Predictive markers for late cervical metastasis in stage I and II invasive squamous cell carcinoma of the oral tongue

Identifying factors related to delayed neck metastasis after surgical treatment in patients with oral squamous cell carcinoma

BACKGROUND

General treatment of oral squamous cell carcinoma (OSCC) is surgical treatment with or without neck dissection. Although the incidence of delayed neck metastasis is rare, it may occur after the surgery and is known to be the most important factor in the prognosis. The purpose of is study is to evaluate the clinical and histopathological factors associated with delayed neck metastasis case among patients.

METHODS

A total of 195 patients who underwent surgical treatment for OSCC from 2016 to 2022 were investigated. Among them, delayed neck metastasis (DNM) was analyzed. The criterion for delayed neck metastasis was a newly developed neck lesion after the primary operation without neck dissection in cN0 necks. To identify the correlation between prognostic factors and the incidence of delayed neck metastasis, χ2 analysis with phi correlation and Cramer's V test was performed. Cumulative survival rates (CRS) were compared between the groups with the incidence of DNM and without DNM. Also, the log rank test for CSR and Cox proportional hazard model was analyzed to estimate the significance of the CSR and confirm the correlations between prognostic factors and DNM.

RESULT

Among 195 patients, 14 were discovered to have DNM. The primary tumor locations were the tongue (n = 5), floor of the mouth (n = 2), mandibular gingiva (n = 1), maxillary gingiva (n = 4), retromolartrigone (n = 1), and buccal mucosa (n = 2) each. The cases consisted of TNM stage I (n = 1), stage II (n = 3), stage III (n = 3), and stage IV (n = 8), respectively. The result of the χ2 analysis identified a correlation between positive neck (p = 0.01), depth of invasion (p = 0.09), radiation therapy (p = 0.003), and DNM. Groups without DNM showed better prognosis compared to groups with DNM. Regarding positive neck, depth of invasion, and radiation therapy, only depth of invasion showed significance in CSR analysis.

CONCLUSION

DNM after surgical treatment of OSCC is a rare event, and few were found in a review of the literature. Also, many prognostic factors have been suggested but controversial. However, in our study, some prognostic factors have been identified to have a significant correlation with the incidence of DNM, and analysis of such factors provides important information predicting neck metastasis and the prognosis.

Histopathological predictors of lymph node metastasis in oral cavity squamous cell carcinoma: a systematic review and meta-analysis

Objectives

Lymph node metastasis (LNM) is the most significant parameter affecting overall survival in patients with oral cavity squamous cell carcinomas (OCSCC). Elective neck dissection (END) is the standard of care in the early management of OCSCC with a depth of invasion (DOI) greater than 2-4 mm. However, most patients show no LNM in the final pathologic report, indicating overtreatment. Thus, more detailed indicators are needed to predict LNM in patients with OCSCC. In this study, we critically evaluate the existing literature about the risk of different histological parameters in estimating LNM.

Methods

A systematic review was conducted using PRISMA guidelines. PubMed, Web of Science, Cochrane, and Scopus were searched from inception to December 2023 to collect all relevant studies. Eligibility screening of records was performed, and data extraction from the selected studies was carried out independently. Inclusion in our systematic review necessitated the following prerequisites: Involvement of patients diagnosed with OCSCC, and examination of histological parameters related to lymph node metastasis in these studies. Exclusion criteria included animal studies, non-English articles, non-availability of full text, and unpublished data.

Results

We included 217 studies in our systematic review, of which 142 were eligible for the meta-analysis. DOI exceeding 4 mm exhibited higher risk for LNM [Risk ratio (RR) 2.18 (1.91-2.48), p<0.00001], as did perineural invasion (PNI) [RR 2.04 (1.77-2.34), p<0.00001], poorly differentiated tumors [RR 1.97 (1.61-2.42), p<0.00001], lymphovascular invasion (LVI) [RR 2.43 (2.12-2.78), p<0.00001], groups and single pattern of invasion [RR 2.47 (2.11-2.89), p<0.00001], high tumor budding [RR 2.65 (1.99-3.52), p<0.00001], tumor size over 4 cm [RR 1.76 (1.43-2.18), p<0.00001], tumor thickness beyond 4 mm [RR 2.72 (1.91-3.87), p<0.00001], involved or close margin [RR 1.73 (1.29-2.33), p = 0.0003], and T3 and T4 disease [RR 1.98 (1.62-2.41), p <0.00001].

Conclusion

Our results confirm the potential usefulness of many histopathological features in predicting LNM and highlight the promising results of others. Many of these parameters are not routinely incorporated into pathologic reports. Future studies must focus on applying these parameters to examine their validity in predicting the need for elective neck treatment.

MUC1 promotes cervical squamous cell carcinoma through ERK phosphorylation-mediated regulation of ITGA2/ITGA3

In contrast to the decreasing trends in developed countries, the incidence and mortality rates of cervical squamous cell carcinoma in China have increased significantly. The screening and identification of reliable biomarkers and candidate drug targets for cervical squamous cell carcinoma are urgently needed to improve the survival rate and quality of life of patients. In this study, we demonstrated that the expression of MUC1 was greater in neoplastic tissues than in non-neoplastic tissues of the cervix, and cervical squamous cell carcinoma patients with high MUC1 expression had significantly worse overall survival than did those with low MUC1 expression, indicating its potential for early diagnosis of cervical squamous cell carcinoma. Next, we explored the regulatory mechanism of MUC1 in cervical squamous cell carcinoma. MUC1 could upregulate ITGA2 and ITGA3 expression via ERK phosphorylation, promoting the proliferation and metastasis of cervical cancer cells. Further knockdown of ITGA2 and ITGA3 significantly inhibited the tumorigenesis of cervical cancer cells. Moreover, we designed a combination drug regimen comprising MUC1-siRNA and a novel ERK inhibitor in vivo and found that the combination of these drugs achieved better results in animals with xenografts than did MUC1 alone. Overall, we discovered a novel regulatory pathway, MUC1/ERK/ITGA2/3, in cervical squamous cell carcinoma that may serve as a potential biomarker and therapeutic target in the future.

Effects of maxillofacial prosthetic treatment on oral health-related quality of life and masticatory ability of patients with head and neck tumors

PURPOSE

Using multivariate analysis, this study investigated the effectiveness of maxillofacial prosthetic treatment in relation to oral health-related quality of life (OHR-QoL), masticatory ability (food intake status score and gum-jelly test score) and related factors in patients who had undergone surgery for head and neck tumors.

METHODS

The study cohort comprised 112 patients who underwent surgical resection and prosthetic treatment among 224 patients with head and neck tumors seen at the Maxillofacial Prosthetics Clinic of Tohoku University Hospital in a 2-year period. Correlations between OHR-QoL, food intake status score, and gum-jelly test score (criterion variables), and age, sex, maxillary defect, tongue/soft tissue defect, reconstructive surgery, and chemoradiotherapy (explanatory variables) were investigated, and the data were examined statistically.

RESULTS

Maxillary defect, tongue and soft palate tissue defect, and chemoradiotherapy were identified as factors that hindered the effectiveness of maxillofacial prosthetic treatment for improvement of the OHR-QoL, food intake status score, and gum-jelly test score. On the other hand, reconstructive surgery was a factor that facilitated the improvement of OHR-QoL and masticatory ability with maxillofacial prosthetic treatment.

CONCLUSION

The factors identified to be related to the success or failure of maxillofacial prosthetic treatment suggest the importance of combining prosthetic intervention with surgical reconstruction.

New Histopathologic Risk Model for Early T-stage Oral Squamous Cell Carcinoma: Focusing on a Modified Worst Pattern of Invasion System and a New Tumor Budding Score

Oral squamous cell carcinoma (OSCC) is treated based on the TNM staging. However, early T-stage OSCC still exhibits substantial nodal metastasis and death rates. Recent literature highlights the independent prognostic value of worst pattern of invasion (WPOI) and tumor budding in OSCC. Nevertheless, WPOI-5 is uncommon in early T-stage OSCC, and the definitions of tumor budding and WPOI-4 overlap. Moreover, WPOI assessment is subjective, and tumor budding evaluation varies across studies. To address these limitations, we aimed to develop a modified WPOI system and a novel tumor budding scoring system that assesses single cells and high-density tumor budding. We also evaluated a new histopathologic risk model for early T-stage OSCC. The study cohort comprised 37 pT1 and 64 pT2 OSCCs. The modified WPOI demonstrated superior interobserver agreement compared with the original system (κ value: 0.98 vs. 0.53). In the multivariate analysis, modified WPOI and tumor budding score were independent prognostic factors for nodal metastasis and disease-free survival, while modified WPOI predicted disease-specific survival. By integrating these factors, our risk model stratified the patients into 3 groups. Notably, the intermediate-risk and high-risk groups exhibited significantly higher rates of nodal metastasis, recurrence, and tumor-related death. Conversely, none in the low-risk group had nodal metastasis or succumbed to the disease. Our model offered simplified scoring and potentially improved prognostic predictions. In conclusion, we've developed a modified WPOI system, a new tumor budding scoring system, and a reliable risk model that classifies early T-stage OSCC patients into distinct risk groups with significant prognostic differences.

