Ardalan Ebrahimi

Lymph node density in oral cavity cancer: results of the International Consortium for Outcomes Research

Background:Lymph node density (LND) has previously been reported to reliably predict recurrence risk and survival in oral cavity squamous cell carcinoma (OSCC). This multicenter international study was designed to validate the concept of LND in OSCC.Methods:The study included 4254 patients diagnosed as having OSCC. The median follow-up was 41 months. Five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), locoregional control and distant metastasis rates were calculated using the Kaplan–Meier method. Lymph node density (number of positive lymph nodes/total number of excised lymph nodes) was subjected to multivariate analysis.Results:The OS was 49% for patients with LND⩽0.07 compared with 35% for patients with LND>0.07 (P<0.001). Similarly, the DSS was 60% for patients with LND⩽0.07 compared with 41% for those with LND>0.07 (P<0.001). Lymph node density reliably stratified patients according to their risk of failure within the individual N subgroups (P=0.03). A modified TNM staging system based on LND ratio was consistently superior to the traditional system in estimating survival measures.Conclusion:This multi-institutional study validates the reliability and applicability of LND as a predictor of outcomes in OSCC. Lymph node density can potentially assist in identifying patients with poor outcomes and therefore for whom more aggressive adjuvant treatment is needed.

Nodal yield and survival in oral squamous cancer: Defining the standard of care.

BACKGROUND: Elective neck dissection (END) is commonly used as a staging and therapeutic procedure for oral squamous cell carcinoma (SCC) at high risk of nodal metastases. The authors aimed to determine whether the extent of lymphadenectomy, as defined by nodal yield, is a prognostic factor in this setting. METHODS: A retrospective database review identified 225 patients undergoing END with curative intent for oral SCC between 1987 and 2009. Nodal yield was studied as a categorical variable for association with overall, disease-specific, and disease-free survival in univariate and multivariate analyses. RESULTS: Nodal yield <18 was associated with 5-year overall survival of 51% compared with 74% in those with nodal yield ≥18 (P = .009). Five-year disease-specific survival rates were 69% in those with <18 nodes and 87% in patients with ≥18 nodes (P = .022). Similar results were obtained for disease-free survival, with 5-year rates of 44% with <18 nodes versus 71% with ≥18 nodes (P = .043). After adjusting for the effect of age, nodal status, T stage, and adjuvant radiotherapy on multivariate analysis, nodal yield <18 was associated with reduced overall (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.1-3.6; P = .020), disease-specific (HR, 2.2; 95% CI, 1.1-4.5; P = .043), and disease-free survival (HR, 1.7; 95% CI, 1.1-2.8; P = .040). In the pathologically lymph node-negative subgroup (n = 148), similar results were obtained. CONCLUSIONS: Nodal yield is an independent prognostic factor in patients undergoing END for oral SCC. These results suggest that an adequate lymphadenectomy in this setting should include at least 18 nodes. Cancer 2011.

Lymph node ratio as an independent prognostic factor in oral squamous cell carcinoma

We aimed to validate the lymph node ratio (LNR) as an independent prognostic factor in oral squamous cell carcinoma (OSCC) and compare its utility with the current nodal staging system.

Primary Tumor Staging for Oral Cancer and a Proposed Modification Incorporating Depth of Invasion: An International Multicenter Retrospective Study

IMPORTANCE The current American Joint Committee on Cancer (AJCC) staging system for oral cancer demonstrates wide prognostic variability within each primary tumor stage and provides suboptimal staging and prognostic information for some patients. OBJECTIVE To determine if a modified staging system for oral cancer that integrates depth of invasion (DOI) into the T categories improves prognostic performance compared with the current AJCC T staging. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of 3149 patients with oral squamous cell carcinoma treated with curative intent at 11 comprehensive cancer centers worldwide between 1990 and 2011 with surgery ± adjuvant therapy, with a median follow-up of 40 months. MAIN OUTCOMES AND MEASURES We assessed the impact of DOI on disease-specific and overall survival in multivariable Cox proportional hazard models and investigated for institutional heterogeneity using 2-stage random effects meta-analyses. Candidate staging systems were developed after identification of optimal DOI cutpoints within each AJCC T category using the Akaike information criterion (AIC) and likelihood ratio tests. Staging systems were evaluated using the Harrel concordance index (C-index), AIC, and visual inspection for stratification into distinct prognostic categories, with internal validation using bootstrapping techniques. RESULTS The mean and median DOI were 12.9 mm and 10.0 mm, respectively. On multivariable analysis, DOI was a significantly associated with disease-specific survival (P < .001), demonstrated no institutional prognostic heterogeneity (I² = 6.3%; P = .38), and resulted in improved model fit compared with T category alone (lower AIC, P < .001). Optimal cutpoints of 5 mm in T1 and 10 mm in T2-4 category disease were used to develop a modified T staging system that was preferred to the AJCC system on the basis of lower AIC, visual inspection of Kaplan-Meier curves, and significant improvement in bootstrapped C-index. CONCLUSIONS AND RELEVANCE We propose an improved oral cancer T staging system based on incorporation of DOI that should be considered in future versions of the AJCC staging system after external validation.

