Pathological features and their prognostic impacts on oral cavity cancer patients among different subsites - A singe institute's experience in Taiwan

Survival outcomes of surgically treated oral cavity squamous cell carcinoma patients at tertiary care hospital in Northern Thailand

OBJECTIVE

This study aimed to evaluate the survival outcomes of surgically treated oral squamous cell carcinoma (OSCC) patients with or without adjuvant therapies and factors predicting treatment outcomes from the largest head and neck cancer center in Northern Thailand.

METHODS

Two hundred and sixty OSCC patients curatively treated between 2017 and 2021 were retrospectively recruited into the study to analyze the clinicopathological characteristics and oncological outcomes and compare them with historical data. A multivariate Cox proportional hazards model analysis was performed to evaluate factors affecting survival outcomes.

RESULTS

Males were slightly predominant (58.1 %). The most common subsite was an oral tongue (48.5 %), followed by an alveolar ridge (18.5 %). Advanced stages (III-IV) presented most at 88.5 %. The majority of the patients (52.3 %) received surgery and chemoradiotherapy, followed by surgery and radiotherapy (36.9 %), and surgery alone (10.8 %). The five-year overall survival (OS), disease-specific survival, and disease-free survival were 28.8 %, 44.0 %, and 46.3 %, respectively. Age > 45, ECOG performance status 2, and positive surgical margin status were found to be independent predictors for decreased OS (aHR 1.74, 95 % CI 1.01-3.00, aHR 2.64, 95 % CI 1.22-5.68, and aHR 1.76, 95 % CI 1.18-2.63, respectively).

CONCLUSIONS

Survival outcomes of OSCC in the study remain poor compared to other studies. The high prevalence of locally advanced stage presentation and inadequate surgical margin are the main problems. Public awareness, cancer screening programs, and intraoperative specimen-driven evaluation might help obtain adequate surgical margins and improve survival outcomes.

Targeting CD276: a promising strategy for CAR-NK cell immunotherapy in human oral tongue squamous cell carcinoma

Human oral tongue squamous cell carcinoma (OTSCC) is a prevalent form of head and neck squamous cell carcinoma (HNSCC), often presenting at an advanced stage with a grim prognosis. Traditional therapeutic approaches such as surgery, adjuvant radiotherapy, and chemoradiotherapy have shown limited efficacy in treating advanced OTSCC, underscoring the urgent need for innovative treatment strategies. Our bioinformatics analysis identified CD276 as a significant biomarker in OTSCC, with high protein expression levels correlating to a markedly reduced survival rate in late-stage patients. This discovery has led us to develop chimeric antigen receptor-natural killer (CAR-NK) cells derived from umbilical cord blood cells (UCBCs), specifically targeting CD276. Our aim is to investigate this novel therapeutic approach for its potential to combat OTSCC under pre-clinical conditions. Our in vitro and ex vivo studies have demonstrated that CD276-targeted CAR-NK cells exhibit remarkable efficacy in lysing OTSCC cell lines and primary cells, as well as in eliminating OTSCC organoids. These promising results underscore the pivotal role of CD276 in OTSCC pathogenesis and highlight the potential of CAR-NK cell therapy as a groundbreaking treatment option for advanced-stage OTSCC, offering new hope for translational medicine in the field of stomatology.

The role of postoperative radiotherapy or chemoradiation in pT1-2N1M0 oral squamous cell carcinoma

BACKGROUND

Postoperative radiotherapy (PORT) and concurrent chemoradiation (CCRT) are indicated for patients with advanced oral cancer. However, the benefits for pT1-2N1 disease without adverse pathological features are controversial.

METHODS

This retrospective study using the Taiwan Cancer Registry database included patients with pT1-2N1 oral cancer from January 1, 2011, to December 31, 2017. Overall survival was analyzed in patients receiving surgery alone, PORT, or CCRT.

RESULTS

Among the 862 patients, the five-year overall survival rate in patients receiving surgery alone, PORT, and CCRT was 62.2%, 58.7%, and 71.1% (P = 0.03), respectively. CCRT was associated with longer survival than PORT (P = 0.008). Survival in patients with pT2 disease was significantly higher with CCRT than PORT (P = 0.001), but no difference was observed in pT1 disease.

CONCLUSION

CCRT demonstrated a favorable impact on survival outcomes in patients diagnosed with pT2N1 oral cancer when compared to PORT. However, no significant survival benefits were observed for patients with pT1 disease.

Prognostic implications of mucosal and deep margin distances according to T-status in oral tongue squamous cell carcinoma: A single-center retrospective study

OBJECTIVE

To elucidate the prognostic implications of mucosal and deep margin distances in oral tongue squamous cell carcinoma (OTSCC), and to assess a different margin cut-off value in T1-T2 versus T3-T4 tumors.

METHODS

This single-center retrospective study included 223 patients who received surgery for a primary OTSCC between January 2017 and December 2021.

RESULTS

Multivariable analysis showed that deep margin distance ≥3 mm in T1-T2 tumors and ≥5 mm in T3-T4 tumors was significantly associated with better RFS and OS. Mucosal and deep margin distances were globally clinically useful for 2-year RFS prediction of T1-T2 tumors, for which deep margins seemed to have more clinical utility than mucosal margins. The influence of margin distances on 2-year RFS seemed greater for T1-T2 tumors than T3-T4 tumors.

CONCLUSION

Mucosal and deep margin distances were associated with OS and RFS in OTSCC. Shorter deep margin distances may be aimed for in T1-T2 versus T3-T4 tumors.

Development and validation of accelerated failure time model for cause-specific survival and prognostication of oral squamous cell carcinoma: SEER data analysis

BACKGROUND

Oral Squamous Cell Carcinoma is the most prevalent malignancies affecting the oral cavity. Despite progress in studies and treatment options its outlook remains grim with survival prospects greatly affected by demographic and clinical factors. Precisely predicting survival rates and prognosis plays a role in making treatment choices for the best achievable overall health outcomes.

OBJECTIVE

To develop and validate an accelerated failure time model as a predictive model for cause-specific survival and prognosis of Oral Squamous Cell Carcinoma patients and compare its results to the traditional Cox proportional hazard model.

METHOD

We screened Oral cancer patients diagnosed with Squamous Cell Carcinoma from the Surveillance Epidemiology and End Results (SEER) database between 2010 and 2020. An accelerated failure time model using the Type I generalized half logistic distribution was used to determine independent prognostic factors affecting the survival time of patients with oral squamous carcinoma. In addition, accelerated factors were estimated to assess how some variables influence the survival times of the patients. We used the Akaike Information Criterion, Bayesian Information Criterion to evaluate the model fit, the area under the curve for discriminability, Concordance Index (C-index) and Root Mean Square Error and calibration curve for predictability, to compare the type I generalized half logistic survival model to other common classical survival models. All tests are conducted at a 0.05 level of significance.

RESULTS

The accelerated failure time models demonstrated superior effectiveness in modeling (fit and predictive accuracy) the cause-specific survival (CSS) of oral squamous cell carcinoma compared to the Cox model. Among the accelerated failure time models considered, the Type I generalized half logistic distribution exhibited the most robust model fit, as evidenced by the lowest Akaike Information Criterion (AIC = 27370) and Bayesian Information Criterion (BIC = 27415) values. This outperformed other parametric models and the Cox Model (AIC = 47019, BIC = 47177). The TIGHLD displayed an AUC of 0.642 for discrimination, surpassing the Cox model (AUC = 0.544). In terms of predictive accuracy, the model achieved the highest concordance index (C-index = 0.780) and the lowest root mean square error (RMSE = 1.209), a notable performance over the Cox model (C-index = 0.336, RMSE = 6.482). All variables under consideration in this study demonstrated significance at the 0.05 level for CSS, except for race and the time span from diagnosis to treatment, in the TIGHLD AFT model. However, differences emerged regarding the significant variations in survival times among subgroups. Finally, the results derived from the model revealed that all significant variables except chemotherapy, all TNM stages and patients with Grade II and III tumor presentations contributed to the deceleration of time to cause-specific deaths.

CONCLUSIONS

The accelerated failure time model provides a relatively accurate method to predict the prognosis of oral squamous cell carcinoma patients and is recommended over the Cox PH model for its superior predictive capabilities. This study also underscores the importance of using advanced statistical models to improve survival predictions and outcomes for cancer patients.

Risk Factors Associated with Occult Nodal Metastasis and Outcomes for cT1-2N0 Maxillary and Mandibular gingival Carcinoma: A Retrospective Study

Objective

This study aims to identify the rate of occult nodal metastasis (ONM), risk factors associated with ONM, and compare regional recurrence (RR), 2-year disease-free survival (DFS) in patients treated with elective neck dissection (END) versus expectant management (OBS) for primary T1-T2 gingival squamous cell carcinoma (GSCC) of the maxilla and mandible.

Methods

A retrospective analysis was conducted and included patients from 2014 to 2021 who were treated at a tertiary referral center.

