Head and Neck Cancers, Version 1.2015

Evaluation of response to neoadjuvant chemotherapy in technically unresectable moderately advanced oral cavity cancers

BACKGROUND

Moderately advanced and technically unresectable oral cavity cancers have a poor prognosis. Neoadjuvant chemotherapy might be beneficial in such patients by reducing tumour bulk and allowing definitive surgery.

AIM

To evaluate the response of neoadjuvant chemotherapy in moderately advanced technically unresectable oral cavity cancers.

METHODOLOGY

Prospective observational study - secondary data analysis of patients with moderately advanced oral cavity cancer, which were treated with neoadjuvant chemotherapy (NACT) during the period November 2014-April 2016. Data was analysed for information on patient characteristics, chemotherapy received, toxicity, clinical response rates, local treatment offered and pathological response rates. The statistical analysis was performed with SPSS version 20.

RESULTS

30 patients, with a median age of 52 years were analyzed. Buccal mucosa was the most common sub site (50%). Three drug regimen was utilized in all patients. Resectability was achieved in 14 patients (46.67%). Febrile neutropenia was seen in 3 patients (10%). The overall response rate was 31%.

CONCLUSION

NACT was effective in converting moderately advanced technically unresectable oral cavity cancers to operable disease in approximately 47% of patients. Post NACT, there is significant association between clinical and pathological findings of response rates. There is no increase in surgical complication rates following NACT.

Recurrent UBE3C-LRP5 translocations in head and neck cancer with therapeutic implications

Head and neck cancer is a major cause of morbidity and mortality worldwide. The identification of genetic alterations in head and neck cancer may improve diagnosis and treatment outcomes. In this study, we report the identification and functional characterization of UBE3C-LRP5 translocation in head and neck cancer. Our whole transcriptome sequencing and RT-PCR analysis of 151 head and neck cancer tumor samples identified the LRP5-UBE3C and UBE3C-LRP5 fusion transcripts in 5.3% of patients of Indian origin (n = 151), and UBE3C-LRP5 fusion transcripts in 1.2% of TCGA-HNSC patients (n = 502). Further, whole genome sequencing identified the breakpoint of UBE3C-LRP5 translocation. We demonstrate that UBE3C-LRP5 fusion is activating in vitro and in vivo, and promotes the proliferation, migration, and invasion of head and neck cancer cells. In contrast, depletion of UBE3C-LRP5 fusion suppresses the clonogenic, migratory, and invasive potential of the cells. The UBE3C-LRP5 fusion activates the Wnt/β-catenin signaling by promoting nuclear accumulation of β-catenin, leading to upregulation of Wnt/β-catenin target genes, MYC, CCND1, TCF4, and LEF1. Consistently, treatment with the FDA-approved drug, pyrvinium pamoate, significantly reduced the transforming ability of cells expressing the fusion protein and improved survival in mice bearing tumors of fusion-overexpressing cells. Interestingly, fusion-expressing cells upon knockdown of CTNNB1, or LEF1 show reduced proliferation, clonogenic abilities, and reduced sensitivity to pyrvinium pamoate. Overall, our study suggests that the UBE3C-LRP5 fusion is a promising therapeutic target for head and neck cancer and that pyrvinium pamoate may be a potential drug candidate for treating head and neck cancer harboring this translocation.

FKBP4 correlates with CD8+ T cells and lymphatic metastases in oral squamous cell carcinoma

OBJECTIVES

To identify the engagement of CD8+ T cells in the lymph node metastasis (LNM) of oral squamous cell carcinoma (OSCC) and significant CD8+ T cell-related genes regulating the LNM.

SUBJECTS AND METHODS

Tumor samples of primary OSCC patients were obtained (n = 71). CD8 expression in LNM- and LNM+ tumors were identified using tissue microarray (TMA)-based immunohistochemistry (IHC) and compared using the Mann-Whitney U test. The LNM status, as well as the metagene expression of CD8+ T cells of OSCC patients, were obtained from The Cancer Genome Atlas (TCGA) database. Metagenes related to LNM were screened using logistic regression analyses and further identified using TMA-based IHC.

RESULTS

CD8 was significantly positively associated with LNM (p < 0.05). Furthermore, tumors with higher expression of FKBP4 had significantly higher LNM rate (HR: 1.63; 95% CI: 1.08 ~ 2.53; p < 0.05), which was also proven using TMA-based IHC analysis.

CONCLUSION

CD8+ T cells might engage in the lymphatic metastases of OSCC. Among CD8+ T cell-related genes, FKBP4 could be a promising biomarker to predict the risk of LNM of OSCC.

Elucidating survival and functional outcomes in patients with primary head and neck malignancies treated in academic versus community settings

BACKGROUND

Differences in treatment outcomes between community or academic centers are incompletely understood.

METHODS

Retrospective review of head and neck cancer patients between 2010 and 2020 in a rural health region. Kaplan-Meier curves and log-rank tests were used to evaluate survival outcomes, along with bivariate and multivariable Cox proportional hazards models. Linear regression was used for functional outcomes of tracheotomy and gastrostomy tube dependence.

RESULTS

Two hundred and forty-eight patients treated at an academic center were compared with 94 patients treated in community centers. In multivariable analysis, the risk of death (HR = 0.60, p = 0.019), and risk of recurrence were lower (HR = 0.29, p < 0.001) for patients treated in academic centers. Patients treated in community centers had longer gastrostomy tube dependence (p = 0.002).

CONCLUSION

Our findings suggest that treatment at an academic center was associated with a lower risk of recurrence and shorter gastrostomy tube dependence compared to treatment in the community.

Cine MRI-based analysis of intrafractional motion in radiation treatment planning of head and neck cancer patients

PURPOSE/OBJECTIVE(S)

To investigate intrafraction motion of (HN) target volumes and to determine patient-specific planning target volume (PTV) margins.

MATERIALS/METHODS

MR-cine imaging was performed for radiation treatment planning in HN cancer patients treated with definitive EBRT (n = 62) or SBRT (n = 4) on a 1.5 T MRI between 2017-2019. Dynamic MRI scans (sagittal orientation, 2 × 82 × 7 mm3 resolution), ranging from 3-5 min and 900-1500 images, were acquired. The position of the maximum tumor displacement along each direction in the anterior/posterior (A/P) and superior/inferior (S/I) position was recorded and analyzed to determine average PTV margins.

RESULTS

Primary tumor sites (n = 66) were oropharynx (n = 39), larynx (n = 24) and hypopharynx (n = 3). PTV margins for A/P/S/I positions were 4.1/4.4/5.0/6.2 mm and 4.9/4.3/6.7/7.7 mm for oropharyngeal and laryngeal/hypopharyngeal cancers when accounting for all motion. V100 for PTV was calculated and compared to the original plans. The mean drop in PTV coverage was in most cases under 5%. For a subset of patients with 3 mm plans available, V100 for PTV had more substantial decreases in coverage averaging 8.2% - and 14.3% for oropharyngeal and laryngeal/hypopharynx plans, respectively.

CONCLUSION

The use of MR-cine in treatment planning allows for quantification of tumor motion during swallow and resting periods and should be accounted for during treatment planning. With motion considered, the derived margins may exceed the commonly used 3-5 mm PTV margins. Quantification and analysis of tumor and patient-specific PTV margins is a step towards real-time MRI guidance adaptive radiotherapy.

Margins in Stage I and II Oral Cavity Squamous Cell Carcinoma: A Review From the American Head and Neck Society

Importance

The assessment and management of surgical margins in stage I and II oral cavity squamous cell carcinoma is one of the most important perioperative aspects of oncologic care, with profound implications for patient outcomes and adjuvant therapy. Understanding and critically reviewing the existing data surrounding margins in this context is necessary to rigorously care for this challenging group of patients and minimize patient morbidity and mortality.

Observations

This review discusses the data related to the definitions related to surgical margins, methods for assessment, specimen vs tumor bed margin evaluation, and re-resection of positive margins. The observations presented emphasize notable controversy within the field about margin assessment, with early data coalescing around several key aspects of management, although studies are limited by their design.

Conclusions and Relevance

Stage I and II oral cavity cancer requires surgical resection with negative margins to obtain optimal oncologic outcomes, but controversy persists over margin assessment. Future studies with improved, well-controlled study designs are required to more definitively guide margin assessment and management.

Deep versus Handcrafted Tensor Radiomics Features: Prediction of Survival in Head and Neck Cancer Using Machine Learning and Fusion Techniques

BACKGROUND

Although handcrafted radiomics features (RF) are commonly extracted via radiomics software, employing deep features (DF) extracted from deep learning (DL) algorithms merits significant investigation. Moreover, a "tensor'' radiomics paradigm where various flavours of a given feature are generated and explored can provide added value. We aimed to employ conventional and tensor DFs, and compare their outcome prediction performance to conventional and tensor RFs.

