Occult metastasis is no burden factor in oral squamous cell carcinoma patients when adhering to a standardized approach in neck dissection

How adequate is supraomohyoid neck dissection for node-negative oral tongue squamous cell carcinoma?

BACKGROUND

Oral tongue squamous cell carcinoma (SCC) has the most nodal metastasis among all oral cancers and this nodal involvement considerably lowers survival. The presence of occult metastasis in lower neck levels or skip metastasis to level IV or V complicates the effectiveness of supraomohyoid neck dissection (SOHND) for node-negative (N0) T1/T2 oral tongue SCC.

AIM & OBJECTIVE

To evaluate the necessity of extended SOHND in managing N0 T1/T2 oral tongue SCC.

MATERIALS & METHODS

This retrospective cross-sectional study utilized institutional records of all histopathologically confirmed T1/T2 oral tongue SCC cases with N0 neck from a mixed Indian population who underwent extended SOHND between 2008 and 2024. The primary outcome was the positivity rate of level IV. Covariates included demographic factors such as age and sex. Positivity rates and their 95% confidence intervals were calculated.

RESULTS

The study included 111 cases meeting the inclusion and exclusion criteria. Positivity rates for levels I-III were 35.5% (32/111; 95% CI = 0.16-0.47), while positivity for level IV was 9% (10/111; 95% CI = 0.0083-0.13). Occult metastasis to level IV was found in only 6.3% (7/111) of cases.

CONCLUSION

The likelihood of occult metastasis to level IV in T1/T2 N0 oral tongue SCC is very low (6.3%). The extended SOHND covers this extremely low risk (6.3%). Neglecting to address level IV in cases of occult metastasis could result in missing a crucial positive node, leading to a failure to administer necessary postoperative radiotherapy.

Can Elective Neck Dissection for Oral Cancer Be Planned on the Basis of Depth of Invasion? Retrospective Analysis

PURPOSE

The literature suggests that elective neck dissection (END) may be avoided in primaries with a depth of invasion (DOI) <3 mm. This study evaluated the accuracy of DOI in predicting nodal metastases (lymph node metastasis [LNM]) in oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

In this retrospective institutional chart review, pathologic N classification (pN) was correlated with DOI using Spearman's rank-order (pN1-3) and point-biserial (pN0 v pN+) correlation statistics. The receiver operating characteristic (ROC) curve was analyzed to determine the accuracy of DOI in predicting LNM. Chi-square statistics were used to measure the association between the DOI groups and pN status (pN0; pN+). Post hoc analysis of variance with Bonferroni statistics was used to compare the three DOI groups.

RESULTS

DOI failed to demonstrate a strong positive correlation with the pN classification (ρ = 0.31; P < .001). DOI was not strongly correlated with pN status (rpb = 0.27; P < .001). ROC curve analysis suggested a poor accuracy of DOI in predicting nodal metastases (AUC = 0.67 [95% CI, 0.6 to 0.73]). A statistically significant difference in LNM (pN+) was found between the DOI >10 mm and DOI ≤10 mm primaries (P < .001 for DOI ≤5 mm; P = .016 for DOI >5 mm and ≤10 mm). However, the sensitivity and specificity achieved by ROC analysis for a DOI cutoff value of 10 mm in the present cohort were 69.3% and 57.9%, respectively.

CONCLUSION

DOI is a poor indicator of LNM in OSCC. The decision to perform END should not be based on the tumor DOI.

Radiology-Pathology Concordance and Prognostication of Nodal Features in pN+ Oral Cavity Cancer

BACKGROUND AND PURPOSE

The aims of our study are to evaluate the diagnostic performance and prognostic value of radiological lymph node (LN) characteristics in pN+ oral cavity squamous carcinoma (OSCC).

MATERIALS AND METHODS

pN+ OSCC treated between 2012 and 2020 were included. Preoperative imaging was reviewed by a single radiologist blinded to pathologic findings for the following nodal features: imaging-positive LN (iN+), laterality and total number, and image-identified extranodal extension (iENE). The sensitivity of iN+ for pN+ was calculated. The diagnostic performance of other nodal features was evaluated in the iN+ subgroup. The association of radiologic nodal features with overall survival (OS) was evaluated. Inter-rater kappa for radiologic nodal features was assessed in 100 randomly selected cases.

RESULTS

Of 406 pN+ OSCC, 288 were iN+. The sensitivity of iN+ for pN+ was 71% overall, and improved to 89% for pN+ LN >1.5 cm. Within iN+, sensitivity/specificity for LN size (>3 cm), total LN number (>4), and ENE were 0.44/0.95, 0.57/0.84, and 0.27/0.96, respectively. Sensitivity of iENE was higher in the subset, with major (>2 mm) versus minor (≤2 mm) pENE (43% vs. 13%, p = 0.001). Reduced OS was observed in iN+ versus iN- (p = 0.006), iENE+ versus iENE- (p = 0.004), LN size >3 versus ≤3 cm (p < 0.001), and higher LN number (p < 0.001). Inter-rater kappa for iN+, laterality, total LN number, and presence of iENE were 0.71, 0.57, 0.78, and 0.69, respectively.

CONCLUSION

Our study shows that despite modest sensitivity of most radiological nodal features, the specificity of image-identified nodal features is high and their prognostic values are retained in pN+ OSCC.

