Tumor-stroma ratio can reliably be assessed in pre-treatment biopsies, shows substantial agreement with resections, and is significantly associated with overall and recurrence-free survival in early-stage oral squamous cell carcinomas

Tumor-stroma ratio can reliably be assessed in pre-treatment biopsies, shows substantial agreement with resections, and is significantly associated with overall and recurrence-free survival in early-stage oral squamous cell carcinomas | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Tumor-stroma ratio can reliably be assessed in pre-treatment biopsies, shows substantial agreement with resections, and is significantly associated with overall and recurrence-free survival in early-stage oral squamous cell carcinomas Katrin Herber, Nikolaus Moeckelmann, Adrian Muenscher, Christoph Thorns, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3955555/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives Early-stage oral squamous cell carcinomas (OSCC) are a heterogeneous group of tumors in terms of patients’ outcomes, and the current TNM classification is often insufficient to predict the clinical course. Recently, tumor-stroma ratio has been shown to better stratify patients into low- and high-risk groups. This study aims to assess whether pre-treatment biopsies can be used for this purpose and correlates findings with resections as well as survival. Materials and Methods 66 resection specimens of early-stage OSCC (UICC stages I and II) and 50 corresponding pre-treatment biopsies were analyzed. Tumor-stroma ratio was determined with a cut-off of 50%. The Kappa correlation coefficient was used to determine the agreement between resections and biopsies. Kaplan-Meier curves for overall and recurrence-free survival were created, and a p-value < 0.05 indicated a significant correlation in all analyses. Additionally, cox proportional hazard analysis (univariate) was performed to test for independence. Results There was substantial agreement between preoperative biopsies and surgical specimens (Kappa correlation coefficient: 0.655). Stroma-rich tumors were associated with significantly decreased overall and recurrence-free survival in both resections and biopsies (p-values < 0.0001 and 0.039). Cox proportional hazard analysis revealed tumor-stroma ratio as an independent prognostic factor, with hazard ratios between 2.81 and 12.46 (p-values 0.002 and 0.049). oral squamous cell carcinomas tumor stroma ratio early stage carcinomas pre-treatment biopsie Figures Figure 1 Figure 2 Figure 3 Introduction Squamous cell carcinoma is the most common histologic subtype of oral cavity cancer and is reported to show increased incidence rates, especially in younger patients (< 50 years of age) [1, 2]. Early-stage tumors are in this context defined as tumors with histopathological stages pT1 or pT2 (according to the current 8th edition of the TNM classification of tumors, which takes into consideration depth of infiltration and tumor size) with no evidence of lymph node metastases (UICC stages I and II) [3, 4]. These tumors are usually treated by surgical excision and managed according to clinical risk assessment, with multimodality treatment only administered in cases that are deemed to follow a more aggressive clinical course [5]. As the current TNM classification is often insufficient to predict the clinical course of early-stage tumors, several groups have aimed to establish new prognostic features; recently, tumor budding, pattern of invasion, tumor-stroma ratio and tumor-infiltrating lymphocytes have been described as prognostic biomarkers [6–8]. Tumor-stroma ratio (TSR) can be scored on H&E-stained sections and can therefore be easily implemented in the routine examination of tumors. Several studies have assessed the stromal content in oral squamous cell carcinomas (OSCC) and found that a high stromal content (≥ 50% stroma) indicates a more aggressive clinical course with decreased overall, recurrence-free and disease-free survival as well as higher incidence of (occult) lymph node metastases [9–11]. These associations have been shown both for early-stage tumors and cases with advanced tumor stages and nodal metastases. In most studies, stromal content is scored in surgical resections, using preoperative biopsies only in cases with neoadjuvant therapy, although especially in early-stage tumors, assessment of the clinical risk profile can be crucial early on in the disease process. We therefore aimed to ascertain whether tumor-stroma ratio can reliably be scored in preoperative biopsies to provide clues for clinicians whether a more aggressive therapeutic approach might be necessary and to show whether a substantial concordance with resections exists. Only very few studies compared tumor-stroma ratios in resection specimens and matching biopsies in head and neck tumors. For laryngeal carcinomas, good agreement could be demonstrated for stromal content and cell nest size in two independent cohorts [12, 13]. as of yet, these data have not been published for OSCC. Materials and Methods A retrospective study was performed, focusing on early-stage oral squamous cell carcinomas (originating from the tongue, the buccal mucosa, the gingiva and the floor of the mouth). All data sets were immediately anonymized after collection. All analyses were conducted in accordance