Incidence of small lymph node metastases with evidence of extracapsular extension: clinical implications in patients with head and neck squamous cell carcinoma

Comparison of four MRI diffusion models to differentiate benign from metastatic retropharyngeal lymph nodes

BACKGROUND

Conventional magnetic resonance diffusion-weighted imaging (DWI) and morphological features have limitations in distinguishing benign from metastatic retropharyngeal lymph nodes (RLNs). We aimed to compare the value of continuous-time random walk (CTRW), fractional-order calculus (FROC), stretched-exponential model (SEM), and conventional DWI, in combination with morphological features, for differentiating between the two groups.

METHODS

Fifty-nine patients with 68 RLNs (23 benign and 45 metastatic) were enrolled. All patients underwent DWI with 12 b-values. Diffusion data were reconstructed using conventional DWI, SEM, FROC, and CTRW models, yielding nine parameters: apparent diffusion coefficient (ADC), distributed diffusion coefficient (DDC)SEM, αSEM, DFROC, βFROC, μFROC, DCTRW, αCTRW, and βCTRW. Diffusion parameters and morphological features were compared using Mann-Whitney U, independent sample t, or χ2 tests. Logistic regression analysis was performed to identify the best diffusion indicator for classification and to develop a multiparameter model combining morphological features. Area under the receiver operating curve (AUC) and DeLong tests were used.

RESULTS

Significant differences in diffusion parameters were found between benign and metastatic RLNs, except for αCTRW (p ≤ 0.022). Benign RLNs exhibited higher ADC, DDCSEM, DFROC, and DCTRW, while metastatic RLNs had higher αSEM, βFROC, μFROC, and βCTRW. Multivariate logistic regression analysis identified βCTRW as the optimal single diffusion indicator (AUC = 0.913). The combined model of βCTRW with morphological features further improved diagnostic performance and yielded an AUC of 0.948.

CONCLUSION

βCTRW is an effective noninvasive biomarker for distinguishing between benign and metastatic RLNs. Thus, combining βCTRW with morphological features enhances diagnostic efficiency.

RELEVANCE STATEMENT

This study demonstrates that βCTRW, derived from the continuous-time random walk diffusion model, when integrated with morphological features, offers a reliable, noninvasive diagnostic approach for differentiating between benign and metastatic retropharyngeal lymph nodes.

KEY POINTS

Non-Gaussian diffusion metrics outperformed conventional DWI. βCTRW was the best indicator for distinguishing benign from metastatic lymph nodes. Combining βCTRW with minimal axial diameter further improved diagnostic efficiency.

Extracapsular nodal extension and tumor deposits in head and neck squamous cell carcinoma

BACKGROUND

Tumor deposits (TDs) are an infrequently mentioned feature of head and neck squamous cell carcinoma (HNSCC) that are currently grouped under extranodal extension (ENE) in the AJCC 8th edition of HNSCC TNM staging. The prognostic implication of TDs in comparison to ENE remains uncertain.

METHODS

This observational, retrospective, non-randomized study evaluated patients with HNSCC who underwent initial surgical resection, with neck dissection and adjuvant radiotherapy ± chemotherapy. Clinical variables were considered, and statistical analyses were conducted to compare time progression and overall survival (OS) in patients with TDs against those with ENE.

RESULTS

Of the 71 patients included in the study, 50 were diagnosed with ENE (pN2a-ENE in 38 patients and pN3b-ENE in 12), while 21 had TDs ± ENE. The median time to progression was significantly different based on the presence of ENE or TDs (p = .002) and pN2a-ENE/pN3b-ENE or TDs (p = .007). The three-year OS was 55.7% for the entire group, 60.4% in ENE and 38.4% in TDs (p = .021). The OS difference between the pN2a-ENE, pN3b-ENE, and the TDs group was also significant (p = .05). The hazard ratio between ENE and TDs was Exp (B) 4.341 (p = .044).

