations in terms of odds ratios (OR). This showed statistically significant associations between status of the nodal metastasis and each of the following 4 histopathological parameters individually: size of the tumour (T), site, POI, and DOI. Specifically, OR of nodal metastasis for tongue cancers relative to buccal mucosal cancers was 1.89, P-value < 0.001. Similarly, ORs for POI type 3 and 4 relative to type 2 were 1.99 and 5.83 respectively. A similar relationship was found with tumour size; ORs for T2, T3, and T4 compared to T1 were 2.79, 8.27 and 8.75 respectively. These four histopathological parameters were then used to develop a predictive model for nodal metastasis. This model showed that probability of nodal metastasis is higher among tongue cancers with increasing POI, with increasing T, and with larger depths while other characteristics remained unchanged. The proposed model provides a way of using combinations of histopathological parameters to identify patients with higher risks of nodal metastasis for surgical management.

Controversies on Tumor Thickness Versus Nodal Metastasis in Oral Squamous Cell Carcinomas Revealed: A Histopathologist’s Perspective

Background: Cervical metastasis has a tremendous impact on prognosis in patients with head and neck squamous cell carcinomas (HNSCCs). However, to date management of clinically negative neck in HNSCC is still a controversial subject. Tumor thickness (TT) is a strong predictor for lymph node involvement in oral squamous cell carcinomas (SCCs). However, controversy exists about the optimal TT cutoff point for a clinically relevant risk to the neck. Aim and Objectives: The aim is to evaluate the relationship between TT and the risk of cervical lymph node involvement and to determine optimal TT cutoff point for prompting prophylactic neck management. Materials and Methods: The clinical files and histological sections of 35 SCC (T1/T2) at buccal mucosa site from clinically determined N0 patients were retrospectively analyzed who underwent surgical treatment of their primary lesion with simultaneous neck dissection. An ocular micrometer was used to measure the TT both in exophytic and ulcerated lesions. Chi-square contingency tables were used to correlate TT and other clinicopathological parameters with metastasis in the neck. Results: Clinically, negative necks turned out pathologically positive in 42.8% (n = 15/35). In the group in which tumor depth exceeded 1.5 mm, the metastatic rate was 86.7% (13/15). In contrast, when the depth of invasion was <1.5 mm, the incidence of cervical metastasis was 13.3% (2/15) irrespective of the 2 stages. Conclusion: TT is a highly significant, objectively measurable prognostic factor in early stage oral cancers and elective neck therapy is indicated for tumors exceeding 1.5 mm invasion.

Prognostic implication of NOTCH1 in early stage oral squamous cell cancer with occult metastases

OBJECTIVE

The objective of this study was to explore the prognostic value of cancer stem cell markers, namely CD133, NANOG, and NOTCH1, in early stage oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

One hundred forty-four patients with early stage (cT1T2N0) OSCC were identified from a pre-existing database of patients with oral cancer. We examined the impact of the immunohistochemical expression of CD133, NANOG, and NOTCH1 in OSCC. Overall survival (OS) curves were calculated using the Kaplan-Meier method. Predictors of outcome were identified using multivariate analysis.

RESULTS

We found that CD133, NANOG, and NOTCH1 were significantly associated with lymph node metastasis, and NOTCH1 was also significantly associated with depth of invasion and locoregional recurrence.

CONCLUSIONS

NOTCH1 was identified as an independent prognostic factor for OS.

CLINICAL RELEVANCE

NOTCH1 might prove to be a useful indicator for high-risk patients with occult metastases from early stage OSCC.

Stage is a prognostic factor for surgically treated patients with early-stage lip cancer for whom a ‘wait and see’ policy in terms of neck status has been implemented

Objectives:

To determine the locoregional control and survival rates (in terms of risk factors) of patients who underwent surgical resection of early-stage lip cancer and for whom a ‘wait and see’ policy in terms of neck status had been implemented.

Methods:

The sociodemographic data, tumour stage, tumour characteristics and histopathological features of 41 patients with early-stage lip cancer were evaluated. Factors predictive of survival and locoregional recurrence were analysed. The five-year overall survival and disease-free survival rates were determined, and the prognostic risk factors were compared.

Results:

The mean follow-up period was 60.5 months (range, 4–92 months). Age, sex, tumour stage, tumour thickness and volume, and perineural involvement were not predictive of locoregional recurrence or survival. Pathological tumour stage (T1vsT2) was a prognostic factor for both five-year overall survival (87.3vs65.6 per cent,p= 0.042) and disease-free survival (88.6vs65.6 per cent,p= 0.037).

Conclusion:

Tumour stage was clearly a major factor affecting the prognosis of surgically treated patients with early-stage lip cancer for whom a ‘wait and see’ policy in terms of neck status had been implemented.

