Histopathologic, stereologic, epidemiologic, and clinical parameters in the prognostic evaluation of squamous cell carcinoma of the oral cavity

P-Cadherin and WNT5A expression in assessment of lymph node metastasis in oral squamous cell carcinoma

BACKGROUND

Oral cancer progression is a multi-step process in which adhesion molecules play a pivotal role in the development of recurrent, invasive, and distant metastasis. The aim of this study was to adopt prognostic biomarkers to assess the lymph node metastasis of OSCC that will facilitate in deciding the treatment modality by the surgeons.

OBJECTIVES

The objectives of the study were to assess the biological behaviour of OSCC by correlating the expression levels of P-Cadherin and WNT5A immunohistochemically.

METHODS

A total of 60 selected OSCCs cases (lymph node metastasis n = 30, non-metastatic n = 30) and 10 normal healthy controls were quantitatively and qualitatively analysed by immunohistochemistry for P-Cadherin and WNT5A. A survival analysis was also performed.

RESULTS

The expression levels of P-Cadherin and WNT5A in OSCC groups were statistically significant between metastatic and non-metastatic groups (p < 0.001). P-Cadherin and WNT5A expression in metastatic (lymph node metastasis) and non-metastatic cases showed a significant correlation coefficient of 0.753 at (p < 0.01). The present study also found that the aberrant expression (high) of P-Cadherin was associated with diminished survival of patients with metastatic OSCC.

CONCLUSION

The present study demonstrated the aberrant expression of P-Cadherin and WNT5A could serve as important prognosticator in OSCC.

CLINICAL RELEVANCE

P-Cadherin and WNT5A could be used as significant predictors of disease outcome.

Prognostic Significance of Tumor-Associated Macrophage Content in Head and Neck Squamous Cell Carcinoma: A Meta-Analysis

Background: Head and neck squamous cell carcinoma (HNSCC) exists within a microenvironment rich in immune cells. Macrophages are particularly abundant in and around tumor tissue, and have been implicated in the growth, malignancy, and persistence of HNSCC (1). However, current literature reports variable degrees of association between the density of tumor-associated macrophages (TAMs) and clinicopathologic markers of disease (2, 3). These inconsistent findings may be a result of differences in approach to TAM detection. Authors have measured total TAMs in tumor tissue, while others have stained tumor samples for individual subtypes of TAMs, which include pro-inflammatory (M1-like) and immunosuppressive (M2-like). Our aim is to more clearly define the prognostic significance of the phenotypes of tumor-associated macrophages in HNSCC. Methods: We conducted a meta-analysis of the existing publications investigating the relationship between TAMs (total and M2-like subtype) and T stage, nodal involvement, vascular invasion, lymphatic invasion, and tumor differentiation (Figure 1). A total of 12 studies were included. Forest plots and risk ratios were generated to report overall effect. Results: Higher density of both total and M2-like subtype of TAMs in the tumor microenvironment is associated with advanced T stage, increased rates of nodal positivity, presence of vascular invasion, and presence of lymphatic invasion (p < 0.0001; Figures 2-9). There is no significant association between TAM density, either total or M2-like subtype, and tumor differentiation (Figures 10, 11). Conclusions: Increased density of TAMs, including those of the M2-like phenotype, correlate with poor clinicopathologic markers in HNSCC. Our findings warrant additional investigation into the subpopulations of TAMs, the mechanisms behind their recruitment and differentiation, and the associated influence of each phenotype on tumor growth and invasion. A greater understanding of TAM dynamics in HNSCC is critical for directing further research and employing TAM-targeted adjunct therapies.

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.

Oral and oropharyngeal squamous cell carcinoma in young adults: A retrospective study in Granada University Hospital

Background

This study aims to evaluate and analyze the clinical features and outcomes of oral and oropharyngeal squamous cell carcinoma (SCC) in patients < 45-years old in our center.

Material and Methods

A retrospective analysis was conducted using the records of patients diagnosed with oral and oropharyngeal SCC between 1998 and 2011 in the University Hospital of Granada (Spain). The analysis identified 33 patients with oral and oropharyngeal SCC with an age of <45 years. Moreover, during the years studied, a further 472 patients were diagnosed with oral and oropharyngeal SCC in our center. Thus, 100 SCC patients with an age of >45 years were randomly selected from the same database. A retrospective analysis was conducted to determine specific features including sites of occurrence, risk factors, sex distribution, socio-economic status, T stage at diagnosis, nodal involvement, degree of tumor differentiation, locoregional failure and overall survival at 5 years was. Further, the results of both groups were compared.

Results

The male-female ratio was 1.2:1 in the group of young adults and 2.03:1 in the group of patients with an age of >45 years. No significant differences were found in terms of site, nodal involvement, locoregional failure, and overall survival. However, there were statistically significant differences between the two groups in terms of features such as risk factors, socio-economic status, T stage at diagnosis, and degree of tumor differentiation. The overall 5-year survival rate was 62% for patients >45 years old, whilst for the group of young adults this rate was 48.4% (p= 0.17).

Conclusions

The poor association between the common risk factors and oral and oropharyngeal cancers in young adults suggests that other pathogenic mechanisms should be investigated. For young patients, the data show evidence of poorer outcomes in terms of overall survival (p=0.17), and locoregional failure (p=0.23). Nevertheless, the literature shows that the results in this field are particularly inconsistent, and further research is therefore needed to provide more in-depth knowledge of the disease in this age group.

Key words:Oral and oropharyngeal squamous cell carcinoma, young adults, poor prognosis,risk factors.

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.

