Prognostic value of the lymph node ratio in oropharyngeal carcinoma stratified for HPV-status

Importance of lymph node ratio in HPV-related oropharyngeal cancer patients treated with surgery and adjuvant treatment

Objectives

The pathologic nodal stage of human papillomavirus (HPV)-related oropharyngeal cancer (OPC) patients is classified according to the number of lymph nodes (LNs), as revised in 2018. Previous studies showed that the LN ratio (LNR) could be also a significant prognostic factor in head and neck cancer, but there are few studies on the LNR in HPV-related [HPV(+)] OPC. The aim of the present study was to analyze the predictive value of the LNR for survival and recurrence in HPV(+) OPC patients.

Materials and methods

HPV(+) OPC patients treated with surgery with or without postoperative radiotherapy from January 2000 to March 2019 were evaluated. The patients were divided into two sets of three groups, according to LN numbers based on pathologic nodal stages, and LNRs by a cutoff value of 0.05. The medical records were reviewed, and the overall survival (OS), disease-free survival, locoregional recurrence, and distant metastasis incidence were analyzed.

Results

Ninty patients were included and the median follow-up period was 38.2 months. There were no significant differences in OS in the LN number groups. However, there was a significant difference in OS in the LNR groups (P = 0.010). The incidence of distant metastasis in the LNR groups was significantly different (P = 0.005).

Conclusion

The LNR in HPV(+) OPC patients may be a more useful tool to predict survival and distant metastasis than the LN number. Additional research and consensus on surgical pathology are needed before applying the LNR to adjuvant treatment decisions and pathologic nodal staging.

Treatment Options in Early Stage (Stage I and II) of Oropharyngeal Cancer: A Narrative Review

Objective: to show an overview on the treatments’ options for stage I and II oropharyngeal carcinomasquamous cell carcinoma (OPSCC). Background: The traditional primary treatment modality of OPSCC at early stages is intensity modulated radiation therapy (IMRT). Trans-oral robotic surgery (TORS) has offered as an alternative, less invasive surgical option. Patients with human papilloma virus (HPV)-positive OPSCC have distinct staging with better overall survival in comparison with HPV-negative OPSCC patients. Methods: a comprehensive review of the English language literature was performed using PubMed, EMBASE, the Cochrane Library, and CENTRAL electronic databases. Conclusions: Many trials started examining the role of TORS in de-escalating treatment to optimize functional consequences while maintaining oncologic outcome. The head–neck surgeon has to know the current role of TORS in HPV-positive and negative OPSCC and the ongoing trials that will influence its future implementation. The feasibility of this treatment, the outcomes ensured, and the side effects are key factors to consider for each patient. The variables reported in this narrative review are pieces of a bigger puzzle called tailored, evidence-based driven medicine. Future evidence will help in the construction of robust and adaptive algorithms in order to ensure the adequate treatment for the OPSCC at early stages.

Occult lymph node metastasis in the contralateral neck of oropharyngeal squamous cell carcinoma: a meta-analysis and literature review

PURPOSE

The purpose of this study was to determine whether contralateral cervical lymph node dissection is needed in patients with oropharyngeal squamous cell carcinoma (OPSCC) with contralateral cervical cN0.

METHODS

We searched the PubMed, Web of Science, Embase, Chinese Biomedical Literature Database (CBM) and Cochrane Library databases up to August 14, 2021 for studies examining the contralateral neck occult metastasis rate of patients with ipsilateral clinical neck-negative (cN0) OPSCC and the contralateral neck occult metastasis rate of patients with ipsilateral clinical neck-positive (cN1, cN2a, cN2b) OPSCC. This rate is used to determine whether patients with contralateral cN0 OPSCC need contralateral cervical lymph node dissection.

