Postoperative radiotherapy with or without concurrent chemotherapy for oral squamous cell carcinoma in patients with three or more minor risk factors: a propensity score matching analysis

Perineural Invasion Unveiled: Deciphering the Prognostic Impact of Diameter and Quantity Subcategories in Oral Cancer

IMPORTANCE

Perineural invasion (PNI) is an established prognostic factor in oral squamous cell carcinoma (OSCC), but the impact of its subcategories on survival is not fully understood. This study quantifies the number and diameter of PNI foci to assess their prognostic relevance in OSCC.

OBJECTIVE

To evaluate the prognostic significance of PNI subcategories, specifically the number and diameter of PNI foci, as predictors of overall survival (OS) and disease-free survival (DFS) in OSCC patients.

DESIGN

Retrospective cohort study, adhering to STROBE guidelines.

SETTING

Single-center study at MacKay Memorial Hospital, Taiwan, including patients diagnosed with OSCC from 2005 to 2018.

PARTICIPANTS

Nine hundred twenty-six patients with biopsy-proven OSCC, excluding those with perioperative mortality or incomplete follow-up.

EXPOSURE

Histological evaluation of PNI, including quantifying the number and diameter of invaded nerves, along with clinicopathological features such as tumor stage and lymphovascular invasion (LVI).

MAIN OUTCOME MEASURES

OS and DFS, assessed via Cox proportional hazards models, Kaplan-Meier survival analysis, and receiver operating characteristic curve analysis for PNI foci subcategories.

RESULTS

PNI was present in 138 (14.9%) patients and was significantly associated with adverse histologic features, advanced tumor stage, nodal involvement, metastasis, and LVI. Multivariate analysis revealed that both the number of PNI foci greater than 4 and nerve diameters exceeding 0.21 mm were significantly associated with poorer OS and DFS (P < .05). After adjusting for clinical variables, PNI remained an independent predictor of worse OS [hazard ratio (HR): 1.37] and DFS (HR: 1.46).

CONCLUSIONS AND RELEVANCE

PNI is a significant independent prognostic factor in OSCC. Patients with more than 4 PNI foci or nerve involvement greater than 0.21 mm in diameter experienced significantly worse survival outcomes. These findings suggest that detailed assessment of PNI subcategories should be incorporated into OSCC management, guiding treatment decisions and potentially informing the need for adjuvant therapies.

Using a machine learning algorithm and clinical data to predict the risk factors of disease recurrence after adjuvant treatment of advanced-stage oral cavity cancer

Objectives

Head-and-neck cancer is a major cancer in Taiwan. Most patients are in the advanced stage at initial diagnosis. In addition to primary surgery, adjuvant therapy, including chemotherapy and radiotherapy, is also necessary to treat these patients. We used a machine learning tool to determine the factors that may be associated with and predict treatment outcome.

Materials and Methods

We retrospectively reviewed 187 patients diagnosed with advanced-stage head-and-neck cancer who received surgery and adjuvant radiotherapy with or without chemotherapy. We used eXtreme Gradient Boosting (XGBoost) - a gradient tree-based model - to analyze data. The features were extracted from the entries we recorded from the electronic health-care system and paper medical record. The patient data were categorized into training and testing datasets, with labeling according to their recurrence status within the 5-year follow-up. The primary endpoint was to predict whether the patients had recurrent disease. The risk factors were identified by analyzing the feature importance in the model. For comparison, we also used regression to perform the variate analysis to identify the risk factors.

Results

The accuracy, sensitivity, and positive predictive value of the model were 57.89%, 57.14%, and 44.44%, respectively. Pathological lymph node status was the most important feature, followed by whether the patient was receiving chemotherapy. Fraction size, early termination, and interruption were the important factors related to radiotherapy and might affect treatment outcome. The area under the curve of the receiver operating characteristic curve was 0.58. The risk factors identified by XGBoost were consistent with those found by regression.

Conclusion

We found that several factors were associated with treatment outcome in advanced-stage head-and-neck cancer. In future, we hope to collect the data according to the features introduced in this study and to construct a stronger model to explain and predict outcomes.