Lewisy promotes migration of oral cancer cells by glycosylation of epidermal growth factor receptor

Aberrant glycosylation changes normal cellular functions and represents a specific hallmark of cancer. Lewis^y (Le^y) carbohydrate upregulation has been reported in a variety of cancers, including oral squamous cell carcinoma (OSCC). A high level of Le^y expression is related to poor prognosis of patients with oral cancer. However, it is unclear how Le^y mediates oral cancer progression. In this study, the role of Le^y in OSCC was explored. Our data showed that Le^y was upregulated in HSC-3 and OC-2 OSCC cell lines. Particularly, glycosylation of epidermal growth factor receptor (EGFR) with Le^y was found in OC-2 cells, and this modification was absent upon inhibition of Le^y synthesis. The absence of Le^y glycosylation of EGFR weakened phosphorylation of AKT and ERK in response to epidermal growth factor (EGF). Additionally, EGF-triggered cell migration was reduced, but cell proliferation was not affected. Le^y modification stabilized EGFR upon ligand activation. Conversely, absence of Le^y glycosylation accelerated EGFR degradation. In summary, these results indicate that increased expression of Le^y in OSCC cells is able to promote cell migration by modifying EGFR which in turn stabilizes EGFR expression and downstream signaling. Targeting Le^y on EGFR could have a potential therapeutic effect on oral cancer.

Beta-catenin and epithelial tumors: a study based on 374 oropharyngeal cancers

Introduction. Although altered regulation of the Wnt pathway via beta-catenin is a frequent event in several human cancers, its potential implications in oral/oropharyngeal squamous cell carcinomas (OSCC/OPSCC) are largely unexplored. Work purpose was to define association between beta-catenin expression and clinical-pathological parameters in 374 OSCCs/OP-SCCs by immunohistochemistry (IHC). Materials and Methods. Association between IHC detected patterns of protein expression and clinical-pathological parameters was assessed by statistical analysis and survival rates by Kaplan-Meier curves. Beta-catenin expression was also investigated in OSCC cell lines by Real-Time PCR. An additional analysis of the DNA content was performed on 22 representative OSCCs/OPSCCs by DNA-image-cytometric analysis. Results and Discussion. All carcinomas exhibited significant alterations of beta-catenin expression (P < 0.05). Beta-catenin protein was mainly detected in the cytoplasm of cancerous cells and only focal nuclear positivity was observed. Higher cytoplasmic expression correlated significantly with poor histological differentiation, advanced stage, and worst patient outcome (P < 0.05). By Real-Time PCR significant increase of beta-catenin mRNA was detected in OSCC cell lines and in 45% of surgical specimens. DNA ploidy study demonstrated high levels of aneuploidy in beta-catenin overexpressing carcinomas. Conclusions. This is the largest study reporting significant association between beta-catenin expression and clinical-pathological factors in patients with OSCCs/OPSCCs.

Clinical significance of preoperative squamous cell carcinoma antigen in oral-cavity squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

Previous studies have demonstrated a relationship between elevated serum squamous cell carcinoma (SCC) antigen (SCC-Ag) levels and shorter survival in cancer patients. Few studies, however, have investigated the role of serum SCC-Ag levels in oral SCC (OSCC). This study was conducted to analyze the relationship between preoperative SCC-Ag levels, clinicopathologic factors, and prognosis in OSCC patients.

STUDY DESIGN

Retrospective case-control study.

METHODS

Seventy-nine OSCC patients from Chang Gung Memorial Hospital were retrospectively recruited between April 2008 and March 2010. Serum SCC-Ag levels were measured preoperatively.

RESULTS

An SCC-Ag level of ≥2.0 ng/mL was significantly associated with the pathologic tumor status (P < .001), pathologic nodal status (P = .037), lymph node extracapsular spread (P = .016), and tumor depth (>10 mm vs. ≤10 mm, P < .001). It was not significantly associated with histologic differentiation (P = 1.000). A univariate analysis revealed that positivity for SCC-Ag was associated with disease-free survival (DFS) (P = .034) and overall survival (OS) (P < .001). In SCC-Ag-positive patients, the distant metastatic rate was higher than in the SCC-Ag-negative patients (P = .053).

CONCLUSIONS

This study demonstrated that preoperative SCC-Ag is a good marker of pathologic lymph node metastasis, an advanced tumor stage, and a higher rate of distant metastasis. The preoperative SCC-Ag level is a potential prognostic indicator in DFS and OS, but studies with a longer follow-up period are needed to confirm these results.

A population-based study of factors associated with early versus late stage oral cavity cancer diagnoses

Oral cavity cancers can be detected early yet many are diagnosed with advanced disease. We assessed risk factors for advanced stage disease in a population-based study. Study population was all Ontario patients with anterior tongue or floor of mouth cancers diagnosed between 1991 and 2000 (n=2033). Data are from a retrospective chart review. Risk factors included: demographic characteristics, co-morbidity, precancerous lesions, dental status, smoking, alcohol use, and social marginalization. Multivariate regression analyses assessed independent associations while controlling for disease grade and site. Forty percent had advanced disease. Eighty-nine percent presented with symptoms and 66% were referred by a family physician. Risk factors in the tongue group were being: age ≥80 (RR 1.47), widowed (RR 1.34), social marginalized (RR 1.69), a current smoker (RR 1.26), or a smoker-heavy drinker (RR 1.73). Risk factors in the floor of mouth group were being: age ≥70 (70-79: RR 1.24 and ≥80: RR 1.43), and socially marginalized (RR 1.22). Having a pre-cancerous lesion (RR 0.44) or a regular dentist (RR 0.84) was protective in the floor of mouth group. Risk factors for those with co-morbid illnesses were being: age ≥70 (70-79: RR 1.28 and ≥80: RR 1.55), separated/divorced (RR 1.26), socially marginalized (RR 1.37), or a smoker-heavy drinker (RR 1.44); while having a regular dentist was protective (RR 0.83). Targeted education to alert those at risk about oral cancer warning signs and better training coupled with opportunistic oral cavity exams by family physicians could reduce the burden of this disease.