METHODS

408 patients with head and neck cancer were selected from TCIA. PET images were first registered to CT, enhanced, normalized, and cropped. We employed 15 image-level fusion techniques (e.g., dual tree complex wavelet transform (DTCWT)) to combine PET and CT images. Subsequently, 215 RFs were extracted from each tumor in 17 images (or flavours) including CT only, PET only, and 15 fused PET-CT images through the standardized-SERA radiomics software. Furthermore, a 3 dimensional autoencoder was used to extract DFs. To predict the binary progression-free-survival-outcome, first, an end-to-end CNN algorithm was employed. Subsequently, we applied conventional and tensor DFs vs. RFs as extracted from each image to three sole classifiers, namely multilayer perceptron (MLP), random-forest, and logistic regression (LR), linked with dimension reduction algorithms.

RESULTS

DTCWT fusion linked with CNN resulted in accuracies of 75.6 ± 7.0% and 63.4 ± 6.7% in five-fold cross-validation and external-nested-testing, respectively. For the tensor RF-framework, polynomial transform algorithms + analysis of variance feature selector (ANOVA) + LR enabled 76.67 ± 3.3% and 70.6 ± 6.7% in the mentioned tests. For the tensor DF framework, PCA + ANOVA + MLP arrived at 87.0 ± 3.5% and 85.3 ± 5.2% in both tests.

CONCLUSIONS

This study showed that tensor DF combined with proper machine learning approaches enhanced survival prediction performance compared to conventional DF, tensor and conventional RF, and end-to-end CNN frameworks.

Criterios PERCIST, Hopkins y parámetros metabólicos de la PET/TC como factores pronósticos en el cáncer escamoso de cabeza y cuello

AIM

To assess the clinical utility of PERCIST and Hopkins criteria and changes in [¹⁸F]FDG PET/CT quantitative parameters as prognostic factors for progression-free survival (PFS) and cancer-specific survival (CSS) in patients with head and neck squamous cell carcinoma treated by chemoradiotherapy.

MATERIAL AND METHODS

Forty patients (34 men) diagnosed with head and neck squamous cell carcinoma were retrospectively assessed over an interval of 8 years. PERCIST and Hopkins criteria were used to assess response to treatment. Variations in the metabolic parameters maximum SUV (ΔSUVmax), metabolic tumor volume (ΔMTV) and total lesion glycolysis (ΔTLG) between pre- and post-treatment PET/CT studies were also determined. The Cox regression model, ROC curves and the Kaplan-Meier method were used for the analysis of prognostic factors and survival curves.

RESULTS

The mean follow-up was 39.4 months, with 24 progressions and 22 deaths. Both PERCIST and Hopkins criteria and the three metabolic parameters were predictive factors in the univariate analysis and only ΔSUVmax was in the multivariate analysis. Survival analysis showed statistically significant differences in PFS and CSS curves for the five parameters considered.

CONCLUSION

Application of PERCIST and Hopkins criteria as well as ΔSUVmax, ΔMTV and ΔTLG from PET/CT studies proved to be prognostic factors for survival in patients in our setting for treating head and neck cancer. The results may help to personalize treatment.

A rare case of peritoneal metastases from oropharyngeal squamous cell carcinoma in a young male after completion of chemoradiotherapy

ABSTRACT

Distant metastases are frequent in head and neck squamous cell carcinomas (HNSCC), but they are limited to some organs like lungs, bone, mediastinum, liver and brain. Peritoneal metastases (PMs) from HNSCC are extremely rare. A 28-year-old chronic smoker and alcoholic was diagnosed with squamous cell carcinoma of oropharynx. Patient was admitted and was given six cycles of concurrent chemo and radiotherapy (CCRT) and was discharged. Two months later, he presented with abdominal pain and lump. Contrast-enhanced CT revealed ascites, peritoneal implants and subcutaneous deposit which were proved to be metastases by histopathology. The present case is the seventh reported case of PM from HNSCC. • Patients of HNSCC shall be screened for distant metastases. • Differential diagnosis of HNSCC needs consideration when encountered with peritoneal metastases. • Research is required to understand the basis of PM in HNSCC while on CCRT to suggest management modifications.

En Block Versus Separate Management of Cervical Nodes in Tongue and Floor of the Mouth Cancers- Is There a Difference? An Analysis of 85 Cases in a Tertiary Care Institute

To evaluate difference in local recurrence, regional (neck) recurrence as well as distant metastases between cases operated with en-block excision of primary cancer and neck nodes versus their separate removal, in squamous cell carcinomas of anterior 2/3 of tongue and floor of the mouth. A total 85 patients of cT1-T4a N0-N2b of carcinoma anterior 2/3 of tongue and floor of mouth were evaluated. Amongst these patients 39 cases of in-continuity en-block neck dissection and 46 cases of discontinuous neck dissection were evaluated for post-operative complications as well as oncological outcome for a follow up period of 3 years. Patient population was similar in both groups with tongue cancers being the commonest site and tobacco being the most common addiction. Primary site hematoma was seen more in the in-continuity en-block neck dissection group with a p-value of 0.0276, which was statistically significant. Post-operative oro-cutaneous fistula occurred more in in-continuity enblock neck dissection as compared to discontinuous neck dissection, but the difference was not statistically significant. Local recurrence rate was significantly more in cases of discontinuous neck dissection (19.565) as compared to in-continuity en-block neck dissection (5.12%) with a p-Value 0.0481. A statistically non-significant but higher loco-regional recurrence was observed in cases of discontinuous neck dissection as compared to cases of in-continuity en-block neck dissection (10.56% vs 2.56). In the present study recurrence-free survival RFS 3 year in cases of en-block in-continuity neck dissection (84.06%) cases as compared to discontinuous neck dissection cases (63.04%) with p Value 0.025698. In-continuity en-block in continuity neck dissection has lower loco-regional recurrence and may impact overall distant metastases. Though early postoperative complications are more in in-continuity en-block in continuity neck dissection as compared to discontinuous neck dissection, most are managed conservatively. Further studies with a larger sample size are needed to evaluate its outcome in a comprehensive manner.

The value of intravoxel incoherent motion model-based diffusion-weighted imaging for predicting long-term outcomes in nasopharyngeal carcinoma

Objective

The aim of this study was to evaluate the prognostic value for survival of parameters derived from intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) in patients with nasopharyngeal carcinoma (NPC).

Materials

Baseline IVIM-DWI was performed on 97 newly diagnosed NPC patients in this prospective study. The relationships between the pretreatment IVIM-DWI parametric values (apparent diffusion coefficient (ADC), D, D*, and f) of the primary tumors and the patients’ 3-year survival were analyzed in 97 NPC patients who received chemoradiotherapy. The cutoff values of IVIM parameters for local relapse-free survival (LRFS) were identified by a non-parametric log-rank test. The local-regional relapse-free survival (LRRFS), LRFS, regional relapse-free survival (RRFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival (OS) rates were calculated by using the Kaplan–Meier method. A Cox proportional hazards model was used to explore the independent predictors for prognosis.

Results

There were 97 participants (mean age, 48.4 ± 10.5 years; 65 men) analyzed. Non-parametric log-rank test results showed that the optimal cutoff values of ADC, D, D*, and f were 0.897 × 10−3 mm2/s, 0.699 × 10−3 mm2/s, 8.71 × 10−3 mm2/s, and 0.198%, respectively. According to the univariable analysis, the higher ADC group demonstrated significantly higher OS rates than the low ADC group (p = 0.036), the higher D group showed significantly higher LRFS and OS rates than the low D group (p = 0.028 and p = 0.017, respectively), and the higher D* group exhibited significantly higher LRFS and OS rates than the lower D* group (p = 0.001 and p = 0.002, respectively). Multivariable analyses indicated that ADC and D were the independent prognostic factors for LRFS (p = 0.041 and p = 0.037, respectively), D was an independent prognostic factor for LRRFS (p = 0.045), D* and f were the independent prognostic factors for OS (p = 0.019 and 0.029, respectively), and f acted was an independent prognostic factor for DMFS (p = 0.020).

Conclusions

Baseline IVIM-DWI perfusion parameters ADC and D, together with diffusion parameter D*, could act as useful factors for predicting long-term outcomes and selecting high-risk patients with NPC.

Risk factors for cervical lymph node metastasis of head and neck squamous cell carcinoma: A retrospective population-based study

INTRODUCTION

Head and neck squamous cell carcinoma (HNSCC) is characterized by high frequency of early cervical lymph node metastases (LNMs), resulting in poor survival of patients. However, cervical LNMs are difficult to detect, which makes the decision-making of which patients should undergo neck dissection surgery challenging for surgeons. This study aimed to analyze the clinicopathological risk factors associated with cervical LNM and determine the indications for neck dissection in HNSCC patients.

METHODS

The medical records of patients diagnosed with HNSCC who were treated at our hospital between January 2010 and June 2020 were retrospectively reviewed. A database of their clinicopathological data, including sex, age at diagnosis, primary tumor regions, tumor size, and grade, was constructed. The associations of these clinicopathological features with cervical LNM were analyzed using univariate and multivariate logistic regression analyses. The TCGA database were used to externally validate the risk factors.

RESULTS

Overall, 531 patients with HNSCC were included; 38.6% had confirmed pathological cervical LNM. Univariate and multivariate analyses identified that tumor size and grade were independent risk factors associated with LNM (odds ratio = 1.338, 95% CI: 1.015-1.767, p &lt; 0.05; odds ratio = 1.936, 95% CI: 1.46-2.587, p &lt; 0.0001, respectively). The significant positive associations of tumor size and grade with LNM were externally validated in the TCGA datasets.

