Int. J. Oral Maxillofac. Surg.

2015; 44: 143–150

http://dx.doi.org/10.1016/j.ijom.2014.10.004, available online at http://www.sciencedirect.com

Clinical Paper
Head and Neck Oncology

A simple novel prognostic A. Almangusha,b, R. D. Colettac, I. O.

Belloa,d, C. Bitue, H. Keski-Sänttif, L. K.
Mäkinenf, J. H. Kauppilag, M. Pukkilah, J.
Hagströma,i, J. Larannej, S. Tommolak, Y.

model for early stage oral Soinil, V.-M. Kosmal, P. Koivunenm, L. P.

Kowalskin, P. Niemineno, R. Grénmanp, I.
Leivoa,s, T. Saloe,q,r

tongue cancer
a
Department of Pathology, Haartman Institute,
University of Helsinki, Helsinki, Finland;
b
Institute of Dentistry, University of Misurata,
Misurata, Libya; cDepartment of Oral
Diagnosis, School of Dentistry, State University
of Campinas, Piracicaba, São Paulo, Brazil;
A. Almangush, R.D. Coletta, I.O. Bello, C. Bitu, H. Keski-Säntti, L.K. Mäkinen, J.H. d
Department of Oral Medicine and Diagnostic
Kauppila, M. Pukkila, J. Hagström, J. Laranne, S. Tommola, Y. Soini, V.-M. Kosma, P. Sciences, King Saud University, Riyadh, Saudi
Koivunen, L.P. Kowalski, P. Nieminen, R. Grénman, I. Leivo, T. Salo: A simple novel Arabia; eDepartment of Diagnostics and Oral
Medicine, Institute of Dentistry, University of
prognostic model for early stage oral tongue cancer. Int. J. Oral Maxillofac. Surg. Oulu, Oulu, Finland; fDepartment of
2015; 44: 143–150. # 2014 International Association of Oral and Maxillofacial Otorhinolaryngology and Head and Neck
Surgeons. Published by Elsevier Ltd. All rights reserved. Surgery, Helsinki University Central Hospital,
Helsinki, Finland; gDepartments of Surgery and
Pathology, University of Oulu and Oulu
University Hospital, Oulu, Finland; hDepartment
of Otorhinolaryngology and Head and Neck
Surgery, Kuopio University Hospital, Kuopio,
Finland; iDepartment of Oral Pathology,
Institute of Dentistry, University of Helsinki,
Helsinki, Finland; jDepartment of
Otorhinolaryngology and Head and Neck
Surgery, Tampere University Hospital,
Tampere, Finland; kDepartment of Pathology,
Tampere University Hospital, Tampere, Finland;
l
Department of Pathology and Forensic
Medicine, University of Eastern Finland,
Kuopio, Finland; mDepartment of
Otorhinolaryngology and Head and Neck
Surgery, Oulu University Central Hospital, Oulu,
Finland; nDepartment of Head and Neck
Surgery and Otorhinolaryngology, A.C.
Camargo Cancer Centre, São Paulo SP, Brazil;
o
Department of Medical Informatics and
Abstract. The prognostication of patient outcome is one of the greatest challenges in Statistics, University of Oulu, Oulu, Finland;
p
Department of Otorhinolaryngology – Head
the management of early stage oral tongue squamous cell carcinoma (OTSCC). This and Neck Surgery, Turku University Hospital,
study introduces a simple histopathological model for the prognostication of University of Turku, Turku, Finland;
q
survival in patients with early OTSCC. A total of 311 cases (from Finland and Department of Diagnostics and Oral Medicine,
Brazil) with clinically evaluated early stage OTSCC (cT1–T2cN0cM0) were Oulu University Hospital and Medical Research
Centre, Oulu, Finland; rInstitute of Dentistry,
included in this multicentre retrospective study. Tumour budding (B) and depth of University of Helsinki, Helsinki, Finland;
invasion (D) were scored on haematoxylin–eosin-stained cancer slides. The cut-off s
Department of Pathology, University of Turku,
point for tumour budding was set at 5 buds (low <5; high 5) and for depth of Turku, Finland
invasion at 4 mm (low <4 mm; high 4 mm). The scores of B and D were
Key words: oral tongue squamous cell carci-
combined into one model: the BD predictive model. On multivariate analysis, a high
noma; prognosis; BD model; tumour budding;
risk score (BD score 2) correlated significantly with loco-regional recurrence depth of invasion.
(P = 0.033) and death due to OTSCC (P < 0.001) in early stage OTSCC. The new
BD model is a promising prognostic tool to identify those patients with aggressive Accepted for publication 6 October 2014
cases of early stage OTSCC who might benefit from multimodality treatment. Available online 11 November 2014

0901-5027/020143 + 08 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
144 Almangush et al.

