Selective Neck Dissection and Survival in Pathologically Node-Positive Oral Squamous Cell Carcinoma

Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

The Impact and Prognostic Significance of Extra-Nodal Extension in Clinically N0 Oral Cancer: A Prospective Clinical Study

Oral cavity squamous cell carcinoma (OCSCC) demonstrates a high propensity to metastasize to regional lymph nodes. Despite technological and scientific advances, identification of pathological adverse features preoperatively remains elusive. This study intended to identify the true occurrence of extra-nodal extension (ENE) in clinically and radiologically N0 OCSCC patients and to investigate its impact and prognostic significance. A prospective, single-centre, non-randomized study was conducted at a tertiary cancer centre in South India to include all untreated operable patients of OCSCC without clinical, radiological, or cytological evidence of nodal metastasis (cN0). All the patients underwent tumor resection surgery with neck dissection and received adjuvant therapy when indicated. Patients were followed up and neck dissection specimens were histopathologically analyzed. The primary outcome was to assess the presence of ENE in cN0 OCSCC patients and its extent. The secondary outcomes were 2-year disease-free survival (DFS) and tumor characteristics. A total of 237 patients with operable OCSCC were evaluated. Out of these, 80 patients who were clinically and radiologically N0 were included in the study and they underwent tumor resection surgery and neck dissection. The final histopathological evaluation revealed that 21.25% of patients (n = 17) had metastatic neck disease and 7.5% of patients (n = 6) had ENE, and all were reported as microscopic ENE. Within the node-positive group, the 2-year DFS for patients with and without ENE were 50% and 90.9%, respectively (p = 0.0362). The results suggest that ENE remains a strong predictor of adverse outcomes, recurrence, and survival in oral cancer patients.

Adjuvant Radiotherapy in Patients with Squamous Cell Carcinoma of the Oral Cavity or Oropharynx and Solitary Ipsilateral Lymph Node Metastasis (pN1)—A Prospective Multicentric Cohort Study

(1) Background: Evaluation of impact of adjuvant radiation therapy (RT) in patients with oral squamous cell carcinoma of the oral cavity/oropharynx (OSCC) of up to 4 cm (pT1/pT2) and solitary ipsilateral lymph node metastasis (pN1). A non-irradiated group with clinical follow-up was chosen for control, and survival and quality of life (QL) were compared; (2) Methods: This prospective multicentric comprehensive cohort study included patients with resected OSCC (pT1/pT2, pN1, and cM0) who were allocated into adjuvant radiation therapy (RT) or observation. The primary endpoint was overall survival. Secondary endpoints were progression-free survival and QL after surgery; (3) Results: Out of 27 centers, 209 patients were enrolled with a median follow-up of 3.4 years. An amount of 137 patients were in the observation arm, and 72 received adjuvant irradiation. Overall survival did not differ between groups (hazard ratio (HR) 0.98 [0.55–1.73], p = 0.94). There were fewer neck metastases (HR 0.34 [0.15–0.77]; p = 0.01), as well as fewer local recurrences (HR 0.41 [0.19–0.89]; p = 0.02) under adjuvant RT. For QL, irradiated patients showed higher values for the symptom scale pain after 0.5, two, and three years (all p < 0.05). After six months and three years, irradiated patients reported higher symptom burdens (impaired swallowing, speech, as well as teeth-related problems (all p < 0.05)). Patients in the RT group had significantly more problems with mouth opening after six months, one, and two years (p < 0.05); (4) Conclusions: Adjuvant RT in patients with early SCC of the oral cavity and oropharynx does not seem to influence overall survival, but it positively affects progression-free survival. However, irradiated patients report a significantly decreased QL up to three years after therapy compared to the observation group.

