Extracapsular Spread in the Clinically Negative Neck (N0): Implications and Outcome

Immune infiltration at the primary tumor is associated with clinical outcome of patients with extranodal extension of lymph node metastasis in oral cancer

BACKGROUND

Extranodal extension (ENE) of lymph node metastasis is one of the most reliable prognostic indicators for patients with locally advanced oral cancer. Although multiple reports have found a close relationship between immune infiltration of tumors and patient clinical outcomes, its association with ENE is unknown.

METHODS

We identified 234 human papillomavirus-negative (HPV-) oral cavity squamous cell carcinoma (OSCC) patients in The Cancer Genome Atlas and investigated the immune infiltration profiles of primary tumors and their association with survival.

RESULTS

Hierarchical clustering analysis clearly classified the overall immune infiltration status in OSCC into high immune or low immune groups. The combination of ENE positivity and low immune infiltration was strongly associated with poor overall survival (OS) compared to the combination of ENE positivity and high immune infiltration [hazard ratio 2.04 (95 %CI, 1.08-3.83); p = 0.024]. The immune infiltration status was not associated with OS rates in patients with ENE-negative or node negative tumors.

CONCLUSION

Overall Immune infiltration at the primary site was significantly associated with clinical outcome of OSCC patients with ENE.

Extra-Capsular Spread of Lymph Node Metastasis in Oral, Oropharyngeal and Hypopharyngeal Cancer: A Comparative Subsite Analysis

BACKGROUND

The extra-capsular spread (ECS) of lymph node metastasis (LNM) is a hallmark of aggressive primary tumor phenotype in head and neck cancer (HNC); however, the factors influencing ECS are poorly understood.

PATIENTS AND METHODS

This was a retrospective study, including 190 cases of oral tongue cancer (OTC), 148 cases of oropharyngeal cancer (OPC) (118 HPV-positive and 30 HPV-negative), and 100 cases of hypopharyngeal cancer (HPC). Tumor dimension, tumor biological variables (lymphovascular/perineural invasion and histologic grade), and LNM variables (LNM number and size) were analyzed according to the presence of ECS using multivariable logistic regression and receiver operating characteristic (ROC) curve analyses.

RESULTS

LNM variables were significant factors for ECS in all subsites of HNC (p < 0.05), except HPV-positive OPC. In OTC, tumor dimensional variables were significantly related to ECS (p < 0.01). Meanwhile, in OPC and HPC, neither the primary tumor dimension nor the T status were significant factors for ECS occurrence. The predictability of ECS by ROC curve using multiple variables was 0.819 [95% confidence interval: 0.759-0.878] in OTC, 0.687 [0.559-0.815] in HPV-positive OPC, 0.823 [0.642-1.000] in HPV-negative OPC, and 0.907 [0.841-0.973] in HPC.

CONCLUSION

LNM variables were correlated with ECS occurrence for most HNC subsites, and site-dependent primary tumor characteristics might contribute differentially to the ECS development of LNM in HNC.

Imaging Characteristics Predictive of Cervical Extranodal Tumor Extension in Patients With Head and Neck Squamous Cell Carcinoma

OBJECTIVES

The aims of the study were to determine the predictive imaging findings of extranodal extension (ENE) in metastatic cervical lymph nodes of head and neck squamous cell carcinoma and to investigate the interobserver agreement among radiologists with different experience levels.

MATERIALS AND METHODS

Patients with cervical lymph node dissection and who had metastatic lymph nodes and preoperative imaging were included. Three radiologists evaluated nodal necrosis, irregular contour, gross invasion, and perinodal fat stranding. They also noted their overall impression regarding the presence of the ENE. Sensitivity, specificity, odds ratios based on logistic regression, and interobserver agreement of ENE status were calculated.

RESULTS

Of 106 lymph nodes (that met inclusion criteria), 31 had radiologically determined ENE. On pathologic examination, 22 of 31 nodes were positive for ENE. The increasing number of metastatic lymph nodes was associated with the presence of the ENE ( P = 0.010). Irregular contour had the highest sensitivity (78.6%) and gross invasion had the highest specificity (96%) for the determination of the ENE. The radiologists' impression regarding the presence of the pathlogical ENE had 39.3% sensitivity and 82% specificity. Metastatic lymph nodes with a perinodal fat stranding and with the longest diameter of greater than 2 cm were found to be strong predictors of the ENE. The gross invasion demonstrated the highest κ value (0.731) among the evaluated imaging criteria.

CONCLUSIONS

In the assessment of ENE, the gross invasion had the highest specificity among imaging features and showed the highest interobserver agreement. Perinodal fat stranding and the longest diameter of greater than 2 cm in a metastatic lymph node were the best predictors of the ENE.

