Current role of primary surgical treatment in patients with head and neck squamous cell carcinoma

Unveiling NRlncRNAs as prognostic biomarkers and therapeutic targets for head-and-neck squamous cell carcinoma through machine learning

Head-and-neck squamous cell carcinoma (HNSCC) patients often exhibit insensitivity to immunotherapy, leading to treatment failure. Identifying potential biomarkers that can predict prognosis and improve the efficacy of treatment is crucial. In this study, we aimed to identify necroptosis-related long noncoding RNAs (NRlncRNAs) as potential therapeutic targets to improve the prognosis of HNSCC patients. By exploring the Genotype-Tissue Expression Project (GTEx) and the Cancer Genome Atlas (TCGA) databases, we identified NRlncRNAs and developed a risk model comprising 17 NRlncRNAs to predict the prognosis of HNSCC patients and to classify patients into two clusters based on their expression levels. We conducted various analyses, such as the Kaplan-Meier analysis, GSEA and IC50 prediction, to evaluate the differences in sensitivity to immunotherapy between the two clusters. Our findings suggest that NRlncRNAs have potential as therapeutic targets for improving the prognosis of HNSCC patients, and that individualized treatment approaches based on NRlncRNA expression levels can improve the sensitivity of immunotherapy and overall treatment outcomes. This study highlights new perspectives within clinical cancer informatics and provides insight into potential therapeutic strategies for HNSCC patients.

Clinical Characteristics and Treatment Outcomes of Oral Cancers Using Transoral Robotic Surgery in an Endemic Region

Oral cancer poses a major health challenge in Taiwan, consistently ranking among the highest globally in both incidence and cancer-related mortality. Transoral robotic surgery (TORS) has potential advantages over open surgery, but its long-term oncologic outcomes are not well established. In this study, we sought to elucidate the role of TORS in improving treatment outcomes among oral cancer patients. A case-control study with propensity score matching was conducted in a single teaching hospital in Taiwan. It included 72 oral cancer patients in each group to analyze and compare survival outcomes between the surgical approaches. The TORS group demonstrated a higher negative resection margin rate, a lower mortality risk and better overall survival than the open-surgery group. Multivariate Cox regression analysis confirmed TORS's association with a reduced risk of death. Kaplan-Meier survival analysis and log-rank tests indicated significantly better survival outcomes for the TORS group across all cancer stages. Moreover, the TORS group exhibited improved overall survival rates for stage III and IV patients compared to the conventional open-surgery group. In conclusion, this study suggests that TORS may offer better overall survival rates and potential advantages over conventional surgery for oral cancer treatment.

Phase I / II trial of metformin as a chemo-radiosensitizer in a head and neck cancer patient population

OBJECTIVES

Retrospective studies have shown that head and neck squamous cell carcinoma (HNSCC) patients taking metformin demonstrate superior survival compared to their counterparts. We sought to determine whether metformin combined with chemoradiation would improve HNSCC patient survival compared to historical controls.

MATERIALS AND METHODS

We conducted a Phase I/II prospective, single arm clinical trial in patients with newly diagnosed HNSCC (NCT02949700). Patients received platinum-based chemoradiation in combination with orally dosed metformin at one of 2 doses- 850 mg BID or 1500 mg BID administered during radiation, with a 2-week lead-in phase. Toxicity, disease response and survival metrics were ascertained throughout the study period.

RESULTS

A total of 25 patients were evaluable for toxicity and survival; 9 failed to reach the predetermined 70% compliance with the study drug. No dose limiting toxicities were identified in the Phase I component and there were no grade 4 adverse events likely related to metformin throughout the study. The primary outcome for the Phase II component was met with a response rate of 96%. Three-year overall survival was ∼70% in the per protocol p16 + cohort and 0% in the per protocol p16- cohort. Survival among participants with a ≥70% metformin compliance to <70% metformin compliance demonstrated a trend towards improvement in the ≥70% compliance cohort, though this did not reach significance.

CONCLUSION

Metformin is well tolerated during concurrent chemoradiation for HNSCC. Its effectiveness as a chemo-radiosensitizer remains unclear and will require further study with randomized controlled clinical trials in this patient population.

Lipidome Analysis of Oropharyngeal Tumor Tissues Using Nanosecond Infrared Laser (NIRL) Tissue Sampling and Subsequent Mass Spectrometry

Ultrashort pulse infrared lasers can simultaneously sample and homogenize biological tissue using desorption by impulsive vibrational excitation (DIVE). With growing attention on alterations in lipid metabolism in malignant disease, mass spectrometry (MS)-based lipidomic analysis has become an emerging topic in cancer research. In this pilot study, we investigated the feasibility of tissue sampling with a nanosecond infrared laser (NIRL) for the subsequent lipidomic analysis of oropharyngeal tissues, and its potential to discriminate oropharyngeal squamous cell carcinoma (OPSCC) from non-tumorous oropharyngeal tissue. Eleven fresh frozen oropharyngeal tissue samples were ablated. The produced aerosols were collected by a glass fiber filter, and the lipidomes were analyzed with mass spectrometry. Data was evaluated by principal component analysis and Welch's t-tests. Lipid profiles comprised 13 lipid classes and up to 755 lipid species. We found significant inter- and intrapatient alterations in lipid profiles for tumor and non-tumor samples (p-value < 0.05, two-fold difference). Thus, NIRL tissue sampling with consecutive MS lipidomic analysis is a feasible and promising approach for the differentiation of OPSCC and non-tumorous oropharyngeal tissue and may provide new insights into lipid composition alterations in OPSCC.

SEC11A contributes to tumour progression of head and neck squamous cell carcinoma

Background

Head and neck squamous cell carcinoma (HNSCC) is a prevalent disease that has a low survival rate and high recurrence risk. Our study aims to investigate the expression and role of SEC11A in HNSCC.

