Prognostic impact of different TNM-based stage groupings for oral squamous cell carcinoma

Development and validation of a model for the prediction of disease-specific survival in patients with oral squamous cell carcinoma: based on random survival forest analysis

OBJECTIVE

To establish a model for predicting the disease-specific survival (DSS) of patients with oral squamous cell carcinoma (OSCC).

METHODS

Patients diagnosed with OSCC from the Surveillance, Epidemiology, and End Results (SEER) database were enrolled and randomly divided into development (n = 14,495) and internal validation cohort (n = 9625). Additionally, a cohort from a hospital located in Southeastern China was utilized for external validation (n = 582).

RESULTS

TNM stage, adjuvant treatment, surgery, tumor sites, age, grade, and gender were used for RSF model construction based on the development cohort. The effectiveness of the model was confirmed through time-dependent ROC curves in different cohorts. The risk score exhibited an almost exponential increase in the hazard ratio of death due to OSCC. In development, internal, and external validation cohorts, the prognosis was significantly worse for patients in groups with higher risk scores (all log-rank P < 0.05).

CONCLUSION

Based on RSF, a high-performance prediction model for OSCC prognosis was created and verified in this study.

The prognostic implications of comorbidity and risk factors for (post)operative complications, days spent in the intensive care unit (ICU), and length of hospitalization in patients with oral squamous cell carcinoma: A prospective study

BACKGROUND

This study aimed to investigate the prognostic implications of comorbidity/risk factors in a cohort of patients with OSCC.

METHODS

The prospective study included patients with biopsy-proven primary OSCC. The impact of potential predictors on (post)operative complications, days spent in the ICU, and length of hospitalization was analyzed using both univariate and multivariate analysis.

RESULTS

Using a microvascular free flap (p = 0.009) and tobacco abuse (p = 0.005) had statistically significant impacts on postoperative complications in univariate, but not in multivariate, analysis. The duration of anesthesia (p < 0.001), type of neck dissection (p = 0.014), reconstruction type (p < 0.001), and red blood cell transfusion during operation (p = 0.007) had statistically significant impacts on spending ≥ 3 days in ICU in univariate analysis, with reconstruction type (p = 0.022) and red blood cell transfusion during operation (p = 0.034) having similar impacts in multivariate analysis. The duration of anesthesia (p < 0.001), pT (p = 0.009), type of neck dissection (p = 0.046), reconstruction type (p < 0.001), and microvascular free flap (p < 0.001) had a statistically significant impacts on length of hospitalization in univariate analysis, with reconstruction type (p < 0.001) also having a significant impact in multivariate analysis.

CONCLUSION

None of the investigated variables showed a significant effect on the prediction of (post)operative complications according to the Clavien-Dindo classification. The type of reconstruction proved to be a valid predictor for the time spent in ICU as well as for the overall length of hospitalization. Red blood cell transfusion during operation further predicted the time spent in ICU after operation. Both variables should be taken into account when performing a comprehensive planning of the patients' hospitalization.

Long non-coding RNA C5orf66-AS1 prevents oral squamous cell carcinoma through inhibiting cell growth and metastasis

Oral squamous cell carcinoma (OSCC) is a major cancer type in the head and neck region. Recent studies have reported a marked rise in the incidence of OSCC. The present study was performed to better understand the roles that long non‑coding RNAs (lncRNAs) serve in OSCC carcinogenesis. The levels of the lncRNA C5orf66 antisense RNA 1 (C5orf66‑AS1) and of cytochrome c1 (CYC1) in OSCC tissues and cells were measured through reverse transcription‑quantitative polymerase chain reaction. In addition, the levels of associated proteins were analyzed by western blotting, while MTT assay was used to detect the cell proliferation ability. Wound healing and transwell assays were also used to detect the migration and invasion abilities of OSCC cells in the experimental groups, while flow cytometry was applied to analyze cell apoptosis. The findings revealed that the expression of lncRNA C5orf66‑AS1 in OSCC tissues and cells was significantly decreased. Overexpression of lncRNA C5orf66‑AS1 significantly inhibited the proliferation, invasion and migration ability of OSCC cells, and promoted cell apoptosis, while lncRNA C5orf66‑AS1 downregulation presented the opposite effects. In addition, it was observed that CYC1 was upregulated in OSCC tissues and cells, and was negatively regulated by lncRNA C5orf66‑AS1. Notably, CYC1 silencing markedly eliminated the effects of lncRNA C5orf66‑AS1 downregulation on OSCC cells. Taken together, these findings indicated that lncRNA C5orf66‑AS1 may prevent OSCC progression by inhibiting OSCC cell growth and metastasis via the regulation of CYC1 expression.

