“Time is not to be wasted”

The recent article by Tagliabue et al. “Oral cancer and prognostic factors: Can a diagnostic procedure influence patient outcome?” (Oral Oncology, 2025) states that suture placement during incisional biopsies may be a potential prognostic factor in patients with oral squamous cell carcinoma of the tongue (OTSCC) [1]. Whilst the authors' efforts in investigating novel prognostic variables are appreciated, some additional consideration regarding the role of stitches in tumor progression might be offered. Tagliabue et al. hypothesize that the mechanical presence of sutures during incisional biopsy promotes local inflammation and thereby negatively influences patient outcomes. These findings have been previously documented in current literature, primarily in other solid tumors. Indeed, it has been postulated that surgical trauma and tissue disruption themselves, rather than the presence of foreign material, are the primary drivers of tumor recurrence and metastatic behavior. This assertion is further supported by evidence that minimally invasive techniques, such as needle biopsies that do not necessitate suturing, can nevertheless induce substantial biological alterations in tumor behavior [2]. A critical variable that was not addressed in the study is the time interval between biopsy and definitive surgery. At least in theory, also timing may have a prognostic impact on tumor growth after biopsy stress. This temporal span, which depends on institutional workflows and the necessity for definitive additional diagnostic analysis (e.g., immunohistochemistry, genetic analyses, tumor board evaluation, etc) is usually from 15 to 30 days or more. Thus, it is conceivable to hypothesize that a longer interval between biopsy and definitive surgery corresponds to higher release of several growth factors, influencing tumor growth and seeding. An increased interval would consequently lead to a more negative prognostic impact. In our clinical practice, a delay in definitive surgery has been shown to result in larger or upstaged tumors, often requiring more extended surgical procedures with obvious implications for prognosis. We acknowledge that early-stage tumors may exhibit a heightened susceptibility to biopsy-induced proliferative alterations, particularly when subjected to deep or extensive biopsies, such those requiring stitches. The relative impact of trauma on a small tumor mass may be disproportionately greater compared to larger tumors. This phenomenon can be attributed to two main factors. Firstly, larger advanced tumors have a reduced number of cancer cells in active proliferation, as well as an increased number of necrotic cells [3]. Secondly, overall, a larger proportion of tissue is disrupted by incisional biopsy. These features may contribute to the worse prognosis observed in some early-stage tumors that undergo aggressive biopsies. Additionally, it is acknowledged that conducting an extended biopsy procedure on small cancers can result in changing in the clinical aspects of the lesion. This phenomenon poses a significant challenge to surgeons, as it hinders the process of achieving a safe oncological excision. In summary, we agree that incisional extended biopsy is not indicated, particularly in the case of early-stage tumors (T1-T2).