Results

Twenty patients underwent END and 36 were managed expectantly, with a mean follow-up period of 28 months. ONM was observed in 26% of the study cohort with 16.7% occurring in the maxilla and 36.4% in the mandible. No specific histopathologic features were predictive for ONM. No regional recurrence occurred. Local recurrence occurred in 5% and 2.8% of END and OBS groups, respectively. Two-year DFS were comparable between the END (93.8%) versus OBS (83.9%) as well as maxilla (90.9%) versus mandible (83.4%), P > 0.05.

Conclusion

ONM remains variable in cT1-T2N0 GSCC with a greater incidence occurring in the mandible when compared to the maxilla, respectively. An END should be strongly considered for mandibular GSCC. Overall, END for the N0 neck has been shown to provide significant overall and disease-free survival benefits. However, further prospective randomized studies are needed to verify risk factors for ONM and validate the disease-related survival benefit of an elective neck dissection in this patient population.

The Prognostic Role of Perineural Invasion for Survival in Head and Neck Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

The aim of this study was to conduct a comprehensive review of the predictive significance of PNI in HNSCC survival outcomes. A systematic search was conducted across multiple databases, and all studies published in the last decade were screened (Research Registry ID: reviewregistry1853). The included studies were assessed using the Quality in Prognosis Studies tool. Survival outcome data were extracted, combined, and presented as hazard ratios (HR) with a 95% confidence interval (CI). Totally, 74 studies encompassing 27,559 patients were analyzed and revealed a cumulative occurrent rate of 30% for PNI in HNSCC. PNI+ HNSCC patients had a worse overall survival (HR: 1.91, 95% CI: 1.71-2.13), disease-specific survival (HR: 1.79, 95% CI: 1.55-2.07), disease-free survival (HR: 1.82, 95% CI: 1.69-1.96), local recurrence (HR: 2.54, 95% CI: 1.93-3.33), locoregional recurrence (HR: 2.27, 95% CI: 1.82-2.82), locoregional relapse free survival (HR: 1.77, 95% CI: 1.28-2.45), distant metastasis (HR: 1.82, 95% CI: 1.34-2.48), and distant metastasis-free survival (HR: 2.97, 95% CI: 1.82-4.85) compared to those PNI- patients. The available evidence unequivocally establishes PNI as a critical prognostic factor for worse survival in HNSCC patients.

Oral cavity cancer and its pre-treatment radiological evaluation: A pictorial overview

PURPOSE

Oral cavity cancer, primarily squamous cell carcinoma (SCC), is a prevalent malignancy globally, necessitating accurate clinical assessment and staging to enable effective treatment planning. Diagnosis requires biopsy and is followed by surgical resection and reconstruction as the primary therapeutic modality. Imaging plays a pivotal role during this process, aiding in the evaluation of tumour extent, nodal involvement and distant metastases. However, despite its value, both radiologists and clinicians must recognise its inherent limitations.

METHODS

This pictorial review article aims to illustrate the application of various imaging modalities in the pre-treatment evaluation of oral cavity SCC and highlights potential pitfalls. It underscores the importance of understanding the anatomical subsites of the oral cavity, the diverse patterns of spread tumours exhibit at each site, alongside the role of imaging in facilitating informed management strategies, while also acknowledging its limitations.

RESULTS

The review delves into fundamentals of current staging including nodal involvement, while, emphasising imaging strategies and potential limitations. Finally, it touches on the potential of novel radiomic techniques in characterising tumours and predicting treatment response.

CONCLUSIONS

Pre-treatment oral cavity cancer staging reflects an ongoing quest for enhanced diagnostic accuracy and prognostic prediction. Recognising the value of imaging alongside its limitations fosters a multidisciplinary approach to treatment planning, ultimately improving patient outcomes.

The effect of treatment package time on locally advanced oral cavity cancer outcomes

OBJECTIVE(S)

To assess the influence of treatment package time (TPT) on overall survival (OS) and event free survival (EFS) in oral cavity cancer (OCC) patients treated with surgery and adjuvant radiation therapy (RT) with or without concurrent chemotherapy (CHT).

MATERIALS/METHODS

354 adult OCC patients treated at a single, high-volume center between 2012-2022 with various pathologic risk features were included. TPT was defined as days from surgery to RT completion. Kaplan-Meier estimates, log-rank p-values, univariable (UVA) and multivariable (MVA) Cox regression analyses were performed to determine the impact of TPT on OS and EFS, and the optimal TPT cutoff.

RESULTS

The optimal TPT cutoff was 105 days. TPT < 105 days was significantly associated with improved OS and EFS (p = 0.002 and p = 0.027, respectively) compared to TPT ≥ 105 days. On UVA, factors significantly associated with OS were TPT < 105 days, former/current smoker status, pathologic stage IV, positive perineural invasion (PNI), and extranodal extension (ENE) (all p < 0.05). On MVA for OS, TPT < 105 days, former/current smoker status, pathologic stage IV, and positive PNI (all p < 0.05) remained significant. Factors significantly associated with EFS on UVA were TPT < 105 days, former/current smoker status, pathologic stage IV, positive PNI or ENE, and concurrent CHT (all p < 0.05). On MVA, TPT < 105 days, pathologic stage IV, and positive PNI (all p < 0.05) remained significant.

CONCLUSIONS

In a large, homogenous cohort of OCCs, optimal TPT was <105 days, with TPT ≥ 105 days significantly associated with worse OS and EFS. Multidisciplinary coordination should analyze factors potentially contributing to treatment delay.

A Concordance Between Clinical and Pathological Tumor Staging of Oral Squamous Cell Carcinoma: An Institutional Study

BACKGROUND

Among oral diseases, oral cancer is the primary cause of death and poses a serious health risk. Primary tumor (T) - regional lymph node (N) - distant metastasis (M) comprising (TNM) staging is crucial for planning treatment strategies for patients with oral squamous cell carcinoma (OSCC).

AIM

This study evaluated the predictive accuracy of clinical TNM staging of OSCC to histopathological staging (pTNM) in an institutional setting.

MATERIALS AND METHODS

Fifty-four consecutive histologically confirmed, surgically treated OSCC cases were evaluated for TNM staging. The study compared the clinical staging at the time of surgery with the pathological staging obtained from excisional biopsy reports. Microsoft Excel (Microsoft® Corp., Redmond, WA, USA) was used for the data compilation and descriptive analysis. The chi-square test, analysis of variance (ANOVA), and Tukey's Honest Significant Difference (HSD) posthoc test were used to compare the data for statistical significance with p value <0.05 using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 23.0, Armonk, NY).

RESULTS

The alveolar mucosa (n=22, 40.74%) was the most frequently occurring site, followed by the tongue (n=17, 31.48%). Out of the 54 included cases, based on clinical tumor size, there were T1 (n=6), T2 (n=13), T3 (n=13), T4a (n=16) and T4b (n=6). T2 tumors were usually upstaged (n=7) while T4a (n=8) tumors were most often downstaged. T4a (n=8) had the best concordance between clinical and histopathological staging, followed by T2, T3, and T1. In nodal status, N1 showed the most variation. The chi-squared test showed statistical significance for tumor size comparison (p <0.001) and nodal status comparison (p=0.002). ANOVA test did not show any statistical significance. Tukey's HSD posthoc test showed statistical significance (p=0.034) for N0 and N1 status. The highest concordance was shown by N0 and N1 followed by N2b.

CONCLUSION

Preoperative radiological and clinical assessments are essential for deciding on a patient's course of treatment. However, not all patients may require radiographs to determine tumor size or nodal status assessment. Accurate diagnosis is vital for the treatment planning of OSCC.

Histopathological predictors of lymph node metastasis in oral cavity squamous cell carcinoma: a systematic review and meta-analysis

Objectives

Lymph node metastasis (LNM) is the most significant parameter affecting overall survival in patients with oral cavity squamous cell carcinomas (OCSCC). Elective neck dissection (END) is the standard of care in the early management of OCSCC with a depth of invasion (DOI) greater than 2-4 mm. However, most patients show no LNM in the final pathologic report, indicating overtreatment. Thus, more detailed indicators are needed to predict LNM in patients with OCSCC. In this study, we critically evaluate the existing literature about the risk of different histological parameters in estimating LNM.

Methods

A systematic review was conducted using PRISMA guidelines. PubMed, Web of Science, Cochrane, and Scopus were searched from inception to December 2023 to collect all relevant studies. Eligibility screening of records was performed, and data extraction from the selected studies was carried out independently. Inclusion in our systematic review necessitated the following prerequisites: Involvement of patients diagnosed with OCSCC, and examination of histological parameters related to lymph node metastasis in these studies. Exclusion criteria included animal studies, non-English articles, non-availability of full text, and unpublished data.

Results

We included 217 studies in our systematic review, of which 142 were eligible for the meta-analysis. DOI exceeding 4 mm exhibited higher risk for LNM [Risk ratio (RR) 2.18 (1.91-2.48), p<0.00001], as did perineural invasion (PNI) [RR 2.04 (1.77-2.34), p<0.00001], poorly differentiated tumors [RR 1.97 (1.61-2.42), p<0.00001], lymphovascular invasion (LVI) [RR 2.43 (2.12-2.78), p<0.00001], groups and single pattern of invasion [RR 2.47 (2.11-2.89), p<0.00001], high tumor budding [RR 2.65 (1.99-3.52), p<0.00001], tumor size over 4 cm [RR 1.76 (1.43-2.18), p<0.00001], tumor thickness beyond 4 mm [RR 2.72 (1.91-3.87), p<0.00001], involved or close margin [RR 1.73 (1.29-2.33), p = 0.0003], and T3 and T4 disease [RR 1.98 (1.62-2.41), p <0.00001].

