Morphological changes of regional lymph node in squamous cell carcinoma of the oral cavity

Tagging the pre-metastatic node in oral cancer: A cross-sectional study

INTRODUCTION

Lymph node involvement is the first indication of spread of oral squamous cell carcinoma (OSCC) and it is also a most significant prognostic factor. Lymph nodes show various tumor-induced histological changes preceding actual metastasis, viz. increased vascularity, follicular hyperplasia and desmoplasia which leads to pre-metastatic niche formation. This pre-metastatic niche primarily provides a favorable microenvironment to for the survival and subsequent growth of cancer cells within the lymph node.

AIM

A retrospective study to evaluate carcinoma-induced changes in lymph nodes harvested from radical neck dissection in OSCC patients.

OBJECTIVES

1) To evaluate cancer-induced histological changes in positive and negative lymph nodes in OSCC patients. 2) To look for common histopathological changes in both pre-metastatic and metastatic lymph nodes.

MATERIALS AND METHODS

Forty lymph nodes harvested from seven OSCC patients were sectioned and stained (Hematoxylin-Eosin) for documentation of histologically evident morphological and functional alterations. The Chi-square test was applied between the non-metastatic and metastatic lymph nodes findings and a statistically significant difference was seen.

RESULTS

Sections from 28 negative nodes showed changes associated with pre-metastatic niche conditioning whereas, 12 sections exhibit frank metastases.

CONCLUSION

The modified immunological responses and remodeling of the vasculature are the most common histologic tumor-induced pre-metastatic changes. This study reviewed and categorized these histological changes that point to pre-metastatic niche conditioning of lymph nodes.

Evaluation of immunomorphological patterns of cervical lymph nodes in oral squamous cell carcinoma

Background:

The Immunomorphological patterns of Lymph Nodes indirectly assess the host immune response facing a malignant tumor. These patterns also help us predict the susceptibility of the patient to Lymph Node Metastasis.

Aims and Objectives:

To evaluate the Immunomorphological patterns of Lymph Nodes in Oral Squamous Cell Carcinoma and to correlate them with the histopathological subtype of Oral Squamous Cell Carcinoma, TNM staging and the degree of tumor involvement within the Lymph Nodes.

Methodology:

A total of 40 subjects were taken for the study. Individuals who were clinically and histopathologically diagnosed as cases of Squamous Cell Carcinoma, who had undergone Radical or Elective Neck dissection were considered. The excised Lymph Nodes along with the primary tumor were collected stained with Hematoxylin and Eosin. The Lymph Nodes were assessed for Metastasis and Immunomorphological patterns. Statistical Correlation was done between the Immunomorphological pattern of Lymph Nodes and (a) Size of the tumor, (b) TNM stage of the tumor, (c) Histopathological Grade of the primary tumor, (d) Metastasis of the Lymph Node and (e) Grade of the Metastasis of Lymph Node. Statistical Correlation was done between the Metastasis of the Lymph Node and (a) Size of the tumor and (b) TNM stage of the tumor.

Results and Conclusion:

Statistically, a significant association was observed between TNM staging and Immunomorphological patterns of Lymph Node (P < 0.01). The relationship between histopathological grade of primary tumor of Squamous Cell Carcinoma and the Immunomorphological patterns was statistically significant (P < 0.01). Statistically, a significant association was observed between Sinus Histiocytosis pattern and decreased occurrence of nodal metastasis (P < 0.01).

Architectural changes in the regional lymph nodes of oral squamous cell carcinoma

Background

The lymph nodes (LNs) in oral squamous cell carcinoma (OSCC) are enlarged as a result of reactive lymphadenopathy, metastasis or both. In response to tumor-associated antigens, diverse cell populations of LNs react in different ways, giving rise to a multitude of morphological patterns (MPs). The prognostic value of MPs has been contested. Hence, the aim of the study was to evaluate morphological alterations in the LNs related to LN metastasis (LNM), tumor size, grade and stage and the prognostic value for OSCC.