Prognostic impact of preoperative serum interleukin-6 levels in patients with early-stage oral squamous cell carcinoma, defined by sentinel node biopsy

Failure to detect recurrence and lymph node metastasis early represents a fundamental barrier to the improvement of survival rate in early stage oral squamous cell carcinoma (OSCC). The present study evaluated the association between serum interleukin-6 (IL-6) level and clinical outcomes in patients with early stage OSCC patients defined by sentinel node biopsy (SNB). A total of 53 patients with clinical stage I/II OSCC who underwent SNB were enrolled. SNB was determined by a radioisotope method, and was evaluated by histopathological examination and genetic analysis. Preoperative sera were measured for IL-6 by ELISA. In the clinical stage I/II patients, disease-free survival (DFS) was demonstrated to be higher in patients with negative SNB compared with patients with positive SNB. In total, 13 patients were demonstrated to exhibit lymph node metastasis by SNB or were reclassified to pathological stage T4 subsequent to analysis of the surgically resected specimens. Thus, 40 patients were diagnosed with early stage OSCC. Of these 40 patients, DFS of the patients with low serum IL-6 was significantly higher compared with the patients with high serum IL-6 (P=0.012). In 19 patients with negative SNB and low serum IL-6, the disease-free rate was 100%. These findings suggested that SNB staging and serum IL-6 level have a high prognostic value in patients with early stage OSCC. Additional investigation and longer follow-up times are warranted to improve understanding of the group of patients that may benefit from this procedure.

Concurrent chemoradiotherapy with S-1 in patients with stage III-IV oral squamous cell carcinoma: A retrospective analysis of nodal classification based on the neck node level

The aim of the present study was to retrospectively evaluate the treatment outcomes of concurrent chemoradiotherapy (CCRT) with S-1, an oral fluoropyrimidine anticancer agent, for advanced oral squamous cell carcinoma (SCC). The study population consisted of 47 patients with clinical stage III or IV oral SCC, who underwent CCRT with S-1. Pretreatment variables, including patient age, clinical stage, T classification, midline involvement of the primary tumor and nodal status, were analyzed as predictors of survival. In addition to the N classification (node-positive, multiple and contralateral), the prognostic impact of the level of nodal involvement was assessed. Nodal involvement was mainly observed at levels Ib and II; involvement at levels Ia and III-V was considered to be anterior and inferior extension, respectively, and was recorded as extensive nodal involvement (ENI). The 3-year overall survival (OS) and progression-free survival (PFS) rates were 37 and 27%, respectively. A finding of ENI was a significant factor for OS [hazard ratio (HR)=2.16; 95% confidence interval (CI): 1.03-4.55; P=0.038] and PFS (HR=2.65; 95% CI: 1.32-5.33; P=0.005); the 3-year OS and PFS rates in patients with vs. those without ENI were 23 vs. 50% and 9 vs. 43%, respectively. The other variables were not significant. Therefore, CCRT with S-1 may be an alternative treatment for advanced oral SCC; favorable outcomes are expected in patients without ENI.

Bryne's grading system predicts poor disease-specific survival of oral squamous cell carcinoma: a comparative study among different histologic grading systems

OBJECTIVES

The aim of this study was to access the prognostic value of 4 histopathologic grading systems of oral squamous cell carcinoma (OSCC): The World Health Organization (WHO), Anneroth, Bryne (1989), and Bryne (1992).

STUDY DESIGN

Eighty-five cases of OSCC diagnosed between 1996 and 2010 at the Clinics Hospital of Porto Alegre (Porto Alegre, Brazil) were included. Slides stained with hematoxylin and eosin were obtained, and a histologic grade was assigned on the basis of the consensus of 3 expert oral pathologists, who were blinded to the clinicopathologic factors. Each system was correlated with proliferative labeling index, accessed through Ki67 immunostaining, clinicopathologic factors, patient outcome (alive or deceased), and survival time.

RESULTS

The increase in Bryne (1992) histologic grades was accompanied by an increase in proliferative labeling index. Moreover, this system was the only one associated with patient outcome (P = .01) and survival. Bryne (1992) grading system grade III tumors were associated with poor disease-specific survival according to univariate and multivariate cox regression analyses and the log-rank test (P < .05). The other systems evaluated presented no association with patients' outcome or survival.