Conclusion

Our results confirm the potential usefulness of many histopathological features in predicting LNM and highlight the promising results of others. Many of these parameters are not routinely incorporated into pathologic reports. Future studies must focus on applying these parameters to examine their validity in predicting the need for elective neck treatment.

Association of Site and Recurrence in Oral Squamous Cell Carcinoma Patients Visiting Private Hospital in Chennai: A Retrospective Study

BACKGROUND

Oral squamous cell carcinoma (OSCC) is the most common malignant neoplasms of the oral cavity. Tongue, buccal mucosa, and gingivobuccal sulcus are the most commonly involved sites for the local recurrence of OSCC. The site of the tumor can be a critical parameter in relation to the recurrence of OSCC because of the varied action of tumor cells in different tumor macro and microenvironments. Hence, the current study aims to evaluate the correlation between the site and recurrence of OSCC among patients visiting private oral cancer hospitals.

MATERIALS AND METHODS

Details of n=300 OSCC cases reported during 2019-2023, which included primary and recurrent OSCC, were collected. The sample population selected includes 261 primary and 39 recurrent oral squamous cell carcinoma cases. The demographic and clinicopathological data were retracted from the institution's common clinical database and transported to IBM-SPSS 23 software for statistical analysis. Chi-square was done to evaluate the association between site and recurrence status, and p<0.05 was considered statistically significant.

RESULTS

Males have a high predilection for OSCC, and the recurrent cases account for 13% of the sample population. The buccal mucosa was the most commonly affected site in primary and recurrent OSCC cases. However, the association between the site of the lesion and the status of recurrence was found to be statistically significant, with a p-value of 0.001.

CONCLUSION

Even though buccal mucosa was the most common site for recurrent OSCC(p value-0.001), the present study carries a small sample size and a location-specific sampling. Hence, further studies must be conducted with a large sample size to test the significant correlation between the site and recurrence rate among patients diagnosed with OSCC.

Factors influencing the 5-year survival rate of oral cancer patients in the Mongolian population: a retrospective cohort study

Introduction

The high mortality rate of head and neck cancers, particularly oral cancer, poses a significant health challenge in developing nations such as Mongolia. This retrospective survival analysis study was conducted to identify factors influencing the 5-year survival rate of oral squamous cell carcinoma patients.

Methods

The study analyzed data from 173 patients diagnosed with oral squamous cell carcinoma, including multiple variables such as age, gender, residence, education, tobacco and alcohol consumption, oral health indicators, family history, precancerous conditions, cancer characteristics, treatment, rehabilitation, cancer recurrence, and 5-year survival. Survival analysis was conducted using the Kaplan-Meier method, and STATA was used for statistical analysis.

Results

The study revealed a 5-year survival rate of 50.3% for oral cancer patients, with a survival rate of 38% for tongue cancer patients. Age, residence, cancer stage, and cancer recurrence were identified as significant survival predictors. Compared to those aged 60 or younger, the hazard ratio (HR) for patients aged 61 or older was 1.52. Survival was associated with female gender (HR = 0.47, CI = 0.29-0.77). Urban residence was associated with decreased survival (HR = 1.92, CI = 1.22-3.05). Significantly worse survival was associated with the presence of cancer recurrence (HR = 1.99, CI = 1.15-3.04). Oral cancer patients in stage IV had a fourfold higher risk of mortality compared to those in stage I (HR = 4.08, CI = 1.2-13.84).

Conclusion

This research highlights the influence of age, urban habitation, and cancer recurrence on oral cancer survival. Age, urban residence, and cancer recurrence were all associated with decreased survival, whereas cancer at stage IV substantially increased the risk of death. The significance of early detection, treatment, and active surveillance to identify oral cancer at an early stage is highlighted by these findings. Compared to industrialized nations, Mongolia's lower oral cancer survival rates emphasize the need to increase public awareness and education. A comprehensive approach is required to improve oral cancer patient survival rates and quality of life, including emphasizing early detection through active surveillance, implementing preventive measures, and advancing cancer education initiatives.

Perineural Invasion Is a Significant Prognostic Factor in Oral Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

(1) Objectives: This systematic review and meta-analysis aimed to summarize current evidence regarding the prognostic role of perineural invasion (PNI) in patients with oral squamous cell carcinoma (OSCC). (2) Methods: We searched Cochrane Central, ProQuest, PubMed, Scopus, Science Direct, and Web of Science, using relevant keywords to identify eligible articles. Two independent reviewers conducted two-stage screening, data extraction, and quality assessment. The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) criteria. All analyses were performed using comprehensive meta-analysis (CMA; version 3.3.070) software. (3) Results: The study included 101 published articles encompassing 26,062 patients. The pooled analyses showed that PNI was associated with significantly worse overall survival (OS; HR = 1.45, 95% CI: 1.32-1.58; p < 0.001), worse disease-specific survival (DSS; HR = 1.87, 95% CI: 1.65-2.12; p < 0.001), and worse disease-free survival (DFS; HR = 1.87, 95% CI: 1.65-2.12; p < 0.001). Similarly, both local recurrence-free survival (LRFS) and regional recurrence-free survival (RRFS) were worse in patients with PNI (HR = 2.31, 95% CI: 1.72-3.10, p < 0.001; and HR = 2.04, 95% CI: 1.51-2.74, p < 0.001), respectively. The random-effect estimate of three studies demonstrated that the presence of PNI was associated with worse failure-free survival (FFS; HR = 2.59, 95% CI: 1.12-5.98, p < 0.001). (4) Conclusions: The current evidence suggests that PNI can be used as an independent predictor of the prognosis for patients with OSCC. The presence of PNI was associated with worse OS, DFS, DSS, FFS, and with recurrence. Asian patients and patients with extra-tumoral or peripheral PNI invasion were associated with worse prognosis.

Prognostic histological markers in oral tongue squamous cell carcinoma patients treated with (chemo)radiotherapy

Treatment of oral tongue squamous cell carcinoma (OTSCC) frequently includes surgery with postoperative radiotherapy (RT) or chemoradiotherapy (CRT). Resistance to RT or CRT remains a major clinical challenge and highlights the need to identify predictive markers for it. We included 71 OTSCC patients treated with surgery combined with RT or CRT. We evaluated the association between tumor budding, tumor-stroma ratio (TSR), depth of invasion (DOI), tumor-infiltrating lymphocytes (TILs), hypoxia-inducible factor-1alpha (HIF-1alpha) expression, octamer-binding transcription factor 4 (OCT4) expression, high-endothelial venules (HEVs), and disease-free survival (DFS) using uni- and multivariate analyses. No significant association was observed between the different histological and molecular markers (TSR, DOI, TILs, HEV, HIF-1alph, OCT4) and DFS. However, an associative trend between DOI, budding, and DFS was noted. Further studies with larger cohorts are needed to explore the prognostic value of DOI and budding for OTSCC patients treated with postoperative RT or CRT.

Circadian rhythm-related genes index: A predictor for HNSCC prognosis, immunotherapy efficacy, and chemosensitivity

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is the most common head and neck cancer and is highly aggressive and heterogeneous, leading to variable prognosis and immunotherapy outcomes. Circadian rhythm alterations in tumourigenesis are of equal importance to genetic factors and several biologic clock genes are considered to be prognostic biomarkers for various cancers. The aim of this study was to establish reliable markers based on biologic clock genes, thus providing a new perspective for assessing immunotherapy response and prognosis in patients with HNSCC.

METHODS

We used 502 HNSCC samples and 44 normal samples from the TCGA-HNSCC dataset as the training set. 97 samples from GSE41613 were used as an external validation set. Prognostic characteristics of circadian rhythm-related genes (CRRGs) were established by Lasso, random forest and stepwise multifactorial Cox. Multivariate analysis revealed that CRRGs characteristics were independent predictors of HNSCC, with patients in the high-risk group having a worse prognosis than those in the low-risk group. The relevance of CRRGs to the immune microenvironment and immunotherapy was assessed by an integrated algorithm.

RESULTS

6-CRRGs were considered to be strongly associated with HNSCC prognosis and a good predictor of HNSCC. The riskscore established by the 6-CRRG was found to be an independent prognostic factor for HNSCC in multifactorial analysis, with patients in the low-risk group having a higher overall survival (OS) than the high-risk group. Nomogram prediction maps constructed from clinical characteristics and riskscore had good prognostic power. Patients in the low-risk group had higher levels of immune infiltration and immune checkpoint expression and were more likely to benefit from immunotherapy.

CONCLUSION

6-CRRGs play a key predictive role for the prognosis of HNSCC patients and can guide physicians in selecting potential responders to prioritise immunotherapy, which could facilitate further research in precision immuno-oncology.

