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Cancer. 2019 Sep 1;125(17):2975-2983. doi: 10.1002/cncr.32161. Epub 2019 May 15.

Pathologic staging changes in oral cavity squamous cell carcinoma: Stage migration and implications for adjuvant treatment.

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Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut.
Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada.
Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.
Section of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
Yale Cancer Center, New Haven, Connecticut.
Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.



The eighth edition of the AJCC Cancer Staging Manual (AJCC 8) incorporates depth of invasion (DOI) into the pathologic tumor (pT) classification and pathologic extranodal extension (pENE) into the pathologic nodal (pN) classification for oral cavity squamous cell carcinoma (OCSCC). This study evaluated the incidence and prognostic importance of stage migration as a result of these changes in the AJCC 8 staging system.


From the National Cancer Database, cohorts were identified from patients with OCSCC undergoing definitive surgery between 2004 and 2013 for pT (n = 7184), pN (n = 13,627), and pathologic stage (pStage) analysis (n = 5580).


DOI and pENE were prognostic in all groups except for pN3 according to the seventh edition of the AJCC Cancer Staging Manual (AJCC 7). Upstaging was seen in 12.4% of patients for the pT classification, in 13.3% for the pN classification, and in 24.8% for the overall pStage grouping. Notably, upstaging led to similar or improved 5-year overall survival (OS) for every AJCC 8 pT/N classification except pStage IVB. Patients with AJCC 7 pT1 tumors that were upstaged to AJCC 8 pT3 tumors had improved OS in comparison with the remainder of the pT3 group (71.7% vs 43.7%; P < .0001). A multivariable analysis of upstaged pT3N0 patients demonstrated a reduced risk of death with the receipt of postoperative radiotherapy (PORT; hazard ratio, 0.56; 95% confidence interval, 0.33-0.95; P = .03).


Upstaging is common in AJCC 8, and patients with upstaged tumors demonstrate improved survival; these factors should be kept in mind when one is interpreting data with the new staging system. PORT may reduce deaths among newly upstaged pT3N0 patients, and further study is needed in this area.


American Joint Committee on Cancer (AJCC); TNM staging; Will Rogers phenomenon; head and neck cancer; oral cavity; prognosis; radiation therapy; volume


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