Metastatic Squamous Cell Carcinoma of the Lower Lip: Analysis of the 5-Year Survival Rate

Objectives

The author analyse the impact of extracapsular lymph node spread and bone engagement in the ipsilateral neck of patients suffering squamous cell carcinoma (SCC) of the lower lip.

Methods

The data of 56 neck dissections performed in patients suffering SCC of the lower lip between January 2000 and December 2008 were retrospectively analysed. Statistical analysis was performed with the Kaplan-Meier life table method, and the survival rate was investigated with the log rank statistic and significance test. The values were considered statistically significant at p<0.05.

Results

Nine patients took advantage from simultaneous treatment of tumor and prophylactic neck dissection (level I-III), reaching 100% survival rate. Patients suffering metastasized disease, who received radical neck dissection at the time of tumor treatment, presented 83.3% survival rate. Patients who underwent previous surgery and radiotherapy presented worse prognosis although radical neck dissection in case of extra-capsular spread only (24.7%) and osseous engagement (22.2%).

Conclusion

Prophylactic neck dissection (level I–III) is recommended in T3–T4 N0 SCC. Simultaneous treatment of tumor and cervical lymph nodes provides a better prognosis as respect to delayed nodal management. Extra-capsular spread with or without bone engagement represents independent risk factor responsible for high mortality rate of SCC of the lower lip.

Frequency of Cervical Nodal Metastasis in Early-Stage Squamous Cell Carcinoma of the Tongue

Introduction  Oral cavity carcinoma is an aggressive tumor, with the tongue being one of the most common subsites of involvement. Surgery is a gold standard method of dealing with advanced-stage tumors. However, for early-stage carcinomas of the tongue, the management remains controversial. Several studies have indicated that early-stage cancers have a high chance of occult cervical node metastasis, which, if left untreated, can greatly affect the prognosis. Certain parameters can help identify patients with occult cervical node metastases, and can avoid unnecessary neck dissection in node negative patients. Tumor thickness is one such objective parameter.

Objective  To estimate the frequency of cervical lymph node metastasis in patients with early-stage, node-negative (N ₀ ) squamous cell carcinoma of the tongue.

Methods  In-patient hospital data was reviewed from January 2013 until March 2014, and 78 patients who underwent primary resection of the tumor and neck dissection for biopsy-proven, early stage squamous cell carcinoma of the tongue were included. Data such as tumor thickness, tumor differentiation and presence of occult nodal metastasis in the surgical specimen were gathered from the histopathology reports. The frequency of subclinical cervical lymph node metastasis in patients with early-stage squamous cell carcinoma of the tongue was estimated.

Results  A total of 69% of the patients with tumor thicknesses > 5 mm had tumor metastases in the neck nodes, while 100% of the patients with tumor thicknesses < 5 mm had no neck nodal metastasis.

Conclusion  A tumor thickness > 5 mm is significantly associated with subclinical metastasis, and prophylactic neck dissection is warranted in such cases.

Tumor Infiltration Depth as a Prognostic Parameter for Nodal Metastasis in Oral Squamous Cell Carcinoma

Oral squamous cell carcinoma (OSCC) has locoregional evolution, with frequent neck involvement. Significant number of studies have been undertaken to assess the parameters for treatment of N0 neck patients with a high likelihood of harboring occult node metastases. Many studies have indicated tumor infiltration depth (or tumor thickness) as one of the most important criteria in determining the further management. Growing evidence in the literature shows that tumor infiltration depth is a reliable parameter for predicting regional node involvement and patient survival in OSCC. The substantial agreement among authors, despite the lack of comparable study groups, of measurement techniques, and cutoff values paradoxically enforced its reliability. Further studies are clearly awaited to reach a consensus on these topics to develop therapy protocols that are also based on this parameter. This article is an attempt to substantiate the use of tumor infiltration depth as a prognostic factor for nodal metastasis in OSCC.