CONCLUSIONS

TDs in HNSCC are associated with a lower OS than ENE, despite intensified adjuvant therapy. Our results confirm a better prognosis for pN2a-ENE vs. pN3b-ENE, and pN3b-ENE vs. TDs. TDs may serve as an indicator of poor prognosis and require separate TNM classification in HNSCC staging. Larger studies are needed to evaluate TDs impact on treatment strategies and outcomes.

Risk factors and prognostic models of lymph node metastatic hypopharyngeal squamous cell carcinoma

PURPOSE

To explore the risk factors for lymph node metastasis (LNM) and establish nomograms for predicting survival outcomes and assessing individual risk in patients with LNM and hypopharyngeal squamous carcinoma (HSCC).

METHODS

Clinical data of patients with HSCC were retrospectively reviewed. The study's primary endpoints were overall survival (OS) and disease-specific survival (DSS). Nomograms were established based on Cox regression analyses. The accuracy and calibration ability of the nomograms were evaluated using the C-index, area under the curve, calibration curves, and decision curve analysis.

RESULTS

Overall, 2888 patients were enrolled, and the LNM rate was 74.2%. Age ≤ 60 years, male sex, unmarried status, pyriform sinus location, grade III-IV, tumor larger than 4 cm, and advanced T stage increased the risk of LNM. In addition, LNM was a negative prognostic factor for OS and DSS. Ten variables were identified and incorporated into nomograms to estimate OS and DSS. Our nomograms outperformed the traditional staging system in training and validation cohorts. Patients were stratified into risk subgroups based on the OS- and DSS-nomogram scores. Patients in the high-risk subgroup had a higher risk of death and disease-specific mortality than those in the low- and intermediate-risk subgroups.

CONCLUSIONS

LNM worsens the prognosis of HSCC. This study identified the independent prognostic factors for HSCC with LNM and developed satisfactory OS- and DSS-monogram to provide individual prediction and risk classification for patients with this diagnosis.

Difference after radiotherapy observed in patients with nasopharyngeal carcinoma

To evaluate the shrinkage rate of small cervical lymph nodes (SCLNs) at different levels in patients with nasopharyngeal carcinoma (NPC) treated with radiotherapy retrospectively. 96 adult patients with NPC who underwent intensity-modulated radiotherapy (IMRT) at our institution were analyzed and followed-up. Evaluation of the response (shrinking rate) of SCLNs was determined by the bidimensional tumor area. Binary logistic regression was conducted to explore the risk factors associated with the shrinking rate of SCLNs. Of the 96 patients included in this study, 1,194 SCLNs were identified. Among the SCLNs, 28.6% were level IIb and 21.3% were level IIa. SCLNs at level IIa (96.1%), tended to have a response effect of no change (NC) with shrinking rate <50% (odds ratio [OR]=0.007; 95% CI: 0.003-0.021, P=5.287×10^-25). Conversely, the most proportionate share of SCLNs for shrinking rate ≥50% (complete response (CR) or partial response (PR)) was observed at level IIb (67.2%) (OR=6.104; 95% CI: 3.267-11.407, P=1.420×10^-8). There was no significant difference of shrinking rate between irradiation doses of 60Gy and 63Gy. Most SCLNs at level IIa were not shrunk after radiotherapy. The irradiation dose of SCLNs at level IIa should be not more than 60Gy to reduce side effects.

Oncological Analysis and Surgical Outcomes in Postcricoid Carcinoma: A 14 Years Retrospective Study

