Prognostic significance of lymph node yield and lymph node ratio in patients affected by squamous cell carcinoma of the oral cavity and oropharynx: Study protocol for a prospective, multicenter, observational study

Post-operative radiotherapy for oral cavity squamous cell carcinoma: Review of the data guiding the selection and the delineation of post-operative target volumes

BACKGROUND AND PURPOSE

To date, no consensus guidelines have been published that systematically guide delineation of primary and nodal Clinical Target Volumes (CTVs) in patients who require post-operative radiotherapy (PORT) for head and neck squamous cell carcinoma (HNSCC). As a result, significant individual, institutional and national variation exists in the way that CTVs are delineated in the post-operative setting, leading to considerable heterogeneity in radiotherapy treatment.

METHODS

A multi-disciplinary group of experts was convened by the European Society for Radiotherapy and Oncology (ESTRO), including radiation oncologists from Europe, North America and Asia, as well as surgery, radiology and pathology representatives. Oral cavity squamous cell carcinoma (OCSCC), where surgery followed by PORT is the standard of care, was first selected for focus. The indications for PORT, and the influence of tumour subsite and stage on post-operative treatment volumes, were considered with reference to current evidence, and clinical experience within the group.

RESULTS

We present clear recommendations regarding the indications for PORT in OCSCC, and propose a new classification of lateralised and non-lateralised OCSCC, to help guide the delineation of post-operative nodal CTVs.

CONCLUSIONS

The evidence and expert opinion summarised in this manuscript provides the background and context required to underpin new international consensus guidelines for the delineation of primary and nodal CTVs for OCSCC in the post-operative setting.

Lymph node ratio (LNR) and lymph node yield (LNY) in head and neck cancer: A systematic review and meta-analysis

INTRODUCTION

A growing amount of evidence points at lymph node yield (LNY) and lymph node ratio (LNR) as useful indicators in the prognostic evaluation of patients affected by head and neck squamous cell carcinoma (HNSCC) who require neck dissection. The aim of this study was to assess the importance of LNY and LNR in the prognostic evaluation of head and neck cancer patients.

MATERIALS AND METHODS

Included studies were those examining LNY and/or LNR in head and neck cancer patients. We excluded case reports or case series, thyroid cancer or salivary gland cancer studies, a sample size less than 20, and studies with incomplete or missing survival estimate. Of the 2435 studies identified through a database search, 95 were reviewed for full text and 63 were finally included for the final analysis. Electronic databases, including PubMed (MEDLINE), Embase, and Scopus were screened up to January 1, 2024. The systematic review was conducted according to the MOOSE checklist. A set of sub-group meta-analyses were performed for oral cavity, oropharynx, hypopharynx, larynx, and mixed subsites using a random-effects model. Overall survival (OS), Disease Specific Survival (DSS), and Disease-Free Survival (DFS) Hazard Ratios (HR) related to a prespecified LNR and LNY exact value were chosen as summary statistics. Cumulative Hazard Ratios with 95% Confidence Interval (CI) were presented, calculated through the inverse variance method. Heterogeneity was evaluated with I2 statistics.

RESULTS

Results of the meta-analysis showed increased OS for a higher LNY (HR 1.33 95% CI 1.23-1.45). Regarding the LNR, a lower LNR value has an impact on survival, with an OS HR of 1.96 (95% CI 1.72-2.24). The same was true for DFS (HR 2.43 95% CI 1.82-3.23), and DSS (HR 2.07 95% CI 1.83-2.33).

CONCLUSIONS

Our analysis confirms the importance of LNY and LNR as prognostic indicators. Future studies are needed to establish the optimal cut-off values for both factors. LNY and LNR have the potential to be routinely evaluated in patients who undergo neck dissection for HNSCC.

Histopathological Prognostic Factors of Surgically Treated HPV-Associated Oropharyngeal Squamous Cell Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

Human papilloma virus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) is rising in prevalence and is associated with better survival than HPV-negative OPSCC. In surgically treated HPV-negative OPSCCs, adverse pathologic features such as positive surgical margins, extra-nodal extension (ENE) and perineural invasion are well described to portend worse clinical outcomes. These adverse pathological features, however, are not validated prognostic markers among surgically treated HPV-positive OPSCCs. To that end, we pooled all available evidence to address the prognostic significance of these histologic features.

