Lymph node ratio for postoperative staging of laryngeal squamous cell carcinoma with lymph node metastasis

Impact of lymph node ratio and number of lymph node metastases on survival and recurrence in laryngeal squamous cell carcinoma

INTRODUCTION

The aim of this study is to assess the impact of lymph node ratio (LNR) and number of positive lymph nodes (NPLN) on mortality and recurrence rates in patients with laryngeal squamous cell carcinoma.

MATERIALS AND METHODS

We conducted a retrospective multicenter international study involving 24 Otorhinolaryngology-Head and Neck Surgery divisions. Disease-specific survival (DSS) and disease-free survival (DFS) were evaluated as the main outcomes. The curves for DSS and DFS according to NPLN and LNR were analyzed to identify significant variations and establish specific cut-off values.

RESULTS

2507 patients met the inclusion criteria. DSS and DFS were significantly different in the groups of patients stratified according to LNR and NPLN. The 5-year DSS and DFS based on LNR and NPLN demonstrated an improved ability to stratify patients when compared to pN staging.

CONCLUSION

Our data demonstrate the potential prognostic value of NPLN and LNR in laryngeal squamous cell carcinoma.

Lymph node ratio as a survival predictor for head and neck squamous cell carcinoma with multiple adverse pathological features

BACKGROUND

The study investigates the prognostic significance of lymph node ratio (LNR) on patients with head and neck squamous cell carcinoma (HNSCC) with coexistence of multiple adverse pathological features.

METHODS

In total, 100 patients with coexistence of perineural invasion, lymphovascular invasion, and extranodal extension of first primary HNSCC treated with radical surgery followed by adjuvant chemoradiotherapy were enrolled.

RESULTS

The optimal LNR cut-off value for predicting overall survival (OS) and cancer specific survival (CSS) was 7%. In Cox model, we observed that LNR ≥7% was a statistically significant unfavorable predictor of OS (HR: 2.689; 95% CI: 1.228-5.889; p = 0.013) and CSS (HR: 3.162; 95% CI: 1.234-8.102; p = 0.016).

CONCLUSION

For HNSCC patients with coexistence of multiple adverse pathological features, LNR is an independent survival predictor. Novel intensified treatments are needed for the subgroup of patients with a high LNR.

A prediction model for the 5-year, 10-year and 20-year mortality of medullary thyroid carcinoma patients based on lymph node ratio and other predictors

Aim

To explore the predictive value of lymph node ratio (LNR) for the prognosis of medullary thyroid carcinoma (MTC) patients, and constructed prediction models for the 5-year, 10-year and 20-year mortality of MTC patients based on LNR and other predictors.

Methods

This cohort study extracted the data of 2,093 MTC patients aged ≥18 years undergoing total thyroidectomy and neck lymph nodes dissection. Kaplan-Meier curves and log-rank tests were performed to compare survival curves between LNR < 15% group and LNR ≥ 15% group. All data was divided into the training set (n = 1,465) and the testing set (n = 628). The random survival forest model was constructed in the training set and validated in the testing set. The area under the curve (AUC) was employed for evaluating the predictive ability of the model.

Results

The 5-year, 10-year and 20-year overall survival (OS) and cause-specific survival (CSS) of MTC patients with LNR <15% were higher than those with LNR ≥15%. The OS was 46% and the CSS was 75% after 20 years' follow-up. The AUC of the model for the 5-year, 10-year, and 20-year OS in MTC patients was 0.878 (95%CI: 0.856-0.900), 0.859 (95%CI: 0.838-0.879) and 0.843 (95%CI: 0.823-0.862) in the training set and 0.845 (95%CI: 0.807-0.883), 0.841 (95%CI: 0.807-0.875) and 0.841 (95%CI: 0.811-0.872) in the testing set. In the training set, the AUCs were 0.869 (95%CI: 0.845-0.892), 0.843 (95%CI: 0.821-0.865), 0.819 (95%CI: 0.798-0.840) for the 5-year, 10-year and 20-year CCS in MTC patients, respectively. In the testing set, the AUCs were 0.857 (95%CI: 0.822-0.892), 0.839 (95%CI: 0.805-0.873) and 0.826 (95%CI: 0.794-0.857) for the 5-year CCS, 10-year CCS and 20-year CCS in MTC patients, respectively.

