Patients

We reviewed the medical records of 327 patients who were treated for OTSCC in a department of oral and maxillofacial surgery and a department of head and neck surgery between 1997 and 2007. Computed tomography (CT) or magnetic resonance imaging (MRI) was used to supplement the clinical evaluation and for staging the primary tumour and regional lymph nodes. Only patients with clinical T1N0M0 or T2N0M0 who had primary surgical treatment without elective neck dissection were recruited. Moreover, no patients received either preoperative or postoperative treatment. There were no recurrences at the primary site. Finally, 76 patients were selected for the study: 30 who developed cervical metastases postoperatively and 46 who had no evidence of disease for 5 years after surgery. The preoperative clinical American Joint Cancer Committee/Union Internationale Contre le Cancer (AJCC/UICC) TNM stages (1997) were 32 cT1N0M0 and 44 cT2N0M0. The median patient age was 61 years (range 29–85 years), and the male to female ratio was 2.3:1 (53 men and 23 women).

Fibrinogen measurement

A peripheral blood sample was collected 48–72 h before the operation, and the plasma fibrinogen was measured by Clauss clotting method using DADE Thrombin ReagentP and a Sysmex CA-7000 automated coagulometer (Sysmex, Kobe, Japan). A plasma fibrinogen level between 200 mg/dl and 300 mg/dl was considered to be normal.

Histopathological evaluation

All pathology slides were reviewed at the maximum cross-section by two pathologists who had no knowledge of the clinical data. The grading scheme of Crissman et al. was used for nuclear polymorphism. Tumour cells were graded in the deep portion. The growth type and infiltrative growth ratio were examined to assess the mode of invasion. The infiltrative growth ratio was calculated as the percentage of the tumour area comprised of small nests of 10 or fewer cells at the periphery of the tumour to the total area of the tumour. Regardless of whether the growth type of the carcinoma was exophytic or invasive, tumour thickness was measured from the surface of the normal mucosa to the deepest portion of the tumour. Vascular invasion and lymphatic vessel invasion were evaluated to assess the cellular response of the host. Perineural invasion was also recorded.

Statistical analysis

Preoperative plasma fibrinogen values were recorded as the mean ± standard deviation (SD). The correlation between preoperative plasma fibrinogen and clinico-pathological factors was evaluated by unpaired t -test and one-way analysis of variance (ANOVA) with the least significant difference (LSD) multiple comparison, where appropriate. Testing of homogeneity variance was performed between fibrinogen levels ≤300 mg/dl and >300 mg/dl ( P = 0.23).

The disease-free survival rate was calculated by Kaplan–Meier method and differences between groups were tested with the log-rank test. Disease-free survival times of patients were censored at the last follow-up date. Univariate analysis comprised sex (male vs. female), age (≤70 vs. >70 years), growth type (exophytic vs. invasive), T-stage (T1 vs. T2), differentiation (well vs. moderately vs. poorly differentiated), thickness (≤4 mm vs. >4 mm), nuclear polymorphism of the deep portion (few, moderate vs. markedly enlarged), infiltrative growth ratio (≤20% vs. >20%), vascular invasion (absent vs. present), lymphatic vessel invasion (absent vs. present), perineural invasion (absent vs. present), and preoperative plasma fibrinogen level (≤300 mg/dl vs. >300 mg/dl). All the variables observed to be statistically significant in the univariate analysis were included in the multivariate analysis (Cox proportional hazards model) by the ‘enter’ method for variable selection. P -values of <0.05 were considered statistically significant. Statistical analyses were performed and graphics drawn using the SPSS 13.0 statistical software package (SPSS Inc., Chicago, IL, USA).

Correlation analysis

The mean preoperative plasma fibrinogen level was 327.2 ± 93.3 mg/dl. The clinico-pathological parameters assessed included sex, age, growth type, T-stage, differentiation, thickness, nuclear polymorphism of the deep portion, infiltrative growth ratio, vascular invasion, lymphatic vessel invasion, perineural invasion, and preoperative plasma fibrinogen levels. Associations between preoperative plasma fibrinogen levels and clinico-pathological parameters are shown in Table 1 . Elevated plasma fibrinogen levels were associated with growth type ( P < 0.001), differentiation ( P < 0.001), thickness ( P < 0.001), and the infiltrative growth ratio ( P = 0.032), but were not significantly associated with T-stage ( P = 0.142), nuclear polymorphism of the deep portion ( P = 0.581), vascular invasion ( P = 0.133), lymphatic vessel invasion ( P = 0.508), or perineural invasion ( P = 0.581). Patients who had cervical metastasis during follow-up had higher preoperative plasma fibrinogen levels.

Univariate analysis

The 5-year disease-free survival rate was 39.5% for all 76 patients. In the univariate analysis, significant prognostic factors included growth type ( P < 0.001), differentiation ( P < 0.001), thickness ( P < 0.001), preoperative plasma fibrinogen level ( P < 0.001), Nuclear polymorphism of the deep portion ( P < 0.001) and infiltrative growth ratio ( P < 0.001) ( Table 2 ). Kaplan–Meier curves for disease-free survival according to the different preoperative plasma fibrinogen levels (≤300 mg/dl and >300 mg/dl) are shown in Fig. 1 .

Table 2

Relationship between clinico-pathological factors and disease-free survival in oral tongue squamous cell carcinoma.

Variable	Number of patients	5-year disease-free survival rate (%)	P -value
Sex			0.263
Female	23	52.2
Male	53	64.2
Age, years			0.523
≤70	54	62.3
>70	22	56.5
Growth type			<0.001
Exophytic	33	90.9
Invasive	43	37.2
Differentiation			<0.001
Well differentiated	39	84.6
Moderately differentiated	34	35.3
Poorly differentiated	3	66.7
Thickness, mm			<0.001
≤4	31	96.8
>4	45	35.6
T-stage			0.191
T1	39	66.7
T2	37	54.1
Nuclear polymorphism of the deep portion			<0.001
Few, moderate	50	74.0
Markedly enlarged	26	34.6
Infiltrative growth ratio			<0.001
≤20%	54	74.1
>20%	22	27.3
Vascular invasion			0.282
Absent	70	58.6
Present	6	83.3
Lymphatic vessel invasion			0.571
Absent	72	59.7
Present	4	75.0
Perineural invasion			0.551
Absent	55	40.0
Present	21	66.7
Fibrinogen, mg/dl			<0.001
≤300	33	93.9
>300	43	34.9

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