Predictive markers for late cervical metastasis in stage I and II invasive squamous cell carcinoma of the oral tongue

The Different Routes to Metastasis via Hypoxia-Regulated Programs

Hypoxia is linked to metastasis; however, how it affects metastatic progression is not clear due to limited consensus in the literature. We posit that this lack of consensus is due to hypoxia being studied using different approaches, such as in vitro, primary tumor, or metastasis assays in an isolated manner. Here, we review the pros and cons of in vitro hypoxia assays, highlight in vivo studies that inform on physiological hypoxia, and review the evidence that primary tumor hypoxia might influence the fate of disseminated tumor cells (DTCs) in secondary organs. Our analysis suggests that consensus can be reached by using in vivo methods of study, which also allow better modeling of how hypoxia affects DTC fate and metastasis.

A model to predict nodal metastasis in patients with oral squamous cell carcinoma

Difficulty in precise decision making on necessity of surgery is a major problem when managing oral squamous cell carcinomas (OSCCs) with clinically negative neck. Therefore, use of clinical and histopathological parameters in combination would be important to improve patient management. The main objective is to develop a model that predicts the presence of nodal metastasis in patients with OSCC.623 patients faced neck dissections with buccal mucosal or tongue squamous cell carcinoma (SCC) were selected from patients’ records. Demographic data, clinical information, nodal status, Depth of invasion (DOI) and pattern of invasion (POI) were recorded. The parameters which showed a significant association with nodal metastasis were used to develop a multivariable predictive model (PM). Univariate logistic regression was used to estimate the strengths of those associations in terms of odds ratios (OR). This showed statistically significant associations between status of the nodal metastasis and each of the following 4 histopathological parameters individually: size of the tumour (T), site, POI, and DOI. Specifically, OR of nodal metastasis for tongue cancers relative to buccal mucosal cancers was 1.89, P-value < 0.001. Similarly, ORs for POI type 3 and 4 relative to type 2 were 1.99 and 5.83 respectively. A similar relationship was found with tumour size; ORs for T2, T3, and T4 compared to T1 were 2.79, 8.27 and 8.75 respectively. These four histopathological parameters were then used to develop a predictive model for nodal metastasis. This model showed that probability of nodal metastasis is higher among tongue cancers with increasing POI, with increasing T, and with larger depths while other characteristics remained unchanged. The proposed model provides a way of using combinations of histopathological parameters to identify patients with higher risks of nodal metastasis for surgical management.

Stage II Oral Tongue Cancer: Survival Impact of Adjuvant Radiation Based on Depth of Invasion

Objective

To determine if adjuvant radiation therapy for patients with pT2N0 oral cavity tongue cancer affects overall survival.

Study Design

Retrospective cohort study.

Setting

National Cancer Database.

Subjects and Methods

Cases diagnosed between 2004 and 2013 with pathologic stage pT2N0 oral cavity tongue cancer with negative surgical margins were extracted from the National Cancer Database. Data were stratified by treatment received, including surgery only and surgery + postoperative radiation therapy. Univariate analysis was performed with a 2-sample t test, chi-square test, or Fisher exact test and log-rank test, while multivariate analysis was performed with Cox regression models adjusted for individual variables as well as a propensity score.

Results

A total of 934 patients were included in the study, with 27.5% of patients receiving surgery with postoperative radiation therapy (n = 257). In univariate analysis, there was no significant difference in 3-year overall survival between the patient groups ( P = .473). In multivariate analysis, there was no significant difference in survival between the treatment groups, with adjuvant radiation therapy having a hazard ratio of 0.93 (95% CI, 0.60-1.44; P = .748). Regarding tumors with a depth of invasion >5 mm, there was no survival benefit for the patients who received postoperative radiation therapy as compared with those who received surgery alone (hazard ratio = 0.93; 95% CI, 0.57-1.53; P = .769).

Conclusion

An overall survival benefit was not demonstrated for patients who received postoperative radiation therapy versus surgery alone for pT2N0 oral cavity tongue cancer, irrespective of depth of tumor invasion.

Pre-treatment Neutrophil-to-Lymphocyte Ratio as a predictor for occult cervical metastasis in early stage (T1-T2 cN0) squamous cell carcinoma of the oral tongue

BACKGROUND

Optimum management of clinically negative neck (cN0) remains controversial in early stage (T1-T2) squamous cell cancer of the oral tongue (OTSCC). The purpose of this study was to investigate the value of pre-treatment Neutrophil-to lymphocyte ratio (NLR) in predicting occult cervical metastasis in stage I and II OTSCC.

METHODS

We carried out a retrospective chart review on 110 patients suffering from early stage OTSCC who were surgically treated with tumour excision and elective neck dissection (END). Our cohort was divided in pN+ and pN0 groups basing on histopathological examination after elective neck dissection. For each patient pre-treatment NLR was calculated.

RESULTS

A statistically significant relationship between high levels of pre-treatment NLR and probability rate for neck occult metastases (0.000496 p-value) has been found. On our model the cut-off value was set for NLR >2.93. Above this level the probability to finding metastasis in a clinically negative neck increases exponentially.

CONCLUSION

These preliminary results offer clinicians an easily obtainable tool to stratify patients based on risks of metastatic node in whom END could be indicated.

Tumor budding is an independent prognostic marker in early stage oral squamous cell carcinoma: With special reference to the mode of invasion and worst pattern of invasion

Pathologically proven regional lymph node metastasis affects the prognosis in early stage oral cancer. Therefore we investigated invasive tumor patterns predicting nodal involvement and survival in patients with clinically node-negative T1 and T2 oral squamous cell carcinoma (cT1,2N0M0 OSCC). Ninety-one cases of cT1,2N0M0 OSCC treated with transoral resection of the primary tumor were assessed based on 3 types of invasive tumor patterns on histopathologic and pancytokeratin-stained immunohistological sections: the mode of invasion, worst pattern of invasion (WPOI), and tumor budding. The correlations among invasive tumor patterns, regional metastasis, and disease-free survival were analyzed. Of the 91 cases, 22 (24%) had pathologically proven regional metastasis. The mode of invasion (p<0.01) and tumor budding (p<0.01) were associated with regional metastasis as well as lymphovascular invasion (p = 0.04) in univariate analysis. In logistic regression analysis, however, tumor budding was the only independent predictor of regional metastasis (hazard ratio (HR) = 3.05, 95% confidence interval (CI) = 0.29–5.30, p<0.01). All three invasive patterns, the mode of invasion, WPOI, and tumor budding, were found to be significant predictors of 5-year disease-free survival (p<0.01, p = 0.03, and p<0.01, respectively) as well as lymphovascular invasion (p = 0.02) and perineural invasion (p = 0.02). A final model for Cox multivariate analysis identified the prognostic advantage of the intensity of tumor budding (HR = 2.19, 95% CI = 1.51–3.18, p<0.01) compared with the mode of invasion and WPOI in disease-free survival. Our results indicate that the intensity of tumor budding may be a novel diagnostic biomarker, as well as a therapeutic tool, for regional metastasis in patients with cT1,2N0M0 OSCC. If the pancytokeratin-based immunohistochemical features of more than five buds, and a grade 4C or 4D mode of invasion are identified, careful wait-and-see follow-up in a short period with the use of imaging modalities is desirable. If there are more than ten buds, a grade 4D mode of invasion, or WPOI-5 in the same section, wide resection of the primary tumor with elective neck dissection should be recommended.