Methods

The expression of SEC11A was assessed in 18 pairs of cancerous and adjacent tissues by qRT-PCR and western blotting. Immunohistochemistry was performed in clinical specimen sections to evaluate the expression of SEC11A and its association with outcomes. Furthermore, the functional role of SEC11A in HNSCC tumor proliferation and progression was investigated using the in vitro cell model with lentivirus-mediated SEC11A knockdown. Colony formation and CCK8 assays were conducted to assess cell proliferation potential, while in vitro migration and invasion were examined using wound healing and transwell assays. To determine the tumor formation potential in vivo, a tumor xenograft assay was used.

Results

In contrast to adjacent normal tissues, SEC11A expression was significantly elevated in HNSCC tissues. SEC11A was mainly localized in the cytoplasm, and its expression was significantly associated with patient prognosis. SEC11A was silenced using shRNA lentivirus in TU212 and TU686 cell lines, and the gene knockdown was confirmed. A series of functional assays demonstrated that SEC11A knockdown reduced cell proliferation, migration and invasion ability in vitro. In addition, the xenograft assay demonstrated that SEC11A knockdown significantly inhibited tumor growth in vivo. Tumor tissue sections of mice showed decreased proliferation potential in the shSEC11A xenografts cells by immunohistochemistry.

Conclusion

SEC11A knockdown decreased cell proliferation, migration and invasion in vitro and subcutaneous tumorigenesis in vivo. SEC11A is crucial to HNSCC proliferation and progression, and may serve as a new therapeutic target.

Novel Local Chimeric Flap Based on Tunnelized Facial Artery Myomucosal Island Flap and Submandibular Gland Flap for Reconstructions After Oral Squamous Cell Carcinoma Surgery

The reconstruction of oral tongue and floor of mouth defects after resections of squamous cell carcinoma is a challenging task in reconstructive surgery aiming for appropriate restoration of oral function and quality of life improvement. In this study, the authors introduce the innovative reconstruction technique of medium-sized defects consisting of tunnelized facial artery myomucosal island flap and submandibular gland flap as the local chimeric flap pedicled on facial vessels. A retrospective case series evaluation of 4 patients suffering from oral cavity cancer (stages III and IVa), who underwent transoral tumor excision with neck dissection and immediate reconstruction in the time period September 2020 to July 2021, was conducted. No flap losses or flap-related complications were identified. No recurrences occurred during the follow-up at 11.0±4.5 months (range: 6-16 mo, median=11 mo). Tunnelized facial artery myomucosal island flap and submandibular gland flap local chimeric flap expands the reconstruction options of medium-sized defects after ablative oral cancer surgery in carefully selected patients primarily not suitable for free flap reconstructions.

IGF2BP2 serves as a core m6A regulator in head and neck squamous cell carcinoma

Methylation of N6 adenosine (m6A) plays a crucial role in the development and progression of cancers. Its modification is regulated by three types of m6A-related regulators (methyltransferases (writers), demethylases (erasers), and RNA-binding proteins (readers)). Till now, the functions and roles of these regulators in head and neck squamous cell carcinoma (HNSC) remain largely unexplored. Therefore, we utilized the open HNSC dataset in The Cancer Genome Atlas (TCGA), four different cell lines, and our HNSC patient samples (n=40) to explore the clinical significance of 19 m6A regulators, and selected the most significant prognosis-related regulator. Authentic analyses based on online websites were also used in the study (Oncomine, UALCAN, Kaplan-Meier plotter, Human Protein Atlas (HPA), cBioPortal, LinkedOmics, String, etc.). From the results, general overexpression of m6A regulators was observed in pan-cancer, especially in HNSC. IGF2BP2 was recognized as the hub m6A regulator, which was an independent, unfavorable prognostic factor in HNSC. Its mRNA and protein expression in HNSC were significantly up-regulated. Gene mutation types of IGF2BP2 in HNSC (32%) were mainly mRNA High or Amplification, which represented the high expression of IGF2BP2. And these mutations were associated with a poor prognosis. In functional analysis, IGF2BP2 was negatively correlated to tumor immune infiltration in HNSC. Finally, HMGA2 might interact with the IGF2BP2 in HNSC. In conclusion, IGF2BP2 serves as a core m6A regulator among all regulators in HNSC, which has a high expression and predicts the poor prognosis of HNSC patients independently. IGF2BP2 might bring a new direction for HNSC treatment in the future.

Quality-of-Life Assessment after Head and Neck Oncological Surgery for Advanced-Stage Tumours

Squamous cell carcinoma of the head and neck (HNSCC) is a common malignancy often diagnosed in the advanced stage with a complex negative influence on the patient’s quality of life (QoL). Given its multi-modal treatment, the first step is to adequately balance the needs of the patient, and the second step includes the consultations, interventions, and care provided by the medical team, with the purpose of improving the overall management of the HNSCC. Current attempts to develop and validate quality-of-life instruments specific to cancers of the head and neck have been reported, and certain questionnaires are now available. We performed a retrospective study in a tertiary centre, involving 89 patients who survived 3 years after HNSCC surgery. A patient-related outcome measurement was made using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-H&N35 instruments to assess QoL at admission and 3 years after treatment. The 3-year survivors reported an overall improvement in QoL compared with those in the pre-treatment period. The unique details of head and neck cancer treatments outline the importance of considering the characteristics of the patient population in quality-of-life research and also identify how quality-of-life data can contribute to the care provided by the multi-disciplinary team involved in a patient’s follow-up.

