Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : EC32 - EC36 Full Version

Prognostic Role of Histological Scoring of Oral Squamous Cell Carcinoma


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56672.16350
SVR Raja Sekhar, Priyanka Pappala, Ravi Chandra Bonu, Gouthami Balli

1. Associate Professor, Department of Pathology, Great Eastern Medical School and Hospital, Srikakulam, Andhra Pradesh, India. 2. Associate Professor, Department of Pathology, Great Eastern Medical School and Hospital, Srikakulam, Andhra Pradesh, India. 3. Assistant Professor, Department of Pathology, Great Eastern Medical School and Hospital, Srikakulam, Andhra Pradesh, India. 4. Assistant Professor, Department of Pathology, Great Eastern Medical School and Hospital, Srikakulam, Andhra Pradesh, India.

Correspondence Address :
Dr. SVR Raja Sekhar,
Associate Professor, Department of Pathology, Great Eastern Medical School and
Hospital, Ragolu, Srikakulam, Andhra Pradesh, India.
E-mail: rajsanuvada@gmail.co

Abstract

Introduction: Diagnosis of oral squamous cell carcinomas require assessment of parameters like histologic grade, tumour depth of invasion, lymphovascular invasion, perineural invasion, margin status, worst pattern of Invasion, But for treatment purpose only Tumour, Nodes and Metastases (TNM) staging is given importance.

Aim: To develop a scoring system based on different histopathological tumour characteristics and to know its prognostic role in oral squamous cell carcinomas.

Materials and Methods: This retrospective study was conducted in Department of Pathology at Great Eastern Medical School and Hospital, Srikakulam, Andhra Pradesh, India, from September 2011 to August 2016 and data was followed-up for 5 years, upto August 2021. Resection of primary oral lesions with cervical lymph nodal dissection were included in the study, while cases of non squamous cell carcinomas, variants of squamous cell carcinoma, post radiotherapy cases, defaulted cases, patients who lost for follow-up were excluded. The Histoscore (H score) was obtained by the scores of all histopathological tumour characteristics and it ranged from 2 to 11.This H score was divided into three groups and mean survival period of these three Histoscore Groups (HS groups) were calculated for their prognostic use (Group 1 has score 2 to 5, Group 2 has score 6 to 8, Group 3 has score 9 to 11). Medians and ranges were used to summarize continuous data, while frequency counts and percentages were used for categorical data. Kaplan-Meier’s analysis was used for evaluating 5 years survival. The p-value <0.05 was considered as statistically significant.

Results: A total of 90 cases were studied. Mean survival period was compared to HS groups, Group 1 had 64±7.59 months, Group 2 had 40.8±11.88 months, Group 3 had 26.06±12.25 months with a p-value <0.001, indicating it as a statistically significant parameter. Based on TNM staging, majority were in T2 (N=41,45.55%), N1(N=34,37.77%) and Mx (N=87,96.66%).

Conclusion: Histoscore groups of the oral squamous cell carcinomas have significant differences in the mean survival period among themselves. Hence, this histoscore groups can be an additive to the TNM classification, which provide more prognostic information to the oncologists.

Keywords

Depth of invasion, Lymphovascular invasion, Oral cancer, Perineural invasion, Score, Survival

Squamous cell carcinoma of oral cavity is one of the prevailing problems in people chewing tobacco related products (1) in developing countries like India. Its incidence is raising all over the world, accounting for 30% of all cancers (2). The diagnosis of this tumour is confirmed only by histopathological examination. During the process of diagnosis, various parameters like histologic grade, tumour depth of invasion, lymphovascular invasion, perineural invasion, margin status, worst pattern of Invasion are evaluated generally for all the cases. Though these tumour characteristics are studied, treatment is based primarily on the Tumour, Nodes and Metastases (TNM) classification (3).

There are significant advances in different therapeutic modalities but there is no significant improvement in the 5 year overall survival rate in the last few decades (4),(5),(6). This maybe due to lack of appropriate prognostic markers which could alter the treatment modalities. There are some studies (6),(7),(8) which recommend to include these tumour characteristics into TNM classification but it may be complicated as it has to be divided into sub groups and sub-subgroups (8). To avoid these complications in pathological diagnosis, at the same time, to provide more information for the oncologists in a simpler manner, present study tried to develop a scoring system basing on histopathological tumour characteristics, which is an addition to TNM classification, helps the patients to get better treatment and decreases the tumour recurrences and improve the overall survival.

