H. Lewis-Jones

Extracapsular spread in oral squamous cell carcinoma.

Extracapsular spread (ECS) in the cervical lymph nodes represents the most significant adverse prognostic indicator in oral squamous cell carcinoma (OSCC).

Correlation of histopathologic findings with clinical and radiologic assessments of cervical lymph-node metastases in oral cancer

The accuracy of preoperative diagnosis of cervical lymph-node metastasis in oral cancer was assessed by comparing the histopathologic findings in 136 sides of neck dissection with physical examination under anaesthesia (EUA) and computerized tomography (CT) assessments of the metastatic status. The overall accuracy of EUA and CT assessments was 72% and 73%, respectively, and a combination of both methods resulted in sensitivity and specificity rates of 55% and 78%, respectively. Twenty-three of the 51 histologically positive necks had been assessed as negative on both EUA and CT. Six of these contained only micro-metastases, and in another 10, the largest positive node was 1.5 cm or less. Extracapsular spread of metastatic carcinoma was found in 12 of the 23 EUA and CT false-negative dissections. Most of the 21 histologically positive necks which had been correctly assessed as positive on both EUA and CT contained enlarged metastatic nodes, fused nodal masses, extensive extracapsular spread, or more than one of these features. Three of the 85 histologically negative necks had been assessed as positive on both EUA and CT; eight had been positive on EUA alone, and another eight on CT alone. Reactive nodal hyperplasia or sialadenitis was seen in most false-positive dissections. We conclude that the accuracy of preoperative diagnosis of metastasis by routine methods remains poor, and that EUA and CT are reliable only in patients with bulky metastatic deposits.

Transoral laser microsurgery for oropharyngeal squamous cell carcinoma: A paradigm shift in therapeutic approach.

The contemporary treatment of oropharyngeal squamous cell carcinoma (SCC) is an area of debate. We report outcomes of a minimally invasive approach involving transoral laser microsurgery (TLM).Background The contemporary treatment of oropharyngeal squamous cell carcinoma (SCC) is an area of debate. We report outcomes of a minimally invasive approach involving transoral laser microsurgery (TLM). Methods A consecutive series of patients (n = 153) undergoing primary TLM for oropharyngeal SCC from 2006 to 2013 was studied. Human papillomavirus (HPV) status was determined by p16 immunohistochemistry and high-risk HPV DNA in situ hybridization. Survival analyses were evaluated using Kaplan–Meier statistics. Results Tumor subsites included tonsil (n = 94; 61.5%), tongue base (n = 38; 24.8%), and soft palate (n = 21; 13.7%), with the majority being American Joint Committee on Cancer (AJCC) stage III/IVa (n = 124; 81.0%) and HPV-positive (n = 101; 66.0%). Three-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were 84.5%, 91.7%, and 78.2%, respectively. HPV-positivity portended favorable oncologic outcomes. One-year gastrostomy tube (G-tube) dependency was 1.3%. Conclusion To the best of our knowledge, this is the largest single-center TLM oropharyngeal SCC series to date. Our data suggest that TLM +/− postoperative radiotherapy (PORT) results in at least as good oncologic outcomes as chemoradiotherapy (CRT), while conferring swallowing function advantages.

The added value of 18F-fluorodeoxyglucose positron emission tomography computed tomography in patients with neck lymph node metastases from an unknown primary malignancy.

BACKGROUND The search for a primary malignancy in patients with a metastatic cervical lymph node is challenging yet ultimately of utmost clinical importance. This study evaluated the efficacy of positron emission tomography computed tomography in detecting the occult primary, within the context of a tertiary referral centre head and neck cancer multidisciplinary team tumour board meeting. METHODS Thirty-two patients (23 men and 9 women; mean and median age, 61 years) with a metastatic cervical lymph node of unknown primary origin, after clinical examination and magnetic resonance imaging, underwent positron emission tomography computed tomography. RESULTS The primary tumour detection rate was 50 per cent (16/32). Positron emission tomography computed tomography had a sensitivity of 94 per cent (16/17) and a specificity of 67 per cent (10/15). Combining these results with those of 10 earlier studies of similar patients gave an overall detection rate of 37 per cent. CONCLUSION Positron emission tomography computed tomography has become an important imaging modality. To date, it has the highest primary tumour detection rate, for head and neck cancer patients presenting with cervical lymph node metastases from an unknown primary.

1 UICC/AJCC pTNM staging in oral squamous cell carcinoma: ECS should now be grouped as pN3

Background: The role of TNM staging is to aid the clinician in planning treatment and to indicate prognosis. It serves to evaluate and compare results of treatments as well as stratification of patients into clinical trials. Existing treatments for OSCC favour surgery with widespread use of neck dissections. Currently pTNM takes no account of extracapsular spread (ECS). Methods: From a consecutive cohort of 489 OSCC patients treated by primary surgery, pN was recorded and the presence, pattern and severity (micro/macro) of ECS was noted in those 400 receiving neck dissections. Results: Using the current staging, 221 (55%) were pN0, 72 (18%) pN1, 105 (26%) pN2 but only 2 (0.005%) were pN3. 101 (25%) of the patients had ECS. Extracapsular spread (ECS) in the cervical lymph nodes was the single most significant adverse prognostic indicator of all those recorded. ECS doubled the incidence of local recurrence and distant metastases, but tripled regional failure. Patients with macroscopic ECS had a 5-year OS of 19% compared with 31% in microscopic ECS. The single change of reclassifying ECS to pN3 resolved the obvious imbalance in nodal stage cased by “underuse” of pN3 in the existing system. With this change 48 (12%) were pN1, 30 (8%) were pN2 and 101 (25%) were pN3 and these stagings were reflected by progressive and uniform worsening of OS and DSS. This reclassification is currently under consideration by AJCC/UICC. Conclusions: Reporting of ECS is essential in accurate prognostication and we advocate that all patients with OSCC and ECS should be grouped as pN3.