The prevalence of lymph node metastases in clinically N0 necks with oral cavity squamous cell carcinoma: is CT good enough for nodal staging?

Risk of Pathologic Extranodal Extension and Other Adverse Features After Transoral Robotic Surgery in Patients With HPV-Positive Oropharynx Cancer

Importance

Understanding patient-specific risk of adverse histopathologic findings after primary surgery for human papillomavirus (HPV)-positive oropharynx squamous cell carcinoma (OPSCC) may help guide patient consultations.

Objective

To determine the likelihood of adverse histopathologic features that may indicate adjuvant radiotherapy or chemoradiotherapy after primary surgery for HPV-positive OPSCC according to 2021 National Comprehensive Cancer Network guidelines.

Design, Setting, and Participants

This retrospective cohort study was performed at a single academic tertiary care center. Of 258 patients who underwent transoral robotic surgery (TORS) from March 1, 2012, to March 1, 2021, 136 consecutive, treatment-naive patients with HPV-positive OPSCC without obvious clinical extranodal extension (ENE) who underwent definitive TORS and neck dissection were included in the analysis. Indications for surgical treatment included non-deeply infiltrative oropharynx tumors, minimal soft palate involvement, and low suspicion for pathologic ENE.

Exposures

Primary site TORS with neck dissection.

Main Outcomes and Measures

The primary outcomes were the adverse histopathologic features of pathologic ENE and positive surgical margins (PSM) that are indications for possible adjuvant chemoradiotherapy. Outcomes were compared among varying American Joint Committee on Cancer 7th edition (AJCC-7) T and N categories and patient clinical characteristics.

Results

Of the 136 patients included in the analysis (113 men [83.1%]; median age, 63 [interquartile range, 55-70] years), 109 (80.1%) had at least 1 indication for possible adjuvant radiotherapy. Twenty-seven patients (19.9%) had pathologic ENE and 10 (7.3%) had PSM. Thirty-four patients (25.0%) had pathologic ENE and/or PSM, whereas 3 (2.2%) had both. Age, smoking history, history of alcohol consumption, and clinical T category were not associated with pathologic ENE, PSM, lymphovascular invasion, perineural invasion, or pN2 category or greater. The proportion of pathologic ENE varied by clinical N category: 0 of 16 for cN0, 8 of 48 (16.7%) for cN1, 3 of 23 (13.0%) for cN2a, and 16 of 45 (35.6%) for cN2b. Compared with patients with cN1-cN2a disease, patients with cN2b disease had higher odds of pathologic ENE (odds ratio, 3.01; 95% CI, 1.14-8.10). Clinical and pathologic N category were concordant in 77 patients (56.6%), whereas 42 (30.9%) were upstaged and 17 (12.5%) were downstaged.

Conclusions and Relevance

In this cohort study, approximately one-quarter of carefully selected patients with HPV-positive OPSCC without obvious clinical ENE undergoing primary surgery had pathologic ENE and/or PSM. Patients with AJCC-7 cT0-cT2 cN0-cN2b disease, especially cN0-cN2a, without signs of clinical ENE may represent appropriate candidates for primary surgery when avoidance of adjuvant chemotherapy and/or reduction of adjuvant radiotherapy dose/extent are the goals.

Is the prediction of one or two ipsilateral positive lymph nodes by computerized tomography and ultrasound reliable enough to restrict therapeutic neck dissection in oral squamous cell carcinoma (OSCC) patients?

INTRODUCTION

Proper management of the clinically involved neck in OSCC patients continues to be a matter of debate. Our aim was to analyze the accuracy of computerized tomography (CT) and ultrasound (US) in anticipating the exact location of lymph node (LN) metastases of OSCC patients across the AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery) levels ipsi- and contralaterally. Furthermore, we wanted to assess the suitability of therapeutic selective neck dissection (SND) in patients with one or two ipsilateral positive nodes upon clinical staging (cN1/cN2a and cN2b(2/x) patients).