Comprehensive survival analysis of oral squamous cell carcinoma patients undergoing initial radical surgery

OBJECTIVE

This study was designed to evaluate the five-year overall survival (OS) rate and postoperative survival time of patients diagnosed with oral squamous cell carcinoma (OSCC), as well as examine the clinical and pathological factors influencing survival outcomes in OSCC patients.

METHODS

Data were collected from OSCC patients who underwent their first radical surgical intervention in the Department of Maxillofacial Surgery at the First Affiliated Hospital of Chongqing Medical University between April 2014 and December 2016. Follow-up was conducted until March 2022.

RESULTS

The study included a total of 162 patients. The observed 5-year OS rate was 59.3%. Approximately 45.7% of OSCC patients experienced postoperative recurrence or metastasis, with a 5-year overall disease-free survival rate of 49.4%. There was no significant difference in the impact of sex, age, smoking, alcohol consumption, primary tumour location, depth of invasion or primary tumour size on the 5-year survival rate (p > 0.05). Univariate analysis revealed that clinical stage (Hazard Ratio = 2.239, p = 0.004), perineural invasion (PNI) (Hazard Ratio = 1.712, p = 0.03), lymph node metastasis (pN) (Hazard Ratio = 2.119, p = 0.002), pathological differentiation (Hazard Ratio = 2.715, p < 0.001), and recurrence or metastasis (Hazard Ratio = 10.02, p < 0.001) were significant factors influencing survival. Multivariate analysis further indicated that pathological differentiation (Hazard Ratio = 2.291, p = 0.001), PNI (Hazard Ratio = 1.765, p = 0.031) and recurrence or metastasis (Hazard Ratio = 9.256, p < 0.001) were independent risk factors of survival. Intriguingly, 11 OSCC patients were diagnosed with oesophageal squamous cell carcinoma (ESCC) within 1-4 years following surgery.

CONCLUSION

The survival prognosis of OSCC patients is significantly associated with clinical stage, PNI, lymph node metastasis, pathological differentiation, and recurrence or metastasis. Pathological differentiation, PNI and recurrence or metastasis are independent risk factors affecting survival. Routine clinical screening for ESCC may be recommended for OSCC patients with a history of alcohol consumption and tobacco use.

Outcome of Adjuvant Radiotherapy and Adjuvant Chemoradiation for Oral Cancers with Close Margins of Resection

Oral cancers comprise 50% of all head and neck malignancies in India which can be attributed to tobacco chewing. Advanced oral cancers are managed with surgery followed by adjuvant radiotherapy or adjuvant chemoradiation. There is paucity of studies regarding need for adjuvant treatment in oral cancers with close margins i.e. ≤ 0.5 cm after formalin fixation. This study aims at documenting the oncological outcome with regards to loco-regional control, disease-free survival, overall survival and complications of adjuvant radiotherapy and adjuvant chemoradiation in operated oral cancer patients having close margins of resection. In this Retrospective cohort study, 163 patients with stage T1-T4 oral cancers operated between 2015 and 2019 who have fulfilled the inclusion and exclusion criteria, received adjuvant treatment and could be followed up for at least one year were included. At the end of 45 months, the overall survival was 74.7% and disease specific survival was 82.7%. Among the 7 patients who defaulted radiotherapy, 4 patients succumbed to the disease. Complications were bone marrow depression (2 patients), dysphagia (17) and Trismus (1). Adjuvant radiotherapy should be given in oral cancer patients with close margins of resection since it improves the oncological outcome and disease specific survival and the benefit often outweighs the risk.

