Technical Considerations and Outcome Analysis of Using Extended Bipaddle Pectoralis Major Myocutaneous Flaps for Reconstructions of Large and Complex Oral Cavity Defects: Expanding the Horizons

Reconstruction of large and complex defects arising from resection of advanced oral cancers requires free flaps or multi-staged reconstructions using a combination of pedicled flaps. Bipaddle (pectoralis major myocutaneous (PMMC) flap is a good alternative for reconstruction of such defects, especially in low-middle-income countries (LMIC). However, care should be taken while expanding its limits to avoid unnecessary morbidity. We discuss technical considerations while extending the PMMC flap design beyond the usual boundaries and analyse surgical and quality of life (QOL) outcomes in our patients with large (≥ 10 cm) oral cavity defects while using extended bipaddle PMMC flaps. We retrospectively analysed the results of 72 oral cancer patients with large buccoalveolar defects with at least one dimension ≥ 10 cm who underwent single-stage reconstruction using extended bipaddle PMMC flaps between January 2018 and December 2019. Total flap loss was seen in one patient and partial loss in 10 (13.8%) patients, while 18 (25.1%) patients had major complications (Clavien-Dindo grade III). Discharge from hospital was delayed beyond a mean of 6 days in 15 (20.8%) patients and the start of adjuvant treatment was delayed in 5 patients (6.9%). On univariate analysis, age > 50 years, female gender, the largest dimension and flap area were significant factors increasing morbidity. The QOL outcomes were acceptable. The satisfactory results from our series reaffirm that extended bipaddle PMMC flaps are a viable alternate option for such reconstructive challenges in resource-limited centres. However, age, gender, the defect dimensions and flap area should be taken into consideration while using this flap.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-021-01345-1.

Effect of Postsurgical Nurse-led Follow-ups on Quality of Life in Head-and-Neck Cancer Patients: A Pilot Randomized Controlled Trial

Objective:

Burden of head-and-neck cancer is disproportionately bigger in India and can be regarded as “tip of iceberg” situation. Postoperatively, head-and-neck cancer patients report tremendous challenges conversely, affects quality of their life. Oncology nurses contribute significantly in supportive care issues encountered by patients in the postoperative period. However, there is a paucity of the literature on effect of nurse-led postsurgical education program on quality of life (QOL) of head-and-neck cancer patients.

Methods:

In this pilot randomized controlled, parallel group trial, 64 head-and-neck cancer patients; who were electively planned for surgery were randomized in experimental (n₁ = 32) and control group (n₂ = 32). In the experimental group, participants received structured nurse-led postsurgical education program through virtual mode and control group participants received standard of care. The QOL as an outcome variable was assessed through face-to-face interview at baseline on first postoperative day and postoperative day-4, 15, and 30 follow-ups by using standardized instruments, i.e., EORTC QLQ-C30 and H and N35 questionnaire.

Results:

The experimental group had a significant improvement in global health (P = 0.02), role functioning (P = 0.02), emotional functioning (P = 0.01), swallowing (P = 0.01), and opening mouth (P = 0.02). Postoperative pain and speech problems were most distressing symptoms in participants of both groups.

Conclusions:

The nurse-led postsurgical virtual education programme was found effective to improve the selected domains of QOL and may be used as an adjuvant intervention for head-and-neck cancer patients.

Robust expression of LINE-1 retrotransposon encoded proteins in oral squamous cell carcinoma

BACKGROUND

Oral Squamous Cell Carcinoma (OSCC) results from a series of genetic alteration in squamous cells. This particular type of cancer considers one of the most aggressive malignancies to control because of its frequent local invasions to the regional lymph node. Although several biomarkers have been reported, the key marker used to predict the behavior of the disease is largely unknown. Here we report Long INterpersed Element-1 (LINE1 or L1) retrotransposon activity in post-operative oral cancer samples. L1 is the only active retrotransposon occupying around 17% of the human genome with an estimated 500,000 copies. An active L1 encodes two proteins (L1ORF1p and L1ORF2p); both of which are critical in the process of retrotransposition. Several studies report that the L1 retrotransposon is highly active in many cancers. L1 activity is generally determined by assaying L1ORF1p because of its high expression and availability of the antibody. However, due to its lower expression and unavailability of a robust antibody, detection of L1ORF2p has been limited. L1ORF2p is the crucial protein in the process of retrotransposition as it provides endonuclease and reverse transcriptase (RT) activity.