Rac1 activation in oral squamous cell carcinoma as a predictive factor associated with lymph node metastasis

OBJECTIVES

Secondary lymph node metastasis (SLNM) indicates a poor prognosis, and limiting it can improve the survival rate in early-stage tongue squamous cell carcinoma (TSCC). Many factors have been identified as predictors of SLNM; however, there is no unified view. Ras-related C3 botulinum toxin substrate 1 (Rac1) was found to be a promoter of the epithelial-mesenchymal transition (EMT) and is also attracting attention as a new therapeutic target. This study aims to investigate the role of Rac1 in metastasis and its relationship with pathological findings in early-stage TSCC.

MATERIALS AND METHODS

Rac1 expression levels of 69 cases of stage I/II TSCC specimens and their association with clinicopathological characteristics were evaluated by immunohistochemical staining. The role of Rac1 in oral squamous cell carcinoma (OSCC) was examined after Rac1 in OSCC cell lines was silenced in vitro.

RESULTS

High Rac1 expression was significantly associated with the depth of invasion (DOI), tumor budding (TB), vascular invasion, and SLNM (p < 0.05). Univariate analyses revealed that Rac1 expression, DOI, and TB were factors significantly associated with SLNM (p < 0.05). Moreover, our multivariate analysis suggested that Rac1 expression was the only independent determinant of SLNM. An in vitro study revealed that Rac1 downregulation tended to decrease cell migration and proliferation.

CONCLUSION

Rac1 was suggested to be an important factor in the metastasis of OSCC, and it could be useful as a predictor of SLNM.

The pattern and spread of invasion can predict late cervical lymph node metastasis in early tongue squamous cell carcinoma

To determine the predictive indexes of late cervical lymph node metastasis in early tongue squamous cell carcinoma (TSCC). We retrospectively analyzed the cases of 25 patients with stage I/II TSCC who had undergone surgical treatment without elective neck dissection. We evaluated the relationships between clinicopathologic factors and the occurrence of late cervical lymph node metastasis. Of the 25 cases, metastasis to the cervical lymph nodes was observed in nine cases (36.0%). The clinicopathological factors associated with late cervical lymph node metastasis were the mode of invasion (MOI, p = 0.032), depth of invasion (DOI, p = 0.004), and perineural invasion (PNI, p = 0.040). A multivariate analysis revealed that only the DOI was an independent predictor of late cervical lymph node metastasis. The combination of the DOI and MOI or the PNI and MOI was significantly correlated with late cervical lymph node metastasis (p = 0.004 and p = 0.012, respectively). Our findings suggest that combinations of the MOI, DOI, and PNI could be used as an index for predicting late cervical lymph node metastasis in early TSCC.

Identification of Neck Lymph Node Metastasis-Specific microRNA-Implication for Use in Monitoring or Prediction of Neck Lymph Node Metastasis

MicroRNAs (miRNAs) have attracted attention as non-invasive cancer biomarkers in various cancers; however, they have not been adequately investigated in oral squamous cell carcinoma (OSCC). This study investigated the diagnostic performance of serum-derived miRNAs at initial diagnosis for primary neck lymph node metastasis and the predictive performance for late neck lymph node metastasis based on long-term (up to approximately 8 years) follow-up of patients with OSCC. The expression of miRNAs in 40 patients with OSCC was quantified using real-time PCR (qPCR), and a comprehensive statistical analysis of the correlation of miRNA expression for primary and late neck lymph node metastases was performed. For the diagnosis of primary neck lymph node metastases, miR-423 and miR-125 were accurate. The miRNA index for primary metastasis diagnosis (miR-PM) calculated by regression analysis showed high diagnostic accuracy. The miR-5100 was useful for predicting late neck lymph node metastases. The miRNA index for late metastasis prediction (miR-LM) calculated using regression analysis showed high prediction accuracy. MiRNAs were useful for diagnosing primary neck lymph node metastases in OSCC and predicting late neck lymph node metastases. It may help to consider individualized treatment, including follow-up, surgical methods, and postoperative management.

Preoperative Determination of Depth of Invasion in Oral Cavity Squamous Cell Carcinoma by Standard Cross-Sectional Imaging With Computed Tomography and Positron Emission Tomography/Computed Tomography

Background Depth of invasion (DOI) is a known indicator of metastatic potential in oral cavity squamous cell carcinoma (SCC). Our purpose was to investigate the accuracy of preoperative determination of DOI in oral cavity SCC by computed tomography (CT) and positron emission tomography/computed tomography (PET/CT). Methodology A retrospective study was performed using consecutive patients with histologically proven oral cavity SCC presenting to our otorhinolaryngology department between January 2014 and July 2019 who underwent preoperative contrast-enhanced CT and/or PET/CT. Pathological assessment of DOI was determined by a review of pathology reports. The degree of DOI determined by radiographic studies was correlated to pathology results. Results A total of 79 patients were screened of whom appropriate radiographic studies were available for 63 patients. The mean DOI by pathological assessment was 12.3 ± 9.1 mm. CT and PET/CT determined depth both correlated with pathological DOI (r = 0.710; p < 0.001, r = 0.798; p < 0.001). No significant correlation was seen for CT-determined depth (r = 0.136; p = 0.709) or PET-determined depth (r = 0.234; p = 0.707) with pathologically confirmed superficial tumors (<5 mm). For patients with pathological tumor depth >10 mm, CT and PET determined depth both correlated with pathological depth (r = 0.577; p = 0.002, r = 0.668; p = 0.001). The sensitivity and specificity of CT and PET for the identification of deep invasion were 88.2% and 41.7% and 52.9% and 50%, respectively. Conclusions DOI measurement is feasible with routine preoperative CT and PET/CT images and is comparable to pathological measurement in patients with oral cavity SCC.

Prediction of cervical lymph node metastasis from immunostained specimens of tongue cancer using a multilayer perceptron neural network

BACKGROUND

Although cervical lymph node metastasis is an important prognostic factor for oral cancer, occult metastases remain undetected even by diagnostic imaging. We developed a learning model to predict lymph node metastasis in resected specimens of tongue cancer by classifying the level of immunohistochemical (IHC) staining for angiogenesis- and lymphangiogenesis-related proteins using a multilayer perceptron neural network (MNN).

METHODS

We obtained a dataset of 76 patients with squamous cell carcinoma of the tongue who had undergone primary tumor resection. All 76 specimens were IHC stained for the six types shown above (VEGF-C, VEGF-D, NRP1, NRP2, CCR7, and SEMA3E) and 456 slides were prepared. We scored the staining levels visually on all slides. We created virtual slides (4560 images) and the accuracy of the MNN model was verified by comparing it with a hue-saturation (HS) histogram, which quantifies the manually determined visual information.

RESULTS

The accuracy of the training model with the MNN was 98.6%, and when the training image was converted to grayscale, the accuracy decreased to 52.9%. This indicates that our MNN adequately evaluates the level of staining rather than the morphological features of the IHC images. Multivariate analysis revealed that CCR7 staining level and T classification were independent factors associated with the presence of cervical lymph node metastasis in both HS histograms and MNN.

CONCLUSION

These results suggest that IHC assessment using MNN may be useful for identifying lymph node metastasis in patients with tongue cancer.

Worst Pattern of Invasion as a Predictor of Nodal Metastasis in Early-Stage Oral Squamous Cell Carcinoma

About one-third of early stage oral cancer patients have occult nodal metastasis. High grade worst pattern of invasion (WPOI) is associated with an increased risk of nodal metastasis and poor prognosis. However, it still remains unanswered whether to perform an elective neck dissection for clinically node-negative disease or not. This study aims to evaluate the role of histological parameters including WPOI in predicting nodal metastasis in early-stage oral cancers. This analytical observational study comprised 100 patients of early-stage, node-negative, oral squamous cell carcinoma, admitted in the Surgical Oncology Department from April, 2018 till the sample size was reached. The socio-demographic data, clinical history, and findings of clinical and radiological examination were noted. The association of nodal metastasis with various histological parameters like tumour size, degree of differentiation, depth of invasion (DOI), WPOI, perineural invasion (PNI), lymphovascular invasion (LVI) and lymphocytic response was determined. SPSS 20.0 statistical tool; student's 't' test and chi-square tests were applied. While the buccal mucosa was the commonest site, the rate of occult metastasis was highest in the tongue. Nodal metastasis was not significantly associated with age, sex, smoking and primary site. While the nodal positivity was not significantly associated with tumour size, pathological stage, DOI, PNI and lymphocytic response, it was associated with LVI, degree of differentiation and WPOI. Increasing WPOI grade correlated significantly with the nodal stage, LVI and PNI, but not with DOI. WPOI is not only a significant predictor of occult nodal metastasis but can also be a novel therapeutic tool in the management of early-stage oral cancers. In patients with an aggressive WPOI pattern or other high-risk histological parameters, the neck can be addressed with either elective neck dissection or radiotherapy after wide excision of the primary tumor; otherwise, an active surveillance approach can be followed.