Selective Neck Dissection for Node-Positive Oral Cavity Squamous Cell Carcinoma: A Retrospective Cohort Study

Introduction  Selective neck dissection in clinically node-negative neck is considered the standard of care for oral squamous cell carcinomas (SCCs). Controversy still prevails in node-positive disease regarding the extent of neck dissection. In our part of the world, comprehensive neck dissection is mostly considered to be the minimal optimal treatment for palpable neck disease.

Objective  To compare regional control and disease-specific survival between clinically node-positive and node-negative patients undergoing selective neck dissection for oral SCC.

Methods  This was a retrospective cohort study conducted in the department of ENT, Head and Neck surgery at a tertiary care hospital. All patients with biopsy-proven oral and lip SCC, with or without nodal disease, who underwent selective neck dissection between April 2006 and July 2015 were included in the study.

Results  During the study period, 111 patients with oral SCC underwent selective neck dissection, of whom 71 (62%) were clinically node-negative and 40 (38%) patients had clinically positive nodes in the neck. The mean follow-up was 16.62 months (standard deviation [SD]: 17.03). The overall regional control rates were 95 versus 96% for clinical negative versus positive nodes, respectively ( p  = 0.589). The disease-specific survival was 84.5% in the node negative group versus 82.5% in the node-positive group ( p  = 0.703).

Conclusion  Selective neck dissection in node-positive neck oral SCC has similar regional control rates when compared with node-negative neck SCC. The difference in disease-specific survival between the two groups is also not significant.

Analysis of the Role of Selective Neck Dissection in Clinically Node-Positive T3/T4 Oral Cancers

Introduction

The concept of selective neck dissection (SND) in locally advanced oral cancers is emerging. Contemporary studies support the feasibility of SND in selected node-positive oral cancers with early primaries. Nevertheless, the suitability of SND in clinically node-positive (cN+) oral cancers with advanced primaries (T3/T4) is unknown.

Aim

This study explores if patients with cN+ advanced primaries were suitable candidates for SND by spotting the involved lymph node distribution in various stations of the neck. Secondary objectives were to check if predictive clinicopathological factors for metastases to the neck in general also apply for lymph node metastases to levels IV and V.

Methods

The present retrospective study analysed the distribution of pathologically involved lymph nodes in 134 patients and explored the interrelation of various predictive factors and cervical metastases overall and those specific to levels IV and V.

Results

Level V was involved in 6.7% (6/83) of T4 and none of the T3 primaries. Depth of invasion (DOI), perineural invasion (PNI), and skin invasion were statistically significant predictors for nodal metastases in general on multivariate analysis.

Conclusion

Our analysis supports the option of considering SND, sparing level V in patients with cN+ oral cancers in a subset with T3 primary and nodal stage N2 and below.

Anlotinib Suppresses Oral Squamous Cell Carcinoma Growth and Metastasis by Targeting the RAS Protein to Inhibit the PI3K/Akt Signalling Pathway

Oral squamous cell carcinoma (OSCC) is a malignant tumour originating from the mucosal lining of the oral cavity. Its characteristics include hidden onset, high recurrence, and distant metastasis after operation. At present, clinical treatment usually includes surgery, chemotherapy, radiotherapy, or the joint use of these modalities. Unfortunately, multidrug resistant is one of the important obstacles that causes cancer chemotherapy failure. Anlotinib, which has recently been proven to have good antitumour effects, is a novel multitargeted tyrosine kinase inhibitor. However, there are few studies of the anlotinib-associated mechanism in OSCC and its underlying molecular mechanism. In our study, in vitro models of human oral squamous cell carcinoma HSC-3 cells were used to determine the efficacy of anlotinib. On the one hand, we showed that anlotinib treatment significantly reduced the viability and proliferation of HSC-3 cells and decreased cell migration by inhibiting the activation of the Akt phosphorylation pathway. On the other side, anlotinib inhibited PI3K/Akt/Bad phosphorylation and promoted apoptosis of HSC-3 cells by activating RAS protein expression. In brief, these results indicated that anlotinib had prominent antitumour activity in OSCC, mainly by inhibiting the PI3K/Akt phosphorylation pathway. This work provides evidences and a basic principle for using anlotinib to treat patients with OSCC for clinical research.