METHODS

Immunohistochemistry and Western blotting were performed on the post-operative oral cancer samples and murine tissues.

RESULTS

Using in house novel antibodies against both the L1 proteins (L1ORF1p and L1ORF2p), we found L1 retrotransposon is extremely active in post-operative oral cancer tissues. Here, we report a novel human L1ORF2p antibody generated using an 80-amino-acid stretch from the RT domain, which is highly conserved among different species. The antibody detects significant L1ORF2p expression in human oral squamous cell carcinoma (OSCC) samples and murine germ tissues.

CONCLUSIONS

We report exceptionally high L1ORF1p and L1ORF2p expression in post-operative oral cancer samples. The novel L1ORF2p antibody reported in this study will serve as a useful tool to understand why L1 activity is deregulated in OSCC and how it contributes to the progression of this particular cancer. Cross-species reactivity of L1ORF2p antibody due to the conserved epitope will be useful to study the retrotransposon biology in mice and rat germ tissues.

Differentially expressed full-length, fusion and novel isoforms transcripts-based signature of well-differentiated keratinized oral squamous cell carcinoma

Highly keratinized oral squamous cell carcinoma (OSCC) exhibits an improved response to treatment and prognosis compared with weakly keratinized OSCC. Therefore, we aimed to develop gene transcript signature and to identify novel full-length isoforms, fusion transcript and non-coding RNA to differentiate well-differentiated (WD) with Moderately Differentiated (MD)/Poorly Differentiated (PD)/WD-lymphadenopathy OSCC through, HTA, Isoform sequencing, and NanoString. Additionally, specific copy number gain and loss were also identify in WD keratinized OSCC through Oncoscan array and validated through Real-time PCR in histopathologically characterized FFPE-WD keratinized OSCC. Three-hundred-thirty-eight (338) differentially expressed full-length (FL) transcript isoforms (317 upregulated and 21 down-regulated in OSCC) were identified through Isoform Sequencing using the PacBio platform. Thirty-four (34) highly upregulated differentially expressed transcripts from IsoSeq data were also correlated with HTA2.0 and validated in 42 OSCC samples. We were able to identify 18 differentially expressed transcripts, 12 fusion transcripts, and two long noncoding RNAs. These transcripts were involved in increased cell proliferation, dysregulated metabolic reprogramming, oxidative stress, and immune system markers with enhanced immune rearrangements, suggesting a cancerous nature. However, an increase in proteasomal activity and hemidesmosome proteins suggested an improved prognosis and tumor cell stability in keratinized OSCC and helped to characterize WD with MD/PD/WD with lymphadenopathy OSCC. Additionally, novel isoforms of IL37, NAA10, UCHL3, SPAG7, and RAB24 were identified while in silico functionally validated SPAG7 represented the premalignant phenotype of keratinized (K4) OSCC. Most importantly we found copy number gain and overexpression of EGFR suggest that TKIs may also be used as therapeutics in WD-OSCCs.

Oral Submucous Fibrosis- Correlation between Clinical Findings and Histopathological Grading

Introduction Oral Submucous fibrosis (OSMF) occurs in young adults, who are in the habit of chewing tobacco mixed with areca nut and its various commercially available preparations. The disease results in progressive inability to open the mouth due to the submucosal fibrosis initiated by chronic inflammation affecting mainly oral mucosa. Authors undertook the present study to correlate the clinical features of OSMF to histopathological features and to find out aetiopathological factors of this condition. Materials and Methods A total of 123 clinically diagnosed OSMF patients, in the age range of 17 to 70 years were studied. Mouth opening was measured using a scale and was recorded in millimeters. Incisional biopsy was taken from the representative areas in the oral cavity. The patients were graded clinically and histopathologically and results were analyzed and discussed. Result Most of the patients were in the age group of 20-30 years (37.4%) with male predominance. The duration of either tobacco or areca nut chewing ranged from 1 to 35 yrs. Most patients had these habits for 6-19 yrs. Majority (55.3% & 54.5%) of the patients belonged to grade-2 (clinical grading) and intermediate grade (HPE grading) respectively. The HPE grading showed significant and direct association with duration of ill habits. The HPE grading showed significant and direct association with clinical grading (χ2=204.08, p<0.001). Discussion The HPE grading showed significant and direct association with duration of ill habits and also with clinical findings of restriction of mouth opening and inter incisal distance. The HPE findings showed significant and direct association with clinical grading i.e. when the clinical grading increases, the histopathological grading also increases. Conclusion OSMF is a disease with a high incidence. It also carries a significant risk of transformation to oral cancer. As no effective medical and surgical treatment is available for this condition; it is desirable to diagnose OSMF at early stages.

