Is the Depth of Invasion a Marker for Elective Neck Dissection in Early Oral Squamous Cell Carcinoma?

Evaluating Depth of Invasion as a Continuous Prognostic Factor in Oral Squamous Cell Carcinoma

BACKGROUND

Depth of invasion (DOI) has a significant clinical impact on the staging system of oral squamous cell carcinoma (OSCC). We aimed to compare the prognostic impact of treating DOI as a continuous variable rather than a categorical one.

METHODS

A retrospective review of 277 OSCC patients surgically treated in a tertiary care center from 2000 to 2020, with a minimum 2-year follow-up. The analyses were performed using Cox and logistic regression.

RESULTS

DOI as a continuous variable significantly predicted mortality in both univariate (p < 0.001) and multivariate (p < 0.001) analyses. It was also a significant predictor of locoregional recurrence (multivariate p = 0.039) and occult lymph node metastasis (univariate p = 0.005, multivariate p = 0.04). Categorical analysis failed to demonstrate the same significance.

CONCLUSIONS

DOI as a continuous factor rather than a categorical one is significantly associated with mortality, locoregional recurrence, and occult lymph node metastasis. This innovative approach promotes personalized risk stratification and better decision-making.

Molecular Markers of Occult Lymph Node Metastasis in Head and Neck Squamous Cell Carcinoma (HNSCC) Patients

The accurate diagnosis of regional lymph node metastasis is critical for guiding treatment decisions in head and neck cancer patients. Despite advances in imaging techniques, detecting nodal metastasis using radiology remains challenging, leading to potential undertreatment or overtreatment. This review aims to identify molecular markers associated with occult metastasis in head and neck squamous cell carcinoma (HNSCC) patients. We divided the results by subsite for markers: lymph node analysis (microRNAs, myosin-5a (MYO5A), ring finger protein 145 (RNF145), F-box only protein 32 (FBXO32), CTONG2002744, cytokeratin 14 (CK14), eukaryotic initiation factor 4E (eIF4E), desmoglein-3 (DSG3), microsatellite D9S171, squamous cell carcinoma antigen, cytokeratin, tumor budding score, human papillomavirus-DNA (HPV-DNA), tumor infiltrating lymphocytes, sentinel lymph node analysis techniques, single fiber reflectance spectroscopy, radiological techniques), tumor tissue analysis (activin A, carcinoma-associated fibroblasts, cyclins, β-catenin, histopathology, genetic amplifications, DNA methylation, ecotropic viral integration site 1, CC-chemokine receptor 7, melanoma associated-A antigens, vascular endothelial growth factor-C (VEGF-C), panitumumab, epidermal growth factor receptor (EGFR), cornulin, total protein analysis, CD133, NANOG homeobox, neurogenic locus notch homolog protein 1 (NOTCH1), metastasis-associated protein 1, 14-3-3-zeta, E-cadherin, focal adhesion kinase, p-epithelial-mesenchymal transition (EMT), small proline rich protein 1B (SPRR1B), transcription factor NKX3-1, DNA copy number aberrations, microfibril-associated protein 5 (MFAP5), troponin C1, slow skeletal and cardiac type (TNNC1), matrix Gla protein (MGP), fibroblast growth factor binding protein 1 (FBFBP1), F-box protein 32 (FBXO32), fatty acid binding protein 5, B cell-specific Moloney murine leukemia virus integration site 1, podoplanin, p53, Bcl-2, epidermal growth factor receptor (EGFR), Ki67, cyclin D1, cox-2, semaphorin-3F, neuropilin-2, histologic features, cellular dissociation grade, prospero homeobox protein 1, radiologic features, Ki-67, poly (ADP-ribose) polymerase (PARP), Bcl-2 associated agonist of cell death (BAD), caspase-9, vascular endothelial growth factor A (VEGF-A), HPV, p16, methylation status of long interspersed element 1 (LINE-1) and Alu elements, mesenchymal-epithelial transition (MET), gene expression analyses, molecular subtypes) and blood markers (standard blood analysis indexes and ratios, circulating tumor cells, HPV-DNA, CD-31, bone marrow analysis). Several promising markers were identified, including miR-205, desmoglein 3 (DSG3), pan-cytokeratin (CK) AE1/AE3, HPV-16, activin-A, cyclin D1, E-cadherin, and neural progenitor lineage (NPL) that demonstrated effectiveness across multiple studies. Future research should focus on exploring combination scoring systems to improve diagnostic precision and optimize treatment selection in HNSCC patients.

Depth of Invasion Threshold for Recommending Elective Neck Dissection in T1 or T2 Oral Squamous Cell Carcinoma

BACKGROUND

There is variability in the literature on the role of the depth of invasion (DOI) for recommending an elective neck dissection (END).

PURPOSE

The purpose of the study is to estimate the DOI threshold for recommending an END.

STUDY DESIGN, SETTING, SAMPLE

A retrospective cohort study was performed at McGill University Health Centre from 2008 to 2018 with 5 years of follow-up. The sample was subjects with clinical T1/T2 oral squamous cell carcinoma and clinically negative neck. Subjects with previous head and neck cancer were excluded.

PREDICTOR VARIABLE

The primary predictor variable was DOI measured from the basement membrane of the adjacent normal mucosa on final pathology, coded as <4 mm or ≥4 mm. DOI is a continuous variable converted to a binary variable.