Cutaneous Squamous Cell Carcinoma: A Review of High-Risk and Metastatic Disease

Non-melanoma skin cancer represents one-third of all malignancies and its incidence is expected to rise until the year 2040. Cutaneous squamous cell carcinoma (cSCC) represents 20 % of all non-melanoma skin cancer and is a deadly threat owing to its ability to metastasize to any organ in the body. Therefore, a better understanding of cSCC is essential to strengthen preventative measures and curable treatment options. Currently, research demonstrates that cSCC is diagnosed at a rate of 15-35 per 100,000 people and is expected to increase 2-4 % per year. With respect to metastatic cSCC, this disease is more common in men; people over the age of 75 years; and inhabitants of the south and mid-west USA. In 2010, the American Joint Committee on Cancer updated the Cancer Staging Manual's primary tumor designation to now include high-risk factors; however, factors such as immunosuppression and tumor recurrence were not included. Other staging systems such as Brigham and Women's Hospital have allowed for increased stratification of cSCC. High-risk cSCC is defined as a cSCC that is staged as N0, extends beyond basement membrane, and has high-risk features associated with sub-clinical metastasis. High-risk features are depth of invasion (>2 mm), poor histological differentiation, high-risk anatomic location (face, ear, pre/post auricular, genitalia, hands, and feet), perineural involvement, recurrence, multiple cSCC tumors, and immunosuppression. Epidermal growth factor receptor and nuclear active IκB kinase (IKK) expression are also predictive of metastatic capabilities. Clinically, the initial lesions of a cSCC tumor can present as a painless plaque-like or verrucous tumor that can ultimately progress to being large, necrotic, and infected. Tumors can also present with paresthesias or lymphadenopathy depending on the location involved. With respect to prognosis, metastatic cSCC is lethal, with several large studies demonstrating a mortality rate of >70 %. Therefore, treatment of metastatic cSCC is difficult and depends on the location involved and extent of metastasis. Treatment options include surgery, radiation therapy, chemotherapy, and any combination of the above. Surgery alone can be used for metastatic cSCC treatment, but is not as effective as surgery in conjunction with radiation therapy. Radiation therapy has some success as a monotherapy in low-risk or cosmetically sensitive areas such as the external ear, eyelid or nose. According to the 2013 National Comprehensive Cancer Network Guidelines, cisplatin as a single agent or combined with 5-fluorouracil hold the strongest support for the treatment of metastatic cSCC; however, the supporting evidence is inconsistent and a curative chemotherapeutic approach is still lacking. Epidermal growth factor receptor inhibitors are a newer class of agents being used in metastatic cSCC and hold some promise as a therapy for this disease. Other areas of interest in finding curative treatments for metastatic cSCC include p53, hypermethylation of specific genes, chromatin remodeling genes, and the RAS/RTK/PI3K pathway. This review addresses the epidemiology, staging, risk factors, clinical presentation, management, and new trends in the treatment of high-risk and metastatic cSCC.

Squamous cell carcinoma of the lip: depth of invasion, local recurrence and regional metastases. Experience of a rural multidisciplinary head and neck unit

BACKGROUND

The internationally recognised American Joint Committee on Cancer (tumour-node-metastasis) staging system utilises tumour size to determine stage. Other factors (i.e. tumour depth) may provide additional prognostic information.

METHOD

A thorough retrospective analysis was performed of 68 patients with primary lip squamous cell carcinoma operated on or discussed by the Darling Downs Health Service between 2005 and 2013.

RESULTS

Twelve patients developed lymphatic spread. There was a statistically significant increased risk of nodal metastasis in: patients with tumours of increased thickness (U = 103.50; degrees of freedom = 68; p < 0.001), those with a larger overall tumour size (U = 163.50; degrees of freedom = 68; p = 0.005) and patients living further from the treatment centre (U = 199.00; degrees of freedom = 68; p = 0.018).

CONCLUSION

It may be reasonable that other factors are considered for staging of lip squamous cell carcinomas, in combination with tumour-node-metastasis staging. Depth of invasion may have utility in prognosis and treatment; however, larger prospective analysis needs to be performed. Patients living in a more rural setting presented with more advanced disease, suggesting an ongoing rural-metropolitan gap in healthcare.

Squamous cell carcinoma of the lip in Australian patients: definitive radiotherapy is an efficacious option to surgery in select patients

BACKGROUND

In Australia, squamous cell carcinoma (SCC) of the lip is a consequence of chronic sun exposure and treated as a nonmelanoma skin cancer. Patients may be recommended radiotherapy (RT) as a treatment modality.

OBJECTIVE

To analyze the outcome of patients with early-stage SCC of the lip treated with definitive RT at Westmead Hospital, Sydney, Australia, between 1980 and 2012.

METHODS AND MATERIALS

Ninety-three patients with early-stage SCC of the lip underwent RT. All patients were clinically node negative based on examination and/or relevant investigations. Retrospective chart review was performed. Patients treated since 2000 had data collected and entered prospectively.

RESULTS

The most frequently involved site was the lower lip (93%). Fifty-six patients (60%) had T1N0 and 37 patients (40%) had T2N0 disease. Most patients were treated with superficial or orthovoltage RT, with the median RT dose delivered 55 Gy (range, 40 to 70 Gy). Local recurrence occurred in 5 patients (5%), whereas regional metastases developed in 5 patients (5%). One patient developed concurrent local and regional relapse. No patient developed distant metastases. The 5-year recurrence-free survival was 90%.