METHODS

We prospectively analyzed the LN status of patients with primary OSCC using CT and US from 2007 to 2013. LNs were individually assigned to a map containing the AAO-HNS levels; patients bearing a single or just two ipsilateral positive nodes (designated cN1/cN2a or cN2b(2/x) patients either by CT (CT group) or US alone (US group) or in a group combining findings of CT and US (CTUS group)) received an ipsi-ND (I-V) and a contra-ND (I-IV). 78% of the LNs were sent individually for routine histopathological examination; the remaining were dissected and analyzed per neck level.

RESULTS

Upon the analysis of 1.670 LNs of 57 patients, the exact location of pathology proven LN metastases in cN1 patients was more precisely predicted by US compared to CT with confirmed findings only in levels IA, IB und IIA. Clearly decreasing the number of missed lesions, the findings in the CTUS group nearly kept the spatial reliability of the US group. The same analysis for patients with exactly two supposed ipsilateral lesions (cN2b(2/x)) yielded confirmed metastases from levels I to V for both methods individually and in combination and, therefore, render SND insufficient for these cases.

CONCLUSION

Our findings stress the importance of conducting both, CT and US, in patients with primary OSCC. Only the combination of their findings warrants the application of therapeutic SND in patients with a single ipsilateral LN metastasis (cN1/cN2a patients) but not in patients with more than one lesion upon clinical staging (≥ cN2b).

Predicting Adverse Histopathology and Need for Postsurgical Adjuvant Therapy for Human Papilloma Virus-Associated Oropharynx Carcinoma

OBJECTIVE

For human papillomavirus-associated oropharynx carcinoma treated with definitive surgery, we aimed to find predictors of adverse histopathology indicating the possible need for adjuvant therapy.

STUDY DESIGN

Retrospective review.

SETTING

National Cancer Database.

METHODS

We analyzed 2347 eligible patients from 2010 to 2015. We evaluated (1) the ability of clinical nodal staging and extranodal extension designation per the AJCC, seventh edition (American Joint Committee on Cancer), to predict histopathology and (2) the likelihoods for adverse postsurgery histopathology by common clinical stages.

RESULTS

Clinical nodal staging predicted pathologic nodal staging 65% of the time, with 24% (569/2347) being upstaged and 11% (251/2347) being downstaged. In patients with cN+ disease, clinical extranodal extension distinction had the following accuracy for pathologic extranodal extension: positive predictive value, 81% (88/109); negative predictive value, 73.1% (505/691); sensitivity, 32.1% (88/274); and specificity, 96.0% (505/526). Patients with cT1-2, N0-N2c, without clinical extranodal extension had the following proportions of pN2+ without pathologic extranodal extension (indicating consideration for adjuvant radiation): cN0, 11%; cN1, 31%; cN2a, 67% (8% downstaged); cN2b, 66% (6% downstaged); and cN2c, 35% (17% downstaged). From this group, patients had the following proportions of pathologic extranodal extension (indicating consideration for adjuvant chemoradiation): cN0, 6%; cN1, 20%; cN2a, 27%; cN2b, 28%; and cN2c, 48%.

CONCLUSION

For human papillomavirus-associated oropharynx carcinoma, nodal clinical staging per the American Joint Committee on Cancer, seventh edition, predicts pathologic stage about two-thirds of the time, leading to up- and downstaging. Clinical extranodal extension assessment has low sensitivity and moderate predictive capability. With careful selection, definitive surgery can allow patients to often avoid adjuvant chemotherapy and sometimes avoid adjuvant radiation.

FDG-PET/CT and Pathology in Newly Diagnosed Head and Neck Cancer: ACRIN 6685 Trial, FDG-PET/CT cN0

OBJECTIVE

FDG-PET/CT (fluorodeoxyglucose-positron emission tomography/computed tomography) is effective to assess for occult neck nodal disease. We report risks and patterns of nodal disease based on primary site and nodal level from data on the dissected cN0 per the results from ACRIN 6685.