Conclusion

The models displayed good predictive performance, which might help identify MTC patients might have poor outcomes and appropriate interventions should be applied in these patients.

Dysregulated YY1/PRMT5 axis promotes the progression and metastasis of laryngeal cancer by targeting Hippo pathway

Metastases lead to high mortality in laryngeal cancer, but the regulation of its underlying mechanisms remains elusive. We identified Protein arginine methyltransferase 5 (PRMT5) was significantly up‐regulated in laryngeal cancer tissues, which predicts poor patient prognosis. Functional assays demonstrated that PRMT5 overexpression promoted the invasive capacity and lymph node metastasis in vitro and in vivo. Mechanistic experiments suggested that LATS2 was a downstream target of PRMT5. PRMT5 inhibition increased the expression of LATS2 and YAP phosphorylation in laryngeal cancer cells, thereby promoting laryngeal cancer metastasis. Furthermore, informatics and experimental data confirmed that PRMT5 gene was transcriptionally activated by YY1. Collectively, our results unravelled the important role of PRMT5 in laryngeal cancer tumorigenesis and metastasis. The dysregulation YY1/PRMT5/LATS2/YAP axis may contribute to laryngeal cancer progression; thus, PRMT5 may be a potential therapeutic strategy for patients with laryngeal cancer.

PRMT5/Wnt4 axis promotes lymph-node metastasis and proliferation of laryngeal carcinoma

Metastasis is the main cause of laryngeal cancer-related death; its molecular mechanism remains unknown. Here we identify protein arginine methyltransferase 5 (PRMT5) as a new metastasis-promoting factor in laryngeal carcinoma, and explore its underlying mechanism of action in regulating laryngeal cancer progression. We illustrated that PRMT5 expression was positively correlated with tumor stages, lymphatic metastasis, and unfavorable outcome. Functional assays revealed that PRMT5 promoted laryngeal carcinoma cell proliferation, migration, and invasive capacity in vitro, as well as lymph-node metastasis in vivo. The ectopic expression of PRMT5 induced EMT with downregulation of E-cadherin and upregulation of N-cadherin, snail, and MMP9. Mechanistic results revealed that the metastatic effects could be attributed to PRMT5-mediated activation of Wnt signaling, and Wnt4 is an important driver of Wnt/β-catenin signaling pathway. Wnt4 silencing could reverse PRMT5-induced cell proliferation, migration, and invasion capacities. Furthermore, inhibition of the Wnt/β-catenin signaling pathway abolished the effect of PRMT5-induced proliferation, whereas activation of the pathway enhanced the effect of PRMT5 overexpression on cell proliferation. These results demonstrated that the oncogenic role of PRMT5 could be attributed to PRMT5/Wnt4 axis-mediated activation of the Wnt/β-catenin signaling pathway. PRMT5 may serve as a novel prognostic marker and a therapeutic target for lymphatic metastasis of laryngeal carcinoma.

Prognostic capacity of the lymph node ratio in squamous cell carcinomas of the head and neck

INTRODUCTION AND OBJECTIVES

Lymph node density or lymph node ratio (LNR), defined as the quotient between the total number of positive lymph nodes and the total number of dissected lymph nodes, has demonstrated a prognostic capacity in several tumour models, including patients with head and neck squamous cell carcinomas (HNSCC). The aim of the present study is to analyse the prognostic value of LNR in a wide cohort of patients with HNSCC.

METHODS

We carried out a retrospective study of a cohort of 1,311 patients with HNSCC treated with unilateral or bilateral neck dissections. Of the patients included in the study, 55.0% had lymph node metastases (pN+). We proceeded to calculate the value of the LNR, and its categorization through a recursive partition analysis considering specific survival as the dependent variable.

