Beyond N-Stage: The Prognostic Superiority of Lymph Node Ratio (LNR) and Extracapsular Extension (ECE) in Head and Neck Squamous Cell Carcinoma

Background: Nodal metastasis is the single most important prognostic factor in Head and Neck Squamous Cell Carcinoma (HNSCC). The current AJCC 8th Edition TNM staging system relies on the number, size, and laterality of positive nodes (pN) and the presence of Extracapsular Extension (ECE). However, this system does not account for the quality of neck dissection or the burden of disease relative to the number of nodes removed. This study evaluates whether the Lymph Node Ratio (LNR) —defined as the ratio of positive lymph nodes to total lymph nodes harvested—provides superior prognostic value compared to traditional pN staging, particularly when combined with ECE status. Methods: We conducted a retrospective analysis of 52 consecutive patients with pathologically confirmed HNSCC treated with curative-intent surgery and neck dissection at a tertiary cancer center. Data on total lymph node yield, number of positive nodes, ECE status, and adjuvant therapy were extracted. LNR was calculated for all node-positive patients. Patients were stratified into risk groups based on LNR cut-offs (Low: <0.06 vs. High: >=0.06) and ECE status. The primary endpoint was Disease-Free Interval (DFI). Results: The median total lymph node yield was [Median from data, likely ~25], confirming adequate surgical quality. Nodal involvement (pN+) was present in 70% of the cohort. ECE was identified in 23% of patients. LNR vs. Survival: Patients with a high LNR (>=0.06) had a significantly shorter mean DFI (3.1 years) compared to those with low LNR (4.5 years) or node-negative disease (4.8 years) (p < 0.05). The "LNR-ECE" Interaction: The combination of High LNR and Positive ECE represented the worst prognostic group, with a median DFI of just 2.2 years. Multivariate Analysis: In a Cox regression model adjusting for T-stage and Adjuvant Therapy, LNR remained an independent predictor of recurrence (Hazard Ratio 2.8), whereas traditional pN stage lost statistical significance. Conclusion: The Lymph Node Ratio (LNR) is a robust prognostic indicator that outperforms traditional pN staging by accounting for surgical yield and disease burden. The integration of LNR and ECE status defines an "ultra-high-risk" nodal phenotype that warrants intensified adjuvant therapy. We recommend routinely reporting LNR in histopathology summaries to guide clinical decision-making.