STUDY DESIGN

Prospective nonrandomized enrollment included participants with first-time head and neck squamous cell carcinoma and at least 1 cN0 neck side to be dissected.

SETTING

Twenty-four ACRIN-certified centers internationally (American College of Radiology Imaging Network).

METHODS

A total of 287 participants were enrolled. Preoperative FDG-PET/CT findings were centrally reviewed and compared with pathology. Incidence, relative risk, pattern of lymph node involvement, and impact upon neck dissection were reported.

RESULTS

An overall 983 nodal levels were dissected (n = 261 necks, n = 203 participants). The highest percentages of ipsilateral positive nodes by primary location and nodal level were oral cavity (level I, 17/110, 15.5%), pharynx (level II, 6/30, 20.0%), and larynx (level VI, 1/3, 33.3%).

CONCLUSION

Levels at greatest risk for nodal disease in cN0 in terms of ipsilateral neck dissection are level I (oral cavity), II (pharynx), and VI (larynx). These data should be considered when treating patients presenting with cN0. This is the first study to comprehensively report the incidence, location, and risk of metastases in cN0 in the FDG-PET/CT era.

Value of preoperative computed tomography in predicting the local staging of cancer of the tongue at primary surgery

Preoperative staging is essential for the planning of treatment of cancer. This study was designed to evaluate the accuracy of computed tomography (CT) in predicting the local stage of tongue cancer by comparing it with the gold standard of histopathology. A total of 233 patients with newly-diagnosed tongue cancer was retrospectively reviewed, and the size of the tumour and the status of the cervical lymph node were compared between CT images and histopathological results. Patients with stage II cancer were followed up to assess the influence of inaccurate preoperative staging on prognosis. The accuracy of local staging by CT was 47.6% (111/233), with 59.7% (139/233) for tumour stage, and 70.4% (164/233) for nodal stage. The greatest dimension of the tumour on the CT image was about 2mm less than that measured by histopathology. The estimated volume of tumour was a quarter smaller. The accuracy of predicting malignant lymph nodes by CT was 68.9% (n=161). Among patients with stage II disease, simultaneous neck dissection was less likely in the understaged group than in the accurately staged one. The reoperation rate was a little higher but not significantly so. We conclude that the accuracy of CT in predicting local staging for tongue cancer was only moderate, because it underestimated the size of the tumour and needed to improve the criteria for detecting malignant lymph nodes. Understaging on CT images may influence the prognosis of patients with early stage tongue cancer.

Reliability of MRI-Derived Depth of Invasion of Oral Tongue Cancer

RATIONALE AND OBJECTIVE

To evaluate the inter-rater reliability of the magnetic resonance imaging (MRI)-derived depth of invasion (DOI) and the agreement between MRI and pathological measurements of oral tongue cancer.

MATERIALS AND METHODS

The institutional review board approved this retrospective study. The study population consisted of 29 patients with clinical T2N0 oral tongue cancer treated by surgery. Routine pretreatment MRI was performed on a 3T superconducting imager. Two raters with 23 and 18 years of head-and-neck MRI experience, respectively, independently chosen MRI sequences for each patient, then delineate the tumor, and then used three protocols to measure the MRI-derived DOI: the axial reconstructed thickness (method 1), the axial invasive portion (method 2), and the coronal invasive portion (method 3). Then they consensually selected the optimal among the three methods for each patient; it was designated method 4. The Bland-Altman plots, intraclass correlation coefficients (ICCs), and the paired samples test were used. According to the median follow-up of 41 months, the relationship between the MRI-derived DOI and nodal recurrence was also investigated.

RESULTS

The inter-rater reliability of methods 2 and 4 was excellent (ICC of 0.829 and 0.807, respectively). The correlation between MRI and pathological measurements was good for method 4 (ICC of 0.611), however, all measurements recorded on MRI were 2-3 mm larger than on pathology. No patients whose MRI-derived DOI was less than 5 mm suffered nodal recurrence.