CONCLUSION

The findings confirm the efficacy of RT as an efficacious treatment option in early-stage lip SCC.

S LM. Affect on survival per increase in each millimeter of tumor depth in tongue cancer

The critical tumor depth at which the risk of occult metastasis increases in tongue cancer has been demonstrated as ≥4-5 mm. Conventional T staging might not be an accurate predictor for survival in situations wherein infiltrative growth pattern is easily overlooked. Thus risk of death associated with increase in tumor depth per millimeter might be useful to understand patient's disease status during follow up. Historical cohorts of patients with pT1N0 and pT2N0 primary squamous cell carcinoma of tongue treated between January 2010 and December 2011 were selected and analyzed in univariate and multivariate cox-regression model to indicate the risk of death associated with an increase in each millimeter of tumor depth. The median period of follow up was 34 months. Total 67 patients fulfilled the above mentioned criteria, among them 11 patients died by the end of study period. The mean (SD) age of the patients studied was 49.7 (12.7) years and their age ranged from 21 to 74 years. Among these 66 % (n = 44) were males. In the univariate log-rank test, margin status (p = 0.016), t-stage (p = 0.018) and increased tumor depth (p < 0.0001) were risk factors for occurrence of death. When adjusted for other risk factors in the multivariate cox-regression model, per one unit increase of tumor depth (mm) there was 1.07 (95 % CI 0.95, 1.21) units increased risk of death. Depth of tumor with increase in each millimeter in tongue cancer appears to be associated with risk of death irrespective of regional lymphatic spread.

Role of Elective Neck Dissection in Early Stage Lip Cancers

Objective

To date, the management of the neck in early stage lower lip cancers remains controversial. The aim of this study is to investigate if prophylactic neck dissection is necessary in early stage lower lip cancers.

Methods

Charts of 11 patients who underwent surgery of the primary site and neck because of T1-2N0 lower lip cancer between 1997 and 2011 were retrospectively examined. Clinical stages, surgeries, histopatological examination results, and loco-regional recurrences were evaluated.

Results

Of the 11 patients, 10 were male (90.9%) and 1 was female (9.09%). The follow-up time of these patients was between 24-168 months (mean, 56.6 months). There were 5 patients with clinically diagnosed T1N0 tumors and 6 patients with clinically diagnosed T2N0 tumors. Suprahyoid neck dissection was performed in 4/5 T1N0 patients and supraomohyoid neck dissection was performed in the remaining 1 patient. For T2N0 tumors, 4 suprahyoid, 1 supraomohyoid, and 1 comprehensive neck dissection was performed. Histopathological examination revealed no occult metastasis in any of the patients. In 1 patient who had lower lip resection and suprahyoid neck dissection for T1N0 lower lip cancer, a contralateral neck metastasis was detected 22 months postsurgery, and a comprehensive neck dissection was performed.

Conclusion

Our results show that in patients with T1N0 lower lip tumors, neck dissection may not be necessary; however, close follow-up is mandatory. Further researches with larger series dividing T2N0 tumors into subgroups for tumor size and thickness are necessary to determine neck treatment in these tumors.

Perioral lesions and dermatoses

The purpose of this article is to review the common neoplasms, infections, and inflammatory dermatoses that may present around or near the mouth. Dental professionals are well positioned to evaluate perioral skin conditions, further contributing to patients' general health. This article includes a review of seborrheic keratosis, warts, actinic keratoses, actinic cheilitis, and squamous cell carcinoma, among several other perioral cutaneous lesions.

Management of neck metastases in T2N0 lip squamous cell carcinoma

BACKGROUND

Prophylactic neck dissection (PND) is indicated when the chance of occult lymph node metastases from head and neck tumors is significant. There is no consensus regarding which tumor size PND would be indicated in cases of lip cancer.

METHODS

A total of 139 patients with surgically treated lip cancer were selected. The size of the lesion (T) and the presence of lymph node metastases (N) were assessed by examining the medical records. For analysis purposes, the T2 group was divided into T2a (2 to 3 cm) and T2b (3 to 4 cm).

RESULTS

The following distribution of incidence of neck metastases was observed in the study groups: 11.7% in T1, 9% in T2a, 43.7% in T2b, and 52.2% in T3+T4. Statistical comparison of the groups (p) revealed the following results: T2aXT2b=0.03; T2aXT3+T4=0.001.

CONCLUSION

PND is indicated for tumors larger than 3 cm.