Oral tongue squamous cell carcinoma consequently be applied only to patients indicator representing the malignant poten-
(OTSCC) is the most aggressive type of at high risk. tial of early OSCC.14 Furthermore, it has
oral SCC and its management may com- Despite the role of epithelial mesenchy- been reported by many recent and well-
prise multimodality treatment even in the mal transition (EMT) in cancer cell mi- documented studies as an important prog-
early stages. Many histomorphological gration and metastasis,7 none of the nostic parameter in early OTSCC.15,16
grading models have been introduced previous prognostic models has included With this background, the aim of the
for the prognostication of OSCC.1–3 The histopathological parameters to consider present study was to introduce a practical
main role of histopathological prognosti- EMT. Thus, it would appear advantageous and simple model by combining the scores
cation is to complement the shortcomings for a prognostic model to include tumour for tumour budding and depth of invasion
of the TNM staging system for OSCC and budding, which correlates with EMT in (BD scoring from 0 to 2) to predict the
thus to provide the clinician with the tools many carcinomas,8,9 including tongue behaviour of early stage OTSCC. Using
to develop a precise treatment plan. In SCC.10 In addition, tumour budding is this model we aim to be able to select those
addition to the complexity of previous known to reflect the biological activity OTSCC patients who could be at high risk
models, a number of studies have reported of cancer11 and has been recognized in- of recurrence and/or distant dissemination
their inability to predict the outcome of creasingly as a significant, independent, of the disease and subsequently dying of the
patients with early stage OSCC4 or early and reproducible prognostic feature.12 disease.
OTSCC.5 This indicates the critical need The depth of tumour invasion or tumour
for a comprehensive predictive model in thickness (these two terms have been used
Patients and methods
order to make the appropriate choices in synonymously by some authors13,14), as
multimodality treatment of early OTSCC. measured from the surface of the tumour A total of 311 cases diagnosed with
Such choices may entail adjuvant therapy to the deepest point of invasion, has been OTSCC between 1979 and 2010 and clin-
with severe toxic effects,6 and should established as a valuable histopathological ically staged as cT1cN0cM0 or
cT2cN0cM0 were included in this study.
Table 1. Clinicopathological characteristics of the 311 study patients. Of these cases, 224 were from the Finnish
Characteristic Number of patients % university central hospitals (Helsinki,
Oulu, Turku, Tampere, Kuopio) and had
Age, years
Median: 63 comprised part of a previously studied
63 157 50.5 cohort of 233 Finnish patients.5 The nine
>63 154 49.5 patients whose data on recurrence were
Gender incomplete were excluded from this latter
Male 165 53.1 group. The remaining 87 patients were
Female 146 46.9 diagnosed and treated at A.C. Camargo
Clinical stage Hospital, São Paulo, Brazil.
T1N0M0 124 39.9 Clinical data and follow-up records
T2N0M0 187 60.1
including cause of death and dates of
Grade (differentiation)
I (well differentiated) 105 33.8
diagnosis, recurrence, and/or death were
II (moderately differentiated) 131 42.1 retrieved. Surgical resection of the prima-
III (poorly differentiated) 75 24.1 ry tumour was carried out for all patients.
Worst pattern of invasion With regard to clinical staging, 124 cases
Superficial 78 25.1 (39.9%) were classified as cT1cN0cM0
Deep 233 74.9 and 187 cases (60.1%) were cT2cN0cM0.
Lymphocytic host response One hundred and sixty five (53.1%) were
Superficial 169 54.3 males and 146 (46.9) were females. Their
Deep 142 45.7 median age at diagnosis was 63 years
Perineural invasion
(range 10–95 years) (Table 1).
Absent 269 86.5
Present 42 13.5 Tumour budding is defined as the pres-
Recurrence ence of a single cancer cell or small cluster
No 222 71.4 of <5 cancer cells at the invasive front.5
Yes 89 28.6 During the scoring of tumour budding, the
Status whole tumour area was scanned at low
Alive 153 49.2 magnification (4), then the highest num-
Died of OTSCC 63 20.3 ber of tumour budding was counted at a
Died of other causes 95 30.5 higher magnification (20) and used as
Tumour budding
the score for budding. Depth of invasion
Superficial (<5 buds) 215 69.1
Deep (5 buds) 96 30.9 (or tumour thickness) was measured from
Depth of invasion the tumour surface to the deepest point of
Superficial (<4 mm) 116 37.3 invasion. The cut-off point for tumour
Deep (4 mm) 195 62.7 budding was set at 5 buds (low <5; high
BD score 5), and the cut-off point for depth of
Low risk (score 0) 103 33.1 invasion was set at 4 mm (low <4 mm;
Intermediate risk (score 1) 125 40.2 high 4 mm). In addition, other previous-
High risk (score 2) 83 26.7 ly examined parameters,5 including worst
OTSCC, oral tongue squamous cell carcinoma; BD, tumour budding (B) and depth of invasion pattern of invasion, lymphocytic host re-
(D). sponse, and perineural invasion, were also
 Prognostic model for early stage OTSCC 145