with the Declaration of Helsinki. From a larger cohort of 162 cases, early-stage OSCC (UICC stages I and II) were selected. This cohort featured 66 resections, in 50 cases (75.76%), pre-treatment biopsies were also available. All patients received biopsies and surgical resections between 2011 and 2022. The whole cohort was composed of 42 male (63.6%) and 24 female patients (36.4%), with a median age of 61 years (range 32–90 years). In total, 20 patients (30.3%) experienced tumor recurrence after a mean duration of 24.21 months, and 6 patients (9.1%) died after a mean follow-up of 35.17 months. The tumor-stroma ratio was assessed as described previously: H&E-stained sections were used, and a cut-off of 50% divided patients into a stroma-poor group (< 50% stroma) and a stroma-rich group (≥ 50% stroma) [14, 15]. Whole tumor sections and whole biopsy sections were evaluated for stromal content after selecting the area with the highest amount of stroma at the invasive tumor front. Tumor cells or tumor cell nests needed to be present on all four sides of the visual field, and the tumor-stroma ratio was scored at 100x magnification [16]. Using established guidelines from previous studies, we did not take into consideration areas that showed abundant necrosis; additionally, areas containing muscle tissue and major vascular structures were avoided [15]. Tumor sections with inflammatory infiltrates, small vessels and nerves were not excluded from the evaluation. Examples of stroma-rich and stroma-poor tumors in resections and corresponding biopsies are shown in Fig. 1 . Statistical analyses were performed with SPSS 22 (IBM Germany, Ehningen). Correlation with clinical features was analyzed with the chi-square test, and survival times were calculated using Kaplan-Meier curves. Additionally, Cox proportional hazard analysis was performed to test for independence and Hazard Ratios (HR) were calculated, including 95% Confidence Intervals (95% CI). A p -value < 0.05 was determined to be significant for all analyses. Concordance between pre-treatment biopsies and resections was evaluated with the Kappa correlation coefficient, and Kappa values were interpreted in the following ranges: <0.20, poor agreement; 0.21–0.40, fair agreement; 0.41–0.60, moderate agreement; 0.61–0.80, substantial agreement; 0.81-1.00, very good agreement. Results The study population consisted of 66 cases (42 cases (63.6%) with pT1 stage and 24 cases (36.4%) with pT2 stage) without any detectable lymph node metastases (pN0). In 50 of these cases (75.76%), pre-treatment biopsies were also available. Here, we found 32 pT1-tumors (64%) and 18 pT2-tumors (36%). Concerning tumor resections, 18 cases were stroma-rich (29%), and 44 cases were stroma-poor (71%). In four cases, the tumor-stroma ratio could not be evaluated due to extensive necrosis with only small tumor islands (6.1%). Looking at preoperative biopsies, 14 cases were stroma-rich (28%) and 36 cases were stroma-poor (72%). Tumor-stroma ratio showed substantial agreement between preoperative biopsies and surgical specimens, with a Kappa correlation coefficient of 0.655 [17]. Correlation with clinical features showed that no significant association with gender, pT-stage, grading or lymphovascular space invasion existed ( p -values 0.163-0.781). Results are shown in Table 1. Table 1. Clinical and pathologic characteristics of the study group in relation to tumor stroma ratio with corresponding p -values. n.k. = not known, LVSI = lymphovascular space invasion Charac-teristic All resec-tions n=66 Stroma-rich cases Stroma-poor cases p -value All biopsies n=50 Stroma-rich cases Stroma-poor cases p -value Gender Male Female n.k. 42 24 14 4 2 26 18 2 0.163 33 17 10 4 23 13 0.613 pT stage pT1 pT2 n.k. 42 24 9 9 2 29 15 2 0.243 32 18 10 4 22 14 0.495 Grading G1 G2 G3 n.k. 9 45 12 2 12 4 2 7 30 7 2 0.781 7 33 10 3 10 1 4 23 9 0.292 LVSI Absent Present n.k. 63 2 1 16 1 2 43 1 3 0.478 48 2 13 1 35 1 0.479 Follow-up data were available for all patients, with a mean follow-up of 62.4 months (range: 1–199 months). Concerning overall survival, we could show that stroma-rich tumors were significantly associated with decreased survival times, both in resections and preoperative biopsies ( p =0.010 and p =0.006; survival curves are shown in Figure 2). The same association could be demonstrated for recurrence-free survival, both for resections and biopsies ( p <0.0001 and p =0.039, respectively; survival curves are shown in Figure 3). In resections, stroma-poor tumors showed a mean overall survival of 193.74 months (±5.19 months) while stroma-rich tumors showed survival times of 141.58 months (±17.73 months). Overall survival times in biopsies were as follows: 192.83 months (±6.07 months) for stroma-poor tumors and 126.91 months (±24.04 months) for stroma-rich cases. When looking at recurrence-free survival in resections, stroma-poor tumors had a mean survival time of 111.91 months (±8.55 months) while stroma-rich tumors showed a mean survival of 55.38 months (±13.32 months). For preoperative biopsies, recurrence-free survival was 98.27 months (±10.6 months) for stroma-poor tumors and 58.53 months (±18.37 months) for stroma-rich tumors. Cox proportional hazard analysis revealed that stromal content was an independent prognostic factor in resections and preoperative biopsies, both for