The Role of Peritumoral Depapillation and Its Impact on Narrow-Band Imaging in Oral Tongue Squamous Cell Carcinoma

A recent study reported that the occurrence of depapillated mucosa surrounding oral tongue squamous cell carcinomas (OTSCC) is associated with perineural invasion (PNI). The present study evaluates the reliability of depapillation as a PNI predictor and how it could affect narrow-band imaging (NBI) performance. This is thus a retrospective study on patients affected by OTSCC submitted to radical surgery. The preoperative endoscopy was evaluated to identify the presence of depapillation. Differences in distribution between depapillation and clinicopathological variables were analyzed. NBI vascular patterns were reported, and the impact of depapillation on those was studied. We enrolled seventy-six patients. After evaluation of the preoperative endoscopies, 40 (53%) patients had peritumoral depapillation, while 59 (78%) had a positive NBI pattern. Depapillation was strongly correlated to PNI, 54% vs. 28% (p = 0.022). Regarding the NBI pattern, there was no particular association with depapillation-associated tumors. The presence of depapillation did not affect the intralesional pattern detected by the NBI, while no NBI-positive pattern was found in the depapillation area. Finally, the NBI-guided resection margins were not affected by depapillation. Peritumoral depapillation is a reliable feature for PNI in OTSCC. NBI margin detection is not impaired by depapillation.

Salivary-Based Cell-Free Mitochondrial DNA Level Is an Independent Prognostic Biomarker for Patients with Head and Neck Squamous Cell Carcinoma

Changes in the copy numbers of cell-free nuclear DNA (cf-nDNA) and cell-free mitochondrial DNA (cf-mtDNA) have shown promising diagnostic utilities among patients with head and neck squamous cell carcinoma (HNSCC). Considering the absence of objective prognostic tools for HNSCC surveillance, this study aimed to assess the utility of saliva-based cf-nDNA and cf-mtDNA in predicting the overall survival of patients with HNSCC. The study included ninety-four patients with a confirmed HNSCC diagnosis with a mean follow-up time of 32.04 months (±19.1). A saliva-based liquid biopsy was collected from each patient. A multiplex quantitative PCR was used to determine the absolute number of cf-nDNA and cf-mtDNA. The Kaplan-Meier estimator and Cox proportional hazards regression models were used to assess overall survival. The absolute copy numbers of cf-nDNA and cf-mtDNA were statistically significantly higher among the deceased patients than among the censored ones (p < 0.05). Individuals with elevated levels of cf-nDNA or cf-mtDNA were associated with a significantly poorer overall survival (p ≤ 0.05). A univariate analysis showed that only the absolute copy number of cf-mtDNA was the sole predictor of overall survival. However, the multivariate analysis showed that all the absolute copy numbers of cf-nDNA, the absolute copy numbers of cf-mtDNA, and the stage of HNSCC were predictors of overall survival. Our study confirms that saliva is a reliable and non-invasive source of data that can be used to predict the overall survival of patients with HNSCC, where cf-mtDNA levels act as the sole predictor.

Worst pattern of invasion and other histopathological features in oral cancer as determinants of prognosis and survival rate: A retrospective cohort analysis

Oral cavity squamous cell carcinoma (OCSCC) is a well-recognized malignancy of the head and neck. Studies on patients with early-stage oral cancer have shown that they develop locally recurring and/or regional lymph node metastasis, which results in disease-associated mortality. Thus, early-stage oral cancer does not always present good prognoses. The present study aimed to determine the efficacy of using worst pattern of invasion (WPOI) and other histopathological features, such as prognostic factors in OCSCC, and analyze the impact of resection margin status and histopathological prognostic indicators on local recurrence (LR) and overall survival (OS) in patients with OCSCC. A retrospective cohort study was conducted by reviewing the charts of 63 patients with OCSCC treated with primary surgery at King Abdulaziz University Hospital between 2012 and 2019. An author and an experienced pathologist reviewed pathology slides. Associations of histopathological factors, including differentiation, stage, lymphovascular invasion, extracapsular extension, perineural invasion (PNI), WPOI and surgical margins, with LR or disease-free survival (DFS) were evaluated. Univariate analysis identified WPOI and PNI, and multivariate analysis identified the WPOI as predictive factors for LR and DFS. Kaplan-Meier analysis identified the WPOI and PNI as predictive factors for OS and WPOI as a predictive factor for DFS. Therefore, it may be concluded that WPOI and PNI are significant independent prognostic factors for local tumor control and DFS in patients with OCSCC.

Prognostic significance of dysplasia associated with oral squamous cell carcinoma in patients undergoing surgery with curative intent

The aim of this study was to evaluate the prognostic significance of dysplasia in patients undergoing primary surgery with curative intent in the treatment of oral squamous cell carcinoma (OSCC). This study specifically aimed to demonstrate the effect of dysplasia on local recurrence, disease specific survival (DSS) and overall survival (OS). Data collection for 833 patients with OSCC undergoing treatment for curative intent was undertaken retrospectively for the period of February 2006 to May 2020. Analysis of any association between known clinicopathological prognostic categorical variables with respect to dysplasia was undertaken using the chi squared test. A Kaplan-Meier analysis was performed to demonstrate the impact of dysplasia on DSS and OS, and Cox's proportional-hazards model deployed to obtain hazard ratios associated with dysplasia and the outcomes of interest. Dysplasia was statistically significant in predicting disease specific and overall survival in patients undergoing primary surgery for OSCC (DSS p<0.001, HR 0.577; 95%CI 0.428 to 0.777), OS p<0.001 HR 0.691; 95%CI 0.562 to 0.850) with the absence of dysplasia predicting poorer outcomes. The absence of dysplasia correlated with pathological higher T and N stage, increased categorised depth of tumour invasion, non-cohesive invasive front, lymphovascular invasion, perineural invasion, extranodal extension and increased modified Glasgow Prognostic Score. No significant prognostic relationship was attributable to the presence of dysplasia at a surgical margin. The absence of dysplasia appeared to be a significant independent prognostic indicator for patients with OSCC. The presence or absence of dysplasia may provide a heuristic means of stratifying OSCC primary lesions in terms of disease hostility.

Clinicopathological characteristics predicting advanced stage and surgical margin invasion of oral squamous cell carcinoma: A single‑center study on 10 years of cancer registry data

The incidence profile of oral squamous cell carcinoma (OSCC) has not previously been comprehensively reported in Indonesia. The present study aimed to identify clinicopathological characteristics of patients with OSCC according to sex and age, to analyze histological differentiation patterns specific to tumor subsites, to highlight the role of lymphovascular invasion (LVI) in metastasis, and to develop a model to predict advanced stage and margin invasion. A retrospective cross-sectional study was performed using 581 medical records and pathological specimens from cancer registry data in the Dr Cipto Mangunkusumo Hospital (Jakarta, Indonesia), between January 2011 and December 2020. Clinicopathological characteristics were analyzed using parametric and non-parametric tests. Multivariate logistic regression analyses were performed for eligible parameters, identified using bivariate analysis, to predict advanced stage and margin invasion. Calibration of the prediction model was evaluated using the Hosmer-Lemeshow test, its discrimination value assessed using the receiver operating characteristic and area under the receiver operating characteristic curve (AUC). Sex-specific patterns in tumor subsites and differences in clinical staging according to age were demonstrated in the patients with OSCC. The proportion of well-differentiated cases was significantly higher in most tumor subsites, except in the buccal mucosa (more moderately differentiated cases) and floor of the mouth (well and moderately differentiated cases being equal). LVI was significantly associated with nodal metastasis but not distant metastasis. Multivariate analysis demonstrated that age ≤45 years [odds ratio (OR), 2.26] and LVI (OR, 8.42) predicted patients having advanced-stage OSCC among general populations (AUC, 0.773); however, LVI (OR, 8.28) was the sole predictor of advanced stage amongst young patients (AUC, 0.737). Margin invasion was predicted solely by tumor subsite, including mouth not otherwise specified (OR, 3.04) and palate (OR, 6.13), in the general population (AUC, 0.711). Furthermore, margin invasion was predicted by the palate subsite (OR, 38.77) and LVI (OR, 11.61) in young patients (AUC, 0.762). Investigating young patients thoroughly when finding SCC in the mouth and palate, and assessing LVI, especially among young patients, is critical to prevent advanced staging and margin invasion.

Survival rate and prognostic factors of oral squamous cell carcinoma in Indonesia: A single-center retrospective study

Background

Oral squamous cell carcinoma (OSCC) is the sixth most common malignancy in Asia. Most patients in Cipto Mangunkusumo Hospital have been diagnosed with an advanced stage. There had not been any survival study for OSCC in Indonesia. This study aimed to investigate the survival rate and prognostic factors of OSCC in Cipto Mangunkusumo Hospital.

Methods

A retrospective cohort study was conducted on OSCC patients diagnosed and treated in Cipto Mangunkusumo Hospital from 2014 to 2018. Data regarding age, gender, site of the primary lesion, clinical stage of the disease, tumor differentiation, invasion, and surgical margins were collected. The main outcomes measured were overall survival (OS) and disease-specific survival (DSS). The predictors of survival were then determined.