Materials and Methods

LN sections of 40 OSCCs were evaluated. Six MPs were observed: germinal center predominance (GCP), lymphocyte predominance (LP), sinus histiocytosis (SH), vascular transformation of sinuses (VTS), lymphocyte depleted (LD) and granulomatous reaction (GR). The data were subjected to Chi-square test.

Results

Four-hundred and eighteen nodes were evaluated, of which 24 were metastatic and 394 nonmetastatic. The predominant MP of LN reactivity was of VTS (116 nodes) followed by GCP (105); LP (90), LD (52), SH (43) and GR (12). A significant association was noted between LN status and the MPs. Risk of LNM with LP was less (13%) when compared with GCP (79%). A statistically significant relation was noted between the predominant MP and metastatic and nonmetastatic cases and with the tumor stage.

Conclusion

GCP pattern prevails in metastatic and advanced-stage tumors. LP or VTS/SH is prominent in early-stage tumors and nonmetastatic cases. MPs indicate the immune status and aid in foreseeing susceptibility to LNM, thus serving as a surrogate marker.

Immuno-reactivity of excised lymph nodes in neck dissections of squamous cell carcinomas of oral cavity

Background:

Regional lymph nodes play an important role in acting as anatomic barriers to systemic dissemination of tumor cells. This reflects in the host immunologic response. Oral squamous cell carcinoma, is known to be associated with early deficiencies of cell-mediated immunity, the pathology of which is reflected in the histology of the regional lymph nodes.

Aim:

The goal of this study was to study the different immunity reactions in the lymph nodes and to correlate it with the histopathology of tumor proper.

Materials and Methods:

Out of 40 head and neck dissections, 30 were male and 10 females within the age range of 21–72 years. According to Tumor Node Metastasis classification, there were 12 cases of stage II and stage III, respectively while 16 were of stage IV. A total of 372 nodes were histologically evaluated. The harvested lymph nodes were categorized into metastatic and non-metastatic nodes exhibiting four patterns as: Lymphocyte predominance pattern, germinal center predominance pattern, lymphocyte depleted pattern and unstimulated pattern.

Results:

The predominant pattern of lymph node reactivity was of lymphocyte predominance (199 nodes) followed by germinal center predominance (117 nodes); lymphocyte depleted (17 nodes) and unstimulated node pattern (39 nodes). Twenty-seven nodes were positive for metastasis. A statistically significant relationship (P = 0.0019 and P = 0.0290, chi square, respectively) was observed between the number of nodes harvested and stage and level of lymph nodes. A brief follow-up period of 3 years was carried out.

Conclusion:

Further studies relating the immuno-morphologic assessment of the lymph nodes in conjunction with other factors may be helpful in assessing the metastases risk of the individual.

Preventable Sternocleidomastoid Muscular Atrophy after Neck Dissection

Background:

Modified radical neck dissection (mRND) [preserving the sternocleidomastoid muscle (SCM) and the spinal accessory nerve] and supraomohyoid neck dissection have become common surgical procedures for treating head and neck cancer. Postoperative severe asymmetry of the neck and severe atrophy of the SCM, however, have been demonstrated.

Methods:

Using computed tomographic images, cross-sectional areas of the SCMs were measured in 99 patients with carcinoma of the oral cavity who underwent unilateral mRND or supraomohyoid neck dissection. An asymmetry index was used.

Results:

Innervation to the SCM was preserved in 91 patients. The spinal accessory nerve and the innervation were sacrificed in 3 patients; the innervation was repaired in 5 patients. Sacrifice of innervation to the SCM resulted in extremely severe asymmetry. Repair of the innervation prevented severe asymmetry in 40%. Preservation of the innervation prevented severe asymmetry in 75% at the middle portion of the neck and in 56% at the lower portion after mRND.

Conclusion:

Preserving innervation to the SCM and gentle handling of the nerve during neck dissection could prevent severe asymmetry after neck dissection.

Immunomorphological patterns of cervical lymph nodes in oral squamous cell carcinoma

Context:

Squamous cell carcinoma (SCC) comprises 80% of the cancers of the oral cavity. Metastases to the cervical lymph nodes affects prognosis. Studying lymph node reactivity may help to understand host immune reaction against the tumor and thus influence prognosis.