Efficacy of Larynx Preservation Surgery and Multimodal Adjuvant Therapy for Hypopharyngeal Cancer: A Case Series Study

Background: Larynx preservation surgery (LPS) combined with multimodal adjuvant therapy (MAT) is re-emerging as treatment option for hypopharyngeal cancer (HPC). This study aims to explore the survival and functional outcome of this combined approach. Methods: This is a retrospective cohort study. Selected patients with primary HPC treated by LPS and MAT at two large Beijing medical centers between 2005 and 2019 were included. In addition to LPS, patients received one or more of the following treatments: preoperative induction chemotherapy, postoperative intensity-modulated radiotherapy, chemotherapy, or targeted therapy. Results: In total, 64 patients were included (62 were men, and median age was 57.5 years). The disease in most patients was in stage III (28.1%) or IV (56.3%), or in stage T2 (34.4%) or T3 (45.3%), based on the TNM scale. Across all patients, the rate of overall survival (OS) was 60.7% at 3 yr and 47.3% at 5 yr. OS was significantly higher for patients with stage I or II disease than for those with stage III or IV disease (HR 8.64, 95% CI 3.69-20.2, log-rank P = .010). Decannulation was successful in 55 patients (85.9%), and swallowing function was satisfactory (stage 0-III, on Functional Outcome Swallowing Scale) for 50 (78.1%). Median Voice Handicap Index-10 score on voice performance was 19 (range 4-40), and median Functional Assessment of Cancer Therapy-General Questionnaire score for QoL was 75 (range 16-105). Conclusions: LPS and MAT can provide satisfactory oncologic control and good functional outcomes for selected patients with HPC, especially those with stage I or II disease.

Current Therapeutic Strategies in Patients with Oropharyngeal Squamous Cell Carcinoma: Impact of the Tumor HPV Status

Simple Summary

Contrary to other head and neck subsites, oropharyngeal squamous cell carcinoma (OPSCC) has shown a considerable increase in incidence over the past 20 years. This growing incidence is largely due to the increasing place of human papillomavirus (HPV)-related tumors. HPV-positive and HPV-negative OPSCC are two distinct entities with considerable differences in terms of treatment response and prognosis. However, there are no specific recommendations yet in the therapeutic management of OPSCC patients according to their tumor HPV-status. The aim of this review is therefore to discuss the therapeutic management of patients with OPSCC and the impact of HPV status on treatment selection.

Abstract

Since there is no published randomized study comparing surgical and non-surgical therapeutic strategies in patients with oropharyngeal squamous cell carcinoma (OPSCC), the therapeutic management of these patients remains highly controversial. While human papillomavirus (HPV)-positive and HPV-negative OPSCC are now recognized as two distinct diseases with different epidemiological, biological, and clinical characteristics, the impact of HPV status on the management of OPSCC patients is still unclear. In this review, we analyze the current therapeutic options in patients with OPSCC, highlighting the most recent advances in surgical and non-surgical therapies, and we discuss the impact of HPV status on the therapeutic strategy.

HPV status and therapeutic initial strategy impact on survival and oncologic outcomes: 5-year results from the multicentric prospective cohort of oropharyngeal cancers Papillophar

PURPOSE

After the 2 years of follow-up, we aimed to evaluate at 5 years the impact of human papillomavirus (HPV) status, tobacco, and initial treatment approach on progression-free survival (PFS) and overall survival (OS) of patients with oropharyngeal cancer (OPC) in France.

METHODS

Papillophar study was designed as a prospective cohort of 340 OPC patients in 14 French hospitals. HPV-positive status (21.7%) was defined with PCR (positivity for HPV DNA and E6/E7 mRNA). Cox proportional hazard models were used to assess the relationship between PFS, OS, HPV, and other prognostic factors. The combined effect of HPV status with smoking, stage, or initial treatment on PFS was also evaluated.

RESULTS

HPV-pos patients had better PFS than HPV-neg patients (HR = 0.46; 95% CI: 0.29-0.74), and worse for older patients (HR for 5-year age increase = 1.14), UICC stage 4 from the 7th TNM classification compared to stage 1-2 (HR = 2.58; CI: 1.33-5.00), and those having had radiotherapy (HR = 2.07; 95% CI: 1.36-3.16) or induction chemotherapy (HR = 2.11; 95% CI: 1.32-3.38) instead of upfront surgery. HPV-neg patients encountered a larger incidence of loco-regional disease than HPV-pos patients (31.5% and 14.0%, respectively, p = 0.0001). Distant metastases proportion was similar. HPV-neg patients developed more second primary tumor than HPV-pos patients (11.7% vs. 3.3%, p = 0.02).

CONCLUSIONS

5-year follow-up confirms the specifically improved prognosis in HPV-positive patients. The prognosis is nevertheless significantly modified through clinical and therapeutical variations.

Evaluation of autofluorescence visualization system in the delineation of oral squamous cell carcinoma surgical margins

INTRODUCTION

Delineating the margins of Oral squamous cell carcinoma (OSCC) is a critical step for optimaltumor resection. The aim of this study was to evaluate the accuracy of lesion surgical margin identification using autofluorescence visualization.

MATERIALS AND METHODS

Thirty patients with OSCC were included in this study. For each lesion, the fluorescence loss boundary was determined using VELscope before ablative surgical resection (with a 1.5-2cm safety margin) was performed. A total of 126 samples were obtained from 30 surgical specimens, each containing the tissue from the fluorescence loss boundary to surgical margin. The status of each sample was determined by oral pathologists and the staining intensities of Ki-67, E-cadherin, and Vimentin at the fluorescence loss boundary and surgical margin were evaluated by immunohistochemistry.