The present study aimed to develop a scoring system based ondifferent histopathological tumour characteristics and to know its prognostic role in Squamous cell carcinomas of oral cavity. The Objectives:

• To reclassify the histopathological parameters as per the latest College of American Pathologists (CAP) protocol.
• To assign scores for each histopathological parameter separately.
• To obtain a Histoscore (H score) for each patient by adding the scores of all histopathological parameters.
• To categorize the H scores into three Histoscore Groups (HS Groups) and compare the mean survival periods among these three groups.

Material and Methods

This retrospective study was conducted in Department of Pathology at Great Eastern Medical School and Hospital, Srikakulam, Andhra Pradesh, India, from September 2011 to August 2016. The study was started in 2017 and the patients were followed-up for 5 years ie., upto August 2021. The study was approved from the Institutional ethical board (IEC:26/2017).

Sample size calculation: Sample size was 87, calculated by taking 95% confidence interval with 5% marginal error and 6% as population proportion.

Inclusion and Exclusion criteria: A total of124 cases of Resectedprimary oral lesions with cervical lymphnodal dissection were included in the study, while cases of non squamous cell carcinomas, variants of squamous cell carcinoma, post radiotherapy cases, defaulted cases, patients who lost for follow-up, which all constituted 34 cases, were excluded from the study.

Procedure

These 90 cases were followed-up for a period of 5 years. Data was retrieved from the records of Histopathology, Great Eastern Medical School and Hospital. All the slides and blocks were reviewed for the various histopathological parameters like histologic grade, tumour depth of invasion, lymphovascular invasion, perineural invasion, margin status and worst pattern of Invasion as per the College of American Pathologists (CAP) protocol, version 4.1.1.0 (9).

• Histological grading of the tumour was done as well differentiated (Grade 1), moderately differentiated (Grade 2) and poorly differentiated (Grade 3) depending on the highest grade present in the tumour proper (10).
• Tumour Depth Of Invasion (DOI) is measured from the basement membrane of the adjacent normal to the deepest point of invasion of the tumour (11),(12).
• Lymphovascular Invasion (LVI) and Perineural Invasion (PNI) were recorded as positive when vessels, nerves of any size were involved, irrespective of their location whether within or outside the tumour (13).
• Margins were said to be involved when the invasive carcinoma or carcinoma in-situ/High grade dysplasia is present at the margin (microscopic cut-through of tumour) (14).
• Worst Pattern of Invasion (WPOI) is graded as mentioned below (15):
Type 1- Pushing border
Type 2- Finger like growth
Type 3- Large separate islands, more than 15 cells per island
Type 4- Small tumour islands, 15 cells or fewer, per island
Type 5- Tumour satellites, >1 mm from main tumour or next closest satellite. Dispersed LVI or PNI.
• The Extranodal Extension (ENE) was taken as positive whenever the metastatic deposit infiltrated through the lymphnode capsule into the surrounding connective tissue.

Scoring is given for all the other histopathological tumour characteristics as per below mentioned (Table/Fig 1). Tumour size, lymphnodal involvement and metastasis is categorized as per TNM staging.

The Histoscore (H score) is obtained by adding the scores of all histopathological tumour characteristics and it ranged from 2 to 11.This H score is divided into three groups as per below mentioned (Table/Fig 2) and mean survival period of these three Histoscore Groups (HS groups) are calculated by taking the average number of years survived by the patients during the follow-up period of 5 years.
Statistical Analysis

Microsoft access databases were combined in Excel. Descriptive statistics were used for patients epidemiological data and histopathological features. Medians and ranges were used to summarize continuous data, while frequency counts and percentages were used for categorical data. Statistical analysis was carried by using Graphpad prism 9.3.1. Univariate and Multivariate analysis through linear regression is used for clinicopathological parameters. Kaplan-Meier’s analysis was used for evaluating 5 year survival. The p-value <0.05 was considered as statistically significant.

Results

A total 90 cases were studied comprising 68 (75.55%) males and 22 (24.44%) females. The age of the patients ranged from 28 to 72 years with peak in the 4th decade (N=35, 38.88%), followed by 3rd decade (N=27,30.00%). The clinicopathological details of these cases are tabulated in (Table/Fig 3). Buccal mucosa (BM) was the most common site (N=42, 46.66% ) in the study, followed by tongue (TG) (N=28, 31.11%), Lower Alveolus (LA) (N=8, 8.88%), Upper Alveolus (UA) (N=5,5.55%), lip (N=4, 4.44%) and Hard Palate (HP) (N=3,3.33%) as shown in (Table/Fig 3).

