Implementing American Joint Committee on Cancer 8th edition for head-and-neck cancer in India: Context, feasibility, and practicality

AJCC 8th Versus AJCC 7th as a Prognostic Indicator in Buccal Mucosal Squamous Cell Carcinoma

American Joint Committee for Cancer (AJCC) staging manual has been recently updated with 8th edition which led to an immense shift in the tumor, node, and composite stages, in comparison to the previous staging. This was mainly due to the incorporation of depth of invasion (DOI) and extranodal extension (ENE) in staging. The impact of new staging system is widely studied as combined subsites in oral cancer. This study is to focus on a single subsite of oral cavity which is known for its poor prognosis. We evaluated 109 patients who had buccal mucosal squamous cell carcinomas (BSCC) who underwent treatment, with a curative intend, between 2014 and 2015. Clinical records were reviewed and the tumors were re-staged as per 8th edition of AJCC; disease-free survival (DFS) was also analyzed. Our study population had a mean age of 54.5 ± 10.35 years and male to female ratio of 4:1. During a median follow-up of 41 months, 35 patients (32.1%) developed recurrence. There was a statistically significant shift in stages between AJCC 7th edition against AJCC 8th edition leading to 34% upshift in T-stage, 43.1% upshift in N-stage, eventually leading to a 23.9% upshift in the composite stage. Tumors which got upgraded due to upshift in nodal stage had a poor survival (p = 0.002). Newer staging system is easy to use in clinical practice. Around a quarter of the BSCC got upstaged with the introduction of the newer staging system. But it was surprising to note that there were no statistically significant differences in DFS between the tumors of the same composite stages with regard to the two staging systems.

Significance of cervical node necrosis in preoperative MRI as a prognostic indicator: retrospective study of patients with SCC of tongue

Aim: To ascertain the prognostic value of cervical nodal necrosis (CNN) observed in patients of tongue squamous cell carcinoma with magnetic resonance imaging. Materials and methods: In this retrospective observational study, records of 144 patients diagnosed with newly diagnosed SCC of tongue were considered. Preoperative MRI study, demographic and clinical data were reviewed. Based on MRI reports, patients were categorised into: with or without the presence of cervical node necrosis (CNN or non CNN). Subsequent treatments, histopathological reports and follow up data were studied to determine key prognostic elements, overall survival and disease free survival by statistical analysis. Results: The incidence of CNN was 55.55% in the study sample. CNN category, depth of invasion, N stage and extra nodal extension were significant negative prognostic factors for overall and disease free survival. Conclusion: Based on our results, pre operative MRI based presence of cervical node necrosis in tongue squamous cell carcinoma is an independent prognostic indicator for poor overall and disease free survival. Long term prospective studies with larger cohorts could be undertaken to establish its role as an important biomarker for precision treatments.

Importance and implications of neurovascular bundle involvement and other MRI findings of oral tongue squamous cell carcinoma (OTSCC) on prognosis

BACKGROUND

The description for T4a oral tongue cancer in the 8th edition AJCC staging can be improved further. In this article we attempted to identify the important radiological (MRI) findings that could possibly be included in the staging eventually.

METHODS

We included all oral tongue squamous cell carcinoma patients who underwent surgery at TMH between Jan 2012 to Dec 2018 and whose MRIs were available for review. The relation of the tumor to the neurovascular bundle (NVB) on MRI was classified as Type I to IV. The association of the type of NVB involvement with DFS and the presence of PNI in the final HPR was analyzed.

RESULTS

Two-hundred and fifty-nine patients satisfied the eligibility criteria. The majority of them were men (82.6%), with a median age of 49 Yrs. Sixty-nine percent of patients had either abutment (Type III) or encasement (Type IV) of the NVB. The presence of Abutment/encasement of the NVB was significantly associated with the presence of PNI in the final HPR (p < 0.001). This abutment/encasement was seen in clinically advanced T-stage tumors. However, the presence of abutment/encasement of the NVB influenced the DFS in the univariate analysis only.

CONCLUSION

Abutment/encasement of the NVB in patients with carcinoma oral tongue is often seen in advanced-stage tumors and is significantly associated with the presence of PNI in the final HPR. Hence, the relation of the tumor with the NVB should be further assessed to understand its importance and its possible inclusion in the AJCC T-staging.

Feasibility of Use of the 8th Edition of the American Joint Committee on Cancer Staging for Head and Neck Cancers in Indian Scenario: An Evaluative Study

INTRODUCTION

Inclusion of depth of invasion (DOI) and a separate classification for human papillomavirus (HPV)-associated Oropharyngeal Cancers (OPCs) are two of the many major changes in the 8th edition of the American Joint Committee on Cancer staging system. After more than 2 years of implementation, the authors found the need to evaluate if the Indian clinicians found it feasible to apply the system in their practice and if the same has influenced their decision-making.