RESULTS

Fluorescence loss regions were identified in all patients. Of the 126 samples collected, HE staining identified 77 normal epithelia (61.1%), 26 mild dysplasia (20.6%), 17 severe dysplasia (13.4%) and 6 carcinomas in situ (4.9%). A significant correlation was found between the differentiation grade of tumor cells and the pathological status of the surgical marginal specimens (P<0.05). Forty-two of the 126 samples were randomly selected for further immunohistochemical staining. No significant differences were seen in Ki-67, E-cadherin, or Vimentin expression at the fluorescence loss boundary or surgical margin, however, the proteins' expression level was positively correlated with the degree of dysplasia (P<0.01).

CONCLUSION

Autofluorescence visualization has potential as a simple surgical margin setting device for OSCC and may help delineate the superficial area of OSCC with acceptable accuracy. However, when considering the inherent limitations of this system, we suggest that the approach should only be applied under certain conditions, such as when dealing with superficial, well-differentiated lesions.

Immune Infiltrates of m6A RNA Methylation-Related lncRNAs and Identification of PD-L1 in Patients With Primary Head and Neck Squamous Cell Carcinoma

Background: The purpose of this study was to determine the association between m⁶A-modified lncRNAs, immune infiltration, and PD-L1 expression in patients with primary head and neck squamous cell carcinoma (HNSCC) and the prognostic value of m⁶A RNA methylation-related lncRNAs in HNSCC. Methods: We downloaded the RNA-seq transcriptome data and the clinical information for HNSCC from the TCGA databases and used consensus clustering analysis to divide the samples into two groups. To identify a risk signature, least absolute shrinkage and selection operator (LASSO) analyses were conducted. the association between m⁶A-modified lncRNAs, immune infiltration, and PD-L1 expression were detected by using the R packages. What is more, we used cBioPortal tools to identify genomic alterations and PD-L1 mutations and Gene set enrichment analysis (GSEA) was utilized to predict downstream access of two clusters. Results: Notably, lncRNAs play significant roles in tumorigenesis and development. In total, we identified two subtypes of HNSCC according to consensus clustering of the m⁶A RNA methylation-related lncRNAs, and the T, grade and age were proven to be related to the subtypes. The Cox regression and LASSO analyses identified a risk signature including GRHL3-AS1, AL121845.4, AC116914.2, AL513190.1. The prognostic value of the risk signature was then proven. The selected gene PD-L1 mutations and the immune infiltration in both groups were further explored. Conclusion: Collectively, our study elucidated the important role of m⁶A RNA methylation- related lncRNAs in tumor microenvironment of HNSCC. The proposed m⁶A RNA methylation- related lncRNAs might serve as crucial mediators of tumor microenvironment of HNSCC, representing promising therapeutic targets in improving immunotherapeutic efficacy.

ECM Remodeling in Squamous Cell Carcinoma of the Aerodigestive Tract: Pathways for Cancer Dissemination and Emerging Biomarkers

Squamous cell carcinomas (SCC) include a number of different types of tumors developing in the skin, in hollow organs, as well as the upper aerodigestive tract (UADT) including the head and neck region and the esophagus which will be dealt with in this review. These tumors are often refractory to current therapeutic approaches with poor patient outcome. The most important prognostic determinant of SCC tumors is the presence of distant metastasis, significantly correlating with low patient survival rates. Rapidly emerging evidence indicate that the extracellular matrix (ECM) composition and remodeling profoundly affect SSC metastatic dissemination. In this review, we will summarize the current knowledge on the role of ECM and its remodeling enzymes in affecting the growth and dissemination of UADT SCC. Taken together, these published evidence suggest that a thorough analysis of the ECM composition in the UADT SCC microenvironment may help disclosing the mechanism of resistance to the treatments and help defining possible targets for clinical intervention.

ECM Remodeling in Squamous Cell Carcinoma of the Aerodigestive Tract: Pathways for Cancer Dissemination and Emerging Biomarkers

Simple Summary

Local and distant metastasis of patients affected by squamous cell carcinoma of the upper aerodigestive tract predicts poor prognosis. In the latest years, the introduction of new therapeutic approaches, including targeted and immune therapies, has improved the overall survival. However, a large number of these patients do not benefit from these treatments. Thus, the identification of suitable prognostic and predictive biomarkers, as well as the discovery of new therapeutic targets have emerged as a crucial clinical need. In this context, the extracellular matrix represents a suitable target for the development of such therapeutic tools. In fact, the extracellular matrix is composed by complex molecules able to interact with a plethora of receptors and growth factors, thus modulating the dynamic crosstalk between cancer cells and the tumor microenvironment. In this review, we summarize the current knowledge of the role of the extracellular matrix in affecting squamous cell carcinoma growth and dissemination. Despite extracellular matrix is known to affect the development of many cancer types, only a restricted number of these molecules have been recognized to impact on squamous cell carcinoma progression. Thus, we consider that a thorough analysis of these molecules may be key to develop new potential therapeutic targets/biomarkers.

Abstract

Squamous cell carcinomas (SCC) include a number of different types of tumors developing in the skin, in hollow organs, as well as the upper aerodigestive tract (UADT) including the head and neck region and the esophagus which will be dealt with in this review. These tumors are often refractory to current therapeutic approaches with poor patient outcome. The most important prognostic determinant of SCC tumors is the presence of distant metastasis, significantly correlating with low patient survival rates. Rapidly emerging evidence indicate that the extracellular matrix (ECM) composition and remodeling profoundly affect SSC metastatic dissemination. In this review, we will summarize the current knowledge on the role of ECM and its remodeling enzymes in affecting the growth and dissemination of UADT SCC. Taken together, these published evidence suggest that a thorough analysis of the ECM composition in the UADT SCC microenvironment may help disclosing the mechanism of resistance to the treatments and help defining possible targets for clinical intervention.