MAIN OUTCOME VARIABLE

The main outcome variable was time to development of neck disease (RD+) defined as the time from surgery to development of pathologic nodes. Time to RD+ for pathologic nodes discovered from the END was considered 0 months. The secondary outcome variable was overall survival.

COVARIATES

Demographics (age, sex, and smoking/alcohol history) and tumor characteristics (tumor location, clinical T, tumor differentiation, perineural invasion, and lymphovascular invasion) were analyzed.

ANALYSES

Time to RD+ and survival were analyzed using Cox hazard ratio, Kaplan-Meier curves, and log-rank test. Student's t-test and χ2 test were used for bivariate analyses; P ≤ .05 was statistically significant.

RESULTS

The final sample were 64 subjects (average age 65.25 [standard deviation 13.06] years and 36 [56.2%] males). Twenty-nine subjects had DOI < 4 mm, and the 5-year RD+ was 3.4% (the 1 occurrence of RD+ was at 5.3 months). Thirty-five subjects had DOI ≥ 4 mm, and the 5-year RD+ was 45.7% (15 subjects had RD+ discovered from the END, and 1 subject had RD+ at 7.6 months). DOI ≥ 4 mm had significantly higher risk of RD+ than DOI < 4 mm (hazard ratio 17.91; 95% confidence interval 2.37 to 135.3; P = .01), which remained significant after adjusting for clinical T, tumor differentiation, perineural invasion, and lymphovascular invasion (hazard ratio 9.53; 95% confidence interval 1.12 to 81.44; P < .05). The shallowest DOI with >20% risk of RD+ was in the DOI 4 mm to 4.9 mm group.

CONCLUSION AND RELEVANCE

Among patients with oral squamous cell carcinoma of T1 or T2 and clinically negative necks, END should be considered with DOI ≥ 4 mm.

Pathological Risk Factors for Occult Nodal Metastasis in Early-Stage Squamous Cell Carcinoma of the Oral Cavity

Occult neck metastasis is the presence of metastasis in the cervical lymph nodes that cannot be radiologically or clinically identified. Presence of metastasis in any neck node can have a significant impact on overall survival of patients with oral squamous cell carcinoma (OSCC). Our aim was to analyze the correlation of various histopathological parameters with occult nodal metastasis in early-stage OSCC and to obtain an optimal DOI cut-off value for predicting its increased risk. We conducted a retrospective study on patients who reported to our institute with clinical stage I and II OSCC. The patients having well-differentiated and moderately differentiated OSCC were included. Association of various histopathological parameters with occult nodal metastasis was assessed using statistical analysis. A total of 102 patients of early-stage well-differentiated and moderately differentiated OSCC with clinically negative necks who underwent elective neck dissection at our institute from the year 2018 to 2023 were enrolled in the study. Depth of invasion (DOI), perineural invasion (PNI), worst pattern of invasion (WPOI), and grade of tumor differentiation were the histopathological parameters entered into the univariate regression analysis as predictive variables, and they were found to be predictors of occult nodal metastasis. An optimal DOI cut-off value of 5.5 mm was obtained for predicting the increase in the risk of occult nodal metastasis. DOI, PNI, WPOI, and grade of tumor differentiation are predictors of occult nodal metastasis. There is a need for searching methods for preoperative and intraoperative detection of all these histopathological factors so that unnecessary elective neck treatment can be avoided.

Sentinel lymph node biopsy in early-stage oral squamous cell carcinoma: A retrospective single-center analysis

Sentinel lymph node biopsy (SLNB) is increasingly incorporated in European national guidelines for the management of the clinically node-negative neck (cN0) in early-stage oral squamous cell carcinoma (OSCC). In Germany, SLNB in OSCCs is not yet routinely performed. This study aimed to evaluate the clinical outcome of SLNB in a German cohort. Patients with primary early-stage OSCC who underwent tumor resection and SLNB were retrospectively analyzed. Clinical-pathological characteristics were documented. Primary endpoints were sensitivity and the negative predictive value (NPV). A total of 46 patients with a mean age of 62.3 (±14.5) years met the inclusion criteria. Most tumors were located in the tongue (63.0%). Bilateral drainage from a lateral tumor was observed in three cases (6.5%), and sentinel lymph node metastasis was detected in three patients (6.5%). Mean follow-up for all patients was 13.8 months (±9.6). One patient developed regional recurrence following a negative SLNB during the observation period, leading to an NPV of 0.98 and a sensitivity of 75.0%. The 2-year neck-specific relapse-free survival was 92.8%. SLNB in early-stage OSCC is a reliable diagnostic tool of the cN0 neck, ensuring a high NPV and RFS. SLNB can be advantageous in comparison to elective neck dissection due to the detection of contralateral lymph drainage.

Prognostic risk factors of buccal squamous cell carcinoma: A case-control study

OBJECTIVES

To describe the clinicopathologic presentation of buccal squamous cell carcinoma and identify risks factors for recurrence and overall survival.

METHODS

This is a retrospective case-control study of patients with oral cavity squamous cell carcinoma (OCSCC) treated at a single tertiary care center between 2010 and 2022. All patients with buccal subsite OCSCC treated during this time frame were included and paired with a randomly selected age and gender matched patient with non-buccal OCSCC. Relevant data was collected via chart review.