Among these 90 cases, tumour size ranged from 0.8 to 6.2 cm. Based on TNM staging (Table/Fig 4), majority were in T2 (N=41,45.55%), N1(N=34,37.77%) and Mx (N=87,96.66%). Grade 1 tumours were 49 (54.44%), Grade 2 tumours were 36 (40.00%) and Grade 3 tumours were only 5 (5.55%) cases. DOI is <5 mm in 13 (14.44%) cases, between 5 mm to 10 mm in 45 (50.00%) cases and >10 mm in 32 (35.55%) cases. Lymphovascular (Table/Fig 5) and perineural invasions (Table/Fig 6) are noted in 52 (57.77%) and 28 (31%) cases respectively.

WPOI is of type 1 in 14 (15.55%) cases, type 2 in 18 (20.00%)cases, type 3 in 24 (26.66%) cases, type 4 in 12 (13.33%) cases and type 5 in 22 (24.44%) cases (Table/Fig 7). Type 3 is the most common followed by type 5 and type 2. When compared types 1-4 with type 5, there is a significant statistical difference in prognosis.Margin is involved in two cases and but free from tumour (>5 mm) in the remaining cases. Lymphnodes were involved in 64 (71.11%) cases, while extranodal extension is seen in 15 (16.66%) cases. Hs group 1 is the most common (N=58, 64.44%), followed by HS groups 2 and 3 with each of 16 cases (17.77%).

Mean survival period of all the above histopathological tumour characteristics are tabulated in (Table/Fig 8), (Table/Fig 9). (Table/Fig 9) shows that most common age is 4th decade. The colour of the bubble indicates the site of the tumours, while size of the bubble corresponds to H score. Tumours with buccal mucosa site and smaller H score had better survival(in months) compared to tumours with Upper alveolus, tongue site and greater H score.

When Mean survival period was compared to HS groups (Table/Fig 10), Group 1 had 64±7.59 Months, Group 2 had 40.8±11.88 Months, Group 3 had 26.06±12.25 Months with a p-value <0.001, indicating it as a statistically significant parameter.

Discussion

Squamous cell carcinomas of oral cavity are one of the most common causes of morbidity in developing countries like India. Current guidelines recommend therapeutic resection of primary tumour with post operative adjuvant therapy (3). This adjuvant therapy is based on the various histopathological details of the resected tumour.The parameters which measure the aggressiveness of the tumour, recurrence and metastasis of oral squamous cell carcinomas are clearly not defined. Several studies were made to identify these and included parameters like histologic grade, tumour depth of invasion, lymphovascular invasion, perineural invasion, margin status, lymphocytic host response, worst pattern of invasion (16),(17),(18),(19). Among these histological grade, lymphovascular invasion and perineural invasion are commonly noted in all the malignancies in general, so newer parameters like tumour depth of invasion, margin status and worst pattern of invasion were detailed in the present study.

Analysis of patients for smoking and alcohol intake was not done as previous studies (1) did not reveal any relation between them and tumour recurrence or disease-free survival. Risk scoring is simple and easy as it can be done on the routine H & E stained slides. Only the resected tumour should be commented upon pattern of invasion, as there are chances of under sampling in biopsies. The entire tumour should be submitted for microscopic examination preferably for exact evaluation of tumour invasion (8),(13). If the tumour size is >4 cm grossly, serial sections 5 mm apart should be given and sections with maximum tumour depth grossly should be submitted. In the present study, tumours having T1 had maximum mean survival period of 68.6 months and T4 had lowest mean survival period of 22.7 months.

Tumour grading, which is being done since many decades, had similar prognostic significance in this study as well, as Grade 1 had mean survival of 63.4 months and Grade 3 tumours had 16 months mean survival. DOI is a valuable parameter for predicting survival and regional nodal involvement, is measured from the basement membrane of adjacent normal mucosa to the deepest point of tumour invasion. Though the word tumour thickness is used interchangeably with DOI, there is slight difference between these two as tumour thickness is measured from mucosal surface of tumour to the deepest tumour invasion. In ulcerated tumours, DOI will be greater than tumour thickness (11),(12).