Advances in the Anti-Tumor Activity of Biflavonoids in Selaginella

Despite the many strategies employed to slow the spread of cancer, the development of new anti-tumor drugs and the minimization of side effects have been major research hotspots in the anti-tumor field. Natural drugs are a huge treasure trove of drug development, and they have been widely used in the clinic as anti-tumor drugs. Selaginella species in the family Selaginellaceae are widely distributed worldwide, and they have been well-documented in clinical practice for the prevention and treatment of cancer. Biflavonoids are the main active ingredients in Selaginella, and they have good biological and anti-tumor activities, which warrant extensive research. The promise of biflavonoids from Selaginella (SFB) in the field of cancer therapy is being realized thanks to new research that offers insights into the multi-targeting therapeutic mechanisms and key signaling pathways. The pharmacological effects of SFB against various cancers in vitro and in vivo are reviewed in this review. In addition, the types and characteristics of biflavonoid structures are described in detail; we also provide a brief summary of the efforts to develop drug delivery systems or combinations to enhance the bioavailability of SFB monomers. In conclusion, SFB species have great potential to be developed as adjuvant or even primary therapeutic agents for cancer, with promising applications.

Adding Concomitant Chemotherapy to Postoperative Radiotherapy in Oral Cavity Carcinoma with Minor Risk Factors: Systematic Review of the Literature and Meta-Analysis

When presenting with major pathological risk factors, adjuvant radio-chemotherapy for oral cavity cancers (OCC) is recommended, but the addition of chemotherapy to radiotherapy (POCRT) when only minor pathological risk factors are present is controversial. A systematic review following the PICO-PRISMA methodology (PROSPERO registration ID: CRD42021267498) was conducted using the PubMed, Embase, and Cochrane libraries. Studies assessing outcomes of POCRT in patients with solely minor risk factors (perineural invasion or lymph vascular invasion; pN1 single; DOI ≥ 5 mm; close margin < 2−5 mm; node-positive level IV or V; pT3 or pT4; multiple lymph nodes without ENE) were evaluated. A meta-analysis technique with a single-arm study was performed. Radiotherapy was combined with chemotherapy in all studies. One study only included patients treated with POCRT. In the other 12 studies, patients were treated with only PORT (12,883 patients) and with POCRT (10,663 patients). Among the patients treated with POCRT, the pooled 3 year OS rate was 72.9% (95%CI: 65.5−79.2%); the pooled 3 year DFS was 70.9% (95%CI: 48.8−86.2%); and the pooled LRFS was 69.8% (95%CI: 46.1−86.1%). Results are in favor of POCRT in terms of OS but not significant for DFS and LRFS, probably due to the heterogeneity of the included studies and a combination of different prognostic factors.

Prognostic impact of perineural invasion in oral cancer: a systematic review

Introduction

Numerous studies have evaluated the prognostic significance of perineural invasion (PNI) in oral cancer; however, the results are inconclusive.

Purpose

To identify the prognostic value of PNI in oral cancer through a metanalysis.

Methods

A literature review was carried out, searching the MedLine databases via Pubmed, Scielo, Lilacs, Cochrane and Websco.

Results

A total of 56 studies were included. The results indicate that PNI in oral cancer has an incidence of 28% (95% confidence interval (CI) 24-31%); 5-year survival with relative risk (RR) 0.67 (0.59-0.75); 5-year disease-free survival RR 0.71 (0.68-0.75); locoregional recurrence with RR 2.09 (1.86-2.35).

Conclusions

PNI is a negative prognostic factor in oral cancer.

Molecular and Cellular Mechanisms of Perineural Invasion in Oral Squamous Cell Carcinoma: Potential Targets for Therapeutic Intervention

Simple Summary

Squamous cell carcinoma is the most common type of oral cavity cancer. It can spread along and invade nerves in a process called perineural invasion. Perineural invasion can increase the chances of tumor recurrence and reduce survival in patients with oral cancer. Understanding how oral cancer interacts with nerves to facilitate perineural invasion is an important area of research. Targeting key events that contribute to perineural invasion in oral cavity cancer may reduce tumor recurrence and improve survival. In this review, we describe the impact of perineural invasion in oral cancer and the mechanisms that contribute to perineural invasion. Highlighting the key events of perineural invasion is important for the identification and testing of novel therapies for oral cancer with perineural invasion.

