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Molecular Markers of Lymph Node Metastases in Oral Cancer

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Molecular Markers of Lymph Node Metastases in Oral Cancer MOLECULAR MARKERS OF LYMPH NODE METASTASES IN ORAL CANCER Frank Karel Johan Leusink The research in this thesis was performed at the departments of Oral & Maxillofacial Surgery and Pathology, University Medical Center Utrecht, the Netherlands, and at the departments of Pathology and Otolaryngology-Head and Neck Surgery, Section Tumor Biology, VU University Medical Center, Amsterdam, the Netherlands. The research was financially supported by the Dutch Cancer Society (KWF Kankerbestrijding) Grant No. KUN 2006-3675 and by the Dutch Society of Oral & Maxillofacial Surgery (NVMKA) BOOA Research Grant 2009. No commercial funding was received to perform this research. Printed by Gildeprint Layout by Nicole Nijhuis, Gildeprint Cover design Karel J. Leusink | kareljleusink.blogspot.nl ISBN: 978-94-6233-502-8 © Copyright 2016, F.K.J. Leusink All rights reserved. No part of this book may be reproduced in any form, by print, photocopy, electronic data transfer or any other means, without prior permission of the author. MOLECULAR MARKERS OF LYMPH NODE METASTASES IN ORAL CANCER Moleculaire markers voor lymfklier metastasen van mondkanker [met een samenvatting in het Nederlands] Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof. dr. G.J. van der Zwaan, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen op dinsdag 31 januari 2017 des middags 2.30 uur door Frank Karel Johan Leusink geboren 7 april 1979 te Hengelo (O.) Promotoren: Prof. dr. P.J. van Diest Prof. dr. R. Koole Copromotoren: Dr. S.M. Willems Dr. R.J.J. van Es CONTENTS Chapter 1. General introduction and outline of the thesis 7 Chapter 2. Lymphatic vessel density and lymph node metastasis in head and neck 21 squamous-cell carcinoma: a systematic review Chapter 3. Validation of a gene expression signature for assessment of lymph node 43 metastasis in oral squamous-cell carcinoma Chapter 4. Novel diagnostic modalities for the clinically node-negative neck in oral 63 squamous-cell carcinoma Chapter 5. Tumor biological determinants of locoregional recurrence of non-HPV 83 head and neck squamous-cell carcinoma Chapter 6. Nodal metastasis and survival in oral cancer: Association with protein 101 expression of SLPI, not with LCN2, TACSTD2, or THBS2 Chapter 7. The co-expression of kallikrein 5 and kallikrein 7 associates with poor 121 survival in non- HPV oral squamous-cell carcinoma Chapter 8. Cathepsin K associates with lymph node metastasis and poor prognosis 145 in oral squamous-cell carcinoma Chapter 9. General discussion 165 Chapter 10. Future perspectives 177 Chapter 11. Summary 185 Chapter 12. Nederlandse samenvatting 195 Chapter 13. List of publications 205 Chapter 14. Dankwoord 209 CHAPTER 1 General introduction and outline of the thesis Chapter 1 R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 R16 R17 R18 R19 R20 R21 R22 R23 R24 R25 R26 R27 R28 R29 R30 R31 R32 R33 R34 R35 R36 R37 R38 R39 8 General introduction and outline of the thesis GENERAL INTRODUCTION R1 1 R2 Head and neck squamous-cell carcinoma R3 Head and neck squamous-cell carcinoma (HNSCC) is the seventh most common malignancy R4 globally and accounts for approximately 4% of all malignant tumors.1,2 HNSCC arises in mucosal R5 linings of the oral cavity, oropharynx, nasopharynx, hypopharynx and larynx (figure 1).3 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 R16 R17 R18 R19 R20 R21 R22 R23 R24 R25 R26 Figure 1 | Head and neck cancer regions. This figure illustrates location of oral cavity, pharynx (including the nasopharynx, oropharynx and hypopharynx) R27 and larynx. (source: 2012, Terese Winslow LLC) R28 R29 The research in this thesis focuses on two subgroups of HNSCC: first, tumors originating in R30 the oral cavity (oral squamous-cell carcinomas, OSCC) and second, tumors originating in the R31 oropharynx (oropharyngeal squamous-cell carcinomas, OPSCC). Risk factors include tobacco R32 smoking, betel nut chewing, excessive alcohol consumption, and human papillomavirus (HPV) R33 infection,4-6 although the etiologic role of HPV in OSCC is unclear.7 Together, OSCC and OPSCC R34 account for two thirds of the worldwide incidence of HNSCC with an estimation of 400.000 cases R35 and 223.000 deaths in 2008.8 R36 R37 R38 R39 9 Chapter 1 R1 Oral squamous-cell carcinoma R2 With approximately 265.000 new cases annually, OSCC has the highest incidence of all HNSCCs. R3 In The Nether1lands, the incidence is around 1.100 cases and this has slowly been rising over R4 the last two decades.9,10 For OSCC the male to female ratio is 1.6 and reflects the distribution of R5 smoking between both sexes. Subsites of the oral cavity include the lips, the anterior two-thirds R6 of the tongue, the floor of the mouth, the gums, the