The effects of tumor size, degree of differentiation, and depth of invasion on the risk of neck node metastasis in squamous cell carcinoma of the oral cavity

Cervical lymph node metastasis is the most important prognostic factor in patients with head and neck carcinoma. We retrospectively analyzed the effects of three different variables-tumor size, degree of differentiation, and depth of invasion-on the risk of neck node metastasis in 50 adults who had been treated with surgery for primary squamous cell carcinoma of the oral cavity. Primary tumor depth and other pathologic features were determined by reviewing the pathology specimens. Preoperatively, 36 of the 50 patients were clinically N0; however, occult lymph node metastasis was found in 13 of these patients (36.1%). The prevalence of neck node metastasis in patients with T1/T2 and T3/T4 category tumors was 51.5 and 58.8%, respectively. The associations between the prevalence of neck node metastasis and both the degree of differentiation and the depth of invasion were statistically significant, but there was no significant association between neck node metastasis and tumor size. We conclude that the prevalence of neck lymph node metastasis in patients with squamous cell carcinoma of the oral cavity increases as the tumor depth increases and as the degree of tumor differentiation decreases from well to poor, as has been shown in previous studies. It is interesting that tumor size, which is the most important component of the TNM system, was not significantly associated with neck node involvement.

Is elective neck dissection in T1-2, N0 patients with lower lip cancer necessary?

The significance of elective neck dissection in the early stages of lower lip cancer is generally underestimated. In the classic textbooks of plastic surgery it has been generally accepted that lymphatic spread to neck is negligible and therefore it is not imperative to perform any kind of neck dissection. However, in some recent studies high rates of clinically positive neck that were initially negative began to appear in the literature especially in otorhinolaryngology and head and neck journals. Our clinical series consisted of 21 lower lip cancer cases with T1-2, N0 tumors; the rate of lymphatic spread to neck was found to be 19%. Because of this high rate, we conclude that it is not sound to discard the importance of neck dissection even in the early stages of lower lip cancers. At least, a suprahyoid neck dissection should be performed in all patients with lower lip cancer.

[Mouth floor and mobile tongue epidermoid carcinomas thickness: prognostic value]

INTRODUCTION

Most cancers of the oral cavity are epidermoid carcinomas. The prognosis is made on the patient's general health status and the tumoral stage. The UICC TNM staging classification system is one of the most important factors taken in consideration for the prognosis. But this classification in oral epidermoid carcinomas does not include the tumor thickness (except for T4 tumors). Several studies demonstrated that tumor thickness could influence the prognosis in epidermoid carcinoma and other types of cancers. The aim of our retrospective study was to assess the prognostic value of tumor thickness in oral epidermoid carcinoma.

PATIENTS AND METHODS

The study included patients with mouth floor or mobile tongue epidermoid carcinoma classified T1N0, T2N0 and T3N0 between 1985 and 2005. All patients were treated with a curative intention. A pathologist analysed the tumor thickness and cervical lymph nodes. All the slides were examined to measure tumor thickness in millimetres.

RESULTS

Three hundred and five patient files were reviewed and 124 patients were included, with 94 men (75.8%), and a mean age of 59.3 years (17-93). The mean and median tumor thickness were respectively 7.7 and 6.5 mm (0.4-30). The median tumor thickness was chosen for the study. There was a statistically significant link between the five-year probability of global survival and the initial tumor thickness and between neck node invasion and tumor thickness (p<0.05).

DISCUSSION

This study suggests that tumor thickness should be taken in consideration in T1N0, T2N0 and T3N0 mouth floor and mobile tongue epidermoid carcinomas. In the future, the clinical evaluation of tumor thickness will help determine the therapeutic management.

Clinical Parameters in T1N0M0 Lower Lip Squamous Cell Carcinoma

This retrospective study was carried out to asses the clinical outcome of T1 (i.e., tumor 2 cm or less at greatest dimension) squamous cell carcinoma of the lower lip (SCCLL) and verify the impact of some clinical parameters on prognosis. Fifty-seven patients with histologically proven T1 SCCLL were analyzed. Fifty-two patients were never treated before admission, whereas five (8.8%) had a second radical resection of the primary tumor location; none had neck nodes (i.e., N0) or distant metastasis (i.e., M0). The global disease-specific survival rate at 32 months was 100%, irrespective of grading and type of surgery, and thus no differences were statistically detected. Therefore, we concluded that radical tumor resection is a viable procedure for T1 SCCLL, irrespectively of grading. In addition, a second surgery on the primary tumor location is possible and has effectiveness on survival. Finally, neck dissection is not necessary in cases of T1 SCCLL.

High-risk cutaneous squamous cell carcinoma of the head and neck: results from 266 treated patients with metastatic lymph node disease

BACKGROUND

Most patients with cutaneous squamous cell carcinoma (cSCC) of the head and neck (HN) are at low-risk (<5%) of developing metastatic SCC to regional lymph nodes. However, patients with unfavorable clinicopathologic factors often are under appreciated by clinicians but remain at higher risk for developing metastatic lymph node disease and dying.