Epigenetic modification of SALL1 as a novel biomarker for the prognosis of early stage head and neck cancer

This study examined Sal-like protein (SALL)1 methylation profiles in head and neck squamous-cell carcinoma (HNSCC) patients at diagnosis and follow-up, and evaluated their prognostic significance and value as a biomarker. SALL1 expression was examined in a panel of cell lines by quantitative reverse transcription PCR (qRT-PCR). Promoter methylation was determined by quantitative methylation-specific polymerase chain reaction (qMSP) and was compared to the clinical characteristics of 205 samples. SALL1 promoter methylation was associated with transcriptional inhibition and was correlated with disease recurrence in 31.7% of cases, with an odds ratio of 1.694 (95% confidence interval: 1.093-2.626; P = 0.018) by multivariate Cox proportional hazard regression analysis. SALL1 promoter hypermethylation showed highly discriminatory receiver operator characteristic curve profiles that clearly distinguished HNSCC from adjacent normal mucosal tissue, and was correlated with reduced disease-free survival in early stage T1 and T2 patients (log-rank test, P < 0.001). SALL1 methylation was significantly correlated with the methylation status of both SALL3 and CDH1. This study suggests that CpG hypermethylation is a likely mechanism of SALL1 gene inactivation, supporting the hypothesis that SALL1 might play a role in HNSCC tumorigenesis and could serve as an important biomarker.

Prognostic value of aberrant promoter hypermethylation of tumor-related genes in early-stage head and neck cancer

Staging and pathological grading are useful, but imperfect predictors of recurrence in head and neck squamous cell carcinoma (HNSCC). Accordingly, molecular biomarkers that predict the risk of recurrence are necessary to improve clinical outcomes. The methylation statuses of the promoters of 11 tumor-related genes (p16, RASSF1A, E-cadherin, H-cadherin, MGMT, DAPK, DCC, COL1A2, TAC1, SST, and GALR1) were analyzed in 133 HNSCC cases using quantitative methylation-specific PCR. We detected frequent methylation of p16 (44%), RASSF1A (18%), E-cadherin (53%), H-cadherin (35%), MGMT (35%), DAPK (53%), DCC (42%), COL1A2 (44%), TAC1 (61%), SST (64%), and GALR1 (44%) in HNSCC. Disease-free survival was lower in patients with 6–11 methylated genes than in those with 0–5 methylated genes (log-rank test, P = 0.001). In a multivariate Cox proportional hazards analysis, the methylation of E-cadherin, COL1A2, TAC1, and GALR1 was associated with poor survival, with hazard ratios of 4.474 (95% CI, 1.241–16.124). In a joint analysis of these four genes, patients with 2–4 methylated genes had a significantly lower survival rate than those with 0–1 methylated genes in early-stage HNSCC. Importantly, the methylation of some genes was closely related to poor prognosis in early-stage HNSCC, providing strong evidence that these hypermethylated genes are valuable biomarkers for prognostic evaluation.

Matrix Metalloproteinase-19 is a Predictive Marker for Tumor Invasiveness in Patients with Oropharyngeal Squamous Cell Carcinoma

Aims

To evaluate the expression of matrix metalloproteinase-19 (MMP-19) in oropharyngeal squamous cell carcinoma along with its association with structural features of invasiveness. To investigate whether MMP-19 expression correlates with lymphatic or systemic metastasis and prognosis in patients who have received definitive radiotherapy.

Methods and results

The histological evaluation of the invasive front was based on Bryne's malignancy grading system. We correlated the immunohistochemical expression pattern with morphological parameters which characterize tumor invasiveness such as keratinization, nuclear polymorphism, invasion pattern, and the host inflammatory response. Local immunoreactivity for MMP-19 was positively correlated with tumor invasiveness as reflected in its structural characteristics and the degree of nuclear polymorphism, and negatively correlated with the inflammatory response of the host. No correlation existed between MMP-19 expression and clinicopathological features (TNM stage, grade of differentiation) or a patient's outcome and prognosis.

Conclusions

This latter finding probably reflects the unique change for MMPs from high immunoreactivity within healthy tissue areas and non-invasive tumor parts, through absence in the least invasive neoplastic regions, to strong re-expression at a highly invasive front of the same tumor. Our findings indicate that MMP-19 can be used as a marker for tumor invasiveness in patients with oropharyngeal squamous cell carcinoma.

AHNS Series: Do you know your guidelines? Evidence-based management of oral cavity cancers

Oral cavity squamous cell carcinoma (OCSCC) is the most common nonmelanoma head and neck cancer in the world, with an estimated 405 000 new cases expected each year. Subsites of the oral cavity include the alveolar ridge, buccal mucosa, anterior tongue, tonsillar pillar, retromolar trigone, hard palate, gingiva, and floor of the mouth. In this issue of the AHNS "Do you know your guidelines?" series, we review the evidence-based approach to the management of oral cavity carcinomas based on the framework provided by the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology.

Development of a New Outcome Prediction Model in Early-stage Squamous Cell Carcinoma of the Oral Cavity Based on Histopathologic Parameters With Multivariate Analysis: The Aditi-Nuzhat Lymph-node Prediction Score (ANLPS) System

The aim of this study was to evaluate the histopathologic parameters that predict lymph node metastasis in patients with oral squamous cell carcinoma (OSCC) and to design a new assessment score on the basis of these parameters that could ultimately allow for changes in treatment decisions or aid clinicians in deciding whether there is a need for close follow-up or to perform early lymph node dissection. Histopathologic parameters of 336 cases of OSCC with stage cT1/T2 N0M0 disease were analyzed. The location of the tumor and the type of surgery used for the management of the tumor were recorded for all patients. The parameters, including T stage, grading of tumor, tumor budding, tumor thickness, depth of invasion, shape of tumor nest, lymphoid response at tumor-host interface and pattern of invasion, eosinophilic reaction, foreign-body giant cell reaction, lymphovascular invasion, and perineural invasion, were examined. Ninety-two patients had metastasis in lymph nodes. On univariate and multivariate analysis, independent variables for predicting lymph node metastasis in descending order were depth of invasion (P=0.003), pattern of invasion (P=0.007), perineural invasion (P=0.014), grade (P=0.028), lymphovascular invasion (P=0.038), lymphoid response (P=0.037), and tumor budding (P=0.039). We designed a scoring system on the basis of these statistical results and tested it. Cases with scores ranging from 7 to 11, 12 to 16, and ≥17 points showed LN metastasis in 6.4%, 22.8%, and 77.1% of cases, respectively. The difference between these 3 groups in relation to nodal metastasis was very significant (P<0.0001). A patient at low risk for lymph node metastasis (score, 7 to 11) had a 5-year survival of 93%, moderate-risk patients (score, 12 to 16) had a 5-year survival of 67%, and high-risk patients (score, 17 to 21) had a 5-year survival of 39%. The risk of lymph node metastasis in OSCC is influenced by many histologic parameters that are not routinely analyzed in pathologic reports. These significant independent factors were graded to design a scoring system that permits accurate evaluation of the risk of metastasis with accuracy independent of the traditional TNM system or isolated histologic parameters. The need for neck node dissection can be predicted depending upon the scores obtained.

CD147 expression correlates with lymph node metastasis in T1-T2 squamous cell carcinoma of the tongue

Cervical lymph node metastasis causes a poor prognosis in cases of stage T1-T2 squamous cell carcinoma (SCC) of the tongue. Recent studies have reported that cluster of differentiation (CD)147, also known as extracellular matrix metalloproteinase inducer, contributes to tumor progression. The present study evaluated the role of CD147 in the tumorigenesis of SCC of the tongue in vitro, as well as the association between CD147 expression and cervical lymph node metastasis in clinical samples of SCC of the tongue. Tongue SCC cell lines were used to evaluate in vitro tumorigenesis. In addition, 41 patients with clinical stage T1-T2 tongue SCC were assessed with a histopathological analysis. Univariate and multivariate analysis were performed to investigate the risk of cervical lymph node metastasis associated with histopathological findings. In the in vitro study, cell invasiveness was upregulated by S100 calcium-binding protein A9 (S100A9) stimulation and downregulated following CD147-blocking antibody treatment. The univariate and multivariate analyses identified CD147 expression in the invasive tumor front as an independent risk factor for metastasis. It was concluded that CD147 induces tongue carcinoma cell invasion through its interaction with S100A9. Thus, an evaluation of the extent of CD147 expression in cancer cell nests at the invasive tumor front may help in predicting cervical lymph node metastasis in patients with clinical N0 T1-T2 tongue SCC.

