Matted nodes: poor prognostic marker in oropharyngeal squamous cell carcinoma independent of HPV and EGFR status

Identifying adverse nodal features associated with poor prognosis in stage IB nasopharyngeal carcinoma patients based on the 9th AJCC/UICC staging system: Implications for treatment intensification

OBJECTIVES

This study aimed to identify adverse lymph node (LN) features, specifically LN necrosis (LNN) and matted nodes (MNs), for the prediction of poor outcomes in stage IB nasopharyngeal carcinoma (NPC) patients according to the 9th edition of the AJCC/UICC staging system (TNM-9), with the ultimate goal of refining patient stratification and tailoring more individualized treatments.

MATERIALS

NPC patients classified as stage IB according to the TNM-9 staging system between January 2017 and December 2019 at our institution were candidates for this study. Baseline MRI assessments focusing on LNN and MNs were performed. Overall survival (OS), locoregional control (LRC), distant control (DC) and progression-free survival (PFS) were analyzed. Cox proportional hazards model analysis was used to identify prognostic factors.

RESULTS

Among the 318 patients included, 91 (28.6 %) presented with LNN, and 72 (22.6 %) presented with MNs. The presence of LNN and MNs was significantly correlated with inferior OS, DC and PFS. On the basis of these two nodal factors, patients were further categorized into low-risk (Group A, without LNN or MNs), intermediate-risk (Group B, with LNN or MNs), and high-risk (Group C, with both LNN and MNs) groups. As the number of adverse nodal features increased, the 5-year OS (Group A/B/C: 98.9 %/97.7 %/78.1 %, overall P < 0.001), DC (Group A/B/C: 99.5 %/94.2 %/78.3 %, overall P < 0.001), and PFS (Group A/B/C: 95.2 %/87.3 %/70.3 %, overall P < 0.001) decreased, whereas LRC (Group A/B/C: 96.8 %/92.9 %/91.4 %, overall P = 0.189) did not significantly differ.

CONCLUSIONS

LNN and MNs are adverse LN features that significantly impact the prognosis of stage IB NPC patients. Stratifying patients into low-, intermediate-, and high-risk groups based on these factors provides a more nuanced understanding of prognosis and treatment needs for personalized care.

Matted Lymph Nodes on MRI in Nasopharyngeal Carcinoma: Prognostic Factor and Potential Indication for Induction Chemotherapy Benefits

BACKGROUND

Lymph node characteristics markedly affect nasopharyngeal carcinoma (NPC) prognosis. Matted node (MN), an important characteristic for lymph node, lacks explored MRI-based prognostic implications.

PURPOSE

Investigate MRI-determined MNs' prognostic value in NPC, including 5-year overall survival (OS), distant metastasis-free survival (DMFS), local recurrence-free survival (LRFS), progression-free survival (PFS), and its role in induction chemotherapy (IC).

STUDY TYPE

Retrospective cohort survival study.

POPULATION

Seven hundred ninety-two patients with non-metastatic NPC (female: 27.3%, >45-year old: 50.1%) confirmed by biopsy.

FIELD STRENGTH/SEQUENCE

5-T/3.0-T, T1-, T2- and post-contrast T1-weighted fast spin echo sequences acquired.

ASSESSMENT

MNs were defined as ≥3 nodes abutting with intervening fat plane replaced by extracapsular nodal spread (ENS). Patients were observed every 3 months for 2 years and every 6 months for 5 years using MRI. Follow-up extended from treatment initiation to death or final follow-up. MNs were evaluated by three radiologists with inter-reader reliability calculated. A 1:1 matched-pair method compared survival differences between MN-positive patients with or without IC. Primary endpoints (OS, DMFS, LRFS, PFS) were calculated from therapy initiation to respective event.

STATISTICAL TESTS

Kappa values assessed inter-reader reliability. Correlation between MN, ENS, and LNN was studied through Spearman's correlation coefficient. Clinical characteristics were calculated via Fisher's exact, Chi-squared, and Student's t-test. Kaplan-Meier curves and log-rank tests analyzed all time-to-event data. Confounding factors were included in Multivariable Cox proportional hazard models to identify independent prognostic factors. P-values <0.05 were considered statistically significant.

RESULTS

MNs incidence was 24.6%. MNs independently associated with decreased 5-year OS, DMFS, and PFS; not LRFS (P = 0.252). MN-positive patients gained significant survival benefit from IC in 5-year OS (88.4% vs. 66.0%) and PFS (76.4% vs. 53.5%), but not DMFS (83.1% vs. 69.9%, P = 0.145) or LRFS (89.9% vs. 77.8%, P = 0.140).

DATA CONCLUSION

MNs may independently stratify NPC risk and offer survival benefit from IC.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Free-Breathing StarVIBE Sequence for the Detection of Extranodal Extension in Head and Neck Cancer: An Image Quality and Diagnostic Performance Study

(1) Background: This study aims to evaluate the image quality of abnormal cervical lymph nodes in head and neck cancer and the diagnostic performance of detecting extranodal extension (ENE) using free-breathing StarVIBE. (2) Methods: In this retrospective analysis, 80 consecutive head and neck cancer patients underwent StarVIBE before neck dissection at an academic center. Image quality was compared with conventional VIBE available for 28 of these patients. A total of 73 suspicious metastatic lymph nodes from 40 patients were found based on morphology and enhancement pattern on StarVIBE. Sensitivity (SN), specificity (SP), and odds ratios were calculated for each MR feature from StarVIBE to predict pathologic ENE. (3) Results: StarVIBE showed significantly superior image quality, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) for enlarged lymph nodes compared to VIBE. The MR findings of "invading adjacent planes" (SN, 0.54; SP, 1.00) and "matted nodes" (SN, 0.72; SP, 0.89) emerged as notable observations. The highest diagnostic performance was attained by combining these two features (SN, 0.93; SP, 0.89). (4) Conclusions: This study confirms that StarVIBE offers superior image quality for abnormal lymph nodes compared to VIBE, and it can accurately diagnose ENE by utilizing a composite MR criterion in head and neck cancer.

Diagnostic challenges and prognostic implications of extranodal extension in head and neck cancer: a state of the art review and gap analysis

Extranodal extension (ENE) is a pattern of cancer growth from within the lymph node (LN) outward into perinodal tissues, critically defined by disruption and penetration of the tumor through the entire thickness of the LN capsule. The presence of ENE is often associated with an aggressive cancer phenotype in various malignancies including head and neck squamous cell carcinoma (HNSCC). In HNSCC, ENE is associated with increased risk of distant metastasis and lower rates of locoregional control. ENE detected on histopathology (pathologic ENE; pENE) is now incorporated as a risk-stratification factor in human papillomavirus (HPV)-negative HNSCC in the eighth edition of the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) TNM classification. Although ENE was first described almost a century ago, several issues remain unresolved, including lack of consensus on definitions, terminology, and widely accepted assessment criteria and grading systems for both pENE and ENE detected on radiological imaging (imaging-detected ENE; iENE). Moreover, there is conflicting data on the prognostic significance of iENE and pENE, particularly in the context of HPV-associated HNSCC. Herein, we review the existing literature on ENE in HNSCC, highlighting areas of controversy and identifying critical gaps requiring concerted research efforts.