METHODS

Patients were identified who had metastatic cSCC to lymph nodes (parotid and cervical) of the HN and who were treated within the context of a multidisciplinary HN cancer service between 1980 and 2005 at Westmead Hospital (Sydney, Australia). Relevant patient details and data from primary lesions were analyzed and reported.

RESULTS

In total, 266 patients were treated with curative intent. The median patient age was 69 years among 219 males and 47 females. The majority of metastatic lymph nodes (162 of 266 lymph nodes; 61%) were located in the parotid with or without cervical lymph node involvement. The median tumor thickness was 6 mm (range, 0.5-28 mm), and the median tumor size was 15 mm (range, 3-70 mm). Most tumors (65%) that measured >or=5 mm in thickness, and 30% of patients had lesions that measured >or=2 cm in greatest dimension. Recurrent cSCC was present in 15% of patients, and most lesions were located within the lymphatic drainage of the parotid on the temple/forehead (28%), on or around the ear (20%), or on the cheek (12%). Forty-six percent of patients had moderately or poorly differentiated cSCC, and 5% of patients were immunosuppressed. A minority of patients (27%) did not have an identifiable index lesion.

CONCLUSIONS

Data from this large, prospective data base, in concordance with other series, suggested that a patient with thick cSCC (>4-5 mm) located in proximity to the parotid gland can be considered at high-risk. Increasing lesion size and recurrence contribute to this risk.

Importance of tumor thickness and depth of invasion in nodal involvement and prognosis of oral squamous cell carcinoma: a review of the literature

BACKGROUND

Oral mucosa squamous cell carcinoma (OSCC) has locoregional evolution, with frequent neck involvement (the most important parameter for prognosis). There are still many doubts concerning the best way to approach N0 neck disease in early-stage lesions (T1 and T2). Many parameters have been studied to identify N0 patients with a high likelihood of harboring occult node metastases or of having them develop.

METHODS

A review of the studies analyzing "tumor thickness"/"depth of invasion" in predicting regional metastases and survival was undertaken.

RESULTS

The literature suggests that "tumor thickness"/"depth of invasion" is a reliable parameter for predicting regional nodal involvement and survival in OSCC.

CONCLUSIONS

Authors are in substantial agreement regarding the reliability of tumor thickness. The lack of comparable study groups, measurement techniques, and cut-off values points to the need for further studies so as to reach a consensus and to develop therapy protocols that include tumor thickness.

Defining patients with high-risk cutaneous squamous cell carcinoma

SUMMARY Non-melanoma skin cancers occur at an epidemic rate in Australia. With an ageing population more Australians will develop these cancers and at an increasing rate. In the majority of cases, local treatment, usually excision, is highly curative. However, a subset of the population are diagnosed with a high-risk cutaneous squamous cell carcinoma, defined as a patient having a higher risk of subclinical metastases to regional lymph nodes based on unfavourable primary lesion features and patient factors. Despite treatment, patients developing metastatic cutaneous squamous cell carcinoma experience mortality and morbidity usually as a consequence of uncontrolled metastatic nodal disease. It is therefore important that clinicians treating skin cancers have an understanding and awareness of these high-risk patients. The aim of this article is to discuss the features that define a high-risk patient and to present some of the issues pertinent to their treatment.

Treatment recommendations in patients diagnosed with high-risk cutaneous squamous cell carcinoma

Non-melanoma cutaneous cancers occur at an epidemic rate in Australia. With an ageing population, more Australians will develop these cancers and at an increasing rate. In the majority of cases local treatment is highly curative. However, a subset of the population will be diagnosed with a high-risk cutaneous squamous cell carcinoma. These can be defined as patients at risk of having subclinical metastases to regional lymph nodes based on unfavourable primary lesion features (including inadequately excised and recurrent lesions), patients with metastatic squamous cell carcinoma to regional lymph nodes, and squamous cell carcinoma in immunosuppressed patients. The mortality and morbidity associated with high-risk cutaneous squamous cell carcinoma is usually as a consequence of uncontrolled metastatic nodal disease and, to a lesser extent, distant metastases. Radiotherapy has an essential role in treating these patients and in many cases the addition of adjuvant radiotherapy may be life saving. It is therefore important that all clinicians treating skin cancers have an understanding and awareness of the optimal approach to these patients. The aim of this article is to present treatment recommendations based on an overview of the current published literature.