CONCLUSIONS

HNSCC patients with large tumor size or poor tumor differentiation degree were at high risk of lymph node metastasis and were recommended to undergo neck dissection.

Effects of 5-ALA mediated photodynamic therapy in oral cancer stem cells

The aim of the present study was to investigate the effects of PDT using the photosensitizer 5-aminoulevulinic acid (5-ALA) in oral squamous cell carcinoma (OSCC) behavior, mainly regarding its role on the cancer stem cell (CSC) phenotypes and in maintenance of the stem cell properties. Two OSCC cell lines were used and divided in the groups: Control, 5-ALA, LED 6 J/cm² and PDT. MTT and Neutral red assays were used to access cellular viability, cell migration was evaluated by the wound healing assay. The stem cell phenotype was analyzed by flow cytometry to evaluate the CD44^high/ESA^high, CD44^high/ESA^low and CD44^low populations, by the clonogenic and tumor sphere formation assays as well as by RT-qPCR. The presence of Protoporphyrin IX in each CSC fraction was evaluated by flow cytometry. The OSCC cell lines showed a significant decrease in cell viability and migration after PDT. The percentage of CD44^high/ESA^high cells decreased after PDT, which was associated with an increase in the CD44^low cells and with a functional decrease in the colony and sphere formation capacity. CD44^high/ESA^high cells showed increased PpIX, which contributed for their greater sensitivity to PDT. INV gene increased significantly after PDT, indicating cellular differentiation. Altogether, our results demonstrate that 5-ALA mediated PDT decreases not only the fraction of oral CSC but also their functional capabilities, inducing their differentiation.

Nurses' practice and educational needs in oral care for postoperative patients with oral cancer in ICUs: a multicenter cross-sectional study

Background

Surgical incision, endotracheal intubation, structural changes in the oral cavity, and other factors lead to a divergence in oral care between patients after oral surgery and ordinary inpatients. High-quality oral care can reduce the incidence of incision infection and ventilator-associated pneumonia. However, there is a lack of guidelines or expert consensus on oral care after oral cancer surgery. Therefore, the aim of this study was to assess the practicing situation of nurses in the intensive care unit (ICU) for postoperative patients with oral cancer and their need for training.

Methods

A multicenter cross-sectional study design was conducted in 19 ICUs of 11 tertiary hospitals from Henan province in China. Data were collected from 173 nurses and 19 head nurses online using a structured questionnaire. Mann–Whitney U and Kruskal–Wallis H tests were performed to analyze the data using SPSS (Version 25.0).

Results

Seven ICUs (36.8%) developed evaluation regulations for the oral care of postoperative patients with oral cancer, and eight ICUs (42.1%) described the operating standards. A total of 173 nurses completed the questionnaire, and the median score was 75 (68, 78). Almost all of the examined nurses (91.2%) assessed patients’ oral hygiene at a fixed time, while in 52.0% and 28.3% of nurses, the first oral care and frequency of oral care after surgery was determined based on the individual patient’s situation. More than half of the nurses (55.5%) spent approximately 5–10 min conducting oral care for patients. Physiological saline solution (82.7%), swabbing (91.9%), and oral care package with cotton ball (86.1%) were the most popular oral care mouthwash, method, and tool, respectively. Nurses sought help from senior nurses (87.3%) and doctors (83.8%), mostly to solve difficulties of oral care. Moreover, 76.9% of the nurses believed that the lack of knowledge and skills surrounding oral care was the main barrier for nurses to implement oral care. The majority of participants (69.4%) had never received continuing education or training in oral care for postoperative patients with oral cancer, and almost all (98.8%) of the respondents stated their preference to receive training in standardized oral care skills. Indications and contraindications (84.4%), tools (81.5%), and mouthwash (80.9%) of oral care were the items that the respondents were most eager to learn about. Approximately three quarters of nurses preferred scenario simulation practice as the training method.

Conclusion

Although the participants had high oral care scores for postoperative patients with oral cancer, there was great diversity in the practice. The lack of oral care knowledge was deemed the main barrier in delivering quality oral care, and the educational need was stated by almost all participants. We suggest that a standard protocol or clinical practice guidelines for oral care for postoperative patients with oral cancer should be developed, and nurses should be educated to equip them with professional knowledge and skills.

Fast and Furious: Fast Neutron Therapy in Cancer Treatment

Fast neutron therapy has been used for decades. In conjunction with recent advances in photonic techniques, fast neutrons are no longer of much oncologic interest, which is not unequivocally positive, given their undoubted therapeutic value. This mini-review recalls the history of medical research on fast neutrons, considers their physical and radiobiological properties alongside their benefits for cancer treatment, and discusses their place in modern radiation oncology.

Carbon dots with intrinsic theranostic properties for photodynamic therapy of oral squamous cell carcinoma

Carbon dots (CDs) are one of the carbon-based materials with remarkable optical properties, good water dispersibility and high biocompatibility. However, few studies have emphasized the intrinsic photodynamic and anticancer properties of CDs. Herein, we used CDs as photosensitizers to explore their photodynamic therapy (PDT) effect on oral squamous cell carcinoma (OSCC) cells. The obtained CDs had an effective cellular internalization capacity and possessed good biocompatibility in both CAL-27 and UM1 cells. After irradiation, the CDs showed obvious photodynamic effects on the test cells, which were confirmed by apoptosis analysis. In addition, the CDs exhibited excellent intracellular ROS generation under irradiation, and the subsequent induced cell death may be related to a lysosome-associated pathway.

UBE2C triggers HIF-1α-glycolytic flux in head and neck squamous cell carcinoma

Head and neck squamous cell carcinoma (HNSCC) is the most common malignancy in Taiwan. Therefore, refining the diagnostic sensitivity of biomarkers for early‐stage tumours and identifying therapeutic targets are critical for improving the survival rate of HNSCC patients. Metabolic reprogramming contributes to cancer development and progression. Metabolic pathways, specifically, play a crucial role in these diverse biological and pathological processes, which include cell proliferation, differentiation, apoptosis and carcinogenesis. Here, we investigated the role and potential prognostic value of the ubiquitin‐conjugating enzyme E2 (UBE2) family in HNSCC. Gene expression database analysis followed by tumour comparison with non‐tumour tissue showed that UBE2C was upregulated in tumours and was associated with lymph node metastasis in HNSCC patients. Knockdown of UBE2C significantly reduced the invasion/migration abilities of SAS and CAL27 cells. UBE2C modulates glycolysis pathway activation and HIF‐1α expression in SAS and CAL27 cells. CoCl₂ (HIF‐1α inducer) treatment restored the expression of glycolytic enzymes and the migration/invasion abilities of UBE2C knockdown cells. Based on our findings, UBE2C expression mediates HIF‐1α activation, increasing glycolysis pathway activation and the invasion/migration abilities of cancer cells. UBE2C may be an independent prognostic factor and a therapeutic target in HNSCC.

Management of the parotid for high-risk cutaneous squamous cell carcinoma: A review from the salivary section of the American Head and Neck Society

BACKGROUND

Metastases to the parotid nodal basin in patients with high-risk cutaneous squamous cell carcinoma (HRcSCC) impact disease specific survival (DSS) and overall survival (OS).

METHODS

A writing group convened by the Salivary Section of the American Head and Neck Society (AHNS) developed contemporary, evidence-based recommendations regarding management of the parotid nodal basin in HRcSCC based on available literature, expert consultation, and collective experience. The statements and recommendations were then submitted and approved by the AHNS Salivary Committee.

RESULTS

These recommendations were developed given the wide variation of practitioners who treat HRcSCC in order to streamline management of the parotid nodal basin including indications for imaging, surgery, radiation, and systemic treatment options as well.

CONCLUSIONS

This clinical update represents contemporary optimal management of the parotid nodal basin in HRcSCC and is endorsed by the Salivary Section of the AHNS.

Risk Analysis of Severe Thrombocytopenia in Nasopharyngeal Carcinoma During Concurrent Radio-Chemotherapy

Objective

To explore the risk factors and predictive indexes of severe thrombocytopenia during concurrent radio-chemotherapy of nasopharyngeal carcinomas.

Methods

Retrospective analysis was performed from the hospitalized patients with nasopharyngeal carcinoma from August 2014 to July 2017, and induction chemotherapy and concurrent radio-chemotherapy were completed. According to the lowest platelet count during concurrent chemotherapy, patients were divided into observation and control groups. General information and laboratory examinations were recorded and analyzed by univariate analysis, multivariate regression analysis, and ROC curve analysis.