Abstract 3396: Characterization of oral squamous cell carcinoma transcriptome through long read sequencing technology

Large and increasing public-databases of oral squamous cell carcinoma (OSCC) transcriptome sequencing data has been generated through next-generation which has limitation for novel full-length transcript isoforms. Hence, our objective was to identify differential specific OSCC-related novel full length transcript isoforms, long noncoding RNA and fusion genes compared to non-matched oral-cavity control samples through PacBio-RSII platform. The OSCC, patients from different anatomical sites (gingivobuccal region, retro-molar trigone and lower gum) were processed through human transcriptome array 2.0 (HTA2.0). Heatmap generated expression patterns showed two distinct subgroups against control. Both tumor and control samples were individually run on Oncoscan array. On aggregate analysis significant copy number gain of Ch 7p11.2 EGFR gene; and Ch11q13.3-13.4 (FGF19, FGF4, FGF3, LOC101928443, ANO1-AS2, ANO1, FADD, MIR548K, PPFIA1, CTTN, SHANK2) were identified. Based on HTA2.0 and Oncoscan array we pooled six oral cancer and three oral control samples for Isoseq analysis. Differentially expressed full length transcripts between OC and OT were generated through GFOLD and were processed through Reactome Pathway. On considering more than 20 transcript-entities, Metabolism of RNA (22), Developmental Biology (25), Cytokine Signaling (25), Innate Immune System (25), Metabolism of proteins (31), Immune System (35), Metabolism (29), and Signal Transduction (21) pathways were identified. Differential regulation was also validated through HTA2.0. The identified high quality full length transcripts were annotated and classified through Blast2Go in different sub-group under Biological-Process, Cellular-Process and Molecular-function in Level 2. Out of these most highly up-regulated were Type I-Keratins (KRT)-KRT17, -KRT16, -KRT14 and Type-II keratins-KRT6A and -KRT6B showing involvement of formation of cornified envelope, Keratinization, Cell-cell communication, Type I hemi-desmosome assembly and developmental biology pathways. Long non-coding RNA-NMD candidates ARL2-SNX15, RAB4B-EGLN2, SENP3-EIF4A1 and fusion genes-ACTA2–ACTB, ACTB–ACTC1, ACTB–ACTG2, CALML3–CALM3, CKM–CKB, ENO1–ENO3, IGKV1-27–IGKV3-15, IGKV4-1–IGKJ1, IGKV4-1–IGKJ2, IGKV4-1–IGKJ3, IGKV4-1–IGKJ4, KRT6B–KRT6A were also differentially expressed. Additionally, 457 novel full length transcript isoforms including 289 from OC and 168 from OT datasets were identified. Hence, differentially regulated-KRT17, KRT16, KRT14, KRT6A, KRT 6B; long non-coding RNA and identified fusion genes and full length novel transcript isofoms may be the characteristic of these tumors after validation in histo-pathologically characterized FFPE-Keratinized OSCC and may also prove as early detection marker for Keratinized OSCC if identified in pre-neoplastic conditions.

Citation Format: Neetu Singh, Dinesh Kumar Sahu, Ratnesh Kumar Tripathi, Archana Mishra, Satyendra Kumar Singh, Rebecca Chowdhry, Sameer Gupta, Divya Mehrotra, Preeti Agarwal, Madhu Mati Goel, Sudhir Singh, Arun Chaturvedi, Akshay Mishra, Satya Prakash Agarwal, Manish Bajpai, Ravi Kant, Madan Lal Bhatt. Characterization of oral squamous cell carcinoma transcriptome through long read sequencing technology [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3396.

