Prognostic significance of lymph node histology in patients with squamous cell carcinoma of the larynx, pharynx, or oral cavity

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

Background:

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

Aims and Objectives:

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

Methodology:

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

Results and Conclusion:

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

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

Background:

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

Aim:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Covalent linking of proteins and cytokines to suture: Enhancing the immune response of head and neck cancer patients

BACKGROUND

The immune system of advanced stage head and neck cancer patients is frequently suppressed. Poor immune function has been correlated with poor clinical outcome. Immunotherapeutic strategies have been previously attempted in an effort to enhance immune function and improve survival. Previous studies have shown surgical suture can be transformed into an immune stimulant capable of activating the T lymphocytes of cancer patients. The development of a process for covalently linking proteins and cytokines to suture could have enormous potential for the in vivo manipulation of the immune system.

HYPOTHESIS

We hypothesize proteins and cytokines can be covalently linked to surgical suture while preserving their functional properties.

STUDY DESIGN

Prospective study testing normal donor and head and neck squamous cell carcinoma (HNSCC) patient lymphocytes.

METHOD

Polyester suture was acid hydrolyzed followed by reacting with 1-ethyl-3(-3-dimethylamino propyl carbodiimide) (EDAC) to create a suture-EDAC intermediate. Next, selected proteins (horseradish peroxidase [HRP] or bovine serum albumin [BSA]) or cytokines (interleukin [IL]-2 or interferon [IFN]-gamma) were reacted with the suture-EDAC intermediate to test the covalent linkage of the selected protein or cytokine to suture. Functional activity of the linked proteins was measured spectrophotometrically. The linking of cytokines to suture was tested by stimulating normal donor peripheral blood lymphocytes (PBL) or HNSCC patients' lymphocytes. The functional activity was confirmed by proliferation, enzyme linked immunoadsorbent assay (ELISA), and phenotype expression of T cells. RESULTS The conditions for optimally linking a protein to polyester suture were defined using HRP as a model protein. HRP retained its enzymatic activity. The optimal conditions for linking IL-2 or IFN-gamma were defined. The covalently linked cytokines retained their immune enhancing properties for stimulating PBL and lymph node lymphocytes (LNL) from HNSCC patients to proliferate, generate a TH1 immunologic profile of cytokines (IL-2, IL-12, IFN-gamma), and stimulate T lymphocytes.

CONCLUSION

This is the first report to demonstrate that cytokines can be covalently linked to surgical sutures and retain their immune-stimulating properties. Proteins linked to suture also retained their enzymatic activity. The clinical implications of functionally active cytokines or proteins linked to surgical suture may be very significant in the future for manipulating the immune system in vivo or enhancing wound healing.

Lymph node histology in head and neck cancer: impact of immunotherapy with IRX-2

OBJECTIVE

To determine if lymph nodes (LN) of patients receiving IRX-2 immunotherapy reflect changes in histology.

SETTING

National Cancer Institute, Mexico City, Mexico.

PATIENTS

Thirty patients with advanced squamous cell carcinoma of the head and neck (H and N SCC) and 10 non-cancer controls.

INTERVENTION

A 21-day cycle of preoperative immunotherapy, including a single intravenous infusion of low-dose cyclophosphamide (300 mg/M(2)), 10 or 20 daily perilymphatic injections of a natural cytokine mixture (IRX-2) (approximately 200 U interleukin-2 equivalence by enzyme-linked immunosorbent assay), daily oral indomethacin, and daily oral zinc with multivitamins, followed by surgery (20 patients); surgery only (10 patients); LN biopsy controls (10).

OUTCOME MEASURES

Pretreatment biopsies were performed to confirm the diagnosis. Clinical responses were assessed at surgery, and the specimen and a sample of lymph node were analyzed with respect to changes in morphology and lymphoid and inflammatory infiltration (T and B lymphocytes, plasma cells, macrophages, granulocytes, and giant cells). The postsurgical characteristics were ascribed percentages based on a representative section and compared.