N-(4-hydroxyphenyl)all-trans-retinamide (4-HPR) high dose effect on DMBA-induced hamster oral cancer: a histomorphometric evaluation

N-(4-hydroxyphenyl)all-trans-retinamide (4-HPR) has shown cancer chemoprevention activity in many experimental and clinical situations. The purpose of this research is to evaluate the in vivo efficacy of 4-HPR in preventing 7,12-dimethylbenz(alpha)antracene (DMBA)-induced oral carcinogenesis and to study histomorphometric changes. 76 Syrian hamsters were separated into four groups: group 1, untreated controls (16 animals); group 2, 4-HPR controls (16 animals); group 3, DMBA-treated animals (28); group 4, animals treated with DMBA and 4-HPR (16). Hamsters were painted with a 0.5% solution of DMBA three times a week in their left buccal pouch. A diet of 2 mmol of 4-HPR/kg was administered. At week 9, 50% of the animals were killed; the remainder were killed at week 12. Pathology and histomorphometric tests were performed on epithelium, dysplasia and carcinomas. At week 9, 5 carcinomas were found in group 3, and 13 in group 4. Cancers in group 4 were more numerous, endophytic and infiltrating than those in group 3 animals. At week 12, 16 carcinomas were detected in group 3 animals, but group 4 developed more carcinomas per animal than group 3. Using these experimental concentrations, 4-HPR cannot express its best chemopreventive effect.

Advances in the biology of oral cancer

The incidence of oral cancer remains high and is associated with many deaths in both Western and Asian countries. Several risk factors for the development of oral cancer are now well known, including smoking, drinking and consumption of smokeless tobacco products. Genetic predisposition to oral cancer has been found in certain cases but its components are not yet entirely clear. In accordance with the multi-step theory of carcinogenesis, the natural history of oral cancer seems to gradually evolve through transitional precursor lesions from normal epithelium to a full-blown metastatic phenotype. A number of genomic lesions accompany this transformation and a wealth of related results has appeared in recent literature and is being summarized here. Furthermore, several key genes have been implicated, especially well-known tumor suppressors like the cyclin-dependent kinase inhibitors, TP53 and RB1 and oncogenes like the cyclin family, EGFR and ras. Viral infections, particularly with oncogenic HPV subtypes and EBV, can have a tumorigenic effect on oral epithelia and their role is discussed, along with potential therapeutic interventions. A brief explanatory theoretical model of oral carcinogenesis is provided and potential avenues for further research are highlighted.

Importance of tumor thickness and depth of invasion in nodal involvement and prognosis of oral squamous cell carcinoma: a review of the literature

BACKGROUND

Oral mucosa squamous cell carcinoma (OSCC) has locoregional evolution, with frequent neck involvement (the most important parameter for prognosis). There are still many doubts concerning the best way to approach N0 neck disease in early-stage lesions (T1 and T2). Many parameters have been studied to identify N0 patients with a high likelihood of harboring occult node metastases or of having them develop.

METHODS

A review of the studies analyzing "tumor thickness"/"depth of invasion" in predicting regional metastases and survival was undertaken.

RESULTS

The literature suggests that "tumor thickness"/"depth of invasion" is a reliable parameter for predicting regional nodal involvement and survival in OSCC.

CONCLUSIONS

Authors are in substantial agreement regarding the reliability of tumor thickness. The lack of comparable study groups, measurement techniques, and cut-off values points to the need for further studies so as to reach a consensus and to develop therapy protocols that include tumor thickness.

Correlation between TNM classification and malignancy histological feature of oral squamous cell carcinoma

Histological staging of deep invasive margin of oral squamous cell carcinoma has a significant influence on survival of patients since the tumor cells are more poorly differentiated in this area and have high prognostic value.

Aim

the purpose of the present study is to correlate TNM clinical classification with histopathologic characteristics (degree of keratinization, nuclear pleomorphism, invasion pattern and lymphoplasmocytic infiltrate) and histologic malignancy scores in 38 cases of oral epidermoid carcinoma in the lesion's deepest areas.

Study Form

Retrospective clinical study.

Material and Method

This is a retrospective study based on histological review of 38 cases of oral squamous cell carcinoma selected from the medical files of Hospital Dr. Luis Antonio, Natal - Rio Grande do Norte, Brazil. TNM clinical classification data were obtained from the analysis of the medical records. Two pathologists performed histological malignancy staging on routine 3 µm-thick sections of invasive tumor areas stained with hematoxylin and eosin. For statistical analysis, parametric (ANOVA) and non-parametric tests (Tukey; Pearson; Chi²) were employed.

Results

We found significant correlation between TNM clinical staging and malignancy mean score (p = 0.001) and histopathologic parameters, such as nuclear pleomorphism (p = 0.016) and degree of keratinization (p = 0.025). Furthermore, there were also statistically significant correlations between lymphocytic infiltration (p = 0.016) and nuclear pleomorphism (p = 0.004) with TNM classification when grouped in two series: TNM I/II and III/IV.

Conclusion

TNM classification, as well as malignancy mean score, had statistically significant correlation with degree of keratinization, nuclear pleomorphism and lymphocytic infiltration. These highly significant results indicated that histologically invasive areas may be primarily responsible for the clinical behavior of the tumor, and this may be important for the therapy of choice for oral squamous cell carcinoma.