Result

169 patients were included. The majority of patients were male (51.5%) and above 50 years old (55.6%). The most prevalent tumor site was the tongue (72.8%) followed by buccal mucosa (13%). The majority (82.2%) of patients had advanced (clinical stage IV) disease at diagnosis. A smaller majority of patients had a well-differentiated tumor (60.4%) and a low-grade tumor (53.8%). The worst one-year and two-year overall survival rates were found in the stage IV group (53.5% and 37.5%, respectively). The disease-specific survival rate was 66.9%.

Conclusion

The one-year and two-year overall survival rates of OSCC in Cipto Mangunkusumo Hospital were 58.6% and 43.1%. Moreover, clinical stage, tumor size, and lymph node involvement were the most significant prognostic factors for OSCC.

CD44-positive cancer stem cells from oral squamous cell carcinoma exhibit reduced proliferation and stemness gene expression upon adipogenic induction

We proposed to assess adipogenic differentiation and its effect on the proliferation and stemness markers in CD44 + OSCC CSCs. D44 + CSCs were sorted by magnetic sorting from the single-cell suspension of the OSCC tumor. Adipogenic differentiation was induced by an adipogenic induction medium. Lipid droplet formation was confirmed by oil red O staining. The expression of the cell surface marker was analyzed by flow cytometry. Real-time qPCR was performed to examine the gene expression activity. CD44 + OSCC CSCs can differentiate into adipocytes and adipogenesis in these cells decrease their proliferation and stemness gene expression. Adipogenic induction can make the cancer stem cells from OSCC tumors lose their stemness potential. Oral cancer, especially OSCC, is a huge burden worldwide. Similar to other stem cells, cancer stem cells can differentiate into other lineage cells. Our study shows that the proliferation and stemness gene expression in the CSCs from OSCC tumors can be thwarted by inducing them to differentiate into adipocytes, which could be advantageous to find out new clinical approaches in the treatment of cancers, like OSCC.

Prognostic Matrisomal Gene Panel and Its Association with Immune Cell Infiltration in Head and Neck Carcinomas

Simple Summary

Squamous cell carcinoma of the head and neck (SCCHN) is a heterogeneous group of tumors arising from squamous cells lining different anatomic sites. This type of malignancy has been mainly investigated by focusing primarily on tumor cells, but recent evidence highlighted the importance of the tumor microenvironment (TME) in cancer growth, progression and metastasis. Hence, we hypothesized that dysregulated matrisomal components could have a common association with patient survival, irrespective of the subsite of origin of the SCCHN. Using bioinformatic methods and public datasets, we successfully identified a gene panel with prognostic value in HPV-negative and non-metastatic node-negative tumors and demonstrated its association with immune cell infiltration.

Abstract

Squamous cell carcinoma of the head and neck (SCCHN) is common worldwide and related to several risk factors including smoking, alcohol consumption, poor dentition and human papillomavirus (HPV) infection. Different etiological factors may influence the tumor microenvironment and play a role in dictating response to therapeutics. Here, we sought to investigate whether an early-stage SCCHN-specific prognostic matrisome-derived gene signature could be identified for HPV-negative SCCHN patients (n = 168), by applying a bioinformatics pipeline to the publicly available SCCHN-TCGA dataset. We identified six matrisome-derived genes with high association with prognostic outcomes in SCCHN. A six-gene risk score, the SCCHN TMI (SCCHN-tumor matrisome index: composed of MASP1, EGFL6, SFRP5, SPP1, MMP8 and P4HA1) was constructed and used to stratify patients into risk groups. Using machine learning-based deconvolution methods, we found that the risk groups were characterized by a differing abundance of infiltrating immune cells. This work highlights the key role of immune infiltration cells in the overall survival of patients affected by HPV-negative SCCHN. The identified SCCHN TMI represents a genomic tool that could potentially aid patient stratification and selection for therapy in these patients.

Chlorine, chromium, proteins of oxidative stress and DNA repair pathways are related to prognosis in oral cancer

The comparison of chemical and histopathological data obtained from the analysis of excised tumor fragments oral squamous cell carcinoma (OSCC) with the demographic and clinical evolution data is an effective strategy scarcely explored in OSCC studies. The aim was to analyze OSCC tissues for protein expression of enzymes related to oxidative stress and DNA repair and trace elements as candidates as markers of tumor aggressiveness and prognosis. Tumor fragments from 78 OSCC patients that had undergone ablative surgery were qualitatively analyzed by synchrotron micro-X-ray fluorescence for trace elements. Protein expression of SOD-1, Trx, Ref-1 and OGG1/2 was performed by immunohistochemistry. Sociodemographic, clinical, and histopathological data were obtained from 4-year follow-up records. Disease relapse was highest in patients with the presence of chlorine and chromium and lowest in those with tumors with high OGG1/2 expression. High expression of SOD-1, Trx, and Ref-1 was determinant of the larger tumor. Presence of trace elements can be markers of disease prognosis. High expression of enzymes related to oxidative stress or to DNA repair can be either harmful by stimulating tumor growth or beneficial by diminishing relapse rates. Interference on these players may bring novel strategies for the therapeutic management of OSCC patients.

Systemic inflammatory response in predicting outcomes of patients undergoing curative resection for oral squamous cell carcinoma

This study aimed to evaluate the prognostic significance of the modified Glasgow prognostic score (mGPS), neutrophil:lymphocyte ratio (NLR), and platelet:lymphocyte ratio (PLR) in patients undergoing resection of oral squamous cell carcinoma (OSCC) with curative intent. We also aimed to explore the relation between activated systemic inflammation and adverse tumour characteristics. Between February 2006 and December 2019, data on 825 patients undergoing curative resection of OSCC were retrospectively gathered. Preoperative C-reactive protein and serum albumin levels were obtained to calculate a mGPS. Full blood count parameters were collected to calculate NLR and PLR values. Categorical factors were analysed using the chi squared test. Multivariate regression was performed to identify independent prognostic variables and the predictive value of each model generated. For disease-specific survival (DSS) and overall survival (OS), mGPS (DSS and OS both p<0.001), NLR (DSS and OS both p<0.001) and PLR (DSS and OS both p<0.001) were significant on univariate analysis. Independent predictive variables for DSS included mGPS, clinical node stage, categorised depth of tumour invasion, non-cohesive invasive front, and lymphovascular invasion. The concordance index was acceptable (0.756) for this model. Replacing mGPS with NLR or PLR as a marker of systemic inflammation demonstrated the same preoperative variables as independently predictive for DSS. The concordance index for these models were acceptable (NLR 0.76 and PLR 0.756). The systemic inflammatory response is prognostically significant in patients undergoing curative resection of OSCC. The potential link between an inflammatory tumour microenvironment and activated systemic inflammation merits further investigation.

The Impact of Histopathological Features on the Prognosis of Oral Squamous Cell Carcinoma: A Comprehensive Review and Meta-Analysis

OBJECTIVE

Over many decades, studies on histopathological features have not only presented high-level evidence of contribution for treatment directions and prognosis of oral squamous cell carcinoma (OSCC) but also provided inconsistencies, making clinical application difficult. The 8th TNM staging system of OSCC has acknowledged the importance of some histopathological features, by incorporating depth of invasion (DOI) to T category and extranodal extension (ENE) to N category. The aim of this systematic review with meta-analysis is to determine the most clinically relevant histopathological features for risk assessment and treatment planning of OSCC and to elucidate gaps in the literature.

METHODS

A systematic review was conducted using PRISMA guidelines, and the eligibility criteria were based on population, exposure, comparison, outcome, and study type (PECOS). PubMed, Cochrane, Scopus, and Web of Science were searched for articles exploring the impact of histopathological features on OSCC outcomes with Cox multivariate analysis. Pooled data were subjected to an inverse variance method with random effects or fixed effect model, and the risk of bias was evaluated using quality in prognosis studies (QUIPS). Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

RESULTS

The study included 172 articles published from 1999 to 2021. Meta-analyses confirmed the prognostic potential of DOI, ENE, perineural invasion, lymphovascular invasion, and involvement of the surgical margins and brought promising results for the association of bone invasion, tumor thickness, and pattern of invasion with increased risk for poor survival. Although with a small number of studies, the results also revealed a clinical significance of tumor budding and tumor-stroma ratio on predicted survival of patients with OSCC. Most of the studies were considered with low or moderate risk of bias, and the certainty in evidence varied from very low to high.

CONCLUSION

Our results confirm the potential prognostic usefulness of many histopathological features and highlight the promising results of others; however, further studies are advised to apply consistent designs, filling in the literature gaps to the pertinence of histopathological markers for OSCC prognosis.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO), identifier CRD42020219630.

Differential cancer risk and survival in Indian oral cancer patients with genic region FAS and FASL polymorphisms

OBJECTIVE

To investigate the association of genic region polymorphisms of FAS and FASL in Indian patients with oral cancer.