RESULTS

All 20 H and N SCC patients treated with IRX-2 showed the changes of immune regression of their tumors, previously characterized [Arch. Pathol. Lab. Med. 122 (1998) 447]. The 10 H and N SCC controls showed no such changes. Lymph node histology of the 10 H and N SCC controls showed, compared to non-cancer controls, reduced size, decreased T cell area and density and increased sinus histiocytosis. The lymph nodes of IRX-2-treated H and N SCC patients showed increased size (over both control groups), increased T cell area and density and decreased follicles and sinus histiocytosis. The T cell and/or B cell areas of LN of IRX-2-treated patients showed a high correlation with T and/or B cell infiltration into these tumors (p<0.001).

CONCLUSION

The lymph nodes of patients with H and N SCC are distinguished by T cell depletion and sinus histiocytosis (SH). Immunotherapy reverses these changes and induces nodal expansion and lymphoid infiltration into the tumor that correlates with LN changes. The correlation of nodal expansion with tumor lymphoid infiltration and regression implies an effective immunization to host tumor antigens occurring at the level of the regional lymph node. The reversal of sinus histiocytosis, by IRX-2 treatment, in association with nodal expansion suggests that tumor antigen processing via dendritic cells is defective in cancer-bearing patients and that it is corrected by the treatment.

Prognostic importance of lymphatic reaction pattern in laryngeal carcinoma

PURPOSE

Cervical lymph node status is a widely accepted important prognostic parameter in laryngeal carcinoma.

PATIENTS AND METHODS

In this study, we retrospectively reviewed neck specimens of 46 laryngeal carcinoma patients operated in our clinic. Presence of neck metastasis and pattern of reactivity in nonmetastatic nodes was correlated with recurrence and survival during a follow-up period of at least 2 years.

RESULTS

Fourteen of the patients had at least one metastatic node and survival was 64%; 32 of the patients had reactional nodes only and the survival was 81%. Pattern of lymph node reactivity was evaluated as stimulated in type I (lymphocyte predominance) and type II (germinal center predominance); as unstimulated in type III (histiocytosis and/or normal) and type IV (lymphocyte depletion). Thirty two neck [-] patients had reactional nodes--16 of them were classified as stimulated and 16 of them as unstimulated; the 2-year survivals were 94% and 68%, respectively. In the 14 patients with cervical metastasis (classified according to nonmetastatic reactional nodes) 9 were stimulated and 5 were unstimulated with 2-year survivals of 100% and 0%, respectively.

CONCLUSION

Stimulated lymphatic pattern reflects a better prognosis, especially in N+ neck laryngeal cancer patients.

Prognostic significance of lymph node reactivity in the control of pathologic negative node squamous cell carcinomas of the oral cavity

BACKGROUND

Identification of high-risk patients and defining prognostic factors may be useful in the treatment of head and neck cancer. The role of the lymph node reactivity is still obscure. The value of the node reactivity pattern as a predictor of tumor control in oral cavity cancer was analyzed.

METHODS

Retrospective analysis of patients with oral cavity squamous cell carcinoma (OCSCC), submitted to tumor resection and neck dissection, with pathologic negative lymph nodes (pN0). Dominant node reactivity pattern was defined as lymphocytic predominance (LP), germinal centers (GC), normal (NL), sinus hystiocytosis (SH), and lymphocytic depletion (LD). Clinical and pathological characteristics of patients free of disease (DF) were compared with those of patients with control failure (CF), which included local, regional, and distant recurrences.

RESULTS

Of the 26 patients with pN0 OCSCC, prevalence of SH was found in 10 cases, GC in 13, and LD, NL and PL in 1 case each. Comparing CF and DF groups, there was no significant statistical difference regarding: age, gender, performance status index, weight loss, smoking and drinking habits, complementary treatment, average follow-up, tumor grade or thickness, margins, or tumor inflammatory and desmoplastic reaction. Although there was a higher proportion of perineural invasion and larger tumors in the CF group, the difference was not statistically significant either. Germinal centers or LP were noted in only 27% of the CF group and in 73% of the DF group. Collectively, NL, SH, or LD patterns were observed in 73% of CF. This incidence was statistically different from 27% of the DF group (P <0.05).