CONCLUSIONS

The Bryne (1992) grading system is more effective in predicting survival in OSCC compared with the systems proposed by the WHO, Anneroth, or Bryne (1989).

Prognostic Performance of Current Stage III Oral Cancer Patients After Curative Intent Resection: Evidence to Support a Revision of the American Joint Committee on Cancer Staging System

BACKGROUND

The American Joint Committee on Cancer (AJCC) stage III classification of oral cavity squamous cell carcinoma (OCSCC) represents a heterogeneous group of patients with early local disease with regional metastases (T1N1 and T2N1) and advanced local disease with or without regional metastasis (T3N0 and T3N1).

OBJECTIVE

The aim of this study was to evaluate prognostic heterogeneity in the stage III category.

METHODS AND PATIENTS

An international retrospective multicenter study of 1815 patients who were treated for OCSCC from 2003 to 2011.

RESULTS

Kaplan-Meier survival analysis and multivariate models of stage III patients revealed better overall survival (OS; HR 2.12, 95 % CI 1.03-4.15; p = 0.01) and disease-specific survival (DSS; HR 1.7, 95 % CI 1.16-4.12; p = 0.04) rates for patients with T1-2N1/T3N0 disease than for patients with T3N1 disease. The outcomes of patients with T3N1 and stage IVa disease were similar (p = 0.89 and p = 0.78 for OS and DSS, respectively). Modifying stage classification by transferring the T3N1 category to the stage VIa group resulted in a better prognostic performance [Harrell's concordance index, C index 0.76; Akaike's Information Criterion (AIC) 4131.6] compared with the AJCC 7th edition staging system (C index 0.65; AIC 4144.9) for OS. When DSS was assessed, the suggested staging system remained the best performing model (C index 0.71; AIC 1061.3) compared with the current AJCC 7th edition staging (C index 0.64; AIC 1066.2).

CONCLUSIONS

The prognosis of T3N1 and stage IVa disease are similar in OCSCC, suggesting that these categories could be combined in future revisions of the nodal staging system to enhance prognostic accuracy.

Comparison of the American Joint Committee on Cancer N1 versus N2a nodal categories for predicting survival and recurrence in patients with oral cancer: Time to acknowledge an arbitrary distinction and modify the system

BACKGROUND

We hypothesized that pathological N1 (pN1) and N2a (pN2a) nodal disease portend a similar prognosis in patients with oral cancer.

METHODS

An international multicenter study of 739 oral squamous cell carcinoma (SCC) patients with pN1 or pN2a stage disease was conducted. Multivariable analyses were performed using Cox proportional hazard models to compare locoregional failure, disease-specific survival (DSS), and overall survival (OS). Institutional heterogeneity was assessed using 2-stage random effects meta-analysis techniques.

RESULTS

Univariate analysis revealed no difference in locoregional failure (p = .184), DSS (p = .761), or OS (p = .475). Similar results were obtained in adjusted multivariable models and no evidence of institutional heterogeneity was demonstrated.

CONCLUSION

The prognosis of pN2a and pN1 disease is similar in oral SCC suggesting these categories could be combined in future revisions of the nodal staging system to enhance prognostic accuracy. However, these results may reflect more aggressive treatment of N2a disease; hence, we caution against using these data to deintensify treatment.

A 10-year analysis of the oral squamous cell carcinoma profile in patients from public health centers in Uruguay

The aim of this study was to evaluate the demographic, clinical, and therapeutic characteristics and predictive factors of poor prognosis in patients with primary oral squamous cell carcinoma (OSCC) in Uruguay. Medical records of patients with the diagnosis of primary OSCC treated between 2000 and 2010 in Uruguayan public hospitals were selected. Data on demographic characteristics, risk factors, clinical features, treatment, and outcome were collected. Associations of independent variables with outcomes were assessed using Pearson chi-squared and Fisher's tests. Of 200 patients with OSCC, 79.4% were men (3.8:1 male:female ratio), with a mean age of 60.75 ± 11.26 years. Tobacco and alcohol consumption were reported by 85.3% and 63.5% of patients, respectively. The most commonly affected location was the tongue (42.5%), with lesions exhibiting ulcerous aspects in 87.9% of cases and pain at the time of diagnosis in 70.4% of cases. One hundred sixty-one (82.1%) patients had advanced-stage (III/IV) OSCC. Surgery was the most common treatment option, and the overall 5-year survival rate was 58.5%. Univariate analysis showed that the predictors of poor prognosis were clinical aspect, size, regional metastasis, clinical stage, and treatment. In Uruguay, OSCC is diagnosed late, which is associated with a low survival rate. Educational and preventive measures and investment to improve early diagnosis should be undertaken.