Clinical vs Microscopic Extranodal Extension and Survival in Oropharyngeal Carcinoma in the Human Papillomavirus Era

OBJECTIVE

Extranodal extension (ENE) is known to be associated with poor outcomes in head and neck squamous cell carcinoma. The objective of this study is to examine the impact of extent of ENE on survival in oropharyngeal carcinoma in the human papillomavirus (HPV) era.

STUDY DESIGN

Retrospective database review.

SETTING

Review of the National Cancer Database.

SUBJECTS AND METHODS

The National Cancer Database was used to examine surgically treated head and neck squamous cell carcinoma of the tonsil and base of tongue from 2010 to 2015. Nodes available for pathologic examination were classified as ENE negative (-), ENE clinically (+), or ENE (+) on pathology only. The primary outcome was overall survival. Cox regression modeling was used to examine the effect of ENE on survival while controlling for patient demographics, HPV status, stage, adjuvant radiation, and chemotherapy.

RESULTS

Of the 66,106 patients identified, 16,845 were treated with surgery ± adjuvant therapy, 8780 of whom were known HPV+. Overall 5-year survival for this group was 86%. Documented ENE was associated with over a 60% decrease in survival for clinical (hazard ratio [HR], 1.63) and pathologic (HR, 1.62) ENE compared to negative ENE, after adjustment for stage, adjuvant radiation ± chemotherapy, HPV, and other variables. No significant differences were found between clinical and pathologic ENE (HR, 1.001).

CONCLUSION

While both surgically resected clinical and pathologic ENE are associated with decreased survival, no significant differences are observed between the two. The impact of these observations on potential de-escalation therapeutic strategies requires further study.

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.

Tumor Satellite in Predicting Occult Nodal Metastasis of Tongue Cancer

Objective. Tongue cancer is well known to have a high potential for locoregional metastasis. However, controversy about electively treating the neck in early-stage tongue cancer remains. Although many risk factors related to cervical occult nodal metastasis (ONM) have been investigated, the ability of the tumor to spread, a phenomenon that results from the intrinsic property of the tumor and its interaction with the surrounding environment, has seldom been addressed.

Study Design. Retrospective case series with chart review.

Setting. Tertiary referral hospital of university.

Subjects. Patients with early-stage squamous cell carcinoma of the oral tongue.

Results. In 71 eligible enrolled patients, ONM was detected in 19 (27%) patients, while the results were negative (ONM(−)) in 52 (73%) patients. The average tumor satellite distance (TSD) in the ONM(+) group was 4.1 ± 4.3 mm, in contrast to that in the ONM(−) group (1.0 ± 1.5 mm; P < .001). When stratified by increased TSD values, the significance of the difference between the 2 groups increased. For clinical applications, the optimal TSD threshold for determining the ONM probability was 3.5 mm. Multivariate analyses demonstrated that TSD was an independent prognosticator.

Conclusions. The results indicate that TSD is a feasible pathological parameter that is useful for determining the status of cervical nodal metastasis. It can be used as an indicator of potential cervical subclinical disease and as a guideline for deciding the necessity and modality of neck treatment.

Do micrometastases detected with cytokeratin immunoperoxidase reactivity affect the treatment approach to neck in supraglottic cancers?

OBJECTIVES

The aim of this study was to determine the occult lymph node metastasis rates with immunoperoxidase staining for cytokeratin in supraglottic larynx cancers and to assess our approach to the neck.

STUDY DESIGN

Twenty-two patients who had squamous cell carcinoma in the supraglottic region and no histopathologic metastasis in the neck who had their cancer detected with the use of hematoxylin-eosin were included in the study. All of the specimens were reevaluated with the use of immunoperoxidase staining for cytokeratin.

RESULTS

Micrometastatic disease (pN1) has been detected in 3 patients (13.61%) in whom no metastasis was detected with routine histopathologic examination.

CONCLUSION AND SIGNIFICANCE

Results suggest that the occult metastasis rates are higher than those detected with routine hematoxylin-eosin staining. However, because it is accepted that neck dissection alone has adequate therapeutic efficiency in pN1 patients, the detected 13.61% rate of micrometastases has not changed our treatment plan in the neck.

Efficacy of selective lymph node dissection in clinically negative neck

OBJECTIVE

The purpose of this study was to evaluate the efficacy of selective neck dissection (SND) for elective treatment of the clinically negative neck in head and neck squamous cell carcinoma (SCC).