Assessment of Radiologic Extranodal Extension Using Combinatorial Analysis of Nodal Margin Breakdown and Metastatic Burden in Oropharyngeal Cancer

The importance of risk stratification in the management of oropharyngeal squamous cell carcinoma (OPSCC) is becoming increasingly obvious with the growing evidence of its variable prognosis. We identified and evaluated imaging characteristics predictive of extranodal extension (ENE) in OPSCC. Preoperative computed tomography and histopathologic results of 108 OPSCC patients who underwent neck dissection as primary treatment were analyzed. Imaging characteristics were reassessed for factors associated with nodal margin breakdown and metastatic burden. Moreover, the predictability of pathological ENE (pENE) was analyzed. Univariate and multivariate binomial logistic regression analyses were performed to examine the predictive power of ENE-related radiologic features. Imaging-based characteristics showed variable degrees of association with pENE. Factors associated with nodal margin breakdown (indistinct capsular contour, irregular margin, and perinodal fat stranding) and factors associated with nodal burden (nodal matting, lower neck metastasis, and presence of >4 lymph node metastases) were significantly predictive of ENE (odds ratio (OR) = 11.170 and 12.121, respectively). The combined utilization of the nodal margin and burden factors further increased the predictive ability (OR = 14.710). Factors associated with nodal margin breakdown and nodal burden were associated with pENE, demonstrating the use of combinatorial analysis for more accurate ENE prediction.

Inguinal Lymph-Node Ratio (LNR) as a predictor of Pelvic Lymph-Node Metastasis in squamous cell carcinoma of penis

OBJECTIVE

To determine the predictors of pelvic lymph-node metastasis in cases of squamous cell carcinoma (SCC) of penis.

METHODS

Data was retrospectively collected from 267 cases of SCC penis that presented at our institute between 2009 and 2019. Univariate and multivariate logistic regression models were used to identify independent significant factors. Receiver Operating Characteristic (ROC) curve was used to determine the cut-off of Lymph-Node Ratio (LNR) and discriminative ability of new model. Survival analysis was done using Kaplan Meier Curve.

RESULTS

Pelvic Lymph-Node Metastasis (PLNM) was pathologically detected in 56 groins (29.2%). A cut-off of 0.25 was calculated for LNR based on ROC. LNR >0.25 (p = 0.003), ENE (p = 0.037), and LVI (p = 0.043) were found significant on multivariate logistic regression. 71.5% showed PLNM in groins with positive LN (PLN) </ = 2 but LNR >0.25 whereas no PLNM was seen in groins with PLN >2 but LNR </ = 0.25. The AUC was 0.918 and 0.821 for LNR and PLN respectively. The probability of finding PLNM was 0% for patients with no risk factors which increased to 83% for 3 risk factors. The 5-year survival was 60% if no PLNM was found as compared to 12.7% if PLNM were found. The survival according to risk score was 81%, 43%, 16% and, 13% for 0, 1, 2 and, 3 risk score respectively.

CONCLUSION

LNR >0.25, LVI and, ENE are independent predictors of PLNM. The discriminative ability of LNR was better than PLN. PLND could be avoided if no risk factors are present.

Management of Recurrent HPV-Positive Oropharyngeal Squamous Cell Carcinoma: a Contemporary Review

PURPOSE OF REVIEW

To review the impact of contemporary treatment strategies on salvage outcomes in patients with recurrent human papilloma virus-positive oropharyngeal squamous cell carcinoma (HPV + OPSCC).

RECENT FINDINGS

Secondary to HPV, changes in disease biology have impacted primary treatments and subsequent approaches to patients with recurrence. With treatment strategies more inclusive of upfront surgery, the characteristics of patients with recurrence HPV + OPSCC have been further redefined. Less invasive endoscopic surgical approaches such as transoral robotic surgery (TORS), and the continued refinement of conformal radiotherapy techniques, have improved treatment options for patients with recurrent HPV + OPSCC. Systemic treatment options have continued to expand including potentially effective immune-based therapies. Effective surveillance with systemic and oral biomarkers offers hope of earlier detection of recurrence. Management of patients with recurrent OPSCC remains difficult. Modest improvements in salvage treatment have been observed within the HPV + OPSCC cohort largely reflecting disease biology and improved treatment techniques.

Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis of Clinical Trial Demographics

Simple Summary

HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) is unique amongst oropharyngeal cancers in its high responsiveness to treatment and its lower mortality rate. As a result, numerous clinical trials have been conducted to identify treatment modalities and protocols. In order for these trials to have meaningful impact on HPV-associated OPSCC patients, proper demographic representation by trial participants is essential. The aim of our systematic review and meta-analysis was to assess the demographics of trial participants for HPV-associated OPSCC clinical trials and compare them with those reported by national databases. We determined that clinical-trial participants were predominately non-smoking white men, with tonsils as the primary tumor site. These findings reflect the demographics reported by the National Cancer Database. Our results imply that HPV-associated OPSCC clinical trials appropriately represent the target population and offer immense benefit.

Abstract

The objective of our paper was to answer the following question: how do patients with HPV-related oropharyngeal squamous cell carcinoma OPSCC (Population) enrolled in clinical trials (Intervention), compared with national database reports of HPV-associated OPSCC patients (Comparison), present demographically (Outcome)? We conducted a systematic review and meta-analysis of studies pertaining to clinical trials of HPV-associated OPSCC and participant demographics in the United States. PubMed, Scopus, CINAHL, and the Cochrane Library were searched from inception to 2 February 2022. Studies of overlapping participant cohorts and/or studies conducted outside of the United States were excluded. Primary outcomes were patient age, sex, and race. Secondary outcomes were smoking history, alcohol history, history of prior cancer, and tumor origin site. Meta-analysis of single means (mean, N for each study, and standard deviation) for age, pack years, and smoking years was performed. Pooled prevalence rates of gender, race, alcohol history, tobacco history, and tumor origin site were expressed as a percentage, with 95% confidence intervals. Meta-analysis found patients to be predominately non-smoking white males, with tumors originating from the tonsil. Our findings reflected the demographics reported by the National Cancer Database (NCDB) for HPV-associated OPSCC. This indicates that HPV-associated OPSCC patients are appropriately represented in clinical trial demographics.

Predictors of Outcome after (Chemo)Radiotherapy for Node-Positive Oropharyngeal Cancer: The Role of Functional MRI

The prognosis of a subset of patients with locally advanced oropharyngeal cancer (LA-OPC) is still poor despite improvements in patient selection and treatment. Identifying specific patient- and tumor-related factors can help to select those patients who need intensified treatment. We aimed to assess the role of historical risk factors and novel magnetic resonance imaging (MRI) biomarkers in predicting outcomes in these patients. Patients diagnosed with LA-OPC were studied with diffusion-weighted imaging (DWI) and dynamic-contrast enhanced MRI at baseline and at the 10th radiotherapy (RT) fraction. Clinical information was collected as well. The endpoint of the study was the development of disease progression, locally or distantly. Of the 97 patients enrolled, 68 were eligible for analysis. Disease progression was recorded in 21 patients (11 had loco-regional progression, 10 developed distant metastases). We found a correlation between N diameter and disease control (p = 0.02); features such as p16 status and extranodal extension only showed a trend towards statistical significance. Among perfusion MRI features, higher median values of K_ep both in primary tumor (T, p = 0.016) and lymph node (N, p = 0.003) and lower median values of v_e (p = 0.018 in T, p = 0.004 in N) correlated with better disease control. K_ep P90 and N diameter were identified by MRMR algorithm as the best predictors of outcome. In conclusion, the association of non-invasive MRI biomarkers and patients and tumor characteristics may help in predicting disease behavior and patient outcomes in order to ensure a more customized treatment.