PATIENTS AND METHODS

This meta-analysis was performed according to PRISMA guidelines. PubMed, Web of Science and Embase databases were systematically searched for articles evaluating 13 known adverse histopathological prognostic factors of surgically treated HPV-associated OPSCC. Data analysis was done using R v4.0.5.

RESULTS

A total of 32 studies (n = 31,535) fulfilled the inclusion criteria. ENE and advanced pT stage were associated with poorer overall survival (OS) [hazard ratio (HR):1.80, 95% confidence interval (CI) [1.59-2.03], p < 0.0001, HR: 3.28, 95% CI [2.20-4.87], p = 0.0025]; disease-specific survival (DSS) (HR: 3.14, 95% CI [1.20-8.26], p = 0.0327, HR: 3.49, 95% CI [2.45-4.96], p = 0.0043) and disease-free survival (DFS) (HR: 2.03, 95% CI [1.05-3.94], p = 0.0397, HR: 3.66, 95% CI [2.81-4.77], p = 0.0001) respectively. The presence of lymphovascular invasion (HR: 1.46, 95% CI [1.22-1.75], p = 0.0018) and positive margins (HR: 1.50, 95% CI [1.185-1.899], p = 0.0069) significantly worsen OS.

CONCLUSION

ENE, advanced pT stage, positive margins and lymphovascular invasion were adverse histologic prognostic marker among surgically treated HPV-positive OPSCC. The presence of these factors should be carefully evaluated in order to select the optimal patients for surgical treatment.

Clinicopathological Characteristics, Prognostic Factors, and Treatment Outcomes of Patients with Oral Tongue Squamous Cell Carcinoma Treated with Glossectomy: A Tertiary Oncology Center Experience

Oral tongue squamous cell cancer (OTSCC) is one of the most prevalent cancers worldwide and incidence increases with age. An alarming increase in the incidence of OTSCC in the younger age group. This study aimed to explore clinical and histopathological characteristics, survival, and other post-surgical outcomes in patients with OTSCC treated with glossectomy through the Department of Otolaryngology-Head & Neck Surgery at the Ministry of National Guard Health Affairs (MNGHA) within our study period. This is a retrospective study carried out through the collection and analysis of data from medical charts of 56 patients with oral tongue cancer who were treated by glossectomy. Treatment was initiated from January 2010 to December 2021. Patient characteristics, tumor characteristics, treatment modality, failure patterns, and survival rates were collected and analyzed. At diagnosis, 62.5% were tobacco smokers, 46.8% had poor dental hygiene, and 76.8% had ulcerative lesions. Furthermore, 33 cases presented with early-stage clinical disease and 23 cases with advanced stage. The median follow-up was 54 months, 28 patients (50%) were free for 3-5 years. Patients who were free on 5-year follow-up had a significantly higher percentage of negative lymphovascular and perineural invasion (p < 0.05). Additionally, 12 patients (21.4%) had developed recurrence. Mortality in all cases was 30.3, but mortality-related cancer was 19.6%. Locoregional failure remains the main cause of treatment failure in resectable OTSCC. Pathological T-stage, N-stage, LVI, PNI, ECE, and LNR are all considered strong prognostic factors.

Prognostic Involvement of Lymph Node Density in Oral Squamous Cell Carcinoma. A New Predictive Model

PURPOSE

Lymph node density (LND) has been reported to be a significant predictor of survival in oral squamous cell carcinoma (OSCC). The aim of this study was to analyze LND as a prognostic factor in OSCC and create a predictive model that determines the probability of death in these patients.

METHODS

A retrospective cohort study was carried out with a cohort of patients who underwent cervical dissection and primary resection of OSCC between 1980 and 2020. The primary predictor variable in this study was LND, which is defined as the number of positive lymph nodes divided by the total number of lymph nodes removed. The cutoff values for prediction of disease-specific survival (DSS) were calculated by receiver operating characteristic curve analysis, which determined the best cutoff value was 0.07. Patients were divided into binary subgroups (low and high risk) using the best cutoff value of LND. The outcome variable was DSS, defined as the duration from the date of diagnosis to death due to OSCC and not due to other causes or secondary tumors. Other variables were type of neck dissection, postsurgical treatment, surgical margin, pathological T category stage, pathological N category (pN) stage, extranodal extension, perineural invasion, bone invasion, and presence of recurrence. A predictive model (score) was generated by selecting variables using a log-rank test and by using the Cox proportional-hazards regression (multivariate analysis).