Prevalence of Metastasis and Involvement of Level IV and V in Oral Squamous Cell Carcinoma: A Systematic Review

The occurrence of occult metastases in oral cavity squamous cell carcinoma (OSCC) to lower levels in the neck (levels IV and V) or development of skip metastases that bypass the upper neck levels (levels I to III) and go directly to level IV or V is common. This challenges the efficacy of conventional neck dissection approaches in the treatment of OSCC. Therefore, the decision to include lower levels cervical nodes during elective neck dissection of OSCC remains controversial.

This systematic review was designed to assess the prevalence of level IV and/or V involvement or skip metastases in patients with the clinically negative neck (cN0) or positive (cN+) oral squamous cell carcinoma (OSCC). We searched for studies published between December 2000 and December 2020. Potentially relevant abstracts and full-text articles were screened, and data from the studies were extracted. Quality was rated using the Newcastle Ottawa Scale (NOS) criteria.

In total, 802 abstracts and 227 full-text articles were screened, and 32 studies were included in this analysis. The prevalence of metastasis ranged from 1.8% to 66.0%. The incidence for skip metastasis to level IV or V was low, reaching 8.5%. Evidence favored elective neck dissection, including levels I to III, in selected patients with OSCC and patients with cN0 or cN+ neck. The literature was non-conclusive on the recommendation for inclusion of lower levels.

Tumor Suppressive Circular RNA-102450: Development of a Novel Diagnostic Procedure for Lymph Node Metastasis from Oral Cancer

Circular RNAs (circRNAs), which form as covalently closed loop structures, have several biological functions such as regulation of cellular behavior by adsorbing microRNAs. However, there is limited information of circRNAs in oral squamous cell carcinoma (OSCC). Here, we aimed to elucidate the roles of aberrantly expressed circRNAs in OSCC. CircRNA microarray showed that circRNA-102450 was down-regulated in OSCC cells. Clinical validation of circRNA-102450 was performed using highly sensitive droplet digital PCR in preoperative liquid biopsy samples from 30 OSCC patients. Interestingly, none of 16 studied patients with high circRNA-102450 had regional lymph node metastasis (RLNM), whereas 4 of 14 studied patients (28.5%) with low expression had pathologically proven RLNM. Overexpressed circRNA-102450 significantly inhibited the tumor metastatic properties of cell proliferation, migration, and invasion. Furthermore, circRNA-102450 directly bound to, and consequently down-regulated, miR-1178 in OSCC cells. Taken together, circRNA-102450 has a tumor suppressive effect via the circRNA-102450/miR-1178 axis and may be a novel potential marker of RLNM in OSCC patients.

The Prognostic Value of Lymph Node Burden in Oral Cavity Cancer: Systematic Review and Meta-Analysis

OBJECTIVES

Lymph node burden has been proposed to estimate the cumulative adverse effect of nodal metastasis. In this study, a meta-analysis was conducted to evaluate the prognostic value of lymph node burden in oral cavity squamous cell carcinoma.

STUDY DESIGNS

Systemic review and meta-analysis.

METHODS

PubMed, EMBASE and the Cochrane Library as well as manual searches were performed until April 2020. The adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of overall survival, disease-specific survival, and disease-free survival were extracted and pooled.

RESULTS

Eleven included studies were published between 2009 and 2019. The cumulative number of patients was 20,607 (range 35-14,554). Extranodal extension was adjusted or evaluated in all of the studies. The meta-analysis indicated that a higher lymph node burden was significantly related to worse overall survival (HR 2.62, 95% CI 2.12-3.25), worse disease-specific survival (HR 3.14, 95% CI 1.85-5.33) and worse disease-free survival (HR 2.30, 95% CI 1.62-3.26). The highest hazard ratio was observed when the cutoff value was 3 for overall survival, 3 for disease-specific survival, and 4 for disease-free survival. The hazard ratio showed an upward trend before the cutoff value of 3 but no significant incremental change when the cutoff exceeded 3.