recurrence-free and overall survival. High stromal content was a predictor of tumor recurrence in biopsies (HR: 2.81, 95% CI 1.0–7.88; p =0.049) as well as resections (HR: 4.8, 95% CI 1.76–13.07; p =0.002). Concerning overall survival, the negative prognostic value for stroma-richness was even stronger in both biopsies (HR: 12.46, 95% CI 1.39–111.55; p =0.024) and resections (HR: 10.7, 95% CI 1.25–91.8; p =0.031). Discussion Tumor-stroma ratio has been investigated in a number of studies that focused on oral squamous cell carcinomas, but comparison between preoperative biopsies and matching resections has not yet been attempted. Similar studies have been conducted for laryngeal carcinomas (conventional squamous cell carcinomas and basaloid carcinomas) and found substantial agreement for TSR with an AC1 statistic of 0.7957 for conventional carcinomas and an AC1 statistic of 0.6604 for basaloid carcinomas, respectively [12, 15]. These results are comparable to our findings, which also showed substantial agreement between resections and biopsies, with a Kappa correlation coefficient of 0.655. Tumor-stroma ratio has been analyzed in a variety of malignant tumors, including OSCC, and high stromal content (> 50% stroma) has commonly been associated with decreased overall, disease-specific and recurrence-free survival [5, 18–23]. High stromal content, in contrast to high tumor cell content, is an indicator of the so-called epithelial-mesenchymal transition of tumors, a phenomenon that occurs during cancer evolution and facilitates metastases through the production of growth factors and extracellular matrix [24]. Epithelial tumor cells that acquire mesenchymal properties, such as cancer-associated fibroblasts, lead to more aggressive behavior and, therefore, significantly reduced survival [25]. In our study, we could also demonstrate that high stromal content is a negative prognostic factor with significantly decreased overall and recurrence-free survival, both when assessed in resections and biopsies ( p -values < 0.0001–0.039). Survival times between stroma-rich and stroma-poor tumors differed considerably: while tumor recurrence occurred after a mean follow-up of 55.38 months and 58.53 months (resections and biopsies) in stroma-rich tumors, patients with stroma-poor tumors experienced tumor recurrence after a mean duration of 111.91 months and 98.27 months, respectively. The same association could be demonstrated for overall survival: Death occurred significantly earlier in stroma-rich tumors after a mean duration of 141.58 months and 126.91 months (resections and biopsies), while patients with stroma-poor tumors showed overall survival times of 193.74 months and 192.83 months, respectively. Additionally, it has been demonstrated that in stroma-rich OSCC, especially early-stage tumors, (occult) nodal metastases occur more frequently, although the association with other unfavorable clinical and prognostic factors such as lymphovascular space invasion is often not as clear [9, 10]. Some studies have reported that high stromal content is in fact associated with increased depth of infiltration and perineural invasion [14, 26, 27]. Other studies, however, could not detect any association with clinical stage, grading or lymphovascular and perinodal invasion, which is in line with our results [27–29]. We could not demonstrate any significant correlation between high stromal content and clinical or histopathological features such as gender, pT-stage, grading and lymphovascular invasion ( p -values 0.163–0.781). This might be attributable to the fact that our study cohort, as well as some of the other studies mentioned, only took into consideration early-stage tumors without the presence of nodal metastases and therefore only analyzed a limited number of cases (less than 100 cases). The statistical significance might be less pronounced in these studies because only a defined subset with often homogenous clinical features but heterogeneous outcome is analyzed. Additionally, we proved that tumor-stroma ratio is an independent prognostic factor in early-stage OSCC with a negative prognostic value and Hazard Ratios between 2.81 and 12.46 ( p -values 0.002–0.049). In accordance with our results, other studies could show the same association in laryngeal carcinomas with Hazard Ratios ranging from 5.890 to 11.207 [12, 15]. For pharyngeal carcinomas, similar results were obtained, although the prognostic value here was lower with Hazard Ratios between 1.925 and 1.999 [23]. In conclusion, we could demonstrate that preoperative biopsies can reliably be used to assess the tumor-stroma ratio in early-stage OSCC and show substantial agreement with resections. Furthermore, the tumor-stroma ratio could be shown to have a strong prognostic value and to be significantly correlated with overall and recurrence-free survival. Declarations Author contribution KH, JK and CT designed the study, collected the data, and wrote and reviewed the manuscript. JK and KH performed statistical analyses. KH, AM and NM collected clinical data and reviewed the manuscript. Ethics approval and consent to participate The authors declare that all analyses were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki. In this retrospective study, all data were immediately anonymized after collection. As this study was carried out on tissue samples no informed consent of the patients was necessary according to the Ethics Committee of the Ärztekammer Hamburg, Germany (2024-TEMP809996-WF). Funding No funding was received. Conflict of interests The authors declare no conflict of interests. References Rivera C and Venegas B (2014) Histological and molecular aspects of oral squamous cell carcinoma (Review). Oncology letters 8:7-11. doi: 10.3892/ol.2014.2103 Warnakulasuriya S and Kerr AR (2021) Oral Cancer Screening: Past, Present, and Future. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3955555","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":273631870,"identity":"d8d54b8c-6b4b-4245-b9fc-9ae2cf1e7ab1","order_by":0,"name":"Katrin Herber","email":"","orcid":"","institution":"Department of Otorhinolaryngology, Katholisches Marienkrankenhaus gGmbH","correspondingAuthor":false,"prefix":"","firstName":"Katrin","middleName":"","lastName":"Herber","suffix":""},{"id":273631871,"identity":"4eec2208-5ef1-4869-a42c-f9b56e8366f2","order_by":1,"name":"Nikolaus Moeckelmann","email":"","orcid":"","institution":"Department of Otorhinolaryngology, Katholisches Marienkrankenhaus gGmbH","correspondingAuthor":false,"prefix":"","firstName":"Nikolaus","middleName":"","lastName":"Moeckelmann","suffix":""},{"id":273631872,"identity":"ac90e51e-00d5-4075-a675-50105017adfa","order_by":2,"name":"Adrian Muenscher","email":"","orcid":"","institution":"Department of Otorhinolaryngology, Katholisches Marienkrankenhaus gGmbH","correspondingAuthor":false,"prefix":"","firstName":"Adrian","middleName":"","lastName":"Muenscher","suffix":""},{"id":273631873,"identity":"a40b11a9-736a-4b4a-8c95-48aa60b7a438","order_by":3,"name":"Christoph Thorns","email":"","orcid":"","institution":"Department of Pathology, MVZ am Marienkrankenhaus gGmbH","correspondingAuthor":false,"prefix":"","firstName":"Christoph","middleName":"","lastName":"Thorns","suffix":""},{"id":273631874,"identity":"0c9fa6bb-e6e1-4653-9eac-1d923fb999fe","order_by":4,"name":"Juliana Knief","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBAC9gbmhgMghsEBxgaGigqwoAFeLYwNjBAthkAGw5kzRGoBM4xBxNk2YrTMSGw88HOHHYOZdHPjg4PzaqMNDjBvfEBAS8PB3jPJDDYyB5sNDm47njuzga0YrzUgLQd425gZbCQS26Q/bjuW28/AYyZB0Ja/bfUMZhKJ7T8OzjmW28bAY/4DnxZBoJbDvG2HGYyBtjAcbKgB24JPB4M0z8OGw7Jtx3kMZyQ2Sxw4diB3ZjNbMV6H8bEnH/74tq1azuBG+sMPB2rqcjccb974Aa81UMADpQ8zMDATox4J1JGofhSMglEwCkYCAABvUFP/omC54gAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Pathology, MVZ am Marienkrankenhaus gGmbH","correspondingAuthor":true,"prefix":"","firstName":"Juliana","middleName":"","lastName":"Knief","suffix":""}],"badges":[],"createdAt":"2024-02-14 08:01:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3955555/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3955555/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51445088,"identity":"caeaa588-59aa-406f-a7da-dbff7a2233e8","added_by":"auto","created_at":"2024-02-21 18:08:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":999113,"visible":true,"origin":"","legend":"\u003cp\u003eExamples of tumor-stroma assessment in OSCC resections and matching biopsies on H\u0026amp;E-stained slides (magnification 40x). Upper left: Stroma-poor tumor with a stromal component \u0026lt;50 % in a resection. Upper right: Corresponding biopsy showing a stroma-rich tumor with a stromal component ≥50 %. Lower left: Stroma-rich tumor with a stromal component ≥50 % in a resection. Lower right: Corresponding biopsy showing a stroma-poor tumor with a stromal component \u0026lt;50 %.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-3955555/v1/724fa9ff66095427ccc50ea3.png"},{"id":51445090,"identity":"086129dd-aea2-4bfe-af85-9f643d4bc2b4","added_by":"auto","created_at":"2024-02-21 18:08:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":42889,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curves for overall survival in resection specimens and preoperative biopsies, based on the stromal content. Left: Overall survival in resections (\u003cem\u003ep\u003c/em\u003e=0.010). Right: overall survival in biopsies (\u003cem\u003ep\u003c/em\u003e=0.006).\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-3955555/v1/d896dbe4d4731c7f29a751bc.png"},{"id":51445089,"identity":"aa3cd899-010d-4905-82f2-1f2a738f92cd","added_by":"auto","created_at":"2024-02-21 18:08:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":47025,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curves for recurrence-free survival in resection specimens and preoperative biopsies, based on the stromal content. Left: Recurrence-free survival in resections (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.0001). Right: recurrence-free survival in biopsies (\u003cem\u003ep\u003c/em\u003e=0.039).\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-3955555/v1/757ebe9637c7d799af3ac5eb.png"},{"id":52063904,"identity":"a4a8d05e-7dd7-4b21-a529-a810630be167","added_by":"auto","created_at":"2024-03-06 06:16:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1501725,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3955555/v1/90b0507a-bd59-443b-81a5-47f7004deaee.