Abstract

The most common oral cavity cancer is squamous cell carcinoma (SCC), of which perineural invasion (PNI) is a significant prognostic factor associated with decreased survival and an increased rate of locoregional recurrence. In the classical theory of PNI, cancer was believed to invade nerves directly through the path of least resistance in the perineural space; however, more recent evidence suggests that PNI requires reciprocal signaling interactions between tumor cells and nerve components, particularly Schwann cells. Specifically, head and neck SCC can express neurotrophins and neurotrophin receptors that may contribute to cancer migration towards nerves, PNI, and neuritogenesis towards cancer. Through reciprocal signaling, recent studies also suggest that Schwann cells may play an important role in promoting PNI by migrating toward cancer cells, intercalating, and dispersing cancer, and facilitating cancer migration toward nerves. The interactions of neurotrophins with their high affinity receptors is a new area of interest in the development of pharmaceutical therapies for many types of cancer. In this comprehensive review, we discuss diagnosis and treatment of oral cavity SCC, how PNI affects locoregional recurrence and survival, and the impact of adjuvant therapies on tumors with PNI. We also describe the molecular and cellular mechanisms associated with PNI, including the expression of neurotrophins and their receptors, and highlight potential targets for therapeutic intervention for PNI in oral SCC.

Oral cancer: changing the aim of the biopsy in the age of precision medicine. A review

Oral cancer is a heterogeneous disease that develops through a complex, multi-step process. Precision medicine should help to better understand its molecular basis, integrate traditional classifications and have a positive impact on cancer management. To apply this information in clinical practice, we need to define its histology and identify biomarkers expressed by the tumour that provide useful information for planning tailored treatment. The most reliable information currently derives from evaluation of biomarkers on post-operative samples. To plan personalised treatment, oncologists need to assess these markers on biopsy samples. We reviewed the recent literature and identified 6 of 184 publications that compared markers measured on biopsy and post-operative samples or assessed their predictivity for the development of lymph node metastases. Data from these studies suggest that markers measured on biopsy samples can provide useful indications for tailoring treatments. However, due to their heterogeneity and low level of evidence, these results need to be confirmed by clinical studies on a large population to standardise and validate biomarkers in biopsies and to assess their reliability in other diagnostic mini-invasive procedures such as radiomics and liquid biopsy.

The T-N tract involvement as a new prognostic factor for PORT in locally advanced oral cavity tumors

OBJECTIVE

The space comprised between tumor and neck lymph nodes (T-N tract) is one of the main routes of tumor spread in oral cavity tumors. Aim of the study was to investigate the impact of T-N tract involvement on the postoperative radiotherapy (PORT) outcomes.

MATERIALS AND METHODS

Patients (pts) treated between 2000 and 2016 with indication to PORT were retrospectively retrieved. Inclusion criteria were: (a) locally advanced tumors of the oral cavity, (b) who received with indication to PORT (c) with a minimum follow-up of six months.

RESULTS

One hundred and fifty-seven pts met the inclusion criteria (136 pts treated with PORT and 21 pts not treated with PORT). In the PORT cohort, the T-N tract involvement had no impact on both OS (p = .09) and LRFS (p = .2). Among the non-PORT cohort, both OS (p = .007) and LRFS (p = .017) were worse for pts with positive T-N tract compared to those with negative T-N tract. PORT improved both OS (p = .008) and LRFS (p = .003) in pts with positive T-N tract but not in those with negative T-N tract (p = .36 and p = .37, respectively).

CONCLUSIONS

Our results suggest that involvement of T-N tract should be considered as prognostic factors informing the indication to PORT.