STUDY DESIGN

The study included 960 consenting control participants and patients with oral cancer. Genotyping was performed using Polymerase Chain Reaction -Restriction Fragment Length Polymorphism (PCR-RFLP). Cancer risk, 5-year survival, and hazards ratio (HRs), with respect to risk and clinical factors, were estimated using Fisher's exact test, Kaplan-Meier analysis, and Cox proportional hazards models.

RESULTS

FASL IVS2nt-124 'AG' increased risk in males with buccal mucosa cancer (BMC) but decreased risk in females. FAS 21196 'CT' decreased risk of tongue cancer (TC) and BMC in females. The survival of the patients also differed between sexes in TC and BMC. FAS 21196 'CT' increased HR by 23-fold in females with BMC when adjusted for age, stage, grade, LVS, PNI, tobacco use, and alcohol. 'TT' genotype increased the HR in females with BMC when adjusted for age, stage, grade, lymphovascular spread (LVS), perineural invasion (PNI), and perinodal spread (PNS). Our bioinformatic study revealed the presence of CTCF binding regions and CpG islands near FAS and FASL.

CONCLUSIONS

These single nucleotide polymorphisms (SNPs) altered the risk and survival of BMC and TC patients differentially that varied with clinical and risk factors.

Prognostic value of lymphovascular and perineural invasion in squamous cell carcinoma of the tongue

OBJECTIVE

The objective of this study was to investigate the association between survival rate and lymphovascular invasion (LVI) and perineural invasion (PNI) in the tumor invasive front (TIF) of squamous cell carcinoma of the tongue (TSCC).

STUDY DESIGN

Seventy patients with TSCC were included. The retrospective analysis included demographic, clinical, and histopathologic data. Tissue blocks containing the TIF were stained with anti-α-smooth muscle actin and anti-S100 to detect LVI and PNI, respectively. Overall survival (OS) and disease-specific survival (DSS) were assessed using Pearson's chi-square test, Kaplan-Meier method, and Cox regression.

RESULTS

LVI and PNI were detected in 61.4% and 78.6% of the TSCC samples at the TIF, respectively. LVI and PNI were present in 54.3% of the cases and were associated with advanced clinical stage, lymph node resection, metastatic nodes, and lower survival (P < .05). The 5-year OS and DSS rates were 44% and 52%, respectively. Multivariate analysis showed that primary tumors >3.0 cm (hazard ratio = 4.29; P = .004) and a concomitant presence of LVI and PNI at the TIF (hazard ratio = 4.0; P = .012) were independent predictors for worse DSS.

CONCLUSION

LVI and PNI, identified by immunostaining at the TIF, are potential prognostic markers of TSCC.

Impact on patients with oral squamous cell carcinoma in different anatomical subsites: a single-center study in Taiwan

The incidence of oral cavity squamous cell carcinoma (OSCC) is particularly high in South Asia. According to the National Comprehensive Cancer Network, OSCC can arise in several subsites. We investigated survival rates and the clinical and pathological characteristics of OSCC in different anatomical subsites in the Taiwanese population. We retrospectively analyzed data for 3010 patients with OSCC treated at the Changhua Christian Hospital. Subsequently, we compared clinical and pathological features of OSCC in different subsites. Pathological T4 stage OSCCs occurred in the alveolar ridge and retromolar trigone in 56.4% and 43.7% of cases, respectively. More than 25% of patients with tongue OSCC and 23.4% of those with retromolar OSCC had lymph node metastasis. The prognosis was worst for hard palate OSCC (hazard ratio 1.848; p < 0.001) and alveolar ridge OSCC (hazard ratio 1.220; p = 0.017). Retromolar OSCC recurred most often and tongue OSCC second most often. The risk for cancer-related mortality was highest for hard palate OSCC, followed by alveolar ridge and retromolar OSCC. We found distinct differences in survival among the different subsites of OSCC. Our findings may also help prompt future investigations of OSCC in different subsites in Taiwanese patients.

TRF2 Overexpression at the Surgical Resection Margin: A Potential Predictive Biomarker in Oral Squamous Cell Carcinoma for Recurrence

Oral squamous cell carcinoma (OSCC) is one of the most prevalent cancers in India with high incidence rate in eastern region due to habits of tobacco, pan and gutkha chewing habits. In majority of OSCC, the cases were presented to clinicians at later stages of the disease which leads to increased mortality. In addition presence of minimal residual disease also significantly contributed towards disease progression. Therefore, identification of potential biomarker for prognostic stratification of patients with high risk of disease recurrence and appropriate management is utmost necessary. In this study, 80 OSCC patients were included and their tumour specimen along with cut margin (CM) was collected after surgical excision. Immunohistochemistry (IHC) was performed to check expression of TRF2 in tumour and CM of OSCC patients. Statistical analysis was carried out using SPSS based on clinical and pathological records. It was observed that 27 OSCC patients developed recurrence during the period of the study (2012-2016). It was observed that, in 34 cases (42.25%) TRF2 expression was positive in tumour, while in 46 cases (57.75%), it was negative, while it was just reverse at CM, respectively. The odds of recurrence among patients having high levels of TRF2 in CM were 2.6 times higher than the odds of recurrence among patients having lower levels of TRF2 in CM. In conclusion, this study showed that TRF2 at surgical cut margin has a prognostic significance and can be used as a molecular marker for predicting survival in OSCC patients.

Is the Depth of Invasion a Marker for Elective Neck Dissection in Early Oral Squamous Cell Carcinoma?

Objective

The depth of invasion (DOI) is considered an independent risk factor for occult lymph node metastasis in oral cavity squamous cell carcinoma (OCSCC). It is used to decide whether an elective neck dissection (END) is indicated in the case of a clinically negative neck for early stage carcinoma (pT1/pT2). However, there is no consensus on the cut-off value of the DOI for performing an END. The aim of this study was to determine a cut-off value for clinical decision making on END, by assessing the association of the DOI and the risk of occult lymph node metastasis in early OCSCC.

Methods

A retrospective cohort study was conducted at the Erasmus MC, University Medical Centre Rotterdam, The Netherlands. Patients surgically treated for pT1/pT2 OCSCC between 2006 and 2012 were included. For all cases, the DOI was measured according to the 8^th edition of the American Joint Committee on Cancer guideline. Patient characteristics, tumor characteristics (pTN, differentiation grade, perineural invasion, and lymphovascular invasion), treatment modality (END or watchful waiting), and 5-year follow-up (local recurrence, regional recurrence, and distant metastasis) were obtained from patient files.

Results

A total of 222 patients were included, 117 pT1 and 105 pT2. Occult lymph node metastasis was found in 39 of the 166 patients who received END. Univariate logistic regression analysis showed DOI to be a significant predictor for occult lymph node metastasis (odds ratio (OR) = 1.3 per mm DOI; 95% CI: 1.1-1.5, p = 0.001). At a DOI of 4.3 mm the risk of occult lymph node metastasis was >20% (all subsites combined).

Conclusion

The DOI is a significant predictor for occult lymph node metastasis in early stage oral carcinoma. A NPV of 81% was found at a DOI cut-off value of 4 mm. Therefore, an END should be performed if the DOI is >4 mm.

Impact of lymphovascular invasion in oral squamous cell carcinoma: A meta-analysis

OBJECTIVE

Lymphovascular invasion (LVI) has been reported as a predictor of prognosis in multiple cancers. The aim of this meta-analysis was to investigate the potential value of LVI as a prognostic predictor of oral squamous cell carcinoma (OSCC).

STUDY DESIGN

To identify relevant studies, PubMed, Embase, Web of Science, and Cochrane Library database were searched from inception to October 2020. All studies exploring the association of LVI with overall survival (OS), disease-specific survival (DSS), or disease-free survival (DFS) and lymph node metastasis (LNM) were identified.

RESULT

Pooled odds ratios for LNM and hazard ratios for survival were calculated using fixed effects or random effects models. Thirty-six studies involving 17,109 patients with OSCC were included and further analyzed. The results showed that positive LVI was significantly associated with LNM and worse survival in patients with OSCC. Moreover, positive LVI was correlated with LNM in patients with early stage OSCC.

CONCLUSIONS

These findings indicate that LVI may serve as a prognostic predictor for the metastasis and prognosis of OSCC and could be considered a routine pathologic examination in clinical work.

Stromal categorization in early oral tongue cancer

Stromal categorization has been used to classify many epithelial cancer types. We assessed the desmoplastic reaction and compared its significance with other stromal characteristics in early (cT1-2N0) oral tongue squamous cell carcinoma (OTSCC). In this multi-institutional study, we included 308 cases treated for early OTSCC at five Finnish university hospitals or at the A.C. Camargo Cancer Center in São Paulo, Brazil. The desmoplastic reaction was classified as immature, intermediate, or mature based on the amount of hyalinized keloid-like collagen and myxoid stroma. We compared the prognostic value of the desmoplastic reaction with a stromal grading system based on tumor-stroma ratio and stromal tumor-infiltrating lymphocytes. We found that a high amount of stroma with a weak infiltration of lymphocytes was associated statistically significantly with a worse disease-free survival with a hazard ratio (HR) of 2.68 (95% CI 1.26–5.69), worse overall survival (HR 2.95, 95% CI 1.69–5.15), and poor disease-specific survival (HR 2.66, 95% CI 1.11–6.33). Tumors having a high amount of stroma with a weak infiltration of lymphocytes were also significantly associated with a high rate of local recurrence (HR 4.13, 95% CI 1.67–10.24), but no significant association was found with lymph node metastasis (HR 1.27, 95% CI 0.37–4.35). Categorization of the stroma based on desmoplastic reaction (immature, intermediate, mature) showed a low prognostic value for early OTSCC in all survival analyses (P > 0.05). In conclusion, categorization of the stroma based on the amount of stroma and its infiltrating lymphocytes shows clinical relevance in early OTSCC superior to categorization based on the maturity of stroma.