Correlação entre a classificação clínica TNM e as características histológicas de malignidade do carcinoma epidermóide oral

A gradação histológica das margens mais profundas do carcinoma epidermóide oral influencia diretamente na sobrevida do paciente, já que células neoplásicas nesse local mostram-se indiferenciadas e de grande valor prognóstico. OBJETIVO: A proposta desse estudo é correlacionar a classificação clínica TNM com as características histopatológicas (grau de queratinização, pleomorfismo nuclear, padrão de invasão e infiltrado linfoplasmocitário) e os escores histológicos de malignidade de 38 casos de carcinoma epidermóide oral nas áreas mais profundas da lesão. FORMA DE ESTUDO: Estudo clínico retrospectivo. MATERIAL E MÉTODO: O estudo foi baseado em uma revisão retrospectiva incluindo a observação histológica de 38 casos de carcinoma epidermóide oral dos arquivos do Hospital Dr. Luis Antônio, Natal-RN, Brasil. Com a análise dos prontuários médicos, foram obtidos os dados referentes à classificação clínica TNM. A gradação histológica de malignidade foi realizada na área invasiva do tumor por dois patologistas em secções histológicas de 3 µm de espessura coradas pela hematoxilina e eosina. Para as análises estatísticas foram aplicados os testes paramétricos (ANOVA) e não-paramétricos (Tukey; Pearson; Qui²). RESULTADOS: Foi encontrada correlação estatisticamente significante do estadiamento clínico TNM com os escores histológicos de malignidade (p= 0,001) e com os parâmetros histológicos isolados tais como: pleomorfismo nuclear (p= 0,016) e grau de queratinização (p= 0,025). Além disso, houve também uma correlação estatisticamente significante entre infiltrado linfoplasmocitário (p= 0,016) e pleomorfismo nuclear (p= 0,004) com a classificação clínica TNM quando agrupada em duas séries: TNM-I/II e III/IV. CONCLUSÕES: A classificação clínica TNM teve uma correlação estatisticamente significante com grau de queratinização, pleomorfismo nuclear e infiltrado linfoplasmocitário, assim como com os escores médios de malignidade. Esses resultados altamente significantes indicam que as áreas invasivas podem ser primariamente responsáveis pelo comportamento clinico do tumor e isso pode ser imprescindível para a escolha da terapia para o carcinoma epidermóide oral.

Prognostic significance of late cervical metastasis and distant failure in patients with stage I and II oral tongue cancers

Stage I and II oral tongue cancers (OTC) generally have a favorable prognosis, but there are some early OTC cases with a poor prognosis. OTC is known for its propensity for subclinical nodal metastasis and, moreover, we must devise a strategy that takes account of the possibility of recurrence and distant metastasis. In the current study, 90 previously untreated patients with stage I or II OTC who underwent surgical treatment were eligible for review. The authors investigated the associations of their clinico-pathologic factors with disease outcomes, and also examined the postoperative course for patients with a poor prognosis. The most common cause of death was distant metastasis and late cervical lymph node metastasis (LCM) was the significantly independent prognostic variable. Since LCM can be treated with salvage surgery, the central issue is to control patients with distant metastises who are free of disease in their loco-regional sites.

P-cadherin expression reduced in squamous cell carcinoma of the oral cavity

BACKGROUND

The loss of cadherin expression has been shown to correlate to the invasion and metastasis of many types of carcinomas. The purpose of the current study was to evaluate whether the impaired expression of E-cadherin (E-cad) and P-cadherin (P-cad) correlated with the clinical evolution and prognosis of oral squamous cell carcinoma (OSCC).

METHODS

The authors used immunohistochemical methods to analyze the expression pattern of E-cad and P-cad in healthy oral mucosa, in oral carcinoma in situ (CIS), and in surgical samples of 50 patients with the early stages (Stages I-II) of OSCC.

RESULTS

E-cad showed weak expression in the basal layer of the healthy oral mucosa and reduced expression in patients with oral CIS. P-cad expression was conserved on the basal and suprabasal layers of the healthy mucosa and, also, in the CIS. In the group of patients with OSCC, univariate analysis demonstrated that reduced expression of E-cad or P-cad correlated significantly with locoregional disease recurrence in the follow-up (P=0.03 and P=0.01, respectively). However, only the reduction in the expression of P-cad emerged as an independent prognostic marker in the multivariate analysis (P=0.04, hazard ratio =8.06).

CONCLUSIONS

These findings suggested that a decrease in E-cad and/or P-cad expression may contribute to the invasive potential of early OSCC. According to the current data, P-cad expression may be a potential independent prognostic factor in patients with OSCC.

Matched-Pair Analysis of Survival of Never Smokers and Ever Smokers With Squamous Cell Carcinoma of the Head and Neck

Purpose

To compare survival rates between patients with squamous cell carcinoma of the head and neck (SCCHN) without a history of smoking (never smokers) and those with a current or previous history of smoking (ever smokers).

Patients and Methods

Fifty never smokers with newly diagnosed SCCHN were matched to 50 ever smokers according to sex, age, tumor site, overall stage, nodal stage, and treatment. Survival analysis was performed using Kaplan-Meier estimates. Matched-pair survival was compared using the Cox proportional hazards model.

Results

The never smokers had a greater overall survival (P = .020), disease-specific survival (P = .022), and recurrence-free survival (P = .016). Furthermore, matched-pair analysis demonstrated smoking was associated with a significant increase in risk of overall death (relative risk [RR] = 3.50; 95% CI, 1.14 to 10.77; P = .029), risk of death owing to disease (RR = 3.98; 95% CI, 1.11 to 14.33; P = .034), and risk of disease recurrence (RR = 3.29; 95% CI, 1.18 to 9.14; P = .023). Smoking was associated with three-fold increases in risk for overall death, death owing to disease, and recurrence after adjustment for cancer-associated symptom severity and alcohol use, but the 95% CI for these adjusted risk estimates each included the null.