RESULTS

Seventy-seven patients with buccal SCC were matched with 77 non-buccal OCSCC controls. The median follow-up time was 27 months (IQR 14-61). Median age was 67 years (IQR 57-75) and 53% of the cohort was female. Twenty (26%) buccal SCC patients experienced a recurrence versus 19 (25%) in the controls. Age ≥65-years-old increased odds of all-cause mortality in the buccal SCC group, but not in the control group. Perineural invasion and positive margins increased odds of recurrence in the buccal group only. Overall survival and progression-free survival did not differ between the groups, despite a greater number of T2 buccal tumors and T1 non-buccal tumors.

CONCLUSIONS

Buccal SCC presents at a higher T stage than other oral cavity SCC subsite and may exhibit variance in the pathologic risk factors that predict poor outcomes versus non-buccal OCSCC. Despite these relatively minor differences, however, oncologic outcomes between these groups were similar.

Predicting lymph node recurrence in cT1-2N0 tongue squamous cell carcinoma: collaboration between artificial intelligence and pathologists

Researchers have attempted to identify the factors involved in lymph node recurrence in cT1-2N0 tongue squamous cell carcinoma (SCC). However, studies combining histopathological and clinicopathological information in prediction models are limited. We aimed to develop a highly accurate lymph node recurrence prediction model for clinical stage T1-2, N0 (cT1-2N0) tongue SCC by integrating histopathological artificial intelligence (AI) with clinicopathological information. A dataset from 148 patients with cT1-2N0 tongue SCC was divided into training and test sets. The prediction models were constructed using AI-extracted information from whole slide images (WSIs), human-assessed clinicopathological information, and both combined. Weakly supervised learning and machine learning algorithms were used for WSIs and clinicopathological information, respectively. The combination model utilised both algorithms. Highly predictive patches from the model were analysed for histopathological features. In the test set, the areas under the receiver operating characteristic (ROC) curve for the model using WSI, clinicopathological information, and both combined were 0.826, 0.835, and 0.991, respectively. The highest area under the ROC curve was achieved with the model combining WSI and clinicopathological factors. Histopathological feature analysis showed that highly predicted patches extracted from recurrence cases exhibited significantly more tumour cells, inflammatory cells, and muscle content compared with non-recurrence cases. Moreover, patches with mixed inflammatory cells, tumour cells, and muscle were significantly more prevalent in recurrence versus non-recurrence cases. The model integrating AI-extracted histopathological and human-assessed clinicopathological information demonstrated high accuracy in predicting lymph node recurrence in patients with cT1-2N0 tongue SCC.

Prediction of nodal disease in oral squamous cell carcinoma of the tongue: histopathological risk assessment with the focus on depth of invasion

OBJECTIVE

Cervical lymph node metastasis (CLNM) is one of the most relevant influencing factors for the oncological outcome of patients with oral squamous cell carcinoma (OSCC). Several studies showed that the tumors depth of invasion (DOI) influences the risk for CLNM, however varying across the oral subsites. The aim of this study is to investigate the role of DOI and other risk factors in OSCC of the tongue in relation to the occurrence of occult CLNM.

MATERIALS AND METHODS

In this retrospective study, n = 139 patients with primary OSCC of the tongue, treated by complete surgical resection (R0) with curative intention between 2013 and 2021, were included. For data analysis, epidemiologic data as well as preoperative tumor staging, surgical therapy including neck management, histopathological tumor data and follow-up were considered. Uni- and multivariate logistic regression were used to determine association between histopathological risk factors and the occurrence of occult CLNM.

RESULTS

The rate of occult cervical metastasis was 19.4%. T-staging, cervical nodal disease (pN+) and lymphatic invasion were significantly associated with reduced OS and RFS. While DOI had no relevant influence on the OS and RFS (p = 0.88 and p = 0.91 respectively), there was significant correlation between DOI and the occurrence of occult CLNM (OR: 1.17, 95%CI: 1.05-1.30; p < 0.01). The optimal cutoff in predicting occult CLNM was 6 mm (Sensitivity: 84.2%, Specificity: 73.5%, AUC: 0.75).

CONCLUSIONS

The DOI is a helpful risk parameter to predict the occurrence of occult nodal disease in OSCC of the tongue. Given the critical decision cutoff between 2 and 4 mm DOI for performing elective neck dissection in the current guidelines, our data suggests that in these cases, surgical de-escalation could be feasible with close follow-up.

CLINICAL RELEVANCE

This study highlights the relevance of DOI as a risk parameter in the prediction of CLNM with the aim to specify the individual patient risk and to deescalate surgical therapy in order to decrease comorbidities while improving the oncological prognosis.

Prognostic Analysis Combining Histopathological Features and Clinical Information to Predict Colorectal Cancer Survival from Whole-Slide Images

BACKGROUND

Colorectal cancer (CRC) is a malignant tumor within the digestive tract with both a high incidence rate and mortality. Early detection and intervention could improve patient clinical outcomes and survival.

METHODS

This study computationally investigates a set of prognostic tissue and cell features from diagnostic tissue slides. With the combination of clinical prognostic variables, the pathological image features could predict the prognosis in CRC patients. Our CRC prognosis prediction pipeline sequentially consisted of three modules: (1) A MultiTissue Net to delineate outlines of different tissue types within the WSI of CRC for further ROI selection by pathologists. (2) Development of three-level quantitative image metrics related to tissue compositions, cell shape, and hidden features from a deep network. (3) Fusion of multi-level features to build a prognostic CRC model for predicting survival for CRC.

