Radiological imaging of the neck for initial decision-making in oral squamous cell carcinomas--a questionnaire survey in the Nordic countries

Incidence and survival in oral and pharyngeal cancers in Finland and Sweden through half century

Background

Cancers of the oral cavity and pharynx encompass a heterogeneous group of cancers for which known risk factors include smoking, alcohol consumption and human papilloma virus (HPV) infection but their influence is site-specific with HPV mainly influencing oropharyngeal cancer. Their incidence and survival rates are not well known over extended periods of time.

Patients/methods

Data were obtained for Finnish (FI) and Swedish (SE) patients from the Nordcan database recently updated through 2019. Age-adjusted incidence trends (FI from 1953, SE from 1960) and relative survival rates for years 1970 through 2019 were calculated.

Results

We observed a prominent increase in oral and oropharyngeal cancers in FI and SE men and women but the trend for oral cancer was interrupted for SE men in 1985 and possibly also for FI and SE women in 2015. The trend changes in male and female oral cancer was confirmed in data for Denmark and Norway. Relative survival for these cancers has improved overall but they differed for one cluster of oral, oropharyngeal and nasopharyngeal cancers with 60–70% 5-year survival in the last period and hypopharyngeal cancer with 25% male survival. In all these cancers, survival for old patients was unfavorable.

Discussion/conclusion

We hypothesize that reduction in smoking prevalence helped to stop the increase in oral cancer especially in men. As the prevalence of smoking is decreasing, HPV is becoming a dominant risk factor, particularly for the increasing oropharyngeal cancer. Prevention needs to emphasize sexual hygiene and HPV vaccination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09337-2.

The occult nodal metastasis rate of early tongue cancer (T1-T2): A protocol for a systematic review and meta-analysis

OBJECTIVES

In this study, a meta-analysis was conducted to evaluate the occult lymph node metastasis rate in patients with early-stage (T1-T2) oral tongue squamous cell carcinoma. Also, the correlation between occult lymph node metastasis rate and T2 ratio among T1-T2 or the reported year of each study was analyzed to adjust other confound variables.

STUDY DESIGN

Literature search.

METHODS

A systematic computerized search of the electronic databases was carried out for articles published between January 1, 1980, and December 31, 2018, which reported occult nodal metastasis rate in T1 and T2 (separately) tongue cancer patients. Statistical analysis was performed using Comprehensive Meta Analysis version 3.3.070. Publication bias was assessed by the Egger test and Begg funnel plot method. The correlation between occult nodal metastasis rate and T2 ratio or reported year, respectively, was assessed by meta-regression analysis.

RESULTS

From 19 studies, a total of 1567 cases were included in the meta-analysis. By random effects model, the mean occult cervical lymph node metastasis was 24.4% (95% confidence interval; 0.205-0.248). The meta-regression revealed that the T2 ratio and the reported year of the studies did not have a significant effect on the occult metastasis rate (correlation coefficient = 0.531 and 0.002, respectively, and P = .426 and 0.921, respectively).

CONCLUSION

The meta-analysis revealed that the early-stage oral tongue squamous cell carcinoma had a rate of 24.4% for occult nodal metastasis. The occult nodal metastasis rate was not significantly affected by neither T2 ratio among T1-T2 nor reported year of the studies.

A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study-Part 1 (Head and Neck Surgery)

Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer.

Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51–74%), moderate (75–84%), and high (≥85%).

Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively.

Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.

Watchful waiting of the neck in early stage oral cancer is unfavourable for patients with occult nodal disease

For cT1/2N0 oral squamous cell carcinoma (OSCC), treatment of the neck is a matter of debate. Two treatment strategies were evaluated in this study: selective neck dissection (SND) and watchful waiting (WW). One hundred and twenty-three SND patients and 70 WW patients with cT1/T2N0M0 OSCC of the tongue, floor of mouth, or buccal mucosa were analysed retrospectively. Extracapsular spread (ECS), 3-year overall survival (OS), and disease-specific survival (DSS) were determined. Twenty-nine percent of SND patients and 13% of WW patients had occult nodal disease. WW-N+ patients showed thicker tumours as compared to WW-N0 patients (5mm vs. 2mm, P=0.02). WW-N+ patients showed significantly more ECS as compared to SND-N+ patients (56% vs. 14%, P=0.016) and had a significantly worse 3-year DSS than SND-N+ patients (56% vs. 82%, P=0.02). For T1 OSCCs, a watchful waiting policy is acceptable if tumour thickness proves to be <4mm. Otherwise, an additional treatment of the neck is advised, since WW-N+ patients show more ECS, with a worse DSS than SND-N+ patients.