RESULTS

A total of 14 articles, including 532 cases, were included in the analysis. When studying the rate of ipsilateral cervical occult metastasis in patients with ipsilateral cN0, 163 cases were included in 11 studies. The results showed that the rate of contralateral cervical occult lymph node metastasis in patients with ipsilateral cN0 was 0.6816% (95% CI 0.0000-4.4880 (P = 0.3005)). In the study of ipsilateral cN+ (cN1, cN2a, cN2b), a total of 369 cases of 10 articles were included in the analysis. The results showed that the rate of contralateral cervical occult lymph node metastasis in patients with ipsilateral cN+ was 11.4920% [95% CI 7.8944-15.5223 (P = 0.0000)].

CONCLUSION

For cancer treatment, the ultimate goal is to achieve the best control of cancer and the lowest complications. It seems unnecessary to intervene in the contralateral neck of patients with OPSCC with ipsilateral cN0. For OPSCC with ipsilateral cN+ , this index is a factor that cannot be ignored when making clinical decisions.

Prognostic value of lymph node ratio versus American Joint Committee on Cancer N classification for surgically resected human papillomavirus-associated oropharyngeal squamous cell carcinoma

BACKGROUND

We compared prognostic values of lymph node ratio (LNR) and AJCC 8 N classification in surgically resected human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

Using the National Cancer Database, we identified patients with HPV-associated OPSCC from 2010 to 2016 who underwent definitive surgical resection. Patients were analyzed by nodal grouping (LNR, N stage) and adjuvant radiation therapy(RT). Primary endpoint was overall survival.

RESULTS

We identified 4166 patients. Survival analysis showed significant improvement for LNR≤6% versus >6% (5 year OS% 92.7% vs. 83.7%, p < 0.001). N classification demonstrated good prognostic ability (5 year OS% for pN0, pN1, pN2 were 91.3%, 90.1%, 78.8%, p < 0.001), but poor separation among stages (compared to pN0: pN1 HR 1.40 [95% CI 0.63, 3.09], p = 0.41; pN2 HR 2.50 [95% CI 1.08, 5.81], p = 0.033). RT improved survival in the LNR > 6% group (5 year OS% 85.4% vs. 74.9%, p < 0.001; HR 0.41 [95% CI 0.28, 0.58], p < 0.001).

CONCLUSIONS

LNR should be considered an adjunct category in future staging systems for HPV-associated OPSCC.

Evaluation of lymph node ratio and lymph node yield as prognosticators of locoregional recurrence in p16-associated oropharyngeal squamous cell carcinoma

BACKGROUND

The prognostic value of lymph node yield (LNY) and lymph node ratio (LNR), or the ratio of number of metastatic LNs to total number dissected, has not been well established in p16-associated oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

This retrospective cohort study evaluated locoregional disease-free survival (LRDFS) in 82 patients with p16+ OPSCC who underwent neck dissection at a single institution from 2009 to 2017. LNR and LNY cutoffs were estimated using time-dependent receiver operator characteristic (ROC) curves. Prognostic significance of these cutoffs was compared with Eighth Edition AJCC Nodal Staging.

RESULTS

An increased LNR ≥ 0.129 was associated with worse 2-year LRDFS (66.9% vs 96.8%, P = .005). LNY was not significantly associated with LRDFS (P = .304). An LNR-based risk model was a better prognosticator than Eighth Edition AJCC Nodal Staging (Harrell's C, 0.9065 vs 0.7668).

CONCLUSIONS

LNR has good prognostic utility in predicting LRDFS in p16+ OPSCC, but further evaluation of this measure is warranted.

Importance of investigating high-risk human papillomavirus in lymph node metastasis of esophageal adenocarcinoma

High-risk human papillomavirus has been suggested as a risk factor for esophageal adenocarcinoma. Tumor human papillomavirus status has been reported to confer a favorable prognosis in esophageal adenocarcinoma. The size of the primary tumor and degree of lymphatic spread determines the prognosis of esophageal carcinomas. Lymph node status has been found to be a predictor of recurrent disease as well as 5-year survival in esophageal malignancies. In human papillomavirus driven cancers, e.g. cervical, anogenital, head and neck cancers, associated lymph nodes with a high viral load suggest metastatic lymph node involvement. Thus, human papillomavirus could potentially be useful as a marker of micro-metastases. To date, there have been no reported studies regarding human papillomavirus involvement in lymph nodes of metastatic esophageal adenocarcinoma. This review highlights the importance of investigating human papillomavirus in lymph node metastasis of esophageal adenocarcinoma based on data derived from other human papillomavirus driven cancers.