Table 2. Description of BD scores.

BD score Histological description
Score 0 Tumour with <4 mm depth of invasion and <5 buds at the invasive front
Score 1 This tumour should have only one of the following features:
Tumour with 4 mm depth of invasion and <5 buds at the invasive front, OR
Superficial tumour (<4 mm), but with high activity of tumour budding at the invasive front (5 buds)
Score 2 Tumour with 4 mm depth of invasion and with high activity of tumour budding at the invasive front (5 buds)
BD, tumour budding (B) and depth of invasion (D).

Table 3. Association of disease-free survival and disease-specific survival with the clinical and histopathological parameters (unadjusted
univariate analysis).
Disease-free survival (DFS) Disease-specific survival (DSS)
a
Variable HR (95% CI) P-value HR (95% CI) P-valuea
Age, years 0.003 0.014
63 1 1
>63 1.89 (1.23–2.89) 1.87 (1.13–3.11)
Gender 0.715 0.441
Male 1 1
Female 1.08 (0.71–1.64) 1.22 (0.74–1.99)
TNM stage 0.527 0.141
T1N0M0 1 1
T2N0M0 0.87 (0.57–1.33) 1.48 (0.87–2.54)
Grade (differentiation) 0.739 0.199
I (well differentiated) 1 1
II (moderately differentiated) 1.11 (0.68–1.82) 1.68 (0.92–3.07)
III (poorly differentiated) 1.25 (0.72–2.16) 1.58 (0.79–3.16)
Worst pattern of invasion 0.045 0.001
Superficial 1 1
Deep 1.71 (0.98–2.99) 3.29 (1.42–7.62)
Lymphocytic host response 0.512 0.889
Superficial 1 1
Deep 0.89 (0.57–1.33) 0.97 (0.59–1.59)
Perineural invasion 0.199 0.502
Absent 1 1
Present 1.46 (0.84–2.55) 1.27 (0.65–2.49)
Tumour budding 0.005 <0.001
Superficial 1 1
Deep 1.85 (1.21–2.82) 2.59 (1.58–4.26)
Depth of invasion 0.109 <0.001
Superficial 1 1
Deep 1.44 (0.91–2.28) 3.15 (1.60–6.18)
BD score 0.025 <0.001
Low risk 1 1
Intermediate risk 1.50 (0.87–2.58) 3.79 (1.57–9.15)
High risk 2.14 (1.22–3.74) 6.24 (2.59–15.04)
HR, hazard ratio; CI, confidence interval; BD, tumour budding (B) and depth of invasion (D).
a
The likelihood ratio statistic was used to test the significance of variables.

