Lymph Node Yield and Ratio in Selective and Modified Radical Neck Dissection in Head and Neck Cancer-Impact on Oncological Outcome

Do we still need Crile or Hayes Martin approach for cervical lymphadenectomy? A retrospective study of 56 patients with minimal access neck dissection

The concept of neck dissection was introduced by Crile more than a century ago. Since then, multiple modifications have been adopted to ensure the preservation of vital structures. With the new era of minimal access surgery, the incorporation of laparoscopic, endoscopic, and robotic surgery is becoming the new normal. Over the years we have carried out neck dissections using minimal access incisions. Although there is no definitive answer about the average nodal yield required in selective or modified neck dissections, it has been reported that the average nodal yield of more than 18 is associated with better survival rate. In this publication we share the results of our three-year retrospective study of 56 patients who underwent minimal access neck dissection. We look at the nodal yield, assess operating duration, complications, outcome with a three-year follow up from a single unit. Our results demonstrate that minimal access neck dissection should be considered in head and neck lymphadenectomies.

Comparison of the prognostic value of lymph node yield, lymph node ratio, and number of lymph node metastases in patients with oral squamous cell carcinoma

BACKGROUND

The aim of this study was to assess the prognostic significance of lymph node yield (LNY), lymph node ratio (LNR), and the number of lymph node metastases (LNMs) in patients affected by oral squamous cell carcinoma (OSCC).

METHODS

The study included patients who underwent surgical treatment for primary OSCC. Receiver operating characteristic curves were generated to determine the optimal threshold values. Kaplan-Meier curves were employed, along with the log-rank test, for the analysis of survival. To compare the performance in terms of model fit, we computed Akaike's information criterion (AIC).

RESULTS

This study enrolled 429 patients. Prognostic thresholds were determined at 22 for LNY, 6.6% for LNR, and 3 for the number of LNMs. The log-rank test revealed a significant improvement in both overall survival and progression-free survival for patients with a LNR of ≤6.6% or a number of LNMs of ≤3 (p < 0.05). Interestingly, LNY did not demonstrate prognostic significance. The AIC analyses indicated that the number of LNMs is a superior prognostic indicator compared to LNY and LNR.

CONCLUSIONS

Incorporating LNR or the number of LNMs into the TNM classification has the potential to improve the prognostic value, as in other types of cancers. Particularly, the inclusion of the number of LNMs should be contemplated for future N staging.

Detectability and intra-fraction motion of individual elective lymph nodes in head and neck cancer patients on the Magnetic Resonance Image guided linear accelerator

Background and purpose

Individual elective lymph node irradiation instead of elective neck irradiation is a new concept for head-and-neck cancer (HNC) patients developed for the Magnetic Resonance Image guided linear accelerator (MR-linac). To prepare this, the detectability, volume changes and intra-fraction motion of elective lymph nodes on the MR-linac was assessed.

Materials and methods

A total of 15 HNC patients underwent diagnostic pre-treatment MRI. Additionally, two MR-linac scans were obtained with a 10-minute time difference in the first week of radiation treatment. Elective lymph node contours inside lymph node levels (Ib-V) were segmented on the pre-treatment MRI and the MR-linac scans and compared on number and maximal transversal diameter. Intra-fraction motion of elective lymph nodes on the MR-linac was estimated using Center of Mass (COM) distances and incremental isotropic expansion of lymph node segmentations.

Results

Of all 679 detected lymph nodes on the pre-treatment MRI, eight lymph nodes were not detectable on the first MR-linac scan and 16 new lymph nodes were detected. Lymph node diameters between the pre-treatment MRI scan and the MR-linac scan varied from -0.19 to + 0.13 mm. COM distances varied from 1.2 to 1.7 mm and lymph node contours had to be expanded with 3 mm.

Conclusions

Nearly all elective lymph nodes were detectable on the 1.5T MR-linac scan with no major changes in target volumes compared to the pre-treatment MRI. Simulated intra-fraction motion during the MR-linac scans was smaller than the 5-mm margin that will be used in the first elective lymph node radiation treatment.

Oncologic Outcome in Advanced Oral Squamous Cell Carcinoma After Refusal of Recommended Adjuvant Therapy

Importance

Clinicians may be confronted with patients refusing recommended adjuvant therapy (AT) after the primary resection of an advanced oral squamous cell carcinoma (OSCC). However, for this tumor entity, data are lacking regarding the oncological outcomes and associated factors after refusal of AT.

Objective

To evaluate the difference in survival and disease recurrence for patients with and without recommended AT after resection of advanced OSCC.

Design, Setting, and Participants

In this single-center retrospective matched cohort study, patients with advanced OSCC who refused recommended AT between January 2010 and December 2021 were matched 1:1 according to Union for International Cancer Control tumor staging with patients who completed AT.

Exposures

Patients with advanced OSCC who refused or completed recommended AT between 2010 and 2021.