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Tumor-stroma ratio can reliably be assessed in pre-treatment biopsies, shows substantial agreement with resections, and is significantly associated with overall and recurrence-free survival in early-stage oral squamous cell carcinomas","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSquamous cell carcinoma is the most common histologic subtype of oral cavity cancer and is reported to show increased incidence rates, especially in younger patients (\u0026lt;\u0026thinsp;50 years of age) [1, 2]. Early-stage tumors are in this context defined as tumors with histopathological stages pT1 or pT2 (according to the current 8th edition of the TNM classification of tumors, which takes into consideration depth of infiltration and tumor size) with no evidence of lymph node metastases (UICC stages I and II) [3, 4]. These tumors are usually treated by surgical excision and managed according to clinical risk assessment, with multimodality treatment only administered in cases that are deemed to follow a more aggressive clinical course [5]. As the current TNM classification is often insufficient to predict the clinical course of early-stage tumors, several groups have aimed to establish new prognostic features; recently, tumor budding, pattern of invasion, tumor-stroma ratio and tumor-infiltrating lymphocytes have been described as prognostic biomarkers [6\u0026ndash;8].\u003c/p\u003e \u003cp\u003eTumor-stroma ratio (TSR) can be scored on H\u0026amp;E-stained sections and can therefore be easily implemented in the routine examination of tumors. Several studies have assessed the stromal content in oral squamous cell carcinomas (OSCC) and found that a high stromal content (\u0026ge;\u0026thinsp;50% stroma) indicates a more aggressive clinical course with decreased overall, recurrence-free and disease-free survival as well as higher incidence of (occult) lymph node metastases [9\u0026ndash;11]. These associations have been shown both for early-stage tumors and cases with advanced tumor stages and nodal metastases. In most studies, stromal content is scored in surgical resections, using preoperative biopsies only in cases with neoadjuvant therapy, although especially in early-stage tumors, assessment of the clinical risk profile can be crucial early on in the disease process. We therefore aimed to ascertain whether tumor-stroma ratio can reliably be scored in preoperative biopsies to provide clues for clinicians whether a more aggressive therapeutic approach might be necessary and to show whether a substantial concordance with resections exists. Only very few studies compared tumor-stroma ratios in resection specimens and matching biopsies in head and neck tumors. For laryngeal carcinomas, good agreement could be demonstrated for stromal content and cell nest size in two independent cohorts [12, 13]. as of yet, these data have not been published for OSCC.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e A retrospective study was performed, focusing on early-stage oral squamous cell carcinomas (originating from the tongue, the buccal mucosa, the gingiva and the floor of the mouth). All data sets were immediately anonymized after collection. All analyses were conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eFrom a larger cohort of 162 cases, early-stage OSCC (UICC stages I and II) were selected. This cohort featured 66 resections, in 50 cases (75.76%), pre-treatment biopsies were also available. All patients received biopsies and surgical resections between 2011 and 2022. The whole cohort was composed of 42 male (63.6%) and 24 female patients (36.4%), with a median age of 61 years (range 32\u0026ndash;90 years).\u003c/p\u003e \u003cp\u003eIn total, 20 patients (30.3%) experienced tumor recurrence after a mean duration of 24.21 months, and 6 patients (9.1%) died after a mean follow-up of 35.17 months.\u003c/p\u003e \u003cp\u003eThe tumor-stroma ratio was assessed as described previously: H\u0026amp;E-stained sections were used, and a cut-off of 50% divided patients into a stroma-poor group (\u0026lt;\u0026thinsp;50% stroma) and a stroma-rich group (\u0026ge;\u0026thinsp;50% stroma) [14, 15]. Whole tumor sections and whole biopsy sections were evaluated for stromal content after selecting the area with the highest amount of stroma at the invasive tumor front. Tumor cells or tumor cell nests needed to be present on all four sides of the visual field, and the tumor-stroma ratio was scored at 100x magnification [16]. Using established guidelines from previous studies, we did not take into consideration areas that showed abundant necrosis; additionally, areas containing muscle tissue and major vascular structures were avoided [15]. Tumor sections with inflammatory infiltrates, small vessels and nerves were not excluded from the evaluation. Examples of stroma-rich and stroma-poor tumors in resections and corresponding biopsies are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eStatistical analyses were performed with SPSS 22 (IBM Germany, Ehningen). Correlation with clinical features was analyzed with the chi-square test, and survival times were calculated using Kaplan-Meier curves. Additionally, Cox proportional hazard analysis was performed to test for independence and Hazard Ratios (HR) were calculated, including 95% Confidence Intervals (95% CI). A \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was determined to be significant for all analyses. Concordance between pre-treatment biopsies and resections was evaluated with the Kappa correlation coefficient, and Kappa values were interpreted in the following ranges: \u0026lt;0.20, poor agreement; 0.21\u0026ndash;0.40, fair agreement; 0.41\u0026ndash;0.60, moderate agreement; 0.61\u0026ndash;0.80, substantial agreement; 0.81-1.00, very good agreement.