Tumours with aggressive behavior have lymphovascular invasion, thereby have poorer prognosis. As in H&E stain it is difficult to different lymphatic vessel from blood vessels, authors have used the term lymphovascular invasion. Tumours without lymphovascular invasion has slightly better mean survival period (63.8 months)in the present study. But as per the previous studies, D2-40 and podoplanin (20) helps in detecting the lymphatic vessels specifically, hence they may be used for predicting the cervical lymphnodal metastasis.

The perineural invasion in the present study is reported as per latest CAP protocol irrespective of its size and location. As with previous studies (13),(16), tumours in present study showing perineural invasion had poorer prognosis (31.1 months).

The status of surgical margins, particularly tumour bed margin is helpful in predicting the recurrences. In the present study, there were only two cases where the margins are involved and the mean survival period was 11 months. A shortcoming in current study is that we dint mentioned any “Close margins”, which in according to some studies is that if the tumour is <3 mm away from the resected margin. This close margin status might be helpful in predicting the recurrences (21),(22).

Extranodal extension is one of the important prognostic factor and has to be commented whenever nodal deposits are present. In this study, tumours with ENE has only 24.6 months mean survival period. Even the distance of extension (> or <2mm) from capsule is also suggested but not required for the nodal positive cases as prognosis is not dependent on distance from capsule but only those with ECE Grade 4 (any size of deposit, large or small, that was discrete and without residual nodal architecture) had poorer out comes (23).

The immunity developed by the host tissue against the tumour cells is also quantified and graded as Lymphocytic Host Response as mild, moderate and severe and is used as one of the prognostic markers in several studies earlier (15),(17),(18). Though this parameter has significant role in prognosis, it is not still included in present study as it was not included in the recent CAP protocol. The lymphocytes particularly which are positive of CD3, CD8 and FoxP3 were found to have favorable prognosis (24). More studies are required to substantiate this finding and is better if a scoring system is adapted for these immunomarkers for universal application.

Broder’s grading, a modification of Byrne et al for prognosis of oral squamous cell carcinomas was initially based on parameters like mitotic count, nuclear atypia and keratinization. Whereas Brandwein GM et al., has introduced new prognostic marker basing on the pattern of invasion by the tumour into the underling stroma and categorized into five Worst Pattern of Invasion (WPOI) types (15). They showed that worst patterns (patterns 5 and 4) were associated with poorer prognosis and lymphnodal metastasis. But, the recent CAP protocol (November 2021) has recommended 1-4 patterns of invasion as one group and pattern 5 as another group indicating prognostic significance for pattern 5 when compared to other patterns (9).

There are many standardized scoring systems for certain malignancies like Bloom Richardson scoring and grading system for Breast carcinoma, Gleasons scoring and grading system for prostatic carcinoma, which helps to know about their prognosis (7),(17). Similarly, some scoring systems were developed for oral squamous cell carcinomas like those published by Bryne M et al., (25) and Brandwein GM et al., (26) and Giacomarra V et al., (27). The drawbacks of these studies were that the tumour parameters included were not clearly defined and standardized, complicated and further some of them required additional testing. The present study tried to develop a simple scoring system for oral squamous cell carcinomas on the H&E stained sections only by summating the scores given for each histopathological tumour characteristics as per the clearly defined and standardized CAP protocol version 4.1.1.0 (9) and diving them into three groups (HS groups). This study found that there was significant difference in mean survival period for these three different groups. Hence, if this scoring system is added to TNM staging, it could provide more information to the oncologists regarding the tumour aggressiveness, thereby they can alter the treatment modalities for the patients, which may finally decrease the tumour recurrences and increase the overall survival period of the patients.

Limitation(s)

This was a smaller sample sizestudy, studies with larger cohorts are essential to substantiate our findings to make it as an additive to the TNM classification. Prognostic role of close margin status should also be considered in future studies as it was not considered in the present study.

Conclusion

Histoscoring for oral squamous cell carcinomas is developed by summating the scores of different histopathological tumour characteristics and to further categorize them into histoscore groups which have significant differences in the mean survival period. Hence this Histoscore groups can be an additive to the TNM classification, which provide more prognostic information to the oncologists.

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DOI and Others

DOI: 10.7860/JCDR/2022/56672.16350

Date of Submission: Mar 26, 2022
Date of Peer Review: Apr 11, 2022
Date of Acceptance: Apr 26, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 02, 2022
• Manual Googling: Apr 18, 2022
• iThenticate Software: Apr 22, 2022 (9%)

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