Background: Postcricoid carcinoma is a rare but aggressive type of hypopharyngeal carcinoma with poor prognosis and high mortality; thus, it is indispensable to investigate the surgical efficacy and multimodal strategies. Methods: This retrospective study included postcricoid carcinoma patients undergoing surgical resection from 2008 to 2022. Treatment methods and clinical characteristics were analyzed to evaluate prognostic factors for oncological outcomes. Results: Of 72 patients, 13 cases were in the I−II stage and 59 in the III−IV stage. The overall survival (OS) was 50.0%; the laryngeal function preservation rate was 69.4%. Univariate analysis found that high mortality was associated with low tumor differentiation, lymph node metastasis, neck recurrence, and smoke history via log-rank test (p < 0.05); postoperative radiotherapy (RT) remained positive in OS (p = 0.04). The multivariable model further revealed that lymph node metastasis was a dominant determinant after accounting for covariates (HR 1.75; 95% CI 0.85−3.59). The data also indicated that neoadjuvant chemotherapy (NAC) and tumor diameter ≤ 2 cm were causing lower rates of pharyngeal fistula and locoregional relapse. Conclusions: Surgeons should emphasize high-risk features and optimize individualized surgical procedures for postcricoid carcinoma patients. Combined with multimodal treatments, it is feasible to reconstruct laryngeal function and lessen postoperative morbidities in advanced patients.

Small size of metastatic lymph nodes with extracapsular spread greatly impacts treatment outcomes in oral squamous cell carcinoma patients

Extracapsular spread (ECS) of metastatic lymph nodes from oral carcinoma is the most significant prognostic predictor of a poor treatment outcome. However, only a few reports on prognostic factors in ECS-positive cases have been investigated. To address this problem, a detailed examination of ECS pathology was conducted to determine the prognostic factors of oral squamous cell carcinoma (OSCC) with ECS of metastatic lymph nodes. This study involved 63 OSCC patients with at least one pathologically metastatic node with ECS. Among the 229 metastatic lymph nodes, 149 exhibited ECS. Univariate analysis revealed that a poor outcome and recurrence were significantly associated with the number of ECS-positive nodes, density of ECS, and the minor axis of the smallest ECS-positive node. However, multivariate analysis identified only small size of ECS-positive nodes as a significant and independent factor predicting recurrence and a poor outcome. Thus, small size of ECS-positive nodes is the most important prognostic indicator for OSCC with ECS in metastatic lymph nodes. The classification of ECS status using the minor axis of ECS-positive nodes may be useful for further prediction of a poorer prognosis in OSCC cases. Standardization of ECS diagnosis and multicenter prospective studies will be required to confirm and refine these findings.

Safety of differential radiation dosing in lymph node positive necks treated with IMRT

PURPOSE

When treating head and neck squamous cell carcinoma (HNSCC) with intensity modulated radiation therapy (IMRT), it is common to use several dose levels for a lymph node positive neck: full dose (66-70 Gy) to gross cancer, intermediate dose (59-63 Gy) to higher risk neck regions, and standard dose (50-54 Gy) to lower risk neck regions. There is no consensus regarding how much of the neck should receive intermediate versus standard dose, however.

METHODS AND MATERIALS

HNSCC patients treated with IMRT were identified from 2 academic medical centers between 2004 and 2016. Intermediate dose was restricted to a region of the neck 2 cm above and below the most superior and inferior involved lymph nodes; standard dose was delivered to more distal neck regions. Descriptive statistics were calculated for demographics and clinical characteristics as well as proportions for failures 2 years after treatment. Failure outside the intermediate dose region was determined by calculating confidence intervals from a modification of the Poisson distribution.

RESULTS

Of the 57 necks included in this study, 17.5% experienced disease recurrence in the neck within 2 years of completing treatment. All failures were within the 2-cm margin above or below the most superior and inferior involved nodes; there were no failures outside this 2-cm margin (95% confidence interval, 0-7.7).

CONCLUSIONS

The results of this study support the feasibility of treating only the neck adjacent to gross neck disease to an intermediate dose, and treating the remainder of the neck to a lower, standard dose. Although these results are encouraging, additional study of this treatment paradigm is warranted.

