# Nodal status dictates divergent prognostic drivers in oral squamous cell carcinoma: metabolic burden in pN0 vs. sarcopenia and nodal burden in pN+

## TL;DR

This study shows that oral cancer patients with and without lymph node involvement have different risk factors, such as tumor metabolism and muscle loss, which can help improve personalized prognosis.

## Contribution

The study identifies distinct prognostic factors for oral cancer patients based on nodal status, enabling more accurate risk stratification.

## Key findings

- High T-SUVmax is a strong predictor of poor survival in pN0 oral cancer patients.
- In pN+ patients, more positive lymph nodes and low muscle index are linked to worse outcomes.
- The findings were validated using bootstrap methods to ensure reliability.

## Abstract

Oral squamous cell carcinoma (OSCC) exhibits heterogeneous outcomes based on nodal status, complicating personalized prognosis. This study aimed to identify nodal-specific prognostic factors in OSCC by integrating metabolic metrics from 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography, body composition (L3 skeletal muscle index, L3-SMI), and key pathological features, to refine risk stratification.

We conducted a retrospective cohort study of 147 OSCC patients (74 pN0, 73 pN+) who underwent curative resection and neck dissection. Associations between metabolic metrics, L3-SMI, pathological factors, and overall (OS) or progression-free survival (PFS) were evaluated using Cox regression. Internal bootstrap validation (1000 repetitions) was performed to assess the stability and potential bias of the prognostic factors.

In pN0 patients, tumor maximum standardized uptake value (T-SUVmax) >13.27 emerged as an independent predictor of poor OS (HR = 10.24, P = 0.003) and PFS (HR = 8.23, P = 0.002), which was validated by bootstrapping. Among pN+ patients, ≥3 positive lymph nodes significantly predicted worse outcomes (OS HR = 4.15, P < 0.001; PFS HR = 1.97, P = 0.049), while higher L3-SMI served as a protective factor for survival (OS HR = 0.13, P = 0.047; PFS HR = 0.18, P = 0.024); both findings were supported by internal validation.

We propose a nodal status-stratified approach for risk assessment in OSCC. For pN0 necks, high risk is characterized by elevated T-SUVmax, whereas in pN+ necks, high nodal burden and sarcopenia define increased risk.