Prognostic significance of interleukin-8 and CD163-positive cell-infiltration in tumor tissues in patients with oral squamous cell carcinoma

Purpose

We investigated whether serum interleukin (IL)-8 reflects the tumor microenvironment and has prognostic value in patients with oral squamous cell carcinoma (OSCC).

Experimental Design

Fifty OSCC patients who received radical resection of their tumor(s) were enrolled. Preoperative sera were measured for IL-8 by ELISA. Expression of IL-8 and the infiltration of immune cells in tumor tissues were analyzed by an immunohistochemical staining of surgical specimens.

Results

We found that disease-free survival (DFS) was significantly longer in the Stage I/II OSCC patients with low serum IL-8 levels compared to those with high levels (p = 0.001). The tumor expression of IL-8, i.e., IL-8(T) and the density of CD163-positive cells in the tumor invasive front, i.e., CD163(IF) were correlated with the serum IL-8 level (p = 0.033 and p = 0.038, respectively), and they were associated with poor clinical outcome (p = 0.007 and p = 0.002, respectively, in DFS) in all patients. A multivariate analysis revealed that N status, IL-8(T) and CD163(IF) significantly affected the DFS of the patients. Further analysis suggested that combination of N status with serum IL-8, IL-8(T) or CD163(IF) may be a new criterion for discriminating between OSCC patients at high and low risk for tumor relapse. Interestingly, the in vitro experiments demonstrated that IL-8 enhanced generation of CD163-positive M2 macrophages from peripheral blood monocytes, and that the cells produced IL-10.

Conclusions

These findings indicate that IL-8 may be involved in poor clinical outcomes via generation of CD163-positive M2 macrophages, and that these factors in addition to N status may have prognostic value in patients with resectable OSCSS.

Level of distress predicts subsequent survival in successfully treated head and neck cancer patients: a prospective cohort study

CONCLUSION

Our findings indicate a unique survival prediction from general health questionnaire (GHQ) sum scores in successfully treated head and neck squamous cell carcinoma (HNSCC) patients and also to some extent with inclusion of health-related quality of life (HRQoL) scores.

OBJECTIVE

To examine the survival prediction from the level of distress, measured by GHQ scores obtained from at inclusion successfully treated HNSCC patients.

METHODS

Structured interviews were conducted for 135 successfully treated cognitive functioning HNSCC patients 67 ± 31 (mean ± SD) months after diagnosis following a regular follow-up visit. GHQ scores, alcohol consumption history, smoking status, present comorbidities, level of neuroticism, choice of psychological coping with the cancer disease, and HRQoL scores (EORTC QLQ-C30 and -H&N35) were determined. The TNM stage, treatment provided and tumour site were obtained from the hospital records. Forty-three deaths were noted during a minimum 8.5 years of observation.

RESULTS

The GHQ sum scores predicted survival in univariate (p < 0.05) and multivariate analyses with the above-mentioned covariates included (p < 0.01). Using clinically relevant cut-off levels, GHQ scores predicted survival in both univariate (hazard ratio (HR) 1.9; p = 0.05) and multivariate Cox regression analyses (HR 3.8; p = 0.001). We also demonstrated survival prediction from GHQ scores when adjusted by HRQoL scores.

CD44+/CD133+ immunophenotype and matrix metalloproteinase-9: Influence on prognosis in early-stage oral squamous cell carcinoma

BACKGROUND

The purpose of this study was to investigate the expression of CD44 and/or CD133 immunophenotypes and the associated effects of matrix metalloproteinase-9 (MMP-9) in early-stage oral squamous cell carcinomas (SCC) to assess their influence on tumor prognosis.

METHODS

The following data were derived from 150 patients: age, sex, primary anatomic site, smoking status, alcohol intake, recurrence, metastases, histological classification, treatment, disease-free survival (DFS), and overall survival (OS). Immunohistochemical study of CD44, CD133, and MMP-9 expression was performed on a tissue microarray of 150 paraffin blocks of oral SCCs.

RESULTS

The predominant immunophenotype identified to exhibit a significant correlation with MMP-9 was the CD44+/CD133+. Multivariate analyses identified a significant correlation of OS with surgical treatment and with CD44+/CD133+ immunophenotype.

