Head and neck cancers, version 2.2013. Featured updates to the NCCN guidelines

Perineural invasion in incisional biopsy is an indication for in-continuity resection in oral squamous cell carcinoma of the tongue and floor of the mouth

PURPOSE

The histologic finding of perineural invasion is a poor prognostic factor in oral squamous cell carcinoma patients. The aim of this study is to detect factors that influence prognosis in patients operated for oral cancer with perineural invasion in their histopathology report and to propose safer options of treatment with respect to recurrence and survival rates.

PATIENTS AND METHODS

We performed a prospective cohort study of all oral squamous cell carcinoma cases operated in our department from January 2018 to January 2022. Overall, 75 cases of patients operated for oral squamous cell carcinoma were included in the study. Of these cases, 14 with perineural invasion were found. We created two groups: one group of patients treated with in-continuity resection and a second group of patients treated with a discontinuous resection between the primary site and the neck. Type of operation was considered the predictor variable and recurrence, survival or death, the outcome variables.

RESULTS

Oral cancer patients with known perineural invasion treated with in-continuity resection had a much better overall and disease-specific survival than patients treated with a discontinuous manner (p < .001). The difference in recurrence rate between these two groups of patients was found to be very significant in our study (p < .0005).

CONCLUSION

It is therefore our suggestion that in oral squamous cell carcinoma of the tongue and floor of the mouth with perineural invasion detected in the incisional biopsy, an extended in-continuity resection to include the affected nerves should be performed.

Exophytic Squamous Cell Carcinoma of the Scalp: A Case Report

Squamous cell carcinoma (SCC) is the second-most common clinical presentation of non-melanoma skin cancer. Despite its prevalence, the rate of growth and development of SCC lesions is low. We present a case report of an exophytic SCC of the midline scalp. Over approximately 18 months, the exophytic portion of this lesion grew to a size of 8.5 x 7 cm due to the fact that the patient did not seek medical attention. The patient suffered from many predisposing factors including active smoking status, type II diabetes, and significant previous sun exposure. In addition to these predisposing factors, the patient did not have comprehensive health insurance to cover outpatient medical care. This case highlights the importance of early intervention in the management of head and neck skin cancers and the negative impact of delayed treatment.

Development and Testing of a Machine Learning Model Using 18F-Fluorodeoxyglucose PET/CT-Derived Metabolic Parameters to Classify Human Papillomavirus Status in Oropharyngeal Squamous Carcinoma

OBJECTIVE

To develop and test a machine learning model for classifying human papillomavirus (HPV) status of patients with oropharyngeal squamous cell carcinoma (OPSCC) using ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET-derived parameters in derived parameters and an appropriate combination of machine learning methods in patients with OPSCC.

MATERIALS AND METHODS

This retrospective study enrolled 126 patients (118 male; mean age, 60 years) with newly diagnosed, pathologically confirmed OPSCC, that underwent ¹⁸F-FDG PET-computed tomography (CT) between January 2012 and February 2020. Patients were randomly assigned to training and internal validation sets in a 7:3 ratio. An external test set of 19 patients (16 male; mean age, 65.3 years) was recruited sequentially from two other tertiary hospitals. Model 1 used only PET parameters, Model 2 used only clinical features, and Model 3 used both PET and clinical parameters. Multiple feature transforms, feature selection, oversampling, and training models are all investigated. The external test set was used to test the three models that performed best in the internal validation set. The values for area under the receiver operating characteristic curve (AUC) were compared between models.

RESULTS

In the external test set, ExtraTrees-based Model 3, which uses two PET-derived parameters and three clinical features, with a combination of MinMaxScaler, mutual information selection, and adaptive synthetic sampling approach, showed the best performance (AUC = 0.78; 95% confidence interval, 0.46-1). Model 3 outperformed Model 1 using PET parameters alone (AUC = 0.48, p = 0.047) and Model 2 using clinical parameters alone (AUC = 0.52, p = 0.142) in predicting HPV status.

CONCLUSION

Using oversampling and mutual information selection, an ExtraTree-based HPV status classifier was developed by combining metabolic parameters derived from ¹⁸F-FDG PET/CT and clinical parameters in OPSCC, which exhibited higher performance than the models using either PET or clinical parameters alone.

Recurrence risk stratification and treatment strategies of patients with stage IVa-b hypopharyngeal squamous cell carcinoma

BACKGROUND

Optimal treatment strategies for patients with stage IVa-b hypopharyngeal squamous cell carcinoma (HSCC) remain controversial. This study aimed to examine the high-risk factors of postoperative tumor recurrence after surgical resection of HSCC and devise individualized postoperative adjuvant treatment (POAT).

METHODS

Overall, 218 patients with stage IVa-b HSCC who received surgery as initial treatment and with negative surgical margins were evaluated. Independent risk factors of recurrence were identified, and survival outcomes were compared according to recurrence risk and POAT use.

RESULTS

POAT significantly improved recurrence-free survival (RFS) and overall survival (OS) only in the high-risk patients (p = 0.003 and 0.018, respectively). Compared with postoperative radiotherapy alone, postoperative chemoradiotherapy (pCRT) achieved significantly better RFS (p = 0.035) and OS (p = 0.048).

CONCLUSIONS

POATs are recommended for high-risk patients with stage Iva-b HSCC, with pCRT achieving superior outcomes. Regular re-examination after tumor resection is sufficient for low-risk patients.

Second primary squamous cell carcinomas treated with trans oral robotic surgery: Oncological and functional results

Background

Recovery of swallowing in patients treated with trans‐oral robotic surgery (TORS) is in general considered as favorable. However, patients afflicted with a secondary primary carcinoma of the head and neck may be more vulnerable to swallowing dysfunctions after trans‐oral surgery as a consequence of previous treatments.

Methods

This is a retrospective monocentric study on patients undergoing TORS for second primary squamous cell carcinoma between 2013 and 2017 (follow‐up until June 2021). Swallowing performance was assessed via the functional outcome swallowing scale (FOSS). Also, overall survival (OS), disease‐free survival (DS) and disease‐specific survival (DSS) were evaluated.

Results

Eighteen patients (median 62 years) underwent TORS with curative intent for T1‐2 oropharyngeal and supraglottic secondary primaries. The average follow‐up was of 52 months. All cases were resected R0 using TORS. 84% of patients had a post‐treatment FOSS score equal or better upon last follow‐up compared with pre‐treatment. Only one patient required a percutaneous gastrostomy long term. DSS/DFS/OS at 5 years was 94%, 60%, and 67%, respectively. The main cause of death was metachronous pulmonary neoplasia.

Conclusions

Our study demonstrates encouraging results in terms of swallowing recovery in patients undergoing TORS for selected secondary primaries of the oropharynx and supraglottic larynx. Further studies into trans‐oral surgery for this condition seem therefore warranted.

Level of Evidence: Case series; Level 4.

Circulating Plasma Epstein-Barr Virus DNA Load During the Follow-up Periods Predicts Recurrence and Metastasis in Nasopharyngeal Carcinoma

BACKGROUND

Epstein-Barr virus DNA (EBV DNA) load has been identified as a prognostic factor in nasopharyngeal carcinoma (NPC), whereas the dynamic changes in the long period have not been explored. In this study, we evaluated EBV DNA kinetics and its role in the survival.

METHODS

We conducted a retrospective review of 900 NPC patients. Plasma EBV DNA levels were measured at various time points after treatment. The correlations of EBV kinetics with recurrence and metastasis were analyzed. After stratifying patients according to the EBV results, survival was compared using Kaplan-Meier estimates. Twelve- and 24-month landmark analyses for overall survival (OS) data were performed according to the EBV groups.

RESULTS

Patients with post-EBV of less than 2500 copies/mL achieved better survival than did those with higher ones. Furthermore, patients with continuously elevated EBV DNA expressed significantly poorer OS (hazard ratio [HR], 2.542, 95% confidence interval [CI], 2.077-3.111; P < 0.001), distant metastasis-free survival (HR, 2.970; 95% CI, 2.392-3.687; P < 0.001), locoregional-free survival (HR, 1.699; 95% CI, 1.072-2.692; P = 0.013), and progression-free survival (HR, 2.535; 95% CI, 1.987-3.233; P < 0.001) than did patients with continuously normal EBV or those with elevated levels at any time point. The 5-year OS with elevated EBV was lower than that of the remission group by using the 12- and 24-month landmark analysis.

CONCLUSIONS

Elevated EBV DNA after treatment was a better predictive indicator of survival than the baseline concentrations. Furthermore, continuously elevated EBV DNA after treatment indicated recurrence, metastasis, and unfavorable prognosis for NPC. In addition, there were consistent patterns of EBV DNA kinetics during long-term follow-up, which warrant further study.

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.