Prognostic capacity of the lymph node ratio in squamous cell carcinomas of the head and neck

INTRODUCTION AND OBJECTIVES

Lymph node density or lymph node ratio (LNR), defined as the quotient between the total number of positive lymph nodes and the total number of dissected lymph nodes, has demonstrated a prognostic capacity in several tumour models, including patients with head and neck squamous cell carcinomas (HNSCC). The aim of the present study is to analyse the prognostic value of LNR in a wide cohort of patients with HNSCC.

METHODS

We carried out a retrospective study of a cohort of 1,311 patients with HNSCC treated with unilateral or bilateral neck dissections. Of the patients included in the study, 55.0% had lymph node metastases (pN+). We proceeded to calculate the value of the LNR, and its categorization through a recursive partition analysis considering specific survival as the dependent variable.

RESULTS

Three categories were defined according to the value of the LNR with a cut-off point at the values < of .025 and .118. The 5-year specific survival for patients with an LNR less than .025 (n=654, 49.8%) was 87.2%, for patients with a LNR .025-.118 (n=394, 30.1%) it was 51.6%, and for patients with a LNR greater than .188 (n=263, 20.1%) it was 27.3% (P=.0001). According to the results of a multivariate analysis, the LNR significantly related to specific survival.

CONCLUSION

The LNR can be a prognostic variable to be considered in the pathological staging of the lymph nodes.

Lymph Node Ratio in HPV-Associated Oropharyngeal Cancer: Identification of a Prognostic Threshold

OBJECTIVE

To evaluate the utility of lymph node ratio (LNR) as a prognostic factor for survival and recurrence in surgically treated patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective cohort study.

METHODS

In this retrospective cohort study of a tertiary healthcare system in a major metropolitan area, we reviewed 169 consecutive patients with HPV-related OPSCC treated using transoral robotic surgery. Univariable and multivariable Cox proportional hazards regression analysis with stratified models were used to compare LNR with other traditional clinicopathologic risk factors forrecurrence and survival. An LNR cutoff was found using the minimal P approach.

RESULTS

Multivariable Cox regression models showed that each additional percentage increase in LNR corresponded to an adjusted hazard ratio (HR) of 1.04 (confidence interval [CI] 1.02-1.07). LNR was more significant when adjusted for adequate lymph node yield of ≥ 18 nodes (HR 5.05, 95% confidence interval [CI] 1.38-18.47). The minimal P generated cutoff point at LNR ≥ 17% demonstrated a HR 4.34 (95% CI 1.24-15.2) for disease-free survival.

CONCLUSION

For HPV-related OPSCC, continuous LNR and an LNR threshold of 17% could be helpful in identifying recurrent disease in addition to measures such as lymph node number alone.

LEVEL OF EVIDENCE

4.

A review of the 8th edition of the AJCC staging system for oropharyngeal cancer according to HPV status

Background

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has increased substantially in recent decades, particularly p16-positive human papillomavirus (HPV)-related OPSCC, which has risen by 50% in western countries. HPV-positivity is the most favourable non-anatomic predictor of oropharyngeal cancer outcomes, which underscores the importance of incorporating this variable into the cancer staging system.

Methods

In the present article, we review the differences between the 7th and 8th editions of the AJCC staging system, with particular focus on the role of HPV-positivity in patients with head and neck cancer.

Results

In the previous edition (7th edition) of the AJCC/UICC manual, HPV status and its correlation with nodal metastasis were not considered, thereby leading to incorrect lymph node (N) staging and, potentially, inadequate treatment and worse outcomes. The 8th edition of the AJCC manual addresses these issues, providing more accurate discrimination between groups and better risk stratification in patients with HPV-positive OPSCC. In the future, additional adjustments are likely to be needed, such as unification of the pathological and clinical staging models.