Main Outcomes and Measures

The primary outcome of this study was the comparison of overall survival (OS) and recurrence-free survival (RFS) between the 2 study groups.

Results

A total of 82 patients (mean [SD] age at time of surgery, 68.0 [11.3] years; 38 [46.3%] female, 44 [53.7%] male) with and without AT (41 per study group) were included in the analysis. Patients refusing AT developed more frequent disease recurrence than patients who completed AT (61.0% vs 26.8%; difference, 34.2%; odds ratio, 4.26; 95% CI, 1.68-10.84). In addition, patients who refused AT presented with lower 2-year OS (72.7% vs 88.6%; difference, 15.9%; 95% CI, 8.6%-40.6%) and much lower 2-year RFS (39.1% vs 74.2%; difference, 35.1%; 95% CI, 0.2%-70.5%). In the patient cohort who rejected AT, a worse OS was associated with female sex (48.6% vs 90.5%; difference, 41.9%; 95% CI, 0.6%-84.4%), pT1-2 category (57.1% vs 92.3%; difference, 35.2%; 95% CI, 3.3%-73.6%), and pN1 or higher category (61.2% vs 82.6%; difference, 21.4%; 95% CI, 14.1%-56.8%). Lower RFS was associated with female sex (37.9% vs 90.9%; difference, 53.0%; 95% CI, 8.0%-97.9%), advanced T category (pT3-4, 35.3% vs 80.0%; difference, 44.7%; 95% CI, 6.4%-95.3%), lymph node yield of 20 or greater (31.4% vs 80.6%; difference, 49.2%; 95% CI, 4.9%-93.4%), and lymph node ratio of less than 4.6% (36.6% vs 84.4%; difference, 47.8%; 95% CI, 1.8%-93.1%).

Conclusions and Relevance

In this cohort study of patients with advanced OSCC, refusal of AT was associated with worse oncological outcomes. The prevalence of disease recurrence during follow-up was 34% higher in patients who refused AT than in patients who completed AT. The results from this study may assist clinicians in guiding patients who are considering refusal of or withdrawal from AT.

Lymph Node Ratio as a Prognostic Factor for Oral Tongue Squamous Cell Carcinoma: A Retrospective Study

Background Oral squamous cell carcinoma (OSCC) incidence and its mortality have increased recently. The oral part of the tongue is one of the commonest sites for OSCC. Apart from Tumour-Node-Metastasis (TNM) staging, lymph node ratio (LNR) has been implicated as one of the useful predictors for the better clinical outcome of the disease. The aim of the present study was to assess the LNR as a prognostic factor for patients having oral tongue squamous cell carcinoma (OTSCC). Materials and methods It is a retrospective study of 122 patients with OTSCC who were managed primarily by surgery with curative intent from January 2014 to December 2016. The mean lymph node ratio was measured and compared with various parameters of clinical outcome such as five-year overall survival (OS), five-year disease-free survival (DFS), locoregional failure (LRF) within three years, and distant metastasis (DM) within five years using Kruskal-Wallis Test followed by Mann-Whitney Post Hoc Test. The association of LNR with other tumor characteristic features like perineural invasion, extra-nodal extension (ENE), and histopathological grading was also elicited. Results The study population's mean age was 50.5 ± 11.77 years. Among them, 85 were males and 37 were females. On comparing the mean LNR value with patient status after primary treatment, the patients with minimal LNR value had statistically significant five-year OS and five-year DFS (p< 0.001). High mean LNR values were associated with other adverse features like perineural invasion and ENE, which were statistically significant (p<0.001). Receiver operator characteristics (ROC) curve analysis for the LNR parameter for determining the cut-off (0.02) between OS and DFS had 86% sensitivity and 40% specificity. Conclusion The LNR could be an important prognosis factor for OTSCC that helps in determining better clinical outcomes.

MRI visibility and displacement of elective lymph nodes during radiotherapy in head and neck cancer patients

Background and purpose

To decrease the impact of radiotherapy to healthy tissues in the head and neck region, we propose to restrict the elective neck irradiation to elective lymph nodes at risk of containing micro metastases instead of the larger lymph node volumes. To assess whether this new concept is achievable in the clinic, we determined the number, volume changes and displacement of elective lymph nodes during the course of radiotherapy.

Materials and methods

MRI scans of 10 head and neck cancer (HNC) patients were acquired before radiotherapy and in week 2, 3, 4 and 5 during radiotherapy. The weekly delineations of elective lymph nodes inside the lymph node levels (Ib/II/III/IVa/V) were rigidly registered and analyzed regarding number and volume. The displacement of elective lymph nodes was determined by center of mass (COM) distances, vector-based analysis and the isotropic contour expansion of the lymph nodes of the pre-treatment scan or the scan of the previous week in order to geographically cover 95% of the lymph nodes in the scans of the other weeks.