Overexpression of E-Cadherin Is a Favorable Prognostic Biomarker in Oral Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

Oral squamous cell carcinoma (OSCC) is characterized by poor survival, mostly due to local invasion, loco-regional recurrence, and metastasis. Given that the weakening of cell-to-cell adhesion is a feature associated with the migration and invasion of cancer cells, different studies have explored the prognostic utility of cell adhesion molecules such as E-cadherin (E-cad). This study aims to summarize current evidence in a meta-analysis, focusing on the prognostic role of E-cad in OSCC. To find studies meeting inclusion criteria, Scopus, Web of Science, EMBASE, Medline, and OpenGrey databases were systematically assessed and screened. The selection process led to 25 studies, which were considered eligible for inclusion in the meta-analysis, representing a sample of 2553 patients. E-cad overexpression was strongly associated with longer overall survival (OS) with Hazard Ratio (HR)  = 0.41 95% confidence interval (95% CI) (0.32-0.54); p < 0.001 and disease-free survival with HR 0.47 95% CI (0.37-0.61); p < 0.001. In terms of OS, patients with tongue cancer experienced better survivability when expressing E-cad with HR 0.28 95% CI (0.19-0.43); p < 0.001. Globally, our findings indicate the prognostic role of the immunohistochemical assessment of E-cad in OSCC and its expression might acquire a different role based on the oral cavity subsites.

Radiomics analysis of [18F]-fluoro-2-deoxyglucose positron emission tomography for the prediction of cervical lymph node metastasis in tongue squamous cell carcinoma

OBJECTIVES

This study aimed to create a predictive model for cervical lymph node metastasis (CLNM) in patients with tongue squamous cell carcinoma (SCC) based on radiomics features detected by [¹⁸F]-fluoro-2-deoxyglucose (¹⁸F-FDG) positron emission tomography (PET).

METHODS

A total of 40 patients with tongue SCC who underwent ¹⁸F-FDG PET imaging during their first medical examination were enrolled. During the follow-up period (mean 28 months), 20 patients had CLNM, including six with late CLNM, whereas the remaining 20 patients did not have CLNM. Radiomics features were extracted from ¹⁸F-FDG PET images of all patients irrespective of metal artifact, and clinicopathological factors were obtained from the medical records. Late CLNM was defined as the CLNM that occurred after major treatment. The least absolute shrinkage and selection operator (LASSO) model was used for radiomics feature selection and sequential data fitting. The receiver operating characteristic curve analysis was used to assess the predictive performance of the ¹⁸F-FDG PET-based model and clinicopathological factors model (CFM) for CLNM.

RESULTS

Six radiomics features were selected from LASSO analysis. The average values of the area under the curve (AUC), accuracy, sensitivity, and specificity of radiomics analysis for predicting CLNM from ¹⁸F-FDG PET images were 0.79, 0.68, 0.65, and 0.70, respectively. In contrast, those of the CFM were 0.54, 0.60, 0.60, and 0.60, respectively. The ¹⁸F-FDG PET-based model showed significantly higher AUC than that of the CFM.

CONCLUSIONS

The ¹⁸F-FDG PET-based model has better potential for diagnosing CLNM and predicting late CLNM in patients with tongue SCC than the CFM.

Prognostic value of preoperative systemic inflammatory response as a prognostic indicator in patients with early-stage oral squamous cell carcinoma

To determine the usefulness of lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and inflammatory response biomarker (IRB) score for predicting disease-specific survival and delayed cervical lymph node metastasis in early-stage oral squamous cell carcinoma (OSCC). We retrospectively analyzed 72 patients with early-stage OSCC. Receiver operating characteristic curve analysis was used to determine the cutoff values for LMR, NLR, and PLR. IRB score was determined as follows: high LMR, high NLR, and low PLR, which were each rated as 1. These scores were added to obtain IRB score (range: 0-3). From univariate analysis, gender, poor mode of invasion, and high IRB score were identified as significant risk factors for disease-specific survival. However, there were no independent factors for poor prognosis in multivariate analysis. On the other hand, for delayed cervical lymph node metastasis, poor mode of invasion, low LMR, high NLR, high PLR, and high IRB score were identified as significant risk factors from univariate analysis, and in multivariate analysis, poor mode of invasion and high IRB score were confirmed as independent risk factors. IRB score and mode of invasion are potentially independent risk factors for delayed cervical lymph node metastasis in early-stage OSCC.

Midline involvement and perineural invasion predict contralateral neck metastasis that affects overall and disease-free survival in locally advanced oral tongue squamous cell carcinoma

Introduction

Although patients with oral squamous cell carcinoma who develop contralateral neck metastasis (CLNM) have worse survival outcomes than those without CLNM, accurate prediction of occult CLNM in clinically negative contralateral neck (contralateral cN0) remains difficult. This study aimed to identify clinicopathological factors that could reliably predict CLNM in patients with locally advanced (clinical T3 and T4a) tongue squamous cell carcinoma (TSCC).

Patients and methods

The medical data of 32 patients with cT3–4a TSCC who underwent curative surgery between 2010 and 2017 were retrospectively analyzed. The correlation of clinicopathological variables with CLNM was examined using logistic regression analysis. The diagnostic performance of significant variables was evaluated using the area under the receiver operating characteristic curves (AUC). Overall survival (OS) and disease-free survival (DFS) were assessed using a Cox proportional hazards model.

Results

CLNM was eventually confirmed in 11 patients (34.4%). Multivariate logistic regression showed that midline involvement [odds ratio (OR) = 23.10, P = 0.017] and perineural invasion (PNI, OR = 14.96, P = 0.014) were independent predictors of CLNM. Notably, the prediction model comprising a combination of midline involvement and PNI exhibited superior diagnostic performance with an even higher OR of 80.00 (P &lt; 0.001), accuracy of 90.3%, and AUC of 0.876. The multivariate Cox hazards model revealed independent significance of CLNM as an unfavorable prognostic factor for both OS [hazard ratio (HR) = 5.154, P = 0.031] and DFS (HR = 3.359, P = 0.038), as well as that of PNI for OS (HR = 5.623, P = 0.033).

Conclusion

Our findings suggest that coexisting midline involvement and PNI of the primary tumor is highly predictive of CLNM development, which independently affects both OS and DFS in patients with locally advanced TSCC. Such reliable prediction enables efficient control of CLNM by optimizing management of the contralateral cN0 neck, which will likely contribute to improved prognosis of those patients without unnecessarily compromising their quality of life.

Histopathologic features predictive of metastasis and survival in 230 patients with cutaneous squamous cell carcinoma of the head and neck and non-head and neck locations: a single-center retrospective study

BACKGROUND

Staging systems for cutaneous squamous cell carcinoma (cSCC) produce inconsistent risk stratification.

OBJECTIVE

The aim of this study was to identify further prognostic parameters for better stratification.

METHODS

We retrospectively analysed the prognostic significance of clinicopathologic parameters of 230 patients who underwent primary excision of invasive cSCC of the head and neck (n = 115) and non-head and non-neck (n = 115) locations. In addition to known high-risk features, we analysed tumour nest shape, invasion pattern, lymphoid response pattern and tumour budding.

RESULTS

On multivariable analysis, lymphovascular invasion (LVI) and high tumour budding predicted worse disease-specific survival, and ulceration, LVI and high tumour budding predicted worse overall survival. Only ulceration was independently associated with risk of nodal metastasis.

CONCLUSION

High tumour budding, LVI and ulceration are independently associated with poor outcome in cSCC and may be used to refine cSCC prognostic stratification, which is crucial to optimize clinical decision and to identify patients who are more likely to benefit from more aggressive interventions or clinical trials.

Emerging histopathologic markers in early-stage oral tongue cancer: A systematic review and meta-analysis

Although there are many histopathologic prognosticators, grading of early oral tongue squamous cell carcinoma (OTSCC) is still based on morphological cell differentiation which has low prognostic value. Here we summarize the emerging histopathological markers showing powerful prognostic value, but are not included in pathology reports. Using PubMed, Scopus, Ovid Medline, and Web of Science databases, a systematic literature search was preformed to identify early OTSCC studies that investigated the prognostic significance of hematoxylin–eosin‐based histopathologic markers. Our meta‐analysis showed that tumor budding was associated with overall survival (hazard ratio [HR] 2.32; 95% CI 1.40–3.84; p < 0.01) and disease‐specific survival (DSS) (1.89; 95% CI 1.13–3.15; p = 0.02). Worst pattern of invasion was associated with disease‐free survival (DFS) (1.95; 95% CI 1.04–3.64; p = 0.04). Tumor–stroma ratio was also associated with DFS (1.75, 95% CI 1.24–2.48; p < 0.01) and DSS (1.69; 95% CI 1.19–2.42; p < 0.01). Tumor budding, worst pattern of invasion, and tumor–stroma ratio have a promising prognostic value in early OTSCC. The evaluation and reporting of these markers is cost‐effective and can be incorporated in daily practice.