Conclusions

The new staging system is substantially more accurate than the previous system and should be widely adopted in routine clinical practice.

Prognostic Significance of Lymph Node Status in p16+ Oropharyngeal Cancer After Surgical Treatment

OBJECTIVES/HYPOTHESIS

In this study, we retrospectively reviewed medical records of patients who underwent surgery for p16+ oropharyngeal cancer and analyzed the prognostic implications of pathologic lymph node (LN) status, including number of metastatic LNs, LN ratio, and location of metastatic LNs.

STUDY DESIGN

Retrospective case series.

METHODS

We retrospectively reviewed data on patients diagnosed with p16+ oropharyngeal cancer.

RESULTS

The study population consisted of 159 males and 29 females with a mean age of 57.2 years. The primary tumor sites were tonsils (n = 160), base of the tongue (n = 24), and soft palate (n = 4). Only recurrence-free survival (RFS) showed a significant correlation with contralateral LN metastasis on multivariate analysis. On Kaplan-Meier analysis, 5-year RFS was 92.4% in patients without contralateral LN metastasis and 68.8% in patients with contralateral LN metastasis.

CONCLUSIONS

Among pathologic LN status in p16+ oropharyngeal cancer, only contralateral LN metastasis showed prognostic significance in disease recurrence of p16+ oropharyngeal squamous cell carcinoma patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 130: 1973-1979, 2020.

Surgical nodal management in hypopharyngeal and laryngeal cancer

Objective

The aim of this study is to compare pre-therapeutic staging of the loco-regional lymphatic basin and subsequent surgical management in cN0 versus cN+ hypopharyngeal and laryngeal cancer patients.

Methods

We analyzed all hypopharyngeal and laryngeal carcinoma patients treated surgically at a single quaternary medical care and cancer center between 2004 and 2014. We established two groups for patients who underwent neck dissection comparing patients with a low LNR (lymph node ratio) to one with a high LNR. Regarding the cN0 cohort, elective neck dissection was evaluated as a secondary predictor variable. Comorbidities, such as anemia and renal insufficiency, were analyzed as potentially influencing disease-free (DFS) and overall survival (OS).

Results

A total of 310 patients (185 glottic and 125 supraglottic/hypopharyngeal carcinoma) were included. Pre-therapeutic neck MRI-/CT-scan and concomitant neck ultrasound revealed cN+ status in 144 patients resulting in a significant over-staging in 63 patients (44%) who were rated as being pN0 after histological examination. 166 patients were staged cN0 and 21 underwent elective neck dissection (11 local advanced glottic and 10 supraglottic/hypopharyngeal carcinoma). Two cN0 patients showed occult cervical lymph node metastases (10%). Furthermore, we could detect a significant negative impact of the LNR divided by the number of dissected lymph nodes and OS.

Conclusion

The pre-therapeutic clinical evaluation of lymphatic outgrowth is over-staged. OS decreases with increasing LNR divided by the number of dissected lymph nodes. Renal insufficiency and anemia are significant negative factors, decreasing both OS and DFS.

[Neck dissection-Surgical treatment of cervical lymphatic drainage pathways]

Neck dissection (ND) is an essential component of treatment in head and neck squamous cell carcinoma (HNSCC). The extent of ND depends on primary tumor location and T and N stage. Trials have demonstrated improved survival for cN+ status with therapeutic ND as well as for cN0 status with selective ND if the primary has a high incidence of occult metastasis. The accuracy of the procedure is of prognostic relevance. In the prognostic model of the TNM classification, the parameter "N" does not only reflect the number of affected lymph nodes, but also their size and extranodal tumor extension. Due to its better prognosis, a positive human papillomavirus (HPV) status is also incorporated in the present TNM classification. In order to minimize morbidity after ND, one seeks to limit its extent without reducing survival time. To this aim, sentinel node biopsy or surveillance with positron-emission computed tomography (PET-CT) in cN0 necks or after primary radio(chemo)therapy are being investigated.