CONCLUSIONS

Lymph node reactivity pattern seems to be a prognostic index in pN0 OCSCC patients. Prospective analysis is advised to confirm these results. Prophylactic neck dissection as a staging procedure could select high-risk patients even when no metastasis is found.

The desmoplastic lymph node reaction as a prognostic factor of cancer of the tongue and floor of the mouth

To determine the prognostic significance of desmoplasia in metastatic lymph nodes of squamous cell carcinoma of the oral tongue and floor of mouth, 37 cases of this disease were studied. Desmoplasia was present in 59.4% of the cases and associated extracapsular spread in 40.5%. The association of desmoplasia with large lymph node involvement occurred in 59.4%. These relationships were statistically significant (p = 0.002 and 0.0069). The results obtained suggest that desmoplasia is a bad prognosis associated factor.

Discriminant analysis in predicting survival of patients with cancer of the larynx or hypopharynx

In order to assess the feasibility of computer-assisted prognostication, step-wise discriminant analysis was applied to data retrospectively obtained from 243 patients who underwent surgery for cancer of the larynx. In all, 62 variables were studied in each patient. Ninety-four out of 243 patients had complete information on the 62 variables studied. With data from these 94 patients a linear discriminant function was obtained, with an overall accuracy of 87.2%. The rate of correct prediction was 84.6% for cancer recurrence, and 88.2% for survival without recurrence. Only 11 variables of the 62 used for analysis were necessary to obtain these results. This paper confirms the usefulness of multivariate analysis in clinical practice.

Lymph node response and its relationship to prognosis in carcinomas of the head and neck

The lymph nodes of 32 patients operated on for carcinomas of the larynx and pharynx, were evaluated for the pattern of lymph node response. Pattern 1 (predominantly lymphocytes) and pattern 2 (predominantly germinal centres) showed a fewer number of nodal metastases than pattern 3 (non-stimulated nodes). Well-differentiated carcinomas predominated in patterns 1 and 2, whereas moderately and poorly differentiated predominated in pattern 3. Patterns 1 and 2 predominated in clinical stages I-III, and pattern 3 in stage IV. The survival decreased progressively from pattern 1 to pattern 3.

Radical neck dissections for squamous carcinomas: pathological findings and their clinical implications with particular reference to transcapsular spread

Two hundred fifty radical neck dissections, undertaken for mucosal squamous carcinomas of the head and neck, were reviewed with reference to pathological findings and their clinical implications. No major differences in descriptive surgical pathology were established between irradiated and non-irradiated resections. In general, irradiated dissections had lower total node counts and somewhat fewer nodal metastases involving a smaller number of different nodal groups. The topography of nodal deposits was similar in irradiated and non-irradiated resections. Palpable keratin granulomas (without intact tumor) were almost confined to irradiated patients. Transcapsular spread of tumor from involved lymph nodes was common: it was demonstrated in 160/188 'positive' dissections (85%) and was subclassified as 'macroscopic' in 90 and 'microscopic' in 70. The incidence and extent of transcapsular spread was similar in irradiated and nonirradiated resections. It was more frequently observed in association with large nodal masses but it was also regularly found with small nodal deposits less than 3 cm in diameter. Statistical analyses showed strong associations (p less than 0.0005) between the presence and/or extent of transcapsular spread and subsequent recurrence in the operated neck and overall survival. The predictive value of other clinical and pathological features vis-a-vis local neck recurrence such as numbers of involved nodal groups was weaker. Macroscopic transcapsulr spread emerges as the major prognostic factor for recurrent disease in the neck (p less than 0.0001). Attention is drawn to the advantages of accurate descriptive categories ('macroscopic', 'microscopic') for this critical prognostic feature.