Endocavitary sonography of early oral cavity malignant tumors

BACKGROUND

Preoperative staging is crucial for oral cancer management. The purpose of this study was to assess the tumor thickness using ultrasound and to correlate the level of histological infiltration with the tumor superficial extension and lesion thickness.

METHODS

Thirty-two subjects affected by oral cavity carcinoma were prospectively evaluated with intraoral ultrasound. The ultrasound sensitivity, the correlation between the ultrasound level of infiltration, and lesion diameters and thickness were assessed.

RESULTS

A 91% ultrasound sensitivity was found with no significant correlation between tumor diameter and level of histological infiltration (P >.05). A thickness of <2 mm was associated to tumor extension to the lamina propria, a value of >6 mm to muscular layer infiltration. Lymph adenopathies were identified in 21% of cases, associated to muscular layer infiltration in all cases.

CONCLUSION

In the study of early oral cavity tumors, ultrasound is accurate for demonstrating the level of tumor infiltration and contributes to the therapeutic choice.

Indications and extent of elective neck dissection in patients with early stage oral and oropharyngeal carcinoma: nationwide survey in The Netherlands

Background:

Different strategies are available for the management of patients with early (i.e. tumour stage one or two) oral or oropharyngeal carcinoma and a clinically negative neck.

Material and methods:

In 2006, a questionnaire was sent to the eight head and neck cancer centres of the Dutch Head and Neck Oncology Cooperative Group. This questionnaire covered: the factors influencing the decision to perform an elective neck dissection; the neck staging procedure; and the types of neck dissection undertaken.

Results:

All eight questionnaires were returned completed. Respondents indicated that the site (n = 6), size (n = 7) and thickness (n = 6) of the primary tumour were important in decisions regarding elective neck dissection. Ultrasound-guided fine needle aspiration cytology was the most frequently used diagnostic technique (n = 7). Depending on the site and stage of the primary tumour presented, in the different cases 3–7 of the centres would perform an elective neck dissection. Selective neck dissections (i.e. levels I to III/IV) were more frequently performed than modified radical neck dissections.

Conclusion:

There was no uniformity regarding management of the clinically negative neck in patients with early stage oral and oropharyngeal carcinoma, within The Netherlands.

Predictive markers for delayed lymph node metastases and survival in early-stage oral squamous cell carcinoma

BACKGROUND

The purpose of this study was to identify clinicopathological and immunohistochemical factors predicting delayed lymph node metastases and survival in early oral squamous cell carcinoma (OSCC).

METHODS

The study included 85 consecutive patients with clinically T1 to T2N0 OSCC who were primarily surgically treated between 2000 and 2004.

RESULTS

There were 68 men and 17 women (median age, 61 years; range, 34-82 years). Of all the patients, 25 (29.4%) developed delayed lymph node metastases within 3 to 42 months after treatment of the primary tumor. Multivariate logistic regression analysis identified poorly differentiated tumors, low laminin, and high fibronectin expression as prognosticators of delayed lymph node metastases. Cox's proportional hazards regression analysis demonstrated that moderately differentiated tumors and delayed lymph node metastases had predictive value regarding survival.

CONCLUSION

Large prospective investigations with reproducibility and the clinical translatability of immunohistochemical methods are needed in order to provide new and effective therapeutic strategies in the future. © 2016 Wiley Periodicals, Inc. Head Neck 39: 694-701, 2017.

Squamous cell carcinoma of the anterior tongue: is tumour thickness an indicator for cervical metastasis?

The incidence of squamous cell carcinoma (SCC) of the tongue accounts for 90% of all malignancies affecting the oral cavity and oropharynx. The distribution between the anterior and posterior tongue is equal. Nodal metastasis is dependent on various factors including tumour thickness, site, size, differentiation, and perineural and perivascular invasion. There is increasing evidence of a close correlation between tumour thickness and metastasis. A retrospective study covering the 16-year period from 2000 to 2016 was performed. Eighty-one patients with anterior tongue SCC were included. The only primary treatment was surgery. All patients were T1/T2N0M0 stage. Sixty-five patients underwent local excision with simultaneous selective neck dissection; 29 of these patients were confirmed to have occult metastasis. Sixteen patients underwent local excision only as an initial treatment. Four of them subsequently developed neck metastasis within a 6- to 18-month period. The results of this study support recent publications associating tumour thickness with nodal disease. Therefore, it is postulated that prophylactic neck dissection should be considered when the tumour thickness of anterior tongue SCC exceeds 5mm, in order to prevent lymphatic spread and improve the survival rate.

Surgical margins in head and neck squamous cell carcinoma: Effect of heat artifact on immunohistochemistry as a future tool for assessment

BACKGROUND

Margins in head and neck squamous cell carcinoma (HNSCC) are determined by morphological changes assessed via hematoxylin-eosin staining. Physiological changes may not be detected by this technique. The purpose of this study was to determine if a protein biomarker, laminin-332γ2, overexpressed in cancer cells at the invasive front in HNSCC, remains unaffected by heat produced during resection, supporting a role for immunohistochemistry assessment of margins.

METHODS

Archived tissue blocks from glottic squamous cell carcinomas (SCCs) resected by CO2 laser likely to contain both cancer cells and artifact were identified; 129-paired slides were obtained. One slide of each pair was stained with hematoxylin-eosin; the second stained for laminin-332γ2. The presence of cancer cells, artifact, and positive laminin-332γ2 staining was recorded. Twenty-seven pairs met the inclusion criteria.

RESULTS

Immunohistochemistry staining of laminin-332γ is preserved in presence of heat artifact.

CONCLUSION

This study supports use of immunohistochemistry to assess margins. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1401-1406, 2016.

The role of prophylactic neck dissection and tumor thickness evaluation for patients with cN0 tongue squamous cell carcinoma

Prophylactic neck dissection (PND) for patients with clinically N0 (cN0) tongue carcinoma remains controversial. We assessed the efficacy of PND for patients with cN0 tongue squamous cell carcinoma (SCC) and investigated the prognostic role of tumor thickness as assessed by diagnostic imaging in predicting the risk of nodal micrometastasis or late nodal recurrence. Eighty-eight patients with cN0 tongue carcinomas underwent surgical treatment. Tumor thickness was measured from magnetic resonance (MR) images or computed tomography (CT) scans. The overall survival rates of patients with or without PND were 94 and 81 %, respectively (p = 0.2857). MR images or CT scans were available for 68 patients. A tumor thickness ≥10 mm or ≥5 mm did not increase the probability of nodal metastasis, with late nodal metastasis observed in 15 % of patients with graphically undetected small tumors. PND appears to have the potential to improve overall survival for patients with cN0 tongue SCC. Careful follow-up management or PND is considered to be needed regardless of tumor thickness in the pre-treatment evaluation.

Squamous cell carcinoma of tongue and buccal mucosa: clinico-pathologically different entities

The objective of this study was to examine the clinical and pathological features of squamous cell carcinoma of the Tongue and Buccal Mucosa and understand their differences. This is a retrospective analysis of prospectively collected data of 735 patients with squamous cell carcinoma of the tongue and 665 cases of carcinoma of the buccal mucosa treated by surgery at our hospital. Statistical analysis was done to examine clinical and pathological differences between carcinoma of the tongue and the buccal mucosa with regards to age, gender, clinical T stage/N stage, pathological T stage/N stage, overall stage, grade, thickness, perinodal extension (PNE), lymphovascular emboli (LVE) and perineural invasion (PNI). Statistically significant differences were found for factors like age (p < 0.001), gender (p < 0.001), clinical T staging (p < 0.001) and pathological stage (p < 0.001), grade of tumor (p < 0.001) and perineural invasion (p < 0.001) between carcinoma of the tongue and the buccal mucosa. Forty-eight percent patients in either subsite had pathologically proven node negative necks (pN0, p = 0.88). Multivariate analysis for occult nodal metastases revealed that predictive factors were different for the two subsites. There are significant differences between cancers of the tongue and buccal mucosa for various clinical and pathological factors. This may be a reflection of the underlying differences in their causation and pathophysiology. Squamous cell carcinoma in these two subsites should therefore be regarded as clinico-pathologically distinct entities.