Lymph node ratio predicts recurrence in pediatric papillary thyroid cancer

BACKGROUND

Regional lymph node (LN) metastasis at the time of presentation plays a significant role in predicting recurrence in patients with papillary thyroid cancer (PTC). Multiple studies in the adult population have demonstrated that the lymph node ratio (LNR) in both the central and lateral neck can improve the accuracy of recurrence prediction, but this ratio has not been studied in the pediatric population. In this study, we sought to investigate the LNR in the central and lateral compartments as a prognostic predictor for recurrence in pediatric patients with PTC.

METHODS

A retrospective analysis of pediatric patients (≤21 years old) at a single institution between 2002 and 2014 who underwent total thyroidectomy with prophylactic central neck dissection (TTpCND) with at least 3 sampled nodes or total thyroidectomy with unilateral modified radical neck dissection (TTMRND) with at least 10 sampled nodes, and on whom at least 24 months of follow up data were available was performed. The LNR was defined as the ratio of metastatic LNs to total number of investigated LNs. Recurrence after TTpCND and TTMRND was examined separately as a function of LNR, using the value of 0.45 as a cutoff.

RESULTS

Forty-eight patients met inclusion criteria. Thirty-two underwent TTpCND, and sixteen underwent TTMRND. Median age at time of operation was 17 years (range 6-20), and median duration of follow-up was 53.5 months (range 24-183). In the TTpCND, LNR ranged from 0 to 1.0. There were two recurrences among the eight patients (25%) undergoing TTpCND in patients with LNRs >0.45 and a single recurrence among the 24 patients (4.2%) undergoing TTpCND with an LNR ≤0.45. In the TTMRND, LNR ranged from 0.1 to 1.0. There were 3 recurrences in 12 patients with LNR ≤0.45 (30.8%%) and 4 recurrences in 4 patients with LNR >0.45 (100%) (p = 0.03).

CONCLUSIONS

Although limited by small sample size, LNR may be a useful predictor to stratify the likelihood of recurrence in pediatric patients undergoing TTpCND or TTMRND for pathologic N1a or N1b PTC.

TYPE OF STUDY

Prognosis study / retrospective case series.

LEVEL OF EVIDENCE

Level IV.

The prognostic value of lymph node ratio in survival of head-and-neck squamous cell carcinoma

BACKGROUND

Head-and-neck squamous cell carcinoma (HNSCC) is the sixth most prevalent type of cancers in the world. Due to its relatively high rate of recurrence, the prognosis of patients is poor and the survival rate is low; therefore, identifying the prognostic factors is considered necessary for better treatment.

MATERIALS AND METHODS

This historical cohort study was conducted on 201 patients diagnosed with aerodigestive SCC who underwent surgery and lymph node dissection. We determined the prognostic value of lymph node ratio (LNR) on overall survival (OS), disease-free survival (DFS), and locoregional failure-free survival (LFFS). We noticed an association between LNR and survival by Kaplan-Meier analysis. Hazard ratio (HR) of LNR was determined by Cox's regression model.

RESULTS

Two hundred and one patients entered this study after their medical histories were evaluated. The mean of lymph node count and LNR was 14.30 (±9.50) and 0.12 (±0.23), respectively. Eighty patients (39.80%) experienced recurrence of SCC. Five-year OS, DFS, and LFFS were 32%, 21%, and 64%, respectively. The median of OS was 40.70 months and 30.11 months in patients with LNR of ≤0.06 and >0.06, respectively (P < 0.01). The LNR >0.06 was found to be a significant prognostic factor for lower OS of patients with HNSCC (HR = 2.11 [1.10, 4.40]; P = 0.04). DFS was not significantly different among patients with LNR ≤0.06 and patients with LNR >0.06 (P = 0.9). However, LFFS was slightly different among two groups (HR = 2.04 [0.90-4.80]; P < 0.1).

CONCLUSION

We recommend more intensive adjuvant therapies such as chemotherapy with radiotherapy and short interval follow-up for patients with LNR >0.06. Further investigations with larger sample sizes are recommended.