RESULTS

The sample consisted of 368 patients, 252 (68.5%) male and 116 (31.5%) female patients, with a mean age of 60.3 years. According to the LND cutoff value, there were 289 patients with a low LND (≤0.07) and 79 with a high LND (>0.07). The univariate analysis showed LND as a significant predictor of DSS at 5 years (67.1% in LND ≤ 0.07 vs 32.9% in LND > 0.07; P < .001). The Cox multivariate analysis identified LND (hazard ratio [HR] = 27.2; 95% confidence interval [CI], 3.18-231; P = .002), recurrence (HR = 4.45; 95% CI, 2.3-8.4; P < .001), and type of treatment (HR = 0.52; 95% CI, 0.34-0.81; P < .001) as independent predictive factors for DSS. In the predictive model, the presence of recurrence was the most important factor with 8 points, whereas LND >0.07 contributed only 1 point; however, the 2 categories resulting from this limit were statistically significant.

CONCLUSIONS

Our study demonstrates that LND is an additional prognostic factor in patients with a pN+ disease. In addition, our predictive model could be useful in the therapeutic algorithm of OSCC patients, as it can predict the probability of death in these patients.

Lymph nodes in health and disease - A pathologist's perspective

A lymph node (LN) being a unique immunological organ has the ability to adapt when exposed to emigrants. The structural and architectural components are tampered, and it acts as an efficient immune checker in the presence of an antigen and also exhibits a morphological drift when neoplastic cells evade the organ. So, understanding the basics of histology of a lymph node is essential for the better identification and interpretation of pathological events occurring in a lymph node. A phenomenon pertaining to LNs, interpretation of reactive and neoplastic lymph nodes at morphological levels and pathological diversity of LNs in selected disease processes are emphasised.

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.

Defining High-Quality Integrated Head and Neck Cancer Care Through a Composite Outcome Measure: Textbook Outcome

OBJECTIVES/HYPOTHESIS

To further improve the quality of head and neck cancer (HNC) care, we developed a composite measure defined as "textbook outcome" (TO).

METHODS

We analyzed a retrospective cohort of patients after curvative-intent primary surgery, radiotherapy (RT), or chemoradiation (CRT) for HNC between 2015 and 2018 at the Netherlands Cancer Institute. TO was defined as 1) the start of treatment within 30 days, 2a) satisfactory pathologic outcomes, without 30-day postoperative complications, for the surgically treated group, and 2b), for RT and CRT patients, no unexpected or prolonged hospitalization and toxicity after the completion of treatment as planned.

RESULTS

In total, 392 patients with HNC were included. An overall TO was achieved in 9.6% of patients after surgery, 20.6% after RT, and 2.2% after CRT. Two indicators (margins >5 mm and start treatment <30 days) reduced TO radically for both groups.

CONCLUSION

TO can aid the evaluation of the quality of care for HNC patients and guide improvement processes.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Comparing prognostic utility between the 8th edition of TNM staging system and the lymph node ratio for oral squamous cell carcinoma

BACKGROUND

Lymph node metastasis in oral squamous cell carcinoma (OSCC) is associated with poor prognosis. The 8th edition of TNM has implemented new nodal staging criteria. We assess the prognostic utility of the lymph node ratio (LNR) and compare it to that of pN in the TNM 8th edition.

METHODS

One hundred and forty-two patients with OSCC were retrospectively studied. Nodal staging was performed using the TMN 8th edition and the prognostic value of the LNR in terms of overall survival (OS) and disease-free survival (DFS) was evaluated.

RESULTS

Fifty-seven patients were eligible for inclusion. The LNR was independently prognostic of OS (p = 0.02). Instead N classification was not significantly predictive of OS (p = 0.10). High LNRs resulted in decreases in OS of approximately 40% within 6 months after surgery.

CONCLUSIONS

The LNR identifies patients with poor outcomes better than N classification. The lack of reliable LNR cutoffs compromises its utility in clinical practice.