RESULTS

Experimental results suggest that each group of features has a particular relationship with the prognosis of patients in the independent test set. In the fusion features combination experiment, the accuracy rate of predicting patients' prognosis and survival status is 81.52%, and the AUC value is 0.77.

CONCLUSION

This paper constructs a model that can predict the postoperative survival of patients by using image features and clinical information. Some features were found to be associated with the prognosis and survival of patients.

Impact of histopathological parameters in prognosis of oral squamous cell carcinoma

OBJECTIVE

Squamous cell carcinomas comprise approximately 90% of all oral malignancies. There is a wide geographical variation in the incidence of oral cancer, with South and South East Asia (SSEA) accounting for almost two third of new cases. The prognosis of oral cancer is influenced by a vast array of factors including demographic, clinical, histopathological and molecular factors. The objective this review is to analyse the impact of histopathological features assessed in hematoxylin and eosin stained sections on the prognosis of OSCC.

MATERIALS AND METHODS

Medline and Scopus data base search was performed in order to identify related articles on histopathological parameters in predicting prognosis of oral squamous cell carcinoma. The primary emphasis is on the studies conducted in SSEA, with an accompanying comparison of their findings with those from research conducted in other parts of the world.

RESULTS

It has been shown that the number of studies conducted in SSEA is not proportionate to the high prevalence of Oral Cancer in the region. There is no significant difference between the findings from SSEA compared to the rest of the world. It is clearly shown that most histopathological parameters can be accurately used to predict nodal metastasis and prognosis.

CONCLUSIONS

Histopathological parameters can be used reliably in planning treatment of Oral cancer. Clinicians should combine clinical and histopathological parameters in drawing treatment plan for Oral Cancer.

The Depth of Invasion and Level IV Cervical Node Metastasis in Patients with Clinically N0 Tongue Cancer

BACKGROUND

The accurate indication for level IV dissection is crucial for preventing complications such as phrenic nerve damage and chylous fistulas in clinically N0 tongue cancer. Although the depth of invasion is an established independent risk factor for occult lymph node metastasis in tongue cancer, its relationship with level IV metastasis has not been evaluated. This study investigated the relationship between the depth of invasion and level IV nodal metastasis in clinically N0 tongue cancer.

METHODS

We retrospectively investigated clinical N0 patients who underwent glossectomy and level I-IV neck dissection. We examined lymph node metastasis, risk factors, and the relationship between depth of invasion and metastasis.

RESULTS

Our study included 58 patients, and no patient had isolated level IV metastasis. Additionally, there was no level IV metastasis in well-differentiated tumors. Tumor size, depth of invasion, differentiation, and perineural invasion were significantly associated with level IV neck metastasis. We found a critical tumor size of 2.5 cm and depth of invasion of 8 mm for level IV neck metastasis.

CONCLUSION

Based on our findings, we recommend that level IV dissection should be considered for poorly differentiated tumors, tumors greater than 2.5 cm in size, and those deeper than 8 mm. This study highlights the importance of depth of invasion as a prognostic factor for predicting level IV metastasis and suggests that our findings can be used to prevent unnecessary level IV dissections that may lead to complications in tongue cancer surgery.

Management of clinically node-negative early-stage oral cancer: network meta-analysis of randomized clinical trials

The best treatments for the clinically node-negative (cN0) neck in early-stage oral squamous cell carcinoma (OSCC) patients are a subject of ongoing debate and there is no consensus. A network meta-analysis (NMA) of randomized clinical trials (RCTs) was conducted to determine the most effective treatment and to rank treatments based on their effectiveness. A systematic search was performed in accordance with the PRISMA guidelines to retrieve RCTs that compared therapeutic neck dissection (TND), sentinel lymph node biopsy (SLNB), and elective neck dissection (END). The outcomes analysed were overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and nodal recurrence. Hazard ratios and risk ratios were calculated by direct meta-analysis and NMA. Ten RCTs with a total of 1858 patients were eligible for inclusion. Direct meta-analysis showed END to be superior to TND and comparable to SLNB. The NMA revealed no statistically significant difference between END and SLNB (very low quality evidence) regarding OS, DSS, DFS, and nodal recurrence. However, END was found to significantly improve OS and DFS, and reduce nodal recurrence when compared to TND (moderate quality evidence). END ranked as probably the top treatment option for maximizing OS and DSS, and reducing nodal recurrence in early-stage OSCC, followed by SLNB and TND. There was very low quality evidence supporting SLNB as non-inferior to END for patients with early-stage OSCC. This NMA yielded favourable results for the use of END (with moderate quality evidence) in early-stage OSCC patients, although excellent results have also been obtained with SLNB. However, data in the literature for SLNB are scarce, as this technique has not yet been formalized in many countries. There is a need to further explore SLNB for early-stage OSCC patients, as well as its value in detecting occult lymph node metastases on the contralateral side. More studies comparing morbidity, quality of life, and costs between the different management strategies for the clinically negative neck in early-stage OSCC patients are needed.

Dosimetric comparison of postoperative interstitial high-dose-rate brachytherapy and modern external beam radiotherapy modalities in tongue and floor of the mouth tumours in terms of doses to critical organs

BACKGROUND

The aim of the study was to dosimetrically compare interstitial high-dose-rate (HDR) brachytherapy (BT) and modern external beam radiotherapy modalities, as volumetric modulated arc therapy (VMAT) and stereotactic radiotherapy with Cyberknife (CK) of tumours of the tongue and floor of the mouth in terms of dose to the critical organs.