RESULTS

Three categories were defined according to the value of the LNR with a cut-off point at the values < of .025 and .118. The 5-year specific survival for patients with an LNR less than .025 (n=654, 49.8%) was 87.2%, for patients with a LNR .025-.118 (n=394, 30.1%) it was 51.6%, and for patients with a LNR greater than .188 (n=263, 20.1%) it was 27.3% (P=.0001). According to the results of a multivariate analysis, the LNR significantly related to specific survival.

CONCLUSION

The LNR can be a prognostic variable to be considered in the pathological staging of the lymph nodes.

Prognostic value of lymph node ratio in laryngeal and hypopharyngeal squamous cell carcinoma: a systematic review and meta-analysis

Background

Several recent studies have indicated that the lymph node ratio (LNR) is an independent prognostic factor for laryngeal and hypopharyngeal squamous cell carcinoma (LHSCC). The purpose of this paper is to assess the prognostic value of LNR and explore appropriate cutoff values by conducting a systematic review and meta-analysis.

Methods

Pubmed, Embase (via Ovid), and Cochrane library were systematically searched for studies on the prognostic value of LNR in LHSCC up to October 31, 2019. Then, Literature review, data extraction, and quality assessment of eligible studies were performed by two independent reviewers back-to-back. Lastly, Stata 14.0 software was hired to conduct a meta-analysis.

Results

A total of 445 articles were retrieved, and 13 studies published in English between 2013 and 2019 were included after the title/abstract and full-text screening. Among the 13 studies contributed to 4197 patients, seven studies were about hypopharyngeal squamous cell carcinoma (HPSCC), four studies about laryngeal squamous cell carcinoma (LSCC), and the remaining two studies about LHSCC. The meta-analysis results showed that shorter overall survival (OS) (HR 1.49; 95%CI: 1.18 to 1.88), disease-specific survival (DSS) (HR 1.66; 95%CI: 1.32 to 2.07) and disease-free survival (DFS) (HR 2.04; 95%CI: 1.54 to 2.71) were significantly correlated with a higher LNR in a random-effect model. The cutoff values of eligible studies were varied from 0.03 to 0.14, and the lowest significant LNR was 0.044.

Conclusion

LNR is a valuable prognostic factor in the survival of LHSCC and may be used to improve the tumor staging systems, which, however, requires the solid support of more high-quality studies.

Analyses of High-Risk Factors for Cervical Lymph Node Metastasis in Laryngeal Squamous Cell Carcinoma and Establishment of Nomogram Prediction Model

Laryngeal squamous cell carcinoma (LSCC) is one of the most common laryngeal tumors, and its incidence is increasing yearly; however, whether lymph node dissection should be performed during surgery remains unclear. We retrospectively analyzed the clinical and pathological data of 246 cases of LSCC and developed a nomogram for the prediction of lymph node metastasis (LNM) of LSCC. The predictive performance and consistency of the model were evaluated using the consistency coefficient (C-index) and calibration curve, respectively. Among 246 cases of LSCC, 52 cases had metastasis with a positivity rate of 21.14%. Multivariate analyses showed that dysphagia, clinical T stage, and pathological differentiation were independent risk factors for LNM in LSCC. The accuracy of the contour map used to predict the risk for LNM was 0.809. Overall, this nomogram model can be used to evaluate LNM in patients with LSCC before surgery to decide whether to conduct neck dissection and improve patient prognosis.

Lymph node yield and lymph node density for elective level II-IV neck dissections in laryngeal squamous cell carcinoma patients

PURPOSE

To determine the minimum lymph node yield (LNY) in patients with laryngeal squamous cell carcinoma (LSCCs).

METHODS

This retrospective study was performed in a tertiary care hospital setting and included 42 LSCC patients aged 39-81 years (females, n = 2; males, n = 40) who underwent a total or partial laryngectomy and elective bilateral level II-IV neck dissections (unilateral neck dissections: n = 84).