Optimizing brief, focused assessment of priority symptoms and concerns in recurrent and/or metastatic squamous cell carcinoma of the head and neck: Content validation of the Functional Assessment of Cancer Therapy/National Comprehensive Cancer Network Head and Neck Symptom Index-10 (FHNSI-10)

BACKGROUND AND AIMS

Patients with recurrent and/or metastatic (R/M) squamous cell carcinoma of the head and neck (SCCHN) experience vast disease and treatment burdens. Brief, focused instruments are needed to assess patient-reported priority symptoms and concerns as targeted outcome assessments for use in clinical research. Although the instrument was developed based on expert and patient input and is psychometrically valid, the Functional Assessment of Cancer Therapy (FACT)/National Comprehensive Cancer Network (NCCN) Head and Neck Symptom Index-10 (FHNSI-10) has yet to undergo content validation from the perspective of R/M SCCHN patients to evaluate its use as a brief symptom-focused targeted endpoint assessment for use in clinical research.

METHODS

Interviews conducted with R/M SCCHN patients explored priority symptoms and concerns, followed by cognitive debriefing of the FHNSI-10 to evaluate face validity. Transcripts were analyzed, and results were mapped to the FHNSI-10. In accordance with published recommendations, expert input from the original development and published literature was considered for content validity assessment.

RESULTS

A total of 18 patients participated in a concept elicitation interview; saturation was obtained at interview 17. Most (83%) were undergoing active treatment, male (94%), white (72%), and did not have a college degree (67%). The most commonly mentioned symptoms were lumps/swelling, pain, sore throat, difficulty swallowing, and voice changes. For all items, ≥75% reported each question was relevant to their R/M SCCHN experience and 94% reported the instrument captured their experiences with R/M SCCHN.

CONCLUSION

Results provide support for the content validity of the FHNSI-10, inasmuch as all 10 items were spontaneously reported and considered relevant to R/M SCCHN. Content validity might be enhanced by adding cough and hearing impairment items; however, the existing FHNSI-10 covers the majority of symptoms uncovered in interviews with a small sample of R/M SCCHN patients.

Quality of life in patients with locally advanced head and neck cancer treated with concurrent chemoradiation with cisplatin and nimotuzumab versus cisplatin alone - Additional data from a phase 3 trial

INTRODUCTION

The addition of Nimotuzumab to radical chemoradiation (CRT) improved outcomes in patients with locally advanced head and neck squamous cell carcinoma (LAHNSCC) undergoing radical CRT in a phase 3 randomized trial. The current study focuses on the quality of life (QoL) of patients in this trial.

METHODS

In this phase III randomized trial, patients with newly diagnosed, nonmetastatic, stage III/IV LAHNSCC of the oral cavity, oropharynx, hypopharynx, or larynx were randomized to receive cisplatin 30 mg/m² or cisplatin 30 mg/m² with nimotuzumab once a week with curative radiotherapy. The primary end point of the trial was PFS. The aim of the current study was to compare the QoL between the two arms. QoL was assessed using the EORTC QLQ-C30 (v3.0) and HN-35 (v1.0). The linear mixed-effects model was used for longitudinal analysis of QoL.

RESULTS

536 patients were randomized in this trial (268 in each arm) and 423 patients were included for QoL analysis. There was a significant change in the global health status QoL scores over time (p = 0.0016) with no difference between the two arms (p = 0.396). On longitudinal analysis there was a significant difference in the QoL scores in most of the function & symptom scales over time, but there was no significant difference in these scores between the two arms. QoL scores for most symptom scales worsened during treatment and improved thereafter in both arms.

CONCLUSION

The addition of nimotuzumab to cisplatin based chemoradiation in LAHNSCC improved PFS, LRC and DFS without negatively impacting QoL.

Small Molecules in the Treatment of Squamous Cell Carcinomas: Focus on Indirubins

Simple Summary

In this review, the genetic landscape of squamous cell carcinoma is related to the potential targets of indirubin-based small molecules in cancer therapy. Being a component of traditional Chinese medicine, indirubins are used to treat chronic or inflammatory diseases, and have received increasing attention in cancer treatment due to their proapoptotic and antiproliferative activity. Frequent genetic alterations of squamous cell carcinomas are summarized, and it is discussed how these may render tumors susceptible to indirubin-based small molecule inhibitors.

Abstract

Skin cancers are the most common malignancies in the world. Among the most frequent skin cancer entities, squamous cell carcinoma (SCC) ranks second (~20%) after basal cell carcinoma (~77%). In early stages, a complete surgical removal of the affected tissue is carried out as standard therapy. To treat advanced and metastatic cancers, targeted therapies with small molecule inhibitors are gaining increasing attention. Small molecules are a heterogeneous group of protein regulators, which are produced by chemical synthesis or fermentation. The majority of them belong to the group of receptor tyrosine kinase inhibitors (RTKIs), which specifically bind to certain RTKs and directly influence the respective signaling pathway. Knowledge of characteristic molecular alterations in certain cancer entities, such as SCC, can help identify tumor-specific substances for targeted therapies. Most frequently, altered genes in SCC include TP53, NOTCH, EGFR, and CCND1. For example, the gene CCND1, which codes for cyclin D1 protein, is upregulated in nearly half of SCC cases and promotes proliferation of affected cells. A treatment with the small molecule 5′-nitroindirubin-monoxime (INO) leads to inhibition of cyclin D1 and thus inhibition of proliferation. As a component of Danggui Longhui Wan, a traditional Chinese medicine, indirubins are used to treat chronic diseases and have been shown to inhibit inflammatory reactions. Indirubins are pharmacologically relevant small molecules with proapoptotic and antiproliferative activity. In this review, we discuss the current literature on indirubin-based small molecules in cancer treatment. A special focus is on the molecular biology of squamous cell carcinomas, their alterations, and how these are rendered susceptible to indirubin-based small molecule inhibitors. The potential molecular mechanisms of the efficacy of indirubins in killing SCC cells will be discussed as well.

Metabolomics of Oral/Head and Neck Cancer

Oral/head and neck cancer is the sixth most common human malignancies in the world. Despite the treatment advances in surgery, chemotherapy, and radiotherapy, the patient survival has not been significantly improved in the past several decades. As a new methodological approach, metabolomics may help reveal the metabolic reprogramming mechanisms underlying head and neck cancer cell proliferation, invasion, and metastasis and may be used to identify metabolite biomarkers for clinical applications of the disease. In this chapter, we briefly review recent metabolomic applications in head and neck cancer.

Prognostic impact of the prognostic nutritional index in cases of resected oral squamous cell carcinoma: a retrospective study

BACKGROUND

The systemic inflammatory response and nutritional status of patients with malignant tumors are related to postoperative results. We examined the usefulness of the prognostic nutritional index (PNI) as a prognostic tool in patients with oral squamous cell carcinoma who underwent radical surgery.

METHODS

From 2008 to 2019, 102 patients (73 males, 29 females; age, 65.6 ± 9.8 years) who visited our hospital and underwent surgical therapy were included in this study. The endpoint was the total survival period, and the evaluation markers included the lymphocyte count and albumin level in peripheral blood obtained 4 weeks preoperatively, age, sex, alcohol consumption, smoking history, site of the tumor, pathological stage, and surgery status. The PNI was calculated using serum albumin levels and the peripheral blood lymphocyte count. The relationship between the PNI and patient characteristics were analyzed using Fisher's exact test. The Kaplan-Meier method was used to evaluate the survival rate. The survival periods were compared using the log-rank method. We evaluated the prognostic factors for overall survival (OS) and disease-free survival (DFS) in a logistic regression model.

RESULTS

The tumor sites included the maxilla (n = 12), buccal mucosa (n = 11), mandible (n = 17), floor of the mouth (n = 9), and tongue (n = 53). The number of patients with stage I, II, III, and IV oral cancers was 28 (27.5%), 34 (27.5%), 26 (33.3%), and 14 (13.7%), respectively. During the observation period, 21 patients died of head and neck cancer. The optimal cut-off PNI value was 42.9, according to the receiver operating characteristic analysis. The proportion of patients with a short OS was lower in those with PNI higher than 42.9, and the 5-year OS in patients with PNI higher and lower than the cut-off value was 62.3% and 86.0%, respectively (P = 0.0105).

CONCLUSIONS

The OS of patients with PNI < 42.9 was lower than that of patients with PNI ≥ 42.9. The PNI, which is a preoperative head-to-foot inflammatory marker, can help in estimating the prognosis of oral cancer.

Evaluation of Scoring Systems for Airway Management After Oral Cancer Surgery: A Retrospective Study

OBJECTIVE

Postoperative airway obstruction following oral cancer surgery is difficult to predict. Scoring systems used to assess the need for tracheotomy use risk factors as criteria. We aimed to examine whether these clinical scoring systems can predict airway obstruction following oral cancer surgery.

METHODS

We assessed 95 patients who underwent oral cancer surgery without tracheotomy under general anesthesia between January 2007 and April 2019. We reviewed multiple factors from the patients' medical records, including age, sex, tumor site, body mass index, tumor stage, type of surgery, airway management method, Cameron and Gupta scores, and postoperative airway complications.