CT-based Radiomic Signatures for Predicting Histopathologic Features in Head and Neck Squamous Cell Carcinoma

Purpose

To determine the performance of CT-based radiomic features for noninvasive prediction of histopathologic features of tumor grade, extracapsular spread, perineural invasion, lymphovascular invasion, and human papillomavirus status in head and neck squamous cell carcinoma (HNSCC).

Materials and Methods

In this retrospective study, which was approved by the local institutional ethics committee, CT images and clinical data from patients with pathologically proven HNSCC from The Cancer Genome Atlas (n = 113) and an institutional test cohort (n = 71) were analyzed. A machine learning model was trained with 2131 extracted radiomic features to predict tumor histopathologic characteristics. In the model, principal component analysis was used for dimensionality reduction, and regularized regression was used for classification.

Results

The trained radiomic model demonstrated moderate capability of predicting HNSCC features. In the training cohort and the test cohort, the model achieved a mean area under the receiver operating characteristic curve (AUC) of 0.75 (95% confidence interval [CI]: 0.68, 0.81) and 0.66 (95% CI: 0.45, 0.84), respectively, for tumor grade; a mean AUC of 0.64 (95% CI: 0.55, 0.62) and 0.70 (95% CI: 0.47, 0.89), respectively, for perineural invasion; a mean AUC of 0.69 (95% CI: 0.56, 0.81) and 0.65 (95% CI: 0.38, 0.87), respectively, for lymphovascular invasion; a mean AUC of 0.77 (95% CI: 0.65, 0.88) and 0.67 (95% CI: 0.15, 0.80), respectively, for extracapsular spread; and a mean AUC of 0.71 (95% CI: 0.29, 1.0) and 0.80 (95% CI: 0.65, 0.92), respectively, for human papillomavirus status.

Conclusion

Radiomic CT models have the potential to predict characteristics typically identified on pathologic assessment of HNSCC.Supplemental material is available for this article.© RSNA, 2020.

Malignant tumors of the maxillary sinus: Prognostic impact of neurovascular invasion in a series of 138 patients

BACKGROUND

Maxillary sinus cancer is a rare disease with heterogeneous biologic behavior. The pattern of neurovascular invasion is known to be an important prognosticator in head and neck cancers, but has not been studied in maxillary malignancies.

MATERIALS AND METHODS

Patients undergoing surgery-based treatment with curative intent for a malignancy of the maxillary sinus at the Unit of Otorhinolaryngology - Head and Neck Surgery of the University of Brescia between November 2000 and October 2018 were included. A description of the characteristics of the patients, tumors, and treatments has been performed along with uni- and multi-variate analysis of prognostic factors. Tumors were classified based on the presence of perineural (P₀/P₁) and lymphovascular invasion (V₀/V₁) in 4 categories: P₀V₀, P₁V₀, P₀V₁, and P₁V₁.

RESULTS

One hundred-thirty-eight patients were included. Mean age at surgery was 61.0 years. Most patients (60.1%) were affected by non-salivary carcinomas, and most tumors (73.9%) were high-grade cancers. One hundred-seven (77.5%) tumors were classified as pT4. The large majority of patients received bi- or tri-modality treatment. Sixty-three (45.7%) cases were classified as P₀V₀, 32 (23.2%) as P₁V₀, 7 (5.1%) as P₀V₁, and 36 (26.1%) as P₁V₁. T category, nodal status, and neurovascular invasion were significantly associated with prognosis. Perineural and lymphovascular invasion were associated with the topographical growth of the tumor.

CONCLUSIONS

Maxillary cancer is often diagnosed at an advanced stage and in most cases requires a multimodal approach. Perineural and lymphovascular invasion are frequent and have a different impact on prognosis and topographical extension of the tumor.

A key genomic signature associated with lymphovascular invasion in head and neck squamous cell carcinoma

Background

Lymphovascular invasion (LOI), a key pathological feature of head and neck squamous cell carcinoma (HNSCC), is predictive of poor survival; however, the associated clinical characteristics and underlying molecular mechanisms remain largely unknown.

Methods

We performed weighted gene co-expression network analysis to construct gene co-expression networks and investigate the relationship between key modules and the LOI clinical phenotype. Functional enrichment and KEGG pathway analyses were performed with differentially expressed genes. A protein–protein interaction network was constructed using Cytoscape, and module analysis was performed using MCODE. Prognostic value, expression analysis, and survival analysis were conducted using hub genes; GEPIA and the Human Protein Atlas database were used to determine the mRNA and protein expression levels of hub genes, respectively. Multivariable Cox regression analysis was used to establish a prognostic risk formula and the areas under the receiver operating characteristic curve (AUCs) were used to evaluate prediction efficiency. Finally, potential small molecular agents that could target LOI were identified with DrugBank.

Results

Ten co-expression modules in two key modules (turquoise and pink) associated with LOI were identified. Functional enrichment and KEGG pathway analysis revealed that turquoise and pink modules played significant roles in HNSCC progression. Seven hub genes (CNFN, KIF18B, KIF23, PRC1, CCNA2, DEPDC1, and TTK) in the two modules were identified and validated by survival and expression analyses, and the following prognostic risk formula was established: [risk score = EXP_DEPDC1 * 0.32636 + EXP_CNFN * (− 0.07544)]. The low-risk group showed better overall survival than the high-risk group (P < 0.0001), and the AUCs for 1-, 3-, and 5-year overall survival were 0.582, 0.634, and 0.636, respectively. Eight small molecular agents, namely XL844, AT7519, AT9283, alvocidib, nelarabine, benzamidine, L-glutamine, and zinc, were identified as novel candidates for controlling LOI in HNSCC (P < 0.05).

Conclusions

The two-mRNA signature (CNFN and DEPDC1) could serve as an independent biomarker to predict LOI risk and provide new insights into the mechanisms underlying LOI in HNSCC. In addition, the small molecular agents appear promising for LOI treatment.

Validation of the Brandwein Gensler Risk Model in Patients of Oral Cavity Squamous Cell Carcinoma in North India

India has one of the highest incidences of oral squamous cell carcinoma (OSCC), with 75,000-80,000 new cases a year. The outcome in early oral cancer is better, but a significant proportion (12-14%) of these patients still relapses and dies due to locoregional or distant recurrences. Several clinicopathological and molecular factors have been used to prognosticate and predict outcomes in these patients of OSCC. The present study aims to validate Brandwein Gensler (BG) risk predictive model in surgically treated OSCC patients in a tertiary care centre in North India. All oral cavity cancer patients, treated in the Department of Surgical Oncology, King George's Medical University, between 2013 and 2017, were reviewed. Patients with histologically diagnosed OSCC, aged > 18 years undergoing primary surgical resection were included in the study. The final histopathological evaluation was done by a dedicated pathologist to categorize patients according to BG model risk categories. This model comprises of three factors, lymphocytic host response, perineural invasion and worst pattern of invasion, scored by the method described by Brandwein Gensler et al. The sum of these scores is used to define low, moderate and high risk categories. The study, conducted during 2013-2017, included 149 patients. Median age was 45 years (range 25-75 years). Tobacco use was noted in 143 patients. Buccal mucosa was the most common site (51%). Surgical margins were clear (> 5 mm) in 97.9% cases. Postoperative radiotherapy was given in 47.7% patients. Locoregional recurrences (LRR) (primary site and neck) were documented in 17 of the 149 patients (11.4%). There was no synchronous or metachronous distant metastasis noted in any of the study patients. Six patients had disease specific mortality. Among the 17 patients with LRR, majority (11) belonged to the high risk category of the BG risk model. Adjuvant radiotherapy had been administered in 10 of these 11 recurrent patients belonging to the high risk category. The Brandwein Gensler risk model is predictive of locoregional recurrences (p = 0.02) for OSCC undergoing primary surgery. It can be used to devise strategies to prevent recurrences or identification of recurrences at an earlier point for salvage. The benefit of further escalation of adjuvant therapy in the high risk category needs further studies, as 90% patients in this group recurred despite complete adjuvant treatment.