CONCLUSION

The MRI-derived DOI was valuable for the preoperative staging. The optimal measurement method should be selected on a case-by-case basis.

A decision analysis model for elective neck dissection in patients with cT1-2 cN0 oral squamous cell carcinoma

Neck metastasis from oral squamous cell carcinoma (OSCC) has a significant impact on disease-specific and overall survival. Physical examination and imaging exams are used to stage the neck, but preoperative neck staging cannot reliably differentiate between metastatic and non-metastatic nodes. The decision to perform elective neck dissection (END) should consider the probability of neck metastasis and the harm of unnecessary surgery. We evaluate if this model can be used to decide treatment and the net benefit with different strategies. We reviewed patients treated from January, 1985 to December, 2012. Inclusion criteria were histological diagnosis of OSCC, initial surgery and primary tumour in the oral cavity staged as cT1-2 cN0. Development of a predictive model for metastatic nodes used patients submitted to END. The probability of neck metastasis was calculated and decision curve analysis was performed. We considered two interventions: watchful waiting and END, and two outcomes, regional recurrence and disease-free survival. We developed the model using logistic regression after multiple inputs with neck metastasis as an outcome. The initial model included all demographic and pathological variables. This model has an area under the curve (AUC) of 0.8423, a positive predictive value (PPV) of 70.7% and a negative predictive value (NPV) of 80.2%. We used LASSO for coefficient reduction and variable selection. This model has an AUC of 0.8265 with PPV of 68.3% and NPV of 80.2%. For neck recurrence, the curves of “treat all by watchful waiting” and “treat none by watchful waiting” crossed at the prevalence of neck metastasis. When focusing on disease-free survival, the decision analysis curve shows a pattern where the predictive model provides a net benefit if used to choose treatment from a 20% until a 54% threshold.

Cell-Free Plasma DNA for Disease Stratification and Prognosis in Head and Neck Cancer

BACKGROUND

Clinicians face many challenges in disease stratification and outcome prediction in head and neck squamous cancer cell (HNSCC) patients. Given the limitations of currently used clinical scoring, repetitive biopsies, and imaging techniques, liquid biopsy approaches may provide valuable additional diagnostic and prognostic information.

METHODS

A noninterventional, single-center observational study was performed with clinical data and plasma samples from HNSCC patients. Cell-free tumor DNA-derived copy number aberrations (CNAs) were determined in 116 patients by low-coverage next-generation sequencing (NGS). Significant CNAs were combined in a genome-wide copy number instability score (CNI), which was evaluated with respect to conventional clinical staging and patient outcome.

RESULTS

Receiver-operating characteristic (ROC) curve analysis comparing the presurgery CNI in patients (n = 103) with that in tumor-free controls (n = 142) yielded an area under the ROC curve of 87.2% (95% CI, 79.4%-93.3%). At a specificity of 95%, the sensitivity to detect tumors varied between 46% (pT1) and 94% (pT4). A CNI above the median (i.e., >72) had a positive predictive value of 90% (95% CI, 79%-96%) for lymph node involvement (LNI), while the negative predictive value was 57% (95% CI, 43%-70%). For a CNI >72, overall survival (OS) was worse (hazard ratio, 4.89; 95% CI, 1.39-17.17; P = 0.01) with 62% and 90% survivors 3 years after surgery for a CNI >72 and ≤72, respectively. In multivariable models, the CNI was a superior predictor of OS compared to established disease features, including LNI.

CONCLUSIONS

The CNI may assist in predicting LNI and prognosis in HNSCC with direct therapeutic implications concerning the need for neck dissection or more aggressive treatment.