RESULTS

Tumors were located in the maxilla (n = 14), buccal mucosa (n = 13), mandible (n = 14), floor of the mouth (n = 6), and tongue (n = 48). Twenty-seven patients (28.4%) were graded as Stage 1, 37 patients (38.9%) as Stage 2, 9 patients (9.5%) as Stage 3, and 3 (3.2%) patients as Stage 4. Nine patients (9.5%) had local recurrences, and ten patients (10.5%) had neck metastases. Postoperative oxygen administration alone failed to improve dyspnea in 4 patients (4.2%). The median Cameron scores between patients with and without airway trouble were not significantly different (P = 0.226). However, a significant difference was observed in median Gupta scores between patients with and without airway trouble (P = 0.01). We created a receiver operating characteristic curve to predict postoperative airway trouble based on the preoperative Gupta score; the area under the curve was 0.856 (95% confidence interval: 0.61-1). A Gupta score cutoff value of 3.0 had a sensitivity of 92.3% and specificity of 75.0%.

CONCLUSIONS

Screening based on the Gupta score appears to be effective in predicting postoperative airway obstruction. We propose that this screening tool can be used to better plan tracheotomy and other airway management strategies during preoperative patient assessment.

Replacement of lip-split mandibulotomy by pull-through approach for T3-4 oral carcinomas

At the study hospital, the lip-split mandibulotomy (LSM) has progressively been replaced by a pull-through (PT) approach. This study compared the outcomes of the LSM and PT approaches in a series of 192 patients with T3-T4a oral tongue and floor of the mouth squamous cell carcinoma treated over the two last decades. No difference in margin status (P = 0.254), rate of early complications (local infections) (P = 0.867), haematoma/haemorrhage (P = 0.221), delayed wound healing (P = 0.438), re-operation (P = 0.083), or Clavien-Dindo classification (P= 0.5281) was found. The LSM approach was associated with a higher rate of late complications such as pseudarthrosis (14.5% vs 0.9%; OR 17.89, P = 0.0005) and trismus (35% vs 13.8%; OR 3.32, P = 0.025), and a trend towards a higher rate of fistulas (24.6% vs 13.1%; OR 2.16, P = 0.088). The quality of life of long-term survivors (median 132 months) was similar in the two groups, with a mean QLQC30 score of 59.7 (P = 0.099) and mean MDADI score of 57.4 (P = 0.213). The 5-year local control rate was 86.4% in the PT group and 86.2% in the LSM group (P = 0.878), while the 5-year overall survival rates were 50.0% and 48.3%, respectively (P = 0.68). In our experience, replacement of LSM by a PT approach in oral carcinoma was associated with decreased rates of late complications such as pseudarthrosis, fistula, and trismus, without any difference in oncological outcomes.

Comparison of Gemcitabine Plus Cisplatin vs. Docetaxel Plus Fluorouracil Plus Cisplatin Palliative Chemotherapy for Metastatic Nasopharyngeal Carcinoma

Objective: Our study aimed to compare the efficacy and toxicity of two chemotherapy regimens, gemcitabine plus cisplatin (GP) vs. docetaxel plus, fluorouracil plus cisplatin (TPF), in metastatic nasopharyngeal carcinoma (NPC) patients.

Methods: We retrospectively enrolled metastatic NPC patients between July 2006 and December 2016 who were treated with TPF or GP palliative chemotherapy (PCT). The association between the PCT regimens and survival conditions was evaluated by log-rank tests and the Cox proportional hazards model. A cohort was created using propensity score matching with the ratio of 1:1 to clarify the results of the multivariable Cox regression analyses. Overall survival (OS) was the primary endpoint.

Results: Of 266 eligible patients, 186 and 80 patients, respectively, received TPF and GP regimen. No significant difference was demonstrated in the survival rate between the GP and TPF groups (3-year OS: 52.6 vs. 50.3%; P = 0.929). However, multivariable analysis suggested receiving GP as an independent protective factor (hazard ratio, 0.864; 95% confidence interval, 0.753–0.992; P = 0.042). In the matched cohort, treatment with GP was also associated with a significantly higher OS (3-year OS: 52.6 vs. 35.6%, P = 0.042). Subgroup analysis indicated that the superiority of GP reflected in patients with secondary metastases rather than primary metastases. The incidence of grade 3 to 4 treatment-related toxicity was more common in the TPF group than in the GP group.

Conclusion: Our study suggested that GP might be superior to TPF for metastatic NPC patients, especially those with secondary distant metastases. Further studies are necessary to validate our results.

Primary tumor volume as a predictor of distant metastases and survival in patients with sinonasal mucosal melanoma

BACKGROUND

Sinonasal mucosal melanoma (SNMM) is an aggressive cancer with high mortality. Identifying patients at risk of distant metastasis assists with management and prognostication. We aimed to define the relationship between volume, survival, and risk of distant metastases.

METHODS

A retrospective review of all patients with SNMM treated at a single institution over a 21-year period was conducted. Tumor volume was calculated using cross-sectional imaging and survival analysis was performed.

RESULTS

Sixty-one patients were included. Tumor volume was predictive of local progression-free survival (P = .03), distant metastases-free survival (DMFS) (P = .002), and overall survival (OS) (P = .02). It was a better predictor than AJCC stage and T-classification. Tumor volume equal to or greater than 5 cm³ was associated with a significantly worse DMFS and OS (P = .02 and .009, respectively).

CONCLUSION

Calculation of tumor volume assists in quantifying the risk of distant metastases and death in SNMM.

Correlation Between FDG Hotspots on Pre-radiotherapy PET/CT and Areas of HNSCC Local Relapse: Impact of Treatment Position and Images Registration Method

Aim: Several series have already demonstrated that intratumoral subvolumes with high tracer avidity (hotspots) in 18F-flurodesoxyglucose positron-emission tomography (FDG-PET/CT) are preferential sites of local recurrence (LR) in various solid cancers after radiotherapy (RT), becoming potential targets for dose escalation. However, studies conducted on head and neck squamous cell carcinoma (HNSCC) found only a moderate overlap between pre- and post-treatment subvolumes. A limitation of these studies was that scans were not performed in RT treatment position (TP) and were coregistred using a rigid registration (RR) method. We sought to study (i) the influence of FDG-PET/CT acquisition in TP and (ii) the impact of using an elastic registration (ER) method to improve the localization of hotpots in HNSCC.

Methods: Consecutive patients with HNSCC treated by RT between March 2015 and September 2017 who underwent FDG-PET/CT in TP at initial staging (PET_A) and during follow-up (PET_R) were prospectively included. We utilized a control group scanned in non treatment position (NTP) from our previous retrospective study. Scans were registered with both RR and ER methods. Various sub-volumes (A_X; x = 30, 40, 50, 60, 70, 80, and 90%SUVmax) within the initial tumor and in the subsequent LR (R_X; x = 40 and 70%SUVmax) were overlaid on the initial PET/CT for comparison [Dice, Jaccard, overlap fraction = OF, common volume/baseline volume = A_XnR_X/A_X, common volume/recurrent volume = A_XnR_X/R_X].

Results: Of 199 patients included, 43 (21.6%) had LR (TP = 15; NTP = 28). The overlap between A₃₀, A₄₀, and A₅₀ sub-volumes on PET_A and the whole metabolic volume of recurrence R₄₀ and R₇₀ on PET_R showed moderate to good agreements (0.41–0.64) with OF and A_XnR_X/R_X index, regardless of registration method or patient position. Comparison of registration method demonstrated OF and A_XnR_X/R_X indices (x = 30% to 50%SUVmax) were significantly higher with ER vs. RR in NTP (p < 0.03), but not in TP. For patient position, the OF and A_XnR_X/R_X indices were higher in TP than in NTP when RR was used with a trend toward significance, particularly for x=40%SUVmax (0.50±0.22 vs. 0.31 ± 0.13, p = 0.094).

Conclusion: Our study suggested that PET/CT acquired in TP improves results in the localization of FDG hotspots in HNSCC. If TP is not possible, using an ER method is significantly more accurate than RR for overlap estimation.

Physical rehabilitation in patients with head and neck cancer: Impact on health-related quality of life and suitability of a post-treatment program

OBJECTIVE

Physical rehabilitation programs hold the potential to mitigate deterioration in health-related quality of life (HRQoL) in patients with head and neck cancer. The objective was to assess development in relevant domains of HRQoL following a physical exercise and nutrition intervention administrated during or after treatment.

METHODS

In a pilot study, 41 patients were randomized to resistance training and oral nutritional supplements during (EN-DUR, n = 20) or after (EN-AF, n = 21) radiotherapy. Global health status/QoL (GHS) and physical functioning (PF) were measured by the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire at baseline, week 6, and week 14. Differences between the groups were assessed by analysis of covariance. A difference of ≥10 points in GHS and PF was interpreted as clinically relevant.

RESULTS

No statistically significant differences were detected between the groups; however, clinically relevant changes and differences in GHS and PF were observed. From baseline to week 6, GHS decreased 9 points in the EN-DUR group and 23 points in the EN-AF group and PF decreased 13 points and 21 points, respectively. From week 6 to week 14, GHS increased 14 points in the EN-DUR group and 26 points EN-AF group and PF did not change (0 points) in the EN-DUR group and increased 16 points in the EN-AF group.