Raman Spectroscopy Analysis for Optical Diagnosis of Oral Cancer Detection

Raman spectroscopy (RS) is widely used as a non-invasive technique in screening for the diagnosis of oral cancer. The potential of this optical technique for several biomedical applications has been proved. This work studies the efficacy of RS in detecting oral cancer using sub-site-wise differentiation. A total of 80 samples (44 tumor and 36 normal) were cryopreserved from three different sub-sites: The tongue, the buccal mucosa, and the gingiva of the oral mucosa during surgery. Linear discriminant analysis (LDA) and quadratic discriminant analysis (QDA) were used with principal component analysis (PCA) to classify the samples and the classifications were validated by leave-one-out-cross-validation (LOOCV) and k-fold cross-validation methods. The normal and tumor tissues were differentiated under the PCA-LDA model with an accuracy of 81.25% (sensitivity: 77.27%, specificity: 86.11%). The PCA-QDA classifier model differentiated these tissues with an accuracy of 87.5% (sensitivity: 90.90%, specificity: 83.33%). The PCA-QDA classifier model outperformed the PCA-LDA-based classifier. The model studies revealed that protein, amino acid, and beta-carotene variations are the main biomolecular difference markers for detecting oral cancer.

Prognostic Significance of Tumor-Associated Macrophage Content in Head and Neck Squamous Cell Carcinoma: A Meta-Analysis

Background: Head and neck squamous cell carcinoma (HNSCC) exists within a microenvironment rich in immune cells. Macrophages are particularly abundant in and around tumor tissue, and have been implicated in the growth, malignancy, and persistence of HNSCC (1). However, current literature reports variable degrees of association between the density of tumor-associated macrophages (TAMs) and clinicopathologic markers of disease (2, 3). These inconsistent findings may be a result of differences in approach to TAM detection. Authors have measured total TAMs in tumor tissue, while others have stained tumor samples for individual subtypes of TAMs, which include pro-inflammatory (M1-like) and immunosuppressive (M2-like). Our aim is to more clearly define the prognostic significance of the phenotypes of tumor-associated macrophages in HNSCC. Methods: We conducted a meta-analysis of the existing publications investigating the relationship between TAMs (total and M2-like subtype) and T stage, nodal involvement, vascular invasion, lymphatic invasion, and tumor differentiation (Figure 1). A total of 12 studies were included. Forest plots and risk ratios were generated to report overall effect. Results: Higher density of both total and M2-like subtype of TAMs in the tumor microenvironment is associated with advanced T stage, increased rates of nodal positivity, presence of vascular invasion, and presence of lymphatic invasion (p < 0.0001; Figures 2-9). There is no significant association between TAM density, either total or M2-like subtype, and tumor differentiation (Figures 10, 11). Conclusions: Increased density of TAMs, including those of the M2-like phenotype, correlate with poor clinicopathologic markers in HNSCC. Our findings warrant additional investigation into the subpopulations of TAMs, the mechanisms behind their recruitment and differentiation, and the associated influence of each phenotype on tumor growth and invasion. A greater understanding of TAM dynamics in HNSCC is critical for directing further research and employing TAM-targeted adjunct therapies.

Molecular prognosticators in clinically and pathologically distinct cohorts of head and neck squamous cell carcinoma-A meta-analysis approach

Head and neck squamous cell carcinomas (HNSCC) includes multiple subsites that exhibit differential treatment outcome, which is in turn reflective of tumor stage/histopathology and molecular profile. This study hypothesized that the molecular profile is an accurate prognostic adjunct in patients triaged based on clinico-pathological characteristics. Towards this effect, publically available micro-array datasets (n = 8), were downloaded, classified based on HPV association (n = 83) and site (tongue n = 88; laryngopharynx n = 53; oropharynx n = 51) and re-analyzed (Genespring; v13.1). The significant genes were validated in respective cohorts in The Cancer Genome Atlas (TCGA) for correlation with clinico-pathological parameters/survival. The gene entities (n = 3258) identified from HPV based analysis, when validated in TCGA identified the subset specifically altered in HPV+ HNSCC (n = 63), with three genes showing survival impact (RPP25, NUDCD2, NOVA1). Site-specific meta-analysis identified respective differentials (tongue: 3508, laryngopharynx: 4893, oropharynx: 2386); validation in TCGA revealed markers with high incidence (altered in >10% of patients) in tongue (n = 331), laryngopharynx (n = 701) and oropharynx (n = 404). Assessment of these genes in clinical sub-cohorts of TCGA indicated that early stage tongue (MTFR1, C8ORF33, OTUD6B) and laryngeal cancers (TWISTNB, KLHL13 and UBE2Q1) were defined by distinct prognosticators. Similarly, correlation with perineural/angiolymophatic invasion, identified discrete marker panels with survival impact (tongue: NUDCD1, PRKC1; laryngopharynx: SLC4A1AP, PIK3CA, AP2M1). Alterations in ANO1, NUDCD1, PIK3CA defined survival in tongue cancer patients with nodal metastasis (node+ECS-), while EPS8 is a significant differential in node+ECS- laryngopharyngeal cancers. In oropharynx, wherein HPV is a major etiological factor, distinct prognosticators were identified in HPV+ (ECHDC2, HERC5, GGT6) and HPV- (GRB10, EMILIN1, FNDC1). Meta-analysis in combination with TCGA validation carried out in this study emphasized on the molecular heterogeneity inherent within HNSCC; the feasibility of leveraging this information for improving prognostic efficacy is also established. Subject to large scale clinical validation, the marker panel identified in this study can prove to be valuable prognostic adjuncts.

Oral Cavity Cancer in the Indian Subcontinent - Challenges and Opportunities

Oral cavity cancer (OCC) poses a global challenge that plagues both the Orient and the Occident, accounting for an estimated 350 000 new cases and 177 000 deaths in 2018. OCC is a major public health problem in the Indian subcontinent, where it ranks among the top three cancer types in both incidence and mortality. Major risk factors are the use of tobacco, betel quid and alcohol consumption. OCC is a heterogeneous group of multiple histologies that affects multiple subsites. The oral cavity includes the lips, buccal mucosa, teeth, gingiva, anterior two-thirds of the tongue, floor of the mouth and hard palate. OCC is defined as cancer of lips, mouth and tongue as defined by the International Classification of Diseases coding scheme. The epidemiology, aetio-pathogenesis and treatment philosophy are similar within this group. Although salivary gland malignancies, sarcomas, mucosal melanomas and lymphomas can also arise within the oral cavity, this review will focus on squamous cell cancer, which is the predominant histology in OCC. We review and contrast data from developing and developed countries. We also highlight the unique regional challenges that countries in the East face; citing India as an example, we elaborate on the opportunities and scope for improvement in the management of OCC.

Long-term disease-free survival in surgically-resected oral tongue cancer: a 10-year retrospective study

Early and loco-regionally advanced oral tongue squamous cell carcinoma (OTSCC) can be treated by surgery alone or followed by adjuvant radiotherapy or chemoradiotherapy. Nevertheless, up to 40% of patients develop tumour relapse. The aim of our study is to investigate the clinical and pathological features associated with reduced disease-free survival (DFS) in a cohort of surgically-resected OTSCC patients. One hundred and six patients surgically resected for OTSCC were retrospectively identified from clinical records. DFS was calculated according to the Kaplan–Meier method and differences between variables were assessed with Log-Rank test. A multivariable Cox regression model was used to analyse the impact of different prognostic factors on DFS. After a median of follow-up of 8.9 years, 22 events, including 11 deaths, were observed. Overall, the 5-year DFS-rate was 87.4%. The presence of extra-nodal extension (p = 0.023) and perineural invasion (p = 0.003) were significantly correlated with shorter DFS (in univariate analysis). In multivariable analysis, extra-nodal extension and perineural invasion confirmed their role as independent prognostic factors associated with an increased risk of disease recurrence [hazard ratio (HR) 2.87, 95% CI 1.11-7.42, p = 0.03; HR 3.85, 95% CI 1.49-9.96, p = 0.006, respectively]. p16 and p53 expressions in tumour cells were detected in 12% (n = 9) and 46% (n = 40) of cases, respectively. No differences in DFS were observed between p16+ and p16- (p = 0.125) and between p53+ and p53- tumours (p = 0.213). In conclusion, radical surgery, eventually followed by adjuvant radiotherapy or chemo-radiotherapy, can achieve high cure rates in OTSCC. After long-term follow-up, perineural invasion and extra-nodal extension confirmed their role as prognostic factors associated with reduced DFS in OTSCC patients.

Salivary lactate dehydrogenase (LDH) as a tool for early diagnosis of oral cancer in individuals with Fanconi anemia

Currently one of the greater challenges is the diagnosis and treatment of cancer. Many studies address the genetic and metabolic aspects to support in early diagnosis and increase the survival of individuals at high risk. Individuals with Fanconi anemia can be included in this high risk group because they have a predisposition to develop head and neck cancer. The use of salivary enzymes as biomarkers to detect the changes in oral tissue at the initial phase seems viable, because saliva is easy to obtain, it moisture oral mucosa and cells metabolic compounds can be found on it. Due to the metabolic characteristics of the cancer cell, an increase in Lactate Dehydrogenase (LDH) may indicate a carcinogenesis process. The hypothesis of this study is to use of salivary LDH as a tool in the early diagnosis of oral cancer on a high risk group such as Fanconi anemia's patients.