Tumour thickness as a determinant of nodal metastasis in oral tongue carcinoma

BACKGROUND

Tumour thickness is a strong predictor for cervical node involvement in oral cavity squamous cell carcinomas (SCCs), with a recent meta-analysis concluding a 4-mm optimal prognostic cut-off point. No consensus has been reached for the tumour thickness cut-off for oral tongue SCCs.

METHODS

A retrospective review of prospectively collected data from 112 patients by the Northern Sydney Cancer Centre (Australia) with primary oral tongue SCC was conducted. Tumour thickness was measured by standard histopathological techniques and cervical node involvement was determined either from neck dissection histopathology or by clinical and radiological follow-up.

RESULTS

Neck dissection was performed in 78 patients (70%). Tumour thickness was a significant predictor of cervical node disease (P < 0.01), with a median tumour thickness of 5.5 mm. Cervical node metastasis rates for tumours <2, 2-3.9 and ≥4 mm thick were 10%, 42.1% and 46.5%, respectively. The rate of cervical node metastasis was significantly higher for patients with tumours thicker than a cut-off of 2 mm (odds ratio: 7.53, P < 0.01). A 4-mm thickness cut-off was also statistically significant (P < 0.05); however, the odds ratio was smaller at 2.52.

CONCLUSION

Despite some previous evidence for a 4-mm tumour thickness cut-off in oral tongue SCCs, thinner tumours (2-3.9 mm) can also have a propensity for cervical node metastasis. Patients in this category require close monitoring for regional recurrence if they do not have a neck dissection.

Tumor thickness and risk of lymph node metastasis in patients with squamous cell carcinoma of the tongue

OBJECTIVES

Oral squamous cell carcinomas, and tongue malignancies in particular, are among the most common tumors of the oral cavity. Classification for therapeutic and prognostic purposes is routinely made using the tumor, node, metastasis (TNM) system; however, current definitions do not include tumor thickness. We therefore aimed to identify variables associated with survival, and to evaluate the correlation between tumor thickness and the occurrence of lymph node metastasis.

PATIENTS AND METHODS

All patients undergoing radical tumor resection for squamous cell carcinomas of the tongue between 2000 and 2012 were included. Specimens were analyzed histopathologically and co-variables were interpreted. Follow-up was performed clinically and radiologically for at least 3years according to current guidelines.

RESULTS

We included 492 patients who had a median follow-up of 70months. Variables associated with survival (p<0.05) were age, tumor stage, N stage, UICC (Union for International Cancer Control) stage, tumor grade, and recurrence. In the receiver operating characteristic curve and Youden-Index analyses, the optimal tumor thickness cut-off was 8mm to detect significant differences in overall survival.

CONCLUSION

We highlight the importance of tumor thickness as a predictive variable in tongue cancer. Specifically, a cut-off point of 8mm allowed for a more accurate and statistically precise prediction of lymph node metastasis. These findings could supplement the current classification of tongue cancers and form the basis for treatment.

Urinary laminin-γ2 is a novel biomarker of non-muscle invasive urothelial carcinoma

Lack of appropriate biomarkers has hampered early detection of urothelial cancer (UC), therefore, development of biomarkers for its diagnosis at earlier stages is of importance. Laminin‐332 (Ln‐332, formerly Ln‐5), a component of basement membranes, consists of Ln‐α3, Ln‐β3, and Ln‐γ2 polypeptides. However, monomeric Ln‐γ2 alone is frequently expressed in malignant neoplasms. If Ln‐γ2 is also expressed in UC and secreted into the urine, its detection could be useful for UC diagnosis. Here, we evaluated Ln‐γ2 levels from 60 patients with urinary diseases (including UC) by Western blotting, and detected it in approximately 53% of UC cases. Using immunohistochemistry, we confirmed Ln‐γ2 expression in UC tissues that were positive for Ln‐γ2, whereas Ln‐α3 expression was absent. We next developed a sandwich enzyme‐linked immunosorbent assay and applied it for screening 39 patients with non‐muscle invasive UC and 61 patients with benign urologic diseases. The Ln‐γ2 levels were higher in UC patients than in those with benign urologic diseases. Ln‐γ2 was detected even in patients with earlier stages of UC, such as Ta, T1, or carcinoma in situ. The sensitivity of Ln‐γ2 testing for UC was 97.4%, and the specificity was 45.9%, using a cut‐off of 0.5 μg/g∙crn. Ln‐γ2 had greater diagnostic value for detecting non‐muscle invasive UC compared to conventional urine cytology and available biomarkers for UC, and may be useful as a urine biomarker for the diagnosis and monitoring of UC.

Expression of Oct3/4 and Nanog in the head and neck squamous carcinoma cells and its clinical implications for delayed neck metastasis in stage I/II oral tongue squamous cell carcinoma

BACKGROUND

The side population (SP) of cancer cells is reportedly enriched with cancer stem cells (CSCs), however, the functional role and clinical relevance of CSC marker molecules upregulated in the SP of head and neck squamous carcinoma (HNSCC) cells are yet to be elucidated. Patients with clinical stage I/II (T1-2N0M0) tongue squamous cell carcinoma (TSCC) typically undergo partial glossectomy; however, development of delayed neck metastasis (DNM) tends to reduce their survival. In the present study, we aimed to determine the CSC markers in the SP of HNSCC cells along with their functions in cellular behaviors, and to clarify the association of these markers with DNM.

METHODS

Flow cytometry was applied to isolate SP from main population (MP) in HNSCC cells. The expression of the CSC markers was examined by semi-quantitative RT-PCR and immunocytochemistry. In vitro proliferation, migration, and invasion assays were performed to assess cellular behaviors. Clinicopathological factors and immunohistochemical expressions of Oct3/4 and Nanog were evaluated using surgical specimens from 50 patients with stage I/II TSCC.

RESULTS

SPs were isolated in all three cell lines examined. Expression levels of Oct3/4 and Nanog were higher in SP cells than MP cells. Additionally, cell migration and invasion abilities were higher in SP cells than MP cells, whereas there was no difference in proliferation. Univariate analysis showed that expression of Oct3/4 and Nanog, vascular and muscular invasion, and mode of invasion were significantly correlated with DNM. Multivariate logistic regression revealed that Oct3/4 expression (risk ratio = 14.78, p = 0.002) and vascular invasion (risk ratio = 12.93, p = 0.017) were independently predictive of DNM. Regarding the diagnostic performance, Oct3/4 showed the highest accuracy, sensitivity, and NPV of 82.0 %, 61.5 %, and 86.8 %, respectively, while vascular invasion showed the highest specificity and PPV of 94.6 % and 71.4 %, respectively.

CONCLUSION

These results suggest that Oct3/4 and Nanog represent probable CSC markers in HNSCC, which contribute to the development of DNM in part by enhancing cell motility and invasiveness. Moreover, along with vascular invasion, expression of Oct3/4 can be considered a potential predictor for selecting patients at high risk of developing DNM.

Oral Cavity Carcinoma: Current Management, Controversies, and Future Directions

Oral cavity carcinoma (OCC) remains a major cause of morbidity and mortality in patients with head and neck cancer. Although the incidence has decreased over the last decade, outcomes remain stagnant with only a 5% improvement in overall survival in the last 20 years. Although surgical resection remains the primary treatment modality, several areas of controversy exist with regard to work-up, management of the primary and neck tumors, and adjuvant therapy. As surgical techniques evolve, so has the delivery of radiotherapy and systemic treatment, which have helped to improve the outcomes for patients with advanced disease. Recently, the addition of cetuximab has shown promise as a way to improve outcomes while minimizing toxicity, and this remains an active area of study in the adjuvant setting. Advances in microvascular free-flap reconstruction have extended the limits of resection and enabled enhanced restoration of function and cosmesis. While these advances have led to limited survival benefit, evaluation of alternative modalities has gained interest on the basis of success in other head and neck subsites. Organ preservation with definitive chemoradiotherapy, though proven in the larynx and pharynx, remains controversial in OCC. Likewise, although the association of human papillomavirus is well established in oropharyngeal carcinoma, it has not been proven in the pathogenesis or survival of OCC. Future study of the molecular biology and pathogenesis of OCC should offer additional insight into screening, treatment selection, and novel therapeutic approaches.