Results

On average, 31 elective lymph nodes in levels Ib-V on each side of the neck were determined. This number remained constant throughout radiotherapy in most lymph node levels. The volume of the elective lymph nodes reduced significantly in all weeks, up to 50% in week 5, compared to the pre-treatment scan. The largest median COM displacements were seen in level V, for example 5.2 mm in week 5 compared to the pre-treatment scan. The displacement of elective lymph nodes was mainly in cranial direction. Geographical coverage was obtained when the lymph node volumes were expanded with 7 mm in case the pre-treatment scan was used and 6.5 mm in case the scan of the previous week was used.

Conclusion

Elective lymph nodes of HNC patients remained visible on MRI and decreased in size during radiotherapy. The displacement of elective lymph nodes differ per lymph node level and were mainly directed cranially. Weekly adaptation does not seem to improve coverage of elective lymph nodes. Based on our findings we expect elective lymph node irradiation is achievable in the clinic.

Prognostic Nomogram for Postoperative Hypopharyngeal Squamous Cell Carcinoma to Assist Decision Making for Adjuvant Chemotherapy

We aimed to investigate the effect of lymph node parameters on postoperative hypopharyngeal squamous cell carcinoma (HSCC) and to establish a nomogram to predict its prognosis and assist in adjuvant chemotherapy decisions. A retrospective analysis of postoperative HSCC in the Surveillance, Epidemiology, and End Results database (2004-2019) was performed. Cutoff points for continuous variables were determined by X-tile software. Univariate and multivariate analyses were performed to identify prognostic factors on overall survival (OS), and these variables were used to construct a nomogram. The nomogram's accuracy was internally validated using concordance index, area under the curve, calibration plot, and decision curve analyses. Furthermore, the value of chemotherapy in each risk subgroup was assessed separately based on individualized scores from the nomogram. In total, 404 patients were eligible for analysis, and the median OS was 39 months. Age, origin, primary site, T stage, number of lymph nodes examined, lymph node ratio, and radiotherapy were identified as prognostic factors for OS and incorporated into the nomogram. In both the training and validation cohorts, favorable performance was exhibited compared with the other stage systems, and patients could be classified into low-, intermediate-, and high-risk subgroups. Chemotherapy significantly improved the OS in the high-risk subgroup, whereas chemotherapy did not confer a survival benefit in the low- or intermediate-risk groups. The lymph node parameter-based nomogram model can better stratify the prognosis of HSCC patients and screen out patients who would benefit from chemotherapy, suggesting that the model could be used as a reference for clinical decision making and to avoid overtreatment.

Peritumor tertiary lymphoid structures are associated with infiltrating neutrophils and inferior prognosis in hepatocellular carcinoma

BACKGROUND

The positive prediction of prognosis and immunotherapy within tertiary lymphoid structure (TLS) in cancerous tissue has been well demonstrated, including liver cancer. However, the relationship between TLS and prognosis in the peritumoral region of hepatocellular carcinoma (HCC) has received less attention. Few studies on whether TLS, as a typical representative of acquired immune cell groups, is associated with innate immune cells. The aim of this paper was to identify the prognostic role of peritumor TLS in HCC and to simply explore the relationship with neutrophils infiltration.

METHODS

This study included cancerous and paracancerous tissue from 170 patients after surgical resection of HCC. TLS was examined and identified by pathological H&E examination, and the impact on prognosis was further classified by determination of total TLS area. Immunohistochemical staining of CD15+ neutrophils was also performed on half of the cases. The obtained results were validated by external public database, as TLS has been widely shown to be tagged with 12 chemokines.

RESULTS

In peritumoral tissue, the TLS- group had better overall survival (OS) and disease-free survival (DFS) outcomes compared with the TLS+ group. On the contrary, the intratumor TLS+ group showed better DFS outcomes. When further investigating the relationship between TLS area distribution and DFS, progressively worse prognosis was only found in the peritumor region with increasing TLS density (TLS- vs. TLS_L vs. TLS_H ). In addition, neutrophil infiltration increased in parallel with TLS density in the peritumoral region, which was not observed in the intratumoral region.

CONCLUSIONS

TLS might have a dual prognostic role in different regions of HCC. The abundance of peritumoral TLS is an independent influence of DFS. The inconsistent correlation between neutrophils and corresponding TLS in different regions may indicate different pathways of immune aggregation and may serve as an explanation for the different prognosis of TLS, which needs to be specifically explored.

Anatomical Variant of Spinal Accessory Nerve Passing through Fenestrated Internal Jugular Vein

Neck dissection (ND) is a major surgery for head and neck cancer. Currently, some or all of the spinal accessory nerve (SAN), sternocleidomastoid muscle, and internal jugular vein (IJV) are aggressively preserved during ND to reduce postoperative complications. Since the anatomical relationship between the SAN and IJV has several variations, knowledge of these variations is necessary to avoid iatrogenic damage. In the present case, the SAN was observed to pass through the fenestrated IJV at the level of the posterior belly of the digastric muscle during ND in a patient with squamous cell carcinoma of the mandible. Although the anatomical structure of the SAN and IJV is rare, surgeons must be aware of this anatomical variation.