Lymph node yield in treatment naïve cases of head and neck squamous cell carcinoma: en bloc lymphadenectomy versus level-by-level dissection

BACKGROUND

Lymph node yield is an important prognostic factor in head and neck squamous cell carcinoma. Variability in neck dissection sampling techniques has not been studied as a determinant of lymph node yield.

METHODS

This retrospective study used lymph node yield and average nodes per level to compare level-by-level and en bloc neck dissection sampling methods, in primary head and neck squamous cell carcinoma cases operated between March 2017 and February 2020.

RESULTS

From 123 patients, 182 neck dissections were analysed, of which 133 were selective and the rest were comprehensive: 55 had level-by-level sampling and 127 had undergone en bloc dissection. The level-by-level method yielded more nodes in all neck dissections combined (20 vs 17; p = 0.097), but the difference was significant only for the subcohort of selective neck dissection (18.5 vs 15; p = 0.011). However, the gain in average nodes per level achieved by level-by-level sampling was significant in both groups (4.2 vs 3.33 and 4.4 vs 3, respectively; both p < 0.001).

CONCLUSION

Sampling of cervical lymph nodes level-by-level yields more nodes than the en bloc technique. Further studies could verify whether neck dissection sampling technique has any impact on survival rates.

Accuracy of fine-needle aspiration cytology in detecting cervical node metastasis after radiotherapy: Systematic review and meta-analysis

PURPOSE

To define the accuracy of fine-needle aspiration cytology (FNAC) in diagnosing persistent or recurrent neck metastases in previously irradiated patients.

METHODS

The study was performed according to the PRISMA-DTA guidelines.

RESULTS

A total of 382 FNACs were used for calculation of diagnostic accuracy parameters. The overall pooled sensitivity and specificity in detecting malignant nodes were 69.1% (95% CI: 56.3%-80.7%; I2 = 79.5%) and 84.2% (95% CI: 71.8%-93.5%; I2 = 87.0%), respectively. Cumulative diagnostic odds ratio (DOR) was 16.54 (95% CI: 4.89-38.99; I2 = 65.8%), while cumulative positive and negative likelihood ratio (PLR and NLR) were 5.4 (95% CI: 2.3-11.2) and 0.37 (95% CI: 0.22-0.54), respectively.

CONCLUSIONS

FNAC alone could not guide the decision to perform a salvage neck dissection in previously irradiated patients, but its results should be assessed in relation to the specific clinical context.

Log odds of positive lymph nodes as an independent predictor of overall survival in oral squamous cell carcinoma

Context:

Log odds of positive lymph nodes (LODDS) have been recently demonstrated as a very promising staging model and have outperformed AJCC pN, lymph node ratio (LNR) category in major cancers. Literature is scarce concerning the prognostic ability of LODDS in oral squamous cell carcinoma (OSCC) patients.

Aims:

The present study was aimed to evaluate the importance of LODDS in predicting locoregional recurrence and overall survival (OS) in patients with OSCC compared to LNR.

Settings and Design:

The retrospective study was carried out on 194 patients with OSCC cases treated by surgery ± adjuvant therapy from 2008 to 2014 at our institution.

Subjects and Methods:

Demographical and clinicopathological details of study cases were recorded. LNR and LODDS were calculated and expressed as a percentage and mean ± standard deviation.

Statistical Analysis Used:

The OS analysis was done by the Kaplan–Meier curve followed by log-rank (mantel-cox) test. Univariate and multivariate survival analysis was done to analyze the prognostic ability of LNR% and LODDS after adjusting the clinicopathological parameters by the Cox proportional hazards model.

Results:

Patients with cut off values of LODDS >−1.2 and LNR% >4 had significantly lower mean OS (P ≤ 0.001). Multivariate analysis indicated that only mean LODDS >−1.2 was significantly associated with poor OS. Although there was a correlation with locoregional recurrence, LODDS and LNR failed to be the independent predictors of locoregional recurrence.

Conclusions:

LODDS was an independent reliable prognostic indicator for patients with OSCCs than conventional staging systems and LNR.

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.

Lymph node characteristics and their prognostic significance in oral squamous cell carcinoma

BACKGROUND

The prognostic significance of various histopathologic lymph node-based biomarkers in oral squamous cell carcinoma (OSCC) needs further evaluation.