Radiomics Metrics Combined with Clinical Data in the Surgical Management of Early-Stage (cT1-T2 N0) Tongue Squamous Cell Carcinomas: A Preliminary Study

Objective: To predict the risk of metastatic lymph nodes and the tumor grading related to oral tongue squamous cell carcinoma (OTSCC) through the combination of clinical data with radiomics metrics by computed tomography, and to develop a supportive approach in the management of the lymphatic cervical areas, with particular attention to the early stages (T1−T2). Between March 2016 and February 2020, patients with histologically confirmed OTSCC, treated by partial glossectomy and ipsilateral laterocervical lymphadenectomy and subjected to computed tomography (CT) before surgery, were identified by two centers: 81 patients (49 female and 32 male) with 58 years as the median age (range 19−86 years). Univariate analysis with non-parametric tests and multivariate analysis with machine learning approaches were used. Clinical, hematological parameters and radiological features extracted by CT were considered individually and in combination. All clinical parameters showed statistically significant differences (p < 0.05) for the Kruskal−Wallis test when discriminating both the tumor grading and the metastatic lymph nodes. DOI, PLR, SII, and SIRI showed an accuracy of 0.70 (ROC analysis) when identifying the tumor grading, while an accuracy ≥ 0.78 was shown by DOI, NLR, PLR, SII, and SIRI when discriminating metastatic lymph nodes. In the context of the analysis of radiomics metrics, the original_glszm_HighGrayLevelZoneEmphasis feature was selected for identifying the tumor grading (accuracy of 0.70), while the wavelet_HHH_glrlm_LowGrayLevelRunEmphasis predictor was selected for determining metastatic lymph nodes (accuracy of 0.96). Remarkable findings were also obtained when classifying patients with a machine learning approach. Radiomics features alone can predict tumor grading with an accuracy of 0.76 using a logistic regression model, while an accuracy of 0.82 can be obtained by running a CART algorithm through a combination of three clinical parameters (SIRI, DOI, and PLR) with a radiomics feature (wavelet_LLL_glszm_SizeZoneNonUniformityNormalized). In the context of predicting metastatic lymph nodes, an accuracy of 0.94 was obtained using 15 radiomics features in a logistic regression model, while both CART and CIDT achieved an asymptotic accuracy value of 1.00 using only one radiomics feature. Radiomics features and clinical parameters have an important role in identifying tumor grading and metastatic lymph nodes. Machine learning approaches can be used as an easy-to-use tool to stratify patients with early-stage OTSCC, based on the identification of metastatic and non-metastatic lymph nodes.

Prognostic and Clinicopathological Significance of the Aberrant Expression of β-Catenin in Oral Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

Simple Summary

β-catenin is a multifunctional protein whose physiological functions are mainly related to the maintenance of cell-cell adhesion by forming complexes with the adhesion molecule E-cadherin, both responsible for the preservation of squamous epithelia homeostasis. The loss of β-catenin expression in the cell membrane, the failure of cytoplasmic degradation mechanisms—essentially related to the activation of Wnt canonical oncogenic pathway—and/or its translocation to the nucleus—developing actions as a transcription factor of oncogenes—are aberrant mechanisms with oncogenic implications in oral carcinogenesis. In this systematic review and meta-analysis on 41 studies and 2746 oral squamous cell carcinoma (OSCC) patients we demonstrate that the aberrant expression of β-catenin—mainly the immunohistochemical analysis of its loss in the cell membrane—behaves as a prognostic biomarker, significantly associated with poor survival, essentially linked to the increased risk for the development of lymph node metastases, higher tumour size and clinical stage in these patients.

Abstract

This systematic review and meta-analysis aims to evaluate the prognostic and clinicopathological significance of the aberrant expression of β-catenin (assessed through the immunohistochemical loss of membrane expression, cytoplasmic and nuclear expression) in oral squamous cell carcinoma (OSCC). We searched for primary-level studies published before October-2021 through PubMed, Embase, Web of Science, Scopus, and Google Scholar, with no limitation in regard to their publication date or language. We evaluated the methodological quality and risk of bias of the studies included using the QUIPS tool, carried out meta-analyses, explored heterogeneity and their sources across subgroups and meta-regression, and conducted sensitivity and small-study effects analyses. Forty-one studies (2746 patients) met inclusion criteria. The aberrant immunohistochemical expression of β-catenin was statistically associated with poor overall survival (HR = 1.77, 95% CI = 1.20–2.60, p = 0.004), disease-free survival (HR = 2.44, 95% CI = 1.10–5.50, p = 0.03), N+ status (OR = 2.39, 95% CI = 1.68–3.40, p < 0.001), higher clinical stage (OR = 2.40, 95% CI = 1.58–3.63, p < 0.001), higher tumour size (OR = 1.76, 95% CI = 1.23–2.53, p = 0.004), and moderately-poorly differentiated OSCC (OR = 1.57, 95% CI = 1.09–2.25, p = 0.02). The loss of β-catenin in the cell membrane showed the largest effect size in most of meta-analyses (singularly for poor overall survival [HR = 2.37, 95% CI = 1.55–3.62, p < 0.001], N+ status [OR = 3.44, 95% CI = 2.40–4.93, p < 0.001] and higher clinical stage [OR = 2.51, 95% CI = 1.17–5.35, p = 0.02]). In conclusion, our findings indicate that immunohistochemical assessment of the aberrant expression of β-catenin could be incorporated as an additional and complementary routine prognostic biomarker for the assessment of patients with OSCC.

Magnetic Resonance Imaging-Based Radiomics Features Associated with Depth of Invasion Predicted Lymph Node Metastasis and Prognosis in Tongue Cancer

Background

Adequate safe margin in tongue cancer radical surgery is one of the most important prognostic factors. However, the role of peritumoral tissues in predicting lymph node metastasis (LNM) and prognosis using radiomics analysis remains unclear.

Purpose

To investigate whether magnetic resonance imaging (MRI)‐based radiomics analysis with peritumoral extensions contributes toward the prediction of LNM and prognosis in tongue cancer.

Study type

Retrospective.

Population

Two hundred and thirty‐six patients (38.56% female) with tongue cancer (training set, N = 157; testing set, N = 79; 37.58% and 40.51% female for each).

Field Strength/Sequence

1.5 T; T2‐weighted turbo spin‐echo images.

Assessment

Radiomics models (R_prim, R_prim+3, R_prim+5, R_prim+10, R_prim+15) were developed with features extracted from the primary tumor without or with peritumoral extensions (3, 5, 10, and 15 mm, respectively). Clinicopathological characteristics selected from univariate analysis, including MRI‐reported LN status, radiological extrinsic lingual muscle invasion, and pathological depth of invasion (DOI) were further incorporated into radiomics models to develop combined radiomics models (CR_prim, CR_prim+3, CR_prim+5, CR_prim+10, CR_prim+15). Finally, the model performance was validated in the testing set. DOI was measured from the adjacent normal mucosa to the deepest point of tumor invasion.

Statistical Tests

Chi‐square test, regression analysis, receiver operating characteristic curve (ROC) analysis, decision analysis, spearman correlation analysis. The Delong test was used to compare area under the ROC (AUC). P < 0.05 was considered statistically significant.

Results

Of all the models, the CR_prim+10 reached the highest AUC of 0.995 in the training set and 0.872 in the testing set. Radiomics features were significantly correlated with pathological DOI (correlation coefficients, −0.157 to −0.336). The CR_prim+10 was an independent indicator for poor disease‐free survival (hazard ratio, 5.250) and overall survival (hazard ratio, 17.464) in the testing set.

Data Conclusion

Radiomics analysis with a 10‐mm peritumoral extension had excellent power to predict LNM and prognosis in tongue cancer.

Immunohistochemical Expression of the Epithelial to Mesenchymal Transition Proteins E-cadherin and ß-catenin in Grades of Oral Squamous Cell Carcinoma

Background

E-Cadherin/β-Catenin protein complexes play a major role in epithelial to mesenchymal transition (EMT) and vice versa. Such types of EMT are implicated physiologically during embryonic development and pathologically in tissue fibrosis and tumorigenesis.

Aims

The aim was the evaluation of E-Cadherin and β-Catenin immunoreactivity in various grades of oral squamous cell carcinoma (OSCC) and to correlate their pattern of expression.

