Protocol for correlation of histological risk assessment/scoring system with a depth of invasion in oral squamous cell carcinoma

Introduction The commonest type of cancer in the head and neck region is oral squamous cell carcinoma (OSCC) due to its high rates of occurrence and mortality. The early diagnosis of oral cancer gives better prognosis. Brandwein-Gensler criteria predict the early stage of OSCC cases with a high risk of locoregional recurrence. Objectives To correlate Brandwein-Gensler criteria and depth of invasion of OSCC with three-year survival. Methodology In the study, This study will include 80 random histopathologically-diagnosed cases of OSCC. hematoxylin-eosin (HE)-stained section slides will be used to evaluate, Brandwein and Gensler criteria by three histopathologists in a blinded manner. The depth of invasion assessment will be done from the basement-membrane (BM), in regions where the BM has been lost, as well as from an illustrative line connecting the BM from the neighbouring epithelium to the point of deepest tumour invasion in the connective-tissue stroma with the help of a research microscope (Leica-DMLB2) in resected tissue specimens of OSCC cases. Expected results The present study will find the correlation between Brandwein-Gensler criteria and depth of invasion in OSCC in order to evaluate the locoregional recurrence in OSCC cases. In high-risk OSCC cases, there may be an increased depth of invasion in resected tissues. Conclusions We hypothesized that the correlation between Brandwein-Gensler criteria and depth of invasion can be used as an independent predictor for locoregional recurrence in OSCC.


Introduction
The commonest type of cancer in the head and neck region is oral squamous cell carcinoma (OSCC) due to its high rates of occurrence and mortality.The early diagnosis of oral cancer gives better prognosis.Brandwein-Gensler criteria predict the early stage of OSCC cases with a high risk of locoregional recurrence.

Objectives
To correlate Brandwein-Gensler criteria and depth of invasion of OSCC with three-year survival.

Methodology
In the study, This study will include 80 random histopathologicallydiagnosed cases of OSCC.hematoxylin-eosin (HE)-stained section slides will be used to evaluate, Brandwein and Gensler criteria by three histopathologists in a blinded manner.The depth of invasion assessment will be done from the basement-membrane (BM), in regions where the BM has been lost, as well as from an illustrative line connecting the BM from the neighbouring epithelium to the point of deepest tumour invasion in the connective-tissue stroma with the help of a research microscope (Leica-DMLB2) in resected tissue specimens of OSCC cases.

Introduction
Oral squamous cell carcinoma (OSCC) is the most widely occurring cancer in the head-neck region. 1 In 2018, OSCC claimed around 177,000 global fatalities. 2 Despite of the advanced treatment modalities and therapeutic approaches, the overall survival rate in OSCC did not rise by more than 50% during a five-year period. 3The clinical diagnosis of OSCC is confirmed by histopathology.In the adjunct therapy such as chemotherapy radiotherapy, histopathological report of OSCC is important.Due to this, many studies emphasize on the histopathological parameters of resected oral cancer tissues in the pathology reports. 4Several authors have proposed various grading systems for OSCC.The first grading system developed by Broder (1920), which is still advised by the WHO 5,6 is likely the most well-known prognostication method using a subjective evaluation of significant histopathological features like differentiation degree of tumor cells, cellular pleomorphism, and mitotic activity, and is grouped into WDSCC (well differentiated), MDSCC (moderately differentiated) and PDSCC (poorly differentiated).Although MDSCC comprises up to 90% of oral cancers, this approach, while widely identified and used, still has poor discriminatory value because in MDSCC pathologically there is a poor cellular differentiation than the WDSCC. 6,7Annoreth et al. gave another classification which emphasise on the association between the tumour and adjacent tissue. 8This included aspects like the leukocyte invasion and the degree of pattern and stage of invasion.A method of invasive-tumour-front grading (IFG) comprising five histopathological characteristics involving lymphocyte-host-response (LHR) was later devised by Bryne et al. 9 Because of the small sample sizes, varied locations of the tumour, and examination of various types of specimens, these models have not proved successful.A risk assessment model put forth in 2005 by Brandwein-Gensler and colleagues was said to have better prognostic value than previously mentioned systems. 10It includes the combined assessment of three important histopathological parameters: PNI (perineural-invasion), LHR (lymphocyte-host-response), and WPOI (worst-pattern of invasion).Scoring is done for all three parameters individually and then the sum of the three variables is computed.The Brandwein-Gensler (BG) system showed a significant correlation with the patient's locoregional recurrence and overall survival, especially in low-stage oral cancers.More aggressive characteristics receive weighted point values in the model. 11Adjuvant radiotherapy may be beneficial in cases of high-risk, low-stage oral cancers, even when the margins are satisfactory.The TNM classification for OSCC (eight edition, 2017), emphasizes on depth-of-tumour invasion (DOI) along with largest diameter of the tumour to determine the T-stage 12 and signifies a shift in the paradigm in Oral Pathology.When determining the specific course of treatment for a particular case, a combined evaluation of clinical staging and histological grading may be a more reliable method. 1 The main goal of our study is to determine the association of DOI with the histological risk assessment/scoring system in order to assess the combined effects of these factors on OSCC pathological staging and locoregional recurrence in three-year survival rate.

Trial design
This study will be retrospective, using archival tissue from OSCC cases.

Study setting
This cross-sectional study will be carried out at Sharad Pawar Dental College and Hospital (SPDC&H), Datta Meghe Institute of Higher Education, Sawangi-Meghe, Wardha in the Oral Pathology and Microbiology Department.This study will include 80 random histopathologically-diagnosed cases of OSCC.Computer-generated randomization technique was used.The staging will be carried out on the basis of the American Joint Committee on Cancer (AJCC) eighth edition criteria. 13Cases with a previous head-neck cancer history, pre-surgical radiation therapy, chemotherapy or any surgery (apart from biopsy) and recurrent or distant disease will be excluded.Patient data comprising of age and sex of the patient, site of the lesion, clinical appearance of the tumor, habits including tobacco and alcohol use and status of lymph node will be obtained.