Results

Factors, including age, PLT, IBIL, APTT at first visit, WBC, RBC, HGB, PLT, NEUT, APTT, IBIL, FFA, Crea, and urea before radio-chemotherapy, which are significant in univariate analysis into multivariate regression analysis, were taken. It turned out that RBC (OR = 10.060, 95% CI 2.679–37.777, p = 0.001), PLT (OR = 1.020, 95% CI 1.006–1.034, p = 0.005), and IBIL (OR = 0.710, 95% CI 0.561–0.898, p = 0.004) are independent predictors of severe TP in NPC. ROC analysis showed that the AUC of RBC, IBIL, PLT, and AGE is 0.746 (p < 0.001), 0.735 (p < 0.001), 0.702 (p = 0.001), and 0.734 (p < 0.001). New variables called joint predictors were calculated by a regression equation (Y = 2.309 * RBC - 0.343 * IBIL + 0.02 * PLT - 10.007), the AUC of which is 0.8700 (p < 0.001); best truncation value is >5.87 mmol/l.

Conclusions

Lower RBC, PLT, and higher IBIL before concurrent radio-chemotherapy are independent risk factors causing severe TP during concurrent radio-chemotherapy of NPC. The RBC, PLT, and IBIL before concurrent radio-chemotherapy and joint predictor have a good predictive value to evaluate the risk of severe TP during concurrent radio-chemotherapy of NPC.

An Immune Feature-Based, Three-Gene Scoring System for Prognostic Prediction of Head-and-Neck Squamous Cell Carcinoma

Head-and-neck squamous cell carcinoma (HNSCC) is characterized by a high frequency of neck lymph node metastasis (LNM), a key prognostic factor. Therefore, identifying the biological processes during LNM of HNSCC has significant clinical implications for risk stratification. This study performed Gene Ontology enrichment analysis of differentially expressed genes between tumors with LNM and those without LNM and identified the involvement of immune response in the lymphatic metastasis of HNSCC. We further identified greater infiltrations of CD8⁺ T cells in tumors than in adjacent normal tissues through immunochemistry in the patient cohort (n = 62), indicating the involvement of CD8⁺ T cells in the antitumor immunity. Hierarchical clustering analysis was conducted to initially identify the candidate genes relevant to lymphocyte-mediated antitumor response. The candidate genes were applied to construct a LASSO Cox regression analysis model. Three genes were eventually screened out as progression-related differentially expressed candidates in HNSCC and a risk scoring system was established based on LASSO Cox regression model to predict the outcome in patients with HNSCC. The score was calculated using the formula: 0.0636 × CXCL11 - 0.4619 × CXCR3 + 0.2398 × CCR5. Patients with high scores had significantly worse overall survival than those with low scores (p < 0.001). The risk score showed good performance in characterizing tumor-infiltrating lymphocytes and provided a theoretical basis for stratifying patients receiving immune therapies. Additionally, a nomogram including the risk score, age, and TNM stage was constructed. The prediction model displayed marginally better discrimination ability and higher agreement in predicting the survival of patients with HNSCC compared with the TNM stage.

ALKBH5-mediated m6A modification of lncRNA KCNQ1OT1 triggers the development of LSCC via upregulation of HOXA9

It has been shown that N6‐methyladenosine (m6A) modification is involved in the development of complex human diseases, especially in the development of cancer. Our research investigated the role and mechanism of the m6A modification of lncRNA KCNQ1 overlapping transcript 1 (KCNQ1OT1) in Laryngeal squamous cell carcinoma (LSCC) progression. Microarray analysis was used to quantitatively detect the m6A apparent transcriptional modification level of lncRNA in LSCC tissue. Methylated RNA immunoprecipitation‐qPCR (MeRIP‐qPCR), in situ hybridization (ISH) and quantitative real‐time PCR (qRT‐PCR) were used to examine the m6A modification and expression of KCNQ1OT1. In addition, in vivo and in vitro experiments have tested the effects of KCNQ1OT1 knockdown on the proliferation, invasion and metastasis of LSCC. Mechanically, we found the N6‐methyladenosine (m6A) demethylase ALKBH5 mediates KCNQ1OT1 expression via an m6A‐YTHDF2‐dependent manner and KCNQ1OT1 could directly bind to HOXA9 to further regulate the proliferation, invasion and metastasis of LSCC cells. In general, our research indicates that ALKBH5‐mediated m6A modification of KCNQ1OT1 triggers the development of LSCC via upregulation of HOXA9.

The Clinical Characteristics and Prognostic Nomogram for Head and Neck Cancer Patients with Bone Metastasis

Background

Head and neck cancer (HNC) is the sixth most common malignancy globally, and many demographics and clinicopathological factors influence its prognosis. This study aimed to construct and validate a prognostic nomogram to predict the prognosis of HNC patients with bone metastasis (BM).

Methods

A total of 326 patients with BM from HNC were collected from the SEER database as the subjects of this study. In a ratio of 7 to 3, patients were randomly divided into training and validation groups. Independent prognostic factors for HNC patients with BM were identified by univariate and multivariate Cox regression analysis. The nomogram for predicting the prognosis was constructed, and the model was evaluated by receiver operating characteristic curves, calibration curves, and decision curve analysis.

Result

The independent prognostic factors for HNC patients with BM included age, primary site, lung metastasis, and chemotherapy. The area under the curve predicting overall survival at 12, 24, and 36 months was 0.768, 0.747, and 0.723 in the training group and 0.729, 0.723, and 0.669 in the validation group, respectively. The calibration curves showed good agreement between the predicted and actual values for overall survival. In addition, the decision curve analysis showed that this prognostic nomogram model has a high clinical application.

Conclusion

This study developed and validated a nomogram to predict overall survival in HNC patients with BM. The prognostic nomogram has high accuracy and utility to inform survival estimation and individualized treatment decisions.

Feature selection and predicting chemotherapy-induced ulcerative mucositis using machine learning methods

OBJECTIVE

Ulcerative mucositis (UM) is a devastating complication of most cancer therapies with less recognized risk factors. Whilst risk predictions are most vital in adverse events, we utilized Machine learning (ML) approaches for predicting chemotherapy-induced UM.

METHODS

We utilized 2017 National Inpatient Sample database to identify discharges with antineoplastic chemotherapy-induced UM among those received chemotherapy as part of their cancer treatment. We used forward selection and backward elimination for feature selection; lasso and Gradient Boosting Method were used for building our linear and non-linear models.

RESULTS

In 2017, there were 253 (unweighted numbers) chemotherapy-induced UM patient discharges from 21,626 (unweighted numbers) adult patients who received antineoplastic chemotherapy as part of their cancer treatment. Our linear model, lasso showed performance (C-statistics) AUC: 0.75 (test dataset), 0.75 (training dataset); the Gradient Boosting Method (GBM) model showed AUC: 0.76 in the training and 0.79 in the test datasets. The feature selection derived from stepwise forward selection and backward elimination methods showed variables of importance--antineoplastic chemotherapy-induced pancytopenia, agranulocytosis due to cancer chemotherapy, fluid and electrolyte imbalance, age, anemia due to chemotherapy, median household income, and depression. Higher importance variable derived from GBM in the order of importance were antineoplastic chemotherapy-induced pancytopenia > co-morbidity score > agranulocytosis due to cancer chemotherapy > age > and fluid and electrolyte imbalance. Further, when the analysis was stratified to females only, the ML models performed better than the unstratified model.

CONCLUSION

Our study showed ML methods performed well in predicting the chemotherapy-induced UM. Predictors identified through ML approach matched to the clinically meaningful and previously discussed predictors of the chemotherapy-induced UM.

Association and risk factors of healthcare-associated infection and burden of illness among chemotherapy-induced ulcerative mucositis patients

Objectives

To evaluate the association and risk factors of healthcare-associated infection (HAI) and burden of illness among chemotherapy-induced ulcerative mucositis (UM) patients.

Methods

For this research, US National Inpatient Sample database 2017 was utilized to study UM patients. The association of healthcare-associated infection-related burden of illness among UM patients was assessed on the outcome––length of hospital stays (LOS), total charges, in-hospital mortality, and discharge disposition.

Result

In 2017, there were 11,350 adult (> 18 years of age) UM patients, among them there were 415 (3.5%) HAI. After adjusting for patient and clinical characteristics, UM patients with HAI were most likely to have higher total charges and longer LOS (1.91; 95% CIs: 1.51–2.41; P < 0.001; 1.84; 95% CIs: 1.53–2.21; P < 0.001) than those without HAI. Further, mortality was not significantly different. UM patients with HAI were less likely to have higher burden of illness who were younger, females, those living in non-metropolitan or micropolitan counties, and those with lower co-morbidity score. Additionally, UM patients with HAI were more likely to discharge to skilled nursing facility (SNF), intermediate care facility (ICF), and another type of facility (ATF), (aOR = 2.58 (1.16–5.76), P = 0.02), than they were to discharge to self-care or home care.

Conclusion

UM patients with HAI were more likely to have higher burden of illness and more likely to discharged to the SNF, ICF, and ATF rather than to home or self-care.

Clinical relevance

UM patients when associated with HAI have higher burden of illness; a tailored approach to oral care might prevent HAIs and burden of illness among UM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-021-04106-0.

Lung metastases in newly diagnosed hypopharyngeal cancer: a population-based study

PURPOSE

Current population-based estimates of the incidence and prognosis of lung metastases of hypopharyngeal cancer are lacking. The purpose of the study is to characterize the incidence proportions and survival probability of patients with hypopharyngeal cancer and lung metastases.