Immunohistochemical study of vascular endothelial growth factor-C/vascular endothelial growth factor receptor-3 expression in oral tongue squamous cell carcinoma: Correlation with the induction of lymphangiogenesis

The aim of the present study was to elucidate the associations between the expression of the vascular endothelial growth factor-C (VEGF-C)/VEGF receptor-3 (VEGFR-3) axis and lymphangiogenesis, regional lymph node metastasis and clinicopathological factors in oral tongue squamous cell carcinoma (OTSCC) using immunohistochemistry. The expression of VEGF-C, VEGFR-3 and podoplanin was immunohistochemically evaluated in specimens obtained from 65 patients with OTSCC (T1-2, N0) who had undergone radical surgery alone. The associations between the expression of VEGF-C, VEGFR-3 and podoplanin, and lymphangiogenesis, regional lymph node metastasis and clinocopathological factors were determined by immunohistochemical analysis. VEGF-C, VEGFR-3 and combined VEGF-C/VEGFR-3 expression was significantly higher in cases with regional recurrence compared with those without lymph node involvement (P<0.001). As regards lymphangiogenesis, a significant correlation was observed between podoplanin expression and VEGF-C, VEGFR-3 and combined VEGF-C/VEGFR-3 expression (P<0.001). Therefore, lymphangiogenesis in the peritumoral stroma was associated with lymph node metastasis. However, podoplanin expression did not exhibit a significant correlation with the progression of lymph node metastasis. The results of the present study suggest that the VEGF-C/VEGFR-3 axis may be associated with lymph node metastasis through lymphangiogenesis. Determining the VEGF-C/VEGFR-3 expression status may help predict which patients will develop regional recurrence and provide novel targets for therapies to suppress lymph node metastasis in the treatment of OTSCC.

Evaluation of histomorphological and immunohistochemical parameters as biomarkers of cervical lymph node metastasis in squamous cell carcinoma of oral cavity: A retrospective study

Introduction:

Oral squamous cell carcinoma (OSCC) is seen worldwide but is more common in India. Lymph node (LN) metastasis has been shown to be the strongest prognostic factor in OSCC. Many histopathological and immunohistochemical markers have been studied to predict the LN metastasis.

Aims:

To identify clinicopathological factors and immunohistochemical (IHC) biomarkers which predict cervical metastasis in OSCC patients.

Study and Design:

A total of 105 cases of OSCC were taken up for our study. Histopathological parameters such as tumor thickness, depth, degree of differentiation, pattern of invasion (POI), lymphovascular and neural invasion were assessed. IHC was done on all cases using antibodies against Ki-67, cyclin D, E-cadherin, p53, CD31 and each antibody was assessed according to the standard protocol.

Statistical Analysis:

To calculate the relation between clinical, histopathological parameter, IHC marker and the occurrence of LN metastasis, chi-square test was used. Variables were tested using multivariate logistic regression method to assess the predictive significance.

Results:

Out of 105 cases studied, 29 cases showed LN metastasis. Maximum numbers of cases affected were females with involvement of buccal mucosa. We found significant association of cervical LN metastasis with high grade of differentiation, lack of E-cadherin expression, high Ki-67 and cyclin D1 expression. In our study; tumor depth, thickness, extent of peritumoral lympho-plasmacytic infiltration, presence of eosinophils, tumor nest type, p53 and microvessel density (MVD) showed no significant correlation.

Conclusion:

Significant association of cervical LN metastasis with high grade of differentiation, lack of E-cadherin expression, high Ki-67 and cyclin D1 expression was seen.

WITHDRAWN: Can depth of invasion of pT1 carcinoma of the oral tongue predict occult metastases in the neck? A retrospective study

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Accuracy of microRNAs as markers for the detection of neck lymph node metastases in patients with head and neck squamous cell carcinoma

BACKGROUND

The presence of metastatic disease in cervical lymph nodes of head and neck squamous cell carcinoma (HNSCC) patients is a very important determinant in therapy choice and prognosis, with great impact in overall survival. Frequently, routine lymph node staging cannot detect occult metastases and the post-surgical histologic evaluation of resected lymph nodes is not sensitive in detecting small metastatic deposits. Molecular markers based on tissue-specific microRNA expression are alternative accurate diagnostic markers. Herein, we evaluated the feasibility of using the expression of microRNAs to detect metastatic cells in formalin-fixed paraffin-embedded (FFPE) lymph nodes and in fine-needle aspiration (FNA) biopsies of HNSCC patients.

METHODS

An initial screening compared the expression of 667 microRNAs in a discovery set comprised by metastatic and non-metastatic lymph nodes from HNSCC patients. The most differentially expressed microRNAs were validated by qRT-PCR in two independent cohorts: i) 48 FFPE lymph node samples, and ii) 113 FNA lymph node biopsies. The accuracy of the markers in identifying metastatic samples was assessed through the analysis of sensitivity, specificity, accuracy, negative predictive value, positive predictive value, and area under the curve values.

RESULTS

Seven microRNAs highly expressed in metastatic lymph nodes from the discovery set were validated in FFPE lymph node samples. MiR-203 and miR-205 identified all metastatic samples, regardless of the size of the metastatic deposit. Additionally, these markers also showed high accuracy when FNA samples were examined.

CONCLUSIONS

The high accuracy of miR-203 and miR-205 warrant these microRNAs as diagnostic markers of neck metastases in HNSCC. These can be evaluated in entire lymph nodes and in FNA biopsies collected at different time-points such as pre-treatment samples, intraoperative sentinel node biopsy, and during patient follow-up. These markers can be useful in a clinical setting in the management of HNSCC patients from initial disease staging and therapy planning to patient surveillance.

The effects of focal adhesion kinase on the motility, proliferation and apoptosis of Caco2 and SMMC-7721 cells

Focal adhesion kinase (FAK) plays important roles in cancer development. However, the significance of FAK expression in colorectal carcinoma and hepatocellular carcinoma has not been clarified. This study aims to explore the roles FAK played in the progression of colorectal carcinoma and hepatocellular carcinoma. RNAi method was used to inhibit the expression of FAK in Caco2 and SMMC-7721 cells. Reverse transcriptase polymerase chain reaction analysis and Western blot analysis were used to examine mRNA and protein expression of FAK. Then, the proliferation, motility and apoptosis of both types of cells were detected using MTT assay, wound healing/transwell assay and nuclear staining assay. The microstructure changes (F-actin, β-tubulin and lamin B1) of SMMC-7721 cells were visualized by immunofluorescence. FAK was overexpressed in both cell lines and down-regulation of FAK resulted in suppression of cell proliferation, inhibition of cell migration and invasion. The apoptosis of cells was increased significantly following the FAK expression inhibition. Moreover, actin polymerization, β-tubulin and lamin B1 expression of cells were significantly decreased. The results highlight the role of FAK in the progression of cancers. These findings suggest FAK serve as a potential therapeutic target for cancer therapy.