Tumour-derived plasma cell-free DNA in patients with head and neck cancer: A short review

Head and neck squamous cell carcinoma is one of the leading causes of cancer mortality worldwide. The prognosis for patients with head and neck squamous cell carcinoma has not substantially improved during the last decades, despite numerous advancements in treatment options. Reliable markers for early tumour detection and treatment response, which complement clinical examinations, imaging techniques, and biopsies would be extremely useful. One fairly new and promising method is the analysis of tumour-derived cell-free DNA (ctDNA) in the plasma of cancer patients. First data indicate that this method may assist, in the future, in the early detection of head and neck squamous cell carcinoma, the real-time monitoring of the disease course, the therapy response, and the prediction of prognosis with direct therapeutic implications by determining the best therapeutic modality for patient care.

CLINICAL AND MAGNETIC RESONANCE IMAGING FEATURES OF INFLAMMATORY VERSUS NEOPLASTIC MEDIAL RETROPHARYNGEAL LYMPH NODE MASS LESIONS IN DOGS AND CATS

Medial retropharyngeal lymph node (MRLN) mass lesions are a common cause of cranial cervical masses in dogs and cats, and are predominantly due to metastatic neoplasia, primary neoplasia, or inflammatory lymphadenitis. The purpose of this retrospective cross-sectional study was to test the hypothesis that clinical and magnetic resonance imaging (MRI) characteristics for dogs and cats with MRLN mass lesions would differ for inflammatory vs. neoplastic etiologies. Dogs and cats with MRLN mass lesions that had undergone MRI and had a confirmed cytological or histopathological diagnosis were recruited from medical record archives. Clinical findings were recorded by one observer and MRI characteristics were recorded by two other observers who were unaware of clinical findings. A total of 31 patients were sampled, with 15 in the inflammatory lymphadenitis group and 16 in the neoplasia group. Patients with inflammatory lymphadenitis were more likely to be younger and present with lethargy (P = 0.001), pyrexia (P = 0.000), and neck pain (P = 0.006). Patients with inflammatory lymphadenitis were also more likely to have a leukocystosis (P = 0.02) and segmental neutrophilia (P = 0.001). Inflammatory masses were more likely to have moderate or marked MRI perinodal contrast enhancement (P = 0.021) and local muscle contrast enhancement (P = 0.03) whereas the neoplastic masses were more likely to have greater MRI width (P = 0.002) and height (P = 0.009). In conclusion, findings indicated that some clinical and MRI characteristics differed for dogs and cats with inflammatory vs. neoplastic medial retropharyngeal lymph node masses. Although histopathological or cytological diagnosis remains necessary for confirmation, these findings may help with the ranking of differential diagnoses of future cases.

Influence of tumor volume on survival in patients with oral squamous cell carcinoma

PURPOSE

The TNM classification is used to assess cancers of the oral cavity, and advancements in imaging techniques have revealed clear variations in tumor volume at presentation. This study therefore aimed to clarify whether preoperative imaging, with exact measurements of the tumor, could affect post-surgery survival after controlling for demographic, clinical, and tumor characteristics.

METHODS

We included 437 patients with histologically confirmed, stage T1-4, N1-3, M0, invasive squamous cell carcinoma of the tongue. Participants were assessed for recurrence every 3 months for the first 2 years, every 6 months for another 2 years, and annually thereafter; routine computed tomography was performed annually. Associations were determined using the Kaplan-Meier estimator, univariate log-rank test, and Cox proportional hazards regression models.

RESULTS

The mean survival of all patients was 68.1 ± 48.2 months. The 2- and 5-year overall survival rates were 82.2 and 66.7 %, respectively. The mean primary tumor volume was 7.14 cm(3) with a range of 1.3-24.21 cm(3). The ROC curve and Youden Index analysis revealed that the optimal cutoff volume was between ≤5.9 and ≤18.3 cm(3) for three different volume groups (p < 0.0001). Large tumor volume was associated with a significantly poorer overall survival (p < 0.0001).

CONCLUSIONS

Tumor volume was significantly associated with the overall survival of patients. This has both prognostic and reconstructive implications that will affect health-related quality of life. In addition, this will inform surgical planning and the allocation of resources.