CONCLUSION

This investigation demonstrated the prognostic importance of CD44/CD133 expression, which can help improve the prognostic value of surgical treatment for oral SCCs when diagnosed in early stages.

Influence of formalin fixation on tissue dimensions in palatal tonsils

AIM

To investigate the change of tissue dimensions after formalin fixation, and to determine the optimal time of fixation.

HYPOTHESIS

Formalin fixation may lead to shrinkage in tissue dimensions and may thus alter tumor stages.

BACKGROUND

It is often observed in tumor surgery that the dimensions in vivo seem larger than after resection, and tissue appears to shrink further after formalin fixation. This might alter dimensions and assessment of spread of the tumor and thus lead to a lesser tumor classification and stage. In cases where the decision for adjuvant chemoradiation is based upon the stage, it may thus be of relevance for the patient to evaluate the pathologic and not the in vivo dimensions of the tumor.

MATERIAL AND METHODS

In order to obtain comparable tissues, we investigated 100 palatal tonsils after cold steel dissection tonsillectomy for chronic tonsillitis. There were four time points investigated: directly after excision in the operating room and after four, 24 and 72 h of fixation in formaldehyde (4% Formaldehyde in phosphate buffer pH 7.4). The tissue was measured in the following dimensions: volume (ml), weight (g) and length, broadness and width (mm).

RESULTS

The tissue size did not change significantly in dimensions except for an increase in length. The time of fixation did not influence the size.

DISCUSSION

Formalin fixation does not significantly influence the tissue dimensions of palatal tonsils in comparison to direct ex vivo measurements. A minimal time of fixation of 20 h is required in order to stop all degenerative processes; however, longer fixation does not change the dimensions of the specimen.

CONCLUSION

The null hypothesis has to be withdrawn that tissue dimensions are altered by formalin fixation. Thus, the histopathological measurements do not influence TNM staging.

Neoadjuvant chemoradiation in squamous cell carcinoma of the maxillary sinus: a 26-year experience

Background. The aim of our study was to evaluate the effects of neoadjuvant platinum-based radiochemotherapy (RCT) in patients with maxillary sinus squamous cell carcinoma and to compare the results with other multimodality treatment concepts for advanced-stage maxillary sinus carcinoma in the literature. Methods. In total, 53 patients with squamous cell carcinoma of the maxillary sinus were reviewed retrospectively. All patients received a neoadjuvant RCT containing either cisplatin or carboplatin followed by radical surgery. Overall survival and locoregional control were plotted by Kaplan-Meier analysis. Prognostic factors were identified through univariate and multivariate analysis. Results. Five-year overall survival for all patients was 35%. Eleven patients achieved a complete response after radiochemotherapy. The complete response rate was significantly higher for patients treated with cisplatin (P = 0.028); however the 5-year overall survival rates did not differ significantly (P = 0.673) for patients treated with cisplatin (37%) and carboplatin (32%). Orbital invasion (P = 0.005) and complete response to radiochemotherapy (P = 0.021) had a significant impact on overall survival in univariate analysis. Conclusions. Neoadjuvant radiochemotherapy followed by radical surgery is an effective treatment for patients with advanced maxillary sinus squamous cell carcinoma. In terms of treatment response cisplatin seems to be more effective than carboplatin.

Stage grouping in tumors of the ethmoid sinuses and the nasal cavity using the sixth edition of the UICC classification of malignant tumors

BACKGROUND

The purpose of this study was to evaluate the prognostic impact of the sixth edition of the Union Internationale Contre le Cancer (UICC) classification and different TNM-based stage groupings for malignant tumors of the ethmoid sinuses and the nasal cavity.

METHODS

We conducted a retrospective analysis of 98 patients with malignant tumors of the ethmoid sinuses and the nasal cavity between 1967 and 2003. The UICC classification of the sixth edition and the T and N Integer Score (TANIS) and Hart were tested for their prognostic significance.

RESULTS

In univariate analysis, all stage groupings revealed discriminatory power for overall survival (OS; p < .05), however, in multivariate analysis only the UICC-stage grouping (p = .033) and the TANIS-8 scheme (p = .044) predicted OS. The TANIS did not have a better prognostic quality than the sixth edition of the UICC classification.

CONCLUSION

The UICC-stage grouping of the sixth edition is a good prognostic index for malignant tumors of the ethmoid sinuses and the nasal cavity.