A clinicopathological study of perineural invasion and vascular invasion in oral tongue squamous cell carcinoma

The risk factors for recurrence of head and neck cancer are classified as being of high or intermediate risk. Those of intermediate risk include multiple positive nodes without extracapsular nodal spread, perineural/vascular invasion, pT3/T4 primary tumours, and positive level IV/V nodes. However, little evidence is available to validate these intermediate risk factors. We analyzed perineural/vascular invasion in 89 patients who underwent radical surgery for oral tongue squamous cell carcinoma, whose records were reviewed retrospectively. Perineural invasion was found in 27.0% of cases and vascular invasion in 23.6%; both had a strong relationship with histopathological nodal status (P = 0.005). The 5-year disease-specific survival (DSS) and overall survival rates of patients with perineural invasion were significantly lower than those of patients without perineural invasion (P < 0.001 and P = 0.002, respectively). The 5-year DSS of UICC stage I and II cases with perineural/vascular invasion was significantly lower than those without (P < 0.001 and P = 0.008, respectively). Perineural invasion and vascular invasion are risk factors for regional metastasis and a poor prognosis. We recommend elective neck dissection when perineural/vascular invasion is found in clinical stage I and II cases. The accumulation of further evidence to consider intermediate risks is required.

Applicability of preoperative nuclear morphometry to evaluating risk for cervical lymph node metastasis in oral squamous cell carcinoma

BACKGROUND

We previously reported the utility of preoperative nuclear morphometry for evaluating risk for cervical lymph node metastases in tongue squamous cell carcinoma. The risk for lymph node metastasis in oral squamous cell carcinoma, however, is known to differ depending on the anatomical site of the primary tumor, such as the tongue, gingiva, mouth floor, and buccal mucosa. In this study, we evaluated the applicability of this morphometric technique to evaluating the risk for cervical lymph node metastasis in oral squamous cell carcinoma.

METHODS

A digital image system was used to measure the mean nuclear area, mean nuclear perimeter, nuclear circular rate, ratio of nuclear length to width (aspect ratio), and nuclear area coefficient of variation (NACV). Relationships between these parameters and nodal status were evaluated by t-test and logistic regression analysis.

RESULTS

Eighty-eight cases of squamous cell carcinoma (52 of the tongue, 25 of the gingiva, 4 of the buccal mucosa, and 7 of the mouth floor) were included: 46 with positive node classification and 42 with negative node classification. Nuclear area and perimeter were significantly larger in node-positive cases than in node-negative cases; however, there were no significant differences in circular rate, aspect ratio, or NACV. We derived two risk models based on the results of multivariate analysis: Model 1, which identified age and mean nuclear area and Model 2, which identified age and mean nuclear perimeter. It should be noted that primary tumor site was not associated the pN-positive status. There were no significant differences in pathological nodal status by aspect ratio, NACV, or primary tumor site.

CONCLUSION

Our method of preoperative nuclear morphometry may contribute valuable information to evaluations of the risk for lymph node metastasis in oral squamous cell carcinoma.

Prognostic value of matrix metalloproteinases in oral squamous cell carcinoma

The aim of this study was to investigate whether there is a correlation between the expressions of four matrix metalloproteinases (MMPs): MMP-2, MMP-7, MMP-9 and MMP-13, and the TNM (tumour–node–metastasis) stages of oral squamous cell carcinoma (OSCC); and to explore the implication of these MMPs in OSCC dissemination. Samples from 61 patients diagnosed with oropharyngeal tumour were studied by immunohistochemistry against MMP-2, MMP-7, MMP-9 and MMP-13. The assessment of immunoreactivity was semi-quantitative. The results showed that MMP-2 and MMP-9 had similar expression patterns in the tumour cells with no changes in the immunoreactivity during tumour progression. MMP-9 always had the highest expression, whereas that of MMP-2 was moderate. MMP-7 showed a significant decrease in expression levels during tumour evolution. MMP-13 had constant expression levels within stage T2 and T3, but showed a remarkable decline in immunoreactivity in stage T4. No significant differences in the MMPs immunoreactivity between tumour cells and stroma were observed. Although strong evidence for the application of MMPs as reliable predictive markers for node metastasis was not acquired, we believe that combining patients’ MMPs expression intensity and clinical features may improve the diagnosis and prognosis. Strong evidence for the application of MMPs as reliable predictive markers for node metastasis was not acquired. Application of MMPs as prognostic indicators for the malignancy potential of OSCC might be considered in every case of tumour examination. We believe that combining patients’ MMPs expression intensity and clinical features may improve the process of making diagnosis and prognosis.

Positive Surgical Margins in Early Stage Oral Cavity Cancer

Objective

To report the incidence of positive surgical margins in early oral cavity cancer and identify patient, tumor, and system factors associated with their occurrence.

Study Design and Setting

Retrospective analysis of the National Cancer Database.

Subjects and Methods

Patients diagnosed with stage I or II oral cavity squamous cell cancer between 1998 and 2011 were identified. Univariate and multivariate analyses of factors associated with positive margins were conducted.

Results

In total, 20,602 patients with early oral cancer were identified. Margin status was reported in 94.8% of cases, and positive margins occurred in 7.5% of those cases. Incidence of positive margins by institution varied from 0% to 43.8%, with median incidence of 7.1%. Positive margins were associated with clinical factors including stage II disease (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.55-1.98), intermediate grade (OR, 1.20; 95% CI, 1.04-1.37), high grade (OR, 1.68; 95% CI, 1.39-2.03), and floor of mouth (OR, 1.78; 95% CI, 1.52-2.08), buccal mucosa (OR, 2.06; 95% CI, 1.59-2.68), and retromolar locations (OR, 2.40; 95% CI, 1.85-3.11). Positive margins were also associated with treatment at nonacademic cancer centers (OR, 1.23; 95% CI, 1.04-1.44) and institutions with a low oral cancer case volume (OR, 1.45; 95% CI, 1.23-1.69).

Conclusion

Positive margins are associated with tumor factors, including stage, grade, and site, reflecting disease aggressiveness and difficulty of resection. Positive margins also are associated with factors such as treatment facility type, hospital case volume, and geographic region, suggesting potential variation in quality of care. Margin status may be a useful quality measure for early oral cavity cancer.

Interactions between E-cadherin and microRNA deregulation in head and neck cancers: the potential interplay

E-cadherin expression in the head and neck epithelium is essential for the morphogenesis and homeostasis of epithelial tissues. The cadherin-mediated cell-cell contacts are required for the anchorage-dependent growth of epithelial cells. Further, survival and proliferation require physical tethering created by proper cell-cell adhesion. Otherwise, the squamous epithelial cells will undergo programmed cell death. Head and neck cancers can escape from anoikis and enter into the epithelial-mesenchymal transition stages via the modulation of E-cadherin expression with epigenetic mechanisms. At epigenetic level, gene expression control is not dependent on the DNA sequence. In the context of E-cadherin regulation in head and neck cancers, 2 major mechanisms including de novo promoter hypermethylation and microRNA dysregulation are most extensively studied. Both of them control E-cadherin expression at transcription level and subsequently hinder the overall E-cadherin protein level in the head and neck cancer cells. Increasing evidence suggested that microRNA mediated E-cadherin expression in the head and neck cancers by directly/indirectly targeting the transcription suppressors of E-cadherin, ZEB1 and ZEB2.

Head and neck squamous cell carcinoma lymphatic spread and survival: Relevance of vascular endothelial growth factor family for tumor evaluation

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is primarily a locoregional disease in which the cervical lymph nodes are the chief site of metastasis. The purpose of this study was to examine the relationship between lymphangiogenesis and clinicopathological aspects of HNSCC and its metastasis.

METHODS

Fifty-two patients with HNSCC and metastatic lymph nodes from 21 of these subjects were analyzed by immunohistochemistry.

RESULTS

The HNSCC samples were predominantly negative for vascular endothelial growth factor (VEGF)-C, VEGF-D, and vascular endothelial growth factor receptor (VEGFR)3. There was an association between the density of lymph vessels (measured by D2-40 staining) in the lymph nodes and advanced-stage tumors. There was no link between the expression of these proteins and survival rates.

CONCLUSION

Although lymphatic spread is a significant event in the progression of HNSCC, the expression of VEGF-C, VEGF-D, and VEGFR3 does not correlate with clinicopathological characteristics, suggesting that other signaling pathways mediate lymphangiogenesis in HNSCC.

Expression of E-cadherin and β-catenin in basaloid and conventional squamous cell carcinoma of the oral cavity: are potential prognostic markers?