PATIENTS AND METHODS

In National Institute of Oncology, Budapest, between March 2013 and August 2022 twenty patients (11 male/9 female) with stage T1-3N0M0 tongue (n = 14) and floor of mouth (n = 6) tumours received postoperative radiotherapy because of close/positive surgical margin and/or lymphovascular and/or perineural invasion. High-dose-rate interstitial brachytherapy applying flexible plastic catheters with a total dose of 15 × 3 Gy was used for treatment. In addition to BT plans VMAT and stereotactic CK plans were also made in all cases, using the same fractionation scheme and dose prescription. As for the organs at risk, the doses to the mandible, the ipsilateral and the contralateral salivary glands were compared.

RESULTS

The mean volume of the planning target volume (PTV) was 12.5 cm3, 26.5 cm3 and 17.5 cm3 in BT, VMAT and CK techniques, respectively, due to different safety margin protocols. The dose to the mandible was the most favourable with BT, as for the salivary glands (parotid and submandibular) the CK technique resulted in the lowest dose. The highest dose to the critical organs was observed with the VMAT technique. The mean values of D2cm3 and D0.1cm3 for the critical organs were as follows for BT, VMAT and CK plans: 47.4% and 73.9%, 92.2% and 101.8%, 68.4% and 92.3% for the mandible, 4.8% and 6.7%, 7.3% and 13.8%, 2.3% and 5.1% for the ipsilateral parotid gland, 3.5% and 4.9%, 6.8% and 10.9%, 1.5% and 3.3% for the contralateral parotid gland, 7.3% and 9.4%, 9.0% and 14.3%, 3.6% and 5.6% for the contralateral submandibular gland.

CONCLUSIONS

The present results confirm that BT, despite being an invasive technique, is dosimetrically clearly beneficial in the treatment of oral cavity tumours and is a modality worth considering when applying radiotherapy, not only as definitive treatment, but also postoperatively. The use of the CK in the head and neck region requires further investigation.

WPOI-5: Accurately Identified at Intraoperative Consultation and Predictive of Occult Cervical Metastases

BACKGROUND

Frozen section analysis of oral cancer specimens is ideal for assessing margin distances and depth of invasion (DOI); the latter impacts intraoperative decisions regarding elective neck dissection (END). Here, we show that intraoperative determination of worst pattern of invasion (WPOI), specifically WPOI-5, has a high level of accuracy. This relates to our demonstration herein that WPOI-5 predicts occult cervical metastases (OCM) for pT1 oral squamous carcinoma (OSC).

METHODS

The presence of OCM was correlated with WPOI in 228 patients with primary T1/T2/cN0 OSC undergoing resection and END. Concordance between intraoperative and final pathology WPOI determination was assessed on 51 cases of OSC.

RESULTS

WPOI-5 predicts OCM in pT1 patients, compared with WPOI-4/WPOI-3 (p < 0.0001). Most pT1 WPOI-5 tumors had DOI of 4-5 mm (24/59 or 40.7%). Only two pT1 WPOI-5 tumors had DOI < 4 mm (3.0 and 3.5 mm). If END were performed in this pT1 cohort for all WPOI-5 OSC patients regardless of DOI, OR all OSC patients with DOI ≥ 4 mm regardless of WPOI, then no OCM would be missed (p = 0.017, 100% sensitivity, 29% specificity, 77% positive predictive value, 23% negative predictive value). With respect to intraoperative WPOI-5 determination, the accuracy, sensitivity, and specificity was 92.16, 73.33, and 100.0%, respectively.

CONCLUSIONS

DOI ≥ 4 mm is the dominant predictor of OCM. For the rare WPOI-5 OSC with DOI < 4 mm, it is reasonable to suggest that surgeons perform END. WPOI-5 may be accurately determined intraoperatively. As microscopic instruction is needed to accurately assess WPOI-5, a teaching link is included in this manuscript.

A preoperative nomogram model for the prediction of lymph node metastasis in buccal mucosa cancer

OBJECTIVES

We sought to construct a nomogram model predicting lymph node metastasis (LNM) in patients with squamous cell carcinoma of the buccal mucosa based on preoperative clinical characteristics.

METHODS

Patients who underwent radical resection of a primary tumor in the buccal mucosa with neck dissection were enrolled. Clinical characteristics independently associated with LNM in multivariate analyses were adopted to build the model. Patients at low risk of LNM were defined by a predicted probability of LNM of less than 5%.

RESULTS

Patients who underwent surgery in an earlier period (January 2015-November 2019) were defined as the model development cohort (n = 325), and those who underwent surgery later (November 2019-March 2021) were defined as the validation cohort (n = 140). Age, tumor differentiation, tumor thickness, and clinical N stage assessed by computed tomography/magnetic resonance imaging (cN) were independent predictors of LNM. The nomogram model based on these four predictors showed good discrimination accuracy in both the model development and validation cohorts, with areas under the receiver-operating characteristic curve (AUC) of 0.814 and 0.828, respectively. LNM prediction by the nomogram model was superior to cN in AUC comparisons (0.815 vs. 0.753) and decision curve analysis of the whole cohort. Seventy-one patients were defined as having a low risk of LNM, among whom the actual metastasis rate was only 1.4%.

CONCLUSIONS

A robust nomogram model for preoperative LNM prediction is built.