Aims:

This study observed patterns of lymph node reactivity, metastases and grades of metastases in cervical lymph nodes and compared them with the histopathology of the primary tumor.

Materials and Methods:

Lymph nodes from 30 patients of oral squamous cell carcinoma (OSCC) were taken. 10 of these were well-differentiated SCC (WDSCC), 10 moderately differentiated SCC (MDSCC) and 10 poorly differentiated SCC (PDSCC). Four immunomorphological patterns were observed: lymphocyte predominance, germinal centre predominance, mixed pattern (sinus histiocytosis) and unstimulated pattern.

Statistical Analysis Used:

Chi square test.

Results:

The predominant lymph node reactive patterns were germinal centre predominance (79.27%), unstimulated pattern (14.63%) and lymphocyte predominance (6.10%). Positive nodes showed invasion in the form of islands (57.14%), cords (39.29%) and total replacement pattern (3.57%). Tumor involvement in positive nodes showed grade 3 invasion, (53.57%), grade 2 invasion (26.79%), grade 4 invasion (17.86%) and grade 1 invasion (1.79%). Statistically significant association was found between:

Lymph node reactive pattern and histopathological grade of primary tumor. Higher numbers of germinal centre predominance lymph nodes were found in WDSCC and MDSCC

Histopathological grade of primary tumor and the grade of lymph node invasion

Conclusions:

Immuno-morphological assessment of draining lymph nodes reflects the immune status of the patient with respect to metastases. This may facilitate identification of high and low risk patients and help in planning appropriate therapy for the high-risk patients.

Applicability of preoperative nuclear morphometry to evaluating risk for cervical lymph node metastasis in oral squamous cell carcinoma

BACKGROUND

We previously reported the utility of preoperative nuclear morphometry for evaluating risk for cervical lymph node metastases in tongue squamous cell carcinoma. The risk for lymph node metastasis in oral squamous cell carcinoma, however, is known to differ depending on the anatomical site of the primary tumor, such as the tongue, gingiva, mouth floor, and buccal mucosa. In this study, we evaluated the applicability of this morphometric technique to evaluating the risk for cervical lymph node metastasis in oral squamous cell carcinoma.

METHODS

A digital image system was used to measure the mean nuclear area, mean nuclear perimeter, nuclear circular rate, ratio of nuclear length to width (aspect ratio), and nuclear area coefficient of variation (NACV). Relationships between these parameters and nodal status were evaluated by t-test and logistic regression analysis.

RESULTS

Eighty-eight cases of squamous cell carcinoma (52 of the tongue, 25 of the gingiva, 4 of the buccal mucosa, and 7 of the mouth floor) were included: 46 with positive node classification and 42 with negative node classification. Nuclear area and perimeter were significantly larger in node-positive cases than in node-negative cases; however, there were no significant differences in circular rate, aspect ratio, or NACV. We derived two risk models based on the results of multivariate analysis: Model 1, which identified age and mean nuclear area and Model 2, which identified age and mean nuclear perimeter. It should be noted that primary tumor site was not associated the pN-positive status. There were no significant differences in pathological nodal status by aspect ratio, NACV, or primary tumor site.

CONCLUSION

Our method of preoperative nuclear morphometry may contribute valuable information to evaluations of the risk for lymph node metastasis in oral squamous cell carcinoma.

Characterization, Localization and Patterning of Lymphatics and Blood Vessels in Oral Squamous Cell Carcinoma: A Comparative Study Using D2-40 and CD-34 IHC Marker

OBJECTIVES

Lymphatic metastasis has always been regarded as a major prognostic indicator for disease progression and as a guide for therapeutic strategies to oral squamous cell carcinoma (OSCC). Differentiating lymphatic vessels from blood vessels is difficult, partly due to lack of specific method for identifying lymphatics. A new lymphatic vessel reactive antibody D2-40 has been introduced recently. Here we examined immunohistochemical localization of lymphatic vessels and blood vessels using D2-40 and CD-34 respectively in different histological grades of OSCC. Their expression in intra-tumoural and peri-tumoural region was also compared.