Background

Basaloid squamous cell carcinoma presents with a preference for the head and neck region, and shows a distinct aggressive behavior, with frequent local recurrences, regional and distant metastasis. The alterations in the cadherin-catenin complex are fundamental requirements for the metastasis process, and this is the first study to evaluate the immunostaining of E-cadherin and β-catenin in oral basaloid squamous cell carcinoma.

Methods

Seventeen cases of this tumor located exclusively in the mouth were compared to 26 cases of poorly differentiated squamous cell carcinoma and 28 cases of well to moderately differentiated squamous cell carcinoma matched by stage and tumor site. The immunostaining of E-cadherin and β-catenin were evaluated in the three groups and compared to their clinicopathological features and prognosis.

Results

For groups poorly differentiated squamous cell carcinoma and basaloid squamous cell carcinoma, reduction or absence of E-cadherin staining was observed in more than 80.0% of carcinomas, and it was statistically significant compared to well to moderately differentiated squamous cell carcinoma (p = .019). A strong expression of β-catenin was observed in 26.9% and 20.8% of well to moderately differentiated squamous cell carcinoma and poorly differentiated squamous cell carcinoma, respectively, and in 41.2% of basaloid squamous cell carcinoma. The 5-year and 10-year overall and disease-free survival rates demonstrated no significant differences among all three groups.

Conclusions

The clinical and biological behavior of three groups of the oral cavity tumors evaluated are similar. E-cadherin and β-catenin immunostaining showed no prognostic value for basaloid and conventional squamous cell carcinomas.

Restoration of E-cadherin expression by selective Cox-2 inhibition and the clinical relevance of the epithelial-to-mesenchymal transition in head and neck squamous cell carcinoma

BACKGROUND

The epithelial-to-mesenchymal transition (EMT) accompanied by the downregulation of E-cadherin has been thought to promote metastasis. Cyclooxygenase-2 (Cox-2) is presumed to contribute to cancer progression through its multifaceted function, and recently its inverse relationship with E-cadherin was suggested. The aim of the present study was to investigate whether selective Cox-2 inhibitors restore the expression of E-cadherin in head and neck squamous cell carcinoma (HNSCC) cells, and to examine the possible correlations of the expression levels of EMT-related molecules with clinicopathological factors in HNSCC.

METHODS

We used quantitative real-time PCR to examine the effects of three selective Cox-2 inhibitors, i.e., celecoxib, NS-398, and SC-791 on the gene expressions of E-cadherin (CDH-1) and its transcriptional repressors (SIP1, Snail, Twist) in the human HNSCC cell lines HSC-2 and HSC-4. To evaluate the changes in E-cadherin expression on the cell surface, we used a flowcytometer and immunofluorescent staining in addition to Western blotting. We evaluated and statistically analyzed the clinicopathological factors and mRNA expressions of Cox-2, CDH-1 and its repressors in surgical specimens of 40 patients with tongue squamous cell carcinoma (TSCC).

RESULTS

The selective Cox-2 inhibitors upregulated the E-cadherin expression on the cell surface of the HNSCC cells through the downregulation of its transcriptional repressors. The extent of this effect depended on the baseline expression levels of both E-cadherin and Cox-2 in each cell line. A univariate analysis showed that higher Cox-2 mRNA expression (p = 0.037), lower CDH-1 mRNA expression (p = 0.020), and advanced T-classification (p = 0.036) were significantly correlated with lymph node metastasis in TSCC. A multivariate logistic regression revealed that lower CDH-1 mRNA expression was the independent risk factor affecting lymph node metastasis (p = 0.041).

CONCLUSIONS

These findings suggest that the appropriately selective administration of certain Cox-2 inhibitors may have an anti-metastatic effect through suppression of the EMT by restoring E-cadherin expression. In addition, the downregulation of CDH-1 resulting from the EMT may be closely involved in lymph node metastasis in TSCC.

Cyclin d1 gene expression in oral mucosa of tobacco chewers"-an immunohistochemical study

OBJECTIVE

The objective of the present study was to evaluate the expression of cyclin D1 in normal oral mucosa of both non tobacco habituated and tobacco habituated individuals histologically and also compare and correlate cyclin D1 expression with histopathologically confirmed cases of oral squamous cell carcinomas.

STUDY DESIGN

The present study involved 20 cases of tobacco habituated individuals with normal oral mucosal tissue and 20 histopathologically confirmed cases of squamous cells carcinomas. Twelve cases of non tobacco habituated individuals served as control group. Chi-square analysis was used to determine statistical significance.

RESULTS

Fifty percent of control cases, 70% of squamous cell carcinoma cases and 80% of tobacco habituated individuals of clinically normal mucosa showed cyclin D1 positivity. Thirteen cases with tobacco chewing habit, with clinically normal mucosa, showed dysplasia, out of which seven were mildly dysplastic and six were moderately dysplastic. A larger percentage of cyclin D1 expression was observed in lower grade dysplasias (53.8%) than higher grade dysplasias (46.1%). However statistical analysis showed no significant association between groups. Chi-square value was < 7.82 for p=0.05.

CONCLUSION

The finding of cyclin D1 expression in 80% of tobacco users with clinically normal mucosa indicates that the mutation of cyclin D1 occurs early, even before clinical changes are apparent. This finding appears to be previously unreported. The presence of dysplasia in the same group and cyclin D1 expression in 84.6% of dysplastic cases show that the patients are susceptible for further changes, including progression to higher grades of dysplasia and development of carcinoma. Relatively lower expression of cyclin D1 positivity (70%), in oral cancer patients, when compared with tobacco users with clinically normal mucosa (80%) is indicative of increased traverse of the cell through the cell cycle, which may occur early in tumor progression. Cyclin D1 immunoreactivity was detected in all the three study groups.

Cervical node metastasis in T1 squamous cell carcinoma of oral tongue- pattern and the predictive factors

BACKGROUND

The squamous cell carcinoma (SCC) of the oral tongue is a common cancer in India. Elective lymphadenectomy is generally performed in all patients with T2-T4 tumors. In this study we have tried to analyze the pattern and risk factors associated with lymph node metastasis in T1 tongue cancers.

METHODS

A retrospective review of the records of 57 patients undergoing surgery for treatment of T1 sqamous cell carcinoma of oral tongue was carried out. The clinicopatological features of the tumor, pattern of nodal metastasis and the risk factors associated with lymph node metastasis were studied.

RESULTS

Totally 57 patients with T1 tumor underwent excision of the primary and modified neck dissection (MND). Lymph node metastasis was found in 36.8 % of the patients. Level I to Level II was the commonest site of metastasis. Skip metastasis at level III and IV was found in 8.5 % of the patients and isolated skip metastasis at level IV in 1.5 % of the patients. The risk factors associated with the lymph node metastasis on univariete analysis were; higher grade, tumor size >1 cm and tumor thickness >3 mm. On multivariate analysis only the tumor thickness was found to be a risk factor for the lymph node metastasis (hazard ratio of 21.59).

CONCLUSIONS

T1 sqamous cell carcinoma of tongue is associated with a high incidence of lymph node metastasis. Elective neck dissection should be considered in all patients with tumors more than 3 mm in thickness.

Preoperative evaluation of oral tongue squamous cell carcinoma with intraoral ultrasound and magnetic resonance imaging-comparison with histopathological tumour thickness and accuracy in guiding patient management

The aim of this study was to investigate the correlation between tumour thickness (TT) on intraoral ultrasound (US) and magnetic resonance imaging (MRI) with the histologically determined TT of tongue cancers. Secondary objectives included evaluation of potential confounders that affect this association and the predictive value for simultaneous neck dissection. Eighty-eight consecutive patients referred to the study institution between January 2007 and August 2012 with the presumptive diagnosis of invasive squamous cell carcinoma (SCC) of the tongue were analyzed. Seventy-nine patients had preoperative US and 81 had MRI. Correlation between image-determined TT and histological TT was assessed by Bland-Altman plot and Pearson's correlation coefficient. Potential confounders were assessed by subgroup analysis. Preoperative TT as determined by US demonstrated high correlation and MRI moderate correlation with histological TT. With subgroup analysis, negative associations were biopsy prior to imaging and resection diagnosis other than invasive SCC. Our experience suggests that US could be considered the initial modality of choice for preoperative assessment of TT.

