Top Line: Consensus has been mounting that extranodal extension (ENE) should be incorporated into staging HPV+ oropharyngeal squamous cell carcinoma (oSCC).
The Study: We’re all familiar that using the current version 8 stages >85% of oSCC as stage I, which isn’t communicating much valuable information for the vast majority of patients. Here the AJCC panel leans on a large NCDB analysis of over 14K patients undergoing resection of HPV+ oSCC between 2010-2019 to create training and validation cohorts for updated staging. In line with prior data–and conventional wisdom–survival was worse with each additional pathologically involved node up to four (HR 1.20) and even worse with the addition of ENE (HR 1.47). Of note, the extent of ENE (≤2 mm versus >2 mm) did not appear to incrementally discern outcomes, so here it is considered a binary variable. As has been suggested, survival with standard treatment was best discriminated by bumping up the nodal stage with the presence of any ENE. Proposed nodal staging is thus: N1a = 1 node ENE-, N1b = 2–4 nodes ENE-, N2 = >4 nodes ENE- or 1–4 nodes ENE+, N3 = >4 nodes ENE+. This makes group staging look like: Stage I = T0-2N0-1, Stage II = T3 or N2-3, Stage III = T3N3 or T4, Stage IV = M1.
TBL: “AJCC version 9 updates HPV+ oSCC staging to reflect current practice…and implements changes that improve prognostication.” | Ho, Lancet Oncol 2025
The Study: We’re all familiar that using the current version 8 stages >85% of oSCC as stage I, which isn’t communicating much valuable information for the vast majority of patients. Here the AJCC panel leans on a large NCDB analysis of over 14K patients undergoing resection of HPV+ oSCC between 2010-2019 to create training and validation cohorts for updated staging. In line with prior data–and conventional wisdom–survival was worse with each additional pathologically involved node up to four (HR 1.20) and even worse with the addition of ENE (HR 1.47). Of note, the extent of ENE (≤2 mm versus >2 mm) did not appear to incrementally discern outcomes, so here it is considered a binary variable. As has been suggested, survival with standard treatment was best discriminated by bumping up the nodal stage with the presence of any ENE. Proposed nodal staging is thus: N1a = 1 node ENE-, N1b = 2–4 nodes ENE-, N2 = >4 nodes ENE- or 1–4 nodes ENE+, N3 = >4 nodes ENE+. This makes group staging look like: Stage I = T0-2N0-1, Stage II = T3 or N2-3, Stage III = T3N3 or T4, Stage IV = M1.
TBL: “AJCC version 9 updates HPV+ oSCC staging to reflect current practice…and implements changes that improve prognostication.” | Ho, Lancet Oncol 2025