Tumor Metabolism in the Microenvironment of Nodal Metastasis in Oral Squamous Cell Carcinoma

Objective In many cancers, including head and neck squamous cell carcinoma (HNSCC), different regions within a tumor have different metabolic phenotypes. Transfer of metabolites between compartments promotes tumor growth and aggressive behavior. Metabolic compartmentalization in HNSCC nodal metastases has not been studied, nor has its impact on extracapsular extension or clinical outcomes been determined. Study Design Retrospective analysis based on immunohistochemistry staining. Setting Tertiary care center. Subjects and Methods Primary tumors and nodal metastases from 34 surgically treated oral cavity HNSCC patients with extracapsular extension (ECE) were stained for monocarboyxlate transporter (MCT) 4, MCT1, translocase of outer mitochondrial membrane 20, and Ki-67. Strength of staining was assessed using a computer-assisted pathology algorithm. Immunohistochemistry (IHC) scores along with clinical factors were used to predict disease-free survival (DFS). Results Patterns of IHC staining showed metabolic compartmentalization both at the primary tumor sites and in nodal metastases. MCT4 staining in the perinodal stroma was significantly higher in specimens with ECE greater than 1 mm (macro-ECE, P = .01). Patients with high perinodal MCT4 staining were compared with those with low perinodal MCT4 staining. On multivariate analysis, only high perinodal MCT4 staining had a significant impact on DFS ( P = .02); patients with high perinodal MCT4 had worse survival. DFS was not significantly worsened by advancing T stage, N stage, ECE extent, or perineural invasion. Conclusion Oral HNSCC displays compartmentalized tumor metabolism at both primary and metastases. Greater cancer-associated stromal conversion around ECE, denoted by high stromal MCT4, may be a biomarker for aggressive disease and worsened DFS.

Prognostic impact and implications of extracapsular lymph node spread in Borrmann type IV gastric cancer

The purpose of this study was to evaluate the relationship between extracapsular lymph node spread (ECS) and clinicopathology and its influence on the prognosis in patients with Borrmann type IV gastric cancer. Between 2002 and 2014, clinical data were reviewed from 486 patients with Borrmann type IV gastric cancer who underwent curative resection. Of the 486 patients, lymph node metastasis was found in 456. ECS was detected in 213 (46.7%) patients with lymph node metastasis. A positive lymph node with ECS was significantly correlated with the N category, lymphatic/venous invasion, tumor location, and TNM stage. For the whole patients, the mean OS was 34.7 months, and the 5-year OS rate was 15.5%. The 5-year OS rate of node-negative patients was 48%, for node-positive patients without ECS 18.7%, and for node-positive patients with ECS 5.7% (P = 0.000). In a multivariate analysis, adjusted for tumor location, lymphatic/venous invasion, body mass index (BMI), and TNM stages, ECS remained an independent prognostic factor. For patients with the same N category and TNM stage, those with ECS still had a worse survival rate. Recurrent sites were confirmed in 367 patients. The most frequent recurrent site was the peritoneum. There was a significant difference between ECS+ (N = 150) and ECS- (N = 142) patients (P = 0.008). Our results suggested that ECS was an independent prognostic value for Borrmann type IV gastric cancer patients with curative resection and a subgroup indicated a significantly worse long-term survival for patients with the same N or TNM stages. ECS+ was an adverse factor for peritoneal metastasis.

Incidence of small lymph node metastases in patients with nasopharyngeal carcinoma: Clinical implications for prognosis and treatment

BACKGROUND

Patients with nasopharyngeal carcinoma (NPC) often present small lymph nodes. The purpose of this study was to determine the prognostic impact on local recurrence of small lymph nodes, defined as smaller than 10 mm in greatest diameter.

METHODS

Consecutive patients treated by intensity-modulated radiotherapy (IMRT) for pathologically confirmed NPC were analyzed retrospectively. Those without small lymph nodes were excluded from the study. From January 2005 to January 2011, 275 patients with NPC represented with 2722 small lymph nodes, which were analyzed. Small lymph node axial diameter was measured using CT/MRI before radiotherapy (RT), at 50 Gy, and 6 months after the end of RT. The dose received by the small lymph nodes and the changes in lymph node diameter were recorded. Clinical endpoints were overall survival (OS), locoregional control, disease-specific survival (DSS), and distant metastasis-free survival. Median follow-up time was 55 months (range, 5-96 months).