Fungal Rhinosinusitis: Microbiological and Histopathological Perspective

INTRODUCTION

On the basis of histopathology Fungal Rhinosinusitis (FRS) is categorized into non-invasive (allergic fungal rhinosinusitis, fungal ball) and invasive (acute invasive, chronic invasive and granulomatous invasive fungal sinusitis). This differentiation helps to decide the treatment. Role of latest molecular methods such as PCR and conventional methods such as KOH microscopy and culture also needs to be evaluated. Therefore, in this study we planned to categorise fungal rhinosinusitis on the basis of histopathology and compare it with other methods such as PCR, culture and KOH microscopy.

AIM

To analyse fungal rhinosinusitis cases by both histopathologically and microbiologically.

MATERIALS AND METHODS

A total of 76 clinically suspected fungal rhinosinusitis cases were included in the study. The tissue of suspected cases were processed and examined by KOH microscopy, histopathologically, culture and PCR. Histopathological examination was done by PAS, GMS and H&E stain.

RESULTS

FRS was diagnosed in 37 (48.68%) cases out of 76 clinically suspected cases of FRS. In which 17 (22.3%) cases were positive by direct microscopy, 21 (27.6%) by culture, 27 (35.5%) by PCR and 14 (18.42%) by histopathology. Approximately 14 cases of FRS were classified according to histopathology; 10 (71.3%) as non-invasive FRS. Out of these 10, 9 (64.2%) were classified as AFRS and 1 (7.14%) as fungal ball. Only 4 cases (28.5%) were diagnosed with invasive FRS. Out of these 4 cases, 2 (14.2%) were of chronic invasive fungal rhinosinusitis, 1 (7.14%) was of granulomatous invasive fungal rhinosinusitis and 1 (7.14%) was of acute fulminant invasive fungal rhinosinusitis. Allergic Fungal Rhinosinusitis (AFRS) is the most common type of FRS. Aspergillus flavus was found to be the most common fungi causing FRS.

CONCLUSION

Diagnosis should not be based on the single method. It should be done by both histopathological and microbiological methods, especially for those cases which are difficult to diagnose.

Juvenile Nasopharyngeal Angiofibroma: Combined Approach for Excision, Transpalatal and Endoscopic; A New Perspective

Juvenile angiofibroma is a rare, highly vascular, histologically benign but locally invasive tumour, affecting predominantly male adolescents. To describe our experience in diagnosis of angiofibroma and treatment by combined endoscopic and transpalatal route. We analysed a case series of 50 patients of nasopharyngeal angiofibroma in Fisch stages I and II who presented at our institute during a period of four years 2011-2014, their clinical presentation, their treatment by combined transpalatal and endoscopic approach, intraoperative and post operative course, complications and tumour recurrence. Patients were aged 8-26 years. All patients were treated surgically by combined approach endoscopic and transpalatal. The mean operation time was 90 min, and the mean bleeding volume was 300 ml. Only 8 % patients came with recurrence and only 10 % came with palatal perforation (fistula formation). With gratifying results we advocate this novel technique for the treatment of early to intermediate JNA.

Huge ossifying fibroma maxilla

Maxillofacial fibro-osseous lesions comprise a group of face and jaw disorders characterized by the replacement of bone by a benign connective-tissue matrix with varying amount of mineralized substances. Fibro-osseous lesions of the maxilla are not an uncommon tumor. Majority of the lesions with fibrous and osseous components include ossifying fibroma, fibrous dysplasia, cemento-ossifying fibroma, and cementifying fibroma. We present a case of 15-year-old female with huge fibroosseous lesion which was treated with total maxillectomy via a Weber-Ferguson approach. Histopathology established that fibroosseous lesion as an ossifying fibroma.