MATERIALS AND METHODS

We identified 2714 adult patients diagnosed with hypopharyngeal cancer between 2010 and 2014 for whom the status of lung metastases was known from the SEER database. Multivariable logistic and Cox regression models were performed to identify the risk factors associated with the presence of lung metastases at diagnosis and 5-year all-cause mortality, respectively.

RESULTS

We identified 128 patients with lung metastases at the time of diagnosis of hypopharyngeal cancer. Females were less likely to have lung metastases. Incidences of lung metastases were higher among patients with histological grade III/IV. For each 10 mm increase in tumor size, the odds of having lung metastases increased by 6.6%. Patients with lung metastases had a shorter survival time.

CONCLUSION

Our study provides insight into the epidemiology of lung metastases in patients with hypopharyngeal cancer. When the tumor is diagnosed, we should pay close attention to the sex, race, tumor size and histological grade to quickly detect the distant metastases.

Chromatin dysregulation associated with NSD1 mutation in head and neck squamous cell carcinoma

Chromatin dysregulation has emerged as an important mechanism of oncogenesis. To develop targeted treatments, it is important to understand the transcriptomic consequences of mutations in chromatin modifier genes. Recently, mutations in the histone methyltransferase gene nuclear receptor binding SET domain protein 1 (NSD1) have been identified in a subset of common and deadly head and neck squamous cell carcinomas (HNSCCs). Here, we use genome-wide approaches and genome editing to dissect the downstream effects of loss of NSD1 in HNSCC. We demonstrate that NSD1 mutations are responsible for loss of intergenic H3K36me2 domains, followed by loss of DNA methylation and gain of H3K27me3 in the affected genomic regions. In addition, those regions are enriched in cis-regulatory elements, and subsequent loss of H3K27ac correlates with reduced expression of their target genes. Our analysis identifies genes and pathways affected by the loss of NSD1 and paves the way to further understanding the interplay among chromatin modifications in cancer.

Farhangdoost et al. use genome editing and TCGA primary tumor data to provide a link between NSD1 loss, chromatin and regulatory landscape, gene expression, and molecular characteristics of this tumor subtype. Their study extends the understanding of tumorigenic mechanisms underlying head and neck cancers with mutations in NSD1.

Quality of life of Japanese elderly oral cancer patients during the perioperative period

Japan's aging society has an increasing incidence of oral cancer. This study investigated perioperative changes in quality of life (QoL) among 172 oral cancer patients (elderly ≥75 years vs non-elderly <75 years), pre-treatment, at treatment completion, and at 1, 3, and 6 months post-treatment, using the following Functional Assessment of Cancer Therapy - Head and Neck (FACT-H&N) subscales: physical well-being (PWB), social/family well-being (SWB), emotional well-being (EWB), functional well-being (FWB), additional head- and neck-specific concerns (H&N). SWB (P=0.026), H&N (P=0.024), and total FACT-H&N (P=0.009) scores were significantly lower in the elderly group than in the non-elderly group at 6 months post-treatment, especially for mastication items (H&N1, P=0.047; H&N11, P=0.004), but not for swallowing items (H&N5 and H&N7, both P> 0.05). PWB (P= 0.004), EWB (P< 0.001), and FWB (P= 0.022) scores in the non-elderly group were significantly higher at 6 months post-treatment than before treatment. In the elderly group, no subscale showed a better score at 6 months post-treatment. Post-treatment QoL in elderly oral cancer patients did not improve, unlike in non-elderly patients.

External validation of nodal failure prediction models including radiomics in head and neck cancer

PURPOSE

To externally validate the previously published pre-treatment prediction models for lymph nodes failure after definitive radiotherapy in head and neck squamous cell carcinoma (HNSCC) patients.

MATERIALS AND METHODS

This external validation cohort consisted of 143 node positive HNSCC patients treated between July 2007 and June 2016 by curative radiotherapy with or without either cisplatin or cetuximab. Imaging and pathology reports during follow-up were analyzed to indicate persisting or recurring nodes. The previously established clinical, radiomic and combined models were validated on this cohort by assessing the concordance index (c-index) and model calibration.

RESULTS

Overall 113 patients with 374 pLNs were suitable for final analysis. There were 20 (5.3%) nodal failures from 15 patients after a median follow-up of 36.1 months. Baseline characteristics and radiomic features were comparable to the training cohort. Both the radiomic model (Least-axis-length of lymph node (LALLN) and correlation of gray level co-occurrence matrix (Corre-GLCM)) and the combined model (T stage, gender, WHO performance score, LALLN and Corre-GLCM) showed good agreement between predicted and observed nodal control probabilities. The radiomic (c-index: 0.71; 95% confidence interval (CI): 0.59-0.84) and combined (c-index: 0.71; 95% CI: 0.59-0.82) models performed better than the clinical model (c-index: 0.57; 95% CI: 0.47-0.68) on this cohort, with a significant difference between the combined and clinical models (z-score test: p = 0.005).

CONCLUSION

The combined model including clinical and radiomic features was externally validated and proved useful to predict nodal failures and could be helpful to guide treatment choices before and after curative radiation treatment for node positive HNSCC patients.

Effect of Periodontitis and Scaling and Root Planing on Risk of Pharyngeal Cancer: A Nested Case-Control Study

This study investigated the association between periodontitis and the risk of pharyngeal cancer in Taiwan. For this population-based nested case–control study using the Longitudinal Health Insurance Database derived from Taiwan’s National Health Insurance Research Database, we identified patients (n = 1292) who were newly diagnosed with pharyngeal cancer between 2005 and 2013 and exactly paired them with propensity score matched control subjects (n = 2584). Periodontitis and scaling and root planing (SRP) were identified before the index date. Pharyngeal cancer was subdivided into 3 subgroups on the basis of anatomic location: nasopharyngeal cancer, oropharyngeal cancer, and hypopharyngeal cancer. A multiple conditional logistic regression model was applied to analyze the adjusted odds ratio (aOR). Periodontitis was associated with an increased risk of pharyngeal cancer (aOR, 1.57; 95% confidence interval (CI), 1.17 to 2.10), especially oropharyngeal cancer (aOR, 2.22; 95% CI, 1.07 to 4.60). We found a decreased risk of pharyngeal cancer in patients who had undergone SRP (aOR, 0.77; 95% CI, 0.61 to 0.96). In conclusion, this study showed that periodontitis was associated with an increased risk of pharyngeal cancer and SRP exerted a protective effect against pharyngeal cancer. Our results suggest that treating periodontitis and performing SRP, which are modifiable factors in oral health, in clinical practice may provide an opportunity to decrease the disease burden of pharyngeal cancer in Taiwan.

Density of CD3+ and CD8+ cells in gingivo-buccal oral squamous cell carcinoma is associated with lymph node metastases and survival

The tumor immune microenvironment is emerging as a critical player in predicting cancer prognosis and response to therapies. However, the prognostic value of tumor-infiltrating immune cells in Gingivo-Buccal Oral Squamous Cell Carcinoma (GBOSCC) and their association with tumor size or lymph node metastases status require further elucidation. To study the relationship of tumor-infiltrating immune cells with tumor size (T stage) and lymph node metastases (N stages), we analyzed the density of tumor-infiltrating immune cells in archived, whole tumor resections from 94 patients. We characterized these sections by immune-histochemistry using 12 markers and enumerated tumor-infiltrating immune cells at the invasive margins (IM) and centers of tumors (CT). We observed that a higher density of CD3+ cells in the IM and CT was associated with smaller tumor size (T1-T2 stage). Fewer CD3+ cells was associated with larger tumor size (T3-T4 stage). High infiltration of CD3+and CD8+ cells in IM and CT as well as high CD4+ cell infiltrates in the IM was significantly associated with the absence of lymph node metastases. High infiltrates of CD3+ and CD8+ cells in CT was associated with significantly improved survival. Our results illustrate that the densities and spatial distribution of CD3+ and CD8+ cell infiltrates in primary GBOSCC tumors is predictive of disease progression and survival. Based on our findings, we recommend incorporating immune cell quantification in the TNM classification and routine histopathology reporting of GBOSCC. Immune cell quantification in CT and IM may help predict the efficacy of future therapies.

Nomogram forecasting 3-, 5-, and 8-year overall survival and cancer-specific survival of gingival squamous cell carcinoma

No nomogram models addressing the personalized prognosis evaluation of patients with gingival squamous cell carcinoma (GSCC) have been documented. We sought to establish nomograms to forecast overall survival (OS) and cancer-specific survival (CSS) of patients with GSCC. We collected the detailed clinicopathological information of 2505 patients with GSCC from the Surveillance, Epidemiology and End Results (SEER) program. Afterward, we divided the 2505 cases into a modeling group (n = 1253) and an external validation cohort (n = 1252) via random split-sample method. We developed the nomograms on the basis of the Kaplan-Meier and multivariate Cox survival analysis of the modeling group and then split the modeling cohort into two parts based on cut-off values: high- and low-risk cohorts. An improved survival was shown in the low-risk group compared to their counterpart, with a significant difference after the log-rank test. The performance of the nomograms was evaluated via concordance-index (C-index), the area under the receiver operating characteristic curve (AUC), and calibration curves. All the C-indexes and AUCs were greater than 0.7, showing high accuracy. Moreover, the calibrations showed that the actual observations were close to the 45° perfect reference line. In conclusion, we successfully developed two nomograms to provide individualized, patient-specific estimates of OS and CSS available for risk-stratification.