Materials and Methods

Immunohistochemical expression of E-Cadherin/β-Catenin was evaluated in a total n = 30 tissue samples comprising of n = 10 well-differentiated squamous cell carcinoma (WDSCC), n = 10 moderately differentiated squamous cell carcinoma (MDSCC), and n = 10 poorly differentiated squamous cell carcinoma (PDSCC). Based on the intensity of staining, an immunoreactivity scoring was calculated.

Statistical Analysis

The scorings obtained were subjected to independent t-test, paired t-test, Chi-square test, and ANOVA test using SPSS version 20.0 statistical analysis software. P < 0.05 was considered statistically significant.

Results

A significant difference was observed in the expression of β-Catenin between normal mucosa and WDSCC; normal mucosa and MDSCC. A gradual decrease in the immunoreactivity score of E-Cadherin is seen in WDSCC, MDSCC, and PDSCC.

Conclusion

Therefore, dysregulation of these proteins can lead to tumor progression, invasion, and metastasis. Further studies are warranted to specify the role of these EMT proteins as prognostic/therapeutic markers in patients suffering from OSCC.

Distribution of Metastases in Ent Area – Comparison of Theory and Practice

In head and neck cancers the occurrence of nodal metastases is the most important prognostic factor. Their early diagnosis is crucial for proper treatment. Detection of early metastases is still very difficult. Predictive diagnostic methods such as the sentinel lymph node detection is limited by the occurrence of skip metastases. At our Clinic we prefer a selective neck dissection based on a surgical treatment of predilected lymphatic spread area for each type of head and neck tumor with a preservation of non-lymphatic structures of the neck. The main objective of this article is to analyze the distribution of neck metastases and to study the frequency of skip metastases in head and neck cancer.

E-Cadherin expression in human tumors: a tissue microarray study on 10,851 tumors

BACKGROUND

The E-Cadherin gene (CDH1, Cadherin 1), located at 16q22.1 encodes for a calcium-dependent membranous glycoprotein with an important role in cellular adhesion and polarity maintenance.

METHODS

To systematically determine E-Cadherin protein expression in normal and cancerous tissues, 14,637 tumor samples from 112 different tumor types and subtypes as well as 608 samples of 76 different normal tissue types were analyzed by immunohistochemistry in a tissue microarray format.

RESULTS

E-Cadherin was strongly expressed in normal epithelial cells of most organs. From 77 tumor entities derived from cell types normally positive for E-Cadherin, 35 (45.5%) retained at least a weak E-Cadherin immunostaining in ≥99% of cases and 61 (79.2%) in ≥90% of cases. Tumors with the highest rates of E-Cadherin loss included Merkel cell carcinoma, anaplastic thyroid carcinoma, lobular carcinoma of the breast, and sarcomatoid and small cell neuroendocrine carcinomas of the urinary bladder. Reduced E-Cadherin expression was linked to higher grade (p = 0.0009), triple negative receptor status (p = 0.0336), and poor prognosis (p = 0.0466) in invasive breast carcinoma of no special type, triple negative receptor status in lobular carcinoma of the breast (p = 0.0454), advanced pT stage (p = 0.0047) and lymph node metastasis in colorectal cancer (p < 0.0001), and was more common in recurrent than in primary prostate cancer (p < 0.0001). Of 29 tumor entities derived from E-Cadherin negative normal tissues, a weak to strong E-Cadherin staining could be detected in at least 10% of cases in 15 different tumor entities (51.7%). Tumors with the highest frequency of E-Cadherin upregulation included various subtypes of testicular germ cell tumors and renal cell carcinomas (RCC). E-Cadherin upregulation was more commonly seen in malignant than in benign soft tissue tumors (p = 0.0104) and was associated with advanced tumor stage (p = 0.0276) and higher grade (p = 0.0035) in clear cell RCC, and linked to advanced tumor stage (p = 0.0424) and poor prognosis in papillary RCC (p ≤ 0.05).

CONCLUSION

E-Cadherin is consistently expressed in various epithelial cancers. Down-regulation or loss of E-Cadherin expression in cancers arising from E-Cadherin positive tissues as well as E-Cadherin neo-expression in cancers arising from E-Cadherin negative tissues is linked to cancer progression and may reflect tumor dedifferentiation.

Prediction of lymph node metastasis in oral tongue squamous cell carcinoma using the neutrophil-to-lymphocyte ratio and platelet-to-neutrophil ratio

Background

Lymph node metastasis in a variety of tumors is associated with systemic inflammatory markers. However, this association has not been reported in oral tongue squamous cell carcinoma (OTSCC). This study aimed to investigate how the preoperative neutrophil‐to‐lymphocyte ratio (NLR) and platelet‐to‐neutrophil ratio (PNR) in OTSCC patients correlated with the occurrence of OTSCC and lymph node metastasis.

Methods

The data of 73 patients with primary OTSCC who underwent surgical resection were retrospectively analyzed. Patients with other malignant tumors, patients who had received radiotherapy or chemotherapy before surgery, and patients with active inflammation were excluded. The enrolled patients were divided into groups N₀ (no early‐stage lymph node metastasis) and N₁ (early‐stage lymph node metastasis). Venous blood samples were collected before surgery and at the third week after surgery and subjected to complete blood counting in a blood analyzer. Eighty‐seven healthy people were included as a control group. In addition, the NLR and PNR in OTSCC patients were compared with those in the controls, and the postoperative NLR and PNR of group N₀ were compared with those of group N₁.

Results

The NLR was significantly higher in the OTSCC patients than the controls (p < 0.05). The area under the receiver operating characteristic curve was 0.595. Further comparison of the NLR and PLR between group N₀ and group N₁ showed that when NLR was ≤1.622, and the probability of early‐stage lymph node metastasis in OTSCC patients was 73.3%, and when PNR was >60.889, the probability was 86.7%. In re‐examination 3 weeks postoperatively, the NLR and PNR were not significantly different between groups.

Conclusion

The NLR has certain reference value for the diagnosis of OTSCC. The preoperative NLR and PNR can be used to predict early‐stage lymph node metastasis in patients with histopathologically confirmed OTSCC.

Development and validation of multiparametric MRI-based nomogram for predicting occult metastasis risk in early tongue squamous cell carcinoma

Background

Nomograms are currently used in predicting individualized outcomes in clinical oncology of several cancers. However, nomograms for evaluating occult nodal metastasis of patients with squamous cell carcinoma of lateral tongue (SCCLT) have not been widely investigated for their functionality. This retrospective cohort study was designed to address this question.

Methods

This study was divided into primary and validation cohorts. The primary cohort comprised 120 patients diagnosed between 2012 and 2017, whereas the validation cohort included 41 patients diagnosed thereafter. The diagnostic value of multiparametric MRI, including radiologic tumor thickness threshold (rTTT) in three-dimensions, paralingual distance, and sublingual distance were investigated. A nomogram was developed based on stepwise logistic regression of potential predictors associated with nodal metastasis in the primary cohort and then tested for predictive accuracy in the validation cohort using area under the curve (AUC) and goodness-of-fit tests.

Results

Multivariate analysis, tumor size (odd ratio [OR] 15.175, 95% confidence interval [CI] 1.436–160.329, P = 0.024), rTTT (OR 11.528, 95% CI 2.483–53.530, P = 0.002), paralingual distance (OR 11.976, 95% CI 1.981–72.413, P = 0.005), and tumor location (OR 6.311, 95% CI 1.514–26.304, P = 0.011) were included in the nomogram to predict the likelihood of having cervical metastasis. A nomogram cutoff value of 210 points (sensitivity 93.8%, specificity 87.5%) was significantly different to classify the patients metastasis risk group (P < 0.001). Nomogram showed predictive accuracy with AUC 0.881 (95% CI 0.779–0.983, P < 0.001) and good calibration after the validation.

Conclusions

A preoperative nomogram incorporating multiparametric MRI demonstrated good prediction and performed adequately in our study. Three-dimensional assessment of occult metastasis risk value obtained from this nomogram can assist in preoperative decision making for individual patients with early-stage SCCLT. The probability of nodal metastasis tended to be greater than 20% in patients with high metastasis risk or nomogram total score > 210 points.

Evaluation of HPV and EBV in OSCC and the expression of p53, p16, E-cadherin, COX-2, MYC, and MLH1

OBJECTIVE

This study aimed to evaluate the presence of human papillomavirus (HPV) and Epstein-Barr virus (EBV) and the expression of p53, p16, E-cadherin, COX-2, MLH1, and MYC in oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

One hundred OSCC specimens were submitted to in situ hybridization for HPV and EBV, and immunohistochemistry for detection of the human proteins.

RESULTS

Thirty-one cases showed HPV in tumor tissue. EBV was not detected in any case investigated. The HPV(+) group demonstrated an increase of staining scores for nuclear p16 (p = .047), cytoplasmic MYC (p = .002), while a decrease for nuclear MLH1 (p = .048), suggesting that HPV may upregulate the expression of the first two proteins and down-regulate the latter.