Abstract A27: DNA methylation and transcriptional dysregulation of miRNA-137 and -193a in premalignant oral lesions and oral squamous cell carcinoma

Background: Oral squamous cell carcinoma (OSCC) is a multistep process arising through the progressive accumulation of multiple genetic and epigenetic events. Tobacco, bidi (tobacco flakes wrapped in a tendu leaf) smoking and alcohol consumption are established risk factors associated with OSCC and premalignant oral lesions (PMOLs) in Indian population. The microRNAs (miRNAs) are non-coding RNAs that leads to gene silencing at the post- transcriptional level by degradation or repression of target mRNA. The miRNA expression may be oncogenic or tumor suppressor and can be regulated epigenetically, either through DNA methylation or histone modification. Tumor suppressor miRNA-137 and -193a are epigenetically silenced in many cancers. In this study, we attempted to elucidate the miRNA methylation and expression in the patient of PMOLs [leukoplakia with (LKP) or without dysplasia (LKPD) and oral submucous fibrosis (OSMF)] and OSCC to determine the potential role of both miRNA as early predictive biomarkers. Both miRNAs methylation was finally correlated with the clinicopathological variables in Indian population.

Material and Methods: Methylation-specific PCR for miR-137 and -193a methylation was performed in biopsy proven tissues; controls (n=34), PMOLs (n=84) and OSCC (n=84) and in corresponding blood samples. Mature miRNA expression was examined using quantitative reverse transcriptase PCR in tissue samples (10 controls, 30 PMOLs and 10 OSCC) using TaqMan chemistry based primers and probes. RNU44 was selected for normalization as an endogenous control for expression analysis. All experiments were performed in triplicate in a clinical setting of a tertiary care hospital.

Results: We observed miR-137 methylation frequency of 48% in tissue and 35% in blood samples of OSCC, and 27% in tissue and 10% in blood samples of PMOL group, as compared to the control samples which showed methylation frequency of 17.6% in tissue and 2.9% in blood samples. Further, we found methylation of miR-193a in patients with OSCC, i.e., 49% in tissue and 39% in blood samples of OSCC group. In PMOL group, methylation frequency of miR-193a was observed in 27% of tissue samples and 10% of blood samples, respectively as compared to the controls which showed miR-193a methylation frequency of 14.7% in tissue and 2.9% in blood samples. The promoter methylation frequency was found higher in histologically well-differentiated OSCC as compared to moderately and poorly differentiated OSCC. Multinomial logistic regression showed tobacco and bidi smoking were significantly associated with methylation of both miRNAs in PMOLs and OSCC group. As compared to controls, significant downregulation of miRNA-137 was observed only in OSCC group (2.23 fold, p=0.049) whereas miRNA-193a was significantly downregulated in both PMOL (LKP: 3.45 fold, p=0.000; LKPD: 3.80 fold, p=0.034) and OSCC group (4.34 fold, p=0.002).

Conclusion: Our results suggest that promoter DNA methylation of both miRNA-137 and -193a in tissue and corresponding blood samples of PMOLs and OSCC group may be predictive biomarkers for early detection and malignant risk in premalignant lesions. Taken together DNA methylation and miRNA downregulation, we concluded that both miRNAs are epigenetically silenced during oral carcinogenesis.

Note: This abstract was not presented at the conference.

Citation Format: Vikram Bhatia, Madhu Mati Goel, Annu Makker, S P Agarwal, Sandeep Kumar, Sudhir K Goel. DNA methylation and transcriptional dysregulation of miRNA-137 and -193a in premalignant oral lesions and oral squamous cell carcinoma. [abstract]. In: Proceedings of the AACR Special Conference on Chromatin and Epigenetics in Cancer; Sep 24-27, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2016;76(2 Suppl):Abstract nr A27.

Huge Osteoclastoma of Hyoid Bone: A Case Report

Giant cell tumors (GCT) of hyoid bone are very rare, and only few individual cases were reported in literature. We present such a case of GCT arising from left cornu of hyoid bone. The patient underwent trans-cervical complete excision of the tumour. Postoperatively, patient did well without recurrence or metastasis for 2 years follow up.

Molecular detection of Schizophyllum commune in a case of allergic fungal rhinosinusitis

We present a rare case of Schizophyllum commune causing allergic fungal rhinosinusitis (AFRS) in a 56-year-old immunocompetent woman. In our case, diagnosis of AFRS was based on the history of illness, CT scan findings, culture and PCR. The PCR product was further analysed by sequencing to confirm S. commune. The patient was treated by functional endoscopic sinus surgery (FESS) and antiallergic drugs.