Overexpression of cyclin D1 and interaction between p27Kip1 and tumour thickness predict lymph node metastases occurrence in lower lip squamous cell carcinoma

We have attempted to identify those subgroups of patients most likely to develop lymph node metastases from squamous cell carcinoma of the lower lip (LLSSC). A total of 97 subjects, who did not undergo elective neck dissection, were recruited into the 60-month disease-free survival study. After univariate analysis, tumour size, histological grading, maximal thickness, perineural invasion and immunoreactivity to cyclin D1 and p27Kip1 proteins proved to be significant factors. Tests of the effect of interaction between p27Kip1 LI and tumour thickness yielded that the impact of tumour thickness on the risk of lymph node metastases was modified by the percentage of p27Kip1 positive cells. Subsequent to models of multivariate analysis, tumour size, positive cyclin D1 protein expression, maximal thickness (> 5 mm), p27Kip1 LI (%) and the interaction term between p27Kip1 LI and tumour thickness retained strong independent predictive values for lymph node metastases. We suggest that immunohistochemistry for cyclin D1 and p27Kip1 may prove to be valuable ancillary tests for identifying LLSSC with metastatic potential.

Carcinoma espinocelular do lábio: avaliação de fatores prognósticos

Dentre os cânceres do lábio de 90% a 95% dos casos afetam o lábio inferior, sendo o carcinoma espinocelular o mais freqüente. A classificação TNM sintetiza as características clínicas do tumor, permitindo realizar um prognóstico e possibilitando comparações dos resultados. Relaciona três parâmetros: tamanho do tumor (T), propagação aos gânglios linfáticos regionais (N) e metástases à distância (M), mas estabelece padrões a partir de 2cm. Para o carcinoma espinocelular do lábio lesões com 2cm são extremamente grandes. OBJETIVO: O objetivo deste estudo é verificar a relação entre as características epidemiológicas, clínicas, evolutivas e histopatológicas do carcinoma espinocelular do lábio tendo como parâmetro lesões de tamanhos a partir de 0,5cm. CASUÍSTICA E MÉTODO: Foi elaborado um estudo retrospectivo transversal em pacientes com carcinoma espinocelular do lábio, no período 1993-2000, em São Paulo, Brasil. Estudou-se prontuários, laudos originais dos exames histopatológicos e lâminas de tumores de pacientes com carcinoma espinocelular do lábio. Os tumores foram classificados de 0.5 em 0.5cm, sendo verificado o tipo, o grau de diferenciação histológica, a presença de desmoplasia, as invasões muscular, neural e vascular, e o tipo de infiltrado inflamatório. RESULTADOS: A análise estatística mostrou que metástases e recidivas não dependem da cor de pele ou do sexo dos pacientes e que há independência entre a localização do tumor, no lábio superior ou inferior, e a incidência de metástases e recidiva. Houve correlação entre o tamanho da lesão a partir de 0,5cm e a ocorrência de metástases e recidiva. Verificou-se que o tamanho da lesão determina a invasão em outros tecidos. O infiltrado inflamatório verificado em todas as lesões era linfoplasmocitário e, em algumas, associado com eosinófilos sem relação com o tamanho do tumor. CONCLUSÃO: Tumores menores que 2cm podem apresentar comportamentos evolutivos distintos, sob o ponto de vista clínico e histopatológico. O tipo mais prevalente de lesão é o ulcerativo e o que mais metastatiza e recidiva é o úlcero-vegetante. Os tipos úlcero-vegetante e vegetante estão ligados a lesões de maior tamanho. O tamanho do tumor se relaciona, de forma semelhante, com os graus II e III, nos quais ocorrem os maiores índices de metástases e recidivas. O tumor invade em ordem decrescente de freqüência músculos, nervos e vasos sanguíneos, e esta pode ser prevista pelo tamanho da lesão. É necessária a invasão dos músculos para a ocorrência de metástases, sendo que os vasos sanguíneos somente podem estar implicados quando há invasão concomitante dos nervos. A desmoplasia está diretamente relacionada ao tamanho da lesão e à ocorrência de metástases.

The relationship between tumor thickness and clinical and histopathologic parameters in cancer of the larynx

OBJECTIVES

We sought to determine the relationship of tumor thickness to clinical and histopathologic parameters in laryngeal cancer. Study design and setting We conducted a retrospective review of laryngectomy specimens of 111 surgically treated T1-3 laryngeal cancer patients for tumor thickness and various histopathologic parameters.

RESULTS

Tumor thickness was significantly related to T, N, and clinical stage; pathologic cervical lymph node metastasis; cartilage invasion; microscopic appearance; mode of invasion to surrounding tissues; perineural invasion; and lymphocytic infiltration (P < 0.05). Tumor thickness had significant correlation with T, N, and clinical stage; cervical lymph node metastasis; cartilage invasion; mode of invasion to surrounding tissues; perineural invasion; and lymphocytic infiltration (P < 0.05). Multifactorial statistical analysis showed that cartilage invasion and lymphocytic infiltration significantly determined tumor thickness independently (P < 0.05).