Conclusion

Survival differed significantly between never smokers and ever smokers with SCCHN. These results are not substantively explained by differences in cancer-associated symptoms or alcohol use, but the CIs are wide and some imprecision remains. Regardless, possible fundamental differences in SCCHN between ever smokers and never smokers may exist, and further molecular characterization of these tumors is needed to determine whether biologic differences needing targeted therapies exist.

Prognostic significance of intratumoral lymphangiogenesis in squamous cell carcinoma of the oral cavity

BACKGROUND

Clinicopathologic data demonstrated that the lymphatic system is the main route for solid tumor metastasis. However, the effect of intratumoral lymphangiogenesis (IL) on prognosis in oral carcinoma is still unknown because, until recently, no reliable markers for lymphatic endothelium were available. The current study analyzed the lymphatic vessels in tumor tissue specimens of patients with primary oral carcinoma using the new marker, PA2.26.

METHODS

The authors investigated IL in surgical tissue samples of 61 patients with early-stage (Stages I-II) oral carcinoma. The tissue specimens were stained for PA2.26 and the correlation between IL and relevant parameters was analyzed by the Pearson chi-square test. In a univariate analysis using the Kaplan-Meier method, IL was analyzed against survival and disease-free period. Statistical significance of differences between distributions was studied by the log-rank test. Clinicopathologic parameters, including IL, were entered in a multivariate analysis to determine independent prognostic significance.

RESULTS

Thirty-three patients had IL. In the follow-up, a strong association was found between IL and locoregional recurrence (30.3 % of the patients with IL and 7.1% of the patients without IL). The presence of IL did not correlate significantly with the pT classification, primary location, or tumor differentiation. IL was found to have no influence on overall survival in univariate analysis, but there was significant association between IL and disease-free survival (P=0.03). Multivariate analysis revealed IL to be the sole independent factor influencing disease-free interval (P=0.02).

CONCLUSIONS

These results suggested that IL is associated with locoregional disease recurrence in early-stage oral carcinoma. The presence of IL was a useful discriminator in predicting the outcome of patients with absence of lymph node metastasis.

Is detection of oral and oropharyngeal squamous cancer by a dental health care provider associated with a lower stage at diagnosis?

PURPOSE

Stage at diagnosis is the most important prognostic indictor for oral and oropharyngeal squamous cell cancers (SCCs). Unfortunately, approximately 50% of these cancers are identified late (stage III or IV). We set out to examinationine the detection patterns of oral and oropharyngeal SCCs and to determine whether detection of these cancers by various health care providers was associated with a lower stage.

PATIENTS AND METHODS

Data were gathered on 51 patients with newly diagnosed oral or oropharyngeal SCC through patient interview and chart audit. In addition to demographic data, specific inquiry was made regarding the circumstances surrounding the identification of the lesion. The main outcome measure was tumor stage grouping based on detection source.

RESULTS

Health care providers detecting oral and oropharyngeal SCCs during non-symptom-driven (screening) examinations were dentists, hygienists, oral and maxillofacial surgeons, and, in 1 case, a denturist. All lesions detected by physicians occurred during a symptom-driven examination. Lesions detected during a non-symptom-driven examination were of a statistically significant lower average clinical and pathologic stage (1.7 and 1.6, respectively) than lesions detected during a symptom-directed examination (2.6 and 2.5, respectively). Additionally, a dental office is the most likely source of detection of a lesion during a screening examination (Fisher exact test, P =.0006). Overall, patients referred from a dental office were of significantly lower stage than those referred from a medical office. Finally, patients who initially saw a regional specialist (dentist, oral and maxillofacial surgeon, or otolaryngologist) with symptoms related to their lesion were more likely to have appropriate treatment initiated than those who initially sought care from their primary care provider.

CONCLUSION

Overall, detection of oral and oropharyngeal SCCs during a non-symptom-driven examination is associated with a lower stage at diagnosis, and this is most likely to occur in a dental office. A regional specialist was more likely than a primary care provider to detect an oral or oropharyngeal SCC and initiate the appropriate treatment during the first visit for symptoms related to the lesion.

Expression of p53R2, newly p53 target in oral normal epithelium, epithelial dysplasia and squamous cell carcinoma

Recently, the p53R2 gene has been isolated and shown to play a crucial role in DNA repair after DNA damage. The p53R2 gene encodes the p53 inducible ribonucleotide reductase small subunit 2 homologue, which is part of the p53 pathway. However, the function of p53R2 in human cancer is still unclear. We investigated p53R2 mRNA expression in human oral normal epithelium, epithelial dysplasias and squamous cell carcinomas (SCCs). Surgical or biopsy-proven specimens of 10 normal epithelium, 48 epithelial dysplasias and 63 SCCs were collected in our department. Then, p53R2 was identified by in situ hybridization to visualize and localize the expression of specific mRNAs. The authors examined the p53 gene mutation by polymerase chain reaction-single strand conformation polymorphism analysis. p53, mdm2, p21(WAF1/CIP1) and Ki-67 expression was detected by immunohistochemistry. p53R2 expression was detected in none of ten normal epithelium (0%), ten of 48 dysplasias (20.8%) and 33 of 63 SCCs (52.4%). In oral SCC, the expression of p53R2 was significantly associated with tumor size, lymph node metastasis and histological differentiation (P=0.014, 0.046 and 0.022, respectively). p53R2 expression was significantly associated with p53 abnormality in epithelial dysplasia and SCC (P=0.034 and 0.009, respectively). Of 63 patients, 37 received preoperative radiochemotherapy. p53R2 mRNA expression was significantly associated with the pathologic response to radiochemotherapy (P=0.031). This study suggested that p53R2 expression could be associated with oral carcinogenesis. The presence of p53R2 mRNA expression would be a predictive factor for tumor development, tumor cell differentiation and the sensitivity to radiochemotherapy in oral SCC.