Human papillomavirus in oral squamous cell carcinoma using p16 and its co-relationship with cervical lymph node metastasis and clinicopathological parameters

Background

Due to the increasing prevalence of oral squamous cell carcinoma (OSCC) in Iran and especially in young people, this study aimed to identify human papillomavirus (HPV) using p16 in OSCC.

Materials and Methods

In this descriptive-analytical cross-sectional study, 40 samples from the archives of the Pathology Department of Kashani Hospital were selected by a definitive diagnosis of OSCC with neck dissection. Demographic information including age, gender, location, and size of the lesion was obtained. Samples were divided into two groups based on lymph node (LN) metastasis. Immunohistochemical staining was performed for p16. Data were entered into SPSS 24 software and statistically analyzed by t-test, ANOVA, and Spearman nonparametric test. P <0.05 was statistically significant.

Results

The mean age of patients was 59.7 ± 17.11 which in terms of age and gender there was no significant difference between the two groups including with and without cervical LN metastasis (P > 0.05). There was no significant difference between the two groups based on the grade of tumor, perninural invasion, tumor size and location (P > 0.05). The only significant difference between the two groups was based on lymphovascular invasion and disease stage (P < 0.05). The p16 expression also showed a significant difference between the two groups (P < 0.05).

Conclusion

In OSCCs without cervical LN metastasis, a significant increase in p16 expression was observed compared to samples with cervical LNs metastasis. The presence of HPV was higher in samples with less LNs metastasis and possibly a better prognosis.

Human papillomavirus in oral squamous cell carcinoma using p16 and its co-relationship with cervical lymph node metastasis and clinicopathological parameters

Background:

Due to the increasing prevalence of oral squamous cell carcinoma (OSCC) in Iran and especially in young people, this study aimed to identify human papillomavirus (HPV) using p16 in OSCC.

Materials and Methods:

In this descriptive-analytical cross-sectional study, 40 samples from the archives of the Pathology Department of Kashani Hospital were selected by a definitive diagnosis of OSCC with neck dissection. Demographic information including age, gender, location, and size of the lesion was obtained. Samples were divided into two groups based on lymph node (LN) metastasis. Immunohistochemical staining was performed for p16. Data were entered into SPSS 24 software and statistically analyzed by t-test, ANOVA, and Spearman nonparametric test. P <0.05 was statistically significant.

Results:

The mean age of patients was 59.7 ± 17.11 which in terms of age and gender there was no significant difference between the two groups including with and without cervical LN metastasis (P > 0.05). There was no significant difference between the two groups based on the grade of tumor, perninural invasion, tumor size and location (P > 0.05). The only significant difference between the two groups was based on lymphovascular invasion and disease stage (P < 0.05). The p16 expression also showed a significant difference between the two groups (P < 0.05).

Conclusion:

In OSCCs without cervical LN metastasis, a significant increase in p16 expression was observed compared to samples with cervical LNs metastasis. The presence of HPV was higher in samples with less LNs metastasis and possibly a better prognosis.

Impact of depth of invasion on local recurrence in R0 resected node-negative oral tongue squamous cell carcinoma

BACKGROUND

This study evaluates the impact of depth of invasion (DOI) on local recurrence (LR) in node-negative oral tongue squamous cell carcinoma (SCC).

METHODS

Fifty-one patients were retrospectively reviewed from an institutional database. Patients were evaluated for local control (LC). Cox-proportional hazards modeling was used to calculate hazard ratios.

RESULTS

There were 84.3% T1/2 and 15.7% T3/4 classification tumors. The 3-year overall survival rate was 97.9%. Local failure rate was 5.7% with a 3-year LC of 93.6%. On Univariate analysis, increased hazard of LR was noted with each unit increase in DOI (HR 1.40, 95% CI 1.07-1.83, p = 0.014). Age, sex, T classification, margins ≥5 mm, lymphovascular invasion (LVI) and perineural invasion (PNI), and adjuvant treatment were not associated with LR. On Multivariate analysis, adjusting for age and adjuvant treatment, results for DOI remained significant (aHR 1.46, 95% CI 1.08-1.98, p = 0.013).

CONCLUSION

On evaluation of our institutional dataset increasing DOI was associated with increased hazard of local recurrence with oral tongue SCC.

Small tongue squamous cell carcinoma with neck metastasis at diagnosis: operative insights and surgical technique

BACKGROUND

The treatment of tongue tumors includes different surgical procedures ranging from a simple mucosal resection to complex combined resection depending on the tumor stage and size. In 2019 we reported an international glossectomy classification with the purpose of standardizing all the different types of surgical procedures adopted for tongue cancer.

METHODS

The present communication aims at providing further insight into the glossectomy classification. More specifically, it is intended to better specify the indications to glossectomy type IIIA and B in selected tongue cancers, with positive cervical lymph nodes at the diagnosis.

RESULTS AND CONCLUSIONS

Type IIIA glossectomy permits a high function sparing surgery in selected cases, with better postoperative functional outcomes. From an oncological perspective, it permits a radical surgery, avoiding postoperative radiation in the absence of extracapsular spread, multiple nodal metastases or T-N tract involvement.

Correlation between radiologic depth of invasion and pathologic depth of invasion in oral cavity squamous cell carcinoma: A systematic review and meta-analysis

OBJECTIVES

To comprehensively assess the correlation between radiologic depth of invasion (rDOI) and pathologic depth of invasion (pDOI) in oral cavity squamous cell carcinoma (OSCC) by meta-analysis.