CONCLUSION

Tumor thickness is well correlated to most of the reliable clinical and histopathologic parameters, and it is an objective and easy-to-obtain measure.

SIGNIFICANCE

Tumor thickness can be used as a reliable histopathological factor and should be measured in every laryngectomy specimen.

Squamous cell carcinoma of the lip: is there a role for adjuvant radiotherapy in improving local control following incomplete or inadequate excision?

BACKGROUND

The treatment of squamous cell carcinoma of the lip with surgery is usually curative but incomplete/inadequate excision may be associated with recurrence and poor outcome. There is no consensus in the literature on the definition of an adequate excision margin.

METHODS

Patients treated for squamous cell carcinoma of the lip at Westmead Hospital, Sydney, between 1980 and 2000 were eligible for inclusion. Polytomous logistic regression analysis was undertaken to assess for predictors of recurrence. Recurrence-free and overall survival were calculated using Kaplan-Meier survival curves.

RESULTS

A total of 130 patients was identified. Median age at diagnosis was 64 years (23-97 years). Most lesions (90%) were located on the lower lip in 96 (74%) male patients. Median follow-up duration was 54 months (0-189 months). Most patients -presented with T1 lesions (75%). Initial treatment was surgery (39%), radiotherapy (48%) or both (13%). Twenty-seven per cent of excised lesions had a close (< or =2 mm) or positive margin. A total of 40 patients (31%) had recurrence (18% lymph nodes, 11% lip and 2% both). In the surgery group recurrence was significantly more likely with close or positive margins (P = 0.05). The 2 year -recurrence-free survival was 82% and 54% for radiotherapy and surgery, respectively (P < 0.001). The 2 year overall survival was similar (90% radiotherapy vs 100% surgery; P = 0.58).

CONCLUSION

Incomplete or inadequate excision of some lip cancers results in local recurrence. If re-excision is not feasible -surgeons should consider the role of adjuvant radiotherapy in improving local control.

Squamous cell carcinoma of the lip. Patterns of relapse and outcome: Reporting the Westmead Hospital experience, 1980-1997

Australia has one of the highest rates of squamous cell carcinoma of the lip in the world. Despite a high cure rate, many studies report relapse rates of between 5% and 20% with an associated mortality of 5-10%. The aim of this study was to review the patterns of relapse and outcome for patients treated at Westmead Hospital, Sydney. Ninety-three eligible patients were identified in a retrospective review of all lip cancer patients referred to Westmead Hospital between 1980 and 1997. Relevant data were extracted from the treatment files and included contact with referring doctors and utilizing the Cancer Council Registry. Equal numbers of patients were treated with radiotherapy alone or surgery (+/- adjuvant radiotherapy). The majority of patients were male (78.5%) with T1N0 cancers (64.5%) of the lower lip. A minority (5.4%) had nodal disease at diagnosis. Following treatment, 31 (33.3%) patients relapsed, 11 at the primary site, 18 at the regional nodes and two at both sites simultaneously. Patients treated with a combined approach (RTx/Sx) experienced a better outcome. Overall cancer-specific survival at 5 years was 85%. These findings highlight a disturbing relapse rate and mortality for a subgroup of patients diagnosed with a more aggressive form of lip cancer. Treatment and follow up of these patients should accordingly be more aggressive.

Reliability of frozen section in determining tumor thickness intraoperatively in laryngeal cancer

OBJECTIVES

The relationship between locoregional lymph metastasis and tumor thickness in head and neck cancer has been well documented in recent years. Determining tumor thickness by frozen section may help the surgeon decide intraoperatively whether to perform elective neck dissection, whereas paraffin section results could be obtained at a later time for this decision. The aim of this study was to evaluate the accuracy of tumor thickness measurements obtained by macroscopic measurement and by frozen section intraoperatively in laryngeal cancer.

STUDY DESIGN

Prospectively we compared the tumor thickness results obtained by gross visual examination, by frozen section, and by paraffin section in 20 total, near-total, and horizontal supraglottic laryngectomy specimens.

METHODS

The sections were stained with hematoxylin and eosin and tumor thickness was measured under a light microscope with an ocular micrometer.

RESULTS

A strong correlation was found between frozen section and paraffin section tumor thickness measurements (Pearson correlation coefficient = 0.993, P <.001). Paired t test showed a 4.59 mm mean difference between macroscopic and paraffin section measurements, and a 0.76 mm mean difference between frozen and paraffin section measurements.

CONCLUSION

Assessment of tumor thickness in laryngeal cancer intraoperatively by frozen section is a reliable method.