Archives of Head and Neck Surgery
Archives of Head and Neck Surgery
Original Article Lip and oral cavity tumors

Staging of oral cavity cancer in the 8th edition of the TNM classification: the role of computed tomography in the assessment of depth of invasion and extranodal extension

Leticia de Franceschi, João Manoel Miranda Magalhães Santo, Anniely Mourão de Abreu, Marco Aurélio Vamondes Kulcsar, Claudio Roberto Cernea, Marcio Ricardo Taveira Garcia, Rogerio Aparecido Dedivitis, Leandro Luongo Matos

Downloads: 6
Views: 491


Introduction: In the TNM staging (TNM-8) for oral cavity cancers (OCC), depth of invasion (DOI) and extranodal extension (ENE) were added to the T and N pathological classification, respectively. It has been recognized for decades that the prognosis of OCC worsens when the tumor is thicker, but more recent data suggest that DOI is a better predictive parameter than tumor thickness. Objective: Suggest and validate pre-surgical tomographic evaluation criteria for OCC based on the pathological DOI criteria. Methods: A retrospective cohort study was conducted with 80 patients with tongue and floor of mouth tumors, T1 and T2, followed from 2009 to 2015. Patients were initially classified according to the 7th edition of the TNM (TNM-7) using pathological samples and then reclassified based on the updated 8th edition of the TNM (TNM-8) criteria. The same was done radiologically, using extrapolation and adaptation of the pathological criteria to tomographic evaluation. The results of pathological staging were compared and correlated with the main clinical outcomes. The same was done with the radiological results. To evaluate the pre-surgical accuracy of tomographic staging, radiological and pathological results were compared. Results: Regardless of the criteria (TNM-7 or TNM-8), it was observed that computed tomography (CT) with venous contrast may be used to guide the initial staging. Strong positive correlation was observed between tumor thickness and DOI at both CT and pathology. Considerable upstaging was observed in the sample of assessed patients for both criteria. In the comparison between tomographic and pathological T classifications, moderate correlation was observed in relation to thickness and DOI. Conclusion: Computed tomography can be used to evaluate the depth of preoperative invasion in oral cavity tumors according to the criteria established in the present study.


mouth; mouth neoplasms; neoplasm staging; lymphatic metastasis


1. Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, Washington MK, Gershenwald JE, Compton CC, Hess KR, Sullivan DC, Jessup JM, Brierley JD, Gaspar LE, Schilsky RL, Balch CM, Winchester DP, Asare EA, Madera M, Gress DM, Meyer LR, editors. AJCC cancer staging manual. 8th ed. Chicago: Springer; 2017.

2. Lydiatt WM, Patel SG, O’Sullivan B, Brandwein MS, Ridge JA, Migliacci JC, Loomis AM, Shah JP. Head and neck cancers-major changes in the American Joint Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017;67(2):122-37. PMid:28128848.

3. Ebrahimi A, Gil Z, Amit M, Yen TC, Liao CT, Chaturvedi P, Agarwal JP, Kowalski LP, Kreppel M, Cernea CR, Brandao J, Bachar G, Bolzoni Villaret A, Fliss D, Fridman E, Robbins KT, Shah JP, Patel SG, Clark JR. Primary tumor staging for oral cancer and a proposed modification incorporating depth of invasion. JAMA Otolaryngol Head Neck Surg. 2014;140(12):1138-48. PMid:25075712.

4. Mermod M, Tolstonog G, Simon C, Monnier Y. Extracapsular spread in head and neck squamous cell carcinoma: A systematic review and meta-analysis. Oral Oncol. 2016;62:60-71. PMid:27865373.

5. Matos LL, Manfro G, Santos RV, Stabenow E, Mello ES, Alves VA, Pinto FR, Kulcsar MA, Brandão LG, Cernea CR. Tumor thickness as a predictive factor of lymph node metastasis and disease recurrence in T1N0 and T2N0 squamous cell carcinoma of the oral tongue. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;118(2):209-17. PMid:24906946.

6. Pinto FR, de Matos LL, Palermo FC, Kulcsar MA, Cavalheiro BG, Mello ES, Alves VA, Cernea CR, Brandão LG. Tumor thickness as an independent risk factor of early recurrence in oral cavity squamous cell carcinoma. Eur Arch Otorhinolaryngol. 2014;271(6):1747-54. PMid:24071858.

7. Edge SB, Byrd DR, Compton CC, Fritz A, Greene FL, Trotti A. AJCC cancer staging manual. 7th ed. New York: Springer Verlag; 2010.

8. American Joint Committee on Cancer. Manual for staging of cancer. Chicago: American Joint Committee; 1977.

9. Howaldt HP, Kainz M, Euler B, Vorast H. Proposal for modification of the TNM staging classification for cancer of the oral cavity: DOSAK. J Craniomaxillofac Surg. 1999;27(5):275-88. PMid:10717829.

10. O’Brien CJ, Lauer CS, Fredricks S, Clifford AR, McNeil EB, Bagia JS, Koulmandas C. Tumor thickness influences prognosis of T1 and T2 oral cavity cancer: but what thickness? Head Neck. 2003;25(11):937-45. PMid:14603454.

11. Lell M, Baum U, Greess H, Nömayr A, Nkenke E, Koester M, Lenz M, Bautz W. Head and neck tumors: imaging recurrent tumor and post-therapeutic changes with CT and MRI. Eur J Radiol. 2000;33(3):239-47. PMid:10699740.

12. Albuquerque MA, Kuruoshi ME, Oliveira IR, Cavalcanti MG. CT assessment of the correlation between clinical examination and bone involvement in oral malignant tumors. Braz Oral Res. 2009;23(2):196-202. PMid:19684956.

13. Vidiri A, Guerrisi A, Pellini R, Manciocco V, Covello R, Mattioni O, Guerrisi I, Di Giovanni S, Spriano G, Crecco M. Multi-detector row computed tomography (MDCT) and magnetic resonance imaging (MRI) in the evaluation of the mandibular invasion by squamous cell carcinomas (SCC) of the oral cavity. Correlation with pathological data. J Exp Clin Cancer Res. 2010;29(1):73. PMid:20565737.

14. Draenert FG, Coppenrath E, Herzog P, Müller S, Mueller-Lisse UG. Beam hardening artefacts occur in dental implant scans with the NewTom cone beam CT but not with the dental 4-row multidetector CT. Dentomaxillofac Radiol. 2007;36(4):198-203. PMid:17536086.

5af09cf20e8825c404e461c1 archives Articles
Links & Downloads

Arch. Head Neck Surg.

Share this page
Page Sections