CONCLUSION

Our findings reinforce the hypothesis of the HPV-related oral carcinogenesis involving the expression of p16 and MYC, and MLH1 suppression. Exclusively cytoplasmic stainings for p16, MLH1, and MYC were also associated with more advanced tumors. Finally, in view of the lack of studies correlating the HPV or EBV infection to the expression of oncoproteins, more researches assessing a broader panel of markers and employing different approaches are still necessary in order to understand the role of these viruses as well as the molecular mechanisms involved in the development and progression of oral carcinomas.

Relationship between the microvascular patterns observed by magnifying endoscopy with narrow-band imaging and the depth of invasion in superficial pharyngeal squamous cell carcinoma

BACKGROUND

Prediction of the invasive depth is the objective of endoscopic observation for digestive cancer. In superficial esophageal cancer, a close relationship between microvascular patterns observed by magnifying endoscopy with narrow-band imaging (M-NBI) and pathological depth of invasion is well known. The ability of M-NBI to predict the invasion depth in superficial pharyngeal squamous cell carcinoma (SPSCC) has been seldom evaluated. This study aimed to clarify the relationship between the microvasculature patterns and pathological depth in SPSCC.

METHODS

SPSCC lesions evaluated with M-NBI followed by endoscopic resection were analyzed between April 2010 and March 2017. Endoscopic images were classified as microvasculature tumor types B1, B2, and B3 according to the Japan Esophageal Society classification. The pathological depth of invasion was described as either squamous cell carcinoma in situ (Tis) or invasive subepithelial cancer, and the tumor thickness of all lesions was examined. Data were analyzed using the unpaired t, χ², or Mann-Whitney U test.

RESULTS

Type B1 and type B2/B3 (35/3) microvessels were found in 180 lesions (82%) and 39 (18%), respectively. Of the flat lesions, 115 (83%) were classified as Tis and 23 (17%) as subepithelial cancer. Positive and negative predictive values of the B1 vessels were 77% and 82%, respectively. Additional analysis showed that the positive predictive value of the B1 vessels for the flat-type lesions was 87%; the negative predictive value for the elevated lesions was 93%.

CONCLUSIONS

Microvascular patterns observed by M-NBI are an important factor in predicting the pathological depth of invasion.

A Prognostic Model Based on Clinicopathological Features and Inflammation- and Nutrition-Related Indicators Predicts Overall Survival in Surgical Patients With Tongue Squamous Cell Carcinoma

Objectives: It is reported that inflammation- and nutrition-related indicators have a prognostic impact on multiple cancers. Here we aimed to identify a prognostic nomogram model for prediction of overall survival (OS) in surgical patients with tongue squamous cell carcinoma (TSCC). Methods: The retrospective data of 172 TSCC patients were charted from the Cancer Hospital of Shantou University Medical College between 2008 and 2019. A Cox regression analysis was performed to determine prognostic factors to establish a nomogram and predict OS. The predictive accuracy of the model was analyzed by the calibration curves and the concordance index (C-index). The difference of OS was analyzed by Kaplan-Meier survival analysis. Results: Multivariate analysis showed age, tumor node metastasis (TNM) stage, red blood cell, platelets, and platelet-to-lymphocyte ratio were independent prognostic factors for OS, which were used to build the prognostic nomogram model. The C-index of the model for OS was 0.794 (95% CI = 0.729-0.860), which was higher than that of TNM stage 0.685 (95% CI = 0.605-0.765). In addition, decision curve analysis also showed the nomogram model had improved predictive accuracy and discriminatory performance for OS, compared to the TNM stage. According to the prognostic model risk score, patients in the high-risk subgroup had a lower 5-year OS rate than that in a low-risk subgroup (23% vs 49%, P < .0001). Conclusions: The nomogram model based on clinicopathological features inflammation- and nutrition-related indicators represents a promising tool that might complement the TNM stage in the prognosis of TSCC.

Role of Cyclooxygenase-2 in Head and Neck Tumorigenesis

The cyclooxygenase-2 (COX-2) is a potent enzyme that converts arachidonic acid to prostaglandins (PG), including PGE2, a key mediator of inflammation and angiogenesis. Importantly, COX-2 is activated in response to inflammatory stimuli, where it is also believed to promote the development and progression of head and neck cancers (HNC). COX-2 can mediate its protumorigenic effect through various mechanisms, such as inducing cell proliferation, inhibition of apoptosis, and suppressing the host’s immune response. Furthermore, COX-2 can induce the production of vascular endothelial growth factors, hence, promoting angiogenesis. Indeed, the ability of COX-2 inhibitors to selectively restrict the proliferation of tumor cells and mediating apoptosis provides promising therapeutic targets for cancer patients. Thus, in this comprehensive review, we summarized the reported differential expression patterns of COX-2 in different stages of head and neck carcinogenesis—from potentially premalignant lesions to invasive carcinomas. Furthermore, we examined the available meta-analysis evidence for COX-2 role in the carcinogenesis of HNC. Finally, further understanding of the biological processes of COX-2 and its role in orchestrating cell proliferation, apoptosis, and angiogenesis may give therapeutically beneficial insight to develop the management plan of HNC patients and improve their clinical outcomes.

Actinin-4 Expression Predicts Poor Disease-free Survival and Correlates with Delayed Lymph Node Metastasis in Patients with Completely Resected Oral Squamous Cell Carcinoma

Oral squamous cell carcinoma is generally characterized by poor prognosis, and biomarkers are needed for development and selection of therapy. The purpose of this study was to assess expression of actinin-4, which has been implicated in cancer invasion and metastasis, to determine its viability as a prognostic indicator in oral squamous cell carcinoma. Clinical factors and tumor samples immunohistochemically stained for actinin-4 were retrospectively investigated in 55 patients who underwent curative surgery for oral squamous cell carcinoma. Overall survival and disease-free survival were estimated by Kaplan-Meier analysis. Significant differences were detected using the Pearson's chi-square and Fisher's exact tests. Univariate and multivariate analyses were performed with the Cox regression model. No association was found between expression of actinin-4 and clinical factors, including age or sex, or histopathological factors, including vascular invasion, lymphatic invasion, stage, mode of invasion, or histological atypicality. Expression of actinin-4 showed a positive correlation with delayed cervical lymph node metastasis. Disease-free survival was significantly lower in patients who were positive for expression of actinin-4 (p=0.010); overall survival showed no difference between patients with or without expression of actinin-4, however. The results revealed that actinin-4 was an independent prognostic factor for disease-free survival. Expression of actinin-4 showed a 73% sensitivity and 68% specificity for prediction of delayed cervical lymph node metastasis. In conclusion, actinin-4 may potentially be a useful biomarker for prediction of delayed cervical lymph node metastasis.

Depth of invasion determined by magnetic resonance imaging in tongue cancer can be a predictor of cervical lymph node metastasis

OBJECTIVES

We evaluated the relationships between depth of invasion (DOI) of tongue cancer, as measured with preoperative T1- and T2-weighted magnetic resonance imaging (MRI) and postoperative histopathologic (Path) specimens, with cervical lymph node metastasis (CLNM) and tumor stage. We also calculated the correlation of MRI and Path DOI measurements.

STUDY DESIGN

This retrospective study included 101 patients who had squamous cell carcinoma of the tongue and were treated surgically. Two observers measured DOI on all 3 modalities.

RESULTS

DOI thresholds for predicting CLNM with high diagnostic efficacy were 6.99 mm and 8.32 mm for MRI and 5 mm for Path. DOI values from all modalities were significantly different for tumors with and without CLNM (P < .01) and for the 4 TNM stages (P ≤ .05), with increasing values corresponding to advancement in tumor stage. Addition of DOI changed the T level of many tumors based on the new TNM (tumor-node-metastasis) classification. The correlation coefficient between DOI calculated on each MRI sequence and Path was 0.90.

CONCLUSIONS

MRI-derived DOI accurately reflected the subsequent metastatic status and degree of progression of tumor stages, with a strong positive correlation to Path values, and may be considered a predictor of tumor stage and CLNM.

Ordinal logistic regression model describing factors associated with extent of nodal involvement in oral cancer patients and its prospective validation

Background

Oral cancer is the most common cancer among Indian men, and has strong tendency of metastatic spread to neck lymph node which strongly influences prognosis especially 5 year survival-rate and also guides the related managements more effectively. Therefore, a reliable and accurate means of preoperative evaluation of extent of nodal involvement becomes crucial. However, earlier researchers have preferred to address mainly its dichotomous form (involved/not-involved) instead of ordinal form while dealing with epidemiology of nodal involvement. As a matter of fact, consideration of ordinal form appropriately may increase not only the efficiency of the developed model but also accuracy in the results and related implications. Hence, to develop a model describing factors associated with ordinal form of nodal involvement was major focus of this study.