NCCN Guidelines® Insights: Head and Neck Cancers, Version 1.2022

The NCCN Guidelines for Head and Neck Cancers address tumors arising in the oral cavity (including mucosal lip), pharynx, larynx, and paranasal sinuses. Occult primary cancer, salivary gland cancer, and mucosal melanoma (MM) are also addressed. The specific site of disease, stage, and pathologic findings guide treatment (eg, the appropriate surgical procedure, radiation targets, dose and fractionation of radiation, indications for systemic therapy). The NCCN Head and Neck Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel's most recent recommendations regarding management of HPV-positive oropharynx cancer and ongoing research in this area.

Inter-rater concordance and operating definitions of radiologic nodal feature assessment in human papillomavirus-positive oropharyngeal carcinoma

BACKGROUND AND PURPOSE

This study aims to evaluate the reliability of radiologic nodal feature assessment in clinical node-positive human papillomavirus-positive oropharyngeal carcinoma.

MATERIALS AND METHODS

Baseline CTs or MRIs of clinical node-positive human papillomavirus-positive oropharyngeal carcinoma diagnosed between 2012 and 2015 were reviewed independently by two neuroradiologists for seven nodal features: radiologic nodal involvement, cystic change, presence of necrosis, clustering, conglomeration, coalescence, and extranodal extension. Consensus operating definitions were derived after discussion. The features were re-reviewed in a randomly selected cohort. Levels of certainty (probability of presence: <25%, ∼50%, ∼75%, and >90%) were recorded. Interrater concordance was calculated using Cohen's kappa coefficient.

RESULTS

A total of 413 patients (826 necks) were eligible. At initial review, the inter-rater kappa values for: radiologic nodal involvement, cystic change, necrosis, clustering, conglomeration, coalescence, and extranodal extension were 0.92, 0.64, 0.48, 0.32, 0.32, 0.62, and 0.56, respectively. A re-review of 94 randomly selected cases (188 necks) after consolidation of operating definitions for nodal features showed that the inter-rater kappa values of these features were 0.83, 0.62, 0.58, 0.32, 0.18, 0.68, and 0.74 when considering ≥50% certainty as positive, and improved to 0.94, 0.66, 0.59, 0.33, 0.19, 0.76, and 0.86 when considering ≥75% certainty as positive.

CONCLUSION

Clearly defined nomenclature results in improved interrater reliability when assessing radiologic nodal features, especially for coalescent adenopathy and extranodal extension. Higher levels of certainty are associated with higher inter-rater agreement. Radiology reporting should include clear definitions of clinically relevant nodal features as well as levels of certainty to serve various needs in clinical care and research.

Prognostic impact of matted lymphadenopathy in patients with oropharyngeal squamous cell carcinoma treated with definitive chemoradiotherapy

OBJECTIVE

To determine whether cervical matted lymphadenopathy (ML) is associated with outcomes in patients with oropharyngeal squamous cell carcinoma (OPSCC) treated with definitive chemoradiotherapy (CRT).

MATERIALS AND METHODS

OPSCC patients treated at our institution with CRT were included (n = 417). ML was defined by three adjacent nodes without an intervening fat plane. Patients were stratified into favorable OPSCC (p16 + with ≤ 10 pack-years smoking history) or unfavorable OPSCC (p16- and/or > 10 pack years). Primary outcomes were overall survival (OS) and progression-free survival (PFS) and the cumulative incidences of regional recurrence (RR) and distant metastasis (DM).

RESULTS

The median follow-up time for the surviving cohort was 49.9 months. In favorable OPSCC (n = 220), there were no significant associations between ML and any outcome. In unfavorable OPSCC (n = 197), ML had a significant negative impact on OS and PFS, with 3-year OS for patients without and with matted nodes at 74% and 56% (HR, 1.61, 95% CI 1.01-2.58). On multivariable Cox regression, patients with ML experienced significantly worsened OS (HR 1.65, 95% CI 1.03-2.65) and PFS (HR 1.94, 95% CI 1.28-2.93). The cumulative incidence of DM was also higher with ML (31% vs. 9%, adjusted HR 3.3, 95% CI 1.71-6.48).

CONCLUSION

ML carries no prognostic importance in patients with favorable OPSCC. However, ML portends significantly worse outcomes in individuals with HPV-negative disease or a significant smoking history. Thus, ML may help risk-stratify this latter population for treatment intensification, but does not seem to be a contraindication for treatment de-escalation in the former.

Advances in Imaging for HPV-Related Oropharyngeal Cancer: Applications to Radiation Oncology

While there has been an overall decline of tobacco and alcohol-related head and neck cancer in recent decades, there has been an increased incidence of HPV-associated oropharyngeal cancer (OPC). Recent research studies and clinical trials have revealed that the cancer biology and clinical progression of HPV-positive OPC is unique relative to its HPV-negative counterparts. HPV-positive OPC is associated with higher rates of disease control following definitive treatment when compared to HPV-negative OPC. Thus, these conditions should be considered unique diseases with regards to treatment strategies and survival. In order to sufficiently characterize HPV-positive OPC and guide treatment strategies, there has been a considerable effort to diagnose, prognose, and track the treatment response of HPV-associated OPC through advanced imaging research. Furthermore, HPV-positive OPC patients are prime candidates for radiation de-escalation protocols, which will ideally reduce toxicities associated with radiation therapy and has prompted additional imaging research to detect radiation-induced changes in organs at risk. This manuscript reviews the various imaging modalities and current strategies for tackling these challenges as well as provides commentary on the potential successes and suggested improvements for the optimal treatment of these tumors.

Development and Assessment of a Model for Predicting Individualized Outcomes in Patients With Oropharyngeal Cancer

IMPORTANCE

Recent insights into the biologic characteristics and treatment of oropharyngeal cancer may help inform improvements in prognostic modeling. A bayesian multistate model incorporates sophisticated statistical techniques to provide individualized predictions of survival and recurrence outcomes for patients with newly diagnosed oropharyngeal cancer.

OBJECTIVE

To develop a model for individualized survival, locoregional recurrence, and distant metastasis prognostication for patients with newly diagnosed oropharyngeal cancer, incorporating clinical, oncologic, and imaging data.

DESIGN, SETTING, AND PARTICIPANTS

In this prognostic study, a data set was used comprising 840 patients with newly diagnosed oropharyngeal cancer treated at a National Cancer Institute-designated center between January 2003 and August 2016; analysis was performed between January 2019 and June 2020. Using these data, a bayesian multistate model was developed that can be used to obtain individualized predictions. The prognostic performance of the model was validated using data from 447 patients treated for oropharyngeal cancer at Erasmus Medical Center in the Netherlands.

EXPOSURES

Clinical/oncologic factors and imaging biomarkers collected at or before initiation of first-line therapy.

MAIN OUTCOMES AND MEASURES

Overall survival, locoregional recurrence, and distant metastasis after first-line cancer treatment.

RESULTS

Of the 840 patients included in the National Cancer Institute-designated center, 715 (85.1%) were men and 268 (31.9%) were current smokers. The Erasmus Medical Center cohort comprised 300 (67.1%) men, with 350 (78.3%) current smokers. Model predictions for 5-year overall survival demonstrated good discrimination, with area under the curve values of 0.81 for the model with and 0.78 for the model without imaging variables. Application of the model without imaging data in the independent Dutch validation cohort resulted in an area under the curve of 0.75. This model possesses good calibration and stratifies patients well in terms of likely outcomes among many competing events.