LEVEL OF EVIDENCE

3 (retrospective review comparing cases and controls) Laryngoscope, 134:4947-4955, 2024.

Prevalence and implications of bilateral and solely contralateral lymph node metastases in oral squamous cell carcinoma

OBJECTIVES

Effective management of neck in oral squamous cell carcinoma (OSCC) is pivotal for oncological outcomes. Although consensus exists for ipsilateral neck dissection (ND), the necessity for contralateral ND remains controversial. This study aimed to assess the prevalence and implications of bilateral/solely contralateral (B/SC) lymph node metastases (LNMs) to determine the need for contralateral elective ND. Additionally, it examined the prevalence and implications of occult B/SC metastases.

MATERIALS AND METHODS

In a retrospective cohort study, 420 OSCC patients underwent primary surgical treatment following German guidelines at a tertiary center. Preoperative contrast-enhanced computed tomography was conducted, and ND adhered to a standardized approach.

RESULTS

Solely contralateral metastases occurred in 0.95% of patients, with bilateral metastases observed in 7.13%. Occult B/SC metastases occurred in 3.81% of the cases. Correlation analysis revealed a statistically significant association between B/SC metastases and higher tumor stages, tumor localization at the upper jaw or floor of the mouth, proximity to the midline, ipsilateral LNMs, and lymphatic invasion (all p < 0.05). Patients with B/SC metastases showed poorer disease-free survival, with statistical significance reached in the bilateral LNMs group (p = 0.010). Similarly, a significant difference was noted in overall survival between patients with bilateral and solely ipsilateral metastases (p = 0.044).

CONCLUSIONS

B/SC LNMs are rare in patients with OSCC, especially in those who present with clinico-radiologically negative ipsilateral necks. Higher rates of B/SC metastases occur in case of advanced tumors and those localized at the upper jaw or floor of the mouth. Ipsilateral LNMs significantly elevate the risk of contralateral LNMs, tripling the associated risk.

CLINICAL RELEVANCE

These findings provide valuable insights for surgeons considering contralateral ND or extended adjuvant treatment for OSCC patients. However, the absence of high-level evidence from randomized controlled trials impedes the establishment of a definitive standard of care.

Improved recurrence rates and progression-free survival in primarily surgically treated oral squamous cell carcinoma - results from a German tertiary medical center

OBJECTIVES

This study aimed to explore survival and recurrence patterns in patients undergoing primarily surgical treatment for oral squamous cell carcinoma (OSCC) at a high-volume tertiary medical center in Germany.

MATERIALS AND METHODS

The study included 421 patients with primary OSCC who underwent radical tumor resection, neck dissection, and reconstruction with a free flap. Prognostic relevance of clinicopathological characteristics was assessed using Cox proportional-hazards models. Kaplan-Meier method estimated local recurrence-free survival, progression-free survival (PFS), and overall survival (OS), while the log-rank test compared survival outcomes between groups.

RESULTS

Recurrence manifested in 16.63% of the patients (70 patients), encompassing local recurrence in 54 patients (77.14%) and distant metastasis in 24 patients (34.28%). Neck recurrence occurred in only 1 patient (0.24%) on the contralateral side. The majority of recurrences occurred within the initial twelve months following primary tumor surgery (64.29%). Overall, the 5-year OS stood at 58.29%, while the 5-year PFS reached 72.53%. Patients with early recurrence within ≤ 12 months showed the least favorable prognosis (log-rank, all p < 0.001).

CONCLUSIONS

Our findings show a significant decrease in recurrence rates and enhanced PFS at a high-volume tertiary medical center in Germany compared to previous studies. Local recurrence was the primary form observed, with most recurrences happening within the initial twelve months post-surgery. Opting for treatment at a high-volume center and devising therapy plans in interdisciplinary tumor boards may not only enhance OS but also contribute to improved PFS.

CLINICAL RELEVANCE

These findings offer valuable insights for physicians regarding the post-treatment care of patients with OSCC. The results underscore the importance of frequent follow-up appointments, particularly during the initial year, and highlight the critical need for vigilance in monitoring for local recurrence.

Predictors of Occult Metastasis and Prognostic Factors in Patients with cN0 Oral Cancer Who Underwent Elective Neck Dissection

Elective neck dissection (END) is recommended for the management of patients with oral squamous cell carcinoma (OSCC) because of the risk of occult metastasis (OM). We hypothesized that some factors predict poor prognosis regardless of a cN0 END. This study aimed to investigate the predictors of OM and prognostic factors in patients with cN0 OSCC who underwent supraomohyoid neck dissection (SOHND). A retrospective cohort study design was created and implemented. The primary predictive variables in this study were OM and risk factors for poor prognosis after SOHND. A Cox proportional hazard model was used to adjust for the effects of potential confounders on the risk factors for poor prognoses. Among 86 patients with OSCC, OMs were observed in 9 (10.5%). The neutrophil-to-lymphocyte ratio (NLR) and vascular invasion are good markers for detecting OM. A Cox multivariable analysis identified two independent predictors of overall survival: pathologic node (pN) and laterality of END. An independent predictive factor for disease-free survival, the surgical margin, was also identified in this study. According to the pN classification, pN1 patients had a worse survival rate than pN2 patients. Therefore, in the case of pN1, regardless of being cN0, additional adjuvant therapy may be necessary.