METHODS

The survey was done in the form of a questionnaire which was distributed personally and via the internet to 100 clinicians. Seventy-two clinicians responded to the questionnaire. The results were analyzed and frequency distribution was computed.

RESULTS

Eighty-three percent of the clinicians experienced that palpation of the tumour was not a reliable method to determine the DOI. The common issues stated by the clinicians were difficulty in assessing DOI in certain subsites of the oral cavity (most commonly retromolar trigone-83%), inability to determine DOI in patients with trismus, and inability to correlate pathological and clinical DOI. Thirteen percent of the clinicians did not rely on radiological tools for measuring the DOI. Seventy percent of the clinicians did not perform a P16 assay for patients with oropharyngeal cancers. Fifty percent of the clinicians preferred chemoradiotherapy for early HPV positive oropharyngeal cancers.

DISCUSSION

Based on the results of the survey, the authors recommend a need for more interpretative guidelines and methods for determining the DOI. The authors also emphasize the need for determining HPV status for all oropharyngeal carcinomas.

Nuclear Magnetic Resonance Metabolomics Biomarkers for Identifying High Risk Patients with Extranodal Extension in Oral Squamous Cell Carcinoma

Extranodal extension (ENE) is an independent adverse prognostic factor in oral squamous cell carcinoma (OSCC), and is difficult to identify preoperatively. We aimed to discover biomarkers for high risk patients with ENE. Tandem tissue, plasma, and urine samples of 110 patients with OSCC were investigated through 600-MHz nuclear magnetic resonance (NMR) metabolomics analysis. We found that the levels of creatine, creatine phosphate, glycine, and tyramine in plasma significantly decreased in stage IV ENE positive OSCC compared with stage IV ENE negative OSCC. To understand the underlying mechanism behind the alteration of plasma metabolites, our tissue analysis revealed that the carnitine level significantly increased in tumors but significantly decreased in the adjacent normal tissue in advanced stage OSCC, in addition to decreased levels of alanine and pyruvate in tumor tissues. The global metabolomics analysis on tumor tissues also showed that stage IV tumors with an ENE positive status demonstrated higher levels of aspartate, butyrate, carnitine, glutamate, glutathione, glycine, glycolate, guanosine, and sucrose but lower levels of alanine, choline, glucose, isoleucine, lactate, leucine, myo-inositol, O-acetylcholine, oxypurinol, phenylalanine, pyruvate, succinate, tyrosine, valine, and xanthine than tumors with an ENE negative status. We concluded that metabolomics alterations in tumor tissues correspond to an increase in the tumor stage and are detectable in plasma samples. Metabolomic alterations of OSCC can serve as potential diagnostic markers and predictors of ENE in patients with stage IV OSCC.

Correlation between ER, PR, P53, Ki67 expression, and high-risk HPV infection in patients with different levels of cervical intraepithelial neoplasia

This study was designed to investigate the correlation between high-risk human papillomavirus (HPV) infection and the expression of IHC markers (ER, PR, p53, Ki67) in patients with different grades of cervical intraepithelial neoplasia (CIN). It was a retrospective study, which was conducted from June 2016 to June 2018. 140 specimens of CIN were collected from the pathology department of a certain hospital that included 40 specimens of CIN1, 50 specimens of CIN2 and 50 specimens of CIN3. The expression of ER, PR, P53 and Ki67 were determined by immunohistochemistry. The high-risk HPV infections were detected by PCR fluorescence quantification and were given the correlation analysis. In the 140 specimens, the positive rates of HPV16 and HPV18 in CIN1 specimens were 27.5% and 25.0% respectively, and in CIN2 specimens were 64.0% and 60.0% respectively, and in CIN3 specimens were 90.0% and 92.0% respectively, the difference were statistically significant (p<0.05). There were no significant correlation (p<0.05) between HPV16 and HPV18 positive rate and patient age, tissue differentiation, and tumor size. With the increased of CIN grade, the positive rate of ER, PR, P53 and Ki67 expression in specimen were also increased significantly, and the difference were statistically significant (p<0.05). Pearson correlation analysis showed there were positive correlation (p<0.05) between the positive rates of HPV16 and HPV18 and the positive rates of ER, PR, P53 and Ki67. With the increase of CIN level, the positive rates of high-risk HPV infection as well as ER, PR, P53 and Ki67 are increased, and they have positive correlation.