MATERIALS AND METHODS

Forty two formalin-fixed paraffin-embedded tissue blocks of excised specimens of OSCC were immunohistochemically evaluated using D2-40 and CD-34 antibodies. Lymphatic vessel density (LVD) (D2-40 positivity) and micro vessel density (MVD) (CD34 positivity) in both intratumoural and peritumoural areas were assessed by hot spot method.

RESULTS

Regardless of histopathological differentiation, LVD-- and MVD in peritumoural areas were found greater than intratumoural areas (p>0.05). Interestingly, other than lymphatic vessels, D2-40 positivity was also detected in tumour cells as well as in basal layer of epithelium adjacent to OSCC. Two patterns of distribution of CD34 positive vessel - circumscribing type and penetrating type were also observed in the cancer nest area.

CONCLUSION

D2-40 can be used as a marker to differentiate lymphatic vessels from blood vessels. Lymphatic and blood vessel proliferation might be much more extensive in the peritumoural area. D2-40 expression in epithelium adjacent to tumour indicates its role in the process of differentiation. Further, its expression in potential malignant disorder may provide better insight in predicting prognosis and pathogenesis of these lesions.

Prognostic Significance of Lymph Node Pattern in Oral Squamous Cell Carcinoma (OSCC)

BACKGROUND

Assessment of lymph node reactivity pattern is an important indicator of the host response status and prognosis of oral squamous cell carcinoma (OSCC).

AIM

To assess the prognostic significance of lymph node reactivity patterns in OSCC.

SETTINGS AND DESIGN

This is a cross-sectional study aimed correlating host status and prognosis of OSCC.

MATERIALS AND METHOD

Morphological patterns of lymph nodes received from 30 histologically proven cases of OSCC were analyzed. Five different patterns of the lymph node reaction were categorized (lymphocytic predominance, germinal center predominance, sinus histiocytosis, normal lymph node and lymphocytic depleted) and compared with the prognosis of OSCC.

STATISTICAL ANALYSIS USED

TNM, Histological grading parameters and Lymph node reactivity pattern were compared with the event of recurrence of OSCC and death of patient using Fisher's Exact test. Survival of the patients was analyzed for association with lymph node patterns using Log rank test.

RESULTS

Recurrence of the tumour was seen in association with all the patterns, with higher rates of mortality seen in patients with sinus histiocytosis of lymph node.

CONCLUSION

Morphological pattern being an aid in predicting prognosis, cannot be used as a lone predictor. An attempt is made to identify and discuss the possible pathogenesis for the reaction patterns.

Prognostic biological features in neck dissection specimens

The superior prognostic value offered by routine histopathological staging of neck dissections, as compared to clinical staging using palpation and modern imaging techniques, is well established in the literature concerning the management of squamous cell carcinoma of the head and neck. In this review, we discuss the definitions and criteria used in standardised routine histopathological reporting and explore additional potential nodal prognostic features. In addition, we critically appraise the value of immunohistochemistry, histochemistry, molecular and other non-morphological techniques and suggest tumour and host features that merit further investigations.

Utility of color Doppler ultrasound in evaluating the status of cervical lymph nodes in oral cancer

OBJECTIVE

The aim was to study the utility of color Doppler ultrasound (CDUS) in diagnosis of cervical lymphadenopathy in oral cancer patients.

STUDY DESIGN

In a prospective study, 70 cervical lymph nodes in 30 known primary oral cancer patients were evaluated with CDUS during a period of 8 months. The intranodal perfusion sites and vascular resistance were the key CDUS features used to differentiate between reactive and metastatic cervical lymph nodes. Histopathologic confirmations were obtained by excisional biopsy of the lymph nodes. The results of preoperative clinical palpation of cervical lymph nodes and CDUS evaluation were compared with histopathologic outcome.