T1a Glottic Cancer: Advances in Vocal Outcome Assessment after Transoral CO2-Laser Microsurgery Using the VEM

Patients with unilateral vocal fold cancer (T1a) have a favorable prognosis. In addition to the oncological results of CO₂ transoral laser microsurgery (TOLMS), voice function is among the outcome measures. Previous early glottic cancer studies have reported voice function in patients grouped into combined T stages (Tis, T1, T2) and merged cordectomy types (lesser- vs. larger-extent cordectomies). Some authors have questioned the value of objective vocal parameters. Therefore, the purpose of this exploratory prospective study was to investigate TOLMS-associated oncological and vocal outcomes in 60 T1a patients, applying the ELS protocols for cordectomy classification and voice assessment. Pre- and postoperative voice function analysis included: Vocal Extent Measure (VEM), Dysphonia Severity Index (DSI), auditory-perceptual assessment (GRB), and 9-item Voice Handicap Index (VHI-9i). Altogether, 51 subjects (43 male, eight female, mean age 65 years) completed the study. The 5-year recurrence-free, overall, and disease-specific survival rates (Kaplan–Meier method) were 71.4%, 94.4%, and 100.0%. Voice function was preserved; the objective parameter VEM (64 ± 33 vs. 83 ± 31; mean ± SD) and subjective vocal measures (G: 1.9 ± 0.7 vs. 1.3 ± 0.7; VHI-9i: 18 ± 8 vs. 9 ± 9) even improved significantly (p < 0.001). The VEM best reflected self-perceived voice impairment. It represents a sensitive measure of voice function for quantification of vocal performance.

Current indications for adjuvant treatment following transoral laser microsurgery of early and intermediate laryngeal cancer

PURPOSE OF REVIEW

This review summarizes the information in the literature on the indications for adjuvant therapy after transoral laser microsurgery (TLM) for early/intermediate stage laryngeal cancer.

RECENT FINDINGS

A high rate of 'nonevaluable' margins after TLM significantly complicates decision-making concerning adjuvant therapy. However, consensus grows that second-look TLM in patients with multiple superficial and deep positive margins is more sensible than sending these patients systematically for adjuvant radiotherapy (RT).

SUMMARY

The classical adagium: 'Failure to achieve negative margins indicates need for adjuvant RT' does not translate automatically to patients with glottic cancer treated by TLM. Rather, specifically patients with multiple superficial positive margins and positive deep margins after TLM need careful judging what constitutes the best additional adjuvant treatment. Second-look resection is nowadays regarded as the preferred adjuvant treatment for many of these patients whereas RT is reserved for those in whom a second look TLM is judged unlikely to result in 'true negative margins.' Additionally, when the pathology of the re-resection reveals multiple foci of residual disease or suggests again a resection with positive margins, adjuvant postoperative RT is likely to result in a better local control. If this strict selection of patients for adjuvant RT is adhered to carefully, oncological and functional results will be optimal.

Comprehensive review of surgical microscopes: technology development and medical applications

SIGNIFICANCE

Surgical microscopes provide adjustable magnification, bright illumination, and clear visualization of the surgical field and have been increasingly used in operating rooms. State-of-the-art surgical microscopes are integrated with various imaging modalities, such as optical coherence tomography (OCT), fluorescence imaging, and augmented reality (AR) for image-guided surgery.

AIM

This comprehensive review is based on the literature of over 500 papers that cover the technology development and applications of surgical microscopy over the past century. The aim of this review is threefold: (i) providing a comprehensive technical overview of surgical microscopes, (ii) providing critical references for microscope selection and system development, and (iii) providing an overview of various medical applications.

APPROACH

More than 500 references were collected and reviewed. A timeline of important milestones during the evolution of surgical microscope is provided in this study. An in-depth technical overview of the optical system, mechanical system, illumination, visualization, and integration with advanced imaging modalities is provided. Various medical applications of surgical microscopes in neurosurgery and spine surgery, ophthalmic surgery, ear-nose-throat (ENT) surgery, endodontics, and plastic and reconstructive surgery are described.

RESULTS

Surgical microscopy has been significantly advanced in the technical aspects of high-end optics, bright and shadow-free illumination, stable and flexible mechanical design, and versatile visualization. New imaging modalities, such as hyperspectral imaging, OCT, fluorescence imaging, photoacoustic microscopy, and laser speckle contrast imaging, are being integrated with surgical microscopes. Advanced visualization and AR are being added to surgical microscopes as new features that are changing clinical practices in the operating room.

CONCLUSIONS

The combination of new imaging technologies and surgical microscopy will enable surgeons to perform challenging procedures and improve surgical outcomes. With advanced visualization and improved ergonomics, the surgical microscope has become a powerful tool in neurosurgery, spinal, ENT, ophthalmic, plastic and reconstructive surgeries.

Upfront surgery or definitive radiotherapy for p16+ oropharyngeal cancer. A GETTEC multicentric study

BACKGROUND

The aim of this study was to assess the impact of the initial therapeutic strategy on oncologic outcomes in patients with HPV-positive OPSCC.

METHODS

All p16-positive OPSCCs treated from 2009 to 2014 in 7 centers were retrospectively included and classified according to the therapeutic strategy: surgical strategy (surgery ± adjuvant radiotherapy and chemotherapy) vs. non-surgical strategy (definitive radiotherapy ± chemotherapy). Univariate, multivariate propensity score matching analyses were performed to compare overall (OS), disease-specific (DSS) and recurrence-free survival (RFS).

RESULTS

382 patients were included (surgical group: 144; non-surgical group: 238). Five-year OS, DSS and RFS were 89.2, 96.8 and 83.9% in the surgical group and 84.2, 87.1 and 70.4% in the non-surgical group, respectively. These differences were statistically significant for DSS and RFS after multivariate analysis, but only for RFS after propensity score matching analysis.