The prognostic and staging implications of bone invasion in oral squamous cell carcinoma

A study was undertaken to determine whether bone invasion is an independent prognostic factor in oral squamous cell carcinoma (SCC) after taking into account the extent of bone invasion.

Improvement in survival of patients with oral cavity squamous cell carcinoma: An international collaborative study

An association between the survival of patients with oral cavity squamous cell carcinoma (OCSCC) and advancements in diagnosis and therapy has not been established.

Central compartment dissection in thyroid papillary carcinoma.

Background:Systematic elective paratracheal dissection for papillary thyroid carcinoma is controversial. Objective:This study aims to analyze the pattern of locoregional recurrence (LRR) to determine the potential benefit of elective paratracheal dissection and to identify prognostic factors influencing locoregional control and disease specific survival. Methods:A cohort of 342 patients who underwent a total thyroidectomy with or without neck dissection for a papillary thyroid carcinoma was retrospectively reviewed. Clinicopathological variables predicting for survival and control were examined. Results:All patients underwent total thyroidectomy and 84 underwent neck dissection as primary treatment. Sixty-six patients underwent a central compartment neck dissection. Twenty-eight (8.2%) patients developed LRR, of which 12 did not undergo neck dissection at initial surgery. The majority of neck recurrences were found in the lateral neck. Two patients (0.7%) without a paratracheal dissection done initially recurred only in the central compartment. On univariable analysis significant pathological predictors of locoregional control included tumor size, extrathyroidal extension (ETE), lymphovascular invasion and pathological lymph node status. Only ETE was a significant adverse prognostic variable for disease specific survival. On regression analysis, ETE and lymphovascular invasion were the only significant independent predictors of LRR. Paratracheal dissection did neither influence LRR nor central compartment control when adjusted for the effect of other variables. Conclusions:Strong conclusions are difficult to draw without a comparable group, but these results suggest that the absolute benefit of elective paratracheal dissection is small.

Predicting the pattern of regional metastases from cutaneous squamous cell carcinoma of the head and neck based on location of the primary

We aimed to analyze the distribution of regional nodal metastases according to primary tumor location in patients with cutaneous squamous cell carcinoma of the head and neck (SCCHN).

Predicting the Prognosis of Oral Squamous Cell Carcinoma After First Recurrence

OBJECTIVES to describe the clinicopathologic features of oral squamous cell carcinoma in patients who develop locoregional recurrence of disease, to identify factors that predict prognosis in the subset of patients treated with salvage surgery, and to determine the adjusted effect of time to recurrence. DESIGN cohort study. SETTING a head and neck cancer institute in Sydney, New South Wales, Australia. PATIENTS a total of 77 patients who underwent salvage surgery for oral squamous cell carcinoma that had been treated initially by surgery, radiotherapy, or surgery with postoperative radiotherapy. MAIN OUTCOME MEASURES univariable and multivariable analysis of clinical and pathologic risk factors. RESULTS median time to recurrence from initial treatment was 7.5 months (range, 0.9-143.9 mo), with 86% of recurrences occurring within the first 24 months. Surgical salvage was attempted in 77 patients who had experienced recurrence at the primary site (n = 39), ipsilateral neck (n = 27), and contralateral neck (n = 11). Time to recurrence, initial treatment modality, and site of failure were independent prognostic variables. CONCLUSIONS the relationship of these prognostic variables displays a dynamic interaction. Initial combined-modality treatment and shorter time to recurrence were associated with worse outcome, while the effect of site of recurrence (local vs regional) was dependent on an interaction with the time to recurrence. The result of this interaction was that local recurrence was worse for those who experienced it early (eg, <6 mo after the initial treatment) and nodal recurrence was worse for those who experienced it late (eg, ≥ 6 mo after the intial treatment).

Metastatic head and neck cutaneous squamous cell carcinoma: Defining a low-risk patient†

The purpose of this study was to determine whether there is a “low‐risk” subset of patients with regional metastatic head and neck cutaneous squamous cell carcinoma (SCC) suitable for treatment with surgery alone and omission of adjuvant radiotherapy.