CONCLUSIONS

In oral squamous cell carcinoma, lymph node burden is an independent prognosticator for survival outcomes. However, more prospective or high-quality studies are required to determine the optimal cutoff.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Salvage Surgery for Recurrent Tongue Cancer With Contralateral Neck Metastasis

PURPOSE

Treatment recommendations have been widely reported for primary tongue squamous cell carcinoma (TSCC) with contralateral neck metastases (CNMs), but little is known concerning recurrent TSCCs with CNMs, especially in patients who have undergone ipsilateral neck dissection. The aim of this study was to estimate overall survival (OS) and to identify prognostic factors associated with OS in patients treated for recurrent TSCCs.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients who underwent salvage surgery (SS) for recurrent TSCC in our institution between January 2010 and December 2014. Before SS, all patients had been surgically treated for primary TSCC with ipsilateral neck dissection. The primary outcome variable was OS, and the patients were grouped by the primary predictor variable of CNM status for comparison. Other heterogeneous variables of interest included demographics, medical histories, clinicopathologic characteristics, surgical data, and adjuvant treatment modalities. In addition, the midline involvement and anatomic subsites of local recurrences were evaluated. Univariate log-rank and Cox regression tests were used for statistical analyses.

RESULTS

The study sample included 177 subjects with a mean age of 55.4 years, and 44.6% were males. The median OS was 18 months. Within the entire cohort, the incidence of CNM was 23.7% (n = 42), with an inclination (n = 30) for contralateral level I or II. Factors associated with improved survival included CNM (hazard ratio [HR], 2.108; 95% confidence interval [95% CI], 1.341 to 3.315; P = .001), disease-free interval (HR, 0.601; 95% CI, 0.387 to 0.934; P = .023), and local recurrence subsite score (HR, 3.276; 95% CI, 0.924 to 11.623; P = .001).

CONCLUSIONS

Patients with both recurrent TSCCs and CNMs had a dismal prognosis (OS rate, 16.2%) compared with those without CNMs (OS rate, 52.7%). SS for TSCC patients with collateral failures should be used cautiously because of the very unfavorable outcomes.

PEP06 polypeptide 30 is a novel cluster-dissociating agent inhibiting v integrin/FAK/Src signaling in oral squamous cell carcinoma cells

Collectively migrating tumor cells have been recently implicated in enhanced metastasis of epithelial malignancies. In oral squamous cell carcinoma (OSCC), αv integrin is a crucial mediator of multicellular clustering and collective movement in vitro; however, its contribution to metastatic spread remains to be addressed. According to the emerging therapeutic concept, dissociation of tumor clusters into single cells could significantly suppress metastasis-seeding ability of carcinomas. This study aimed to investigate the anti-OSCC potential of novel endostatin-derived polypeptide PEP06 as a cluster-dissociating therapeutic agent in vitro. Firstly, we found marked enrichment of αv integrin in collectively invading multicellular clusters in human OSCCs. Our study revealed that metastatic progression of OSCC was associated with augmented immunostaining of αv integrin in cancerous lesions. Following PEP06 treatment, cell clustering on fibronectin, migration, multicellular aggregation, anchorage-independent survival and colony formation of OSCC were significantly inhibited. Moreover, PEP06 suppressed αv integrin/FAK/Src signaling in OSCC cells. PEP06-induced loss of active Src and E-cadherin from cell–cell contacts contributed to diminished collective migration of OSCC in vitro. Overall, these results suggest that PEP06 polypeptide 30 inhibiting αv integrin/FAK/Src signaling and disrupting E-cadherin-based intercellular junctions possesses anti-metastatic potential in OSCC by acting as a cluster-dissociating therapeutic agent.