Methods

The data for model building were taken from the Department of Surgical Oncology, Dr.BRA-IRCH, AIIMS, New Delhi, India. All the OSCC patients (duly operated including neck dissection) and confirmed histopathologically from 1995 to 2013 were included. Further, another data of 204 patients collected prospectively from 2014 to 2015 was considered for the validation of the developed model. To assess the factors associated with extent of nodal involvement, as a first attempt in the field of OSCC, stepwise multivariable regression procedure was used and results are presented as odds-ratio and corresponding 95% confidence interval (CI). For appropriate accounting of ordinal form, the ordinal models were assessed and compared. Also, performance of the developed model was validated on a prospectively collected another data.

Results

Under multivariable proportional odds model, pain at the time of presentation, sub mucous fibrosis, palpable neck node, oral site and degree of differentiation were found to be significantly associated factors with extent of nodal involvement. In addition, tumor size also emerged to be significant under partial-proportional odds model.

Conclusions

The analytical results under the present study reveal that in case of ordinal form of the outcome, appropriate ordinal regression may be a preferred choice. Present data suggest that, pain, sub mucous fibrosis, palpable neck node, oral site, degree of differentiation and tumor size are the most probable associated factors with extent of nodal involvement.

Lingual Lymph Node Metastasis in cT1-2N0 Tongue Squamous Cell Carcinoma: Is It an Indicator for Elective Neck Dissection

Objective: Accurate predictors for occult metastasis in cT1-2N0 tongue squamous cell carcinoma (SCC) remains scarce, the main goal in current study was to evaluate whether there is significant association between lingual lymph node (LLN) metastasis and occult lymph node metastasis as well as whether there is prognostic value of LLN metastasis in early stage tongue SCC.

Methods: Patients with surgically treated primary cT1-2N0 tongue SCC were prospectively enrolled from January 2010 to December 2018. LLNs were dissected independently for pathologic analysis. The main study endpoints were locoregional control survival (LRC) and disease-specific survival (DSS). The Chi-square test and multivariate regression analysis were used to assess the predictors for occult metastasis. The Kaplan-Meier approach and Cox model were used to analyze the potential prognostic factors.

Results: A total of 317 patients were enrolled for analysis. Eighty-eight patients had occult metastasis with a prevalence of 27.8%. LLNs presented in 89 patients, in which 43 patients had LLN metastasis. In the 43 patients with positive LLNs, 20 patients had occult metastasis, in 274 patients with negative LLNs or no LLNs, 68 patients had occult metastasis, the difference was significant (p = 0.012). Further multivariate regression analysis confirmed the independence of LLN metastasis in predicting the occult metastasis. In patients without LLNs, the 5-year LRC rate was 79%, in patients with negative LLNs, the 5-year LRC rate was 78%, in patients with positive LLNs, the 5-year LRC rate was 62%, the difference was significant (p = 0.024). In patients without LLNs, the 5-year DSS rate was 84%, in patients with negative LLNs, the 5-year DSS rate was 74%, in patients with positive LLNs, the 5-year DSS rate was 51%, the difference was significant (p < 0.001), further Cox model confirmed the independence of LLN metastasis in affecting the LRC and DSS.

Conclusions: LLN metastasis is significantly associated with occult neck lymph node metastasis, and decrease the LRC and DSS in early stage tongue SCC.

Significance of depth of invasion determined by MRI in cT1N0 tongue squamous cell carcinoma

Depth of invasion (DOI) can be calculated preoperatively by MRI, and whether MRI-determined DOI can predict prognosis as well as whether it can be used as an indicator of neck dissection in cT1N0 tongue squamous cell carcinoma (SCC) remains unknown. The main goal of the current study was to answer these unknowns. A total of 151 patients with surgically treated cT1N0 tongue SCC were retrospectively enrolled, and MRI-determined DOI was measured based on T1-weighted layers with a 3.0T scan. The Chi-square test was used to evaluate the association between clinical pathologic variables and neck lymph node metastasis, and the factors that were significant in the Chi-square test were then analyzed in a multivariate logistic regression analysis model to determine the independent predictors. The main study endpoints were locoregional control (LRC) and disease-specific survival (DSS), and the Kaplan-Meier method (log-rank test) was used to calculate the LRC and DSS rates. The factors that were significant in univariate analysis were then analyzed in the Cox model to determine the independent prognostic factors. A value of p < 0.05 was considered significant, and all statistical analyses were performed with SPSS 20.0. Occult neck lymph node metastasis was noted in 26 (17.2%) patients, and the ROC curve indicated that the optimal cutoff value of MRI-determined DOI was 7.5 mm for predicting neck lymph node metastasis, with a sensitivity of 86.9%. The factors of lymphovascular invasion, MRI-determined DOI, pathologic DOI, and pathologic tumor grade were significantly associated with the presence of neck lymph node metastasis in univariate analysis, and further logistic regression analysis confirmed the independence of lymphovascular invasion, MRI-determined DOI, and pathologic DOI in predicting neck lymph node metastasis. The 5-year LRC and DSS rates were 84% and 90%, respectively. Cox model analysis suggested the MRI-determined DOI was an independent prognostic factor for both LRC and DSS. Therefore, elective neck dissection is suggested if MRI-determined DOI is greater than 7.5 mm in cT1N0 tongue SCC, and MRI-determined DOI ≥ 7.5 mm indicates additional risk for disease recurrence and cancer-related death.

ERK Activation Modulates Cancer Stemness and Motility of a Novel Mouse Oral Squamous Cell Carcinoma Cell Line

We established the NHRI-HN1 cell line from a mouse tongue tumor induced by 4-nitroquinoline 1-oxide (4-NQO)/arecoline, with further selection for cell stemness via in vitro sphere culture, to evaluate potential immunotherapies for oral squamous cell carcinoma (OSCC) in East and Southeast Asia. In vivo and in vitro phenotypic characterization, including tumor growth, immune modulator administration, gene expression, morphology, migration, invasion, and sphere formation assays, were conducted. NHRI-HN1 cells are capable of generating orthotopic tumors in syngeneic mice. Interestingly, immune stimulation via CpG oligodeoxynucleotide (CpG-ODN) dramatically reduced the tumor growth in NHRI-HN1 cell-injected syngeneic mice. The pathways enriched in genes that were differentially expressed in NHRI-HN1 cells when compared to non-tumorigenic cells were similar to those that were identified when comparing human OSCC and non-tumorous tissues. NHRI-HN1 cells have characteristics of epithelial-mesenchymal transition (EMT), including enhanced migration and invasion. NHRI-HN1 cells showed aggressive cell growth and sphere formation. The blockage of extracellular signal-regulated kinase (ERK) activation suppressed cell migration and reduced stemness characteristics in NHRI-HN1 cells, similar to human OSCC cell lines. Our data suggest that NHRI-HN1 cells, showing tumorigenic characteristics of EMT, cancer stemness, and ERK activation, are sufficient in modeling human OSCC and also competent for use in investigating oral cancer immunotherapies.

Which Factors Affect the Long-Term Survival of Patients With Oral Squamous Cell Carcinoma With Distant Metastasis?

PURPOSE

The development of distant metastases (DMs) in patients with oral squamous cell carcinoma (OSCC) leads to dismal prospects for survival. The present study aimed to identify the risk factors for DM development and long-term survival.

PATIENTS AND METHODS

The present study was a retrospective cohort study of patients with OSCC at a single institution. The predictor variables were age, gender, lymph node classification, histologic grade, neck dissection, infiltrative growth pattern (INF), vascular/lymphatic invasion, perineural invasion (PI), extranodal extension, local recurrence, nodal metastasis, DMs, interval to the diagnosis of DMs, and surgery for DMs. The primary outcome variables were the 5-year overall survival (OS) and median survival time (MST), which were estimated using the Kaplan-Meier method. Cox hazard models were used to identify the risk factors for DM development.

RESULTS

The cohort included 526 patients; the data from 402 were available for analysis. Of these 402 patients, 37 developed DMs. On multivariate analysis, clinical N1 (cN1)-cN2 (hazard ratio [HR], 3.36), moderate/poor differentiation (HR, 2.51), INFc (HR, 3.27), vascular/lymphatic invasion (HR, 2.95), and PI (HR, 2.17) were independent predictors of DM development. The 5-year OS was 84.6% for the non-DM patients and 9.7% for the DM patients, with a MST of 16.9 months. In those with DMs with cN0, the 5-year OS was 18.2% and the MST was 37.2 months. For those with DMs with cN1-cN2, the 5-year OS was 4.7% and the MST was 12.9 months. In patients with an interval to the DM diagnosis of 10.0 months or longer, the 5-year OS was 20.0% and the MST was 38.6 months. In the patients with an interval to the DM diagnosis of less than 10.0 months, the MST was 11.7 months. The 5-year OS of the patients who had undergone pulmonary metastasectomy was 60.0% and the MST of the nonsurgery group was 16.0 months.