CONCLUSION

In p16+ OPSCC patients, upfront surgery results in higher RFS than definitive radiotherapy ± chemotherapy but does not impact OS.

Digitalized healthcare for head and neck cancer patients

The ongoing shortage in healthcare services and the increasing cancer incidence, highlight the need for new strategies to ensure optimal treatments, cares and follow-up for all patients. Digitalized healthcare, which includes various concepts (digital health, telemedicine, telemonitoring and digital therapeutics), are a promising option to meet these needs. In this scoping review, we provide an overview of the recent available research evidence on digitalized healthcare for HNC patients and caregivers. Through the interrogation of PubMed and Cochrane Library databases, a total of 32 relevant articles reporting the use of digitalized healthcare in different settings of HNC patients' care management, were analyzed. Overall, HNC patients as well as caregivers were highly satisfied, especially because digitalized healthcare allows the early detection of health disorders, improve patient's management, quality of life, self-confidence and communication. Furthermore, digitalized healthcare were significantly time- and cost-effective. While the benefits digitalized healthcare has been reported to be feasible and clinically relevant, our future efforts should focus on the demonstration of their clinical utility in well-designed clinical trials. It is tempting to anticipate that this approach will improve patients' management and quality of life and change the way patients interact with family and professional health care givers.

Prior chemoradiotherapy and pathological perineural invasion predict the survival outcomes of salvage surgery in head and neck squamous cell carcinoma

BACKGROUND

The purpose of the study was to evaluate the oncological outcomes of salvage surgery in squamous cell carcinoma of the head and neck (SCCHN).

METHODS

This is a retrospective analysis of all patients of SCCHN with recurrence or second primary, post-treatment, who underwent salvage surgery. The outcomes were analyzed in terms of overall survival, overall survival postsalvage surgery and disease-free survival (DFS) postsalvage surgery. Clinical and pathological predictors were considered.

RESULTS

Two hundred and forty-one patients were included. The mean follow-up was 56.33 months. Five-year survival OS from date of initial diagnosis of the tumor was 61.2%. The 5-year OS survival after salvage surgery was 47.1%. Five-year DFS after salvage surgery was 28.1%. Prior chemoradiotherapy and pathological perineural invasion were independent predictors on multivariate analysis.

CONCLUSIONS

Survival outcomes after appropriate salvage treatment are good. Prior chemoradiotherapy and perineural invasion on salvage pathology are predictors of poorer outcomes.

Upfront surgery or definitive radiotherapy for patients with p16-negative oropharyngeal squamous cell carcinoma. A GETTEC multicentric study

INTRODUCTION

Therapeutic management of oropharyngeal squamous cell carcinomas (OPSCC) is still debated. Since the role of HPV was demonstrated, few studies have focused on HPV-negative OPSCC. The aim of our study was to assess the impact of therapeutic strategy (surgical vs. non-surgical) on oncologic outcomes in patients with HPV-negative OPSCC.

MATERIAL AND METHOD

All p16-negative OPSCCs treated from 2009 to 2014 in 7 tertiary-care centers were included in this retrospective study and were classified according to the therapeutic strategy: surgical strategy (surgery ± adjuvant radiotherapy and chemotherapy) vs. non-surgical strategy (definitive radiotherapy ± chemotherapy). Patients not eligible for surgery (unresectable tumor, poor general-health status) were excluded. Univariate, multivariate and propensity score matching analyses were performed to compare overall (OS), disease-specific (DSS) and recurrence-free survival (RFS).

RESULTS

Four hundred seventy-four (474) patients were included in the study (surgical group: 196; non-surgical group: 278). Five-year OS, DSS and RFS were 76.5, 81.3 and 61.3%, respectively, in the surgical group and 49.9, 61.8 and 43.4%, respectively, in the non-surgical group. The favorable impact of primary surgical treatment on oncologic outcomes was statistically significant after multivariate analysis. This effect was more marked for locally-advanced than for early-stage tumors. Propensity score matching analysis confirmed the prognostic impact of primary surgical treatment for RFS.

CONCLUSION

Therapeutic strategy is an independent prognostic factor in patients with p16-negative OPSCC and primary surgical treatment is associated with improved OS, DSS and RFS. These results suggest that surgical strategy is a reliable option for advanced stage OPSCC.

Correlations between long-term quality of life and patient needs and concerns following head and neck cancer treatment and the impact of psychological distress. A multicentric cross-sectional study

OBJECTIVES

To assess patient needs and concerns after head and neck squamous cell carcinoma (HNSCC) treatment and their possible correlations with long-term quality of life (QoL) and to examine the potential impact of psychological distress on these results.

METHODS

Alive and disease-free HNSCC patients at least 1 year after treatment were enrolled in this cross-sectional multicentric study and completed the EORTC QLQ-C30 and H&N35 QoL questionnaires, the head and neck cancer-specific patient concerns inventory (PCI-HN) questionnaire and the hospital anxiety and depression scale (HADS). Correlations between QoL outcomes and patient needs and concerns were investigated using Spearman's correlation tests.

RESULTS

Seventy-two patients were enrolled in the study. Fear of cancer recurrence was the main patient concern followed by dental, salivary, fatigue, speech, and eating problems. The leading patient needs in terms of consultation were to be referred to the surgeon, the speech, and swallow therapist and the oral rehabilitation team. The number of patient concerns correlated negatively (r < .40) with functioning scales score and positively (r > .40) with general and head and neck symptoms. Psychological distress was the main determinant of QoL outcomes (p < .0001). We found a significant impact of gender (p = .002) on the number of patient concerns, and of patient age (p = .003) on the number of staff members selected by patients.