Stridor: an unusual presentation of juvenile nasopharyngeal angiofibroma

Nasopharyngeal angiofibroma is a rare and benign disease, which is mainly found in adolescent male subjects. It is usually diagnosed on clinical grounds on the basis of its presenting symptoms of nasal obstruction, nasal mass and most importantly unprovoked recurrent moderate to severe epistaxis. Imaging studies are only needed to confirm the diagnosis and formulate the management plan. A case of juvenile nasopharyngeal angiofibroma is presented here, which presented to us with severe respiratory distress and stridor. Urgent tracheostomy had to be performed before definitive management could be started. Definitive treatment was excision through modified transpalatal with sublabial route, which resulted in successful outcome.

Cephalometric evaluation of mandibular advancement at different horizontal jaw positions in obstructive sleep apnoea patients: a pilot study

BACKGROUND

The aim of this study was to comparatively evaluate the efficacy of the mandibular advancement device (MAD) at 50% (P2) and 75% (P3) of maximum mandibular advancement, relative to maximum intercuspation (P1) subjectively and objectively.

METHODS

Eighteen subjects previously diagnosed with obstructive sleep apnoea (OSA) were selected for the study. ESS score, VAS score, soft palate angle, MP-H distance, S-H distance, a C4 -H distance, a Pu -p Pu distance and total pharyngeal area were calculated at P1, P2 and P3 positions with the help of an adjustable MAD. The results were statistically analysed.

RESULTS

ESS score, VAS score, soft palate angle, MP-H distance, S-H distance and radius of curvature of airway at P2 and P3 were significantly lower compared to P1, but there was no significant difference between P2 and P3.

CONCLUSIONS

The MAD produced significant improvement in objective signs and subjective symptoms at both 50% and 75% of the maximum mandibular protrusion positions at comparable comfort levels. Therefore, MAD may be given at 50% of maximum advancement in order to reduce dental or temporomandibular joint disturbances.

Seasonal variations in serum levels of thyroid hormones and their relation with seminal quality and libido in buffalo bulls

Blood samples from 15 Murrah buffalo bulls, (10- to 15- years-old) were collected during the summer, monsoon and winter seasons. The serum samples were analysed for thyroxine (T4) and triiodothyronine (T3) by RIA. Semen samples from these bulls were evaluated for various attributes. Sexual behaviour of these bulls was also recorded during the different seasons and was expressed as reaction time and refusal response. T4, T3, (T4 + T3) level and T4:T3 ratio did not reveal significant difference between seasons. Similarly, seminal characteristics did not exhibit any seasonal variation except for the percentage of live spermatozoa. However, the refusal response (no interest in mounting and ejaculating) was highest during summer months. T4 was significantly correlated to T(3) (r=0.53). Overall, T4 showed a positive correlation with seminal volume and initial motility while T3 exhibited a positive correlation with total sperm concentration and percentage of live spermatozoa. T3 was negatively correlated with refusal response only during the monsoon season. Correlation with other seminal and behavioural characteristics were not significant. The results indicated that although the sexual interest of buffalo bulls is reduced during the summer, the bulls can produce semen throughout the year under appropriate feeding and management conditions.

Serum thyroid hormone levels in male buffalo calves as related to age and sexual development

A total of 155 male buffalo calves were classified into 17 groups according to chronological age. The body weight was recorded on a balance or computed. Sera samples were analysed for thyroxine (T(4)) and triiodothyronine (T(3)) by radioimmunoassay. Highest concentration of thyroid hormones (T(4), 87.6+/-17.6; T(3), 3.1+/-0.07 ng/ml) were seen during the first week after birth followed by a gradual decline until two months of age. Later, the mean T(4) and T(3) levels fluctuated between 30 and 40 ng/ml and at around 1.0 ng/ml, respectively, except for a mild peak at 12 to 15 months of age. T4:T3 ratio did not vary significantly among various age groups. Both T4 and T3 were negatively correlated with age.