RESULTS

The average LNY in the unilateral level II-IV lymph node dissections was 25.9 ± 10, and the average metastatic LNY was 0.9 ± 1.9. The unilateral neck dissections were grouped according to the number of lymph nodes. There was no significant difference between the groups in terms of the metastatic LNY (p = 0.5). The metastatic lymph node density (LND) (metastatic lymph node yield/LNY) was 0.043 for unilateral neck level II-IV neck dissections. A Cox regression analysis revealed no significant relationship between survival and the LNY and LND in bilateral neck dissections (p = 0.4 and p = 0.8, respectively).

CONCLUSIONS

The results revealed no minimum number of lymph nodes that could reliably detect metastatic lymph nodes in LSCC patients.

The Prognostic Significance of Lymph Node Ratio and Log Odds Ratio in Laryngeal Squamous Cell Carcinoma

Objective

To investigate whether lymph node ratio (LNR) and log odds ratio (LODDS) have prognostic significance for overall survival (OS) and disease-free survival (DFS) in patients with laryngeal squamous cell cancer (LSCC) treated with curative intent.

Study Design

Case-control study.

Setting

University hospital.

Subjects and Methods

Records of 229 patients with LSCC who underwent surgery with a curative intent with or without adjuvant treatment from 2000 to 2014 were reviewed. The clinicopathological parameters LNR and LODDS were analyzed; univariate and multivariate analysis was performed to evaluate the prognosis of each for OS and DFS.

Results

The 5-year OS was 81.7% for LNR ≤0.233 and 47.1% for LNR >0.233, and the 5-year OS was 79.6% for LODDS ≤–0.1 and 51.8% for LODDS >–0.1, respectively. In the univariate analysis, the independent variables were subsites, pT stage (pT1 and pT2 vs pT3 and pT4), pN, pTNM, alcohol consumption, and LNR and LODDS (P < .05). By multivariate analysis, we determined that subsites, pT stage, alcohol consumption, LNR, and LODDS were independent prognostic predictors of survival (P < .05). Univariate and multivariate models identified that both LNR and LODDS were significant prognostic factors for survival. However, the hazard ratio (HR) for LNR >0.233 vs ≤0.233 was 8.95 (95% confidence interval [CI], 3.18-25.16; P < .001) in OS, and the HR was 11.37 (95% CI, 4.02-32.15; P < .001) in DFS. The risk of LNR was noticeably greater than other factors.

Conclusions

LNR and LODDS were both prognostic factors for OS and DFS. However, LNR was confirmed as a more reliable indicator for evaluating the prognosis, and it can be used to increase the prognostic value of the traditional TNM classification of LSCC.

Development of comprehensive nomograms for evaluating overall and cancer-specific survival of laryngeal squamous cell carcinoma patients treated with neck dissection

Background

Neck dissection for laryngeal squamous cell carcinoma (LSCC) patients could provide complementary prognostic information for AJCC N staging, like lymph node ratio (LNR). The aim of this study was to develop effective nomograms to better predict survival for LSCC patients treated with neck dissection.

Results

2752 patients were identified and randomly divided into training (n = 2477) and validation (n = 275) cohorts. The 3- and 5-year probabilities of cancer-specific mortality (CSM) were 30.1% and 37.2% while 3- and 5-year death resulting from other causes (DROC) rate were 6.2% and 11.3%, respectively. 13 significant prognostic factors including LNR for overall (OS) and 12 (except race) for CSS were enrolled in the nomograms. Concordance index as a commonly used indicator of predictive performance, showed the nomograms had superiority over the no-LNR models and TNM classification (Training-cohort: OS: 0.713 vs 0.703 vs 0.667, CSS: 0.725 vs 0.713 vs 0.688; Validation-cohort: OS: 0.704 vs 0.690 vs 0.658, cancer-specific survival (CSS): 0.709 vs 0.693 vs 0.672). All calibration plots revealed good agreement between nomogram prediction and actual survival.

Materials and Methods

We identified LSCC patients undergoing neck dissection diagnosed between 1988 and 2008 from Surveillance, Epidemiology, and End Results (SEER) database. Optimal cutoff points were determined by X-tile program. Cumulative incidence function was used to analyze cancer-specific mortality (CSM) and death resulting from other causes (DROC). Significant predictive factors were used to establish nomograms estimating overall (OS) and cancer-specific survival (CSS). The nomograms were bootstrapped validated both internally and externally.