analyzed. The scoring of all parameters
was carried out on haematoxylin–eosin-
stained sections by an independent observ-
er (A.A.) and reviewed by an experienced
head and neck pathologist (I.L.). Both
observers were blinded to the patient data
and clinical outcome.
Tumour budding ‘B’ and depth of inva-
sion ‘D’ were combined in one model, the
BD model, as follows (Table 2):
Score 0: neither budding nor depth of
invasion is higher than the cut-off
(Fig. 1A, B).
Score 1: only one of the parameters
(budding or depth of invasion) is higher
than the cut-off (Fig. 1C–F).
Score 2: both parameters (budding and
depth of invasion) are higher than the cut-
off (Fig. 1G, H).
In accordance with the BD model, each
case was assigned a score between 0 and 2.
Cases with a score of 0 were classified as
low risk, those with a score of 1 as inter-
mediate risk, and those with a score of 2 as
high risk.
Statistical analysis
The x2 test was used to assess possible
relationships between clinicopathological
variables and the BD score. The Kaplan–
Meier method was used to obtain the
estimated time to recurrence and time to
disease-specific death. The statistical sig-
nificance of the differences in Kaplan–
Meier curves between the BD groups
was determined by log rank test. Univari-
ate analysis was done using the Cox pro-
portional hazard regression model to
evaluate the relationship between the
BD model scores and recurrence or death
from OTSCC. Multivariate analysis (using
Cox regression) was performed to evalu-
ate the independent prognostic strength of
BD scores when adjusted for other clini-
copathological covariates (age, gender,
tumour stage, and tumour grade) and
worst pattern of invasion. The likelihood
146 Almangush et al.

ratio statistic was used to test the signifi-

cance of variables in the estimated models.
Statistical significance was set at
P < 0.05. Harrell’s C-statistic was used
to evaluate the predictive power of surviv-
al models.17,18 Since the BD score is a
linear derivative of both tumour budding
(B) and depth of invasion (D), it is not
possible to include all three variables in a
single model. Thus, two separate models
(BD included vs. B and D included) were
estimated for both disease-free survival
(DFS) and disease-specific survival
(DSS) to show their relationship with B,
D, and BD variables.
All statistical analyses were done using
IBM SPSS Statistics for Windows, version
20.0 (IBM Corp., Armonk, NY, USA) and
Stata 13 (StataCorp LP, College Station,
TX, USA).

Results
Clinicopathological characteristics of the
patients are summarized in Table 1. The
median follow-up time was 57 months
(range 1–278 months). Sixty-three
patients (20.3%) died of OTSCC, 95
patients (30.5%) died of causes other than
OTSCC, and 153 patients (49.2%) were
alive at the end of follow-up or at the last
visit on record.
Loco-regional recurrence (LRR) was
reported in 89 patients (28.6%), and 48
(53.9%) of them died from OTSCC. The
presence of LRR was significantly associ-
ated with poor DSS (P < 0.001).
Of all histopathological parameters
evaluated in this study, only the worst
pattern of invasion and tumour budding
were associated with both DFS and DSS
in the unadjusted univariate analysis
(Table 3). Depth of invasion was related
to DSS, but not to DFS. Fig. 1. Scores of the BD model. (A) Score 0: superficial tumour with only large islands at the IF
(20); (B) high magnification of the region inside the rectangle in A showing the absence of
tumour budding at the IF (100). (C) Score 1: presence of tumour budding at the IF of a
BD model and relationship with
superficial tumour (20); (D) high magnification of the region inside the rectangle in C
clinicopathological parameters demonstrating the presence of more than 5 buds at the IF (200). (E) Score 1: deep tumour
There were 103 cases (33.1%) with a low without any small clusters at the IF (4); (F) magnification of the rectangle region in E (10).
risk score (score 0), 125 (40.2%) with an (G) Score 2: presence of tumour budding at the IF of a deep tumour (40); (H) high
magnification of the rectangle in G showing tumour budding at the IF (200). A–F: haematox-
intermediate risk score (score 1), and 83
ylin–eosin-stained sections; G and H: pan-cytokeratin-stained sections. IF = invasive front.
(26.7%) with a high risk score (score 2).
There was no statically significant associ-
ation between BD score and age, gender, death from OTSCC (log rank P < 0.001) Multivariate analysis
or histological differentiation (tumour as the patients were previously classified
grade). into risk groups (Fig. 2A). On the other In the multivariate analysis, the BD score
hand, BD scores did not show any signifi- showed a predictive value in the high
cant association with death from other score group (score 2) compared to the
Univariate analysis
causes (log rank P = 0.808; Fig. 2B). low score group, with a hazard ratio
According to Kaplan–Meier analyses, There was a similar curve for BD scores (HR) of 2.19 (95% confidence interval
there was a stepwise gradation of BD in relation to LRR (log rank P = 0.023; (CI) 1.20–4.00) for recurrence, and of
scores ranging from favourable (score 0) Fig. 2C). In addition, worst pattern of 5.11 (95% CI 2.05–12.75) for cancer death
to intermediate (score 1) and unfavourable invasion was associated with patient sur- (Table 4). Based on this stepwise model,
prognosis (score 2) in relation to the risk of vival (Table 3). there was no statistically significant
 Prognostic model for early stage OTSCC 147