Expression of the cancer stem cell markers CD44v6 and ABCG2 in tongue cancer: effect of neoadjuvant chemotherapy on local recurrence

The efficacy of neoadjuvant chemotherapy (NAC) is controversial, and no report supports NAC with a high evidence level. Recently, we showed that a deep surgical margin was resected very close to the tumor site in many NAC-treated oral squamous cell carcinoma patients, suggesting that NAC may lead to local recurrence and poor outcomes. The purpose of this study was to evaluate the effect of NAC on tumor local recurrence using cancer stem cell marker immunohistochemistry. We retrospectively analyzed 89 patients who underwent radical surgery for tongue cancer, and examined the effect of NAC on tumor local recurrence. Cancer stem cell marker (CD44v6 and ABCG2) expression was detected by immunohistochemistry. In our study, the local recurrence rate was 12.4%. CD44v6 and ABCG2 expression was significantly associated with regional lymph node metastasis, pattern of invasion, depth of invasion, perineural invasion and local recurrence, respectively. Tumor local recurrence was a significant independent predictive factor of the 5-year disease specific survival. CD44v6 or ABCG2 positivity in NAC-treated patients was significantly associated with tumor local recurrence. It was suggested that local recurrence in NAC-treated cases is associated with cancer stem-like cells. We propose that NAC leads to the selection and/or residue of more aggressive cancer stem-like cells.

Lack of claudin-7 is a strong predictor of regional recurrence in oral and oropharyngeal squamous cell carcinoma

OBJECTIVES

Adequate treatment of oral and oropharyngeal squamous cell carcinoma (OSCC) is dependent on correctly predicting the presence of lymph node metastases. Current methods to diagnose nodal metastases partly result in overtreatment with associated morbidity and undertreatment with decreased disease-free survival. E-cadherin has been studied extensively as potential marker for lymph node metastases. EpCAM and claudin-7 have a functional relationship with E-cadherin, forming a complex that promotes tumourigenicity in vitro. We hypothesize that the co-expression patterns of these related molecules is a better prognostic marker for nodal status and regional recurrences.

MATERIALS AND METHODS

We constructed separate tissue microarrays of tumour centre and tumour invasive front of 227 OSCC with complete clinicopathological and follow-up data, including HPV status, and performed immunohistochemistry for these molecules.

RESULTS

Lack of E-cadherin and presence of cytoplasmic EpCAM expression in the tumour front were predictive for nodal metastasis, but no co-expression pattern was found clinically relevant. Lack of claudin-7 in the tumour centre was highly and independently predictive for shorter regional disease-free survival (HR=0.19; 95%CI: 0.06-0.62) and disease-specific survival (HR=0.43; 95%CI: 0.21-0.87). High-risk HPV was not associated with any marker.

CONCLUSIONS

The expression of E-cadherin and EpCAM, depending on the specific tumour sublocalization, is predictive for nodal status. However, co-expression did not improve the prediction of nodal status, indicating that the proposed in vitro complex is not functional in clinical samples. Additionally, lack of claudin-7 expression in the tumour centre may be used to identify patients with increased risk for regional recurrence.

Clinical significance of altered expression of β-catenin and E-cadherin in oral dysplasia and cancer: potential link with ALCAM expression

Background

Perturbations in cell adhesion molecules are linked to alterations in cadherin-catenin complexes and likely play major roles in invasion and metastasis; their impact on early precancerous stages remains yet unknown. We showed ALCAM overexpression in early oral lesions and its cytoplasmic accumulation in oral squamous cell carcinoma (OSCC) to be a predictor of disease progression and poor prognosis. This study tested the hypothesis that alterations in E-cadherin and β -catenin expressions are early events in oral tumorigenesis, associated with disease prognosis, and correlate with perturbations in ALCAM expression.

Methods

Expressions of E-cadherin and β-catenin were analyzed in the same cohort of 105 OSCCs, 76 oral lesions and 30 normal oral tissues by immunohistochemistry and correlated with clinicopathological parameters and prognosis. The effect of siRNA mediated ALCAM knockdown on E-cadherin and β -catenin was determined using western blot, confocal microscopy and RT-PCR analysis in oral cancer cells.

Results

Significant loss of membranous E-cadherin and β-catenin expression was observed from normal, hyperplasia, dysplasia to OSCCs (p_trend <0.001); and correlated with cytoplasmic ALCAM accumulation in OSCCs (p  = 0.006). Multivariate analysis revealed β-catenin membrane loss and ALCAM/β-catenin_{nuclear/cytoplasmic} accumulation to be significant predictors for late clinical stage (p<0.001, OR = 8.7; p = 0.006, OR = 9.9, respectively) and nodal metastasis (p = 0.003, OR = 3.8; p = 0.025, OR = 3.4 respectively). Cox’s regression showed E-cadherin membrane loss/ALCAM cytoplasmic expression [p<0.001; HR = 4.8] to be independent adverse prognosticators in OSCCs. siRNA mediated silencing of ALCAM resulted in concurrent increase in E-cadherin and β-catenin both at the transcript and protein levels.

Conclusions

Losses of E-cadherin and β-catenin expressions are early events in oral tumorigenesis; their associations with aggressive tumor behavior and disease recurrence underscore their potential as prognostic markers. Correlation of loss of E-cadherin and β-catenin with cytoplasmic ALCAM accumulation both in vitro and in in vivo suggests that these dynamic changes in cell adhesion system may play pivotal role in oral cancer.

Predictors of locoregional recurrence in T1-2N0 tongue cancer patients

Locoregional recurrence of oral tongue squamous cell carcinoma (OTSCC) has been considered a poor prognostic entity in terms of survival rate. The purpose of this study was to evaluate the incidence of locoregional recurrence and to identify significant risk factors for locoregional recurrence in early-stage OTSCC. We retrospectively reviewed the records of 58 patients who underwent radical surgery for T1-2N0 OTSCC. The local recurrence and regional recurrence rates were 10.3 % (6/58 patients) and 15.5 % (9/58 patients) in this study, respectively. The survival rate of patients with local recurrence was 66.7 %, which was significantly lower than that (96.2 %) of patients without local recurrence, whereas the survival rates of patients with or without regional recurrence were not significantly difference. Pattern of invasion (POI), neoadjuvant chemotherapy (NAC) and the status of the surgical margin were identified as factors influencing local recurrence. In particular, the status of the deep surgical margin was a high potential independent risk factor. The deep surgical margin was resected closely in many NAC-treated cases, suggesting that NAC may lead to local recurrence and a poor outcome. No efficacy of NAC was observed, suggesting that the standard treatment for early OTSCC is surgery alone.

Podoplanin and E-cadherin Expression in Preoperative Incisional Biopsies of Oral Squamous Cell Carcinoma Is Related to Lymph Node Metastases

Metastases to cervical lymph nodes (LNs) are an important independent adverse indicator in the prognosis of oral squamous cell carcinoma (OSCC). An accurate evaluation of molecular patterns favoring the metastatic process can be helpful in predicting cases of OSCC with elevated probability of early or late metastases and, moreover, in planning the proper therapeutic procedures before surgery. To this end, immunohistochemical expressions of both E-cadherin and podoplanin were evaluated on preoperative incisional biopsies of OSCC from 102 patients. The probability to have or develop metastases was very low when high E-cadherin expression was found in a preoperative sample or when a low podoplanin expression was found. Therefore, because of the strong association with LN metastases, high E-cadherin/low podoplanin immunohistochemical expression should also be assessed on preoperative incisional biopsies as a useful tool for evaluating the probability of early or late LN metastases of OSCCs.