METHODS

Retrospective analysis of 212 OSCC patients with regional metastasis to determine the association of extranodal extension (ENE), extent of ENE, size of metastatic deposit, lymph node yield (LNY), lymph node ratio (LNR), and topography of involvement with survival outcomes.

RESULTS

The presence of ENE, larger nodal deposit, higher pN stage, lymph nodes in the lower levels, and patients who did not receive adjuvant treatment had poor disease-free survival (DFS). In addition, more positive nodes and high LNR showed worse overall survival (OS). ENE beyond 5 mm resulted in poorer outcomes. Larger sizes of metastatic deposit predisposed to ENE. Multivariate analyses showed only lower level of neck involvement to affect both DFS and OS.

CONCLUSIONS

Lymph node metastasis to lower levels and other lymph node characteristics affect prognosis and must be considered in the evolution of staging systems for OSCC.

Nodal characteristics associated with adverse prognosis in oral cavity cancer are linked to host immune status

BACKGROUND AND OBJECTIVE

Nodal metastasis is one of the strongest predictors of outcomes in oral cavity squamous cell carcinomas (OSCC). The aim was to analyze the interplay of nodal characteristics in OSCC prognosis.

METHODS

In this retrospective cohort study we included OSCC patients treated with primary surgery including neck dissection between 2005 and 2015 (n = 619). Disease-specific survival (DSS) was the primary endpoint. Optimal cutoffs were identified using recursive-partitioning analysis (RPA). A novel characteristic-metastatic focus-to-lymph node size ratio (MLR)-was introduced. We compared the American Joint Committee on Cancer, Eighth Edition (AJCC8) pN categories to a new categorization.

RESULTS

Patients with higher neutrophil-to-lymphocyte ratio had more adverse nodal characteristics. All nodal characteristics were significant predictors of DSS in univariable analysis. In multivariable analysis, only number of positive nodes and MLR remained significant. An RPA including all nodal covariates confirmed the results. Compared with AJCC8, our RPA categorization had better hazard discrimination (0.681 vs. 0.598), but poorer balance value (0.783 vs. 0.708).

CONCLUSION

Patients with higher neutrophil-to-lymphocyte ratio had more adverse nodal characteristics. Total number of metastatic lymph nodes is the strongest predictor of outcomes in OSCC. MLR is a more powerful predictor than metastatic lymph node size or metastatic focus size alone.

Impact of Lymph Node Yield on Survival in Surgically Treated Oropharyngeal Squamous Cell Carcinoma

Objectives

(1) To estimate the association between neck dissection lymph node yield (LNY) and survival among patients with surgically treated human papilloma virus (HPV)–associated oropharyngeal squamous cell carcinoma (OPSCC). (2) To identify a clinically relevant quality metric for surgical treatment of HPV-related OPSCC.

Study Design

Retrospective cohort study.

Setting

National Cancer Database.

Subjects and Methods

From the National Cancer Database, 4130 patients were identified with HPV-associated OPSCC treated with primary surgery from 2010 to 2016. Based on prior literature, an adequate neck dissection LNY was defined as ≥18 lymph nodes. To determine whether LNY is associated with survival, univariable and multivariable Cox proportional hazards regression was performed. Analysis was stratified by adjuvant therapy regimen.

Results

A total of 2113 patients (51.2%) underwent surgery with or without adjuvant radiation (S ± RT), and 2017 patients (48.8%) underwent surgery with adjuvant chemoradiation. LNY ≥18 was associated with a 5-year survival benefit of 7.15% (91.7% for LNY ≥18, 84.5% for LNY <18, P = .004) for the S ± RT cohort on unadjusted survival analysis. For the S ± RT group, LNY ≥18 was associated with decreased hazard of death (hazard ratio, 0.45; 95% CI, 0.29-0.70; P < .001) after adjustment for patient characteristics, TNM staging, surgical margins, extranodal extension, and treating facility characteristics. For surgery with adjuvant chemoradiation, the adjusted hazard ratio estimate for LNY ≥18 was 0.64 (95% CI, 0.41-1.00), but the result was not statistically significant ( P = .052).