MATERIALS AND METHODS

PubMed and Embase databases were searched to find pertinent articles reporting rDOI of OSCC. Studies evaluating the correlations and mean differences (MDs) between rDOI and pDOI were included. The rDOI was measured based on ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI). The correlation coefficients and MDs between rDOI and pDOI were meta-analytically pooled. Between-study heterogeneity was assessed using Higgins' inconsistency index (I²). Subgroup analysis was performed based on imaging modality.

RESULTS

Twenty-three studies with 1787 patients were included. The pooled correlation coefficient and MD were 0.86 (95 % confidence interval [CI], 0.82-0.90; I² = 66.9 %) and 1.84 mm (95 % CI, 1.02-2.65 mm; I² = 88.2 %), respectively. In subgroup analysis, MRI showed the largest MD (n = 12, 2.61 mm), followed by US (n = 2, -0.41 mm) and CT (n = 2, 0.12 mm). US showed the highest correlation coefficient (n = 3, 0.91), followed by MRI (n = 12, 0.85) and CT (n = 3, 0.82).

CONCLUSION

rDOI measured by US, CT, and MRI demonstrated excellent correlations with pDOI.

High-Frequency Intraoral Ultrasound for Preoperative Assessment of Depth of Invasion for Early Tongue Squamous Cell Carcinoma: Radiological-Pathological Correlations

The eighth edition of the TNM classification officially introduced "depth of invasion" (DOI) as a criterion for determining the T stage in tongue squamous cell carcinoma. The DOI is a well-known independent risk factor for nodal metastases. In fact, several experts strongly suggest elective neck dissection for tongue cancer with a DOI > 4 mm due to the high risk of early and occult nodal metastases. Imaging plays a pivotal role in preoperative assessments of the DOI and, hence, in planning the surgical approach. Intraoral ultrasound (IOUS) has been proposed for early-stage SCC of the oral tongue as an alternative to magnetic resonance imaging (MRI) for local staging. The aim of this work is to investigate the accuracy of IOUS in the assessment of the DOI in early oral SCC (CIS, pT1, and pT2). A total of 41 patients with tongue SCCs (CIS-T2) underwent a preoperative high-frequency IOUS. An IOUS was performed using a small-size, high-frequency hockey-stick linear probe. The ultrasonographic DOI (usDOI) was retrospectively compared to the pathological DOI (pDOI) as the standard reference. In patients who underwent a preoperative MRI, their usDOI, magnetic resonance DOI (mriDOI), and pDOI were compared. Specificity and sensitivity for the IOUS to predict a pDOI > 4 mm and to differentiate invasive and noninvasive tumors were also evaluated. A high correlation was found between the pDOI and usDOI, pDOI and mriDOI, and usDOI and mriDOI (Spearman's ρ = 0.84, p < 0.0001, Spearman's ρ = 0.79, p < 0.0001, and Spearman's ρ = 0.91, p < 0.0001, respectively). A Bland-Altman plot showed a high agreement between the usDOI and pDOI, even though a mean systematic error was found between the usDOI and pDOI (0.7 mm), mriDOI and pDOI (1.6 mm), and usDOI and mriDOI (-0.7 mm). The IOUS was accurate at determining the T stage (p < 0.0001). The sensitivity and specificity for the IOUS to predict a pDOI ≥4 mm were 92.31% and 82.14%, respectively, with an AUC of 0.87 (p < 0.0001). The specificity, sensitivity, negative predictive value (NPV), and positive predictive value (PPV) for the IOUS to predict an invasive cancer were 100%, 94.7%, 60%, and 100%, respectively. The AUC was 0.8 (95% CI 0.646-0.908, p < 0.0001). The IOUS was accurate in a preoperative assessment of a pDOI and T stage, and can be proposed as an alternative to MRI in the preoperative staging of tongue SCC.

Loss of intercellular bridges in the depth of invasion measurement area is a novel negative prognostic factor for oral squamous cell carcinoma: A retrospective study

OBJECTIVE

This study aimed to evaluate intercellular bridges in the depth of invasion (DOI) measurement area as prognostic factors in oral squamous cell carcinoma (OSCC).

STUDY DESIGN

The mode of invasion was determined based on the Yamamoto-Kohama classification system by observing the hematoxylin-eosin-stained whole-slide images of specimens obtained from 78 patients with OSCC, and the clinicopathologic features were characterized. The presence of intercellular bridges was analyzed in 46 patients with Yamamoto-Kohama classification grade ≥3 whose DOI was measured by dividing the measurement area into 3 parts: the surface, center, and front of the tumor.

RESULTS

Univariate analyses identified lymph node metastasis, loss of intercellular bridges in the DOI measurement area, DOI of ≥4500 µm, and pattern of invasion 4C-4D as negative prognostic factors. Multivariate analyses revealed that lymph node metastasis and the loss of intercellular bridges in the entire area were independent factors, with hazard ratios of 9.34 (95% confidence interval, 2.09-42.03; P = .003) and 3.64 (95% confidence interval, 1.10-11.99; P = .045), respectively.

CONCLUSIONS

Loss of intercellular bridges in the DOI measurement area is a negative prognostic factor for OSCC and may be useful in selecting treatment.

Occult Metastases During Salvage Oral Cavity and Oropharyngeal Free Flaps: Oncologic Outcomes

OBJECTIVES

To define rates of occult metastases in salvage oral cavity and oropharyngeal cancer resection requiring free flap, to examine the location of occult metastases, and to determine associations between occult metastasis and survival.