CONCLUSIONS AND RELEVANCE

In this prognostic study, a multistate model of oropharyngeal cancer incorporating imaging biomarkers appeared to estimate and discriminate locoregional recurrence from distant metastases. Providing personalized predictions of multiple outcomes increases the information available for patients and clinicians. The web-based application designed in this study may serve as a useful tool for generating predictions and visualizing likely outcomes for a specific patient.

The Potential Impact and Usability of the Eighth Edition TNM Staging Classification in Oral Cavity Cancer

AIMS

In the current eighth edition head and neck TNM staging, extranodal extension (ENE) is an adverse feature in oral cavity squamous cell cancer (OSCC). The previous seventh edition N1 with ENE is now staged as N2a. Seventh edition N2+ with ENE is staged as N3b in the eighth edition. We evaluated its potential impact on patients treated with surgery and postoperative intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

OSCC patients treated with primary surgery and adjuvant (chemo)radiotherapy between January 2005 and December 2014 were reviewed. Cohorts with pathological node-negative (pN-), pathological node-positive without ENE (pN+_pENE-) and pathological node-positive with ENE (pN+_pENE+) diseases were compared for local control, regional control, distant control and overall survival. The pN+ cohorts were further stratified into seventh edition N-staging subgroups for outcomes comparison.

RESULTS

In total, 478 patients were evaluated: 173 pN-; 159 pN+_pENE-; 146 pN+_pENE+. Outcomes at 5 years were: local control was identical (78%) in all cohorts (P = 0.892), whereas regional control was 91%, 80% and 68%, respectively (P < 0.001). Distant control was 97%, 87%, 68% (P < 0.001) and overall survival was 75%, 53% and 39% (P < 0.001), respectively. Overall survival for N1 and N2a subgroups was not significantly different. In the seventh edition N2b subgroup of pENE- (n = 79) and pENE+ (n = 79) cohorts, overall survival was 67% and 37%, respectively. In the seventh edition N2c subgroups, overall survival for pENE- (n = 17) and pENE+ (n = 38) cohorts was 65% and 35% (P = 0.08), respectively. Overall, an additional 128 patients (42% pN+) were upstaged as N3b.

CONCLUSIONS

When eighth edition staging was applied, stage migration across the N2-3 categories resulted in expected larger separations of overall survival by stage. Patients treated with primary radiation without surgical staging should have outcomes carefully monitored. Strategies to predict ENE preoperatively and trials to improve the outcomes of pENE+ patients should be explored.

Novel imaging classification system of nodal disease in human papillomavirus-mediated oropharyngeal squamous cell carcinoma prognostic of patient outcomes

BACKGROUND

Matted nodes in human papillomavirus (HPV)-mediated oropharyngeal squamous cell carcinoma (OPC) is an independent predictor of distant metastases and decreased overall survival. We aimed to classify imaging patterns of metastatic lymphadenopathy, analyze our classification system for reproducibility, and assess its prognostic value.

METHODS

The metastatic lymphadenopathy was classified based on radiological characteristics for 216 patients with HPV-mediated OPC. Patient outcomes were compared and inter-rater reliability was calculated.

RESULTS

The presence of ≥3 abutting lymph nodes with imaging features of surrounding extranodal extension (ENE), one subtype of matted nodes, was associated with worse 5-year overall survival, overall recurrence-free survival, regional recurrence-free survival, and distant recurrence-free survival (p ≤ 0.03). Other patterns were not significantly associated with outcome measures. Overall inter-rater agreement was substantial (κ = 0.73).

CONCLUSION

One subtype of matted nodes defined by ≥3 abutting lymph nodes with imaging features of surrounding ENE is the radiological marker of worst prognosis.

Unambiguous advanced radiologic extranodal extension determined by MRI predicts worse outcomes in nasopharyngeal carcinoma: Potential improvement for future editions of N category systems

BACKGROUND AND PURPOSE

To explore the prognostic value of different radiologic extranodal extension (rENE) grades and their potential improvement for the 8th edition N category in nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

From 2009 to 2013, a cohort of 1887 patients with NPC was retrospectively enrolled and randomized to the training (n = 955) and validation (n = 932) groups. rENE was categorized as follows: grade 0, nodes without rENE; grade 1, nodes with rENE infiltrating the surrounding fat only; grade 2, matted nodes; grade 3, nodes with rENE infiltrating adjacent structures.

RESULTS

The percentage of patients with MRI-positive cervical nodes was 66.5% (1254/1887), of whom grade 0, 1, 2 and 3 rENE cases accounted for 33.2% (416/1254), 14.9% (187/1254), 36.5% (458/1254) and 15.4% (193/1254), respectively. The kappa coefficients for the inter-rater and intra-rater assessments were 0.63, 0.51, 0.65 and 0.93, and 0.76, 0.69, 0.72 and 1.0 in grade 0, 1, 2 and 3 rENE, respectively. Grade 3 rENE rather than grades 0-2 rENE was an independent unfavorable predictor of overall survival and disease-free survival (P < 0.001). Recursive partitioning analysis was applied to refine the N category: eN0 (N0), eN1 (N1 without grade 3), eN2 (N2 without grade 3), and eN3 (N1/N2 with grade 3, N3). Compared to the current system, the proposed N category performed better in hazard consistency, hazard discrimination, sample size balance and outcome prediction.

CONCLUSION

Grade 3 rENE was an independent unfavorable indicator of NPC. Upstaging patients in N1-2 with grade 3 rENE to N3 led to a superior prognostic performance.

CT and FDG-PET radiologic biomarkers in p16+ oropharyngeal squamous cell carcinoma patients treated with definitive chemoradiotherapy

PURPOSE

To assess associations between imaging biomarkers from standard of care pre-treatment CT and FDG-PET scans and locoregional (LR) and distant metastatic (DM) recurrences in patients with p16+ oropharyngeal squamous cell carcinoma (OPSCC) treated with definitive chemoradiotherapy (CRT).

METHODS

An institutional database from a single NCI-designated cancer center identified 266 patients with p16+ OPSCC treated with definitive CRT in our department from 2005 to 2016 with evaluable pre-treatment FDG-PET scans. Quantitative SUV metrics and qualitative imaging metrics were determined from FDG-PET and CT scans, while clinical characteristics were abstracted from the medical record. Associations between clinical/imaging features and time to LR (TTLRF) or DM (TTDMF) failure and overall survival (OS) were assessed using univariable Cox regression and penalized stepwise regression for multivariable analyses (MVA).

RESULTS

There were 27 LR and 32 DM recurrences as incident failures. Imaging biomarkers were significantly associated with TTLRF, TTDMF and OS. FDG-PET metrics outperformed CT and clinical metrics for TTLRF, with metabolic tumor volume being the only significant feature selected on MVA: C-index = 0.68 (p = 0.01). Radiographic extranodal extension (rENE), positive retropharyngeal nodes (RPN+), and clinical stage were significant on MVA for TTDMF: C-index = 0.84 (p < 0.001). rENE, group stage, and RPN+ were significant on MVA for OS: C-index = 0.77 (p < 0.001).

CONCLUSIONS

In the largest study to date of uniformly treated patients with CRT to evaluate both pretreatment CT and FDG-PET, radiographic biomarkers were significantly associated with TTLRF, TTDMF and OS among patients with p16+ OPSCC treated with CRT. CT metrics performed best to predict TTDMF, while FDG-PET metrics showed improved prediction for LRRFS. These metrics may help identify candidates for treatment intensification or de-escalation of therapy.