CONCLUSION

The findings from the present pilot study are promising and indicate that a physical rehabilitation program may have a positive impact on HRQoL during treatment and enhance recovery after treatment. A definitive randomized trial is warranted.

LEVEL OF EVIDENCE

1b-Individual randomized controlled trial.

Pituitary Dysfunction after Radiation for Anterior Skull Base Malignancies: Incidence and Screening

Background  Management of anterior cranial base malignancies requires multidisciplinary care. Radiation therapy remains a mainstay of definitive or adjuvant treatment. Apart from primary hypothyroidism, the effects of radiation on the hypothalamic-pituitary axis after high-dose treatment of head and neck malignancies remain poorly described. We describe a comprehensive screening protocol for surveillance and characterize the incidence of pituitary dysfunction after radiation for anterior cranial base malignancies. Methods  A review of patients prospectively enrolled in a skull base registry at an academic center was performed. Included patients had a history of anterior skull base malignancy and external beam radiation to the primary site, with comprehensive post-treatment pituitary serologies and at least 1 year of post-radiation follow-up. Routine hormonal screening was initiated during the study period for all patients with anterior skull base irradiation. Results  Eighty-one patients met inclusion. Fifty-eight patients (71%) demonstrated some laboratory abnormality. Thirty patients (37%) demonstrated evidence of hypopituitarism. Twenty-four (29%) demonstrated central hypogonadism, and 16% of patients showed central hypothyroidism. Ten patients (12%) displayed central adrenal insufficiency with six patients demonstrating panhypopituitarism. Primary tumor location and maximum dose of radiation to the gland appeared to correlate with incidence of hypopituitarism. Conclusion  Radiation for malignancies of the anterior skull base resulted in a 37% incidence of hypopituitarism in our study. Given the potential morbidity of hypopituitarism, we recommend annual post-treatment screening in these patients. We describe a comprehensive set of serologies that can be utilized, and recommend updating clinical guidelines to reflect the necessity of this screening.

Establishment and validation of two nomograms to predict the benefit of concurrent chemotherapy in stage II-IVa nasopharyngeal carcinoma patients with different risk factors: Analysis based on a large cohort

Objective

We aimed to establish and validate two nomograms that predict progression‐free survival (PFS) and overall survival (OS) in patients with stage II–IVa nasopharyngeal carcinoma (NPC) while evaluating the benefit of concurrent chemotherapy.

Patients and Methods

We randomly divided 3412 patients newly diagnosed with stage II‐IVa NPC between 2008 and 2013 into training and validation ‘A’ cohorts (n = 1706 each). Another set of patients diagnosed between 2014 and 2016 served as validation cohort ‘B’ (n = 1503). A Cox multivariate model using the backward stepwise approach was applied to develop the nomograms, which were assessed for accuracy (Harrel C index) and calibration.

Results

The 3‐ and 5‐year PFS rates in the training cohort were 86.8% (95% confidence interval [CI] 85.0%‐88.6%) and 82.3% (95% CI 80.1%‐84.5%), respectively. For the PFS nomogram, 5 variables were selected based on a backward procedure in the multivariate Cox model (gender, T stage, N stage, Epstein‐Barr virus DNA, and treatment method). The same variables plus patient age and diabetes mellitus were used for the OS nomogram. The Harrell C indices of the training, validation A, and validation B cohorts were 0.711, 0.700, and 0.703, respectively, for PFS, and 0.775, 0.743, and 0.727, respectively, for OS. Both nomograms performed well in terms of calibration in the training and validation cohorts.

Conclusions

Our nomograms are reliable prognostic predictors of PFS and OS in patients with stage II‐IVa NPC. These nomograms could robustly estimate an individual's benefit from concurrent chemotherapy, which assists in treatment decision‐making.

Establishment and validation of a nomogram for predicting the benefit of concurrent chemotherapy in stage II nasopharyngeal carcinoma: A study based on a phase III randomized clinical trial with 10-year follow-up

BACKGROUND AND PURPOSE

Our previous phase III randomized trial demonstrated that the addition of concurrent chemotherapy to radiotherapy (RT) could improve survival in stage II nasopharyngeal carcinoma (NPC). Based on the study, we sought to develop a nomogram for predicting the 5-year and 10-year survival of patients with stage II NPC and estimating the benefit of concurrent chemoradiotherapy (CCRT) for individual patients.

MATERIALS AND METHODS

Data of 199 enrolled patients from the original trial was analyzed to build a nomogram. Overall survival (OS) was the primary endpoint. The discrimination and calibration capacities were evaluated using Harrell Concordance Index (C-index) and calibration curves, respectively. Internal validation of the nomogram was performed by a separate cohort of 306 patients from the same cancer center.

RESULT

In training cohort, patients in CCRT group achieved higher 5-year and 10-year OS compared with patients in RT group. Three independent prognostic factors, which were age, N stage and treatment method from multivariable analysis were extracted to enter the nomogram. T stage was also included due to its importance in clinical decisions. The Harrell C-index of the nomogram in training and validation cohort was 0.748 and 0.653 respectively. The calibration curves showed an acceptable agreement between prediction and observed probability.

CONCLUSION

We developed and validated a nomogram to predict the 5-year and 10-year OS in stage II NPC patients. The nomogram could serve as a pragmatic tool in clinical decisions to estimate the individual risk of stage II patients and identify those who could benefit from chemotherapy.

Integrin α7 correlates with worse clinical features and prognosis, and its knockdown inhibits cell proliferation and stemness in tongue squamous cell carcinoma

The present study aimed to evaluate the correlation of integrin α7 (ITGA7) with clinicopathological characteristics and overall survival (OS) in patients with tongue squamous cell carcinoma (TSCC), and to investigate the effect of ITGA7 knockdown on proliferation, apoptosis and stemness of TSCC cells in vitro. ITGA7 expression was measured in tumor tissues and paired adjacent normal tissues from 60 patients with TSCC using immunohistochemistry. ITGA7 expression in human TSCC cell lines and normal oral keratinocytes was measured using quantitative PCR and western blotting. Lentiviruses carrying short hairpin (sh) RNA targeting ITGA7 were used to knockdown its expression in CAL-27 and HSC-4 cells, and then proliferation, apoptosis and stemness were measured. In addition, CAL-27 and HSC-4 cancer stem cells (CSCs) were constructed and their ITGA7 expression was measured. The results demonstrated that ITGA7 was upregulated in the tumor tissues compared with the paired adjacent tissues, and its high expression was correlated with worse pathological grade, N stage, TNM stage and OS. In vitro, ITGA7 expression levels were demonstrated to be increased in the TSCC CAL-27, SCC-9, HSC-4 and SCC-25 cell lines compared to the normal HOK cell line. In CAL-27 and HSC-4 cells, ITGA7 knockdown inhibited cell proliferation, promoted apoptosis, increased CD24 expression, decreased CD44 and CD133 expression, reduced drug resistance to cisplatin and attenuated sphere formation efficiency. Finally, ITGA7 expression levels were greatly elevated in CAL-27 and HSC-4 CSCs compared with parental CAL-27 and HSC-4 cells. In conclusion, ITGA7 knockdown inhibited tumor cell proliferation and stemness in TSCC cells. These findings indicated that ITGA7 might serve as a potential marker for CSCs and may correlate with worse clinical features and prognosis in TSCC.

Defect-oriented reconstruction after transoral robotic surgery for oropharyngeal cancer: a case series and review of the literature

Transoral robotic surgery (TORS) is a fascinating new technique that has been shown to be a safe and feasible treatment for selected oropharyngeal cancers. Furthermore, TORS might offer some advantages in selected locoregionally advanced cancers. Thus, the patient selection is the keypoint for the useful application of TORS. However, the reconstruction of large oropharyngeal defects is challenging due to the restoration of velopharyngeal competency and swallowing. Moreover, the absence of mandibular splitting increases the difficulties faced by reconstructive surgeons. The paradigm for oropharyngeal reconstruction has undergone changes paralleling reflecting the overall change in the trend of the treatment alternatives over the last few decades. Flap choice and harvesting should be tailored to obtain significant advantages both in functional terms and for easy insetting. In this review, we analyse the strengths and weaknesses of the various flaps used in TORS framework with particular regards on our preliminary experience.

The effectiveness of intensity-modulated radiation therapy versus 2D-RT for the treatment of nasopharyngeal carcinoma: A systematic review and meta-analysis

BACKGROUND

At present, the management of nasopharyngeal carcinoma (NPC) is mainly based on radiotherapy, but there are many radiation delivery techniques such as intensity-modulated radiotherapy (IMRT) and 2-dimensional radiotherapy (2D-RT).

MATERIALS AND METHODS

We searched all the eligible studies through the PubMed, Cochrane Library, Medline, and Embase. The endpoint events in meta-analysis were overall survival (OS), tumor local control including local-regional free survival (LRFS), progression-free survival (PFS), and distant metastasis-free survival (DMFS), and late toxicities.