Oral cancer treatment

Oral cancer is the sixth most common cancer in the world, and it continues to represent a serious public health problem. Oral cancer is a preventable disease, related to behavioral and lifestyle factors, including tobacco and alcohol. Prevention and early detection of oral cancer remain the goals of national efforts to reduce the impact of this disease on the public. Surgical treatment is the mainstay of therapy for patients with oral cancer, particularly in advanced stages of cancer. External beam radiation therapy and brachytherapy have been used successfully as the primary modality for treating patients with early stage oral cancer, and they are the standard of care for use as adjuvant therapy in postoperative cases of patients with advanced stage oral cancer. There is an emerging trend for the use of chemotherapy in combination with radiation therapy and surgery for patients with advanced, recurrent, and metastatic head and neck cancer, although evidence is limited regarding survival benefit when used for treating patients with oral cavity carcinoma. Any report on the treatment of oral cancer is incomplete without consideration of functional and aesthetic outcomes, particularly addressing speech, swallowing, masticatory efficiency, and dental rehabilitation. Future generations will continue to fight these dreadful diseases until scientists and clinicians are provided the opportunities to expand efforts to prevent, detect (early), and eradicate oral and other head and neck cancers.

The expression of p53, c-erbB-1 and c-erbB-2 molecules and their correlation with prognostic markers in patients with head and neck tumors

Molecular prognostic and predictive factors have extensively been studied in different cancers during the past decades, some of which were found to be useful in diagnosis, follow up or even treatment of some malignant tumors. To assess the significance of c-erbB-1, c-erbB-2 and p53 expression in head and neck tumors among Iranian patients and their correlation with known prognostic factors, samples from 53 patients with squamous cell carcinomas of larynx and tongue were studied immunohistochemically. Strong immunoreactivity of c-erbB-1, c-erbB-2 and p53 was observed in 37 (70%), 40 (76%) and 37 (70%) of cases, respectively. The coexpression of these molecules was detected in 27 (50.9%) samples. Neither histological grading nor nodal involvement revealed correlation with c-erbB-1 and/or c-erbB-2 expression. No correlation was found between p53 expression and histological grade. However, a significant positive association was observed between p53 expression and nodal involvement. This data, which is the first report on head and neck squamous cell carcinomas (HNSCC) in Iran, indicates the significance of p53 protein expression which may result from p53 tumor suppressor gene inactivation in lymph node metastasis of HNSCC among Iranian patients.

Risk factors for late cervical lymph node metastases in patients with stage I or II carcinoma of the tongue

BACKGROUND

Many histopathologic parameters in squamous cell carcinoma of the tongue have been identified as predictive factors for cervical lymph metastasis. However, predictive factors for occult cervical lymph node metastases and the criterion for elective therapy remain inconclusive. This study analyzed the clinicopathologic factors associated with late cervical lymph node metastases in patients with carcinoma of the tongue.

METHODS

The clinicopathologic features of 50 consecutive patients seen between January 1985-December 1996 with previously untreated stage I or II squamous cell carcinoma of the tongue were reviewed. All patients were treated with partial glossectomy without elective neck dissection. Their mean age was 54.5 y (range, 23-90 y) and the male-female ratio was 1.2:1 (27 men and 23 women); 30 cases were stage I, and 20 cases were stage II. Clinicopathologic factors were analyzed to determine factors predicting late cervical lymph node metastasis.

RESULTS

The overall cervical lymph node metastasis rate was 14.0% (7 of 50). Clinicopathologic factors significantly associated with the development of cervical lymph node metastasis were tumor size (> or =30 mm), tumor depth (> or =4 mm), differentiation, mode of invasion, microvascular invasion, and histologic grade of malignancy. In a multivariate logistic regression analysis, moderately differentiated squamous cell carcinoma of the tongue with tumor depth > or =4 mm had predictive value for late cervical lymph node metastasis and diminished overall survival (odds ratio, 10.0; p =.02; hazards ratio, 7.0; p =.039).

CONCLUSIONS

The findings of this study demonstrate tumor depth > or =4 mm moderately differentiated squamous cell carcinoma of the tongue have a substantially higher rate of late cervical metastases. In the basis of these data, it is our recommendation that this be used in the decision to electively treat the neck.

Histopathologic parameters in the evaluation of T1 squamous cell carcinomas of the oral cavity

BACKGROUND

Prognostic indicators that could assist in a more precise selection of patients with small oral carcinomas for differentiated therapy would be valuable. A significant fraction of patients with stage I disease have a relatively poor prognosis despite the small size of the tumor, but in general stage I tumors of the oral cavity have a favorable prognosis.

METHODS

Seventy-eight patients with stage I (T1N0M0) oral squamous cell carcinoma from two different ENT departments were included in the study. The pretreatment biopsy specimens were graded according to the modified classification of Jakobsson et al. Eight individual parameters were recorded, four parameters describing the tumor cell population and four parameters describing the tumor/host interaction.

RESULTS

The only significant prognostic parameter for disease-specific survival was "mode of invasion." The histologic mean score was not significantly correlated to disease-specific or crude survival.

CONCLUSIONS

Mode of invasion is the most important histologic parameter when evaluating the prognosis. Histologic evaluation of small squamous cell carcinomas of the oral cavity may assist the design of a differentiated treatment strategy (eg, monotherapy vs combined treatment).