association between worst pattern of inva-

sion and patient survival, although a high
worst pattern of invasion showed a ten-
dency towards an association with cancer
death in both models for DSS (Table 4).

Discussion
Early stage OTSCC (cT1–T2cN0cM0)
shows a higher mortality rate than early
stage tumours at other subsites of the oral
cavity (39% vs. 15.5%)19 indicating that,
for unknown reasons, OTSCC is highly
aggressive in nature. The optimal treat-
ment for patients with early OTSCC
remains a controversial issue,20 but in
many instances such cases are treated by
local surgical excision only. However,
early OTSCC is reported to have a risk
of loco-regional recurrence in 23%21 and/
or occult metastasis in 30% of cases.22
Thus, multimodality therapies should be
administered to those patients who are at
higher risk of metastasis or recurrence.
Unfortunately, these therapies have a po-
tential to cause complications, so it is of
great importance to avoid unnecessary
therapy. In general, there are no clear
indications as to when to perform an elec-
tive neck dissection (END) in early stage
head and neck cancer.23 This means that
patients may be subjected to the morbidity
associated with extensive neck dissections
even though they have no evidence of
loco-regional metastasis.13 Although sen-
tinel node navigation surgery (SNNS) has
been recommended for early stage
OTSCC in a recent study,24 further sup-
portive evidence is still required before
this can be advocated as a routine prog-
nostic procedure. In addition, the com-
plexity of lymphatic drainage in the
head and neck region usually make the
detection of all sentinel lymph nodes in
carcinomas of this area a difficult and
time-consuming procedure.25 Moreover,
in some instances, exposure, dissection,
and the time required to complete the
sentinel lymph node biopsy may approxi-
mate that which is sufficient to perform a
selective neck dissection.26
The use of single or combined histo-
pathological parameters for the prognosti-
cation of OSCC has been introduced in a
number of previous studies.1,2,14 In addi-
tion, traditional histopathological evalua-
tion of surgically removed tissues is still
Fig. 2. Low risk, intermediate risk, and high risk cases. (A) Deaths due to OTSCC. (B) Other the cornerstone of pathological grading in
causes of death. (C) Loco-regional recurrence. routine clinical practice.27 However, com-
bining histopathological parameters to
identify high risk patients could be highly
successful in reducing therapeutic compli-
cations. Such a model for prognostication
might also enhance survival by allowing
148 Almangush et al.

P-valueb
clinicians to determine the most appropri-

0.044

0.019

0.119
ate treatment for each risk group.28
In this study, we introduce a promising
model for the prognostication and treat-
Model 2a ment planning of patients with early

(1.01–3.06)

(1.09–4.65)

(0.80–4.80)
95% CI
OTSCC. In the multivariate analysis, a

0.7109
strong relationship was found with loco-
regional recurrence and with DSS (likeli-
hood ratio P = 0.033 and P < 0.001 re-
spectively). The significant association of
Death from OTSCC

the BD score with patient outcome may

1.76

2.26

1.96
HR

allow its use in treatment planning, which

1

1
could include the consideration of END
even in cases of early OTSCC when a high
P-valueb