Sentinel lymph node mapping using ICG fluorescence and cone beam CT - a feasibility study in a rabbit model of oral cancer

BACKGROUND

Current sentinel lymph node biopsy (SLNB) techniques, including use of radioisotopes, have disadvantages including the use of a radioactive tracer. Indocyanine green (ICG) based near-infrared (NIR) fluorescence imaging and cone beam CT (CBCT) have advantages for intraoperative use. However, limited literature exists regarding their use in head and neck cancer SLNB.

METHODS

This was a prospective, non-randomized study using a rabbit oral cavity VX2 squamous cell carcinoma model (n = 10) which develops lymph node metastasis. Pre-operatively, images were acquired by MicroCT. During surgery, CBCT and NIR fluorescence imaging of ICG was used to map and guide the SLNB resection.

RESULTS

Intraoperative use of ICG to guide fluorescence resection resulted in identification of all lymph nodes identified by pre-operative CT. CBCT was useful for near real time intraoperative imaging and 3D reconstruction.

CONCLUSIONS

This pre-clinical study further demonstrates the technical feasibility, limitations and advantages of intraoperative NIR-guided ICG imaging for SLN identification as a complementary method during head and neck surgery.

Determining the molecular landscape and impact on prognosis in HPV-associated head and neck cancer

BACKGROUND

Human papillomavirus (HPV) associated head and neck squamous cell carcinoma (HNSCC) has a better prognosis than HNSCC due to other risk factors. However, there is significant heterogeneity within HPV-associated HNSCC and 25% of these patients still do poorly despite receiving aggressive therapy. We currently have no good molecular tools to differentiate and exclude this "high-risk" sub-population and focus on "low-risk" patients for clinical trials. This has been a potential barrier to identifying successful de-escalation treatment strategies in HPV-associated HNSCC. We conducted an analysis of molecular markers with a well-known role in the pathogenesis of HPV-associated HNSCC and hypothesized that these markers could help independently predict recurrence and prognosis in these patients and therefore help identify at the molecular level "low-risk" patients suitable for de-escalation trials.

METHODS

We analyzed 24 tumor specimens of patients with p16+ HNSCC who underwent definitive resection as primary treatment. Tissue microarray (TMA) was generated from the 24 pathology blocks and immunohistochemistry (IHC) was performed using highly specific antibodies for our chosen biomarkers (PI3K-PTEN, AKT pathway, mTOR, 4EBP1, S6, and pAMPK, ERCC-1). Transcriptome data was also obtained for 7 p16+ HNSCC patients from The Cancer Genome Atlas (TCGA). Data from the TMA and TCGA were analyzed for association of relapse-free survival (RFS) and overall survival (OS) with protein and gene expression of the chosen biomarkers.

RESULTS

Increased pAMPK protein activity by IHC and AMPK gene expression by TCGA gene expression data was correlated with improved RFS with a trend towards statistical significance.

CONCLUSIONS

This data suggests that increased pAMPK activity and expression may portend a better prognosis in HPV-associated HNSCC undergoing primary definitive resection. However, these findings require validation in larger studies.

Comparative Study Between Integrated Positron Emission Tomography/Magnetic Resonance and Positron Emission Tomography/Computed Tomography in the T and N Staging of Hypopharyngeal Cancer: An Initial Result

OBJECTIVE

To compare the diagnostic accuracy of positron emission tomography/magnetic resonance (PET/MR) versus PET/computed tomography (PET/CT) for T and N staging of hypopharyngeal cancer.

METHODS

Integrated PET/MR and PET/CT examinations were performed in 20 patients with hypopharyngeal cancer after same-day single injection. Eleven of 20 patients underwent surgery with histologic findings directly compared with imaging findings. Statistical analysis included Spearman correlation and McNemar test.

RESULTS

Accuracy of PET/MR, PET/CT, and MRI for T staging was 81.8%, 63.6%, and 72.7%, respectively. Sensitivity and specificity for detecting metastatic lymph nodes was 88.2% and 98.2% on PET/MR, 76.5% and 98.3% on PET/CT, and 64.7% and 94.7% on MRI.

CONCLUSIONS

The PET/MR and PET/CT provide comparable results for assessing hypopharyngeal carcinoma and detecting metastatic lymph nodes.

Applying nomograms based on the surveillance, epidemiology and end results database to predict long-term overall survival and cancer-specific survival in patients with oropharyngeal squamous cell carcinomas: A case-control research

Few models regarding to the individualized prognosis assessment of oropharyngeal squamous cell carcinoma (OPSCC) patients were documented. The purpose of this study was to establish nomogram model to predict the long-term overall survival (OS) and cancer-specific survival (CSS) of OPSCC patients. The detailed clinical data for the 10,980 OPSCC patients were collected from the surveillance, epidemiology and end results (SEER) database. Furthermore, we applied a popular and reasonable random split-sample method to divide the total 10,980 patients into 2 groups, including 9881 (90%) patients in the modeling cohort and 1099 (10%) patients in the external validation cohort. Among the modeling cohort, 3084 (31.2%) patients were deceased at the last follow-up date. Of those patients, 2188 (22.1%) patients died due to OPSCC. In addition, 896 (9.1%) patients died due to other causes. The median follow-up period was 45 months (1-119 months). We developed 2 nomograms to predict 5- and 8- year OS and CSS using Cox Proportional Hazards model. The nomograms' accuracy was evaluated through the concordance index (C-index) and calibration curves by internal and external validation. The C-indexes of internal validation on the 5- and 8-year OS and CSS were 0.742 and 0.765, respectively. Moreover, the C-indexes of external validation were 0.740 and 0.759, accordingly. Based on a retrospective cohort from the SEER database, we succeeded in constructing 2 nomograms to predict long-term OS and CSS for OPSCC patients, which provides reference for surgeons to develop a treatment plan and individual prognostic evaluations.

Follow up imaging of oral, oropharyngeal and hypopharyngeal cancer patients: Comparison of PET-CT and MRI post treatment

There is currently no consensus as to the ideal timing, frequency and modality of imaging for follow up of head and neck cancer patients. The aim of this study was to analyze the diagnostic accuracy of PET-CT versus MRI, and imaging at 3 versus 6 months for follow up of head and neck cancer patients treated with curative intent with no clinical signs of treatment failure.

MATERIALS AND METHODS

A retrospective study was performed for all head and neck cancers treated with curative intent at the Royal Derby Hospital. Data collected included demographic information, site of primary cancer, staging, treatment provided, type of follow up imaging performed and results of follow up imaging. Inclusion in the study was for oral, oropharyngeal and hypopharyngeal cancers treated with curative intent, asymptomatic patients, those who have had follow up imaging within 6 months of treatment, and those followed up for at least 2.5 years since treatment.

RESULTS

A total of 140 patients were included in the study. 25% of patients had evidence of recurrent/metastatic disease on imaging, 60% of which were identified within 6 months post treatment. The majority (60%) of failures were due to distant metastases. The sensitivity and specificity of both MRI and PET-CT was higher at 6 months post-treatment compared to 3 months post-treatment. Overall the sensitivity and specificity for PET-CT and MRI within 3-6 months post treatment were 94.7% and 83.5% and 60% and 85.7% respectively for identifying treatment failure.

CONCLUSION

Follow up Imaging at 6 months post treatment is more likely to accurately identify treatment failures with fewer false positives than imaging at 3 months. PET-CT is preferable to MRI for identifying post treatment locoregional and distant treatment failure.

Clinical Outcome of Minor Salivary Gland Cancers in the Oral Cavity: A Comparative Analysis With Squamous Cell Carcinomas of the Oral Cavity

Purpose: Salivary gland cancer (SGC) in the oral cavity is not common and has been less studied in comparison with oral squamous cell carcinoma (SCC). This study aimed to identify the clinical characteristics and outcomes of SGC in the oral cavity compared with oral SCC.

Methods: The medical charts of the patients with SGC (N = 68) arising from minor salivary glands and SCC (N = 750) in the oral cavity between 1995 and 2017 were reviewed retrospectively. The clinical and pathological factors and treatment outcomes were compared to identify clinical differences between oral SGC and SCC in total cases and in tumor size and subsite (propensity score)-matched pairs (N = 68 in each group). In addition, pattern of local invasion was pathologically assessed in a subset of SGC and SCC tumors.

Results: Patients with SGC in the oral cavity showed >90% survival at 5 years. Most common pathologies of SGC were mucoepidermoid carcinoma (39.7%) and adenoid cystic carcinoma (35.3%), where high-grade tumors (including adenoid cystic carcinomas having solid components, grade 2 or 3) represented only 36.8%. Compared with oral SCC, surgery for SGC had narrow surgical safety margin. However, local control was very successful in SGC even with <5 mm or positive resection margin through surgery plus adjuvant radiation treatments or surgery alone for small low-grade tumors. Pathologic analysis revealed that the frequency of oral SGC with infiltrative tumor border was significantly lower than that of oral SCC (46.4 vs. 87.2%, P < 0.001).