Immunohistological reaction patterns of cervical lymph nodes in patients with laryngeal carcinomas

An attempt was made to assess the immunological importance of regional lymph node histology in relation to the survival of 107 patients with carcinoma of the larynx, operated on from 1973 to 1982 at the ENT-Clinic in Marburg. A total of 2765 sections of lymph nodes removed during neck dissections were examined microscopically to evaluate the morphological patterns of response. Microscopically, four distinct patterns were defined. Patients whose lymph nodes demonstrated immunological responses according to patterns I and II in the form of either expanded inner cortices or increased numbers of germinal centers had a greater 5-year survival rate than those patients whose lymph nodes showed an unstimulated pattern. Eight patients whose lymph nodes showed a depleted pattern, IV, did not survive more than 3 years. Morphological assessment of immunological activity in lymph nodes draining malignant tumors seems to be of value in predicting survival. The evaluation of the reaction pattern and difficulties in methodology, however, set definite limitations to our study.

Impact of metastases on nodal immunoreactivity in head and neck cancer

It has been previously demonstrated by the authors that lymph nodes from patients with head and neck cancer are capable of regional immunoreactivity and that this immunoreactivity could be enhanced with certain nonspecific immunostimulants. However, it is unknown how metastases to the neck nodes would affect this immunoreactivity. The purpose of this study is to compare the immunoreactivity of matched node pairs (metastatic versus nonmetastatic) from head and neck cancer patients. The soft agar assay system was the methodology employed. The effect of nodal lymphocytes on tumor growth in soft agar was studied with and without nonspecific immunostimulation in both normal and metastatic nodes from the same location in the neck in 16 patients. The results demonstrate that lymph nodes from head and neck cancer patients are capable of an immune reaction to cancer, and that this immunoreactivity appears to be significantly increased in metastatic lymph nodes with and without the use of specific immunostimulants.

An assessment of neck node immunoreactivity in head and neck cancer

Current conventional forms of cancer treatment represent non-specific modalities that destroy not only cancerous but also non-cancerous tissue in an effort to totally eradicate the neoplasm. It was unknown in head and neck cancer whether a more specific form of treatment, as it relates to neck nodal disease, was advisable. The purpose of this investigation was to study the cervical node immunoreactivity in head and neck cancer patients as a means of determining their immunologic capabilities and thus provide information about the merits of specific vs. non-specific cancer treatment. The results demonstrated that lymphocytes arising from cervical nodes caused alterations in the tumor growth. There appeared to be no particular difference in immunoreactivity of lymphocytes arising from nodes located in different areas of the neck. The regional immune system of neck nodes in the head and neck cancer patient appears to be capable of mounting an immune response irrespective of the patient's tumor status. Usual measures of systemic immunocompetence failed to identify any patients with advanced stage disease and showed little correlation with the regional immunoreactivity. The regional nodal immunoreactivity also did not correlate with the size or the numbers of metastatic neck nodes. The results demonstrate that cervical neck nodes are capable of mounting an immune response to head and neck cancer and are not mere passive filters that are periodically involved with tumor emboli. These results support the need for the development of reliable treatments which are directed at tumor tissue only.

Immunology and oral cancer

This paper summarises the evidence for the involvement of the immune response in the development of neoplasia, discusses the immunological abnormalities found in patients with head and neck carcinoma, and outlines recent attempts at treatment of patients with head and neck carcinoma by modulation of the immune response (immunotherapy).

Prognostic indicators in induction cis-platinum bleomycin chemotherapy for advanced head and neck cancer

A complete response to induction cis-platinum bleomycin chemotherapy significantly increases the probability of local tumor control and overall disease-free survival. Factors that favor a good response to chemotherapy are tumor histology (well differentiated), location of the primary site (oral cavity and oropharynx), nodal status (N0) and size of the primary lesion (t3 better than T4). Increased cellular maturation after chemotherapy correlates with an improved clinical response. The importance of induction and maintenance chemotherapy in the treatment of advanced head and neck cancer still needs to be determined with larger randomized series. Reliable predictors of therapy outcome are needed for realistic treatment planning, especially when the potential morbidity is considered.

