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 Table of Contents  
LETTER TO EDITOR
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 93-94

Commentary on 8th Edition of tumor node metastasis for staging of cancers of the oral cavity


Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication22-Jan-2018

Correspondence Address:
Dr. Sarbani Ghosh Laskar
Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_42_17

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How to cite this article:
Chatterjee A, Laskar SG. Commentary on 8th Edition of tumor node metastasis for staging of cancers of the oral cavity. J Head Neck Physicians Surg 2017;5:93-4

How to cite this URL:
Chatterjee A, Laskar SG. Commentary on 8th Edition of tumor node metastasis for staging of cancers of the oral cavity. J Head Neck Physicians Surg [serial online] 2017 [cited 2019 Sep 15];5:93-4. Available from: http://www.jhnps.org/text.asp?2017/5/2/93/223766



Sir,

Oral cavity cancer remains predominantly a disease of the developing world. The proposed tumor-node-metastasis (TNM) staging for the American Joint Committee on Cancer (AJCC) 8 poses major challenges in its widespread applicability in the nations where this disease is rampant.

First, the oral cavity is an extremely heterogeneous site. Tongue and floor of mouth cancers are very different from gingival–buccal complex cancers in their biology, behavior, and patterns of spread. The proposed TNM classification remains insensitive to this distinction.

The most distinguishing feature of the new T-classifier is the usage of depth of infiltration (DOI). There are several issues with the same. The data justifying the usage of DOI as an omnipotent arbiter of T stage is culled mainly from series studying tongue and floor of mouth cancers,[1],[2] where indeed an increased DOI increases the chances of lymph nodal spread. The comprehensive analysis by Ebrahimi et al. do not allude to the site-wise distribution of cases.[3] The same is not true for gingival–buccal cancers. Moreover, DOI can be influenced by subjectivity and is often not reported in routine pathology.

The N classifier has accorded a lot of importance to the presence of extracapsular extension (ECE), which is known to confer an adverse prognosis. However, ECE is mainly a pathological finding. We feel that any staging for oral cavity cancer (a site easily accessible to examination) should incorporate elements which are easily assessable clinicoradiologically. A contrast-enhanced computed tomography scan of the face and neck, which is the most commonly used cross-sectional imaging modality has been shown to have poor sensitivity in detecting ECE.[4] Clinical estimation of ECE would be even more fraught with error. The cN stage may not be reproducible. One of the utilities of the TNM is to be able to carry out multi-institutional studies. This aspect of the cN staging may be fraught with a lot of subjectivity, making interobserver comparisons unreliable.

Extensive soft-tissue infiltration is typically seen in locally advanced cancers of the oral cavity. Such infiltration has also been found to confer a poorer disease-free interval.[5] Deep infiltration of the adjacent soft tissues is an easily recognizable feature and as such could be taken cognizance of in staging.

We tested the changes in staging between the 7th and 8th edition of the AJCC staging on 100 patients accrued on a prospective randomized trial of adjuvant therapy in locally advanced oral cavity cancer. The dataset predominantly comprised of gingivobuccal cancers (72 patients) with 27 patients of cancer of the oral tongue and floor of mouth.

N-Stage migration occurred in 58 patients, all being upstaged. The most common stage migration occurred from N2b (AJCC 7) to N3b (AJCC 8) in 34 patients, followed by migration from N2c (AJCC 7) to N3b (AJCC 8) in 9 patients. However, at a median follow-up of 20.5 months, the overall survival was 58.3 months for the patients with N2b disease (AJCC 7), which was similar to the survival of patients restaged as N3b (AJCC 8). The migration in stage did not lead to worsening of survival. Whether this is a true reflection of stage migration or the effect of selection bias would remain a point of debate.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shim SJ, Cha J, Koom WS, Kim GE, Lee CG, Choi EC, et al. Clinical outcomes for T1-2N0-1 oral tongue cancer patients underwent surgery with and without postoperative radiotherapy. Radiat Oncol 2010;5:43.  Back to cited text no. 1
    
2.
Spiro RH, Huvos AG, Wong GY, Spiro JD, Gnecco CA, Strong EW, et al. Predictive value of tumor thickness in squamous carcinoma confined to the tongue and floor of the mouth. Am J Surg 1986;152:345-50.  Back to cited text no. 2
    
3.
International Consortium for Outcome Research (ICOR) in Head and Neck Cancer, Ebrahimi A, Gil Z, Amit M, Yen TC, Liao CT, Chaturvedi P, et al. Primary tumor staging for oral cancer and a proposed modification incorporating depth of invasion: An international multicenter retrospective study. JAMA Otolaryngol Head Neck Surg 2014;140:1138-48.  Back to cited text no. 3
    
4.
Prabhu RS, Magliocca KR, Hanasoge S, Aiken AH, Hudgins PA, Hall WA, et al. Accuracy of computed tomography for predicting pathologic nodal extracapsular extension in patients with head-and-neck cancer undergoing initial surgical resection. Int J Radiat Oncol Biol Phys 2014;88:122-9.  Back to cited text no. 4
    
5.
Walvekar RR, Chaukar DA, Deshpande MS, Pai PS, Chaturvedi P, Kakade AC, et al. Prognostic factors for loco-regional failure in early stage (I and II) squamous cell carcinoma of the gingivobuccal complex. Eur Arch Otorhinolaryngol 2010;267:1135-40.  Back to cited text no. 5
    




 

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