Abstract
ObjectiveTo analyze the impact of the lymph node ratio (LNR, ratio of metastatic to examined nodes) on the prognosis of hypopharyngeal cancer patients.MethodsSEER (Surveillance, Epidemiology and End Results)-registered hypopharyngeal cancer patients with lymph node metastasis were evaluated using multivariate Cox regression analysis to identify the prognostic role of the LNR. The categorical LNR was compared with the continuous LNR and pN classifications to predict cause-specific survival (CSS) and overall survival (OS) rates of hypopharyngeal cancer patients.ResultsMultivariate analysis of 916 pN+ hypopharyngeal cancer cases identified race, primary site, radiation sequence, T classification, N classification, M classification, the number of regional lymph nodes examined, the continuous LNR (Hazard ratio 2.415, 95% CI 1.707–3.416, P<0.001) and age as prognostic variables that were associated with CSS in hypopharyngeal cancer. The categorical LNR showed a higher C-index and lower Akaike information criterion (AIC) value than the continuous LNR. When patients (n = 1152) were classified into four risk groups according to LNR, R0 (LNR = 0), R1 (LNR ≤0.05), R2 (LNR 0.05–0.30) and R3 (LNR >0.30), the Cox regression model for CSS and OS using the R classification had a higher C-index value and lower AIC value than the model using the pN classification. Significant improvements in both CSS and OS were found for R2 and R3 patients with postoperative radiotherapy.ConclusionsLNR is a significant prognostic factor for the survival of hypopharyngeal cancer patients. Using the cutoff points 0.05/0.30, the R classification was more accurate than the pN classification in predicting survival and can be used to select high risk patients for postoperative treatment.
Highlights
Hypopharyngeal cancer accounts for 2–6% of head neck cancers. [1,2] The prognosis of patients with cancer of the hypopharynx can be poor despite aggressive combined modality treatment. [3] Traditionally, laryngopharyngectomy with reconstruction of the pharynx has been the preferred initial treatment modality for hypopharyngeal cancers
[4] For patients with a T4a classification, surgery plus neck dissection followed by adjuvant chemotherapy/radiotherapy or radiotherapy has been preferred in accordance to the NCCN guidelines. [3]
The univariate analysis showed that race, primary site, radiation sequence, cancer directed surgery, T classification, N classification and M classification were all associated with cause-specific survival (CSS) in 916 pN+ hypopharyngeal cancer cases. When these factors were assessed using multivariate Cox regression analysis, we found that race, primary site, radiation sequence, T classification, N classification, M classification, the number of regional lymph nodes examined, continuous lymph node ratio (LNR) and age were all independent variables (Table 2)
Summary
Hypopharyngeal cancer accounts for 2–6% of head neck cancers. [1,2] The prognosis of patients with cancer of the hypopharynx can be poor despite aggressive combined modality treatment. [3] Traditionally, laryngopharyngectomy with reconstruction of the pharynx has been the preferred initial treatment modality for hypopharyngeal cancers. [2] While for selected patients with early T classification hypopharyngeal cancer, transoral laser microsurgery in combination with neck dissection and postoperative radiotherapy shows results comparable to those of open surgical procedures and radiotherapy, morbidity and complication rates tend to be lower. [4] For patients with a T4a classification (tumor invasion of thyroid/cricoid cartilage, hyoid bone, thyroid gland or the central compartment of soft tissue), surgery plus neck dissection followed by adjuvant chemotherapy/radiotherapy or radiotherapy has been preferred in accordance to the NCCN guidelines. When primary surgery is the selected management path for resectable hypopharyngeal cancer cases, postoperative chemotherapy/radiotherapy is recommended (level I evidence) for the adverse pathologic features of extracapsular nodal spread and/or a positive mucosal margin. Primary site Pyriform sinus Postcricoid region Aryepiglottic fold Posterior wall Overlapping lesion Hypopharynx, NOS
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