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study population consisted of 66 cases (42 cases (63.6%) with pT1 stage and 24 cases (36.4%) with pT2 stage) without any detectable lymph node metastases (pN0). In 50 of these cases (75.76%), pre-treatment biopsies were also available. Here, we found 32 pT1-tumors (64%) and 18 pT2-tumors (36%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConcerning tumor resections, 18 cases were stroma-rich (29%), and 44 cases were stroma-poor (71%). In four cases, the tumor-stroma ratio could not be evaluated due to extensive necrosis with only small tumor islands (6.1%). Looking at preoperative biopsies, 14 cases were stroma-rich (28%) and 36 cases were stroma-poor (72%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTumor-stroma ratio showed substantial agreement between preoperative biopsies and surgical specimens, with a Kappa correlation coefficient of 0.655\u0026nbsp;[17].\u003c/p\u003e\n\u003cp\u003eCorrelation with clinical features showed that no significant association with gender, pT-stage, grading or lymphovascular space invasion existed (\u003cem\u003ep\u003c/em\u003e-values 0.163-0.781). Results are shown in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. Clinical and pathologic characteristics of the study group in relation to tumor stroma ratio with corresponding \u003cem\u003ep\u003c/em\u003e-values. n.k. = not known, LVSI = lymphovascular space invasion\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharac-teristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll resec-tions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=66\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroma-rich cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroma-poor cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll \u0026nbsp;biopsies\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=50\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroma-rich cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroma-poor cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Male \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Female\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; n.k.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.613\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003epT stage\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; pT1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; pT2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; n.k.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.243\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.495\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrading\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; G1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; G2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; G3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; n.k. \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.781\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.292\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLVSI\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Absent\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Present\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; n.k.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.478\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.479\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFollow-up data were available for all patients, with a mean follow-up of 62.4 months (range: 1\u0026ndash;199 months). Concerning overall survival, we could show that stroma-rich tumors were significantly associated with decreased survival times, both in resections and preoperative biopsies (\u003cem\u003ep\u003c/em\u003e=0.010 and \u003cem\u003ep\u003c/em\u003e=0.006; survival curves are shown in Figure 2). The same association could be demonstrated for recurrence-free survival, both for resections and biopsies (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.0001 and \u003cem\u003ep\u003c/em\u003e=0.039, respectively; survival curves are shown in Figure 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn resections, stroma-poor tumors showed a mean overall survival of 193.74 months (\u0026plusmn;5.19 months) while stroma-rich tumors showed survival times of 141.58 months (\u0026plusmn;17.73 months). Overall survival times in biopsies were as follows: 192.83 months (\u0026plusmn;6.07 months) for stroma-poor tumors and 126.91 months (\u0026plusmn;24.04 months) for stroma-rich cases. When looking at recurrence-free survival in resections, stroma-poor tumors had a mean survival time of 111.91 months (\u0026plusmn;8.55 months) while stroma-rich tumors showed a mean survival of 55.38 months (\u0026plusmn;13.32 months). For preoperative biopsies, recurrence-free survival was 98.27 months (\u0026plusmn;10.6 months) for stroma-poor tumors and 58.53 months (\u0026plusmn;18.37 months) for stroma-rich tumors.