Brigham and Women's (BWH) cSCC staging concept
Brigham and Women's cSCC T-stage; Jambusaria-Pahlajani T-stage; BWH cSCC staging
The Brigham and Women's (BWH) cSCC T-staging system (Jambusaria-Pahlajani et al., JAMA Dermatol 2013) uses four high-risk features — tumour diameter ≥ 2 cm, poor differentiation, perineural invasion of a nerve ≥ 0.1 mm calibre, and tumour invasion beyond subcutaneous fat — to assign T1 (0 factors), T2a (1), T2b (2–3) and T3 (≥ 4 factors or bone invasion) categories. BWH outperforms AJCC 8 in stratifying nodal-metastasis and disease-specific death risk in head-and-neck cSCC, and is recommended in BAD 2020 (Keohane et al.) as the preferred UK staging system. Approximate cohort-level estimates from the derivation series place T1 nodal metastasis < 1%, T2a ~ 5%, T2b ~ 20%, T3 > 50% — but these are imprecise (T3 numbers small) and should be interpreted as risk stratification rather than individual prediction. Pairs with the interactive cSCC staging calculator.
Four BWH risk factors
- Tumour diameter ≥ 2 cm — measured clinically or histologically at the greatest dimension.
- Poor differentiation — moderate differentiation does NOT count; only poorly differentiated cSCC is a BWH factor.
- Perineural invasion (high-risk) — any one of: nerve calibre ≥ 0.1 mm, PNI extending beyond the dermis, or PNI of a named nerve. See PNI.
- Tumour invasion beyond subcutaneous fat — into fascia, muscle, perichondrium, periosteum. Bone invasion is automatic T3 regardless of other factors.
- Bone invasion — automatic T3 (highest tier).
BWH T categories
- T1 — 0 risk factors.
- T2a — 1 risk factor.
- T2b — 2–3 risk factors.
- T3 — ≥ 4 risk factors OR bone invasion.
- Combine with N (regional nodes) and M (distant metastasis) per AJCC 8 for full TNM staging.
Risk estimates (Jambusaria-Pahlajani 2013 cohort)
- Approximate cohort-level estimates from the derivation series:
- T1 — nodal metastasis < 1%, disease-specific death ≈ 0%.
- T2a — nodal metastasis ~ 5%, disease-specific death ~ 1%.
- T2b — nodal metastasis ~ 20%, disease-specific death ~ 10%.
- T3 — nodal metastasis > 50%, disease-specific death > 30%; estimates imprecise (T3 numbers small).
- Use as risk stratification, not as individual prediction.
- Validated in multiple subsequent cohorts (Karia et al., Roozeboom et al., Schmults et al.) with broadly consistent stratification.
BWH vs AJCC 8
- BWH outperforms AJCC 8 in stratifying nodal-metastasis and disease-specific death risk in head-and-neck cSCC in most validation studies.
- BWH explicitly captures perineural-calibre criteria more rigorously.
- AJCC 8 cSCC staging is limited to head-and-neck cSCC; BWH applies to any cSCC site.
- UK practice — BAD 2020 (Keohane et al., BJD 2021) recommends BWH as the preferred cSCC staging system.
- Continue to record both BWH and AJCC 8 staging on the pathology report for international comparability.
BWH-stage implications (BAD 2020)
- BWH T1 (low-risk) — standard 4 mm peripheral margin WLE; follow-up per BAD 2020 low-risk schedule (single post-treatment review then discharge).
- BWH T2a — 6 mm peripheral margin; high-risk follow-up (4-monthly × 12 mo, 6-monthly × 12 mo, discharge year 2).
- BWH T2b / T3 — consider 10 mm margins or Mohs micrographic surgery; discuss adjuvant RT at MDT; baseline imaging (CT NCAP, MRI if PNI); very-high-risk follow-up (4-monthly × 24 mo, 6-monthly × 12 mo, discharge year 3); consider cemiplimab (TA802) for unresectable / metastatic disease.
- See cSCC staging tool for interactive computation.
References
- Jambusaria-Pahlajani A et al. Evaluation of AJCC tumor staging for cutaneous squamous cell carcinoma — proposed alternative staging system (BWH). JAMA Dermatol; 2013;149:402–10.
- Keohane SG et al. British Association of Dermatologists' guidelines for the management of people with cutaneous squamous cell carcinoma 2020. Br J Dermatol; 2021.
- Karia PS et al. Evaluation of AJCC and Brigham and Women's Hospital T classifications for cutaneous SCC. J Clin Oncol; 2014.
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