Conclusions: SGC in the oral cavity represents relatively good prognosis and has a locally less aggressive pathology compared with oral SCC. Adjuvant radiation can be very effective to control minimal residual disease in oral SGC. Our study proposed that a different treatment strategy for oral SGC would be reasonable in comparison with oral SCC.

Pre-treatment radiomic features predict individual lymph node failure for head and neck cancer patients

BACKGROUND AND PURPOSE

To develop and validate a pre-treatment radiomics-based prediction model to identify pathological lymph nodes (pLNs) at risk of failures after definitive radiotherapy in head and neck squamous cell carcinoma patients.

MATERIALS AND METHODS

Training and validation cohorts consisted of 165 patients with 558 pLNs and 112 patients with 467 pLNs, respectively. All patients were primarily treated with definitive radiotherapy, with or without systemic treatment. The endpoint was the cumulative incidence of nodal failure. For each pLN, 82 pre-treatment CT radiomic features and 7 clinical features were included in the Cox proportional-hazard analysis.

RESULTS

There were 68 and 23 nodal failures in the training and validation cohorts, respectively. Multivariable analysis revealed three clinical features (T-stage, gender and WHO Performance-status) and two radiomic features (Least-axis-length representing nodal size and gray level co-occurrence matrix based - Correlation representing nodal heterogeneity) as independent prognostic factors. The model showed good discrimination with a c-index of 0.80 (0.69-0.91) in the validation cohort, significantly better than models based on clinical features (p < 0.001) or radiomics (p = 0.003) alone. High- and low-risk groups were defined by using thresholds of estimated nodal failure risks at 2-year of 60% and 10%, resulting in positive and negative predictive values of 94.4% and 98.7%, respectively.

CONCLUSION

A pre-treatment prediction model was developed and validated, integrating the quantitative radiomic features of individual lymph nodes with generally used clinical features. Using this prediction model, lymph nodes with a high failure risk can be identified prior to treatment, which might be used to select patients for intensified treatment strategies targeted on individual lymph nodes.

P2 Receptors as Therapeutic Targets in the Salivary Gland: From Physiology to Dysfunction

Although often overlooked in our daily lives, saliva performs a host of necessary physiological functions, including lubricating and protecting the oral cavity, facilitating taste sensation and digestion and maintaining tooth enamel. Therefore, salivary gland dysfunction and hyposalivation, often resulting from pathogenesis of the autoimmune disease Sjögren's syndrome or from radiotherapy of the head and neck region during cancer treatment, severely reduce the quality of life of afflicted patients and can lead to dental caries, periodontitis, digestive disorders, loss of taste and difficulty speaking. Since their initial discovery in the 1970s, P2 purinergic receptors for extracellular nucleotides, including ATP-gated ion channel P2X and G protein-coupled P2Y receptors, have been shown to mediate physiological processes in numerous tissues, including the salivary glands where P2 receptors represent a link between canonical and non-canonical saliva secretion. Additionally, extracellular nucleotides released during periods of cellular stress and inflammation act as a tissue alarmin to coordinate immunological and tissue repair responses through P2 receptor activation. Accordingly, P2 receptors have gained widespread clinical interest with agonists and antagonists either currently undergoing clinical trials or already approved for human use. Here, we review the contributions of P2 receptors to salivary gland function and describe their role in salivary gland dysfunction. We further consider their potential as therapeutic targets to promote physiological saliva flow, prevent salivary gland inflammation and enhance tissue regeneration.

Association of Adjuvant Radiation Therapy With Survival in Patients With Advanced Cutaneous Squamous Cell Carcinoma of the Head and Neck

Importance

Cutaneous squamous cell carcinoma (CSCC) is one of the most common malignant tumors worldwide. There is conflicting evidence regarding the indications for and benefits of adjuvant radiation therapy for advanced CSCC tumors of the head and neck.

Objective

To assess indications for adjuvant radiation therapy in patients with CSCC.

Design, Setting, and Participants

Retrospective analysis of 349 patients with head and neck CSCC treated with primary resection with or without adjuvant radiation therapy at 2 tertiary referral centers from January 1, 2008, to June 30, 2016.

Main Outcomes and Measures

Data were compared between treatment groups with a χ2 analysis. Disease-free survival (DFS) and overall survival (OS) were analyzed using a Kaplan-Meier survival analysis with log-rank test and a Cox proportional hazards multivariate regression.

Results

A total of 349 patients had tumors that met the inclusion criteria (mean [SD] age, 70 [12] years; age range, 32-94 years; 302 [86.5%] male), and 191 (54.7%) received adjuvant radiation therapy. The 5-year Kaplan-Meier estimates were 59.4% for DFS and 47.4% for OS. Patients with larger, regionally metastatic, poorly differentiated tumors with perineural invasion (PNI) and younger immunosuppressed patients were more likely to receive adjuvant radiation therapy. On Cox proportional hazards multivariate regression, patients with periorbital tumors (hazard ratio [HR], 2.48; 95% CI, 1.00-6.16), PNI (HR, 1.90; 95% CI, 1.12-3.19), or N2 or greater nodal disease (HR, 2.16; 95% CI, 1.13-4.16) had lower DFS. Immunosuppressed patients (HR, 2.17; 95% CI, 1.12-4.17) and those with N2 or greater nodal disease (HR, 2.43; 95% CI, 1.42-4.17) had lower OS. Adjuvant radiation therapy was associated with improved OS for the entire cohort (HR, 0.59; 95% CI, 0.38-0.90). In a subset analysis of tumors with PNI, adjuvant radiation therapy was associated with improved DFS (HR, 0.47; 95% CI, 0.23-0.93) and OS (HR, 0.44; 95% CI, 0.24-0.86). Adjuvant radiation therapy was also associated with improved DFS (HR, 0.36; 95% CI, 0.15-0.84) and OS (HR, 0.30; 95% CI, 0.15-0.61) in patients with regional disease.

Conclusions and Relevance

Among patients with advanced CSCC, receipt of adjuvant radiation therapy was associated with improved survival in those with PNI and regional disease.

Predictive quantitative ultrasound radiomic markers associated with treatment response in head and neck cancer

Aim:

We aimed to identify quantitative ultrasound (QUS)-radiomic markers to predict radiotherapy response in metastatic lymph nodes of head and neck cancer.

Materials & methods:

Node-positive head and neck cancer patients underwent pretreatment QUS imaging of their metastatic lymph nodes. Imaging features were extracted using the QUS spectral form, and second-order texture parameters. Machine-learning classifiers were used for predictive modeling, which included a logistic regression, naive Bayes, and k-nearest neighbor classifiers.

Results:

There was a statistically significant difference in the pretreatment QUS-radiomic parameters between radiological complete responders versus partial responders (p < 0.05). The univariable model that demonstrated the greatest classification accuracy included: spectral intercept (SI)-contrast (area under the curve = 0.741). Multivariable models were also computed and showed that the SI-contrast + SI-homogeneity demonstrated an area under the curve = 0.870. The three-feature model demonstrated that the spectral slope-correlation + SI-contrast + SI-homogeneity-predicted response with accuracy of 87.5%.

Conclusion:

Multivariable QUS-radiomic features of metastatic lymph nodes can predict treatment response a priori.

In this study, quantitative ultrasound (QUS) and machine-learning classification was used to predict treatment outcomes in head and neck cancer patients. Metastatic lymph nodes in the neck were scanned using conventional frequency ultrasound (US). Quantitative data were collected from the US-radiofrequency signal a priori. Machine-learning classification models were computed using QUS features; these included the linear fit parameters of the power spectrum, and second-order texture parameters of the QUS parametric images. Treatment outcomes were measured based on radiological response. Patients were classified into binary groups: radiologic complete response (CR) or radiological partial response (PR), which was assessed 3 months following treatment. Initial results demonstrate high accuracy (%Acc = 87.5%) for predicting radiological response. The results of this study suggest that QUS can be used to predict head and neck cancer response to radiotherapy a priori.

Prognostic Value of the Pretreatment Primary Lesion Quantitative Dynamic Contrast-Enhanced Magnetic Resonance Imaging for Nasopharyngeal Carcinoma

RATIONALE AND OBJECTIVES

Early identifying the long-term outcome of chemoradiotherapy is helpful for personalized treatment in nasopharyngeal carcinoma (NPC). This study aimed to investigate the prognostic significance of pretreatment quantitative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for NPC.

MATERIALS AND METHODS

The relationships between the prognosis and pretreatment quantitative DCE-MRI (K^trans, K_ep, V_e, and f_pv) values of the primary tumors were analyzed in 134 NPC patients who received chemoradiotherapy. Kaplan-Meier analysis was performed to calculate the local-regional relapse-free survival (LRRFS), local relapse-free survival (LRFS), regional relapse-free survival, distant metastasis-free survival (DMFS), progression-free survival, and overall survival rates. Cox proportional hazards model was used to explore the independent predictors for prognosis.