Intervention
Staining of the archival slides and new slides (where needed) will be done with Heamtoxyline and eosin stain.Worstpattern of invasion WPOI, Lymphocyte-host-response LHR, and Perineural-invasion PNI will be assessed by three histopathologists in a blinded manner.Evaluation will be done according to the Risk Model mentioned below.Three groups will be made depending on the sum of the score of each case:

REVISED Amendments from Version 1
In the new version, we have updated the methodology in detail.
Any further responses from the reviewers can be found at the end of the article Group 1low-risk cases = total score 0 Group 2moderate-risk cases = 1 or 2 Group 3high risk-cases = 3 or more.
The DOI assessment will be done from the basement-membrane (BM), in regions where the BM has been lost, as well as from an illustrative line connecting the BM from the neighbouring epithelium to the point of deepest tumour invasion in the connective-tissue stroma with the help of a research microscope (Leica-DMLB2) with standard software (Leica-Qwin).The DOI will be measured and recorded.

Outcomes
The present study will find the correlation between Brandwein-Gensler criteria and DOI in OSCC.In the high-risk category, there may be increased DOI in resected tissue of OSCC.

Sample size
Considering the prevalence of OSCC as 70.7% in the outpatient department of the Oral Pathology and Microbiology department, using the single proportion formula, sample size is calculated by applying the formula: Where, Z21 À α=2 -The significance level at 5% i.e. 95 % confidence interval = 1.96 p = Sample showing positive CD44 expression focally in small group cells in the basal layer of epithelium = 70.7%= 0.707

Dissemination
The results will be published in an indexed journal.

Study status
The study has not started yet.

Discussion
Incidence of OSCC in Indian men (11.28%) ranks first while it ranks fifth in women (4.3%). 1,2The clinical diagnosis is always confirmed by the histopathology.There are numerous histopathological grading systems mentioned in the literature for OSCC.Among them, the BG risk predictive model gives the best results regarding the loco-regional recurrence of OSCC. 4 Arun Chaturvedi evaluated the BG risk predictive model in surgically treated OSCC patients in North India.The author studied 149 patients with histologically diagnosed OSCC.The patients were divided into three groups: low, moderate, and high risk according to the BG criteria.Out of 149 patients, 17 patients showed locoregional recurrences (11.4%).Most of these 17 patients belonged to the high-risk category of the BG risk model.The authors hypothesised that the BG risk model is predictive of locoregional recurrences for OSCC undergoing primary surgery and it can be used to model for recognition of recurrences and prevention at early stages of the disease. 14ayany de Castro Ribeiro Lindenblatt studied 53 cases of OSCC in which they evaluated four grading systems (Malignancy Grading of the Deep Invasive Margins, Multiparameter Grading System, Histologic Risk Assessment and the World Health Organization grading system).They concluded that the Histologic Risk Assessment scoring system established the best results for locoregional recurrence and survival prediction in OSCC patients. 15omi Rahman evaluated the BG risk model criteria in OSCC patients to assess disease progression and survival of patients.They studied 134, OSCC cases, in which they compared two AJCC criteria, i.e. seventh and eighth.In the latest eighth criteria they included DOI according to which they staged the tumor.Due to this, 30 cases of OSCC previously classified into the T1 and T2 stage according to the seventh edition were upstaged to T3 stage according to the eighth AJCC criteria.Three individual histopathologists scored BG risk model criteria and DOI of the same samples.They concluded that the BG is the most effective parameter for grading tumors and locoregional recurrence of patients. 16e staging of OSCC, which is based on the TNM system, has been used for several years to estimate both the clinical response to therapy and survival outcomes.In the eighth AJCC edition, DOI is included as a new histopathological parameter for the assessment of tumor grade, The DOI is measured from the basement membrane to invasive the front of the tumor.The stage and grade of the tumor are major contributing factors to prognosis and treatment selection for OSCC. 17As the BG risk model gives the locoregional recurrence status of OSCC, assessment and corelation of BG model and depth of tumor give the best results in predicting three-year survival in locoregional recurrence of OSCC patients.

Conclusions
For OSCC, the BG risk model comprises effective criteria to determine locoregional recurrence.Therefore, it can be used in early-stage OSCC for identification and prevention of the recurrences.The correlation between BG and DOI in resected OSCC tissues will give better results about the locoregional recurrence and survival rate of OSCC.

Alessandro Polizzi
University of Catania, Catania, Italy In their revised version the authors successfully addressed my comments.The protocol may be accepted after the following minor correction: _ ABSTRACT, Correct the errors in the sentences: "In the study, This study will include 80 random histopathologically-diagnosed cases of OSCC.hematoxylin-eosin…".
Is the rationale for, and objectives of, the study clearly described?Yes

Is the study design appropriate for the research question? Yes
Are sufficient details of the methods provided to allow replication by others?Yes

Are the datasets clearly presented in a useable and accessible format? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Oral pathology and medicine; periodontology, orthodontics, oral surgery.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Version 1
Reviewer

Alessandro Polizzi
University of Catania, Catania, Italy In the manuscript entitled "Protocol for correlation of histological risk assessment/scoring system

the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests:
Ethical approval was received from Datta Meghe Institute of Higher Education and Research, Sawangi, Wardha, Maharashtra India (IEC reference number-DMIHER (DU)/IEC/2023/578).No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
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