RESULTS

A total of ten publications met the criteria and were identified through searches of the databases and references. We included 13304 patients in the meta-analysis, of whom 5212 received IMRT and 8092 were allocated to 2D-RT alone group. Compared with 2D-RT treatment, the IMRT group was associated with a better 5-year OS (OR = 1.70; 95% CI = 1.36-2.12), LRFS (OR = 2.08; 95% CI = 1.82-2.37), and PFS (OR = 1.40; 95% CI = 1.26-1.56). Additionally, the incidence of late toxicities such as late xerostomia (OR = 0.21; 95% CI = 0.09-0.51), trismus (OR = 0.16; 95% CI = 0.04-0.60), and temporal lobe neuropathy (TLN) (OR = 0.40; 95% CI = 0.24-0.67) for NPC patients in IMRT group were significantly lower than 2D-RT.

CONCLUSIONS

The meta-analysis demonstrates that IMRT provides improved long-term tumor overall survival and local control including LRFS and PFS. Additionally, IMRT yields a lower incidence of late toxicities induced by irradiation in NPC patients. Compared to 2D-RT, IMRT may be an effective treatment for patients with NPC. Further intensive studies should be pursued to examine the association.

Individualized concurrent chemotherapy by pretreatment plasma Epstein-Barr viral DNA in II-III stage nasopharyngeal carcinoma: A propensity score matching analysis using a large cohort

Object

To ascertain the treatment effect of concurrent chemotherapy (CCT) in stage II‐III nasopharyngeal carcinoma (NPC) patients with different Epstein‐Barr virus (EBV) DNA level in intensity‐modulated radiotherapy (IMRT) era.

Methods

A total of 2742 patients diagnosed with stage II‐III NPC were involved in this study. Patients received IMRT with/without CCT. Overall survival (OS) was the primary endpoint. Receiver operating characteristics curve was used to determine the cut‐off value of pre‐DNA based on OS. After propensity score matching, the role of CCT was explored in patients with different EBV DNA level.

Results

In our cohort, the cut‐off value of pre EBV DNA was 1460 copies/mL (area under curve [AUC], 0.695‐0.769; sensitivity, 0.766; specificity, 0.599). Patients with high EBV DNA level showed poor survival in OS, progression free survival (PFS), locoregional relapse‐free survival (LRFS) and distant metastasis‐free survival (DMFS). In patients with EBV DNA level >1460 copies/mL, the concurrent chemoradiotherapy (CCRT) group achieved higher 3‐year OS compared with IMRT groups. However, the CCRT and IMRT groups showed comparable OS in patients with EBV DNA ≤1460 copies/mL. In multivariate analyses, CCT was a protective factor for OS, PFS, and LRFS in high‐risk patients (EBV DNA level >1460 copies/mL), while not an independent prognostic factor among the low‐risk patients (EBV DNA level ≤1460 copies/mL).

Conclusion

Pre‐EBV DNA could be a useful tool to guide individualized treatment for stage II‐III NPC patients. Additional CCT to IMRT improved the survival for patients with high pre‐EBV DNA, while those with low pre‐EBV DNA could not.

A randomized phase 3 trial comparing nimotuzumab plus cisplatin chemoradiotherapy versus cisplatin chemoradiotherapy alone in locally advanced head and neck cancer

BACKGROUND

Because the addition of nimotuzumab to chemoradiation in patients with locally advanced head and neck cancer improved outcomes in a phase 2 study, the authors conducted a phase 3 study to confirm these findings.

METHODS

This open-label, investigator-initiated, phase 3, randomized trial was conducted from 2012 to 2018. Adult patients with locally advanced head and neck cancer who were fit for radical chemoradiation were randomized 1:1 to receive either radical radiotherapy (66-70 grays) with concurrent weekly cisplatin (30 mg/m² ) (CRT) or the same schedule of CRT with weekly nimotuzumab (200 mg) (NCRT).The primary endpoint was progression-free survival (PFS); key secondary endpoints were disease-free survival (DFS), duration of locoregional control (LRC), and overall survival (OS). An intent-to-treat analysis also was performed.

RESULTS

In total, 536 patients were allocated equally to both treatment arms. The median follow-up was 39.13 months. The addition of nimotuzumab improved PFS (hazard ratio [HR], 0.69; 95% CI, 0.53-0.89; P = .004), LRC (HR, 0.67; 95% CI, 0.50-0.89; P = .006), and DFS (HR, 0.71; 95% CI, 0.55-0.92; P = .008) and had a trend toward improved OS (HR, 0.84; 95% CI, 0.65-1.08; P = .163). Grade 3 through 5 adverse events were similar between the 2 arms, except for a higher incidence of mucositis in the NCRT arm (66.7% vs 55.8%; P = .01).

CONCLUSIONS

The addition of nimotuzumab to concurrent weekly CRT improves PFS, LRC, and DFS. This combination provides a novel alternative therapeutic option to a 3-weekly schedule of 100 mg/m² cisplatin in patients with locally advanced head and neck cancer who are treated with radical-intent CRT.

Organ Preservation Protocols in T4 Laryngeal Cancer: a Review of the Literature

Population-based studies indicate that chemoradiation has become the most popular treatment for advanced laryngeal cancers; however, by extrapolating trial results to the general population, several issues have emerged, such as reduced overall survival, non-functional laryngeal preservation, and poor response to treatment. Although included in these trials, T4 laryngeal and hypopharyngeal cancers with cartilage invasion formed a small percentage of these patients and questions over whether they were appropriately staged remain unanswered. Literature on the use of chemoradiation in this set of patients, including the challenges, treatment considerations, and factors predicting response to treatment and outcomes, was reviewed. Current evidence indicates that all patients of T4 laryngeal and hypopharyngeal cancer are not suitable candidates for organ preservation; this modality should be offered only to select patients with good performance status and access to rehabilitative care and regular follow-up in order to achieve good results.

Association between pretreatment obesity, sarcopenia, and survival in patients with head and neck cancer

BACKGROUND

Body mass index (BMI), sarcopenia, and obesity-related comorbidities have been associated with head and neck squamous cell carcinoma (HNSCC) progression.

METHODS

We conducted a retrospective analysis of 441 normal-weight, overweight, and obese HNSCC patients treated at Montefiore Medical Center (New York). Patients were grouped by BMI prior to treatment and assessed for differences in survival adjusting for comorbid conditions (cardiovascular disease and diabetes). Evidence of sarcopenia was also assessed using pretreatment abdominal CT scans in a subset of 113 patients.

RESULTS

Prior to treatment, 55% of HNSCC patients were overweight or obese. Overweight/obese patients had significantly better overall survival (hazard ratio [HR] = 0.4, 95% CI: 0.3-0.6) compared to normal-weight patients, independent of comorbid conditions. Patients with sarcopenia had significantly poorer survival (HR = 2.1, 95% CI: 1.1-3.9) compared to non-sarcopenic patients, with the strongest association seen among overweight/obese patients.

CONCLUSION

Our data support the importance of sarcopenia assessment, in addition to BMI, among patients with HNSCC.

The role of elective neck dissection in patients with adenoid cystic carcinoma of the head and neck

OBJECTIVE

To investigate the frequency and outcomes of elective neck dissection (END) for adenoid cystic carcinoma (ACC) of the head and neck.

METHODS

The National Cancer Database was queried for a cohort study of patients with ACC of the major salivary glands, nasal cavity/nasopharynx, hard/soft palate, tongue, floor of mouth, larynx, and oral cavity who underwent primary surgical resection from 2004 to 2014. Multivariable logistic regression was used to identify predictors of END and occult nodal metastasis. Overall survival (OS) was estimated using the Kaplan-Meier method and modeled with Cox proportional hazards regression.

RESULTS

Among 2,807 patients with ACC treated surgically, 636 (22.7%) underwent END. Patients with ACC of the salivary glands and tongue most frequently underwent END; patients with hard/soft palate (odds ratio [OR] 0.06, P < 0.001) and nasal cavity/nasopharynx (OR 0.05, P < 0.001) ACC rarely underwent END compared to patients with major salivary gland cancer. Increasing tumor (T) stage (T4 vs. T1, OR 3.02, P < 0.001) was associated with END. Patients with advanced T3 to T4 ACC of the major salivary glands demonstrated extended OS associated with END (5-year OS 78.1% vs. 70.4%, P = 0.041) on Kaplan-Meier analysis and with END with adjuvant radiation therapy (hazard ratio 0.55, P = 0.027) using Cox proportional hazards regression. Elective neck dissection for T4 ACC of the salivary glands (21.3%) and tongue (25.5%) most consistently revealed occult nodal metastasis.

CONCLUSION

Elective neck dissection for ACC of the major salivary glands or tongue is most likely to reveal occult nodal metastasis. Elective neck dissection is associated with extended OS for advanced-stage ACC of the major salivary glands.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2094-2104, 2019.

Identifying optimal candidates for local treatment of the primary tumor among patients with de novo metastatic nasopharyngeal carcinoma: a retrospective cohort study based on Epstein-Barr virus DNA level and tumor response to palliative chemotherapy

Background

To evaluate the clinical outcome in patients with de novo metastatic nasopharyngeal carcinoma (NPC) treated or not treated with locoregional radiotherapy (LRRT) based on plasma Epstein–Barr virus (EBV) DNA level and tumor response after palliative chemotherapy (PCT).

