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Stratifying Extranodal Extension to pN2a and pN3b: Is the Rationale Justified?
Maroti Wadewale1, Anoop Attakil2, Sandeep Vijay2
1Consultant, Head and Neck Surgical Oncology, Department of Surgical Oncology, Kolhapur Cancer Centre, Kolhapur, Maharashtra, India.
Background:
In oral squamous cell carcinoma (OSCC), nodal metastasis halves survival, and extranodal extension (ENE) further worsens outcomes. However, limited evidence supports its American Joint Committee on Cancer classification as pN2a or pN3b.
Purpose:
The purpose was to compare survival and prognostic factors in OSCC patients treated with adjuvant chemoradiation for ENE, stratified into pN2a and pN3b groups.
Study Design, Setting, Sample:
This retrospective cohort study at Malabar Cancer Center, Thalassery, included OSCC patients with ENE treated with curative surgery and adjuvant chemoradiotherapy between 2017 and 2021, with a minimum follow up of 3 years; cases with insufficient data or positive margins were excluded.
Predictor Variable:
The predictor variable was ENE-positive nodal status (pN2a vs pN3b).
Main Outcome Variable(S):
The primary outcomes were overall survival and recurrence-free survival.
Covariates:
The covariates were ENE in a single node <3 cm versus >1 node or >3 cm, sex, lifestyle habits, tumor subsites, neck dissection, pathological T-staging, nodal ratio, and ENE topography.
Analyses:
Survival was analyzed using Kaplan-Meier, with log-rank tests for group comparisons and Cox regression for subgroup analyses (P < .05 considered significant).
Results:
A total of 92 subjects (73 males (79.3%), 19 females (20.7%) were evaluated, with a mean age of 54.4 years (standard deviation 24-80) and an overall median follow-up of 43.5 months (interquartile range 4-71). The majority were pN3b (78; 84.2%), with 14 (15.8%) classified as pN2a. Three-year overall survival (57.1 vs 45.2%) and recurrence-free survival (50.0 vs 42.5%) were comparable between groups (P > .7). pN2a had more locoregional failures, while pN3b had more distant metastases (P > .2, hazard ratio 1.71 (0.61-4.78). Median survival was longer for N2a (39.5 months) compared to pN3b (29.6 months), though this was not statistically significant (P > .9, hazard ratio 1.71 (0.61-4.78). ENE topography, nodal ratio, and additional covariates showed no statistically significant association with survival.
Conclusions And Relevance:
pN2a and pN3b demonstrated similar survival outcomes, indicating the need for re-evaluation of prognostic stratification in the American Joint Committee on Cancer 8th edition. However, this interpretation should be made in the context of the small sample size.
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