Poor Correlation of Histologic Parameters Between Biopsy and Resection Specimen in Early Stage Oral Squamous Cell Carcinoma

OBJECTIVES

Infiltration depth, perineural growth (PG), vascular invasive growth (VG), and infiltrative growth (IG) are associated with regional metastases in oral squamous cell carcinomas (OSCCs). Preoperative knowledge of these parameters could facilitate the treatment planning of the neck. The aim of this study was to evaluate if the biopsy specimen correlates with the resection specimen.

METHODS

In total, 149 patients with a pT1-2cN0 OSCC were included. Biopsy thickness and tumor thickness were analyzed. Occurrence of PG, VG, and IG was determined on biopsy and resection specimens and correlated with the N status and survival. Sensitivity, specificity, positive and negative predictive value, and diagnostic gain of the biopsy specimen were calculated.

RESULTS

N+ patients showed PG, VG, and IG significantly more often in the resection specimen compared with N- patients (P = .02, P = .001, and P = .001, respectively). Histologic parameters in the biopsy specimens did not correlate with N status or survival. The positive diagnostic gain for biopsy specimens with PG, VG, and IG was 57%, 40%, and 19%, respectively. The negative diagnostic gain was 2%, 0%, and 22%, respectively.

CONCLUSIONS

Histologic parameters in biopsy specimens do not represent the resection specimen. Determination of histologic parameters in routinely taken biopsy specimens of OSCC is not helpful in deciding whether to treat the neck.

Staging of cervical lymph nodes in oral squamous cell carcinoma: adding ultrasound in clinically lymph node negative patients may improve diagnostic work-up

INTRODUCTION

Clinical staging of patients with oral squamous cell carcinoma (OSCC) is crucial for the choice of treatment. Computed tomography (CT) and/or magnetic resonance imaging (MRI) are typically recommended and used for staging of the cervical lymph nodes (LNs). Although ultrasonography (US) is a non-expensive, accessible and non-ionising imaging modality this method is not consistently used. This study aimed to investigate if addition of US of patients classified as clinically LN negative (cN0) by CT and/or MRI, increases the detection of LN metastases. Also, we aimed to identify which of the sonographic characteristics: echogenicity, border, shape, appearance of hilum and nodal blood-flow pattern best detect metastases in this patient group.

METHOD

Fifty-one patients with OSCC classified as cN0 by CT/MRI were consecutively included and prospectively examined with US prior to sentinel node biopsy or selective neck dissection. Localisation, size and sonographic characteristics were registered for each LN and compared with the pathological findings. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for different size measurements and sonographic characteristics.

RESULTS

We found that short axial diameter was the best size criterion for detection of metastases. However, the sonographic characteristics were better predictors than size and the presence at least four of the sonographic characteristics: hypo-echoic or heterogeneous appearance; irregular border; spherical shape; absence of nodal hilum; and peripheral nodal blood-flow resulted in a sensitivity of 43.8; specificity 91.4; PPV 70.0; and NPV 78.0. The number of patients with occult metastases decreased from 16 out of 51 (31%) to nine out of 51 (18%). Three patients (6%) were over-staged by US.

CONCLUSION

The addition of US to the clinical work-up of patients with cN0 OSCC increases the detection of metastases, thus US potentially reduces the number of patients requiring a secondary neck surgery after sentinel node biopsy.

Waiting times for diagnosis and treatment of head and neck cancer in Denmark in 2010 compared to 1992 and 2002

BACKGROUND AND AIM

Significant tumour progression was observed during waiting time for treatment of head and neck cancer. To reduce waiting times, a Danish national policy of fast track accelerated clinical pathways was introduced in 2007. This study describes changes in waiting time and the potential influence of fast track by comparing waiting times in 2010 to 2002 and 1992.

METHODS

Charts of all new patients diagnosed with squamous cell carcinoma of the oral cavity, pharynx and larynx at the five Danish head and neck oncology centres from January to April 2010 (n=253) were reviewed and compared to similar data from 2002 (n=211) and 1992 (n=168).

RESULTS

The median time to diagnosis was 13 days (2010) versus 17 days (2002; p<0.001) and 20 days (1992; p<0.001). Median days from diagnosis to treatment start were 25 (2010) versus 47 (2002; p<0.001) and 31 (1992; p<0.001). Total pre-treatment time was median 41 days in 2010 versus 69 days (2002) (p<0.001) and 50 days (1992; p<0.001). Significantly more diagnostic imaging was done in 2010 compared to 2002 and 1992. When compared to current fast track standards the adherence to diagnosis improved slightly from 47% (1992) to 51% (2002) and 64% (2010); waiting time for radiotherapy was within standards for 7%, 1% and 22% of cases, respectively; waiting time for surgery was within standards for 17%, 22% and 48%, respectively.

CONCLUSION

The study showed a significant reduction in delay of diagnosis and treatment of head and neck cancer in 2010, but still less than half of all patients start treatment within the current standards.