CONCLUSION

Identification of patient needs and concerns along with multidisciplinary management of persistent symptoms and psychological distress seem essential steps towards improving QoL of HNSCC patients.

Discovery and Validation of a CT-Based Radiomic Signature for Preoperative Prediction of Early Recurrence in Hypopharyngeal Carcinoma

Purpose

In the clinical management of hypopharyngeal squamous cell carcinoma (HSCC), preoperative identification of early recurrence (≤2 years) after curative resection is essential. Thus, we aimed to develop a CT-based radiomic signature to predict early recurrence in HSCC patients preoperatively.

Methods

In total, 167 HSCC patients who underwent partial surgery were enrolled in this retrospective study and divided into two groups, i.e., the training cohort (n = 133) and the validation cohort (n = 34). Each individual was followed up for at least for 2 years. Radiomic features were extracted from CT images, and the radiomic signature was built with the least absolute shrinkage and selection operator (LASSO) logistic regression (LR) model. The associations of preoperative clinical factors with early recurrence were evaluated. A radiomic signature-combined model was built, and the area under the curve (AUC) was used to explore their performance in discriminating early recurrence.

Results

Among the 1415 features, 335 of them were selected using the variance threshold method. Then, the SelectKBest method was further used for the selection of 31 candidate features. Finally, 11 out of 31 optimal features were identified with the LASSO algorithm. In the LR classifier, the AUCs of the training and validation sets in discriminating early recurrence were 0.83 (95% CI: 0.76-0.90) (sensitivity 0.8 and specificity 0.83) and 0.83 (95% CI: 0.67-0.99) (sensitivity 0.69 and specificity 0.71), respectively.

Conclusions

Using the radiomic signature, we developed a radiomic signature to preoperatively predict early recurrence in patients with HSCC, which may serve as a potential noninvasive tool to guide personalized treatment.

Prognostic impact of resection margin involvement in surgically managed HPV-positive tonsil cancer

OBJECTIVES

To find out the role of resection margin involvement in surgically managed HPV-positive tonsil cancer.

MATERIALS AND METHODS

The study included 94 subjects with HPV-positive tonsil cancer undergoing surgical treatment. We evaluated the relationships between the resection margin status, clinicopathological factors, and oncological outcome.

RESULTS

The rate of resection margin involvement was 22.3% (21/94) after ablative surgery. Margin involvement, lymphatic invasion, and extracapsular spread were associated with the 5-year disease-free survival (DFS) and disease-specific survival (DSS) rate in univariate analysis. Multivariate Cox regression analysis confirmed a significant association between the margin involvement and 5-year DFS rate (HR = 4.602; 95% CI = 1.202-17.620; p = 0.026) and 5-year DSS rate (HR = 12.826; 95% CI = 1.399-117.593; p = 0.024). The incidence of resection margin involvement was significantly higher in patients with larger tumors (35.19 ± 15.07 mm vs. 25.53 ± 10.32 mm, p = 0.011) and more invasive tumors (17.84 ± 7.90 mm vs. 13.46 ± 6.88 mm, p = 0.037). The cutoff value of tumor size and depth of invasion for resection margin involvement was 29.5 mm (74% sensitivity and 63% specificity) and 14.5 mm (74% sensitivity and 61% specificity), respectively.

CONCLUSION

Resection margin involvement was significantly correlated with tumor size and the depth of invasion in HPV-positive tonsil cancer. Furthermore, resection margin involvement was associated with adverse outcomes.

How to select candidates for microvascular head and neck reconstruction in the elderly? Predictive factors of postoperative outcomes

INTRODUCTION

The proportion of elderly patients with head and neck cancer is increasing. However, predictive factors of postoperative outcomes are insufficiently explored in this population. In this study, we aimed to determine predictive factors of postoperative outcomes in elderly patients undergoing head and neck free-flap reconstructive surgery in order to determine criteria on which patient selection could be based.

METHODS

All patients aged 65 years or over who underwent head and neck free-flap reconstructive surgery at our institution, between 2000 and 2016, were included in this retrospective study. Predictive factors of postoperative outcomes were investigated in uni- and multivariate analysis.

RESULTS

Two-hundred patients were included in the study. Older age (>70, >75 or > 80 yrs) had no significant impact on postoperative outcomes. Free flap failure local and general complications rates were 11%, 34% and 43%, respectively. Oromandibular reconstruction (p = 0.04) was significantly associated with free flap failure and salvage surgery (p = 0.04) with local complications. A high comorbidity level (Charlson Comorbidity Index score ≥ 4; p = 0.02) was associated with a higher risk of general complications. A G8 (Geriatric 8 questionnaire) score < 15 (p = 0.004), a high comorbidity level (Kaplan-Feinstein Index score ≥ 2; p = 0.04) and oromandibular reconstruction (p = 0.04) were associated with poor swallowing function at 6 months.

CONCLUSION

Head and neck free flap reconstruction should be offered to fit (G8 score ≥ 15) elderly patients without severe comorbidities (KFI < 2 or CCI < 4), particularly when oral/pharyngeal soft-tissue reconstruction is planned.

Genomics and precision surgery for head and neck squamous cell carcinoma

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

Imaging angiogenesis in patients with head and neck squamous cell carcinomas by [68Ga]Ga-DOTA-E-[c(RGDfK)]2 PET/CT

Purpose

Angiogenesis plays an important role in the growth and metastatic spread of solid tumours and is characterised by the expression of integrins on the cell surface of endothelial cells. Radiolabelled RGD peptides specifically target angiogenesis-related α_vβ₃ integrins, expressed on the activated endothelial cells of sprouting blood vessels. Here, we validated the feasibility of ⁶⁸Ga[Ga]-DOTA-E-[c(RGDfK)]₂ (⁶⁸Ga-RGD) PET/CT to visualise angiogenesis in patients with oral squamous cell carcinoma (OSCC).