RESULTS

The local-failure group had significantly higher V_e (p = 0.033) and f_pv values (p = 0.005) than the non-local-failure group. The V_e-high group showed significantly lower LRRFS (p = 0.015) , LRFS (p = 0.013) , DMFS (p = 0.027) and progression-free survival (p = 0.035) rates than the V_e-low group. The f_pv-high group exhibited significantly lower LRRFS (p = 0.004) and LRFS (p = 0.005) rates than the f_pv-low group. V_e was the independent predictor for LRRFS (p = 0.008), LRFS (p = 0.007), DMFS (p = 0.041), and overall survival (p = 0.022). f_pv was the independent indicator for LRRFS (p = 0.003) and LRFS (p = 0.001).

CONCLUSION

Baseline quantitative DCE-MRI may be valuable in predicting the prognosis for NPC.

Incorporating Multiple Perspectives Into the Development of an Electronic Survivorship Platform for Head and Neck Cancer

PURPOSE

To improve the care of survivors of head and neck cancer, we developed the Head and Neck Survivorship Tool: Assessment and Recommendations (HN-STAR). HN-STAR is an electronic platform that incorporates patient-reported outcomes into a clinical decision support tool for use at a survivorship visit. Selections in the clinical decision support tool automatically populate a survivorship care plan (SCP). We aimed to refine HN-STAR by eliciting and incorporating feedback on its ease of use and usefulness.

METHODS

Human-computer interaction (HCI) experts reviewed HN-STAR using think-aloud testing and the Nielsen Heuristic Checklist. Nurse practitioners (NPs) thought aloud while reviewing the clinical decision support tool and SCP and responded to an interview. Survivors used HN-STAR as part of a routine visit and were interviewed afterward. We analyzed themes from the feedback. We described how we addressed each theme to improve the usability of HN-STAR.

RESULTS

Five HCI experts, 10 NPs, and 10 cancer survivors provided complementary usability insight that we categorized into themes of improvements. For ease of use, themes included technical design considerations to enhance user interface, ease of completion of a self-assessment, streamlining text, disruption of the clinic visit, and threshold for symptoms to appear on the SCP. The theme addressing usefulness was efficiency and comprehensiveness of the clinic visit. For each theme, we report revisions to HN-STAR in response to the feedback.

CONCLUSION

HCI experts provided key technical design insights into HN-STAR, whereas NPs and survivors provided usability feedback and clinical perspectives. We incorporated the feedback into the preparation for additional testing of HN-STAR. This method can inform and improve the ease of use and usefulness of the survivorship applications.

Association of Fludeoxyglucose F 18-Labeled Positron Emission Tomography and Computed Tomography With the Detection of Oropharyngeal Cancer Recurrence

Importance

No guidelines at present describe when fludeoxyglucose F 18-labeled positron emission tomography and computed tomography (FDG PET-CT) should be used in the initial posttreatment period for evaluation of oropharyngeal squamous cell carcinoma treatment outcome and recurrence.

Objective

To compare accuracies of the initial posttreatment PET-CT between primary treatment groups and to define indicators of false-positive findings.

Design, Setting, and Participants

This retrospective cohort study identified adults with a new diagnosis of oropharyngeal squamous cell carcinoma who received treatment with curative intent from October 1, 2006, through November 30, 2016, using the Alberta Cancer Registry (n = 380). Patients who underwent PET-CT within 1 year of treatment completion were included (n = 190). Of these, 103 patients (54.2%) had PET-CT findings positive for residual or recurrent disease, and 61 (32.1%) had false-positive findings. Among the 61 patients, 42 (68.9%) had received chemoradiotherapy (CRT) and 19 (31.1%) had primary surgery. Forty-two patients had true-positive findings, indicating a prevalence rate of disease of 22.1%. Data were analyzed from July through October 2017.

Exposures

One of 2 primary treatment modalities (surgery with or without adjuvant therapy vs CRT). All patients had posttreatment FDG PET-CT.

Main Outcomes and Measures

Primary outcome measures included the diagnostic odds ratio, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET-CT for detecting residual and/or recurrent disease. A multivariate analysis determined indicators of false-positive findings. Discriminative ability was assessed using receiver operating characteristic curve analysis of maximum standardized uptake value (SUVmax) metabolic data.

Results

Of the 190 participants, 77.9% were men, with a mean (SD) age at diagnosis of 58.5 (8.5) years. The diagnostic odds ratio was 19.3 (95% CI, 5.7-65.1); pooled sensitivity, 93.3% (95% CI, 80.7%-98.3%); and pooled specificity, 57.9% (95% CI, 49.4%-66.0%). The PPV of detecting disease was 54.7% (95% CI, 38.8%-69.8%) for primary surgery and 31.1% (95% CI, 20.2%-44.4%) for CRT. The NPV was 100% (95% CI, 94.7%-100%) for primary surgery and 96.6% (95% CI, 89.5%-99.1%) for CRT. Multivariate analysis identified treatment type, p16 disease, and smoking status as indicative of false-positive findings. In the receiver operating characteristic curve analysis for primary tumors, the optimal cutoff SUVmax for indicating true- vs false-positive results was 5.1 for surgically treated patients (area under the curve, 0.729; 95% CI, 0.570-0.888) and 5.3 for patients treated with CRT (area under the curve, 0.844; 95% CI, 0.700-0.989).

Conclusions and Relevance

The results indicate a higher specificity for FDG PET-CT for initial posttreatment surveillance imaging among patients treated with primary surgery compared with nonsurgical management. Both sets of patients with posttreatment FDG PET-CT findings with an SUVmax greater than 5.0 should undergo close evaluation for possible residual or recurrent disease.

Palliative chemotherapy in carcinoma nasopharynx

Introduction

Nasopharyngeal carcinoma is a rare malignancy. We conducted an audit of systemic therapies received in palliative setting in carcinoma nasopharynx and studied their outcomes.

Methods

Patients who underwent first-line palliative systemic chemotherapy between January 2014 and April 2017 for carcinoma nasopharynx at the department of medical oncology at authors' institute were selected for this analysis. Toxicities, responses, progression-free survival (PFS), and overall survival (OS) were analyzed. In addition, a Quality-Adjusted Time without Symptoms or Toxicity analysis with threshold utility analysis was performed.

Results

Fifty-one patients were included in this analysis. The indication of palliative chemotherapy was locoregionally recurrent disease in 25 (49.0%) patients and metastatic disease in 26 (51.0%) patients. The overall response rate was 62.0% (n = 33). The median PFS was 225 days (95% confidence interval [CI]: 164-274 days) and median OS was 513 days (95% CI: 286-931 days). The restricted mean TOX state duration was 2.6 days (95% CI: 0.3-4.9), restricted mean TWiST duration was 219.2 days (95% CI: 184.0-254.4), and restricted mean REL duration was 74.3 days (95% CI: 38.1-110.4).

Conclusion

Systemic cytotoxic therapy in nasopharyngeal cancers is associated with high response rates and clinically meaningful PFS; with low duration of time spent in adverse events.

Malnutrition evaluation in head and neck cancer patients: Practice patterns among otolaryngologists and radiation oncologists

BACKGROUND

Physician practice patterns regarding diagnosis and management of malnutrition in the head and neck cancer patient population are not well studied.

METHODS

A 17-question survey was distributed to 1392 members of the American Head and Neck Society (AHNS). The impact of hospital type, fellowship training, experience, and specialty was assessed.

RESULTS

Among AHNS members, there were 124 total respondents (9% response rate), including both otolaryngologists and radiation oncologists. Respondents strongly agreed (90%) that malnutrition negatively impacts patient outcomes. The majority (63%) felt comfortable screening for malnutrition, but 13% reported no routine assessment of malnutrition; 57% were unfamiliar with relevant guidelines. Barriers to screening included lack of familiarity with screening tools/guidelines, lack of time, and lack of access to dietitian.

CONCLUSION

Although there was a strong consensus among respondents that the identification and management of malnutrition among head and neck cancer patients is critical, familiarity with relevant guidelines was poor.

Nomogram predicting long-term overall survival and cancer-specific survival of lip carcinoma patients based on the SEER database: A retrospective case-control study

Our study was designed to construct nomograms to predict the overall survival (OS) and cancer-specific survival (CSS) of lip carcinoma patients.A search of the Surveillance, Epidemiology, and End Results (SEER) database provided us with detailed clinical data of the 1780 lip carcinoma patients. On the basis of the credible random split-sample method, the 1780 patients were placed into 2 groups, with 890 patients in the modeling group and 890 patients in the counterpart's group (proportion = 1:1). By employing Kaplan-Meier univariate and Cox multivariate survival analyses based on the modeling cohort, the nomograms were developed and then used to divide the modeling cohort into low-risk cohort and high-risk cohort. The survival rates of the 2 groups were calculated. Internal and external evaluation of nomogram accuracy was performed by the concordance index (C-index) and calibration curves.With regard to 5- and 8-year OS and CSS, the C-indexes of internal validation were 0.762 and 0.787, whereas those of external validation reached 0.772 and 0.818, respectively. All the C-indexes were higher than 0.7. The survival curves of the low-risk cohort were obviously better than those of the high-risk cohort.Credible nomograms have been established based on the SEER large-sample population research. We believe these nomograms can contribute to the design of treatment plans and evaluations of individual prognosis.