Conclusions

Comprehensive nomograms were constructed to predict OS and CSS for LSCC patients treated with neck dissection more accurately.

Prognostic value of lymph node ratio in head and neck squamous cell carcinoma

BACKGROUND

Lymph node ratio (LNR) is increasingly reported as a potential prognostic tool. The purpose of this review was to analyze the available literature on the prognostic significance of LNR in head and neck squamous cell carcinoma (HNSCC).

METHODS

A PubMed internet search was performed and articles meeting selection criteria were reviewed.

RESULTS

Twenty-eight studies were identified in the literature dealing with the prognostic value of LNR. The published results are variable with a range of cutoff values of LNR associated with prognosis (overall survival [OS] and/or disease-specific survival [DSS]) between 0.02 and 0.20, with an average of 0.09.

CONCLUSION

The LNR is reported to be of value in assessing prognosis in the patients with HNSCC. Although it is easy to calculate and could be considered in the staging of these patients, the currently available evidence in the literature does not yet provide a solid base for implementation.

The prognostic value of negative lymph node count for patients with cervical cancer after radical surgery

Negative lymph node (NLN) count has been recognized as a prognostic indicator in various cancers. However, the relationship between NLN count and the prognosis of cervical cancer is still unknown. In this study, 10, 500 cervical cancer patients after radical surgery were selected from Epidemiology and End Results Program (SEER) data. Clinicopathological characteristics were collected for analysis, including year of diagnosis, age, race, grade, primary site, FIGO stage and cause specific survival (CSS). Univariate and multivariate Cox proportional hazards model was used to assess risk factors for survival of patients. X-tile plots identified 6 as the optimal cutoff value of NLN count to divide patients into high and low risk subsets in terms of CSS (χ² = 183.95, P < 0.001). The rate of 5-year CCS of cervical cancer patients was improved with an increase in NLN count from 0 to 23 (all P < 0.001). NLN count was validated as an independently prognostic factor by the multivariate Cox analysis (HR: 1.571, 95% CI: 1.370~1.801, P < 0.001). Subgroup analysis showed that NLN count was a prognosis factor in FIGO stage I (χ²=35.023, P < 0.001), stage II (χ² = 12.910, P < 0.001), stage III + IV (χ² = 9.732, P = 0.002) and unknown stage (χ² = 16.654, P < 0.001). Conclusively, this study demonstrated the NLN count was an independent prognostic factor for cervical cancer patients.

AHNS Series: Do you know your guidelines? Review of current knowledge on laryngeal cancer

The following article is part of a series in an initiative by the American Head and Neck Society's Education Committee and will review clinical practice guidelines for head and neck oncology. The primary goal is to increase awareness of current best practices pertaining to head and neck surgery and oncology. This manuscript is a review of current knowledge in laryngeal cancer with a focus on anatomy, epidemiology, diagnosis, evaluation, and treatment.

Matched-pair analysis of survival in patients with poorly differentiated versus well-differentiated glottic squamous cell carcinoma

To compare survival outcomes between patients with poorly differentiated versus well-differentiated glottic squamous cell carcinoma (GSCC). Fifty-five patients with well-differentiated newly diagnosed GSCC were pair-matched to 55 patients with poorly differentiated GSCC according to age, sex, year of diagnosis, overall stage, treatment (surgery type, neck dissection, surgical margin, and chemoradiation), smoking, and alcohol use. Survival analysis was performed using Kaplan-Meier estimates, and matched-pair survival was estimated using the Cox proportional hazards regression model. Patients with well-differentiated GSCC had significantly better overall survival (OS) (P = 0.001), disease-specific survival (DSS) (P < 0.001), and disease-free survival (DFS) (P = 0.003) than patients with poorly differentiated GSCC. Moreover, matched-pair analysis indicated that increased differentiation was associated with a significantly reduced risk of overall death (HR, 0.18; 95% confidence interval [CI], 0.07–0.46), death owing to disease (HR, 0.16; 95% CI, 0.05–0.45), and disease recurrence (HR, 0.17; 95% CI, 0.07–0.41), and these risks were reduced approximately 4-fold, 3.7-fold, and 9-fold, respectively, after adjustment for cancer-associated variables. Survival differed significantly between the well-differentiated and poorly differentiated GSCC patients after adjustment for cancer prognosis-associated variables. Thus, identifying potential differences in the molecular characteristics between these two groups of patients would help to further stratify these patients and ensure appropriate individualized treatment decisions. Basing treatment strategies on the level of differentiation may improve survival.