Methods

From 2007 to 2016, 502 patients with de novo metastatic NPC were included in this study. All patients were treated with PCT and 315 patients received LRRT. Our primary study endpoint was overall survival (OS).

Results

EBV DNA was detected in 461 patients (91.8%) before treatment but was undetectable in 249 patients (49.6%) after PCT. Three hundred and seventeen patients (63.1%) achieved satisfactory response (complete response or partial response) to PCT. Both the post-PCT EBV DNA level and tumor response were independent prognostic factors. Among low-risk patients (patients with undetectable EBV DNA and satisfactory tumor response after PCT), the 3-year OS rate was 80.4% in LRRT-treated patients and 45.3% in patients not treated with LRRT (P < 0.001). Multivariate analyses demonstrated that LRRT was an independent prognostic factor of OS in the low-risk patients (P < 0.001). However, among the high-risk patients (patients with detectable EBV DNA and/or unsatisfactory response after PCT), no statistically significant survival differences were observed between the LRRT and non-LRRT groups.

Conclusions

EBV DNA level and tumor response after PCT both correlate with the prognosis of de novo metastatic NPC. In such cases, LRRT may benefit the patients with undetectable EBV DNA levels and satisfactory tumor response after PCT.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5281-5) contains supplementary material, which is available to authorized users.

Predictive value of pretreatment MRI texture analysis in patients with primary nasopharyngeal carcinoma

Objectives

To determine the predictive value of pretreatment MRI texture analysis for progression-free survival (PFS) in patients with primary nasopharyngeal carcinoma (NPC).

Methods

Ethical approval by the institutional review board was obtained for this retrospective analysis. In 79 patients with primary NPC, texture analysis of the primary tumour was performed on pretreatment T2 and contrast-enhanced T1-weighted images (T2WIs and CE-T1WIs). The Cox proportional hazards model was used to determine the association of texture features, tumour volume and the tumour-node-metastasis (TNM) stage with PFS. Survival curves were plotted using the Kaplan-Meier method. The prognostic performance was evaluated with the receiver operating characteristic (ROC) analyses and C-index.

Results

Tumour volume (hazard ratio, 1.054; 95% confidence interval [CI], 1.016–1.093) and CE-T1WI-based uniformity (hazard ratio, 0; 95% CI, 0–0.001) were identified as independent predictors for PFS (p < 0.05). Kaplan-Meier analysis showed that smaller tumour volume (less than the cut-off value, 11.699 cm³) and higher CE-T1WI-based uniformity (greater than the cut-off value, 0.856) were associated with improved PFS (p < 0.05). The combination of CE-T1WI-based uniformity with tumour volume and the overall stage predicted PFS better (area under the curve [AUC], 0.825; Cindex, 0.794) than the tumour volume (AUC, 0.659; C-index, 0.616) or the overall stage (AUC, 0.636; C-index, 0.627) did (p < 0.05).

Conclusions

A texture parameter of pretreatment CE-T1WI-based uniformity improves the prediction of PFS in NPC patients.

Key Points

• Higher CE-T1WI-based uniformity and smaller tumour volume are predictive of improved PFS in NPC patients.

• The combination of CE-T1WI-based uniformity with tumour volume and the overall stage has a better predictive ability for PFS than the tumour volume or the overall stage alone.

• Pretreatment MRI texture analysis has a prognostic value for NPC patients.

Electronic supplementary material

The online version of this article (10.1007/s00330-018-5961-6) contains supplementary material, which is available to authorized users.

Subdivision of Nasopharyngeal Carcinoma Patients with Bone-Only Metastasis at Diagnosis for Prediction of Survival and Treatment Guidance

Purpose

The purpose of this study was to subdivide M1 stage nasopharyngeal carcinoma (NPC) patients with bone-only metastases for prognosis prediction while identifying the treatment effect of locoregional radiotherapy (LRRT) and metastasis radiotherapy (MRT) among patients with different risk.

Materials and Methods

From November 2006 to October 2016, a total of 226 patients with bone-only metastasic NPC were retrospectively enrolled. All patients developed distant lesions before receiving treatment. All potential prognostic factors were considered and the correlation of the M1 subdivisions with overall survival (OS) was determined by Cox regression hazards model. Kaplan–Meier curves were used to appraise survival condition and log-rank testing was used to compare the differences.

Results

The median follow-up time was 33.9 months (range, 3 to 126 months). According to multivariate Cox proportional hazard analysis, the number of metastatic lesions and Epstein-Barr virus (EBV) DNA status after palliative chemotherapy (PCT) were independent prognostic factors for OS. Thus, we subdivided patients into three risk groups according to these two factors. Systemic chemotherapy combined with LRRT may benefit patients in low- and intermediate-risk groups but not in the high-risk group. Further aggressive MRT based on systemic chemotherapy showed no survival benefit in any risk group.

Conclusion

The stratification of NPC patients with bone-only metastasis based on EBV DNA after PCT and the number of metastatic lesions provided promising prognostic value and could aid clinicians in person-specific treatment.

Composition and Clinical Impact of the Immunologic Tumor Microenvironment in Oral Squamous Cell Carcinoma

Immunotherapy shows promising results and revolutionizes treatment of oral squamous cell carcinoma (OSCC). The immunologic microenvironment might have prognostic/predictive implications. Morphologic immunologic parameters (inflammatory infiltrate, stromal content, and budding activity [BA] [potentially indicating epithelial-mesenchymal transition]) were evaluated in 66 human primary therapy-naive OSCCs. Intraepithelial/stromal tumor-infiltrating lymphocytes (TILs; CD3⁺/CD4⁺/CD8⁺/CD4⁺FOXP3⁺/IL-17A⁺) were quantified, and ratios were calculated. HLA class I in tumor cells was evaluated immunohistochemically. mRNA in situ hybridization to detect IFN-γ was performed. Analysis was performed within invasive front (IF) and tumor center (TCe). Decreased HLA expression was associated with low TIL density, pronounced stromal content, and high BA; IFN-γ in TILs was correlated with high-density TILs; and IFN-γ in tumor cells was correlated with absence of BA (p < 0.05). Heterogeneity of parameters (TCe/IF) was rare. Low density of stromal CD4⁺FOXP3⁺ TILs within TCe and IF was identified as an independent prognostic factor for poor overall, disease-specific, and disease-free survival (p ≤ 0.011). Refining prognostication in OSCC with high-density CD4⁺FOXP3⁺ infiltrate within TCe and/or IF, high FOXP3:CD4 ratio was significantly correlated with favorable outcome in this subgroup. Furthermore, high-stromal CD8:CD4 ratio was found to be an independent favorable prognostic factor. In summary, immunologic parameters were closely intertwined. Morphologic correlates of epithelial-mesenchymal transition were associated with downregulation of HLA and decreased inflammation. Heterogeneity was infrequent. Low-density stromal CD4⁺FOXP3⁺ infiltrate within TCe and IF was an independent poor prognostic factor. Stratification of cases with high-density CD4⁺FOXP3⁺ TILs by FOXP3:CD4 ratio enables refinement of prognostication of this subgroup. CD8:CD4 ratio was identified as an independent prognostic factor.

The existence of early stage oral mucosal melanoma: A 10-year retrospective analysis of 170 patients in a single institute

BACKGROUND

Oral mucosal melanoma (OMM) is an aggressive tumor with an extremely low incidence, and the current TNM Staging System has classified all OMMs as high stage. However, controversy remains regarding the existence of early stage OMMs.

PATIENTS AND METHODS

The clinical and pathological features, treatments and outcomes of 170 OMM patients treated in a single institution from January 2007 to July 2017 were retrospectively analyzed. Multivariate analysis was performed to identify significant prognostic factors for overall survival (OS).

RESULTS

Multivariate analysis identified positive cervical lymph nodes (p < 0.0001), nodular OMMs (p < 0.0001), ulceration (p = 0.002), and level III or level IV invasion (p < 0.0001) as independent poor prognostic factors for OS. Nodular OMM patients with a tumor size ≤1 cm had a better outcome than those with a tumor size >1 cm (p < 0.0001). Twenty-two patients with superficial invasion had a favorable survival without the need of adjuvant therapy (postoperative chemotherapy or radiotherapy), and the current TNM Staging System was not suitable for those patients. Patients with deep invasion were more likely to suffer from recurrence and distant metastasis.

CONCLUSIONS

Tumor size ≤1 cm and OMM in situ, although extremely rare, do exist. It is advisable for AJCC to consider tumor size ≤1 cm and OMM in situ as the early stage of OMM when updating the new Oral Melanoma Staging System.

EphA8 is a Prognostic Factor for Oral Tongue Squamous Cell Carcinoma

Background

Oral tongue squamous cell carcinoma (OTSCC) is the most common malignancy of the oral cavity. Here we explore the potential effects of EphA8, which is one of the receptors in Ephs subfamily of RTKs (receptor tyrosine kinases), in the progression and prognosis of OTSCC.