lining inside the cheeks and lips, the hard R7 palate and the retromolar trigone. Symptoms can consist of a white or red patch or an ulcer on R8 the mucosal lining of the mouth, a mucosal swelling of the jaw that causes dentures to fit poorly R9 or become uncomfortable and unusual bleeding or pain in the mouth.3 R10 R11 Staging of the tumor and the neck is performed by clinical examination (i.e. palpation) and R12 imaging, but accuracy of these techniques to detect small lymph node metastases (LNM) is R13 limited. In general, 30–40% of patients will have occult nodal disease and will develop clinically R14 detectable LNM when the neck is left untreated.11 R15 R16 Surgery is the preferred modality for local treatment of the primary OSCC. Adjuvant treatment R17 (re-resection, radiotherapy, or chemotherapy) may be indicated based on adverse tumor features R18 diagnosed at histopathological examination. For regional treatment of the node-positive neck R19 (cN+) a therapeutic neck dissection (TND) is indicated, but for the clinically node-negative neck R20 (cN0) the choice is either elective neck dissection (END) or watchful waiting (WW) followed by R21 TND in patients who develop manifest metastases. R22 R23 Oropharyngeal squamous-cell carcinoma R24 OPSCC occurs with an annual estimated worldwide incidence of 136.000 cases.8,9 Subsites of R25 the oropharynx include the base of tongue, the tonsils, the soft palate and the posterior and R26 lateral walls of the oropharynx. HPV is reported as a causative factor with prevalence rates varying R27 between 15-90%.12 In The Netherlands the prevalence rate of HPV in OPSCC is around 25% and R28 has increased in the last two decades,13 in contrast to the HPV prevalence rate in OSCC which is R29 reported to be around 3%.14 R30 R31 Treatment of early OPSCC (T1-T2) can be curatively performed effectively with primary radiotherapy R32 or surgery.15 More advanced OPSCC (T3-4 or node positive) calls for multimodal therapy consisting R33 of chemoradiation or primary radiotherapy.16 Although patients with a HPV-positive tumor usually R34 present with a smaller primary tumor, and show more often nodal disease at time of diagnosis16-17 R35 they respond better to therapy and therefore have a better outcome compared to patients with R36 HPV-negative OPSCC.17 However, clinical management for the HPV-positive OPSCC has not R37 changed. Therefore, as in OSCC, the most important factor for management and prognosis in R38 HPV-positive as well as HPV-negative OPSCC is regional LNM. R39 10 General introduction and outline of the thesis “To treat or not to treat?” - The dilemma of the clinically node-negative neck R1 The presence of regional neck metastases is a major determinant of both prognosis and treatment 1 R2 decisions in patients with OSCC.20 However, the low sensitivity of currently available diagnostic R3 modalities is a problem, because a fairly high proportion (30–40%) of LNM are left undetected in R4 this population. These metastases will develop into overt neck disease during follow-up. R5 R6 A policy has been in place during the last decades to treat the neck even when the tumor has R7 been classified as cN0, indicating no disease is detectable in the neck21 on physical examination R8 and imaging. This strategy prevents disease in the neck becoming more advanced once previously R9 occult metastases become clinically apparent or are detected late during follow-up. Thus, 60–70% R10 of patients receive unnecessary treatment, which in the case of elective neck dissection (END) R11 encompasses a surgical procedure potentially causing disfigurement and associated morbidity.22-25 R12 R13 The alternative approach of watchful waiting (WW) entails careful monitoring of the neck (eg, by R14 ultrasound-guided fine-needle aspiration cytology during follow-up).26,27 Treatment (therapeutic R15 neck dissection) will be given only to patients who develop manifest metastasis, which usually R16 arises within 1–2 years. Although some authors report evidence showing convincingly that END R17 should be preferred over WW,28 others doubt the generalizability of these results and question R18 whether they can be implemented worldwide.29 Consensus—partly based on an often cited R19 but outdated decision analysis model—suggests that elective neck treatment is indicated when R20 the chance of occult nodal disease exceeds 20%.30 Hence, increased accuracy to ascertain the R21 metastatic status of the neck will result in fewer unnecessary elective treatment of the neck. R22 R23 Currently, the neck is staged by palpation and different imaging techniques, including CT, MRI, R24 PET/CT, and ultrasound, which are more accurate than palpation alone.31-33 Morphological and R25 size criteria are the main determinants of specificity of imaging techniques, whereas sensitivity R26 is limited by the detection threshold.
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