CONCLUSIONS

In the patients with DMs, stage cN0 and a late interval to DM diagnosis were associated with long-term survival. Pulmonary metastasectomy could be worth considering to improve survival.

Understanding approaches to measurement and impact of depth of invasion of oral cavity cancers: A survey of American Head and Neck Society Membership

OBJECTIVES

To investigate methods used by head and neck surgeons to pre-operatively measure depth of invasion (DOI) in light of the new staging for oral cavity squamous cell carcinoma (OCSCC).

MATERIALS AND METHODS

A survey was designed and sent to all American Head and Neck Society (AHNS) members via an email link. The last response was recorded on January 16, 2019.

RESULTS

We received 185 (13.3%) responses from 184 surgeons and 1 radiation oncologist. The majority of surgeons correctly identified DOI (78.9%) and indicated measuring DOI pre-operatively (86%). The most common methods for measuring DOI were manual palpation (32.5%) and full thickness biopsy (25.2%). In addition, most surgeons (84.7%) reported using a DOI threshold (in mm) as their primary criterion in their decision to pursue a neck dissection in the N0 neck. The most common reported threshold was 4 mm (37.4% of those that reported using DOI), however, the range varied from 2 to >10 mm. Two-thirds of surgeons considered DOI an important indicator for adjuvant therapy.

CONCLUSION

DOI is believed to be an important prognostic indicator guiding neck dissection and the need for adjuvant therapy. While most surgeons currently measure DOI pre-operatively, most use subjective methods. Future studies are needed to establish objective pre-operative DOI measurement techniques and to better inform the decision to perform prophylactic neck dissection, given the current majority practice of prophylactic neck dissection for DOI of 4 mm or greater.

The Role of E-Cadherin as a Prognostic Biomarker in Head and Neck Squamous Carcinoma: A Systematic Review and Meta-Analysis

PURPOSE

In this study, we systematically investigated and analyzed articles focusing on the prognostic value of E-cadherin (E-cad) in human head and neck squamous cell carcinoma (HNSCC).

METHODS

Searching through the different databases, the studies examining the associations between E-cad and HNSCC prognosis were identified. Outcomes such as disease-specific survival and overall survival were considered acceptable. Hazard ratio (HR) with 95% confidence interval (CI) was used to demonstrate prognostic value.

RESULTS

A total of 40 studies were systematically analyzed, and finally, 1939 subjects were included in our meta-analysis. Our findings showed that significant aberrant expression of E-cad was associated with poor survival. However, some studies showed increased expression of E-cad in metastatic lesions was associated with poor prognosis. Alteration in location of E-cad expression also showed significant association with cancer survival, i.e., increased cytoplasmic E-cad. We conducted a meta-analysis on the eligible articles using a random effect model because of moderate heterogeneity. Strong association between aberrant expression of E-cad and poor survival was demonstrated (pooled HR = 2.28; 95% CI 1.78-2.91).

CONCLUSIONS

Aberrant expression of E-cad may be a promising prognostic signature for HNSCC, especially when it is used with other prognostic markers.

Differentiation Between Benign and Metastatic Cervical Lymph Nodes Using Ultrasound

Purpose

The oral cavity is the most common site for squamous cell carcinoma, which has a distinct predilection for lymphatic spread before distant systemic metastasis. The cervical lymph node status is a very important consideration in the assessment of squamous cell carcinoma. Ultrasound is a noninvasive and inexpensive technique that can be used to differentiate between the benign and metastatic nodes. So the aim of this study was to evaluate reliability of ultrasound for such differentiation and to correlate them with histopathological finding.

Materials and Methods

A total of 200 lymph nodes from 38 patients histopathologically proven for oral squamous cell carcinoma who underwent surgical neck dissection were considered. The patients underwent ultrasound examination of cervical lymph nodes prior to surgical neck dissection. The lymph nodes were differentiated into benign and metastatic based on the assessment of size, shape, shortest diameter/longest diameter (S/L ratio), margin, and internal architecture, and also the internal echo structure of the lymph nodes and histopathological findings were analyzed.

Results

On correlation of ultrasonographic diagnosis with histopathological evaluation for metastatic lymph nodes, the overall accuracy of ultrasonographic analyses was 77.83%, and the sonographic criterion of irregular margin showed the highest predictability followed by the size. The correlation of internal echo structure with histopathological findings was highly variable.

Conclusion

The ultrasound parameters such as size, shape, margin, S/L ratio, and internal echo structure might assist in differentiation between benign and metastatic lymph nodes. Combining these findings should raise the accuracy, as each sonographic parameter has some limitation as a sole criterion.

Controversies in relation to neck management in N0 early oral tongue cancer

The standard local treatment for early-stage tongue cancer with no clinical lymph node metastases is partial glossectomy. The frequency of occult lymph node metastasis is ~20-30%. Thus, whether prophylactic neck dissection with glossectomy or glossectomy alone should be performed has been a controversial issue since the 1980s. Both treatments have advantages and disadvantages; however, especially in cases involving prophylactic neck dissection, surgical invasion and complications including the cosmetic disadvantage caused by neck skin incision, accessory nerve paralysis or facial nerve (mandibular marginal branch) paralysis, stiffness of the shoulder or neck and a feeling of neck tightness have been considered issues that could be solved by providing less-invasive treatment to the 70-80% of patients without occult lymph node metastasis. A more accurate preoperative diagnosis and strict follow-up are required to provide minimally invasive treatment while ensuring the therapeutic effect. It is also necessary to narrow down the target based on the risk-benefit balance. The depth of invasion should be considered in cases involving oral cavity malignancies. This was also taken into account in recent revisions of eighth edition of the TNM Classification of Malignant Tumors and it is an important factor for N0 neck management. This review article summarizes previous and recent reports on neck management, focusing on the risk-benefit and future perspectives of the diagnosis and treatment of early-stage oral tongue cancer. This effort is an attempt to establish treatment from the patient's point of view, with the patient's quality of life taken into account.

Tumor Budding and Worse Pattern of Invasion Can Predict Nodal Metastasis in Oral Cancers and Associated With Poor Survival in Early-Stage Tumors

The management and prognosis of oral squamous cell carcinoma (OSCC) depend on tumor stage and lymph node (LN) metastasis status. Early-stage (T1/T2 N0M0) OSCC comprises a heterogeneous group. We evaluated the role of histological parameters including worst pattern of invasion (WPOI) and tumor budding to determine the risk of LN metastasis in cases of OSCC and to determine the risk of recurrence and death in early-stage OSCC in north Indian patients. All cases of buccal mucosa and tongue SCC which underwent excision over 4 and half years were reviewed for histological parameters including histologic grade, WPOI, tumor budding, lymphovascular emboli (LVE), perineural invasion (PNI), depth of invasion (DOI), host lymphocyte response, and stromal response and compared to LN metastasis. Clinical follow-up of early-stage tumor was obtained and compared. A total of 126 cases of OSCC were included, of which 48 showed LN metastasis. Histological grade, WPOI, tumor budding (≥3/×40 field), LVE, and PNI were significantly associated with risk of LN metastasis. On multivariate analysis, WPOI and tumor budding were 2 most significant factors. Among the early-stage tumors with available follow up (n = 48), DOI, WPOI, tumor budding, and LVE were associated with a shorter overall survival, although it was not statistically significant. To conclude, WPOI and tumor budding are important risk factors for predicting LN metastasis in all stages of OSCC and associated with a poorer outcome in early-stage tumors. These are easy and reliable prognostic factors and should be included in the histopathological reporting guidelines.

New NSAID-Pt(IV) prodrugs to suppress metastasis and invasion of tumor cells and enhance anti-tumor effect in vitro and in vivo

The great interest in epithelial-to-mesenchymal transition (EMT) programme lies in its association with process of metastasis and invasion, which is a crucial cause of cancer-related death. Herein, we designed and reported three new NSAID-Pt(IV) prodrugs, taking Non-Steroid Anti-Inflammatory Drugs (NSAIDs) to disrupt EMT programme and assist genotoxic platinum-based drugs as a cytotoxicity booster, to offer a class of potential anticarcinogens with a multi-functional action mechanism. The NSAID-Pt(IV) prodrugs, especially Eto-Pt(IV), highly enhanced cellular uptake with amount up to 42-fold at 3 h compared with CDDP, and greatly increased DNA damage and cell apoptosis, showing much higher cytotoxicity than cisplatin in the tested cancer cells even in A549/cis cells. Among of them, Eto-Pt(IV) and Car-Pt(IV) exhibited more excellent activity than Sul-Pt(IV), arising from their reduction-labile and favorable lipophilicity. Most strikingly, Eto-Pt(IV) markedly inhibited metastasis and invasion of MCF-7 cells, owing to its COX-2 suppression that down-regulated active MMP-2, vimentin protein and up-regulated E-cadherin. In vivo, Eto-Pt(IV) displayed potent antitumor activity and no observable toxicity in BALB/c nude mice bearing MCF-7 tumors.