WPOI-5: Accurately Identified at Intraoperative Consultation and Predictive of Occult Cervical Metastases

John E. Beute, Lily A. Greenberg, Lauren E. Wein, Danielle A. Kapustin, Jun Fan, Eric M. Dowling, Shabnam Samankan, Ammar Matloob, Monica Xing, Ippolito Modica, Daniel Chung, William Carroll, Eben L. Rosenthal, Mohemmed Nazir Khan, Raymond L. Chai, Margaret S. Brandwein-Weber, Mark L. Urken

Research output: Contribution to journalArticlepeer-review


Background: Frozen section analysis of oral cancer specimens is ideal for assessing margin distances and depth of invasion (DOI); the latter impacts intraoperative decisions regarding elective neck dissection (END). Here, we show that intraoperative determination of worst pattern of invasion (WPOI), specifically WPOI-5, has a high level of accuracy. This relates to our demonstration herein that WPOI-5 predicts occult cervical metastases (OCM) for pT1 oral squamous carcinoma (OSC). Methods: The presence of OCM was correlated with WPOI in 228 patients with primary T1/T2/cN0 OSC undergoing resection and END. Concordance between intraoperative and final pathology WPOI determination was assessed on 51 cases of OSC. Results: WPOI-5 predicts OCM in pT1 patients, compared with WPOI-4/WPOI-3 (p < 0.0001). Most pT1 WPOI-5 tumors had DOI of 4–5 mm (24/59 or 40.7%). Only two pT1 WPOI-5 tumors had DOI < 4 mm (3.0 and 3.5 mm). If END were performed in this pT1 cohort for all WPOI-5 OSC patients regardless of DOI, OR all OSC patients with DOI ≥ 4 mm regardless of WPOI, then no OCM would be missed (p = 0.017, 100% sensitivity, 29% specificity, 77% positive predictive value, 23% negative predictive value). With respect to intraoperative WPOI-5 determination, the accuracy, sensitivity, and specificity was 92.16, 73.33, and 100.0%, respectively. Conclusions: DOI ≥ 4 mm is the dominant predictor of OCM. For the rare WPOI-5 OSC with DOI < 4 mm, it is reasonable to suggest that surgeons perform END. WPOI-5 may be accurately determined intraoperatively. As microscopic instruction is needed to accurately assess WPOI-5, a teaching link is included in this manuscript.

Original languageEnglish
JournalHead and Neck Pathology
StateAccepted/In press - 2023


  • Cervical occult metastases
  • Frozen section pathology
  • Oral cavity squamous cell carcinoma
  • Permanent section pathology
  • Worst pattern of invasion


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