\u003c/p\u003e\n\u003cp\u003eCox proportional hazard analysis revealed that stromal content was an independent prognostic factor in resections and preoperative biopsies, both for recurrence-free and overall survival. High stromal content was a predictor of tumor recurrence in biopsies (HR: 2.81, 95% CI 1.0\u0026ndash;7.88; \u003cem\u003ep\u003c/em\u003e=0.049) as well as resections (HR: 4.8, 95% CI 1.76\u0026ndash;13.07; \u003cem\u003ep\u003c/em\u003e=0.002). Concerning overall survival, the negative prognostic value for stroma-richness was even stronger in both biopsies (HR: 12.46, 95% CI 1.39\u0026ndash;111.55; \u003cem\u003ep\u003c/em\u003e=0.024) and resections (HR: 10.7, 95% CI 1.25\u0026ndash;91.8; \u003cem\u003ep\u003c/em\u003e=0.031).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTumor-stroma ratio has been investigated in a number of studies that focused on oral squamous cell carcinomas, but comparison between preoperative biopsies and matching resections has not yet been attempted. Similar studies have been conducted for laryngeal carcinomas (conventional squamous cell carcinomas and basaloid carcinomas) and found substantial agreement for TSR with an AC1 statistic of 0.7957 for conventional carcinomas and an AC1 statistic of 0.6604 for basaloid carcinomas, respectively [12, 15]. These results are comparable to our findings, which also showed substantial agreement between resections and biopsies, with a Kappa correlation coefficient of 0.655.\u003c/p\u003e \u003cp\u003eTumor-stroma ratio has been analyzed in a variety of malignant tumors, including OSCC, and high stromal content (\u0026gt;\u0026thinsp;50% stroma) has commonly been associated with decreased overall, disease-specific and recurrence-free survival [5, 18\u0026ndash;23]. High stromal content, in contrast to high tumor cell content, is an indicator of the so-called epithelial-mesenchymal transition of tumors, a phenomenon that occurs during cancer evolution and facilitates metastases through the production of growth factors and extracellular matrix [24]. Epithelial tumor cells that acquire mesenchymal properties, such as cancer-associated fibroblasts, lead to more aggressive behavior and, therefore, significantly reduced survival [25]. In our study, we could also demonstrate that high stromal content is a negative prognostic factor with significantly decreased overall and recurrence-free survival, both when assessed in resections and biopsies (\u003cem\u003ep\u003c/em\u003e-values\u0026thinsp;\u0026lt;\u0026thinsp;0.0001\u0026ndash;0.039). Survival times between stroma-rich and stroma-poor tumors differed considerably: while tumor recurrence occurred after a mean follow-up of 55.38 months and 58.53 months (resections and biopsies) in stroma-rich tumors, patients with stroma-poor tumors experienced tumor recurrence after a mean duration of 111.91 months and 98.27 months, respectively. The same association could be demonstrated for overall survival: Death occurred significantly earlier in stroma-rich tumors after a mean duration of 141.58 months and 126.91 months (resections and biopsies), while patients with stroma-poor tumors showed overall survival times of 193.74 months and 192.83 months, respectively.\u003c/p\u003e \u003cp\u003eAdditionally, it has been demonstrated that in stroma-rich OSCC, especially early-stage tumors, (occult) nodal metastases occur more frequently, although the association with other unfavorable clinical and prognostic factors such as lymphovascular space invasion is often not as clear [9, 10]. Some studies have reported that high stromal content is in fact associated with increased depth of infiltration and perineural invasion [14, 26, 27]. Other studies, however, could not detect any association with clinical stage, grading or lymphovascular and perinodal invasion, which is in line with our results [27\u0026ndash;29]. We could not demonstrate any significant correlation between high stromal content and clinical or histopathological features such as gender, pT-stage, grading and lymphovascular invasion (\u003cem\u003ep\u003c/em\u003e-values 0.163\u0026ndash;0.781). This might be attributable to the fact that our study cohort, as well as some of the other studies mentioned, only took into consideration early-stage tumors without the presence of nodal metastases and therefore only analyzed a limited number of cases (less than 100 cases). The statistical significance might be less pronounced in these studies because only a defined subset with often homogenous clinical features but heterogeneous outcome is analyzed.\u003c/p\u003e \u003cp\u003eAdditionally, we proved that tumor-stroma ratio is an independent prognostic factor in early-stage OSCC with a negative prognostic value and Hazard Ratios between 2.81 and 12.46 (\u003cem\u003ep\u003c/em\u003e-values 0.002\u0026ndash;0.049). In accordance with our results, other studies could show the same association in laryngeal carcinomas with Hazard Ratios ranging from 5.890 to 11.207 [12, 15]. For pharyngeal carcinomas, similar results were obtained, although the prognostic value here was lower with Hazard Ratios between 1.925 and 1.999 [23].\u003c/p\u003e \u003cp\u003eIn conclusion, we could demonstrate that preoperative biopsies can reliably be used to assess the tumor-stroma ratio in early-stage OSCC and show substantial agreement with resections. Furthermore, the tumor-stroma ratio could be shown to have a strong prognostic value and to be significantly correlated with overall and recurrence-free survival.