STATEMENT OF TRANSLATIONAL RELEVANCE

Pre-treatment imaging features from standard-of-care PET/CT imaging show promise for predicting long-term outcomes following HPV-associated oropharynx cancer (HPV-OPC) therapy. This study comprehensively characterizes qualitative and quantitative pre-treatment imaging metrics associated with time to pattern-specific failure in a cohort of 266 patients treated uniformly with definitive chemoradiation. Multivariate analysis (MVA) for time to locoregional failure (TTLRF), time to distant metastatic failure (TTDMF), and overall survival (OS) was performed. FDG-PET metrics outperformed CT and clinical metrics for TTLRF. CT radiographic extranodal extension, positive retropharyngeal nodes, and stage strongly predicted TTDMF (combined C-index = 0.84, log rank p < 0.001). Number of smoking pack-years complemented clinical and imaging features only in patients without radiographic extranodal extension or positive retropharyngeal nodes. Time to pattern-specific failure is important for guiding treatment de-escalation strategies, which intend to reduce treatment-related toxicity in patients with relatively long expected survival times. This study suggests that PET/CT features should play a crucial role in future de-escalation trials and management of HPV-OPC patients.

Prognostic Value of Nodal Matting on MRI in Nasopharyngeal Carcinoma Patients

BACKGROUND

Nodal (N) stage is one of the most important predictors for distant metastasis in nasopharyngeal carcinoma (NPC) patients. It may ignore potentially useful nodal features, such as nodal matting (three or more lymph nodes abutting together with the absence of intervening fat planes).

PURPOSE

To explore the prognostic value of nodal matting in NPC patients and construct a nomogram with nodal matting for predicting distant metastasis-free survival (DMFS).

STUDY TYPE

Retrospective.

POPULATION

In all, 792 NPC patients treated with intensity modulated radiation therapy from 2010 to 2013 were enrolled with 2:1 training (n = 527) and validation (n = 65) cohorts.

FIELD STRENGTH/SEQUENCE

T₁ - and T₂ -weighted imaging at 1.5 or 3.0T.

ASSESSMENT

Nodal matting and other nodal characteristics were assessed with MRI. MR images were evaluated separately by three radiologists. The association between nodal matting and DMFS was analyzed.

STATISTICAL TESTS

Univariate and multivariate analyses were performed using the Cox proportional hazards regression model. Nomograms were constructed from a multivariate logistic regression model with and without nodal matting. The predictive accuracy and discriminative ability of the nomograms were determined by concordance index (C-index) and calibration curves. The results were validated using bootstrap resampling and validation cohort.

RESULTS

The incidence of nodal matting was 24.6% (195/792) in all patients. In the training cohort, nodal matting was independently associated with DMFS (hazard ratio [HR] = 1.97 [1.05-3.69], P < 0.05). N1 patients with nodal matting had worse DMFS than N1 patients without (P < 0.05). However, no significant difference was observed when comparing N1 patients with nodal matting to N2 patients (P = 0.464). The C-index of the nomogram with nodal matting was higher than the nomogram without (0.717 vs. 0.699, P = 0.084).

DATA CONCLUSION

Nodal matting was an independent prognostic factor for DMFS in NPC patients. It may help to select patients at high risk of distant metastasis.

Prognostic Value of Radiologic Extranodal Extension in Human Papillomavirus-Related Oropharyngeal Squamous Cell Carcinoma

Objective

To determine whether radiologic extranodal extension (ENE) appearing on pretreatment CT and MRI could predict the prognosis in patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC).

Materials and Methods

The study population was obtained from a historical cohort diagnosed with HPV-related OPSCC. A total of 134 OPSCC patients who had a metastatic lymph node on pretreatment CT or MRI were included, and radiologic ENE was evaluated by two experienced head and neck radiologists. Kaplan-Meier and multivariate Cox regression analyses were performed to evaluate the impact of radiologic ENE on progression-free survival (PFS). The diagnostic performance of CT and MRI for the diagnosis of ENE was also evaluated in patients who underwent neck dissection.

Results

Seventy patients (52.2%) showed radiologic ENE-positive findings. Although patients showing radiologic ENE had a worse 3-year PFS (83.7% vs. 95.3%, p = 0.023), the association between radiologic ENE and PFS was not statistically significant on multivariate analysis (p = 0.141; hazard ratio, 2.68; 95% confidence interval, 0.72–9.97). CT or MRI had a sensitivity of 62%, specificity of 77.8%, and accuracy of 71.9% for predicting pathologic ENE.

Conclusion

Radiologic ENE on CT or MRI did not predict poor PFS in patients with HPV-related OPSCC, although there was a trend towards worse PFS. Further studies are warranted to determine whether radiologic ENE is a useful imaging biomarker to risk-stratify patients with HPV-related OPSCC.

Predictive value of computed tomography in identifying extranodal extension in human papillomavirus-positive versus human papillomavirus-negative head and neck cancer

Pathologic extranodal extension (pENE) impacts treatment planning and is an important prognostic indicator for patients with head and neck squamous cell carcinoma (HNSCC). Computed tomography (CT) is a commonly used modality for assessment of radiographic ENE (rENE). To determine the predictive value of CT-identified rENE in predicting pENE, we performed a systematic review through a search of 4 databases (PubMed, Scopus, Cochrane, and OVID). Meta-analysis of diagnostic performance based on human papillomavirus (HPV) status was conducted. For HPV-negative HNSCC, pooled sensitivity, specificity, and accuracy were 60.6%, 93.3%, and 82.6%, respectively. Overall positive predictive value (PPV) was 82.7%. For HPV-positive HNSCC, pooled sensitivity, specificity, and accuracy were 77.7%, 72.2%, and 63.8%, respectively. Overall PPV was 68.6%. Significant differences were observed in diagnostic performance parameters between the two cohorts. The radiographic characteristics of HPV-positive and HPV-negative nodal metastases in HNSCC differ and radiographic evaluation of ENE in HPV-positive nodes is challenging. Development of refined imaging characteristics of HPV-positive nodes is needed to improve diagnostic performance.

'Good cancer gone bad': a narrative review of HPV oropharyngeal cancer and potential poor outcomes

PURPOSE

Oropharyngeal cancer (OPC) remains a significant health burden and about 15-30% of these have been attributed to the human papillomavirus (HPV). Human papillomavirus-related oropharyngeal cancer (HPV OPC) includes tumours which are detected to be p16INK4A positive or have the HPV DNA detected by in situ hybridisation or polymerase chain reaction. HPV OPC is generally believed to have a relatively good prognosis. More recently, there is a recognised pattern of atypical spread in a highly aggressive subset of HPV OPC. These are HPV OPCs which develop distant metastasis or recurrence. This review raises awareness of this subset of HPV OPC and factors associated with poor outcomes.

METHODS

A review of the literature available on HPV OPC was carried out. Studies were sourced from PubMed with searching of relevant headings and sub-headings and cross-referencing.

RESULTS

Factors associated with highly aggressive HPV OPC include nodal stage and nodal morphology, alcohol and tobacco use, age and biological characteristics. Treatment options in cases of disease recurrence include salvage resection radiotherapy and/or chemotherapy and management options vary depending on the nature of recurrence and initial treatment. Recent updates in HPV OPC staging have made staging and treatment of tumours more accurate.

CONCLUSION

While HPV OPC overall carries a relatively good prognosis, it is important for clinicians to be aware of potentially highly aggressive cases of HPV OPC and to be aware of factors that should prompt close monitoring.

Expression of CD44, EGFR, p16, and their mutual combinations in patients with head and neck cancer: Impact on outcomes of intensity-modulated radiation therapy

BACKGROUND

Progress in radiation treatment of head and neck squamous cell carcinoma (HNSCC) deserves the studies focused on molecular predictors that would help to enhance individually tailored treatment.