Prognostic factors in tongue cancer - relative importance of demographic, clinical and histopathological factors

The incidence of and mortality from squamous cell carcinoma (SCC) of the tongue have increased during the recent decades in the Western world. Much effort has been made to predict tumour behaviour, but we still lack specific prognostic indicators. The aim of our study was to evaluate the relative importance of the known demographic, clinical and histological factors in a homogeneous population-based group of patients with SCC of the mobile tongue. The demographic and clinical factors were reviewed retrospectively from primary and tertiary care patient files. Histological prognostic factors were determined from pre-treatment biopsies. The TNM stage was found to be the most important prognostic factor. In particular, local spread outside the tongue rather than spread to regional lymph nodes was related to poor prognosis. Several demographic and histopathological factors were closely related to TNM stage. When the cases were divided into stage I-II carcinomas and stage III-IV carcinomas, it appeared that the patient's older age (> 65 years), a high malignancy score and an absence of overexpressed p53 protein were associated with a poorer prognosis in stage I-II carcinomas. Such cases may require more aggressive treatment. Among patients with stage III-IV carcinomas, heavy use of alcohol was significantly associated with a poor disease-specific survival time.

Natural history and patterns of recurrence of tongue tumours

This retrospective study comprises 226 patients with squamous cell carcinoma of the tongue treated at Canniesburn Hospital, Glasgow between 1980 and 1996. The male:female ratio was 1.2:1 and the average age was 64 years. The ratio of anterior 2/3 to posterior 1/3 tongue lesions was 1.8:1. A total of 23% of patients were clinically staged as T1, 50% were T2 and 27% were T3/T4. At presentation 156 patients (69%) had a clinically negative neck, while 110 patients (49%) had a neck dissection at the time of treatment of the primary. A comparison between the clinical and pathological T and N stages highlighted the difficulties of clinical TNM staging with upstaging of the primary T stage in 21% of patients and downstaging in 6% and upstaging of neck disease in 36% and downstaging in 7.7%. The incidence of clinically occult disease in the neck was 41% including six patients (4.5%) with occult disease in the contralateral neck.

Severe anemia is associated with poor tumor oxygenation in head and neck squamous cell carcinomas

PURPOSE

To investigate the relationship between tumor oxygenation and the blood hemoglobin (Hb) concentration in patients with squamous cell carcinoma of the head and neck (SCCHN).

METHODS AND MATERIALS

A total of 133 patients with SCCHN underwent pretreatment polarographic pO2 measurements of their tumors. In 66 patients measurements were also made in sternocleidomastoid muscles. The patients were divided into three groups according to their Hb concentration-severe anemia (Hb < 11.0 g/dl), mild anemia (female: Hb 11.0-11.9 g/dl; male: Hb 11.0-12.9 g/dl), and normal Hb concentration (female: Hb > or =12.0 g/dl; male: > or =13.0 g/dl).

RESULTS

No significant difference in tumor oxygenation could be detected between mildly anemic patients and patients with a normal Hb level. However, the tumor oxygenation in the severely anemic group was significantly below that of each of the other two groups (p < 0.0001). There was no significant difference between the Hb groups in oxygenation of sternocleidomastoid muscles. In a multivariate analysis including Hb group, tumor volume, smoking habits, gender, T-stage, N-stage, and histologic grade a Hb level < 11 g/dl was found to be the strongest predictor for a poor tumor oxygenation. Smoking also had a marginal influence on median pO2.

CONCLUSION

Our data suggest that a low Hb concentration and cigarette smoking contribute to inadequate oxygenation of SCCHN and thus for increased radioresistance. Consequently, Hb correction and abstinence from smoking may significantly improve tumor oxygenation.

Prognostic factors and relative risk for survival in N1-3 oral squamous cell carcinoma: a multivariate analysis using Cox's hazard model

The records of 136 patients with N1-3 oral squamous cell carcinoma treated by surgery were investigated retrospectively, with the aim of finding out which factors were predictive of survival on multivariate analysis. Four independent factors significantly influenced survival in the following order: pN stage; T stage; histological grade; and N stage. The most significant was pN stage, the five-year survival for patients with pN0 being 91% and for patients with pN1-3 41%. A further study was carried out on the 80 patients with pN1-3 to find out their prognostic factors for survival and the independent factors identified by multivariate analysis were T stage and presence or absence of extracapsular spread to metastatic lymph nodes.

Surfing prognostic factors in head and neck cancer at the millennium

The ability to reliably predict cancer outcome could tailor therapy to the aggressiveness of the tumour to achieve the best results in terms of loco-regional control, overall survival and quality of life. Retrospective and prospective clinical trials involving large series of patients have validated some predictive clinical and pathological factors, whereas the utility of many other prognostic factors has not been established. This has led to some confusion in clinical practice. In order to clarify the significance, role and cost of these prognostic factors we carried out a Medline search of all papers published between 1993 and 1998 concerning the reliability and cost of markers with prognostic significance, in head and neck squamous cell carcinoma, and assessed the results according to a number of criteria relating to reliability and cost. Regarding reliability we classified prognostic factors into: (1) those with a proven significance based on the fact that they were unanimously reported as having an independent statistical correlation with outcome and prognosis; and (2) those for which results were not unanimous, and which significance is still controversial. Cost analysis showed a substantial difference between validated tests which are of low cost and experimental tests which are expensive. Based on these data regarding both the reliability and cost of each prognostic factor, we propose guidelines for their use in clinical practice in the year 2000.

Improved survival for patients with clinically T1/T2, N0 tongue tumors undergoing a prophylactic neck dissection

BACKGROUND

Prophylactic surgical treatment of the neck in "early tongue tumors" is a controversial issue.