Methods

Ten patients with OSCC and scheduled for surgical resection including elective neck dissection received an intravenously administration of ⁶⁸Ga-RGD (42 ± 8 μg; 214 ± 9 MBq). All patients subsequently underwent dynamic (n = 5) or static PET/CT imaging (n = 5) for 60 min or for 4 min/bed position at 30, 60 and 90 min after injection, respectively. Quantitative tracer uptake in tumour lesions was expressed as standardised uptake values (SUV). Additionally, tumour tissue was immunohistochemically stained for α_vβ₃ integrin to assess the expression pattern.

Results

⁶⁸Ga-RGD tumour accumulation was observed in all patients. At 60 min post injection, tumour SUV_max ranged between 4.0 and 12.7. Tracer accumulation in tumour tissue plateaued at 10 min after injection. Uptake in background tissue did not change over time, resulting in tumour-to-muscle tissue of 6.4 ± 0.7 at 60 min post injection.

Conclusions

⁶⁸Ga-RGD PET/CT of α_vβ₃ integrin expression in OSCC patients is feasible with adequate tumour-to-background ratios. It will provide more insight in angiogenesis as a hallmark of the head and neck squamous cell carcinomas’ tumour microenvironment.

Trial registration

https://eudract.ema.europa.eu no. 2015-000917-31

Electronic supplementary material

The online version of this article (10.1007/s00259-020-04766-2) contains supplementary material, which is available to authorized users.

Survival differences between definitive radiotherapy and surgery followed by adjuvant radiotherapy in supraglottic and hypopharyngeal carcinoma

Background:

Organ preservation has long been a consideration in the treatment of supraglottic and hypopharyngeal carcinoma to improve the quality of life (QOL). Definitive radiotherapy (DRT) with or without systematic treatment, such as chemotherapy, is always the first choice to achieve improved QOL. This retrospective study focused on the survival differences between DRT and surgery followed by adjuvant radiotherapy (S + RT) in supraglottic and hypopharyngeal carcinoma.

Methods:

This study included adult patients with supraglottic or hypopharyngeal carcinoma undergoing single-modality treatment with either DRT or S + RT between January 2012 and August 2016. A total of 59 patients were identified, of whom 31 were treated with DRT, and 28 were treated with S + RT. In the 31 cases of DRT, 23 cases were treated with concurrent chemoradiotherapy (CRT), one case was treated with DRT plus cetuximab, and seven cases were treated with DRT alone. Of the other 28 cases of S + RT, 15 cases were treated with adjuvant concurrent CRT. Survival analysis was used to compare the overall survival (OS), local recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) between DRT and S + RT groups.

Results:

The median follow-up was 20 months (range, 4–67 months). The patients of the two groups were similar with respect to mean age, original sites, and tumor stages. The 1-, 2-, and 5-year OS rates were 80.6%, 53.4%, and 24.7% for the DRT group and 85.7%, 67.1%, and 24.7% for the S + RT group, respectively. There was no significant difference between the two groups (χ² = 3.183, P = 0.074). The 1-, 2-, and 5-year LRFS and DMFS were 90.4%, 61.7%, and 18.0% and 87.4%, 49.2%, and 9.9%, respectively, and no statistical difference was observed between the two groups (LRFS: χ² = 0.028, P = 0.868; DMFS: χ² = 3.347, P = 0.067). No significant difference was found between the two groups in acute radiotoxicity.

Conclusion:

Without loss of laryngeal function, the survival of DRT is comparable to that of S + RT in supraglottic and hypopharyngeal carcinoma.

Hyperspectral Imaging of Head and Neck Squamous Cell Carcinoma for Cancer Margin Detection in Surgical Specimens from 102 Patients Using Deep Learning

Surgical resection of head and neck (H and N) squamous cell carcinoma (SCC) may yield inadequate surgical cancer margins in 10 to 20% of cases. This study investigates the performance of label-free, reflectance-based hyperspectral imaging (HSI) and autofluorescence imaging for SCC detection at the cancer margin in excised tissue specimens from 102 patients and uses fluorescent dyes for comparison. Fresh surgical specimens (n = 293) were collected during H and N SCC resections (n = 102). The tissue specimens were imaged with reflectance-based HSI and autofluorescence imaging and afterwards with two fluorescent dyes for comparison. A histopathological ground truth was made. Deep learning tools were developed to detect SCC with new patient samples (inter-patient) and machine learning for intra-patient tissue samples. Area under the curve (AUC) of the receiver-operator characteristic was used as the main evaluation metric. Additionally, the performance was estimated in mm increments circumferentially from the tumor-normal margin. In intra-patient experiments, HSI classified conventional SCC with an AUC of 0.82 up to 3 mm from the cancer margin, which was more accurate than proflavin dye and autofluorescence (both p < 0.05). Intra-patient autofluorescence imaging detected human papilloma virus positive (HPV+) SCC with an AUC of 0.99 at 3 mm and greater accuracy than proflavin dye (p < 0.05). The inter-patient results showed that reflectance-based HSI and autofluorescence imaging outperformed proflavin dye and standard red, green, and blue (RGB) images (p < 0.05). In new patients, HSI detected conventional SCC in the larynx, oropharynx, and nasal cavity with 0.85-0.95 AUC score, and autofluorescence imaging detected HPV+ SCC in tonsillar tissue with 0.91 AUC score. This study demonstrates that label-free, reflectance-based HSI and autofluorescence imaging methods can accurately detect the cancer margin in ex-vivo specimens within minutes. This non-ionizing optical imaging modality could aid surgeons and reduce inadequate surgical margins during SCC resections.