Lymph Node Density in Node-Positive Laryngeal Carcinoma: Analysis of Prognostic Value for Survival

OBJECTIVE

We investigated the value of lymph node density (LND) as a predictor of survival in patients with laryngeal squamous cell carcinoma (SCC) and positive neck node (pN+) after laryngectomy.

STUDY DESIGN

Case series with chart review.

SETTING

Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey.

SUBJECTS AND METHODS

We reviewed the records of 289 patients with newly diagnosed primary laryngeal carcinomas who underwent partial or total laryngectomy and combined neck dissection at a tertiary referral center between June 2006 and December 2014. Patients with pN+ laryngeal SCC (n = 101) were included in the study. Overall survival (OS) and disease-free survival (DFS) were used to evaluate the prognostic significance of LND.

RESULTS

In 101 patients with pN+ laryngeal SCC, LND ≥0.09 and number of metastatic lymph nodes >4 were significantly associated with OS and DFS but not the overall tumor, node, and metastasis stage. Forward stepwise Cox regression analysis revealed that LND ≥0.09 was the only independent predictor of both DFS and OS. Furthermore, the odds ratio of LND ≥0.09 was 10 times higher in patients with regional recurrence when compared patients without regional recurrence.

CONCLUSIONS

LND was the only independent prognostic predictor of OS and DFS in patients with pN+ laryngeal SCC. Moreover, patients with LND ≥0.09 were significantly associated with high risk of regional recurrence. Thus, patients with LND ≥0.09 are at high risk of regional recurrence and death and may be considered for adjuvant chemoradiation.

Long non-coding RNA profiling in laryngeal squamous cell carcinoma and its clinical significance: potential biomarkers for LSCC

Long non-coding RNAs (lncRNAs) are novel transcripts that may play important roles in cancer. Our study aimed to resolve the lncRNA profile of larynx squamous cell carcinoma (LSCC) and to determine its clinical significance. The global lncRNA expression profile in LSCC tissues was measured by lncRNA microarray. Distinctly expressed lncRNAs were identified and levels of AC026166.2-001 and RP11-169D4.1-001 lncRNAs in 87 LSCC samples and paired adjacent normal tissue were analyzed by real-time quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR). The clinical significance of these lncRNAs in laryngeal cancer was analyzed and survival data were estimated by the Kaplan–Meier method and the log-rank test. A receiver operating characteristic (ROC) curve was constructed to check the diagnostic value. In the lncRNA expression profile of tumor samples, 684 lncRNAs were upregulated and 747 lncRNAs were downregulated (fold-change >2.0). Of these, AC026166.2-001 and RP11-169D4.1-001 were distinctly dysregulated, with AC026166.2-001 exhibiting lower expression in cancer tissues and RP11-169D4.1-001 higher expression. We verified that both AC026166.2-001 and RP11-169D4.1-001 were expressed at a lower level in cervical lymph nodes compared with paired laryngeal cancer tissues and paired normal tissues. RP11-169D4.1-001 levels were positively correlated with lymph node metastasis (P = 0.007). From the survival analysis, decreased levels of AC026166.2-001 and RP11-169D4.1-001 were associated with poorer prognosis. The area under the ROC curve was up to 0.65 and 0.67, respectively, and the cut-off point of ΔCt was 11.23 and 10.53, respectively. AC026166.2-001 and RP11-169D4.1-001 may act as novel biomarkers in LSCC and may be potential therapeutic targets for LSCC patients. Both AC026166.2-001 and RP11-169D4.1-001 could be independent prognostic factors for survival in LSCC.