<0.001

BD score is found. Unlike the previously

0.102
introduced histopathological prognostic
models, the BD model shows a strong
correlation with patient survival in early
a

stage OTSCC. However, the advanced

(2.05–12.75)
Model 1

(1.54–9.22)

(0.82–4.84)
95% CI

stages of OTSCC are serious diseases,

which require wide surgical resection,
0.7163

neck dissection, and adjuvant therapy

(mostly radiation therapy).
The current study evaluated six histo-
pathological parameters including tumour
3.77
5.11

2.00
HR

grade (differentiation), worst pattern of

1

invasion, lymphocytic host response, peri-

neural invasion, tumour budding, and
P-valueb

depth of invasion. In the multivariate sta-

0.020

0.486

0.357

tistical analysis, only tumour budding and

depth of invasion were strongly associated
with patient survival. However, our pro-
a

posed histopathological model combined

Model 2

HR, hazard ratio; CI, confidence interval; BD, tumour budding (B) and depth of invasion (D).
(1.10–2.93)

(0.72–1.98)

(0.72–2.43)
Table 4. Multivariate analysis for loco-regional recurrence and for death from early OTSCC.

95% CI

tumour budding to represent the invasion

0.6523

pattern and depth of invasion to represent

the depth of tumour penetration. Impor-
tantly, tumour budding is suggested to be a
sign of epithelial to mesenchymal transi-
The likelihood ratio statistic was used to test the significance of variables.
Adjusted for age, gender, grade (tumour differentiation), and TNM stage.

tion of carcinoma cells, reflecting the

1.80

1.20

1.32
HR

powerful invasive growth of tongue,10

1

colorectal,8 and breast9 cancers.

Fresh-frozen diagnosis of a surgical
P-valueb

specimen during surgery has been sug-

0.033

0.276

gested as a method for intraoperative path-

ological classification of OSCC29 that will
Loco-regional recurrence

influence the treatment protocol. During

a

surgical removal of an early OTSCC, we

Model 1

(0.89–2.72)
(1.20–4.00)

(0.76–2.51)
95% CI

recommend performing immunohisto-

0.6541

chemical cytokeratin staining on frozen

sections of the tumour specimen. Then,
BD scoring can be undertaken and cases of
high risk (score 2) might benefit from
1.59
2.19