The irradiated radical neck dissection in squamous carcinoma: a clinico-pathological study

A preliminary clinico-pathological survey is presented of radical neck dissections from 50 patients with advanced (T3, T4) squamous carcinomas of the head and neck, previously treated by irradiation and combination chemotherapy. The total yield of lymph nodes (1411) from these dissections was high--mean of 28 nodes/dissection, range 8-60; the proportion of nodes containing metastatic carcinoma was low--100 (7%)--with only 1 or 2 nodal masses/dissection in most instances. The involved nodes tended to be concentrated in 1 or 2 anatomical groups, principally in the upper anterior neck, with apparent sparing of nodes in the posterior triangle. There was a high incidence (88%) of transcapsular spread. Keratin granulomas, with or without intact metastatic carcinoma, were commonly found; on occasions they formed large masses simulating nodal metastases. The morphological patterns in uninvolved lymph nodes were shown to be of no prognostic significance. Initial data on postoperative follow-up indicated a crude survival of 52% (24 patients) at 30 months. Most deaths (80%) occurred within 12 months of major surgery; the majority (72%) died with residual malignant disease; and uncontrolled primary tumour, particularly in the oral cavity and oropharynx, was found more frequently than metastatic disease in the neck or elsewhere. Clinical implications are discussed with reference to the use of modified radical neck dissection in the surgical salvage of this poor-risk group of previously irradiated patients.

Relationships between cervical node histological patterns and rosette test scores: possible prognostic value in laryngeal cancer

In previous research the authors have remarked that some hystological patterns--macrophagic hyperplasia and thymus-dependent areas hyperplasia--when prevailing in cervical nodes of laryngeal cancer patients, possess a positive prognostic value. In this study the possible relationship between the results of E and EAC-rosettes and prevailing hystologic patterns in cervical nodes is investigated. A positive correlation was not found. Conclusively, the inconsistency of aspecific tests for prognostic purposes and the need for a specific immunological monitoring system are outlined.

Immunobiology of head and neck cancer: basic concepts

Patients with squamous cancer of the head and neck have unique perturbations of the immune system. These patients have marked depression of cellular immunity even in the early stages of disease. The known facts about the immunobiology and the immunodeficiencies that commonly occur are discussed. Also reviewed are the relationships of the immunologic deficits to stage of disease, to prognosis, and to the suspected etiologic factors of smoking, alcoholism, and malnutrition. Highlights are given of current immunotherapeutic trials. To date, most of the successful efforts in both immunologic research and immunotherapy of head and neck cancer have dealt with general, rather than specific, immune reactions. Further development in the area of specific immune responses may permit more meaningful measurements of tumor-specific reactions, thus yielding useful tools for immunodiagnosis as well as providing more effective and precise methods of immunotherapy.

A retrospective study of 131 cases of carcinoma of the posterior pharyngeal wall

Between 1958 and 1973, 131 patients with carcinoma of the posterior pharyngeal wall were treated at the Institute Gustave-Roussy (127 men, 4 women, mean age 61 years). Nine had a tumor of the oropharynx, 37 of the hypopharynx and 85 of the oro-hypopharynx. Nine had T1 tumors, 19 T2 and 103 T3 (TNM-UICC 1975). 122 patients were treated by irradiation: 83% were T3 lesions, 81% were more than 4 cm in diameter, 80% were ulcerated and 42% were staged N3. The survival rate of these patients was very poor (3% at five years). The nine patients who had been treated by surgical excision had a better survival rate and three are alive at 5 years, but the initial prognostic factors were better in this group. It seems that the indications for surgery should be widened to increase the survival rate in these poor prognosis cancers.