Material/Methods

A total of 119 OTSCC patients were enrolled in this retrospective study. Immunohistochemistry (IHC) staining and quantitative polymerase chain reaction (Q-PCR) were utilized to examine the expression of EphA8 in OTSSC tissues and adjacent non-tumor tissues. The relationship between EphA8 expression and the clinicopathological features of OTSCC patients were analyzed by chi-square. Survival analysis was carried out with Kaplan-Meier curve and the related log-rank test. Multivariate analysis was then undertaken to assess the prognosis factor by utilizing the Cox proportional hazard regression model. In addition, MTT assay and Matrigel invasion assay were performed to examine the effects of EphA8 on the proliferation and invasion capacities of human oral squamous carcinoma cells (SCC-25) and human tongue squamous cell carcinoma cells (H357).

Results

Q-PCR and IHC staining revealed that EphA8 was highly expressed in OTSCC tissues, especially in advanced stage OTSCC tissues. Kaplan-Meier curve showed that high EphA8 expression was significantly associated with poor prognosis, similar to age, smoking habit, drinking habit, tumor size, and TNM stage. Multivariate analysis indicated that EphA8 expression could serve as an independent prognostic factor in OTSCC. In vitro experiments revealed that overexpression of EphA8 might promote the progression of OTSCC via enhancing the invasion capacity but not proliferation capacity of tumor cells.

Conclusions

EphA8 was highly expressed in OTSCC tissues and was significantly associated with poor prognosis of OTSCC.

Impact of postoperative radiotherapy on survival and loco-regional control in node-negative oral cavity tumours classified as T3 using the AJCC Cancer Staging Manual eighth edition

According to the eighth edition of the AJCC Cancer Staging Manual (AJCC8), a depth of invasion (DOI) >10mm is classified as pT3, representing a locally advanced tumour requiring postoperative radiotherapy (PORT). When node-negative, however, evidence regarding whether PORT improves loco-regional control or survival is unclear. To clarify this, two cohorts of patients were studied: (1) patients classified as pT3N0 by the seventh edition of the AJCC manual (AJCC7), with DOI >10mm and a tumour diameter >4cm (17 patients who received PORT), and (2) patients classified as pT1N0 and pT2N0 by AJCC7, with DOI >10mm and a tumour diameter <4cm (55 patients who did not receive PORT). Loco-regional control and survival were analysed. PORT was found not to impact overall survival or disease-free survival. It was also found not to impact local, regional, or distant recurrence. Although the two subsets of patients considered here (DOI >10mm with tumour diameter below or above 4cm) were previously distinct, they are both considered pT3 in AJCC8. Data from this study indicate that the routine administration of PORT to patients with a DOI >10mm may not be warranted in the absence of other risk features such as nodal disease or close margins.

Peri-operative outcomes following major surgery for head and neck cancer in the elderly: institutional audit and case–control study

Objective

Elderly patients have been consistently shown to receive suboptimal therapy for cancers of the head and neck. This study was performed to determine the peri-operative outcomes of these patients and compare them with those of younger patients.

Methods

In this retrospective analysis, 115 patients aged 70 years or more undergoing major surgery for head and neck cancers were matched with 115 patients aged 50–60 years, and univariate analysis was performed.

Results

Elderly patients had a reduced performance status (p < 0.001) and more co-morbid illnesses (p = 0.007), but a comparable intra-operative course. They had a longer median hospital stay (p = 0.016), longer intensive care unit stay (p = 0.04), longer median tracheostomy dependence (p = 0.04) and were more often discharged with feeding tubes (p < 0.001). They also had a higher incidence of post-operative non-fatal cardiac events (p = 0.045).

Conclusion

Elderly patients with good performance status should receive curative-intent surgery. Although hospital stay and tube dependence are longer, morbidity and mortality are comparable with younger patients.

Factors pertaining to long-term mortality following emergency visits for head and neck cancer

Background/purpose

Avoiding mortality has been the ultimate goal in the management of head and neck cancer (HNC) patients with emergency department (ED) visits, however, risk factors and causes of mortality are not well studied. The objective of the present study is to verify the factors associated with long-term mortality of patients with HNC who visited ED.

Materials and methods

We retrospectively collected data of 1660 HNC patients who made ED visits from the Longitudinal Health Insurance Database 2000 during 2000–2012 in Taiwan. The multivariate Cox proportional hazard model was used to measure the mortality-associated risk factors in HNC patients who made ED visits.

Results

The prognostic factors associated with mortality risk were age (≥65 vs. < 65 y; HR = 1.58, p < 0.0001), geographic region (central vs. northern; HR = 1.20, p = 0.0384; southern vs. northern; HR = 1.38, p = 0.0001), surgery (yes vs. no; HR = 0.61, p < 0.0001), radiotherapy (yes vs. no; HR = 1.80, p < 0.0001), chemotherapy (yes vs. no; HR = 1.68, p < 0.0001), acute myocardial infarction (yes vs. no; HR = 2.01, p = 0.0303), diabetes mellitus (yes vs. no; HR = 1.60, p < 0.0001), chronic obstructive pulmonary (yes vs. no; HR = 1.51, p = 0.0002), number of ED visits (≥4 vs. 1; HR = 0.69, p = 0.0003), and number of admissions (1 vs. 0; HR = 1.54, p < 0.0001; ≥2 vs. 0; HR = 1.48, p = 0.0002).

Conclusion

Higher mortality was associated with older age, living in southern Taiwan, not having undergone surgery, having received radiotherapy and chemotherapy, comorbidities, and more hospital admissions. A coordinated and extended multidisciplinary approach including ED care is required to improve the long-term survival and further decrease the economic burden of HNC treatment.

Expressional analysis of disease-relevant signalling-pathways in primary tumours and metastasis of head and neck cancers

Head and neck squamous cell carcinoma (HNSCC) often metastasize to lymph nodes resulting in poor prognosis for patients. Unfortunately, the underlying molecular mechanisms contributing to tumour aggressiveness, recurrences, and metastasis are still not fully understood. However, such knowledge is key to identify biomarkers and drug targets to improve prognosis and treatments. Consequently, we performed genome-wide expression profiling of 15 primary HNSSCs compared to corresponding lymph node metastases and non-malignant tissue of the same patient. Differentially expressed genes were bioinformatically exploited applying stringent filter criteria, allowing the discrimination between normal mucosa, primary tumours, and metastases. Signalling networks involved in invasion contain remodelling of the extracellular matrix, hypoxia-induced transcriptional modulation, and the recruitment of cancer associated fibroblasts, ultimately converging into a broad activation of PI3K/AKT-signalling pathway in lymph node metastasis. Notably, when we compared the diagnostic and prognostic value of sequencing data with our expression analysis significant differences were uncovered concerning the expression of the receptor tyrosine kinases EGFR and ERBB2, as well as other oncogenic regulators. Particularly, upregulated receptor tyrosine kinase combinations for individual patients varied, implying potential compensatory and resistance mechanisms against specific targeted therapies. Collectively, we here provide unique transcriptional profiles for disease predictions and comprehensively analyse involved signalling pathways in advanced HNSCC.

Anatomical locations in the oral cavity where surgical resections of oral squamous cell carcinomas are associated with a close or positive margin-a retrospective study

OBJECTIVES

This study aimed to identify anatomical areas where resections of oral squamous cell carcinomas (OSCC) are significantly associated with close or positive margins.

MATERIALS AND METHODS

This retrospective study included 330 patients with a primary OSCC from 2010 to 2015. Patient and tumour data were categorised into three groups by R-status (R0 [clear], ≥ 5 mm, 185 patients [56.06%]; R1 [positive], < 1 mm, 24 patients [7.27%]; and R0 [close], 1-5 mm, 121 patients [36.67%]).

RESULTS

Areas where resections were significantly associated with close or positive margins were the hard palate (p < 0.001), buccal mucosa (p = 0.03), floor of the mouth (p = 0.004), lower alveolar ridge (p = 0.01), retromolar triangle (p = 0.005), and dorsal tongue (p = 0.02).

CONCLUSIONS

Anatomical areas were identified in the oral cavity where it is challenging to resect OSCCs with an adequate safety margin.

CLINICAL RELEVANCE

These results may enable surgeons to achieve a postulated safe distance during tumour resection, leading to a survival benefit for patients.

Unilateral radiotherapy treatment for p16/human papillomavirus-positive squamous cell carcinoma of unknown primary in the head and neck

OBJECTIVES/HYPOTHESIS

The outcomes of unilateral radiotherapy treatment for patients with p16/HPV-positive squamous cell carcinomas of unknown primary (SCCUP) affecting cervical lymph nodes are under-reported. Compared to radiating large volumes of the pharyngeal axis (the more common approach), this is potentially a much less toxic treatment for a good prognosis group.

STUDY DESIGN

Retrospective cohort study.

METHODS

We identified patients with SCCUP who were treated radically at our center and did not have parotid or isolated level IV or V nodal involvement. Failure-free and overall survivals were calculated using Kaplan-Meier methods.