Conclusion

An adequate LNY from a neck dissection may affect survival when HPV-related OPSCC is treated with up-front surgery.

Compartmental Surgery With Microvascular Free Flap Reconstruction in Patients With T1-T4 Squamous Cell Carcinoma of the Tongue: Analysis of Risk Factors, and Prognostic Value of the 8th Edition AJCC TNM Staging System

Compartmental surgery and primary reconstruction with microvascular free flaps represent the gold-standard in the treatment of oral tongue squamous cell carcinoma (OTSCC). However, there are still unclear clinical features that negatively affect the outcomes. This retrospective study included 80 consecutive patients with OTSCC who underwent compartmental surgery and primary reconstruction by free flap. The oncologic outcomes, the reliability of the 8th edition American Joint Committee on Cancer (AJCC) staging system and the prognostic factors were evaluated. Fifty-nine males and 21 females (mean age 57.8 years, range 27-81 years) were treated between November 2010 and March 2018 (one patient had two metachronous primaries). Seventy-one patients (88.75%, 52 males, 19 females, mean age of 57.9 years, range of 27-81 years) had no clinical history of previous head and neck radiotherapy and were considered as naive. Histology showed radical surgery on 80/81 lesions (98.8%), with excision margins >0.5 cm, while in 1 case (1.2%), a close posterior margin was found. According to the 8th AJCC classification, 37 patients (45.7%) were upstaged shifting from the clinical to the pathological stage, and 39 (48.1%) showed an upstaging while shifting from the 7th to the 8th AJCC staging system (no tumors were downstaged). Nodal involvement was confirmed in 33 patients (40.7%). Perineural and lymphovascular invasion were present in 9 (11.1%) and 11 (13.6%) cases, respectively. Twenty-two patients (27.1%) underwent adjuvant therapy. The 5-years disease-specific, overall, overall relapse-free, locoregional relapse-free and distant metastasis-free survival rates were 73.2, 66.8, 62.6, 67.4, and 86%, respectively. Patients with a lymph node ratio >0.09 experienced significantly worse outcomes. Univariate analysis showed that patients with previous radiotherapy, stage IV disease, nodal involvement, and lymphovascular invasion had significantly worse outcomes. Multivariate analysis focused naive patients and showed that lymphovascular invasion, advanced stage of disease, and node involvement resulted reliable prognostic factors, and patients with the same tumor stage and histological risk factors who did not undergo adjuvant therapy experienced significantly worse outcomes. In our series, surgery played a major role in the treatment of local extension; adjuvant therapy resulted strictly indicated in patients with advanced-stage disease associated with risk factors.

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.

Lymph node yield and lymph node ratio in oral cavity and oropharyngeal carcinoma: Preliminary results from a prospective, multicenter, international cohort

OBJECTIVES

Recently, Lymph Node Yield (LNY) and Lymph Node Ratio (LNR) have emerged as prognostic indicators in head and neck cancer. However, there is a lack of data regarding the LNY and LNR values in the specific neck levels dissected and regarding the factors that influence these values.

MATERIALS AND METHODS

Preliminary results of the NCT03534778 trial are reported. LNY and LNR values were estimated for 100 patients with oral or oropharynx carcinoma, from November 1, 2018 to September 30, 2019.

RESULTS

Overall, the mean number of lymph nodes retrieved was 34.4 (95% confidence interval [CI] 31.6-37.3). LNY means and CI per single neck level were as follows: level I 5.5 lymph nodes harvested (95% CI 3.5-7.5), level II 15.4 (95% CI 10.6-20.2), level III 8.0 (95% CI 4.6-11.3), level IV 6.3 (95% CI 3.4-9.15), level V 6.3 (95% CI 3.6-9.0). cN+ patients had a higher number of lymph nodes retrieved, odds ratio (OR) 1.2 (95% CI 1.05-1.36). Smokers had less lymph nodes harvested, OR 0.78 (95% CI, 0.71-0.87). Mean LNR was 0.063 (95% CI 0.047-0.078). A multiple regression analysis showed that anatomic site, pN, smoking status and LNY statistically significantly predicted the LNR (p < 0.05) CONCLUSIONS: The LNY and LNR values are influenced by various demographic and pathological characteristics of the patient, such as the number of dissected levels, primary site, cN positivity, and smoking status.