RESULTS

Patients were grouped according to the dose received by the small lymph nodes and the number of small lymph nodes. Only 27 patients (9.8%) had a decrease ≥50% in the small lymph node diameter at 50 Gy and 53 patients (19.3%) had a decrease ≥50% at 6 months after RT. The 5-year locoregional control, distant metastasis-free survival, DSS, and OS were 93.5%, 85.2%, 88.8%, and 87.0%, respectively. Multivariate analyses showed that T classification and N classification are independent prognostic factors for OS. However, the dose received and the numbers of small lymph nodes were not statistically associated with any of the survival endpoints.

CONCLUSION

In the IMRT era, N classification remains an independent prognostic factor in NPC. However, the incidence of small lymph nodes is not a significant prognostic factor in patients with NPC. The presence of small lymph nodes should not influence the nodal contouring or the dose delivered to nodal areas. © 2016 Wiley Periodicals, Inc. Head Neck 39: 305-310, 2017.

Parotid area lymph node metastases from preliminarily diagnosed patients with nasopharyngeal carcinoma: report on tumor characteristics and oncologic outcomes

The parotid area lymph node (PLN) is an uncommon site of metastasis originating from nasopharyngeal carcinoma (NPC). The study aimed to investigate clinical characteristics and outcomes of patients with preliminarily diagnosed NPC with PLN metastases. Here we retrospectively reviewed Magnetic resonance imaging (MRI) scans of 2221 patients with untreated nonmetastatic NPC who received intensity-modulated radiation therapy (IMRT). Finally, 64 (2.9%) patients were identified with PLN metastases, of which, 34 received PLN-sparing IMRT and 30 received PLN-radical IMRT. We also found that 42.2% had N3 disease and 95.3% had stages III-IVb. PLN metastases on MRI were characterized by ipsilateral retropharyngeal lymph node (RLN) or level II nodal extracapsular spread (ECS), ipsilateral giant cervical nodes, ipsilateral parapharyngeal extension, or solitary parotid metastasis. The 5-year overall survival, distant metastasis-free survival, regional relapse-free survival, and parotid relapse-free survival rates were 70.4%, 64.3%, 76.7%, and 87.9%, respectively. Distant metastases were the main cause of treatment failure and death. Using PLN-sparing IMRT, sparing PLN with minimal axial diameter of <10 mm, could increase the risk of parotid recurrence. However, it was not an independent prognostic factor. N classification and concurrent-based chemotherapy were almost statistically significant for distant failure and death. Overall, we demonstrated that the PLN metastases might be derived from RLN or level II nodal ECS, giant cervical nodes in a retrograde fashion, or parapharyngeal extension. Sparing PLN of <10 mm by IMRT should consider the risk of parotid recurrence. Distant metastases remained the dominant treatment failure. Further effective systemic chemotherapy should be explored.

Tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers: a critical appraisal

Objective:

The tumour–node–metastasis staging system has a dynamic structure that is continuously being updated as scientific data develops. This review discusses some suggested revisions on tumour–node–metastasis staging of human papillomavirus negative upper aerodigestive tract cancers.

Methods:

The seventh edition of The American Joint Committee on Cancer Staging Manual was reviewed and important issues that could be considered for revision were identified and discussed.

Results:

According to our assessment of the oncological outcomes of previous studies, the following factors should be considered for revision: anterior commissure involvement and subglottic extension in laryngeal cancers; underlying bone involvement in hard palate and upper alveolar ridge cancers; tumour thickness in oral cancers; and extracapsular spread and carotid artery involvement in neck metastases.

Conclusion:

Sufficient data on the prognostic importance of these issues have been reported. Suggested revisions in line with current knowledge on the clinical behaviour of upper aerodigestive tract cancers would improve the relevancy of staging.

Imaging of head and neck lymph nodes

The cervical lymph nodes can be affected by a variety of infectious, inflammatory, benign, and malignant pathologic conditions. Clinical history and physical examination with the complementary use of imaging is essential to accurately make a diagnosis or appropriate differential. Knowledge of cervical lymph node anatomy, drainage pathways, morphologic variations, and common nodal pathology is key to correct interpretation of cervical lymph nodes on imaging. Computed tomography (CT), MR, ultrasound, and PET/CT are complementary imaging modalities that can be used in the evaluation of cervical lymph node pathology.