Cytoglobin protects cancer cells from apoptosis by regulation of mitochondrial cardiolipin

Cytoglobin is important in the progression of oral squamous cell carcinoma but the molecular and cellular basis remain to be elucidated. In the current study, we develop a new cell model to study the function of cytoglobin in oral squamous carcinoma and response to cisplatin. Transcriptomic profiling showed cytoglobin mediated changes in expression of genes related to stress response, redox metabolism, mitochondrial function, cell adhesion, and fatty acid metabolism. Cellular and biochemical studies show that cytoglobin expression results in changes to phenotype associated with cancer progression including: increased cellular proliferation, motility and cell cycle progression. Cytoglobin also protects cells from cisplatin-induced apoptosis and oxidative stress with levels of the antioxidant glutathione increased and total and mitochondrial reactive oxygen species levels reduced. The mechanism of cisplatin resistance involved inhibition of caspase 9 activation and cytoglobin protected mitochondria from oxidative stress-induced fission. To understand the mechanism behind these phenotypic changes we employed lipidomic analysis and demonstrate that levels of the redox sensitive and apoptosis regulating cardiolipin are significantly up-regulated in cells expressing cytoglobin. In conclusion, our data shows that cytoglobin expression results in important phenotypic changes that could be exploited by cancer cells in vivo to facilitate disease progression.

Prognostic significance of the preoperative systemic immune-inflammation index in patients with oral cavity squamous cell carcinoma treated with curative surgery and adjuvant therapy

OBJECTIVES

To investigate the prognostic value of the preoperative systemic immune-inflammation index (SII) in patients with oral cavity squamous cell carcinoma (OC-SCC) treated with curative surgery followed by adjuvant radiotherapy (RT) or chemoradiotherapy (CCRT).

MATERIALS AND METHODS

We retrospectively reviewed the clinical records of patients with OC-SCC who received surgery and postoperative adjuvant RT/CCRT between January 2005 and December 2012. Blood samples were drawn in the 2 weeks preceding surgery. SII was calculated by multiplying the absolute neutrophil and platelet counts, and then, divided by the absolute lymphocyte count, and its optimal cutoff value was identified using the Youden's index. The study endpoints included overall survival (OS), local control (LC), regional control (RC), and distant control (DC).

RESULTS

The study sample consisted of 993 patients (58.8% of them treated with CCRT). The optimal cutoff value for SII was 810.6. A total of 347 (34.9%) study participants had high preoperative SII values. After allowance for potential confounders in multivariable analysis, high SII values were independently associated with less favorable DC (adjusted hazard ratio [HR] = 1.683, p = 0.001) and OS (adjusted HR = 1.466, p < 0.001). No independent association between SII and LC/RC was observed.

CONCLUSION

Increased SII values predict poor DC and OS in patients with OC-SCC treated with curative resection and adjuvant RT/CCRT. Owing to the higher risk of systemic failure in this patient group, a thorough follow-up surveillance schedule may be advisable pending independent confirmation of our data.

A retrospective investigation of minor risk factors as prognostic predictors and treatment indications in oral squamous cell carcinoma

Abstract

Background/purpose

The clinical significance of minor risk factors remins uncertain in oral squamous cell carcinoma (OSCC) patients. The purpose of this study was to investigate the clinical impact of minor risk factors in OSCC patients.

Materials and methods

The cases of OSCC patients that underwent surgery were retrospectively analyzed. Patients with major risk factors for recurrence, such as positive surgical margins or extracapsular spread, were excluded. The impact of possible minor risk factors on treatment outcomes was analyzed. One hundred and seventy-five patients with primary OSCC that underwent surgery were included in this study.

Results

The 5-year overall survival (OS), cancer-specific survival (CSS), and relapse-free survival (RFS) rates were 81.2%, 91.0%, and 72.4%, respectively. In multivariate analyses, RFS exhibited a significant association with the pattern of invasion (grade 4 vs. grades 1–3: hazard ratio: 3.096, 95% confidence interval: 1.367–6.884, p < 0.01), OS exhibited a tendency towards associations with the pattern of invasion and perineural invasion, and CSS displayed a tendency towards an association with perineural invasion. The prognosis of the patients with ≥2 minor risk factors was significantly worse than that of the patients with 0 or 1 minor risk factor(s) (OS: 91.6% vs. 64.5%, respectively, p < 0.01; CSS: 98.9% vs. 78.9%, respectively, p < 0.001; and RFS: 81.2% vs. 58.5%, respectively p < 0.05).

Conclusion

Grade 4 invasion and perineural invasion might be significant minor risk factors in OSCC patients. The presence of ≥2 minor risk factors might be a predictor of a poor prognosis in OSCC patients.