METHODS

p16/epidermal growth factor receptor (EGFR)/cluster of differentiation-44 (CD44) was immunohistochemically analyzed in 165 HNSCC patients.

RESULTS

In the entire group and the p16 negative cohort, better 3-year overall survival and locoregional control correlated with p16 positivity, CD44, and EGFR negativity were observed. Combined analysis revealed the worst results in the CD44+/p16-, EGFR+/p16-, and EGFR+/CD44+ groups and in the EGFR+/CD44+ within p16 negative cohort. Multivariate analysis found tumor stage, Karnofsky index, p16, and CD44 as prognostic factors of overall survival and clinical stage, and p16 as a prognostic factor for locoregional control. Clinical stage and Karnofsky index affected overall survival and tumor stage. EGFR affected locoregional control in the p16 negative subgroup.

CONCLUSION

Our study confirmed the negative effect of CD44 and EGFR and the positive effect of p16 on radiotherapy results.

Radiographic nodal prognostic factors in stage I HPV-related oropharyngeal squamous cell carcinoma

BACKGROUND

The updated AJCC Cancer Staging Manual groups all p16-positive oropharyngeal squamous cell carcinoma (OPSCC) with unilateral nodal involvement within 6 cm into the new clinical N1 classification, consolidating a heterogeneous group of disease with varying radiographic findings.

METHODS

A central radiological review was conducted identifying 233 patients with stage I node-positive (cT1-2N1) disease who underwent definitive concurrent chemoradiation. Factors evaluated included lymph node size, low-neck lymphadenopathy, retropharyngeal lymphadenopathy, overt radiographic extracapsular extension, and matted lymphadenopathy.

RESULTS

On multivariate analysis adjusted for age, smoking history, and chemotherapy regimen, low-neck lymphadenopathy (hazard ratio (HR) = 6.55; P < .001) and retropharyngeal lymphadenopathy (HR = 3.36; P = .009) predicted for inferior progression-free survival (PFS). low-neck lymphadenopathy (HR = 6.38; P = .001) and retropharyngeal lymphadenopathy (HR = 3.32; P = .02) also predicted for inferior overall survival (OS). All other radiographic characteristics showed no prognostic impact for PFS or OS.

CONCLUSIONS

This analysis suggests that caution should be advised against de-intensification efforts among patients with stage I node-positive p16-positive OPSCC with low-neck lymphadenopathy or retropharyngeal lymphadenopathy.

Smoking-induced control of miR-133a-3p alters the expression of EGFR and HuR in HPV-infected oropharyngeal cancer

Purpose

Human papillomavirus (HPV) infected oropharyngeal squamous cell carcinoma (OPSCC) patients have a better prognosis compared to HPV(-) counterparts. However, a subset of HPV(+) patients with a smoking history fail to respond to the standard of care treatments such as radiation and chemotherapy. To understand the underlying mechanism driving HPV(+) OPSCC patient resistance to treatment and recurrence, we sought to identify and characterize the differentially expressed miRNAs and their target genes in HPV(+) smokers and non-smokers.

Experimental design

MicroRNA expression analysis was performed using Nanostring in tumor tissues isolated from a prospective cohort of HPV(+) smoking (n = 9) and HPV(+) (n = 13) non-smoking OPSCC patients. Identified miRNAs of interest were further validated using qRT-PCR in cigarette smoke extract (CSE) treated HPV(+) and E6/E7 overexpressing HPV(-) cells.

Results

In comparison to OPSCC HPV(+) non-smokers, 38 miRNAs were significantly altered in the HPV(+) smoker patients cohort and out of that 9 were downregulated. Altered miRNA expression was also detected in the serum and metastatic lymph nodes of HPV(+) smokers versus non-smokers. Expression of miR-133a-3p was significantly downregulated in OPSCC smokers, HPV(+) cells and E6/E7 overexpressing HPV(-) cells treated with CSE. Reduction of miR-133a-3p induced the upregulation of miR-133a-3p target mRNAs EGFR and HuR.

Conclusions

Our results indicate that miR-133a-3p is a target of smoking-induced changes in HPV(+) patients and alters the expression of EGFR and HuR which may promote HPV associated oropharyngeal cancer. Therefore, future treatment strategies for HPV(+) OPSCC smokers should focus on EGFR inhibition and the development of selective therapies to target HuR.

The interplay of IMRT and transoral surgery in HPV-mediated oropharyngeal cancer: Getting the balance right

Transoral surgery (TOS) and IMRT represent two primary local ablative treatment modalities for oropharyngeal cancer (OPC). The choice of one over the other represents an interplay between the chance of cure vs risk of late sequelae. HPV-mediated (HPV+) OPC patients generally have excellent outcomes, especially in TNM-8 stage I disease. Controversies exist over which treatment has a more favorable toxicity profile and equal efficacy in the management of this population. Non-randomized retrospective data show comparable oncological and functional outcomes between TOS-based vs IMRT-based treatment for this disease. Several de-intensification concepts have been explored in this subset in both primary surgery-based vs primary radiotherapy-based trials. However, no robust mature trial data are available to convincingly guide treatment selection. TOS is often presented as one of the de-intensification options although the majority of series also describe the use of adjuvant treatments which inevitably result in non-negligible toxicities. Patient selection and surgeons' training are paramount. Understanding tumor biology and the prognostic value of traditional 'adverse' features will further guide trial design for refinement of risk tailored approach. In conclusion, comparative data suggests TOS and IMRT are both effective treatment for TNM-8 stage I HPV+ OPC with similar oncological and functional outcomes. TOS as a single modality has potential advantages in mitigating radiation included toxicities. TOS should be avoided in the presence of clinically overt extranodal extension or when negative margins are unlikely to be achieved. TOS is also less ideal for cases with radiological features predicting a high risk of distant metastasis.

Differences in LC3B expression and prognostic implications in oropharyngeal and oral cavity squamous cell carcinoma patients

Background

This study examined the prognostic significance of microtubule-associated protein light chain 3B (LC3B) expression in oropharyngeal and oral cavity squamous cell carcinoma (SCC). The prognostic significance of LC3B expression in relation to human papillomavirus (HPV) status in oropharyngeal SCC was also examined.

Methods

Tissue microarrays (TMAs) were constructed from formalin-fixed, paraffin-embedded oropharyngeal (n = 47) and oral cavity (n = 95) SCC tissue blocks from patients with long-term recurrence and overall survival data (median = 47 months). LC3B expression on tumour was assessed by immunohistochemistry and evaluated for associations with clinicopathological variables. LC3B expression was stratified into high and low expression cohorts using ROC curves with Manhattan distance minimisation, followed by Kaplan–Meier and multivariable survival analyses. Interaction terms between HPV status and LC3B expression in oropharyngeal SCC patients were also examined by joint-effects and stratified analyses.

Results

Kaplan–Meier survival and univariate analyses revealed that high LC3B expression was correlated with poor overall survival in oropharyngeal SCC patients (p = 0.007 and HR = 3.18, 95% CI 1.31–7.71, p = 0.01 respectively). High LC3B expression was also an independent prognostic factor for poor overall survival in oropharyngeal SCC patients (HR = 4.02, 95% CI 1.38–11.47, p = 0.011). In contrast, in oral cavity SCC, only disease-free survival remained statistically significant after univariate analysis (HR = 2.36, 95% CI 1.19–4.67, p = 0.014), although Kaplan-Meier survival analysis showed that high LC3B expression correlated with poor overall and disease-free survival (p = 0.046 and 0.011 respectively). Furthermore, oropharyngeal SCC patients with HPV-negative/high LC3B expression were correlated with poor overall survival in both joint-effects and stratified presentations (p = 0.024 and 0.032 respectively).