Anti-lymphangiogenic properties of mTOR inhibitors in head and neck squamous cell carcinoma experimental models

BACKGROUND

Tumor dissemination to cervical lymph nodes via lymphatics represents the first step in the metastasis of head and neck squamous cell carcinoma (HNSCC) and is the most significant predictor of tumor recurrence decreasing survival by 50%. The lymphatic suppressing properties of mTOR inhibitors are not yet well understood.

METHODS

Lymphatic inhibiting effects of rapamycin were evaluated in vitro using two lymphatic endothelial cell (LEC) lines. An orthotopic mouse model of HNSCC (OSC-19 cells) was used to evaluate anti-lymphangiogenic effects of rapamycin in vivo. The incidence of cervical lymph node metastases, numbers of tumor-free lymphatic vessels and those invaded by tumor cells in mouse lingual tissue, and expression of pro-lymphangiogenic markers were assessed.

RESULTS

Rapamycin significantly decreased lymphatic vascular density (p = 0.027), reduced the fraction of lymphatic vessels invaded by tumor cells in tongue tissue (p = 0.013) and decreased metastasis-positive lymph nodes (p = 0.04). Rapamycin also significantly attenuated the extent of metastatic tumor cell spread within lymph nodes (p < 0.0001). We found that rapamycin significantly reduced LEC proliferation and was correlated with decreased VEGFR-3 expression in both LEC, and in some HNSCC cell lines.

CONCLUSIONS

The results of this study demonstrate anti-lymphangiogenic properties of mTOR inhibitors in HNSCC. mTOR inhibitors suppress autocrine and paracrine growth stimulation of tumor and lymphatic endothelial cells by impairing VEGF-C/VEGFR-3 axis and release of soluble VEGFR-2. In a murine HNSCC orthotopic model rapamycin significantly suppressed lymphovascular invasion, decreased cervical lymph node metastasis and delayed the spread of metastatic tumor cells within the lymph nodes.

Improving target definition for head and neck radiotherapy: a place for magnetic resonance imaging and 18-fluoride fluorodeoxyglucose positron emission tomography?

Defining the target for head and neck radiotherapy is a critical issue with the introduction of steep dose gradients associated with intensity-modulated radiotherapy. Tumour delineation inaccuracies are a major source of error in radiotherapy planning. The integration of 18-fluoride fluorodeoxyglucose positron emission tomography ((18)FDG-PET) and magnetic resonance imaging directly into the radiotherapy planning process has the potential to greatly improve target identification/selection and delineation. This raises a range of new issues surrounding image co-registration, delineation methodology and the use of functional data and treatment adaptation. This overview will discuss the practical aspects of integrating (18)FDG-PET and magnetic resonance imaging into head and neck radiotherapy planning.

Observer variation in the histopathologic assessment of extranodal tumor spread in lymph node metastases in the neck

BACKGROUND

Extranodal spread (ENS) of tumors is widely used as a prognosticator for patients with head and neck cancer and is used as an indicator for postoperative treatment. However, the histopathologic agreement among pathologists on the assessment of the presence or absence of this criterion has never been studied.

METHODS

The interobserver and intraobserver agreement among 10 pathologists on the diagnosis of ENS in 41 tumor-positive lymph nodes was evaluated.

RESULTS

The kappa value of the interobserver agreement among pathologists varied between 0.14 and 0.75, the overall kappa value was 0.42 and 0.49 in the 2 scoring sessions. The intraobserver kappa value varied between 0.49 and 0.95.

CONCLUSION

The intraobserver and interobserver agreement among pathologists in the assessment of the presence of ENS was low in metastatic lymph nodes in the neck. Because of the widely accepted prognostic significance and therapeutic consequences of ENS, there is a need for internationally accepted reproducible criterion for the histopathologic assessment of ENS in metastatic lymph nodes in the neck.