1.38
HR

END. A definitive operation can then be

1

carried out without interrupting the anaes-

thesia.
In addition to the significant prognostic
Worst pattern of invasion

value of the BD model, a combination of

these two parameters will increase the
Depth of invasion

accuracy and reliability of prognostication

Tumour budding

Intermediate

compared to the use of each parameter

Superficial

Superficial

Superficial

Superficial

separately. The main clinical significance

BD scores

C-statistic

of the BD model is that it allows the

Deep

Deep

Deep

Deep

decision on multimodality treatment for

b
a

patients with a high risk score (score 2) to


be made. In the present study, 46% of
patients who died from OTSCC had a high
risk score (score 2), indicating a high
mortality rate in this group of patients.
From a biological point of view, the BD
model deals with depth of tumour inva-
sion, which indicates the efficacy of tissue
penetration, and it also measures tumour
budding, which reflects EMT and tumour
dissociation at the invasive front. Tumour
budding has also been reported recently to
have a strong association with the density
of stromal myofibroblasts in oral SCC.30
Briefly, the BD model gives a snapshot of
tumour invasiveness and its ability to
progress or metastasize.
The current study has the advantage of
homogeneity of tumour size and location,
as all cases were T1 or T2 OTSCC. At the
same time, it was a multi-institutional
study involving two different geographic
regions (Finland and Brazil) and a large
patient cohort. In addition, the predictive
model introduced in this study is based on
simple and well-defined parameters; this is
in contrast to previous models that have
included parameters such as lymphocytic
host response, tumour keratinization, and
degree of nuclear pleomorphism, which
have low reproducibility and are subject to
high inter-observer variation.
In conclusion, the BD model is a simple
predictive model that can be applied easily
on routine haematoxylin–eosin- or cyto-
keratin-stained slides. Moreover, the BD
model is an important addition to existing
prognosticators of OTSCC, and may even
be useful for other oral subsites. We sug-
gest that it could be used as a prognostic
index to help plan an individualized treat-
ment protocol. Further validation of this
model in other patient cohorts is recom-
mended.
Funding
This study was funded by The Finnish
Cancer Society, Sigrid Juselius Founda-
tion, and Libyan Ministry of Higher Edu-
cation and Scientific Research.
Competing interests
None.
Ethical approval
This study was approved by the institu-
tional review boards of all hospitals in-
cluded. In addition, the approval of the
Brazilian Human Research Ethics Com-
mittee and the Finnish National Supervi-
sory Authority for Welfare and Health
(VALVIRA) were obtained.
Prognostic model for early stage OTSCC
Patient consent
Not required.
References
1. Anneroth G, Batsakis J, Luna M. Review of
the literature and a recommended system of
malignancy grading in oral squamous cell
carcinomas. Scand J Dent Res 1987;95:
229–49.
2. Bryne M, Koppang HS, Lilleng R, Stene T,
Bang G, Dabelsteen E. New malignancy
grading is a better prognostic indicator than
Broders’ grading in oral squamous cell car-
cinomas. J Oral Pathol Med 1989;18:432–7.
3. Brandwein-Gensler M, Teixeira MS, Lewis
CM, Lee B, Rolnitzky L, Hille JJ, et al. Oral
squamous cell carcinoma: histologic risk
assessment, but not margin status, is strongly
predictive of local disease-free and overall
survival. Am J Surg Pathol 2005;29:167–78.
4. Bundgaard T, Rossen K, Henriksen SD,
Charabi S, Sogaard H, Grau C. Histopatho-
logic parameters in the evaluation of T1
squamous cell carcinomas of the oral cavity.
Head Neck 2002;24:656–60.
5. Almangush A, Bello IO, Keski-Säntti H,
Mäkinen LK, Kauppila JH, Pukkila M,
et al. Depth of invasion, tumor budding,
and worst pattern of invasion: prognostic
indicators in early-stage oral tongue cancer.
Head Neck 2013;36:811–8.
6. Gil Z, Carlson DL, Boyle JO, Kraus DH,
Shah JP, Shaha AR, et al. Lymph node
density is a significant predictor of outcome
in patients with oral cancer. Cancer
2009;115:5700–10.
7. Liang X. EMT: new signals from the inva-
sive front. Oral Oncol 2011;47:686–7.
8. Prall F. Tumour budding in colorectal carci-
noma. Histopathology 2007;50:151–62.
9. Liang F, Cao W, Wang Y, Li L, Zhang G,
Wang Z. The prognostic value of tumor
budding in invasive breast cancer. Pathol
Res Pract 2013;209:269–75.
10. Wang C, Huang H, Huang Z, Wang A, Chen
X, Huang L, et al. Tumor budding correlates