Conclusions

High LC3B expression correlates with poor prognosis in oropharyngeal and oral cavity SCC, which highlights the importance of autophagy in these malignancies. High LC3B expression appears to be an independent prognostic marker for oropharyngeal SCC but not for oral cavity SCC patients. The difference in the prognostic significance of LC3B between oropharyngeal and oral cavity SCCs further supports the biological differences between these malignancies. The possibility that oropharyngeal SCC patients with negative HPV status and high LC3B expression were at particular risk of a poor outcome warrants further investigation in prospective studies with larger numbers.

Refining prognostic stratification of human papillomavirus-related oropharyngeal squamous cell carcinoma: different prognosis between T1 and T2

PURPOSE

To validate the 8th edition of the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) TNM staging system for human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) and investigate whether a modified classification better reflects the prognosis.

MATERIALS AND METHODS

Medical records of patients diagnosed with non-metastatic HPV-related OPSCC between 2010 and 2016 at a single institution were retrospectively reviewed. HPV status was determined by immunohistochemical analysis of p16 and/or HPV DNA polymerase chain reaction (PCR). We reclassified TNM stage T0-1 and N0-1 as group A, T2-3 or N2 as B, and T4 or N3 as C. Survival analysis according to 8th AJCC/UICC TNM staging and the modified classification was performed.

RESULTS

Of 383 OPSCC patients, 211 were positive for HPV DNA PCR or p16. After exclusion, 184 patients were included in this analysis. Median age was 56 years (range, 31 to 81 years). Most primary tumors were in the palatine tonsil (148 tumors, 80%). The eighth AJCC/UICC TNM classification could not differentiate between stage I and II (p = 0.470) or II and III (p = 0.209). Applying modified grouping, the 3-year overall survival rate of group A was significantly higher than that of group B and C (98% vs. 91%, p = 0.039 and 98% vs. 78%, p < 0.001, respectively). Differentiation between group B and C was marginally significant (p = 0.053).

CONCLUSION

The 8th AJCC/UICC TNM staging system did not clearly distinguish the prognosis of stage II from that of other stages. Including the T2N0-1 group in stage II may improve prognostic stratification.

Dual role for p16 in the metastasis process of HPV positive head and neck cancers

Several studies show that human papillomavirus (HPV) positive head and neck cancers (HNSCC) are typically characterized by low tumor and high regional node stages, intrinsically indicating high local metastatic potential. Despite this, the distant metastasis rates of HPV positive and negative HNSCC are similar. To date, majority of the studies focus on molecular characterization of HPV positive disease and on treatment outcome. Here we assessed the biological mechanisms of metastasis by combining in vitro and in vivo head and neck carcinoma xenograft models with patient data. We provide experimental evidence for a dual role of p16, a surrogate marker for HPV infections, in the metastasis process of HNSCC. We found that p16 regulates the invasiveness and metastatic potential of HNSCC cells by impairing angiogenesis. In parallel, we found that p16 is regulating the nodal spread by mediating lymphatic vessel formation through the upregulation of integrins. These findings not only provide understanding of the biology of the different dissemination patterns but also suggest that inhibition of lymphangiogenesis in HPV positive cancers and inhibition of angiogenesis in HPV negative cancers can form a treatment strategy against metastasis.

Morphologic and topographic radiologic features of human papillomavirus-related and -unrelated oropharyngeal carcinoma

BACKGROUND

The purpose of this study was to compare the clinicoradiologic characteristics of human papillomavirus (HPV)-related (HPV-positive) and HPV-unrelated (HPV-negative) oropharyngeal carcinoma (OPC).

METHODS

Primary tumor and lymph node features of HPV-positive and HPV-negative OPCs from 2008 to 2013 were compared on pretreatment CT/MRI. Intrarater/interrater concordance was assessed. Multivariable analyses identified factors associated with HPV-positivity to be used in nomogram construction.

RESULTS

Compared to HPV-negative (n = 194), HPV-positive (n = 488) tumors were more exophytic (73% vs 63%; p = .02) with well-defined border (58% vs 47%; p = .033) and smaller axial dimensions; lymph node involvement predominated (89% vs 69%; p < .001) with cystic appearance (45% vs 32%; p = .009) but similar topography. Intrarater/interrater concordance varied (fair to excellent). Nomograms combining clinical (age, sex, smoking pack-years, subsite, T/N classification) and/or radiologic (nonnecrotic tumor and cystic lymph node) features were used to weigh the likelihood of HPV-driven tumors (area under the curve [AUC] = 0.84).

CONCLUSION

HPV-positive OPC has different radiologic tumor (exophytic/well-defined border/smaller axial dimension) and lymph node (cystic) features but similar lymph node topography.

Solid Lymph Nodes as an Imaging Biomarker for Risk Stratification in Human Papillomavirus-Related Oropharyngeal Squamous Cell Carcinoma

BACKGROUND AND PURPOSE

Human papillomavirus-related oropharyngeal squamous cell carcinoma is associated with cystic lymph nodes on CT and has a favorable prognosis. A subset of patients with aggressive disease experience treatment failure. Our aim was to determine whether the extent of cystic lymph node burden on staging CT can serve as an imaging biomarker to predict treatment failure in human papillomavirus-related oropharyngeal squamous cell carcinoma.

MATERIALS AND METHODS

We identified patients with human papilloma virus-related oropharyngeal squamous cell carcinoma and staging neck CTs. Demographic and clinical variables were recorded. We retrospectively classified the metastatic lymph node burden on CT as cystic or solid and assessed radiologic extracapsular spread. Biopsy, subsequent imaging, or clinical follow-up was the reference standard for treatment failure. The primary end point was disease-free survival. Cox proportional hazard regression analyses of clinical, demographic, and anatomic variables for treatment failure were performed.

RESULTS

One hundred eighty-three patients were included with a mean follow-up of 38 months. In univariate analysis, the following variables had a statistically significant association with treatment failure: solid-versus-cystic lymph nodes, clinical T-stage, clinical N-stage, and radiologic evidence of extracapsular spread. The multivariate Cox proportional hazard model resulted in a model that included solid-versus-cystic lymph nodes, T-stage, and radiologic evidence of extracapsular spread as independent predictors of treatment failure. Patients with cystic nodal metastasis at staging had significantly better disease-free survival than patients with solid lymph nodes.

CONCLUSIONS

In human papilloma virus-related oropharyngeal squamous cell carcinoma, patients with solid lymph node metastases are at higher risk for treatment failure with worse disease-free survival. Solid lymph nodes may serve as an imaging biomarker to tailor individual treatment regimens.

Confirmation of the eighth edition of the AJCC/UICC TNM staging system for HPV-mediated oropharyngeal cancer in Japan

BACKGROUND

Several studies have demonstrated that the seventh edition of the American Joint Committee on Cancer/American Joint Committee on Cancer (AJCC/UICC) TNM staging system does not consistently distinguish between prognostic subgroups for human papillomavirus (HPV)-mediated oropharyngeal squamous cell carcinoma (OPSCC). The eighth edition of the AJCC/UICC TNM staging system came into effect for use with HPV-mediated OPSCC on or after 1 January 2017. This study confirms that the eighth edition of the AJCC/UICC TNM staging system for HPV-mediated OPSCC accurately reflects disease outcomes.