RESULTS

Clinical evaluation suspected 61 cervical lymph nodes to be malignant. According to the CDUS, out of 70 nodes, 49 lymph nodes showed features of benign lymphadenopathy and 21 lymph nodes showed features of malignant lymphadenopathy, whereas histopathologic evaluations were in favor of reactive for 57 (81.42%) and for malignant lymphadenopathy in 13 (18.57%).

CONCLUSION

The CDUS evaluation was found to be highly significant with a sensitivity of 92.90% and a specificity of 84.21%, after comparing the CDUS findings with histopathologic findings.

Lymph node staging

Cancers of the head and neck (HNC) include cancers of the larynx, nasal passages/nose, oral cavity, pharynx, salivary glands, buccal regions, and thyroid. In these cancers, lymph node staging and localization of pathological lymph nodes are necessary to decide on either (neo) adjuvant or surgical therapy and are a major factor for the prognosis in HNC patients. Cervical node metastases have different incidence, and their presence is associated with a decrease in global survival to roughly half and with higher recurrence rates. The node metastases can be categorized in the following 2 groups: overt (clinical) or nonovert (occult). The latter can be subcategorized as metastases detectable by traditional methods (eg, staining) or "submicroscopic" metastases, only evident with immunohistochemical or molecular analysis. Compared with clinical invasive and laboratory examinations, which may have complications and are expensive, radiology plays an important role in lymph node staging. Mainly, the overt node metastases are the field of radiological imaging, and second, the detection of nonovert metastases is important and holds promise for the future because many patients of those initially classified as cN0 have, in fact, occult metastatic disease (pN1). Vice versa, radiological imaging has to avoid false-positive results that can lead to an elective or radical neck dissection, which are associated with increased morbidity and mortality and thus overshadow the improvement in survival. Radiological imaging plays a role not only as an initial staging of N+ but also in the case of N0 due to the continuing controversy for the treatment of N0 patients. A close observation of the patient may reveal a positive node in the follow-up. The imaging modalities used for the node staging in HNC patients include ultrasound, contrast-enhanced computed tomography, contrast-enhanced magnetic resonance imaging (MRI), and positron emission tomography scans. None of the above-mentioned methods reaches a 100% sensitivity or specificity, and the accuracy of the exact number of metastases or levels involved has not been studied; thus, neck dissection with subsequent pathological examination remains the gold standard for node staging. Among the described cross-sectional imaging modalities, MRI presents a lot of advantages mainly due to the increased soft tissue contrast and the ability to obtain tissue characteristics in different sequences, including diffusion- and perfusion-weighted sequences and proton spectroscopy imaging. The lack of the radiation burden makes MRI suitable for a close follow-up of the patient, and the imaging with the use of new intravenous contrast material (such as ultrasmall iron oxide particles) seems superior to the conventional. In this article, we will focus on the lymph node MRI staging in HNC patients and the MR anatomy of the nodes, the necessary diagnostic workup, and the advantages of the method over computed tomography. The possibilities of the new imaging sequences and the treatment implications will be addressed as well.

Presence of prostate cancer metastasis correlates with lower lymph node reactivity

BACKGROUND

Several reports suggest that the dissemination of neoplastic cells and cancer progression are associated with the generation of an immunosuppressive environment.

METHODS

In this report, we investigated immunological effects of prostate cancer by comparing metastastic and non-metastatic pelvic lymph nodes (LNs) from 25 patients with carcinomatous involvement of LNs to the non-metastatic LNs from 26 control patients with no metastatic involvement by immunohistochemistry and histological analyses.

RESULTS

Our results showed a decreased abundance of CD20+ B lymphocytes (P = 0.031), CD38+ activated lymphocytes (P = 0.038), and CD68+ macrophages (P < 0.001), and less evidence of follicular hyperplasia (P = 0.014), sinus hyperplasia (P < 0.001), and fibrosis (P=0.028) in metastatic LNs comparatively to control LNs. Finally, we observed that metastatic LNs were significantly smaller than control LNs (P = 0.005).

CONCLUSIONS

Our results suggest that the development of prostate cancer LN metastasis is accompanied with smaller LN size and decreased LN reactivity suggesting the development of an immununosuppressive microenvironment.