METHODS

A retrospective review was undertaken on 91 previously untreated patients with T1-4 SCC of oral cavity (23), oropharynx (5), hypopharynx (7), larynx (56), and clinically negative neck (N0), undergoing 126 SND from January 1990 to March 1999 at a single institution. Twenty-five patients received postoperative radiation therapy on the basis of histologic evidence of >2 positive nodes, extracapsular spread (ECS), and/or the presence of advanced primary lesion.

RESULTS

On pathologic examination the average number of lymph nodes was 20.5 per neck, occult disease was detected in 14 (11.11%) of 126 necks; of necks with positive nodes, 6 (42.85%) of 14 had ECS. The median follow-up was 36 months. Overall recurrence rate (local, regional, and distant) was 12.8% (11 of 91). Recurrent disease developed in the neck of one patient, outside the dissected field. There was no difference in recurrence rate between pN0 and pN+ patients, as well as between pN+ with or without ECS. Overall survival rate was 84% (77 of 91), with a statistically significant difference between pN0 and pN+ necks.

CONCLUSION

SND seems to be a pragmatic approach that is as effective as comprehensive procedures for staging and treating the clinically negative neck.

Extracapsular spread in ipsilateral neck and contralateral neck metastases in laryngeal cancer

We investigated the incidence of extracapsular spread (ECS) and the impact of ECS on contralateral neck metastasis in 67 patients with ipsilateral nodal metastasis (IpN+) whose records were extracted retrospectively from those of 155 laryngeal cancer patients. The incidence of ECS in association with variables was determined: T stage, N stage, tumor location, tumor extension, number of positive nodes, and contralateral neck status. The variables were evaluated to identify their impact on the rates of contralateral neck metastasis (CNM) and 3-year survival. Of the 67 patients, 30 (44.7%) had ECS. A significant relationship was found between ECS positivity and increased N stage, tumor extension up to the midline, number of positive nodes, and CNM (p = .04, p = .0001, p = .018, p = .0001, respectively). Multivariate analysis revealed that N stage (p = .002; odds ratio, 3.5517) and the presence of ECS (p = .0036; odds ratio, 7.7840) in IpN+ were associated with the greatest risk of CNM. The 3-year survival rate of patients with ipsilateral ECS was significantly lower than that of patients without ECS (43% versus 81%, p = .0002). Both CNM and presence of ECS in IpN+ emerged as significant independent predictors for survival with Cox multivariate analysis (p = .0086 and p = .0234, respectively). This result indicates the necessity of treating the contralateral N0 neck in cases of IpN+ with ECS.

Functional neck dissection for the clinically negative neck: effectiveness and controversies

This study was performed to evaluate the effectiveness of functional neck dissection in controlling metastasis to the clinically negative (cN0) neck, focusing on recurrences in the pathologically negative (pN0) neck and the role of extracapsular spread in the cN0 neck. A series of 172 patients (253 dissected fields) treated for cN0 laryngeal or hypopharyngeal cancer with a 5-year minimum follow-up is presented. Occult metastasis was observed in 30% of the patients. Extracapsular spread was present in 39% of the positive nodes. The neck recurrence rate was 5.2%. Surgical specimens from cases of neck recurrence in pN0 necks were reevaluated for micrometastasis by immunostaining with antibody for cytokeratins. The immunohistochemical findings were positive in 1 of 4 cases. Functional neck dissection provides good neck control and survival rates for the cN0 neck. The accurate prognostic significance of extracapsular spread in cN0 necks is still unknown. Micrometastasis alone may be insufficient to explain recurrences in pN0 necks.

Patterns of spread in recurrent head and neck squamous cell carcinoma

OBJECTIVE

To examine the pattern of spread regarding recurrent disease in primary head and neck squamous cell carcinoma.

STUDY DESIGN AND SETTING

A retrospective study reviewed 128 patients who underwent primary tumor resection and postoperative radiation and/or chemoradiation for squamous cell carcinoma at Loyola University Medical Center from July 1993 to August 1998. Patterns of spread of recurrent disease were grouped according to site of recurrence and compared with the histopathology.

RESULTS

Of 128 patients, 40 (32%) had recurrent disease, 22 (17%) died without disease, and 66 (51%) are disease free. Although the recurrences in patients who were N0 were primarily local-regional (8/11), the majority of recurrences in patients that were N+ with extracapsular nodal spread involved distant sites (18/24); 17/18 involved metastasis to the lung.

SIGNIFICANCE

This study gives the first report at our institution of patterns of spread in recurrent head and neck squamous cell cancer and compares these patterns within subgroups of patients based on the extent of neck disease at the time of primary surgical resection.

CONCLUSION

Not only was there a higher rate of recurrent disease in patients with extracapsular nodal spread, there was a much higher involvement of distant metastatic sites as opposed to local-regional recurrence more often seen with the N0 neck. The most common site of distant metastasis was the lung.