PATIENTS AND METHODS

We retrospectively analyzed 195 patients with OPSCC treated at Hokkaido University Hospital, Sapporo, Japan between 1998 and 2015. HPV status was evaluated by immunohistochemical analysis of p16.

RESULTS

Of the 195 OPSCC patients evaluated, 111 (56.9%) were p16 positive and 84 (43.1%) were p16 negative. The 3-year overall survival rate (OS) was significantly lower in the p16-negative patients with stage III-IV in comparison with those with stage I-II (55.0 vs. 93.1%, respectively; p < 0.01). The 3-year OS did not differ significantly between stage I-II and stage III-IV in the p16-positive patients (86.7 vs 87.7%). According to the eighth edition of the AJCC/UICC TNM staging system, stage I-II and stage III can be differentiated on the basis of the 3-year OS in the p16-positive patients (90.9 vs 70.2%, respectively; p < 0.01).

CONCLUSIONS

The seventh edition of the AJCC/UICC TNM staging system is suitable for use with p16-negative patients; however, it does not effectively discriminate between p16-positive patients. Therefore, the eighth edition of the AJCC/UICC TNM staging system is more suitable for HPV-mediated OPSCC in Japan.

High expression of myoferlin is associated with poor outcome in oropharyngeal squamous cell carcinoma patients and is inversely associated with HPV-status

Myoferlin (MYOF) is a member of ferlin family of membrane proteins that was originally discovered as a muscle specific protein. Recent studies have shown that myoferlin is also expressed in other cell types including endothelial cells and cancer cells. However, very little is known about the expression and biological role of myoferlin in head and neck cancer. In this study, we examined expression profile of myoferlin in oropharyngeal squamous cell carcinoma (OPSCC) and assessed its correlation with disease progression and patient outcome. In univariate analyses, nuclear MYOF was associated with poor overall survival (p<0.001) and these patients had 5.5 times increased hazard of death (95% Cl 3.4-8.8). Nuclear myoferlin expression was also directly associated with tumor recurrence (p<0.001), perineural invasion (p=0.008), extracapsular spread (p=0.009), higher T-stage (p=0.0015) and distant metastasis (p<0.001). In addition, nuclear MYOF expression was directly associated with IL-6 (p<0.001) and inversely with HPV status (p=0.0014). In a subgroup survival analysis, MYOF nuclear+/IL-6+ group had worst survival (84.6% mortality), whereas MYOF nuclear-/IL-6- had the best survival. Similarly, patients with HPV-negative/MYOF-positive tumors had worse survival compared to HPV-positive/MYOF-negative. Taken together, our results demonstrate for the first time that nuclear myoferlin expression independently predicts poor clinical outcome in OPSCC patients.

E6 and E7 Antibody Levels Are Potential Biomarkers of Recurrence in Patients with Advanced-Stage Human Papillomavirus-Positive Oropharyngeal Squamous Cell Carcinoma

Purpose: There is a paucity of biomarkers to predict failure in human papillomavirus-positive (HPV⁺) oropharyngeal squamous cell carcinoma (OPSCC) following curative therapy. E6/E7 viral oncoproteins are constitutively expressed in HPV⁺ tumors and highly immunogenic, resulting in readily detected serum antibodies. The purpose of this study is to determine whether serum E6 and E7 antibody levels can potentially serve as a biomarker of recurrence in patients with HPV+OPSCC.Experimental Design: We evaluated E6/E7 antibody levels in patients with previously untreated, advanced stage (III, IVa-b), HPV+OPSCC receiving definitive chemoradiation under a uniform protocol from 2003 to 2010. Baseline and longitudinal serum samples were obtained from our archived repository. E6/E7 serum levels were measured using a glutathione-S-transferase capture ELISA and quantified by approximating the area under the dilution curve, and were analyzed using ANOVA and linear mixed model for longitudinal analysis.Results: We compared 22 HPV+OPSCC patients who developed recurrence with 30 patients who remained disease-free. There were no differences in T classification, N classification, disease subsite, or smoking status between the groups. In a longitudinal analysis, recurrent patients had significantly higher E6 and E7 serum antibody levels than the nonrecurrent patients over the follow-up period (P = 0.02 and P = 0.002, respectively). Patients who recurred had a lower clearance of E7 antibody than patients who remained disease-free (P = 0.0016).Conclusions: Patients with HPV+OPSCC whose disease recurs have a lower clearance of E6 and E7 antibodies than patients who do not have recurrence. The ratio of E7 antibody at disease recurrence compared with baseline is potentially a clinically significant measurement of disease status in HPV+OPSCC. Clin Cancer Res; 23(11); 2723-9. ©2016 AACR.

Oncolytic adenoviruses targeted to Human Papilloma Virus-positive head and neck squamous cell carcinomas

OBJECTIVES

In recent years, the incidence of Human Papilloma Virus (HPV)-positive head and neck squamous cell carcinomas (HNSCC) has markedly increased. Our aim was to design a novel therapeutic agent through the use of conditionally replicative adenoviruses (CRAds) that are targeted to the HPV E6 and E7 oncoproteins.

METHODS

Each adenovirus included small deletion(s) in the E1a region of the genome (Δ24 or CB016) intended to allow for selective replication in HPV-positive cells. In vitro assays were performed to analyze the transduction efficiency of the vectors and the cell viability following viral infection. Then, the UPCI SCC090 cell line (HPV-positive) was used to establish subcutaneous tumors in the flanks of nude mice. The tumors were then treated with either one dose of the virus or four doses (injected every fourth day).

RESULTS

The transduction analysis with luciferase-expressing viruses demonstrated that the 5/3 fiber modification maximized virus infectivity. In vitro, both viruses (5/3Δ24 and 5/3CB016) demonstrated profound oncolytic effects. The 5/3CB016 virus was more selective for HPV-positive HNSCC cells, whereas the 5/3Δ24 virus killed HNSCC cells regardless of HPV status. In vivo, single injections of both viruses demonstrated anti-tumor effects for only a few days following viral inoculation. However, after four viral injections, there was statistically significant reductions in tumor growth when compared to the control group (p<0.05).

CONCLUSION

CRAds targeted to HPV-positive HNSCCs demonstrated excellent in vitro and in vivo therapeutic effects, and they have the potential to be clinically translated as a novel treatment modality for this emerging disease.

Matted nodes as a predictor of distant metastasis in advanced-stage III/IV oropharyngeal squamous cell carcinoma

BACKGROUND

We recently described the imaging characteristics of multiple confluent regional metastases (matted nodes) and found that this characteristic was associated with distant metastasis in patients with oropharyngeal squamous cell carcinoma (SCC). The purpose of this study was to determine if matted nodes are a predictive marker for distant metastasis.

METHODS

Radiologic lymph node characteristics on 205 patients with untreated stage III/IV with oropharyngeal SCC of whom 192 had known human papillomavirus (HPV) status underwent weekly carboplatin and paclitaxel with concomitant intensity-modulated radiation therapy (IMRT) between 2003 and 2010 with a minimum of 2-year of follow-up.

RESULTS

The 3-year disease-specific survival (DSS) for patients with matted nodes was 58% versus 97% with nonmatted nodes (p = .0001). The prevalence of matted nodes in the population was 20%. The positive predictive value of matted nodes for distant metastasis was 66%, and the negative predictive value was 99%.

CONCLUSION

Matted nodes are a predictive marker for distant disease and can be used for planning new clinical interventions.