METHODS

From a database of 226 patients with squamous cell carcinoma of the tongue treated at Canniesburn Hospital, Glasgow, U.K., between 1980 and 1996, a total of 137 patients with a minimum follow up of 24 months or until death were clinically identified as being T1/T2, N0 (UICC) when first seen. These patients were divided into three groups according to the management of the neck; 53 patients did not have a neck dissection at any time (NKD0), 47 patients underwent a synchronous neck dissection at the time of treatment of the primary (NKDS), and 37 patients subsequently required a metachronous neck dissection when lymph node metastasis became clinically apparent (NKDM). These three groups were compared with respect to age, sex, site, duration of symptoms, previous treatment (if any), initial treatment protocol, resection margin, type of neck dissection (if any), loco-regional recurrence, systemic escape, number of positive lymph nodes, and presence of extracapsular spread. Disease-related survival was calculated using Kaplan-Meier survival curves with logrank test and chi-square statistical analysis.

RESULTS

The pT stage was upgraded to T3/4 in 3/53 patients (6%) of the NKD0 group, 11/47 patients (23%) of the NKDS group, and 2/37 patients (5%) of the NKDM group (p < 0.001). The 5-year determinate survival rates for the three groups were: NKD0 59.7%, NKDS 80.5%, NKDM 44.8%, and (NKD0 + NKDM) 53.6% with a statistically significant improvement in survival for NKDS vs NKDM (logrank 10.58, p = 0.001) and for NKDS vs (NKD0 + NKDM) (logrank 6.06, p = 0.014). The incidences of positive nodes in the NKDS and NKDM groups were 18/47 patients (38%) and 32/37 patients (86%) respectively. Neck positive patients in the NKDM group had a significantly greater number of positive nodes in comparison with N positive patients in the NKDS group (chi trend, p = 0.001), a higher incidence of extracapsular spread, 30/32 vs 9/18 (chi test, p < 0. 0001), and decreased survival. The incidence of occult cervical metastasis for the whole group was 41%.

CONCLUSION

Patients with clinical T1/2, N0 tongue tumors who underwent a synchronous neck dissection had an improved survival outcome even though as a group they had a higher incidence of occult metastasis, relatively more T2 lesions, a worse pT stage, and had more posterior third lesions requiring more difficult initial surgery. Tongue tumors have a high incidence of subclinical nodal disease, which is less curable when it presents clinically. The information gleaned from the nodal status allows a more informed plan of adjuvant therapy.

Oral cancer in the UK: to screen or not to screen

Although oral squamous cell carcinoma accounts for only a small proportion of malignant neoplasms in the UK, oral cancer incidence and mortality rates have been rising in recent years. The natural history of oral cancer is not adequately understood at present and there is very little information about the epidemiology of precancerous lesions in the UK. There are also insufficient data to provide firm evidence that the percentage of cases arising de novo is greater in the UK and the Western world as compared to the Indian subcontinent. Screening for oral cancer by visual examination is simple, inexpensive and causes little discomfort; however, there is no evidence for the effectiveness of screening for oral cancer either in reducing mortality from the disease or in reducing the incidence of invasive disease by detection and treatment of precancerous lesions. There is currently insufficient evidence to recommend population screening for oral cancer in the UK. Measures aimed at primary prevention of the disease may be a more feasible method of disease control at present.

An analysis of the prognostic significance of p53 status for squamous cell carcinoma of the oral cavity treated by radiotherapy

The status of the p53 gene in biopsy specimens was analyzed to determine whether it is predictive of the outcome of radiotherapy of squamous cell carcinomas of the oral cavity. Biopsy materials were obtained from 45 patients, and the p53 status of each patient was determined using a single-strand conformation polymorphism analysis. Fourteen of the patients were treated with radiation therapy alone; the other 31 patients underwent radiotherapy in combination with surgery or chemotherapy. Twenty-seven patients had tumors with wild-type p53 and 18 patients had a tumor with mutant p53. The initial tumor response was not significantly different between these two groups. Kaplan-Meier survival plots (log-rank test) showed that the probability of survival was not significantly different between two groups although the patients with mutant p53 had a tendency for longer survival (P = 0.2941). However, among the patients with stage III/IV tumors (n = 24), those with a wild-type p53 status tended to have longer survivals.

Tumor thickness predicts cervical metastasis in patients with stage I/II carcinoma of the tongue

BACKGROUND

The incidence of cervical metastases after surgery for Stages I/II carcinoma of the tongue is 30-40%. Postoperative cervical metastases are an adverse prognostic factor for patients with this malignancy. The purpose of this study was to evaluate the clinicopathologic factors associated with late cervical metastases in patients with carcinoma of the tongue.

METHODS

The clinicopathologic features of 44 patients with previously untreated Stage I/II carcinoma of the tongue were reviewed. All patients were treated with partial glossectomy only.

RESULTS

Cervical metastases developed in 21 of 44 patients within 5 years. Factors significantly associated with the development of cervical metastases were invasive growth, differentiation, nuclear polymorphism in the deep portion, tumor border, nest formation, infiltrative growth ratio, depth, and thickness. No statistical correlations between cervical metastases and age, gender, tumor location, clinical stage, Brinkman index, alcohol index, mitosis, connective tissue, lymphocytic infiltration, or perineural invasion were found. Multivariate analysis demonstrated that only tumor thickness > 4 mm had a predictive value for cervical metastasis (risk ratio 9.4; 95% confidence interval, 1.5-57.7).

CONCLUSIONS

The current study data indicate that patients with Stage I/II carcinoma of the tongue > 4 mm in thickness are at increased risk for subsequent cervical metastasis. Thus, conservative supraomohyoid neck dissection is indicated in patients with Stage I/II carcinoma of the tongue > 4 mm in thickness.