with poor prognosis and epithelial–mesen-
chymal transition in tongue squamous cell
carcinoma. J Oral Pathol Med 2011;40:
545–51.
11. Teramoto H, Koike M, Tanaka C, Yamada S,
Nakayama G, Fujii T, et al. Tumor budding
as a useful prognostic marker in T1-stage
squamous cell carcinoma of the esophagus. J
Surg Oncol 2013;108:42–6.
12. Lugli A, Karamitopoulou E, Zlobec I. Tu-
mour budding: a promising parameter in
colorectal cancer. Br J Cancer 2012;106:
1713–7.
13. Huang SH, Hwang D, Lockwood G, Gold-
stein DP, O’Sullivan B. Predictive value of
tumor thickness for cervical lymph-node
involvement in squamous cell carcinoma
of the oral cavity: a meta-analysis of reported
studies. Cancer 2009;115:1489–97.
149
14. Jerjes W, Upile T, Petrie A, Riskalla A,
Hamdoon Z, Vourvachis M, et al. Clinico-
pathological parameters, recurrence, locor-
egional and distant metastasis in 115 T1-T2
oral squamous cell carcinoma patients. Head
Neck Oncol 2010;2:9.
15. Lin MJ, Guiney A, Iseli CE, Buchanan M,
Iseli TA. Prophylactic neck dissection in
early oral tongue squamous cell carcinoma
2.1 to 4.0 mm depth. Otolaryngol Head Neck
Surg 2011;144:542–8.
16. Ganly I, Goldstein D, Carlson DL, Patel SG,
O’Sullivan B, Lee N, et al. Long-term re-
gional control and survival in patients with
‘low-risk’ early stage oral tongue cancer
managed by partial glossectomy and neck
dissection without postoperative radiation:
the importance of tumor thickness. Cancer
2013;119:1168–76.
17. Harrell Jr FE, Lee KL, Mark DB. Multivari-
able prognostic models: issues in developing
models, evaluating assumptions and adequa-
cy, and measuring and reducing errors. Stat
Med 1996;15:361–87.
18. Uno H, Cai T, Pencina MJ, D’Agostino RB,
Wei LJ. On the C-statistics for evaluating
overall adequacy of risk prediction proce-
dures with censored survival data. Stat Med
2011;30:1105–17.
19. Rusthoven K, Ballonoff A, Raben D, Chen
C. Poor prognosis in patients with stage I and
II oral tongue squamous cell carcinoma.
Cancer 2008;112:345–51.
20. O-charoenrat P, Pillai G, Patel S, Fisher C,
Archer D, Eccles S, et al. Tumour thickness
predicts cervical nodal metastases and sur-
vival in early oral tongue cancer. Oral Oncol
2003;39:386–90.
21. Brennan S, Corry J, Kleid S, Porceddu S,
Yuen K, Rischin D, et al. Prospective trial to
evaluate staged neck dissection or elective
neck radiotherapy in patients with CT-staged
T1-2 N0 squamous cell carcinoma of the oral
tongue. Head Neck 2010;32:191–8.
22. Yuasa-Nakagawa K, Shibuya H, Yoshimura
R, Miura M, Watanabe H, Kishimoto S, et al.
Cervical lymph node metastasis from early-
stage squamous cell carcinoma of the
oral tongue. Acta Otolaryngol 2013;133:
544–51.
23. Grabenbauer GG, Rödel C, Ernst-Stecken A,
Brunner T, Hornung J, Kittel K, et al. Neck
dissection following radiochemotherapy of
advanced head and neck cancer—for select-
ed cases only? Radiother Oncol 2003;66:
57–63.
24. Yamauchi K, Fujioka Y, Kohno N. Sentinel
node navigation surgery versus observation
as a management strategy for early tongue
carcinoma. Head Neck 2012;34:568–72.
25. Liu XC, Yang WJ, Zhang CP, Qu XZ, Wang
T, Qiu LH, et al. An exploration of the
surgical modality of sentinel lymph node
biopsy in patients with cN0 tongue carcino-
ma: an animal study. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod
2011;112:439–45.
150 Almangush et al.
26. Nason RW, Torchia MG, Morales CM, Thli-
veris J. Dynamic MR lymphangiography and
carbon dye for sentinel lymph node detec-
tion: a solution for sentinel lymph node
biopsy in mucosal head and neck cancer.
Head Neck 2005;27:333–8.
27. Woolgar JA, Triantafyllou A. Pitfalls and
procedures in the histopathological diagno-
sis of oral and oropharyngeal squamous cell
carcinoma and a review of the role of pa-
thology in prognosis. Oral Oncol
2009;45:361–85.
28. Kim KY, Cha IH. Risk stratification of oral
cancer patients using a combined prognostic
factor including lymph node density and
biomarker. J Cancer Res Clin Oncol
2012;138:483–90.
29. Chen CH, Hsu MY, Jiang RS, Wu SH, Chen
FJ, Liu SA. Shrinkage of head and neck
cancer specimens after formalin fixation. J
Chin Med Assoc 2012;75:109–13.
30. Marangon Junior H, Rocha VN, Leite CF, de
Aguiar MC, Souza PE, Horta MC. Laminin-
5 gamma 2 chain expression is associated
with intensity of tumor budding and density
of stromal myofibroblasts in oral squamous
cell carcinoma. J Oral Pathol Med
2013;43:199–204.
Address:
Alhadi Almangush
Department of Pathology
Haartman Institute University of Helsinki
FIN-00014
Finland
Tel: +358 45 2044668; Fax: +358 9 19126675
E-mail: alhadi.almangush@helsinki.fi