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eAuthor contribution\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eKH, JK and CT designed the study, collected the data, and wrote and reviewed the manuscript. JK and KH performed statistical analyses. KH, AM and NM collected clinical data and reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that all analyses were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki. In this retrospective study, all data were immediately anonymized after collection. As this study was carried out on tissue samples no informed consent of the patients was necessary according to the Ethics Committee of the Ärztekammer Hamburg, Germany (2024-TEMP809996-WF).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConflict of interests\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRivera C and Venegas B (2014) Histological and molecular aspects of oral squamous cell carcinoma (Review). Oncology letters 8:7-11. doi: 10.3892/ol.2014.2103\u003c/li\u003e\n\u003cli\u003eWarnakulasuriya S and Kerr AR (2021) Oral Cancer Screening: Past, Present, and Future. 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Sci Rep 9:16018. doi: 10.1038/s41598-019-52606-7\u003c/li\u003e\n\u003cli\u003eRani P, Gupta AJ, Mehrol C, Singh M, Khurana N and Passey JC (2020) Clinicopathological correlation of tumor-stroma ratio and inflammatory cell infiltrate with tumor grade and lymph node metastasis in squamous cell carcinoma of buccal mucosa and tongue in 41 cases with review of literature. J Cancer Res Ther 16:445-451. doi: 10.4103/0973-1482.193113\u003c/li\u003e\n\u003cli\u003eAlmangush A, Heikkinen I, Bakhti N, Makinen LK, Kauppila JH, Pukkila M, Hagstrom J, Laranne J, Soini Y, Kowalski LP, Grenman R, Haglund C, Makitie AA, Coletta RD, Leivo I and Salo T (2018) Prognostic impact of tumour-stroma ratio in early-stage oral tongue cancers. Histopathology 72:1128-1135. doi: 10.1111/his.13481\u003c/li\u003e\n\u003cli\u003eMascitti M, Zhurakivska K, Togni L, Caponio VCA, Almangush A, Balercia P, Balercia A, Rubini C, Lo Muzio L, Santarelli A and Troiano G (2020) Addition of the tumour-stroma ratio to the 8th edition American Joint Committee on Cancer staging system improves survival prediction for patients with oral tongue squamous cell carcinoma. Histopathology 77:810-822. doi: 10.1111/his.14202\u003c/li\u003e\n\u003cli\u003eUnlu M, Cetinayak HO, Onder D, Ecevit C, Akman F, Ikiz AO, Ada E, Karacali B and Sarioglu S (2013) The prognostic value of tumor-stroma proportion in laryngeal squamous cell carcinoma. Turk Patoloji Derg 29:27-35. doi: 10.5146/tjpath.2013.01144\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"oral squamous cell carcinomas, tumor stroma ratio, early stage carcinomas, pre-treatment biopsie","lastPublishedDoi":"10.21203/rs.3.rs-3955555/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3955555/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eEarly-stage oral squamous cell carcinomas (OSCC) are a heterogeneous group of tumors in terms of patients\u0026rsquo; outcomes, and the current TNM classification is often insufficient to predict the clinical course. Recently, tumor-stroma ratio has been shown to better stratify patients into low- and high-risk groups. This study aims to assess whether pre-treatment biopsies can be used for this purpose and correlates findings with resections as well as survival.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003e66 resection specimens of early-stage OSCC (UICC stages I and II) and 50 corresponding pre-treatment biopsies were analyzed. Tumor-stroma ratio was determined with a cut-off of 50%. The Kappa correlation coefficient was used to determine the agreement between resections and biopsies. Kaplan-Meier curves for overall and recurrence-free survival were created, and a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated a significant correlation in all analyses. Additionally, cox proportional hazard analysis (univariate) was performed to test for independence.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere was substantial agreement between preoperative biopsies and surgical specimens (Kappa correlation coefficient: 0.655). Stroma-rich tumors were associated with significantly decreased overall and recurrence-free survival in both resections and biopsies (p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.0001 and 0.039). Cox proportional hazard analysis revealed tumor-stroma ratio as an independent prognostic factor, with hazard ratios between 2.81 and 12.46 (p-values 0.002 and 0.049).\u003c/p\u003e","manuscriptTitle":"Tumor-stroma ratio can reliably be assessed in pre-treatment biopsies, shows substantial agreement with resections, and is significantly associated with overall and recurrence-free survival in early-stage oral squamous cell carcinomas","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-21 18:08:49","doi":"10.21203/rs.3.rs-3955555/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b56572b7-91ee-4739-90fc-4463fcae8cc0","owner":[],"postedDate":"February 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-06T06:08:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-21 18:08:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3955555","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3955555","identity":"rs-3955555","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}