RESULTS

From 2004 to 2012, there were 49 radically treated patients with SCCUP. Fourteen patients had bilateral neck treatment (they had bilateral nodal disease or suspected lesions in the base of tongue, though not proven with biopsy), two had surgery alone, whereas 33 had unilateral radiotherapy (after neck dissection, excisional biopsy, or definitively with concurrent chemotherapy). Of the 33 patients, 21 tested positive to p16/HPV and had median follow-up of 57 months. In this group, no isolated contralateral neck failures or putative primaries emerged. There was 1/21 (4.3%) ipsilateral neck failure, 1/21 (4.3%) concurrent contralateral neck and distant failure, and 1/21 (4.3%) patient with distant failure. The 5-year freedom from failure was 78% (95% confidence interval [CI]: 56%-100%) and overall survival was 90% (95% CI: 79%-100%).

CONCLUSIONS

With no emergence of putative primaries and no isolated contralateral neck failures, this single-institution experience in p16/HPV-positive SCCUP patients suggests that unilateral radiotherapy may be an underutilized management strategy.

LEVELS OF EVIDENCE

4 Laryngoscope, 128:2076-2083, 2018.

Radiation Therapy for the Head and Neck Patient: Advances, Challenges, and Perspectives

Radiation therapy for head and neck malignancies has made remarkable advances in treatment technology, resulting in improved clinical and functional outcomes. It is necessary for the radiation oncologist to have a complex understanding of the patient's tumor and its relationship to the surrounding normal anatomy, in order to safely limit dose to normal tissues. Complications following radiation can be managed with timely intervention, usually on an outpatient basis. This chapter will discuss the technological advances in the field, the impact of human papillomavirus (HPV)-mediated disease on radiation treatment, efforts to limit dose to critical salivary and swallowing structures, and management of certain radiation-related toxicities.

Intraoperative Brief Electrical Stimulation of the Spinal Accessory Nerve (BEST SPIN) for prevention of shoulder dysfunction after oncologic neck dissection: a double-blinded, randomized controlled trial

Background

Shoulder dysfunction is common after neck dissection for head and neck cancer (HNC). Brief electrical stimulation (BES) is a novel technique that has been shown to enhance neuronal regeneration after nerve injury by modulating the brain-derived neurotrophic growth factor (BDNF) pathways. The objective of this study was to evaluate the effect of BES on postoperative shoulder function following oncologic neck dissection.

Methods

Adult participants with a new diagnosis of HNC undergoing Level IIb +/− V neck dissection were recruited. Those in the treatment group received intraoperative BES applied to the spinal accessory nerve (SAN) after completion of neck dissection for 60 min of continuous 20 Hz stimulation at 3-5 V of 0.1 msec balanced biphasic pulses, while those in the control group received no stimulation (NS). The primary outcome measured was the Constant-Murley Shoulder (CMS) Score, comparing changes from baseline to 12 months post-neck dissection. Secondary outcomes included the change in the Neck Dissection Impairment Index (ΔNDII) score and the change in compound muscle action potential amplitude (ΔCMAP) over the same period.

Results

Fifty-four patients were randomized to the treatment or control group with a 1:1 allocation scheme. No differences in demographics, tumor characteristics, or neck dissection types were found between groups. Significantly lower ΔCMS scores were observed in the BES group at 12 months, indicating better preservation of shoulder function (p = 0.007). Only four in the BES group compared to 17 patients in the NS groups saw decreases greater than the minimally important clinical difference (MICD) of the CMS (p = 0.023). However, NDII scores (p = 0.089) and CMAP amplitudes (p = 0.067) between the groups did not reach statistical significance at 12 months. BES participants with Level IIb + V neck dissections had significantly better ΔCMS and ΔCMAP scores at 12 months (p = 0.048 and p = 0.025, respectively).

Conclusions

Application of BES to the SAN may help reduce impaired shoulder function in patients undergoing oncologic neck dissection, and may be considered a viable adjunct to functional rehabilitation therapies.

Trial registration

Clinicaltrials.gov (NCT02268344, October 17, 2014).

Clinicopathological factors influencing the outcomes of surgical treatment in patients with T4a hypopharyngeal cancer

Background

The purpose of this study was to determine prognostic factors influencing outcomes of surgical treatment in patients with T4a hypopharyngeal cancer.

Methods

The present study enrolled 93 patients diagnosed with T4a hypopharyngeal cancer who underwent primary surgery between January 2005 and December 2015 at six medical centers in Korea. Primary tumor sites included pyriform sinus in 71 patients, posterior pharyngeal wall in 14 patients, and postcricoid region in 8 patients. Seventy-two patients received postoperative radio(chemo)therapy.

Results

Five-year disease-free survival (DFS) and disease-specific survival (DSS) rates were 38% and 45%, respectively. In univariate analysis, 5-year DFS was found to have significant and positive correlations with margin involvement (p < 0.001) and extracapsular spread (p = 0.025). Multivariate analysis confirmed that margin involvement (hazard ratio (HR): 2.81; 95% confidence interval (CI): 1.49-5.30; p = 0.001) and extracapsular spread (HR: 2.08; 95% CI: 1.08-3.99; p = 0.028) were significant factors associated with 5-year DFS. In univariate analysis, cervical lymph node metastasis (p = 0.048), lymphovascular invasion (p = 0.041), extracapsular spread (p = 0.015), and esophageal invasion (p = 0.033) were significant factors associated with 5-year DSS. In multivariate analysis, extracapsular spread (HR: 2.98; 95% CI: 1.39-6.42; p = 0.005) and esophageal invasion (HR: 2.87; 95% CI: 1.38-5.98; p = 0.005) remained significant factors associated with 5-year DSS.

Conclusion

Margin involvement and extracapsular spread are factors influencing recurrence while extracapsular spread and esophageal invasion are factors affecting survival in patients with T4a hypopharyngeal cancer treated by primary surgery.

CD274/PD-L1 gene amplification and PD-L1 protein expression are common events in squamous cell carcinoma of the oral cavity

Immunomodulatory therapies, targeting the immune checkpoint receptor-ligand complex PD-1/PD-L1 have shown promising results in early phase clinical trials in solid malignancies, including carcinomas of the head and neck. In this context, PD-L1 protein expression has been proposed as a potentially valuable predictive marker. In the present study, expression of PD-L1 and PD-1 was evaluated by immunohistochemistry in 80 patients with predominantly HPV-negative oral squamous cell carcinomas and associated nodal metastasis. In addition, CD274/PD-L1 gene copy number status was assessed by fluorescence in situ hybridization analysis. PD-L1 expression was detected in 36/80 (45%) cases and concordance of PD-L1 expression in primary tumor and corresponding nodal metastasis was present in only 20/28 (72%) cases. PD-1 expression was found in tumor-infiltrating lymphocytes (TILs) but not in tumor cells. CD274/PD-L1 gene amplification was detected in 19% of cases, with high level PD-L1 amplification present in 12/80 (15%), and low level amplification in 3/80 (4%). Interestingly, CD274/PD-L1 gene amplification was associated with positive PD-L1 immunostaining in only 73% of cases. PD-L1 copy number status was concordant in primary tumor and associated metastases. Clinically, PD-L1 tumor immunopositivity was associated with a higher risk for nodal metastasis at diagnosis, overall tumor related death und recurrence. Based on our findings we propose to include PD-L1 copy number status in addition to protein status in screening programs for future clinical trials with immunotherapeutic strategies targeting the PD-1/PD-L1 axis.

Role of Adjuvant Treatment in Sinonasal Mucosal Melanoma

Purpose  Sinonasal mucosal melanoma (SNMM) is a locally aggressive tumor. This study aimed to define the role of adjuvant treatment and its association with survival outcomes of SNMM. Methods  This retrospective study investigated 152 patients with SNMM treated between 1991 and 2016 in MD Anderson Cancer Center. Patients were divided into the following treatment groups: surgery alone, surgery with postoperative radiotherapy (PORT), surgery with postoperative chemoradiation (POCRT), and induction chemotherapy followed by surgery and PORT. Overall survival (OS), disease-specific survival, and relapse-free survival were compared. Survival between the groups was compared using univariate and multivariate analyses. Results  The median follow-up was 28 months (range: 2-220 months). Five-year OS rates were 39, 42, 47, and 27% for the surgery only, PORT, POCRT, and neoadjuvant chemotherapy groups, respectively (log rank p  = 0.73). Distant metastasis was the most common form of treatment failure and occurred in 59 (39%) patients. Five-year distant metastasis rates were 51, 45, and 58% for patients treated with surgery alone, PORT, and POCRT, respectively (log rank p  = 0.21) but unable to be estimated in the neoadjuvant chemotherapy group due to low OS rates. Multivariate analysis demonstrated tumor site (hazard ratio [HR] = 2.32, 95% confidence interval [CI] = 1.24-4.15) and smoking status (HR = 1.77, 95% CI = 1.02-3.1) to be significant prognostic factors for survival. Conclusion  Tumor site and smoking status were significant prognosticators in SNMM. A high rate of distant metastatic disease suggests that further investigation into novel, systemic therapies is required to improve outcomes in this disease entity.