Indirect Immunofluorescence and Tumorspheres Enrichment Technique for Identifying Cancer Stem Cell Markers in Cancer Cell Lines From Primary Oral Cancer Tissues: An In Vitro Study

Aim:

The cancer stem cells (CSCs) are known to be responsible for drug resistance and cancer relapse in the treatment of cancer. Identification and isolation of CSCs and study of their properties will play a crucial role in developing an effective drug against these targets. The aim of the study was to isolate CSCs from primary cancer by the tumorspheres enrichment method, to confirm by indirect immunofluorescence and gene expression of stem cell markers by using real-time polymerase chain reaction (RT-PCR) technique.

Materials and Methods:

In this in vitro study, we enriched oral CSCs through tumorsphere formation assay from seven primary cultures of OSCC patients with defined serum media. The expression and localization of the cell surface markers of CD133 and CD44 were tested by indirect immunofluorescence. Gene expression of stem cell markers such as CD44, CD133, Oct4, Sox2, and Nanog were quantified by RT-PCR technique. One-way analysis of variance was applied to analyze gene expression.

Results:

Tumorsphere formation has been used to isolate the CSCs from the OSCC tissue culture. Both CD133 and CD44 antibody confirmed the presence of CSCs through indirect immunofluorescence. In comparison to parental cell lines, the expression levels of CD133, CD44, Oct4, Sox2, and Nanog stem cell were significantly higher in CSC-enriched subpopulations.

Conclusions:

The cost-effective spheroid enrichment and the indirect immunofluorescence methods are useful for the isolation of CSCs from the primary tumor.

The role of adjuvant (chemo-)radiotherapy in oral cancers in the contemporary era

Squamous cell carcinoma of oral cavity (OSCC) is predominantly managed with surgery. Post-operative radiotherapy (PORT) and chemoradiotherapy (POCRT) enhance disease control in OSCC patients with adverse anatomic and pathologic primary and nodal features. Knowledge about disease behavior, surgery and radiotherapy advances, and the emergence of new systemic agents prompt refinement of PORT volumes and POCRT regimens. Traditional and emerging prognostic models that include adverse histopathological features underpin such approaches. This review summarizes research over recent decades with emphasis on the 2015 to Feb 2019 period describing: (1) Indications for PORT and/or POCRT, addressing surgical "margin status" including the definition of a "clear" margin to permit withholding PORT/POCRT; these concepts include characterizing the specimen yielding these measurements, the optimal time point to assess these findings, and the putative value of a "revised margin" performed during the same operative procedure, (2) Emerging prognostic factors including nodal burden (total number of involved lymph nodes) and perineural invasion, (3) PORT volume design, dose/fractionation and optimal surgery-to-PORT interval, (4) Chemotherapy dose, schedule, and agents, and (5) On-going clinical trials involving systemic agents and combinations of chemotherapy with immunotherapy.

Multifocal perineural invasion is a better prognosticator than depth of invasion in oral squamous cell carcinoma

OBJECTIVES

Prognostic significance of perineural invasion (PNI) in oral squamous cell carcinoma (OSCC) characterized as unifocal and multifocal was compared to depth of invasion (DOI) and extranodal extension (ENE).

MATERIALS AND METHODS

Univariable and multivariable analyses of 861 consecutive patients with OSCC undergoing treatment between 1995 and 2018 were performed, with local failure (LF) and disease-specific mortality (DSS) as the primary endpoints.

RESULTS

After adjusting for other adverse histopathological factors and adjuvant therapy, multifocal PNI was associated with a greater risk of LF (P = .01) and DSS (P = 0.02) compared to DOI. The effect of multifocal PNI was comparable to the effect of nodal metastases without ENE (P = 0.02). LF and DSS were not improved by the administration of adjuvant radiotherapy within unifocal or multifocal PNI groups.

CONCLUSION

Multifocal PNI is associated with a greater risk of death in OSCC than DOI. Its effect is comparable to that of nodal metastases (without ENE).