STUDY DESIGN

Retrospective cohort study.

SETTING

Two tertiary care referral centers.

METHODS

We identified previous cases of irradiation with recurrent or second primary oral cavity or oropharyngeal squamous cell carcinoma that had no evidence of regional metastasis and required free tissue transfer reconstruction of the primary site. Patients who underwent elective neck dissection or exploration were reviewed. The main outcome measures were the presence and location of occult nodal metastasis. Disease-free survival and overall survival were measured. Odds ratios and hazard ratios were used for analysis.

RESULTS

A total of 83 patients were included: 52 with oral cavity primary tumors and 31 with oropharynx. An overall 78 (94%) underwent elective salvage neck dissection. Occult metastases were found in 9 (11.5%) patients. The most common nodal station for occult metastasis was level 2. Neither elective neck dissection nor the presence of occult metastasis was significantly associated with regional disease-free or overall survival. Oropharyngeal primary tumors were associated with higher risk of occult metastasis (odds ratio, 1.38; P < .01) and worse overall survival (hazard ratio, 2.09; P = .01).

CONCLUSION

There is a low incidence of occult metastasis in postradiated recurrent or second primary oral cavity and oropharyngeal tumors. Elective neck dissection and occult nodal metastases were not associated with regional or overall survival. This series may help surgeons make decisions regarding the extent of neck surgery after prior radiation, especially when free flap reconstruction is required.

Automatic discrimination of Yamamoto-Kohama classification by machine learning approach for invasive pattern of oral squamous cell carcinoma using digital microscopic images: a retrospective study

OBJECTIVE

The Yamamoto-Kohama criteria are clinically useful for determining the mode of tumor invasion, especially in Japan. However, this evaluation method is based on subjective visual findings and has led to significant differences in determinations between evaluators and facilities. In this retrospective study, we aimed to develop an automatic method of determining the mode of invasion based on the processing of digital medical images.

STUDY DESIGN

Using 101 digitized photographic images of anonymized stained specimen slides, we created a classifier that allowed clinicians to introduce feature values and subjected the cases to machine learning using a random forest approach. We then compared the Yamamoto-Kohama grades (1, 2, 3, 4C, 4D) determined by a human oral and maxillofacial surgeon with those determined using the machine learning approach.

RESULTS

The input of multiple test images into the newly created classifier yielded an overall F-measure value of 87% (grade 1, 93%; grade 2, 67%; grade 3, 89%; grade 4C, 83%; grade 4D, 94%). These results suggest that the output of the classifier was very similar to the judgments of the clinician.

CONCLUSIONS

This system may be valuable for diagnostic support to provide an accurate determination of the mode of invasion.

Experimental study on needle insertion force to minimize tissue deformation in tongue tissue

This study reports on the effects of insertion velocity, needle tip geometry and needle diameter on tissue deformation and maximum insertion force. Moreover, the effect of multiple insertions with the same needle on the maximum insertion force is reported. The tissue deformation and maximum insertion force strongly depend on the insertion velocity and the tip geometry. No correlation was found between the outer diameter and the maximum insertion force for small needles (30G - 32G). The endurance experiments showed no remarkable difference in the maximum insertion force during 100 insertions.

The Potential of MET Immunoreactivity for Prediction of Lymph Node Metastasis in Early Oral Tongue Squamous Cell Carcinoma

Objective

MET positivity is independently associated with survival in oral squamous cell carcinoma (OSCC). Since MET is a known orchestrator of invasive tumor growth, we investigated its association with LNM in early oral tongue squamous cell carcinoma (OTSCC). As it is recommended by the NCCN to use tumor depth of invasion (DOI) in making decisions on elective neck dissection (END), the results obtained for MET positivity were aligned with those for DOI > 4 mm. The cutoff value used in our institution.

Methods

Tumor samples from patients who underwent primary tumor resection and neck dissection between 1995 and 2013, were collected from the archives of the Leiden and Erasmus University Medical Center. Immunohistochemistry with D1C2 was performed to identify MET negative (< 10% uniform positivity) and MET positive (≥ 10% uniform positivity) cancers. ROC curve analysis and the Chi-squared test were used to investigate the association of MET positivity with LNM (pN+ and occult). Binary logistic regression was used to investigate the association of MET positivity with LNM.

Results

Forty-five (44.1%) of the 102 cancers were MET positive. Ninety were cN0 of which 20 were pN+ (occult metastasis). The remaining 12 cancers were cN+, of which 10 were proven pN+ and 2 were pN0. MET positivity was associated with LNM with a positive predictive value (PPV) of 44.4% and a negative predictive value (NPV) of 82.5% for pN+. For the occult group, the PPV was 36.8% and the NPV was 88.5%. Regression analysis showed that MET positivity is associated with pN+ and occult LNM (p-value < 0.05).

Conclusion

MET positivity is significantly associated with LNM in early OTSCC, outperforming DOI. The added value of MET positivity could be in the preoperative setting when END is being considered during the initial surgery. For cases with DOI ≤ 4 mm, MET positivity could aid in the clinical decision whether regular follow-up, watchful waiting, or END is more appropriate. Realizing that these preliminary results need to be independently validated in a larger patient cohort, we believe that MET positivity could be of added value in the decision making on END in early OTSCC.